microsoft word 23. royala zaka mm 302 pakistan journal of ophthalmology, 2020, vol. 36 (3): 302-304 case report tadpole pupil: a very rare entity royala zaka1, muhammad moeez-ud-din2, mirza zaki-ud-din ahmed sabri3, zunair aziz4 1,2,3,4prevention of blindness, a trust based hospital, karachi abstract tadpole pupil is a very rare clinical entity. only few cases have been reported to date in the literature. this is the first case reported in pakistan to the best of our knowledge. a 19-year old female came with the complaint of repeated episodes of 2 to 3 times per week of irregular shaped pupil with blurry vision that subsided itself in few minutes within an hour. at presentation, her examination showed normal va of 6/6 in both eyes with normal pupillary reactions in light and dark. color vision, contrast, visual fields by confrontation, extraocular movements were all normal. ophthalmic and neurologic examination was also unremarkable. her condition was not associated with horner syndrome, adies or migraine which were excluded after examination. she was counseled about the benign nature of her condition and advised for regular follow up or report in case of new appearance of symptoms. key words: tadpole pupil, horner syndrome, adies pupil. how to cite this article: zaka r. tadpole pupil: a very rare entity (a case report). pak j ophthalmol. 2020; 36 (3): 302-304. doi: 10.36351/pjo.v36i3.1061 introduction first described in 1912 by erlenmeyer1, the term “tadpole pupil”was coined by thompson in 1983. it is characterized by spontaneous intermittent segmental dilation of the pupil2. thompson presented the largest number of these cases. only few cases have been described in literature to date2-4. it most commonly occurs in young healthy females but 2 pediatric cases have been found recently5,6. usually it is unilateral and any segment of the iris can be involved and appears as tadpole. the cause for this condition is unknown but some associations are found with horner syndrome, adie’s pupil and migraine2. patient can present with only pupil distortion to blurry vision, headache, peculiar sensation and dizziness. correspondence to: royala zaka prevention of blindness, a trust based hospital, karachi email: drroyala@hotmail.com received: may 2, 2020 revised: may 4, 2020 accepted: may 4, 2020 case report a 19 – year old female came with the complaint of painless irregular shape of her left pupil that became tear-shaped or pear shaped for few minutes within an hour for 2 to 3 times per week. she had this complaint for the previous 2 years. the pupil returned to its normal shape with regain of normal vision. the patient complained of recurrent mild blurry vision during this period. her episodes remitted itself and reappeared after every 3 to 4 weeks. it was not associated with haloes, headache, syncope, drooping of eyelids or loss of sweating. there were no relieving or aggravating factors for the episodes. the patient herself took the pictures during her episodes. her examination showed normal va of 6/6 fig. 1: tadpole pupil left eye after 35 min during the episode. tadpole pupil: a very rare entity pakistan journal of ophthalmology, 2020, vol. 36 (3): 302-304 303 fig. 2: normal shape of left pupil after an episode. in both eyes with normal pupillary reactions in light and dark. color vision, contrast, visual fields by confrontation, extraocular movements were all normal. ophthalmic and neurologic examination was also unremarkable. 10% phenylephrine did not show any change in pupil size. a diagnosis of left tadpole pupil was made and patient was reassured about the benign nature of her condition that was not associated with horner’s syndrome. discussion most of the data available by thompson, who described 26 cases, reveals that tadpole pupil is usually a spontaneous unilateral condition and the side and the peaked iris segment of the pupil involvement can be different at different times of episodes. although most cases have been found in young females for few minutes and mostly without any systemic association but aggarwal et al described 2 year old girl with tadpole pupil associated with congenital horner syndrome5. similarly, weir et al described 2 year old boy with this pupillary abnormality during uncomplicated strabismus surgery6. hansen et al. presented atypical case of a 12 year old girl who developed tadpole pupil after physical exercise7. vijayaraghavan et al presented a case of 19-year old boy who had bilateral tadpole pupil with reference to seizures associated with hyponatremia8. the reason of the tadpole pupil is not known but these atypical cases suggest the presence of different pathophysiology. since tadpole pupil is frequently seen with horner syndrome3 as compared to the general population, it may be because of denervation hypersensitivity of iris dilator muscle. lee et al9 excluded it by doing horner syndrome by using phenylephrine test. we did the same in our patient. tadpole pupil is also found to be associated with migraine and adies pupil but that was not the case with our patient. the iris dilator muscle is the muscle that shows segmental spasm10 in tadpole pupil. since its not known whether the tadpole pupil or horner syndrome precedes, the importance is to diagnose such a rare case and exclude its associations like horner that can be life threatening. it points to the significance of this case. as our patient had no associations till now, we counseled her for the benign nature with reinforcement of the regular follow-up. conclusion since tadpole pupil itself is a benign condition but all patients should be checked for horner syndrome because of its high association with it. this can save the patient from life threatening condition associated with horner’s syndrome. conflict of interest authors declared no conflict of interest. author’s designation and contribution royala zaka; ophthalmologist: study design, manuscript writing, literature review, critical review. muhammad moez uddin; ophthalmologist: study design, literature review, critical review. zaki uddin ahmed sabri; ophthalmologist: study design, literature review, critical review. zunair aziz; ophthalmologist: study design, literature review, critical review. references 1. erlenmeyer a. beschreibung von periodischem auftreten einer wandernden pupille. berlin klin wschr. 1912; 49: 539-42. 2. udry m, kardon r, sadun f, kawasaki a. the tadpole pupil: case series with review of the literature and new considerations. front neurol. 2019; 10: 846. doi. org/10.3389/fneur.2019.00846. 3. thompson hs, zackon dh, czarnecki jsc. tadpole-shaped pupils caused by segmental spasm of royala zaka, et al 304 pakistan journal of ophthalmology, 2020, vol. 36 (3): 302-304 the iris dilator muscle. am j ophthalmol. 1983; 96 (4): 467-77. 4. tang ra, winn tl, lee kf, marroquin g, patchell l, yeakley jw. unilateral pupillary distortion: a case report. j clin neuro-ophthalmol. 1985; 5 (2): 105-8. 5. aggarwal k, hildebrand grd. the tadpole pupil. jama neurology. 74 (4): 481-. 6. weir re, hajdu sd, greaves bp. transient tadpole pupil associated with primary uncomplicated medial rectus reattachment. j pediatr ophthalmol strabismus. 2010 may 21; 47 online: e1-2. doi: 10.3928/01913913-20100507-06. 7. hansen jk, m㸠ller hu. is tadpole pupil in an adolescent girl caused by denervation hypersensitivity? neuropediatrics. 48 (03): 185-7. 8. vijayaraghavan r, philips ca, choudhury sp. bilateral tadpole pupils. neurology. 86 (11): 1074-5. 9. lee tj, westfall dp, fleming ww. the correlation between spontaneous contractions and postjunctional supersensitivity of the smooth muscle of the rat vas deferens. j pharm exp ther. 1975; 192 (1): 136-48. 10. balaggan ks, hugkulstone ce, bremner fd. episodic segmental iris dilator muscle spasm: the tadpole-shaped pupil. archives ophthalmol. 2003; 121 (5): 744-5. .……. 186 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology short communication topographic interpretation of posterior keratoconus tayyaba gul malik, muhammad khalil, moeen bhatti pak j ophthalmol 2016, vol. 32 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyaba gul malik ophthalmology department lahore medical and dental college, lahore e.mail: tayyabam@yahoo.com …..……………………….. we present a case of a sixty years old asian male who presented to us with gradual decrease in vision of both eyes. slit lamp examination revealed paracentral thinning with a dome-shaped excavation in the posterior corneal surface in each eye. other than the early lens changes, rest of the ocular examination was normal. a diagnosis of bilateral posterior keratoconus was made. corneal topography was done to confirm the diagnosis. findings of the galilei scan of the patient are discussed in this case report in relation to normal corneas. key words: posterior keratoconus, corneal curvature, galilei scan, pachymetry, corneal topography. osterior keratoconus is a rare sporadic condition which is characterized by non progressive increase in curvature of posterior surface of cornea.1 anterior corneal surface remains normal, so visual acuity is unimpaired. posterior keratoconus is a non progressive, non inflammatory, unilateral (rarely bilateral) disorder which, is characterized by increase in the curvature of posterior corneal surface2,3. corneal involvement can be diffuse or localized. diffuse form is called keratoconus posticus generalis in which cornea typically remains clear. localized form is called keratoconus posticus circumscriptus, in which, central or paracentral areas of posterior excavation is seen4. decrease in visual acuity occurs because of irregular astigmatism but it is not as severe as seen in anterior keratoconus. as the refractive indices of cornea and aqueous humour are similar i.e. 1.376 and 1.336 respectively, there is minimal effect on refraction at aqueous-posterior corneal surface interface. usually diagnosis occurs by chance when the patient comes for other reason. a similar patient who came to our outpatient department for decreased vision was found to have posterior keratoconus. a sixty years old asian male presented, in a tertiary care hospital of lahore, with gradual decrease of vision in both eyes for previous six months. visual complaint was not associated with redness, watering or pain in the eyes. there were no aggravating or relieving factors. he was nondiabetic, nonhypertensive and non-smoker. on examination, the patient was an average stature, average built male and had no systemic abnormality. he was orthotropic and had uncorrected visual acuity of 6/18 in each eye. there was no improvement with pinhole. his color vision was normal. slit lamp examination revealed normal conjunctiva and sclera. cornea showed paracentral thinning with a dome – shaped excavation in the posterior corneal surface in each eye (figure 1). anterior chamber was deep and quiet. cortical cataract and nuclear changes were seen in the crystalline lens. pupillary reactions were normal and dilated fundus examination showed normal discs and macula. keratometry was performed which revealed vertical keratometry (kv) of 45 d and horizontal k (kh) of 47 d in right eye. in the left eye, kv was 43d and kh was 45.5 d. galilei scan was performed. on topographic scan, anterior axial curvature of a normal eye shows enantiomorphism (the maps of both eyes are mirror p topographic interpretation of posterior keratoconus pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 187 table 1: pachymetry comparison of normal and patient’s eyes. parameters normal right eye left eye thickness at the thinnest location 500 microns -52 microns 97 microns y co-ordinate of thinnest location < 500 microns 3.83 mm 3.83 thickness at corneal apex minus thickness at thinnest location < 10 um 570 um 452 um s-i difference on central 5mm < 30 mm. 39 mm 284 mm fig. 1: slit lamp examination showing excavation of the posterior corneal surface. fig. 2: anterior axial curvature map. fig. 3: kissing bird sign in right eye and trefoil pattern in left posterior curvature map. fig. 4: posterior elevation maps. images of each other), symmetric bow tie pattern and steep k of less than 48 d. in our patient, the normal enantiomorphism was absent, there was loss of symmetric bow tie pattern and steep k was 48.77 d in right eye and 44.66 d in left eye (figure 2). findings of pachymetry are shown in table 1. posterior corneal curvatures were -9.96 d in right eye and -5.41d in the left eye (figure 3). in our patient, isolated island patterns were seen in posterior elevation maps of both eyes. (normal eyes have symmetric sandy watch pattern). best fit toric elevation (bfte) in central 5mm was 132 mm in right eye and 40 mm in the left eye (figure 4), which were higher than the normal value of less than 15mm. based on these findings a diagnosis of posterior keratoconus was made. treatment is not required in posterior keratoconus with clear corneas. glasses were prescribed and the patient was suggested follow up after six months. discussion posterior keratoconus is a rare, non-progressive corneal condition, which was first described by t. harrison butler in 19305. this condition is classified tayyaba gul malik, et al 188 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology into diffuse and localized forms depending on the area of cornea involved. however, srinivas has further classified localized form into central, paracentral and peripheral types6. our patient had paracentral type of localized posterior keratoconus. posterior keratoconus is also divided into congenital and acquired forms. electron microscopy of the congenital type has shown an abnormal anterior banded layer of descemet's membrane which corresponds to an abnormality in 6 to 8 months of gestation7. later, krachmer suggested that the abnormality would have originated in the fifth or sixth month of gestation8. acquired type is reported to have occurred secondary to trauma and interstitial keratitis9,10. it should be kept in mind that posterior keratoconus is not the same as keratoconus. they are entirely different entities. there is only one case, reported in literature in which, a patient had anterior keratoconus in one eye and posterior keratoconus in the other eye11. however, clinical similarity does exist between peter’s anomaly and posterior keratoconus. in peters' anomaly, contrary to posterior keratoconus, the corneal endothelium and descemet's membrane are absent or thinned out. histologically, epithelium is disorganized, bowman’s layer is replaced by fibrous tissue, stroma becomes thinned and structural changes are seen in descemet’s membrane. in some cases absence of bowman’s membrane in generalized posterior keratoconus is also seen. in the same patient, amyloid deposits were seen in the stroma13. histology of our case was not done and amyloid deposits were also not seen. recently, slit-scanning topography analysis (orbscan) and anterior segment oct is used to identify the structural and histopathological abnormalities in cases of posterior keratoconus. although many ocular and systemic associations of posterior keratoconus are described in literature but our patient had no such associations. ocular anomalies include anterior cleavage syndrome. other anterior segment abnormalities include aniridia, ectropion uvea, iris atrophy, glaucoma, anterior lenticonus, ectopia lentis, and anterior lens opacities. systemic abnormalities include cleft lip and palate, genitourinary abnormalities, short stature, and mental retardation. none of these changes were present in our case. conclusion posterior keratoconus is a rare corneal disorder in which visual drop is not marked because of the normal anterior curvature. visual disturbance usually occurs as a result of stromal scarring, anterior segment anomalies or amblyopia. corneal topographic maps are helpful in understanding the basic pathology of this disease. author’s affiliation dr. tayyaba gul malik associate professor of ophthalmology lahore medical and dental college, lahore dr. muhammad khalil associate professor of ophthalmology lahore medical and dental college, lahore dr. moeen bhatti assistant professor lahore medical and dental college, lahore role of authors tayyaba gul malik data collection and manuscript writing muhammad khalil manuscript writing moeen bhatti data acquisition references 1. bowling brad. cornea. in: kanski’s clinical ophthalmology. 8th edi. elsevier; 2016; 237. 2. krachmer jh, feder rs, belin mw. keratoconus and related non inflammatory corneal thinning disorders. surv ophthalmol. 1984; 28: 293-322. 3. chan dq. bilateral circumscribed posterior keratoconus. j am optom assoc. 1999; 70: 581-6. 4. kanski jj, bowling brad. cornea. in: kanski and bowling’s clinical ophthalmology. 7th edi. elsevier; 2011. p 313. 5. butler th. two rare corneal conditions. br j ophthalmol. 1932; 16: 30–5. 6. rao sk, padmanabhan p. posterior keratoconus.:an expanded classification scheme based on corneal topography. ophthalmology. 1998; 105: 1206-12. 7. wulle kg. electron microscopy of the fetal development of the corneal endothelium and descemet's membrane of the human eye. invest ophthalmol. 1972; 11: 897-904. topographic interpretation of posterior keratoconus pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 189 8. krachmer jh, rodrigues mm. posterior keratoconus. arch ophthalmol. 1978; 96: 1867-73. 9. cote ma, gaster rn. keratohematoma leading to acquired posterior keratoconus. cornea, 1994; 13: 534–8. 10. williams r. acquired posterior keratoconus. br jr ophthalmol. 1987; 71: 16–7. 11. vajpayee rb, sharma n. association between anterior and posterior keratoconus. aust n z j ophthalmol. 1998; 26: 181-3. pak j ophthalmol. 2021, vol. 37 (3): 330-332 330 brief communication (on career counselling) educational and postgraduate study opportunities, for an ophthalmology resident in pakistan usama iqbal gujranwala medical college/teaching hospital, gujranwala ophthalmology postgraduate training in pakistan has undergone a significant reforms and modifications in the last one decade. there are currently two categories of ophthalmology postgraduate courses in pakistan i.e. two year courses ofmcps or doms and four year courses of fcps or ms. among these membership/ fellowship programs are offered by the college of physicians and surgeons of pakistan (cpsp) while diplomas and master degree programs are offered by the medical universities. pm&dc the former medical licensing body of pakistan categorized two year postgraduate programs as leveland four year postgraduate programs as level-qualifications, which differ in scale of appointment and promotion preference. recently pakistan medical commission (pmc), the successor of pm&dc, has categorized postgraduate qualifications into additional, postgraduate and alternative qualifications. 1 a resident ophthalmologist after starting postgraduate (pg) training in ophthalmology can also avail additional opportunities besides continuing with the course in which he/she is admitted. how to cite this article: iqbal u. educational and postgraduate study opportunities, for an ophthalmology resident in pakistan. pak j ophthalmol. 2021, 37 (3): 330-332. doi: 10.36351/pjo.v37i3.1245 correspondence: usama iqbal mbbs, mrcsed (ophth), fico (uk) gujranwala medical college/teaching hospital, gujranwala email: usamaiqqbal@gmail.com received: march 26, 2021 accepted: april 27, 2021 foreign postgraduate courses ophthalmology residents can pursue postgraduate fellowship programs offered by the royal colleges of united kingdom (uk) along with their pg training in pakistan. these fellowships are nationally as well as internationally recognized qualifications in ophthalmology, which can be completed without having any work experience in uk. successful completion of fellowship with any of the royal college of uk, allows a candidate to get himself registered with the general medical council (gmc). 2 details about these colleges and their exams are given below. 1. the royal college of ophthalmologists (rcophth): the fellowship of rcophth (frcophth) is open for the international ophthalmology residents. eligibility criteria to appear in part 1 fellowship exam of rcophth require no previous experience in ophthalmology. from 2020 onward, the part 1 exam is conducted online and candidates can appear in exam from their home. part 1 is followed by ‘refraction certificate’ which can be taken in centers where exam is offered. currently there is no exam center in pakistan for rcophth ‘refraction certificate’ and a candidate is required to travel out of country for appearing in this exam. successful completion of part 1 and refraction certificate leads to part 2 fellowship exam of rcophth which is in fact the exit exam of this fellowship having written and oral components. 3 currently there is no exemption criteria or reciprocity for rcophth fellowship examination. the website of rcophth www.rcophth.ac.uk, is updated regularly and most recent information can be found by visiting website of the college. open access http://www.rcophth.ac.uk/ usama iqbal 331 pak j ophthalmol. 2021, vol. 37 (3): 330-332 2. royal college of surgeons of edinburgh (rcsed) fellowship of rcsed in ophthalmology (frcsed) is gmc enlisted acceptable post graduate qualification 2 and also recognized by pmc as a foreign post graduate qualification. recently rcsed has collaborated with the international council of ophthalmology (ico) for their written examinations. 4 successful completion of frcsed part b or equivalent reciprocal exams conducted by ico leads to the award of membership of rcsed (mrcsed). success in part c, which requires 4-year experience to appear in this exam, leads to award of frcsed. 3. royal college of physician and surgeons glassgow (rcpsg) fellowship of rcpsg in ophthalmology (frcs) is another pathway which can be opted during ophthalmology pg training in pakistan. 5 the exam reciprocity of rcsed, rcpsg and ico exams allows a candidate to pursue fellowships of both these colleges at the same time but final parts i.e. part 3 or part c are to be passed by each of these colleges separately. eligibility to appear in part 2 of frcs ophthalmology by rcpsg requires a candidate to have 5 year of clinical experience in ophthalmology. written exams can be taken in pakistan, but for clinical exam a candidate needs to travel out of country because currently no exam center is available in pakistan. 4. international council of ophthalmology (ico) ico exams consist of standard and advanced examination. successful completion of these exams lead to award of fellowship with ico (fico). 6 fico is not recognized as a licensed postgraduate qualification either by gmc or pmc. however successful completion of ico exams allows a candidate to get exemption from all written exams of frcsed (part a and part b) and part 1 and part 2 (mcq’s) portion of frcs glassgow. candidates who are successful in ico exams also have improved chances to get selected for fellowships offered by ico or other international ophthalmology fellowships e.g. international ophthalmological fellowship foundation 7 after completing their post graduations. memberships and license of internationally recognized ophthalmological organizations: a pg-student during ophthalmology residency in pakistan can also claim free membership of international organizations of ophthalmology including american academy of ophthalmology (aao) ophthalmic news and education(one ® ) network 8 as well as european society of cataract and refractive surgery (escrs). 9 aao one ® networkprovides an updated educationalcontent to the licensed members including free access to academy mcq’s pool, clinical videos, case discussions and ophthalmology journals. 8 the educational content available on aao one network is updated regularly and is also a valuable resource while preparing for mcq based exams in ophthalmology. a candidate wishing to seek access to aao one network need to send a request email to oneintl@aao.org stating that he/she is located in pakistan. european society of cataract and refractive surgery (escrs) also offers free trainee membership to ophthalmology residents less than 35 years of age. escrs members get benefits of free access to escrs journals, research grants and i-learn online courses. 9 a candidate wishing to get the membership of escrs is required to fill an online form available on website https://www.escrs.org/ and needs to produce a certificate from his/her supervisor or head of department stating the candidates date of birth and training duration. british pakistani ophthalmic society (bpos): bpos conducts educational webinars and grand rounds which include case presentations by young residents. these webinars are hosted by a panel of high profile speakers from uk and pakistan. these webinars provide an excellent opportunity to the young residents to learn about national ophthalmology practice in relation to international advancements. all webinars can be attended free of cost by registering mailto:oneintl@aao.org?subject=one%20network%20access%20for%20individuals https://www.escrs.org/ educational and postgraduate study opportunities, for an ophthalmology resident in pakistan pak j ophthalmol. 2021, vol. 37 (3): 330-332 332 form their website https://bpos.org.uk/or their facebook page. bpos also offers specialty fellowships for ophthalmologists in pakistan. recently they have launched an electronic audit tool which can be used for keeping record of departmental and personal audit. educational websites and online courses there is a long list of online websites which offer educational content related to ophthalmology. a few of these resources include timroot.com, eyewiki.org, cataractcoach.com, eyerounds.org, retinapodcast.com, octcases.com, eyeguru.org. 10 cybersight (orbis) cyber sight is a telemedicine initiative founded by orbis international which operates from united states. they offer online courses (with certification of completion), educational webinars, online library and artificial intelligence based online consultation facility for developing countries. detailed information can found from their website https://cybersight.org/. research grants and opportunities a resident can also avail research grants offered by ophthalmological organizations mentioned above, by sharing their research proposal. the members of societies like escrs and rcsed can also avail travel and educational grants to participate in an educational events. to find updates about research grants a candidate can subscribe to the official social media pages of these societies or their news letters sent via email. facebook/whatsapp/youtube educational groups & channels most of the renowned ophthalmologists have found their youtube channels and share their experience on these channels regularly. besides this, there are educational groups on whatsapp, where a participant can share cases for discussion and can seek advice from the subject specialists. conclusion in conclusion, the pg residency in ophthalmology is not limited to institutional educational activities only. a resident can avail a lot more opportunities by utilizing online educational forums. by planning to appear in foreign postgraduate exams along with national postgraduate exams, a resident can also get foreign postgraduate fellowship staying in their home country. conflict of interest author declared no conflict of interest. references 1. policy of the council on definitions and scope of qualifications. available from: https://www.pmc.gov.pk/policiesanddecisions 2. acceptable postgraduate qualifications general medical council, 2021 [available from: https://www.gmcuk.org/registration-and-licensing/join-theregister/before-you-apply/acceptable-postgraduatequalifications. 3. examinations: the royal college of ophthalmologists; 2021 [available from: https://www.rcophth.ac.uk/examinations/. 4. rcsed and international council of ophthalmology (ico) collaboration: the royal college of surgeons of edinburgh; august 2018 [cited 2021 26 march 2021]. available from: https://www.rcsed.ac.uk/exams/rcsedand-international-council-of-ophthalmology-icocollaboration. 5. examinations and assessments: royal college of physicians and surgeons of glassgow; 2021. [cited 2021 26 march 2021]. available from: https://rcpsg.ac.uk/surgeons/exams. 6. ico exams website: international council of ophthalmology; 2021 [cited 2021 26 march 2021]. available from: www.icoph.org/refocusing_education/examinations.ht ml. 7. about the program: international ophthalmological fellowship foundation [cited 2021 26 march 2021]. available from: https://ioff.org/about-the-program/. 8. one network participating societies: american academy of ophthalmology; 2021 [cited 2021 26 march 2021]. available from: https://www.aao.org/international/programs/participatin g-societies. 9. escrs membership: escrs; 2021 [cited 2021 27 march 2021]. available from: https://www.escrs.org/escrs-membership/default.asp. 10. angela chen bs, benjamin lin, m.d. ophthalmology resources for medical students and residents website: eyeguru.org; 2019 [cited 2021 26 march 2021]. available from: https://eyeguru.org/blog/ophthoresource-guide/. author’s designation and contribution usama iqbal; registrar: concept, data collection, manuscript writing. https://bpos.org.uk/ https://cybersight.org/ https://www.gmc-uk.org/registration-and-licensing/join-the-register/before-you-apply/acceptable-postgraduate-qualifications https://www.gmc-uk.org/registration-and-licensing/join-the-register/before-you-apply/acceptable-postgraduate-qualifications https://www.gmc-uk.org/registration-and-licensing/join-the-register/before-you-apply/acceptable-postgraduate-qualifications https://www.gmc-uk.org/registration-and-licensing/join-the-register/before-you-apply/acceptable-postgraduate-qualifications https://www.rcophth.ac.uk/examinations/ https://www.rcsed.ac.uk/exams/rcsed-and-international-council-of-ophthalmology-ico-collaboration https://www.rcsed.ac.uk/exams/rcsed-and-international-council-of-ophthalmology-ico-collaboration https://www.rcsed.ac.uk/exams/rcsed-and-international-council-of-ophthalmology-ico-collaboration https://rcpsg.ac.uk/surgeons/exams ../e-mail/www.icoph.org/refocusing_education/examinations.html ../e-mail/www.icoph.org/refocusing_education/examinations.html https://ioff.org/about-the-program/ https://www.aao.org/international/programs/participating-societies https://www.aao.org/international/programs/participating-societies https://www.escrs.org/escrs-membership/default.asp https://eyeguru.org/blog/ophtho-resource-guide/ https://eyeguru.org/blog/ophtho-resource-guide/ 417 pak j ophthalmol. 2021, vol. 37 (4): 417-419 brief communication reliability of duo chrome test in different age groups considering patient satisfaction as gold standard zehwa mazhar 1 , rabia manzoor 2 , shazia kanwal 3 , ghazala iqbal 4 1-4 department of ophthalmology, king edward medical university, lahore abstract purpose: to check the reliability of the duo-chrome test in different age groups after best correction. study design: descriptive, cross sectional study. place and duration of study: college of ophthalmology and allied vision sciences. king edward medical university, lahore from september 2019 – december 2019. methods: forty two cooperative patients of both genders more than 15 years of age were included but patients with poor fixation, any opacity or any other ocular pathology were excluded. equipment used was trial box trial frame auto-refractor and snellen chart. group 1 composed of 17 patients (15 – 35 years of age). group 2 (36 – 60 years) had 15 patients and group 3 (age 61-80 years) comprised of 10 patients. data was collected on selfdesigned performa. duo chrome was dependent variable and gender was independent variable. data was analyzed by using statistical package for social science (spss22.00) and chi square test was applied. results: out 42, 21 patients reported red, 12 reported green and 9 patients reported equally clear in the right eye. p value=0.156 showed that duo chrome test was equally reliable in every age group in the right eye. similar results with p = 0.755 showed that duo chrome test was equally reliable in every age group in the left eye. test when performed bilaterally, showed similar results. out of 42 patients, 32 were satisfied and 10 were not satisfied with the test. conclusion: red green duo-chrome test is equally reliable in all age groups to confirm refraction. key words: duo chrome test, refraction, myopia, hypermetropia. how to cite this article: mazhar z, manzoor r, kanwal s, iqbal g. reliability of duo chrome test in different age groups considering patient satisfaction as gold standard. pak j ophthalmol. 2021, 37 (4): 417-419. doi: 10.36351/pjo.v37i4.1118 correspondence: rabia manzoor king edward medical university, lahore email: rabiajanvi@gmail.com received: august 14, 2020 revised: february 7, 2021 accepted: august 06, 2021 introduction post refraction tests are done for the verification of subjective refraction including duo-chrome, plus one blur and pinhole etc. since its introduction by brown in 1927, the duo chrome test is a good clinical tool. 1 it is a test commonly used to refine the final sphere in refraction, which utilizes the phenomenon of transverse chromatic aberration of the eye. the patient is asked to compare the clarity of the green and red side letters on the bottom of the chart. if the green letters are clearer, sphere of +0.25 d is added and if the red letters are clear, a minus sphere of 0.25 d is added in the prescription. with best spherical correction, the letters in the red and green halves of the open access mailto:rabiajanvi@gmail.com reliability of duo chrome test in different age groups considering patient satisfaction as gold standard pak j ophthalmol. 2021, vol. 37 (4): 417-419 418 chart appear equally clear. because the principle of duo chrome test is chromatic aberration and not color discrimination, it is used even with people having deficiency of color vision. the eye with excessive accommodation may still require too much negative sphere to balance red and green. cycloplegia may be required in these cases. duo chrome test is not used in patients with visual acuity worse than 20/30 (6/12), as the difference of 0.50 d between the two sides is too small to be distinguished. 2 the initial duo-chrome test, which is also known as the bichrome test, uses the principle of chromatic aberration because the light of different wavelengths is refracted to a different extent. 3 the shortest wavelength (green) is refracted more as compared to the longest (red). the test first requires the power of the spherical lens to be known monocularly. the duo chrome test should be used after monocular refraction and shows the endpoint process of the examined eye. the prism dissociated duo chrome test is used to match the stimulus with the accommodation of the two eyes in binocular vision. this test is initially used for presbyopia that need near add. the duo chrome test can be used clinically for the verification of final refraction for more than 60 years. the duo chrome test is used in research protocols for the final spherical adjustment of refraction and to avoid over or under distance correction. a study showed that red-green equality with fully corrected cylinder and without the cylindrical correction were not significantly different concluding that the red-green duo chrome test could be used both before and after cylindrical correction. 4 this study was carried out to see the reliability of duo chrome test in three different age groups in a tertiary care hospital. methods this cross-sectional study was conducted between september 2019 to december 2019 among three groups of 42 patients. cooperative patients of both genders more than 15 years of age were included but patients with poor fixation, any opacity or any other ocular pathology were excluded. equipment used was trial box trial frame autorefractor and snellen chart. group 1 composed of 17 patients (15 – 35 years of age). group 2 (36 – 60 years) had 15 patients and group 3 (age 61 – 80 years) comprised of 10 patients. age, distance visual acuity, autorefraction, pinhole improvement, subjective refraction and duo-chrome were noted. data was collected on self-designed performa. duo chrome was dependent variable and gender was independent variable. data was analyzed by using statistical package for social science (spss22.00) and chi square test was applied. results this table shows that out 42, 21 patients reported red 12 reported green and 9 patients reported equally clear. p value = 0.156 shows that duo chrome test was equally reliable in every age group in the right eye. similar results with p = 0.755 shows that duo chrome test was equally reliable in every age group in the left eye. out of 42 patients, 32 were satisfied and 10 were not satisfied with the test. table 1: duo chrome test of right eye, left eye and both eyes in different age groups. duo_od total red green equally clear/blurr age 15 – 35 8 6 3 17 36 – 60 9 1 5 15 61 – 80 4 5 1 10 total 21 12 9 42 discussion uncorrected refractive disorders are the main cause of distance visual loss and around 108 million human beings are affected by it. 5 it has been assessed that refractive errors which are not corrected (especially myopia)results in a huge financial burden i.e. around 202 billion dollars per year. therefore, eradication of all the preventable reasons of visual damage including uncorrected refractive errors could lead to a fundamental financial gain. 6 in order to rectify these refractive errors standard clinical processes should be established and modernized bylatest scientific researchesso that finest prescription is offered to the patients. in another study, it was shown that the refractive end point measurements obtained from duo chrome and cross grid were well correlated and comparable, suggesting that they could be used interchangeably in most clinical settings. however, caution is needed when using measurements obtained by cross grid method in dim illumination. 7 rabia manzoor, et al 419 pak j ophthalmol. 2021, vol. 37 (4): 417-419 similar results were seen in a korean study. 8 another important point is that before performing duo chrome test, eye should be pathologically perfect because in the presence of yellow crystalline lens, sometimes red background appears clearer compared to greenbackground. 9.10 limitation of the study was that not all the refractive errors were equally represented. it was a single center study and accomodation was not disabled by cycloplegics. ethical approval the study was approved by the institutional review board/ethical review board (coavs/892/20). conflict of interest authors declared no conflict of interest. conclusion red green duo chrome test is equally reliable in all three considered age groups as a post refraction confirmatory test as its p value is >0.05 which is nonsignificant and should be used by practitioners in clinical refraction. precise refraction is also very significant before certain surgical procedures like refractive surgery in order to avoid under or overcorrection, which could later be difficult to treat. references 1. colligon-bradley p. red-green duochrome test. j ophthalmic nurs technol. 1992; 11 (5): 220-222. 2. myron yanoff, jay s. duker. ophthalmology (3 rd ed.). mosby elsevier, 2009: p. 67. 3. sivak j. the validity of the bichrome (duochrome) test. optomvis sci. 1975; 52 (9): 604-606. 4. gantz l, schrader s, ruben r, zivotofsky az. can the red-green duochrome test be used prior to correcting the refractive cylinder component? plos one, 2015. 16; 10 (3): e0118874. doi: 10.1371/journal.pone.0118874. 5. kovin sn, janet l, rupert r, seth rs, jost jb, jill k, et al. serge for the vision loss expert group of the global burden of disease study a global vision impairment and blindness due to uncorrected refractive error, 1990 – 2010, optom vis sci. 2016; 93 (3): 227-234. doi: 10.1097/opx.0000000000000796 6. smith ts, frick kd, holden ba, fricke tr, naidoo ks. potential lost productivity resulting from the global burden of uncorrected refractive error. bull world health organ. 2009; 87 (6): 431-437. doi: 10.2471/blt.08.055673. 7. makgaba nt. a study to determine the use of cross cylinder in conjunction with the cross grid at distance as an alternative method for the duochrome technique amongst university of limpopo optometry students. available at: http://ulspace.ul.ac.za/handle/10386/2862. accessed on 9 th june 2021. 8. yang sm, kim sh, cho ya. the usefulness of duochrome test for prevention of overcorrection in refraction tests of myopic children. j korean ophthalmol soc. 2006; 47 (2): 269-272. 9. chowdhury ph, shah bh, tiwar n. brief explanation of turville infinity balance and duochrometest. intern j med sci clin res rev. 2019; 2 (3): 60-70. 10. keirl a, christie c. editors. clinical optics and refraction: a guide for optometrists, contact lens opticians and dispensing opticians. elsevier health sciences; 2007 oct. 10. authors’ designation and contribution zehwa mazhar; optometrist: concepts, literature search, data acquisition, manuscript preparation, manuscript review. rabia manzoor; optometrist: concepts, design, literature search, manuscript preparation, manuscript review. shazia kanwal; optometrist: concepts, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript review. ghazala iqbal; optometrist: concepts, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript review. .…  …. 49 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology case report lightning induced ocular complications: a case report chandana chakraborti pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: chandana chakraborti department of ophthalmology calcutta national medical college & hospital kolkata 700006 west bengal india …..……………………….. lightning injuries range from various forms of transient focal damage to instant death. eye injuries from lightning are not uncommon. we report a case of lightning injury in a 30 – year old female who presented to us one month after the injury. on examination her best corrected visual acuity (bcva) was 6/24 in right eye (re) and 6/60 in left eye (le). slit lamp biomicroscopy revealed anisocoria, bilateral uveitis and sphincter tear in left eye. there was lightning induced cataract in both eye and macular hole in left eye. optical coherence tomography (oct) revealed macular cyst in right eye (re) and a full thickness macular hole (ftmh) in left eye. patient was treated with topical corticosteroid and cycloplegics in both the eyes. at subsequent follow up cataract surgery was done in both eyes (be). post-operative best corrected visual acuity at 1 month was 6/9 and 6/12 in right and left eye. there was a spontaneous resolution of the macular lesion in both eyes. ightning injury can cause multi system damage and often results in high mortality. the consequences of being struck by lightning depend on several factors at the time of the incident. important features are the type of stroke, the current and its distribution, and the victim’s position and clothing1. ocular injuries like thermal keratopathy, uveitis, hyphaema, anterior and posterior subcapsular cataract, lens dislocation have been reported2. posterior segment complications like vitreous hemorrhage, retinal edema and haemorrhage, retinal detachment, vascular occlusion, choriodal rupture, macular involvement in the form of cystoid macular edema and macular hole have been documented. lightning induced nystagmus, anisocoria, optic neuropathy, horner's syndrome and multiple cranial nerve palsies has been reported2-4. we report a rare case of ocular injury due to lightning strike involving both anterior and posterior segments with good final visual outcome. case report a 30 – years old female presented with painless diminution of vision in be following a lightning strike one month back. she was struck by lightning when she along with her two family members were sitting on the veranda of their house while it was raining outside. the neighbour who accompanied her gave the rest of the history. she was unaware of the incident. all three became unconscious following a lightning strike on a coconut tree situated near the house. the coconut tree was burnt out. all three were admitted in hospital in unconscious state and treated conservatively. among the three one sustained skin burns around her necklace, her husband sustained a fracture of right humerus, may be due to fall on ground. but these two did not develop any ocular complaints. after seven days of the incident she complained of blurring of vision and redness in both eyes. she was examined by an ophthalmologist and diagnosed as bilateral uveitis and was treated with topical steroids and cycloplegics. systemic examination like pulse, bp and renal function were normal. there was no skin or eyelid burns. she developed loss of hearing in the left ear due to rupture of tympanic membrane. on examination, her bcva was 6/24 and 6/60 and intraocular pressure was 16 and 18 mm hg respectively in re and le. slit lamp examination l lightning induced ocular complications: a case report pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 50 fig. 1: slit lamp photography showing sphincter tear at 5’o clock fig. 2: colour fundus picture showing rpe pigmentation. fig. 3: colour fundus picture showing macula hole. fig. 4: oct showing cystic changes in the macula fig. 5: lightning induced full thickness macular hole. revealed bilateral resolving iridocyclitis, anisocoria (le > re) and sphincter tear at 5-0’clock position and anterior and posterior subcapsular cataract in both eyes (le > re) (fig. 1). slit lamp biomicroscopy with a 90 d revealed pigmentation of macula in re (fig. 2) and macular hole in le (fig. 3). the watzke allen sign was positive in le. oct revealed macular cyst in re (fig. 4) and a full thickness macular hole with a thin bridging tissue over it in le (fig. 5). non steroidal anti-inflammatory drops were prescribed in both eyes for the uveitis. the patient reviewed with us 3 months later, when she had developed a total cataract in her le and advanced immature cataract in re. small incision cataract surgery was done in be. post-operative bcva was 6/9 in re and 6/12 in le. pigmentary changes chandana chakraborti 51 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology were found in macular area of be. the watzke – allen sign was negative in le. we assume that there was a spontaneous closure of the macular hole in le but the oct could not be done because of patient’s unwillingness. discussion lightning is an uncommon cause of ocular injury. the power of lightning is 10,000 to 2,00,000 amperes and a voltage of 20 million to 1 billion volts. lightning exposure time is only 1 to 100 milliseconds, taking less time to cause damage of tissue5. tissue destruction is caused by both thermal effect and electrolysis. nonnervous tissue offering high resistance is responsible for the thermal effects of lightning resulting in rapid coagulation of the cellular proteins. lightning induced cataract is mostly bilateral. possibility of cataract formation increases with the proximity of the contact area to the eye6,7. lightning may reach its victims by any of the four routes and causes injuries4,7: 1. direct strike: when the major current flows directly through the victim and is facilitated by metal objects. 2. splash: where lightning strikes an object first and then arcs through the path of least resistance. 3. contact: the bolt strikes an object the victim is in contact with i.e. electrocution while telephonic conversation. 4. ground current: here the lightning travels along the surface towards the victim after striking the ground. our patient probably sustained the injury by the second mechanism mentioned; lightning passed through the nearby coconut tree and through the ground. current passed initially through the left side of the body as indicated by left sided hearing loss, poorer vision in le (6/60) than re (6/24) and denser posterior sub-capsular cataract in le. severity of uveitis and macular damage was also more in the le. in case of bilateral cataract, it starts in the eye on the more affected side first and there may be a gap of 1 – 10 months between the two eyes. lightning induced cataract may be attributed to, decreased permeability of lens capsule, protein coagulation by electrical current, nutritional impairment of lens due to iritis and mechanical damage to the lens fibers. lightning induced cataract is morphologically characteristic, affecting both anterior and posterior parts of the lens. regression of the opacity as a whole or partially has been reported7-11. in our case there was both anterior and posterior-sub-capsular cataract in be (le > re). the macula is very sensitive to thermal damage because of the high melanin content of the retinal pigment epithelium (rpe)3–4. electrical current damages the rpe by electrolysis. melanin resists the electric current leading to thermal denaturation of the outer retina and rpe. lightning strike may cause localized inflammation of the rpe. retinal edema may result from decreased transport of fluid out of retina or development of retinal vascular incompetence3. early development of macular edema seen after lightning strike may lead to formation of macular cyst, macular hole or solar maculopathy3,4. lightning maculopathy is supported by the lack of posterior vitreous detachment and operculum3. we advised our patient macular hole surgery when she presented to us after the injury but the patient denied. subsequently after cataract surgery patient had good visual outcome in both eyes. we presume that the hole had resolved on its own which was clinically proven by negative watzke – allen sign (le). lightning induced macular holes may undergo spontaneous closure with a good visual outcome4 which was a feature in our case though there is no oct documentation. it is important to differentiate between lightning induced macular cyst and full-thickness macular hole, as cystic changes may resolve spontaneously but for full – thickness macular whole surgery may be required12. to the best of our knowledge, this is the first case reporting bilateral lightning induced anterior and posterior segment ocular damage with a good final visual outcome in both the eyes. author’s affiliation dr. chandana chakraborti assistant professor dept. of ophthalmology calcutta national medical college and hospital kolkata 700006 west bengal india references 1. anastassios c. koumbourlis. electrical injuries. crit care med. 2002; 30: 424-30. http://www.ncbi.nlm.nih.gov/pubmed/8036326 http://www.ncbi.nlm.nih.gov/pubmed/12476114 http://www.ncbi.nlm.nih.gov/pubmed/8036326 http://www.ncbi.nlm.nih.gov/pubmed/8036326 http://www.ncbi.nlm.nih.gov/pubmed/12476114 http://www.ncbi.nlm.nih.gov/pubmed/12476114 http://www.ncbi.nlm.nih.gov/pubmed/15805923 lightning induced ocular complications: a case report pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 52 2. norman me, albertson d, younge br. ophthalmic maniestations of lightning strike. surv ophthalmol. 2001; 46: 19-24. 3. handa jt, jaffe gj. lightning maculopathy. retina. 1994; 14: 164-72. 4. lee ms, gunton kb, fischer dh, brucker aj. ocular manifestations of remote lightning strike. retina. 2002; 22: 808-10. 5. david rl. lightning induced maculopathy. aecs illumination. 2012; 3: 20-22. 6. dimick ar. harrison's principles of internal medicine. in: fauci as, braunwald e, isselbacher kj, wilson jd, martin jb, kasper dl, et al., editors. health professions division. 14th ed. new york: mcgraw-hill. 1998: 2559. 7. rao ka, raolg, kamath an, jain v. bilateral macular hole secondary to remote lightning strike. indian j ophthalmol. 2009; 57: 470-2. 8. duke-elder sir s, macfaul pa. in: system of ophthalmology. duke-elder sir s, editor. vol xiv. london: henry kimpton. 1972; 2: 813-35. 9. biro z, pamer z. electrical cataract and optic neuropathy. int ophthalmol. 1994; 18: 43-7. 10. hanna c, fraunfelder ft. electric cataracts i. sequential changes, unusual and prognostic findings. ii. ultrastructural lens changes. arch. ophthalmol. 1972; 87: 184. 11. wallace jf. harrison's principles of internal medicine. in: braunwald e, isselbacher kj, petersdorf rg, wilson jd, martin jb, fauci as, editors. health professions division. 11th ed. new york: mcgraw-hill. 1987; 859-60. 12. moon sj, kim je, han dp. photo essay on lightning induced maculopathy. retina. 2005; 25: 380–2. microsoft word 15. asima rafique 292 pak j ophthalmol. 2022, vol. 38 (4): 292-295 case report nodular posterior scleritis masquerading as amelanotic choroidal melanoma asima rafique1, muhammad shaheer2, muhammad suhail sarwar3 department of ophthalmology, 1-3mayo hospital, lahore abstract we report a patient of choroidal mass, masquerading as amelanotic choroidal melanoma. a 48 years old male presented in outpatient department (opd) with painless decrease in vision of left eye. fundus examination revealed a two disc diameter, non-pigmented, sub-retinal lesion with approximately 3mm basal diameter, superior to the disc with no choroidal folds, retinal detachment or pigmentation over the lesion. b scan revealed a small nodular thickening superior to the optic nerve head with moderate to low internal reflectively and no choroidal excavation. swept-source optical coherence tomography (ss oct) showed massive elevation of retina due to underlying scleral thickening. he was diagnosed as nodular posterior scleritis (nps). the lesion regressed completely after treatment with topical and systemic non-steroidal anti-inflammatory drugs (nsaids). despite its low prevalence, nps should be kept in differential diagnosis of an amelanotic choroidal mass. key words: scleritis, melanoma, optical coherence tomography. how to cite this article: rafique a, shaheer m, sarwar ms. nodular posterior scleritis masquerading as amelanotic choroidal melanoma. pak j ophthalmol. 2022, 38 (4): 292-295. doi: 10.36351/pjo.v38i4.1392 correspondence: muhammad shaheer department of ophthalmology, mayo hospital, lahore email: mshaheer212@gmail.com received: march 30, 2022 accepted: june 04, 2022 introduction posterior scleritis is a potentially blinding, often misdiagnosed form of scleritis due to its inconsistent manifestations, often labelled as pseudo melanomas.1 most of the cases of posterior scleritis are isolated, but some of the cases can be associated with systemic diseases.2 it can present as diffuse or sectoral scleral involvement. the latter is particularly notorious for resembling choroidal granuloma, hemangioma and most of all amelanotic choroidal melanoma, which can lead to inadvertent treatment options like enucleation, chemotherapy or radiotherapy.3 a case review series of 400 referred ocular oncology patients showed that 1.5% cases of posterior scleritis were misdiagnosed as choroidal melanoma leading to misguided treatment even enucleation.4 the relevant ancillary tests need to be interpreted correctly for making a correct diagnosis. in this case report, we aim to present a case of nps masquerading amelanotic choroidal melanoma, treated successfully with topical and systemic nsaids. case report a 48 years old healthy male presented in opd on january 15th, 2022 with complaints of loss of vision in right eye associated with redness and peri orbital pain for past 3 weeks and painless decrease in vision of his left eye. his past medical and ocular history was not significant. visual acuity in the right eye was normal ‘’perception and projection of light’’ in all four quadrants while best corrected visual acuity (bcva) in the left eye was 6/60. extra ocular motility was normal in all gazes. pupillary reactions were normal in the left eye but could not be elicited in the right eye due to media opacity. however, there was no relevant afferent pupillary defect (apd). examination of right eye showed mild periorbital swelling, diffuse conjunctival injection and hazy cornea with central 2.5 x 3 mm area of corneal thinning. there was shallow anterior chamber, van herick ‘’grade ii’’ and mature cataract. the anterior segment examination of left eye was unremarkable and no inflammatory cells were nodular posterior scleritis masquerading as amelanotic choroidal melanoma pak j ophthalmol. 2022, vol. 38 (4): 292-295 293 noted in the anterior vitreous phase. the intraocular pressure of left eye was 16 mmhg while right eye was digitally soft. the dilated fundus examination of left eye revealed a 2 disc diameter (dd), approximately 3mm in basal diameter, nonpigment, sub-retinal lesion, superior to the disc with superonasal arcade crossing over it (figure 1). there was no evidence of sub retinal fluid, hemorrhages, pigmentary changes, lipofuscin deposition, choroidal folds or disc edema. red free photograph of the left eye depicted a corresponding elevated mass with no overlying vessels (figure 1). figure 1: colored fundus photograph of left eye showing 2 dd of nonpigmented, sub-retinal lesion superior to the disc with superonasal arcade crossing over it (left).red free photograph of left eye showing elevated mass with no overlying vessels (right). figure 2: b scan of left eye showing small nodular thickening of sclera. a scan shows medium reflectivity spikes at sclera-choroidal level. b-scan of left eye revealed a homogenous lesion superior to the optic nerve head with moderate to low internal reflectively suggestive of small nodular scleral thickening approximately 3-4 mm in basal diameter and 1.5 mm in elevation with no exudative retinal detachment, choroidal excavation, collar stud sign, orbital shadowing or definitive t-sign (figure 2). on a-scan, low to medium reflectivity spikes were noted at sclera-choroidal level; approximately 40% or less than the height of retinal spike. swept-source optical coherence tomography (ss oct) revealed elevation of retina due to underlying scleral thickening, with normal choroidal tissue and vasculature and no sub retinal fluid (figure 3). the high resolution ss oct clearly indicates the pathology to be in scleral tissue rather than choroid obliviating the need for invasive test like fundus fluorescein angiography (ffa). figure 3: ss oct of left eye showing elevation of retina due to underlying scleral thickening (left). sequential photographs of ss oct (right). magnetic resonance imaging (mri) of the orbit and brain revealed a focal, elevated, enhancing lesion in the superotemporal part of the left eye bulging into the vitreous cavity. post contrast images depicted diffuse enhancement of the lesion along with enhancement of peri ocular tissue posterior to the globe (figure 4). figure 4: mri scan axial section of brain and orbit revealed focal, elevated lesion bulging into the eyeball (left). post contrast image showing diffuse enhancement of the lesion (right). detailed inflammatory disease workup including erythrocyte sedimentation rate (esr), c-reactive protein (crp), serum angiotensin converting enzyme muhammad shaheer, et al 294 pak j ophthalmol. 2022, vol. 38 (4): 292-295 (ace), quantiferon tb gold standard test, rheumatoid arthritis (ra) factor, antinuclear antibodies (ana) and venereal disease research laboratory (vdrl) for syphilis was done. chest xray was also performed. all tests were unremarkable. the patient was referred to an internist for detailed evaluation. the non-pigmented appearance of the lesion and normal intrinsic choroidal vasculature along with b scan, mri and ss oct findings led to the diagnosis of nps ruling out amelanotic choroidal melanoma. topical nsaids (three times a day) and flurbiprofen tablet 100 mg (twice daily) were advised. oral steroids were avoided due to corneal thinning in the right eye. a temporary tarsorrhaphy was performed in the right eye to prevent inadvertent trauma to eyeball due to blinking. patient was called on follow up after 2 weeks. our case showed that nps can simulate a choroidal tumor. in this case, b scan and ss oct findings led to the diagnosis of nps. however, malignancy could still not be ruled out confidently but complete resolution of lesion with topical and systemic nsaid’s confirmed the diagnosis of nps. discussion posterior scleritis is inflammation of sclera posterior to ora serrata. nps has been reported only as case reports.5 clinically, pain in eye is a common symptom that can lead the ophthalmologist towards the diagnosis of inflammatory disease with conjunctival injection or painful extraocular movements. on fundus examination, absence of halo and no lipofuscin deposition are indicative of nps.6 on reviewing the literature, it has been noted that mean age of presentation of a patient of nps is 50 years with female preponderance.7 the age of the patient is consistent with the available literature; however, there were no complaints of pain or redness. b scan plays a pivotal role in differentiating nps from malignant conditions. malignant melanomas will demonstrate mixed echogenicity with medium to low amplitude echoes and a collar stud shape.8 mri serves as an additional diagnostic modality to differentiate the inflammatory process from malignant lesion. mri of the orbit and brain of our patient revealed a focal, elevated, enhancing lesion in the superotemporal part of the left eyeball bulging into the vitreous cavity.9 ffa has been considered to be diagnostic of choroidal melanoma with characteristic double circulation while such a pattern is absent in case of posterior scleritis. we did not perform ffa in our patient considering it an invasive test because enough information was gathered from b scan, mri and ss oct. in our opinion, oct is a very important diagnostic tool for nps, particularly when the sub retinal mass is not very large. in this particular case, the scans depicted that choroidal tissue was normal and vessels of choroid were of normal configuration.10 treatment options vary according to the severity of disease, which include nsaids to even immunosuppressant. our patient was successfully managed with topical and systemic nsaids for a period of 12 weeks. post treatment visual acuity of the patient improved to counting fingers in the right eye and 6/9 in the left eye. post treatment colored fundus photograph revealed complete resolution of mass (figure 5). it is this therapeutic response which helped to confirm the diagnosis to be of inflammatory nature rather than neoplastic. figure 5: post treatment colored fundus photograph of left eye showing complete resolution of mass. the prognosis of nps is excellent, with no recurrence reported in the literature (table 1). most of the cases respond to systemic steroids with a few cases treated with immunosuppressive agents (table 2). nodular posterior scleritis masquerading as amelanotic choroidal melanoma pak j ophthalmol. 2022, vol. 38 (4): 292-295 295 table 1: literature review of patients with nps: demographics and historical findings. study age gender laterality systemic work up initial visual acuity final visual acuity current case, 2022 48 male u/l -ve 20/200 waleed, 2020 25 male u/l -ve cf 1 foot 20/20 shibata, 2019 59 female u/l hepatitis b 20/200 n/a hatef, 2010 55 female u/l -ve 20/40 20/20 finger, 1990 66 male u/l -ve 20/200 n/a table 2: treatment modalities and outcomes of patients with nps. study management outcome current case, 2022 topical and systemic nsaids resolution waleed, 2020 iv steroids followed by oral steroids and mycofenolate mofetil resolution shibata, 2019 oral steroids (20 mg) resolution hatef, 2010 iv steroids (1g/day) followed by oral steroids (60 mg) + mycofenolate mofetil resolution finger, 1990 enucleation conclusion choroidal mass can present a diagnostic challenge for ophthalmologists. clinical misinterpretation of nps as malignant melanoma can lead to misguided therapy and devastating outcomes, including enucleation. in any instance of diagnostic uncertainity, a trial of antiinflammatory medication may serve as a therapeutic test and help spare patients from unnecessary intervention. conflict of interest: authors declared no conflict of interest. references 1. sin py, liu dt, young al. nodular posterior scleritis mimicking choroidal tumor in a patient with systemic lupus erythematous: a case report and literature review. asia pac j ophthalmol (phila). 2016; 5 (5): 324-329. doi: 10.1097/apo.0000000000000165. 2. lavric a, gonzalez-lopez jj, majumder pd, bansal n, biswas j, pavesio c, et al. posterior scleritis: analysis of epidemiology, clinical factors, and risk of recurrence in a cohort of 114 patients. ocul immunol inflamm. 2016; 24 (1): 6-15. doi: 10.3109/09273948.2015.1005240. 3. shukla d, kim r. giant nodular posterior scleritis simulating choroidal melanoma. indian j ophthalmol. 2006; 54 (2): 120-122. doi: 10.4103/0301-4738.25835. 4. liu at, luk fo, chan ck. a case of giant nodular posterior scleritis mimicking choroidal malignancy. indian j ophthalmol. 2015; 63 (12): 919-921. doi: 10.4103/0301-4738.176038. 5. hage r, jean-charles a, guyomarch j, rahimian o, donnio a, merle h. nodular posterior scleritis mimicking choroidal metastasis: a report of two cases. clin ophthalmol. 2011; 5: 877-880. doi: 10.2147/opth.s21255. 6. sainz de la maza m, foster cs, jabbur ns. scleritis associated with systemic vasculitic diseases. ophthalmology, 1995; 102 (4): 687-692. doi: 10.1016/s0161-6420(95)30970-0. 7. alsarhani wk, abu el-asrar am. multimodal imaging of nodular posterior scleritis: case report and review of the literature. middle east afr j ophthalmol. 2020; 27 (2): 134-138. doi: 10.4103/meajo.meajo_115_20. 8. echography (ultrasound) procedures for the collaborative ocular melanoma study (coms), report no. 12, part ii. j ophthalmic nurs technol. 1999; 18 (5): 219-232. 9. osman saatci a, saatci i, kocak n, durak i. magnetic resonance imaging characteristics of posterior scleritis mimicking choroidal mass. eur j radiol. 2001; 39 (2): 88-91. doi: 10.1016/s0720-048x(01)00278-9. 10. ozkaya a, alagoz c, koc a, ozkaya hm, yazıcı at. a case of nodular posterior scleritis mimicking choroidal mass. saudi j ophthalmol. 2015; 29 (2): 165168. doi: 10.1016/j.sjopt.2014.06.012. authors’ designation and contribution asima rafique; medical officer: concepts, literature search, data acquisition, manuscript preparation, manuscript editing. muhammad shaheer; assistant professor: literature search, data acquisition, manuscript review. muhammad suhail sarwar; professor: data acquisition, data analysis. pak j ophthalmol. 2022, vol. 38 (1): 63-66 63 original article use of triamcinolone acetonide in external dacryocystorhinostomy qirat qurban 1 , zeeshan kamil 2 , khalid mehmood 3 1-3 khalid eye clinic, nazimabad, karachi abstract purpose: to study the effect of triamcinolone acetonide injection into the ostium through the external wound after one week of external dacryocystorhinostomy. study design: quasi experimental study. place and duration of study: khalid eye clinic, karachi, from july 2018 to june 2019. methods: this study included forty patients with age ranging between 18 to 36 years. all patients had obstruction of the nasolacrimal duct. patients were categorized into two groups. both groups underwent external dacryocystorhinostomy with silicone intubation, with the difference being that patients in group a were injected with 20 units of triamcinolone acetonide 40 mg/ml into the ostium through wound using 27 gauge needle, one week after the surgery. group b did not receive any injection. both groups were followed for a period of four months, at which time the silicone tube was removed and patency of lacrimal system was ascertained via syringing with balanced salt solution through the lacrimal puncta. main outcome measure was the success rate of procedure. results: the mean age of the patients was 27.1 ± 5.48 years. success rate was 100% among the patients of group a and 85% in the patients of group b at the end of the four months followup period. however, the results were statistically insignificant (p = 0.115). conclusion: although statistically insignificant but clinically triamcinolone acetonide proved helpful in reducing fibrosis and ostium granuloma formation in patients with ex-dcr. thus preventing failure of external dacryocystorhinostomy. key words: triamcinolone acetonide, external dacryocystorhinostomy, dcr. how to cite this article: qurban q, kamil z, mehmood k. use of triamcinolone acetonide in external dacryocystorhinostomy. pak j ophthalmol. 2022, 38 (1): 63-66. doi: 10.36351/pjo.v38i1.1094 introduction obstruction of the nasolacrimal duct is one of the commonest causes of watery eyes and discharge from correspondence: qirat qurban khalid eye clinic, nazimabad, karachi email: qirat_89@hotmail.com received: july 06, 2021 accepted: december 12, 2021 the lacrimal sac. surgical management of this disorder includes external dacryocystorhinostomy (ex dcr), which is performed by making a skin incision, removing the lacrimal bone, amalgamation of the sac mucosa to the nasal mucosa, followed by intubation with silicone tube, forming a functional passage via the lacrimal sac to the nasal cavity and increasing drainage of the tears in order to relieve watering and improve patient’s distress. 1 it was first introduced by toti in 1904 to allow passage of tears straight into the nasal cavity from the canaliculi through an innovative low-resistance conduit. 2 ex dcr is a cost effective, open access qirat qurban, et al 64 pak j ophthalmol. 2022, vol. 38 (1): 63-66 gold standard procedure in patients with obstruction of the nasolacrimal duct with a success rate of > 90% depending upon the surgeon’s experience. 3 however, the success of ex dcr is difficult to monitor due to lack of standardization of outcome. numerous factors have been discussed which may have an effect on the success rate of ex dcr, such as incision shape, nasal mucosal flaps design, use of mitomycin c (mmc) as an adjunct and use of intubation made of different materials. 4-6 use of intra operative and post operative corticosteroids have beenrecognized to curtailswelling and fibroblast recruitment and diminish scar configuration and resulting in a greater success rate. 7,8 this study was done to find out the effect of postoperative injection of triamcinolone acetonide into the ostium through the external wound after one week of dacryocystorhinostomy. the idea was to suppress fibrosis and granulation tissue formation which are responsible for occlusion of the osteotomy site. this will reduce the failure rate. methods this study was conducted at khalid eye clinic, karachi, from july 2018 to june 2019 and included forty patients with ages ranging between 18 to 36 years. all patients had nasolacrimal duct obstruction (nldo). all patients underwent a thorough ocular assessment prior to the surgery. probing and syringing of the lacrimal drainage system was performed in all the patients to identify the obstruction of nasolacrimal duct and to exclude the canalicular block. patients with one-sided or two – sided obstruction of the nasolacrimal duct (as assessed by irrigation of the nasolacrimal duct), ages between 18 to 36 years, absence of lid or eyelash abnormality and willingness to follow-up for at least 4 months were included in this study. patients with obstruction of the superior or inferior or common canaliculus were excluded from the study. informed verbal consent was obtained and institutional ethical review board approval was taken. patients were randomly divided into two groups and both groups underwent standard external dacryocystorhinostomy with silicone intubation. patients in group a were injected with 20 units of triamcinolone acetonide 40 mg/ml into the ostium via operative site using 27 gauge needle one week after the surgery. group b patients did not receive any injection. both groups were followed for a period of four months, at which time the silicone tube was removed and patency of lacrimal system was ascertained via syringing with balanced salt solution through the lacrimal puncta. main outcome measure was the success rate of procedure assessed by improvement in symptoms (no epiphora) and open dcr fistula checked by syringing at four months post surgery. data was analyzed on spss version 25. results this study included forty patients of age group between 18 to 36 years and divided into two groups. the mean age was 27.1 ± 5.48 years. there were 32 (80%) females and 8 (20%) males. right eye was involved in 18 (45%) cases and left eye in 22 (55%) patients. at the end of four months follow-up, patency of lacrimal system via syringing with balanced salt solution was confirmed in all 20 patients (100%) of group a, whereas 17 out of 20 patients (85%) of group b had a patent lacrimal drainage system. p-value (0.115 by fisher exact test) was not significant. group a patients receiving triamcinolone acetonide injection were of concern to the authors due to steroid related local complications but none of patients of group a reported any complication such as wound infection, wound dehiscence, surrounding fat atrophy or skin depigmentation. mean followup period was 136.6 ± 12.78 days. discussion external dacryocystorhinostomy (ex dcr), despite a very commonly performed procedure sometimes leads to failure. it occurs due to blockage of ostium caused by granulation tissue, scarring and formation of adhesions in the nasal cavity with subsequent signs of disproportionate watering post operatively. it results in failure to drain the tears. 9,10 previous studies have shown that patients who underwent subsequent operation, had a thick scar tissue at the osteotomy site. 11 similarly, it is also reported that the reason of failure of dacryocystorhinostomy was blockage of the drainage conduit by an occluding film composed of organized granulation tissue. 12 thus, reducing fibrous tissue formation at the osteotomy site and the anastomosed flapscan enhance thesuccess of ex dcr. various procedures and adjunctive have been studied to improve the success rate of ex dcr. 13,14 a synthetic corticosteroid, triamcinolone acetonide use of triamcinolone acetonide in external dacryocystorhinostomy pak j ophthalmol. 2022, vol. 38 (1): 63-66 65 (ta), had been used to treat orbital diseases such as thyroid ophthalmopathy, capillary hemangioma of the orbit and idiopathic inflammation of the orbitin the precedent decade. 15,16 studies have demonstrated a significant independent association with failure in revision external dcr. inadequate ostium size was the most common cause of failure in primary external, endonasal, and laser dcr. canalicular or common canalicular obstruction, intranasal pathology, and bilateral lacrimal obstruction were significant predictors of failure in revision external dcr. 17 another researcher used triamcinolone acetonide (ta) soaked gelfoam in dcr nasal septoplasty with a success rate of 96.4%. 18 ninety three percent success rate was reported in another case series using intraoperative ta in endonasal endoscopic dcr. 19 this study observed a 100% success rate following the injection of ta in group a patients. factors responsible for failure of dcr are improper positioning of the rhinostomy, insufficient sac aperture and fibrosis at the ostium. 20 therefore, a good anatomical knowledge is required along with a careful surgery by a skilled surgeon to maximize the success rate. following ex dcr, healing occurs in three steps; inflammation phase, proliferation phase and maturation phase. 10 in this study, we used ta after one week of ex dcr to prevent swelling in the earlystage of wound healing and todecrease the proliferative stage of healing. another study described the use of ta and at the end of the follow-up period of six months, did not report any corticosteroid associated adverse effects such as rise of intraocular pressure, mucosal thinning, skinpigment abnormality or fat wasting. 15 this was in accordance to our study. every study has a different parameter for the definition of dcr success. therefore, it is tricky to weigh against printed accomplishment rates of dcr. in this study, the success of ex dcr surgery was assessed on the basis of improvement of symptoms such as no watering and open lacrimal passageway on syringing at four months post surgery. limitations of this study were less number of patients in the study, single center study and four months followup. further long term followup needs to be done to find out the effectiveness of this technique. conclusion triamcinolone acetonide injection after one week of ex dcr surgery, proved to be safe and successful in reducing fibrosis and ostium granuloma formation with improvement of watering and anatomical patency of inner ostia. although the results were not statistically significant but clinically this technique was helpful in preventing failure of external dacryocystorhinostomy. no major complications associated with triamcinolone acetonide injection were encountered. ethical approval the study was approved by the institutional review board/ethical review board (erc-18-20). conflict of interest authors declared no conflict of interest. references 1. ali mj, naik mn, honavar sg. external dacryocystorhinostomy: tips and tricks. oman j ophthalmol. 2012; 5 (3): 191-195. doi:10.4103/0974620x.106106 2. toti a. endoscopic endonasal dacryocystorhinostomy: our experience clin moderna firenze. 1904; 10: 385387. 3. walland mj, rose ge. factors affecting the success rate of open lacrimal surgery. br j ophthalmol. 1994; 78: 888–891 4. erdöl h, akyol n, imamoglu hi, sözen e. longterm follow-up of external dacryocystorhinostomy and the factors affecting its success. orbit. 2005; 24 (2): 99–102. 5. pandya vb, lee s, benger r, danks jj, kourt g, martin pa, et al., external dacryocystorhinostomy: assessing factors that influence outcome. orbit. 2010; 29 (5): 291–297. 6. seider n, kaplan n, gilboa m, gdal-on m, miller b, beiran i. effect of timing of external dacryocystorhinostomy on surgical outcome. ophthalmic plast reconstruct surg. 2007; 23 (3): 183– 186. 7. waly ma, shalaby oe, elbakary ma, hashish aa. the cosmetic outcome of external dacryocystorhinostomy scar and factors affecting it. indian j ophthalmol. 2016; 64 (4): 261-265. doi:10.4103/0301-4738.182933 8. naik vn, kumar v. intraoperative injection of triamcinolone acetonide in external dacryocystorhinostomy. int j ophthalmol eye res. 2020; 8 (2): 424-428. doi: http://dx.doi.org/10.19070/2332-290x-2000086 qirat qurban, et al 66 pak j ophthalmol. 2022, vol. 38 (1): 63-66 9. ali mj, wormald pj, psaltis aj. the dacryocystorhinostomy ostium granulomas: classification, indications for treatment, management modalities and outcomes. orbit. 2015; 34: 146–151. 10. allen k, berlin aj. dacryocystorhinostomy failure: association with nasolacrimal silicone intubation. ophthalmic surg. 1989; 20: 115–119. 11. deka a, bhattacharjee k, bhuyan sk, barua ck, bhattacharjee h, khaund g. effect of mitomycin c on ostium in dacryocystorhinostomy. clinexp ophthalmol. 2006; 34 (6): 557-561. 12. harish v, benger rs. origins of lacrimal surgery, and evolution of dacryocystorhinostomy to the present. clin exp ophthalmol. 2014; 42 (3): 284-287. doi: 10.1111/ceo.12161. epub 2013 aug 4. pmid: 23845081. 13. kühnel t. erkennung und vermeidung von schwierigkeitenbei der tränenwegschirurgie [recognition and prevention of problems in lacrimal duct surgery]. hno. 2018; 66 (6): 432-437. german. doi: 10.1007/s00106-018-0507-4. pmid: 29761204. 14. roozitalab mh, amirahmadi m, namazi mr. results of the application of intraoperative mitomycin c in dacryocystorhinostomy. eur j ophthalmol. 2004; 14: 461–463. 15. leibovitch i, prabhakaran vc, davis g, selva d. intraorbital injection of triamcinolone acetonide in patients with idiopathic orbital inflammation. arch ophthalmol. 2007; 125: 1647–1651. 16. ebner r, devoto mh, weil d, bordaberry m, mir c, martinez h, et al. treatment of thyroid associated ophthalmopathy with periocular injections of triamcinolone. br j ophthalmol. 2004; 88 (11): 13801386. doi: 10.1136/bjo.2004.046193. pmid: 15489477; pmcid: pmc1772392. 17. meryem ea, seyda ku, hasan a, sevinc sa. failure in revision dacryocystorhinostomy: a study of surgical technique and etiology. j craniofac surg. 2020; 31 (1): 193-196. doi: 10.1097/scs.0000000000005829 18. kang ts, won yk, kim jy, kim kn, lee sb. efficacy of triamcinolone-soaked nasal packing on endoscopic dacryocystorhinostomy. ophthalmic plast reconstr surg. 2021; 37 (3s): s44-s47. doi: 10.1097/iop.0000000000001791. pmid: 32773515. 19. li ey, cheng ac, wong ac, sze am, yuen hk. safety and efficacy of adjunctive intranasal mitomycin c and triamcinolone in endonasal endoscopic dacryocystorhinostomy. int ophthalmol. 2016; 36 (1): 105-110. doi: 10.1007/s10792-015-0088-0. epub 2015 may 26. pmid: 26003991. 20. ghasemi h, asghariasl s, yarmohammadi me, jafari f, izadi p. external dacryocystorhinostomy; success rate and causes of failure in endoscopic and pathologic evaluations. iran j pathol. summer, 2017; 12 (3): 189-194. epub 2017 jul 1. pmid: 29531542; pmcid: pmc5835365. authors’ designation and contribution qirat qurban; consultant ophthalmologist: concepts, design, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing. zeeshan kamil; consultant ophthalmologist: concepts, design, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing. khalid mehmood; consultant ophthalmologist: data acquisition, manuscript review. .…  …. pak j ophthalmol. 2022, vol. 38 (1): 67-70 67 original article effect of supra-choroidal triamcinolone injection on best-corrected visual acuity and central retinal thickness in patients with macular edema secondary to retinal vein occlusion irfan muslim 1 , nasir chaudhry 2 , rana muhammad mohsin javed 3 1-3 king edward medical university, mayo hospital lahore abstract purpose: to find out the effect of suprachoroidal triamcinolone injection on best corrected visual acuity (bcva) and central retinal thickness (crt) in patients with macular edema secondary to retinal vein occlusion. study design: interventional case series. place and duration of study: college of ophthalmology and allied vision sciences, ophthalmology department, unit ii mayo hospital, lahore, from september 2019 to january 2020. methods: this study included 45 patients diagnosed with unilateral, retinal vein occlusion associated with macular edema. patients with previous anti-vascular endothelial growth factor injection or any steroid injection received in the last 3 months or macular edema due to any other cause were excluded from the study. only one eye of each patient was enrolled. the patients were treated with suprachoroidal triamcinolone injection (4 mg/ 100µl concentration). patients with baseline central retinal thickness (crt) of > 300 µm were included in the study. serial changes in this parameter were evaluated at 1 week, 1 month and 3 months after suprachoroidal triamcinolone injection. final crt and best-corrected visual acuity (bcva) was recorded after three months. results: out of 45 patients, 26 (57.7%) were males and 19 (42.2%) were females. majority of the patients (35.4%) were 51–60 years old. during first week the visual acuity was 0.321 ± 0.273 logmar, after one month it was 0.468 ± 0.291 and 0.406 ± 0.318 after 03 months with a p value of 0.003. after three months significant decrease in crt was observed. with a p-value of 0.002. conclusions: suprachoroidal injection significantly improves bcva and decreases crt in patients with macular edema due to retinal vein occlusion. keywords: retinal vein occlusion, suprachoroidal injection, triamcinolone acetonide. how to cite this article: muslim i, chaudhry n, javed rmm. effect of supra-choroidal triamcinolone injection on best corrected visual acuity and central retinal thickness in patients with macular edema secondary to retinal vein occlusion. pak j ophthalmol. 2022, 38 (1): 67-70. doi: 10.36351/pjo.v38i1.1347 correspondence: irfan muslim department of ophthalmology king edward medical university mayo hospital, lahore email: dr.irfanmuslim@gmail.com received: november 18, 2020 revised: november 17, 2021 accepted: december 12, 2021 introduction among the leading causes of retinal vascular disorders is retinal vein occlusion. reason for macular edema and vision loss include retinal vascular congestion, endothelial damage, epithelial tissue damage and inflammatory cytokines in patients with brvo and crvo (branch and central retinal vein occlusion). current treatment of choice for macular edema open access https://doi.org/10.36351/pjo.v38i1.1347 irfan muslim, et al 68 pak j ophthalmol. 2022, vol. 38 (1): 67-70 associated with rvo include anti-vascular endothelial growth factor agents or steroids. 1 in both brvo and crvo, macular edema (me) is the commonest complication and is a definite cause of significant loss of vision in both cases. 2,3 the basic pathogenesis of macular edema in such cases is abnormal blood vessels due to release of cytokines (such as vegf and interleukins), and cellular inflammatory mediators (such as inter cellular adhesion molecule). 4 all of these lead to retinal ischemia that ultimately compromises retinal function. our abilities are limited to measure these mediators in vivo. however, me (in the form of central retinal thickness) can be gauged with optical coherence tomography (oct). 5 decrease in central retinal thickness (crt) is taken into account as a measure of the treatment success and is associated with improvements in bcva. in geneva trial it has been established that the utilization of ozurdex (dexamethasone implant) is associated with improvements in macular edema caused by central retinal vein occlusion and branch retinal vein occlusion. in both cases the crt and bcva was improved. 6,7 in hulk trial, it was established that using suprachoroidal triamcinolone injection in diabetic macular edema resulted in improvement in bcva and decrease in crt with low rate of adverse effects. however, treatment naïve eyes showed better bcva than those which were previously treated for diabetic macular edema (with antivegf or lasers). 8 suprachoroidal injection of steroids minimizes the amount of steroids in anterior chamber of the eye while therapeutic effect of the drug on retina is good. the adverse effects of steroids for example cataract and glaucoma are minimal. 9 as data in this regard is scarce in our setup, we tried to find out the effects of suprachoroidal triamcinolone injection on bcva and crt. methods this study was conducted in ophthalmology department unit ii, institute of ophthalmology, mayo hospital lahore. all patients provided informed consent before performing the procedure. institutional review boards approved the study and data was collected from august 2019 to january 2020. we evaluated 45 patients diagnosed with unilateral, retinal vein occlusion associated with macular edema. patients with retinal vein occlusion of less than/equal to 12 months duration, bcva (best corrected visual acuity) of 20/50 to 20/200 and crt of more than 300 µm as measured by oct were included in the study. patients with previous anti-vascular endothelial growth factor injection or any steroid injection received in the last 3 months or macular edema due to any other cause were excluded from the study. only one eye of each patient was enrolled. complete history was taken and ocular examination was performed which included bcva, iop, slit lamp examination and fundoscopy. me (macular edema) as a result of retinal vein occlusion was assessed by edi-oct (enhanced depth imaging optical coherence tomography). each patient received one suprachoroidal injection of triamcinolone suspension of 4 mg/100 µl concentration. disposable 1 ml syringes with 30 gauge needle attached via luer lock microinjector (clear side biomedical inc. alpharetta, ga) were used for suprachoroidal injections. 6 the injection side was 4 mm behind the limbus about 200–300 µm anterior to retina. the follow-up examinations were scheduled to be on 1 week, one month and 3 months. results out of 45 patients 26 (57.7%) were males and 19 (42.2%) were females. results of table 1 show the age distribution of 45 patients. table 1: age distribution of participants. age distribution percentage 30 — 40 years 19.6% 41—50 years 21.1% 51— 60 years 35.4% 16 — 70 years 24.3% table 2: comparison of variables at different times of followup. baseline 1 week 1 month 3 months p value bcva (logmar) 0.321 ± 0.273 0.468 ± 0.291 0.406± 0.318 0.003 crt, um 325.1 ± 74.2 305.2 ± 89.3 289 ± 47.5 0.002 mean pre-injection visual acuity was 0.241±0.254 logmar and post injection visual acuity was 0.406 ± supra-choroidal triamcinolone injection in patients with macular edema pak j ophthalmol. 2022, vol. 38 (1): 67-70 69 0.318 logmar. there was a significant improvement in visual acuity after the injection with a p value of 0.003, which was statistically significant. mean pre injection crt was 342.2 ± 40.2 um and post injection crt was 289 ± 47.5 um with a p value of 0.002, which was also statistically significant. discussion there are multiple causes of me due to rvo that include ischemia, turbulent flow at the arteriovenous crossing and other vessel wall characteristics that cause instability of fluids in the vessels. 5 different modes of drug delivery to the retina have been in use. the usual treatment of me after rvo is by anti-vegf injections given monthly, 6 substituted by intravitreal steroids 7 in those cases where anti-vegf has not been responding or is contraindicated. however, these intravitreal steroids have potential complications. drug delivery to suprachoroidal space is important as it can maximize the drug delivery to retina and other posterior segment tissues while minimizing the drug exposure to anterior chamber and lens avoiding the potential complications. 10 in this particular study, better visual and anatomical results were seen after 3 months follow-up with respect to baseline bcva and crt after suprachoroidal injections of triamcinolone. recent reports suggested that crt decreases and significant improvement in bcva occurs in patients with me secondary to retinal vein occlusion. 11 in patients with rvo and me, the choroidal thickness was also increased which was reduced with suprachoroidal injection. however there are also some reports of choroidal thinning after intravitreal steroid and anti-vegf injections. 12,13 studies have shown that intravitreal steroid injections cause raised iop. 14 after suprachoroidal injection, the drugs get rapidly dispersed in the suprachoroidal space and this leads to minimal change in aqueous humor drainage or production. 15 thus the side effects associated with other modes of delivery of steroids are minimized by this method. 16.17 other studies have also shown many benefits of this drug delivery method which include less chance of iop elevations, negligible incidence of glaucoma and cataract and more sustained release of drug at potential action site. 18,19 nevertheless, further investigation is the need of time as this is a new drug delivery method. 20 a study was conducted to treat me in rvo with combination of suprachoroidal injection of triamcinolone and intravitreal aflibercept. it was concluded that this combination had superior results as compared to intravitreal aflibercept alone in 3 months follow-up in terms of crt and visual acuity improvements. 21 our results were approximately same at 3 months follow-up without aflibercept. limitations of this study are it was not a comparative study. we have presented a case series of small sample. follow up was also only for three months. further studies are needed to see the effects of multiple injections of triamcinolone with longer follow-ups. ethical approval the study was approved by the institutional review board/ ethical review board. 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for health-care reform. diabetes care, 1994; 17 (8): 909–917. 15. hoerauf h, feltgen n, weiss c, paulus e, schmitzvalckenberg s, pielen a, et al. reply. am j ophthalmol. 2016; 169: 292–3. 16. huynh e, chandrasekera e, bukowska d, mclenachan s, mackey da, chen fk. past, present, and future concepts of the choroidal scleral interface morphology on optical coherence tomography. asia pac j ophthalmol (phila). 2017; 6 (1): 94–103. 17. yiu g, pecen p, sarin n, chiu sj, farsiu s, mruthyunjaya p, et al. characterization of the choroid-scleral junction and suprachoroidal layer in healthy individuals on enhanced-depth imaging optical coherence tomography. jama ophthalmology, 2014; 132 (2): 174–181. 18. emi k, pederson je, toris cb. hydrostatic pressure of the suprachoroidal space. invest ophthalmol vis sci. 1989; 30 (2): 233–238. 19. jordan jf, engels bf, dinslage s, et al. a novel approach to suprachoroidal drainage for the surgical treatment of intractable glaucoma. j glaucoma, 2006; 15 (3): 200–205. 20. einmahl s, savoldelli m, d'hermies f, tabatabay c, gurny r, behar-cohen f. evaluation of a novel biomaterial in the suprachoroidal space of the rabbit eye. invest ophthalmol vis sci. 2002; 43 (5): 1533– 1539. 21. willoughby as, vuong vs, cunefare d, farsiu s, noronha g, danis rp, et al. choroidal changes after suprachoroidal injection of triamcinolone acetonide in eyes with macular edema secondary to retinal vein occlusion. am j ophthalmol. 2018; 186: 144-151. authors’ designation and contribution irfan muslim; senior registrar: concepts, design, literature search, final approval of the manuscript nasir chaudhry; head of department: data acquisition, data analysis, statistical analysis, final approval of the manuscript rana muhammad mohsin javed; assistant professor: data acquisition, data analysis, statistical analysis, final approval of the manuscript. .…  …. pak j ophthalmol. 2021, vol. 37 (4): 424-427 424 brief communication challenges and future implications for ophthalmologists in covid-19 environment ambreen gul 1 , maryam noor 2 , fuad ahmad khan niazi 3 1-3 department of ophthalmology, rawalpindi medical university, rawalpindi abstract in this brief communication, we have highlighted the challenges confronted by ophthalmologists during covid-19 pandemic and formulated steps to develop a comprehensive strategy towards minimizing risk of infection transmission between health care workers and patients. to reduce the risk of cross infection, screening and triaging of the patients was done at very initial stage with only high risk patients (red category) were seen directly on slit lamp biomicroscope with ppe. green and yellow category (low risk) patients were seen via teaching aids or lcds and telemedicine methods. elective surgeries were postponed. less number of attendants were allowed with the patients. continued teaching services for undergraduate and post graduate students were done by online methods like zoom or microsoft teams meeting. departmental meetings were planned via video conferencing (zoom or microsoft teams). recommendations are made in this article to ensure safe access to specialized health care in face of covid-19 pandemic. key words: covid-19, personal protective equipment, ophthalmologists, pandemic, health care workers. how to cite this article: gul a, noor m, niazi fak. challenges and future implications for ophthalmologists in covid-19 environment. pak j ophthalmol. 2021, 37 (4): 424-427. doi: 10.36351/pjo.v37i4.1254 introduction covid-19 has spread globally and in pakistan, the first case was reported in karachi on february 26 th , 2020. since then the virus had spread across all regions thus becoming an epidemic. 1 human to human transmission occurs mainly through respiratory droplets and less likely from tears as well as conjunctival secretions of infected patients. 2 as ocular secretions of symptomatic as well as asymptomatic patients harbor active virus, it is apparent that ophthalmologists are particularly at risk. 3 centers for disease control (cdc) defines close correspondence: ambreen gul department of ophthalmology rawalpindi medical university, rawalpindi email: amber-gul@hotmail.com received: april 20, 2021 accepted: september 23, 2021 contact as less than 2 meters (within 6 feet) from an infected patient for a prolonged duration. 4 risk to ophthalmologists is significantly enhanced due to close vicinity to patients during examination, vulnerability to droplet transmissions from tears, conjunctival secretions and the necessary physical contact with patients’ eyes. 5 on 7 th february, dr li, an ophthalmologist at wuhan died of acquiring novel corona virus while dr. li warned his colleagues that they should wear personal protective equipment. two other ophthalmologists from the central hospital of wuhan, had also passed away from this virus highlighting the challenges faced by ophthalmologists in this pandemic. 5 holy family hospital is one of the largest public sector hospitals in twin cities and it is also the main screening and management center for covid-19 patients in rawalpindi. crowded opd with average of 500 out-patients per day, difficulty in maintaining appropriate physical distance owing to slit lamp open access ambreen gul, et al 425 pak j ophthalmol. 2021, vol. 37 (4): 424-427 examination and direct fundoscopy, doing other prolonged outpatient laser procedures like yag capsulotomy and argon laser photocoagulation, visit to other wards including covid-19 isolation wards to attend emergency cases and most importantly nonadherence of general population to recommended preventive measures were the challenges. as major proportion of eye clinic patients are elderly with multiple comorbidities, attendants cannot be prevented from accompanying them. reducing the volume of clinics was done with one patient at a time; patient advised to come alone or only one support attendant to avoid overcrowding at waiting places. with high volume clinics, aerosol transmission is increased due to prolonged exposure to the high concentrations of droplets in relatively closed environments. therefore, proper ventilation of room was made mandatory. it is recommended by american academy of ophthalmology to protect eyes along with mouth and nose while dealing covid-19 infected or suspected patients. 6 typical protocol for all clinical staff was wearing of surgical masks and protective goggles or face shields to avoid inadvertent exposure of health care workers to asymptomatic cases of covid-19. ophthalmology practice is exclusive as it involves frequent use of high touch equipments and surfaces. a-scan, b-scan, goldman applanation tonometer, fundus contact lenses, eye drop bottles, forehead and chin rests and other diagnostic procedures require contact with conjunctival and ocular secretions directly or indirectly. all these frequently touched surfaces serve as hot-beds making them potential source of iatrogenic infection transfer. 7 aerosol generating procedures such as non-contact tonometry should be avoided. cleaning and disinfection of the equipment and frequently touched surfaces should be done with alcohol based solutions, 70% ethanol or isopropanol or diluted bleach. 7 ophthalmic consultation also requires multiple investigations which include visual acuity testing, iop measurements, pupillary dilation and fundus evaluation which leads to prolonged stay of patient leading to increased risk of cross infection. ophthalmologists need to practice social distancing along with wearing ppe and surgical masks. in outpatient department, effective screening and triage should be done according to complaints. red category patients are high risk requiring face to face examination such as open globe injuries, lid lacerations, blunt trauma, acute angle closure glaucoma, neovascular glaucoma, retinal detachment, acute corneal hydrops and keratitis. these cases were directly dealt by ophthalmologists on slit lamp. yellow and green category patients are intermediate and low risk with refractive errors, cataracts, open angle glaucoma patients with controlled iops stable diabetic retinopathy and conjunctivitis. these were rescheduled and provided telemedicine care. history of travel or contact with covid-19 case and upper respiratory tract infection were ruled out at opd counter. those who were cleared were again triaged at out-patient registration counter according to their complaints. those patients who were positive for any of above criteria were labelled as suspected cases and sent to separate room and were reassessed for need of urgent consultation or not. if needed, they were examined by ophthalmologist with proper ppe donning and were advised isolation protocols. direct ophthalmic consultations were only for red category. at filter clinics, run by senior doctors, follow-up of patients were dealt with and medications were advised to the yellow and green category patients. our outpatient influx was significantly reduced to half during this period. the department was providing them telemedicine care via whatsapp, skype calls or hospital administration. cross infection was avoided by little interaction of indoor and outdoor patients. indoor patients were examined only at bed side and if they required specific investigations from diagnostic equipment at outpatient area, they were kept in separate room. interdisciplinary referral from different departments were given separate timeframes to minimize the risk of cross infection. procedures done under general anesthesia require endotracheal intubation and manual ventilation, these are aerosol generating procedures posing the health care workers to acquiring respiratory tract infections 8 . therefore, only emergency procedures requiring intubation were performed and elective general anesthesia procedures were postponed and rescheduled by administrative section and unit receptionists 9 . elective general anesthesia procedures were only performed if covid-pcr was negative. daily surgeries rate was reduced to almost 60%. for surgical procedures such as probing and syringing along with dacryocystorhinostomy, wearing of face masks n95 along with goggles and face shields was mandatory. anterior segment surgeries like challenges and future implications for ophthalmologists in covid-19 environment pak j ophthalmol. 2021, vol. 37 (4): 424-427 426 cataract and posterior segment vitreoretinal procedures utilizing phacoemulsification probe and high-speed vitrectomy cutters are all aerosol generating procedures. hence, eye protection via protective goggles, face shields and filtering face piece with 3 respirators were recommended for surgeons and assistant staffs. masks with better filter efficacy, surgical/latex gloves, face shields, disposable gowns coveralls, eye protective goggles and slit lamp guards/shields are recommended personal protective equipment for ophthalmologist. 8 we also recommend use of mask for all patients and their attendants visiting out patients departments. protection against virus is even more complicated due to difficulty to use protective equipment including face shields and goggles during procedures on slit lamp and microscope because of fogging and depth perception issues. high turnover of patients in clinics was managed by putting cross marks on every alternate seat in patient waiting areas and marking circles on floor for safe distance queuing of patients. morning meetings and department sessions were cancelled. 10 indoor clinical rounds were limited to average of 4 – 5 persons. seating was distanced and tea times were segregated. video conferencing zoom or microsoft teams were used for monthly departmental meetings. undergraduate and postgraduate teachings including class lectures and clinical classes were continued via microsoft teams meetings. online clinical ward tests and monthly theory tests were planned according to microsoft forms software with fair continuation of educational activities. virtual conferences and webinars were planned by institution for continuing learning throughout the pandemic. departmental communication was continued through whatsapp groups and emails. this allowed propagation of important information at larger groups. in addition to all this, there were lots of psychological stresses faced by health care workers due to this pandemic hence immediate psychologists’ referral along with psychiatric consultations were planned for counseling sessions and stress coping therapies. 11 furthermore, self-help methods to reduce stresses were practiced. in current pandemic of covid-19, imperative contemplations were described for ophthalmologists in this article. initial importance was given to reduce infection transmission and to protect both patients and healthcare workers. long term strategies for sustainable clinical and surgical eye health care and teaching services were devised. the aim was to maintain safe access to eye care while preventing the disease outbreak. references 1. covid 19 situation. available at: https://covid.gov.pk/stats/pakistan . accessed july 8, 2020. 2. young be, ong swx, kalimuddin s, low jg, tan sy, loh j, et al. epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore. jama. 2020; 323 (15): 1488-1494. 10.1001/jama.2020.3204 3. amesty ma, alió del barrio jl, alió jl. covid-19 disease and ophthalmology: an update. ophthalmol ther. 2020; 9 (3): 1–12. doi:10.1007/s40123-020-00260-y 4. veritti d, sarao v, bandello f, lanzetta p. infection control measures in ophthalmology during the covid19 outbreak: a narrative review from an early experience in italy. eur j ophthalmol. 2020; 30 (4): 621–628. doi:10.1177/1120672120927865 5. li j-po, lam dsc, chen y, ting dsw. novel coronavirus disease 2019 (covid-19): the importance of recognising possible early ocular manifestation and using protective eyewear. br j ophthalmol. 2020; 104 (3): 297–298. doi:10.1136/bjophthalmol-2020-315994 6. american academy of ophthalmology (aao). important coronavirus updates for ophthalmologists; september 5, 2020. available from: https://www.aao.org/headline/alert-importantcoronavirus-context. accessed october1, 2020. 7. jammal hm, alqudah nm, khader y. awareness, perceptions, and attitude regarding coronavirus disease 2019 (covid-19) among ophthalmologists in jordan: cross-sectional online survey. clin ophthalmol. 2020; 14: 2195–2202. doi:10.2147/opth.s260460 8. chandra s, flanagan d, hingorani m, lotery a. covid19 and ophthalmology: a brief summary of the literature. eye, 2020; 34 (7): 1-3. 10.1038/s41433-0200956-3. 9. tsao hm, sun yc, liou dm. a rational approach to estimating the surgical demand elasticity needed to guide manpower reallocation during contagious outbreaks. plos one, 2015; 10 (4): e0122625. doi: 10.1371/journal.pone.0122625. 10. ahmed f, zviedrite n, uzicanin a. effectiveness of workplace social distancing measures in reducing influenza transmission: a systematic review. bmc public health, 2018; 18 (1): 518. doi: 10.1186/s12889018-5446-1 https://www.aao.org/headline/alert-important-coronavirus-context https://www.aao.org/headline/alert-important-coronavirus-context ambreen gul, et al 427 pak j ophthalmol. 2021, vol. 37 (4): 424-427 11. nickell la, crighton ej, tracy cs, al-enazy h, bolaji y, hanjrah s, et al. psychosocial effects of sars on hospital staff: survey of a large tertiary care institution. cmaj. 2004; 170 (5): 793–798. doi: 10.1503/cmaj.1031077. authors’ designation and contribution ambreen gul; assistant professor: concepts, design, literature search, manuscript preparation, manuscript editing, manuscript review. maryam noor; post graduate trainee: concepts, literature search, manuscript review. fuad ahmad khan niazi; professor: concepts, manuscript preparation, manuscript editing, manuscript review. .…  …. pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 91 original article fixed dose botulinum toxin therapy for blepharospasm muhammad moin, saher khalid pak j ophthalmol 2016, vol. 32 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: saher khalid post-graduate resident department of ophthalmology ameer ud din medical college postgraduate medical institute lahore email. viakhan123@gmail.com received: december 14, 2015 accepted: june 5, 2016 \ …..……………………….. purpose: to find the efficacy of a fixed dose of botulinum toxin a for the treatment of blepharospasm. study design: quasi experimental study. place and duration of study: yaqin vision clinic, lahore from (august 2010 – august 2015). material and methods: all patients of blepharospasm treated with botulinum toxin included in the study were assessed on first visit for the presence of blepharospasm and graded into 4 patterns from mild to severe. ocular examination was done to rule out any cause of secondary blepharospasm due to trichiasis or entropion. ct or mri scan was performed to rule out any neurological cause of the disease. injections were given at 7 periocular sites in a fixed dose. follow up was done at 2 weeks, 6 weeks and 3 months. results: there were 53 cases of blepharospasm, 27 males and 26 females, which were treated with botulinum toxin. average age of the patients was 55.3 +/8.4. out of these only 34 patients (64%) had regular injections while 19 patients (36%) had only one injection and did not turn up for further treatment. average number of injections given to each patient was 5.5 +/4.7. the average duration of relief of symptoms was 3.1 +/1 month with 25 units of botulinum toxin at 7 periocular sites on each side. relief of symptoms started after 3.6 +/ 1.8 days in most of the patients. pre-op 23 patients had moderate and 11 had severe spasms. average spasms at 1 month post injection were slight to mild with better response in patient with moderate pre-op spasms. one patient each had post injection headache and drooping of lid after injection. conclusion: fixed dose therapy gives satisfactory results in patients with moderate blepharospasm. key words: to severe botolinum toxin, blepharospasm, injections. lepharospasm is characterized by abnormal, involuntary over contraction of orbicular muscle and occasionally underlying aetiology is basal ganglia disease1. blepharospasm affects women more commonly than men by a 3:1 ratio and has an onset in the sixth decade2. increased frequency of blinking, eyelid spasm, mid facial or lower facial spasm, eyelid tics and involuntary chronic contractions affecting both eyes are the main symptoms of blepharospasm. in cases with blepharospasm, reading, writing and driving becomes difficult for the patient because of spasms of the orbicular muscle causing closure of both eyelids3 leading to a disaster effect on the quality of life4. botulinum toxin a (botox a, allergan) prevents acetylcholine secretion from pre synaptic vesicles thus causing neuromuscular blockade. due to its efficacy and safety, botulinum toxin a is the only best therapy for blepharospasm now-a-days5. b mailto:viakhan123@gmail.com muhammad moin, et al 92 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology botulinum toxin is an expensive drug therapy for patients with blepharospasm in our country. therefore the rationale of our study was to assess the results of fixed dose (50 units for both sides) therapy with botulinum toxin in all patients presenting with blepharospasm. this treatment regimen is the most economical as the injection cost can be shared between two patients. materials and methods the study was prospective case series conducted in the last 5 years (august 2010-august 2015) at yaqin vision clinic, lahore. patients of all ages with essential blepharospasm) were included in the study patients who were non-willing, had neurologic or psychiatric disease, and had history of eyelid surgery on initial presentation were excluded from the study. preinjection ct/mri was done in all patients to rule out any neurological cause of the disease. informed consent was taken from all the patients and they were explained about the procedure and the study. standard precautions of injecting botox injection were taken and 7 periocular sites were selected e.g. nasally and temporally in upper brow, upper lid (pre-tarsal area), lower lid (pre-tarsal area) and one below lateral canthus on the orbital rim. these patients were seen on follow up after one week, 6 weeks and at 3 months. results there were 53 cases of blepharospasm, 27 males and 26 females, which were treated with botulinum toxin. average age of the patients was 55.3 +/8.4. severity of blepharospasm at initial visit and average 4 years response at 1 month is given in table 1 and grade of orbicularis tone is given in table 2. twenty five units of botulinum toxin were distributed over 7 periocular sites in fixed doses (fig. 1). out of these only 34 patients (64%) had regular injections while 19 patients (36%) had only one injection and did not turn up for further treatment. average number of injections given to each patient was 5.5 +/4.7 (fig. 2). the average duration of relief of symptoms was 3.1 +/1 month with 25 units of botulinum toxin at 7 periocular sites on each side. relief of symptoms started after 3.6 +/ 1.8 days in most of the patients. average spasms at 1 month post injection were slight to mild with better response in patient with moderate pre-op spasms. one patient had post injection headache. one patient had drooping of lid after injection. table 1: severity of blepharospam pre op and post injection after 1 month. grade clinical features pre-op n (%) average post-op 1 month (n%) 0 none 0 21 (61) 1 slight. increase blinking in response to external stimulus 0 10 (30) 2 mild, spontaneous lid flutter 0 3 (9) 3 moderate, very noticeable spasm of eyelids only 23 (67) 4 severe, incapacitating eyelids and facial muscles spasm. 11 (32) table 2: grades of orbicularis tone at initial presentation. grade clinical features no. of patients n (%) 0 incomplete closure of eyelids 0 1 eyelids just closing with minimal resistance 0 2 good eyelids closure with some resistance 0 3 strong eyelids closure but can be overcome with difficulty 0 4 very strong closure of eyelids that cannot be overcome 18 (100) discussion benign essential blepharospasm (beb) is 2 – 3 times more common in women than men and more so in people over the age of 50 years6. but in our study we found males were affected slightly more probably due to easy access of males to medical examination. postmenopausal women using phenothiazine’s and with thyroid dysfunction are more prone to develop beb7. incidence of blepharospasm in usa is 2000 cases annually while prevalence is 1.6-30/100,0008. fixed dose botulinum toxin therapy for blepharospasm pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 93 fig 1: periocular sites for botulinum toxin injection. fig. 2: number of injections in each patient (n = 34). clostridium botulinum is the bacterium which produces botulinumtoxin. the fda approved its usage in the late 1980s when they discovered that botulinum toxin could help in diseases like blepharospasm (uncontrolled blinking) and strabismus (lazy eye)9. in april 2002, fda approved it for the treatment of glabellar lines as well10. but it can be used for other areas of the face as well. blepharospasm and dystonia of muscles of the face and neck are not only the source of physical discomfort but also result in significant social blemishers. best available treatment is botulinum toxin injection into the muscles11. response is best in pure essential blepharospasm. duration of action is variable ranging from 6 weeks to 6 months. because of financial constraints, many patients cannot afford to have repeated injections. oral medication including tri-cyclic anti-depressants and anti-cholinergic have been tried but the results are not very encouraging12. in our study some of the patients had tried these medications with poor results. botulinum toxin is available in pakistan13. one vial contains 100 units for one patient and is quite expensive. we shared one vial between 2 patients by using a fixed dose treatment of 50 units which was more economical for the patient. other studies have reported this as well13. it is injected in pretarsal and preseptal regions of the eyelids for the treatment of blepharospasm. one of its complication is that when we inject it in the upper lid, it can migrate to the orbit and can lead to temporary ptosis. it is highly recommended that the toxin dose should not exceed 200 iu in a 1 month period and the injection should not be repeated before 90 days. we preferred the pretarsal injection as in other studies because with site of injection there are few complications due to less diffusion into the levator muscle14. it has been stated in different studies that the initial dose of botulinum toxin is between 1.25 – 5 units for the treatment of blepharospasm at each site15. in our patients, the dose that was enough for all patients was 2.5 to 5 units at each site. in our study, although the treatment needed to be repeated after every 90 days but we found botulinum very effective in the control of blepharospasm. the sign and symptom free duration with every injection remained same over the long term treatment. almost same results are found in studies carried out by ainsworth, burns and czyz16. our patients were satisfied because of better quality of life, both socially and physically due to its long symptom free periods. our experience was similar from studies carried out at other centers where blepharospasm disability index (bsdi) scoring was done17. a national study having 4 patients of belpharospasm found botulinum toxin effective in its treatment.13 same results were also shown by iwashige18, parsuad r19 and park yc20. our study has some limitations like low patient compliance, due to infrequent referrals from other centres of the country. conclusion the therapeutic use of botulinum toxin for the diseases of the face and periocular region is safe, muhammad moin, et al 94 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology repeatable and temporarily effective. patients should be selected carefully and before injection potential complications should be discussed with the patient thoroughly. botulinum toxin type a is the standard treatment of choice as the first line therapy for essential blepharospasm. the only drawback is that the effect wears off in about 3 months and the injections need to be repeated every 12 weeks. this demands good counselling by the doctor and patients’ motivation and affordability. author’s affiliation prof. muhammad moin department of ophthalmology ameer ud din medical college postgraduate medical institute lahore dr. saher khalid pgr ophthalmology lahore general hospital, lahore role of authors prof. dr. muhammad moin data collection, data analysis, critical review dr. saher khalid manuscript writing and literature review references 1. grandas f, elston j, quinn n, marsden cd. blepharospasm: a review of 264 patients. j neurol neurosurg psychiatry. 1988; 51: 767–72. 2. anderson rl, patel bc, holds jb, jordan dr. blepharospasm: past, present, and future. ophthal plast reconstr surg. 1998; 14: 305-17. 3. jankovic j, havins we, wilkins rb. blinking and blepharospasm. mechanism, diagnosis, and management. jama. 1982; 248: 3160–4. 4. reimer j, gilg k, karow a, esser j, franke gh. health – related quality of life in blepharospasm or hemifacial spasm. actaneurol scand. 2005; 111: 64–70. 5. ozkan sb, can d, söylev mf, arsan ak, duman s. chemodenervation in treatment of upper eyelid retraction. ophthalmologica. 1997; 211: 387–90. 6. holds jb, white gl, thiese sm, anderson rl. facial dystonia, essential blepharospasm and hemifacial spasm. am fam physician. 1991; 43: 2113–20. 7. jankovic j, hallet m. therapy with botulinum toxin. new york, hong kong: marcel dekker. 1994; 191–7. 8. hallett m, evionger c, jankovic j, stacy m. update on blepharospasm. report from the bebrf international workshop. neurology. 2008; 71: 1275-82. 9. gürsoy d, öztürk s. botox treatment and common treatment indications. turkiyeklinikleri j med sci. 2009; 29: 102–3. 10. karp bi, alter k. botulinum toxin treatment of blepharospasm, orofacial/oromandibular dystonia and hemifacial spasm. semin neurol. 2016; 36: 84-91. 11. osaka m. botulinum toxin in ophthalmology. survophthalmol 1991; 36: 28-46. 12. mauriello ja jr1, dhillon s, leone t, pakeman b, mostafavi r, yepez mc. treatment selection of 239 patients with blepharospasm and meige syndrome over 11 years. br j ophthalmol. 1996; 80: 1073-6. 13. shoaib kk, haq i, khan md. use of botulinuma toxin (botox) in different types of facial dystonia. j coll physicians surg pak. 2009; 19: 742–43. 14. cakmur r, ozturk v, uzunel f, donmez b, idiman f. comparison of preseptal and pretarsal injections of botulinum toxin in the treatment of blepharospasm and hemifacial spasm. j neurol. 2002; 249: 64–8. 15. költringer p, haselwander h, reisecker f. the treatment of blepharospasm with botulinum toxin a. wien klinwochenschr. 1990; 13; 102: 403–7. 16. czyz cn, burns ja, petrie tp, watkins jr, cahill kv, foster ja. long-term botulinum toxin treatment of benign essential blepharospasm, hemifacial spasm, and meige syndrome. am j ophthalmol. 2013; 156: 173–7. 17. lee rm, chowdhury hr, hyer jn, smith hb, jones ca. patient – reported benefit from botulinum toxin treatment for essential blepharospasm: using 2 assessment scales. ophthal plast reconstr surg. 2013; 29: 196–7. 18. kumar p, crowley wj jr. neurological applicationn of botulinum toxin. mo med. 1989; 86: 815-7. 19. parsuad r, garas g, silva s. an evidence based review on botulinum toxin (botox) application in non cosmetic head and neck conditions. journal of the royel society of medicine, 2013; 4: 10. 20. park yc, lim jk, lee dk. botulinum a toxin treatment of hemifacial spasm and blepharospasm. journal of korean medical science. 1993; 8: 334-40. http://www.ncbi.nlm.nih.gov/pubmed/?term=mauriello%20ja%20jr%5bauthor%5d&cauthor=true&cauthor_uid=9059273 http://www.ncbi.nlm.nih.gov/pubmed/?term=dhillon%20s%5bauthor%5d&cauthor=true&cauthor_uid=9059273 http://www.ncbi.nlm.nih.gov/pubmed/?term=leone%20t%5bauthor%5d&cauthor=true&cauthor_uid=9059273 http://www.ncbi.nlm.nih.gov/pubmed/?term=pakeman%20b%5bauthor%5d&cauthor=true&cauthor_uid=9059273 http://www.ncbi.nlm.nih.gov/pubmed/?term=mostafavi%20r%5bauthor%5d&cauthor=true&cauthor_uid=9059273 http://www.ncbi.nlm.nih.gov/pubmed/?term=yepez%20mc%5bauthor%5d&cauthor=true&cauthor_uid=9059273 pak j ophthalmol. 2021, vol. 37 (2): 208-212 208 original article demographic characteristics and causes of acquired non-senile ptosis: experience at a tertiary oculoplastic center mohammad idris 1 , hasan yaqoob 2 , muhammad adnan khan 3 , adnan zar 4 , muhib-ul-alam 5 1,3,5 lady reading hospital, medical teaching institute (mti), peshawar, 2 north west teaching hospital, peshawar, 3 hayatabad medical complex, medical teaching hospital, peshawar abstract purpose: to determine the demographic characteristics and causes of acquired, non-senile ptosis in patients presenting to an oculoplastic clinic of a tertiary care centre. study design: observational case series. place and duration of study: lady reading hospital, from january 2016 to december 2017. methods: twenty eight patients were fulfilling the inclusion criteria were recruited in the study. detailed history with complete examination and investigations like electromyography, acetylcholine receptor antibody test and ct/mri brain were performed when required. cause of each ptosis was determined and the relative proportions were calculated. results: there were 28 cases with acquired, non-senile ptosis. fifty seven percent were males while females were 42.9%. patients were divided into four age groups. most of the patients were in age group of 42–62 years. eyelid/orbit tumor and chronic progressive external ophthalmoplegia (cpeo) was seen in 3.6% and 7.1% patients of < 20 years of age respectively. myasthenia gravis and thyroid related pseudoptosis was common in patients of 21-41 years. in patients with age 42-62 years, pseudoptosis due to thyroid disorder was the commonest. in patients with age more than 63 years, 3 rd nerve palsy, eyelid/orbital mass and myasthenia gravis was seen. third nerve palsy and pseudoptosis secondary to thyroid and eyelid/orbit mass were more common in males while myasthenia gravis was more common in females. cpeo was equally seen in both genders with p = 0.575. conclusion: thyroid related eyelid pseudoptosis of the contralateral eye was the commonest cause in this case series. key words: blepharoptosis, third nerve palsy, myasthenia gravis. how to cite this article: idris m, yaqoob h, khan ma, zar a, alam m. demographic characteristics and causes of acquired non-senile ptosis: experience at a tertiary oculoplastic center. pak j ophthalmol. 2021, 37 (2): 208-212. doi: http://doi.org/10.36351/pjo.v37i2.1173 correspondence: mohammad idris department of ophthalmology, lady reading hospital, medical teaching institute (mti), peshawar email: idrisdaud80@gmail.com received: december 1, 2020 accepted: february 27, 2021 introduction ptosis is caused by a number of conditions. some of which must be investigated thoroughly to identify the possible systemic cause and to prevent any lifethreatening complication. 1 generally ptosis is divided into three diagnostic categories which include congenital, acquired and pseudo ptosis. myogenic and neurogenic are important causes of acquired ptosis. 2 laterality is important in systemic cause of ptosis. http://doi.org/10.3352/jeehp.2013.10.3 mailto:idrisdaud80@gmail.com mohammad idris, et al 209 pak j ophthalmol. 2021, vol. 37 (2): 208-212 bilateral involvement is seen in cpeo, congenital ptosis and senile ptosis. neurogenic ptosis is usually unilateral although bilateral involvement is also reported. 3 pseudoptosis is a type which should be excluded after proper ptosis measurement. hemifacial spasm, palpebral fissure narrowing, unilateral hypotropia, hypertropia on the contra lateral side, abnormally small globe, dermatochalasis and thyroid related eyelid retraction in contra lateral side are important causes of pseudoptosis. 4 apart from the clinical diagnosis of ptosis based on measurements like vertical fissure height, marginal reflex distance, crease height, and function of levator muscle, specific cause of ptosis needs proper history and investigations along with systemic investigations. imaging such as mri of whole tract like oculomotor nerve is sometimes necessary to find any hidden cause of ptosis like third nerve palsy. 5 blepharoptosis in patients with horner's syndrome, myasthenia, chronic progressive external ophthalmoplegia, myotonic dystrophy and acute neurovascular events need timely diagnosis and management. 6 rationale of this study was to determine the demographic features and causes of acquired nonsenile ptosis in patients visiting an oculoplastic clinic of a tertiary care centre. methods a cross sectional observational study was carried out in lady reading hospital, peshawar, from january 2016 to december 2017. informed consent was obtained from all patients or their guardians. this study was approved by the institutional review board. patients with congenital and senile ptosis were excluded from the study. the cause of each ptosis was investigated after detailed history, examination, ptosis measurements and investigations including electromyography and acetylcholine receptor antibody test for myasthenia gravis and ct/mri brain for cranial nerve palsy. cause was determined in each ptosis and their relative proportions were calculated. results we observed 28 cases of ptosis fulfilling the inclusion criteria. majority of the patients were male (57.1%) while females were 42.9%. patients were divided into four age groups. maximum number of ptosis patients were in the age group 42–62 years (13). further details are shown in table 1. causes of ptosis with specific age groups are shown in figure 1. ptosis caused by eyelid/orbit tumor and cpeo (chronic progressive external ophthalmoplegia) was seen in patients < 20 years of age. myasthenia gravis and pseudoptosis caused by thyroid related lid retraction was seen in patients of 21-41 years of age. in patients with age group 42-62 years, pseudo ptosis due to thyroid disorder was the commonest followed by myasthenia gravis. in patients with more than 63 years of age, 3 rd nerve palsy, eyelid/orbital mass and myasthenia gravis (7.1%) was were the causes of ptosis. bar chart (figure 2) shows distribution of causes in male and female. 3 rd nerve palsy, pseudo ptosis secondary to thyroid and eyelid/ orbit mass were more common in males while myasthenia gravis was more common in females. cpeo was seen equally seen in both genders with p value of 0.575. table 1: demographic data of the study group. n= 28 gender males 57.1% (16) females 42.9% (12) age groups 0 – 20 years 10.7% (3) 21 – 41 years 14.3% (4) 42 – 62 years 46.4% (13) > 63 years 28.6% (8) causes of ptosis pseudoptosis 32.1% myasthenia gravis 28.6% eyelid/orbit mass 17.9% third nerve palsy 14.3% cpeo 7.1% fig. 1: comparison of causes of ptosis with age groups (n = 28). 42-62 years 21-41 years < 20 years > 63 years demographic characteristics and causes of acquired non-senile ptosis: experience at a tertiary oculoplastic center pak j ophthalmol. 2021, vol. 37 (2): 208-212 210 fig. 2: gender comparison of causes of ptosis (n = 28). discussion blepharoptosis or simply ptosis is dropping of eyelids weather congenital or acquired. it is a cosmetic problem which needs surgical correction but the cause needs to be determined. occasionally, ptosis may be the initial presenting clinical feature of a systemic disorder. therefore, it is of great importance to know the causes of ptosis, its clinical presentation and the systemic evaluation that one must undergo before going into surgery. 7 serious systemic causes of ptosis include conditions related with muscles, nerves and blood. myasthenia gravis and thyroid disorders are autoimmune diseases, which are common in females. 8 in our study, myasthenia gravis was more common in females than males. serious systemic causes of ptosis are seen in all age groups. 9 in our study, we observed such causes in a range of ages from childhood to old age. some oculoplastic conditions are serious and rare but important conditions warrant close examination. pseudoptosis secondary to thyroid related lid retraction of the contralateral side also needs to be identified. 10 in our study this was the commonest type of ptosis. retraction of upper eyelid is common (90%) in patients with thyroid eye disease (ted) even at initial stage. the contralateral normal eyelids may be mistakenly diagnosed as ptosis. therefore, eyelid retraction may be early sign of pseudoptosis, most common sign of ted. this condition should be identified and treated accordingly. 11 therefore, confirming a true ptosis is important as it can give important clue to the cause of any systemic disorder. auto immune disorders, degenerative conditions, hereditary diseases, eyelid tumors and infections need to be excluded before managing the actual ptosis. 12 ptosis is sometimes the first symptom of conditions like chronic progressive external ophthalmoplegia (cpeo) which is present in < 1% of ptosis patients. 13 cpeo is a mitochondrial disorder involving muscles which can present as slowly progressive bilateral ptosis and ocular motility weakness in which ptosis usually precedes the motility problem. 14,15 it needs to be diagnosed and managed properly. it is a rare disorder and in our study, it was seen in only two patients. third cranial nerve palsy caused by tumor or intra cranial hemorrhage can be life-threatening. such cases require urgent neuroimaging. 16 myasthenia gravis is a considerably common systemic cause of ptosis. fortunately majority of cases have stable symptoms but sometime patient can present in acute stage. in such condition, timely diagnosis and referral is life saving. questions to ask and document in such patients include difficulty with breathing and eating .frequently according to our experience, patients usually do not volunteer to give such information to ophthalmologists. these patients rather give typical history of ptosis variability throughout the day. in dangerous situations like myasthenic crisis, shortness of breath is the important presentation along with ptosis and it requires immediate initiation of intravenous corticosteroid treatment. 17 all patients with ptosis should undergo careful examination especially eversion of upper eyelid for any abnormal mass, occult foreign bodies like lost contact lens, which can cause trauma to the conjunctiva and upper eyelid and can present as ptotic lid. similarly, lymphoma should be suspected in old patient. other important causes of mechanical ptosis due to cicatricial conditions are inflammation, stevens-johnson syndrome, and ocular cicatricial pemphigoid. 18 the differential diagnosis of an increasing orbital mass at this age includes the rapidly growing, rhabdomyosarcoma. 19 its timely diagnosis based on clinical examination and histopathology is necessary for proper treatment. 20 in our study, eyelid /orbit mass was seen in five patients. this stresses the importance of excluding any hidden tumor in cases of ptosis. in the nutshell, ptosis is benign in majority of patients, but the attending oculoplastic surgeon should be vigilant to exclude any possible cause of life threatening cause of ptosis. https://www.sciencedirect.com/topics/neuroscience/differential-diagnosis https://www.sciencedirect.com/topics/medicine-and-dentistry/rhabdomyosarcoma mohammad idris, et al 211 pak j ophthalmol. 2021, vol. 37 (2): 208-212 limitation of this study was the small sample size and lack of data regarding the management of these patients. further prospective studies with management and follow ups are needed to have a deep insight into these types of ptosis. conclusion any ptosis irrespective of age and gender should be properly investigated and examined to rule out any underlying serious systemic disease. ethical approval the study was approved by the institutional review board/ethical review board. (ref no. 2181) conflict of interest authors declared no conflict of interest. references 1. lee cc, feng ij, lai ht, huang sh, kuo yr, lai cs. the epidemiology and clinical features of blepharoptosis in taiwanese population. aesthetic plast surg. 2019; 43 (4): 964-972. doi: 10.1007/s00266-019-01344-2. 2. yadegari s. approach to a patient with blepharoptosis. neurol sci. 2016; 37 (10): 1589-1596. doi: 10.1007/s10072-016-2633-7. 3. kishi m, kurihara t, kinoshita m. a case of bilateral ptosis associated with cerebral hemispheric lesions. jpn j psychiatry neurol. 1990; 44 (3): 585– 588, 4. edmonson bc, wulc ae. ptosis evaluation and management. otolaryngol clin n am. 2005; 38: 921– 946. 5. braungart s, craigie rj, farrelly p, losty pd. paediatric horner's syndrome: is investigation for underlying malignancy always required? arch dis child. 2019; 104 (10): 984-987. doi: 10.1136/archdischild-2019-317007. 6. grusha yo, fisenko nv, blinova iv. blepharoptosis: diagnostic tests. vestn oftalmol. 2016; 132 (3): 61-65. doi: 10.17116/oftalma2016132361-65. 7. ben simon gj, huna-baron r, goldan o, ben cnaan r, rosen n. ptosis--etiology, diagnosis and management. harefuah. 2003; 142 (1): 42-47. 8. desai mk, brinton rd. autoimmune disease in women: endocrine transition and risk across the lifespan. front endocrinol. 2019; 10: 265. doi: 10.3389/fendo.2019.00265. 9. díaz-manera j, luna s, roig c. ocular ptosis: differential diagnosis and treatment. curr opin neurol. 2018; 31 (5): 618-627. 10. marenco m, macchi i, macchi i. clinical presentation and management of congenital ptosis. clin ophthalmol. 2017; 11: 453–463. 11. young sm, kim yd, lang ss, woo ki. transconjunctival triamcinolone injection for upper lid retraction in thyroid eye disease-a new injection method. ophthalmic plast reconstr surg. 2018; 34 (6): 587-593. doi: 10.1097/iop.0000000000001120. 12. finsterer j. ptosis: causes, presentation, and management. aesthetic plast surg. 2003; 27 (3): 193204. doi: 10.1007/s00266-003-0127-5. 13. pfeiffer mj. chronic progressive external ophthalmoplegia ptosis: problems with diagnostics and treatment. klin monbl augenheilkd. 2018; 235 (1): 31-33. doi: 10.1055/s-0043-124370. 14. lee ag, brazis pw. chronic progressive external ophthalmoplegia. curr neurol neurosci rep. 2002; 2 (5): 413–417. 15. mcclelland c, manousakis g, lee ms. progressive external ophthalmoplegia. curr neurol neurosci rep. 2016; 16 (6): 53. doi: 10.1007/s11910-016-0652-7. 16. radia m, stahl m, arunakirinathan m, kadhim m. examination of a third nerve palsy. br j hosp med. 2017; 78 (12): c188-c192. doi: 10.12968/hmed.2017.78.12.c188. 17. fazel m, jedlowski pm. severe myositis, myocarditis, and myasthenia gravis with elevated anti-striated muscle antibody following single dose of ipilimumab-nivolumab therapy in a patient with metastatic melanoma. case reports immunol. 2019; 2019: 2539493. doi: 10.1155/2019/2539493. 18. lyon db, dortzbach rk. upper eyelid malpositions: acquired ptosis. in: albert dm, jakobiec fa, azar dt, gragoudas es eds. principles and practice of ophthalmology. wb saunders, philadelphia. 2000: pp 3469–3475 19. american academy of ophthalmology. rhabdomyosarcoma in a 4-year-old boy. available at: https://www.aao.org/image/rhabdomyosarcoma-in4yearold-boy-2 20. sarigül sezenöz a, karalezli a, özkan arat y, çoban g, kiratli h, terzi a. metastatic embryonal conjunctival rhabdomyosarcoma in a 4-year-old boy. ophthalmic plast reconstr surg. 2017; 33 (3s suppl. 1): s125-s127. doi: 10.1097/iop.0000000000000583. authors’ designation and contribution mohammad idris; assistant professor: concepts, design, literature search, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. hasan yaqoob; associate professor: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing. https://www.aao.org/image/rhabdomyosarcoma-in-4yearold-boy-2 https://www.aao.org/image/rhabdomyosarcoma-in-4yearold-boy-2 demographic characteristics and causes of acquired non-senile ptosis: experience at a tertiary oculoplastic center pak j ophthalmol. 2021, vol. 37 (2): 208-212 212 huzaifullah; fcps trainee: literature search, data acquisition, statistical analysis, manuscript preparation, manuscript editing. syed itrat hussain; fcps trainee: literature search, data acquisition, manuscript preparation, manuscript editing muhib-ul-alam; post graduate trainee: data analysis, manuscript review. .…  …. 48 pak j ophthalmol. 2022, vol. 38 (1): 48-51 clinical practice article outcomes of trabeculectomy at a newly established glaucoma clinic in khyber pakhtunkhwa ali hassan nasir 1 , mashal bano 2 , yousaf jamal mahsood 3 1-3 hayatabad medical complex, peshawar abstract purpose: to determine the outcomes of trabeculectomy in patients with open angle glaucoma at a newly established glaucoma clinic in a tertiary care hospital of khyber pakhtunkhwa. study design: retrospective chart review. place and duration of study: glaucoma clinic, hayatabad medical complex, peshawar from may 2018 to december 2019. methods: a retrospective chart review of patients of 18 years age or above and who underwent trabeculectomy for open angle glaucoma, with at least one follow-up visit were included. data was collected for age, gender, type of glaucoma, preoperative best-corrected visual acuity (bcva), intraocular pressure (iop), number of preoperative/post-operative topical anti-glaucoma medications, indication for trabeculectomy, preoperative comorbidities and postoperative complications. data were analyzed using spss version 23. the student’s paired t-test was used for comparative analysis of the same group. a p-value of < 0.05 was considered significant. results: a total of 20 eyes of 20 patients were included in this study, 13 (65%) patients were males, and the mean age was 54.60 ± 18.22 years. there was a statistically significant change in mean iop postoperatively (35.60 ± 13.28 versus 11.2 ± 6.1, p < 0.001) and number of antiglaucoma medication (2.95 ± 1.19 versus 0.4 ± 0.99, p < 0.001). while there was no significant change in best-corrected visual acuity (1.35 ± 0.88 versus 1.06 ± 0.72, p = 0.36). conclusion: trabeculectomy performed at the newly established glaucoma clinic showed a significant reduction in intraocular pressure without compromising the visual acuity of the study participants. key words: trabeculectomy; open angle glaucoma; intraocular pressure. how to cite this article: nasir ah, bano m, mahsood yj. outcomes of trabeculectomy at a newly established glaucoma clinic in khyber pakhtunkhwa. pak j ophthalmol. 2022, 38 (1): 48-51. doi: 10.36351/pjo.v38i1.1306 correspondence: yousaf jamal mahsood department of ophthalmology, hayatabad medical complex, peshawar email: yousaf82@hotmail.com received: june 21, 2021 accepted: november 30, 2021 introduction glaucoma is one of the leading causes of irreversible blindness with 76 million people affected by this disease globally. 1 however, less than half of the population suffering from glaucoma are aware of their disease. 2 this is the main reason that many glaucoma patients present when the disease is in an advanced stage. 3 pakistan has a burden of over 1.8 million people suffering from glaucoma with more and more people becoming blind to this disease due to delayed presentation primarily due to lack of knowledge. 4 control of intraocular pressure (iop) can be achieved with iop-lowering topical medications, open access outcomes of trabeculectomy at a newly established glaucoma clinic in khyber pakhtunkhwa pak j ophthalmol. 2022, vol. 38 (1): 48-51 49 lasers, or surgery. trabeculectomy, a filtration surgery, first introduced by cairns in 1968 and then modified subsequently by watson in 1970, has been the gold standard surgical procedure for glaucoma. 5 studies have shown that progression of optic neuropathy is controlled to some extent in patients undergoing trabeculectomy over 3–6 years. 6 trabeculectomy, although a successful procedure, has variable outcomes due to age, gender, type of glaucoma, and ethnicity. 7 although data is available on the indications, technique, and success of trabeculectomy 8 , yet we have no national consensus. glaucoma is emerging as a new subspecialty in pakistan and our hospital has recently started regular glaucoma clinic. the main purpose of this study is to determine the outcomes of trabeculectomy in patients presenting to this newly established glaucoma clinic in a tertiary care hospital in khyber pakhtunkhwa. methods a retrospective chart review was conducted in the glaucoma clinic of ophthalmology department of hayatabad medical complex, peshawar. this study was conducted after approval of the hospital ethical committee (ref. no. 376/hec/b&psc/2020) and followed the helsinki declaration guidelines. charts of those patients who underwent trabeculectomy between may 2018 and december 2019 were searched. patients with open angle glaucoma who were 18 years or above at the time of trabeculectomy and with at least one follow-up visit were eligible for inclusion in the study. data was collected for age, gender, type of glaucoma, preoperative best-corrected visual acuity (bcva), intraocular pressure (iop), number of preoperative topical antiglaucoma medications, indication for trabeculectomy, and any preoperative comorbidities. the follow-up data was bcva, iop, number of antiglaucoma medications, postoperative complications like loss of visual acuity, intraocular pressure, shallow anterior chamber, choroidal detachment, hypotony, maculopathy, macular edema, and disc swelling. the technique used in all surgeries was the same and details were retrieved from surgical records of the patients. all surgeries were fornix based done under peri-bulbar anesthesia. corneal traction suture with 7/0 vicryl was used to expose the superior surface of the conjunctiva. a 4 mm conjunctival flap measured with calipers was made with westcott scissors, wet-field cautery was used to clear the scleral vessels, and 0.4mg/ml mitomycin c soaked cotton sponges were placed on the sclera for 2 minutes, which was then thoroughly washed with balanced saline solution. a 3 × 3 mm partial-thickness triangular scleral flap was made and trabeculectomy was performed using kelly’s punch and iridectomy was performed with scissors. the flap was secured with 3 slip knots using 10/0 nylon thread. a side port was made to check the patency of the bleb and the anterior chamber was maintained. conjunctiva was sutured with two 10/0 nylon wing sutures. subconjunctival dexamethasone 4 mg/ml was injected in the inferior fornix at the end of the surgery. after the surgery, all patients were prescribed topical moxifloxacin eye drops four times a day, topical dexamethasone eye drops two hourly, topical tobramycin and dexamethasone eye ointment thrice daily. data were analyzed using spss version 23 (ibm corp., armonk, n.y., usa). for categorical variables (like laterality, diagnosis, indications, and complications), frequencies with valid percentages were calculated. for continuous variables (like age, iop, visual acuity, and the number of antiglaucoma medications), mean ± standard deviation were calculated. the student’s paired t-test was used for comparative analysis of the same group. a p-value of < 0.05 was considered significant. results a total of 54 patients underwent trabeculectomy from may 2018 till december 2019. out of these, 33 patients underwent trabeculectomy for open angle glaucoma while 21 patients underwent trabeculectomy for causes other than open angle glaucoma like angle closure glaucoma and congenital glaucoma. out of the 33 patients, records of 10 patients could not be traced while 3 patients did not have a post-operative visit and were excluded from the study. baseline demographics are shown in table 1. comparison of preoperative and postoperative results are shown in table 2. a statistically significant reduction in both iop and antiglaucoma medication was noted (p < 0.001). there was no significant statistical change in final bcva as compared to the preoperative value (p ≤ 0.364). table 3 highlights prior ocular comorbidities, 7 patients (35%) had previous cataract surgery and 3 patients (15%) had a prior trabeculectomy done. no patient had any intraoperative complications. yousaf jamal mahsood, et al 50 pak j ophthalmol. 2022, vol. 38 (1): 48-51 table 1: baseline demographics of our study population. characteristics frequency (%) n = 20 mean (sd) gender male 13 (65) female 7 (35) laterality of the eye right 5 (25) left 15 (75) diagnosis poag 13 (65) soag 7 (35) indications uncontrolled iop 14 (70) progression despite treatment 2 (10) poor compliance 2 (10) others 2 (10) age (years) 54.6 ± 18.22 pre-operative anti glaucoma medications 2.95 ± 1.19 best corrected visual acuity (logmar units) 1.35 ± 0.88 pre-operative intraocular pressure (mmhg) 35.60 ± 13.28 n = total number of eyes, % = percentage, poag = primary open angle glaucoma, soag = secondary open angle glaucoma, iop = intraocular pressure, sd = standard deviation, logmar = log of minimum angle of resolution, mmhg = millimeter of mercury. table 2: comparison of preoperative and postoperative results. characteristics preoperative (sd) final visit (sd) pvalue* bcva (logmar units) 1.35 (0.88) 1.06 (0.72) 0.36 iop (mmhg) 35.60 (13.28) 11.2 (6.1) < 0.001 no. of antiglaucoma medications 2.95 (1.19) 0.4 (0.99) < 0.001 iop = intraocular pressure, sd = standard deviation, logmar = log of minimum angle of resolution, mmhg = millimeter of mercury, no. = number.* paired t-test was applied. table 3: ocular comorbidities. characteristics frequency percentage no ocular comorbidity 8 40 cataract surgery 7 35 uveitis 1 5 trabeculectomy 3 15 others 1 5 total 20 100 discussion the purpose of this study was to determine the outcomes of trabeculectomy in patients performed at a newly established glaucoma clinic. our study showed that trabeculectomy, has a significant impact on the reduction of iop and medication along with stabilization of visual acuity. 8,9 the most common indication for trabeculectomy in our study was uncontrolled iop (70%), while the progression of optic nerve head changes and deterioration of visual field defects was noted in a study conducted at manchester royal eye hospital. 10 the reason for this difference is that we have reported short-term results as our glaucoma clinic is newly established. on the other hand, there was no statistically significant change in visual acuity of our patients which is in line with other studies reported. 4,9,11 the mean decrease in iop noted in our study was similar to the results of a study conducted by shahid et al. 4 similarly, a study conducted in nigeria also reported a significant reduction in iop. 12 even though a higher iop reduction was reported in our study, setting a target pressure is always individualized according to the patient individual characteristics. 9 the goal of treatment with control of iop being to help stabilize progressive visual field loss. 13 we also found a significant reduction in antiglaucoma medications in our patients which was similar to a study conducted in brazil. 11 similar drop in the use of antiglaucoma medications was reported in a study conducted in sweden. 14 new surgical technologies for example shunts, canaloplasty, trabectome and endoscopic cyclophotocoagulation (ecp), have been developed to provide safe and effective control of intraocular pressure but conventional trabeculectomy has an important role in glaucoma management. 15 with the establishment of a new glaucoma clinic comes its own set of difficulties in adopting a procedure and treatment guidelines that are according to the population being treated. outcomes of treatment are usually masked when data is not taken into account to highlight the potential benefits and outline the shortcomings to comply with international standards. comparing the results achieved in our study, it is safe to say that trabeculectomy, as a procedure is having the desired effect as mentioned in different published studies. this study, being retrospective in nature was limited by its design along with the lack of availability of all the files with the proper data recording. the average follow-up was limited to only one follow-up visit. we recommend a multi-centered study with longer follow-up, which will further contribute to the data. outcomes of trabeculectomy at a newly established glaucoma clinic in khyber pakhtunkhwa pak j ophthalmol. 2022, vol. 38 (1): 48-51 51 conclusion trabeculectomy performed at the newly established glaucoma clinic showed good results in controlling iop along with reducing antiglaucoma medication. ethical approval the study was approved by the institutional review board/ ethical review board. (376/hec/b&psc/2020). conflict of interest authors declared no conflict of interest. references 1. tham y-c, li x, wong ty, quigley ha, aung t, cheng c-y. global prevalence of glaucoma and projections of glaucoma burden through 2040 a systematic review and meta-analysis. ophthalmology, 2014; 121: 2081–2090. 2. quigley ha. number of people with glaucoma worldwide. br j ophthalmol. 1996; 80 (5): 389–393. 3. thapa ss, paudyal i, khanal s, twyana sn, paudyal g, gurung r, et al. a population-based survey of the prevalence and types of glaucoma in nepal: the bhaktapur glaucoma study. ophthalmology, 2012 apr; 119 (4): 759–764. 4. shahid e, fasih u, shaikh a. outcome of conventional trabeculectomy in terms of intraocular pressure and visual acuity in primary open angle glaucoma. pakistan j ophthalmol. 2020; 36 (4): 386– 390. 5. koike kj, chang pt. trabeculectomy: a brief history and review of current trends. int ophthalmol clin. 2018; 58 (3): 117–133. 6. nouri-mahdavi k, brigatti l, weitzman m, caprioli j. outcomes of trabeculectomy for primary open-angle glaucoma. ophthalmology, 1995; 102 (12): 1760–1769. 7. hah mh, omar rnr, jalaluddin j, jalil nfa, selvathurai a. outcome of trabeculectomy in hospital melaka, malaysia. int j ophthalmol. 2012; 5 (3): 384– 388. 8. gedde sj, feuer wj, lim ks, barton k, goyal s, ahmed iik, et al. treatment outcomes in the primary tube versus trabeculectomy study after 3 years of follow-up. in: ophthalmology. elsevier inc.; 2020: p. 333–345. 9. tabassum g, ghayoor i, pak ra. the effectiveness of conventional trabeculectomy in controlling intraocular pressure in our population. pak j ophthalmol. 2013; 29 (1): 26-30. 10. shiwani ha, naqvi s, cristian c, au l, spencer af, fenerty ch, et al. outcomes of primary trabeculectomy from two same-centre cohorts ten years apart. journal of glaucoma, 2021 may 27. doi: 10.1097/ijg.0000000000001887. epub ahead of print. pmid: 34049346. 11. abe ry, shigueoka ls, vasconcellos jpc, costa vp. primary trabeculectomy outcomes by glaucoma fellows in a tertiary hospital in brazil. j glaucoma, 2017; 26 (11): 1019–1024. 12. adegbehingbe b., majemgbasan t. a review of trabeculectomies at a nigerian teaching hospital. ghana med j. 2010 jun. 7; 41 (4). 13. rao hl, addepalli uk, jonnadula gb, kumbar t, senthil s, garudadri cs. relationship between intraocular pressure and rate of visual field progression in treated glaucoma. j glaucoma, 2013 dec; 22 (9): 719–724. 14. binibrahim ih, bergström ak. the role of trabeculectomy in enhancing glaucoma patient’s quality of life. oman j ophthalmol. 2017; 10 (3): 150–154. 15. brooks am, gillies we. new techniques in glaucoma surgery. br j ophthalmol. 2000; 84 (12):1339-41. doi: 10.1136/bjo.84.12.1339. pmid: 11090469; pmcid: pmc1723352. authors’ designation and contribution ali hassan nasir; trainee medical officer: design, literature search, data acquisition, statistical analysis, manuscript preparation, manuscript editing, manuscript review. mashal bano; trainee medical officer: design, literature search, data acquisition, statistical analysis, manuscript preparation, manuscript editing, manuscript review. yousaf jamal mahsood; assistant professor: concept, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. .…  …. summary pak j ophthalmol. 2022, vol. 38 (3): 165-169 165 original article dacryocystorhinostomy with or without mitomycin c: experience from north west pakistan zubair ullah khan 1 , mohammad idris 2 , hasan yaqoob 3 , muhammad adnan khan 4 , hadia sabir 5 1 women medical college abbottabad, 2,3,4,5 lady reading hospital, medical teaching institute (mti), peshawar abstract purpose: to evaluate the surgical outcomes of dacryocystorhinostomy with mitomycin c versus dacryocystorhinostomy (dcr) without mitomycin c in patients of chronic dacryocystitis visiting tertiary oculoplastic service. study design: quasi experimental study. place and duration of study: lady reading hospital, medical teaching institute (mti), peshawar, from january 2015 to december 2017. methods: a total of 80 patients with chronic dacryocystitis were divided into two groups of 40 each. group-1 included patients who underwent dacryocystorhinostomy (dcr) with intraoperative mitomycin-c and group-2 included patients with dcr without mitomycin-c. data was entered in spss version 22.00. descriptive statistics were used to calculate means and standard deviation of age. for categorical factors such as gender and efficacy, frequency and percentage were determined. the chi square test was performed to compare the effectiveness of the two groups, with a p value of less than 0.05 considered significant. tables were used to represent the findings. results: there were 68 female patients (85%) and 12 male patients (15%) among the 80 patients. male to female ratio was 1:6.27. the average age was 45.34. six months after surgery, dcr was successful in thirty seven (92.5%) patients of group-i, and thirty six (90%) cases of group ii. overall success rate of dcr in our study was 91.25%. the paired t test was applied and the p value was 0.697. conclusion: there was no statistically significant difference in surgical results of dcr with mitomycin c versus dcr without mitomycin c. both the procedures were equally effective in relieving symptoms. key words: chronic dacryocystitis, external dacryocystorhinostomy, nasolacrimal duct obstruction, mitomycin c. how to cite this article: khan zu, idris m, yaqoob h, khan ma, sabir h. dacryocystorhinostomy with or without mitomycin c: experience from north west pakistan. pak j ophthalmol. 2022, 38 (3): 165-169. doi: 10.36351/pjo.v38i3.1377 correspondence: mohammad idris lady reading hospital, medical teaching institute (mti), peshawar email: idrisdaud80@gmail.com received: march 3, 2022 accepted: june 7, 2022 introduction one of the many causes of watering of eyes is obstruction of lacrimal passages. 1 females of reproductive age are much more likely to be affected. one of the predisposing factors being narrower bony conduit for nasolacrimal duct (the commonest site of obstruction) in females. 2 external dacryocystorhinostomy (ext-dcr) has been recognised as a very effective approach by most ophthalmic surgeons in managing obstructive epiphora but still dcr failures have been observed. 3,4 the two major reasons for dcr failure are: fibrous closure of osteotomy site and obstruction of the common canaliculus. 5 to reduce such fibrosis, intraoperative use of antifibrinolytic agent like mitomycin-c (mmc) is useful in preventing the fibroblast activity linked to the blockage of the muhammad idris, et al 166 pak j ophthalmol. 2022, vol. 38 (3): 165-169 osteotomy point. 6 mitomycin-c was utilised intraoperatively by many researchers with success rates ranging from 90 to 100%. 7,8,9 mmc is an antiproliferative substance derived from streptomyces caespitosus, a soil bacterium. it prevents the production of dna, cellular rna, and proteins, as well as the development and scarring of fibrous tissue. 10 the rationale of this study was to find out whether there is any effect of intraoperative use of mitomycin-c (mmc) on the success rate of external dacryocystorhinostomy (ext-dcr) in the north west part of pakistan. the purpose of this study was to evaluate the treatment outcome of dcr with mitomycin c mmc versus dcr without mmc in patients who visited a tertiary oculoplastic clinic. methods this experimental study was conducted at lady reading hospital, medical teaching institute (mti), which is a key referral centre, from january 2015 to december 2017. patients were selected by consecutive non-probability method. patients irrespective of age with chronic dacryocystitis or mucocele of lacrimal sac were included and patients with acute dacryocystitis, failed dcr, history of nasal fracture/nasal surgery and gross nasal pathology were excluded. approval was sought from ethical committee of the institution. patients were recruited after informed consent. they were divided into two groups of forty cases each. group 1 included patients who underwent dcr with intraoperative mitomycin-c (experimental group). group 2 included patients with dcr without intraoperative mitomycin-c (control group). detailed ocular and systemic history was taken. examination included regurgitation test, slit lamp evaluation of puncta, and probing and irrigation (syringing). the only difference between the two treatments was that a cotton dipped with mitomycin-c (0.2 mg/ml) was used for 10 minutes in patients of group-1. majority of the cases were done under local anaesthesia. four anxious young patients and three uncooperative elderly patients were operated under general anaesthesia. before the start of surgery, injection mitomycin-c was prepared for cases undergoing dcr with mitomycin-c. a sterilized 10 cc disposable syringe was taken and filled with 10ml of sterile water for injection. a vial of 2 mg of mitomycin was taken and its cap was sterilized with cotton soaked in methylated spirit. water of 10ml was injected and vial was shaked well so 0.2 mg/ml mitomycin-c injection was prepared. after the surgery patients were examined on 1 st post operative day and discharged. second follow up was at 3 months after surgery. data was entered in spss version 22.00. descriptive statistics were used to calculate mean and standard deviation of age. for categorical data like gender and effectiveness, frequency and percentage were determined. the chi square test was performed to compare the effectiveness of the two groups, with a p value of less than 0.05 considered significant. tables were used to display the findings. results there were 68 female patients (85%) and 12 male patients (15%). male to female ratio was 1:6.27. average age of the patients was 45.34 years, with the youngest being 20 years old and the oldest being 60 years old. table 1 shows the age and gender distribution. patients were divided into two groups of forty cases each. success of the procedure was described as symptomatic relief of the patient, negative regurgitation test and patent lacrimal passages on irrigation (syringing). after six months, success rate was 92.5% in group-1 and 90% in group 2. overall success rate of dcr was 91.25 %. the paired t test was applied and the p value was 0.697. this difference was not statistically significant (table 3). table 1: age and gender distribution of the whole sample. age (years) gender male n (%) female n (%) 10 – 20 0 2 (2.5) 21 – 30 0 8 (10) 31 – 40 4 (5) 15 (18.75) 41 – 50 3 (3.75) 22 (27.5) 51 – 60 5 (6.25) 21 (26.25) total 12 (15) 68 (85) table 2: group-wise gender distribution. group gender male n (%) female n (%) i. external dcr with mmc 2 (2.5) 38 (47.5) ii. external dcr without mmc 10 (12.5) 30 (37.5) total 12 (15) 68 (85) dacryocystorhinostomy with or without mitomycin c: experience from north west pakistan pak j ophthalmol. 2022, vol. 38 (3): 165-169 167 table 3: comparison of results between the two groups. group n successful mean sd p value group-i 40 37 1.08 0.27 0.697* group-ii 40 36 1.10 0.30 discussion in the current study, we employed the dutemps and bourguet procedures for external dcr. 11 only the anterior flaps were sutured, with a small change to the surgical repair of the bridge with the muscular layer. lacrimal drainage system blockage may be due to various reasons and it is frequently found in middle aged females more frequently than males. 12 in the current study, the majority of participants in both groups were between the ages of 41 and 60 years. similar to our results, in another study, 70.8 percent of the patients were between the ages of 31 and 50. 13 in this particular study, conventional dcr was done in group 2 with a success rate of 90%. this is comparable to the results of other authors like hussain et al, who reported 93.33% success. 14 these results are well in comparison with the work of liao et al 7 and you et al. 8 rahman et al 15 has reported a success rate of 97.77%. in our current research, the difference in success rates between the two treatments was not statistically significant, and the combined failure rate of dcr was 8.75 percent. on the second operation of a failed dcr, pico 16 discovered an occluding membrane clogging the new drainage channels. the occluding membrane was discovered to be made up of granulation tissue on histology. in patients who had a second procedure, mcpherson and egelston 17 saw extensive scar tissue at the osteotomy site. this demonstrates that minimising fibrous growth at the osteotomy site of anastomosed flaps may improve success rates. however, the results are not statistically significant. we used 0.2 mg/ml of mmc. ugurbas et al 18 used 0.5 mg/ml mmc soaking over the osteotomy site to investigate the clinicopathologic impact of mitomycinc on transnasal dcr. on mitomycin-c soaked tissues, they discovered reduced epithelial and hypocellular subepethelial connective tissue using light and electron microscopes. as a result, it reduced the volume and cellularity of the mucosa, increasing the dcr success rate. in this particular study, three patients (7.5%) of group 1 complained persistent watering (epiphora) after 6 months of follow up and were labelled as failed dcr. gonzalvo et al used helical computed tomography to investigate the influence of mmc on osteotomy size. 19 the residual osteotomy size at the end of sixth postoperative month was 93.82+/-4.55 percent in their research, compared to the osteotomy size immediately after surgery. fang et al found that osteotomy size was maintained with 0.2 mg/ml mmc to the anterior flap applied for 10 minutes. 7 the drug was administered to the anterior flaps without intubation, with a 92.5 percent success rate. in our study, no significant complication was noted due to mitomycin-c. there were three patients who developed excessive nasal bleeding on removal of the nasal packing. these patients were kept under observation for another 24 hours. in their work, kao et al identified a number of potential problems associated with intraoperative mitomycin-c usage in dcr, including delayed wound healing, unusual nasal haemorrhage, mucosal necrosis, and infection. 20 mitomycin-c administration in external dcr caused no concerns according to studies. 21,22 in the present study, no such complications reported. limitations of the study are small sample size and a single center study. we did not compare different concentrations of mmc, which could have different results from the current outcomes. conclusion there is no statistically significant difference in results between dcr with mmc and without mmc. hence, routine use of mmc is not necessary unless the case with complicated chronic dacryocystitis are encountered. conflict of interest: authors declared no conflict of interest. ethical approval the study was approved by the institutional review board/ethical review board (ref. no. 1297). muhammad idris, et al 168 pak j ophthalmol. 2022, vol. 38 (3): 165-169 references 1. ulusoy mo, kıvanç sa, atakan m, akova-budak b. how important is the etiology in the treatment of epiphora? j ophthalmol. 2016; 2016: 1438376. doi: 10.1155/2016/1438376. 2. shen gl, ng jd, ma xp. etiology, diagnosis, management and outcomes of epiphora referrals to an oculoplastic practice. int j ophthalmol. 2016; 9 (12): 1751-1755. doi: 10.18240/ijo.2016.12.08. 3. meireles mn, viveiros mm, meneghin rl, galindoferreiro a, marques me, schellini sa. dacryocystectomy as a treatment of chronic dacryocystitis in the elderly. orbit. 2017; 36 (6): 419421. doi: 10.1080/01676830.2017.1353111. 4. sibley d, norris jh, malhotra r. management and outcomes of patients with epiphora referred to a specialist ophthalmic plastic unit. clin exp ophthalmol. 2013; 41 (3): 231-238. doi: 10.1111/j.1442-9071.2012.02866.x. 5. altin ekin m, karadeniz ugurlu s, aytogan h, sahin 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modified technique of external dacryocystorhinostomy. am j ophthalmol. 1971; 72: 679-690. 17. mcpherson sd, egelston d. dacryocystorhinostomy: a review of 106 operations. am j ophthalmol. 1959; 47: 28-31. 18. ugurbas sh, zilelioglu g, sargon mf. histopathological effects of mitomycin c on endoscopic transnasal dacryocystorhinostomy. ophthalmic surg lasers, 1997; 28: 300-304. 19. gonzalvo ibanez fj, fuertes fernandez i, fernandez tirado fj, hernandez delgado g, rabinal arbues f, honrubia lopez fm. external dacryocystorhinostomy with mitomycin-c. clinical and anatomical evaluation with helical computer tomography. arch soc esp. oftalmol. 2000; 75: 611617. 20. kao scs, liao cl, tseng jhs. dacryocystorhinostomy with intraoperative mitomycin c. ophthalmology, 1997; 104: 86-91. doi: 10.1016/s0161-6420(97)30357-1. 21. masoomian b, eshraghi b, latifi g, esfandiari h, masoomian b. efficacy of probing adjunctive with low-dose mitomycin-c irrigation for the treatment of epiphora in adults with 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c: experience from north west pakistan pak j ophthalmol. 2022, vol. 38 (3): 165-169 169 authors’ designation and contribution zubair ullah khan; assistant professor: concepts, design, literature search, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. mohammad idris; assistant professor: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. hasan yaqoob; associate professor: literature search, data acquisition, statistical analysis, manuscript preparation, manuscript editing. muhammad adnan khan; vr fellow: literature search, data acquisition. hadia sabir; resident: data analysis, manuscript review. .…  …. pak j ophthalmol. 2022, vol. 38 (1): 31-35 31 original article comparison of peri-lesional triamcinolone acetonide versus incision and curettage in the treatment of primary chalazion hafiza sadia imtiaz 1 , asman jabran 2 , amna anam 3 , wasim ghous 4 1-3 dhq teaching hospital gujranwala, 4 dhq hospital, sheikhupura abstract purpose: to compare the results of peri-lesional triamcinolone acetonide (ta) with incision and curettage in the treatment of primary chalazia. study design: quasi experimental study. place and duration of study: eye department of district head quarter/teaching hospital, gujranwala, from june 2018 to may 2019. methods: one hundred and twenty patients with primary chalazion, either gender and age between 10–30 years, were enrolled in this study. they were equally divided into two groups. in group a, incision and curettage was done. in group b, perilesional ta (40 mg/ml) was given. followup was done at 5 th day, 14 th day, 1 month and 3 months. lesion resolution or recurrence and complications were recorded. iop monitoring was also carried out at each followup. results: mean age was 18.0 ± 2.14 years with range of 10 – 30 years. there were 45.0% females and 55.0% males. no statistically significant difference was found in age, gender and complication rates between the two groups. complete resolution was seen in 95.0% in group a and 88.3% cases in group b. the difference between the two groups was not statistically significant regarding small and medium sized chalazia. in case of large chalazia, 23 out of 24 patients in group a and 19 out of 23 patients in group b showed complete resolution and the difference in success rate of two groups was statistically significant (p = 0.014). conclusion: incision and curettage and perilesional ta injection are equally effective in treating small and medium primary chalazia. while for large chalazia, incision and curettage offered superior results. key words: chalazion, incision and curettage, triamcinolone acetonide, how to cite this article: imtiaz hs, jabran a, anam a, ghous w. comparison of peri-lesional triamcinolone acetonide versus incision and curettage in the treatment of primary chalazion. pak j ophthalmol. 2022, 38 (1): 31-35. doi: 10.36351/pjo.v38i1.1290 correspondence: hafiza sadia imtiaz department of ophthalmology dhq teaching hospital gujranwala email: sadiaimtiaz69@gmail.com received: june 8, 2021 accepted: december 8, 2021 introduction chalazion is a benign eyelid nodule due to chronic granulomatous inflammation secondary to blockage of meibomian glands orifices. 1 its clinical presentation varies from painless swelling of gradually increasing in size to painful when become secondarily infected. chalazion can cause cosmetic disfigurement, irritation, discomfort, corneal astigmatism and mechanical ptosis. 2 initial conservative management involves hot open access hafiza sadia imtiaz, et al 32 pak j ophthalmol. 2022, vol. 38 (1): 31-35 compresses, 3 lid hygiene and massage, antibiotic eye ointment and mild topical steroids. 4 other treatment modalities are considered once conservative management fails and include incision and curettage, intralesional or perilesional steroid injection and carbon dioxide laser treatment. 5,6 incision and curettage is a conventional method that is considered a gold standard by some ophthalmologists. it is carried out under local anaesthesia in adults and requires general anaesthesia for children in proper operation theater (ot) settings. 7,8 intralesional or perilesional triamcinolone acetonide (ta) is considered another alternative approach with certain advantages and disadvantages. as chalazion is a sterile inflammation, it is sensitive to anti-inflammatory effect of steroids. it is less time consuming and requires only topical anaesthesia without the need for special instruments and special ot settings. 9,10 rich data is available for comparison of incision and curettage and intralesional ta but comparison of perilesional ta and incision and curettage is limited. the rationale of this study is to compare the success rate and complications rate between incision and curettage and perilesional ta treatment for primary chalazion. perilesional ta reduces the confounding factor associated with intralesional ta injection as it causes direct rupture of chalazion and release of its secretions. methods after getting institutional review committee approval and taking special consent from every patient/ guardian, a study was conducted at eye department of dhq – uth, gujranwala for a period of 12 months from june 2018 to may 2019. one hundred and twenty patients with primary chalazion, after failed conservative treatment, either gender, age between 10–30 years, were enrolled in this study. they were divided equally into two groups based on random number generator (60 in each group). patients with any lid abnormality, patients with recurrent chalazion and those who did not complete 3 months post-injection followup were removed from this study. baseline matching was also carried out in both groups. all patients underwent complete eye examination, which included digital photography of the lesion as well. pre-operatively, chalazion size was also graded into 3 groups as follow; small < 4.0 mm, medium 4.0–8.0 mm and large > 8 mm. thirty three patients had small sized chalazia (16 included in group a and 17 in group b). medium sized chalazia of 4–8 mm were present in 40 patients (20 in each group). large sized chalazia were found in 47 patients (24 patients in group a and 23 in group b). in group a, incision and curettage was carried out as treatment modality of primary chalazion, under local anesthesia in adults while under general anesthesia in children. after infiltrating 2cc injection lignocaine 1% peri-lesionally, chalazion clamp was applied over the chalazion and lid was everted. small vertical incision was given with surgical blade 11 over the highest point of swelling and thorough scooping was done. chalazion clamp was removed, antibiotic selected (n = 120) excluded from study (n = 30) (declined to participate, lost to followup, other reasons) allocated to incision and curettage group (group a) n = 60 allocated to peri-lesional ta group (group b) n = 60 enrolled into study by assessing for eligibility (n = 150) peri-lesional triamcinolone acetonide versus incision and curettage in the treatment of primary chalazion pak j ophthalmol. 2022, vol. 38 (1): 31-35 33 eye ointment was applied immediately and eye pad was applied for 4 hours. postoperative antibiotic tobramycin was given in tds frequency for 3 days. in group b, perilesional ta (40 mg/ml) was given as treatment option to primary chalazion under topical anesthesia. after instilling 1 drop of topical anesthetic proparacaine 0.5% eye drops, 0.2cc perilesional injection of ta was given from palpebral conjunctival side. antibiotic ointment was applied and eye pad was done for 4 hours. post-operative antibiotic tobramycin was prescribed in tds frequency for 3 days. followup was done at 5 th day, 14 th day, 1 month and 3 months post-treatment. along with determining lesion resolution or recurrence and complete ophthalmic examination, iop monitoring was also carried out at each followup. complete resolution was defined as lesion regression of 90–100% of its initial size. treatment was considered a failure if no resolution was achieved after the first attempt. recurrence was defined as reappearance of swelling after its initial resolution within 3 months of treatment. results mean age was 18.0 ± 2.14 years with range of 10–30 years. in group a, mean age was 19.88 ± 3.82 years while in group b, it was 18.28 ± 2.93 years. no statistically significant difference was found in age distribution between two groups. (p value = 0.26). in general, 45.0% were female and 55.0% were male. in group a, 43.4% were female and 56.6% were male while in group b, 46.6% were female and 53.3% were male. no statistically significant difference was found in gender distribution between two groups (p value = 0.34) table 1: gender distribution in the groups. male female total group a 34 (56.6%) 26 (43.4%) 60 (100%) group b 32 (53.3%) 28 (46.6%) 60 (100%) total 66 (55.0%) 54 (45.0%) 120 (100%) in general, left eye was involved in 42.50% patients while right eye in 51.6% patients. ninety-five percent patients had unilateral disease. in group a, right eye was involved in 50% and left eye in 45.0% patients while in 5.0% patients, both eyes were involved. in group b, percentage for bilateral involvement was 6.6%, while right eye involvement was in 53.3% patients and left eye in 40% patients. in group a, complete resolution was seen in 95.0% while in group b, complete resolution was seen in 88.3% cases. p-value obtained for both groups was not statistically significant (p-value = 0.27). chart 1 shows the details. 0 10 20 30 40 50 60 group a group b complete resolution failure recurrence fig. 1: clustered bar chart showing success rate and failure rate in both groups. further stratification of success rate was done with regard to size of chalazion. difference in success rate of two groups was not statistically significant regarding small and medium sized chalazia. in case of large sized chalazia, 23 out of 24 patients in group a and 19 out of 23 patients in group b showed complete resolution and the difference in success rate of two groups was statistically significant (p = 0.014). table 2: success rate stratification with regard to size of chalazion. chalazion size group a (success rate) group b (success rate) p-value ( < 0.05) small (33) 93.75% 94.11% 0.23 medium (40) 95% 90% 0.12 large (47) 95.83% 82.6% 0.014 complication rate was also assessed between the two groups. the difference in complication rate of two groups was not statistically significant. (p = 0.34). figure 2 shows the details. hafiza sadia imtiaz, et al 34 pak j ophthalmol. 2022, vol. 38 (1): 31-35 0 10 20 30 40 50 60 b le e d in g s k in d is c o lo ra ti o n w h it e p re c ip it a te s p re -s e p ta l c e ll u li ti s group a group b fig. 2: clustered bar chart showing different complications between the two groups. discussion in this study, mean age was 18.0 ± 2.14 years with range of 10–30 years, which included both children and adult population. the comparison of resolution was not statistically significant between different age groups. lee et al. compared intralesional steroid injection for primary chalazia in children and adults and found out no statistically significant difference in resolution time in pediatric and adult age group (p value: 0.7). 11 in this study, we found male predominance of 55%. similar predominance was observed in both groups individually as well. ilhan et al. studied primary and recurrent chalazion occurrence according to gender distribution and they concluded female dominance of 51.6% while males were 48.4%. 12 this difference in gender dominance may be explained by difference in ethnicity. in our study, success rate in incision and curettage was 95%, while in perilesional ta group, it was 88.5% and the difference was not statistically significant. in a meta-analysis carried out by putterman, success rate with incision and curettage was 78%, while with steroid injection it was 60.4%. 13 ahmad et al, also compared the same therapeutic options for primary chalazion, and success rate in incision and curettage group was 79%, while with steroid injection was 62%. 14 in literature, intra-lesional steroid injection was given while in our study it was given perilesionally, which might explain its relatively higher success rate. we have studied the success rates of two groups according to the size of chalazion. the results showed that in small and medium sized chalazion, both incision and curettage and perilesional ta were equally effective with no statistically significant difference. while in case of larger chalazion, difference in success rate was statistically significant with higher rate in incision and curettage group. singhania et al, studied the same success rate of two groups between medium and large sized chalazion and found that intralesional ta was as effective as incision and curettage for both medium and large sized chalazion. 15 while khurana et al. concluded that incision and curettage was better choice in case of larger chalazion. 16 in our study, recurrence was found as 3.3% in incision and curettage group and 10% in ta group. nabie et al, reported recurrence of 34% in intralesional ta group and 2% in incision and curettage. 17 pavicic et al, did not report any recurrence after intralesional ta injection in primary and recurrent chalazia. 18 complication rate was also assessed between the two groups in this study and no statistically significant difference was found. park et al. reported 2 patients with fat atrophy and skin depigmentation after intralesional ta injection for chalazion. 19 while wong et al. reported no complication with intralesional ta injection. 20 in a meta-analysis, where complication rate was compared between the two groups and studies failed to show any difference in the incidence of complications with either procedure. 21 limitations of this study were short duration of followup and factors responsible for recurrence were not considered. conclusion both incision and curettage and perilesional ta injection can be used for treating primary chalazion of small and medium size. while in case of large sized chalazion, incision and curettage offer superior results. ethical approval the study was approved by the institutional review board/ethical review board (admn. 273/gmc). peri-lesional triamcinolone acetonide versus incision and curettage in the treatment of primary chalazion pak j ophthalmol. 2022, vol. 38 (1): 31-35 35 conflict of interest authors declared no conflict of interest. references 1. jordan ga, beier k. chalazion. 2021 aug 9. in: statpearls [internet]. treasure island (fl): statpearls publishing, 2021 jan–. pmid: 29763064. 2. görsch i, loth c, haritoglou c. mein linkes oberlidistgeschwollen [chalazion diagnosis and therapy]. mmw fortschr med. 2016; 158 (12): 52-55. 3. goawalla a, lee v. a prospective randomized treatment study comparing three treatment options for chalazia: triamcinolone acetonide injections, incision and curettage and treatment with hot compresses. clin exp ophthalmol. 2007; 35 (8): 706-712. 4. wu ay, gervasio ka, gergoudis kn, wei c, oestreicher jh, harvey jt. conservative therapy for chalazia: is it really effective? acta ophthalmol. 2018; 96 (4): e503-e509. 5. unal m. chalazion treatment. orbit. 2008; 27 (6): 397-398. 6. khurana a, ahluwalia b, rajan c. chalazion therapy. acta ophthalmologica. 2009; 66 (3): 352-354. 7. varma s, kam jk. marking technique to improve primary success of incision and curettage of eyelid chalazia. clin exp ophthalmol. 2018; 46 (1): 89-90. 8. lee j, kim s. comparison of effectiveness between intralesional triamcinolone injections and incision and curettage for the primary chalazia. j korean ophthalmol soci. 2013; 54 (10): 1488. 9. lohana n. to compare the efficacy and safety of intralesional kenacort injection vs. surgical intervention (incision and curettage) in primary chalazion. pak j ophthalmol. 2019; 35 (3). 10. khan t, zafar s, huda w. efficacy of intralesional triamcinolone acetonide for the treatment of chalazion. pak j ophthalmol. 2017; 33 (1): 46-50. 11. lee jw, yau gs, wong my, yuen cy. a comparison of intralesional triamcinolone acetonide injection for primary chalazion in children and adults. the scientific world journal, 2014; 2014: 413729. 12. i̇lhan ç, yılmazbaş p. are there any difference between primary and multiple operated chalazion according to age, gender or lesion location?. intern j ophthalmic res. 2017; 3 (3): 249-251. 13. putterman am. re: incision and curettage versus steroid injection for treatment of chalazia: a metaanalysis. ophthalmic plast reconstr surg. 2017; 33 (2): 151. 14. ahmad s, baig ma, khan ma, khan iu, janjua ta. intralesional corticosteroid injection vs surgical treatment of chalazia in pigmented patients. j coll physicians surg pak. 2006; 16 (1): 42-44. 15. singhania r, sharma n, vashisht s, dewan t. intralesional triamcinolone acetonide (ta) versus incision and curettage (i & c) for medium and large size chalazia. nepal j ophthalmol. 2018; 10 (19): 310. 16. khurana ak, ahluwalia bk, rajan c. chalazion therapy. intralesional steroids versus incision and curettage. acta ophthalmol (copenh). 1988; 66 (3): 352-354. 17. nabie r, soleimani h, nikniaz l, raoufi s, hassanpour e, mamaghani s, et al. a prospective randomized study comparing incision and curettage with injection of triamcinolone acetonide for chronic chalazia. j curr ophthalmol. 2019; 31 (3): 323-326. 18. pavicić-astalos j, iveković r, knezević t, krolo i, novak-laus k, tedeschi-reiner e, et al. intralesional triamcinolone acetonide injection for chalazion. acta clin croat. 2010; 49 (1): 43-48. 19. park j, chang m. eyelid fat atrophy and depigmentation after an intralesional injection of triamcinolone acetonide to treat chalazion. j craniofac surg. 2017; 28 (3): e198-e199. 20. wong my, yau gs, lee jw, yuen cy. intralesional triamcinolone acetonide injection for the treatment of primary chalazions. int ophthalmol. 2014; 34 (5): 1049-1053. 21. aycinena ar, achiron a, paul m, burgansky-eliash z. incision and curettage versus steroid injection for the treatment of chalazia: a meta-analysis. ophthalmic plast reconstr surg. 2016; 32 (3): 220-224. authors’ designation and contribution hafiza sadia imtiaz; postgraduate resident: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation. aamna jabran; assistant professor: concepts, design, data acquisition, manuscript preparation, manuscript editing, manuscript review. amna anam; postgraduate resident: design, literature search, data acquisition, manuscript preparation, manuscript editing. wasim ghous; medical officer: literature search, data analysis, statistical analysis, manuscript editing, manuscript review. .…  …. 213 pak j ophthalmol. 2021, vol. 37 (2): 213-217 original article outcome of intraoperative mitomycin c injection in trabeculectomy and phacotrabeculectomy in patients with glaucoma saadia farooq 1 , hajra farooq 2 , momina faisal 3 1 shifa international hospital, islamabad, 2,3 the aga khan university, karachi abstract purpose: to determine the efficacy and safety of per-operative mitomycin c injection during trabeculectomy and combined phaco-trabeculectomy in different types of glaucoma. study design: interventional case series. place and duration of study: shifa international, between january 2018 to july 2020. methods: thirty one patients requiring trabeculectomy or phaco-trabeculectomy with mitomycin c because of maximum tolerable anti-glaucoma treatment or poor compliance were included in the study. out of these 15 in group a underwent simple trabeculectomy with intra-operative mitomycin c and 16 patients in group b underwent phacotrabeculectomy with intra-operative mitomycin c and iol implantation. all patients underwent an eye examination (including iop and visual acuity) before surgery and then afterwards at 1 week, 1 month, 2 months, 6 months and 1 year. main outcome measures were best corrected visual acuity, intra-ocular pressure and number of medications at base line and post-operatively. results: demographic results of the two groups were similar. mean follow-up period was 1 year, mean iop was 11 in group aand 15.5 in group b in last follow-up.mean iop reduction at 1 year was significant in both group a and b (p = 0.001, p = 0.022 respectively). hypotony, post-operative inflammatory membrane and bleb fibrosis were the main complications in group a and group b. conclusion: trabeculectomy with mitomycin c and phaco-trabeculectomy with mitomycin c are equally successful at lowering iop in common types of glaucoma permitting significant and safe reduction of antiglaucoma medications for atleast 1 year after surgery. key words: mitomycin, glaucoma, intra ocular pressure. how to cite this article: farooq s, farooq h, faisal m. outcome of intraoperative mitomycin c injection in trabeculectomy and phacotrabeculectomy in patients with glaucoma. pak j ophthalmol. 2021, 37 (1): 213-217. doi: http://doi.org/10.36351/pjo.v37i2.1204 introduction mitomycin c (mmc) is a common wound modulator correspondence: hajra farooq department of ophthalmology, the aga khan university, karachi email: hajrafarooq11123@gmail.com received: january 16, 2021 accepted: march 3, 2021 used in ophthalmology in glaucoma, pterygium surgery and refractive lasers. 1 in the past decade mmc has been routinely used in high risk “trabeculectomies” including young patients, african american or who had previous glaucoma surgery. 2 traditionally mmc is applied per-operatively via soaked sponges for two minutes. with popularity and variety of anti-glaucoma medications as a first line management option, there has been a change in trend to use mmc in all trabeculectomies to improve the survival of bleb. 3 moreover, shift to sub conjunctival http://doi.org/10.3352/jeehp.2013.10.3 outcome of intraoperative mitomycin c injection in trabeculectomy and phacotrabeculectomy in patients with glaucoma pak j ophthalmol. 2021, vol. 37 (2): 213-217 214 injection of mitomycin c is found to be effective and results in more diffuse bleb formation. 4-6 this technique not only saves time, reduces conjunctival surface exposure to mitomycin with consequent less chances of wound leak, but is also proven as an effective modality with ideal bleb formation. 4 primary open angle glaucoma and chronic narrow angle glaucoma are the two most common causes of blindness among elderly asian population. in hypermetropic eyes proportionately large lens plays a crucial role in the pathogenesis of angle closure. 7,8 removal of lens not only reduces crowding in the anterior chamber but also improves vision by removing the lens with opacities. it reduces the need of sequential surgery which is needed with rapid progression of lens opacities into visually significant cataract post-trabeculectomy. 9-11 on the other hand, primary open-angle glaucomapatients are generally elderly with concurrent cataract and glaucoma. they need combined procedure. phacotrabeculectomy again not only improves vision but reduces the need for sequential surgery. 12-14 however, some surgeons prefer separate procedures over combined. so there is lack of consensus on the best approach in such cases. 15,16 long term data for the use of per-operative injection of mmc in phacotrabeculectomy and trabeculectomy is insufficient especially in south asian population. we analyzed the effectiveness of trabeculectomy and phacotrabeculectomy with mmc (20 micro gram) in different types of glaucoma over an observation time of 1 year. methods out of 31 eyes, 15 underwent trabeculectomy with mmc whereas 16 patients underwent phacotrabeculectomies with intra-operative mmc. all surgeries were performed by one surgeon at shifa international trust, between january 2018 to july 2020 and followed up for one year. patients who had progressive damage with maximum tolerable antiglaucoma treatment or poor compliance with topical drugs and with or without lens changes were included. exclusion criteria were patients who underwent previous glaucoma lasers or glaucoma valve surgeries or patients who were lost in follow-up in less than 6 months. institutional ethical board approved this study and informed consent was obtained from every patient. data was collected pre-operatively and postoperatively at 1 week, 1 month, 3-months, 6-months and 1 year. assessment included best corrected visual acuity, goldmanapplanation tonometry, cup-disk ratio, number of anti-glaucoma medications, postoperative interventions and outcomes. complete successwas defined as iop 6 – 18 mmhg without antiglaucoma treatment and improved or stable visual acuity compared to pre-operative visual acuity. conditional success was defined as iop less than 18 mmhg with 1 or 2 anti-glaucoma medications with stable visual acuity as compared to pre-operative. failure was defined as iop higher than 23 mmhg with 2 or more anti-glaucoma medications, severe comorbidity such as choroidal detachment, recurrent encysted bleb needing revision more than 3 times. similar protocol was followed for phacotrabeculectomy. same surgeon performed all procedures under local anesthesia.following sub-tenon’s or peribulbar anesthesia, 7 – 0 silk stay suture was placed in the superior cornea. standard dosage of mmc 0.2 mg/ml (0.1 cc) was used as an intra-operative subconjunctival injection, 8mm from limbus at the beginning of procedure. injection xylocaine with adrenaline was used to dissect conjunctiva and tenon at surgical site. the exposed sclera under the conjunctival flap was cleaned with gentle bipolar diathermy. partial thickness scleral flap (4x3 mm 2/3 rd thickness) was made and advanced to 2mm into clear cornea. internal window was marked and completed after paracentesis. bss was injected through paracentesis to confirm the patency of fistula. scleral flapwas stitched with 10/0 nylon at the ends of flap. conjunctiva and tenon were stitched. combined phaco-trabeculectomy was done with the same standard steps till the marking of internal window. keratome (2.2mm) was used to make a phaco-incision temporal to the scleral flap. capsulorhexis, hydrodissection, phaco chop or flip and lens matter aspiration was done. after iol implantation in bag, miochol was used to constrict the pupil, internal scleral window was removed, pi done and conjunctival flap was stitched as described above. subconjunctival injectionof dexamethasone was given at the end of combined procedure. post-operative predforte eye drops were given 02 hourly for two weeks then 5 times a day. eye drops were reduced by 1 drop every week and discontinued after 7 weeks. in case of bleb vascularization or increase in iop, digital massage was introduced from saadia farooq, et al 215 pak j ophthalmol. 2021, vol. 37 (2): 213-217 2 nd week onwards and steroid frequency was increased to 2 hourly for 3 days. no bleb needling was performed post-operatively. vigamox was continued for 02 weeks. cyclopentolate was given in phacotrabeculectomy for 05 days.considering the sample size, the significance level was set to 0.5 and confidence coefficient to 0.95. statistical analysis was performed with spp software (version 21). results the meanpreoperative iop at the baseline was 25.59± 8.69 mmhg. post-operatively the mean iop had decreased to 8.14 ± 3.25 mmhg at 1 month, 12.30 ± 3.94 mmhg at 6 months and 12.39 ± 3.94 after 1 year. the iop reduction after surgery was statistically significant at the end of observation period. no significant difference of iop was found in different types of glaucoma and different sex. visual acuity significantly improved (in both groups) from 32.3% (6/12-6/6) preoperatively to 64.5% (6/12-6/6) post operatively. applying the success/failure criteria, complete surgical success was achieved in 73.3% in a, 62.5% in b. qualified success was 18.75% in group b. failure was seen in 12.5% in group b and in 6.67% in group a. loss of 1 year follow up was observed in 6.25% in group b and 20% in group a. a decrease in number of medications was observed in post-operative period up to 1 year. postoperatively the number of medications were significantly decreased to 3.22 (p value less than 0.005) and digital massage was needed in 6.45 patients. intraoperative and post-operative complications were evaluated in all surgeries. most common complications were hypotony in 9.67% and postoperative inflammatory membrane in 6.45% and bleb fibrosis in 3.22%. table 1: different types of glaucoma and their frequency. diagnosis frequency percent valid percent cumulative percent secondary angle glaucoma 3 9.7 10.0 10.0 open angle glaucoma 13 41.9 43.3 53.3 narrow angle glaucoma 1 3.2 3.3 56.7 valid steroid induced glaucoma 3 9.7 10.0 67.7 drug allergy 4 12.9 13.3 80.0 advanced glaucoma 3 9.7 10.0 90.0 pxf glaucoma 2 6.5 6.7 96.7 post vitrectomy 1 3.2 3.3 100.0 total 30 96.8 100.0 missing system 1 3.2 total 31 100.0 table 2: pre-operative and post-operative visual acuities in the patients. frequency percent valid percent cumulative percent pre-op vision valid c.f. – 6/36 11 35.5 36.7 36.7 6/24 – 6/12 9 29.0 30.0 66.7 6/12 – 6/6 10 32.3 33.3 100.0 total 30 96.8 100.0 missing system 1 3.2 total 31 100.0 post-op vision valid c.f. – 6/36 7 22.6 22.6 22.6 6/24 – 6/12 4 12.9 12.9 35.5 6/12 – 6/6 20 64.5 64.5 100.0 total 31 100.0 100.0 outcome of intraoperative mitomycin c injection in trabeculectomy and phacotrabeculectomy in patients with glaucoma pak j ophthalmol. 2021, vol. 37 (2): 213-217 216 fig. 1: comparison of iop in both groups till 1 year post-operative. discussion injection of mitomycin is comparable to sponge application with less need of visits and bleb intervention. efficacy of mmc injection in trabeculectomy and phaco-trabeculectomy is comparable. in the current study, complete treatment success was73.3% in trabeculectomy group and 62.5%in phacotrabeculectomy group over the time of 1 year. intra-operative injection offers several advantages over conventional procedures. it provides large area and longer surface area exposure reducing diffusely elevated blebs. 17 there is also increased long term success with minimal complications. 18 another advantage is predictable dose delivery as compared to sponge application. 19 the main complications of mmc are bleb leak, hypotony, corneal epithelial toxicity and overhanging blebs. 20 some of these are related to unpredictable mmc concentration in deep scleral and sub scleral layers, 21 whereas others are related to exposure of mmc to edges of the wound and small area of exposure with thin walled bleb. 17 in a prior study of injection of mmchypotony and serous choroidal detachment were seen as the commonest complications. 4 in our study, hypotony was found in 13.4% and serous choroidal detachment in 6.7% which resolved spontaneously with time.we have seen effective control of iop and lesser need of anti-glaucoma medication with per-operative injection of mmc. this is consistent with an earlier study in which similar results were reported regarding iop decrease and need of fewer anti-glaucoma medications after injection of mmc in trabeculectomy. 1 we analyzed the efficacy of intraoperative mmc in combined phaco-trabeculectomy and found it to be a safe and effective procedure for control of glaucoma with complete success in 62.5% and need of fewer medication in 18.75%. data related to mmc injection during phaco-trabeculectomy is scarce. in a previous study it was shown that two site phaco trabeculectomy with mmc (sponge application) in west indian patientsproved to be a safe and effective treatment. 22 contrary to that other authors have reported that trabeculectomy and single site phacotrabeculectomy with intraoperative sponge mmc was safe and effective treatment for iop control. 23 reported results of inject mitomycin in trabeculectomy and phacotrabeculectomy are rarely seen together in literature. we have found it to be safer than conventional and equally comparable to sponge mmc application with predictable results in variety of glaucoma patients at 1-year follow-up. limitations of this study includes relatively small sample size and follow-up limited to 1 year. future studies in prospective long term and larger cohort are necessary to further confirm its safety and efficacy as a modality. additional influencing risk factors to be considered include number of anti-glaucoma medications, duration of treatment, pre-operative conjunctival injection, previous eye surgeries with and without conjunctival injections, active skin disease, intraocular inflammation, races, and thinness of conjunctiva to standardize risk factor adjusted protocol for mmc application. ethical approval the study was approved by the institutional review board/ ethical review board (irb#335-1155-2020). conflict of interest authors declared no conflict of interest. references 1. s khouri a, huang g, y huang l. intraoperative injection vs sponge-applied mitomycin c during trabeculectomy: one-year study. j curr glaucoma pract. 2017; 11 (3): 101–106. saadia farooq, et al 217 pak j ophthalmol. 2021, vol. 37 (2): 213-217 2. swogger j, conner ip, rosano m, kemmerer m, happ-smith c, wells a, et al. injected versus sponge-applied mitomycin c (mmc) during modified trabeculectomy in new zealand white rabbit model. transl vis sci technol. 2020; 9 (11): 23. doi: 10.1167/tvst.9.11.23. 3. ya y, ys g, ct f, xq m. long-term effects of simultaneous subconjunctival and subscleral mitomycin c application in repeat trabeculectomy. j glaucoma. 2002; 11 (2): 110–118. 4. lee e, doyle e, jenkins c. trabeculectomy surgery augmented with intra-tenon injection of mitomycin c. acta ophthalmol (copenh). 2008; 86 (8): 866–870. 5. al-habash a, aljasim la, owaidhah o, edward dp. a review of the efficacy of mitomycin c in glaucoma filtration surgery. clin ophthalmol. 2015; 9: 1945-1951. doi: 10.2147/opth.s80111. 6. sisto d, vetrugno m, trabucco t, cantatore f, ruggeri g, sborgia c. the role of antimetabolites in filtration surgery for neovascular glaucoma: intermediate-term follow-up. acta ophthalmol scand. 2007; 85 (3): 267–271. 7. dietlein ts, widder ra, jordan jf, jonescucuypers c, rosentreter a. combined cataract and glaucoma surgery. current options. ophthalmol z dtsch ophthalmol ges. 2013; 110 (4): 310–315. 8. khandelwal r, bijlani m, raje d, rathi a. evaluating the efficacy of short duration mitomycin c in safe surgery system trabeculectomy combined with cataract surgery. clin ophthalmol. 2019 may 22; 13: 849-857. doi: 10.2147/opth.s192044. 9. alsagoff z, aung t, ang lp, chew pt. long-term clinical course of primary angle-closure glaucoma in an asian population. ophthalmology, 2000; 107 (12): 2300–2304. 10. morgan wh, yu d-y. surgical management of glaucoma: a review. clin experiment ophthalmol. 2012; 40 (4): 388–399. 11. tan am, loon sc, chew ptk. outcomes following acute primary angle closure in an asian population. clin experiment ophthalmol. 2009; 37 (5): 467–472. 12. vijaya l, david rl. safety and efficacy of single-site phacotrabeculectomy with mitomicin c using nylon and polyglactin suture for scleral tunnel closure. j glaucoma. 2015; 24 (5): e64-68. 13. rao hl, maheshwari r, senthil s, prasad kk, garudadri cs. phacotrabeculectomy without mitomycin c in primary angle-closure and open-angle glaucoma. j glaucoma. 2011; 20 (1): 57–62. 14. augustinus cj, zeyen t. the effect of phacoemulsification and combined phaco/glaucoma procedures on the intraocular pressure in open-angle glaucoma. a review of the literature. bull soc belge ophtalmol. 2012; (320): 51–66. 15. emanuel me, parrish rk, gedde sj. evidencebased management of primary angle closure glaucoma. curr opin ophthalmol. 2014; 25 (2): 89–92. 16. li h-j, xuan j, zhu x-m, xie l. comparison of phacotrabeculectomy and sequential surgery in the treatment of chronic angle-closure glaucoma coexisted with cataract. int j ophthalmol. 2016; 9 (5): 687–692. 17. cordeiro mf, constable ph, alexander ra, bhattacharya ss, khaw pt. effect of varying the mitomycin-c treatment area in glaucoma filtration surgery in the rabbit. invest ophthalmol vis sci. 1997; 38 (8): 1639–1646. 18. onol m, aktaş z, hasanreisoğlu b. enhancement of the success rate in trabeculectomy: large-area mitomycin-c application. clin experiment ophthalmol. 2008; 36 (4): 316–322. 19. maheshwari d, kanduri s, rengappa r, kadar ma. intraoperative injection versus sponge-applied mitomycin c during trabeculectomy: one-year study. indian j ophthalmol. 2020; 68 (4): 615-619. doi: 10.4103/ijo.ijo_963_19 20. holló g. wound healing and glaucoma surgery: modulating the scarring process with conventional antimetabolites and new molecules. dev ophthalmol. 2012; 50: 79–89. 21. georgopoulos m, vass c, vatanparast z. impact of irrigation in a new model for in vitro diffusion of mitomycin-c after episcleral application. curr eye res. 2002; 25 (4): 221–225. 22. the safety and efficacy of two-site phacotrabeculectomy with mitomycin c under retrobulbar and topical anesthesia [internet]. [cited 2020 oct 15]. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc48757 29/ 23. murthy sk, damji kf, pan y, hodge wg. trabeculectomy and phacotrabeculectomy, with mitomycin-c, show similar two-year target iop outcomes. can j ophthalmol. 2006; 41 (1): 51–59. author’s designation and contribution saadia farooq; consultant ophthalmologist: concepts, design, data acquisition, manuscript preparation, manuscript review. hajra farooq; mbbs student: data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. momina faisal; mbbs student: literature search, manuscript editing, manuscript review. .…  …. 216 pakistan journal of ophthalmology, 2020, vol. 36 (3): 216-220 original article accuracy of the corvis biomechanical index in keratoconus screening fazle hanan 1 , zulfiqar ali 2 , muhammad naeem 3 1 amanat eye hospital, peshawar, 2 ayub medical college, abbottabad, 3 lady reading hospital, peshawar abstract purpose: to evaluate the accuracy of the corvis biomechanical index (cbi) in screening of patients with keratoconus. study design: cross sectional study. place and duration of study: amanat eye hospital peshawar from july 2018 to june 2019. material and methods: one thousand eyes were included in this study. patients who came for keratorefractive laser procedure or collagen cross linkage were included in the study by convenient sampling technique. six hundred and eleven patients had early keratoconus and 389 were normal controls. control group included those individuals who had visual acuity of 6/6 with no clinical feature of keratoconus and normal tomographic and biomechanical index (tbi). all individuals included in the study underwent a thorough ocular examination, cbi and tbi tests. spss version 23 was used for statistical analysis of collected data. results: the mean cbi value was 0.3186 ± 0.407 standard deviation (sd), the standard error (se) of the mean was 0.0129 with a 95% confidence interval (ci) of 0.293 to 0.343. the minimum cbi value was 0.00 and the maximum value was 1.00. the mean tomographic biomechanical index (tbi) value was 0.465 ± 0.392 sd, se was 0.124 with a 95% ci of 0.222 to 0.708. the range of tbi values was 0.00 to 1.00. for cbi, sensitivity was 58.2%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 61.2%. conclusion: the current study showed acceptable accuracy of cbi in terms of specificity and sensitivity. however, the result should be interpreted in combination with clinical data and other topographic and tomographic parameters. key words: corvis biomechanical index, tomographic and biomechanical index, belin/ambrosio enhanced ectasia index. how to cite this article: hanan f, ali z, naeem m. accuracy of the corvis biomechanical index in keratoconus screening. pak j ophthalmol. 2020; 36 (3): 216-220. doi: 10.36351/pjo.v36i3.1072 introduction identification and exclusion of forme fruste keratoconus prior to any photorefractive procedure is correspondence to: fazle hanan amanat eye hospital peshawar email: drfazalhanan@gmail.com received: may 28, 2020 revised: june 22, 2020 accepted: june 25, 2020 important because it can develop into established keratoconus after surgery resulting in deterioration of vision. 1 it is essential that patient should have normal corneal parameters without any suspicion or sign of keratoconus. moreover, if early keratoconus is diagnosed, collagen cross linking can arrest the progression of keratoconus. 2,3,4 keratoconus is a bilateral disease in which there is thinning and steepening of the central and paracentral cornea, appearing around puberty. in early stage, which is also mailto:drfazalhanan@gmail.com accuracy of the corvis biomechanical index in keratoconus screening pakistan journal of ophthalmology, 2020, vol. 36 (3): 216-220 217 called subclinical, forme fruste keratoconus or keratoconus suspect, the clinical signs are not obvious and the diagnosis can be made with the help of a screening test, which has high degree of sensitivity and specificity 5 . different devices are used nowadays for keratoconus screening, incorporating corneal tomography or pachymetry and topography. these include; orbscan ii 6 (bausch & lomb, new york, us), pentacam 7 (oculus optikgeräte gmbh, wetzlar germany), galilei g4 8 (ziemer, port, switzerland), and sirius 9 (cso, firenze, italy). these devices measure corneal curvature, corneal thickness, and elevation of the anterior and posterior corneal surface. recently, it has been found that changes in biomechanical stability of the cornea precedes topographic and tomographic changes in keratoconus. 10,11 to study the biomechanical behavior of cornea, currently used devices are ocular response analyzer r (ora; reichert, new york, us) and the corneal visualization scheimpflug technology corvis st; (oculus optikgerate gmbh, wetzlar, germany). the ocular response analyzer 2 determines the corneal hysteresis and the corneal resistance factor. the corvis st is a non-contact tonometer with a dual scheimpflug, high-speed camera that takes more than 4,300 images per second of the central 8 mm of the cornea in horizontal meridian. the corvis st determine the dynamic corneal response (dcr) parameters and the ambrosio relational thickness (art). the salient dcr parameters include a1 and a2 velocities, which are the speeds of corneal apex at first and second applanation respectively. the deflection and deformation amplitudes; displacement of corneal apex with reference to the initial state of cornea is the deflection amplitude while the largest displacement of corneal apex in the anterior-posterior direction at the moment of highest concavity is the deformation amplitude which also includes whole eye movement. deflection amplitude ratio describes the ratio between the deflection amplitude at the apex and the average deflection amplitude measured at 1 or 2 mm from the center. similarly, deformation amplitude ratio describes the ratio between the deformation amplitude at the apex and the average deformation amplitude measured at 1 or 2 mm from the center. the delta arc length describes the change in arc length during the highest concavity moment from the initial state, in a defined 7-mm zone. the force balance between the external air pressure and the iop is determined at first applanation (a1), which defines the reference position for the stiffness parameter (sp-a1) in the form of force divided by displacement. therefore, the sp-a1 is defined as resultant pressure (pr) divided by deflection amplitude at a1. ambrósio's relational thickness (arth) is calculated by first measuring the corneal thickness and the percentage thickness increase relative to the smallest value at points with 0.2 mm spacing. the ratio between the percentage values (percentage thickness increase) and the corresponding normative values is calculated for each position. the average ratio for all positions provides the pachymetric progression index (ppi). arth is finally calculated by dividing corneal thickness at thinnest point with pachymetric progression index. the rationale of the study was to compare the accuracy of cbi in keratoconus screening with tbi which was taken as the gold standard. the combination of pachymetric and biomechanical parameters is referred to as tomographic and biomechanical index or tbi 12,13,14 which has proven to be more accurate than other diagnostic parameters. the purpose of the current study was to evaluate the accuracy of corvis biomechanical index (cbi) in keratoconus screening by comparing it with tbi. material and methods this was a cross sectional study of patients who visited amanat eye hospital peshawar between july, 2018 to june 2019. amanat eye hospital peshawar is an eye care center providing keratoconus screening services and laser treatment facilities for patients having refractive errors. the data set included two types of patients; those who were interested in photorefractive keratectomy or femto lasik treatment for their refractive error or those who were advised corvis and tbi tests because of the clinical suspicion of keratoconus in them and hence consideration of collagen cross linkage treatment. these patients were either seen by the consultant of amanat eye hospital peshawar, or they were seen and referred by other ophthalmologists for screening purpose. all those patients who had previous keratorefractive procedure and those patients who had clinical signs of advanced keratoconus were excluded. fazle hanan, et al 218 pakistan journal of ophthalmology, 2020, vol. 36 (3): 216-220 the age range was 5 to 50 years and both sexes were included. one thousand eyes of 500 patients were included in the study, out of whom 611 were patients with subclinical or early keratoconus and 389 were normal controls. control group included those individuals who had visual acuity of 6/6 with no clinical feature of keratoconus and normal tbi. all individuals included in the study underwent a thorough ocular examination, cbi and tbi tests. the devices used for screening were the oculus pentacam hr reference 70900 (oculus optikgeräte gmbh, wetzlar germany) and the oculus corvis st reference 72100 (oculus optikgerate gmbh, wetzlar, germany). the study was conducted while strictly adhering to the study guidelines of the tenets of declaration of helsinki. results a total of 1000 eyes of 500 patients were recruited in the study. the number of male and female patients was 318 and 182 with a ratio of 1.747 to 1 respectively. the age range of the patients was 5 to 49 years, with a mean of 21.89 ± 8.434 years. 95% confidence interval for age was 21.151-22.628 with a standard error of 0.377 years. the cut off ranges for cbi and tbi were 0.00 to 0.25 as normal, 0.26 to 0.5 as suspicious and 0.51 to 1.00 as diseased. the cut off points were similar to those considered by koh s and ambrosio r jr 15 in their study which were cbi > 0.5 and tbi > 0.29. the result of cbi in our patients is given in table 1. the mean cbi value was 0.3186 ± 0.407, the table 1: corvis biomechanical index. category frequency od frequency os total %age normal 309 326 635 63.5 suspicious 45 33 78 7.8 diseased 146 141 287 28.7 total 500 500 1000 100 standard error of the mean was 0.0129 with a 95% confidence interval of 0.293 to 0.343. the minimum cbi value was 0.00 and the maximum value was 1.00. the result of tbi is given in table 2. the mean tbi value was 0.465 ± 0.392. the standard error was 0.124 with a 95% confidence interval of 0.222 to 0.708. the minimum tbi value was 0.00 and the maximum value was 1.00. table 2: tomographic biomechanical index. category frequency od frequency os total %age normal 192 197 389 38.9 suspicious 114 113 227 22.7 diseased 194 190 384 38.4 total 500 500 1000 100 table 3: evaluation of cbi comparing it with tbi. cbi result disease present disease absent total positive test (suspicious plus diseased) 365 (true positive) 0 (false positive) 365 negative test 246 (false negative) 389 (true negative) 635 total 611 389 1000 sensitivity = 58.2% specificity = 100% positive predictive value = 100% negative predictive value = 61.2% table 4: cbi vs tbi (p value calculation). cbi observed (expected) tbi observed (expected) total normal 635 (512) 389(512) 1024 suspicious plus diseased 365 (488) 611(488) 976 total (observed) 1000 1000 2000 chi square value = 29.5 degree of freedom = 1 p value = 0˂.001 discussion in keratoconus, cornea is soft and thin. scarcelli 11 suggested that as the effect of strain is more on the softer area of the cornea, intraocular pressure and external factors such as eye rubbing cause softer area of the cornea to bulge out and become thin to redistribute the effect of strain. corneal bulging results in focal reduction in stress as a compensatory mechanism resulting in a vicious circle of straining, bulging and thinning. the data available in literature does not prove to be definitive in diagnosing keratoconus as there is a considerable overlap between normal corneas and forme fruste keratoconus 16,17 . in this study, we compared the accuracy of cbi in keratoconus screening by calculating their sensitivity and specificity against tbi from the collected data and their positive and negative predictive value. accuracy of the corvis biomechanical index in keratoconus screening pakistan journal of ophthalmology, 2020, vol. 36 (3): 216-220 219 in the current study, sensitivity and specificity of cbi was 58.2% and 100% respectively. the positive and negative predictive value of cbi was 100% and 72.3% respectively. in the study of vinciguerra et al 18 , the sensitivity of cbi was found to be 94.1% and specificity of 100%. the reason for the higher sensitivity in that study was that they compared the results of normal individuals with those having established keratoconus whereas our study included forme fruste keratoconus, in which diagnosis is more difficult and challenging. however, wang et al 19 in his study described sensitivity and specificity of cbi in forme fruste keratoconus as 63.2% and 80.3% respectively. the reason for the lower specificity of cbi in that study might be the comparison of subclinical keratoconus with normal population whereas we compared both subclinical and early established keratoconus cases with normal cases. the difference between the results of different studies is due to the observation 20 that the discriminatory power of these indices decreases in the following order a) comparing normal eyes with established keratoconus. b) comparing normal eyes with early keratoconus in which the opposite eye of the patient has normal topography. c) comparing normal eyes with subclinical keratoconus in which the opposite eye has both normal topography and tomography. this data show cbi was highly specific, which means that its positive result is reliable. however, this index has acceptable sensitivity, which may imply the possibility of false negative results in subclinical keratoconus at early stage. if a patient is labeled negative with cbi and there is clinical suspicion of forme fruste keratoconus, the test should be interpreted in combination with other parameters such as bad-d, tbi, mean keratometry, index of vertical asymmetry and index of surface variance. applying the chi square statistics, the p value of the comparison of the two tests is ˂ 0.001, which is due to the presence of significant number of false negative cbi results. limitation of the study is that the study was done at a single center. further data from other centers is required to support our results. conclusion the result of cbi should be interpreted in combination with other topographic, tomographic and topometric parameters such as bad_d, tbi, mean keratometry, index of surface variance and index of vertical asymmetry. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution fazle hanan; associate professor: study concept and design, data collection, analysis and interpretation of data, writing the manuscript, critical revision, supervision. zulfiqar ali; associate professor: analysis and interpretation of data, critical revision. muhammad naeem; assistant professor: analysis and interpretation of data, critical revision. references 1. spadea l, cantera e, cortes m, conocchia ne, stewart cw. corneal ectasia after myopic laser in situ keratomileusis: a long-term study. clin ophthalmol. (auckland, nz). 2012; 6: 1801. 2. vinciguerra r, ambrósio r, elsheikh a, roberts cj, lopes b, morenghi e, et al. detection of keratoconus with a new biomechanical index. j refract surg. 2016; 32 (12): 803-10. 3. alhayek a, lu pr. corneal collagen cross linking in keratoconus and other eye disease. intern j ophthalmol. 2015; 8 (2): 407. 4. meiri z, keren s, rosenblatt a, sarig t, shenhav l, varssano d. efficacy of corneal collagen cross-linking for the treatment of keratoconus: a systematic review and meta-analysis. cornea. 2016; 35 (3): 417-28. 5. kymionis gd, siganos cs, tsiklis ns, anastasakis a, yoo sh, pallikaris ai, et al. long-term follow-up of intacs in keratoconus. am j ophthalmol. 2007; 143 (2): 236-44. 6. wei rh, zhao sz, lim l, tan dt. incidence and characteristics of unilateral keratoconus classified on corneal topography. j refract surg. 2011; 27 (10): 74551. fazle hanan, et al 220 pakistan journal of ophthalmology, 2020, vol. 36 (3): 216-220 7. bae gh, kim jr, kim ch, lim dh, chung es, chung ty. corneal topographic and tomographic analysis of fellow eyes in unilateral keratoconus patients using pentacam. am j ophthalmol. 2014; 157 (1): 103-9. 8. golan o, piccinini al, hwang es, gonzalez im, krauthammer m, khandelwal ss, et al. distinguishing highly asymmetric keratoconus eyes using dual scheimpflug/placido analysis. am j ophthalmol. 2019; 201: 46-53. 9. bayramoğlu se, sayın n, ekinci dy, erdoğan m. comparison of keratometry, central corneal thickness, and anterior chamber depth results measured with nidek-al scan biometry and sirius topography devices. istanb med journal. 2018; 19 (2): 158-61. 10. ambrósio r jr, dawson dg, salomão m, guerra fp, caiado al, roberts cj. biomechanics in keratoconus. in: barbara a, ed. textbook of keratoconus: new insights, 1st ed. new delhi: jaypee brothers medical publishers; 2012: 29–32. 11. scarcelli g, besner s, pineda r, yun sh. biomechanical characterization of keratoconus corneas ex vivo with brillouin microscopy. invest ophthalmol vis sci. 2014; 55: 4490–4495. 12. salomão mq, hofling-lima al, gomes esporcatte lp, lopes b, vinciguerra r, vinciguerra p, et al. the role of corneal biomechanics for the evaluation of ectasia patients. int j environ res public health. 2020; 17 (6): 2113. 13. kataria p, padmanabhan p, gopalakrishnan a, padmanaban v, mahadik s, ambrósio jr r. accuracy of scheimpflug-derived corneal biomechanical and tomographic indices for detecting subclinical and mild keratectasia in a south asian population. j cataract refract surg. 2019; 45 (3): 32836. 14. ferreira-mendes j, lopes bt, faria-correia f, salomão mq, rodrigues-barros s, ambrósio jr r. enhanced ectasia detection using corneal tomography and biomechanics. am j ophthalmol. 2019; 197: 7-16. 15. koh s, ambrosio r jr, inoue r, maeda n, nishida k. detection of subclinical corneal ectasia using corneal tomographic and biomechanical assessment in japanese population. j refract surg. 2019; 35 (6): 383390. 16. ortiz-toquero s, martin r. keratoconus screening in primary eye care–a general overview. eur ophth. 2016; 10 (2): 80-5. 17. hashemi h, beiranvand a, yakta a, maleki a, yazdani n, khabazkhoob m. pentacam top indices for diagnosing subclinical and definite keratoconus: j curr ophthalmol. 2016; 28 (1): 21-26. 18. vinciguerra r, ambrosio r jr, elsheikh a, roberts jc, lopes b, morenghi e, et al. detection of keratoconus with a new biomechanical index: j refract surg. 2016; 32 (12): 803-810. 19. wang ym, chan tcy, yu m, jhanji v. comparison of corneal dynamic and tomographic analysis in normal, forme fruste keratoconus, and keratoconic eyes: j refract surg. 2017; 33 (9): 632-638. 20. steinberg j, siebert m, katz t, frings a, mehlan j, druckiv v, et al. tomographic and biomechanical scheimpflug imaging for keratoconus characterization: a validation of current indices. journal of refractive surgery. 2018; 34 (12): 840-7. .…  …. pak j ophthalmol. 2021, vol. 37 (3): 312-316 312 original article comparison of endonasal endoscopic dacryocystorhinostomy with external dacryocystorhinostomy muhammad tariq 1 , ahmad zeeshan jamil 2 , shahid ali 3 , muhammad khalid 4 , ali akash 5 1-5 district headquarter teaching hospital & sahiwal medical college, sahiwal abstract purpose: to compare anatomical and functional success of endonasal dacryocystorhinostomy (dcr) with that of external dacryocystorhinostomy. study design: quasi-experimental study. place and duration of study: department of ophthalmology and otolaryngology, district headquarter teaching hospital, sahiwal, from july 2018 to july 2019. methods: sixty patients with nasolacrimal duct obstruction were selected by convenient sampling technique and were divided into two groups. group 1 underwent endonasal dcr while group 2 underwent external dcr. detailed history with regard to symptoms and duration of the obstruction was taken. detailed ophthalmological and otolaryngological examination was performed. patients were followed up for three months. chi-square test was used to compare the success between two groups. confidence level of 95% was used and p value of less than 0.05 was considered significant. results: male to female ratio was 4:11. the most common presenting symptoms was epiphora that was present in all patients. regurgitation of lacrimal sac was present in 75%, conjunctivitis was present in 53.33% and dacryocystitis was present in 41.66% patients. anatomical success rate for endonasal dcr was 25 (83.33%) and for external dcr was 27 (90%). functional success rate for endonasal dcr was 23 (76.67%) and for external dcr was 22 (73.33%). there was no statistically significant difference in the short term success of surgery between the two groups. conclusion: endonasal dcr offers minimal invasive approach with comparable anatomical and functional results to the external dcr. key words: conjunctivitis, dacryocystorhinostomy, dacryocystitis, epiphora. how to cite this article: tariq m, jamil az, ali s, khalid m, akash a. comparison of endonasal endoscopic dacryocystorhinostomy with external dacryocystorhinostomy. pak j ophthalmol. 2021, 37 (3): 312-316. doi: 10.36351/pjo.v37i3.1226 introduction tears have important role in ocular surface wellbeing. correspondence: ahmad zeeshan jamil district headquarter teaching hospital & sahiwal medical college, sahiwal email: ahmadzeeshandr@gmail.com received: february 11, 2021 accepted: april 28, 2021 drainage of tears from the conjunctival sac through the lacrimal passages into the nose is important as it prevents stagnation of the tears. blockage in the drainage of tears through the lacrimal passages not only causes discomforting epiphora but it can also lead to infections. 1 restoring patency of the lacrimal drainage system into the nose relieves the agonizing epiphora and stops occurrence of recurrent infections. dacryocystorhinostomy (dcr) is creating a fistula between the lacrimal sac and the nasal cavity. for the open access mailto:ahmadzeeshandr@gmail.com muhammad tariq, et al 313 pak j ophthalmol. 2021, vol. 37 (3): 312-316 first time dcr was performed via intranasal approach in nineteenth century. 2 in the twentieth century dcr was performed by toti by a novel technique. in that procedure external skin incision was used to approach the lacrimal sac and an opening was made to the nasal cavity. 3 endoscopic assisted transnasal dcr was first concocted by mcdonogh and meiring in 1989. 4 with the development of better visualization systems, small guage instruments and introduction of lasers in the field of surgery, more emphasis is given towards minimally invasive surgical approaches. as a result, endonasal dcr is gaining popularity. with the increasing experience of the surgeons, results of endonasal dcr are coming close to the results of external dcr. 5 endonasal dcr offers the advantage of no skin scar, preservation of lacrimal part of orbicularis oculi, less operative time once the learning curve of surgeon has plateaued and faster recovery of the patient. moreover, endonasal dcr can be done in the setting of active infection. 6 external dcr is considered a gold standard. its main advantages include no dependency on expensive instrumentation, lacrimal sac direct approach for examination, treatment of intra-sac pathologies and capability of creation and suturing of lacrimal sac and nasal mucosal flaps. 7 in the current study we have compared success of endonasal dcr with that of conventional external dcr. the idea was to see whether endonasal dcr is as promising a technique as external dcr with less morbidity to the patient and faster postoperative recovery. methods this prospective quasi-experimental study was conducted from july 2018 to july 2019. departments of ophthalmology and otolaryngology of district headquarter teaching hospital, sahiwal, contributed to this study. institutional review board approval was sought before the start of the study. informed consent was taken from all the patients included in the study. patients were selected from outpatient department of ophthalmology. diagnosis of nasolacrimal duct obstruction was made on the basis of symptoms, presence of regurgitation test and by probing and syringing of the lacrimal passages. inclusion criteria were patients with age ranging from 20 years to 60 years, both genders and presenting with chronic dacryocystitis. exclusion criteria comprised of obstruction of lacrimal passages proximal to the lacrimal sac, previous history of dacryocystorhinostomy, history of trauma, presence of nasal pathologies obstructing lacrimal drainage pathway, hypersecretion of tears, lower lid laxity manifested by lateral distraction of more than 5 mm, punctal eversion and conjunctivochalasis. detailed history was obtained from all the patients with respect to duration and severity of the symptoms. detailed ophthalmological and otolaryngological examination were performed. ct scan of paranasal sinuses and orbit was obtained for all the patients. all the patients were operated under general anesthesia. patients were divided into two groups. group 1 patients were operated by endonasal approach while group 2 patients were operated by external approach. in the external dcr group, local infiltration of the medial canthus and lower lid region was done with 5 ml of 2% lidocaine and 1:100,000 epinephrine solution. nasal cavity was packed with dressing soaked in a solution of 2% lidocaine and 1:100,000 epinephrine. skin incision was given over the side of the nose 10 mm away from the medial canthus. periosteum over the anterior lacrimal crest was approached by dissecting the soft tissue. lacrimal sac was exposed by elevating the periosteum. bone was removed with the help of kerrison bone rongeur. lacrimal sac and nasal mucosal flaps were fashioned. nasal packing was removed. silicon tube was passed through the superior and inferior canaliculus into the nasal cavity and tied by square knots. anterior flaps of lacrimal sac and nasal mucosa were sutured together. cut ends of orbicularis oculi muscle were sutured together. sub cuticle suture was used to close the skin incision. nasal packing soaked in 1:100,000 adrenaline was put. nose was packed with ribbon gauze soaked in 1:100,000 adrenaline solution. in endonasal dcr group, nasal mucosa was infiltrated with 1:100,000 adrenaline and 2% lidocaine solution. with the help of endoscope, inspection of nasal cavity was performed and nasal mucosa was incised. kerrison bone rongeur was used to remove the bone until lacrimal sac was exposed. twenty three gauge light pipe used in vitreoretinal surgery was passed through one of the canaliculus into the lacrimal sac. trans-illumination helped in the identification of lacrimal sac. lacrimal sac was opened with the help of blade. silicon tube was passed through upper and lower canaliculus into the nasal cavity. two ends of the silicon tube were secured with the help of surgical comparison of endonasal endoscopic dacryocystorhinostomy with external dacryocystorhinostomy pak j ophthalmol. 2021, vol. 37 (3): 312-316 314 stapler. nasal mucosa was approximated with lacrimal sac mucosa. nasal packing with alginate foam soaked in triamcinolone was done at the end of the procedure. all patients were prescribed topical antibiotics and steroids eye drops and decongestant nasal spray. all patients were followed up at 1 week, 1 month and 3 months. in both groups, silicon tube was removed at 12 weeks after the surgery. patients were followed up for 3 months. patency of lacrimal drainage system was checked by irrigating with florescence-stained normal saline at 2 weeks, 1 month and 3 months. functional success of the procedure was judged on the basis of relief of symptoms and anatomical success was based on patency of lacrimal passage on irrigation. data was entered in statistical package for social sciences version 23. chi-square test was used to compare the success between two groups. p value equal to or less than 0.05 was considered significant. results in this quasi-experimental study, there were 30 patients in each group. distribution of cases in both groups and presenting symptoms are given in table number 1. symptoms were present for less than 6 months in 17 (28.3%). in 12 (20%) symptoms were present for 6 to 12 months. in 19 (31.7%) cases symptoms were present for one year to two years. in 12 (20%) cases symptoms were present for more than 2 years. anatomical and functional success in both groups is given in table number 2. there was no statistically significant difference in anatomical and functional success between the two groups. table 1: demographic characteristics of patients and presenting symptoms in two groups. group male female age epiphora regurgitation dacryocystitis conjunctivitis endonasal 7 (23.3%) 23 (76.67%) 42.40 ± 12.67 30 (100%) 24 (80%) 11 (36.67%) 14 (46.67%) external 9 (30%) 21 (70%) 41 ± 11.67 30 (100%) 21 (70%) 14 (46.67%) 18 (60%) table 2: anatomical and functional success. group anatomical success chisquare/ p-value functional success chisquare/ p-value endonasal 25(83.33%) 0.577/0.35 23(76.67%) 0.089/0.50 external 27(90%) 22(73.33%) discussion external dcr has been considered as the gold standard for the treatment of nasolacrimal drainage system blockage beyond common canaliculus. recent advances in endoscopic visualization system, surgical instrumentation and growing expertise of surgeons have paved the way to the minimal invasive surgical approach. as a result, endonasal dcr is gaining popularity. 8 likewise, in our institution there is a growing trend in transition to the minimally invasive surgical approach whereby more and more patients are being offered endonasal dcr. dcr is all about creating a fistula between lacrimal sac and nasal cavity. making window in the bony wall of nose is essential part of this procedure. the most common cause of failure of dcr surgery is closure of the bony ostium into the bony wall of the nose. intraoperative tissue damage leading to postoperative scarring is one the main contributing factors in the closure of the opening of bony ostium. 9 interestingly initial size of the bony ostium is not related to the postoperative final size of bony opening. 10 more emphasis is given on minimizing surgical trauma to prevent postoperative scarring of the ostium. better visualization with the help of endoscopes and minimal tissue dissection with fine surgical instrumentation is the key concept behind minimally invasive surgical techniques. 11 approximation of lacrimal sac and nasal mucosa appears to offer the best result in maintaining the patency of bony opening in dcr surgery. 12,13 in the present study, meticulous care was taken to approximate the flaps of lacrimal sac and nasal mucosa. at the same time unnecessary dissection and cautery was avoided in both groups to minimize postoperative scarring. anatomical success rate for endonasal dcr was 25 (83.33%) and for external dcr was 27 (90%). functional success rate for endonasal dcr was 23 (76.67%) and for external dcr was 22 (73.33%). the success rate of endonasal dcr in the current study is comparable to the results of herzallah et al. where success rate was 87.88%. 8 in a study done by muhammad tariq, et al 315 pak j ophthalmol. 2021, vol. 37 (3): 312-316 hartikainen and colleagues external dcr was successful in 91% cases while endonasal dcr was successful in 63% cases. 14 in another study done by the same author endonasal endoscopic dcr success rate was 75% and external dcr success rate was 91% at the end of one year. 15 javate and coauthors performed a longitudinal study comparing the success rate of endonasal dcr with that of external dcr. success rate of endonasal dcr was 90% as compared to 94% for external dcr. 16 study done by hii et al. showed success rate of 92.1% for endonasal dcr and 91.7% for external dcr. 17 in a study done by walker and colleagues endonasal dcr success rate was 90.2% and external dcr success rate was 89.8%. 18 su and colleagues compared the anatomical and functional success rate between endonasal and external dcr. in their study no significant difference was noted in the success between the two groups. anatomical success for endonasal and external dcr was 93.5% and 95.8% respectively. functional success for endonasal and external dcr was 90.7% and 90.1% respectively. 19 ben and colleagues study demonstrated a significantly higher success rate of endonasal dcr (84%) as compared to external dcr (70%). 20 in another study conducted by karim and coauthors success rate of endonasal and external dcr was 82.4% and 81.6% respectively. 21 jain et al study showed equal success rate of 87% in endonasal versus external dcr. 22 success rate of external and endonasal dcr was 90.9% and 91.3% in study of gupta. 23 it was 94% and 86% in a study of leong. 24 results of all studies show equal and reasonably higher success rate of endonasal and external dcr. results of our study are comparable to all those results. endonasal dcr with less manipulation of tissue and less extensive dissection theoretically promotes healing with primary intension. this leads to less formation of granulation tissue and subsequent scarring and stenosis of internal ostium. 25 limitation of the current study was small sample size, shorter follow up and being conducted in a single center. in future large scale multi-center study with long term follow up is required to conclude the outcome of endo nasal dcr. conclusion endonasal dcr offers minimal invasive approach with comparable anatomical and functional results to the external dcr. ethical approval the study was approved by the institutional review board/ethical review board. (ref no. 51/dme/slmc/swl) conflict of interest authors declared no conflict of interest. references 1. singh ap, narula v, mehr r. a new approach to endoscopic dcr. braz j otorhinolaryngol. 2012; 78 (5): 7-11. 2. caldwell gw. two new operations for obstruction of the nasal duct, with preservation of the canaliculi and an incidental description of a new lacrimal probe. n y med j. 1893; 57: 581e582. 3. toti a. nuovo metodo conservatore di cura radicale delle suporazioni chroniche del sacco lacrimale. clin mod firenze. 1904; 10: 385e389. 4. mcdonogh m, meiring jh. endoscopic transnasal dacryocystorhinostomy. j laryngol otol. 1989; 103 (6): 585-587. 5. sobel rk, aakalu vk, wladis ej, bilyk jr, yen mt, mawn la. a comparison of endonasal dacryocystorhinostomy and external dacryocystorhinostomy: a report by the american academy of ophthalmology. ophthalmology, 2019; 126 (11): 1580-1585. 6. li ey, wong es, wong ac, yuen hk. primary vs. secondary endoscopic dacryocystorhinostomy for acute dacryocystitis with lacrimal sac abscess formation: a randomized clinical trial. jama ophthalmology, 2017; 135 (12): 1361-1366. 7. amadi aj. endoscopic dcr vs. external dcr: what's best in the acute setting? j ophthalmic vis res. 2017; 12 (3): 251. 8. herzallah i, alzuraiqi b, bawazeer n, marglani o, alherabi a, mohamed sk, et al. endoscopic dacryocystorhinostomy (dcr): a comparative study between powered and non-powered technique. j otolaryngol head neck surg. 2015; 44: 56. doi 10.1186/s40463-015-0109-z 9. kim sy, paik js, jung sk, cho wk, yang sw. no thermal tool using methods in endoscopic dacryocystorhinostomy: no cautery, no drill, no illuminator, no more tears. eur arch otorhinolaryngol. 2013; 270 (10): 2677-2682. 10. linberg jv, anderson rl, bumsted rm, barreras r. study of intranasal ostium external dacryocystorhinostomy. arch ophthalmol. 1982; 100 (11): 1758–1762. comparison of endonasal endoscopic dacryocystorhinostomy with external dacryocystorhinostomy pak j ophthalmol. 2021, vol. 37 (3): 312-316 316 11. codère f, denton p, corona j. endonasal dacryocystorhinostomy: a modified technique with preservation of the nasal and lacrimal mucosa. ophthalmic plast reconstr surg. 2010; 26 (3): 161– 164. 12. mann bs, wormald pj. endoscopic assessment of the dacryocystorhinostomy ostium after endoscopic surgery. laryngoscope, 2006; 116 (7): 1172-1174. 13. ullrich k, malhotra r, patel bc. dacryocystorhinostomy. in: stat pearls. treasure island (fl): stat pearls publishing; 2020 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk557851/ 14. hartikainen j, grenman r, puukka p, seppä h. prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy. ophthalmology. 1998;105(6): 1106-1113. 15. hartikainen j, antila j, varpula m, puukka p, seppä h, grénman r. prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. laryngoscope, 1998; 108 (12): 1861-1866. 16. javate rm, campomanes jr bs, co nd, dinglasan jr jl, go cg, tan en, tan fe. the endoscope and the radiofrequency unit in dcr surgery. ophthalmic plastic and reconstructive surgery, 1995; 11 (1): 5458. 17. hii bw, mcnab aa, friebel jd. a comparison of external and endonasal dacryocystorhinostomy in regard to patient satisfaction and cost. orbit, 2012; 31 (2): 67e76. 18. walker ra, al-ghoul a, conlon mr. comparison of non-laser non-endoscopic endonasal dacryocystorhinostomy with external dacryocystorhinostomy. can j ophthalmol. 2011; 46 (2): 191e195. 19. su py. comparison of endoscopic and external dacryocystorhinostomy for treatment of primary acquired nasolacrimal duct obstruction. taiwan j ophthalmol. 2018; 8 (1): 19e23. 20. simon gj, joseph j, lee s, schwarcz rm, mccann jd, goldberg ra. external versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. ophthalmology, 2005; 112 (8): 1463-1468. 21. karim r, ghabrial r, lynch t, tang b. a comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. clin ophthalmol. 2011; 5: 979e989. 22. jain s, ganguly a, singh s, mohapatra s, tripathy d, rath s. primary non-endoscopic endonasal versus delayed external dacryocystorhinostomy in acute dacryocystitis. ophthalmic plast reconstr surg. 2017; 33 (4): 285-288. 23. gauba v. external versus endonasal dacryocystorhinostomy in a specialized lacrimal surgery center. saudi j ophthalmol. 2014; 28 (1): 36e39. 24. leong sc, karkos pd, burgess p, halliwell m, hampal s. a comparison of outcomes between nonlaser endoscopic endonasal and external dacryocystorhinostomy: single-center experience and a review of british trends. am j otolaryngol. 2010; 31 (1): 32-37. 25. bharangar s, singh n, lal v. endoscopic endonasal dacryocystorhinostomy: best surgical management for dcr. indian j otolaryngol head neck surg. 2012; 64 (4): 366-369. authors’ designation and contribution muhammad tariq; professor: concepts, design, manuscript preparation. ahmad zeeshan jamil; associate professor: literature search, drafting of article, critical revision. shahid ali; assistant professor: manuscript writing, critical revision. muhammad khalid; professor: literature search, statistical analysis. ali akash; postgraduate resident: literature search, drafting of article. .…  …. 48 pak j ophthalmol. 2021, vol. 37 (1): 48-52 original article effect of fasting on intraocular pressure zahid kamal 1 , ahmad zeeshan jamil 2 , muhammad khalid 3 , muhammad luqman ali bahoo 4 muhammad junaid iqbal 5 , nauman aziz 6 1,2,3,5,6 sahiwal medical college, sahiwal, 4 cmh institute of medical sciences, bahawalpur abstract purpose: to determine the effect of fasting on intraocular pressure (iop) in fasting individuals. study design: cross sectional observational study. place and duration of study: district headquarter teaching hospital/sahiwal medical college sahiwal, from april 2020 to may 2020. methods: four hundred eyes of two hundred healthy fasting subjects were included in this study. intraocular pressure was measured one week before and during the second week of ramadan using a non-contact tonometer. t-test was used to calculate the difference of means of intraocular pressure one week before and during the second week of ramadan. results: mean age of the subjects was 34.56 ± 12.52 years. iop in male subjects before and during ramadan was 14.23 mm hg and 13.20 mm hg respectively, while iop in female subjects before and during ramadan was 14.43 mm hg and 13.20 mm hg respectively. mean iop before ramadan in the right and left eye was 14.38 ± 3.00 mm hg and 14.21 ± 2.79 mm hg and during ramadan it was 13.24 ± 2.87 mm hg and 13.15 ± 2.71 mm hg respectively. t-test indicated that the difference in means of iop for right eye before and during ramadan was 25.74 (p = 0.000) while for the left eye it was 41.54 (p = 0.000). conclusion: fasting results in a decrease in intraocular pressure in normal population. there was no difference in intraocular pressure changes between male and female subjects. intraocular pressure was higher in older age group in both genders. key words: intraocular pressure, tonometry, glaucoma. how to cite this article: kamal z, jamil az, khalid m, bahoo mla, iqbal mj, aziz n. effect of fasting on intraocular pressure. pak j ophthalmol. 2021, 37 (1): 48-52. doi: https://doi.org/10.36351/pjo.v37i1.1083 introduction physiology of eye is determined by its special anatomy that in turn depends on an intricate balance between tension inside the eye and the rigidity of its wall. this balance is important to maintain the normal spherical shape of the eye. 1 intraocular pressure (iop) is due to correspondence: ahmad zeeshan jamil sahiwal medical college, sahiwal email:ahmadzeeshandr@gmail.com received: june 16, 2020 accepted: august 15, 2020 the difference in aqueous humour production by ciliary processes and aqueous humour outflow through the trabecular meshwork and uveo-scleral pathways. intraocular pressure range is 11 – 21 mm hg in the normal eye when measured with an applanation tonometer. 2 intraocular pressure is known to have diurnal fluctuation. 3 it is also affected by the temperature, season, exercise, blood pressure, respiration and medicine intake for ocular and systemic diseases. 4,5,6 intraocular pressure in children is lower as compared to adults. 7 it also varies in different races and different parts of the world. 8 fasting is practised by followers of different religions. muslims practice fasting during the month effect of fasting on intraocular pressure pak j ophthalmol. 2021, vol. 37 (1): 48-52 49 of ramadan. as the islamic calendar is based on lunar cycle so ramadan can occur in different seasons. muslims do not eat or drink while fasting from dawn until sunset. 9 they are allowed to eat and drink from the breaking of fast till the beginning of next fasting. 10 so, there is a considerable change in the dietary pattern. 11,12 there is also a change in sleeping and behavioural pattern during fasting. 13 fasting is obligatory for all adult healthy muslims. relaxation is given for sick, travellers, pregnant, lactating and menstruating women. 14 they have to complete the count of fasting in other days when they are fit to do so. 15 as millions of muslims observe fasting so it is especially important to know its effects on ocular health. due to variation in diet, climate, lifestyle practices, there are discrepancies in literature about the effect of ramadan on iop. due to a change in dietary habits during fasting, iop may be affected. 16 this study was conducted to know the effect of fasting on intraocular pressure of the population of a particular region. this knowledge will help us in answering the question of people regarding the effect of ramadan on ocular health. methods in this cross-sectional study, four hundred eyes of two hundred healthy fasting subjects were included. the study was conducted at district headquarter teaching hospital/sahiwal medical college sahiwal, from april 2020 to may 2020. employees of the institution of both genders were included in the study. age ranged from 20 to 60 years. following individuals were excluded from the study: individuals with hypertension, diabetes mellitus and thyroid dysfunction. individuals using steroids, persons with a history of ocular trauma or surgery, astigmatism higher than 4 dioptre, orbital malformations and positive history of glaucoma or having an abnormal cup to disc ratio were also excluded. convenient nonprobability sampling technique was used. approval of the study was taken from the institutional review board. informed consent was taken from the participants of the study. a detailed history and clinical examination including visual acuity, slitlamp examination of anterior and posterior segment was conducted. intraocular pressure was measured using a non-contact tonometer. keeler pulsair desktop tonometer was used. average of three readings of each eye was recorded. iop readings were measured from 1 pm to 2 pm. all participants’ iop was recorded one week before and during the second week of ramadan. data was analysed using spss version 24. mean and standard deviation of age and intraocular pressure were calculated. frequency of male and female participants was also calculated. t-test was used to calculate difference in means of iop before and during ramadan. results there were four hundred eyes of two hundred subjects in our study. one hundred and thirty-five (67.5%) males and sixty-five (32.5%) females were included in the study. mean age of the subjects was 34.56 ± 12.52 years. intraocular pressure (iop) one week before and during the second week of ramadan is given in table number 1. p-value of ≤ 0.05 was considered statistically significant. intraocular pressures in various age groups in females and males are given in table no. 2 and 3 respectively. intraocular pressure was higher in older age group as compared to the younger age group in both genders before and during ramadan. this difference was statistically significant with a p value of less than 0.05. there was no difference in intraocular pressure between two genders before and during ramadan with a p value > 0.05. table 1: intraocular pressure (iop) one week before and during second week of ramadan. iop measurement iop right eye (mm hg) iop left eye (mm hg) one week before ramadan 14.38 ± 3.00 14.21 ± 2.79 during second week of ramadan 13.24 ± 2.87 13.15 ± 2.71 table 2: intraocular pressure (iop) in female subjects. age group (years) number of cases iop before ramadan (mmhg) iop during ramadan (mmhg) right eye left eye right eye left eye 20 to 40 38 13.40 ± 31.15 13.47 ± 2.84 12.53 ± 2.96 12.37 ± 2.71 41 to 60 27 15.85 ± 3.03 15.81 ± 2.63 14.04 ± 2.77 14.49 ± 2.44 total 65 14.42 ± 3.29 14.45 ± 2.97 13.15 ± 2.96 13.25 ± 2.79 zahid kamal, et al 50 pak j ophthalmol. 2021, vol. 37 (1): 48-52 table 3: intraocular pressure (iop) in male subjects. age group (years) number of cases iop before ramadan (mm hg) iop during ramadan (mm hg) right eye left eye right eye left eye 20 to 40 89 13.06 ± 2.22 13.18 ± 1.97 12.02 ± 2.20 12.19 ± 1.95 41 to 60 46 16.87 ± 2.23 15.89 ± 3.04 15.74 ± 2.26 14.87 ± 3.01 total 135 14.36 ± 2.86 14.10 ± 2.70 13.29 ± 2.84 13.10 ± 2.68 paired samples test paired differences t df sig. (2tailed) mean std. deviation std. error mean 95% confidence interval of the difference lower upper pair 1 iop before ramadan right eye iop in ramadan right eye 1.13500 .62347 .04409 1.04806 1.22194 25.745 199 .000 pair 2 iop before ramadan left eye iop in ramadan left eye 1.06500 .36254 .02564 1.01445 1.11555 41.545 199 .000 discussion in the current study, mean age of subjects was 34.56 ± 12.52 years which was lesser than that of other studies. in a study conducted by hassan and co-authors, the mean age of fasting subject was 42.3 ± 16.7 years. 16 in another study done by assadi et al mean age of fasting subjects was 40.7±7.1 years. 9 in our study mean intraocular pressure in male subjects was 14.36 ± 2.86 mm hg in right eye and 14.10 ± 2.70 mm hg in left eye before ramadan, while mean intraocular pressure was 13.29 ± 2.84 mm hg in right eye and 13.10 ± 2.68 mm hg in left eye during ramadan. in female subjects mean intraocular pressure was 14.42 ± 3.29 mm hg in right eye and 14.45 ± 2.97 mm hg in left eye before ramadan, while mean intraocular pressure was 13.15 ± 2.96 mm hg in right eye and 13.25 ± 2.79 mm hg in left eye during ramadan. in a study conducted by nomura and colleagues, mean intraocular pressure was 13.6 ± 2.6 mm hg in male and 13.3 ± 2.6 mm hg in female subjects. 17 the results of that study were comparable to the results of our study. in the present study, there was a significant decrease in iop pressure during fasting. our results are in accordance with the results of rabbanikhah and co-authors where there was a reduction of iop of 1.1 mm hg in the morning and 1.5 mm hg in the afternoon during ramadan fasting. 18 in contrast to the results of our study, there was no change in iop during ramadan fasting in a study done by assadi and colleagues. a study conducted by kerimoglu and coauthors showed an increase in iop and tear production in the morning and decrease in iop and tear production in the evening during fasting. that change was due to fluid intake at the beginning of fasting and dehydration at the end of fasting. 10 another research showed a difference in intraocular pressure between fasting and non-fasting persons. the iop was lower in fasting individuals. 19 our study results are comparable to the results of that study. there is disparity in the effects of ramadan fasting on intraocular pressure as is evident by the results of various studies mentioned above. the reason for such a difference may be because ramadan occurs in different seasons of a year. moreover, there may be a difference in lifestyle and dietary habits in different geographical regions of the world. duration of fasting varies between 11 to 18 hours. fasting affects the pattern of food intake, sleep pattern and physical activity. 20 these changes in lifestyle are different in different parts of the world and different seasons. this could be an explanation for the inconsistent effect of fasting on intraocular pressure. ramadan fasting results in a decrease in intraocular pressure within the normal range. this decrease in intraocular pressure is thought to be due to changes in serum electrolyte concentration and hydration status of the body. due to fasting, serum sodium, potassium and selenium are decreased while serum phosphorus is elevated. 21 change in serum electrolyte concentration and osmolality of plasma is thought to be the reason behind the decrease in intraocular pressure during ramadan. moreover, during fasting, there is also a change in the secretion of insulin and glucagon. insulin secretion is decreased while glucagon secretion is increased. 13 there is also a effect of fasting on intraocular pressure pak j ophthalmol. 2021, vol. 37 (1): 48-52 51 change in the lipid metabolism of the body. all these changes have profound effects on the homeostasis of the body. 22 these metabolic changes may be reason behind the changes in intraocular pressure during fasting. the sample size of our study is not large enough that is a limitation of our study. in our study intraocular pressure was measured only at one time of the day and effects on diurnal fluctuation is not considered. erroneous measurement of intraocular pressure can occur due to thick or thin corneas. 23 effect of corneal thickness was not taken into consideration that constitutes another limitation of the present study. measurement with goldmann tonometer is considered the most accurate measurement of iop. air puff measurement of iop can give an overestimation of the reading. 24 iop was measured with the help of air puff tonometer in our study. as all the normal subjects were included in the study, our results cannot be applied to the patients with glaucoma. further studies are needed to answer these limitations. nevertheless, our work described the change in iop in normal individuals during fasting. our work will help in explaining the effects of fasting on the ocular health of pakistani population. conclusion fasting results in a decrease in intraocular pressure in normal population. there was no difference in intraocular pressure changes between male and female subjects. intraocular pressure was higher in older age group in both genders. ethical approval the study was approved by the institutional review board/ ethical review board. (30/dme/slmc/swl) conflict of interest authors declared no conflict of interest. references 1. shafiq i. influence of central corneal thickness (cct) on intraocular pressure (iop) measured with goldmann applanation tonometer (gat) in normal individuals. pak j ophthalmol. 2008; 24: 196-200. 2. domple vk, gaikwad av, khadilkar ha, doibale mk, kulkarni ap. a study on visual outcomes after cataract surgery with intraocular lens implants at the rural health training center, paithan, maharashtra. indian j public health, 2011; 55 (1): 22-24. 3. liu j, roberts cj. influence of corneal biomechanical properties on intraocular pressure measurement: quantitative analysis. j cataract refract surg. 2005; 31: 146–155. 4. mukhtar sa, jamil az, ali z. estimation of range of intraocular pressure in normal individuals by air puff tonometer. pak j ophthalmol. 2014; 30 (3): 129-132. 5. vandeviere s, germononpre p, renier c, stalmans i, zeyen t. influences of atmospheric pressure and temperature on intra-ocular pressure. invest ophthalmol vis sci. 2008; 49: 5392-5396. 6. sawada a, yamamoto t. posture-induced intraocular pressure changes in eyes with open-angle glaucoma, primary angle closure with or without glaucoma medications, and control eyes. invest. ophthalmol. vis. sci. 2012; 53: 7631-7635. 7. sihota r, tuli d, data t, gupta v, sachdeva mm. distribution and determinants of intraocular pressure in a normal pediatric population. j pediatr ophthalmol strabismus, 2006; 43: 14-18. 8. yazici a, sen e, ozdal p, aksakal fn, altinok a, oncul h, et al. factors affecting intraocular pressure measured by noncontact tonometer. eur j ophthalmol. 2009; 19: 61-65. 9. assadi m, akrami a, beikzadeh f, seyedabadi m, nabipour i, larijani b, et al. impact of ramadan fasting on intraocular pressure, visual acuity and refractive errors. singapore med j. 2011; 52 (4): 263266. 10. kerimoglu h, ozturk b, gunduz k, bozkurt b, kamis u, okka m. effect of altered eating habits and periods during ramadan fasting on intraocular pressure, tear secretion, corneal and anterior chamber parameters. eye, 2010; 24 (1): 97-100. 11. nowroozzadeh mh, mirhosseini a, meshkibaf mh, roshannejad j. effect of ramadan fasting in tropical summer months on ocular refractive and biometric characteristics. clin exp optom. 2012; 95 (2): 173e176. 12. vasan sk, karol r, mahendri nv, arulappan n, jacob jj, thomas n. a prospective assessment of dietary patterns in muslim subjects with type 2 diabetes who undertake fasting during ramadan. indian j endocrinol metab. 2012; 16 (4): 552e557. 13. baser g, cengiz h, uyar m, seker un e. diurnal alterations of refraction, anterior segment biometrics, and intraocular pressure in long-time dehydration due to religious fasting. semin ophthalmol. 2016; 31 (5): 499-504. 14. azizi f. islamic fasting and health. ann nutr metab. 2010; 56 (4): 273-282. zahid kamal, et al 52 pak j ophthalmol. 2021, vol. 37 (1): 48-52 15. sedaghat mr, heravian j, askarizadeh f, jabbarvand m, nematy m, rakhshandadi t, et al. investigation of the effects of islamic fasting on ocular parameters. j curr ophthalmol. 2017; 29: 287-292. 16. hassan mb, isawumi ma. effects of fasting on intraocular pressure in a black population. middle east afr j ophthalmol. 2014; 21 (4): 328-331. doi: 10.4103/0974-9233,142271. 17. nomura h, ando f, niino n, shimokata h, miyake y. the relationship between age and intraocular pressure in a japanese population: the influence of central corneal thickness. curr eye res. 2002; 24 (2): 81-85. 18. rabbanikhah z, rafati n, javadi ma, sanago m. effect of religious fasting on intraocular pressure in healthy individuals. bina j ophthalmol. 2005; 42 (12): 732-738. 19. soleymani a, rasoulinezhad s, mahdipour e, khalilian e. effect of fasting on intraocular pressure (iop) in normal individuals. j babol univ med sci. 2009; 11 (1): 57-61. 20. salehi a, rahimi-madise m, rasti-boroujeni a. the effectiveness of fasting on the intraocular pressure in individuals suffering from open-angle glaucoma. j shahrekord univ med sci. 2011; 12 (4): 16-20. 21. karimirad r, nematy m, sedaghat mr, askarizade f, rakhshandadi t, mahmoudi z, et al. the effect of ramadan fasting on intraocular pressure changes in healthy subjects. j fasting health, 2017; 5 (2): 78-82. doi: 10.22038/jfh.2017.24204.1088 22. mattson mp, allison db, fontana l, harvie m, longo vd, malaisse wj, et al. meal frequency and timing in health and disease. proc natl acad sci usa. 2014; 111 (47): 16647-16653. 23. dueker dk, singh k, lin sc, fechtner rd, minckler ds, samples jr, et al. corneal thickness measurement in the management of primary open angle glaucoma: a report by the american academy of ophthalmology. ophthalmology, 2007; 114: 17791787. 24. chou cy, jordan ca, mcghee cnj, patel dv. comparison of intraocular pressure measurement using 4 different instruments following penetrating keratoplasty. am j ophthalmol. 2012; 153: 412-418. authors’ designation and contribution zahid kamal; professor: concept and design of study. interpretation of data and manuscript writing. ahmad zeeshan jamil; associate professor: literature search, drafting of the article, critical revision. muhammad khalid; professor: manuscript writing and critical revision. muhammad luqman ali bahoo; associate professor and head of department: literature search and statistical analysis. muhammad junaid iqbal; assistant director medical education: literature search and proof reading. nauman aziz; assistant professor of physiology: literature search and drafting of article. .…  …. original article 90 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology original article diode laser trans-scleral cycloablation as surgical treatment for primary open-angle glaucoma after maximum tolerated medical therapy jawad bin yamin butt, tariq mehmood qureshi, muhammad tariq khan, anwar-ul-haq ahmad pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: jawad bin yamin butt layton benevolent trust hospital (lrbt), 436 a/i township lahore …..……………………….. purpose: to establish the role of diode laser trans-scleral cycloablation (dlca) as a primary treatment choice in open angle glaucoma (poag) after maximum endured medical therapy. material and methods: it is a quasi-experimental study which was conducted at layton rahmatullah benevolent trust free eye care and cancer hospital, lahore (lrbt). the duration of study was 1 year (29-03-2013 to 29-03-2014). sixty patients meeting the inclusion criteria (inclusion criteria were primary open angle glaucoma and maximum tolerated oral / topical medication) were selected from the glaucoma unit of lrbt for this study. twenty five to 30 burns of diode laser were applied to 270 degrees avoiding 3 and 9 o clock positions, 1.5 mm posterior to the limbus. laser was set at duration of 1.5 seconds and power between 1500 and 2000 mw. the power was attuned till a popping sound was heard and then reduced to just below that level. patients were followed up for a period of one year. results: out of a total of 60 eyes with mean age 52.73 ± 7.40 years, 36 (60%) were male and 24 (40%) were female. the mean pre-operative iop was ± 41.62 mm hg (the pre-operative iop ranged from 28 mm hg to 60 mm hg). the mean post-operative iop was 18.97 mm hg on day one, 16.75 mm hg at 1 week, 15.68 mm hg at 1 month, 15.00 mm hg at 6 months and by the end of a year it was about 14.15 mm hg (the post-operative iop ranged from 6 mmhg to 52 mm hg). there was a considerable drop of more than 50% of post-operative iop in contrast to pre-operative iop. conclusion: diode laser trans-scleral cycloablation is a convenient, swift, well – endured modus operandi that provides a modest and variable lowering of intraocular pressure with few complications. laucoma is the major cause of irrevocable blindness1,7. the incidence rate and prevalence of glaucoma in pakistan is similar to that of other dark colored population of the developing countries, but tangible statistical data is lacking. according to a study carried out in lahore, 23% of the blindness is found to be due to glaucoma6. long term medical treatment is improbable, however, because of the long distances patients must travel for treatment, the high cost and low accessibility to medications. glaucoma is often taken to be a surgical problem. trabeculectomy with anti metabolites is an effective treatment for poag1,7. primary trabeculectomy is still a procedure of choice all over for cases in which a great lowering in iop is the intent of the treatment, especially when high iop g dlca as surgical treatment for poag after max tolerated medical therapy pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 91 persists despite of giving maximum tolerable anti glaucoma medication (which varies from patient to patient)2,8. diode laser trans-scleral cycloablation (dlca) has been used effectively for the cure of refractory glaucoma, as well as those eyes in which other surgical treatments have failed1,7. diode laser is widely established as the remedy of choice in severe glaucoma cases and is appropriate as a primary surgical procedure4,5. in developing countries, there is a scarcity of both ophthalmologists and resources for eye care. regrettably, medical and surgical treatment cannot be accessible to every glaucoma patient. therefore, dlca is an easy, swift and low cost surgical procedure for patients with poag after maximum endured medical treatment. diode laser is a harmless, efficient method to reduce the iop in the treatment of different glaucomas with few severe complications. material and methods sixty patients satisfying the inclusion criteria were chosen from the glaucoma unit of layton rahmatullah benevolet trust (lrbt) hospital to be included in this study. the duration of study was one year which included six months of recruitment and six months of follow-up. after taking well versed permission, socio-demographic data (name, age, sex, occupation) was recorded. a complete ophthalmological history was taken. preoperative and postoperative evaluation was done by including visual acuity with snellen chart, iop with goldmann applanation tonometer and topcon air puff. slit lamp examination with haag streit bq-900 was done for anterior segment examination. super field 90 d lens was used for fundus evaluation including cup-disc ratio. gonioscopic evaluation of anterior chamber angle with goldmann triple mirror and perimetry with humphry visual field analyser was also done. inclusion criteria were primary open angle glaucoma and maximum tolerated oral / topical medication while exclusion criteria were uveitis, cataract, diabetes mellitus, hyper tension. treatment course of action included preoperative administration of peribulbar or subtenon anesthesia. transscleral diode laser cyclophotocoagulation (“cyclodiode”) was performed using the iridis quantal. laser was applied for 1.5 seconds with power between 1500 to 2000 mw. the power was adjusted until a popping sound was heard and then reduced to just below that level. approximately 30 burns were placed 1.5 mm posteriorly to the limbus over 270 degrees. oral nsaids, topical dexamethasone 0.1% eye drops along with anti glaucoma medication were continued for the 1st week. miotics were discontinued for the 1st week. anti glaucoma medication was tapered according to the drop in iop. at 1 week post laser treatment oral acetazolamide was discontinued if the lop was < 21 mm hg. oral acetazolamide was given to eighteen patients and was continued for up to one week. topical steroids, usually dexamethasone 0.1% eye drops, were given four times a day for 2 – 4 weeks after treatment. follow up was noted on 1st day, 1st week, 1st month, 6th month and 1 year. pre-op gonioscopic examination revealed poag grade iii in all the patients. visual acuity and visual field remained unchanged in all the patients. any complications occurring in patients like anterior segment inflammation, cataract, hyphema and hypotony were also taken into account. results sixty patients were included in the study. their ages ranged between 45 to 60 years and the mean age of patients was about 52.73 ± 7.40 years. 60% of the patients were male and 40% were female. 52% operated eyes were right and 48% were left eyes. most of the patients were using three or more anti-glaucoma drugs pre-op (figure 1). the mean pre-operative iop was ± 41.62 mm hg (the pre-operative iop ranged from 28 mm hg to 60 mm hg). the mean post-operative iop was 18.97 mm hg on day one, 16.75 mm hg at 1 week, 15.68 mm hg at 1 month, 15.00 mm hg at 6 months and by the end of a year it was about 14.15 mm hg (the postoperative iop ranged from 6 mm hg to 52 mm hg). mean post-operative iop lessened by more than 50% as compared to mean pre-operative iop (figure 2). (the post-operative iop ranged from 6 mm hg to 52 mm hg) (table 1). the mean post-operative iop continued to decrease by the end of one year. anterior segment inflammation was seen in only eight eyes (13.3%) out of 60 eyes. similarly cataract as a complication occurred in 8 eyes (13.3%), hyphema in 5 eyes (8.3%) while 6 eyes (10%) developed hypotony. we had a maximum of 3 sessions in our series. retreatment was jawad bin yamin butt, et al 92 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology done in 44% of which only 6% received 3 treatment sessions. preoperative and postoperative mean intra ocular pressure was assessed using paired t test and final p values were 0.00 which is less than 0.05, and this shows that the test is highly significant (table 2). number of anti glaucoma medications being used prior to dlca 0 10 20 30 40 50 60 70 2 3 4 5 percent fig. 1: most of the patients were using three or more anti-glaucoma drugs pre-operatively. 0 5 10 15 20 25 30 35 40 45 p re -o p er at iv e 1 d ay 1 w ee k 1 m o nt h 6 m o nt hs 1 y ea r mean iop fig. 2: drop of mean iop following dlca this proves that iop decrease after dlca by the end of one year is notably lower than the preoperative iop. the complications with dlca were evaluated using chi square test, that included anterior segment inflammation, cataract, hyphema and hypotony, and it showed that the minimum expected frequency is 30.0, and p value for each complication is 0.00 which is less than 0.05, showing that the complication rate is not significant. discussion in this study of dlca as primary treatment for poag, the treatment was rapid and straight forward. patient reception of treatment was exceptional and patient. dlca is relatively safe as no major complications came into account. dlca has established itself a satisfactory track record for the treatment of refractory glaucoma9-12. it has also been tried as a primary surgical treatment in different types of glaucoma13-15. the complications are tolerable. inconsequential and transitory complications like pain and inflammation were noted by most authors16-18. some surgeons are trying it as an alternative to drainage implant surgery in complex glaucoma19. a constraint of the study may be that the group had a small number of 60 patients. however, adequate follow-up information from all patients was acquired and the cases were included on consecutive basis. no standard protocol has yet been agreed upon for the energy settings. different settings have been used ranging from 1.5 watts to 2.5 watts for 1 – 2 seconds20-22. we used a power of 1500-2000 mw titrating with the pop sounds. spencer and vernon used a fixed setting and did not alter it to hear the pop sound3. 3 and 9 o’ clock positions should be avoided to save ciliary nerves and in phakic eyes the probe must be 1.5 mm posterior to the limbus to avoid lens damage. structural changes occurring with diode laser trans-scleral photocoaggulation are thermal coagulative necrosis of ciliary epithelia and stroma followed by atrophy, fibrosis and fusion of ciliary processes. oral nsaids, topical dexamethasone 0.1% eye drops along with anti glaucoma medication except miotics were continued for the 1st week. anti glaucoma medication was tapered in accordance with the drop in intraocular pressure. at 1 week post laser treatment oral acetazolamide was discontinued if the lop was < 21 mm hg. topical steroids, usually dexamethasone 0.1 % eye drops, were prescribed four times a day for 2 – 4 weeks after treatment. we had a mean drop of 50.08% in iop. this is comparable to other studies mentioned above where a decrease of 20 – 65% in mean iop has been reported. there is no agreement on how many times the procedure should be repeated. spencer and vernon repeated the procedure up to five times22. we had a m e a n i o p ( m m h g ) dlca as surgical treatment for poag after max tolerated medical therapy pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 93 maximum of 3 sessions in our series. brancato18 and bock23 had a retreatment rate of 65% and 70% respectively. noureddin20 recommends that a high power setting results in better iop control and lesser need for re-treatments. the drop in iop was more than 50% and final iop was ± 14.15 mm hg. results in literature vary from 48%-92%12,15,19,22. literature review advocates that better success rate is seen with higher power settings and increased number of treatments. egbert15 had a success rate of 48%. their power settings were low and treatment repeated only in 20% cases. repeated treatment and higher power settings would improve success but they were conservative because they were undertaking the procedure as a primary treatment. highest rate we could find in literature is that of gupta and agarwal which is 92%. a remarkable difference in their method was that they treated 360 degrees instead of 270 degrees. murphy have also measured the sensitivity to cyclophotocoagulation and found chronic angle closure glaucoma and glaucoma secondary to retinal surgery to be the most sensitive to this treatment. though we specifically did not measure the sensitivity but our findings seem to confirm this. hypotony and phthisis are the most serious adverse effects of this therapy. in our series there was no case of phthisis and hypotony occurred only in 6 out of 60 patients. the advantages of diode laser trans-scleral cycloablation are: • better scleral penetration due to longer wavelength • back scatter lessened • compact, light weight & portable • air or electrically cooled • standard current used the findings of other investigators that dlca is highly effective in lowering intraocular pressure were confirmed by our results. high success and low complication rate along with portability, resilience and easy to learn technique makes diode laser jawad bin yamin butt, et al 94 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology cycloablation the treatment of choice for refractory and complex glaucoma. conclusion diode laser trans-scleral cycloablation is a convenient, swift, well – endured modus operandi that provides a modest and variable lowering of intraocular pressure with few solemn complications. it can be used safely for treatment of poag after maximum tolerated oral / topical therapy. author’s affiliation dr. jawad bin yamin butt layton benevolent trust hospital free eye care and cancer hospital lahore dr. tariq mehmood qureshi layton benevolent trust hospital free eye care and cancer hospital lahore dr. muhammad tariq khan layton benevolent trust hospital free eye care and cancer hospital lahore dr. anwar-ul-haq ahmad layton benevolent trust hospital free eye care and cancer hospital lahore references 1. reiss gr, lee da, topper je. aqueous humor flow during sleep. invest ophthalmol viscid. 1984; 25: 776-8. 2. davson h. the eye: vegetative physiology and biochemistry. 3rd ed. san diego: academic press; 1984. 3. leydhecker w. the intraocular pressure, clinical aspects. ann ophthalmol. 1996; 8: 389-90. 4. duckman rh, fitzgerald de. evaluation of intraocular pressure in pediatric population. optom visci. 1992; 69: 705-9. 5. becker m, funk j. diode laser cyclophotocoagulation as the primary surgical intervention in glaucoma. ophthalmologe. 2001; 98: 1145-8. 6. jahangir s. a survey of blindness in eye patients in punjab. pak j ophthalmol. 1993; 9: 43-5. 7. egbert pr, fiadoyor s, budenz dl, dadzie p, byrd s. diode laser transscleralcycloablation as a primary surgical treatment for primary open-angle glaucoma. arch ophthalmol. 2001; 119: 345-50. 8. jalal t, mohammad s. three years retrospective study of patients underwent trabeculectomy in lady reading hospital peshawar. j postgrad med inst. 2004; 18: 487-94. 9. cc murphy, cam burnett, pgd spry, dc broadway, jp diamond. a two centre study of the dose-response relation for transcleral diode laser cyclophotocoagulation in refractory glaucoma. br j ophthalmol. 2003; 87: 1252-7. 10. ataullah s, biswas s, artes ph, o’donoghue e, ridgway aea, spencer af. long term results of diode laser cycloablation in complex glaucoma using the zeiss visulas ii system. br j ophthalmol. 2002; 86: 39-42. 11. martin krg, broadway dc. cyclodiode laser therapy for painful, blind glaucomatous eyes. br j ophthalmol. 2001; 85: 474-6. 12. schlote t, derse m, zierhut m. trans-scleral diode laser cyclophotocoagulation for the treatment of refractory glaucoma secondary to inflammatory eye diseases. br j ophthalmol. 2000; 84: 999-1003. 13. heinz c, koch jm, heiligenhaus a. transscleral diode laser cyclophotocoagulation as primary surgical treatment for secondary glaucoma in juvenile idiopathic arthritis: high failure rate after short term follow up. br j ophthalmol. 2006; 90: 737-40. 14. lai js, tham cc, chan jc, lam ds. diode laser trans-scleral cyclophotocoagulation as primary surgical treatment for medically uncontrolled chronic angle closure glaucoma: longterm clinical outcomes. j glaucoma. 2005; 14: 114-9. 15. egbert pr, fiadoyor s, budenz dl, dadzie p, byrd s. diode laser trans-scleral cyclophotocoagulation as a primary surgical treatment for primary open angle glaucoma. arch ophthalmol. 2001; 119: 345-50. 16. bloom pa, tsai jc, sharma k. cyclodiode trans-scleral diode laser photocoagulation in the treatment of advanced refractory glaucoma. ophthalmology. 1997; 104: 1508-19. 17. kosoko o, gaasterland de, pollack ip. the diode laser ciliary ablation study group. long term outcome of initial ciliary ablation with contact diode laser trans-scleral cyclophotocoagulation for severe glaucoma. ophthalmology 1996; 103: 1294-302. 18. brancato r, carassa rg, bettin p. contact trans-scleral cyclophotocoagulation with diode laser in refractory glaucoma. eur j ophthalmol. 1995; 5: 32-9. 19. gupta v, agarwal hc. contact trans-scleral laser cyclophotocoagulation treatment for refractory glaucomas in the indian population. indian j ophthalmol. 2000; 48: 295-300. 20. noureddin bn, zein w, haddad c, ma'luf r, bashshur z. diode laser transcleral cyclophotocoagulation for refractory glaucoma: a 1 year follow-up of patients treated using an aggressive protocol. eye. 2006; 20: 329-35. 21. chang sh, chen yc, li cy, wu sc. contact diode laser transscleral cyclophotocoagulation for refractory glaucoma: comparison of two treatment protocols. can j ophthalmol. 2004; 39: 511-6. 22. spencer af, vernon sa. “cyclodiode”: results of a standard protocol. br j ophthalmol. 1999; 83: 311-6. 23. bock cj, freedman sf, buckley eg. trans-scleral diode laser cyclophotocoagulation for refractory pediatric glaucomas. j pediatr ophthalmol strabismus. 1997; 34: 235-9. ../../../m.%20hannan%20jamil/my%20documents/mitomycin%20references/introduction/journal.php http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstract&term=%22heinz+c%22%5bauthor%5d 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http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstract&term=%22wu+sc%22%5bauthor%5d 15 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology original article trans-scleral effect of mitomycin-c on ciliary body epithelium p. s. mahar pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p. s. mahar department of surgery, section of ophthalmology, aga khan university hospital stadium road, karachi 74800, pakistan …..……………………….. purpose: to determine the toxic effect of intraoperative adjunctive topical mitomycin c (mmc) on ciliary body epithelium resulting in decrease in intraocular pressure (iop). material and methods: an interventional case series of 120 patients (120 eyes) with pterygium treated from 2005 to 2010. all patients underwent pterygium excision with intraoperative mmc, (0.2 mg/ml) administered for 3 minutes. the toxic effect of mmc on ciliary body was determined through changes in the iop. any change in iop of greater than 5 mm hg was considered significant. the iop was recorded on day 1, day 7, at 1 month and at 3 months. the data were analyzed using proportion, group means, standard deviations and student t test. results: there was no significant decline in iop throughout the follow-up period (p = 0.44). at 3 months postoperatively, 105 eyes (87.5%) had no changes in iop of >5 mm hg. the mean iop changed from a preoperative level of 14.85 mm hg to 14.44 mm hg at 3 months follow up signifying no change statistically. conclusions: our results showed that use of mmc as an adjunctive treatment in pterygium excision has no effect on intraocular pressure and do not support the trans-scleral toxic effect of mmc on the ciliary body epithelium as an intraocular pressure lowering mechanism. itomycin c (mmc) has been used for treating various ocular disorders ranging from pterygium to glaucoma. chen et al1 were the first researchers to use mmc intraoperatively for refractory glaucoma. since then it has become the drug of choice to augment trabeculectomy for effectively controlling intraocular pressure (iop) in different types of glaucoma. the success of mmc has been attributed primarily to its antimetabolitic and antifibrotic effect shown in numerous clinical2,3 and laboratory studies4,5. the most important postoperative complications of this procedure are early and late hypotony6-8. in the immediate postoperative state, increased flow of aqueous through the filtering site has been cited as the major contributing factor resulting in decreased iop9. conversely, this does not explain the late onset of hypotony (< 6 mm hg) in some patients undergoing trabeculectomy with mmc. there is growing evidence from experimental studies that mmc may be toxic to the ciliary body epithelium, resulting not only in decreased iop, but also affecting aqueous humor dynamics and causing a number of other complications10. xia et al observed swelling of the intracellular mitochondria along with the non-pigmented epithelium of the ciliary body in rabbit eyes exposed to mmc, signifying its toxic effect, with decreased aqueous production resulting in hypotony11. in a study by levy and coworkers, microscopic examination of rat eyes treated with mmc showed pyknotic nuclei in conjunction with irregular flattened cells in the ciliary body12. the severity of changes correlated with the concentration and duration of exposure to mmc. the authors concluded that mmc and other antimetabolites have a direct toxic effect on the ciliary body epithelium, besides their known effect on the conjunctiva. the application of mmc, both topically in glaucoma filtering surgeries and by the subconjunctival method of mahar et al in glaucoma patients,13 has yielded significant decreases in iop in m trans-scleral effect of mitomycin-c on ciliary body epithelium pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 16 both experimental and human models. since topical mmc is extensively used as an adjunct in pterygium excision to prevent recurrence, the purpose of this study was to determine the effect of mmc on ciliary body epithelium through the changes in iop in eyes that were undergoing pterygium excision with topical mmc. material and methods this non-randomized interventional case series was performed at the section of ophthalmology, department of surgery, aga khan university hospital, karachi, pakistan, from 2005 to 2010. one hundred and fifty six patients with unilateral progressive pterygium who had undergone supervised surgical excision by the bare sclera technique with mmc were enrolled. the exclusion criteria were previous drainage surgery, suspicious growth other than pterygia or corneal scarring, antiglaucoma therapy in either eye, history of sjogren’s syndrome or any other ocular disease, and keratoconjunctivitis sicca. the study protocol was approved by the hospital ethics committee and the study was performed in accordance with the declaration of helsinki. all patients provided informed consent. the primary outcome measure was to determine the toxic effect of mmc on the ciliary body epithelium through the comparison of mean baseline iop with the iop measured in the ipsilateral eye affected by pterygium at 3 months after intraoperative treatment with topical mmc. the baseline iop measurement was established by taking the mean of the two highest values measured at 9:00 am and 4:00 pm by goldmann applanation tonometry (gat) before pterygium excision. all patients underwent complete ocular examination, including best-corrected visual acuity, biomicroscopic examination of the anterior segment with gat, and fundus examination with a +90 diopter lens. pterygium excisions were performed on an outpatient basis by the same surgeon (psm) using the same technique.14 no premedication was given to any patient. after pterygium excision with the bare scleral technique under topical anesthesia (proparacaine, alcon – belgium), a 5x 5-mm sterile sponge soaked in 8 to 10 drops of mmc (kyowa – japan) 0.2 mg/ml19–21 was applied over the corneosclera and the area from where pterygia was excised for 3 minutes. the sponge was removed and the eye was irrigated with 20 ml of 0.9% normal saline. this was followed by topical administration of dexamethasone 0.1% plus tobramycin 0.3% (tobradex, alcon – belgium) and hydroxypropyl methylcellulose (tear naturale ii, alcon – belgium), which was instilled 4 times daily for 4 weeks to prevent postoperative inflammation. the patients’ iops were measured on days 1, day 7 at 1 month and after 3 months. any adverse effects or physical findings were also noted at each visit. statistical analysis the data analysis was conducted into the statistical package for the social sciences version 16 (spss inc. chicago, usa). the entire continuous variable i.e. age, baseline iop, post-op iop and change in iop presented as mean ± standard deviation and categorical variables like gender, affected eye, iop and pterygium site presented as frequency and percentage. to estimate the comparison between the iop’s, we applied paired sample t test using preoperative levels. the iop was considered to be higher or lower than the preoperative level if the difference was more than 5 mm hg. the iop value measured preoperatively was taken as the baseline measurement to reduce any bias due to recruitment. results one hundred and fifty six patients were enrolled; 120 eyes of 120 patients were followed for at least 3 months, 36 patients were lost to follow-up and hence their data has been excluded from this study. there were 76 male (63.3%) and 44 female (36.7%) with a mean age of 52.3 years (range, 26 to 83 years) and standard deviation 2.4. the pterygium was located on the nasal side in 99 eyes (82.5%) and on the temporal side in 21 eyes (17.5%). there were 55 right eyes and 65 left eyes. the baseline characteristics of the patients are shown in (table 1). there were no significant changes in iop in 105 eyes (87.5%) at 3 months (p = 0.44, paired student t test); eight eyes (6.7%) had a decrease in iop >5 mm hg and 7 eyes (5.8%) had an increase in iop >5 mm hg, which were not statistically significant (tables 2 and 3). fifty five affected eyes were on the right side, of which 49 eyes (89.1%) had no significant change in iop throughout the follow-up period (p = 0.23); 17 eyes (30.9%) had no change in iop and 31 (56.4%) had minimal changes (≤ 5 mm hg). three eyes (5.4%) had a decrease in iop of > 5 mm hg and 4 (7.3%) had an increase in iop of > 5 mm hg. there was a change in p. s. mahar 17 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology iop level from a mean of 14.90 mm hg ± 1.5 sd at baseline to a mean of 14.35 mm hg ± 1.8 sd after 3 months, which was statistically not significant. sixty five affected eyes were on the left side, of which 56 eyes (86.1%) had no significant change in iop throughout the follow-up period (p = 0.64); 21 eyes (32.3%) had no change in iop and 36 eyes (55.4%) had minimal changes (≤ 5 mm hg). five eyes (7.7%) had a decrease in iop of > 5 mm hg and 3 (4.6%) had an increase in iop of > 5 mm hg. there was a change in iop level from a mean of 14.80 mm hg ± 1.4 sd at baseline to a mean of 14.53 mm hg ± 1.1 sd after 3 months, which was statistically not significant. discussion this study investigated the toxic effect of mmc on ciliary body epithelium through the changes in iop in eyes, undergoing pterygium excision with topical mmc. in a laboratory study by letchinger et al15, subconjunctival injection of mmc was administered to rabbit eyes and a consequent drop in iop was noted. in an experimental study in monkeys, kee et al noted a decrease in iop from baseline after administration of mmc, and a possible mechanism of aqueous suppression was suggested to be responsible for the iop reduction16. in a clinical study by gandolfi et al,17 subconjunctival injection of mmc was administered to 12 eyes with no perception of light and a decrease of about 5 mm hg (sd, 1.61 mm hg) in iop was observed at 60 days. these researchers also performed tonography on their patients to detect the possible effect of mmc on the aqueous outflow from the eye, and found no significant change in the ‘c’ coefficient throughout the follow-up period. the results of this study differ from the results of the above mentioned studies,15-17 in that the decrease in iop was observed only in 4% to 5% of patients, which is statistically insignificant. in a prospective study, raiskup et al described the long-term effect of intraoperative application of mmc 0.2 mg/ml for 5 minutes in patients undergoing pterygium excision and noted a normal iop on follow-up.18 similarly in a study by mahar et al. patients undergoing pterygium excision with mmc applied topically in 5 different group of patients with application time difference of 1 trans-scleral effect of mitomycin-c on ciliary body epithelium pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 18 to 5 minutes, no change in iop greater than 5 mmhg was seen in either of the groups19. the difference in the effect of application of intraoperative topical mmc on iop can be attributed to the variation between the procedures carried out for pterygium excision and glaucoma filtering surgery. in trabeculectomy, a partial thickness flap is created at the corneoscleral junction, with a window opening under the flap made by removing a portion of the trabecular meshwork. this allows aqueous fluid to flow out of the eye, resulting in decreased iop with the formation of a bleb. the scarring at the conjunctivoscleral interface is prevented by the application of mmc due to its anti-fibrotic property, which can sometimes lead to hypotony. the disparity in the results of this study with those carried out in glaucoma filtering surgery,20-22 in which a significant drop in iop was noted, suggests that scleral flap formation with internal sclerotomy may be responsible for the decline in iop by either causing damage to the ciliary body by diffusion of mmc inside the eye or increasing the aqueous outflow by preventing scleral adhesions4. in pterygium excision where no such flap is formed, there is no trans-scleral effect of mmc on the ciliry body epithelium and hence there is no change in iop. other factors, not effecting iop could be smaller dosage of mmc at 0.2 mg/ml, when mmc has been used in concentration of 0.1 mg/ml to 0.5 mg/ml in various studies. the smaller application time of 3 minutes of mmc can also be other contributory factor. our data showed no significant decrease in iop after intraoperative topical application of mmc during pterygium surgery. the eye in this study had not undergone any previous surgery or medical treatment, so iop changes by these methods seems unlikely. to decrease the effect of inflammation or prostaglandin release after surgery, corticosteroids that do not have any iop – lowering effects were administered. furthermore, to exclude the effect of steroid response among the study population, the prevalence was assumed to be that of the general population (18% to 36%)23. although most people with primary open angle glaucoma (poag) are classified as steroid responders, in this study none of the patients had poag. however, while there are steroid responders who do not have poag, most of the patients (96.6%) did not show an increase in iop to such an extent as to be classified as steroid responders. hence, any change in iop attributed to steroid use is unlikely. this study found no significant effect on iop by intraoperative use of topical mmc in patients undergoing pterygium excision, confirming the safety of mmc with regards to any effect on the ciliary body for this type of surgical procedure. conclusion our results showed that use of mmc as an adjunctive treatment in pterygium excision has no effect on intraocular pressure, at least for three months after the surgery. these results also do not support the transscleral toxic effect of mmc on the ciliary body epithelium as an iop lowering mechanism. author’s affiliation prof. dr. p.s. mahar department of surgery section of ophthalmology aga khan university hospital stadium road, karachi 74800 references 1. chen c, huang h, bair j, lee c. trabeculectomy with simultaneous topical application of mitomycin-c in refractory glaucoma. j ocul pharmacol. 1990; 6: 175-82. 2. stone rt, herndon lw, allinghan rr, shield mb. results of trabeculectomy with 0.3 ml / mitomycin-c titrating exposure times based on risk factor for failure. j glaucoma. 1998; 7: 3944. 3. singh k, mehta k, shaikh nm, tsai jc, moster mr, budenz dl, greenfield ds, chen pp, cohen js, baerveldt gs, shaikh s. trabeculectomy with intraoperative mitomycin-c versus fluorouracil. prospective randomized clinical trial. ophthalmology. 2000; 107: 2305-9. 4. khaw pt, sherwood mb, mackay sl, rossi mj, schultz g. five minutes treatment with fluorouracil, floxuridine and mitomycin have long term effect on human tenon’s capsule fibroblasts. arch ophthalmol. 1992; 110: 1150-4. 5. crowston jg, chang lh, daniels jt, khaw pt, akbar an. t lymphocytes mediated lysis of mitomycin-c treated tenon’s capsule fibroblasts. br j ophthalmol. 2004; 88: 399-405. 6. sunar ij, greenfield ds, miller mp, nicolela mt, palmberg pf. hypotony maculopathy after filtering surgery with mitomycin-c. incidence and treatment. ophthalmology. 1997; 104: 207-15. 7. mietz h, diestelhorst m, addicks k, krieglstein gk. extraocular application of mitomycin-c in a rabbit model: cytotoxic effects on the ciliary body and epithelium. ophthalmic surg. 1994; 25: 240-4. 8. bindlish r, condorn gp, schlosser jd, d’antonio j, lauer kb, lehrer r. efficacy and safety of mitomycin-c in primary trabeculectomy. five years follow-up. ophthalmology. 2002; 109: 1336-42. 9. mietz h, jacobi p, krieglstein gk. intraoperative episcleral versus postoperative topical application of mitomycin-c for trabeculectomies. ophthalmology. 2002; 109: 1343-9. http://www.ncbi.nlm.nih.gov/pubmed?term=tsai%20jc%5bauthor%5d&cauthor=true&cauthor_uid=11097613 http://www.ncbi.nlm.nih.gov/pubmed?term=moster%20mr%5bauthor%5d&cauthor=true&cauthor_uid=11097613 http://www.ncbi.nlm.nih.gov/pubmed?term=budenz%20dl%5bauthor%5d&cauthor=true&cauthor_uid=11097613 http://www.ncbi.nlm.nih.gov/pubmed?term=budenz%20dl%5bauthor%5d&cauthor=true&cauthor_uid=11097613 http://www.ncbi.nlm.nih.gov/pubmed?term=budenz%20dl%5bauthor%5d&cauthor=true&cauthor_uid=11097613 http://www.ncbi.nlm.nih.gov/pubmed?term=greenfield%20ds%5bauthor%5d&cauthor=true&cauthor_uid=11097613 http://www.ncbi.nlm.nih.gov/pubmed?term=chen%20pp%5bauthor%5d&cauthor=true&cauthor_uid=11097613 http://www.ncbi.nlm.nih.gov/pubmed?term=cohen%20js%5bauthor%5d&cauthor=true&cauthor_uid=11097613 http://www.ncbi.nlm.nih.gov/pubmed?term=baerveldt%20gs%5bauthor%5d&cauthor=true&cauthor_uid=11097613 http://www.ncbi.nlm.nih.gov/pubmed?term=shaikh%20s%5bauthor%5d&cauthor=true&cauthor_uid=11097613 http://www.ncbi.nlm.nih.gov/pubmed?term=rossi%20mj%5bauthor%5d&cauthor=true&cauthor_uid=1386726 http://www.ncbi.nlm.nih.gov/pubmed?term=schultz%20g%5bauthor%5d&cauthor=true&cauthor_uid=1386726 p. s. mahar 19 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology 10. ustundag c, diestelhorst m. effect of mitomycin-c on aqueous humor flow, flare and intraocular pressure in eyes with glaucoma 2 years after trabeculectomy. graefes arch clinic exp ophthalmol.1998; 336: 734-8. 11. xia x, jiang y, huang p, wu z, zeng q, wen j. cytotoxic effect of mitomycin-c on the non-pigmented epithelium of ciliary body in rabbit eye. zhongua van ke za zhi. 1998; 34: 190-3. 12. levy j, tessler z, rosenthal g, klemperer i, zirkin hj, kachko l, lifshitz t. toxic effect of sub-conjunctival 5fluorouracil and mitomycin-c on ciliary body of rats. int ophthalmol. 2001; 34: 199-203. 13. mahar ps, manzar n, hassan m. effect of subconjunctival mitomycin-c on intraocular pressure in various types of glaucoma. asian j opthalmol. 2010; 12: 2-6. 14. mahar ps, nwokora ge. role of mitomycin-c in pterygium surgery. br j ophthalmol. 1993; 77: 433-5. 15. letchinger sl, becker b, wax mb. the effect of subconjunctival administration of mitomycin-c on intraocular pressure in rabbits. invest ophthalmol vis sci. 1992; 33: 736-7. 16. kee c, pelzek cd, kaufman pl. mitomycin c suppresses aqueous humor flow in cynomolgus monkeys. arch ophthalmol. 1995; 113: 239-42. 17. gandolfi sa, vecchi m, braccio l. decrease of intraocular pressure after subconjunctival injection of mitomycin-c in human glaucoma. arch ophthalmol. 1995; 113:582-5. 18. raiskup f, solomon a, landau d, m ilsar, j frucht – pery. mitomycin c for pterygium: long-term evaluation. br j ophthalmol. 2004; 88: 1425-8. 19. mahar ps, manzar n, ahmad k. the effect of intra-operative use of topical mitomycin-c on intra-ocular pressure in patients with pterygium excision. asian j ophthalmol. 2010; 12: 144-8. 20. mandal ak, prasad k, naduvilath tj. surgical results and complications of mitomycin-c augmented trabeculectomy in refractory developmental glaucoma. opthalmic surg lasers. 1999; 30; 473-80. 21. sidoti pa, belmonte sj, leibmann jm, ritch r. trabeculectomy with mitomycin-c in the treatment of pediatric glaucomas. ophthalmology. 2000; 107: 422-31. 22. hye a. primary trabeculectomy with topical application of mitomycin-c in primary glaucoma. pak j ophthalmol. 2000; 16: 124-30. 23. tripathi, parapuram sk, tripathi bj, zhong y, chalam kv. corticosteroids and glaucoma risk. drugs aging. 1999; 15: 43950. http://www.ncbi.nlm.nih.gov/pubmed?term=levy%20j%5bauthor%5d&cauthor=true&cauthor_uid=12678396 http://www.ncbi.nlm.nih.gov/pubmed?term=tessler%20z%5bauthor%5d&cauthor=true&cauthor_uid=12678396 http://www.ncbi.nlm.nih.gov/pubmed?term=rosenthal%20g%5bauthor%5d&cauthor=true&cauthor_uid=12678396 http://www.ncbi.nlm.nih.gov/pubmed?term=klemperer%20i%5bauthor%5d&cauthor=true&cauthor_uid=12678396 http://www.ncbi.nlm.nih.gov/pubmed?term=zirkin%20hj%5bauthor%5d&cauthor=true&cauthor_uid=12678396 http://www.ncbi.nlm.nih.gov/pubmed?term=kachko%20l%5bauthor%5d&cauthor=true&cauthor_uid=12678396 http://www.ncbi.nlm.nih.gov/pubmed?term=lifshitz%20t%5bauthor%5d&cauthor=true&cauthor_uid=12678396 http://www.ncbi.nlm.nih.gov/pubmed/?term=ilsar%20m%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=frucht-pery%20j%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed?term=ritch%20r%5bauthor%5d&cauthor=true&cauthor_uid=10711876 http://www.ncbi.nlm.nih.gov/pubmed?term=parapuram%20sk%5bauthor%5d&cauthor=true&cauthor_uid=10641955 http://www.ncbi.nlm.nih.gov/pubmed?term=tripathi%20bj%5bauthor%5d&cauthor=true&cauthor_uid=10641955 http://www.ncbi.nlm.nih.gov/pubmed?term=zhong%20y%5bauthor%5d&cauthor=true&cauthor_uid=10641955 http://www.ncbi.nlm.nih.gov/pubmed?term=chalam%20kv%5bauthor%5d&cauthor=true&cauthor_uid=10641955 pak j ophthalmol. 2021, vol. 37 (1): 83-87 83 original article visual outcome of phacoemulsification versus small incision cataract surgery narain das 1 , asma shams 2 , jai kumar 3 , beenish khan 4 , nasir bhatti 5 1,2,3,5 department of ophthalmology, shaheed mohtarma benazir bhutto medical college, layari karachi 4 department of ophthalmology, united medical & dental college, karachi abstract purpose: to determine visual rehabilitation of phacoemulsification in comparison to small incision cataract surgery (sics) after implantation of rigid intraocular lens. study design: quasi experimental study. place and duration of study: shaheed mohtarma benazir bhutto medical college lyari and sindh government lyari general hospital, karachi, from july 2018 to december 2019. methods: patients aged 35 – 70 years and diagnosed with senile cataracts and visual acuity of ≤ 6/36 were included. patients having any corneal disease, intra-ocular pressure > 22 mm hg, high ametropia, any other eye disease were excluded. patients were divided into two groups of 80 patients each. group i underwent phacoemulsification and group ii had small incision cataract surgery. for data analysis, spss version 20.0 was used. frequency and percentages were calculated for qualitative data and quantitative data was presented as mean and standard deviation. results: in total 160 patients underwent cataract surgery. there were equal male and female patients. the range of astigmatism after 6 months in the group i was between 0.5 – 1.00 d while in the group ii, it was between 0.75 – 1.75 d. uncorrected visual acuity and best corrected visual acuity of 6/18 or better was seen at 1 month and 6 months in 88% and 97% group 1 while it was 85% and 95% in group ii patients. conclusion: no significant difference was seen in uncorrected and best corrected visual acuity between the two groups. time of surgery was lesser in patients undergoing sics while astigmatism was lesser in phacoemulsification group. key words: phaco-emulsification, small incision cataract surgery, visual rehabilitation. how to cite this article: das n, shams a, kumar j, khan b, bhatti n. visual outcome of phacoemulsification versus small incision cataract surgery. pak j ophthalmol. 2021, 37 (1): 83-87. doi: https://doi.org/10.36351/pjo.v37i1.1140 correspondence: narain das department of ophthalmology shaheed mohtarma benazir bhutto medical college layari karachi email: narainpagarani@yahoo.com received: september 29, 2020 accepted: november 30, 2020 introduction cataract is one of the most important and leading cause of preventable blindness especially among the older, senile population. it is common throughout the world. 1 latest cataract surgery using modern technologies with intra-ocular lens (iol) implant is regarded as the safest, simple, highly successful, and commonly performed cataract surgery. 2 the use of small incision cataract surgery (sics) has gained much popularity as compared to phaco-emulsification (phaco) especially in developing countries. sics is more cost-effective than phaco-emulsification. however, both phaco and sics have benefits such as early post-operative visual rehabilitation, decreased induced astigmatism as well as minimal suture-related https://www.umdc.edu.pk/ https://www.umdc.edu.pk/ mailto:narainpagarani@yahoo.com nasrin das, et al 84 pak j ophthalmol. 2021, vol. 37 (1): 83-87 complications such as toxic suture syndrome. 3 expectations for both the patient as well as the surgeon have increased owing to the fact that with astounding advancements in technology and predictability, the outcomes of surgeries have increased as well. the main aim of the surgeons is to meet the patient’s individual needs with optimum refractive goal and patient expectation for improved vision without needing the use of spectacles especially at immediate post-operative time period. 4 post-operative complications such as refractive errors following cataract surgery have become almost absent in the recent years. subsequently, the surgeries for cataract have overcome surgeries for refractive errors leading to an improvement in both the “uncorrected” and “best corrected” visual acuity as well. 5 cataract surgery is an elective surgery, however most patients from low socio-economic background residing in rural areas tend to be operated in free medical camps. since sics, being a faster, safer and non-invasive non-machine dependent surgery, is the most preferred options by the surgeons in such settings while in more advanced centers having state-of-the-art technologies, phacoemulsification remains the routinely performed surgery. 6 nonetheless, most patients from rural areas are lost to follow-up, which are a key factor in postoperative visual rehabilitation, post-operative precautions as well as treatment of complications. 7 even though the number of cataract surgeries has increased since the initiative of who vision 2020, poor vision outcome after surgery remains one of the major concerns. 8 population based researches in latin america, africa and asia have reported a minimum of 20% post-operative cataracts to present with a < 6/60 vision. 9 any treatment or surgery which could improve visual outcomes after surgery is vital in contributing to vision 2020. phaco-emulsification following foldable iol is the surgery of choice in high-income countries. 10 small incisions lead to reduction in astigmatism with improved and better visual outcomes following the procedure. among middle and low-income countries, researches on sics versus phaco have reported variations in results. 11 equipment needed for phaco is costly and therefore not commonly used in low-income areas. clinical observations have suggested implants of inexpensive rigid iol following phaco to attain similar visual outcomes compared to the use of more expensive foldable iols. 12 phaco and sics surgeries in terms of visual outcome of patients, safety of the lenses, intraoperative and post-operative complications and finally the cost of the whole procedure are all important aspects of cataract surgeries. 13 the objective of this study was to determine the visual rehabilitation of phacoemulsification in comparison to small incision cataract surgery after implantation of rigid intraocular lens and also to report its safety and effectiveness. methods this prospective study using non-probability convenient sampling technique was carried out for a period of 1.5 years at the ophthalmology department of shaheed mohtarma benazir bhutto medical college, lyari general hospital, karachi. after ethical approval from the respective institutional review board (irb), a total of 160 patients were selected from the ophthalmology opd of lyari general hospital, karachi from 1 st july 2018 to 1 st dec 2019. after written and informed consent, patients presenting to the eye opd between 35 – 70 years and diagnosed with age-related cataract having visual acuity of 6/36 or less in eye to be operated were included in the study. patients having any corneal disease, intra-ocular pressure > 22 mm hg, high ametropia, and any other eye disease or diabetes mellitus were excluded from the study. all the patients were explained about the procedure they were about to undergo and were counseled for possible post-operative complications. the patients were divided into two groups of 80 each, one group underwent phaco and the other group sics. patients in phaco group were operated via a clear corneal superior incision (about 11 o’clock) of 2.8 mm, that was enlarged to around 5.2 mm and rigid 5.25 mm lens was then implanted. in the sics group, superior straight 1.5 mm incision from limbus was made which was extended to 5.5 – 6.5 mm with 5.25 mm iol implantation. all the operations were performed by the same surgeon. operative time in patients undergoing either of the procedures was noted. all the patients were followed up on day one, 1 month and at 6 months after surgery. patients were compared in both the groups in terms of post-operative un-corrected visual acuity (ucva), best-corrected visual acuity (bcva), frequency of astigmatism and the visual outcomes at each respective follow-up. spss version 20.0 was used for data analysis. qualitative data of gender, uncorrected and bestcorrected visual acuity was reported as frequency and visual outcome of phacoemulsification versus small incision cataract surgery pak j ophthalmol. 2021, vol. 37 (1): 83-87 85 percentages while quantitative data was presented as mean and standard deviation. results total of 160 patients were recruited in the study and were divided into two groups. in group i, 35 (44%) patients were male while 45 (56%) patients were female. in group ii, 36 (45%) of the patients were male while 44 (55%) of the patients were female the mean operating time taken for small incision cataract surgery procedure was comparatively lesser than for phacoemulsification (phaco). the range of astigmatism after 6 months in group-i was reported between 0.5 – 1.00 diopters while in group-ii it was between 0.75 – 1.75 d. poor visual outcome of 6/60 or worse was seen in 3% in group-i and 5% in group-ii. at the first post-operative day, the bcva of 6/18 or better was seen in 73% in group-i and 60% in groupii. for further follow-ups see graph 1. graph 1: showing best corrected visual acuity of 6/18 or better at serial follow-ups. discussion cataract continues to be the main reason for impairment of vision in pakistan. since most of the population resides in the low-income areas, many of the patients tend to undergo for cheaper surgical methods. due to the fact that majority of the patients of cataract are elderly and illiterate they have a mindset of cheapest and quickest method of cataract treatment/surgery. 14 cataract surgeries are of high volume and in order to ensure that patients adhere to proper follow-ups and medicinal/hygiene needs, continuous supervision as well as higher vigilance on part of health professionals is necessary. both groups phaco and sics have been regarded as good options even in high volume surgical areas. rigid iols are reported to be cost-effective in comparison to foldable iols. in such case, any surgical option, which is not only safe, faster as well as provides an optimum visual outcome should be the preferred method. 15 according to the results of this study, the reported ucva and bcva at 1 st post-operative day, follow up at 1 st and 6 th month between phaco and sics groups were found to be more of less the same, so no significant difference was reported between both the groups. likewise, many other studies have also observed similar findings. jaggernath et al in his study compared phaco and sics. he reported that both the techniques presented similar trends in visual outcomes where 98% of patients in both the groups achieved bcva of 6/18 or better at the 6 th month follow-up. however, he also concluded that sics was superior to phaco is terms of significant time-line in visual rehabilitation, cost-effectiveness and lesser dependency on technology. 16 gogate et al in another study in which phaco and sics were compared reported that both the procedures were safe as well as effective in visual rehabilitation in patients of cataracts. the study recorded bcva of 6/18 or better in 98.4% of patients in both the groups at follow-up on 6 th post-operative week. however, phaco provided improved ucva in more number of patients than with sics. 17 gogate et al reported that no significant difference in time of surgery as well as intra and post-operative complications were found in either of the groups. however, in both the groups, ucva of the patients did not improve substantially. another study reported that sics had better ucva than phaco. 18 comparable reports of bcva and ucva showed that intra and post-operative complications such as endothelial cell loss makes sics an equivalent technique when compared with phaco. 19 it is important to note that phaco has an advantage of smaller size of incision as compared to sics procedure. the incidence of post-operative astigmatism is reported to be substantially low in phaco. 20 surgical time-period is reported to be lower in sics as compared with phaco. furthermore, in sics rigid iol is used most of the times, which is cheaper than the foldable iol. this makes the cost of sics nasrin das, et al 86 pak j ophthalmol. 2021, vol. 37 (1): 83-87 further less making sics a more preferred option especially in low-income areas. 21,22 although no significant differences have been found in terms of immediate post-operative complications or in long-term complications of in either of the two techniques, astigmatism was lesser in phaco group as compared to sics. a study reported that although there was no significant difference in post-operative visual acuities of the patients that underwent either phaco or sics, post-operative astigmatism was substantially higher in the sics group having rigid iol implantation than in phaco with rigid iol implantation. 23 likewise, mahayana et al also observed similar results, reporting a mean astigmatism of 0.98 d in the phaco group while 1.45 d in sics group. 24 in line with our study, iqbal et al reported slightly higher astigmatism in sics group as compared to phaco group. 25 limitation of our study was that only phaco and sics were compared. comparison of different types of lenses was also not made. it was a single-center study. multi-centered studies on a larger scale with greater sample size would be enlightening in determining the differences of phaco and sics among a variety of patients. conclusion even though no significant difference existed in terms of uncorrected visual acuity and best corrected visual acuity, time for surgery was lower in patients with small incision cataract surgery while in patients with phacoemulsification, astigmatism was less frequent. ethical approval the study was approved by the institutional review board/ ethical review board. (f-smbbmcl/(erc)/2020-20/156) conflict of interest authors declared no conflict of interest. references 1. ali am, abdulla am, howaidy ai, mohammed rm. comparative study between the refractive outcome following phacoemulsification and small incision cataract surgery. egypt j hosp med. 2019; 76 (1): 30373038. 2. moodley s, alberto k. visual outcomes in manual small incision cataract surgery versus phacoemulsification: a prospective comparative data analysis. south afr ophthalmol j. 2019; 14 (3): 21-24. 3. bhandari a, bhandari d. comparative study of visual outcome in eyes following phacoemulsification and in eyes following manual small incision cataract surgery. ind j bas appl med res. 2019; 8 (2): 11-17. 4. jian z, chun-ping l. comparison of improved phacoemulsification through limbus tunnel incision versus manual small-incision cataract surgery on ophthalmic operation vehicle. intern eye sci. 2017; 17 (11): 2085-2088. 5. pant sr, bhatta rc, awasthi s. post-operative astigmatism and visual outcome among superior approach manual small incision cataract surgery at surgical eye camp in nepal. j clin exp ophthalmol. 2019; 10 (807): 2-5. 6. kanellopoulos aj, asimellis g. standard manual capsulorhexis/ultrasound phacoemulsification compared to femtosecond laser-assisted capsulorhexis and lens fragmentation in clear cornea small incision cataract surgery. eye and vis. 2016; 3 (1): 20-25. 7. kaur t, singh k, kaur i, kaur p, chalia d. a comparative study of endothelial cell loss in cataract surgery: small incision cataract surgery versus phacoemulsification. ind j clin exp ophthalmol. 2016; 2 (4): 318-322. 8. signes-soler i, javaloy j, munoz g, moya t, montalban r, albarran c. safety and efficacy of the transition from extracapsular cataract extraction to manual small incision cataract surgery in prevention of blindness campaigns. middle east afr j ophthalmol. 2016; 23 (2): 187-194. 9. sharma n, vandana ps. to compare post-operative astigmatism in temporal clear corneal incision phacoemulsification and temporal manual small incision cataract surgery. ind j clin exp ophthalmol. 2017; 3 (2): 177-179. 10. mittal r, peter j, mani t, david s. visual outcome and patient satisfaction after cataract surgery: a pragmatic study. clin epidemiol glob health, 2019; 7 (3): 509-512. 11. hamid ka, habibullah s. comparison of visual outcomes in patients undergoing small incision cataract surgery versus phacoemulsification at divisional headquarters hospital, new mirpur, azad kashmir. professional med j. 2019; 26 (08): 1365-1369. 12. chu l, zhao jy, zhang js, meng j, wang mw, yang yj, et al. optimal incision sites to reduce corneal aberration variations after small incision phacoemulsification cataract surgery. intern j ophthalmol. 2016; 9 (4): 540-545. visual outcome of phacoemulsification versus small incision cataract surgery pak j ophthalmol. 2021, vol. 37 (1): 83-87 87 13. saif my, saif at, saif ps, abdel khalek mo, mahran w. dry eye changes after phacoemulsification and manual small incision cataract surgery (msics). int j ophthalmol eye res. 2016; 4 (2): 184-191. 14. donaldson k, fernandez-vega-cueto l, davidson r, dhaliwal d, hamilton r, jackson m, et al. perioperative assessment for refractive cataract surgery. j cat refract surg. 2018; 44 (5): 642-653. 15. li s, jie y. cataract surgery and lens implantation. curr opin ophthalmol. 2019; 30 (1): 39-43. 16. jaggernath j, gogate p, moodley v, naidoo ks. comparison of cataract surgery techniques: safety, efficacy, and cost-effectiveness. eur j ophthalmol. 2014; 24 (4): 520-526. 17. gogate p, optom jj, deshpande s, naidoo k. metaanalysis to compare the safety and efficacy of manual small incision cataract surgery and phacoemulsification. middle east afr j ophthalmol. 2015; 22 (3): 362-369. 18. gogate p, ambardekar p, kulkarni s, deshpande r, joshi s, deshpande m. comparison of endothelial cell loss after cataract surgery: phacoemulsification versus manual small-incision cataract surgery: six-week results of a randomized control trial. j cat refract surg. 2010; 36 (2): 247-253. 19. ramalakshmi v, rani mrh, rajalakshmi a, anandan h. comparison of merits and demerits of manual small incision cataract surgery with phacoemulsification. int j sci stud. 2017; 4 (12): 161163. 20. el-sayed sh, el-sobky hm, badawy nm, el-shafy ea. phacoemulsification versus manual small incision cataract surgery for treatment of cataract. meno med j. 2015; 28 (1): 191-196. 21. harakuni u, bubanale s, smitha ks, tenagi al, kshama kk, meena a, et al. comparison of surgically induced astigmatism with small incision cataract surgery and phacoemulsification. j. evol. med. dent. sci. 2015; 4 (71): 12354-12360. 22. ali am, abdulla am, howaidy ai, mohammed rm. comparative study between the refractive outcome following phacoemulsification and small incision cataract surgery. the egypt j hosp med. 2019; 76 (1): 3037-3038. 23. devendra j, agarwal s, singh pk. a comparative study of clear corneal phacoemulsification with rigid iol versus sics; the preferred surgical technique in low socio-economic group patients of rural areas. j clin diag res. 2014; 8 (11): 1-4. 24. mahayana it, setyowati r, winarti t, prawiroranu s. outcomes of manual small incision cataract surgery (msics) compared with phacoemulsification from population based outreach eye camp, in yogyakarta and southern central java region, indonesia. j comm emp health, 2018; 1 (1): 6-10. 25. iqbal s, kv sm, menon a, krishnan p, latheef n, kiran kr. a prospective comparative study of visual outcome and complications in small incision cataract surgery and phacoemulsification. nat j med all sci. 2015; 4 (1): 50-55. authors’ designation and contribution narain das; assistant professor: concepts, design. asma shams; senior registrar: literature search, data acquisition. jai kumar; postgraduate trainee: data analysis, statistical analysis. beenish khan; assistant professor: manuscript preparation, manuscript editing. nasir bhatti; professor: manuscript review. .…  …. microsoft word 2. munira shakir pak j ophthalmol. 2022, vol. 38 (4): 229-233 229 original article efficiency of moria one-use plus sub-bowman’s keratomileusis head in achieving predicted corneal flap thickness in sub bowmans keratomileusis munira shakir1, sahira wasim2, ronak afza memon3, shakir zafar4 department of ophthalmology, 1,2,3liaquat national hospital, karachi. 4united medical & dental college, karachi abstract purpose: to evaluate the difference between predicted and resultant corneal flap thickness in sub-bowmans keratomileusis using moria one-use plus sub-bowman’s keratomileusis head. study design: interventional case series. place and duration of study: liaquat national hospital, karachi, from april 2019 to september 2019. methods: total 55 patients of either gender with age 20 to 45 years undergoing sub-bowmans keratomileusis (sbk) were included. frequencies and percentages were computed for qualitative variables. quantitative variables were presented as mean ± standard deviation. student t-test, pair t test and anova were used to compare the mean of resultant and predicted corneal flap thickness. effect modifiers were controlled through stratification. post stratification student t-test was again used to compare the mean of resultant and predicted corneal flap thickness. p-value ≤ 0.05 was considered significant. results: the mean age was 26.83 ± 4.38. there was an insignificant differences in preoperative, intraoperative and corneal flap thickness of both eye with respect to gender (p > 0.05). there was insignificant mean difference in preoperative and intraoperative corneal thickness (p > 0.05) of both eye with respect to age group but significant mean difference in resultant flap corneal thickness seen with both age group (p < 0.05). significant difference was found in the flap thickness between the right and left eyes. the difference in the predicted and resultant flap thickness was statistically significant for right eye and insignificant for the left eye. conclusion: with moria microkeratome, accuracy of the flap can be predicted in sbk. it is a safe and effective method to achieve the desired results. key words: corneal flap, moria one use plus, microkeratome, refractive surgery, lasik. how to cite this article: shakir m, wasim s, afza r, zafar s. efficiency of moria one-use plus sub-bowman’s keratomileusis head in achieving predicted corneal flap thickness in sub bowmans keratomileusis. pak j ophthalmol. 2022, 38 (4): 229-233. doi: 10.36351/pjo.v38i4.1405 correspondence: ronak afza department of ophthalmology, liaquat national hospital, karachi email: ronakafzamemon@yahoo.com received: april 20, 2022 accepted: august 20, 2022 introduction freedom from spectacle and contact lenses by correction of refractive error has been accomplished by corneal refractive surgeries.1 among the refractive surgeries, laser-assisted in situ keratomileusis (lasik) is the most widely used procedure for the correction of refractive errors including myopia, hyperopia, and astigmatism.2,3 this refractive technique provides good safety and efficacy and yields predictable and stable results without significant complications.4 during lasik anterior flap is created and corneal stroma is photoablated. first critical step during lasik surgery is creation of successful flap of adequate thickness.5 excellent lasik outcomes require safe, predictable, and reproducible flap ronak afza, et al 230 pak j ophthalmol. 2022, vol. 38 (4): 229-233 parameters.6,7 great attention must be given to improve the predictability and to minimize the degree of variation in corneal flap thickness, which is directly related to lasik predictability and safety.8 the procedure is fast, with painless recovery of vision and lack of sub epithelial haze, which are mainly due to the creation of a corneal flap with a microkeratome. proper preoperative screening of candidates should be done for stable refraction and normal cornea that are free of diseases that predispose to complications.subbowman’s keratomileusis (sbk) is a lasik procedure in which a special mechanical blade (sbk one-use plus blade) is used to create a thinner flap. although much work is being done in pakistan on refractive surgery but data related with accuracy of corneal flap thickness and sbk is scarce.9,10 the rationale of our study is to evaluate the mean thickness of corneal flap created using one use plus sbk head microkeratome and to compare it from the intended flap thickness in our population. this will help in planning sbk to achieve best results of refractive surgery. methods we conducted this study at department of ophthalmology, liaquat national hospital, karachi, from april 2019 to may 2020, after approval from hospital ethical review committee. by taking mean flap thickness of right eyes as 97.50 ± 11 µm11 and margin of error (d) = 5%, the total calculated sample size was 19 (who software for sample size calculation taking 95% confidence level). we included 55 patients of either gender with age 20 to 45 years. data included; name, gender, age, pre-operative refraction, unaided visual acuity and visual acuity after spectacle correction with spherical equivalent and slit lamp examination. surgical procedure was performed after informed consent from the patient. data was analyzed using spss version 21. all the information was collected on especially designed proforma. patients with preoperative refractive error of -2.00 to -12.00d myopia up to +4.00 hyperopia, cylinder of <-3.00d, and central corneal thickness greater than or equal to 490 μm were included. exclusion criteria was patients with ocular pathologies such as dystrophy, degeneration, scarring, viral herpetic disease, glaucoma, collagen vascular diseases, uveitis, use of systemic corticosteroids or antimetabolites, topographically diagnosed corneal ectasia and dry eye. corneal topography was done pre-operatively (wave light allegro oculyzer) for the measurement of central corneal thickness (cct), and residual corneal stromal bed. before creating the flap with pupil centration and focusing on corneal apex cct was obtained intraoperatively (wave front optimized via wave light). corneal flap with nasal hinge was created using moria one use plus microkeratome with mechanical stop safety design to create flap thickness of 100 µm. first right then left flap was made with the use of same blade. suction ring was chosen on the reading of keratometric (k1) value. hinged flap was raised to ablate the stromal bed using wave light® ex500 excimer laser and the residual stromal bed (rsb) was immediately measured. subtracting rsb thickness from the preoperative total central corneal thickness gave flap thickness. moxifloxacin and lubricant eye drops were started 2 days before the procedure and continued for 2 weeks and 2 months respectively. dexamethasone 1% was used and tapered from five times a day to twice a day. results the mean age was 26.83 ± 4.38 with range from 20 to 45 years. there were 22 (40%) patients with age ≤ 25 years and 33 (60%) with > 25 years. females were 42.9% and males were 57.1%. the spherical equivalent refraction was distributed as 46% patients had myopia, 9.5% had hyperopia and 44.4% had myopic with astigmatism. we compared the mean preoperative, intraoperative and resultant flap corneal thickness of both eyes with respect to gender, age group and spherical equivalent refraction. there was an insignificant difference in preoperative, intraoperative and flap corneal thickness of both eye sides with respect to gender (p > 0.05). there was insignificant mean difference in preoperative and intraoperative corneal thickness (p > 0.05) of both eye with respect to age group but significant mean difference in resultant flap corneal thickness seen with both age groups (p < 0.05). the details are presented in table 1. there was statistically insignificant difference in the pre-operative and intra-operative corneal flap thickness between the right and left eyes. however, significant difference was found in the flap thickness between the right and left eyes (table 2). the difference in the predicted and resultant flap thickness was statistically significant for right eye and insignificant for the left eye (table 3). efficiency of moria one-use plus sub-bowman’s keratomileusis head in achieving predicted corneal flap thickness pak j ophthalmol. 2022, vol. 38 (4): 229-233 231 table1: association of gender, age group and spherical equivalent refraction with corneal and flap thickness. pre-operative corneal thickness re pre-operative corneal thickness le intra-operative corneal thickness re intra-operative corneal thickness le corneal flap thickness-re corneal flap thickness-le gender male 534.18 ± 23.48 534.36 ± 24.64 532.63 ± 23.54 532.22 ± 529.72 101.45 ± 3.92 100.9 ± 3.72 female 534.81 ± 20.81 532.21 ± 21.08 530.48 ± 20.92 529.72 ± 21.68 101 ± 3.25 100.42 ± 3.37 p-value 0.916 0.730 0.724 0.686 0.643 0.619 age group ≤25 years 535.72 ± 20.15 533.95 ± 21.58 531.22 ± 20.84 530.86 ± 20.92 102.54 ± 3.56 101.90 ± 3.63 >25 years 533.78 ± 22.96 532.48 ± 23.20 530.86 ± 20.92 530.63 ± 23.27 100.27 ± 3.21 99.75 ± 3.16 p-value 0.749 0.814 0.974 0.971 0.017* 0.024* spherical equivalent refraction myopic 528.45 ± 27.11 526.62 ± 28.15 525.08 ± 27.50 524.66 ± 27.97 102.37 ± 3.39 101.79 ± 3.33 hyperopia 549.40 ± 5.54 548.60±2.50 548.40 ± 6.10 545.60 ± 3.91 99.60 ± 4.39 99.22 ± 4.43 myopia with astigmatism 537.34 ± 15.78 536.03 ± 15.93 533.84 ± 14.97 533.46 ± 15.85 100.38 ± 3.22 99.80 ± 3.24 p-value 0.096 0.086 0.066 0.107 0.075 0.083 student t-test, pair t test, anova is applied. *significant at p ≤ 0.05 or p ≤ 0.01 **highly significant at p ≤ 0.001 table 2: mean comparison of right versus left eye corneal thickness. mean ± sd p-value pre operative corneal thickness re 534.56 ± 21.71 0.115 pre operative corneal thickness le 533.07 ± 22.37 intra operative corneal thickness re 531.34 ± 21.82 0.417 intra operative corneal thickness le 530.72 ± 22.16 corneal flap thickness re 101.18 ± 3.51 < 0.0001** corneal flap thickness le 100.61 ± 3.49 paired t-test is applied. *significant at p≤0.05 or p ≤ 0.01 **highly significant at p ≤ 0.001 table 3: mean comparison of resultant versus predicted corneal flap thickness. mean ± sd p-value resultant corneal flap thickness re 101.18 ± 3.51 0.016* predicted corneal flap thickness 100 ± 0.00 resultant corneal flap thickness le 100.61 ± 3.49 0.195 predicted corneal flap thickness 100 ± 0.00 figure 1: corneal flap thickness of right eye & left eye. discussion corneal topography is considered a standard of care for all refractive surgical procedures. there is a relationship between preoperative corneal thickness, ablation depth, and flap thickness in determining the relative amount of biomechanical change that has occurred after a lasik procedure.11 intraoperative measurements can help surgeons determine the accuracy of programmed versus achieved flap thickness (ft). mechanical microkeratomes may have a wide variance from the intended to actual flap thickness. thinner flaps usually occur in thinner corneas and when the same blade is used for the second eye.12 a wide variety of microkeratomes are in clinical use nowadays. different microkeratomes have shown that the achieved flap thickness varies from the intended value. research shows that there is difference in the flap thickness when same blade is used between the first and the second eye.13 ronak afza, et al 232 pak j ophthalmol. 2022, vol. 38 (4): 229-233 special mechanical blade (sbk one-use plus blade) is used in sub-bowman’s keratomileusis to create a thinner flap providing greatest advantage by leaving sufficient stromal tissue to allow safer excimer laser ablation, especially in patients with moderate or high myopia.14 it has been suggested, that a minimal stromal depth of 250 μm should remain after lasik and the amount of residual stroma left behind after its formation influence the correction of refractive error and the visual outcome of the patient.15,16 thin flaps may lead to striae and tearing, flap irregularities, buttonholes and epithelial defects. however, thicker flaps result in decreased stromal-bed thickness leading to instable integrity of eye and cloudiness and iatrogenic corneal ectasia. if the flap is uniformly made it results in more residual corneal stoma and nerve preservation. this helps in reduction of post-operative dry eye.17 moreover, careful evaluation for precise estimation of flap thickness results in minimizing the post-operative complications and avoids the need for additional surgery. with the advent of single one use head microkeratome as compare to previous metallic head microkeratomes, there is a decreased in the rate of complications related to flap.18,19 this corresponds to our results in which the flap thick was close to the predicted values and lesser complications. practitioners have considered that the ideal flap thickness should be 130 um or slightly greater than this, because thinner flaps are more prone to develop corneal folds, in growth of corneal epithelium and astigmatism. this was very successfully achieved by moria keratome in our study. contrary to that kanclerz p et al have shown that the evidence of the superiority of one technique in terms of complications over another cannot be stated.20 in our study the resultant corneal flap thickness was found as 101.18 ± 3.51 in right eye (p < 0.05) and 100.61 ± 3.49 in left eye (p > 0.05) which was statistically significant in right but insignificant in left eye respectively from the predicted value. there is a highly significant mean difference in resultant corneal flap thickness (p < 0.0001) of right and left eye. similar result were reported by du s et al, who showed that the intended corneal flap thickness was 100 um and the difference in flap thickness between the two eye was not statistically significant.18 zhai cb found that the flap thickness created by the moria one use-plus sbk was more uniform, more regular and more accurate than those created by the moria m2.19 limitations of our study was limited follow up and single center research. more work needs to be done using different variables and different centers so that the results can be generalized. conclusion with the use of one use plus sbk, accuracy of the flap can be predicted, it is a safe and effective method to achieve the desired results. with creation of thinner flap, higher error of refraction can be treated while leaving more residual stromal bed tissue. ethical approval the study was approved by the institutional review board/ethical review board (0474-2019-lnh-erc). conflict of interest: authors declared no conflict of interest. references 1. shehadeh mm, akkawi mt, aghbar aa, musmar mt, khabbas mn, kharouf mf, et al. outcomes of wave front-optimized laser-assisted in-situ keratomileusis and photorefractive keratectomy for correction of myopia and myopic astigmatism over one year follow-up. open ophthalmol j. 2018; 12: 256-263. doi: 10.2174/1874364101812010256. 2. kamiya k, igarashi a, hayashi k, negishi k, sato m, bissen-miyajima h. survey working group of the japanese society of cataract and refractive surgery. a multicenter prospective cohort study on refractive surgery in 15 011 eyes. am j ophthalmol. 2017; 175: 159-168. doi: 10.1016/j.ajo.2016.12.009. 3. kymionis gd, tsiklis n, pallikaris ai, diakonis v, hatzithanasis g, kavroulaki d, et al. long-term results of superficial laser in situ keratomileusis after ultrathin flap creation. j cataract refract surg. 2006; 32 (8): 1276-1280. doi: 10.1016/j.jcrs.2006.02.054. 4. agarwal s, thornell e, hodge c, sutton g, hughes p. visual outcomes and higher order aberrations following lasik on eyes with low myopia and astigmatism. open ophthalmol j. 2018; 12: 84-93. doi: 10.2174/1874364101812010084. 5. karabela y, muftuoglu o, kaya f. corneal flap thickness with the moria m2 single-use head 90 microkeratome in 72 consecutive lasik procedures. clin ophthalmol. 2017; 11: 487-492. doi: 10.2147/opth.s129830 efficiency of moria one-use plus sub-bowman’s keratomileusis head in achieving predicted corneal flap thickness pak j ophthalmol. 2022, vol. 38 (4): 229-233 233 6. xia lk, yu j, chai gr, wang d, li y. comparison of the femtosecond laser and mechanical microkeratome for flap cutting in lasik. int j ophthalmol. 2015; 8 (4): 784-790. doi: 10.3980/j.issn.2222-3959.2015.04.25. 7. mifflin md, mortensen xm, betts bs, gross c, zaugg b. accuracy of alcon wave light® ex500 optical pachymetry during lasik. clin ophthalmol. 2017; 11: 1513-1517. doi: 10.2147/opth.s138459. 8. zhang j, zhang ss, yu q, wu jx, lian jc. comparison of corneal flap thickness using a fs200 femtosecond laser and a moria sbk microkeratome. int j ophthalmol. 2014; 7 (2): 273-277. doi: 10.3980/j.issn.2222-3959.2014.02.14. 9. qasim msa, sarwar ms, qasim mma. laser assisted in situ keratomileusis (lasik) versus trans epithelial photorefractive keratectomy (t-prk) in astigmatic patients. pak j ophthalmol. 2022; 38 (1): 48. doi: 10.36351/pjo.v38i1.1250. 10. ahmad k. lasik in hyperopic eyes with congenital nystagmus: a case report. pak j ophthalmol. 2018; 29 (2): 106-109. 11. rashad df, khallaf me, khalil am, aly mm. clinical outcome of femtosecond laser flap formation versus mechanical microkeratome in laser in situ keratomileusis for treatment of myopia. delta j. ophthalmol. 2021; 22 (2): 103-109. 12. santhiago m, smadja d, gomes b, mello g, monteiro m, wilson s, et al. association between the percent tissue altered and post–laser in situ keratomileusis ectasia in eyes with normal preoperative topography. am j ophthalmol. 2014; 158: 87-95. 13. pietilä j, huhtala a, mäkinen p, seppänen m, jääskeläinen m, uusitalo h. corneal flap thickness with the moria m2 microkeratome and med-logics calibrated lasik blades. acta ophthalmol. 2009; 87 (7): 754-758. doi: 10.1111/j.1755-3768.2008.01500.x. 14. abdelwahab s, elfayoumi ma. moria one-use plus sub-bowman’s keratomileusis head: a useful tool in the refractive surgeon’s armamentarium. j egypt ophthalmol soc. 2016; 109 (3): 105. doi: 10.4103/2090-0686.202258 15. ho t, cheng ac, lau s, lam ds. comparison of corneal flap thickness between primary eyes and fellow eyes using the zyoptix xp microkeratome. j cataract refract surg. 2007; 33 (12): 2049-2053. doi: 10.1016/j.jcrs.2007.07.027. 16. phelps po, tran aq, nehls sm. complication following radial keratotomy and lasik. ophthalmology, 2015; 122 (6): 1172. doi: 10.1016/j.ophtha.2014.12.026. 17. elgazzar af, ahmed re. corneal flap thickness created by two different types of femtosecond lasers (wave light fs200 and intra lase fs60). glob j curr res. 2021; 8 (4): 46-61. 18. du s, lian j, zhang l, ye s, dong s. flap thickness variation with 3 types of microkeratome heads. j cataract refract surg. 2011; 37 (1): 144-148. doi: 10.1016/j.jcrs.2010.11.002. 19. zhai cb, tian l, zhou yh, zhang qw, zhang j. comparison of the flaps made by femtosecond laser and automated keratomes for sub-bowman keratomileusis. chin med j (engl). 2013; 126 (13): 2440-2444. 20. kanclerz p, khoramnia r. flap thickness and the risk of complications in mechanical microkeratome and femtosecond laser in situ keratomileusis: a literature review and statistical analysis. diagnostics (basel). 2021; 11 (9): 1588. doi: 10.3390/diagnostics11091588. authors’ designation and contribution munira shakir; professor: concepts, design, literature search, manuscript preparation, manuscript review. sahira wasim; consultant ophthalmologist: design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. ronak afza memon; consultant ophthalmologist: statistical analysis, manuscript preparation, manuscript editing, manuscript review. shakir zafar; professor: literature search, statistical analysis, manuscript review. .……. 92 pak j ophthalmol. 2021, vol. 37 (1): 92-96 original article role of nepafenac 0.1% ophthalmic solution in preventing intraoperative miosis during phacoemulsification sairam ahmed 1 , iqra ghazanfar 2 , fuad ahmad khan niazi 3 , ali raza 4 1-4 holy family hospital, rawalpindi medical university abstract purpose: to compare 0.1% nepafenac ophthalmic solution with placebo in terms of decreasing mean intraoperative miosis in patients undergoing cataract surgery. study design: quasi experimental study. place and duration of study: department of ophthalmology, holy-family hospital rawalpindi from september 2017 to march 2018. methods: a total of 150 eyes with senile cataract of patients between 40-80 years of age and of both genders, undergoing uneventful cataract surgery and fulfilling the inclusion criteria were included. patients were divided into 2 equal groups. group a received nepafenac eye drops and group b received placebo drops (preservative free artificial tears). the diameter of pupil as viewed through the operating microscope was measured with castroviejo caliper at following steps; immediately before the start of surgery (baseline), after complete nucleus removal and at the end of surgery. results: mean decrease in pupil size from the start of surgery to the end of phacoemulsification in group a (nepafenac group) was 0.48 ± 0.26 mm while in group b (placebo group) it was 1.40 ± 0.49 mm (p = 0.0001). mean decrease in pupil size from start to end in group a (nepafenac group) was 0.75 ± 0.32 mm while in group b (placebo group) was 2.02 ± 0.62 mm (p = 0.0001). conclusion: intraoperative miosis in terms of mean decrease in pupils size (both from start of surgery till phacoemulsification and also from start of surgery till end of surgery) was lower in 0.1% nepafenac group as compared to placebo group. key words: phacoemulsification, miosis, nepafenac. how to cite this article: ahmed s, ghazanfar i, niazi fak, raza a. role of nepafenac 0.1% ophthalmic solution in preventing intraoperative miosis during phacoemulsification. pak j ophthalmol. 2021, 37 (1): 92-96. doi: https://doi.org/10.36351/pjo.v37i1.1038 introduction phacoemulsification with foldable intraocular lens implantation is the treatment of choice for cataract. 1 correspondence: sairam ahmed holy family hospital, rawalpindi medical university email: sairamahmed90@gmail.com received: april 14, 2020 accepted: september 27, 2020 preoperative dilation of pupil is the most important prerequisite for cataract surgery especially during phacoemulsification. constriction of pupil during surgery can lead to increased difficulty in surgery and greater chances of complications. tropicamide 1% (anticholinergic agent) and phenylephrine 2.5% (sympathomimetic agent) are used before surgery for pupil dilation. addition of adrenaline in the irrigation fluid used during surgery also has a role in dilatation of the pupil. as the lens is role of nepafenac 0.1% ophthalmic solution in preventing intraoperative miosis pak j ophthalmol. 2021, vol. 37 (1): 92-96 93 situated behind the iris, sufficient dilatation of the pupil is necessary for cataract extraction. 2 in case of adequately dilated pupil visibility of the posterior chamber structures is improved, hence surgery can be accomplished more easily and safely. it has been described that with pupillary diameter of more than 6 mm the rate of complications during surgery especially posterior capsular rupture is reduced. 2 surgical trauma during cataract surgery results in breakdown of blood aqueous barrier. this results in release of prostaglandins in the anterior chamber, which has a role in constriction of the pupil. 3 preoperative administration of nonsteroidal antiinflammatory drugs (nsaids) results in decrease in synthesis of prostaglandins through inhibition of cyclo–oxygenase (cox) enzyme. nepafenac 0.1% is an ophthalmic nsaid with an inert and prodrug structure. 4 nepafenac has a neutral molecule in contrast to acidic nature of the other topical nsaids. this allows nepafenac to enter through the corneal surface into the anterior chamber. intraocular hydrolases convert it to more active compound amfenac. 4 these hydrolase enzymes are usually present in iris, ciliary body, retina and choroid. 4 so, nepafenac is unique to other nsaids in that its transformation to active product amfenac occurs in the target tissues where its action is required. previous studies have confirmed effectiveness of various topical nsaids in preventing intraoperative miosis during cataract surgery. commonly used nsaids eye drops include diclofenac, flurbiprofen, indomethacin and ketrolac, which have shown efficacy in reducing intraoperative miosis during cataract surgery. 4 the lower side effects and better bioavailability profile of nepafenac makes its use superior as compared to other nsaids used traditionally in preoperative period of cataract surgery. our study determined the role of nepafenac in reducing intraoperative miosis during cataract surgery. currently there are no specific guidelines for use of nepafenac in the preoperative period for preventing pupillary constriction during cataract surgery. if effective, this will ultimately lead to decrease in intraoperative complications related to intra-operative miosis of the pupil. methods we conducted this study in the department of ophthalmology, holy family hospital rawalpindi medical university. a sample size of 150 eyes was calculated with who sample size calculator. sampling was done from 1 st september, 2017 to 1 st march, 2018. consecutive sampling technique was adopted. both male and female patients with age between 40 to 70 years and diagnosed with senile cataract were included in the study. all patients included in the study underwent uneventful cataract surgery. all patients with any local pupillary abnormality, pseudoexfoliation, history of ocular trauma, complicated cataract, intraoperative complications, glaucoma, previous intraocular surgery to the same eye, diabetes mellitus, hypertension, pupil size less than 6mm before the surgery and hypersensitivity to nsaids were excluded from the study. after approval from the ethical committee and taking informed verbal consent, all the patients fulfilling the selection criteria were included in the study. patients were divided into 2 equal groups. using spss, a randomly generated list of 150 cases were randomly allocated to either group a or group b, each with 75 patients. each patient fulfilling the selection criteria and consenting for study was assigned chronological id number and was assigned respective study group a or b according to the allocation in the list. the sequence of allocation in the list was followed until the sample size of 150 was attained. group a patients received nepafenac eye drops (3 drops; 1 drop at 15 minutes interval beginning 1 hour before surgery) and group b received placebo drops (preservative-free tears solution). additionally, the pupil was dilated with topical tropicamide 1% (3 drops; 1 drop every 15 minutes beginning 1 hour before surgery) in both groups. no other drug was used pre-operatively or intra-operatively. all surgeries were done by the same surgeon. the surgeon was masked to patient randomization. all eyes had phacoemulsification and posterior chamber foldable intraocular lens (pc iol) implantation. the diameter of pupil as viewed through the operating microscope was measured with castroviejo caliper at following steps; immediately before the start of surgery (baseline), at the end of phacoemulsification and at the end of surgery. data entry and analysis was done by using spss 20. the mean diameter of pupil was measured at 3 surgical steps i.e. before start of surgery, at the end of nucleus removal and at the end of the surgery. mean decrease in pupil size from start of the surgery to end of nucleus removal and from start of the surgery to the end of surgery was calculated in both groups. the significance of difference in the mean sairam ahmed, et al 94 pak j ophthalmol. 2021, vol. 37 (1): 92-96 table 1: mean pupil size in both groups. group n mean sd p-value pre-operative pupil size nepafenac 75 8.03 0.72 0.004 placebo 75 7.72 0.54 pupil size after complete removal of nucleus in both groups. nepafenac 75 7.56 0.79 0.0001 placebo 75 6.32 0.88 pupil size at the end of surgery nepafenac 75 7.26 0.78 0.0001 placebo 75 5.71 0.98 decrease in pupil size from start of surgery to end of phacoemulsification nepafenac 75 0.48 0.26 0.0001 placebo 75 1.40 0.49 decrease in pupil size from start to end nepafenac 75 0.75 0.32 0.0001 placebo 75 2.02 0.62 decrease in pupil size between the two groups was determined using the student t test. results age range in this study was from 40 to 80 years with mean age of 59.55 ± 0.585 years. out of 150 patients 81 (54.0%) were males and 69 (46.0%) were females with male to female ratio of 1.2:1. mean pre-operative pupil size in group a (nepafenac group) was 8.03 ± 0.72 mm while in group b (placebo group) was 7.72 ± 0.54 mm as shown in table 1 (p-value = 0.004). further details are shown in table 1. discussion with substantial advancement in surgical techniques and equipment for phacoemulsification, current cataract surgery has attained a drop of physical surgical insult and a reduction in the release of inflammatory mediators especially prostaglandins, which play a key role in the development of postoperative ocular inflammation. 5-6 nevertheless, most patients still manifest clinically significant ocular inflammation after surgery. this uncontrolled intraocular inflammation leads to disruption of bloodocular barrier and results in entrance of inflammatory mediators like prostaglandins and cytokines into aqueous humor. these inflammatory mediators are a major source of patient distress, late recovery, hyperemia, photophobia and suboptimal visual outcomes. if allowed to continue, uncontrolled release of these mediators can result in serious complications like cystoid macular edema (cme), synechiae formation, corneal edema and raised intraocular pressure (iop). 6-8 in this era of patients’ high expectations and with introduction of latest apparatus and finest quality of intraocular lenses, postoperative discomfort and delayed recovery are un-desirable to patients. surgical trauma triggers the inflammatory cascade in the eye, thereby releasing different types of inflammatory mediators such as prostaglandins (pg), prostacyclin, thromboxane a2, leukotrienes, lipoxins, hepoxylins, and platelet-activating factor. these substances are involved in intraoperative and postoperative pain, conjunctival congestion and hyperemia, intra-operative pupillary constriction, increase in intraocular pressure (iop), synechiae formation, posterior capsular opacification, and surgically induced cystoid macular edema (cme). 9 by inhibiting the release of these inflammatory mediators with pre-operative use of topical nonsteroidal antiinflammatory drugs (nsaids), mydriasis is adequately maintained during surgery. this may ultimately result in decrease in intra-operative and post-operative complications related to prostaglandins. 10 nepafenac has also shown similar favourable effects. it has a prodrug structure, which is hydrolyzed by intraocular enzymes to amfenac which is a potent inhibitor of cyclooxygenase-1 (cox-1) and cox-2 enzymes. 11 high ocular bioavailability, permeability and quick activation by intra-ocular hydrolases by the ocular tissues, make nepafenac a unique and target-specific drug for the inhibition of prostaglandin formation in the anterior and posterior segments of the eye where, its action is required. 12 its availability in a prodrug structure also helps in reduction of toxicity on the corneal surface and improves its infiltration into specific tissues. 13-14 previous studies have confirmed effectiveness of various topical nsaids in preventing intraoperative miosis during cataract surgery. study conducted in egypt by abdel et al reported that use of topical flurbiprofen 0.03% and dexamethasone acetate 0.1% was effective in maintaining intra-operative pupillary dilatation. 15 in that study flurbiprofen had superior and role of nepafenac 0.1% ophthalmic solution in preventing intraoperative miosis pak j ophthalmol. 2021, vol. 37 (1): 92-96 95 prolonged effect as compared to dexamethasone. similar results were shown by gimbel et al in which flurbiprofen 0.03% and indomethacin 1% had similar effect in preventing pupillary constriction during cataract surgery. 16 moreover, zanetti et al showed superior effect of prednisolone acetate, ketorolac tromethamine and nepafenac in maintaining intraoperative mydriasis as compared to placebo. 17 in 2009, cervantes-coste et al. showed that nepafenac was effective in preventing pupillary constriction as compared to placebo during cataract surgery. there was a statistically significant difference in pupillary diameter from the start of surgery to the end of surgery between nepafenac group (6.84 ± 0.93 mm) and the placebo group (7.91 ± 0.74 mm). 18 in a prospective, randomized, double-masked comparative study, which included adult cataract patients, the researchers used topical nsaids (ketorolac or nepafenac) or balanced salt solution (control) prior to phacoemulsification and capsular bag intraocular-lens (iol) implantation. 19 a total of 47 eyes of 44 cataract surgery patients, 13 males and 34 females, with a mean age of 66.04 ± 8.87 years, were included in the study. the mean horizontal and vertical diameters of pupils in the three groups were similar at the start of surgery. significant differences were seen after iol implantation, with the nepafenac group having the largest mean diameters in both horizontal (p = 0.012) and vertical (p = 0.012) pupil measurements. 19 other studies have also reported similar results. 20,21 a study conducted in india by sarkar et al 2 reported that the decrease in horizontal pupillary diameter from the start of surgery to end of surgery was significantly (p = 0.009) less in nepafenac group compared to flurbiprofen group. study done in hyderabad by surhio et al 3 in 2013 reported that the mean reduction in pupillary size from the start of surgery to the end of phacoemulsification was 0.20 ± 0.31 mm in nepafenac group as compared to 0.73 ± 0.60 mm in placebo group (p–value < 0.001). mean reduction in pupillary size from the start of surgery to the end of surgery was 0.55 ± 0.51 mm in nepafenac group as compared to 1.05 ± 0.87 mm in placebo group (p = 0.009). conclusion intraoperative miosis in terms of mean decrease in pupil size (both from start of surgery to phacoemulsification and also from start of surgery to the end of surgery) is lower in 0.1% nepafenac group as compared to placebo. ethical approval the study was approved by the institutional review board/ethical review board. (r-17/rmu) conflict of interest authors declared no conflict of interest. references 1. carifi g, miller mh, pitsas c, zygoura v, deshmukh rr, kopsachilis n, et al. complications and outcomes of phacoemulsification cataract surgery complicated by anterior capsule tear. am j ophthalmol. 2015; 159 (3): 463-469. 2. sarkar s, mondal kk, roy ss, gayen s, ghosh a, de rr. comparison of preoperative nepafenac (0.1%) and flurbiprofen (0.03%) eye drops in maintaining mydriasis during small incision cataract surgery in patients with senile cataract: a randomized, doubleblind study. indian j pharmacol. 2015; 47 (5): 491. 3. surhio sa, memon m, talpur r, talpur ki. efficacy of nepafenac 0.1% in maintaining mydriasis during phacoemulsification surgery. j liaquat uni med health sci. 2013; 12 (02): 74. 4. wilson dj, schutte sm, abel sr. comparing the efficacy of ophthalmic nsaids in common indications: a literature review to support cost-effective prescribing. ann pharmacother. 2015; 49 (6): 727-734. 5. simone jn, pendelton ra, jenkins je. comparison of the efficacy and safety of ketorolac tromethamine 0.5% and prednisolone acetate 1% after cataract surgery. j cataract refract surg. 1999; 25 (5): 699– 704. 6. jones bm, neville mw. nepafenac: an ophthalmic nonsteroidal antiinflammatory drug for pain after cataract surgery. ann pharmacother. 2013; 47 (6): 892– 896. 7. sahu s, ram j, bansal r, pandav ss, gupta a. effect of topical ketorolac 0.4%, nepafenac 0.1%, and bromfenac 0.09% on postoperative inflammation using laser flare photometry in patients having phacoemulsification. j cataract refract surg. 2015; 41 (10): 2043–2048. 8. duffin rm, camras cb, gardner sk, pettit th. inhibitors of surgically induced miosis. ophthalmology, 1982; 89 (8): 966–979. 9. podos sm. prostaglandins, nonsteroidal antiinflammatory agents and eye disease. trans am ophthalmol soc. 1976; 74: 637–660. sairam ahmed, et al 96 pak j ophthalmol. 2021, vol. 37 (1): 92-96 10. muhtaseb m, kalhoro a, ionides a. a system for preoperative stratification of cataract patients according to risk of intraoperative complications: a prospective analysis of 1441 cases. br j ophthalmol. 2004; 88: 1242–1246. 11. lane ss. nepafenac: a unique nonsteroidal prodrug. int ophthalmol clin. 2006; 46: 13–20. 12. raizman m, ernest p, gayton j, lehmann r. in vivo pharmacokinetics and in vitro pharmacodynamics of nepafenac, amfenac, ketorolac, and bromfenac. j cataract refract surg. 2007; 33: 1539–1545. 13. ke tl, graff g, spellman jm, yanni jm. nepafenac, a unique nonsteroidal prodrug with potential utility in the treatment of trauma-induced ocular inflammation: ii. in vitro bioactivation and permeation of external ocular barriers. inflammation, 2000; 24: 371–384. 14. lindstrom r, kim t. ocular permeation and inhibition of retinal inflammation: an examination of data and expert opinion on the clinical utility of nepafenac. curr med res opin. 2006; 22: 397–404. 15. abdel m, mahdy s. effect of flurbiprofen and dexamethasone acetate in prevention of surgically induced miosis during cataract surgery. j am sci. 2011; 7: 474–478. 16. gimbel h, van westenbrugge j, cheetham jk, degryse r, garcia cg. intraocular availability and pupillary effect of flurbiprofen and indomethacin during cataract surgery. j cataract refract surg. 1996; 22: 474–479. 17. zanetti fr, fulco ea, chaves fr, da costa pinto ap, arieta ce, lira rp. effect of preoperative use of topical prednisolone acetate, ketorolac tromethamine, nepafenac and placebo, on the maintenance of intraoperative mydriasis during cataract surgery: a randomized trial. indian j ophthalmol. 2012; 60 (4): 277. 18. cervantes-coste g, sánchez-castro yg, orozcocarroll m, mendoza-schuster e, velasco-barona c. inhibition of surgically induced miosis and prevention of postoperative macular edema with nepafenac. clin ophthalmol. 2009; 3: 219–226. 19. atanis r, tuaño pm, vicencio j, martinez jm, verzosa l. effect of topical ketorolac tromethamine and topical nepafenac on maintaining pupillary dilation during phacoemulsification. philipp j ophthalmol. 2011; 36: 23–27. 20. mahdy ma. effect of flurbiprofen and dexamethasone acetate in prevention of surgically induced miosis during cataract surgery. j am sci. 2011; 7: 474–478. 21. gamache da, graff g, brady mt, spellman jm, yanni jm. nepafenac, a unique nonsteroidal prodrug with potential utility in the treatment of trauma-induced ocular inflammation: i. assessment of antiinflammatory efficacy. inflammation, 2000; 24: 357– 370. authors’ designation and contribution sairam ahmed; post graduate trainee: concepts, literature research, data analysis, statistical analysis, manuscript preparation, manuscript review. iqra ghazanfar; medical officer: design, literature research, data acquisition, manuscript preparation. fuad ahmad khan niazi; professor: data acquisition, manuscript editing, manuscript review. ali raza; professor: data analysis, statistical analysis, manuscript editing, manuscript review. .…  …. 361 pak j ophthalmol. 2021, vol. 37 (4): 361-365 original article demographic characteristics and causes of low vision in children: a hospital–based study from khartoum, sudan saif hassan al-rasheed 1 , eslah saeed awad 2 , zoelfigar dafalla mohamed 3 department of ophthalmology, 1 college of applied medical science, qassim university, saudi arabia, 2 faculty of optometry and visual sciences, al-neelain university, khartoum, 3 university of buraimi, oman abstract purpose: to determine the demographic characteristics and causes of low vision in children who attended alfaisal eye center, khartoum sudan. place and duration of study: alfaisal eye center, khartoum, sudan, from february 2018 to october 2020. study design: cross sectional observational study. methods: clinical record of 105 patients who visited the low vision clinic were retrieved. demographic features, history, ocular examination, cause of low vision, refractive state of the eye (by self-luminance streak retinoscope, and auto refractometer), and type of low vision devices used by the patients were noted. data was analyzed by using spss software version 20. results: mean age was 11.70 ± 2.19. seventy three percent patients had visual acuity(va) less than 6/60. majority (59%) were male patients. commonest refractive error associated with low vision was myopia (65.71%). retinitis pigmentosa, congenital glaucoma, and albinism were other major causes of pediatric low vision (19.5%). progressive myopia was seen in 15%. about 9.5% of children presented with cataracts, nystagmus in 9.5%, and congenital refractive error in 9.5%.the cause of low vision among children was not statistically different between males and females p=0.890. more than half of the children 78.1% used glasses and about 21.9% were corrected by telescope. conclusion: retinitis pigmentosa, albinism, and congenital glaucoma were the most common causes of pediatric low vision. common low vision devices prescribed to these children were glasses and telescopes. key words: retinitis pigmentosa, congenital glaucoma, albinism, myopia, cataract. how to cite this article: al-rasheed sh, awad es, mohamed zd. demographic characteristics and causes of low vision in children: a hospital – based study from khartoum, sudan. pak j ophthalmol. 2021, 37 (4): 361365. doi: 10.36351/pjo.v37i4.1274 correspondence: saif hassan alrasheed college of applied medical science qasim university saudi arabia email: s.rasheed@qu.edu.sa received: may 15, 2021 accepted: september 03, 2021 introduction global estimates indicate that there are around 17.5 million children with low vision and most of them are in developing countries. childhood low vision has a long-term effect on motor and cognitive development resulting in poor quality of life. 1,2 low vision was defined by world health organization(who) as an impairment of visual functioning even after treatment and/or standard refractive correction and has a visual acuity of less than 6/18 to light perception, or the open access mailto:s.rasheed@qu.edu.sa demographic characteristics and causes of low vision in children: a hospital – based study from khartoum, sudan pak j ophthalmol. 2021, vol. 37 (4): 361-365 362 visual field less than 10° from the point of fixation in the better eye. 3 the major causes of childhood visual impairment are varying widely from region to region, being largely determined by socioeconomic development. causes include albinism, congenital cataract, congenital glaucoma, congenital idiopathic nystagmus, high refractive error, and myopic degeneration. 4,5 etiological factors, age of onset, presence of other impairments, environmental aspects, and the interactions among these will determine the child's difficulties and delay in development. 6,7 the eye care professionals such as ophthalmologists and optometrists couldhelp visually impaired children with visual and non-visual aids. 8 low vision aids (optical, non-optical) aim to improve visual resolution through changes in the retinal image (magnification, displacement, filtering, or condensation) or enhance the environmental condition and by rehabilitation. 9,10 these supports are prescribed when children start experiencing visual difficulties at school, which is usually around the age of 8 or 9 years.often, learning to use alow vision aids (lva) at that age turns out to be too demanding for a child. this is the period when several novel academic skills, in particular reading and writing, must be mastered as well. children with visual impairment already have difficulties with reading and pre-school mastering of aid will be beneficial in at least partly preventing developmental delays. additional factors are that at this age, children tend to reject the use of an lva, because they are afraid of stigmatizing. 11 studies regarding low vision in sudan are scarce. therefore, this study was conducted to assess pediatric low vision in khartoum, sudan. methods this was a descriptive cross sectional hospital-based study, conducted at alfaisal eye center, khartoum sudan. data was retrievedfrom the low vision clinics from 2018 to 2020. one hundred and five pediatric low vision patients were included in this study, their ages ranged between six to sixteenth years. all patients underwent detailed ocular examination by a pediatric ophthalmologist and optometrist, then referred to a low vision clinic for low vision assessment. ethical permission for the performance of the research was obtained from al-neelain university and permission to use the patients’ records was sought from al-faisal eye hospital.informed consent was waived because of the retrospective nature of the study. however, efforts were made to ensure that patients’ confidentiality was guaranteed. it was made sure that the data would only be used for the current research purpose. data included patients’ identification data, history and cause of low vision, vision, and visual acuity (by snellen chart), refractive state of the eye (by self-luminance streak retinoscope, and auto refractometer), and type of low vision devices which was prescribed. the data was entered in an excel sheet and analyzed using a statistical program for social studies (spss 20) software. descriptive statistics were used to describe the study parameters (the tests included means, standard deviations, and frequencies). results a total of 105 pediatric patients who attended alfaisal eyecenter complaining of reduced visual acuity and qualifying the definition of low vision were included in this study. the age of the participants table 1: demographic and clinical characteristics of patients. characteristic(105 patients) frequency (%) age (mean ± sd (standard deviation) range (yrs.) 11.70 ± 2.19 6 to 16 gender males females 62 (59.0%) 43 (41.0%) visual acuity(va) mean va right eye range va mean va left eye range va 0.11 ± 0.08 0.01 to 0.33 0.11 ± 0.07 0.01 to 0.4 type of refractive error hyperopia myopia 36 (34.3%) p-value = 0.37 69 (65.7%) p-value = 0.001 hyperopia by degree low(2-3d) moderate(3-6d) high (6d and over) 15 (41.6%) 14 (38.8%) 7 (19.2) myopia by degree low(1-3d) moderate(3-6d) high (6d and over) 23 (33.4) 23 (33.3) 23 (33.3) devices for management eyeglasses telescope 82 (78.1) p-value = 0.001 23 (21.9 p-value = 0.785 saif hassan al-rasheed, et al 363 pak j ophthalmol. 2021, vol. 37 (4): 361-365 ranged between 6 and 16 years with a mean age of 11.70 ± 2.19 years. almost 68.4% of participants had their age between (11 – 16) years, followed by age group (6 – 10) years representing 31.6%.with regards to the distribution of gender, about 59% were males and 41% were females. majority (73.30%)of the children presented with visual acuity less than 6/60 in their right eye with a mean of 0.11 ± 0.08, and 33.20% had low vision in their left eye with a mean of 0.11 ± 0.07. the leading causes of low vision among children were retinitis pigmentosa, albinism, and congenital glaucoma. further details are given in table 2. table 2: causes of childhood low vision. gender total (%) pvalue causes male (%) female (%) retinitis pigmentosa 13 (21.0) 7 (16.3) 20 (19.04) 0.890 albinism 10 (16.1) 10 (23.3) 20 (19.04) congenital glaucoma 11 (17.7) 9 (20.9) 20 (19.04) pathological myopia 10 (16.1) 5 (11.6) 15 (14.3) congenital cataract 5 (8.0) 5 (11.6) 10 (9.5) refractive error 6 (9.7) 4 (9.3) 10 (9.5) nystagmus 7 (11.3) 3 (7.0) 10 (9.5) total 62 (100) 43 (100) 105 (100) discussion global estimations show that there are around 19 million visually impaired children. of these, 1.4 million are blind and 17.5 million have low vision and most of them are found in poor countries. 12 while low vision among children is less common than adults, it has a serious significant negative impact on the lifespan of the child with an estimate of 60% of children dying within one year of becoming blind. 13 this study revealed that majority 59% of the patients attending low vision clinics were males which was consistent with uprety, et al. 10 they found that 63.7% of patients attending low vision clinics were males. the most common age group affected by the low vision in the current study was 10 to 16 years. this data also corresponds with the findings of uprety, et al. 10 whoreported that the high prevalence of low vision impairment was found among 11 to 16 years age group. from the above-mentionedresults it is clear that an effort should be directed to diagnose childhood visual impairment as early as possible and to provide a treatment plan to reduce the serious deterioration of vision. this can reduce the negative impact of low vision on child's development and academic activities. low vision aids can be used at an appropriate time to maximize the visual functions which can reflect on their academic performance and productive activites. 14,15 regarding the refractive error, most of the children were myopic (65.7%) in both eyes. this indicates the importance of visual assessment at an early age before going to school. 16 the leading cause of childhood low vision in the current study was albinism, retinitispigmentosa, and congenital glaucoma with a percent of 19%, followed by progressive myopia 14.3%. however, the major cause of low vision among children was not significantly different between males and females (p = 0.890). our results are slightly different from those reported by shah, et al. they showed the main causes were nystagmus followed by stargardt's disease. 17 this difference could be due to the dissimilar geographic location of studies and socioeconomic status of study sample. on the other hand,the present results are comparable with a study from brazil 18 which reported that the leading causes were congenital cataract, toxoplasmosis, and congenital glaucoma. our study showed that the hereditary/congenital ocular anomalies (albinism, retinitis pigmentosa, and congenital glaucoma) accounted for 57.1% of low vision patients, this is comparablewith shah, et al. 17 they found that 21% of low vision patients were affected by hereditary/congenital ocular anomalies. our results arealso in agreement with uprety, et al, 10 who revealed that 50% of the causes of low vision congenital. the reason for this high proportion of hereditary/congenital anomalies in this study may be due to inter-family marriages, which are common in sudan. 19 most of these conditions were not treatable but prevention is possible through genetic counseling. the present study revealed that spectacles were prescribed for 78.1% of the low vision children, and telescopes for 21.9%. thisis in contrast with a report by shah et al, 17 which showed that spectacles were prescribed for 66.2% of low vision patients and telescopes to 33.8%. the above results show lesser use low vision aids in our setup. the eye care professionals should encourage the parents of children with low vision to use low vision aids. 20 these devicescan improvethe child’s quality of life through visual rehabilitation. arrangements should be madeto teach them how to demographic characteristics and causes of low vision in children: a hospital – based study from khartoum, sudan pak j ophthalmol. 2021, vol. 37 (4): 361-365 364 use their remaining vision more effectively. 20 using a variety of visual and adaptive aids may help them to keep-up the pace of the developing world. this study has some limitations. it was a retrospective study in which records are sometimes incomplete which decreases the sample size. secondly, the study came from a low vision clinic which may not reflect the demographics of the general sudanese population. the assessment of vision, refraction, and causes of childhood low vision in preverbal children may be exceedingly difficult and not as accurate as the measurement in an older age group. this can lead to bias. the refractive error was considered as hypermetropia or myopia, and astigmatism was added as minus equivalent sphere resulting in increase in the mean frequency of myopic refractive error. conclusion low vision problems are common in children with a higher with frequency in males than females. albinism, retinitis pigmentosa, and congenital glaucoma is the most common cause of low vision in children. eye care professionals should teach the parents about the importance of early diagnosis and treatment of childhood vision problems and using low vision aids. acknowledgments the authors are grateful to the staff of the alfaisal eye center, khartoum, sudan for their help with the process of data collection. ethical approval the study was approved by the institutional review board/ ethical review board.(18-07-10) conflict of interest authors declared no conflict of interest. references 1. pascolini d, mariotti sp. global estimates of visual impairment: 2010. br j ophthalmol. 2012; 96 (5): 614618. 2. american optometric association. low vision. online at: http://www.aoa.org/patients-and-public/caring-foryour-vision/low-vision?sso=y [accessed on 11 march, 2017]. 3. ghasemifard f, mirzaie h, oori mj, riazi a. characteristics and efficacy of play therapy interventions in visually impaired children and adolescents: a systematic review study. iran j pediatr. 2020; 30 (6): 1-8. 4. ovenseri-ogbomo go, osafo-agyei h, akpalaba reu, addy j, ovenseri eo. impact of low vision services on the quality of life of low vision patients in ghana. afr vision eye health, 2016; 75 (1): a19. 5. walter w, marie-céline l, samuel n, michael t, scott ga, judith ge, et al. the effect of a headmounted low vision device on visual function. optom vis sci. 2018; 95 (9): 774-784. doi: 10.1097/opx.0000000000001262 6. brilliant lb, pokhrel rp, grasset nc, lepkowski jm, kolstad a, hawks w, et al. epidemiology of blindness in nepal. bull world health organ. 1985; 63: 375–386. 7. negiloni k, ramani kk, jeevitha r, kalva j, sudhir rr. are children with low vision adapted to the visual environment in classrooms of mainstream schools? indian j ophthalmol. 2018; 66 (2): 285. 8. magdalene d, bhattacharjee h, dutta p, ali a, sundar s, paidi rm. vision improvement with low vision aids and functional vision assessment among children studying in schools for the blind in north-east india. ophthalmology j. 2021; 6: 72-75. 9. barría von-b f, rodrigoa ph, loretoc tf, patriciad rg, martae md. ophthalmological evaluation in children referred to a low-vision rehabilitation project of a social assistance agency. rev chil pediatr. 2019; 90 (3): 293-301. 10. uprety s, khanal s, morjaria p, puri lr. profile of paediatric low vision population: a retrospective study from nepal. clin exp optom. 2016; 99 (1): 61-65. 11. schurink j, cox rf, cillessen ah, van rens gh, boonstra fn. low vision aids for visually impaired children: a perception-action perspective. res dev disabil. 2011; 32 (3): 871-882. 12. courtright p, hutchinson ak, lewallen s. visual impairment in children in middle-and lower income countries. arch dis child, 2011; 96 (12): 1129-1134. 13. alrasheed sh, elmadina aem. the effect of binocular vision problems on childhood academic performance and teachers’ perspectives. pak j ophthalmol. 2020; 36 (2): 163-168. 14. colenbrander a, liegner jt, fletcher dc. enhancing impaired vision. in: fletcher dc. low vision rehabilitation: caring for the whole person. am acad ophthalmol. 1999: 49-59. 15. mohamed zd, abdu m, alrasheed sh. management plan for childhood visual impairment in traditional quranic boarding schools in al-gazira state of sudan. albasar int j ophthalmol. 2018; 5: 1-5. http://www.aoa.org/patients-and-public/caring-for-your-vision/low-vision?sso=y http://www.aoa.org/patients-and-public/caring-for-your-vision/low-vision?sso=y saif hassan al-rasheed, et al 365 pak j ophthalmol. 2021, vol. 37 (4): 361-365 16. de paula ch, vasconcelos gc, nehemy mb, granet d. causes of visual impairment in children seen at a university-based hospital low vision service in brazil. j am assoc pediatr ophthalmol strabismus, 2015; 19 (3): 252-256. 17. shah m, khan md. causes of low vision amongst the low-vision patients attending the low-vision clinic at khyber institute of ophthalmic medical sciences (kioms), hayatabad medical complex peshawar, pakistan. vis impair res. 2004; 6 (2-3): 89-97. 18. schellini sa, meneghim rl, satto l, cavinatto p, galindo-ferreiro a, khandekar r. magnitude of visual impairment, blindness and causes in the southwest region of são paulo state, brazil. arquivosbrasileiros de oftalmologia. 2018; 81: 414420. 19. alrasheed sh, naidoo ks, clarke-farr pc, binnawi kh. building consensus for the development of child eye care services in south darfur state in sudan using the delphi technique. afr j prm health care med. 2018; 10 (1): a1767. https://doi.org/10.4102/ phcfm. v10i1.1767 20. javed m, afghani t, zafar k. barriers to low vision services and challenges faced by the providers in pakistan. j korean clin health sci. 2015; 3 (3): 399408. authors’ designation and contribution saif hassan alrasheed; assistant professor of optometry: concepts, design, literature search, statistical analysis, manuscript preparation, manuscript editing, manuscript review. eslah saeed awad; optometrist: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation. zoelfigar dafalla mohamed ; assistant professor of optometry: literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. disclaimer all the autors are from al-neelain university khartoum sudan. however, saif hassan alrasheed joined qassim university in 2020 for a temporary position for five years. zoelfigar dafalla mohamed from sudan joined the university of buraimi, oman in 2021 for a temporary position. all the authors contributed to preparing and finalizing the manuscript. .…  …. 176 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology original article prevalence of amblyopia amongst children presenting in a tertiary care center in karachi saba alkhairy, farnaz siddiqui, mazhar-ul-hasan pak j ophthalmol 2016, vol. 32, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. saba alkahiry assistant professor department of ophthalmology eye opd of dow university of health science (ohja campus), karachi – pakistan e.mail: saba.alkhairy1@gmail.com …..……………………….. purpose: to determine the prevalence and causes of amblyopia amongst children presenting to the opd department of dow university of health science, karachi, pakistan. study design: cross sectional study. place and duration of study: eye opd of dow university of health science (ohja campus), karachi, pakistan from january 2016 to june 2016. material and methods: this was a cross sectional study conducted in the eye opd of dow university of health science, karachi, pakistan. all children aged 5 to 20 years were examined. they underwent visual acuity assessment with snellen acuity chart. those with visual acuity less than or equal to 6l9 or having a difference of two lines on snellens chart between the two eyes were examined further with cycloplegic refraction with cyclopentolate 1% and dilated fundo exam was performed. further tests included hirschberg light reflex test, cover test, prism cover-uncover and extraocular movements. results: a total of 2500 children were screened and 169 (6.7%) were found to be amblyopic. there were 61 (36.1%) males and 108 (63.9%) females. amblyopia was most commonly seen in the age group less than 12 years 63 (37.3%) and the most common cause of amblyopia was isometropia 61 (36.1%) followed by meridional 45 (36.6% mixed 42 (24.9%), anisometropia 15 (8.8%) and squint 6 (3.6%). the prevalence of amblyopia among was found children presenting to the opd of dow university of health science was found to be 6.7% which is higher than any other published studies on amblyopia. conclusion: screening for amblyopia is essential in all children aged 5 years or more, presenting to outpatient. key words: amblyopia, screening, strabismus, prevalence. definition of amblyopia according to friendly is “amblyopia is a reduction in the quality of central, corrected vision resulting from the disturbance in retinal image formation during the first decade of human life’¹. the estimated prevalence of amblyopia in different parts of the world is 1.6 to 3.6%². it is one of the major causes of visual disability in children and is usually seen in early childhood³. five major causes of amblyopia include: isometropic amblyopia: when the refractive error in the two eyes exceeded or equaled to 5.0d. anisometropic amblyopia: when there is a difference of refractive error in both eyes of ≥ 1d of astigmatisim, ≥ 2d of hypermetropia and ≥ 4d of myopia. strabismic amblyopia: this was defined as amblyopia present in an eye that had constant manifest strabismus. meridional amblyopia: when amblyopia was as a a prevalence of amblyopia amongst children presenting in a tertiary care center in karachi pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 177 result of astigmatism of ≥ 2.00d in one or both eyes. mixed amblyopia: it is said to occur when more than one cause of amblyopia is present in a single eye4. the prevalence of amblyopia in united states is stated to be 1-4% studied by doshi et al who further stated that only 20% of school going children have visual screening and if amblyogenic factors such as uncorrected refractive error and strabismus were identified and treated early the risk of amblyopia would decrease5. several studies have investigated the prevalence of amblyopia such as a study conducted in australia in children aged 6 years stated it to be 1.8% while another study done on british children aged 7 years in the avon longitudinal study of parents and children estimated it to be 3.6%6,7. to the best of our knowledge no similiar study has been conducted in karachi although another study has been published on the prevalence and risk factors in lahore pakistan. the purpose of conducting our study is not only to compare our results to other published studies but also to identify the most common risk factors for amblyopia. there is no proper system of visual screening in school going children and often amblyopia is incidentally discovered in older individuals as they present to the ophthalmologists for other complaints. visual screening should be made mandatory in all schools and treatment should commence as early as possible as amblyopia generally develops in childhood years up to 7 to 8 years of age and can be efficiently corrected before 9 to 10 years of age8,9. material and methods we recruited patients aged 5 to 20 years from the eye opd of dow university of health science. there were a total of 2500 children screened of which 900 were boys and 1600 were girls. the patient was initially evaluated by an optometrist who took a detailed history and assessed visual acuity using a snellens chart. for children who were unable to identify the letters on the snellen chart we retested the visual acuity with single letter optotype. children less than 5 years were excluded because of resistance to examination and poor communication. any child with a visual acuity of 6l9 or less or with a difference of more than two lines on snellens chart was further investigated by cycloplegic refraction. for cycloplegic refraction we used tropicamide 1% and cyclopentolate 1% instilled five minutes apart every ten minutes for thirty minutes. both an autorefractometer as well as retinoscopy was done to evaluate the refractive status. furthermore the patients anterior segment and fundus was examined to rule out any other cause of decreased vision. we also checked the patients extraocular movements and did a comprehensive pupillary exam, and ocular alignment tests such as hirshberg and cover and uncover which were performed with fixation targets at 0.5m and 4m. the data was analyzed on ibm spss version 22.0 and the results were presented as frequency and percentages for gender, cause, age groups, unilateral or bilateral, and best corrected visual acuity. mean ± sd was reported for the age variable. statistical comparisons were performed using binomial test for proportion for gender and unilateral or bilateral variables. test proportion was 50% and p-value was computed if one of the proportion is higher or lower than 50%. chi-square goodness of fit test was performed for cause, best corrected visual acuity and age groups which test proportions of all categories for a specific variable are same or different. chi-square test was applied to see the association between gender and amblyopia. a p-value of 0.01 or less was considered statistically significant. results in total we screened 2500 subjects of which 169 were found to have amblyopia. females were 108 (63.9%) and males were 61 (36.1%) which is also significant due to the higher proportion of female reported in table 01. the average age of the study population was 12.3 years ± 3.6 sd. there are gradually increasing number of subjects in age groups, for less than 12 years 63 (37.3%), most population was found in 12 to 15 group 84 (4%) and relatively less was found in 16 and above age group 22 (13.0%). table 1 the statistics for shows etiology. amongst causes isometropia was found to account for the highest number of amblyopia patients which were 61 (36.1%). a similar pattern can be observed for best corrected visual acuity. patients were more bilateral 133 (78.7%) them unilateral 36 (21.3%). graphically the same was reported and significance reported in the table 1. table 2 distribution of amblyopia which shows that females were larger in number than males but there was the same proportion of amblyopia among males 61 (6.8%) and in females 108 (6.8%). saba alkahiry, et al 178 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology table 1: distribution of patients having amblyopia. characteristics zas n = 169 % p-value gender female 108 63.9 < 0.001** male 61 36.1 age (mean ± sd = 12.3 ± 3.6) <12 years 63 37.3 < 0.001** 12 15 years 84 49.7 16 + years 22 13 cause isometropic 61 36.1 < 0.001** anisomtetropic 15 8.9 squint 6 3.6 meridional 45 26.6 mixed 42 24.9 unilateral or bilateral bilateral 133 78.7 < 0.001** unilateral 36 21.3 best corrected visual acuity 6/9 114 67.5 < 0.001** 6/12 27 16 6/18 8 4.7 6/24 9 5.3 6/36 4 2.4 6/60 or less 7 4.1 **significant at 1% 61 15 6 45 42 0 10 20 30 40 50 60 70 is o m e tr o p ic a n is o m te tr ip ic s q u in t m e ri d io n a l m ix e d causes fig. 1: distribution of causes. 114 27 8 9 4 7 0 20 40 60 80 100 120 6/9 6/12 6/18 6/24 6/36 <6/60 fig. 2: distribution of best corrected visual acuity. discussion pakistan is ranked as the sixth most populated country in the world10. a survey done in 2015 stated that the table 2: distribution of patients of amblyopia by gender. characteristics amblyopia total (n = 2500) pvalue yes (n = 169, 6.8%) no (n = 2331, 93.2%) gender male 61 (06.8%) 839 (93.2%) 900 0.979 female 108 (06.8%) 1492 (93.3%) 1600 visual acuity prevalence of amblyopia amongst children presenting in a tertiary care center in karachi pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 179 pakistani population estimates to more than 191.71 million and a study done on pakistani population showed the prevalence of blindness to be 0.9%11. the total number of blinds will increase to almost double in the year 2020, if the prevalence rate remains the same (1.25 million in 2003 to 2.4 million in 2020)12. throughout the world the leading cause of blindness is cataract and this is seconded by uncorrected refractive error13. uncorrected refractive error leads to amblyopia which is defined as a reduction in corrected visual acuity (va) in absence of visible organic abnormalities and is due to misdirected, distorted, or absent retinal images during maturity of visual system.14 it is the most common cause of uniocular visual impairment in both children as well as adults15. it can be as a result of strabismus which is deviation of eyes and abnormal inter ocular interaction, or any form of a form vision deprivation e.g. dense corneal or lenticular opacity, high myopias and hyperopias, anisometropia or astigmatism. early recognition of amblyopia and prompt treatment is necessary to improve or correct the vision in amblyopia. the prognosis is better if treatment of amblyopia is administered latest by 7 – 8 years of life in cases amblyopia of squint and for refractive amblyopias treatment should be instituted maximum by early teens16. the prevalence of amblyopia in our study was higher as compared to the figure quoted in other studies. amblyopia was present in 169 children of the total 2500 children screened thus making a prevalence rate of 6.7%. to our knowledge this is the highest rate ever quoted. this disparity may be explained by the different diagnostic criteria for amblyopia used in various studies some using visual acuity of 6/9 or less while others defining amblyopia as less than or equal to 6/12 on snellen chart. furthermore lack of awareness amongst general population of importance of visual acuity assessment and also poor accessibility of health care centers may be the cause of this high prevalence of amblopia in karachi, pakistan. our prevalence rate of amblyopia is significantly higher when compared to a study done in primary schools in nigeria which has stated the prevalence rate to be only 0.23%17. in another study done in another city of pakistan the prevalence rate of amblyopia was 3.0%18 while still another study conducted by rahi et al showed the prevalence of amblyopia was 4.8%19. the number of females having amblyopia 108 (63.9%) were more as compared to amblyopic males 61 (36.1%). this is in contrast to other studies such as the one conducted in southern india where the number of boys with amblyopia (n = 25, 57%) was slightly higher than the number of girls with amblyopia (n = 19, 43%; p = 0.6)20, also in china where the male to female ratio was 57 to 42.97%21. however a slightly increased preponderance of amblyopia was seen in female subjects as compared to male subjects in a study done in iran in which 2% of the male students (95% ci: 0.9 – 3.1) and 2.5% in girls (95%ci: 1.5 – 3.6) had amblyopia which is comparable to our results22. the number of amblyopic females were more in our study because the total number of females presenting to the opd of our department were more than males: 1600 female subjects versus 900 male subjects. the causes of amblyopia in our study included isometropia 61 (36.1%), meridional 45 (26.6%), mixed 42 (24.9%), anisometropia 15 (8.9%) and squint 6 (3.6%). our results are comparable to a study done in southern india where underlying amblyogenic causes were ametropia (50%), anisometropia (40.9%), strabismus (6.8%), visual deprivation (4.5%) and combined causes (2.2%)20. in a study done on rural chinese population the causes of amblyopia included were anisometropia (67.3%), strabismus (5.4%), mixed strabismus and anisometropia (4.4%), visual deprivation (9.8%), astigmatism association (9.8%), and other (3.4%)23. in another study done in lahore, pakistan the causes listed were strabismic amblyopia in 110 (55%), anisometropic amblyopic in 42 (21%), combined mechanism amblyopia in 32 (16%), ammetropia in 12 (6%), and stimulus deprivation in 4 (2%) of the children24. in terms of laterality patients in our study are more bilateral 133 (78.7%) and a very less are unilateral i.e. 36 (21.3%). we also found that there were gradually increasing number of subjects in age groups, for less than 12 years 63 (37.3%), in 12 to 15 group 84 (4%) and in 16 and above age group 22 (13.0%). sean p conducted a study in which the prevalence was 40% (32/80) for 2-year-olds, 65% (119/182) for 3-year-olds, and peaked at 76% (age 5) showing a steady increase in the prevalence of amblyopia with age25. we also see that the best corrected visual acuity gradually decreases from 6/9 to < 6/60 with a significant p-value. patients having 6/9 corrected visual acuity were 114 (67.5%), 6/12 were 27 (16.0%), 6/18 were 8 (4.7%), 6/24 were 9 (5.3%), 6/36 were 4 (2.4%), ≤ 6/60 were7 (4.1%). the limitations of this study are that it is a single saba alkahiry, et al 180 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology center study and children under 5 years were excluded due to poor communication. further studies should be multicentered and should comprise of a larger sample size for more accurate results. in summary we have the highest prevalence rate of amblyopia i.e. 6.7% as compared to studies conducted in other parts of the world. this high prevalence rate is mostly because there is lack of effective visual screening programs for children. another reason for this high prevalence rate may be as a result of usage of a lower threshold for the diagnosis of amblyopia used in our study. nevertheless we feel the government of pakistan should not only strategize screening programs in all schools but should also facilitate timely treatment to prevent and treat amblyopia. the prevalence of amblyopia among children presenting to the opd of dow university of health science is determined to be 6.7% which is higher than any other published studies on amblyopia. conclusion screening for amblyopia is essential in all children aged 5 years or more, presenting in the outpatient departments of all hospitals. authors affiliation dr. saba alkahiry mbbs, fcps assistant professor duhs, dimc dr. farnaz siddiqui mbbs, fcps assistant professor duhs, dimc dr. mazhar-ul-hasan mbbs, fcps, peads fellow prof. h.o.d duhs, dimc role of authors dr. saba alkahiry writer and data collector dr. farnaz siddiqui data collection and editor dr. mazhar-ul-hasan data collection references 1. friendly ds. amblyopia: definition, classification, diagnosis, and management considerations for pediatricians, family physicians, and general practitioners pediatr clin north am 1987 dec. 34 (6): 1389-1401. 2. shafique mm, naeemullah, butt nh, khalil m, gul t. incidence of amblyopia in strabismic populations, pak j ophthalmol,. 2007; 23 (1). 3. homood y. prevalence of amblyopia in primary school children in qassim province, kingdom of saudia arabia. middle east african journal of ophthalmology, 2015: 22 (1). 4. akbe ba, abadom eg, omoti ea. prevalence of amblyopia in primary school pupils in benin city, edo state, nigeria. afr j med health sci. 2015; 14: 110-4. 5. doshi nr, rodriguez ml. amblyopia. am fam physician, 2007 feb. 1; 75 (3): 361. 6. robaei d, kifley a, rose ka, mitchell p. impact of amblyopia on vision at age 12 years: findings from a population based sample of 6 year old australian children. arch ophthalmol. 2006; 124: 878-84. 7. willaims c, northstone k, howard m et al. prevalence and risk factors for common visual problems in children alspac study.br j ophthalmolog. 2008; 92: 959-64. 8. simons k. amblyopia characterization, treatment and prophylaxis. surv ophthalmol. 2005; 50: 123-66. 9. park kh, hwang jm, ahn jk. efficiency of amblyopia therapy initiated after 9 years of age. eye (lond.), 2004; 18: 571-4. 10. pakistan .wikipedia the free enclylopedia.28th march 2016. available from url: https://en.wikipedia.org/wiki/pakistan 11. z mohammed, d brenden, r rupert et al. prevalence of blindness and visual impairment in pakistan: the pakistan national blindness and visual impairment survey. iovs, 2006; 47: 11. 12. world health organization. preventing blindness in children. report of a who/iapb scientific meeting. who/ pbl/00.77.geneva: who, 2000. 13. yeo r, moore k. including disabled people in poverty reduction work: ‘‘nothing about us, without us.’’ world development, 2003; 31: 571–90. 14. friendly ds. amblyopia: definition, classification, diagnosis and management consideration for pediatricians, and family physicians and general practitioners. pedr clin north am. 1987; 34: 1389-1401. 15. dandona r, dandona l, srinivas m, sahare p, narsaiah s, munoz sr, et al. refractive errors in children in rural population. invest oph vis sci. 2002; 43: 615-22. 16. jack j kanski, brad bowling. clinical ophthalmology: a systemic approach. 7th ed. edinburgh: elsevier saunders; 2011: 745. 17. akpe ba, abandom eg, omoti ea. prevalence of amblyopia in primary school pupils in benin city, edo state, nigeria. afr j med health sci. 2015; 14: 110-4. prevalence of amblyopia amongst children presenting in a tertiary care center in karachi pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 181 18. a awan, a imran, a khan. prevalence of amblyopia among government middle school children in city of lahore, pakistan. ijavms, 2010; vol. 4; 2: 41-46. 19. js rahi, pm cumberland, cs pecham. does amblyopia affect educational, health and social outcomes? bmj, 2006; 332 (7545): 820-825. 20. dorairaj s et al. prevalence and etiology of amblyopia in southern india: results from screening of school children aged 5 – 15 years. ophthalmic epidemiol. 2013; 20 (4): 228-31. 21. abdelrazik st, khalil mf. prevalence of amblyopia among children attending primary schools during the amblyogenic period in minia county. j egypt ophthalmol soc. 2014; 107: 220-5. 22. ay abbas et al. the prevalence of amblyopia and strabismus among schoolchildren in northeastern iran. iranian journal of ophthalmology, 2012; 24 (4): 3-10. 23. yue w et al. prevalence and causes of amblyopia in a rural adult population of chinese : the handan eye study. 2011; 118 (2): 279–283. 24. sethi s et al. causes of amblyopia in children coming to ophthalmology outpatient department khyber teaching hospital, peshawar. jpma, 2008; 58: 125-128. 25. donahue p. the relationship between anisometropia, patient age, and the development of amblyopia. trans am ophthalmol soc. 2005; 103: 313–336. comparison of image opacity between swept source oct and spectral domain oct in the setting of media opacification 128 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology original article comparison of image quality between swept source and spectral domain oct in media opacification hina khan, aamir asrar, bisma ikram, maha asrar pak j ophthalmol 2016, vol. 32, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hina khan, consultant ophthalmologist, head of ophthalmic diagnostics department, amanat eye hospital, islamabad email: drhinakhan79@gmail.com …..……………………….. purpose: the study aimed to compare the image quality of sd oct and ss oct in the setting of media opacification i.e. cataract. study design: prospective cross sectional study. place and duration: amanat eye hospital from 1 st october 2015 till 31 st december 2015. material and methods: prospective cross sectional study was carried out on 366 eyes of 241 subjects. all subjects were scanned with both ss – oct and sd – oct with dilated pupils and scans were evaluated by two ophthalmologists. chi square/ fisher exact test was applied to assess the results. results: in the sample of 366 eyes, there were 174 eyes with grade 1; 96 with grade 2; 72 with grade 3; and 24 with grade 4 cataract media opacification. the images obtained from media opacification grade 1 and 4 were almost constant and statistically non significant. the results of images obtained with grade 2 media opacification was significant with p = 0.001. similarly, the results obtained from grade 3 media opacification were highly significant with p < 0.001. conclusion: the image quality of ss oct and sd oct performs better in moderate media opacification. both machines performed equally and efficiently in mild media opacification whereas failed to provide clinically useful scans for dense media opacification. keywords: swept source optical cohorence tomography, spectral domain oct, image quality, media opacity, cataract. ct has established itself as indispensible for monitoring of vitreo retinal choroidal disorders1,2. since its advent over 20 years ago, it has seen tremendous transformation from time domain models with an axial resolution of 50µm to sd oct with resolution of less than 5µm. however, two major limitations were consistently observed with previous models. firstly visualization of the choroid has been sub optimal. secondly visualization through media opacification such as cataract leads to a deterioration of image quality3,4. the wavelength employed for illumination in sd models is 800 – 870 µm. this is optimal for imaging the retina but does not offer large penetration depths since in sd technology the signal strength seems to decay rapidly with an increase in the spatial distance from zero delay line which is the axial distance for maximum sensitivity for signal detection (conventionally placed near the vitreo retinal interface), a phenomenon known as sensitivity role off5. in an attempt to overcome this limitation, the enhance depth imaging (edi) mode was introduced in sd technology. parallel to this, swept source oct technology has been invented which uses a longer wavelength of light (1050mm) with a tunable laser and narrower band width. this technology offers much o mailto:drhinakhan79@gmail.com comparison of image quality between swept source and spectral domain oct in media pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 129 less sensitivity role off without affecting signal strength in other regions and has claimed to perform better in eyes with media opacification. many comparisons between these modalities have already been published. the choroidal thickness estimates6,7, the automated choroidal segmentation8, the penetration depth9,10, the contrast at deep choroidal vessel level, image quality in pathological myopia11, have been studied. all of these studies have excluded cases with media opacification, citing it as a limitation. the purpose of this study was to compare the image quality between sd oct and ss oct in the setting of media opacification i.e. cataract. material and methods a comparative cross – sectional study conducted in the settings of amanat eye hospital, equipped with both sd-oct (heidelberg spectralis) and the ss–oct (topcon triton). consecutive sampling technique was used to collect the sample of 366 eyes of 241 patients in the time frame of three months (from 1st october 2015 till 31st december 2015). patients presenting to amanat eye hospital and found to have cataract on ophthalmic examination were included in the study. an informed consent was obtained from all the patients enrolled in the study. an approval was taken from the hospital ethical committee. two consultant ophthalmologists separately graded the media opacification on the basis of fundus view on slit lamp bio microscopy with the 90d lens (fig. 1) as in table 1. where there was a discrepancy in the grades awarded to any opacity by the two consultants, that patient was excluded from the study. head to head comparison of swept source oct and spectral domain oct (sd – oct) was done in all subjects. for spectral oct a 6 mm line scan using edi setting with 100 images average per scan was used. for triton 12 mm line scan centered on the fovea with 90 images averaged for each b – scan. all images were taken in mesopic lighting conditions and with a dilated pupil. all scans were performed by single trained ophthalmic technologist. the image thereby acquired was then assessed on the machine and graded on the basis of clarity in table 2. here again, any image in which there was a disagreement between the two consultants was excluded from the study. the observers were masked to the patients and the grade of cataract but were not masked to the machine. table 1: media opacification gradation. media opacification disc macula grade 1 clear clear grade 2 clear mild blur grade 3 blur moderate blur grade 4 no visibility no visibility the statistical package for social sciences software (spss, version 22) was applied to organize and tabulate the data collected. descriptive statistics of all variables were calculated and pearson chi square/ fisher exact test (95% confidence interval) was applied to determine the association between swept source oct and spectral domain oct (sd – oct). media opacification was graded on the basis of fundus view on slit lamp biomicroscopy with the 90d lens as in table 1 (fig. 1). the image from both octs was graded on the basis of clarity of the retinal layers as in table 2, which was called posterior segment gradation. results there were 366 eyes of 241 patients (151 females and 90 males), the mean age was 61 years (±6.22 sd). there were 174 samples of grade 1, 96 of grade 2, 72 of grade 3 and 24 of grade 4 media opacification observed (table 3). for grade 1 media opacifiation, there were 174 eyes. no statistics were computed because the image quality with swept source oct and spectral domain oct were constant. for grade 2 media opacification, 96 eyes were observed. fisher exact test was applied to find out the association between swept source oct and spectral domain oct (sd – oct). it was found to be significant with p value = 0.001 (df 1, n = 96), at significance level (α) 0.05 and 95% confidence interval (ci) (table 3). for grade 3 media opacifiation, 72 eyes were observed. fisher exact test was applied to find out the association between swept source oct and spectral domain oct (sd – oct). it was found to be significant with p value < 0.001 (df 1, n = 72), at significance level (α) 0.05 and 95% ci (table 3). for grade 4 media opacifiation, there were 24 eyes. no statistics were computed because the image quality with swept source oct and spectral domain oct were constant. hina khan, et al 130 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology table 2: oct image quality graduation image quality retinal layers vitreous grade 1 distinct clear grade 2 less distinct but identifiable mild haze grade 3 significant blur but gross pathology still visible. software misjudging retinal layers. moderate haze grade 4 image quality is too low for reliable interpretation. severe haze fig. 1: grading of media opacification on the basis of fundus view. discussion the effect of cataract on oct image has been studied before. in a study of 800 nm oct12, only moderate cataracts were included the signal strength or reduction thereof was observed but it did not attempt comparison with ss oct. in another study with moderate cataract, ss oct provided details of the retinal choroidal structure irrespective of the density of the cataracts13. the results of the current study do not reflect the same where it was observed that image quality deteriorated with density of cataract. a study conducted in uk observed the effect of mild to severe cataract on posterior segment visualization by 3d 1060 nm oct and compared it with sd oct. it involved scanning patients with undilated pupils whereas in the present study, patients were scanned with dilated pupil to optimize the images obtained. studies14 conclude that pupil size does not affect the quality of scans in modern oct machines but these studies have excluded eyes with media opacification. it was speculated that due to the presence of cataract, pupil size will have an effect in this setting and will influence the image quality. other investigators have employed the lens opacities classification system iii (locs iii)15 to fig. 2: grading of image quality of oct scans. table 3: comparison of image quality between ss-oct and sd – oct with increasing density of media opacification. media opacification ss – oct image quality sd – oct image quality p value gr. i gr. ii gr. iii gr. iv gr. i gr. ii gr. iii gr. iv grade 1 (n = 74) 174 0 0 0 174 0 0 0 grade 2 (n = 96) 91 5 0 0 71 25 0 0 p = 0.001 grade 3 (n = 72) 0 64 8 0 0 57 15 0 p < 0.001 grade 4 (n = 24) 0 0 2 22 0 0 0 24 comparison of image quality between swept source and spectral domain oct in media pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 131 grade the density of cataract. since lociii does not specify the exact location of the cortical and posterior cataract, it has been observed by those investigators16 that using this classification, there was no consistency in image quality and signal strength with the same loc iii grades. the current study attempts to overcome this limitation by use of two separate arbitrary grading systems (based on clinical significance) devised for assessment of media opacification and the quality of the image consequently obtained. we preferred to use this instead of the locs iii so that the end point i.e. the degree of haziness of fundus caused by any cataract was directly addressed irrespective of location and type of cataract. as a result, more consistent results were seen using this method. fig. 3: (a) media opacification grade 1; (b) image quality on sd – oct (grade 1); (c) image quality on ss – oct (grade 1); (d) media opacification grade 2; (e) image quality on sd – oct (grade 2); (f) image quality on ss – oct (grade 1); (g) media opacification grade 3; (h) image quality on sd-oct (grade 3); (i) image quality on ss-oct (grade 2). for grade i opacification, (figure. 3 a-c) the image quality from both machines fell in the same category. although it was clearly seen that ss oct had better contrast between the retinal layers imaged however, the sd oct also efficiently detected all retinal layers at this grade of opacification for clinical interpretation and correlation. important to note is that we did not include choroidal depth and visualization of the choroidoscleral junction as criteria. there are a number of studies17,18,19 that establish the ss oct does indeed view to a greater depth due to the use of a tunable laser and a longer wavelength. therefore, these parameters if included in the present study would have added an obvious bias in favor of ss oct. it was in the moderate grades of cataract that we found the most significant difference in image quality between the two machines (figure 3 d-i). ss oct performed better with less light scattering and artifacts. the retinal layers were adequately detected by the software in more cases than the sd oct. subtle retinal pathologies such as early epiretinal membranes intraretinal cystoid spaces which were missed by sd oct were detected by ss oct. a comparison of performance between sd oct and ss oct in high myopes has been studied20. the current study also observed better visualization in pathological myopia with ss oct. the characters of ped’s were seen in more detail. it is clinically important to be able to detect these changes because they are often the cause of unexpected and unfavorable visual results post cataract surgery. this knowledge of pre existing retinal pathology is invaluable in practice since it serves to bring the patients expectations at a reasonable level and makes him more receptive to further treatment. it is observed that for dense cataracts, the image quality deteriorated for both ss and sd. in cases of dense cataract, where sd oct failed the ss oct also was unable to provide adequate and reliable images. a few exceptions noted but not statistically significant (2/24 for this group). the strength of this study is a large number of subjects that reduced the significance of any confounders. also the images scanned were by the same experienced technologist and assessed independently by the same consultants. limitations are that this study did not include media opacification other than cataracts. the presence of media opacification might affect certain depths of the retinochoroid more than others. since oct works on the principle of interferometery the depth at which light is reflected might be affected by the distance of the opacification from the zero delay line. these would certainly be useful areas of study in future. hina khan, et al 132 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology conclusion ss oct performs better than sd oct in moderate media opacification caused by cataract. both machines perform equally and efficiently in mild media opacification whereas fail to provide clinically useful scans in the setting of dense cataract. acknowledgment we would like to acknowledge the contribution of ms naila boota, mr. mohammad kashif and mr. rizwan waris for lending us their expertise in scan acquisition. competing interests and funding none. authors affiliation dr. hina khan mbbs, fcps, consultant ophthalmologist, head of ophthalmic diagnostic department, amanat eye hospital, islamabad – pakistan dr. aamir asrar mbbs, mrcophth, frcs, fellowship in vitreoretinal surgery, fellowship in corneorefractive surgery, chief consultant ophthalmologist, amanat eye hospital, islamabad –pakistan ms. bisma ikram optometrist and orthoptist, msph, research consultant, ophthalmic diagnostic department, amanat eye hospital, islamabad – pakistan ms. maha asrar medical student, shifa college of medicine, islamabad role of authors dr. hina khan sharing of data, write up, literature review, scan analysis and data collection. dr. aamir asrar sharing of data and scan analysis. ms. bisma ikram data collection and analysis. ms. maha asrar data collection. references 1. wang j, gao x, huang w, wang w, chen s, du s, li x, zhang x. swept – source optical coherence tomography imaging of macular retinal and choroidal structures in healthy eyes. bmc ophthalmol. 2015. 17; 15:122. 2. costa ra, skaf m, melo las 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(6): 561-570. 11. lim ls, cheung g, lee sy. comparison of spectral domain and swept – source optical coherence tomography in pathological myopia. eye (lond). 2014 apr; 28 (4): 488-91. 12. velthoven me, linden mh, smet md, faber dj, verbraak fd. influence of cataract on optical coherence tomography image quality and retinal thickness. br j ophthalmol. 2006 oct; 90 (10): 1259–1262. comparison of image quality between swept source and spectral domain oct in media pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 133 13. povazay b, herman b, unterhuber. a three dimentsional optical coherence tomogrpahy at 1050nm versus 800nm in retinal pathologies: enhanced performance and choroidal penetration in cataract patients. j biomed opt. 2007; 12 (4): 7. 14. tanga l, roberti g, oddone f, quaranta l, ferrazza m, berardo f, manni g, centofanti m. evaluating the effect of pupil dilation on spectral – domain optical coherence tomography measurements and their quality score. bmc ophthalmol. 2015; 15: 175. 15. chylack lt jr, wolfe jk, singer dm, leske mc, bullimore ma, bailey il, friend j, mccarthy d, wu sy. the lens opacities classification system iii. the longitudinal study of cataract study group. arch ophthalmol. 1993; 111 (6): 831-6. 16. esmaeelpour m, povazay b, hermann b, hofer b, kajic v, kapoor k, sheen nj, north rv, drexler w. three – dimensional 1060-nm oct: choroidal thickness maps in normal subjects and improved posterior segment visualization in cataract patients. invest ophthalmol vis sci. 2010; 51 (10): 5260-6. 17. adhi m, ferrara d, mullins rf, baumal cr, mohler kj, kraus mf, liu j, badaro e, alasil t, hornegger j, fujimoto jg, duker js, waheed nk. characterization of choroidal layers in normal aging eyes using enface swept-source optical coherence tomography. plos one. 2015 jul 14; 10 (7): 18. barteselli g, bartsch du, weinreb rn, camacho n, nezgoda jt, marvasti ah, freeman wr. real – time full – depth visualization of posterior ocular structures: comparison between full-depth imaging spectral domain optical coherence tomography and swept – source optical coherence tomography. retina, 2015 nov 11. 19. copete s, flores – moreno i, montero ja, duker js, ruiz – moreno jm. direct comparison of spectral domain and swept source oct in the measurement of chroidal thickness in normal eyes.br j ophthalmol. 2014; 98 (3): 334-8. 20. itakura h, kishi s, li d, nitta k, akiyama h. vitreous changes in high myopia observed by swept-source optical coherence tomography. invest ophthalmol vis sci. 2014. 10; 55 (3): 1447-52. http://www.ncbi.nlm.nih.gov/pubmed/?term=esmaeelpour%20m%5bauthor%5d&cauthor=true&cauthor_uid=20445110 http://www.ncbi.nlm.nih.gov/pubmed/?term=povazay%20b%5bauthor%5d&cauthor=true&cauthor_uid=20445110 http://www.ncbi.nlm.nih.gov/pubmed/?term=hermann%20b%5bauthor%5d&cauthor=true&cauthor_uid=20445110 http://www.ncbi.nlm.nih.gov/pubmed/?term=hofer%20b%5bauthor%5d&cauthor=true&cauthor_uid=20445110 http://www.ncbi.nlm.nih.gov/pubmed/?term=kajic%20v%5bauthor%5d&cauthor=true&cauthor_uid=20445110 http://www.ncbi.nlm.nih.gov/pubmed/?term=kapoor%20k%5bauthor%5d&cauthor=true&cauthor_uid=20445110 http://www.ncbi.nlm.nih.gov/pubmed/?term=sheen%20nj%5bauthor%5d&cauthor=true&cauthor_uid=20445110 http://www.ncbi.nlm.nih.gov/pubmed/?term=north%20rv%5bauthor%5d&cauthor=true&cauthor_uid=20445110 http://www.ncbi.nlm.nih.gov/pubmed/?term=drexler%20w%5bauthor%5d&cauthor=true&cauthor_uid=20445110 http://www.ncbi.nlm.nih.gov/pubmed/20445110 http://www.ncbi.nlm.nih.gov/pubmed/20445110 http://www.ncbi.nlm.nih.gov/pubmed/20445110 pak j ophthalmol. 2021, vol. 37 (4): 394-398 394 original article comparison of online assessment with traditional assessment of ophthalmology students: experience from public sector medical college in pakistan muhammad hammad ayub 1 , muhammad hassaan ali 2 , uzma hamza 3 , kashif jahangir 4 department of ophthalmology, 1-4 allama iqbal medical college, jinnah hospital, lahore abstract purpose: to perform online assessment of undergraduate ophthalmology students and compare the online examination results with conventional in-person examination during covid-19 pandemic. study design: comparative, cross-sectional study. place and duration of study: department of ophthalmology, allama iqbal medical college, lahore, pakistan. from october 2019 to december 2020. methods: we used online google assessment forms to administer the online ophthalmology send-up examination to 4th-year mbbs students. the exam consisted of 50 test items with varying difficulty levels and pictures were incorporated into them. the examination results were compared with the conventional face-to-face send-up ophthalmology examination conducted a year ago, which consisted of 50 multiple-choice questions (mcqs). results: there were 50 questions in the online examination with categorization into c1:c2:c3 levels of cognition. a total of 336 students submitted their responses for online assessment with a mean score of 36.28 out of 50 marks (73.0%) (range: 7 – 45 marks). c1, c2, and c3 questions were correctly answered by 95.3%, 45.1%, and 11.0% of the students, respectively. the conventional examination was taken by 326 students and consisted of 50 mcqs with c1:c2:c3 questions. the online exam yielded more mean scores than the in-person exam (73.0% versus 56.0%, p-value: 0.001). the rate of failure with scores less than 50% marks was significantly higher in students appearing in conventional exam versus online exam (16.6% versus 1.5% respectively, p-value: 0.0412). conclusion: online assessment of undergraduate ophthalmology students is a possible alternative to the conventional examinations during this pandemic. key words: ophthalmology, covid-19 pandemic. medical education. how to cite this article: ayub mh, ali mh, hamza u, jahangir k. online assessment of undergraduate ophthalmology students and its comparison with traditional assessment: experience from public sector medical college in pakistan. pak j ophthalmol. 2021, 37 (4): 394-398. doi: 10.36351/pjo.v37i4.1330 correspondence: muhammad hammad ayub allama iqbal medical college jinnah hospital, lahore email: drhammadayub@gmail.com received: september 01, 2021 accepted: september 23, 2021 introduction covid-19 pandemic has impactedall spheres of human life. but its impact on education and particularly medical education, has been tremendous. 1,2 although e-learning and telemedicine/ telehealth concepts are not new, these ideas are pretty open access mailto:drhammadayub@gmail.com muhammad hammad ayub, et al 395 pak j ophthalmol. 2021, vol. 37 (4): 394-398 novel from pakistan's perspective. our medical education has evolved during this era of the covid19 pandemic and more contemporary concepts are shaping into reality.online teaching, which was suddenly thrust upon teachers and students alike, is now becoming a norm. the concepts of e-learning are being improvised constantly to replace face-to-face learning. 3-5 this has led to another challenge of planning and rapidly implementing assessment methods to determine whether the learning objectives have been achieved successfully. 6-9 the medical students of 4th-year mbbs, in the subject of ophthalmology, are traditionally evaluated in their finalprofessional examination both in written, in the form of multiple-choice questions (mcqs) and short essay questions (seqs) and clinically in the form of objectively structured practical examination (ospe). the department of ophthalmology devised an online formative assessment tool that could cover both of these assessment modalitiesto a greater extent.we also compared the online assessment results with the traditional in-person examination results given a year ago to determine the difference between the outcomes of these two different assessment methods. the rationale of the study was to find out the feasibility of online assessment in our set-up and to find out if it can be used as an alternative in the coming years. methods the study was conducted after obtaining its approval from the ethical review board of allama iqbal medical college, jinnah hospital, lahore. we compared two groups of fourth-year mbbs students. one group consisted of 336 students who underwent online examination, and the other group comprised 326 students who attempted on-campus paper-based test. we prepared a question paper for the online examination, which consisted of 50 mcqs, and the candidates were instructed to choose one best option from a given list of five options. we highlighted the correct answer in the question bank to enable automatic grading of the responses. care was taken to turn off the option for automatic release of grades and visibility of correct answers at the end of response submission by the examinee. ait-expert invigilator was assigned to be available to troubleshoot any it problem during the actual examination. to avoid any technological hiccup during the real exam, we did not install any external plug-in in the google form and resorted to manually turning off response acceptance after the end of the designated examination time. in this way, no student could submit any response once the time for the exam was over. secondly, we turned on the email collection of responses and did not allow multiple submissions from the same candidate. after devising the form, we test run the assessment form and administered it to the examiners to see the outlook of the document and its contents and improve its utility before the final examination.we reduced the time of this onlineexam, and the candidates had to answer 50 questions in 45 minutes instead of one hour, which was required for an inperson on-campus examination using paper. this step also ensured that the candidates focused on their exam and did not resort to unfair means due to a perceived shortage of time for attempting the examination. there were 50 questions in the online send-up examination with categorization into c1: c2: c3 (c1 = recall of knowledge, c2 = interpretation, c3 = application of knowledge) levels of cognition, which were in the ratio of 50: 30: 20 (table 1). the google forms selfanalyzed the responses and gave us the mean score of candidates and individual breakdown of correct answers to each question. we could individually assess each student's performance and provide focused feedback depending on his responses. all the students were eventually informed about their final results with focused feedback on their performance through email. the online examination experience was very smooth, and no student faced any connectivity issue or inability to submit the response before finishing time. the data recorded online could be transcribed into microsoft excel and various other statistical software for subsequent research and publications. the conventional examination consisted of 50 mcqs with categorization into c1, c2 and c3. the questions were shuffled in four different sets of paper. each set was rotated in a set pattern to avoid repeating the same paper to the students sitting next to each other. the examination was held under direct invigilation, and the students were seated with ample spacing between the two adjacent students. all the data were entered and analyzed usingstatistical package for social sciences (spss version 25.0, ibm statistics inc, chicago, il, usa). numerical variables werecalculated in the form of online assessment of ophthalmology students and its comparison with traditional assessment pak j ophthalmol. 2021, vol. 37 (4): 394-398 396 mean ± sd, whereas descriptive variables were evaluated in the form of frequencies and percentages. the results of the two examinations were compared using a student's t-test with a p-value < 0.05 considered significant. results a total of 336 students submitted their online responses for evaluation. the average score of the online exam was found to be 36.28 marks out of 50 ( 73.0%) with a range of 7 – 45 marks. most of the students (95.3%) correctly answered c1 questions, whereas c2 and c3 questions were correctly attempted by 45.1 and 11.0% of the students, respectively. a total of 326 students appeared in the conventional examination. question distribution into c1: c2: c3 levels was in the ratio of 34:36:30 respectively (table 1). the detailed marks of the candidates in both formats of the examinationare given in table 1. table 1: distribution of questions and scores obtained by students in online and in-person examination variable in-person exam (n,%) online exam (n,%) p-value cognition levels of questions c1 17, 34.0 25, 50.0 0.075 c2 18, 36.0 15, 30.0 0.542 c3 15, 30.0 10, 20.0 0.613 scores obtained < 50% 54, 16.6 5, 1.5 0.0412 51-60% 129, 39.6 24, 7.1 0.051 61-70% 106, 32.5 101, 30.1 0.656 71-80% 35, 10.7 154, 45.8 0.0012 >80% 2, 0.60 52, 15.5 0.0042 mean score 56.0% 73.0% 0.001 the online exam yielded more mean scores than the in-person exam, possibly owing to a higher percentage of simple recall c1 questions (50.0% versus 34.0%, respectively). similarly, marks distribution of both the exams revealed mode values as following: maximum number of students (129, 39.6%) scored marks in the range of 51 – 60% in face-to-face exam whereas the majority of the students (154, 45.8%) scored marks between 71 – 80% in the online format. compared with the online format, the percentage of students who scored more than 70% in the in-person exam was significantly less than those taking an online exam, 11.30% versus 61.3% (p-value: 0.001). figures 1 & 2 show the grading of individual questions and overall analysis of the responses obtained by google forms. lastly, the rate of failure with scores less than 50% marks was significantly higher in students appearing in conventional exam versus online exam (16.6% versus 1.5% respectively, p-value: 0.0412). figure 1: test question analyzed by google forms with chart depiction of correct responses by candidates. figure 2: automatic analysis and grading of responses by google forms. discussion we successfully met the study's primary objectives to investigate an easily accessible software for administering the online examination and compare the results with an in-person paper-based test. we found google forms to be a potentially handy tool in giving assessments in a resource-deficient setting where it is challenging to purchase other expensive examination software. since the coronavirus pandemic, medical colleges were faced with an urgent need to modify their teaching and assessment, which also received significant attention in the recent medical literature. 10,11 this led to innovations in various education and assessment tools for administering examinations, including shifting to online lectures, online examination using different virtual assessment muhammad hammad ayub, et al 397 pak j ophthalmol. 2021, vol. 37 (4): 394-398 platforms, and online invigilation using multiple software. 12-15 imperial college london pioneered these online examinations and administered home-based online tests. 16 they also introduced the idea of 'open book examination'. the candidate was given access to normal reference values for various parameters but was given questions that required higher levels of cognition and application of knowledge at multiple steps to reach a final correct answer. 17 secondly, they kept these exams time-pressured and gave 60 seconds to solve a clinical scenario. 17 these problematic questions could not be answered by simple google search and could only be attempted correctly if the candidate had a thorough understanding of the tested topic. we also employed a similar technique in our examination in which we administered c3 level questions. these questions were primarily clinical scenarios and tested the in-depth knowledge of the students. however, since the students had only attended online lectures, the proportion of c3 questions was relatively low (20.0%). this also explains the trend of a higher score in the online examination because of a higher percentage of simple recall c1 questions (50.0%). we administered more c1 questions intentionally in the online test due to the students' lesser clinical experience during the pandemic. the online examination consisted of various pictures of different clinical conditions. we believe that ability to incorporate multiple types of questions like pictures, videos and audios of various clinical signs in the examination, which can help the examiners assess the students from different aspects, shows one of the most significant advantages and strengths of the online system. this functionality of online display of various visual content can help administer objectively structured clinical or practical examinations (osce or ospe) for undergraduate medical students. this could yet be another possible reason for a higher score in the online version, as the visual content might have been more straightforward for the students to recall. furthermore, we could not rule out the possibility of students using unethical means or working in groups to solve the paper mutually and eventually scoring higher scores in the online examination. this deficiency of online examination can be resolved by incorporating invigilation through various methods, including asking the students to solve the questions in front of a camera by taking the help of zoom or any other similar application. 18,19 nevertheless, invigilating a class of 300 medical students poses another challenge and requires significant capital and human resource. a recent study has reported the results of using zoom application for video monitoring and recording of students during online assessment. 20 they divided their class into multiple groups of nine students, each under the invigilation of one proctor. we also propose that the students be dividedinto a cohort of at least ten studentsobserved under direct invigilation by teams of multiple proctors. needless to say that it will require a lot of trained it workforce and capital resources. unfortunately, most public-sector medical colleges still lack fully equipped it departments. clinical specialty departmentsare left with no choice but to manage all the it-related planning and execution under the meager resources available. at least 30 invigilators with thoroughly modern computer systems must invigilate a class of 300 students subdivided into groups of 10 students. only then can we improve the reliability of students' scores in the online examination. although it was possible to assessthe type of responses to various test items and individualized feedback to the students could be provided using this digital platform, there are certain limitations of this research. firstly, we could not assess the use of unfair means by the students during examinations. secondly, the difficulty level of the questions could not be evaluated. it was a single center study. lastly, online assessment poses multiple challenges. conclusion we conclude that online assessment is possible through free online google forms assessment tools. the software automatically analyzes the results and helps in rapid paper marking and result compilation. human resource training for online invigilation and allocation of funds to establish fully equipped it departments still remain the most critical limitations for public sector medical colleges. ethical approval the study was approved by the institutional review board/ethical review board (136/16/09/2021/s2 erb.) conflict of interest authors declared no conflict of interest. online assessment of ophthalmology students and its comparison with traditional assessment pak j ophthalmol. 2021, vol. 37 (4): 394-398 398 references 1. ahmed h, allaf m, elghazaly h. covid-19, and medical education. lancet infect dis. 2020; 20 (7): 777–778. 2. arja sb, wilson l, fatteh s, kottathveetil p, fateh a, arja sb. medical education during covid-19: response 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shih kc, chan jc, chen jy, lai js. ophthalmic clinical skills teaching in the time of covid-19: a crisis and opportunity. med educ. 2020; 54 (7): 663– 664. 19. kaup s, jain r, shivalli s, pandey s, kaup s. sustaining academics during covid-19 pandemic: the role of online teaching-learning. indian j ophthalmol. 2020; 68 (6): 1220. 20. fatima ss, idrees r, jabeen k, sabzwari s, khan s. online assessment in undergraduate medical education: challenges and solutions from a lmic university. pakistan j med sci. 2021; 37 (4): 945. authors’ designation and contribution muhammad hammad ayub; associate professor of ophthalmology: concept, data analysis, manuscript writing, final critical review. muhammad hassaan ali; senior registrar ophthalmology: data collection, data analysis, manuscript writing. uzma hamza; assistant professor of ophthalmology: concept, data analysis, final critical review. kashif jahangir; assistant professor of ophthalmology: data analysis, literature review, final critical review. .…  …. 64 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology original article frequency and grading of diabetic retinopathy in diabetic end stage renal disease patients samreen jamal, muhammad hassaan ali, muhammad hammad ayub, nadeem hafeez butt pak j ophthalmol 2016, vol. 32 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad hassaan ali postgraduate resident ophthalmology department of ophthalmology jinnah hospital, lahore address: 388-d, dha phase xii (eme), multan road, lahore. mail: mhassaanali@hotmail.com received: april 21, 2016 accepted: may 22, 2016 …..……………………….. purpose: to find out the prevalence of diabetic retinopathy (dr) and its grades in diabetic end stage renal disease (esrd) patients. study design: descriptive, cross – sectional, study. place and duration of study: the study was conducted in department of ophthalmology, jinnah hospital, lahore from may 2015 to november 2015. materials and methods: patients aged 35 – 75 years of either gender with esrd caused solely by diabetes were included in the study. retinal examination was done using 90d slit lamp bio microscopy and 20d lens with indirect ophthalmoscope. presence or absence of dr and grades of retinopathy were documented in each case following etdrs classification of diabetic retinopathy. results: there were 100 subjects in the study: 55% males and 45% females. mean age was 53.99 ± 11.88 years. frequency of diabetic retinopathy in diabetic esrd patients was recorded in 51.0% of the cases. of the diabetic retinopathy patients, 68.63% had non-proliferative (npdr) while 31.37% had proliferative diabetic retinopathy (pdr). out of 35 cases with npdr, 34.29% had mild, 40.0% had moderate and 5.71% had severe npdr. out of 16 cases with pdr, 68.75% had mild to moderate pdr while 31.25% had high risk pdr. conclusion: diabetic retinopathy is quite prevalent among diabetic end stage renal disease patients. non-proliferative diabetic retinopathy is significantly higher than proliferative diabetic retinopathy in such cases. key words: diabetic end stage renal disease, diabetic retinopathy, frequency. n pakistan, the prevalence of diabetes mellitus is increasing and is estimated to be around 7.6 to 11% currently1. diabetic nephropathy, neuropathy and retinopathy are well known complications of the disease2,3. out of 93 million people with diabetic retinopathy (dr), 17 million have proliferative diabetic retinopathy (pdr), 21 million suffer from diabetic macular edema, and 28 million face vision threatening diabetic retinopathy worldwide4. as the prevalence of diabetes increases, so is the expected increase in diabetes related end stage renal disease (esrd)5. in a study done by el-menyar, it was shown that diabetic retinopathy was present in 45% of the patients who were on regular hemodialysis with esrd5. solini et al showed that advanced diabetic retinopathy was present only in 15.28% of individuals with chronic kidney disease6. data from various pakistani studies estimate the prevalence of blindness in pakistani adults to be around 2.7% and amongst them, 15.3% due to diabetes related various fundal pathologies3. we searched for the topic on pubmed, embase, cochrane library, google scholar and pak medinet, but found that no such study had been published so i mailto:mhassaanali@hotmail.com frequency and grading of diabetic retinopathy in diabetic end stage renal disease patients pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 65 far on diabetic retinopathy in esrd patients solely due to diabetes mellitus in our country. limitations of previous published studies include small sample size (7 cases only) which gave a good rationale to conduct this study with sample size of 100 cases. the study was conducted with the objective to determine the frequency of diabetic retinopathy and its grades in diabetic end stage renal disease patients. the results of this study are expected to help create awareness about importance of ocular examination and grading of diabetic retinopathy in patients with diabetes related end stage renal disease. material and methods this was a descriptive, cross – sectional, hospital based study conducted in department of ophthalmology, jinnah hospital lahore, pakistan – a tertiary care teaching hospital, from may 2015 to november 2015. the study was conducted after approval from institutional review board of allama iqbal medical college/ jinnah hospital, lahore following declaration of helsinki and principles of good clinical practice. 100 patients were included in the study after taking written informed consent. the sample size was calculated using who sample size calculator with 95% confidence level, 7% margin of error with an expected percentage of mild grades of diabetic retinopathy as 14%7 in end stage renal disease (esrd). the patients were sampled using non-probability purposive sampling and following strict inclusion criteria: age 35 – 75 years of either gender, patients with diabetes mellitus (type 2) as defined below, patients with diabetic end stage renal disease as defined below. the following patients were excluded: patients with end stage renal disease with causative factor other than diabetes e.g. hypertension, glomerulonephritis, renal calculi. patients who underwent any form of retinal surgery/laser therapy were also not included in the study. 100 subjects those fulfilling the inclusion criteria were selected from dialysis centre, jinnah hospital lahore, pakistan. pupils of both eyes were dilated using tropicamide 1% eye drops. preand postmydriatic intraocular pressure was measured using goldmann applanation tonometer. retinal evaluation was done using the 90d lens with slit lamp biomicroscopy and 20d lens with indirect ophthalmoscope by same consultant ophthalmologists (mha, nhb). presence or absence of retinopathy and grades of retinopathy were documented in each case. confounders were strictly controlled by following the exclusion criteria and getting the patient evaluated by the same ophthalmologists. data was analyzed using computer software spss version 20.0. the variables included age, gender, presence or absence of retinopathy and grades of retinopathy. mean and standard deviation was calculated for numerical variables e.g. age, duration of diabetes mellitus and duration of renal disease. qualitative variables like gender, presence or absence of retinopathy and grading of retinopathy were presented as frequencies and percentages. data was stratified for age, gender and duration of diabetes to see the effect of these variables on outcome. chi-square test was used poststratification with p-value < 0.05 considered as statistically significant. all the patients of diabetes mellitus were labeled to have diabetic retinopathy after examination with the help of slit lamp biomicroscope with 90d lens and indirect ophthalmoscope showing any one of the following abnormal patterns, according to early treatment diabetic retinopathy study classification11:  non-proliferative diabetic retinopathy (npdr) mild: microaneurysms, retinal hemorrhages, exudates, cotton wool spots at least in two quadrants. moderate: severe intraretinal hemorrhages in one to three retinal quadrants or mild intraretinal microvascular abnormalities (irma), significant venous beading in no more than 1 quadrant, cotton wool spots. severe: ≥ 1 severe hemorrhages in all four retinal quadrants, significant venous beading in two or more retinal quadrants, moderate irma in one or more retinal quadrants.  proliferative diabetic retinopathy (pdr) mild-moderate: new vessels on the disc (nvd) or new vessels elsewhere (nve), but extent insufficient to meet high risk criteria. high risk: new vessels on 1/3rd disc area. nvd with vitreous or pre-retinal hemorrhage, new vessels greater than ½ disc area elsewhere with vitreous or pre-retinal hemorrhage. samreen jamal, et al 66 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology advanced diabetic eye disease: tractional retinal detachment, significant persistent vitreous hemorrhage, neo-vascular glaucoma.  diabetic patients: already diagnosed patients of type 2 diabetes mellitus with more than 5 years of duration of disease were included. the patients having glomerular filtration rate (gfr) less than 15ml/min and were on dialysis were labeled as end stage renal disease (esrd) patients. gfr was calculated according to cock croft equation.12 gfr = 140 – age in yrs × weight in kg/72× creatinine in mg/dl results there were a total of 100 subjects in the study. mean age was 53.99 ± 11.88 years. 55% (n=55) of the patients were males and 45% (n=45) were females. 63% (n=63) of the patients had esrd for 1 – 3 years and 37% (n=37) had esrd for more than 3 years. mean esrd duration was calculated as 3.67 ± 1.09 years. 68% (n=68) of the patients had diabetes mellitus for 6 – 10 years and 32% (n=32) had diabetes for more than 10 years of duration. mean duration of diabetes was 9.57± 2.65 years (table 1). diabetic retinopathy was seen in 51% (n=51) of the patients with diabetic esrd while remaining 49% (n=49) had no ophthalmic findings (table 2). frequency of grades of diabetic retinopathy in diabetic end stage renal disease patients showed that out of 51 cases, 68.63% (n=35) had npdr while 31.37% (n=16) had pdr (p-value=0.002). out of 35 cases, 34.29% (n=12) had mild, 40.0% (n=14) had moderate while 25.71% (n=9) had severe npdr. out of 16 cases of pdr 68.75% (n=11) had mild to moderate pdr while 31.25% (n=5) had high risk pdr (table 1). stratification for frequency of diabetic retinopathy with regards to age showed that out of 51 cases of diabetic retinopathy 26 (51%) were between 35 – 50 years and 25 (49%) were between 52 – 75 years of age with p-value = 0.30. frequency of diabetic retinopathy with regards to gender showed that out of 51 cases of diabetic retinopathy 33 (64.7%) were males and 18 (35.3%) were females with p-value 0.04. frequency of diabetic retinopathy with regards to duration of diabetes showed that out of 51 cases of diabetic retinopathy, 33 (64.7%) had diabetes for 6 – 10 years and 18 (35.3%) had diabetes for more than last 10 years (p-value = 0.47) (table 2). table 1: characteristics of the patients in the study. parameters no. of patients n (%) age (years) 35-50 46 (46) 51-75 54 (54) total 100 (100) mean ± sd 53.99± 11.88 gender male 55 (55) female 45 (45) total 100 (100) duration of ersd (years) 1-3 63 (63) >3 37 (37) total 100 (100) mean ± sd 3.67± 1.09 duration of diabetes (years) 6-10 68 (68) >10 32 (32) total 100 (100) mean ± sd 9.57± 2.65 diabetic retinopathy yes 51 (51) no 49 (49) total 100 (100) grades of diabetic retinopathy npdr: 35 (68.63%) mild 12(34.29) moderate 14 (40) severe 9 (5.71) pdr: 16 (31.37%) mild to moderate 11 (68.75) high risk 5 (31.25) frequency and grading of diabetic retinopathy in diabetic end stage renal disease patients pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 67 discussion the main objective of the study to determine the frequency of diabetic retinopathy and its grades in diabetic esrd patients was successfully met. to the best of our knowledge, no such study has earlier been published on diabetic retinopathy in solely diabetic esrd patients in our country. table 2: relationship of diabetic retinopathy with different variables. age (years) diabetic retinopathy (n=51) p-value yes no 35 – 50 26 20 0.30 51 – 75 25 29 gender male 33 22 0.04 female 18 27 duration of diabetes (years) 6 – 10 33 35 0.47 >10 18 14 the frequency of diabetic retinopathy was calculated to be 51.0% in our study. the result is in agreement with a study conducted by grunwald on 925 participants with diabetes mellitus. out of 925 subjects, 456 (49%) had diabetic retinopathy; the presence of retinopathy was associated with lower glomerular filtration rate (gfr) (p<0.001); with the lowest estimated glomerular filtration rate (i.e. less than 15 ml/min) in patients with proliferative retinopathy. this association even existed after adjustment for traditional and non-traditional risk factors (p=0.005)7. another study by mohmad et al showed that the commonest abnormality in diabetic patients was nonproliferative diabetic retinopathy (ranging from mild, moderate and severe) on fundus examination in patients having diabetic nephropathy8. mild diabetic retinopathy was mostly seen in mild chronic renal failure group but moderate and severe proliferative diabetic retinopathy were seen in higher grades of chronic renal failure. our results are in agreement with this study as well since the maximal frequency was found to be of npdr in 68.32% of the patients out of which 34.29% had mild, 40.0% had moderate while 25.71% had severe npdr. a study conducted by bajracharyia et al included only 7 patients of end stage renal disease and showed that 29% of subjects had pdr and 71% had npdr9. when patients of end stage renal disease were evaluated for grades of non-proliferative diabetic retinopathy, it was observed that mild grade was seen in 14%, moderate in 42.85% and severe in 14% of the cases. for proliferative diabetic retinopathy mild to moderate grade was noted in 14% and high risk in 14% of cases with end–stage renal disease9. limitation of this study was its small sample size (only 7 cases). our study overcame this shortcoming by evaluating more cases (100 cases). our findings correlate with this study in overall frequency of various types of diabetic retinopathy (npdr and pdr) but differ in frequency of individual grades of various types of diabetic retinopathy (mild, moderate, and severe). the patients in our study had more severe grades of dr. severe pdr was observed in 14% of the patients in aforementioned study versus 68.75% in our study. this indicates that patients present late with advanced disease in our part of the world. it is recommended to conduct further research in this area to find out reasons of such delayed presentation with advanced stage of the disease. lee wj et al13. studied the association between diabetic retinopathy and progression of chronic kidney disease. 21.6% and 13.7% of their subjects had pdr and high – risk pdr at baseline respectively. they concluded that patients with extensive retinal ischemia and capillary non-perfusion had a greater risk for progression of chronic kidney disease (hazard ratio = 6.64; p = 0.002). frequencies of pdr and its high risk grade were calculated to be 31.37% and 31.25% in our study respectively which were relatively higher as compared to the aforementioned study. in a recent study conducted by wong et al, the prevalence of diabetic retinopathy in patients with chronic kidney disease due to diabetes mellitus was shown to be 34.7% after adjusting for various comorbidities14. many other studies have also shown various risk factors of diabetic retinopathy and end stage renal disease in diabetic patients15-20. in light of the above studies and our results it is evident that frequency of diabetic retinopathy is higher among patients with diabetic esrd. however, ocular screening of these patients may be helpful in samreen jamal, et al 68 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology preventing irreversible visual loss and severe visual impairment. with timely management of diabetic retinopathy, the progression of the disease can be monitored and controlled as well. people need to be educated for their regular ophthalmic examinations to detect the disease at an earlier, treatable and reversible stage. conclusion we conclude that the diabetic retinopathy is present in a significant proportion of diabetic esrd patients. non-proliferative diabetic retinopathy is seen significantly more as compared with proliferative diabetic retinopathy. steps should be taken to diagnose the disease earlier to prevent irreversible vision loss in all such patients. further research should be conducted to check the level of awareness of diabetic patients about diabetic retinopathy and reasons of delayed presentation with advanced stage of the disease. author’s affiliation dr. samreen jamal chief resident department of ophthalmology jinnah hospital, lahore dr. muhammad hassaan ali postgraduate resident ophthalmology department of ophthalmology jinnah hospital, lahore dr. muhammad hammad ayub assistant professor of ophthalmology allama iqbal medical college/ jinnah hospital, lahore prof. dr. nadeem hafeez butt professor of ophthalmology head of ophthalmology department allama iqbal medical college/ jinnah hospital, lahore role of authors: dr. samreen jamal conception, design, data collection, analysis, manuscript writing. dr. muhammad hassaan ali conception, design, data analysis, manuscript writing. dr. muhammad hammad ayub data analysis, manuscript writing, final review. prof. dr. nadeem hafeez butt conception, manuscript writing, final critical review. references 1. hakeem r, fawwad a. diabetes in pakistan: epidemiology, determinants and prevention journal of diabeto1ogy. 2010; 3:4. 2. stitt aw, lois n, medina rj, adamson p, curtis tm. advances in our understanding of diabetic retinopathy. clin sci 2013; 125 (1): 1-17. 3. ghani u, niaz z, cheema tm, abaidullah s, salman s, latif f. determining the association between retinopathy and metabolic syndrome in patients with type 2 diabetes mellitus visiting mayo hospital ,lahore. annals kemu, 2010; 16: 101-4. 4. yau jw, rogers sl, kawasaki r, lamoureux el, kowalski jw, bek t. metaanalysis for eye disease (meta – eye) study group. global prevalence and major risk factors of diabetic retinopathy. diabetes care, 2012; 35: 556-64. 5. el-menyar a, al thani h, hussein a, sadek a, sharaf a, al suwaidij. diabetic retinopathy: a new predictor in patients on regular hemodialysis. curr med res opin. 2012; 28: 999-1055. 6. solini a, penno g, zoppini g, orsi e, zerbini g, trevisan r. renal insufficiency and cardiovascular events (riace) study group. rate and determinants of association between advanced retinopathy and chronic kidney disease in patients with type 2 diabetes. diabetes care, 2012; 35: 2317-23. 7. grunwald je, alexander j, ying js, maguire m, daniel e, whittock mr. retinopathy and chronic kidney disease in the chronic renal insufficiency cohort (crie) study. arch ophthalmo1. 2012; 130: 1136-44. 8. mohmad ah, hassan a, sidique a, gadour mh, hamad m, aldar mm. correlation between retinopathy, nephropathy and peripheral neuropathy among adult sudanese diabetic patients. sudan jour med sci. 2011; 6: 27-32. 9. bajracharya, shah dn, raut kb, koirala s. ocular evaluation in patients with chronic renal failure – a hospital based study. nepal med coll j. 2008; 10: 209-14. 10. wahab s, mahmood n, shaikhzi. frequency of retinopathy in newly diagnosed type 2 diabetes patients. j pak med assoc. 2008; 58: 557-61. 11. chew ey, klein ml, ferris fl, remaley na, murphy rp, chantry k et al. association of elevated serum lipid levels with retinal hard exudate in diabetic retinopathy: early treatment diabetic retinopathy study (etdrs) report 22. archives of ophthalmology, 1996; 114: 107984. 12. stevens la, schmid ch, zhang yl, coresh j, manzi j, landis r, et al. development and validation of gfr – estimating equations using diabetes, transplant and frequency and grading of diabetic retinopathy in diabetic end stage renal disease patients pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 69 weight. nephrol dial transplant. 2010; 25: 449-57. 13. lee wj, sobrin l, kang mh, seong m, kim yj, yi jh et al. ischemic diabetic retinopathy as a possible prognostic factor for chronic kidney disease progression. eye (lond). 2014; 28: 1119-25. 14. wong cw, lamoureux el, cheng cy, cheung gcm, tai es, wong ty et al. increased burden of vision impairment and eye diseases in persons with chronic kidney disease — a population – based study. e bio medicine, 2016; 5: 193-197. 15. rodríguez – poncelas a, mundet – tudurí x, miravet – jiménez s, casellas a, barrot – de la puente jf, franch-nadal j et al. chronic kidney disease and diabetic retinopathy in patients with type 2 diabetes. plos one, 2016; 11 (2): e0149448. 16. ko ys, yun h, lee ey, jang k, yi jh, han sw. rapid progression of diabetic glomerulosclerosis with crescents to end – stage renal disease in newly diagnosed type 2 diabetes. the korean journal of medicine, 2016; 90: 46-9. 17. echouffo – tcheugui jb, venkat narayan km, weisman d, golden sh, jaar bg. association between prediabetes and risk of chronic kidney disease: a systematic review and meta – analysis. diabetic medicine, 2016; 1. 18. al mawed s, unruh m. diabetic kidney disease and obstructive sleep apnea: a new frontier? current opinion in pulmonary medicine, 2016; 22: 80-8. 19. thomas mc, cooper me, zimmet p. changing epidemiology of type 2 diabetes mellitus and associated chronic kidney disease. nature reviews nephrology, 2016; 12: 73-81. 20. guo k, zhang l, zhao f, lu j, pan p, yu h et al. prevalence of chronic kidney disease and associated factors in chinese individuals with type 2 diabetes: cross-sectional study. journal of diabetes and its complications, 2016; 17. http://www.ncbi.nlm.nih.gov/pubmed/?term=rodr%c3%adguez-poncelas+a%2c+mundet-tudur%c3%ad+x%2c+miravet-jim%c3%a9nez+s%2c+casellas+a%2c+barrot-de+la+puente+jf%2c+franch-nadal+j+et+al.+chronic+kidney+disease+and+diabetic+retinopathy+in+patients+with+type+2+diabetes.+plos+one.+2016%3b+11%3a+e0149448 pak j ophthalmol. 2020, vol. 36 (2): 156-161 156 original article external dacryocystorhinostomy with intubation in shrunken fibrotic sac in chronic dacryocystitis erum shahid 1 , asad raza jafri 2 , uzma fasih 3 , arshad shaikh 4 1-3 abbasi shaheed hospital & kmdc. 4 spencer eye hospital & kmdc, karachi abstract purpose: to assess anatomical success rate of external dacryocystorhinostomy (dcr) with intubation in long standing chronic dacryocystitis with shrunken fibrotic sac. secondary objective was to document frequency of intraoperative and postoperative complications of external dcr in such cases. study design: quasi experimental study. place and duration of study: ophthalmology department, abbasi shaheed hospital, karachi from january 2015 to december 2017. methods: patients with chronic dacryocystitis for 2 years or more, 18 to 60 years old, repeated acute attacks twice or more in past 1 year and fibrotic sacs were included. canaliculitis, canalicular blocks, punctal agenesis and enlarged sacs were excluded. surgeries were carried out under general anaesthesia. fibrotic lacrimal sac was identified and excised, ostium was created in nasal bone and bi-canalicular intubation was done. surgery was labeled successful if patency of the pathway was achieved by syringing at 6 months postoperatively. results: there were 82 patients, with 59 (72%) females. mean ages were 32 ± 10.3 years. left eye was seen in 44 (53.7%) patients. surgery was successful in 61 (74.3%) patients. intraoperative bleeding occurred 8 (9.8%) and lacrimal crest was difficult to locate in 6 (7.3%) cases. postoperatively wound infection and ecchymosis was seen in 8 (9.8%) patients, cheese wiring in 5 (6.1%) and fistula was seen in 2 (2.4%) patients. cross tabulation was done between gender and successful dacryocystorhinostomy which was statistically not significant (p value 0.71). conclusion: dacryocystorhinostomy with intubation has good surgical outcome in long standing chronic dacryocystitis with fibrosed sacs. it has few intraoperative and postoperative complications but they are manageable. key words: dacryocystorhinostomy, canalicular intubation, dacryocystitis, chronic dacryocystitis, lacrimal sac, nasolacrimal duct blockage. how to cite this article: shahid s, jafri ar, fasih u, shaikh a. external dacryocystorhinostomy with intubation in shrunken fibrotic sac in chronic dacryocystitis. pak j ophthalmol. 2020, 36 (2): 156-161. doi: 10.36351/pjo.v36i2.1027 correspondence: erum shahid abbasi shaheed hospital, karachi email: drerum007@yahoo.com received: february 20, 2020 accepted: march 20, 2020 introduction one of the significant causes of ocular morbidity in children and adults is dacryocystitis. 1 an acute inflammation of the lacrimal sac with tenderness and erythema of overlying tissues is termed as acute dacryocystitis. 2 however, chronic dacryocystitis is more common than acute condition. initially it may mailto:drerum007@yahoo.com erum shahid, et al 157 pak j ophthalmol. 2020, vol. 36 (2): 156-161 present with only epiphora but later there can be mucoid discharge, conjunctival hyperemia and chronic conjunctivitis. 2 lacrimal abscess has also been reported in 23% of eyes. 2,3 dacryocystectomy was first described by wool house in 1724 as treatment of choice for recurrent dacryocystitis secondary to nasolacrimal duct obstruction. 4 in recent years dacryocystectomy i.e. complete excision of lacrimal sac is limited to lacrimal sac tumors. less commonly, if recurrent dacryocystitis is due to inflammatory causes such as wegener’s granulomatosis, risk of subsequent nasal cutaneous fistula formation following dcr surgery or recurrent dacryocystitis without epiphora as well as in cases of dry eyes. 5,6 . currently dacryocystorhinostomy (dcr) is the treatment of choice for patients with acquired nasolacrimal duct obstruction (nldo). 7 various techniques have been employed like anterior and posterior lacrimal flap suturing with nasal flaps, with or without rubber catheter or silicone tube. intubation with silicone tube was first introduced by gibbs in 1967, which is now widely practiced in lacrimal surgeries. 8 the cause of primary failure in patients with dcr is frequently due to closure of the rhinostomy site. 9 this closure is most commonly due to scarring, adhesion and granulation tissue formation. 10 most of the patients reporting to a government sector hospital belong to a poor socioeconomic background. they present to us late and are unwilling for surgical treatment as first option. in fact, surgery is the last option for them either due to financial problems or illiteracy. in such patients, lacrimal sacs are fibrosed and shrunken such that the sac has to be sacrificed by removing it. if these sacs are to be left in place they are source of recurrent infections and failed procedure due to insufficient marsupialization. 11 lee et al has reported small sacs to have a high risk of failure. 12 endolaser equipment for dcr is expensive, needs more expertise and is not available in our setup. objective of this study was to assess anatomic success rate of external dcr with intubation of fibrosed and shrunken sacs in chronic dacryocystitis. further we studied the frequency of intraoperative and postoperative complications of external dcr in such cases. methods this study was conducted in the department of ophthalmology, abbasi shaheed hospital, karachi, a tertiary care hospital, karachi from january 2015 to december 2017. it was a quasi experimental study with non-probability convenient sampling technique. the study was conducted in adherence to tenets of the declaration of helsinki. written inform consent was taken from all the patients informing about the details of the procedure along with its complications. we included patients between 18 to 60 years of age with chronic dacryocystitis of 2 year or more in duration, repeated acute attacks twice or more in past 1 year and presence of shrunken fibrosed sacs on dissection at the surgical table. patients who had canaliculitis, canalicular blocks, punctal agenesis, mucoceles and enlarge sacs peroperatively were excluded. detailed history of patients was recorded including demographics and duration of symptoms. lacrimal passages were checked by probing and syringing in every patient. nasal examination was carried out with the help of an ent surgeon to exclude nasal pathologies. significant nasal pathologies like polyps and severe deviated nasal septum were treated first by an ent surgeon and then considered for an eye surgery. all the surgeries were carried out under general anaesthesia by a single surgeon. skin was cleaned with 10% povidone. nasal packing was done with gauze piece soaked in xylocaine with 2% adrenaline. upper and lower puncta were dilated with nettleship punctum dilator and probes were passed to check the patency. vertically curved skin incision was given 8 to 10 mm away from the medial canthus and 12 to 15 mm long with surgical blade no 15. hemostasis was achieved with suctioning and cotton swabs soaked in xylocaine with 2% adrenaline. blunt dissection was done to separate skin and fascia, to expose medial palpebral ligament. this ligament was excised with blade. underlying sac was identified and separated from periosteum. fibrosed sacs were identified and defined as shrunken and contracted on surgical microscope. it was not possible to incise them and make a flap. they were completely excised. periosteum was elevated to expose lacrimal fossa with periosteal elevator. lacrimal osteotomy was created with kerrison’s rongeurs bone punch, about 15 mm to 20 mm in diameter. nasal pack was removed and curved artery forceps was introduced to check the opening of fistula. nasal mucosa was cut open with blade. silicone tube was then passed from external dacryocystorhinostomy in shrunken fibrotic sac pak j ophthalmol. 2020, vol. 36 (2): 156-161 158 upper and lower puncta tied near lacrimal fossa. now the tube was passed through the created fistula and retrieved in nasal cavity with an artery forcep. another knot was tied in the tube and secured with silk 4/0. dissected area was irrigated with an antibiotic solution (gentamycin 80 mg/2 ml). the wound was closed in two layers. inner layer of medial palpebral ligament and subcutaneous tissue was closed with an interrupted vicryl 6/0 and skin layer with an interrupted proline 4/0. nasal cavity was packed with gauze piece rubbed in polyfax ointment. antibiotic ointment was applied to the wound and it was bandaged for 24 hours for hemostasis. patients were discharged on the same day. nasal pack and bandage was removed next day. patients were given oral antibiotic ciprofloxacin 500 mg bd, an anti-inflammatory agent (danzen ds) and an analgesic (diclofenic sodium) and antihistamine for 5 days. topical steroid and antibiotic eye drops (moxifloxacin & dexamethasone) were given qid for 2 weeks with steroid and antibiotic ointment (tobramycin dexamethasone) at bed time. skin sutures were removed on 10 th postoperative day and silicone tube was removed at 6 months. surgery was labeled successful if patient was symptom-free and patency was achieved on syringing at 6 months. intra-operative complications like an angular vein tear, nasal mucosal bleeding, and difficulty in passing tube or identifying lacrimal crest were recorded. postoperative complications like infection, bleeding, ecchymosis, cheese wiring of puncta, lacrimal fistula and wound related complications were noted and entered in spss version 22. frequencies and percentages were calculated for categorical data. means with standard deviation, minimum and maximum were calculated for numerical data. results there were 82 patients in this study, males were 23 (28%) and females were 59 (72%) with ratio of 1:3. their mean ages were 32 ± 10.3 sd years. left eye was involved in 44 (53.7%) patients. other demographic features are given in table 1. table 1: demographic features of patients in this study. variables frequency (%) mean age in years 32 ± 10.3 sd minimum age 18 maximum age 60 females 59 (72%) variables frequency (%) right eye 38 (46.3%) left eye 44 (53.7%) nasal pathologies 3 (3.7%) mean duration of symptoms 3.5 years ± 2.0 sd successful procedure 61 (74.3%) intra-operative bleeding was seen in 8 (9.8%) and lacrimal crest was difficult to locate in 6 (7.3%) patients. post-operatively wound infection and ecchymosis was seen in 8 (9.8%) patients. fistula was least common and seen in 2 (2.4%) patients. main outcome was successful surgery, which was seen in 61 (74.3%) patients. other intraoperative and postoperative complications of surgery are summarized in table 2. table 2: intraoperative and postoperative complications of cdcr. variables frequency % intraoperative complications angular vein cut 4 4.9 nasal mucosal bleed 4 4.9 difficult lacrimal crest 6 7.3 postoperative complications infection 8 9.8 ecchymosis 8 9.8 cheese wiring 5 6.1 tube displacement 4 4.9 wound contracture 3 3.7 fistula 2 2.4 total 48 58.7 cross tabulation was done between gender and successful dacryocystorhinostomy which was statistically not significant (p value 0.71) given in table 3. table 3: cross tabulation showing association of success of procedure with gender. gender dcr total successful failed male 18 (21.9%) 5 (6.1%) 23 (28%) female 43 (52.4%) 16 (19.5%) 59 (72%) total 61(74.3%) 21 (25.6%) 82 (100%) p value: 0.71 discussion external dacryocystorhinostomy with silicone tube intubation gives 80 to 90% results depending upon erum shahid, et al 159 pak j ophthalmol. 2020, vol. 36 (2): 156-161 surgical techniques, surgeon’s skills, correlated systemic or nasal disease and patient’s response to surgery. 13 anatomic success rates vary from 90% to 100% reported by various studies 14 . whereas success rate in our study was 74.3% (61 out of 82 patients), checked by syringing the lacrimal passages at 6 th month post operatively. success rate of our patients was relatively less as compared to other studies. 13,14 repeated infections make theses sacs fibrosed. it is documented that chronic inflammation and fibrosis are most common histopathological changes of lacrimal sac in patients suffering from nasolacrimal duct obstruction. 15 it is very difficult to make complete marsupialization of fibrosed flaps so the sac has to be removed. we have specifically selected fibrosed and shrunken sacs with chronic dacryocystitis of minimum 2-year duration. the above mentioned studies did not discuss mean duration of symptoms. patients in developed countries present early and they have easy access to health care facilities. we can infer that longer the duration of symptoms, more are the episodes of acute infection more the sac will be fibrosed. more delayed the surgery more is the chance of failure. early surgery will certainly improve outcome. failed cases in our study were 21 (25.7%). syringing was done at 6 th months post operatively and early if, and when required. absence of fluid in nasal cavity was labeled as failed dcr. an ent surgeon examined nasal cavity of these patients. the cause of failure in our patients was closed osteotomy site due to scarring. inadequate or inappropriate sac marsupialization is reported to be 60.2% in etiological analysis of 100 failed dcr during re-operation. 11 we removed whole sac in long standing dacryocystitis to avoid failure and patient’s agony of reoperations. smaller fibrosed sacs are documented to have high failure risk. 12 diverse aspects of causes of failed dcr have been reported in literature ranging from cicatricial ostium closure, scarring of common canaliculus, distal canalicular obstruction, granuloma formation and bone neogenesis. 16 incorrect localization of sac, inappropriate osteotomy size and location, insufficient sac opening, significant deviated nasal septum and concha bullosa are few reported intraoperative surgical causes that lead to subsequent failures. 16 however, success rate of dcr can be increased by the use of intraoperative anti-fibrotic agent, mitomycin c. 17 acquired nasolacrimal duct obstruction usually occurs in middle-aged or older people. 18 female patients in our study were 59 (72%) with male to female ratio of 1:3. most of other studies have similar male to female ratio with female preponderance. 6-8 females are more frequently affected by this disease due to narrow lacrimal canals, hormonal factors, using colliriums (kajal/surma) and working in the dusty environment. 19 in our country women work in hot humid kitchen for long hours, they wear makeup and use of talcum powder could be another possible contributory factor. however, success rate of dacryocystorhinostomy does not depend on gender specified by insignificant p value (0.71). intraoperative bleeding including angular vein cut and nasal mucosal bleeding were seen in 8 (9.8%) of patients in our study. it depends on surgeon’s skill and experience. other studies have reported 0 and 45% intraoperative bleeding and almost negligible bleeding post operatively (1.9%). 13,14 it can be avoided by careful and blunt dissection. accidental angular vein cut in our patients was ligated with vicryl 6/0. nasal mucosal bleeding was controlled with nasal packing for 24 hours and fortunately there was no bleeding in any patient on removing nasal pack on first postoperative day. it was difficult to find lacrimal crest for making ostium in 6 (7.3%) patients as it was deep seated. these patients had wide depressed nasal bridge and probably brachycephalic skull. this complication should be anticipated when selecting patients as flat nose and narrow face are at higher risk of developing dacryocystitis. brachycephalic heads have high incidence of developing dacryocystitis because of narrow lacrimal fossa, longer nasolacrimal duct and small diameter of inlet of nasolacrimal duct. 20 two (2.4%) patients came with recurrent infections at wound site and they had developed fistula. other studies have reported wound infection to be 1.9% after external dcr. 13,14 the wound of our patients was reopened and remnants of the sac were removed in these cases. a study conducted in uk, reported cellulitis rate of 8 to 18% when systemic antibiotic prophylaxis was not given. 13 this rate of infection can be reduced five times with routine administration of antibiotics. 21 in our set up routine postoperative broad spectrum antibiotics were given. silicone tube intubation in lacrimal drainage system during dcr prevents obstruction of these passages by keeping pathway open throughout the healing process. 22 it prevents formation of granulation tissue at the osteotomy and anastomosis site and also external dacryocystorhinostomy in shrunken fibrotic sac pak j ophthalmol. 2020, vol. 36 (2): 156-161 160 prevents common canalicular obstruction. 23 silicone tubes are also being used for small fibrotic sacs, distal and common canalicular obstruction. 24 cheese wiring was seen in 5 (6.1%) patients. silicone tubing is reported to cause cheese wiring of canaliculus. 8 it was observed within a week after surgery which had to be manipulated, to break free the tube with adhesions and with copious use of lubricating ointment. it was witnessed in those patients where it was difficult to pass tube due to anatomical variations. cheese wiring can be avoided by gentle dilatation of punctum, gently passing the silicone tube through the punctum and early recognition for early manipulation. four (4.9%) of our patients had tube displacement. in one patient tube recoiled back in an orbital area habitually on sneezing and when she blew nose it came back into the nasal cavity. she was advised to avoid loud sneezing until tube was removed at 6 th month. another patient came with tube extrusion in 2 nd week; this was because of poor quality of tube in which one end of tube was accidentally cut when tying with silk. but its other end was secured intraoperatively. in one patient tube had to be removed early at 3 rd month because its upper part in canalicular area was loose and causing constant unbearable irritation to her. ecchymosis was seen in 8 (9.8%) patients and probably due to rough handling of tissues during surgery. however, it is painless condition and it resolved within 2 weeks. wound contracture was seen in 3 (3.7%) patients. it depends on type of incision and type of suture material. limitation of the study is lack of control group. another research should be conducted to compare the results of dcr in enlarged sacs with fibrosed sacs. conclusion external dacryocystorhinostomy with bicanalicular silicone intubation has good surgical outcome in patients with long standing chronic dacryocystitis and fibrosed sacs. it has few intra-operative and postoperative complications but they are manageable. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. ghose s, nayak n, satpathy g, jha rk. current microbial correlates of the eye and nose in dacryocystitis-their clinical significance. aioc proceedings, 2005: 437-439. 2. ali mj, joshi sd, naik mn, honavar sg. clinical profile and management outcome of acute dacryocystitis: two decades of experience in a tertiary eye care center. in seminars in ophthalmology. informa health care, 2015; 30 (2): 118-123. 3. ali mj, motukupally sr, joshi sd, naik mn. the microbiological profile of lacrimal abscess: two decades of experience from a tertiary eye care center. journal of ophthalmic inflammation and infection, 2013; 3 (1): 57. 4. karesh jw, perman ki, rodrigues mm. dacryocystitis associated with malignant lymphoma of the lacrimal sac. ophthalmology, 1993; 100 (5): 669-673. 5. holds jb, anderson rl, wolin mj. dacryocystectomy for the treatment of dacryocystitis patients with wegener's granulomatosis. ophthalmic surgery, lasers & imaging retina, 1989; 20 (6): 443. 6. boynton jr, anawis ma. role of dacryocystectomy in the management of failed dacryocystorhinostomy associated with chronic dacryocystitis. ophthalmic surg lasers, 1996; 27 (2): 133–136. 7. dolman pj. comparison of external dacryocystorhinostomy with non-laser endonasal dacryocystorhinostomy. ophthalmology, 2003; 110: 78–84. 8. kim jh, hwang sw, choung hk, lee jc, khwarg s. lacrimal silicon intubation for anatomically successful but functionally failed external dacryocystorhinostomy. korean j ophthalmol. 2007; 21 (2): 70-73. 9. carter kd, nerad ja. primary acquired nasolacrimal duct obstruction. principles and practice of ophthalmic plastic and reconstructive surgery, 1996: 784-796. 10. vishwakarma r, singh n, ghosh r. a study of 272 cases of endoscopic dacryocystorhinostomy. indian j otolaryngol head and neck surg. 2004; 56 (4): 259261. 11. dave tv, mohammed fa, ali mj, naik mn. etiologic analysis of 100 anatomically failed dacryocystorhinostomies. clin ophthalmol. (auckland, nz). 2016; 10: 1419. 12. lee mj, khwarg si, kim ih, choi jh, choi yj, kim n et al. surgical outcomes of external dacryocystorhinostomy and risk factors for functional failure: a 10-year experience. eye (lond) 2017; 31: 691-697. 13. walland mj, rose ge. factors affecting the success rate of open lacrimal surgery. br j ophthalmol. 1994; 78 (12): 888-891. erum shahid, et al 161 pak j ophthalmol. 2020, vol. 36 (2): 156-161 14. hartikainen j, grenman r, puukka p, seppä h. prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy1. ophthalmology, 1998; 105 (6): 1106-1113. 15. salour h, hatami mm, parvin m, ferdowsi aa, abrishmi m, baqheri a, et al. clinicopathological study of lacrimal sac specimens obtained during dcr. orbit. 2010; 29: 250-253. 16. liang j, hur k, merbs sl, lane ap. surgical and anatomic considerations in endoscopic revision of failed external dacryocystorhinostomy. otolaryngolhead and neck surg. 2014; 150 (5): 901-905. 17. liao sl, kao sc, tseng jh, chen ms, hou pk. results of intraoperative mitomycin c application in dacryocystorhinostomy. br j ophthalmol. 2000; 84 (8): 903-906. 18. preechawai p. results of nonendoscopic endonasal dacryocystorhinostomy. clin ophthalmol. (auckland, nz). 2012; 6: 1297. 19. badhu b, dulal s, kumar s, thakur sk, sood a, das h. epidemiology of chronic dacryocystitis and success rate of external dacryocystorhinostomy in nepal. orbit. 2005; 24 (2): 79-82. 20. mills dm, bodman mg, meyer dr, morton ad. the microbiologic spectrum of dacryocystitis: a national study of acute versus chronic infection. ophthal plast reconstr surg. 2007; 23 (4): 302-306. 21. ma'luf r, dbaibo g, araj gf. bacterial flora of the ocular fornix in patients with lacrimal silicone tubes. ann ophthalmol. 2001; 33 (1): 31-34. 22. duffy mt. advances in lacrimal surgery. curr opin ophthalmol. 2000; 11 (5): 352-356. 23. verma s, gupta p, shakeet d. to compare the results of external dcr with and without silicone tube in chronic dacryocystitis. world j pharm sci. 2017; 6: 6. 24. çoban dt, beden u, sönmez b, erkan d. dakriosistorinostomi e. outcomes of external dacryocystorhinostomy and effects of the incision type on cosmetic and functional outcomes. j clin anal med. 2011; 2 (1): 21-24. authors’ designation and contribution erum shahid; assistant professor: concept, data collection, manuscript writing, statistical analysis, critical review. asad raza jafri; associate professor: concept, data collection, critical review. uzma fasih; associate professor: concept, literature search, critical review. arshad shaikh; professor: concept, critical review. .…  …. pak j ophthalmol. 2020, vol. 36 (4): 412-417 412 original article immediate effect of intravitreal bevacizumab injection on intraocular pressure rabeeah zafar 1 , amna rizwan 2 , badar-ud-din ather naeem 3 , asfandyar asghar 4 , naila obaid 5 department of ophthalmology, 1,2 al-shifa trust eye hospital, 3,4,5 fauji foundation hospital, rawalpindi abstract purpose: to determine the immediate effect of intravitreal bevacizumab on intraocular pressure (iop) in eyes with retinal vascular disorders. study design: interventional case series. place and duration of study: ophthalmology department, fauji foundation hospital, rawalpindi, from january 2019 to july 2019. methods: patients of both genders between 15 – 80 years of age suffering from retinal pathologies and suitable for intravitreal bevacizumab were included in the study. systemic diseases like diabetes mellitus, hypertension and asthma were also considered in the data as an effect modifier for iop change. iop was measured before intravitreal injection (baseline) and at 5 and 30 minutes post-injection. descriptive statistics were obtained using spss version 21.0. results: one hundred and thirty-one eyes of 131 patients were included in the study out of which 23 (18%) were males and 108 (82.4%) were females. mean age was 57.57 ± 13.09 years. mean iop at baseline was 16.16 ± 2.52 mm hg which increased to a maximum of 44 mm hg at 5 minutes after injection in 108 eyes (82.4%), p = 0.005 (≤0.05). at 30 minutes the iop had fallen back to normal in 94 eyes (71.7%), p = 0.081. iop rise was not significantly correlated to gender, age, hypertension and asthma at any interval (p value > 0.05). however, iop rise was significantly correlated in diabetic patients at 30 minutes. conclusion: significant iop elevation has been observed after intravitreal bevacizumab in immediate postinjection period which warrants the monitoring of iop in this critical period to avoid serious blinding complications. key words: bevacizumab, vascular endothelial growth factor, intraocular pressure, goldmann applanation tonometer. how to cite this article: zafar r, rizwan a, naeem bda, asghar a, obaid n. immediate effect of intravitreal bevacizumab injection on intraocular pressure. pak j ophthalmol. 2020; 36 (4): 412-417. doi: https://doi.org/10.36351/pjo.v36i4.1109 introduction retinal vascular disorders have been listed among the leading causes of irreversible blindness in developed correspondence: rabeeah zafar department of ophthalmology, al-shifa trust eye hospital, rawalpindi email: rabeeah.zafar11@yahoo.com received: july 23, 2020 accepted: september 3, 2020 as well as developing countries. 1 retinal hypoxia is the main initiating event resulting in release of vascular endothelial derived growth factor (vegf) and pathological neovascularization with eventual catastrophic vascular leakage and anatomical disruption of retina, leading to visual deterioration. 2 in the past, laser photocoagulation had been broadly utilized but the visual benefits were less encouraging. the advent of intravitreal anti-vegf injections in early 21 st century led to a paradigm shift in the treatment of retinal vascular disorders owing to their efficacious profile in terms of visual improvement. 3 rabeeah zafar, et al 413 pak j ophthalmol. 2020, vol. 36 (4): 412-417 pegabtanib was the first anti-vegf agent approved for intravitreal injection followed by ranibizumab and aflibercept with robust efficacy profile. 4 they are in wide practice worldwide under different treatment regimens. 5 trials for newer anti-vegfs are underway. 6 bevacizumab is a recombinant humanized full length monoclonal antibody which blocks angiogenesis by inhibiting vegf isoforms. its off label use has been widely carried out in ophthalmological practice since 2005; although it was initially devised for systemic treatment of metastatic colorectal cancer via intravenous route. 7 the efficiency profile of bevacizumab is comparable to ranibizumab (comparison of age-related macular degeneration treatments trials research group) but its economic benefits are more being a cost effective substitute, hence it offers a better treatment option for a developing country like pakistan. 8 despite an efficacious treatment modality, its ocular complications are very serious and can potentially result in vision loss. 9,10 of these, iop elevation is the most frequently reported complication. this elevated iop can affect vascular supply of optic nerve by elevating pressure gradient across lamina cribrosa and can damage it, resulting in irreversible blindness. the rationale of our study was to demonstrate statistically conclusive iop changes after intravitreal bevacizumab (ivb) injection. moreover, to assess the outcome of influence of systemic disorders in terms of iop changes after bevacizumab. very inadequate local data is present in this regard. hence, it would be a valuable source of information to compare statistics in pakistani population and help ophthalmologists to modify the protocols regarding iop monitoring after intravitreal bevacizumab. the objective of this study was to evaluate effect of intravitreal bevacizumab on iop changes in immediate post-injection period. methods this interventional case series was conducted at ophthalmology department, fauji foundation hospital, rawalpindi from january, 2019 to july, 2019. sample size was calculated using who calculator. a total of 131 patients were recruited from outdoor patient department using non probability consecutive sampling. both genders were included between 15 – 80 years of age. patients suffering from retinal pathologies and suitable for intravitreal bevacizumab were included. systemic diseases like diabetes mellitus, hypertension and asthma were also considered in the data as an effect modifier for iop change. exclusion criteria consisted of any history of previous intravitreal injection, glaucoma, ocular trauma, and active ocular surface infections. study was approved by institutional ethical review committee. informed consent was taken from the patients. standard pre-injection ophthalmological examination was conducted. baseline iop was taken 5 minutes before giving injection using goldmann applanation tonometer (at 900 haag-streit) in the sitting position. injection was given in minor operation theatre under standard sterile conditions. topical proparacaine hydrochloride 0.5% was instilled thrice, 1 minute apart. it was followed by instilling 5% povidone-iodine in cul-de-sac for 3 minutes. a dose of 1.25 mg/0.05 ml bevacizumab (avastin ® by roche pakistan ltd) was injected through pars plana according to phakic status of each eye by the same surgeon in all cases. after giving injection, iop was recorded at 5 and 30 minutes in each eye. normal iop range was 11 – 21 mm hg and 22 mm hg and above was considered an iop rise. standard post-injection ophthalmic examination was done. all patients having iop rise of > 30 mm hg after 30 minutes of injection were kept under observation with serial iop monitoring and were dealt according to standard ophthalmic emergency protocol in order to lower iop within safer range. patients were prescribed topical ofloxacin 0.3% four times a day for 5 days. data was recorded in a predesigned proforma. data analysis was done using statistical package for the social sciences (spss) version 21.0. frequency and percentages were calculated for qualitative variables like gender and iop rise. mean and standard deviation were calculated for quantitative variables like age. moreover, age, gender, diabetes mellitus, hypertension, asthma were controlled by stratification. to see correlation of iop changes with these factors, chi-square test was applied with confidence interval of 95% and was considered significant if p value was ≤ 0.05. results out of 131 patients (131 eyes) recruited in the study, 108 were females (82%) whereas rest were males (18%). average age of the patients was 57.57 ± 13.09 years with minimum age being 20 years and maximum immediate effect of intravitreal bevacizumab injection on intraocular pressure pak j ophthalmol. 2020, vol. 36 (4): 412-417 414 being 78 years. in 81 patients, injections were given in left eye (61.8%) and in 50 patients in the right eye (38.2%). majority of the injected eyes had a diagnosis of diabetic retinopathy (as mentioned in figure 1). fig. 1: distribution of retinal disorders among sample population. mean iops and standard deviations for each tested variable are presented in table 1. mean iop at baseline was 16.16 ± 2.52 mm hg, with maximum being 24 mm hg. at 5 minutes post-injection, iop rise (≥ 22 mm hg) was noted in 108 eyes (82.4%). maximum iop recorded was 44 mm hg, while mean iop was 27.44 ± 5.66 mm hg. there was a statistically significant correlation between iop at baseline and 5 minutes post-injection, applying chisquare test with p value = 0.005 (≤ 0.05). at 30 minutes post-injection, mean iop was 19.97 ± 3.95 mm hg with maximum iop recorded being 36 mm hg. statistically, an insignificant correlation was present between baseline iop and iop at 30 minutes with p value = 0.081 (> 0.05). (please see table 2). diabetes mellitus was present in 86 (65.6%) patients and iop rise was noted in 69 (63.9%) and 31 (83.8%) eyes at 5 and 30 minutes, respectively. statistically there was no difference in iop at baseline and 5 minutes (p = 0.251 and 0.358). however, at 30 minutes iop had a statistically significant relation in diabetic patients i.e. p value = 0.006. table 1: comparison of iop at baseline, 5 minutes and 30 minutes with age, gender, diabetes, hypertension, asthma. (iop = intraocular pressure in millimeters of mercury (mmhg, n = no. of patients). age iop groups n mean std. deviation at baseline 15 – 50 34 15.76 2.62 51 – 80 97 16.30 2.48 at 5 mins 15 – 50 34 26.38 4.68 51 – 80 97 27.80 5.94 at 30 mins 15 – 50 34 19.03 2.44 51 – 80 97 20.30 4.32 gender at baseline male 23 16.43 2.01 female 108 16.10 2.61 at 5 mins male 23 27.57 5.48 female 108 27.41 5.72 at 30 mins male 23 20.35 4.37 female 108 19.89 3.88 diabetes mellitus at baseline yes 86 16.38 2.77 no 45 15.73 1.90 at 5 mins yes 86 27.84 6.19 no 45 26.67 4.42 at 30 mins yes 86 20.56 4.38 no 45 18.84 2.67 hypertension at baseline yes 107 16.03 2.53 no 24 16.75 2.40 at 5 mins yes 107 27.55 5.77 no 24 26.92 5.20 at 30 mins yes 107 19.85 4.10 no 24 20.50 3.25 asthma at baseline yes 8 16.88 0.641 no 123 16.11 2.59 at 5 mins yes 8 28.00 6.65 no 123 27.40 5.62 at 30 mins yes 8 20.12 2.94 no 123 19.96 4.02 among 131 patients, 107 (81.7%) had hypertension. iop at baseline, 5 minutes and 30 minutes post-injection was not significantly correlated among hypertensive patients (p = 0.471, 0.641, and 0.540 respectively). only 8 (6.1%) patients in our data had asthma. iop change was not significantly related among them (p value > 0.05). similarly, iop changes among gender and age groups were not significantly related at baseline, 5 minutes and 30 minutes (p = 0.209, 0.219, 0.443, and p = 0.294, 0.987, 0.111, respectively). therefore, none of them were proven to be an effect modifiers regarding iop rise based on chisquare test. rabeeah zafar, et al 415 pak j ophthalmol. 2020, vol. 36 (4): 412-417 table 2: stratification of iop at baseline with 5 minutes and 30 minutes. comparison of iop at baseline and 5 minutes iop at baseline iop at 5 minutes total pvalue 11 – 21 rise (≥ 22 ) 11 – 21 19 82.6% 105 97.2% 124 94.7% 0.005 rise ( ≥ 22) 4 17.4% 3 2.8% 7 5.3% total 23 108 131 comparison of iop at baseline and 30 minutes iop at baseline iop at 30 minutes total pvalue 11-21 rise (≥ 22) 11 – 21 91 96.8% 33 89.2% 124 94.7% 0.081 rise ( ≥ 22) 3 3.2% 4 10.8% 7 5.3% total 94 37 131 discussion this study was conducted to investigate safety profile of bevacizumab based on severity of iop rise in postinjection period. the authors were able to demonstrate that iop rise was significantly high as early as 5 minutes post-intravitreal injection with maximum recording being 44 mm hg. this high iop potentially can result in sight-threatening event like central retinal vein occlusion. 11 international literature well supports the observation of iop spike after the drugs are introduced into the vitreous, be it anti-vegfs, steroids or antibiotics. 12,13 among anti-vegfs, bevacizumab has a tendency to raise iop more as compared to other agents. 14 lemos-reis et al. assessed iop trends after intravitreal bevacizumab and reported very high iops of > 50 mm hg in 32% eyes. however, they did not reveal post-injection time at which such high iop was recorded. 15 gismondi et al. observed iop rise of > 30 mm hg in 89% eyes as early as 5 seconds of intravitreal injection. 16 although exact mechanism of iop rise after intravitreal injection is unknown. some researchers have proposed that iop elevation occurs due to temporary increase in vitreous volume, which is usually brief and no intervention like anterior chamber paracentesis is needed to lower iop. 17 however, soheilian et al. suggested that intravitreal injections can result in significant iop spikes and retinal nerve fiber loss in post-injection period. they had proven the efficacy of anterior chamber paracentesis in their randomized clinical study to lower this spike and hence, preventing the eventual nerve damage. 18 another possible mechanism of post-injection iop spike could be multiple intravitreal injections. falkenstein et al. supported this hypothesis by observing higher and prolonged iop elevations in eyes with multiple previous injections. 19 moreover, multiple injections are also a risk factor for long term iop elevation, and thus necessitating the need of early glaucoma surgery. 20 our study excluded patients with history of multiple previous injections and could not enlighten the effect of multiple injections on iop trends. adverse events after intravitreal anti-vegfs are under investigation since their revolutionary breakthrough and pricing advantages. researchers all over the world are devising techniques to lower this expected iop spike precluding ocular complications. qureshi et al. studied iop trends after intravitreal bevacizumab and also demonstrated the effect of preinjection ocular decompression at injection site on iop rise by randomizing 100 eyes into 2 groups (ivb after decompression and ivb only). 21 they observed a significant iop rise in each study group. however, iop rise in decompression group was less as compared to iop in ivb only group and hence demonstrated the beneficial effects of this procedure in lowering the iop spike in early post-injection period. 21 some researchers emphasize the need of antiglaucoma drugs before and after intravitreal injections. some favour the protective role of post injection vitreous reflux in lowering iop spikes. 15 kim et al. proposed that eyes having glaucoma took longer to lower the iop after injection due to already compromised outflow tracts. 22 our study excluded glaucomatous eyes to avoid any confounding effect on iop. the strength of our study is the demonstration of effect of systemic diseases on iop changes in postinjection period. the correlation of vascular disorders like diabetes and hypertension is well established with glaucoma. however, evidence of their role in iop changes after intravitreal bevacizumab is lacking in non-glaucomatous population. in our study, diabetes has proven to have a statistically positive correlation with iop rise at 30 minutes post injection (p < 0.05). in our study, despite the pressure rise in majority of eyes, iop fell within a safer range (< 21 mm hg) in two-third of the patients after 30 minutes of injection. these studies along with ours, gave an impression that iop spike is must after intravitreal bevacizumab and is strongly related to the time at which iop measurement is made, the greatest rise being observed shortly after immediate effect of intravitreal bevacizumab injection on intraocular pressure pak j ophthalmol. 2020, vol. 36 (4): 412-417 416 injection. however, it is reassuring that iop returned to normal or near-normal levels within 30 to 60 minutes postinjection. the limitation of our study is that it was limited a single center. further multicenter studies are required to assess the results in a larger population conclusion this study positively contributes to clinical observation of significant iop elevation after bevacizumab injection in immediate post-injection period. it may aid clinicians in improving and revising the protocols of serial iop monitoring after intravitreal injections. the authors feel a strong need to further 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after intravitrealbevacizumab injection with ocular decompression using a sterile cotton swab soaked in proparacaine 0.5%: a quasi-experimental study taiwan j ophthalmol. 2016; 6 (2): 75–78. 22. kim je, mantravadi av, hur ey, covert dj. shortterm intraocular pressure changes immediately after intravitreal injections of anti–vascular endothelial growth factor agents. am j ophthalmol. 2008; 146: 930–934. authors’ designation and contribution rabeeah zafar; registrar: concepts, design, data acquisition, data analysis, statistical analysis, manuscript preparation. amna rizwan; registrar: literature research, data acquisition, data analysis. badar-ud-din ather naeem; professor: concepts, design, manuscript editing, manuscript review. asfandyar asghar; professor: concepts, design, literature research, manuscript editing, manuscript review. naila obaid; assistant professor: literature research, data acquisition, manuscript editing, manuscript review. .…  …. 97 pak j ophthalmol. 2022, vol. 38 (2): 97-102 original article postoperative complications of trabeculectomy in primary open angle glaucoma versus primary angle closure glaucoma erum shahid 1 , uzma fasih 2 , arshad shaikh 3 1-3 karachi medical and dental college & abbasi shaheed hospital, karachi abstract purpose: to compare the frequency of postoperative complications of trabeculectomy in primary open angle glaucoma (poag) with primary angle closure glaucoma (pacg). study design: comparative experimental study. place and duration of study: department of ophthalmology, abbasi shaheed hospital, karachi, from january 2017 to november 2019. methods: seventy-one patients who underwent primary trabeculectomy without antimetabolites for primary open-angle glaucoma and primary angle-closure glaucoma during the given period were included in the study. patients who had significant cataract, repeated trabeculectomy, failed argon laser trabeculoplasty and trabeculectomy done for congenital glaucoma, traumatic glaucoma, secondary glaucoma were excluded from the study. patients were followed up for 12 months and complications were compared. secondary outcome was reduction in iop. results: out of 71 patients, 52 had poag and 19 had pacg. the mean age was 56.7 ± 10.9 for poag and 52.2 ± 9.5 for pacg. the frequency of complications in poag group was 28.2% and in pacg group was 21.1% (p >0.005).complications were: cataract, uveitis, hyphema, choroidal folds, shallow anterior chamber, high iop and positive seidel test. mean iop reduction was from 31 ± 6.7mm of hg and 40 ± 14.8 to 15.6 ± 4.2 and 13.8 ± 4.7 in poag and pacg respectively (p-value > 0.005).trabeculectomy was successful in 80.7% poag and 73.6% pacg patients (p value > 0.005). conclusion: no significant difference was observed in the frequency of complications in poag and pacg patientsfollowing trabeculectomy, over a period of 12 months. trabeculectomy was equally effective in lowering iop in both the groups. key words: glaucoma, primary open angle glaucoma, primary angle closure glaucoma, trabeculectomy, how to cite this article: shahid e, fasih u, shaikh a. postoperative complications of trabeculectomy in primary open angle glaucoma versus primary angle closure glaucoma. pak j ophthalmol. 2022, 38 (2): 97102. doi: 10.36351/pjo.v38i2.1360 correspondence to: erum shahid karachi medical and dental college & abbasi shaheed hospital, karachi email: drerum007@yahoo.com received: december 13, 2021 accepted: march 10, 2022 introduction glaucoma is the second leading cause of blindness after cataract worldwide and is accounted for 8% blindness among 39 million blind individuals. 1 a meta-analysis by tham has estimated a global prevalence of glaucoma of 3.54%between 40 to 80 years of age. 2 there was an escalation by 74% in number of patients suffering from glaucoma from 2013 to 2020 due to a change in aging population. 2 pakistan has a burden of more than 1.8 million glaucoma patients and half of them have permanently lost their sight. 3 glaucoma refers to a group of disorders characterized by optic disc cupping and atrophy of postoperative complications of trabeculectomy in primary open angle glaucoma versus primary angle closure glaucoma pak j ophthalmol. 2022, vol. 38 (2): 97-102 98 optic nerve head, with specific visual field loss, often, but not always with increased intraocular pressure. 4 elevated intraocular pressure (iop) is a risk factor for developing glaucoma along with age, ethnicity, family history, thin corneas, myopia, and oxidative stress. 5 glaucoma is categorized into open angle and closed angle based on the visibility of angle structures on gonioscopy. 6 primary open-angle glaucoma (poag) is chronic progressive optic neuropathy with a visual field defect, open-angle on gonioscopy and absence of secondary cause. 6 primary angle-closure glaucoma (pacg) is characterized by elevated iop due to iridotrabecular contact and peripheral anterior synechia on gonioscopy. 6 poag is the most common subtype of glaucoma in all the regions accounting for 68.8% of all glaucoma cases. 2 pacg is the less common type but results in more blindness than poag. 7 poag is dominant among caucasian and african descendants while pacg is more common in the east asian population. 8 trabeculectomy is the gold standard treatment, when pressure reduction is unsuccessfully controlled by medical treatments or lasers. it is the most frequently performed procedure for lowering iop in glaucoma patients worldwide. 6,7 as compared to the medical treatment, trabeculectomy is more successful in achieving low iop. 9 it has the advantage of stabilizing iop by minimizing diurnal fluctuation in iop and by decreasing dependence on patient compliance with medication. 10 trabeculectomy has also been associated with several postoperative complications including wound leak, blebitis, endophthalmitis, shallow anterior chamber, hypotony, hypotony maculopathy, aqueous misdirection syndrome, malignant glaucoma, choroidal detachment and loss of vision. 11-13 numerous studies have been published regarding post-operative complications of trabeculectomy but few have compared the complications of trabeculectomy in poag patients and pacg patients. 14-16 there is a dearth of data regarding complications of trabeculectomy from pakistan.this study would be helpful to in adding data about this region. this study has been conducted to determine the frequency of postoperative complications of trabeculectomy in primary open-angle glaucoma compared to primary angle-closure glaucoma. methods this study was conducted in the department of ophthalmology, abbasi shaheed hospital, karachi, from january 2017 to january 2019. it was a comparative case series with consecutive sampling technique. the study was approved by ethical review committee and adheres to the tenants of the declaration of helsinki. all the patients who had undergone primary trabeculectomy without antimetabolites for primary open-angle glaucoma and primary angle-closure glaucoma with a 12 months follow up during the given period were included in the study. patients who had significant cataract preoperatively, repeated trabeculectomy, failed argon laser trabeculoplasty and trabeculectomy done for congenital glaucoma, traumatic glaucoma, secondary glaucoma were excluded from the study. patients who were lost to follow-up were also excluded. surgeries were performed by the first two surgeons. all the surgeries were fornix-based and done under retrobulbar anesthesia. superior rectus suture was applied with 4/0 silk for adequate exposure of the superior sclera and limbus. a side port was made with a phacoemulsification knife 3.2mm for access to the anterior chamber. conjunctiva was cut for fornixbased conjunctival flap near limbus along with radial relaxing incision using westcott scissors. non-tooth forceps were used for handling conjunctiva to avoid buttonholing. conjunctiva and tenon capsules were separated from the episclera and sclera. hemostasis was achieved with light wet field cautery to avoid shrinkage of the conjunctiva. a rectangular, partial thickness, a limbus-based scleral flap was outlined with a surgical blade no 11, measuring 3 x 4mm, within 2 o’clock to 10 o’clock hour of the limbus. the flap was lifted and dissected towards the limbus with a surgical blade no 16 till peripheral cornea. the anterior chamber was entered with a blade. a small window measuring 2 x 1mm was made by removing a piece of trabecular meshwork at the posterior edge of the anterior chamber incision with scissors. peripheral iridectomy was done by grasping the iris through this newly formed window with the help of iris scissors. the scleral flap was closed with interrupted nylon 10/0 sutures. irrigation was done through the side port to wash the anterior chamber, check the functioning of the bleb and reform the anterior chamber with air. conjunctiva and tenon capsule was also closed with interrupted 10/0 nylon suture. subconjunctival steroids and antibiotics were given at the end of the procedure. erum shahid, et al 99 pak j ophthalmol. 2022, vol. 38 (2): 97-102 the dressing was done after applying antibiotic drop and ointment. postoperatively topical steroid antibiotic drops (moxifloxacin and dexamethasone) and antibiotic ointment were prescribed for 8 – 10 weeks. systemic antibiotic ciprofloxacin 500mg twice daily and analgesic were given for 5 days. atropine eye drops were also prescribed in eyes at risk for developing aqueous misdirection syndrome. the dressing was removed on the first postoperative day. patients were examined on a slit lamp biomicroscope. visual acuity was assessed on snellen’s chart and intraocular pressure was checked by applanation tonometer on every visit. patients were followed up postoperatively, day after surgery, at 1st week, 15th day, monthly for 3 months, and then at 6 months. they were assessed for complications, bestcorrected visual acuity (bcva), and intraocular pressure (iop). siedel test was performed in every patient by putting a drop of 2% fluorescein over the wound site and then examining it under a cobalt blue filter. early and frequent follow-ups were requested for complicated cases. the primary outcome of the study was frequency of complications among the two groups. hyphema, uveitis, wound leak, shallow anterior chamber, choroidal detachment, choroidal folds, hypotonic maculopathy, over filtering blebs, suprachoroidal hemorrhage, raised iop, blebitis, endophthalmitis, malignant glaucoma and cataract were look for. the secondary outcome was the reduction of iop after surgery, failed or successful trabeculectomy. encapsulated blebs or flat blebs with iop of more than 21 mm of hg that required medical treatment were considered as failed trabeculectomy. iop of less than 21 mm of hg without any medical treatment was referred as successful trabeculectomy. data was collected on a pre-designed proformaand analyzed on spss version 21. frequencies were calculated for categorical variables like gender and complications. means with standard deviation (sd) were calculated for numerical data including age and iop. reduction in preoperative and postoperative iop was analyzed with a pair t-test among poag and pacg groups. complications of trabeculectomy for poag and pacg were compared with help of the pearson chi-square test. statistical significance was defined as a p-value of less than .005. results out of 71 patients 52(73.3%) had poag and 19 (26.7%) had pacg. there were 36 (50.7%) males for the poag group and 6 (8.5%) males for the pacg group. mean age of the patients for the poag group was 56.7±10.9 and for the pacg group was 52.2±9.5 years. the age rangedfrom 33 to 74 years. the right eye was dominantly affected in the poag group and left eye in the pacg group. the overall frequency of complications seen in poag patients was 20 (28.2%) and in pacg patients was15 (21.1%). patients with successful trabeculectomy in the poag group were 42 (80.7%) as compared to 14 (73.6%) patients in the pacg group with a statistically non-significant pvalue (0.517). failed trabeculectomy was seen in 10 (19.2%) patients in the poag group as compared to pacg group i.e. 5 (26.3%) patients with a statistically non-significant p-value. other demographic features are given in table 1. table 1: demographic features and clinical characteristics of the study participants (n = 71). variables poag pacg mean age minimum maximum gender males females laterality right eye left eye diabetes complications successful trabeculectomy failed trabeculectomy total 56.7 ± 10.9 33 74 36 (50.7%) 16 (22.5%) 32 (45%) 20 (28%) 6 (8.5%) 20 (28.2%) 42 (80.7%) 10 (19.2%) 52 (73.3%) 52.2 ± 9.5 33 65 6 (8.5%) 13 (18.3%) 6 (8.5%) 13 (18%) 0 15 (21.1%) 14 (73.6%) 5 (26.3%) 19 (26.7%) poag – primary open angle glaucoma, pacg – primary angle closure glaucoma there was no significant difference in reduction of iop at follow-ups among the two groups as shown by the p-value given in table 2. among the complications of trabeculectomy presented in table 3, a shallow anterior chamber with high intraocular pressure was seen in 5 (7.0%) pacg patients as compared to 2 (2.8%) poag patients with a statistically non-significant p value (0.015). shallow anterior chamber with low intraocular pressure was more common in poag patients i.e. 12 (17%) as compared to pacg patients i.e. 4 (5.6%) with postoperative complications of trabeculectomy in primary open angle glaucoma versus primary angle closure glaucoma pak j ophthalmol. 2022, vol. 38 (2): 97-102 100 statistically non-significant p-value (0.86). seidel test was positive in 10 (14.1%) poag patients. resuturing of the wound was also required in the poag group in 6 (8.5%) patients only. tenon cysts, uveitis, hyphema, and choroidal folds were seen in few patients among both the groups with a statistically non-significant pvalue. cataract developed in 8 (11.3%) patients of the poag group and 4 (5.6%) patients of pacg within 1 year of follow-up (p value > .005). a comparison of complications among the two groups with p values is given in table 3.sight-threatening complications blebitis, endophthalmitis, and malignant glaucoma were not encountered in our patients within the follow up period. table 2: comparison of iop before and after trabeculectomy in poag and pacg patients. variables poag pacg p value a pre-operative iop iop 3 months iop 6 months iop 12 months 31 ± 6.7 14.6 ±3.2 15.7 ±4.0 15.6 ±4.2 40 ± 14.8 17.0 ± 7.8 15.8 ± 4.7 13.8 ± 4.7 0.001 0.067 0.589 0.353 apair t test, iopintra ocular pressure, poag-primary open angle glaucoma, pacg-primary angle closure glaucoma table 3: percentage distribution of complications after trabeculectomy in both groups. complications poag pacg p-value b cataract choroidal fold tenon cysts block pi uveitis hyphema shallow ac high iop shallow ac low iop seidel +ve resuturing pressure patching 8 (11.3%) 2 (2.8%) 2 (2.8%) 0 2 (2.8%) 2 (2.8%) 2 (2.8%) 12 (17%) 10 (14.1%) 6 (8.5%) 6 (8.5%) 4 (5.6%) 0 0 2 (2.8%) 2 (2.8%) 3 (4.2%) 5 (7.0%) 4 (5.6%) 0 0 6 (8.5%) 0.573 0.386 0.386 0.018 0.280 0.082 0.015 0.857 0.039 0.122 0.028 b pearson chi square poag-primary open angle glaucoma pacg-primary angle closure glaucoma piperipheral iridectomy acanterior chamber +vepositive discussion in this study, 20 (28.2%) poag patients and 15 (21.1%) pacg patients developed complications after trabeculectomy, within 12 month of surgery (p value > .005). mahar had reported complications in 40% of their pacg patients and in 30% of poag patients; the difference was however, not statistically significant. 12 they had performed trabeculectomy augmented with antimetabolite and it was a small-scale study (n = 20). 12 tan et al. have reported a frequency of complications in 8.7% poag and 8.0% in the pacg group. 13 this complication rate is comparatively lower than the present study.the trabeculectomy was done by 8 different surgeons on a total of 320 patients. 13 the most frequent complication observed in our study was a shallow anterior chamber with low intraocular pressure (iop), seen in 12 (17%) patients with poag and 4 (5.5%) patients with pacg. among them, 10 (14.1%) patients had a positive seidel test in the poag group. the most frequent complication reported by mahar was flat bleb in 20% patients with pacg and 13% patients with poag. 12 flat bleb can be due to over or under filtration. over filtration is a known complication of augmented trabeculectomy. the shallow anterior chamber was the most frequent complication encountered by sihota et al in 40% of pacg patients and 30% in poag patients (n = 64) within 10 year follow up. 16 divyalakshmi et al. have reported shallow anterior chamber with choroidal detachment in just one pacg patient. 17 tan et al. have reported shallow anterior chamber due to bleb leak in 0.9% of pacg group and 2.9% in poag group. 13 all of the above studies are common in reporting no statistically significant difference in complications among poag and pacg patients. in this study, shallow anterior chamber was treated with pressure patching in 8.5% of patients in both the groups. resuturing and reformation of the anterior chamber (surgical intervention) were required in 8.5% of patients only in the poag group. all the patients with the shallow anterior chamber in the study by sihota et al were treated by non-surgical intervention. 16 resuturing was required in 1% of patients in the poag group and 3.6% of patients in the pacg group in a study by tan et al. 13 cataract is a well-known complication of trabeculectomy. advanced glaucoma intervention study (agis) has reported an increased risk of cataract formation by 78% after adjustment for age and diabetes. 18 cataract had developed in 8 (11.3%) patients in the poag group and 4 (5.6%) patients in the pacg group in this study. mahar had not reported cataract formation within 12 months follow-up period. 12 cataract was the main complication (13%) after trabeculectomy with antimetabolite in indian erum shahid, et al 101 pak j ophthalmol. 2022, vol. 38 (2): 97-102 studies. 19,20 study by thatsnarong has reported cataract formation in 6 (16.7%) patients following trabeculectomy in pacg patients. 15 the limited sample size of our study probably made the difference insignificant and longer duration follow up is also required. development and progression of cataracts should be considered post trabeculectomy especially in patients with pacg. 16 choroidal folds and tenon cysts were observed in 2 (2.8%) patients in the poag group while blocked pi was seen in 2 (2.8%) patients in the pacg group. tenon cyst was seen in 3.3% and 6% of patients, post trabeculectomy, in studies by divyalakshmi et al. and borgreffeet al. 17,21 the reported incidence of tenon cyst following trabeculectomy is about 9 – 15%. 22 the secondary outcome was the reduction in iop in poag and pacg patients. preoperatively mean iop in poag was 31 ± 6.7 mm of hg and 40 ± 14.8 mm of hg in pacg patients. post-operatively at 1 year, it was reduced to15.6 ± 4.2mm of hg in poag and 13.8 ± 4.7mm of hg in pacg patients. however, there was no statistically significant difference in the reduction of iop between the two groups of glaucoma in this study. mahar had reported a mean drop of 10.63 ± 3.2 mm of hg in the poag group compared to 9.42 ± 2.1 mm of hg in the pacg group. 12 mean postoperative iop reductions was 14.63 mm of hg after trabeculectomy by suresh et al. 23 sihota et al. did not find any significant difference in reduction of iop with trabeculectomy. 16 in this study successful trabeculectomy was observed in 42 (80.7%) poag patients and 14 (73.6%) pacg patients with an insignificant difference. other studies have reported success rates of 80% and 93.4% in trabeculectomies augmented with antimetabolites. 19,20 sihota have reported a 50% success rate in poag and 54% in pacg after 10 years. 16 there is a gradual decline in the success rate of trabeculectomy with longer duration of follow-up. primary open-angle glaucoma and primary angleclosure glaucoma are two different entities of the same disease. they have entirely different pathophysiology. there is a generalized impression that patients with pacg have a greater risk of developing postoperative complications as shallow anterior chamber, hypotony and malignant glaucoma following trabeculectomy as compared to patients with poag. 18 the results of our study and other studies of the region (asia) are consistent with the fact that surgical complications of trabeculectomy are independent of poag and pacg. 12,13,16,17 early postoperative period is very crucial for prompt detection and management of complications. surgical technique, surgeon’s expertise and vigilant post-operative management are other important aspects to have a successful trabeculectomy in closed and open-angle glaucoma. the limitations of the study are the retrospective design, and relatively small sample size of patients amongthe two groups. we have not analyzed complications based on ethnicity so our results cannot be generalized in our population. further prospective studies are recommended with a large sample size from our region to study/analyze the long-term effects of trabeculectomy in our population. conclusion the outcome of trabeculectomy in terms of complications was not significantly different in the poag versus pacg, over a period of 12 months. trabeculectomy is equally advantageous in lowering iop in poag and pacg patients. successful trabeculectomy is independent of the type of glaucoma as established by other studies in the literature. ethical approval the study was approved by the institutional review board/ethical review board (osp-irb/2021/004). conflict of interest authors declared no conflict of interest. refrences 1. bourne rr, taylor hr, flaxman sr, keeffe j, leasher j, naidoo k, et al. number of people blind or visually impaired by glaucoma worldwide and in world regions 1990-2010: a meta-analysis. plos one, 2016; 11: e0162229. 2. tham yc, li x, wong ty, quigley ha, aung t, cheng cy. global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. ophthalmology, 2014; 121 (11): 2081-2090. 3. khan l, ali m, qasim m, jabeen f, hussain b. molecular basis of glaucoma and its therapeutical analysis in pakistan: an overview. biomed res ther. 2017; 4 (03): 1210-1227. 4. thylefors b, negrel ad. the global impact of glaucoma. bull world health org. 1994; 72 (3): 323. postoperative complications of trabeculectomy in primary open angle glaucoma versus primary angle closure glaucoma pak j ophthalmol. 2022, vol. 38 (2): 97-102 102 5. levkovitch-verbin h, quigley ha, martin kr, valenta d, baumrind la, pease me. trans-limbal laser photocoagulation to the trabecular meshwork as a model of glaucoma in rats. invest ophthalmol vissci. 2002; 43 (2): 402-410. 6. european glaucoma society terminology and guidelines for glaucoma, 4th edition – chapter 2: classification and terminology supported by the egs foundation. br j ophthalmol. 2017; 101: 73–127. 7. wells ap, bunce c, khaw pt. flap and suture manipulation after trabeculectomy with adjustable sutures: titration of flow and intraocular pressure in guarded filtration surgery. j glaucoma, 2004; 13 (5): 400-406. 8. foster pj, johnson gj. glaucoma in china: how big is the problem? br j ophthalmol. 2001; 85 (11): 12771282. 9. wells ap, cordeiro mf, bunce c, khaw pt. cystic bleb formation and related complications in limbusversus fornix-based conjunctival flaps in pediatric and young adult trabeculectomy with mitomycin c. ophthalmology, 2003; 110 (11): 2192-2197. 10. schwartz k, budenz d. current management of glaucoma. curr opin ophthalmol. 2004; 15 (2): 119126. 11. henderson hw, ezra e, murdoch ie. early postoperative trabeculectomy leakage: incidence, time course, severity, and impact on surgical outcome. br j ophthalmol. 2004; 88 (5): 626-629. 12. mahar ps, laghari da. intraocular pressure control and post operative complications with mitomycin c augmented trabeculectomy in primary open angle and primary angle-closure glaucoma. pak j ophthalmol. 2011; 27 (1). 13. tan yl, tsou pf, tan gs, perera sa, ho cl, wong tt, et al. postoperative complications after glaucoma surgery for primary angle-closure glaucoma vs primary open-angle glaucoma. arch ophthalmol. 2011; 129 (8): 987-992. 14. maheshwari d, kanduri s, kadar ma, ramakrishnan r, pillai mr. midterm outcome of mitomycin c augmented trabeculectomy in open angle glaucoma versus angle closure glaucoma. indian j ophthalmol. 2019; 67 (7): 1080. 15. thatsnarong d, ngamchittiampai c. outcome of trabeculectomy in primary angle-closure glaucoma. j med assoc thai. 2017; 100 (8): 907. 16. sihota r, gupta v, agarwal hc. long-term evaluation of trabeculectomy in primary open angle glaucoma and chronic primary angle closure glaucoma in an asian population. clinexp ophthalmol. 2004; 32 (1): 23-28. 17. divyalakshmi ks, ramakrishna r. a comparative study of complications and its management following phaco-trabeculectomy in primary open angle glaucoma, primary angle closure glaucoma and pseudo-exfoliative glaucoma with cataract. indian j clin exp ophthalmol, 2019; 5 (1): 121-126. 18. agis investigators. the advanced glaucoma intervention study, 8: risk of cataract formation after trabeculectomy. arch ophthalmol. 2001; 119 (12): 1771-1779. 19. ramakrishnan r, michon j, robin al, krishnadas r. safety and efficacy of mitomycin c trabeculectomy in southern india: a short-term pilot study. ophthalmology, 1993; 100 (11): 1619-1623. 20. lamba pa, pandey pk, raina uk, krishna v. short-term results of initial trabeculectomy with intraoperative or postoperative 5-fluorouracil for primary glaucomas. indian j ophthalmol. 1997; 45 (3): 173. 21. borggrefe j, lieb w, grehn f. a prospective randomized comparison of two techniques of combined cataract-glaucoma surgery. graefes arch clin exp ophthalmol. 1999; 237: 887– 892. 22. vijaya l, manish p, ronnie g, shantha b. management of complications in glaucoma surgery. indian j ophthalmol. 2011; 59 (suppl. 1): s131. 23. suresh hh, samhitha hr, kishore h, prasad k, solse s, divya p. primary angle-closure glaucoma: a retrospective interventional case series in south india. oman j ophthalmol. 2016; 9 (1): 17. authors’ designation and contribution erum shahid; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. uzma fasih; associate professor: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. arshad shaikh; professor: concepts, design, manuscript editing, manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (3): 254-261 254 original article subconjunctival bevacizumab as an adjunct to 5fluorouracil enhanced trabeculectomy: 1 year outcomes sana nadeem 1 1 department of ophthalmology, foundation university medical college/fauji foundation hospital, rawalpindi abstract purpose: to compare the results of trabeculectomy with subconjunctival bevacizumab and 5-fluorouracil (5fu); with trabeculectomy with 5-fu alone; in terms of intraocular pressure (iop) lowering, bleb formation, and complications, in the long term. study design: quasi experimental study. place and duration of study: fauji foundation hospital, rawalpindi, from december 2013 to august, 2019. methods: a total of 30 eyes (15 in each group) with glaucoma were recruited. exclusion criteria were previous trabeculectomy, congenital, traumatic, uveitic, neovascular glaucomas, aphakia, or ocular surface disease. trabeculectomy with 5fu was performed in both groups. in one group, subconjunctival bevacizumab was injected into the bleb at the end of surgery. the patients were observed for iop control, bleb configuration, and complications for 1 year. results: primary open angle glaucoma was the predominant diagnosis in 17 (56.7%) eyes. the mean preoperative iop in the 5-fu group was 30.8 ± 17.03 mmhg, & in the 5-fu+bevacizumab group it was 28.9 ± 18.9 mmhg. the mean iops of the 5-fu group at 1 year was 14.5 ± 5.04 mmhg. in 5-fu+bevacizumab group, mean iops at 1 year was 12.7 ± 4.38 mmhg. the differences between pre-operative and post-operative iops in both groups at 6, 9 and 12 months were statistically significant. however, differences in mean iops between the two groups, bleb morphology and complications were not statistically significant. conclusion: no added benefit of subconjunctival bevacizumab used as an adjunct to 5-fu enhanced trabeculectomy was found at the end of 1 year follow-up. key words: trabeculectomy, 5-fluorouracil, bevacizumab, glaucoma, intraocular pressure. how to cite this article: nadeem s. subconjunctival bevacizumab as an adjunct to 5-fluorouracil enhanced trabeculectomy: 1 year outcomes. pak j ophthalmol. 2021, 37 (3): 254-261. doi: 10.36351/pjo.v37i3.1159 introduction glaucoma envelops a group of disorders characterized by progressive optic neuropathy and consequential correspondence: dr. sana nadeem department of ophthalmology, foundation university medical college/fauji foundation hospital, rawalpindi email: sana.nadeem018@gmail.com received: june 11, 2020 revised: december 20, 2020 accepted: april 28, 2021 visual field loss, in which intraocular pressure (iop) is a primary modifiable risk factor. 1 according to the world health organization, glaucoma accounts for greater than 12% of the burden of global blindness, with around 4.5 million people blinded worldwide by it. 2 it is the leading cause of irreversible blindness 3 , and surgery is often necessary when topical therapy, laser or all else fails in controlling the iop. trabeculectomy still remains the gold standard incisional surgery for iop reduction. it involves the creation of a fistula between the anterior chamber and open access mailto:sana.nadeem018@gmail.com sana nadeem 255 pak j ophthalmol. 2021, vol. 37 (3): 254-261 sub-tenon/sub-conjunctival space, beneath a partial thickness scleral flap, from where aqueous humor passes into a filtering bleb, from where it is absorbed into surrounding structures. hence, a functional filtering bleb is vital for surgical success. 4-7 the success of glaucoma filtration surgery (gfs) is hindered by scarring and fibrosis. antimetabolites used intraoperatively or postoperatively, prevent this scarring. conventionally, 5-fluorouracil (5-fu) and mitomycin c (mmc) are the most commonly used agents to modulate the healing response post-surgery, by prevention of the activation, proliferation and migration of fibroblasts. however, these may cause collateral damage. angiogenesis, mediated by the vascular endothelial growth factor (vegf), plays a primary role in wound modulation leading to granulation tissue formation. vegf also directly promotes inflammatory mediator migration and fibroblast activity. these hypotheses lead to researchers to investigate the role of anti-vegf agents like bevacizumab (bvz) as adjuvants in gfs to enhance its success rates and safety profile. 1,8 the rationale of our study is to compare the effect of subconjunctival bvz as an adjunct to 5-fu enhanced trabeculectomy to the effect of 5-fu alone; in terms of iop lowering, bleb formation, and complications, in the long term and to see if it gives an additional benefit. methods a total of 30 eyes in patients with glaucoma presenting to the eye out patient department, were included in this prospective, interventional study. thirty eyes were grouped into two (15 in each group). the study was carried out in the department of ophthalmology, fauji foundation hospital, rawalpindi, which is a tertiary care, teaching hospital affiliated with foundation university medical college; from 18th december, 2013 to 16th august, 2019. approval from the ethical committee was taken prior to the study. convenience sampling was done. inclusion criteria were patients above 40 years of age with primary open or angle closure glaucoma, pseudoexfoliative glaucoma, or pseudophakic glaucoma who had uncontrolled iop with maximally tolerated medical therapy, or noncompliance, or advanced glaucomatous damage at presentation, or as a combined procedure for cataract and glaucoma, if on multiple medications. patient preference for trabeculectomy was also respected if on 2 or more topical anti-glaucoma medications. exclusion criteria were young patients with glaucoma, congenital, juvenile, secondary, uveitic, traumatic, neovascular, aphakic glaucoma or the presence of ocular surface disease. pre-operatively, thorough ocular examination with slit lamp examination of the anterior and posterior segments, goldmann applanation tonometry, pachymetry and gonioscopy was done. the patients were assessed and monitored for glaucomatous progression by serial humphrey perimetry and optical coherence tomography (oct) of the optic nerve head and retinal nerve fiber layer. all surgeries were performed under local anaesthesia by the author using a standardized technique for facial nerve and retrobulbar blocks. the fornix based approach for trabeculectomy was used in all cases with a limbal conjunctival peritomy performed, and then a triangular superficial scleral flap was fashioned measuring 4 x 4 mm with a blade no.15, then 5-fu (50 mg/ml) was applied above and below the superficial flap with cotton pledgets for 5 minutes. after thorough washing of the 5-fu, a paracentesis was performed, and a deep scleral window was made 1.5 x 2 mm in size with a blade no. 11. peripheral iridectomy was performed using the vannas scissors. the superficial flap was then approximated to the sclera with 10/0 nylon sutures one at the apex, and one on the right side, with the left side being left un-sutured. the conjunctiva was then sutured with 8-0 silk or 6-0 vicryl on the right side ensuring a water-tight closure. fluid was injected through the paracentesis to ensure bleb formation and patency of the filtration procedure. in cases of subconjunctival bevacizumab (avastin®) injection (2.5 mg in 0.1 ml), the injection was performed from the left side with a bent needle of a 1 cc (30 g) syringe, horizontally into the bleb, about 8mm from the limbus. a subconjunctival antibiotic and steroid injection was given at the end of the surgery. in case of combined phaco-trabeculectomy, after peritomy and fashioning of superficial flap, phacoemulsification with an intraocular lens (iol) implantation was performed, following which the trabeculectomy was then completed. post-operatively the patients were given a topical antibiotic-steroid combination and cycloplegics, eventually tapered off at 6 weeks’ time. the patients were examined by the operating surgeon on the post-operative visits at day 1, 1 week, 1 month, and then monthly for 1 year. visual acuity, goldmann tonometry, and slit lamp examination with subconjunctival bevacizumab as an adjunct to 5-fluorouracil enhanced trabeculectomy pak j ophthalmol. 2021, vol. 37 (3): 254-261 256 fundus assessment was done as routine post-operative examination. bleb assessment using a simple grading system was done after healing of the conjunctiva, according to which blebs were classified into four types; type 1: thin-walled, polycystic (wellfunctioning), type 2: diffuse, flatter and thicker (good functioning), type 3: flattened bleb with scarring and little or no function, and type 4: encapsulated (tenon’s cyst) with engorged blood vessels and poor function. the data was analyzed on spss version 20. frequencies and percentages were calculated for all the variables. unpaired and paired samples t-tests were used for the data analysis as the case may be. the wilcoxon signed-rank test was used to assess the types of bleb formation between the two groups, and the complications between the two groups. a p-value of less than 0.05 was considered statistically significant. results a total of 30 eyes of 24 patients were included in this study, with 15 eyes in each group. majority of the patients were females accounting for 29 (96.7%) eyes. primary open angle glaucoma was the predominant diagnosis in 17 (56.7%) eyes, primary angle closure in 10 (33.3%) eyes, pseudoexfoliative glaucoma in 2 (6.7%) eyes, and pseudophakic glaucoma in 1 (3.3%) case only (table 1). in 22 (73.3%) eyes, enhanced trabeculectomy with 5-fu alone or combined 5-fu with subconjunctival bevacizumab was performed and phaco-trabeculectomy was performed in 8 (26.7%) eyes. the difference of means of pre-operative iop between the groups was not statistically significant [p = 0.730]. iop differences were analyzed at month 6, month 9 and 1 year, to assess the long term effects of the drugs and were compared with pre-operative iop as well as between the two groups (tables 2, 3). the differences between pre-operative and postoperative iop in the 5-fu group was significant at both month 6 (p = 0.003), month 9 (p = 0.003), and 1 year (p = 0.003), thus pointing to its surgical success in the long term period. in case of the 5-fu + bevacizumab group, the differences between preoperative and post-operative iop in the 5-fu + bevacizumab group was also statistically significant at month 6 (p = 0.007), month 9 (p = 0.007) and 1 year (p = 0.009). comparison of differences in the mean iop between the two groups did not reveal a significant difference between the two groups; either at month 6 (p = 0.277), month 9 (p = 0.564) or at 1 year (p = 0.256); although the mean iop in the 5-fu + bevacizumab group was lower on all occasions. table 1: baseline patient characteristics. age years (mean ± sd) range, years 62.6±7.35 50 – 84 gender n (%) male female 1 (3.3) 23 (96.7) eye n (%) right left 18 (60) 12 (40) glaucoma diagnosis n (%) poag × pacg ʃ pxf ¶ pseudophakic 17 (56.7) 10 (33.3) 2 (6.7) 1 (3.3) pre-op antiglaucoma drugs 5-fu ø group mean ± sd range 5-fu + bevacizumab group mean ± sd range 3.87 ± 0.35 (3-4) 3.93 ± 0.26 (3-4) surgical procedure n (%) enhanced trabeculectomy phacotrab 22 (73.3) 8 (26.7) × primary open angle glaucoma ʃ primary angle closure glaucoma ¶ pseudoexfoliative glaucoma ø 5-fluorouracil table 2: iop § at different time periods. iop mmhg (mean ±sd) and range at different times pre-operative baseline month 6 month 9 1 year trabeculectomy with 5-fu ø mean 30.8 ± 17.03 [maximum 68] [minimum 15] 14.33 ± 4.57 [8-25] 13.86 ± 4.22 [6-23] 14.5 ± 5.04 [6-28] trabeculectomy with 5-fu ø + s/c ¤ bevacizumab mean 28.9 ± 18.9 [maximum 78] [minimum 14] 12.8 ± 3.89 [5-18] 12.8 ± 3.89 [5-18] 12.7 ± 4.38 [4-20] ø 5-fluorouracil § intraocular pressure ¤ subconjunctival sana nadeem 257 pak j ophthalmol. 2021, vol. 37 (3): 254-261 table 3: paired samples t-test in the 5-fu group (iop)& in the bevacizumab + 5-fu group (iop). paired differences 95% confidence interval of the difference mean std. deviation std. error mean lower upper pair 1 pre-op iop in 5fu group iop at 6 months 5-fu group 16.46 17.71 4.57 6.65 26.27 .003 pair 2 pre-op iop in 5fu group iop at 9 months 5-fu group 16.93 18.45 4.76 6.71 27.15 .003 pair 3 pre-op iop in 5fu group iop at 1 year 5-fu group 16.26 17.78 4.59 6.41 26.11 .003 pair 4 pre-op iop in bvz+5-fu group iop at 6 months bvz+5fu group 16.13 19.65 5.07 5.24 27.01 .007 pair 5 pre-op iop in bvz+5-fu group iop at 9 months bvz+5fu group 15.86 19.68 5.08 4.96 26.76 .007 pair 6 pre-op iop in bvz+5-fu group iop at 1 year bvz+5-fu group 16.20 20.76 5.36 4.70 27.69 .009 fig. 1: bar chart depicting the comparison of means of iop over time in both groups. subconjunctival bevacizumab as an adjunct to 5-fluorouracil enhanced trabeculectomy pak j ophthalmol. 2021, vol. 37 (3): 254-261 258 bleb morphology analysis and comparison between the two groups, revealed a slightly higher frequency of cystic bleb formation in the 5-fu + bevacizumab group in 5 (16.7%) eyes, as compared to 4 (13.3%) eyes in the 5-fu group, with 1 (6.7) case of an encapsulated bleb, in the later, for which needling of the bleb was required. however, bleb morphology comparison between the two groups did not reveal statistically significant differences (p = 0.366) using the wilcoxon signed ranks test (table 4). table 4: bleb analysis. type of bleb trabeculectomy with 5-fu n (%) trabeculectomy with 5-fu + s/c bevacizumab n (%) type 1 cystic 4 (13.3) 5 (16.7) type 2 diffuse 10 (33.3) 10 (33.3) type 3 flattened 0 0 type 4 encapsulated 1 (3.3) 0 test statistics a type of bleb bevacizumab+5fu group type of bleb 5 fu group a. wilcoxon signed ranks test z -.905 b b. based on positive ranks. asymp. sig. (2-tailed) .366 there was a significant long term reduction of drugs post-operatively in both groups. the comparison for the 5-fu group between the pre-operative drugs [3.87 ± 0.35] and the post-operative drugs at month 6 [0.33 ± 0.48], month 9 [0.60 ± 0.83] and 1 year [0.73± 1.03] was statistically significant [p = 0.000]. for the 5-fu + bevacizumab group, similarly the comparison between the pre-operative anti-glaucoma drugs [2.93 ± 0.26] and post-operative drugs at month 6 [0.40 ± 0.83], month 9 [0.53 ± 0.99] and 1 year [0.60 ± 1.12] was statistically significant [p = 0.000]. the drugs used were dorzolamide hcl 2%, timolol maleate 0.5%, brimonidine tartarate o.1% and latanoprost 0.005% or a combination of these agents only. the difference in anti-glaucoma agents between the two groups was not statistically significant either at month 6 [p = 0.499], month 9 [p = 0.698] or 1 year [p = 0.582], although the number of post-operative drugs required was less in the 5-fu + bevacizumab group, at month 9 and 1 year. early complications were encountered equally in both groups, summarized in table5. the differences between the two groups were not statistically significant {p = 0.167}. shallow anterior chamber (ac) was considered only if iris cornea touch was present in the mid-peripheral iris and this was present in 1 (3.3%) case each, which led to choroidal detachment in the 5-fu + bevacizumab group, both of which were successfully treated with steroids and cycloplegics. one (3.3%) case of an imperforate peripheral iridectomy (pi) required nd: yag (neodymium: yttrium-aluminium-garnet) laser iridotomy post-operatively for completion, also in the same group. bleb leaks were discovered in 2 (6.7%) cases of the 5-fu group, which were successfully managed with bandage contact lenses (table 5). table 5: complications of trabeculectomy. complications n (%) trabeculectomy with 5-fu hyphema shallow ac β failure of filtration bleb leak peaked pupil/other pupil abnormalities 1 (3.3) 1 (3.3) 2 (6.7) 2 (6.7) 1 (3.3) trabeculectomy with 5-fu + s/c bevacizumab n (%) epithelial defect 1 (3.3) imperforate pi α 1 (3.3) hyphema 1 (3.3) shallow ac β & choroidal detachment 1 (3.3) peaked pupil/other pupil abnormalities 1 (3.3) posterior synechiae 2 (6.7) α peripheral iridectomy β anterior chamber discussion wound healing in gfs requires four phases: hemostasis, inflammation, proliferation and remodelling of tissue. controlled angiogenesis plays an integral part in the healing process. glaucoma surgeons sought to use anti-vegf agents as wound modulators to inhibit the healing response, which is vital to the success of gfs. blockage of the fistula occurs by aggressive collagen accumulation, angiogenesis, and fibroblast activity and proliferation at the subconjunctival and episcleral level; all contributing to trabeculectomy failure and continued visual loss. avascular blebs are associated with favourable outcomes and vascularization of the bleb is associated with loss of iop control. conventionally used antimetabolites like 5-fu and mmc can result in sana nadeem 259 pak j ophthalmol. 2021, vol. 37 (3): 254-261 bothersome hypotony, endothelial damage and thin blebs susceptible to leaks and infections. although beneficial in neovascular glaucomas, bevacizumab and ranibizumab both have been tried for iop control in traditional gfs but their effects are still limited and uncertain. 8-11 at the end of 1 year of follow-up, the results of our study indicated no significant additional benefit of subconjunctival bevacizumab used as an adjunct to 5fu enhanced trabeculectomy; in comparison to 5-fu alone in glaucoma filtration surgery; considering hypotensive efficacy, bleb morphology or complication rate. in terms of iop lowering, although mean iop at 6 months, 9 months and 1 year was slightly lower in the 5-fu + bevacizumab group on all three occasions, the differences between the two groups was not statistically significant. previously, we reported 12 the short term results of our study, in which we did not observe any additional significant iop lowering effect of bvz, although at month 3, the mean iop in the 5-fu + bevacizumab group was lower as compared to the 5-fu group. in both groups, the mean post-operative iop at month 6, month 9 and at 1 year was significantly lower compared to the preoperative baseline iop, indicating surgical success of the glaucoma filtration surgery in both groups. our study findings are similar to those of suh et al 13 , who stated that bvz did not exert additional effect when used in conjunction with 5-fu in trabeculectomy at 24 months. jukowska-dudzińska et al 14 compared 5-fu to subconjunctival bvz in trabeculectomy and also found no significant differences between the two groups at 12 months follow-up. however, contrary to our findings, more medical therapy was required in the bvz group postoperatively for iop control in their study. elgin et al 15 compared a single dose of subconjunctival bvz + 5fu to 5-fu alone in trabeculectomy in pseudoexfoliative glaucoma and found no added benefit at 6 months in terms of iop lowering and reported successful gfs in both groups, similar to ours. freiberg et al 16 compared adjunctive subconjunctival bvz injections with subconjunctival 5-fu to 5-fu injections alone, in patients who underwent trabeculectomy with mmc. they found a reduction in the number of 5-fu applications in eyes in which bvz had been applied at the end of 12 months of follow-up. however, gfs success rates were comparable in their two groups. many other authors have compared bvz to mmc in gfs and have reported their outcomes. one year outcomes reported by kaushik et al 17 , of comparison of bvz to mmc enhanced trabeculectomy in primary open angle glaucoma patients yielded comparable results in iop lowering terms. akkan 18 et al in their one-year study comparing bvz to mmc, found mmc to show superior iop control. mahdy 19 et al have reported a positive role of combined bvz-mmc trabeculectomy in recurrent pediatric glaucomas. similarly, arish 20 et al have reported superior outcomes in gfs with a single application of bvz in the short term. el-kasaby 21 reported comparable outcomes between bvz and mmc enhanced trabeculectomy. zarei 22 et al also showed no superiority after 2 weeks of topical use postoperatively in gfs with mmc. in terms of bleb morphology, our study demonstrated a slightly higher occurrence of cystic bleb formation in the 5-fu + bevacizumab group as compared the 5-fu group, with early bleb failure and one case of an encapsulated bleb in the later group, which required needling. however, statistically significant differences were not observed upon bleb comparison between the two groups. kaushik 17 et al found statistically significant bleb avascularity in comparison to mmc, whereas bitelli 26 et al did not observe any avascular blebs in their patients. akkan 18 et al found a higher incidence of encapsulated blebs in the bvz group, contrary to ours. chua 23 et al found a higher incidence of bleb related complications in the bvz-5-fu group when compared to 5-fu alone in gfs, but central bleb avascularity was not found to be statistically significant. liu 24 et al in their metaanalysis revealed a significantly higher incidence of encysted blebs as compared to mmc. in terms of complications; an equal number of complications was noted in both groups, and the differences between the two groups were not found to be statistically significant. contrary to what is reported in research, early bleb leaks were present in two eyes of our 5-fu group, which required bandage contact lens application. no late bleb leaks or sweating was observed at the end of one year. cheng 10 et al in 2016, searched extensively in the electronic database for randomized controlled trials comparing subconjunctival bevacizumab to other antimetabolites, and concluded that there is inadequate and low quality evidence to recommend or negate its use for wound modulation in gfs. chen and coworkers 25 in their meta-analysis in 2018, concluded subconjunctival bevacizumab as an adjunct to 5-fluorouracil enhanced trabeculectomy pak j ophthalmol. 2021, vol. 37 (3): 254-261 260 that adjunctive use of bevacizumab (1.25 mg/ml) with a regular concentration of antimetabolites (5-fu or mmc) did not show any advantage or detrimental effect when compared with using antimetabolites alone. strengths of our study is that equal allotment of cases has been ensured in the two groups and meticulous follow-up has been done. all procedures were performed by one surgeon. limitations of our study are small sample size. we are not a glaucoma facility and not every patient with glaucoma fulfils the criteria for undergoing trabeculectomy. recruiting patients and following them up has taken a long time. the loss of follow-up of one patient led us to recruit another one, which has taken a longer time to report our results. however, further randomized controlled trials with larger number of patients are needed to better assess the advantages and safety of bevacizumab in gfs. conclusion subconjunctival bevacizumab in conjunction with 5fluorouracil enhanced trabeculectomy does not offer any significant additional benefit in terms of iop lowering, bleb morphology or post-operative complications; when compared to 5-fu enhanced trabeculectomy alone, at the end of a 1 year follow-up. ethical approval the study was approved by the institutional review board/ ethical review board. 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r, masoumpour m, moghimi s, fakhraei g, eslemi y, mohammadi m. evaluation of topical bevacizumab as an adjunct to mitomycin c augmented trabeculectomy. j curr ophthalmol. 2017; 29 (2): 85– 91. doi: 10.1016/j.joco.2016.10.003 23. chua be, nguyen dq, qin q, ruddle jb, wells ap, niyadurupola n, et al. bleb vascularity following post-trabeculectomy subconjunctival bevacizumab: a pilot study. clin exp ophthalmol. 2012; 40 (8): 773779. doi: 10.1111/j.1442-9071.2012.02798.x. 24. liu x, du l, li n. the effects of bevacizumab in augmenting trabeculectomy for glaucoma: a systematic review and meta-analysis of randomized controlled trials. medicine (baltimore), 2016; 95 (15): 1-13. doi: 10.1097/md.0000000000003223 25. chen h, lin c, lee c, chen y. efficacy and safety of bevacizumab combined with mitomycin c or 5fluorouracil in primary trabeculectomy: a metaanalysis of randomized clinical trials. ophthalmic res. 2018; 59: 155-163. https://doi.org/10.1159/000486576 authors’ designation and contribution sana nadeem; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. .…  …. https://dx.doi.org/10.1016%2fj.joco.2016.10.003 53 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology case report masquerade syndrome: retinoblastoma presenting as sympathetic ophthalmia noor bakht nizamani, khalid iqbal talpur, sajjad ali surhio pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: noor bakht nizamani department of ophthalmology liaquat university eye hospital jail road, hyderabad, 71000, …..……………….…………….. purpose: masquerade syndromes are a group of ocular diseases that may mimic chronic intraocular inflammation, they may be benign or malignant. we report a case of retinoblastoma presenting as sympathetic ophthalmia: malignant uveitic masquerade syndrome. material and methods: a 6 year old female presented with trauma in the right eye following which she developed uveitis in the left eye two months later. she was diagnosed as a case of sympathetic ophthalmia and enucleation of right eye was done. the histopathology suggested it was a retinoblastoma (rb). since the child’s history was not suggestive of rb and her age was old for rb we requested the laboratory to review the slides again. a board of pathologists reviewed the slides, concluding that it was a rb undoubtedly. result: based on this, she was diagnosed as a case of malignant uveitic masquerade syndrome. patient was referred to advance oncology unit for further management of rb. conclusion: refractory uveitis in a young child should be thoroughly evaluated for malignant uveitic masquerade syndromes. group of diseases mimicking intraocular inflammation and uveitis are termed as masquerade syndrome,1 which may be classified as benign or malignant. sympathetic ophthalmia is an autoimmune granulomatous intra-ocular inflammation occurring most commonly within one year of surgery or trauma2. the injured eye termed as the excited eye while the fellow eye that develops inflammation without any obvious reason is called as sympathizing eye. retinoblastoma is the most common pediatric intraocular tumor occurring classically prior to 5 years of age. it usually presents as leukocoria, strabismus or decreased vision. only 1 – 3% present of retinoblastomas present as intraocular inflammation3. we present as case report of a 6 year old girl in which retinoblastoma presented as sympathetic ophthalmia, thus masquerade syndrome. case report a six year old female child first presented with chief complaint of painful loss of vision in her right eye (od) for a few days after trauma with stick. on examination her od had large hyphema with markedly raised intraocular pressure (iop) (fig. 1.a) and left eye (os) was within normal limits. paracentesis of od was done and blood was sent for gram staining and culture, which revealed no growth or micro-organism. two months later the child presented with complaint of no vision in her od and painful reduced vision and photophobia in os. her general health was good with no history of fever and review of systems was normal. on examination her visual acuity (va) was no perception of light (npl) in od and not recordable in os due to photophobia. on slit lamp examination her os had multiple keratic precipitates, cells in anterior chamber (ac) and vitreous, posterior synchiae, fundus view was hazy (fig. 1.b). her baseline investigations, x-ray chest and b-scan of os were normal. based on these findings patient was provisionally diagnosed as a case of sympathetic ophthalmia, her od being the excited eye and os the sympathetic eye which developed uveitis without any obvious etiology other than the trauma to the od. she was kept on systemic and topical steroids a masquerade syndrome: retinoblastoma presenting as sympathetic ophthalmia pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 54 prior to proceeding for enucleation of od. following the enucleation the os became quiet (fig. 1.c) and the child was sent home. to our surprise the histopathology report of the enucleated eye concluded it to be a retinoblastoma (rb). since the child’s history was not suggestive of rb and her age was old for rb we requested the laboratory to review the slides again. a board of pathologists reviewed the slides, concluding that it was a rb indisputably showing well differentiated homer wright rosettes and flexener wisternsteiner rosettes (fig. 2). on tnm staging patient had a pt2 nx mx with no optic nerve involvement. patient was referred to an advance oncology unit for further management of rb. fig. 1: (a) right eye on first presentation showing hyphema, anterior staphyloma. (b) left eye at second visit showing keratic precipitates, posterior synchiae (c) post enucleation right eye with prosthesis and left eye is normal fig. 2: histopathological slide of enucleated right eye, arrow showing mitotic figures. fig. 3: normal ultrasound b scan of left eye after enucleation of right eye fig. 4: ct scan of brain and orbit done after enucleation, showing implant in right eye and normal left eye. discussion masquerade syndrome is a rare entity as it presents an unusual presentation of relatively rare conditions; therefore mostly they are either undiagnosed or under diagnosed. they may be benign or malignant; however the latter are more common. some of the malignant masquerading conditions include primary intraocular lymphoma, uveal melanoma, retinoblastoma, leukemia, metastatic lesions and paraneoplastic syndromes.1 uveitis in the pediatric population is less common than adults. a british study reported the incidence of pediatric uveitis to be 3.15 per 100,000 children up to 5 years of age4. the literature does not give the actual incidence of sympathetic ophthalmia (so), as it is a rare condition but most studies concur that it is 0.2% to 0.5% noor bakht nizamani, et al 55 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology following ocular trauma and comprises only 0.3% of all uveitis2. the treatment protocol is mainly medical comprising of corticosteroids or immuno-suppressive therapy. enucleation remains a debatable topic in so: studies suggest primary enucleation done within 10 days of injury, is beneficial for reducing the inflammation in the sympathetic eye. but it is quite difficult to give a definite time frame for enucleation especially if the patient is a child. in our case we performed a secondary enucleation as the excited eye was a painful blind eye5 and the fellow eye developed refractory uveitis, which resolved following the surgery. less than 10% of retinoblastomas (rb) present as intraocular inflammation and 50% of these present as orbital cellulitis6. any other presentation makes the already difficult diagnosis next to impossible, accounting for the majority of misdiagnosed rbs. our case did not have a typical presentation of rb, she had no relevant family history and she had passed the age of usual rb which is mostly diagnosed prior to 5 years of age6. the definite diagnosis can only be reached after a histopathological evidence as was in our case. conclusion our case highlight a rare and unique presentation of retinoblastoma as sympathetic ophthalmia, thus masquerade syndrome. any refractory uveitis particularly in a child should raise a high index of suspicion of a masquerade syndrome and should be evaluated thoroughly. author’s affiliation dr. noor bakht nizamani department of ophthalmology, liaquat university of medical & health sciences, jamshoro/hyderabad, pakistan dr. khalid iqbal talpur department of ophthalmology, liaquat university of medical and health sciences, jamshoro / hyderabad, pakistan dr. sajjad ali surhio department of ophthalmology, liaquat university of medical & health sciences, jamshoro / hyderabad, pakistan references 1. trzaska k, romanowska – dixon b. malignant uveitis masquerade syndromes. klin oczna. 2008; 110: 199-202. 2. arevalo jf, gracia ra, al-dhibi ha, sanchez jg, suareztata l. update on sympathetic ophthalmia. middle east afr j ophthalmol. 2012; 19: 13-21. 3. català-mora j, parareda – salles a, vicuña-muñoz cg, medina-zurinaga m, prat – bartomeu j. uveitis masquerade syndrome presenting as a diffuse retinoblastoma. arch soc esp oftalmol. 2009; 84: 477-80 4. edelsten c, reddy ma, stanford mr, graham em. visual loss associated with pediatric uveitis in english primary and referral centers. am j ophthalmol. 2003; 135: 676-80. 5. savar a, andreoli mt, kloek ce, andreoli cm. enucleation for open globe injury. am j ophthalmol. 2009; 147: 595-600. 6. tsai t, o'brien jm. masquerade syndromes: malignancies mimicking inflammation in the eye. international ophthalmology clinics. 2002; 42: 115-31. microsoft word 1. editorial pak j ophthalmol. 2022, vol. 38 (2): 82-84 82 editorial intra arterial chemotherapy (iac) – advantages and pitfalls lubna siddiq mian1, muhammad moin1 1lahore general hospital, post graduate medical institute, ameer ud din medical college. introduction retinoblastoma is a blinding malignancy of childhood, which is curable when diagnosed early and treated properly, but retinoblastoma is dismal when the basic elements in diagnosis and treatment are lacking. survival and ocular prognosis is 30% in africa, 60% in asia and 95% in europe and united states and mirrors economic development of the countries.1 in the past three decades there has been marked improvement in the prognosis among victims of childhood cancer; reporting more than 75% survival rates in the united states;2 however, we cannot ignore the fact that 80% of retinoblastoma affects children in the developing countries. the complexity of the required multidisciplinary approach makes treatment difficult in the developing countries.3 we have set an example of a retinoblastoma treatment center that caters for early diagnosis, systemic chemotherapy, intra-arterial chemotherapy, intra vitreal chemotherapy, focal laser ablation and long term follow up assisted with retinal camera. the treatment for retinoblastoma relies heavily on chemotherapy, which can be given through various routes. systemic intra venous chemotherapy (ivc) has the advantage of addressing systemic metastasis, second tumor, lesser cost and bearable systemic toxicity.4 early diagnoses, appropriate staging and international classification of retinoblastoma grouping remain crucial predictive factors regarding prognosis. how to cite this article: mian ls, moin m. intra arterial chemotherapy (iac) – advantages and pitfalls.. pak j ophthalmol. 2022, 38 (2): 82-84. doi: 10.36351/pjo.v38i2.1393 the major challenge is when we encounter eyes refractory to systemic intravenous chemotherapy (ivc), or showing early recurrence after systemic chemotherapy. intra-arterial chemotherapy (iac) stands out as a hope to save these eyes and preserve useful vision, especially when this eye is the only eye. the developed countries have been using iac as the primary treatment modality for unilateral retinoblastoma in order to avoid systemic side effects caused by ivc.5 advanced tumors classified as group d and e commonly need a combination of iac and ivc.4 iac involves the cannulation of the femoral artery and navigating through the ipsilateral internal carotid artery. we use a headway 17 micro-catheter manufactured by microvention terumo, california, usa. the ostium of the ophthalmic artery is selectively engaged in order to give targeted infusion of potent chemotherapeutic agent at tumor site and therefore, maximum drug concentration is achieved at the tumor bed.6 successful cannulation of ophthalmic artery ostium is reported to be as high as 98% with no angiography related complications.7 the success of iac is attributed to the ability of using a highly potent chemotherapeutiic agent with short half-life, mainly melphalan, which is otherwise highly toxic through intravenous route.8 iac ensures maximum drug concentration in the tumor and in vitreous cavity to combat both subretinal and vitreous seeding. sheilds et al reported 100% eye salvage in group b, c and d retinoblastoma and 33% eye salvage in group e retinoblastoma.9 another retrospective study of 70 eyes reported 100% success with iac in group b and c, 94% in group d and 36% in group e.5 this success is much higher compared to the rate of eye salvage achieved with ivc alone that is 93% for group a, 83% for group b, 73% lubna siddiq mian, et al 83 pak j ophthalmol. 2022, vol. 38 (2): 82-84 for group c, 40% for group d, and 19% for group e eyes.10 iac being a local therapy, the treatment of systemic metastasis remains a challenge when iac is used as the sole primary treating modality. yousef et al reported 2.1% metastatic deaths in a meta-analysis including 613 eyes.12 however, abramson et al published <1% metastatic deaths among 6 centers treating retinoblastoma with iac, which seems to be very reassuring.12 in pakistan, the limited number of trained interventional neuro-radiologists and flouroscopy suites form a significant limitation in offering iac to victims of retinoblastoma. a developing country like pakistan cannot ignore the burden of cost. at our center, lahore general hospital, only the disposable equipment costs about $1,000 per session. aziz et al estimated that 3 sessions of iac require $16,000. they also stated that enucleation is the cheapest treatment for retinoblastoma and ivc is relatively cheaper than iac.13 we would like to mention that iac delivers potent chemotherapeutic drug directly to ocular vasculature, which carries risk of retinal and choroidal vascular occlusion and toxicity. munier et al reported choroidal or retinal ischemia in 3/13 patients.14 sheilds et al reported choroidal vasculopathy or retinal arterial occlusion in 6/17 patients.9 muen et al also reported cranial nerve palsy, orbital edema and vitreous hemorrhage.15 dose adjustment according to patients age works as the best preventive factor according to what we observed in our practice. gobin et al also support the role of age adjusted dose in preventing sight threatening complications.7 iac is a promising treatment modality for retinoblastoma and it is an important option for refractory tumors. national support to iac centers is the only hope to flourish iac in the country in order to avoid enucleation and retinoblastoma related blindness. references 1. kivelä t. the epidemiological challenge of the most frequent eye cancer: retinoblastoma, an issue of birth and death. br j ophthalmol. 2009;93(9):1129-1131. doi: 10.1136/bjo.2008.150292 2. ries lag, smith ma, gurney jg. cancer incidence and survival among children and adolescents: united states seer program 1975– 1995. national cancer institute, seer program; 1999. nih pub.no.99-4649. 3. rodriguez-galindo c, wilson mw, chantada g, fu l, qaddoumi i, antoneli c, et al. retinoblastoma: one world, one vision. pediatrics. 2008;122(3):e763-770. doi: 10.1542/peds.20080518. pmid: 18762512; 4. shields cl, fulco em, arias jd, alarcon c, pellegrini m, rishi p, et al. retinoblastoma frontiers with intravenous, intra-arterial, periocular, and intravitreal chemotherapy. eye (lond). 2013;27(2):253-264. doi: 10.1038/eye.2012.175. epub 2012 sep 21. 5. shields cl, manjandavida fp, lally se, pieretti g, arepalli sa, caywood eh, et al. intra-arterial chemotherapy for retinoblastoma in 70 eyes: outcomes based on the international classification of retinoblastoma. ophthalmology. 2014;121(7):1453-1460. doi: 10.1016/j.ophtha.2014.01.026. 6. jabbour p, chalouhi n, tjoumakaris s, gonzalez lf, dumont as, chitale r, et al. pearls and pitfalls of intraarterial chemotherapy for retinoblastoma. j neurosurg pediatr. 2012;10(3):175-181. doi: 10.3171/2012.5.peds1277. 7. gobin yp, dunkel ij, marr bp, brodie se, abramson dh. intra-arterial chemotherapy for the management of retinoblastoma: four-year experience. arch ophthalmol. 2011;129(6):732737. doi: 10.1001/archophthalmol.2011.5. 8. inomata m, kaneko a. chemosensitivity profiles of primary and cultured human retinoblastoma cells in a human tumor clonogenic assay. jpn j cancer res. 1987;78(8):858-868. 9. shields cl, bianciotto cg, jabbour p, ramasubramanian a, lally se, griffin gc, et al. intra-arterial chemotherapy for retinoblastoma: report no. 1, control of retinal tumors, subretinal seeds, and vitreous seeds. arch ophthalmol. 2011;129(11):1399-1406. doi: 10.1001/archophthalmol.2011.150. 10. daniels ab, patel sn, milam rw, kohanim s, friedman dl, koyama t. effect of intravenous chemotherapy regimen on globe salvage success rates for retinoblastoma based on disease classa meta-analysis. cancers (basel). 2021;13(9):2216. doi: 10.3390/cancers13092216. intra arterial chemotherapy (iac) – advantages and pitfalls pak j ophthalmol. 2022, vol. 38 (2): 82-84 84 11. yousef ya, soliman se, astudillo ppp, durairaj p, dimaras h, chan hsl, et al. intra-arterial chemotherapy for retinoblastoma: a systematic review. jama ophthalmol. 2016;134(5):584-591. doi: 10.1001/jamaophthalmol.2016.0244. 12. abramson dh, shields cl, jabbour p, teixeira lf, fonseca jrf, marques mcp, et al. metastatic deaths in retinoblastoma patients treated with intraarterial chemotherapy (ophthalmic artery chemosurgery) worldwide. int j retina vitreous. 2017;3:40. doi: 10.1186/s40942-017-0093-8. 13. aziz ha, lasenna ce, vigoda m, fernandes c, feuer w, aziz-sultan ma, et al. retinoblastoma treatment burden and economic cost: impact of age at diagnosis and selection of primary therapy. clin ophthalmol. 2012;6:1601-1606. doi: 10.2147/opth.s33094. 14. munier fl, beck-popovic m, balmer a, gaillard mc, bovey e, binaghi s. occurrence of sectoral choroidal occlusive vasculopathy and retinal arteriolar embolization after superselective ophthalmic artery chemotherapy for advanced intraocular retinoblastoma. retina. 2011 mar;31(3):566-73. doi: 10.1097/iae.0b013e318203c101. 15. muen wj, kingston je, robertson f, brew s, sagoo ms, reddy ma. efficacy and complications of super-selective intra-ophthalmic artery melphalan for the treatment of refractory retinoblastoma. ophthalmology. 2012 mar;119(3):611-6. doi: 10.1016/j.ophtha.2011.08.045. .……. pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 121 case report radiation retinopathy/maculopathy: a case report hussain ahmad khaqan, usman imtiaz, farrukh jameel pak jophthalmol 2016, vol. 32, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: usmanimtiaz post graduate resident, eye unit 3 lahore general hospital, lahore email: dr.usmanimtiaz@gmail.com received: april 02, 2016 accepted: june 13, 2016 …..……………………….. a 29-year-old male presented to opd with complaint of decreased vision in left eye. about 6months back he was diagnosed with myxofibrosarcoma of the left zygomatic bone. patient underwent radiation therapy for the tumor. 3 months after the last session of radiotherapy, patient experienced decreased vision in left eye. va was 6/6 od and 6/36 os. anterior segment examination revealed madarosis, trichiasis and conjunctival congestion of left eye. fundus examination of the left eye showed cotton wool spots, intraretinal hemorrhages and macular edema. patient was given intravitreal injection bevacizumab (avastin) 1.25mg/0.05ml in the left eye. after 4 weeks of the injection va was improved to 6/9 in left eye. patient wasasked to have a monthly follow-up. on the 5 th follow-up vision was again reduced to 6/18 os. oct revealed increased macular thickness. patient was again advised intravitreal injection bevacizumab. 3 injections were given monthly. vision improved to 6/6 os and patient is still on follow-up for 18 months. anti-vegf bevacizumab is effective in the treatment of radiation associated macular edema. key words: radiation retinopathy bevacizumab, intraretinal hemorrhages. adiation has been used therapeutically for the treatment of neoplastic lesions for over 100 years.stallard first described ocular complications following radiation therapy in 19331. radiation retinopathy can occur following either external-beam or local plaque therapy.the disease process is slow and onset often occurs months or years after the initial exposure to radiation2. characteristics of radiation retinopathy include cotton wool spots, retinal microaneurysms, intraretinal hemorrhages, macular edema, telangiectasia, exudates, perivascular sheathing, optic disc edema and atrophy. the clinical features of radiation retinopathy resemble that of diabetic retinopathy. the underlying pathology is also the same i.e. microangiopathy leading to micro vascular leakage and occlusion. the primary cause of vision loss is usually due to exudative or ischemic maculopathy. case description a 29-year-old male presented to opd with complaint of decreased vision in left eye. the past history revealed that he was diagnosed with myxofibrosarcoma of the left zygomatic bone about six months back. the tumor was indenting the left orbital floor.patient underwent intensity – modulated radiation therapy (imrt) for the tumor.total of 30 sessions of radiotherapy was given over 1 month period with the dosage of 25 greys. according to the patient left eye could not be covered during the therapy as the orbital floor had to be irradiated. 3 months after the last session of radiotherapy, patient fig. 1: pre treatment. fig. 2: post treatment. r hussain ahmad khaqan, et al 122vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology fig. 3: pre-treatment. fig. 4: post treatment. experienced decreased vision in left eye.on examination va was 6/6 od and 6/36 os. anterior segment examination revealed madarosis, trichiasis and conjunctival congestion of left eye.conjunctival congestion was due to the dry eye caused by disruption of the goblet cells of conjunctiva. fundus examination of the left eye showed cotton wool spots, intraretinal hemorrhages and macular edema. fundus photos were taken and oct was done which confirmed macular edema of 600 um and subretinal fluid accumulation (fig. 1, 3). patient was given intravitreal injection bevacizumab (avastin®) 1.25 mg/0.05 ml in the left eye. after 4 weeks of the injection va improved to 6/9 in left eye. oct was done which showed partial resolution of macular edema. macular thickness was reduced to 370 um. patient was given topical nepafenac eye drops 4 times a day and was asked to have a monthly follow-up. the visual acuity remained stable for 8 weeks and then the patient was lost to follow-up. five months after patient again presented to our opd with complaint of decreased vision. visual acuity was reduced to 6/18 os. oct revealed increased macular thickness of about 500 um. patient was again advised intravitreal injection bevacizumab. three injections were given on a monthly basis. post treatment vision improved to 6/6 os with complete resolution of macular edema, intraretinal hemorrhages and cotton wool spots (fig. 2). oct shows normal macular thickness (fig. 4). patient is still on follow-up for 18 months and vision is stable. discussion the development of radiation retinopathy has many variables. it depends on total dose of the radiation, fraction numbers and size as well as the location. 35 greys has been accepted as the upper limit of the safe dose. however cases of radiation retinopathy have been described with doses lower than this as in our case (25 greys). many studies have been performed to understand the pathophysiology of the disease. egbert et al, described the pathological changes in 1980. they demonstrated that there is thickening of the arteriolar and capillary walls due to deposition of the fine fibrillary material within and outside the wall3. they proposed that occlusion occurs due to the narrowing of the vessel lumen3. in 1987 irvine et al reported focal loss of capillary endothelial cells and pericytesresulting in edema in 11 primates after radiation therapy4. they postulated that as more capillaries become incompetent, retinal ischemia follows. retinal ischemia leads to neovascularization and finally neovascular glaucoma4. several treatment modalities have been used for the treatment of radiation retinopathy. hyken et al, studied the effect of focal laser on radiation induced macular edema. he concluded that though there is modest improvement in visual acuity and resolution of macular edema in the initial 6 months of the treatment, no significant difference in visual acuity was found at 2 year follow-up compared to observation group5. different other techniques have been proposed for the treatment. this includes the use of oral pentoxifylline, intravitreal triamcinolone, verteporfin photodynamic therapy, pan – retinal photocoagulation for proliferative disease and hyperbaric oxygen6,7,8,9. all of these treatment modalities have not proven to have long lasting effects on visual acuity and macular edema.with the advent of new modalities targeting vascular endothelial growth factor (vegf), these agents have been used for the treatment of maculopathy and also for proliferative radiation retinopathy. three main agents have been used in previous studies, including bevacizumab, ranibizumab and pegaptanib sodium. studies have shown that anti-vegf therapy was associated with initial decrease in capillary permeability10. it is evidenced by resolution of hemorrhages and exudates. finger et al concluded that continuous therapy with anti-vegf agents produces a preserved vision and sustained response for up to 10 years11. in our case also there was initial decrease in the capillary permeability and macular edema, which was proven by clinical examination and oct. after the initial decrease in edema, there was again gradual increase in the macular edema and vascular permeability as evidenced by increased retinal hemorrhages and oct. regular monthly dose of intravitreal bevacizumab for 3 months provided a sustained response, which is maintained even after 18 months. though results of anti-vegf agents are promising in the treatment of radiation retinopathy, radiation retinopathy/maculopathy: a case report pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 123 yet long term multi – center collaborative efforts will be needed to design the clinical trials with sufficient statistical power to evaluate the safety, efficacy, and role of these emerging pharmacotherapeutic agents. authors affiliation dr.hussain ahmad khaqan assistant professor, eye unit 3 lahore generalhospital, lahore dr.usmanimtiaz post graduate resident, eye unit 3 lahore generalhospital, lahore dr.farrukhjameel post graduate resident, eye unit 3 lahore generalhospital, lahore role of authors: dr. hussain ahmad khaqan patient management. dr. usmanimtiaz literature review and manuscript writing. dr. farrukhjameel follow-up examination. references 1. stallard hb. radiant energy as (a) a pathogenic (b) a therapeutic agent in ophthalmic disorders. british journal of ophthalmology monograph suppl. 1933; vi: p. 70. 2. daniel ma, joan wm. principles and practice of ophthalmology. 3rd ed.: saunders; 2008. 3. egbert pr, donaldson ss, moazet k, rosenthal ar. visual results and ocular complications following radiotherapy for retinoblastoma. arch ophthalmol. 1978;(96): p. 1826-1830. 4. irvine ar, wood is. radiation retinopathy as an experimental model for ischemic proliferative retinopathyand rubeosis irides. am j ophthalmol. 1987;(103): p. 790-797. 5. hykin pg, shields cl, shields ja, arevalo jf. the efficacy of focal laser therapy in radiation induced macular edema. ophthalmology, 1998;(105): p. 14251429. 6. gupta p, meisenberg b, amin p. radiation retinopathy: the role of pentoxifylline. retina. 2001;(21): p. 545-547. 7. shields cl, demiric h, dai v. intravitreal triamcinolone acetonide for radiation maculopathy after plaque radiotherapy for choroidal melanoma. retina. 2005;(25): p. 868-874. 8. bakri sj, beer pm. photodynamic therapy for maculopathy due to radiation retinopathy. eye. 2005;(19):p. 795-799. 9. stanford mr. retinopathy after irradiation and hyperbaric oxygen. j r soc med. 1984;(77): p. 1041-1043. 10. gian pg, ama s, david mh&e, rand s. current treatments for radiation retinopathy. acta oncologica. 2011; i(50): p. 6-13. 11. paul tf, kimberly jc, ekaterina as. intravitreal an vegf therapy for macular radia on re nopathy: a 10 – year study. european journal of ophthalmology. 2016;(26): p. 60-66. pak j ophthalmol. 2021, vol. 37 (2): 198-202 198 original article patient satisfaction: a tool towards quality improvement ume sughra 1 , mannal siddiqui 2 , sorath noorani 3 , hassan mansoor 4 , sultana kausar 5 1,3,4,5 department of ophthalmology, al-shifa trust eye hospital, rawalpindi 2 weill cornell medicine, doha – qatar abstract purpose: to determine the importance of patient satisfaction as a tool for quality improvement. study design: cross sectional survey. place and duration of study: pediatric ophthalmology department of al-shifa trust eye hospital, rawalpindi, from may 2017 to september 2017. methods: this study included 500 individuals, who were caregivers of children visiting the hospital at the time of data collection. individuals who visited departments other than pediatric department were excluded. two groups were made. group 1 included 300 individuals who were interviewed for to assess the patient satisfaction. on the basis of response, play area was made spacious, additional registration counters were placed and more reception staff members were hired to shorten the waiting and registration time, additional fans were installed in the waiting area and patient information was displayed on tv screens to aid uneducated patients and their attendants. second group with 200 individuals were interviewed after these improvements. pretested structured questionnaire was used to collect data regarding socio-demographic characteristics and experience of visit to the hospital. spss version 20 was used for descriptive and inferential data analysis. results: participants in this survey showed high level of satisfaction after interventions 45 to 65%.there was statistically significant association between satisfaction level and improvement in services was found (p < 0.001). conclusion: satisfaction level of patients depends upon the quality of services and medical care provided and it can be used as a good tool for improving the services in the hospitals. key words: satisfaction, outpatient department, hospital. how to cite this article: sughra u, siddiqui m, noorani s, mansoor h, kausar s. patient satisfaction: a tool towards quality improvement. pak j ophthalmol. 2021, 37 (2): 198-202. doi: http://doi.org/10.36351/pjo.v37i2.1150 introduction patient’s satisfaction is an essential means of measuring the effectiveness of health care delivery and quality of services for the health and wellbeing of correspondence: sultana kausar department of ophthalmology, alshifa trust eye hospital, rawalpindi email: kausarsultana180@gmail.com received: october 20, 2020 accepted: february 10, 2021 humans. 1 it indicates the provision of health care to the patients according to their requirements. patient satisfaction surveys are conducted to identify possible problems and provide opportunity to resolve them before they become serious. 2 patient satisfaction is a consumer’s perception and an attitude regarding the total experience of health care. 3 it comprises of both cognitive and emotional features and is influenced by previous experience, expectations and social networks. 4,5 outpatient department in any hospital is considered a shop window of the hospital. a simple and practical definition of satisfaction is the degree to which desired goals have been achieved. 6 patient http://doi.org/10.3352/jeehp.2013.10.3 ume sughra, et al 199 pak j ophthalmol. 2021, vol. 37 (2): 198-202 satisfaction is a fundamental focus of healthcare delivery outcomes. 7 higher levels of patient satisfaction is associated with time spent with the doctor, wait times and other factors. 8,9 al-shifa trust eye hospital, rawalpindi is regarded as one of the leading tertiary care ophthalmology centers in pakistan. it is believed that there exists a relationship between patient expectations and treatment outcomes. therefore, it is imperative to understand the expectations of the patients in order to minimize dissatisfaction, and to enhance compliance, when planning clinical services. we conducted this survey to find out the relationship of patient satisfaction with the improvements in health care delivery. methods this was a descriptive cross sectional study conducted in pediatric department of al-shifa trust eye hospital. the study was designed to assess relation of patient satisfaction with the services provided in outpatient pediatric department of al-shifa trust eye hospital from may 2017 to september 2017. the standard used in this study was national health survey (nhs) tool. sample size was calculated by using formula z 2 pq/e 2 , p (prevalence) as 50%, q is 100 – p = 50%, allowable error was kept as 9% of the prevalence (50%), that came out to be 5 individuals. after putting all the values in the formula z 2 pq/e 2 = 1.96*1.96*50*50/5*5, sample size came out to be 474. after adding a non response rate 5% (26) the sample size became 500. final sample size was 500, which was divided into two groups. the first group comprised of 300 individuals who were interviewed to find out the baseline for assessing patient satisfaction. second group comprised of 200 individuals who were presented the same questionnaire after the implementation of intervention. the interventions were based on the deficiencies pointed out by the group 1. male and female caregivers of 20 – 50 years age who were accompanying the children at the time of data collection were included. individuals who visited departments other than pediatric department were excluded. data was collected by using a structured questionnaire containing demographic characteristics and questions related to services provided. formal permission from the ethical review committee of pakistan institute of ophthalmology (pio) was sought. separate identification numbers were assigned to each questionnaire to ensure the confidentiality of the participants. reliability of the tool was also checked before start of study. the crohn bach’s alpha value came out to be 0.814 which guaranteed that tool was reliable for the data collection. data collection was done primarily by the principal researcher after taking informed consent from each participant. spss version 20 was used for descriptive and inferential data analysis. in the current research, 5 areas of patient satisfaction level (before appointment, waiting in the hospital, environment, seeing a doctor, overall impression) were selected and modified according to respective settings. likert scale was used for the responses of questions. on the basis of responses from the group 1, following deficiencies were identified: congested children play-area with less toys and activities for children. waiting time was for too long. hot and humid waiting area. difficulty in understanding the information charts displayed on the walls for uneducated persons. work was done on the problems identified by the patients’ attendants and children play area was made spacious with more toys and games, additional registration counters were placed and more reception staff members were hired to shorten the waiting and registration time. additional fans were installed in the waiting area and patient information was displayed on tv screens as well to aid uneducated patients and their attendants. results participants of the survey got information about alshifa pediatric department from different sources as shown in table 1. satisfaction level before and after improvement of services was calculated by the computation of responses given by the participants. the normality of outcome variable was checked in spss. the outcome (satisfaction) was found to be normally distributed (k-s p value > 0.05). afterwards that was categorized into poor and good satisfaction level by keeping mean as cutoff value. overall satisfaction level raised from 45% to 63% after improvement of identified problems regarding services (table 2). patient satisfaction: a tool towards quality improvement pak j ophthalmol. 2021, vol. 37 (2): 198-202 200 table 1: source of information about al-shifa pediatric department (n = 500). source number % relative 100 20 referred by doctor 185 37 referred by school 25 5 friends 55 11 panel 15 3 live in the area 40 8 heard from someone else 45 9 did not remember 35 7 table 2: mean scores of satisfaction level (n = 500). before after good poor good poor scores > 20 < 20 > 20 < 20 frequency 135 165 126 74 percentage 45 55 63 37 ninety two percent participants reported that their expectations were fulfilled by the doctor (simple instructions, explained eye condition, answers of each query, good attitude and cooperation) (table 3). best thing experienced by most of the participants (45%) was doctor attitude followed by good environment (28%) and after intervention doctor attitude was followed by cleanliness (30%).worst experience by most of the participants was waiting time and after interventions most of the participants (58%) reported nothing as worst experience. a chi-square test for independence indicated significant strong association between improvement in services and satisfaction level, [x 2 (1, n = 500) = 159.91, p = 0.001, phi = 0.92] (table 4). table 3: satisfaction about doctor’s attitude and cooperation (n = 500). strongly disagree disagree neither strongly agree agree simple instructions 10 (2) 10 (2) 5 (1) 410 (82) 65 (13) doctor explained eye condition 15 (3) 15 (3) 50 (10) 285 (57) 135 (27) expectation fulfillment 0 (0) 15 (3) 25 (5) 230 (46) 230 (46) table 4: association between improvement in services and satisfaction level (n = 500). satisfaction level x 2 (500-2) p-value good poor before 135 (45) 165 (55) 159.91 0.001 after 126 (63) 74 (37) discussion literature shows that the patients who are satisfied with their hospital visits are more adherent and compliant to their treatment and advices given by the treating physicians as compared to those who are not satisfied with the health care facilities. 10,11 it has been reported that a relation exists between the outcome of the healthcare and the patient satisfaction. 12,13 umar a s et al have done different surveys on the same subject and the results showed that quality healthcare services always have impact on the patient satisfaction and retention of patients in the long-run. 14 one of the who's six building blocks of health systems is the delivery of health services that are safe, effective and good quality for those who require them. 15,16 experience of patients is a key indicator of measuring strength of health service delivery. 17 patient satisfaction level with the nhs, uk varies from 60 to 65%. 18 in the current survey patient satisfaction improved from 45% to 63% after improving health care services and correcting the deficiencies pointed out by the patients. arvind sharma reported 73% satisfaction level in the opd of a tertiary care hospital of india. 19 in bangkok 91% satisfaction level was reported in a study. 20 this clearly visible difference is due to the fact that thailand being a developed country has better quality of health care services than pakistan and india. the meta-analysis done by zolnierek kb on 127 studies, concluded that patient adherence was associated statistically significantly to the communication of physicians. better physician’s communication with patients can improve that adherence. physician communication skill in the medical setting may be a main factor to enhance patient adherence because it improves the transmission of clinical and psychosocial information and aids in decision-making. it builds harmony and trust to create comfort level for patient involvement to discuss benefits, risks, and barriers to adherence. 11 in another study conducted by mcmullen m et al satisfaction with the time spent waiting was most strong predictor correlated with overall satisfaction in the outpatient eye clinic. these findings recommend that clinics could effectively improve the overall ume sughra, et al 201 pak j ophthalmol. 2021, vol. 37 (2): 198-202 patient satisfaction by reducing the waiting time. 9 limitation of this study was that it was an interview based survey and subjectivity can be a source of bias. secondly, it was a single department study and results cannot be generalized to the entire hospital. before and after groups were comprised of different individuals. it is suggested that similar group of individuals should be interviewed before and after the intervention. conclusion satisfaction level depends upon the services provided, doctor and staff attitude, and cooperation. patients who seek treatment with care and in a comfortable setting are more satisfied with hospital and this affects the compliance and adherence of patients with treatment that is necessary for their health. ethical approval the study was approved by the institutional review board/ ethical review board. (erc-25/ast-17). conflict of interest authors declared no conflict of interest. references 1. bintabara d, ntwenya j, maro ii, kibusi s, gunda dw, bonaventura c, et al. client satisfaction with family planning services in the area of high unmet need: evidence from tanzania service provision assessment survey, 2014-2015. reprod health, 2018; 127: 15. doi: 10.1186/s12978-018-0566-8 2. wambua jm, mbayaki r, munyao pm, kabue mm, mulindi r, change pm, et al. client satisfaction determinants in four kenyan slums. int j health care qual assur. 2015; 28: 667–677. 3. gadalean i, cheptea m, constantin i. evaluation of patient satisfaction. appl med inform. 2011; 29 (4): 4147. 4. jackson j, chamberlin j, kroenke k. predictors of patient satisfaction. soc sci med. 2001; 52: 609-620. 5. the health boards executive. measurement of patient satisfaction guidelines. health strategy implementation project, ireland, 2003; 37. 6. boyer l, francois p, doutre e. perception and use of the results of patient satisfaction surveys by care providers in a french teaching hospital. int j qual health care, 2006; 18: 359–364. 7. imam s, syed k, ali s, ali s, fatima k, gill m, et al. patients' satisfaction and opinions of their experiences during admission in a tertiary care hospital in pakistan – a cross sectional study. bmc health services research, 2007; 7 (1). 8. al-abri r, al-balushi a. patient satisfaction survey as a tool towards quality improvement. oman med j. 2014; 29 (1): 3-7. doi: 10.5001/omj.2014.02. 9. mcmullen m, netland pa. wait time as a driver of overall patient satisfaction in an ophthalmology clinic. clin ophthalmol. 2013; 7: 1655-1660. doi:10.2147/opth.s49382. 10. rasouli o, zarei mh. monitoring and reducing patient dissatisfaction: a case study of an iranian public hospital. total qual manag bus excell. 2016; 27 (5-6): 531-559. doi: 10.1080/14783363.2015.1016869 11. zolnierek kb, dimatteo mr. physician communication and patient adherence to treatment: a meta-analysis. med care, 2009; 47 (8): 826-834. 12. rao jk, weinberger m, kroenke k. visit-specific expectations and patient-centered outcomes: a literature review. arch fam med. 2000; 9 (10): 1148-1155. 13. sequist td, schneider ec, anastario m. quality monitoring of physicians: linking patients' experiences of care to clinical quality and outcomes. j gen intern med. 2008; 23 (11): 1784-1790. 14. umar as. patient waiting time in a tertiary health institution in northern nigeria, j pub health epidemiol. 2011; 3 (2); 78-82. 15. who, everybody’s business: strengthening health systems to improve health outcomes, geneva, switzerland world health organization, 2007. available at: https://apps.who.int/iris/handle/10665/43918 16. usaid, sustaining health gains—building health systems: health systems report to congress, washington, dc united states agency for international development. 2009. available at: http://purl.access.gpo.gov/gpo/lps119458 17. world bank, healthy development: the world bank strategy for health, nutrition, and population results, washington, dc world bank, 2007. available at: https://openknowledge.worldbank.org/handle/10986/68 43 18. cleary p, edgman-levitan s, roberts m, moloney t, mcmullen w, walker j, et al. patients evaluate their hospital care: a national survey. health affairs, 1991; 10 (4): 254-267. doi: 10.1377/hlthaff.10.4.254 19. sharma a, kasar pk, sharma r. patient satisfaction about hospital services: a study from the outpatient department of tertiary care hospital, jabalpur, madhya pradesh, india. natl j community med. 2014; 5 (2): 199-203. https://dx.doi.org/10.1080/14783363.2015.1016869 https://apps.who.int/iris/handle/10665/43918 http://purl.access.gpo.gov/gpo/lps119458 https://www.bibliomed.org/?jtt=0976-3325 patient satisfaction: a tool towards quality improvement pak j ophthalmol. 2021, vol. 37 (2): 198-202 202 20. pongsupap y, van lw. choosing between public and private or between hospital and primary care: responsiveness, patient-centredness and prescribing patterns in outpatient consultations in bangkok. trop med int heal. 2006; 11: 81–89. authors’ designation and contribution ume sughra; associate professor: concepts, design, data analysis, statistical analysis, manuscript review. mannal siddiqui; pre medical student: concepts, design, manuscript preparation, manuscript review. sorath noorani; professor and head of department: literature search, data acquisition, manuscript preparation, manuscript review. hassan mansoor; consultant ophthalmologist: literature search, data acquisition, manuscript preparation, manuscript review. sultana kausar; research assistant: data analysis, statistical analysis, manuscript preparation, manuscript review. .…  …. 147 pak j ophthalmol. 2022, vol. 38 (2): 147-150 original article ptosis repair with additional blepharoplasty qirat qurban 1 , zeeshan kamil 2 , khalid mahmood 3 1-3 khalid eye clinic, nazimabad, karachi abstract purpose: to share the results of levator resection with additional blepharoplasty in patients with ptosis. study design: interventional case series. place and duration of study: this study was carried out at khalid eye clinic, karachi, from january 2019 to june 2019. methods: we recruited twelve patients belonging to either gender with ages ranging from 18 to 35 years. patients with moderate to severe ptosis with fair to good levator function were included in the study. whereas, patients with previous history of eyelid procedure or any bleeding diathesis were excluded. all patients were briefed about the study dynamics and complete ocular examination along with ptosis evaluation were performed. levator resection was done with additional blepharoplasty. the amount of skin removal was solely dependent upon the surgeon’s clinical judgment. main outcome measure was cosmetic appearance by assessing the vertical fissure height as compared to the contra lateral eye, and the amount of overhanging skin at the lid crease as judged by the patients and the oculoplastic surgeon. result: this study included thirteen eyes of both genders with a mean age of 23.7±4.19 years. twelve out of thirteen eyes had a satisfactory final cosmetic appearance, and were also graded as excellent by another oculoplastic surgeon. one patient required revision of surgery for the overhanging skin at the lid crease. conclusion: additional blepharoplasty with levator resection can be a good option for ptosis correction and it provides a good aesthetic appearance. key words: ptosis, levator resection, blepharoplasty. how to cite this article: qurban q, kamil z, mahmood k. ptosis repair with additional blepharoplasty. pak j ophthalmol. 2022, 38 (2): 147-150. doi: 10.36351/pjo.v38i2.1096 correspondence: qirat qurban khalid eye clinic, nazimabad, karachi email: qirat_89@hotmail.com received: july 07, 2020 accepted: march 27, 2021 introduction one of the most frequent eyelid procedures, blepharoplasty, corrects the deformities and disfigurement of the eyelids for functional and cosmetic reasons. it is usually performed by oculoplastic surgeons in patients who require repositioning after removal of excess skin and fat tissue to give a more aesthetically pleasing appearance. the commonest indication for ptosis surgery is visual compromise due to ptotic upper eyelids as the patient frequently complains of loss of peripheral vision due to the excess skin overhanging the eyelid margin and obscuring vision like a window shade. this condition improves by physically lifting the eyelids with fingers or forehead muscle. perimetry can be performed to assess the loss of visual field. 1 the normal eyelid margin rests 3.5 to 4.5 mm above the central pupil, whereas in functional ptosis, it rests 2.5 mm or less, above the central pupil. ptosis should be corrected while performing blepharoplasty because sometimes it becomes more apparent after blepharoplasty due to eyelid debulking. in most instances, the upper eyelids are droopy or ptotic, so ptosis procedure is combined with an upper eyelid blepharoplasty. with an additional procedure, the levator aponeurosis is repositioned on the tarsal plate, ptosis repair with additional blepharoplasty pak j ophthalmol. 2022, vol. 38 (2): 147-150 148 and the upper eyelid height is set compared to the fellow eye. once the upper eyelid height is positioned, the excess skin and fat are removed to give a more youthful look. blepharoplasty is indicated for functional reasons where the upper eyelid fat, orbicularis hypertrophy or laxity, skin laxity and lash ptosis may affect the patient's visual field. 2 the causes may include levator dehiscence due to age, infections, trauma, tumors or inflammation as well as less common causes such as myasthenia gravis, trauma, orbital or eyelid tumors, congenital ptosis, third nerve palsy or horner syndrome. therefore, it is of importance that levator status is evaluated before ptosis repair is attempted. 3 this study was done with the aim to share the cosmetic outcome of performing additional blepharoplasty in patients undergoing ptosis repair. methods this study was conducted at khalid eye clinic, karachi, from january 2019 to june 2019. approval was obtained from the ethical review committee and we recruited twelve patients of both genders with ages ranging from 18 to 35 years. inclusion criteria comprised of moderate to severe ptosis with fair to good levator function whereas patients with history of lid surgery or any bleeding disorder were excluded from this study. all patients were counseled about the nature of the study dynamics and the surgical procedure and informed verbal consent was taken from each patient. patients were encouraged to voice their desires and concerns regarding the aesthetic appearance and functional features of their eyelids and to inform the surgeon about their desired outcome in the initial assessment following which, ptosis and other ocular examination was carried out. old photographs were used in some patients to determine the patient’s upper eyelid fold configuration to serve as a guidepost. pre and post-operative photographs were taken to compare the cosmetic improvement in each patient. main outcome measure was cosmetic appearance by assessing the vertical fissure height as compared to the contra lateral eye and the amount of overhanging skin at the lid crease as judged by the patients and the oculoplastic surgeon. it was graded as excellent if the difference between the two eyes was ≤ 1.0 mm post operatively. all surgeries were done under general anesthesia. each patient underwent a standard ptosis repair procedure with levator resection and the required amount of levator resection was done with an additional blepharoplasty by one oculoplastic surgeon (qq) in all the patients. the amount of skin removal was solely dependent upon the surgeon’s clinical judgment on each patient individually. after marking the skin and making the initial incision, the required amount of skin was removed and orbicularis muscle was dissected with scissors not extending down to the orbital septum. once the excision of skin and dissection of the muscle was complete, the orbital septum was opened from medial to lateral side. the lateral, middle and medial fat pads were identified followed by cattery of the base to maintain a good hemostasis. excess fat was removed to yield a better defined upper lid crease. the aponeurosis and levator muscle were identified. the aponeurosis was cut transversely with scissors at the mid-tarsal plate level. 6 – 0 vicryl sutures were passed through skin including the orbicularis muscle to form a lid crease and the lid level was checked compared to the contralateral eyelid. closure of the upper lid wound was performed with a 6 – 0 vicryl suture followed by ophthalmic ointment and gauze pads on the upper lid area to prevent opening. results this study included thirteen eyes of twelve patients of both genders with a mean age of 23.7 ± 4.19 years. there were eight (61.54%) female eyes and five (38.46%) male eyes. right eye was involved in seven patients and left eye in six. twelve out of thirteen eyes had a satisfactory final cosmetic appearance and graded as excellent by the oculoplastic surgeon. one patient required revision surgery for the overhanging skin at the lid crease. mean follow up period was 131.1 ± 8.7 days. discussion functional and cosmetic concerns are the main indications for the patient and a surgeon to opt for blepharoplasty in addition to ptosis correction which is usually performed by an oculoplastic surgeon. studies have shown that impairment of the visual field due to ptosis and overhanging skin in the primary position and down gaze serves as a functional indication for surgical repair. 4,5 procedures have been fashioned in such a way to safely achieve ptosis correction along with removal of the excessive skin. 6,7 two case series qirat qurban, et al 149 pak j ophthalmol. 2022, vol. 38 (2): 147-150 were done which documented a significant improvement in the visual field and quality of life. 8,9 waller et al 10 reported visual field impairment in down gaze due to ptosis which was subsequently reported in other peer-reviewed publications. 11,12 in this study, thirteen eyes of twelve patients underwent levator resection for ptosis repair followed by additional blepharoplasty. twelve eyes out of the thirteen had an excellent final cosmetic outcome with an adequate palpebral fissure height comparable to the fellow eye and the patients were very pleased with the results. only one eye required a revision surgical procedure due to the overhanging skin at the lid crease. additional blepharoplasty with ptosis correction via levator resection significantly improves the superior field of vision, both in primary gaze and reading gaze with a reported qualitative enhancement in reading vision, comfort and visible aesthetic appeal in the period after surgery. battu et al and federici et al observed the quality of life in larger populations in relation to the significant association between visual field impairment and difficulty with driving activities, sense of dependency, mental health, subjective distance vision, and peripheral vision. 8,9 very few studies have been done to observe the impairment caused by dermatochalasis or overhanging skin. hacker and hollsten reported dermatochalasis leading to impairment of visual field in patients who underwent upper eyelid blepharoplasty surgery. 13 another study showed that patients undergoing upper eyelid blepharoplasty experienced blurred vision but this complaint was not found in any of the patients in this study. 14 ophthalmologists have also noticed refractive changes in patients undergoing eyelid repositioning. 15 we did not observe this in our study. previous data has shown that blepharoplasty improved the superior field of vision but did not eliminate the visual field impairment caused by ptosis. 16,17 in such patients, there was superior visual field defect even after blepharoplasty. temporal visual field loss has not been widely discussed but it frequently accompanies the superior visual field loss caused by ptosis and dermatochalasis. 16,17 this contributes to the functional and cosmetic disability as documented in population studies of quality of life impairment. 18-20 this study was limited in terms of the small sample size of patients undergoing ptosis repair with additional blepharoplasty and the surgical and cosmetic outcome relied on the patient’s preference and satisfaction level. conclusion ptosis and dermatochalasis independently impair visual field and patient’s physical aesthetic well-being which increase with more severe upper eyelid malposition. additional blepharoplasty with ptosis correction provides a significant functional and an excellent cosmetic outcome. ethical approval the study was approved by the institutional review board/ethical review board (erc-13-20). conflict of interest no conflicting relationship exists for any author. references 1. kim mj, oh ts. treatment for ophthalmic paralysis: functional and aesthetic optimization. arch craniofac surg. 2019; 20 (1): 3-9. doi: 10.7181/acfs.2019.00066. 2. weaver dt. current management of childhood ptosis. curr opin ophthalmol. 2018; 29 (5): 395-400. 3. liu cy, chhadva p, setabutr p. blepharoptosis repair. curr opin otolaryngol head neck surg. 2018; 26 (4): 221-226. 4. dryden rm, kahanic da. worsening of blepharoptosis in downgaze. ophthal plast reconstr surg. 1992; 8: 126 –129. 5. meyer dr, linberg jv, powell sr, odom jv. quantitating the superior visual field loss associated with ptosis. arch ophthalmol. 1989; 107: 840 –843. 6. altieri m, truscott e, kingston ae, bertagno r, altieri g. ptosis secondary to anterior segment surgery and its repair in a two-year follow-up study. ophthalmologica. 2005; 219 (3): 129-135. doi:10.1159/000085244 7. shore jw, bergin dj, garrett sn. results of blepharoptosis surgery with early postoperative adjustment. ophthalmology, 1990; 97: 1502–1511. 8. battu vk, meyer dr, wobig jl. improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery. am j ophthalmol. 1996; 121: 677–686. 9. federici tj, meyer dr, lininger ll. correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. ophthalmology, 1999; 106: 1705–1712. ptosis repair with additional blepharoplasty pak j ophthalmol. 2022, vol. 38 (2): 147-150 150 10. waller rr, mccord cd jr, tanenbaum m. evaluation and management of the ptosis patient. in: mccord cd jr, tanenbaum m, eds. oculoplastic surgery. 2nd ed. new york: raven press; 1987: 325– 376. 11. meyer dr, rheeman ch. downgaze eyelid position in patients with blepharoptosis. ophthalmology, 1995; 102: 1517–1523. 12. olson jj, putterman a. loss of vertical palpebral fissure height on downgaze in acquired blepharoptosis. arch ophthalmol. 1995; 113: 1293–1297. 13. hacker hd, hollsten da. investigation of automated perimetry in the evaluation of patients for upper lid blepharoplasty. ophthal plast reconstr surg. 1992; 8: 250 –255. 14. adamson pa, constantinides ms. complications of blepharoplasty. facial plast surg clin north am. 1995; 3: 211-221. 15. wilson g, bell c, chotai s. the effect of lifting the lids on corneal astigmatisms. am j optom physiol opt. 1982; 59: 670-674. 16. cahill kv, burns ja, weber pa. the effect of blepharoptosis on the field of vision. ophthal plast reconstr surg. 1987; 3: 121–125. 17. meyer dr, stern jh, jarvis jm, lininger ll. evaluating the visual field effects of blepharoptosis using automated static perimetry. ophthalmology, 1993; 100: 651–659. 18. freeman ee, munoz b, rubin g, west sk. visual field loss increases the risk of falls in older adults: the salisbury eye evaluation. invest ophthalmol vis sci. 2007; 48: 4445–4450. 19. black aa, wood jm, lovie-kitchin je, newman bm. visual field loss and falls among older adults with glaucoma. invest ophthalmol vis sci. 2008; 49: e5458. 20. cocchiarella l, anderson gbj, eds. the visual system. in: guides to the evaluation of permanent impairment. 5th ed. chicago, il: american medical association, 2000: 277–304. authors’ designation and contribution qirat qurban; consultant ophthalmologist: concepts, design, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing. zeeshan kamil; consultant ophthalmologist: concepts, design, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing. khalid mahmood; consultant ophthalmologist: data acquisition, manuscript review. .…  …. 333 pak j ophthalmol. 2021, vol. 37 (3): 333-335 brief communication anton’s syndrome in occipital lobe infarction khalid mehmood 1 , sabeen khalid 2 , nauman ismat butt 3 , fahmina ashfaq 4 , aniqa anser khan 5 1-5 azra naheed medical college, lahore abstract anton's syndrome implies the situation when affected patient contradicts blindness in spite of objective documentation of loss of vision, and often confabulate to assert their bearing. it is an infrequent sequel of cortical blindness affecting both occipital cortex and other cortical centers, while patients genuinely act as if they are sighted. our case report is of a lady, 55 years old, who presented to us with history of uncontrolled diabetes, hypertension and visual loss as a consequence of occipital lobe infarction bilaterally. in patients with evidence of occipital lobe injury and atypical visual loss, an assessment for cortical blindness and anton's syndrome must be included. anton's syndrome is most frequently caused by cerebrovascular disease. any condition that causes cortical blindness may, however, lead to anton's syndrome. improvement in visual function after occipital lobe infarction due to cerebrovascular events is limited. therefore, the management should be focused on rehabilitation and secondaryprevention. keywords: anton’s syndrome, occipital lobe infarct, diabetes mellitus, hypertension. how to cite this article: mehmood k, khalid s, butt ni, ashfaq f, khan aa. anton’s syndrome in occipital lobe infarction. pak j ophthalmol. 2021, 37 (3): 333-335. doi: 10.36351/pjo.v37i3.1228 introduction anton's syndrome, also known as visual anosognosia, is defined as “negation of visual loss, accompanied by confabulation in the presence of evident loss of vision and cortical blindness”. 1 in this condition, visual association centers of the occipital lobe is affected but the anterior visual tracts are intact. patients affected with anton's syndrome are confirmed that they are seeing what they actually cannot. they act as if they have vision. 1 however, awareness to the likelihood of the syndrome is drawn with accidents such as walking into walls, falling over furniture and describing things, which may not be present. 2 wepresent a case of anton's syndrome caused by un-controlled diabetes mellitus and hypertension, ultimately leading to occipital lobe infarct. correspondence: nauman ismat butt azra naheed medical college, lahore email: nauman_ib@yahoo.com received: february 18, 2021 accepted: may 10, 2021 case presentation a 55-year old woman presented to chaudhary muhammad akram teaching and research hospital, lahore with the complaint of decreased vision from last 2 days. she had history of uncontrolled diabetes and hypertension from last 4 and 3 years respectively. on presentation, her glasgow coma scale was 15/15 with normal power in all groups of muscles of 4 limbs and down going plantars. there was peripheral neuropathy as well. on examination of eyes, her pupillary reflexes were preserved bilaterally but patient was not able to perceive light and threatened response. the most conspicuous clinical sign was marked limitation of visual acuity. according to her, she would walk into things as if plainly blind. in spite of an objective attenuation of her vision, the patient asserted she could 'see' objects surrounding her but with blackish haze. pupillary reflexes were normal (highlighting an intact anterior visual pathway), along with fundoscopic findings of non-proliferative diabetic retinopathy and macular edema in both eyes. her random blood sugar was 390mg/dl and blood pressure of was 160/90 mmhg. open access anton’s syndrome in occipital lobe infarction pak j ophthalmol. 2021, vol. 37 (3): 333-335 334 figure 1: ct scan brain of the patient showing hypo-dense area in the occipital lobe indicating infarction. ct of brain (figure 1) was performed which showed an old infarct of right occipital lobe and new evolving infarct of left occipital lobe. she needed assistance in moving safely due to her impaired vision, and needed assistance for daily routine chores. she would reach out for utensils on the tray and start eating if placed in front of her, however she was unable to see her meals, but help was needed to assist her avoid spillage and to finish the meals. during her stay in the hospital, her blood sugar was controlled and then patient was referred to ophthalmology department for treatment of non-proliferative diabetic retinopathy and macular edema. after the control of blood sugar her macular edema also reduced. consent consent was taken from the patient’s attendants regarding sharing all the information. discussion neurological impairment of vision encompasses a vast gamut of conditions including visual neglect and agnosia, cerebral visual impairment, homonymous hemianopia and numerous perceptual vision disorders, lack of facial recognition, delayed visual development and cortical blindness. moving objects may nonetheless be perceived in total cortical blindness caused by damage to the occipital cortices bilaterally, whether consciously as in riddoch's syndrome or unconsciously as in blindsight. 2 moreover, motion blindness is also described, where patients are able to see things but are unable to perceive their movements. this may be because of presence of projections from the lateral geniculate nucleus towards the visual cortex (v1) via optic radiations, directed to the middle temporal area. 3,4 other demonstrations of visual impairment can compromise charles bonnet syndrome, when patients may experience elaborate hallucinations, with images of unfamiliar buildings or people although insight is preserved. 5 anton's syndrome implies the situation when patients contradict their blindness in spite of objective documentation of loss of vision, and often confabulate to assert their bearing. 1 often patients with damaged bilateral occipital lobes also have injury to the visual association cortex, that can lead to their deficit in awareness. affected visual areas may be functionally disengaged from monitoring centers, such as speech and language centers, as suggested by aston and these functioning speech areas may confabulate a response even in absence of input. 1 another hypothesis suggests that the monitor of visual stimuli is dysfunctional and interprets images incorrectly. 4 the others advocate the presence of false feedback from another visual system. in this aspect, the superior colliculus, pulvinar and temporo-parietal regions can channel signals to the center if the geniculocalcarine system ebbs. 6 this internal imagery convinces the speech areas to make a response, in the absence of visual input. anton's syndrome is most frequently caused by cerebrovascular disease. 5 any condition which may lead to cortical blindness can, however, possibly culminate in anton's syndrome such as obstetric haemorrhage, hypertensive encephalopathy, preeclampsia, hypoperfusion, multiple sclerosis and brain trauma. 7,8 our patient had occipital infarction bilaterally leading to cortical blindness and visual khalid mehmood, et al 335 pak j ophthalmol. 2021, vol. 37 (3): 333-335 anosognosia, and asserted her visual aptitude firmly in spite of an obvious visual impairment. recovery in visual function is often good in diseases such as hypertensive encephalopathy and cortical hypoperfusion as resolution of the etiologic cause can result in correction of symptoms. 7 our patient, having occipital lobe infarcts bilaterally, is less likely to gain a substantial improvement in spite of a partial recovery of her vision and therefore it is important to opt for secondary prevention, and guide her rehabilitation. conclusion this case report accentuates to the scarce data available on anton's syndrome. our case report of a lady, 55 years old, who presented with history of uncontrolled diabetes, hypertension and visual loss as a consequence of occipital lobe infarction bilaterally due to anton’s syndrome. in patients with evidence of occipital lobe injury and atypical visual loss, an assessment for cortical blindness and anton's syndrome must be contemplated and investigated. conflict of interest authors declared no conflict of interest. references 1. m das j, naqvi ia. anton syndrome. [updated 2019 dec 3]. in: stat pearls [internet]. treasure island (fl): stat pearls publishing; 2020 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk538155/ 2. arcaro mj, thaler l, quinlan dj, monaco s, khan s, valyear kf, et al. psychophysical and neuroimaging responses to moving stimuli in a patient with the riddoch phenomenon due to bilateral visual cortex lesions. neuropsychologia. 2019; 128: 150-165. doi: 10.1016/j.neuropsychologia.2018.05.008. 3. sincich lc, park kf, wohlgemuth mj, horton jc. bypassing v1: a direct geniculate input to area mt. nat neurosci. 2004; 7: 1123-1128.10.1038/nn1318. 4. barleben m, stoppel cm, kaufmann j, merkel c, wecke t, goertler m, et al. neural correlates of visual motion processing without awareness in patients with striate cortex and pulvinar lesions. hum brain mapp. 2015; 36 (4): 1585-1594. doi: 10.1002/hbm.22725. 5. menon gj, rahman i, menon sj, dutton gn. complex visual hallucinations in the visually impaired: the charles bonnet syndrome. surv ophthalmol. 2003; 48: 58-72. 10.1016/s0039-6257(02)00414-9. 6. kwong yew k, abdul halim s, liza-sharmini at, tharakan j. recurrent bilateral occipital infarct with cortical blindness and anton syndrome. case rep ophthalmol med. 2014; 2014: 795837 7. kim n, anbarasan d, howard j. anton syndrome as a result of ms exacerbation. neurol clin pract. 2017; 7 (2): e19-e22. 8. misra m, rath s, mohanty ab. anton syndrome and cortical blindness due to bilateral occipital infarction. indian j ophthalmol. 1989; 37: 196. authors’ designation and contribution khalid mehmood; assistant professor: concepts, literature search, manuscript preparation, manuscript review. sabeen khalid; senior registrar: design, data acquisition, manuscript review. nauman ismat butt; senior registrar: design, data acquisition, manuscript review. fahmina ashfaq; assistant professor: concepts, literature search, manuscript review. aniqa anser khan; assistant professor: data acquisition, manuscript review. .…  …. https://www.ncbi.nlm.nih.gov/books/nbk538155/ pak j ophthalmol. 2021, vol. 37 (1): 43-47 43 original article corneal endothelial cell density and retinal nerve fiber layer in primary open angle glaucoma, normal tension glaucoma and ocular hypertension bakht samar khan 1 , abid nawaz 2 , lyla shami 3 , zubaida irshad 4 , mansoor ahmad 5 1,3,5 khyber teaching hospital, 2 kabir medical college, 4 hayatabad medical complex, peshawar abstract purpose: to compare the corneal endothelial cell density (ced) and retinal nerve fiber layer thickness (rnfl) in primary open angle glaucoma (poag), normal tension glaucoma (ntg) and ocular hypertension (oht). study design: cross sectional observational study. place and duration of study: khyber teaching hospital, peshawar, from april 2016 to march 2018. methods: patients having a single iop reading of 21 mm hg or more with glaucomatous cupping, visual field defect and open angle were labeled as poag. patients with iop less than 21 mm hg with same findings were labeled as ntg. those eyes with raised iop (more than 21 mm hg), normal visual field and optic disc were labeled as oht. corneal endothelial cell count, central corneal thickness and retinal nerve fiber layer (rnfl) thickness were measured in patients of poag, ntg and oht. these were compared with normal age matched values. results: thirty eyes with poag, 10 with oht and 10 with ntg were included in the study. in patients with poag there was 13.33% ced and 27.7% mean rnfl thickness loss. in patients with ntg there was 3.06% ced and 34.04% mean rnfl thickness loss. in patients with oht there was 7.17% ced and 5.5% mean rnfl thickness loss. conclusion: the loss of both rnfl thickness and ced occurs in poag, oht and ntg. severe loss of rnfl thickness occurs in poag and ntg while severe loss of ced occurs in poag and oht. mild loss of rnfl thickness occurs in oht while mild loss of ced occurs in ntg. key words: specular microscopy, optical coherence tomography, nerve fiber layer, open angle glaucoma, ocular hypertension. how to cite this article: khan bs, nawaz a, shami l, irshad z, ahmad m. corneal endothelial cell density and retinal nerve fiber layer in primary open angle glaucoma, normal tension glaucoma and ocular hypertension. pak j ophthalmol. 2021, 37 (1): 43-47. doi: https://doi.org/10.36351/pjo.v37i1.1062 correspondence: bakht samar khan department of ophthalmology khyber teaching hospital peshawar email: bestbakht@yahoo.com received: may 4, 2020 accepted: august 19, 2020 introduction glaucoma is a progressive optic neuropathy associated with transient or permanent rise of iop leading to visual field defects or even blindness. glaucoma is a multi-factorial disease in which there is progressive degeneration of retinal ganglion cells along with their axons. the proposed theories of glaucomatous damage are ischemic, mechanical and neurotoxin related. glaucomatous optic neuropathy with physiological iop was labeled as low tension glaucoma (ltg) by bakht samar khan, et al 44 pak j ophthalmol. 2021, vol. 37 (1): 43-47 voncraft in 19 th century. 1 within the spectrum of poag, a physiological iop has been classified as normal tension glaucoma (ntg), or low tension glaucoma (ltg). 2,3 ntg is the most accurate terminology used for these types of glaucoma. oct and scanning laser modalities have confirmed thinning of the peri-papillary choroid as well as thinning of ganglion cell layer in ntg as compared to normal eyes. 4,5 the term ocular hypertension (oht) was used by chandler pa and drance in 1962. this was defined by perkins and others in 1966 as a condition with the following criteria; 6 iop greater than 21 mm hg on two or more occasions, normal vf, optic disc and rnfl, normal open angle, absence of ocular conditions contributing to a rise in the iop e.g. uveitis and neovascular conditions. the terms ocular hypertension, glaucoma suspect and pre-glaucoma were used by jhonson td and zimmerman tj. 7 whatever is the mechanism of glaucoma, its effects will be on all ocular tissues especially on corneal endothelium, optic nerve head and retinal nerve fiber layer. normally 0.6% of corneal endothelial cell density is lost per year from age 15 years onwards. 8 normal endothelial cell count in the sub-continent population is 2408 ± 274 cell/mm 2 , while in japanese it is 3749 ± 407 cell/mm 2 at the age of 40 years and above. with specular microscope, the examination of corneal endothelial cell density is possible in detail. at birth, the endothelial cell count is between 4000-5000 cells/mm 2 . with age there is a decline in the cell count; at the age of 40 and above it comes down to 20003000 cells/mm 2 . endothelial cell count below 500 cells/mm 2 poses a risk for corneal endothelial dysfunction. 8 in glaucoma, the corneal endothelial cell density (ced) is affected directly by the high iop or by congenital anomaly of endothelium or by antiglaucoma medication toxicity. 9,10 there are anatomical and functional changes. the anatomical changes appear before the functional changes. early diagnosis relies on detecting the anatomical changes. the analysis of these structural changes is facilitated by color fundus images and optical coherence tomography (oct). these give us qualitative and quantitative information about optic nerve and rnfl in glaucoma. 11 a normal non-glaucomatous eye has rnfl thickness of 80 microns or greater, whereas 70-79 microns thickness of rnlf is suspicious while 60-69 microns thickness is glaucomatous in 95% of cases. normally the neuro retinal rim of optic nerve head is comparatively thickest inferiorly and thinnest temporally. when the optic nerve does not follow this rule, it may have glaucomatous damage 12 but it may not be very effective in detection of early glaucoma. 13 the aim of this study was to find the relationship between loss of corneal endothelium and retinal nerve fiber layer in open angle glaucoma, normal tension glaucoma and ocular hypertension. methods this prospective study included 50 eyes, 30 with poag, 10 eyes with ntg and 10 eyes diagnosed with oht. we used specular microscopy to find out the corneal endothelial status. to determine the thickness of rnfl, oct was performed. the results were compared with normal age-matched database. specular microscopy was performed to see status of corneal endothelial cells with non-contact instrument (konan medical, hyogo, japan). several photographs were taken and only clear ones were selected for interpretation of ced. endothelial cells were analyzed by the dot method, in which the sites of approximately 30 – 80 contiguous cells were marked. ultrasonic pachymetry was performed for central corneal thickness. iop phasing was done at 6 hour intervals with goldman applanation tonometer. a single iop reading of 21 mm hg or more with glaucomatous cupping, visual field defect and open angle were labeled as poag. patients with iop of 21 mm hg or less, with glaucomatous cupping, visual field defect and open angle were labeled as ntg. the eyes with raised iop (more than 21 mm hg), normal visual field and optic disc were labeled as oht. oct of optic disc and rnfl were performed on all patients. the findings were compared with normal age-matched controls (table 1). corneal endothelial cell density and retinal nerve fiber layer in poag, ntg and oht pak j ophthalmol. 2021, vol. 37 (1): 43-47 45 table 1: specular microscopy and oct findings. specular microscopy mean corneal endothelial cell count (cells/mm 2 ) mean rnfl thickness (oct) (in µm) patients normal data base loss %age patients normal data base loss %age open angle glaucoma 2320 (n = 30) 2677 13.33% 65 (n = 30) 90 27.7% normal tension glaucoma 2595 (n = 10) 2677 3.06% 59 (n = 10) 90 34.4% ocular hypertension 2485 (n = 10) 2677 7.17% 85 (n = 10) 90 5.5% discussion the two important non regenerative structures in eye are corneal endothelium (ce) and rnfl. corneal endothelial cell loss and decreased rnfl has been reported by raised iop in poag and oht. several studies have been conducted employing specular microscopy to examine the ced separately in either poag or oht or ntg. no reliable study was found to have examined ced and retinal nerve fiber layer (rnfl) loss in poag, oht and ntg together. association of corneal endothelial cell loss with poag, ntg and oht has been reported in literature. 9 other studies have also reported lower ced in ntg eyes. 10 the association between raised iop and endothelial cell loss has been reported by cho sw et al, 14 where the mean ced was 2696.7 ± 303.9 cells/mm 2 in ntg, 2370.5 ± 392.3 cells/mm 2 in poag and 2723.6 ± 300.6 cells/mm 2 in the normal age matched population. while this shows a significantly lower ced in eyes with poag than in ntg, it also indicates a loss of ced in ntg as compared to the normal group. in our study the ced was 2595 cells/mm 2 in ntg as compared to 2677 cells/mm 2 in the normal age group. this shows a loss of 3.06%. similar results were reported in other studies. 15,16 in ntg/ltg, optic neuropathy and endothelial cell loss or damage has been reported by lee et al. in their study the endothelial cell count was significantly lower in ntg vs poag (2380 ± 315.4 vs 2530 ± 320.4). 17 changes and decrease in corneal endothelial cell density in poag have been reported in other studies. 18,19 knorr et al. reported a 31% reduction of ced in poag. 20 urban et al in their study found that the ced was significantly lower in eyes with poag, being 2639.5 cells/mm 2 as compared with 2924.5 cells/mm 2 in oht and 2955 cells/mm 2 in the control group. 21 in the study of prasannakumary et al, the mean ced in poag patients was significantly lower (2211.13 ± 171.49 cells/mm 2 in right eye, 2198.20 ± 154.39 cells/mm 2 in left eye) compared to control group (2417.43 ± 116.92 in right eye and 2390.18 ± 101.31 cells/mm2 in left eye). 22 this study is similar to our poag findings. all these studies confirm the loss of ced in poag and oht. the hypothesis for corneal endothelial damage in glaucoma and ocular hypertension is that it is brought about by elevated iop and medication induced toxicity. 22 as far as loss of thickness of rnfl is concerned, it has been reported with raised iop. interestingly thin rnfl has been reported in ocular hypertensive eyes with thinner corneas, whereas ocular hypertensive eyes with thick and normal cornea had normal nerve fiber layer thickness. 16 asymmetry in intra ocular pressure in the two eyes of the same patients with ntg resulted in more thinning of the rnfl in eyes with the higher iop. in the study by tarek et al the mean rnfl thickness was 97.2 ± 9.24 um in healthy subjects, while it was thinner being 60.2 ± 15.9 um in poag eyes. 23 this is comparable to our study where it was 65 um in poag. in the study of gyatsho at et al, oct detected rnfl thickness differences in poag, oht and normal age matched controls. the findings were thinner rnfl in oht eyes than normal while thinner rnfl in poag eyes than oht eyes. 24 in a study by christopher et al, the mean rnfl thickness was 72.8 um in oht eyes compared to normal eyes, which was 85 um. this observation shows thinner rnfl in oht eyes. further findings of his study were that rnfl was thinner in the inferior quadrant, 84.8 um versus 107.6 um, while in the nasal quadrant it was 44 um versus 61.8 um respectively. in the same study, rnfl thickness was less in glaucomatous eyes than in oht and normal eyes in all quadrants. 25 in our study the mean rnfl thickness in oht was 85 um compared with 90 um in the normal eyes. many studies including our study confirm the loss of rnfl thickness in open angle glaucoma and oht. based on the findings of this study our observation is bakht samar khan, et al 46 pak j ophthalmol. 2021, vol. 37 (1): 43-47 that in poag, oht and in ntg both the vital tissues i.e., the corneal endothelium and the nerve fiber layer are affected. the mechanism may be raised iop, ischemia and toxins in ocular fluids. limitation of this study was small sample size. large population and multiple centered studies are needed to get a complete picture of these characteristics in a particular region. conclusion the loss of both rnfl thickness and ced occurs in poag, oht and ntg. severe loss of rnfl thickness occurs in poag and ntg while severe loss of ced occurs in poag and oht. mild loss of rnfl thickness occurs in oht while mild loss of ced occurs in ntg. ethical approval the study was approved by the institutional review board/ ethical review board. (994/adr/kmc) conflict of interest authors declared no conflict of interest. references 1. lee bl, bathija rnw. the definition of normal tension glaucoma. j glaucoma. 1998; 7 (6): 366-371. 2. levene rz. low tension glaucoma part ii clinical characteristic and pathogenesis ann ophthalmol. 1980; 12 (12): 1383. 3. trivli a, koliarakis i, terzidou c, goulielmos gn, siganos cs, spandidos da, et al. normal-tension glaucoma: pathogenesis and genetics (review). exp ther med. 2019; 17 (1): 563-574. https://doi.org/10.3892/etm.2018.7011 4. hirooka k, tenkumo k, fujiwara a, baba t, sato s, shiraga f. evaluation of peripapillary choridal thickness in patients with ntg bmc ophthalmol. 2012; 12: 29. 5. firat pg, ozsoy e, demirel s, cumurcu t, gunduz a. evaluation of peripapillary retinal nerve fiber layer, macula and ganglion cell thickness in amblyopia using spectral optical coherence tomography. int j ophthalmol. 2013; 6 (1): 90–94. doi.org/10.3980/j.issn.2222-3959.2013.01.19 6. chandler pa, grant wm. ocular hypertension vs open angle glaucoma. arch. ophthalmol. 1977; 95 (4): 585-586. 7. jhonson td, zimmerman t. ocular hypertension, glaucoma suspect, preglaucoma or glaucoma. synopsis of view. ann ophthalmol. 1986; 18 (11): 313-314. 8. celebi arc, mirza ge. age related change in retinal nerve fiber layer thickness measured with spectral domain optical coherence tomography. invest ophthalmol vis sci. 2013; 54: 8095-8103. 9. gagnon mm, boisjoly hm, brunette i, charest m, amyot m. corneal endothelial cell density in glaucoma. cornea. 1997; 16: 314–318. 10. higa a, sakai h, sawaguchis s, iwase a, tomidokoro a, amano s, et al. corneal endothelial cell density and associated factor in a population study in japan: the kumejama study. am j ophthalmol. 2010; 149: 794-799. 11. badala f, nouri-mahdavi k, reoof da, lew sk, caprioli s. optic disc and nfl imaging to detect glaucoma. am j ophthalmol. 2007; 144 (5): 724-732 12. chan ew, liao jiemin, wong r, luon sc, aung t, wong ty, et al. diagnostic performance of the isnt rule for glaucoma based on the heidelberg retinal tomograph. transl visc sci technol. 2013; 2 (5): 2. 13. moon j, park kh, kim dm, kim sh. factors affecting isnt rule satisfaction in normal and glaucomatous eyes. korean j ophthalmol 2018; 32 (1): 38-44. 14. cho sw, kim jm, choicy, parl kh. change in corneal endothelial cell density in patients with ntc – jpn. ophthalmol. 2009; 53: 569-573. 15. gugleta k, flammer j. asymmetry in intraocular pressure and retinal nerve fiber layer thickness in normal tension glaucoma. ophthalmologica. 1999; 213 (4): 219-223. 16. henderson pa, medeiros fa, zangwill lm, weinreb rn. relationship between central corneal thickness and rnl thickness in ocular hypertension patients. ophthalmology, 2005; 112 (2): 251-256. 17. lee jwy, wong rlm, chan jch, wong iyh, lai jm. differences in corneal parameters between normal tension glaucoma and primary open angle glaucoma. int ophthalmol. 2015; 35 (i): 67-72. 18. sihota r, lakshmaiah c, titiyal js, dada t, agarwal hc. corneal endothelial status in the subtypes of primary angle closure glaucoma. clin exp ophthalmol. 2003; 31: 492–495. 19. korey m, gieser d, kass ma, waltman sr, gordon m, becker b. central corneal endothelial cell density and central corneal thickness in ocular hypertension and primary open-angle glaucoma. am j ophthalmol. 1982; 94: 610–616. 20. knorr hl, händel a, naumann go. morphometric and qualitative changes in corneal endothelium in primary chronic open angle glaucoma. fortschr ophthalmol. 1991; 88: 118–120. https://www.ncbi.nlm.nih.gov/pubmed/?term=fujiwara%20a%5bauthor%5d&cauthor=true&cauthor_uid=22839368 https://www.ncbi.nlm.nih.gov/pubmed/?term=baba%20t%5bauthor%5d&cauthor=true&cauthor_uid=22839368 https://www.ncbi.nlm.nih.gov/pubmed/?term=sato%20s%5bauthor%5d&cauthor=true&cauthor_uid=22839368 https://www.ncbi.nlm.nih.gov/pubmed/?term=shiraga%20f%5bauthor%5d&cauthor=true&cauthor_uid=22839368 https://pubmed.ncbi.nlm.nih.gov/?term=iwase+a&cauthor_id=20231011 https://pubmed.ncbi.nlm.nih.gov/?term=tomidokoro+a&cauthor_id=20231011 https://pubmed.ncbi.nlm.nih.gov/?term=amano+s&cauthor_id=20231011 https://pubmed.ncbi.nlm.nih.gov/?term=waltman+sr&cauthor_id=7148942 https://pubmed.ncbi.nlm.nih.gov/?term=gordon+m&cauthor_id=7148942 https://pubmed.ncbi.nlm.nih.gov/?term=becker+b&cauthor_id=7148942 corneal endothelial cell density and retinal nerve fiber layer in poag, ntg and oht pak j ophthalmol. 2021, vol. 37 (1): 43-47 47 21. urban b, bakunowicz-łazarczyk a, michalczuk m, krętowska m. evaluation of corneal endothelium in adolescents with juvenile glaucoma. j ophthalmol. 2015; 2015: 895428. 22. prasannakumary c, ragi tk, raju kv. corneal endothelial cell changes in poag & its relation with severity of field defect. jmed sci clin res. 2017; 5 (5): 22339-22343. 23. tarek a, kaidi w, fei y, field mg, lee h, baniasadi n, et al. correlation of retinal nerve fiber layer thickness and vf in glaucoma. a broken stick model. am j ophthalmol. 2014; 157 (5): 953-959. 24. gyatsho j, kaushik s, gupta a, pandav ss, ram j. retinal nfl thickness is normal, ocular hypertensive and glaucomatous in indian eyes. an optical coharent tomography study. j glaucoma. 2008; 17 (2): 122-127. 25. christopher b, robert nw, julia mw. the rnfl thickness in oh, normal and glaucomatous eye with oct. arch ophthalmol. 2000; 118 (1): 22-26. authors’ designation and contribution bakht samar khan; associate professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation. abid nawaz; literature search, data analysis, statistical analysis, manuscript review. lyla shamim; medical officer: literature search, data acquisition. zubaida irshad; assistant professor: literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing. mansoor ahmad; senior house officer: literature search, data acquisition, manuscript editing. .…  …. https://pubmed.ncbi.nlm.nih.gov/?term=field+mg&cauthor_id=24487047 https://pubmed.ncbi.nlm.nih.gov/?term=lee+h&cauthor_id=24487047 https://pubmed.ncbi.nlm.nih.gov/?term=baniasadi+n&cauthor_id=24487047 https://pubmed.ncbi.nlm.nih.gov/?term=pandav+ss&cauthor_id=18344758 https://pubmed.ncbi.nlm.nih.gov/?term=ram+j&cauthor_id=18344758 blindness due to glaucoma ahmad i, khan bs 58 pak j ophthalmol. 2022, vol. 38 (1): 58-62 original article angle recession in patients with closed globe injury mohammad farhan 1 , omar illyas 2 , mubashir rehman 3 , jawad humayun 4 , adnan ahmad 5 1,3,4,5 nowshera medical college, nowshera, 2 gajju khan medical college, swabi abstract purpose: to determine the frequency of angle recession following closed globe injury in patients presenting to the department of ophthalmology of a tertiary care hospital of pakistan. study design: descriptive observational study. place and duration of study: study was conducted at eye-a unit, hayatabad medical complex, peshawar from 14 th march 2017 to 14 th sept 2017. methods: one hundred and sixty three patients were selected for this study after applying who sample size calculation formula. patients with history of closed globe injury were recruited through consecutive sampling technique. a detailed history regarding trauma, causative agent, duration of injury and site of impact was taken. ocular examination including visual acuity and detailed examination of both anterior and posterior segment was carried out using slit lamp biomicroscope. gonioscopy was performed to check the presence and extent of angle recession. results: mean age was 33 ± 8.82 years. seventy five percent patients were male and 25% female. type of trauma included; 57 (35%) patients had road traffic accidents, 33 (20%) patients had stone injuries, 37 (23%) patients had sports injuries while 36 (22%) patients had eye trauma due to other types like fall, fight, glass injuries, chemical exposures etc. in 90 (55%) patients, right eye was affected while 73 (45%) patients had trauma in left eye. duration of trauma was ≤ 2 days in 124 (76%) patients while mean duration was 1 day with sd ± 1.034. conclusion: frequency of angle recession was 28% following closed globe injury. key words: angle recession, closed globe injury, ocular trauma. how to cite this article: farhan m, illyas o, rehman m, humayun j, ahmad a. angle recession in patients with closed globe injury. pak j ophthalmol. 2022, 38 (1): 58-62. doi: 10.36351/pjo.v38i1.1248 correspondence: mubashir rehman department of ophthalmology nowshera medical college nowshera email: drmubashirrehman78@gmail.com received: march 31, 2021 revised: july 28, 2021 accepted: december 12, 2021 introduction ocular trauma is one of the important causes of preventable blindness globally. 1 eighteen million people worldwide have uniocular blindness from traumatic injury. 2 in the united states, there are approximately 2.5 million cases of eye trauma every year, resulting in approximately 50000 people who suffer from partial or complete loss of vision. in addition, the rates at which eye injuries require hospitalization are in the range of 4.9-89 per 10 million in developing countries. 3 open access angle recession in patients with closed globe injury pak j ophthalmol. 2022, vol. 38 (1): 58-62 59 blunt trauma forms a major part of ocular trauma. squash balls, elastic luggage straps, falls and champagne corks are the most common causes of blunt ocular trauma. 4 blunt ocular trauma or ocular contusions cause an antero-posterior compression of the globe and elongation of the equatorial area. both anterior and posterior segment structures may be influenced by this rapid deformation of ocular tissues. cornea, iris, lens and zonules are the most affected tissues from trauma as they are vulnerable to acute deformation. 5 hyphema, glaucoma, angle recession, iris deformities, cataract, and lens luxation or subluxation are reported complications of ocular contusion. 6 angle recession is a common result of blunt trauma. as contact with the globe occurs, anterior-toposterior compression forces the aqueous laterally, stressing the limbus. the longitudinal fibers of the ciliary muscle become separated from the circular fibers. this can also shear small vessels of the anterior ciliary arteries, leading to hyphema. 7 the incidence of angle recession after eye trauma ranges from 20 to 94%. 8 patients with traumatic angle recession are prone to develop angle recession glaucoma. the possibility of developing glaucoma in an eye with angle recession appears to be related to the extent of angle recession. if more than 180° of the anterior chamber angle is involved, there is a greater chance of subsequent development of glaucoma. 8 anterior chamber angle recession has been reported to be the most common sign of previous blunt trauma to the eye. a patient who has experienced blunt ocular trauma needs a comprehensive eye examination for the presence of angle recession and other abnormalities. 9 as angle-recession glaucoma can occur even many years after trauma, patients should receive adequate counselling, and follow-up examinations should be performed regularly. this study will give us a magnitude of angle recession following closed globe injury in our setup, which can help in early diagnosis of angle recession glaucoma in future. methods the total sample size was 163 by using who sample size calculator, based on 14.6% prevalence of angle recession after blunt ocular trauma where confidence level = 95, absolute precision = 5% and population proportion (p) = 14.6%. consecutive (non-probability) sampling technique was used for sample selection. all patients presenting with closed globe injury (diagnosed on clinical examination), with duration of less than 01 week and intensity mild to severe were selected. age ranged from 18 to 60 years. patients of either gender were included in the study. noncooperative patients, patients not willing to be part of the study and those having corneal opacity obscuring angle view (on the basis of clinical examination) were excluded from the study. closed globe injury was defined as trauma to eyeball in which the corneoscleral wall of the globe was intact. closed globe injuries were further classified on the basis of visual acuity on initial examination as mild when initial visual acuity was equal to or greater than 6/12, moderate when initial visual acuity was greater than 3/60 but less than 6/12 and severe when the initial visual acuity was less than 3/60. angle recession was considered as variable degree of cleavage between circular and longitudinal fibres of the ciliary muscle seen on gonioscopy. the purpose and benefits of the study was explained to the patients/attendants and written informed consent was obtained from each patient. a data collection proforma was filled for each patient having a detailed record of the disease including age, gender and laterality. a detailed history regarding trauma, causative agent, duration of injury and site of impact was noted. ocular examination including visual acuity and detailed examination of both anterior and posterior segment was carried out using slit lamp. gonioscopy was performed to check the presence and extent of angle recession. all the analysis was done in spss version 20.0. frequencies and percentages were calculated for categorical variables like gender, type of trauma, laterality and angle recession. mean ± standard deviation was computed for numeric variable like age and duration of trauma. angle recession was stratified among age, gender, laterality, type of trauma and duration of trauma to see effect modifications. post stratification chi square test was applied keeping p-value <0.05 as significant. all the results were presented in the form of tables and charts. results in this study, mean age was 33 ± 8.821 years. sixty five (40%) patients were 20-30 years of age, 54 (33%) mubashir rehman, et al 60 pak j ophthalmol. 2022, vol. 38 (1): 58-62 patients were in the age range of 31 – 40 years, 33 (20%) patients were between 41 – 50 years and 11 (7%) patients were 51 – 60 years. there were 122 (75%) males and 41 (25%) females. ninety (55%) patients had trauma in right eye while 73 (45%) patients had trauma in left eye. duration of trauma was ≤ 2 days in 124 (76%) patients and 39 (24%) patients had duration of trauma of > 2 days. mean duration was 1 day with sd ± 1.034. road traffic accident was the cause of trauma in 57 (35%) patients, 33 (20%) patients had stone injuries, 37 (23%) patients had sports injuries while 36 (22%) patients had eye trauma due to other causes; e.g. fall, fight, glass injuries, chemical exposures etc. forty six (28%) patients had angle recession while 117 (72%) patients did not have angle recession. stratification of angle recession with age, type of trauma and duration of trauma is given in tables 1, 2 and 3. table 1: stratification of angle recession with respect to age distribution (n = 163). angle recession 20 – 30 years 31 – 40 years 41 – 50 years 51 – 60 years total yes 18 15 9 4 46 no 47 39 24 7 117 total 65 54 33 11 163 chi square test was applied in which p value was 0.9425 table 2: stratification of angle recession with respect to duration of trauma (n = 163). angle recession ≤ 2 days > 2 days total yes 35 11 46 no 89 28 117 total 124 39 163 chi square test was applied in which p value was 0.9980 table 3: stratification of angle recession with respect to type of trauma (n = 163). angle recession rta injuries stone injuries sports injuries other injuries total yes 16 9 11 10 46 no 41 24 26 26 117 total 57 33 37 36 163 chi square test was applied in which p value was 0.9961 discussion our study shows that the mean age was 33 years with sd ± 8.821. the frequency of angle recession was found to be 28% following closed globe injury. in a study done in central india, it was seen that out of a total of 220 cases of trauma, mean age was 8.74 ± 3.93 years, males were predominantly affected and open globe injuries outnumbered blunt injuries. 10 another researcher reported cricket-related ocular injuries. his results showed that these injuries had poor prognosis with most cases being closed globe injuries with retinal detachment. angle recession was seen in 18% cases in his series. 11 it has been reported that among patients who experience traumatic angle recession, 5% to 20% will develop glaucomatous optic neuropathy. 12 literature shows that no difference was seen between the incidences of angle-recession glaucoma when comparing hyphema versus microhyphema. 13 a study conducted by kaur s, et al 14 showed that the incidence of angle recession after eye trauma ranged from 20 to 94%. according to one study, a total of 5 to 20% of patients with traumatic angle recession would go on to develop glaucoma. 15 a very low incidence of only 79% is reported by other author, which is quite less than our results. 16 the possibility of developing glaucoma in an eye with angle recession appears to be related to the extent of angle recession. 17 on examination, if there is presence of increased pigmentation at the angle, raised iop, blood in anterior chamber, subluxation of lens, and angle recession of more than 180 degrees , there are chances that it will lead to chronic glaucoma after closed globe injury. ubm findings include a wider angle and the absence of cyclodialysis cleft. 18 if more than 180° of the anterior chamber angle is involved, there is a greater chance of subsequently developing glaucoma. 19 similar findings were observed in another study conducted by salmon jf et al 20 in which anterior chamber angle recession had been reported to be the most common sign of previous blunt trauma to the eye. the prevalence of post-traumatic angle recession in that report was 14.6%. limitation of the study is that it lacks long term follow up which is a mandatory part of examination of a patient with blunt ocular trauma. further longitudinal studies are required for this purpose. conclusion our study concludes that the frequency of angle recession was 28% following closed globe injury. angle recession in patients with closed globe injury pak j ophthalmol. 2022, vol. 38 (1): 58-62 61 patients with blunt trauma need long term follow up which should include gonioscopy as a mandatory part of examination. ethical approval the study was approved by the institutional review board/ethical review board (227/hec/b&psc/2016). conflict of interest authors declared no conflict of interest. refrences 1. osman ea, al-fawaz n, al-otaibi ag, almansouri sm, mousa a, al-mezaine hs. glaucoma after open globe injury at a tertiary care university hospital in central saudi arabia. saudi med j 2012; 33 (4): 374-378. 2. abbott j, shah p. the epidemiology and etiology of pediatric ocular trauma. surv ophthalmol. 2013; 58 (5): 476-485. 3. qi y, zhang fy, peng gh, zhu y, wan gm, wang wz, et al. characteristics and visual outcomes of patients hospitalized for ocular trauma in central china: 2006-2011. int j ophthalmol. 2015; 8 (1): 162-168. 4. pai sg, kamath sj, d'souza s, dudeja l. a clinical study of blunt ocular trauma in a tertiary care centre. online j health allied scs. 2013; 12 (2): 10. 5. firat pg, doganay s, cumurcu t, demirel s, kutukde d. anterior segment complications in ocular contusion. j trauma treatment, 2011; 1: 101. 6. puodžiuvienė e, jokūbauskienė g, vieversytė m, asselineau k. a five-year retrospective study of the epidemiological characteristics and visual outcomes of pediatric ocular trauma. bmc ophthalmol. 2018; 18: 10. 7. paciuc m, dalma-weiszhausz j, phan r, smits d, velez-montoya r. trauma: anterior segment injuries. american academy of ophthalmology. nov. 2015. 8. kaur s, kaushik s, pandav ss. traumatic glaucoma in children. j curr glaucoma pract. 2014; 8 (2): 58–62. 9. herschler j. trabecular damage due to blunt anterior segment injury and its relationship to traumatic glaucoma. trans sect ophthalmol am acad ophthalmol otolaryngol. 1977; 83 (2): 239-248. pmid: 406709. 10. singh s, sharma b, kumar k, dubey a, ahirwar k. epidemiology, clinical profile and factors, predicting final visual outcome of pediatric ocular trauma in a tertiary eye care center of central india. indian j ophthalmol. 2017; 65: 1192–1197. 11. mahapatra sk, malhotra k, mendke rg. a 3-year prospective study on ocular injuries with tennis or cricket ball while playing cricket: a case series. indian j ophthalmol. 2018; 66: 256–261. 12. nguyen qh. clinical approach to angle-recession glaucoma. early diagnosis and the aggressive management of elevated iop after blunt trauma are essential. glaucoma today, 2012: 37-38. 13. ng ds, ching rh, chan cw. angle-recession glaucoma: long-term clinical outcomes over a 10-year period in traumatic microhyphema. int ophthalmol. 2015; 35 (1): 107-13. doi: 10.1007/s10792-014-00275. epub 2014 dec 18. pmid: 25520267. 14. kaur s, kaushik s, pandav ss. traumatic glaucoma in children. j curr glaucoma pract. 2014; 8 (2): 58–62. 15. kalamkar c, mukherjee a. incidence, clinical profile, and short-term outcomes of post-traumatic glaucoma in pediatric eyes. indian j ophthalmol. 2019; 67 (4): 509–514. 16. razeghinejad r, lin mm, lee d, katz lj, myers js. pathophysiology and management of glaucoma and ocular hypertension related to trauma. surv ophthalmol. 2020; 65 (5): 530-547. 17. mokbel th, el hefney em, hagras sm, al nagdy aa, badawi ae, kasem ma, et al. childhood glaucoma profile in dakahelia, egypt: a retrospective study. int j ophthalmol. 2018; 11 (4): 674–680. 18. sihota r, kumar s, gupta v, dada t, kashyap s, insan r, et al. early predictors of traumatic glaucoma after closed globe injury: trabecular pigmentation, widened angle recess, and higher baseline intraocular pressure. arch ophthalmol. 2008; 126 (7): 921-926. doi: 10.1001/archopht.126.7.921. pmid: 18625937. 19. mansoori t, reddy aa, balakrishna n. identification and quantitative assessment of schlemm's canal in the eyes with 360° angle recession glaucoma. j curr glaucoma pract. 2020; 14 (1): 25–29. 20. salmon jf, mermoud a, ivey a, swanevelder sa, hoffman m. the detection of post-traumatic angle recession by gonioscopy in a population-based glaucoma survey. ophthalmology, 1994; 101 (11): 1844-1850. author’s designation and contribution mohammad farhan; senior registrar: concepts, design, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. omar ilyas; medical officer: concepts, design, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. mubashir rehman; associate professor: concepts, design, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. https://www.ncbi.nlm.nih.gov/pubmed/?term=kalamkar%20c%5bauthor%5d&cauthor=true&cauthor_uid=30900584 https://www.ncbi.nlm.nih.gov/pubmed/?term=mukherjee%20a%5bauthor%5d&cauthor=true&cauthor_uid=30900584 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6446624/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5902376/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5902376/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5902376/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5902376/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7302608/ mubashir rehman, et al 62 pak j ophthalmol. 2022, vol. 38 (1): 58-62 jawad humayun; junior registrar: literature search, manuscript review. adnan ahmad; assistant professor: literature search, manuscript review. .…  …. original article pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 20 original article accuracy of iop measured by non-contact (air – puff) tonometer compared with goldmann applanation tonometer javied ahmad, muhammad rizwan khan, muhammad naeem azhar, tariq mahmood arain, zaheer-ud-din aqil qazi pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: javied ahmad eye unit 2 bvh, bahawalpur …..……………………….. purpose: to determine the frequency of accuracy of intraocular pressure (iop) measured by non-contact (air puff) tonometer compared with goldmann applanation tonometer. material and methods: this comparative study was done from april 2011 to september 2011, 286 patients between 10 to 72 years of age, both male and females coming to eye opd for refraction and ocular examination included. selected patients were explained and after informed consent; intraocular pressure was taken by consultant ophthalmologist with goldmann applanation tonometer (haag – streit at900) and air puff tonometer (keeler pt100) between 8 am to 1 pm. results: air puff tonometer had an overall accuracy of 49.70% to measure intraocular pressure within ± 2 mm hg difference compared with goldmann applanation tonometer. air puff tonometer is more accurate at low pressure range, 54.40% at 10 – 20 mm hg and accuracy decreases at higher pressure range, 20% at 51 – 60 mm hg. at all ranges of intraocular pressures air puff tonometer measured higher (mean 2.87 mm hg) values than goldmann applanation tonometer. conclusion: airpuff tonometer is quick, a non-contact method to measure intraocular pressure and is useful for screening purposes but the measurements should be confirmed with goldmann applanation tonometer for accurate labelling of intraocular pressure. ntraocular pressure (iop) is one of the most important parameters in the diagnosis and treatment of glaucoma1. glaucoma has been established as the second leading cause of blindness. the treatment of glaucoma focuses mainly on lowering intraocular pressure (iop). the target iop is often set to a level 20% to 30% of iop reduction, and consequent large iop reduction beyond 30% or even 40% in cases of advanced glaucoma2. the different methods of tonometery are: goldman applanation tonometery, noncontact (air-puff) tonometery, perkins tonometery, tonopen tonometery, transpalpebral tonometery3. goldmann applanation tonometer is the method of choice in the optometric and ophthalmological clinical settings. based on imbert-fick principle, the goldmann tonometer assesses the intraocular pressure by measuring the force necessary to applanate a fixed area of cornea3. air puff tonometry is based on the principle of applanation, the central part of cornea is flattened by a jet of air to measure the level of iop5. the main advantages of non-contact tonometers are that they are i javied ahmad, et al 21 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology non-invasive and thus comfortable for the patient with a minimal risk of infection. the performance of noncontact tonometery and the interpretation of results are easier than with goldmann tonometery. therefore, iop screening with non-contact tonometer can be delegated by ophthalmic assistants3. the purpose of this study was to evaluate the difference, if any, between iop measurements taken by a goldman applanation tonometer and those taken by an air puff tonometer material and methods from april 2011 to september 2011 this comparative study was done, 286 patients between 10 to 72 years of age, both male and females coming to eye opd for refraction and ocular examination included. a complete history was taken from the patients and a thorough ocular examination was done on all selected patients. patients who have corneal opacity or disfigured cornea, corneal ulceration or inflammation, conjunctivitis or ocular infection, corneal dystrophy, corneal degeneration, keratoconus and pterygium were excluded. selected patients were explained and after informed consent; two readings of intraocular pressure were taken by consultant ophthalmologist with goldmann applanation tonometer (haag – streit at900) and air puff tonometer (keeler pt100) each, between 8 am to 1 pm. data analysis all the data was computer based and spss version 10 was used for analysis. mean and standard deviation were computed for quantitative variables like age and intraocular pressure readings. frequencies and %age were computed for categorical variables like sex, accuracy of air puff tonometer to measure iop in stratified ranges of iop. effect modifiers like age and genders were controlled by stratification to observe the effect on outcome of accuracy of air puff tonometer. all the data was presented in the form of tables 1, 2 and 3. results in this study, 286 patients; 148 male and 138 female patients were included. the mean ± sd age was 42.965 ± 16.304 years with range of age was 10 years to maximum 72 years. the mean ± sd intraocular pressures were 19.692 ± 9.952 mm hg with goldmann accuracy of iop measured by non-contact (air – puff) tonometer compared with goldmann applanation pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 22 applanation tonometer as shown in table 2 and 22.562 ± 10.355 with air-puff tonometer as shown in table 1. the range of measurement was 10 to 54 mm hg with goldmann applanation tonometer and 11 to 58 mm hg with air-puff tonometer. the frequency of accuracy of air – puff tonometer within limit of ± 2 mm hg from goldmann applanation tonometer was stratified over different ranges of intraocular pressure as 10-20 mm hg, 21 – 30 mm hg, 31 – 40 mm hg, 41 – 50 mm hg and 51 – 60 mm hg. the overall frequency of accuracy of air-puff tonometer was found to be 49.70%. this frequency of accuracy of air-puff tonometer was different in different ranges of intraocular pressure as shown in table 3. it was most accurate 54.40% in normal range of intraocular pressure i.e. 10 to 20 mm hg and accuracy decreased with increasing range of intraocular pressure. the accuracy was only 20% at 51 to 60 mm hg range of intraocular pressure. the frequency of accuracy of air-puff tonometer was checked over different stratified ranges of age and found no specific pattern of accuracy with age as shown in table 3. discussion more recently, the development of noncontact tonometers has simplified iop screening. goldmann applanation tonometer and air puff (i.e., noncontact) tonometers are the most common devices for measuring iop in daily practice. air puff tonometers are easier to use and are more convenient, for both the patient and the examiner, than gat. the gat is currently the most widely used instrument for measuring iop4, and is considered the ‘gold standard’5. various studies have been done to assess the accuracy of air puff tonometers in the past. a study conducted by salim s et al6 to compare the measurements by the portable, noncontact tonometer with goldmann applanation tonometry. a total of 98 eyes were examined for iop. the results showed the mean ± sd intraocular pressure measurements were 15.98 ± 5.48 mm hg and 15.65 ± 4.26 mm hg for the pt100 and gat, respectively. the range of measurements by gat was from 4 to 29 mm hg and by pt100 was 7 to 33 mm hg. the frequency of measurements by the two tonometers that were in agreement by ≤ 3 mm hg was 92.8%. the drawbacks of this study were limited number of subjects and the most of the measurements were made in normal range of iop. in this study the air puff tonometer consistently overestimated iop than goldmann applanation tonometer that was also shown in other studies7. in contrast some studies have shown that air puff tonomaters returned lower values relative to goldmann tonometer. yet the other studies8 conclude that the air puff tonometers overestimated at normal range of iop and underestimated at high iops relative to goldmann applanation tonometer. in this study the accuracy of air puff tonometer was higher 54.40% in normal range of iop 10-20 mm hg but the accuracy progressively decreased at higher ranges of iop. conclusion air puff tonometer is quick, a non-contact method to measure intraocular pressure and is useful for screening purposes but the measurements should be confirmed with goldmann applanation tonometer for accurate labelling of intraocular pressure. author’s affiliation dr. javied ahmad medical officer bahawal victoria hospital, bahawalpur dr. muhammad rizwan khan medical officer bahawal victoria hospital, bahawalpur dr. muhammad naeem azhar ophthalmologist lrbt free eye hospital, lahore dr. tariq mahmood arain associate professor of ophthalmology bvh bahawalpur dr. zaheer-ud-din aqil qazi chief consultant lrbt free eye hospital, lahore references 1. wells ap, garway-heath df, poostchi a, wong t, chan kc, sachdev n. corneal hysteresis but not corneal thickness correlates with optic nerve surface compliance in glaucoma patients. invest ophthalmol vis sci. 2008; 49: 3262-8. 2. cheng jw, cheng sw, goa ld, lu gc, weo rl. intraocular lowering effects of commonly used fixed-combination drugs with timolol. a systemic review and meta-analysis. plos one 2012; 7 (9): e4 5079. 3. lee aj, rochtchina e, wang jj, schneider j. does smoking effects intraocular pressure, findings of blue mountains study. j glaucoma. 2003; 12: 212. 4. chihara e. assessment of true intraocular pressure: the gap between theory and practical data, surv ophthalmol 2008; 53 (3): 203-18. http://www.ncbi.nlm.nih.gov/pubmed?term=wells%20ap%5bauthor%5d&cauthor=true&cauthor_uid=18316697 http://www.ncbi.nlm.nih.gov/pubmed?term=garway-heath%20df%5bauthor%5d&cauthor=true&cauthor_uid=18316697 http://www.ncbi.nlm.nih.gov/pubmed?term=poostchi%20a%5bauthor%5d&cauthor=true&cauthor_uid=18316697 http://www.ncbi.nlm.nih.gov/pubmed?term=wong%20t%5bauthor%5d&cauthor=true&cauthor_uid=18316697 http://www.ncbi.nlm.nih.gov/pubmed?term=chan%20kc%5bauthor%5d&cauthor=true&cauthor_uid=18316697 http://www.ncbi.nlm.nih.gov/pubmed?term=sachdev%20n%5bauthor%5d&cauthor=true&cauthor_uid=18316697 javied ahmad, et al 23 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology 5. almubrad tm, ogbuehi kc. the effect of repeated applanation on subsequent iop measurements. clin exp optom 2008; 91: 524-9. 6. salim s, linn dj, echols jr, netland pa. comparison of intraocular pressure measurement with the portable pt-100 non-contact tonometer and goldmann applanation tonometry. clin ophthalmol. 2009; 3: 342-4 7. yaoeda k, shirakashi m, fukushima a, funaki s, funaki h, ofuchi n, nakatsue t, abe h. measurement of intraocular pressure using the nt-4000: a new non-contact tonometer equipped with pulse synchronous measurement function. j glaucoma. 2005; 14: 201-5. 8. tonnu pa, ho t, sharma k, white e, bunce c, garwayheath d. a comparison of four methods of tonometry: method agreement and interobserver variability. br j ophthalmol. 2005; 89: 847-50. 182 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology short communication bilateral moorens ulcer tarun sood, mandeep tomar, anuj sharma, ravinder k. gupta pak j ophthalmol 2016, vol. 32 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tarun sood m.s. ophthalmology (igmc shimla) eye surgeon civil hospital sarkaghat himachal pardesh, india e.mail: tarunsood_86@yahoo.co.in ..………………………………. a 36 year old male presented with chief complaints of foreign body sensation watering, redness, diminished vision ocular pain and photophobia in both eyes for last 2 months, on examination right eye revealed a perforated mooren ulcer with uveal tissue herniation at 4 – 5 o’clock position. in both eyes, an undermined overhanging edge with grey white opacification and extending centrally and circumferentially could be appreciated. no hypopyon or ac cells could be discovered on examination, a diagnosis of bilateral mooren’s ulcer was made and systemic immunosuppressive therapy was started in terms of oral methotrexate 10 mg once a week and oral prednisone 1 mg / kg / day, bandage contact lens was applied in right eye and conjunctival recession was performed. key words: moorens ulcer, peripheral ulcerative keratitis lcus rodens corneae or mooren's ulcer has been described as an agonizing, unrelenting, unabating ulcerative keratitis that initiates from peripheral cornea and then enlarges circumferentially and centrally. if primarily location of ulcer is at the periphery of the cornea and there is no separation, it becomes an indicator to investigate for collagen vascular diseases. the general ophthalmologist needs to be meticulous if the peripheral corneal disease has the following characteristics: if the epithelium is not intact, if there is some loss of stroma, if it is a real keratitis and inflammation is present, if white blood cells have infiltrated into the peripheral cornea. the fact to keep in mind is that puk is a diagnosis of exclusion. a 36 year old male presented with chief complaints of foreign body sensation watering, redness, diminished vision ocular pain and photophobia in both eyes for last 2 months. the symptoms were pronounced od with excruciating pain since last two weeks. no history of ocular or systemic disease however could be elicited. ocular examination revealed a visual acuity of 6/9 od and 6/6 os. ocular examination demonstrated a 360 degree circumferential zone of scarring and ectasia of the right cornea but no associated scleritis. scarring and neovascularization encroached upon but did not obscure visual axis. 360 degree circumferential area of scarring and ectasia of cornea was also present in left eye. on examination right eye revealed a perforated mooren ulcer with uveal tissue herniation at 4-5 o’clock position. in both eyes, an undermined overhanging edge with grey white opacification and extending centrally and circumferentially could be appreciated. the pupil revealed peaking nasally od due to impending uveal tissue herniation. no hypopyon or ac cells could be discovered on examination. dilated indirect ophthalmoscopy revealed no abnormality. there was no history of trauma or joint pain or systemic disease. circumcorneal congestion was present. extraocular movements were full ou. posterior segment examination in both eyes was inconclusive. a battery of investigations was conducted which included – complete heamogram with esr, x-ray chest and small joints, urine routine and microscopy, vdrl, ra factor, anca (antinuclear cytoplasmic antibodies), ana (antinuclear antibodies), hbsag (hepatitis b surface antigen), sgpt, hcv (hepatitis c virus). scraping of the ulcer were done, which was inconclusive. finally a diagnosis of bilateral mooren’s u mailto:tarunsood_86@yahoo.co.in bilateral moorens ulcer pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 183 fig. 1: 360 degree circumferential zone of scarring and ectasia of the left cornea. fig. 2: 360 degree circumferential zone of scarring and thinning of right cornea but no associated scleritis with perforation at 4 -5 oclock, partially epithelised. ulcer was made and systemic immunosuppressive therapy was started in terms of oral methotrexate 10 mg once a week and oral prednisone 1 mg / kg / day. bandage contact lens was applied in right eye and conjunctival recession was performed. discussion mooren's ulcer also known as chronic serpiginous ulcer of cornea has been defined as an entity with cascade of unknown events existing in absolute absence of any ocular infection or systemic rhematological diseases accountable for the ongoing devastation of the cornea. it has been recognized as an immensely destructive corneal lesion starting from corneal periphery and spreading centrally centrifugally and posteriorly. absence of scleritis is of substantial importance. precise pathophysiology still remains unknown, although evidences suggest cell mediated and humoral immune mechanisms as a basis of pathogenesis. though many modern approaches have been devised in step approach management of moorens ulcer, notable amount of cases are recalcitrant to accessible treatments and end in severe visual morbidity. presenting complaints in mooren's ulcer usually are redness, epiphora, and photophobia, but excruciating agony out of proportion to inflammation is typically the prominent feature. related iritis, central corneal involvement and irregular astigmatism due to peripheral corneal ectasia may lead to decreased visual acuity. the disease begins with many variegated, peripheral stromal infiltrates that merge later on, more frequently in the medial and lateral quadrants than in the superior and inferior ones. this is followed by formation of epithelial defect and a shallow furrow in this area1. involvement of anterior one-third to one-half of the stroma occurs typically with a sloping, overhanging edge. this is followed by healing and vascularization with the lesion gradually taking its course in 4 – 18 months. iritis, glaucoma, cataract and very rarely hypopyon are associated with moorens ulcer2. the ulceration encompasses corneal periphery leaving a central island of oedematous opacified cornea else progresses transversely and relentlessly replaces stroma with thin scar tissue. corneal perforation is a much common occurrence in mu leading to visual morbidity. the adjacent scleral and dm tissue is largerly spared3. on the basis of clinical presentation and the lowdose anterior segment fluorescein angiographic findings, mooren's ulcer has been classified into three main types: unilateral mooren's ulcer is usually recognized as excessively painful progressive keratitis in elder age group in this variety of mu superficial vascular plexus of the anterior segment remains nonperfused. bilateral aggressive mooren's ulceration (bam), clinical entity more frequent in young individuals, progresses circumferentially and, only later, centrally in the cornea. angiography shows tarun sood, et al 184 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology vascular leakage and new vessel formation at the base of the ulcer. bilateral indolent mooren's ulceration (bim) common in middle-age group patients results in progressive peripheral corneal guttering in both eyes, with minimal inflammatory response. vascular architecture is usually normal on angiography with an exception that extension of new vessels into the ulcer may be noted4,5. if one uses a fine instrument to explore the ulcer, one will find that it has an overhanging lip; if this fine instrument is exploring the ulcer toward the center of the cornea, one can be absolutely astonished at how far into the cornea the instrument can go before it meets resistance. in other words, there's a lot more destruction than is clinically apparent at the slit lamp. the systemic evaluation should not discover that the patient has an elevated c-reactive protein, an elevated sedimentation rate, auto-antibody production of any type but particularly antineutrophil cytoplasmic antibody." moorens ulcer has been linked with different systemic entities including toxoplasma, hepatitis b and c, herpes simplex and zoster, syphilis, tb and intestinal hookworm1,2 histopathology of mooren’s ulcer reveals increased number of antigen-presenting cells, mast cells and immunoglobulins6. bilateral mooren’s ulcer as seen in our case is frequently found in indian subcontinent and in patches of west africa. the age group most commonly involved is 14 – 40. they may present with unilateral typical lesion in one eye but soon may develop lesion in the other eye. angiography reveals altered architecture of episcleral vessels along with some areas of closure. there are no changes in conjunctiva but the angiogram reflects a breakup of the limbal arcade, extension of the vessels into the ulcer bed and leaky vessel tips. this variety has a tendency to perforate spontaneously and if not paid attention can lead to significant visual morbidity7. conclusion bilateral mooren’s ulcer in young population needs to be given an immediate attention as visual morbidity remains significant in this variety. only if the aggressive systemic evaluation turns out inconclusive and the adjacent sclera is not involved, it's appropriate to hang the label mooren's ulcer. aggressive systemic immunomodulatory medication is absolute if cause of patient's puk is discovered to be a consequence of polyarteritis nodosa or microscopic polyangiitis and granulomatosis with polyangiitis. author’s affiliation dr. tarun sood m.s. ophthalmology (igmc shimla) eye surgeon civil hospital sarkaghat himachal pardesh, india dr. mandeep tomar registrar rpgmc tanda himachal pardesh deptt of ophthalmology dr. anuj sharma md dermatology zonal hospital, bilaspur himachal pardesh dr. ravinder k gupta prof. and head ms ophthalmology igmc shimla role of authors dr. tarun sood diagnosis and managing the case. dr. mandeep tomar managing the case and photography. dr. anuj sharma managing the case and editing the final write–up. dr. ravinder k gupta managing the case and editing the final write–up. references 1. frangieh t, kenyon k. mooren's ulcer. in: brightbill fs, ed. corneal surgery: theory, technique, and tissue, ed 2. st louis: mosby, 1993: 328-335. 2. keitzman b. mooren's ulcer in nigeria. am j ophthalmol. 1968; 65: 679-685. 3. muthaiah srinivasanmichael e zegans joseph r zelefsky. clinical characteristics of mooren’s ulcer in south india. british journal of ophthalmology, 91 (5): 570-5. https://www.researchgate.net/researcher/39289608_muthaiah_srinivasan https://www.researchgate.net/researcher/39289608_muthaiah_srinivasan https://www.researchgate.net/profile/joseph_zelefsky https://www.researchgate.net/profile/joseph_zelefsky https://www.researchgate.net/profile/joseph_zelefsky bilateral moorens ulcer pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 185 4. watson pg. management of mooren's ulceration. eye 1997; 11: 349–356. 5. lewallen s, courtright p. problems with current concepts of the epidemiology of mooren's corneal ulcer. ann ophthalmol. 1990; 22: 52-55. 6. foster cs. mooren’s ulcer following salmonella gastroenteritis. massachusetts eye and ear infirmary immunology service, 1999. 7. keitzman b. moorens ulcer in nigeria. am j ophthalmol. 1986; 65: 679-85. 315 pak j ophthalmol. 2020, vol. 36 (4): 315-317 guest editorial assisted reproductive technology and retinopathy of prematurity raazia tanveer 1 , imrana abid 2 1,2 department of gynecology, madinat zayed hospital, abu dhabi. uae the first pregnancy as a result of in vitro fertilization (ivf) in humans was reported in 1976 and later in 1978, the first ivf baby was born. 1 since then, millions of pregnancies have occurred worldwide by ivf and other modifications of this technology. all these procedures are commonly termed assisted reproductive technology or art. the most common techniques are; intracytoplasmic sperm injection (icsi), zygote intra-fallopian transfer (zift) and gamete intra-fallopian transfer (gift). with more and more experience and advancement in technology, the success rates of art have increased. not only that, the indications for these procedures have also changed. research in this field is complicated by the need to distinguish between the effects of art on outcomes in offspring versus multiple other confounding or mediating factors. furthermore, these outcomes are influenced by technological changes in the performance of art, as well as changes in obstetric and neonatal care, over time. art related pregnancies very often result in multiple pregnancies, which are more prone to result in preterm labour. it was reported that in the united states, multiple pregnancies mostly occur as a result of infertility treatments. 2 the preterm birth rate ranges from 5 percent in parts of europe to 18 percent in africa. it was also reported that approximately 15 million pre-term children are born every year. 3,4 the risk of preterm delivery is higher for multiple pregnancies compared with singletons and it increases how to cite this article: tanveer r, abid i. editorial: assisted reproductive technology and retinopathy of prematurity. pak j ophthalmol. 2020; 36 (4): 315-317. doi: https://doi.org/10.36351/pjo.v36i4.1130 correspondence: imrana abid specialist obgy at madinat zayed hospital abu dhabi. uae email: imranaabid@yahoo.com with each additional infant. in 2013, the incidence of prematurity in the united states was 57, 93, 96, and 100 percent for twins, triplets, quadruplets, and quintuplets, respectively. 5,6 similarly, the incidence of very low birth weight (vlbw) infants (birth weight < 1500 g) rose as the number of infants increased; 10, 37, 67, and 88 percent for twins, triplets, quadruplets, and quintuplets and higher order multiples, if an infant is born before 37 completed weeks (less than 259 days) of gestation, it is termed as premature birth. mortality rate of infants born at or before 25 weeks of gestation is quite high. even if they manage to survive, there is a huge risk of complications including retinopathy of prematurity. 6 one classification based upon birth weight (bw) includes the following categories: ● low birth weight (lbw) – bw less than 2500 g. ● very low birth weight (vlbw) – bw less than 1500 g. ● extremely low birth weight (elbw) – bw less than 1000 g. prematurity is also defined by gestational age (ga) as follows: ● late preterm infants – ga between 34 weeks and 36 weeks and 6 days. ● moderate preterm infants – ga between 32 weeks and 33 weeks and 6 days. ● very preterm (vpt) infants – ga at or below 32 weeks. ● extremely preterm (ept) infants – ga at or below 28 weeks. preterm infants are at risk for developing short and long-term complications that result from anatomic or functional immaturity during the neonatal period. with decreasing gestational age (ga) and birth weight (bw), chances of complications of prematurity increase which definitely includes retinopathy of mailto:imranaabid@yahoo.com editorial: assisted reproductive technology and retinopathy of prematurity pak j ophthalmol. 2020, vol. 36 (4): 315-317 316 prematurity (rop). rop is a retinal pathology, which occurs as a result of premature retina, post-natal hyperoxia and later retinal ischemia. the lesser the gestational age, greater is the incidence and severity of rop. although the disease may be experienced as early as 30 to 32 weeks, it typically begins at 34 weeks postmenstrual age (pma). rop progresses until 40 to 45 weeks pma and may subsequently resolve in majority of the infants. 7 it is less commonly seen in infants with birth weight more than 1500 g and/or gestational age greater than 32 weeks. however, different geographical areas have varying data regarding its prevalence. the severity of rop leading to blindness is more in infants of birthweight less than 1000 g. the environment is relatively hyperoxic to the premature infant after birth, even if there is no supplemental oxygen. the choroidal circulation is not auto-regulated in response to changes, which occur in oxygen saturation after birth. as hyperoxia occurs, more oxygen is diffused from choroid to the retina. retinal vessels constrict in response to high oxygen. when the eyeball size increases, there is increased demand of oxygen leading to hypoxia and formation of vascular endothelial growth factors. free radicals, which are formed from oxygen, also play some role in pathogenesis of rop. rop may regress even without treatment. this may occur at any stage of the disease. there can be resultant impairment of vision after regression. if the disease progresses, there are many treatment options which depend upon the stage of the disease at which the diagnosis is made. earlier the treatment, better are the results. the main idea behind early treatment is to destroy the ischemic retina. at later and advanced stages, retinal surgery may be the answer. 8 regressed rop may present with strabismus, amblyopia, myopia and retarded ocular growth. in different types of art, a strong relationship of rop was seen with ivf. in a meta-analysis, it was found that art was more commonly associated with stage 3 rop. 9 another report showed that rop in cases of art infants was seen even in the heavier newborns. these studies indicated that there may be a need for re-evaluation of the screening protocols. 10 although art has changed the lives of many people, it has increased the burden on neonatologist and ophthalmologists with all types of complications related to prematurity in multiple births. in the last 20 to 25 years, there have been vast improvements in art and neonatal intensive care, which has resulted in increased survival of most of the immature infants. there are specialized centers, which provide high‐risk obstetric care, intensive neonatal care, use of steroids in the prenatal care, improved postnatal treatment with surfactant and nitric oxide and better respirators and advanced equipment for the care of extremely immature infants. all these have contributed to improved survival. therefore, current changes in neonatal care warrant careful ongoing evaluation during the coming years regarding rop. references 1. steptoe pc, edwards rg. birth after the reimplantation of a human embryo. lancet, 1978; 2: 366. 2. ory sj. the national epidemic of multiple pregnancy and the contribution of assisted reproductive technology. fertil steril. 2013; 100: 929. 3. who, march of dimes, partnership for maternal, newborn & child health, save children. born too soon: the global action report on preterm birth. available at: www.who.int/maternal_child_adolescent/documents/bo rn_too_soon/en/ (accessed on may 04, 2020). 4. national vital statistics reports. births: final data for 2018. 2019; 68 (13). available at https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_13_ tables-508.pdf (accessed on january 16, 2020). 5. roberts we, morrison jc, hamer c, wiser wl. the incidence of preterm labor and specific risk factors. obstet gynecol. 1990; 76: 85s. 6. bodeau-livinec f, zeitlin j, blondel b, arnaud c, fresson j, a, et al. do very preterm twins and singletons differ in their neurodevelopment at 5 years of age? arch dis child fetal neonatal ed. 2013; 98 (6): f480-487. 7. trifonova k, slaveykov k, mumdzhiev h, dzhelebov d. artificial reproductive technology – a risk factor for retinopathy of prematurity. open access maced j med sci. 2018; 6 (11): 2245–2249. doi: 10.3889/oamjms.2018.448. 8. connolly bp, ng ey, mcnamara ja, regillo cd, vander jf, tasman w. a comparison of laser photocoagulation with cryotherapy for threshold retinopathy of prematurity at 10 years: part 2. refractive outcome. ophthalmology, 2002; 109: 936– 941. 9. wheatley cm, dickinson jl, mackey da, craig je, sale mm. retinopathy of prematurity: recent advances in our understanding. br j ophthalmol. 2002; 86: 696– 700. https://www.uptodate.com/contents/pregnancy-outcome-after-assisted-reproductive-technology/abstract/2 https://www.uptodate.com/contents/pregnancy-outcome-after-assisted-reproductive-technology/abstract/2 https://www.uptodate.com/contents/pregnancy-outcome-after-assisted-reproductive-technology/abstract/4 https://www.uptodate.com/contents/pregnancy-outcome-after-assisted-reproductive-technology/abstract/4 https://www.uptodate.com/contents/pregnancy-outcome-after-assisted-reproductive-technology/abstract/4 https://www.uptodate.com/contents/neonatal-complications-outcome-and-management-of-multiple-births/abstract/11 https://www.uptodate.com/contents/neonatal-complications-outcome-and-management-of-multiple-births/abstract/11 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https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6290440/ https://dx.doi.org/10.3889%2foamjms.2018.448 raazia tanveer, et al 317 pak j ophthalmol. 2020, vol. 36 (4): 315-317 10. gao l, shao w, li na, tian c, jia h, peng x, et al. the risk of retinopathy of prematurity in the infants following assisted reproductive technology: a metaanalysis. biomed res int. 2019; 2019: 2095730. doi: 10.1155/2019/2095730. .…  …. https://www.ncbi.nlm.nih.gov/pubmed/?term=gao%20l%5bauthor%5d&cauthor=true&cauthor_uid=31380413 https://www.ncbi.nlm.nih.gov/pubmed/?term=shao%20w%5bauthor%5d&cauthor=true&cauthor_uid=31380413 https://www.ncbi.nlm.nih.gov/pubmed/?term=li%20n%5bauthor%5d&cauthor=true&cauthor_uid=31380413 https://www.ncbi.nlm.nih.gov/pubmed/?term=tian%20c%5bauthor%5d&cauthor=true&cauthor_uid=31380413 https://www.ncbi.nlm.nih.gov/pubmed/?term=jia%20h%5bauthor%5d&cauthor=true&cauthor_uid=31380413 https://www.ncbi.nlm.nih.gov/pubmed/?term=peng%20x%5bauthor%5d&cauthor=true&cauthor_uid=31380413 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6657639/ https://dx.doi.org/10.1155%2f2019%2f2095730 pak j ophthalmol. 2021, vol. 37 (2): 168-172 168 original article comparison of ac/a ratio in true and simulated divergence excess exotropia sana sagheer 1 , muhammad ali haider 2 , attaullah shah bukhari 3 , uzma sattar 4 , iftikhar ahmed 5 1,2,4,5 punjab rangers teaching hospital/rahbar medical & dental college, lahore 3 khairpur medical college, khairpur mirs abstract purpose: to compare the accommodation convergence per accommodation ratio (ac/a) in true and simulated divergence excess exotropia. study design: comparative cross sectional study. place and duration of study: department of ophthalmology, punjab rangers teaching hospital, lahore, from july 2019 to december 2019. methods: the study included 20 patients each of intermittent exotropia (xt) true and simulated divergence excess exotropia (xt).all the subjects underwent complete orthoptic assessmentthat included ac/a ratio calculation through heterophoria method after monocular occlusion. results: the results showed that patients with true divergence excess exotropia have a high ac/a ratio as compared to patients with simulated divergence excess exotropia who have a normal ac/a ratio. 57% patients showed true divergence excess exotropia with high ac/a ratio while 43% had divergence excess with normal ac/a ratio. conclusion: the response of ac/a was found to be higher in patients with true divergence excess exotropia after monocular occlusion. key words: intermittent exotropia, true simulated divergence excess exotropia, simulated divergence excess exotropia. how to cite this article: sagheer s, haider ma, bukhari as, sattar u, ahmed i. comparison of ac/a ratio in true and simulated divergence excess exotropia. pak j ophthalmol. 2021, 37 (2): 168-172. doi: http://doi.org/10.36351/pjo.v37i2.1192 introduction the control of squint depends upon different factors such as the distance of fixation fatigue, bright light, concentration and ill health. 1 in intermittent exotropia, eyes remain straight with binocular single vision at correspondence: muhammad ali haider department of ophthalmology, rahbar medical & dental college, lahore email: alihaider_189@yahoo.com received: january 3, 2021 accepted: february 14, 2021 some times and manifest suppression at other times. presentation is usually around age of 2 years with exophoria which breaks down to tropia under above mentioned circumstances. 2 in distance exotropia, deviation of eyes is greater at distance then near and increases further beyond 6 meters. it is further classified into two as true divergence excess exotropia and simulated divergence excess exotropia. 3 in true divergence excess exotropia the distance deviation is greater than near deviation before and after patch test. the difference of distance and near is almost 10 prism diopters. in cases of simulated divergence excess exotropia, the near deviation equals distance deviation after patch test of 30 minutes. 4 patch test differentiate between true divergence and http://doi.org/10.3352/jeehp.2013.10.3 mailto:alihaider_189@yahoo.com sana sagheer, et al 169 pak j ophthalmol. 2021, vol. 37 (2): 168-172 simulated divergence excess exotropia. monocular occlusion eliminates the tenacious proximal fusion. 5 all the cases of divergence excess exotropia donot have true divergence excess exotropia.monocular occlusion of 30 to 60 minutes reveals large deviation at near in cases of simulated divergence exotropia. 6 when a patient shows large deviation at near after monocular occlusion test it is called tenacious proximal fusion and when a patient shows a small deviation after prolonged patch test this is called high ac/a ratio. but when patients show same amount of deviation after patch of 3d lenses, it is called proximal convergence, which is true convergence excess. 7 ac/a ratio are the amount of accommodative convergence induced by each diopters of accommodation exerted and is measured in prism diopters. normal range of ac/a ratio is 2-4. the relationship of ac/a ratio is fixed and remains unchanged from childhood till the age of presbyopia. the ac/a ratio can be modified permanently by surgery of the extra ocular muscles and temporarily by drugs and lenses. 8 different methods are used to measure ac/a ratio; heterophoria method, gradient method, fixation disparity method and graphical method. most common method is heterophoria method in which a prism cover test is performed for distance and near fixation .inter-pupillary distance is measured. a positive sign is used for esotropia and negative sign is used for exotropia. ac/a ratio = ipd (in cm) + near pct – distance pct amount of accom. exerted the patch test is used to control the tonic fusional convergence to differentiate pseudo-divergence excess from true divergence excess and to reduce the angle variability. contrary to the earlier practice of patching one eye for 24 hours, it is now found that patching the eye for 30 minutes is sufficient to suspend the tonic fusional convergence and thus reveals the actual amount of deviation. 9 comparison of distance and near deviation is important part of evaluation in strabismus. in majority of esotropic patients, the difference of distance and near deviation shows a normal linkage of convergence and accommodation and this relation can be explained by ac/a ratio. in cases of intermittent exotropia it is different because many are slow to dissipate proximal fusion mechanism which prevents them from manifesting true near deviation during a brief cover test. 10 if a patch test is not performed in cases of intermittent exotropia before surgery they may develop cyclic esotropia with high ac/a ratio. 11 rationale of the study was to compare the accommodative convergence per unit accommodation ratio (ac/a) in true and simulated divergence excess exotropia in pakistani patients. methods in this analytical, comparative cross sectional study, patients with divergence excess exotropia presenting in the orthoptics clinic of ophthalmology department of punjab rangers teaching hospital, rahbar medical and dental college were enrolled. patients with constant and basic type of deviations were excluded. the minimum age chosen for study was 5 years and maximum 30 years to ensure maximum cooperation. examination included visual acuity (va) record by using log mar chart.va was recorded in adults using alphabets. in young children using picture charts and in illiterates with tumbling e chart. all the subjects underwent complete orthoptic assessment and cycloplegic refraction when required. ac/a ratio were calculated using heterophoria method. for all measurements, patient and observer were at same eye level with good room illumination. for distance measurements, patient was seated at 6meters. fixation target at log mar chart was 2 lines above the best corrected visual acuity to maintain accurate fixation. patient was asked to fixate at a distant target and prism was placed in front of deviated eye. alternate prism cover test was performed. prism power was increased until there was no movement of eyes to take up fixation. amount of deviation at distance was calculated. a patch test of 30 minutes was performed in each patient. one eye was occluded for half an hour, deviation was measured again for near and any change in deviation was noted. inter-pupillary distance was measured by instructing the patient to see straight ahead.ac/a ratio was calculated by formula described above. all the collected data was noted and analyzed by using spss 22 version. results ac/a ratio was high in true divergence excess exotropia (28.21%) and normal in simulated divergence excess exotropia (13.19%) table 1. table 2 shows that there was significant difference between true and pseudo divergence excess exotropia. ac/a ratio was normal in cases of simulated divergence comparison of ac/a ratio in true and simulated divergence excess exotropia pak j ophthalmol. 2021, vol. 37 (2): 168-172 170 table 1: group statistics. type of deviation n mean std. deviation std. error mean accommodative convergence /accommodation true divergence excess 23 11.0739 1.93537 0.40355 simulated 17 5.1765 0.24630 0.05974 interpupillary distance true divergence excess 23 5.3913 0.47569 0.09919 simulated divergence excess 17 5.1765 0.24630 0.05974 table 2: independent samples test. levene's test for equality of variances t-test for equality of means f sig. t df sig. (2-tailed) mean difference std. error difference 95% confidence interval of the difference lower upper ac/a equal variances assumed 15.910 0.000 12.448 38 0.000 5.89744 0.47377 4.93835 6.85654 equal variances not assumed 14.456 22.959 0.000 5.89744 0.40795 5.05345 6.74143 inter-pupillary distance equal variances assumed 30.268 0.000 1.698 38 0.098 .21483 0.12655 -0.04136 0.47102 equal variances not assumed 1.855 34.595 0.072 .21483 0.11579 -0.02033 0.44999 excess exotropia and high ac/a ratio was recorded in true divergence excess exotropia. (t = 12.448, df 38, p = 0.000). this graph shows that most of the patients of true and simulated divergence excess exotropia were myopic or without refractive errors. thirty percent of patients were myopic in true divergence excess exotropia and 17.50% were myopic in simulated. in both groups 20% to 25% were emmetrope. discussion the study was designed to differentiate the cases of true divergence excess exotropia from simulated divergence excess exotropia by performing a patch test and measuring ac/a ratio by herterophoria method. apparently both types of cases show high ac/a (accommodative convergence per unit accommodation) ratio prior to patch test but post monocular occlusion test the results are different.patch test reveals the real amount of deviation at near. 12 it is generally believed that ac/a ratio was found higher in divergence excess exotropia type. over 75% of patient have increase in near deviation after patch test and decrease in calculated ac/a ratio. 13 by using standard methods, cooper and coworkers calculated ac/a in patients of intermittent exotropia. patient first underwent a monocular occlusion of one hour for measurement of actual near deviation. 14,15 if the patient had high ac/a ratio before occlusion test but had normal ac/a ratio after monocular occlusion test they described these cases as pseudo high ac/a ratio. if tenacious proximal fusion sana sagheer, et al 171 pak j ophthalmol. 2021, vol. 37 (2): 168-172 was not suspended, the near measurements were contaminated in patients of exotropia. 16,17 in addition to the factors enumerated by scobee to explain this phenomenon, we believe that extremely active convergence tonus during childhood may be a factor in obscuring the exodeviation at near fixation. this mechanism enables patients with a basic deviation to keep their eyes aligned for near vision but not for distance vision, where convergence is less active. momentary disruption of fusion by alternately covering each eye rapidly in prism cover test or alternate cover test is not enough to break the compensatory mechanism that have been developed in years. kushner introduced the term "tenacious proximal fusion" for the persistent convergence innervation that hides the exodeviation at near fixation. this term seems awkward and does not add to the clarification of the issue. the term "convergence aftereffect" is a more appropriate description of this phenomenon. 18,19 in another study which was conducted to evaluate the diagnostic method of divergence excess exotropia, 237 patients were evaluated. they were divided into two groups according to their response to monocular occlusion and the use of +3.00 diopters add at near. they observed that in ten patients there was increase in deviation in both tests. they considered these cases as simulated divergence excess exotropia and ten patients who did not respond to monocular occlusion and remained unchanged, these were the true divergence excess exotropia patients. 20 to review the multiple factors responsible for the discrepancy in distance and near deviation, two clinical tests (occlusion test and +3.00 diopter lens) were described. patients with intermittent exotropia usually have more deviation at distance as compared to near, and these cases have high ac/a ratio after occlusion of one eye and with the use of +3.00 spheres at near. 18 conclusion the response of ac/a was found to be higher in patients with true divergence excess exotropia after monocular occlusion. ethical approval the study was approved by the institutional review board/ethical review board. 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convergence to accommodation ratio after surgery for intermittent exotropia. int ophthalmol.2017; 37 (4): 1069-1072. 12. han jm, yang hk, hwang j. efficacy of diagnostic monocular occlusion in revealing the maximum angle of exodeviation. br j ophthalmol. 2014; 98 (11): 1570-1574. comparison of ac/a ratio in true and simulated divergence excess exotropia pak j ophthalmol. 2021, vol. 37 (2): 168-172 172 13. le t, koklanis k, georgievski z. the fixation target influences the near deviation and ac/a ratio in intermittent exotropia. j aapos. 2010; 14 (1): 25-30. 14. cooper j, medow n. intermittent exotropia basic and divergence excess type. binocular vision eye muscle surg q. 1993; 8 (3): 185-216. 15. niederker ow. the value of diagnostic occlusion for intermittent exotropia. am orthopt j. 1974; 24: 69-72. 16. khawam e, zein w, haddad w, haddad c, allam s. intermittent exotropia with high ac/a ratio is it a bane to surgical cure? some facts and fictions of the two clinical tests: occlusion of one eye and the use of +3.00 spherical lenses. binocul vis strabismus. 2003; 18 (4): 209-216. 17. arnoldi ka, reynolds jd. diagnosis of pseudodivergence excess exotropia secondary to high accommodative convergence to accommodation ratio. am orthopt j. 2006; 56 (1): 133-137. 18. zhang kk, koklanis k, georgievski z. exotropia. a review of the natural history and non-surgical treatment outcomes. aus orthopt j. 2007; 39 (1): 3137. 19. frantz ka. the importance of multiple treatment modalities in a case of divergence excess. j am optom assoc. 1990; 61 (6): 457-462. 20. daum km. divergence excess: characteristics and results of treatment with orthoptics. ophthalmic physiol opt. 1984; 4 (1): 15-24. authors’ designation and contribution sana sagheer; orthoptist: concepts, design, literature search, data acquisition, data analysis, manuscript review. muhammad ali haider; assistant professor: literature search, manuscript preparation, manuscript editing, manuscript review. attaullah shah bukhari: assistant professor: data analysis, statistical analysis, manuscript review. uzma sattar; investigative occulist: manuscript editing, manuscript review. iftikhar ahmed; professor: manuscript editing, manuscript review. .…  …. microsoft word 10. usama rahim pak j ophthalmol. 2022, vol. 38 (4): 271-274 271 original article frequency of dry eyes after cataract surgery and effect of gender, duration of cataract and age on dry eye symptoms after phacoemulsification usama rahim1, syed abdullah mazhar2, nazish mazhar ali3, nabeel iqbal4, moneeb tariq5 1,2,4,5layton rahmatulla benevolent trust (lrbt), 3government college university (gc), lahore abstract purpose: to determine the frequency of dry eyes in patients after cataract surgery and to find out the effect of gender, duration of cataract and age on dry eye symptoms after phacoemulsification. study design: descriptive observational study. place and duration of study: layton rehmatulla benevolent trust free eye and cancer hospital, lahore from october 2015 to april 2016. methods: one hundred and twenty patients between 40-80 years of age and suffering from cataract were included. past medical history and current medical information was recorded. to control bias, only one experienced surgeon carried out the procedures. follow-up was done at 1st post-operative day, one week, one month and 3 months. tear film break up time was noted at each visit. quantitative variables like age and tear film break-up time (tbut) were presented as mean ± sd. the qualitative variables were presented as frequency and percentages. data was stratified according to age, gender and duration of cataract. post-stratification chi-square test was applied and p-value ≤0.05 was considered significant. results: out of 120 patients, there were 47 (39%) males and 73 (61%) females. a total of 35 (29.2%) patients had dry eyes. mean age was 59.11 ± 12.358 years while mean tbut was 11.27 ± 2.582 seconds. there was no relation of dry eye with gender, duration of cataract and different age groups (p > 0.05). conclusion: frequency of dry eyes after cataract surgery was 29.2% (n = 35). there was no effect of gender, duration of cataract and age of the patient on the post-operative tbut after phacoemulsification. key words: cataract, tbut, phacoemulsification, dry eye disease. how to cite this article: rahim u, iqbal n, mazhar sa, ali nm, tariq m. frequency of dry eyes after cataract surgery and effect of gender, duration of cataract and age on dry eye symptoms after phacoemulsification. pak j ophthalmol. 2022, 38 (4): 271-274. doi: 10.36351/pjo.v38i4.1378 correspondence: syed abdullah mazhar layton rahmatulla benevolent trust (lrbt), lahore email: abdullah_mazhar@hotmail.com received: march 03, 2022 accepted: august 07, 2022 introduction according to who, 2.2 billion people have been suffering from vision impairment.1 among different causes of preventable blindness, cataract is one of the major reasons.2 cataract is a multifactorial disease in which early symptoms can be improved with the help of glasses, better lighting, anti-glare or magnifying lenses. however, the ultimate solution is cataract surgery. there are many post-operative complications of cataract surgery including dry eyes disease. dry eye disease (ded) is a condition, which results in discomfort, visual difficulty, and instability of tear film and damage to ocular surface. severity in ded affects the ocular and general health of the patient and the quality of life.3,4 patient’s ability to perform everyday work is badly affected. recent researches have shown that dry eye symptoms are aggravated after cataract surgery.5 numerous epidemiological studies have reported that aging, syed abdullah mazhar, et al 272 pak j ophthalmol. 2022, vol. 38 (4): 271-274 connective tissue disease, history of allergy or diabetes, use of antihistamines, and an ocular procedure, most commonly cataract or lasik surgery are the major risk factors for developing des or exacerbating preexisting des.6 cataract surgery results in denervation of cornea and also impaired corneal sensation. decreased corneal sensation may result in reduced tear production, which in turn can lead to irritation and dry eyesymptoms.7,8 almost 40,000 cataract surgeries are performed each year in layton rahmatulla benevolent trust eye and cancer hospital, lahore. due to this large number of cataract surgeries with associated increase in ded, it becomes important to study the frequency of dry eye symptoms in post-surgical patients. local data is scarce in this regard. this study will indicate whether there is some relation of gender and different age groups with ded after cataract surgery. methods one hundred and twenty patients between 40 – 80 years of age and suffering from cataract were included. patients with anterior chamber abnormalities i.e. pterygium, corneal edema (assessed by slit lamp examination), history of any medication which could cause dry eye (anti-histamines, antidepressants, birth control pills, decongestants), any autoimmune or systemic diseases i.e. sarcoidosis, diabetes mellitus, complicated cataract surgery were excluded. the study was approved by the ethical review committee. one hundred and twenty patients who fulfilled the inclusion criteria were recruited from the outpatient department of layton rahmatullah benevolent trust eye hospital, lahore. demographic information, past medical history and current medical information was recorded for each patient. informed consent was taken. to control bias, only one experienced surgeon carried out the procedures. phacoemulsification was done under local anesthesia using lidocaine 4% and bupivacaine 0.75%. follow-up was done at 1st postoperative day, one week, one month and 3 months. tear film break up time was noted at each visit. dry eyes were labeled as per operational definition. collected data was entered and analyzed using spss version 17. the quantitative variables like age and tear film break-up time (tbut) were presented as mean ± sd. the qualitative variables like gender and dry eyes were presented as frequency and percentages. data was stratified according to age, gender and duration of cataract. post-stratification chi-square test was applied and p-value ≤ 0.05 was considered significant. results out of 120 patients, there were 47 (39%) males and 73 (61%) females. a total of 35 (29.2%) patients had dry eyes. mean age in my study was 59.11 ± 12.358 years while mean tbut was 11.27 ± 2.582 seconds. there was no relation of dry eye with gender, duration of cataract and different age groups (p > 0.05). the details of the results are presented in table 1. table 1: comparison of dry eyes between male and female patients. dry eyes gender p-value male female yes 12 23 0.48 no 35 50 table 2: comparison of dry eyes between patients of different duration of cataract. dry eyes duration of cataract p-value ≤ 1 year 1 – 2 years 2 – 3 years 3 – 4 years 4 – 5 years yes 7 9 6 10 3 0.28 no 27 16 10 16 16 table 3: comparison of dry eyes in patients belonging to different age groups. dry eyes age groups p-value 40 – 50 years 50 – 60 years 60 – 70 years 70 – 8 0years yes 13 6 9 7 0.45 no 25 23 15 22 discussion in experienced hands, cataract surgery is usually without any complications. however, some complications have been reported in literature including dry eyes.9,10 mean age in this particular study was 59.11 ± 12.358 years and the percentage of dry eyes was 29.2% (35 patients). in the study done by venincasa, v. d. et al. mean age was 73.2 ± 10.7 years while mean tear film break up time was 8.86 ± 4.78 seconds frequency of dry eyes after cataract surgery and effect of gender, duration of cataract and age on dry eye symptoms pak j ophthalmol. 2022, vol. 38 (4): 271-274 273 as compared to my study which had a tbut of 11.27 ± 2.582 seconds.11 this difference in the mean tbut may be due to a smaller sample size with only 29 patients as compared to 120 patients, difference in demographics and epidemiology. it was reported by another group of researchers that cataract surgery caused the onset or the worsening of dry eye and the use of artificial tears could reduce symptoms and signs of dry eye in patients after phacoemulsification.12 we did not use any artificial tears in our study. it has also been reported that inadvertent use of eye drops after cataract surgery may also be a contributing factor in causing dry eye after phacoemulsification.13 miyake et al found that dry eyes were found in 31% of patients after cataract surgery. this was very much close to our results of 29%.14 in a prospective study of 86 patients, it was reported that 32% of the operated patients experienced symptoms of ded up to 6 months.15 however, kohli et al, and cetinkaya et al, reported that the signs and symptoms of ded returned to pre-operative levels at 3 months after surgery.16,17 the condition is aggravated if the symptoms of ded are present before the cataract surgey.18 we did not check the tbut before surgery but earlier studies have compared pre-operative dry eye parameters with post-operative dry eye findings.19 although our results showed that there was no effect of gender difference on the ded but sajnani r et al described more ded related discomfort among the females.20 limitations of our study were absence of a control group, use of ocular lubricants and limited duration of follow up. we only considered tbut in our study, however, there are other ded parameters which can also be considered while doing research on dry eye. conclusion in this study, the frequency of dry eyes after cataract surgery was found to be 29.2% (n = 35). there was no effect of gender, duration of cataract and age of the patient on the post-operative tbut after phacoemulsification. ethical approval the study was approved by the institutional review board/ethical review board (no.2/admn/ex/cer/lrbt-2015). conflict of interest: authors declared no conflict of interest. references 1. vision loss expert group of the global burden of disease study. causes of blindness and vision impairment in 2020 and trends over 30 years: evaluating the prevalence of avoidable blindness in relation to “vision 2020: the right to sight”. lancet global health 2020. doi. 10.1016/s2214-109x(20)30489-7 2. vision loss expert group of the global burden of disease study. trends in prevalence of blindness and distance and near vision impairment over 30 years: an analysis for the global burden of disease study. lancet global health 2020. doi: 10.1016/s2214109x(20)30425-3 3. naderi k, gormley j, o'brart d. cataract surgery and dry eye disease: a review. eur j ophthalmol. 2020; 30 (5): 840-855. doi: 10.1177/1120672120929958. 4. ishrat s, nema n, chandravanshi scl. incidence and pattern of dry eye after cataract surgery. saudi j ophthalmol. 2019; 33 (1): 34-40. doi: 10.1016/j.sjopt.2018.10.009. 5. garg p, gupta a, tandon n, raj p. dry eye disease after cataract surgery: study of its determinants and risk factors. turk j ophthalmol. 2020; 50 (3): 133142. doi: 10.4274/tjo.galenos.2019.45538. 6. cho yk, kim ms. dry eye after cataract surgery and associated intraoperative risk factors. korean j ophthalmol. 2009; 23 (2): 65-73. doi: 10.3341/kjo.2009.23.2.65. 7. meyer jj, gokul a, wang mtm, sung j, craig jp. alterations in the ocular surface and tear film following keratoplasty. sci rep. 2022; 12 (1): 11991. doi: 10.1038/s41598-022-16191-6. 8. rahman ez, lam pk, chu ck, moore q, pflugfelder sc. corneal sensitivity in tear dysfunction and its correlation with clinical parameters and blink rate. am j ophthalmol. 2015; 160 (5): 858-866.e5. doi: 10.1016/j.ajo.2015.08.005. 9. kohli p, arya sk, raj a, handa u. changes in ocular surface status after phacoemulsification in patients with senile cataract. int ophthalmol. 2019; 39 (6): 1345-1353. doi: 10.1007/s10792-018-0953-8. 10. zamora mg, caballero ef, maldonado mj. shortterm changes in ocular surface signs and symptoms after phacoemulsification. eur j ophthalmol. 2020; 30 (6): 1301-1307. doi: 10.1177/1120672119896427. syed abdullah mazhar, et al 274 pak j ophthalmol. 2022, vol. 38 (4): 271-274 11. venincasa vd, galor a, feuer w, lee dj, florez h, venincasa mj. long-term effects of cataract surgery on tear film parameters. the scientific world journal. 2013; 2013: 643764. https://doi.org/10.1155/2013/643764 12. rossi gcm, tinelli c, milano g, lanteri s, ricciarelli g, giannì l, et al. randomised, single blind, controlled, three-month clinical trial on the evaluation and treatment of the ocular surface damage following phacoemulsification. vision (basel). 2022; 6 (3): 42. doi: 10.3390/vision6030042. 13. li xm, hu l, hu j, wang w. investigation of dry eye disease and analysis of the pathogenic factors in patients after cataract surgery. cornea. 2007; 26 (9 suppl 1): s16-20. doi: 10.1097/ico.0b013e31812f67ca. 14. miyake k, yokoi n. influence on ocular surface after cataract surgery and effect of topical diquafosol on postoperative dry eye: a multicenter prospective randomized study. clin ophthalmol. 2017; 11: 529540. doi: 10.2147/opth.s129178. 15. iglesias e, sajnani r, levitt rc, sarantopoulos cd, galor a. epidemiology of persistent dry eye-like symptoms after cataract surgery. cornea, 2018; 37 (7): 893-898. doi: 10.1097/ico.0000000000001491. 16. kohli p, arya sk, raj a, handa u. changes in ocular surface status after phacoemulsification in patients with senile cataract. int ophthalmol. 2019; 39 (6): 1345-1353. doi: 10.1007/s10792-018-0953-8. 17. cetinkaya s, mestan e, acir no, cetinkaya yf, dadaci z, yener hi. the course of dry eye after phacoemulsification surgery. bmc ophthalmol. 2015; 15: 68. doi: 10.1186/s12886-015-0058-3. 18. gupta pk, drinkwater oj, vandusen kw, brissette ar, starr ce. prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. j cataract refract surg. 2018; 44 (9): 10901096. doi: 10.1016/j.jcrs.2018.06.026. 19. trattler wb, majmudar pa, donnenfeld ed, mcdonald mb, stonecipher kg, goldberg df. the prospective health assessment of cataract patients' ocular surface (phaco) study: the effect of dry eye. clin ophthalmol. 2017; 11: 1423-1430. doi: 10.2147/opth.s120159. 20. sajnani r, raia s, gibbons a, chang v, karp cl, sarantopoulos cd, et al. epidemiology of persistent postsurgical pain manifesting as dry eye-like symptoms after cataract surgery. cornea, 2018; 37 (12): 1535-1541. doi: 10.1097/ico.0000000000001741. authors’ designation and contribution usama rahim; consultant ophthalmologist: concepts, design, literature search. syed abdullah mazhar; assistant professor: manuscript preparation, manuscript editing, manuscript review. nazish mazhar ali; associate professor: data acquisition, data analysis, statistical analysis. nabeel iqbal; consultant ophthalmologist: concepts, design, literature search. moneeb tariq; consultant ophthalmologist: data acquisition, data analysis, statistical analysis. .……. pak j ophthalmol. 2022, vol. 38 (2): 114-118 114 original article combined trabeculotomy and trabeculectomy with application of mitomycin c in managing primary congenital glaucoma khawaja khalid shoaib 1 , sidra anwar 2 , akhwand abdul majeed jawwad 3 1,3 mughal eye hospital, lahore abstract purpose: to determine the success of combined trabeculotomy and trabeculectomy with application of mitomycin c in primary congenital glaucoma. study design: interventional case series. place and duration of study: mughal eye hospital lahore from january 2018 to december 2019. methods: twenty-four patients of primary congenital glaucoma were included. secondary glaucoma and patients with corneal haze were excluded. corneal diameter above 11.5, 12.5 and 13 mm (when combined with raised iop) were considered indications for the surgery in neonates, at 1 year of age and at any age respectively. i-care tonometer was used to measure iop in all the cases. trabeculotomy combined with trabeculectomy plus mmc was performed in all cases. procedure was successful if post-operative iop was between 5 and 21 mm of hg and stable optic nerve head at 3 months after surgery. results: mean age of the patients was 9.7 ± 7.6 months. mean preoperative intraocular pressure (iop) was 27.8 ± 4.4 mm of hg. mean post operative iop was 13.5 ± 6.5, 17.8 ± 5 and 16.9 ± 4.8 mm of hg on first day, at the end of one month and after 3 months respectively.twenty-one (88 %) cases were successful based on the set criteria.complications included non-identification of canal of schlemn, full thickness superficial flap with uveal show due to very thin sclera, hyphema, collapse of anterior chamber and choroidal detachment. conclusion: combined trabeculotomy and trabeculectomy with application of mitomycin c is effective in decreasing iop significantly. key words: trabeculotomy, trabeculectomy, mitomycin c, primary congenital glaucoma. how to cite this article: shoaib kk, anwar s, jawwad aam. combined trabeculotomy and trabeculectomy with application of mitomycin c in managing primary congenital glaucoma. pak j ophthalmol. 2022, 38 (2): 114118. doi: 10.36351/pjo.v38i2.1349 correspondence: khawaja khalid shoaib sahara medical college email: kkshoaib@gmail.com received: november 19, 2021 accepted: march 6, 2022 introduction primary congenital glaucoma (pcg) has been subdivided depending upon the age of presentation e.g. neonatal/ newborn onset (0 – 1 month), infantile onset (1 – 24 months) and late onset/late recognized (> 24 months) and juvenile open angle glaucoma (joag). pathophysiology of pcg includes increased resistance to aqueous outflow and abnormal development of anterior chamber angle tissue, which is derived from neural crest cells. 1 iop in infants and young children is less than iop found in adults. iop is 10 – 12 mm hg in newborns and 14 mm hg by age 7 – 8 years. in pcg, iop is 30 – 40 mm hg and usually > 20 mm hg. asymmetric iop is suspicion of glaucoma. once considered an untreatable blinding disease, pcg can now be treated using multiple surgical techniques with variable results. various studies have explored variation in the trabeculotomy technique. khawaja khalid shoaib, et al 115 pak j ophthalmol. 2022, vol. 38 (2): 114-118 circumferential trabeculotomy with 5/0 prolene suture has been found to be more successful than conventional trabeculotomy. 2 another study showed that 240 degree trabeculotomy (120 degree superior and 120 degree inferior) performed with harm’s trabeculotome also proved successful. 3 trab 360 device/omni (which consists of a stainless steel needle with internal 4/0 nylon blue filament) is also useful to give good results. 4 viscotrabeculotomy has been found to be a little more effective than conventional trabeculotomy as far as reduction in iop is concerned. 5 this study was carried out to analyze reduction in iop and complications of combined trabeculotomy and trabeculectomy with application of mitomycin c (mmc) procedures. methods a total of 24 combined trabeculotomy and trabeculectomy with application of mmc procedures were performed in mughal eye hospital lahore from january 2018 to december 2019. patients with primary congenital glaucoma with large cornea were included. corneal diameter above 11.5, 12.5 and 13 mm (when combined with raised iop) were considered indications for the surgery in neonates, at 1 year of age and at any age respectively. inclusion criteria was all cases of pcg presenting with clinical manifestations of epiphora, photophobia and blepharospasm. exclusion criteria constituted any secondary cause of glaucoma. cases with dense corneal haze with no details of anterior chamber were also excluded. i-care tonometer was used to measure iop in all the cases. portable slit lamp was used to exclude anterior segment pathology in all the cases. indirect ophthalmoscopy was performed to examine posterior segment including cup to disc ratio. ultrasound b scans were done to rule out posterior segment pathology when corneal haze made it difficult. operation included following steps in all the cases. eyeball was rotated down with the help of a traction suture applied with the 6/0 vicryl applied at the clear cornea adjacent to the superotemporal limbus. superotemporal quadrant of sclera and limbus were selected for the operation. limbal-based conjunctival flap was raised. triangular superficial scleral flap of 4x4mm was made. mitomycin c 0.02% was applied for 2 minutes. thorough irrigation of the wound was done with normal saline. stab paracentesis incision in clear cornea was made to reform anterior chamber at the end of the procedure. a radial incision in deep sclera at the junction of gray and white limbus was madeunder high magnification of the microscope. canal of schlemm was identified by gush of aqueous. harm’s trabeculotome was introduced on one side and then the other. schlemm canal was connected with the anterior chamber through incision of the trabecular meshwork by rotary motion of the trabeculotome (figure 1 and 2). trabeculectomy was done by excising deep sclera and trabecular meshwork. three interrupted 10/0 nylon sutures were applied to superficial scleral flap and conjunctiva was sutured with continuous suturing. procedure was considered successful if it met the following criteria; post op iop between 5 and 21 mm of hg, disappearance of corneal cloudiness/haze and stable optic nerve head at 3 months post operatively. per-operative and post-operative complications were also noted. figure 1: trabeculotome introduced in the canal of schlemm. figure 2: trabeculotome introduced and being rotated in the anterior chamber. combined trabeculotomy and trabeculectomy with application of mitomycin c in managing primary congenital glaucoma pak j ophthalmol. 2022, vol. 38 (2): 114-118 116 results mean age of the patients at the time of operation was 9.7 ± 7.6 months (range of 3 months to 24 months). mean preoperative intraocular pressure (iop) was 27.8 ± 4.4 mm of hg. mean post operative iop was 13.5 ± 6.5, 17.8 ± 5 and 16.9 ± 4.8 mm of hg on first day, at the end of one month and after 3 months respectively. total of 21 (88%) cases were successful based on the pre-determined criteria. complications included; nonidentification of canal of schlemm in 4 cases during the procedure. in two patients incision for superficial flap went full thickness and there was uveal show due to very thin sclera. additional sutures were required to support deep sclera. hyphema occurred in two cases at the end of the operation. it cleared in a few days. collapse of anterior chamber (ac) was seenin one case on the first post-operative day. ac was reformed after two days of patching.choroidal detachment was encountered in one patient post operatively. discussion combined trabeculotomy and trabeculectomy augmented with mmc resulted in iop drop of about 14 mm of hg and this decrease was maintained by 3 months post operatively (11 mm of hg iop drop). the only significant complication especially in the initial cases was non-identification of canal of schlemm. literature shows different studies where trabeculotomy has been compared with trabeculectomy and found equally effective. 6 however, long term results showed that trabeculotomy was inferior to trabeculectomy over a period of 6 years follow up. 7,8 in another study, trabeculotomy was found to be superior to goniotomy in the management of primary congenital glaucoma. 9 klezlova a et al described a rare case of urretszavalia syndrome (in which pupil remains fixed and dilated after the operation due to brief periods of high intraocular pressure) after combined trabeculotomytrabeculectomy surgery. 10 we did not encounter this complication in any of our case. there are other variations of the procedures as well. trabectome-initiated gonioscopy-assisted transluminal trabeculotomy (tigatt) has also been claimed to give good results. 11 gonioscopy-assisted transluminal trabeculotomy is included in migs (minimally invasive glaucoma surgeries) that take less time and has less complications than trabeculectomy and implantation of drainage device procedures. 12 trabeculotomy with a trabectome reduces iop but size of trabeculotomy is not corelated with reduction of iop pointing to more complex interations 13 and this reduction of iop is also effective in uveitic glaucoma. 14,15 we used harm’s trabeculotome in our study. however, literature shows trabeculotomy to be performed using different kinds of trabecular hooks, the tanito ab interno trabeculotomy micro-hook (tmh) or the kahook dual blade (kdb). both has been found to be equally effective as far as iop reduction is concerned. 16 mitomycin c augmented trabeculectomy has been found effective in reducing the iop. 360 degree trabeculotomy with illuminated catheter is gaining popularity now. 17,18 multiple studies concluded that illuminated catheter 360 degree trabeculotomy results in a higher success rate as compared to conventional trabeculotomy. 19 microcatheter assisted trabeculotomy (mat) 20 has been found safe and effective as a secondary procedure in reduction of iop. 21 mat has been found to be equally effective as 2 site trabeculotomy with rigid trabectome. 22 in pakistan a few studies have been reported regarding operations in pcg. in a study performed in bolan medical college quetta, mean iop decreased from 30 to 12 mm of hg in primary congenital glaucoma patients. 23 in another study of 17 patients of pcg, trabeculectomy resulted in reduction of iop and success in 77% ofcases. 24 combined trabeculotomy and augmented trabeculectomy in primary congenital glaucoma resulted in drop of iop from 32 to 13 mm of hg. 25 limitation of this case series is the small sample size with a short follow up period. this study was also a single centered study without a control or comparison group. large comparative trials are neededto further prove the effectiveness of this combined procedure. conclusion combined trabeculotomy and trabeculectomy with application of mitomycin c (mmc) is effective in decreasing iop significantly with few complications. khawaja khalid shoaib, et al 117 pak j ophthalmol. 2022, vol. 38 (2): 114-118 ethical approval the study was approved by the institutional review board/ethical review board (osp-irb/2022/1349). conflict of interest authors declared no conflict of interest. references 1. badawi ah, al-muhaylib aa, al owaifeer am, alessa rs, al-shahwan sa. primary congenital glaucoma: an updated review. saudi j ophthalmol. 2019; 33 (4): 382-388. doi: 10.1016/j.sjopt.2019.10.002. 2. aktas z, ucgul ay, atalay ht. outcomes of circumferential trabeculotomy and converted 180degree traditional trabeculotomy in patients with neonatal-onset primary congenital glaucoma. j glaucoma, 2020; 29 (9): 813-818. doi: 10.1097/ijg.0000000000001559. pmid: 32459688. 3. wagdy fm. ab externo 240-degree trabeculotomy versus trabeculotomy-trabeculectomy in primary congenital glaucoma. int ophthalmol. 2020; 40 (10): 2699-2706. doi: 10.1007/s10792-020-01453-x. 4. areaux rg jr, grajewski al, balasubramaniam s, brandt jd, jun a, edmunds b, et al. trabeculotomy ab interno with the trab360 device for childhood glaucomas. am j ophthalmol. 2020; 209: 178-186. doi: 10.1016/j.ajo.2019.10.014. 5. elwehidy as, hagras sm, bayoumi n, abdel ghafar ae, badawi ae. five-year results of viscotrabeculotomy versus conventional trabeculotomy in primary congenital glaucoma: a randomized controlled study. eur j ophthalmol. 2021; 31 (2): 786795. doi: 10.1177/1120672120922453. 6. strzalkowska a, strzalkowski p, al yousef y, hillenkamp j, grehn f, loewen na. retrospective evaluation of two-year results with a filtering trabeculotomy in comparison to conventional trabeculectomy by exact matching. f1000 res. 2020; 9: 1245. doi: 10.12688/f1000research.26772.2. 7. bao w, kawase k, huang h, sawada a, yamamoto t. the long-term outcome of trabeculotomy: comparison with filtering surgery in japan. bmc ophthalmol. 2019; 19 (1): 99. doi: 10.1186/s12886019-1107-0. 8. fang l, guo x, yang y, zhang j, chen x, zhu y, et al. trabeculotomy versus combined trabeculotomytrabeculectomy for primary congenital glaucoma: study protocol of a randomised controlled trial. bmj open. 2020; 10 (2): e032957. doi: 10.1136/bmjopen-2019032957. 9. el sayed y, esmael a, mettias n, el sanabary z, gawdat g. factors influencing the outcome of goniotomy and trabeculotomy in primary congenital glaucoma. br j ophthalmol. 2021; 105 (9): 1250-1255. doi: 10.1136/bjophthalmol-2018-313387. 10. klezlova a, liebezeit s, prokosch-willing v, gericke a, pfeiffer n, hoffmann em. urrets-zavalia syndrome after combined trabeculotomytrabeculectomy surgery. j glaucoma. 2018; 27 (4): e80-e83. doi: 10.1097/ijg.0000000000000894. 11. smith bl, ellyson ac, kim wi. trabectome-initiated gonioscopy-assisted transluminal trabeculotomy. mil med. 2018; 183 (suppl_1): 146-149. doi: 10.1093/milmed/usx174. 12. mathew dj, buys ym. minimally invasive glaucoma surgery: a critical appraisal of the literature. annu rev vis sci. 2020; 6: 47-89. doi: 10.1146/annurevvision-121219-081737. 13. wecker t, anton a, neuburger m, jordan jf, van oterendorp c. trabeculotomy opening size and iop reduction after trabectome® surgery. graefes arch clinexp ophthalmol. 2017; 255 (8): 1643-1650. doi: 10.1007/s00417-017-3683-0. 14. swamy r, francis ba, akil h, yelenskiy a, francis ba, chopra v, et al. clinical results of ab interno trabeculotomy using the trabectome in patients with uveitic glaucoma. clinexp ophthalmol. 2020; 48 (1): 31-36. doi: 10.1111/ceo.13639. 15. wang q, wang j, fortin e, hamel p. trabeculotomy in the treatment of pediatric uveitic glaucoma. j glaucoma, 2016 sep; 25 (9): 744-9. doi: 10.1097/ijg.0000000000000516 16. omoto t, fujishiro t, asano-shimizu k, sugimoto k, sakata r, murata h, et al. comparison of the short-term effectiveness and safety profile of ab interno combined trabeculotomy using 2 types of trabecular hooks. jpn j ophthalmol. 2020; 64 (4): 407-413. doi: 10.1007/s10384-020-00750-3. 17. hoffmann em. 360°-trabekulotomiebeimkindlichen glaukom [360° trabeculotomy for pediatric glaucoma]. ophthalmologe, 2020; 117 (3): 210-214. german. 18. toshev ap, much mm, klink t, pfeiffer n, hoffmann em, grehn f. catheter-assisted 360degree trabeculotomy for congenital glaucoma. j glaucoma, 2018; 27 (7): 572-577. doi: 10.1097/ijg.0000000000000966. 19. ling l, ji k, li p, hu z, xing y, yu y, et al. microcatheter-assisted circumferential trabeculotomy versus conventional trabeculotomy for the treatment of childhood glaucoma: a meta-analysis. biomed res int. 2020; 2020: 3716859. doi: 10.1155/2020/3716859. 20. hu m, wang h, huang as, li l, shi y, xu y, et al. microcatheter-assisted trabeculotomy for primary congenital glaucoma after failed glaucoma surgeries. j glaucoma, 2019; 28 (1): 1-6. doi: 10.1097/ijg.0000000000001116. combined trabeculotomy and trabeculectomy with application of mitomycin c in managing primary congenital glaucoma pak j ophthalmol. 2022, vol. 38 (2): 114-118 118 21. al habash a, otaif w, edward dp, al jadaan i. surgical outcomes of microcatheter-assisted trabeculotomy as a secondary procedure in patients with primary congenital glaucoma. middle east afr j ophthalmol. 2020; 27 (3): 145-149. doi: 10.4103/meajo.meajo_317_20. 22. el sayed ym, gawdat gi. microcatheter-assisted trabeculotomy versus 2-site trabeculotomy with the rigid probe trabeculotome in primary congenital glaucoma. j glaucoma, 2018; 27 (4): 371-376. doi: 10.1097/ijg.0000000000000892. 23. qayyum a, baloch ra. trabeculotomy in primary congenital glaucoma. pak j ophthalmol. 2014; 30 (3): 125-128. 24. mengal m, khan ma, khan a, ahmed m, chaudhry rk, khan nq. outcomes of trabeculectomy in congenital glaucoma; experience in helpers eye hospital quetta. pak j ophthalmol. 2020; 36 (3): 253-257. 25. shakir m, bokhari a, kamil z, zafar s. combined trabeculotomy and augmented trabeculectomy in primary congenital glaucoma. j coll physicians surg pak. 2013; 23 (2): 116-119. authors’ designation and contribution khawaja khalid shoaib; associate professor: concepts, design, literature search, manuscript preparation, manuscript review. sidra anwar; senior registrar: concepts, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing. akhwand abdul majeed jawwad; consultant ophthalmologist: concepts, design, data acquisition, data analysis, statistical analysis, manuscript preparation manuscript review. .…  …. microsoft word 11. adnan abdul majeedtg 135 pak j ophthalmol. 2022, vol. 38 (2): 135-139 clinical practice article lateral tarsal strip – a method of choice for management in variety of lower lid malposition fariha sher wali1, adnan abdul majeed2, rafeen talpur3, shahzad memon4, khalid iqbal talpur5 1-5sindh institute of ophthalmology & visual sciences (siovs) abstract purpose: to determine the effectiveness of lateral tarsal strip procedure (lts) in treating different types of lid malposition. study design: interventional case series. place and duration of study: sindh institute of ophthalmology and visual sciences from january 2019 to december 2019. method: there were 49 eyelids on which lts procedure was performed. a complete ophthalmic examination was done and patients were assessed for horizontal lid laxity by pinch test. patients with severe and moderate to severe medial canthal laxity were excluded. patients with medial ectropion and minimal medial canthal laxity were included in the study where lts was combined with medial spindle. results: twenty three patients had involutional ectropion. spindle procedure was performed in addition to lts in 3 of these 23 patients. six patients had involutional entropion. one patient had recurrent ectropion and lts was combined with everting sutures in 3 of them. five patients had facial palsy and two of them had combined spindle procedure. one patient had traumatic avulsion of lateral canthal tendon which was not repaired primarily. two patients had previous cantholysis. in one patient lts was performed to support the prosthesis in a previously eviscerated eye. all the patients underwent lts with variation in length of lateral tarsal strip which was adjusted to horizontal lid laxity and presumed post-operative position of lower lids in relation to lower limbus and canthal angle. conclusion: .lateral tarsal strip is a simple and effective procedure for correction of different types of lower lid laxity and malposition. key words: lateral tarsal strip, lid malposition, horizontal lid laxity. how to cite this article: wali fs, majeed aa, talpur r, memon s, talpur ki. lateral tarsal strip – a method of choice for management in variety of lower lid malposition. pak j ophthalmol. 2022, 38 (2): 135-139. doi: 10.36351/pjo.v38i2.1296 correspondence: adnan abdul majeed sindh institute of ophthalmology & visual sciences (siovs) email: adnanbinabdulmajeedsanghar@gmail.com received: june 14, 2021 accepted: december 10, 2021 introduction anatomically lids are divided into anterior and posterior lamellae. anterior lamella consists of skin and orbicularis oculi. the anterior lamella attaches externally and anteriorly to the orbital rim. posterior lamella of upper lid consists of tarsus, levator aponeurosis and conjunctiva whereas posterior lamella of lower lid consists of tarsus, retractors also known as capsule-palpebral fascia, conjunctiva and tendons of tarsus that attach to the inside of orbital rim.1 the pretarsal and preseptal orbicularis contributes to the formation of superficial and deep portions of medial and lateral canthal tendons. the medial canthal tendon supports the nasal aspect of the eyelids.2 the lateral canthal tendon has both tendinous and ligamentous components. the tendinous part is formed by pretarsal orbicularis and inserts at the lateral orbital tubercle. the ligamentous component of lateral canthal tendon is direct extension of the tarsus, which slips lateral tarsal strip – a method of choice for management in variety of lower lid malposition pak j ophthalmol. 2022, vol. 38 (2): 135-139 136 posterior to the orbital septum to insert at lateral orbital tubercle. this deep extension pulls the eyelid laterally and superiorly and approximates it to the globe.3 at the lateral canthus there is bidirectional pull on the eyelid and causes the curve of the lower lid to hug the globe.4 the curve of the upper lid fits to the curve of the globe but in the lower lid the tone and position of canthal attachments is also important to hold the lower lid in position.5 normal shape of eye fissure varies however, the lower lid rests at an inferior limbus or just above it and the lateral canthal angle is in line with the inferior edge of pupil. the dehiscence of the lateral canthal attachments can be caused by ageing, trauma and paralysis of orbicularis muscle. this can lead to poor eyelid closure, fish-mouthing, entropion and ectropion.6 with ageing, the collagen fibers of the tarsus decrease in number and the elastic fibers increase. this leads to increased horizontal lid laxity and tarsal atrophy. smaller tarsal plates allow for increased chances of orbicularis override and hence lead to entropion while larger tarsus are prone to ectropion.7 the rationale of our study was to apply a simple technique i.e. lateral tarsal strip procedure for correction of multiple lower lid problems. methods this interventional cases series was conducted at sindh institute of ophthalmology and visual sciences from january 2019 to december 2019. forty nine eyes were included. patients with lower lid malposition and horizontal lid laxity of more than 6 mm were included. this included patients with involutional ectropion, entropion, facial palsy, traumatic or surgical lateral canthal damage. patients with cicatricial causes of lower lid malposition and those with severe loss of retractor function were excluded. patients with moderate to severe medial canthal laxity were also excluded. out of 49 eyes, the procedure was performed bilaterally in eleven eyes. twenty three patients had involutional ectropion (figure 1). spindle procedure was performed in addition to lts in three of these 23 patients. six patients had involutional entropion. one of the patients had recurrent ectropion and lts was combined with everting sutures in 3 of them. five patients of facial palsy also underwent lts (figure 2). two of them had combined spindle procedure. one patient had traumatic avulsion of lateral canthal tendon which was not repaired primarily. two patients had previous cantholysis due to retrobulbar hemorrhage after a road traffic accident. in one patient lts was performed to support the prosthesis in a previously eviscerated eye. all the patients underwent lts with variation in length of lateral tarsal strip which was adjusted to horizontal lid laxity and presumed post-operative position of lower lids in relation to lower limbus and canthal angle. figure 1: figure 2: adnan abdul majeed, et al 137 pak j ophthalmol. 2022, vol. 38 (2): 135-139 table 1: lts (only) lts+ spindle lts + weiss procedure total ectropion 20 3 -------------------23* entropion 3 -------------------3 6 facial palsy 3 2 -------------------5 traumatic surgery 3 --------------------------------------3 prosthesis support 1 --------------------------------------1 total eyelids on which lts performed 49 *in 11 of them lts was performed bilaterally. surgical procedure under aseptic measures and local anesthesia, lateral canthotomy and cantholysis was performed. a new tendon was manufactured from the tarsal plate by excising skin, orbicularis, lashes and conjunctiva from the tarsal plate as far as the proposed position of lateral canthus. this tendon was stretched to estimate the degree of shortening and was shortened accordingly. periosteum was exposed over the lateral orbital rim. then the new lateral canthal tendon was suspended to the orbital periosteum through 4/0 prolene. it pulled the lateral canthal tendon strip behind the orbital rim. 6/0 vicyl suture was passed through the grey line of both upper and lower lid at the new canthus and tied to re-establish canthal angle. orbicularis and skin were closed separately. postoperatively patients were advised polymyxin eye ointment twice daily, analgesic if required and oral antibiotics for 5 days. results all patients had good cosmetic results. eighty percent of patients had marked decrease in symptoms of epiphora at one week. at one month three patients with facial palsy had epiphora and improper lid closure. they were scheduled for gold weight implants at later date. complications after surgery were minimal. lid edema and conjunctival chemosis were common and short lived. healing defects with scar formation were common in young patients but gradually decreased with massage and scar contracture over time. one diabetic patient suffered infection of suture site at medial canthus in which lts was combined with spindle procedure. he recovered uneventfully after removal of suture, diabetes control and broad spectrum antibiotics. discussion many different procedures are performed for the correction of lower lid malpositions; like medial and lateral canthal tendon plication, wedge resection and lateral tarsal strip.8 different studies have reported successful outcome for malposition of lower lids with lateral tarsal strip for correcting laxity of lateral canthal tendon and lower lid laxity.9 the lts replaced many other strategies for lower eyelid surgeries with conditions like ectropion, entropion and other causes of lower lid malposition.10 lateral tarsal strip procedure involves anchoring and suspension of lower lid without altering the anatomy of lower lid.11 the main benefit of lts is rapid rehabilitation and good cosmetic results. it also avoids complications like horizontal phimosis and diminishes the recurrence of canthal laxity.12 lts has proven to be a successful procedure avoiding stretching of tarsal plate over a period of time.13 jana vydlakova et al. conducted study including 43 eyes of patients with average age of 79 years.14 twenty three eyes had ectropion and 20 eyes had entropion. majority of the cases were of involutional malposition of lower lids. correction of eyelid malposition was achieved by lateral tarsal strip procedure with successful post-operative outcomes in more than 90% of cases. the study concluded, lateral tarsal strip technique as safe, reliable and effective surgical technique for correction of lid malpositons.14 lópez-garcía et al, in a study on surgical correction of 88 eyelids with ectropion and 96 with entropion described recurrence of entropion in eight eyelids (17.4%) treated with conventional lateral tarsal strip procedure, while only two eyelids (4%) showed recurrence treated with the modified technique in which they applied an extra suture.15 after procedure, the horizontal laxity improved in both groups. kyr kam et al. performed a retrospective, comparative case series comparing lateral tarsal strip (lts) with medial spindle (tarso-conjunctival diamond excision) for correction of involution ectropion.16 patients who underwent lts alone had functional success rate of 87% (95% ci (66.4, 97.2%)) compared to patients who underwent lts with a medial spindle procedure of 89% (75.4, 96.2%) complication rates were similar in both procedures. lateral tarsal strip can be altered in terms of length of the tendon, position of tendon attachment and modification in anchoring style which makes it lateral tarsal strip – a method of choice for management in variety of lower lid malposition pak j ophthalmol. 2022, vol. 38 (2): 135-139 138 versatile. it can also be combined easily with other procedures such as medial spindle and medial canthal tendon plication. in our study we assessed and confirmed length of the tendon, proper eyelid position and vector of fixation to the orbit intra-operatively. in addition we also adjusted the vector of fixation to orbit in terms of height and placement in respect to the orbital margin. with deep set eyes fixation point of canthal anchoring is shifted downwards and more internally to prevent cloth slinging of the lower lid. in prominent eyes it was shifted upwards to prevent lid retraction and downward cloth slinging. we also combined it with other procedures such as, in ectropion, the lateral tarsal strip was combined with medial spindle procedure in three eyes. similarly in cases of facial palsy lts was combined with medial spindle procedure, in entropion it was combined with everting sutures. complications after surgery were minimal. lid edema and conjunctival chemosis were common and short lived. in our cases results were satisfactory in terms of both functional and cosmetic outcome. limitations of the study are that it was a small case series and we did not have any control group to compare the results. conclusion lower lid malpositions can occur in a variety of clinical scenarios. lateral tarsal strip is a simple and effective procedure for correction of lower lid laxity and malposition. room for modifications makes it suitable for improved functional and cosmetic outcomes. ethical approval the study was approved by the institutional review board/ethical review board (siovs: 3407). conflict of interest authors declared no conflict of interest. references 1. matsuo t, takeda y, ohtsuka a. stereoscopic threedimensional images of an anatomical dissection of the eyeball and orbit for educational purposes. acta med okayama, 2013; 67 (2): 87-91. doi: 10.18926/amo/49666. 2. knize dm. the superficial lateral canthal tendon: anatomic study and clinical application to lateral canthopexy. plast reconstr surg. 2002; 109 (3): 11491157; discussion 1158-1163. doi: 10.1097/00006534200203000-00056. 3. awadeen ae. lateral tarsal strip, can it be one solution for all types of lower eyelid malposition? egypt j hosp med. 2019; 75 (5): 2745-2752. 4. muzaffar ar, mendelson bc, adams wp jr. surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. plast reconstr surg. 2002; 110 (3): 873-884; discussion 897-911. doi: 10.1097/00006534-200209010-00025. 5. kakizaki h, zako m, nakano t, asamoto k, miyaishi o, iwaki m. the levator aponeurosis consists of two layers that include smooth muscle. ophthalmic plast reconstr surg. 2005; 21 (4): 281-284. pmid: 16052141. 6. orbit, eyelids, and lacrimal system, section 7. basic and clinical science course. san francisco: american academy of ophthalmology, 2009. 7. american academy of ophthalmology focal points: ectropion and entropion, volume 12, number 10, 1994. 8. compton cj, melson at, clark jd, shipchandler tz, nunery wr, lee hb. combined medial canthopexy and lateral tarsal strip for floppy eyelid syndrome. am j otolaryngol. 2016 may-jun; 37 (3): 240-4. doi: 10.1016/j.amjoto.2016.01.007. epub 2016 jan 22. erratum in: am j otolaryngol. 2017; 38 (3): 370. 9. lee h, park m, chang m, kang dw, lee js, baek s. clinical characteristics and effectiveness of the lateral tarsal strip and medial spindle procedure. ann plast surg. 2015; 75 (4): 365-369. doi: 10.1097/sap.0000000000000145. 10. de silva dj, prasad a. aesthetic canthal suspension. clin plast surg. 2015; 42 (1): 79-86. doi: 10.1016/j.cps.2014.08.005. 11. dulz s, green s, mehlan j, schüttauf f, keserü m. a comparison of the lateral tarsal strip with everting sutures and the quickert procedure for involutional entropion. acta ophthalmol. 2019; 97 (6): e933-e936. doi: 10.1111/aos.14093. 12. georgescu d. surgical preferences for lateral canthoplasty and canthopexy. curr opin ophthalmol. 2014; 25 (5): 449-454. doi: 10.1097/icu.0000000000000094. 13. ghafouri rh, allard fd, migliori me, freitag sk. lower eyelid involutional ectropion repair with lateral tarsal strip and internal retractor reattachment with fullthickness eyelid sutures. ophthalmic plast reconstr surg. 2014; 30 (5): 424-426. doi: 10.1097/iop.0000000000000218. adnan abdul majeed, et al 139 pak j ophthalmol. 2022, vol. 38 (2): 135-139 14. vydláková j, tesař j, krátký v, šín m, němec p. lateral tarsal strip technique in correction of eyelid ectropion and entropion. cesk slov oftalmol. 2021; 77 (2): 73-78. english. doi: 10.31348/2021/10. 15. lópez-garcía js, garcía-lozano i, giménez-vallejo c, jiménez b, sánchez á, de juan ie. modified lateral tarsal strip for involutional entropion and ectropion surgery. graefes arch clinexp ophthalmol. 2017; 255 (3): 619-625. doi: 10.1007/s00417-0163536-2. 16. kam ky, cole cj, bunce c, watson mp, kamal d, olver jm. the lateral tarsal strip in ectropion surgery: is it effective when performed in isolation? eye (lond). 2012; 26 (6): 827-832. doi: 10.1038/eye.2012.34. authors’ designation and contribution fariha sher wali; assistant professor: concepts, design. literature search, data analysis, manuscript editing. adnan abdul majeed; postgraduate resident: literature search, statistical analysis, manuscript preparation. rafeen talpur; assistant professor: data acquisition. shahzad memon; associate professor: manuscript editing. khalid iqbal talpur; professor: manuscript review. .……. pak j ophthalmol. 2021, vol. 37 (4): 344-346 344 editorial corneal transplant; changing trends of the twenty first century and where do we stand? tayyaba gul malik 1 1 department of ophthalmology, ameer-ud-din medical college/post graduate medical institute/ lahore general hospital, lahore according to the world health organization, corneal blindness accounts for the 4 th leading cause of global blindness after cataract, glaucoma and age-related macular degeneration. 1 major causes of corneal blindness include keratoconus, infectious keratitis, vitamin a deficiency, inherited corneal diseases, corneal degenerations, corneal dystrophies and trauma. in a country like pakistan, poor rural communities are prone to increased risk of contaminated corneal injuries and infectious corneal diseases while the health facilities are scarce leading to an increased frequency of cornea associated visual impairment. to tackle corneal blindness, penetrating keratoplasty (pk) was introduced in 1905 by eduard zirms. 3 itremained the only corneal transplant option for a long time till the middle of twentieth century. with technological evolution in every field of science, new surgical techniques in keratoplasty were also developed. as the understanding of the corneal anatomy and physiology further improved, the idea of partial thickness corneal grafts became a special consideration of the corneal surgeons. this was followed by superficial and deep anterior lamellar how to cite this article: malik tg. corneal transplant; changing trends of the twenty first century and where do we stand? pak j ophthalmol. 2021, 37 (4): 344-346. doi: 10.36351/pjo.v37i4.1334 correspondence: tayyaba gul malik department of ophthalmology ameer-ud-din medical college/post graduate medical institute/lahore general hospital, lahore email: tayyabam@yahoo.com received: august 21, 2021 accepted: september 15, 2021 keratoplasties, in cases where corneal endothelium was healthy. burden of the corneal disease was further increased with the iatrogenic corneal insult caused by surgical trauma during cataract surgery. with the advent of phacoemulsification, which has a long learning curve, there was an increase in the number of patients with pseudophakic bullous keratopathy. according to one study, even in uncomplicated phacoemulsification there was 9% endothelial cell loss during one year after surgery. 2 although, it does not have detrimental effectson a healthy cornea but in eyes with already compromised corneal endothelium, this can lead to disaster. the rate of corneal endothelial cell loss is definitely high if the surgery is performed by a beginner. a healthy corneal endothelium is vital for corneal transparency. in a new born, corneal endothelium consists of around 6000 cells/mm, 2 which falls with the advancing age at a rate of 0.6% each year. any trauma to the endothelium, which results in excessive corneal endothelial cell loss, will lead to corneal edema and loss of corneal transparency. thus the focus started to change from full thickness corneal grafts to partial thickness posterior lamellar keratoplasty. a time came when corneal endothelium transplant was thought to be a more useful procedure to tackle endothelial dysfunction. in 1998, posterior lamellar keratoplasty was performed in animals and cadaver eyes by gerrit. 4 it was followed by descemet stripping endothelial keratoplasty (dsek). in 2006, microkeratome was introduced in this field and grafts were prepared using microkeratome leading to procedure called descemet stripping automated endothelial keratoplasty (dsaek). 5 this was indeed a game changer in the field of corneal transplant. it is a open access professor tayyaba gul malik 345 pak j ophthalmol. 2021, vol. 37 (4): 344-346 minimally invasive procedure avoiding open sky technique of pk. endothelial transplant procedures proved to have better tensile strength of cornea as compared to the full thickness corneal transplant procedures. further improvement was brought about by a more improved and thin corneal graft. it was observed that decreasing the graft thickness to less than 100 microns resulted in better visual outcomes. in ultrathin dsaek, patients achieved visual acuity of 20/20. 6 this resulted in the development of a new technique called descemet’s membrane endothelial keratoplasty (dmek). in this procedure, the graft thickness was reduced to approximately 10 μm. 6 advancement in today’s keratoplasty is the use of intra-operative oct, which can be used to measure the central corneal thickness of the host and donor cornea. falk or femto laser assisted lamellar keratoplasty is another breakthrough for sharp and accurate cuts of the donor as well as host tissue, leading to perfection of the procedure and minimizing post-operative complications. new developments always bring new challenges. demand of corneal tissue increased with the successful transplant surgeries leading to an imbalance between the demand and supply of corneal tissue. scientists began to think about the alternatives and this led to introduction of newer techniques. in 2017, descemet stripping only (dso) technique, also called descemetorhexis without endothelial keratoplasty (dwek) was introduced. in this technique, central 4mm zone of descemet membrane was removed without transplant. this technique is useful for central endothelial disease with normal corneal periphery. minimum endothelial count required for this procedure to be successful is more than 1000 cells per square millimeter. 7 this procedure was improved upon by the use of rho kinase (rock) inhibitor which facilitates endothelial migration towards the corneal center. recently, ripasudil has shown good results in patients undergoing dso. 8 this drug reduced the recovery time of the patient from an average of 6.5 weeks to 4.6 weeks. cell culture technology for corneal endothelium was another breakthrough in corneal transplant journey. in this technique, endothelial cells are obtained from a single donor, cultured and can be transplanted into many patients. kinoshita and his colleagues conducted first human trial of cultivated corneal endothelial cells in cases with bullous keratopathy. 9 they injected cultured endothelial cells in the anterior chamber and injected rho kinase inhibitors. after injection of air in the anterior chamber, the patient was asked to lie down in the face down position for three hours to help adhesion of the endothelial cells. a 5 – year follow up study of 11 patients has been published which has opened new horizons for the corneal disease management. 10 this procedure once established for human use will not only overcome the problem of donors but there will be an additional advantage of cultured endothelial cells to be stored for extended time period.another advantage of cell culture is that the mesenchymal cells can be obtained from the patient him/herself, which decreases the chances of immunological reactions. this procedure can be repeated as well. there is still a long way to go in this field. which mesenchymal cells have best results, how long they can be stored, what is the minimum number of cells needed for corneal endothelial layer recovery, what are the factors that can improve the efficacy of this technique, all these questions need to be answered? another quantum leap is the bioengineered corneal transplant surgeries. this is done in cases where all the above mentioned maneuvers have failed. bioengineered keratoprosthesis is the last resort in refractory corneal diseases. although few types of keratoprosthesis are available but their importance in multiple failed grafts and corneal autoimmune diseases cannot be overlooked. in pakistan we have to go a long way in this field. much work needs to be done in the private and the public sector because of the huge burden of corneal blindness in our country. like any other organ donation in pakistan, there are cultural as well as religious issues along with the ethical considerations regarding corneal transplant. another hurdle is the availability of corneas. ninety percent of the corneas used in pakistan are imported. we need to become self-sufficient but this requires public education. religious scholars have to play a pivotal role and the role of the state comes into play in case of unclaimed dead bodies. to add further to the already existing challenges, health care system of pakistan has remained unattended for long. time has come to develop an up to date database in the health sector where all the record of the donor and host tissues should be maintained and retrieved when needed. https://www.healio.com/ophthalmology/cornea-external-disease/news/print/ocular-surgery-news/%7b3e16c701-a793-429f-b7dc-1cdd29e380da%7d/would-you-recommend-descemets-stripping-alone-for-fuchs-dystrophy corneal transplant; changing trends of the twenty first century and where do we stand? pak j ophthalmol. 2021, vol. 37 (4): 344-346 346 conflict of interest authors declared no conflict of interest. references 1. corneal blindness: available at: https://www.seeintl.org/corneal-blindness/. accessed on september 16 th 2021. 2. werblin tp. long-term endothelial cell loss following phacoemulsification: model for evaluating endothelial damage after intraocular surgery. refract corneal surg. 1993; 9 (1): 29-35. 3. zirm ek. eineerfolgreichetotale keratoplastik (a successful total keratoplasty). 1906. refract corneal surg. 1989; 5: 258–261. 4. melles gr, eggink fa, lander f, pels e, rietveld fj, beekhuis wh, et al. a surgical technique for posterior lamellar keratoplasty. cornea, 1998; 17 (6): 618-626. doi: 10.1097/00003226-199811000-00010. 5. gorovoy ms. descemet-stripping automated endothelial keratoplasty. cornea, 2006; 25 (8): 886889. doi: 10.1097/01.ico.0000214224.90743.01. 6. johnson dh, bourne wm, campbell rj. the ultrastructure of descemet’s membrane. i.changes with age in normal corneas. arch ophthalmol. 1982; 100: 1942–1947. doi: 10.1001/archopht.1982.01030040922011 7. dhaliwal d. descemet stripping only: who is the best candidate? presented at: american society of cataract and refractive surgery annual meeting; may 3-7, 2019; 8. borkar ds, veldman p, colby ka. treatment of fuchs endothelial dystrophy by descemet stripping without endothelial keratoplasty. cornea, 2016; 35 (10): 1267-1273. doi: 10.1097/ico.0000000000000915. 9. kinoshita s, koizumi n, ueno m, okumura n, imai k, tanaka h, et al. injection of cultured cells with a rock inhibitor for bullous keratopathy. n engl j med. 2018; 378 (11): 995-1003. doi: 10.1056/nejmoa1712770. 10. numa k, imai k, ueno m, kitazawa k, tanaka h, bush jd, et al. five-year follow-up of first 11 patients undergoing injection of cultured corneal endothelial cells for corneal endothelial failure. ophthalmology, 2021; 128 (4): 504-514. doi: 10.1016/j.ophtha.2020.09.002. epub 2020 sep 6. author’s designation and contribution tayyaba gul malik; professor of ophthalmology: concepts, literature search, manuscript preparation, manuscript review. .…  …. https://www.seeintl.org/corneal-blindness/ https://doi.org/10.1001/archopht.1982.01030040922011 pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 95 original article ease of removal of posterior segment metallic intraocular foreign body with intraocular forceps vs endomagnet plus forceps tehmina jahangir, bilal zaheer qureshi, qasim lateef chaudhry, asad aslam khan pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tehmina jahangir eye department kemu/ mayo hospital, lahore …..……………………….. purpose: to compare the ease of removal of posterior segment intraocular foreign body with intraocular forceps alone or endomagnet plus forceps. material and methods: a comparative case series conducted at department of ophthalmology, mayo hospital lahore from march 2013 to august 2013. fifty eyes of fifty patients with ocular trauma and concurrent metallic posterior segment intraocular foreign body underwent pars plana vitrectomy and we analyzed the ease of removal of posterior segment iofb with endomagnet plus intraocular forceps (group a) or intraocular forceps alone (group b) by comparing the frequency of intra operative complications with either method. results: the comparison of the two methods of removal revealed that in group a (endomagnet plus forceps) there was a higher rate of iofb slippage during removal as well as failure to lift the iofb as compared to group b. however, iatrogenic retinal break formation was only encountered in group b (forceps alone). conclusion: the best instrument to use for removal depends on the size, shape and magnetic properties of the iofb as well as its location within the eye. the primary goal in managing iofb is to preserve vision. ntraocular foreign bodies (iofbs) represent a subset of ocular injuries that present complex surgical challenges for successful removal while preserving the vision, restoring ocular architecture and preventing complications. studies have reported that an iofb may be present in 14% to 45% of cases of penetrating injuries of the globe1, 2. removal of posterior segment iofbs by vitrectomy is advocated because it provides direct viewing and also precise removal of the iofb2. vitrectomy, by removal of blood in the vitreous, prevents inflammatory and fibrous responses that may lead to tractional sequelae in the posterior segment3,4. the hammer-chisel injury is the most common cause of iofb in adults5. the iofb most commonly causes damage to the eye by mechanical ways, introduction of infection and specific chemical reaction in the intraocular tissues6, 7. in this particular study we present our experience with posterior segment iofb removal with endomagnet plus intraocular forceps vs intraocular forceps alone. thus ocular trauma with an iofb is an important cause of ocular morbidity and blindness and is often under reported material and methods this was a comparative case-series conducted at mayo hospital, lahore. the study was carried out over a period of six months from march to august 2013. fifty eyes of fifty patients with ocular trauma and concurrent metallic posterior segment intraocular i tehmina jahangir, et al 96 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology foreign body underwent pars plana vitrectomy and we studied the ease of removal of posterior segment iofb with intraocular forceps or endomagnet plus forceps. the ease of removal was judged by the various per-operative difficulties / complications encountered during the removal of the iofb. the patients randomly were assigned into two groups: endomagnet plus forceps (ef) and forceps alone (f). we used a 20 g crocodile forceps and a permanent retractable endomagnet. an iofb was suspected in all cases of open globe injuries. the preoperative workup included a dedicated history to determine the time lapsed and modality of injury along with detailed data about the composition of the object. a careful ocular examination with minimal manipulation of the globe to avoid further expulsion of its contents was done. if view to the posterior pole was limited, gentle b-scan ultrasound by an experienced ultrasonographer was arranged ensuring that no pressure was applied to the globe. ct scan was done in selected cases to further aid in identifying the objects and evaluating the globe, orbital bones and retrobulbar space. the surgical technique employed was a standard three port pars plana vitrectomy with simultaneous pars plana lensectomy or phacoemulsification if and when considered necessary. after identification of iofb, core vitrectomy and induction of pvd was performed. the iofb was then removed by forceps alone or elevated from the retinal surface by an endomagnet and then grasped with forceps as the magnet is not able to hold the iofb during its passage through the sclerotomy. for the changeover from magnet to forceps, the endomagnet tip was brought just behind the lens, kept in view with the help of microscope light. an intraocular foreign body forceps was then inserted through the other sclerotomy. in cases where there was inadequate view through the pupil, we used a self-retaining 25g awh chandelier (synergetics, inc) for illumination. this was inserted through a separately created 4th port with a 25g mvr. we used perfluorocarbon intra operatively to protect the macula and silicone oil as postoperative intraocular tamponade, if required. endolaser photocoagulation of the breaks and 360 degree photocoagulation of the retinal periphery were performed. before securing the iofb, the route of removal was planned so that either the sclerotomy was enlarged or a keratome incision created to remove the iofb through the limbus in aphakic patients. results fifty eyes of fifty patients (all male with a mean age of 38; age range 22 to 50 years) were treated during this study period. in our study we assessed the ease of removal of iofb by comparing the complication rates of the two methods under discussion. the iofb slipped during removal in 9 (36%) of the 25 patients in group a while slippage occurred in only 5 (20%) of the patients in group b. in 3(12%) cases in group a there was failure to lift the iofb during removal with the endomagnet predominantly due to the large size of the iofb; however such a complication was not encountered with the group b. one of the drawbacks of using forceps is iatrogenic retinal break due to the sharp edges of the various foreign body forceps coming in contact with the retinal surface. this complication was encountered in 7 (28%) of the 25 cases in group b; in contrast, none of the patients in group b encountered this complication (table 1). discussion ppv for removal of iofb often presents a formidable surgical task. however, the final results can be favorable, despite the serious nature of the initial injury8-10. the most common location for a retained intraocular foreign body is within the vitreous cavity11. iofb removal with intraocular forceps vs. endomegnet plus forceps pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 97 like other traumatic injuries to the eye, occurrence of iofbs is effectively prevented by strict adherence to the recommended safety measures because most of them are occupational 12, 13. some of the activities like hammering metal on metal and chiseling related activities have a relatively high probability of producing high velocity projectiles that can enter and damage the globe14. war injuries also have a high probability of iofbs15. although occasionally other tools may also be utilized e.g., paper clips, catheter, snare16, 17 there are three basic types of instruments for iofb removal: external electro magnets (eems), intraocular forceps and intraocular magnets (ioms)18. eems may be equipped with intraocular attachments but they are bulkier and less convenient to use than ioms19. the inherent problem of the eem is that the surgeon has to view the removal process from an angle, making it difficult to align the following: external magnetic pole. surgical incision / instrument tip. iofb. the potential for complications is significant. the eem also has a tendency to overheat, reducing efficiency and possibly burning the patient’s skin. the weight (up to 1 ton) can cause logistical difficulties. intraocular forceps allow controlled maneuvers but may require considerable dexterity to grasp the iofb (e.g., lifting up sharp objects from the retinal surface) or to adjust its position (e.g., aligning the iofbs longest axis with that of the instrument) 20. use of additional tools such as heavy liquids provides limited help. the intraocular magnets are permanent magnets that allow controlled iofb removal with no need for special dexterity. free-flying of the iofb, inherently considerable with eems is ≤ 2 mm. however, most ioms gradually lose power with time and have a limited pull force, commonly requiring concurrent forceps use19. the aim in managing an iofb is to achieve the best visual outcome possible by identifying and closing the entry and exit sites, reconstructing the eye and removing the object. conclusion the primary goal in managing iofb is to preserve vision. the best instrument to use for removal depends on the size, shape and magnetic properties of the iofb as well as its location within the eye. author’s affiliation dr. tehmina jahangir vitreo-retinal fellow eye department kemu / mayo hospital, lahore dr. bilal zaheer qureshi vitreo-retinal fellow eye department kemu / mayo hospital, lahore dr. qasim lateef chaudhry assistant professor eye department kemu / mayo hospital, lahore prof. dr. asad aslam khan professor of ophthalmology eye department kemu / mayo hospital, lahore references 1. ehlers jp, kunimoto dy, ittoop s, maguire ji, allen c, regillo cd. metallic intraocular foreign bodies: characteristics, interventions and prognostic factors for visual outcome and globe survival. am j ophthalmol. 2008; 146: 42733. 2. yeha s, colyerb mh, weichel ed. current trends in the management of intraocular foreign bodies. curr opin ophthalmol. 2008; 19: 225-33. 3. katz g, moisseiev j. posterior-segment intraocular foreign bodies: an update on management. retinal physician. april 2009: 1-9. 4. demircan n, soylu m, yagmur m, akkaya h, ozcan aa, varinli i. pars plana vitrectomy in ocular injury with intraocular foreign body. j trauma. 2005; 59: 1216-8. 5. falavarjani kg, hashemi m, modarres m, parvaresh mm, naseripour m, nazari h, et al. vitrectomy for posterior segment intraocular foreign bodies, visual and anatomical outcomes. middle east afr j ophthalmol. 2013; 20: 244-7. 6. kuhn, ferenec (editor). ocular trauma: principles and practice. new york, ny, usa: thieme medical publishers, incorporated, 2002: 235-63. 7. wani vb, al-ajmi m, thalib l. vitrectomy for posterior segment intraocular foreign bodies, visual results and prognostic factors. retina. 2003; 23: 654-60. 8. greven cm, engelbrecht ne, slusher m, nagy ss. ocular foreign bodies: management, prognostic factors and visual outcomes. ophthalmology 2000; 107: 608-12. 9. zafar s, kamil z, shakir m, bokhari sa, rizvi sf. management of intraocular foreign body in tertiary care hospital. pak j ophthalmol. 2012; 28: 118-21. 10. woodcock mg, scott ra, huntbach j. mass and shape as factors in intraocular foreign body injuries. ophthalmology 2006; 113: 2262-9. tehmina jahangir, et al 98 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology 11. chow dr, garretson br, kuczynski b. external versus internal approach to the removal of metallic intraocular foreign bodies. retina 2000; 20: 364-9. 12. iqbal m. consensus report. retained intraocular foreign body. pak j ophthalmol. 2010; 26: 158-61. 13. memon aa, iqbal ms, cheema a, niazi jh. visual outcome and complications after removal of posterior segment intraocular foreign bodies through pars plana approach. jcpsp. 2009; 19: 436-9. 14. sriprakash ks, sujatha bl, kesarwani s. surgical intervention in retained intra-ocular foreign body: our experience. retina/vitreous session 2. aioc 2006 proceedings; 493-5. 15. thach ab, ward tp, dick ii js, bauman wc, madigan jr wp, goff mj, thordsen je. intraocular foreign body injuries during operation iraqi freedom. ophthalmology. 2005; 112: 1829-33. 16. yao y, wang zj, yan s, huang yf. an alternative method of extraction: use of a catheter to remove intraocular foreign bodies during vitrectomy. retina 2009; 29: 552-5. 17. erakgun t, akkin c, mentes j. management of the posterior segment foreign bodies with a simple snare. retina 2003; 23: 858-60. 18. pieramici dj. open globe injuries are rarely hopeless. managing the open globe calls for creativity and flexibility of surgical approach tailored to the specific case. review of ophthalmology. 2005; 12: 6. 19. erakgun t, egrilmez s. prognostic factors in vitrectomy for posterior segment intraocular foreign bodies. j trauma. 2008; 64: 1034-7. 20. szijarto z, gaal v, kovacs b, kuhn f. prognosis of penetrating eye injuries with posterior segment intraocular foreign body. graefes arch clin exp ophthalmol. 2008; 246: 161-5. http://www.ncbi.nlm.nih.gov/pubmed?term=kuhn%20f%5bauthor%5d&cauthor=true&cauthor_uid=17674019 147 pak j ophthalmol. 2021, vol. 37 (2): 147-151 original article early post-operative effect of phacoemulsification on anterior chamber depth and intraocular pressure in patients with cataract mashal tayyab 1 , awaid abid 2 1-2 department of ophthalmology, layyton rehmatullah benevolent trust free eye and cancer hospital, lahore abstract purpose: to determine the anterior chamber depth and intraocular pressure change following uncomplicated phacoemulsification. study design: quasi experimental study. place and duration of study: layyton rehmatullah benevolent trust free eye and cancer hospital, lahore from 16/12/2017 to 15/06/2018. methods: one hundred and thirty nine patients who came to layyton rehmatullah benevolent trust free eye for phacoemulsification and iol implantation were included in the study. anterior chamber depth was measured with iol master and intraocular pressure was determined using goldmann applanation tonometer one day before and one month after surgery. data was recorded on a self-designed proforma. comparison between pre and post-operative data with respect to change was analyzed by chi-square test. p-value ≤ 0.05 was considered significant. results: the mean intra-ocular pressure dropped from 14.36 ± 4.19 mmhg to 12.14 ± 4.26 mmhg 1 month after surgery with a mean drop of 2.21 ± 0.65 mmhg while the mean anterior chamber depth increased from 2.31 ± 0.08 mm to 3.59 ± 0.37 mm with a mean increase of 1.29 ± 0.36 mm. there was no statistically significant difference in the mean change of intra-ocular pressure and anterior chamber depth across various subgroups based on patient’s age, gender and duration of cataract. conclusion: phacoemulsification and iol implantation not only improves the visual acuity by removing the cataract but also deepens the anterior chamber and decreases intra-ocular pressure, which can have a beneficial effect in glaucoma patients. key words: phacoemulsification, cataract, intraocular pressure, lens, anterior chamber depth. how to cite this article: tayyab m, abid a. early post-operative effect of phacoemulsification on anterior chamber depth and intraocular pressure in patients with cataract. pak j ophthalmol. 2021, 37 (2): 147-151. doi: http://doi.org/10.36351/pjo.v37i2.1176 introduction aqueous humor is secreted by the ciliary epithelium, correspondence: mashal tayyab department of ophthalmology, layyton rehmatullah benevolent trust free eye and cancer hospital, lahore email: mashal_tayyab@yahoo.com received: december 4, 2020 accepted: march 6, 2021 and enters the posterior chamber. it then flows around the lens through the pupil into the anterior chamber. 1 aqueous leaves the eye by passive bulk flow mainly via two pathways at the anterior chamber angle. anterior chamber angle widening following cataract extraction was significantly correlated with anterior chamber biometric factors like anterior chamber depth. 2 literature shows that cataract surgery significantly deepens the anterior chamber and widens its angle. the more shallow the preoperative anterior http://doi.org/10.3352/jeehp.2013.10.3 mailto:mashal_tayyab@yahoo.com early post-operative effect of phacoemulsification on anterior chamber depth and intraocular pressure pak j ophthalmol. 2021, vol. 37 (2): 147-151 148 chamber, the greater is the postoperative change in the of the chamber. 3 preoperative lens vault appears to be a significant factor in angle widening and intraocular pressure reduction after phacoemulsification. 2 the reduction in intraocular pressure is the result of increased anterior chamber depth (acd) and widening of iridocorneal angle following cataract surgery. 4 changes in anterior chamber depth following uncomplicated cataract extraction via phacoemulsification is associated with decrease in intraocular pressure. this study was carried out to see the change in anterior chamber depth and intra ocular pressure after phacoemulsification in non-glaucomatous patients. methods study was conducted in lrbt lahore from december 2017 to june 2018. study design was quasiexperimental and non-probability consecutive sampling technique was used. after approval from ethical committee, a total of 139 patients, between 20 and 60 years of age and of either gender were admitted to undergo phacoemulsification for cataract extraction. detailed history and examination including best corrected visual acuity, dilated fundus examination, gonioscopy, iop measurement and ac depth measurements were carried out before surgery and then 1 month after surgery. patients with nuclear cataracts ns ++/+++, intraocular pressure of 20 mmhg or less and axial length of 21.0 to < 25.0 mm were included in the study. patients with known glaucoma, any complication during cataract surgery like posterior capsular rupture and vitreous loss, previous surgery and co-morbid conditions were excluded. phacoemulsification was done using horizontal chopping method and posterior chamber intra-ocular lens was implanted under local anesthesia. all patients were evaluated by the same experienced consultant using iol master and goldmann applanation tonometery. data was recorded on a selfdesigned proforma. comparison between pre and postoperative data with respect to change was analyzed by chi-square test. p-value ≤ 0.05 was considered significant. all the collected data was entered and analyzed through spss version 22.0. numerical variables i-e age, pre-operative, post-operative anterior chamber depth and intraocular pressure were presented as mean ± sd. categorical variables i-e gender was presented as frequency and percentage. data was stratified for age, gender and duration of cataract to address effect modifiers. post stratification t-test was applied taking p value ≤ 0.05 as significant. results the age of the patients ranged from 40 years to 65 years with a mean of 62.3 ± 4.3 years. there were 68 (48.9%) males and 71 (51.1%) female patients. duration of cataract was from 1 year to 6 years with a mean of 2.8 ± 1.3 years as shown in table 8.1. the mean intra-ocular pressure dropped from 14.36 ± 4.19 mmhg to 12.14 ± 4.26 mmhg 1 month after surgery with a mean drop of 2.21 ± 0.65 mmhg while the mean anterior chamber depth increased from 2.31 ± 0.08 mm to 3.59 ± 0.37 mm with a mean increase of 1.29 ± 0.36 mm. there was no statistically significant difference in the mean change of intraocular pressure and anterior chamber depth across various subgroups based on patient’s age, gender and duration of cataract. table1: baseline characteristics of study sample. characteristics participants (n = 139) age (years) 62.3 ± 4.3 40-52 years 7 (5.0%) 53-60 years 132 (95.0%) gender male 68 (48.9%) female 71 (51.1%) duration of cataract (years) 2.8 ± 1.3 1-3 years 106 (76.3%) 4-6 years 33 (23.7%) table 2: early post-operative effect of phacoemulsification on iop and acd (n = 139). parameter pre-operative postoperative mean change iop (mmhg) 14.36 ± 4.19 12.14 ± 4.26 2.21 ± 0.65 acd (mm) 2.31 ± 0.08 3.59 ± 0.37 1.29 ± 0.36 table 3: stratification of mean change in iop across various subgroups (n = 139). characteristics n mean change in iop (mmhg) p-value age 40 – 52 years 7 2.23 ± 0.53 0.952 53 – 60 years 132 2.21 ± 0.66 gender male 68 2.22 ± 0.62 0.858 female 71 2.20 ± 0.68 mashal tayyab, et al 149 pak j ophthalmol. 2021, vol. 37 (2): 147-151 duration of cataract 1 – 3 years 106 2.20 ± 0.64 0.724 4 – 6 years 33 2.25 ± 0.69 table 4: stratification of mean change in acd across various subgroups (n = 139). characteristics n mean change in acd (mm) p-value age 40 – 52 years 7 1.31 ± 0.22 0.848 53 – 60 years 132 1.29 ± 0.37 gender male 68 1.29 ± 0.38 0.861 female 71 1.28 ± 0.34 duration of cataract 1 – 3 years 106 1.29 ± 0.36 0.821 4 – 6 years 33 1.28 ± 0.38 t-test, observed difference was statistically insignificant discussion crystalline lens is an important refractive medium of eye. modern cataract surgery (phacoemulsification technique) helps to improve vision by exchanging damaged inelastic lens with intra-ocular lens. literature shows a positive association between shallower temporal iridotrabecular angle and small anterior chamber depth and larger lens vault. 5 the lens vault quantifies the portion of the lens located anterior to the anterior chamber angle. 6 a larger lens vault is independently associated with narrow angles. 7 anterior chamber depth correlates highly with anterior chamber angle. 8 phacoemulsification surgery has the ability to deeply alter the anterior segment morphology, especially in eyes with shallow anterior chamber (ac) and narrow anterior chamber angle (aca). an earlier study showed an increase in anterior chamber depth from 2.76 (0.08) mm preoperatively to 3.95 (0.05) mm post-operatively and a mean change of 1.20 (0.06) mm six months following surgery. 9 a mean change of intraocular pressure of 1.55 (0.47) mmhg in open-angle patients six months after surgery was also observed in the same study. 9 another study showed an increase in anterior chamber depth following cataract extraction in eyes with glaucoma. 10 angle widening following phacoemulsification is postulated to be a cause of intraocular pressure reduction. in the present study, the mean age of the patients was 62.3 ± 4.3 years. a similar mean age of 63 ± 6.7 years has been reported by tahir et al among patients presenting with cataract at jinnah post graduate medical centre, karachi. 11 khan et al 12 has reported similar mean age of 62 ± 10.2 years at holy family hospital, rawalpindi and zafar et al 13 reported it to be 62.4 ± 7.8 years at shifa international hospital, islamabad. a comparable mean age of 63.8 ± 8.9 years has been reported by bharath et al 14 among indian patients while in bangladesh it was reported it to be 66.7 ± 8.1 years. 15 we observed a slight female predominance with 48.9% males and 51.1% female patients. a similar female predominance has been reported in another local study, where tahir et al. 11 reported 53.7% females and 46.3% male patients. similar frequency of male (48.6%) and female (51.4%) patients has been reported at liaquat university of medical and health sciences, hyderabad. 16 our observation is also in line with indian studies. 14 in the present study, we observed that the mean intra-ocular pressure dropped from 14.36 ± 4.19 mmhg to 12.14 ± 4.26 mmhg 1 month after surgery with a mean drop of 2.21 ± 0.65 mmhg while the mean anterior chamber depth increased from 2.31 ± 0.08 mm to 3.59 ± 0.37 mm with a mean increase of 1.29 ± 0.36 mm. our observation is line with another local study where ahmad et al. 17 reported similar change in mean iop (17 ± 2 mmhg to 13 ± 2 mmhg) and anterior chamber depth (1.5mm) following cataract surgery in glaucoma patients. bhallil et al 18 in morocco reported similar decrease in mean intraocular pressure (2.25 mmhg) from 14.18 ± 3.4 to 12.07 ± 2.6 mmhg after phacoemulsification in normal patients. they also reported similar increase in mean anterior chamber depth (1.13 mm) from 2.96 mm to 4.09 mm. in a chinese study, liu et al. 19 reported similar decrease in mean iop (14.86 ± 3.79 mmhg to 12.17 ± 4.22 mmhg) and increase in mean anterior chamber depth (2.38 ± 0.32 mm to 3.04 ± 0.39 mm) following phacoemulsification in normal subjects. qu et al 20 observed comparable decrease in mean iop (14.3 ± 3.1 mmhg to 12.7 ± 3.3 mmhg) with a comparable increase in mean acd (2.54 ± 0.41 mm to 3.99 ± 0.33 mm). dooley et al 21 reported decrease in mean iop (2.5 ± 3.2 mmhg) from 14.8 ± 3.1 to 12.3 ± 2.7 mmhg after phacoemulsification. they also reported similar increase in mean anterior chamber depth (1.08 ± 0.50 mm) from 2.66 ± 0.38 to 3.70 ± 0.75mm among normal irish subjects with cataract. takmaz et al. 22 early post-operative effect of phacoemulsification on anterior chamber depth and intraocular pressure pak j ophthalmol. 2021, vol. 37 (2): 147-151 150 reported similar fall in mean intraocular pressure from 14.6 ± 3.5 to 10.4 ± 2.4 mmhg and increase in mean anterior chamber depth from 2.7 ± 0.4 to 3.5 ± 0.3 mm after uneventful phacoemulsification in turkish patients with cataract. the results of the present study are in line with the already published research on the topic and establish that phacoemulsification and iol implantation not only improves the visual acuity by removing the cataract but also deepens the anterior chamber and decreases intra-ocular pressure, which can be beneficial for glaucoma patients. so in future practice, patients having cataract and glaucoma with uncontrolled intra-ocular pressure by non-surgical means should be offered cataract surgery as it will not only improve their visual acuity but may also help in controlling iop and avoiding or at least delaying glaucoma surgery. conclusion phacoemulsification and iol implantation deepens the anterior chamber and decreases intra-ocular pressure, which is sustained over 1 month, this may be beneficial for glaucoma patients irrespective of gender and cataract duration. ethical approval the study was approved by the institutional review board/ ethical review board. (no.2/admn/excer/lrbt-2020) conflict of interest authors declared no conflict of interest. references 1. levin l, nilsson s. adler's physiology of the eye. 11 th ed. china saunders elsevier; 2011. 2. elgin u, sen e. early postoperative effects of cataract surgery on anterior segment parameters in primary open-angle glaucoma and pseudoexfoliation glaucoma. turk j ophthalmol. 2016; 46 (3): 95-98. 3. huang, g, gonzalez, e. association of biometric factors with anterior chamber angle widening and intraocular pressure reduction after uneventful phacoemulsification for cataract. j cataract refract surg. 2012; 38 (1): 108-116. 4. kurimoto, y, park, m. changes in anterior chamber configuration after small incision cataract surgery with posterior chamber intraocular lens implantation. am j ophthalmol. 1997; 124 (6): 775-780. 5. rüfer f, schröder a, klettner a, frimpong-boateng a, roider jb, erb c. anterior chamber depth and iridocorneal angle in healthy white subjects: effects of age, gender and refraction. acta ophthalmol. 2010; 88 (8): 885-890. doi: 10.1111/j.1755-3768.2009.01588.x. 6. moghimi s, vahedian z, zandvakil n. role of lens vault in subtypes of angle closure in iranian subjects. eye. 2014; 28: 337–343. doi: 10.1038/eye.2013.296 7. takmaz t, kösekahya p, kürkçüoğlu pz. anterior segment morphometry and intraocular pressure change after uneventful phacoemulsification. turk j med sci. 2013; 43 (2): 289-293. 8. schuster ak, pfeiffer n, nickels s, schulz a, höhn r, wild ps, et al. distribution of anterior chamber angle width and correlation with age, refraction, and anterior chamber depth—the gutenberg health study. invest. ophthalmol. vis. sci. 2016; 57 (8): 3740-3746. doi: 10.1167/iovs.16-19600. 9. cho yk. early intraocular pressure and anterior chamber depth changes after phacoemulsification and intraocular lens implantation in non-glaucomatous eyes comparison of groups stratified by axial length. j cataract refract surg. 2008; 34 (7): 1104-1109. 10. hayashi k, hayashi h. changes in anterior chamber angle width and depth after intraocular lens implantation in eyes with glaucoma. j ophthalmol. 2000; 107 (4): 698-703. 11. tahir ma, cheema a, tareen s. frequency of hepatitis-b and c in patients undergoing cataract surgery in a tertiary care center. pak j med sci. 2015; 31 (4): 895-898. 12. khan qa, iqbal y, zai s, niazi fk. posterior capsular opacification after cataract surgery. j riphah univ. 2015; 12 (2): 34-38. 13. zafar f, shaheen f, muid j, afzal f. impact of cataract surgery on cognitive functions in elderly patients presenting to a tertiary care center in islamabad. neurology, 2018; 90 (15): 216-226. 14. bharath b, krishnaiah s, imtiaz a, ramani rv. prevalence and determinants of cataract surgical coverage in india: findings from a population-based study. int j commun med public health, 2017; 4 (2): 320-327. 15. danquah l, kuper h, eusebio c, rashid ma, bowen l. the long term impact of cataract surgery on quality of life, activities and poverty: results from a six year longitudinal study in bangladesh and the philippines. plos one, 2014; 9 (4): e94140. 16. nizamani nb, surhio sa, memon s, talpur ki. axial length variability in cataract surgery. j coll physicians surg pak. 2014; 24 (12): 918-921. https://doi.org/10.1167/iovs.16-19600 mashal tayyab, et al 151 pak j ophthalmol. 2021, vol. 37 (2): 147-151 17. ahmad s, sabih a. role of cataract surgery in lowering intraocular pressure. pak armed forces med j. 2015; 1 (3): 402-404. 18. bhallil s, andalloussi ib, chraibi f, daoudi k, tahri h. changes in intraocular pressure after clear corneal phacoemulsification in normal patients. oman j ophthalmol. 2009; 2 (3): 111-113. 19. liu xq, zhu hy, su j, hao xj. effects of phacoemulsification on intraocular pressure and anterior chamber depth. exp ther med. 2013; 5 (2): 507-510. 20. qu j, sasaki h, yaguchi h, nagai k. anterior chamber depth and intraocular pressure changes after uneventful phacoemulsification in eyes without glaucoma. invest ophthalmol vis sci. 2005; 46: 763. 21. dooley i, charalampidou s, malik a, loughman j, molloy l, beatty s, et al. changes in intraocular pressure and anterior segment morphometry after uneventful phacoemulsification cataract surgery. j med assoc. 2011; 24 (2): 716416. 22. takmaz kp, kurkçuoglu p. anterior segment morphometry and intraocular pressure change after uneventful phacoemulsification. turkish j med sci. 2012; 43: 289–293. author’s designation and contribution mashal tayyab: consultant ophthalmologist: concepts, design, literature search, statisitical analysis, manuscript preparation, manuscript editing, manuscript review. awaid abid: medical officer: data acquisition, data analysis, statistical analysis, manuscript editing. .…  …. pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 165 original article comparison between early and late nasolacrimal stents for congenital nasolacrimal obstruction muhammad moin, asif mahmood khokhar, jamshaid hameed pak j ophthalmol 2016, vol. 32, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. asif mahmood khokhar postgraduate trainee lahore general hospital, lahore. e-mail: drasifkhokhar@gmail.com …..……………………….. purpose: to compare the success of silicone tube stents for treatment of congenital nasolacrimal obstruction in children between the age of 1 – 3 years and 3 – 5 years. study design: quasi experimental study. place and duration of study: mayo hospital and lahore general hospital from 2007 to 2016. material and methods: it is a retrospective review of 98 children with epiphora due to congenital nasolacrimal obstruction. all patients less than 5 years with failed probing were included in the study. patients with traumatic nasolacrimal duct obstruction were excluded from the study. patients were divided into 2 groups. in group 1 children between 1–3 years and in group 2 children between 3–5 years were included. patients were seen at follow up at 1 week, 4 weeks and one year at the time of tube removal. success was defined as resolution of epiphora completely or patients having mild epiphora. results: group 1 included 46 patients and group 2 included 52 patients. the success rate in group i (with younger children) was 91% while in group ii (with older children) the success rate was 82%. complications included cheese writing in 3 patients and mild nasal bleeding in 18 patients. conclusion: our study shows that nasolacrimal stent intubation is better option in children with persistent epiphora after failed probing between 1 – 3 years. keywords: epiphora, nasolacrimal stent, congenital nasolacrimal obstruction, silastic nasolacrimal intubation. he most common cause of epiphora in children is congenital nasolacrimal obstruction. it occurs in approximately 5% of newborns1. the most common cause of obstruction in congenital cases is imperforate membrane at the valve of hasner. in 90% of the cases the obstruction resolves spontaneously with massage within first year of life2. in case of non-resolution of epiphora probing is performed between 1-2 years. nasolacrimal stents and balloon dacroplasty are the two most commonly used modalities in cases of failed probing. these techniques are minimally invasive and help in opening the natural tear passage of the patient without any external incision. as the child gets older the success rate of nasolacrimal stents decreases and dacryocystorhinostomy is the procedure of choice after 5 years. the rationale of our study was to compare the success rates of nasolacrimal stents for the treatment of congenital nasolacrimal duct obstruction in children between the age of 1 and 5 years in case of failed probing by dividing them into two groups. materials and methods it was a quasi experimental study of 98 children with t mohammad moin, et al 166 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology epiphora due to congenital nasolacrimal obstruction. we divided them into 2 groups. in group 1 the children were between 1–3 years and in group 2 the children were between 3–5 years. the patients presented in mayo hospital and lahore general hospital between 2007 to 2016. all children less than 5 years of age having failed probing for congenital lacrimal duct obstruction were included in the study. patients with traumatic nasolacrimal duct obstruction were excluded from the study. duration of symptoms and time of previous probing was recorded. epiphora was graded as mild (increased tear lake and occasional watering), moderate (continuous watering) and severe (continuous watering with regurgitation positive). they were operated by a single ophthalmologist. bicanalicular nasolacrimal stents were place and their ends secured in the nose with small piece of silicone tyre. patients were seen at follow up at 1 week, 4 weeks and one year at the time of tube removal. success was defined as resolution of epipora completely or patients having mild epiphora. results there were 46 patients in group 1 and 52 patients in group 2. the success rate in group was 83% while in group 2 success rate was 64%. the male to female ratio was 3:1 between the two groups. complications included cheese wiring in 3 patients and mild nasal bleeding in 18 patients. results are shown in table 1 and 2. discussion in most cases of nasolacrimal obstruction, spontaneous resolution occurs during the first year of life. during this period observation and conservative therapy (massage and topical antibiotics) is recommended. zia et al2 studied that spontaneous resolution of nasolacrimal duct obstruction occurs in most cases with conservative treatment and massage. in another study nasir et al3 showed that spontaneous resolution of nasolacrimal duct obstruction occurs in most infants. they also showed that in majority of cases not table 1: demographic data and outcome. group 1(total 54) group 2 (total 44) p value gender male 35 (65%) 30 (68%) female 19 14 laterality unilateral 44 (81%) 34 (77%) bilateral 10 10 primary success successful 45 (83%) 28 (64.0%) 0.0280 failed 9 16 table2. age outcome cross tabulation outcome total failed successful age 12 – 18 months 2 20 22 19 – 24 months 3 4 7 25 – 30 months 1 1 2 31 – 36 months 3 20 23 37 – 42 months 2 7 9 43 – 48 months 4 12 16 55 – 60 months 10 9 19 total 25 73 98 comparison between early and late nasolacrimal stents for congenital nasolacrimal obstruction pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 167 resolving spontaneously, probing and irrigation is successful. after 12 months of age probing is successful in 70% to 97% of cases4,5. kashkouli et al6 proved that even in older children probing should be adopted as the primary procedure. it is successful even in older children with complex blockage of the nasolacrimal duct. the study conducted by mirza et al7 and eshragi et al8 have shown that even in significant number of adults probing can be considered as an initial treatment. when probing fails and epiphora persists different options have been recommended. traditionally dcr (with or without intubation) is not recommended under the age of 5 years. the rationale is incomplete development of nasal bones at this age. another useful technique is dilation of the nasolacrimal duct with a balloon catheter which is quite expensive9. due to these reasons nasolacrimal stent intubation has been adopted as the procedure of choice. in this procedure a specially designed silicone tube is placed in the lacrimal drainage system. a loop of tube passes through the two puncti followed by passage of the long ends through canaliculi, lacrimal sac and nasolacrimal duct with creation of no new passage. the obstruction in the passage is broken with the help of guiding steel wires. winn et al10 and some others10 have adopted this procedure as first choice even before probing. most of the studies recommend probing as first choice and if probing fails then closed intubation as a second procedure11, 12, 13, 14. various types of tubes for intubation have been used including crawford15 and retleng16.. in our study simple bicanalicular stents were used. saeed et al17 has reported closed intubation with silicone tube as an effective treatment modality for children of age between 1 to 5 years with a follow up of 1 year. rehman et al18 operated on 200 children and reported closed intubation with silicone tube as an effective treatment modality for children between 1 to 4 years of age. our study included 83 children with epiphora due to congenital nasolacrimal obstruction between ages 1 to 5 years. our success rate compares favourably with the study conducted by migliori et al19 for intubation who reported success rate of 91% with intubation as primary procedure. yaziciet al16 have also reported a success rate of 86%. engel and colleagues have reported a success rate of 96%20. in our study the silicone tube was removed after 12 months. however, there is little agreement in the ophthalmic literature on the optimum length of time for removal of silicone tubes after closed intubation. memon et al11 removed tube before 3 months in 6 eyes with resolution of symptoms in 5 eyes. they recommended at least 6 months for retention of tube. engel et al20 reported that there is no impact on the success from premature loss of tube in their large series of cases who underwent primary intubation. migliori et al19 recommend that only 6 weeks are sufficient for retention of tube for a satisfactory outcome. another studyreported that in children younger than 24 months early removal was not significant but in children older than 24 months early removal resulted with poor outcome21. pediatric eye disease investigator group9 evaluated nasolacrimal intubation after dilation with a balloon catheter in cases with failed probing. their success rate was 74% in balloon dilation group compared to 84% in simple intubation with balloon dilation. dortzbach et al14 reported that silicone intubation should be procedure of choice for congenital or acquired nasolacrimal duct obstructions in children after failure of medical therapy and nasolacrimal duct probings. this has been shown in different studies from pakistan22, 23. conclusion our study shows that nasolacrimal stent intubation is better option in children with persistent epiphora after probing. nasolacrimal stents should be procedure of choice for congenital nasolacrimal duct obstructions in children after failure nasolacrimal duct probing. early stents are more favourable as very few cases (9%) need to repeat the procedure. authors affiliation prof. muhammad moin mbbs, frcs, frcophth postgraduate medical institute, lahore lahore general hospital dr. asif mahmood khokhar mbbs, mcps lahore general hospital, lahore dr. jamshaid hameed mbbs lahore general hospital, lahore role of authors prof. muhammad moin study design, data collection, review. mohammad moin, et al 168 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology dr. asif mahmood khokhar manuscript writing. dr. jamshaid hameed data analysis. references 1. okumuş s, öner v, durucu c, coşkun e, aksoy ü, durucu e, şahin l, erbağcı i. nasolacrimal duct intubation in the treatment of congenital nasolacrimal duct obstruction in older children. eye (lond) 2106; 301(1): 85-8. 2. muhammad z, tariq m, shoaib kk, islam zu. timing of probing for congenital nasolacrimal duct obstruction. pak j ophthalmol. 2012; 28(1): 43-46. 3. nasir j, mohyuddin m, bhatti sa. non massaging management of congenital and infantile nasolacrimal duct obstruction. pak j ophthalmol. 2007; 23(2): 84-6. 4. khan n, khan mn, jan s, mohammad s. congenital nasolacrimal duct obstruction: presentation and management. pak j ophthalmol. 2006; 22(2): 74-8 5. stager d, baker jd, frey t, et al. office probing of congenital nasolacrimal duct obstruction. ophthalmic surg 1992; 23 (7): 482–484. 6. kashkouli mb, beigi b, parvaresh mm, kassaee a, tabatabaee z. late and very late initial probing for congenital nasolacrimal duct obstruction: what is the cause of failure? br j ophthalmol. 2003; 87 (9): 1151– 1153. 7. mirza sa, siyal na, memon a, khanzada ma, aqi aem, mirza aa, mirza sa. efficacy of probing in young adult in nasolacrimal duct obstruction. pak j surg. 2012; 28 (4): 301-4. 8. eshragi b, fard ma, masomian b and akbari mr. probing for congenital nasolacrimal duct obstruction in older children. middle east afr j ophthalmol. 2013; 20 (4): 349–352. 9. repka mx, chandler dl, holmes jm, hoover dl, morse cl, schloff s, silbert di, tien dr; pediatric eye disease investigator group. balloon catheter dilation and nasolacrimal duct intubation for treatment of nasolacrimal duct obstruction after failed probing. arch ophthalmol. 2009; 127 (5): 633-9. 10. winn bj, smith sd, garcia dd, jian–amadi a, sires bs. prospective randomised comparison of external dacryocystorhinostomy with and without silicone intubation. br j ophthalmol. 2009; 93(9): 1220-2. 11. memon mn, siddiqui sn, arshad m, altaf s. nasolacrimal duct obstruction in children: outcome of primary intubation. jpma, 2012; 62(12): 1329. 12. mocan mc, gulmez-sevim, kocabeyoglu s, irkec m. prognostic value of metal-metal contact during nasolacrimal duct probing. can j ophthalmol 2015; 50(4):314-7. 13. mauffray ro, hassan as, elner vm. double silicone intubation as treatment for persistent congenital nasolacrimal duct obstruction. ophthal plast reconstr surg. 2004; 20 (1): 44-9. 14. dortzbach rk, france td, kushner bj, gonnering, rs. silicone intubation for obstruction of the nasolacrimal duct in children. am j ophth 1982; 94(5): 585-90. 15. al-faky yh, mousa a, kalantan h, al-otaibi a, alodan h, alsuhaibani ah. a prospective, randomized comparison of probing versus bicanalicular cy6silastic intubation for congenital nasolacrimal duct obstruction. br j ophthalmol 2015; 99(2):246-50. 16. yazici b, akarsu c, salkaya m. silicone intubation with ritleng method in children with congenital nasolacrimal duct obstruction. jaapos, 2006; 10(4): 328-32. 17. saeed m, ghaffar z, farhat f, ahme n. nasolacrimal duct obstruction in infants: a simple technique of silicon intubation. j sheikh zayed med coll 2011; 2 (1): 144-7. 18. rehman a, qayyum i, zain-ul-abidin a, iqbal n, iqbal j, hussain m. timing of closed intubation in recurrent epiphoric children. pak j ophthalmol. 2014; 30 (1): 42-44. 19. migliori me, putterman am. silicone intubation for the treatment of congenital lacrimal duct obstruction: successful results removing the tubes after six weeks. ophthalmology, 1988; 95(6): 792-5. 20. engel jm, hichie–schmidt c, khammar a, ostfeld bm, vyas a, ticho bh. monocanalicular silastic intubation for the initial correction of congenital nasolacrimal duct obstruction. jaapos, 2007; 11(2): 1836. 21. zafar sn, khan a, azad n. treatment outcome of intubation in congenital nasolacrimal duct obstruction. al-shifa j ophthalmol 2007; 3 (1): 31-4. 22. mehmood t. watery eyes (editorial). pak j ophthalmol. 2006; 22: 58-9. 23. maheshwari r, maheshwari s. late probing for congenital nasolacrimal duct obstruction. jcpsp, 2007, 17 (1): 41-43. pak j ophthalmol. 2021, vol. 37 (3): 278-282 278 original article outcome of ahmed glaucoma valve in refractory glaucoma – our population analysis saadia farooq 1 , momina faisal 2 , hajra farooq 3 department of ophthalmology, 1 shifa international hospital, islamabad, 2,3 agha khan university abstract purpose: to find out the outcomes of ahmed glaucoma valve (agv) implantation in a tertiary care hospital. study design: retrospective case series. place and duration of study: shifa international hospital islamabad from january 2018 to july 2020. methods: this retrospective case series of 19 eyes of 17 patients with refractory glaucoma included patients who underwent agv implantation with a follow-up period of 6 months to 01 year. agv was done as a primary procedure in 3 patients and secondary procedure in 17 patients after a previously failed trabeculectomy. all patients underwent complete eye examination, before surgery and then at 1 month, 2months, 6 months and 1 year. goldman tonometer was used to check iop. complications, interventions and the number of anti-glaucoma medications (in post-operative period) needed to achieve the target pressure were noted. success was defined as an iop of less than 18 mm hg, with or without a single anti-glaucoma medication. results: complete success was achieved in 57.9% and conditional success in 42.2%. the most common complication was encapsulated cyst formation in 31.6% and post-operative interventions were bleb deroofing in 10.5%, tube readjustment and tube wash in 10.5% and yag vitreolysis in 5.3%. conclusion: agv is an effective and relatively safe procedure in refractory glaucoma irrespective of initial diagnosis and age of the patient. encapsulated bleb was the commonest complication. key words: ahmad glaucoma valve, glaucoma, intra ocular pressure. how to cite this article: farooq s, faisal m. farooq h. outcome of ahmed glaucoma valve in refractory glaucoma – our population analysis. pak j ophthalmol. 2021, 37 (3): 278-282. doi: 10.36351/pjo.v37i3.1206 introduction glaucoma is the most common irreversible cause of blindness globally. 1 of an estimated 79.6 million people worldwide, glaucoma prevalence was more than 50% among asians. 2 .the aim of glaucoma management is to prevent progression of disease and prevent blindness by lowering iop. this can be achieved by medications, lasers or surgical treatments. considering the high risk of scarring in asian eyes correspondence: momina faisal shifa international hospital, islamabad email: mominafaisal17@gmail.com received: january 16, 2021 accepted: april 28, 2021 (which limits the success of glaucoma surgery), there is an increasing shift from simple trabeculectomy to the use of mitomycin and glaucoma drainage devices. 3 many surgical techniques are in practice for refractory glaucoma such as use of mitomycin c, augmented trabeculectomy and the use of glaucoma drainage devices. glaucoma drainage devices are commonly used worldwide for refractory glaucoma especially when filtering surgery has failed or there is a high risk of failure. ahmed valve with a protective sleeve opening at pressure higher than 8 mmhg reduces the risk of post-operative hypotony as compared to non-valve devices. 4 many studies have reported successful iop control after agv implant. 3,4,5 the reported complications are similar to those of tube surgery i.e. tube blockage, retraction, exposure, hypotony, cataract and corneal decompensation. 6 open access momina faisal, et al 279 pak j ophthalmol. 2021, vol. 37 (3): 278-282 this study was conducted to see the efficacy, complications and visual outcome in refractory glaucoma in al-shifa trust hospital. methods we analyzed the clinical records of glaucoma patients who underwent agv implantation at shifa international hospital, islamabad, pakistan, between january 2018 to july 2020. ethical approval was obtained from ethical committee at shifa international hospital. patient diagnosed with refractory glaucomas (primary agv) or previous failed glaucoma surgeries (secondary agv), iop higher than the target with maximum topical anti-glaucoma patients and record of minimum post-operative follow-up of greater than 6 months were included. age less than 10 years (pediatric glaucoma) and patients with a follow-up of less than 6 months were excluded. all surgeries were performed by a single surgeon. fp7/fp8 was implanted superotemporally under general anesthesia. 2% xylocaine with adrenaline was used to dissect conjunctiva and tenon superotemporally . fp7/ fp8 (in small hypermetropic eyes.) was primed and stitched with 8-0 proline, 8-10 mm from limbus. a tube was inserted in anterior chamber (phakic eyes) and ciliary sulcus (pseudophakic eyes) via entry made with 23-gauge needle 2.53 mm from limbus. tube end was trimmed for not more than 3mm entry in anterior chamber with bevel up or just at pupil edge when in ciliary sulcus with bevel down. the tube was covered with partial thickness donor scleral flap stitched with 7-0 vicryl. conjunctiva and tenon was stitched with 7-0 vicryl at limbus. success was defined as: complete successiop 6-18 mmhg without antiglaucoma treatment and improved or stable visual acuity compared to pre-operative iop. conditional success-iop less than 18 mmhg with 1 or 2 anti-glaucoma medications with stable visual acuity as compared to pre-operative iop. failure-iop higher than 23 mmhg with 2 or more anti-glaucoma medications, severe co-morbids such as choroidal detachment, recurrent encysted needing revision more than 3 times. visual status was defined in the following terms: improved visual acuity; if the best corrected visual acuity improved at least one line in last follow-up. stable visual acuity; best corrected vision acuity remained stable. decreased visual acuity; best corrected vision acuity decreased at least one line or more. regular follow-ups were conducted on post-op day 1, 1 week, 1 month, 3 months, 6 months, 1 year and 2 years. statistical analysis of all data was conducted using the spss 21. analysis was done using t-test. a p value < 0.05 was considered statistically significant. the following variables were assessed as influencing factors for surgical failure: age, gender, previous operation history, primary disease, and preoperative iop. results agv fp-7/fp-8 was performed in 19 patients. among them 13 were male and 6 were females. mean age was 45.167 plus minus 20.549. all patients were on maximum anti-glaucoma treatment with 84.2% having table 1: pre/postoperative vision. frequency percent valid percent cumulative percent < 6/60 10 52.6 52.6 52.6 6/36 – 6/12 6 31.6 31.6 84.2 6/9 – 6/6 3 15.8 15.8 100.0 total 19 100.0 100.0 < 6/60 5 26.3 26.3 26.3 6/36 – 6/12 9 47.4 47.4 73.7 6/9 – 6/6 5 26.3 26.3 100.0 total 19 100.0 100.0 figure 1: post operative iop. outcome of ahmed glaucoma valve in refractory glaucoma pak j ophthalmol. 2021, vol. 37 (3): 278-282 280 table 2: frequency of different glaucoma. frequency percent valid percent cumulative percent previous failed surgeries 2 10.5 10.5 10.5 ice syndrome 1 5.3 5.3 15.8 valid neurovascular glaucoma 5 26.3 26.3 52.6 angle closure glaucoma 2 10.5 10.5 63.2 post virectomy glaucoma 5 26.3 26.3 89.5 steroid induced glaucoma 1 5.3 5.3 94.7 juvenile glaucoma 1 5.3 5.3 100.0 total 19 100.0 100.0 1 or more than 1 previous surgery and 15.8% had primary valve implantation. a total of 89.5% eyes received fp-7 implant and 10.5% received fp-8 implant. preoperatively 5.3% patients had iop in the range of range of 11-20mmhg, whereas at 1 month the percentage increased to 73.7%, at 2 months 68.4% and at 1 year 92.2% patients fell in this range. the number of medications were reduced from4 to nil in 57.9%, 1 drug in 21.1% and 2 drugs in 21.1%. complete success was achieved in 57.9% and conditional success in 42.2%. the most common complication was encapsulated cyst formation in 31.6% and post-operative interventions were bleb deroofing in 10.5%, tube readjustment and tube wash in10.5% and yagvitreolysis in 5.3%. discussion ahmed glaucoma valve (fp-7 and fp-8) is a promising treatment for refractory glaucoma either in primary procedure or previous failed filtration surgeries. overall success rate is reported from 60%to 100% at 1 year follow-up in different case series. 7 most such studies are from developed countries 8 , very few from middle east. 9,10 in our study agv implant decreased the mean preoperative iop from 41.58 mmhg to 13.77 mmhg at 1 year, reducing the number of medications from 4 to nil in 57.9%. this corresponds with zarei et al who reported mean iop decrease from 30.8 ± 5.6 to 20 ± 6.4 mmhg at 4 years follow-up. 11 souza et al 7 and wishart et al 8 reported significant reduction in medication after agv implantation. in our study complete success was achieved in 57.9% and conditional success in 42.2%, which did not vary with different types of glaucoma, age, gender or indication for surgery. this is contrary with smith et al who reported complete success in 10.5% and guarded success in 73.7%. 12 in another study increased risk of agv failure was seen with previous incisional surgeries. 13 favorable surgical outcome is reported by souza et al 7 and zarei et al 11 reporting 50% success at 5 years and 70% at 4 consecutive years respectively. differences in study population implants, duration of follow-up and surgical techniques could explain the differences in success rates. major cause of failure was fibrosis and encapsulated bleb in 31.6% of the cases, which is consistent with other reports. 14 deroofing of bleb was done in 10.5%, with success in 66.7%.valimaki et al reported 52% success and lai et al reported 87.5% success in bleb revision. 15,16 tube erosion and implant extrusion were reported by lai et al in 3.1% and 6.2% respectively. 16 we have seen no such complication till one year follow up because scleral patch graft was used to cover the tube. quaranta et al achieved better outcome with bovine pericardial implants to cover the valve. 17 zarei et al reported corneal decomposition in 10.7% due to tube touch. 11 where as in our study it was seen in 5.27% patients who were successfully managed by tube placement revision. different studies have reported hypotony varying from 9.4% to 12%. 18,19 cataract formation is reported in 7.25% by zareietal 11 and endophthalmitis in 6.3%. 20,21 (28,29). no such complication was seen in our study group. limitation of our study is that it was a retrospective study with a small sample size and a follow-up of one year. conclusion ahmed glaucoma valve is an effective way to manage refractory glaucoma irrespective of etiology. proper technique with posterior placement of valve, sealed conjunctival closure and short, trimmed tube in anterior chamber/posterior chamber maximally away from cornea reduces chances of unexpected momina faisal, et al 281 pak j ophthalmol. 2021, vol. 37 (3): 278-282 complications. bleb encapsulation was the most common complication affecting outcome. this probably needs more modifications like tenon excision, blunt dissection of conjunctiva and tenon with subconjunctival irrigation or use of antimetabolites. ethical approval the study was approved by the institutional review board and ethics committee, shifa international hospital islamabad. (irb#294-1114-2020) conflict of interest authors declared no conflict of interest. references 1. toh zh, lee csy, chew acy, perera s. time heals all wounds: obstacles in glaucoma surgery from an asian perspective. proc singap healthc. 2015; 24 (2): 103–112. 2. the number of people with glaucoma worldwide in 2010 and 2020 | br j ophthalmol. available from: https://bjo.bmj.com/content/90/3/262.short 3. elhefney e, mokbel t, abou samra w, kishk h, mohsen t, el-kannishy a. long-term results of ahmed glaucoma valve implantation in egyptian population. int j ophthalmol. 2018; 11 (3): 416–421. 4. xu y, hong t, li w. long-term outcomes of ahmed glaucoma valve implantation for treating refractory glaucoma. zhonghua yi xue za zhi. 2015; 95 (6): 440–443. 5. erçalık ny, i̇mamoğlu s. ahmed glaucoma valve implantation in vitrectomized eyes. j ophthalmol. hindawi; available from: https://www.hindawi.com/journals/joph/2018/9572805/ accessed 5, may 2020. 6. aqueous drainage device surgery in refractory pediatric glaucomas: i. long-term outcomes science direct. available from: https://www.sciencedirect.com/science/article/abs/pii/s 1091853107004065. accessed 5, may 2020 7. souza c, tran dh, loman j, law sk, coleman al, caprioli j. long-term outcomes of ahmed glaucoma valve implantation in refractory glaucomas. am j ophthalmol. 2007; 144 (6): 893–900. 8. wishart pk, choudhary a, wong d. ahmed glaucoma valves in refractory glaucoma: a 7-year audit. br j ophthalmol. 2010; 94 (9): 1174–1179. 9. aljazzaf am, abdelmoaty sma, behbehani ah, abdulmuez aa, aljazzaf ha. the outcome of the ahmad glaucoma valve implantation for refractory glaucoma in kuwait. saudi j ophthalmol. 2013; 27 (1): 15–18. 10. alasbali t, alghamdi aa, khandekar r. outcomes of ahmed valve surgery for refractory glaucoma in dhahran, saudi arabia. int j ophthalmol. 2015; 8 (3): 560–564. 11. zarei r, amini h, daneshvar r, nabi fn, moghimi s, fakhraee g, et al. long-term outcomes of ahmed glaucoma valve implantation in refractory glaucoma at farabi eye hospital, tehran, iran. middle east afr j ophthalmol. 2016; 23 (1): 104–109. 12. smith m, geffen n, alasbali t, rachmiel r, buys ym, trope ge. outcome of ahmed valve implantation when preoperative iop less than 21 mm hg. j glaucoma. 2009; 18 (9): 674–678. 13. gedde sj, schiffman jc, feuer wj, herndon lw, brandt jd, budenz dl, et al. three-year follow-up of the tube versus trabeculectomy study. am j ophthalmol. 2009; 148 (5): 670–684. 10. kirwan c, o’keefe m, lanigan b, mahmood u. ahmed valve drainage implant surgery in the management of paediatric aphakic glaucoma. br j ophthalmol. 2005; 89 (7): 855–858. 11. chen tc, bhatia ls, walton ds. ahmed valve surgery for refractory pediatric glaucoma: a report of 52 eyes. j pediatr ophthalmol strabismus, 2005; 42 (5): 274–283. 12. a one-piece drainage system for glaucoma surgery. europe pmc. available from: http://europepmc.org/article/med/3477894. accessed may 7 2020. 13. lee jh, kim ss, hong yj. a clinical study of the ahmed valve implant in refractory glaucoma. j korean ophthalmol soc. 2001; 42 (7): 1003–1010. 14. eibschitz-tsimhoni m, schertzer rm, musch dc, moroi se. incidence and management of encapsulated cysts following ahmed glaucoma valve insertion. j glaucoma, 2005; 14 (4): 276–279. 15. välimäki j, tuulonen a, airaksinen pj. capsule excision after failed molteno surgery. ophthalmic surg lasers, 1997; 28 (5): 382–386. 16. lai js, poon as, chua jk, tham cc, leung at, lam ds. efficacy and safety of the ahmed glaucoma valve implant in chinese eyes with complicated glaucoma. br j ophthalmol. 2000; 84 (7): 718–721. 17. quaranta l, riva i, floriani ic. outcomes of using a sutureless bovine pericardial patch graft for ahmed glaucoma valve implantation. eur j ophthalmol. 2013; 23 (5): 738–742. 18. ayyala rs, zurakowski d, smith ja, monshizadeh r, netland pa, richards dw, et al. a clinical study of the ahmed glaucoma valve implant in advanced glaucoma. ophthalmology, 1998; 105 (10): 1968–1976. 19. topouzis f, coleman al, choplin n, bethlem mm, hill r, yu f, et al. follow-up of the original cohort with the ahmed glaucoma valve implant. am j ophthalmol. 1999; 128 (2): 198–204. outcome of ahmed glaucoma valve in refractory glaucoma pak j ophthalmol. 2021, vol. 37 (3): 278-282 282 20. gedde sj, scott iu, tabandeh h, luu kk, budenz dl, greenfield ds, et al. late endophthalmitis associated with glaucoma drainage implants. ophthalmology, 2001; 108 (7): 1323–1327. 21. rao a, wallang b, padhy tr, mittal r, sharma s. dual infection by streptococcus and atypical mycobacteria following ahmed glaucoma valve surgery. semin ophthalmol. 2013; 28 (4): 233–235. authors’ designation and contribution saadia farooq; consultant ophthalmologist: concepts, design, data acquisition, manuscript preparation, manuscript review. momina faisal; mbbs student: literature search, manuscript preparation, manuscript editing, manuscript review. hajra farooq; mbbs student: data analysis, statistical analysis, manuscript preparation. .…  …. pak j ophthalmol. 2021, vol. 37 (1): 115-119 115 original article outcomes of rhegmatogenous retinal detachment muhammad tariq khan 1 , sidrah riaz 2 , khurram azam mirza 3 1-2 akhtar saeed medical & dental college, lahore, 3 hameed latif medical centre, lahore, abstract purpose: to study demographic characteristics and treatment outcomes of rhegmatogenous retinal detachment in a private vitreo-retinal setup of lahore. study design: cross sectional observational study. place and duration of study: lahore medicare eye center, from march 2017 to april 2019. methods: total 102 patients with rhegmatogenous retinal detachment (rrd) were included. patients with retinal detachment other than rrd were excluded. detailed history and ocular examination was performed. type of break, procedure adopted for rrd repair and type of endo-tamponade were also recorded. these patients had either 23 g pars plana vitrectomy (ppv) or scleral buckling (sb) procedures or combined scleral buckling with ppv. patients were followed-up for six months. results: out of 102 total rrd cases, 63.70% were males and 36.30% were females. mean age was 47.44 ± 18.44 years. macula was attached in 48% and off in 52%. phakic patients were 53.92%, pseudophakic 41.19% and aphakic 4.90%. position of break in rrd was superotemporal in 39.2%, inferotemporal in 30.4% and inferonasal in 2.9%. total rrd was observed in 27.5% patients. one or more breaks were identified in 82.4% patients and giant tear in 4.9%. three ports 23 g ppv was done in 64.7%, ppv with iol in 18.6%, scleral buckling in 10.8% and combined ppv + sb in 5.9% patients. anatomical success was achieved in 96.07% patients on first attempt while 3.9% needed second surgery within six months of follow-up. conclusion: anatomical success rate in retinal attachment surgeries in experienced hands is comparable with leading international retinal centers of the world. key words: rhegmatogenous retinal detachment, pars plana vitrectomy, scleral buckling, silicon oil. how to cite this article: khan mt, riaz s, mirza ka. outcomes of rhegmatogenous retinal detachment. pak j ophthalmol. 2021, 37 (1): 115-119. doi: https://doi.org/10.36351/pjo.v37i1.1073 introduction retinal detachment includes rhegmatogenous, tractional and exudative types. 1,2 rrd is the commonest type of retinal detachment with worldwide incidence of 6.3 to 17.9 per 100,000 populations. 3 vitreous is a unique structure, composed of water, collagen fibers and hyaluronic acid which plays a correspondence: sidrah riaz akhtar saeed medical & dental college, lahore email: sidrah893@yahoo.com received: 2021 accepted: 2021 pivotal role in the development of rrd. the giant retinal tear (grt) is defined as full thickness retinal break in neurosensory retina with circumferential extent of at least 3 clock hours in the presence of posterior vitreous detachment (pvd). 4 rrd can result in total vision loss if not treated timely and properly. there are many approaches for treatment of retinal detachment like scleral buckling (sb), pars plana vitrectomy (ppv), combined sb and ppv and pneumatic retinopexy. history of scleral buckling dates back to 1950 5 and ppv was introduced in 1971 by robert machemer 6 , who used disposable 17-gauge cutter. recently 20g, 23g, 25g and 27g ppv is being used by different eye muhammad tariq khan, et al 116 pak j ophthalmol. 2021, vol. 37 (1): 115-119 surgeons in different centers. 7 these three techniques are used interchangeably depending upon the surgeon’s skills, training, type of retinal detachment, age of patient, lens status, ocular media clarity and vitreous status. the traditional sb procedure is performed usually in young phakic patients and ppv in pseudophakic patients with pvd and complicated rrd. sb has advantage of early visual rehabilitation and prevention of cataract formation whereas ppv has benefit of less pain and management of large, posterior breaks under l/a. in international literature the surgical success rate of retinal surgery in terms of achieving retinal attachment for rrd is variable. for sb, it is 74 – 94% and for ppv, it is 75 – 96%. 8,9 the commonly used agents for internal tamponade are silicon oil, expansile gases, perfluorocarbon liquid (pfcl) and semiflourinated alkanes. 10 the choice of internal tamponading agent is a debatable issue but silicon oil is commonly used in retinal surgeries since 1962 when cibis used it for the first time in management of rd. purpose of this study was to find out the demographic characteristics and anatomical results of rrd in a private set up in lahore, pakistan. methods after approval from ethical review board, patients were recruited by convenient sampling technique. over the two years period from march 2017 to april 2019, all patients with rhegmatogenous retinal detachment (rrd) presenting to private vitreoretinal surgeon were included in the study. all surgeries were performed at lahore medicare eye center, lahore. the diagnosis was clinical and b scan was done if required. other causes of retinal detachments like tractional retinal detachment (trd), combined rrd and trd, exudative retinal detachments and funnelshaped rd were excluded. total 102 eyes were included in this study. surgeries were performed under local or general anesthesia depending upon patient’s age, procedure and patient’s health. all cases were done by a single senior retinal surgeon. detailed history and ocular examination were performed. patients were also enquired about associated factors like history of trauma and refractive error. patient’s age, gender, laterality of eye, lens status, macular status, position and type of break, procedure adopted for rrd repair and type of endo-tamponade were noted. sb was performed under general anesthesia (ga). after 360º peritomy, 3.5 mm silicon band was anchored with 5/0 ethibond. srf drainage and cryotherapy was done with indirect ophthalmoscope. peritomy was closed with 6/0 vicryl. 23-g ppv was performed under local anesthesia (la) or ga, with 3ports using biom viewing system. vitrectomy was completed after staining with triamcinolone and indentation for peripheral shaving. retinotomy was done at suitable site to drain srf. air fluid exchange, endolaser, injection of suitable tamponading agent and digital checking of iop were done before port closure. patients were advised antibiotic eye drops, oral medicines and postoperative positioning. follow-up was done on the first day, one week and one month postoperatively. these patients were followed-up for six months. on each visit, vision, retinal status and intraocular pressures were checked. data was analyzed using spss 25. results there were 102 rrd cases, 93 primary rd (65 males, 37 females) and 9 with re-detachment after failed primary surgery (done somewhere else and referred for second surgery). mean age was 47.44 ± 18.44 years (fig 1). for further details, see table 1 and 2. fig. 1: age distribution in rrd patients. table 1: general characteristics. gender male 65 63.70% female 37 36.30% macula macula off 49 48.00% macula on 53 52.00% outcomes of rhegmatogenous retinal detachment pak j ophthalmol. 2021, vol. 37 (1): 115-119 117 lens pseudophakia 42 41.18% phakia 55 53.92% aphakia 5 4.90% rd position superotemporal 40 39.20% inferotemporal 31 30.40% superonasal 0 0.00% inferonasal 3 2.90% total rd 28 27.50% eye right 49 48.00% left 53 52.00% anesthesia la 80 78.40% ga 22 21.60% break no break 13 12.70% one or more 84 82.40% giant tear 5 4.90% tamponade silicon oil 1000 50 49% silicon oil 5000 34 33.33% gas 7 6.90% procedure ppv 66 64.70% ppv + iol 19 18.60% sb 11 10.80% combined 6 5.90% table 2: procedure & lens status. procedure phakic pseudo phakia aphakia ppv 22 41 3 ppv + iol 19 0 0 sb 10 1 0 combined 4 0 2 discussion the visual loss due to rhegmatogenous retinal detachment remains a major concern for vitreoretinal surgeons as rd affects 0.6 to 1.8 people/100000/ year. 11 in this study, maximum number of patients were between 50 and 60 years. studies from united states and european countries have shown similar single peaked age distribution but data from east asia and scotland, on the contrary, had showed bi modal age distribution in patients of rrd. first peak in age group 20 – 30 years and 2 nd in 60 – 70 years. 12-14 it may be associated with increased prevalence of myopic refractive error in young population. mean age of patients with rrd in our study for phakic patients was 41.22 years and 56.19 years for pseudophakic patients. the younger patients were more in sb and combined ppv+sb group. pseudophakia was an important factor associated with development of rrd. the literature review has revealed that pseudophakic patients with rrd were in their 6 th decade at the time of presentation. 15 large scale studies have consistently confirmed that frequency of rrd was more in men than women. 16-18 our data showed male to female ratio of 2:1. the reason for male predominance in rrd patients is not clear. as more men are bread-earning members of their family in asian families so they are more prone to external environment and blunt trauma. an interesting finding was identification of more temporal retinal breaks 71 (69.60%), which may be related to early presentation as patients become symptomatic early due to involvement of central vision. one or more than one breaks were identifiable in 89 (87.30%) and no break was found in 13 (12.70%). myopia was a common association of rrd in younger age group, observed in 13 (28.26%) cases. vitreous degeneration and liquefaction with increasing age, myopia and cataract surgery, resulting in pvd, is an important factor in pathogenesis of rrd. 19,20 pars plana vitrectomy (ppv) with or without iol implantation is a common procedure adopted worldwide for rd repair. pars plana vitrectomy showed better outcome as compared to sb in pseudophakic rrd. 21,22 pseudophakia was poor prognostic factor in management of rrd using sb but not with ppv. 21 pars plana vitrectomy is also indicated in complicated rrd with proliferative vitreoretinopathy (pvr). recent advancement in technology had made vitrectomy more common procedure in management of phakic rrd. 23 majority of ophthalmic surgeons are of the opinion that ppv alone without sb is enough for successful repair of rrd. 24 better vitrectomy instruments and wide angle viewing system may be the reason for dramatic increase in ppv procedures. advantage of sb over ppv include prevention of cataract progression, early visual rehabilitation and no specific head position restriction after surgery. repeated taking on and off the indirect ophthalmoscope, deeper anesthesia, and myopic shift induction postoperatively are relatively undesirable effects. complications associated with silicon oil are raised iop, cataract formation and emulsification which were managed medically or surgically by same principal surgeon. successful surgical repair was achieved in majority of cases after single surgery, only 4% required 2 nd operation. muhammad tariq khan, et al 118 pak j ophthalmol. 2021, vol. 37 (1): 115-119 the limitations of study are retrospective nature of study, small sample size and private sector patients so financial matter can create bias. there is a need of multicentric studies on larger number of patients. conclusion anatomical success rates in retinal attachment surgeries in experienced hands are comparable with leading international retinal centers of the world. ethical approval the study was approved by the institutional review board/ ethical review board. (et/02/17) conflict of interest authors declared no conflict of interest. references 1. park sj, choi nk, choi nk, park kh, woo sj. five year nationwide incidence of rhegmatogenous retinal detachment requiring surgery in korea. plos one, 2013; 8 (11): e80174. 2. mitry d, fleck bw, wright af, campbell h, charteris dg. pathogenesis of rhegmatogenous retinal detachment: predisposing anatomy and cell biology. retina. 2010; 30 (10): 1561–1572. 3. jamil h, farooq n, khan mt, jamil az. characteristics and pattern of rhegmatogenous retinal detachment in pakistan. j coll physician surg pak. 2012; 22: 501-504. 4. shunmugam m, ang gs, lois n. giant retinal tears. surv ophthalmol. 2014; 59 (2): 192–216. 5. awan a. primary rhegmatogenous retinal detachment surgery in modern era. pak j ophthalmol. 2018; 34 (2). doi. /10.36351/pjo.v 34 i 2.223. 6. machemer r, buettner h, norton ew, parel jm. vitrectomy: a pars plana approach. trans am acad ophthalmol otolaryngol. 1971; 75 (4): 813–820. 7. grosso a, arias l, mariotti c, faraldi f, panico c, figueroa m. recent advancements in vitreoretinal techniques – a critical reappraisal. eur ophth rev. 2014; 8 (1): 46–52. doi: 10.17925/eor.2014.08.01.46 8. park sw, kwon hj, kim hy, byon is, lee je, oum bs. comparison of scleral buckling and vitrectomy using wide angle viewing system for rhegmatogenous retinal detachment in patients older than 35 years. bmc ophthalmol. 2015; 115: 121. 9. kobashi h, takano m, yanagita t, shiratani t, wang g, hoshi k, et al. scleral buckling and pars plana vitrectomy for rhegmatogenous retinal detachment: an analysis of 542 eyes. curr eye res. 2014; 39 (2): 204–211. 10. vaziri k, schwartz sg, kishor ks, flynn hw jr. tamponade in surgical management of retinal detachment. clin ophthalmol. 2016; 10: 471-476. 11. mitry d, charteries dg, fleck bw, campbell h, singh, j. the epidemiology of rhegmatogenous retinal detachment: geographical variation and clinical associations. br j ophthalmol. 2010; 94 (6): 678-684. doi:10.1136/bjo.2009.157727 12. park sj, choi nk, park kh, woo sj. five year nationwide incidence of rhegmatogenous retinal detachment requiring surgery in korea. plos one, 2013; 8 (12): e80174. 13. mitry d, chalmers j, anderson k, williams l, fleck bw. temporal trends in retinal detachment incidence in scotland between 1987 and 2006. br j ophthalmol. 2011; 95: 365–369. 14. mitry d, singh j, yorston d, siddiqui ma, wright a. the predisposing pathology and clinical characteristics in the scottish retinal detachment study. ophthalmology, 2011; 118: 1429–1434. 15. heimann h, bartz-schmidt ku, bornfeld n, weiss c, hilgers rd, foerster mh. scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study group scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. ophthalmology, 2007; 114 (12): 2142– 2154. 16. wong ty, tielsch jm, schein od. racial difference in the incidence of retinal detachment in singapore. arch ophthalmol. 1999; 117: 379–383. 17. polkinghorne pj, craig jp. northern new zealand rhegmatogenous retinal detachment study: epidemiology and risk factors. clin experiment ophthalmol. 2004; 32: 159–163. 18. limeira-soares ph, lira rp, arieta ce, kara-jose n. demand incidence of retinal detachment in brazil. eye (lond). 2007; 21: 348–352. 19. elige c, christophe m, john c, bruno m, francos d. ppv and sb for patients with retinal detachment. ophthalmology, 2018; 9 (6): 425-429. 20. degirmenci c, afrashi f, mentes j, oztas z, nalcaci s, akkin c. evaluation of posterior vitreous detachment after uneventful phacoemulsification surgery by optical coherence tomography and ultrasonography. clin exp optom. 2017; 100 (1): 49– 53. 21. hocaoglu m, karacorlu m, ersoz mg, muslubas is, arf. vitrectomy with silicon oil tamponade for retinal detachment associated with giant retinal tear: favorable outcomes without scleral buckling. acta ophthalmol. 2019; 97: 271-276. 22. arya av, emerson jw, engelbert m, hagedorn cl, adelman ra. surgical management of pseudophakic retinal detachments: a meta-analysis. ophthalmology, 2006; 113 (10): 1724–1733. outcomes of rhegmatogenous retinal detachment pak j ophthalmol. 2021, vol. 37 (1): 115-119 119 23. park sj, cho sc, choi nk, park kh, woo sj. age, sex, and time-specific trends in surgical approaches for rhegmatogenous retinal detachment: a nationwide, population-based study using the national claim registry. retina, 2017; 37 (12): 2326–2333. 24. wong cw, wong wl, yeo iy, loh bk, wong ey, wong dw, et al. trends and factors related to outcomes for primary rhegmatogenous retinal detachment surgery in a large asian tertiary eye centre. retina, 2014; 34 (4): 684-692. authors’ designation and contribution muhammad tariq khan; professor: concepts, literature research, manuscript editing, manuscript review. sidrah riaz; assistant professor: design, literature research, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing. khurram azam mirza; consultant ophthalmologist: literature research, manuscript editing, manuscript review. .…  …. pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 169 original article comparison of secondary anterior and posterior intraocular lens implantation for aphakia syed shahid asad, arshad sheikh, uzma fasih pak j ophthalmol 2016, vol. 32, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. syed shahid asad assistant professor department of ophthalmology karachi medical and dental college, and abbasi shaheed hospital, karachi e.mail: drshahidasad@hotmail.com …..……………………….. purpose: to study the visual outcomes and complications after secondary anterior and posterior intraocular lens implantation surgery in aphakic patients. study design: quasi experimental study. place and duration of study: ophthalmology dept. abbasi shaheed hospital, karachi from 30-7-2002 to 30-6-2003. material and methods: we selected 40 aphakic patient for secondary intraocular lens (iol) implantation from the outpatient department. a proforma was filled pre and postoperatively. patients were followed up for at least two months. the statistical data analysis was done on spss version 13. all aphakic patients came to eye outpatient department were asked to participate in the study. secondary intraocular lens implantation was done along with peripheral iridectomy, broad iridectomy, vitrectomy and corneal repair according to the requirement. results: eighteen (45%) patients were male and 22 (55%) patients were female. patients were between 20 to 60 years of age. thirty three (82.5%) patients had senile cataract while 7 (17.5%) patients had traumatic cataract. most of traumatic cataract patient were below 30 years of age. twenty seven (67.5%) patients had secondary anterior chamber intraocular lens (ac iol) and 13 (32.5%) patients had secondary posterior chamber intraocular lens (pc iol) implantation done. visual status after pc iol implantation was better in 69.2%, remained same in 15.3% and decreased in 15.3% of patient while visual status after ac iol improved in 62.9%, remained same in 25.9% and decreased in 11.11%. vitrectomy was done in 15% of the patients who had ac iol. there was increase in intraocular pressure which was controlled by medication. three (7.5%) patients had vitritis while 2 (5%) patients had iris prolapse that was adequately managed. conclusion: secondary pc and ac iol implantation produces similar results and should be the procedure of choice and for the visual rehabilitation in aphakic patients. key words: aphakia, secondary intraocular lens implantation, visual rehabilitation. he leading cause of treatable blindness in pakistan is age related cataract. the united nations population division has labeled cataract as the most prevalent ophthalmic disease and aphakia is considered to be the first complication of cataract surgery1,2. spectacle lenses were acceptable 30 years ago because of two reasons. first, no other method of aphakic correction was available and secondly, the cataract was fully mature or nearly so in one eye and the vision was greatly reduced in the second eye, so that vision improvement was dramatic for the patient, t syed shahid asad, et al 170 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology when spectacles were provided. the visual acuity may be good, but the patient faced the problems like, enlarged images, about 1/3 of normal size, prismatic effect, aberrational effects, decreased visual fields, ring scotoma, jack-in-box phenomenon and misjudgment of the distance leading to difficulty in daily routine life. there is no binocular vision if the other eye is phakic with good vision3. although contact lenses overcomes many of these problems, but most aphakic patients are old and slow to adopt and learn. contact lenses are unsuitable for use in dusty environment and most unilateral aphakic patients stop wearing a contact lens within two years4. with contact lens there is also binocularity problem, which can be improved with an intraocular lens.5 graham et al demonstrated a low success rate with the use of daily wear and extended wear contact lens for aphakia in over 70 years of age and suggested that this group of patients should be given full consideration for secondary intraocular lens implant procedures6. this practice of secondary intra-ocular lens implantation in management of aphakia has gained wide-spread acceptance in usa7-11. the implantation of an intra-ocular lens in an already aphakic eye is termed as “the secondary intraocular lens implantation”. these lenses can be implanted in anterior or posterior chamber of an eye. extracapsular cataract extraction provides support for posterior chamber implants. it has less complication than anterior chamber implants, so considered to be a preferred procedure. posterior chamber lens can be fixed without the capsular support due to new techniques12-13. in case of posterior capsular rupture, vitreous loss or intracapsular cataract extraction, anterior chamber lens implantation should be considered as the most suitable procedure, although it may lead to complications like cystoid macular edema, retinal detachment, uveitis and bullous keratopathy, increase iop. modified techniques, use of viscoelastics and improved quality of lenses have make less chance of complications than earlier. the rationale of our study is to compare the results of secondary anterior and posterior chamber intraocular lens implantation in patients with aphakia due to various reasons. material and methods the study design was quasi interventional/ comparative. done at ophthalmology department abbasi shaheed hospital, karachi, from 30-7-2002 to 30-6-2003. we selected 40 aphakic patient for secondary i.o.l implantation from the outpatient department. the study design was quasi interventional/comparative. patients after selection, were admitted in ophthalmology department of abbasi shaheed hospital from 30-7-2002 to 30-6-2003. a proforma was filled pre and postoperatively. there was a system of follow up for at least two months. which was extended to six months in few patients. the indication of secondary iol implantation were intolerance to aphakic glasses and traumatic cataract with monocular aphakia. all surgeries were done under local anaesthesia. inclusion criteria were contra-lateral pseudophakia, age between 20 – 60 years of any gender, monocular aphakia, spectacles intolerance because of the weight of the spectacle, prismatic effect, spherical aberration14,15, contact lens intolerance e.g. parkinsonism, cerebrovascular accident, rheumatoid arthritis in very old age patient16, occupational limitation e.g. athletes, labour working in dusty environment and posterior capsular rupture. exclusion criteria were central corneal opacity, optic atrophy, uncontrolled glaucoma, retinal detachment, diabetic retinopathy and hypertensive retinopathy. comprehensive history of the patient regarding the cause of aphakia and questions related with general physical health were taken. a personal data of name, age, gender, address, occupation were noted. ocular history included indications for previous surgery including senile cataract, traumatic cataract and congenital cataract.. time after the previous surgery , problems faced related with the aphakia, problems faced related with aphakia glasses and contact lenses, any coexisting ocular disease like glaucoma and ocular disease for which one had took treatment in past were documented. complete examination of the eye included any deviation of eye ball, visual acuity for distance and near with and without glasses was recorded. slit lamp examination included lids and adnexa, conjunctiva, cornea and fornice. any corneal opacity in traumatic cataract was of interest regarding visual prognosis. types of previous surgery i.e. icce or ecce or any iridectomy or any conjoint surgery, iris, pupil and posterior capsule were examined and noted. fundi were examined with both direct and indirect ophthalmoscope, 78d and biomicroscopy. intraocular comparison of secondary anterior and posterior intraocular lens implantation for aphakia pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 171 pressure was noted. all the patient had preoperative biometry and iol power calculation using srk – formula. systemic investigations included full blood count, urine complete and blood glucose random. valium 5mg and diamox 250mg were given orally. all surgeries were done under local anaesthesia using injection xylocaine 2% with adrenaline. after 24 hours, eye pad was removed and noted for any discharge or bleeding. visual acuity was recorded. slit lamp examination was done to examined for wound, flare, keratic precipitates and hyphema. patients were discharge. usual protocol for follow up was 2nd day, 1st week, 2nd week, 1st month and 2 months post-operatively. on each follow up patients were examined for visual acuity, biomicroscopy, refraction, iop and fundus examination. refraction between 1.5 to 2 months special attention was given to post-operative astigmatism. all post-operative surgical complications were noted. antibiotics with steroid combination were given 6 hourly for 6 – 8 weeks, oral antibiotic and analgesic for 5 days. in case of any complication drugs were adjusted accordingly. results in these 40 cases 18 (45%) patients were male and 22 (55%) were female (table 1). the patients aged between 20 – 30 years were 5 (12.5%), mostly of traumatic cataract, between 31 – 40 years were 4 (10%) patients, while from 41 – 60 years of age the number of patients were 31 (77.5%), mostly of senile type. the mean age was 40 years, so there was a significant relationship found between age and the cause of cataract below 30 years (table 2). among 40 patients, 33 (82.5%) patients were of senile cataract and 7 (17.5%) patients were of traumatic cataract as seen in table 2. out of 33 patients in which aphakia was due to senile cataract extraction, 11 (33.3%) patients had intracapsular cataract extraction (icce), while 22 (66.6%) patients had extra-capsular cataract extraction (ecce). seven patients who had aphakia due to traumatic cataract, all had ecce as mentioned in table 3. anterior chamber lens implantation was done in 27 (67.5%) cases and 13 (32.5%) patients had pc iol implantation (table 4). the pre-operative visual status of the patients is mention in table 5. after pc iol implantation, 2 (15%) patients had no improvement in vision, while 2 (15%) patients had decrease in the visual activity postoperatively, while 9 (69%) patients had improvement in their vision on snellen’s chart as indicated on table 6. visual improvement after ac iol implantation can be seen on the table 7, which indicates that the vision of secondary ac iol was same in 7 (25%) patients, decreased in 3 (11%) patients, while improvement was seen in 17 (62.9%) patients. nineteen (47.5%) patients had no complication in our study. while 3 (7.5%) patients developed transient rise in intraocular pressure. three (7.5%) patients of table 1: gender distribution (n = 40). gender no. of patients percentage male 18 45% female 22 55% total: 40 100% p value = 0.336 there was no correlation between gender and cause of cataract. table 2: distribution of age group (n = 40). age senile traumatic 20 – 30 years 0 5 (71.4%) 31 – 40 years 3 (9.1%) 1 (14.3%) 41 – 60 years 30 (90.9%) 1 (14.3%) total: 33 (100.0%) 7 (100.0%) p value = 0.000 table 3: surgery for aphakia (n = 40). cause of cataract i.c.c.e e.c.c.e senile (n = 33) 11 (33.3%) 22 (66.6%) traumatic (n=7) 0 7 (100%) p value = 0.315 syed shahid asad, et al 172 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology table 4: procedure done for secondary iol (n = 40). procedure no. of patients percentage secondary ac iol + pi 15 37.5% secondary ac iol 3 7.5% secondary ac iol + broad iridectomy 2 5% secondary ac iol + vitrectomy + pi 5 12.5% secondary ac iol + vitrectomy 1 2.5% secondary ac iol + corneal repair 1 2.5% secondary pc iol 12 30% secondary pc iol + pi 1 2.5% total secondary ac iol 27 67.5% total secondary pc iol 13 32.5% p value = 0.592 table 5: pre-operative vision (n = 40). pre-op vision no. of patients percentage 6/6 5 12.5% 6/9 12 30.0% 6/12 4 10.0% 6/18 4 10.0% 6/24 6 15.0% 6/36 4 10.0% 6/60 3 7.5% c/f n-i with ph 1 2.5% pl pr 1 2.5% total: 40 100% table 6: visual outcome after pc iol implantation (by snellen’s chart) (n = 13). visual outcome no. of patients percentage decrease of vision 2 15.3% remain same 2 15.3% partial improvement of line 2 15.3% one line improvement 5 38.4% two lines improvement 1 7.6% three lines improvement 1 7.6% total: 13 100% improvement in vision 69.2% table 7: visual outcome after ac iol implantation (by snellen’s chart) (n = 27). visual outcome no. of patients percentage decrease of vision 3 11.11% remain same 7 25.9% partial improvement of line 3 11.11% one line improvement 8 29.6% two lines improvement 4 14.8% three lines improvement 1 3.7% four lines improvement 1 3.7% total: 27 100% improvement in vision 62.9% traumatic cataract had scar but not in the pupillary region. three (7.5%) patients had vitritis. two (5%) patients had iris prolapse. four (10%) patients had striate kerotopathy. post-operative astigmatism against the rule found in 3 (7.5%) patients as mentioned on table 8. there was a significant relationship between age and cause of cataract. below 30 years of age, trauma was more likely the cause of cataract. comparison of secondary anterior and posterior intraocular lens implantation for aphakia pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 173 table 8: post-operative complications. complications no. of patients percentage no complications 19 47.5% transient increase in iop 3 7.5% corneal opacity not in the pupillary region 3 7.5% vitiritis 3 7.5% hyphema formed on iridectomy, vitreous floaters 2 5.0% iris prolapse 2 5.0% striate keratopathy + iris atrophy 2 5.0% striate keratopathy 2 5.0% difficult in setting haptics 1 2.5% astigmatism 3 7.5% total: 40 100% discussion cataract is one of the leading cause of reversible blindness in our region. for the last two to three decades intracapsular cataract extraction was the only way to treat such blindness. all post cataract aphakic eyes were rehabilitated by the aphakic glasses or contact lenses. although, the results were better in comparison with cataract or aphakia, but these treatments had certain problems and limitations. the major problems with aphakic glasses were their weight, magnification, distortion and aberration17. while a much better alternative for the aphakic patient were contact lenses. but such lenses also had their own limitations such as difficulty to be used by elderly patient as they were unable to maintain proper hygienic conditions, allergy, infections and restriction of their use in dusty environment18. currently primary iol is a routine procedure, therefore all the patients formerly operated by older method should be considered for placement of iol as a secondary procedure, so as to get the privilege of optimum correction of their aphakia19. secondary iol implantations were the most appropriate alternative to aphakic glasses and contact lenses. in those patient who had ecce with intact posterior capsules provides support for the post chamber iol2,13. while anterior chamber iol implantation in those patient who had ruptured posterior capsule or had icce. in our study, the major indication for secondary iol implantation was intolerance to aphakic glasses, 50% of our patient had this problem, this is quite in accordance with other studies. in a study by hahn tw et al20 56.2% of patients under went secondary iol implantation because of the discomfort. in other studies also, the major indication for such surgery was intolerance to aphakic glasses (biglan aw et al21 and ali et al)14. as mentioned earlier the site of iol implantation largely depends upon the state of the posterior capsule. in our study 13 (32.5%) patients had pc iol, and 27 (67.5%) patients had ac iol, when we compare our study with other studies we found similar result as ali et al, 37.93% had pc iol implantation and 62.07% had ac iol implantation, same results found in another study by synder et al,11 78.5% case were implanted in ac iol and 21.5% were pc iol. a study regarding comparison of pre and postoperative vision was conducted by shammas and milkie,22 in which a decrease in visual acuity was seen in 3% of patients, increase in 55% of cases and no improvement in 42% of patients. similarly in our study the vision remained same in 9 (22.5%) patients. improvement of vision from 1 line to 4 lines were in 20 (50%) patients and 5 (12.5%) patients had partial improvement of vision on snellen’s chart, so overall improvement in vision was 62.5%. decrease in postoperative patient vision was noticed in 6 (15%) patients on snellen’s chart. hykin et al (1991)23 suggest that correct ac iol positioning is more likely with a secondary procedure, but the complications such as chronic angle closure glaucoma, bullous keratopathy and hyphema may be directly related to the position of ac iol. we observed no such complication in our study. according to the stark et al24 (1989) “because of high incidence and great variety of complications associated with ac lens, we have developed a technique for the implantation of pc iol in the absence of posterior capsular support. many other authors supported this statement (colvard et al 1983 syed shahid asad, et al 174 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology and stark et al25 1988). but our results of ac iols and pc iols were near about the same regarding improvement of vision and there were no significant early complication caused by ac lens implantation. open sky vitrectomy (anterior vitrectomy) was done in 6 (15%) cases due to vitreous loss, all patients had ac iol implantation done. according to the hykin et al (1991) vitreous loss is a serious complications of cataract surgery. final visual acuity is less than in uncomplicated cases and the incidence of long term complication is higher, complication like retinal detachment and cystoid macular oedema are related more to the vitreous loss rather than to the position of implant. we observed iris prolapse in 2 (5%) patients, which was surgically managed. while striate keratopathy was observed in 4 (10%) patients, hyphema with iridectomy in 2 (5%) patients. at the last of our discussion we come to end that there was a risk of reduced vision after secondary intraocular lens implantation due to the possibility of complications that follows this procedure. however, functional vision was better with intraocular lens in the comparison with the aphakic eye,23 especially the peripheral vision.9 the procedure of secondary intraocular lens implantation is being done all over the world, with secondary iol patient have the benefit of “good binocular single vision” and also “improvement in peripheral vision” with the “liberation from heavy aphakic spectacles”. so it considered to be quite effective procedure. now, with more expertise, better techniques, latest equipment, good material used during operation and excellent sterilization procedures have “declined the graph of complications” over the past few years. conclusion secondary pc and ac iol implantation produces similar results and should be the procedure of choice for visual rehabilitation in aphakic patients. author’s affiliation dr. syed shahid asad assistant professor department of ophthalmology karachi medical and dental college and abbasi shaheed hospital, karachi dr. arshad sheikh professor of ophthalmology department of ophthalmology karachi medical and dental college and abbasi shaheed hospital, karachi dr. uzma fasih associate professor department of ophthalmology karachi medical and dental college and abbasi shaheed hospital, karachi role of authors: dr. syed shahid asad study concept, data collection, data analysis dr. arshad sheikh critical review & overall supervision dr. uzma fasih patient selection, statistics, data analysis references 1. bucher pjm. jsselmuiden cb. prevalence and cause of blindness in north transvaal. br j ophthalmol. 1988; 72: 721. 2. elkington ar, frank hj. optics of ametropia. in: clinical optics 2nd ed. blackwell scientific publications london, 1991: 11 – 3. 3. khan aj. experience with iol in children. pak j ophthalmol. 1987; 3: 90 – 3. 4. cole md, hay a, eagling em. cyclic oestrogen in a patient with unilateral traumatic aphakia: a case report. br j ophthalmol. 1988; 72: 305 – 8. 5. graham cm, dart jkg, wilson – holt nw, buckley rj. prospect for contact lens wear in aphakia. eye, 1988; 2: 48 – 55. 6. durrie ds, hobrich dl, dietze tr. secondary intraocular lens implantation vs epikeratophakia for the treatment of aphakia. am j ophthalmol. 1987; 103: 384– 91. 7. lorsen wj. human embryology 1st edition. churchill livingstone, 1993; 12: 348. 8. trevor pd, cullan pv. the eye and its disorder 2nd edition. backwell scientific 5. 9. snell rs. clinical anatomy of the eye. blackwell scientific, 1989; 1: 11. 10. fundamentals and principles of ophthalmology. basic and clinical science course. american academy of ophthalmol. 1999 – 2000; 2 (2): 152. 11. trevor pd, cullan pv. the eye and its disorder 2nd edition. backwell scientific 5. 12. snell rs, lemp ma. clinical anatomy of the eye 2nded. 1997: 143. 13. stark wj; goodman g; goodman d; tottsch j. post. comparison of secondary anterior and posterior intraocular lens implantation for aphakia pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 175 chamber intraocular implantation in the absence o post. capsular support. ophthalmic – surg. 1998; 4: 240 – 3. 14. ali a, ahmed t, sharif–ul–hassan k. secondary intra. ocular lens implantation. pak j ophthalmol 2001; 17 (3): 74 – 78. 15. norman sj. atlas of ophthalmic surgery. jb lippincott: philadelphia: grouser med pulluating new york, 1990: 1: 68. 16. norman sj. atlas of ophthalmic surgery. jb lippincott, philadelphia: grouser medical publishing new york, 1990; 1: 70. 17. woods ac. the adjustment to aphakia. am j ophthalmol. 1952; 35: 11 – 122. 18. linksz a. optical complications of aphakia. in theodore fh editors. complications after cataract surgery. boston: little, brown and company, 1964. 19. niclson is, johansen j. secondary lens implantation. acta ophthalmol. copenh. 1988; 66 (5): 552 – 5. 20. hahn tw. kim ms, kim jh. secondary intraocular lens implantation in aphakia. j cataract perfracl surg. 1992; 18 (2): 174 – 9. 21. biglan aw, cheng kp, davis js, gerontis cc. secondary iol implantation in children. trans am ophthamlol. 1997; 124: 134. 22. shammas hj. milkie cf. secondary implantation of anterior chamber lenses. j am intraocul implant soc. 1983; 9: 313 – 6. 23. hykin pg, gardner id, corbat mc, cheng h. primary. or secondary anterior chamber lens implantation after extra capsular cataract surgery and vitreous loss, 1991; 5 (pf 6): 694 – 8. 24. stark wj, gottsch jd, goodman df, goodman gl, pratzer k. posterior chamber intraocular lens implantation in the absence of capsular support. archophthalmol. 1989; 107 (7): 1078 – 83. 25. colvard dm, mazzocco tr, davidson b, kratz rp, johnson sh. technique for implanting secondary posterior chamber intraocular lenses. j am intraocul implant soc. 1983; 9 (4): 463 – 5. 38 pak j ophthalmol. 2021, vol. 37 (1): 38-42 original article efficacy of oral alprazolam and mefenamic acid in relieving pain during pan retinal photocoagulation muhammad ali haider 1 , uzma sattar 2 , iftikhar ahmed 3 department of ophthalmology, 1 al-ehsan eye hospital, 2,3 rahbar medical and dental college, lahore abstract purpose: to find out the efficacy of oral alprazolam and mefenamic acid in relieving pain during pan retinal photocoagulation in patients with proliferative diabetic retinopathy. study design: quasi experimental study. place and duration of study: department of ophthalmology, al-ehsan eye hospital, lahore, from january 2018 to december 2018. methods: patients were divided into two groups; groups a received one tablet of xanax (alprazolam 0.5 mg) and 2 tablets of ponston forte (mefenamic acid 500 mg) an hour before prp. in group b no pain relieving medicines were prescribed. proparacaine hydrochloride 0.5% eye drops were instilled in the eye to achieve corneal anesthesia before the procedure in both the groups. pain was scored, 15 minutes after prp, using standard verbal rating scale and results were analyzed. paired sample t-test was used to measure the mean difference in pain between the two groups. a p value of less than 0.01% was considered significant. results: five hundred and sixty patients with proliferative diabetic retinopathy (pdr) requiring pan retinal photocoagulation (prp) were enrolled. there were 272 males and 288 females. mean age of patients was 64.0 ± 6.8 years. mean pain score for group a was 4.0 ± 0.6 and for group b was 2.1 ± 0.3. difference in pain score felt by each group was -1.93 ± 0.7 with significant p value of ˂0.01%. conclusion: oral administration of alprazolam and mefenamic acid one hour before prp in patients with proliferative diabetic retinopathy was effective in reducing pain and in attaining patient cooperation during the procedure. key words: pan retinal photocoagulation, pain, proliferative diabetic retinopathy, alprazolam, mefenamic acid. how to cite this article: haider ma, sattar u, ahmed i. efficacy of oral alprazolam and mefanamic acid in relieving pain during pan retinal photocoagulation. pak j ophthalmol. 2021, 37 (1): 38-42. doi: 10.36351/pjo.v37i1.1084 correspondence: muhammad ali haider al-ehsan eye hospital, lahore email: alihaider_189@yahoo.com. received: june 19, 2020 accepted: december 3, 2020 introduction diabetic retinopathy is one of the most prevalent forms of retinopathy affecting the diabetic patients in developed and undeveloped world. 1 life expectancy of diabetic patients is increasing with better medical provision, resulting in increased prevalence of diabetic retinopathy in the present world. this disease burden has many social and economic effects that have a far more serious impact in the under developed world because of limited human and technological resources to deal with the disease burden. 2,3 the disease burden of diabetic retinopathy has increased many folds in recent years however early diagnosis and prompt treatment of patients is still a huge challenge. recent advancements in anti-vegf efficacy of alprazolam and mefenamic acid in relieving pain during pan retinal photocoagulation pak j ophthalmol. 2021, vol. 37 (1): 38-42 39 therapy has revolutionized the treatment strategies for proliferative diabetic retinopathy, but prp still has a major role in treatment. 4-6 the procedure is less invasive and systemic risks are not involved as compared to anti-vegf administration. since the advent of argon laser numerous studies have been conducted to document the efficacy of treating proliferative diseases especially diabetic retinopathy. the diabetic retinopathy study (drs) and early treatment diabetic retinopathy study (etdrs) are landmark studies, documenting the effects of argon laser treatment in diabetic retinopathy. 7,8 many factors like lack of patient education, limited treatment centers with proper equipment and financial constraints contribute to failure of patients in receiving proper laser administration. compounding this problem is non-compliance on part of patients. one of the main reasons of failure to get proper argon laser sessions at our hospital for proliferative diabetic retinopathy was pain felt during the procedure. 9,10 numerous studies and trials have been conducted at various treatment facilities and various protocols have been devised to address this issue. it includes use of various common analgesics such asentonox, paracetamol, nonsteroidal anti-inflammatory drugs (nsaids), diazepam, and peri-bulbar anaesthesia. 11-13 however, the most clinically effective analgesic is yet unknown. in order to tackle the problem of non-compliance with argon laser treatment sessions secondary to pain, a protocol was established and applied to patients presenting at the retinal clinic at al-ehsan eye trust hospital, lahore. retinal service at al-ehsan eye hospital, lahore is faced with the challenge of increased patient burden, with an average daily turnover of 500 patients. a large proportion of the patients presenting in the service are diagnosed with diabetic retinopathy at various stages of evolution of the disease process. the scale of the problem is compounded by the patient’s hesitation to undergo regular and timely sessions of prp due to the pain encountered during the process. a protocol was devised to reduce the pain during the treatment process at the center ensuring completion of treatment sessions and better compliance. the aim of the study was to document the intensity of pain and efficacy of pain relief after argon laser photocoagulation in patients with proliferative diabetic retinopathy, who followed the specified designed protocol at the hospital before undergoing laser application over the course of the study. methods this quasi experimental study was conducted in the ophthalmology department of al-ehsan eye hospital, lahore. total 560 patients were enrolled over the course of one year from january 2018 to december 2018 after approval from hospital ethical committee. diabetic patients (phakic or pseudophakic) without having any significant media opacity, diagnosed with proliferative diabetic retinopathy by retina consultant, based on fundus examination and fundus fluorescein angiography were included. patients with any other associated ocular pathology such as neovascular glaucoma, media opacities or vitreous hemorrhage, history of prior argon treatment, or patients taking any pain medications for chronic systemic or ocular disorders and patients with cervical vertebral issues were excluded from the study. informed consent was obtained. the relevant patient demographic profile, brief history, associated risk factors, stage of retinopathy and planned treatment were documented. all the selected patients were divided into two groups by convenient sampling technique. each group a and b consisted of 280 patients each. patients were counseled before laser application about the procedure. any drug allergy was documented. pupillary dilation was achieved with 1% tropicamide (1% mydriacyl, alcon laboratories) instilled every 15 minutes for an hour. in group a, one tablet of 0.5 mg of alprazolam (xanax) and 2 tablets of ponston forte (mefenamic acid 500 mg) were given orally one hour before the pan retinal photocoagulation procedure. in group b, no pain relieving medicine was given. once the patients were ready for the procedure, 0.5% proparacraine hydrochloride (alcaine, alcon novartis) eye drops were instilled in the eye twice with a 5-minute interval in-between before the procedure to anesthetize the cornea. treatment guidelines as described in drs were followed. argon laser was performed using nidek argon green laser machine with the laser settings of wavelength 521nm, laser spot size 500 µm, repetitive mode with an exposure time of 0.1sec. prp 165 wide field lens was applied to the eye using methylcellulose gel as a coupling agent. the laser power settings were adjusted to achieve moderate white burn one burn-width apart. a single muhammad ali haider, et al 40 pak j ophthalmol. 2021, vol. 37 (1): 38-42 surgeon performed the laser sessions in the retina clinic. each session comprised of 1500 shots of laser. during laser application, a specific pattern was followed. inferior half of retina was lasered first. laser settings were tuned to the minimum possible when applying laser in the horizontal meridians. fifteen minutes after the laser application, pain score was documented from each patient by using a standard verbal rating scale. this verbal scale included a range from 0 (no pain at all), 1 (slight discomfort), 2 (mild pain), 3 (moderate pain), 4 (severe pain), to 5 (extremely painful). all patients (group a and b) underwent the same set of standard protocol. data was recorded and analyzed by using spss version 22. mean pain score was evaluated for both groups. difference of pain score between two groups was evaluated by using paired sample t-test. a p value of less than 0.05 was considered significant. results out of total 560 patients, 272 were male and 288 were females. mean age of patients was 64.0 ± 6.8 years. mean pain score recorded in ‘group a’ was 2.1 ± 0.3 on standard verbal rating scale. in ‘group b’ the mean pain score recorded was 4.0 ± 0.6. this table shows that most of the patients in ‘group b’ felt moderate to extreme pain. in ‘group a' most of the patients felt pain at mild to moderate level (p value 0.00). details are depicted in table 1. table 1: mean of difference in pain between group a and b. graph 1: showing pain score in group a with distribution curve. graph 2: showing pain score in group b with distribution curve. paired differences t df sig.(2-tailed) mean std. deviation std. error mean 95% confidence interval of the difference lower upper group a – group b -1.939 .771 .046 -2.030 -1.849 -42.074 279 .000 efficacy of alprazolam and mefenamic acid in relieving pain during pan retinal photocoagulation pak j ophthalmol. 2021, vol. 37 (1): 38-42 41 discussion pan retinal photocoagulation is a relatively painful procedure and requires pre-emptive pain relief for patients to remain comfortable. most units do not deliver pain relieving agents as shown in a national survey of all ophthalmic units within the nhs in uk. 14 at other units, various methods are employed to control pain encountered by the patients during the procedure. we adopted a protocol that was noninvasive, cost effective, easily available, with least amount of side effects and easily applicable in our hospital settings and documented the results. the results of our study are comparable to the studies conducted elsewhere. in a study conducted at ophthalmology service of the hospital das clínicas university of são paulo medical school by rafael barbosa de araújo et al. they concluded that the use of 1000 mg of metamizole 40 minutes before prp significantly reduced pain associated with the procedure in patients with pdr. 15 similarly, hazem et al in their study reported lower degree of pain associated with a better hemodynamic response in patients given 150 mg pregabalin before photocoagulation. 16 the laser energy is focused on the retinal tissue and is absorbed by the underlying retinal pigment epithelium (rpe) and choroid. 17,18 pigments within the rpe absorb laser energy and this is converted to thermal energy, raising tissue temperature, causing cellular death and coagulative necrosis. 19 during laser application, the patients feel a pinching sensation with varying degrees of associated pain which is thought to arise from the photocoagulation of ciliary nerves running in the supra-choroidal space. pain is a product of higher brain center. it is a complex event with an emotional component and not just the appreciation of presence, location, and magnitude of nociceptive input. 20-22 psychological factors can significantly influence the experience of pain. fear and anxiety can enhance responses and interpretation of pain-producing events. measures to reduce anxiety either with cognitive interventions or anxiolytic drugs can reduce pain. 23 limitation of this study is a single center trial. placebo was not used in group b which could have psychological effect on the patients of this group. conclusion oral administration of alprazolam (xanax 0.5 mg) and 2 tablets of ponstan forte (mefenamic acid 500 mg) one hour before pan retinal photocoagulation in patients with proliferative diabetic retinopathy was effective in reducing pain and in attaining patient cooperation during the procedure. ethical approval the study was approved by the institutional review board/ ethical review board. 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232 (04): 509–513. doi: 10.1055/s-0035-154579. 20. inan uu, polat o, inan s, yigit s, baysal z. comparison of pain scores between patients undergoing pan retinal photocoagulation using navigated or pattern scan laser systems. arq bras oftalmol. 2016; 79 (1): 15-18. doi: 10.5935/0004-2749.20160006. 21. vujosevic s, martini f, longhin e, convento e, cavarzeran f, midena e. sub threshold micro pulse yellow laser versus sub threshold micro pulse infrared laser in center involving diabetic macular edema. retina, 2015; 35 (8): 1594–1603. doi: 10.1097/iae.0000000000000521-2015. 22. chhablani j, sambhana s, mathai a, gupta v, arevalo jf, kozak i. clinical efficacy of navigated pan retinal photocoagulation in proliferative diabetic retinopathy. am j ophthalmol. 2015; 159 (5): 884– 889. doi: 10.1016/j.ajo.2015.02.006. 23. kaczkurkin an. cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. dialogues clin neurosci. 2015; 17 (3): 337–346. author’s designation and contribution muhammad ali haider; assistant professor: concepts, design, literature search, data acquisition, manuscript preparation. uzma sattar; investigative occulist: literature search, data analysis, statistical analysis, manuscript preparation. iftikhar ahmed; professor: literature search, manuscript editing, manuscript review. .…  …. https://www.ncbi.nlm.nih.gov/pubmed/?term=hua%20w%5bauthor%5d&cauthor=true&cauthor_uid=23561600 https://www.ncbi.nlm.nih.gov/pubmed/?term=cao%20s%5bauthor%5d&cauthor=true&cauthor_uid=23561600 https://www.ncbi.nlm.nih.gov/pubmed/?term=cui%20j%5bauthor%5d&cauthor=true&cauthor_uid=23561600 https://www.ncbi.nlm.nih.gov/pubmed/?term=maberley%20d%5bauthor%5d&cauthor=true&cauthor_uid=23561600 https://www.ncbi.nlm.nih.gov/pubmed/?term=matsubara%20j%5bauthor%5d&cauthor=true&cauthor_uid=23561600 https://clinicaltrials.gov/ct2/bye/rqopwworrxs9-i-wudngpqdxudhwudnzlxnizip9ei7ym67vzr0regcn-rcja6h9ei4l3bugwwng0it. https://clinicaltrials.gov/ct2/bye/rqopwworrxs9-i-wudngpqdxudhwudnzlxnizip9ei7ym67vzr0regcn-rcja6h9ei4l3bugwwng0it. https://clinicaltrials.gov/ct2/bye/rqopwworrxs9-i-wudngpqdxudhwudnzlxnizip9ei7ym67vzr0regcn-rcja6h9ei4l3bugwwng0it. https://clinicaltrials.gov/ct2/bye/rqopwworrxs9-i-wudngpqdxudhwudnzlxnizip9ei7ym67vzr0regcn-rcja6h9ei4l3bugwwng0it. https://clinicaltrials.gov/ct2/bye/rqopwworrxs9-i-wudngpqdxudhwudnzlxnizip9ei7ym67vzr0regcn-rcja6h9ei4l3bugwwng0it. https://clinicaltrials.gov/ct2/bye/rqopwworrxs9-i-wudngpqdxudhwudnzlxnizip9ei7ym67vzr0regcn-rcja6h9ei4l3bugwwng0it. https://pubmed.ncbi.nlm.nih.gov/?term=richardson+c&cauthor_id=19169228 https://pubmed.ncbi.nlm.nih.gov/?term=waterman+h&cauthor_id=19169228 https://doi.org/10.1186/s40942-015-0021-8 http://jeos.eg.net/searchresult.asp?search=&author=hazem+a+hazem&journal=y&but_search=search&entries=10&pg=1&s=0 http://jeos.eg.net/searchresult.asp?search=&author=jehan+a+sayed&journal=y&but_search=search&entries=10&pg=1&s=0 microsoft word 25. muhammad moshin ali mm 308 pakistan journal of ophthalmology, 2020, vol. 36 (3): 308-311 review article eye in covid-19: a brief review muhammad mohsin ali1, qudsia anwar dar2, zahid kamal siddiqui3, alishba khan4 1-4king edward medical university, mayo hospital, lahore abstract this is a brief review covering the currently available literature on ocular manifestations of covid-19, and prevention strategies for ophthalmologists. a literature search was carried out of pubmed, google scholar and who database of publications on covid. keywords used in the search were eye, ocular manifestations, ophthalmology, covid-19, ncov-2019, and coronavirus disease. all available articles were reviewed and those pertinent to the study topic were included. considering the dearth of information available, ophthalmology journals were also searched separately for relevant articles. major ocular manifestation of covid reported in literature is red eye, which usually presents before the onset of respiratory symptoms. since the eye can be a possible transmission route for sars-cov-2, infection control measures should be undertaken by ophthalmologists, including use of personal protection equipment and eye/face covering. a framework for structuring ophthalmological services during the covid pandemic is also presented in this review. key words: covid-19, ophthalmologist, conjunctivitis. how to cite this article: ali mm, dar qa, siddiqui zk, khan a. the eye in covid-19: a brief review. pak j ophthalmol. 2020; 36 (3): 308-311. doi: 10.36351/pjo.v36i3.1040 introduction the covid-19 pandemic, caused by the sars cov2 virus, a member of the beta coronavirus genus, has led to widespread public health concerns across the globe1. according to the who global situation report of 10th april 2020, there are more than 1.5 million confirmed cases with almost ninety two thousand deaths globally2. in south east asia, 12,978 confirmed cases have been reported so far, with 569 deaths due to covid-9; considering the pattern of disease spread across the european region and america, this number is only expected to rise with time. many common public health concerns have been raised regarding covid-19, especially its mode of transmission, symptoms, and preventive measures correspondence to: muhammad mohsin ali king edward medical university, mayo hospital lahore email: mohsinali@kemu.edu.pk received: april 14, 2020 revised: may 4, 2020 accepted: may 4, 2020 carriers reported in the literature as well; or it can lead to acute respiratory distress syndrome (ards), against its spread3. covid-19 initially presents as fever, cough, dyspnea, fatigue and myalgias; the clinical course may remain mild, with asymptomatic associated with need for ventilator support and high overall mortality4. ocular manifestations have also been reported in covid-19, and have been purported by some to be the earliest sign of the disease in symptomatic individuals5. previously other respiratory viruses, especially influenza, have been shown to use the eye as a portal of entry, with the h7 subtype having a particular ocular tropism 6. considering the scarcity of personal protection equipment (ppe), the mode of transmission through respiratory droplets, and the highly infectious nature of the disease, it is imperative that these manifestations are not overlooked. we present here a brief review of major ocular manifestations in covid-19 as well as preventive measures that can be undertaken by healthcare professionals (hcps) in this regard. we also provide a basic framework to be followed while planning eye in covid-19: a brief review pakistan journal of ophthalmology, 2020, vol. 36 (3): 308-311 309 delivery of healthcare within a covid-19 affected healthcare system. material and methods a literature search was carried out using pubmed, google scholar and who database of publications on covid. keywords used in the search were eye, ocular manifestations, ophthalmology, covid-19, ncov2019, and coronavirus disease. all available articles were reviewed and those pertinent to the study topic were included. considering the dearth of information available, ophthalmology journals were also searched separately for relevant articles. the earliest ocular manifestation of covid-19, reported by guangfa wang, a member of the chinese national expert panel on pneumonia in january 2020, included redness of the eyes, which had occurred several days prior to the onset of pneumonia and positive testing for sars-cov-25. this raised the suspicion that the exposed eye could be a possible extra-respiratory transmission route for the virus, following which the chinese cdc recommended eye protection to healthcare workers exposed to covid19. an observational study was carried out in a chinese hospital on 114 patients who underwent consecutive nasopharyngeal and conjunctival swab tests for detection of sars-cov-2 on rt-pcr. the study reported negative conjunctival samples from all the patients, 79% of whom had tested positive for covid-19 on nasopharyngeal swabs. furthermore, no obvious ocular symptoms were documented in the study; it was suggested, however, that the presence of the virus in the conjunctival sac or tear fluid might occur for a very brief period of time, and in suspected patients presenting with red eye, testing with conjunctival swabs concurrent with nasopharyngeal swabs would hold diagnostic significance6,7. in a non-peer reviewed retrospective cohort study, 67 confirmed and suspected cases of covid-19 underwent concurrent nasopharyngeal and conjunctival swabs; 1 patient with confirmed covid had positive conjunctival pcr for sars-cov-2, while 2 others had probable positive pcr results from conjunctival swabs. interestingly, however, none of the patients with positive conjunctival swabs had any ocular manifestations, and the patient who reported red eye prior to testing were found negative for sarscov-2 on conjunctival swab pcr8. in another brief report from thailand, out of 48 patients who tested positive for sars-cov-2 and underwent a complete ocular examination including direct ophthalmoscopy and corneal scrapings in suspected cases, no ocular manifestations were found9. apart from anecdotal evidence for red eye as a manifestation of covid-19, no objective evidence is available regarding any other ocular signs and symptoms. however, considering the ocular manifestations reported with other coronaviruses previously, especially sars10, it is imperative that medical practitioners should be on the lookout for suspicious ocular symptoms in patients with suspected or confirmed covid-19, and that such patients should undergo a complete ocular examination, conjunctival swabs, and follow up ocular examination as well. preventive measures for healthcare professionals the first ocular manifestations were reported from centers where wearing eye protection was not within the normal routine of donning personal protection equipment5. in many countries, ophthalmologists do not normally use eye protection in the form of goggles or face shields during daily clinical activities9. in the context of covid-19, it was found in a survey conducted on accident and emergency (a&e) ophthalmologists that 79% had no training in using ppe; more than 50% were dissatisfied with the guidelines that did not recommend ppe for ophthalmology practitioners; and a similar number were unaware of the recommended ppe for close patient contact11. considering that ophthalmologists have close contact with patients for slit lamp eye examinations, and face a high burden of eye disease on daily basis, it is important that they are aware of the correct preventive measures that need to be undertaken in the healthcare settings. infection control measures for ophthalmologists need to be stepped up, with proper training of healthcare staff and utilization of a triage system and telemedical services to reduce unnecessary patient presentation12,13. based on the guidelines issued by the royal college of ophthalmologists14 and the american academy of ophthalmology (aao)15, we present the following brief recommendations for prevention of covid-19 in ophthalmology healthcare workers: 1. eye protection and face protection should be used by hcps working in the inpatient department muhammad mohsin ali, et al 310 pakistan journal of ophthalmology, 2020, vol. 36 (3): 308-311 within two meters of patients, in emergency and acute hospital clinics and outpatient departments, and in operation theaters or high dependency units, especially when performing an eye review. for aerosol generating procedures such as intubation, single use eye protection must be utilized. fig. 1: framework for provision of eye healthcare during covid-19. *standard precautions include frequent hand washing, use of ppe, cough etiquette, disinfection of examination rooms. 2. slit lamp barrier or breath guard must be used whenever slit lamp examination needs to be performed in the inpatient or outpatient department or acute eye clinics. 3. disposable gloves, aprons and water resistant gowns must be donned by professionals working in the operation theaters. gowns are not essential for inpatient areas and outpatient clinics. similarly, respirator masks are only suitable for use during aerosol generating procedures or in high dependency units; simple fluid resistant surgical masks should be used in all other places. 4. a minimum distance of two meters should be kept from the patient except when clinical examination is required. 5. prior to any exam, especially in patients with conjunctivitis, history of fever, respiratory symptoms, travel, or covid contact must be taken by the ophthalmologist. 6. while checking intraocular pressure, disposable tonometer tips must be used by the ophthalmologists. air puff tonometry should be avoided; i-care tonometry can be used instead; whereas goldmann applanation tonometry should be used only when essential. 7. investigations such as visual field testing, ocular computed tomography (oct) and ultrasound bscan should be avoided unless absolutely essential. 8. indirect ophthalmoscopy should be used in preference to slit lamp biomicroscopy whenever appropriate. framework for delivering ophthalmology services in lower middle income countries, there is a high burden of ophthalmic diseases. considering the case of pakistan, the burden of disease is on the rise, with almost 4.3% of the total population suffering from visual deficiency, ranging from moderate loss to complete blindness16. in a study conducted at a public sector hospital in pakistan, ocular emergencies accounted for 20% of all ophthalmology department admissions, with 55% of the emergencies being traumatic17. considering the high number of ocular emergency presentations, a framework of ophthalmology services has been devised—this frame work is in accordance with the guidelines set forth by the aao and the royal college of ophthalmologists. ocular emergencies requiring urgent review include the following: acute glaucoma (iop > 40 mm hg); rapidly progressive glaucoma; wet active age-related macular degeneration (armd); severe uveitis; acute retinal detachments; proliferative diabetic retinopathy; retinopathy of prematurity; endophthalmitis; sight threatening trauma; orbital cellulitis; and giant cell arteritis, among others. if the patient is below 70 years old, with the disease being in only or better seeing eye, treatment must continue for these patients, while keeping standard precautions in view18,19,20. conclusion covid-19 is currently impacting the global healthcare landscapein an unprecedented way. while ocular manifestations of covid-19 have not been reported widely in literature, the eye remains a possible transmission route for sars-cov-2. healthcare workers and ophthalmologists must take this under consideration and utilize proper eye protection equipment, social distancing, and infection control measures to reduce the impact of disease burden. eye in covid-19: a brief review pakistan journal of ophthalmology, 2020, vol. 36 (3): 308-311 311 conflict of interest authors declared no conflict of interest. authors’ designation and contribution muhammad mohsin ali; house officer: literature review, manuscript writing, final review. qudsia anwar dar; senior registrar: literature review, manuscript writing, final review. zahid kamal siddiqui; professor: literature review, manuscript writing, final review. alishba khan; house officer: literature review, manuscript writing, final review. references 1. del rio c, malani pn. covid-19—new insights on a rapidly changing epidemic. jama. 2020. feb 28. doi: 10.1001/jama.2020.3072. 2. who. coronavirus disease 2019 (covid-19) situation report – 81: who; 2020 [cited 2020 10th april]. available from: https://reliefweb.int/sites/reliefweb.int/files/resources/2 0200410-sitrep-81-covid-19.pdf. 3. she j, jiang j, ye l, hu l, bai c, song y. 2019 novel coronavirus of pneumonia in wuhan, china: emerging attack and management strategies. clin trans med. 2020; 9 (1): 19. 4. jiang f, deng l, zhang l, cai y, cheung cw, xia z. review of the clinical characteristics of coronavirus disease 2019 (covid-19). jgen intern med. 2020: mar 4. doi: 10.1007/s11606-020-05762-w. 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[online] the royal college of ophthalmologists. available at: <https://www.rcophth.ac.uk/about/rcophth-covid-19response/.> [accessed 23 may 2020]. 15. medscape. 2020. covid-19 guidance for ophthalmologists (aao, 2020). [online] available at: <https://reference.medscape.com/viewarticle/927354> [accessed 23 may 2020]. 16. hassan b, ahmed r, li b, noor a, ul hassan z. a comprehensive study capturing vision loss burden in pakistan (1990-2025): findings from the global burden of disease (gbd) 2017 study. plos one. 2019; 14 (5). 17. qayyum a, khokhar ah, achakzai as. prevalence of ocular emergencies in quetta-balochistan. pak jmed sci. 2009; 3 (3): 43-5. 18. rcophth. management of ophthalmology services during the covid pandemic 2020. 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[online] available from: <https://rcopath.ac.uk/2020/03/covid-19-updateand-resources-for-ophthalmologists > [accessed 23 may 2020]. .……. microsoft word 17. adnan alam mm 272 pakistan journal of ophthalmology, 2020, vol. 36 (3): 272-276 original article cystoid macular edema after extracapsular cataract extraction performed by residents adnan alam1, mohammad idris2, hassan yaqoob3, eemaz nathaniel4, hadia sabir5 syed ittrat hussain6 1,2,5,6lady reading hospital, 3north west teaching hospital, 4rehman medical college, peshawar abstract purpose: to determine the frequency and outcome of management of cystoid macular edema after extra capsular cataract extraction performed by residents. study design: interventional case series. place and duration of study: lady reading hospital, mti, peshawar from oct 2018 to oct 2019. material and methods: total 400 patients with mature cataract were included in our study. patients having preexisting disease such as uveitis, hypertensive retinopathy, diabetic retinopathy and retinal degenerations were excluded. all surgeries were performed by 4th year residents under supervision. complicated cases before or during surgery were excluded from the study. cystoid macular edema cases were classified as follows; acute occurring within three months of cataract extraction and with duration fewer than 6 months, chronic persisting more than 6 months. patients were either managed conservatively or with anti-vegf. all cases were followed for 3 months or longer until resolution of cystoid macular edema. results: twenty patients developed cystoid macular edema out of which 16 patients (80%) improved with conservative treatment and 4 patients (20%) developed resistant cystoid macular edema. all four patients were given intravitreal bevacizumab injection monthly for three months. our findings showed that best corrected visual acuity (bcva) before injection ranged from 6/60 to 6/24. after three injections bcva improved between 6/18 to 6/6. pre injection central subfield thickness (csft) was between 611 to 480 micron which improved to 272 -260 micron after injections. conclusion: cystoid macular edema responds well to conservative treatment but resistant cases need repeated inj of anti vegf. key words: extra capsular cataract extraction, cystoid macular edema, cataract, anti-vegf. how to cite this article: alam a, idris m, yaqoob h, huzaifullah, alam m, hussain si. cystoid macular edema after extracapsular cataract extraction performed by residents. pak j ophthalmol. 2020; 36 (3): 272-276. doi: 10.36351/pjo.v36i3.1029 introduction pseudo-phakic cystoid macular edema (cme) or irvine-gass syndrome, is a common cause of visual correspondence to: mohammad idris lady reading hospital, peshawar email: idrisdaud80@gmail.com received: march 22, 2020 revised: may 4, 2020 accepted: may 4, 2020 loss after cataract surgery1,2. this is a painless condition characterized by the formation of multiple fluid filled cystic areas in the outer plexiform and inner nuclear layer of the macula resulting in increased thickness. this causes blurring or distortion of vision3. it typically develops 4-12 weeks after surgery with peak incidence at four to six weeks following surgery4. vision loss in majority of cases of cme is transient. in majority of cases, it shows good response with the use of topical medications like corticosteroids and non-steroidal anti-inflammatory drugs. however, cystoid macular edema after extracpsular cataract extraction performed by residents pakistan journal of ophthalmology, 2020, vol. 36 (3): 272-276 273 few cases were reported to last for more than 6 months resulting in permanent visual loss. although the incidence of chronic cme is much less, being reported at 1 – 2% of uncomplicated cases, the associated vision loss makes it a serious complication. cme still persists in uncomplicated cases even with the advances in surgical machinery and newer techniques being employed in different methods of cataract extraction1. cme is suspected in otherwise healthy patients with poor visual outcomes after cataract extraction diagnosed clinically by fundoscopy, fluorescein angiography by oct findings of central subfield macular thickening. some studies have shown that angiographic edema occurs in 60% of intracapsular surgeries, varying between 15 – 30% in extracapsular surgeries, and 4 – 11% in phacoemulsification5,6. clinical cme, on the other hand, is reported in 8% of intracapsular surgeries, 0.8 – 20%7 in ecce surgeries and 0.1 to 2.35% in phacoemulsification8. oct evidence of cme after phacoemulsification is 4% shown by belair 5. we employed oct scan as a diagnostic tool in analyzing cme in our patients. macular thickness (extrafoveal and foveal) was recorded in cross sectional high resolution oct images. the progression and regression of the edema was recorded. the purpose of our study was to determine the frequency and outcome of management of cystoid macular edema after extra capsular cataract extraction performed by residents material and methods this interventional case series included patients with cme after extra capsular cataract extraction (ecce) with posterior chamber intraocular lens implantation, performed by the residents under supervision. a total of 400 cases were included in the study. ethical approval from taken from the hospital and written consent was taken from all patients. non probability consecutive sampling technique was used. patients with mature cataract of either gender, having age 40 – 80 years, who underwent ecce cataract surgery, without any complication i.e. posterior capsular rent with or without vitreous loss and post-operative endophthalmitis were included in the study. patients having pre-existing disease i.e. uveitis, hypertensive retinopathy, diabetic retinopathy and retinal degenerations (assessed on slit lamp examination) were excluded. data was collected through proforma after fulfilling the inclusion criteria. all patients were operated by a senior resident. cme was diagnosed both clinically and on optical coherence tomography. all eyes were dilated before oct examination and were monitored regularly using oct. cme cases were classified as follows; acute which developed within three months of cataract extraction and lasted for less than 6 months. chronic lasted for more than 6 months. all this information was recorded through pre designed proforma. patients were followed up for improvement in visual acuity. those patients with vision less than 6/9 with best correction were examined in detail for suspected macular pathology and were advised optical coherence tomography to properly diagnosis and manage such patients on time. quantitative variables like age, and centre subfield thickness were presented in the form of mean ± s.d. qualitative variables like gender, and cystoids macular edema were presented in the form of frequencies and percentages. results out of 400 patients, 150 (38%) were male while 250 (62%) were females. the patients were followed up fig. 1: pre-injection and post-injection central subfield thickness on oct. adnan alam, et al 274 pakistan journal of ophthalmology, 2020, vol. 36 (3): 272-276 table 1: demographic features and final visual outcome of refractory (resistant) cme after treatment. s/n age gender bcva on 1st post-op visit bcva after 3 injections of bevacizumab 1 70 female 6/24 6/6 2 68 female 6/60 6/18 3 66 male 6/36 6/12 4 81 female 6/60 6/9 table 2: pre and post injection (bevacizumab) central subfield thickness. s/n age gender pre injection csft post injection csft 1 70 female 611micron 272 micron 2 68 female 550 micron 260 micron 3 66 male 520 micron 250 micron 4 81 female 480 micron 269 micron for 3 months, 20 (5%) patients developed cystoid macular edema diagnosed on oct. patients were managed conservatively with topical non-steroidal anti-inflammatory drugs (nsaids) and topical steroids. these patients were further followed up for 6 months. sixteen patients (80%) improved with conservative treatment while 04 (20%) were found resistant (refractory), who were given intravitreal bevacizumab monthly for three months. after 3 months, all 4 patients (100%) reported improvement in bcva of two or more lines on snellen visual acuity chart ranging between 6/18 to 6/6. central macular thickness improved from 611 micron to 250 micron on oct (figure 1). visual acuity and oct remained stable at 24 weeks of follow-up as shown in table 1 and 2. discussion multiple factors are involved in the pathogenesis of pseudophakic cme. however, inflammatory process appears to be the main factor of edema. prostaglandin mediated inflammation and subsequent breakdown of blood aqueous and blood retinal barrier increases vascular permeability9 with accumulation of fluid in retinal layers creating cystic spaces that subsequently coalesce to form larger pockets of fluid10. the incidence of cme increases when complications occur during surgery11. the most common complications are posterior capsular rent with loss of vitreous, incarceration of vitreous in the wound, lens drop in the vitreous, iris damage, intraocular lens dislocation, and implantation of anterior chamber lens. known history of retinal diseases such as uveitis, retinal vein occlusion, diabetes mellitus. latanoprost usage for glaucoma treatment also increase the risk of macular edema after cataract surgery. patient factors like age and sex, are also factors which affect development of cme12. according to stern et al younger people are more prone to cme after cataract surgery13. on the other hand, rosetti et al said that older people are more prone to cme after cataract surgery14. in our study 15 (75%) out of 20 cme cases were 50 or above. thus, in our study old age group developed cme more frequently than young age group. in our study, in 20 cme cases, 12 (60%) were females and 8 (40%) were males. these results were slightly different from the previous literature which stated that there was no sexual predilection for cme3,4. treatment is aimed at the underlying etiology. steroids directly inhibit the enzyme phospholipase thereby reducing the formation of prostaglandins and leukotrienes. they are considered primary treatment in many instances. steroid are administered topically, systemically, intravitreally15. they can also be given in posterior subtenon space. however, they are associated with increased intraocular pressure. nsaids inhibit the enzyme cyclooxygenase and can be used in prevention and treatment of cmo. they are advised for 3-4 months; they do not increase the intraocular pressure. carbonic anhydrase inhibitors and pars plana vitrectomy are also treatment options. anti-vascular endothelial growth factor (vegf) therapy has revolutionized many retinal treatments. vegf not only promotes angiogenesis, but it also promotes inflammation and capillary permeability that causes cme. bevacizumab is a humanized monoclonal antibody that inhibits vegf-a. bevacizumab can be used as primary as well as refractory treatment for cme16. in our study we injected all the four refractory cme cases with intraviteral bevacizumab. all the patients showed significant improvement in bcva of two or more lines on snellen visual acuity chart as well as significant reduction in central sub field thickness on oct. multiple studies have reported cases of refractory cme treated with intravitreal bevacizumab with significant improvement in visual acuity as well macular thickening17-19. arevalo et al16 reported a series of 39 eyes with pseudophakic macular edema unresponsive to conservative treatment. he showed that in 26 eyes cystoid macular edema after extracpsular cataract extraction performed by residents pakistan journal of ophthalmology, 2020, vol. 36 (3): 272-276 275 (72%) bcva improved by at least two lines and mean baseline bcva and central macular thickening improved from 6/60 and 500 micometer to 6/24 and 286 microns respectively after a mean of 2.7 injections per eye. barone et al17 reported 10 eyes with refractory cme and showed significant improvement in va and macular thickness. cme remains a common and difficult problem for patients and surgeons. similar to previous studies, oct has proved to be an excellent tool for diagnosis, management and follow up of cme after cataract extraction20,21. limitation of our study was that it only included residents. frequency of cme in expert hands could not be studied. conclusion even uneventful cataract surgeries can end up in macular edema, which needs proper follow up and management in the form of topical nsaid or intravitreal bevacizumab as a primary treatment or in refractory cases. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution adnan alam; specialist registrar: study design, data interpretation, manuscript writing, final review. mohammad idris; assistant professor: manuscript writing, final review. hassan yaqoob; associate professor: manuscript writing, final review. eemaz nathaniel; manuscript writing, final review. hadia sabir; post graduate trainee: manuscript writing, final review. syed ittrat hussain; posgraduate trainee: manuscript writing, final review. references 1. mccafferty s, harris a, kew c, kassm t, lane l, levine j, et al. pseudophakic cystoid macular edema prevention and risk factors; prospective study with adjunctive once daily topical nepafenac 0.3% versus placebo. bmc ophthalmol. 2017 feb 20; 17 (1): 16. 2. cho h, madu a. etiology and treatment of the inflammatory causes of cystoids macular edema. j inflamm res. 2009; 2: 37-43. 3. zur d1, fischer n, tufail a, monés j, loewenstein a. postsurgical cystoid macular edema. eur j ophthalmol. 2011; 21 suppl. 6: s62-8. 4. subramaniam ml, devaiah ak, warren ka. incidence of postoperative cystoid macular edema by a single surgeon. digit j ophthalmol. 2009; 28; 15 (4): 37-41. doi: 10.5693/djo.01.2009.010. 5. belair ml, kim sj, thorne je, dunn jp, kedhar sr, brown dm, et al. incidence of cystoid macular edema after cataract surgery in patients with and without uveitis using optical coherence tomography. am j ophthalmol. 2009; 148 (1): 128-35 e2. 6. yoon dh, kang dj, kim mj, kim hk. new observation of microcystic macular edema as a mild form of cystoid macular lesions after standard phacoemulsification: prevalence and risk factors. medicine (baltimore). 2018 apr; 97 (15): e0355. 7. bradford jd, wilkinson cp, bradford rh jr. cystoid macular edema after extracapsular extraction and posterior chamber inraocular lens implantation. retina, 1988; 8 (3): 161-164. 8. henderson ba, kim jy, ament cs, ferrufinoponce zk, grabowska a, cremers sl. clinical pseudophakic cystoid macular edema. risk factors for development and duration after treatment. j cataract refract surg. 2007; 33 (9): 1550-8. 9. flach aj. the incidence, pathogenesis and treatment of cystoid macular edema following cataract surgery. trans am ophthalmol soc. 1998; 96: 557-634. 10. the incidence, pathogenesis and treatment of cystoid macular edema following cataract surgery. trans am ophthalmol soc 1998; 96: 557-634. 11. benitah nr, arroyo jg. pseudophakic cystoid macular edema. int ophthalmol clin 2010; 50 (1): 139153. 12. t-t lai, j-s huang, p-t yeh. incidence and risk factors for cystoid macular edema following scleral buckling. eye (lond). 2017 apr; 31 (4): 566–571. 13. stern al, taylor dm, dalburg la, cosentino rt. pseudophakic cystoid maculopathy: a study of 50 cases. ophthalmology 1981; 88: 942-6. 14. rosetti l, autelitano a. cystoid macular edema following cataract surgery. curr opin ophthalmol 2000; 11: 65-72. 15. altintas agk, ilhan c. intravitreal dexamethasone implantation in intravitreal bevacizumab treatmentresistant pseudophakic cystoid macular edema. korean j ophthalmol. 2019 jun; 33 (3): 259-266. 16. arevalo jf, maia m, garcia-amaris ra, roca ja, sanchez jg, berrocal mh, et al. intravitreal adnan alam, et al 276 pakistan journal of ophthalmology, 2020, vol. 36 (3): 272-276 bevacizumab for refractory pseudophakic cystoid macular edema: the pan american collaborative retina study group results. ophthalmology, 2009; 116: 14811487. 17. barone a, prascina f, russo v, iaculli c, primavera v, querques g, et al. successful treatment of pseudophakic cystoid macular edema with intravitreal bevacizumab. j cataract refract surg. 2008; 34: 12101212. 18. mason jo 3rd, albert ma jr, vail r. intravitreal bevacizumab (avastin) for refractory pseudophakic cystoid macular edema. retina, 2006; 26: 356-537. 19. díaz-llopis m, amselem l, cervera e, garcía delpech s, torralba c, montero j. intravitreal injection of bevacizumab for pseudophakic cystoid macular edema resistant to steroids. arch soc esp oftalmol. 2007; 82: 447-450. 20. georgopoulos gt, papaconstantinou d, niskopoulou m, moschos m, georgalas i, koutsandrea c. foveal thickness after phacoemulsification measured by optical coherence tomography. clin ophthalmol. 2008; 2: 817-20. 21. blanco tf, moreno r, novella f, sánchez-cano a, honrubia-lópez fm. pseudophakic cystoid macular edema. assessment with optical coherence tomography. arch soc esp oftalmol. 2006; 81: 14754. .……. 4 pak j ophthalmol. 2021, vol. 37 (1): 4-6 guest editorial role of optical coherence tomography angiography in diagnosis of early glaucoma ozlem dikmetas, 1 ali bülent cankaya 2 1,2 department of ophthalmology, hacettepe university school of medicine, ankara, turkey 1 orcıd id: 0000-0001-5670-2384, 2 orcid id: 0000-0002-0169-4740 glaucoma is one of the leading causes of irreversible blindness worldwide. its estimated prevalence is 111.8 million by 2040. 1 it is a multifactorial disease characterized by loss of retinal ganglion cells (rgc) and retinal nerve fiber layer (rnfl). optic nerve head (onh) blood supply varies in different segments. the nerve fiber layer is supplied from the central retinal artery. however, the blood flow of the optic nerve head is from the short posterior ciliary arteries rather than the central retinal artery. these arteries make the incomplete anastomosis around the optic nerve head at the scleral lamina level. this missing anastomotic ring is called the zinn-haller arterial ring. 2 some theories such as vascular dysregulation and mechanical trauma have been described in the etiopathogenesis of rgc damage due to glaucoma. 2 vascular dysregulation is anchored by the hypothesis that ischemia causes rgc death. 3 this theory suggests ischemia of the onh leads to rgc death. the role of the vasculature and blood flow in the pathophysiology of glaucoma, which is a progressive optic neuropathy, has been extensively investigated. 3 clinical findings such as migraine, raynaud’s syndrome, and nocturnal how to cite this article: dikmetas o, cankaya ab. role of optical coherence tomography in diagnosis of early glaucoma. pak j ophthalmol. 2021, 37 (1): 46. doi:https://doi.org/10.36351/pjo.v37i1.1163 correspondence: ozlem dikmetas department of ophthalmology, hacettepe university school of medicine, ankara, turkey email: ozlemdikmetas@gmail.com received: november 13, 2020 accepted: november 30, 2020 hypotension have been described as an evidence of the role of disturbed blood supply in the development of glaucoma. 4, 5 various technologies have been explored for the vascular supply of the eye but none of these were appropriate for the optic nerve head. 6 recently much work is being done on the optical coherence tomography angiography (octa) studies. octa is still in evolution and optical coherence tomography (oct) devices are changing rapidly but the basic principles remain the same. 6 octa has been recently introduced as a noninvasive and reproducible tool to evaluate the vasculature of the retinal layers. 6 the basic working principle of octa is that red blood cells are used as an intrinsic contrast agent to create three dimensional images of microvascular networks. 6 functional and structural tests are important for glaucoma diagnosis. however, early diagnosis is critical in glaucoma so octa is the new approach in this cause. in the analysis of octa, the parameters which are employed include foveal avascular zone, choriocapillaris, foveal and optic nerve head vessel density (vd) and flow index. vd within the peripapillary retinal nerve fiber layer (prnfl) is measured from the internal limiting membrane (ilm) to prnfl posterior boundary. 7 it is well known that prnfl is mainly affected in the inferior and superior quadrants in pre-perimetric and early glaucoma. 7 wang et al showed that the prnfl decreased in 77% of the eyes showing early ganglion cell inner plexiform layer (gcipl) thinning, suggesting that prnfl analysis may overlook early glaucomatous macular damage. 8 zheng et al showed that the superotemporal and infero-temporal prnfl and bruch membrane opening thicknesses below the fifth percentile yielded the best diagnostic performance for glaucoma detection. 9 mailto:ozlemdikmetas@gmail.com role of optical coherence tomography angiography in diagnosis of early glaucoma pak j ophthalmol. 2021, vol. 37 (1): 4-6 5 octa can be helpful to see the relationship between neuronal and vascular changes in glaucomatous eyes. octa-based studies investigated the macular region and found that glaucomatous eyes had a significantly lower superficial vascular complex (svc) at the macula than healthy eyes. in contrast, no significant difference was found in the intermediate and deep capillary plexuses at the macula. chung et al showed decreased macular and peripapillary vd in the glaucomatous eyes. 10 the vd parameters were found significantly correlated with other structural and functional parameters. the peripapillary vd differences may be helpful for the diagnosis of glaucoma suspects and healthy eyes. 10 yarmohammadi et al showed significantly lower vd in glaucoma eyes compared with glaucoma suspects and healthy eyes. 11 the studies related to the ocular blood flow in glaucoma are important but difficulty arises as ocular hemodynamics may be different in different populations. triolo et al evaluated the macular and peripapillary vascular density. 12 they showed that peripapillary vd on average and in the superior and inferior quadrants decreased in the glaucoma group (p = 0.001). however, macular vd was not statistically different (p > 0.05). a correlation between rnfl thickness and vd was also found at the peripapillary area; but the correlation was not found in all groups. 12 the early manifest glaucoma trial showed that low perfusion pressure was a risk factor for glaucoma progression. 13 perfusion pressure is affected by multiple factors including nocturnal hypotension and raynaud phenomenon. various studies have shown their relation with the glaucomatous changes. 5 as these studies did not consider blood flow at the optic nerve head directly, the relationship between optic nerve perfusion and glaucoma remains incompletely described. lee et al investigated the relationship between the decreased peripapillary retinal perfusion as examined by octa and rnfl defect in eyes with primary open-angle glaucoma (poag) and a localized rnfl defect. 14 they found that areas of low perfusion on octa coincided with the rnfl defect, suggesting that decreased vd is the result of the capillary shut down secondary to rnfl cell death. a decrease in octa parameters could be seen in glaucoma, but the clinical application of this information is still being investigated. there is not enough evidence to use this technology in diagnosing very early stage of glaucoma. however, octa studies still remain the key role to explain the relationship between perfusion and the pathogenesis of glaucoma. octa is a noninvasive technique. octa data strongly indicates the value of ocular perfusion in different stages of glaucoma. the combined use of various measurement techniques should be helpful for us. to analyse the diagnostic effects of the perfusion parameters, further studies are necessary. conflict of interest authors declared no conflict of interest references 1. tham yc, li x, wong ty, quigley ha, aung t, cheng cy. global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. ophthalmology 2014; 121 (11): 2081-2090. 2. flammer j, orgul s. optic nerve blood-flow abnormalities in glaucoma. prog retin eye res. 1998; 17 (2): 267-289. 3. cioffi ga. three common assumptions about ocular blood flow and glaucoma. surv ophthalmol. 2001; 45 suppl 3: s325-331. 4. chuang lh, koh yy, chen hsl, lo yl, yu cc, yeung l et al. normal tension glaucoma in obstructive sleep apnea syndrome: a structural and functional study. medicine (baltimore), 2020; 99 (13): e19468. 5. emre m, orgul s, gugleta k, flammer j. ocular blood flow alteration in glaucoma is related to systemic vascular dysregulation. br j ophthalmol 2004; 88 (5): 662-666. 6. triolo g, rabiolo a. optical coherence tomography and optical coherence tomography angiography in glaucoma: diagnosis, progression, and correlation with functional tests. ther adv ophthalmol. 2020; 12: 2515841419899822. 7. lommatzsch c, rothaus k, koch jm, heinz c, grisanti s. octa vessel density changes in the macular zone in glaucomatous eyes. graefes arch clin exp ophthalmol. 2018; 256 (8): 1499-1508. 8. wang dl, raza as, de moraes cg, chen m, alhadeff p, jarukatsetphorn r, et al. central glaucomatous damage of the macula can be overlooked by conventional oct retinal nerve fiber layer thickness analyses. transl vis sci technol. 2015; 4 (6): 4. 9. zheng f, yu m, leung ck. diagnostic criteria for detection of retinal nerve fibre layer thickness and neuroretinal rim width abnormalities in glaucoma. br j ophthalmol 2020; 104 (2): 270-275. ozlem dikmetas, et al 6 pak j ophthalmol. 2021, vol. 37 (1): 4-6 10. chung jk, hwang yh, wi jm, kim m, jung jj. glaucoma diagnostic ability of the optical coherence tomography angiography vessel density parameters. curr eye res 2017; 42 (11): 1458-1467. 11. yarmohammadi a, zangwill lm, diniz-filho a, suh mh, manalastas pi, fatehee n, et al. optical coherence tomography angiography vessel density in healthy, glaucoma suspect, and glaucoma eyes. invest ophthalmol vis sci. 2016; 57 (9): oct451-459. 12. triolo g, rabiolo a, shemonski nd, fard a, di matteo f, sacconi r et al. optical coherence tomography angiography macular and peripapillary vessel perfusion density in healthy subjects, glaucoma suspects, and glaucoma patients. invest ophthalmol vis sci. 2017; 58 (13): 5713-5722. 13. leske mc, heijl a, hussein m, bengtsson b, hyman l, komaroff e, et al. factors for glaucoma progression and the effect of treatment: the early manifest glaucoma trial. arch ophthalmol. 2003; 121 (1): 48-56. 14. lee ej, lee km, lee sh, kim tw. oct angiography of the peripapillary retina in primary open-angle glaucoma. invest ophthalmol vis sci. 2016; 57 (14): 6265-6270. authors’ designation and contribution ozlem dikmetas: ali bülent cankaya: .…  …. pak j ophthalmol. 2021, vol. 37 (4): 370-374 370 original article outcomes of squint surgery in terms of motor alignment within 10 prism diopters in a tertiary care hospital: a clinical audit shaukat ali chhipa 1 , sharmeen akram 2 , asma rahman 3 department of ophthalmology, 1-3 the aga khan university hospital, karachi abstract purpose: to determine the outcome of squint surgery in terms of motor ocular alignment within 10 prism diopters, in a tertiary care hospital. study design: a clinical audit at a tertiary care hospital. place and duration of study: the study was conducted in ophthalmology department, of aga khan university hospital, karachi between december 2016 and june 2017. methods: medical records of all patients who underwent squint surgery were retrieved and included in the study. patients with amblyopia, corneal or retinal pathologies and those who lost to follow-up or with incomplete records were excluded. all the available demographic and clinical data including pre-operative visual acuity, squint measurements, procedure performed and post-operative ocular alignment up to maximum of 6 months of followup was compiled. results: one hundred and nineteen patients fulfilled the inclusion criteria. there were 54.6% males and 45.4% were females. squint was unilateral in 75.4% of patients and bilateral in 24.5%. exotropia was present in 74 (62%) and esotropia in 45 (38%) patients. the frequency of post-operative outcomes among the study participants were analyzed and it was reported that at six months follow-up central straight eye position or squint less than 10 prism diopters was seen among 75.5% of patients. the association of age and gender with primary outcome was obtained by applying independent sample t test. all the categories of age and gender showed statistically significant results i.e. p-value ≤ 0.05, except one week follow-up among different categories of gender showing insignificant results with p value = 0.740. conclusion: in present study 75.5% patients achieved the required result of ocular alignment within 10 prism diopters of orthotropia at the final follow-up visit. key words: squint, esotropia, exotropia, 10 prism diopters. how to cite this article: chhipa sa, akram s, rahman a. outcome of squint surgery in terms of motor alignment within 10 prism diopters in a tertiary care hospital: a clinical audit. pak j ophthalmol. 2021, 37 (4): 370-374. doi: 10.36351/pjo.v37i4.1276 correspondence: shaukat ali chhipa department of ophthalmology the aga khan university hospital karachi email: shaukat.chhipa@aku.edu received: may 17, 2021 accepted: september 03, 2021 introduction strabismus is greek word meaning eyes looking obliquely. the causes of squint/strabismus include refractive errors, failure to keep normal fusion mechanism and neuromuscular anomalies of extra ocular muscles. it is one of the most common ophthalmic problems in pediatric population affecting open access outcome of squint surgery in terms of motor alignment within 10 prism diopters in a tertiary care hospital: a clinical audit 371 pak j ophthalmol. 2021, vol. 37 (4): 370-374 5% of the preschool children but also occurs in adults. 1,2 the presentation of misalignment of eyes may be vertical, horizontal, and torsional or a mixture of all. treatment for squint comprise of conservative management such as correction of refractive errors, prisms, patching, orthoptic exercises and surgical correction if not corrected with conservative management. 3,4,5 most commonly surgeries are executed on horizontal muscles for horizontal squints. 6,7,8 the principle objective of strabismus surgery is to align the eyes. surgery is also carried out to rebuild binocular single vision (stereopsis), improve ocular straining due to eyes deviation, improve visual confusion, correct abnormal head positioning and reestablish peripheral visual field. 9,10 squint surgery also indirectly affects the socioeconomic status of the patient and improves the quality of life. 11,12 ocular alignment after surgery is the criteria to determine the success of the procedure. 13 this particular study was done to evaluate the ocular alignment within 10 prism diopters post operatively for horizontal squint surgery with a 6 months’ followup in aga khan university hospital. methods this retrospective observational study was conducted to evaluate the success rate of squint correction surgery that is ocular alignment within 10 prism diopters and to determine the association of age and gender with success rate in a tertiary care hospital. all those patients that who underwent horizontal squint correction surgery at the aga khan university hospital karachi between december 2016 and june 2017 were included. six months follow-up was included. medical records were retrieved using the hospital information system. patients with amblyopia, corneal or retinal pathologies and those who lost to follow-up were not included in the study. a proforma was filled containing patient’s bio data, squint measurements, procedure performed and post-operative ocular alignment up to 6 months of follow-up. primary outcome measure was ocular alignment within 10 prism diopters. secondary outcome was to find out the association of ocular alignment with age and gender. data was entered and analyzed using spss v.19 (ibm corp, armonk, ny). qualitative data was reported as frequencies and percentages while quantitative data was presented as means and standard deviation. association of age and gender with primary outcome was obtained by applying independent sample t test. a p-value of < 0.05 was considered statistically significant. results one hundred and nineteen patients fulfilled the inclusion criteria out of the six month record. postoperative squint surgery outcomes at 1 st post-operative follow-up, one week, one month and six months was recorded. out of 119 patients 54.6% were males and 45.4% were females. most of the patients 41(34.5%) belonged to 0 – 6 years of age group (table-1). squint was unilateral in 75.4% of patients and bilateral in 24.5%. exotropia was present in 74 (62%) and esotropia in 45 (38%) patients. the frequency of post-operative outcomes among the study participants were analyzed and it was reported that at six months follow-up central straight eye position or squint less than 10 prism diopters was seen among 75.5% of patients (table-2). the association of age and gender with primary outcome was obtained by applying independent sample t test. all the categories of age and gender showed statistically significant results i.e. p-value ≤ 0.05, except one week follow-up among different categories of gender showing insignificant results with p value = 0.740 (table-3). table 1: demographic variables. age frequency (n = 119) percentage 0 – 6 years 41 34.5% > 6 – 12 years 22 18.5% > 12 – 18 years 17 14.3% > 18 – 38 years 30 25.2% > 28 – 40 years 5 4.2% > 40 – 55 years 3 2.5% > 55 years 1 0.8% shaukat ali chhipa, et al pak j ophthalmol. 2021, vol. 37 (4): 370-374 372 table 2: outcomes at six months. frequency percent valid percent cumulative percent valid squint within 10 prism diopters 28 23.5 29.8 29.8 squint more than 10 prism diopters 23 19.3 24.5 54.3 central good 43 36.1 45.7 100.0 total 94 79.0 100.0 incomplete data or lost to follow-up 25 21.0 total 119 100.0 table 3: assessment of association of age and gender with primary outcome. age first follow-up p-value one week follow-up p-value one month follow-up p-value six months follow-up p-value 0 – 6 years > 6 – 12 years > 12 – 18 years > 18 – 38 years > 28 – 40 years > 40 – 55 > 55 missing* total 21 12 7 14 4 0 1 60 59 0.000* 30 12 7 23 4 0 1 42 77 0.017* 23 11 12 19 5 3 0 48 71 0.011* 38 15 11 21 5 3 1 26 94 0.000* gender first follow-up p-value one week follow-up p-value one month follow-up p-value six months follow-up p-value male female missing* total 29 30 60 59 0.03* 38 39 43 77 0.740 37 34 49 71 0.023* 47 47 25 94 0.016* *significant p-value by independent sample t test discussion it is difficult to determine the true outcome of currently available treatments for horizontal squint because of lack of a standard definition for a successful outcome, variability in classification systems, multiple treatment approaches, and unavailability of long-term data. short-term studies with 6 months to 1-year follow-up reported the success rates of approximately 80%, whereas studies with long follow-up period i.e.5 – years or above follow-up have shown a 32.8% – 58% success rate with one surgery. 14,15 most of the studies have described their achievement in relation to ocular alignment of within 10 prism diopters (pd) of orthotropia. 14,15 short-range studies of 6 – month follow-up have stated surgical success rates of about 63% – 80%. 14 while studies with 5years or above follow-up have stated a 32.8% – 58%. 15 the successful outcome depends entirely on the criteria used for such success. squint correction success is differently seen in different studies like type of squint, age at the time of onset, surgical procedure adopted for correction, binocularity and alignment of eyes. 16 but most of the studies yield alignment as success and outline satisfactory alignment as within 10 prism diopters of orthotropia. awadein et al reported a 67% success rate (within 10 prism diopters) for correction of large-angle exodeviation after surgery for intermittent exotropia. 15 pineless et al, described 197 patients with a follow-up of 10 years and found 60% success rate of surgery. 17 kim et al, included 526 patients and found 75% success rate up in one month follow-up. 2 yang et al included large number of patients 1228 and have found 80% success rate in 8 months’ follow-up. 18 in our study 94 patients attended the follow-up of 6 months out of 119 and at that time the alignment was 75.5% either central or less than 10 prism diopters. our results are consistent with international figure of 60% – 80% for horizontal squint surgery. 19 rajasekaran reported that exotropia was the most prevalent type of strabismus followed by esotropia. 20 we had exotropia in 62% patients and esotropia in 38%. there is scarcity of data regarding significant reports on gender difference in squint patients. in our outcome of squint surgery in terms of motor alignment within 10 prism diopters in a tertiary care hospital: a clinical audit 373 pak j ophthalmol. 2021, vol. 37 (4): 370-374 study 54.6% were males and 45.4% were females and we find similar results in literature. 21 maximum number of patients belonged to 0-6 years of age group i.e. 34.5%. the age of presentation of squint differs in many studies but the range is somewhat similar. 21,22 limitations of this study are the retrospective design, single center data, limited follow-up and small sample size. multicenter long-term follow-up studies with large sample size with multiple approaches to treat horizontal squint are needed in future to establish results that can be generalized to larger populations. conclusion in the present study 75.5%patients achieved the required result of ocular alignment within 10 prism diopters of orthotropia at the final follow-up visit, which is comparable with the international data. ethical approval the study was approved by the institutional review board/ethical review board. (5314-sur-erc-18) conflict of interest authors declared no conflict of interest. references 1. sharma a, et al. horizontal strabismus surgery: outcome and satisfaction. nepal j ophthalmol 2014; 6 (12): 162-169. 2. yang m, chen j, shen t, kang y, deng d, lin x, wu h, chen q, ye x, li j, yan j. clinical characteristics and surgical outcomes in patients with intermittent exotropia: a large sample study in south china. medicine (baltimore), 2016; 95 (5): e2590. doi: 10.1097/md.0000000000002590. 3. kim hj, choi dg. consecutive esotropia after surgery for intermittent exotropia: the clinical course and factors associated with the onset. br j ophthalmol. 2014; 98: 871–887. 4. chiu ak, din n, ali n. standardizing reported outcomes of surgery for intermittent exotropia—a systematic literature review. strabismus, 2014; 22: 32– 36. 5. lim sh, hwang bs, kim mm. prognostic factors for recurrence after bilateral rectus recession procedure in patients with intermittent exotropia. eye, 2012; 26: 84. 6. robaei r, rose ka, kifley a, cosstick m, ip jm, mitchell p. factors associated with childhood strabismus: findings from a population-based study. ophthalmol. 2006; 7: 113. 7. gharabaghi dam. binocular vision and stereopsis following delayed strabismus surgery. iran j ophthalmol. 2006; 19: 46e50. 8. kushner bj. the efficacy of strabismus surgery in adults: a review for primary care physicians. postgrad med j. 2011; 87: 269–273. 9. von noorden gk, campos ec. binocular vision and ocular motility: theory and management of strabismus. orbis cyber-sight. available at: http://telemedicine.orbis.org/bins/content_page.asp?cid =1-2193-2194. accessed july 31, 2021 10. kampanartsanyakorn s, surachatkumtonekul t, dulayajinda d, jumroendararasmee m, tongsae s. the outcomes of horizontal strabismus surgery and influencing factors of the surgical success. j med assoc thai. 2005; 9: 88 11. beauchamp gr, black bc, coats dk, enzenauer rw, hutchinson ak, saunders ra, et al. the management of strabismus in adults--i. clinical characteristics and treatment. j aapos. 2003; 4: 233240. 12. repka mx, connet je, scott we. the one-year surgical outcome after prism adaptation for the management of acquired esotropia. ophthalmology, 1996; 103: 922. 13. mills md, coats dk, donahue sp, wheeler dt. american academy of ophthalmology. strabismus surgery for adults: a report by the american academy of ophthalmology. ophthalmology, 2004; 111 (6): 1255-1262. doi: 10.1016/j.ophtha.2004.03.013. 14. hatt sr, leske da, holmes jm. responsiveness of health-related quality-of-life questionnaires in adults undergoing strabismus surgery. ophthalmology, 2010; 117 (12): 2322-2328.e1. doi:10.1016/j.ophtha.2010.03.042 15. lee jy, ko sj, baek su. survival analysis following early surgical success in intermittent exotropia surgery. int j ophthalmol. 2014; 7 (3): 528–533. 16. awadein a, eltanamly rm, elshazly m. intermittent exotropia: relation between age and surgical outcome: a change-point analysis. eye (lond). 2014; 28 (5): 587– 593. 17. sharma a, thapa m, shrestha gb, sitaula s, shrestha gs. horizontal strabismus surgery: outcome and satisfaction. nepal j ophthalmol. 2014; 6 (12): 162-169. 18. pineles sl, ela-dalman n, zvansky ag, yu f, rosenbaum al. long-term results of the surgical management of intermittent exotropia. j aapos. 2010; 14 (4): 298-304. doi: 10.1016/j.jaapos.2010.06.007. http://telemedicine.orbis.org/bins/content_page.asp?cid=1-2193-2194 http://telemedicine.orbis.org/bins/content_page.asp?cid=1-2193-2194 shaukat ali chhipa, et al pak j ophthalmol. 2021, vol. 37 (4): 370-374 374 19. yang x, man tt, tian qx, zhao gq, kong ql, meng y, et al. long-term postoperative outcomes of bilateral lateral rectus recession vs. unilateral recessionresection for intermittent exotropia. int j ophthalmol. 2014; 7 (6): 1043-1047. doi: 10.3980/j.issn.2222-3959.2014.06.25. 20. kumari n, amitava ak, ashraf m, grover s, khan a, sonwani p. prognostic preoperative factors for successful outcome of surgery in horizontal strabismus. oman j ophthalmol. 2017; 10 (2): 76-80. doi:10.4103/ojo.ojo_133_2016 21. rajasekaran r, kumari rm, balagopal a, ramesh pv, mohan k. prevalence of various types of strabismus among patients attending a tertiary eye care hospital at tiruchirappalli. j. evolution med. dent. sci. 2018; 7 (52): 5484-5487. doi:10.14260/jemds/2018/1213 22. chaudhry ta, khan a, khan mb, ahmad k. gender differences and delay in presentation of childhood squint. j pak med assoc. 2009; 59 (4): 229231. 23. mohney bg, greenberg ae, diehl nn. age at strabismus diagnosis in an incidence cohort of children. am j ophthalmol 2007; 144 (3): 467-469. doi.org/10.1016/j.ajo.2007.04.022 authors’ designation and contribution shaukat ali chhipa; assistant professor: concepts, design, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. sharmeen akram; assistant professor: concepts, data analysis, manuscript editing, manuscript review. asma rahman; medical officer: design, literature search, data analysis, statistical analysis, manuscript preparation. .…  …. https://doi.org/10.1016/j.ajo.2007.04.022 36 pak j ophthalmol. 2022, vol. 38 (1): 36-42 original article implementation of standard operating procedure in ophthalmic practice during covid 19 era across pakistan uzma taqi 1 , erum shahid 2 , uzma fasih 3 1 baqai medical university, 2-3 karachi medical and dental college & abbasi shaheed hospital, karachi abstract purpose: to analyze the implementation of standard operating procedures (sop) in different ophthalmic settings of pakistan during covid 19. study design: cross sectional online survey. place and duration of study: baqai medical university & karachi medical and dental college, from 11 th to 25 th january 2021. methods: this online survey included doctors working as consultants, medical officers and trainees in ophthalmology setups. a self-designed questionnaire on google forms was sent online to see the implementation of standard operating procedures during covid 19. results: a total of 400 participants were selected by snowball sampling technique. a response rate was 105 (26.5%). females were 66 (62.86%). among all participants, 36.19% responded that they always screened patients for covid 19 at reception. doctors who always wore masks were 96.19%. out of those who responded, 16.19% and 11.43% always wore protective goggles and disposable gowns respectively. only 55.24% practiced hand sanitization, 18.10% washed hands with soap and 30.48% cleaned slit lamps after seeing each patient. doctors who always asked for pcr before ocular surgery under general anesthesia were 65 (61.90%) and for local anesthesia were 36 (34.29%). direct ophthalmoscopy, tonometry, and gonioscopy were performed when necessary by 56.19%, 80.00%, 80.00% of doctors respectively. only 69.5% were satisfied with precautionary measures. conclusion: clinic management needs improvement in implementing sops among patients in an eye opd. fifty percent of the ophthalmologists received ppe by their administration. only 69.5% doctors were satisfied with precautionary measures. key words: covid 19, standard operating procedures, pakistan, ophthalmology how to cite this article: taqi u, shahid e, fasih u. implementation of standard operating procedure in ophthalmic practice during covid 19 era across pakistan. pak j ophthalmol. 2022, 38 (1): 36-42. doi: 10.36351/pjo.v38i1.1307 correspondence: erum shahid karachi medical and dental college & abbasi shaheed hospital, karachi email: drerum007@hotmail.com received: june 24, 2021 accepted: december 12, 2021 introduction the ongoing covid–19 pandemic is a rapid rise catastrophic warning to human lives and livelihood all over the world. 1 severe acute respiratory syndrome coronavirus 2 (sars-cov-2) spreads primarily through person to person in close contact by droplets of saliva or discharge from the nose when they talk, cough or sneeze, by touching a virus containing open access implementation of standard operating procedure in ophthalmic practice during covid 19 era pak j ophthalmol. 2022, vol. 38 (1): 36-42 37 surface or an object, and then touching the eyes, mouth or nose, 2,3 or by aerosol droplets of the conjunctiva in case of conjunctivitis. 4 as of january 22, 2021, 219 countries and territories have been affected around the world. reported registered cases were 99,538,884 and a mortality rate of 2.14% with 2,134,449 deaths had been recorded. 5 it has spread like bush fire with tremendous pressure on the healthcare system. healthcare workers are a part of the front line, which are fighting against the pandemic. 6 according to paho director carissa f. etienne, large number of healthcare workers have been infected with covid– 19 virus and have died globally. by september 2020, over 10,000 healthcare workers got infected with coronavirus in africa. 7 in washington d.c., by september 02, 2020, nearly 570,000 health workers have contracted the virus and more than 2,500 could not make their way out and died. 8 there were 3387 healthcare workers in china, who got sick with this virus and 23 passed away. 9 the first two cases of coronavirus were confirmed on february 26th, 2020 in pakistan. by january 22, 2021, 532,412 cases of covid–19 were recorded and 11,295 succumbed to this virus in pakistan. at least, 10,300 health professionals have been infected and amid them, 100 have died. 10 khyber pakhtunkhwa reported the highest number of infections among health care workers at 2,638, followed by 2,463 in sindh and 2,534 in punjab. 11 however, ophthalmologists are one of the most high-risk medical specialties as they are very close to the patients during examination. slit-lamp is an extremely necessary tool for an eye examination in which the distance between the patient and ophthalmologist is less than 12 inches. furthermore, there is no distance between the examiner and the patient during direct ophthalmoscopy. 12 the ocular secretions and tears could be responsible for the spread of virus. dr. li wenliang, md a 33-year old ophthalmologist working in wuhan, china, was the first doctor who raised the alarm about the novel coronavirus, the first ophthalmologist who contracted this virus by an asymptomatic glaucoma patient and died. 13 this study was conducted to see the implementation of standard operating procedures (sop) in various ophthalmic settings all over pakistan during the covid-19 era. it will help to identify the flaws in our health care system and also let the ophthalmologists be aware of the importance of sops. moreover, it will be beneficial for policy makers and stakeholders to facilitate the implementation of standard operating procedures in ophthalmic departments of various hospitals and clinics to curb virus among health care workers and patients. methods this cross-sectional survey was conducted online in the ophthalmology department of baqai medical university & karachi medical and dental college. the study was approved by the institutional ethics committee of baqai medical university, hospital. all the doctors working as consultants, medical officers, trainees and residents in ophthalmology clinics, ophthalmology departments of government and private hospitals all over the country during the last 6 months of covid-19 lockdown, were invited to participate in the study, from 11 th to 25 th january 2021. a self-designed questionnaire in english language was used on google forms to collect the data. the form was shared via e-mail and whatsapp link to the participants. the sampling technique was the snowball technique. we accepted responses for 2 weeks. participation and completion of the survey were regarded as informed consent of the respondents. the survey and the participants were kept anonymous. participants provided demographic data including age range, gender, qualification, place of practice, and designation. incomplete forms were excluded from the analysis. the study questionnaire consisted of 23 multiple choice questions. other than demographic details, there were 15 questions based on standard operating procedures (sop) selected from the guidelines provided by the indian ophthalmological society. 14 among them 3 questions were related to the administration, whether the patients were screened at the reception of the hospital by asking questions related to symptoms of covid-19 and history of travel. whether they were seated with social distancing in the waiting area of the clinic and the patients had worn face mask were also asked. seven questions were about the participating doctors; (wearing a face mask, washing hands with soap, cleaning with a sanitizer, using a breath shield on the slit lamp, wearing protective goggles or face shield, gown, and cleaning slit lamp after each patient). the responses were classified into every time, frequently, often, or never. the next 3 questions were about erum shahid, et al 38 pak j ophthalmol. 2022, vol. 38 (1): 36-42 performing diagnostic procedures including direct ophthalmoscopy, tonometry, and gonioscopy (always, never, and when mandatory in a patient for an eye examination). two questions were about practicing polymerase chain reaction (pcr) testing before ophthalmic surgeries under local and general anesthesia (always, frequently, often, or never). the last two questions were about the personal protective equipment (ppe) provided to the doctors by their hospital or arranged by themselves and were they satisfied with the precautions they were taking. data was compiled on microsoft excel. frequencies were generated for the categorical variables and means for numerical variables. results a total of 400 participants were requested to fill the questionnaire online. one hundred and five (105) participants responded. participants with missing data were excluded. the response rate of complete data was 26.25%. data analysis was done on 105 participants. in this study, 39 (37.14%) participants were males and 66 (62.86%) were females. their ages ranged between 21 to 80 years, which were further categorized in decades (table 1). most of the respondents, (35.24%) were in the age group of 41–50 years. table 2 shows the details of responses received by the participants. approximately 22% never asked screening questions for covid-19. only 1 (0.95%) responded that patients never wore masks. however, majority of the participants (96.19%) always wore masks and only 16.19% and 11.43% always wore protective goggles and disposable gowns respectively. more than half of the responders sanitized their hands after examining each patient (55.24%). doctors who always ordered pcr for covid–19 for local anesthesia were 36 (34.29%) and for general anesthesia were 65 (61.90%). the highest number of participants, who performed direct ophthalmoscopy, tonometry, and gonioscopy when necessary were, 56.19%, 80.00%, and 80.00% respectively while only 3.81% never did tonometry during pandemic. only 51% were provided ppe by the hospital. sixty one percent of the participants were satisfied by the sop. table 1: demographic features of the participants in percentages. variables n (%) gender males females age range 21 – 30 years 31 – 40 years 41 – 50 years 51 – 60 years 61 – 70 years 71 – 80 years qualification fcps/frcs mcps ms mbbs province sindh punjab islamabad balochistan khyber pakhtun khawa kashmir place of work urban rural place of work government hospital private hospital private clinic designation consultant resident/trainee medical officer house officer 39 (37.14%) 66 (62.86%) 14 (13.33%) 31 (29.52%) 37 (35.24%) 19 (18.10%) 4 (3.81%) 0 (0.00%) 79 (75.24%) 3 (2.86%) 2 (1.90%) 21 (20.00%) 53 (50.48%) 37 (35.24%) 4 (3.81%) 4 (3.81%) 6 (5.71%) 1 (0.95%) 99 (94.29%) 6 (5.71%) 58 (55.24%) 36 (34.29%) 11 (10.47%) 83 (79.05%) 10 (9.52%) 12 (11.43%) 7 (6.67%) fcps: fellow of college of physicians and surgeons. frcs: fellow of royal college of surgeons. mcps: member of college of physicians and surgeons. ms: master of surgery. mbbs: bachelor of medicine and bachelor of surgery. implementation of standard operating procedure in ophthalmic practice during covid 19 era pak j ophthalmol. 2022, vol. 38 (1): 36-42 39 table 2: percentages of implementation of sops in various ophthalmic practices across pakistan. questions always (%) frequently (%) often (%) never (%) patient is screened at reception 38 (36.19%) 20 (19.05%) 24 (22.86%) 23 (21.90%) patient wears mask 54 (51.43%) 35 (33.33%) 15 (14.29%) 1 (0.95%) patient is seated with social distancing in waiting area 23 (21.90%) 28 (26.67%) 30 (28.57%) 24 (22.86%) do you wear a mask 101 (96.19%) 3 (2.86%) 0 (0.00%) 1 (0.95%) do you wear protective goggles/ face shield 17 (16.19%) 10 (9.52%) 34 (32.38%) 44 (41.90%) do you wear a disposable gown in opd 12 (11.43%) 11 (10.48%) 26 (24.76%) 56 (53.33%) do you sanitize your hands after examining each patient 58 (55.24%) 29 (27.62%) 16 (15.25%) 2 (1.90%) do you wash hands with soap after seeing each patient 19 (18.10%) 35 (33.33%) 40 (38.10%) 11 (10.48%) do you clean slit lamp after every patient 32 (30.48%) 31 (29.52%) 23 (21.90%) 19 (18.10%) do you use slit lamp breath shield 99 (94.29%) − − 6 (5.71%) do you screen patient before local surgery by pcr 36 (34.29%) 15 (14.29%) 8 (7.62%) 46 (43.81%) do you screen patient before general surgery by pcr 65 (61.90%) 12 (11.43%) 7 (6.67%) 21 (20.00%) figure 1: percentages of participants using various diagnostic procedures during covid 19. discussion ophthalmology practice is distinctive, as it requires close contact during patient examination, routine usage of reusable equipment, and many highly touch surfaces, which results in a high risk of disease transmission among ophthalmology patients. we have broadly categorized the sop into clinic management and staff protection for ease of understanding. in our study, 21.90% of patients presenting for an eye examination at an ophthalmology clinic were never asked about the screening questions at the reception and 22.86% of them were never seated with social distance. patients coming to an eye outpatient department always wore a mask represented by 51.43% of the total. it has been recommended by the american academy of ophthalmology that every ophthalmology clinic must be equipped with screening stations and patients should be screened before entering the waiting area. 15 a detailed history of respiratory symptoms, fever, recent travel from a highrisk area, and in contact with a family member back from covid 19 outbreak zones, is important. on the basis of this, patients have been further categorized into low, medium, or high-risk patients. patients with urgent ophthalmic problems either a medium risk or high risk should be immediately attended by an ophthalmologist with full ppe to decrease the time spent at the clinic. covid-19 patients with urgent ophthalmic problems can be attended following local hospital guidelines and taking precautions. 16 waiting areas of the outpatient departments (opd) should be kept as empty as possible and patient seated with a minimum distance of 2 meters or 6 feet apart. 17 the statistics of our clinic setups specify that sop’s are not rigorously followed in hospitals and there is no accountability by higher authorities. in our study, 96.19% of the ophthalmologists always wore face masks but only 16.19% wore protective goggles or face shields and 11.43% wore protective gowns while attending patients in eye clinics. this could be because of a lack of awareness or shortage of disposable supplies by the hospital administration. it is important not only to provide ppe to the health worker but also provide instructions on how to don and remove ppe to decrease the risk of infection. 18 the importance of hand hygiene is highlighted during the pandemic outbreak and every healthcare personnel should follow guidelines provided by who using alcohol-based sanitizer or washing hands with soap after every patient encounter. 19 use of sanitizer after every patient was adopted by 55.24% and washing hand with soap by 18.10% of the doctors in our study. direct ophthalmoscopy, tonometry and gonioscopy were performed in every patient by 6.67%, 16.19% and 0.95% of the ophthalmologists respectively. tonometer tips should be disinfected with 70% alcohol or disposable tonometer tip should be used. however, the best option is the use of noncontact tonometer. 20 this option is not widely available especially in small clinics and in rural areas erum shahid, et al 40 pak j ophthalmol. 2022, vol. 38 (1): 36-42 of our country. instead of slit lamp fundus examination, ophthalmologist should consider using indirect ophthalmoscopy. 21 specialties including ophthalmologists, anesthesiologists, and otorhinolaryngologists are prone to get infections as they are exposed to aerosolized particles of respiratory droplets and conjunctival secretions. 22 tracheal intubation and manual ventilation cause a 3 to 7 folds increase in the respiratory tract infection in a health care worker. ophthalmologist in pakistan that never screen their patients with covid pcr testing before ocular surgeries under local anesthesia was 43.81% and 20.00% never screened their patients before surgery under general anesthesia. selected public hospitals in our country have been providing pcr testing for covid-19 free of cost. this test is quite expensive in private setups of our country (7000–10,000 pkr or 62.26 us dollars) and is not accessible for everyone. these factors bound doctors to continue with their surgical practices without pcr testing, jeopardizing their own safety. however, it should be kept in mind that elective surgery and laser treatment patients should be deferred in the outbreak of pandemic. 22 if surgery is required, proper ppe should be worn by all the operation theatre staff and the surgeon. ophthalmologists in pakistan, who have to arrange for ppe themselves, were 51.43%. the private practice of ophthalmologists has been hugely affected by the pandemic, the surgical burden has been reduced. many doctors have become jobless and their pay has been reduced. in the presence of all these factors, buying your own ppe is an extra burden and it should be taken care of by the hospital administration or government. it has been reported that lack of ppe increases stress and anxiety level among health care professionals. 23 fortunately, our country did not experience the disaster of severe acute respiratory syndrome (sars) epidemic in 2003. this is the time we should learn a lesson and be prepared for the challenges that might come in future. it is highly recommended for the competent authorities and the stakeholders to make sure that all the leading hospitals and independent private clinics are following sops to prevent the spread of covid–19 among our patients, staff, and ophthalmologist. the government should also provide financial assistance to the hospitals and ophthalmologists working in independent eye clinics or hospitals for their ppe including n95 masks, protective goggles or headgear, disposable gowns, sanitizers, and breath-shields on the slit lamp. health care workers should be trained vigilantly for appropriate use of ppe, protocols regarding clinic flow and instrument cleaning. covid19 diagnostic kit should be widely and readily available so that pcr testing can be routinely done for every ophthalmic surgery under local and general anesthesia. this is the era, where the significance of artificial intelligence and telemedicine should be emphasized globally. furthermore, third world countries like pakistan cannot afford to lose a qualified ophthalmologist, because it takes years to reach a competency level. the limitation of our study is the low response rate to the survey resulting in a small sample size. secondly, data gathered from rural areas of pakistan is very scarce, as the accessibility of the internet is inadequate in these areas. large data gathered equally from rural and urban areas would have different results. thirdly self-reporting surveys have their own biases as an interpretation by the participants is different. the strength of the study is that it represents data from pakistan about the standard operating procedures in ophthalmic practice that are being followed by the ophthalmologist and doctors working in eye hospitals and clinics. the study gives us insight into improving our daily ophthalmic practice. it points out the domains of standard operating procedures that are lacking and need implementation. conclusion clinic management needs improvement in implementing sops among patients in an eye opd. fifty percent of the ophthalmologists received ppe by their administration. only 69.5% doctors were satisfied with precautionary measures. ethical approval the study was approved by the institutional review board/ethical review board (bmu-ec/02-2021). conflict of 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45 (6): 653-658. 21. wan kh, huang ss, young al, lam ds. precautionary measures needed for ophthalmologists during pandemic of the coronavirus disease 2019 (covid‐19). 22. lim lw, yip lw, tay hw, ang xl, lee lk, chin cf, yong v. sustainable practice of ophthalmology during covid-19: challenges and solutions. graefe's arch clin exp ophthalmol. 2020; 258 (7): 1427-1436. 23. dong l, bouey j. public mental health crisis during covid-19 pandemic, china. emerging infectious diseases, 2020; 26 (7): 1616. doi: 103201/eid2607200407. authors’ designation and contribution uzma taqi; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. https://dx.doi.org/10.1016%2fj.ijid.2020.10.064 https://www.cdc.gov/coronavirus/2019-ncov/prepare/transmission.html https://www.cdc.gov/coronavirus/2019-ncov/prepare/transmission.html https://www.aao.org/headline/alert-important-coronavirus-context(2020) https://www.aao.org/headline/alert-important-coronavirus-context(2020) erum shahid, et al 42 pak j ophthalmol. 2022, vol. 38 (1): 36-42 erum shahid; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. uzma fasih; associate professor: data analysis, manuscript preparation, manuscript editing, manuscript review. .…  …. 170 pak j ophthalmol. 2022, vol. 38 (3): 170-174 original article frequency of diabetic retinopathy among known diabetics at district level teaching hospital zia ghaffar 1 , zamir butt 2 , syed muhammad ali shah 3 , shahida hussain tarar 4 , muhammad afzal 5 department of ophthalmology, 1,2,4,5 nawaz sharif medical college 3 aziz bhatti shaheed teaching hospital, gujrat abstract purpose: to determine the frequency of diabetic retinopathy in patients with type 2 diabetes mellitus presenting at aziz bhatti shaheed teaching hospital gujrat. study design: descriptive observational study. place and duration of study: department of ophthalmology, aziz bhatti shaheed teaching hospital from march 2020 to march 2021. methods: all patients who presented in out-patient department of medicine and ophthalmology with type 2 diabetes mellitus for more than 3 years were included. direct and indirect ophthalmoscopy was performed and diabetic retinopathy was classified. other complications of diabetes were also noted. spss version 20.0 was used for statistical analysis. age, duration of diabetes, hba1c and random blood glucose levels were expressed as mean ± sd and gender, type of retinopathy and nerve abnormalities were expressed as percentage. results: out of 765 patients with type 2 diabetes mellitus, 397 (51.9%) were males and 368 (48.1%) were females and 428 (55.95%) patients had diabetic retinopathy. mean age was 42.18±12.37 years, mean duration of diabetes mellitus was 5.87±3.42 years and mean random blood glucose was 261±65 mg/dl. mean glycosylated hemoglobin (hba1c) was 9.2±2.5%. patients with normal retina were advised yearly follow up. patients with diabetic retinopathy were managed with argon grid laser, intravitreal anti-vegf or referred for surgery depending upon the stage of the disease. oculomotor palsy was seen in 7 patients and facial nerve palsy in 5 patients. conclusion: frequency of diabetic retinopathy is considerably high 55.96% in this particular study at gujrat. lack of ophthalmic evaluation and awareness among patients leads to considerably high rates of diabetic retinopathy. key words: diabetic retinopathy, diabetes, hba1c, argon grid laser. how to cite this article: ghaffar z, shah sma, tarar sh, afzal m. frequency of diabetic retinopathy among known diabetics at district level teaching hospital. pak j ophthalmol. 2022, 38 (3): 170-174. doi: 10.36351/pjo.v38i3.1361 correspondence to: syed muhammad ali shah nawaz sharif medical college, gujrat email: syedmuhammadlishah5@gmail.com received: december 14, 2021 accepted: june 18, 2022 introduction diabetes is a chronic debilitating disorder that has reached epidemic in almost all parts of the world. it is predicted that by year 2030, 439 million people will be affected by diabetic retinopathy. 1 in pakistan the prevalence of diabetes mellitus is 11% and has sixth largest population of diabetic patients with the prediction of rising to 5 th position by 2030 having 13.9 million patients with diabetes mellitus. 2,3 according to the american diabetes association (ada), 21% of the diabetic patients have diabetic retinopathy at the time of diagnosis and > 60% develop within 20 years after diagnosis. 4 world health organization (who) states that 4.8% (37 million) blindness is attributed to diabetic retinopathy. 5 in a meta-analysis it was observed that diabetic retinopathy frequency of diabetic retinopathy among known diabetics at district level teaching hospital pak j ophthalmol. 2022, vol. 38 (3): 170-174 171 was present in 34.6% of patients with diabetes mellitus with > 10% having vision-threatening retinopathy. 6 two major diabetes trials, the diabetes control and complications trial (dcct) 7 and the united kingdom prospective diabetes study (ukpds) 8 have emphasized that keeping hba1c < 7% reduce microvascular complications specifically in early stages of diabetic retinopathy and nephropathy. furthermore, results of the dcct, ukpds, and accord 9 eye study also depict that good glycaemic control does not stop retinopathy completely but reduces the risk of progression of disease. thus it can result in reduced treatment need and preservation of sight. 9 classification of diabetic retinopathy includes non-proliferative diabetic retinopathy (npdr), which is further divided as mild, moderate and severe; and proliferative diabetic retinopathy (pdr). in severe disease, there is microvascular occlusion, vascular endothelial growth factor production and ultimately resulting in neovascularization. these fragile blood vessels may rupture causing hemorrhage. further progression may lead to tractional retinal detachment and permanent visual loss. a study in karachi showed that 55.3% of diabetic patients had diabetic retinopathy at different stages. 10 another study from multan reported the prevalence of diabetic retinopathy to be 73, 1%. 11 yet another report from a multicenter study described prevalence to be 56.9%. 12 in contrast in a large study conducted in 11,158 patients, 24.7% patients had diabetic retinopathy. 13 another lahore based study showed only 22.7% in type 2 diabetic patients. 14 prevalence of as low as 17% was found from hyderabad district. 15 as frequency of diabetic retinopathy is different in different studies and no research was done in gujrat, our aim was to determine percentage of diabetic retinopathy in patients with type 2 diabetes mellitus presenting at a tertiary care hospital in gujrat. methods the observational study was conducted at department of ophthalmology, aziz bhatti shaheed teaching hospital from march 2020 to march 2021. ethical approval from ethical committee and informed consent of patients was taken. all patients who presented in out-patient department of medicine and ophthalmology with type 2 diabetes mellitus for more than 3 years were included. non-probability consecutive sampling technique was used. patients who had developed cataract and grading of diabetic retinopathy was not possible were excluded. random blood glucose levels were checked for every patient. hba1c was also advised and was noted on follow up visits. age, gender and duration of diabetes were also noted. direct and indirect ophthalmoscopy was performed and diabetic retinopathy was classified as per standard classification. other complications of diabetes were also noted. spss version 20.0 was used for statistical analysis. continuous variables like age, duration of diabetes, hba1c and random blood glucose levels were expressed as mean ± sd and categorical variables like gender, type of retinopathy and nerve abnormalities were expressed as percentage. results a total of 765 patients with type 2 diabetes mellitus presented to us and were screened for diabetic retinopathy and its complications. out of these 397 (51.9%) were males and 368 (48.1%) were females. mean age was 42.18 ± 12.37 years. mean duration of diabetes mellitus was 5.87 ± 3.42 years. mean random blood glucose was 261 ± 65 mg/dl. only 407 patients got their hba1c done and mean was 9.2 ± 2.5%. out of 765 patients, 428 (55.95%) patients had diabetic retinopathy. patients with normal retina were advised yearly follow up. details of patients with diabetic retinopathy are shown in table 1. patients with mild npdr were advised 6 monthly follow up, patients table 1: details of diabetic retinopathy and management. type of diabetic retinopathy number of patients (n) treatment advised mild npdr 282 (36.86%) 6 month follow up moderate to severe npdr 97 (12.68%) 1 month follow up maculopathy 56 eyes argon green grid laser and intra-vitreal anti-vegf therapy proliferative diabetic retinopathy 49 (6.4%) 38 (77.56%) panretinal photocoagulation (prp) along with intraretinal anti-vegf vitreous hemorrhage 6 (12.24%) referred to mayo hospital lahore tractional retinal detachment 5 (10.2%) referred to mayo hospital lahore syed muhammad ali shah, et al 172 pak j ophthalmol. 2022, vol. 38 (3): 170-174 with moderate to severe npdr and maculopathy were treated with argon green grid laser and intravitreal anti-vegf therapy with bevacizumab (avastin ® ) and were advised follow up after every month. other findings along with diabetic retinopathy included oculomotor palsy in 7 patients and facial nerve palsy in 5 patients. discussion our study shows that more than half of diabetic patients presenting at our hospital have changes consistent with diabetic retinopathy within first decade after diagnosis of diabetes mellitus. these findings are consistent with american diabetes association, which states that more than 60% patients will develop diabetic retinopathy within first two decades after diagnosis of diabetes mellitus. 4 prevalence in our study population is higher than global estimates of 34.6%. 6 the prevalence of diabetic retinopathy in our patients (55.95%) is comparable to studies by alkhairy et al. (55.3%) 10 and sohail et al. (56.9%). 12 however the prevalence of mild npdr was less (36.86% vs. 40.5%) and moderate to severe npdr was high in our study (12.68% vs. 1.9%) as compared to alkhairy et al. this may be attributable to different ethnic, educational and social backgrounds of patients included in both studies. raza et al. found diabetic retinopathy in 73.9% patients with most patients having mild to moderate diabetic retinopathy. 11 however their sample size was smaller than our study population and prevalence of reported diabetic retinopathy was higher than our results. our results are contrary to study by memon et al. according to which the prevalence of diabetic retinopathy was only 24.7% patients. 13 these differences may be due to large sample size in their study although they included patients with type 1, type 2 and gestational diabetes mellitus as well. prevalence was highest among type 2 diabetes mellitus patients. however, distribution of types of diabetic retinopathy was similar to our results. sadiq et al. demonstrated diabetic retinopathy in 22.7% patients with type 2 diabetes mellitus 14 in lahore, which is much less than our results. they had less frequency of npdr as compared to our study but the frequency of pdr was similar in both studies. in a large screening study in hyderabad district even less number of cases with diabetic retinopathy were reported (17%). 15 one recent study conducted in pakistan showed much less frequency of diabetic retinopathy compared to this study. 16 this may be explained due to different sample sizes and patient selection criteria. among international studies, a report from hungary with almost similar sample size to our study showed that 33.5% patients with type 2 diabetes had diabetic retinopathy (compared to 55.95% in our sample). 17 similarly, an ethiopian study showed that prevalence of diabetic retinopathy was 34.1% which was also lower than our results. they concluded that low family monthly income, longer duration of diabetes and poor glycemic control were associated with diabetic retinopathy. 18 in a systemic review conducted in pakistan, it was seen that prevalence of diabetic retinopathy was 28.78% with a wide range of 10.6% to 91.3% in different studies. 19 it supports the results of this study. however one recent meta-analysis showed global prevalence of diabetic retinopathy to be 22.27% with least prevalence among asians. 20 it shows that variation in frequency of diabetic retinopathy are common throughout the world. diabetic retinopathy is prevalent in patients with type 2 diabetes mellitus in our population. various studies from pakistan show a high prevalence, which shows a poor glycemic control in our diabetic population leading to early development of diabetic retinopathy in our population. it can be reduced by tight glycaemic control as shown by major trials in diabetic population. 7,8,9 patient education regarding diabetes mellitus, its complications and benefits of tight glycaemic control must be addressed. for this purpose educationists, nurses, doctors and media need to play their role. regular screening for diabetic patients for retinopathy must be done in every patient and they should be guided for regular followup. seminars for awareness of diabetic retinopathy should be conducted as well. limitation of this study was a single center analysis. a nationwide survey is needed so that it be tackled as a national issue and necessary precautions must be taken to prevent blindness caused by diabetic retinopathy. frequency of diabetic retinopathy among known diabetics at district level teaching hospital pak j ophthalmol. 2022, vol. 38 (3): 170-174 173 conclusion frequency of diabetic retinopathy is considerably high in patients with type 2 diabetes mellitus. lack of ophthalmic evaluation and awareness among patients leads to considerably high rates of diabetic retinopathy. regular ophthalmic examination is warranted for all patients with type 2 diabetes mellitus. conflict of interest: authors declared no conflict of interest. ethical approval the study was approved by the institutional review board/ethical review board (nsmc/absth 18/2020). references 1. shaw je, sicree ra, zimmet pz. global estimates of the prevalence of diabetes for 2010 and 2030. diabetes res clin pract. 2010; 87: 4-14. 10.1016/j.diabres.2009.10.007 2. yang sh, dou kf, song wj. prevalence of diabetes among men and women in china. n engl j med. 2010; 362: 2425-2426. 10.1056/nejmoa0908292. 3. wild s, roglic g, green a, sicree r, king h. global prevalence of diabetes: estimates for the year 2000 and projections for 2030. diabetes care, 2004; 27: 10471053. 10.2337/diacare.27.5.1047. 4. fong ds, aiello lp, ferris fl, klein r. diabetic retinopathy. diabetes care, 2004; 27: 2540-2553. 10.2337/diacare.27.10.2540 5. resnikoff s, pascolini d, etya’ale d. global data on visual impairment in the year 2002. bulletin of the world health organization, 2004; 82: 844–851. 6. yau jw, rogers sl, kawasaki r, lamoureux el, kowalski jw, bek t, et al. global prevalence and major risk factors of diabetic retinopathy. diabetes care, 2012; 35: 556-564. 10.2337/dc11-1909. 7. lasker rd. the diabetes control and complications trial. implications for policy and practice. n engl j med. 1993; 329: 1035-1036. 10.1056/nejm199309303291410 8. uk prospective diabetes study (ukpds) group. intensive blood-glucose control with sulphonyl ureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (ukpds 33). lancet, 1998; 352: 837–853. doi: 10.1016/s0140-6736(98)00090-7 9. chew ey, ambrosius wt, davis md, danis rp, gangaputra s, greven cm, et al. accord study group; accord eye study group. effects of medical therapies on retinopathy progression in type 2 diabetes. n engl j med. 2010 jul 15; 363 (3): 233-44. doi: 10.1056/nejmoa1001288. 10. alkhairy s, rasheed a, aziz f, mazhar-ul-hassan, nawaz s. frequency of diabetic retinopathy in karachi, pakistan: hospital based study. j dow uni health sci. 2015; 9 (2): 56-59. 11. raza, i., ahmed, n. prevalence of diabetic retinopathy in diabetic patients with five years’ duration presenting in eye opd nishtar hospital, multan. ophthalmol. pak; 2015; 5 (01): 7-11. 12. sohail m. prevalence of diabetic retinopathy among type–2 diabetes patients in pakistan–vision registry. pak j ophthalmol. 2014; 30 (4): 204-212. 13. memon s, ahsan s, riaz q, basit a, sheikh sa, fawwad a, et al. frequency, severity and risk indicators of retinopathy in patients with diabetes screened by fundus photographs: a study from primary health care. pak j med sci. 2014; 30 (2): 366-372. 14. saddiq ma, rehman mu, fatima m, hussain a, khan aa, mahju t, et al. diabetic retinopathy in patients presenting to the screening clinic of a tertiary care hospital in pakistan. ophthalmol. pak: 2017; 5 (04): 7-9. 15. nizamani nb, talpur ki, awan f, khanzada ma, memon mn. results of a community based screening programme for diabetic retinopathy and childhood blindness in district hyderabad, pakistan. bmj open ophthalmology, 2017; 2: e000099. doi: 10.1136/bmjophth-2017-000099. 16. riaz s, jahangir t, khan t. frequency of diabetic retinopathy and factors for suboptimal diabetic control in type 2 diabetic patients in a trust hospital of pakistan. pak j ophthalmol. 2021; 37 (2): 183-187. doi: 10.36351/pjo.v37i2.1123. 17. eszes dj, szabó dj, russell g, lengyel c, várkonyi t, paulik e et al. diabetic retinopathy screening in patients with diabetes using a handheld fundus camera: the experience from the south-eastern region in hungary. j diabetes res. 2021; 2021: 6646645. doi: 10.1155/2021/6646645 18. alemu mersha g, alimaw ya, woredekal at. prevalence of diabetic retinopathy among diabetic patients in northwest ethiopia—a cross sectional hospital based study. plos one, 2022: 17 (1): e0262664. doi: 10.1371/journal.pone.0262664. 19. mumtaz sn, fahim mf, arslan m, shaikh sa, kazi u, memon ms. prevalence of diabetic retinopathy in pakistan; a systematic review. pak j med sci. 2018: 34 (2): 493-500. doi: 10.12669/pjms.342.13819. https://doi.org/10.1016/j.diabres.2009.10.007 https://doi.org/10.2337/diacare.27.10.2540 https://doi.org/10.1016/s0140-6736(98)00090-7 http://doi.org/10.36351/pjo.v37i2.1123 https://doi.org/10.1155/2021/6646645 https://doi.org/10.1371/journal.pone.0262664 syed muhammad ali shah, et al 174 pak j ophthalmol. 2022, vol. 38 (3): 170-174 20. teo zl, tham yc, yu m, chee ml, rim th, cheung n et al. global prevalence of diabetic retinopathy and projection of burden through 2045: systematic review and meta-analysis. ophthalmology, 2021; 128 (11): 1580-1591 doi: 10.1016/j.ophtha.2021.04.027. authors’ designation and contribution zia ghaffar; associate professor: concepts, data acquisition, manuscript preparation, manuscript review. zamir butt; assistant professor: literature search, data acquisition, manuscript editing. syed muhammad ali shah; consultant ophthalmologist: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing. shahida hussain tarar; associate professor: literature search, data acquisition, data analysis, manuscript editing. muhammad afzal; associate professor: data acquisition, statistical analysis, manuscript review. .…  …. 210 pak j ophthalmol. 2022, vol. 38 (3): 210-215 original article using survey scale to assess the reduction in intensity of vernal keratoconjunctivitis symptoms after administration of drugs in tertiary care hospital poombal 1 , rashad qamar rao 2 , waseem sajjad 3 , wamiq mehmood 4 , aiman 5 1-4 nishtar medical university &hospital, multan, 5 quaid-e-azam medical college, bahawalpur abstract purpose: to establish the practicality of survey scale in estimating baseline severity at the time of diagnosis and resolution of vernal keratoconjunctivitis (vkc) symptoms after topical medication study design: longitudinal survey design place and duration of study: ophthalmology department of nishtar medical hospital, multan from june 2021 to november 2021 methods: a total of 267 vkc (vernal keratoconjunctivitis) patients' data was filled in on preformed google forms. improvement in symptoms after follow-ups was recorded on it. chi-squared test and kruskal-wallis test were employed to determine the statistical significance of the variables. results: there were 52.4% females and mean age of the patients was 29.52 ± 18.39 years. there was preponderance of patients falling under 20 years of age. at baseline, 63.3% patients were on topical steroids, while 5.6% of patients were using steroids at the second follow-up visit. the mean interval between patients’ visits to the hospital was 7.64 ± 2.086 weeks. nonparametric kruskal-wallis test was used to calculate the difference in means of radial point scale scores at the baseline examination (4.47 ± 2.321) and second follow-up (1.31 ± 1.615) visits. z-score value was 15.266 with a significance of 0.001. for patient satisfaction and resolution of symptoms at the second follow-up visit, chi-square values were 164.75 and 119.55, respectively, with a significance of 0.001 in each case. conclusion: the survey scale aided in quantifying disease symptoms, which can be useful in prescribing and adjusting the medications’ dosage easier. key words: vernal keratoconjunctivitis, antihistamines, steroids, cyclosporine how to cite this article: poombal, rao rq, sajjad w, mehmood w, aiman. using survey scale to assess the reduction in intensity of vernal keratoconjunctivitis symptoms after administration of drugs in tertiary care hospital. pak j ophthalmol. 2022, 38 (3): 210-215. doi: 10.36351/pjo.v38i3.1410 correspondence: wamiq mehmood nishtar medical university &hospital, multan email: wamiqhassan312@gmail.com received: april 26, 2022 accepted: june 6, 2022 introduction vernal keratoconjunctivitis is a bilateral cicatricial inflammatory disease of the ocular surface. people living in dry, sunny climates such as the mediterranean, sub-saharan africa, the middle east, india, and pakistan are more prone to it. it commonly occurs in younger age groups with male predominance, which is thought to be caused by altered levels of circulating androgens and oestrogens. 1 in temperate climates vkc occurs seasonally, while hot humid weather keeps high load of airborne allergens thus leading to more severe symptoms in the patients. 2 reduction in intensity of vernal keratoconjunctivitis symptoms pak j ophthalmol. 2022, vol. 38 (3): 210-215 211 risk factors for vkc include age, males, close animal contact, personal systemic allergy history, and dust exposure. 3 it is a severe form of recurrent allergic conjunctivitis involving both ige and cell mediated immune mechanisms. initially it was thought to be solely type i hypersensitivity mediated by mast cell activation. however, type iv hypersensitivity reaction occurs with t-helper 2 (th2) cell type. th2 cytokines inhibit matrix metalloproteinases (mmps) which result in conjunctival collagen build-up. 4 school-going children are mostly affected and ocular itching affects their attendance and social performance negatively. 5 multi-morbidities are the term coined for the conditions that share common ige immune mediation. allergic asthma, allergic rhinitis, rhino conjunctivitis, atopic dermatitis, vernal keratoconjunctivitis, chronic rhinosinusitis with nasal polyps, food allergies, and allergic bronchopulmonary aspergillosis. 6 a patient with vkc might have one of these conditions as well. the disease has been classified into three types: the palpebral vkc, which presents with giant papillae on the tarsal conjunctiva of the lids; the limbal vkc, which has horner-trantas dots at the limbus; and the mixed vkc, which has characteristics of both the types. the terms given to them are palpebral, limbal, and mixed, respectively. 7 although vkc is most of the time diagnosed using an ophthalmologic examination, some studies have been conducted where conjunctival scraping and tear cytology reveal leucocytosis with an eosinophilic predominance. 8 vernal keratoconjunctivitis in paediatric patients has led to ocular surface remodelling due to constant itching. complications like corneal erosions, shield ulcers and scars. despite being self-limiting condition, these changes in cornea are sight threatening and require therapeutic approach which will cut off inflammatory cascade causing histamine wave. 9 a lesser-known complication is keratoconus which occurs due to corneal epithelium rubbing resulting in apical protrusion like state. 10 although data is available regarding effects of different drugs used for vkc, we have used a survey scale to assess the reduction in intensity of vernal keratoconjunctivitis symptoms after administration of drugs in tertiary care hospital. there is scarcity of such surveys from pakistan which led us to do this research. methods this study was conducted at nishtar medical hospital, affiliated with nishtar medical university, multan. the duration of study was from june 2021 to november 2021. informed consent was obtained from all the participants and their parents, in case of minors. non-probability consecutive sampling technique was employed for the enrolment of patients. sample size was calculated according to the following formula: s = z 2 p (1-p)/m 2 s is the sample size ‘z’ is z score its value is 1.96 ‘p’ is the population proportion assumed to be 50% or 0.5 ‘m’ is the margin of error that is taken 6% or 0.06 s = (1.96) 2 (0.5) (1 – 0.5)/(0.06) 2 = 266.7 = 267 inclusion criteria was bilateral disease clinically diagnosed by an ophthalmologist. exclusion criteria was patients already on topical steroids, pregnant females, or suffering from any other ocular infectious or inflammatory pathology. patients with glaucoma or diabetes or having a family history of either of the two were also not kept in the study. anyone who did not show up on follow-up visits was not counted when considering attrition. the ethical board of the hospital reviewed and allowed the commencement of this research. diagnosis was established based on comprehensive history and clinical examination. history of any other skin, nasal, or respiratory allergies was considered. patients or parents of minors were asked about symptoms of itching, redness of conjunctiva, photophobia, and discharge. a thorough slit lamp examination was done to look for papillae, trantas spots, and the severity of redness. fundus of the patient was also examined. iop was checked using perkin tonometer on 1st and 2nd follow-ups if topical steroids were prescribed. a radial point scale with description of numeric points was developed whereby clinical presentations of itching, redness of conjunctiva and photophobia were used to calculate the score. ophthalmologists calculated the score on examination of patients’ first and follow up visits. the score helped estimate the severity of disease and help initiate and modify medical therapy. the scale was devised with the help of four ophthalmologists. it was made in english, but the doctors explained it to the patient or underage wamiq mehmood, et al 212 pak j ophthalmol. 2022, vol. 38 (3): 210-215 patient’s parents in urdu. for each end point, "severe" meant 3 points, "moderate" earned 2 points, and "mild" was equal to 1 point.  score of 3 was given in case of constant itching, score of 2 in case of frequent itching (present 50% of time), score of 1 if occasional episode of severe itching, score of 0 if no itching.  score of 3, if vasodilation of all vessels on bulbar conjunctiva, score of 2 if many vessels were dilated, score of 1 was given in case of several vessels. if no manifestation of hyperaemia on bulbar conjunctiva, then score 0 was awarded.  score of 3 in alarming photophobia (present when dark glasses worn). score 2 for moderate photophobia (requiring dark glasses). score 1 was given in case of mild photophobia (present only in daylight). if no photophobia then score was given 0. all the data was entered into a pre-designed google form. data was analysed using spss version 28.0. frequencies and percentages were computed for categorical variables like gender and age. mean ± standard deviation was computed for numeric variables like age, gender, types of conjunctivitis, symptoms at baseline visit, resolution of symptoms at consecutive follow-ups, and patient satisfaction. mean and standard deviation were calculated for age and radial point scale scores at baseline, first follow-up, and second follow-up. mean and standard deviation were also calculated for the intervals between the baseline examination and the first and second followup visits. non-parametric kruskal-wallis test was used to calculate the difference in means of radial point scale scores at baseline and second follow-up visits. the ‘p’ value of 0.05 was considered statistically significant. for patient satisfaction and resolution of symptoms at the second follow-up visit, the chisquare test was used with a p-value of less than 0.05. results in our study, total of 267 patients were included. for age distribution, see table 1. there were 103 (38.6%) under 20 years of age. age range was 3 to 64 years. female-to-male ratio was1.102:1. we had 127/267 male patients as compared 140/267 female patients. mean age of males was 29.56 ± 21.265 and mean age of females was 29.48 ± 15.407. palpebral form of vkc was the most dominant type, which accounted for 71.5% versus limbal vkc 12.7% and mixed vkc in 15.7%. figure 1: distribution of vkc patients among age groups. with the results from radial point scale, 249 (93.3%) patients were satisfied while 18 (6.7%) patients were not satisfied at the second follow-up visit. in 239 cases (89.5%) cases, vkc was controlled at the second follow-up visit. however, in 28 (10.5%) patients, vkc was not controlled at the second followup visit. radial point scale mean scores and standard deviation are shown in table 1. table 1: survey scale score. mean std. deviation survey scale score baseline 4.47 2.321 survey scale score first follow up 2.79 2.122 survey scale score second follow up 1.31 1.615 disease control at 3rd follow up 1.10 .307 table 2 shows the drug regimen at baseline visit and at second follow-up visit along with the dosage of drugs prescribed. non-parametric kruskal-wallis one way analysis of variance was used to calculate the difference in means of radial point scale scores at baseline examination and second follow-up visits. z score value was 15.266 with significance of 0.001. for patient’s satisfaction at the second follow-up visit, chi-square test was used. the calculated value of chi-square was 164.750 with a significance value of 0.001. for disease control at second follow-up visit, reduction in intensity of vernal keratoconjunctivitis symptoms pak j ophthalmol. 2022, vol. 38 (3): 210-215 213 chi-square value was 119.550 with a significance value of 0.001. table 2: drug regimen at baseline visit and 2 nd follow-up. drug regimen baseline visit second follow-up (0) no drugs 0 104 (39%) (1) olopatadine a twice per day 76 (28.5%) 119 (44.6%) (2) 1 + cyclosporine b twice per day 22 (8.2%) 29 (10.9%) (3) 1+ fluorometholone d four times per day 148 (55.4%) 10 (3.7%) (4) 3 + oral desloratadine e once per day 21 (7.9%) 5 (1.9%) key a = olopatadine eye drops 0.2% b = cyclosporine eye drops 0.05% d = flouromethalone 0.25% eye drops e = desloratadine tablet 5 mg or desloratadine syrup 0.5 mg/ml discussion the predominance of the patients who presented to us in this study were residents of south punjab, and some of the cases were from baluchistan, interior sindh as well, and a few from khyber pakhtunkhwa. in this study we assessed the use of different medications used for vkc. common topical medications prescribed are antihistamines such as olopatadine and immunosuppressants like ciclosporin, but steroids are needed in cases of flare ups or resistant cases. 11 ciclosporin can be used for as long as 12 months with better efficacy and safety in paediatric patients. 12 laboratory data, vital signs, slit lamp examination, best-corrected distance visual acuity, and intraocular pressure raised no safety concerns. however, patients should be instructed to protect their eyes against sunlight. 13 supratarsal injection of triamcinolone are also used for severe vernal keratoconjunctivitis in children. 14 there is a steroid misuse in the rural population, inciting a health crisis. misused topical steroids are into: highly potent drugs (dexamethasone, betamethasone), b-moderate (prednisolone), c-weak (loteprednol, fluorometholone). 15 a fortnightly followup for visual assessment and iop measurement is crucial to rule out steroid responders. the steroid treatment acts as a domino effect, contributing to a rise in iop and glaucomatous optic disc damage, and eventually blindness. 16 recently, some trials have been conducted showing remarkable success with omalizumab. 17 brief time duration of anti-ige therapy is effective for steroid refractory vkc patients. it has opened new horizons for immune pharmacology. 18 our study had a slight female majority as compared to other studies done on vkc. 1,4,19,20,21 it could be because there are more females in the general population. however, our findings that most patients with vkc belong to the prepubescent/teen age group were consistent with numerous studies. 7,20,21 our study's mean age was 29 years, which was higher than that of previous studies. for instance, a retrospective study done by nagpal et al in a tertiary care hospital for 6 months, reported the highest incidence of vkc occurred in the age group of 11 – 15 years. palpebral form was the most frequent type found in our research, consistent with the observational study by irfan et al. 7 very few studies probed into the devising of a clinical grading score system. to mention jamil az and co-authors' study on the sliding scale to investigate the severity of symptoms for management of the patient with allergic conjunctivitis. a scale was printed and given to the patient to be used by both the doctor and the patient to estimate severity, which aided in the modification of the drug regimen. this caused minimal use of medicines and less frequent follow-up visits to the hospital, hence saving time and money of the patients. 22 our study had online forms on cell phones that were only filled out by ophthalmologists in opd. the similarity among both studies was that neither studied the efficacy of the drugs, resolution of symptoms, or patient satisfaction. earlier, a.m. zicari et al tried to grade vernal keratoconjunctivitis by devising the criteria based on presence of major symptoms (and how many) and minor symptoms. it was not uniform or agile to be used in paediatricpatients. 23 pacci et al used serum ecp (eosinophil cationic protein) as a useful marker of disease activity in tarsal and mixed forms. despite being subjective, it resulted in findings merging with allergic conjunctivitis. 24 we need a reliable and valid scoring system which suits both practitioner and patient alike. something, which benefits paediatricians in evaluation of ocular involvement during baseline diagnosis and looking through course of this disease and treating it. limitations of our study was that only 3 symptoms wamiq mehmood, et al 214 pak j ophthalmol. 2022, vol. 38 (3): 210-215 were used in the study, which did not include conjunctival discharge. the study will not be feasible in peripheral non-urban centres that do not have access to stable internet facilities. moreover, a flare up in symptoms due to seasonal variation was not considered. conclusion the survey scale made quantifying the severity of clinical features of vkc and the progression or regression of the disease, along with the patient’s contentment during subsequent visits, computationally convenient. drug regimens were modified using disease estimations from this scale. conflict of interest: authors declared no conflict of interest. ethical approval the study was approved by the institutional review board/ethical review board (ref. no. 4121). references 1. sacchetti m, lambiase a, moretti c, mantelli f, bonini s. sex hormones in allergic conjunctivitis: altered levels of circulating androgens and estrogens in children and adolescents with vernal keratoconjunctivitis. j immunol res. 2015; 2015: 945317. doi: 10.1155/2015/945317. 2. sofi ra, mufti a. vernal keratoconjunctivitis in kashmir: a temperate zone. int ophthalmol. 2016; 36 (6): 875-879. doi: 10.1007/s10792-016-0213-8. 3. alemayehu am, yibekal bt, fekadu sa. prevalence of vernal keratoconjunctivitis and its associated factors among children in gambella town, southwest ethiopia, june 2018. plos one, 2019; 14 (4): e0215528. doi: 10.1371/journal.pone.0215528. 4. fukuda k, fujitsu y, kumagai n, nishida t. inhibition of matrix metalloproteinase-3 synthesis in human conjunctival fibroblasts by interleukin-4 or interleukin-13. invest ophthalmol vis sci. 2006; 47 (7): 2857-2864. doi: 10.1167/iovs.05-1261. 5. marey hm, mandour ss, el morsy oa, farahat hg, shokry sm. impact of vernal keratoconjunctivitis on school children in egypt. semin ophthalmol. 2017; 32 (5): 543-549. doi: 10.3109/08820538.2015.1123737 6. humbert m, bousquet j, bachert c, palomares o, pfister p, kottakis i, et al. ige-mediated multimorbidities in allergic asthma and the potential for omalizumab therapy. j allergy clin immunol pract. 2019; 7 (5): 1418-1429. doi: 10.1016/j.jaip.2019.02.030. 7. irfan m, khan sar, jan w, zeeshan, khalid k. frequency of different types of vernal keratoconjunctivitis in patients presenting to a tertiary care hospital. j postgrad med inst. 2020; 34 (4): 227230. 8. leonardi a. management of vernal keratoconjunctivitis. ophthalmol ther. 2013; 2 (2): 7388. doi: 10.1007/s40123-013-0019-y. 9. heinz c, heiligenhaus a. keratoconjunctivitis vernalis [vernal keratoconjunctivitis]. klin monbl augenheilkd. 2014; 231 (5): 505-511. german. doi: 10.1055/s-0034-1368335. 10. ben-eli h, erdinest n, solomon a. pathogenesis and complications of chronic eye rubbing in ocular allergy. curr opin allergy clin immunol. 2019; 19 (5): 526534. doi: 10.1097/aci.0000000000000571. 11. vichyanond p, pacharn p, pleyer u, leonardi a. vernal keratoconjunctivitis: a severe allergic eye disease with remodeling changes. pediatr allergy immunol. 2014; 25 (4): 314-322. doi: 10.1111/pai.12197. 12. bremond-gignac d, doan s, amrane m, ismail d, montero j, et al. vektis study group. twelvemonth results of cyclosporine a cationic emulsion in a randomized study in patients with pediatric vernal keratoconjunctivitis. am j ophthalmol. 2020; 212: 116-126. doi: 10.1016/j.ajo.2019.11.020. 13. pucci n, novembre e, cianferoni a, lombardi e, bernardini r, caputo r, et al. efficacy and safety of cyclosporine eye drops in vernal keratoconjunctivitis. ann allergy asthma immunol. 2002; 89 (3): 298-303. doi: 10.1016/s1081-1206(10)61958-8. 14. costa axd, gomes jáp, marculino lgc, liendo vl, barreiro tp, santos msd. supratarsal injection of triamcinolone for severe vernal keratoconjunctivitis in children. arq bras oftalmol. 2017; 80 (3): 186-188. doi: 10.5935/0004-2749.20170045. 15. sen p, jain s, mohan a, shah c, sen a, jain e. pattern of steroid misuse in vernal keratoconjunctivitis resulting in steroid induced glaucoma and visual disability in indian rural population: an important public health problem in pediatric age group. indian j ophthalmol. 2019; 67 (10): 1650-1655. doi: 10.4103/ijo.ijo_2143_18. 16. senthil s, thakur m, rao hl, mohamed a, jonnadula gb, sangwan v, et al. steroid-induced glaucoma and blindness in vernal keratoconjunctivitis. br j ophthalmol. 2020; 104 (2): 265-269. doi: 10.1136/bjophthalmol-2019-313988. reduction in intensity of vernal keratoconjunctivitis symptoms pak j ophthalmol. 2022, vol. 38 (3): 210-215 215 17. mozo cuadrado m, orive bañuelos a, etxebarria ecenarro j. kératoconjonctivitevernale (kcv) traitée avec succès par omalizumab [vernal keratoconjunctivitis (vkc) successfully treated with omalizumab]. j fr ophtalmol. 2020; 43 (6): e193-e195. french. doi: 10.1016/j.jfo.2019.10.019. 18. gatta a, della valle l, farinelli a, scarano g, lumaca a, cavallucci e. et al. vernal keratoconjunctivitis: a case of anti-ige treatment with short-lasting remission. case rep ophthalmol. 2020; 11 (2): 268-275. doi: 10.1159/000508031 19. kumar s. vernal keratoconjunctivitis: a major review. acta ophthalmologica. 2009; 87 (2): 133–147. doi: 10.1111/j.1755-3768.2008.01347.x 20. marey hm, mandour ss, el morsy oa, farahat hg, shokry sm. impact of vernal keratoconjunctivitis on school children in egypt. semin ophthalmol. 2017; 32 (5): 543-549. doi: 10.3109/08820538.2015.1123737. 21. nagpal h, rani n, kaur m. a retrospective study about clinical profile of vernal keratoconjunctivitis patients at a tertiary care hospital in patiala, punjab, india. kerala j ophthalmol. 2017; 29: 189-91. doi: 10.4103/kjo.kjo_100_17 22. jamil az, bahoo mlq, kamal z, rizwan m, ovais m. sliding scale in the management of allergic conjunctivitis. pak j ophthalmol. 2020; 36 (4): 365370. doi.org/10.36351/pjo.v36i4.1055 23. zicari am, capata g, nebbioso m, de castro g, midulla f, leonardi l, et al. vernal keratoconjunctivitis: an update focused on clinical grading system. italian j pediatr. 2019; 45 (1). doi: 10.1186/s13052-019-0656-4 24. pucci n, novembre e, lombardi e, cianferoni a, bernardini r, massai c, et al. atopy and serum eosinophil cationic protein in 110 white children with vernal keratoconjunctivitis: differences between tarsal and limbal forms. clin exp allergy, 2003; 33 (3): 325330. doi: 10.1046/j.1365-2222.2003.01538.x. authors’ designation and contribution poombal; house officer: design, data analysis, statistical analysis. rashad qamar rao; professor: concepts, manuscript review. waseem sajjad; medical officer: literature search, data analysis, manuscript preparation. wamiq mehmood; postgraduate registrar: data acquisition, manuscript editing, manuscript review. aiman; final year student: literature search, manuscript review, final approval. .…  …. https://doi.org/doi 292 pakistan journal of ophthalmology, 2020, vol. 36 (3): 292-297 original article change in visual acuity in relation to central macular thickness after intravitreal bevacizumab in diabetic macular edema muhammad ali haider 1 , uzma sattar 2 1-2 department of ophthalmology, rahbar medical and dental college, lahore abstract purpose: to evaluate the change in visual acuity (log mar) in relation to decrease in central macular thickness, after a single dose of intravitreal bevacizumab injection. study design: quasi experimental study. place and duration of study: rahbar medical & dental college, punjab rangers teaching hospital, lahore, from january 2019 to june 2019. material and methods: 70 eyes of 70 patients diagnosed with diabetic macular edema were included in the study. patients having high refractive errors (spherical equivalent of > ± 7.5d) and visual acuity worse than +1.2 or better than +0.2 on log mar were excluded. patients with ocular diseases other than diabetic macular edema were also excluded. central macular edema was measured in µm on oct and visual acuity was documented using log mar chart. these values were documented before and at 01 month after injection with intravitreal bevacizumab (1.25 mg in 0.05 ml). wilcoxon signed rank test was used to evaluate the difference in va before and after the anti-vegf injection. difference in visual acuity and macular edema (central) was observed, analyzed and represented in p value. p value was considered statistically significant if it was less than 0.01%. results: mean age of patients was 52.61 ± 1.3. vision improved from 0.90 ± 0.02 to 0.84 ± 0.02 on log mar chart. the change was statistically significant with p value < 0.001. central macular thickness reduced from 328 ± 14 to 283 ± 10.6 µm on oct after intravitreal anti-vegf, with significant p value < 0.001. conclusion: a 45 µm reduction in central macular thickness was associated with 0.1 log mar unit improvement in visual acuity after intravitreal bevacizumab in diabetic macular edema. key words: visual acuity, macular edema, central macular thickness, bevacizumab. how to cite this article: haider ma, sattar u. zaidi sr. change in visual acuity in relation to central macular thickness after intravitreal bevacizumab in diabetic macular edema. pak j ophthalmol. 2020, 36 (3): 292-297. doi: 10.36351/pjo.v36i3.1051 introduction diabetic macular edema results in increased central retinal thickness at macula which is a sight correspondence to: muhammad ali haider department of ophthalmology rahbar medical and dental college, lahore email: alihaider_189@yahoo.com received: april 20, 2020 revised: may 8, 2020 accepted: june 17, 2020 threatening condition. this increased thickness leads to reduction in visual acuity. currently, intravitreal anti-vegf drugs are recommended for management of diabetic macular edema 1 . these drugs are safe, decrease macular edema and restore vision. amongst the various anti-vegf agents available, bevacizumab (1.25 mg in 0.05 ml) has revolutionized the management of diabetic macular edema in recent years. it is used off label in the developing world 2,3 . it is a humanized monoclonal antibody that swathes with all isoforms of vascular endothelial growth factors-a, change in visual acuity in relation to central macular thickness after intravitreal bevacizumab in diabetic macular edema pakistan journal of ophthalmology, 2020, vol. 36 (3): 292-297 293 with a molecular mass of 149 kda that effectively binds and inhibits all the isoforms of vegf 4,5 . significant decrease in leakage from vessels has also been observed in proliferative diabetic retinopathy treated with single dose of intravitreal bevacizumab (1.25 mg) 6 . it results in improved visual acuity (va) with reduction in macular thickness 7 . anti-vegf or implantable dexamethasone with or without retinal laser are considered to be the treatment of choice in dme 8 . improvement in diabetic macular edema is gauged by repeatedly measuring central retinal thickness, before and after the start of treatment using high resolution oct (optical coherence tomography), a diagnostic tool for management of retinal diseases 9,10 . the aim of this prospective study was to correlate the improvement in visual acuity with the corresponding reduction in central macular thickness after a single dose of intravitreal bevacizumab therapy in patients with diabetic macular edema. material and methods the study was conducted at the department of ophthalmology rahbar medical & dental college, punjab rangers teaching hospital, lahore after approval from the ethical committee. in this quasi experimental study, 70 eyes with diabetic macular edema were enrolled, having a clear media for oct with minimum of 3 mm pupil diameter and best corrected visual acuity (bcva) of +0.2 to +1.2 on log mar with snellen equivalent of 6/12 to 6/120. the patients having high refractive errors (spherical equivalent of > ± 7.5d) and visual acuity worse than +1.2 or better than +0.2 on log mar were excluded. any other ocular condition in which after treatment, the improvement in vision was not significant (e.g. ocular degenerative/dystrophic changes) and patients having any media opacity that could affect the visual acuity and oct measurements were also excluded. in the selected patients, prior to intravitreal injection of anti-vegf, logmar distance visual acuity was recorded and a full ophthalmological examination including evaluation of refractive status, slit lamp examination for anterior and posterior segments was performed. based on the clinical findings diabetic macular edema was diagnosed and the central macular thicknesswas measured in micron meter (µm) on oct (nidek rs-3000 advance). in selected patients, single dose of intravitreal anti-vegf was injected by senior consultant ophthalmologist. distance visual acuity and oct parameters were re-evaluated one month after the intravitreal anti-vegf therapy. data was analyzed using spss version 22. quantitative data was represented as mean ± s.d. and s.e. while the qualitative data was represented in the form of pie chart. results a total of 70 eyes of 70 patients, 40 (57%) males and 30 (43%) females were enrolled in this research by convenient sampling technique. mean age of the patients was 52.61 ± 1.3 with minimum age of 22 years and maximum 74 years (table 1). normality table 1: assumption test of normality using shapiro-wilk. kolmogorov-smirnov a shapiro-wilk statistic df sig. statistic df sig. va after injection .160 70 .000 .919 70 .000 va before injection .169 70 .000 .935 70 .001 oct before injection .255 70 .000 .791 70 .000 oct after injection .206 70 .000 .832 70 .000 assumption was checked by using shapiro-wilk test. all quantitative variables were considered to have normal distribution with p-value > 0.05 while the pvalue of ≤ 0.05 was considered as not normally distributed. shapiro-wilk test shows abnormal distribution of visual acuity and macular measurements (µm) on oct (table 2). there were table 2: descriptive statistic of age (years). n r a n g e m in im u m v a lu e m a x im u m v a lu e m e a n v a lu e s td . d e v ia ti o n s td . e r r o r o f m e a n s ta ti st ic age of patients 70 52 22 74 52.61 1.373 11.488 muhammad ali haider, et al 294 pakistan journal of ophthalmology, 2020, vol. 36 (3): 292-297 table 3: distribution of macular edema among patients having different types of diabetic retinopathy. type of diabetic retinopathy type of macular edema total csmo diffuse high risk pdr 1 1 2 low risk pdr 7 3 10 severe npdr 27 6 33 very severe npdr 22 3 25 total 57 13 70 different stages of diabetic retinopathy in 70 eyes. details are shown in table 3. wilcoxon signed rank test was used to evaluate the difference in va before and after the anti-vegf injection. it improved from 0.90 ± 0.02 to 0.84 ± 0.02 on log mar chart. the change was statistically significant with p value < 0.001. central macular thickness reduced from 328 ± 14 to 283 ± 10.6 µm on oct after intravitreal anti-vegf, with significant p value < 0.001 (table 4). table 4: description and comparison in visual acuity and oct. range um minimum value statistics maximum value statistics mean value statistics std. deviation p value statistic va before injection 1.0 .3 1.3 .890 .0261 .2181 < 0.001 va after injection 0.9 .3 1.2 .840 .0278 .2324 oct before injection 490 215 705 328.43 14.348 120.041 < 0.001 oct after injection 319 161 480 283.44 10.672 89.287 graph 1: visual acuity before and after the intravitreal anti-vegf (bevacizumab). va_a: visual acuity before va_b: visual acuity after graph 2: macular thickness before and after intravitreal anti-vegf (bevacizumab). oct_a = oct after injection oct_b= oct before injection discussion clinical evidence has established that increase in central macular thickness in diabetic macular edema results in corresponding decrease in visual acuity, and the treatment which reduces the retinal thickening improves vision. oct can detect macular edema that is not clinically evident, and several oct-derived biomarkers are useful predictors of its progression, severity, and visual outcome 11 . in this study, we documented the correlational change after a single injection of intravitreal bevacizumab injection between visual acuity and central macular thickness on oct. at any given central macular thickness, there was a corresponding significant change in visual acuity. many eyes with significant macular edema had very good visual acuity and eyes with mild edema exhibited a profound decrease in vision. it is also reported that there is inconsistence increase in thickness of central change in visual acuity in relation to central macular thickness after intravitreal bevacizumab in diabetic macular edema pakistan journal of ophthalmology, 2020, vol. 36 (3): 292-297 295 macular point with the increase in visual acuity as well as incongruous decrease in thickness of central retina with the decrease in visual acuity is not common. 2 according to this, oct measurement can be a good surrogate for visual acuity in macular edema related to diabetes. diabetic macular edema is the major clinical factor affecting visual acuity in diabetic retinopathy and is quantified for assessment and response to treatment by the central retinal thickness measured by oct. visual acuity is inversely related to the retinal thickness to some extent. in this study we found a strong correlation of visual acuity with oct measurements of macular thickness (r 2 = -0.46). after the intravitreal bevacizumab therapy, the visual acuity improved with the reduction in retinal thickness. this study has shown that after a single dose of bevacizumab therapy the central retinal thickness on oct improved from 328 ± 14 to 283 ± 10.6 µm with a corresponding improvement in the mean visual acuity from 0.9 ± 0.02 to 0.84 ± 0.02 with significant p value 0˂.01. recent studies have suggested that anti-vegf drugs are safe, cost effective, and easily admissible in clinical settings, well tolerated by the patients and remarkably well suited for treating macular edema secondary to diabetes. the efficacy of bevacizumab (1.25 mg) has been demonstrated in a study conducted on patients having diabetic macular edema. there was significant decrease in area of leaking vessels in proliferative diabetic retinopathy when treated with single dose of intravitreal bevacizumab (1.25 mg). there was a significant improvement in mean visual acuity associated with it 8 . these studies reported that often in bilateral dme, bevacizumab effects reduction in macular thickness in un–injected fellow eye and improvement in visual acuity was seen in 40% eyes injected with bevacizumab 12 . according to previous studies, significant improvement of visual acuity was appreciated in diabetic macular edema with bevacizumab when combined with dexamethasone, as compared to bevacizumab monotherapy 13 . in this study, efficacy of treating diabetic macular with anti-vegf injection bevacizumab in diabetic patients was documented. visual acuity on log mar chart and central retinal thickness on oct were the efficacy markers that were documented. the mean bcva on log mar chart at the start of the treatment was 0.42+/-0.14 log mar units. there was a significant improvement from baseline to 0.34+/-0.13, 0.25+/-0.12 and 0.17+/-0.12 log mar units at 1 monthly intervals after the three injections. at final visit at 6 months, the visual acuity was 0.16+/0.14 log mar units. with a p value of p > 0.0001, the difference was statistically significant. the mean central retinal thickness of central 1 mm area improved from 452.9 +/143.1 microns at base linento 279.8 +/65.2 microns (p < 0.0001) on the final visit. 14 another study also suggested that bevacizumab is helpful in significant macular edema reduction and visual acuity improvement in wet age related macular degeneration. 15 in their study santos et al. described the factors affecting response to intravitreal anti-vegf injections in patients of diabetic macular edema. they found that bcva improved from 4.78 and 5.52 letters, and a central retinal thickness decreased from 80.25 and 106.12 microns after 3 and 6 months of treatment. they concluded that optimal responders to anti-vegf therapy could be identified based on their response to decrease in central retinal thickness and hence, could be a predictor of bcva improvement after the treatment 16 . mansourian et al determined the efficacy of a single anti-vegf injection of bevacizumab as primary treatment for diabetic macular edema. they compared the response to treatment using bevacizumab alone, in combination with intravitreal triamcinolone acetonide and compared the response to macular laser photocoagulation. the result showed no significant difference between these two treatments in reducing the central macular thickness with improvement in visual acuity 17 . yang et al compared the visual acuity, central retinal thickness and retinal sensitivity in different types of macular edema. he found that there was positive correlation between central foveal thickness and log mar bcva in patients with focal, diffuse and ischemic diabetic macular edema (r = 0.56, -0.62; p < 0.01). 18 recent studies showed that visual outcome improves significantly if anti-vegf therapy is started earlier in the course of disease. patients presenting earlier with a shorter history of symptoms had better improvement in visual acuity and sustained decrease in central retinal thickness, 6 months after treatment. however patients with a prolonged disease history, the central retinal thickness and visual acuity at 3 months muhammad ali haider, et al 296 pakistan journal of ophthalmology, 2020, vol. 36 (3): 292-297 and 6 months post treatment would not be significantly different from baseline values at the start of treatment 19 . thus, based on these results early treatment of macular edema is indicated for better and sustained anatomical and visual results. thus earlier detection of reduced visual acuity is significantly important for the treatment of recurring macular edema. another study highlighted the correlation between central subfield thickness and baseline visual acuity after treatment with bevacizumab 20 . consistent with other studies, younger age of patients with diabetic macular edema was associated with significantly improved visual acuity s and reduced central retinal thickness after every 6 weeks of treatment. however, if the treatment is delayed by more than 6 weeks, repetition of intravitreal bevacizumab would not result in significant visual improvement 22 . limitation of our study was the small sample size. we did not study the association of vascular patterns of macula on octa with decreased visual acuity, which is also a contributory factor in decreased visual acuity. conclusion thus based on our study results, 45µm reduction in central macular thickness is associated with 0.1 logmar unit improvement in visual acuity in patients with diabetic macular edema after a single dose of intravitreal bevacizumab (1.25 mg). ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. author’s designation and contribution muhammad ali haider; assistant professor: study design, data collection, manuscript writing, and review. uzma sattar; optometrist: compiling results, data analysis, article review. references 1. bahrami b, hong t, gilles mc, chang a. antivegf therapy for diabetic eye diseases. asia pac j ophthalmol (phila). 2017 nov-dec; 6 (6): 535-545. doi: 10.22608/apo.2017350. 2. lam ds, lai ty, lee vy, 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525-36. 11. bhende m, shetty s, parthasarathy mk, ramya s. optical coherence tomography: a guide to interpretation of common macular diseases. indian j ophthalmol. 2018; 66 (1): 20-35. https://www.ncbi.nlm.nih.gov/pubmed/29076303 https://www.ncbi.nlm.nih.gov/pubmed/29076303 https://www.ncbi.nlm.nih.gov/pubmed/29076303 change in visual acuity in relation to central macular thickness after intravitreal bevacizumab in diabetic macular edema pakistan journal of ophthalmology, 2020, vol. 36 (3): 292-297 297 12. hanhart j, tiosano l, averbukh e, banin e, hemo i, chowers i, et al. fellow eye effect of unilateral intravitreal bevacizumab injection in eyes with diabetic macular edema. eye, 2014; 28 (6): 646-53. 13. maturi rk, bleau l, saunders j, mubasher m, stewart mw. a 12-month, single-masked, randomized controlled study of eyes with persistent diabetic macular edema after multiple anti-vegf injections to assess the efficacy of the dexamethasone-delayed delivery system as an adjunct to bevacizumab compared with continued bevacizumab monotherapy. retina, 2015; 35 (8): 1604-14. 14. tareen iu, rahman a, mahar ps, memon ms. primary effects of intravitreal bevacizumab in patients with diabetic macular edema. pak j med sci. 2013; 29 (4): 1018-22. 15. ristic d, vukosavljevic m, draganic b, cerovic v, petrovic n, janicijevic-petrovic m. the effect of intravitreal administration of bevacizumab on macular edema and visual acuity in age-related macular degeneration with subfoveolar choroidal neovascularisation. vojnosanitetski pregled. 2013; 70 (7): 660-3. 16. santos ar, gomes sc, figueira j, nunes s, lobo cl, cunha-vaz jg. degree of decrease in central retinal thickness predicts visual acuity response to intravitreal ranibizumab in diabetic macular edema. ophthalmologica. 2014; 231 (1): 16-22. 17. mansourian m, kazemnejad a, kazemi i, zayeri f, soheilian m. using skew-symmetric mixed models for investigating the effect of different diabetic macular edema treatments by analyzing central macular thickness and visual acuity responses. j res med sci. 2011; 16 (10): 1319-25. 18. yang xl, zou hd, xu x. correlation of retinal sensitivity, visual acuity and central macular thickness in different types of diabetic macular edema. chinese j ophthalmol. 2013; 49 (12): 1081-8. 19. jeong sh, kim jh, kim jw, lee tg, kim cg, yoo sj, et al. patient's self-recognition of reduced visual acuity due to recurrence of macular edema and prompt visitation to the hospital in retinal vein occlusion. korean j ophthalmol. 2014; 28 (3): 213-9. 20. deak gg, schmidt-erfurth um, jampol lm. correlation of central retinal thickness and visual acuity in diabetic macular edema. jama ophthalmology, 2018. 21. scott iu, vanveldhuisen pc, ip ms, blodi ba, oden nl, king j, et al. baseline factors associated with 6-month visual acuity and retinal thickness outcomes in patients with macular edema secondary to central retinal vein occlusion or hemiretinal vein occlusion: score2 study report4. jama ophthalmology, 2017; 135 (6): 639-49. 22. epstein dl, algvere pv, von wendt g, seregard s, kvanta a. benefit from bevacizumab for macular edema in central retinal vein occlusion: twelve-month results of a prospective, randomized study. ophthalmology, 2012; 119 (12): 2587-91. .…  …. pakistan journal of ophthalmology, 2020, vol. 36 (3): 205-210 205 original article comparison of safety and efficacy of intravitreal zivaflibercept vs bevacizumab for the treatment of macular edema hussain ahmad khaqan 1 , usman imtiaz 2 , hasnain muhammad buksh 3 hafiz ateeq-ur-rehman 4 , raheela naz 5 1-5 ameer-ud-din medical college pgmi, lahore general hospital, lahore – pakistan abstract purpose: to study the safety and efficacy of intravitreal ziv-aflibercept vs. bevacizumab for the management of edema caused by different retinal pathologies. study design: comparative interventional study. place and duration of study: department of ophthalmology, unit ii, lahore general hospital, lahore, from july 2018 to june 2019. material and methods: all patients with resistant, center involving macular edema due to diabetes, retinal vein occlusion and age related macular degeneration were recruited in this study. complete baseline ocular examination was performed at presentation. all the patients were randomly grouped into two i.e. ivz (intravitreal ziv-aflibercept) and ivb (intravitreal bevacizumab). each eye underwent intravitreal injection of 0.05 ml of fresh filtered ziv-aflibercept (1.25 mg) or 0.05 ml of fresh filtered bevacizumab. outcome was measured in terms of variation in central macular thickness (cmt) and also best corrected visual acuity (bcva) at 3 months. results: total of 156 eyes of 136 patients completed whole duration of study and were included in the results. the mean baseline cmt was 510 μm (± 94 μm) in the ivb group and 493μm (±102 μm) in the ivz group (p = 0.94). the mean baseline bcva (log mar) was 0.78 (snellen's equivalent 6/36) in the ivz and 0.70 (snellen's equivalent 6/30) in the ivb group (p = 0.78). central macular thickness was significantly reduced at 1 st , 2 nd and 3 rd month in the ivz group and ivb group (p < 0.001). conclusion: intravitreal ziv-aflibercept is safe and more effective than bevacizumab for the treatment of edema caused by diabetes mellitus, retinal vein occlusion and wet age related macular degeneration. key words: aflibercept, ziv-aflibercept, bevacizumab, diabetic retinopathy, wet age related macular degeneration, retinal vein occlusion. how to cite this article: khaqan ha, imtiaz u, buksh hm, r hau, naz r. intravitreal ziv-afibercept vs bevacizumab for the treatment of macular edema. pak j ophthalmol. 2020;36 (3): 205-210. doi: 10.36351/pjo.v36i3.1014 introduction anti-vascular endothelial growth factor (vegf) drugs correspondence to: hussain ahmad khaqan ameer-ud-din medical college, lahore – pakistan email: drkhaqan@hotmail.com received: march 10, 2020 revised: may 4, 2020 accepted: june 16, 2020 related macular degeneration (amd), macular edema secondary to diabetes and retinal vein occlusions 1 . have become the standard of care for several chorioretinal vascular conditions including wet age second most common retinal vascular condition i.e. macular edema secondary to retinal vein occlusion results in considerable decrease in best corrected visual acuity (bcva) 2 . vegf mediates the development of neovascularization in retinal vein mailto:drkhaqan@hotmail.com hussain ahmad khaqan, et al 206 pakistan journal of ophthalmology, 2020, vol. 36 (3): 205-210 occlusion which results in severe irreversible vision loss. the wesdr (wisconsin epidemiologic study of diabetic retinopathy) found that there are 26% chances of developing dme after 14 years in type i diabetes, whereas diabetes control and complication trial (dcct) reported that 27% of type i diabetics develop dme after 9 years 4 . type ii diabetes in older patients is associated with higher incidence of macular edema 5 . retinal ischemia promotes vegf production, which in turns mediates the development of neovascularization in diabetic retinopathy and may lead to severe irreversible vision loss. the basic problem in wet age related macular degeneration (amd) leading to 1.6% of blindness of american population is abnormal neovascularization and vascular permeability. positive regulators like vascular endothelial growth factor a (vegf-a), transforming growth factor α and β (tgf α and β), fibroblast growth factor, hepatocyte growth factor, connective tissue growth factor and interleukins; and negative regulators: pigment epithelium-derived factor (pedf), thrombostatin, angiostatin and endostatins play an important role in angiogenesis 6 . intraocular vegf is reduced by the anti-vegf agents administered in the eyes of patients, which reduces the vascular permeability and stops vascular leakage 7 . ranibizumab was the first approved anti-vegf agent that revolutionized dme treatment 8 . recently, newer anti-vegf (vascular endothelial growth factor) drug, aflibercept (eyelea®, bayer healthcare, germany), approved by food and drug administration (fda), has shown good treatment outcomes in patients with macular edema secondary to crvo 7 . eylea (aflibercept) is approved therapy for macular edema caused by age related macular degeneration, diabetes and retinal vein occlusion 8 . ziv-aflibercept (zaltrap; regeneron, new york, usa) is pharmacologically similar to aflibercept, and the mechanism of action is also similar to aflibercept i.e. it acts on all vegf subtypes as well as placental growth factor. it is approved by fda for the treatment of colon cancer, and is available at pharmacies much cheaper than aflibercept particularly for ocular use 9 . toxicity to rpe (retinal pigment epithelial cells) has never been studied in previous studies by using approved cancer protein, ziv-aflibercept 10 . the aim of our study was to compare the efficacy and safety of intravitreal ziv-aflibercept with that of bevacizumab for the treatment of edema caused by diabetes mellitus, rvo and wet amd. material and methods a prospective, comparative interventional study was conducted in the ophthalmology department, unit ii of lahore general hospital, lahore from july 2018 to june 2019. institutional review board approval was obtained and study followed tennets of declaration of helsinki. informed consent was obtained from the patients. all patients with resistant, center involving macular edema due to diabetes; retinal vein occlusion and wet age related macular degeneration were recruited in this study. patients with only eye, uncontrolled diabetes, uncontrolled hypertension, advanced cataract, uncontrolled glaucoma, epiretinal membrane (erm) or vitreo macular traction and prior intervention with laser and intravitreal injection were excluded from the study. complete baseline ocular examination was performed at presentation including best corrected visual acuity (bcva), anterior segment examination, posterior segment examination and indirect ophthalmoscopy, intra-ocular pressure assessment, oct and ffa (optical coherence tomogram and fundus fluorescein angiography respectively). bcva was performed using snellen’s visual acuity chart and also using log mar scale. the oct was performed using cirrus 5000 (zeiss, dublin, ca). thickness of central retina was measured in a 3 mm circle centered on point of fixation. central 1 mm zone was taken as central macular thickness (cmt). all the patients that fulfilled the inclusion and exclusion criteria were assigned to one of the two different treatment groups randomly: 1.25 mg (0.05 ml) of ziv-aflibercept (zaltrap; regeneron pharmaceuticals inc) (ivz group) and 1.25 mg (0.05 ml) of bevacizumab (avastin; genentech inc, south san francisco, ca) (ivb group). randomization was performed using random number table. participants and the investigators were masked of the study groups. surgeons other than the study investigators performed all the interventions. after taking aseptic measures, each eye received intravitreal injection of 0.05 ml of filtered zivaflibercept (1.25 mg) or 0.05 ml of fresh filtered bevacizumab in the operation theater. 30-guage tuberculin syringes were used to deliver the injection under topical anesthesia. all eyes underwent slit-lamp comparison of safety and efficacy of intravitreal ziv-aflibercept vs bevacizumab for the treatment of macular edema pakistan journal of ophthalmology, 2020, vol. 36 (3): 205-210 207 examination at 1 st and 7 th post-operative day to look for any intra-ocular inflammation and raised intraocular pressure. minimum of three doses were given to all the participants at 4 weekly intervals. bcva, slit lamp assessment and optical coherence tomography were performed again at 1 st , 2 nd , 3 rd and 6 th months. measurement of change in cmt (central macular thickness) and bcva (best corrected visual acuity) at 3 rd month was the primary outcome. secondary outcome measures were change in bcva and cmt at 1 st , 2 nd and 6 th month. any potential eye related and systemic complications related to the intervention were assessed at each follow-up visit. results primarily 162 eyes of 141 patients satisfied our inclusion and exclusion criteria. of this 5 patients (7 eyes) were lost to follow-up. so total of 156 eyes of 136 patients completed whole duration of study and were included in the results. ivz group included 70 patients (81 eyes) and ivb group had 66 patients (75 eyes). twenty patients had bilateral injections. table 1 shows demographic data. two groups carry no difference regarding demographic and baseline features. the mean baseline central macular thickness was 510 μm (± 94 μm) in the intravitreal bevacizumab group and 493 μm (±102 μm) in the intravitreal ziv-aflibercept group (p = 0.94). the mean baseline bcva (logmar) was 0.78 (snellen's equivalent 6/36) in the ivz and 0.70 (snellen's table 1: demographic data of the two groups. groups total ivz ivb no. of eyes 156 81 75 no. of subjects 136 70 66 age (years) mean sd 59.5 ± 3 60 ± 2 59 ± 4 sex male female 75 61 41 29 34 32 eye right left 90 66 51 30 39 36 lens status phakic pseudophakic 107 49 66 23 41 26 baseline bcva (log mar) mean ± sd 0.7 ± 0.21 0.78 ± 0.22 0.70 ± 0.21 baseline cmt mean ± sd 501.5µm ± 98µm 493µm ± 102µm 510µm ± 94µm equivalent 6/30) in the ivb group (p = 0.78). there was significant improvement in the best corrected visual acuity (bcva) after every 1 month interval in both groups (p < 0.001). at 3 rd month best corrected visual acuity difference was significant among the groups. intravitreal ziv-aflibercept group showed significant changes in the best corrected visual acuity (bcva) as compared to intravitreal bevacizumab group (table 2 and fig 1). table 2: comparison of visual acuity at 1 st , 2 nd and 3 rd month. groups total ivz ivb baseline 0.74 ± 0.21 0.78 ± 0.22 0.70 ± 0.21 4 weeks change 0.61 ± 0.20 0.13 ± 0.21 0.60 ± 0.21 0.18 ± 0.20 0.62 ± 0.19 0.08 ± 0.20 8 weeks change 0.52 ± 0.16 0.22 ± 0.19 0.48 ± 0.17 0.30 ± 0.19 0.56 ± 0.15 0.14 ± 0.18 12 weeks change 0.45 ± 0.12 0.29 ± 0.16 0.42 ± 0.13 0.36 ± 0.16 0.48 ± 0.11 0.22 ± 0.16 fig. 1: graph showing bcva during the course of study. in comparison to the baseline values, central macular thickness decreased significantly at 1 st , 2 nd , and 3 rd month in the ivz group and ivb group (p < 0.001). overall, in all visits, cmt was much reduced in the ivz group in comparison to the ivb group (table 3 and fig. 2). at 24 weeks follow-up, bcva and cmt were significantly improved in both treatment arms (p < 0.001). bcva changes were significantly better in the ivz group as compared to the ivb group. in our study, in ivz group, 3 eyes experienced sterile intraocular inflammation while 2 eyes showed significant progression of cataract. hussain ahmad khaqan, et al 208 pakistan journal of ophthalmology, 2020, vol. 36 (3): 205-210 table 3: comparison of cmt between two groups at 1 st , 2 nd and 3 rd month. groups total ivz ivb baseline 501.5 µm ± 98 µm 493 µm ± 102 µm 501.5 µm ± 94 µm 4 weeks change 433 µm ± 90 µm 68.5 ± 94 420 µm ± 94 µm 73 ± 87 446 µm ± 86 µm 64 ± 90 8 weeks change 387 µm ± 77 µm 114.5 ± 86 328 µm ± 66 µm 213 ± 78 378 µm ± 76 µm 132 ± 86 12 weeks change 310 µm ± 68 µm 191.5 ± 78 280 µm ± 66 µm 213 ± 78 340 µm ± 70 µm 170 ± 82 fig. 2: graphs showing central macular thickness (cmt) changes during the study. discussion limited data is available which compares the safety profiles and efficacy of zivaflibercept anti-vascular endothelial growth factor (vegf) drug with other commonly used agents. oliveira dias et al stated that there were no changes in erg in patients with amd who received intravitreal ziv-aflibercept showing no toxicity to retinal tissue and there was visual and oct improvements seen in the patients. intra ocular inflammation was observed in one of the eyes and the inflammation resolved after taking appropriate therapy 11 . de andrade g et al conducted a study in which they injected intravitreal ziv-aflibercept in seven patients with macular edema due to diabetes. they studied the safety and efficacy of ziv-aflibercept over 48 weeks period and concluded that the drug was safe and effective 12 . another study conducted by singh et al constituted the largest pooled safety report on ivz use and included patients from 14 centres distributed across the globe. it showed that ivz had an acceptable ocular and systemic safety profile with incidence of adverse events similar to those of other vascular endothelial growth factor inhibitory drugs. the analysis supported the continued use of ivz in various retinal disorders 13 . papadopoulos et al compared two different doses of ziv-aflibercept with other anti vegf in treating wet age related macular degeneration. they followed the patients for 16-weeks and concluded that both doses of ziv-aflibercept were superior to bevacizumab in terms of final bcva and cmt 14 . baghi et al compared two different doses of zaltrap with avastin for the management of macular edema due to diabetes. they followed the patients for 12-weeks and concluded that both doses of zivaflibercept were superior to bevacizumab in terms of final bcva and cmt 15 . in one study of intravitreal injections of ziv aflibercept for dme, a prospective single-treatment clinical trial, demonstrated that ziv-aflibercept monotherapy was linked with substantial improvement in mean bcva and cmt in a 24-week follow-up. there was also no erg evidence of retinal toxic reactions after intravitreal ziv-aflibercept injections in eyes with dme 16 . cost is a major factor when it comes to selecting anti-vegf for the treatment of macular edema. most of these patients require monthly injections and this can add up to a huge amount of money. compounded intravitreal bevacizumab and ziv-aflibercept costs arount usd 50 per dose, which is 15-20 times less than the cost of ranibizumab or aflibercept 17 . one study showed that use of aflibercept instead of bevacizumab has lead to overspending of about €335 million in one year in europe 18 . so zivaflibercept can prove to be a very valuable agent for the treatment of macular edema especially in underdeveloped and developing countries where insurance covering is scarce. one of the major concerns for compounded intravitreal injections is the risk of endophthalmitis 19 . both aflibercept and ziv-aflibercept are structurally similar containing the same fusion protein, but there are few differences like in the osmolarity. 300 mosm/kg is the osmolarity of aflibercept which is iso-osmotic solution and 1000 mosm/kg is the osmolarity of ziv-aflibercept which is more concentrated. in addition, the 0.05ml of ziv-aflibercept contains 1.25 mg whereas aflibercept contains 2.0 mg. comparison of safety and efficacy of intravitreal ziv-aflibercept vs bevacizumab for the treatment of macular edema pakistan journal of ophthalmology, 2020, vol. 36 (3): 205-210 209 in our study we demonstrated intermediate term outcomes, which were in favour of ziv-aflibercept. at all follow-ups, bcva was significantly better in patients who received ziv-aflibercept as compared to those who received bevacizumab. similarly, better cmt reduction was achieved in ziv-aflibercept group than in bevacizumab group. ziv-aflibercept shares the same molecular structure as aflibercept. however, the manufacturing process of aflibercept involves more robust purification and use of buffers to reduce the ocular irritation and toxicity 20 . in our study 3 eyes (3.7%) demonstrated sterile intraocular inflammation in zivaflibercept group. this is significant and difference in manufacturing process of ziv-aflibercept may explain this incidence. all of the three patients were managed medically and none of them had reduction in final bcva as compared to than baseline. ziv-aflibercept is prepared in laboratory with slightly hypertonic sucrose, which damages the lens and retina, it causes mild mitochondrial toxicity in human rpe cells 8 . in our study however, we did not experience any case of retinal toxicity but in 2 eyes (2.5%) there was significant cataract progression. limitations of our study include small sample size and relatively shorter follow-up period. long term outcomes and complications need to be addressed by having a larger patient pool and longer duration of follow-ups. conclusion intravitreal ziv-aflibercept is more effective than bevacizumab for the treatment of diabetic macular edema. however, complications like sterile intraocular inflammation and cataract progression caused by intravitreal ziv-aflibercept needs to be investigated in detail. acknowledgement this study was funded by the osp research fund. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest authors’ designation and contribution hussain ahmad khaqan; associate professor: study conception, study design, manuscript revision. usman imtiaz; vitreoretinal fellow: manuscript writing, data analysis, critical revision. hasnain muhammad buksh; vitreoretinal fellow: manuscript writing, literature review, study design. hafiz ateeq-ur-rehman; post graduate resident: data collection, data analysis, proofreading. raheela naz; post graduate resident: data collection, literature review, proofreading. references 1. chhablani j. intravitreal ziv-aflibercept for recurrent macular edema secondary to central retinal venous occlusion. indian j ophthalmol. 2015; 1; 63 (5): 469. 2. paulose r, chhablani j, dedhia cj, stewart mw, mansour am. intravitreal ziv-aflibercept for macular edema following retinal vein occlusion. clin ophthalmol. (auckland, nz). 2016; 10: 1853. 3. klein r, klein be, moss se, cruickshanks kj. the wisconsin epidemiologic study of diabetic retinopathy: xvii: the 14-year incidence and progression of diabetic retinopathy and associated risk factors in type 1 diabetes. ophthalmology, 1998; 105: 1801–15. 4. diabetes control and complications trial research group. progression of retinopathy with intensive versus conventional treatment in the diabetes control and complications trial. ophthalmology, 1995; 102: 647– 61. 5. bhagat n, grigorian ra, tutela a, zarbin ma. diabetic macular edema: pathogenesis and treatment. surv ophthalmol. 2009; 54: 1–32. 6. dervenis n, mikropoulou am, tranos p, dervenis p. ranibizumab in the treatment of diabetic macular edema: a review of the current status, unmet needs, and emerging challenges. advther. 2017; 34 (6): 1270-1282. doi: 10.1007/s12325-017-0548-1. 7. de oliveira dias jr, de andrade gc, novais ea, farah me, rodrigues eb. fusion proteins for treatment of retinal diseases: aflibercept, zivaflibercept, and conbercept. int j retin vitr. 2016; 2 (1): 3. 8. malik d, tarek m, del carpio jc, ramirez c, boyer d, kenney mc, et al. safety profiles of antivegf drugs: bevacizumab, ranibizumab, aflibercept and ziv-aflibercept on human retinal pigment epithelium cells in culture. br j ophthalmol. 2014; 98 (suppl 1): i11-6.. hussain ahmad khaqan, et al 210 pakistan journal of ophthalmology, 2020, vol. 36 (3): 205-210 9. chhablani j, narayanan r, mathai a, yogi r, stewart m. short-term safety profile of intravitreal zivaflibercept. retina. 2016 jun 1; 36 (6): 1126-31. 10. mansour am, al-ghadban si, yunis mh, et al. zivaflibercept in macular disease br j ophthalmol. 2015; 99: 1055-1059. 11. de oliveira dias jr, de andrade gc, kniggendorf vf, novais ea, takahashi vk, maia a, et al. intravitreal ziv-aflibercept for neovascular age-related macular degeneration: 52-week results. retina. 2019 apr 1; 39 (4): 648-55. 12. andrade g, de oliveira dias j, maia a, farah m, meyer c, rodrigues e. intravitreal ziv-aflibercept for diabetic macular edema: 48-week outcomes. ophthalmic surg lasers imaging retina, 2018; 49: 245-250. doi: 10.3928/23258160-20180329-06. 13. singh sr, stewart mw, chattannavar g, ashraf m, souka a, eldardeery m, et al. safety of 5914 intravitreal ziv-aflibercept injections. br j ophthalmol. 2019; 103 (6): 805-10. 14. papadopoulos z. aflibercept: a review of its effect on the treatment of exudative age-related macular degeneration. eur j ophthalmol. 2019 jul; 29 (4): 36878. 15. baghi a, bonyadi mhj, ramezani a, azarmina m, moradian s, dehghan mh, et al. two doses of intravitreal ziv-aflibercept versus bevacizumab in treatment of diabetic macular edema: a threearmed, double-blind randomized trial. ophthalmol retin. 2017; 1 (2): 103–10. 16. andrade gc, dias jr, maia a, farah me, meyer ch, rodrigues eb. intravitreal injections of zivaflibercept for diabetic macular edema. retina, 2016; 36 (9): 1640-5. 17. ross el, hutton dw, stein jd, bressler nm, jampol lm, glassman ar, et al. cost-effectiveness of aflibercept, bevacizumab, and ranibizumab for diabetic macular edema treatment: analysis from the diabetic retinopathy clinical research network comparative effectiveness trial. jama ophthalmol. 2016; 134 (8): 888–896. doi: 10.1001/jamaophthalmol.2016.1669. 18. asten vf, michels ctj, hoyng cb, van der wilt gj, klevering bj, rovers mm, et al. the costeffectiveness of bevacizumab, ranibizumab and aflibercept for the treatment of age-related macular degeneration-a cost-effectiveness analysis from a societal perspective. plos one. 2018; 13 (5): e0197670. 19. schwartz sg, flynn hw jr. endophthalmitis associated with intravitreal anti-vascular endothelial growth factor injections. curr ophthalmol rep. 2014; 2 (1): 1–5. doi: 10.1007/s40135-013-0033-1. 20. trichonas g, kaiser pk. aflibercept for the treatment of age-related macular degeneration. ophthalmol ther. 2013; 2 (2): 89–98. doi: 10.1007/s40123-013-0015-2. .…  …. https://www.ncbi.nlm.nih.gov/pubmed/?term=bressler%20nm%5bauthor%5d&cauthor=true&cauthor_uid=27280850 https://www.ncbi.nlm.nih.gov/pubmed/?term=jampol%20lm%5bauthor%5d&cauthor=true&cauthor_uid=27280850 https://www.ncbi.nlm.nih.gov/pubmed/?term=glassman%20ar%5bauthor%5d&cauthor=true&cauthor_uid=27280850 https://www.ncbi.nlm.nih.gov/pubmed/?term=van%20der%20wilt%20gj%5bauthor%5d&cauthor=true&cauthor_uid=29772018 https://www.ncbi.nlm.nih.gov/pubmed/?term=van%20der%20wilt%20gj%5bauthor%5d&cauthor=true&cauthor_uid=29772018 https://www.ncbi.nlm.nih.gov/pubmed/?term=van%20der%20wilt%20gj%5bauthor%5d&cauthor=true&cauthor_uid=29772018 https://www.ncbi.nlm.nih.gov/pubmed/?term=klevering%20bj%5bauthor%5d&cauthor=true&cauthor_uid=29772018 https://www.ncbi.nlm.nih.gov/pubmed/?term=rovers%20mm%5bauthor%5d&cauthor=true&cauthor_uid=29772018 pak j ophthalmol. 2021, vol. 37 (1): 129-132 129 brief communication short-term steroid-induced central serous chorioretinopathy in a patient with laser foveal burn nasir ahmed memon 1 , abdul sami memon 2 , israr ahmed bhutto 3 , ps mahar 4 1-4 isra postgraduate institute of ophthalmology, karachi abstract oral intake of steroids has been associated with central serous chorio-retinopathy (cscr) for long time. we report a 23 years old male who had exposure to green laser pointer after which he developed laser maculopathy. the treating ophthalmologist started oral steroids with patient developing cscr in his left eye. he was referred to our retina clinic for further evaluation. on examination his vision was 6/6 part in his right eye and 6/9 part in his left eye. his dilated fundus examination revealed small foveal scar in his right eye and dull foveal reflex in his left eye. on oct he had laser maculopathy in the right eye and left fundus findings coincided with diagnosis of central serous chorio-retinopathy (cscr). patient was called for review after 3 weeks with instructions to discontinue his deltacortil tablets. his vision improved and sub retinal fluid was absorbed. later he went back to his primary ophthalmologist who restarted deltacortil tablets and he presented to us with recurrence of cscr. key words: maculopathy, burn, steroids, central serous chorio-retinopathy. how to cite this article: memon na, memon as, bhutto ia, mahar ps. short-term steroid-induced central serous chorio-retinopathy in a patient with laser foveal burn. pak j ophthalmol. 2021, 37 (1): 129-132. doi: https://doi.org/10.36351/pjo.v37i1.1151 introduction central serous chorio-retinopathy (cscr) is characterized by elevation of neuro sensory retina at the posterior pole. in majority of the cases, the cause of this condition remains unknown. however, cscr has been associated with intake of steroids taken in oral, inhaled and topical form. 1 we report a 23-year old male who developed cscr following 2 weeks intake of oral steroids. case presentation a 23-year old male had exposure to green laser pointer and complained of blurred vision. he went to see his correspondence: p s mahar isra postgraduate institute of ophthalmology, karachi email: salim.mahar@aku.edu received: october 20, 2020 accepted: november 10, 2020 local ophthalmologist who diagnosed laser maculopathy in his right eye and started oral prednisolone (deltacortil) 50 mg/day in divided doses. after 2 weeks of intake of deltacortil tablets, the patient noticed blurred vision in his left eye. he was referred to our retina clinic for further evaluation. on examination, his vision was 6/6 partial in his right eye and 6/9 partial in his left eye. anterior segments were unremarkable with intraocular pressures (iop) of 12 mm hg in each eye. his dilated fundus examination revealed small foveal scar in his right eye and dull foveal reflex in his left eye (figure 1). vitreous was free of any inflammatory cells. optical coherence tomography (oct) with macular map of 6.6 mm × 6.6 mm showed rectangular outer retinal defect, focal loss of is-os/ ellipsoid layer with intact external limiting membrane (elm) in his right eye. the oct of his left eye revealed presence of sub-retinal fluid over posterior pole (figure 2). diagnosis of laser maculopathy and central serous chorio-retinopathy was made in the right and left eye respectively. patient was asked to discontinue deltacortil tablets. nasir ahmed memon, et al 130 pak j ophthalmol. 2021, vol. 37 (1): 129-132 the patient was again reviewed after 3 weeks. his visual acuity was 6/6 partial in right eye and 6/6 in the left eye. the oct of his right eye showed persistent outer retinal defect but left fundus showed disappearance of sub-retinal fluid (figure 3). the patient was advised to return after 4 weeks with no treatment. the patient went back to his primary ophthalmologist who restarted deltacortil tablets 40 mg/day. he again developed blurred vision in his left eye and came back to our retinal clinic. oct of right eye showed persistent is/os loss with very mild shrinkage of focal outer retinal disruption, while left fundus showed presence of small sub-retinal fluid (figure 4). fig. 1: fundus photographs of right & left eye. fig. 2: optical coherence tomography of right and left macula with thickness map. right eye showed focal loss is-os/ ellipsoid zone with intact external limiting membrane (elm), left eye central serous chorioretinopathy. short-term steroid-induced central serous chorio-retinopathy in a patient with laser foveal burn pak j ophthalmol. 2021, vol. 37 (1): 129-132 131 fig. 3: optical coherence tomography of right and left macula with thickness map. right eye showed persistent outer retinal defect with intact external limiting membrane (elm), left eye has sub-retinal fluid settled down. fig. 4: optical coherence tomography of right and left macula with thickness map. right eye persistent is/os loss with very mild shrinkage of focal outer retinal disruption under fovea, left eye presence of small sub-retinal fluid. discussion cscr is a self-limiting disease with spontaneous resolution occurring within 3–4 months of initial episode resulting in good visual outcome. 2 observation alone with no treatment is therefore advised as the first line approach in the newly diagnosed cases. however, risk factors such as increased stress score, raised homocysteine and serum cortisol level should be addressed. 3 cscr has been associated with intake of oral steroids and also described in patients with cushing disease, pregnancy and stress with endogenous high level of cortisol secretion. 4 the exact role of glucocorticoids in pathogenesis of cscr is not known but possible nasir ahmed memon, et al 132 pak j ophthalmol. 2021, vol. 37 (1): 129-132 mechanism includes increased capillary fragility and hyper-permeability leading to choroidal decompensation with leakage of fluid in the sub-retinal space. 5 the exact duration of steroids intake which may result in cscr is not known. however, the patients on chronic deltacortil therapy such as kidney transplants are at higher risk. we report a 23-year old man taking deltacortil for 2 weeks resulting in cscr with fluid accumulation in sub-retinal space of his left eye. this was clearly demonstrated on oct of his left eye. cscr recovered after discontinuation of oral steroids and recurred with re-commencement of deltacortil therapy. a similar patient is described by alkin and coworkers 6 . they had a 54-year old male with decreased vision in his right eye diagnosed with nonarteritic anterior ischemic optic neuropathy. he was treated with intravenous methyl prednisolone 1 gm/day for 3 days followed by oral steroids in dose of 1 mg/kg daily for 1 week. after 6 days of oral treatment with steroids, patient developed cscr in his left eye. grixty and kumar 7 published their case report of 67 years old female with biopsy proven giant cell arteritis with no visual symptoms. she was treated with intravenous methyl prednisolone for 3 consecutive days followed by 60 mg oral prednisolone daily. five days after initiation of treatment, the patient complained of blurred vision in her left eye. examination showed visual acuity of 6/18 with diagnosis of cscr which was confirmed on oct. hardwig and collegues 8 have described three patients, two of whom received intramuscular corticosteroid injections and the third one received epidural corticosteroid injections 6 weeks prior to development of cscr. our patient developed cscr two weeks after taking oral steroids. koyama and colleagues believed that the duration from the beginning of corticosteroid treatment to the onset of cscr can range from three days to 23 years and in dose as low as 10–15 mg/day. 9 conclusion this case report reinforces cscr as a potential side effect of oral intake of corticosteroids. conflict of interest authors declared no conflict of interest. references 1. bouzas ea, karadimas p, pournaras cj. central serous chorioretinopathy and glucocorticoids. surv ophthalmol. 2002; 47 (5): 431-448. 2. marmor mf. new hypotheses on the pathogenesis and treatment of serous retinal detachment. graefes arch clin exp ophthalmol. 1988; 226: 548-552. 3. agarwal a, garg m, dixit n, godara r. evaluation and correlation of stress scores with blood pressure, endogenous cortisol levels, and homocysteine levels in patients with central serous chorio-retinopahty and comparison with age-matched controls. indian j ophthalmol. 2016; 64: 803-805. 4. sharma t, shah n, rao m, et al. visual outcome after discontinuation of corticosteroids in atypical severe central serous chorio-retinopathy. ophthalmology, 204; 111: 1708-1714. 5. garg sp, dada t, talwar d, et al. endogenous cortisol profile in patients with central serous chorioretinopathy. br j ophthalmol. 1997; 81: 962-964. 6. alkin z, yilmaz i, ozkaya a, tazici at. steroidinduced central serous chorio-retinopathy in a patient with non-arteritic anterior ischemic optic neuropathy. saudi jr ophthalmol. 2015; 29: 232-234. 7. grixti a, kumar v. steroid induced central serous chorio-retinopathy in giant cell arteritis. case rep ophthalmol med. 2013: 924037. doi: 10.1155/2013/924037. 8. hardwig pw, silva ao, pulido js. forgotten exogenous corticosteroid as a cause of central serous chorio-retinopathy. clin ophthalmol. 2008; 2 (1): 199201. 9. koyama m, mizota a, igarahi y, adachi-usami e. seventeen cases of central serous chorio-retinopathy associated with systemic corticosteroid therapy, 2004; 218 (2): 107-110. authors’ designation and contribution nasir ahmed memon; assistant professor: manuscript preparation. abdul sami memon; assistant professor: data analysis. israr ahmed bhutto; associate professor: manuscript editing. ps mahar; professor and dean: manuscript review. .…  …. 355 pak j ophthalmol. 2020, vol. 36 (4): 355-359 original article management of glaucoma capsulare: outcomes and complications of trabeculectomy abdul rafio soomro 1 , fayaz ahmed soomro 2 , munawar hussain 3 , abdul qadeem soomro 4 asif mashood qazi 5 , anas bin tariq 6 1-5 al-ibrahin eye hospital, isra postgraduate institute of ophthalmology, 6 al-tibri medical college & hospital isra university, karachi campus abstract purpose: to analyze the results of filtration surgery in cases of glaucoma capsulare. study design: interventional case series. place and duration: al-ibrahim eye hospital, karachi, from january 2018 to december 2018. methods: forty eyes of forty patients, between 50 to 80 years of age, with glaucoma capsulare, not controlled with topical medication were included in the study. patients not willing for filtration surgery and those who had any other ocular disease were excluded. pre-operative examination, including visual acuity, retinoscopy, intra ocular pressure and fundus examination was done. complete blood count, blood sugar and urine complete were also carried out to rule out any other illness. all collected data was analyzed through software spss version 20. results: there were 26 (65.0%) males and 14 (35.0%) females. mean age was 62.1 ± 12.44 years. mean preoperative iop was 34.0 ± 2.43 mm hg. at first follow-up visit mean iop (mm hg) was 11.44 ± 3.2 and at 12 weeks follow-up, the iop was 10.14 ± 4.1. angle 0 – i (closed angle) was seen in 6 (15.0%), angle grade ii – iii (open angle) was seen in 10 (25.0%) and grade iii – iv (open angle) was seen in 24 (60.0%) patients. base line visual acuity was 6/9 in 4 (10.0%), 6/12 – 6/18 in 10 (25.0%), 6/18 – 6/24 in 12 (30.0%) and 6/36 – 6/60 in 14 (35.0%) patients. early complications were flat anterior chamber in 4 (10%) and corneal edema in 4 (10%) patients. however late complications were hyphema and cataract in 2 (5%) and 25 (62.5%) patients respectively. conclusion: trabeculectomy significantly lowers the intraocular pressure in patients with glaucoma capsulare. key words: glaucoma capsulare, trabeculectomy, gonioscopy, hyphema, pseudoexfoliation glaucoma. how to cite this article: soomro ar, soomro fa, hussain m, soomro aq, qazi am, tariq ab. management of glaucoma capsulare: outcomes and complications of trabeculectomy. pak j ophthalmol. 2020; 36 (4): 355359. doi: https://doi.org/10.36351/pjo.v36i4.1000 introduction glaucoma is one of the leading causes of irreversible blindness. pseudo-exfoliation glaucoma (pxg)/ glaucoma capsulare is the most common secondary correspondence: anas bin tariq al-tibri medical college & hospital isra university, karachi campus email: anastariq93@gmail.com received: february 7, 2020 accepted: july 29, 2020 open-angle glaucoma, which occurs in elderly population. 1 five to six million people are affected with pxg globally. in a report of who, it has been notified that glaucoma accounts for 15 percent of total global blindness (43 percent after cataract). 2 in pakistan the prevalence of glaucoma capsulare is 6.45%. 3 many people of east asia, due to shallower anterior chamber depth are prone to develop angle closure glaucoma. 4 initially, optic nerve head and visual fields are normal regardless of the measurement management of glaucoma capsulare: outcomes and complications of trabeculectomy pak j ophthalmol. 2020, vol. 36 (4): 355-359 356 of intraocular pressure (iop). in comparison, patients with pxg, have elevated iop with glaucomatous damage to the optic nerve head along with the pseudoexfoliation. 5 in 1954, georgiana dvoraktheobald, pathologist and ophthalmologist, named this abnormal condition as “pseudo-exfoliation syndrome” by finding deposits of pseudo-exfoliation material on the ciliary body, zonules and lens capsules. 6 glaucoma is classified into primary and secondary. 7 amongst the main pathophysiological features of pxg are elastosis, i.e. a disturbance of elastin metabolism and abnormal synthesis and degradation of components of the extracellular material. 8 several studies suggested that males are three times more prone than females and the disease itself is not restricted to middle-aged and elderly people only. 9,10 pseudo-exfoliation glaucoma is a clinical diagnosis. most patients are asymptomatic and diagnosis is incidental. it is not unusual for pxg patients to present in one eye with advanced disease, in which case they may be conscious of a gradual reduction in vision. rarely, there is a sudden increase in iop that can cause eye pain, blurring of vision, and seeing haloes. 11 assessment of glaucoma should include tonometry, anterior chamber angle examination, gonioscopy and fundoscopy to look for any visible damage to optic nerve. visual field test should also be carried out. imaging techniques such as optical coherence tomography, laser polarimetry scanning and/or laser ophthalmoscopy scanning (heidelberg retinal tomogram) can be used to assess the retinal nerve fiber layer. 12,13 trabeculectomy is considered as a useful procedure for the management of glaucoma capsulare. the purpose of this study was to observe the reduction of intraocular pressure (iop) after trabeculectomy in cases of glaucoma capsulare. methods this was an interventional case series conducted at alibrahim eye hospital, postgraduate institute malir, karachi, from january 2018 to december 2018. approval from ethical review committee was taken. patients were selected using convenient sampling technique. total forty eyes of forty patients were enrolled in this study with age ranging from fifty to eighty years. all patients with pxg not controlled with medication were included in the study. patients with pxg, not willing for filtration surgery; those who had undergone previous filtration surgery and those with complications like cataract, corneal opacity or any other ocular pathology were excluded from the study. pre-operative examination included unaided visual acuity for distance and near, best spectaclecorrected visual acuity, tonometry, gonioscopy, anterior segment examination and fundus examination. other investigations like blood pressure, blood glucose, urine complete and blood complete were also carried out to rule out chronic illness or foci of infection in the body. written consent was taken from each patient regarding the surgical procedure and complications. all the surgeries were conducted under local anesthesia by administration of 2% lidocaine in the retrobulbar space. the surgeon dissected fornix-based conjunctival flap and created one half-thickness scleral flap at corneo-scleral junction. during trabeculectomy, peripheral iridectomy was performed and a block of trabecular meshwork tissue was removed at the edge of corneo-scleral bed. using monofilament 10/0 nylon sutures (around 6 – 7), scleral flap was sutured which was adjusted for ensuring small amounts of leakage to be observed around margins of scleral flap without causing any shallowing of anterior chamber. post-operatively after 24 hours, the dressing was removed followed by several tests including distance visual acuity with and without pinhole and near vision. slit lamp examination was done to assess the condition of the wound and bleb formation, anterior chamber, for depth, cells, flare and hyphema, iris for any damage, pupillary reaction, patency of peripheral iridectomy and membrane formation. intra ocular pressure was noted by goldman applanation tonometer while visual acuity was measured unaided and with glasses. all patients were followed up postoperatively after one week, third week, sixth week and twelfth week during the entire study period. pre-operatively, visual acuity was categorized from 6/9 to 6/60 and iop was categorized into 3 groups including; 28 – 30 mm hg, 36 – 38 mm hg and 40 – 42 mm hg. data analysis was done using spsss version 20. results a total of 40 eyes of 40 patients were included in the study. there were 26 (65.0%) males and 14 (35.0%) females. mean age of the patients was 62.1 ± 12.44 abdul rafio soomro, et al 357 pak j ophthalmol. 2020, vol. 36 (4): 355-359 years. mean pre-operative iop (mm hg) was 34.0 ± .2.43 mm hg. range of iop was 28 – 30 mm hg in 20 (50.0%), 36 – 38 mm hg in 10 (25.0%) and 40 – 42 mm hg in 10 (25.0%) patients. grade 0 – i (closed angle) was seen in 6 (15.0%) patients, grade ii – iii (open angle) in 10 (25.0%) and angle grade iii – iv (open angle) in 24 (60.0%) patients. visual acuity was 6/9 in 4 (10.0%), 6/12 – 6/18 in 10 (25.0%), 6/18 – 6/24 in 12 (30.0%) and 6/36 – 6/60 in 14 (35.0%) patients (table 1). for further details, see table 2. table 1: showing intraocular pressure range and visual acuity at baseline. variable range mean ± sd n (%) iop 28 – 30 mmhg 20 (50.0%) 36 – 38 mmhg 10 (25.0%) 40 – 42 mmhg 10 (25.0%) grading of the angle i – 0 (closed angle) 6 (15.0%) ii – iii (open angle) 10 (25.0%) iii – iv (open angle) 24 (60.0%) visual acuity 6/9 4 (10.0%) 6/12 – 6/18 10 (25.0%) 6/18 – 6/24 12 (30.0%) 6/36 – 6/60 14 (35.0%) table 2: showing intraocular pressure ranges and visual acuity at 1 st and 12 th week of treatment. follow-up variable range mean ± sd n (%) at first week range of iop 4 – 8 mm hg 8 (20.0%) 10 – 14 mm hg 20 (50.0%) 16 – 20 mm hg 12 (30.0%) visual acuity 6/9 4 (10.0%) 6/12 – 6/18 8 (20.0%) 6/18 – 6/24 8 (20.0%) 6/36 – 6/60 20 (50.0%) at twelve week range of iop 4 – 8 mm hg 26 (65.0%) 10 – 12 mm hg 10 (25.0%) 14 – 16 mm hg 4 (10.0%) visual acuity 6/12 – 6/18 9 (22.5%) 6/18 – 6/24 6 (15.0%) 6/36 – 6/60 22 (55.0%) h.m – pl +ve 3 (7.5%) iop = intraoccular pressure pl= perception of light hm = hand movement early complications were flat anterior chamber in 4 (10%) and corneal edema in 4 (10%) patients. however late complications were hyphema and cataract in 2 (5%) and 25 (62.5%) patients respectively. fig. 1: showing intraocular pressure (mm hg) before and after treatment. discussion association of pseudo-exfoliation to increased iop has been well documented and proposed that patients with bilateral pseudo-exfoliation, are usually older and have higher prevalence of glaucoma or ocular hypertension in comparison to patients with unilateral involvement. 14,15 genetic factors are also linked as a predisposing factor, however the results are still not clear and studies are still on-going in this respect. 16 in our study, patients had either unilateral or bilateral disease. in a study 37 patients with mean age of 62.1 ± 10.4 years were analyzed. mean baseline iop was 18.16 ± 5.91 mm hg. they underwent trabeculectomy and the iop at final follow up decreased significantly to 15.37 ± 2.90 mmhg. 17 similarly, in our study the baseline iop was 34.0 ± 2.34 mm hg which decreased significantly to 11.44 ± 3.2 mm hg at 1 st week and to 10.14 ± 4.1 mm hg at the final follow-up at 12 th week of treatment. in normal tension glaucoma (ntg), glaucoma filtration surgery has been well-documented. 18 aoyama reported that visual field progression among ntg patients was arrested in majority of patients after filtration surgery. 19 in our study, significant decrease in iop was observed post-operatively. jampel et al. reported hypotony in 15 – 20% patients undergoing trabeculectomy with antineoplastic agents. 20 there are also reports which show that hypotony did not have any effect on visual acuity. 21 similarly, goodkin et al observed that eyes with post-operative hypotony and absence of foveal disruption often retained good central visual acuity. 22 however, hypotony was not reported as a postoperative complication in our study. flat or shallow anterior chamber, corneal edema and hyphema were management of glaucoma capsulare: outcomes and complications of trabeculectomy pak j ophthalmol. 2020, vol. 36 (4): 355-359 358 the post-operative complication found in 04, 04 and 02 patients. another study by hirooka et al 23 determined to evaluate the vision-related quality of life following glaucoma filtration surgery on 103 glaucoma patients, the baseline iop was 19.0 ± 8.1 mm hg while the post-operative iop was 9.7 ± 3.9 mm hg showing a significant decrease in iop (p < 0.001). the study also reported that glaucoma filtration surgery in combination with cataract filtration surgery was found to have higher significant improvement in visionrelated quality of life. although in our study, similar significant decrease in iop from 34.0 ± 2.34 mm hg at baseline to 10.14 ± 4.1 and mm hg at the final follow up at 12 th week was observed. francis et al in a study on 23 patients of glaucoma undergoing trabeculectomy reported a baseline iop of 23.0 ± 10.7 mm hg and post-operative iop of 11/0 ± 5.7 mm hg. 24 however, significant complications were also reported such as hypotony and choroidal detachment. similarly, rao et al in a study on 72 patients with baseline iop of 20.3 ± 7.2 mm hg and post-operative iop of 15.5 ± 3.5 mm hg also reported significant post-operative complications of posterior capsular retraction, bleb leakage and endophthalmitis. 25 difference in study design, genetic variation among countries and surgical technique might play a role in different findings of results in our study as compared with the above mentioned researches. the limitations of our study are small sample size and single-centred study. further multi-centred studies should be considered for comparing the different treatment options of glaucoma in terms of iop and post-operative complications. conclusion glaucoma filtration surgery in patients of glaucoma capsulare is safe and it significantly lowers the intraocular pressure between baseline and at subsequent post-operative follow-ups. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. wani fr, romana m, singh t, wani ir, wani ir, lone ra. prevalence of exfoliative glaucoma among kashmiri population: a hospital based study. int j health sci. 2009; 3 (1): 51. 2. quigley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006; 90 (3): 262-267. 3. rao rq, arain tm, ahad ma. the prevalence of pseudo-exfoliation syndrome in pakistan. hospital based study. bmc ophthalmology, 2006 dec; 6 (1): 15. 4. wang n, wu h, fan z. primary angle closure glaucoma in chinese and western populations. chin med j. 2002; 115 (11): 1706-1715. 5. zenkel m, krysta a, pasutto f, juenemann a, kruse fe, schlötzer-schrehardt u. regulation of lysyl oxidase-like 1 (loxl1) and elastin-related genes by pathogenic factors associated with pseudoexfoliation syndrome. invest ophthalmol vis scie. 2011; 52 (11): 8488-8495. 6. dvorak-theobald g. pseudo-exfoliation of the lens capsule*: relation to “true” exfoliation of the lens capsule as reported in the literature and role in the production of glaucoma capsulocuticulare. am j ophthalmol. 1954; 37 (1): 1-2. 7. chen y, lin y, vithana en, jia l, zuo x, wong ty, et al. common variants near abca1 and in pmm2 are associated with primary open-angle glaucoma. nature genetics, 2014; 46 (10): 1115. 8. ritch r, schlötzer-schrehardt u. exfoliation syndrome. surv ophthalmol. 2001; 45 (4): 265-315. 9. zenkel m, krysta a, pasutto f, juenemann a, kruse fe, schlötzer-schrehardt u. regulation of lysyl oxidase-like 1 (loxl1) and elastin-related genes by pathogenic factors associated with pseudoexfoliation syndrome. invest ophthalmol vis sci. 2011; 52 (11): 8488-8495. 10. taqi u, fasih u, jafri sf, sheikh a. frequency of primary open angle glaucoma from abbasi shaheed hospital. j pak med assoc. 2011; 61 (8): 778. 11. stamper rl, lieberman mf, drake mv. beckershaffer's diagnosis and therapy of the glaucomas ebook. elsevier health sciences; 2009 12. farandos nm, yetisen ak, monteiro mj, lowe cr, yun sh. contact lens sensors in ocular diagnostics. adv healthcare mat. 2015; 4 (6): 792-810. 13. lim tc, chattopadhyay s, acharya ur. a survey and comparative study on the instruments for glaucoma detection. med eng phys. 2012; 34 (2): 129-139. 14. plateroti p, plateroti am, abdolrahimzadeh s, scuderi g. pseudoexfoliation syndrome and pseudoexfoliation glaucoma: a review of the literature with updates on surgical management. j ophthalmol. 2015; 2015: 370371. doi:10.1155/2015/370371. abdul rafio soomro, et al 359 pak j ophthalmol. 2020, vol. 36 (4): 355-359 15. mansoor hm, fawzi ha. clinical survey of pseudoexfoliation syndrome. glob j health sci. 2019; 11 (5): 144-148. 16. moghimi s, latifi g, amini h, mohammadi m, fakhraie g, eslami y, et al. cataract surgery in eyes with filtered primary angle closure glaucoma. j ophth vis res. 2013; 8 (1): 32-38. 17. kim cs, seong gj, lee nh, song kc, society kg. namil study group. prevalence of primary open-angle glaucoma in central south korea: the namil study. ophthalmology, 2011; 118 (6): 1024-1030. 18. tham yc, li x, wong ty, quigley ha, aung t, cheng cy. global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. ophthalmology, 2014; 121 (11): 2081-2090. 19. aoyama a, ishida k, sawada a, yamamoto t. target intraocular pressure for stability of visual field loss progression in normal-tension glaucoma. jap j ophthalmol. 2010; 54 (2): 117-123. 20. jampel hd, solus jf, tracey pa, gilbert dl, loyd tl, jefferys jl, et al. outcomes and bleb-related complications of trabeculectomy. ophthalmology, 2012; 119 (4): 712-722. 21. schultz sk, iverson sm, shi w, greenfield ds. achieving single-digit intraocular pressure targets with filtration surgery in eyes with progressive normal-tension glaucoma. j glaucoma, 2016; 25 (2): 217. 22. goodkin ml, grewal ds, greenfield ds. threedimensional high-speed optical coherence tomography for diagnosis of hypotony maculopathy after glaucoma filtration surgery. j glaucoma, 2010; 19 (6): 349-355. doi: 10.1097/ijg.0b013e3181bd59c. 23. hirooka k, nitta e, ukegawa k. vision-related quality of life following glaucoma filtration surgery. bmc ophthalmol. 2017; 17: 66. https://doi.org/10.1186/s12886-017-0466-7 24. francis ba, winarko j. combined trabectome and cataract surgery versus combined trabeculectomy and cataract surgery in open-angle glaucoma. clin surg ophthalmol. 2011; 29: 4-10. 25. rao hl, maheshwari r, senthil s, prasad kk, garudadri cs. phacotrabeculectomy without mitomycin c in primary angle-closure and open-angle glaucoma. j glaucoma, 2011; 20 (1): 57-62. authors’ designation and contribution abdul rafio soomro; consultant ophthalmologist: concept, design & write up of study. fayaz ahmed soomro; senior consultant ophthalmologist: concept, design & final approval of study. munawar hussain; assistant professor: concept, design & corrections of the study. abdul qadeem soomro; associate professor: concept & design of study. asif mashood qazi; associate professor: concept & final approval of study. anas bin tariq; lecturer: data collection, data analysis & write-up. .…  …. https://doi.org/10.1186/s12886-017-0466-7 microsoft word 7. umara gul pak j ophthalmol. 2022, vol. 38 (4): 257-261 257 original article co-relation between metabolic status and stage of diabetic retinopathy in patients visiting mayo hospital, lahore umara gul1, fatima zahid2, zehwa mazhar3, ubaidullah jan4 department of ophthalmology, 1king edward medical university,mayo hospital lahore. 2,3,4superior university, lahore abstract purpose: to find out correlation of metabolic status (hba1c, liver function tests, renal function tests, and hemoglobin (hb)) with stage of diabetic retinopathy. study design: observational correlational study. place and duration of study: mayo hospital lahore, from april 2016 to october 2016. methods: after approval from the institutional review board of king edward medical university,188 patients with diabetic retinopathy (dr) in any one of their eyes, were enrolled. the mean age of subjects was 54.43 ± 9.17 years. staging of diabetic retinopathy was done by an ophthalmologist and relevant blood workup was carried out. if a patient had dr in both eyes, the eye in the advanced stage was recorded. spearman rho (ρ) correlation coefficients were analyzed. the determination coefficient (r2) was also evaluated. results: the male-to-female ratio was 1:1. there were 161 (85%) patients with non proliferative diabetic retinopathy (npdr), 16 (8.5%) had proliferative diabetic retinopathy (pdr), and 11 (5.8%) had adevanced diabetic eye disease. spearman rho correlation of stage of retinopathy with hba1c, bun, serum creatinine, bilirubin, sgpt, sgot, alp, and hb were -0.20, 0.160, 0.052, 0.008, -0.13, 0.119, 0.294 and -0.61 respectively; showing positive correlation to bun, serum creatinine, bilirubin, sgot, and alkaline phosphate, and negative to hba1c, sgpt, and hb. the correlation was significant with bun and alp; p = 0.03 and p < 0.001 respectively. conclusion: stages of dr showed a positive correlation with bun, serum creatinine, bilirubin, sgot, and alp, and negative to hba1c, sgpt, and hb. metabolic state of the diabetic patients should be determined and kept under control while managing diabetic retinopathy. key words: diabetic retinopathy, serum creatinine, bilirubin, hemoglobin, alkaline phosphate. how to cite this article: gul u, zahid f, mazhar z, jan u. co-relation between metabolic status and stage of diabetic retinopathy in patients visiting mayo hospital, lahore. pak j ophthalmol. 2022, 38 (4): 257-261. doi: 10.36351/pjo.v38i4.1397 correspondence: fatima zahid department of ophthalmology, superior university, lahore email: fatimaramay2015@gmail.com received: april 06, 2022 accepted: july 26, 2022 introduction diabetes mellitus is a major global health problem.1 according to who, there were 437.9 million cases of type 2 diabetes in 2019, which represents a 49% increase since 1990.2 diabetes association (da) has defined diabetes mellitus as high blood glucose, of > 126 after fasting or random > 200 mg/dl including the presence of symptoms of hyperglycemia.3 in type i diabetes, the immune system destroys the pancreas and ultimately decreases the production of insulin. type ii diabetes occurs as a result of insulin deficiency.4,5 hemorrhages and microvascular abnormalities are hallmark of this disease. microvascular abnormalities caused by non-proliferative diabetic retinopathy fatima zahid, et al 258 pak j ophthalmol. 2022, vol. 38 (4): 257-261 (npdr) include microaneurysms, and dilation of vessels in the posterior retina and macula. in npdr, visual loss is noted with diabetic macular edema (dme). pdr occurs when there is proliferation of new vessels on the retina.6,7 high blood pressure is also a risk factor for development of diabetic retinopathy.8 for the diagnosis of diabetes, the hba1c is the most preferable criterion. however, dm is diagnosed by blood glucose level in fasting and after 2 hours of the meal.9 to check the renal fuctions, (bun) blood urea nitrogen is very important which measures the total amount of nitrogen in blood.10 the breakdown product of protein is urea nitrogen. the range of normal value of bun is between7 – 20. liver fuction tests are also diaturbed in uncontrolled diabetes.11 decrease insulin production is not the only cause of diabetes. sometimes there is metabolic disturbance and genetic factors resulting in insulin resistance.12 this study assessed the renal, function, liver function, diabetes control and hemoglobin levels in patients with diabetic retinopathy.with the help of this study, patients can control or stabilize their metabolic status through early diagnosis of diabetic retinopathy. methods ethical clearance to conduct the study was obtained from the college of ophthalmology and allied vision sciences, king edward medical university lahore. a total of 188 patients who were diagnosed with diabetic retinopathy by the diabetic clinic, mayo hospital lahore were included. the participants who were not willing, had any other systemic disease like asthma, nephropathy, or ischemic heart disease, cataract, glaucoma, uveitis and other fundus anomalies, history of any co-morbid condition (except that related to vision loss), psychological disorders or taking psychiatric medications were excluded. a consent form in containing information related tothe purpose, significance, and intended procedures of the research study was completed and signed by each participant. data were collected by clinical examination and selfdesigned proforma. venous blood samples were collected in dipotassium edta and tested within 1 hour of collection to minimize variations due to old sample. metabolic functions like liver function test, renal function tests, hba1c, and hemoglobin levels were done using an automatic blood counter system kx-21 in the hematology laboratory of the pathology department at kemu lahore. samples were maintained at room temperature. the collection of quality blood specimens from patients requires specific tools for obtaining the sample and for postcollection processing, handling, shipping, and storage. the following were needed: dipotassium edta vacuolated collection tubes, tourniquet (to cause blood to pool in the area and to enlarge the veins, making them easier to palpate), alcohol wipes (to disinfect the skin before blood collection), adhesive bandages/tape (to protect the vein puncture site after collection), syringes disposal unit, gloves (worn to protect the patient and the phlebotomist). a non-mydriatic fundus camera canon no 300191 cr1 retinal imaging camera was used for the grading of diabetic retinopathy. improperly collected samples and hemolyzed and clotted samples were discarded. samples were maintained at room temperate. fundoscopy of selected patients was done by an ophthalmologist according to the defined protocol in the ophthalmology department of kemu lahore. data was entered and analyzed in spss-20. quantitative variables like age were presented as mean ± standard deviation. qualitative variables like gender were presented as frequency and percentages. comparison of grading and values were checked with spearman rho and r. to maintain confidentiality the use of a code rather than the participant’s name was employed. results the male-to-female ratio was 1:1. there were 161 (85%) patients with npdr, 16 (8.5%) had pdr, and 11 (5.8%) had adevanced diabetic eye disease. spearman rho correlation of stage of retinopathy with hba1c, bun, serum creatinine, bilirubin, sgpt, sgot, alp, and hb were -0.20, 0.160, 0.052, 0.008, -0.13, 0.119, 0.294 and -0.61 respectively; showing positive correlation to bun, serum creatinine, bilirubin, sgot, and alkaline phosphate, and negative to hba1c, sgpt, and hb. the correlation was significant with bun and alp; p = 0.03 and p < 0.001 respectively. see table 1 for details. co-relation between metabolic status and stage of diabetic retinopathy in patients visiting mayo hospital, lahore pak j ophthalmol. 2022, vol. 38 (4): 257-261 259 table 1: correlation of diabetic retinopathy with metabolic status. s ta g e o f d r h b a 1 c b u n s er u m c re a ti n in e b il ir u b in s g p t s g o t a l p h b s p ea rm a n r h o t es t stage of dr correlation coefficient 1 -0.02 .160* 0.052 0.008 -0.013 0.119 .294** 0.061 sig. (2-tailed) 0.783 0.03 0.49 0.914 0.866 0.112 0 0.408 n 188 188 186 178 184 182 180 188 187 hba1c correlation coefficient -0.02 1 -.232** -0.145 -0.088 -.165* -0.11 -.172* -0.014 sig.(2-tailed) 0.783 . 0.001 0.054 0.235 0.026 0.143 0.018 0.848 n 188 188 186 178 184 182 180 188 187 bun correlation coefficient .160* -.232** 1 .427** -0.041 -0.051 -0.041 0.014 0.066 sig. (2-tailed) 0.03 0.001 . 0 0.584 0.5 0.59 0.852 0.372 n 186 186 186 178 182 180 178 186 185 serum creatinine correlation coefficient 0.052 -0.145 .427** 1 -0.015 -0.111 -0.051 -0.018 .190* sig. (2-tailed) 0.49 0.054 0 . 0.842 0.146 0.507 0.812 0.011 n 178 178 178 178 174 173 171 178 177 bilirubin correlation coefficient 0.008 -0.088 -0.041 -0.15 1 0.094 0.062 0.025 -.146* sig. (2-tailed) 0.914 0.235 0.584 0.842 . 0.213 0.417 0.74 0.049 n 184 184 182 174 184 178 176 184 183 sgpt correlation coefficient -0.013 -.165* -0.051 -0.111 0.094 1 0750** 288* -0.097 sig. (2-tailed) 0.866 0.026 0.5 0.146 0.213 . 0 0 0.193 n 182 182 180 173 178 182 180 182 181 sgot correlation coefficient 0.119 -0.11 -0.041 -0.051 0.062 .750** 1 .218** -0.061 sig. (2-tailed) 0.112 0.143 0.59 0.507 0.417 0 . 0.003 0.419 n 180 180 178 171 176 180 180 180 179 alp correlation coefficient .294** -.172* 0.014 -0.018 0.025 .288** .218** 1 0.044 sig. (2-tailed) 0 0.018 0.852 0.812 0.74 0 0.003 . 0.55 n 188 188 186 178 184 182 180 188 187 hb correlation coefficient 0.061 -0.014 0.066 .190* -.146* -0.097 -0.061 0.044 1 sig. (2-tailed) 0.408 0.848 0.372 0.011 0.049 0.193 0.419 0.55 . n 187 187 185 177 183 181 179 187 187 discussion diabetic retinopathy (dr) is a metabolic syndrome. early diagnosis and management is mandatory to prevent complications. use of intravitreal antivascular endothelial growth factors has revolutionized the treatment of dr.13,14 for any treatment to be effective, the metabolic control is of primary importance. in the present study, metabolic prameters including, renal fuction tests (rft), liver function tests (lft), hba1c and hb levels were assessed and correlated with the severity of dr. the mean value of hba1c was 9.46 which was quite higher. it increased with the increase in the severity of dr. other studies have shown that higher values of hba1c were associated with fundus changes.15 in this particular study, lfts and bilirubin were also affected but in the borderline. the bilirubin levels were not affected in mild npdr cases. bun and serum creatinine also had deranged values but the bun values were more prone to affect dr than creatinine. the value of hb was also not affected in fatima zahid, et al 260 pak j ophthalmol. 2022, vol. 38 (4): 257-261 mild stages of dr. in another study, hba1c was found to be higher in diabetics even without retinopathy as compared to the controls and the highest values were seen in the mild npdr.16 the total number of patients with moderate npdr were 74 in our study. the values of hba1c, bun and serum creatinine were higher in moderate npdr than mild npdr. the liver functions were also deranged, similar to a previous study in which the lft were more deranged in severe dr than mild disease.17 according to one study, a positive relationship between incidence and progression of retinopathy and glycosylated hemoglobin was found even after controlling for duration of diabetes, age, sex, and baseline retinopathy. these data suggest a strong and consistent relationship between hyperglycemia and incidence and progression of retinopathy.18 in an african research, a j-shaped relationship was reported between poor control of glycemia ≥ 126 mg/dl and the severity of non proliferative diabetic retinopathy.19 thus, as the values of blood glucose are increased the stage of diabetic retinopathy was also higher. the status of hb remained the same until late stages of the disease. at late stages, hb showed a significant inverse association with the severity of dr.20,21 the limitation of our study is that it was a single center study with a one time correlational design. further research can be done by following up the patients by controlling the variables and then finding their correlation with dr. conclusion control of metabolic status and diabetic retinopathy goes side by side. one factor affects other factors as well. therefore, lfts, rfts, hba1c and hb must be checked in all patients with dr on regular basis. ethical approval the study was approved by the institutional review board/ethical review board (10330/reg/kemu/2016). conflict of interest: authors declared no conflict of interest. references 1. king h, aubert re, herman wh. global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. diabetes care, 1998; 21 (9): 14141431. doi: 10.2337/diacare.21.9.1414. 2. safiri s, karamzad n, kaufman js, bell aw, nejadghaderi sa, sullman mjm, et al. prevalence, deaths and disability-adjusted-life-years (dalys) due to type 2 diabetes and its attributable risk factors in 204 countries and territories, 1990-2019: results from the global burden of disease study 2019. front endocrinol. 2022; 13: doi:10.3389/fendo.2022.838027. 3. nathan dm, davidson mb, defronzo ra, heine rj, henry rr, pratley r, et al. american diabetes association. impaired fasting glucose and impaired glucose tolerance: implications for care. diabetes care, 2007; 30 (3): 753-759. doi: 10.2337/dc07-9920. 4. american diabetes association. diagnosis and classification of diabetes mellitus. diabetes care, 2014; 37 suppl 1: s81-90. doi: 10.2337/dc14-s081. 5. genuth s, alberti kg, bennett p, buse j, defronzo r, kahn r, et al. expert committee on the diagnosis and classification of diabetes mellitus. follow-up report on the diagnosis of diabetes mellitus. diabetes care, 2003; 26 (11): 3160-3167. doi: 10.2337/diacare.26.11.3160. 6. american diabetes association. standards of medical care in diabetes--2010. diabetes care, 2010; 33 suppl. 1 (suppl. 1): s11-61. doi: 10.2337/dc10-s011. erratum in: diabetes care, 2010 mar; 33 (3): 692. 7. mettler m, kemper dw. information therapy: the strategic role of prescribed information in disease selfmanagement. stud health technol inform. 2006; 121: 373-383. 8. liu l, quang nd, banu r, kumar h, tham yc, cheng cy, et al. hypertension, blood pressure control and diabetic retinopathy in a large population-based study. plos one, 2020; 15 (3): e0229665. doi: 10.1371/journal.pone.0229665. 9. pippitt k, li m, gurgle he. diabetes mellitus: screening and diagnosis. am fam physician, 2016; 93 (2): 103-109. erratum in: am fam physician, 2016; 94 (7): 533. 10. qiu j, yard ba, krämer bk, van goor h, van dijk p, kannt a. association between serum carnosinase concentration and activity and renal function impairment in a type-2 diabetes cohort. front pharmacol. 2022; 13: 899057. doi: 10.3389/fphar.2022.899057. 11. cuthbertson dj, brennan g, walsh s, henry e. hepatic glycogenosis: abnormal liver function tests in type 1 diabetes. diabet med. 2007; 24 (3): 322-323. doi: 10.1111/j.1464-5491.2007.02085.x. co-relation between metabolic status and stage of diabetic retinopathy in patients visiting mayo hospital, lahore pak j ophthalmol. 2022, vol. 38 (4): 257-261 261 12. alqahtani n, khan wa, alhumaidi mh, ahmed ya. use of glycated hemoglobin in the diagnosis of diabetes mellitus and pre-diabetes and role of fasting plasma glucose, oral glucose tolerance test. int j prev med. 2013; 4 (9): 1025-1029. 13. brown ae, walker m. genetics of insulin resistance and the metabolic syndrome. curr cardiol rep. 2016; 18 (8): 75. doi: 10.1007/s11886-016-0755-4. 14. chatziralli i, loewenstein a. intravitreal antivascular endothelial growth factor agents for the treatment of diabetic retinopathy: a review of the literature. pharmaceutics, 2021; 13 (8): 1137. doi: 10.3390/pharmaceutics13081137 15. behl t, kotwani a. exploring the various aspects of the pathological role of vascular endothelial growth factor (vegf) in diabetic retinopathy. pharmacol res. 2015; 99: 137-148. doi: 10.1016/j.phrs.2015.05.013. 16. jamshaid s, hanif a, malik iq, zahid n, imtiaz hs. relationship between hba1c levels and severity of diabetic retinopathy. pak j ophthalmol. 2021; 37 (4): 352-355. doi: 10.36351/pjo.v37i4.1210 17. mukherjee b, shankar s, ahmed r, singh k, bhatia k. association of glycated haemoglobin and serum apolipoproteins with diabetic retinopathy: an indian overview. j clin diagn res. 2017; 11 (9): bc19-bc23. doi: 10.7860/jcdr/2017/25933.10667. 18. arkkila pe, koskinen pj, kantola im, rönnemaa t, seppänen e, viikari js. diabetic complications are associated with liver enzyme activities in people with type 1 diabetes. diabetes res clin pract. 2001; 52 (2): 113-118. doi: 10.1016/s0168-8227(00)00241-2. 19. klein r, klein be, moss se, davis md, demets dl. glycosylated hemoglobin predicts the incidence and progression of diabetic retinopathy. jama. 1988; 260 (19): 2864-2871. 20. longo-mbenza b, muaka m, mbenza g, mbungufuele s, mabwa-mbalanda l, nzuzi-babeki v, et al. risk factors of poor control of hba1c and diabetic retinopathy: paradox with insulin therapy and high values of hdl in african diabetic patients. int j diabetes & metabolism, 2008; 16: 69-78. 21. traveset a, rubinat e, ortega e, alcubierre n, vazquez b, hernández m, et al. lower hemoglobin concentration is associated with retinal ischemia and the severity of diabetic retinopathy in type 2 diabetes. j diabetes res. 2016; 2016: 3674946. doi: 10.1155/2016/3674946. authors designation and contribution umara gul; optometrist: concepts, design, literature seach, data acquisition, statistical analysis. fatima zahid; lecturer: data analysis, statistical analysis, manuscript preparation, manuscript editing. zehwa mazhar; demonstrator: literature search, manuscript review. ubaidullah jan; optometrist: literature search, manuscript review. .……. 379 pak j ophthalmol. 2021, vol. 37 (4): 379-383 original article central corneal thickness: ultrasound pachymetry verus anterior segment optical coherence tomography waqas ali 1 , munira shakir 2 , sahira wasim 3 , ronak afza 4 1-4 department of ophthalmology, liaquat national hospital, karachi abstract purpose: to determine the mean difference in central corneal thickness between ultrasound pachymetry and anterior segment optical coherence tomography in patients visiting tertiary care hospital of karachi. study design: cross sectional study. place and duration of study: department of ophthalmology, liaquat national hospital, karachi from 27 th december 2018 to 26 th june 2019. methods: total 216 eyes of 108 patients were divided into two groups. central corneal thickness was measured using ultrasound pachymeters in group a and with anterior segment optical coherence tomography in group b. data was collected and analyzed using spss version 21. mean central corneal thickness was compared between the two methods. stratification was done on gender, age and post-stratification independent sample t-test was applied for mean difference cct and p-value ≤ 0.05 was taken as significant. results: total 108 patients were equally divided into two groups. mean age was 48.70 ± 7.82 years in group a and 50.66 ± 6.88 years in group b. in group a, there were 74.1% males and 25.9% females while in group b, there were 75.9% males and 24.1% females. there was statistically significant difference between the mean central corneal thickness of group a and group b for right and left eyes (p < 0.001). mean difference was also compared for gender and age groups. we found statistically significant differences in central corneal thickness in between the two methods in both age groups (≤45 years and > 45 years). conclusion: central corneal thickness was more with pachymeters as compared to the as-oct (p value < 0.05). key words: central corneal thickness, anterior segment optical coherence tomography, ultrasound pachymetry. how to cite this article: ali w, shakir m, wasim s, afza r. comparison of central corneal thickness: ultrasound pachymetry verus anterior segment optical coherence tomography. pak j ophthalmol. 2021, 37 (4): 379-383. doi: 10.36351/pjo.v37i4.1260 correspondence: sahira wasim department of ophthalmology liaquat national hospital karachi email: sahirawasim@gmail.com received: april 29, 2021 accepted: august 8, 2021 introduction one of the important and sensitive indicator of corneal health is central corneal thickness. 1 measurement of corneal thickness is crucial in many clinical and research projects. 2 it is also integral for the diagnosis and management of treatable ocular conditions such as dystrophies of cornea, corneal edema, and endothelial diseases. 3,4 in the era of refractive surgery there is an increasing demand for a more accurate measurement open access central corneal thickness: ultrasound pachymetry verus anterior segment optical coherence tomography pak j ophthalmol. 2021, vol. 37 (4): 379-383 380 of corneal thickness. 5 if the measurements are not accurate, it can cause excessive tissue removal from the stromal bed that can lead to complication like iatrogenic corneal ectasia. 6 the gold-standard approach to measure cct is ultrasound pachymetry (usp). errors can occur in measurements if the centration of corneal measurement is not considered. incidence of ultrasound waves on the cornea is not accurate; lack of control of gaze fixation, fluctuation of the sound speed across tissues, or by the use of any topical anesthetic agent can also lead to errors. 3 it can also occur with insufficient tear film displacement after probe compression. 4 recently, anterior segment oct (as-oct) has been introduced which is a noncontact method of central corneal thickness measurement. as-oct can objectively determine central corneal thickness with higher precision and convenience with no risk of corneal contamination and no need for topical anesthesia. 7,8 in addition, as-oct also provides assessment for corneal surgeries such as corneal crosslinking and intra-stromal ring placement and also detect and provide treatment plan for glaucoma by measuring central corneal thickness and anterior chamber angle width. 3 fourier domain oct studies reported that the ultrasound cct values were higher than the oct values. 1 measurement of cct by as-oct was consistently thinner than measured by usp. both measurement modalities had good intra-examiner and inter-examiner repeatability. 7 ultrasound pachymetry, being a contact method, is uncomfortable for the patient and there is always a margin of technician error. previous international studies also indicate that the research on this subject has been insufficient. the purpose of our study is to determine the measurement of central corneal thickness by both the techniques, (ultrasound pachymetry and anterior segment oct) and consequently find out whether there is a significant difference between the two or not that can affect our results so that these techniques can be interchangeable. this study will also find out baseline data of these two techniques in our setup. methods the study was conducted in department of ophthalmology, liaquat national hospital, karachi within the duration of six months from 27 th december 2018 to 26 th june 2019after approval from hospital ethical review committee. the sample size was calculated using open epi sample size calculator considering 516.28 ± 29.76 1 cct in ultrasound pachymetry and 532.42 ± 29.71 1 in as-oct, 80% power of test and 95% confidence level. nonprobability consecutive sampling was done. total 108 patients with 54 in each group were required, so total 216 eyes with 108 eyes (both right and left in each group were evaluated. the inclusion criteria was age between 30-70 years, either gender and patients with refractive errors with no corneal abnormality. exclusion criteria were patients with corneal scarring, corneal trauma and patients with history of previous refractive surgery. subjects of group a underwent acoustic pachymetry while individuals of group b had anterior segment optical coherence tomography for measurement of central corneal thickness. we made two groups because it was difficult for the patients to undergo two different tests for the corneal thickness due to the financial constraints. patients attending the eye o.p.d and fulfilling the inclusion criteria were included in this study. informed verbal consent was taken from all the patients and the information retrieved was collected on self-designed proforma. central corneal thickness was measured using ultrasound pachymeters in group a and with anterior segment optical coherence tomography (heidelberg) in group b. both the procedures were done by an experienced ophthalmologist. data was collected, compiled and analyzed using spss version 21. gender was presented as frequency and percentages while variables like age, cct on ultrasound pachymetry, cct on anterior segment oct were presented as mean ± sd. mean central corneal thickness was compared between the two methods. stratification was done on gender, age and poststratification independent sample t-test was applied for mean difference cct and p-value ≤ 0.05 was taken as significant. results one hundred and eight patients were equally divided into two groups. the mean age was 48.70 ± 7.82 years in group a and 50.66 ± 6.88 years in group b. in group a, there were 74.1% males and 25.9% females while in group b, there were 75.9% males and 24.1% females. central corneal thickness of both groups is presented in table-1. sahira wasim, et al 381 pak j ophthalmol. 2021, vol. 37 (4): 379-383 table 1: descriptive statistics of participants. group-a n = 54, 108 eyes group-b n = 54, 108 eyes age (mean ± sd) 48.70 ± 7.82 50.66 ± 6.88 gender male 40 (74.1) 41 (75.9) female 14 (25.9) 13 (24.1) central corneal thickness (mean ± sd) right 532.09 ± 17.18 516.62 ± 18.25 left 533.48 ± 16.33 514.53 ± 18.36 we found statistically highly significant difference between the mean central corneal thickness (532.09 ± 17.18 μm) of group a and group b (516.62 ± 18.25 μm) for right eye (p < 0.001). similarly, we also found statistically significant difference between the mean central corneal thickness (533.48 ± 16.33 μm) of group a and group b (514.53 ± 18.36 μm)for the left eye (p < 0.001). mean difference of central corneal thickness for right eye and left eye was noted as 15.46 ± 25.46 μm and 18.94 ± 25.52 μm respectively with p value of < 0.001. mean difference was also compared for stratified categories of gender and age group which are presented in table – 3. we found statistically significant differences in central corneal thickness in two age groups (≤ 45 years and > 45 years). central corneal thickness was more with pachymeters as compared to the as-oct (p value < 0.05). table 2: comparisons of measurement central corneal thickness in ultrasound pachymetry and anterior segment oct. right eye left eye group – a (n = 54) group – b (n = 54) p-value group – a (n = 54) group – b (n = 54) p-value age ≤45 years 533.54 ± 16.46 515.31±15.72 0.002* 533.40 ± 15.78 508.81 ± 18.14 < 0.001* >45 years 531.09 ± 17.85 517.18±19.39 0.003* 533.53 ± 16.95 516.94 ± 18.14 < 0.001* gender male 531.72 ± 18.50 516.14±19.37 < 0.001* 536. 6 ±16.07 517.24 ± 19.00 < 0.001* female 533.14 ± 14.06 506.00±13.46 0.010* 524.57 ± 14.06 506.00 ± 13.46 0.002* discussion ultrasound pachymetry is thought to be a goldstandard approach to measure cct. several noncontact optical technologies such as anterior segment oct has been introduced in the last decade. corneal thickness plays an important role to determine corneal integrity. 9 it also helps in evaluating the endothelial pump function and to monitor the corneal diseases like keratoconus and corneal oedema. it is also helpful in the selection of patients before refractive surgeries. 10,11 there is also a role of cct measurement in the evaluation of contact lens wear and selection of patients with dry eye for therapy in clinical practice. 12,13 significant risk factor for progression of ocular hypertension to poag can be evaluated by the measurement of cct. 14,15 intraocular pressure (iop) measurement by applanation tonometry is influenced by cct which is a predictive factor for glaucoma progression. in patients with higher baseline iop, cct is measured and for that it is important to obtain the reliable corneal pachymetry and adjust the iop accordingly to the measured cct values. 16 there are numerous available methods to measure cct. ultrasound pachymetry is easy, fast, convenient and several measurements can be repeated to minimize error. it also has a high degree of inter-operator, intraoperator and inter-instrument reproducibility. 17 ultrasound pachymetry being a contact procedure, requires contact with the cornea and it uses doppler effect to measure the thickness. 12 as-oct devices are non-invasive and non-contact procedures, which rely on the principle of interferometry to detect minute differences in the depth of tissue. 15 they provide high resolution cross-sectional imaging of the both central and regional pachymetry of cornea. anterior segment structures are also imaged along with sophisticated goniometry of the irido-corneal angle. 15 pentacam, orbscan and as-oct are newer developed modalities which have widened the options and accuracy of measurement. according to one study, as-oct values were lesser than the ultrasound values. 1 several investigators who used time domain oct (td-oct) had reported that ultrasound pachymetry gave central corneal thickness: ultrasound pachymetry verus anterior segment optical coherence tomography pak j ophthalmol. 2021, vol. 37 (4): 379-383 382 systematically higher values than that measured by td–oct. 15 in another study, there was a statistically significant difference between us pachymetry and as-oct, with us pachymetry measurements being consistently thicker. the authors suggested that cct should be interpreted in the context of the instrument used. 18 according to prospero ponce cm et al, 19 scheimpflug and oct, cct measurements were reproducible but always thinner than us pachymetry in normal and keratoconus-suspect eyes. however, in post-lasik eyes, oct pachymetry maps were more accurate than scheimpflug maps. li ey et al reported that anterior segment optical coherence tomography underestimated corneal thickness when compared with that measured with usp. 20 according to zao, cct with ultrasound pachymetry was highly correlated with the equivalent as-oct reading (the pearson correlation coefficient = 0.93, p < .001). however, with bland-altman analysis it was shown that cct measured by ultrasound pachymetry was significantly higher by 16.5 +/11.7 μm. 21 in contrast to the above mentioned studies there is another research which has shown that measurement of cct was in good correlation to the values obtained by up. 22 in corneal edema, the difference between the two methods was increased, but continued to demonstrate excellent consistency. chang sw et al, reported that the ultrasound cct values were higher than the oct values. 23 with these differences in the studies, accuracy of corneal thickness measurements still remain unclear. it is also difficult to assess whether the two instruments took measurements from the same exact location. however, evidence suggests that, there is a systematic difference between oct and ultrasound, which uses different hardware, software for analysis among the two modalities. there are also technique differences used by the individuals and placement of probe direction. use of local anesthetic drops can lead to corneal edema as well. 24 theoretical explanations for the discrepancy would be that in ultrasound, the uncertainty of exact speed of sound as it passes between the corneal tissue can affect measurement of cct. 15 exact location of signal peak for the posterior reflection point in the ultrasound pachymetry remains unknown, it may be located between descemet’s membrane and anterior chamber of eye. this ambiguity in ultrasound measurement could be one the reasons for greater variations. small sample size was the limitation of our study. other limitations of this study include a single-center experience and nonrandomized study design. the study was conducted among the urban environment therefore; results may not be generalizable to larger populations. in our study as we have divided the individuals into two groups so we couldn’t evaluate the central corneal thickness in the same individual but among the two groups by both the instruments. conclusion central corneal thickness measurement by ultrasound pachymetry gives higher values as compared to asoct measurement. ethical approval the study was approved by the institutional review board/ethical review board (osp-irb/2021/005). conflict of interest authors declared no conflict of interest. refrences 1. ramesh pv, jha kn, srikanth k. comparison of central corneal thickness using anterior segment optical coherence tomography versus ultrasound pachymetry. j clin diagn res. 2017; 11 (8): nc08nc11. doi:10.7860/jcdr/2017/25595.10420 2. kumar kk, prakash aa, neeraja tg, adappa kt, prabha tsc, gangasagara sb. to compare central corneal thickness measurements obtained by pentacam with those obtained by iol master 700, cirrus anterior segment optical coherence tomography and tomey specular microscopy in normal healthy eyes. indian j ophthalmol. 2021; 69 (7): 1713-1717. doi:10.4103/ijo.ijo_3364_20 3. williams r, fink ba, king-smith pe, mitchell gl. central corneal thickness measurements: using an ultrasonic instrument and 4 optical instruments. cornea, 2011; 30 (11): 1238-1243. 4. khaja wa, grover s, kelmenson at, ferguson lr, sambhav k, chalam kv. comparison of central corneal thickness: ultrasound pachymetry versus slitlamp optical coherence tomography, specular microscopy, and orbscan. clin ophthalmol. 2015; 9: 1065. 5. üçer mb, bozkurt e. comparison of central corneal thickness measurements with three different optical devices. ther adv ophthalmol. 2021; 13: 2515841421995633. sahira wasim, et al 383 pak j ophthalmol. 2021, vol. 37 (4): 379-383 6. doğan m, ertan e. comparison of central corneal thickness measurements with standard ultrasonic pachymetry and optical devices. clin exp optom. 2019; 102 (2): 126-130. 7. lin cw, wang th, huang yh, huang jy. agreement and repeatability of central corneal thickness measurements made by ultrasound pachymetry and anterior segment optical coherence tomography. taiwan j ophthalmol. 2013; 3 (3): 98102. 8. thiagarajan k, srinivasan k, gayam k, rengaraj v. comparison of central corneal thickness using noncontact tono-pachymeter (tonopachy) with ultrasound pachymetry in normal children and in children with refractive error. indian j. ophthalmol. 2021; 69 (8): 2053-2059. 9. ortiz s, mena l, rio-san cristobal a, martin r. relationships between central and peripheral corneal thickness in different degrees of myopia. j. optom. 2014; 7 (1): 44–50. 10. chong j, dupps jr wj. corneal biomechanics: measurement and structural correlations. exp. eye res. 2021; 205: 108508. 11. baptista pm, ambrosio r, jnr lo, meneres p, beirao jm. corneal biomechanical assessment with ultra-high-speed scheimpflug imaging during noncontact tonometry: a prospective review. clin ophthalmol (auckland, nz). 2021; 15: 1409. 12. bovelle r, kaufman sc, thompson hw, hamano h. corneal thickness measurements with the topcon sp-2000p specular microscope and an ultrasound pachymeter. arch ophthalmol. 1999; 117 (7): 868–870. 13. guzey m, satici a, karaman sk, ordulu f, sezer s. the effect of topical cyclosporine a treatment on corneal thickness in patients with trachomatous dry eye. clin exp optom. 2009; 92 (4): 349–355. 14. gordon mo, beiser ja, brandt jd. the ocular hypertension treatment study: baseline factors that predict the onset of primary open-angle glaucoma. arch ophthalmol. 2002; 120 (6): 714-720. 15. kim hy, budenz dl, lee ps, feuer wj, barton k. comparison of central corneal thickness using anterior segment optical coherence tomography vs. ultrasound pachymetry. am. j. ophthalmol. 2008; 145 (2): 228– 232. 16. doughty mj, zaman ml. human corneal thickness and its impact on intraocular pressure measures: a review and meta-analysis approach. surv ophthalmol. 2000; 44 (5): 367-408. 17. gordon a, boggess ea, molinari jf. variability of ultrasonic pachymetry. optom vis sci. 1990; 67 (3): 162–165. 18. grewal ds, brar gs, grewal sp. assessment of central corneal thickness in normal, keratoconus, and post-laser in situ keratomileusis eyes using scheimpflug imaging, spectral domain optical coherence tomography, and ultrasound pachymetry. j cataract refract surg. 2010; 36 (6): 954-964. 19. prospero cm, rocha km, smith sd, krueger rr. central and peripheral corneal thickness measured with optical coherence tomography, scheimpflug imaging, and ultrasound pachymetry in normal, keratoconussuspect, and post-laser in situ keratomileusis eyes. j cataract refract surg. 2009; 35 (6): 1055-1062. 20. li ey, mohamed s, leung ck. agreement among 3 methods to measure corneal thickness: ultrasound pachymetry, orbscan ii, and visante anterior segment optical coherence tomography. ophthalmology, 2007; 114 (10): 1842–1847. 21. zhao ps, wong ty, wong wl, saw sm, aung t. comparison of central corneal thickness measurements by visante anterior segment optical coherence tomography with ultrasound pachymetry. am j ophthalmol. 2007; 143 (6): 1047–1049. 22. bechmann m, thiel mj, neubauer as. central corneal thickness measurement with a retinal optical coherence tomography device versus standard ultrasonic pachymetry. cornea, 2001; 20 (1): 50–54. 23. chang sw, su pf, lo ay, huang jy. central corneal thickness by fourier domain optical coherence tomography, ocular response analyzer and ultrasound pachymetry. taiwan j ophthalmol. 2014; 4 (4): 163169. 24. wongchaisuwat n, metheetrairat a, chonpimai p, nujoi w, prabhasawat p. comparison of central corneal thickness measurements in corneal edema using ultrasound pachymetry, visante anterior-segment optical coherence tomography, cirrus optical coherence tomography, and pentacam scheimpflug camera tomography. clin ophthalmol. 2018; 12: 1865-1873. doi:10.2147/opth.s172159 authors’ designation and contribution waqas ali; resident: concepts, design, literature search, manuscript preparation, manuscript review. munira shakir; professor: design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. sahira wasim; resident: design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. ronak afza; resident: literature search, data analysis, statistical analysis, final review and approval 194 pakistan journal of ophthalmology, 2020, vol. 36 (3): 194-196 editorial ocular surface disease: an integral part of glaucoma management aysha salam 1 1 consultant ophthalmologist, royal liverpool hospital, united kingdom glaucoma has been a silent and symptomless diseasecausing relentless loss of vision requiring lifelong treatment. it is often hard to gain patient acceptance for a condition, the treatment for which does not manifest in the form of any direct visual gains. this is in turn is compounded by the adverse effects of medication. these are most commonly poor tolerance and preservative toxicity in addition to the active ingredient which in itself can compromise a vulnerable ocular surface. 1,2 glaucoma patients are presumably at a much higher risk of developing ocular surface disease and one of the commonest reasons for that is being treated with preservative-containing medications over a prolonged period. 1,2 this editorial will highlight some of the common risk factors and possible remedies in glaucoma patients manifesting with ocular surface disease. preservative toxicity is a well-known concept but is still under diagnosed and poorly managed in most patients. benzalkonium chloride (bak) is the most commonly used preservative, in most ophthalmic preparations. the other preservatives used are polyquad and peroxide derivatives. 3 the main benefit of using preservatives is to prevent bacterial contamination along with the requirement by the regulatory authorities for a safe dispensing of the medication. 4,5 however, the bak is known to induce necrosis (at conc. of 0.05 – 0.1%) and cellular apoptosis (at conc. of 0.01%) by disturbing cellular membrane in bacterial cells. human ocular surface how to cite this article: salam a. ocular surface disease: an integral part of glaucoma management. pak j ophthalmol. 2020; 36 (2): 194-196. doi: 10.36351/pjo.v36i3.1064 correspondence to: aysha salam consultant ophthalmologist, royal liverpool hospital email: aysha.salam320@gmail.com cells absorb bak, which has damaging effects similar to those in bacterial cells. they are cumulative and become more severe with more concentrated and frequent exposures. the inflammatory changes induce permanent damage to the conjunctival goblet cells, which can seriously compromise the success of any future filtration procedures. 3,4,5 in order to fully analyse the histological and morphological changes in patients treated with bak containing glaucoma drops, a prospective, doublemasked, placebo-controlled study was performed by barabino et al who assessed corneal thickness, goblet cell density and conjunctival immunohistochemistry using cd45 detection in rats at day 7 of treatment. 6 the study revealed higher incidence of punctate fluorescein staining in bak treated eyes as compared to the control group although the changes in corneal thickness were not statistically significant. the baktreated eyes showed a significantly lower number of goblet cells than those in all control groups (*p < 0.05), whereas it induced a significant increase in the cd45 expression in the bulbar conjunctiva showing an increase in the inflammatory activity. 6 the significance of this is further endorsed in a study by agnifil et al 7 , who analysed the pre-operative conjunctival goblet cell density (gc), muc5ac which is the main mucin product of gc, and hla-dr in glaucomatous patients undergoing trabeculectomy, using laser scanning confocal microscopy (lscm) and impression cytology (ic). they divided their patients into three groups. the group with complete success revealed good population of goblet cells with scattered microcysts showing a functioning bleb. the impression cytology also confirmed muc5ac being significantly over expressed compared to failed surgeries along with a better iop control. the groups with qualified success and failed trabeculectomies had much lower goblet cell densities and muc5ac concentrations although the inflammatory component mailto:aysha.salam320@gmail.com https://iovs.arvojournals.org/solr/searchresults.aspx?author=stefano+barabino ocular surface disease: an integral part of glaucoma management pakistan journal of ophthalmology, 2020, vol. 36 (3): 194-196 195 hal-dr was not statistically different in the three groups. 7 the study establishes the most important myths behind a successful filtration procedure which would appear to be a favourable density of the goblet cells which could in future be used as a biomarker to predict the chances of success of surgery and post-operative bleb management. a decrease in the concentration of goblet cells with increase in mast cells, squamous metaplasia, dendritic cell proliferation and fibroblasts would be the most likely progenitors for scarring and surgical failure. 6,7. glaucoma is common in the elderly and due to chronicity, is more likely to require more frequent use of multiple topical medications which precipitate the risk of ocular surface disease. the underlying pathophysiology includes functional changes with reduced function of the lacrimal glands causing aqueous tear deficiency with under function of the meibomian glands as well as reduced number of conjunctival goblet cells. there is often secondary inflammation of the ocular surface as a result of meibomian gland dysfunction which can in turn blunt the effect of glaucoma medications causing poor control and intolerance to glaucoma drops. the ageing of the ocular adenexa with lid laxity, pump failure and conjunctivochalasis are other risk factors common in this age group, which further predispose to ocular surface disease 8 . early onset glaucoma most commonly requires surgical intervention as it is more aggressive and harder to treat. however, given that the disease process persists through an extended period of time, younger patents are likely to be exposed to topical medications for longer length of time and are more likely to suffer from cumulative toxicity of the preservatives 9 . it is well known that dry eyes and osd is much more common in older women particularly in the postmenopausal age groups. the role of hormone replacement therapy (hrt) in improving the osd is not well established, as the bulk of the problem is loss of circulating androgens, which are not given as a part of hrt. the largest cross-sectional study to date showed increase in the risk and severity of osd in women. 10 there is a wide range of medical and ocular conditions associated with increased risk of ocular surface disease 11 . a detailed history is therefore crucial. medical illnesses include collagen vascular disorders, chronic graft versus host disease (gvhd) after stem cell transplantation only seen in allogenic transplantation, androgen insufficiency, iatrogenic factors including; chemotherapy and immunosuppressive therapy, anti-histamines and antidepressants, beta-blockers, anti-androgens, isotretinoin, radiation therapy and any ocular surgery can spark dry eye disease. it is recommended to discontinue bak containing medicines and substitute with preservative free medications or in severe cases, stop medications altogether and substitute with oral acetazolamide. take home message is liberal use of preservative free medications, early slt or primary treatment, consider early surgery where there is disc damage and progression, pre-perimetric glaucoma progression, poor compliance, poor response to treatment and poor ocular surface. it is evident that protecting the integrity of the ocular surface is as crucial as is treating glaucoma because without a healthy ocular surface, glaucoma management is bound to fail. glaucoma care pathway is essentially incomplete without the ocular surface optimization. early detection and treatment will predict a smoother journey with a successful long term outcome. conflict of interest author declared no conflict of interest references 1. baudouin c, labbé a, liang h, pauly a, brignolebaudouin f. preservatives in eye drops: the good, the bad and the ugly. prog retin eye res. 2010; 29 (4): 312-334. 2. leung e, mendeiros f, weinreb r. prevalence of ocular surface disease in glaucoma patients. journal of glaucoma, 2008; 17 (5): 350-355. 3. freeman, p and kahook m. preservatives in topical medications. historical and clinical perspectives. expert rev ophthalmol. 2009; 4 (1): 59-64. 4. maiti s., sadhukhan s., bakshi p. ocular preservatives: risks and recent trends in its application in ocular drug delivery (odd). in: pathak y., sutariya v., hirani a. (eds). nanoaysha salam 196 pakistan journal of ophthalmology, 2020, vol. 36 (3): 194-196 biomaterials for ophthalmic drug delivery. springer, cham. 2016. 5. jean mds, brignole f, bringuier af, bauchet a, feldmann g, baudouin c. effects of benzalkonium chloride on growth and survival of chang conjunctival cells. invest. ophthalmol. vis. sci. 1999; 40 (3): 619630. 6. barabino s, antonelli s, cimbolini n, mauro v, bouzin m. the effect of preservatives and antiglaucoma treatments on the ocular surface of mice with dry eye. invest. ophthalmol. vis. sci. 2014; 55 (10): 6499-6504. 7. agnifili l, fasanella v, mastropasqua r, frezzotti p, curcio c, brescia l, et al. in vivo goblet cell density as a potential indicator of glaucoma filtration surgery outcome. invest. ophthalmol. vis. sci. 2016; 57 (7): 2928-2935. 8. ding j, sullivan da. aging and dry eye disease. exp gerontol. 2012; 47 (7): 483–490. 9. huang w. pediatric glaucoma: a review of the basics, 2014. available from: http://https://www.reviewofophthalmology.com/article/ pediatric-glaucoma-a-review-of-the-basics 10. sullivan da, rocha em, aragona p, clayton ja, ding j, golebiowski b, et al. tfos dews ii sex, gender, and hormones report. ocul surf. 2017; 15 (3): 284-333. 11. messmer em. the pathophysiology, diagnosis, and treatment of dry eye disease. dtsch arztebl int. 2015 jan 30; 112 (5): 71-81. .…  …. https://www.reviewofophthalmology.com/article/pediatric-glaucoma-a-review-of-the-basics https://www.reviewofophthalmology.com/article/pediatric-glaucoma-a-review-of-the-basics https://www.reviewofophthalmology.com/article/pediatric-glaucoma-a-review-of-the-basics https://www.ncbi.nlm.nih.gov/pubmed/?term=sullivan%20da%5bauthor%5d&cauthor=true&cauthor_uid=28736336 https://www.ncbi.nlm.nih.gov/pubmed/?term=rocha%20em%5bauthor%5d&cauthor=true&cauthor_uid=28736336 https://www.ncbi.nlm.nih.gov/pubmed/?term=aragona%20p%5bauthor%5d&cauthor=true&cauthor_uid=28736336 https://www.ncbi.nlm.nih.gov/pubmed/?term=clayton%20ja%5bauthor%5d&cauthor=true&cauthor_uid=28736336 https://www.ncbi.nlm.nih.gov/pubmed/?term=ding%20j%5bauthor%5d&cauthor=true&cauthor_uid=28736336 https://www.ncbi.nlm.nih.gov/pubmed/?term=golebiowski%20b%5bauthor%5d&cauthor=true&cauthor_uid=28736336 https://www.ncbi.nlm.nih.gov/pubmed/28736336 https://www.ncbi.nlm.nih.gov/pubmed/?term=messmer%20em%5bauthor%5d&cauthor=true&cauthor_uid=25686388 https://www.ncbi.nlm.nih.gov/pubmed/25686388 445 pak j ophthalmol. 2020, vol. 36 (4): 445-447 brief communication vogt – koyanagi harada syndrome in a pakistani female rebecca 1 , murtaza sameen junejo 2 , fahad feroz shaikh 3 , nazir ashraf laghari 4 1-4 department of ophthalmology, isra university hospital, hyderabad abstract vogt-koyanagi-harada syndrome is a rare multiorgan inflammatory disorder characterized by bilateral uveitis with serous retinal detachment and is often associated with headache, hearing loss, vitiligo, and poliosis. here we present a case of 37 years old female who presented with chronic photophobia, redness and progressive decreased vision in both eyes for 5 years along with cutaneous and hearing symptoms. on ocular examination her best-corrected visual acuity was 6/60 od and perception of light os, while the intraocular pressure was 16 mm  hg od and 18  mm  hg os, measured with goldmann applanation tonometer. the slit-lamp examination of right anterior segment showed diffuse keratic precipitates along with diffuse iris atrophy and seclusion pupillae (360 degree). on detailed examination she was found to be a case of vkh syndrome. this case is presented to familiarize ophthalmologists and health care professionals about its findings and complications that are usually found in such patients. key words: uveitis, poliosis, vogt koyanagi harada, vitiligo. how to cite this article: rebecca, junejo ms, shaikh ff, laghari na. vogt – koyanagi harada syndrome in a pakistani female. pak j ophthalmol. 2020; 36 (4): 445-447. doi: https://doi.org/10.36351/pjo.v36i4.1120 introduction vogt-koyanagi harada syndrome is a rare multi organ inflammatory disease characterized by uveitis and serous retinal detachment. neurological and cutaneous associations have also been found in this condition, which includes headache, poliosis, hearing loss, and vitiligo. 1 the etiology and pathogenesis of vkh syndrome remains unknown. a few studies have shown an association between hla-dr4 and hladr53 with vkh syndrome. in this granulomatous autoimmune disorder, melanocyte containing organs are highly affected. one out of three findings are necessary for the diagnostic criteria for vkh correspondence: murtaza sameen junejo department of ophthalmology isra university hospital, hyderabad email: drmurtazasameen@gmail.com received: august 16, 2020 accepted: september 2, 2020 syndrome according to american uveitis society diagnostic criteria. 2 this syndrome consists of four clinical stages: a) in first stage there are nonspecific symptoms such as nausea, fever and the neurological symptoms like headaches, muscle weakness; 2) ophthalmologic stage, in which patients complain of blurred vision, pain, photophobia or central scotoma (bilateral in 80% of the cases); bilateral serous retinal detachment often occurs, tinnitus is often present; 3) third stage, occurs within months from the onset and is characterized by poliosis involving the eyebrows, eyelashes, hair loss and vitiligo; 4) chronic recurrent stage: recurrent uveitis and ophthalmological complications. 3 the aim to report this case is to familiarize ophthalmologists and health care professionals about its findings and complications that are usually found in such patients. vogt – koyanagi harada syndrome in a pakistani female pak j ophthalmol. 2020, vol. 36 (4): 445-447 446 case presentation a well oriented 37-year old female presented to isra university hospital on august 11, 2020 with complaint of chronic progressive deterioration of vision in left eye for 06 months and decreased vision in both eyes for 5 years. she was using prednesone acetate eye drops and atropine 1% eye drops the for the last 3 years. on ocular examination her best-corrected visual acuity (bcva) was 6/60 (od) and perception of light (os), while the intraocular pressure (iop) was 16 mm   hg (od) and 18   mm  hg (os) measured with goldmann applanation tonometer. the slit-lamp examination of right anterior segment showed diffuse keratic precipitates along with diffuse iris atrophy and seclusio pupillae (360 degree). there were mild lenticular changes in right eye along with sunset glow fundus. left eye revealed poliosis, diffuse keratic precipitates, diffuse iris atrophy along with seclusio pupillae and white cataract. the fundus view of left eye was hazy due to cataract. ultrasound b-scan of both eyes was within normal limits. on general physical examination a young female well oriented in time place and person showed numerous white patches throughout the body. she gave history of vitiligo which was diagnosed 2 years back at isra university hospital. meanwhile, she was also suffering from tinnitus. for this reason she was referred to e.n.t specialist for expert opinion. there was no significant history of trauma or neurological illness. a cataract surgery was planned in her left eye fig. 1: 37 years old female with vitiligo. both eyes show 360 posterior synechia, iritis and lenticular changes. at least 3 months after the absence of any ocular inflammation. discussion vkh syndrome is a rare multisystem autoimmune disorder in which the incidence and risk have not been substantially established. however ocular complications are adverse and can lead to vision threatening events. 4 uveitis is relatively common with the incidence of 0.3 to 1.2%. 5 vkhd is an anti‐melanocyte granulomatous autoimmune disease that affects eyes, inner ear, meninges, skin, and hair. 5,6 it has been studied that hla‐dr4 is strongly associated with vkhd. the clinical features of vkhd include: bilateral chronic iritis, pan uveitis, neurological signs like headache, meningitis, and cutaneous findings of alopecia, poliosis, or vitiligo. 7 among individuals of pigmented skin including asians, it is an important cause of noninfectious uveitis. 7,8 our patient was kept on topical steroids and cycloplegics which did not show improvement. the patient we reported here was a young female with an ocular and cutaneous involvement. there was no neurological involvement. various immunesuppressants have been used to treat this disorder, however the risk of ocular complications remains, therefore regular follow-up is required. in summary, although vkh is a rare disorder, the ocular complications can be vision threatening, therefore, a regular and long-term follow-up is necessary by an ophthalmologist. conflict of interest authors declared no conflict of interest. references 1. neves a, cardoso a, almeida m, campos j, campos a, castro sousa jp. castro sousa unilateral vogt-koyanagi-harada disease: case rep ophthalmol. 2015; 6: 361-365. 2. sakata vm, da silva ft, hirata ce, de carvalho jf, yamamoto jh. diagnosis and classification of vogt-koyanagi-harada disease. autoimmun rev. 2014; 13: 550-555. 3. kurono y, takeda t, kunimatsu y, tani n, hashimoto n, hirose k. vogt-koyanagi-harada disease during chemo-immunotherapy for non-small cell lung cancer. respirol case report, 2020; 8 (3): e00545. doi: 10.1002/rcr2.545. rebecca, et al 447 pak j ophthalmol. 2020, vol. 36 (4): 445-447 4. o'keefe gad, rao na. vogt-koyanagi-harada disease. surv ophthalmol. 2017; 62 (1): 1-25. doi: 10.1016. 5. street d, sivaguru a, sreekantam s, mollan sp. vogt-koyanagi-harada disease. pract neurol. 2019; 19 (4): 364-367. doi: 10.1136. 6. khan f, zahid s, raza ss, iqbal m. a case of vogt koyanagi harada disease in a 16 year old girl. jpma. 2017; 67 (11): 1759-1761. 7. chee sp, jap a, bacsal k. prognostic factors of vogtkoyanagiharada disease in singapore. am j ophthalmol. 2009; 147: 15461.e1. 8. cunningham et, rathinam sr, tugal tutkun i, muccioli c, zierhut m. vogt koyanagi harada disease ocul immunol inflamm. 2014; 22: 249-252. authors’ designation and contribution rebecca; resident: design, literature research, statistical analysis manuscript editing. murtaza sameen junejo; senior registrar: data collection and manuscript writing. fahad feroz shaikh; associate professor: data collection and manuscript writing. nazir ashraf laghari; professor: manuscript review and final approval of manuscript. .…  …. 120 pak j ophthalmol. 2021, vol. 37 (1): 120-123 brief communication understanding ocular visual function beyond the sphere and cylinder using multimodal imaging nauman hashmani 1 , sharif hashmani 2 1,2 department of ophthalmology and visual sciences, hashmanis hospital, karachi – pakistan abstract multimodal imaging is the mainstay when diagnosing diseases of the retina. this same technique is applicable to the refractive surgeries including lasik and refractive lens exchange. in the modern day, visual problems have moved beyond mere lower order aberrations and the snellen chart. we present two interesting cases that demonstrate the use of multimodal imaging in refractive surgery cases. the first case demonstrates a simple capsular contraction causing immense problems of light spread in an otherwise normal trifocal implanted patient. the second is a case of a hidden and problematic refractive surgery that again complicated a trifocal lens surgery. we have made many advancements in understanding the eyes optical elements and must use this to our advantage to help our patients. how to cite this article: hashmani n, hashmani s. understanding ocular visual function beyond the sphere and cylinder using multimodal imaging. pak j ophthalmol. 2021, 37 (1): 120-123. doi: https://doi.org/10.36351/pjo.v37i1.1179 introduction multimodal imaging is the mainstay when diagnosing diseases of the retina. this same technique should be applied by refractive surgeons practicing modalities such as lasik and refractive lens exchange. in the modern day, visual problems have moved beyond mere lower order aberrations and the snellen chart. 1,2 nowadays, there are modalities to understand structure and function of the optical system. the anterior segment optical coherence tomography and the corneal tomography systems can help us understand corneal anatomy through cross sectional imaging and shape analysis. 3,4 secondly, we have a variety of optical aberrometers, like the hartman shack 5 and ray tracing 6 , available that can map out the correspondence: nauman hashmani 68/b khayaban-e-shahbaz, dha phase 7 karachi – pakistan email: naumanhashmani@hashmanis.edu.pk received: november 1, 2020 accepted: december 9, 2020 functional wave front errors of the eye. additionally, these aberrometers can separate the corneal from internal aberrations and can map these while the patient has fixated at different distances like near, intermediate and far. 7 this article aims to explain the benefits of multimodal imaging within the arena of refractive surgery using a case-based approach. we are presenting two cases to show how a patient’s problems can be mapped using the variety of tools available at our disposal. case 1 a 60-year-old patient presented with a complaint of inability to see the oncoming lights at night. the complaint was so severe that he could not see a truck coming until it was about 1 meter away. this patient was previously implanted with a trifocal intraocular lens (acrysof iq panoptix, alcon laboratories, fort worth, tx) and this was his 1-month postoperative checkup. there were no remarkable findings on slit lamp examination and his fundus was normal. the patient had an uncorrected distance visual acuity (udva) of 6/6 bilaterally with a refraction of 0, -0.25 understanding ocular visual function beyond the sphere and cylinder pak j ophthalmol. 2021, vol. 37 (1): 120-123 121 × 67 diopters (d) in the right eye and -0.50 × 0.25 × 91 d in the left. he was put through several tests to elucidate the cause of his complaints. he underwent a spectral domain anterior segment oct (as-oct; optovue, inc.) with epithelial mapping which were normal. his tomography scan (pentacam hr; oculus, wetzlar, germany) showed no evidence of corneal abnormalities. he underwent a ray tracing aberrometer examination (itrace, tracey technology, houston, tx), as shown in figure 1. fig. 1: (a) a normal axial map on a corneal topography. (b) zernike polynomial divided in to corneal, internal, and total eye. the eye seems to be clear with mild trefoil present in the cornea that shows on the total eye. (c) image of the eye showing scan points centered on the visual axis. the red arrow shows the contracted rhexis. (d) a retinal spot diagram with a bump in the visual function coinciding to the contracted rhexis. this was the source of the patient’s problems. figure 1a shows a uniform anterior surface with progressive steepening in the periphery, like a normal cornea. figure 1b shows the breakup of higher order aberrations, the first row being the anterior surface of the cornea, the second, internal minus the anterior surface and, the last, the total eye. this image would suggest a problem with the cornea as there is trefoil present that is shown on the total eye analysis. however, it did not correlate with the severity of patient’s complaint. figure 1c shows an infrared image of the patients non-dilated eye with 256 points scanned centered on the visual axis. the red arrow shows a white opacification in the inferior region right above the pupil. figure 1d shows a retinal spot diagram with a single large bump, shown by the red arrow. the points on figure 1c and 1d showed that there was capsular contraction that encroached on the visual axis when the patient was dark-adapted, causing light spreading. this singular point caused the intense symptoms of the patient. he, subsequently, underwent a yag capsulotomy, which relieved the patient of his symptoms. case 2 as this patient had similar findings in both eyes, we shall only discuss the left eye. a 65-year-old female came with a complaint of double vision and a ring around lights. in general, she was unhappy with her vision. she was implanted with trifocal intraocular lenses one month prior to this visit at another hospital. she gave no history of co-morbidities. slit lamp examination was un-remarkable and the fundus was within normal limits. manifest refraction of the right eye was -0.50, -0.25 x 160 d and of left eye was +1.00, -2.75 x 168 d. the left eye had a udva of 6/12. fig. 2: (a) a simulated vision showing problems arising in the cornea. (b) a corneal tomography showing normal elevation points with a thinned-out cornea. (c) an epithelial map with a central epithelial hypertrophy. nauman hashmani, et al 122 pak j ophthalmol. 2021, vol. 37 (1): 120-123 figure 2 shows the test findings of the left eye. in figure 2a, we can observe that even in its best corrected form, the vision has blurriness originating in the cornea. in figure 2b, we see a tomography image showing normal elevation points, but a relatively thinned cornea with a slight inferotemporal dislocation. figure 2c shows a hypertrophied corneal epithelium. fig. 3: an anterior segment oct b scan showing central undulations at the lasik flap interface (green arrows). the periphery shows a meniscus style flap that proves this was a lasik performed with a microkeratome (red arrow). figure 3 gives the final diagnosis. this is anasoct scan image. two points can be seen: a meniscus style flap can be seen in the periphery (red arrow), and the multiple undulations seen in the center (green arrow). this is a post refractive surgery case complicated by an irregular flap. discussion first case indicates the importance of ray tracing aberrometer and its ability to provide clues into the true optical elements of the eye. we always think of higher order aberrations in terms of zernicke’s polynomials 8 but it should be noted that not all wavefront patterns fit into this model. relying solely on this model, we would have suspected a problem in the cornea. there are elements in the eye other than the cornea and the lens, that can cause monochromatic aberrations; these must be considered before we make a final diagnosis. in the second case, the patient herself claimed that no surgery was performed on her eye. performing any type of iol calculation is problematic in such eyes, as different formulas are to be utilized in such cases. 9 if no corneal tomography or as-oct facilities are available at the hospital, it is not possible to provide these patients with an accurate iol power. the error in iol power calculation along with the astigmatism can be explained by two variables: 1. unreported refractive surgery and 2. irregular flap. additionally, the epithelial hypertrophy can be explained by the irregular flap; the epithelium hypertrophied due to the sudden stromal curvature changes. 10 even in its best-corrected form, the resolving power of the cornea was reduced due to a prior problematic refractive surgery. this had magnified the limitations of the trifocal lens. secondly, there arises a question whether this patient was fit for a non-toric tri focal implantation? in our practice, we exclude patients with a significant corneal astigmatism. the corneal tomography showed us a -3.5 d astigmatism and thus should have been excluded. significant lower orders impair image quality to a large degree, and divide light into different foci. therefore, they would amplify all the shortcomings of a trifocal lens. the challenge to treat this patient remains. the first option would be to treat the cornea with a regularization procedure like topography guided photorefractive keratectomy. however, this would worsen hyperopia. only two other options remain: lens exchange with a recalculation of power or to wear glasses. at this time, the patient has opted for the latter. conflicts of interest there are no conflicts of interest to note. references 1. hashemi h, khabazkhoob m, jafarzadehpur e, yekta a, emamian mh, shariati m, et al. higher order aberrations in a normal adult population. j curr ophthalmol. 2015; 27 (3–4): 115–124. 2. hartwig a, atchison da. analysis of higher-order aberrations in a large clinical population. investig ophthalmol vis sci. 2012; 53 (12): 7862–7870. 3. hashmani n, hashmani s, saad cm. wide corneal epithelial mapping using an optical coherence tomography. invest ophthalmol vis sci. 2018; 59 (3): 1652–1658. 4. hashmani n, hashmani s, hanfi an, ayub m, saad cm, rajani h, et al. effect of age, sex, and refractive errors on central corneal thickness measured by oculus pentacaml®. clin ophthalmol. 2017; 11: 1233–1238. 5. thibos ln. principles of hartmann-shack aberrometry. j refract surg. 2000; 16 (5):s563-565 6. molebny v v, panagopoulou si, molebny s v, wakil ys, pallikaris ig. principles of ray tracing aberrometry. j refract surg. 2000; 16 (5):s572-575. understanding ocular visual function beyond the sphere and cylinder pak j ophthalmol. 2021, vol. 37 (1): 120-123 123 7. hao j, li l, tian f, zhang h. comparison of two types of visual quality analyzer for the measurement of high order aberrations. int j ophthalmol. 2016; 9 (2): 292–297. 8. mcalinden c, mccartney m, moore j. mathematics of zernike polynomials: a review. clin exp ophthalmol. 2011; ;39(8):820-827 9. chen x, yuan f, wu l. metaanalysis of intraocular lens power calculation after laser refractive surgery in myopic eyes. j cataract refract surg. 2016;42(1):163170 10. reinstein dz, gobbe m, archer tj, silverman rh, coleman j. epithelial, stromal, and total corneal thickness in keratoconus: three-dimensional display with artemis very-high frequency digital ultrasound. j refract surg. 2010; 26 (4): 259–271. authors’ designation and contribution nauman hashmani: consultant ophthalmologist: data acquisition, manuscript write-up, final review. sharif hashmani: consultant ophthalmologist: data acquisition, manuscript write-up, final review. .…  …. pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 24 original article causes of blindness in patients with open angle glaucoma, an alarming situation imran ahmad, bakht samar khan, mubashir rehman, muhammad rafiq pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: imran ahmad house no. 40, street 2 sector h1 phase 2, hayatabad, peshawar. …..……………………….. purpose: to determine the causes of blindness in patients with open angle glaucoma. material and methods: it was a retrospective cohort study in which 500 eyes with legal blindness were investigated. in all these patients detailed history was taken followed by examination including best corrected visual acuity, tonometry, gonioscopy and perimetry, central corneal thickness and where indicated other investigations like oct, hrt and mri were done. results: the causes of blindness in patients with open angle glaucoma were late presentations (26%), misdiagnosis (13.60%), poor compliance (19.20%), unable to afford medications (8.4%), refusal of surgery (10.60%) and failure of medications (22.40%). conclusion: open angle glaucoma is a serious problem which can lead to blindness due to many reasons. therefore patient must be well educated about the course and progression of disease. laucoma is defined as an optic neuropathy in which there is visual field loss along with optic disc cupping and may or may not be associated with raised intraocular pressure (iop). open angle glaucoma is an asymptomatic disease until central vision is affected and is the leading cause of irreversible blindness worldwide. it is an old age disease and the prevalence of blindness increases as the population ages. according to who statistics glaucoma after cataract is the second most common cause of blindness worldwide (15%) and majority of them reside in asia1,2. however, glaucoma is dangerous than cataract as the blindness it causes is permanent whereas that due to cataract is reversible. in spite of new methods of diagnosis, medical education and management, the blindness due to open angle glaucoma is alarming. it has been estimated that 73 million people are affected by glaucoma worldwide and 6.7 million are thought to be blind due to this disease. it is estimated that by 2020 about 80 million people will be affected by glaucoma3. although there has been progress in both medical and surgical strategies for glaucoma treatment, blindness from open angle glaucoma still occurs despite therapy4. on one hand in developed countries where cases of blindness due to glaucoma continue to appear, on the other hand in developing countries like pakistan late presentation, misdiagnosis, compliance problem, financial restraints and refusal of treatment are the main obstacles. since it is an old age disease, glaucoma is causing a major threat to vision in developing countries as the population ages. blindness caused by glaucoma is more prevalent in rural than urban areas due to the difficulties of access to health care institutions which lead to late diagnosis and treatment5,6. the number of ophthalmologists available in developing countries per patient are very few and are estimated as one per 200,000 patients in asia, showing increased workload on ophthalmologist7. open angle glaucoma is not curable, but can be treated and the primary aim of treatment is to prevent progressive loss of vision and blindness in patient’s life. another factor which further complicates the problem is poor adherence to glaucoma therapy. studies have shown that about 50% of patients with glaucoma do not comply with their medication over g imran ahmad, et al 25 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology 5% of the times8. the purpose of this study was to document the causes that lead to blindness due to open angle glaucoma in developing country like pakistan. material and methods it was retrospective cohort study conducted in the department of ophthalmology khyber teaching hospital, peshawar from september 2008 to december 2011. patients with diagnosed open angle glaucoma with blindness (visual acuity worse than 3/60) and cup to disc ratio more than 0.8 were enrolled in the study after taking well informed consent. patients with history of trauma, corneal opacity, cataract and patients with other retinal pathologies were excluded from the study to avoid biased in the study results. detailed history was taken from the patient including inquiry about use of ocular medications or ocular surgery followed by a comprehensive ocular examination including best corrected visual acuity, pupillary examination, tonometry, gonioscopy, central corneal thickness, visual fields, color vision and fundoscopy. other investigations including mri scan, hrt and oct were advised where required. once the diagnosis of open angle glaucoma was made, all data including information about previous consultation, compliance, drug types and misdiagnosis were recorded in proforma. results a total of 500 eyes of 338 patients with open angle glaucoma were included in the study. 272 eyes (54.4%) were of female patients and 228 eyes (45.6%) were of male patients (chart 1). out of 338 patients 122 (36.09%) patients were having bilateral involvement. 368 (73.60%) eyes were known glaucomatous whereas 132 (26.40%) were newly diagnosed cases of open angle glaucoma with advanced damage. out of 500 eyes 174 (34.8%) were having no perception of light whereas the remaining 326 were legally blind. mean age was 59.57 ± 16.2 years, but advanced glaucomatous damage was found in patients with advancing age. out of these 500 eyes 130 eyes (26%) were blind due to late presentation, as they consulted ophthalmologist for the first time. in 112 eyes (22.4%) the cause of blindness was failure of medication despite of good compliance. 96 (19.20%) eyes were legally blind due to poor compliance of the patient for prescribed drugs. 67 eyes (13.60%) were blind due to missed diagnosis, as these patients had consulted ophthalmologists but diagnosis of glaucoma had not been made. 53 eyes (10.6%) were advised surgery but they refused to go for surgery. in 42 eyes (8.4%) were diagnosed as glaucomatous and medications or surgery had been prescribed but due to nonaffordability they were unable to use medications or go for surgery (chart 2). 54.40% 45.60% female male chart 1: male / female percentage 22.4% 28% 15% 15.60% 8.40% 10.60% late presentation misdiagnosis poor compliance unaffordable refusal of surgery failure of medications chart ii. discussion as blindness from open angle glaucoma is irreversible, it is better to develop strategies to prevent blindness due to glaucoma which is treatable. in our study late presentation or consultation was found in 130 eyes (26%) which was the leading cause of blindness. by the time these patients presented there was advanced optic nerve damage and visual field loss. most of these patients were confusing their visual loss to be due to cataract rather than glaucoma because of poor health education or they were using alternative or traditional medicine. another reason for causes of blindness in patients with open angle glaucoma, an alarming situation pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 26 late presentation is poor socioeconic condition in developing countries. in a study done by akhtar f et al, also reported that late presentation is a cause of blindness in 30% of cases which is close to our results9. uncertain effectiveness of some medications to stop or prevent visual loss was the second common cause of blindness in our study, responsible for 22.40% of eyes which is alarming. it is because either the medications prescribed are ineffective or the type of glaucoma was resistant to the advised medication or the target iop was not achieved. it may be due to uncertain affectivity of some topical preparations as described in the study done by thomas r and his colleagues10. another challenge in glaucoma patients is to ensure drug compliance, as in our study 96 (19.20%) eyes were blind due to poor compliance, whereas in a study done by olthoff cm et al found the nonadherence in glaucoma patients to be 27.3%11. there is a strong link between drug adherence and basic health literacy in the developing world12. the reason for poor compliance is that patients were not well educated about the course and nature of the disease, importance of medications in prevention of visual loss, its continuation and regular follow-ups with tonometry and visual fields. 75 (15%) eyes visited an ophthalmologist but diagnosis of glaucoma were missed and decrease visual acuity was attributed to some other reason either because of increased work load on ophthalmologist or due to lack of specialized glaucoma training in our country. in barbados eye study same observations were made that many patients after visiting ophthalmologist, the diagnosis of glaucoma was missed13. in 8.40% of patients medications were prescribed but due to poor socioeconomic condition either they could not afford medication or have used medications for short period of time and then stopped its use. in a study from scotland, uk, demonstrated that regions which were more deprived economically had more advanced visual damage due to glaucoma14. in another study done by dandona r et al reported that in 12.8% of patients over the age of 50 years became blind due to poor socioeconomic status15. 53 (10.60%) eyes were advised surgical intervention but they refused to undergo surgical procedure, which resulted in progressive visual field loss. the main concerns for refusal of surgery were fear from surgery and fear of becoming blind almost similar to the observation made by adekoya bj and his colleagues where when surgery was advised 31.2% of patients refused to undergo surgical procedure, so they were offered medical treatment16. conclusion glaucoma blindness is a serious problem. late presentation, proper diagnosis, compliance, refusal of surgery and cost ratio can be managed with proper counseling, health education and tracing of health professionals but the main obstacle is failure of medications due to poor quality of some drugs which needs proper addressal. author’s affiliation dr. imran ahmad medical officer khyber teaching hospital peshawar dr. bakht samar khan assistant professor khyber teaching hospital peshawar dr. mubashir rehman medical officer lady reading hospital peshawar dr. muhammad rafiq senior registrar rehman medical instituate peshawar references 1. resnikoff s, pascolini d, etya’ale d, kocur i. global data on visual impairment in the year 2002. bull world health organ 2004; 82: 844-51. 2. foster pj, johnson gj. glaucoma in china: how big is the problem? br j ophthalmol. 2001; 85: 1277-82. 3. quigley ha, broman at. number of people with glaucoma worldwide. br j ophthalmol. 2006; 90: 262-7. 4. oliver je, hattenhauer mg, herman d, hodge do, kennedy r. blindness and glaucoma: a comparison of patients progressing to blindness from glaucoma with patients maintaining vision. am j ophthalmol. 2002; 133: 764-72. 5. cronemberger s, lourenco lf, silva lc, calixto n, pires mc. prognosis of glaucoma in relation to blindness at a university hospital. arq bras oftalmol. 2009; 72: 199-204. 6. garudadri c, senthil s, khana rc, rao hb. prevalence and risk factors for primary glaucomas in adult urban and rural populations in the andhra pradesh eye disease study. ophthalmology. 2010; 117: 1352–9. 7. thylefors b. a global initiative for the elimination of avoidable blindness. indian j ophthalmol. 1998; 46: 129-30. 8. okeke co, quigley ha, jampel hd, ying gs, plyler rj, jiang y, et al. adherence with topical glaucoma medication monitored electronically: the travatan dosing aid study. ophthalmology. 2009; 116: 191–9. 9. akhtar f, ali m. glaucoma related morbidity at a tertiary care hospital. ann king edward med uni. 2008; 14: 8-12. imran ahmad, et al 27 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology 10. thomas r, paul p, rao gn, muliyil jp, mathai a. present status of eye care in india. surv ophthalmol. 2005; 50: 85–101. 11. olthoff cm, hoevenaars jg, van den bw, webers ca, schouten js. prevalence and determinants of non-adherence to topical hypotensive treatment in dutch glaucoma patients. graefes arch clin exp ophthalmol. 2009; 247: 235-43. 12. hahn sr, friedman ds, quigley ha, kotak s, kim e, onofrey m, et al. effect of patient-centered communication training on discussion and detection of non-adherence in glaucoma. ophthalmology. 2010; 117: 1339–47. 13. hennis a, wu s, nemesure b, honkanen r, leske mc. barbados eye studies group. awareness of incident openangle glaucoma in a population study: the barbados eye studies. ophthalmology. 2007; 114: 1816–21. 14. ng ws, agarwal pk, sidiki s, mackay l, townend j, azuara blanco a. the effect of socioeconomic deprivation on severity of glaucoma at presentation. br j ophthalmol. 2010; 94: 85–7. 15. dandona r, dandona l. socioeconomic status and blindness. br j ophthalmol. 2001; 85: 1484-8. 16. adekoya bj, akinsola fb, balogun bg, baloun mm, obidapo oo. patient refusal of glaucoma surgery and associated factors in lagos, nigeria. middle east afr j ophthalmol. 2013; 20: 168-73. 66 pak j ophthalmol. 2021, vol. 37 (1): 66-69 original article frequency of convergence insufficiency in a refraction clinic of karachi izmal urooj 1 , shari mussadiq ali 2 , abdul ghayas 3 , ammara sheikh 4 , maryam hussain 1-5 isra school of optometry, isra university, karachi abstract purpose: to find out the frequency of convergence insufficiency in a refraction clinic of karachi. study design: cross sectional study. place and duration of study: al-ibrahim rye hospital, karachi from june to december 2019. methods: a total of 150 patients were included in the study (52 males and 98 females). patients with uncorrected visual acuity of ≥6/9 and age between 16 – 35 years were included. patients who had received treatment for convergence insufficiency (ci), mentally retarded patients, patients with manifest strabismus or any other ocular pathology were excluded. near point of convergence (npc), near phoria and positive fusional vergence (pfv) were measured for the diagnosis of ci. results: mean age of the patients was 23.55 years. gender wise distribution showed that 52 (34.7%) were males and 98 (65.3%) were females. out of 150 patients, 64 patients had ci and 42 were normal with no reduction in npc, pfv or exophoria. rest of the patients had only one of the three criteria of ci but did not qualify our definition of ci. twenty-five male patients and 39 female patients had ci. ci was more common in teenagers. with increasing age, the frequency of ci was reduced. ci due to remote npc was seen in 12 (8%) and ci due to decreased pfv was seen in 21 (14%). conclusion: females are affected more with ci than males especially in the younger age group. keywords: convergence insufficiency, near point of convergence, positive fusional vergence. how to cite this article: urooj i, talpur ah, ali sm, ghayas a, sheikh a. frequency of convergence insufficiency in a refraction clinic of karachi. pak j ophthalmol. 2021, 37 (1): 66-69. doi: https://doi.org/10.36351/pjo.v37i1.1131 introduction convergence insufficiency (ci) was first described by von graefein 1855 and later details were given by duane. 1 evans defined ci as a condition that involves the inability of the eyes to obtain or maintain sufficient convergence for comfortable binocular vision at near distance. 2 convergence insufficiency is a typical condition in young and aging adults and may be correspondence: izmal urooj isra school of optometry, isra university karachi email: izmalurooj@gmail.com received: september 16, 2020 accepted: november 12, 2020 isolated and idiopathic or associated with other neurologic diseases. 3 it can cause problem in reading, for which parents or teachers might think of the child having problem in learning rather than having an eye disorder. 4 it is characterized by exophoria that is greater at near than at distance, a remote near point of convergence (npc) or decreased positive fusional vergence (pfv) at near. 5 near visual tasks such as reading can prompt the symptoms of convergence insufficiency. if near work is continued for a long time, the symptoms are increased. extreme tiredness (fatigue) can also generate symptoms. the potential symptoms include; headache, double vision, eye fatigue, blurred vision, sleepiness when reading, needing to re-read things a few times, trouble concentrating on reading, words frequency of convergence insufficiency in a refraction clinic of karachi pak j ophthalmol. 2021, vol. 37 (1): 66-69 67 seem to move, jump, or float on the page, motion sickness and/or vertigo. some people may also observe moving of one eye outwards while reading. the person may close one eye while reading to avoid double vision. 6 young adults commonly present with ci despite the fact that it can be present almost at any age. although 1% of the general population presents with exodeviation, the incidence of ci is estimated to be 0.1 to 0.2% and 11 – 19% of children with exodeviation have ci. the prevalence of ci in the pediatric and young adults ranges from 2.25 to 8.3%. 7 the prevalence of convergence insufficiency in united states ranges from 2.25% to 8.30% in adults and children respectively. 8 a survey conducted in britain showed 1 in 300 children had ci, 9 and one in 100 of the symptomatic patients had ci in a study conducted in spain. 10 a study conducted in the romanian population showed that 3 in 5 (60.4%) adolescents who complained of blurred vision while performing near task had ci. 11 in iranian population ci was found to be 5.46%. 12 however, it was 16.5% and 17.6% in indian urban and rural arms, respectively. 13 with effective conservative therapies, prognosis of ci is excellent in most of the patients. in order to restore ci a small percentage of patients may require surgery. 14 the purpose of this study was to find out the frequency of convergence insufficiency in a refractive clinic of karachi. methods a cross sectional study with non-probability convenient sampling technique was conducted on 150 patients at al ibrahim eye hospital malir karachi during a span of 6 months to determine the frequency of convergence insufficiency. patients with uncorrected visual acuity greater than or equal to 6/9 and age between 16 – 35 years were included in the study and those having any ocular pathology or manifest strabismus were excluded from the study. after taking consent the patient’s history was taken. test performed included visual acuity, refraction, near point of convergence (measured using the raf ruler), exophoria at near (measured using maddox wing) and positive fusional vergence (measured with prism bar). those patients who had any two of the following criteria were regarded to have convergence insufficiency. npc > 10 cm, pfv < 15 prism diopter (base out) and exophoria > 4 prism diopters. statistical analysis was done from statistical package for social science (spss) version 20.0 all the continuous variables were presented as mean ± sd and the entire categorical data was presented as frequency and percentage. results mean age of the patients was 23.55 years. gender wise distribution showed that 52 (34.7%) were males and 98 (65.3%) were females. out of 150 patients, 64 (42.6%) patients had ci and 42 (28%) were normal with no reduced npc, pfv or exophoria. rest of the patients had only one of the three criteria of ci but did not qualify our definition of ci. twenty-five male patients and 39 female patients had ci. ci was more common in teenagers. with increasing age, the frequency of ci was reduced. ci due to remote npc was seen in 12 (8%) and ci due to decreased pfv was seen in 21 (14%). for details see table 1. table 1: parameter of convergence insufficiency with percentage. parameter percentage npc < 10cm 101 (67.3%) npc > 10cm 49 (32.7%) pfv < 15 prism diopters 82 (54.7%) pfv > 15 prism diopters 68 (45.3%) exophoria of < 4 prism diopters 98 (65.3%) exophoria > 4 prism diopters 52 (34.7%) discussion vergence anomalies have become more troublesome in the current times as computer usage and near tasks have increased over the past few decades. ci is the most predominant and treatable form of vergence anomaly. patients with ci develop ocular fatigue due to breakdown of binocular vision leading to asthenopia during near tasks. a study conducted in iran on the students of iran university of medical sciences showed that 10% of the students had ci disorder out of which 7.5% had ci and 2.5% were pseudo ci. 15 our percentage was quite higher than iranian study. another study that was conducted in india showed that 27.5% of the population had ci 16 and a study conducted in china showed ci to be present in 9.6% of the patients. 17 izmal urooj, et al 68 pak j ophthalmol. 2021, vol. 37 (1): 66-69 this study demonstrated that more ci patients displayed reduced npc and pfv than only reduced npc or pfv. ci due to remote npc was seen in 12 (8%) and ci due to decreased pfv was seen in 21 (14%). this contrasted with the findings of a previous study that was conducted in sudan in which 20.36% of students with ci had reduced npc and ci due to reduced pfv was seen in 1.22% of the students. 18 in this study ci was seen in 42.6% in which males were 25 (39%) and females were 39 (60.90%). a study conducted in mashhad city of iran showed that 5.51% of the population had ci out of which 4.78% was seen in males and 5.86% in females. this shows that females are affected more than male and also there is a large gap in the percentage of ci in both the studies. the discrepancies in the reported ci may be due to differences in the definition of ci (in this study ci was defined on 3 diagnostic criteria and the study mentioned above used 4 diagnostic criteria). the other reason could be the sample population. the study mentioned was a general population study and this study was a clinical study. the above study used cluster sampling but we used convenient sampling in our study. different methods of analysis and differences in testing protocols (in this study npc was measured using the raf ruler while the study mentioned used scale to measure the npc) can also be the reasons for difference in the results. as it is mostly symptomatic patients who present to clinics, such studies are expected to find higher rates compared to population‐based studies. 19,20 limitation of our study is that it was a clinic-based study. the results cannot be regarded as a true picture of general population. the sample size was small and it was a single-centered research. conclusion convergence insufficiency is quite high in patients presenting in the refraction clinic. females are affected more than males regarding ci. ethical approval the study was approved by the institutional review board/ethical review board. (rec/ipio/2020/008) conflict of interest authors declared no conflicts of interest. references 1. von graefe a. uber myopia in distansnebstbetrachtungen uber sehenjenseits der grenzenunserer (accommodation). graefes arch clin exp ophthalmol. 1855; 2: 158-166. 2. evans bj. decompensated exophoria at near, convergence insufficiency and binocular instability: diagnosis and the development of a new treatment regimen. in: evans b, doshi s, editors. binocular vision and orthoptics. oxford: butterworthheinemann; 2001: p. 39-49. 3. sassonov o, sassonov y, koslowe k, shneor e. the effect of test sequence on measurement of positive and negative fusional vergence. optometry and vision development, 2010; 41 (1): https://cdn.ymaws.com/www.covd.org/resource/resmgr/ ovd41-1/article_effecttestsequence.pdf 4. ghadban r, martinez jm, diehl nn, mohney bg. the incidence and clinical characteristics of adult-onset convergence insufficiency. ophthalmology, 2015; 122 (5): 1056-9. doi: 10.1016/j.ophtha.2014.12.010. 5. scheiman m, wick b. clinical management of binocular vision: heterophoric, accommodative and eye movement disorders 2014. philadelphia: lippincott, williams, and wilkins; 2014. 6. rouse mw, hyman l, hussein m, solan h. cirs group frequency of convergence insufficiency in optometry clinic settings. optom vis sci. 1998; 75: 88– 96. 7. gregory i, gappy c, monte ad, al-hashimi r. convergence insufficiency. https://eyewiki.aao.org/convergence_insufficiency#pre valence.c2.a0 (accessed 10 september 2019). 8. scheiman m, cooper j, mitchell gl, paul de l, cotter s, borsting e, et al. a survey of treatment modalities for convergence insufficiency, 2002; 79 (3): 151-157. https://pubmed.ncbi.nlm.nih.gov/11913841/ 9. stidwill d. epidemiology of strabismus. ophthalmic physiol opt. 1997; 17: 536-539. 10. lara f, cacho p, garcía a, megías r. general binocular disorders: prevalence in a clinic population. ophthalmic physiol opt. 2001; 21: 70-74. 11. dragomir m, truş l, chirilă d, stîngu c. orthoptic treatment efficiency in convergence insufficiency treatment. oftalmologia 2001; 53: 66-69. 12. hashemi h, nabovati p, khabazkhoo m, ostadimoghaddam h, doostdar a, shiralivand e, et al. the prevalence of convergence insufficiency in iran: a population-based study, 2017; 100 (6): 704-709. 13. hussaindeen jr, rakshit a, singh nk, george r, swaminathan m, kapur s, et al. prevalence of nonstrabismic anomalies of binocular vision in tamil nadu: report 2 of band study, 2017; 100 (6): 642648. https://cdn.ymaws.com/www.covd.org/resource/resmgr/ovd41-1/article_effecttestsequence.pdf https://cdn.ymaws.com/www.covd.org/resource/resmgr/ovd41-1/article_effecttestsequence.pdf frequency of convergence insufficiency in a refraction clinic of karachi pak j ophthalmol. 2021, vol. 37 (1): 66-69 69 14. wallace dk. treatment options for symptomatic convergence insufficiency. arch ophthalmol. 2008; 126 (10): 1455-1456. 15. sharif z, mirzajani a, jafarzadehpur e. prevalence of convergence insufficiency in a population of university students. j paramed sci rehab. 2014; 3 (1): 47-52. 16. vaishali rs, jha kn, srikanth k. prevalence of convergence insufficiency between 18 and 35 years and its relation to body mass index. j ophth sci res. 2019; 57 (1): 27-30. 17. ming-leung m, yeo ac, scheiman m, chen x. vergence and accommodative dysfunctions in emmetropic and myopic chinese young adults. hindawi j ophthalmol. 2019; 5904903. https://doi.org/10.1155/2019/5904903 18. hassan li, ibrahim sm, abdu m, sharif am. prevalence of convergence insufficiency among secondary school students in khartoum, sudan. oman j ophthalmol. 2018; 11 (2): 129-133. 19. hashemi h, nabovati p, khabazkhoob m, ostadimoghaddam h, doostdar a, shiralivand e, et al. the prevalence of convergence insufficiency in iran: a population-based study, 2017; 100 (6): 704-709. 20. ghadban r, martinez jm, diehl nn, mohney bg. the incidence and clinical characteristics of adult-onset convergence insufficiency. ophthalmology, 2015; 122 (5): 1056-9. doi: 10.1016/j.ophtha.2014.12.010. authors’ designation and contribution izmal urooj; senior lecturer: concepts, design, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. shari mussadiq ali; optometrist: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. abdul ghayas; optometrist: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing. ammara sheikh; optometrist: design, literature search, data acquisition, data analysis, manuscript preparation. maryam hussain; optometrist: design, literature search, data acquisition, manuscript preparation .…  …. https://doi.org/10.1155/2019/5904903 88 pak j ophthalmol. 2021, vol. 37 (1): 88-91 original article visual outcome after sutureless scleral fixation of intraocular lens muhammad sajid munir 1 , muhammad ramzan 2 , muhammad arshad 3 , shahid nazir 4 muhammad rizwan ullah 5 1-2 niazi medical and dental college sargodha, 3 bahawal victoria hospital, bahawalpur 4 red cresent medical and dental college, kasur, 5 postgraduate medical institute ameer-ud-din medical college pgmi lahore general hospital, lahore abstract purpose: to study the results of sutureless scleral fixation of intraocular lens (iol) in cases of complicated cataract surgery. study design: interventional case series. place and duration of study: niazi medical and dental college sargodha from jan 2018 to dec 2019. methods: twenty-five eyes of 25 consecutive patients were selected for this study. patients of traumatic cataract with zonular dehiscence, patients who had per-operative complications like pc rent with insufficient capsular bag, and children with subluxated lens of marfan, ehler danlos syndrome were included in this study. after routine investigation all patients were operated under local anesthesia except children, who were operated under general anesthesia. sclerotomies were made at 3 and 9 o’clock positions with mvr blade. sutureless scleral fixation of intraocular lens was done. the haptics of lenses were buried in the scleral pockets which were already made at 3 and 9 o‘clock position. post-operative antibiotics and steroids were given for 8 weeks and patients were followed up for two years. results: out of 25, 18 (72%) female patients and 7 (28%) male patients underwent surgery. most of the patients had previous surgical complications of posterior capsular rent 15 (60%). four (16%) patients had eye trauma, three had lens subluxation for pseudo-exfoliation and 3 patients (children) were suffering from marfan syndrome. seventy-two percent patients had visual acuity of more than 6/18, 16% had 6/18 to 6/24 and 12% had 6/24 to 6/60. conclusion: properly done suture-less scleral fixation is a safe technique with little chance of iol dislocation. key words: scleral fixation, intraocular lens, cataract. how to cite this article: munir ms, ramzan m, arshad m, nazir s, ullah mr. visual outcome after sutureless scleral fixation of intraocular lens (iol). pak j ophthalmol. 2021, 37 (1): 88-91. doi: https://doi.org/10.36351/pjo.v37i1.1141 correspondence: muhammad ramzan department of ophthalmology niazi medical and dental college sargodha email: mroph1998@gmail.com received: september 29, 2020 accepted: november 15, 2020 introduction cataract is the major cause of preventable blindness all over the world. most of the cataract surgeries are uneventful and can be managed easily. in some cases, complications may occur; for example, posterior capsular rent, accidental intracapsular extraction and weak zones in pseudo exfoliation. 1 we need to modify different techniques for iol implantation in such cases. each year approximately 18 million people suffer from ocular trauma worldwide. 2 traumatic mailto:mroph1998@gmail.com visual outcome after suture less scleral fixation of intraocular lens pak j ophthalmol. 2021, vol. 37 (1): 88-91 89 cataract, lens dislocation and loss of phakic lens are the most common sequelae of ocular trauma. marfan syndrome, ehler danlos syndrome, stickler syndrome where lens subluxation is common, aphakia is not a desirable long-term option. to treat such conditions multiple options like anterior chamber intraocular lens (ac iol) implantation, iris fixed intraocular lens and scleral fixation of iol with 10/0 prolene are still considered good alternatives. 3,4 the ac iol and iris fixed iols are almost discouraged because of their post-operative complications. ac iols cause corneal decompensation and glaucoma while iris fixed iols cause chronic cystoid macular edema and iris chafing in most patients. the risk of all these above complications are much less in cases of scleral fixation iols. this can be performed as either a primary or a secondary procedure. 5,6 however, in case of scleral fixed iol with 10/0 prolene suture breakage, exposure of suture knot causing inflammation and a grave complication like drop of iol after 8 to 10 years are reported complications. 7,8 in order to reduce these problems, suture-less scleral fixation is an excellent technique which has maximum advantages and minimum disadvantages. 9 we carried out this case series to find out the visual and anatomical outcomes of suture-less scleral fixation of iol in a tertiary care hospital. methods the study was conducted at niazi medical and dental college sargodha from jan 2018 to dec 2019. twenty-five patients were selected on the basis of non-probability convenience sampling method. patients of traumatic cataract with zonular dehiscence, patients of per operative complications like pc rent with insufficient capsular bag, and children with subluxated lens of marfan, ehler danlos syndrome were included in this study. after routine investigation all patients were operated under local anesthesia except children, who were operated under general anesthesia. after application of povidone iodine and draping, we marked the 3 and 9 o‘clock positions. peritomy was done and sclerotomy sites were marked 2 mm behind the limbus. intra-scleral tunnels of 2 mm length and 50% of scleral thickness, were fashioned with 3.2 mm slit knife in anti-clock and clock wise movement at 3 and 9 o’clock positions respectively. an ac maintainer was inserted at anterior limbus. 25 g mvr (micro vitreo-retinal) blade was used to create full thickness sclerotomies parallel to the limbus at 3 and 9 o’clock. in our study we used alcon ma 60 model (alcon acrysof) intraocular lens. we made two side ports at 10 and 2’o clock position of eye. from one side port we injected intraocular lens and grasped its front haptic with 25-g iol gripping forceps and pulled out through sclerotomy at 3 o’clock. the trailing haptic, which was left outside was grasped with 25-g lens forceps, fed to the second instrument, inside the anterior chamber and pulled out through the sclerotomy at 9 o’clock. we buried both ends in the pockets at 3 and 9 o‘clock position. peritomies were closed with 10/0 nylone suture. post-operative antibiotics and steroids were given for 8 weeks. results in our study most of the patients were females. out of 25, there were 18 (72%) female patients and 7 (28%) male patients. there were different indications for suture-less fixation of iol. most of the patients had previous surgical complications of pc rent 15 (60%), 4 (16%) patients had eye trauma, 3 patients had lens subluxation caused by pseudo-exfoliation and 3 patients who were children had marfan syndrome. the complications related with this procedure are shown in table 1. most of the patients achieved good visual acuity according to who criteria as shown in table 2. table 1: early complications no of patients % transient corneal edema 5 20 mild vitreous hemorrhage 4 16 transient elevated iop 2 8 normal post operative patients 14 56 late complications cystoid macular edema 2 20 table 2: post-operative visual outcomes. visual acuity no of patients 6/6 to 6/12 3 (12%) 6/12 to 6/18 15 (60%) 6/18 to 6/24 4 (16%) 6/24 to 6/60 3 (12%) muhammad sajid munir, et al 90 pak j ophthalmol. 2021, vol. 37 (1): 88-91 discussion suture-less scleral fixation is a unique advancement in complicated cataract surgeries. different surgeons describe this technique in different ways. 10 our technique is very simple, needs less instrumentations and time saving. it is far superior technique than scleral fixation with sutures. sutures induce inflammation due to erosion. other associated complications like suture breakage, subluxation and decentration of iol are not seen in this technique. otha t reported dislocation of sutured iol after 10 years in 99% of eyes. 11 in our study, marfan syndrome eyes with subluxated lenses were operated with this technique with good results. similarly, wilguckie et al performed sutureless scleral fixation and reported long-term stability and absence of suture associated decentrations. 12 they described this technique as safe with long term stability and durability because haptics were incarcerated in the scleral tunnel giving it support for whole life. 12 however, gabor and pavlidis’ technique of inserting the iol haptic into the scleral tunnel was not easy because of proximity of sclerotomy and scleral tunnel. 13 in our study we made large and wide tunnels for easy haptic entry and positioning. in our study, the results were encouraging regarding early and late complications of surgery and final visual acuity. development of mild corneal edema in 5% eyes was due to second surgery after the first complicated procedure. another complication was mild vitreous haemorrhage which occurred as a result of iol and instrument manipulation during the procedure like pulling out iol haptic through sclerotomies. it was resolved usually after one to two weeks. these were transient and manageable complications encountered in our study. kim ss and gabor and totan y reported same kind of complications in their studies. 14,15,16 haszcz et al considered it a long term stable iol implantation technique. 17 visual results are also superior to anterior chamber iol because this technique restores iol to its probable anatomical position. 17 several new techniques including a trocar assisted, a suture-less 27g needle guarded, a y-fixation intrascleral iol implantation technique and yamane technique are recently reported. 18,19,20 our technique gives us an opportunity to implant iol with minimal manipulation and instrumentation. limitations of this case series is the small sample size and only two years follow up. further multi-center trials with quasi experimental study designs are needed to prove its superiority. conlusion sutureless scleral fixation technique is simple, less time consuming and lifelong particularly in aphakic and syndromic children. it is without the problems related with sutures and iol is close to its anatomical position. so, the chance of long term complications is less. ethical approval the study was approved by ethical review board of institution. (nmdc/993/20) conflict of interest author declared no conflict of interest. references 1. mcallister as, hirst lw. visual outcomes and complications of scleral-fixation posterior chamber intraocular lenses. j cataract refract surg. 2011; 37: 1263-1269. 2. agarwal a, kumar da, nair v. cataract surgery in the setting of trauma. curr opin ophthalmol. 2010 jan;21(1):65-70. 3. gabor sg, pavlidis mm. sutureless intrascleral posterior chamber intraocular lens fixation. j cataract refract surgery, 2007; 33: 1851-1854. 4. kim ej, brunin gm, al-mohtaseb zn. lens placement in the absence of capsular support: scleralfixated versus iris-fixated iol versus aciol. int ophthalmol clin. 2016 summer;56(3):93-106. 5. kumar da, agarwal a, prakash d, prakash g, jacob s, agarwal a. glued intrascleral fixation of posterior chamber intraocular lens in children. am j ophthalmol. 20012; 153: 594-601. 6. totan y, karadag r. trocar-assisted suture-less intrascleral posterior chamber foldable intra-ocular lens fixation. eye, 2012; 26: 788-791. 7. price mo, price fw jr, werner l, berlie c, mamalis n. late dislocation of scleral-sutured posterior chamber intraocular lenses. j cataract refract surg. 2005 jul;31(7):1320-6. 8. scharioth gb, prasad s, gerogalas i, tataru c, pavlidis m. intermediate results of suture-less intrascleral posterior chamber intraocular lens fixation. j cataract refract surg. 2010; 36: 254-259. visual outcome after suture less scleral fixation of intraocular lens pak j ophthalmol. 2021, vol. 37 (1): 88-91 91 9. yamane s, inoue m, arakawa a, kadonosono k. sutureless 27 guage needle -guided intrascleral lens implantation with lamellar scleral dissection. ophthalmology, 2014; 121: 61-66. 10. gabor sg, pavlidis mm. sutureless intrascleral posterior chamber intraocular lens fixation. j cataract refract surg. 2007; 33: 1851-1854. 11. otha t, toshida h, murakami a. simplified and safe method of sutureless intrascleral posterior chamber intraocular lens fixation: y fixation technique. j cataract refract surg. 2014; 40: 2-7. 12. wilgucki jd, wheatley hm, feiner l, ferrone mv, prenner jl. one year outcomes of eyes treated with a suture-less scleral fixation technique for intraocular lens placement or rescue. rerina, 2015; 35: 1036-1040. 13. gabor sg, pavlidis mm. suture-less intra-scleral posterior chamber intraocular lens fixation j cataract refract surg. 2007; 33: 1851-1854. 14. kim ss, smiddy we, feuer w, shi w. management of dislocated intraocular lenses. ophthalmology, 2008; 115 (10): 1699-1704. 15. totan y, karadag r. two techniques for sutureless intrascleral posterior chamber iol. j refract surg. 2013; 29 (2): 90-94. doi: 10.3928/1081597x-20130117-02. 16. takayama k, akimoto m, taguchih, nakagawa s, hiroi k. transconjunctival sutureless intrascleral intraocular lens fixation using intrascleral tunnels guided with catheter and 30-guage needle,” br j ophthalmol. 2015; 99 (11): 1457-1459. 17. haszcz d, nowemiejska k, oleszczuket a. visual outcomes of posterior chamber intraocular lens intrascleral fixation in the setting of postoperative and posttraumatic aphakia. bmc ophthalmology, 2016; 16 (1): 50. 18. hu z, lin hs, ye l, lin z, chen t, lin k, et al. sutureless intrascleral haptic-hook lens implantation using 25-gauge trocars. j ophthalmol. 2018; 9250425. 19. por ym, lavin mj. techniques of intraocular lens suspension in the absence of capsular/zonular support. surv ophthalmol. 2005; 50: 429469. 20. yamane s, ito a. flanged fixation: yamane technique and its application. curr opin ophthalmol. 2021 jan; 32 (1): 19-24. authors’ designation and contribution muhammad sajid munir; associate professor: concepts, design. muhammad ramzan; professor: literature search, data acquisition. muhammad arshad; assistant professor: data analysis, statistical analysis. shahid nazir; associate professor: manuscript preparation, manuscript editing. muhammad rizwan ullah; associate professor: manuscript review. .…  …. https://pubmed.ncbi.nlm.nih.gov/?term=hiroi+k&cauthor_id=25855502 https://pjo.org.pk/index.php/pjo/workflow/access/1084 https://pjo.org.pk/index.php/pjo/workflow/access/1084 https://pjo.org.pk/index.php/pjo/workflow/access/1084 391 pak j ophthalmol. 2020, vol. 36 (4): 391-395 original article manual sutureless cataract surgery (mscs) in patients with pseudo-exfoliation yasir iqbal 1 , qaim ali khan 2 , sohail zia 3 , muhammad usman arshad qureshi 4 , masud-ul-hassan 5 1 watim medical college, rawat, rawalpindi 2 poonch medical college, rawalakot, 3-5 ripah international university, islamabad abstract purpose: to document the complications of manual suture-less cataract surgery in eyes with pseudo-exfoliation. study design: interventional case series. place and duration of study: naseer memorial hospital, dadyal, azad jammu kashmir, from 4 july 2017 to 3 july 2019. methods: one hundred and fifty patients with pseudo-exfoliation (pex) and cataract were selected by convenient sampling. patients with systemic diseases, history of trauma, intraocular pressure ≥15 mm hg on applanation tonometry and any other associated ocular disease for example retinal detachment or retinal disease, previous history of glaucoma or narrow/closed angle on gonioscopy were excluded from the study. dark brown cataracts were also excluded. pseudo-exfoliation was diagnosed on slit lamp on the basis of presence of dandruff like material on the pupil and the anterior lens capsule. the patients underwent manual suture less cataract surgery under local anesthesia intraoperative and post-operative complications were noted. first day postoperatively. the collected data and analyzed using statistical package for social sciences (spss) version 21 for analysis. results: the study group consisted of 64% males and 36% females with mean age of 65 ± 15.32 years. the most common difficulty encountered was poor pupil dilatation in 37.3% cases followed by zonular dehiscence in 7.3%. on the first post-operative day, the most common complication was intraocular lens decentration in 2.6% of the cases. conclusion: pupils of patients with pseudo-exfoliation dilate poorly and makes surgery difficult. w ith good pupillary dilatation, careful capsulorhexis and minimal stress on the zonules, mscs can be safely performed in eyes with cataract and pex. key words: pseudo-exfoliation, cataract, pupil. how to cite this article: iqbal y, khan qa, qureshi mua, hassan m. manual sutureless cataract surgery (mscs) in patients with pseudo-exfoliation. pak j ophthalmol. 2020; 36 (4): 391-395. doi: https://doi.org/10.36351/pjo.v36i4.1097 introduction pseudo-exfoliation (pex) is an ocular condition in which a grey white fibrillar material appears on the correspondence: yasir iqbal department of ophthalmology watim medical college, rawat, rawalpindi email: yazeriqbal@gmail.com received: july 8, 2020 accepted: august 18, 2020 pupil, anterior lens surface, trabecular meshwork and anterior hyloid. pex is an extracellular material produced by abnormal aging cells epithelium and has been seen in other visceral organs and skin which suggests that it is a systemic disease. 1 deposition of pex material leads to clogging of the trabecular meshwork which causes increase in intraocular pressure and secondary open angle glaucoma. 2 globally the prevalence of pex is variable i.e. ethiopia 39.3%, greece 28%, turkey 16.7%, indian manual sutureless cataract surgery in patients with pseudo-exfoliation pak j ophthalmol. 2020, vol. 36 (4): 391-395 392 occupied kashmir 26.3% and in pakistan it is reported to be 8%. 3 pex is usually present in the old age group and it is the old age group in which cataract is also coomon. 4 cataract surgery is the most common ocular surgery being performed in all ophthalmic departments. recent estimates are that 94 million people are visually impaired and 20 million are blind due to cataract worldwide and this number is increasing with every passing day. 5 cataract can be normal age related or it can secondary either due to trauma, drugs, ocular causes or systemic diseases. whatever the cause, the only available treatment of cataract is surgery with implantation of intraocular lens. ophthalmic surgery and especially cataract surgery is undergoing advancement day by day. conventional extracapsular cataract extraction (ecce) has become almost obsolete and surgeons have shifted to phacoemulsification and manual sutureless cataract surgery (mscs). 6 phacoemulsification has a good quick visual recovery time, less intraocular inflammation and less postoperative astigmatism and is normally present in all tertiary care hospitals in the western world. the technique of mscs, although developed much later than phacoemulsification, has become a frequent procedure for cataract surgery in the developing world because of its cost effectiveness and low socioeconomic status of the masses. 6 techniques of cataract surgery are being customized in patients with pex but no particular technique has been demonstrated to be completely safe and without complications. limited information exists about problems and complications of performing mscs in pex. therefore, we aimed to document complications of performing mscs in eyes with pex. methods it was an interventional case series conducted at naseer memorial hospital, dadyal, azad jammu kashmir during period of two years from 4 july 2017 to 3 july 2019. the study was conducted according to the guidelines of declaration of helsinki. the patients were allotted the medical registration number before the initiation of study. they underwent complete eye examination including visual acuity assessment, pupil examination, slit lamp examination, intraocular pressure measurement and detailed fundoscopy. one hundred and fifty patients were selected by using convenient sampling. pex was diagnosed on slit lamp on the basis of presence of fibrin like material on the pupil of the lens surface. the inclusion criterion was any age and gender, presence of pseudo-exfoliation along with cataract and intraocular pressure ≤14 mm of hg. exclusion criteria were systemic disease, history of trauma, intraocular pressure ≥15 mm hg on applanation tonometry and any associated ocular disease like retinal detachment or retinal disease, previous history of glaucoma or narrow/closed angle on gonioscopy. dark brown cataracts were also excluded because of more chances of per-operative complications. the operative procedure and its complications were explained to the patients before the surgery and they signed written consent form. demographic information and eye to be operated were recorded. the patients underwent manual sutureless cataract surgery under local anesthesia by a single surgeon having expertise in the procedure. one hour before the start of the surgery, tropicamide 2% and phenylephrine eye drops were instilled. pupillary dilatation was measured under an operating microscope with a caliper. any pupillary dilatation < 5 mm was considered to be poor pupillary dilatation. before the initiation of the surgery, 5% iodine was instilled in the conjunctival sac after draping the eye. at the temporal side the conjunctiva was undermined while cauterizing the bleeding vessels. using a 3.2 mm keratome, a partial thickness 6-6.5 mm curved scleral incision was made 2 mm behind the limbus. a tunnel was constructed and was extended 1 mm into the corneal stroma. an internal corneal incision was made for entry into the anterior chamber and was extended 0.5mm more than the external incision. capsulorhexis was done with the help of a cystitome made by bending 1cc syringe and filling of anterior chamber with viscoelastic substance. nucleus was rotated, picked up by the cystitome, displaced into the anterior chamber and expressed through the corneoscleral tunnel with the help of viscoelastic. lens matter was removed by irrigation/aspiration cannula and intraocular lens was implanted. a sub-conjunctival injection of antibiotic/ steroid was given and the eye was padded for 24 hours. intraoperative complications, if any, were documented on the proforma and the surgical technique was modified according to the complication. the patients were followed up on the first postoperative day and complications, if any, were recorded on the proforma. data was analyzed using statistical yasir iqbal, et al 393 pak j ophthalmol. 2020, vol. 36 (4): 391-395 package for social sciences (spss) version 21 for analysis. results during the period of 2 years, 2457 patients were diagnosed and advised for cataract surgery. pex was found in 8% (197 cases). in 78% cases, it was bilateral. pex was found on pupil in 72% cases and on the anterior lens capsule in 28% cases. mean intraocular pressure was 18.63 ± 3.85 mm of hg. during the study period, 1382 cataract surgeries were performed but after fulfilling the inclusion and exclusion criteria 150 patients were selected for the study. the study group consisted of 64% males and 36% females having mean age of 65 ± 15.32 years respectively. during surgery, difficulty was encountered in 58.6% of the cases. the common difficulty encountered was poor pupil dilatation, which was seen in 37.3% cases (table 1). 19.3% of the patients required pupillary sphincterotomy for nucleus delivery. posterior capsular rupture occurred in 5.3%, 4% cases were converted to extracapsular cataract extraction and 2.6% were implanted with anterior chamber iol. on the first post-operative day, residual lens matter was noted in 2.6% of the study group. other complications are shown in table 2. table 1: intraoperative complications of mscs in eyes with pex. complications n = 150 poor pupil dilatation 56 (37.3%) zonular dehiscence 11 (7.3%) posterior capsular rupture with vitreous prolapse 8 (5.3%) conversion to extracapsular extraction 6 (4%) anterior chamber iol implantation 4 (2.6%) button hole 1 (0.6%) nucleus drop 1 (0.6%) iridodialysis 1 (4%) total 88 (58.6%) table 2: early postoperative complications of mscs in eyes with pex. complications n = 150 residual lens matter 4 (2.6%) iol decentration 4 (2.6%) up drawn pupil with vitreous in anterior chamber 3 (2%) shallow anterior chamber 2 (1.3%) discussion incidence of pseudo-exfoliation has been reported from 1.87% to 21% in different ethnicities but researchers have concluded that the frequency of pex increases with increasing age. 4 rao et al reported in their study that 75% of pex patients were of 70 years and above. 7 he found that pex prevalence was 2.6% in less than 70 years but increased to 13.04% after 70 years. yalaz et al reported incidence of pex in 11.2% after 60 years. 8 similarly in an epidemiological study, erkayhan et al found pex in mean age of 74.64 ± 6.88 years. 9 in our study, pex was seen in 8% of the patients and more after 60 years of age. in our study, male to female ratio was 16:9. there are conflicting reports about sex predilection of pex in literature. some researchers have shown male preponderance 10 while arvind et al 11 showed no sex predilection. 10,11 avramides reported a female preponderance. 12 literature shows that cataract surgery in pex is a challenging procedure as the pex material is deposited on the lens, the trabecular meshwork and the pupil leading to frequent problems during cataract surgery. this comprises of intraoperative complications like corneal edema, zonular weakness and posterior capsule dehiscence with vitreous loss. the most frequent reported intraoperative problem is non-dilating or poorly dilating pupil despite instillation of strong mydriatics. islam et al 3 reported that 75% of pex patients had poorly dilating pupil whereas erkayhan et al 9 reported 8.98% eyes with poor pupil dilatation. we also found a significantly high rate of poorly dilating pupils in our study. in eyes with pex signs of zonular instability like lens subluxation, zonular dialysis, iridodonesis or phacodonesis should be looked for pre-operatively to avoid intraoperative complications. 3,4 this zonular instability along with poor dilating pupil make capsulorhexis difficult and there are more chances of posterior capsule rupture and vitreous loss. erkayhan et al 9 reported a high rate of zonular dialysis, posterior capsular rupture and vitreous loss in pex eyes as compared to controls (12.5% vs. 3.4%). islam et al 3 did not report such high rates of such complications in pex. katsimpris et al reported that posterior capsular rupture occurred in 4.2% of patients who underwent phacoemulsification and in 17% who were operated using extracapsular cataract extraction procedure. 13 according to him there was a higher rate of vitreous manual sutureless cataract surgery in patients with pseudo-exfoliation pak j ophthalmol. 2020, vol. 36 (4): 391-395 394 loss (17% vs. 4.2%) in extracapsular cataract surgery compared to phacoemulsification but we did not find such high frequency using mscs. katsimpris et al recommended that in the presence of zonular weakness careful capsulorhexis should be done and nucleus delivery should be carried out either by doing sphincterectomy or by using iris hooks or retractors. 13 furthermore, in order to prevent posterior capsular rupture and vitreous loss in the event of non-dilating pupil, mscs can be converted into extracapsular cataract extraction and visual restoration can be done by intraocular lens implantation either in the sulcus or the anterior capsular rim and even anterior chamber iol implantation is possible. 14 in our study, 4% of the cases were converted to extracapsular extraction due to posterior capsular rupture. intraoperative complications of mscs reported from previous studies were hyphema and iridodialysis. 3 we also came across per-operative complications but hyphema was not found in our study. postoperative striate keratopathy and iritis in cataract surgery occurs due to unwarranted intraoperative manipulations and prolong surgery time. islam et al 3 reported iritis in 11.91% of his cases and 4.49% corneal decompensation in his study after performing cataract surgery in pex. gogate found corneal striate in 7% cases. 15 venkatesh 16 had 2% cases of postoperative corneal edema. in our study we found none in our study. in mscs, proper wound integrity is to be maintained at the conclusion to prevent shallow anterior chamber. on the first post-operative day, we found shallow anterior chamber in 1.3% of our cases similar to the study conducted in rawalpindi which reported it in 1.6% cases. 6 a high frequency of postoperative intraocular lens decentration was reported in pex by shingleton bj et al 17 but we found it in 2.6% of our cases. there are some suggestions to minimize the peroperative problems while performing cataract surgery in pex eyes. fontana l et al 18 suggested that sufficient pupil dilation is achievable using a viscoelastic with more dispersion properties or by using iris hooks and pupillary rings. similarly hosseini h et al 19 recommended the use of trypan blue in pex eyes for good staining of the anterior capsule to minimize stress on the zonules during capsulorhexis. for the support of zonular dehiscence and the capsular bag use of capsular tension ring (ctr) has been recommended by haripriya a et al. 20 limitations of our study was that it was a hospital based study which does not truly represent the whole population. secondly, the preoperative and postoperative visual acuity was not compared. we did not perform corneal pachymetry and did not consider intraocular pressure as a confounding factor. despite these short-comings this study provides a road map to safety of mscs in pex cataract surgery. conclusion we observed that due to poor pupillary dilatation in pseudoexfoliation, caution should be taken during surgery to minimize capsular rupture. however, with good pupillary dilatation, careful capsulorhexis and minimal stress on the zonules, mscs can be safely performed in eyes with cataract and pex. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. brajković j, kalauz-surać i, ercegović a, miletićjurić a, sušić n, burić ž. ocular pseudoexfoliation syndrome and internal systemic diseases. acta clinica croatica. 2007; 46 (1-supplement 1): 57-61. 2. kounsar h, shaheen n, rather sr. epidemiology of pseudoexfoliation syndrome: a hospital based comparative study. int j res med sci. 2018; 6 (4): 1314. 3. islam mn, goswami s, khanam bsm, mukherji s. complications of cataract surgery in patients with pseudoexfoliation syndrome in a tertiary care hospital of west bengal. int j sci stud. 2017; 5 (3): 11-15. 4. pranathi k, magdum rm, maheshgauri r, patel k, patra s. a study of complications during cataract surgery in patients with pseudoexfoliation syndrome. j clin ophthalmol res. 2014; 2 (1): 7. 5. song p, wang h, theodoratou e, chan ky, rudan i. the national and subnational prevalence of cataract and cataract blindness in china: a systematic review and meta-analysis. j glob health, 2018; 8 (1): 010804. yasir iqbal, et al 395 pak j ophthalmol. 2020, vol. 36 (4): 391-395 6. iqbal y, zia s, baig mau. intraoperative and early postoperative complications of manual sutureless cataract extraction. j coll physicians surg pak. 2014; 24 (4): 252-255. 7. rao rq, arain tm, ahad ma. the prevalence of pseudoexfoliation syndrome in pakistan. hospital based study. bmc ophthalmology, 2006; 6 (1): 27. 8. yalaz m, othman i, nas k, eroğlu a, homurlu d, cikintas z, et al. the frequency of pseudoexfoliation syndrome in the eastern mediterranean area of turkey. acta ophthalmol (copenh), 1992; 70: 209-213. 9. erkayhan ge, dogan s. cataract surgery in patients with pseudoexfoliation syndrome. eurasian j med. 2017; 49: 22-25. 10. naik au, gadewar sb. visual outcome of phacoemulsification versus small incision cataract surgery in pseudoexfoliation syndrome–a pilot study. j clin diagn res. 2017; 11 (1): 5. 11. arvind h, raju p, paul pg, baskaran m, ramesh sv, george rj, et al. pseudoexfoliation in south india. br j ophthalmol. 2003; 87: 1321-1323. 12. avramides s, traianidis p, sakkias g. cataract surgery and lens implantation in eyes with exfoliation syndrome. j cataract refract surg. 1997; 23: 583-587. 13. katsimpris jm, petropoulos ik, apostolakis k, feretis d. comparing phacoemulsification and extracapsular cataract extraction in eyes with pseudoexfoliation syndrome, small pupil, and phacodonesis. klin monbl augenheilkd. 2004; 221 (05): 328-333. 14. gimbel hv, sun r, ferensowicz m, penno ea, kamal a. intraoperative management of posterior capsule tears in phacoemulsification and intraocular lens implantation. ophthalmology, 2001; 108 (12): 2186-2189. 15. gogate pm. small incision cataract surgery: complications and mini-review. indian j ophthalmol. 2009; 57: 45-49. 16. venkatesh r, das m, prasanth s, muralikrishnan r. manual small incision cataract surgery in eyes with white cataracts. indian j ophthalmol. 2005; 53: 173176. 17. shingleton bj, neo yn, cvintal v, shaikh am, liberman p, o'donoghue mw. outcome of phacoemulsification and intraocular lens implantion in eyes with pseudoexfoliation and weak zonules. acta ophthalmol. 2017; 95 (2): 182-187. 18. fontana l, coassin m, iovieno a, moramarco a, cimino l. cataract surgery in patients with pseudoexfoliation syndrome: current updates. clin ophthalmol. 2017; 11: 1377. 19. hosseini h, nowroozzadeh mh, razeghinejad mr, ashraf h, salouti r, ashraf mj. anterior lens capsule has more affinity to trypan blue in patients with pseudoexfoliation. eye, 2011; 25 (9): 1245-1246. 20. haripriya a, ramulu py, schehlein em, shekhar m, chandrashekharan s, narendran k, et al. the aravind pseudoexfoliation study (apex): 5-year postoperative results. the effect of iol choice and capsular tension rings. am j ophthalmol. 2020. doi: 10.1016/ j.ajo.2020.06.031. authors’ designation and contribution yasir iqbal; associate professor: concepts, design, manuscript preparation, manuscript review. qaim ali khan; associate professor: design, literature research, manuscript editing. sohail zia; associate professor: literature research, data analysis, manuscript editing. muhammad usman arshad qureshi; senior registrar: data acquisition, data analysis, manuscript editing. masud-ul-hassan; consultant ophthalmologist: concepts, statistical analysis, manuscript editing. .…  …. https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=ero%c4%9flu+a&cauthor_id=1609569 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=homurlu+d&cauthor_id=1609569 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=cikintas+z&cauthor_id=1609569 microsoft word 24. javeria nasir mm pakistan journal of ophthalmology, 2020, vol. 36 (3): 305-307 305 author communication persistent lower lid swelling in an infant – impacted foreign body! javeria nasir1, anum javed2, mohammad owais arshad3, mohammad hanif chatni4 1-4department of ophthalmology patel hospital, karachi abstract ophthalmologists, including general practitioners definitely encounter ocular foreign bodies in their clinics. the conjunctival fornices are potential sites of impaction. we report a case of a 9-month infant boy who was referred to us for a persistent lower lid swelling for one month. he had already been to an eye specialist before presenting to us. upon examination, a round, pink coloured, toy cart-wheel came out of his lower eye lid of the right eye. surprisingly, there was no associated conjunctival or adnexal damage. the authors wish to emphasize the importance of taking a thorough history and adequate general physical examination. a missing part of a toy, elucidated on history, should always raise the suspicion among parents and/or care givers for a probable foreign body in infants and children. key words: foreign body, ocular trauma, eyelid. how to cite this article: nasir j, javed a, arshad mo, chatni mh. persistent lower lid swelling in an infant – impacted foreign body! pak j ophthalmol. 2020; 36 (3): 305-307. doi: 10.36351/pjo.v36i3.1052 introduction ophthalmologists, including general practitioners definitely encounter ocular foreign bodies in their clinics. in most instances, a detailed history about the nature of injury is sufficient to elucidate the presence of a foreign body, however many times they may be missed even by the experts. the conjunctival fornices (upper and lower) are known to be notorious for harboring foreign bodies for considerably longer period of time1,2,3. they may be organic or inorganic, commonly include plant material, metallic fragments, silica/sand particles, and even lost contact lenses. here we report a case of an infant who was referred to us in eye clinic for correspondence to: dr. javeria nasir department of ophthalmology patel hospital, karachi email: i_m_jav@hotmail.com received: april 21, 2020 revised: may 4, 2020 accepted: may 4, 2020 evaluation of lower eyelid swelling that had been there for the past one month. case presentation a 9 month old male infant was referred to the eye department from the peadiatric unit where he was admitted for community acquired pneumonia. his mother complained of noticing right lower eyelid swelling of one-month duration. on further history and examination, the mother informed that he got hurt in his right eye by a plastic toy while he was playing with his elder sibling around a month ago. the baby developed lower lid swelling without any redness or sticky discharge (picture 1). over the course of previous one month, the swelling did not reduce or increase in size. he was then taken to an eye specialist, a week after the injury, where the swelling was diagnosed as a hordoelum of the right eye and was prescribed topical antibiotic eye drops along with steroid ointment. despite topical treatment for two weeks, the swelling did not regress. javeria nasir, et al 306 pakistan journal of ophthalmology, 2020, vol. 36 (3): 305-307 picture 1(a): (right) persistent lid swelling. picture 1(b): (right) after foreign body removal. two weeks after injury, the child developed cough and runny nose along with three episodes of high fever and febrile fits. he was rushed to the emergency department, where he was admitted under the care of pediatric department and was diagnosed as community acquired pneumonia (cap) based on clinical examination and chest x-ray findings. he was on intravenous ceftriaxone and vancomycin. fever subsided after 48 hours of starting the treatment. other symptoms also improved gradually with the exception of lower lid swelling which persisted despite three days of iv antibiotics. opinion of an ophthalmologist was sought before discharge. at the eye clinic, on general physical examination he was a healthy looking, smiling, active child, slightly irritable in his mother’s lap with obvious right eye lower lid swelling. he was a febrile with no lymphadenopathy. gross visual acuity was intact in both eyes and child was following and fixating normally. upon palpation the swelling was non-tender and mobile with no associated skin changes. on right lower lid retraction, by the examining doctor, a bright, circular, pink coloured 1.1 cm × 1.1 cm (picture 2), plastic foreign body popped out and fell on the floor. this foreign body was a wheel of a four-wheeled toy cart with which the baby was playing one month back. later, the mother informed us that she had been looking for that wheel since one wheel of the toy cart had been missing from the day the boy developed the swelling. picture 2: measurement of the extracted foreign body. conjunctiva showed no sign of granulation and/or inflammation. cornea was lustrous and clear without any epithelial defects. rest of the anterior segment examination along with fundoscopy was unremarkable. written informed consent was obtained from the patient’s parents for purpose of reporting the case. discussion ocular foreign bodies are a common finding in patients of all age group presenting in outpatient department with or without history of trauma. in children, however, due to the difficult examination and insufficient history of associated symptoms, conjunctival foreign particles are easily over-looked4. reflex tearing and blinking are the inherent protective ways that usually wash out any foreign body inside the conjunctival fornices5. initially when there is any foreign body in the fornix there is acute inflammatory response causing fibrinous exudate formation in an attempt to dislodge the foreign body, however, if there is a large surface area to the foreign body this mechanism is minimal causing granuloma formation around foreign body6,7. granuloma tissue formation around foreign body as a means of its mechanical stabilization is another protective phenomenon observed in some case reports as well. hence, once stable, the simultaneous damage to cornea and persistent lower lid swelling in an infant – impacted foreign body! pakistan journal of ophthalmology, 2020, vol. 36 (3): 305-307 307 conjunctiva is avoided leading to prolonged tolerance and minimal irritation8. however, in our case, we did not find any evidence of granuloma formation, except for mild hyperemia. there are cases in literature in which unusual subconjunctival foreign bodies are reported. park et al have described a foreign body which was confused with uveal prolapse9. similarly, subconjunctival insect wings are also reported10. with this author communication, the authors wish to highlight the importance of a thorough yet proactive history and clinical examination, which are often neglected due to poor co-operation in children, and lack of awareness among parents too. in our case the foreign body had been there for one month. it was missed at three levels, i.e. by the parents, by the ophthalmologist and by the pediatrician. a missing part of a toy, elucidated on history, should always raise the suspicion among parents and/or care givers for a probable foreign body in children. the concept of a “holistic” approach towards the patient tops the list when providing medical care. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution javeria nasir; registrar: concept, data collection, manuscript writing. anum javed; resident: manuscript writing, final review. mohammad owais arshad; senior registrar: critical analysis, acquisition of data, final review. mohammad hanif chatni; head of department: concept, final review. references 1. balakrishnan e, abraham je, naim-ud-din m. unusual foreign body in the conjunctiva. br j ophthalmol. 1963; 47: 250–2. 2. sakata, c., hiraoka, t., & oshika, t. unusually large plastic toy as a persisting conjunctival foreign body. japan j ophthalmol. 2007; 51 (3): 232234. doi: 10.1007/s10384-007-0434-5. 3. gerding h. unusually long foreign body of the conjunctival fornix in a child overlooked by 3 ophthalmologists. klinische monatsblätterfür augenheilkunde. 2013; 230 (04): 390-1. doi: 10.1055/s-0032-1328391. 4. qayum s, anjum r, rather s. epidemiological profile of pediatric ocular trauma in a tertiary hospital of northern india. chinese journal of traumatology. 2018; 1; 21 (2): 100-3. 5. giuliano ea. diseases of the adnexa and nasolacrimal system. equine ophthalmology. 2016; 27: 197. 6. weinberg jc, eagle jr rc, font rl, streeten bw, hidayat a, morris da. conjunctival synthetic fiver granuloma: a lesion that resembles conjunctivitis nodosa. ophthalmology. 1984; 91 (7): 867-72. 7. sowmya v, nazareth ne, kamath vb. foreign-body conjunctival granuloma secondary to finger-nail trauma. asian j ophthalmol. 2015; 14; 14 (2): 73-6. 8. alabi eb, simpson tl. conjunctival redness response to corneal stimulation. optometry and vision science. 2019 jul 1; 96 (7): 507-12. doi: 10.1097/opx.0000000000001398. 9. park ym, jeon hs, yu hs, lee js. a subconjunctival foreign body confused with uveal prolapse. indian j ophthalmol. 2014 jun; 62 (6): 730– 731. 10. fogla r, rao sk, anand ar, madhavan hn. insect wing case: unusual foreign body. cornea. 2001; 20: 119–21. .……. pak j ophthalmol. 2021, vol. 37 (4): 356-360 356 original article effect of topical versus sub-conjunctival anaesthesia during administration of intravitreal bevacizumab injection amna rizwan 1 , rabeeah zafar 2 , asfandyar asghar 3 , naila obaid 4 , b. a. naeem 5 department of ophthalmology, 1 king edward medical university, mayo hospital, lahore 2 al-shifa trust eye hospital, 3-5 fauji foundation hospital, rawalpindi abstract purpose: to compare the anesthetic effect of topical proparacaine hydrochloride 0.5% with sub-conjunctival lidocaine 2% for intravitreal injection of bevacizumab. study design: quasi experimental study. place and duration of study: department of ophthalmology fauji foundation hospital, rawalpindi, from july 2017 to january 2018. methods: sixty 60 patients who needed intravitreal bevacizumab were included in the study after approval from the ethical review board. exclusion criteria were patients with conditions that could affect pain sensation, acute ocular inflammation, history of intravitreal injection, using systemic analgesic/sedatives, uncooperative patients and unable to understand the pain scale. written informed consent was taken. name, age, gender, diagnosis, previous intravitreal injection, hospital registration number, address and contact numbers were noted. patients were briefed about the visual analogue scale. patients were divided into two groups. group a received proparacaine drops and group b was given subconjunctival lidocaine injections before intravitreal bevacizumab. results: the mean age of patients in this study was 60.38 ± 10.55 years. there were 03 (5.0%) males and 57 (95.0%) females. majority of the patients (30%) presented with choroidal neovascularization followed by diabetic maculopathy, vitreous hemorrhage, central retinal vein occlusion and proliferative diabetic retinopathy. mean pain score among both the groups was 3.67 ± 1.97 (topical group) and 1.70 ± 1.51 (sub-conjunctival group) respectively which was statistically significant (p-value 0.000). among age, diabetes, duration of diabetes and hypertension, only hypertension had moderate correlation with the pain score (correlation coefficient = 0.316, p values = 0.017). conclusion: sub-conjunctival anaesthesia results in less pain during intravitreal drug administration as compared to the topical anaesthesia. key words: intravitreal injections, bevacizumab, intravitreal anti-vegf, anesthesia. how to cite this article: rizwan a, zafar r, asghar a, obaid n, naeem ba. effectiveness of topical versus subconjunctival anaesthesia during administration of intravitreal bevacizumab injection. pak j ophthalmol. 2021, 37 (4): 356-359. doi: 10.36351/pjo.v37i4.1249 correspondence: amna rizwan king edward medical university mayo hospital lahore email: aamnarizwan@hotmail.com received: april 3, 2021 accepted: august 3, 2021 introduction intravitreal injections are a standard and effective method for the treatment of posterior segment diseases like endophthalmitis, intraocular inflammation, neovascular glaucoma, retinopathy of prematurity, etc. 1,2 recently, use of intravitreal injection has seen open access amna rizwan, et al 357 pak j ophthalmol. 2021, vol. 37 (4): 356-360 an upsurge with the maturation of anti-vascular endothelial growth factor (anti-vegf) drugs for the treatment of age related macular degeneration, diabetic macular edema and macular edema following central or branch retinal vein occlusion. 3,4,5 bevacizumab, vegf-a inhibitor, is a recombinant humanized monoclonal antibody that is typically used for the treatment of colorectal cancer. 6,7 it is used ‘off label’ as intravitreal injection as it is cost effective and similar in efficacy to other agents. side effects include endophthalmitis, transient rise in intraocular pressure, pain, subconjunctival hemorrhage, rhegmatogenous retinal detachment, macular hole, retinal pigment epithelium tear, lens trauma and wound leak. 8,9 intravitreal anti-vegf treatment requires several injections typically administered on a monthly basis. 10 it is, therefore, of considerable interest to identify some favorable anesthetics for this procedure. however, to date there is no agreement on the effectiveness of one anaesthetic over another. 11 this is partly because there is a genuine disagreement between different studies on the expected pain scores in different anesthetics. the most common modes for administration of anesthetics are eye drops, subconjunctival injections, lidocaine gel and lidocaine soaked cotton tipped swabs. 12 kaderli and avci have demonstrated that there is a statistically significant difference in the post intravitreal pain levels with the subconjunctival injection being strongly favored over topical anesthetics. 13 in particular, kaderli and avci reported a mean pain score of 1.64 ± 0.67 with topical anaesthetic as opposed to 0.85 ± 0.2 for the subconjunctival group (p < 0.001) during intravitreal drug administration. in contrast, karabus et al. claimed no statistically significant difference in the pain score between topical anaesthetics (mean pain score 1.90) and sub-conjunctival injections (mean pain score 1.71, p = 0.746). 4 it is this disagreement in the literature that we address in this study. we propose to investigate the pain level and focus on subconjunctival injections and topical medications as the two anesthetics of choice. this study is important because so far only topical anesthetic is being used in our hospital. absence of any clear recommendation for the better anaesthetic also makes this study worthwhile. it is, therefore, imperative to get the anesthetic right for this step. purpose to compare the anesthetic effect of topical proparacaine hydrochloride 0.5% with subconjunctival lidocaine 2% for intravitreal injection of bevacizumab. methods this study was conducted at the department of ophthalmology, fauji foundation hospital, rawalpindi from july, 2017 to january, 2018. ethical committee of hospital approved this study. sampling technique was non-probability consecutive sampling. inclusion criteria was age 20 – 70 years, both gender and all patients presenting to ophthalmology department of the hospital with diseases that required intravitreal bevacizumab injection. exclusion criteria were patients with conditions that could affect pain sensation, such as acute conjunctivitis, keratitis, stye, acute dacrocystitis and neo-vascular glaucoma, patients who already had received an intravitreal injection, patients using systemic analgesic or sedatives, uncooperative patients and those who were unable to understand the pain scale. sample size was calculated by who calculator which it came out to be 30 in each group. 13 the nature of study was explained to every subject and a written informed consent was taken. name, age, gender, diagnosis, previous intravitreal injection, hospital registration number, address and contact numbers were noted. patients were briefed about the visual analogue scale. patients were divided into two groups. group a received proparacaine drops and group b was given subconjunctival lidocaine injections before intravitreal bevacizumab. the periocular area was cleaned with 10% povidone iodine and 5% povidone iodine was instilled in conjunctival sac 3 minutes before the injection. the patients were divided in two groups based on lottery method; one group had received proparacaine drops and the other was given subconjunctival lidocaine injections. a sterile lid speculum was applied and intravitreal injection was given infero-temporally 3.5mm away from the limbus in pseudophakic and 4 mm away from the limbus in phakic eyes. after withdrawing the needle, pressure was applied with a sterilized cotton-tipped applicator to minimize vitreal reflux and sub-conjunctival hemorrhage. patients were asked about their pain sensation immediately after the injection. the pain score was noted on the visual effect of topical versus subconjunctival anaesthesia during administration of intravitreal bevacizumab injection pak j ophthalmol. 2021, vol. 37 (4): 356-360 358 analog pain scale aided by the wong-baker faces pain scale. the visual analog pain scale classifies pain on a continuous basis on a scale from 0 to 10, with 10 signifying the worst imaginable pain. the patients were shown the scale on a chart of a3 paper size so as to identify the pain score with a high sensitivity. to eliminate bias, anaesthetic and intravitreal injections were given by the same team and investigation of pain was done by the staff nurse who had not known the type of anaesthetic used. data was entered and analyzed in spss version 22.0. results the mean age for patients in the study was 60.38 ± 10.55 years. there were 03 (5.0%) males and 57 (95.0%) females. female predominance was seen in both groups which could be because of the fact that at this facility, families of ex-servicemen were entitled for treatment. frequency and percentage of diagnosis of patients was assessed in the study. majority of the patients presented with choroidal neovascularization (cnv) 30%, diabetic maculopathy 25%, vitreous hemorrhage 16.7%, central retinal vein occlusion (crvo) 15% and proliferative diabetic retinopathy (pdr) 13.3%. in table 1 we show the demographic attributes of the two groups. we ran the chi-square test of homogeneity on this data to show that there was no statistically significant difference in the demographic distribution of the two groups from the point of view of hypertension (p = 0.781), diabetes (0.791) and the duration of diabetes (p = 0.284). while not shown in the table, of the three males, one was assigned to group a and the other two to group b. hence, the two groups represent homogenous samples. the objective of the study was to compare topical drops (proparacaine hydrochloride 0.5%) and subconjunctival injection (lidocaine 2%) as anaesthetics for the purpose of intravitreal drug administration. in the study, mean pain score among the two groups was 3.67 ± 1.97 and 1.70 ± 1.51, respectively. independent sample t-test was used to compare mean pain score between the two groups which was found to be statistically significant (p-value 0.000). table 1: demographic attributes of patients included in the study. anesthesia total p value topical subconjunctival n % n % n % hypertension 30 100 30 100 60 100 0.781 yes 21 70 20 66.7 41 68.3 no 9 30 10 33.3 19 31.7 diabetes 30 100 30 100 60 100 0.791 yes 18 60 19 63.3 37 61.7 no 12 40 11 36.7 23 38.3 duration of diabetes 30 100 30 100 60 100 0.284 > 10 years 17 56.7 21 70 38 63.3 < 10 years 13 43.3 9 30 22 36.7 applying pearson’s coefficient of correlation of pain score with the age, as well as the dichotomous categorical variables of diabetes, duration of diabetes and hypertension, only hypertension had a statistically significant moderate correlation with the pain score (correlation coefficient = 0.316, p values = 0.017). in table 2, comparison between the two groups regarding complications of administering the intravitreal injection are shown. table 2: complications of intravitreal injections in the two groups. complications group a group b 1 hyperemia 7 (23%) 9 (30%) 2 sub-conjunctival hemorrhage 5 (16.6%) 11 (36.6%) 3 chemosis 2 (6.67%) 16 (53.3%) 4 keratitis nil nil 5 raised iop nil nil 6 uveitis nil nil 7 endophthalmitis nil nil discussion intravitreal injections were first described by deutschmann and ohm who used rabbit vitreous and air to repair retinal detachments in humans. 14 nowadays, antivirals, antibiotics, anti-inflammatory and vascular endothelial growth factor (anti-vegf) are given intravitreally as a standard ophthalmic practice. intravitreal injections are now a part of the standard treatment for retinal diseases. it is, therefore, important to make the experience of intravitreal drug amna rizwan, et al 359 pak j ophthalmol. 2021, vol. 37 (4): 356-360 administration as pain-free for the patient as possible. a study by the american society of retina specialists reported in 2010 that there was no clear preference for use of anaesthetic during intravitreal injection administration. it was found that 25.44% specialists preferred topical anaesthetic drops, 25.15% used a topical gel, 26.33% used pledget in combination with drops, while 22.19% used subconjunctival injections. 4 the mean pain score of our study is 2.68 ± 2.00 for both groups which is consistent with the mean pain score of 2.14 ± 1.90 reported by kaderli et al. 13 in our study, mean age (years) in the study was 60.38 ± 10. similarly, for kaderli et al, 13 mean age in years was 59 ± 14.5. in our study, mean pain score of topical and subconjunctival groups was 3.67 ± 1.97 and 1.70 ± 1.51 respectively. the difference is statistically significant (p = 0.000). likewise, kaderli and avcireport reported mean pain score of 1.64 ± 0.67 with topical anaesthetic as opposed to 0.85 ± 0.2 for the sub-conjunctival group (p < 0.001) during intravitreal drug administration. 13 similarly, andrade et al, compared the effectiveness of topical proparacaine, subconjunctival lidocaine and 2% lidocaine gel. they reported that 86.2% patients who received sub-conjunctival anaesthetic rated the overall procedure of receiving an intravitreal injection as very good or excellent (37.9%). no one receiving topical drops reported the procedure as being excellent and only 19.2% reported it as being very good. patients in topical drops group had the worst mean pain scores during the injection. they concluded subconjunctival lidocaine was most effective in preventing pain. lidocaine gel was effective but it had high incidence of keratitis. they also studied the eye movement while administering the intravitreal injection and concluded that sub-conjunctival group had the least eye movement consistent with a low mean pain score. whereas, chemosis was high in subconjunctival group, the overall conclusion of the superiority of using subconjunctival anaesthetic is quite consistent with our findings. 15 in our study, chemosis was more in subconjunctival group which is consistent with results of andarde et al. 15 kozak et al reported a higher rate of chemosis in the subconjunctival group. 16 while andarde et al 15 advocated the use of subconjunctival anaesthetic as compared to lidocaine gel, kozak et al 16 had recommended the use of gel based on higher rate of chemosis. karabus et al found higher incidence of subconjunctival hemorrhage in patients of sub conjunctival group which is consistent with our study. 4 however, it is to be noted that whereas 36.6% patients reported subconjunctival hemorrhage as compared to 16.6% patients in topical group, the hemorrhage was not troublesome to the patient. in our experience, chemosis and subconjunctival hemorrhage were not very bothersome to the patients as compared to the pain. blaha et al found no statistically significant difference in pain score while comparing four different anaesthetic methods (proparacaine, tetracaine, lidocaine pledget and subconjunctival injection of lidocaine). 17 this, of course, is in contradiction to our study as well as that of kaderli et al. 13 rifkin and schaal observed factors that could influence pain during in-office intravitreal drug administration. 10 they observed factors (improved vision from previous injection, female gender, age greater than 65 years and number of injection) that could influence pain. pain decreased with each subsequent injection. we therefore excluded such patients (those that had received intravitreal drugs in the past). cohen et al concluded that most patients preferred sub conjunctival anesthesia to topical anesthesia for intravitreal injections. 18 they suggested to give ample time after subconjunctival anaesthetic and based their recommendations on patients’ preference. according to them 88% patients preferred subconjunctival anesthesia and 12% preferred topical anesthesia for on-going treatments. 18 a survey of canadian retina specialists showed that at least a quarter of them routinely used subconjunctival anaesthetics and up to half of them infrequently used the same. 19,20 complications reported in the literature of intravitreal injections include raised intraocular pressure, uveitis and endophthalmitis. no patient in our study reported these complications. the drawbacks in our study are small sample size and short term follow-up. these should be addressed in a more detailed analysis. conclusion subconjunctival anaesthesia results in less pain during intravitreal drug administration compared with topical anaesthesia. effect of topical versus subconjunctival anaesthesia during administration of intravitreal bevacizumab injection pak j ophthalmol. 2021, vol. 37 (4): 356-360 360 ethical approval the study was approved by the institutional review board/ethical review board. (469-rc/ffh/rwp) conflict of interest authors declared no conflict of interest. references 1. haas p, falkner-radler c, wimpissinger b, malina m, binder s. needle size in intravitreal injections – pain evaluation of a randomized clinical trial. acta ophthalmol. 2016; 94 (2): 198-202. 2. shikari h, samant pm. intravitreal injections: a review of pharmacological agents and techniques. j clin ophthalmol. res. 2016; 4: 51-59. 3. shimura m, kitano s, muramatsu d, fukushima h, takamura y, matsumoto m, et al. real-world management of treatment-naïve diabetic macular oedema in japan: two-year visual outcomes with and without anti-vegf therapy in the streat-dme study. br j ophthalmol. 2020; 104 (9): 1209-1215. doi: 10.1136/bjophthalmol-2019-315199. 4. karabus vl, ozkan b, kocer ca, altintas o, pirhan d, yuksel n. comparison of two anesthetic methods for intravitreal ozurdex injection. j ophthalmol. 2015; 2015: 861535. 5. fukami m, iwase t, yamamoto k, kaneko h, yasuda s, terasaki h. changes in retinal microcirculation after intravitreal ranibizumab injection in eyes with macular edema secondary to branch retinal vein occlusion. invest ophthalmol vis sci. 2017; 58 (2): 1246-1255. doi: https://doi.org/10.1167/iovs.16-21115. 6. ferrara n. humanization of an anti-vegf monoclonal antibody for the therapy of solid tumors and other disorders. cancer res. 2016; 76 (17): 49134915. doi: 10.1158/0008-5472.can-16-1973. 7. franchi m, barni s, tagliabue g, ricci p, mazzucco w, tumino r, et al. effectiveness of first‐line bevacizumab in metastatic colorectal cancer: the observational cohort study greta. oncologist, 2019; 24 (3): 358-365. doi: 10.1634/theoncologist.2017-0314. 8. pradhan e, duwal s, bajimaya s, thapa r, sharma s, manandhar a. acute endophthalmitis after intravitreal bevacizumab injections at the tertiary centre in nepal. nepal j ophthalmol. 2018; 10 (19): 107-110. doi: 10.3126/nepjoph. v10i1.21727. 9. park j, lee m. short-term effects and safety of an acute increase of intraocular pressure after intravitreal bevacizumab injection on corneal endothelial cells. bmc ophthalmol. 2018; 18 (1): 17. doi: 10.1186/s12886-018-0682-9. 10. rifkin l, schaal s. factors affecting patients' pain intensity during in office intravitreal injection procedure. retina, 2012; 32: 696-700. 11. azmeh am. ocular and systemic vascular adverse events following intravitreal bevacizumab injection. j ophthalmol vis sci. 2016; 1: 1004. 12. yau gl, jackman cs, hooper pl, sheidow tg. intravitreal injection anesthesia-comparison of different topical agents: a prospective randomized controlled trial. am j ophthalmol. 2011; 151: 333-337. 13. kaderli b, avci r. comparison of topical and subconjunctival anesthesia in intravitreal injection administrations. eur j ophthalmol. 2006; 16: 718-721. 14. shikari h, samant pm. intravitreal injections: a review of pharmacological agents and techniques. j clin ophthalmol. 2016; 4: 51-59. 15. andrade gc, carvalho acm. comparison of 3 different anesthetic approaches for intravitreal injections: a prospective randomized trial. arq bras oftalmol. 2015; 78: 27-31. 16. kozak i, cheng l, freeman wr. lidocaine gel anesthesia for intravitreal drug administration. retina, 2005; 25 (8): 994-998. 17. blaha gr, tilton ep, barouch fc, marx jl. randomized trial of anesthetic methods for intravitreal injections. retina 2011; 31 (3): 535-539. 18. cohen sm, billiris-findlay k, eichenbaum da, pautler se. topical lidocaine gel with and without subconjunctival lidocaine injection for intravitreal injection: a within-patient study. ophthalmic surg lasers imaging retina, 2014; 45 (4): 306-310. 19. xing l, dorrepaal sj, gale j. survey of intravitreal injection techniques and treatment protocols among retina specialists in canada. can j ophthalmol. 2014; 49 (3): 261–266. doi: 10.1016/j.jcjo.2014.03.009. 20. han j, rinella nt, chao dl. anesthesia for intravitreal injection: a systematic review. clin ophthalmol. 2020; 14: 543-550. doi:10.2147/opth.s223530. authors’ designation and contribution amna rizwan; vitreoretina fellow: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation. rabeeah zafar; registrar: data acquisition, manuscript editing, manuscript review. asfandyar asghar; professor: manuscript editing, manuscript review. naila obaid; assistant professor: literature search, data acquisition. manuscript review b. a. naeem; professor and hod: manuscript review. .…  …. https://doi.org/10.1167/iovs.16-21115 445 pak j ophthalmol. 2020, vol. 36 (4): 445-448 original article comparison of topical steroid drops with cyclosporine eye drops in epidemic keratoconjunctivitis abdul rafe 1 , muhammad tariq munawar 2 1-2 department of ophthalmology, combined military hospital, kharian abstract purpose: to compare the effect of topical steroid with cyclosporine eye drops in recurrence of sub-epithelial corneal infiltrates in epidemic keratoconjunctivitis. study design: quasi experimental study. place and duration of study: cmh kharian from jan 2017 to june 2018. material and methods: eighty eight patients with epidemic keratoconjunctivitis, were divided into two groups. group a included patients who received topical steroid drops and group b received topical cyclosporine eye drops. the inclusion criteria comprised of fresh cases of seis, between the ages of 20 to 50 years, having a vision of 6/6 before the illness. the exclusion criteria included patients suffering from allergic conjunctivitis, ocular surface disease like sjogren syndrome, corneal ulcer, blepharitis, old corneal opacity, glaucoma and those who had been using steroids in the past e.g. uveitis. the patients were followed up at 2, 4, 8 and 12 weeks. on resolution of sub-epithelial infiltrates (seis), both regimen were tapered off in next two weeks. the patients were advised to continue monthly follow up for two months to see any recurrence. results: seis resolved in both the groups by week 12, however the resolution was slightly quicker in group a. seis resolved in 84.1% of cases in group a and in 70.4% cases in group b at the end of 4 weeks. recurrence was higher in group a (11.3%) while it was 4.5% in group b. conclusion: cyclosporine eye drops are a safe and equally effective treatment of epidemic keratoconjunctivitis related seis, with an added advantage of reduced recurrence rate. key words: epidemic, keratoconjunctivitis (ekc), cornea, subepithelial infiltrates, cyclosporine. how to cite this article: rafe a, munawar mt. comparison of topical steroid drops with cyclosporine eye drops in epidemic keratoconjunctivitis. pak j ophthalmol. 2020, 36 (4): 445-448. doi: introduction epidemic keratoconjunctivitis (ekc) is the most common cause of infectious conjunctivitis worldwide correspondence to: dr. abdul rafe department of ophthalmology combined military hospital, kharian email: mabdulrafe@yahoo.com received: 2020 accepted: 2020 accounting for about 75% of all cases. 1 its morbidity is high in children and immunocompromised patients. 2 it is caused by adenovirus strains 8, 19 and 37. 3,4,5,6 it has a direct mode of transmission, i.e. by hands, fomites etc. and indirect i.e. by tonometer, eye dropper bottle, slit lamp. 3 the incubation period is usually 2 to 14 days and the person remains infectious for up to 10 to 14 days after the onset of symptoms. 7,8 the corneal involvement typically appears after 7 to 10 days of initial presentation in the form of sub epithelial infiltrates (seis) in the anterior stroma. 9 these opacities are pathognomonic of ekc and may persist comparison of topical steroid drops with cyclosporine eye drops in epidemic keratoconjunctivitis pak j ophthalmol. 2020, vol. 36 (4): 445-448 446 for several weeks to years causing visual deterioration, glare, photophobia and irregular astigmatism. 10 seis represent cellular immune reaction comprising of lymphocytes, macrophages and antigen presenting langerhans cells. 11 although it is a self-limiting disease, but treatment is frequently needed to shorten the duration and relieve the symptoms. 12 some ophthalmologists have used topical steroid eye drops to resolve these lesions with encouraging results, however these drops are associated with increased frequency of recurrence of these lesions. 13 cyclosporin eye drops have also shown promising results in resolution of seis with an added advantage of reduced chances of recurrence. 13 this study was done to compare recurrence of seis after stopping topical cyclosporin eye drops versus steroid eye drops. material and methods this study was conducted at cmh kharian from january 2017 to june 2018, after taking approval from the hospital ethical committee. a total of 88 patients fulfilling the above criteria were included in the study. after taking the informed consent the patients were divided into group a and group busing nonprobability lottery method. group a included patients who received topical steroid drops and group b received topical cyclosporine a eye drops. the inclusion criteria comprised of fresh cases of seis, between the ages of 20 to 50 years, having a vision of 6/6 before the illness. the exclusion criteria was patients suffering from allergic conjunctivitis, ocular surface disease like sjogren syndrome, corneal ulcer, blepharitis, old corneal opacity, glaucoma and those who had been using steroids in the past. diagnosis of epidemic keratoconjunctivitis related seis was made clinically based on symptoms of glare, photophobia and blurred vision after recent episode of epidemic keratoconjunctivitis. on slit lamp examination, seis were confirmed as greyish white granular sub epithelial lesions with fuzzy borders. all patients underwent complete ophthalmic examination including visual acuity, tear film assessment, corneal examination and anterior chamber assessment. intra ocular pressure was measured using air puff tonometer. the corneal sub epithelial opacities were examined under high magnification of slit lamp and counted, and the patients were divided into two groups depending upon the number of seis in each cornea, i.e. less than eight seis or more than eight seis. patients in group a were started with topical loteprednol eye drops eight hourly and those of group b were started with topical cyclosporine 0.05% eye drops eight hourly. the patients were followed up at 2, 4, 8 and 12 weeks. resolution of seis were defined as complete disappearance of these opacities leaving behind clear cornea. on resolution both cyclosporine and loteprednol eye drops were tapered off in next two weeks. the patients were advised to continue monthly follow up for next two months, during which they were assessed for any recurrence of corneal seis. data was recorded in predesigned proforma and spss version 21 was used for data analysis. frequency and percentages were calculated and presented for qualitative data. student t-test was applied for numerical variables. p value ≤ 0.05 was considered as significant. results a total of 88 patients were included in this study. the demographic details are shown in table 1 which shows the mean age of patients in group a was 30.47 years (20 to 49 years) while it was 29.54 years for group b (20 to 46 years). table 1: demographic characteristics. age in years group a group b 20 – 30 23 25 31 – 40 15 14 41 – 50 6 5 range 20 to 49 years 20 to 46 years mean age 30.48 ± 7.53 29.55 ± 7.17 no. of males 29 26 no. of females 15 18 table 2: resolution of corneal seis. corneal involvement group a (n = 44) group b (n = 44) less than 8 seis 30 (68.18%) 26 (59.09%) more than 8 seis 14 (31.81%) 18 (40.90%) resolution in 2 weeks 14 (31.8%) 10 (22.7%) resolution in 4 weeks 23 (52.2%) 21 (47.7%) resolution in 8 weeks 4 (9.1%) 11 (25%) resolution in 12 weeks 3 (6.8%) 2 (4.5%) as is clear from table 2 that seis resolved in both the groups by week 12, however the resolution was slightly quicker in group a. in group a 31.8% of seis resolved at the end of second week and another 52.3% abdul rafe, et al 447 pak j ophthalmol. 2020, vol. 36 (4): 445-448 by the end of fourth week(total 84.1%) whereas 22.7% resolved at second week and another 47.7% at the end of fourth week( total 70.4%) in group b at the end of same interval. table 3: recurrence of seis. total number recurrence p value group a 44 5 (11.3%) 0.017 group b 44 2 (4.5%) discussion viral keratoconjunctivitis is a condition that frequently affects the population as an epidemic especially in summers. the human adenovirus accounts for about 65% to 90% of these. 14,15,17 in addition to its morbidity it also costs in the form of lost productivity and cost of medicines etc. which amounts to 430 million us dollars. 16 epidemic keratoconjunctivitis involves both the conjunctiva and cornea and can cause long lasting morbidity in the form of development of corneal seis. traditionally it had been treated symptomatically with artificial tears, topical antihistamine drops and cold compresses, however the patients demand some treatment to shorten the course of illness and relieve symptoms. in a study conducted by butt al, the corneal subepithelial infiltrates lasted for about 45 days causing photophobia, blurring of vision and astigmatism. 10 it was observed in our study as well where about70% to 80% of seis lasted for about 30 days. some of the ophthalmologists use topical steroids with the aim to shorten the duration and decrease patients discomfort. 17 these drops make the patients comfortable however they are associated with a higher rate of recurrence of these seis and they also increase virus shedding there by prolonging the infectivity periods. 18,19 our study also showed that those patients who had used topical steroids showed relatively early resolution as compared to those who used cyclosporine drops, however it was observed that ultimately the corneal lesions resolved in both the groups. there are studies in which there was complete resolution of seis in patients who used cyclosporin eye drops. 20,21 our study also showed that recurrence of seis was lower in patients who used cyclosporine drops being only 4.5% as compared to 11.7% in steroid group. levinger et al in their study, compared the efficacy of cyclosporin eye drops and showed improvement in seis in 9 out of 12 patients who had previously used topical steroid drops and were resistant to it. 22 similar results were seen in a study by jeng et al on twelve eyes which have developed seis and were responsive to steroids drops but were resistant to tapering. after the initiation of cyclosporin drops, steroids could be successfully tapered without any recurrence. 23 romanowisky et al showed in their study that use of topical steroids only improved patients’ discomfort, however it did not shorten the course of illness, rather their prolonged use was associated with serious side effects like glaucoma, cataract and corneal thinning. 13 we have also found in our study that cyclosporine eye drops are comparable to topical steroid drops in resolving the seis but has an added advantage of reduced recurrence rate. limitation of our study is the small sample size and single center trial. conclusion cyclosporine eye drops are a safe and effective treatment of epidemic keratoconjunctivitis related seis, with an added advantage of reduced incidence of recurrence. references 1. jhanji v, chan tc, li ey, agarwal k, vajpayee rb. adenoviral keratoconjunctivitis. surv ophthalmol. 2015; 60 (5): 435-443. 2. ghebremedhin b. human adenovirus: viral pathogen with increasing importance. eur j of microbial immuno l (bp). 2014; 4: 26-33. 3. lion t. adenovirus infection in immunocompetent and immunocompromised patients. clinical microbiol rev. 2014; 27: 441-462. 4. zhang l, zhao n, sha j et al. virology and epidemiology analysis of global adeno virus associated conjunctivitis outbreak 1953-1013. epidemiol infect. 2016; 144 (8): 1661-1672. 5. lee yc, chan n, hnng it et al. human adenovirus type 8 epidemic keratoconjunctivitis with large corneal epithelial full layer detachment. an endemic outbreak with uncommon manifestations. clin. ophthalmol. 2015; 9: 953-957. 6. melendez cp, florentino mm, martinez il. outbreak of epidemic keratoconjunctivitis caused by adenovirus in medical students. mol vis 2009; 15: 557562. 7. kaufman he. adenovirus advances. new diagnostic and therapeutic options. current opin in ophthalmol. 2011; 22: 290-293. comparison of topical steroid drops with cyclosporine eye drops in epidemic keratoconjunctivitis pak j ophthalmol. 2020, vol. 36 (4): 445-448 448 8. ford e, nelson ke, warren d. epidemiology of epidemic keratoconjunctivitis. epidemiol review. 1987; 9: 244-261. 9. rajaiya j, chodosh j. new paradigms in infectious eye disease; adenoviral keratoconjunctivitis. arch soc esp oftalmol 2006; 81: 493-498. 10. butt al, chodosh j. adenoviral keratoconjunctivitis in a tertiary care eye clinic. cornea, 2006; 25: 199-202. 11. kurna sa, altun a, oflaz a, arsan ak. evaluation of impact of persistent subepithelial corneal infiltrates on the visual performance and corneal optical quality after epidemic keratoconjunctivitis. acta ophthalmol. 2015; 93 (4): 377-382. 12. leanerts l, naesens l. antiviral therapy for adenovirus infection. antiviral res. 2006; 17: 172-180. 13. romanowisky eg, yates ka, gordon yj. short term treatment with a potent topical corticosteroid of an acute ocular adenoviral infection in the new zealand white rabbit. cornea; 20: 657-660. 14. lund e, stefani fh. corneal histology after epidemic keratoconjunctivitis. arch ophthalmol. 1978; 96: 208588. 15. o’ brien tp, jeng bh, mc donald m, raizman mb. acute conjunctivitis truth and misconceptions. curr med res opin. 2009; 25 (8): 1953-61. 16. udeh bl, schneider je, obsfeldt rl. cost effectiveness of a point of care test for adenoviral conjunctivitis. am j med sci. 2008; 336 (3): 254-64. 17. wilkins mr, khan s, bunce c, khawaja a, siriwardena d, larkin df. a randomized placebocontrolled trial of topical steroids in presumed viral conjunctivitis. br. j ophthalmol. 2011; 95: 1299-1303. 18. clement c, capriotti ja, kumar m, et al. clinical and antiviral efficacy of an ophthalmic formulation of dexamethasone povidone-iodine in a rabbit model of adenoviral keratoconjunctivitis. inves sci. 2011; 52 (1): 845-850. 19. ghanem rc, vargas jf, ghanem vc. tacrolimus for the treatment of subepithelial infiltrates resistant to topical steroids after adenoviral keratoconjunctivitis. cornea, 2014; 33: 1210-13. 20. clement c, coskun e, jatar mg, kaydu e, yayuspayi r, comez a, et al. cyclosporin a0.5% eye drops for the treatment of subepithelial infiltrates after epidemic keratoconjunctivitis. bmc ophthalmol. 2012; 12: 42. 21. aydin kurna s, altun s, olfaz a, karatay arsan a. evaluation of the impact of persistent subepithelial corneal infiltration on the visual performance and optical quality after epidemic keratoconjunctivitis. acta ophthalmol. 2015; 93: 77-82. 22. levinger e, slomovic a, sansanayndh w, bahar i, stomovic ar. topical treatment with 1% cyclosporin eye drops for subepithelial infiltrates secondary to adenoviral keratoconjunctivitis. cornea, 2010; 29: 638640. 23. jeng bh, holsclaw ds. cyclosporin a 1% eye drops for the treatment of subepithelial infiltrates after adenoviral keratoconjunctivitis. cornea, 2011; 30 (9): 958-61. author’s designation and contribution abdul rafe; consultant ophthalmologist: critical appraisal, drafting and actual write-up of the manuscript. muhammad tariq munawar; consultant ophthalmologist: concepts, interpretation of data. .…  …. microsoft word 5. asghar ali pak j ophthalmol. 2022, vol. 38 (4): 245-249 245 original article mean change in pterygium induced astigmatism in patients undergoing pterygium excision with conjunctival autograft asghar ali1, muhammad adnan2, sajida parveen shaikh3, abdul sami4, hafiza riffat5 1,2,4,5dow university of health sciences, (duhs) karachi, 3bilawal medical college, jamshoro abstract purpose: to determine the mean change in pterygium induced astigmatism in patient undergoing pterygium excision with conjunctival auto graft. study design: quasi experimental study. place and duration of study: department of ophthalmology dow university of health sciences/chk from march 2018 to november 2018. methods: thirty patients with pterygium were selected through non-probability consecutive sampling. all patients meeting inclusion criteria were enrolled after taking written consent. history of duration of symptoms and comorbidity was taken. all surgeries were performed by consultant with more than 5 years experience with conjunctival auto graft under topical anesthesia. patient was followed up after one week, 15 days and then monthly for four months with the final outcome at the end of fourth month. difference between preoperative and postoperative astigmatism was taken as mean change. data was analyzed on spss version 21. mean and standard deviation were calculated for all quantitative variables like age, astigmatism (keratometric reading) and duration of symptoms. frequency and percentage was calculated for gender and grade of pterygium. p < 0.05 was considered significant. results: mean age of the patients was 50.07 ± 12.48 years. there were 19 (63.33%) males and 11 (36.67%) females. preoperative mean astigmatism was 3.70 ± 1.36 and postoperative mean astigmatism was 1.91 ± 0.97. post-operative mean astigmatism was significantly low as compare to preoperative astigmatism (p = 0.0005). conclusion: this study concludes that successful pterygium excision surgery reduces the pterygium induced refractive astigmatism and improves the visual outcome either by reducing the astigmatism or by removal of the pterygium from the visual axis as in grade iv pterygium. key words: pterygium, astigmatism, conjunctival autograft. how to cite this article: ali a, adnan m, shaikh sp, sami a, riffat h. mean change in pterygium induced astigmatism in patients undergoing pterygium excision with conjunctival autograft. pak j ophthalmol. 2022, 38 (4): 245-249. doi: 10.36351/pjo.v38i4.1379 correspondence: muhammad adnan dow university of health sciences, (duhs), karachi email: adnanshaikh1986@hotmail.com received: march 10, 2022 accepted: september 11, 2022 introduction pterygium is a triangular fibro vascular growth of degenerative bulbar conjunctiva progressing towards the cornea.1pterygium causes significant amount of astigmatism which is caused either by mechanical traction on cornea, exerted by pterygium or due to accumulated tears at the edge of pterygium.2 the astigmatism produced in the majority of cases is withthe-rule astigmatism.3 larger the pterygium greater the amount of astigmatism. pterygium causes decrease of vision by inducing astigmatism.4 the standard management option for pterygium is surgical excision which significantly reduces muhammad adnan, et al 246 pak j ophthalmol. 2022, vol. 38 (4): 245-249 astigmatism and hence improvement in vision.5,6 surgical excision with conjunctival autograft is safe and effective technique and it carries less recurrence rate as compared to scleral bare technique.7,8 with the use of refraction and automated keratometry we were able to measure effect on astigmatism before and after pterygium excision.910 the purpose of this study is to determine the mean change in pterygium induced astigmatism after conjunctival autograph in patients undergoing pterygium surgery. methods it was a quasi experimental study, done from march 2018 to november 2018 at department of ophthalmology, dow university of health sciences/ chk. sample size was calculated through pass version-11, taking preoperative and postoperative difference of astigmatism 3.92 ± 0.13 for grade-iv pterygium and 5% alpha and 10% power.19 thirty patients with pterygium were selected through nonprobability consecutive sampling. patients with pterygium induced astigmatism of more than four weeks duration, progressive type (more vascularized and complaints of foreign body like sensation and interference in vision), grade of ii, iii and iv pterugium, age between 20 and 70 years and either gender were included. patients with pseudo-pterygium, recurrent pterygium, ulceration or scaring of cornea, poor wound healing from any ocular or other diseases as dry eye, rheumatoid arthritis and eyes with previous surgery were excluded. keratometric reading greater than 0.75 diopters astigmatism was taken as pterygium induced astigmatism. grading of pterygium was as follows: grade-i: presence of triangular red mass crossing and reaching on corneo-scleral margin. grade-ii: presence of triangular red mass reaching in between corneo-scleral margin and pupil. grade-iii: presence of triangular red mass reaching upto pupil margin. grade-iv: presence of triangular red mass reaching at the centre of cornea and blocking the vision. all patients meeting inclusion criteria were enrolled after taking written consent. history of duration of symptoms and co-morbidity was taken. all surgeries were performed by consultant with more than 5 years experience with conjunctival auto graft under topical anesthesia. patient was followed up after one week, 15 days and then monthly for four months with the final outcome at the end of fourth month. keratometric data was obtained with (hubitz hrk7,000) automated keratometer and difference between preoperative and postoperative astigmatism was taken as mean change. data was analyzed on spss version 21. mean and standard deviation were calculated for all quantitative variables like age, astigmatism (keratometric reading) and duration of symptoms. frequency and percentage was calculated for gender and grade of pterygium. paired sample t-test was applied to check the difference of preoperative and postoperative astigmatism. p value of less than 0.05 was considered as significant. stratification was done with respect to age, gender, and duration of symptoms, comorbidity (hypertension and diabetes mellitus) and grades to see the effects of these variables in outcome. post stratification independent sample t test was applied and p < 0.05 was considered significant. results a total of 30 patients with pterygium induced astigmatism were included in this study. age distribution of the patients is shown in figure 1. the average age of the patients was 50.07 ± 12.48 years (median = 49.5 with interquartile range of 21) and mean duration of symptoms was 3.73 ± 1.64 months (median 3.5 months with inter quartile range of 3). there were 19 (63.33) male and 11 (36.67%) female as shown in figure 2. out of 30 cases, 76.67% were diabetic and 60% were hypertensive as presented in figure 3 and 4 respectively. regarding type of pterygium, 13 (43.33%) had grade ii pterygia, 10 (33.33%) had grade iii pterygia, 7 (23.33%) had grade iv pterygia as shown in figure 5. pre and post mean comparison of change in pterygium induced astigmatism in patient undergoing pterygium excision with conjunctival autograft is shown in figure 6. preoperative mean of pterygium was 3.70 ± 1.36 and postoperative mean of pterygium was1.91 ± 0.97.post-operative mean pterygium was significantly low as compare to pre pterygium (p = 0.0005). the amount of astigmatism varied with the grade of pterygium. postoperative mean astigmatism difference was significantly low as compare to preoperative for all grade of pterygium. the amount of mean change in pterygium induced astigmatism in patients undergoing pterygium excision with conjunctival autograft pak j ophthalmol. 2022, vol. 38 (4): 245-249 247 astigmatism was seen to increase with the grade of pterygium as shown in table 2. similarly postoperative mean astigmatism difference was significantly low as compare to pretreatment for age groups, gender, diabetes mellitus, hypertension and duration of symptoms as shown in table 3 to 7 respectively. table 1: comparison of pre and post astigmatism with respect to grade of pterygium. grade of pterygium n pre-operative astigmatism post-operative astigmatism p-value mean ±sd mean ±sd grade ii 13 2.58 ± 0.51 1.42 ± 0.59 0.0005 grade iii 10 3.70 ± 0.14 1.44 ± 0.29 0.0005 grade iv 7 5.77 ± 0.97 2.47 ± 0.13 0.001 age groups ≤40 7 3.40 ± 1.15 1.33 ± 0.99 0.0005 41 to 50 11 3.15 ± 0.91 1.82 ± 0.92 0.0005 >50 12 4.37 ± 1.61 2.31 ± 0.90 0.0005 gender male 19 3.94 ± 1.32 1.95 ± 0.96 0.0005 female 11 3.28 ± 1.39 1.81 ± 1.04 0.0005 diabetes mellitus yes 23 3.61 ± 1.14 1.85 ± 0.96 0.0005 no 7 4.00 ± 2.03 2.06 ± 1.07 0.004 hypertension yes 18 3.71 ± 1.21 1.84 ± 0.99 0.0005 no 12 3.69 ± 1.62 2.00 ± 0.98 0.0005 duration of symptoms 2-4 19 3.96 ± 1.60 2.08 ± 1.03 0.0005 >4 11 3.24 ± 0.65 1.60 ± 0.82 0.0005 discussion pterygium is a fibro elastic degeneration of the conjunctiva with encroachment towards the cornea.1 pterygium can lead to significant astigmatism. due to flattening along the horizontal meridian. pterygium excision surgery is advised if it is growing towards cornea and visual axis is blocked. surgical excision decreases pterygium induced corneal distortion and improves visual symptoms caused by encroachment of pterygium into the visual axis. fong et al, observed that pterygium excision often results in reversal of pterygium induced corneal flattening.9 we performed conjunctival autograft surgery which resulted in decrease in pterygium. our results are in consistence with other studies using different surgical techniques in pterygium and improving astigmatism.11-12 consequently, successful pterygium surgery can improve visual acuity which is also supported by the different techniques used for evaluation of corneal astigmatism.13,14,15 according to a report by american academy of ophthalmology, bare sclera excision of pterygium resulted in a grossly higher recurrence ratio compared with excision along with the use of conjunctival auto graft.16 this is the reason that bare sclera technique is very rarely performed in the treatment of pterygium. nowadays variety of surgical procedures has been done to decrease chances of recurrence. the common surgical management options include primary closure with conjunctival autograft, amniotic membrane transplantation, use of mitomycin c, etc.17,18,19 eknath shelke et al, in their study of 37 patients of pterygium reported that 51.84% of patients had grade ii pterygium, while 37.84% had grade iii and 8.11% had grade iv pterygium.11 this observation was also seen by maheshwari et al, in which, 36 eyes were diagnosed as primary pterygium.5 most of their patients belonged to grade ii (44.45%) and 33.33% had grade iii. this is very much consistent with our findings. stern and lin reported improvement in topographic indices in 16 eyes; they reported corneal astigmatism to reduce from 5.93 ± 2.46d to 1.92 ± 1.68d.20 in the current study all the topographic parameters were seen to improve significantly following pterygium excision. preoperative mean of pterygium was 3.70 ± 1.36 and postoperative mean of pterygium was1.91 ± 0.97. post-operative mean pterygium was significantly low as compare to pre pterygium (p = 0.0005). postoperative mean astigmatism difference was significantly low as compare to preoperative for all grade of pterygium. lindsay and sullivan also concluded same significant correlation between successful pterygium excision surgery and improvement in the visual acuity.21 the quantity of astigmatism depends on the grade of pterygium. in our study the postoperative mean astigmatism difference was significantly low as compare to preoperative for all grade of pterygium. the quantity of astigmatism was seen to increase with the grade of pterygium. it was also reported earlier that a significant correlation existed between the size of pterygium and corneal astigmatism.20 it was also seen that pterygium covering more than 45% of corneal diameter resulted in higher degrees of astigmatism. mohammad-salih and co-workers concluded relationship with corneal astigmatism with the pterygium extension, width and total area. in these parameters, an extension had the strongest and the most significant correlation with the astigmatism (ρ = muhammad adnan, et al 248 pak j ophthalmol. 2022, vol. 38 (4): 245-249 0.462, p < 0.001, pearson correlation analysis).4 limitations of our study are the single center study, small sample size and absence of control group. conclusion the patients with pterygium along with astigmatism include both naturally occurring astigmatism and pterygium induced astigmatism. the size of pterygium is directly proportional to the amount of induced astigmatism. the present study also verifies that successful pterygium excision surgery reduces the pterygium induced refractive astigmatism and improved the visual acuity either by reducing the astigmatism or by removal of the pterygium from the visual axis as in grade iv pterygium. ethical approval the study was approved by the institutional review board/ethical review board (cpsp/reu/opl-2015183-1661). conflict of interest: authors declared no conflict of interest. references 1. singh sk. pterygium: epidemiology prevention and treatment. community eye health, 2017; 30 (99): s5s6. 2. yagmur m, özcan aa, sari s, ersöz tr. visual acuity and corneal topographic changes related with pterygium surgery. j refract surg. 2005; 21: 166-170. 3. avisar r, loya n, yassur y, weinberger d. pterygium-induced corneal astigmatism. isr med assoc j. 2000; 2 (1): 14-15. 4. mohammad-salih pa, sharif af. analysis of pterygium size and induced corneal astigmatism. cornea, 2008; 27 (4): 434-438. doi: 10.1097/ico.0b013e3181656448. 5. maheshwari s. effect of pterygium excision on pterygium induced astigmatism. indian j ophthalmol. 2003; 51: 187-188. 6. khan fa, khan niazi sp, khan da. the impact of pterygium excision on corneal astigmatism. j coll physicians surg pak. 2014; 24 (6): 404-407. 7. kamil z, bokhari sa, rizwi f. comparison of conjunctival autograft and intraoperative application of mitomycin-c in the treatment of primary pterygium. pak j ophthalmol. 2011; 27: 221-225. 8. shehla dareshani ja. a long term follow up after limbal conjunctival autograft for recurrent pterygium. pak j ophthalmol. 2016; 32 (1): 16-18. 9. fong ks, balakrishnan v, chee sp, tan dt. refractive change following pterygium surgery. clao j. 1998; 24: 115-117. 10. mehravaran s, asgari s, bigdeli s, shahnazi a, hashemi h. keratometry with five different techniques: a study of device repeatability and interdevice agreement. int ophthalmol. 2014; 34 (4): 869875. doi: 10.1007/s10792-013-9895-3. 11. shelke e, kawalkar u, wankar r, nandedkar v, khaire b, gosavi v. effect of pterygium excision on pterygium induced astigmatism and visual acuity; intern j advanced health sciences, 2014; 40 (9): 1-4. 12. shahraki t, arabi a, feizi s. pterygium: an update on pathophysiology, clinical features, and management. ther adv ophthalmol. 2021; 13: 25158414211020152. doi: 10.1177/25158414211020152. 13. tomidokoro a, miyata k, sakaguchi y, samejima t, tokunaga t, oshika t. effects of pterygium on corneal spherical power and astigmatism. ophthalmology, 2000; 107: 1568–1571. 14. errais k, bouden j, mili-boussen i, anane r, beltaif o, meddeb ouertani a. effect of pterygium surgery on corneal topography. eur j ophthalmol. 2008; 18 (2): 177-181. doi: 10.1177/112067210801800203. 15. minami k, miyata k, otani a, tokunaga t, tokuda s, amano s. detection of increase in corneal irregularity due to pterygium using fourier series harmonic analyses with multiple diameters. jpn j ophthalmol. 2018; 62 (3): 342-348. doi: 10.1007/s10384-018-0583-8. 16. kaufman sc, jacobs ds, lee wb, et al. options and adjuvants in surgery for pterygium: a report by the american academy of ophthalmology. ophthalmology, 2013; 120 (1): 201–208. 17. fonseca ec, rocha em, arruda gv. comparison among adjuvant treatments for primary pterygium: a network meta-analysis. br j ophthalmol. 2018; 102 (6): 748–756. 18. masters js, harris dj., jr. low recurrence rate of pterygium after excision with conjunctival limbal autograft: a retrospective study with long-term followup. cornea, 2015; 34 (12): 1569–1572. 19. rosen r. amniotic membrane grafts to reduce pterygium recurrence. cornea, 2018; 37 (2): 189–193. 20. stern ga, lin a. effect of pterygium excision on induced corneal topographic abnormalities. cornea, 1998; 17 (1): 23-27. doi: 10.1097/00003226-199801000-00004. 21. lindsay rg, sullivan l. pterygium-induced corneal astigmatism. clin exp optom. 2001; 84 (4): 200-203. doi: 10.1111/j.1444-0938.2001.tb05026.x. mean change in pterygium induced astigmatism in patients undergoing pterygium excision with conjunctival autograft pak j ophthalmol. 2022, vol. 38 (4): 245-249 249 authors’ designation and contribution asghar ali; medical officer: concepts, design, literature search, data acquisition, manuscript preparation, manuscript review. muhammad adnan; assistant professor: literature search, data acquisition, statistical analysis, manuscript preparation, manuscript review. sajida parveen shaikh; associate professor: literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. abdul sami; consultant ophthalmologist: concepts, design, literature search, data acquisition, data analysis, manuscript editing. hafiza riffat; fcps trainee: design, data acquisition, statistical analysis, manuscript editing, manuscript review. .……. 283 pak j ophthalmol. 2021, vol. 37 (3): 283-288 original article comparison of central subfoveal choroidal thickness in diabetic patients with and without diabetic retinopathy muhammad ali haider 1 , uzma sattar 2 , muhammad amjad 3 1,2 rahbar medical & dental college, punjab rangers teaching hospital, lahore 3 huddersfield royal infirmary, uk, calderdale royal hospital, halifax, uk abstract purpose: to compare the central subfoveal choroidal thickness (cct) in diabetic patients with and without diabetic retinopathy. study design: cross sectional observational study. place and duration of study: al-ehsan welfare eye hospital, lahore, from june 2019 to may 2020. methods: one hundred and twenty patients with type ii diabetes were included with a mean age of57±0.9. patients were divided into two groups (60 in each group) based on presence or absence of diabetic retinopathy after ophthalmic examination. group a comprised of patients showing signs of retinopathy and group b with no signs of diabetic retinopathy. after detailed ophthalmic examination, spectral–domain oct was performed for the measurement of central subfoveal choroidal thickness. the differences in measurements were analyzed and measured by using spss version 22. results: out of 120 patients, 69 (57.5%) were males and 51 were females (42.5%). mean age of patients was 58.8 ± 10 years with minimum 28 years and maximum 94 years. central choroidal thickness in group a showed a mean value of 239 ± 41 µm with standard error of mean 3.76. while diabetic patients having no signs of diabetic retinopathy (group b) showed mean subfoveal choroidal thickness of 240 ± 42 µm with standard error of mean 3.89. the difference in central subfoveal choroidal thickness in both groups was 1.337 which is statistically insignificant with p value of 0.250. conclusion: central choroidal thickness amongst diabetic patients with and without signs of retinopathy does not have any significant changes. key words: choroid, diabetic retinopathy, optical coherence tomography. how to cite this article: haider ma, sattar u, amjad m. comparison of central subfoveal choroidal thickness in diabetic patients with and without diabetic retinopathy. pak j ophthalmol. 2021, 37 (3): 283-288. doi: 10.36351/pjo.v37i3.1207 introduction diabetes mellitus due to chronic hyperglycemia can stimulate ocular complications especially micro correspondence: muhammad ali haider rahbar medical & dental college, lahore email: alihaider_189@yahoo.com. received: january 17, 2021 accepted: april 28, 2021 vascular abnormalities including retinal and choroidal vasculature. these ocular micro vascular abnormalities affect the quality of patient’s life by influencing vision. 1 diabetic retinopathy leads to significant capillary drop-out that in turn causes non-perfusion of retinal tissue. 2 abnormal choroidal performance due to hyperglycemia include luminal narrowing, capillary drop-out and choroidal neovascularization. the most important parameter for analyzing choroidal open access mailto:alihaider_189@yahoo.com central subfoveal choroidal thickness in diabetic patients with and without diabetic retinopathy pak j ophthalmol. 2021, vol. 37 (3): 283-288 284 vasculature abnormality is choroidal thickness measurement. retinal pigment epithelium and the outer layers of retina derive their nutrition from the choroid so disturbed hemodynamics of choroidal vasculature can affect their thickness. 3 recently, many studies have been published on using choroidal thickness changes as an indicator of early retinal and choroidal vascular abnormalities. 4 previously it was thought that diabetic retinopathy is a disease which primarily affects the retinal vasculature resulting in retinopathy but recent studies have highlighted that thinning of choroiocapillaris also occurs in diabetic patients. 5 doppler flowmetry in early diabetic retinopathy has also shown decreased choroidal vessels perfusion. 6 on scanning electron microscopy, eyes with long-standing diabetes show increased vascular tortuosity, dilation and narrowing, hyper cellularity, vascular loop and micro aneurysm formation, drop-out of choroiocapillaris and sinus-like structure formation between choroidal lobules. 7,8 blood flow through the choroid also appears to be reduced in subjects with diabetes, especially those with macular edema. in vivo evaluation of choroid using enhanced depth imaging has also shown various changes in choroidal structures in recent literature. it thus follows that, structural alterations in the choroid, if any, may contribute to the pathogenesis of diabetic retinopathy. 9 the rationale of this study was to find out the central sub-foveal choroidal thickness in patients with diabetic retinopathy and compare with those without retinopathy. it may help in early detection of the microvascular changes before retinopathy actually sets in. methods this cross-sectional study was carried out at the retinal unit of al-ehsan eye hospital, lahore after approval from the ethical committee. total 120 patients were enrolled in this study. patients, who were diagnosed with diabetic retinopathy and underwent oct were included in group ‘a’. a control group ‘b’ was created of diabetic patients without any signs of diabetic retinopathy. consent, demographic profile and detailed history were recorded. all participants underwent recording of visual acuity, slit-lamp examination, intraocular pressure (iop) measurement and dilated fundal examination. diabetic retinopathy classification in group a was performed as per early treatment diabetic retinopathy study (etdrs) criteria. in case where there was any doubt as to the stage of dr, fundus fluorescein angiography was performed. inclusion criteria for group a included a history of type ii diabetes mellitus, treated with either oral hypoglycemic agents or insulin and having non proliferative or proliferative diabetic retinopathy changes without diabetic macular edema. exclusion criteria comprised of media opacities hampering fundal view and imaging, high myopia or hyperopia (> −6 or + 6 diopters of refractive error), presence of diabetic macular edema, history of treatment with antivegf or pan-retinal photocoagulation, any associated retinal pathology and previous history of retinal surgery. optical coherence tomography scans were obtained by using nidek rs-300 advance angiooct gamagori, japan (spectral domain oct optical z: 7 μm, x-y: 20 μm, digital z: 4 μm, x-y: 3 μm, x: 3 to 12 mm (12 mm for line scan only), y: 3 to 9 mm, z: 2.1 mm, sld, 880 nm, max. 53,000 a-scans / s, 1.6 s in regular mode). the scan used for imaging in this study was hd 1-line raster with enhanced depth imaging. the sclera-choroidal interface was drawn manually in the macular map x-y (9 x 9mm [512 x 128]) scan. choroidal thickness was measured between the hyper-reflective outer border of the retinal pigment epithelium (rpe) and the line of sclerachoroidal interface, and central thickness was measured as subfoveal distance in micrometer between the outer borders of retinal pigment epithelium to the line of sclera-choroidal interface. figure 1: one line raster, hd oct scan showing choroidal thickness. data was analyzed by using spss version 22. all the qualitative variables were analyzed through descriptive statistics. for quantitative variables, normality assumption was checked by using shapiromuhammad ali haider, et al 285 pak j ophthalmol. 2021, vol. 37 (3): 283-288 wilk and kolmogorov-smirnov tests. subfoveal choroidal thickness was compared in both groups of diabetics with and without retinopathy by using levene's test for equality of variances. a p value of < 0.01 was considered significant. results total 120 patients were enrolled in this study. out of which 69 (57.5%) were males and 51 were females (42.5%). mean age of patients was 58.8 ± 10 years with minimum of 28 years and maximum of 94 years. central choroidal thickness in patients with diabetic retinopathy (group a) showed a mean value of 239 ± 41 µm with standard error of mean 3.76. while diabetic patients having no any sign of diabetic retinopathy (group b) showed mean subfoveal choroidal thickness of 240 ± 42 µm with standard error of mean 3.89. normality test of central choroidal thickness with and without diabetic retinopathy showed a p value of more than 0.01 indicating statistically insignificant difference between the two groups (table 1 and 2). table 1: tests of normality. kolmogorov-smirnov a shapiro-wilk statistic df sig. statistic df sig. cct with dr .105 120 .002 .973 120 .017 cct without dr .052 120 .200 * .990 120 .548 *. this is a lower bound of the true significance. a. lilliefors significance correction table 2: comparison of subfoveal central choroidal thickness in group a and group b applying independent sample test. independent samples test levene's test for equality of variances t-test for equality of means f sig. t df sig. (2tailed) mean difference std. error difference 95% confidence interval of the difference lower upper cct equal variances assumed 1.33 .250 .429 118 .668 3.367 7.842 -12.163 18.896 equal variances not assumed .429 117.14 .668 3.367 7.842 -12.164 18.897 figure 1a: normality plot of central choroidal thickness in diabetic patients with diabetic retinopathy (group a). figure 1b: normality plot of central choroidal thickness in diabetic patients with diabetic retinopathy (group a). central subfoveal choroidal thickness in diabetic patients with and without diabetic retinopathy pak j ophthalmol. 2021, vol. 37 (3): 283-288 286 figure 1c: normality plot of central choroidal thickness in diabetic patients with diabetic retinopathy (group a). figure 2a: normality plot of central choroidal thickness in diabetic patients without diabetic retinopathy (group b). figure 2b: normality plot of central choroidal thickness in diabetic patients without diabetic retinopathy (group b). figure 2c: normality plot of central choroidal thickness in diabetic patients without diabetic retinopathy (group b). discussion enhanced depth imaging optical coherence tomography has revolutionized choroidal thickness measurements, which are useful in aiding diagnosis of diabetic eye diseases. choroidal thickness can predict the response to anti angiogenic agents in retinal pathologies including diabetic retinopathy. 10 while analysis of data on choroidal thickness in subjects with diabetes have been published, recent studies have reported conflicting results. rewbury et al. published a systematic review of articles on sub-foveal choroidal thickness in diabetic patients. as per their results, severity of diabetic retinopathy correlated with increase in sub-foveal choroidal thickness. based on their findings they made the observation that retinal vasculature changes affected the choroidal layer. 11 reliable and reproducible choroidal layer thickness measurements have been made possible through the advent of spectral domain oct. 12 our result did not show any relation of diabetic retinopathy with central choroidal thickness. however, studies have shown that metabolic changes in diabetic patients affect the vasculature of choroid and may thus play a role in development of diabetic retinopathy. 14 in one study it was seen that cct was significantly thicker in severe diabetic retinopathy as compared to the mild disease. 15 muhammad ali haider, et al 287 pak j ophthalmol. 2021, vol. 37 (3): 283-288 another researcher showed that choroidal thickness was altered in diabetes and was related to the severity of retinopathy. he also described the association of diabetic macular edema with significant decrease in the choroidal thickness. 16 similar results were shown by other authors. 17 contrary to the above mentioned studies, our results were consistent with a study which indicated no difference in the choroidal volume of patients with pdr and control subject. 18 it was recently reported that cct increased in the early stage of dr, and further decreased with dr progression. 19 yet another study has shown that disease duration was associated with a reduction of choroidal thickness and decreased cct proved to be correlated with the severity of dr. 20 the authors explained that for outer retinal layers, choroidal vasculature is the main source of nutrition. any change affecting the choroid can indirectly affect the metabolic state and functioning of retina. strength of this study is that choroidal thickness was measured at a higher resolution and with an accurate device by adjusting various confounding factors. there are certain limitations of our study. it was a cross sectional study. a longitudinal study may be carried out to document the changes occurring over a period of time in diabetic patients. we also did not compare the severity of retinopathy with choroidal thickness. the study was limited to patients with type 2 diabetes only. the scope of the study can be further enhanced with inclusion of type-1 diabetics. conclusion there is no significant difference in the central choroidal thickness between the diabetic patients with diabetic retinopathy and the patients without diabetic retinopathy. ethical approval the study was approved by the institutional review board/ ethical review board. (ec ref no: 01/19) conflict of interest authors declared no conflict of interest. references 1. adhi m, brewer e, waheed n, duker j. analysis of morphological features and vascular layers of choroid in diabetic retinopathy using spectral-domain optical coherence tomography. jama ophthalmol. 2013; 131 (10): 1267–1274. doi: 10.1001/jamaophthalmol.2013.4321. 2. sim d, keane p, mehta h, fung s, zarranz-ventura j, fruttiger m, et al. repeatability and reproducibility of choroidal vessel layer measurements in diabetic retinopathy using enhanced depth optical coherence tomography. invest ophthalmol vis sci. 2013; 54 (4): 2893–2901. doi: 10.1167/iovs.12-11085. 3. spaide r, koizumi h, pozzoni m. enhanced depth imaging spectral-domain optical coherence tomography. am j ophthalmol. 2008; 146 (4): 496– 500. 4. xu j, xu l, du k, shao l, chen c, zhou j, et al. subfoveal choroidal thickness in diabetes and diabetic retinopathy. ophthalmology, 2013; 120 (10): 2023– 2028. doi: 10.1016/j.ophtha.2013.03.009. 5. lee h, lim j, shin m. comparison of choroidal thickness in patients with diabetes by spectral-domain optical coherence tomography. korean j ophthalmol. 2013; 27 (6): 433–439. doi:10.3341/kjo.2013.27.6.433. 6. regatieri c, branchini l, carmody j, fujimoto j, duker j. choroidal thickness in patients with diabetic retinopathy analyzed by spectral-domain optical coherence tomography. retina, 2012; 32 (3): 563–568. doi: 10.1097/iae.0b013e31822f5678. 7. querques g, lattanzio r, querques l, del turco c, forte r, pierro l, et al. enhanced depth imaging optical coherence tomography in type 2 diabetes. invest ophthalmol vis sci. 2012; 53 (10): 6017–6024. doi: 10.1167/iovs.12-9692. 8. vujosevic s, martini f, cavarzeran f, pilotto e, midena e. macular and peripapillary choroidal thickness in diabetic patients. retina, 2012; 32 (9): 1781–1790. doi: 10.1097/iae.0b013e31825db73d. 9. ferreire jt, vicente a, proenca r, santos b, cunha j, alves m. choroidal thickness in diabetic patients without diabetic retinopathy. retina, 2018; 38 (4): 795804. doi: 10.1097/iae.0000000000001582. 10. sudhalkar a, chnablani kj, venkata a, raman r, rao s, jonnadula bg. choroidal thickness in diabetic patients of indian ethnicity. indian journal of ophthalmology, 2015; 63 (12): 912-916. doi: 10.4103/0301-4738.176024. 11. ferrar d, waheed nk, duker js. investigating the choriocapillaries and choroidal vasculature with new optical coherence tomography technologies. prog retina eye, 2015; 52: 130-155. doi:10.1016/j.preteyers.2015.10.002. central subfoveal choroidal thickness in diabetic patients with and without diabetic retinopathy pak j ophthalmol. 2021, vol. 37 (3): 283-288 288 12. rayess n, rahimy e, ying gs, bagheri n, ho ac, regillo cd, et al. baseline choroidal thickness as a predictor for response to anti-vascular growth factor therapy in diabetic macular edema. am j ophthalmol. 2015; 159 (1): 85-91. doi:10.1016/jj.ajo.2014.09.033. 13. abidia b, sunen i, calvo p, bartol f, verdes g, ferreras a. choroidal thickness measured using swept-source optical coherence tomography is reduced in patients with type 2 diabetes. plos one, 2018; 13 (2). doi: 10.1371/journal.pone.0191977. 14. okamoto m, matsuura t, ogata n. effects of panretinal photocoagulation on choroidal thickness and choroidal blood flow in patients with severe nonproliferative diabetic retinopathy. retina, 2016; 36: 805–811. doi: 10.1097/iae.0000000000000800. 15. ohara z, tabuchi h, nakakura s, yoshizumi y, sumino h, maeda y, et al. changes in choroidal thickness in patients with diabetic retinopathy. int ophthalmol. 2018; 38 (1): 279-286. doi: 10.1007/s10792-017-0459-9. 16. regatieri cv, branchini l, carmody j, fujimoto jg, duker js. choroidal thickness in patients with diabetic retinopathy analyzed by spectral-domain optical coherence tomography. retina, 2012; 32: 563– 568. doi: 10.1097/iae.0b013e31822f5678. 17. unsal e, eltutar k, zirtiloğlu s, dinçer n, ozdoğan erkul s, güngel h. choroidal thickness in patients with diabetic retinopathy. clin ophthalmol. 2014; 8: 637–642. doi: 10.2147/opth.s59395 18. schocket ls, brucker aj, niknam rm, grunwald je, dupont j, brucker aj. foveolar choroidal hemodynamics in proliferative diabetic retinopathy. int ophthalmol. 2004; 25 (2): 89-94. doi: 10.1023/b:inte.0000031744.93778.60. 19. wang w, liu s, qiu z, he m, wang l, li y, huang w. choroidal thickness in diabetes and diabetic retinopathy: a swept source oct study. invest ophthalmol vis sci. 2020; 61 (4): 29. doi: 10.1167/iovs.61.4.29. 20. horváth h, kovács i, sándor gl, czakó c, mallár k, récsán z, et al. choroidal thickness changes in non-treated eyes of patients with diabetes: swept-source optical coherence tomography study. acta diabetol. 2018; 55 (9): 927-934. doi: 10.1007/s00592-018-1169-0. authors’ designation and contribution muhammad ali haider; assistant professor: concepts, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. uzma sattar; investigative oculist: design, data analysis, statistical analysis, manuscript review. muhammad amjad; consultant ophthalmologist: literature search, manuscript editing, manuscript review. .…  …. pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 105 original article visual outcomes of immediate versus delayed vitrectomy for dropped nucleus during phacoemulsification shakir zafar, syed asaad mahmood, munira shakir, saima amin, syed fawad rizvi pak j ophthalmol 2016, vol. 32 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syed asaad mahmood mbbs resident lrbt free base eye hospital korangi 2½, karachi. email. syed_asaad@yahoo.com received: march 25, 2016 accepted: may 24, 2016 …..……………………….. purpose: to compare the visual outcome of patients undergoing immediate pars plana vitrectomy (ppv) surgery for dropped nucleus during versus delayed phacoemulsification. study design: retrospective quasi – experimental. place and duration of study: this study was conducted at lrbt tertiary eye hospital, karachi from february 2008 to february 2014. material and methods: records of patients who underwent ppv for dislocated lens fragments were reviewed. patients were divided into two groups depending on whether they underwent ppv immediately following nucleus drop (group a) or as a second procedure within 15 days’ time (group b). data collected included patient demographics, pre-operative best – corrected visual acuity (bcva), duration of follow up, post-operative intraocular pressure, final bcva and postoperative complications. patient data was analysed at 12 months postoperatively. ibm spss 21 was used for data analysis. results: fifty seven patients (30 in group a and 27 in group b) were included in this study. the mean postoperative bcva at 12 months for group a was 6/12 -1 (range 6/6 – 6/36) and for group b was 6/12 (range 6/6 – 6/36). the mean improvement seen in bcva was by 4.83 ± 1.39 lines of snellen chart in group a and 4.67 ± 1.94 lines in group b compared to the preoperative visual acuities (pvalue = 0.709). cystoid macular edema (cme) occurred in 16% (5 patients) in group a and 11% (3 patients) in group b while corneal edema was encountered in 7% (2 patients) in group a and 4% (1 patient) in group b. conclusion: although the final visual outcomes were comparable between the two groups, early vitrectomy reduces the morbidity and results in a quicker visual recovery. key-words: dropped nucleus; lens subluxation; phacoemulsification; posterior capsular rupture; vitrectomy. ataract surgery is the most commonly performed ocular surgery in the adult population. the cataract surgical rate (csr) varies considerably among different parts of the world, from 2000 per million populations to 25000 per million populations1,2. the technology involved in this procedure has progressed rapidly over the last few decades which have resulted in ophthalmic surgeons shifting from intra capsular cataract extractions to extra capsular cataract extractions (ecce) with intra ocular lens (iol) implantation and later onto sutureless small incision cataract extractions (sics) and phacoemulsification. the technological evolution is still ongoing with the introduction of femtosecond c mailto:syed_asaad@yahoo.com shakir zafar, et al 106 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology laser that has automated several of the manual steps of phacoemulsification surgery resulting in more precise refractive outcomes3. generally, cataract surgery is a very safe procedure with good results in a large majority of the cases. however, like any surgical procedure, it has its associated set of complications. posterior dislocation of the nucleus (or of a partially emulsified nucleus) into the posterior segment is one of the most dreaded complication, that may lead to further problems secondary to severe inflammation, such as macular edema, glaucoma and retinal detachment4. its incidence is about 0.2% – 1.5%5. if detected in the initial stages, there are several approaches that the surgeon may employ to prevent nucleus dropping into the vitreous cavity, including the posterior assisted levitation, hema life boat and iol scaffold technique6. however, if the nucleus has reached the posterior pole or is in the posterior vitreous, further management is best left for the vitreo-retinal surgeon as any attempt to chase after the nucleus may result in retinal tears and detachment7. timely pars plana vitrectomy (ppv) for removal of the dropped nucleus/ nuclear fragments is a well – established method for restoring good vision and preventing secondary complications8,9. the ideal timing of vitrectomy after cataract surgery still remains debated. traditionally, the ppv was delayed so that the eye could recover from the inflammation caused by the initial surgery5. but several recent studies have advocated for vitrectomy to be performed on the same day as the complicated cataract surgery, citing reduced complication rates and better visual prognosis.5,10 in practice though, a few other significant factors come into play when deciding the vitrectomy timing including the availability of an experienced vitreo-retinal surgeon and the necessary machinery, both of which are not readily available in all the cataract surgery centres in regions similar to ours. the purpose of this study was to compare the visual outcomes achieved in same-day vitrectomy with the results of delayed vitrectomy for the management of dropped nucleus / nuclear fragments in a tertiary eye care setup. material and methods records of patients undergoing surgery at lrbt free eye hospital, karachi during february 2008 to february 2014 were reviewed retrospectively for this study. the hospital ethics board reviewed the study before it was performed and a written informed consent had been taken from all participants in the study. included in this study were all patients who had loss of nucleus (or part of it) into the posterior segment during a phacoemulsification surgery and subsequent pars plana vitrectomy (ppv) surgery to remove it. patients were divided into two groups depending on the time interval between phacoemulsification and ppv surgeries; whether pars plana vitrectomy was performed immediately following nucleus drop (group a) or it was performed later on, within 15 days’ time (group b). in addition to these, patients with corneal opacities, glaucoma, pre-existing macular disorders limiting visual prognosis postphacoemulsification, and those presenting with concomitant retinal detachments were screened out of the study. moreover, patients with follow up of less than 12 months were excluded from the analysis. a proforma was used to record demographics, preoperative and postoperative visual acuity, intraocular pressure via applanation tonometry, corneal oedema, anterior chamber reaction, hyphema, vitritis, vitreous haemorrhage, retinal detachment, postoperative complications and time interval between the two surgeries. for sake of comparison, the preoperative visual acuity of group b used for calculation is the visual acuity recorded before the initial cataract surgery. all patients were re-assessed on post-op day 1, day 7, 1 month, 3 months and at 12 months, although a few required more frequent follow-ups. data was analysed using ibm spss statistics 21. pearson chi-square test and t-test were applied to test for significance between groups. a p-value < 0.05 was considered significant. the ppv was performed by one of the two vitreoretinal surgeons under local anaesthesia using the same procedure. mvr knife was used to make 3-ports for 20 gauge pars plana vitrectomy. core vitrectomy was performed to avoid jabbing the vitreous during aspiration. the density of nuclear fragments was assessed on the operating table. in case of a complete nucleus drop or a large fragment, perfluorocarbon liquid (pfcl) was used to lift it away from posterior pole, displaced into the anterior chamber and removed via a limbal incision. for small fragments and soft remnants, 1 – 2 ml of perfluorocarbon liquid was used to float the fragments away from the visual outcomes of immediate versus delayed viterctomy pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 107 posterior pole (to protect the underlying retina) and these were then removed with a vitreotome, using the endoilluminator to break the fragments into smaller pieces where needed. laser photocoagulation of peripheral retina using endolaser was done in myopic eyes. at the end of the surgery, posterior chamber intraocular lens (iol) was placed in patients with adequate posterior capsular support while anterior chamber iol was implanted in the rest. postoperatively, all eyes received topical drops containing moxifloxacin 0.5% and dexamethasone 0.1% 2 hourly for first week which was tapered off over eight weeks. in addition, ciprofloxacin 500mg twice a day and ibuprofen 200 mg 3 times a day was given for the first 3 postoperative days. postoperative examination during the follow-up visits included va, bcva, iop measurement, and screening for any postoperative complications, which were managed on individual basis. results fifty seven patients were included in this study. 53% (30 patients 17 males and 13 females) were in group a and 47% (27 patients – 18 males and 9 females) in group b. mean age at the time of surgery was 50.2 ± 11.1 years for group a and 54.8 ± 10.3 years for group b patients (p-value = 0.938). the mean postoperative bcva (snellen decimal) at 12 months for group a was 0.484 ± 0.200 (equivalent to snellen fraction of 6/12-1) and for group b was 0.507±0.191 (equivalent to snellen fraction of 6/12). the mean improvement seen in visual acuities on snellen chart testing was of 4.83 ± 1.39 lines in group a and 4.67 ± 1.94 lines in group b (p-value = 0.709). details of visual acuities achieved after surgery in the two groups is given in (table 1). table 1: postoperative bcva achieved by the two groups at 12 months. postop visual acuity group no. of patients n (%) a (immediate) n (%) b (delayed) n (%) 6/36 2 (7) 1 (4) 3 (5) 6/24 1 (3) 1 (4) 2 (4) 6/18 10 (33) 7 (26) 17 (30) 6/12 8 (27) 10 (37) 18 (31) 6/9 6 (20) 5 (18) 11 (19) 6/7.5 2 (7) 2 (7) 4 (7) 6/6 1 (3) 1 (4) 2 (4) total 30 27 57 chart 1: postoperative bcva achieved by group a. cystoid macular edema (cme) occurred in 16% (5 patients) in group a and 11% (3 patients) in group b while corneal edema was encountered in 7% (2 patients) in group a and 4% (1 patient) in group b. the difference between the groups was statistically insignificant in both cases (p-values of 0.540 for cme and 0.415 for corneal edema). anterior chamber iol implantation was done in 10% (3 patients) in group a compared to 29% (8 patients) in group b (p-value = 0.061). discussion while the overall incidence of nucleus drop is low, some institutions such as those incorporating resident training, are likely to have a higher than average incidence of surgical complications11. this complication is seen more commonly in cataract procedures done through a smaller incision as they involve more ‘in-the-bag’ manipulation of the nucleus. excessive infusion, weak zonules, ultrasound shakir zafar, et al 108 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology repulsion, vitreous syneresis, or posterior capsular rupture may all cause the nucleus to fall posteriorly. this may result in a number of complications that include intraocular inflammation, corneal decompensation, glaucoma, cystoid macular edema (cme) and retinal detachment5. chart 2: postoperative bcva achieved by group b. once posterior capsular rupture is detected, the strategy of the cataract surgeon should be to minimize vitreous traction, stabilize anterior chamber volume, maintain capsular and zonular integrity, and protect the corneal endothelium12. this includes the use of ophthalmic viscoelastic devices (ovd) to buoy the nucleus fragments and to push back the anterior hyaloid face, removal of as much of the remaining lens matter as safely possible, anterior vitrectomy and placement of an iol if possible. conventionally, in case of a complete nucleus drop, the iol is not implanted as the nucleus may have to be removed anteriorly in case intra-vitreal fragmentation was not possible. where secondary vitrectomy is indicated, early referral is recommended by some authors to reduce patient morbidity13. a meta-analysis found significantly better outcomes in terms of visual acuity, as well as decreased risk of complications with earlier vitrectomy for retained lens fragments.10 chalam et al, mentions decreased patient stress levels, reduced risks of repeated anaesthesia, and reduced collateral damage to intraocular structures due to fewer interventions by cataract surgeon as major advantages of having the patient undergo same day vitrectomy, although reduced visualization due to an edematous cornea, hypotony, suprachoroidal haemorrhage and patient fatigue due to prolonged operative time may occur5. in a study by chen et al., patients who underwent ppv within a day of experiencing a dropped nucleus experienced no complications with 76% achieving a final visual acuity of ≥ 6/12 whereas increasing delays was associated with decrease in visual prognosis and an increase in complication rates14. on the other hand, colyer et al, found no difference between same-day ppv and non-same-day ppv patients15. similarly orlin et al, found no significant difference in visual acuity or post-operative complications between the same-day or the delayed vitrectomy groups16. in contrast to the earlier studies, orlin et al. also found that visual acuity ≥ 6/12 was obtained in 66.7% of the delayed group compared with 23.1% of the same-setting group16. this study shows no statistically significant differences between the visual acuities achieved in the two groups. 29.8% (17 patients) in the immediate vitrectomy group achieved ≥ 6/12 whereas the same was achieved by 31.6% (18 patients) in the delayed vitrectomy group, and a visual acuity of ≥ 6/18 was obtain by at least 90% patients in both groups. no differences were seen in the complication rates either and the number of complications was lower than that reported in earlier studies17,18,19. the decrease in the number of complications over the years has also been seen in other parts of the world1. scott et al. has implicated persistent cme as the most common cause of decreased final vision19. in a review by romano et al., the incidence of cme after vitrectomy surgery is reported to be 5.5%20. in this study, postoperative cme occurred in 14% (8 cases) and this was managed conservatively. a reason for the relatively higher incidence of cme could be the dropped nuclear material causing intraocular inflammation, and hence cme, before the surgical intervention takes place. although several patients continued to have subclinical cme as assessed by oct, clinical cme had resolved in all patients by the end point of the study. in the current study, 3 patients required an anterior chamber iol implantation in group a compared to 8 anterior chamber iols implanted in group b. although the result failed to achieve visual outcomes of immediate versus delayed viterctomy pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 109 statistical significance, this difference may be an indication that due to the non-availability of a vitreoretinal surgeon for group b, the cataract surgeon may have attempted retrieval of the dropped nucleus fragment unsuccessfully and enlarged the posterior capsular tear in the process thereby not leaving enough capsular support for a posterior chamber iol to be placed. conclusion the final visual outcomes after nucleus drop during phacoemulsification were comparable in patients who underwent pars plana vitrectomy immediately and those who had the procedure after a delay of up to 15 days. the authors like to recommend immediate vitrectomy in setups where a vitreo-retinal theatre and surgeon are available as it reduces the morbidity and results in a quicker visual recovery. in cases where this is not possible, an ethically acceptable alternative would be to schedule the procedure within 2 weeks’ time as it is seen to have similar outcomes in terms of final visual acuity achieved. author’s affiliation dr. shakir zafar consultant ophthalmologist lrbt free base eye hospital korangi 2 ½, karachi74900 dr. syed asaad mahmood resident lrbt free base eye hospital korangi 2 ½, karachi74900 dr. munira shakir consultant ophthalmologist liaquat national hospital national stadium road karachi74800 dr. saima amin resident lrbt free base eye hospital korangi 2 ½, karachi-74900 dr. syed fawad rizvi chief consultant ophthalmologist lrbt free base eye hospital korangi 2 ½, karachi postal code: 74900 role of authors: dr. shakir zafar conceptualized this study. dr. syed asaad mahmood literature review. dr. munira shakir statistical analysis. dr. saima amin study design review. prof. syed fawad rizvi manuscript review. references 1. lundström m, goh pp, henry y, salowi ma, barry p, manning s, rosen p, stenevi u. the changing pattern of cataract surgery indications: a 5-year study of 2 cataract surgery databases. ophthalmology, 2015; 122: 31-8. 2. murthy g, gupta sk, john n, vashist p. current status of cataract blindness and vision 2020: the right to sight initiative in india. indian journal of ophthalmology, 2008; 56: 489-94. 3. bowling b. kanski’s clinical ophthalmology: a systemic approach, 8th ed. philadelphia: elsevier, 2015: 285. 4. gilliland gd, hutton wl, fuller dg. retained intravitreal lens fragments after cataract 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vitrectomy improves outcome in retained intravitreal lens fragments after phacoemulsification. ophthalmologica journal international d'ophtalmologie international journal of ophthalmology zeitschrift fur augenheilkunde, 2008; 222: 277-83. 15. colyer mh1, berinstein dm, khan nj, weichel ed, lai mm, deegan wf, katira rc, phillips wb, sanders rj, garfinkel ra. same – day versus delayed vitrectomy with lensectomy for the management of retained lens fragments. retina, 2011; 31: 1534-40. 16. orlin a, parlitsis g, chiu yl, d'amico dj, chan rv, kiss s. a comparison of same setting versus delayed vitrectomy in the management of retained lens fragments after cataract surgery. retina, 2014; 34: 196976. 17. kim ik, miller jw. management of dislocated lens material. seminars in ophthalmology, 2002; 17: 162-6. 18. romero – aroca p, fernandez – ballart j, mendez – marin i, salvat – serra m, baget – bernaldiz m, buil – calvo ja. management of nucleus loss into the vitreous: long term follow up in 63 patients. clin ophthalmol. 2007; 1: 505-12. 19. scott iu1, flynn hw jr, smiddy we, murray tg, moore jk, lemus dr, feuer wj. clinical features and outcomes of pars plana vitrectomy in patients with retained lens fragments. ophthalmology, 2003; 110: 1567-72. 20. romano v1, angi m, scotti f, del grosso r, romano d, semeraro f, vinciguerra p, costagliola c, romano mr. inflammation and macular oedema after pars plana vitrectomy. mediators of inflammation, 2013; 2013: 971758. http://www.ncbi.nlm.nih.gov/pubmed/?term=colyer%20mh%5bauthor%5d&cauthor=true&cauthor_uid=21799466 http://www.ncbi.nlm.nih.gov/pubmed/?term=berinstein%20dm%5bauthor%5d&cauthor=true&cauthor_uid=21799466 http://www.ncbi.nlm.nih.gov/pubmed/?term=khan%20nj%5bauthor%5d&cauthor=true&cauthor_uid=21799466 http://www.ncbi.nlm.nih.gov/pubmed/?term=weichel%20ed%5bauthor%5d&cauthor=true&cauthor_uid=21799466 http://www.ncbi.nlm.nih.gov/pubmed/?term=lai%20mm%5bauthor%5d&cauthor=true&cauthor_uid=21799466 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http://www.ncbi.nlm.nih.gov/pubmed/?term=romano%20d%5bauthor%5d&cauthor=true&cauthor_uid=24288446 http://www.ncbi.nlm.nih.gov/pubmed/?term=semeraro%20f%5bauthor%5d&cauthor=true&cauthor_uid=24288446 http://www.ncbi.nlm.nih.gov/pubmed/?term=vinciguerra%20p%5bauthor%5d&cauthor=true&cauthor_uid=24288446 http://www.ncbi.nlm.nih.gov/pubmed/?term=costagliola%20c%5bauthor%5d&cauthor=true&cauthor_uid=24288446 http://www.ncbi.nlm.nih.gov/pubmed/?term=romano%20mr%5bauthor%5d&cauthor=true&cauthor_uid=24288446 http://www.ncbi.nlm.nih.gov/pubmed/?term=romano%20mr%5bauthor%5d&cauthor=true&cauthor_uid=24288446 http://www.ncbi.nlm.nih.gov/pubmed/?term=romano%20mr%5bauthor%5d&cauthor=true&cauthor_uid=24288446 pak j ophthalmol. 2021, vol. 37 (2): 188-191 188 original article anatomical and functional outcome of rectangular three snip punctoplasty in primary acquired punctal stenosis in a tertiary care hospital of karachi nazia qidwai 1 , muhammad ashraf 2 , mujahid inam 3 , adil salim jafri 4 , saima majid 5 1-5 department of ophthalmology, isra postgraduate institute of ophthalmology, karachi abstract purpose: to find out the anatomical and functional outcomes of rectangular three-snip punctoplasty in primary acquired punctal stenosis. study design: quasi experimental study. place and duration of study: isra postgraduate institute of ophthalmology, karachi, from july to december 2020. methods: patients of age 50 years and above, from either gender with primary acquired punctal stenosis of any grade (0-5) presenting with epiphora were recruited from oculoplasty outpatient department. punctal stenosis with secondary causes like lesion on or around punctum or lacrimal drainage system and history of surgery or radiotherapy, lower canalicular or common canalicular stenosis were excluded from the study. punctal stenosis was graded by kashkouli scale and epiphora by the munk score. after local anesthesia, two vertical cuts were given in the posterior wall of the punctum and a third cut was given horizontally to connect the vertical cuts. this resulted in a posterior ampullectomy. syringing and probing was done to assess patency of the lower lacrimal drainage system. the patients were followed up for 6 months to assess for anatomical and functional success. results: at the end of six month anatomical success was achieved in 85% cases and functional success in 70% patients. fifteen percent patients suffered re-stenosis of punctum. conclusion: rectangular punctoplasty is a functionally successful procedure for treating primary acquired punctal stenosis. the anatomy is least distorted and long-term recurrence rate is also low. key words: epiphora, primary acquired punctual stenosis, punctoplasty, munk score. how to cite this article: qidwai n, ashraf m, inam m, jafri as, majid s. anatomical and functional outcome of rectangular three snip punctoplasty in primary acquired punctal stenosis in a tertiary care hospital of karachi. pak j ophthalmol. 2021, 37 (2): 188-191. doi: http://doi.org/10.36351/pjo.v37i2.1166 introduction punctal stenosis results in epiphora in 94% eyes. 1 incidence of acquired punctal stenosis has been correspondence: nazia qidwai department of ophthalmology, isra postgraduate institute of ophthalmology, karachi email: nazia_qidwai@hotmail.com received: november 16, 2020 accepted: january 27, 2021 reported to be between 8 and 54.3%. 2 it can be idiopathic or secondary to chronic inflammation, eyelid malpositioning, infection (herpes zoster, chlamydia, human papilloma virus, and actinomyces), cicatricial conjunctivitis, trauma, eyelid neoplasms, use of topical antiglaucoma agents or chemotherapeutic agents such as mitomycin c, aggressive lacrimal probing, tumors, porphyria cutanea tarda, acrodermatitis enteropathica, systemic chemotherapy, and irradiation and last but not the http://doi.org/10.3352/jeehp.2013.10.3 mailto:nazia_qidwai@hotmail.com nazia qidwai, et al 189 pak j ophthalmol. 2021, vol. 37 (2): 188-191 least, aging. 3,4 these factors result in scarring and fibrosis. 5,6 punctal stenosis is graded according to the size of lumen of the punctum visible on slit lamp examination. kashkouli et al suggested a scale of punctal stenosis. 7 various methods have been tried over the years to treat punctal stenosis. one snip procedure was first described by bowman in 1853. 8 as this did not relieve the symptom effectively, two, three and four snip punctoplasty were subsequently introduced. three snip which is the most successful technique has two types, the triangular and the rectangular types. 9 in the triangular type, a triangular flap is made by cutting the vertical canaliculus and then the horizontal canaliculus. the base of the canaliculus is then cut. in the rectangular type, however, two snips are made in the vertical canaliculus and a snip at the base. a posterior ampullectomy is hence created. 9 kim et al suggested yet another modification, the four snip punctoplasty. in this technique one snip is given in the vertical canaliculus followed by a horizontal snip. a third vertical or horizontal cut is given after which the base of the flap is removed. 10,11 various surgical techniques and adjunct therapies have thereby, been undertaken in a hope to improve surgical outcome. adjunct therapies like use of mitomycin c, kelly’s and reiss punctal punch, stents, punctal plugs, pigtail probe and placement of interrupted sutures after punctoplasty have been employed to aid management of complicated cases of punctal stenosis. 12,13,14 anatomical outcome of punctoplasty in various studies has been recorded to be 74.7%, 86% and 91%. 15,16 whereas, functional success was achieved in 64% in the study by shahid et al and 89.8% in a study by chak et al. 9 rationale of this study was to find out the functional and anatomical results in a tertiary care center of karachi. methods sample size was calculated through rao soft sample size calculator having a prevalence of 54.3% 17 of punctal stenosis with a 95% ci and 5% margin of error. non-probability convenient sampling technique was used. punctal stenosis was defined as a condition in which the punctum was narrowed or occluded. patients of 50 years and above age, with lower punctal stenosis of any grade (0-5) according to kashkouli et al’s scale of punctal stenosis, patent upper punctum, canaliculi and nasolacrimal duct as proven on syringing and probing through upper punctum and normal lower eyelid margin position were included in the study. patients with past history of eyelids surgery, punctal stenosis with secondary causes like lesion on or around punctum or lacrimal drainage system, history of radiotherapy and lower canalicular or common canalicular stenosis were excluded. this study was conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. informed consent was obtained from all patients before surgery. before surgery, grading of punctal stenosis was done according to the kashkouli et al’s scale. 3 epiphora was graded according to the munk score. 18,19 upper punctum was assessed for patency and then syringing and probing was performed via the upper punctum to assess the lacrimal drainage system. local anesthesia was injected below the punctum and the standard rectangular three-snip procedure was performed. two vertical cuts were given in the posterior wall of the punctum and a third cut was given horizontally to connect the vertical cuts. this resulted in a posterior ampullectomy. syringing and probing was done to assess patency of the lower lacrimal drainage system. for punctal stenosis grade 0, where no punctum could be found, a pigtail probe was used to identify the punctal site. incision was given by the tip of a 1cc needle vertically at this identified site. standard procedure for punctoplasty and syringing and probing was performed. antibiotic eye drops were instilled and the patient was reviewed at 1 st week and then 1 st , 3 rd and 6 th months. on these follow up visits, improvement in subjective epiphora was assessed by munk score and objectively by kashkouli scale. the munk score is as under. 0 no epiphora 1 occasional epiphora requiring drying or dabbing less than twice a day 2 epiphora requiring dabbing two to four times per day 3 epiphora requiring dabbing five to ten times per day 4 epiphora requiring dabbing more than ten times daily or constant tearing kashkouli scale. grade clinical findings 0 no punctum (agenesis) 1 papilla is covered with a membrane (difficult to recognize) 2 less than normal size, but recognizable anatomical and functional outcome of rectangular three snip punctoplasty in primary acquired punctal stenosis in a tertiary care hospital pak j ophthalmol. 2021, vol. 37 (2): 188-191 190 3 normal 4 small slit (< 2 mm) 5 large slit (≤ 2 mm) results two hundred and seventy two patients underwent rectangular punctoplasty. at the time of admission, 90% presented with epiphora and 10% with ocular discomfort. according to kashkouli scale, punctal stenosis was of grade 2 in 210 patients, 42 had grade 1 and 20 had grade 0 punctal stenosis. epiphora was graded by munk score according to which 190 patients fell in grade 4, 30 fell in grade 3, 25 in grade 2 and 27 in grade 1. scoring was repeated after the procedure. at the end of 6 th month anatomical success was achieved in 85% cases and functional success in 70% patients. presence of epiphora despite punctual patency was in 10%patients and 15% suffered restenosis of punctum. discussion punctoplasty has developed over the years in the form of one to four snip procedures. various studies have been conducted to assess results of the various types of punctoplasty. it is generally agreed that rectangular three snip punctoplasty has better results than the rest of the procedures in terms of anatomical and functional outcome. the purpose is to make the punctum patent again. by giving cuts in the vertical canaliculus and avoiding the horizontal canaliculus, we save the proximal lacrimal pump action. the triangular three snip procedure affects the lacrimal pump action. chak et al 9 showed more failures in the triangular punctoplasty group as compared to the rectangular one. functional epiphora was commoner in the triangular punctoplasty group being 16.9% whereas in the rectangular punctoplasty group it was10.2%. functional success in this study was 89.8%. they concluded that rectangular 3-snip punctoplasty was less destructive procedure hence preserving the proximal lacrimal pump mechanisms. 9 in triangular punctoplasty, the horizontal and vertical canaliculi are cut. this causes more anatomical destruction and prevention of the opposition and occlusion of the puncta and creation of an active pump and vacuum. in rectangular punctoplasty, however, only the vertical section of the canaliculus is excised. this preserves the anatomy and physiology of the lacrimal system. 20 mj ali et al showed that 74.7% achieved functional success after rectangular punctoplasty. 1 caesar and mcnab retrospectively evaluated 53 cases of punctal stenosis and found that 92% of patients showed subjective improvement in epiphora. 4 murdock et al found in their study that 86% were primarily asymptomatic following rectangular punctoplasty at an average of 1.2 months after surgery without the need for further surgical intervention. however, 14% suffered restenosis and were dealt with secondary procedures using adjuncts which eventually elevated the success rate to 100%. 17 shahid et al showed 91% anatomical success and 64% functional success. however, 40.8% reported epiphora despite patent punctum. 18 an audit conducted by baig et al found 66.7% to improve functionally after rectangular punctoplasty. 23 in our study 85% anatomical and 70% functional success indicates that rectangular punctoplasty is a good procedure for primary punctual stenosis. restenosis in a small number of patients however, remains to be a concern and requires secondary surgical procedures including use of adjuncts. the various causes that have been attributed to punctual restenosis include chronic blepharitis, lid laxity and post-op cicatrisation. 17 limitation of this study is the single center trial and there was no control group. further multi-center studies comparing different procedure should be carried out with long term follow-ups. conclusion rectangular three snip is a good procedure for primary acquired punctal stenosis. it provides long term relief from ephiora without causing any substantial complications. ethical approval the study was approved by the institutional review board/ ethical review board. (rec/ipio/2020/003) conflict of interest authors declared no conflict of interest. references 1. ali mj, ayyar a, naik mn. outcomes of rectangular 3-snip punctoplsaty in acquired punctal stenosis: is there a need to be minimally invasive? eye, 2015; 29 (4): 515–518. nazia qidwai, et al 191 pak j ophthalmol. 2021, vol. 37 (2): 188-191 2. soiberman u, kalkizaki h, selva d, leibovitch i. clin punctal stenosis: definition, diagnosis, and treatment. clin ophthalmol. 2012; 6: 1011–1018. 3. kashkouli mb, beigi b, murthy r, astbury n. acquired external punctal stenosis: etiology and associated findings. am j ophthalmol. 2003; 136 (6): 1079–1084. 4. caesar rh, mcnab aa. a brief history of punctoplasty: the 3-snip revisited. eye reconstr surg. 2005; 19 (1): 16–18. 5. port ad, chen yt, lelli gj. histopathological changes in punctal stenosis. ophthal plast reconstr surg. 2013; 29: 201–204. 6. ali mj, mishra dk, baig f, lakshman m, naik mn. punctal stenosis: histology, immunology and electron microscopic features—a step towards unravelling the mysterious etiopathogenesis. ophthal plast reconstr surg. 2015; 31 (2): 98-102. 7. kashkouli mb, nilforushan n, nojomi n, rezaee r. external lacrimal punctum grading: reliability and interobserver variation. eur j ophthalmol. 2008; 18 (4): 507–511. 8. bowman w. method of treatment for epiphora depends on the overturning or obliteration of the tear points. ann oculist. 1853; 29: 52-55. 9. chak m, irvine f. rectangular 3-snip punctoplasty outcomes: preservation of the lacrimal pump in punctoplasty surgery. ophthal plast reconstr surg. 2009; 25 (2): 134-135. 10. kim se, lee sj, lee sy, yoon js. outcomes of 4snip punctoplasty for severe punctal stenosis: measurement of tear meniscus height by optical coherence tomography. am j ophthalmol. 2012; 153 (4): 769-773. 11. park sj, noh jh, park kb, jang sy, lee jw. a novel surgical technique for punctal stenosis: placement of three interrupted sutures after rectangular three-snip punctoplasty. bmc ophthalmology, 2018; 18: 70. https://doi.org/10.1186/s12886-018-0733-2. 12. ma’luf rn, hamush ng, awwad st, noureddin bn. mitomycin c as adjunct therapy in correcting punctal stenosis. ophthal plast reconstr surg. 2002; 18 (4): 285-288. 13. wong es, li ey, yeun hk. long-term outcomes of punch punctoplasty with kelly punch and review of literature. eye (london, england). 2017; 31 (4): 560565. 14. mandour ss, said-ahmed ke, khairy ha, elsawy mf, zaky ma. a simple surgical approach for the management of acquired severe lower punctal stenosis. j ophthalmol. 2019: 35618. https://doi.org/10.1155/2019/3561857 15. murdock j, lee ww, zatezalo cc. three-snip punctoplasty outcome rates and follow-up treatments. orbit, 2015; 34 (3): 160-163. 16. shahid h, sandhu a, keenan t, pearson a. factors affecting outcome of punctoplasty surgery: a review of 205 cases. br j ophthalmol. 2008; 92 (12): 1689-1692. 17. bukhari a. prevalence of punctal stenosis among ophthalmology patients. middle east afr j ophthalmol. 2009; 16 (2): 85-87. 18. munk pl1, lin dt, morris dc. epiphora: treatment by means of dacryocystoplasty with balloon dilation of the nasolacrimal drainage apparatus. radiology, 177 (3): 687-690. 19. ozlen ro, levent a, nesrin t, onur k. management of acquired punctal stenosis with perforated punctal plugs. saudi j ophthalmol. 2015; 29 (3): 205-209. 20. lemp ma, wolfley de. the lacrimal apparatus. in: hart wm, ed. adler’s physiology of the eye. 9th ed. chapter 2. st. louis, mo: mosby-year book inc, 1992. 21. baig r, aslam b, ahmed k. an audit of 3-snip procedures performed at the aga khan university hospital, karachi, pakistan. j pak med assoc. 2020; 70 (3): 494-496. authors’ designation and contribution nazia qidwai; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. muhammad ashraf; associate professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation. mujahid inam; assistant professor: concepts, design, literature search, data acquisition, manuscript preparation. adil salim jafri; assistant professor: design, literature search, data acquisition, manuscript editing, manuscript review. saima majid; assistant professor: design, literature search, data acquisition, manuscript editing, manuscript review. .…  …. https://doi.org/10.1186/s12886-018-0733-2 https://www.ncbi.nlm.nih.gov/pubmed/?term=shahid%20h%5bauthor%5d&cauthor=true&cauthor_uid=18786958 https://www.ncbi.nlm.nih.gov/pubmed/?term=sandhu%20a%5bauthor%5d&cauthor=true&cauthor_uid=18786958 https://www.ncbi.nlm.nih.gov/pubmed/?term=keenan%20t%5bauthor%5d&cauthor=true&cauthor_uid=18786958 https://www.ncbi.nlm.nih.gov/pubmed/?term=pearson%20a%5bauthor%5d&cauthor=true&cauthor_uid=18786958 https://www.ncbi.nlm.nih.gov/pubmed/18786958 https://www.ncbi.nlm.nih.gov/pubmed/?term=munk%20pl%5bauthor%5d&cauthor=true&cauthor_uid=2243969 https://www.ncbi.nlm.nih.gov/pubmed/?term=lin%20dt%5bauthor%5d&cauthor=true&cauthor_uid=2243969 https://www.ncbi.nlm.nih.gov/pubmed/?term=morris%20dc%5bauthor%5d&cauthor=true&cauthor_uid=2243969 179 pak j ophthalmol. 2021, vol. 37 (2): 179-182 original article late within the capsular bag intraocular lens dislocation (ten – year experience) munir amjad baig 1 , rabeeya munir 2 1 department of ophthalmology, ajk medical college, muzaffar abad, 2 islami medical and dental college abstract purpose: to find out the frequency and causes of within the bag intraocular lens dislocation. study design: descriptive, retrospective study. place and duration of study: federal government services hospital islamabad, from 2008 to 2018. methods: records of all the patients who underwent uneventful phacoemulsification were studied. patients with pseudoexfoliation and glaucoma were excluded. out-of-the bag iol dislocations and early dislocations that occurred within first three months after the cataract surgery were also not included. percentage of patients with dislocated lens within the capsular bag after three months or more was calculated and the cause of dislocation was found. results were presented in percentages. results: three thousand patients underwent uneventful phacoemulsification. two thousand nine hundred thirty two (2932) patients fulfilled the inclusion criteria while 68 patients did not return for follow up. age ranged between 25 and 75 years. there were 1600 males and 1332 were females. one thousand seven hundred and sixty were right eyes and one thousand one hundred and seventy two were left eyes. sixty one (2.08%) developed late iol dislocations, 35 (57.3%) males and 26 (42.7%) females. patients of age group 50 – 75 years had more iol dislocations. causes of dislocation included; advanced mature cataract 21.3%, 19.7% with postoperative trauma, uveitis 14.7%, myopia 9.8%, silicon plate design in 9.8%, eccentric capsulorhexis 8.1%, small capsulorhexis 6.5%, retinitis pigmentosa 3.2% and in 6.5% no cause was found. conclusion: advanced mature cataract and postoperative trauma were the commonest causes of iol dislocation. key words: cataract surgery, phacoemulsification, trauma, capsulorhexis. intra ocular lens dislocation. how to cite this article: baig ma, munir r. late within the capsular bag intraocular lens dislocation (ten – year experience). pak j ophthalmol. 2021, 37 (2): 179-182. doi: http://doi.org/10.36351/pjo.v37i2.1110 introduction with improved techniques, phacoemulsification with intra ocular lens (iol) implantation has proved to be a successful and safe surgery for cataract extraction. correspondence: munir amjad baig department of ophthalmology, ajk medical college, muzaffar abad email: drmuniramjad@gmail.com received: july 27, 2020 accepted: january 26, 2021 within the bag lens implantation is the gold standard for phacoemulsification. 1,2 apart from many known surgical complications like cystoid macular edema (cme), capsule shrinkage or rupture, posterior capsule opacification (pco) and vitreous loss, dislocation of adequately placed iol within the bag may occur any time within or more than three months of the safe surgery. 3,4 iol dislocations are termed as early and late depending on the time of occurrence. 5 dislocations that occur within three months after surgery were categorized as early and after three months or many years after uneventful surgery were grouped as late. late in the bag dislocation generally http://doi.org/10.3352/jeehp.2013.10.3 munir amjad baig, et al pak j ophthalmol. 2021, vol. 37 (2): 179-182 180 occurs as a result of zonular fiber weakness after uncomplicated surgery. 6 the incidence of posterior chamber iol dislocation is reported in the literature as 0.2% to3%. 7,8 the iol dislocation risk after 10 years, 15 years, 20 years and after 25 years was 0.1%, 0.2%, 0.7% and 1.7% respectively causes for late dislocation number percentage males females advanced mature cataract 13 21.3 7 (53.8%) 6 (46.2%) postoperative trauma 12 19.6 9 (75%) 3 (25%) uveitis 9 14.7 5 (55%) 4 (45%) myopia 6 9.8 2 (33.3%) 4 (66.7) eccentric capsulorhex 5 8.1 3 (60%) 2 (40%) small capsulorrhexis 4 6.5 2 (50%) 2 (50%) retinitis pigmentosa 2 3.2 2 (100%) 0 silicon plate design of iol 6 9.8 2 (33.3%) 4 (66.7) unknown cause. 4 6.5 1 (25%) 3 (75%) in a large retrospective, observational populationbased study. 9 the rationale of this study is to find out the percentage of within the bag dislocation of iol in a tertiary care hospital and to highlight the risk factors for dislocation. methods records of patients with age 25 – 75 years and operated for routine cataract surgery in federal government services hospital islamabad were retrieved. silicone and hydrophobic acrylic lenses manufactured with designs of both 1-piece and 3-piece were implanted. patients with within the capsular bag iol dislocation occurring three months after the safe surgery were included in this study. two thousand nine hundred thirty two of total 3000 patients were followed up (97.7%), 68 patients did not return for follow-up or reported dead. there were 1600 males and 1332 were females. the eye first operated was included in this study. the exclusion criteria was pseudoexfoliation and glaucoma patients, out-of-the bag iol dislocation and early dislocations that occurred within first three months after the cataract surgery. patient demographic data, surgery dates, lens material/design, capsular bag anomalies, yag laser and presence/absence of known risk factors were recorded. detailed ocular examination was carried out by single surgeon which consisted of slit lamp examination, ophthalmoscopic examination, corrected visual acuity and intraocular pressure checkup. data analyzed in frequencies/percentages. results in this study 61 (2.08%) patients had developed late iol dislocation, among them 35 (57.3%) were males and 26 (42.7%) were females. average time between surgery and iol dislocation was 5.8 years. during initial years, 2008 – 2012, the rate of iol dislocation was high. patients of 50 – 75 years of age had more iol dislocations. advanced mature cataract and trauma were the most common associated conditions in this series. discussion davison reported the first case of late spontaneous inthe-bag iol dislocation in 1993 from capsular contraction syndrome. between 1988 and 2001, 2663 iols were explanted and the cause for explanation in eight cases (0.3%) was zonular dehiscence. 10 the mechanisms of late iol dislocation comprises of progressive zonular weakness and capsule contraction syndrome. zonular weakness causes imbalance between centripetal and centrifugal forces over the capsular bag, resulting in dislocation. 11 in the united states, the frequency of iol dislocation ranges from 0.2 – 1.8% and is comparable to our study of 2.08%. 12 clinically insignificant decentration occurs in 25% of cases and clinically significant decentration occurs in about 3% of the cases. 12 the mean interval of late in-the-bag dislocation has been estimated to be 7.5 years. in our study, it was 5.8 years. krėpštė et al. 13 reported that patients with lax zonules, advanced or mature cataracts and uveitis had shorter time interval. in this study, patients of 50 – 75 years age group developed iol dislocation at an earlier stage. it was similar to another study, according to which zonular dehiscence and older age at cataract surgery were associated with a shorter interval between surgery and dislocation. 14 thirteen (21.3%) patients having advanced mature cataract in our study developed late in-the-bag iol dislocation similar to other study that mentioned its increased risk in advanced mature cataract. 15 the most common condition associated with late iol dislocation is pseudo-exfoliation syndrome (pex) due to inadequate capsular and zonular support. late within the capsular bag intraocular lens dislocation (ten – year experience) 181 pak j ophthalmol. 2021, vol. 37 (2): 179-182 subjects with pseudo-exfoliation syndrome exhibit weak zonules by a process of elastinolysis. 15 it also increases the anterior capsule contraction, which leads to zonular failure. in (pex) iol dislocation after cataract surgery had mean interval time of 5.5 – 8.5 years. however, cases of pseudoexfoliation were excluded in our study. some surgeons had faced iol dislocation 18 years after surgery. 16 in this study 6 (9.8%) myopic patients had iol dislocation. myopic eyes are large in all three dimensions (i.e. equatorial, vertical and anteroposterior axis) resulting in zonular fibre elongation and zonular failure. 17 in another study, high myopia as cause of dislocation of iol was found in only 2.22%. 18 in our study, most of the patients who had late iol dislocation were males 35 (57.3%) similar to some authors while according to other reports it was more common in women. 19 the present study showed eccentric capsulorhexis in 4(6.5%) patients. a survey by mamalis et al 20 showed that an eccentric capsulorhexis might allow one of the lens edges to be more peripheral than the optic. in contrast, late decentration was due to subluxation associated with capsular fibrosis. iol dislocation/decentration is influenced by its material and design as well. silicone-plate iol design was prone to capsular contraction forces and may decenter, tilt or rotate. in our study 5 (8.1%) patients developed iol dislocation in which silicon plate design was used. however, some authors reported that any type of iol was at risk for late in-the-bag iol dislocation. 21 history of postoperative trauma was present in 12 (19.7%) patients in this study similar to dabrowska et al 22 who reported 11.1% of patients had history of trauma. østern et al 16 highlighted bilateral cases of iol dislocation within the bag after many years of operation in 9.1% of the patients. bilaterality has also been observed by other authors 8 but was not consistent with our study which entails only first operated eyes. capsular tension ring ctrs was not used in any case in this study but reports reveal that it can prevent intraoperative zonular dehiscence and decrease postoperative capsule shrinkage. 23 however, other authors have reported that period between original surgery and dislocation is shorter in cases where a capsular traction ring ctr was present within the capsular bag (4.9 ± 1.9 years). 5 the continuous curvilinear capsulorrhexis (ccc) during phacoemulsification has decreased the rate of iol dislocation. ccc supports the iol optic for 360 degrees thus allowing good iol fixation. 24 limitation of this study was retrospective design and single center study. reports from other centers and other surgeon will give a true picture of frequency of within the bag dislocation of iol. conclusion the mechanism of late iol dislocation comprises of progressive zonular weakness and capsule contraction syndrome. zonular weakness results in balance between centrifugal and centripetal forces over the capsular bag, resulting in dislocation. ethical approval the study was approved by the institutional review board/ ethical review board. (erb/ajkmc/phy14/6). conflict of interest authors declared no conflict of interest. references 1. hirata a, okinami s, hayashi k. occurrence of capsular delamination in the dislocated in-the-bag intraocular lens. graefes arch clin exp ophthalmol. 2011; 249 (9): 1409-1415. doi: 10.1007/s00417-0101605-5. 2. pueringer sl, hodge do, erie jc. risk of late intraocular lens dislocation after cataract surgery, 1980–2009: a population-based study. am j ophthalmol. 2011; 152: 618–623. 3. dabrowska-kloda k, kloda t, boudiaf s, jakobsson g, stenevi u. incidence and risk factors of late in-the-bag intraocular lens dislocation: evaluation of 140 eyes between 1992 and 2012. j cataract refract surg. 2015; 41 (7): 1376-1382. doi: 10.1016/j.jcrs.2014.10.040. 4. ganesh sk, sen p, sharma hr. late dislocation of in-the-bag intraocular lenses in uveitic eyes: an analysis of management and complications. indian j ophthalmol. 2017; 65 (2): 148-154. doi: 10.4103/ijo.ijo_938_16. 5. steeples lr, jones np. late in-the-bag intraocular lens dislocation in patients with uveitis. br j ophthalmol. 2015; 99: 1206–1210. javascript:showrefcontent('refrenceslayer'); munir amjad baig, et al pak j ophthalmol. 2021, vol. 37 (2): 179-182 182 6. kawano s, takeuchi m, tanaka s. current status of late and recurrent intraocular lens dislocation: analysis of real-world data in japan. jpn j ophthalmol. 2019; 63: 65–72 https://doi.org/10.1007/s10384-018-0637-y 7. gimbel hv, condon gp, kohnen t, olson rj, halkiadakis i. late in-the-bag intraocular lens dislocation: incidence, prevention, and management. j cataract refract surg. 2005; 31: 2193–2204. 8. fernández-buenaga r, alio jl, pérez-ardoy al, larrosa-quesada a, pinilla-cortés l, barraquer r, et al. late in-the-bag intraocular lens dislocation requiring explantation: risk factors and outcomes. eye (lond). 2013; 27: 795–801. 9. ford jr, werner l, owen l, vasavada sa, crandall a. spontaneous bilateral anterior partial inthe-bag intraocular lens dislocation following routine annual eye examination. j cataract refract surg. 2014; 40: 1561–1564. 10. davison ja. capsule contraction syndrome. j cataract refract surg. 1993; 19: 582–589. 11. shingleton bj, yang y, o’donoghue mw. management and outcomes of intraocular lens dislocation in patients with pseudoexfoliation. j cataract refract surg. 2013; 39: 984-993. 12. slade ds, hater ma, cionni rj, crandall as. ab externo scleral fixation of intraocular lens. j cataract refract surg. 2012; 38: 1316–1321. 13. krepste l, kuzmiene l, miliauskas a, januleviciene i. possible predisposing factors for late intraocular lens dislocation after routine cataract surgery. medicina (kaunas). 2013; 49 (5): 229-234. 14. zetterberg m, sundelin k, stenevi u. surgical repositioning of intraocular lenses after late dislocation: complications, effect on intraocular pressure, and visual outcomes. j cataract refract surg. 2013; 39 (12): 1879-1885. 15. shingleton bj, yang y, o’donoghue mw. management and outcomes of intraocular lens dislocation in patients with pseudoexfoliation. j cataract refract surg. 2013; 39: 984–993. 16. østern ae, sandvik gf, drolsum l. late in-the-bag intraocular lens dislocation in eyes with pseudoexfoliation syndrome. acta ophthalmol. 2014; 92: 184–191. 17. werner l, zaugg b, neuhann t, burrow m, tetz m. in the bag capsular tension ring and intraocular lens subluxation or dislocation. a series of 23 cases. ophthalmology, 2012; 119: 266–271. 18. laude a, agrawal a. spontaneous partial dislocation of an aphakic capsular bag in high myopia. j cataract refract surg. 2011; 37 (2): 427–428. 19. jakobsson g, zetterberg m, lundström m. late dislocation of in-the-bag and out-of-the bag intraocular lenses: ocular and surgical characteristics and time to lens repositioning. j cataract refract surg. 2010; 36: 1637–1644. 20. mamalis n, brubaker j, davis d, espandar l, werner l. complications of foldable intraocular lenses requiring explantation or secondary intervention--2007 survey update. j cataract refract surg. 2008; 34 (9): 1584-1591. 21. clark a, morlet n, ng jq. whole population trends in complications of cataract surgery over 22 years in western australia. ophthalmology, 2011; 118: 10551061. 22. dabrowska-kloda k, kloda t, boudiaf s. incidence and risk factors of late in-the-bag intraocular lens dislocation: evaluation of 140 eyes between 1992 and 2012. j cataract refract surg. 2015; 41: 1376-1382. 23. michaeli a, soiberman u, loewenstein a. outcome of iris fixation of subluxated intraocular lenses. graefes arch clin exp ophthalmol. 2012; 250 (9): 1327-1332. 24. gonnermann j, klamann mk, maier ak, rjasanow j, joussen am, bertelmann e, et al. visual outcome and complications after posterior irisclaw aphakic intraocular lens implantation. j cataract refract surg. 2012; 38 (12): 2139-2143. authors’ designation and contribution munir amjad baig; associate professor: concepts, design, literature search, dana analysis, manuscript editing, manuscript review. rabeeya munir; demonstrator: literature search, data acquisition, statistical analysis, manuscript preparation, manuscript editing. .…  …. 30 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology original article anterior chamber depth changes after uneventful phacoemulsification mustafa kamal junejo, tanveer anjum chaudhry pak j ophthalmol 2016, vol. 32, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mustafa kamal junejo instructor ophthalmology section of ophthalmology, department of surgery aga khan university, karachi, pakistan e-mail: mkjunejo@yahoo.com received: october 30, 2015 accepted: april 10, 2016. …..……………………….. purpose: to measure changes in anterior chamber depth (acd) after uneventful cataract surgery through phacoemulsification along with intraocular lens (iol) implantation in healthy eyes using ultrasonography (amplitude scan). study design: prospective observational clinical case series. place and duration of study: section of ophthalmology, department of surgery, aga khan university hospital karachi pakistan from september 2011 to march, 2012. material and methods: seventy four eyes (74 patients) underwent ultrasonography a scan to evaluate anterior chamber configuration before, 1 day after, 1 week after and 1 month post-operative. we measured central acd. pre-operative and post-operative data was compared by using paired t tests. results: a total of 74 subjects were enrolled in this study. there were 42 males (56.8%) and 32 females (43.2%).before surgery, overall mean anterior chamberdepth (mm) acd was 3.02 ± 0.43; in males was 3.07 ± 0.43 and in females was 2.96 ± 0.43. overall, the mean acd after 1 day of cataract surgery 3.46 ± 0.44,after 1 week of surgery was 3.64 ± 0.46, and after 1 month of surgery was 3.81 ± 0.46.significant increase of 0.73 ± 0.58mm (p < 0.0001) in the mean acd was seen after 1 month of surgery. however , mean difference in acd after 1 month of surgery between male and female groups was 0.11 ± 0.09; which was not statistically significant (p = 0.42). after uneventful phacoemulsification along with iol implantation, the anterior chamber angle depth increased markedly. conclusion: following uneventful phacoemulsification along with intraocular lens implantation, the acd markedly increased which, was statistically significant. ultrasound a scan is simple and easily available tool for obtaining quantitative data about anterior chamber depth. keywords: cataract, anterior chamber depth, phacoemulsification, ultrasonography a scan. introduction ataract surgery is the most common surgical procedure done worldwide. in phacoemulsification cataractous lens is extracted after lens is crushed by ultrasound waves and then suctioned out of the capsule and intraocular lens (iol) is implanted in capsule to obtain good visual acuity post operatively.1 theoretical formulas for the calculation of axial length, iol power calculation and anterior chamber depth measurements has been evolving for the better outcomes of cataract surgery.srk/t being one of the older formulas measures only axial length (al), keratometry and anterior chamber depth (acd) which is calculated from the corneal curvature as compared to newer formulas which involve c mailto:mkjunejo@yahoo.com anterior chamber depth changes after uneventful phacoemulsification pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 31 measurements of anterior chamber depth preoperatively which, predicts the postoperative effective lens position (elp) and postoperative refraction indirectly.1,2 cataract extraction with intraocular lens (iol) implantation results in widening of the anterior chamber angle and depth to deepen in healthy and especially in glaucomatous eyes.3 advanced imaging studies have proven that crystalline lens pushes the peripheral iris anteriorly and hence causes narrowing of anterior chamber angle particularly in cataractous lenses.4 several methods have been used in previous studies to calculate anterior chamber depth after cataract surgery. the object of this study was tomeasure changes in the anterior chamber depth after uneventful phacoemulsification with iol implantation in healthy eyes using a scan. we gathered quantitative data from normal pakistani eyes as measured by a scan ultrasound and standardized parameters of anterior chamber were compared. materials and methods this prospective observational clinical case series study conducted at section of ophthalmology, department of surgery, aga khan university hospital karachi pakistan from september 2011 to march, 2012comprised of 74 eyes from 74 consecutive patients who underwent cataract surgery from september 2011 to december 2011. patients age, gender and eye whether right or left were kept under consideration for the study.axial lengths were obtained using ascan. single examiner took measurements of all patients on different visits. anterior chamber depth measurements were taken on once pre-operative visit and thrice on post-operative visits i.e. 1 day, 1 week and 1 month post-operatively. verbal consent was taken from all patients who participated in this study. patients who consented for procedure. those whose intra ocular lens was implanted in the capsular bag and those patients who completed all postoperative follow up visits were included in this study. a thorough eye examination was performed pre operatively. the visual acuity was measured using the snellen’s chart. nuclear grading (1 to 4) was performed using a cobalt blue filter light and the type of cataract (cortical, nuclear, posterior sub capsular and polar) was noted by slit lamp biomicroscopy. keratometric values were measured with a javalkeratometer, and mean of 2 values taken from the main axis was calculated. the axial length was measured with a-scan ultrasonography and iol power calculation by the srk t and holladay formulas corresponding to respective axial lengths. posterior segment examination was done with +90.0 diopter lens in eyes without dense cataract. b-scan ultrasonography was used in those patients whose posterior segment examination was not possible due to their dense cataracts. the acd was measured by ascan ultrasonography the day before surgery and 1 day, 1 week, and 1 month postoperatively by same examiner. average of the four consecutive measurements was calculated and used in the study. surgery was performed using topical anaesthesia with propracaine hydrochloride (63 eyes; 85%) and retrobulbaranaesthesia with xylocaine 2% (11 eyes; 15%). the same surgeon performed all surgeries. a 3 – plane clear corneal incision was made in the steep meridian. a capsulorrhexisranging from 4.0 mm to 5.0 mm was made with cystotome, and cortical-cleaving, hydro dissection and hydro delineation were performed. the nucleus was sculpted and emulsified through stop-and-chop and divide and conquer techniques. after cortical clean up, an injectable acrylic aspheric iol with a 6.0 mm optic and 12.5 mm haptic diameter was implanted in the bag. the incisions were not sutured. postoperatively, patients were prescribed topical antibiotics and topical steroids as 01 hourly on the day of surgery, 02 hourly on 1st post-operative day and tapered down in 4 weeks on weekly basis as qid, tid and bid, then stopped. statistical analysis was done on spss version 19.0 for windows. frequencies and percentages were calculated for categorical variables like gender and age groups; and median were computed for numerical variables like age. tables and charts were used to present the results. paired t-test was used to compare means pre and post operatively. independent t –test was performed to compare acd changes between gender groups. p < 0.05 was considered to be statistically significant. results total of 74 eyes were recruited in this study {male= 42 (56.8%), female = 32 (43.2%)}. 64.9% eyes were of right side with frequency and percentage of 48 and 64.9%,remaining one (left sided) with frequency and percentage of 26 and 35.1%. 51 patients (68.9%) of our study population were myopic and remaining 23 patients (31.0%) were hypermetropic (table 1). mustafa kamal junejo, et al 32 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology table 1: characteristics of the study population n= no. of eyes. age (years) frequency percent mean 59.7 ± 7.9 n = 74 100% gender male 42 56.8 female 32 43.2 eye right 48 64.9 left 26 35.1 refractive error myopia 51 68.9 hypermetropia 23 31.0 patient flow chart n = 103 first post op: visit 96 patients 7 lost to follow second post op visit 78 patients 18 lost at 1 week final post op visit 74 patients figure 1: flow chart of patients showing number of patients who lost to follow during postoperative visits. table 2: mean anterior chamber depth (acd) after cataract surgery (n = 74 eyes). ac depth (mm) gender mean std. deviation number of subjects before surgery male 3.07 0.43 42 female 2.96 0.43 32 overall 3.02 0.43 74 1 day after surgery male 3.45 0.48 42 female 3.47 0.40 32 overall 3.46 0.44 74 1 week after surgery male 3.67 0.51 42 female 3.60 0.39 32 overall 3.64 0.46 74 1 month after surgery male 3.83 0.49 42 female 3.77 0.43 32 overall 3.81 0.46 74 according to table 2 mean and standard deviation were measured gender wise. mean anterior chamber depth (acd) before surgery, 1 day after surgery, 1 week after surgery and 1 month after surgery in male was 3.07 ± 0.43, 3.45 ± 0.48, 3.67 ± 0.51 and 3.83 ± 0.49. similarly mean anterior chamber depth in females was 2.96 ± 0.43, 3.47 ± 0.40, 3.60 ± 0.39 and 3.77 ± 0.43 with overall mean of 3.02 ± 0.43, 3.46 ± 0.44, 3.64 ± 0.46 and 3.81 ± 0.46. there was statistically significant increase in the mean acd, from 3.02 ± 0.43mm preoperatively to 3.81 ± 0.46mm 1 month after surgery (p < 0.0001); an increase of 0.73 ± 0.58mm. however, when mean acd one month after surgery was compared between male (3.83 ± 0.49 mm) and female (3.77 ± 0.43mm) groups, no statistically significant difference was found (p = 0.42). anterior chamber depth changes after uneventful phacoemulsification pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 33 discussion according to this study uneventful phacoemulsification with in the bag injectable intraocular lens implantation widens the anterior chamber angle and increases anterior chamber depth by pushing back the iris lens diaphragm. advantage of anterior chamber depth after phacoemulsification with intra ocular lens implantation surgery is that deep postoperative anterior chamber facilitates aqueous drainage more as compared to anterior chamber with normal lens in human eyes. most of the subjects with ocular hypertension before cataract surgery absolutely get normal iop levels after cataract surgery and doesn’t require management anymore.1-4 in this prospective clinicalcase series study 103 patients were enrolled for the study but only 74 patients followed till last visit. it means 103 patients got measured their anterior chamber depth preoperatively and lost to follow up were 29 patients. to the best of author’s knowledge no one has conducted this study in pakistani population and the purpose of this study is to calculate that how much percent anterior chamber depth increases after uneventful phacoemulsification and iol implantation. the overall increase in mean anterior chamber depth of 74 patients after 4 weeks of surgery was 790 microns which is evident with other studies as well1,2. there was increase in overall anterior chamber depth of 440 microns 1 day after surgery, 620 microns one week after surgery, followed by overall increase in anterior chamber depth of 740 microns after one month of surgery (table 2). other studies have demonstrated increase in anterior chamber depth in normal population after phacoemulsification by measuring depth by different methods like scheimpflug or ultrasound biomicroscope imaging methods.4 hayashi et al found out by scheimpflug imaging that width and depth of anterior chamber angle increased significantly i.e. 39.7% after cataract extraction followed by iol implantation.4-8 however increase in anterior chamber depth in this study is somehow less i.e. 26.1% than reported by other investigators which may be possibly that our group of patients were more myopic than others as it has been reported that hypermetropes show more change in anterior chamber depth than myopes. difference between our study and study conducted by dooley et al, is that refractive status of patients were not measured in our study but mean age of most of the patients in both the studies was 69 years, other major difference between the two studies is of ethnic groups that in our study all patients are asians as compared to white caucasians in the study of dooley et al.5-12 nonaka et al, reported that lens plays important role in pathogenesis of primary angle closure glaucoma because of its anatomic features like lens thickness which increases with age, with cataractous changes and relatively its anterior positioning, hence he proved that lens extraction would widen the anterior chamber angle and therefore resolve pupillary block glaucoma.4,6-8 postoperative capsular shrinkage and iol positioning also alters anterior chamber depth. previous studies have shown change in anterior chamber depth with different types of iol designs and types.9-12 matsuura et al in 1989 also have reported that anterior chamber depth increased after cataract extraction and iol implantation. some other investigators reported rather shallowing of anterior chamber (yoshida et al 1989).10,-17 thill – schwaninger and giers in 1989 suggested that anterior chamber depth depends upon different shapes of iol haptics.10,-20 other techniques should be used to calculate change in anterior chamber depth and complete morphology. we only measured anterior chamber depth through ultrasound a scan so this is being the limitation of our study because for proper anterior chamber assessment we need to assess all the parameters such as anterior chamber angle, volume, central and peripheral depths and last but not the least complete corneal topography through anterior segmentoct. conclusion this study proves that anterior chamber depth increases approximately 26% after uneventful cataract surgery with intra ocular lens in capsular bag implantation which, helps in aqueous drainage by pushing back iris lens diaphragm and widening the anterior chamber angle, hence prevents improper diagnosis and unnecessary treatment of glaucoma entities. mustafa kamal junejo, et al 34 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology author affiliation dr. mustafa kamaljunejo instructor ophthalmology section of ophthalmology, department of surgery, aga khan university, karachi, pakistan dr. tanveer anjum chaudhry section head of ophthalmology department of surgery, aga khan university hospital karachi, pakistan role of author mustafa kamal junejo data collection, manuscript writing and statistics. tanveer anjum chaudhry data collection. references 1. arai m, ohzuno i, zako m. anterior chamber depth after posterior chamber intraocular lens implantation. actaophthalmologica. 1994; 72 (6): 694-7. 2. doganay s, bozgul firat p, emre s, yologlu s. evaluation of anterior segment parameter changes using the pentacam after uneventful phacoemulsification. actaophthalmologica. 2010; 88 (5): 601-6. 3. dooley i, charalampidou s, malik a, loughman j, molloy l, beatty s. changes in intraocular pressure and anterior segment morphometry after uneventful phacoemulsification cataract surgery. eye, 2010; 24 (4): 519-27. 4. engren al, behndig a. anterior chamber depth, intraocular lens position, and refractive outcomes after cataract surgery. j cataract refract surg. 2013; 39 (4): 572-7. 5. hayashi k, hayashi h, nakao f, hayashi f. changes in anterior chamber angle width and depth after intraocular lens implantation in eyes with glaucoma. ophthalmology, 2000; 107 (4): 698-703. 6. huang g, gonzalez e, peng p-h, lee r, leeungurasatien t, he m, et al. anterior chamber depth, iridocorneal angle width, and intraocular pressure changes after phacoemulsification: narrow vs. open iridocorneal angles. archives of ophthalmology, 2011; 129 (10): 1283-90. 7. kim m, park kh, kim t-w, kim dm. changes in anterior chamber configuration after cataract surgery as measured by anterior segment optical coherence tomography. korean journal of ophthalmology, 2011; 25 (2): 77-83. 8. nonaka a, kondo t, kikuchi m, yamashiro k, fujihara m, iwawaki t, et al. angle widening and alteration of ciliary process configuration after cataract surgery for primary angle closure. ophthalmology, 2006; 113 (3): 437-41. 9. norn m. depth of anterior chamber after cataract extraction. british journal of ophthalmology, 1978; 62 (7): 474-7. 10. simsek a, ciftci s. evaluation of ultrasonic biomicroscopy results in anterior eye segment before and after cataract surgery. clinical ophthalmology (auckland, nz). 2012; 6: 1931. 11. uçakhan öö, özkan m, kanpolat a. anterior chamber parameters measured by the pentacam ces after uneventful phacoemulsification in normotensive eyes. actaophthalmologica. 2009; 87 (5): 544-8. 12. wirtitsch mg, findl o, menapace r, kriechbaum k, koeppl c, buehl w, et al. effect of haptic design on change in axial lens position after cataract surgery. journal of cataract and refractive surgery, 2004; 30 (1): 45-51. 13. dawczynski j, koenigsdoerffer e, augsten r, strobel j. anterior segment optical coherence tomography for evaluation of changes in anterior chamber angle and depth after intraocular lens implantation in eyes with glaucoma. eur j ophthalmol 2007; 17 (3): 363 – 367 14. kusano m; tsuiki e; uematsu m; fujikawa a; kumagami t; suzuma k; kitaoka t. changes in anterior chamber depth and refractive power after cataract surgery with or without simultaneous vitreous surgery. investigative ophthalmology and visual science march, 2012; vol. 53: 6657. 15. melancia d, pinto la, neves cm. cataract surgery and intraocular pressure departments of a pharmacology and neurosciences and ophthalmology, faculty of medicine, lisbon university, lisbon , portugal. ophthalmic res. 2015; 53: 141–148 doi: 10.1159/000377635. 16. bilak s, simsek a, capkin m, guler m, and bilgin b. biometric and intraocular pressure change after cataract surgery. optometry and vision science, vol. 92, no. 4, april 2015. 17. rękas m, kucia kb, konopińska j, mariakz and żarnowski t. analysis and modeling of anatomical changes of the anterior segment of the eye after cataract surgery with consideration of different phenotypes of eye structure.current eye research 2015; volume 40, issue 10: pages 1018-1027. 18. watanabe a, shibata t, ozaki m, okano k, kozaki k, and tsuneoka h. department of ophthalmology, the jikei university school of medicine, tokyo, japan. change in anterior chamber depth following combined pars plana vitrectomy, phacoemulsification, and intraocular lens implantation using different types of intraocular lenses. jpn j ophthalmol. 2010; 54: 383–386 doi 10.1007/s10384-010-0840 19. miraftab m, hashemi h, fotouhi a, khabazkhoob m, rezvan f, asgari s. effect of anterior chamber depth on the choice of intraocular lens calculation formula in patients with normal axial length. middle east african journal of ophthalmology, 2014; volume 21, issue 4: page: 307-311. http://iovs.arvojournals.org/solr/searchresults.aspx?author=mao+kusano http://iovs.arvojournals.org/solr/searchresults.aspx?author=eiko+tsuiki http://iovs.arvojournals.org/solr/searchresults.aspx?author=masafumi+uematsu http://iovs.arvojournals.org/solr/searchresults.aspx?author=azusa+fujikawa 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http://www.meajo.org/searchresult.asp?search=&author=mehdi+khabazkhoob&journal=y&but_search=search&entries=10&pg=1&s=0 http://www.meajo.org/searchresult.asp?search=&author=farhad+rezvan&journal=y&but_search=search&entries=10&pg=1&s=0 http://www.meajo.org/searchresult.asp?search=&author=soheila+asgari&journal=y&but_search=search&entries=10&pg=1&s=0 anterior chamber depth changes after uneventful phacoemulsification pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 35 20. shin hc, subrayan v, tajunisah i. changes in anterior chamber depth and intraocular pressure after phacoemulsification in eyes with occludable angles. j cataract refract surg. 2010; 36: 1289 – 1295 q 2010 ascrs and escrs. pak j ophthalmol. 2020, vol. 36 (4): 396-401 396 original article orbital rhabdomyosarcoma – a case series from north – west pakistan ibrar hussain 1 , tajamul khan 2 , zaman shah 3 , zulfiqar ali 4 department of ophthalmology, 1-3 khyber teaching hospital, peshawar, 4 teaching hospital, abbottabad abstract purpose: to find out the demographic characteristics, clinical behavior and outcome of rhabdomyosarcoma in north west pakistan. study design: retrospective case series. place and duration of study: department of ophthalmology, khyber teaching hospital peshawar pakistan, from 2015 to 2019. methods: all patients with orbital rhabdomyosarcoma consulting our department were registered and a selfdesigned proforma was used to document demography, clinical features, management, and follow-up of all cases. at the end of study, the data was analyzed using spss version 25 and results compiled. results: twelve patients with “orbital rhabdomyosarcoma” were included in the study with mean age of 7.2 ± 1.6 years. majority of patients presented with mass in upper lid with proptosis. ct-scan and/or mri orbit proved that in seven (58.3%) cases the mass was occupying the superior orbit, in 3 (25%) cases inferior orbit and in 2 (16.6%) cases the tumor was advanced enough to occupy the whole orbit. biopsy showed embryonic type (66.7%), alveolar type (25%) and undifferentiated (8.3%) tumour. all patients received chemotherapy and radiotherapy with excision of tumor in 16.7% and exenteration in 41.7% patients. the course of follow-up extended from 7 to 24 months. five (41.7%) patients felt well at the end of last follow-up and four (33.3%) developed recurrence. at the end of follow-up, 3 (25%) patients died of tumor. conclusion: in north west pakistan patients with orbital rhabdomyosarcoma present late and the prognosis is poor due to not following the proper protocol for follow-up. key words: rhabdomyosarcoma, orbital rhabdomyosarcoma, irs staging. how to cite this article: hussain i, khan t, shah z, ali z. orbital rhabdomyosarcoma – a case series from north – west pakistan. pak j ophthalmol. 2020; 36 (4): 396-401. doi: https://doi.org/10.36351/pjo.v36i4.1075 introduction orbital rhabdomyosarcoma (rms) is a rare malignancy of childhood. 1 however, it is the most correspondence: ibrar hussain department of ophthalmology khyber teaching hospital, peshawar email: dribrab@hotmail.com received: june 6, 2020 accepted: september 1, 2020 common primary malignant tumor of the orbit in children. 2 the tumor arises from undifferentiated mesenchymal cells that have the capacity to differentiate into striated muscle. 3 it usually presents in the first decade of life with relatively sudden unilateral proptosis that may be associated with lid swelling. there is a male preponderance and the tumor has the tendency to involve the supero-medial part of the orbit. 4 posteriorly located tumors may press upon the optic nerve thereby causing disc swelling and dimness of vision. most common histological type of rhabdomyosarcoma is “embryonal” type, which has better prognosis than other types. 5 treatment of rms ibrar hussain, et al 397 pak j ophthalmol. 2020, vol. 36 (4): 396-401 is a combination of chemotherapy and external beam radiation with or without surgery. purpose of this study was to review the demographic features, clinical presentation, management and follow-up of patients of rms presenting to a tertiary care hospital of north western part of pakistan. methods it was a retrospective case series where the record of 12 patients, with orbital rhabdomyosarcoma was evaluated and analyzed. these patients were admitted in “orbit and oculoplastics” department of khyber teaching hospital, peshawar pakistan between 2015 and 2019. a proforma was designed in which age, gender, presenting symptoms, duration of symptoms, amount of proptosis and dystopia (where possible) was noted. after detailed history and examination, each patient underwent ct-scan and/or mri orbit, chest xray, abdominal ultrasound and complete blood examination. incisional biopsy was done in all patients and sample was sent for histopathology. after confirmation of diagnosis, each patient consulted oncologist where most patients received chemotherapy and radiotherapy while others were sent back to our department for surgical management. surgical excision of the tumor was carried out in two cases and exenteration in five cases. few patients also needed chemotherapy and/or radiotherapy post-operatively, for which they consulted oncologist after surgery. the follow-up period of the patients was 7 months to 2 years. various variables including age, gender, visual acuity, amount of proptosis, histological type, treatment modality and post-treatment improvement at last follow-up was analyzed using spss-version 25. results twelve patients were included in this case series, out of which 8 (66.7%) were males and 4 (33.3%) were females. mean age of all patients was 7.2 ± 1.6 years and median age was 6 years. one patient presented at the age of one week with upper lid mass (figure 1). seven (58.3%) patients presented with mass in upper lid with 5 (51.7%) having associated proptosis, 3 (25%) patients with swelling of lower lid and proptosis, 1 (8.3%) patient with proptosis and no lid swelling and finally one (8.3%) patient presented with fig. 1: patient with rhabdomyosarcoma. marked proptosis and swelling of both upper and lower lids. amount of proptosis could be measured in 6 (50%) patients and the mean difference of proptosis between affected and non-affected eye was 5.8 ± 3.9 mm. ct-scan and/or mri of orbit proved that in seven (58.3%) cases the mass was occupying the superior orbit, in 3 (25%) cases inferior orbit and in 2 (16.6%) cases the tumor was advanced enough to occupy the whole orbit. at presentation, bony erosion was seen on ct-scan in one (8.3%) case but during the course of follow-up, 2 (16.7%) other patients who developed recurrence, had bony erosions and extension of tumor into cranial cavity and ethmoidal sinuses. incisional biopsy proved the diagnosis of rms in all cases with embryonic type in 8 (66.7%), alveolar type in 3 (25%) and undifferentiated in 1 (8.3%) case. as far as intergroup rhabdomyosarcoma study (irs) group staging system is concerned, 2 (16.7%) of our cases fell into “group ii”, 9 (75%) into “group iii” and 1 (8.3%) into “group iv”. none of our patients fell into “group i”. all patients consulted oncologist. four (33.3%) patients received chemotherapy (vincristine, actinomycin-d, cyclophosphamide (vac) and radiotherapy. two patients underwent excision of the mass followed by chemotherapy (vac) and radiotherapy. five (41.7%) patients with huge tumors received chemotherapy (vac) followed by exenteration. the course of follow-up extended from 7 to 24 months. five (41.7%) patients felt well at the end orbital rhabdomyosarcoma – a case series from north–west pakistan pak j ophthalmol. 2020, vol. 36 (4): 396-401 398 table 1: demography, clinical features, management and outcome of all patients. (f = female, ll = lower lid, m = male, radio = radiotherapy, ul = upper lid, vac = vincristin, actinomycin-d, cyclophosphamide). s/n age (year) gender laterality presentation tumor location in orbit histology treatment ultimate outcome 1. 6 m r ul swelling with proptosis superior embryonal vac + exentration + radio passed away in 2 years 2. 19 m r ul swelling with proptosis superior rms undifferentia ted vac + exentration recurrence under treatment 3. 9 f r ll swelling with proptosis inferior embryonal excisional biopsy + vac ok till last follow-up 4. 12 m r ul swelling with proptosis superior embryonal vac + radio ok till last follow-up 5. 4 f r ul & ll swelling with proptosis whole orbit alveolar vac + exentration died after 2 years 6. 6 f r ul swelling with proptosis superior alveolar vac + exentration + radio recurrence under treatment 7. 3 m l proptosis inferior embryonal vac + radio recurrence under treatment 8. 4 m r ll swelling with proptosis inferior embryonal excisional biopsy + vac ok till last follow-up 9. 0.1 m r ul mass since birth upper lid embryonal refused treatment 10. 6 m l ul swelling superior embryonal vac + radio ok till last follow-up 11. 15 m l ulcerative ll mass with proptosis inferior alveolar exentration + radio recurrence passed away after 1 year 12. 2 f l ll swelling with proptosis inferior embryonal vac + radio ok till last follow-up of last follow-up, four (33.3%) developed recurrence for which surgical excision/debulking of the tumor was performed followed by radiotherapy. at the end of follow-up, 3 (25%) patients died of tumor. table 1 represents demography, clinical features, management and outcome of all patients. discussion orbital rhabdomyosarcoma is a rare malignancy of childhood; however, it is the most common primary malignant tumor of the orbit. in a study from punjab (pakistan), rms constituted 6.3% of total malignant orbital tumors. 6 in our case-series, the mean age of the patients was 7.2 ± 1.6 years. in a study from south pakistan (karachi) the mean age for embryonal rms was 10.4 years. 7 one of our patients had congenital rhabdomyosarcoma (embryonal type). few case reports of congenital rms have been mentioned in the literature. 8 sueters m et al, described a unique case of fetal rms detected in 3 rd trimester of pregnancy by ultrasound examination. 9 after birth histopathological examination confirmed rms with sparse alveolar element. rms is more common in boys and this is true for our cases where two third of the patients were boys. 10 due to rapid growth of tumor in the orbit, presentation in most of the cases is in the form of relatively rapid proptosis. ten (83.3%) of our patients presented with progressive proptosis for 2 – 4 months. in 2 (16.7%) cases there was no proptosis because of anteriorly located tumor in the upper orbit. both of these cases presented with hard swelling in the upper lid. posterior tumors, in addition to proptosis, tend to cause optic disc edema, choroidal folds and some degree of ophthalmoplegia. ct and mri orbit are important for preoperative evaluation and to know the extent of tumor and also for follow-up. 11 ct scan helps in detecting bone involvement. 12 in our case series there was one case with bone erosion into maxillary sinus at presentation. moreover, in the course of follow-up bony erosion with extension to cranial cavity and ethmoidal sinuses was found in 2 cases of recurrence (figure 2). karcioglu za et al, stated in their research that ibrar hussain, et al 399 pak j ophthalmol. 2020, vol. 36 (4): 396-401 fig. 2: ct-scan showing bony erosion in a huge recurrent rhabdomyosarcoma. there was correlation between location in the orbit and histology. embryonal subtype was more frequently seen in superior orbit whereas alveolar subtype was more common in inferior orbit. 3 in our study out of 7 tumors involving the superior orbit, 5 (71.4%) were embryonal (figure 2). fig. 3: superior orbital rhabdomyosarcoma with upper lid swelling. the embryonal subtype is the most frequently observed subtype in children, accounting for approximately 60% to 70% of childhood rhabdomyosarcomas. 13 approximately 30% of children with rhabdomyosarcoma have the alveolar subtype. an increased frequency of this subtype is noted in adolescents. following biopsy, the tumor is staged according to “intergroup rhabdomyosarcoma study.” 14,15 this grouping is as follows: group i: localized disease completely resected (excisional biopsy). group ii: microscopic disease remaining after biopsy. group iii: gross residual disease remaining after biopsy. group iv: distant metastasis present at onset. this classification is useful for treatment strategy and for prognosis prediction. 10,16 current management includes surgery, chemotherapy and radiotherapy. 17,18 group i are treated with chemotherapy only va (vincristine and actinomycin-d). group ii are treated with combination of chemotherapy (va plus cyclophosphamide: vac) and radiotherapy (36 gy). group iii are treated with combination of chemotherapy (vac) and radiotherapy (45 gy). group iv are treated with a combination of intensive chemotherapy and radiotherapy. 7 in our case series no patient was included in group i. two patients (16.7%) were in group ii, nine (75%) patients had group iii and one (8.3%) was in group iv at presentation. due to multiple socio-economic factors in developing countries like ours, exact above mentioned international protocol for treatment of different groups could not be followed. two patients with group ii stage underwent excisional biopsy followed by chemotherapy (vac) and were doing well at the end of their follow-up of about one and a half year. eight patients with group iii underwent chemotherapy (vac) and radiotherapy but most of them received patchy therapy and did not complete the course. therefore, four (50%) of those eight patients later presented with recurrence and they underwent exentration, followed by radiotherapy. two of those patients passed away during the course of follow-up. in one patient with congenital rms (group iii), the treatment was refused by the parents. one patient in group iv, underwent exentration followed by chemotherapy and radiotherapy to the orbit but passed away in three months. he had metastasis in the chest at presentation. orbital rhabdomyosarcoma – a case series from north–west pakistan pak j ophthalmol. 2020, vol. 36 (4): 396-401 400 in good centers of the world where proper protocols for the treatment of orbital rms is followed, overall survival is excellent for group i, ii and iii i.e., 95% at 5 years. 4,19,20 in our study the poor outcome seems to be due to late presentation and taking irregular treatment on the part of the patient due to multiple socioeconomic reasons including poverty and late approach to the centers, where treatment facilities are available. the patients also take irregular or no treatment due to the “myth” that cancer is untreatable. overall behavior of rms is the same as other parts of the world. advances in chemotherapy and radiotherapy have improved survival rates of patients with orbital rms in developed countries. limitation of our study was the sample size as it is a rare disease. multicenter study is needed to further study the pattern of disease across the country. conclusion in our set up overall prognosis is poor due to ignorance and non-adherence to the proper protocol for treatment by the patients. this can be improved by liaison between orbital surgeon and oncologist and proper education and counselling of the patient/parents about the treatment strategy and its importance. moreover, governmental supporting agencies and ngos working for cancer patients should come forward to support these patients. references 1. malu kn, ngbea ja, mohammand h. primary orbital rhabdomyosarcoma in an 11-year-old boy: a management challenge in a resource limited environment. j med trop. 2015; 17(1): 37. 2. bajaj ms, pushker n, chaturvedi a, betharia sm, kashyap s, balasubramanya r, et al. orbital space occupying lesion in indian children. j pediatr ophthalmol strabismus, 2007; 44: 106-111. 3. karcioglu za, hadjistilianou d, rozans m, defrancesco s. orbital rhabdomyosarcoma. cancer control, 2004; 11 (5): 328-333. 4. rootman j. neoplasia. diseases of the orbit: a multidisciplinary approach, 54. philadelphia: lippincott williams and wilkins; 2003: p. 262–268. 5. olivier pascual n, calvo jm, abelairas gómez jm. orbital rhabdomyosarcoma: difficulties with european treatment protocol. arch soc esp oftalmol. 2005; 80: 331–338. 6. khan aa, sarwar s, sadiq ma, ahmad i, tariq n. analysis of orbital malignancies presenting in a tertiary care hospital in pakistan. pak j med sci. 2017; 33 (1): 70. 7. bhurgri y, mazhar a, bhurgri h, usman a, malik j, bhurgri a, et al. orbital embryonal rhabdomyosarcomain karachi (1998-2002). j pak med assoc. 2004; 54 (11): 561. 8. bentefouet tl, dieng m, keita a, thiam i, wane a. primitive neonatal orbital 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and vincristine for the treatment of children with rhabdomyosarcoma: a report from the intergroup rhabdomyosarcoma study (irs) iv pilot study. j pediatr hematol oncol. 1997; 19: 124–129. 15. blank le, koedooder k, van der grient hn, wolffs na, van de kar m, merks jh, et al. brachytherapy as part of the multidisciplinary treatment of childhood rhabdomyosarcomas of the orbit. int j radiat oncol biol phys. 2010; 77: 1463–1469. 16. ruymann fb, vietti t, gehan. cyclophosphamide dose escalation in combination with vincristine and actinomycin d (vac) in gross residual sarcoma: a pilot study without hematopoietic growth factor support evaluating toxicity and response. j pediatr hematol oncol. 1995; 17: 331–337. 17. breneman j, meza j, donaldson ss, raney rb, wolden s, michalski j, et al. local control with reduced-dose radiotherapy for low-risk rhabdomyosarcoma: a report from the children’s oncology group d9602 study. int j radiat oncol biol phys. 2012; 83: 720–726. 18. tyl jw, blank le, koornneef l. brachytherapy in orbital tumors. ophthalmology, 1997; 104: 1475–1479. https://pubmed.ncbi.nlm.nih.gov/?term=anderson+j&cauthor_id=9149741 https://pubmed.ncbi.nlm.nih.gov/?term=jenson+m&cauthor_id=9149741 https://pubmed.ncbi.nlm.nih.gov/?term=link+m&cauthor_id=9149741 ibrar hussain, et al 401 pak j ophthalmol. 2020, vol. 36 (4): 396-401 19. sohaib sa, moseley i, wright je. orbital rhabdomyosarcoma-the radiological characteristics. clin radiol. 1998; 53: 357–362. 20. mazzoleni s, bisogno g, garaventa a, cecchetto g, ferrari a, sotti g. outcomes and prognostic factors after recurrence in children and adolescents with nonmetastatic rhabdomyosarcoma. cancer, 2005; 104: 183–190. authors’ designation and contribution ibrar hussain; professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. tajamul khan; associate professor: design, literature search, data acquisition, data analysis, statistical analysis. zaman shah; associate professor: literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. zulfiqar ali; professor: literature search, data analysis, statistical analysis, manuscript review. .…  …. causes of decrease vision in glaucoma patients attending outpatient department of a tertiary care hospital pak j ophthalmol. 2021, vol. 37 (2): 228-233 228 original article non-glaucomatous causes of decreased vision in glaucoma uzma fasih 1 , erum shahid 2 , arshad shaikh 3 1-3 department of ophthalmology, abbasi shaheed hospital, karachi abstract purpose: to determine the non-glaucomatous causes of decreased visual acuity in glaucoma patients presenting in the eye opd of a tertiary care hospital. study design: descriptive cross-sectional study. place and duration of study: abbasi shaheed hospital from july 2019 to september 2020. methods: patients above 18 years of age, visual acuity of less than 6/6 and diagnosed case of glaucoma were included in this study. patients with congenital glaucoma and patients not willing to participate in the study were excluded. detailed history was taken and ocular examination of the patient was done. causes of decreased visual acuity were determined. data was collected and analyzed on spss version 20. results: there were 369 glaucoma patients with a mean age of 58.2 ± 11.54 sd years. males were 224 (60.4%), with mean duration of glaucoma as 5.4 ± 5.2 years. primary open-angle glaucoma was seen in 209 (56.6%) and primary angle-closure glaucoma was in 96 (26%) of patients. treatable causes were 119 (32.2%) and nonglaucomatous causes of decrease vision were 221 (59.9%). glaucomatous optic atrophy was seen in 182 (49.3%) patients followed by cataract in 96 (26%). patients with corneal pathologies were 38 (10.2%) and armd were 26 (7%). conclusion: the commonest cause of decreased visual acuity in glaucoma patients is irreversible glaucomatous optic atrophy. age-related macular degeneration, corneal pathologies, and amblyopia also contribute to irreversibly decreased visual acuity in glaucoma patients. reversible causes include cataract, refractive errors, cystoid macular edema and diabetic macular edema. key words: cataract, glaucoma, glaucomatous optic atrophy, vision. how to cite this article: fasih u, shahid e, shaikh a. non-glaucomatous causes of decreased vision in glaucoma. pak j ophthalmol. 2021, 37 (2): 228-233. doi: http://doi.org/10.36351/pjo.v37i2.1193 introduction glaucoma is the second leading cause of blindness worldwide. 1 it affects 60 million people globally and is correspondence: uzma fasih department of ophthalmology, abbasi shaheed hospital, karachi email: yousufuzma@hotmail.com received: january 5, 2021 accepted: february 10, 2021 responsible for 12% of global blindness. 2 glaucoma is often known as "sneak thief of sight" because it generally presents without any symptoms. visual acuity is not affected until and unless there is significant damage to the optic nerve. several glaucoma patients present with decreased vision. causes other than glaucoma e.g., cataract, uveitis, refractive errors, amblyopia, myopic degeneration, age-related macular degeneration, cystoid macular edema, ischemic optic atrophy, corneal edema, opacity, diabetic and hypertensive retinopathy should also be considered for a cause of decreased visual acuity. it http://doi.org/10.3352/jeehp.2013.10.3 uzma fasih, et al 229 pak j ophthalmol. 2021, vol. 37 (2): 228-233 has been reported that decreased visual acuity among glaucoma patients might not be due to glaucoma itself. 3 it could be caused by cataract, age-related macular degeneration (armd), vitreoretinal surgeries, retinal disorders, corneal pathologies and neuro‐ophthalmological disorders. the incidence of cataract and glaucoma increases with age and they can coexist in the elderly population. glaucoma is more frequently associated with cataracts and there is an increased risk of developing cataracts in glaucoma patients. 4 uveitis can also lead to potentially blinding glaucoma. intraocular pressure (iop) elevation in uveitis can be secondary to openangle or angle-closure mechanisms or due to long-term corticosteroids use. 5 the prevalence of glaucoma associated with uveitis varies but is estimated to be 10 to 20%. however, in severe chronic uveitis, it can be as high as 46%. 6 a persistent rise in intra-ocular pressure can result in glaucomatous optic neuropathy, visual field loss, and a decrease in visual acuity. 7 a study from singapore had reported axial myopia as a potential risk factor for primary open-angle glaucoma. 8 an important aspect of glaucoma patients is that central vision is preserved in these patients until the development of advanced glaucomatous optic atrophy. most of the time reversible causes of decrease vision remain undiagnosed and neglected. these reversible causes need to be identified, evaluated, and managed accordingly. this will help to improve the quality of life and morbidity among glaucoma patients. the objective of this study was to determine the causes of decreased visual acuity in glaucoma patients presenting in the eye outpatient department of a tertiary care hospital. methods this was descriptive cross-sectional study conducted in the ophthalmology department of abbasi shaheed hospital, karachi. the study was conducted from july 2019 to september 2020. the approval from the ethical review committee was taken. adult patients above 18 years of age, visual acuity of less than 6/6, a diagnosed case of primary open-angle, primary angleclosure, secondary open-angle, and secondary angleclosure glaucoma, were included in this study. patients with congenital glaucoma and patients not willing to participate in the study were excluded. the calculated sample size was 369 using open epi sample size calculator version 3 for demographic studies. keeping the population size 1,000,000, confidence interval of 95%, the margin of error 5%, and hypothesized frequency p (40) for cataract as the cause of decreased vision. 3 patients were registered through non-probability consecutive sampling technique from an outpatient department of abbasi shaheed hospital, which is a tertiary care facility. verbal informed consent was taken from every patient. a detailed history of the patient was taken including duration, decrease vision, treatment taken, and any systemic illness. a detailed ocular examination of the patient was done. bestcorrected visual acuity (bcva) was assessed on snellen’s chart. anterior segment was assessed on a slit lamp biomicroscope. cornea was examined for corneal edema, bullae, opacity, and keratic precipitates. the anterior chamber was examined for its depth, inflammatory cells, and flare. iris was examined for any signs of inflammation, granulomas, atrophy, anterior or posterior synechia, and neovascularization. cataract was evaluated for its type and graded accordingly. direct, indirect, and relative afferent pupillary defect were checked. fundoscopy was done with a direct and indirect ophthalmoscope to evaluate the optic nerve head and nerve fiber layer for glaucomatous damage. other than glaucomatous damage retina was examined for other pathologies including age-related macular degeneration, cystoid macular edema, clinically significant macular edema, presence of diabetic and hypertensive retinopathy. intraocular pressure (iop) was measured with the goldman applanation tonometer. gonioscopy, perimetry and optical coherence tomography were also done. data was collected and analyzed on spss version 20. means were calculated for numerical data like age, duration of glaucoma, and iop. frequencies were calculated for categorical variables including different types of glaucoma, laterality, reversible, irreversible, glaucomatous, and non-glaucomatous causes of decreased visual acuity. refractive error, cataract, cystoid macular edema were classified into reversible causes. glaucomatous optic atrophy, age-related macular degeneration (armd), bullous keratopathy, amblyopia were classified into irreversible causes of decreased visual acuity as they could not be corrected by any surgical or medical intervention. non-glaucomatous causes of decreased vision in glaucoma pak j ophthalmol. 2021, vol. 37 (2): 228-233 230 results a total of 369 glaucoma patients were studied. the mean age was 58.2 ± 11.54 sd years. the minimum age of the patient in this study was 33 years and the maximum age was 76 years. there were 224 (60.4%) male patients. the mean duration of glaucoma was 5.4 years ± 5.2 sd. mean iop was 22.3 ± 11.6 sd mmhg. primary open-angle glaucoma was seen in 209 (56.6%) and primary angle-closure glaucoma was in 96 (26%) patients. reversible causes were seen in 119 (32.2 %) patients. non-glaucomatous causes of decrease visual acuity were seen in 221 (59.9%) patients. other demographic details are given in table 1. table 1: demographic features of the patients. variable frequency mean age minimum age maximum age males females right eye left eye primary open angle glaucoma primary closed angle glaucoma secondary open angle glaucoma secondary closed angle glaucoma diabetes mellitus hypertension mean glaucoma duration range of duration mean iop range of iop reversible causes irreversible causes glaucomatous decreased vision non-glaucomatous decreased vision 58.2 ±11.54 years 33 years 76 years 223 (60.4%) 146 (39.6%) 206 (55.8%) 163 (44.2%) 209 (56.6%) 96 (26%) 49 (13.3%) 15 (4.1%) 16 (4.3%) 20 (5.4%) 5.4 ±5.2 sd years 1 month to 20 years 22.3 ± 11.6 sd mmhg 10 to 60 mmhg 119 (32.2%) 250 (67.8%) 221 (59.9%) 148 (40.1%) glaucomatous optic atrophy was the most frequent cause of decreased visual acuity seen in 182 (49.3%) patients followed by cataract in 96 (26%) patients. patients with corneal pathologies were 38 (10.2%) and armd was 26 (7%). other causes of decreased visual acuity are given in table 2. figure 1 depicts the status of best-corrected visual acuity in glaucoma patients. patients presenting with visual acuity between 6/60 and counting finger (cf) were 111 (30.1%). patients with visual acuity between 6/18 to 6/36 were 94 (25.5%) and between 6/9 to 6/12 were 60 (16.3%). patients with no light perception were 13 (3.5%). patients with visual acuity of hand movement and less were 104 (28.2%). graphical representation of causes of decreased visual acuity at a glance is given in figure 2. table 2: causes of decreased vision. causes of decreased vision frequency n (%) glaucomatous optic atrophy 182 (49.3%) cataract 96 (26%) corneal pathologies 38 (10.2%) armd 26 (7%) refractive error 12 (3.3%) cystoid macular edema 9 (2.20%) amblyopia 4 (1.10%) diabetic maculopathy 2 (0.5%) fig. 1: frequency of visual acuity in glaucoma patients given in percentages. fig. 2: frequency of pathologies causing decrease vision in glaucoma patients. uzma fasih, et al 231 pak j ophthalmol. 2021, vol. 37 (2): 228-233 discussion this study was conducted to determine the common causes of decreased visual acuity in glaucoma patients. our study included 369 patients diagnosed with different etiologies of glaucoma. the most frequent irreversible cause of decreased visual acuity in our study was glaucomatous optic atrophy, seen in 182 (49.3%) patients. more than half of the patients i.e. 67.8% in our study presented with irreversible causes and 59.9% of patients with glaucomatous causes of decreased visual acuity. optic nerve head is more susceptible to damage by raised intraocular pressure (iop) due to the increased effect of shearing forces. 9 there is greater susceptibility for glaucomatous optic nerve fiber loss in highly myopic eyes. 10 akhtar had reported 33% of glaucoma patients with advance glaucomatous damage at the initial presentation. 11 a study by n ayachoua had reported visual loss with glaucomatous optic atrophy in 40% of patients. 3 in africa, up to 70% of glaucoma patients presented with advanced glaucomatous optic atrophy in better eye. 12 the frequency of glaucomatous optic atrophy was higher in our patients in comparison to other studies. 3,11 we included glaucoma patients with different etiologies, and the duration of the disease varied from recently diagnosed to 20 years. initially, there is peripheral visual loss among glaucoma patients and central vision is preserved until the advanced stage of the disease. patients usually complain of decreased vision, when central vision start to deteriorate and there is complete glaucomatous optic atrophy. sometimes, instead of reporting these symptoms, the patients complain of blurred vision and increased requirement of light for work. 13 lack of awareness about the disease and poor socioeconomic conditions of the patients contribute to late presentation. this may be the possible reason that treatable and reversible causes of decreased vision in glaucoma patients remain undiagnosed, untreated and overlooked. in our study, cataract was the cause of decreased visual acuity in 96 (26%) patients. in a study by n ayachoua, 17% of cases of decreased vision were due to cataract. 3 in another report it was 50.4%. 14 cataract is a common cause of decreased visual equity in the elderly and it is a common reversible cause of decreased visual acuity in glaucoma patients. 15 uveitis, pseudo exfoliation, acute angle-closure glaucoma, trabeculectomy, laser treatment, and steroids in any form can accelerate cataract formation. 16 even though the central vision is improved by cataract surgery, the damaged areas of the visual field due to glaucoma cannot be reversed. any surgical intervention in advance glaucoma increases the risk of damage to remaining nerve fibers called snuff out. 16 age-related macular degeneration (armd) was seen in 26 (7%) patients. literature shows that primary open-angle glaucoma patients have a significantly higher prevalence of retinal comorbidities as compared to other types of glaucoma. 17 periodic ocular examination in glaucoma patients must be carried out for the detection of such diseases as early armd. n ayachoua reported acquired retinal disorders in 10% of patients in their study. 3 decreased visual acuity due to corneal pathologies was seen in 38 (10.2%) patients, among them bullous keratopathy caused decreased visual acuity in 26 (7%) patients in our study. another study reported corneal pathologies in 4.5% of patients. 3 a persistent rise in iop causes failure of the barrier function of the endothelium and the development of bullous keratopathy. it then leads to a significant decrease in visual acuity. refractive errors were seen in 12 (3.3%) patients in our study out of which 8 (2.1%) patients were myopic and 4 (1.2%) were hypermetropic. the association between refractive error and glaucoma had been investigated and reported in other studies as well. 18 a study from singapore had reported population-attributable risk of poag associated with myopia in 14.6% and for moderate or high myopia in 5.5% of cases. 19 kargi et al had reported, moderate to high myopia correlated with a high risk of primary open-angle glaucoma (poag), low-tension glaucoma, and ocular hypertension. 20 associations in our patients with refractive errors cannot be calculated because of small sample size. amblyopia was seen in 4 (1.10%) patients in our study. we had included adult patients above 18 years of age. kargi et al had reported poor visual acuity in 47% of childhood glaucoma. 20 amblyopia and glaucomatous optic damage were reported to be the most frequent cause of decreased vision in their study. we observed that 16.3% patients had visual acuity of 6/9-6/12, 25.5% patients had 6/18-6/36, 30.1% patients had 6/60, and counting finger, and 17.1% patients presented with hand movements. no perception of light was seen in 3.5% of our patients. non-glaucomatous causes of decreased vision in glaucoma pak j ophthalmol. 2021, vol. 37 (2): 228-233 232 mehar had reported 45.2% of patients with bestcorrected visual acuity between 6/6-6/18, 35.45% patients with 6/18-6/60 and 2.01% patients between 6/603/60. 21 in our study 228 (61.8%) patients had visual acuity of 6/60 or less and 49.3% of them were with advanced glaucomatous optic atrophy. one of the hospital-based studies by akhtar 11 had reported 40.6% of their patients had visual acuity of 3/60 in one eye at the time of presentation. primary open-angle glaucoma was the most frequent type of glaucoma, seen in 209 (56.6%) patients in our study. this was followed by primary angle-closure glaucoma (pacg) in 96 (26%) of patients. meher had reported poag in 41.6%, pacg in 30.7%, and secondary glaucoma in 22.8% of his patients attending glaucoma clinic. 21 irreversible causes of decrease visual acuity were found among 250 (67.8%) patients while reversible causes were found among 119 (32.3%) patients in our study. irreversible causes are significantly high and alarming. in one of the studies, 30% of people were already blind from glaucoma in both eyes at presentation. 22 cataract is on top of the list among reversible causes followed by refractive errors in our study. if we treat these reversible causes timely, it will significantly improve the morbidity of glaucoma patients. population awareness and screening programs regarding glaucoma should be implemented by government and non-government organizations to reduce the burden of glaucoma in our population. the general population should be encouraged for regular eye examinations. early diagnosis, timely management of the disease itself and associated reversible factors of decrease vision will definitely improve the quality of life of glaucoma patients. only then we will be able to combat the silent thief of vision. the limitation of this study was its cross-sectional study design. further studies are needed to see the effect of managing non-glaucomatous factors on visual acuity and to see the impact on the quality of life of glaucoma patients after treating reversible causes. conclusion the commonest cause of decreased visual acuity in glaucoma patients is irreversible glaucomatous optic atrophy. age-related macular degeneration, corneal pathologies, and amblyopia also contribute to irreversibly decreased visual acuity in glaucoma patients. reversible causes include cataract, refractive errors, cystoid macular edema and diabetic macular edema. ethical approval the study was approved by the institutional review board/ ethical review board. 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designation and contribution uzma fasih; associate professor: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. erum shahid; assistant professor: concepts, design, literature search, data analysis, statistical analysis, manuscript editing, manuscript review. arshad shaikh; professor: concepts, design, literature search, manuscript review. .…  …. blindness due to glaucoma ahmad i, khan bs pakistan journal of ophthalmology, 2020, vol. 36 (3): 267-271 267 original article recurrence rate of primary pterygium following excision with mitomycin c versus excision with amniotic membrane transplant jawad humayun 1 , mubashir rehman 2 , mohammad farhan 3 , muhammad kashif karman 4 shahid adbur-rauf khan 5 1-3 nowshera medical college, qazi hussain ahmad medical complex, nowshera, 4 dhq hospital, mishtimela district orakzai, 5 hayatabad medical complex, peshawar abstract purpose: to compare recurrence rate of primary pterygium following excision with mitomycin c verses excision with amniotic membrane transplant. study design: quasi experimental study. place and duration of study: qazi hussain ahmad medical complex, nowshera, from january 2019 to june 2019. material and methods: one hundred and two patients presenting for the first time with pterygium were included in the study and were divided into two groups. patients having conjunctivitis, blephritis, keratitis or any other ocular inflammatory condition and patients having history of chemical burns and symblepharon were excluded from the study. group a underwent surgical excision with 0.02% mitomycin–c application for 3 minutes and group b was surgically treated with application of amniotic membrane. patients of both groups were followed up for six months to detect recurrence of pterygium. data was analyzed using spss version 20. frequency and percentages were calculated for categorical data like age, gender and recurrence rate. recurrence rate was stratified among age and sex to see the effect modifiers. results: mean age in both groups was 39.98 ± 9.11 years. in group a, 64.70% patients were males and in group b, 62.74% patients were male. recurrence of pterygium was seen in 21.5% patients in group a and 7.84% in group b. the difference was statistically significant with a p value of 0.05. conclusion: recurrence rate of primary pterygium following excision with mitomycin c is higher than excision with amniotic membrane transplant. key words: pterygium, mitomycin-c, amniotic membrane. how to cite this article: humayun j, rehman m, farhan m, karman mk, khan sar. recurrence rate of primary pterygium following excision with mitomycin c versus excision with amniotic membrane transplant. pak j ophthalmol. 2020; 36 (3): 267-271. doi: 10.36351/pjo.v36i3.1033 introduction pterygium is a fibrovascular in growth of degenerative correspondence to: mubashir rehman nowshera medical college, nowshera e. mail: drmubashirrehman78@gmail.com received: april 2, 2020 revised: april 17, 2020 accepted: may 4, 2020 the limbus onto the cornea 1 . ultraviolet exposure, hot climates and chronic surface dryness are the risk subepithelial bulbar conjunctival tissue extending over factors for the development of the pterigium 2 . it can lead to complications like astigmatism and inflammation. histologically it is an elastotic degenerative change in the vascularized sub-epithelial stromal collagen 3 . mailto:drmubashirrehman78@gmail.com jawad humayun, et al 268 pakistan journal of ophthalmology, 2020, vol. 36 (3): 267-271 treatment of pterygium includes medical and surgical modalities. medical treatment includes tears substitute, topical steroids and sunglasses 4 . different surgical procedures used for the treatment are bare sclera technique, simple conjunctival flap, conjunctival auto-grafting, adjunctive treatment with mitomycin c or beta irradiation, amniotic membrane patch grafting and occasionally peripheral lamellar keratoplasty 5,6 . each procedure is associated with certain recurrence rates. multiple studies have been done comparing different surgical procedures 7 . mitomycin c (mmc) is an alkylating agent, which has been used during pterygium surgery to reduce chances of recurrence. mmc causes cell death by inhibiting dna synthesis. it is applied directly over the sclera using sponges during pterygium surgery. it acts by inhibition of fibroblast proliferation in the episcleral region and hence reduces chances of recuirrence 8 . one of the methods to cover the gap created by pterigium excision is to use amniotic membrane graft over the bare sclera. amniotic membrane has also been used in other ocular surface diseases such as persistent corneal epithelial defects, chemical burns, stevens–johnson syndrome and ocular cicatricial pemphigoid 9 . amniotic membrane grafts reduce chances of recurrence of pterygium because of their anti-inflammatory properties and cause suppression of transforming growth factor β signaling and fibroblast proliferation, hence promoting epithelial healing. studies have shown that recurrence rates of pterygia following amniotic membrane graftingis between 14.5% and 27.3% 10 . our study intends to compare the recurrence rate of pterygium following excision with mitomycin-c and excision with amniotic membrane transplant. material and methods the study was conducted at the department of ophthalmology, qazi hussain ahmad medical complex, nowshera. non-probability consecutive sampling technique was used. sample size was calculated using who calculator, p1; proportion of recurrence rate in mitomycin group = 40% 6 , p2; proportion of recurrence rate in amniotic membrane transplant group = 14.6% 7 , power of test = 90% and keeping confidence interval = 95% (ci), the sample size was 51 patients in each group. total sample size was 102. all those patients presenting for the first time with pterygium, both genders and age 18 – 60 years were included in the study. patients with recurrent pterygium, conjunctivitis, blephritis, keratitis or any other ocular inflammatory condition and patients having history of chemical burns and symblepharon were excluded from the study. all patients were divided into two groups using non probability consecutive sampling. group a was treated with surgical excision with 0.02% mitomycin–c application for 3 minutes and group b was treated with surgical excision and application of amniotic membrane. amniotic membrane was retrieved by getting placenta from patients booked for elective c-section in the obs/gynae department. the patients were seronegative for hepatitis b and c. amniotic membrane was separated from chorion and was scrapped to remove debris. all the debris/blood was washed with antibiotic cocktail in balanced salt solution (ampicillin, streptomycin and amphotericin-b). after surgery, patients were given eye drops of moxifloxacin and dexamethasone. patients of both groups were followed up for six months to detect recurrence of pterygium on slit lamp examination. data was analyzed using spss version 20. frequency and percentages were calculated for categorical data like age, gender and recurrence rate. chi square test was applied on the two groups to see the difference between the two groups. p value ≤ 0.05 was considered significant. recurrence rate was stratified against age and sex to see the effect modifiers. results a total of 102 patients were divided in two equal groups; patients in group a underwent primary table 1: age distribution (n = 102). age group group a (n = 51) group b (n =51) 18 – 30 years 12 (23.52%) 12 (23.52%) 31 – 40 years 18 (35.29%) 18 (35.29%) 41 – 50 years 11 (21.5%) 11 (21.5%) 51 – 60 years 10 (19.6%) 10 (19.6%) total 51 (100%) 51 (100%) mean and sd 40.35 ± 9.62 39.98 ± 9.11 table 2: efficacy (n = 102); chi square test was applied in which p value was 0.050. efficacy group a (n = 51) group b (n = 51) effective (no recurrence) 40 (78.43%) 47 (92.15%) not effective (recurrence) 11 (21.5%) 04 (7.84%) total 51 (100%) 51 (100%) recurrence rate of primary pterygium following excision with mitomycin c versus excision with amniotic membrane transplant pakistan journal of ophthalmology, 2020, vol. 36 (3): 267-271 269 table 3: stratification of efficacy with age (n = 102). age efficacy excision with mitomycin c excision amniotic membrane transplant p value 18 – 30 years effective 09 11 0.273 not effective 03 01 total 12 12 31 – 40 years effective 14 17 0.148 not effective 04 01 total 18 18 41 – 50 years effective 09 10 0.534 not effective 02 01 total 11 11 51 – 60 years effective 08 09 0.531 not effective 02 01 total 10 10 table 4: stratification of efficacy with gender. gender efficacy excision with mitomycin c excision amniotic membrane transplant p value male effective 28 29 0.478 not effective 05 03 total 33 32 female effective 14 18 0.131 not effective 04 01 total 18 19 pterygium excision with mmc and group b had pterygium excision with amniotic membrane transplant. age distribution among two groups is shown in table no 1. in both groups, 35.29% patients were in ages between 31 – 40 years. mean age was 39.98 ± 9.11. male were more than females in both groups i.e. in group a, 33 (64.70%) patients were male where as in group b, 32 (62.74%) patients were male. recurrence was seen in 21.5% patients of group a and 7.84% patients of group b. stratification of efficacy with age and gender is given in table number 3 and 4. discussion pterygium is one of the most common disorders in tropical and subtropical region 11 . most important risk factors are exposure to sunlight, hot, windy dry weather and old age 12 . short body height is also cited in literature as a risk factor for pterygium development. it causes irritation, redness and affects the visual acuity either by directly affecting the visual axis or by producing changes in the corneal curvature 13-14 . yu c et al compared the efficacy of amniotic membrane transplantation, corneal limbus stem cell conjunctival transplantation and pedicle conjunctival flap transposition in the treatment of pterygium and observed that the recurrence rates of pterygium for the three surgeries were 14.6%, 13.9% and 7.7%, respectively. no significant difference was identified when comparing the recurrence rate between any two groups 15 . zeng et al in their meta-analysis compared limbal conjunctival autograft and other adjuvants for pterygium excision. they stated that the recurrence rates after pterygium excision with limbal conjunctival autograft were lower as compared to pterygium excision with bare sclera technique (p < 0.01), bulbar conjunctival autograft (p < 0.01), and with use of mitomycin c (p < 0.01). however, there was no statistically significant difference in the recurrence rates after limbal conjunctival autograft and amniotic membrane graft (p = 0.39) 16 . liang w et al compared the recurrence rate of pterygium excision with conjunctival autograft versus pterygium excision with amniotic membrane graft and found that conjunctival autograft group had low recurrent rate; 6 eyes (7.4%) versus amniotic membrane transplantation group; 10 eyes (19.2%) 17 . the recurrence rates in our study were similar to koranyi g et al who compared outcome of a 4 years study on pterygium excision using mitomycin c with suturing a free conjunctival autograft and found that the recurrence rate was 38% in mitomycin c group and 15% in conjunctival autograft group (p < 0.05) 18 . kheirkhah a et al compared the prevention of recurrence in patients with primary or recurrent pterygium using adjunctive mitomycin c application following pterygium excision with free conjunctival autograft versus conjunctival-limbal autograft. they observed that in free conjunctival autograft group no eye developed pterygium recurrence; however, two eyes (5.1%) in conjunctival-limbal autograft group developed recurrence, including one patient (3.2%) with primary pterygia and one patient (12.5%) with recurrent pterygia with no statistically significant difference in recurrence rates between the two groups or in the primary and recurrent pterygium groups 19 . salman ag et al compared the recurrence rate after limbal stem cell transplantation versus amniotic http://www.ncbi.nlm.nih.gov/pubmed?term=koranyi%20g%5bauthor%5d&cauthor=true&cauthor_uid=20528781 http://www.ncbi.nlm.nih.gov/pubmed?term=kheirkhah%20a%5bauthor%5d&cauthor=true&cauthor_uid=22153864 jawad humayun, et al 270 pakistan journal of ophthalmology, 2020, vol. 36 (3): 267-271 membrane transplantation as ocular surface reconstructing procedure. they also evaluated the use of antimetabolite drugs as an adjunctive therapy for amniotic membrane transplantation and conjunctival autograft. they observed that the recurrence rate was 10% in limbal stem cell transplantation plus conjunctival autograft group, 30% in amniotic membrane transplantation group and 20% in mitomycin c plus amniotic membrane transplantation group. the rate of recurrence was statistically significantly between the three groups (p < 0.001) 20 . fakhry observed that in pterygium excision and limbal-conjunctival autograft transplantation group there were four cases of recurrences while in group operated with injection of 0.1 ml of mitomycin-c, 0.15 mg/ml one month before limbal-conjunctival autograft transplantation surgery, there was one case of recurrence 21 . hafez mi compared one-year outcome of two procedures for primary pterygium excision with mmc and excision with suturing a free conjunctival autograft. the recurrence rate of mmc group was 40% compared with 5.3% in conjunctival autograft group 22 . the limitation of our study was that it was a single centered study. moreover, a comparison was only made between two adjuvants. conclusion recurrence rate of primary pterygium following excision with mitomycin c has a higher recurrence rate as compared to excision with amniotic membrane transplant. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution jawad humayun; registrar: concept, manuscript writing, final review. mubashir rehman; associate professor: study design, data analysis, final review. mohammad farhan; senior registrar: study design, data analysis, final review. muhammad kashif karman; medical officer: study design, data analysis, final review. shahid adbur rauf khan; vitreo-retina fellow: study design, data analysis, final review. references 1. kanski jj. clinical ophthalmology. a systemic approach, 9 th edition. butterworth, heinmenn, london. 2019; 5 (7): 163. 2. khoo j, saw sm, banerjee k, chia se, tan d. outdoor work and the risk of pterygia: a casecontrol study. int ophthalmol. 1998; 22 (5): 293-8. 3. tsim nc, young al, jhanji v, ho m, cheng ll. combined conjunctival rotational autograft with 0.02% mitomycin c in primary pterygium surgery: a long-term 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dai h, yan m, luo h, ke m, cai x. anti-fibrotic, anti-vegf or radiotherapy treatments as adjuvants for pterygium excision: a systematic review and network meta-analysis. bmc ophthalmol. 2017; 17: 211-14. 17. liang w, li r, deng x. comparison of the efficacy of pterygium resection combined with conjunctival autograft versus pterygium resection combined with amniotic membrane transplantation. eye sci. 2012; 27 (2): 102-5. 18. koranyi g, artzén d, seregard s, kopp ed. intraoperative mitomycin c versus autologous conjunctival autograft in surgery of primary pterygium with four-year follow-up. acta ophthalmol. 2012; 90 (3): 266-70. 19. kheirkhah a, hashemi h, adelpour m, nikdel m, rajabi mb, behrouz mj. randomized trial of pterygium surgery with mitomycin c application using conjunctival autograft versus conjunctival-limbal autograft. ophthalmology, 2012; 119 (2): 227-32. 20. salman ag, mansour de. the recurrence of pterygium after different modalities of surgical treatment. saudi j ophthalmol. 2011; 25 (4): 411-5. 21. fakhry ma. the use of mitomycin c with autologous limbal-conjunctival autograft transplantation for management of recurrent pterygium. clin ophthalmol. 2011; 26 (5): 123-7. 22. hafez mi. autologous conjunctival autograft versus intraoperative mitomycin c in surgery of primary pterygium. life sci j. 2013; 10 (3): 403-8. .…  …. http://www.ncbi.nlm.nih.gov/pubmed?term=yu%20c%5bauthor%5d&cauthor=true&cauthor_uid=22187301 http://www.ncbi.nlm.nih.gov/pubmed?term=liang%20w%5bauthor%5d&cauthor=true&cauthor_uid=22187301 http://www.ncbi.nlm.nih.gov/pubmed?term=huang%20y%5bauthor%5d&cauthor=true&cauthor_uid=22187301 http://www.ncbi.nlm.nih.gov/pubmed?term=guan%20w%5bauthor%5d&cauthor=true&cauthor_uid=22187301 http://www.ncbi.nlm.nih.gov/pubmed/22187301 https://www.ncbi.nlm.nih.gov/pubmed/?term=zeng%20w%5bauthor%5d&cauthor=true&cauthor_uid=29178848 https://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20z%5bauthor%5d&cauthor=true&cauthor_uid=29178848 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http://www.ncbi.nlm.nih.gov/pubmed?term=artz%c3%a9n%20d%5bauthor%5d&cauthor=true&cauthor_uid=20528781 http://www.ncbi.nlm.nih.gov/pubmed?term=seregard%20s%5bauthor%5d&cauthor=true&cauthor_uid=20528781 http://www.ncbi.nlm.nih.gov/pubmed?term=kopp%20ed%5bauthor%5d&cauthor=true&cauthor_uid=20528781 http://www.ncbi.nlm.nih.gov/pubmed/20528781 http://www.ncbi.nlm.nih.gov/pubmed?term=kheirkhah%20a%5bauthor%5d&cauthor=true&cauthor_uid=22153864 http://www.ncbi.nlm.nih.gov/pubmed?term=hashemi%20h%5bauthor%5d&cauthor=true&cauthor_uid=22153864 http://www.ncbi.nlm.nih.gov/pubmed?term=adelpour%20m%5bauthor%5d&cauthor=true&cauthor_uid=22153864 http://www.ncbi.nlm.nih.gov/pubmed?term=nikdel%20m%5bauthor%5d&cauthor=true&cauthor_uid=22153864 http://www.ncbi.nlm.nih.gov/pubmed?term=rajabi%20mb%5bauthor%5d&cauthor=true&cauthor_uid=22153864 http://www.ncbi.nlm.nih.gov/pubmed?term=behrouz%20mj%5bauthor%5d&cauthor=true&cauthor_uid=22153864 http://www.ncbi.nlm.nih.gov/pubmed/22153864 http://www.ncbi.nlm.nih.gov/pubmed?term=salman%20ag%5bauthor%5d&cauthor=true&cauthor_uid=23960956 http://www.ncbi.nlm.nih.gov/pubmed?term=mansour%20de%5bauthor%5d&cauthor=true&cauthor_uid=23960956 http://www.ncbi.nlm.nih.gov/pubmed/23960956 http://www.ncbi.nlm.nih.gov/pubmed?term=fakhry%20ma%5bauthor%5d&cauthor=true&cauthor_uid=21339805 http://www.ncbi.nlm.nih.gov/pubmed/21339805 pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 99 original article role of sub-conjunctival bevacizumab in regression of corneal neovascularization ibrar hussain, akhunzada muhammad aftab pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ibrar hussain h # p-11, near masjid e firdos university campus peshawar25125. …..……………………….. purpose: to evaluate therapeutic effect of subconjunctival bevacizumab on corneal neovascularization. material and methods: thirty two eyes, with corneal neovascularization caused by different ocular surface disorders, were studied. each eye received 2 injections of 2.5 mg/0.1ml bevacizumab at monthly interval. morphological changes in corneal neovessels were evaluated using slit lamp biomicroscopy and digital corneal photography. results: out of total 32 patients, 21(65.5%) were males and 11(35.5%) were females. mean age of all patients was 41.59 ± 17.6 years. causes of corneal neovascularization included trauma (28.1%), failed corneal graft (21.9%), chemical burn (12.5%), healed corneal ulcer (12.5%), trachoma (3.1%) and unknown cause (21.9%). mean corneal surface involved by neovessels before injection was 50.56 ± 30.4% which reduced to 35.81 ± 26.94% after subconjunctival injection of bevacizumab (p = 0.000) and the extent of neovessels reduced from 7.47 ± 3.83 clock hours to 6.56 ± 3.78 clock hours (p = 0.002). no adverse effect of subconjunctival bevacizumab was noted. conclusion: sub-conjunctival bevacizumab is effective in regressing corneal neovessels partially due to different causes. but for this purpose repeated injections are needed. ornea is avascular structure to serve its optical function in a best way. its neovascularization is always pathologic and represents an important cause of visual morbidity. corneal neovessels, compromise both the corneal transparency1 as well as its immune privilege. patent corneal vessels impair the process by which migrating limbal stem cells differentiate into transparent corneal epithelial cells2. corneal neovascularization is induced by a variety of inflammatory, infectious, degenerative and traumatic (both mechanical and chemical) disorders3. to maintain corneal avascularity under basal conditions there are low levels of angiogenic factors and high levels of anti-angiogenic factors in the cornea4. imbalance of this homeostasis may occur in pathogenesis of corneal neovessels2. it is shown that there is up-regulation of vascular endothelial growth factor (vegf) in inflamed and vascularized cornea5-7. thus vegf promotes angiogenesis in cornea. anti vegf antibodies are commonly used to regress retinal and choroidal neovessels in proliferative diabetic retinopathy, wet age related macular degeneration (armd) and few other conditions. bevacizumab, a humanized monoclonal antibody against all types of vegf8,9, can be an effective option to regress corneal neovessels. initially it was used by researchers in animal models and found effective in reducing corneal neovessels. then it was used in human eyes and its affectivity in regressing corneal neovessels was proved4 we planned a study in which effect of subconjunctival bevacizumab (avastin®) injection on corneal neovessels was assessed. the rationale of the study is that once it is proved by multiple studies that subconjunctival bevacizumab is effective, the regime can be used to regain transparency of cornea in many pathological conditions, where corneal neovessels c ibrar hussain, et al 100 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology develop. moreover, the regime can also be used to reduce chance of corneal graft rejection in vascularized corneas. material and methods this quasi-experimental study was conducted at khyber teaching hospital peshawar, pakistan from september 2011 to may 2013. approval was taken from institutional ethical committee of khyber medical college peshawar, pakistan. 32 eyes were included in the study. all eyes had moderate to severe corneal neovessels. eyes with active anterior segment disease like corneal ulcer, active anterior uveitis, etc. were excluded from the study. each eye was thoroughly examined on slit lamp, digital photograph taken and extent of corneal neovascularization (conv) noted. moreover corneal clarity in the area involved by neovessels was graded as follows. grade i: iris crypts visible grade ii: iris visible but crypts not visible grade iii: iris not visible, but slit lamp beam passes into anterior chamber. grade iv: totally opaque cornea for each patient pre-injection digital corneal photograph was taken. the eye was anaesthetized with 1% topical proparacaine drops. under operating microscope, sub conjunctival injection of 0.1ml (2.5mg) of bevacizumab was given near the limbus in the area where maximum density of neovessels found in the nearby cornea. photograph of cornea repeated one week after injection. a second dose of bevacizumab was given one month after the first injection with same protocol. slit lamp examination for corneal clarity was done and a final corneal photograph was taken one month after the second injection. pre injection corneal photographs were compared with final photographs in terms of extent of corneal neovascularization in clock hours and percentage of corneal surface involved by neovessels. the data was analyzed using spss version 15. means with standard deviation were calculated for numerical variables like age and percentage of corneal surface involved by neovessels. proportions were calculated for string variables like gender, causes of corneal neovessels and clarity of cornea. paired samples ‘t’ test was used to calculate pvalue and a p value of 0.005 was considered significant. results thirty two eyes were included in the study. twenty one 65.6% patients were males and 34.4% were females. mean age of all patients was 41.59 ± 17.6 years. physical trauma with corneal scarring was the most common cause of corneal neovascularization which was found in 9 (28.1%) patients. this was followed by failed corneal graft in 7 (21.9%), chemical burn in 4 (12.5%), healed corneal ulcer in 4 (12.5%), trachoma in 1 (3.1%) and unknown cause in 7 (21.9%) patients (figure 1). mean corneal surface involved by neovessels before injection was 50.56 ± 30.4% which reduced to 35.81 ± 26.94% one month after second subconjunctival injection of bevacizumab (p=0.000) (figure 2) and the extent of neovessels reduced from 7.47 ± 3.83 clock hours to 6.56 ± 3.78 clock hours (p = 0.002) (table 1). no significant change was found in corneal clarity. fig. 1: causes of corneal neovascularization. (cu = corneal ulcer, cg = corneal graft) fig. 2: corneal neovascularizaion in alkali burn, showing significant reduction in extent of neovessels after subconjunctival injection of bevacizumab. 0 2 4 6 8 10 trauma failed cg alkali burn healed cu trachoma unknown no. of eyes role of sub-conjunctival bevacizumab in regression of corneal neovascularization pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 101 discussion normally to keep the cornea avascular, there is low level of angiogenic and high level of anti-angiogenic factors in cornea. imbalance of this homeostasis may occur in inflamed corneas which lead to formation of neovessels in it that primarily sprout from limbal vessels. vegf-a is produced by a variety of cells including retinal pigment epithelial cells, macrophages, astrocytes, muller cells, smooth cells and tcells. vegf-a up-regulation has been demonstrated in inflammatory diseases associated with neovascularization in human cornea.10 role of vegf in pathophysiology of corneal neovascularization was proved by the researchers in rabbits and other primates11-14. the anti vegf role of bevacizumab has been proved in regressing corneal neovessels in animals and human beings15-21. moreover safety of this drug with no harmful effect on corneal cells in vitro was also established22. after that this drug was used by many researchers in reducing conv in human beings6,23,24. no serious side effects of bevacizumab have been reported while used subconjunctival25-27, intracornreal28 or topical29 on ocular surface, to regress conv. in our study we did not notice any serious adverse effect of sub-conjunctival bevacizumab (2.5 mg/ 0.1 ml), except mild sub-conjunctival hemorrhage in few eyes which resolved spontaneously. in our study we observed clinically significant reduction in area of corneal surface involved by conv from 50.56 ± 30.4% to 35.81 ± 26.94% or extent of conv from 7.47 ± 3.83 clock hours to 6.56 ± 3.78 clock hours. this is consistent with many other international studies. in a study from canada25 the extent of conv reduced from 6.00 ± 1.2 to 4.6 ± 1.00 clock hours after bevacizumab injection (p = 0.008). in this study all eyes received at least two injections (2.5 mg / o.1 ml). in another study from egypt by zaki and farid30, the area of conv decreased from 14.00 ± 5.4% to 9.4 ± 3.9% of corneal surface (p < 0.01) and extent decreased from 4.3 ± 1.5 clock hours to 2.4 ± 1.1 clock hours (p < 0.01) fifteen days after single subconjunctival injection of 2.5 mg /0.1 ml of bevacizumab. in a study from france23 mean conv area decreased from 41.1% to 33.7% at day 45 (p = 0.000) and to 33.9% at day 120 (p = 0.0013). in this study sample size was 12 eyes and each eye received 2 to 4 subconjunctival bevacizumab (2.5 mg / 0.1 ml) injections. a pilot randomized placebo – controlled double masked trial from moorfield eye hospital, london also proved that mean area of conv reduced by -36% in eyes that received 3 sub-conjunctival injections of 2.5mg / 0.1ml bevacizumab at monthly intervals compared with an increase of 90% in eyes that received saline placebo (p = 0.007)31. in our study we observed that subconjunctival injection regresses newly formed small vessels and not the well-established bigger vessels. this was also observed by bahar i et al25 and petsoglou c et al31 in their studies. these established vessels are probably not affected by imbalance of vegf, hence not responding to bevacizumab. moreover like many other international studies mentioned above25,30,31. in our study reduction in conv was only partial. this could be due to factors other than vegf, that can induce conv and remain unaffected by bevacizumab32,33. conclusion subconjunctival bevacizumab is effective in regressing corneal neovessels partially and for this purpose repeated injections are needed. randomized control trials are needed to prove the results. acknowledgement we are thankful to ophthalmological society of pakistan (centre) for financial support of this study. author’s affiliation dr. ibrar hussain professor of ophthalmology khyber teaching hospital peshawar dr. akhunzada muhammad aftab trainee medical officer department of ophthalmology khyber teaching hospital peshawar ibrar hussain, et al 102 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology references 1. huang aj, watson bd, hernandez e, tseng sc. induction of conjunctival trans differentiation on vascularized corneas by photothrombotic occlusion of corneal neovascularization. ophthalmology 1988; 95: 228-35. 2. kinoshito s, kiorpes tc, friend j, thoft ra. limbal epithelium in ocular surface wound healing. invest ophthalmolvis sci. 1982; 23: 73-80. 3. change jh, gabison ee, kato t, azar dt. corneal neovascularization. curr opin ophthalmol. 2001; 12: 242-9. 4. hisham ah, zaki ima, ramzy m. subconjunctival bevacizumab, a potential therapeutic strategy for corneal neovascularization. life science j. 2010; 7: 112-6. 5. chen j, liu w, liu z, 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http://www.ncbi.nlm.nih.gov/pubmed?term=forte%20r%5bauthor%5d&cauthor=true&cauthor_uid=22357391 http://www.ncbi.nlm.nih.gov/pubmed?term=robert%20py%5bauthor%5d&cauthor=true&cauthor_uid=22357391 http://www.ncbi.nlm.nih.gov/pubmed/?term=benayoun+y%2c+adenis+jp%2c+casse+g%2c+et+al.+effect+of+subconjunctival+bevacizumab+on+corneal+neovascularization%3a+results+of+a+prospective+study http://www.ncbi.nlm.nih.gov/pubmed?term=dastjerdi%20mh%5bauthor%5d&cauthor=true&cauthor_uid=19365012 http://www.ncbi.nlm.nih.gov/pubmed?term=al-arfaj%20km%5bauthor%5d&cauthor=true&cauthor_uid=19365012 http://www.ncbi.nlm.nih.gov/pubmed?term=nallasamy%20n%5bauthor%5d&cauthor=true&cauthor_uid=19365012 http://www.ncbi.nlm.nih.gov/pubmed?term=hamrah%20p%5bauthor%5d&cauthor=true&cauthor_uid=19365012 http://www.ncbi.nlm.nih.gov/pubmed?term=jurkunas%20uv%5bauthor%5d&cauthor=true&cauthor_uid=19365012 http://www.ncbi.nlm.nih.gov/pubmed?term=pineda%20r%202nd%5bauthor%5d&cauthor=true&cauthor_uid=19365012 http://www.ncbi.nlm.nih.gov/pubmed?term=pavan-langston%20d%5bauthor%5d&cauthor=true&cauthor_uid=19365012 http://www.ncbi.nlm.nih.gov/pubmed?term=dana%20r%5bauthor%5d&cauthor=true&cauthor_uid=19365012 http://www.ncbi.nlm.nih.gov/pubmed/?term=mohammad+h%2c+dastjerdi+md%2c+ai-arfaj+km.+topical+bevacizumabin+the+treatment+of+corneal+neovascularization.+results+of+a+prospective%2c+open+label%2cnoncomparative pak j ophthalmol. 2020, vol. 36 (4): 348-354 348 case series role of anterior segment oct in the management of primary narrow angle disease sadia farooq 1 , javeria muid 2 1-2 ophthalmology clinic, shifa international hospital h-8/4, islamabad abstract purpose: to highlight the role of anterior segment oct, in complementing gonioscopic findings in the management of angle closure glaucoma. study design: descriptive observational case series. study place and duration: study was conducted at eye department of shifa international hospital, from january 2019 to march 2019. methods: after taking informed consent from the patients, the study was conducted at shifa international hospital islamabad. patients were selected by convenient sampling technique. patients were diagnosed on the basis of history and clinical examination. patients with angle closure on gonioscopy were included in this series. detailed ocular examination including visual acuity for distance and near, tonometry, gonioscopy and anterior segment oct were performed. data was collected and presented as case series. results: there were 8 patient included in the study with median age of 57 years with 50% more than 60 years and 50% less than 60 years of age. presenting iop was less than 21 mm hg in 50% and higher in remaining 50%. on examination 37.5% were categorized as primary angle closure suspects (pacs), 12.5% having primary angle closure (pac) and 50% as primary angle closure glaucoma (pacg). after definitive treatment 12.5% still needed medical treatment to prevent progression in pacg and none in pacs and pac. conclusion: in narrow angle disease, treatment is designed not only to control intraocular pressure (iop) but also to keep angle open as much as possible. appositional closure or peripheral anterior synechiae (pas) can damage the trabecluar meshwork. iridoplasty, peripheral iridotomy (pi) and early lens extraction can defer the need for filtration procedure if done well in time. key words: oct anterior segment, narrow angle, optic nerve head. how to cite this article: farooq s, muid j. role of anterior segment oct in the management of primary narrow angle disease. pak j ophthalmol. 2020; 36 (4): 348-354. doi: https://doi.org/10.36351/pjo.v36i4.1039 introduction it is estimated that asians account for over half of primary open angle glaucoma (poag) patients worldwide and more than three quarters of those with correspondence: javeria muid ophthalmology clinic, shifa international hospital h-8/4, islamabad email: javeriamuid90@gmail.com received: april 14, 2020 accepted: july 25, 2020 primary angle closure glaucoma (pacg). the higher rate of glaucomatous optic neuropathy in asians is probably attributed to pacg. 1 in a regional population-based study, up to 36% of poag and 70% of pacg patients were blind at the time of presentation. out of 1.7 million blind people in china, pacg is responsible for the vast majority (91%) of these cases. 2,3 pacg is diagnosed by the presence of irido-trabecular contact(itc) on gonioscopy, contact of 180 o or more is considered as sufficient to be labelled as pac. one out of four patients of primary angle closure suspect (pacs) will progress to iop mailto:javeriamuid90@gmail.com sadia farooq, et al 349 pak j ophthalmol. 2020, vol. 36 (4): 348-354 elevation and peripheral anterior synechiae (pas) in 05 years. 4 second stage is pac, 180 o or more of itc and iop elevation or pas not secondary to any ocular cause. finally, it is labeled as pacg in the presence of itc with glaucomatous optic neuropathy. a population-based study from south india reported 22% progression of pacs to pac and 29% of pac to pacg over five years. a study of mongolian population, of people with central anterior chamber (ac) depth of less than 2.53mm the incidence of pacs is reported to be 20.4% over 06 years. understanding the pathogenesis of pac is crucial for management. most common underlying mechanism is pupil block increasing the differential pressure between posterior and anterior chamber. it causes convex iris with peripheral itc. studies demonstrate that darker (thicker) irides may predispose to pupil block. 5 anteriorly positioned lens, choroidal expansion due to changes in arterial and venous pressure, blood volume and loose zonules all contribute to development of pac via anterior lens shift. 6 angle crowding is another mechanism due to anteriorly positioned ciliary body compressing the iris root forward against trabecular meshwork. thirty percent of pacs were diagnosed with plateau iris on ultrasound biomicroscopy (ubm) after laser iridotomy. 7 some eyes may have deep central anterior chamber (ac) but have sharp posterior turn at iris root on gonioscopy. gonioscopy with four mirror lenses with 9mm contact area can help visualize all four angles quickly without the use of coupling agent. it also differentiates appositional from synechial angle closure hence helps in deciding management plan. oct of anterior segment has made it possible to objectively analyze angle, ac depth, lens vault and pas, all possible risk factors towards pacg development. anterior chamber angle was the best predictable parameter for narrow angle disease and the south asian studies concludes the same. 8 hence, oct proves to be an important non-contact device to detect and follow narrow angle glaucoma cases with limitation of less penetration through pigment epithelium and poor resolution of inferior quadrants. 9,10,11 with gonioscopy still being the gold standard, oct is more sensitive adjunct to screen narrow angles with future risks of angle closure (12) and helps in patient education as well. 12,13 this case series is presented to find out various mechanisms which are causing the angle closure in our population and to discuss management in each case in a tertiary care setting of pakistan and the role of anterior segment swept source oct in management of such cases. methods after taking informed consent from the patients, the study was conducted at shifa international hospital islamabad. patients were selected by convenient sampling technique. patients were diagnosed on the basis of history and clinical examination. patients with angle closure on gonioscopy were included in this series. detailed ocular examination including visual acuity for distance and near, tonometry, gonioscopy and anterior segment oct were performed. data was collected and presented as case series. patient 1 a 41 years old female with occasional symptom of ocular pain and redness came for evaluation. she was not using any treatment for glaucoma. her bestcorrected visual acuity (bcva) was 6/6 in both eyes (be). her central corneal thickness (cct) was within normal range in both eyes with iop of 16 mmhg in both eyes. she had cup/disc ratio (c/d) of 0.3 bilaterally. gonioscopy and oct angle showed narrow angles (non-synechial) in either eye. laser iridoplasty with pi was done in both eyes one by one and oct angle was repeated which showed open angles. patient 2 a 65 years old lady on her routine examination was found to have very narrow angles in be on slit lamp examination. her bcva was 6/6 (+2.75 ds) in the right eye (re) and 6/9 (+3.0/-0.50 × 10) in the left eye (le). she had early cataracts and c/d of 0.5 in be. her cct was 543µm in the re and 534µm in le. iop were 14 mmhg in be. her gonioscopy was performed which showed itc in either eye but open on indentation. oct rnfl did not show any thinning and oct angle showed irido-trabecular contact. her early phaco with iol were performed in be. her role of anterior segment oct in the management of primary narrow angle disease pak j ophthalmol. 2020, vol. 36 (4): 348-354 350 angles were wide open on gonioscopy post operatively. patient 3 a 70 years old man was diagnosed as nanophthalmos and prominent lens vault. oct showed synechial angle closure in left eye, iop was 42 mmhg and cd ratio was 0.6. he was managed by phacotrabeculectomy. he had iop 28 mmhg, narrow angle and cd 0.2 in rt eye, where phacoemulsification alone resulted in deepening of anterior chamber and angle and control of iop. patient 4 a 66 years old female came with complaints of blurred vision in be for few months. examination showed cataract in be with bcva of 6/15 in re and 6/9 in le. iop was 19 mmhg in re and 21 mmhg in le. on gonioscopy angles were crowded with higher iris root insertion in be and c/d were normal. she underwent bilateral phacoemulsification with iol implant. she was 6/6 (unaided) post-operatively, angles widened and well controlled iop in be. patient 5 a 43 years old female presented for glaucoma assessment. she was 6/9 with 0.5ds in be. she was using dorzolamide, latanoprost, and timolol in be. on gonioscopy she had narrow angles in be which were open on indentation in one quadrant only. her iop were 22 mmhg with c/d of 0.9 and 16 mmhg with c/d ratio of 0.6 in le and re respectively. slit lamp examination showed early cataracts in either eye. her oct optic nerve head showed severe thinning in all the four quadrants in re and early disc damage in le. she underwent phaco-trabeculectomy with 0.02% mitomycin c in be after which her iop were controlled without anti-glaucoma treatment till the last follow-up. patient 6 a 40 years old male came for glaucoma checkup. he was diagnosed with glaucoma three years back and was using latanoprost, dorzolamide, timolol and brimonidine. his iop were 20 mmhg in either eye and had c/d ratio of 0.8 in re and 0.7 in le. gonioscopy showed narrow angles opening on indentation with peripheral iris hump. oct of angles showed angle of less than 15 o in all quadrants in be. oct optic nerve head showed very early damage. his laser trabeculoplasty (slt) combined with iridoplasty was done in both eyes. oct angle was repeated which showed significantly opened angles in be and his iop were well controlled after slt. patient 7 a 59 years old male presented for glaucoma checkup. his bcva was 6/9 with narrow angles on gonioscopic examination bilaterally and c/d ratio of 0.7 in re and 0.4 in le plus bilateral ns++. oct showed ganglion cell and rnfl loss in right eye and normal le. he had pacg in re with open angle on indentation and pac in le. his iop was 28 mmhg in re and 25 mmhg in le. his phacoemulsification with lens implant was done in re followed by le (figure 1). his pressures were under control without any further topical glaucoma treatment and he is on follow-up every 6 months. fig. 1a: before cataract surgery. fig. 1b: after cataract surgery. patient 8 a 69 years old female presented for routine eye examination. her bcva was 6/6 (+3.0ds) with normal slit lamp examination, normal iop and c/d ratio of 0.3 bilaterally. her gonioscopy revealed narrow angles but open on indentation. oct angle showed angle of less than 15 o and thicker iris (figure 2a) with no ganglion cell or rnfl loss on oct glaucoma analysis. her bilateral 360º iridoplasty was done and oct anterior segment was repeated which showed great improvement in angle appearance (figure 2b). she is on 03 monthly follow-up and doing perfectly fine with no symptoms or signs of progression to glaucoma so far. sadia farooq, et al 351 pak j ophthalmol. 2020, vol. 36 (4): 348-354 results there were 8 patients in total out of whom 5 were females and 3 were males. the median age of the patients was 57 years with 50% of them being more than 60 years and 50% less than 60 years of age. presenting iop was less than 21 mmhg in 50% and higher in remaining 50%. on examination, 37.5% were categorized as pacs, 12.5% as pac and 50% as pacg. after definitive treatment, 12.5% still needed medical treatment to prevent progression in pacg and none of them required treatment to stop progression to pacs and pac. the detailed results are summarized in table 1. fig. 2a: before iridoplasty thick iris with crowded angles. fig. 2b: after iridoplasty showing deep angle with flat iris hump. table 1: results according to age, sex, type of intervention, outcome and post-treatment iop. age sex symptoms at presentation initial iop mmhg interventions outcome medications after intervention 41 f pain and redness 16 (both eyes) pi and laser iridoplasty open angle normal iop nil 65 f no 22 (both eyes) phacoemulsification with iol open angle normal iop nil 70 m blurring and redness 28 rt 42 lt phacoemulsification with iol phacoemulsification with trabeculectomy + iol normal iop-rt eye 2 anti glaucoma in-lt eye nil rt eye 2 anti glaucoma lt eye 66 f blurred vision 19 rt 21 lt phacoemulsification with iol normal iop both eyes nil 43 f known glaucoma on 3 antiglaucoma treatment 22 rt 16 lt phacoemulsification with trabeculectomy with iol normal iop b/l nil 40 m glaucoma check up 20 rt 20 lt iridoplasty and slt b/l normal iop nil 59 m glaucoma check-up 28 rt 25 lt phacoemulsification with iol iop controlled nil 69 f routine eye check-up 12 rt 12 lt bilateral iridoplasty open angle on gonioscopy nil table 2: number of patients according to intervention. s. no. intervention number of patients 1. peripheral iridotomy with laser iridoplasty 2 eyes of 1 patient 2. laser iridoplasty alone 2 eyes of 1 patient 3. selective laser trabecuplasty with laser iridoplasty 2 eyes of 1 patient 4. phacoemulsification with lens implant alone 6 eyes of 3 patients 5. phacoemulsification + trabeculectomy with lens implant 3 eyes of 2 patients table 3: stage of glaucoma and number of patients. s. no stage of glaucoma number of patients 1. primary angle closure suspect 3 2. primary angle closure 1 3. primary angle closure glaucoma 4 table 4: outcome according to sex and number of patients (3 months follow-up). s. no outcome number of patients 1. open angle on gonioscopy 6 patients 2. controlled iop after management without any medication 15 eyes of 8 patients 3. controlled iop after management with 1 topical antiglaucoma medication nil 4. controlled iop after management with 2 topical antiglaucoma medications 1 eye of 1 patient discussion once screened, management options for pacs and pac may vary among individuals due to subjective role of anterior segment oct in the management of primary narrow angle disease pak j ophthalmol. 2020, vol. 36 (4): 348-354 352 experiences and intentions to treat or observe. lasers are simple and effective when some intervention is needed as they help to alter the mechanism of angle closure, 14 yag laser iridotomy helps relieve pupil block, the most common mechanism in angle closure glaucoma. 15 eyes with thicker iris, higher iris insertion and thicker lens will still have narrow angle after laser iridotomy. 16 greatest effect of laser peripheral iridotomy is seen in eyes with greatest baseline pupil block. 17 laser trabeculoplasty has role in narrow angle as well once angle is opened by laser iridotomy or iridoplasty. its efficacy is proved in laser glaucoma study, 18 early manifest glaucoma trial 19 and advanced glaucoma intervention study. 20 laser peripheral iridoplasty flattens the peripheral hump of iris, widens the angle in all patients with narrow occludable angles after lpi and changes were maintained till 03 months follow-up. still its efficacy in pac stays controversial. 21 pacs/pac 2/3 rd or more than 180 o itc on gonioscopy oct anterior segment >15 o of angle width/no pas <15 o of angle width/pas/ symptomatic patient/increased iop look for symptoms thicker iris iop normal no symptoms symptoms of blurring of vision difficult to follow observe early lens extraction lpi laser iridoplasty iridoplasty+/iridotomy iridotomy follow-up for oct optic nerve head changes significant lens changes phacoemulsification with lens implantation progressive changes iop increasing/increased narrowing of angle phacoemulsification with trabeculectomy or phacoemulsification with medical treatment iop normal/ increased narrowing phacoemulsification with lens implantation sadia farooq, et al 353 pak j ophthalmol. 2020, vol. 36 (4): 348-354 lens extraction remains an effective treatment in narrow angle disease. in eagle study, lens extraction group needed minimal intervention for control of iop and opening of angle than in laser iridotomy group. 22 once pacg is there phacoemulsification alone can help if angle is 50% open on indentation. phacoemulsification with trabeculectomy in cases with lens changes and 2/3 rd of the angle is closed and trabeculectomy alone if lens is clear and angle is 2/3 rd or more closed. primary narrow angle disease can present at different stages. use of new imaging technology has made it easier to have more objective staging of the pathology than ever before. dr schumann have found anterior segment oct, a useful tool in patients with narrow and suspicious angles. with added advantages of being noncontact and can be performed in dark as well. 23 medical treatment can help control iop, which may even worsen the anterior shift of iris lens diaphragm, due to reduced aqueous in ac. pilocarpine can pull the ciliary body and help to improve the outflow by opening up the trabecular meshwork. it can overcome pupil block and crowding in the plateau iris. potential side effects are ciliary spasm, miosis and retinal detachment. 24 laser peripheral iridotomy (lpi) bypasses the pupil block and favorably slows the disease progression but some eyes often need further medical treatment or surgical intervention in long term. 25 laser peripheral iridoplasty alone or with lpi mechanically contracts the iris stroma and pulls open the angle. it works best when pupil block is not the main mechanism and may defer the further treatment in pacs and pac. early cataract extraction with minimal lens changes in pac and pacs has rationale when used specially in cases with increased lens thickness, prominent lens vault and crowding of angle. on an oct of 62 chinese patients, prevalence of high iop and crowding of angle structures was found to be 46.7% in lpi group as compared to phacoemulsification group in which prevalence was 3.3%. 26 gonio-synechialysis is performed surgically to strip pas from trabecular surface. irreversible damage to meshwork may occur in areas of synechial closure if angle closure exists for longer duration. more aggressive approach towards modifying the angle structures by minimum possible intervention can help prevent millions of people going downhill towards blindness. being part of a susceptible population, we need to accumulate evidence as we manage patients. considering this background, following can be logical approach to pac and pacs patients. conclusion narrow angle disease presents at different stages and in varied age groups. patients with permanent adhesion were those who were not diagnosed well in time with gonioscopy and oct. anterior segment oct is a good diagnostic tool in the management of angle closure glaucoma. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. tham yc, li x, wong ty, quigley ha, aung t, cheng cy. global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. ophthalmology, 2014; 121 (11): 2081-2090. 2. baasanhu j, johnson gj, burendei g, minassian dc. prevalence and causes of blindness and visual impairment in mongolia: a survey of populations aged 40 years and older. bulletin of the world health organization, 1994; 72 (5): 771. 3. foster pj, johnson gj. glaucoma in china: how big is the problem? br j ophthalmol. 2001; 85 (11): 12771282. 4. radhakrishnan s, chen pp, 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(4): nc18. 14. kumar h, mansoori t, warjri gb, somarajan bi, bandil s, gupta v. lasers in glaucoma. ind j ophthalmol. 2018; 66 (11): 1539. 15. nolan wp, foster pj, devereux jg, uranchimeg d, johnson gj, baasanhu j. yag laser iridotomy treatment for primary angle closure in east asian eyes. br j ophthalmol. 2000; 84 (11): 1255-1259. 16. sihota r, rishi k, srinivasan g, gupta v, dada t, singh k. functional evaluation of an iridotomy in primary angle closure eyes. graefe's arch clin exp ophthalmol. 2016; 254 (6): 1141-1149. 17. zebardast n, kavitha s, krishnamurthy p, friedman ds, nongpiur me, aung t, et al. changes in anterior segment morphology and predictors of angle widening after laser iridotomy in south indian eyes. ophthalmology, 2016; 123 (12): 2519-2526. 18. glaucoma laser trial research group. the glaucoma laser trial (glt) and glaucoma laser trial follow-up study: 7. results. am j ophthalmol. 1995; 120 (6): 718-731. 19. heijl a, peters d, leske mc, bengtsson b. effects of argon laser trabeculoplasty in the early manifest glaucoma trial. am j ophthalmol. 2011; 152 (5): 842848. 20. schimiti rb, abe ry, tavares cm, vasconcellos jp, costa vp. intraocular pressure control after implantation of an ahmed glaucoma valve in eyes with a failed trabeculectomy. j curr glauc prac. 2016; 10 (3): 97. 21. bourne rr, zhekov i, pardhan s. temporal ocular coherence tomography-measured changes in anterior chamber angle and diurnal intraocular pressure after laser iridoplasty: impact study. br j ophthalmol. 2017; 101 (7): 886-891. 22. azuara-blanco a, burr j, ramsay c, cooper d, foster pj, friedman ds, et al. eagle study group. effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (eagle): a randomised controlled trial. the lancet, 2016; 388 (10052): 1389-1397. 23. kent c. making the most of anterior segment octthe detailed images produced by this technology are proving to be of value in many clinical situations. rev ophthalmol. 2011; 18 (4): 39. 24. aung t, ang lp, chan sp, chew pt. acute primary angle-closure: long-term intraocular pressure outcome in asian eyes. am j ophthalmol. 2001; 131 (1): 7-12. 25. lee jr, choi jy, kim yd, choi j. laser peripheral iridotomy with iridoplasty in primary angle closure suspect: anterior chamber analysis by pentacam. kor j ophthalmol. 2011; 25 (4): 252-256. authors’ designation and contribution sadia farooq; consultant ophthalmologist: primary surgeon of the patients, wrote the introduction, discussion, tables and results, approved the final version. javeria muid; post graduate trainee: wrote the details of cases, helped with discussion, tables, results and references and approved the final version. .…  …. 216 pak j ophthalmol. 2022, vol. 38 (3): 216-218 case series virtual reality for treatment of amblyopia in adults rebecca 1 , murtaza sameen junejo 2 , muhammad tahir 3 , fahad feroz shaikh 4 , nazir ashraf laghari 5 department of ophthalmology, 1,2,4,5 isra university hospital hyderabad, 3 combined military hospital, mardan abstract purpose: to observe efficacy of virtual reality technology as a potential treatment for improving vision in anisometropic amblyopia without the need of occlusion or penalization. study design: experimental case series. place and duration of study: isra university hospital, hyderabad, from nov 2020 to oct 2021. methods: patients (more than 12 years of age), with anisometropic amblyopia, were included in this study. patients with history of strabismus, cataract or any active ocular surface disease were excluded. unaided visual acuity, pinhole test and best-corrected visual acuity were recorded, before and after treatment. logmar chart was used for this purpose. crowding phenomenon was also checked. anterior segment and posterior segment examination was done to rule out any organic cause of disease. a head mounted device-virtual reality glasses (hmd-vr) was used 40 min daily for 03 months to improve visual acuity. all the data was recorded on a proforma. spss version 22.0 was used for data analysis and p-value of <0.05 was considered significant. result: mean age of the patients was 24.2 years (range 14 – 35 years). out of 14 registered cases, 08 (57.1%) patients showed improvement after 08 weeks of initiation of treatment with vr glasses. two (14.3%) patients showed improvement after 12 weeks and two showed no improvement, while two (14.3%) patients lost to follow up. after applying paired t test the value of p was < 0.001, which was statistically significant. conclusion: this hmd vr glasses seems to be an effective option for treatment in adults with anisometropic amblyopia. key words: anisometropic amblyopia, head mounted virtual reality glasses, neuroplasticity. how to cite this article: rebecca, junejo ms, tahir m, shaikh ff, laghari na. virtual reality for treatment of amblyopia in adults. pak j ophthalmol. 2022, 38 (3): 216-218. doi: 10.36351/pjo.v38i3.1398 correspondence: murtaza sameen junejo department of ophthalmology, isra university hospital hyderabad email: drmurtazasameen@gmail.com received: april 9, 2022 accepted: june 20, 2022 introduction plasticity is the ability of the nervous system to rewire its synaptic connections, to improve functioning. worldwide, 1.5:100 people are suffering from normotypic vision due to amblyopia and another 1:4000 have retinal dystrophies. 1 various techniques have been developed to rehabilitate vision. 2 there is a good and noticeable preservation of visual pathway from retina to visual cortex, which can be stimulated in any age group. 3,4 cells in human cortex have the capability to divide and assume a wide range of cognitive functions. in lieu of pluripotency hypothesis, cognitive function is a ubiquitous phenomenon in human cortical development. 5,6 patients with amblyopia present with reduced contrast sensitivity and visual acuity. amblyopia is treated by prescribing the accurate eye glasses, correction of any underlying organic cause and or occlusion. recent studies have shown that certain other techniques can be applied to reinstate normal visual function (i-e video games, 3-d devices, which stimulate neurons at cognitive level). 7 these technologies are user friendly and are well-tolerated. virtual reality glasses have been reported to enhance brain functions and improve visual output in a short duration of period. as local data regarding such mailto:drmurtazasameen@gmail.com virtual reality for treatment of amblyopia in adults pak j ophthalmol. 2022, vol. 38 (3): 216-218 217 type of amblyopia therapy is scarce, our aim is to evaluate the visual potential of an amblyopic eye in adults after treating it with head mounted device i-e vr glasses. methods this case series was conducted at isra university hospital, hyderabad, from november 2020 to october 2021. patients were recruited from out-patient department. patients above 12 years of age with anisometropic amblyopia were included in this study. patients with strabismus, any ocular organic disease and previous ocular surgery were excluded. unaided visual acuity, pin hole acuity and best corrected visual acuity were recorded, before and after treatment using logmar chart. crowding phenomenon was also checked with the help of logmar chart. anterior segment and posterior segment examination was done to rule out any organic cause of disease. a head mounted virtual reality device was used for 40 minutes, daily for 03 months. data was recorded on a specific designed proforma. p-value of < 0.05 was considered significant. spss version 22.0 was used for data calculation. results twelve patients with more than 12 years of age, were diagnosed with anisometropic amblyopia between november 2020 to october 2021. they were treated with hmd-vr glasses. there were nine males (64.3%) and five females (35.7%) with mean age of 24.2 years (range 12-35 years). pre-treatment visual acuity was 0.80 logmar. there was 3 logmar lines improvement in 08 patients (57.1%) after 08 weeks while there was 2 line improvement in 02 (14.3%) patients at 12 weeks and no improvement in 02 table 1: clinical characteristics of patients. characteristics value mean age in years 24.2 gender male 9 (64.3%) female 5 (35.7%) visual acuity visual acuity ( pre treatment) 0.80 ± 0.12 logmar visual acuity ( post treatment) 0.15 ± 0.12 logmar 08 weeks (3 line improvement) 08 (57.1%) 12 weeks(2 line improvement) 02 (14.3%) 12 weeks ( no improvement) 02 (14.3%) lost to follow up 02 (14.3%) total 14 (100%) (14.3%) patients even at 12 weeks and two patients lost to follow up (table 1). mean visual acuity at baseline was 0.07 ± 0.12 logmar. after hmd-vr it was improved to 0.15 ± 0.12 logmar (p < 0.001). there were no ocular or systemic adverse effects during or after the use of head mounted vr glasses. discussion in patients with anisometropic amblyopia, virtual reality glasses play an important role in rehabilitation of visual acuity. they are cost effective and easily available. activation of neurons leads to advanced synaptic stimulation that enhances strength between neurons and thus changes occur at the level of sensory-motor networks. 8 viston-vr™ system was proposed by qiu and colleagues. 9 in this system, the main feature was using two dissociated optical systems that provided independent displaying contents for each eye. each eye was stimulated by viewing different cartoon films or playing interactive vr games by means of specially devised glasses. this is in contrast to our study, in which we used head mounted vr glasses that are portable and easy to use and also safe and well tolerated by the individuals. gottlob and stanglerzuschrott, introduced levodopa for the first time to treat low levels of dopamine in adults having amblyopia. 10 increased contrast sensitivity and decrease in scotoma was observed with the single dose administration of levodopa. in our study, we did not measure dopamine levels or its effects while using virtual reality glasses, though the levels of dopamine should be monitored during and after successful sessions of vr glasses. there are different opinions regarding the treatment modalities of amblyopia after the sensitive period of 9 years that might lead to diplopia, strabismus and may not be able to be treated with prisms or surgery. 11 in our study, no such adverse effects like diplopia or strabismus were observed during or after the successful sessions with vr glasses. similarly, eaton et al. suggested that visual acuity could only be regained after repetitive visual experience. 12 in our study, we also advised continuous visual stimulation through virtual reality glasses which became the cause of improvement in visual acuity. sengpiel, also claimed that repetitive visual training murtaza sameen junejo, et al 218 pak j ophthalmol. 2022, vol. 38 (3): 216-218 promoted acuity and enhanced stereopsis. 13 however, we did not record stereopsis in our study. stimulation of primary visual cortex with the help of electrophysiological activity, was also reported in patients with retinal diseases. 14 however one of the study claimed that improvements in visual acuity with binocular treatment occur much faster than monocular with patching. the study reported gains of almost 2 lines occurring in just 4 – 8 weeks rather than with 4 – 6 months of patching. 15 despite our success of treating amblyopia with hmd vr glasses in adults, further work need to be done in this field. we did not include strabismic amblyopia and children less than 09 years of age in our study. a large study should be conducted in adults as well as in pediatric age group. conclusion there is a crucial role of neuroplasticity in the recovery of visual system in adults having anisometropic amblyopia. hmd vr glasses are a good option in such cases. conflict of interest: authors declared no conflict of interest. ethical approval the study was approved by the institutional review board/ethical review board (iuh/asst dean(cs)/04/30). references 1. castaldi e, lunghi c, morrone mc. neuroplasticity in adult human visual cortex. neurosci biobehav rev. 2020 may; 112: 542-552. doi: 10.1016/j.neubiorev.2020.02.028. 2. barocelli l, lunghi c. neuroplasticity of the visual cortex: in sickness and in health. exp neurol. 2021; 335: 113515. doi: 10.1016/j.expneurol.2020.113515. 3. lunghi c, resta l g, binda p, cicchini g m, placidi g, falsini b, et al. visual cortical plasticity in retinitis pigmentosa. invest ophthalmol vis sci. 2019; 60 (7): 2753–2763. doi: 10.1167/iovs.18-25750. 4. park kh, hwang jm, ahn jk. efficacy of amblyopia therapy initiated after 9 years of age. eye (lond). 2004 jun; 18 (6): 571-4. doi: 10.1038/sj.eye.6700671. 5. bendy m. evidence from blindness for a cognitively pluripotent cortex. trends cogn sci. 2017; 21 (9): 637648. doi: 10.1016/j.tics.2017.06.003. 6. farivar r, zhou j, huang y, feng l, zhou y, hess rf. two cortical deficits underlie amblyopia: a multifocal fmri analysis. neuroimage, 2019; 190: 232241. doi: 10.1016/j.neuroimage.2017.09.045. 7. singh ak, phillips f, merabet lb, sinha p. why does the cortex re-organize after sensory loss? trends cogn sci. 2018; 22 (7): 569-582. doi: 10.1016/j.tics.2018.04.004. 8. coco-martin mb, pinero d p, leal-vega l, hemandez-rodriguez cj, adiego j, molina-martin a, et al. the potential of virtual reality for inducing neuroplasticity in children with amblyopia. j ophthalmol. 2020; 2020: 7067846. doi: 10.1155/2020/7067846. 9. qiu f, wang lp, liu y, yu l. interactive binocular amblyopia treatment system with full-field vision based on virtual reality. in 2007 1st international conference on bioinformatics and biomedical engineering, 2007; jul 6: (pp. 1257-1260). ieee. 10. gottlob i, stangler-zuschrott e. effect of levodopa on contrast sensitivity and scotomas in human amblyopia. invest ophthalmol vis sci. 1990; 31 (4): 776-780. 11. tailor vk, schwarzkopf ds, dahlmann-noor ah. neuroplasticity and amblyopia: vision at the balance point. curr opin neurol. 2017; 30 (1): 74-83. doi: 10.1097/wco.0000000000000413. 12. eaton nc, sheehan hm, quinlan em. optimization of visual training for full recovery from severe amblyopia in adults. learn mem. 2016; 23 (2): 99-103. doi: 10.1101/lm.040295.115. 13. sengpiel f. plasticity of the visual cortex and treatment of amblyopia. curr biol. 2014; 24 (18): 936-940. doi: 10.1016/j.cub.2014.05.063. 14. gore c, wu c. medical therapies of amblyopia: translational research to expand our treatment armamentarium. semin ophthalmol. 2016; 31 (1-2): 155-158. doi: 10.3109/08820538.2015.1114851. 15. takao hensch. lifting brakes on visual cortical plasticity. j vis. 2022; 22 (3): 49. doi: 10.1167/jov.22.3.49. authors’ designation and contribution rebecca; concepts, design, literature search, manuscript editing. murtaza sameen junejo; data analysis, manuscript preparation. muhammad tahir; statistical analysis. fahad feroz shaikh; manuscript review, final approval of manuscript. nazir ashraf laghari; manuscript review, final approval of manuscript. https://dx.doi.org/10.1155%2f2020%2f7067846 https://dx.doi.org/10.1101%2flm.040295.115 https://pubmed.ncbi.nlm.nih.gov/?term=hensch+t&cauthor_id=35120211 pak j ophthalmol. 2021, vol. 37 (4): 388-393 388 original article comparison of manual small incision cataract surgery between the patients of cataract with pseudoexfoliation and those without pseudoexfoliation priyanka yadav 1 , yashas goyal 2 , lubhavni dewan 3 , nitin nema 4 1,2,4 sri aurobindo institute of medical sciences, 3 choithram netralaya – the best eye specialist hospital abstract purpose: to compare the risk factors, intraoperative complications and postoperative visual outcome between patients of cataract with pseudoexfoliation (pxf) and those without pseudoexfoliation undergoing manual small incision cataract surgery (msics) with posterior chamber intra ocular lens implantation. study design: quasi experimental study. place and duration of study: methods: fifty-six eyes of patients with cataract and pxf and 56 eyes of patients with cataract without pxf were recruited. complete history and ocular examination was performed. pre-operative pupillary dilation of the eye to be operated was measured. manual small incision cataract surgery was performed with implantation of posterior chamber intraocular lens. patients were examined on 1st post-operative day then on45 th day. risk factors for per-operative complications and visual outcomes were compared between two groups. results: mean age in the pxf group was 55 ± 5 years and in the control group was 45 ± 5 years. pxf group showed female preponderance. preoperative risk factors (higher in the pxf group) included poor pupillary dilatation, iridodonesis, zonular weakness/phacodonesis and subluxation. pxf was associated with raised intraocular pressure (10.6%). in 5% cases of pxf, intraoperative posterior capsular rent and vitreous loss occurred. best-corrected visual acuity on the 45th postoperative day was significantly better in patients without pxf (p-value < 0.05). conclusion: cataract patients with pxf have higher preoperative risk factors for intra-operative complications as compared to patients without pxf. this can result in compromised visual outcome as compared to the eyes without pxf. key words: cataract, pseudoexfoliation, manual small incision cataract surgery, iridodonesis, phacodonesis. how to cite this article: yadav p, goyal y, dewan l, nema n. comparison of pre-operative risk factors, intra-operative complications and visual outcomes between the patients of cataract with pseudoexfoliation and those without pseudoexfoliation. pak j ophthalmol. 2021, 37 (4): 388-393. doi: 10.36351/pjo.v37i4.1297 correspondence: yashas goyal sri aurobindo institute of medical sciences email: goyal.yashas@gmail.com received: june 13, 2021 accepted: september 23, 2021 introduction age-related cataract is the leading cause of visual impairment in india. 1 the only current treatment modality for cataract is the surgical removal of cataractous lens and implantation of an artificial intraocular lens, as non-surgical treatment options are open access https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewjo8_hby_hyahxotd8kheufblsqfnoecaqqaq&url=https%3a%2f%2fchoithramnetralaya.com%2f&usg=aovvaw3hygdqarcxnd53hd5mcw9a https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewjo8_hby_hyahxotd8kheufblsqfnoecaqqaq&url=https%3a%2f%2fchoithramnetralaya.com%2f&usg=aovvaw3hygdqarcxnd53hd5mcw9a comparison of manual small incision cataract surgery between the patients of pseudo-exfoliation and those without pseudo-exfoliation 389 pak j ophthalmol. 2021, vol. 37 (4): 388-393 still in their nascent research phases. 2,3 pseudoexfoliation (pxf) is an independent age-related disorder that enhances the progression of nuclear sclerotic cataract and presents with multiple preoperative risk factors for cataract surgery. it is still a matter of conflict whether those risk factors lead to an impaired visual outcome following cataract surgery. 4 pxf was originally defined by the presence of grayish-white material on the anterior lens capsule near the pupillary margin and on the anterior surface of iris. with improved understanding of the pathology, pxf is now believed to be a multisystem disorder with varied ocular and extraocular manifestations. 5 the disorder is characterized by the production and accumulation of extracellular fibrillary material in the ocular and visceral structures due to a dysregulation of the lysyl oxidase like-1 (loxl-1) gene, leading to systemic endothelial and vascular dysfunction and its attendant complications. 6 within the eye, fibrillary pxf material deposits on virtually all tissues but more commonly in the anterior segment as seen on corneal endothelium, trabecular meshwork, iris surface, pupillary border, anterior lens capsule and the zonules. 7 due to the ubiquitous deposition of fibrillary material in the eye, pxf can lead to complications during and after cataract surgery such as increased peroperative endothelial cell loss, intraoperative floppy iris, iridodialysis, posterior capsular rent (pcr), zonular dialysis and vitreous loss. 8 it also predisposes to ocular hypertension and pseudo-exfoliative glaucoma. 9 early postoperative complications such as persistent anterior chamber reaction, pigment dispersion and iol deposits, corneal edema, iop spikes and anterior capsular phimosis have been reported. 10 late postoperative complications such as dislocation of the iol-bag complex have also been observed. 11 pseudoexfoliation thus poses a challenge to cataract surgeons, especially in resource limited settings where msics, with its inherent requirement of a larger capsulorrhexis, is the routinely performed cataract extraction procedure. use and availability of assistive surgical techniques and devices that have been shown to improve surgical outcome in these cases such as dispersive-cohesive ocular viscoelastic devices (ovds), pupil expanders and capsular bag stabilizing devices is also a limitation in such settings. present study was undertaken in patients of senile cataract undergoing msics with pciol implantation under the national program for control of blindness. 12 we studied the risk factors for complications during cataract surgery and compared the final visual outcomes between pxf and non-pxf patients undergoing a standardized msics procedure by a single experienced surgeon, with minimal use of assistive devices and techniques to maintain uniformity and increase the applicability of results to resource limited settings. methods this study was conducted with the primary objective to compare the visual outcome between senile cataract patients with and without pxf undergoing msics. it was a quasi experimental study including 112 participants (56 cases and 56 controls) aged > 40 years. the study was approved by the institutional review board and ethics committee and written informed consent was obtained from all participants. primary outcomes that were assessed prospectively included the perioperative complication rates as well as best-corrected visual acuity at 45 days post-surgery. patients of either sex, more than 40 years of age, diagnosed with either senile cataract or senile cataract with pxf on slit lamp examination, and consenting for study and follow-up were included. patients less than 40 years of age, with complicated cataract, glaucomatous changes, previous history of ocular trauma or surgeries and presence of any systemic complications like diabetes mellitus, hypertension or stroke were excluded from the study. patients with cataract and clinically apparent pxf were included in cases and age-matched controls consisted of patients who had cataract without pxf. pupillary dilation was achieved by topical instillation of a combination of 5% phenylephrine and 0.8% tropicamide, three times, once every 10 minutes. cataract grading was done as per the lens opacification classification system iii (locs iii). in patients with mature cataract, a b-scan was done to rule out gross posterior segment pathology and fundus evaluation was planned postoperatively. an assessment of visual acuity using selfilluminated snellen box, thorough examination of anterior and posterior segments on slit-lamp biomicroscope and measurement of intraocular pressure (iop) using goldmann applanation tonometer yashas goyal, et al pak j ophthalmol. 2021, vol. 37 (4): 388-393 390 were done preoperatively. pfx was identified by the presence of white granular material on the lens surface, iris, or pupillary margin. the preoperative risk factors that were assessed were raised iop, poor pupillary dilatation, frank lens subluxation as assessed by irregular ac depth or visibility of lenticular margin through dilated pupil, and/or zonular weakness as assessed by phacodonesis or iridodonesis. pupillary diameter of less than 6mm after dilation was graded as poor while 8-9 mm of pupillary dilation was graded as good. patients with raised iop were given aqueous suppressant (timolol maleate 0.5% bd) and proceeded for surgery only when iop reduced to < 20 mm hg. the patients were admitted one day prior to surgery and prophylactic moxifloxacin 0.5% was given topically every 6 hours. pupillary dilation on the day of the surgery was achieved with a combination of topical phenylephrine 5% and tropicamide 0.8% along with topical flurbiprofen 0.03% to maintain pupillary dilation. the eye to be operated was marked and locally anesthetized with a combination of 3ml of 2% lignocaine and 3ml of 0.5% bupivacaine injected in the peri-bulbar space. painting and draping was done. eye speculum was placed. a 5% povidoneiodine solution was instilled in the conjunctival sac. all patients underwent msics with polymethylmethacrylate (pmma) posterior chamber intraocular lens (pciol) implantation in the bag. a superior fornix based conjunctival flap was raised and frown shaped scleral incision given 2mm away and superior to the limbus with #15 blade. a sclerocorneal tunnel was then made with a crescent blade. side port was made at 9 o’clock position. trypan blue dye, available as 0.1% solution, was then injected into the anterior chamber. the dye was washed with balanced salt solution. in eyes with poor pupillary dilation, 2% hydroxypropylmethylcellulose (hpmc) was used to dilate the pupil. a 26g ½ inch needle cystitome was used to make a continuous curvilinear capsulorrhexis. hydrodissection was then performed to separate the nucleus from the cortex. nucleus was prolapsed out of capsular bag using hydro-prolapsing method and delivered out of the anterior chamber with wire vectis. irrigation and aspiration of residual cortical matter was done with simcoe’s two-way cannula. a single piece, biconvex, pmma pciol lens was placed in the bag. in cases with zonular dialysis or bag dialysis, use of capsular tension rings was avoided and the pciol was placed in the sulcus. post-operative treatment consisted of topical prednisolone 1% 4 hourly, moxifloxacin 0.5%, and carboxy-methylcellulose 0.5% 6 hourly tapered as required. cycloplegics and anti-glaucoma medications were added at the first follow-up if indicated. the patients were given refractive correction and the bestcorrected visual acuity (bcva) was noted on the 45 th day postoperatively. number of cases and controls having preoperative risk factors and intraoperative complications were documented along with the bcva at 45 th postoperative day. the data was analyzed qualitatively and quantitatively using appropriate statistical tests. the data was collected in tabulated form and analyzed with student’s t-test for quantitative variables and chi-square test for qualitative variables. the data was presented in terms of means and percentages. p value < 0.05 was considered as significant. results cataract with pxf was most commonly seen in 60 to 70 years age group which composed of 27 (48.2%) out of 56 patients. majority of non-pxf cataract patients belonged to 51 to 60 years age (41%) (table 1). table 1: age distribution of cases and controls. age (in years) no. of cases pxf (n=56) no. of controls non-pxf (n=56) 40 to 50 07 (12.5%) 06 (10.7%) 51 to 60 13 (23.2%) 23 (41%) 61 to 70 27 (48.2%) 19 (33.9%) 71 to 80 08 (14.2%) 08 (14.2%) > 80 01 (1.7%) – total 56 56 mean age of presentation for pxf-associated cataract was 64 ± 8.67 versus 62.4 ± 8.26 for non-pxf cataract (p = 0.25; student’s t test). cataract with pxf showed a slight female preponderance at 55.3% while majority (64.2%) of the control group comprised of males (p < 0.05; chi-square test). pxf was commonly seen with nucleus sclerosis (nucleus opalescence grade ii 55.3%, nucleus opalescence grade iii & iv 21.4%) (table 2). in control group 39.2 % patients were found to be with nucleus opalescence grade ii, and 21.4% with nucleus opalescence grade iii & iv (p-value was > 0.05) which indicate; cases and control groups were comparison of manual small incision cataract surgery between the patients of pseudo-exfoliation and those without pseudo-exfoliation 391 pak j ophthalmol. 2021, vol. 37 (4): 388-393 comparable as per cataract grading. cortical cataract was seen more frequently in controls than in cases (39.3% vs. 23.2%; p value= < 0.01; chi square test). table 2: grading of cataract in cases and controls. grading cases controls nuclear sclerosis (ns) ii 31 (55.3%) 22 (39.2%) nsiii 11 (19.6%) 11 (19.6) nsiv 01 (1.7%) 1 (1.7%) cortical cataract 13 (23.2%) 22 (39.3%) total 56 56 preoperative risk factors were noted more frequently in pxf group (table 3). 78.6% of pxf patients had unilateral presentation while only 16.1 % of the non-pxf cases presented unilaterally (p < 0.001). table 3: preoperative risk factors among cases and controls. preoperative risk factors cases (n = 56) control (n = 56) p values poor pupillary dilation (< 6 mm) mean pupil size 24 (42.8%) 5.9 ± 1.2mm 1 (1.7%) 8.14 ± 0.77mm p < 0.0001 iridodonesis 7 (12.5%) 0 − raised iop 6 (10.7%) 1 (1.7%) p = 0.04 zonular weakness (phacodonesis) 3 (5.35%) 0 − subluxation 1 (1.7%) 0 − intra-operative complication rate was 16.071% in the pxf group and there was no complication encountered in the control group (p < 0.01). floppy iris 3 cases (5.35%), posterior capsule rupture (pcr) with vitreous loss 3 cases (5.35%), pcr without vitreous loss 2 cases (3.57%). pcr with vitreous loss were left aphakic and managed later with anterior chamber intraocular lens implantation. these were the cases with preoperatively diagnosed zonular weakness with or without subluxation. on comparison of bcva on postoperative day 45 between cases and controls, mean va in cases was 0.3 ± 0.17 (logmar va) vs. 0.13 ± 0.1 in controls (p< 0.005). within pxf cases, patients without any preoperative risk factors had a mean final bcva of 0.15 ± 0.07 versus 0.39 ± 0.2 in cases with preoperative risk factors (p = < 0.01) (table 4). table 4: comparison of bcva. bcva (convert to logmar) pxf group nonpxf cases without risk factors cases with risk factors <0.47 (better than 6/18) 20 24 52 0.47 to 1 (6/18 to 6/60) 3 6 04 > 1 (worse than 6/60) − 03 − total 23 33 56 discussion in our study, cataract with pxf was seen mostly in 60 to 70 years age group (48.2%) whereas non-pxf related cataract tended to present earlier in the 50 to 60 years group (41%). however, on comparing the mean age of the two groups (64 ± 8.67 vs. 62.4 ± 8.26), the difference was not statistically significant (p = 0.25). this is in contrast to findings of previous authors like turalba et al and joshi et al, who reported a significantly higher age of presentation for pxfassociated cataract. 13,14 a female preponderance (55%) was seen in pseudoexfoliation cases whereas a male predominance of 64% was seen in controls. bangal et al, also reported a female preponderance (58%) of pxf among their study group of 50 patients. 15 few studies reported that pxf was more common among male population, however, some studies also reported no significant difference in male and female incidence of pxf. 13,16,17 most patients in both the groups in our study presented with grade ii nuclear opalescence (55.3% and 39.2%; case and control respectively). both groups showed equal number of patients presenting with grade iii and grade iv nuclear opalescence. however, cortical cataract was seen more frequently in the non-pxf group (39.3% versus 23.3%; p < 0.01). these findings corroborate with results of a study by soni et al who reported a majority of grade ii nuclear opalescence among their pxf cases. 9 most studies, however, indicate increasing grade of cataract in association with pxf with majority of the patients presenting with mature or hypermature cataracts. 4,13,18 this discrepancy in results might be attributed to the wide range of sample sizes in the studies and some selection bias as studies reporting advanced grade of presentation of cataract were carried out in backward rural areas. 13 an assessment of laterality among cases and controls showed predominance of unilateral cases with pxf (78.5%). yildirim et al reported unilateral yashas goyal, et al pak j ophthalmol. 2021, vol. 37 (4): 388-393 392 involvement in 62% of pxf patients. 19 in a 10-year follow-up study conducted by puska et al, on a cohort of 56 patients, 38% of the patients with initial unilateral involvement were seen to develop bilateral pxf by the end of the follow up period. 20 as unilateral pxf is considered a precursor for development of pxf in the other eye, and because most patients in our study had grade 2 nuclear opalescence, the results of our study may point towards our patients having presented early. the most observed risk factor in pxf group in our study was poor dilatation of pupil. the mean pupillary dilatation amongst cases was 5.9 ± 1.2 mm and amongst control was 8.14 ± 0.77 mm (p < 0.0001). a poorly dilating pupil of < 6 mm was noted in 24 (42.8%) cases whereas in control group only 1 patient (1.7%) had <6 mm pupillary dilatation. other preoperative risk factors were iridodonesis in 7 cases (12.5%), zonular weakness in 3 cases (5.35%), and lens subluxation in 1 case (1.7%); none of which were seen in control group. sastry et al, found the mean pupillary dilation in pxf patients to be 5.1 mm ± 1.47 mm, with 86% of the patients having a maximum dilation of less than 6 mm. 18 haripriya et al, reported a pupil size of ≤ 5.9 mm in 39.4% of pxf patients as compared to 19.1% in controls. 4 eleven percent of the pxf cases had raised iop without glaucomatous changes at presentation as compared to only 1.8% in the control group (p < 0.01). preoperative mean iop among cases and control was 19.07 ± 8.8 and 16.03 ± 2.7 mm of hg respectively (p = 0.01). prevalence of raised iop in pxf patients at the time of cataract surgery has been reported to be as high as 49% by drolsum et al. 21 turalba et al reported preoperative glaucoma incidence of 48% in cases versus 11% in controls. 14 multiple studies conducted in south indian population groups have also demonstrated increased incidence of preoperatively raised iop in pxf patients. 16,17,22 in the present study, intraoperative complications occurred in 9 patients (16%) in the pxf group as compared to none in the control group (p < 0.01). we encountered floppy iris, pcr with vitreous loss, pcr without vitreous loss and bag dialysis. haripriya et al, reported pcr with vitreous loss as the most common complication (1.1%). 4 other complications reported by them were pcr without vitreous loss (0.7%), zonular dialysis with or without vitreous loss (0.2% each), and capsulorrhexis tear with an intact posterior capsule in 0.6%. 4 on assessment of bcva on day 45, controls were seen to have a better outcome as compared to the pxf cases. the difference in final bcva was also significant for pxf cases with and without preoperative risk factors. these findings are in contrast with those reported by haripriya et al, where excellent final visual outcome was seen in both cases and controls with no difference in final bcva post 1 month of follow-up. 4 this difference can be attributed to multiple factors, such as preferential patient selection with exclusion of known preoperatively complicated cases, their surgical technique (phacoemulsification), use of assistive devices (iris retractors, capsule tension rings) and high surgeon experience. 4 in the study by turalba et al, better final visual acuity was reported in non-pxf versus pxf cases (p = 0.0003) although both groups had significant improvement from their respective preoperative visual acuities. 14 limitation of this study is the single center research. results from different surgeons and different centers may show different results. the sample size was limited to only 56 which can also modify the outcomes. conclusion cataract patients with pxf have higher preoperative risk factors for intra-operative 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george r, et al. pseudexfoliation in south india. br j ophthalmol. 2003; 87: 1321–1323. 18. sastry pv, singal ak. cataract surgery outcome in patients with non-glaucomatous pseudoexfoliation. romanian j ophthalmol. 2017; 61 (3): 196–201. 19. yildirim n, yasar e, gursoy h, colak e. prevalence of pseudoexfoliation syndrome and its association with ocular and systemic diseases in eskisehir, turkey. int j ophthalmol. 2017; 10 (1): 128–134. 20. puska p. unilateral exfoliation syndrome: conversion to bilateral exfoliation and to glaucoma: a prospective 10-year follow-up study. j glaucoma, 2003; 11: 517– 524. 21. drolsum l, haaskjold e, davanger m. pseudoexfoliation syndrome and extracapsular cataract extraction. acta ophthalmol (copenh). 1993; 71 (6): 765–770. 22. ravi t, nirmalan p, krishnaiah s. pseudoexfoliation in southern india: the andhra pradesh eye disease study. invest ophthalmol vis sci. 2005; 46: 1170– 1176. authors’ designation and contribution priyanka yadav; senior resident: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. yashas goyal; junior resident: design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. lubhavni dewan; senior resident: literature search, data analysis, manuscript preparation, manuscript editing. nitin nema; professor: concepts, literature search, statistical analysis, manuscript preparation, manuscript editing, manuscript review. pak j ophthalmol. 2022, vol. 38 (3): 193-198 193 original article factors associated with non-compliance to long term glaucoma medication in a developing country huma munir 1 , muhammad sadiq 2 , shama khan 3 , sarah zafar 4 , farah akhtar 5 department of ophthalmology, 1-5 al-shifa trust eye hospital, rawalpindi abstract purpose: to assess the level of adherence with long-term glaucoma therapy at a tertiary care center and to correlate the factors associated with non-compliance. study design: cross sectional study. place and duration of study: al-shifa trust eye hospital (asteh), rawalpindi from october 2018 to february 2019. methods: two hundred patients presenting at the glaucoma clinic were recruited. an interview-based questionnaire was used to gather data. the dependent variable, adherence to long-term glaucoma treatment, was determined and independent variables were; demographic profile, socio-economic variables, ocular and medical history, personal knowledge and understanding about disease and satisfaction level of the patient. the data was analyzed using spss version 24. descriptive analysis was followed by inferential statistics. to determine any association between independent and outcome variables, chi-square test was applied. all inferential statistics were based on a 5% significance value. results: a high rate (30%) of non-compliance was found. a significant correlation was present between chief complaints of patients with compliance to medication (p < 0.05). knowledge about disease, education status was also found to be correlated with the compliance to glaucoma treatment (p < 0.05). however, age and gender had no effect on level of compliance. eighty two percent knew that glaucoma can lead to blindness which urged them to have regular follow-up. conclusion: thirty percent participants were non-compliant to glaucoma therapy. compliance with glaucoma treatment is an important factor for preventing progression of disease. factors leading to poor compliance can be controlled by good communication between patient and physician. key words: glaucoma, intraocular pressure, patient compliance, anti glaucoma agents. how to cite this article: munir h, sadiq m, khan s, zafar s, akhtar f. factors associated with noncompliance to long term glaucoma medication in a developing country. pak j ophthalmol. 2022, 38 (3): 193198. doi: 10.36351/pjo.v38i3.1417 correspondence: huma munir al-shifa trust eye hospital, rawalpindi email: ophthalmo54@gmail.com received: may 4, 2022 accepted: june 18, 2022 introduction glaucoma is defined as a multitude of conditions affecting the optic nerve, causing irreversible damage to visual function which may be deferred or intercepted by surgical or medical intervention. this damage mostly results from an abnormally elevated intraocular pressure leading to permanent loss of visual function without any noticeable symptoms in the early and moderate stages of the disease. therefore, the condition is called the ‘silent killer of sight.’ glaucoma contributes 6.6% of global blindness, making it the 2 nd leading cause of blindness. 1 an increase of 0.8 million (or 62%) in the number of patients blinded by the disease and 2.3 million (or 83%)in number of visually impaired patients has been reported from 1990 to 2010. 2 in south asia, primary open angle glaucoma (poag) predominated over primary angle closure glaucoma (pacg) while the prevalence of disease in 2013 was 3.54%. 3 compared with other asian sub regions, south asia is expected mailto:ophthalmo54@gmail.com huma munir, et al 194 pak j ophthalmol. 2022, vol. 38 (3): 193-198 to report the most abrupt increase in prevalence of this condition, from 17.06 million in 2013 to an estimate of 32.90 million in 2040. 4 in pakistan, reported incidence of glaucoma related blindness is 7% while cataract, corneal opacities, and refractive errors are responsible for 66%, 12.6% and 11.4% of blindness respectively. as a result of unawareness of disease and its costly treatment, almost 0.9 million glaucoma patients have developed blindness in pakistan due to this condition. 5 medications for glaucoma are divided into various classes based on their chemical structure and pharmacologic action. once put on medical therapy, patients are usually required to instill these drops for the rest of life in addition to visiting the clinic on regular basis for monitoring the progression of the disease. in clinical terms, compliance may be defined as; a measure of extent to which patient follows a prescribed treatment plan. according to various researches in different parts of the world, noncompliance to glaucoma medications was high with most usual reason entailed was asymptomatic nature of the disease until late stages when tunnel vision was left. 6 expensive treatment greatly influenced compliance, while long-term therapy required by this chronic disease also led to non-compliance. moreover, local side effects of treatment are sometimes more prominent than its benefit. the complexity of the therapeutic regimen and the factor like forgetfulness with increasing age also played significant role towards non-compliance. a study reported lack of compliance being related to environmental factors (49%), patient carelessness (16%), medication regimen (32%), and service provider factors (3%). 7 other factors attributable were time required for a glaucoma clinic visit, living alone, increased number of glaucoma medications, comorbidities, low-income levels, and medical mistrust. to eradicate this and enforce compliance, communication between physicians and patients are pivotal. in pakistan, there is a gap in comprehensive analysis of the main causes for poor compliance and adherence to glaucoma medical therapy as most research was conducted in other countries like france, mexico and india. 8,9,10 the objective of current study was to assess the extent of non-compliance with glaucoma therapy among patients presenting at glaucoma department of a tertiary care eye hospital and to determine factors associated with it. methods a cross-sectional study was conducted at al-shifa trust eye hospital rawalpindi between october 2018 to february 2019. study was approved by the institutional ethical review committee and the participants were included after taking an informed consent. a sample size of 200 was calculated using open-epi calculator where glaucoma prevalence was taken from world health organization (who). data was entered with confidence interval set at 95% and eliminating the possibility of non-response-rate or missing data. a properly formatted interview-based questionnaire was used to gather data. the dependent variable, adherence to long-term glaucoma treatment, was determined using three markers consisting of timely follow up, comparison of the prescribed and used drug, and adherence to prescribed dosage of the drug. independent variables were categorized into 5 parts, demographic profile, socio-economic variables, ocular and medical history, personal knowledge and understanding about disease while the last part had questions about satisfaction level of the patient related to services and family support. the data was assessed and analyzed via statistical package for social sciences (spss) version 24. evaluation of data was carried out in two stages. descriptive analysis, which included all independent variables, was followed by inferential statistics. frequencies and percentages were used to display categorical data while valid percentages were used to illustrate the parameters with absent numbers. to determine any association between independent and outcome variables, chi-square test was applied. all inferential statistics were based on a 5% significance value. results out of the 200 participants in the study, majority belonged to the age group 20-50 (n=106, 53%) while a major proportion of respondents were males (n=114, 57%). most of the respondents had secondary level education, followed by illiteracy and primary level education with 35.5%, 26.5% and 22.5% representation respectively. regarding marital status, 24% of participants were unmarried followed by 12% widows or divorced while rest was married. most of the respondents had glaucoma for 1 – 5 years (n = 104, 52%). factors associated with non-compliance to long term glaucoma medication pak j ophthalmol. 2022, vol. 38 (3): 193-198 195 almost half (n = 98, 49%) of the respondents were dependent on others for fulfilling daily life activities while 62.5% participants were residents of urban areas. almost half of the participants reported as being the only earning member of their family (n = 98, 49%). regarding affordability to treatment, 43% of participants clearly reported that the treatment was not affordable to them while 42% considered it as affordable. the average expanses to reach the hospital were reported to be less than 10 us dollars (converted value) by 88.5% respondents. about 21.5% of the participants replied of not taking the prescribed dosage of the medication at the proper time. compliance with medication calculated on the basis of various parameters is illustrated in table 1. table 1: compliance with medication calculated on the basis of various parameters. regular follow-up to the hospital 162 (81%) instilling proper medication as per prescription 172 (86%) following proper dosage advised by the physician 157 (78.5%) table 2: determinants of compliance on the basis of patients’ history determinants compliant noncompliant p-value education 0.03 illiterate 34 (23.6%) 19 (33.9%) primary 35 (24.3%) 10 (17.9%) secondary 47 (32.6%) 24 (42.9%) higher 28 (19.4%) 3 (5.4%) medical history chief complaint / reason of visit 0.001 routine follow up 111 (77.08%) 19 (33.93%) pain / discomfort 11 (7.64%) 21 (37.5%) blurred vision 13 (9.03%) 9 (16.07%) lacrimation 9 (6.25%) 7 (12.5%) side effects of treatment 0.18 no 90 (62.5%) 37 (66.07%) itching 13 (9.03%) 7 (12.5%) burning 14 (9.72%) 8 (14.29%) stinging 27 (18.75%) 4 (7.14%) overall satisfaction with treatment 0.001 no 1 (0.69%) 17 (30.36%) neutral 38 (26.39%) 21 (37.5%) yes 105 (72.92%) 18 (32.14%) out of total 53 illiterate respondents, 33.9% (n = 19) were non-compliant while out of 31 respondents with higher education only 5.4% (n = 3) reported noncompliance to the treatment. there was a significant association between compliance and education status (p = 0.03). a significant association was found between reason of visit to clinic (p = 0.001) with compliance to medication however exposure to treatment related side effects had no significant effect on compliance. almost 30% (n = 59) of respondents said that they were un-decisive about their satisfaction with the treatment options, while 9% (n = 18) reported dissatisfaction with the treatment. a significant association between medication compliance and satisfaction with treatment options was found (p = 0.001). factors like personal knowledge and understanding about disease, confusion regarding table 3: association of personal knowledge, understanding of disease and family support with compliance to treatment. parameters compliant noncompliant p-value personal knowledge knowledge about disease 0.003 yes 132 (91.7%) 33 (58.9%) no 12 (8.33%) 23 (41.07%) understanding that control over disease provided by eye drops 0.008 yes 78 (54.17%) 13 (23.21%) somehow 65 (45.14%) 30 (53.57%) no 1 (0.69%) 13 (23.21%) facing confusion regarding schedule of medication 0.01 yes 22 (15.28%) 18 (32.14%) no 121 (84.03%) 38 (67.86%) family support difficulty in putting drops in eyes 1.03 yes 22 (15.28%) 8 (14.29%) no 122 (84.72%) 48 (85.71%) attendant required for visit to hospital 0.81 yes 61 (42.36%) 22 (39.29%) no 83 (57.64%) 34 (60.71%) huma munir, et al 196 pak j ophthalmol. 2022, vol. 38 (3): 193-198 schedule of medication and the family support was also studied. a significant association was found between knowledge about disease (p = 0.003) and the participants' understanding that medication controls the disease (p = 0.008) with compliance. table 3 shows association of personal knowledge, understanding of disease and family support with compliance to treatment. discussion the most significant finding of the current study was a high rate of non-compliance (30%) with long-term glaucoma medication among the participants presenting at a tertiary care eye hospital. our results are in accordance with those reported in a review article where non-compliance rate was reported between 4.6%-59%. 11 another study reported higher levels of non-compliance (53.6%) compared to this study. 12 this implicates a consistent trend of noncompliance across developing countries which might be explained by various personal and healthcare system related factors. 13 almost 20% of respondents in the current study expressed confusion regarding the schedule of instilling eye drops. about two thirds of the patients attributed the confusion to the numerous medications and their daily consumption, which is in accordance with the results of another article where multiple doses of eye drops resulted in higher rate of non-compliance to glaucoma treatment. 14 about 15.5% participants reported that they were unable to visit according to the prescribed schedule which could disturb the treatment plans and increase the risk of visual loss as reported in a study where adherence to the advice was found to be critical for better outcomes oftreatment. 15 numerous side effects with long-term treatment including itching, watering, stinging or burning were frequently reported by the participants which is also in agreement with the results of another study where adverse effects of medicines negatively affected the compliance to treatment. 16 about 27.5% of patients were confused about whether the doctor explained the disease or not and this was found to be of statistical significance with the compliance level (p < 0.05). evidence suggests that lack of communication between physician and patient is a substantial factor leading to non-compliance. 9 almost 30% of respondents reported to be somehow satisfied with the therapy, which is in contrast to the study by lemij et al where 89% of patients reported satisfaction with glaucoma treatment despite adverse ocular effects; however, the author recommended further studies since adverse events lead to dissatisfaction which might negatively affect the compliance. 17 in many developing countries preservative-free medicines are not available which may lead to ocular surface diseases resulting in ocular discomfort and dissatisfaction and ultimately leading to poor compliance. age and gender were statistically associated with glaucoma compliance in many studies. 18,19 however, these demographic variables were not found to be statistically significant in the current study. almost 30% of patients were illiterate, followed by only 15.5% who had higher education and the level of education was found to be significantly associated with the degree of compliance (p < 0.05) in the current study. this finding was in contrast to an ethiopian study where the level of education was not found statistically associated with non-adherence to glaucoma treatment. 20 a possible explanation to this finding could be the lack of healthcare facilities in african countries which predominantly has more effect on compliance than the education level of the patients. many studies have shown that glaucoma has posed an economic burden on patients in different ways. 20,21 however, other factors like cost of medications, job status, working status, duration of glaucoma, residence, and expense per visit to the hospital were not found associated with the level of compliance in the current study. reason for visiting the hospital was also found to be associated with adherence to glaucoma treatment in the current study. a previous study has also shown an association between presenting complaints and glaucoma compliance. 22 this study was unique in a way as only a few studies have attempted to evaluate factors affecting compliance to glaucoma therapy in developing countries. however, since the current study was conducted in a tertiary care trust healthcare setting, some important factors could have been concealed as many patients visit regularly to get free medicines provided by the trust hospital. patients presenting at private eye clinics might report less compliance due to more economic burden related to drugs. hence, the results of current study cannot be generalized to every factors associated with non-compliance to long term glaucoma medication pak j ophthalmol. 2022, vol. 38 (3): 193-198 197 set up. multicentered studies are required to assess other factors resulting in poor compliance which could help in overcoming these problems, leading to efficient utilization of healthcare services. conclusion knowledge of the disease, poor communication with the doctor, lack of satisfaction with treatment and level of education were associated with non-compliance to long-term glaucoma therapy. compliance towards anti-glaucoma medication can be improved by developing good communication between patient and physician as well as encouraging better understanding by the patient for the need of treatment. for better compliance, it is important to develop awareness programs to educate the patients and general public about the importance of regular eye examination. conflict of interest: authors declared no conflict of interest. ethical approval the study was approved by the institutional review board/ethical review board (erc-09/ast-18). references 1. bathija r, gupta n, zangwill l, weinreb rn. changing definition of glaucoma. j glaucoma, 1998; 7 (3): 165-169. doi: 10.1097/00061198-19980600000004. 2. quigley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006; 90 (3): 262-267. doi: 10.1136/bjo.2005.081224. 3. bourne rr, taylor hr, flaxman sr, keeffe j, leasher j, naidoo k, et al. vision loss expert group of the global burden of disease study. number of people blind or visually impaired by glaucoma worldwide and in world regions 1990-2010: a metaanalysis. plos one, 2016; 11 (10): e0162229. doi: 10.1371/journal.pone.0162229. 4. chan ew, li x, tham yc, liao j, wong ty, aung t, et al. glaucoma in asia: regional prevalence variations and future projections. br j ophthalmol. 2016; 100 (1): 78-85. doi: 10.1136/bjophthalmol-2014306102. 5. dineen b, bourne rra, jadoon z, shah sp, khan ma, foster a, et al. pakistan national eye survey study group. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91 (8): 1005-1010. doi: 10.1136/bjo.2006.108035. 6. mulugeta a. management of absolute glaucoma: experience of rasdesta damtew hospital, addis abeba, ethiopia. ethiop med j. 2017; 55 (2). 7. shafranov g. glaucoma therapy: compliance, adherence, persistence, and alliance. understanding the terminology and addressing the issues it represents. glaucoma today, 2006; 8: 40-42. 8. tsai jc, mcclure ca, ramos se, schlundt dg, pichert jw. compliance barriers in glaucoma: a systematic classification. j glaucoma, 2003; 12 (5): 393-398. doi: 10.1097/00061198-200310000-00001. 9. taylor sa, galbraith sm, mills rp. causes of noncompliance with drug regimens in glaucoma patients: a qualitative study. j ocul pharmacol ther. 2002; 18 (5): 401-409. doi: 10.1089/10807680260362687. 10. nordmann jp, auzanneau n, ricard s, berdeaux g. vision related quality of life and topical glaucoma treatment side effects. health qual life outcomes, 2003; 1: 75. doi: 10.1186/1477-7525-1-75. 11. castro anbvd, mesquita wa. noncompliance with drug therapy of glaucoma: a review about intervening factors. braz j pharm sci. 2009; 45 (3): 453-459. doi: 10.1590/s1984-82502009000300010. 12. subathra gn, rajendrababu sr, senthilkumar va, mani i, udayakumar b. impact of covid-19 on follow-up and medication adherence in patients with glaucoma in a tertiary eye care centre in south india. indian j ophthalmol. 2021; 69 (5): 1264-1270. doi: 10.4103/ijo.ijo_164_21. 13. abu hussein nb, eissa im, abdel-kader aa. analysis of factors affecting patients’ compliance to topical antiglaucoma medications in egypt as a developing country model. j ophthalmol. 2015; 2015: 234157. doi: 10.1155/2015/234157. 14. cook pf, schmiege sj, mansberger sl, kammer j, fitzgerald t, kahook my. predictors of adherence to glaucoma treatment in a multisite study. ann behav med. 2015; 49 (1): 29-39. doi: 10.1007/s12160-0149641-8. 15. denis p. adverse effects, adherence and cost-benefits in glaucoma treatment. eur. ophthal rev. 2011; 5 (2): 116-122. 16. bloch s, rosenthal ar, friedman l, caldarolla p. patient compliance in glaucoma. br j ophthalmol. 1977; 61 (8): 531-534. doi: 10.1136/bjo.61.8.531. 17. lemij hg, hoevenaars jg, van der windt c, baudouin c. patient satisfaction with glaucoma therapy: reality or myth? clin ophthalmol. 2015; 9: 785-793. doi: 10.2147/opth.s78918. huma munir, et al 198 pak j ophthalmol. 2022, vol. 38 (3): 193-198 18. masoud m, sharabi-nov a, pikkel j. noncompliance with ocular hypertensive treatment in patients with primary open angle glaucoma among the arab population in israel: a cross-sectional descriptive study. j ophthalmol. 2013; 2013: 405130. doi: 10.1155/2013/405130. 19. tripathi s, gupta s, arora v. socio-demographic determinants of glaucoma medications compliance: a north indian cross sectional study. indian j clin exp ophthalmol. 2017; 3 (1): 53-56. 20. nayak b, gupta s, kumar g, dada t, gupta v, sihota r. socioeconomics of long-term glaucoma therapy in india. indian j ophthalmol. 2015; 63 (1): 2024. doi: 10.4103/0301-4738.151458. 21. hoevenaars jg, schouten js, van den borne b, beckers hj, webers ca. socioeconomic differences in glaucoma patients’ knowledge, need for information and expectations of treatments. acta ophthalmol scand. 2006; 84 (1): 84-91. doi: 10.1111/j.1600-0420.2005.00587.x 22. ng ws, agarwal pk, sidiki s, mckay l, townend j, azuara-blanco a. the effect of socio-economic deprivation on severity of glaucoma at presentation. br j ophthalmol. 2010; 94 (1): 85-87. doi: 10.1136/bjo.2008.153312. authors’ designation and contribution huma munir; optometrist: concepts, design, data analysis. muhammad sadiq; lecturer: manuscript preparation, manuscript editing. shama khan; associate professor: literature search, data analysis. sarah zafar; professor: literature search, data analysis. farah akhtar; professor: manuscript editing. .…  …. pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 9 original article explaining “unexplained visual loss” with optical coherence tomography hina khan, aamir asrar, muhammad siddique, sumaira amir joya, maria akhtar pak j ophthalmol 2016, vol. 32 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hina khan consultant ophthalmologist amanat eye hospital rawalpindi e.mail:drhina@amanathospital.com …..……………………….. purpose: to determine various pathologies detected by optical coherence tomography (oct) in patients with unexplained visual loss (uvl). study design: a retrospective case review. place and duration: amanat eye hospital from october 2014 to october 2015. material and methods: all cases of uvl were scanned on heidelberg spectralis spectral domain oct machine on edi mode. the scans so obtained were evaluated for a possible pathology that was responsible for the visual loss. frequency tables were charted on this basis. results: 83 patients with unexplained visual loss and apparently normal fundi were reviewed. in 37 cases, a definitive diagnosis was provided with the help of oct imaging. 10 (27.03%) patients showed vitreomacular traction, 5 (13.51%) showed epiretinal membranes, 4 (10.81%) showed early stages of macular hole, 2 (5.4%) showed lamellar holes, 3 (8.1%) showed idiopathic macular telangiectasia, 4 (10.81%) were children with cone dystrophy and there were single cases (2.7%) each of juvenile x-linked retinoschisis, retinal arteritis, acute macular neuroretinopathy and solar maculopathy. 5 (13.51%) patients showed a selective foveal atrophy of one or both eyes but the cause could not be determined. 46 patients with unexplained visual loss showed a normal oct. conclusion: oct was able to identify various retinal pathologies in patients with uvl that was missed on fundus exam. with its help, a wide fraction of patients labeled with uvl were excluded from this obscure diagnosis. key words: visual loss, ocular coherence tomography, vitreo-retinal diseases. nexplained visual loss (uvl) is defined as reduced vision without any identifiable physical cause.1 it is a common problem amongst patients presenting to ophthalmic care services2 and poses anxiety to both the doctor and patient alike. many algorithms have been defined and approaches to uvl have been suggested but the problem often remains unresolved.3,4 published literature has emphasized the importance of a thorough ocular exam as an integral part of solving uvl.5 uncommon and subtle problems that should be kept in mind when faced with uvl have also been enumerated by studies.6 studies have been done regarding the use of investigative tools like electroretinogram and visual evoked potential to decipher the cause of uvl.7 but in spite of all of the above, patients diagnosis remains a dilemma and it is common practice then to refer such patient to a neurologist in the blind hope that neuroimaging of the optic pathway may reveal an abnormality. needless to say, this also often proves a futile exercise at the expense of the patient or his provider. when all else fails, the patient with uvl may even be referred to a psychiatrist on an assumed diagnosis of non organic u hina khan, et al 10 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology visual loss which adds further to the patients distress. oct has established itself as a novel noninvasive retinal imaging modality. it has been likened to an “in vivo optical biopsy” providing highly magnified high resolution images of the vitreous, retina and even choroid. we intended to study if oct could help us decipher a cause in a patient with uvl. after extensive search of literature we were unable to find a single study with the same objective. material and methods we conducted this study at amanat eye hospital, rawalpindi in a period of one year (from oct 2014 to oct 2015). approval was taken from the hospitals ethical committee. a retrospective review of cases of uvl was done from the diagnostic register. we based the diagnosis uvl on an apparently normal ocular (including fundus exam) or one in which the fundus findings were too subtle to explain the extent of visual loss (e.g. a dull foveal reflex). whenever, possible the referring consultant was contacted to discuss the case. then the findings of oct were reviewed. results 83 cases of uvl were identified from our records and included in this study. 34 patients were referred from within the hospital and 49 were referred from various ophthalmic set ups in the region. fig. 1: vitreomacular traction. of the 83 patients labeled uvl, oct detected an organic cause to the visual loss in 37. the male: female was 17:20. the mean age in years was 50.10 ± 17.11yrs. the minimum age was 04yrs and maximum age was 80yrs. the various pathologies detected on oct, along with the demographic data are presented in table 1 and shown in figures 1-10. 46 patients of uvl had normal oct scans. fig. 2: stage 1b macular hole. dehiscence of the neurosensory retina. table 1: frequency of pathologies detected on sd oct. vmts: vitreomacular traction synrdrome, erm: epiretinal membrane, ijft: idiopathic juxtafoveal telangiectasia, jxlr: 004 auvenile x linked retinoschisis, amn: acute macular neuroretinopathy. no. pathology n % mean age (yrs) (sd) m:f 1. vmts 10 27.03 50.24 ±5.21 4:6 2. erm 05 13.51 68.41±4.63 2:3 3. macular hole 04 10.81 74.54±5.82 2:2 4. lamellar hole 02 5.40 61.0±8.91 0:2 5. ijft 03 8.10 56.70±3.24 1:2 6. cone dystrophy 04 10.81 5.93±2.32 2:2 7. jxlr 01 2.7 4.00 1m 8. retinal arteritis 01 2.7 34.00 1m 9. amn 01 2.7 36.00 1f 10. solar maculopathy 01 2.7 32.00 1m 11. foveal atrophy 05 13.51 57.33±4.36 3:2 fig. 3: early epiretinal membrane. lack of surface wrinkling makes this difficult to see with 90d. explaining “unexplained visual loss” with optical coherence tomography pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 11 fig. 4: lamellar hole secondary to epiretinal membrane and chronic cystoid foveal edema fig. 5: ijft type 2. right eye showing atrophic cysts at the fovea and a gap in the is/os layer fig. 6: cone dystrophy shows selective outer foveal degradation with loss of photoreceptors and back scattering of the light signal. discussion oct has allowed better in vivo visualization of macular anatomy increasing our capability to evaluate the retina at a resolution that was unprecedented by conventional retinal imaging methods. by utilizing this property we have been able to reach a diagnosis in almost 45% of patients in our study group and have therefore attempted to justify its use in uvl with apparently normal fundus. fig. 7: juvenile xlinked retinoschisis. intraretinal split at the fovea fig. 8: retinal arteritis right eye oct and corresponding ffa. the left eye was normal. fig. 9: acute macular neuroretinopathy hyper reflectivity at the onl/opl junction (yellow arrow). hina khan, et al 12 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology fig. 10: solar retinopathy. selective subfoveal outer retinal degradation for this retrospective review we chose to work on the heidelberg spectralis (sd oct with edi mode). it is a state of the art oct device with a resolution of 5 microns and the highest coefficient of variability yet. waldstein et al8 compared the spectralis to swept source topcon dri oct 1 and cirrus oct (sd oct without edi mode). he states that the heidelberg spectralis has a greater penetration depth and visibility compared to cirrus and equal to topcon ss oct system. in regard to contrast levels of deep choroidal vessels spectralis gave superior results compared to both topcon and cirrus oct. such characteristics, we predicted, would help in evaluation of our patients with uvl. vitreomacular traction syndrome was amongst the most common causes detected on oct that could explain uvl. sd oct enables us to study the posterior vitreous and the intricate relationship it has with the inner retina. we are easily able to differentiate vitreomacular adhesion from vitreoschisis and vitreomacular traction which is not clinically visible. also the 3-d image reconstruction feature can help identify surgical plans improve pre operative planning and therefore optimize surgical outcomes. koizumi et al9 performed three dimensional scanning of vmts and demonstrated that vmts is frequently associated with undiagnosed epiretinal membranes that can negatively impact vision and the surgical ease with which vitreous traction can be relieved per operatively. we also observe erm in 4 of our cases of vmts. important to note is that 07 of our patients with vmts were diabetics without retinopathy. vmt is essential to diagnose in patients with diabetes. a study vitreoretinal interaction was studies in eyes with dme established that dme is aggravated by abnormal vr interaction.9 macular holes are a consequence of centrifugal displacement of cone receptors to form a dehiscence at the umbo. abnormal vitreofoveolar interaction is said to lead to this pathology. clinically early macular holes stage 1 and full thickness macular holes less than 200 microns are difficult to detect. early macular holes may be seen on oct as a schitic cavity at the level of the outer plexiform layer and the outer nuclear layer10. this then extends to involve the is/os junction and the layer representing the interaction of the cone outer segments with the rpe.11 lamellar hole can arise secondary to chronic cystoid intraretinal edema. it poses a challenge when cystoid thickening is adequately treated and, as a consequence, the retinal thickness improves but with no subsequent improvement in vision. enface visualization of macular hole makes differentiation from lamellar hole and pseudohole difficult (figure 04). all show central macular window defect hyperfluorescence on ffa. oct helps to clearly distinguish these conditions from one another12. furthermore and more recently a mathematical analogue based on oct of premacular hole pathology has been designed to predict the risk of full thickness macular hole formation in fellow eyes of patients with ftmh.13 additionally, using oct we can go beyond diagnosis. in evaluation of macular holes, it has been established that the magnitude of the defect of ellipsoid zone both before and after surgery can impact the visual prognosis.14 epiretinal membrane is a fibrocellular membrane growing over the retina. in advanced stages it can cause macular pucker which is easily visible. but in early stages it may be missed especially since the age at which a patient is prone to develop epiretinal membrane is also the age at which lenticular changes become advance and cause problems in visualizing the macula15. surgery for this condition was previously advised after the vision had deteriorated more than 6/12 (20/40). however, oct had demonstrated that macular thickening and is/os distortion much before this stage is reached. these features on oct can compromise the visual results of treatment. idiopathic juxtafoveal telangiectasia can cause obscure visual symptoms. the fundus exam is initially normal. even on ffa, early lesions are not delineated as clear telangiectatic vessels but rather as an indiscrete mild late leakage abutting the foveal area. however, on oct the telltale sign of this disorder is a disruption of the is/os segment of the photoreceptor, explaining “unexplained visual loss” with optical coherence tomography pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 13 atrophic cystoid changes at the fovea without exudation or thickening and a characteristic retinal ilm drape over the cysts. 4 cases were identified in which children were reported to have decrease vision with an apparently normal fundus. color vision tests were consistently abnormal in all cases (figure 06). a diagnosis of cone dystrophy was made. cone dystrophy is a hereditary disorder. most cases are sporadic. the most frequent established pattern is ad but ar and xl cases have also been reported. in our set up owing to a high frequency of consanguineous marriages, hereditary retinal dystrophies are seen with increasing prevalence than reported internationally with crowding within the same family. these children present with more severe forms and sometimes atypical forms of this disease. 4 major categories of sd – oct findings have been defined by cho,16 based on the status of the ellipsoid portion of the photoreceptor inner segment (ise), outer segment (os) contact cylinder, and retinal pigment epithelium (rpe) layer. the more subtly presenting subtypes will present with an essentially normal fundus and the child would be symptomatic. 06 years old male child was included. the visual acuity was 6/24 in both eyes with no significant refractive error and a subtle yet undiagnosed maculopathy. on oct both eyes were showing a similar picture (figure. 08). these findings were consistent with juvenile x-linked retinoschisis. differential diagnosis included cystoid macular edema associated with retinitis pigmentosa.16 important to note is that both these conditions are angiographically silent (show no leakage on ffa). incidence of jxlr is estimated at 1:5000. these features have been discovered on oct by other investigators who also state their presence in an apparently normal fundus.17 in a 35 years old female, fundus examination revealed subtle tear drop shaped retinal lesions pointing to the center of the fovea. the oct revealed corresponding intraretinal hyper reflectivity at the onl/opl junction (figure. 09) characteristic of acute macular neuroretinopathy. hanson18 states in his study that advanced optics scanning laser ophthalmoscope is a better tool than oct to observe changes of amn. however, we were still able with oct to diagnose and counsel our patient which proved fruitful. of 05 cases of selected foveal atrophy, the cause was not found19. however, even in these cases we were able to explain the loss of vision and could counsel the patient accordingly. in light of the above, it seems important to consider oct in cases of unexplained visual loss even if apparently the fundus is normal. it is prudent to note that more than 50% of patients with uvl, we were unable to find any abnormality on oct. this is one limitation of our study. we would have liked to follow up on patients who did not have any abnormality on oct, so further stats could be provided as to what diagnosis was eventually reached. however, more than half of our patients were referred from other set ups in the region and it was not always possible to maintain adequate follow up for this purpose. as mentioned above, after extensive search of literature we were unable to find a single published study with the same objective. we recommend based on our study, that oct be advised in all patients in whom, after a thorough and detailed clinical ophthalmic examination, no cause could be found. we suggest that this valueable investigation be taken advantage of before such a patient is referred to other specialties such as neurology or psychiatry because once it is stated that ophthalmic exam is „normal‟, he/she is unlikely to return to ophthalmic set ups. this will entail further anxieties as well as costs to undergo further investigations like neuroimaging etc. by using sd-oct, we were able to help almost half of the patients with uvl and were able to give them a definitive diagnosis. they were then subsequently counseled about their disease and referred appropriately for treatment where possible. this not only served to alleviate their anxieties but also prevented unnecessary referrals to physicians, psychiatrist and other specialists. conclusion oct was able to identify various retinal pathologies in patients with uvl that was missed on fundus exam. with its help, a wide fraction of patients labeled with uvl were excluded from this obscure diagnosis. author’s affiliation dr. hina khan consultant ophthalmologist amanat eye hospital rawalpindi hina khan, et al 14 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology dr. aamir asrar chief consultant ophthalmologist amanat eye hospital rawalpindi dr. muhammad siddique assistant professor sheikh zayed hospital rahim yar khan sumaira amir joya optometrist and orthoptist amanat eye hospital rawalpindi maria akhtar optometrist amanat eye hospital rawalpindi role of authors dr. hina khan collection of data, interpretation of oct scans and writes up of article. dr. aamir asrar sharing of data and interpretation of oct scans dr. muhammad siddique sharing and compilation of data sumaira amir joya data analysis maria akhtar data analysis references 1. griffiths pg, ali n. medically unexplained visual loss in adult patients. curr opin neurol. 2009 feb; 22 (1): 415. 2. kiernan df, mieler wf, and hariprasad sm. spectral – domain optical coherence tomography: a comparison of modern high – resolution retinal imaging systems. american journal of ophthalmology, vol. 149, no. 1, pp. 18.e2–31.e2, 2010. 3. o'leary éd, mcneillis b, aybek s, riordan – eva p, david as. medically unexplained visual loss in a specialist clinic: a retrospective case – control comparison. j neurol sci. 2016 feb 15; 361: 272-6. 4. brown rj. introduction to the special issue on medically unexplained symptoms: background and future directions. clin psychol rev. 2007 oct; 27 (7): 769-80. 5. eminson dm. medically unexplained symptoms in children and adolescents. clin psychol rev. 2007 oct; 27 (7): 855-71. 6. acosta pc, trobe jd, shuster jj, krischer 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http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=23615345 explaining “unexplained visual loss” with optical coherence tomography pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 15 imaging in achromatopsia. jama ophthalmol. 2014 apr 1; 132(4): 437–445. 20. sundaram v, wilde c, aboshiha j, cowing j, han c, langlo cs, chana r, davidson ae, sergouniotis pi, bainbridge jw, ali rr, dubra a, rubin g, webster ar, moore at, nardini m, carroll j, michaelides m. retinal structure and function in achromatopsia: implications for gene therapy. ophthalmology, 2014 jan; 121 (1): 234-45. 119 pak j ophthalmol. 2020, vol. 36 (2): 119-123 original article diagnostic accuracy of direct ophthalmoscopy and non-mydriatic retinal photography for screening of diabetic retinopathy muhammad saleh memon 1 , shahid ahsan 2 , muhammad fahadullah 3 khalida parveen 4 , sumaira salim 5 , muhammad faisal fahim 6 13’4’5’ al-ibrahim eye hospital, isra postgraduate institute of ophthalmology, karachi, 2 jinnah medical and dental college, karachi, 6 bahria university medical and dental collage, karachi abstract purpose: to determine the reliability of direct ophthalmoscopy and non-mydriatic fundus photography for screening of diabetic retinopathy by optometrist. study design: observational, cross sectional. place and duration of study: al-ibrahim eye hospital, karachi from october to december 2018. methods: all individuals with type 2 diabetes of ≥ 40 years of age were screened for diabetic retinopathy (dr) by two trained optometrists and an ophthalmologist. first optometrist used non mydriatic fundus camera (nmfc) and second optometrist used direct ophthalmoscopy (do) after dilating the pupils. final examination was done by the ophthalmologist with slit lamp using volk fundus lens which was considered as reference standard. every investigator was kept unaware of the findings of others. results: a total of 698 eyes of 349 respondents were screened. ophthalmologist could not make decision by bio microscopy in 44 (6.3%) individuals as compared to 128 (18.3%) by 1 st optometrist by nmfc and 142 (20.3%) by 2 nd optometrist with do. diabetic retinopathy (dr) diagnosed with slit lamp bio microscopy was 140 (21.4%), with nmfc was 124 (19.1%), with do was 110 (16.8%). sensitivity of nmfc was 76% and that of do was 64.8%. specificity of nmfc was 97.45% and that of do was 96.63%. positive predictive value (ppv) of nmfc was 89.33% and that of do was 84.3% negative predictive value (npv) of nmfc was 93.33% and that of do was 90.7%. conclusion: nmfc is recommended tool for dr screening; but do by well-trained optometrist can be reliable where neither ophthalmologist nor nmfc is available. key words: diabetic retinopathy, direct ophthalmoscopy, non mydriatic fundus camera, optometrist. how to cite this article: memon ms, ahsan s, fahadullah m, parveen k, salim s, fahim mf. diagnostic accuracy of direct ophthalmoscopy and non-mydriatic retinal photography for screening of diabetic retinopathy. pak j ophthalmol. 2020; 36 (2): 119-123. doi: 10.36351/pjo.v36i2.1015 correspondence: muhammad saleh memon isra ophthalmic research & development center, alibrahim eye hospital email: salehmemon@yahoo.com received: march 11, 2020 accepted: march 23, 2020 introduction diabetic retinopathy is one of the leading causes of avoidable blindness in people of working age group. 1,2 it has been shown that diabetic retinopathy (dr) is present in 28.78% diabetics whereas sight threatening diabetic retinopathy (stdr) is present in 8.6% of the mailto:salehmemon@yahoo.com screening of diabetic retinopathy pak j ophthalmol. 2020, vol. 36 (2): 119-123 120 diabetics. 3 the most recent survey of diabetes in pakistan reported 26.3% prevalence of diabetes, of which 19.2% had known diabetes and 7.1% were diagnosed on screening. 4 in order to prevent progression of dr to stdr leading to gross impaired vision, at least all the known diabetics should undergo annual dr screening as per recommendations. 5,6 it is commonly observed in clinical practice that many individuals having diabetes in pakistan present with varying degree of retinopathy and visual deterioration on their first presentation, jeopardizing the final visual outcome. this state of affairs may arise either from failure to detect retinopathy at an appropriate stage or a delay in treatment. 7 diversity of the tools and operators has resulted in marked variations in the results attributed not only to modality by which screening was performed but to the expertise of the health care provider. developed countries have their own screening methodologies. 8 developing countries have to find out screening methods which are not only feasible, cost-effective but meet international standards of > 80% sensitivity, and > 95% specificity. 9 (standards set by british diabetic association (bda). though pakistan has an elaborative network of health care facilities at primary, secondary and tertiary care level, a proper functioning referral system is lacking. 10 this situation is further accentuated by shortage of trained and qualified ophthalmologists. currently, country has nearly 30,000 qualified registered ophthalmologists against the required number of 100,000. 11 thus mandatory screening of all patients by ophthalmologist as per recommended guidelines is out of questions for a long time to come. non-mydriatic fundus camera (nmfc) has been recommended as useful tool for mass screening. 12 it can be used at primary/secondary level by trained paramedics to lessen the burden on ophthalmologist and meet the required criteria. the cost and maintenance prevents its use in resource strained country like ours. direct ophthalmoscopy in the hands of well-trained optometrist might be a cheaper method. a study carried in a tertiary care diabetes center reported sensitivity of 60% and specificity of 76%. 13 the findings of this study though did not validate the use of direct ophthalmoscopy by diabetologist; authors however advocated its use and suggested to invest on the training of health care providers till financial resources allow shifting to the modern technology like fundus camera. in another study from lahore, ―direct ophthalmoscopy‖ in the hands of ophthalmologist considering as gold standard was compared to "arc light‖, concluded that ―arc light‖ can be used as a replacement of ophthalmoscope for diagnosing dr or other diseases as shown by the sensitivity and specificity analysis in this study‖. the researcher found optometrist almost equal to ophthalmologist in diagnosis of dr with ophthalmoscope as well as ―arc light. 14 apart from this study, sensitivity and specificity of ―direct ophthalmoscope‖ in the hands of optometrist has been scarcely studied in pakistan. present study was conducted with two objectives. first, to validate the findings of an earlier study using nmfc by optometrist. second, to find out the diagnostic accuracy of direct ophthalmoscopy in the hands of optometrist. the standard reference in the present study was bio-microscopy with 90d fundus lens by ophthalmologist. methods this was a comparative cross sectional study with non-probability, purposive sampling, carried out at diabetic eye clinic of al ibrahim eye hospital (aieh). duration of the study was from october to december 2018. all newly registered type 2 patients with diabetes, ≥ 40 years of age, irrespective of gender and ethnicity and willing for eye examination with dilated pupil were inducted whereas patients with type 1 and gestational diabetes or patient having any other eye disease were excluded from the study. all patients were examined for routine basic eye examination like refraction and best-corrected vision and entered into database. first screening was carried by an optometrist (optometrist a) without dilatation of pupil. two 45 degree retinal images one center to macula and other center to optic disc were taken using non mydriatic fundus camera (nmfc) (cannon cr-1). the data of fundus image was saved in the hmis (aieh) database. the consent was obtained from the patient for dilatation of pupil after informing about transitional haziness of vision after dilatation and confirming that patient is not driving after examination. tropicamide 0.1% was used for dilatation of pupil. after full mydriasis, optometrist (optometrist b) examined the fundus with direct ophthalmoscopy and entered the data in the hmis (aieh) database. the optometrists were instructed to identify presence or other wise of the diabetic retinopathy based on presence of hemorrhages, exudates, blood vessel changes and macular edema. they did not grade the retinopathy. in order to eliminate the observer bias both optometrists were shahid ahsan, et al 121 pak j ophthalmol. 2020, vol. 36 (2): 119-123 kept blind to the findings of each other. final retinal examination (c) was done by the retina-trained ophthalmologist using fundus lens and slit lamp. findings were entered into hmis database. these findings were taken as the reference standard for this study. dr was classified as a routine examination for the purpose of management using ―early treatment diabetic retinopathy study (etdrs– the modified airlie house classification. dr was classified as non–proliferative diabetic retinopathy (npdr), proliferative diabetic retinopathy (pdr) and table 1: n: 698 eyes (349 individuals with diabetes). tool used examiner diagnosis not possible dr detection nmfc optometrist (n: 142) 20.3% (n:124) 19.1% direct ophthalmoscopy optometrist (n:128) 18.3% (n: 110) 16.8% slit lamp bio-microscopy ophthalmologist (n:44) 6.3% (n: 140) 21.4% table 2: validity chart n = 698 eyes (349 individuals with diabetes). sensitivity specificity ppv npv kappa statistic british diabetic association (bda) recommendations > 80% > 95% nmfc 76% 97.45% 89.62% 93.33% 0.725 direct ophthalmoscopy 64.80% 96.63% 84.38% 90.72% 0.621 *positive predictive value (ppv), negative predictive value (npv) clinically significant macular edema (csme) with or without npdr/pdr. for the purpose of present study presence or absence of dr alone was compared with findings of nmfc done by optometrist a and direct ophthalmoscopy done by optometrist b. sample size calculation drawn by using on-line software raosoft.com and inculcating 95% confidence interval, given 5% margin of error with expected population size 5000 per year. the required sample size was found to be 357. ethical approval was taken from research ethical committee (rec) of isra post graduate institute of ophthalmology, al ibrahim eye hospital (aieh). statistical analysis was done by spss version 20.0. the entire continuous variables were presented as mean ± standard deviation. all the categorical variables were shown as frequency and percentage. sensitivity, specificity, ppv, npv and likelihood ratio was calculated by 2 × 2 contingency table. kappa statistics was also done to show the association (level of agreement) between two observers. results a total of 698 eyes of 349 individuals with diabetes type 2 were screened for dr using nmfc without dilating pupil, using direct ophthalmoscope (do) after dilating pupil and slit lamp with volk’s lens. result of slit lamp examination was used as a reference standard for comparison of nmfc ophthalmoscopy. non-readable fundi with bio microscopy were 44 (6.3%), with nmfc were 142 (20.3%) and with do were 128 (18.3%). diabetic retinopathy (dr) diagnosed with slit lamp bio microscopy was 140 (21.4%), with nmfc was 124 (19.1%), with do was 110 (16.8%) (table 1). validity of the procedures is shown in table 2. kappa statistic in terms of dr detection by nmfc as compared to slit lamp diagnosis (standard) was found to be 0.725. this indicates good agreement between the observers of nmfc with standard. kappa statistic in terms of dr detection with direct ophthalmoscopy (do) as compared to slit lamp diagnosis (standard) was found to be 0.621. this also shows good agreement between the observers of do with standard. discussion present study showed nmfc in the hands of an optometrist has sensitivity of 76%, specificity of 96.63%, ppv of 84.3% and npv of 90.7%. findings of the present study not only validated the findings of earlier study with nmfc by optometrists but showed improvement over previous figures of 72% sensitivity, 86.3% specificity, 62% positive predictive value and 90% negative predictive value. several studies have evaluated non-mydriatic fundus photography, and compared it with more-established methods of detecting diabetic retinal disease. the real question to be considered is whether non-mydriatic fundus photography will help to detect early treatable retinopathy better than the average physician using ophthalmoscopy. 15-18 this study thus supports that digital photography with nmfc camera is a useful tool for mass screening. it is to be considered that initial cost of nmfc is ≥ $ 20,000 and maintenance screening of diabetic retinopathy pak j ophthalmol. 2020, vol. 36 (2): 119-123 122 limits use for screening of retinopathy and calls for more cost effective methodology. ophthalmoscope is economical, age-old equipment which has been used by general physician, diabetologists, opticians and nurses. direct ophthalmoscopy by an optometrist can be most cost effective tool especially in community screening and primary eye care centers only if it meets the recommended criteria. present study has shown that direct ophthalmoscopy in the hands of optometrist had sensitivity of 64.8%, specificity of 96.63% with ppv of 84.3% and npv of 90.7%. the results have fallen short of recommended levels by bda of > 80% sensitivity, and > 95% specificity. this shows that in 100 dr eyes, optometrist missed 34 cases and wrongly diagnosed 4 cases. results of international studies are variable. studies from the uk have shown sensitivity levels for the detection of sight-threatening diabetic retinopathy of 41–67% for general practitioners, 48–82% for optometrists, 65% for an ophthalmologist, and 27–67% for diabetologist and hospital physicians using direct ophthalmoscopy. 19,20 this shows missing rates, of do for sight threatening diabetic retinopathy screening with direct ophthalmoscopy, as high as 52% for optometrists, 45% for general practitioners and 33% for hospital physicians. these studies have suggested no or limited role of ―direct ophthalmoscopy‖ in screening of dr so much so that even elimination of training in direct ophthalmoscopy for medical students has been suggested. 21,22 in present times of technology, ophthalmoscopy is not considered as an option, in spite of limited availability and cost considerations of non-mydriatic fundus photography. on the other hand, data are available in favor of optometrists. european working group in their study concluded that direct ophthalmoscopy through dilated pupils is the recommended test to screen for diabetic retinopathy, because it is inexpensive, efficient and rapid. in the opinion of this group 60% sensitivity is good enough for dr screening purpose and very little is gained from increasing the sensitivity to 80%. 23 in view of all above studies, it can be suggested that direct ophthalmoscopy can relied upon as cost effective screening tool if the optometrists are trained well and aware of proper referral protocols. conclusion digital photography with nmfc is promising screening method where trained ophthalmologists are not available. direct ophthalmoscopy in the hands of well-trained optometrist can be depended upon in the primary care setups and in the community where neither ophthalmologist nor nmfc is available. acknowledgement we are thankful to sight savers for their technical and financial support through the entitled project ―strengthening pakistan’s response to diabetic retinopathy‖. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest references 1. klein bek. overview of epidemiologic studies of diabetic retinopathy. ophthal epidemiol. 2007; 14 (4): 179–183. 2. ting ds, cheung gc, wong ty. diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review. clin exp ophthalmol. 2016; 44 (4): 260-277. 3. mumtaz sn, fahim mf, arslan m, shaikh sa, kazi u, memon ms. prevalence of diabetic retinopathy in pakistan: a systematic review. pak j med sci. 2018; 34 (2): 493-500. doi: https://doi.org/10.12669/pjms.342.13819. 4. basit a, fawwad a, siddiqui sa, baqa k. current management strategies to target the increasing incidence of diabetes within pakistan. diabetes metab syndrobes. 2019; 12: 851. 5. park yg, roh yj. new diagnostic and therapeutic approaches for preventing the progression of diabetic retinopathy. j diab res. 2016; 1753584. doi:10.1155/2016/1753584. 6. ghanchi f. diabetic retinopathy guidelines, 2012. https://www.rcophth.ac.uk/wpcontent/uploads/2014/12/2013-sci-301-final-drguidelines-dec-2012-updated-july-2013.pdf. page 65. accessed date: 27-04-2019. 7. corcostegui b, duran s, gonzález-albarran mo, hernandez c, ruiz-moreno jm, salvador j et al. update on diagnosis and treatment of diabetic retinopathy: a consensus guideline of the working group of ocular health (spanish society of diabetes and spanish vitreous and retina society). j ophthalmol. 2017: 8234186.1-10 doi: 10.1155/2017/8234186. https://doi.org/10.12669/pjms.342.13819 https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2013-sci-301-final-dr-guidelines-dec-2012-updated-july-2013.pdf.%20page%2065 https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2013-sci-301-final-dr-guidelines-dec-2012-updated-july-2013.pdf.%20page%2065 https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2013-sci-301-final-dr-guidelines-dec-2012-updated-july-2013.pdf.%20page%2065 https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2013-sci-301-final-dr-guidelines-dec-2012-updated-july-2013.pdf.%20page%2065 https://www.ncbi.nlm.nih.gov/pubmed/?term=corc%c3%b3stegui%20b%5bauthor%5d&cauthor=true&cauthor_uid=28695003 https://www.ncbi.nlm.nih.gov/pubmed/?term=dur%c3%a1n%20s%5bauthor%5d&cauthor=true&cauthor_uid=28695003 https://www.ncbi.nlm.nih.gov/pubmed/?term=gonz%c3%a1lez-albarr%c3%a1n%20mo%5bauthor%5d&cauthor=true&cauthor_uid=28695003 https://www.ncbi.nlm.nih.gov/pubmed/?term=hern%c3%a1ndez%20c%5bauthor%5d&cauthor=true&cauthor_uid=28695003 https://www.ncbi.nlm.nih.gov/pubmed/?term=ruiz-moreno%20jm%5bauthor%5d&cauthor=true&cauthor_uid=28695003 https://www.ncbi.nlm.nih.gov/pubmed/?term=salvador%20j%5bauthor%5d&cauthor=true&cauthor_uid=28695003 https://www.ncbi.nlm.nih.gov/pubmed/28695003 https://www.ncbi.nlm.nih.gov/pubmed/28695003 https://www.ncbi.nlm.nih.gov/pubmed/28695003 shahid ahsan, et al 123 pak j ophthalmol. 2020, vol. 36 (2): 119-123 8. pieczynski j, grzybowski a. review of diabetic retinopathy screening methods and programs adopted in different parts of the world. eur ophth rev. 2015; 9 (1): 49-55. doi: 10. 17925/ eor. 2015. 09.01.49 9. mead a, burnett s, davey c. diabetic retinal screening in the uk. j royal soci med. 2001; 94: 127129. 10. siddiqi s, kielmann aa, khan ms, ali n, ghaffar a, sheikh u, et al. the effectiveness of patient referral in pakistan. health policy plann. 2001; 16 (2): 193198. 11. pakistan requires sizeable increase in the number of qualified ophthalmologists: cpsp official. available at:https://www.urdupoint.com/en/health/pakistanrequires-sizeable-increase-in-the-nu-256174.html. accessed on 1-05-2019. 12. american academy of ophthalmology retina panel: preferred practice pattern guidelines. diabetic retinopathy, san francisco, ca: american academy of ophthalmology, 2008. june 2010. 13. ahsan s, basit a, ahmed kr, ali l, shaheen f, ulhaque ms, et al. diagnostic accuracy of direct ophthalmoscopy for detection of diabetic retinopathy using fundus photographs as a reference standard. diabetes metab syndr. 2014; 8 (2): 96-101. 14. moin m, manzoor a, riaz f. arc light as an alternative approach to diagnose diabetic retinopathy (dr) at grass root level of health care system. pak j ophthalmol. 2018; 34 (3): 154-162. 15. fahadullah m, memon na, salim s, ahsan s, fahim mf, mumtaz sn, et al. diagnostic accuracy of non-mydriatic fundus camera for screening of diabetic retinopathy: a hospital based observational study in pakistan. j pak med assoc. 2019; 69 (3): 378-384. 16. harding sp, broadbent dm, neoh c, white mc, vora j. sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the liverpool diabetic eye study. br med j. 1995; 311: 1131-1135. 17. scanlon ph, malhotra r, thomas g, foy c, kirkpatrick jn, lewis-barned n, et al. the effectiveness of screening for diabetic retinopathy by digital imaging photography and technician ophthalmoscopy. diabet med. 2003; 20 (6): 467-474. 18. lin dy, blumenkranz ms, brothers rj, grosvenor dm. the sensitivity and specificity of single-field non mydriatic monochromatic digital fundus photography with remote image interpretation for diabetic retinopathy screening: a comparison with ophthalmoscopy and standardized mydriatic color photography. am j ophthalmol. 2002; 134 (2): 204213. 19. gibbins rl, owens dr, allen jc, eastman l. practical application of the european field guide in screening for diabetic retinopathy by using ophthalmoscopy and 35mm retinal slides. diabetologia. 1998; 41: 59-64. 20. buxton mj, sculpher mj, ferguson ba, humphreys je, altman jfb, spiegelhalter dj et al. screening for treatable diabetic retinopathy: a comparison of different methods. diabet med. 1991; 8: 371-377. 21. mackay dd, garza ps, bruce bb, newman ng, biousse v. the demise of direct ophthalmoscopy. nerol clin pract. 2015; 5 (2): 150-157. 22. purbrick rmj, chong nv. direct ophthalmoscopy should be taught to undergraduate medical students – no. eye, 2015; 29 (8): 990–991. 23. javitt jc, canner jk, frank rg, steinwachs dm, sommer w. detecting and treating retinopathy with type i diabetes mellitus: a health policy model. ophthalmology, 1990; 97 (4): 483—495. authors’ designation and contribution muhammad saleh memon; director research: manuscript writing, final review. shahid ahsan; professor: manuscript writing and final review. muhammad fahadullah; retina specialist: data collection, final review. khalida parveen; optometrist: data collection, final review. sumaira salim; optometrist: data collection, final review. muhammad faisal fahim; statistician: statistical analysis, manuscript writing, final review. .…  …. https://www.urdupoint.com/en/health/pakistan-requires-sizeable-increase-in-the-nu-256174.html.%20accessed%20on%201-05-2019 https://www.urdupoint.com/en/health/pakistan-requires-sizeable-increase-in-the-nu-256174.html.%20accessed%20on%201-05-2019 https://www.urdupoint.com/en/health/pakistan-requires-sizeable-increase-in-the-nu-256174.html.%20accessed%20on%201-05-2019 461 pak j ophthalmol. 2020, vol. 36 (4): 461 obituary professor mohammad naqaish sadiq (1959 – 2020) how to cite this: naeem ba, masood s. professor mohammad naqaish sadiq (1959 – 2020). pak j ophthalmol. 2020; 36 (4): 461. doi: https://doi.org/10.36351/pjo.v36i4.1132 prof. m. naqaish sadiq died from a prolonged illness with covid 19 on 20 th july, 2020. it was a very sad news for his innumerable friends, colleagues, students and family members. he was born on the 15th of june 1959 in a small village (roopwal) near district chakwal. there was no electricity or water supply in the village and he had to walk long distance for his primary and secondary education. he got highest marks in district and got scholarship in matriculation exam. he had a simple, gentle personality. he was a noble and very hardworking student and passed his final mbbs exam with first class and distinction in ophthalmology. his initial training in ophthalmology was at rawalpindi general hospital. he did diploma in ophthalmology (do) from nishtar medical university and later fcps (ophth) and frcs from edinburgh. he went to middle east and worked in sultanate of oman for 11 years. he did his clinical fellow-ship in pediatric ophthalmology, oculoplastic surgery and squint surgery at moorfield’s hospital london. on his return to pakistan he worked as an associate professor at shifa college of medicine and as professor at islamabad medical college and rawal medical college. he was a member of surgical trainers of royal college of surgeons edinburgh and since 2014, he was also an examiner of the same college. he presented more than 70 papers in both national and international conferences. he received various academic, service awards and gold medals during his career. he was president (elect) of pakistan glaucoma association. he was also examiner for university of health sciences lahore, bahria university & national university of medical sciences (nums). to help the people of his area, he built a hospital at balkasar near chakwal and was practicing at naqaish medicare in islamabad. sadly, indeed, when prof. naqasih was reaching the zenith of his experience and career he was taken away from us. he will be greatly missed by his family, friends and patients. he passed away on the 20 th of july 2020 at the age of 61 after being infected with covid-19, followed by multi organ failure. he left a wife, a son and a daughter. his wife taqdees naqaish is a professor of gynecology, son rehan naqaish is a trainee doctor and daughter warda naqaish is a 2 nd year bds student in islamabad. his funeral service held at islamabad was attended by many colleagues from all branches of medicine, by relatives and friends who had traveled the length and breadth of the area. he was finally laid to rest at hblock graveyard in islamabad. may allah bless his soul, rest in jannat-ul-firdous and allah bless the family with strength and patience to bear this irreparable loss. dr. b. a. naeem professor of ophthalmology foundation medical college, rawalpindi shahid masood consultant plastic surgeon, uk microsoft word 15. sidrah riaz mm pakistan journal of ophthalmology, 2020, vol. 36 (3): 263-266 263 original article shifting paradigm: from general anesthesia to local anesthesia in posterior segment surgeries sidrah riaz1, muhammad tariq khan2, munir ahmad3, nadeem hafeez butt4, shabana chaudhay5 1-3akhtar saeed medical and dental college, 4allama iqbal medical and dental college, 5mayo hospital, lahore abstract purpose: to evaluate the type and methods of anesthesia used in posterior segment ocular surgeries. study design: cross sectional survey. place and duration of study: akhtar saeed medical college, from april 2017 to may 2019. material and methods: two hundred and three patients who underwent posterior segment surgeries were selected by convenient sampling technique. average surgery time was 45 minutes under local anesthesia (la) but all patients whose surgery was performed in general anesthesia (ga), had at least 6 hours hospital stay and four hour nothing by mouth before and after procedure, under observation of doctor/anesthetist and nursing staff. patient age, gender, indication for surgery, type of surgery performed and type of anesthesia were noted. data was analyzed by using spss 25. results: total 203 patients were included in study, 122 (60.1%) male and 81 (39.9%) females. general anesthesia (ga) was used in 18.2% surgeries and local anesthesia (la) was opted in 81.8%. mean age of patients who underwent ga was 30.62 years and 51.71 years for la. three major indications for la were retinal attachment surgery 64 (38.6%), vitreous hemorrhage 20 (12%) and endophthalmitis in 12 (7.2%) patients. indications for surgery under ga were surgery for retinal detachment in 23 (62.2%), endophthalmitis 6 (16.2%) and removal of silicon oil 2 (5.4%). ppv was done in 64.5% patients under la and 9.8% in ga but all combined procedures (ppv and scleral buckling) were done under ga. conclusion: the local anesthesia is favorable for posterior segment ocular surgeries in term of less hospital stay, no need of npo, fast recovery and cost effectiveness. key words: local anesthesia (la), general anesthesia (ga), scleral buckling, retinal detachment (rd), pars plan vitrectomy (ppv). how to cite this article: riaz s, khan mt, ahmad m, butt nh. shifting paradigm: from general anesthesia to local anesthesia in posterior segment surgeries. pak j ophthalmol. 2020; 36 (3): 263-266. doi: 10.36351/pjo.v36i3.1001 introduction history of anesthesia dates back to 3400 bc1,2. there is a deep desire inside human, since ancient times that they want to be pain free. first evidence of use of term anesthesia came in 1846, coined by oliver wendell correspondence to: sidrah riaz akhtar saeed medical and dental college, lahore email: sidrah893@yahoo.com received: february 8, 2020 revised: may 4, 2020 accepted: may 4, 2020 holmes3. alcohol is oldest known sedative 4. an ideal anesthetic agent is good analgesic, cost effective, long acting and free of side effects. over the last two decades vitreoretinal surgeries have increased and new techniques, instruments and modalities have been introduced for pars plana vitrectomies (ppv)5-7. initially the trend was towards general anesthesia and nearly all pars plana vitrectomies, sclera buckling and retinopexies were performed under general anesthesia. for last one decade there is increased frequency of posterior segment surgeries under local anesthesia with or without intravenous sedation. local anesthesia sidrah riaz, et al 264 pakistan journal of ophthalmology, 2020, vol. 36 (3): 263-266 has many advantages over general anesthesia including less hospital stay, ambulatory surgery, no need of specialized theatre facilities, early recovery and cost effectiveness. pakistan is a developing country and delayed presentation of retinal detachment added with fewer resources like unavailability of retinal surgeon and special operation theaters are major factors leading to poor visual outcomes after surgery. the ability and facility to perform ocular posterior segment surgeries under local anesthesia significantly decreases recovery time and cost. rationale of this study was to find out the feasibility of posterior segment surgeries under local anesthesia by evaluating the type and methods of anesthesia used in posterior segment ocular surgeries. material and methods over the last two years, from april 2017 to may 2019, all patients who underwent posterior segment ocular surgeries were included in study. informed consent was taken by all patients and patient fitness for general anesthesia was checked by consultant anesthetist. before surgery blood pressure, serum sugar, hepatitis b and c tests were checked by anesthetist in all patients and ecg for selected patients and intravenous access was secured. the technique for local anesthesia was peri-bulbar and facial block, performed by ophthalmologist himself, using lignocaine injection 2% and bupivacaine 0.5%. nearly 3cc of combined lignocaine and bupivacaine was injected in peri-bulbar area of the eye to be operated and also in pre-auricular area of ipsilateral side. anesthetist was available for monitoring of vitals and to counteract any unforeseen events. the main drugs used by the anesthetist for sedation were propofol, ketamine and midazolam in general anesthesia with endotracheal intubation. average surgery time was 40 minutes but all patients whose surgery was performed in general anesthesia, had at least 6 hour hospital stay and 4 hour nothing by mouth after procedure, under the observation of doctor/anesthetist and nursing staff. patient age, gender, indication for surgery, type of surgery performed and type of anesthesia were noted. data was analyzed by spss version 25. results total 203 patients were included in the study, including 122 (60.1%) males and 81 (39.9%) females. general anesthesia was used in 37 (18.2%), out of whom 25 (67.6%) were males and 12 (32.4%) were females. local anesthesia was opted in majority of patients; 166 (81.8%) including 97 males (58.4%) and 69 females (41.6%). age ranged from 2 years to 83 years and mean age of patients who underwent surgery in general anesthesia was 30.62 years and 51.71 years for local anesthesia patients (shown in table 1). three top most indications for la were retinal detachment (rd) in 64 (38.6%) patients, vitreous hemorrhage in 20 (12%) and endophthalmitis in 12 (7.2%) patients (pie chart 1). most common indication for surgery under ga were rd in 23 (62.2%), endophthalmitis in 6 (16.2%) and removal of silicone oil in 2 (5.4%) patients (pie chart 2). the common procedure for rd repair was ppv with or without scleral buckling. out of 203 posterior segment ocular surgeries, 131 (64.5%) were performed under la and 20 (9.8%) in ga. all patients of scleral buckling were operated in ga except 2 in whom la with sedation. table 1: anesthesia eye age gender right left mean male female la 79 87 51.71% 97 69 ga 15 22 30.62% 25 12 was used. all combined procedures (ppv & scleral buckling) were done under ga. discussion vitreoretina has recently been recognized as a separate specialty and is flourishing in ophthalmology. new trends and techniques are being evolving.8-10 previously, almost every posterior segment surgery was performed under general anesthesia, but now more posterior segment surgeries are being performed under local anesthesia. general anesthesia is used only in selected cases, reserved for children, mentally handicapped patients, for scleral buckling and patients with complex or complicated medical history. scleral buckling is traditionally performed under ga, but in our study out of total 10 patients, one patient was done under la combined with iv sedation. the painful steps during vitreoretinal surgery are sclerectomies (trocar cannula placement and withdrawal), application of endolaser, and scleral indentation for peripheral vitreous shaving.11-15 shifting paradigm: from general anesthesia to local anesthesia in posterior segment surgeries pakistan journal of ophthalmology, 2020, vol. 36 (3): 263-266 265 anesthesia is required to make patient comfortable during these steps. duration of vitreoretinal procedure is usually from 35 to 55 minutes. lignocaine 2% combined with bupivacaine 0.5% is safe, effective and acceptable anesthetic agent in ocular surgery providing anesthetic effect up to 60 minutes16,17. lignocaine and bupivacaine combined mixture is better in analgesia and akinesia for longer duration than lignocaine alone. the retro-bulbar injection is safe in expert and trained hands with minimal side effects. its complications are very rare but sight threatening. retrobulbar block is rarely associated with complications like ocular perforation, brain stem infarction18 as patient co-operation is very important during peri-bulbar or retro-bulbar injections and patient looking toward wrong direction can lead to undesirable effects. in our study we did not have any of these complications. the different pharmacological agents, depending upon patient age, comorbid associations and anesthetist preference, used in ga are propofol, ketamine and midazolam which have average duration of 10, 20 and 30 minutes respectively19,20,21. an ideal anesthetic agent is of sufficient duration with least side effects so that patient and surgeon both are comfortable. la has certain advantages over ga including less hospital stay, less cost, less surgical time, no npo required, quick and early recovery. la is usually given by eye surgeon and anesthetist monitors patient’s vitals. ga is associated with more significant side effects in geriatric patients. as we are living in a developing country and resources do matter; la is cheaper than ga. small gauge 23 g vitrectomies are also being done under topical anesthesia22 as in report by mahajan et al. but it also depends upon patient factors (threshold of pain varies from person to person) and surgeon expertise23 (duration of surgery and skills). in a study by gupta et al. in neighboring country india, intracameral preservative free lignocaine 2%, augmented with topical anesthesia with proparacaine 0.5% was found sufficient 24 for pars plana vitrectomy in 114 eyes (78 male, 36 females) but so far la is much more effective and safe as compared to ga25 for most cases of vitreoretinal surgeries. the limitations of the study were the limited number of patients in private sector, surgeon preferences and surgical abilities of surgeon. conclusion the surgical practices change with time according to resources and prevalent conditions. now there is a trend of performing anterior segment surgeries in topical anesthesia rather local anesthesia and posterior segment surgery under local anesthesia rather general anesthesia. the local anesthesia is favourable and beneficial for posterior segment ocular surgeries in terms of less hospital stay, no need of npo, fast recovery and cost effectiveness especially in developing countries. the patient is also able to maintain required head positioning within hour after surgery, if it is performed under local anesthesia. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution sidrah riaz; associate professor: data collection, data analysis, manuscript writing. muhammad tariq khan; associate professor: primary surgeon, final review. munir ahmad; associate professor: concept, final review. nadeem hafeez butt; professor: concept, final review. shabana chaudhary; assistant professor: concept, final review. references 1. evans, tc. the opium question, with special reference to persia (book review). transactions of the royal society of tropical medicine and hygiene. 1928; 21 (4): 339–340. doi: 10.1016/s0035-9203(28)90031-0. 2. booth m. the discovery of dreams. opium: a history. london: simon & schuster, ltd. 1996; p. 15. isbn 978-0-312-20667-3. retrieved 18 september 2010. 3. small, mr. oliver wendell holmes. new york: twayne publishers, 1962; 55. 4. powell ma. wine and the vine in ancient mesopotamia: the cuneiform evidence. in mcgovern pe, fleming sj, katz sh (eds). the origins and ancient history of wine. food and nutrition in history sidrah riaz, et al 266 pakistan journal of ophthalmology, 2020, vol. 36 (3): 263-266 and anthropology. 11 (1 ed.). amsterdam: taylor & francis. 2006; pp. 96–124. retrieved 15 september 2010. 5. pak ky, lee sj, kwon hj, park sw, byon is, lee je. exclusive use of air as gas tamponade in rhegmatogenous retinal detachment. j ophthalmol. 2017; 2017: 1341948. 6. park sw, kwon hj, kim hy, byon is, lee je, oum bs. comparison of scleral buckling and vitrectomy using wide angle viewing system for rhegmatogenous retinal detachment in patients older than 35 years. bmc ophthalmol. 2015; 15: 121. 7. wong cw, wong wl, yeo iy, loh bk, wong ey, wong dw, et al. trends and factors related to outcomes for primary rhegmatogenous retinal detachment surgery in a large asian tertiary eye center. retina. 2014; 34 (4): 684–692. 8. schneider ew, geraets rl, johnson mw. pars plana vitrectomy without adjuvant procedures for repair of primary rhegmatogenous retinal detachment. retina. 2012; 32 (2): 213–219. 9. schwartz sg, flynn hw. pars plana vitrectomy for primary rhegmatogenous retinal detachment. clin ophthalmol. 2008; 2 (1): 57–63. 10. feltgen n, heimann h, hoerauf h, walter p, hilgers rd, heussen n. writing group for the spr study investigators. scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (spr study): risk assessment of anatomical outcome. spr study report no. 7. acta ophthalmol. 2013; 91 (3): 282–287. 11. deka s, bhattacharjee h, barman mj, kalita k, singh sk. no-patch 23-gauge vitrectomy under topical anesthesia: a pilot study. indian j ophthalmol. 2011; 59: 143–5. 12. raju b, raju ns, raju as. 25 gauge vitrectomy under topical anesthesia: a pilot study. indian j ophthalmol. 2006; 54: 185–8. 13. theocharis ip, alexandridou a, tomic z. a twoyear prospective study comparing lidocaine 2% jelly versus peribulbar anaesthesia for 25g and 23g sutureless vitrectomy. graefes arch clin exp ophthalmol. 2007; 245: 1253–8. 14. tang s, lai p, lai m, zou y, li j, li s, et al. topical anesthesia in transconjunctival sutureless 25-gauge vitrectomy for macular-based disorders. ophthalmologica. 2007; 221: 65–8. 15. bardocci a, lofoco g, perdicaro s, ciucci f, manna l. lidocaine 2% gel versus lidocaine 4% unpreserved drops for topical anesthesia in cataract surgery: a randomized controlled trial. ophthalmology, 2003; 110: 144–9. 16. tan cs, fam hb, heng wj, lee hm, saw sm, au eong kg, et al. analgesic effect of supplemental intracameral lidocaine during phacoemulsification under topical anaesthesia: a randomised controlled trial. br j ophthalmol. 2011; 95: 837–41. 17. devi ns, singh k n. comparison of lignocaine 2% with adrenaline and a mixture of bupivacaine 0.5% plus lignocaine 2% with hyaluronidase for peribulbar block analgesia. j med soc. 2018; 32: 190-4. 18. hamilton rc. complications of ophthalmic regional anaesthesia. ophthalmic clin north am. 1998; 11: 99114. 19. wildt sn, hoog m, vinks aa, giesen ve, anker jn. population pharmacokinetics and metabolism of midazolam in pediatric intensive care patients. crit care med. 2003; 31: 1952. 20. bourgoin a, albanèse j, léone m, sampol-manos e, viviand x, martin c. effects of sufentanil or ketamine administered in target-controlled infusion on the cerebral hemodynamics of severely brain-injured patients. crit care med. 2005; 33: 1109. 21. veselis ra, feshchenko va, reinsel ra, beattie b, akhurst tj. propofol and thiopental do not interfere with regional cerebral blood flow response at sedative concentrations. anesthesiology, 2005; 102: 26. 22. mahajan d, sain s, azad s, arora t, azad r. comparison of topical anesthesia and peribulbar anesthesia for 23-gauge vitrectomy without sedation. retina. 2013; 33: 1400–1406. 23. trujillo-sanchez gp, rosa ag, navarro-partida j, haro-morlett l, altamirano-vallejo jc, santos a. response to comment on: feasibility and safety of vitrectomy under topical anesthesia in an office-based setting. indian j ophthalmology, 2019; 67: 182-183. 24. gupta sk, kumar a, sharma a. trojan horse anaesthesia: a novel method of anaesthesia for pars plana vitrectomy. oman j ophthalmology. 2018; 11: 119-123. 25. selim emad, selim mazen, auf rehab. anesthesia for vitreous surgery. clin rev cases. 2019; 1 (1): 1-2. .……. microsoft word 3. yasir iqbal maliktg 91 pak j ophthalmol. 2022, vol. 38 (2): 91-96 original article depressive illness in patients with eye disease, a hidden entity yasir iqbal1, aqsa malik2, waqas ahmad3, m. farooq4 1,3,4watim medical college, rawat rawalpindi, 2mohtarma benazir bhutto shaheed medical college, mirpur, ajk abstract purpose: to determine the frequency of depressive illness in patients presenting with ocular complaints. study design: observational cross sectional study, place and duration of study: watim medical college, rawat, rawalpindi, from october 2021 to november 2021. methods: all the patients presenting with ocular diseases and visiting were included in the study. patients were asked to complete an urdu translated version of patient health questionnaire (phq 9). inclusion criteria was patients more than 40 years of age, with ocular complaints and either gender. patients with age less than 40 years, mentally and physically handicapped, having a previous history of psychiatric disease, deaf and mute, any terminal, chronic or debilitating ocular or systemic disease were excluded. the results were analyzed and expressed with descriptive data in frequencies and the numerical data in average and standard deviations. chi square test of significance was applied taking p value of less than 0.05 as significant. results: a total of 537 patients (43.95% males and 56.05% females) were included. 60.71% of the participants were suffering from moderate to severe depression. among them 12.1% had moderately severe and 16.76% had severe depression. more females (19.55%) suffered from depression which required treatment than males (9.31%). conclusion: significant number of patients presenting with ocular complaints suffered from depression, which can affect or may be effected by the underlying ocular disease. the ophthalmologists should be aware of the entity and should take into account while treating the ocular disease. key words: eye, depression, dry eye disease how to cite this article: iqbal y, malik a, ahmad w, farooq m. depressive illness in patients with eye disease, a hidden entity. pak j ophthalmol. 2022, 38 (2): 91-96. doi: 10.36351/pjo.v38i2.1363 correspondence: yasir iqbal watim medical college, rawat, rawalpindi yazeriqbal@gmail.com received: december 27, 2021 accepted: march 20, 2022 introduction depression is defined as feeling of unhappiness or being irritable along with body and cognitive alterations lasting for 2 weeks and hindering the capability of a person to function normally.1 it has become exceedingly frequent so much so that who has declared depression as the 4th primary source of health problems and debilities.1 according to a research, it is estimated that 3.8% of the world population is affected with depression2 whereas in pakistan studies have estimated depression as high as 66% in women and 10% in men.3 depression often takes a chronic picture and can even occur at a comparatively young age leading to a deep influence on living style and personal health. furthermore, depression can directly or indirectly affect the onset, course and management of other systemic diseases.4 literature reports peak of depression incidences at the age of 44 to 65 years and older.5 so it can be assumed that the incidence of depression increases after the age of 45 years. similar to this, the incidences of eye diseases like presbyopia, cataract, glaucoma, dry eyes and age related macular degeneration etc also increase depressive illness in patients with eye disease, a hidden entity pak j ophthalmol. 2022, vol. 38 (2): 91-96 92 after the age of 45 years.6 therefore it can be hypothesized that depressive illness might be prevalent in patients with ocular diseases and the course of diseases might be affected by it or vice versa. during the past many years, psychiatric problems like depression have gained importance in health due to its increasing prevalence and its effects as a morbid and a disabling disease.7,8 the situation might be alarming for a country like pakistan in which such behavioral diseases are neither acknowledged nor addressed. in order to fill this gap, we conducted a study to determine prevalence of depression in patients with ocular complaints to determine the magnitude of the problem and to set a road map to determine the association of depression with ocular diseases. methods it was an observational cross sectional questionnaire based study conducted in the outdoor department of ophthalmology after approval from the institutional ethical review board. convenient consecutive sampling method was used to collect the data. sample size was calculated online using the website https:// www.calculator.net/sample-size-calculator, setting the confidence level at 95% and margin error of 5% and was found to be 385. a written informed consent was obtained from the patients before collecting their data with the assurance that their anonymity will be maintained and the principles of declaration of helsinki were followed. all the patients presenting with ocular symptoms/complains and diseases were included in the study. the inclusion criteria was patients with ocular complains above the age of 40 years and either gender. patients with age less than 40 years, mentally and physically handicapped, previous history of psychiatric disease, deaf and mute, any terminal, chronic or debilitating ocular or systemic disease were excluded from the study. those refusing consent, illiterate or not accompanied by attendant for helping/ understanding the language were also excluded from the study. at the initiation of the study, the patients were enquired about their gender and marital status and then were asked to complete an urdu translated version of patient health questionnaire (phq 9).9 this was later analyzed according to the key provided with phq 9. the phq-9 is reliable and validated module for detecting and grading depression which can score each of the 9 diagnostic and statistical manual of mental disorders. it is a very simple questionnaire in which patient gives answer is yes and no with options of “0” (not at all) to “3” (every day). the scoring of phq-9 (table 1) was done from the key provided with the questionnaire. the scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively (table 2). after completing the questionnaire, the patients under went complete eye examination including visual acuity assessment after refraction, slit lamp examination with intraocular pressure measurement with applanation tonometer and 90d retinal examination. the diagnosis was made accordingly and documented for later analysis. table 1: patient health questionnaire (phq-9). over the last 2 weeks, how often have you been bothered by any of the following problems? not at all several days more than half the days nearly every day 1. little interest or pleasure in doing things 0 1 2 3 2. feeling down, depressed, or hopeless 0 1 2 3 3. trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. feeling tired or having little energy 0 1 2 3 5. poor appetite or overeating 0 1 2 3 6. feeling bad about yourself – or that you are a failure or have let yourself or your family down 0 1 2 3 7. trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. moving or speaking so slowly that other people could have noticed? or the opposite – being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 adopted from kroenke k, spitzer rl, williams jb. the phq-9: validity of a brief depression severity measure. j gen intern med. 2001; 16 (9): 606-613. yasir iqbal, et al 93 pak j ophthalmol. 2022, vol. 38 (2): 91-96 table 2: guidelines to interpret phq 9 scores. guide for interpreting phq-9 scores score depression severity action 0 – 4 none-minimal patient may not need depression treatment. 5 – 9 mild use clinical judgment about treatment, based on patient’s duration of symptoms and functional impairment. 10 – 14 moderate use clinical judgment about treatment, based on patient’s duration of symptoms and functional impairment. 15 – 19 moderately severe treat using antidepressants, psychotherapy or a combination of treatment. 20 – 27 severe treat using antidepressants with or without psychotherapy. (adopted from kroenke k, spitzer rl, williams jb. the phq-9: validity of a brief depression severity measure. j gen intern med. 2001; 16 (9): 606-613.). the results were analyzed using spss version 0.8.3 software while expressing descriptive data in frequencies and the numerical data in average and standard deviations. chi square test of significance was applied while taking p value of less than 0.05 as significant. results a total of 537 patients participated in the study. there were 43.95% males with mean age of 55 ± 13.32 years and 56.05% females with mean age of 59 ± 15.22 years. among them, 82.3% participants were married, 8.38% were divorced and 7.82% were widow. we divided the patients according to the age group i (41 – 50 years), group ii (51 to 60 years), group iii (61 to 70 years) and group iv (71 and above). it was also found that 22.52% participants who had moderate to severe depression belonged to 61 – 70 years age group. on evaluating the phq 9 questionnaire score according to the key we found that 60.71% of the participants were suffering from moderate to severe depression. among them 12.1% had moderately severe and 16.76% had severe depression (table 3). we also found that 19.55% of females suffered from depression requiring treatment (use of antidepressants, psychotherapy or a combination of treatment) whereas this figure was 9.31% in males. when severity of depression was compared to the marital status, it was found that severe depression was present in 12.29% married people, 2.05% in widows and 1.12% in widowers. (chi square test of significance x2 (1, n = 537) =36.40. = .000) (table 4) the most common ocular complaints among the participants were blurred vision in 45.43% and headache in 35.93%.watery and itchy eyes was complained by 13.59% and complete loss of vision by 3.09% (table 5). table 3: gender wise distribution of depression. severity of depression gender total male female (n = 537) none/minimal 20.11% 19.18% 39.29% mild 9.87% 9.31% 19.18% moderate 4.66% 8.01% 12.67% moderately severe 3.91% 8.19% 12.1% severe 5.4% 11.36% 16.76% chi square test of significance x2 (1, n = 537) = 16.87 = 0.002 table 4: relationship of marital status with severity of depression. marital status severity of depression nonminimal mild moderate moderately severe severe married 34.08% 16.95% 9.87% 9.12% 12.29% divorced 3.17% 1.12% 1.12% 1.68% 1.3% widow 2.05% 0.56% 1.68% 1.3% 2.05% widower 0 0.56% 0 0 1.12% (n = 537) (chi square test of significance x2 (1, n = 537) =36.40. = .000) table 5: presenting ocular complaints of the participants. gender male female total (n = 537) blurred vision 21.97% 23.46% 45.43% headache 17.5% 18.43% 35.93% watery/itchy eyes 8.75% 4.84 % 13.59% loss of vision 1.86% 2.23% 3.09% red eye 0.55% 0.37% 0.92% discussion depression has become a global burden on the health care system (prevalent in 2.8 – 7.3% of the general depressive illness in patients with eye disease, a hidden entity pak j ophthalmol. 2022, vol. 38 (2): 91-96 94 population).10 it has a relatively chronic course and seemingly can occur in any age group. it influences living style of the individual, the general well being of the patient and affects other systemic diseases but is largely undetected by medical practitioners. depressive illness in patients with ocular diseases has been explored by some researchers with different results. they have reported prevalence from 5.4% to 57% in different settings.11,12 in our study we detected moderate to severe depression in 60.71% of the patients. a similar screening done in australia on patients attending an eye care service found depression in 37%.13 nollett c et al14 reported significant depressive symptoms in 43% of patients in the united kingdom. the findings varied among the studies probably because of the difference in depression measuring tools. there are more than 100 depressionmeasuring tools, most of these being selfadministrable. we used phq 9 a validated module for detecting and grading depression which can score each of the 9 diagnostic and statistical manual of mental disorders. it suits the ophthalmology practice where primary focus is eye examination in a limited time.15 we found a gender association in the prevalence of depression (19.55% female vs. 9.31% male). this is similar to already reported literature that females tend to suffer more from depression compared to males.16 altaf a et al17 also found that depressed females were more in number than males. holloway et al13 reported the same but nollett c et al14 found no conclusive evidence of linking depression and gender. we found most of the elderly patients suffered from depression in accordance to the findings of minallah a.18 altaf a et al17 found that higher frequency of depression was found in individual survivors (both widows and widowers) but our findings were on the contrary. we found severe depression in 12.29% married people, 2.05% in widows and 1.12% in widowers whereas minallah a18 reported a maximum depression rate (100%) in divorced individuals. depression and visual impairment go side by side. depression can alter vision and can cause visual alterations like seeing floaters, tunnel vision, altered contrast perception, increased light sensitivity and blurred vision. similarly, in visually impaired individuals depression is common. in our study, the most common ocular complaint was blurred vision in 45.43% and headache in 35.93%. nollett c et al14 found a strong association between vision deterioration and depression and concluded that visual deteriorated individuals were 2 – 3 times more prone to develop depression. similarly, zheng y19 reported that depression was in 25% of patients with glaucoma, 24% of age-related macular degeneration and 23% of cataract patients. in the circuitry of vision, dopamine plays an important role and deeply affects vision. it is responsible for night vision, contrast sensitivity as well as the visual acuity.20,21 dry eye disease is associated with numerous factors including female gender, increasing biological age, environmental effects, autoimmune diseases, prolonged contact lens usage and medications (both topical and systemic). the symptoms of dry eyes are burning, watering, itching and foreign body sensation in the eyes and many researchers have found an association between the two diseases. we had 13.59% patients with depression complaining of watery and itchy eyes. zheng y19 reported depression in 29% of cases with dry eye disease whereas al-dairi w et al22 reported 42% in his study. in contrast to this yilmaz et al23 reported that individuals who suffer from depression are more inclined to develop dry eye disease. the reason of this strong association might be serotonin. serotonin receptors are present around the epithelium of the eye which are affected by the pathway of depressive illness or it is vice versa.24 this study is not without limitations. even though the sample size was large enough, it did not take into account certain variables like socioeconomic background, ethnicity and educational level. furthermore, the data is based upon a particular part of the city and cannot be applied to the whole population. we also did not take into account patients having a concurrent disease with the primary ocular disease but the strength of the study is that we included patients who were not on any psychiatric or other medication and the patients did not have morbid disease beforehand. therefore, this study will provide a guide map to find further association of eye diseases and depressive illness. conclusion we found that a significant number of patients presenting with ocular complaints suffered from depression. the ophthalmologists should be aware of this entity and should take it into account while treating the ocular diseases. yasir iqbal, et al 95 pak j ophthalmol. 2022, vol. 38 (2): 91-96 ethical approval the study was approved by the institutional review board/ ethical review board (4/erb/july/2021). conflict of interest authors declared no conflict of interest. references 1. mukeshimana m, chironda g. depression and associated factors among the patients with type 2 diabetes in rwanda. ethiop j health sci. 2019; 29 (6): 709-718. doi: 10.4314/ejhs.v29i6.7. 2. global burden of disease study 2019 (gbd 2019) data resources. institute for health metrics and evaluation. http://ghdx.healthdata.org/gbd-2019. accessed 23rd january 2022. 3. husain n, creed f, tomenson b. depression and social stress in pakistan. psychol med. 2000; 30 (2): 395-402. doi: 10.1017/s0033291700001707. 4. goh zs, griva k. anxiety and depression in patients with end-stage renal disease: impact and management challenges a narrative review. int j nephrol renovasc dis. 2018; 11: 93-102. doi: 10.2147/ijnrd.s126615. 5. snowdon j. how high is the prevalence of depression in old age? braz j psychiatry, 2002; 24: 42-47. 6. xiao z, wu w, zhao q, liang x, luo j, ding d. association of glaucoma and cataract with incident dementia: a 5-year follow-up in the shanghai aging study. j alzheimers dis. 2020; 76 (2): 529-537. doi: 10.3233/jad-200295. 7. bitar ms, olson dj, li m, davis rm. the correlation between dry eyes, anxiety and depression: the sicca, anxiety and depression study. cornea, 2019; 38 (6): 684-689. 8. vu kv, mitchell p, dharamdasani detaram h, burlutsky g, liew g, gopinath b. prevalence and risk factors for depressive symptoms in patients with neovascular age-related macular degeneration who present for anti-vegf therapy. acta ophthalmologica. 2021; 99 (4): e547-554. 9. urtasun m, daray fm, teti gl, coppolillo f, herlax g, saba g, et al. validation and calibration of the patient health questionnaire (phq-9) in argentina. bmc psychiatry, 2019; 19 (1): 1-0. 10. lépine jp, briley m. the increasing burden of depression. neuropsychiatr dis treat. 2011; 7 (suppl 1): 3-7. doi: 10.2147/ndt.s19617. 11. van der aa hp, comijs hc, penninx bw, van rens gh, van nispen rm. major depressive and anxiety disorders in visually impaired older adults. invest ophthalmol vis sci. 2015; 56 (2): 849-854. 12. kong x, yan m, sun x, xiao z. anxiety and depression are more prevalent in primary angle closure glaucoma than in primary open-angle glaucoma. j glaucoma, 2015; 24 (5): e57-63. doi: 10.1097/ijg.0000000000000025. 13. holloway ee, sturrock ba, lamoureux el, keeffe je, rees g. depression screening among older adults attending low-vision rehabilitation and eye-care services: characteristics of those who screen positive and client acceptability of screening. australas j ageing, 2015; 34 (4): 229-234. doi: 10.1111/ajag.12159. 14. nollett c, ryan b, bray n, bunce c, casten r, edwards rt, et al. depressive symptoms in people with vision impairment: a cross-sectional study to identify who is most at risk. bmj open, 2019; 9 (1): e026163. doi: 10.1136/bmjopen-2018-026163. 15. lamoureux el, tee hw, pesudovs k, pallant jf, keeffe je, rees g. can clinicians use the phq-9 to assess depression in people with vision loss? optom vis sci. 2009; 86 (2): 139-145. doi: 10.1097/opx.0b013e318194eb47. 16. schoevers ra, deeg dj, van tilburg w, beekman at. depression and generalized anxiety disorder: cooccurrence and longitudinal patterns in elderly patients. am j geriatr psychiatry, 2005; 13 (1): 31-39. doi: 10.1176/appi.ajgp.13.1.31. 17. altaf a, khan m, shah sr, fatima k, tunio sa, hussain m, et al. sociodemographic pattern of depression in urban settlement of karachi, pakistan. j clin diag res. 2015; 9 (6): vc09. 18. minallah a, azam n, merani i. frequency of depression with associated risk factors among elderly in two tertiary care hospitals in rawalpindi. pak armed forces med j. 2019; 69 (suppl 2): 17-21. 19. zheng y, wu x, lin x, lin h. the prevalence of depression and depressive symptoms among eye disease patients: a systematic review and metaanalysis. sci rep. 2017; 7: 46453. doi: 10.1038/srep46453. 20. jackson cr, ruan gx, aseem f, abey j, gamble k, stanwood g, et al. retinal dopamine mediates multiple dimensions of light-adapted vision. j neurosci. 2012; 32 (27): 9359-9368. doi: 10.1523/jneurosci.0711-12.2012. 21. grace aa. dysregulation of the dopamine system in the pathophysiology of schizophrenia and depression. nat rev neurosci. 2016; 17 (8): 524-532. doi: 10.1038/nrn.2016.57. 22. al-dairi w, al sowayigh om, alkulaib ns, alsaad a. the relationship of dry eye disease with depression in saudi arabia: a cross-sectional study. cureus, 2020; 12 (12): e12160. doi: 10.7759/cureus.12160. depressive illness in patients with eye disease, a hidden entity pak j ophthalmol. 2022, vol. 38 (2): 91-96 96 23. yilmaz u, gokler me, unsal a. dry eye disease and depression-anxiety-stress: a hospital-based case control study in turkey. pak j med sci. 2015; 31 (3): 626-631. doi: 10.12669/pjms.313.7091. 24. weatherby tjm, raman vrv, agius m. depression and dry eye disease: a need for an interdisciplinary approach? psychiatr danub. 2019; 31 (suppl. 3): 619621. authors’ designation and contribution yasir iqbal; professor: concepts, design, manuscript preparation, manuscript editing, manuscript review. aqsa malik; assistant professor: literature search, data analysis, statistical analysis, manuscript preparation. waqas ahmad; optometrist: data acquisition, data analysis, manuscript preparation. m. farooq; associate professor: concepts, design, literature search, statistical analysis, manuscript editing, manuscript review. .……. pak j ophthalmol. 2022, vol. 38 (1): 9-15 9 original article intraocular pressure control after trabeculectomy with adjunctive use of mitomycin-c versus bevacizumab: a hospital based study p. s. mahar 1 , sobia tabassum 2 , mujahid inam 3 , muhammad faaz malik 4 , tauseef mahmood 5 1-5 isra postgraduate institute of ophthalmology, karachi abstract purpose: to compare the control of intra ocular pressure (iop) after trabeculectomy with adjunctive use of mitomycin–c (mmc) versus bevacizumab. study design: quasi experimental study. place and duration of study: al-ibrahim eye hospital, isra postgraduate institute of ophthalmology, karachi, from august 2017 to august 2019. methods: one hundred and six patients of either gender, fulfilling the inclusion criteria were planned for trabeculectomy with adjunctive use of mitomycin-c (mmc) or bevacizumab. each group consisted of 53 patients (53 eyes). the patients diagnosed with primary open angle glaucoma (poag) with iop ˃ 21 mm hg and not controlled with topical anti-glaucoma medication were selected. data were analyzed by using spss version 22.0. independent sample t test was used to check significance between two drugs. paired sample t test was used to check significance of pre and post-operative iop. results: mean age of patients was 56.67±7.34 years. mean preoperative iop was 31.51 ± 9.66 mm hg in mmc group and 29.21 ± 7.69 mm hg in bevacizumab group. at first postoperative day, mean iop after use of mmc was 14.75 ± 9.46 mm hg and for bevacizumab was 15.07 ± 6.47 mm hg (p-value 0.001). similarly, at one year follow-up, mean iop for mmc group was 11.26 ± 2.31 mm hg and for bevacizumab was 11.73 ± 2.12 mm hg (p-value 0.001). conclusion: there was significant reduction in iop in both mmc and bevacizumab groups. however, the difference between the two groups was not statistically significant at mean follow-up of one year. key words: primary open angle glaucoma, mitomycin–c, intraocular pressure, bevacizumab, trabeculectomy. how to cite this article: mahar ps, tabassum s, inam m, malik mf, mahmood t. intraocular pressure control after trabeculectomy with adjunctive use of mitomycin-c versus bevacizumab: a hospital based study. pak j ophthalmol. 2022, 38 (1): 9-15. doi: 10.36351/pjo.v38i1.1335 correspondence: p. s. mahar department of ophthalmology isra postgraduate institute of ophthalmology karachi email: salim.mahar@aku.edu received: september 22, 2021 accepted: december 12, 2021 introduction glaucoma is a vision-threatening condition characterized by progressive optic neuropathy and visual field loss with raised intraocular pressure (iop) in majority of the patients. there were 60.5 million people with glaucoma worldwide in 2010 and it is was estimated that this number would be more than 79.6 million people by 2020. 1 trabeculectomy was introduced by cairns in 1968 and is considered to be open access p. s. mahar, et al 10 pak j ophthalmol. 2022, vol. 38 (1): 9-15 the gold standard to reduce iop in patients with pharmacologically uncontrolled iop. 2 failure of trabeculectomy is associated with postoperative scarring of conjunctiva and tenon capsule at the site of filtering bleb due to inflammatory response associated with healing. 3 this inflammatory response includes fibroblasts migration and proliferation leading to formation of adhesions between epi-sclera and conjunctiva, decreasing aqueous outflow with a resultant increase in iop. 4 to overcome this problem, several antimetabolites like mitomycin-c and 5flurouracil have been used. these are antifibrotic agents that have been used successfully in trabeculectomy to delay the wound healing process. however, due to inconsistent findings in terms of iop control, there has been need for further studies. 5-7 mitomycin c (kowa, japan) is an antineoplastic/ antibiotic agent isolated from soil bacterium streptomyces caespitosus. it inhibits the fibroblast proliferation by acting as a deoxyribonucleic acid cross-linker. it is used in medicine as a chemotherapeutic agent in treatment of a variety of cancers. its use in glaucoma filtration surgery is a common practice because of its modulatory effects on wound healing. 8 chen et al. used mmc in patients with refractory glaucoma with successful outcome in control of iop. since then it is routinely used in trabeculectomy. mmc inhibits the postoperative episcleral fibrosis thus enhancing the successful outcome regarding the control of iop. 9 vascular endothelial growth factor (vegf) is a cytokine with multiple effects on wound healing. it stimulates the scar formation through collagen deposition, angiogenesis and epithelialization. vegf has been shown to be elevated in glaucoma patients and is suggested that it might be playing a role in the scar formation after filtering surgery. bevacizumab (avastin, roche pakistan) is a full-length humanized monoclonal antibody that binds to all isoforms of vegf. it has been approved by the us food and drug administration for intravenous treatment of metastatic colorectal cancer. it is used off label in various choroidal and retinal vascular disorders universally. there has been some evidence that it reduces filtering bleb failure after sub-conjunctival injections. 10 multiple publications in literature has suggested different results with the use of bevacizumab in trabeculectomy. akkan and colleagues conducted a study in turkey and found that post-operative iop target was achieved in 71% of eyes in mmc group while 33% success in patients in bevacizumab group (p = 0.02), at 12 months follow-up. 11 nilforushan et al. reported a study from iran where they found statistically significant difference in iop control between the two groups; 34% in bevacizumab and 56% in mmc group (p = 0.32) 12 . sengupta and coworkers however reported that bevacizumab group had better success rate than mmc group (90% versus 60%; p = 0.04). 13 as there is limited number of studies on bevacizumab use in glaucoma filtering surgery with inconsistent findings, we conducted this prospective study to compare the frequency of controlled iop after trabeculectomy with the adjunctive use of mmc and bevacizumab. the primary end-point was control of iop of ˃18 mm hg without any added anti-glaucoma drug or 30% reduction in iop from baseline at oneyear follow-up. the secondary outcomes were; associated adverse effects with each drug and any change in visual acuity. we also evaluated the bleb morphology in both drugs. methods this study was carried out in glaucoma department of al-ibrahim eye hospital/isra postgraduate institute of ophthalmology, karachi from august 2017 to august 2019. the study commenced after clearance from the hospital research ethical committee and was carried out in accordance with declaration of helsinki. sample size was calculated with open epi sample calculator, using success of 94.4% of mmc group with 95% confidence interval and 5% margin of error. 12 the final sample size was 106 patients with 53 patients in mmc group and 53 patients in the bevacizumab group. patients were divided by non-probability consecutive sampling. all participants were given information about the study and an informed consent was taken. patients > 40 years of age and having a diagnosis of primary open angle glaucoma (poag) with intraocular pressure (iop) of more than 21 mmhg, uncontrolled medically and having glaucomatous optic disc cupping were included in the study. we excluded patients with angle closure glaucoma, secondary glaucoma, corneal diseases, uveitis (or history of uveitis) and with a history of any intraocular surgery. a detailed history was taken from all patients regarding any comorbids, ocular trauma, antiglaucoma medications with dosage and duration. intraocular pressure control after trabeculectomy with adjunctive use of mitomycin-c versus bevacizumab: a hospital based study pak j ophthalmol. 2022, vol. 38 (1): 9-15 11 patients were also inquired about any addiction and family history of glaucoma. before surgery, all patients had detailed ocular examination including best-corrected visual acuity (bcva), slit lamp bio-microscopic examination of anterior segment with recording of iop using goldman applanation tonometer (gat). gonioscopy was performed using goldman two-mirror lens. dilated fundus examination was carried out with +90 diopter volk lens. every patient had visual field examined on humphrey field analyzer, central corneal thickness (cct) was determined and optical coherence tomography (oct) was performed for retinal nerve fiber layer (rnfl) thickness and macular analysis. pre-operative blood pressure and blood sugar of all the patients were recorded. intravenous mannitol 1gram/kg body weight was given 1 hour before surgery whenever required. pupil was miosed preoperatively with single drop of pilocarpine 2% to prevent lens damage and to facilitate peripheral iridectomy. all surgeries were performed using retrobulbar 2% xylocaine local anesthesia. surface anesthesia was achieved with topical proparacaine drops (alcaine – alcon, belgium). the operated eye was prepped and draped. each patient underwent a fornix-based trabeculectomy. a 6/0 vicryl traction suture was inserted onto superior cornea. a fornix based flap of conjunctiva and tenon capsule was fashioned superiorly. episcleral tissue was cleared and major vessels cauterized with wet-field bipolar cautery. incision was made for 50% scleral thickness, to create a trapdoor lamellar scleral flap. the flap was triangular in shape of about 4 × 4 mm. in group one, mitomycinc was applied in sponge form on sclera and under the scleral flap for 3 minutes duration and then washed with 20 ml of balanced salt solution (bss) for 30 seconds. paracentesis was done on temporal side and anterior chamber was maintained with 1% sodium hyaluronate viscoelastic (provisc – alcon, belgium). a peripheral iridectomy was performed and corneoscleral block was removed measuring about 1 × 1 mm. scleral flap and conjunctiva were closed with 10/0 nylon sutures. in patients receiving bevacizumab, same steps were taken for trabeculectomy without using mmc soaked sponges. however, at the end of procedure, 0.1 ml (2.5 mg) of bevacizumab was taken in 1 ml syringe with 30 gauge needle. the needle was introduced sub-conjunctively away from the scleral flap site and forwarded over the flap with deposition of the drug. the point of needle entry was pressed with cotton applicator to avoid reflux of the drug. our postoperative treatment regimen included moxifloxacin 0.3 % drops (vigamox – alcon, belgium) every hour for first 24 hours, 2 hourly for next 3 days followed by 4 times a day for 4 weeks. we used dexamethasone 0.1% drops (maxidex – alcon, belgium) every hour for 24 hours, 2 hourly for 4 weeks, then 4 times a day for another 6 weeks. all patients were examined on day 1, one week, 4 weeks, 3 months, 6 months and 12 months postoperatively. data were analyzed by using spss version 22.0. mean and standard deviation was calculated for quantitative variables like age and iop (pre and post treatment). frequencies with percentages were presented for qualitative variables like complications, gender and type of glaucoma. independent sample t test was used to check significance between two drugs. paired sample t test was used to check significance of pre and post-operative iop. results a total of 106 patients (106 eyes) including 63 (59.43%) male and 43 (40.56%) female were recruited in the study. mean age of the patients was 56.67 ± 7.34 years (range 40–70 years). patients were divided into two groups based on drug prescribed by an ophthalmologist. nine patients in mmc group and eleven patients in bevacizumab group were lost to followup at the end of 1 year. therefore, 44 patients in mmc group and 42 patients in bevacizumab group were available for the final analysis. pre-operatively mean iop in mmc group was 31.51 ± 9.66 mm hg. this was reduced to 11.26 ± 2.31 mm hg at one-year postoperatively with a pvalue of 0.001. in bevacizumab group, preoperatively mean iop was recorded as 29.21 ± 7.69 mm hg and was dropped to 11.73 ± 2.12 mm hg at one-year follow-up with a p-value 0.001 respectively (table 1). at day 1, 41 (77.3%) out of 53 patients had controlled iop ( ˃ 18 mm hg) in mmc group. while after the use of bevacizumab, frequency of controlled iop of ˃ 18 mm hg was noticed in 48 (90.56%) patients at first day post-operatively. similarly, at one year, all 44 (100%) patients who completed follow-up had iop of ˃ 18 mm hg after the use of mmc. p. s. mahar, et al 12 pak j ophthalmol. 2022, vol. 38 (1): 9-15 whereas in case of bevacizumab, all attended 42 (100%) patients had controlled iop (table 2). table 1: post-operative comparison of mean iop between mitomycin – c & bevacizumab groups mmc group bevacizumab group iop mean p-value mean p-value pre op iop 31.51 ± 9.66 − 29.21 ± 7.69 first day 14.75 ± 9.46 0.001 15.07 ± 6.47 0.001 sixth week 14.90 ± 7.84 0.001 16.27 ± 6.59 0.001 third month 13.73 ± 7.18 0.001 15.02 ± 6.15 0.001 sixth month 12.06 ± 3.95 0.001 12.87 ± 3.68 0.001 one year 11.26 ± 2.31 0.001 11.73 ± 2.12 0.001 *iop = intraocular pressure *mmc = mitomycin c comparative analysis of iop reduction in both groups after trabeculectomy is given in table 3 and figure 1. mean postoperative bcva (log mar) was 0.68 + 0.40 and 0.63 + 0.41 in mmc and bevacizumab groups respectively at first day postoperatively with no significant difference. (p-value 0.538). whereas at one-year follow-up, mean postoperative bcva (log mar) was 0.50 + 0.39 and 0.38 + 0.27 in mmc and bevacizumab groups respectively with significant difference (p-value 0.01) (table 4) regarding bleb morphology, 28 (52.8%) and 35 (66.03%) patients had elevated bleb for mmc and bevacizumab group at day 1 postoperatively. similarly, at one-year follow-up, 42 (79.24%) and 39 (73.58%) patients had elevated bleb in mmc and bevacizumab groups respectively. at first day postoperatively, 48 (90.56%) and 51 (96.22%) patients had vascularized bleb for mmc and bevacizumab, respectively. however, at one-year follow-up, only 8 (15.09%) and 15 (28.30%) patients had vascularized bleb for mmc and bevacizumab group. needling was done in one case 1 (1.88%) in both mmc and bevacizumab groups at third month post operatively. suture lysis with argon laser was carried out at 6 weeks postoperatively in 13 (24.5%) and 16 (30.1%) patients in mmc and bevacizumab groups. at first day post operatively, hyphema was observed in 2 (3.77%) eyes in mmc group and none in bevacizumab group. hyphema was transient and disappeared in next 3 days without any added treatment. similarly, 10 (18.8%) and 4 (7.54%) patients had flat anterior chamber for mmc and bevacizumab group at first day postoperatively. two patients in mmc group developed hypotomy (iop ˃6 mm hg) after 3 months of surgery. one patient in each group had conjunctival leak postoperatively. all these complications resolved conservatively without any added procedure. table 2: comparison of controlled iop after use of mmc and bevacizumab post-operatively. post-operative follow-ups mmc group bevacizumab group iop controlled < 18 iop uncontrolled > 21 patients come on followup iop controlled < 18 iop uncontrolled > 21 patients come on followup iop at 1st day 41 (77.35%) 12 (22.64%) 53 (100%) 48 (90.56%) 5 (9.43%) 53 (100%) iop at 6th week 42 (80.76%) 10 (19.23%) 52 (100%) 42 (82.35%) 9 (17.64%) 51 (100%) iop at 3rd month 43 (87.75%) 6 (12.24%) 49 (100%) 45 (91.83%) 4 (8.16%) 49 (100%) iop at 6th month 46 (95.83%) 2 (4.16%) 48 (100%) 47 (95.91%) 2 (4.08%) 49 (100%) iop at one year 44 100%) 0 (0%) 44 100%) 42 100%) 0 (0%) 42 (100%) *iop = intraocular pressure *mmc = mitomycin c table 3: pre and postoperative changes in mean iop in mitomycin – c versus bevacizumab groups. intraocular pressure mitomycin c bevacizumab pvalue first day 14.75 ± 9.46 15.07 ± 6.47 0.839 sixth week 14.90 ± 7.84 16.27 ± 6.59 0.340 third month 13.73 ± 7.18 15.02 ± 6.15 0.076 sixth month 12.06 ± 3.95 12.87 ± 3.68 0.293 one year 11.26 ± 2.31 11.73 ± 2.12 0.364 *intraocular pressure *mmc = mitomycin c figure i: mean iop comparison between mitomycin – c and bevacizumab. *iop = intraocular pressure *mmc = mitomycin c intraocular pressure control after trabeculectomy with adjunctive use of mitomycin-c versus bevacizumab: a hospital based study pak j ophthalmol. 2022, vol. 38 (1): 9-15 13 table 4: post-operative mean changes in bcva (logmar) between mmc and bevacizumab. bcva mmc bevacizumab p-value first day 0.68 ± 0.40 0.63 ± 0.41 0.538 sixth week 0.57 ± 0.41 0.42 ± 0.35 0.067 third month 0.51 ± 0.36 0.36 ± 0.29 0.034 sixth month 0.51 ± 0.36 0.35 ± 0.23 0.01 one year 0.50 ± 0.39 0.38 ± 0.27 0.01 *iop = intraocular pressure *mmc = mitomycin c *bcva = best corrected visual acuity discussion the main cause of failure of trabeculectomy is excessive postoperative conjunctival scarring at the site of filtering bleb due to inflammatory reaction. to overcome this problem, several antimetabolites like 5 – fluorouracil and mmc had been used successfully with filtration surgery. over last few years, anti-vegf agents such as bevacizumab has been introduced as a potent adjunct in trabeculectomy with good outcome in control of iop. the fibroblasts of tenon capsule, which produce collagen and elastin are the most important mediators of ocular scar formation after filtration surgery. various in vitro studies have shown effectiveness of anti-vegf agent on corneal and conjunctival fibroblast. 14-15 in this particular study, we compared iop control after trabeculectomy with the adjunctive use of mmc and bevacizumab. we report a significant reduction of iop in both groups at one year (p = 0.001), with a reduction in iop values of about 83% and 79% respectively. both the groups were comparable in terms of iop control at one year. in terms of bleb characteristics, we noticed increase in bleb vascularity in bevacizumab group as compared to mmc group i.e., 34% and 19%, at one year followup. postoperative complication rates were slightly higher in mmc group, although statistically not significant. there was no difference in number of anti-glaucoma medications required at one year after surgery between the two groups. kahook et al. reported that bevacizumab prevented excessive scar formation after needle bleb revision in failed trabeculectomy, a finding similar to our study. 16 a study conducted by sengupta et al. showed that sub-conjunctival bevacizumab was equally effective in reducing iop, with a better safety profile compared with mmc. the mean iop was 16.2 ± 4.3 mm hg in their patients receiving mmc and 16.2 ± 3.7 mm hg in bevacizumab group at six months follow-up. 13 grewal et al. reported on the efficacy of a single postoperative injection of 1.25 mg/ 0.05 ml of bevacizumab in 12 glaucomatous eyes that underwent trabeculectomy. 17 their findings showed a reduction in mean iop from 24.4 mm hg to 11.6 mmhg (52%) at six months’ follow-up. in another study conducted by jaya kaushik and associates, adjunctive bevacizumab in trabeculectomy was found to be effective and comparable to mmc for controlling iop in poag patients at one-year followup (p = 0.43). however, there was statistically significant difference in peripheral bleb vascularity with bevacizumab group exhibiting a low degree of vascularity at one year (p = 0.029). 18 this finding is different from our study where we found increased bleb vascularity in bevacizumab group at one year. akkan et al. showed the frequency of iop control after one year in 41% and 46% of their patients receiving bevacizumab and mmc, respectively. 11 nilforushan et al, reported that 2.5 mg/0.1 ml subconjuctival bevacizumab application after primary trabeculectomy provided effective iop control, but when compared to the mmc administered group, it was less effective. 12 they observed a 56% fall of iop in the mmc group, and 34% in the bevacizumab group, after an average followup of 7 months. however, this study had a small sample size and short follow-up period that may be the reason for findings different from our study. xiaoyan liu and associates found that bevacizumab was an effective adjunct in trabeculectomy concerning the complete success rate, iop and anti-glaucoma medications reduction when compared with placebo. however, its use increased the risk of bleb leakage and encysted bleb formation compared with mmc. 19 this study had a shorter follow-up period of six months that may explain findings different from our study. kopsinis et al compared the effects of intracameral bevacizumab to sub tenon mitomycin c in trabeculectomy. they concluded that average iop and glaucoma medications decreased significantly in both groups at all follow-up points compared to baseline (p < 0.001), without significant difference between groups at 3 years. 20 bilgic et al, compared the outcomes of trabeculectomy using two different routes of bevacizumab administration as an adjunct in patients with primary open angle glaucoma. a significant reduction was observed in the iop post trabeculectomy in all patients in both groups (paired tp. s. mahar, et al 14 pak j ophthalmol. 2022, vol. 38 (1): 9-15 test, p < 0.001, both groups), a change that had persisted at one-year follow-up. 21 another report found that bevacizumab along with mitomycin c in trabeculectomy was not superior to trabeculectomy with mitomycin c or trabeculectomy with mitomycin c and intracameral bevacizumab. however, both groups showed a statistically significant reduction in iop after 6 and 12 months (p-0.001). 22 nadeem s, published her work of 30 patients who underwent trabeculectomy with adjunctive use of 5 – fluorouracil (5 – fu) applied topically for 5 minutes. in half of the eyes, bevacizumab was injected over scleral flap at the end of the procedure. after 3 months follow-up, iop control and bleb appearance was indifferent between the two groups. the author concluded no added benefit of sub-conjunctival bevacizumab. 23 limitations of our study are that 9 patients lost to follow-up in mmc group and 11 in bevacizumab group at the end of one year. secondly, followup was limited to one year. however, this study is a significant contribution to the available literature regarding glaucoma, particularly in pakistan. conclusion adjunctive use of mitomycin-c (mmc) or bevacizumab with trabeculectomy are equally effective in reducing iop in patients with diagnosis of primary open angle glaucoma. though, vascularity of bleb was slightly increased in bevacizumab group as compared to mmc group at one year followup, whereas postoperative complications were slightly lower in bevacizumab group. these findings were statistically not significant. acknowledgment this study is supported by a research grant from ophthalmological society of pakistan (osp). ethical approval the study was approved by the institutional review board/ethical review board (a-00093). conflict of interest authors declared no conflict of interest. references 1. quigley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006; 90: 262–67. 2. cairns je. trabeculectomy. preliminary report of a new method. am j ophthalmol. 1968; 66: 673-8. 3. skuta gl, parrish rk. wound healing in glaucoma filtering surgery. surv ophthalmol. 1987; 32: 149–70. 4. addicks em, quigley ha, green wr, robin al. histologic characteristics of filtering blebs in glaucomatous eyes. arch ophthalmol. 1983; 101: 795– 98. 5. greenfield ds, suner ij, miller mp, kangas ta, palmberg pf, flynn hw jr. endophthalmitis after filtering surgery with mitomycin. arch ophthalmol 1996; 114: 943–949. 6. jurkowska-dudzinska j, kosior-jarecka e, zarnowski t. comparison of the use of 5-fluorouracil and bevacizumab in primary trabeculectomy: results at 1 year. clin experiment ophthalmol. 2012; 40 (4): e135–42. doi: 10.1111/j.1442-9071.2011.02608.x. 7. hollo g. wound healing and glaucoma surgery: modulating the scarring process with conventional antimetabolites and new molecules. dev ophthalmol. 2012; 50: 79–89. 8. wilkins m, indar a, wormald. intra-operative mitomycin – c in c for glaucoma surgery. syst rev. 2001; 2 (2): 28-97. 9. chen cw, huang ht, bair js, lee cc. trabeculectomy with simultaneous topical application of mitomycin – c in refractory glaucoma. j ocul pharmacol. 1990; 6 (3): 175-182. 10. cheng jw1, cheng sw, wei rl, lu gc. antivascular endothelial growth factor for control of wound healing in glaucoma surgery. cochrane database syst rev. 2016; 1: cd009782. doi: 10.1002/14651858.cd009782.pub2. 11. akkan ju, cilsim s. role of subconjunctival bevacizumab as an adjuvant to primary trabeculectomy: a prospective randomized comparative 1-year follow-up study. j glaucoma, 2015; 24 (1): 1-8. 12. nilforushan n, yadgari m, kish sk, nassiri n. subconjunctival bevacizumab versus mitomycin c adjunctive to trabeculectomy. am j ophthalmol. 2012; 153: 352–57. 13. sengupta s, venkatesh r, ravindran rd. safety and efficacy of using off-label bevacizumab versus mitomycin c to prevent bleb failure in a single-site phacotrabeculectomy by a randomized controlled clinical trial. j glaucoma, 2012; 21 (7): 450-9. doi: 10.1097/ijg.0b013e31821826b2. intraocular pressure control after trabeculectomy with adjunctive use of mitomycin-c versus bevacizumab: a hospital based study pak j ophthalmol. 2022, vol. 38 (1): 9-15 15 14. wilgus ta, ferreira am, oberyszyn tm, bergdall vk, dipietro la. regulation of scar formation by vascular endothelial growth factor. lab invest. 2008; 88 (6): 579-90. doi: 10.1038/labinvest 2008.36. epub 2008 apr 21. pmid: 18427552; pmcid: pmc2810253. 15. li z, van bergen t, van de veire s, van de vel i, moreau h, dewerchin m. et al. inhibition of vascular endothelial growth factor reduces scar formation after glaucoma filtration surgery. invest ophthalmol vis sci. 2009; 50 (11): 5217-25. 16. kahook my, schuman js, noecker rj. needle bleb revision of encapsulated bleb with bevacizumab. ophthalmic surg laser imaging, 2006; 37: 148-50. 17. grewal ds, jain r, kumar h, grewal sp. evaluation of subconjuctival bevacizumab as an adjunct to trabeculectomy: a pilot study. ophthalmology, 2008; 115 (12): 2141-2145. e2. doi: 10.1016/j.ophtha.2008.06.009. epub 2008 aug 9. pmid: 18692246. 18. kaushik j, parihar jk, jain vk, gupta s, nath p, durgapal p, et. al. efficacy of bevacizumab compared to mitomycin c modulated trabeculectomy in primary open angle glaucoma: a one-year prospective randomized controlled study. curr eye res. 2017; 42 (2): 217-224. doi: 10.3109/02713683.2016.1164188. epub 2016 jun 7. pmid: 27269279. 19. liu x, du l, li n. the effects of bevacizumab in augmenting trabeculectomy for glaucoma: a systematic review and meta-analysis of randomized controlled trials. medicine (baltimore). 2016; 95 (15): e3223. doi: 10.1097/md.0000000000003223. pmid: 27082560; pmcid: pmc4839804. 20. kopsinis g, tsoukanas d, kopsini d, filippopoulos t. intracameral bevacizumab versus sub-tenon's mitomycin c as adjuncts to trabeculectomy: 3-year results of a prospective randomized study. j clin med. 2021; 10 (10): 2054. doi: 10.3390/jcm10102054. pmid: 34064843; pmcid: pmc8151253. 21. bilgic a, sudhalkar a, sudhalkar a, trivedi m, vasavada v, vasavada s. et al. bevacizumab as an adjunct to trabeculectomy in primary open-angle glaucoma: a randomized trial. j ophthalmol. 2020; 2020: 8359398. doi: 10.1155/2020/8359398. pmid: 32089872; pmcid: pmc7013315. 22. rabina g, barequet d, mimouni m, kurtz s, shemesh g, rosenblatt a, et al. intracameral bevacizumab role in trabeculectomy: a 1-year prospective randomized controlled study. eur j ophthalmol. 2020; 30 (6): 1356-1361. doi: 10.1177/1120672119874682. epub 2019 sep 9. pmid: 31496260. 23. nadeem s. subconjunctival bevacizumab as an adjunct to 5 – fluorouracil enhanced trabeculectomy: short term results. pak j. ophthalmol. 2018; 34 (4): 272-278. authors designation & contribution p. s. mahar; professor & dean: concepts, design, manuscript preparation. sobia tabassum; senior registrar: data acquisition, data analysis. mujahid inam; associate professor: manuscript review. muhammad faaz malik; senior registrar: literature search. tauseef mahmood; statistician: study design. statistical analysis. .…  …. pak j ophthalmol. 2021, vol. 37 (2): 234-238 234 original article sub-threshold micro pulse laser (810nm): treatment for chronic central serous retinopathy mariam shamim kashif 1 , najia uzair 2 , lubna feroz 3 , asaad mehmood 4 1-4 department of ophthalmology, layton rahmatullah benevolent trust eye hospital, lahore abstract purpose: to find the effectiveness of sub-threshold (810nm) micropulse diode laser treatment (smt) in chronic central serous retinopathy (csr). study design: interventional case series. place and duration of study: layton rahmatulla benevolent trust eye hospital, from april 2019 to july 2020. methods: the patients of chronic csr (≥ 6 months) participated in the study. we used spectral domain optical coherence tomography (sd-oct) to record baseline central retinal thickness (ct). best corrected visual acuity (bcva) was recorded with snellen’s chart and converted to log mar for statistical analysis. all patients underwent treatment with sub-threshold laser (810nm) in micropulse mode with 5% duty cycle (dc). results: twenty five eyes with chronic csr were enrolled in the study. the patients were treated with laser and final assessment was made at 6 months. mean bcva at presentation was 0.46 log mar ± 0.12 and a mean baseline ct of 362.2 μm ± 32.6µm. at final follow-up there was a mean decrease in ct of 97.2 μm ± 21.8 from the baseline. after treatment mean bcva was 0.33 log mar ± 0.12 and mean ct was 266 μm ± 20.9. nineteen out of twenty-five eyes (76%) achieved a gain of vision between 1 to 3 lines and gain of 3 lines was achieved in 8% of cases. at the final follow-up there was incomplete resolution of sub retinal fluid in 4 eyes (16%) with no improvement in bcva. conclusion: smt (810 nm) is an effective and minimally invasive treatment modality for chronic csr. key words: how to cite this article: kashif ms, uzair n, feroz l, mehmood a. sub-threshold micro pulse laser (810nm): treatment for chronic central serous retinopathy. pak j ophthalmol. 2021, 37 (2): 234-238. doi: http://doi.org/10.36351/pjo.v37i2.1152 introduction central serous retinopathy (csr) is a retinal disorder characterized by a localized serous retinal detachment at the macula due to leakage from choriocapillaries through a dysfunctional retinal pigment epithelium correspondence: mariam shamim kashif department of ophthalmology, layton rahmatullah benevolent trust eye hospital, lahore email: mariamshamim@hotmail.com received: october 21, 2020 accepted: march 1, 2021 (rpe). it is a unilateral condition, usually affecting young and middle-aged adults, with a male predominance. 1,2 common risk factors include type a personality, male gender, steroid use, stress, pregnancy, alcoholism, smoking, h. pylori infection and hypermetropia. 3 patients present with blurring of vision, metamorphopsia, micropsia and mild dyschromatopsia. spontaneous resolution occurs in 36 months. more than 30% of the patients may have recurrent or chronic serous detachment, which leads to photoreceptors and rpe degeneration causing permanent loss of vision. duration of chronic csr is http://doi.org/10.3352/jeehp.2013.10.3 mariam shamim, et al 235 pak j ophthalmol. 2021, vol. 37 (2): 234-238 varying; in some studies, the duration is 3 months while in others 4 to 6 months. 4,5 in our study we have used duration of ≥ 6 months to define chronic csr. observation with adjustment of modifiable risk factors, like cessation of steroid use and control of systemic hypertension, remains first line of management. 6 treatment is usually indicated in patients with chronic csr, patients who require early visual recovery or in patients with loss of vision due to csr in the fellow eye. treatment options include photodynamic therapy (pdt), focal laser of the leaking points, sub threshold micro pulse laser and intravitreal anti-vascular endothethial growth factor (anti-vegf). however, all these treatments are associated with risk and complications. 7 complications of focal laser include foveal burn, choroidal neovascularization (cnv) and scotoma. 8 pdt with half dose vertiporfin dye is an effective treatment, but it is a relatively invasive and expensive procedure with risk of rpe atrophy, choroidal ischemia, and secondary cnv. 9 intravitreal anti vegf has varying response in the treatment of chronic csr and can cause complications like increased intraocular pressure, intraocular inflammation and endophthalmitis. 10 because of above mentioned risks, sub-threshold micropulse laser treatment (smt) can be a safe and effective alternative. in smt the laser impact is divided into many repetitive micropulses. each micropulse depending on the duty cycle (dc) has an active time of work of laser (“on” time) and interpulse time (“off” time). for instance, for a 5% dc a 200 ms envelope is divided into 100 micro pulses, the micropulse duration on time will be 0.1 ms. 11 the sub-threshold laser stimulates rpe to improve its function causing resolution of sub retinal fluid (sf). the purpose of our study was to find out the effectiveness of (smt) for the treatment of chronic csr. methods all procedures were performed at layton rahmatulla benevolent trust eye hospital after obtaining approval from the local ethical committee. the study was conducted from april 2019 to july 2020. the inclusion criteria were age ≥ 20 years, visual complaints of ≥ 6 months and presence of sub retinal fluid (sf) on sdoct. patients with history of treatment with other modalities like anti-vegf, focal laser or pdt, other retinal disorders and associated cnv were excluded from the series. all patients underwent comprehensive ocular examination, baseline bcva was recorded with snellen‟s chart and then converted to log mar for statistical analysis. baseline sd oct and fundus fluorescein angiography (ffa) were performed in all patients using spectralis (heidelberg engineering). sub-retinal fluid (sf) and central retinal thickness (ct) were recorded with automated segmentation program and was used to measure the outcome of the treatment. on ffa focal and diffuse leaking points were identified to use as a guide for laser treatment. a written and informed consent was taken after explaining the benefits and potential risks of laser treatment. all patients underwent treatment with subthreshold micropulse (iris medical oculight slx, 810nm diode) laser. power was titrated in each patient. first, a „test' spot of 100 μm was placed outside the arcade in superotemporal retina. exposure time was 100ms and the power was enough to cause mild retinal reaction. with the same spot size and exposure time but half the power, 5% dc and in micro pulse mode, confluent laser burns were applied over areas of rpe leak on ffa. there was no retinal burn evident at the end of laser. follow up of patients was at four weeks, three months, and six months. the final assessment was done at 6 months and treatment outcome was measured as final bcva, resolution of sub retinal fluid (sf) and change in ct on oct. data was analyzed using the statistical package for social sciences (ibm spss 25). results twenty five eyes of 24 patients of chronic csr (≥ 6 months‟ duration) were recruited in the study. mean age of the patients was 43 ± 6 years. mean baseline ct was 362.2 μm ± 32.6 with maximum thickness of 450 µm and presenting mean bcva was 0.46 log mar ± 0.12. laser was applied in all patients only once and the final evaluation was done at 6 months. mean ct at 6-month follow-up was 266 μm ± 20.9, correlating with a mean decrease of 97.2 μm ± 21.8 from the baseline. the mean bcva after treatment was 0.33 log mar ± 0.12, as shown in table 1. there was a maximum gain of 0.3 log mar in 8% of eyes. at the final follow-up, there was incomplete resolution of sf in 4 (16%) eyes with no improvement in bcva, and they were referred for alternate treatment. sub threshold micro pulse laser (810nm): treatment for chronic central serous retinopathy pak j ophthalmol. 2021, vol. 37 (2): 234-238 236 table 1: treatment results (visual acuity is reported in log mar). minimum maximum mean std. deviation baseline bcva 0.30 0.80 0.46 0.128 baseline ct 298 450 363.24 32.684 bcva at 6months 0.00 0.80 0.33 0.155 ct at 6months 232 320 266.04 20.983 bcva difference at 6months 0.00 0.30 0.13 0.085 ct difference at 6months 56 144 97.20 21.897 discussion in the micropulse mode, the laser impulse is divided into repetitive short pulses between which there are intermissions that allow the retinal tissue to cool down. this restricts heat conduction to the neighboring tissues, therefore, rpe confined laser is delivered while sparing the neurosensory retina. the idea is to stimulate rpe causing resorption of sub retinal fluid. 12 temperature rise is below the threshold for coagulation hence micropulse laser does not heal by coagulation and scarring. it produces therapeutic benefit with no detectable sign of iatrogenic damage. the 810 nm sub-threshold diode laser (near infrared spectrum) used in current study allows deeper penetration of tissues, in particular the choroid. this deep penetration is beneficial for central serous retinopathy since diseased choroid plays a role in the pathogenesis of csr. a likely side effect of the 810nm laser is pain during laser; however, this is infrequent in the micropulse treatment. 13 sub-threshold micropulse laser has also been used for treatment of macular edema caused by different retinal diseases. 14,15,16 various studies have been conducted using micropulse laser for successful treatment of chronic csr. bandello et al presented pilot study exploring smt for csr in 2003. 17 they used sub-threshold micro pulse diode laser (810 nm) with 10%-15% dc. their study reported complete resolution of srf in 100% of the eyes, and no recurrence during follow-up. present study demonstrates use of 810nm at 5% dc smt for chronic csr. in this study, we observed the patients for ≥ 6 months, and laser treatment was offered when spontaneous resolution was unlikely. most of the patients in our study had focal leakage which was demonstrated on ffa prior to laser treatment and laser was applied to the leaking points. we have used improvement in bcva, changes in ct and resolution of sf on sd-oct to assess response to laser. similar parameters were used by khatri, anadi et al who studied role of sub-threshold green laser (532nm) in csr of > 3 months. 18 at final follow-up they reported a mean visual gain of 3.91 ± 0.98 lines and incomplete resolution of sub-retinal fluid in one patient. our study reported a mean visual gain of 1.32 ± 0.85 lines at final follow-up and an incomplete resolution of sf in four (16%) eyes. chen et al, in 2008 also treated patients of csr of >4 months duration and juxtafoveal leak, using 810nm diode laser. 19 in their study a gain in vision of ≥ 3 lines was attained in 57% of patients and between 1 to 3 lines in 23% of cases after 6 months. in our study, 19 out of 25 eyes (76%) achieved a gain of vision between 1 to 3 line and of 3 lines in 8% of cases. yadav et al studied the effect of 577nm (yellow) sub-threshold laser for chronic csr treatment. 7 they used average decrease in sf height as a parameter and followed the patients for a mean period of 8 weeks. in their study there was a mean decrease in sf height by 182 μm. fluid height was not measured in our study, instead we have used a decrease in the ct as a parameter to measure the treatment outcome. there was a mean decrease of 97.2 μm ± 21.8 in ct from the baseline. one drawback of using sub-threshold laser was the absence of laser marks on retina hence there is a chance of multiple treatments over the same area. ricci et al overcame this problem by doing an icga guided sub-threshold laser directly over the leakage. 20 our patients did not undergo icga before laser, and we feel this was a limitation of our study. present study revealed reduction of ct in all cases. though the bcva improvement was small, this was comparable with results of gawęcki, maciej et al. 21 this may be because of chronicity of csr which results in permanent damage to the photoreceptor and rpe. wang et al demonstrated that persistence of sf for more than 4 months could result in foveal atrophy. 22 luttrull jk reported a substantial improvement in bcva. they included acute cases in their study, which could be the cause of better visual gain. 23 the reasonable interpretation that can be mariam shamim, et al 237 pak j ophthalmol. 2021, vol. 37 (2): 234-238 obtained from this is the consideration of smt earlier than 6 months after onset of csr. our study outcomes provide adequate evidence that smt with 810nm diode laser leads to resolution of sf and a decrease in ct with satisfactory morphological improvement and can be used in the treatment of chronic csr. a longer duration and a lager sample size study would be valuable to further evaluate the response to smt. furthermore, to prove limited neurosensory retinal damage with sub-threshold laser supplementary investigations for instance, fundus autoflourescence (faf), multifocal electroretinography and microperimetry may be beneficial. conclusion for chronic csr, sub-threshold micropulse diode laser (810 nm) treatment is an effective and safe option with good morphological and functional outcomes. ethical approval the study was approved by the institutional review board/ethical review board. (lrbt/tteh/erc/2722/21). conflict of interest authors declared no conflict of interest. references 1. breukink mb, dingemans aj, den hollander ai, keunen je, maclaren re, fauser s, et al. chronic central serous chorioretinopathy: long-term follow-up and vision-related quality of life. clin ophthalmol. 2017; 11: 39. 2. sinawat s, thongmee w, sanguansak t, laovirojjanakul w, sinawat s, yospaiboon y. oral spironolactone versus conservative treatment for nonresolving central serous chorioretinopathy in reallife practice. clin ophthalmol. 2020; 14: 1725. 3. chatziralli i, kabanarou sa, parikakis e, chatzirallis a, xirou t, mitropoulos p. risk factors for central serous chorioretinopathy: multivariate approach in a case-control study. curr eye res. 2017; 42 (7): 1069-1073. 4. yannuzzi la. central serous chorioretinopathy: a personal perspective. am j ophthalmol. 2010; 149 (3): 361-363. 5. manayath gj, ranjan r, shah vs, karandikar ss, saravanan vr, narendran v. central serous chorioretinopathy: current update on pathophysiology and multimodal imaging. oman j ophthalmol. 2018; 11 (2): 103. 6. abouammoh ma. advances in the treatment of central serous chorioretinopathy. saudi j ophthalmol. 2015; 29 (4): 278-286. 7. yadav nk, jayadev c, mohan a, vijayan p, battu r, dabir s, et al. sub-threshold micropulse yellow laser (577 nm) in chronic central serous chorioretinopathy: safety profile and treatment outcome. eye, 2015; 29 (2): 258-265. 8. sun z, huang y, nie c, wang z, pei j, lin b, et al. efficacy and safety of subthreshold micropulse laser compared with threshold conventional laser in central serous chorioretinopathy. eye, 2019; 29: 1-8. 9. dhirani na, yang y, somani s. long-term outcomes in half-dose verteporfin photodynamic therapy for chronic central serous retinopathy. clin ophthalmol. 2017; 11: 2145. 10. schargus m, frings a. issues with intravitreal administration of anti-vegf drugs. clin ophthalmol. 2020; 14: 897. 11. abdelhamid ah. sub-threshold micropulse yellow laser treatment for non-resolving central serous chorioretinopathy. clin ophthalmol. 2015; 9: 2277. 12. hanumunthadu d, tan ac, singh sr, sahu nk, chhablani j. management of chronic central serous chorioretinopathy. indian j ophthalmol. 2018; 66 (12): 1704. 13. scholz p, altay l, fauser s. a review of subthreshold micropulse laser for treatment of macular disorders. advances in therapy, 2017; 34 (7): 15281555. 14. qiao g, guo hk, dai y, wang xl, meng ql, li h, et al. sub-threshold micro-pulse diode laser treatment in diabetic macular edema: a meta-analysis of randomized controlled trials. intern j ophthalmol. 2016; 9 (7): 1020. 15. akhlaghi m, dehghani a, pourmohammadi r, asadpour l, pourazizi m. effects of sub-threshold diode micropulse laser photocoagulation on treating patients with refractory diabetic macular edema. j curr ophthalmol. 2019; 31 (2): 157-160. 16. vignesh tp. sub-threshold micropulse yellow laser in the treatment of central serous chorioretinopathy. tnoa j ophth sci res. 2019; 57 (2): 118. 17. bandello f, lanzetta p, furlan f, polito a. non visible sub-threshold micropulse diode laser treatment of idiopathic central serous chorioretinopathy. a pilot study. invest ophthalmol vis sci. 2003; 44 (13): 4858. sub threshold micro pulse laser (810nm): treatment for chronic central serous retinopathy pak j ophthalmol. 2021, vol. 37 (2): 234-238 238 18. khatri a, pradhan e, singh s, rijal r, khatri bk, lamichhane g, going green–treatment outcome and safety profile of chronic central serous chorioretinopathy treated with sub-threshold green laser. clin ophthalmol. 2018; 12: 1963. 19. chen sn, hwang jf, tseng lf, lin cj. subthreshold diode micropulse photocoagulation for the treatment of chronic central serous chorioretinopathy with juxtafoveal leakage. ophthalmology, 2008; 115 (12): 2229-2234. 20. ricci f, missiroli f, regine f, grossi m, dorin g. indocyanine green enhanced sub-threshold diode-laser micropulse photocoagulation treatment of chronic central serous chorioretinopathy. graefe's arch clin exp ophthalmol. 2009; 247 (5): 597-607. 21. gawęcki m, jaszczuk-maciejewska a, jurska-jaśko a, grzybowski a. functional and morphological outcome in patients with chronic central serous chorioretinopathy treated by sub-threshold micropulse laser. graefe's arch clin exp ophthalmol. 2017; 255 (12): 2299-2306. 22. wang ms, sander b, larsen m. retinal atrophy in idiopathic central serous chorioretinopathy. am j ophthalmol. 2002; 133 (6): 787-793. 23. luttrull jk. low-intensity/high-density sub-threshold diode micropulse laser for central serous chorioretinopathy. retina, 2016; 36 (9): 1658-1663. authors’ designation and contribution mariam shamim kashif; associate ophthalmologist: concept, design, manuscript preparation, manuscript editing. najia uzair; consultant ophthalmologist: literature search, manuscript editing. lubna feroz; consultant ophthalmologist: data acquisition, data analysis, manuscript review. asaad mehmood; consultant ophthalmologist: statistical analysis, manuscript review. .…  …. 413 pak j ophthalmol. 2021, vol. 37 (4): 413-416 clinical practice article awareness of contact lens related ocular complications among opticians of lahore ahmed sohail 1 , zain-ul-abideen 2 , fatima zahid 3 , wahid baksh 4 1,3 department of allied health sciences, superior university 2,4 university institute of public health, university of lahore abstract purpose: to determine the awareness regarding contact lens related ocular complications among opticians of lahore and to find out the relationship between the awareness and their educational qualification. study design: cross sectional survey. place and duration of study: university of lahore from april 2020 – december 2020. methods: this survey included opticians of different areas of lahore, pakistan. two hundred and eleven opticians responded to a pre-tested, structured close ended questionnaire. data comprised of demographics and contact lens selling experience. information regarding awareness about contact lens related complications was also sought. the data were analyzed using spss 25.0. results: a total of 211 opticians participated in the survey. all subjects were males. fifty four (25.6%) subjects were from the age group of 15 to 30 years, 122 (57.8%) were from the age group of 31 to 45 and 35 (16.6%) were from the age group of 46 to 60 years. only 4.7% had contact lens dispensing diploma. thirty seven percent patients had contact lens selling experience of 2 to 10 years. similar percentage had more than 10 years of experience. ten percent had less than one year of experience. only 54 participants out of 211 had knowledge about dry eye, 9 knew about acanthamoeba keratitis and bacterial keratitis and only 2 were aware of corneal opacity. conclusion: majority of the opticians of lahore are unaware of the contact lenses related complications. sale of cosmetic lenses for fashion purpose should be discouraged and banned if not prescribed by optometrist/ ophthalmologist. key words: opticians, contact lenses, bacterial keratitis. how to cite this article: sohail a, abideen z, zahid f, baksh w. awareness of contact lens related ocular complications among opticians of lahore. pak j ophthalmol. 2021, 37 (4): 413-416. doi: 10.36351/pjo.v37i4.1262 correspondence: ahmed sohail department of allied health sciences superior university, lahore email: sohailmkd12@gmail.com received: april 30, 2021 accepted: september 23, 2021 introduction eighty percent worldwide blindness is avoidable. 1 uncorrected refractive errors are among the major causes. according to one estimate, 153 million people are blind due to uncorrected refractive error. 2 more than 125 million population around the globe use contact lenses in which 33 million of contact lenses users are from united states and females are on the top of this list. 3 refractive errors and fashion purpose are the top indications for soft contact lens use. contact lens associated common ocular complications include dry eyes, giant papillary conjunctivitis, neovascularization, corneal ulceration, abrasion, edema and keratitis. 4 percentage of open access awareness of contact lens related ocular complications among opticians of lahore pak j ophthalmol. 2021, vol. 37 (4): 413-416 414 acanthamoeba, fungal and bacterial keratitis due to contact lenses are 93%, 25% and 33.7% respectively. 5,6,7 in developed countries the opticians are qualified in their field to dispense glasses or contact lenses but unfortunately in middle income countries like pakistan they are only working on the basis of experience and many are selling contact lenses without proper prescription by an optometrist or ophthalmologist. there is also lack of regularization of ophthalmic products which is another cause of ocular complications. all these and many other factors lead to corneal conjunctival infections. 8 overnight use of soft contact lenses increases the chance of developing microbial keratitis and its annual incidence is 20 per 10,000. 9 some other contributing factors for contact lens associated microbial keratitis are purchasing contact lenses from internet, bad hygienic practice of contact lens case and unusual replacement of contact lens case. cosmetic contact lenses are main contributing factors toward microbial keratitis because mostly these lenses not advised by eye care practitioner or contact lens practitioner and users specially new wearers are unaware of its care and maintenance. majority of the people who use contact lenses have very poor contact lens knowledge regarding how to handle contact lenses properly, their most probable complications & appropriate care. the complications linked with contact lens use can be prevented by spreading awareness among users. with all the contact lens related complication in mind and the educational status of our opticians, this study was conducted to find out the awareness of contact lens related problems in the opticians of lahore. methods it was a cross sectional survey which included opticians of different areas of lahore, pakistan. the study was conducted from april 2020 – december 2020. two hundred and eleven participants responded the questionnaire. it was a non-probability convenient sampling technique. the age of the participants ranged from 15 to 60 years. we used a pre-tested, structured close ended questionnaire (cronbach’s alpha value .892)to collect data. data comprised of demographics such as age and sex, general qualification and contact lens related qualification from any registered medical college, years of contact lens selling experience and some questions related to the use of contact lens. it also included information regarding awareness about contact lens related ocular complications like dry eyes, conjunctivitis, keratitis, abrasion, hypoxia and corneal opacity. the data were collected after the approval from irb of university of lahore. an informed consent of the study participants was taken who were assured of privacy and confidentiality. the data were analyzed using spss 25.0. simple descriptive statistics (frequencies and percentages) were computed for demographics and contact lens related general questions. chi square was applied to compare their level of knowledge with their qualification. p ≤ 0.05 was taken as significant. results a total of 211 opticians were questioned regarding contact lens related ocular complications. all subjects 211 (100%) were males. fifty four (25.6%) subjects were from the age group of 15 to 30 years, 122 (57.8%) were from the age group of 31 to 45 and 35 (16.6%) were from the age group of 46 to 60 years. only 4.7% had contact lens dispensing diploma. thirty seven percent patients had contact lens selling experience of 2 to 10 years. similarly similar percentage had more than 10 years of experience. ten percent had less than one year of experience. only 54 participants out of 211 had knowledge about dry eye, 9 knew about acanthamoeba keratitis and bacterial keratitis and only 2 were aware of corneal opacity. details are shown in table 1. discussion in this study, 54 (25.6%) individuals were aware of dry eye being linked with contact lens use while according to a study conducted in 2015 among medical students at king abdul aziz university showed that 181 (71.3%) subjects had knowledge regarding contact lens induced dry eye. 10 however, same study revealed that 81 (31.9%) students were aware of corneal ulcers but our study shows that only 9 (4.3%) subjects had knowledge regarding corneal ulcers being caused by use of tap water for cleaning contact lenses. this significant difference in awareness could be due to the fact that the medical students have more knowledge regarding such complications. this endorse the idea that contact lenses must not be dispensed by the un-qualified individuals. ahmed sohail, et al 415 pak j ophthalmol. 2021, vol. 37 (4): 413-416 table 1: knowledge of ocular complications and qualification of the participants. ocular complications qualification of the participants primary middle matric intermediate graduation post graduation total count count count count count count count knowledge of corneal ulcer yes 0 0 0 6 3 0 9 no 15 19 59 72 28 9 202 knowledge of fungal keratitis yes 0 0 0 6 3 0 9 no 15 19 59 72 28 9 202 knowledge of papillary conjunctivitis yes 0 0 0 6 3 0 9 no 15 19 59 72 28 9 202 knowledge of acanthamoeba keratitis yes 0 0 0 6 3 0 9 no 15 19 59 72 28 9 202 knowledge of corneal abrasion yes 0 0 0 6 3 0 9 no 15 19 59 72 28 9 202 knowledge of bacterial keratitis yes 0 0 0 6 3 0 9 no 15 19 59 72 28 9 202 contact lens related corneal opacity yes 4 3 15 17 12 2 53 no 11 16 44 61 19 7 158 knowledge of corneal neovascularization yes 0 0 0 6 3 0 9 no 15 19 59 72 28 9 202 knowledge of dry eye yes 3 6 14 20 6 5 54 no 12 13 45 58 25 4 157 in this study, 158 (74.9%) individuals were familiar with contact lens associated eye infections due to the use of tap water. these results can be compared with a study conducted in 2017, in which ninety percent (90%) individuals were aware of the dangers of using tap water for contact lens cleaning. 11 another study conducted in 2016, showed that 3.7% individuals were using tap water for cleaning contact lenses. 12 furthermore, according to another study which was done in 2018 in rawalpindi showed that nearly nineteen percent (19%) participants were using tap water in order to clean their contact lenses. 13 all of the individuals in our study were aware of importance of hand washing before insertion and removal of contact lenses. this was in contrast to another study from baluchistan which demonstrated that around 45.8% were adherent to hand washing before handling contact lenses. 14 in another study percentage of people not cleaning their lenses was 60%. 12 this is due to either poor communication of eye care practitioners or because of patient’s incompliance. in this study, 150 (71.1%) individuals said that ocular examination is must before using contact lenses. these results can be compared with a study carried out in 2013 to evaluate awareness of contact lens indications and maintenance among medical students which indicated that 90 percent students knew significance of ocular checkup prior to contact lens use. 14 eye care practitioners play an important role in diagnosing and managing complications of contact lens use. 15 the data shows lack of regularization of optical product’s sale by government. only qualified opticians should be allowed to carry out this business. there are laws but their implementation is a big question mark. to counter this, there should be wide-spread awareness related to this topic through print, electronic and social media. sale of cosmetic lenses for fashion purpose should be discouraged or even banned especially if not prescribed by optometrist/ ophthalmologist. ethical approval the study was approved by the institutional review board/ethical review board (irb-uol-fahs-75411/2020). conflict of interest authors declared no conflict of interest. references 1 ackland p. the accomplishments of the global initiative vision 2020: the right to sight and the focus for the next 8 years of the campaign. indian j ophthalmol. 2012; 60 (5): 380. 2. bourne rr, stevens ga, white ra, et al. causes of vision loss worldwide, 1990-2010: a systematic analysis. lancet glob health, 2013; 1 (6): e339-e349. doi:10.1016/s2214-109x(13)70113-x awareness of contact lens related ocular complications among opticians of lahore pak j ophthalmol. 2021, vol. 37 (4): 413-416 416 3. key je. development of contact lenses and their worldwide use. eye contact lens, 2007; 33 (6 pt 2): 343-363. doi:10.1097/icl.0b013e318157c230 4. alipour f, khaheshi s, soleimanzadeh m, heidarzadeh s, heydarzadeh s. contact lens-related complications: a review. jophth vis res. 2017; 12 (2): 193. 5. khan mh, mubeen sm, chaudhry ta, khan sa. contact lens use and its compliance for care among healthcare workers in pakistan. indian j ophthalmol. 2013; 61 (7): 334. 6. ross j, roy sl, mathers wd, ritterband dc, yoder js, ayers t, et al. clinical characteristics of acanthamoeba keratitis infections in 28 states, 2008 to 2011. cornea, 2014; 33 (2): 161-168. doi: 10.1097/ico.0000000000000014. 7. keay lj, gower ew, iovieno a, oechsler ra, alfonso ec, matoba a, et al. clinical and microbiological characteristics of fungal keratitis in the united states, 2001 – 2007: a multicenter study. ophthalmology, 2011; 118 (5): 920-926. 8. aldebasi y. assessment of knowledge and compliance regarding contact lens wear and care among female college students in saudi arabia. intern j curr res rev. 2012; 4 (20): 162. 9. cope jr, collier sa, rao mm, chalmers r, mitchell gl, richdale k, et al. contact lens wearer demographics and risk behaviors for contact lensrelated eye infections—united states, 2014. mmwr. morbidity and mortality weekly report, 2015; 64 (32): 865-870. 10. alasiri ra, wa'ad ma, neama sh, alsulami ia, bawazeer am. practice and knowledge of contact lens wear and care among female medical college students in kingdom of saudi arabia. int j biol med res. 2015; 6 (4): 5240-5242. 11. arif s, hussain a. knowledge, attitude and practice (kap) regarding contact lens use among people of different literacy levels. ophthalmol pak. 2017; 7 (04): 6-9. 12. khan am. awareness of contact lens indications and care. j rawal med coll. 2013; 17 (2): 260-261. 13. sughra u, khan wa, munir f, kausar s, akbar m, imran m, et al. knowledge and practices regarding contact lens wear and care among contact lens users in twin cities of pakistan. al-shifa j ophthalmol. 2018; 14 (3): 141-147. 14. baryalai r. awareness of contact lens wear in the students of university of baluchistan. ophthalmol pak. 2018; 8 (01): 18-21. 15. zimmerman ab, nixon ad, rueff em. contact lens associated microbial keratitis: practical considerations for the optometrist. clin optom. 2016; 8: 1. authors’ designation and contribution ahmed sohail; lecturer: concepts, literature search, statistical analysis, manuscript preparation. zain-ul-abideen; optometrist: design, manuscript preparation. fatima zahid; lecturer: data acquisition, data analysis, manuscript editing. wahid baksh; optometrist: concepts, literature search, manuscript review. .…  …. pak j ophthalmol. 2020, vol. 36 (4): 376-380 376 original article co-relation of myopia with the use of smart phones and outdoor activities hafiza sadia imtiaz 1 , muhammad sharjeel 2 , irfan qayyum malik 3 department of ophthalmology, 1,3 gujranwala medical college, gujranwala 2 gomal medical college, dera ismail khan abstract purpose: to determine the frequency of myopia among children and to find out the role of smart phone usage and outdoor activities in myopia development and progression. study design: descriptive cross-sectional study. place and duration of study: ophthalmology department dhq-uth gujranwala, from january 2019 to june 2019. methods: after approval from the hospital ethical committee and informed consent from each participant, a descriptive cross-sectional study was carried out with a sample size of 250 patients. patients of either gender between 4 – 14 years of age using smart phones for ≥ 2 hours daily and found to have refractive error were included in this study. routine ophthalmic examination was carried out, data was recorded on proforma, and daily usage of smart phones and weekly outdoor activity in hours along with school grade, family history and previous history of using refractive glasses was also determined and documented. data was analyzed using spss v.20 results: there were 250 patients included in this study, out of which 142 (56.8%) were male and 108 (43.2%) were female. mean age was 10.1 ± 2.45 years. mean outdoor activity was 0.95 ± 0.98 hours per week while mean daily smart phone usage was 2.89 ± 0.93 hours. pearson correlation coefficient for daily smart phone usage and ucva was +0.297 (0.3) which showed a positive moderate association between two variables while the value obtained for ucva and weekly outdoor activity was – 0.51 that depicted a negative strong association. conclusions: in conclusion, myopia occurrence is higher among smart phone users showing a moderate positive correlation while outdoor activities reduce myopia prevalence and progression depicting strong negative correlation. key words: refractive errors, myopia, visual acuity, smartphone. how to cite this article: imtiaz hs, sharjeel m, malik iq. association of myopia with the use of smart phones and outdoor activities in pakistan. pak j ophthalmol. 2020; 36 (4): 376-380. doi: https://doi.org/10.36351/pjo.v36i4.1067 introduction myopia is the commonest refractive error. its prevalence varies considerably over various regions of correspondence: hafiza sadia imtiaz department of ophthalmology gujranwala medical college, gujranwala email: sadiaimtiaz69@gmail.com received: may 18, 2020 accepted: july 31, 2020 the world with the maximum growing tendency among east asian countries. 1 it can occur in adults and children and its worldwide prevalence is 30%. 2 according to some recent studies, number of people who developed myopia were about 1406 million in 2000 which increased to 1950 million in 2010 and it is highly predicted that this number will increase to 4758 million by 2050. 3 etiology of myopia is quite cumbersome with complex interactions between genetic and environmental factors. many researchers have studied http://www.gmcdikhan.edu.pk/ http://www.gmcdikhan.edu.pk/ http://www.gmcdikhan.edu.pk/ mailto:sadiaimtiaz69@gmail.com hafiza sadia imtiaz, et al 377 pak j ophthalmol. 2020, vol. 36 (4): 376-380 various genes involved with onset and progression of myopia which include igf-1, pax-6 gene, and bicc family rna binding protein 1. 4,5,6 previously, it was assumed that only genetic factors contribute towards myopia but newer researches have documented the strong association of environmental factors. for example, high intelligence and education, lifestyle, low vitamin d levels, and most importantly use of electronic devices including the smartphones. 7,8 computers, tablets, and smart phones are the demand of every home and working environment and are considered to be a part and parcel of modern life. children are among the most growing users of smart phones and that is reflected by the international statistics. many studies have linked myopia progression with the use of smart phones due to small screens and close working distance. close target results in retinal defocusing which causes the eye to accommodate thus increasing its power to bring near objects in sharp focus. areas of defocus on retina render the eyeball to grow thus adding to the magnitude of myopia. 9 the purpose of this study is to determine the prevalence of myopia among children and also to find out the role of smart phone usage as a contributing factor to myopia development and progression. methods after approval from the hospital ethical committee, verbal informed consent was collected from each patient/guardian. patients of either gender between 414 years of age using smart phones for ≥ 2 hours daily presented to eye outdoor patient department of dhquth gujranwala. patients with any other intraocular disease or previous history of intraocular surgery were excluded from this study. it was a descriptive crosssectional study with a sample size of 250 patients (included by convenient sampling technique) and time duration of six months (january june 2019). all included patients underwent the routine ophthalmic examination of visual acuity with pinhole testing, refractive error evaluation with the use of autorefractometer followed by subjective refraction to determine the best-corrected visual acuity (bcva). slit-lamp biomicroscopy and fundoscopy were carried out to exclude other causes of reduced visual acuity. data was collected on a self-designed performa. daily usage of smart phones and weekly outdoor activity in hours along with school grade, family history and previous history of using refractive glasses was also determined and documented. data was analyzed using spss version 20. frequencies and percentages were calculated for categorical variables like gender, school grade, family history, previous history of using refractive glasses and age groups while mean ± s.d was computed for numerical variables like age, visual acuity (log mar) and refractive error (diopters). pearson’s correlation was used to determine the significant association as well as strength of association between visual acuity (log mar) and time spent using a smart phone and in outdoor activities with r-value denoting the strength of association and r-sign showing a positive or negative association. results 250 patients were included in this study, out of whom 142 (56.8%) were male and 108 (43.2%) were female. mean age was 10.1 ± 2.45 years and all patients were divided into three age groups with 41 patients (16.4%) in 4 – 7 years age group, 105 (42%) in 8-11 years age group and 104 (41.6%) in 12 – 14 years age group. patients were also stratified according to school grade into three groups of 0 – 4 class, 5 – 8 class, 9 – 12 class, and their frequency as well as percentage in each group is depicted via the following pie chart; (figure 1). fig. 1: pie chart showing stratification according to school grade. co-relation of myopia with the use of smart phones and outdoor activities pak j ophthalmol. 2020, vol. 36 (4): 376-380 378 family history of myopia was present among 40.4% of patients and the previous history of using glasses was present only in 17.6% of patients. mean outdoor activity recorded was 0.95±0.98 hours per week. thirty eight percent patients had no outdoor activity, 28.4% had 1 hour and 22% had 2 hours of weekly outdoor activity. mean daily smart phone usage was 2.89 ± 0.93 hours. 38.4% with 2 hours daily usage, 8.0% with 2.5 hours, 29.2% with 3 hours, 0.4% with 3.5 hours, 17.6% with 4 hours, 5.6% with 5 hours and 0.8% with 6 hours daily smart phone usage shown by bar chart in figure 2. fig. 2: bar chart showing daily smart phone usage in hours. fig. 3: scatter chart showing positive correlation between daily smart phone usage and ucva (log mar). mean uncorrected visual acuity (ucva) was log mar 0.64 ± 0.35 and the range was log mar 0.18 – 1.30. mean refractive error was -1.31 ± 1.64 d with 92% having myopia while 8% with hyperopic refractive error. following is the simple scatter graph between ucva (log mar) and daily smart phone usage (hours) and it shows r 2 linear of 0.088 and a positive association between two variables (figure 3). fig. 4: scatter chart showing -ve correlation b/w weekly outdoor activity and ucva (log mar). assuming linear relationship between smart phone usage and ucva (log mar), pearson correlation coefficient obtained was 0.297 (0.3) that shows intermediate/moderate association between two variables and positive direction of relationship depicts that increased smart phone usage causes increased ucva (refractive error) (table 1). following is the simple scatter graph between ucva (log mar) and weekly outdoor activity (hours) and it shows r 2 linear of 0.2601 and negative correlation (figure 4). table 1: correlations b/w smart phone usage and ucva. daily smart phone usage (hours) uncorrected visual acuity (log mar) daily smart phone usage (hours) pearson correlation 1 .297 ** sig. (2-tailed) .000 n 250 250 ucva (log mar) pearson correlation .297 ** 1 sig. (2-tailed) .000 n 250 250 **. correlation is significant at the 0.01 level (2-tailed). hafiza sadia imtiaz, et al 379 pak j ophthalmol. 2020, vol. 36 (4): 376-380 pearson correlation coefficient test was applied to determine the association between ucva and weekly outdoor activity and it showed strong association (r = 0.51). negative sign depicts direction of association and thus increased outdoor activity is associated with less ucva (refractive error) (table 2). table 2: correlation b/w ucva and outdoor activity. visual acuity (log mar) weekly outdoor activity (hours) ucva (log mar) pearson correlation 1 -.510 ** sig. (2-tailed) .001 n 250 250 weekly outdoor activity (hours) pearson correlation -.510 ** 1 sig. (2-tailed) .001 n 250 250 **. correlation is significant at the 0.01 level (2-tailed). discussion myopia is a growing problem in the field of ophthalmology and here comes the need to determine its aggravating factors. in this study, we determined the relationship between smart phone usage and outdoor activity with myopia. results showed the male to female ratio of 1.3:1 with a mean age of 10 years. hittalamani et al. determined myopia prevalence among school-going children and their results showed that it was more common among girls 155 (58.27%) than boys 111 (41.73%). 10 family history was present in 40.4% of patients in our study showing a remarkable genetic association and it was more marked in children with high refractive error of >5.00d. this finding is supported by another study carried out in taiwan which showed an odd’s ratio of > 5.5 among high myopic patients with positive family history depicting a strong association. 11 iribarren et al. modified this approach and proved with their study that family history though important but not related to the final amount of refractive error in low and moderate myopia. 12 mean outdoor activity recorded in our study is almost 1 hour per week and pearson correlation showed a strong negative correlation (r = -0.51) between outdoor activities and reduced visual acuity (refractive error). this finding is supported by many ongoing researches which showed a positive impact of outdoor activities in slowing the development and progression of myopia. 13 oner et al. showed that myopia progression was associated with time spent on reading and writing and initial refraction value, during puberty. 14 several hypotheses are presented to focus on different aspects of outdoor activity, to explain the role of more outdoor activity in protecting against myopia. one is that the constricted pupil under sunlight leads to increased depth of focus and decreased blurriness. another hypothesis is elevated retinal dopamine activity with sunlight exposure. this results in exposure to different light spectrums in natural light as compared to indoor light. far less diopter variation in outdoor activities is also considered a contributing factor. 15 a meta-analysis was carried out by deng l and pang y and results suggested a lower risk of myopia onset and myopic shift with more time spent in outdoor activities. 16 mean daily smart phone usage recorded in this study was 2.89 ± 0.93 hours. pearsons correlation coefficient depicted an intermediate/moderate positive association (r = +0.297) between daily smart phone usage and refractive error. previous data is lacking in documenting an association between smart phone usage and myopia development though studies are available regarding the use of electronic devices 17 and near work. a cross-sectional survey was carried out in beijing in 2008. the data was collected from 15,316 chinese school students aged 6 to 18 years. univariate and multiple logistic regression analyses were performed to compare the differences among different areas. myopia was associated with shorter sleep times versus longer sleep times. it was also related with reading or writing distances less than 33 cm compared to distances greater than 33 cm. 18 other studies showed association of near work with increase in myopia. 19,20 the limitation of this study is that it is a crosssectional study where further follow up of patients was not done. future studies will be carried out for a longer follow-up to determine the effect of smart phone usage upon the progression of myopia. conclusion in conclusion, myopia occurrence is higher among smart phone users showing a moderate positive correlation while outdoor activities reduce myopia prevalence and progression depicting a strong negative correlation. co-relation of myopia with the use of smart phones and outdoor activities pak j ophthalmol. 2020, vol. 36 (4): 376-380 380 ethical approval` the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. ding b, shih y, lin l, hsiao c, wang i. myopia among school children in east asia and singapore. surv ophthalmol. 2017; 62 (5): 677-697. 2. r. greene p, m. green j. prevalence and incidence of myopia and high myopia. new front ophthalmol. 2016; 2 (6): 1-4. 3. holden b, fricke t, wilson d, jong m, naidoo k, sankaridurg p et al. global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. ophthalmol. 2016; 123 (5): 1036-1042. 4. guo l, du x, lu c, zhang w. association between insulin-like growth factor 1 gene rs12423791 or rs6214 polymorphisms and high myopia: a metaanalysis. plos one. 2015; 10 (6): 1-14. 5. tang s, rong s, young a, tam p, pang c, chen l. pax6 gene associated with high myopia. optom vis sci. 2014; 91 (4): 419-429. 6. jin w, hepei l, mingkun x, li w. assessment of bicc family rna binding protein 1 and ras protein specific guanine nucleotide releasing factor 1 as candidate genes for high myopia: a case–control study. indian j ophthalmol. 2017; 65 (10): 926-930. 7. verma a, verma a. a novel review of the evidence linking myopia and high intelligence. j ophthalmol. 2015; 2015 (2015): 1-8. 8. yazar s, hewitt a, black l, mcknight c, mountain j, sherwin j et al. myopia is associated with lower vitamin d status in young adults. invest ophthalmol vis sci. 2014; 55 (7): 4552-4559. 9. lougheed t. myopia: the evidence for environmental factors. environ health perspect. 2014; 122 (1): a1319. 10. hittalamani s, jivangi v. prevalence of myopia among school going children. int j res med sci. 2015; 3 (10): 2786-2790. 11. liang c, yen e, su j, liu c, chang t, park n et al. impact of family history of high myopia on level and onset of myopia. invest ophthalmol vis sci. 2004; 45 (10): 3446. 12. iribarren r, balsa a, armesto a, chiaradia p, despontin l, fornaciari a et al. family history of myopia is not related to the final amount of refractive error in low and moderate myopia. clin exp ophthalmol. 2005; 33 (3): 274-278. 13. suryathi n, budhiastra i, handayani a. outdoor activities and myopia on junior high school student in rural area of bali. ophthalmologica indonesiana. 2018; 44 (1): 30. 14. öner v, bulut a, oruç y, özgür g. influence of indoor and outdoor activities on progression of myopia during puberty. int ophthalmol. 2015; 36 (1): 121-125. 15. deng l, pang y. the role of outdoor activity in myopia prevention. j eye sci. 2015; 30 (4): 137-139. 16. deng l, pang y. effect of outdoor activities in myopia control. optom vis sci. 2019; 96 (4): 276-282. 17. liu s, ye s, xi w, zhang x. electronic devices and myopic refraction among children aged 6‐14 years in urban areas of tianjin, china. ophthalmic physiol opt. 2019; 39 (4): 282-293. 18. gong y, zhang x, tian d, wang d, xiao g. parental myopia, near work, hours of sleep and myopia in chinese children. health, 2014; 06 (01): 64-70. 19. sivaraman v, rizwana j, ramani k, price h, calver r, pardhan s et al. near work-induced transient myopia in indian subjects. clin exp optom. 2015; 98 (6): 541-546. 20. muhamedagic l, muhamedagic b, halilovic e, halimic j, stankovic a, muracevic b. relation between near work and myopia progression in student population. mater sociomed. 2014; 26 (2): 100. authors’ designation and contribution hafiza sadia imtiaz; postgraduate trainee: manuscript writing, data collection, data analysis. muhammad sharjeel; senior registrar: topic selection, data collection, data analysis. irfan qayyum malik; associate professor: supervisor, study design, manuscript review. .…  …. . pak j ophthalmol. 2021, vol. 37 (1): 7-11 7 original article effects of intra-vitreal injection of bevacizumab as an adjunct during phacoemulsification in diabetic maculopathy ali afzal bodla 1 , syeda minahil kazmi 2 , noor tariq 3 , ayeza moazzam 4 , muhammad muneeb aman 5 1-5 department of ophthalmology, multan medical and dental college, multan abstract purpose: to study the effects of intra-vitreal injection of bevacizumab as an adjunct during phacoemulsification in patients with diabetic retinopathy. study design: quasi experimental study. place and duration of study: multan medical and dental college and bodla eye care, multan, between march 2018 to february 2019. methods: the study included 108 eyes of 108 diabetic patients who were scheduled to undergo phacoemulsification. they were equally divided into two groups; bevacizumab and control group. complete ocular examination and macular thickness and volume were determined using an optovue-oct machine. the patients in the bevacizumab group were given intra-vitreal injection of 1.25 mg/0.05ml of bevacizumab at the time of phacoemulsification. results: the bevacizumab group manifested low value of central macular thickness (cmt) one-month postsurgery as compared to the control group (262.2 ± 32.2 and 288.5 ± 54.1, respectively) with p = 0.01. the total macular volume, and best-corrected visual acuity in the two groups showed no significant difference one month after surgery. two (4%) patients in the bevacizumab group and five (10%) patients in the control group developed post-surgical macular edema one month after surgery which was not statistically significant (p = 0.244). we found no significant relationship between the post-surgical macula edema with the presence of mild non proliferative diabetic retinopathy. (fisher's test, p = 0.321). conclusion: ocular anti-vegf therapy substantially reduces macular edema secondary to post-surgical inflammation in diabetic patients. it effectively reduces the central macular thickness although the results are not found to be statistically significant when compared with the control group. key words: diabetes mellitus; diabetic macular edema; diabetic retinopathy, bevacizumab. how to cite this article: bodla aa, kazmi sm, tariq n, moazzam a, aman mm. effects of intra-vitreal injection of bevacizumab as an adjunct during phacoemulsification in diabetic maculopathy. pak j ophthalmol. 2021, 37 (1): 7-11. doi: https://doi.org/10.36351/pjo.v37i1.1122 correspondence: syeda minahil kazmi department of ophthalmology multan medical and dental college multan email: minahilkazmi257@gmail.com received: august 21, 2020 accepted: october 22, 2020 introduction subsequent to cataract surgery performed on diabetics, the most sight threatening retinopathy is gross and/or cystoid macular edema, which is indicated as fluid accumulation in the macula. 1-3 after cataract surgery there is a substantial increment in angiogenesis and inflammation, thereby surging cytokines, chemokines and vaso-permeability factors in the vascular ali afzal bodla, et al 8 pak j ophthalmol. 2021, vol. 37 (1): 7-11 endothelium which trigger breakdown of blood retinal barrier, manifesting clinically as macular edema and resulting in visual loss. 4,5 the pathophysiology encompasses between the vascular endothelial growth factor (vegf) and inflammatory mediators. 6,7 this study has been conducted to clinically investigate the potential therapeutic effects of anti vegfs in the control of macular edema in patients with nonproliferative diabetic retinopathy. methods in this study, we enrolled 108 eyes of 108 patients from hospital of multan medical and dental college and bodla eye care, multan, between march 2018 to february 2019. a written ethical review statement was obtained before the beginning of study and the research was conducted according to the principles of declaration of helsinki. these patients had significant cataract but with visible posterior segment. at the first visit patients were divided into control (got phacoemulsification alone) and intervention group (who got intravitreal injection of 1.25 mg/0.05 ml of bevacizumab at the end of surgery) depending upon their treatment choice. the inclusion criteria was diabetic patients (diabetes mellitus type 2) with significant cataract and early diabetic retinopathy or moderate non proliferative diabetic retinopathy. the exclusion criteria were patients with preoperative central macular thickness (cmt) of > 280 μm and/or any attestation of cystic spaces indicated by optical coherence tomography (optovue-oct; optovue companies; usa), hba1c greater than 6.8, intractable non proliferative diabetic retinopathy or proliferative diabetic retinopathy, diabetes mellitus type 1, uncontrolled persistent hypertension and precedent retinal laser therapy. during the preliminary visit, the anterior and posterior segment examination was done using slit lamp and 90 d lens. goldmann applanation tonometry was performed to determine the intra ocular pressure whereas oct was used to assess retinal structures and macular thickness. etdrs was employed to assess the degree of retinopathy. the complete post-operative ophthalmic examinations were performed at day one, day seven, and one month later. oct was performed one month post-surgery on all patients. by using the 512 × 128 scan pattern, oct images were acquired and center of 6 × 6-mm scanning area was fixed at the fovea centralis. central macular thickness (cmt) was measured which is the average thickness of retina in the central foveal 1 mm subfield. total macular volume (tmv) was also determined. phacoemulsification was performed by a single surgeon (infinity® vision system; alcon laboratories). at the end of cataract surgery, an injection of 1.25 mg of bevacizumab was injected intravitreally given in the inferotemporal quadrant, 3.5 mm away from limbus using a standard 1cc insulin syringe. it was pre-defined that cmt > 280 μm using oct would be considered as a consequential postoperative macular edema. spss version 20 was employed to analyze the statistical data. the variables found in the data were demonstrated in terms of mean ± standard error of mean. the analysis was done by using wilcoxon mann – whitney test. it was determined that p value less than 0.05 will be significant. results the study included 108 eyes from 108 patients. three patients were omitted due to advancement of postoperative cystoid macular edema not secondary to diabetes as in accordance with guidelines suggested by munk et al. five of these patients were lost during follow up. after excluding the patients who were lost during follow-up, there were fifty eyes included in the bevacizumab group and fifty eyes in the control group. the pre requisite criterion for the patients was type 2 dm. the two groups were much the same in terms of age, male to female ratio, stage of diabetic retinopathy baseline cmt and tmv, hba1c and blood pressure. the bevacizumab group manifested low value of cmt one-month post-surgery as compared to the control group (262.2 ± 32.2 and 288.5 ± 54.1, respectively) with p = 0.02. the tmv and bcva in the two groups showed no significant difference one month after surgery (table 1). in the light of our definition in study set in accordance with drcr. net protocols, (cmt > 280 μm using sdoct), two (4%) patients in the bevacizumab group and five (10%) patients in the control group developed post-surgical macular edema one month after surgery. although the frequency of macular edema was somewhat higher in the control group, this distinction was not statistically significant at one month after surgery (p = 0.244). we found no significant relationship between the post-surgical macula edema with the presence of mild non proliferative diabetic retinopathy. (fisher's test, p = 0.321). effects of intra-vitreal injection of bevacizumab during phacoemulsification in diabetic maculopathy pak j ophthalmol. 2021, vol. 37 (1): 7-11 9 table 1: mean central macular thickness (cmt) and total macular volume (tmv) before and at 1 month after cataract. cmt: central macular thickness; tmv: total macular volume; bcva: best corrected visual acquity; pme: postoperative macular edema. bevacizumab group control group p-value cmt (pre-operative) 255.4 ± 24.3 262.5 ± 27.4 0.30 cmt (1 month postoperative) 262.2 ± 32.2 288.5 ± 54.1 0.01 tmv (pre operative) 8.29 ± 0.54 8.30 ± 0.51 0.93 tmv (1 month post-operative) 8.30 ± 0.62 8.53 ± 0.70 0.14 bcva 0.58 ± 0.21 0.50 ± 0.09 0.13 bcva (1 month post operative) 0.08 ± 0.06 0.11 ± 0.09 0.226 post operative pme% 2 (%4) 5 (%10) 0.24 discussion vascular endothelial growth factor is one of the key agents responsible for causing macular edema. antivegf act as promising halters of this macular edema. in such patients a mono-therapy or combination of topical nsaids and corticosteroids can be employed right after the surgery as a prophylactic therapy or as treatment. 8,9 however, there are other options which include intravitreal anti-vegf and steroid therapy at the time of surgery. 10,11 multiple anti-vegf drugs e.g. afilibercept, intravitreal ranibizumab (ivr) or intravitreal bevacizumab (ivb) are administered as an adjunct in cataract surgery for the management of macular edema in diabetic patients having danger of post-operative macular edema. 12-16 these drugs are used widely and are effective in vision improvement and prevention of vision loss caused by diabetic macular edema. the effect of anti-vegf is not enough sometimes and many patients do not show complete remission of fluid. the optical coherence tomography (oct) is used for the clinical assessment of diabetic macular edema that discerns visual loss by objective evaluation of macular thickness and evaluates the vitreo-macular interface. 17,18 the most certain rationale of poor vision in diabetics after cataract surgery is cystoid and/or gross macular edema. it has been demonstrated that aqueous vegf levels are greatly responsible for clinically remarkable changes in central macular thickness. the pre-operative vegf levels play a pivotal role in causing post-operative macular edema. 19 therefore, it is hypothesized that controlling this vegf would productively play a crucial role in impeding postoperative elevation in central macular thickness and thereby refining the visual outcomes in the patients. the present study showed that patients who had no or mild diabetic retinopathy had an insignificant decrease in macular thickness subsequently after the administration of intravitreal bevacizumab injection at the time of surgery. takamura et al. appraised the effects of intravitreal bevacizumab supplemented shortly after phacoemulsification in diabetics with pre-existing macular edema. 12 while in first month post-surgery macular edema decreased proficiently by bevacizumab, it somehow was increased in the control group. likewise, best corrected visual acuity (bcva) was significantly lower in the control group then in the bevacizumab group. conducive to the hypothesis stating that total macular volume is a better reflection of changes in macular status rather than central macular thickness, we measured both tmv and cmt in order to observe any change with the use of intravitreal bevacizumab. often quoted, post-op macular edema was taken as an increase of cmt ≥ 60 μm in relation to the preoperative baseline. interestingly, cmt changes until 1 month after surgery were depicted differently in these two groups. fard et al. in their study, found a significant increase in the control group one month post-operative as compared to the bevacizumab group while evaluating the effect of intravitreal bevacizumab in patients with cmt < 200 μm. they concluded that intravitreal administration of 1.25 mg bevacizumab was effective in reducing macular thickness. 20 it is apparent that progression of diabetic retinopathy or development of subsequent macular edema after surgery occurs more commonly in patients with moderate to severe npdr and/or macular edema prior to phacoemulsification as compared to patients with no or mild npdr. 21 there are a few limitations to our study. first, sample size of each group was small and perhaps not considerable enough to explicate the beguiling differences particularly of post-operative cystoid ali afzal bodla, et al 10 pak j ophthalmol. 2021, vol. 37 (1): 7-11 macular edema between the control and the bevacizumab group. second, the follow up period was small. it is possible that some change would be imminent in further follow-ups. third, macular edema was defined as cmt > 280 μm using sd-oct. a comparable conclusion might have been drawn by considering an increase of ≥ 60 μm. conclusion the ocular anti-vegf therapy substantially reduces central macular thickness secondary to post-surgical inflammation in diabetic patients. however, the results are not found to be statistically significant when compared with the control group. ethical approval the study was approved by the institutional review board/ ethical review board. (mmdc/b-24-418) conflict of interest authors declared no conflict of interest references 1. zhao lq, cheng jw. a systematic review and metaanalysis of clinical outcomes of intravitreal antivegf agent treatment immediately after cataract surgery for patients with diabetic retinopathy. j ophthalmol. 2019; 2019: 2648267. doi: 10.1155/2019/2648267. 2. dong n, xu b, wang b. aqueous cytokines as predictors of macular edema in patients with diabetes following uncomplicated phacoemulsification cataract surgery. bio med research international. 2015; 2015: 8. doi: 10.1155/2015/126984.126984 3. lim ll, morrison jl, constantinou m, rogers s, sandhu ss, wickremasinghe ss, et al. diabetic macular edema at the time of cataract surgery trial: a prospective, randomized clinical trial of intravitreous bevacizumab versus triamcinolone in patients with diabetic macular oedema at the time of cataract surgerypreliminary 6 month results. clin exp ophthalmol. 2016; 44 (4): 233–242. doi: 10.1111/ceo.12720. 4. virgili g, parravano m, evans jr, gordon i, lucenteforte e. anti-vascular endothelial growth factor for diabetic macular oedema: a network metaanalysis. cochrane database syst rev. 2017; 6. doi: 10.1002/14651858.cd007419.pub5.cd007419 5. lin wh, lu m, tang hy, zeng zr. clinical application of ranibizumab in the therapy of diabetic cataract. guoji yanke zazhi. 2015; 15: 880–882. 6. cheng mz, wang c, chen m. phacoemulsification combined with intravitreal injection of lucentis for diabetic cataract. recent adv ophthalmol. 2016; 36: 754–756. 7. bakri sj, snyder mr, reid jm, pulido js, singh rj. pharmacokinetics of intravitreal bevacizumab (avastin). ophthalmology, 2007; 114: 855–849. 8. li t. the effect of senile cataract surgery combined with vitreous cavity injection of monoclonal antibody on diabetic macular edema. china cont med edu. 2016; 8: 149–151 9. audren f, lecleire-collet a, erginay a, haouchine b, benosman r, bergmann jf, et al. intravitreal triamcinolone acetonide for diffuse diabetic macular edema: phase 2 trial comparing 4 mg vs. 2 mg. am j ophthalmol. 2006; 142: 794–799. 10. haritoglou c, kook d, neubauer a, wolf a, priglinger s, strauss r, et al. intravitreal bevacizumab (avastin) therapy for persistent diffuse diabetic macular edema. retina. 2006; 26: 999–1005. 11. scott iu, edwards ar, beck rw. a phase ii randomized clinical trial of intravitreal bevacizumab for diabetic macular edema. ophthalmology, 2007; 14: 1860–1867. 12. takamura y, kubo e, akagi y. analysis of the effect of intravitreal bevacizumab injection on diabetic macular edema after cataract surgery. ophthalmology, 2009; 116 (6): 1151–1157. 13. lanzagorta-aresti a, palacios-pozo e, menezo rozalen jl, naveatejerina a. prevention of vision loss after cataract surgery in diabetic macular edema with intravitreal bevacizumab. retina, 2009; 29 (4): 530–535. 14. cheema ra, al-mubarak mm, amin ym, cheema ma. role of combined cataract surgery and intravitreal bevacizumab injection in preventing progression of diabetic retinopathy. j cat refract surg. 2009; 35 (1): 18–25. doi: 10.1016/j.jcrs.2008.09.019. 15. chae jb, joe sg, yang sj. effect of combined cataract surgery and ranibizumab injection in postoperative macular edema in non-proliferative diabetic retinopathy. retina, 2014; 34 (1): 149–156. doi: 10.1097/iae.0b013e3182979b9e. 16. lin wh, lu m, tang hy, zeng zr. clinical application of ranibizumab in the therapy of diabetic cataract. guoji yanke zazhi. 2015; 15: 880–882. 17. sze am, luk fo, yip tp, lee gk, chan ck. use of intravitreal dexamethasone implant in patients with cataract and macular edema undergoing phacoemulsification. eur j ophthalmol. 2015; 25 (2): 168–172. doi: 10.5301/ejo.5000523. 18. elman mj, qin h, aiello lp, beck rw, bressler nm, ferris fl, et al. intravitreal ranibizumab for diabetic macular edema with prompt versus deferred laser treatment: three-year randomized trial results. ophthalmology, 2012; 119: 2312–2318. effects of intra-vitreal injection of bevacizumab during phacoemulsification in diabetic maculopathy pak j ophthalmol. 2021, vol. 37 (1): 7-11 11 19. hartnett me, tinkham n, paynter l. aqueous vascular endothelial growth factor as a predictor of macular thickening following cataract surgery in patients with diabetes mellitus. am j ophthalmol. 2009; 148 (6): 895-901. 20. fard ma, abyane ya, malihi m. prophylactic intravitreal bevacizumab for diabetic macular edema (thickening) after cataract surgery: prospective randomized study. eur j ophthalmol. 2011; 21 (3): 276–281. 21. cetin en, yildirim c. adjuvant treatment modalities to control macular edema in diabetic patients undergoing cataract surgery. int ophthalmol. 2013; 33 (5): 605–610. authors’ designation and contribution ali afzal bodla; associate professor: concepts, design, manuscript editing, manuscript review. syeda minahil kazmi; consultant ophthalmologist: data acquisition, data analysis, statistical analysis, manuscript review. noor tariq; consultant ophthalmologist: literature search, data analysis, manuscript preparation, manuscript editing. ayema moazzam; consultant ophthalmologist: data acquisition, statistical analysis, manuscript preparation, manuscript editing. muhammad muneeb aman; consultant ophthalmologist: literature search, data acquisition, data analysis, statistical analysis. .…  …. pak j ophthalmol. 2022, vol. 38 (1): 21-30 21 original article a national survey of endophthalmitis prophylaxis during cataract surgery in pakistan: a 2020 perspective yarrow scantling-birch 1 , hassan naveed 2 , hira khan 3 , ijaz sheikh 4 , rashid zia 5 1 university hospital sussex nhs foundation trust, 2 royal surrey county hospital, uk, 3 the agha khan university hospital, 4 east surrey hospital, surrey and sussex healthcare nhs trust, 5 new hayes bank ophthalmology services abstract purpose: to assess national endophthalmitis prophylaxis practice patterns during phacoemulsification surgery in pakistan. study design: cross sectional survey. place and duration of study: eye units registered with the british pakistani ophthalmic society (bpos) between september and november 2020. methods: a survey-based cross sectional study was conducted in pakistan between september and november 2020. a proforma was designed using a survey client (survey monkey) and distributed to the eye units registered with the british pakistani ophthalmic society (bpos). the survey explored demographic factors, current antibiotic prophylaxis practice during cataract surgery and audit practice in pakistan. results: a total of 339 respondents completed the survey. the survey was representative of ophthalmic surgeons working in the major provinces of pakistan. a small majority of ophthalmic surgeons provided some form of routine antibiotic prophylaxis (n = 140, 53.8%). povidone iodine 5% (pvp-i) solution on skin and in the conjunctival sac proved the most popular protocol (n = 163, 66.3%). this was followed by immediate postoperative topical antibiotics (n = 101, 41.1%). intracameral antibiotic prophylaxis accounted for less than half of current antibiotic practice during cataract surgery in pakistan (n=99, 40.3%). most of the respondents did not conduct any audit regarding endophthalmitis (n = 119, 55.6%). conclusion: our survey provides an up-to-date view on the state of antibiotic prophylaxis during cataract surgery in pakistan and highlights several areas for improvement. this includes policy changes to increase adherence to gold standard antibiotic prophylaxis guidelines, improvement in transparency of surgical outcomes and to audit current postoperative outcomes. key words: acute postoperative endophthalmitis, surgical wound infection, antibiotic, cataract, pakistan. how to cite this article: birch ys, naveed h, khan h, sheikh i, zia r. a national survey of endophthalmitis prophylaxis during cataract surgery in pakistan: a 2020 perspective. pak j ophthalmol. 2022, 38 (1): 21-30. doi: 10.36351/pjo.v38i1.1278 correspondence: yarrow scantling-birch university hospital sussex nhs foundation trust email: yarrow.scantlingbirch@gmail.com received: july 21, 2021 accepted: september 30, 2021 introduction endophthalmitis remains one of the most dreaded complications following modern day cataract surgery. 1 risk factors include surgical factors, such as posterior capsular rupture (pcr), vitreous loss, poor corneal wound integrity, silicon lenses and the type of operative antibiotic prophylaxis, local factors, such as open access yarrow scantling-birch, et al 22 pak j ophthalmol. 2022, vol. 38 (1): 21-30 chronic eyelid disease, and systemic factors, such as older age (above 80) and diabetes. 2 a variety of operative protocols have been used in the prevention of postoperative endophthalmitis, including topical/oral antibiotics, use of povidone iodine (pvp-i) solution, subconjunctival injection of antibiotics and antibiotics in irrigating solution. 3 in a multicentre, randomised control trial run by the european society for cataract and refractive surgeons (escrs), it was shown that intracameral cefuroxime administered at the time of surgery significantly reduced the risk of developing endophthalmitis following cataract surgery. 4 this study proved seminal in introducing the concept that intracameral antibiotics may be the new gold standard of antibiotic prophylaxis in cataract surgery. since then, multiple international centres have adopted the routine use of intracameral injections during cataract surgery and have shown a reduction in the incidence of postoperativeendophthalmitis. 5,6 a recent cochrane review summarises the growing literature that injection with cefuroxime (intracameral antibiotic prophylaxis) lowers the chance of endophthalmitis following surgery. 7 several countries and professional bodies now mandate annual audit of cataract surgery. such initiatives aid in monitoring practice standards and can ascertain the impact of antibiotic prophylaxis on the annual incidence of postoperative endophthalmitis following cataract surgery as well as provide appropriate guidelines. the royal college of ophthalmologists (rcophth), united kingdom (uk), deliver an annual national audit that covers endophthalmitis incidence 8 and the escrs have provided recent guidelines on the prevention and treatment of endophthalmitis following cataract surgery. 9 however, the practice of antibiotic prophylaxis in many developing countries, such as pakistan, remains inconsistent and unknown. the collection of robust data allows for the introduction of practice improvement guidelines in developing nations that may have limited resources. through a national survey distributed to ophthalmic surgeons operating in pakistan, our study objectives were to assess national endophthalmitis prophylaxis practice patterns during phacoemulsification surgery in pakistan. this data will help in finding out adherence of surgeons to national and international clinical standards in clinical practice and identifying strengths and weaknesses in the healthcare system. methods a cross-sectional survey-based study was conducted by the british pakistani ophthalmic society (bpos) between the period of 24 th september 2020 and 8 th november 2020.study protocol was approved by bpos before survey distribution to various ophthalmology units across pakistan via the whatsapp encrypted messaging platform (whatsapp inc, ca, usa). the survey was carried out for service improvement and guidance. therefore, ethical approval was not required for this study. no personal information was acquired from survey participants and all survey data was handled in a confidential manner. an 8–item survey was designed following a literature review on international postoperative endophthalmitis audit practice and after expert opinion from members of bpos. questions were devised to ascertain demographic details regarding the individual ophthalmology sites performing cataract surgery, the volume of surgery and the details around surgical antibiotic prophylaxis. rz designed the initial version of the survey and this was subsequently revised through three iterations by bpos. the survey employed multiple choice questions with either single or multi-select options. an ‘other’ option was provided where appropriate and respondents were allowed to elaborate on these answers. questions 1 to 2 were single – select responses, whilst questions 3 to 8were multi-select responses. ‘high-volume’ (question 2) was defined as a surgeon who carried out at least 8 cataract operations on a standard morning, afternoon or evening list that lasted between 3 – 4 hours. ‘acute-onset postoperative endophthalmitis’ (questions 4 – 5) was defined as iatrogenic infective endophthalmitis that had arisen within 6 weeks following cataract surgery. 4 the survey was created and disseminated using an online survey client (survey monkey, ca, usa). data was exported from survey monkey as a microsoft excel file (version 16, microsoft, wa, usa), which was uploaded to prism (version 9, graph pad, ca, usa) for diagram creation. data was analysed by two authors (ysb, rz). demographic details and survey responses were represented using simple statistics as counts (n) and percentages (%). multiple responses from the same survey respondent a national survey of endophthalmitis prophylaxis during cataract surgery in pakistan: a 2020 perspective pak j ophthalmol. 2022, vol. 38 (1): 21-30 23 were removed and accounted for by identifying unique internet protocol addresses. results a total of 339responses were received from all four providences of pakistan and the top 24 most populated cities (figure 1). largest responses were from major cities. high volume phacoemulsification was performed by 186 (62.3%) respondents. majority of the ophthalmic surgeons performed cataract surgery at a recognised teaching, or training institute (n = 157, 57.1%). other popular sites included private hospital (n = 84, 30.5%), private clinic (n = 54, 19.6%) or unrecognised institute (n = 24, 8.7%). charity camps were the least popular locations for performing cataract surgery (figure 1). antibiotic prophylaxis against postoperative endophthalmitis following cataract surgery varied widely amongst survey participants. there were surgeons who provided some form of routine antibiotic prophylaxis against postoperative endophthalmitis as standard operative procedure (140, 53.8%). whereas others declared no routine antibiotic prophylaxis (107, 41.2%) (figure 2). pvp – i 5% solution on skin and in the conjunctival sac was the most popular (n = 163, 66.3%). hundred respondents (43.1%) stated they had an ‘other’ regimen (off-label antibiotics, such as moxifloxacin and vancomycin, n = 51, 51%) for preparing intracameral antibiotics on the day of surgery (figure 3). most survey respondents did not conduct an annual endophthalmitis audit in their respective departments (figure 4). majority (n = 47, 41.2%) undertook audit practice for personal development. yes 62.6 37.4% % no 0 50 100 150 200 1 2 3 4 5 22 24 54 84 157 1 charity camps 2 unrecognised training institute 3 private clinic 4 private hospital 5 recognised teaching & training institute ( %) ( %) ( %) ( %) ( %)8.0 8.7 19.6 30.5 57.1 number of survey respondents (total = 275) s it e o f c a ta r a c t s u r g e r y please choose your current place of cataract surgery practice: do you preform high-volume cataract phacoemulsification surgery? please choose where you preform cataract surgery? a b c 0 20 40 60 80 100 jhang sheikhupura okara wah cantonment mardan faisalabad sahiwal gujrat sialkot kasur sargodha larkana gujranwala dera ghazi khan quetta multan rawalpindi rahim yar khan islamabad hyderabad 'other' bahawalpur peshawar karachi lahore 0 1 1 2 2 2 3 3 4 4 5 5 5 6 7 7 13 15 22 25 26 28 30 42 86 number of survey respondents (total = 339) l o c a ti o n i n p a k is ta n figure 1: demographic details of cataract surgeons in pakistan: (a) geographical location (b) volume (c) location of practice. yarrow scantling-birch, et al 24 pak j ophthalmol. 2022, vol. 38 (1): 21-30 0 50 100 150 1 2 3 4 3 15 107 140 number of survey respondents (total = 260) r e s p o n s e s ( %) ( %) ( %) ( %)1.2 5.8 41.2 53.8 1 yes, only when operating in a teaching & training setting 2 yes, only when operating in a private setting 3 no 4 yes, in all cases as standard operative procedure 0 50 100 150 200 1 2 3 4 5 6 7 8 9 10 11 1 2 15 16 33 48 59 88 99 101 163 number of survey respondents (total = 246) a n ti b io ti c p r o to c o l ( %) ( %) ( %) ( %) ( %) ( %) ( %) ( %) ( %) ( %) ( %)0.4 0.8 6.1 6.5 13.4 19.5 24.0 35.8 40.2 41.1 66.3 1 transzonular ± intravitreal injection of antibiotic 2 intracameral antibiotics not available 3 preoperative oral antibiotics 4 other (please specify) 5 antibiotics in irrigating fluid 6 methylated spirit as skin preparation 7 preoperative and postoperative topical antibiotic drops 8 combination (topical antibiotic drops & 5% povidone iodine skin preparation) 9 intracameral antibiotic ± steroid 10 postoperative topical antibiotics 11 5% povidone iodine solution on skin and in conjunctival sac do you offer routine antibiotic prophylaxis against endophthalmitis in cataract surgery?a b what is your current practice for prophylaxis against endophthalmitis in cataract surgery? c what type of intracameral protocol is available to you? 0 20 40 60 1 2 3 4 5 6 7 8 9 10 00 1 1 2 3 7 12 21 54 number of survey respondents (total = 101) t y p e o f in tr a c a m e ra l p r o to c o l ( %) ( %) ( %) ( %) ( %) ( %) ( %) ( %) 0 ( %) 0 ( %) 53.5 20.8 11.9 6.9 3.0 2.0 1.0 1.0 0.0 0.0 1 intracameral cefuroxime + steroid (triamcinolone acetonide) 2 intracameral vancomycin + steroid (triamcinolone acetonide) 3 intracameral moxifloacin + steroid (triamcinolone acetonide) 4 intracameral vancomycin + steroid (dexamethasone) 5 intracameral antibiotics not available 6 intracmeral vancomycin only 7 intracameral cefuroxime + steroid (dexamethasone) 8 intracameral moxifloacin + steroid (dexamethasone) 9 intracameral cefuroxime only 10 intracameral moxifloxacin only figure 2: antibiotic prophylaxis amongst ophthalmic surgeons: (a) yes / no (b) type of abx (c) type of intracameral ab×. a national survey of endophthalmitis prophylaxis during cataract surgery in pakistan: a 2020 perspective pak j ophthalmol. 2022, vol. 38 (1): 21-30 25 the type of commercial, off-label antibiotic used (n = 49) what types of intracameral antibiotics are available to you? please specify the ‘other regimes’ used in your practice (n = 100)a b c 0 50 100 150 1 2 3 4 8 32 95 100 number of survey respondents (total = 232) r e s p o n s e s 3.4( %) ( %)13.8 ( %) ( %)40.9 43.1 1 prepared by hospital pharmacy 2 licensed, commercially available intracameral cefuroxime (aprokam) 3 prepared by theatre staf f on the day from commercially available, of f-label formulations 4 other regimes off-label antibiotics (e.g. moxifloxacin, vancomycin) 51.0 37.0 10.0 1.0 1.0 % % % % % not using intracameral antibiotics not available antibiotics and steroids intravitreal antibiotics vigamox unspecified commerical prep moxigon avelox zinacef 61.2% % % % % 32.7 2.0 2.0 2.0 figure 3: type of intracameral antibiotics used: (a) preparation (b) ‘other’ regimes (c) off-label antibiotics. 0 50 100 150 yes no 114 119 number of survey respondents (total = 214) r e s p o n s e s 53.3( %) ( %)55.6 0 50 100 150 1 2 3 4 12 53 59 119 number of respondents (n = 212) r e s p o n s e s ( %) ( %) ( %) ( %)5.7 25.0 27.8 56.1 1 other 2 cataract and refractive association pakistan 3 escrs guidelines 4 learned behaviour from seniors a do you or your institution do annual endophthalmitis audit in your cataract practice? what is the rationale behind your current practice of antibiotic prophylaxis? b what is your rationale behind your current audit practice? 0 10 20 30 40 50 1 2 3 4 5 6 2 2 4 25 34 47 number of survey respondents (total = 1 14) r e s p o n s e s ( %) ( %) ( %) ( %) ( %) ( %)1.8 1.8 3.5 21.9 29.8 41.2 1 mandatory requirement for licence renewal 2 annual audit for legal reasons within private practice 3 annual audit for legal reasons within training & teaching institute 4 annual audit for service improvement within private practice 5 annual audit for service improvement within training & teaching institute 6 personal development c figure 4: the audit and service improvement practice amongst ophthalmic surgeons: (a) yes / no (b) rationale behind audit (c) rationale behind antibiotic prophylaxis. yarrow scantling-birch, et al 26 pak j ophthalmol. 2022, vol. 38 (1): 21-30 discussion this survey provides the latest update on cataract surgery practice in pakistan. intracameral injection of cefuroxime is the gold standard in cataract surgery for endophthalmitis prevention after several international landmark studies. 4–6 our survey demonstrated this was only the third most common (40.2%) endophthalmitis prophylaxis practice in pakistan, despite evidence showing that the incidence of postoperative endophthalmitis could be reduced to as low as 0.014%. 10 the most common endophthalmitis prophylaxis intervention used in pakistan was preoperative pvp-i antiseptic solution on the skin and in the conjunctival sac (66.3%). the incidence of endophthalmitis can be reduced up to 4 – fold with pvp – i. 11 novel routes of pvp – i administration are being explored, including intravitreal injection and combining with surgical irrigation fluid. 12 the causative organisms in postoperative endophthalmitis are gram-positive bacteria in the overwhelming majority of cases. these are typically coagulase-negative staphylococci (of which staphylococcus epidermis is the most common) or staphylococcusaureus. 13 however, the microbial spectrum of post-cataract endophthalmitis has geographical variation due to antibiotic practice and local antisepsis protocols, with countries such as india and china reporting higher percentages of cultured gram-negative bacteria and fungal cases. 14 a landmark study in 1995 by the endophthalmitis vitrectomy study (evs) group 15 set the early standards for the management of postoperative endophthalmitis. the group recommended the omission of systemic antibiotic treatment, due to the potential toxic side effects and low penetrance in the eye. early pars plana vitrectomy (ppv) was only recommended for individuals presenting after cataract extraction, or lens implantation, with a visual acuity of light perception. subjects who had a visual acuity of hand motions and above had no advantage with immediate ppv and local antibiotic therapy should remain the mainstay of treatment. local antibiotics achieve sufficient ocular therapeutic levels to inhibit the growth of many bacteria responsible for endophthalmitis, reducing the risk of systemic toxicity and the need for longer hospital stay. 16 following the evs group, the escrs study 4 evaluated the effects of intracameral cefuroxime compared to other antibiotic protocols: no perioperative antibiotics, topical antibiotics only, combination therapy (topical and intracameral antibiotics) and placebo group. the study concluded that the use of intracameral cefuroxime (injection of 1mg at the end of surgery) reduced the incidence of postoperative endophthalmitis 5-fold, proving superior to other local antibiotic protocols. this evidence of intracameral antibiotics is supported by numerous global studies. 4–6 to date, the most commonly used intracameral antibiotics are cefuroxime, moxifloxacin and vancomycin. in europe, aprokam® (cefuroxime) has been approved by the european medicines agency (ema) as a commercially available intracameral cefuroxime injection. in us, there is no food and drug administration (fda) approved intracameral antibiotics, therefore antibiotic solutions need to be constituted prior to injection on the day of surgery. vancomycin is considered the drug of choice for gram-positive organisms, including methicillinresistant staphylococcal species. however, it has no cover for anaerobic or gram-negative organisms. moxifloxacin (for example, vigamox®, auromox®) is another alternative with a broad spectrum of coverage, including gram-positive, gram-negative and pseudomonas, but may be becoming less effective due to growing resistance. 17 in india, a country that conducts over one million routine cataract operations each year and has close proximity to pakistan, moxifloxacin has been a staple brand of locally manufactured intracameral injection since 2013 due to two indian pharmaceutical companies. after a recent online survey of cataract practice in india, it was established that intracameral moxifloxacin contributed to 90% of antibiotic prophylaxis. 18 out of the three commonly used intracameral antibiotics, cefuroxime had the greatest evidence having been studied in randomised control trials (rct) and large prospective studies, 4–6 as well as gained approval by european regulatory bodies. our survey of endophthalmitis prophylaxis in cataract surgery demonstrated that intracameral moxifloxacin was the most popular choice (53.5%) of commercially repurposed and off-label intracameral antibiotic used in pakistan. this was followed by the gold standard – intracameral cefuroxime (20.8%) – and then combination therapy (moxifloxacin plus steroid, 11.9%). when questioned on the type of preparation of intracameral moxifloxacin, 61.2% of survey respondents selected vigamox®, which remains the a national survey of endophthalmitis prophylaxis during cataract surgery in pakistan: a 2020 perspective pak j ophthalmol. 2022, vol. 38 (1): 21-30 27 popular choice amongst ophthalmic surgeons in pakistan. however, there are several disadvantages regarding moxifloxacin. due to a dose-dependent response, an initial high dose maybe required to provide adequate antibiotic prophylaxis against specific bacterial species: staphylococcus and pseudomonas. 13 from anecdotal evidence, it is often routine for ophthalmic surgeons in pakistan to use one bottle of commercially available antibiotic throughout the day, raising the question of antibiotic lifespan and efficacy as sequential doses are used in multiple theatre cases. finally, there is a rise of antibiotic resistance to moxifloxacin due to exposure to bacterial colonies present in the ocular and nasopharyngeal flora. 14 other intracameral antibiotics that were routinely used by survey respondents included cefuroxime (20.8%) and vancomycin (3.0%), which also provide adequate cover for certain bacterial species. however, resistance may also be developing to these traditional intracameral antibiotics. 4 this raises concerns for developing nations, such as pakistan, who do not routinely conduct audits in cataract surgery and may not spot trends in growing antimicrobial resistance. the optimum distribution of surgical care in middle to low-income countries is debated amongst national policy makers and governments. there is lack of infrastructure in delivery of safe surgical care, maldistribution of a surgical workforce and reduced healthcare funding in low – income countries. our survey shows there is a wide distribution of cataract practice in pakistan, ranging from the private to charitable sector, which can lead to an unequal distribution of postoperative endophthalmitis cases. independent and private practices are more likely to have state-of-the-art technology, sterile equipment, cleaner airflow systems and personal protective equipment that contribute to reduced complications following cataract surgery. recognised training institutes are more likely to have recognised training programmes, centralised cataract services for a particular region and optimised theatre protocols. in comparison, charity camps may operate in less sterile environments, use only basic antiseptic protocols and re-use surgical instruments amongst cases. despite these factors, the outcomes between larger, recognised cataract units and cataract camps are not dissimilar with respect to visual acuity and complication rates. 19 this might be explained by the fact that the same local ophthalmic professionals that operate in larger units, or privately, may undertake charitable work in cataract camps. there is also an increasing influx of foreign ophthalmologists that are running charitable organisations and outreach programmes to contribute to the improvement of reversable causes of blindness. finally, there is new evidence exploring the outcomes of manual small – incision cataract surgery (msics), which tends to be more commonly performed in low-resource and charitable settings due to the superior cost-benefit analysis to traditional phacoemulsification. studies have shown postoperative endophthalmitis rates with msics are comparable to high-income countries using phacoemulsification. 20 the technical skills of an ophthalmic surgeon is another important factor in considering postoperative cataract surgery outcomes. a large cohort study observed that newly-qualified surgeons undertaking independent practice were 9 times more likely to have high complication rates (greater than 2%), including endophthalmitis, when compared to surgeons in their tenth year of practice. 21 in addition, studies have shown that increasing surgical volume has correlation with better visual acuity outcomes and less complications following cataract surgery. 22 an estimate of 350 cataract cases per year, or greater than 2 years of independent surgical practice, have been suggested as requirements to maintain high-volume and low – complication status amongst ophthalmic surgeons. diminishing returns and statistically insignificant differences are seen beyond these arbitrary values otherwise. 20 clinical audits are a method of ensuring that healthcare is provided in line with set standards. it allows care providers, as well as patients, know if a service is performing well, or if improvements can be made. just over half of survey respondents did not conduct an annual endophthalmitis audit in their respective departments (n = 119, 55.6%). these figures do not provide confidence in creating standardised and safe cataract surgery practice for pakistan, especially when audit data remains in the hands of individual surgeons, and latest guidelines from leading professional societies, such as escrs, remain ignored. 4 there is a push for increasing contribution and transparency for national audits of postoperative cataract complications. examples include the british ophthalmology surveillance unit (buso), which runs yarrow scantling-birch, et al 28 pak j ophthalmol. 2022, vol. 38 (1): 21-30 the national ophthalmology database (nod) 8 ;a database that specifically measures outcomes following cataract surgery, including postoperative infections. unfortunately there are a lack of national registries or audits with respect to postoperative cataract complications in south asia. malaysia has been exempla in setting up a national cataract registry (national eye database 23 ) and inviting all ophthalmologists operating within government and university-funded hospitals participate in this registry, which also explores the incidence of postoperative endophthalmitis and delivers on regular annual reports. other countries, such as india, are trialling the early stages of a registry and agree that auditing is required to implement uniform national policy and protocol for cataract surgery. 24 reporting standards and registries allow for increased transparency of practice amongst ophthalmologists, set targets for the reduction of postoperative complications, improvement in practice guidelines and associated cost savings. 25 to ensure the highest quality of audit and national data registry, bpos has commissioned and made available a free, state-of-the-art, web-based electronic patient care summary record for all pakistani ophthalmologists. the electronic record is designed to promote data collection and is capable of generating robust audits of postoperative complications, visual and refractive outcomes following cataract surgery. strength of this study is that it looks at the latest update of cataract surgery practice in pakistan, focusing primarily on postoperative endophthalmitis prophylaxis. it is a heterogenous survey that covers all four provinces of pakistan and all types of cataract centres, from recognised teaching units to charity eye camps. in addition, the survey questions were internally validated with senior members of bpos who were highly aware of the type of practice that may be occurring in pakistan. through a collaborative effort between bpos and the ophthalmological society of pakistan, the major hope is this study aids in defining national standards of cataract practice in pakistan. limitations associated with this study include firstly the sample size, which may just contribute to only a snapshot of ophthalmic practice in pakistan, and not necessarily reflective of the wider ophthalmic community. secondly, there is a volunteer bias with respect to survey responses, especially if this survey response were disseminated via a professional society with a limited contact list. thirdly, this study is not generalisable to other developing nations, which will have factors such as local antibiotic practices and environmental factors impacting the postoperative endophthalmitis rates. finally, certain questions were identified retrospectively to be poorly worded to deliver on an intended outcome (for example, please specify the ‘other regimens’ used in your practice) and may have been treated as a repeat question. however, discussion points drawn from these biased questions were limited. conclusion the burden of postoperative cataract complications, especially infection, is felt largely in developing nations. our survey provides an up-to-date view on the state of antibiotic prophylaxis following cataract surgery in pakistan and highlights several areas for improvement. this includes policy changes to increase adherence to gold standard antibiotic prophylaxis guidelines, improvement in transparency of surgical outcomes and to audit current postoperative outcomes. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. friling e, lundström m, stenevi u, montan p. sixyear incidence of endophthalmitis after cataract surgery: swedish national study. j cataract refract surg. 2013; 39 (1): 15-21. doi: 10.1016/j.jcrs.2012.10.037. 2. cao h, zhang l, li l, lo s. risk factors for acute endophthalmitis following cataract surgery: a systematic review and meta-analysis. plos one, 2013; 8 (8): e71731. doi: 10.1371/journal.pone.0071731. 3. garg p, roy a, sharma s. endophthalmitis after cataract surgery: epidemiology, risk factors, and evidence on protection. curr opin 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10.1097/j.jcrs.0000000000000217 21. campbell rj, el-defrawy sr, gill ss, whitehead m, campbell el, hooper pl, et al. new surgeon outcomes and the effectiveness of surgical training: a population-based cohort study. ophthalmology, 2017; 124 (4): 532-538. doi: 10.1016/j.ophtha.2016.12.012. epub 2017 jan 24. erratum in: ophthalmology, 2017; 124 (12): 1879. 22. bell cm, hatch wv, cernat g, urbach dr. surgeon volumes and selected patient outcomes in cataract surgery: a population-based analysis. ophthalmology, 2007; 114 (3): 405-410. doi: 10.1016/j.ophtha.2006.08.036. epub 2006 dec 14. 23. goh p, mohamad a. the 5th report of the national eye database 2011. available at: http://www.acrm.org.my/ned/cataractsurgeryregistry.h tml. accessed december 10, 2020. 24. lahane tp. tackling the cataract backlog an initiative by the maharashtra state, india. indian j ophthalmol. 2018; 66: 1391–1393. 25. yorston d, wormald r. clinical auditing to improve patient outcomes. community eye heal. 2010; 23: 48– 49. authors’ designation and contribution yarrow scantling-birch; foundation year 2 doctor: literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. hassan naveed; registrar: literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. hira khan; clinical year 3 student: literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. yarrow scantling-birch, et al 30 pak j ophthalmol. 2022, vol. 38 (1): 21-30 ijaz sheikh; consultant ophthalmologist: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. rashid zia; lead ophthalmologist: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. .…  …. pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 117 case report posterior uveal effusion syndrome following ectopia lentis surgery in a case with marfan's syndrome ozgur bulent timucin, mehmet fatih karadag, mehmet baykara, m. emin aslanci pak j ophthalmol 2016, vol. 32 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ozgur bulent timucin urartu eye centre, i̇pekyolu-van turkey email: bulenttimucin@gmail.com received: february 21, 2016 accepted: june 05, 2016 …..……………………….. to describe a case of acute uveal effusion with hypermetropic refraction that was limited to the posterior pole in a patient with marfan’s syndrome and bilateral ectopia lentis who underwent surgery for her left eye. a 22-year-old female with marfan’s syndrome and concomitant bilateral ectopia lentis was admitted for surgery on her left eye. on post-operation day one, we detected a shallow posterior uveal effusion (ue) and disc edema that did not include peripheral retina. shallow posterior ue and disc edema were almost totally recovered after 3 weeks of the operation. to the best of our knowledge, this is the first case of marfan’s syndrome with concomitant ectopia lentis in medical literatures who had uveal effusion limited to the posterior pole after surgery. it is considered as marfan's syndrome might be a predisposing factor for posterior ue. key words: choroidal diseases, lentis ectopia, hypermetropia, marfan's syndrome, posterior uveal effusion syndrome. veal effusion (ue) is characterized by abnormal fluid collection in the suprachoroidal area following surgery and usually occurs in hyperopic eyes with abnormally thick scleras1. although it is often reported after intraocular surgery, rarely, non-surgical reasons including inflammation, infections, trauma, neoplasm, drug reactions, pan retinal photocoagulation, corneal ulcer and venous congestion have also been reported.2 visual acuity is generally decreased due to the affected visual axis. it usually starts from the pars plana or the ora serrata and spreads through the eye to the equator and sometimes to the posterior pole. uveal effusion that is limited to the posterior pole is rare3,4. there is no clearly defined predisposing factor of ue. to the best of our knowledge, there are no cases with uveal effusion in marfan’s syndrome that are related or unrelated to surgery. marfan’s syndrome is an inherited disease that affects connective tissues which provides strength, support and elasticity to tendons, heart valves, blood vessels, ocular tissues, and other vital tissues of the body5. depending on the extend of genetic expression, cardiovascular, locomotor and ocular system abnormalities may occur5. ectopia lentis is the most frequent eye pathology in marfan’s syndrome6. in this report, we present a young female patient with marfan’s syndrome who had ectopia lentis and had posterior ue with acute hyperopic refraction following surgery of her left eye. case report a 22-year-old female with marfan’s syndrome presented to our outpatient clinic with the complaint of decreased vision. the patient met the criteria for marfan’s syndrome with characteristic ocular, locomotor and cardiovascular findings. the patient with marfan’s syndrome and concomitant bilateral ectopia lentis was admitted for surgery on her left eye. u ozgur bulent, et al 118 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology left lensectomy, anterior vitrectomy and intraocular lens implantation using scleral fixation were planned. retrobulbar anesthesia was applied (a mixture of bupivacaine 0.75% and lidocaine 2%). on postoperation day one, we performed fundoscopy and detected shallow posterior ue and disc edema that did not include peripheral retina. there was a mild anterior chamber reaction. anterior chamber depth was 2.95 mm. we did not detect any leakage with seidel test. we discovered acute hypermetropic shift related to posterior shallow uveal effusion (fig. 1). on post-operation day 1 refraction was +14.00 +2.00 × 80. best corrected visual acuity was 5/200 on the first day after the operation. axial length decreased from 25.34 mm to 21.25. topical antibiotic, cycloplegic agent (1% cyclopentolate qid), topical steroid (prednisolone acetate, per hour) as well as oral steroid (prednisolone 32 mg/day) and acetazolamide (500 mg/day) were given. after the 3rd day post-operation, axial length was 22.50 mm, refraction was +10 +2.25 × 90 and corrected visual acuity was 20/200. on post-operation day 10, visual acuity was 20/50, refraction was + 6.00 +200 × 90 and axial length was 24.01 mm. regular post operative fundoscopy showed that retinal folds and fig. 1: left fundus on post-operation day 2 and day 20. disc edema and folds (arrow heads) around the optical nerve are disappearing after topical and systemic steroid treatment. disc edema began to disappear the first week after the operation. after 3 weeks of the operation, corrected visual acuity was 16/20, axial length was 25.16 mm and refraction was +1.00 +200 × 85. shallow posterior ue and disc edema were almost totally recovered after 3 weeks of the operation (fig. 2, 3). fig. 2: a. 3–d oct image of the left eye, on postoperation day 2. b. disc edema and folds around the optic nerve had resolved on post-operation day 20. c. 3-d oct image of a normal fellow eye of the same patient. m = macula, od: optic disc, s: superior, t: temporal. fig. 3: subluxated lens before surgery. anterior segment on post-operation day 2 and day 20. discussion uveal effusion is choroidal capillary leakage and accumulation of this fluid in the space between uvea and sclera. there is no clear, well – defined genetic predisposition of ue and risk factors are also unclear. the most important risk factor is low intraocular pressure. also, inflammation related to surgery is also posterior uveal effusion syndrome following ectopia lentis surgery in a case with marfan's syndrome pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 119 associated with serous choroidal detachment. it can be thought that decreasing intraocular pressure and preventing inflammation may decrease the risk of ue. inflammation increases the capillary permeability of choroid and a decrease in intraocular pressure may enhance the fluid collection in the interstitial space. uveal effusion is related to increased capillary permeability of the choroid, decreased intraocular pressure as a result of an increased outflow of aqueous humor, disrupted scleral permeability as seen in nanopthalmic eyes and decreased production of aqueous humor as a result of iridocyclitis. it was thought that ue is more common at the anterior side of the equator because uveoscleral connections at this part are weak7. the form that is limited to the posterior pole is rare3,4. in our case, predisposing factors for ue included trauma of surgery, hypotony, minimal inflammation and combinations of these factors. on the other hand, gass hypothesized that aging, hormonal changes in the collagen and ground substance of the congenitally abnormal sclera are responsible for reducing the scleral permeability to protein8. in time the eye becomes incapable of handling even small amounts of extravascular protein occurring from minor injuries to the uveal vasculature. in this respect it is not clear whether marfan’s syndrome, a congenital disorder of collagen that exist in vascular tissue and in the sclera, has any direct effect on the pathogenesis of posterior ue or not. local inflammation may provoke effusion at the posterior pole by increasing permeability in the choroidal vessels. in our case, it can be suggested that subtenon’s anesthesia may stimulate the sclera around the injection area increasing intraorbital pressure temporarily and this may induce a local inflammatory reaction that reaches to the choroid9. similarly, during the retrobulbar anesthesia, retrobulbar venous flow might be damaged which could affect the choroidal circulation. moreover, it has been shown that injected medications may pass through the choroidal circulation even if there is no retrobulbar venous damage10. although, our patient did not report any drug sensitivity, she could have developed a hypersensitivity reaction to the injected substances (mixture of bupivacaine 0.75% and lidocaine 2%). there are several mechanisms that can explain the unexpected hyperopic shift after surgery. incorrect iol power or intraocular fluid leakage causing shortening in the axial length may explain hyperopic shift. in our case, however, abnormal fluid collection in the suprachoroidal area caused an internal elevation of the choroid and formation of folds in the retina thereby shortening the axial length. during follow-up, retinal folds disappeared and axial length reached the pre-operative levels as accumulated fluid receded. we conclude that acute hyperopic shift following surgery for ectopia lentis in the marfan’s syndrome should cause one to suspect a posterior ue syndrome. it was observed that monitoring axial length, refractive changes, fundus imaging and proper treatment were adequate for the patient. on top of that, it is considered as marfan’s syndrome, a congenital disorder of collagen might be a predisposing factor for ue. author’s affiliation ozgur bulent timucin urartu eye centre, i̇pekyolu-van, turkey mehmet fatih karadag istanbul hospital, department of ophthalmology, van, turkey mehmet baykara uludag university, school of medicine, department of ophthalmology, bursa, turkey m. emin aslanci uludag university, school of medicine, department of ophthalmology, bursa, turkey role of authors: ozgur bulent timucin concept and design, data collection, critical analysis. mehmet fatih karadag concept and design, data collection, literature review. mehmet baykara critical analysis, technical support. m. emin aslanci critical analysis, technical support, data collection. references 1. bellows ar, chylack lt, jr, hutchinson bt. choroidal detachment. clinical manifestation, therapy and mechanism of formation. ophthalmology. 1981; 88: 1107-15. 2. davani s, delbosc b, royer b, kantelip jp. choroidal detachment induced by dorzolamide 20 years after cataract surgery. br j ophthalmol. 2002; 86: 1457-8. ozgur bulent, et al 120 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology 3. pautler se, browning dj. isolated posterior uveal effusion: expanding the spectrum of the uveal effusion syndrome. clin ophthalmol. 2014; 9: 43-9. 4. brubaker rf, pederson je. ciliochoroidal detachment. surv phthalmol. 1983; 27: 281-9. 5. comeglio p, evans al, brice g, cooling rj, child ah. identification of fbn 1 gene mutations in patients with ectopia lentis and marfanoid habitus. br j ophthalmol. 2002; 86: 1359-62. 6. rubin se. nelson lb. ocular manifestations of autosomal dominant systemic conditions. duane’s clinical ophthalmology on cd-rom. vol. 3. ch. 58. philadelphia: lippincott williams and wilkins, 2006. 7. lee yy, sheu sj. acute hyperopic shift in refraction associated with posterior choroidal detachment following phacoemulsification surgery. eur j ophthalmol. 2011; 21: 328-30. 8. gass jd. uveal effusion syndrome: a new hypothesis concerning pathogenesis and technique of surgical treatment. retina. 1983; 3: 159-63. 9. suto c, mita s, hori s. choroidal detachment after uncomplicated small incision cataract surgery. case rep ophthalmol. 2012; 3: 175-9. 10. lincoff h, stanga p, movshovich a, palleroni a, madjarov b, rivera r, silverman r. choroidal concentration of interferon after retrobulbar injection. invest ophthalmol vis sci. 1996; 37: 2768-71. http://www.ncbi.nlm.nih.gov/pubmed?term=lincoff%20h%5bauthor%5d&cauthor=true&cauthor_uid=8977493 http://www.ncbi.nlm.nih.gov/pubmed?term=stanga%20p%5bauthor%5d&cauthor=true&cauthor_uid=8977493 http://www.ncbi.nlm.nih.gov/pubmed?term=movshovich%20a%5bauthor%5d&cauthor=true&cauthor_uid=8977493 http://www.ncbi.nlm.nih.gov/pubmed?term=palleroni%20a%5bauthor%5d&cauthor=true&cauthor_uid=8977493 http://www.ncbi.nlm.nih.gov/pubmed?term=madjarov%20b%5bauthor%5d&cauthor=true&cauthor_uid=8977493 http://www.ncbi.nlm.nih.gov/pubmed?term=rivera%20r%5bauthor%5d&cauthor=true&cauthor_uid=8977493 84 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology original article role of propranolol in the management of periocular infantile hemangioma seema qayyum pak j ophthalmol 2016, vol. 32, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. seema qayyum mbbs, fcps (ophthalmology) associate professor and head of department pediatric ophthalmology the children’s hospital and institute of child health, lahore email: seemaqayyum@gmail.com received: may 31, 2016 accepted: june 30, 2016 …..……………………….. purpose: to find the efficacy of oral -blocker propranolol in the management of periocular infantile hemangioma in the pediatric population. study design: prospective interventional case series. place and duration of study: department of pediatric ophthalmology, the children's hospital and institute of child health, lahore (dec. 14 – dec. 15). material and methods: in this study we included 15 patients found to be suffering from vision – threatening hemangioma. patients were evaluated as per protocol approved in our hospital adapted from international studies. all patients underwent a complete medical examination by a pediatrician, cardiologist, and a dermatologist. when needed an mri was arranged. oral propranolol was initiated between one month to twelve months of age. results: a total of fifteen patients were treated with oral propranolol. there was a dramatic improvement with complete resolution of the lesion in 66.6% of patients. in two patients (13.3%) there was more than 50% decrease in the size of the lesion, whereas there was cessation of growth in two patients (13.3%). none of the patients developed any significant complication. the duration of drug use ranged from two to ten months, mean being 5.2 months with a standard deviation of 1.8. propranolol was weaned off by tapering the dose over a period of two weeks on discontinuation of the drug. conclusions: oral propranolol significantly reduces the size of vision threatening periocular hemangiomas with minimal or no side effects. key words: peri-ocular hemangioma, propranolol,, beta blockers emangioma are the most common benign soft tissue tumor of infancy. they belong to the group of congenital vascular anomalies being historically referred to as vascular birth marks2. this entity is seen more frequently in females, premature infants, twins and in babies born to mothers of higher maternal age3. the pathogenesis of hemangioma remains unclear most likely arising from hematopoietic progenitor cells. ―altered levels of matrix metalloproteinase (mmp-9) and proangiogenic factors (vegf, b-fgf, and tgf-beta 1) appear to be responsible for the development and persistence of infantile hemangioma‖4,5. the life cycle of hemangioma can be differentiated into three distinct developmental phases (table 1)2,6,7. in majority of cases of infantile hemangiomas, only counselling and reassurance of the parents are required. however, nearly 40% of children suffering of infantile hemangioma require intervention because of serious complications.8 intralesional and systemic corticosteroids have been the first line medical therapy until recently in complicated and aggressive hemangiomas. in cases of steroid-unresponsive hemangiomas interferon-α and vincristine have been tried. these modalities of treatment are not free of serious and long lasting side effects. in 2008, a group of physicians from bordeaux children’s hospital in h role of propranolol in the management of periocular infantile hemangioma pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 85 table 1: developmental phases of hemangiomas. proliferation first three months of life. may result in ischemia, necrosis, ulceration and bleeding quiescence 9 – 12 months of age there is no or slow growth involution this phase is heralded with a change in the color of overlying skin with shrinking of deeper components. occurs in 70% of cases by seven years of age france noted a regression in the size of extensive infantile hemangiomas, in patients who received treatment with propranolol for obstructive hypertrophic cardiomyopathy and high cardiac output9. since then propranolol has been used widely by dermatologist, ophthalmologist and pediatricians for the management of aggressive infantile hemangiomas. in this article we present our experience in treating periocular and orbital hemangiomas with oral propranolol. material and methods a prospective interventional study was conducted in the department of pediatric ophthalmology of children’s hospital and institute of child health, lahore between december 2014 and december 2015. all patients who presented in the pediatric ophthalmology outpatient clinic, with vision threatening infantile hemangioma, were included in the study. they were treated in accordance with the protocol adopted by the department in line with lawley and colleagues10 (figure 1). a screening ecg was done in all patients. all except two patients had normal screening ecg. both of them underwent echocardiogram with normal results as per advice of the pediatric cardiologist. four patients had significantly large segmental facial hemangioma. they were evaluated in detail by the cardiologist, neurologist and dermatologist to rule out any systemic association. mri of the face and head was advised in these patients. no other systemic association was identified in these patients. one patient had involvement of parotid gland as well. she began taking propranolol after unsuccessful treatment with systemic steroids. the remaining patients received propranolol as their initial and only intervention. consultation was done with the pediatric cardiologist so as to determine the dose of propranolol. figure 1: pretreatment evaluation of patients. seema qayyum 86 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology table 2: ―protocol for administration and discontinuation of propranolol‖1. preparation 10mg in the form of tablets (instruction to the mother/guardian-crush the tablets and give the powder in divided dose, can be given to the infant mixed with honey) dosing 0.5mg/kg/day in 3 divided dosed as starting dose. 1.0mg/kg/day in 3 divided dosed for the three days 1.5mg/kg/day in 3 divided dosed for three days 2.0mg/kg/day in 3 divided dosed for three days monitoring blood pressure/heart rate are monitored after any increase in dosage, including initial administration. follow up every 4 – 6 weeks with serial photographs/mri (if indicated) instructions to the mother/guardian there should be minimum six – hour interval between doses as the child may develop hypoglycemia the mother was instructed to feed the child after every dose. parents should be educated as regards identifying signs of hypotension, bradycardia and hypoglycemia discontinuation reduce dose over 2-3 week period. figure 2: grading scale of response of treatment.1 the patient was kept under observation for 4 – 6 hours after administration of first dose, so as to monitor for any change in blood pressure and heart rate. in the absence of any untoward effect he/she was allowed to go home. the infant’s care givers were trained to identify signs and symptoms of adverse reaction to propranolol and were advised to have their child examined by their local primary care physician in the event of any untoward reaction of the drug. advice was also given to the parents against abrupt discontinuation of the drug as it may result in rebound growth of the lesion. the treatment was initiated with 25% of the full dose of propranolol (0.5 mg/kg/day) slowly increasing to full maintenance dose of 2 mg/kg/day given in three divided doses (table 2)1. patients were initially monitored every two to three weeks and later every four to six weeks thereafter. photographic documentation was done at all examinations. if need be a repeat mri was obtained after four weeks of initiation of treatment and before cessation of treatment. the treatment continued until there was complete regression or resolution to the point of eliminating visual compromise. at this pointthe dose of propranolol was tapered over the course of two to three weeks. adapting from the study published in 2010 in journal of american academy of pediatrics ophthalmology and strabismus the results were defined as ―excellent, good, fair and poor‖ (figure 3)1. results a total of fifteen children age one month to a year were included in the study. mean age being 2.8 months with a standard deviation of 1.4. out of fifteen role of propranolol in the management of periocular infantile hemangioma pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 87 patients twelve were females i.e. 80% (graph 1). ten patients (66.6%) had involvement of the upper lid with obscuration of the visual axis. large hemangioma involving the distribution of trigeminal nerve were seen in 3 patients (20%). there was involvement of parotid gland along with orbit in one patient (6.6%). one patient with lower lid involvement was included in the study as it was cosmetically unacceptable by the parents. the duration of treatment ranged from two to ten months. the mean duration being 5.2 months with a standard deviation of 1.8. in ten (66.6%) of the fifteen patients there was a dramatic decrease in the size of the hemangiomas (graph 2). none of the patient experienced any significant complication. mother of only one patient noted that the child appeared to sleep for longer hours during the first three weeks of starting the therapy. graph 1: gender distribution. table 3: age range of patients. age of patient n patients 0 – 1 month 2 1 – 2 months 4 2 – 3 months 4 3 – 4 months 2 4 – 5 months 1 5 – 6 months 2 mean age 3.3 months total = 15 discussion infantile hemangiomas are often imperceptible at birth having a period of rapid proliferation followed by gradual involution12. given the natural history of involution, observation and waiting is the best management of this disease entity. however, in cases where the hemangioma involves a vital structure causing a functional problem or permanent disfigurement treatment should be sought13. the treatment of hemangioma with intralesional and systemic steroids have frequent and even serious side effects1,14. even after successful regression rebound of growth can occur following cessation of treatment with steroids15. table 4: duration of treatment. duration of treatment n patients 2 months 2 4 months 3 5 months 2 6 months 3 7 months 1 8 months 2 10 months 2 total number of patients 15 graph 2: response to propranolol. propranolol is commonly used by pediatric cardiologists in infants for the management of various seema qayyum 88 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology cardiac disorders like dysrhythmias, idiopathic hypertrophic sub-aortic stenosis, paroxysmal hypoxemic spells and congestive heart failure. frequently seen side effects of propranolol being bradycardia, hypotension, and hypoglycemia. a comprehensive review of literature was undertaken before starting this study so as to fig 3: at birth – large facial hemangioma also involving right eye. fig 4: one month after initiation of treatment. fig 5: 4 months after initiation of treatment. understand the current clinical practice for the management of infantile hemangioma. a pubmed as well as google scholar search, using the terms propranolol and infantile hemangioma yielded approximately 200 articles. majority of these publications were retrospective reports and literature meta – analysis. although response to therapy with propranolol was discussed in majority of articles, no definite definition and measures of response was identified. the terms used for response to therapy varied widely from ―stabilization‖ to ―complete resolution‖ of the lesion16. positive response in all treated patients was reported in 90% of publications. only a few articles reported treatment failures (1.6%). thus on the basis of literature search, use of propranolol appears to be a safe modality for the treatment of periocular and orbital infantile hemangioma children17. the most significant and frequent reported serious complication are ―asymptomatic hypotension, pulmonary symptoms related to direct blockade of adrenergic bronchodilation, hypoglycemia, hypoglycemic seizure, asymptomatic bradycardia and hyperkalemia‖18,19. in our study 73.33% of cases had almost complete resolution of the lesion following treatment with oral propranolol whereas 13.3% showed a decrease in size of more than 50%. we did not encounter any significant side effect in our patients. taking into consideration the natural tendency of involution of disease the role of the pediatric role of propranolol in the management of periocular infantile hemangioma pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 89 ophthalmologist is to identify which infant is at a high risk for development of complications and thus in need for systemic treatment13. treatment with oral propranolol should be considered in presence of serious complications, such as impairment of visual function, proptosis and permanent disfigurement. before the initiation of therapy, risks of adverse effects should be carefully considered and weighed against the potential benefits of treatment (table 4)20. it is most appropriate to have an interdisciplinary approach involving medical, cardiac and ophthalmic team with expertise in both the management of infantile hemangioma and the use of oral propranolol in infants in order to provide the most optimal care. table 4: risks of propranolol use. contraindications to propranolol adverse effects of propranolol cardiac shock hypotension sinus bradycardia hypoglycemia hypotension bradycardia bronchial asthma sleep disturbance heart failure gastro esophageal reflux hypersensitivity to propranolol hydrochloride hyperkalemia despite being aware of the potential side effects of propranolol we at children’s hospital were encouraged by the reports in literature of the drug being well tolerated by infants when initiated in standard doses. our experience with the use of oral propranolol for the management of difficult infantile hemangioma in children has been very rewarding. we hope that our results will encourage others to further explore the safety and effectiveness of this modality of treatment. when faced with the challenge of treating a child with infantile hemangioma following key points should be kept in mind: pre-treatment ecg should be an essential part of patient evaluation. the daily dose of propranolol should be divided into three doses with a minimum of six – hours interval in between. the propranolol dose should be slowly increased to the desired dose, starting at 0.5 mg/kg/day. any change in the heart rate and blood pressure is evident during the first three to four hours after initiation of treatment so the child should be kept under observation for this period. a dramatic change in color is apparent within hours of the first dose of propranolol. propranolol should be discontinued during intercurrent illness, especially in cases of restricted oral intake to prevent hypoglycemia. conclusion in the absence of any serious side effects and the excellent response rate, propranolol should be considered a highly promising pharmacologic agent as first-line therapy in complicated and aggressive cases of periocular and orbital infantile hemangioma irrespective of age, site, size and stage of lesion author’s affiliation dr. seema qayyum associate professor and head of department pediatric ophthalmology, the children’s hospital and institute of child health, lahore. role of author dr. seema qayyum study design, manuscript review and result compilation, collection of data, manuscript writing references 1. haider km, plager da, neely de, elkenberry j h. outpatient treatment of periocular infantile hemangiomas with oral propranolol. j am assoc pediatr ophthalmol strabismus {jaapos}. 2010; 14 (3): 251–6. 2. richter gt, friedman ab. hemangiomas and vascular malformations: current theory and management. int j pediatr. 2012; 2012: 10. 3. chang mw. updated classification of hemangiomas and other vascular anomalies. lymphat res biol [internet]. 2003; 1 (4): 259–65. 4. chaudhry ta, kamal m, ahmad k. periocular infantile haemangioma and the role of propranolol jcpsp 2013; 23 (8): 593–5. 5. lowe lh, marchant tc, rivard dc, scherbel aj. vascular malformations: classification and seema qayyum 90 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology terminology the radiologist needs to know. semin roentgenol. 2012; 47 (2): 106–17. 6. haik bg, karcioglu za, gordon ra, pechous bp. capillary hemangioma (infantile periocular hemangioma). survey of ophthalmology, 1994: p. 399– 426. 7. tambe k, munshi v, dewsbery c, ainsworth jr, willshaw h, parulekar m v. relationship of infantile periocular hemangioma depth to growth and regression pattern. j aapos. 2009; 13 (6): 567–70. 8. léauté – labrèze c, prey s, ezzedine k. infantile haemangioma: part ii. risks, complications and treatment. j eur acad dermatology venereol. 2011; 25 (11): 1254–60. 9. shayan.r yasamann, prendiville. s. julie gdr. use of propranolol in treating hemangiomas. can fam physician, 2011; vol. 57, no (march): 302–3. 10. lawley lp, siegfried e, todd jl. propranolol treatment for hemangioma of infancy: risks and recommendations. pediatr dermatol. 2009; 26 (5): 610–4. 11. nivedita gunturi sr. propranolol therapy for infantile hemangioma. indian pediatr. 2013; 50 (march): 307–13. 12. sun hee chung, md, dong hyuk park, hye lim jung m. successful and safe treatment of hemangioma with oral propranolol in a single institution. korean joural pediatr. 2012; 55 (5): 164–70. 13. ni n, guo s, langer p. current concepts in the management of periocular infantile (capillary) hemangioma. curr opin ophthalmol. 2011; 22 (5): 419– 25. 14. mark s ruttum, md; gary w abrams, md; gerald j harris, md; mary k ellis m. bilateral retinal embolization associated with intralesional corticosteroid injection for capillary hemangioma of infancy. heal j pediatr ophthalmol strabismus, 1993; 30 (1: 47). 15. d gidaris, m economou vh. use of propranolol in infantile haemangiomas: report of five cases and review of the literature. hippokratia, 2011; 15 (1) (jan-mar): 81– 3. 16. ng m, knuth c, weisbord c ma. propranolol therapy for problematic infantile hemangioma. ann plast surg. 2016; 76 (3): 306–10. 17. li yc, mccahon e, rowe na, martin pa, wilcsek ga, martin fj. successful treatment of infantile haemangiomas of the orbit with propranolol. clin exp ophthalmol. 2010; 38 (6): 554–9. 18. k spitri cornish ar. the use of propranolol in the management of periocular capillary haemangioma—a systematic review. eye, 2011; 25 (10): 1277–83. 19. case rofa. propranolol for isolated orbital infantile hemangioma, 2016; 94 (40): 1–4. 20. beth a. drolet, md, a peter c. frommelt, md b, sarah l. chamlin, md et al. initiation and use of propranolol for infantile hemangioma: report of a consensus conference. pediatrics, 2013; 1 (131): 128–40. 34 pak j ophthalmol. 2021, vol. 37 (1): 34-37 original article role of optical coherence tomography (oct) in early detection of subclinical cystoid macular edema after nd-yag laser capsulotomy muhammad adnan 1 , shela dareshani 2 , khowaja faiz-ur-rab 3 , tariq saleem 4 , mazhar ali 5 1-5 department of ophthalmology, unit 1, dow university of health sciences, karachi abstract purpose: to determine role of optical coherence tomography (oct) in early detection of subclinical cystoid macular edema (cme) after nd-yag laser capsulotomy in patients with posterior capsular opacification (pco). study design: descriptive case-series. place and duration of study: department of ophthalmology unit 1, dow university of health sciences and civil hospital karachi from 1-july-2015 to 31-dec-2015. methods: a total of 72 eyes with unilateral or bilateral visually significant pco following uncomplicated cataract surgery with posterior chamber intraocular lens implantation were included in the study. patients with corneal opacities, glaucoma, retinopathy, maculopathy, optic neuropathy, complicated cataract surgery, previous ocular surgery other than cataract surgery and high refractive errors were excluded from the study. best-corrected visual acuity (bcva), slit lamp examination, posterior segment examination and macular thickness was measured using spectral domain (topcon 3d oct) optical coherence tomography before laser and at 1 week and at 1 month after laser. results: mean age was 55.76 ± 5.28 with confidence interval of 55.02 – 56.49 years. forty were males and 32 were females. subclinical cystoid macular edema (cme) was found in 10 (14%) patients. out of the patients who had cme, 3 were in age group of 40-55 years and seven were in age group of 56-70 years. p value was found to be significant i.e. (p = 0.039). conclusion: optical coherence tomography oct is a non invasive and useful tool for early detection and management of subclinical cystoid macular edema after nd-yag laser capsulotomy in patients having posterior capsular opacification (pco). key words: cystoid macular edema, nd-yag laser, posterior capsular opacification. optical coherence tomography (oct). how to cite this article: adnan m, dareshani s, rab f, saleem t, ali m. role of optical coherence tomography (oct) in early detection of subclinical cystoid macular edema after nd-yag laser capsulotomy. pak j ophthalmol. 2021, 37 (1): 34-37. doi: https://doi.org/10.36351/pjo.v37i1.1143 correspondence: muhammad adnan department of ophthalmology unit 1, dow university of health sciences karachi email: adnanshaikh1986@hotmail.com received: october 8, 2020 accepted: november 15, 2020 introduction cystoid macular edema (cme) is one of the main causes of poor visual outcome following uncomplicated cataract surgery. the incidence of postoperative cme following cataract surgery is 0.6– 2.6% which is diagnosed by the presence of macular cysts and/or decreased visual acuity. 1 cme affects both genders equally and has no racial predominance. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewi3j-hu2zrtahvbrhekhcala3mqfjaaegqibhac&url=http%3a%2f%2fwww.duhs.edu.pk%2fdownload%2fprospectus%2520bs%2520optometry-20191211.pdf&usg=aovvaw3zbbufp1pqonv9jambwhbh https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewi3j-hu2zrtahvbrhekhcala3mqfjaaegqibhac&url=http%3a%2f%2fwww.duhs.edu.pk%2fdownload%2fprospectus%2520bs%2520optometry-20191211.pdf&usg=aovvaw3zbbufp1pqonv9jambwhbh role oct in subclinical cystoid macular edema after nd-yag capsulotomy pak j ophthalmol. 2021, vol. 37 (1): 34-37 35 it is caused by various groups of diseases including ocular inflammatory diseases (uveitis, scleritis,), retinal vascular diseases (retinal vein occlusion, diabetic retinopathy) and retinal dystrophies (retinitis pigmentosa). it can also occur post-operatively (after cataract surgery, yag laser capsulotomy, laser photocoagulation) and after certain drugs administration (topical 2% adrenaline, topical latanoprost). 2,3 nd:yag laser capsulotomy is an out-patientdepartment procedure with few complications which can occur like lens pitting, iop rise, retinal detachment and cystoid macular edema. 4 the exact cause of cme is not known and its pathogenesis is thought to be due to multiple factors. macular edema may be due to damage to the blood aqueous barrier which is caused by inflammatory mediators released due to movement and damage of the vitreous gel. 5 as a result, transudates accumulate in the outer plexiform layer and inner nuclear layers resulting in cystoid spaces at macula called cme. 5-6 when foveal edema and retinal thickening is more than 300 um it is clinically visualized by slit lamp bio-microscope by using green light to delineate the cystoid spaces. retinal imaging like fundus fluorescein angiography (ffa) and optical coherence tomography (oct) are used to detect subclinical macular edema less than 300 um. 7 different incidences have been reported by different studies from 0.85% to 9.6% of cystoid macular edema after nd:yag laser capsulotomy. 8,9 for monitoring macular thickness oct is a useful tool in patients undergoing nd:yag laser capsulotomy. 10,11 now-a-days nd:yag laser capsulotomy is a frequently performed procedure in opd for pco patients. cystoid macular edema is the most common cause of decreased vision in patients following capsulotomy. once cme becomes chronic, there is permanent damage to the macular architecture that results in loss of quality of vision. the rationale of our study was to make an early diagnosis of cme by doing early oct, and treat cme early to prevent permanent damage to macula. the main objective of this study was to determine the role of optical coherence tomography (oct) in early detection of cystoids macular edema (cme) after nd-yag laser capsulotomy in patients with posterior capsular opacification (pco). methods it was a descriptive case series study done at the department of ophthalmology unit 1 dow university of health sciences and civil hospital karachi. it was carried out from july 2015 to december 2015. sample size was calculated by using who sample size calculator by taking frequency of cme i.e. p = (10%), margin of error (d) = 6%, confidence interval = 95%. the estimated sample size was 72 eyes. nonprobability consecutive sampling technique was used. inclusion criteria comprised of patients with unilateral or bilateral visually significant pco following uncomplicated cataract surgery with posterior chamber intraocular lens implantation. all those pco cases in which there was reasonable fundal view on non-contact lens fundoscopy. it was made sure that the time-period after cataract surgery was not less than 6 months. age range was between 40 and 70 years. either sex were included. patients with corneal opacities, glaucoma, retinopathy, maculopathy, optic neuropathy, diabetes mellitus, complicated cataract surgery, previous ocular surgery other than cataract surgery and patients with high refractive errors greater than -6.0 or +6.0 diopters were excluded from the study. consent was taken from the recruited patients. all patients had a complete ocular examination before and one month after nd:yag laser capsulotomy. best-corrected visual acuity (bcva), slit lamp examination, posterior segment examination and macular thickness was measured using spectral domain (topcon 3d oct) optical coherence tomography before laser and at 1 week and at 1 month after laser. tropicamide 1% was administered for dilation of pupil before the procedure. after capsulotomy, prednisolone acetate 1% four times daily for 5 days was prescribed. data was analyzed using spss version 20. mean and standard deviations were calculated for age and visual acuity (va). frequencies and percentages were calculated for gender, side of eyes and outcome variable that is cme (yes/no). effect modifier were controlled through age, gender and side of eyes to see the effect of these on outcome variable. chi-square test was used with p ≤ 0.05 taken as significant. results in this study 72 eyes of 72 patients were included to assess the cystoid macular edema (cme), among the patients who underwent nd-yag laser capsulotomy for posterior capsular opacification (pco). mean age was 58.23 ± 8.46 years with c.i (56.24 – 60.21) years. muhammad adnan, et al 36 pak j ophthalmol. 2021, vol. 37 (1): 34-37 out of 72 patients 12 had visual acuity between 6/6 – 6/9, 29 had 6/12 – 6/18 and 31 had 6/24 – 6/60 as shown in table 1. table 1: visual acuity frequency percentage (%) 6/6 – 6/9 12 17 6/12 – 6/18 29 40 6/24 – 6/60 31 43 out of 72 patients 40 (56%) were male and 32 (44%) were females. thirty-five (49%) had right and 37 (51%) had left eye affected. eyes cystoid macular edema (cme) was seen in 10 (14%) while 62 (86%) eyes were normal. out of 10 patients who had cme, three were in age group of 40 — 55 years and seven were in age group of 56 – 70 years. p value was found to be significant i.e. (p = 0.039). regarding gender p value was not significant i.e. (p = 0.519). status of visual acuity is shown in table 1. discussion most common late complication after cataract surgery is posterior capsular opacification (pco). definitive treatment option for pco patients is nd-yag laser capsulotomy. parajuli et al in his study found gross increase in macular thickness after nd:yag laser capsulotomy which did not need any treatment. 12 other studies have reported retinal detachment and macular edema as complications after nd-yag laser capsulotomy. 13 the possible mechanism could be liquefaction of the vitreous and disruption of the anterior hyaloid face. ari et al found gross increase in macular thickness after nd-yag capsulotomy which was significantly high in patients who received higher energy. 14 karahan et al found significant central macular thickness after nd:yag capsulotomy after 7 days which reduced to pre yag levels after one month irrespective of the capsulotomy size. 15 raza reported cme in 3% of 550 patients treated with nd:yag laser capsulotomy for pseudophakic and aphakic pco. 16 in our study 10 patients developed subclinical cme at 1 st week follow-up which was detected on oct and after 1 to 3 months, it improved significantly. there are other studies as well which have shown no statistically significant changes in retinal, and optical nerve fiber layer thicknesses after yag capsulotomy. 17,18 although slight thickness changes in these structures were observed, particularly during the first days. another author found that foveal thickness did not change in the first year after nd:yag laser capsulotomy, as determined by oct. 19 increase in sub-foveal choroidal thickness after yag capsulotomy was also reported in a japanese study. 20 limitations of this study include not considering the visual status of the patient with regard to macular thickening. laser shots and power was also not taken into account. conclusion optical coherence tomography oct is a non invasive and useful tool for early detection and management of cystoid macular edema after nd: yag laser capsulotomy in patients having posterior capsular opacification (pco). ethical approval the study was approved by the institutional review board/ ethical review board. (cpcp/reu/opl-2012183-1473) conflict of interest authors declared no conflict of interest references 1. apple dj, solomon kd, tetz mr. posterior capsule opacification. surv ophthalmol. 1992; 37 (2): 73–116. 2. bertelmann e, kojetinsky c. posterior capsule opacification and anterior capsule opacification. curr opin ophthalmol. 2001; 12 (1): 35-40. 3. schaumberg da, dana mr, christen wg, glynn rj. a systematic overview of the incidence of posterior capsule opacification. ophthalmology, 1998; 105 (7): 1213–1221. 4. novotny ge, pau h. myofibroblast-like cells in human anterior capsular cataract. virchows arch a pathol anat histopathol. 1984; 404 (4): 393–401. 5. mcdonnell pj, zarbin ma, green wr. posterior capsule opacification in pseudophakic eyes. ophthalmology, 1983; 90 (12): 1548–1553. 6. cobo lm, ohsawa e, chandler d. pathogenesis of capsular opacification after extracapsular cataract extraction: an animal model. ophthalmology, 1984; 91 (7): 857–863. 7. wormstone im. posterior capsule opacification: a cell biological perspective. exp eye res. 2002; 74 (3): 337– 347. http://www.ncbi.nlm.nih.gov/pubmed/11150079 http://www.ncbi.nlm.nih.gov/pubmed/11150079 http://www.ncbi.nlm.nih.gov/pubmed/11150079 role oct in subclinical cystoid macular edema after nd-yag capsulotomy pak j ophthalmol. 2021, vol. 37 (1): 34-37 37 8. meacock wr, spalton dj, stanford mr. role of cytokines in the pathogenesis of posterior capsule opacification. br j ophthalmol. 2000; 84 (3): 332–336. 9. saika s, ohmi s, kanagawa r. lens epithelial cell outgrowth and matrix formation on intraocular lenses in rabbit eyes. j cataract refract surg 1996; 22 (suppl. 1): 835–840. 10. lee eh, seomun y, hwang kh. over expression of the transforming growth factor-beta-inducible gene betaig-h3 in anterior polar cataracts. invest ophthalmol vis sci. 2000; 41 (7): 1840–1845. 11. lee eh, joo ck. role of transforming growth factorbeta in transdifferentiation and fibrosis of lens epithelial cells. invest ophthalmol vis sci. 1999; 40 (9): 2025– 2032. 12. parajuli a, joshi p, subedi p, pradhan c. effect of nd:yag laser posterior capsulotomy on intraocular pressure, refraction, anterior chamber depth, and macular thickness. clin ophthalmol. 2019; 13: 945952. 13. wesolosky jd, tennant m, rudnisky cj. rate of retinal tear and detachment after neodymium: yag capsulotomy. j cataract refract surg. 2017; 43 (7): 923– 928. 14. ari s, cingü ak, sahin a, çinar y, çaça i. the effects of nd: yag laser posterior capsulotomy on macular thickness, intraocular pressure, and visual acuity. ophthalmic surg lasers imaging retina. 2012; 43 (5): 395–400. 15. karahan e, tuncer i, zengin mo. the effect of nd:yag laser posterior capsulotomy size on refraction, intraocular pressure, and macular thickness. j ophthalmol. 2014; 2014: 846385. 16. raza a. complications after nd: yag posterior capsulotomy. j rawalpindi med coll. 2007; 11: 27–29. 17. i̇sa y, emine p, yudum y, sümeyra y, nurettin b, melek dy, et al. optic coherence tomography measurement of choroidal and retinal thicknesses after uncomplicated yag laser capsulotomy. arq. bras. oftalmol. 2015; 78 (6): 344-347. 18. wróblewska-czajka e, wylegała e, tarnawska d, nowińska a, dobrowolski d. assessment of retinal thickness obtain by optical coherence tomography after nd: yag capsulotomy. klin oczna. 2012; 114 (3): 194-197. 19. altiparmak ue, ersoz i, hazirolan d, koklu b, kasim r, duman s. the impact of nd:yag capsulotomy on foveal thickness measurement by optical coherence tomography. ophthalmic surg lasers imaging, 2010; 41 (1): 67-71. 20. fujiwara a, shiragami c, shirakata y, manabe s, izumibata s, shiraga f. enhanced depth imaging spectral-domain optical coherence tomography of subfoveal choroidal thickness in normal japanese eyes. japan j ophthalmol. 2012; 56 (3): 230-235. authors’ designation and contribution muhammad adnan; medical officer: concepts, design, literature search, data acquisition, data analysis, manuscript preparation, manuscript editing. shela dareshani; associate professor: design, statistical analysis, manuscript preparation, manuscript review. khowaja faiz-ur-rab; assistant professor: statistical analysis, manuscript preparation, manuscript editing. tariq saleem; assistant professor: literature search, data acquisition, data analysis. mazhar ali; consultant ophthalmologist: literature search, data analysis, manuscript review. .…  …. 48 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology original article etiology of infectious keratitis as seen at a tertiary care center in larkana, pakistan syed imtiaz ali shah, shujaat ali shah, partab rai, safdar ali abbasi, huda fatima, ali akbar soomro pak j ophthalmol 2016, vol. 32 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syed imtiaz ali shah department of ophthalmology chandka medical college larkana email: syedimtiazalinaqvi@yahoo.com received: november 17, 2015. accepted: march 25, 2016. …..……………………….. purpose: to determine the different causes of infectious keratitis and their relative frequencies in the patients coming to a tertiary care center in larkana, pakistan. study design: prospective case series. place and duration of study: this study was carried out at the department of ophthalmology, chandka medical college hospital larkana, pakistan, from february 2004 up till february 2015. material and methods: the number of patients clinically diagnosed as case of infectious keratitis included in the study, were 2411. patients excluded from the study were under the age of 16 years, or having mooren’s ulcer, or ulcers associated with exposure, autoimmune and systemic diseases. corneal swabs or scrapings were taken and prepared on separate slides for microscopic evaluation of bacteria, fungi and acanthamoeba; while the viral keratitis was diagnosed on clinical grounds. a standard proforma, including sex and age of the patient, clinical diagnosis and the results of corneal scrapings, was filled for each patient. spss version 20 was used for data entry and analysis. results: out of the total 2411 patients, 60.02% were males and 39.98% were females. the mean age (± standard deviation) was 36.73 ± 15.49 years. the final report showed that the major cause of infectious keratitis were bacteria with 56.12% of the total cases, followed by fungi with 38.45%. cases of viral keratitis were 3.65% and 1.78% patients had acanthamoeba keratitis. conclusion: bacteria and fungi are responsible for the bulk (94.57%) of infectious keratitis but virus and acanthamoeba should not be ignored or underestimated. keywords: keratitis, acanthamoeba keratitis, eye infections, bacterial, fungal, viral. ornea is one of the most important and sensitive parts of the human eye as it contributes the majority of its refractive power and also provides a clear entrance to the light rays in the eye.1 cornea is privileged because of its transparency which depends mainly upon its avascularity,2 dehydrated state, smooth surface epithelium and well organized stromal collagen fibers.3 although cornea does not depend on oxygen provided by lungs through blood and takes oxygen from air directly,4 but this a vascularity makes it vulnerable to a variety of infections because it is deprived of the usual defense mechanisms of the body in the form of circulating polymorphs, lymphocytes and antibodies. although there is some protection for the cornea in the form of lysozyme, lactoferrin, iga, lipocalin5 etc, but it is meager and the cornea acts like a tied prisoner in the face of pathogens when it is breached. infectious keratitis is the most common cause of uniocular blindness in the world6. in pakistan corneal opacity is the second most common cause of blindness after cataract.7 infectious or microbial c etiology of infectious keratitis as seen at a tertiary care center in larkana, pakistan pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 49 keratitis can be caused by a wide spectrum of organisms, including a huge variety of bacteria, fungi, viruses and parasites.8 a lot of variation is seen in the etiology and epidemiology of infectious keratitis from place to place9 and time to time, that’s why it is essential to have local data available, so that the burden of problem is understood and preventive and curative strategies are planned and established. the objective of this study was to identify the different causes of infectious keratitis and their prevalence and frequencies in the patients coming to the department of ophthalmology, chandka medical college and hospital larkana. materials and methods this was a prospective case series study carried out at the department of ophthalmology, chandka medical college hospital larkana, sindh, pakistan, from february 2004 up till february 2015. all patients attending the outpatient department, clinically diagnosed as a case of infectious keratitis and given informed consent were included in the study. patients excluded from the study were under the age of 16 years, or having mooren’s ulcer, or ulcers associated with exposure, autoimmune and systemic diseases. corneal swabs or scrapings were taken and the specimens were prepared on three separate slides, one was prepared with potassium hydroxide (koh 10%) to see the fungal hyphae or pseudohyphae, the second stained with gram’s stain to identify the bacteria, and the third was stained with hematoxylin and eosin stain to look for acanthamoeba. slides were then seen under the microscope for evaluation and final report. a standard proforma was filled for each patient, which included gender and age of the patient, clinical diagnosis and the results of corneal scrapings except for the patients suspected of viral ulcers, in which case the diagnosis was clinical and considered definite if there was improvement seen on antiviral treatment. in case of polymicrobial infections if acanthamoebae were identified then it was labeled as acanthamoeba keratitis regardless of the results of the other two slides. if fungal hyphae were seen, it was labeled as fungal keratitis. bacterial keratitis was only labeled if bacteria alone were seen. spss version 20 was used for data entry and analysis. results a total of 2411 patients were clinically diagnosed as having infectious keratitis and included in the study during the period of eleven years, out of which 1447 (60.02%) were males and 964 (39.98%) were females (fig. 1). the mean age (± standard deviation) was 36.73 ± 15.49 years and the range was 17 – 76 years. the final report after combining the results of corneal scrapings and clinical diagnosis showed that 1353 (56.12%) patients were fulfilling the criteria of bacterial keratitis. 927 (38.45%) patients had fungal keratitis, 88 (3.65%) patients were diagnosed as case of viral keratitis and 43 (1.78%) patients had acanthamoeba keratitis (fig. 2). discussion this study shows that males have a greater tendency to fall prey to infectious keratitis than females, which is consistent with other studies from pakistan,8,12 malaysia24 and india.20 this is probably due to greater fig. 1: fig. 2: syed imtiaz ali shah, et al 50 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology fig. 3: fungal keratitis. fig. 4: bacterial keratitis fig. 5: viral keratitis (herpes simplex) exposure of males to outdoor risk factors, physical activity and professional hazards. patients in middle ages are more prone to develop infectious keratitis according to our study, which is similar to the studies from pakistan8,12 and india20. the mean age being 36.73 ± 15.49 years which is lower than the mean age fig. 6: amebic keratitis. (44.5 ± 20.9 years) reported by norina tj et al24 and the mean age (64.3 ± 10.3 years) reported by ahn m et al22. this study shows that bacteria are more common (56.12%) among the organisms causing infectious keratitis and it is consistent with some other research studies around the world8, 10, 11, although, other studies have reported fungus as the major cause of infectious keratitis.12-15 epidemiology of infectious keratitis varies with geography and climate but generally gram-positive bacteria are more frequently recovered in temperate climatic regions16-18 and gram negative bacteria and fungi in tropical or sub-tropical climates19, 20. stapleton f et al21 states that fungi account for 5 – 40% of culture proven infections which is rather similar to our results of 38.45%. in our study the cases of viral keratitis were 3.65% less than that reported by patel s et al23 and that of acanthamoeba keratitis (1.78%) were approximately equal to that reported by srinivasan m et al25 (1%) and less than that reported by riaz q et al12 (8%). conclusion infectious keratitis is an economic and social problem of huge magnitude due to the fact that the affected etiology of infectious keratitis as seen at a tertiary care center in larkana, pakistan pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 51 population is middle aged, males more than females who are actively involved in their household and national progress. bacteria and fungi are responsible for the bulk (94.57%) of infectious keratitis but virus and acanthamoeba may not be underestimated. author’s affiliation dr syed imtiaz ali shah professor department of ophthalmology chandka medical college larkana dr. shujaat ali shah trainee registrar department of ophthalmology chandka medical college larkana dr. partab rai professor department of ophthalmology chandka medical college larkana dr. safdar ali abbasi ophthalmologist department of ophthalmology chandka medical college larkana dr. huda fatima trainee registrar department of ophthalmology chandka medical college larkana dr. ali akbar soomro professor department of pathology chandka medical college larkana role of authors dr syed imtiaz ali shah manuscript writing, study design. dr. shujaat ali shah data analysis, review of images. dr. partab rai manuscript review. dr. safdar ali abbasi manuscript review. dr. huda fatima manuscript design. dr. ali akbar soomro manuscript writing. references 1. willoughby ce, ponzin d, ferrari s, lobo a, landau k, omidi y. anatomy and physiology of the human eye: effects of mucopolysaccharidoses disease on structure and function–a review. clin exp ophthalmol. 2010; 38: 2-11. 2. azar dt. corneal angiogenic privilege: angiogenic and antiangiogenic factors in corneal avascularity, vasculogenesis, and wound healing (an american ophthalmological society thesis). trans am ophthalmol soc. 2006; 104: 264-302. 3. qazi y, wong g, monson b, stringham j, ambati bk. corneal transparency: genesis, maintenance and 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http://www.ncbi.nlm.nih.gov/pubmed/?term=opintan%20ja%5bauthor%5d&cauthor=true&cauthor_uid=12386069 http://www.ncbi.nlm.nih.gov/pubmed/?term=kalavathy%20cm%5bauthor%5d&cauthor=true&cauthor_uid=12386069 http://www.ncbi.nlm.nih.gov/pubmed/?term=essuman%20v%5bauthor%5d&cauthor=true&cauthor_uid=12386069 http://www.ncbi.nlm.nih.gov/pubmed/?term=jesudasan%20ca%5bauthor%5d&cauthor=true&cauthor_uid=12386069 http://www.ncbi.nlm.nih.gov/pubmed/?term=johnson%20gj%5bauthor%5d&cauthor=true&cauthor_uid=12386069 syed imtiaz ali shah, et al 52 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology 16. bourcier t, thomas f, borderie v, chaumeil c, laroche l. bacterial keratitis: predisposing factors, clinical and microbiological review of 300 cases. br j ophthalmol. 2003; 87: 834-8. 17. keay l, edwards k, naduvilath t, taylor hr, snibson gr, forde k stapleton f. microbial keratitis: predisposing factors and morbidity. ophthalmology. 2006; 113: 109-16. 18. bennett hg, hay j, devonshire p, seal dv, kirkness cm. antimicrobial treatment of presumed microbial keratitis: guidelines for treatment of central and peripheral ulcers. br j ophthalmol. 1998; 137-45. 19. fong cf, tseng ch, hu fr, wang ij, chen wl, hou yc. clinical characteristics of microbial keratitis in a university hospital in taiwan. am j ophthalmol. 2004; 137: 329-36. 20. gopinathan u, sharma s, garg p, rao gn. review of epidemiological features, microbiological diagnosis and treatment outcome of microbial keratitis. ind j ophthalmol. 2009; 57: 273-9. 21. stapleton f, carnt n. contact lens – related microbial keratitis: how have epidemiology and genetics helped us with pathogenesis and prophylaxis. eye, 2012; 26: 185-93. 22. ahn m, yoon kc, ryu sk, cho nc, you ic. clinical aspects and prognosis of mixed microbial (bacterial and fungal) keratitis. cornea. 2011; 30: 409-13. 23. patel s, chaudhari am, solu tm, gharat v. epidemiological and microbiological profile of patients having microbial keratitis. natl j community med. 2014; 5: 463-7. 24. norina tj, raihan s, bakiah s, ezaqnee m, liza sat, wan hwh. microbial keratitis: aetiological diagnosis and clinical features in patients admitted to hospital universiti sains malaysia. singapore med j. 2008; 49: 6771. 25. srinivasan m, gonzales ca, george c, cevallos v, mascarenhas jm, asokan b wilkins j, smolin g, whitcher jp. epidemiology and etiological diagnosis of corneal ulceration in madurai, south india. br j ophthalmol. 1997; 81: 965-71. http://www.ncbi.nlm.nih.gov/pubmed/?term=stapleton%20f%5bauthor%5d&cauthor=true&cauthor_uid=16360210 http://www.ncbi.nlm.nih.gov/pubmed/?term=wilkins%20j%5bauthor%5d&cauthor=true&cauthor_uid=9505820 http://www.ncbi.nlm.nih.gov/pubmed/?term=smolin%20g%5bauthor%5d&cauthor=true&cauthor_uid=9505820 http://www.ncbi.nlm.nih.gov/pubmed/?term=whitcher%20jp%5bauthor%5d&cauthor=true&cauthor_uid=9505820 62 pak j ophthalmol. 2021, vol. 37 (1): 62-65 original article effect of cataract surgery on intraocular pressure in glaucoma patients shua azam 1 , abdul hameed talpur 2 , mahak shaheen 3 , sadia bukhari 4 1-3 isra school of optometry, al-ibrahim eye hospital, karachi 4 department of ophthalmology, al-tibri medical college abstract purpose: to determine the change in intraocular pressure after cataract surgery in patients diagnosed with glaucoma. study design: interventional case series. place and duration of study: glaucoma clinic. al-ibrahim eye hospital (aieh) karachi, pakistan from may to october, 2019. methods: thirty-eight patients diagnosed with glaucoma and cataract and registered in glaucoma clinic were recruited for this study. inclusion criteria was age > 41 years and patients diagnosed with primary open/closed angle glaucoma and cataract. patients with secondary glaucoma, history of trabeculectomy and any other ocular diseases were excluded from the study. pre-operative assessment was done for phacoemulsification. in postoperative examination, first and second follow-up iop was measured. data analysis was done on statistical package for social science (spss) version 20.0. statistical changes were present in the form of bar chart, frequency and graphs. the mean standard deviation for pre-operative, post-operative 1st and 2nd follow-up iop was calculated. results: a total of 38 participants and 48 eyes satisfied the inclusion criteria. out of 48 eyes, 39 (81.3%) eyes were diagnosed with primary open angle glaucoma and 9 (18.8%) eyes with primary angle closure glaucoma. the pre-operative mean iop was 16.56 ± 6.67 mm hg and post-operative mean iop at first follow-up was 13.39 ± 4.04 mm hg. at second follow-up at one-month mean iop was 12.14 ± 2.28 mm hg. conclusion: phacoemulsification produces a useful decrease in iop in glaucoma patients. key word: glaucoma, cataract, phacoemulsification, intraocular pressure. how to cite this article: azam s, talpur ah, shaheen m, bukkhari s. effect of cataract surgery on intraocular pressure in glaucoma patients. pak j ophthalmol. 2021, 37 (1): 62-65. doi: https://doi.org/10.36351/pjo.v37i1.1167 introduction the global prevalence of glaucoma in 40 – 80 years old patients is 3.54%. 1 the prevalence of primary open correspondence: shua azam isra school of optometry al-ibrahim eye hospital, karachi email: optomshuaazam@gmail.com received: october 17, 2020 accepted: november 30, 2020 angle glaucoma (poag) is highest in africa and the prevalence of primary angle closure glaucoma (pacg) is highest in asia. people of european ancestry and people living in urban areas are more likely to have poag than those in rural areas. 1 in pakistan, poag is the most common type followed by primary angle closure, aphakic, secondary and congenital glaucoma. 2 cataract surgery may alter iop and several studies have reported these changes, which include increased iop, decreased iop and even hypotony. 3 cataract surgery has been shown to reduce iop in eyes with or without glaucoma. 4 in eyes with effect of cataract surgery on iop in glaucoma patients pak j ophthalmol. 2021, vol. 37 (1): 62-65 63 angle closure glaucoma (acg), phacoemulsification is an effective procedure in lowering intra-ocular pressure (iop). in eyes with open angle glaucoma (oag) a decline in iop is also seen. 5 higher preoperative iop, shallow anterior chamber and higher preoperative iop were reported to be the indicators of more prominent iop drop after surgery. 6 this interventional case series was carried out to see the drop in intraocular pressures in cases of primary open glaucoma and primary closed glaucoma following phacoemulsification. methods patients diagnosed with glaucoma and cataract were registered in glaucoma clinic for detailed assessment. inclusion criteria was male or female patients with age more than 41 years and patients diagnosed with primary open/closed angle glaucoma and cataract. patient diagnosed with pseudoexfoliation, history of trabeculectomy or retinal surgery, other ocular disease and secondary glaucoma were excluded. pre-operative assessment was done and in the post-operative followup, iop was measured at one week and one month using goldmann applanation tonometer. data analysis was done on statistical package for social science (spss) version 20.0. the mean standard deviation for pre-operative and post-operative iop at first and second follow-up was calculated. results the study included age group from 41 to 70 years old and the mean age was 54.72 years. there were 22 eyes from male patients and 26 eyes from female patients. out of 48 eyes, 39 (81.3%) eyes were diagnosed with poag and 9 (18.8%) eyes with pacg. the preoperative mean iop was 16.65 ± 6.67 mm hg and the mean iop for first post-operative follow-up at week one was 13.39 ± 4.04 mm hg. out of 48 eyes, only 34 eyes presented for second follow-up at one month when the mean iop was 12.14 ± 2.28 mm hg. the pre-operative iop was in the range of 8 – 30 mm hg which was reduced to 9 – 20 mm hg on first postoperative follow-up which was further reduced to 9 – 15 mm hg on second post-operative follow-up at one month. graph 1: changes in iop (mmhg) at one and four weeks after phacoemulsification with intraocular lens implantation. discusion our results co-relate with a study conducted in sankara eye care institution in india in which they took a retrospective interventional case series of 218 patients which included 120 females and 98 males and all patients underwent phacoemulsification surgery. they recorded change in iop for operated and fellow eye. they found a mean reduction in iop in operated eye with a p value of 0.004. 7 some other studies showed same results that iop significantly decreased after phacoemulsification. 8 different studies have reported that cataract extraction alone lowers iop two to four mm hg which correlates with our results. in patients with higher preoperative iop the reduction in iop was more significant. 1 other studies showed that addition to preoperative iop and lens thickness, parameters like changes in anterior chamber area and angle opening distance were also significantly associated with reduction in iop after phacoemulsification. 10,11 these factors were not studied in our research. pre-operative iop was the sole factor significantly related to postoperative iop reduction after cataract surgery in poag patients. high pre-operative iop was strongly related to a greater postoperative iop reduction. patients with low pre-operative iops have minimal reduction or perhaps a gentle increase in postoperative iops while our study did not categorize preoperative iops. 12 some studies reported that phacoemulsification resulted in a very small average decrease in iop in shua azam, et al 64 pak j ophthalmol. 2021, vol. 37 (1): 62-65 patients with open angle glaucoma. a sizeable proportion of medically controlled glaucoma patients with open angles undergoing phacoemulsification experienced a rise in iop or required more aggressive treatment to regulate iop postoperatively. 13,14 in contrast to this, our study did not take into account the pre-operative medical treatment of glaucoma into consideration. various studies have shown that combined glaucoma/cataract surgery results in more iop reduction as compared to cataract surgery alone. our study took phacoemulsification alone into consideration. 15,16 both surgical and medical treatment of glaucoma increase the risk for cataract development. phacoemulsification (pe) in any case, can be actually more challenging in glaucoma patients due to visual conditions such as the exfoliation syndrome, a past episode of acute angle closure or a history of past ocular surgeries, miotic treatment, injury, or uveitic glaucoma. in some situations, uncomplicated pe alone may serve to decrease the long-term intraocular pressure. 16,17 however, our study did not take into consideration the treatment strategy of glaucoma. systematic review and meta-analysis of the clinical data showed net effect of cataract surgery on iop reduction. for angle-closure glaucoma, there was reduction in iop for about -6.4 mm hg (95% ci: -9.4 to -3.4) at final follow-up (12 months and longer) while for the open-angle glaucoma group, there was an overall iop change of -2.7 mm hg (95% ci -3.7 to 1.7) from baseline. 18 these results are consistent with our study findings. cataract surgery decreases iop in patients with ocular hypertension over a long period of time but we took only two post-operative follow-ups. 19 another study reported that the mean decrease in iop and percentage of iop reduction in the angle closure glaucoma (acg) group were greater than in the open angle glaucoma (oag) group. however, our study findings showed overall reduction for the both types of glaucoma. 20 other study revealed that phacoemulsification done on glaucomatous eyes results in lowering of lop but the dosage of glaucoma drugs over the long term should be simplified or even discontinued. 21 lancu et al reported that intraocular pressure (iop) decreased significantly after phacoemulsification in patients with uncontrolled poag, but the decrease was not adequate for optimal glaucoma management and many patients needed subsequent glaucoma surgery but our study did not focus on the treatment regimen of glaucoma. 22 legrand et al. compared intraocular pressure (iop) during the first month following cataract surgery among patients with primary open-angle glaucoma (poag) and nonglaucomatous patients. they found raised iop in poag patients than non-glaucomatous patients while our study did not include healthy individuals. 23 limitation of our study was that we did not take into account other factors which affect iop including anterior chamber depth, pre-operative medications and lens thickness. secondly the sample size was small and a single center was involved in this study. further follow-ups are also needed to comment on the long term effects on the iop after phacoemulsification. conclusion phacoemulsification produces a useful decrease in iop in glaucoma patients. ethical approval the study was approved by the institutional review board/ ethical review board. (rec/ipio/2020/006) conflict of interest authors declared no conflict of interest. references 1. yih-chung t, xiang li, tien yw. global prevalence of glaucoma and projections of glaucoma. am j ophthalmol. 2014; 121 (11): 2081-2090. 2. tariq m, jafri w, ansari t, awan s, ali f, shah m, et al. medical mortality in pakistan: experience at a tertiary care hospital. postgrad med j. 2009; 85 (1007): 470-474. doi: 10.1136/pgmj.2008.074898. 3. shingleton b, rosenberg r, teixeira r. evaluation of intraocular pressure in the immediate postoperative period after phacoemulsification. j cataract refract surg. 2007; 33 (11): 1953-1957. 4. poley b, lindstrom r, samuelson t. intraocular pressure reduction after phacoemulsification with intraocular lens implantation in glaucomatous and nonglaucomatous eyes: evaluation of a causal relationship between the natural lens and open-angle glaucoma. j cataract refract surg. 2009; 35: 1946-1955. effect of cataract surgery on iop in glaucoma patients pak j ophthalmol. 2021, vol. 37 (1): 62-65 65 5. chen pp, lin sc, junk ak, radhakrishnan s, singh k, chen tc. the effect of phacoemulsification on intraocular pressure in glaucoma patients: a report by the american academy of ophthalmology. ophthalmology, 2015; 122 (7): 1294-1307. doi: 10.1016/j.ophtha.2015.03.021. 6. issa sa, pacheco j, mahmood u, nolan j, beatty s. a novel index for predicting intraocular pressure reduction following cataract surgery. br j ophthalmol. 2005; 89 (5): 543-546. doi: 10.1136/bjo.2004.047662. 7. kumar s, ajita s. analysis of change in intraocular pressure after phacoemulsification. sudan j ophthalmol. 2013; 5 (01): 7-8. 8. baek su, kwon s, park iw, suh w. effect of phacoemulsification on intraocular pressure in healthy subjects and glaucoma patients. j korean med sci. 2019; 34 (6): e47. doi: 10.3346/jkms.2019.34.e47. 9. friedman ds, jampel hd, lubomski lh, kempen jh, quigley h, congdon n, et al. surgical strategies for coexisting glaucoma and cataract: an evidencebased update. ophthalmology, 2002; 109: 1902–1913. 10. hyun sy, lee j, choi s. ocular biometric parameters associated with intraocular pressure reduction after cataract surgery in normal eyes. am j ophthalmol. 2013; 156 (1): 89-94. 11. bilak s, simsek a, capkin m, guler m, bilgin b. biometric and intraocular pressure change after cataract surgery. optom vis sci. 2015; 92 (4): 464-470. doi: 10.1097/opx.0000000000000553. 12. guan h, mick a, porco t, dolan bj. preoperative factors associated with iop reduction after cataract surgery. optom vis sci. 2013; 90 (2): 179-184. doi: 10.1097/opx.0b013e31827ce224. 13. slabaugh ma, bojikian kd, moore db, chen pp. the effect of phacoemulsification on intraocular pressure in medically controlled open-angle glaucoma patients. am j ophthalmol. 2014; 157 (1): 26-31. doi: 10.1016/j.ajo.2013.08.023 14. majstruk l, leray b, bouillot a, michée s, sultan g, baudouin c, et al. long term effect of phacoemulsification on intraocular pressure in patients with medically controlled primary open-angle glaucoma. bmc ophthalmol. 2019; 19 (1): 149. 15. rehman ma, khairy ha, azuara-blanco a. effect of cataract extraction on sita perimetry in patients with glaucoma. j glaucoma, 2007; 16: 205–208. 16. friedman ds, jampel hd, lubomski lh, kempen jh, quigley h, congdon n, et al. surgical strategies for coexisting glaucoma and cataract: an evidencebased update. ophthalmology, 2002; 109: 1902–1913. 17. rehman ma, khairy ha, azuara-blanco a. effect of cataract extraction on sita perimetry in patients with glaucoma. j glaucoma, 2007; 16: 205–208. 18. maire m, patrick m, eileen p, shan cl. the role of phacoemulsification in glaucoma therapy: a systematic review and meta-analysis. surv ophthalmol.2018; 63(5):700-710. doi: 10.1016/j.survopthal.2017.08.006. 19. steven l, mae o, henry j, et al. reduction in intraocular pressure after cataract extraction: the ocular hypertension treatment study. ophthalmology. 2012: 119(9):1826-1831.doi: 10.1016/j.ophtha.2012.02.050 20. hayashi k, hayashi h, nakao f, hayashi f. effect of cataract surgery on intraocular pressure control in glaucoma patients. j cataract refract surg. 2001; 27:1779–86. 21. mierzejewski a, eliks i, kałuzny b, zygulska m, harasimowicz b, kałuzny jj. cataract phacoemulsification and intraocular pressure in glaucoma patients. klin ocz. 2008; 110:11–7. 22. lancu r, corbu c. intraocular pressure after phacoemulsification in patients with uncontrolled primary open angle glaucoma. j med life. 2014; 7:11. 23. legrand m, blumen-ohana e, laplace o, adam r, akesbi j, colas e, et al. early postoperative intraocular pressure after phacoemulsification: normal patients versus glaucoma patientsj fr ophthalmol. 2015; 38:633–8. authors’ designation and contribution shua azam; optometrist: design, data analysis, statistical analysis. abdul hameed talpur; consultant ophthalmologist: concepts, literature search, manuscript preparation, manuscript review. mahak shaheen; optometrist: literature search, data acquisition. sadia bukhari; professor: concepts, manuscript review. .…  …. pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 28 original article outcomes of congenital cataract surgery in a tertiary care hospital kanwal latif, munira shakir, shakir zafar, syed fawad rizvi, saliha naz pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. kanwal latif resident medical officer lrbt free base eye hospital kornagi 2 ½ karachi-74900 …..……………………….. purpose: to determine outcomes of congenital cataract surgery in a tertiary care hospital. material and methods: a total of 192 eyes of 120 patients of age group 3-8 years with visually significant congenital cataract (≥ 3 mm in diameter) underwent cataract surgery with posterior chamber foldable intraocular lens implantation were enrolled in this interventional study. posterior capsulotomy with anterior vitrectomy was performed in all cases. the span of study was july 2011 to january 2013. the minimum follow up of patients was 6 months. in follow-up period postoperative treatment, management of surgical complications, amblyopia therapy and assessment of visual acuity was done. final outcome of congenital cataract surgery in terms of improvement in visual acuity was assessed at the end of 6 th month. the study was performed at layton rehmatullah benevolent trust eye hospital, karachi. results: at the end of study 51% of patients achieved good vision and the better visual outcome is significantly higher in younger age groups. fibrinous reaction was the most common complication occurred in this study. conclusion: this study demonstrate that early congenital cataract surgery is a safe procedure and beneficial in achieving good visual acuity. hildhood blindness is a priority of vision 2020: the right to sight, the global initiative to reduce the world’s burden of avoidable blindness1,2. globally there are estimated 1.5 million blind children, almost three-quarters of them living in developing countries3. the prevalence of blindness in children in pakistan is estimated to be about 10 per 10,000 children4. various studies across the globe show one third to half of childhood blindness is either preventable or treatable 5. cataract is the leading treatable cause of childhood blindness in children6,7. worldwide 5 – 20% of the blindness in children is due to congenital cataract and the global incidence of congenital cataracts has been reported to be 1 – 15/ 10,000 live births7. a hospital based study in pakistan showed that 54.7% of the children are visually handicapped and 23% of them are because of congenital cataract8. congenital cataract usually present as a whitish reflex called leukocoria in eye. the morphology of cataract is important because it may indicate a likely etiology, mode of inheritance and effects on vision9. congenital cataract requires early detection and treatment to prevent permanent visual impairment from amblyopia (‘lazy eye’)10. earlier cataract surgery with adequate visual rehabilitation contributes a better visual outcome11. optimal surgical treatment of the pediatric cataract requires a procedure that will provide a clear optical axis. the visual axis may be obstructed by posterior capsule opacification, inflammatory membranes, thickening and opacification of the hyaloid face, and proliferation of the lens epithelial cells12. leaving the posterior capsule intact in children predisposes to an unacceptably high rate of capsule opacification13,14. to reduce the rate of visual axis opacification in the post operative period posterior continuous curvilinear capsulorhexis with anterior c kanwal latif, et al 29 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology vitrectomy, has become the gold standard in the treatment of congenital cataract15. this procedure will give a clear visual axis with a reduce rate of visual axis opacification and postoperative need of yag laser capsulotomy. along with posterior capsulotomy and anterior vitrectomy implantation of posterior chamber intraocular lenses (pc – iol) in children is becoming more common and better accepted procedure throughout the world16. there are various postoperative complications encountered in children after surgery. increased reactivity of uveal tissue in children causes formation of membranes, fibrinous reaction and posterior synechie. it may results in pupillary block and cause raised intraocular pressure postoperatively17. the rationale of this study is to determine the outcomes of congenital cataract surgery in a series of patients in tertiary care hospital. material and methods a total of 192 eyes of 120 patients aged 3 to 8 years with visually significant congenital cataract (≥ 3mm diameter) treated and followed up at our hospital between july 1st, 2011 and january 31st, 2013, were included in this interventional study. the study was performed at layton rehmatullah benevolent trust eye hospital karachi. informed consent was taken from the guardians. exclusion criteria were other congenital anomalies like microphthalmia and microcornea, history of intrauterine infections, traumatic cataract, congenital glaucoma, nystagmus, ptosis, strabismus, retinal pathologies and fundal dystrophies, systemic disorders like galactosemia, hyper and hypoglycemia and complicated surgeries. after detailed history patients were examined thoroughly and relevant investigations were done. ophthalmic checkup including visual acuity, slit lamp examination of anterior and posterior segment, keratometery, b-scan ultrasonography and intra ocular lens power calculation wherever possible were done. un-cooperative children were examined under general anesthesia before surgery for keratometry and intraocular lens power calculation. intra ocular lens power was calculated by using srk ii formula. pre operatively dilatation of pupil was done by using cyclopentolate 1% and phenylepherine 2.5%. under general anesthesia and sterilized draping supero-temporal limbal incision of 3mm was made with surgical knife no.3.2. a viscoelastic agent was injected to maintain the anterior chamber depth and facilitates easy entry of instruments with less surgical trauma during surgery. anterior capsulorrhexis was done by a bent 26 gauge needle or utrata forceps according to the elasticity of anterior capsule. lens matter aspiration was done by means of an irrigationaspiration hand piece. after aspiration of lens matter posterior chamber foldable acrylic intra ocular lens was implanted in the bag on posterior capsule. posterior capsulotomy and anterior vitrectomy was performed. incision was closed by one interrupted 100 monofilament nylon suture and an air bubble is injected so as to maintain anterior chamber depth postoperatively. one drop of topical atropine 1% and an antibiotic was instilled and pad applied. dressing removed after 24 hrs. systemic antibiotics were given for five days after surgery. topical antibiotics, steroids and cycloplegic were given in the follow-up period for six weeks. patients were followed on 1st post operative day and 1st post operative week for early postoperative complications and then patients were followed after 1 month, 3 months and 6 months. visual acuity was assessed using the lea symbols and etdrs charts depending on the age, intelligence and cooperation of child. amblyopia therapy was given to those whose visual acuity was greater than log mar 0.5. the therapy was given according to the age and density of amblyopia. occlusion of normal eye with better visual acuity was done by means of a patch applied to that eye. hours of patching depends on the age of the child. these patients were followed at one month interval to monitor the improvement of vision. final visual acuity was assessed at 6 months and considered to be good if it ranged between log mar 0.0 to 0.5. results a total of 192 eyes of 120 patients with visually significant congenital cataract were included in this study. out of 120 patients, 70 (58.3%) were males and 50 (41.6%) were females. regarding site of eye, 102 (53.1%) left and 90 (46.9%) right eyes were involved. mild to moderate anterior chamber inflammation (up to grade +2 anterior chamber cells and flare) was seen in 25 (13%) eyes on first postoperative day. patients were treated with topical prednisolone aceatate 1% and cyclopentolate 1% and were closely followed. anterior chamber inflammation was completely settled after 2 weeks. severe anterior chamber inflammation (grade +3 to +4 anterior chamber cells and flare) with pupillary membrane was outcomes of congenital cataract surgery in a tertiary care hospital pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 30 seen in 30 (15%) eyes on first post operative day. they received topical and systemic steroids treatment for 2 weeks along with atropine 1% inflammation settled down in 20 (10%) children while 10 (5%) children underwent yag laser membranectomy. surgical membranectomy was not required as children were cooperative. they were repeatedly followed after one week and prolonged steroid treatment was given for one month. postoperative inflammation was well controlled in both the age groups and there was no visually significant complication after treatment. raised intra ocular pressure was seen in 10 (5.2%) eyes at first post operative week. those patients were treated with topical anti glaucoma medications (beta blockers) and followed after one week to check intra ocular pressure. intra ocular pressure was settled down after one week with topical medication and did not rise within the follow up period. pupillary deviation was seen in 8 (4.1%) eyes. this was due to trauma to iris at the time of surgery. intraocular lens (iol) capture was observed in 4 (2%) eyes. decentration of intra ocular lens was seen in 9 (4.6%) eyes. small upward decentration was seen in these cases and none of the iol decentrations was visually significant or a true dislocation, and no eye required surgical repositioning of the iol. loose corneal scleral sutures were seen in 4 (2%) patients. those sutures were removed under sedation in younger children and at slit lamp in older and cooperative children. final outcome of best corrected visual acuity was assessed at the end of 6th month after surgery. mean bcva at first month was 0.8 ± 0.15, at 3rd month was 0.7 ± 0.19 and at 6th month was 0.5 ± 0.25 (figure 1). mean best corrected visual acuity (range bcva log mar 0.0 to 0.5) was observed in 51% (98/192) while not good (bcva > 0.5) was observed in 49% (94/192) cases as presented in figure 2. bcva was significantly better in 3 to 5 years of age as compared to 6 to 8 years of age (table 1). 0.8 0.7 0.5 0.0 0.2 0.4 0.6 0.8 1.0 1st month 3rd month 6th month fig. 1: mean best corrected visual acuity according to follow-up (n = 192) not good 51.0% good 49.0% good not good fig. 2: final best corrected visual acuity in children after congenital cataract surgery at 6th months there were no severe complications encountered after surgery such as post operative endophthalmitis, retinal detachment, glaucoma or significant postoperative inflammation with lens deposits or synechias. discussion congenital cataract is the most common cause of visual impairment in children because of sensory deprivation during the period of visual maturation 18. m e a n b c v a ( l o g m a r) follow-up duration bcva kanwal latif, et al 31 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology its etiology is multifactorial and among the various risk factors, most important is the age of child. management of the posterior capsule, aggressive amblyopia therapy, and refractive management are major factors governing the ultimate visual outcomes of congenital cataract surgery15. many surgical procedures have been used to reduce the rate of posterior capsular opacification in children. posterior chamber intra ocular lens implantation with posterior capsulotomy and anterior vitrectomy is the most accepted surgical procedure in management of congenital cataracts16. the age at which anterior vitrectomy and posterior capsulotomy should be performed is controversial. many studies have different results. basti et al performed primary posterior capsulotomy with anterior vitrectomy in children younger than 8 years14. dahan and salmenson recommended posterior capsulorhexis and anterior vitrectomy in children younger than 8 years 19. vasavada and desai suggested that anterior vitrectomy with posterior continuous curvilinear capsulorhexis was desirable in children with congenital cataracts younger than 5 years20. in our study we performed anterior vitrectomy and posterior capsulotomy in all cases so as to minimize the rate of visual axis opacification and to achieve early postoperative visual rehabilitation. in our study after treatment of postoperative complications and amblyopia therapy 51% of eyes achieved good best corrected visual acuity (bcva). it ranges from 0.0 to 0.5 log mar. vision was not improved in 49% eyes despite proper management of complications and aggressive amblyopia therapy. the results of good visual acuity after congenital cataract surgery are variable. kim et al reported improved visual acuity in 51.7% of patients7. lai et al showed improvement in 50% of patients21. magnusson et al reported 50% of children achieved improvement in vision after surgery22. in follow-up period visual acuity was not improved during the 1st month but in subsequent follow-ups most of the patients achieve good vision with mean value of log mar 0.5. magnusson et al also showed a mean value of log mar 0.5 at the end of followups22. improvement in visual acuity after congenital cataract surgery was seen in patients who presented in younger age. in younger age group of 3 5 years 96% of children achieved good vision as compared to older age group of 6-8 years in which only 2% achieved good vision. in older age groups late intervention was the cause of decreased vision because of form deprivation due to cataract during the sensitive period of visual maturation. this showed that visual outcome following cataract surgery depends on the age and earlier cataract surgery is beneficial in achieving good vision11. moderate anterior chamber inflammation was seen in 13% and severe inflammation was seen in 15% of eyes. keech et al reported 10% of eyes developed inflammation and secondary membrane formation23. zwaan et al reported 13% of eyes developed fibrinous membranes after surgery24. raised intra ocular pressure was seen in 5% of eyes. ondraaek and lokaj reported raised introcular pressure in 4.3% of cases25. pupillary deviation was seen in 4.1% of eyes. ondraaek and lokaj reported pupillary deviation in 3.8% of eyes25. iol capture was observed in 2% of eyes. luo et al observed iol capture in 2.6% of patients26. conclusion this study concludes that timing of the congenital cataract surgery is the most important factor for visual prognosis. author’s affiliation dr. kanwal latif resident medical officer lrbt free base eye hospital kornagi 2½ karachi-74900 dr. munira shakir consultant ophthalmologist lrbt free base eye hospital kornagi 2½ karachi-74900 dr. shakir zafar consultant ophthalmologist lrbt free base eye hospital kornagi 2½ karachi-74900 dr. syed fawad rizvi chief consultant ophthalmologist lrbt free base eye hospital kornagi 2½ karachi-74900 dr. saliha naz resident medical officer lrbt free base eye hospital kornagi 2½ karachi-74900 outcomes of congenital cataract surgery in a tertiary care hospital pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 32 references 1. gogate p, gilbert c. blindness in children: a worldwide perspective. community eye health. 2007; 20: 32-33. 2. chak m, wade a, rahi js. british congenital cataract interest group. long-term visual acuity and its predictors after surgery for congenital cataract: findings of the british congenital cataract study. invest ophthalmol vis sci. 2006; 47: 4262-9. 3. sethi s, sethi mj, saeed n, kundi nk. pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital. pak j ophthalmol. 2008; 24: 166-71. 4. mahdi z, munami s, shaikh za, awan h, wahab s. pattern of eye diseases in children at secondary level eye department in karachi. pak j ophthalmol. 2006; 22: 145-51. 5. gogate p, gilbert c, zin a. severe visual impairment and blindness in infants: causes and opportunities. middle east afr j ophthalmol. 2011; 18: 109-114. 6. chandna a, gilbert c. when your eye patient is a child. community eye health. 2010; 23: 1-3. 7. kim kh, ahn k, chung es, chung ty. clinical outcomes of surgical techniques in congenital cataract. korean j ophthalmol. 2008; 22: 87-91. 8. butt ia, jalisl m, waseem s, abdul moqeet, inam-ul-haq m. spectrum of congenital and developmental anomalies of eye. al shifa j ophthalmol. 2007; 3: 56-60. 9. amaya l, taylor d, russell – eggitt i, nischal kk, lengyel d. the morphology and natural history of childhood cataracts. surv ophthalmol. 2003; 48: 125-44. 10. sethi s, sethi mj, hussain i, kundi nk. causes of amblyopia in children coming to ophthalmology outpatient department, khyber teaching hospital, peshawar. j pak med assoc. 2008; 58: 125-8. 11. ye hh, deng dm, qian yy, lin z, chen wr. long term visual outcome of dense bilateral congenital cataract. chin med j (engl). 2007; 120: 1494-7. 12. nishi o. fibrinous membrane formation on the posterior chamber lens during the early postoperative period. j cataract refract surg. 1988; 14: 73-7. 13. benezra d, cohen e. posterior capsulectomy in pediatric cataract surgery; the necessity of a choice. ophthalmology. 1997; 104: 2168–74. 14. basti s, ravishankar u, gupta s. results of a prospective evaluation of three methods of management pediatric cataracts. ophthalmology. 1996; 103: 713-20. 15. petric i, lonèar vl. surgical technique and postoperative complications in pediatric cataract surgery: retrospective analysis of 21 cases. croatian medical journal. 2004; 45: 287-91. 16. astle wf, alewenah o, ingram ad, paszuk a. surgical outcomes of primary foldable intraocular lens implantation in children: understanding posterior opacification and the absence of glaucoma. j cataract refract surg. 2009; 35: 1216-22. 17. kariman f, ali javadi m, reza jafarinasab m. pediatric cataract surgery. iran j ophthalmic res. 2007; 2: 146-53. 18. kaul h, riazuddin sa, yasmeen a, mohsin s, khan m, nasir ia, et al. a new locus for autosomal recessive congenital cataract identified in a pakistani family. mol vis. 2010; 16:240-5. 19. dahan e, salmenson bd. pseudophakia in children: precautions, techniques, and feasibility. j cataract refract surg. 1990; 16: 75-82. 20. vasavada a, desai j. primary posterior capsulorhexis with and without anterior vitrectomy in congenital cataracts. j cataract refract surg. 1997; 23: 645-51. 21. lai j, yao k, sun zh, zhang z, yang yh. long term follow up of visual functions after pediatric cataract extraction and intra ocular lens implantation. zhonghua yan ke za zhi. 2005; 41: 200-4. 22. magnusson g, abrahamsson m, sjostrand j. changes in visual acuity from 4 to 12 years of age in children operated for bilateral congenital cataract. br j ophthalmol. 2002; 86: 1385-9. 23. keech rv, tongue ac, scott we. complications after surgery for congenital and infantile cataract. br j ophthalmol. 1989; 108: 136-41. 24. zwaan j, mullaney pb, awad a, al-mesfer s, wheeler dt. pediatric intraocular lens implantation. surgical results and complications in more than 300 patients. ophthalmology. 1998; 105: 112-8. 25. ondraaek o, lokaj m. visual outcome after congenital cataract surgery. long term clinical results. scripta medica (brno). 2003; 78: 95-102. 26. luo y, lu y, lu g, wang m. primary posterior capsulorhexis with anterior vitrectomy in preventing posterior capsule opacification in pediatric cataract microsurgery. microsurgery. 2008; 28: 113-6. http://www.ncbi.nlm.nih.gov/pubmed?term=chandna%20a%5bauthor%5d&cauthor=true&cauthor_uid=20523854 100 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology original article effect of provocative test in hypermetropic eyes: a comparative study erum shahid, arshad shaikh, muzna kamal, asad raza jaffery, uzma fasih pak j ophthalmol 2016, vol. 32, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: erum shahid senior registrar, ophthalmology abbasi shaheed hospital and kmdc e-mail: drerum007@yahoo.com received: march 08, 2016 accepted: may 23, 2016 …..……………………….. purpose: to determine the effect of mydriatic provocative test on intraocular pressure in hypermetropic eyes as compared to emmetropic eyes. study design: prospective analytic cohort study. place and duration: department of ophthalmology, abbasi shaheed hospital, karachi between october 2014 to july 2015. material and methods: we recruited 109 patients from eye opd who were emmetropic, hypermetropic and presbyopic. we excluded known cases of glaucoma, closed angle, operated cases and using topical medications. after taking detail history and examination, iop was measured then tropicamide was instilled. after mydriasis iop was again measured. data was collected and analyzed on spss 21. a descriptive analysis of continuous and categorical variables was performed. means of iop was compared before and after dilatation in hypermetropes and emmetropes. results: we had 109 eyes of 109 patients in which 27 (25%) were males and 82 (75%) were females. their mean age was 44.2 ± 8.81sd. emmetropic eyes were 58 (53%) and hypermetropic eyes were 51 (47%). mean base line iop before dilatation was 14.7 ± 2.2sd and after dilatation was15.4 ± 2.8.the means of iop before and after dilatation was compared in hypermetropes with emmetropes with help of independent t test. its value was 0.322. provocative test was not positive in any group so we accept null hypothesis. conclusion: there was no statistically significant difference in intraocular pressure after mydriasis in hypermetropes as compared to emmetropes. key words: provocative test, hypermetropes, mydriasis, intraocular pressure he leading cause of blindness in asia is primary angle – closure glaucoma (pacg) and it is predicted that 26% of 80 million glaucomatous patients will be suffering from primary angle closure glaucoma (pacg) by 20201. the most widespread type of glaucoma to be considered in people with asian origin is pacc2. one of the emergencies that an ophthalmologist faces is an attack of acute angle – closure glaucoma (aacg). its acute presentation, requirement for immediate management and well – established anatomic pathology make it distinct from other ocular emergencies3. eyes that experience angle closure have short axial lengths, flat corneas and shallow anterior chambers. their lenses are situated more anterior and more thicker4. these eyes are not only anatomically are diverse than normal eyes but are also physiologically different5. an early diagnosis of pacg is vital to prevent ocular morbidity. as it is a known fact that a safe procedure is available in recent time. eyes that need to undergo these diagnostic tests are the ones that have a high index of suspicion for intermittent attacks of t mailto:drerum007@yahoo.com http://emedicine.medscape.com/article/1206956-overview effect of provocative test in hypermetropic eyes: a comparative study pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 101 angle closure or after resolution of an acute attack of pacg and asymptomatic eyes with shallow anterior chambers and narrow angles on gonioscopy. female gender, advancing age, asian descent, family history of angle closure glaucoma, hyperopia, shallow anterior chamber depth, shorter axial lengths and thicker lens raises suspicion for pacg2,4. to achieve this objective, many types of provocative tests have been proposed and assessed over time.6 precise and easy to perform provocative test should be proposed as screening tools for glaucoma, as it will not only decrease the number of visual impairment due to glaucoma but also help in reducing the direct and indirect expenses of the disease7. most of the patients coming to the public sector hospitals in third world countries are from low socioeconomic backgrounds. they are unable to go for expensive diagnostic tests and further management. we want to establish a mydriatic provocative test to be a quick and inexpensive screening method for these hospitals with limited resources. the objective of the study is to determine the effect of mydriatic provocative test on intraocular pressure in hypermetropic eyes as compared to emmetropic eyes in adults. materials and methods this study was conducted in the department of ophthalmology, abbasi shaheed hospital, karachi in a tertiary care hospital. it was a prospective analytic cohort study. it was started in october 2014 after approval from ethics and scientific research committee of karachi medical and dental college and was completed by july 2015. sample size calculated was 109 with help of who software edited by lawanga and lemeshaw8 where alpha = 5%, 1-beta power of the test = 90, test value of population proportion po = 0.8, anticipated value of population proportion pa = 0.9 hypermetropic, emmetropic and presbyopic patients with open angles attending an eye opd were selected on the basis of nonprobability convenient sampling. those patients who were known glaucoma patients, intra ocular pressure of more than 20mm of hg, closed angle, using any topical pressuring lowering agent and past ocular surgery were excluded from the study. patients were enrolled only after written informed consent. they were explained about the side effects of medication. detailed history about presenting complaints, refractive error, any associated disease of every patient was taken. their distance visual acuity was checked on snellen’s chart and near acuity was also checked with help of near vision chart. they were examined on slit lamp for anterior segment including cornea, anterior chamber and its depth with van herick's method. pupillary reflexes were checked before dilatation. baseline intraocular pressure was checked with help of fluorescein staining by using applanation tonometer by a single observer. gonioscopy was done to examine angles and to make sure angles are open before dilatation. mydriatic agent i.e. tropicamide 1% was instilled in both eyes three times after every ten minutes. they were asked to keep their eyes closed. patients were examined after full dilatation of pupil that took minimum of 30 minutes to maximum of 45 minutes. intraocular pressure was checked again with applanation tonometer and recorded. a rise in iop of 8 mm hg9 was considered to be positive. after dilatation fundus was also examined with direct and indirect ophthalmoscope. data was entered and analyzed on statistical package for social sciences (spss 21). a descriptive analysis of continuous and categorical variables was performed. refractive error was compared with other variables with help of chi square test. independent t test was used to compare change in iop in emmetropes with hypermetropes. p value of less than 0.05 was considered to be significant. results there were total of 109 eyes of 109 patients in which 27 (25%) were males and 82 (75%) were females. their age varied between 28 years to 70 with mean age 44.2 ± 8.81 sd. emmetropic eyes were 58 (53%) and hypermetropic eyes were 51 (47%). the most common complaint with which they presented was decreased vision in 62 (55%) followed by headache in 18 (16%). hypertension was most common associated factor in 18 (19%) of them (table 1). independent t test was used to compare the means of iop before and after dilatation in hypermetropes with emmetropes (table 1). mean iop before dilatation in emmetropes was 14.7 ± 2.2 and in hypermetropes was 15.2 ± 2.5. this changes to 15.1 ± 2.8 in emmetropes and 15.8 ± 2.3 in hypermetropes. its p value was 0.322, which is also not statistically significant. discussion literature was thoroughly searched before starting and at concluding this study. various provocative erum shahid, et al 102 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology table 1: demographics. variables emmetrope hypermetrope total % p-value no 58 51 109 age 41.2 ± 8.9 41.4 ± 7.4 male female 8 50 19 32 27 (25%)* 82 (75%) .005 c/o headache decreased vision pain 11 36 2 7 26 6 18 (16%)* 62 (55%) 8 (7%) .260 comorbidites dm htn 5 10 7 8 12 (14%)* 18 (19%) .854 mean iop baseline mean iop after 14.7 ± 2.2 15.1 ± 2.8 15.2 ± 2.5 15.8 ± 2.3 .290 ^ .322 *chi square test ^ independent t test tests have been conceived in literature to induce angle closure and a rise of intraocular pressure (iop), with contradictory results. these tests includes dark room provocative test10, prone test11, ibopamine provocative test,12 mydriatic provocative test13 and water drinking test14 just to predict angle closure in patients at risk. these tests have been employed not only on patients at risk of pacg but also their relatives13. these tests need to be cost effective, less time consuming and easy to perform. in literature no one has compared the difference in rise of iop in hypermetropes with emmetropes after mydriasis up to our knowledge. due to the structural difference of hypermetropic eyes4,5 than normal eyes we had this novel idea to compare the change in iop after mydriatic provocative test. if we compare our results with other study that was conducted on pac, pac suspects and its relatives11 out of 6 (8.1%) diagnosed pac4 (66.7%) had a positive dark prone provocative test response (dppt), 8 (10.8%) were pac suspects in which 87.5% had a positive or a borderline dppt response. but in our study the negative results could be due to the fact that we have enrolled all normal patients with open angles and without history of glaucoma. all of these patients were best corrected 6/6. another dark room test15 showed 32 (42%) eyes with a positive drpt, however their results are based on optical cohrence tomography (oct) and gonioscopy. they measure iop after 3 minutes and after 1.5 hours of dark adaptation as compared to our study where duration was maximum 45 minutes. the darkroom and prone provocative tests are physiological tests with poor specificity10. additionally these tests have not been found to be very predictive of angle closure14. if we compare our results with ibopamine provocative test12, it was positive in 44.33% of cases in group 1 that included offspring of at least 1 parent with primary open angle glaucoma with a mean increase in iop of 5.57 mm hg (p < 0.001). whereas group 2 that consisted of offspring of healthy parents had negative test results with even 1 to 2 mm hg of iop reduction. group 2 of that study recruited normal patients like our study so the results are similar. group 1 had patients with family history of open angle glaucoma not angle closure glaucoma so the results differ. however pukrushpan et al16 showed that postdilatation iop in non-glaucomatous patients with open angles, undergoing routine diagnostic mydriasis with tropicamide was equivalent to the pre-dilatation iop. another study showed that in majority of patients, the changes in iop were within 2.0 mmhg17 and we also report the rise in iop within 2 mm of hg but statistically insignificant. effect of provocative test in hypermetropic eyes: a comparative study pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 103 luckily no patient in either group developed an attack of angle closure in our study. mydriatic or cycloplegic agents can cause a rise in iop, which might be due to decrease aqueous outflow, caused by decreased pull on the trabecular meshwork due to ciliary muscle paralysis.18 on the other hand valle19 noted an increase in aqueous inflow in patients who experienced a rise in iop following dilation and suggested a decrease in aqueous outflow in the same patients. other reason could be due to the duration of dilation. as acute angle closure glaucoma occurs while the pupil constricts over hours after dilatation, when it is mid dilated to a diameter of 3 – 4.5 mm. during this period, the posterior vector force of the iris sphincter muscle reaches its maximum. the peripheral iris is under less tension and is more easily pushed forward into contact with the trabecular meshwork. this dilation results in thickening of the peripheral iris and it also bunches in the angle3. due to lack of similar studies in literature the comparison of results of our study cannot be drawn precisely. this could be taken as limitation of study. conclusion although hypermetropic eyes are immensely diverse anatomically from emmetropic eyes but there was no statistically significant difference in intraocular pressure before and after mydriasis in hypermetropes as compared to emmetropes. provocative test was not positive in any patient in either group so we accept null hypothesis. author’s affiliation dr. erum shahid senior registrar, ophthalmology abbasi shaheed hospital and kmdc dr. arshad shaikh head of the department, ophthalmology abbasi shaheed hospital and kmdc dr. muzna kamal resident medical officer abbasi shaheed hospital dr. asad raza jaffery associate professor abbasi shaheed hospital and kmdc dr. uzma fasih associate professor abbasi shaheed hospital and kmdc role of authors dr. erum shahid concept, manuscript writing, data collection, date analysis, result interpretation, critical review. dr. arshad shaikh concept, result interpretation, critical review. dr. muzna kamal concept, data collection, critical review. dr. asad raza jaffery concept, critical review, drafting. dr. uzma fasih concept, critical review, drafting of manuscript. refrences 1. quigley ha. number of people with glaucoma worldwide. br j ophthalmol. 1996; 80: 389–93. 2. bonomi l. epidemiology of angle – closure glaucoma. acta ophthalmol scand suppl. 2002; 236: 11–3. 3. berkoff dj, sanchez ld. an uncommon presentation of acute angle closure glaucoma. j emerg med. jul 2005; 29 (1): 43-4. 4. alsbirk ph. corneal diameter in greenland eskimos. anthropometric and genetic studies with special reference to primary angle – closure glaucoma. acta ophthalmol (copenh). 1975; 53: 635–646. 5. wyatt h, ghosh j. behaviour of an iris model and the pupil block hypothesis. br j ophthalmol. 1970; 54: 177– 185. 6. r sihota, s mohan, t dada, v gupta, r m pande y, d ghate. an evaluation of the darkroom prone provocative test in family members of primary angle closure glaucoma patients. eye, 2007; 21: 984–989. 7. lee, p. economic concerns in glaucoma management in the 21st century. j glaucoma, 1993; 2 (2): 148-51. 8. ang lp, aung t, chew pt. acute primary angle closure in an asian population: long-term outcome of the fellow eye after prophylactic laser peripheral iridotomy. ophthalmology, 2000; 107: 2092-6. 9. wang b, congdon ng, wang n, lei k, wang l, aung t. dark room provocative test and extent of angle closure: an anterior segment oct study.j glaucoma, 2010 mar; 19 (3): 183-7. 10. r sihota, s mohan, t dada, v gupta, r m pandey, d ghate. an evaluation of the darkroom prone provocative test in family members of primary angle closure glaucoma patients. eye, 2007; 21: 984–989. 11. m zahari, ym ong, r taharin. darkroom prone provocative test in primary angle closure glaucoma relatives. optometry and vision science, 2014: 91 (4): 459–463. 12. m virno, r sampaolesi, jp giraldi. ibopamine: d1dopaminergic agonist in the diagnosis of glaucoma. journal of glaucoma, 2013; 22 (1): 5–9. http://www.ncbi.nlm.nih.gov/pubmed/19593203 https://scholar.google.com.pk/citations?user=qq0mrtaaaaaj&hl=en&oi=sra erum shahid, et al 104 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology 13. wilensky jt1, kaufman pl, frohlichstein d, gieser dk, kass ma, ritch r, anderson r.follow-up of angle-closure glaucoma suspects. am j ophthalmol. 1993; 115: 338–346. 14. t tran, n niyadurupola, j o'connor. rise of intraocular pressure in a caffeine test versus the water drinking test in patients with glaucoma. clinical and experimental ophthalmology, 2014: 42 (5): 427–432. 15. li, d., wang, n., wang, b., wang, t. and jonas, j. b. modified dark room provocative test for primary angle closure. journal of glaucoma, 2012; 21 (3): 155-159. 16. pukrushpan p, tulvatana w, kulvichit k. intraocular pressure change following application of 1% tropicamide for diagnostic mydriasis. acta ophthalmol scand. 2006; 84: 268–270. 17. tsai, i.-l., tsai, c.-y., kuo, l.-l., liou, s.-w., lin, s. and wang, i.-j. transient changes of intraocular pressure and anterior segment configuration after diagnostic mydriasis with 1% tropicamide in children. clinical and experimental optometry, 2012; 95: 166–172. 18. velasco cabrera j, eiroamozos p, garcia sanchez j, bermudez rodriguez f. changes in intraocular pressure due to cycloplegia. clao j. 1998; 24: 111–114. 19. valle o. the cyclopentolate provocative test in suspected or untreated open – angle glaucoma. v. statistical analysis of 431 eyes. acta ophthalmol copenh. 1976; 54: 791–803. 20. frideman ds, gazzrd g, foster p, devereux j, broman a, quigley h, et al. ultrasonographic biomicroscopy, scheimpflug photography, and novel provocative tests in contralateral eyes of chinese patients initially seen with acute angle closure. arch ophthalmol. 2003; 121 (5): 633-42. 21. gray rh, hoare nj, ayliffe whr. efficacy of nd – yag laser iridotomies in acute angle closure glaucoma. br j ophthalmol. 1989; 73 (3): 182-5. http://www.ncbi.nlm.nih.gov/pubmed/?term=wilensky%20jt%5bauthor%5d&cauthor=true&cauthor_uid=8442493 http://www.ncbi.nlm.nih.gov/pubmed/?term=kaufman%20pl%5bauthor%5d&cauthor=true&cauthor_uid=8442493 http://www.ncbi.nlm.nih.gov/pubmed/?term=frohlichstein%20d%5bauthor%5d&cauthor=true&cauthor_uid=8442493 http://www.ncbi.nlm.nih.gov/pubmed/?term=gieser%20dk%5bauthor%5d&cauthor=true&cauthor_uid=8442493 http://www.ncbi.nlm.nih.gov/pubmed/?term=gieser%20dk%5bauthor%5d&cauthor=true&cauthor_uid=8442493 http://www.ncbi.nlm.nih.gov/pubmed/?term=gieser%20dk%5bauthor%5d&cauthor=true&cauthor_uid=8442493 http://www.ncbi.nlm.nih.gov/pubmed/?term=kass%20ma%5bauthor%5d&cauthor=true&cauthor_uid=8442493 http://www.ncbi.nlm.nih.gov/pubmed/?term=ritch%20r%5bauthor%5d&cauthor=true&cauthor_uid=8442493 http://www.ncbi.nlm.nih.gov/pubmed/?term=anderson%20r%5bauthor%5d&cauthor=true&cauthor_uid=8442493 http://onlinelibrary.wiley.com/doi/10.1111/ceo.12259/full http://onlinelibrary.wiley.com/doi/10.1111/ceo.12259/full http://onlinelibrary.wiley.com/doi/10.1111/ceo.12259/full http://onlinelibrary.wiley.com/doi/10.1111/ceo.2014.42.issue-5/issuetoc pak j ophthalmol. 2020, vol. 36 (4): 386-390 386 original article outcomes of conventional trabeculectomy in terms of intraocular pressure and visual acuity in primary open angle glaucoma erum shahid 1 , uzma fasih 2 , arshad shaikh 3 1-3 department of ophthalmology, abbasi shaheed hospital & karachi medical and dental college, karachi abstract purpose: to determine the outcomes of conventional trabeculectomy in terms of decrease in intraocular pressure (iop) and improvement in visual acuity in patients of primary open glaucoma, coming to a tertiary care hospital. study design: retrospective case series. place and duration of study: department of ophthalmology abbasi shaheed hospital from january 2017 to december 2018. methods: patients undergoing trabeculectomy for primary open angle glaucoma were included. patients with repeated trabeculectomy, failed argon laser trabeculoplasty, advanced cataract, corneal opacities and absolute glaucoma were excluded. all the trabeculectomies were done under retrobulbar anaesthesia after taking all aseptic measures. primary outcome measures were preoperative and postoperative visual acuity, intraocular pressure, number of anti-glaucoma medications and failed or successful trabeculectomy. results: total 52 patients underwent trabeculectomy. there were 36 (69.2%) males and 16 (30.8%) females. mean age was 56.73 years ± 10.9 sd. mean preoperative iop was 30.96 ± 6.71 mm hg, post operatively iop at 1 year was 15.6 ± 4.2 mm hg. p value was <.000. mean number of antiglaucoma medications was 3.03 and 1.19, pre and post-operatively respectively (p value <.000). improvement in visual acuity after trabeculectomy was seen in 32 (61.5%) patients. complete surgical success was seen in 28 (53.8%) and qualified success in 21 (40.4%) patients. failed trabeculectomy was seen in 3 (5.8%) patients. conclusion: conventional trabeculectomy is effective in lowering iop in primary open angle glaucoma patients. it maintains iop within normal range with and without anti-glaucoma medications at 1 year follow-up. trabeculectomy significantly reduces number of anti-glaucoma medications. key words: intraocular pressure, primary open angle glaucoma, trabeculectomy. how to cite this article: shahid e, fasih u, shaikh a. outcomes of conventional trabeculectomy in terms of intraocular pressure and visual acuity in primary open angle glaucoma. pak j ophthalmol. 2020, 36 (4): 386390. doi: https://doi.org/10.36351/pjo.v36i4.1086 correspondence: erum shahid department of ophthalmology abbasi shaheed hospital & karachi medical and dental college, karachi email: drerum007@hotmail.com received: june 23, 2020 accepted: august 8, 2020 introduction there are approximately 60 million people affected by glaucoma globally. it is the second leading cause of blindness after cataract. 1 it is responsible for 10% of the total world blindness. 2 approximately half of the population with glaucoma resides in asia including most populated areas including china, india and pakistan. 3 fifty percent of the glaucoma patients are erum shahid, et al 387 pak j ophthalmol. 2020, vol. 36 (4): 386-390 unaware of their disease at the time of diagnosis and they present at an advanced stage. 4 pakistan has burden of more than 1.8 million glaucoma patients and nearly half of them have lost their sight irreversibly due to delay in diagnosis and treatment. more and more people are becoming permanently blind in pakistan due to untreated glaucoma and 90% of our population is ignorant of the disease. 5 trabeculectomy is the gold standard procedure for lowering intra ocular pressure (iop) in primary open angle glaucoma (poag) and normal tension glaucoma patients, not responding to medical and laser treatments. 6 studies comparing the results of initial treatment with trabeculectomy versus medical treatment reported superior results of trabeculectomy in lowering iop. 7 it has an additional benefit of stabilizing iop by reducing diurnal fluctuation and dependence on patient compliance with medication. 8 most of the trabeculectomies attain successful outcome in reducing iop over long term and thereby minimizing progression of glaucoma. 6,9 trabeculectomy has been modified with use of antimetabolites, limbal versus fornix based flaps and argon suture lysis. early postoperative wound leak is a risk factor for failed trabeculectomy reported by 5 flourouracil filtration surgical study. 10 surgical failure is the most frequent complication of trabeculectomy that leads to high postoperative iop, progression of visual field loss and eventual blindness. 8 most frequent cause of failure is scar formation at conjunctiva-tenons-episcleral interface and at sclerostomy site. 11,12 poor compliance, multi drug therapy, lost to follow-up, financial burden are major concerns of glaucoma patients especially those coming to public sector hospitals of a developing country. trabeculectomy in these circumstances would be beneficial for such patients. this purpose of this study was to document the outcomes of trabeculectomy in terms of iop and visual acuity in our population. this study will help in generating a local database in this context. methods a retrospective case series was conducted in the department of ophthalmology, abbasi shaheed hospital from january 2017 to dec 2018.the study adheres to the tenants of declaration of helsinki. we included patients who underwent trabeculectomy for primary open angle glaucoma. patients with advanced cataract, corneal opacities, absolute glaucoma, history of failed trabeculectomy and failed argon laser trabeculoplasty were excluded from the study. data was retrieved and collected from the hospital records about age, gender, duration and type of glaucoma, laterality of eye, preoperative and postoperative iop, visual acuity and number of medications used. all the trabeculectomies were done under retrobulbar anaesthesia after taking all aseptic measures. all the surgeries had fornix based conjunctival flap. bridle traction suture with 4/0 silk was used to expose superior conjunctiva and stabilize the globe. conjunctival flap was made at superior nasal or superior temporal site. incision was made in conjunctiva 0.5 – 1.0 mm posterior to the limbus with westcott scissors and tenon’s capsule was carefully dissected from underlying sclera. a vertical relaxing incision was made in conjunctiva in case of tight fibrosed conjunctiva. wet field cautery was applied at the site of bleeding on sclera. a rectangular flap measuring 3 by 4 mm with calipers was marked and incised with blade 11. partial thickness window was created with blade 15. piece of trabecular mesh work about 2 mm by 1 mm was removed followed by iridectomy with the help of iridectomy scissors. a side port was made to wash anterior chamber and to check the patency of fistula. anterior chamber was washed with normal saline in case of hyphema and was formed with air. scleral flap was closed with interrupted 10/0 nylon sutures at two ends. tenon’s and conjunctiva were closed with 10/0 nylon in interrupted fashion. post operatively topical steroid dexamethasone was prescribed for 8–12 weeks and antibiotic moxifloxacin for 4 weeks. steroid antibiotic ointment was given for 2 weeks. systemic antibiotics (ciprofloxacin 500 mg bd) were also given. patients were followed-up to see the iop, visual acuity and any post-operative complications. best corrected visual acuity was assessed with the help of snellen’s chart. iop was measured with goldman applanation tonometer. follow-up was done on first postoperative day then on 1 st week, 2 nd week, 1 st month, 3 rd month, 6 th month and at 1 year. frequent follow-ups were done if necessary. data was analyzed using spss version 21. primary outcome measures were preoperative and postoperative visual acuity, intraocular pressure, number of medications, improvement in visual acuity and failed or successful trabeculectomy. mean with standard deviation was calculated for numerical outcomes of conventional trabeculectomy in primary open angle glaucoma pak j ophthalmol. 2020, vol. 36 (4): 386-390 388 variables like age, duration of disease, number of preoperative and post-op medications, base line and follow-up iop. frequencies were computed for categorical variables like gender, laterality of eye, best corrected visual acuity (bcva), improvement or deterioration of visual acuity, successful and failed trabeculectomy. one sample t test was used to compare means of iop and number of medications pre-operatively and post-operatively. p value of less than 0.05 was taken as significant. effectiveness of trabeculectomy was classified into three groups, complete success, qualified success and failed trabeculectomy. intra ocular pressure of less than 20 mm hg or less at 1 year after trabeculectomy without any medication was labeled as complete success. iop of 20 mm hg or less with help of medications at 1 year was labeled as qualified success. trabeculectomy was defined ‘fail’ in case of iop of 20 mm hg or more in spite of maximum medical management. 13,14 results total number of patients in this study were 52 who underwent trabeculectomy. the detailed demographic features are given in table 1. table 1: demographics of glaucoma patients that underwent trabeculectomy. variables mean age 56.73 ± 10.9 sd min 33 max 74 male 36 (69.2%) female 16 (30.8%) duration of glaucoma 3.8 ± 2.3 years right eye 32 (61.5%) left eye 20 (38.5%) mean preoperative iop 30.96 ± 6.71 improvement in lines 32 (61.5%) deterioration in lines 4 (7.7%) no improvement 16 (30.8%) table 2: preoperative and postoperative visual acuity, intraocular pressure and number of medications. bcva pre-operative post-operative p value 6/6 to 6/18 6/36 to 6/24 6/60 and less plpr to lp 10 10 24 8 10 12 28 2 .000 iop mm hg at 3 rd month 30.96 ± 6.71 14.6 ± 3.2 .000 at 6 th month at 12 th month 15.7 ± 4.0 15.6 ± 4.2 no. of medications 3.03 1.19 .000 *nonparametric test chi square ^one sample t test, one sample t test plpr = perception of light and projection of light, lp = light perception complete surgical success was seen in 28 (53.8%) patients. qualified success was in 21 (40.4%) patients requiring additional medication. failed trabeculectomy was seen in 3 (5.8%) patients requiring surgical intervention. discussion trabeculectomy remains the most common non-laser surgical procedure for management of glaucoma. medical treatment has been found to be insufficient in patients belonging to third world countries because of very poor compliance. 15 complete success was seen in 28 (53.8%) patients, qualified success was seen in 21 (40.4%) patients. overall success was seen in 49 (94.2%) cases. failed trabeculectomy was seen in 3 (5.8%) patients at 1 year in this study. a study conducted in nigerian teaching hospital reported complete success in 34 (61.8%) and qualified success in 15 (27.3%) at 1 year post trabeculectomy. their overall success was seen in 91.1%. their failure rate was 6 (10.9%). 14 their mean follow-up time was 3.03 years. complete success was seen in 66.7% of chinese people (18 patients) and qualified success in 16.7%. their failure rate was seen in 10% patients at 3 months. 16 complete success and qualified success rates of our study are comparable with other studies. 14,16 trabeculectomy gradually fails over passage of time due to fibroblastic proliferation and sub conjunctival fibrosis seen as a normal process of wound healing. 17 mean pre-operative iop in our study was 30.96 ± 6.71 and at 1 year it was 15.6 ± 4.2 mm hg. in a nigerian study pre-operative iop was 32.5 ± 6.2 mm hg and 1 year, it was 16.2 ± 3.7 mm hg. 14 tabassam et al had reported pre op iop 32.7 ± 12.43 and at 1 year it was 15.78 ± 3.71 mm hg. 18 in all of the above studies mean pre-operative iop was exceeding 30 mm hg and trabeculectomy had successfully reduced it to 14 – 16 mm hg at 1 year. the goal of glaucoma management is to achieve a target pressure, which will erum shahid, et al 389 pak j ophthalmol. 2020, vol. 36 (4): 386-390 help to preserve visual function. 19 target pressure is different for every patient and it has to be reassessed according to visual field progression and optic nerve head changes for each patient. if iop remains high normal after trabeculectomy, patient can end up with legal blindness. fluctuation of iop will lead to optic disc damage and visual field progression. a surgeon has achieved his goal if trabeculectomy is attaining and maintaining target pressure for his patient. in this study, there was no change in visual acuity in 30.8% of patients after trabeculectomy. reduction in visual acuity was seen in 7.7% of patients. study by tabassam et al documented no change in visual acuity at 1 year. 18 there was no difference in visual acuity in a study done in nigerian teaching hospital and in chinese population. 14,16 however, they did not specify any improvement in lines. 14,18 it has been reported that filtration surgery may lead to decrease quality of vision in some patients. however, these changes are reversible and visual acuity returns to pre-operative levels within three-month period. trabeculectomy may induce some refractive changes like changes in corneal contour, anterior chamber depth and axial length. 20,21 every single line on snellen’s chart is important for glaucoma patient who realizes that with passage of time it will deteriorate. if trabeculectomy stabilizes and maintains visual acuity of poag patient, it will certainly have effects on quality of life. decrease in number of anti-glaucoma medications after trabeculectomy from 3.5 to 1.5 drops was also reported in a study conducted in sweden. 20 trabeculectomy has an advantage of reducing patient’s dependence on medication. 8 patients on topical anti-glaucoma medications have increased incidence of ocular surface diseases. 22 trabeculectomy maintains quality of life by lowering number of topical medications. 20,22 and quality of vision affected by use of topical medications with preservatives. males were twice than females with ratio of 2.2:1 in our study. other studies also demonstrated male preponderance. 13,14,17,18 we did not use antimetabolites in routine cases. they are associated with frequent wound leaks, late bleb leaks, hypotony so they are advisable in young and negro patients with high risk of postoperative fibrosis. 23 glaucoma is a disease that cannot be cured but its progression can be controlled successfully. glaucoma is neither treatable nor preventable but appropriate management can halt its progression. 24 not only surgical skill but appropriate postoperative bleb management is crucial for a successful surgery. limitation of our study is being a retrospective design and a limited sample size. visual field progression analysis and documenting optic nerve head changes could have made our study results more comprehensive. conclusion conventional trabeculectomy is effective in lowering iop in primary open angle glaucoma patients. it maintains iop within normal range with and without anti-glaucoma medications in most of the patients at 1 year follow-up. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. quigley ha. number of people with glaucoma worldwide. br j ophthalmol. 1996; 80 (5): 389-93. 2. resnikoff s, pascolini d, mariottia sp. global magnitude of visual impairment caused by uncorrected refractive errors in 2004. bull world health organ, 2008; 86: 63-70. 3. jacob a, thomas r, koshi sp, braganza a, muliyil j. prevalence of primary glaucoma in an urban south indian population. indian j ophthalmol. 1998; 46 (2): 81. 4. thapa ss, paudyal i, khanal s, twyana sn, paudyal g, gurung r, et al. a population-based survey of the prevalence and types of glaucoma in nepal: the bhaktapur glaucoma study. ophthalmology, 2012; 119 (4): 759-764. 5. khan l, ali m, qasim m, jabeen f, hussain b. molecular basis of glaucoma and its therapeutical analysis in pakistan: an overview. biomed res ther. 2017; 23; 4 (03): 1210-1227. 6. radhakrishnan s, quigley ha, jampel hd, friedman ds, ahmad si, congdon ng, et al. outcomes of surgical bleb revision for complications of trabeculectomy. ophthalmology, 2009; 116 (9): 17131718. https://pubmed.ncbi.nlm.nih.gov/?term=twyana+sn&cauthor_id=22305097 https://pubmed.ncbi.nlm.nih.gov/?term=paudyal+g&cauthor_id=22305097 https://pubmed.ncbi.nlm.nih.gov/?term=gurung+r&cauthor_id=22305097 https://pubmed.ncbi.nlm.nih.gov/?term=friedman+ds&cauthor_id=19643490 https://pubmed.ncbi.nlm.nih.gov/?term=ahmad+si&cauthor_id=19643490 https://pubmed.ncbi.nlm.nih.gov/?term=congdon+ng&cauthor_id=19643490 outcomes of conventional trabeculectomy in primary open angle glaucoma pak j ophthalmol. 2020, vol. 36 (4): 386-390 390 7. lichter pr, musch dc, gillespie bw, guire ke, janz nk, wren pa, et al. cigts study group. interim clinical outcomes in the collaborative initial glaucoma treatment study comparing initial treatment randomized to medications or surgery. ophthalmology, 2001; 108 (11): 1943-1953. 8. landers j, martin k, sarkies n, bourne r, watson p. a twenty-year follow-up study of trabeculectomy: risk factors and outcomes. ophthalmology, 2012; 119 (4): 694-702. 9. dada t, kusumesh r, bali sj, sharma s, sobti a, arora v, et al. trabeculectomy with combined use of subconjunctival collagen implant and low-dose mitomycin c. j glaucoma. 2013; 22: 659–662. 10. the fluorouracil filtering surgery study group. fiveyear follow-up of the fluorouracil filtering surgery study. am j ophthalmol. 1996; 121: 349–366. 11. singh k, mehta k, shaikh nm, tsai jc, moster mr, budenz dl, et al. trabeculectomy with intraoperative mitomycin c versus 5-fluorouracil: prospective randomized clinical trial. ophthalmology, 2000; 107 (12): 2305-2309. 12. schwartz k, budenz d. current management of glaucoma. current opinion in ophthalmology, 2004; 15 (2): 119-126. 13. agbeja-bayeroju am, omoruyi m, owoaje et. effectiveness of trabeculectomy on glaucoma patients in ibadan. afr j med sci. 2001; 31: 39-44 14. adegbehingbe bo, majemgbasan t. a review of trabeculectomies at a nigerian teaching hospital. ghana med j. 2007; 41 (4). 15. nouri-mahdavi k, hoffman d, coleman al, liu g, li g, gaasterland d, et al. predictive factors for glaucomatous visual field progression in the advanced glaucoma intervention study. ophthalmology, 2004; 111 (9): 1627-1635. 16. choy bn. comparison of surgical outcome of trabeculectomy and phacotrabeculectomy in chinese glaucoma patients. intern j ophthalmol. 2017; 10 (12): 1928. 17. agbeja-bayeroju am, owoaje et, omoruyi m. trabeculectomy in young nigerian patients. afr j med sci. 2002; 31 (1): 33-35. 18. tabassum g, ghayoor i, ahmed r. the effectiveness of conventional trabeculectomy in controlling intraocular pressure in our population. pak j ophthalmol. 2013; 29 (1): 26-30. 19. rao hl, addepalli uk, jonnadula gb, kumbar t, senthil s, garudadri cs. relationship between intraocular pressure and rate of visual field progression in treated glaucoma. j glaucoma. 2013; 22: 719–724. 20. binibrahim ih, bergström ak. the role of trabeculectomy in enhancing glaucoma patient's quality of life. oman journal of ophthalmology, 2017; 10 (3): 150. 21. wagschal ld, trope ge, jinapriya d, jin yp, buys ym. prospective randomized study comparing express to trabeculectomy: 1-year results. j glaucoma, 2015; 24 (8): 624-629. 22. hirooka k, nitta e, ukegawa k, tsujikawa a. vision-related quality of life following glaucoma filtration surgery. bmc ophthalmology, 2017; 17 (1): 66. 23. butt nh, ayub mh, ali mh. challenges in the management of glaucoma in developing countries. taiwan j ophthalmol. 2016; 6 (3): 119-122. 24. robin a, grover ds. compliance and adherence in glaucoma management. indian j ophthalmol. 2011; 59 (suppl. 1): s93. authors’ designation and contribution erum shahid; assistant professor: concepts, design, literature research, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. uzma fasih; associate professor: concepts, design, data acquisition, manuscript editing, manuscript review. arshad shaikh; professor & head of department: concepts, design, data analysis, manuscript editing, manuscript review. .…  …. https://pubmed.ncbi.nlm.nih.gov/?term=guire+ke&cauthor_id=11713061 https://pubmed.ncbi.nlm.nih.gov/?term=janz+nk&cauthor_id=11713061 https://pubmed.ncbi.nlm.nih.gov/?term=wren+pa&cauthor_id=11713061 https://pubmed.ncbi.nlm.nih.gov/?term=tsai+jc&cauthor_id=11097613 https://pubmed.ncbi.nlm.nih.gov/?term=moster+mr&cauthor_id=11097613 https://pubmed.ncbi.nlm.nih.gov/?term=budenz+dl&cauthor_id=11097613 https://pubmed.ncbi.nlm.nih.gov/?term=liu+g&cauthor_id=15350314 https://pubmed.ncbi.nlm.nih.gov/?term=li+g&cauthor_id=15350314 https://pubmed.ncbi.nlm.nih.gov/?term=gaasterland+d&cauthor_id=15350314 pak j ophthalmol. 2020, vol. 36 (4): 402-407 402 original article effects of intravitreal aflibercept in patients with central serous chorioretinopathy muhammad afzal bodla 1 , ali afzal bodla 2 , syeda minahil kazmi 3 , ayema moazzam 4 1-4 department of ophthalmology, multan medical and dental college, multan abstract purpose: to assess the efficacy of intravitreal injection of aflibercept in patients with chronic central serous chorioretinopathy (cscr). study design: interventional case series. place and duration of study: multan medical and dental centre and bodla eye care from february 2019 to february 2020. methods: this study was conducted on fifteen eyes with sub-acute to chronic central serous chorioretinopathy. all patients who had undergone previous treatment with laser photocoagulation, intravitreal triamcinolone, or bevacizumab in past 3 months, history of glaucoma (intraocular pressure > 21 mm hg), patients who were lost to follow-up, and those with previously vitrectomized eyes were excluded. patients were treated with a single dose of intravitreal injection of aflibercept (0.5 mg/0.05 ml). visual acuity with log mar chart and central retinal thickness were studied before and after the injection. results: the mean age of the patients was 30.46 years ± 9 years. after one month of intravitreal aflibercept injection, visual acuity improved from 0.32 log mar to 0.173 log mar and at 3 months (the last follow-up) it was 0.206 log mar. central retinal thickness (crt) improved from 437 ± 82 µm (at the time of presentation) to 349 ± 67 µm at 1 month post injection. at the last follow-up the mean crt decreased to 309 ± 121 µm. except for two eyes, all eyes showed visual improvement. these two eyes had a higher crt as compared to other participants. conclusion: intravitreal injection of aflibercept is effective in improving bcva and decreasing the central retinal thickness in patients central serous chorioretinopathy. key words: central retinal thickness, central serous chorioretinopathy, aflibercept. how to cite this article: bodla ma, bodla aa, kazmi sm, moazzam a. effects of intravitreal injection of afibercept in patients with central serous chorioretinopathy. pak j ophthalmol. 2020; 36 (4): 402-407. doi: https://doi.org/10.36351/pjo.v36i4.1098 introduction central serous chorioretinopathy (cscr) is a chorioretinal disorder distinguished by serous retinal detachments repeatedly engaging the macula and with correspondence: ali afzal bodla department of ophthalmology, multan medical and dental college, multan email: aliafzal111@gmail.com received: july 9, 2020 accepted: september 2, 2020 occasional focal pigment epithelial detachments (ped), choroidal hyper-permeability and increased choroidal thickness. 1 the pathogenesis of central serous chorioretinopathy (cscr) is inadequately understood and can be associated with systemic involvement, an aetiology influenced by multiple factors and an intricate pathogenesis. variations from the norm in the choroidal circulation have been conjectured to be causative variables. a few recent findings in cscr were noted using advanced indocyanine green angiography. these changes include hyper permeability of the choroidal circulation surrounding active retinal pigment epithelial leaks muhammad afzal bodla, et al 403 pak j ophthalmol. 2020, vol. 36 (4): 402-407 which can be extra central and multifocal and numerous assumed serous retinal epithelial separations. 2-3 other studies demonstrated an extremely thick choroid in patients with focal serous chorioretinopathy using enhanced depth imaging spectral domain optical coherence tomography. this finding implicates that focal serous chorioretinopathy might be brought about by expanded hydrostatic pressure in the choroid. 4 despite the fact that most instances of cscr are self-limiting, chronicity in few can lead to structural changes of retinal pigment epithelium and a subsequent visual compromise. other researches show that anti-vascular endothelial growth factor (antivegf) therapy can result in decrease in sub retinal fluid in cscr by lowering choroidal vascular hyper permeability, due to its anti-permeability properties. 5–6 aflibercept is a unique and a recombinant protein that consists of parts of vascular endothelial growth factor (vegf) receptor r1 and (vegf) receptor r2 with extracellular domains joined to the fc portion of human immunoglobulin g1. 7 intravitreally injected aflibercept is more effective in reducing subfoveal cmt in comparison to ranibizumab. after aflibercept injection, choroidal thinning extends beyond the macula. 8 intravitreal aflibercept can accomplish abatement of exudative retinal changes in eyes with wet age related macular degeneration having choroidal neovascularization refractory to ranibizumab and bevacizumab. moreover, it demonstrated more noteworthy outcome in the choroidal and retinal pigment epithelial detachments than the mentioned drugs. 9 in patients not responding to ranibizumab and bevacizumab, aflibercept has proven to be effective resulting in improvement of cmt. in such patients it can be used as an alternative therapy. in light of these outcomes, aflibercept’s primary power in decreasing leakage from hyper permeable choroidal vessels could be put to use for the treatment of cscr. 10 this case series was conducted to highlight the effects of aflibercept in reducing the cmt and improving the visual acuity in patients with cscr. methods this case series included 15 eyes of patients with semi chronic cscr (symptoms persisting for 3 – 4 months). the study included patients aged between 22 years and 40 years. the study included both males and females out of whom majority were males (73.3%). all patients were from rural and urban population of southern punjab, pakistan. patients with documented non resolving neurosensory detachment on optical coherence tomography (oct), active leakage on fluorescein angiography (fa) and with no signs of choroidal neovascularization were included in the study. all patients who had undergone previous treatment with laser photocoagulation, intravitreal triamcinolone, or bevacizumab in past 3 months, history of glaucoma (intraocular pressure > 21 mm hg), patients who were lost to follow-up, and those with previously vitrectomized eyes were excluded. the procedure was done in a single centre, conducted by a single surgeon. a 1cc insulin syringe was used to inject aflibercept. it was injected 3.5 mm from limbus in phakic patients and 3 mm from limbus in pseudophakics. post intravitreal injection, a single drop of ofloxacin with 5% povidone-iodine was instilled. patients were checked for retinal artery patency and were prescribed topical ofloxacin 4 times daily for 5 days. all eyes were injected with a single dose of intravitreal aflibercept (0.5 mg/0.05 ml). on the next follow-up visit, patients were subjected to best corrected visual acuity (bcva) on log mar chart, intra ocular pressure evaluation using goldmann tonometer, slit lamp examination and dilated fundus examination. above mentioned assessments along with an oct of macula on angio vue by opto vue was performed at 4 and subsequently 12 weeks. central retinal thickness as well as change in foveal architecture was assessed on oct. out of 15 eyes included in the study 13 eyes had a complete or near complete resolution of neurosensory retinal elevation by the end of 12 weeks. the two remaining eyes were found to be completely nonresponsive to aflibercept. out of these two eyes, one continued to have same central retinal thickness while other had an increase in retinal elevation and crt at the end of 12 weeks compared to the time of enrolment in the study. statistical analysis was done using spss version 23. statistical significance was calculated using the t test. intravitreal afliberceptin in central serous chorioretinopathy pak j ophthalmol. 2020, vol. 36 (4): 402-407 404 table 1: baseline demographic and clinical characteristics of the patients. best-corrected visual acuity (bcva) changes from the time of administration of the injection and during the follow-up time. case no. age gender eye axial length lens status iop bcva at presentation 1 month postinjection 3 months postinjection 1. 30 m od 24.5mm phakic 20 0.0 0.0 0.0 2. 25 m os 22.9mm phakic 18 0.2 0.0 0.0 3. 32 m od 23.3mm pseudo phakic 12.6 0.3 0.0 0.0 4. 35 m od 22.2mm phakic 15.4 0.5 0.1 0.1 5. 27 m os 24.7mm phakic 16 0.1 0.0 0.1 6. 33 f os 22.3mm phakic 14.2 0.7 0.4 0.4 7. 39 m os 23.4mm pseudo phakic 12.9 0.5 0.5 0.9 8. 22 m os 23.0mm phakic 19.5 0.5 0.1 0.1 9. 26 f od 23.1mm phakic 16.1 0.3 0.2 0.2 10. 37 m os 23.4mm phakic 13.9 0.4 0.1 0.1 11. 31 f os 23.5mm pseudo phakic 13.5 0.0 0.0 0.1 12. 40 m od 22.3mm phakic 15 0.6 0.7 0.9 13. 29 m od 21.3mm phakic 14.4 0.2 0.0 0.0 14. 23 f os 25.9mm pseudo phakic 13.2 0.2 0.0 0.0 15. 28 m os 23.2mm phakic 22.5 0.3 0.3 0.2 results the study included fifteen eyes of fifteen patients (table 1). the mean age was 30.46 years ± 9 years. the follow-up time was 3 months. the mean baseline visual acuity at the time of presentation was 0.32 log mar, improving to 0.173 log mar at 1 month and a final visual outcome of 0.205 log mar at 3 months. except two eyes (13.3 %), rest had visual improvement. this particular group did not respond to the use of aflibercept. for the rest of the cases (86.6%), there was a considerable decrease in crt at the end of first month, eleven eyes (73.3%) continued with persistent improvement of the visual parameters till the end of study i.e. 3 months. there was a considerable decrease in crt at the end of study, which was relevant with the amelioration in both of bcva and fa leakage (graph 1). by formulating a null hypothesis that aflibercept is not effective for cscr, we used the t table to calculate our p values. our value post 1 month was 0.02 and 0.03 at 3 months i.e. end of study. thus, we rejected the null hypothesis. the mean crt for all patients at the time of presentation was 437 ± 82 µm which decreased to 349 ± 67 µm at 1 month (graph 2). at the last follow-up the mean crt decreased to 309 ± 121 µm. 0.32 0.206 0.173 0.1 0.15 0.2 0.25 0.3 0.35 mean bcva at the time of presentation mean bcva at 1 month mean bcva at 3 months graph 1: variations among the mean bcva at the time of injection, at 1 month and at 3 months post injection administration. two of our cases were non-responsive to the use of aflibercept (fig. 1). these two cases (case 7 & 12) were found to have a higher crt as compared to other participants. we also observed that the base line bcva of non-responding cases were lower than rest of the group. they were found to have a significant level of is/os junction breakdown and all these changes in author’s opinion led to the poor visual outcome. muhammad afzal bodla, et al 405 pak j ophthalmol. 2020, vol. 36 (4): 402-407 437 309 329 250 300 350 400 450 mean crt at the time of presentation mean crt at 1 month mean crt at 3 months graph 2: mean central retinal thickness changes from the start of the treatment and after 1 and 3 months. fig. 1: spectral domain oct images of eyes with active cscr, fig. a-d. there is presence of a variable amount of sub retinal fluid in the subfoveal region of all patients with an age range of 22 to 40 years. fig. a (patient 3) has minimal srf and a resolution of symptoms and fluid while in fig. b (patient 15), fig. c (patient 6), fig. d (patient 12), we can appreciate disruption of isos layer and presence of debris in sub retinal fluid. discussion cscr is a disease characterized by serous separation of the neurosensory retina secondary to one or more focal or diffuse leakage points. conservative management is preferred by majority of ophthalmologists as a first line option. the actual benefit of immediate resolution may be intervened by a lower rate of rpe degeneration in the concerned eye. 11-12 the process by which intravitreal bevacizumab therapy improves rpe leak and resorption of sub retinal fluid in cscr is obscure. indocyanine green angiography in patients with cscr has demonstrated signs of choroidal venous congestion and choroidal lobular ischemia. 13-15 indicating a generalized rpe or choroidal vascular disturbance. 16-18 it is a known fact that increased amount of vegf is released by choroidal ischemia. only a decrease in vegf concentration can bring about a positive change in patients with cscr by ending the series of events, which result in neurosensory detachment. 19 several anti-vegf agents have been used in the treatment of cscr like bevacizumab, ranibizumab and aflibercept. aflibercept is preferred as it not only attaches multiple isoforms of vegf-a but also inhibits the activation of vegfr1and vegfr2. aflibercept binds to vegf-a faster and with higher affinity than bevacizumab and ranibizumab. 20 as anticipated by a scientific model, aflibercept has a powerful intravitreal vegf-binding activity for 10 – 12 wk after a single injection. 21 the biological activity of a therapeutic macromolecule varies on its binding affinity and intraocular half-life. the binding affinity for vegf of aflibercept is about 100 times higher than that of ranibizumab or bevacizumab. 22 the half-life of aflibercept (molecular weight: 115 kda) has not yet been examined in human eyes. as the intraocular half-life of a macro molecule is decided by its molecular size, aflibercept is likely to have a halflife between ranibizumab (molecular weight: 48 kda) and bevacizumab (molecular weight: 149 kda). 23 hence, the fundamental purpose behind the longer activity of aflibercept could be clarified by a large increase in binding affinity in comparison to similar elimination half-times. in our research we suggest that an intravitreal aflibercept injection in patients with cscr can induce immediate resorption of sub retinal fluid in majority of cases, and as a result of which there can be a significant improvement in vision. this outcome gave a solid ground for the research and encourage additional investigation of the treatment. 19 this study showed effective management of cscr with aflibercept and none of the patients faced any adverse side effects. patients with cscr can undergo natural resolution of symptoms and improvement of retinal architecture. in cases of unilateral cscr the contralateral eye needs to be intravitreal afliberceptin in central serous chorioretinopathy pak j ophthalmol. 2020, vol. 36 (4): 402-407 406 examined at regular intervals along as there is a probability of subclinical cscr or development of cscr in the future. 20 further investigations should be carried out to find the role of vegf in the pathogenesis and treatment of cscr with anti vegf agents. 19 in our study out of improved cases, eleven continued to maintain the improvement in bcva while two had a subsequent drop in their vision at their third and last visit. among these two, one eye (case 5) dropped back to the base line bcva. in this particular case, there was some recurrence of fluid but amount of residual fluid at completion of study was found to be less than what was noticed at the time of presentation. our other case, (case 11) had an initial resolution but later the crt was found to be more than from the time of presentation, which got translated in drop of bcva at the end of study compared from baseline. in a previous study kim et al studied the efficiency of intravitreal ranibizumab injection for acute cscr in 20 eyes. 24 a dose of (0.5 mg/0.05 ml) was given. all patients had increased bcva, decreased crt, and resolution of the neurosensory detachment. the overall mean of bcva in this study improved from 0.77 log mar at the start to 0.17 log mar after 1 month and stayed static for 6 months. all eyes had visual improvement and eighty percent of patients improved. the results are comparable to our study. however, in our study seventy-four percent of the patients improved. in another study, jung et al analysed the response of aflibercept in acute cscr. 25 in their control group there was a significant decrease of retinal thickness and improvement in bcva. authors believe that we have seen similar effects in our series of sub-acute and chronic cases, hence pharmacological efficacy of aflibercept can be of good use in such group of patients. comparing the rebounding tendency of the disease process, their 11.4% patients compared to our 15% had an increase of crt between 2 and 3 months. our study does carry some limitations starting from its relatively small number of eyes without any control group. in our study a single dose of aflibercept was administered which obviously cannot be compared with the standard practiced regimen of the loading dose of three injections of ranibizumab, bevacizumab or aflibercept. it would have been interesting to see the effect of three injections of aflibercept especially for the patients who did not perform well. the reason for minimalistic intervention was the cost limitation in southern punjab due to a higher prevalence of a lower socio economic class. conclusion in conclusion, based on acquired data our study supports the efficacy of aflibercept in terms of improvement in bcva and reduction of crt in patients with sub-acute and chronic presentation refractory to self-resolution. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. daruich a, matet a, marchionno l, azevedo jd, ambresin a, mantel i, et al. acute central chorioretinopathy: factors influencing episode duration. retina, 2017; 37 (10): 1905-1915. 2. guyer dr, yannuzzi la, slakter js, sorenson ja, ho a, orlock d. digital indocyanine green video angiography of central serous chorioretinopathy. arch ophthalmol. 1994; 112 (8): 1057-1062. 3. gemenetzi m, salvo gd, lotery aj. central serous chorioretinopathy: an update on pathogenesis and treatment. eye (lond). 2010; 24 (12): 1743-1756. 4. imamura y, fujiwara t, margolis r, spaide rf. enhanced depth imaging optical coherence tomography of the choroid in central chorioretinopathy. retina, 2009; 29 (10): 1469-1473. 5. inoue m, kadonosono k, wantanabe y, kobayashi s, yamane s, arakawa a. results of one-year followup examinations after intravitreal bevacizumab administration for chronic central serous chorioretinopathy. ophthalmologica, 2011; 225 (1): 3740. 6. artunay o, yuzbasioglu e, rasier r, sengul a, bahcecioglu h. intravitreal bevacizumab in treatment of idiopathic persistant central serous chorioretinopathy: a prospective, controlled clinical study. curr eye res. 2010; 35 (2): 91-98. 7. trichonas g, kaiser pk. aflibercept for the treatment of age-related macular degeneration. ophthalmol ther. 2013; 2 (2): 89–98. muhammad afzal bodla, et al 407 pak j ophthalmol. 2020, vol. 36 (4): 402-407 8. yun c, oh j, ahn j, young-hwang s, lee b, woo ks, et al. comparison of intravitreal aflibercept and ranibizumab injections on subfoveal and peripapillary choroidal thickness in eyes with neovascular agerelated macular degeneration. graefes arch clin exp ophthalmol. 2016; 254 (9): 1693-1702. 9. hata m, oishi a, tsujikawa a, yamashiro k, miyake m, ooto s, et al. efficacy of intravitreal injection of aflibercept in neovascular age-related macular degeneration with or without choroidal vascular hyperpermeability. invest ophthalmol vis sci. 2014; 55 (12): 7874-7880. 10. maksys s, richter-müksch s, weingessel b, vẻcseimarlovits pv. short-term effect of aflibercept on visual acuity and central macular thickness in patients not responding to ranibizumab and bevacizumab. wien kim wochenschr. 2017; 129 (910): 351-357. 11. wang m, sander b, larsen m. retinal atrophy in idiopathic central serous chorioretinopathy. am j ophthalmol. 2002; 133: 78793. 12. fuhrmeister h. a long-term study of morphological and functional developments after central serous chorioretinitis. klin monatsbal augenheilkd. 1983; 182: 549-551. 13. hayashi k, hasegawa y, tokoro t. indocyanine green angiography of central serous chorioretinopathy. int ophthalmol. 1986; 9: 37-41. 14. prünte c. indocyanine green angiography findings in central serous chorioretinopathy. int ophthalmol. 1995; 19: 77-82. 15. prünte c, flamme j. choroidal capillary and venous congestion in central serous chorioretinopathy. am j ophthalmol. 1996; 121: 26-34. 16. stanga pe, lim ji, hamilton p. indocyanine green angiography in chorioretinal diseases: indications and interpretation: an evidence-based update. ophthalmology, 2003; 110: 15-21. 17. piccolino fc, borgia l. central serous chorioretinopathy and indocyanine green angiography. retina, 1994; 14: 231-242. 18. piccolino fc, borgia l, zinicola e, zingirian m. indocyanine green angiographic findings in central serous chorioretinopathy. eye, 1995; 9: 324-332. 19. seong hk, bae jh, kim es, han jr, nam wh, kim hk. intravitreal bevacizumab to treat acute central serous chorioretinopathy: short-term effect. ophthalmologica, 2009; 223: 343-347. doi: 10.1159/000224782. 20. radhke n, kalamkar c, mukherjee a, radhke s. intravitreal ziv-aflibercept in treatment of naїve chronic central serous chorioretinopathy related choroidal neovascular membrane. case reports in ophthalmol med. 2017; 2017: 5036248. 21. stewart mw, rosenfeld pj. predicted biological activity of intravitreal vegf trap. br j ophthalmol. 2008; 92 (5): 667-668. 22. stewart mw. aflibercept (vegf trap-eye): the newest anti–vegf. br j ophthalmol. 2012; 96 (9): 11571158. 23. stewart mw. pharmacokinetics, pharmacodynamics and pre-clinical characteristics of ophthalmic drugs that bind vegf. expert rev clin pharmacol. 2014; 7 (2): 167-180. 24. kim m, lee s, lee s. intravitreal ranibizumab for acute central serous chorio-retinopathy. ophthalmologica, 2013; 229: 152-157. 25. jung bj, lee k, park jh, lee jh. chorioretinal response to intravitreal aflibercept injection in acute central serous chorioretinopathy. int j ophthalmol. 2019; 12 (12): 1865–1871. authors’ designation and contribution muhammad afzal bodla; professor: concepts, design, manuscript editing, manuscript review. ali afzal bodla; associate professor: data acquisition, data analysis, statistical analysis, manuscript review. syeda minahil kazmi; consultant ophthalmologist: literature search manuscript preparation, manuscript editing. ayema moazzam; consultant ophthalmologist: statistical analysis, manuscript preparation, manuscript editing. .…  …. 109 pak j ophthalmol. 2022, vol. 38 (2): 109-113 original article effect of pupil dilation on ocular biometric measurements in high myopes nida haider 1 , nighat parveen 2 , sadaf rani 3 , sarfraz hussain anwar 4 1,2,4 allied hospital faisalabad, 3 tehsil headquarters hospital, shorkot abstract purpose: to determine the effect of pupil dilation on different biometric measurements of eye in high myopes. study design: descriptive observational study. place and duration of study: the study was carried out eye out-patient department of mayo hospital, lahore from august 2018 to december 2018. methods: we recruited 72 (144 eyes) young, non-cataractous myopes of -6 diopters or more (mean spherical equivalent -7.41 ± 1.35) and age above 15 years (range 15 – 38 years). sampling was based on non-probability convenient sampling whereas those with any ocular pathology and history of surgery were excluded. biometric measurements were taken with non-contact biometer len star (ls900) with haigis formula used for iol power calculation, before and after pupil dilation data was analyzed on spss (v25) and p < .001 was taken as significant. results: mean axial length (al) difference between preand post-dilation was -0.006 ± 0.17 (p = 0.66), mean central corneal thickness (cct) difference was -1.70 ± 8.95 (p = 0.024), mean anterior chamber depth (acd) difference was -0.018 ± 0.04 (p = 0.001), mean lens thickness (lt) difference was 0.001 ± 0.53 (p = 0.81), mean keratometry difference was 0.0013 ± 0.14 (p = 0.91), mean white to white (wtw) difference was 0.003 ± 0.01 (p = 0.67) and mean iol power difference was 0.000 ± 0.22 (p = 1.00). bland altman plots were drawn to indicate the 95% limits of agreement between preand post-dilation measurements. conclusion: there was a statistically significant difference between pre and post dilation measurements of acd but no clinically significant change was noted in iol power calculations indicating that pupil dilation does not affect the biometric measurements. key words: biometry, len star, myopia, axial length, anterior chamber depth. how to cite this article: haider n, parveen n, rani s, anwar sh. effect of pupil dilation on ocular biometric measurements in high myopes. pak j ophthalmol. 2022, 38 (2): 109-113. doi: 10.36351/pjo.v38i2.1353 correspondence: nida haider department of ophthalmology, allied hospital, faisalabad email: nidahr143@gmail.com received: november 26, 2021 accepted: march 6, 2022 introduction intraocular lens (iol) implantation is one of the most frequent procedures performed on eye. the success of this procedure depends largely upon accurate biometric measurements. the modernization of ocular biometry has progressed the cataract surgery into refractive cataract surgery where in the surgeon can customize the refractive outcomes of the surgery. in order to achieve desired results, it is very important that accurate iol power be calculated. optical biometry has now replaced acoustic biometry. len star (haag streit), a non-contact optical biometer, uses the principle of optical low coherence reflectometry (olcr) and provides with one click, repeatable and accurate measurements of axial length (al), anterior chamber depth (acd), keratometry, central corneal thickness (cct), lens thickness (lt), white to white (wtw) distance. 1 studies have shown good agreement between both gold standard iol master and len star with no clinically significant effect of pupil dilation on ocular biometric measurements in high myopes pak j ophthalmol. 2022, vol. 38 (2): 109-113 110 differences in their measurements. 2,3 len star, also used in current research, has all iol power calculation formulas built into its system and has the capability to incorporate future generation of such formulas and hence a reliable instrument for biometry. it is well known that anterior chamber depth increases in high myopes and it is also known that acd is altered with pupil dilation 4,5 which leads to the idea that there is a difference in iol power calculations made with and without pupil dilation. since dilation causes the lens to relax its accommodation, the lens flattens and moves backward, hence deepening the anterior chamber and since anterior chamber is already deep in myopic eyes, so a significant increase may be expected in acd measurements post-dilation. e.g., one study reported significant change in acd post-dilation whereas another study reported a change in keratometric readings after dilation. 6,7 an indian study, however, concluded with a decrease in al, cct, lt and increase in acd in pediatric sample. 8 our study intends to explore the effect of pupil dilation on biometric parameters in high myopes owing to the fact that there are several factors that influence iol power calculation which when calculated for lower errors may be ignored and that highly myopic eyes when operated for cataract often result in hyperopic post-op error. so, an appropriate iol power calculation must be done in order to achieve desired post-operative refraction. methods we included 144 eyes of 72 high myopes with spherical equivalent of -6ds or above and mean spherical equivalent of -7.411 ± 1.355 (range -6ds to -12ds). mean age was 23.81 ± 7.058 (range 15 – 38 years). forty (56%) out of total subjects were males and 32 (44%) were females. this study was carried out at the eye department of mayo hospital lahore, pakistan from august to december 2018. the subjects were enrolled based on non-probability convenient sampling. all patients underwent refraction and complete ocular examination to rule out any ocular (including cataract and pathological myopia) and systemic diseases. institutional review board (irb) granted approval before the study could be started. the subjects/ guardians who agreed to be a part of the study were requested to sign the consent form. the biometric measurements were obtained on len star (ls900, software eyesuite tm iol, v4.2.1), a non-optical biometer. the drug used for dilation was cyclopentolate 1% whereas the iol power calculation was done with haigis formula which is suitable for eyes with longer axial lengths. 9,10 dilatation was considered achieved with at least a 4mm difference between dilated and non-dilated pupil. results all biometric measurements: al, cct, acd, lt, keratometry, wtw and iol power were measured three times consecutively before and after pupil dilation and the average measurements were recorded for analysis. iol power calculations were done with haigis formula with a constant as 118.30. the data was entered and analyzed on ibm spss (version 25.0) for windows. descriptive analysis was performed on all individual variables followed by comparative analysis using paired t-test (table 1). bland altman scatter plots were used to establish limits of agreement (loa) between measurements taken before and after pupil dilation (figure 1). p < .001 was taken as significant. the results showed that there was no statistically significant difference between the pre dilation and post dilation measurements of axial length, cct, keratometry, wtw and lens thickness as presented in table 1. only acd presented with a statistically significant increase on post-dilation measurements with p-value as 0.001. table 1: comparative analysis of biometric parameters variable pre-dilation mean ± sd post-dilation mean ± sd mean difference ± sd p-value 1. axial length 25.92 ± 1.09 25.99 ± 1.09 -0.006 ± 0.17 0.66 2. central corneal thickness 528.13 ± 33.04 529.83 ± 33.06 -1.70 ± 8.95 0.024 3. anterior chamber depth 3.66 ± 0.311 3.67 ± 0.300 -0.018 ± 0.04 0.001 4. lens thickness 3.44 ± 0.28 3.44 ± 0.27 0.001 ± 0.53 0.815 5. keratometry (average) 45.07 ± 1.09 45.07 ± 1.08 0.0013 ± 0.14 0.910 6. white to white distance 11.99 ± 0.35 11.99 ± 0.34 0.003 ± 0.01 0.581 7. intraocular lens power 11.72 ± 2.67 11.72 ± 2.64 .000 ± 0.22 1.00 nida haider, et al 111 pak j ophthalmol. 2022, vol. 38 (2): 109-113 figure 1: bland altman plots for limits of agreement between pre and postdilation biometric parameters: graphs (a-e) indicate good agreement between both measurements. table 2: comparison with different studies on ocular biometry taken with and without pupil dilation our data babbak et al 21 arriola-villalobos et al 22 huang et al 23 device used len star len star len star len star sample size 144 eyes 24 cases 22 controls 72 eyes 43 eyes age 23.81 ± 7.05 61.9 ± 8.4 74.71± 7.53 22.1 ± 4.7 dilating agent cyclopentolate tropicamide tropicamide tropicamide + phenylephrine al mm -0.006 ± 0.17 p=0.66 -0.04 ± 0.23 p = 0.313 0.0035 ± 0.018 p = 0.102 0.00 ± 0.02 p = 0.427 cct -1.70 ± 8.95 p=0.024 nsa 1.125 ± 5.454 p=0.084 nsa acd (mm) -0.018 ± 0.04 p<0.001* -0.05 ± 0.04 p<0.001* 0.048 ± 0.032 p<0.001* -0.06 ± 0.07 p < 0.01* lt (mm) 0.001 ± 0.53 p = 0.81 nsa −0.00125 ± 0.055 p= 0.847 nsa median k (d) 0.0013 ± 0.14 p = 0.91 p = 0.006 0.033 ± 0.247 p = 0.261 0.02 ± 0.15 p = 0.34 wtw (mm) 0.003 ± 0.01 p = 0.67 nsa nsa 0.10 ± 0.17 p = 0.001* iol power 0.000 ± 0.22 p = 1.00 change of 0.5d in 9.1% of cases holladay ii -0.006 ± 0.33, p = 0.869 srk/t -0.05 ± 0.28, p = 0.128 p = 0.008* formula used haigis srk/t srk/t, holladay ii srk/t, holladay 1, hoffer q, haigis refractive error high myopia no specifications cataractous eyes no specifications cataractous eyes low, moderate and high myopia nsa: no statistical analysis/variable not part of study. *indicates significant results discussion optical biometry is a very useful method of biometry and surgeons rely on this method except in the cases where there is central and dense cataract where only acoustic biometry can be done. it has been reported that len star and partial coherence interferometry effect of pupil dilation on ocular biometric measurements in high myopes pak j ophthalmol. 2022, vol. 38 (2): 109-113 112 (pci) based iol master can be used interchangeably because len star provides as accurate measurements as iolmaster. 1,11 calculation of iol power depends upon accurate measurements of keratometry and axial length as well as iol power calculation formula and any change in these parameters will produce considerable change in refractive results. 12 wang et al evaluated the accuracy of iol formulas for prediction of iol power and reported that all formulae provide similar accurate outcomes but haigis predicted the best post-operative refraction for long eyes. 13 haigis is also most sensitive to changes in post-operative refractive changes. the results of our study (table 1) indicated no effect of pupil dilation on al, cct, lt, keratometry, wtw and iol power which suggests that measurements taken with or without dilation are interchangeable. while the lt, in our study doesnot change, studies have reported decrease in lt with pupil dilation. 14,15 another research reported changes in wtw post-dilation. 16 the increase in acd, in our study, could be attributed to the backward movement of the iris-lens plane during dilation. an increase in depth of anterior chamber with dilation has also been reported in many studies. 17,18 the results of our study also agree well with published evidence that pupil dilation produces statistically significant change in acd measurements. 19,20 the results can also be compared with other studies as shown in table 2. 21-23 there is, however, little evidence available related with the refractive error. the iol power remains unaffected to the changes in acd. bland altman plots (figure 1) illustrate the 95% limits of agreement between biometric measurements taken before and after pupil dilation with mean plotted against x-axis and difference plotted on y-axis. as recommended, the data on the resulting scatter plot must lie within ± 1.96 of mean difference. 24 for figure 01, the graphs a-e display that most of the scatter points lie within the prescribed limit of bland altman analysis hence indicating no change in biometrics after dilation. the graph f shows that although some points lie outside of upper and lower limits but the difference is clinically insignificant and less than 0.5ds therefore producing no effect on final iol power calculation. there was no respective graph plotted for acd for bland altman plotting cannot be done if the results/pvalue of a variable is significant, 25 which in our case was 0.001 for acd. this study only evaluated high myopic eyes with no comparison made to low/moderate myopes, hyperopes and emmetropes to establish the effect of dilation on biometrics of eyes. another limitation is the lack of effective sample size as well as comparison between children, adults and elderly and cataractous eyes. these limitations, hence, provide proposals for further research into this matter. conclusion it is recommended that haigis formula/any formula with acd measurements incorporated within it, must be used to calculate iol power to avoid any post-op refractive surprises especially in eyes with longer axial lengths. it is also advisable to mention whether the measurements were taken with or without pupil dilation in order to eliminate any possible change in predicted iol powers. ethical approval the study was approved by the institutional review board/ ethical review board (209-rc/kemu/). conflict of interest authors declared no conflict of interest. references 1. bullimore ma, slade s, yoo p, otani t. an evaluation of the iol master 700. eye contact lens. 2019; 45 (2): 117-123. 2. arriola-villalobos p, almendral-gómez j, garzon n, ruiz-medrano j, fernández-pérez c, martínezde-la-casa jm, et al. agreement and clinical comparison between a new swept-source optical coherence tomography-based optical biometer and an optical low-coherence reflectometry biometer. eye, 2017; 31 (3): 437-442. 3. shetty n, kaweri l, koshy a, shetty r, nuijts rm, roy as. repeatability of biometry measured by three devices and its impact on predicted intraocular lens power. j cataract refract surg. 2021; 47 (5): 585-592. 4. tasci yy, yesilirmak n, yuzbasioglu s, ozdas d, temel b. comparison of effects of mydriatic drops (1% cyclopentolate and 0.5% tropicamide) on anterior segment parameters. indian j ophthalmol. 2021; 69 (7): 1802-1807. 5. huang j, mcalinden c, su b, pesudovs k, feng y, hua y, et al. the effect of cycloplegia on the lenstar and the iol master biometry. optom vis sci. 2012; 89 (12): 1691-1696. nida haider, et al 113 pak j ophthalmol. 2022, vol. 38 (2): 109-113 6. tuncer i, zengin mö, yıldız s. the effect of cycloplegia on the ocular biometry and intraocular lens power based on age. eye, 2021; 35 (2): 676-681. 7. can e, duran m, çetinkaya t, arıtürk n. the effect of pupil dilation on al-scan biometric parameters. int ophthalmol. 2016; 36 (2): 179-183. 8. raina uk, gupta sk, gupta a, goray a, saini v. effect of cycloplegia on optical biometry in pediatric eyes. j ophthalmol strabismus. 2018; 55 (4): 260-165. 9. yang s, whang wj, joo ck. effect of anterior chamber depth on the choice of intraocular lens calculation formula. plos one, 2017; 12 (12): e0189868. 10. razmjoo h, atarzadeh h, kargar n, behfarnia m, nasrollahi k, kamali a. the comparative study of refractive index variations between haigis, srk/t and hoffer-q formulas used for preoperative biometry calculation in patients with the axial length > 25 mm. adv biomed res. 2017: 6. 11. huang j, mcalinden c, huang y, wen d, savini g, tu r, et al. meta-analysis of optical low-coherence reflectometry versus partial coherence interferometry biometry. sci rep. 2017; 7: 43414. doi: 10.1038/srep43414. 12. jeong j, song h, lee jk, chuck rs, kwon jw. the effect of ocular biometric factors on the accuracy of various iol power calculation formulas. bmc ophthalmol. 2017; 17 (1): 1-7. 13. wang jk, hu cy, chang sw. intraocular lens power calculation using the iol master and various formulas in eyes with long axial length. j cataract refract surg. 2008; 34 (2): 262-267. 14. mitsukawa t, suzuki y, momota y, suzuki s, yamada m. anterior segment biometry during accommodation and effects of cycloplegics by sweptsource optical coherence tomography. clin ophthalmol. 2020; 14: 1237. 15. hashemi h, asharlous a, khabazkhoob m, iribarren r, khosravi a, yekta a, et al. the effect of cyclopentolate on ocular biometric components. optom and vis sci. 2020; 97 (6): 440-447. 16. arici c, turk a, ceylan om, kola m. the effect of topical 1% cyclopentolate on iol master biometry. optom vis sci. 2014; 91 (11): 1343-1347. 17. momeni-moghaddam h, maddah n, wolffsohn js, etezad-razavi m, zarei-ghanavati s, rezayat aa, et al. the effect of cycloplegia on the ocular biometric and anterior segment parameters: a cross-sectional study. ophthalmol ther. 2019; 8 (3): 387-395. 18. özyol p, özyol e, baldemir e. changes in ocular parameters and intraocular lens powers in aging cycloplegic eyes. am j ophthalmol. 2017; 173: 76-83. 19. simon nc, farooq av, zhang mh, riaz km. the effect of pharmacological dilation on calculation of targeted and ideal iol power using multivariable formulas. ophthalmol ther. 2020 sep; 9 (3): 1-11. doi: 10.1007/s40123-020-00261-x. 20. khambhiphant b, chatbunchachai n, pongpirul k. the effect of pupillary dilatation on iol power measurement by using the iol master. int ophthalmol. 2015; 35 (6): 853-859. 21. bakbak b, koktekir be, gedik s, guzel h. the effect of pupil dilation on biometric parameters of the lenstar 900. cornea, 2013; 32 (4): 21-24. 22. arriola-villalobos p, díaz-valle d, garzon n, ruizmedrano j, fernández-pérez c, alejandre-alba n, et al. effect of pharmacologic pupil dilation on olcr optical biometry measurements for iol predictions. eur j ophthalmol. 2014; 24 (1): 53-57. 23. huang j, mcalinden c, su b, pesudovs k, feng y, hua y, yang f, pan c, zhou h, wang q. the effect of cycloplegia on the lenstar and the iol master biometry. optom vis sci. 2012 dec; 89 (12): 16911696. doi: 10.1097/opx.0b013e3182772f4f. 24. bland jm, altman dg. agreement between methods of measurement with multiple observations per individual. j biopharm stat. 2007; 17 (4): 571-582. 25. giavarina d. understanding bland altman analysis. biochemia medica. 2015; 25 (2): 141-151. authors’ designation and contribution nida haider; refractionist: concepts, design, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. nighat parveen; refractionist: concepts, design, data acquisition, manuscript editing, manuscript review. sadaf rani; refractionist: design, literature search, data acquisition, manuscript preparation, manuscript review. sarfraz hussain anwar; refractionist: literature search, data acquisition, manuscript editing, manuscript review. .…  …. 381 pak j ophthalmol. 2020, vol. 36 (4): 381-385 original article topical cyclosporine in treatment of post-lasik symptomatic dry eye muhammad saeed iqbal 1 , kanwal latif 2 1-2 department of ophthalmology, sir syed college of medical sciences and hospital, karachi abstract purpose: to determine the role of 0.05% topical cyclosporine a (csa) in treatment of symptomatic dry eye after lasik (laser-assisted in situ keratomileusis). study design: interventional case series. place and duration of study: ophthalmology department, sir syed hospital, karachi, from july 2018 to dec. 2019. methods: seventy-five patients who underwent lasik for myopic refractive error and presented with symptomatic dry eye and showed no response to artificial tears therapy after 1 month of lasik were selected. the patient had ablation zone diameter of 6 mm and flap diameter was 8.5 mm to 9 mm. cyclisporine a 0.05% ophthalmic preparation was added to treatment regimen and response was observed at 1, 3 and 6 months. osdi (ocular surface disease index) scores, tear film break up time (tbut), schirmer's test (st) values and best corrected visual acuity (bcva) were recorded to analyze the treatment response at each visit. the statistical interpretation was done by using spss version 21. to interpret the correlation between pre-treatment and 6 month post treatment, paired sample t test was applied with 95% confidence interval; ci and p-value of ≤ 0.05. results: the mean post-lasik osdi score of enrolled patients was 54.25 ± 10.81. after 6 months of treatment mean osdi score was improved to 21.05 ± 5.13 (p < 0.001). post-lasik mean st value was 5.2 ± 1.2 mm and mean tbut value was 5.6 ± 1.3 seconds, which changed to 9.8 ± 1.0 mm and 8.9 ± 1.1 seconds respectively. bcva improved from log mar 0.14 ± 0.09 to 0.01 ± 0.03 (p < 0.001). conclusion: topical csa 0.05% was effective in alleviating the symptoms of post-lasik dry eye. key words: lasik, dry eye, ocular surface disease index score, cyclosporine a. how to cite this article: iqbal ms, latif k. topical cyclosporine in treatment of post-lasik symptomatic dry eye. pak j ophthalmol. 2020; 36 (4): 381-385. doi: https://doi.org/10.36351/pjo.v36i4.1078 introduction lasik surgery is fda approved and a widely acceptable procedure throughout the world for correspondence: kanwal latif department of ophthalmology, sir syed college of medical sciences and hospital, karachi email: kanwallatif@hotmail.com received: june 12, 2020 accepted: july 16, 2020 correction of myopia, hypermetropia and astigmatism 1 . although it is safe and effective, symptoms of postlasik dry eye, which is the most commonly reported complaint of patients, often makes final outcomes of lasik unpredictable 2 . a study reported that dry eye was responsible for 19% of referrals to the cornea service in a tertiary care hospital due to nonsatisfaction with the results after lasik 3 . the pathophysiology of post-lasik dry eye still remains arguable but iatrogenic damage to corneal nerve plexus is the main reason proposed by researchers. other suggested mechanisms include topical cyclosporine in treatment of post-lasik symptomatic dry eye pak j ophthalmol. 2020, vol. 36 (4): 381-385 382 inadvertent damage to conjunctival goblet cells during flap-creation, post-operative inflammation and tearfilm instability due to post-lasik corneal re-shaping. 4 environmental factors such as sitting in room with chilled air conditioning, facing towards fans, windy conditions etc. and prolonged use of visual display terminals (vdts) may also contribute to the exacerbation of symptoms in post-operative period. 5 dry eye related ocular complaints are fairly common among patients presenting in ophthalmic clinics. due to diverse etiology and poorly recognized pathogenesis, its management always remains a challenge among ophthalmologists and researchers. 6 as lasik predisposes an individual towards worsening of dry eye, identifying patients at risk is the most crucial step in pre-operative evaluation. 7 patients with symptomatic dry eye may present with minimal to intense foreign body sensation, grittiness, photophobia, ocular discomfort and blurred vision. the hypothesized mechanisms for these symptoms are tear-film instability and hyper-osmolarity, inflammation and damage to the ocular surface. 8 the conventional regimen of using artificial lubricants stabilizing the pre-corneal tear-film is the first choice for post-lasik dry eye. though majority of patients do well with lubricating eye drops, some still require another regimen that is based on antiinflammatory property. topical steroids always remain beneficial in treating post-lasik dry eye but their well-known adverse ocular effects make them undesirable for longer use. 4 topical csa acts as an efficient anti-inflammatory agent in dry eyes because it decreases inflammation, increases the density of goblet cells and also increases the tear production. 9 additionally, it improves the corneal sensitivity by a suggested mechanism of regenerating corneal nerve axons. 10 this case series aimed to assess the effects of 0.05% topical csa on symptomatic post-lasik dry eye. methods this study was performed at ophthalmology department, sir syed hospital karachi from january 2017 to july 2019. study approval was given by the hospital ethical review committee and consent was taken from all the patients. seventy-five patients presenting with post-operative dry eye were selected. they were graded as moderate to severe according to osdi scores based on a validated osdi questionnaire. patients who had dry eye even after the use of lubricants for one month after lasik were included. they all had undergone un-eventful bilateral lasik for correction of myopia and were unresponsive to initial artificial tears therapy. the exclusion criteria for lasik patients were: 1) severe dry eye 2) corneal ectasias; 3) media opacities such as cataract and corneal scarring; 4) associated systemic and ocular diseases; 5) any previous ocular surgical procedure; and 6) pregnancy and lactation. the excimer laser system used for myopic lasik was alcon wavelight® ex500 and a superiorly hinged flap was created by hansatome microkeratome. the diameter of ablation zone was 6 mm in all cases and flap diameter was 8.5 mm to 9 mm. any patient who lost his/her follow-up during study period was also excluded. all patients were treated with topical csa 0.05% and were advised to fill the osdi questionnaire at each visit. the osdi score grading was as follows: normal: 0-12 points, mild: 13-22 points, moderate: 23-32 points and severe: 33-100 points. 11 bcva measurement with etdrs chart, slit-lamp biomicroscopic anterior segment examination, tbut and schirmer’s test (st) were performed prior to and after the treatment. st-1 value of < 10 mm and tbut of < 10 seconds was considered abnormal. topical csa (0.05%) was prescribed 4 times a day with artificial tears eye drops as needed. patients were followed at one, three and six months. at each follow-up patient’s bcva, osdi scores, st and tbut were assessed. patients who reported symptomatic relief and showed improvement in osdi scores as compared to baseline values were advised to taper topical csa two times in a day. treatment was discontinued if osdi scores became normal or mild and st and tbut values were improved. final values were recorded for analysis at the end of 6 months. the statistical analysis of quantitative values (age, bcva, osdi scores, st and tbut) and qualitative values (gender) was done by using the statistical package for social sciences (spss) software version 21. mean with standard deviation (for quantitative variables) and frequency and percentage (for gender) were computed. to interpret the correlation between pre-treatment and 6 month end treatment results, paired sample t test was applied with 95% confidence interval (ci) and p-value of ≤ 0.05 was considered significant. muhammad saeed iqbal, et al 383 pak j ophthalmol. 2020, vol. 36 (4): 381-385 table 1: pre-treatment and post-treatment findings. parameters pre-treatment mean ± sd post-treatment at 1 month mean ± sd post-treatment at 3 months mean ± sd post-treatment at 6 months mean ± sd mean change p-value odsi score 54.25 ± 10.81 46.12 ± 9.31 33.40 ± 7.88 21.05 ± 5.13 33.19 ± 9.16 < 0.001 st (mm) 5.2 ± 1.2 6.4 ± 0.8 8.6 ± 0.7 9.8 ± 1.0 -4.16 ± 1.18 < 0.001 tbut (seconds) 5.6 ± 1.3 6.3 ± 1.4 7.5 ± 1.2 8.9 ± 1.1 -3.29 ± 0.96 < 0.001 bcva (log mar) 0.14 ± 0.09 0.08 ± 0.06 0.05 ± 0.05 0.01 ± 0.03 0.126 ± 0.094 < 0.001 results mean pre-lasik myopic refractive error was 5.79 ± 1.9 d (-2.25d to -9.50 d) mean age of the subjects was 32.39 ± 5.6 years (23 – 43 years). the study included 54.7% females (n = 41) and 45.3% males (n = 34). the mean post-lasik osdi score which had been considered as pre-treatment score was 54.25 ± 10.81. at the end of six month mean osdi score changed to 21.05 ± 5.13 with statistically significant improvement (p < 0.001). see details of st, tbut, bcva and osdi scores in table 1. all the patients reported an overall improvement in their quality of vision at the end of follow-up. despite improvement in parameters, patients were not satisfied in initial three months of treatment as symptoms became mild but did not ameliorate fully. after six months, majority of patients were subjectively improved and satisfied as compared to their initial complaints. discussion refractive surgeons face various complaints after lasik but dry eye related problems are by far the most common. virtually every post-lasik patient presents with some degree of dry eye in the follow-up period but incidence varies widely with 40–59% reporting at 1 month and 10–40% at 6 months. 6,12 majority of patients attain 20/20 vision but the drastic effects of dry eye on quality of vision leads to significant discontentment and annoyance among patients as well as the concerned surgeons. as the asian population is more prone to develop postlasik dry eye (28% as compared to caucasian race), 13 identifying this risk factor prior to successful lasik is the most pivotal step for a refractive consultant working in this territory. the study had included those post-lasik subjects who had no symptoms pre-operatively but developed severe dry eyes after 1 month of myopic lasik correction. shoja 14 and nassaralla et al 15 have found that even patients who were pre-operatively asymptomatic, may experience irritating dry eye symptoms in their follow-up period and severity is correlated with ablation depth. de paiva et al reported that the relative risk (rr) of dryness per diopter of myopia was 0.88 and it also depends on the depth of ablation and combined ablation depth and flap creation (rr 1.01/µm). 16 in this study, the procedure of myopic lasik ablation was preceded by cutting a superior-hinged flap (a lamellar flap remained attached at the upper cornea) which might be considered as another factor for developing dry eyes. donnenfeld 17 and feng et al 18 suggested that symptomatic post-lasik dry eye may depend on hinge position as the hinge provides a preserved path for corneal nerves. various trials supported the fact that superior-hinge flaps have a greater susceptibility of damaging corneal nerves as compared to nasal-hinge flaps, and can cause significant dry eyes in early post-lasik period. 19, 20 although csa is not the first choice among refractive specialists, it is usually reserved for unresponsive cases. various clinical trials have favored the beneficial effects of topical csa on lasik induced dry eyes. 21,22 in this study, patients experienced distressing symptoms of dry eye with osdi scores of 54.25 (severe grade) and abnormal st values of 5.2 mm and tbut of 5.6 seconds. they were non-responsive to artificial tear therapy but after commencement of topical csa osdi scores improved to 21.05 (mild grade), st and tbut values increased to 9.8 mm and 8.9 seconds respectively with marked subjective improvement. kanellopoulos has also evaluated the efficacy of topical csa and reported that post-lasik osdi score was 52.51, st value of 4.5 mm and tbut of 6.5 seconds which effectively changed to 23.03, 8.2 mm and 7.6 seconds respectively. 23 the study published by kang and kim 21 also proved the clinical efficacy of the drug in improving the dry eye parameters in patients of lasik refractive surgery. salib et al has observed that lasik outcomes were more successful in topical csa topical cyclosporine in treatment of post-lasik symptomatic dry eye pak j ophthalmol. 2020, vol. 36 (4): 381-385 384 treated group as compared to treatment with artificial tears. 24 mean bcva showed significant change of log mar 0.12 at the end of treatment. ursea and colleagues also supported the fact that visual recovery was hastened by using csa 0.05% and majority of their patients attained the desired results. 25 limitation of our study was the small sample size and single center of study. conclusion topical csa treatment regimen is a good option to treat dry eye symptoms in resistant cases and is an efficacious adjunct to conventional tear supplementation. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. agarwal s, thornell e, hodge c, sutton g, hughes p. visual outcomes and higher order aberrations following lasik on eyes with low myopia and astigmatism. open ophthalmol j. 2018; 12: 84–93. 2. fatima k, saddique z, akram sn, furqan a. lasik; effect on tear film stability. professional med j. 2017; 24 (2): 293-295. 3. levinson ba, rapuano cj, cohen ej, hammersmith km, ayres bd, laibson pr. referrals to the wills eye institute cornea service after laser in situ keratomileusis: reasons for patient dissatisfaction. j cataract refract surg. 2008; 34: 32– 39. 4. toda i. dry eye after lasik. invest ophthalmol vis sci. 2018; 1; 59 (14): 109-115. 5. wimalasundera s. computer vision syndrome. galle med j. 2009; 11: 25–29. 6. gjerdrum b, gundersen kg, lundmark po, potvin r, aakre bm. prevalence of signs and symptoms of dry eye disease 5 to 15 after refractive surgery. clin ophthalmol. 2020; 14: 269-279. 7. solomon r, donnenfeld ed, perry hd. the effects of lasik on the ocular surface. ocul surf. 2004; 2 (1): 34–44. 8. messmer me. the pathophysiology, diagnosis, and treatment of dry eye disease. dtsch arztebl int. 2015; 112 (5): 71–82. 9. kymionis gd, bouzoukis di, diakonis vf, siganos c. treatment of chronic dry eye: focus on cyclosporine. clin ophthalmol. 2008; 2 (4): 829-836. 10. peyman ga, sanders dr, batlle jf, féliz r, cabrera g. cyclosporine 0.05% ophthalmic preparation to aid recovery from loss of corneal sensitivity after lasik. j refract surg. 2008; 24 (4): 337-343. 11. miller kl, walt jg, mink dr, hoang ss, wilson se, perry hd, et al. minimal clinically important difference for the ocular surface disease index. arch ophthalmol. 2010; 128 (1): 94‐101. 12. toda i. lasik and the ocular surface. cornea, 2008; 27 (suppl. 1): 70–76. 13. albietz jm, lenton lm, mclennan sg. dry eye after lasik: comparison of outcomes for asian and caucasian eyes. clin exp optom. 2005; 88 (2): 89-96. 14. shoja mr, besharati mr. dry eye after lasik for myopia: incidence and risk factors. eur j ophthalmol. 2007; 17 (1): 1–6. 15. nassaralla ba, mcleod sd, nassaralla jj jr. effect of myopic lasik on human corneal sensitivity. ophthalmology, 2003; 110 (3): 497-502. 16. de paiva cs, chen z, koch dd, hamill mb, manual fk, hassan ss, et al. the incidence and risk factors for developing dry eye after myopic lasik. am j ophthalmol. 2006; 141: 438-445. 17. donnenfeld ed, solomon k, perry hd, doshi sj, ehrenhaus m, solomon r, et al. the effect of hinge position on corneal sensation and dry eye after lasik. ophthalmology, 2003; 110 (5): 1023–1029. 18. feng yf, yu jg, wang dd, li jh, huang jh, shi jl, et al. the effect of hinge location on corneal sensation and dry eye after lasik: a systematic review and meta-analysis. graefes arch clin exp ophthalmol. 2013; 251 (1): 357-366. 19. lee kw, joo ck. clinical results of laser in situ keratomileusis with superior and nasal hinges. j cataract refract surg. 2003; 29 (3): 457-461. 20. nassaralla ba, mcleod sd, boteon je, nassaralla jj jr. the effect of hinge position and depth plate on the rate of recovery of corneal sensation following lasik. am j ophthalmol. 2005; 139 (1): 118-124. 21. kang kw, kim hk. efficacy of topical cyclosporine in mild dry eye patients having refractive surgery. j korean ophthalmol soc. 2014; 55 (12): 1752-1757. 22. torricelli aa, santhiago mr, wilson se. topical cyclosporine a treatment in corneal refractive surgery and patients with dry eye. j refract surg. 2014; 30 (8): 558-564. muhammad saeed iqbal, et al 385 pak j ophthalmol. 2020, vol. 36 (4): 381-385 23. kanellopoulos aj. incidence and management of symptomatic dry eye related to lasik for myopia, with topical cyclosporine a. clin ophthalmol. 2019; 13: 545–552. 24. salib gm, mcdonald mb, smolek m. safety and efficacy of cyclosporine 0.05% drops versus unpreserved artificial tears in dry-eye patients having laser in situ keratomileusis. j cataract refract surg. 2006; 32 (5): 772-778. 25. ursea r, purcell tl, tan bu, nalgirkar a, lovaton me, ehrenhaus mr, et al. the effect of cyclosporine a (restasis) on recovery of visual acuity following lasik. j refract surg. 2008; 24 (5): 473-476. authors’ designation and contribution muhammad saeed iqbal; professor and head of department: concepts, design, manuscript preparation, manuscript editing, manuscript review. kanwal latif; assistant professor: literature research, data acquisition, data analysis, statistical analysis, manuscript preparation. .…  …. 365 pak j ophthalmol. 2020, vol. 36 (4): 365-370 original article sliding scale in the management of allergic conjunctivitis ahmad zeeshan jamil 1 , muhammad luqman ali bahoo 2 , zahid kamal 3 muhammad rizwan 4 , muhammad ovais 5 1,3,4,5 sahiwal medical college, sahiwal, 2 cmh institute of medical sciences, bahawalpur abstract purpose: to verify the usability of the sliding scale in the management of allergic conjunctivitis. study design: quasi-experimental. place and duration of study: district headquarter teaching hospital/sahiwal medical college, sahiwal, from january 2016 to december 2019. methods: a sliding scale was developed and used to score the severity of the ocular allergy. patients were instructed to use the sliding scale to adjust the treatment regimen and follow-up at regular intervals. at baseline and at third follow-up visit, sliding scale score and use of drug regimens were noted. at third follow-up visit patient’s satisfaction and disease control were documented. results: there were 398 patients. mean age of patients was 29.45 ± 18.77 years. at baseline, 62.8% of patients were using topical steroids while at third follow-up visit only 5% of patients were using topical steroids. mean interval of patients’ visit to the hospital was 8.53 ± 1.44 weeks. non-parametric mann whitney test was used to calculate the difference in means of sliding scale scores at baseline (4.49 ± 2.39) and third follow-up visit (1.03 ± 1.68). z score value was -16.917 and significance was 0.000. for patient’s satisfaction at third follow-up visit chisquare value was 263.759 with significance value of 0.000. for disease control at third follow-up visit chi-square value was 223.123 with significance value of 0.000. conclusion: use of sliding scale in the management of allergic conjunctivitis was well accepted by the patients. it helped in disease control with minimal use of topical steroids and less frequent visits to the hospital. key words: allergic conjunctivitis, steroids, trantas dots. how to cite this article: jamil az, bahoo mlq, kamal z, rizwan m, ovais m. sliding scale in the management of allergic conjunctivitis. pak j ophthalmol. 2020; 36 (4): 365-370. doi: https://doi.org/10.36351/pjo.v36i4.1055 introduction allergic diseases have increased over the last one decade. ophthalmologists frequently encounter ocular allergy patients. air pollution and genetic correspondence: muhammad luqman ali bahoo department of ophthalmology, sahiwal medical college, sahiwal email: drluqmanali@yahoo.com received: april 22, 2020 accepted: july 29, 2020 predisposition are considered responsible. 1 moreover, climate has changed due to industrialization and urbanization. the rise in environmental temperatures and intense seasons can lead to earlier pollen season and subsequently more ocular allergies. allergic conjunctivitis disease (acd) is increasing worldwide. 2 the term allergic conjunctivitis (ac) or ocular allergy (oa) refers to a collection of ocular surface disorders that affect the palpebral and bulbar conjunctiva. 3 conjunctiva is the mucous membrane of the eye surface and it is persistently and commonly exposed to extensively diverse antigens present in air. 4 in allergic conjunctivitis (ac) ige and non‐ige sliding scale in the management of allergic conjunctivitis pak j ophthalmol. 2020, vol. 36 (4): 365-370 366 mediated hypersensitivity reactions take place. 5 resulting inflammation leads to pathological interactions between different immune cells and local cells of eye resulting in various lesions on conjunctiva. itching is the hall mark of allergic conjunctivitis. other clinical presentations include conjunctival hyperemia, photophobia, watering and conjunctival and lid swelling. 6 almost 40% of the population is affected by symptoms of ac. among the patients of acd, 90 – 95% cases are of seasonal allergic conjunctivitis (sac) or perennial allergic conjunctivitis (pac). 7 the intense sign and symptoms of disease are so troublesome that these can lead to reduction in work efficiency, absence from educational institutes and work place, restricted daily activities and poor quality of life. 8 among different drugs, the anti-allergic eye drops are the first drug of choice for basic treatment of the disease, followed by selective use of steroid eye drops depending upon the severity of the disease. in case of more severe disease immunosuppressive eye drops, oral steroids, supratarsal steroid injection and surgical treatment such as papillary resection can also be considered in addition to anti-allergic and steroid eye drops. while managing ac, the sufferers of ac face an economic burden, which is imposed on them by medication and health care visits as well as decreased productivity. the appropriate management of ac advocates comprehensive strategies like avoidance of suspected allergens, relief of symptoms and suppression of inflammatory response with pharmacological preparations. 9 for assessing the clinical severity of acd, translating clinical observations into quantitative clinical scores is expedient. multiple studies measured and reported the effects of therapeutic drugs using clinical scores. 10,11 due to consumption of health care resources and reduced quality of life of affected patients of ac, the studies on different prospective of the disease are justified. in an attempt to minimize the burden of this commonly prevalent disease on the health care resources, a sliding scale was designed and used to score the severity of ocular allergy with an additional aim to educate the patients to use sliding scale for adjustment of the prescribed treatment regimen at home themselves. this study was carried out to authenticate the usability of sliding scale in the management of allergic conjunctivitis. the sliding scale make it possible to tangibly determine the indication or cancellation stage for therapeutic drugs by the patient himself. along with it, sharing of such type of sliding scale enhances the doctor patient bonding and vigilant involvement of patient in mutual scheduling for treatment and follow-up. it might also boost sense of self-care in patients as well. methods this quasi-experimental study was conducted in district headquarter teaching hospital affiliated with sahiwal medical college, sahiwal. duration of study was from january 2016 to december 2019. study was approved by the institutional review board. informed consent was obtained from all the participants and parents in case of minors. non-probability purposive sampling technique was used. sample size was calculated according to the following formula: s=z 2 p(1-p)/m 2 s is the sample size z is z score its value is 1.96 p is the population proportion assumed to be 50% or 0.5 m is the margin of error that is taken 5% or 0.05 s = (1.96) 2 (0.5)(1-0.5)/(0.05) 2 = 384.16 = 384 inclusion criteria was patients older than 2 years, bilateral disease. exclusion criteria was steroid responders, patients of glaucoma, trauma, intraocular inflammation, diabetic retinopathy, age related maculopathy, dry eyes and with history of ocular surgery in the previous six months. failure to come on follow-up visits and failure to follow treatment according to sliding scale also resulted in exclusion of patient from the study. diagnosis of allergic conjunctivitis was based on history and clinical examination. history of nasal allergy, atopy, pollen allergy, dust allergy, seasonal exacerbation, respiratory allergy, skin allergy and previous treatment were taken into account. patients or parents of minors were asked for symptoms of itching, redness of conjunctiva and photophobia. thorough clinical examination was performed. presence of papillae, horner’s trantas dots, severity of redness of conjunctive, type of discharge from eyes and severity of photophobia was noted. https://www.sciencedirect.com/topics/medicine-and-dentistry/immunosuppressive-drug ahmad zeeshan jamil, et al 367 pak j ophthalmol. 2020, vol. 36 (4): 365-370 a sliding scale was developed whereby clinical presentations of itching, redness of conjunctiva and photophobia were used to calculate score of sliding scale. ophthalmologists calculated score of sliding scale at examination visits and patients used that scale at home. score of 4 was given in case of continuous itching (present all the time), score of 3 was given in case of frequent itching (present 50% of time), score of 2 was given in case of occasional episode of severe itching (present 25% of time), score of 1 was given in case of occasional episode of mild itching (present 25% of time) and score of 0 was given in case of absence of itching. likewise score of 3 was given in case of complete bulbar conjunctival redness, score of 2 was given in case of redness involving less than full and more than half of the bulbar conjunctiva. score of 1 was given in case of redness involving less than half of the bulbar conjunctiva. score of 0 was given in case of absence of bulbar conjunctival redness. score of 3 was given in case where history suggests severe photophobia (present in dim light). score of 2 was given in case of moderate photophobia (present in well-lit room). score of 1 was given in case of mild photophobia (present in daylight). score of 0 was given in case of absence of photophobia in daylight. patients/parents in case of minors were instructed how to use sliding scale to calculate score of their allergy severity and use of medicines accordingly. patients reviewed their score after every one week and adjusted treatment. follow-up of patients was according to the schedule of sliding scale. for example, on baseline examination, a score of 5 was noted and patient started treatment accordingly. one week later patient reviewed his symptoms and scored the severity of his disease. this time a score of 3 was noted and patients modified treatment according to the new score. in that way, patients reviewed their symptoms every week and managed their treatment up or down the sliding scale. content validity of the sliding scale was done with the help of three ophthalmologists to approve the selection of scale. a pilot study was conducted before the full-scale study to find out the feasibility. english and urdu version of the patient’s information sheet and sliding scale were developed. after first examination, patients were followed up for three consecutive visits. patient’s satisfaction at third follow-up examination and treatment success was defined by sliding scale score of 3 or less at third follow-up examination. for statistical analysis, statistical package for social sciences (spss) version 23 was used. frequencies were calculated for gender, involvement of palpebral and bulbar conjunctiva, patient’s satisfaction and treatment success. mean and standard deviation was calculated for age, sliding scale score at baseline, first follow-up, second follow-up and third follow-up. mean and standard deviation was also calculated for interval of first, second and third followup visits. non-parametric mann whitney test was used to calculate difference in means of sliding scale at baseline and at third follow-up visit. p value less than 0.05 was considered statistically significant. for patient’s satisfaction and treatment success at third follow-up visit chi square test was used with a pvalue of less than 0.05. results there were 398 patients. mean age of the patients was 29.45 ± 18.77 years. age range was from 3 years to 64 years. there were 192 (48.2%) male and 206 (51.8%) female patients. in 278 (69.8%) cases palpebral conjunctiva was involved, in 58 (14.6%) patients limbal papillary conjunctivitis was present and in 62 (15.6%) cases both palpebral and limbal papilla were present at baseline visit. frequencies of itching, conjunctival redness and photophobia at baseline visit is given in chart number 1. by the use of sliding scale 361 (90.7%) patients were satisfied while 37 (9.3%) patients were not satisfied at third follow-up visit. in 348 (87.4%) cases, allergic conjunctivitis was controlled at third follow-up visit. in 50 (12.6%) cases allergic conjunctivitis was not controlled at third follow-up visit. sliding scale score mean and standard deviation is given in table number 1. examination visit duration mean and standard deviation is given in table number 2. table 1: sliding scale score. examination visit score mean & standard deviation baseline 4.49 ± 2.39 first follow-up 2.81 ± 2.17 second follow-up 1.38 ± 1.77 third follow-up 1.03 ± 1.68 sliding scale in the management of allergic conjunctivitis pak j ophthalmol. 2020, vol. 36 (4): 365-370 368 table 2: follow-up interval from baseline examination. follow-up visit interval (weeks) first 5.96 ± 2.87 second 7.64 ± 2.11 third 8.53 ± 1.44 at initial visit, 62.8% patients were started on topical steroids while at third follow-up visit 5% of patients were using topical steroids. eight percent of patients were using oral anti-allergy medicine at baseline examination while 5% of patients were using oral anti-allergy medicine at third follow-up visit. at baseline examination, 70.4% of patients were using cyclosporine eye drops while at third follow-up examination 5% of patients were using cyclosporine eye drops. at baseline examination, all patients were using olopatadine eye drops while at third follow-up examination, only 12.6% patients were using chart 1: frequencies of itching, conjunctival redness and photophobia at baseline visit. table 3: drug regimen at baseline and third follow-up. drug regimen baseline third follow-up (0) no drugs (1) olopatadine once a day 0 48 (12.1%) 174 (43.7%) 174 (43.7%) (2) olopatadine twice a day 70 (17.6%) 20(5%) (3) 2 + cyclosporine 30 (7.5%) 10 (2.5%) (4) 3+ one steroid drop once a week 44 (11.1) 0 (5) 3+ one steroid drop after two days 60 (15.1) 0 (6) 3+ one steroid drop once a day 44 (11.1) 0 (7) 3+ one steroid drop twice a day 70 (17.6) 10 (2.5%) (8) 3+ one steroid drop thrice a day + oral desloratadine 18 (4.5) 10 (2.5%) (9) 3+ one steroid drop four times in a day+ oral desloratadine + steroid ointment at night 4 (1.0) 0 (10) 3+ one steroid drop six times in a day + oral desloratadine + ointment at night 10 (2.5) 0 key = cyclosporine eye drops 0.05% = olopatadine eye drops 0.2% = flouromethalone 0.25% eye drops = desloratadine tablet 5 mg or desloratadine syrup 0.5 mg/ml = flouromethalone 0.1% eye ointment olopatadine eye drops. table number 3 shows drug regimen at baseline and at third follow-up visit. ahmad zeeshan jamil, et al 369 pak j ophthalmol. 2020, vol. 36 (4): 365-370 nonparametric mann whitney test was used to calculate difference in means of sliding scale at baseline and third follow-up visit. z score value was 16.917 and significance was 0.000. for patient’s satisfaction at third follow-up visit chi-square test was used. chi-square value was 263.759 with a significance value of 0.000. for disease control at third follow-up visit chi-square value was 223.123 with a significance value of 0.000. discussion in our study mean age of the patients was 29.45 ± 18.77 years. age range was from 3 years to 64 years. allergic conjunctivitis is more prevalent in children. a study conducted among 818 children of age 5-19 years in karachi found that 19.2% had allergic conjunctivitis with significant association between increasing age and allergic conjunctivitis. 12 review of literature shows different ocular allergies affect different age groups. seasonal allergic conjunctivitis most frequently affects individuals younger than 20 years, vernal keratoconjunctivitis is most often seen in patients younger than 10 years, atopic keratoconjunctivitis is most frequently encountered in persons from 30 to 50 years of age and giant papillary conjunctivitis is seen is teenagers and young adults. 13 ocular allergy may be associated with allergies of nose, skin or respiratory system. 14,15 treatment of systemic allergy often ameliorates the clinical presentation of ocular allergy. systemic anti-allergy medicine proved helpful in severe cases of ocular allergies without involvement of other parts of the body. 16 in the present study oral anti-allergic medicine was started in 8% of patients with good results. for the treatment of ocular allergies, topical steroids are reserved for acute exacerbations and in cases that are not controlled otherwise. for the treatment of ocular allergies steroids are used topically, sub conjunctively, supratarsally, orally and nasally. 17 steroid use may be associated with corneal infection, raised intraocular pressure and formation of cataract. 18 judicious use of steroids is mandatory considering its adverse effects. allergic conjunctivitis can significantly affect the quality of life, result in economic and educational loss. eye rubbing associated with ocular allergy can cause other eye problems like progression of myopia and development of keratoconus. 19 shoji and co-authors developed a scoring system to grade different types of allergic conjunctivitis into mild, moderate and severe categories. 20 our grading system is different from the grading system used by shoji and co-authors. the clinical features used by our patients were supervised by the ophthalmologists to decide a treatment regimen. sliding scale use results in follow-up visits at longer intervals and use of minimal eye drops for the control of thereby it is possible to avoid unnecessary use of steroids. at the same time, an appropriate dose of medicine allows adequate control of the disease. 21 moreover, better control of ocular allergy results in minimal use of medicines and less frequent follow-up visits to hospital hence, saving time and money of the patients. 1 limitation our study was that duration of our follow-up visits was small. we did not separately identify patients of seasonal allergic conjunctivitis, vernal keratoconjunctivitis and atopic conjunctivitis. individual variation in the perception of symptoms exists. selection of drugs in different regimens was authors’ choice. different drugs can be compared in future for their effects using proposed sliding scale. nevertheless, our proposed sliding scale was useful in the management of allergic conjunctivitis whereby patients were actively involved in planning a drug regimen and follow-up visit under the supervision of the treating ophthalmologist. minimal use of topical steroids with increasing interval between follow-up visits was associated with improved patient’s satisfaction and more disease control at the end of the study. conclusion use of sliding scale in the management of allergic conjunctivitis was well accepted by the patients. it helped in disease control with minimal use of topical steroids and less frequent visits to the hospital. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. sliding scale in the management of allergic conjunctivitis pak j ophthalmol. 2020, vol. 36 (4): 365-370 370 references 1. kohli cm, kohli gm. assessment of clinical profile of patients with allergic conjunctivitis. j adv med dent scie res. 2014; 2 (4): 190-193. 2. gomes pj. trends in prevalence and treatment of ocular allergy. curr opin allergy clin immunol. 2014; 14: 451–456. 3. leonardi a, bogacka e, fauquert jl, kowalski ml, groblewska a, jedrzejczak-czechowicz m, et al. ocular allergy: recognizing and diagnosing hypersensitivity disorders of the ocular surface. allergy, 2012; 67: 1327‐1337. 4. cronau h, kankanala rr, mauger t. diagnosis and management of red eye in primary care. am fam physician, 2010; 81 (2): 137-144. 5. takamura e, uchio e, ebihara n, ohno s, ohashi y, okamoto s, et al. japanese guidelines for allergic conjunctival diseases 2017. allergol int. 2017; 66 (2): 220-229. 6. azari aa, barney np. conjunctivitis: a systematic review of diagnosis and treatment. jama. 2013; 310 (16): 1721–1729. doi: 10.1001/jama.2013.280318. 7. singh k, axelrod s, bielory l. the epidemiology of ocular and nasal allergy in the united states, 1988– 1994. j allergy clin immunol. 2010; 126: 778–783. 8. chigbu di. the pathophysiology of ocular allergy: a review. cont lens anterior eye, 2009; 32 (1): 3–15; quiz 43–44. 9. o’brien tp. allergic conjunctivitis: an update on diagnosis and management. curr opin allergy clin immunol. 2013; 13 (5): 543–549. 10. shoji j, inada n, sawa m. evaluation of novel scoring system named 5-5-5 exacerbation grading scale for allergic conjunctivitis disease. allergol int. 2009; 58 (4): 591-597. doi: 10.2332/allergolint.09-oa-0100. epub 2009 sep 25. 11. bielory l, meltzer eo, nichols kk, melton r, thomas rk, bartlett jd. an algorithm for the management of allergic conjunctivitis. allergy asthma proc. 2013; 34 (5): 408–420. doi: 10.2500/app.2013.34.3695. 12. baig r, ali aw, ali t, ali a, shah mn, sarfaraz a, et al. prevalence of allergic conjunctivitis in school children of karachi. j pak med assoc. 2010; 60 (5): 371-373. 13. baab s, le ph, kinzer ee. allergic conjunctivitis. [updated 2020 feb 21]. in: stat pearls. treasure island (fl): stat pearls publishing; 2020 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk448118/ 14. mashige kp. ocular allergy. health sa gesondheid. 2017; 22: 112-122. 15. maspero j, lee bw, katelaris ch, potter pc, cingi c, lopatin a, et al. quality of life and control of allergic rhinitis in patients from regions beyond western europe and the united states. clin exp allergy, 2012; 42 (12): 1684– 1696. doi: 10.1111/j.1365-2222.2012.04025x. 16. leonardi a. management of vernal keratoconjunctivitis. ophthalmol ther. 2013; 2 (2): 7388. 17. ackerman s, smith lm, gomes pj. ocular itch associated with allergic conjunctivitis: latest evidence and clinical management. ther adv chronic dis. 2016; 7 (1): 52-67. 18. bowling e. the conjunctivitis conundrum. review of optometry, 2020 february 15. available from: https://www.reviewofoptometry.com/article/theconjunctivitis-conundrum. (accessed march 22, 2020) 19. pitt ad, smith af, lindsell l, voon lw, rose pw, bron aj. economic and quality-of-life impact of seasonal allergic conjunctivitis in oxfordshire. ophth epidemiol. 2004; 11 (1): 17-33. 20. shoji j, inada n, sawa m. evaluation of novel scoring system named 5-5-5 exacerbation grading scale for allergic conjunctivitis disease. allergol int. 2009 dec; 58 (4): 591-7. doi: 10.2332/allergolint.09-oa-0100. epub 2009 sep 25. pmid: 19776677. 21. rathi vm, murthy si. allergic conjunctivitis. community eye health, 2017; 30 (99): s7-s10. authors’ designation and contribution ahmad zeeshan jamil; associate professor: concepts, design, data analysis, manuscript preparation. muhammad luqman ali bahoo; associate professor and head of department: literature research, manuscript preparation. zahid kamal; professor and head of department: manuscript preparation, manuscript editing, manuscript review. muhammad rizwan; assistant professor: data acquisition, statistical analysis, manuscript preparation. muhammad ovais; senior registrar: literature research, data analysis, manuscript preparation. .…  …. https://www.ncbi.nlm.nih.gov/pubmed/?term=leonardi%20a%5bauthor%5d&cauthor=true&cauthor_uid=22947083 https://www.ncbi.nlm.nih.gov/pubmed/?term=bogacka%20e%5bauthor%5d&cauthor=true&cauthor_uid=22947083 https://www.ncbi.nlm.nih.gov/pubmed/?term=fauquert%20jl%5bauthor%5d&cauthor=true&cauthor_uid=22947083 https://www.ncbi.nlm.nih.gov/pubmed/?term=kowalski%20ml%5bauthor%5d&cauthor=true&cauthor_uid=22947083 https://www.ncbi.nlm.nih.gov/pubmed/?term=kowalski%20ml%5bauthor%5d&cauthor=true&cauthor_uid=22947083 https://www.ncbi.nlm.nih.gov/pubmed/?term=groblewska%20a%5bauthor%5d&cauthor=true&cauthor_uid=22947083 https://www.ncbi.nlm.nih.gov/pubmed/?term=jedrzejczak-czechowicz%20m%5bauthor%5d&cauthor=true&cauthor_uid=22947083 https://www.ncbi.nlm.nih.gov/pubmed/?term=baig%20r%5bauthor%5d&cauthor=true&cauthor_uid=20527610 https://www.ncbi.nlm.nih.gov/pubmed/?term=ali%20aw%5bauthor%5d&cauthor=true&cauthor_uid=20527610 https://www.ncbi.nlm.nih.gov/pubmed/?term=ali%20t%5bauthor%5d&cauthor=true&cauthor_uid=20527610 https://www.ncbi.nlm.nih.gov/pubmed/?term=ali%20a%5bauthor%5d&cauthor=true&cauthor_uid=20527610 https://www.ncbi.nlm.nih.gov/pubmed/?term=shah%20mn%5bauthor%5d&cauthor=true&cauthor_uid=20527610 https://www.ncbi.nlm.nih.gov/pubmed/?term=sarfaraz%20a%5bauthor%5d&cauthor=true&cauthor_uid=20527610 https://www.ncbi.nlm.nih.gov/pubmed/20527610 https://www.ncbi.nlm.nih.gov/books/nbk448118/ https://www.reviewofoptometry.com/article/the-conjunctivitis-conundrum https://www.reviewofoptometry.com/article/the-conjunctivitis-conundrum dacryolithiasis: clinical presentation and management pak j ophthalmol. 2021, vol. 37 (2): 156-160 156 original article surgical management of orbital fractures using x-ray film plate: a retrospective case series zahid kamal siddique 1 , qudsia anwar dar 2 , amna farooq 3 , muhammad ijaz anjum 4 muhammad mohsin ali 5 1,2,3,5 department of ophthalmology, king edward medical university/mayo hospital 4 lahore general hospital, lahore abstract purpose: orbital trauma is associated with orbital blowout fractures, with associated globe injuries and loss of vision. orbital reconstruction can be done with various implant materials. the aim of this study is to identify the safety and postoperative outcomes of using x-ray films as orbital implants during orbital reconstruction surgery. study design: an interventional case series. place and duration of study: ophthalmology departments of lahore general hospital and mayo hospital, lahore from june 2001 to may 2017. methods: retrospective data of all the patients who came for orbital reconstruction surgeries from june 2001 to may 2017 was retrieved. all patients had undergone ct scan prior to surgery. orbital reconstruction was done by a single surgeon, by bridging bony defect with sterilized x-ray film. all patients received post-operative antibiotics for 1 week. results: twenty three male patients were included in the series, with a mean age of 28 ± 2.47 years. assault and sports injuries with a ball were the commonest form of trauma. diplopia was the major presenting complaint in 91% of the patients. all patients underwent surgical reconstruction of the orbital floor of orbit with sterilized x-ray film using a lateral canthotomy approach. only mild postoperative diplopia was recorded in 7 of the cases, with uneventful recovery in the majority. conclusion: sterilized x-ray film is a safe, cost effective, and durable material for reconstruction after orbital blowout fracture, especially in developing countries. key words: orbital fracture, x-ray film, diplopia. how to cite this article: siddique zk, dar qa, farooq a, anjum mi, ali mm. surgical management of orbital fractures using x-ray film plate: a retrospective case series. pak j ophthalmol. 2021, 37 (2): 156-160. doi: http://doi.org/10.36351/pjo.v37i2.1111 introduction orbital trauma is a common presentation for patients presenting to oculoplastic surgical units. when a blunt correspondence: qudsia anwar dar department of ophthalmology, king edward medical university, mayo hospital, lahore email: qudsiaabbas@gmail.com received: july 27, 2020 accepted: january 16, 2021 rounded object of diameter more than 5cm hits the orbit, there is a sudden rise in orbital hydraulic pressure, which can result in fracture of the orbital wall with bony fragment moving out of orbit along with the soft tissue; thisis labelled as orbital blow out fracture (obf). if there is no involvement of the orbital rim or facial bones it is called pure obf. 1,2 fractures of the orbital wall are classified as either isolated fractures, where a single orbital wall is involved; or as combined fractures, when more than one orbital wallsare involved. out of all the four orbital walls, the floor of orbit is the most frequently http://doi.org/10.3352/jeehp.2013.10.3 zahid kamal siddique, et al 157 pak j ophthalmol. 2021, vol. 37 (2): 156-160 injured. it contains the largest open space and it lacks structural support, henceit is often fractured following blunt traumas of the face and orbits. the frequency of orbital floor fractures is becoming more common due to the increasing number of traffic accidents, sportsrelated injuries and physical aggressions. 3 repair of orbital wall and floor fractures can be challenging due to the demanding three-dimensional anatomy and limited intraoperative view. poorly fitted implants and inaccurate surgical technique may lead to visual disturbance and unaesthetic results. 3 moreover, the cost of implants is a barrier towards appropriate management in the developing countries. the goal of orbital reconstruction is to repair trauma related defects; to correct the anatomical position of the eye; torestore the volume of the orbit; to avoid enophthalmos and diplopia; and to restore ocular function. there is no ideal implant for orbital fracture reconstruction. recently published studies have highlighted following points for a suitable orbital implant for repair of orbital blow out fractures: (1) stability and fixation; (2) contouring and handling; (3) biological behavior; (4) donor site morbidity; (5) radio-opacity (6) availability (7) cost-effectiveness. 4-8 a variety of implants have been reported including; bone, cartilage, titanium mesh, porous polyethelene and teflon. 9,10 however, the cost and availability of these implants is often a restricting factor for oculoplastic surgeons in developing countries. a sterilized x-ray film is advantageous for orbital floor reconstruction as it is easily available with cheap cost. being a semi-rigid material, inert and a smooth surface it can be easily sterilized using a standard 134°c autoclave cycle. it provides adequate support and is well-tolerated by orbital tissue. it can be easily trimmed with a pair of heavy scissors to cover the bony defect. its smooth surface may also help to reduce the risk of postoperative adhesions and restrictive strabismus. 9 the purpose of this study was to assess the efficacy and safety of x-ray film plate as an orbital floor implant to repair obf. multicenter experience of a single surgical operator is presented with record of postoperative complications to show that x-ray film plates can be an efficient alternative implant in lower middle income countries. methods a retrospective analysis of patients with orbital fractures, who presented to the ophthalmology departments of lahore general hospital and mayo hospital, lahore, was conducted. only those cases, which required surgical intervention were included in this study. the study period included all cases from june 2001 to may 2017. those cases with adjacent facial fractures or associated head injury were excluded from the study. the globe injuries were identified and treated. extra ocular movements were recorded as a percentage of the normal movements. all patients underwent computed tomography of the head and orbits with axial and coronal sections of 2 – 3 mm and bone windows. the indications for repair of the fracture were persistent diplopia, hypophthalmos or enophthalmos and a large fracture (> 50% of orbital floor). all the procedures were performed under general anaesthesia. the surgeon used a head mount light for coaxial illumination. lateral canthotomy was done and the inferior orbital rim was exposed through a transconjunctival approach. the orbital periosteum was lifted and orbital wall fracture was identified. free bony fragments were removed and orbital soft tissue contents were retrieved from the adjacent para-nasal sinus. the defect in the bone was bridged with a sterilized x-ray film cut to appropriate size. the periosteum, conjunctiva and lateral canthotomy were closed by absorbable sutures in separate layers. a light patch was applied at the end of procedure. all the patients were given oral cephalosporins (cefuroxime) for 1 week. they were advised to avoid blowing their nose. cold compresses were done 8 hourly using ice packs in a sterilized glove. visual functions (visual acuity, colour vision and pupillary light reaction) were recorded 6 hourly in the first 24 hours after the surgery to identify any optic nerve compression secondary to post-operative intra-orbital bleeding. the patients were followed for at least two months. any complications that occurred in the postoperative periodwere recorded. postoperative diplopia was recorded as mild, moderate or severe on basis of ocular motility restriction; in mild cases, 75% movement beyond the midline was possible, while in severe cases, 25% or no movement was possible beyond the midline. permission was taken from the institutional review board of the concerned institutions for the use of patient data. all ethical considerations were followed by the authors in data collection. spss surgical management of orbital fractures using x-ray film plate: a retrospective case series pak j ophthalmol. 2021, vol. 37 (2): 156-160 158 software version 23 was used for data analysis, with qualitative statistics reported as frequency and percentages, and quantitative statistics as mean ± sd. results twenty-three patients were included in this study. all of the participants were males, ranging from 13 to 49 years of age. the mean age in the study was 28 ± 2.47 years. the underlying causes of the fractures are summarised in table 1. table 1: cause of injury and presenting symptom. cause of injury n (%) assault 08 (35) sports 07 (30) motor vehicle accidents 08 (35) symptoms n (%) diplopia 21 (91) hypaesthesia 08 (35) lid ecchymosis 08 (35) enophthalmos > 2 mm or hyophthalmos 05 (22) the sources of injury in cases of trauma and assault were punch by a closed fist or a ball. it was difficult to establish the exact source of injury in cases of motor vehicle accidents. the clinical presentation of patients is shown in table 1. the ophthalmic examination showed subconjunctival haemorrhage (n = 5), hyphema (n = 2) and globe rupture (n = 1). the interval between injury and presentation ranged from 0 to 7 days (mean 4 ± 0.73 days). the interval between injury and surgery ranged from 3 to 16 days (mean 13 ± 0.85 days). in 87% of the cases, ct scan of the orbit revealed fracture of the orbital floor only, whereas in 13% of the cases it showed fracture of both the orbital floor and the medial wall of the orbit. no significant intraoperative complications were recorded. only minor postoperative complications were noted: in one case, lateral canthal pyogenic granuloma developed, for which excision and thermal cauterization was done. in another case, there was anterior migration of the x-ray film plate, which was removed without affecting the ultimate results. the final outcome regarding diplopia is summarised in table 2. wilcoxon signed rank test showed mean rank of 3.5 and 13.28 for preoperative diplopia and postoperative diplopia respectively with z = -3.753 and p = 0.000, signifying that x-ray film implant corrected diplopia significantly. table 2: postoperative diplopia (n = 23). grading of diplopia n (%) none 13 (56.5) mild 07 (30) moderate 01 (4.3) intermittent 02 (8.6) ranks diplopia n mean rank sum of ranks pre-operative post-operative negative ranks 4 a 3.50 14.00 positive ranks 18 b 13.28 239.00 ties 1 c total 23 a. pre-operative diplopia < postoperative diplopia b. pre-operative diplopia>postoperative diplopia c. pre-operative diplopia = postoperative diplopia test statistics a pre-operative diplopia – post-operative diplopia z -3.753 b asymp. sig. (2-tailed) .000 a. wilcoxon signed ranks test b. based on negative ranks. discussion orbital fractures are usually seen in young adults, as evidenced by kakibuchi et al, 3 who reported a mean age of 23.5 years in their study of orbital blow out fractures, and hatton et al, 11 who reported 96 cases of orbital fractures in patients under the age of 18 years, most of whom were males. these results are consistent with our study, which consisted of only males with a mean age of 28 ± 2.47 years. in our study, the causes of the fractures were assaults, sports and motor vehicle accidents, which are similar to the already published literature. 11,12 in the case series of hatton et al, there was one case with associated globe rupture, indicating that globe injury should always be carefully excluded while managing orbital fractures. most of the fractures occur due to accident or assaults. the mode of trauma was a fist or ball in 70% of our cases. all the patients in our study were males due to the likelihood of males coming across accidents and being involved in the fights. the trauma typically occurred due to an object bigger than 5 cm. other studies also report similar aetiology. 12,13 in two of our zahid kamal siddique, et al 159 pak j ophthalmol. 2021, vol. 37 (2): 156-160 cases police investigation was needed. one should always address medico-legal aspects (e.g. photography, records written in details and securely stored) while dealing with these cases. during the clinical examination any associated ocular, neuronal or head injury should be carefully excluded. we excluded any case with such associated disorders from this series. although we managed to get lees’ screen (hess) test in 60% of our cases, but it was not quite possible to obtainit in all cases, due to restricted resources and unavailability in some cases. all the patients of obf should be advised to avoid blowing the nose as there have been reports of orbital emphysema and cellulites following this manoeuvre in the cases with orbital injury. 14,15,16 we counselled all the patients to refrain from blowing the nose and started them on broad-spectrum antibiotics. the zero incidence of peri-orbital emphysema or infection in our case series can be attributed to this precaution. thin slice (2 – 3 mm) ct scan images provide the most relevant information regarding orbital floor fracture, therefore we requested axial/coronal sections and bone density windows with special attention to orbital floor and medial wall depending upon clinical assessment in all our cases. in a couple of cases where direct coronal imaging was not possible reconstructed image gave enough guidelines to plan for surgery. recent studies have also shown that ct imaging with coronal and axial images is superior to conventional radiography. 17 the use of sterilized x-ray film as orbital implant is associated with low cost, easy availability, and improved support to the orbital floor without any aggravated inflammation. the sheet of x-ray film can be stabilized at the anterior orbital rim by merely suturing the periosteum, preventing anterior migration. it is well-supported by surrounding bone in smallmedium sized fractures. as the implant does not require fixation, the risk of iatrogenic trauma to the infraorbital nerve through screw placement is reduced. however, as the x-ray film implant cannot be fixed to bone, the cases with larger fractures without an intact maxilla-ethmoidal strut are not suitable for this material. the first case report of the use of an autoclaved x-ray film for management of orbital floor fracture also promoted this improvisation for lowmiddle income countries as the film is tough, provides support and healing occurs within three weeks. it is also easily available for use at a very low cost. 18 although, insul et al 9 reported good outcome in 56 patients with the use of x-ray film, they encountered a case of pseudo-capsule formation around the film leading to recurrent proptosis. we did not come across any such complication in our series. recent studies show that timing of surgery is not much important while repairing orbital floor fractures, even delayed surgery can give functional and cosmetic benefits. 19 moreover, it has also been shown that postoperative imaging in the absence of persistent clinical symptoms has no additional benefit in determining the complication rate. 20 consequently, we did not obtain postoperative images of the participants in our study. limitations of this case series is the retrospective study design, small sample and short follow-up. conclusion sterilized x-ray film is a safe, and low cost implant material for the repair of small to medium-sized orbital blowout fractures. it is well tolerated and readily available in all the hospitals at no added cost compared with other implant materials. our case series provides evidence of its safety in treating orbital floor and medial wall fractures. it can provide an excellent alternative for orbital implants in countries with low healthcare spending, and can improve healing outcomes significantly for affected patients. ethical approval the study was approved by the institutional review board/ ethical review board. (1003/rc/kemu). conflict of interest authors declared no conflict of interest. acknowledgment thank are due to miss hafiza ummara rasheed for helping in statistical analysis. references 1. salmon jf. trauma in: kanski’s clinical ophthalmology. 9 th edition. elsevier, 2020: p. 892-896. 2. mcnab aa. a manual of orbital and lacrimal surgery. 2 nd edition. butterworth heinemann, 1998: p.77-82. 3. kakibuchi m, fukazawa k, fukuda k, matsuda k, kawai k, tomofuji s, et al. combination of transconjunctival and endonasal-transantral approach in the repair of blowout fractures involving orbital floor. br j plast surg. 2004; 57 (1): 37-44. surgical management of orbital fractures using x-ray film plate: a retrospective case series pak j ophthalmol. 2021, vol. 37 (2): 156-160 160 4. dubois l, steenen sa, gooris pj, bos rr, becking ag. controversies in orbital reconstruction-iii. biomaterials for orbital reconstruction: a review with clinical recommendations. int j oral maxillofac surg. 2016; 45: 41-50. 5. gunarajah dr, samman n. biomaterials for repair of orbital floor blowout fractures: a systematic review. j oral maxillofac surg. 2013; 71: 550-570. 6. van leeuwen ac, ong sh, vissink a, grijpma dw, bos rr. reconstruction of orbital wall defects: recommendations based on a mathematical model. exp eye res. 2012; 97: 10-18. 7. wajih wa, shaharuddin b, razak nh. hospital universiti sains malaysia experience in orbital floor reconstruction: autogenous graft versus medpor. j oral maxillofac surg. 2011; 69: 1740-1744. 8. boyette jr, pemberton jd, bonilla-velez j. management of orbital fractures: challenges and solutions. clin ophthalmol. 2015; 9: 2127-2137. doi:10.2147/opth.s80463. 9. insull ea, hart rh, sloan bh, ben-simon gj, mcnab aa. use of x-ray film implant for the repair of orbital fractures. ophtha lm plast reconst surg. 2013; 29 (5): 393–395. 10. grob s, yonkers m, tao j. orbital fracture repair. semin plast surg. 2017; 31 (1): 31-39. doi: 10.1055/s0037-1598191. 11. hatton mp, watkins lm, rubin pa. orbital fractures in children. ophthal plast reconstr surg. 2001; 17 (3): 174-179. 12. karsteter pa, yunker c. recognition and management of an orbital blowout fracture. j orthop sports phys ther. 2006; 36 (8): 611-618. 13. yazici b, hammad am, meyer dr. lacrimal sac dacryoliths: predictive factors and clinical characteristics. ophthalmol 2001; 108 (7): 1308-1312. 14. iliadelis e, karabatakis v, sofoniou m. dacryoliths in chronic dacryocystitis and their composition (spectrophotometric analysis). eu j ophthalmol. 1999; 9 (4): 226-228. 15. ye lx, sun xm, zhang yg, zhang y. materials to facilitate orbital reconstruction and soft tissue filling in posttraumatic orbital deformaties. plast aesthet res. 2016; 3: 86-91. doi.10.20517/2347-9264.2015.122. 16. kim hs, jeong ec. orbital floor fracture. arch craniofac surg. 2016; 17 (3): 111-118. doi:10.7181/acfs.2016.17.3.111. 17. shah s, uppal sk, mittal rk, garg r, saggar k, dhawan r. diagnostic tools in maxillofacial fractures: is there really a need of three-dimensional computed tomography? indian j plast surg. 2016; 49 (2): 225. doi: 10.4103/0970-0358.191320. 18. shoaib ck, ali k, mukhtar ma. management of orbital floor fracture with autoclaved x-ray film. pak armed forces med j. 2008; 58 (3): 353-356. 19. scawn rl, lim lh, whipple km, dolmetsch a, priel a, korn b, et al. outcomes of orbital blow-out fracture repair performed beyond 6 weeks after injury. ophth plast reconstr surg. 2006; 32 (4): 296– 301. doi: 10.1097/iop.0000000000000511. 20. carpenter d, shammas r, honeybrook a, brown cs, chapurin n, woodard cr. the role of postoperative imaging after orbital floor fracture repair. craniomaxillofac trauma reconstr. 2018; 11 (2): 96101. doi: 10.1055/s-0038-1625949 authors’ designatin and contribution zahid kamal siddique; professor: concepts, design, literature search, data acquisition, manuscript review. qudsia anwar dar; senior registrar: literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing. amna farooq; post graduate trainee: literature search, data acquisition, data analysis, manuscript review. muhammad ijaz anjum; post graduate trainee: design, literature search, data acquisition, manuscript review. muhammad mohsin ali; house surgeon: literature search, manuscript editing. .…  …. https://doi.org/10.1097/iop.0000000000000511 https://doi.org/10.1055/s-0038-1625949 pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 103 original article modified scleral buckling technique using endoillumination and non contact wide angle viewing system haroon tayyab, muhammad ali haider, sana jahangir, bilal zaheer qureshi pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: haroontayyab house # suh-24, askari xi cobbe lane near qasim market rawalpidi cantt …..……………………….. purpose: to assess feasibility and surgical outcome of a new scleral buckling technique for rhegmatogenous retinal detachment using endo illumination and noncontact wide angle viewing system. material and methods: eleven eyes of 11 patients underwent modified scleral buckling for rhegmatogenous retinal detachment. a custom modified 23 g endo illuminator and noncontact wide angle viewing system was utilized instead of binocular indirect ophthalmoscope to visualize fundus intra operatively. results: the mean age of patients was 45.3 years. out of 11 patients, 9 patients (82%) achieved retinal reattachment while 2 patients had to undergo pars plana vitrectomy with silicone oil tamponade due to development of proliferative vitreoretinopathy. 8 (72%) patients achieved stabilization / improvement in visual acuity. 2 patients had minimal subretinal hemorrhage at the time of subretinal fluid drainage. conclusion: combining wide angle viewing system and microsurgery with scleral buckling provides a useful and safe alternative for viewing fundus during retinal reattachment surgery. cleral buckling and cryopexy has been a time tested and valuable surgical technique for repairing rhegmatogenous retinal detachments (rd)1. although there has been increasing trend towards pars plana vitrectomy (ppv) and internal tamponade as a primary treatment for rhegmatogenous rd, still, high success rates of functional and anatomic outcomes can be achieved with scleral buckling procedures2. the steps in conventional scleral buckling include limbal conjunctiva peritomy, recti muscle bridle sutures, localization and cryotherapy to retinal breaks, application of scleral exoplants, subretinal fluid drainage and injection of gas or air in vitreous cavity in case of superior breaks3. it is important that surgeon should be very efficient and comfortable with indirect ophthalmoscopy when performed intra-operatively for precise application of cryotherapy and placement and adjustment of position and height of scleral exoplants. however, indirect ophthalmoscopy presents the surgeon with a reverse and inverted image of fundus which can cause significant difficulty in performing retinal procedures and observing fundus at the same time.5 also, indirect ophthalmoscopy becomes less yielding in terms of details and accuracy in cases of hazy media. repeated use of indirect ophthalmoscopy also makes the procedure inconvenient5. owing to advanced fundal viewing systems and improved microincisional vitrectomy instruments, surgeons have recently tried to evaluate the feasibility of viewing fundus using contact and noncontact lens during scleral buckling procedures with excellent results.6 in this series, we have performed modified scleral buckling procedures utilizing noncontact fundal viewing system and endoillumination; thus alleviating the need of using indirect ophthalmoscope intra operatively. s haroon tayyab, et al 104 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology material and methods this prospective interventional study was conducted in vitreoretinal section of al ehsan welfare eye hospital, lahore, pakistan (a tertiary care and registered ophthalmic facility) from may 2013 to november 2013. a total of 11 patients belonging to all age groups and gender with rhegmatogenous rd and up to grade b proliferative vitreoretinopathy (pvr) were enrolled in this study. all patients under went detailed fundal examination on slit lamp (wide field noncontact lens and triple mirror contact lens) and with indirect ophthalmoscope; all breaks were localized and extent of rd was documented on specially designed rd charts. all patients were phakic or had undergone uncomplicated cataract surgery. patients with breaks in multiple quadrants or breaks posterior to equator were not included in this study. all surgeries were performed under general anesthesia and by a single surgeon. anatomic success was defined as reattachment of retina and functional success was defined as stabilization or improvement of best corrected visual acuity (bcva) after 2 months of follow up. a detailed informed consent about the nature of disease and type of surgical procedure was obtained from all patients. approval for this study was sought from hospital’s ethical committee. limbal conjunctival peritomy was performed with 2 radial relaxing incisions 180° apart avoiding the quadrants where final placement of scleral exoplant was planned.after peritomy, all 4 recti muscles were engaged with squint hooks and bridle sutures were passed underneath them using 4 – 0 silk suture. after consulting the rd diagrams of patient, a 23 g autoseal pms cannula (oertli® instruments ag, switzerland) (figure 1) was introduced 3.5 mm away from limbus (4 mm in phakic patients), using 1 step 23 g trocar (oertli® instruments ag, switzerland). placement of cannula was 120° away from the meridian of retinal break (or a location that afforded maximum globe maneuvering while keeping the distance between cannula and break at least 3 clock hours). a self retaining custom modified (chandelier type) 23 g endoilluminator (figure 2) was inserted in the autoseal cannula. next, fundus was viewed through the aid of surgical microscope equipped with oculus stereoscopic diagonal inverter (oculus® surgical, inc. fl, usa) and oculus binocular indirect ophthalmo microscope (biom®) with oculus noncontact wide field enhanced lens (120° field of view). after adjusting the image inverter, position of retinal break was accurately marked on sclera. while viewing retina in the same way, cryotherapy burns were applied at marked site. endoilluminator was then removed and circumferential solid silicone tyre/radial silicone sponge was secured with sclera using mattress sutures with 5-0 ethibond. endoilluminator was again inserted in vitreous cavity and final position and height of scleral exoplant was adjusted while viewing retina through biom®. subretinal fluid was drained when needed in conventional manner and fundus was evaluated with scleral indentation and for adequate retinal perfusion while observing central retinal artery patency. endoilluminator was removed along with 23 g cannula and the site was secured with 6-0 vicryl suture when needed. isovolumetric concentration of sf6 gas was injected in vitreous cavity through pars plana where indicated. the surgery was completed by closing conjunctiva with 6-0 vicryl suture. results out of 11 patients, 6 (54%) were male and 5 (46%) were females. 7 (63%) patients had rd in right eye and 4 (36%) had rd in left eye. range of age of patients was from 23 to 64 years with mean age of 45.3 years. 5 (45%) patients had solitary break whereas 6 (54%) patients had more than one break. distribution of breaks according to quadrants is shown in fig 3. 4 (36%) patients underwent radial silicone sponge where as 7 (64%) patients under went solid silicone tyre with 360° silicone band. anatomic success was achieved in 82% of patients and functional success was achieved in 72% of patients as shown in figure 4. bcva of all patients is depicted in table 1. one patient had failed scleral bucking on first post operative day with persistent inferior subretinal fluid. fig. 1. 23 g auto seal pms cannula with self sealing membrane. modified scleral buckling technique using endoillumination and non contact wide angle viewing system pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 105 fig. 2. self retaining custom modified 23 g endo illuminator. 2 3 5 1 supero-temporal supero-nasal inf ero-temporal inf ero-nasal fig. 3: quadrant wise distribution of retinal breaks 3 2 89 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% anatomic outcome functional outcome success failure fig. 4: anatomic and functional outcome after 2 month follow up one patient had rd with grade c pvr 3 weeks post surgery. both patient had to undergo ppv and silicone oil tamponade to reattach the retinas. one patient had deterioration of bcva despite retinal reattachment. her reason for progressively declining bcva was extensive epimacular membrane. this patient lost to follow up after 2 months. 2 patients had minimal subretinal hemorrhage immediately after draining subretinal fluid without any long term complications. discussion helmholtz is credited with invention of first ophthalmoscope in 1850 that could be effectively used for viewing retina7 and accurate description of retinal breaks was made possible after 2 years by coccius8 and von graefe9. over the next century, various instruments for viewing retina rose to horizon before schepens10 introduced the first clinically effective binocular indirect ophthalmoscope in 1947; and indirect ophthalmoscope has changed little since schepens classic description. the concept of modern scleral buckling (post jules gonin era) started with custodis11 when he became the first surgeon to perform scleral buckling using episcleralexoplant (polyviol) in 1949. his methods of scleral buckling underwent various advancements in terms of materials used for scleral exoplants and in methods of retinopexy before lincoff introduced cryopexy and silicone exoplants; thus introducing the basis of modern scleral buckling12. thistechnique demands an efficient use of binocular indirect ophthalmoscope while viewing a reverse and inverted fundus image. also its use is considerably inconvenient and time consuming when it comes to performing cryopexy while viewing fundus at same time; thus demanding a considerable degree of expertise.5 repeated surgical maneuvers needed while performing intra-operative indirect ophthalmoscopy may also render the media hazy; thus compounding the problem of accurate retinal break localization and its cryopexy. recently, surgeons have utilized various instruments used in modern day ppv to assist them in conventional scleral buckling to overcome the drawbacks mentioned above. first of many such reports came from kumar where he used endo light pipe to localize subretinal fluid drainage site while performing scleral buckling in hazy ocular media.13 nam5 recently reported a series of 12 cases where he successfully reattached retinas through sclera haroon tayyab, et al 106 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology buckling with the help of 25-g chandelier light (alcon, chandelier lighting system, fort worth. tx, usa) and wide – field contact lens (mini quad; volk, mentor, oh). he concluded that endoillumination systems are much easier to use while doing scleral buckling when compared to conventional methods of viewing fundus intra operatively. nawrocki et al14 performed scleral buckling on 7 patients using optic fiber free intravitreal surgical system (offiss®, topcon inc, paramus, nj, usa). he reported superior magnification and more precise control of surgery using offiss® with lesser intra-operative complications. aras et al15 concluded that using a 25-g torpedo light (alcon laboratories, fort worth, tx, usa) and a noncontact wide angle viewing system enhanced visualization and surgical precision in his study of 16 patients. we conducted a similar series on 11 patients using custom modified 23-g endoilluminator compatible with faros™ vitrectomy machine (oertli® instruments ag, switzerland) and biom®. we used 23-g valved cannula that did not require a metal plug when endoilluminator was removed from vitreous cavity whereas nam5 used 25-g non valved cannula needing metal plugs to avoid vitreous escaping the cavity. although using a larger gauge cannula, our results are comparable in terms of success and complication profile to nam and his colleagues. but it is worth mentioning that we needed to secure the scleral entry sites for 23-g cannula in 2 cases where as nam’s 25-g system was self sealing in all of his cases. we also preferred using noncontact wide field viewing system as opposed to surgical contact lens because noncontact system afforded better eye maneuverability when indenting and rotating the globe while keeping fundal view clear and focused at the same time. similarly, in the series conducted by aras et al15 who used 25-g torpedo light, we preferred using 23-g modified self retaining endoilluminator. this was because firstly, torpedo light can always damage lens when the eye ball is being moved and secondly, since torpedo light needs a blade assisted vertical incision in sclera for its insertion, its removal can lead to vitreous escape. our anatomic and functional success rate was comparable as well. we achieved retinal attachment in 9 (82%) of our cases when compared to aras et al15 (81%) and nawrocki et al14 (87%). we did not encounter any scleral perforation during indentation where as aras15 reported 2 such cases. we experienced mild subretinal hemorrhage in 2 (13%) of our cases which was comparable to aras et al15. conclusion overall, in our experience, this modified method of scleral buckling using wide field retinal viewing systems and endoillumination is safe, more precise modified scleral buckling technique using endoillumination and non contact wide angle viewing system pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 107 and controlled operative technique when compared to conventional method of scleral buckling using binocular indirect ophthalmoscope; especially for intraoperative rd evaluation and cryopexy. we leave the choice of wide field viewing system (contact vs non contact) to individual surgeons but recommend use of “chandelier type” self retaining endoillumination for this surgery. author’s affiliation dr. haroon tayyab consultant ophthalmologist al-ehsan welfare eye hospital, lahore dr. muhammad ali haider consultant ophthalmologist al-ehsan welfare eye hospital, lahore dr. sana jahangir assistant professor of ophthalmology sharif medical and dental college, lahore dr. bilal zaheer qureshi visiting eye 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http://www.ncbi.nlm.nih.gov/pubmed/?term=aras+c%2c+ucar+d%2c+koytak+a%2c+yetik+h.+scleral+buckling+with+a+noncontact+wide-angle+viewing+system.+ophthalmologica+2012%3b227%3a+107%e2%80%93110. pak j ophthalmol. 2021, vol. 37 (3): 306-311 306 original article what to choose for trabeculectomy, 10/0 nylon monofilament or 8/0 virgin silk? erum shahid 1 , uzma fasih 2 , arshad shaikh 3 1-3 karachi medical and dental college & abbasi shaheed hospital abstract purpose: to compare between 10/0 nylon monofilament and 8/0 virgin silk for conventional trabeculectomy in terms of rate of complications and bleb morphology. study design: quasi experimental study. place and duration of study: abbasi shaheed hospital, karachi, from january 2017 to december 2018. methods: thirty six patients who underwent conventional trabeculectomy with 6 months follow-up were included. trabeculectomy for congenital, neovascular, traumatic glaucoma, revised surgery and laser trabeculoplasty were excluded. in group a, scleral flap and conjunctiva were closed with 8/0 virgin silk and in group b, 10/0 nylon monofilament was used. main outcome measure was complications. results: group a had 13 (36%) and group b had 23 (63.9%) patients. mean age was 55.5 ± 10.69. preoperative intraocular pressure (iop) was 33.4 ± 6.3 and 33.5 ± 12 mm hg in group a & b respectively. postoperatively at 3 rd month iop was 16.8 in group a and 15.0 in group b (p = 0.24).shallow anterior chamber was in 53% (n = 7) patients with 8/0 silk and 13% (n = 3) patients with 10/0 nylon with p value of < 0.05. seidel test was positive in 38% (n = 5) patients in group a (p < 0.01). re-suturing was done in 38% (n = 5) patients in group a with a p-value (p < 0.01). conclusion: shallow anterior chamber, wound leak with positive seidel test and additional intervention for resuturing were more common in group a than group b. diffuse blebs were frequently seen with both suture materials. suture material does not affect final intra ocular pressure and success of trabeculectomy. key words: bleb, trabeculectomy, 10/0 nylon, 8/0 silk. how to cite this article: shahid e, fasih u, shaikh a. what to choose for trabeculectomy, 10/0 nylon monofilament or 8/0 virgin silk? pak j ophthalmol. 2021, 37 (3): 306-311. doi: 10.36351/pjo.v37i3.1230 introduction trabeculectomy is the gold standard and most commonly performed procedure for lowering intra ocular pressure in glaucoma not responding to medical or laser treatment. 1 studies report superior results of trabeculectomy compared with medical treatment in correspondence: erum shahid karachi medical and dental college & abbasi shaheed hospital email: drerum007@yahoo.com received: february 18, 2021 accepted: april 28, 2021 lowering intra ocular pressure. 2 most of the trabeculectomies achieve successful outcome and lower intra ocular pressure (iop) in the long run thereby reducing progression of glaucoma. 1 surgical management of glaucoma is continuously evolving by the surgeons in recent years. there are a variety of new techniques including fornix versus limbus based flaps, adjustable sutures, trabeculectomy with antimetabolites, minimally invasive glaucoma surgery and non filtering glaucoma surgery. diverse range of drainage devices and adjunct tools are now available to surgeons to improve the outcome of trabeculectomy. 3 open access mailto:drerum007@yahoo.com erum shahid, et al 307 pak j ophthalmol. 2021, vol. 37 (3): 306-311 preservation of adequate aqueous outflow through the fistula formed by trabeculectomy is most important factor to prevent bleb failure. this includes size of scleral flap, internal sclerostomy and thickness of the flap. excess aqueous drainage to lower intra ocular pressure will lead to ocular hypotony, maculopathy and choroidal detachment. 4,5 correct tension of the scleral flap and the speed of aqueous filtration are regulated by the sutures. they sometimes require postoperative manipulations including suture adjustment, argon laser suture lysis or manual suture release. 6,7 standard trabeculectomy results in 1 – 2% cases of ocular hypotony. 8 it can lead to complications including flat anterior chamber, corneal edema, maculopathy, cataract and loss of vision. 9 various studies have been conducted regarding mechanism of scleral flap and different techniques for wound closure. 3,6,7 in this study we have compared wound related complications and bleb morphology using 10/0 nylon monofilament with 8/0 virgin silk for closing scleral flap and conjunctival tenon closure. it will help us to understand the role of suture material in achieving desired bleb formation and associated complications after trabeculectomy. methods this was a quasi experimental study performed in the department of ophthalmology, abbasi shaheed hospital, karachi. the study adhered to the tenets of declaration of helsinki. written informed consent was taken from every patient prior to the surgery. patients above 18 year of age, both genders, without antimetabolites, minimum follow up of 6 months from january 2017 to december 2018 were included. trabeculectomy for congenital, neovascular, traumatic glaucoma, revised trabeculectomy and anterior segment laser trabeculoplasty were excluded from the study. trabeculectomies were performed under retrobulbar anaesthesia. all the trabeculectomies were fornix based conjunctival flap at superior temporal or superior nasal site. bridle traction suture with silk 4/0 was used to stabilize the eye. conjunctival incision was made 1mm posterior to the limbus with westcott scissors. conjunctiva and tenon’s capsule was separated from sclera. non-tooth corneal forceps was used to prevent from button-holing of conjunctiva. bleeding was controlled with wet field cautery. a rectangular partial thickness scleral flap measuring 3 × 4 mm was created with surgical blade no 11. full thickness window was made in sclera measuring 1 × 2 mm with help of surgical blade no 15. this was followed by iridectomy of prolapsed iris tissue with iris scissors. scleral flap was closed at two ends with sutures. paracentesis was made to check the patency of scleral flap and adequate flow of fluid through it. conjunctiva and tenon were closed with interrupted sutures. anterior chamber was completely packed with air bubble. adequacy of wound closure, suture tension and absence of leakage was ensured after every surgery. post operatively systemic antibiotics (tab ciprofloxacin 500 mg) and analgesics were prescribed for 5 days. topical steroids (dexamethasone) and antibiotic (moxifloxacin) were given for six weeks. steroid was tapered in three months. these cases were divided into 2 groups. group a consisted of patients where scleral flap and conjunctiva were closed with 8/0virgin silk (aurolab, silk sutures, double arm).group b had sclera and conjunctiva closed with 10/0 nylon monofilament (aurolab, nylon sutures double arm).their wound was assessed on first post-operative day and on every follow up visit on slit lamp. these patients were examined for shallow anterior chamber (ac), wound leak, iritis, hyphema, suture abscess, striate keratopathy, malignant glaucoma, choroidal detachment, macular hypotony, endophthalmitis, block peripheral iridectomy (pi) and intra ocular pressure (iop) measurement with help of applanation tonometer. sutures were removed after 3 weeks. seidel test was performed in every patient on first postoperative day and subsequently. topical anaesthesia was instilled in the conjunctival sac. moistened fluorescein strip was directly applied on the potential site of leakage. this was observed with slit lamp under cobalt blue light. in case of aqueous leak fluorescein dye was diluted and green stream of aqueous was seen flowing from the wound. seidel positive patients were managed with pressure bandage for 48 hours after a drop of atropine. patients in whom anterior chamber failed to form were taken to operation theatre. anterior chamber was reformed with air and wound reclosed with additional sutures. in case of high iop due to drainage obstruction ocular massage was done with muscle hook. data was collected and analyzed using spss version 21. mean with standard deviation (sd) was calculated for numerical variables like age, duration of what to choose for trabeculectomy, 10/0 nylon monofilament or 8/0 virgin silk? pak j ophthalmol. 2021, vol. 37 (3): 306-311 308 table 1: percentage distribution of demographic features of trabeculectomy patients. variables group a n = 13 (36.15) group b n = 23 (63.9%) total (%) mean age minimum maximum 52.6 33 70 57.0 45 74 55.5 ± 10.69 sd gender male female laterality right eye left eye duration of glaucoma mean pre op iop type of glaucoma open angle glaucoma angle closure glaucoma bleb morphology thin polycystic diffuse flat avascular tenon cyst comorbidity diabetes mellitus 10 (77%) 3 (23%) 7(54%) 6(46%) 2.3 years 33.46mmhg 12 (92%) 1 (8%) 3 (8.3%) 9 (25%) 0 1 (2.6%) 3 (23%) 11 (48%) 12 (52%) 12 (52%) 11 (48%) 3.4 years 33.5 mmhg 14 (60%) 9 (40%) 3 (8.3%) 15 (41.6%) 5 (13.8%) 0 0 21 (58.3%) 15 (41.7%) 19 (52.8%) 17 (47.2%) 3 years ± 3.6 sd 33.4 ± 10 sd mmhg 26 (72%) 10 (28%) 6 (16.6%) 24 (66.6%) 5 (13.8%) 1 (2.6%) 3 (8.3%) glaucoma, preoperative and postoperative iop. frequencies and percentages were computed for categorical variables like gender, laterality of eye, wound leak, shallow anterior chamber, iritis, hyphema and suture abscess. intra ocular pressure of less than 20 mmhg at 6 month after trabeculectomy without any medication was labeled as successful. trabeculectomy was defined failed, if iop was 20 mmhg or more in spite of maximum medical management. 10,11 pearson chi square was used to compare categorical variables in two suture groups. paired student t test was used to compare pre and postoperative iop in two groups. p value less than 0.05 was considered statistically significant. results total number of patients in this study were 36. mean age of the patients in group a was 52.6 ± 10.12 sd years and 57 ± 10.84 sd years in group b. etiology of glaucoma, morphology of bleb type and details of other demographic features of both groups are given in table 1. table 2 shows the comparison of means of iop preoperatively and post operatively between two groups with help of paired t-test. there was no significant difference in post-operative iop amongst suture 8/0 and 10/0 calculated by pair t test at 3 rd and 6 th month. pearson chi square test showed statistically significant difference in seidel positive test among two groups with p value (p < 0.01). re-suturing was done in 3 patients in group a with statistically significant p value (p < 0.01).there was a significant difference in wound leak and re-suturing among two groups. difference in frequency of ocular massage and pressure patching were statistically insignificant between two groups calculated by pearson chi square test. pearson chi square test was used to compare the rate of complications between two groups including table 2: comparison of means between two groups. variables group a (n = 13) group b (n = 23) p value pre op iop* postoperative 1 week iop* 33.46 13.5 ± 7.4 33.50 12.7 ± 4.0 .992 .678 1 month iop* 16.2 ± 4.2 14.6 ± 4.2 .358 3 month iop* 6 month iop* 16.8 ± 4.5 16.3 ± 4.4 15.0 ± 5.2 15.4 ± 4.1 .239 .224 functional bleb^ 10 (77%) 18 (78%) .926 failed bleb^ seidel +ve^ ocular massage^ pressure patching^ re-suturing in theatre^ 3 (23%) 5 (38%) 1 (7.6%) 3(23%) 5 (38%) 5 (21%) 0 1 (4.3%) 3 (13%) 1 (4.3%) .926 .001 .674 .577 .008 *pair t test ^chi square erum shahid, et al 309 pak j ophthalmol. 2021, vol. 37 (3): 306-311 table 3: comparison of complications between two groups. complications # 8/0 silk 10/0 nylon p value shallow ac high iop low iop hyphema uveitis block pi tenon cyst choroidal detachment cataract wound leak 7 (53%) 1 (7.6%) 7 (53%) 1 (7.6%) 0 0 1 (7.6%) 1 (7.6%) 4 (30%) 5 (38%) 3 (13%) 3 (13%) 1 (4.3%) 2 (9%) 2 (9%) 1 (4.3%) 0 0 2 (9%) 0 .009* .624 .001* .917 .274 .446 .177 .177 .088 .001* #pearson chi square test * statistically significant hyphema, uveitis, block peripheral iridectomy, tenon cyst, cataract and choroidal fold. details of the complications of trabeculectomy among two groups are given in table 3. discussion the main outcome of our study was rate of complications related to different sutures used between two groups. shallow anterior chamber with low intraocular pressure was more frequent in group a 53% (n = 7) where 8/0 silk was used to close the wound as compared to 10/0 nylon 13% (n = 3). a review of trabeculectomies closed with silk 8/0, done by adegbehingbe in nigeria, consisting of 53 patients had reported shallow anterior chamber and hypotony in 5.5% (n = 4) of cases with hyphema being most common 15.3%. 10 they had managed all of their cases conservatively. 10 hyphema was not frequently encountered in our patients, since at the end of surgery anterior chamber was washed and fully packed with air. a study with 10 year review of trabeculectomies on 433 patients had reported shallow anterior chamber in 4.2% (n = 18) of cases followed by uveitis in 2.3% (n = 10) cases. 11 these surgeries were closed with 8/0 silk but included both fornix and limbal based flaps. 11 in group b, with 10/0 nylon closure, shallow anterior chamber was seen in 13% (n = 3), low iop in 4.3% (n = 1), hyphema and uveitis in 9% (n = 2) each. tulay simsek had used 10/0 nylon for conventional trabeculectomy, observed shallow anterior chamber in 34.3% (n = 11), patients with iridocorneal touch in 15.6% (n = 5) patients. 12 anand et al had reported shallow anterior chamber in 22.5% (n = 32), hyphema in 12.7% (n = 18), transient wound leak and choroidal detachment in 2.8% (n = 4), blebitis 0.7% (n = 1) and malignant glaucoma in 1.4% (n = 2) in patients with wound closure with 10/0 nylon. 13 only one of his patients required re-suturing. alwitry et al, had reported 25.8% wound leaks after fornix based trabeculectomy and 2.7% required re-suturing. 14 fortunately we did not encounter blebitis and endophthalmitis within 6 months follow-up time. the difference in frequencies of complication is possibly due to the small sample size that included both angle closure and open angle glaucoma. we had 28% angle closure glaucoma patients as history of angle closure glaucoma predisposes to postoperative flattening of anterior chamber. 15 in group a where 8/0 virgin silk was used seidel test was positive in 38% (n = 5) patients and all of them required re-suturing. in group b, none of the patients had positive seidel test but one patient had to undergo anterior chamber reformation. frequency of ocular massage and pressure patching was not associated with any specific suture type. in an early postoperative period, there was change in the dynamics of aqueous outflow drainage. equilibrium fluctuated between the two extremes resulting in over or under filtration. over-filtering blebs must be managed urgently to avoid complications of ocular hypotony and flat anterior chamber. whereas underfiltering blebs are initially managed conservatively. 16 their further management depends on level of iop, bleb type, anterior chamber depth and time since surgery. 17 cataract was seen in 30% (n = 4) cases in group a with silk 8/0 and 9% (n = 2) in group b with nylon 10/0 within 6 month duration. in a national survey of trabeculectomy in uk cataract was the commonest late complication and was reported in 20% (n = 251) cases but they had large sample size. 18 development of cataract soon after trabeculectomy has been associated with postoperative hypotony and flat or shallow anterior chamber. 19 since the frequency of shallow anterior chamber was predominant in group a, more frequent is the development of cataract in that group. but the development of cataract is not related to the type of sutures as indicated by the p value. intra ocular pressure was a secondary outcome in this study. mean pre-operative iop was 33.4 ± 10 sd mm hg in our study. post-operatively at first week iop was 13.5 ± 7.4 mm hg in group a and 12.7 ± 4.0 mm hg in group b. by 3 rd month iop was 16.8 ± 4.5 mm and 15.0 ± 5.2 mm in group a and b respectively. mean pre op iop by adegbehingbe was 32.5 +/6.2 mmhg. 10 their mean post op iop on 1 st post op day what to choose for trabeculectomy, 10/0 nylon monofilament or 8/0 virgin silk? pak j ophthalmol. 2021, vol. 37 (3): 306-311 310 was 10.6 +/2.3 mmhg and at 3 rd month was 16.8 +/7.2 mmhg. 10 post-operative control of iop is similar to the above study. at sixth month, iop was 16.3 ± 4.4 in group a and 15.4 ± 4.1 in group b. there was statistically no significant difference among the two groups in our study. sutures did not affect post operative iop. diffuse blebs were more common after trabeculectomy with 10/0 nylon 41.6% (n = 15) and 8/0 silk i.e. 25% (n = 9).avascular blebs in 8.3% (n = 3) in both groups. diffuse blebs were seen in 72.7% (n = 40) and cystic in 10.9% (n = 6) in nigerian study. 10 suture materials did not affect the bleb morphology. an ideal bleb should be a low-lying diffuse bleb with reduced vascularity, cystic changes, iop towards low teens, well-formed ac with tight conjunctival closure. 20 trabeculectomy was functional in 77% (n = 10) and 78% (n = 18) in group a and group b respectively. therefore, successful trabeculectomy and an ideal bleb did not depend on the material of suture used in our study. nylon 10/0 suture has an advantage of high elasticity, low antigenicity, negligible tissue inflammation and prolong tensile strength. 21 these factors help to make a water tight closure and avoid early shallow anterior chamber due to leakage. however, they can lead to a number of complications after long periods, like vascularization, astigmatism, loosening, mucous accumulation, suture break down causing giant papillary conjunctivitis, limbitis, conjunctivitis, and suppurative keratitis. 22 silk is associated with greater amount of tissue inflammation but it is easy to handle and tie, well tolerated by patients in terms of comfort. 22 polyglactin 9/0 sutures were used by tyler et al for wound closure after trabeculectomy. he had proposed a needle should be minimally spatulated, micropoint, with diameter of the needle similar to the diameter of suture to minimize leakage through suture track. 23 nylon 10/0 has specific feature of being minimally spatulated micropoint needle as compared to 8/0 silk to reduce postoperative leakage. in the literature, comparisons have been done between limbal based and fornix based trabeculectomies, with or without antimetabolites. 24 not only limbal based, fornix based, thickness, shape and size of scleral flap, suturing technique are important but type of suture material is equally important validated by this study, to maintain wound integrity and making a successful trabeculectomy. limitation of the study is small sample size, being retrospective in nature and single-centered. conclusion shallow anterior chamber, wound leak and low iop with positive seidel test were more common with 8/0 virgin silk as compared to nylon 10/0 monofilament. additional intervention where patients were taken back to operation theatre for re-suturing and reforming anterior chamber was more common where 8/0 virgin silk was used to close the wound as compared to nylon 10/0 monofilament. bleb morphology is not affected by suture material. suture material does not affect final intra ocular pressure and success of trabeculectomy. suture selected for trabeculectomy does play a significant role to maintain wound integrity and final outcome. ethical approval the study was approved by the institutional review board/ ethical review board. (osp-irb/2021/002) conflict of interest authors declared no conflict of interest. refrences 1. radhakrishnan s, quigley ha, jampel hd, friedman ds, ahmad si, congdon ng, et al. outcomes of surgical bleb revision for complications of trabeculectomy. ophthalmology, 2009; 116 (9): 17131718. 2. lichter pr, musch dc, gillespie bw, guire ke, janz nk, wren pa, et al. cigts study group. interim clinical outcomes in the collaborative initial glaucoma treatment study comparing initial treatment randomized to medications or surgery. ophthalmology, 2001; 108 (11): 1943-1953. 3. tse km, lee hp, shabana n, loon sc, watson pg, thean sy. do shapes and dimensions of scleral flap and sclerostomy influence aqueous outflow in trabeculectomy? a finite element simulation approach. british journal of ophthalmology, 2012; 96 (3): 432437. 4. matlach j, hoffmann n, freiberg fj, grehn f, klink t. comparative study of trabeculectomy using single sutures versus releasable sutures. clin ophthalmol. (auckland, nz). 2012; 6: 1019. 5. lu lj, hall l, liu j. improving glaucoma surgical outcomes with adjunct tools. j curr glauc prac. 2018; 12 (1): 19. erum shahid, et al 311 pak j ophthalmol. 2021, vol. 37 (3): 306-311 6. cohen js. releasable scleral flap suture. ophthalmol clin north am. 1988; 1: 187-197. 7. melamed s, ashkenazi i, glovinsky j, blumenthal m. tight scleral flap trabeculectomy with postoperative laser suture lysis. am j ophthalmol. 1990; 109: 303309. 8. watson pg, jakeman c, ozturk m, barnett mf, barnett f, khaw kt. the complications of trabeculectomy (a 20-year follow-up). eye, 1990; 4 (3): 425. 9. fourman s. management of cornea-lens touch after filtering surgery for glaucoma. ophthalmology, 1990; 97 (4): 424-428. 10. adegbehingbe bo, majemgbasan t. a review of trabeculectomies at a nigerian teaching hospital. ghana med j. 2007; 41 (4). 11. agbeja-baiyeroju am, omoruyi m, owoaje et. effectiveness of trabeculectomy on glaucoma patients in ibadan. afr j med med sci. 2001; 30: 39-42. 12. simsek t, citirik m, batman a, mutevelli s, zilelioglu o. efficacy and complications of releasable suture trabeculectomy and standard trabeculectomy. inter ophthalmol. 2005; 26 (1-2): 9-14. 13. anand n, mielke c, dawda vk. trabeculectomy outcomes in advanced glaucoma in nigeria. eye. 2001; 15 (3): 274. 14. alwitry a, rotchford a, patel v, abedin a, moodie j, king aj. early bleb leak after trabeculectomy and prognosis for bleb failure. eye, 2009; 23 (4): 858-863. 15. austin mw, wishart pk. reformation of the anterior chamber following trabeculectomy. ophthalmic surg. 1993; 24: 461–466. 16. dorcs bj, sultan m, tajammul a. trabeculectomy: a comparison between pressure patching and bleb repair in management of early onset leaking bleb. professional med j. 2006; 13: 676-679. 17. shetty rk, wartluft l, moster mr. slit-lamp needle revision of failed filtering blebs using high-dose mitomycin c. j glaucoma, 2005; 14 (1): 52-56. 18. edmunds b, thompson jr, salmon jf, wormald rp. the national survey of trabeculectomy. ii. variations in operative technique and outcome. eye, 2001; 15: 441–448. 19. vuori ml, viitanen t. “scleral tunnel incision” ‐ trabeculectomy with one releasable suture. acta ophthalmologica scandinavica. 2001; 79 (3): 301-304. 20. sawchyn ak, slabaugh ma. innovations and adaptations in trabeculectomy. curr opin ophthalmol. 2016; 27 (2): 158-163. 21. hutz w, ullerich k. microsurgical suture material in ophthalmic microsurgery; instrumentation, microscopes and technique. basel: karger. 1987: 136-141. 22. acheson jf, lyons cj. ocular morbidity due to monofilament nylon corneal sutures. eye, 1991; 5 (1): 106. 23. smith jh, macsai ms. needles, sutures, and instruments. in ophthalmic microsurgical suturing techniques. springer, berlin, heidelberg. 2007: pp 920. 24. kirk tq, condon gp. modified wise closure of the conjunctival fornix-based trabeculectomy flap. j cataract refract surg. 2014; 40 (3): 349-3s53. authors’ designation and contribution erum shahid; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analyses, manuscript preparation, manuscript review. uzma fasih; associate professor: concepts, design, data acquisition, manuscript review. arshad shaikh; professor: concepts, design, manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (2): 192-197 192 original article comparison of intravitreal bevacizumab versus intravitreal ranibizumab in treatment naive macular edema patients (real world evidence in pakistan) hajra arshad malik 1 , rayyan sabih 2 , hina khan 3 , aamir asrar 4 , muhammad asif 5 1-4 department of ophthalmology, amanat eye hospital, rawalpindi 5 departemnt of public health, government college university, faisalabad abstract purpose: to compare the short-term efficacy and safety of intraocular ranibizumab and bevacizumab in patients with treatment naïve macular edema. study design: quasi experimental study. place and duration of study: amanat eye hospital, from august 2018 to november 2019. methods: patients with macular edema confirmed with optical coherence tomography (oct) or leakage on fluorescein angiography were included. patients with nve, pdr without macular edema and patients who switched to alternative anti-vegf compounds prior to the completion of three consecutive monthly injections of their respective anti-vegf or switched to other treatment options were excluded from the study. a thorough clinical examination was conducted including best corrected visual acuity (bcva, intraocular pressure (iop), anterior and posterior segment examination and oct macula. the patients were then allocated to one of the two study arms (either bevacizumab or ranibizumab) based on the doctor’s input and patient affordability. all patients underwent three consecutive injections of the selected molecule at one month intervals. bcva, crt and macular volume were then recorded 04 weeks after the third injection. results: a statistically significant mean vision gain was observed from baseline in both groups (p < 0.05). however, the change in bcva was not significantly different between intravitreal bevacizumab group and intravitreal ranibizumab group (p > 0.05). similarly, although there was improvement in crt and macular volume in both groups but there was no statistically significant difference between the two. conclusions: treatment with intravitreal bevacizumab and ranibizumab injections cause statistically similar anatomical and functional results in cases of treatment naïve macular edema. key words: bevacizumab, ranibizumab, macular edema, diabetic retinopathy, macular degeneration, retinal vein occlusion. how to cite this article: malik ha, sabih r, khan h, asrar a, asif m. comparison of intravitreal bevacizumab versus intravitreal ranibizumab in treatment naïve macular edema patients (real world evidence in pakistan). pak j ophthalmol. 2021, 37 (1): 192-197. doi: http://doi.org/10.36351/pjo.v37i2.1194 correspondence: hajra arshad malik department of ophthalmology, amanat eye hospital, rawalpindi email: hajra.arshad93@gmail.com received: january 5, 2021 accepted: march 5, 2021 introduction macular edema can be a potential outcome of a wide array of pathological conditions and represents the final common pathway of a multitude of both intraocular and systemic insults. 1,2 common diseases associated with macular edema include diabetic retinopathy (dr), retinal vein occlusion (rvo), http://doi.org/10.3352/jeehp.2013.10.3 hajra arshad malik, et al 193 pak j ophthalmol. 2021, vol. 37 (2): 192-197 choroidal neovascularization (cnv), and uveitis. 3 vascular endothelial growth factor (vegf) production is induced by hypoxia and it is a potent endothelial cell angiogenic factor that promotes the growth of new blood vessels and mediates vascular permeability, ultimately contributing to macular edema. 4,5 in view of this, the introduction of anti-vascular endothelial growth factor (anti-vegf) injections such as bevacizumab, ranibizumab and aflibercept has revolutionized the treatment of macular edema and is one of the most promising approaches to the management of macular edema and prevention of its possible detrimental effects. 6.7 while anti-vegf agents such as ranibizumab and aflibercept are fda (food and drug administration) approved drugs for retinal pathologies including neovascular age-related macular degeneration (namd), dr and rvo, 8,9 bevacizumab was approved by fda for the treatment of metastatic colorectal carcinomas, renal carcinomas and glioblastoma multiforme of the brain in 2004. 10 however, owing to its vegf inhibiting properties, easy availability and substantially lower cost as opposed to other antivegf agents, it is being used off-label for the treatment of namd, dr, rvo and iris neovascularization. in fact, the use of bevacizumab in eye care surpasses that of licensed anti-vegf drugs especially in the developing countries. 11 several trials have been conducted previously to compare the efficacy of ranibizumab to bevacizumab. in our study, we prospectively evaluated and compared the efficacy of ranibizumab and bevacizumab in patients with various retinal pathologies that warranted anti-vegf therapy as part of the treatment regimen in a real-world setting in pakistan. methods the study was conducted at amanat eye hospital in rawalpindi and islamabad between 1 st august 2018 and 1 st november 2019.all the cases in this study were between the ages of 33 to 79 years. we recruited 79 eyes of 63 patients with macular edema caused by dr, rvo and cnv, in which treatment with anti-vascular endothelial growth factor (anti-vegf) injections was indicated. macular edema was confirmed with optical coherence tomography (oct) or leakage on fluorescein angiography. exclusion criteria was; patients with nve (neovascularization elsewhere) and pdr (proliferative diabetic retinopathy) with no macular edema, patients who had switched to alternative anti-vegf compounds prior to the completion of three consecutive monthly injections of their respective anti-vegf molecules or switched to treatment options other than vegf inhibitors such as ozurdex ® (dexamethasone intravitreal implant, allergan, inc., irvine, ca) and patients who received any other treatment, including thermal laser photocoagulation, submacular surgery, any other antivegf and photodynamic therapy prior to receiving treatment with their respective anti-vegf. ethical approval was obtained from irb of amanat eye hospital. this study adhered to the tenets of the declaration of helsinki and informed written consent was obtained before the investigation began. clinical record was maintained and it included duration of diabetes, severity, underlying nephropathy and cardiac disease, hyperlipidemias and history of stroke. a thorough clinical examination was conducted including best corrected visual acuity (bcva). measurements were converted to logarithm of the minimum angle of resolution [log mar]). intraocular pressure, anterior and posterior segment examination and baseline optical coherence tomography (oct) parameters were recorded, namely central retinal thickness (crt) and macular volume. the patients were then allocated to one of the two study arms (either bevacizumab or ranibizumab) based on the doctor’s input and patient affordability. all patients underwent three consecutive injections of the selected anti-vegf at one month intervals. bcva, crt and macular volume were then recorded 04 weeks after the third injection. if further injections were required on the post operative visit, the patients were counseled and managed accordingly. the data was analyzed by using spss version 23. the descriptive variables were presented as frequencies, percentages, mean and standard deviation. the continuous data was checked for normality by using kolmogorov-smirnov test. as the data was not normally distributed, the non-parametric tests were applied for analysis. the change in bcva, crt and macular volume were compared between intravitreal bevacizumab group and intravitreal ranibizumab group by using mann-whitney u test. at 95% confidence interval, the p value < 0.05 was considered as showing statistically significant results. comparison of intravitreal bevacizumab versus intravitreal ranibizumab in treatment naive macular edema patients (real world evidence pak j ophthalmol. 2021, vol. 37 (2): 192-197 194 results in total, 35 eyes of 29 patients were analyzed who received intravitreal bevacizumab. the mean age was 59.7 ± 8.9 years in this group and were predominantly 14 (40%) males and 21 (60%) females. twenty six (74.2%) patients had concomitant co-morbidities, including 20 (57.1%) patients with hypertension, 3 (8.6%) with hypercholesterolemia, 4 (11.4%) suffering from nephropathy and 5 (14.3%) from ischemic heart disease. seven (20%) patients had glaucoma along with retinal pathology. mean bcva (log mar) at baseline was 1.00. in addition, the mean crt at baseline was 492.77 and the mean macular volume at baseline was 11.61. in total, 44 eyes of 34 patients received intravitreal ranibizumab. the patients had a mean age of 58.8 ± 9.4 years. there were 34 (77.3%) males and 10 (22.7%) females. thirty two (72.7%) patients had concomitant co-morbidities, including 28 (63.6%) patients with hypertension, 14 (31.8%) with hypercholesterolemia, 6 (13.6%) suffering from nephropathy and 16 (36.4%) from ischemic heart disease. 16 (36.4%) patients also had glaucoma accompanying their retinal pathology. of the 44 treated eyes, 36 (81.8%) exhibited dr with dme, 4(9.1%) had rvo, and 4 (9.1%) showed evidence of cnv. mean bcva (log mar) at baseline was 0.6. in addition, the mean crt at baseline was 428.5 and the mean macular volume at baseline was 9.9. a mann-whitney u test was conducted to compare the change in bcva between intravitreal bevacizumab group and intravitreal ranibizumab group. with the intravitreal bevacizumab injection, a statistically significant mean vision gain was observed from baseline as 0.18 (p < 0.05). the bcva improved in 17 (48.5%) patients, stabilized in 10 (28.6%) and deteriorated in 8 (22.9%) patients. with intravitreal ranibizumab, a statistically significant mean vision gain was observed from baseline as 0.34 (p < 0.05). the bcva improved in 30 (68.2%) patients, stabilized in 6 (13.6%) and deteriorated in 8 (18.2%) patients. the bcva significantly improved in either group. however, the change in bcva was not significantly different between the two groups (p > 0.05). it proved that both injections were equally effective in improving visual acuity in cases of macular edema. with the intravitreal bevacizumab injection, a statistically significant decrease in crt was observed table 1: mann-whitney u test to compare the change in bcva between intravitreal avastin® injection and intravitreal patizra® injection. change in bcva median (iqr) z p-value with third intravitreal avastin® injection 0.00 ± 0.48 -1.49 0.13 with third intravitreal patizra® injection 0.30 ± 0.68 from 492.77 ± 192.31 at baseline to 362.91 ± 126.11 after the third injection (p < 0.05). with the intravitreal ranibizumab, a statistically significant decrease in crt was observed from 428.54 ± 187.06 at baseline to 364.50 ± 170.49 after the third injection (p < 0.05). the reduction in crt between the two injections was not significantly different as p > 0.05 (table 2). table 2: mann-whitney u test to compare the reduction in crt between intravitreal avastin® injection and intravitreal patizra® injection. central retinal thickness reduction median (iqr) z p-value with third intravitreal avastin® injection 68.00 ± 178 -0.27 0.79 with third intravitreal patizra ® injection 66.0 ± 83.0 similar results were seen with macular volume in both groups (table 3). table 3: mann-whitney u test to compare the reduction in macular volume between intravitreal avastin® injection and intravitreal patizra ® injection. macular volume reduction median (iqr) z p-value with third intravitreal avastin® injection 0.76 ± 2.08 -0.51 0.61 with third intravitreal patizra ® injection 0.75 ± 1.29 in the patizra ® group, 168 injections were administered to the patients in total. 30 eyes (68.2%) did not require additional injections, because no recurrence of exudation was observed after three consecutive monthly injections of patizra ® . 14 eyes (31.8%) required additional injections. among them, 2 eyes required five extra injections, 6 eyes needed 3 more injections, 2 eyes required an hajra arshad malik, et al 195 pak j ophthalmol. 2021, vol. 37 (2): 192-197 additional 2 injections, and the remaining 4 eyes needed one extra injection of patizra ® . in the avastin ® group, 131 injections were administered to the patients in total. 27 patients (77.1%) did not require additional injections, because no recurrence of exudation was observed after three consecutive monthly injections of avastin ® . 8 patients (22.9%) required additional injections. among them, 1 eye required 6 more injections, 1 required an additional 5 injections, 3 eyes required 3 extra injections, and the remaining 3 eyes needed 2 extra injections of avastin ® . no patient was observed to develop ocular complications, including endophthalmitis, rhegmatogenous retinal detachment, intraocular pressure elevation, cataracts, rpe tears or ocular hemorrhage. in addition, no incidences of systemic side effects including cerebrovascular accident (cva), myocardial infarction or allergic reactions were noted. discussion the results of this prospective study establishes that treatment with intravitreal ranibizumab and bevacizumab provided clinically and statistically significant improvement in sd-oct parameters and visual acuity in patients with macular edema secondary to various retinal pathologies in a ‘realworld’ clinical setting in pakistan. ranibizumab and bevacizumab are both humanized recombinant monoclonal antivegf antibodies, though they differ in terms of structure and molecular weight. bevacizumab is a 149 kd full-length antibody, whereas ranibizumab is a 49 kd fab fragment 12,13 consequently, they differ substantially in pharmacokinetics such as half-life and retinal penetration. owing to its smaller molecular size, ranibizumab enjoys better retinal penetration as opposed to bevacizumab and is additionally a more potent neutralizer of vegf. 14,15 on the other hand, owing to its larger molecular size, bevacizumab may have a longer half-life and duration of action as opposed to ranibizumab. a single vial of bevacizumab can be used to produce multiple doses for intravitreal administration. 16 the indications as well as the interval between the injections are recommended to be the same for both molecules. several studies have been conducted worldwide to establish the efficacy of the intravitreal anti-vegf agents in various retinal pathologies and to compare their functional and anatomical outcomes. the diabetic retinopathy clinical research network (drcr.net) conducted a multi-center randomized controlled trial to assess the efficacy of anti-vegf compounds in patients with center involving diabetic macular edema. the drcr.net protocol t results showed a significant improvement in visual acuity from baseline with both bevacizumab and ranibizumab and decrease in the central subfield thickness of 101 ± 121 μm and 147 ± 134 μm with bevacizumab and ranibizumab respectively at the 1year visit. 17 our results are also consistent with the findings of a study conducted on korean patients with branch retinal vein occlusion (brvo), which established that both compounds share a similar effectiveness in terms of visual and anatomical outcome as well as retreatment rate. 18 the mean increase in bcva was 0.30 log mar and 0.28 log mar, and the mean reduction in crt was 236.7 µm and 219.0 µm in the ranibizumab group and the bevacizumab group respectively. 18 similarly, solomon et al. conducted a systematic review of randomized controlled trials comparing the effectiveness of the two molecules in patients with neovascular age-related macular degeneration and identified no significant difference in the efficacy or safety of the two drugs but a large difference in cost. 19 another study by cai et al. established no apparent differences between the two molecules when treating diabetic macular edema. 20 a major strength of our study was its prospective study design and the fact that it encompassed most of the common retinal pathologies that lead to macular edema. the analysis was limited, however, by the short follow-up time, relatively small sample size and the fact that it was single-centered. despite these limitations, our study supports the current data available regarding the comparable short-term effectiveness of intravitreal ranibizumab and bevacizumab and proved that they are both equally effective in managing macular edema. further avenues of research in this direction will include the possibility of a multicenter trial, more extended follow-up and comparison with other anti-vegf molecules. comparison of intravitreal bevacizumab versus intravitreal ranibizumab in treatment naive macular edema patients (real world evidence pak j ophthalmol. 2021, vol. 37 (2): 192-197 196 conclusion both ranibizumab and bevacizumab are effective for the management of macular edema associated with various retinal pathologies. ethical approval the study was approved by the institutional review board/ ethical review board. (irb no. 1910h). conflict of interest authors declared no conflict of interest. acknowledgements the authors are thankful to mr. rizwan waris, the it manager and ophthalmic photographer at amanat eye hospital, for his assistance in conducting oct scans and in data collection. references 1. johnson mw. etiology and treatment of macular edema. am j ophthalmol. 2009; 147 (1): 11-21. 2. tranos pg, wickremasinghe ss, stangos nt, topouzis f, tsinopoulos i, pavesio ce. macular edema. surv ophthalmol. 2004; 49 (5): 470–490. 3. rotsos tg, moschos mm. cystoid macular edema. clin ophthalmol. 2008; 2 (4): 919–930. 4. yorston d. anti-vegf drugs in the prevention of blindness. comm eye health, 2014; 27 (87): 44–46. 5. kaya m, karahan e, ozturk t, kocak n, kaynak s. effectiveness of intravitreal ranibizumab for diabetic macular edema with serous retinal detachment. korean j ophthalmol. 2018; 32 (4): 296–302. 6. sacconi r, giuffrè c, corbelli e, borrelli e, querques g, bandello f. emerging therapies in the management of macular edema: a review. f1000 res. 2019 aug 12; 8: f1000 faculty rev-1413. doi: 10.12688/f1000research.19198. 7. wykoff cc, clark wl, nielsen js, brill jv, greene ls, heggen cl. optimizing anti-vegf treatment outcomes for patients with neovascular age-related macular degeneration. j manag care spec pharm. 2018; 24 (2-a suppl): s3-s15. 8. mansour am, al-ghadban si, yunis mh, elsabban me. ziv-aflibercept in macular disease. br j ophthalmol. 2015; 99 (8): 1055–1059. 9. malik d, tarek m, caceres del carpio j, ramirez c, boyer d, kenney mc, et al. safety profiles of antivegf drugs: bevacizumab, ranibizumab, aflibercept and ziv-aflibercept on human retinal pigment epithelium cells in culture. br j ophthalmol. 2014; 98 (suppl 1): i11-i16. 10. akiyode o, dunkelly-allen n. ranibizumab: a review of its use in the treatment of diabetic retinopathy in patients with diabetic macular edema. j pharm technol. 2016; 32 (1): 22–28. 11. jan s, nazim m, karim s, hussain z. intravitreal bevacizumab: indications and complications. j ayub med coll abbottabad. 2016; 28 (2): 364-368. 12. bakri sj, snyder mr, reid jm, pulido js, singh rj. pharmacokinetics of intravitreal bevacizumab (avastin). ophthalmology, 2007; 114 (5): 855–859. 13. bakri sj, snyder mr, reid jm, pulido js, ezzat mk, singh rj. pharmacokinetics of intravitreal ranibizumab (lucentis). ophthalmology, 2007; 114 (12): 2179-2182. 14. terasaki h, sakamoto t, shirasawa m, yoshihara n, otsuka h, sonoda s, et al. penetration of bevacizumab and ranibizumab through retinal pigment epithelial layer in vitro. retina. 2015; 35 (5): 1007– 1015. 15. yu l, liang xh, ferrara n. comparing protein vegf inhibitors: in vitro biological studies. biochem biophys res commun. 2011; 408 (2): 276-281. 16. poku e, rathbone j, wong r, everson-hock e, essat m, pandor a, et al. the safety of intravitreal bevacizumab monotherapy in adult ophthalmic conditions: systematic review. bmj open, 2014; 4: e005244. 17. wells ja, glassman ar, ayala ar, jampol lm, aiello lp, antoszyk an, et al. aflibercept, bevacizumab, or ranibizumab for diabetic macular edema. n engl j med. 2015; 372 (13): 1193–1203. 18. son bk, kwak hw, kim es, yu sy. comparison of ranibizumab and bevacizumab for macular edema associated with branch retinal vein occlusion. korean j ophthalmol. 2017; 31 (3): 209–216. 19. solomon sd, lindsley kb, krzystolik mg, vedula ss, hawkins bs. intravitreal bevacizumab versus ranibizumab for treatment of neovascular agerelated macular degeneration: findings from a cochrane systematic review. ophthalmology, 2016; 123 (1): 70-77. 20. cai s, bressler nm. aflibercept, bevacizumab or ranibizumab for diabetic macular oedema: recent clinically relevant findings from drcr.net protocol t. curr opin ophthalmol. 2017; 28 (6): 636-643. authors’ designation and contribution hajra arshad malik; research assistant: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing. rayyan sabih; research assistant: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing. hajra arshad malik, et al 197 pak j ophthalmol. 2021, vol. 37 (2): 192-197 hina khan; research assistant: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. aamir asrar; consultant ophthalmologist: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. muhammad asif; lecturer: concepts, design, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. .…  …. microsoft word 14. fariha sher wali pak j ophthalmol. 2022, vol. 38 (4): 289-291 289 case report a rare case of pachydermoperisotosis (pdp) and its ocular manifestations fariha sher wali1, adnan abdul majeed2, sajjad ali suriho3 1-3sindh institute of ophthalmology & visual sciences (siovs) abstract a case of 56 years old pakistani male visited opd with complaint of thickening of both eyelids, ptosis and left lower lid ectropion caused by rare condition named pachydermoperiostosis (pdp). pdp is a rare autosomal dominant condition but autosomal recessive families probably can also occur. it is manifested by clubbing of digits, hyperhidrosis of palm and feet, peri-ostosis, acro-osteolysis and pachydermia. ocular features include blepharoptosis, floppy eyelids, eyelid and palpebral conjunctival hypertrophy, mechanical ectropion, meibomian gland dysfunction, tear film abnormalities, punctate epithelial erosions and ocular surface disease. surgical management was given by full-thickness wedge resection leading to horizontal tightening and this was done along with shortening of levator and its advancement. histopathology demonstrated chronic non-specific inflammation and foreign body giant cell reaction. key words: eyelids, blepharoptosis, pachydermoperiostosis, clubbing. how to cite this article: wali fs, majeed aa, suriho sa. a rare case of pachydermoperisotosis (pdp) and its ocular manifestations. pak j ophthalmol. 2022, 38 (4): 289-291. doi: 10.36351/pjo.v38i4.1399 correspondence: adnan abdul majeed sindh institute of ophthalmology & visual sciences (siovs) email: adnanbinabdulmajeedsanghar@gmail.com received: april 10, 2022 accepted: july, 26, 2022 introduction pachydermoperiostosis (pdp) is another name of primary hypertrophic osteoarthropathy. in 1868, friedreisch reported the first case of pdp.1 precise prevalence and incidence of the disease are still unknown. in males, this disease is 9 times more common and more severe than females.1 pdp is a very rare hereditary disorder. it is autosomal dominant condition but autosomal recessive inheritance is also reported.2 there are two subtypes; primary and secondary. primary cases are rare inherited disorder and present soon after puberty.it is manifested by clubbing of digits, hyperhidrosis of palm and feet, peri-ostosis, acro-osteolysis and pachydermia.3 most prominent feature of pdp is facial involvement which includes thickening and furrowing of the face and scalp skin (resembling cutis verticisgyrate) and sebaceous glands over activity. ocular features include lengthening and thickening of the eyelids and chronic inflammation of tarsus secondary to palpebral tissues hypertrophy, which may results in mechanical ectropion. we report a case of pachydermoperiostosis associated with both eyes, blepharoptosis and left lower lid ectropion. case report we report this case considering the declaration of helsinki. a 56-year old male presented with complaint of heaviness in eyelids and problem in keeping both eyes open. he was offspring of consanguineous parents. in his family, his nephew had similar complaint of drooping of eyelids. on presentation, he had coarse facial features, oily facial skin and skin of scalp and forehead were wrinkled and thickened. patient’s both eyelids were massively thickened. he had bilateral blepharoptosis with marginalreflex distance (mrd) of 2mm and poor (0 mm) levator function. patient was usingpredominantly the frontalis muscles to open his eyes. his left lower lid had mechanical ectropion (figure: 1). patient’s hands and feet were larger than the normal and he had digital adnan abdul majeed, et al 290 pak j ophthalmol. 2022, vol. 38 (4): 289-291 clubbing (figure: 2). he also had excessive sweating of the palms and soles. his vision was 20/120 in both figure 1: showing thickened and wrinkled forehead and scalp skin, thickened eyelids with bilateral blepharo-ptosis, left lower lid was having mechanical ectropion. figure 2: showing enlarged hands with distal clubbing. eyes due to nuclear cataract. extra-ocular movements and rest of the intraocular examination were normal. patient’s x-rays showed peri-osteosis, acro-osteolysis and soft tissue swelling of limbs joint (figure: 3). diagnosis of pachydermoperiostosis associated with bilateral ptosis and left eye ectropion was made. in the surgical management of left eye, excision of excess skin was done after an incision at upper lid crease. the full-thickness wedge resection was done along with levator aponeurosis shortening (15 mm) and advancement (2 mm) and then lateral tarsal strip was performed. tissue from left upper and lower eyelid was submitted for histopathology evaluation. the result demonstrated chronic non-specific inflammation and foreign body giant cell reaction. after 6 months his both eyes were operated for cataract with gap of 1 month. patient was referred to endocrinologist and dermatologist for further management. figure 3: showing x-rays feet indicating peri-osteosis, acroosteolysis and soft tissue swelling. discussion hypertrophic osteoarthropathy is of two types. primary hypertrophic osteoarthropathy, which is another name of pachydermoperiostosis (pdp), accounting for 5% of all hypertrophic osteoarthropathy cases. secondary hypertrophic osteoarthropathy is related to underlying cardiopulmonary disorders and malignancies and occurs predominantly in men of 3070 years of age.4,5 clinically pachydermoperiostosis are of three types: the complete includes peri-ostosis and pachyderma, incomplete includes only periostosis but no pachydermia and for me fruste has pachyderma a rare case of pachydermoperisotosis (pdp) and its ocular manifestations pak j ophthalmol. 2022, vol. 38 (4): 289-291 291 but with mild or no periosteal involvement.6 our case belongs to complete type of pdp. the exact cause of pdp is yet not known.7 in familial pdp cases, homozygous and compound heterozygous germ line mutations in the hpgd gene is detected, which encodes 15-hydroxyprostaglandin dehydrogenase (15pgdh). prostaglandin degradation mainly depend upon 15-pgdh and when it gets defective or absent, it results in excessive levels of prostaglandins, particularly pge2 which contribute to the pathogenesis of pdp.4 the prostaglandin transporter gene (slco2a1) mutations have been documented with pachydermoperiostosis. mutations in slco2a1 deactivate pge2 transport and leads to deregulation of pge2. ocular manifestation of this disease is of particular importance which includes blephero-ptosis, floppy eyelid syndrome, eyelid and palpebral conjunctiva hypertrophy, mechanical ectropion, meibomian gland dysfunction, tear film abnormalities, punctate epithelial erosions, and ocular surface disease.8 in its surgical management,(as we did in our case), excision of the upper eyelid skin is done to correct both the vertical and horizontal dimensions of the eyelids.9 three step method of eyelid shortening, tarsectomy, and blepharoplasty was described in cases of delayed healing. however, upper and lower eyelid blepharoplasties and full-thickness wedge resections can be performed on both sides simultaneously.10 we combined shortening and thinning of eyelid with shortening and advancement of levator muscle which effectively corrected ptosis, lid laxity and ectropion. histopathology confirmed the diagnosis of pachydermoperiostosis. conclusion pachydermoperiostosis is a rare disease. it can present with ocular manifestations along with other systemic features. as in this case, patient presented with ptosis and mechanical ectropion but on further systemic evaluation, it was found that he had clubbing, periosteosis and pachyderma. although rare, but such cases should be kept in mind while evaluating and managing the patients with ptosis, ectropion and eyelid thickening. conflict of interest: authors declared no conflict of interest. references 1. honório mlp, bezerra gh, costa vldc. complete form of pachydermoperiostosis. an bras dermatol. 2020; 95 (1): 98-101. doi: 10.1016/j.abd.2019.04.009. 2. joshi a, nepal g, shing yk, panthi hp, baral s. pachydermoperiostosis (touraine-solente-gole syndrome): a case report. j med case rep. 2019; 13 (1): 39. doi: 10.1186/s13256-018-1961-z. 3. salah bi, husari ki, hassouneh a, al-ali z, rawashdeh b. complete primary pachydermoperiostosis: a case report from jordan and review of literature. clin case rep. 2019; 7 (2): 346352. doi: 10.1002/ccr3.1971. 4. mukherjee b, alam ms. a rare case of pachydermoperiostosis associated with blepharoptosis and floppy eyelids. indian j ophthalmol. 2016; 64 (12): 938-940. doi: 10.4103/0301-4738.198865. 5. tanese k, niizeki h, seki a, otsuka a, kabashima k, kosaki k, et al. a pathological characterization of pachydermia in pachydermoperiostosis. j dermatol. 2015; 42 (7): 710-714. doi: 10.1111/1346-8138.12869. 6. supradeeptha c, shandilya sm, vikram reddy k, satyaprasad j. pachydermoperiostosis a case report of complete form and literature review. j clin orthop trauma. 2014; 5 (1): 27-32. doi: 10.1016/j.jcot.2014.02.003. 7. akaranuchat n, limsuvan p. touraine-solente-gole syndrome: clinical manifestation with bilateral true eyelid ptosis. jpras open, 2019; 21: 6-13. doi: 10.1016/j.jpra.2019.04.004. erratum in: jpras open. 2021 24; 30: 176-177. 8. arinci a, tümerdem b, karan ma, erten n, büyükbabani n. ptosis caused by pachydermoperiostosis. ann plast surg. 2002; 49 (3): 322-325. doi: 10.1097/00000637-200209000-00015. 9. taichao d, fuling l, hengguang z. comprehensive surgical strategies for the management of pachydermoperiostosis. facial plastic surgery, 2018; 34: 330-334.doi:10.1055/s-0038-1653992. 10. ohtsuka m, takayanagi s. eyelid reconstruction in pachydermoperiostosis. plast reconstr surg. 1988; 81 (1): 88-90. doi: 10.1097/00006534-198801000-00016. authors’ designation and contribution fariha sher wali; assistant professor: concepts, design, literature search, data acquisition, statistical analysis, manuscript preparation, manuscript review. adnan abdul majeed; postgraduate resident: design, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing. sajjad ali suriho; professor: concepts, manuscript review. 70 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology original article community perception and service utilization of diabetic retinopathy management project in gaddap town muhammad saleh memon, seema n. mumtaz, sikandar ali sheikh, muhammad faisal fahim pak j ophthalmol 2016, vol. 32, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. muhammad saleh memon director projects isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, gaddap town, malir, karachi – 75040 email: salehmemon@yahoo.com received: february 04, 2016 accepted: june 29, 2016 …..……………………….. purpose: to find the changes in the community perception and service utilization of diabetic retinopathy management project in gaddap town. study design: cross sectional study. place and duration of study: the first phase of the project covered jannuary 2006 to december 2008, second from jannuary 2009 to dec. 2011 and final from jan 2012 to march 2015 in gaddap town. material and methods: a community based project was initiated by al-ibrahim eye hospital karachi to devlop a replicable model for prevention and control of diabetic retinopathy in gaddap town. all individuals in the age group 30 years were included except those with history of any addiction or any chronic disease. post prandil (2.5 hours after breakfast) blood sugar levels was checked with glucometer. blood glucose level of 140 mg/dl was considered non diabetic, 199 mg/dl was considered latent diabetes and 200 mg/dl was considered as diabetes. diabetics were screened for retinopathy. diabetics with retinopathy were referred to tertiary center for management. results: blood screening was availed by 42,998 persons with combined mean age of 36.26 ± 9.8. during three phases response to blood screening was 23%, 14.1%, 13.8% and to retinal screening was 26.57%, 55.6%, 81.1%. turn out at tertiary center was 18.1%, 24%, 42.2%. acceptance of laser therapy was 17.3%, 83.3%, 68.4%. conclusion: service utilization is a challenge; but it can be improved with persistant awareness, councilling, quality and patient friendly service. key words: service acceptance, diabetic retinopathy; diabetic screening. iabetic retinopathy (dr) is the fifth-leading cause of global blindness affecting 1.8 billion people worldwide and is the cause of 4.8% of the world blindness. it is the most common cause of blindness among people of working age in the developed world1-3. prevalence of diabetes in member states of the who eastern mediterranean region ranges from 3.5% to 30%.16 national studies have shown that 10% of the people in age group of ≥ 30 years4,5 have diabetes type 2 in pakistan. prevalence of dr in pakistan as reported in gaddap study was 27.43%6 and according to dap study was 24.7%7. an important aspect of diabetes and its complication is its silent nature. at least 25% diabetic remain unknown8 and dr remains asymptomatic until it causes damage and can lead to blindness without giving any warning symptom. there exists enough evidence that if diabetes is detected early and controlled properly risk of dr is greatly reduced. not only that; but optimum control of blood glucose, blood pressure, and possibly blood lipids remains the foundation for reduction of risk of retinopathy development and progression9. if dr is detected early, its progress can be checked or even regressed. if dr progresses to sight threatening d community perception and service utilization of diabetic retinopathy management project in gaddap town pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 71 diabetic retinopathy (stdr) and is detected early, timely laser therapy with or without anti vegf is effective for preservation of sight in proliferative retinopathy and macular edema9,10. once dr reaches advanced stages surgery is indicated which is very costly due to scarcity of trained human resources and advanced equipment. in low-income countries like ours, local health-care systems do not have the personnel and financial capacity to cope. that is why emphasis is put on primary prevention by detecting diabetes, dr and stdr as early as possible to ensure early intervention11. another important constrains in developing countries is poor “utilization” of the available services. according to who globally only a quarter of people in need currently use eye services12. a method is to be evolved which can respond to this challenge and provide an accessible method of management of diabetes retinopathy. with this intention in mind a community based project was initiated in gaddap town with the support of sightsavers to find out a replicable model for the prevention and management of diabetes related blindness (drb) with special attention to dr. project continued for ten years (january 2006 to march 2015). this study reports challenges and changes in behavior of the community during project. material and methods this was an observational, cross sectional study with non-probability convenient sampling at gaddap town as service project from january 2006 to march 2015. an approval from “research ethical committee” (rec) of the isra post graduate institute of ophthalmology was taken to report the project outcomes. community based project “prevention and management of diabetic retinopathy” was initiated in january 15, 2006. every three years the performance was reviewed and some changes in the strategies were made. the first phase of the project covered jannuary 2006 to december 2008, second from jannuary 2009 to dec 2011 and final from jan 2012 to march 2015. awareness and education material regarding diabetes and diabetic related blindness was prepared after consultation. community was sensitized through lhws, family physicians, religious leaders, community based organizations using electronic as well as print media. while most of the respondents were referred by lhws, medical and paramedical staff, few patients attended on their own. all individual ≥ 30 years age group irrespective of gender were included. drug addicts and those with chronic diseases were excluded from this project. blood screening for diabetes was done in primary eye care (pec), centers established in rural health centers (rhc) of gaddap town. in the first phase, there were six centers reduced to three in next two phases. post prandil (2.5 hours after breakfast) blood sugar levels was checked with glucometer by ophthalmic technician. blood glucose level of ≤ 140 mg/dl was considered non diabetic, ≤ than 199 mg/dl was considered impaired glucose tolerance (igt) diabetes and ≥ 200 mg/dl was considered as diabetetes.10 in the first and second phases, an appointment was given for retinal screening, whereas in the third phase retinal screening was done on the same day. diabetic patients were counselled by “diabetic educator” during 2nd and 3rd phases. retinal screening was done at pec centers. consent was taken from respondents coming for retinal examination and the pupil was dilated with mydriacyl 1%. the fundus was examined by resident ophthalmologist with direct ophthalmoscope in the 1st phase, by the retina specialist with direct as well indirect ophthalmoscope in the second phase and by optometrist with direct ophthalmoscopy in 3rd phase. patients having dr were referred to tertiary center (aieh). diabetes counselling was provided to the patients in 2nd and 3rd phases of the project by the diabetic educator”. at the tertiary center (aieh) “retina specialist” examined the patients after taking consent and dilating pupil using 90d fundal lens and slit lamp. dr was confirmed and graded according to etdrs classification.11 patients with non-proliferating diabetic retinopathy without macular edema were labelled as non sight threatening diabetic retinopathy (nstdr) and were given follow up at aieh. patients with proliferative diabetic retinopathy (pdr), clinically significant macular edema (csme) with or without dr were labeled as sight threatening diabetic retinopathy (stdr) and advised laser. those with advanced diabetic eye disease (aded) after necessary investigations like were offered surgery. the patients were counselled by “diabetic educator” and necessary consultation was provided by the physician. a standard performa was used in all the phases for collecting the data. to assess levels of knowledge, attitude and practices in the community regarding diabetes and dr two studies were designed during the project. questionnaire based activates were conducted. first muhammad saleh memon, et al 72 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology study was done during the middle of the project (junejuly 2012) and second study was undertaken after the end of the project (jan – march 2015). in the first study, a sample of 527 individuals from all eight union councils was drawn and interviewed. second study (jan to march 2015), was repeated on the same sample except 20 respondents who had either died or migrated. the data was analyzed through statistical package for social sciences version 20.0. all the continuous variables were presented in mean ± sd. categorical variables were shown in frequency and percentages. results according to 1998 census, gaddap town had population of 0.3 million with 100,000 (33%) people in the age group of ≥ 30 years. this was the target of our project. during all three phases covering 10 years, 42,998 individuals were screened for diabetes. the combined mean age of respondents was 36.26 ± 9.8. male to female ratio in the beginning was found to be 3:1 and in the final phase 0.7:1 (demographic characteristics of study population, detailed in table 1. table 1: demographic statistics of study population. 2006 – 2008 age, years 39.3 ± 10.2 male 6406 (27.8%) female 16604 (72.1%) total 23008 2009 – 2011 age, years 36.5 ± 7.35 male 3637 (33.4%) female 7222 (66.5%) total 10859 2012 – 2015 age, years 37.1 ± 6.92 male 3950 (43.2%) female 5181 (56.7%) total 9131 total 42998 total male 13993 (32.5%) total female 29005 (66.46%) kap 2012 age, years 32 ± 12.9 male 287 (54.4%) female 240 (45.5%) total 527 post kap 2015 age, years 36.4 ± 12.6 male 271 (53.4%) female 236 (46.5%) total 507 *data shown in mean ± sd and frequency and percentages (%) table 2: comparative statistics for service uptake during 3 projects, spread over 9 years. years 2006 – 2008 2009 – 2011 2012 – 2015 target population n = 100,000 blood screening 43% (n = 42998) 23% (n = 23008) 14.1% (n = 10859) 13.8% (n = 9131) diabetes 6.86% (n = 2953) 7.5% (n = 1742) 5.5% (n = 597) 6.6% (n = 614) unknown diabetes 24.6% (n = 727) 24.8% (n = 432) 24.6% (n = 146) 26.4% (n = 149) turn out for retinal screening 42.6% (n = 1259) 26.4% (n = 460) 55.6% (n = 301) 81.1% (n = 498) diabetic retinopathy 22.3% (n = 281) 26.5% (n = 120) 21% (n = 63) 19.6% (n = 98) turn out at tertiary center 28.1% (n = 79) 18.1% (n = 22) 24.0% (n = 15) 42.2% (n = 42) sight threatening diabetic retinopathy 44.3% (n = 35) 45 % (n = 10) 39.6% (n = 6) 45.2% (n = 19) intervention accepted 57.1% (n = 20) 17.3% (2 out of 10) 83.3% (5 0ut of 6) 68.4% (13 out of 19) *data shown in frequency and percentages (%) community perception and service utilization of diabetic retinopathy management project in gaddap town pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 73 table 3: referral pattern for past nine years of the study (n = 42998). period total referred (frequency) lhws (%) rhc doctors (%) family physician (%) self (%) 1st phase 23008 50.55 31.17 7.37 10.9 2nd phase 10859 20.6 39.3% 6.4 33.5 3rd phase 9131 16.6 37.8 7.5 40.0 *data shown in frequency and percentages in the first phase (2006 – 08), out of the target population 23% (23008) availed blood screening. amongst the individuals screened, 5.02 % (1156) had impaired glucose tolerance, 7.57% (1742) were diabetics amongst whom 24.8% (432) were unaware of their disease. all diabetics (1742) were given appointment for retinal screening at the same center. turn out rate was 26.57% (460). on ophthalmoscopy, 26.5% (120) were found to have dr and were referred to aieh for further management. turn out at aieh were 18.1% (22). sight threatening diabetic retinopathy (stdr) was found in 45% (10) and they all were advisedlaser, which was accepted by 17.3% (4). in the second phase (2009 – 11) out of remaining target population (76992), turn out for blood screening was 14.1% (10851). out of these 6.14% (667) were found to have igt, 5.4% (597) had diabetes with 24.6% (146) not knowing about their disease. all diabetics (597) were given appointment for retinal screening after counseling by the “diabetic educator”. turn out rate (597) for retinal screening was 55.6% (301) amongst whom 21% (63) were found to have dr. all dr patients were referred to aieh where 24% (15) turned up for further examination and 39.6% (6) were confirmed stdr. patients accepting intervention were 83.3% (5). in the final phase (jan 2012 to march 2015), out of remaining target population (66141), the turn out for blood screening was 13.8% (9131) with 6.44% (538) ig t, 6.6% (614) had diabetes amongst whom 26.4% (149) were unaware of their diabetes. retinal screening was done in all the diabetics (614) on the same day. retinal screening was accepted by 81.1% (498). dr was found in 19.6% (98), who were referred to tertiary center (aieh) after counseling by the “diabetic educator”. turn out rate at aieh was 42.8% (42). on examination, 45.2% (19) were confirmed as stdr. all of these 19 patients were offered laser; but 68.4% (13) accepted laser (comparative results table 2). source of referral for blood screening in initial period was 50% by lhws and 11% on their own (self) which changed in the final phase to 16.6% by lhws and 40% self. referral by family physician remained 7.37% in the beginning and 7.5% in the end (table 3). the score for knowledge, attitude and practice regarding diabetes in the first study (jun-july 2012) was 35.23%, 24.72% and 36%, while in the second study (jan – march 2015) the respective figures were 33.56%, 28.84% and 33% (fig. 1). discussion gaddap town was selected for the project because it has a multi ethnic community and mixture of rural and urban culture. it has network of basic health units (bhu), rural health centers (rhc) and a tertiary center with well-developed vitro retina unit (al ibrahim eye hospital). it has 8 union councils and is located in district malir. it is largest town area wise, stretching over an area of about 1800 sq. km; but smallest in terms of population with 0.3 million peoples according to 1998 census.13 it was mostly agricultural but is fast turning into urban culture. literacy rate is not more than 30%. it was expected to be an ideal town to develop a model for the prevention and management of blindness due to diabetic retinopathy. prevalence of diabetes type – 2 according to this study was 6.86% (24.6% unware of diabetes). impaired glucose tolerance was found in 5.6% people which is an important target for the primary prevention of diabetes mellitus. if these people continue their life style unchanged, there will be an addition of 3.24% (58% of igt) more diabetics in the community after 3 years9. this study matches with national statistics of 7.6% to 11%14. as well as with study from uk which reports that 7.3% male and 8.6% females of pakistani origin suffer from diabetes type 215. muhammad saleh memon, et al 74 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology fig. 1: comparison of knowledge, attitude and practices for 2 phases of “change of perception regarding service utilization in patients with diabetic retinopathy; (n = 527). fig. 2: targets for diabetic related blindness projected and achieved. diabetic retinopathy according to this study was 22.3% (281 from 1259) and stdr was 44.3% (35 out of 79 dr). gaddap study reported higher dr (27.43%) and lower stdr (27.39)16. one study from dap (diabetic association of pakistan) reported 24.7% dr in 10768 diabetics (march 2009 – dec. 2011)17. second study (jan 2011 to 2012) from the same center reported 21.2% dr and 39.5% stdr18. on the basis of these studies one can safely assumes that in 100 diabetic patients, 23 to 25 diabetics will have dr and 8 to 10 diabtics have stdr. on the basis of the results of this project, one can highlight 6800 (5175 known and 1625 latent) diabetics, 5600 impaired glucose tolerance, 1523 dr, and 674 stdr in gaddap town. as compared to this in actual we found 2953 diabetics (727 latent), 2411people with impaired glucose tolerance , 281 with dr and 35 with stdr (figure 2). these low figures as compared to projected are because of poor service uptake. at aggregate level 43% availed blood screening, 42.6% turn out for retinal screening, 28.1% turnout at tertiary center and 57.1% availed intervention (table 4). it is a common perception that the effectiveness of “prevention of blindness programs” is seriously hampered by the low levels of service up-take. up till now as main focus in ophthalmology has been cataract, such studies are cataract related only. the effectiveness of prevention of blindness programs studies have been carried out in cataract uptake on the basis of which who states that globally only a quarter of people in need of eye care use eye services12. this is supported by evidence from studies conducted in india, nepal and pakistan which demonstrate levels of utilization of eye services, and uptake of cataract surgery ranging from 7% to 35%18-20. this study validates the hypothesis of “poor uptake of eye care services by community” in developing country like pakistan in reference to diabetic retinopahthy. it has been generally argued at global and national levels that health care system unable to provide services to the people. the project findings contradicts with this common perception as service outlets established remained under-utilized as community was not willing to avail the eye care services. the project outlined some criticial challenges of the poor uptake of services. first challenge is willingness of the community to get blood screened for diabetes. only 43% people willingly availed the blood screening. during first three years when there were six screening centers, 23% individuals availed the service. in the second and third phases the screening centers were reduced to three which obviously reduced service uptake to 14.3% in the 2nd phase and 13.8% in the 3rd phase. this decreasing pattern inspite of awareness campaign using medical, paramedical personnels, print and electronic media to educate the community highlights the importance of easily reachable service outlets. solution gradual improvement in blood screening can be anticipated if it is carried out at basic health unit (bhu) or at rhc level in addition to diabetes awarness activities at community. second challenge was devlopment of referral chain: second challenge identified in the proejct was the poor turn out for retinal screening. when patients community perception and service utilization of diabetic retinopathy management project in gaddap town pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 75 were given date for retinal screening at same center where the blood screening was carried, only 26.4% turned out for follow up eye examination. introduction of diabetic councelor was done during 2nd phase which increased turn out for retinal screening to 55.6% showing importance of diabetes counselling. further improvement in the turn out for retinal screening was when retinal screening was offered on the same day (although optometrist did the screening instead of ophtalmologist or retina specialist). acceptance of retinal screening in the third phase increased to 81.1%. only those who objected to mydriasis refused screening. non-mydriatic fundus camera (nmfc) could have improved the compliance for retinal screening still further. this was noted in a study done at “dap” where nmfc was used, retinal screening was 100%18. this shows that acceptance of retinal screening is not the problem. patient’s turnout at the primary eye care center is important. referal chain between the community and the primary eye care service outlet is to be established. this was facilitated by the diabetic educator at the time of initial diagnosis of diabetes. second component of the referral chain was between rhc and tertiary center. when the patients were referred to tertiary centr (aieh) which was at a distance of 0-25km from the community, the collective attendence was 28.1%. with persistance a&e program and councilling by the diabetic educator there was an improvement in attendance at tertiary center with the time. in the first phase the turn out was 18.1%, increasing to 24% in second phase and 42.2% in the last phase. solution to development of referral chain is initial awarness and education program in the community augmented awareness at the first level of contact when diabetes is diagnoseed, counselling through diabetic councelor at the time of retinal secreening and friendly, quality service at teritary center. third challenge noted in this study was the acceptamce of intervention. after screening of 42,998 individuals and identifying 2,953 diabetics, intervention was possible in 20 patients in ten years. in first phase (2 out of 10) 17.3% agreed for laser. in second phase laser acceptance incresase to 5 out of 6 patients (83.3%). in the final phaase intervention accpetance was 13 out of 19 (68.4%). combined rate of intervention at the end of project was 57% in another study on laser uptake showed 70% acceptance14. although six months post laser follow up was 21.2%. these discouraging results had only one bright aspect. there was a gradual change in response of the community not only in service uptake; but in the behaviour of the respondent also (table 2 & 3). in the period 2006 – 8, most of the respondents were referred by lhws (50.5%) which reduced to 16.6% during 2012 – 15. self attendence in the first phase was 10.9% which increased to 40% in the last phase. change in the acceptance of the service was apparent in change of the gender ratio. in first phase females constituted 72.1% (16604 out of total 23008) with female to male ratio of 3:1. in the final phase females were 56.7% (5181 out of 9131) with a female to male ratio of 1:0.7. initially members of the community were referred by lhws with a greater influence over females. less number of the males can also be attributed to fear of loosing income for daily wagers. solution to acceptance of intervention is awareness, councilling at each level of service outlet provision. conclusion challenges to the prevention and management of drb are acceptance of blood screening, retinal screening and lasers. solutions are establishing referral chain between the community and service outlets like bhus, rhcs, tertiary centers by increasing awareness in the community through awareness program and councilling by the diabetic educator. the researchers strongly believe that quality and patient friendly services are very important solution for community mobilaization. collaborative efforts with government health department and the local cbos in utilizing the health workers’ network and awareness raising on drb can bring behavioral changes and increased identification and treatment of diabetic related eye problems. linkages between primary and tertiary level health facilities can establish an effective referral chain, reaching people with preventive and curative treatment. there is a dire need to train all local health professionals particularly woman health workers to create awareness about detection, prevention and control of diabetes, and encouraging them to refer the cases to health centers. blood screening at bhus, retinal screening at rhc level by optometrist preferably using nmfc and strenthening of eye departments at dhq hospitals as laser centers. muhammad saleh memon, et al 76 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology author’s affiliation dr. muhammad saleh memon director projects do, frcs (edin) isra postgraduate institute of ophthalmology, alibrahim eye hospital, gaddap town, malir, karachi – 75040. dr. seema n. mumtaz mbbs, m.phill, mph, mba (health), dcps (hscm), fellow of lead (cohorat-15) isra postgraduate institute of ophthalmology, alibrahim eye hospital, gaddap town, malir, karachi – 75040 sikandar ali sheikh project manager m.a (sociology) isra postgraduate institute of ophthalmology, alibrahim eye hospital, gaddap town, malir, karachi – 75040. muhammad faisal fahim statistician m.sc (statistics) isra postgraduate institute of ophthalmology, alibrahim eye hospital, gaddap town, malir, karachi – 75040. role of authors dr. muhammad saleh memon the conception, design and actual write up of manuscript. dr. seema n. mumtaz critical appraisal and final approval. sikandar ali sheikh data collection and review the draft. muhammad faisal fahim literature search, analysis and interpretation of the data & critical review. references 1. american academy of ophthalmology retina panel. preferred practice pattern guidelines. diabetic retinopathy. san francisco, ca: american academy of ophthalmology, 2008. june 2010. 2. hirai fe, tielsch jm, klein be, klein r. ten – year change in vision – related quality of life in type 1 diabetes: wisconsin epidemiologic study of diabetic retinopathy. ophthalmology, 2011; 118: 353–8. 3. cheung n, mitchell p, wong ty. diabetic retinopathy. lancet, 2010; 376 (9735): 124-36. 4. shera as, rafique g, khwaja ia, baqai s, khan ia, king h.pakistan national diabetes survey prevalence of glucose intolerance and associated factors in north west at frontier province (nwfp) of pakistan. j pak med assoc 1999; 49: 206-1. 5. shera as, rafique g, khwaja ia, ara j, baqai s, king h. pakistan national diabetes survey: prevalence of glucose intolerance and associated factors in shikarpur, sindh province. diabet med. 1995; 12: 1116-21. 6. study p. s. mahar, m. zahid awan, nabeel manzar and m. saleh memon prevalence of type – ii diabetes mellitus and diabetic retinopathy: the gaddap study journal of the college of physicians and surgeons pakistan, 2010; vol. 20 (8): 528-532. 7. memon s, ahsan s, riaz q, basit a, sheikh sa, fawwad a, et al. frequency, severity and risk indicators of retinopathy in patients with diabetes screened by fundus photographs: a study from primary health care. pak j med sci. 2014; 30 (2): 366-372. 8. shera as, rafique g, ahmend ki, baqai s, khan ia, king h. pakistan national diabetes survey. prevalence of glucose intolerance and associated factors in north west frontier province (nwfp) of pakistan. journal of the pakistan medical association, 1999; 49: 206-211. 9. king p, peacock i and donnelly r. the uk prospective diabetes study (ukpds): clinical and therapeutic implications for type 2 diabetes. british journal of clinical ophthalmology, 1999; 48 (5): 643-648. 10. namperumalsamy p, nirmalan pk and ramasamy k.. developing a screening program to detect sight threatening diabetic retinopathy in south india. diabetes care, 2003; 26: 1831-35. 11. dean t jamison, lawrence h summers at el. global health 2035: a world converging within a generation. the lancet commissions, 2013; 6736 (11): http://www.afdb.org/fileadmin/uploads/afdb/docu ments/publications/global%20health%202035%20%20a%20world%20converging%20within%20a%20gene ration.pdf (accessed 26 january, 2016). 12. world health organization, w.h.o. 1. the who diagnostic criteria of diabetes of 1999 as revised in 2006 at the 19th world diabetes conference. [online]. available from: http:// www.who.int/diabetes/publications/en. [accessed 28 january 2016]. read more: http://www.ukessays.com/tools/vancouverreferencing/reference.php#ixzz3yafthzii 13. akhtar hassan khan. 1998 cencus; the results and implication. the pakistan developmental review, 1998; 37 (4): 481-493. 14. study p. s. mahar, m. zahid awan, nabeel manzar and m. saleh memon prevalence of type – ii diabetes mellitus and diabetic retinopathy: the gaddap study journal of the college of physicians and surgeons pakistan, 2010; vol. 20 (8): 528-532. 15. diabetes in the uk 2010: key statistics on diabetes. diabetes uk website. www.diabetes.org.uk/documents/ diabetes_in_the_uk_2010.pdf. http://www.ukessays.com/tools/vancouver-referencing/reference.php#ixzz3yafthzii http://www.ukessays.com/tools/vancouver-referencing/reference.php#ixzz3yafthzii community perception and service utilization of diabetic retinopathy management project in gaddap town pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 77 16. study p. s. mahar, m. zahid awan, nabeel manzar and m. saleh memon prevalence of type-ii diabetes mellitus and diabetic retinopathy: the gaddap study journal of the college of physicians and surgeons pakistan, 2010; vol. 20 (8): 528-532. 17. memon s, ahsan s, riaz q, basit a, sheikh sa, fawwad a, et al. frequency, severity and risk indicators of retinopathy in patients with diabetes screened by fundus photographs: a study from primary health care. pak j med sci. 2014; 30 (2): 366-372. 18. memon s, ahsan s, et al. retinal screening acceptance, laser treatment uptake and follow-up response in diabetics requiring laser therapy in an urban diabetes care centre journal of the college of physicians and surgeons pakistan, 2015; vol. 25 (10): 743-746. 19. fletcher ae, donoghue m, devavaram j, thulasiraj rd, scott s, abdalla m, shanmugham cak, balamurugan p. low uptake of eye services in rural india: a challenge for programs of blindness prevention. arch ophthalmol. 1999; 117: 1393-9. 20. brilliant ge, lepkowski jm, zurita b, thulasiraj rd. social determinants of cataract surgery utilization in south india. rchophthalmol 1991; 109: 584-9. pak j ophthalmol. 2021, vol. 37 (4): 384-387 384 original article comparison of complications between manual small incision cataract surgery and phacoemulsification israr ahmad bhutto 1 , maria nazish memon 2 , irshad ali 3 , abdul qadeem soomro 4 , abdul haleem mirani 5 department of ophthalmology, 1,3,4,5 isra postgraduate institute of ophthalmology, karachi 2 liaquat university of medical & health sciences, jamshoro abstract purpose: to compare per-operative and early post-operative complications between manual small incision cataract surgery and phacoemulsification in patients with senile cataract. study design: quasi experimental study. place and duration of study: al-ibrahim eye hospital karachi from december 2018 to october 2019. methods: two hundred and seventy patients with senile cataract were recruited for this study by convenient sampling technique. they were divided equally into two groups. group i underwent manual small incision cataract surgery (msics), whereas group ii underwent phacoemulsification. per-operative and early postoperative complications were recorded on day 1 in both groups. data was analyzed using spss 24.0. independent t-test was carried out with p-value of ≤0.05 was considered statistically significant. results: mean age group – i was 54.95 ± 11.0 and in group – ii was 57.09 ± 10.59 (p = 0.546). there were 72 (53.3%) males in group – i and 74 (54.8%) in group – ii with a non-significant difference (p-value > 0.01). there was significant difference for posterior capsule rupture and striate keratitis between the two groups (p = 0.031 and 0.044 respectively). rest of the study parameters was not statistically different in the both group. none of the groups had a nucleus drop and vitreous prolapse. no significant difference was seen between the two groups concerning iris trauma (p = 0.56), wound leakage (p = 0.15) and hyphema (p = 0.32). conclusion: there is no significant difference between per-operative and early post-operative complications between msics and phacoemulsification in patients with senile cataract except posterior capsular rupture and striate keratopathy which were more common in phacoemulsification group. key words: cataract, senile cataract, phacoemulsification, small incision cataract surgery. how to cite this article: bhutto ia, memon mn, ali i, soomro aq, indhar i. comparison of per-operative and early post-operative complications between manual small incision cataract surgery and phacoemulsification in patients with senile cataract. pak j ophthalmol. 2021, 37 (4): 384-387. doi: 10.36351/pjo.v37i4.1317 correspondence: israr ahmad bhutto isra postgraduate institute of ophthalmology karachi email: drisrarbhutto@gmail.com received: july 12, 2021 accepted: september 23, 2021 introduction cataract is classified into congenital and acquired and it can affect one eye or both eyes. 1 it is the leading cause of blindness worldwide. 2 according to the world health organization (who), cataract is responsible for 47.8% of blindness and accounts for 17.7 million blind people. 3 it is associated with various modifiable risk factors. these risk factors include uvlight exposure, hypertension, diabetes, body mass open access comparison of complications between manual small incision cataract surgery and phacoemulsification 385 pak j ophthalmol. 2021, vol. 37 (4): 384-387 index (bmi), drugs, nutrition, smoking and socioeconomic status. 4,5 however, the advancement of age, a non-modifiable risk factor, is the single most important reason for cataract. 6 this progression of age is what leads to senile cataract. senile cataract develops in the absence of any form of physical, chemical, or radiation trauma. in pakistan, 570,000 adults are said to be blind (< 3/60) due to cataract, with 3,560,000 eyes having a visual acuity of < 6/60 due to cataract. 7,8 with the global burden of cataract being enormous and age-related cataract being the leading causes of visual impairment worldwide. cataract surgery is the most commonly performed operation of the eye. it is estimated that 19.5 million procedures of cataract were performed in 2011. 9 the two most commonly used surgical techniques to treat cataract are manual small incision cataract surgery (msics) and phacoemulsification. as these surgical methods are widely performed, complication rates associated with these procedures must also be considered. studies have shown that phacoemulsification and msics yield low complications if performed with experienced hands. 10,11 rationale of this study was to find out complications in msics and phacoemulsification in patients with senile cataract in our setup. methods this experimental interventional study was carried out at the isra postgraduate institute of ophthalmology alibrahim eye hospital karachi, from december 2018 to october 2019. the study was approved by the ethical review board. a total of 270 patients diagnosed with senile cataract were selected for this study by convenient sampling and divided into two groups. group i included patients that underwent manual small incision cataract surgery and group ii comprised of patients who underwent phacoemulsification. patient with other types of cataract including congenital and secondary cataract were excluded. per-operative and post-operative complications were assessed in both groups. these included; rupture of posterior capsule, nucleus drop, vitreous prolapse, trauma to the iris, striate keratitis, wound leakage and hyphema. data were analyzed using the statistical package of social science version 24.0, with an independent t-test applied to compare the two groups. p-value ≤ 0.05 was considered statistically significant. results mean age in group i was 54.95 ± 11.0 and in group ii was 57.09 ± 10.59. there was no significant difference between the two groups (p = 0.546). it was observed that 72 (53.3%) patients were male in group i and 74 (54.8%) in group ii, with a non-significant difference (p-value > 0.01, table 1). there was significant difference for posterior capsule rupture and striate keratitis between the two groups (p-value < 0.05). for rest of the study parameters, there was no statistically significant difference between the two groups (table 2). table 1: showing frequency and percentage of gender based distribution of patients. variable group – i group – ii p-value n % n % male 72 53.3 74 54.8 0.807 female 63 46.7 61 45.2 table 2: showing the frequency and percentage of postoperative complication. post-operative complications group – i group – ii p value posterior capsule rupture 2 (1.5%) 4 (3.0%) 0.031 nucleus drop 0 (0%) 0 (0%) ----- vitreous prolapse 0 (0%) 0 (0%) ----- trauma of iris 1 (0.7%) 2 (1.5%) 0.562 striate keratitis 4 (3.0%) 6 (4.5%) 0.044 wound leakage 1 (0.7%) 0 (0%) 0.156 hyphema on day 1 1 (0.7%) 0 (0%) 0.316 chi-square test was applied discussion our study aimed to see if there are significant complications related with particular type of surgical treatment of cataract. the study focused on msics and phacoemulsification as these two methods are the most frequently employed when it comes to cataract surgery; however, future studies can be done on other surgical techniques as well. only 2 (1.5%) patients out of 135 in the msics group developed posteriorcapsule rupture while none of them had a nucleus drop and vitreous prolapse. in a study by ruit et al., it was reported that msics and phacoemulsification showed equal level of visual acuity and lower complication rates. 12 venkatesh et al., in his study, also showed that israr ahmad bhutto, et al pak j ophthalmol. 2021, vol. 37 (4): 384-387 386 both surgical techniques delivered excellent visual outcomes and very low complications in rates, with only three eyes having posterior capsule rupture in the phacoemulsification group and only two eyes having rupture in the msics group. 13 these findings were in line with our study. gogate et al. showed that both surgical techniques were safe to perform and were highly effective for visual rehabilitation. 14 similar results were evident in our study, showing both phacoemulsification and msics as being equally secure procedures. bhargava et al., in his study, concluded that there was no significant difference in the complication rates of both msics and phacoemulsification. however, msics was a much faster and preferred technique due to its easy accessibility in places such as eye camps. 15 msics has proven to be a much cheaper option as compared to phacoemulsification as it requires lesser equipment and proves to have lower complication rates and excellent visual outcomes. although msics is a cheaper option, better results concerning visual acuity are observed in phacoemulsification surgery. although these surgical procedures are safe, and our study showed that there are no significant postoperative complications, the tendency of postoperative complications is still persistent. posterior capsule rupture, recurrent uveitis, and cystoid macular edema all could occur in patients undergoing phacoemulsification surgery. nonetheless, both procedures have low complications rates. cook et al. conducted a study on 100 patients on which msics and phacoemulsification were carried out and showed there was no difference in operative complications. 19 therefore, both procedures can be carried out safely without the fear of developing complications as the complication rate in both techniques is very low. msics is the preferred technique, especially in the developing world, as it is much cheaper than phacoemulsification, and more people can, therefore seek treatment for their cataract. 20 limitations of this study are small sample size, single centered study and limited follow up of the patients. conclusion our study concluded that both msics and phacoemulsification have low complication rates in patients with senile cataract. there is no significant difference between per-operative and early postoperative complications between msics and phacoemulsification in patients with senile cataract except posterior capsular rupture and striate keratopathy, which are more common in phacoemulsification group. ethical approval the study was approved by the institutional review board/ethical review board (a-00079). conflict of interest authors declared no conflict of interest. references 1. congdon n, vingerling jr, klein be, west s, friedman ds, kempen j, et al. prevalence of cataract and pseudophakia/aphakia among adults in the united states. arch ophthalmol. 2004; 122 (4): 487-494. 2. rao gn, khanna r, payal a. the global burden of cataract. curr opin ophthalmol. 2011; 22 (1): 4-9. 3. liu yc, wilkins m, kim t, malyugin b, mehta js. cataracts. the lancet, 2017; 390 (10094): 600-612. 4. nangia v, jonas jb, sinha a, matin a, kulkarni m. refractive error in central india: the central india eye and medical study. ophthalmology, 2010; 117 (4): 693699. 5. haag r, sieber n, hebling m. cataract development by exposure to ultraviolet and blue visible light in porcine lenses. medicina (kaunas), 2021; 57 (6): 535. doi: 10.3390/medicina57060535. 6. choi jh, lee e, heo yr. the association between dietary vitamin a and c intakes and cataract: data from korea national health and nutrition examination survey 2012. clin nutr res. 2020; 9 (3): 163-170. doi: 10.7762/cnr.2020.9.3.163. 7. jadoon z, shah sp, bourne r, dineen b, khan ma, gilbert ce, et al. pakistan national eye survey study group. cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in pakistan: the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91 (10): 1269-1273. 8. quigley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006; 90 (3): 262-267. 9. lawless m, hodge c. femtosecond laser cataract surgery: an experience from australia. asia-pac j ophthalmol. 2012; 1 (1): 5-10. comparison of complications between manual small incision cataract surgery and phacoemulsification 387 pak j ophthalmol. 2021, vol. 37 (4): 384-387 10. manning s, barry p, henry y, rosen p, stenevi u, young d, et al. femtosecond laser–assisted cataract surgery versus standard phacoemulsification cataract surgery: study from the european registry of quality outcomes for cataract and refractive surgery. j cataract refract surg. 2016; 42 (12): 1779-1790. 11. zhang w, pasricha nd, kuo an, vann rr. influence of corneal diameter on surgically induced astigmatism in small-incision cataract surgery. can j ophthalmol. 2019; 54 (5): 556-559. doi: 10.1016/j.jcjo.2018.12.013. 12. ruit s, tabin g, chang d, bajracharya l, kline dc, richheimer w, et al. a prospective randomized clinical trial of phacoemulsification vs. manual sutureless small-incision extra-capsular cataract surgery in nepal. am j ophthalmol. 2007; 143 (1): 32-38. 13. venkatesh r, muralikrishnan r, balent lc, prakash sk, prajna nv. outcomes of high volume cataract surgeries in a developing country. br j ophthalmol. 2005; 89 (9): 1079-1083. 14. gogate pm, kulkarni sr, krishnaiah s, deshpande rd, joshi sa, palimkar a, et al. safety and efficacy of phacoemulsification compared with manual smallincision cataract surgery by a randomized controlled clinical trial: six-week results. ophthalmology, 2005; 112 (5): 869-874. 15. bhargava r, kumar p, sharma sk, arora y. phacoemulsification versus manual small incision cataract surgery in patients with fuchsheterochromiciridocyclitis. asia pac j ophthalmol. 2016; 5 (5): 330-334. 16. kosker m, sungur g, celik t, unlu n, simsek s. phacoemulsification with intraocular lens implantation in patients with anterior uveitis. j cataract refract surg. 2013; 39 (7): 1002-1007. 17. ram j, gupta a, kumar s, kaushik s, gupta n, severia s. phacoemulsification with intraocular lens implantation in patients with uveitis. j cataract refract surg. 2010; 36 (8): 1283-1288. 18. kawaguchi t, mochizuki m, miyata k, miyata n. phacoemulsification cataract extraction and intraocular lens implantation in patients with uveitis. j cataract refract surg. 2007; 33 (2): 305-309. 19. cook c, carrara h, myer l. phaco-emulsification versus manual small-incision cataract surgery in south africa. s afr med j. 2012 jun; 102 (6): 537-540. 20. msc rm, md rv, prajna v, frick k. economic cost of cataract surgery procedures in an established eye care centre in southern india. ophth epidemiol. 2004; 11 (5): 369-380. authors’ designation and contribution israr ahmad bhutto; associate professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. maria nazish memon; associate professor: literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. irshad ali; consultant ophthalmologist: literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. abdul qadeem soomro; associate professor: literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. abdul haleem mirani; consultant ophthalmologist: literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. .…  …. pak j ophthalmol. 2022, vol. 38 (1): 71-75 71 original article knowledge, attitude and practice about diabetic retinopathy among medical students shehla dareshani 1 , fiza farooq 2 , mir amjad ali 3 , nusrat shah khan 4 , zaheer sultan 5 1,2 dow university of health sciences & civil hospital, karachi 3,4 bilawal medical college, hyderabad, 5 dr. ruth km pfau/civil hospital, karachi abstract purpose: the study was conducted with the aim to decipher knowledge, attitude and practice of diabetic retinopathy among mbbs students of a medical college. study design: a cross sectional survey. place and duration of study: dow medical college, from october 2019 to march 2020. methods: a cross sectional study was conducted among 3 rd and 4 th year medical students. a total of 133 students were questioned through specific questionnaire. after informed consent, demographic details were noted. apart from source of information of students’ knowledge, set of 14 questions were asked. in the first 7 questions information of knowledge of diabetic retinopathy was addressed. four questions were about attitude and 3 regarding practice towards diabetic retinopathy. windows ms excel was used for quantitative and qualitative analysis. results: the mean of the overall kap score for all students was 53.3 ± 1.2 (maximum, 70). male students scored better in knowledge (24.8 vs 23.7) and attitude (17.3 vs 16.5). students scored poor in identifying correct values of hba1c and prevalence of diabetes in our country in the knowledge section. students also lacked in identifying proper time of followup for screening of diabetic retinopathy. many students thought uneducated people develop diabetic retinopathy earlier than educated. conclusion: our study pointed out weakness in knowledge and practice of medical students regarding prevention and management of diabetic retinopathy. proper training and teaching of students is required for improved management and counselling of diabetic retinopathy. key words: diabetic retinopathy medical students how to cite this article: dareshani s, farooq f, ali ma, khan ns, sultan z. knowledge, attitude and practice about diabetic retinopathy among medical students. pak j ophthalmol. 2022, 38 (1): 71-75. doi: 10.36351/pjo.v38i1.1299 introduction diabetes is a non-communicable global crisis, which has become prevalent over the past years. number of correspondence: mir amjad ali bilawal medical college, hyderabad email: dramjad169@gmail.com received: june 14, 2021 accepted: december 12, 2021 people with diabetes has increased from 108 million in 1980 to 422 million in 2014. 1 in middle east and north africa every 10 th individual is suffering from diabetes. while is south east asia half of the patients with diabetes remain undiagnosed. 2 it is estimated that in developed world it will increase from 51 to 72 million meanwhile in the developing countries, a 170% rise is expected from 84 to 228 million by year 2025. 3 in pakistan diabetes will rise to 11.6 million by 2025. 4 current prevalence of diabetes in pakistan was 11.77%. 5 open access mailto:dramjad169@gmail.com mir amjad ali, et al 72 pak j ophthalmol. 2022, vol. 38 (1): 71-75 diabetes is associated with various complications related to micro vessels and nerves. ocular pathology specifically retinopathy is an emerging diabetic complication. around 35.6% of all diabetic patients have diabetic retinopathy. 6 this has placed diabetes as the fourth leading cause of blindness. 7 however, blindness associated with diabetes is avoidable and can be delayed with prompt detection and treatment. risk factors of diabetic retinopathy includes duration of diabetes, increasing age, and smoking. 8 other risk factors include hypertension, pregnancy and obesity. type 1 diabetic patients are more prone to go blind from diabetic retinopathy. wisconsin epidemiologic study of diabetic retinopathy (wesdr) showed that 3.6% of young patients (type 1 diabetes) and 1.6% of older (type 2 diabetes) lost their vision. 9 duration of diabetes is a good demarcation of the progression of diabetic retinopathy. twenty five percent of type-i diabetics have retinopathy after 5 years of diagnosis, 60% develop after 10 years, and 80% after 15 years. 10 early screening of diabetes assists in treatment protocols. according to american academy of ophthalmology first fundus examination in type 1 should be done 3 – 5 years after diagnosis and in type 2 immediately after diagnosis. 11 pan retinal photocoagulation prp can reduce risk of vision loss to < 2% for severe non-proliferative and proliferative retinopathy according to early treatment of diabetic retinopathy study (etdrs). 12 early vitrectomy has benefit in very severe pdr as it improves visual acuity to 6/12 or better after vitrectomy. 13 anti vegf has shown promising results in patients with macular edema. glycosylated hemoglobin (hba1c) levels are tested for glycemic status in diabetes mellitus. the optimal cutoff value of hba1c for diabetic in pakistan is taken as < 6.05%. 14 prevention and treatment of diabetic retinopathy needs multi-disciplinary approach. cooperation from community level and participation of practitioner together play important role. this study was therefore carried to evaluate knowledge, practice and attitude of medical students regarding diabetic retinopathy. their knowledge was addressed by the understanding that they had about diabetic retinopathy as a complication of diabetes. attitude was perceived as their own ideas and feelings while practices are the ways that they put knowledge and attitude together to implement actions. methods a cross sectional study was conducted amongst 3 rd and 4 th year medical students of dow medical college who rotated in ophthalmology department from october 2019 to march 2020 during their clinical rotation. owing to ethical considerations permission was obtained from institutional review board. confidentiality of the data was maintained at all levels. a total of 133 students were questioned through specific questionnaire. after informed consent, demographic details were noted. apart from source of information of students’ knowledge, set of 14 questions were asked. in the first 7 questions information of knowledge of diabetic retinopathy was addressed. four questions were about attitude and 3 regarding practice towards diabetic retinopathy. table 1: questionnaire. what is normal hba1c level? what is prevalence of diabetes in pakistan? what are the risk factors of diabetes? what are the symptoms of diabetic retinopathy? which diabetics are at greater risk of dr? type 1 type 2 control of diabetes is important in prevention of dr? yes no duration of diabetes is important in prevention of dr? yes no visual loss due to dr can be prevented? yes no more uneducated people develop dr? yes no routine examination is must for all dr? yes no early detection can prevent visual loss? yes no what are the treatment options for dr? what advice will you give to the patients? how often should diabetic visit ophthalmologist? what advice will you give to patients? the knowledge questions were assigned marks according to the answers. each correct answer was rewarded 5 marks and 0 if the person was unaware or gave wrong answer. while questions regarding attitude were asked with option of yes or no. cumulative marks of questions related to knowledge, attitude and practice were classified into 3 groups. excellent response was 75 – 100%, fair was 50 – 74% and 0 to 49% was poor. 15 data was collected and analyzed and coded via windows ms excel. graphical analysis was used for qualitative data while mean and standard deviation was calculated for quantitative data. perception of knowledge, attitude and practice of diabetic retinopathy amongst medical students pak j ophthalmol. 2022, vol. 38 (1): 71-75 73 results a total of 133 students were questioned from 5 th semester to 8 th semester. mean age of the students were 21.3 ± 1.3 years. among 133 students 18% were male and 82% were females. further details are found in table 2. table 2: semester distribution and education of diabetic retinopathy of medical students. variables n % semester 5 th 19 14.3 6 th 42 31.6 7 th 33 24.8 8 th 39 29.3 education about diabetic retinopathy acquired from medical college education 50 37.6 internet 31 23.3 books and combination of sources 38 28.6 journals and continued medical education 14 10.5 regarding knowledge, 39.1% of the students did not have any idea regarding value of hba1c and 36.8% gave wrong answer. only 6% answered correctly regarding prevalence of diabetes in pakistan. ninety seven percent students responded that duration of diabetes was important in developing diabetic retinopathy and 98.5% responded that control of diabetes was significant in prevention of diabetic retinopathy. symptoms and risk factors of diabetes were assessed by scoring. majority of the students identified risk factors of diabetic retinopathy as uncontrolled diabetes. variable other risk factors like obesity, smoking, hyperlipidemia and sedentary lifestyle were also recorded along with uncontrolled sugar levels. ninety three percent reported that symptoms of diabetic retinopathy were blurred vision, vision loss and floaters and 52.6% students considered type 1 diabetes to be more associated with diabetic retinopathy than type 2. regarding attitude, 89.5% of the students considered that visual loss due to diabetes can be prevented and 95.5% responded that routine ophthalmic examination is must for all diabetic patients. role of early detection of diabetes in preventing diabetic retinopathy was highlighted by 96.2% students. seventy three percent students had the concept that diabetic retinopathy was more common in uneducated patients. ten percent students did not know about the time of followup for a diabetic patient and 46.6% responded that 6 months to 1 year was the followup time. thirteen percent students were unable to give advice to the patients. overall kap score the mean of the overall kap score for all students was 53.3 ± 1.2 (76%). the knowledge score was 23.9 ± 1.77 (68%), attitude score was 17.7 ± 0.5 (85%) and practice score was 11.7 ± 0.65 (78%). the mean overall score for males (54.66 ± 4.04) was higher than for females (53 ± 3.86). the male students scored better in knowledge and attitude while females scored better in practice. table 3: shows kap score by gender. variables mean + sd gender knowledge maximum: 35 attitude maximum: 20 practice maximum: 15 total maximum: 70 male 24.8 + 5.0 17.3 + 3.9 12.5 + 3.2 54.6 + 4.04 female 23.7 + 4.6 16.5 + 3.6 12.8 + 3.4 53 + 3.86 p value 0.15 0.12 0.34 discussion our results of study will help in establishing a uniform pathway to assist us in promoting methods of teaching amongst students in areas where they lag behind. need for cme and encouraging students to read medical journals will be our proposed methods. study is going to play important role in prevention of diabetic retinopathy in community too since these students are the first one to come in contact with patients in their teaching clinics. maximum kap score in our study was 76%. a similar study conducted in pakistan found kap score of more than 70%. 16 our study revealed that knowledge information about diabetic retinopathy was good amongst students 68.5% (kap: 23.9/35). whereas study in switzerland reported mediocre knowledge among their students. 17 majority of the students according to our study results were able to identify risk factors of diabetic retinopathy correctly like study of odisha. 18 many of our students could not tell prevalence of diabetic retinopathy in pakistan. this is in accordance with study conducted in saudia where 40% did not know the prevalence. 19 a positive attitude was found amongst our students as 95% believed that diabetes was preventable with early detection and therefore required routine mir amjad ali, et al 74 pak j ophthalmol. 2022, vol. 38 (1): 71-75 ophthalmic assessment. it was similar to the study conducted in odisha. 18 seventy four percent of students believed that diabetes was more prevalent among uneducated population. such results have also been reported in a study at saudia. 19 this shows confusion prevailing among students regarding practice towards diabetes. another study highlighted the salient reasons for low kap status. it included a busy schedule, less resources, inadequate periodic training in eye care and absence of retinal evaluation training. 20 practice assessment revealed that our students lagged behind in this area. only 8.6% students identified correct modalities of treatment of diabetic retinopathy like intravitreal injection, laser procedures and surgical procedures. a fair percentage was totally unaware of the idea that how frequent should be the followup be done by an ophthalmologist. limitations of this study are that we considered knowledge of 3 rd year students equal to the 4 th year students who have completed their ophthalmology teaching and clinical rotation by that time. comparison between these two groups of students should also be done. it was a single center study and do not represent the overall picture of all our medical students. conclusion our study pointed out weakness in knowledge and practice of medical students regarding prevention and management of diabetic retinopathy. it also assisted us in deciphering common confusion faced by our students regarding treatment modalities. there is a dire need to conduct workshops and seminars to address the teaching modalities of our medical system. special attention is required in teaching our young graduates to aid in treating this reversible cause of blindness prevailing in our society. ethical approval the study was approved by the institutional review board/ethical review board (irb-1296/duhs/approval/2021). conflict of interest authors declared no conflict of interest. references 1. diabetes. world health organization. available at: https://www.who.int/nmh/publications/fact_sheet_diabe tes_en.pdf. accessed 26 th november 2021. 2. international diabetes federation. idef diabetes atlas. 6th ed. 2014 update. [updated 2014. cited 2014 oct 20]. geneva (ch): world health organization; 2014 3. king h, aubert re, herman wh. global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections. diabetes care, 1998; 21 (9): 14141431. 4. atlas ii. 7th edn. international diabetes federation, 2015. 5. meo sa, zia i, bukhari ia, arain sa. type 2 diabetes mellitus in pakistan: current prevalence and future forecast. j pak med assoc. 2016; 66 (12): 16371642. pmid: 27924966. 6. yau jw, rogers sl, kawasaki r, lamoureux el, kowalski jw, bek t, et al. global prevalence and major risk factors of diabetic retinopathy. diabetes care, 2012; 35: 556-564. 7. tumosa n. eye disease and the older diabetic. clin geriatr med. 2008; 24: 515-527. 8. gadkari ss, maskati qb, nayak bk. prevalence of diabetic retinopathy in india: the all india ophthalmological society diabetic retinopathy eye screening study 2014. indian j ophthalmol. 2016; 64 (1): 38. 9. fong ds, aiello l, gardner tw, king gl, blankenship g, cavallerano jd, et al. retinopathy in diabetes. diabetes care, 2004; 27 (suppl. 1): s84-87. 10. kanski jj. clinical ophthalmology: a systematic approach. 9 th edition. butterworth heinemann elsevier, 2019. 11. american academy of ophthalmology retina panel: preferred practice pattern guidelines: available at: https://www.aao.org/preferred-practice-pattern/diabeticretinopathy-ppp accessed 26th november 2021. 12. early treatment diabetic retinopathy study research group: early photocoagulation tor diabetic retinopathy (etdrs report number 9). ophthalmology, 1991; 98 (5 suppl.): 766-785. 13. diabetic retinopathy vitrectomy study research group: early vitrectomy for severe proliferative diabetic retinopathy in eyes with useful vision: results of a randomized trial (drvs report number3). ophthalmology, 1988; 95: 1307-1320. 14. nida s, khan da, ijaz a, khan mq, aleef h, abbasi m. determination of mean glycated haemoglobin in healthy adults of a local population. j coll physicians surg pak. 2017; 27 (7): 399-403. 15. al-wadani fa. nursing students perceived knowledge, attitudes, and practices concerning ocular complications of diabetes. int j innov res multidiscip field, 2016; 2 (9): 119-128. https://www.who.int/nmh/publications/fact_sheet_diabetes_en.pdf https://www.who.int/nmh/publications/fact_sheet_diabetes_en.pdf https://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp%20accessed%2026th%20november%202021 https://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp%20accessed%2026th%20november%202021 perception of knowledge, attitude and practice of diabetic retinopathy amongst medical students pak j ophthalmol. 2022, vol. 38 (1): 71-75 75 16. mumtaz s, ashfaq t, siddiqui h. knowledge of medical students regarding diabetes mellitus at zia-uddin university, karachi. j pak assoc. 2009; 59: 163166. 17. roman trepp, tonio wille, thomas wieland and walter h. reinhart diabetes-related knowledge among medical and nursing house staff, department of internal medicine, kantonsspital graubunden, chur, switzerland, swiss med wkly. 2010; 140 (25-26): 370-375. 18. panigrahi s, sahu rk, jali sn, rath b, pati s, kerketta m. knowledge, attitude and practice regarding diabetic retinopathy among medical and nursing students of a tertiary care teaching hospital of odisha: a cross sectional study. iosr j dent med sci. 2017; 16: 1-7. 19. wadaani fa. the knowledge attitude and practice regarding diabetes and diabetic retinopathy among final year student of king faisal university medical college of al-hasa region of saudia arabia a cross sectional survey, niger j clin prac. 2013; 16 (2): 164-168. 20. abu-amara tb, al rashed wa, khandekar r, qabha hm, alosaimi fm, alshuwayrikh aa, et al. knowledge, attitude and practice among nonophthalmic health care providers regarding eye management of diabetics in private sector of riyadh, saudi arabia. bmc health serv res. 2019; 19 (1): 375. doi: 10.1186/s12913-019-4216-9. author’s designation and contribution shehla dareshani; associate professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. fiza farooq; post graduate student: design, data acquisition, data analysis, statistical analysis, manuscript review. dr. mir amjad ali; professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. nusrat shah khan; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. dr. zaheer sultan; consultant ophthalmologist: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (4): 420-423 420 brief communication revamping the ophthalmic clinical practice during pandemic covid 19; a potential new normal nausheen hayat 1 , saad jaan sarhandi 2 , alyscia cheema 3 1-3 department of ophthalmology, jinnah postgraduate medical centre, karachi abstract this paper discusses how covid-19 affected ophthalmology practices at jpmc and the measures taken to minimize the spread of infection among doctors, nurses, administrative staff, and patients. staff members and doctors were divided into groups consisting of a consultant, two trainees, a house-officer and eight paramedics. out of the eight paramedics, three were posted in theatre, two inwards and the remaining in outpatient clinics. these measures helped us in the restoration of our services quickly. all elective surgeries were cancelled. in the ward, social distancing was observed. no one was allowed inside the ward without thermal scanning. only one attendant was allowed with pediatric patients and all the adults, including patient were required to wear m asks. before admitting patients to the ward, a negative covid-19 pcr test was compulsory. these precautionary measures helped to reduce the spread of coronavirus among the department staff. how to cite this article: hayat n. revamping the ophthalmic clinical practice during pandemic covid 19; a potential new normal. pak j ophthalmol. 2021, 37 (4): 420-423. doi: 10.36351/pjo.v37i4.1279 introduction covid-19, which is caused by severe acute respiratory syndrome corona virus 2 (sars-cov-2), emerged in wuhan, china in 2019 and spread rapidly across the world. 1 world health organization (who) declared covid-19 as a pandemic on 11 th march 2020. 2 there are over 130 million confirmed cases so far and over 3 million people have lost their lives in pakistan, the confirmed cases are over 700,000, resulting in over15,000 deaths. 3 all across the world, governments announced kerbs on movement of people including lockdowns to control the spread of virus. pakistan went into a nationwide lockdown on 1 st april 2020, with all businesses closed and only emergency services allowed to operate to curb the growing spread correspondence: nausheen hayat department of ophthalmology jinnah postgraduate medical centre, karachi email: nausheen.hayat@hotmail.com received: may 22, 2021 accepted: september 23, 2021 of covid-19. jinnah postgraduate medical centre (jpmc), the largest tertiary care hospital in karachi, took immediate measures by making compulsory to wear masks, closing opds, postponing elective surgeries and allowing only on-call doctors and paramedics. the eye department conducted a risk review, considering the additional danger posed to ophthalmologists due to proximity between the doctor and the patient during ophthalmic examination. it was also reported by lu et al. that ocular surfaces potentially transmittedcoronavirus. 4 this paper discusses how covid-19 affected ophthalmology practices at jpmc and the measures taken to minimize the spread of infection among doctors, nurses, administrative staff, and patients. staff members and doctors were divided into groups consisting of a consultant, two trainees, a house-officer and eight paramedics. out of the eight paramedics, three were posted in theatre, two inwards and the remaining in outpatient clinics. these measures helped us in the restoration of our services quickly. open access nausheen hayat 421 pak j ophthalmol. 2021, vol. 37 (4): 420-423 later, two parallel teams were created to work on alternate days, thus minimizing the physical contact between the two teams to contain the virus spread. 5 general adult and pediatric outpatient clinics remained open, whereas all specialised clinics were closed. in the general clinic, the team comprised of a consultant and four resident physicians, whilst in the paediatric clinics, the team comprised of a consultant and two resident physicians [figure 1]. in the outpatient clinics, all surfaces were disinfected daily with alcohol and chlorine-based chemicals. specially-designed face shields covered slit lamps to prevent infection. 6 the slit lamp, breath shields, tonometer tips and other instruments were disinfected after each use. hand sanitisers and alcohol swabs were provided in all the rooms and were used after examining every patient. a triage counter was setup (figure 2) to screen patients for body temperature and other covid-19 symptoms. patients with minor ailments, such as allergic, viral, or mild bacterial conjunctivitis, were seen at the triage counter with a pen-torch and given appropriate treatment. considering infection transmission via conjunctiva of the eye, optometry services were shut down to reduce the risk to the staff and the patients, except in cases where biometry services were required for the urgent surgeries. 7 ppes, including hazmat suits, aprons, face shields, kn95 masks, gloves, and disposable scrub caps, were provided to doctors and staff. all elective surgeries were cancelled. in the ward, social distancing was observed. no one was allowed inside the ward without thermal scanning. only one attendant was allowed with pediatric patients and all the adults, including patient were required to wear masks. before admitting patients to the ward, a negative covid-19 pcr test was compulsory. all doctors, nurses and administrative staff in the ward, clinics and ors took periodic covid-19 antibody test. in the case of a positive test result, the individual was required to isolate at home, take a covid-19 pcr test, and return after two consecutive negative pcr tests. after two months of lockdown, all doctors, paramedics, and other staff underwent serum corona virus antibody test. results revealed the following:  mean age: 36.32 ± 12.10 years.  gender distribution: male (64%), female (36%).  antibody positive rate: 20%.  gender distribution of antibody positive: male (16%), female (4%). it was found that the oldest age group of 61 – 70 years showed negative results (graph 1). all members with positive covid-19 antibody test were placed on the front line in emergency. academic activities such as daily and weekly rounds were suspended, while teaching was continued online. rubric grading was introduced for academic assessment of trainees. wet lab for phacoemulsification and corneal suturing, was conducted weekly with reduced number of participants, while wearing masks and maintaining two meters amongst the participants. telemedicine was not feasible due to lack of infrastructure especially at the patients’ end. the above-mentioned precautionary measures helped to reduce the spread of coronavirus among the department staff. following guidelines were practiced throughout the pandemic and which can be recommended to the ophthalmic community. 1. urgent care should be given to sight-threatening or life-threatening conditions, such as; trauma, tumours, proptosis, retinal detachment, pediatric traumatic cataract or retinal detachment, examination under general anaesthesia of children suspected of glaucoma, retinoblastoma and retinopathy of prematurity. 2. social distancing should be practiced waiting area, doctors and staff community rooms and wards which make a significant difference. 3. frequent surface disinfection with alcohol and chlorine-based chemicals. 4. personal protective equipment including face shields, slit lamp shields, protective goggles, hazmat suits, gloves, hand sanitizers and disposable aprons should be provided to all staff. 5. triage area should be set up to ascertain symptoms, recent travelling and recent contact with a covid positive patient in family and close friends. 6. covid testing should be made part of all preoperative assessment, particularly for the patients undergoing general anaesthesia. revamping the ophthalmic clinical practice during pandemic covid 19; a potential new normal pak j ophthalmol. 2021, vol. 37 (4): 420-423 422 figure 1: distribution of patient by age groups and reactivity. figure 2: nausheen hayat 423 pak j ophthalmol. 2021, vol. 37 (4): 420-423 7. avoid surgeries which includes contact with nasopharyngeal fluids e.g., dcr. references 1. chen l, liu w, zhang q, xu k, ye g, wu w, et al. rna based mngs approach identifies a novel human coronavirus from two individual pneumonia cases in 2019 wuhan outbreak. emerg microbes infect. 2020; 9 (1): 313–319. https://doi.org/10.1080/22221751.2020. 2. who director-general's opening remarks at the media briefing on covid-19 – 11 march 2020. available at https://www.who.int/dg/speeches/detail/who-directorgeneral-s-opening-remarks-at-the-media-briefing-oncovid-19---11-march-2020 3. waris a, atta uk, ali m, asmat a, baset a. covid-19 outbreak: current scenario of pakistan. new microbes new infect. 2020; 35: 100681. doi:10.1016/j.nmni.2020.100681 4. lu cw, liu xf, jia zf. 2019-ncov transmission through the ocular surface must not be ignored. lancet (london, england), 2020; 395 (10224): e39. 5. american academy of ophthalmology. coronavirus impact: practice operations and safety considerations. available at: https://www.aao.org/practicemanagement/article/coronavirus-practiceoperationssafety-advice 6. american academy of ophthalmology. alert: important coronavirus updates for ophthalmologists. available at: https://www.aao.org/headline/alertimportant-coronavirus-context 7. liang l, wu p. there may be virus in conjunctival secretion of patients with covid‐19. acta ophthalmologica. 2020; 98 (3): 223. doi: 10.1111/aos.14413. author’s designation and contribution nausheen hayat; consultant orbit oculoplastic surgeon: concepts, design data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. saad jaan sarhandi; fcps trainee: design, literature search, manuscript preparation. alyscia cheema; professor: concepts, manuscript review. .…  …. https://doi.org/10.1080/22221751.2020 https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 https://www.aao.org/practice-management/article/coronavirus-practice-operationssafety-advice https://www.aao.org/practice-management/article/coronavirus-practice-operationssafety-advice https://www.aao.org/practice-management/article/coronavirus-practice-operationssafety-advice https://www.aao.org/headline/alert-important-coronavirus-context https://www.aao.org/headline/alert-important-coronavirus-context pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 1 editorial advanced approaches for management of retinal detachment vitrectomy without scleral buckling1 for rhegmatogenous retinal detachment is often referred to as “primary vitrectomy”2; a term which at least initially implied that scleral buckling was the standard of care and should be tried before resorting to vitrectomy. this “rescue therapy” approach is considered to be “conservative” and applied in many specialties and disease processes but can produce the unintended consequence of delaying adoption of improved therapies and putting the patient through an unnecessary procedure. anterior segment surgeons do not try intracapsular cataract extraction before resorting to phaco or rk before lasik. long bone fractures were not randomized to sham therapy after casts were developed. there are no high quality clinical trials comparing vitrectomy3,4, scleral buckling, and combined vit-buckle procedures for rhegmatogenous retinal detachment surgery because there are a high number of clinical variables and many treatment options which are often used in combination. pre-operative variables include type of breaks, size of breaks, number of breaks, lens status, refractive error, vitreous hemorrhage, vitreous traction, family history, status of the other eye, medical status, and many others. variables in scleral buckling include: hard silicone versus sponges, subretinal fluid drainage versus non-drainage, radial versus circumferential elements, encircling versus segmental buckles, use of air or gas, paracentesis and many others. variables in vitrectomy include air, sf6, c3f8 or silicone oil, laser versus cryo, 20, 23, 25 or 27 gauge5, use of liquid perfluorocarbons, combined lensectomy6 or phacoemulsification, post-operative positioning, and many others. scleral buckle advocates7 have stated that pneumatic retinopexy often causes pvr but they manage “fish-mouthing” in scleral buckling with gas injection; this is not rational. some surgeons use vitrectomy only for pseudophakic eyes believing incorrectly that vitrectomy causes de novo nuclear sclerosis when, in fact, it only causes progression of pre-existing nuclear sclerosis because a permanent increase in the partial pressure of oxygen (12 mmhg). complications of scleral buckling proponents of scleral buckling often minimize the complications of scleral buckling7. and state that they “never” produce strabismus yet a high quality prospective trial reported by the late ron michels, an excellent surgeon, demonstrated a 50% incidence of increased tropias and phorias. encircling buckles may result in damage to the superior oblique or superior rectus tendons producing problematic vertical strabismus. fortunately, most buckle surgeons have given up the unnecessary practice of removing and reattaching extraocular muscles. aggressive traction on retromuscle traction sutures, especially with small diameter sutures can damage and potentially sever intraocular muscle tendons. aggressive stripping of the intramuscular septum, tenon’s capsule, and episclera combined with cautery can create adhesions between these layers causing problems when there is subsequent glaucoma filtering procedures. many surgeons use encircling bands7 in essentially all buckle cases. a circumferential buckle produces the same outcomes in most instances without inducing myopia or causing damage to extraocular muscles potentially causing diploplia or damage to the levator aponeurosis resulting in ptosis. patients spend substantial sums of money in the pursuit of emmetropia; lasik, prk, and refractive lens exchange have raised patient’s expectations of life without glasses or contacts. cataract surgery patients expect emmetropia as well; substantial effort has been applied to microincisional surgery, foldable iols, toric iols, multi-focal intraocular lenses, accommodative (minimally) iols, and femtosecond laser surgery. an encircling band produces 2.75 diopters of myopia on average; this is completely unacceptable to a patient that has paid for refractive cataract surgery, lasik, or prk. more serious complications of scleral buckling include late intrusion of the buckle and buckle extrusion and infection7. intraoperative complications include a 5% incidence of retinal incarceration at the drainage site when using cut-down drainage as well steve charles 2 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology as bleeding related to the drainage site. scleral, choroidal, retinal perforation with scleral sutures is a not uncommon as well; sometimes with serious consequences. vit-buckles many vitreoretinal surgeons use encircling bands in conjunction with vitrectomy for repair of rhegmatogenous retinal detachment; so called vitbuckles8. i have not used this approach for two decades in order to eliminate buckling induced refractive errors, strabismus, ptosis, and pain as well to reduce operating times and therefore labor costs. patients would not want a vitreoretinal surgeon to use encircling bands when having vitrectomy repair of retinal detachment if they were informed about outcomes and complications. there is no level one evidence that vit-buckles produce better outcomes than vitrectomy without scleral buckles, even in pvr cases. vitrectomy techniques wide-angle visualization techniques and/or scleral depression are essential if vitrectomy is to be used for retinal detachment repair.9 contact-based wide-angle visualization (volk, avi) produces 10 degrees greater field of view than non-contact (biom, resight, merlin and eliminates all corneal asphericity (keratoconus, lri, rk, pk, cataract surgery, lasik, prk). in addition, contact-based wide-angle visualization greatly reduces the need for ocular rotation to view the periphery which reduces flexural forces on 25/27 gauge tools. just as with scleral buckling, all retinal breaks must be identified and treated with retinopexy.10 traction to the flap as well as vitreous traction surrounding all breaks must be eliminated to produce ~90% single procedure success rates. internal drainage of subretinal fluid performed simultaneously with fluid-air exchange with a soft-tip cannula usually drains most of the subretinal fluid. if internal drainage is initiated prior to fluid-air exchange, posterior migration of subretinal fluid is reduced. drainage retinotomy can be used if substantial posterior migration of subretinal fluid occurs or the retinal breaks are very small and far peripheral which can make internal drainage challenging. another option for removal of subretinal fluid is perfluorocarbon liquids; n-perfluorooctane (pfo) is the preferred agent because the interface is visible unlike perflurodecalin. pfo will remove all subretinal fluid if the optimal techniques are utilized while internal drainage of subretinal fluid plus fluid-air exchange always leaves a thin layer of fluid which must be pumped out by the rpe. because pfo causes subretinal fluid to float anteriorly, care must be taken to remove all srf anterior to the retinal breaks to enable surrounding all breaks with endolaser. this can be done by extending the break to the ora or making a very peripheral, small drainage retinotomy but the best approach is to slowly drain srf through the retinal break using a 25g soft-tip cannula just when the pfo reaches the break12. care must be taken to not remove any pfo. the medone 25g dual-bore vfi is ideal to inject pfo while allowing infusion fluid egress to maintain optimal iop. 25/27 gauge sutureless vitrectomy the author utilizes 25/27g sutureless13 approach for all vitrectomies including rhegmatogenous retinal detachments, pvr, giant breaks, and diabetic traction retinal detachments. just as today’s patients expect emmetropia without strabismus or ptosis as discussed above, they expect a painless procedure and a noninflamed eye. a non-inflamed, pain-free eye is not achievable with 20g sutured wounds or vit-buckles. contrary to what some surgeons believe, 25g vitrectomy fluidics are preferable to 23g or 20g fluidics for rd14 cases because port-based flow limiting due to a smaller lumen reduces pulsatile vitreoretinal traction. the author strongly recommends use of the highest possible cutting rate for all tasks and all cases; especially for giant breaks and other retinal detachment cases. the author uses the alcon constellation vision system at 7500 cuts/minute. sutured-on contact lenses damage the conjunctiva, cause sub-conjunctival bleeding, and are inappropriate for sutureless, trans-conjunctival surgery. medium term pfo for inferior retinal detachments the author developed and has used medium term pfo for virtually all inferior retinal detachments including phakic and pseudo-phakic eyes, young myopes without pvds, giant breaks and early pvr. vitrectomy, pfo injection and laser is performed at the initial procedure; the pfo is removed at 14 days. the patients can sit, stand, work and fly; no bedrest is required. pfo is not toxic; it causes a reversible foreign body response in some patients with no long term sequela. retained small bubbles in the anterior chamber must be removed with a 30 gauge needle at the slit lamp to prevent long term glaucoma. if pvd if advanced approaches for management of retinal detachment pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 3 not present at the initial procedure, it will slowly and safely occur during the 14 days the pfo is in place. silicone oil silicone oil injection is not difficult with the alcon 25/27 gauge tools; there is no need for reverting to 20 or 23 gauge surgery for silicone oil cases. 1000 cs oil has the same emulsification rate as 5000 cs oil and is 5x faster to inject and remove; there is no need for 5000 cs oil. oil should be injected with a short thin wall cannula after fluid air-exchange not through infusion cannula tubing system. removal of oil is not necessary or advantageous for pvr re-operation or epimacular membrane; forceps membrane peeling with alcon 25g dsp ilm forceps, retinectomy, removal of subretinal fluid an endophotocoagulation can all be performed handily “under” oil. summary sutureless, trans-conjunctival microincisional vitrectomy is ideal for retinal detachment repair. in the author’s opinion, vit-buckles are no longer indicated; the focus should be on microincisional vitrectomy techniques and wide-angle visualization to repair retinal detachments without causing pain, refractive error, strabismus, ptosis, cosmetic problems and longer, more costly operating times. references 1. goezinne f, la heij ec, berendschot tt, kessels ag, liem at, diederen rm, hendrikse f. acta incidence of redetachment 6 months after scleral buckling surgery. scleral buckling versus vitrectomy, brazitikos p., ophthalmology. 2006; 113: 1245. 2. ho jd, kuo nw, tsai cy, liou sw, lin hc. surgeon age and operative outcomes for primary rhegmatogenous retinal detachment: a 3-year nationwide population-based study. ophthalmol. 2009; 23. 3. von fricken ma, kunjukunju n, weber c, ko g. 25gauge sutureless vitrectomy versus 20-gauge vitrectomy for the repair of primary rhegmatogenous retinal detachment. eye. 2009 may 1. 4. d'amico dj. clinical practice. primary retinal detachment. retina. 2009; 29: 444-50. 5. heimann h. [primary 25and 23-gauge vitrectomy in the treatment of rhegmatogenous retinal detachment-advancement of surgical technique or erroneous trend?] n engl j med. 2008; 27: 359. 6. acar n, kapran z, altan t, unver yb, yurtsever s, kucuksumer y. primary 25-gauge sutureless vitrectomy with oblique sclerotomies in pseudophakic retinal detachment. retina. 2008; 28: 1075-81. 7. hedaya j, nigam n, freeman wr. scleral buckling versus vitrectomy. retina. 2008; 28: 1068-74. 8. miller dm, riemann cd, foster re, petersen mr. primary repair of retinal detachment with 25-gauge pars plana vitrectomy. ophthalmology. 2008; 115: 1634-5. 9. lai mm, ruby aj, sarrafizadeh r, urban ke, hassan ts, drenser ka, garretson br. repair of primary rhegmatogenous retinal detachment using 25-gauge transconjunctival sutureless vitrectomy. retina. 2008; 28: 931-6. 10. dubey ak, dubey b. primary 25-guage transconjunctival sutureless vitrectomy in pseudophakic retinal detachment. retina. 2008; 28: 729-34. 11. zhou p, zhao mw, li xx. re: phacovitrectomy for primary retinal detachment repair in presbyopes. retina. 2008; 28: 666. 12. mendrinos e, dang-burgener np, stangos an, sommerhalder j, pournaras cj. primary vitrectomy without scleral buckling for pseudophakic rhegmatogenous retinal detachment. retina. 2008; 28: 665. 13. pastor jc, fernández i, rodríguez de la rúa e, coco r, sanabria-ruiz colmenares mr, sánchez-chicharro d, martinho r, ruiz moreno jm, garcía arumi j, suárez de figueroa m, giraldo a, manzanas l. surgical outcomes for primary rhegmatogenous retinal detachments in phakic and pseudophakic patients: the retina 1 project--report 2. am j ophthalmol. 2008; 145: 1063-70. 14. ho jd, liou sw, tsai cy, tsai rj, lin hc. trends and outcomes of treatment for primary rhegmatogenous retinal detachment: a 9-year nationwide populationbased study. br j ophthalmol. 2008; 92: 378-82. steve charles, md facs, fics clinical professor of ophthalmology university of tennessee founder & ceo, charles retina institute www.charlesretina.com http://www.ncbi.nlm.nih.gov/pubmed/19432848?ordinalpos=1&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/19432848?ordinalpos=1&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/19432848?ordinalpos=1&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/19407840?ordinalpos=2&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/19407840?ordinalpos=2&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/19407840?ordinalpos=2&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum 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http://www.ncbi.nlm.nih.gov/pubmed/18303159?ordinalpos=15&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/18303159?ordinalpos=15&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/18303159?ordinalpos=15&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/18303159?ordinalpos=15&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/18239675?ordinalpos=16&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/18239675?ordinalpos=16&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/18239675?ordinalpos=16&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.ncbi.nlm.nih.gov/pubmed/18239675?ordinalpos=16&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_defaultreportpanel.pubmed_rvdocsum http://www.charlesretina.com/ 317 pak j ophthalmol. 2021, vol. 37 (3): 317-321 original article comparison of mean axial length measured by acoustic biometry versus optical biometry munira shakir 1 , ronak afza 2 , mariyam azam 3 , sahira wasim 4 , waqas ali 5 1-5 department of ophthalmology, liaquat national university hospital, karachi abstract purpose: to compare the mean axial length measured by acoustic biometry with optical biometry. design: descriptive observational study. place and duration of study: department of ophthalmology liaquat national hospital and medical college, karachi from november 2018 to april 2019. methods: were 246 patients with visually significant cataract who were recruited in this study by consecutive sampling. axial lengths were measured by non-contact optical method using carl zeiss iol master. after instillation of local anesthetic, axial lengths were re-measured by contact method with a-scan probe. all readings were taken by a single observer to avoid data collection bias. mean and standard deviation was computed for quantitative variable i.e. age, axial length by applanation ultra sound and axial length by optical biometry. frequency and percentage was calculated for qualitative variables i.e. gender. differences of axial length between the applanation and optical biometry were compared by using pair t-test. effect modifiers like age and gender were addressed through stratification, post stratification independent test for two groups and anova for more than two groups was applied. results: the average age of the patients was 58.09 ± 7.27 years. mean axial length by optical biometry was 23.744 ± 0.74mm as compared to 22.29 ± 0.76 mm by acoustic method and this difference was statistically significant (p = 0.0005). conclusion: results of axial length with optical and acoustic biometry are significantly different with p value less than 0.05. however, optical biometers fail in cases of dense media opacities where acoustic biometry in needed. key words: cataract, axial length, applanation ultrasound, optical biometry. how to cite this article: shakir m, afza r, azam m, wasim s, ali w. comparison of mean axial length measured by acoustic biometry versus optical biometry. pak j ophthalmol. 2021, 37 (3): 317-321. doi: 10.36351/pjo.v37i3.1264 introduction cataract surgery with intraocular lens (iol) implantation is one of the most common and frequent surgical procedures performed in ophthalmology. 1 correspondence: ronak afza department of ophthalmology, liaquat national university hospital, karachi email: ronakafzamemon@yahoo.com received: may 03, 2021 accepted: june 07, 2021 now-a-days cataract surgery is also considered as a type of refractive surgery. 2 therefore, appropriate iol power calculation is a crucial step to achieve the best possible refractive outcomes. 3 axial length and corneal curvatures are the two important parameters for iol power calculation, among which axial length is the most important one. 4 at present, biometry is done by two different methods, using distinct principles. one of these is a-scan contact ultrasound, which uses 10 mhz ultrasonic waves to measure axial length up to vitro-retinal interface only. it uses the echo delay time to measure intraocular distances. 5 for accurate measurement 3 consecutive readings should open access comparison of mean axial length measured by acoustic biometry versus optical biometry pak j ophthalmol. 2021, vol. 37 (3): 317-321 318 be taken with a difference of 0.02m. 6 optical biometry (iol master)was introduced in 1999 by carl zeiss meditec and uses the principle of partial coherence interferometry (pci) with a 780nm laser diode infrared light and measures the axial length from tear film to retinal pigment epithelium. 7 advantages of this recent technology include high precision, its non-contact method and independency of observers bias. it is also useful in pseudophakic and silicone filled eyes. on the other hand, its limitations include media opacities like dense cataract and vitreous hemorrhage where ultrasound biometry is the method of choice. a study conducted at king saoud university showed that the mean axial length by iol master was 23.7mm ± 0.5 as compared to 23.6mm ± 0.6 by acoustic method. this study showed that there was no statistically significant difference in the axial length measured by the two methods. 6 the purpose of our study was to determine the mean axial length measured by acoustic versus optical biometer and consequently find out whether there was difference between the two or not. this will help in refining post-operative refractive outcome by calculating the iol power more accurately. previous studies also indicate that the research on this subject has been scarce nationally as well internationally. methods the study was conducted in department of ophthalmology, liaquat national hospital and medical college, karachi. it was a cross-sectional study of 6 months duration and was carried out between november 2018 to april 2019. by using open epi, taking axial length of iol master = 23.18 ± 0.77 3 axial length by ultrasound = 22.94 ± 0.75, 3 power of test = 80% and 95% confidence level, sample size was calculated. mean difference equal to 00.24 – 0.02 and margin of error of 0.0025, the calculated sample size was 246. it was non probability consecutive sampling. inclusion criteria was age 40 – 80 years, either gender with visually significant cataract (examined by slit lamp examination & the best-corrected visual acuity of < 20/40 or 6/12 vision in the study eye on snellen’s chart). patients with axial length between 22 – 25mm were included. patients with axial length less than 22mm and greater than 25mm, dense cataract, history of previous refractive surgery, patients with corneal opacities or scars, corneal edema, keratoconus, keratoglobus, vitreous hemorrhage, retinal detachment or retinitis pigmentosa and history of ocular trauma were excluded. after the approval of study, all the consecutive patients fulfilling the inclusion criteria were recruited. informed verbal consent was taken from all the patients. procedure was explained to the patients thoroughly. axial lengths were measured by noncontact optical method using carl zeiss iol master. then, after instillation of local anesthetic, proparacaine, axial lengths were measured by contact method using a-scan probe. to overcome the examiner bias, single researcher performed the measurements. readings from both devices were compared and analyzed by using spss version 21. mean and standard deviation was computed for quantitative variable i.e. age, axial length by applanation ultra sound and axial length by optical biometry. frequency and percentage was calculated for qualitative variables i.e. gender. differences of axial length between the applanation and optical biometry were compared by using pair t-test. effect modifiers like age and gender was addressed through stratification, post-stratification independent test for two groups and anova for more than two groups was applied. p-value less than or equal to 0.05 was taken as significant. results there were 246 patients with visually significant cataract, who were recruited in this study. most of the patients were 51 to 70 years of age. the average age of the patients was 58.09 ± 7.27 years. there were 112 (45.53%) males and 134 (54.47%) females. there were 102 (41.46%) right and 144 (58.54%) left eyes. table 1: mean comparison of axial length with age group, gender and technique. axial length p-value age group 41 – 50 years 0.14 ± 0.14 .572 50 to 60 years 0.14 ± 0.19 60 to 70 years 0.17 ± 0.22 > 70 years 0.09 ± 0.15 gender male 0.17 ± 0.25 0.301 female 0.14 ± 1.4 technique applanation ultrasound 22.29 ± 0.76 < 0.0005 optical biometry 23.44 ± 0.74 independent t-test and anova is applied *p < 0.05 is considered as significant munira shakir, et al 319 pak j ophthalmol. 2021, vol. 37 (3): 317-321 mean axial length by optical biometry was 23.744 ± 0.74mm as compared to 22.29 ± 0.76mm by acoustic method. this difference was statistically significant (difference = 0.153 ± 0.197; p = 0.0005). further detail is given in table 1. discussion with an incidence of 53.7%, cataract remains a significant ophthalmic morbidity where surgical treatment continues to be the definitive treatment and active area of research. 8,9 an increasing number of technologies have been introduced over time to assist in biometric measurement of the eye, further enhancing refractive accuracy and precision as an achievable quality metric. modern cataract surgery is considered a form of refractive surgery, aimed not only to restore visual clarity, but to provide excellent vision in refractive terms as well even when no intraocular lens (iol) is implanted. when prescribed, an iol is given to achieve a certain refractive status for the eye unlike what was obtainable in the past when refractive errors were corrected only after the surgery. this is made possible because of the development of modern, accurate diagnostic and surgical techniques. biometry values can be obtained either by contact (applanation), immersion or optical methods. to determine the mean difference in axial length measured by applanation ultrasound and optical biometry, a total 246 patients of either gender, age 4080 years with visually significant cataractwere recruited in this study. most of the patients were 51 to 70 years of age and the average age of the patients was 58.09 ± 7.27 years. most patients become aware of cataracts after the age of 60. however, cataracts start developing much earlier than that in the form of dysfunctional lens syndrome in which the natural lens goes through a normal aging process, which may cause changes in vision from the age of 40. in our study there were 112 (45.53%) male and 134 (54.47%) female. it has been shown in australian blue mountain study that females are more associated with senile cataract and the findings of our study follow the same pattern. 10 these findings are suggestive of female gender as a risk factor for cataract. 11 optical biometry offers many distinct advantages compared to acoustic biometry. it is a non-contact approach with accuracy and reproducibility in the context of non-severe pathology. when limitations such as dense media opacity, high axial myopia, and/or poor fixation prevent use of optical biometry, acoustic biometry becomes a useful alternative method, as it can be used in cases with significant media opacity. 12,13 the advantage of the applanation method is the faster measurements in the hands of a skilled operator. however, the disadvantage is the potential for corneal compression that may result in shorter axial length measurements. the disadvantage of the first optical biometery (e.g. iol master) in common clinical use, was the inaccurate measurement in cases of media opacities such as corneal scar and vitreous hemorrhage. in this study, we found statistically significant difference between the results of two methods. (p = 0.0005). however, in a previous study, no statistically significant difference was seen between the two methods for myopic eyes. 14 similarly henessy et al, 15 reported that there was longer measurement by contact method as compared to immersion technique. they also suggested that repeating measurements made contact ultrasound biometry comparable to that of immersion with no clinically significant difference in mean axial lengths. in a recent local study, comparison between axial length measured with non-contact and ultrasound technique showed that there was statistically significant difference (p < 0.05) between the two. 16 inone study, the precision achieved with optical biometry was equal to acoustic biometry. 17 another researcher observed significant underestimation of axial length measurement when using the iol master in eyes with rhegmatogenous retinal detachment with macular involvement, which could affect iol power selection. 18 in an indian study, applanation biometry with acoustic method showed significantly smaller axial lengths as compared to the optical biometry. 19 in contrast to this, kaswin, et al, compared the performance of acoustic scan with iolmaster 500 in 50 eyes and reported excellent correlation in the axial lengths obtained by the 2 devices when the axial length was in the range of 22 – 27mm. 20 limitation of this study is that we did not consider the other factors which affect the biometry, the most important of which is the keratometry. the effect on the final intraocular lens power calculation was also not taken into account. only a single formula srk/t comparison of mean axial length measured by acoustic biometry versus optical biometry pak j ophthalmol. 2021, vol. 37 (3): 317-321 320 was used. further research to address these issues is required to bring the results of biometry closer to emmetropia. conclusion results of axial length with optical and acoustic biometry are significantly different with p value less than 0.05. however, optical biometers fail in cases of dense media opacities where acoustic biometry in needed. ophthalmologist must keep ultrasound biometry in hand for patients whosebiometry cannot be done with optical device use to density of the cataract. ethical approval the study was approved by the institutional review board/ ethical review board. (ref: app 0450-2018-lnh-erc) conflict of interest authors declared no conflict of interest. refrences 1. zocher mt, rozema jj, oertel n, dawczynski j, wiedemann p, rauscher fg, et al. biometry and visual function of a healthy cohort in leipzig, germany. bmc ophthalmol. 2016; 16: 79. 2. chen m. refractive cataract surgery – what we were, what we are, and what we will be: a personal experience and perspective. taiwan j ophthalmol. 2019; 9 (1): 1-3. doi: 10.4103/tjo.tjo_133_18. 3. behndig a, montan p, stenevi u, kugelberg m, zetterström c, lundström m, et al. aiming for emmetropia after cataract surgery: swedish national cataract register study. j cataract refract surg. 2012; 38: 1181–1186. 4. wissa ar, wahba ss, roshdy mm. agreement and relationship between ultrasonic and partial coherence interferometry measurements of axial length and anterior chamber depth. clinic ophthalmol. 2012; 6: 193. 5. moshirfar m, buckner b, ronquillo yc, hofstedt d. biometry in cataract surgery: a review of the current literature. curr opin ophthalmol. 2019; 30 (1): 9-12. doi: 10.1097/icu.0000000000000536. 6. nakhli fr. comparison of optical biometry and applanation ultrasound measurements of the axial length of the eye. saudi j ophthalmol. 2014; 28 (4): 287-291. 7. huang j, savini g, li j, lu w, wu f, wang j, et al. evaluation of a new optical biometry device for measurements of ocular components and its comparison with iol master. br j ophthalmol. 2014; 98 (9): 12771281. 8. klein be, klein r, lee ke. incidence of age-related cataract over a 10-year interval: the beaver dam eye study. ophthalmology, 2002; 109 (11): 2052–2057. 9. congdon n, vingerling jr, klein be, west s, friedman ds, kempen j, et al. prevalence of cataract and pseudophakia/aphakia among adults in the united states. arch ophthalmol. 2004; 122 (4): 487–494. 10. cumming rg, michel p. hormone replacement therapy, reproductive factors and cataract. the blue mountain eye study. am j epidemiol. 1997; 145: 242249. 11. michel p, cumming rg, attebo k, panchapakesan j. prevalence of cataract in australia. the blue mountain eye study, ophthalmology, 1997; 104: 581588. 12. verhulst e, vrijghem jc. accuracy of intraocular lens power calculations using the zeiss iol master. a prospective study. bull soc belge ophtalmol. 2001; 281 (281): 61–65. 13. goebels sc, seitz b, langenbucher a. comparison of the new biometer oa-1000 with iol master and tomey al-3000. curr eye res. 2013; 38 (9): 910–916. 14. wang xg, dong j, pu yl, liu hj, wu q. comparison axial length measurements from three biometric instruments in high myopia. int j ophthalmol. 2016; 9 (6): 876. 15. hennessy mp, franzco dg. contact versus immersion biometry of axial length before cataract surgery. j cataract refract surg. 2003; 29: 2195-2198. 16. ashraf ma, sarwar ms, afzal ma, khalid i, shahid s. comparison of axial ocular measurements with contact and non-contact biometry, pak j ophthalmol. 2020; 36 (1): 72-78. doi: https://doi.org/10.36351/pjo.v36i1.922. 17. tappeiner c, rohrer k, frueh be, waelti r, goldblum d. clinical comparison of biometry using the non-contact optical low coherence reflectometer (lenstar ls 900) and contact ultrasound biometer (tomey al-3000) in cataract eyes. br j ophthalmol. 2010; 94 (5): 666-667. 18. pongsachareonnont p, tangjanyatam s. accuracy of axial length measurements obtained by optical biometry and acoustic biometry in rhegmatogenous retinal detachment: a prospective study. clin ophthalmol. 2018; 12: 973-980. https://doi.org/10.2147/opth.s165875 19. chandra m, jitendra s, chandra am, singh indian tg. the comparative study of applanation and optical coherence biometry methods for the intra ocular lens power calculation. j. pharm. biol. res. 2018; 6 (3): 1-8. munira shakir, et al 321 pak j ophthalmol. 2021, vol. 37 (3): 317-321 20. kaswin g, rousseau a, mgarrech m, barreau e, labetoulle m. biometry and intraocular lens power calculation results with a new optical biometry device: comparison with the gold standard. j cataract refract surg. 2014; 40: 593-600. authors’ designation and contribution munira shakir; professor: concepts, manuscript editing, manuscript review. ronak afza; resident: design, literature search, data acquisition, manuscript review. mariyam azam; resident: data acquisition, data analysis, manuscript review. sahira wasim; resident: statistical analysis, manuscript preparation, v waqas ali; resident: statistical analysis, manuscript preparation, manuscript review. .…  …. 12 pak j ophthalmol. 2021, vol. 37 (1): 12-16 original article results of intravitreal bevacizumab as an adjunct to metdrs grid laser in diabetic macular edema mahtab alam khanzada 1 , munawar ahmed 2 , azfar ahmed mirza 3 , ghazi khan mari 4 , muhammad arshad mahmood 5 1-4 department of ophthalmology, liaquat university of medical & health sciences, jamshoro, 5 department of ophthalmology, gulab devi teaching hospital, lahore abstract purpose: to assess the efficacy of intravitreal bevacizumab as an adjuvant to grid laser photocoagulation in patients with diffuse macular edema (dme) in type ii diabetes. study design: quasi experimental study. place and duration of study: institute of ophthalmology, liaquat university of medical and health sciences, jamshoro, from september 2016 to november 2018. methods: ninety-five type ii diabetic patients with diffuse macular edema were selected by convenient sampling. group i patients were treated with etdrs grid laser photocoagulation. group ii patients were treated with etdrs grid laser photocoagulation followed by intravitreal bevacizumab after one week monthly for 2 months and then as per need. all patients were examined after 1 st , 2 nd and 3 rd month and mean change in best corrected visual acuity (bcva) and central macular thickness (cmt) was recorded. results: the results of study were compared with the baseline values. the mean change in bcva in group 1 was from 46 ± 18 letters to 52 ± 17 letters and in group 2 was from 46 ± 18 letters to 56 ± 17 letters (p < 0.001). mean base line cmt was 504 µm (sd±189) in g-i and 506 µm (sd±189) in g-ii. mean cmt reduction was statistically significant in both groups during all follow up visits but in g-i it was 194 µm (p ≤ 0.001) and in g-ii 272 µm (p ≤ 0.001) at 6 months. conclusion: macular grid laser with or without intravitreal bevacizumab significantly improves vision and decreases macular edema but combined treatment led to more stable improvement in dme during follow-up. key words: grid laser, bevacizumab, macular edema, anti-vegf. how to cite this article: khanzada ma, ahmed m, mirza aa, mari gk, mahmood ma results of intravitreal bevacizumab as an adjunct to metdrs grid laser in diabetic macular edema. pak j ophthalmol. 2021, 37 (1): 12-16. doi: https://doi.org/10.36351/pjo.v37i1.1135 introduction according to international diabetic federation report published in 2017 there are four hundred and fifty-one correspondence: munawar ahmed department of ophthalmology, liaquat university of medical & health sciences, jamshoro email: munawar_404@yahoo.com received: september 9, 2020 accepted: october 9, 2020 million people in the world who have diabetic mellitus. by the year 2045 this figure may reach up to six hundred and ninety-three and half of them do not know about the disease. 1 worldwide the leading cause of visual impairment in working age group population is diabetic macular edema (dme) which is another worse manifestation of diabetic retinopathy. 2 there are so many different strategies to treat diabetic macular edema (dme) but medical management of systemic risk factors should be optimized before any treatment. otherwise, it may https://www.lumhs.edu.pk/ https://www.lumhs.edu.pk/ https://www.lumhs.edu.pk/ https://www.lumhs.edu.pk/ https://www.lumhs.edu.pk/ https://www.lumhs.edu.pk/ results of intravitreal bevacizumab as an adjunct to metdrs grid laser in diabetic macular edema pak j ophthalmol. 2021, vol. 37 (1): 12-16 13 remain insufficient to control the progression of the disease and prevent recurrence of ocular complications. 3 different patients have different response to the treatment of dme. therefore, we should adopt such strategies which give good results and have less side effects. 4 for the management of dme laser photocoagulation was the best option few decades back. it was established by early treatment of diabetic retinopathy study (etdrs) in 1980s. 4 nowadays intravitreal injection of anti-vascular endothelial growth factor (avegf) is more popular than laser due to easy administration and early recovery of vision. 3 but a research conducted by diabetic retinopathy clinical research network (drcr.net) stated that modified etdrs (metdrs) protocol to treat dme was the best approach 5 and protocol t clinical trial showed that 50% patients with dme required additional laser therapy within sixth months after injection of anti-vegf. 6 it means laser photocoagulation still has a role to treat dme but laser and anti-vegf both have their own efficacy and visual outcomes. macular laser therapy is a good treatment option as an adjuvant because it is able to improve macular thickness outcomes and reduce the number of injections needed. in this study, anti-vegf was used as an adjunct to laser photocoagulation in patients with dme to get early vision recovery and to decrease the financial burden on the society. the purpose of the study was to assess the efficacy of intravitreal bevacizumab as an adjuvant to grid laser photocoagulation in patients with diffuse macular edema (dme) in type ii diabetes. methods ninety-five eyes of type ii diabetic patients, with diffuse macular edema (48 males and 47 females) were recruited for this prospective study, from the outpatient clinic of institute of ophthalmology liaquat university of medical and health sciences jamshoro. the duration of study was from september 2016 to november 2018 after approval from ethics committee of the university. written informed consent was obtained from all participating patients after explaining to them all the study procedures with its benefits and hazards. patients older than 40 years with macular edema caused by type ii diabetes, bcva of 6/18 to 6/60, central macular thickness (cmt) more than 300 μm, intra ocular pressure less than 20 mm hg, clear optical zone with properly dilated pupils and no iris neovascularization were included in the study. patients who had diabetic macular edema (dme) with subfoveal exudates, macular edema caused by diseases other than dm, macular ischemia & traction, cmt greater than 1000 um, preexisting macular pathology, history of (h/o) intravitreal injection/vitrectomy, h/o cataract surgery within the past 6 months and h/o renal pathology, glaucoma/ocular hypertension, hba1c more than 8%, blood pressure more than 150/90 mm hg and significant media opacity were excluded from the study. all patients who fulfilled the inclusion criteria were subjected to clinical examination and base line bcva was recorded by snellen chart, intra ocular pressure (iop) was recorded using applanation tonometer with slit lamp biomicroscope and colored fundus photograph and cmt was taken with sd-oct. all patients were divided in two groups group i patients were treated with etdrs grid laser photocoagulation. group ii patients were treated with etdrs grid laser photocoagulation combined with intravitreal bevacizumab (1.25 mg/0.05 ml). all patients were examined at baseline and followed-up at 1, 2 and 3 months after treatment. changes in bcva were recorded with snellen acuity chart & converted into etdrs letter for facilitating statistical calculation. intravitreal injections of anti-vegf were performed with aseptic technique and post injection moxifloxacin 3% one drop four times a day and post laser non-steroidal anti-inflammatory one drop three times a day was advised. combination of acetazolamide and timolol one drop twice a day was advised in patients with raised iop. macular grid photocoagulation was performed with argon green laser delivering 2–3 rows using metdrs grid laser parameters for dme. burn size for grid was 75 µm, burn duration was 0.05 – 0.10 s, burn separation was 2 visible burn widths apart and burn intensity was light gray descriptive analysis of subjects like mean, standard deviation and range was performed by using spss version 20. mean change in va and cmt was estimated with paired t-test. the level of statistical significance was set at p < 0.05. changes in bcva were recorded with snellen acuity chart and converted into etdrs letters for facilitating statistical calculation. mahtab alam khanzada, et al 14 pak j ophthalmol. 2021, vol. 37 (1): 12-16 results the demographic and base line clinical characteristics are listed in table i. the mean age of g-1 group patients was 59.45 (sd ± 8.23) years and of g-2 table 1: baseline demographic and clinical characteristics of each group of study patients characteristics group-1 group-2 age (years) 59.45 ± 8.23 60.11 ± 7.36 male, n (%) 25 (26.31%) 23 (24.21%) female, n (%) 22 (23.15%) 25 (26.31%) disease duration (year) 11.10 ± 2.42 12.48 ± 2.91 hba1c (%) 07.85 ± 0.78 07.96 ± 0.76 iop (mmhg) 17.68 ± 2.49 18.20 ± 3.19 blood pressure (mm hg) systole 145 ± 17.11 138 ± 15.90 diastole 85 ± 8.10 83 ± 8.10 cmt (μm) 504 ± 189 507 ± 189 patients was 60.11 (sd ± 7.36) years. out of ninetyfive patients, 25 (26.31%) males and 22 (23.15%) females were treated with metdrs grid laser photocoagulation and 23 (24.21%) male and 25 (26.31%) females were subjected to combined treatment. bcva ranged from 4 to 76 letters (snellen equivalent 1/60 to 6/9). eyes with poor base line bcva achieved greatest mean improvement at 6 months (table 2). mean base line cmt was 504 µm (sd ± 189) in g-i and 506 µm (sd ± 189) in g-ii. mean cmt reduction was statistically significant in both groups during all follow up visits but in g-i it was 194 µm (p ≤ 0.001) and in g-ii 272 µm (p ≤ 0.001) at 6 months. only 0.045% patients of g-2 were found with raised iop that was controlled by anti-glaucoma drops. table 2: change in base line bcva & cmt. subject mean bcva (letters) p-value mean cmt (µm) p-value (etdrs letter score) baseline baseline g-1 (n = 47) 46 ± 18 504 ± 189 g-2 (n = 48) 46 ± 18 507 ± 189 1 st months pt 1 st months pt g-1 (n = 47) 47 ± 21 0.912 365 ± 143 0.018 g-2 (n = 48) 48 ± 21 0. 801 350 ± 157 0.004 2 nd months pt 2 nd months pt g-1 (n = 47) 50 ± 17 0.021 350 ± 150 0.001 g-2 (n = 48) 53 ± 17 0.009 322 ± 160 0.002 3 rd months pt 3 rd months pt g-1 (n = 47) 52 ±17 0.004 310 ± 130 0.001 g-2 (n = 48) 56 ± 17 0.004 235 ± 128 0.001 g-1 = group i, g-2 = group ii, pt = post treatment, bcva = best corrected visual acuity, cmt = central macular thickness etdrs = early treatment of diabetic retinopathy study, sd = stander deviation discussion prevalence of dme is approximately 19% to 65% and it is the main cause of severe loss of vision among patients with diabetes mellitus. 7 pathogenesis of dme is multi factorial like: angiogenesis, inflammation and oxidative stress. 8,9 therefore, a single treatment option does not show adequate response especially in diffuse, chronic and refractory dme. various variants of vegf increase vascular permeability by increasing phosphorylation of endothelial tight junction proteins in diabetes mellitus that may lead to dme. 10 another proposed reason of dme is the breakdown of outer and inner retinal barrier. 11 solaiman et al 12 suggested that the laser photocoagulation causes proliferation of endothelial cells in the retinal capillaries as well as retinal pigment epithelial cells thus improving the functions of outer and inner retinal barriers. bevacizumab has the ability to block all form of vegf receptors. this stabilizes the vascular permeability and helps to reduce dme. 13 since last three-decades conventional etdrs laser photocoagulation was standard treatment for dme but results of visual outcome were modest. 14,15 visual acuity may decrease due to extension of macular scar, results of intravitreal bevacizumab as an adjunct to metdrs grid laser in diabetic macular edema pak j ophthalmol. 2021, vol. 37 (1): 12-16 15 and patients may suffer central scotoma and altered color vision. 16 to avoid these complications, we used metdrs laser treatment in this study. as we compare the base line during each visit, we found significant reduction in cmt in both groups during each follow-up visit but at 6 months it was stable and more significant in combined group (p ≤ 0.001). at 6 months, visual acuity letters gain was more significant in combined group than laser group. our results are in consistence with previous studies which reported that the combined intravitreal bevacizumab (ivb) and laser photocoagulation was the best option not only to treat dme but also to help in decreasing the chance of recurrence. 17,18 shalaby et al 19 reported that combined intravitreal anti vegf and metdrs laser had more stable functional and anatomical out comes after treating dme. we also had the same results but difference was that we applied laser before injecting ivb. other studies have also reported that combined treatment was more effective in treating dme than conventional macular laser photocoagulation. adelman et al 20 , and do et al 21 stated that by adding macular laser photocoagulation with ivb to treat dme may not give significant results and more extensive laser treatment may help to reduce the number of intravitreal anti-vegf injection. that is why in this study we did first grid laser photocoagulation before injecting ivb to reduce the burden of injection to patients. ethical approval the study was approved by the institutional review board/ ethical review board. (lumhs/04) conflict of interest authors declared no conflict of interest references 1. cho nh, shaw je, karuranga s, huang y, da rocha fernandes jd, ohlrogge aw, et al. idf diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. diabetes res clin pract. 2018; 138: 271-278. 2. stefanini fr, badaró e, falabella p, koss m, farah me, maia m. anti-vegf for the management of diabetic macular edema. j immun res. 2014: 1-8. 3. marashi a. laser therapy for diabetic retinopathy and diabetic macular edema laser still plays an important role in the treatment of diabetic eye disease, despite the popularity of anti-vegf agents. retina today, 2017: 38-42. 4. stanga pe, martinez mg, pastor-iodate s. new laser technology and techniques for treating dme and pdr. supplement to retina today. 2013: 6-8. 5. fong ds, strauber sf, aiello lp, beck rw, callanan dg, danis rp, et al. comparison of the modified early treatment diabetic retinopathy study and mild macular grid laser photocoagulation strategies for diabetic macular edema. arch ophthalmol. 2007; 125: 469-480. 6. wells ja, glassman ar, ayala ar, jampol lm, bressler nm, bressler sb, et al. aflibercept, bevacizumab, or ranibizumab for diabetic macular edema: two-year results from a comparative effectiveness randomized clinical trial. ophthalmology, 2016; 123: 1351-1359. 7. virgili g, menchini f, murro v, peluso e, rosa f, casazza g, et al. optical coherence tomography (oct) for detection of macular oedema in patients with diabetic retinopathy,” cochrane database of syst rev. cochrane database syst rev. 2011; 7: cd008081. 8. ehrlich r, harris a, ciulla ta, kheradiya n, winston dm, wirostko b. diabetic macular oedema: physical, physiological and molecular factors contribute to this pathological process. acta ophthalmol. 2010; 88 (3): 279-291. 9. tang j, kern ts. inflammation in diabetic retinopathy. prog retin eye res. 2011; 30 (5): 343358. 10. ferrara n. vascular endothelial growth factor: basic science and clinical progress. endocr rev. 2004; 25: 581-611. 11. mohalhal aa, ghalwash ga. short-term effect of a single intravitreal injection of bevacizumab (avastin) alone, triamcinolone alone, or in combination, followed by macular grid laser photocoagulation on diffuse diabetic macular edema. j egypt ophthalmol soc. 2014; 107: 127-131. 12. solaiman ka, diab mm, dabour sa. repeated intravitreal bevacizumab injection with and without macular grid photocoagulation for treatment of diffuse diabetic macular edema. retina. 2013; 33: 1623-1629. 13. soheilian m, ramezani a, obudi a, bijanzadeh b, salehipour m, yaseri m, et al. randomized trial of intravitreal bevacizumab alone or combined with triamcinolone versus macular photocoagulation in diabetic macular edema. ophthalmology, 2009; 116: 1142-1150. mahtab alam khanzada, et al 16 pak j ophthalmol. 2021, vol. 37 (1): 12-16 14. elman mj, aiello lp, beck rw, bressler nm, bressler sb, edwards ar, et al. diabetic retinopathy clinical research network. randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. ophthalmology, 2010; 117 (6): 1064-1077. 15. heng lz, comyn o, peto t, tadros c, ng e, sivaprasad s, et al. diabetic retinopathy: pathogenesis, clinical grading, management and future developments. diabet med. 2013; 30 (6): 640-650. 16. roider j. laser treatment of retinal diseases by subthreshold laser effects. semin ophthalmol. 1999; 14: 19-26. 17. seo jw, park iw. intravitreal bevacizumab for treatment of diabetic macular edema. korean j ophthalmol. 2009; 23: 17-22. 18. zhang xl, chen j, zhang rj, wang wj, zhou q, qin xy, et al. intravitreal triamcinolone versus intravitreal bevacizumab for diabetic macular edema: a meta-analysis. int j ophthalmol. 2013; 6: 546-552. 19. shalaby ua, soliman tt, el-hameed fayed aa. intravitreal bevacizumab alone or combined with macular laser for treatment of diabetic macular edema. egypt retina j. 2017; 4: 37-42. 20. adelman r, parnes a, michalewska z, parolini b, boscher c, ducournau d. strategy for the management of diabetic macular edema: the european vitreo retinal society macular edema study. biomed res int. 2015; 2015: 1-9. 21. do dv, nguyen qd, khwaja aa, channa r, sepah yj, sophie r, et al. ranibizumab for edema of the macula in diabetes study: 3-year outcomes and the need for prolonged frequent treatment. jama ophthalmol 2013; 131: 139-145. authors’ designation and contribution mahtab alam khanzada: associate professor: concepts, design, manuscript preparation. munawar ahmed: associate professor: data analysis, statistical analysis, manuscript editing. azfar ahmed mirza: assistant professor: literature search. ghazi khan mari: assistant professor: data acquisition. muhammad arshad mahmood; professor: manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (2): 152-155 152 original article effect of oral contraceptive pills on tear film status and intraocular pressure zeeshan kamil 1 , qirat qurban 2 , khalid mahmood 3 1-3 khalid eye clinic, nazimabad, karachi, pakistan abstract purpose: to find out the effect of oral contraceptive pills on tear film and intraocular pressure of women of reproductive age group. study design: observational study. place and duration of study: khalid eye clinic, karachi, from february 2019 to january 2020. methods: eighty females between the 20 to 40 years of age were recruited for this study. they were divided into two groups of forty each. group a included females using oral contraceptive pills for at least last nine months. whereas, group b included control group of age matched females not using any contraceptive pills. the study dynamics was explained to all participants and informed consent was obtained. tear film status was assessed on the basis of tear film break up time (tbut) on slit lamp examination and schirmer strip test 2 (without anesthesia). intraocular pressures were checked using goldman applanation tonometer. studywas approvedfrom ethical review committee of the hospital. results: mean age was 29.3 ± 3.27 years. tear film break up time was < 7 ± 1.5 sec in group a and > 10 ± 1.2 sec in group b. schirmer strip test was ≤ 9 ± 1 mm of wetting in group a and ≥ 13 ± 1 mm of wetting in group b. mean intraocular pressure was 17 ± 2 mmhg in group a whereas 13 ± 2 mmhg in group b. grittiness, heaviness and foreign body sensation were more common in group a. conclusion: use of oral contraceptive pills has an adverse effect on the tear film status and intraocular pressures. key words: oral contraceptive pills, tear film, tbut, schirmer’s test, intraocular pressure. how to cite this article: kamil z, qurban q, mahmood k. effect of oral contraceptive pills on tear film status and intraocular pressure. pak j ophthalmol. 2021, 37 (2): 152-155. doi: http://doi.org/10.36351/pjo.v37i2.1069 introduction oral contraceptives pills (ocp) are known to be one of the most common, safest and efficient ways of birth control among the females of reproductive age group. with the highest fertility rate among adolescent correspondence: zeeshan kamil khalid eye clinic nazimabad, karachi, pakistan email: dr.zeeshankamil@yahoo.com received: may 20, 2020 accepted: january 22, 2021 females of pakistan, along with a high prevalence of home births, the need for using birth control such as ocps has become pivotal to avoid unplanned pregnancies. 1 ocps are comprised of estrogen and progesterone and like any pharmaceutical drug have its own sets of pros and cons including some significant adverse effects on the physiology and pathophysiology of certain ocular tissues. rocha described the presence of estrogen and progesterone receptors on the lacrimal gland, meibomian gland, lid, palpebral and bulbar conjunctivae, cornea, uveal body, lens, and retina of humans. 2 this observation lead to the belief that http://doi.org/10.3352/jeehp.2013.10.3 zeeshan kamil, et al 153 pak j ophthalmol. 2021, vol. 37 (2): 152-155 females of the reproductive age who use ocps are at risk of developing complications pertaining to the ocular surface, anterior segment, lens opacities as well as posterior segment (retinal neuro-ophthalmologic or vascular complications owing to thromboembolic events). 3 despite the general fact that estrogen reduces lipid secretion and decreases the size of sebaceous glands 4 few studies have been done to evaluate this relationship. 5,6 studies have postulated that using ocps result in dry eyes owing to the estrogen and progesterone affecting the secretion of lacrimal and meibomian glands 7 but sullivan reported that using hormone containing contraceptives, improved the quality and the production of the tear film status. 8 on the other hand, no significant difference was observed in ocular surface characteristics and tear film status of young women receiving oral contraceptive, in a study done by tomlinson. 9 in addition to dry eyes, recently it has been found that both estrogen and progesterone affect the aqueous outflow and thereby regulates the intraocular pressure (iop). the exact mechanism causing such changes in iop is yet to be discovered. this indicated that glaucoma may be considered as a component of the risk profile for a patient on oral contraceptive pills, in concert with other existing risk factors. 10 this study was carried out to find out the effect of oral contraceptive pills on tear film and intraocular pressure of women of reproductive age group of pakistan. methods this study was conducted at khalid eye clinic, karachi, from february 2019 to january 2020 and recruited eighty females between 20 to 40 years of age. inclusion criteria comprised of women between the ages of 20 to 40 years using oral contraceptive pills for at least since the last nine months, whereas the exclusion criteria included pregnant patients, menopausal women and those who previously underwent any surgery as well as those women having any presence of systemic disease or using systemic medication. females with ocular surgery, contact lens use, chronic topical medication, laser treatment, chemical injury, blepharitis and any other obvious ocular disorderwere also excluded. they were divided into two groups of forty each. group a included females using oral contraceptive pills for the last nine months, whereas, group b included control group of females not using any contraceptive pills. the patients of both the groups were demographically matched. the study dynamics was explained to all patients and informed consent was obtained. study approval was obtained from ethical review committee. a thorough history including personal information, gynecological history, medicine use and duration of hormonal contraceptive was taken from each patient along with presence of or complain of any ocular problem. comprehensive ocular examination was performed in the opd to rule out the presence of ocular surface and anterior segment abnormality. the tear film status was assessed in each patienton the basis of tear film break up time (tbut) on slit lamp examination and schirmer strip test 2 (without anesthesia). intraocular pressure measurement was done with goldman applanation tonometry. schirmer’s strip test 2 (without anesthesia) was performed using whatmann filter paper 41 which was gently placed at the intersection of middle and outer two thirds of the lower lid taking care not to tap cornea or the eye lashes. patients were advised to look up and blink normally or close the eyes as per their convenience. the paper was removed after five minutes and reading was documented from bent portion of the paper in millimeters. readings less than 10 mm after 5 min was considered as abnormal. tear film break up time (tbut) was measured using fluorescein dye drop into the cul-de-sac and tear film was observed on slit lamp with cobalt blue light. patients were asked not to blink and the appearance of the first dry spot over the cornea was observed indicating a break in the continuity of the tear film. the time between the first complete blink and the appearance of the first dry spot was measured. iop of both eyes were recorded. results mean age was 29.3 ± 3.27 years. tear film break up time was < 7 ± 1.5 sec in group a and > 10 ± 1.2 sec in group b, whereas schirmer strip test result was ≤ 9 ± 1 mm of wetting in group a and ≥ 13 ± 1 mm of wetting in group b. mean intraocular pressure was 17±2 mmhg in group a whereas 13 ± 2 mmhg in group b. complains such as grittiness, heaviness and foreign body sensation were also more common in patients of group a. effect of oral contraceptive pills on tear film status and intraocular pressure pak j ophthalmol. 2021, vol. 37 (2): 152-155 154 discussion production of tears in the eyes act as a natural lubrication, nourishment provider and protection against the environmental dust particles, irritants and infections along with the maintenance of a smooth ocular surface. any imbalance in the tear film status, either due to composition changes, production abnormality or increased evaporation may lead to dry eyes. 11 endocrine system has a significant effect on the lacrimal gland, as proved by the presence of receptors for androgens, estrogen and progesterone in the ocular tissues. 9,12 recent studies have also supported that owing to the its expression in several ocular tissues, estrogen has a vital protective part in the pathogenesis of glaucoma by having an impact on the regulation of blood flow. 13-16 however, the amount or method of estrogen release in order to be protective is yet to be defined. contraceptive pills most commonly work by inhibiting ovulation. 17 our results were similar to the observations made by previous studies which reported that oral contraceptive pills in the reproductive age group lead to dry eye syndrome owing to the androgen deficiency caused by the use of oral contraceptive pills. 18-21 a study by sullivan had a similar observation that androgen insufficiency could be animperative etiological aspect in the pathogenesis of evaporative dry eye in reproductive age women. despite such findings, the effects of oral contraceptives in pathogenesis of dry eye remain controversial. 9 a minority of studies has found no association between the androgen levels and tear film status in women. 7,22,23 this was contradictory to this study since this study did observe a difference in the tear film status of the women of both groups i.e. those using oral contraceptives had a reduced tbut and schirmer strip test result as compared to non oral contraceptive pill users. this study also found an increase in the mean intraocular pressure at 17 ± 2 mmhg in women of group a using oral contraceptive pills as compared to 13 ± 2 mmhg in group b women, who were not using any form of contraceptives. this was in accordance with a study performed among oral contraceptive users for three or more years and it was reported that the use of oral contraceptives was associated with raised intraocular pressure. 23 it was further supported by a study done by pasquale in whom the researchers established a 25% amplified risk of developing primary open angle glaucoma among women who were using oral contraceptives for the last five years or more but this was controversial since it could be related to developing an early menopause. 24 the release of estrogen from the ovaries regulates the menstrual cycle and using oral contraceptive pills results in low estradiol and progesterone levels thereby increasing serum follicle stimulating hormone levels via negative feedback. the blockage of this natural cycle occurs with the use of oral contraceptive pills hence supporting the proposition by previous literature, which describes that estrogen has a vital protective role in the pathogenesis of glaucoma via regulation of blood flow. 14-16 in addition to this, none of the oral contraceptive pills have an exact configuration like the physiological hormones during the menstrual cycle, therefore resulting in significant changes in the natural daily, or even hourly, variations in hormone levels and secretion which may be essential in the pathogenesis of glaucomatous diseases. 25 all the aforementioned findings correlated with this study where the oral contraceptive users reported an increase in the mean intraocular pressure as compared to non users. the emerging evidence of the consequences of female sex hormones on the development of glaucoma suggests that there are unique, gender specific risk factors such as early menopause or use of hormones. therefore, a better understanding is required for the application and use of oral contraceptives and management of the resulting outcomes. conclusion this study concluded that using oral contraceptive pills has an adverse effect on the tear film status and results in an increase in the intraocular pressure as compared to the non users. however, large scale longer duration studies are required for the affirmation of the possible consequences of using oral contraceptives on the ocular tissues. ethical approval the study was approved by the institutional review board/ ethical review board. (erc-23-20). conflict of interest authors declared no conflict of interest. zeeshan kamil, et al 155 pak j ophthalmol. 2021, vol. 37 (2): 152-155 references 1. iftikhar h, rashid m, shakoor mu. decisionmaking for birth location among women in pakistan: evidence from national survey. bmc pregnancy childbirth, 2018; 18: 226. https://doi.org/10.1186/s12884-018-1844-8 2. rocha em, wickham la, da silveira la, krenzer k, yu f, toda i, et al. identification of androgen receptor protein and 5 a-reducase mrna in human ocular tissues. br j opthalmol. 2000; 84: 76-84. 3. leff sp. side-effect of oral contraceptives: occlusion of branch artery of the retina. bull sinai hosp detroit. 1976; 24 (4): 227-229. 4. sullivan da, yamagami h, lui m, schirra f, liu m, richards s, et al. sex steroids, the meibomian gland and evaporative dry eye. adv exp med biol. 2002; 506 (pt a): 389–399. 5. frankel s, ellis p. effect of oral contraceptives on tear production. ann ophthalmol. 1978: 1585-1588. 6. tomlinson a, pearce ei, simmons pa, blades k. effect of oral contraceptives on tear physiology. ophthalmic physiol opt. 2001; 21 (1): 9–16. 7. schaumberg da, buring je, sullivan da, dana mr. hormone replacement therapy and dry eye syndrome. j am med assoc. 2001; 286: 2114-2119. 8. sullivan da, wickham la, rocha em, kelleher rs, silveira la, toda i. influence of gender, sex steroid hormones and the hypothalamic – pituitary axis on the structure and function of the lacrimal gland. adv exp med biol. 1998; 438: 11-42. 9. treister g, mannor s. intraocular pressure and outflow facility. effect of estrogen and combined estrogen-progestin treatment in normal human eyes. arch ophthalmol. 1970; 83: 311-318. 10. gupta pd. pathophysiology of lacrimal gland in old age. w j med sci. 2006; 1: 1-8. 11. coles n, lubkin v, kramer p, weinstein b, southern l, vitter j. hormonal analysis of tears, saliva, and serum from normals and postmenopausal dry eyes. invest ophthalmol vis sci. 1988; 29: 48-52. 12. munaut c, lambert v, noël a, frankenne f, deprez m, foidart jm, et al. presence of oestrogen receptor type beta in human retina. br j ophthalmol. 2001; 85 (7): 877–882. 13. wang sb, hu km, seamon kj, mani v, chen y, gronert k. estrogen negatively regulates epithelial wound healing and protective lipid mediator circuits in the cornea. faseb j. 2012; 26 (4): 1506–1516. 14. kirker mr, gallagher km, witt-enderby pa, davis vl. high affinity nuclear and nongenomic estradiol binding sites in the human and mouse lens. exp eye res. 2013; 112: 1–9. 15. schmidl d, schmetterer l, garhöfer g, popacherecheanu a. gender differences in ocular blood flow. curr eye res. 2014: 1–12. 16. christin-maitre s. history of oral contraceptive drug and their use worldwide. best pract res clin endocrinol metab. 2013; 27 (1): 3-12. 17. nanavaty ma, long m, malhotra r. transdermal androgen patches in evaporate dry eye syndrome with androgen deficiency: a pilot study. br j ophthalmol. 2014; 98: 567-569. 18. chen sp, massaro-giordano g, pistilli m, schreiber ca, bunya vy. tear osmolarity and dry eye symptoms in women using oral contraception and contact lenses. cornea, 2013; 32 (4): 423-428. 19. azcarate pm, venincasa vd, feuer w, stanczyk f, schally av, galor a. androgen deficiency and dry eye syndrome in the aging male. invest ophthalmol vis sci. 2014; 55: 5046-5053. 20. ding j, sullivan da. aging and dry eye disease. exp gerontol. 2012; 47: 483-490. 21. malik tg, nadeem h, ayesha e, alam r. effect of short-term use of oral contraceptive pills on intraocular pressure. pak j ophthalmol. 2019; 35 (3): 184-187. 22. burkman r, bell c, serfaty d. the evolution of combined oral contraception: improving the risk to benefit ratio. contraception, 2011; 84 (1): 19-34. 23. wang y, caitlin k, diego b, travis p, rebecca c, sophia w, et al. oral contraceptive use and prevalence of self-reported glaucoma or ocular hypertension in the united states. ophthalmology, 2016; 123 (4): 729–736. doi:10.1016/j.ophtha.2015.11.029. 24. pasquale lr, kang jh. female reproductive factors and primary open-angle glaucoma in the nurses' health study. eye (lond). 2011; 25 (5):633–641. 25. ahn rs, choi jh, choi bc, kim jh, lee sh, sung ss. cortisol, estradiol-17β, and progesterone secretion within the first hour after awakening in women with regular menstrual cycles. j endocrinol. 2011; 211 (3): 285–295. authors’ designation and contribution zeeshan kamil; consultant ophthalmologist: examiner, manuscript writer, final review. qirat qurban; consultant ophthalmologist: data collection, manuscript writer, final review. khalid mahmood; consultant ophthalmologist: helped in data collection, final review. .…  …. https://doi.org/10.1186/s12884-018-1844-8 https://www.ncbi.nlm.nih.gov/pubmed/?term=krenzer%20k%5bauthor%5d&cauthor=true&cauthor_uid=10611104 https://www.ncbi.nlm.nih.gov/pubmed/?term=yu%20f%5bauthor%5d&cauthor=true&cauthor_uid=10611104 https://www.ncbi.nlm.nih.gov/pubmed/?term=toda%20i%5bauthor%5d&cauthor=true&cauthor_uid=10611104 https://pubmed.ncbi.nlm.nih.gov/?term=schirra+f&cauthor_id=12413064 https://pubmed.ncbi.nlm.nih.gov/?term=liu+m&cauthor_id=12413064 https://pubmed.ncbi.nlm.nih.gov/?term=richards+s&cauthor_id=12413064 125 pak j ophthalmol. 2022, vol. 38 (2): 125-129 original article causes of delayed presentation of retinoblastoma in a tertiary care hospital of pakistan asma mushtaq 1 , huma zafar gondal 2 , seema qayyum 3 , ahmed raza 4 , fiza azhar 5 1-5 university of child health sciences, the children’s hospital, lahore abstract purpose: to find out the causes of delayed presentation of retinoblastoma in a tertiary care hospital. study design: questionnaire based survey. place and duration of study: pediatric ophthalmology department of the children’s hospital, lahore, from january 2018 to december 2019. methods: mothers of patients who presented in the hospital were recruited for this survey. a questionnaire with details of the patient were noted. it included first symptom, time lapse since onset of first symptom, gender, age at presentation to first doctor (general practitioner), time lapse to presentation at tertiary care center (the children’s hospital & institute of child health), gender and laterality. general physical examination was done by an oncologist and examination under anesthesia was done by a pediatric ophthalmologist. data was analyzed using spss version 20. pearson chi square test was used to find significance of each cause. results: seventy participants were included in the study. delayed presentation was seen in 42 patients (60%). the various factors identified for delay in diagnosis and treatment in descending order are residence in rural areas 54 %, lack of finances 64%, social pressure 27%, awareness about disease severity 60%, lack of transport 54%, fear of enucleation 38% and seeking non-medical treatment/ alternate medication 32%. significance of each factor was calculated using chi-square test. conclusion: the causes identified can be highlighted on national level for development of health facilities in rural areas. key words: retinoblastoma, cancer, malignant tumor, leucocoria. how to cite this article: mushtaq a, gondal hz, qayyum s, raza a, azhar f. causes of delayed presentation of retinoblastoma in a tertiary care hospital of pakistan. pak j ophthalmol. 2022, 38 (2): 125-129. doi: 10.36351/pjo.v38i2.1338 correspondence: asma mushtaq university of child health sciences the children’s hospital, lahore email: drasmamushtaq18@gmail.com received: september 27, 2021 accepted: december 26, 2021 introduction retinoblastoma, the most common intraocular malignancy of infants has an incidence of 1 in 15,000 to 1 in 20,000 live births. 1 this corresponds to almost 9000 new cases per year worldwide. forty percent of cases have bilateral disease, which are hereditary and are part of a genetic cancer predisposition syndrome. all children with a bilateral or familial form and 10 to 15% of children with a unilateral form, carry an rb1 gene mutation. sixty percent retinoblastoma cases are not hereditary. 2,3 the median age of diagnosis is 24 months in unilateral cases and 9–12 months in bilateral ones. 4 leucocoria and strabismus are the most common clinical presentations in the developed world. however, proptosis, buphthalmos and red eye is frequently seen in the retinoblastoma patients of the developing countries. 5 the management of retinoblastoma requires a multidisciplinary approach by a team of oncologist, ophthalmologist and radiation oncologist. the treatment is highly individualized. the aim of primary treatment is to save the life of the patient, followed by globe saving and any useful causes of delayed presentation of retinoblastoma in a tertiary care hospital of pakistan pak j ophthalmol. 2022, vol. 38 (2): 125-129 126 vision if possible with also minimal treatment related complications. in the last century, a paradigm shift is seen in the management of retinoblastoma. the survival and visual outcome has improved dramatically in the developed world. this can be attributed to early tumor recognition and advances in the management of retinoblastoma. chemo-reduction followed by adjuvant consolidative treatment has replaced external beam radiotherapy as the primary modality of treatment for intraocular retinoblastoma. further, histopathological high-risk factors have been identified in enucleated eyes, allowing use of prophylactic chemotherapy to take care of possible micrometastasis. intra-arterial chemotherapy (iac) for retinoblastoma has been adopted as a first-line treatment option by numerous tertiary centers. iac may be effective in saving eyes of group d retinoblastoma that have failed in systemic chemotherapy and were destined for enucleation, in addition to group a, b & c. 6 the survival in case of extraocular retinoblastoma is still low, and the reported survival rate ranges between 50% and 70%. in developing countries, the overall survival of retinoblastoma patients remains low, primarily due to a delayed presentation, resulting in larger proportions of extraocular disease compared with the developed world, where majority of the disease is intraocular. 7 according to a study, the five-year survival rate for children with unilateral retinoblastoma increased from 85% in 20 th century to 97% in 21 st century, in london. 8 the overall survival rate exceeds 95% in germany per year. 9 this remarkable improvement cannot be expected in all parts of the world. the reports from africa predict a disease-free survival of around 20%. 10 an editorial has been written by kivelia highlighting the advancement in the medical field in the last century. he concluded that, it may take another 200 years for the benefit to spread worldwide. 11 the main challenge in treating retinoblastoma effectively in our country is a delay in presentation, resulting in advanced disease and consequently higher treatment-related morbidity and disease-related mortality. this survey was designed to find out the causes of delayed presentation of the patients of retinoblastoma at tertiary care centers of pakistan. this will help in addressing the issue and overcoming the barriers to decrease the morbidity and mortality related with the disease. methods this survey was conducted in the pediatric ophthalmology department of the children’s hospital, lahore. the new patients who were enrolled for the treatment of retinoblastoma from january 2018 to december 2019 were included in the study. parental complaint time (lag time 1) was defined as the time starting from the first noticing of the disease by the parent to presentation to the general practitioner/ ophthalmologist. delayed presentation was defined as the lag time 1 if it was more than 2 weeks. referral time (lag time 2) was defined as the time from the first doctor/general practitioner visit till the presentation to the children’s hospital and institute of child health, lahore. delayed referral was defined if lag time 2 was more than 2 weeks. total delay (total lag time = lag time 1 + lag time 2) was measured from time of initial parental complaint to the time of the first examination at tertiary care hospital. 12 the parents (mostly mothers) were source of history in our patients. the details of the patient were noted, namely first symptom,time lapse since onset of first symptom, gender, age at presentation to first doctor (general practitioner), time lapse to presentation at tertiary care center (the children’s hospital & institute of child health), gender and laterality. general physical examination was done by oncologist and examination under anesthesia was done by a pediatric ophthalmologist. the staging/grouping of disease at presentation to tertiary care hospital was done before starting treatment (international intraocular retinoblastoma classification and tnm staging). the tumors were classified as intraocular or extraocular based on clinical and radiological evaluation. the new patients of retinoblastoma with group d or e in worse eye or extraocular retinoblastoma were labeled as advanced disease and included in the study. the mothers were inquired about their hurdles and challenges in the treatment of their children. a questionnaire identifying the major issues was filled by all the parents (with the help of paramedic staff) included in the study. data was analyzed using spss version 20. pearson chi square test was used to find significance of each cause. results eighty four patients presented to the children’s hospital, lahore with retinoblastoma from january asma mushtaq, et al 127 pak j ophthalmol. 2022, vol. 38 (2): 125-129 2019 to december, 2020. seventy patients fulfilled the inclusion criteria and were included in the study. fifty one had intraocular disease and 19 cases had extraocular retinoblastoma. two patients had distant metastasis and four had intracranial extension at presentation. forty five patients had unilateral and 25 had bilateral retinoblastoma. the mean age for bilateral disease was 14 months whereas for unilateral it was 25 months. delayed presentation was seen in 42 patients (60%). delayed referral was seen in 47 patients (67.14%). total delay was 2 weeks to 13 months. fifty five patients (79%) had advanced disease at presentation to (figure 1). 0 20 40 60 80 100 delayed presentation delayed referral advanced disease patients figure 1: disease presentation pattern at a tertiary care hospital. the significance of various factors identified for delay in diagnosis and treatment in descending order is presented in table 1. table 1: percentage and significance (chi-square test) of various factors responsible for delayed presentation of retinoblastoma. factor percentage significance (chi-square test) rural areas 54 0.592 lack of finance 64 0.406 social pressure 27 0.365 awareness about nature of disease 60 0.014 lack of transport 54 0.003 fear of enucleation 38 0.000 discussion pakistan is a developing country and treatment facility of intra-arterial chemotherapy, intra-vitreal chemotherapy and focal laser consolidation in addition to intravenous chemotherapy is available at tertiary care hospitals of the country. however, presentation of advanced disease and limited finances leaves no choice for the retinoblastoma team other than enucleation, in most of the cases. 13,14,15 although survival rate is good for advanced intraocular disease, if enucleation is done in time, but fear of eye loss, social norms of our culture and alternative medicine may contribute to a poor outcome. compliance to treatment is also poor in our country. 16 timely screening definitely helps in earlier diagnosis of the disease. the diagnosis of most of the cancers is delayed in developing countries including pakistan due to many factors. 17 this has been particularly noticed in most of the studies done so far on retinoblastoma in pakistan, as most of patients in these studies had advanced disease. 18 a rapid advancement took place in terms of availability of advanced treatment options in pakistan including intra arterial chemotherapy. 19 little has been done so far in detection of early tumors (iirc group a &b) where we can save useful vision in addition to globe and life of the patient. as a result, we are not able to save useful vision in these patients. the most important factor highlighted in our study for delayed presentation of retinoblastoma is the people living in remote rural areas where adequate health facilities are not available. in pakistan, 61.4% of the population lives in rural areas, where 21% live below the poverty line. 20 the primary health care staff is the front line worker. people have to walk several miles to reach a proper general practitioner. their poor financial status adds up to their misery. sometimes they need loan to travel to a nearby district for medical consultation. the family pressure for people living in close communities also hinder patients from seeking proper medical advice. ignorance adds up to all the other factors. sometimes, leucocoria, which is a first sign of retinoblastoma, is taken by parents as a sign of good luck. there is common practice of seeking non medical treatment for almost all diseases in most of the subcontinent. lack of trained medical professional coupled with freely available faith healers makes them first choice for treatment in many cases. the faith of community is deep rooted in these people especially causes of delayed presentation of retinoblastoma in a tertiary care hospital of pakistan pak j ophthalmol. 2022, vol. 38 (2): 125-129 128 for life threatening diseases, so many people go to them until it is too late. 21 another important cause of delayed treatment of retinoblastoma is fear of enucleation. loss of an organ has a huge impact on human psychology. in many patients, enucleation to save the life of the child is refused by the parents. they go on to search for a person who can treat without enucleation. this leads to wastage of valuable time. similar reasons have been reported in the past in other developing countries especially india, which has similar demography and social set up. 22 detection of leucocoria in newborns especially in children at risk can be helpful in better disease outcomes. the role of genetic counseling cannot be denied in early cancer detection and treatment in genetic retinoblastoma. the power of social media can be utilized to spread awareness about life threatening diseases like retinoblastoma. awareness campaign about retinoblastoma has been taken up in many centers of developing countries, such as india and has helped in early detection of retinoblastoma. it is necessary for us to address these causes at national level. better medical education and training of health care professionals regarding retinoblastoma diagnosis is essential in this regard. considering the importance of the issue, the biggest limitation of this study is the single center survey. such surveys should be done at national level which will help in making policies in the health sector. ethical approval the study was approved by the institutional review board/ ethical review board (2020-107-chich). conflict of interest authors declared no conflict of interest. references 1. pizzo pa, poplack dg. principals and practice of pediatric oncology, 4th ed. lippincott-raven: philadelphia, 2001: 828-846. 2. kivelä t. the epidemiological challenge of the most frequent eye cancer: retinoblastoma, an issue of birth and death. br j ophthalmol. 2009; 93: 1129-1131. 3. shields ja, shields cl. management of retinoblastoma. in: shields ja, shields cl. intraocular tumours. an atlas and textbook. philadelphia, pa: lippincott williams wilkins; 2008: p. 334-351. 4. shields cl, shields ja. basic understanding of current classification and management of retinoblastoma. curr opin ophthalmol. 2006; 17 (3): 228–234. 5. adhi mi, kashif s, muhammed k, siyal n. clinical pattern of retinoblastoma in pakistani population: review of 403 eyes in 295 patients. j pak med assoc. 2018; 68 (3): 376-380. pmid: 29540871. 6. yousef ya, soliman se, astudillo ppp, durairaj p, dimaras h, chan hsl, et al. intra-arterial chemotherapy for retinoblastoma: a systematic review. jama ophthalmol. 2016; 134 (5): 584-591. doi:10.1001/jamaophthalmol.2016.0244. 7. meel r, radhakrishnan v, bakhshi s. current therapy and recent advances in the management of retinoblastoma. indian j med paediatr oncol. 2012; 33 (2): 80-88. doi: 10.4103/0971-5851.99731. 8. maccarthy a, birch j, draper g, hungerford j, kingston j, kroll m, et al. retinoblastoma: treatment and survival in great britain 1963 to 2002. br j ophthalmol. 2009; 93 (1): 38-39. 9. temming p, lohmann d, bornfeld n, sauerwein w, goericke s, eggert a. current concepts for diagnosis and treatment of retinoblastoma in germany: aiming for safe tumor control and vision preservation. klinische padiatrie. 2012; 224 (6): 339-347. 10. bowman r, mafwiri m, luthert p, luande j, wood m. outcome of retinoblastoma in east africa. pediatr blood cancer, 2008; 50 (1): 160-162. 11. kivelä t. 200 years of success initiated by james wardrop’s 1809 monograph on retinoblastoma. acta ophthalmologica. 2009; 87 (8): 810-812. 12. s. e.soliman, w. eldomiaty, m.b. goweida, a. dowidar, clinical presentation of retinoblastoma in alexandria: a step towards earlier diagnosis, saudi j ophthalmol. 2017. doi: http:// dx.doi.org/10.1016/j.sjopt.2017.03.003. 13. khurram d, zaheer n, sharif n. effects of primary chemotherapy, radiotherapy plus local treatments on regression patterns of posterior pole retinoblastoma. pak j ophthalmol. 2011; 27 (4): 214-219. 14. bukhari s, aziz-ur-rehman bi, qidwai u. presentation pattern of retinoblastoma. pak j ophthalmol. 2011; 27 (3): 142-145. 15. islam f, zafar sn, siddiqui sn, khan a. clinical course of retinoblastoma. j coll physician surg pak. 2013; 23 (8): 566-569. 16. khan sj, inayat n. paediatric retinoblastoma presentation in a regional cancer centre in pakistan. j cancer allied spec. 2017; 3 (2). 17. ashraf t, ahmed s, tanveer s. factors associated with delay in cancer diagnosis and treatment in children, a study from northern pakistan. professional med j. 2019; 26: 1156-1161. asma mushtaq, et al 129 pak j ophthalmol. 2022, vol. 38 (2): 125-129 18. mushtaq a, khan aa, sadiq maa, qayyum s, khan mr, raza a. retinoblastoma treatment outcomes in pakistan. professional med j. 2020; 27 (11): 2499-2503. 19. khaqan ha, imtiaz u, ateeq-ur-rehman, rasheed u. experience of selective intra-arterial chemotherapy for retinoblastoma. j pak med assoc. 2020; 70 (1): 178-182. doi: 10.5455/jpma.15646. pmid: 31954049. 20. shehla z, nasir i, atif r. comprehensive case study from pakistan primary health care systems (primasys). 21. sharma db, gupta v, saxena k, shah um, singh us. role of faith healers: a barrier or a support system to medical carea cross sectional study. j family med prim care, 2020; 9 (8): 4298-4304. doi: 10.4103/jfmpc.jfmpc_868_20. 22. singh u, katoch d, kaur s, dogra mr, bansal d, kapoor r. retinoblastoma: a sixteen-year review of the presentation, treatment, and outcome from a tertiary care institute in northern india, ocul oncol pathol. 2017; 4 (1): 23-32. doi: 10.1159/000477408. authors’ designation and contribution asma mushtaq; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. huma zafar gondal; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing. seema qayyum; professor: concepts, design, data acquisition, manuscript editing, manuscript review. ahmed raza; senior registrar: concepts, design, data acquisition, manuscript preparation. fiza azhar; fellow in paediatric ophthalmology: concepts, design, literature search, data acquisition, manuscript preparation. .…  …. microsoft word 11. rana naveed iqbal mm pakistan journal of ophthalmology, 2020, vol. 36 (3): 241-246 241 original article outcome of bimanual 23g, 5-ports versus 3-ports pars plana vitrectomy for advanced diabetic eye disease rana naveed iqbal1, asad aslam khan2, khalid waheed3 haroon tayyab4, mohsin ihsan5 intzar hussain6 1’3’5’6services institute of medical sciences, 2king edward medical university, mayo hospital lahore 4agha khan university, karachi abstract purpose: evaluation of efficacy and safety of 23 – guage five ports vitrectomy versus 23 – guage three ports pars plana vitrectomy (ppv) in diabetic tractional retinal detachment. study design: prospective interventional case series. place and duration of study: mayo hospital and services hospital, lahore, from february 2018 to december 2018. material and methods: forty eyes of forty patients were equally divided into two groups. one group which underwent five ports ppv and the other group had three ports ppv. patients with tractional retinal detachment (trd) with fibrovascular membranes were included and patients who had undergone previous ocular surgery (except cataract surgery) or having trd due to other ocular diseases were excluded. preoperative work-up included visual acuity, intra ocular pressure measurement and slit lamp examination of anterior and posterior segment. gender, age, pre-operative and post-operative bcva and intraocular pressure presented by calculating frequency and percentages. results: pre-operative bcva improved from 1.11 ± 0.5 to 0.66 ± 0.5 in 3-port groups and from 1.7 ± 0.9 to 0.87 ± 0.8 in 5-port groups. duration of surgery was 74.40 ± 5.4 and 53.40 ± 2.5 minutes in 3 ports and 5-ports group respectively. iatrogenic retinal tear developed in two patients in each group. per-operative vitreous hemorrhage developed in three patients in 3-ports group and in two patients in 5-ports group. two patients in each group developed post vitrectomy cavity hemorrhage. conclusion: bimanual 5ports 23-guage vitrectomy is a faster procedure than three ports 23 – guage vitrectomy in diabetic tractional retinal detachment but with similar intraoperative and postoperative complications. key words: pars plana vitrectomy, tractional retinal detachment, vitreous haemorrhage. how to cite this article: iqbal rn, khan aa, waheed k, tayyab h, ihsan m, hussain i. outcome of bimanual 23 – guage, 5 – ports pars plana vitrectomy versus 23 – guage, 3 – ports pars plana vitrectomy for advanced diabetic eye disease. pak j ophthalmol. 2020; 36 (3): 241-246. doi: 10.36351/pjo.v36i3.1041 introduction about half a billion of world population is expected to ____________________________________________ correspondence to: rana naveed iqbal services institute of medical sciences, lahore email: rananaveediqbal14@yahoo.com received: april 16, 2020 revised: may 4, 2020 accepted: may 4, 2020 suffer from diabetes mellitus by 2030. diabetic retinopathy causes blindness in 4.8% people globally and is one of the most common diabetic complications.1 various anti vascular endothelial growth factors have been used intravitreally in patients with vitreous hemorrhage caused by proliferative diabetic retinopathy but still pars plana vitrectomy is required for one third of these eyes.2 rana naveed iqbal, et al 242 pakistan journal of ophthalmology, 2020, vol. 36 (3): 241-246 we have seen a revolution in the treatment of diabetic retinopathy with the introduction of various anti vegf agents and advancements in laser treatment for diabetic retinopathy (dr) but surgical treatment in the form pars plana vitrectomy is still required in non-clearing vitreous hemorrhage (ncvh) with and without trd. trd is an advanced and devastating complication of pdr which can cause irreversible damage to retinal architecture. the most important part of vitrectomy for diabetic trd is careful segmentation and removal of fibrovascular tissue that can cause severe complications.3 there are different surgical techniques for delamination of taut and tough fibrovascular membrane using bimanual delamination technique like en-bloc perfluoro-dissection in vitreoretinal surgery and the 'suck-and-cut' bimanual technique for delamination of fibrovascular membranes in proliferative diabetic retinopathy.4,5 more expertise can be achieved for bimanual vitrectomy for more extensive and threatening trd especially those with more adherent and widely spread fibrovascular tissue which can cause per-operative complications that may become very difficult to manage.6 various studies have been conducted in the past which involved bimanual dissection of proliferative retinal membranes and for this purpose specially designed sophisticated instruments were used in these studies.7,8,9 23–gauge vitrectomy has been used by many surgeons worldwide and over the years it is found to be a safe and swift technique with less ocular surgical trauma, shorter duration, less inflammation in postoperative period and most importantly better and quick recovery in patients with retinal surgery including those with advanced diabetic eye disease.9 previous studies have been conducted to observe the safety and efficacy of four ports pars plana bimanual vitrectomy, which has been found to be an excellent surgical procedure that helps in safe and adequate removal of proliferative fibrovascular tissue in advanced pdr.10 the structural and functional results of bimanual 23 – gauge vitrectomy were reported with illumination source, which did not require manual fixation by the assistant during surgery for complicated vitreoretinal cases.11 a variety of chandelier lighting systems have been developed to provide stationary, wide-angle and uniform endoillumination for obtaining adequate visualization of retina during surgery.12 chandelier endo-illumination with two optic fibers described by eckardt as the twin light chandelier, is more useful than a single fiber system for obtaining homogeneous and more widespread illumination. the 2-fiber system eliminates the need to reposition the fiber and minimizes the shadow seen with single-fiber chandelier endo-illumination because the illumination comes from 2 different directions.6,13,14 mercury vapor and xenon have been used in chandelier lights of smaller size for improved illumination with wide angle view of retina.15,16,17,18 in our five ports bimanual vitrectomy, the fourth and fifth port were made at 5 and 7 o'clock position. main outcome measures in this study include preoperative and postoperative best corrected visual acuity along with intraocular pressure, intraoperative and postoperative complications and duration of surgical procedure. the purpose of our study was to observe the outcome of 23-guage, 5-ports versus 23-guage, 3-ports pars plana vitrectomy in advanced diabetic eye disease. material and methods total eyes of 40 patients were divided into two groups with one group undergoing 23 – guage three ports ppv and the other group undergoing five ports ppv. there were 20 eyes in each group. patients with trd and fibrovascular membranes extending over an area of greater than two quadrants of retina and also having an impending or actual macular detachment irrespective of the presence or absence of vitreous hemorrhage were included in the study. those patients who had undergone previous ocular surgery (excluding cataract surgery) or having trd due to other ocular diseases were not included in our study. every patient was examined for pre-operative best-corrected visual acuity, intra ocular pressure measurement and slit lamp examination of anterior and posterior segment especially for tractional retinal detachment. patients fulfilling the inclusion criteria were selected for 23 guage five ports bimanual pars plana vitrectomy or three ports conventional vitrectomy and the duration of surgery along with peroperative and postoperative complications, postoperative best corrected visual acuity and intra ocular pressure were noted. in all patients, a 23 – gauge trocar cannula was inserted at 15° to 30° angle through pars plana at 3.5– 4.0 mm from the limbus. the cannula for infusion was inserted inferotemporally. the remaining two ports outcome of bimanual 23 gauge, 5-ports versus 3-ports pars plana vitrectomy for advanced diabetic eye disease pakistan journal of ophthalmology, 2020, vol. 36 (3): 241-246 243 were for fibreoptic light and vitrectomy cutter. biom was used to get the wide angle view of the retina during vitrectomy. the surgery started with core vitrectomy along with clearance of vitreous haemorrhage (if present) and then the removal of posterior hyaloid was performed. peripheral vitrectomy along with vitreous base shave was done to get rid of anteroposterior tractions. in the five ports group, bimanual surgery helped in easy and more appropriate removal of fibro vascular tissue. the fourth and fifth ports were placed at 5 and 7 o’ clock position. as the illumination source was self-retained, so bimanual technique was used for peeling, segmentation and delamination of fibrovascular tissue. all the instruments used were of 23 – gauge including vitreous cutter, endo-illumination light, micro-scissors, forceps, laser probe, intraocular diathermy probe and flute needle. tractional tissue was removed with vitrectomy cutter or micro-scissors and the proliferative membranes were elevated with endgripping forceps or with cutter through aspiration. intraocular diathermy was used to control the bleeding. pan-retinal photocoagulation was performed up to the peripheral retina. endolaser was applied around iatrogenic breaks. after the fluid was exchanged with air, silicone oil was injected only in those patients who developed iatrogenic break. at the end, micro-cannulas were removed with firm pressure applied on to the sclerotomy sites with a cotton-tip applicator to enhance the sealing of the sclerotomies. a nylon 10/0 suture was applied if there was any leakage through the sclerotomy site. finally, injection of dexamethasone and antibiotic was given subconjunctivally. topical antibiotics and steroids were advised post operatively. patients with silicone oil tamponade were advised to maintain face down position for initial 5 to 7 days. snellen visual acuity was converted into logarithms of the minimum angle of resolution for statistical analysis. counting fingers vision was defined as 0.01 (2.0 log mar), and hand movements were defined as 0.001 (3.0 log mar). statistical analyses were performed using spss version 20.0. age, pre-operative bcva and post-operative bcva of patients, pre-operative and post-operative intraocular pressures were presented by calculating mean and standard deviation. mean improvement in bcva was obtained by subtracting mean postoperative bcva at 4 weeks from mean pre-operative bcva. improvement or deterioration of the postoperative visual acuity was defined as a decrease or increase of log mar units by 0.3 or more. a pvalue of less than 0.05 was defined as statistically significant. gender and all the variables including age, pre-operative bcva, post-operative bcva, preoperative and post operative intraocular pressure, duration of the surgery and increase in visual acuity were presented by calculating frequency and percentages. results mean age in 3 port group was 54.50 ± 7.7 years and in 5 port group 57.60 ± 9.8 years with p-value of 0.273 (table 1). gender distribution showed that there were table 1: age distribution. age (years) 3 – port, n (%) 5 – port, n (%) total 20 (100.0) 20 (100.0) mean ± sd 54.50 ± 7.7 57.60 ± 9.8 minimum 45 40 maximum 71 73 p-value 0.273 8 females (40%) and 12 males (60%) in 3-port pars plana vitrectomy group while in 5 – port pars plana vitrectomy group this distribution was 5 females (25%) and 15 males (75%). overall collectively both the groups consisted of 13 females (32.5%) and 27 males (67.5%) with p value of 0.501 (table 2). table 2: gender distribution. gender 3 port n (%) 5 port n (%) total n (%) female 8 (40.0) 5 (25.0) 13 (32.5) male 12 (60.0) 15 (75.0) 27 (67.5) total 20 (100.0) 20 (100.0) 40 (100.0) p value 0.501 safety of the surgical procedure was considered in terms of intraoperative and postoperative complications. two (10%) patients in each group developed iatrogenic retinal tears with a p-value of 1.00. iatrogenic per-operative vitreous hemorrhage developed in three patients (15%) in 3-ports group and two patients (10%) developed this complication in 5ports group (table 3). two (10%) patients in each group developed post vitrectomy vitreous cavity rana naveed iqbal, et al 244 pakistan journal of ophthalmology, 2020, vol. 36 (3): 241-246 table 3: intraoperative complications. complications 3 – port n (%) 5 – port n (%) p value iatrogenic retinal tears no 18 (90.0) 18 (90.0) 1.000 yes 2 (10.0) 2 (10.0) iatrogenic vitreous hemorrhage no 17 (85.0) 18 (90.0) 1.000 yes 3 (15.0) 2 (10.0) hemorrhage which did not require any intervention and resolved by itself 4 weeks post operatively. none of the patients developed any rhegmatogenous retinal detachment because in those patients who developed iatrogenic retinal breaks the complication was promptly managed with the use of endo-laser application around the break. there was no iatrogenic cataract formation in each group (table 4). table 4: postoperative complication. complications 3 – port n (%) 5 – port n (%) p value post vitrectomy vitreous cavity hemorrhage no 18 (90.0) 18 (90.0) 1.000 yes 2 (10.0) 2 (10.0) rhegmatogenous retinal detachment no 20 (100.0) 20 yes 0 (0.0) 0 (0.0) cataract no 20 (100.0) 20 yes 0 (0.0) 0 (0.0) pre-op intraocular pressure in 3 ports group was noted to be 17.70 ± 1.6 mmhg and postoperative intraocular pressure was 16.35 ± 1.9 mmhg with a net change of about 1.35 ± 2.2 mmhg. in 5 ports pars plana vitrectomy group, pre-op iop was 15.55 ± 1.6 mmhg and post operatively it changed to 14.35 ± 2.3 mmhg. the change in intraocular pressure between the two groups was insignificant as the p value was 0.837. duration of surgery in 3 ports group was 74.40 ± 5.4 minutes and in 5 ports group was 53.40 ± 2.50 minutes with a difference of about 21.00 minutes. it was statistically significant with a p-value of 0.001. in 3 ports group pre-operative bcva (log mar) was 1.11 ± 0.5 which changed to 0.66 ± 0.5 and in 5 ports group pre-operative bcva was 1.71 ± 0.9 and this improved to 0.87 ± 0.8 (table 5). table 5: preoperative and post-operative intraocular pressure, duration of surgical procedure and bcva. parameters 3 – port mean ± sd 5 – port mean ± sd p value preoperative intraocular pressure 17.70 ± 1.6 15.55 ± 1.6 0.001 postoperative intraocular pressure 16.35 ± 1.9 14.35 ± 2.3 0.001 change in intraocular pressure 1.35 ± 2.2 1.20 ± 2.4 0.837 duration of surgical procedure 74.40 ± 5.4 53.40 ± 2.5 0.001 preoperative bcva (log mar) 1.11 ± 0.5 1.71 ± 0.9 0.022 postoperative bcva (log mar) 0.66 ± 0.5 0.87 ± 0.8 0.345 discussion with the development of advanced and smaller gauge instruments, the safety and efficacy has improved due to which pars plana vitrectomy is now performed more frequently in proliferative diabetic retinopathy and even at an earlier stage, especially in cases with diabetic vitreous hemorrhage.19,20 in our study intra operative complications included iatrogenic retinal tear formation in two (10%) patients in each group while in a previous study, 4 ports pars plana vitrectomy group had lower number of iatrogenically induced retinal tears (22.2%) than in 3 ports vitrectomy group (43.3%) and this difference was statistically insignificant (p = 0.067)10. this difference in the formation of retinal break is due to the fact that bimanual surgery allows more and safer dissection and peeling of proliferative tissue because of both hands being used. improved illumination of vitreous cavity also plays a pivotal role in this whole mission. a study from thailand evaluated the results of three ports 23-guage pars plana vitrectomy for tractional retinal detachment and they found that iatrogenic retinal tear formation leading to retinal detachment occurred in 20/434 (4.6%) eyes of the 23g pars plana vitrectomy group.11 per-operative iatrogenic hemorrhage during membrane peeling occurred in three (15%) patients in 3 ports group and in two (10%) patients in 5 ports group and this is in comparison to previous study where it was similar in both groups.10 post-operative vitreous cavity hemorrhage developed in 2 patients in each group of our study. this has also been reported in another study conducted by josé alberto lemos and his companions that post vitrectomy cavity hemorrhage occurred in 19 eyes (17.6%) which was quite high as compared to both groups in our study.12 there was no rhegmatogenous retinal detachment and surgically induced cataract formation in our study. outcome of bimanual 23 gauge, 5-ports versus 3-ports pars plana vitrectomy for advanced diabetic eye disease pakistan journal of ophthalmology, 2020, vol. 36 (3): 241-246 245 duration of surgery was shorter in 5 ports group, where it was 53.40 ± 2.5 minutes than in 3 ports group in which it was 74.40 ± 5.4 minutes. this can be attributed to significantly better illumination due to the use of chandelier light which led to better visualization with wider view. due to this bimanual surgical intervention was quick and swift with safe handling of tissues. there was no significant change in the intraocular pressure between the two groups under study which shows that increasing the number of ports does not affect intraocular pressure provided the cannulas used are valved and also the use of chandelier light in additional ports does not allow leakage of intraocular fluid. bcva was noted pre operatively and post operatively in both groups and was found to improve post operatively in both groups but the improvement was more prominent in bimanual 5 ports pars plana vitrectomy group than 3 ports pars plana vitrectomy group. in a previous study, the vision improved significantly in patients who underwent bimanual vitrectomy for diabetic tractional retinal detachment.13 limitation of this study is that our sample size was small and the study was conducted in only two hospitals of lahore. however, this study will help in further research in other centers to validate the findings. conclusion five ports bimanual pars plana vitrectomy is better in treating extensive diabetic tractional retinal detachment as compared to conventional three port pars plana vitrectomy in terms of shorter duration of surgical procedure. intraoperative and postoperative complications were quite similar in both groups. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution rana naveed iqbal; senior registrar: research design, data analysis, manuscript writing, literature review. asad aslam khan; professor: research design, final review. khalid waheed; professor: research design, final review. haroon tayyab; assistant professor: data collection, data analysis, final review. mohsin ihsan; associate professor: research design, final review. intzar hussain; associate professor: research design, final review. references 1. yau gl, silva ps, arrigg pg, sun jk. postoperative complications of pars plana vitrectomy for diabetic retinal disease. semin ophthalmol. 2018; 33 (1): 126133. 2. bhavsar ar, torres k, glassman ar, jampol lm, kinyoun jl. evaluation of results 1 year following short-term use of ranibizumab for vitreous hemorrhage due to proliferative diabetic retinopathy. jama ophthalmology, 2014; 132 (7): 889-90. 3. newman dk. surgical management of the late complications of proliferative diabetic retinopathy. eye, 2010; 24 (3): 441. 4. cheema ra, sengupta r. the 'suck-and-cut' bimanual technique for delamination of fibrovascular membranes in proliferative diabetic retinopathy. acta ophthalmol scand. 2007; 85 (2): 225. 5. arevalo jf. en bloc perfluoro dissection in vitreoretinal surgery: a new surgical technique. retina, 2008; 28 (4): 653-6. 6. eckardt c. twin lights: a new chandelier illumination for bimanual surgery. retina, 2003; 23 (6): 893-4. 7. gonvers m. new instrumentation and technique for epiretinal surgery. arch ophthalmol. 1987; 105 (9): 1292-3. 8. steinmetz rl, grizzard ws, hammer me. vitrectomy for diabetic traction retinal detachment using the multiport illumination system. ophthalmology, 2002; 109 (12): 2303-7. 9. kadonosono k, yabuki k, nishide t, nomura e, uchio e, yamakawa t. multicoated contact lens for bimanual vitreous surgery without endoillumination. arch ophthalmol. 2004; 122 (3): 367-8. 10. wang zy, zhang q, zhao ds, zhao pq. four-port bimanual vitrectomy in fibrovascular membrane removal. retina, 2011; 31 (4): 798-800. 11. choovuthayakorn j, khunsongkiet p, patikulsila d, watanachai n, kunavisarut p, chaikitmongkol v, et al. characteristics and outcomes of pars plana vitrectomy for proliferative diabetic retinopathy rana naveed iqbal, et al 246 pakistan journal of ophthalmology, 2020, vol. 36 (3): 241-246 patients in a limited resource tertiary center over an eight-year period. j ophthalmol. 2019; 2019. 12. lemos ja, carvalho r, teixeira c, martins jn, menezes c, coelho p, et al. pars plana vitrectomy in proliferative diabetic retinopathy–retrospective analysis of results and complications. oftalmologia. 2017; 40: 279-87. 13. park kh, woo sj, hwang jm, kim jh, yu ys, chung h. short-term outcome of bimanual 23-gauge transconjunctival sutureless vitrectomy for patients with complicated vitreoretinopathies. ophthalmic surg lasers imaging 2010; 41 (2): 207-14. 14. oshima y, awh cc, tano y. self-retaining 27 – gauge transconjunctival chandelier endoillumination for panoramic viewing during vitreous surgery. am j ophthalmol. 2007; 143 (1): 166-7. 15. sakaguchi h, oshima y, nishida k, awh cc. a 29/30 – gauge dual-chandelier illumination system for panoramic viewing during micro-incision vitrectomy surgery. retina, 2011; 31 (6): 1231-3. 16. oshima y, chow dr, awh cc, sakaguchi h, tano y. novel mercury vapor illuminator combined with a 27/29 – gauge chandelier light fiber for vitreous surgery. retina, 2008; 28 (1): 171-3. 17. williams ga. 27 – gauge twin light chandelier illumination system for bimanual transconjunctival vitrectomy. retina, 2008; 28 (3): 518-9. 18. chow d. tips on improving your use of endoillumination. retin physician, 2011; 8 (4): 43-6. 19. baig ms, rehman a, burney ja. intravitreal bevacizumab (avastin) for proliferative diabetic retinopathy. pak j surg. 2009; 25 (2): 110-4. 20. yorston d, wickham l, benson s, bunce c, sheard r, charteris d. predictive clinical features and outcomes of vitrectomy for proliferative diabetic retinopathy. br j ophthalmol. 2008; 92 (3): 365-8. .……. pak j ophthalmol. 2020, vol. 36 (4): 324-328 324 original article voriconazole in treatment of resistant fungal keratitis khalid mehmood 1 , sidrah riaz 2 , tariq khan 3 , mahfooz hussain 4 , sara riaz 5 1 avicenna medical college, 2-3 akhtar saeed medical and dental college, lahore, 4 leading reading hospital, peshawar, 5 islam medical college, gujranwala abstract purpose: to study the effect of intrastromal voriconazole for the treatment of resistant fungal keratitis in a tertiary care eye hospital in lahore, pakistan. study design: experimental interventional study. place and duration of study: avicenna medical college hospital, lahore, from july 2017 to july 2019. methods: sixty four patients were selected. all patients with fugal keratitis were included. the patients with previous corneal scar, mature cataract, endophthalmitis, panophthalmitis, scleral involvement, impending or frank corneal perforation and uncontrolled diabetic patients were excluded. corneal scrapings of all patients were sent for 10% koh staining. all patients were given intrastromal voriconazole at 3 to 4 sites in divided doses in one ml syringe with 27-guage needle. injection was repeated on 4 th and 8 th day. it was combined by topical antifungal and antibiotic eye drops six hourly. patients were followed at day two, five, nine, three weeks and at 3 months. results: there were 55 males and 9 females. average size of ulcer was 6.4 mm ranging from 5.5 mm ± 1.8 mm. fifty six (88%) patients showed improvement while eight (12%) patients ended up in melting of cornea which was managed with tectonic corneal graft. in three (5%) patients penetrating keratoplasty was done. conjunctival congestion and ocular pain improved significantly one week after third dose but final visual acuity was not significantly improved due to scarring. conclusion: intrastromal corneal voriconazole is an effective treatment for fungal keratitis in term of healing of the corneal ulcer, control of infection and prevention of corneal perforation and permanent blindness. key words: voriconazole, fungal keratitis, penetrating keratoplasty. how to cite this article: mehmood k, riaz s, khan t, hussain m, riaz s. variconazole in treatment of resistant fungal keratitis. pak j ophthalmol. 2020; 36 (4): 324-328. doi: https://doi.org/10.36351/pjo.v36i4.1002 introduction fungal keratitis is challenging disease, which is difficult to diagnose and treat. once colonized in the cornea, fungi have the propensity to penetrate deeper correspondence: sidrah riaz akhtar saeed medical and dental college lahore email: sidrah893@hotmail.com received: february 8, 2020 accepted: july 20, 2020 corneal layers and if they get access to anterior chamber of eye then control of infection is extremely difficult. 1 cornea is an avascular structure and restricted defense mechanisms make it easy for fungi to colonize. these are usually found in soil, water and on plants. the important risk factors in developing fungal keratitis are trauma with vegetative material, contact lens wear and immunocompromised status. 2,3,4,5 the prevalence of fungal keratitis is more in warm climate. commonly implicated organisms in developing warm countries are fusarium and aspegillus. 6,7 the rapid development of fungal khalid mehmood, et al 325 pak j ophthalmol. 2020, vol. 36 (4): 324-328 keratitis leads to visual loss so early diagnosis is essential to prevent long term ocular complications. 8 poor outcome of fungal keratitis than bacterial keratitis is due to poor penetration and limited availability of antifungal drugs. 9,10 fungus was first documented in 1879 and accounts for 40 to 50% of all cases of keratits. 11,12 there are some 70 different types of fungi but two are more relevant in ophthalmology which are yeast and filamentous fungi (septate and non-septate). fungal keratitis is very difficult to treat. many a times, anti-fungal drugs given in the form of eye drops are not sufficient. the purpose of our study was to find out the effectiveness of intrastromal voriconazole in the treatment of fungal keratitis. methods there were 64 patients included in the study. study duration was from july 2017 to july 2019. all patients with clinical diagnosis of fugal keratitis were included either from outpatient department (opd) or were referred from other medical centers. patients’age, gender, size of ulcer and visual acuity were noted. the patients with previous corneal scar, mature cataract, endophthalmitis, panophthalmitis, scleral involvement, impending or frank corneal perforation and uncontrolled diabetic patients were excluded. clinical features of fungal keratitis included ocular pain, photophobia, decreased vision, satellite corneal lesions, corneal edema, haze and hypopyon. corneal scrapingswere sent for 10% koh staining in all patients. voriconazole is an antifungal drug available in 200 mg vial, which needs dilution and once reconstituted it needs refrigeration. it can be used for 7 to 10 days after dilution. all patients were given intrastromal injection. the dose was 50 micro-lit/ml at 3 to 4 sites, in divided doses, in clear cornea around the lesion. it produced hydration of corneal stroma around the lesion. one ml syringe with 27guage needle was used for injection, with needle bevel down wards in corneal stroma. it was given at first, 4 th and 8 th day of presentation. moderate to severe pain was common complaint by all patients which was treated by oral nsaids in all patients at the time of injection. intrastromal injection was combined by topical antifungal, voriconazole eye drops 1mg/ml and antibiotic eye drops, moxifloxacin 0.5% both qid for 4 weeks. patients were followed-up on day two, five, nine, three weeks and 3 monthly post treatment. visual acuity was noted at each visit. patient was asked about pain and slit lamp examination was done to note size of lesion, resolution of hypopyon and epithelization of defect. no systemic side effects of the drug were detected. no case of endophthalmitis or panophthalmitis was observed. the patients were followed-up for 6 months. results sixty four patients were selected, fifty five were males and nine were females. mean age was 32 ± 8 years and age range was 18 to 60 years. corneal scrapings were sent to lab for 10% koh staining. only 37% showed positive staining and 63% were negative. fifty six patients (88%) responded well (47 males and 8 fig. 1: corneal ulcer before (left) and after treatment (right). voriconazole in treatment of resistant fungal keratitis pak j ophthalmol. 2020, vol. 36 (4): 324-328 326 fig. 2: corneal ulcer before (left) and after treatment (right). females) to intrastromal voriconazole, in terms of decrease in size of corneal infiltrates, improvement in ocular pain, resolution of corneal edema and healing of corneal ulcer with scarring of cornea. eight (12%) patients (7 males and 1 female) did not respond and ended up in melting of cornea which was managed with tectonic corneal graft. out of these eight, only three patients required penetrating keratoplasty for visual restoration. conjunctival congestion and ocular pain improved significantly one week after third dose of intrastromal voriconazole but final visual acuity was not significantly improved due to scarring and most patients had counting finger vision after resolution of keratitis. no patient needed evisceration during 6 months follow-up period. discussion there are different anti-fungal drugs; which include, polyenes, imidazoles, triazoles and fluorinated pyrimidines. 13 commonly used antifungal drugs are; natamycin, amphoteracin b, and voriconazole. these drugs are used as topical and systemic therapy for treatment of fungal keratitis. we found intrastromal anti fungal drug delivery most effective as it achieved targeted drug delivery. higher incidence of fungal keratitis in male patients may be due to our social set up where males are more exposed to outdoors than women and it was comparable with other studies done by al-hatim et al and ch cho et al. 14,15 ideally every corneal scraping should be sent for pcr and culture for diagnosis. pcr takes only two to three hours and culture takes up to 35 days. 16 we did not perform these tests in our study. natamycin 5% eye drops belong to polyene group and it was the first approved antifungal agent. it inhibits transport of amino acids and glucose across fungal plasma membrane by binding with ergosterol leading to cell damage, but it is used only as a topical drug as negligible oral absorption makes it unfit for systemic drug. 17 voriconazole belongs to triazole group, fungistatic and fungicidal, available for oral and parenteral use and metabolized in liver. it inhibits fungal cytochrome p-450 3a dependent enzymes and inhibits ergosterol synthesis, which is the principal sterol in cell wall of fungus and inhibits cell membrane synthesis. it is effective against candida, aspergillus, fusarium, scedosporium and paecilomyces. it is effective in fungal keratitis resistant to polyenes and first line triazoles. it is also used as alternative to amphoteracin b in fungal endophthalmitis. recent studies show that intrastromal use of voriconazole has produced better results in term of control of fungal infection and healing of ulcer. ganapathy k showed that intrastromal voriconazole helped to resolve the infection in 18 (72%) patients and about 15% of these needed more than one injection. smaller ulcers responded better to treatment. fusarium species were responsible for six of the seven cases. 18 according to namrata sharma, of 12 eyes, 10 eyes healed with scar formation, and the mean resolution time was 39.75 ± 7.62 days. two corneas perforated and required therapeutic penetrating keratoplasty. 19 other studies also showed that voriconazole has potential to achieve adequate drug khalid mehmood, et al 327 pak j ophthalmol. 2020, vol. 36 (4): 324-328 concentration at the site of infection through a targeted drug delivery. 20-22 intrastromal amphoteracin b is used in the same fashion as voriconazole. average healing time in our study was 21 days which was comparable with studies in other countries. a study in india by kalaisselvi et al, showed mean resolution time of resistant fungal keratitis in 25 patients was 17 days. 18 another study by sharma et al. showed healing time of 39 ± 7 days. 19 in our study 5% patients showed no response to treatment and ended up as candidate of penetrating keratoplasty. literature shows that 30% patients with fungal keratitis develop corneal perforation or do not respond to topical antifungal therapy. 23-25 penetrating keratoplasty is expensive treatment but if intraocular contents are not involved it can result in complete eradication of infection. limitation of our study are that we did not compare our results with any other antifungal drug, single center study and small sample size. conclusion our study showed that intrastromal voriconazole is effective in fungal keratitis in term of good healing of corneal ulcer, control of infection, saving eye from corneal perforation, evisceration and loss of vision. no systemic side effects of drug were observed. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. gopinathan u, sharma s, garg p, rao gn. review of epidemiological features, microbiological diagnosis and treatment outcome of microbial keratitis: experience of over a decade. ind j ophthalmol. 2009; 57: 273–279. 2. zapp d, loos d, feucht n, khoramnia r, tandogan t, reznicek l, et al. microbial keratitis-induced endophthalmitis: incidence, symptoms, therapy, visual prognosis and outcomes. bmc ophthalmol. 2018; 18 (1): 112. 3. shimizu e, yamaguchi t, yagi-yaguchi y, dogru m, satake y, tsubota k, et al. corneal higher-order aberrations in infectious keratitis. am. j. ophthalmol. 2017; 175: 148-158. 4. taneja mj, ashar n, mathur a, nalamada s, grag p. microbial keratitis following vegetative matter injury. int ophthalmol. 2013; 33 (2): 117-123. 5. thomas pa, kaliamurthy j. mycotic keratitis: epidemiology, diagnosis and management. clin microbiol infect. 2013; 19 (3): 210–220. 6. foster cs. fungal keratitis. infect dis clin north am. 1992; 6 (4): 851-857. 7. wong ty, ng tp, fong ks, tan dt. risk factors and clinical outcomes between fungal and bacterial keratitis: a comparative study. clao j. 1997; 23: 275– 281. 8. sharma s. diagnosis of fungal keratitis: current options. expert opin med diagn. 2012; 6 (5): 449-455. 9. florcruz nv, evans jr. medical intervention for fungal keratitis. cochrane database syst rev. 2012; 2: 2015. 10. lalitha p, shapiro bl, srinivasan m, prajna nv, acharya nr, fothergill aw, et al. antimicrobial susceptibility of fusarium, aspergillus, and other filamentous fungi isolated from keratitis. archives of ophthalmology, 2007; 125 (6): 789-793. 11. tena d, rodríguez n, toribio l, gonzálezpraetorius a. infectious keratitis: microbiological review of 297 cases. jpn. j. infect. dis. 2019; 72 (2): 121-123. 12. mittal r, ahooja h, sapra n. corneal plaque formation after anti-acanthamoeba therapy in acanthamoeba keratitis. indian j ophthalmol. 2018; 66 (11): 1623-1624. 13. bhartiya p, daniell m, constantinou m, islam fma, taylor hr. fungal keratitis in melbourne. clin exp ophthalmol. 2007; 35 (2): 124-130. 14. al-hatmi ams, castro ma, de hoog gs, badali h, alvarado vf, verweij pe, et al. epidemiology of aspergillus species causing keratitis in mexico. mycoses. 2019; 62 (2): 144-151. 15. cho ch, lee sb. comparison of clinical characteristics and antibiotic susceptibility between pseudomonas aeruginosa and p. putida keratitis at a tertiary referral center: a retrospective study. bmc ophthalmol. 2018; 18 (1): 204. 16. ferrer c, alio jl. evaluation of molecular diagnosis in fungal keratitis ten years of experience. journal of ophthalmic inflammation and infection, 2011; 1: 15–22. 17. farrell s, mcelnea e, moran s, knowles s, murphy cc. fungal keratitis in the republic of ireland. eye (lond). 2017; 10: 1427-1434. 18. kalaiselvi g, narayana s, krishnan t, sengupta s. intrastromal voriconazole for deep recalcitrant fungal keratitis: a case series. br j ophthalmol. 2015; 99 (2): 195–198. voriconazole in treatment of resistant fungal keratitis pak j ophthalmol. 2020, vol. 36 (4): 324-328 328 19. sharma n, agarwal p, sinha r, titiyal js, velpandian t, vajpayee rb. evaluation of intrastromal voriconazole injection in recalcitrant deep fungal keratitis: case series. br j ophthalmol. 2011; 95 (12): 1735–1737. 20. siatiri h, daneshgar f, siatiri n, khodabande a. the effects of intrastromal voriconazole injection and topical voriconazole in the treatment of recalcitrant fusarium keratitis. cornea, 2011; 30 (8): 872–875. 21. prakash g, sharma n, goel m, titiyal js, vajpayee rb. evaluation of intrastromal injection of voriconazole as a therapeutic adjunctive for the management of deep recalcitrant fungal keratitis. am j ophthalmol. 2008; 146 (1): 56–59. 22. jones a, muhtaseb m. use of voriconazole in fungal keratitis. j cataract refract surg. 2008; 34 (2): 183184. doi: 10.1016/j.jcrs.2007.09.031. 23. fontana l, moramarco a, mandarà e, russello g, iovieno a. interface infectious keratitis after anterior and posterior lamellar keratoplasty. clinical features and treatment strategies. a review. br j ophthalmol. 2019; 103 (3): 307-314. 24. mcelnea e, power b, murphy c. interface fungal keratitis after descemet stripping automated endothelial keratoplasty: a review of the literature with a focus on outcomes. cornea, 2018; 37 (9): 12041211. 25. xie l, dong x, shi w. treatment of fungal keratitis by penetrating keratoplasty. br j ophthalmol. 2001; 85: 1070-1074. authors’ designation and contribution khalid mehmood; professor: concepts, data acquisition, literature research, manuscript preparation, manuscript review. sidrah riaz; associate professor: design, literature research, statistical analysis, manuscript preparation, manuscript editing. tariq khan; professor: literature research, manuscript preparation, manuscript review. mahfooz hussain; assistant professor. manuscript writing, critical review. sara riaz; assistant professor: manuscript editing, manuscript review. .…  …. orbit as window to systemic infections, inflammation, tumors and non ocular trauma: frequency and causes 70 pak j ophthalmol. 2021, vol. 37 (1): 70-74 original article pattern of orbital diseases at a tertiary oculoplastic center mohammad idris 1 , hasan yaqoob 2 , muhammad adnan khan 3 , adnan zar 4 , saifullah 5 1,2 lady reading hospital, medical teaching institute (mti), peshawar, 2 department of ophthalmology, north west teaching hospital, peshawar, 3 hayatabad medical complex, medical teaching hospital, peshawar, 5 lrbt free eye hospital, akora khattak, kpk abstract purpose: to determine the causes and frequency of orbital involvement by systemic disorders and non-ocular trauma at a tertiary oculoplastic centre. study design: descriptive cross-sectional retrospective study. ophthalmology unit place and duration of study: department of ophthalmology, lady reading hospital medical teaching institute, peshawar from january 2012 and dec 2016. methods: a total of 45 patients were included in this study. patients’ demographics, clinical cause of orbitopathy and time delay between the problem noticed by the patient and presentation were recorded. orbitopathy included the presence of corneal and conjunctival changes, optic nerve disorders, proptosis, orbital bone changes and soft tissue swelling of eyelids. the data was analyzed using spss software (version 22). the frequency (percentage) and mean ± standard deviation were reported for categorical variables. results: mean age of the patients was 28.89 ± 22.02 years. there were 26 (57.8%) males 19 (42.2%) females. commonest disorder was bacterial infection in 16 (35.6%) patients followed by thyroid orbitopathy, which was seen in 14 (31.1%) cases. other causes included leukemia, lymphoma, retrobulbar hemorrhage, neurofibromatosis, neuroblastoma, maxillary osteosarcoma, teratoma and fungal infection. time delay between presentation of orbital swelling and first noticed by patient was 147.02 ± 155.18 weeks in male while in female the time delay was 148.79 ± 146.47 weeks. conclusion: the commonest inflammation was due to thyroid, commonest infection was bacterial infection and commonest tumor was leukemia. imaging and proper workup is important to properly treat any orbital disease. key words: orbit, ocular trauma, neuroblastoma, orbital lymphoma. how to cite this article: idris m, yaqoob h, khan ma, zar a, saifullah. pattern of orbital diseases at a tertiary oculoplastic center. pak j ophthalmol. 2021, 37 (1): 70-74. doi: https://doi.org/10.36351/pjo.v37i1.1154 introduction orbit is a well-protected bony area filled with eyeball, soft tissues, nerves and blood vessels. the bony part correspondence: mohammad idris lady reading hospital, medical teaching institute (mti), peshawar email: idrisdaud80@gmail.com received: october 24, 2020 accepted: november 16, 2020 has four walls, which continue with the skull through various foramen. 1 this well protected part of the body needs the help of proper work up, notably imaging, for getting relevant important details for the underlying disease process. many delicate structures are placed within this cavity with well protected mechanisms. there are many ocular and non-ocular disorders which can cause changes in the orbit (proptosis, eyelid odema and conjunctival swelling, etc). 2 there are many non-ocular systemic conditions with similar presentations for which orbit serves as window through which important and early pattern of orbital diseases at a tertiary oculoplastic center pak j ophthalmol. 2021, vol. 37 (1): 70-74 71 information can be gathered and proper and timely management is possible. 3 the rationale of this study was to highlight the importance of orbital abnormalities, which might be the first clinical presentation of a systemic disease or non-ocular trauma. timely referral by physicians to the ophthalmologist and vice versa may help in early intervention. the purpose of the study was to determine the causes and frequency of orbital involvement by systemic disorders and non-ocular trauma at a tertiary oculoplastic centre. methods a descriptive cross sectional study was performed by consecutive sampling of 45 patients who were diagnosed with orbitopathy at the department of ophthalmology lady reading hospital medical teaching institute, peshawar between january 2012 and dec 2016. diagnosis was based on clinical features, imaging and necessary work up in lesion with relevant departments. informed consent was obtained from all patients or their guardians. this study adhered to the tenets of the declaration of helsinki and was approved by the institutional review board. data collected included patient demographics, clinical cause of orbitopathy and time between problem noticed by the patient or guardian and presentation to the ophthalmologist. orbitopathy included the presence of corneal and conjunctival changes, optic nerve disorders, proptosis, orbital bone changes and soft tissue swelling of eyelids. the data were analyzed using spss software (version 22). the frequency (percentage) and mean ± standard deviation were reported for categorical variables. means and proportions were compared using student’s t test and the chi-square test (or fisher’s exact test, if appropriate), respectively. all tests were two-sided, and a p value < 0.05 was considered statistically significant. results mean age of the patients was 28.89 ± 22.02 years. male were in majority 26 (57.8%) while females were 19 (42.2%). commonest disorder was bacterial infection in 16 (35.6%) patients followed by thyroid orbitopathy, which was seen in 14 (31.1%) cases. other rare but serious causes included leukemia, lymphoma, retrobulbar hemorrhage, neurofibromatosis, neuroblastoma, maxillary osteosarcoma, teratoma and fungal infection involving orbit. time delay between presentation of orbital swelling and first noticed by patient was 147.02 ± 155.18 weeks in male while in female the time delay was 148.79 ± 146.47 sd in weeks which was slightly more (table 1). table 1: etiology of orbital involvement by different pathologies and patient demographics. n % age groups 0.08-18years 22 48.9% 19 and above 23 51.1% gender male 26 57.8% female 19 42.2% cause/disorder thyroid orbitopathy 14 31.1% bacterial infection 16 35.6% leukemia 2 4.4% lymphoma 1 2.2% retrobulbar hemorrhage 2 4.4% neurofibromatosis 2 4.4% brain tumor 1 2.2% neuroblastoma 2 4.4% maxillary osteosarcoma 1 2.2% teratoma 2 4.4% fungal infection 2 4.4% fig. 1: distribution according to age groups. a total of 45 patients were selected. four age groups were made. for details see figure 1. the most frequent disorder disorders reported or recorded included bacterial infections (35.6%) and the 2 nd most common was thyroid orbitopathy (31.1%). further details are shown in table 2 and figure 2. mohammad idris, et al 72 pak j ophthalmol. 2021, vol. 37 (1): 70-74 table 2: association of disorders with age groups. disorder in years p value 0 – 17 18 – 35 36 – 53 > 54 total thyroid orbitopathy 0% 0% 22.2% 8.9% 31.1% 0.001 bacterial infection 26.7% 2.2% 4.4% 2.2% 35.6% leukemia 4.4% .0% .0% .0% 4.4% lymphoma .0% .0% .0% 2.2% 2.2% retrobulbar haemorrhage .0% .0% 2.2% 2.2% 4.4% neurofibromatosis 2.2% 2.2% .0% .0% 4.4% brain tumor 2.2% .0% .0% .0% 2.2% neuroblastoma 4.4% .0% .0% .0% 4.4% maxillary osteosarcoma .0% 2.2% .0% .0% 2.2% teratoma 4.4% .0% .0% .0% 4.4% fungal infection 4.4% .0% .0% .0% 4.4% total 48.9% 6.7% 28.9% 15.6% 100.0% fig. 2: association of gender with disorders. discussion orbit is involved in many important non ocular conditions which include infections, inflammations, tumors and trauma which shows the importance of all necessary workup for any patient with such abnormality in orbit. 4 according to the present study, based on our experience of more than 10 years dealing with orbital diseases at our centre, the non ophthalmic diseases which cause changes in the orbit are broadly classified as infective, inflammatory, neoplastic and traumatic. thyroid eye disease was the most common cause of orbital disease in our study which is supported by the previous researchers. 5,6,7 thyroid eye disease includes eyelid edema, conjunctival chemosis, proptosis, eyelid retraction and optic nerve compression. therefore, proper detection and management by ophthalmologist as well as the endocrinologist and other related specialties are important to prevent its complications. 8 according to ackuaku-dogbe et al, it is common in middle aged females with more than 80% under the age 50 years. 9 however, more severe disease is encountered in males which was also seen in our study. 10 infections involving orbital region both ocular and systemic are also quite common. the common causes of orbital cellulitis include infections of surrounding areas particularly sinuses, dental area and nose. 11,12 immune compromised individuals are mostly infected by the fungi. 13 according to our study, sinusitis was the most common cause of orbital cellulitis which is in accordance with literature. 14 orbital cellulitis as a complication of sinusitis is seen in both genders equally and more common in young children. 15 these findings were also seen in our study. variety of common and rare tumors also cause different changes in the orbit which range from mild swelling to a large proptosis. one of the common tumors which involve orbit is lymphoma. 16 leukemia was seen in one patient which is extremely rare as a cause of proptosis. 17 rare tumors of orbit include orbital teratoma. 18 other tumors include maxillary tumor invading the orbit, brain tumors and neuroblastoma. 19,20,21 all the above mentioned tumors were seen in comparatively least frequency in our study. according to our results, neurofibromatosis and leukemia were the most common ones. when neurofibromatosis involves orbit it may cause globe destruction and huge proptosis. it was also evident from our study. 22 trauma is common in our region. the common cause of proptosis due to non-ocular trauma was retrobulbar hemorrhage, which is a rare complication pattern of orbital diseases at a tertiary oculoplastic center pak j ophthalmol. 2021, vol. 37 (1): 70-74 73 of non-ocular trauma. the need for early detection through imaging and proper and timely workup is vision saving. delay in diagnosis can result in optic nerve damage due to compression and ischemia. 23,24 untreated or unrecognized cases may result in permanent visual loss within 90-120 minutes. 25 therefore immediate management and most importantly recoding of visual acuity at trauma room with proper referral to ophthalmologist and long follow-up is recommended to save vision. limitations of this study were descriptive crosssectional design and vascular lesions like fistulas, vascular tumors and av malformations were not included. conclusion orbit serves as an important window to both local and systemic diseases, which includes inflammation, infection and tumors and trauma. the commonest inflammation was due to thyroid, commonest infection was bacterial orbital cellulitis and commonest tumor was leukemia. imaging and proper workup is important to properly treat any orbital disease. majority of our patients presented at late and advanced stage. ethical approval the study was approved by the institutional review board/ ethical review board. (3273) conflict of interest authors declared no conflict of interest. references 1. felding una. blowout fractures – clinic, imaging and applied anatomy of the orbit. dan med j. 2018; 65 (3): b5459. 2. nguyen vd, singh ak, altmeyer wb, tantiwongkosi b. demystifying orbital emergencies: a pictorial review. radiographic. 2017; 37 (3): 947962. 3. mc nab aa. the 2017 doyne lecture: the orbit as a window to systemic disease. eye (lond). 2018; 32 (2): 248-261. 4. abad s, héran f, terrada c, sène d, trad s, saadoun d, et al. orbitopathies inflammatories. que doit savoir l’interniste? (management of orbital inflammation in internal medicine. proposal for a diagnostic work-up). rev med interne. 2018; 39 (9): 746-754. 5. wang y, tooley aa, mehta vj, garrity ja, harrison ar, mettu p. thyroid orbitopathy. int ophthalmol clin. 2018; 58 (2): 137-179. 6. drui d, fediaevski dpl, clermont c, daumerie c. graves' orbitopathy: diagnosis and treatment. ann endocrinol (paris). 2018; 79 (6): 656-664. 7. shi tt, hua l, wang h, xin z. the potential link between gut microbiota and serum trab in chinese patients with severe and active graves' orbitopathy. int j endocrinol. 2019; 2019: 9736968. 8. drui d, du-pasquier fl, clermont vc, daumerie c. graves' orbitopathy: diagnosis and treatment. ann endocrinol (paris). 2018; 79 (6): 656-664. 9. ackuaku-dogbe em, akpalu j, abaidoo b. epidemiology and clinical features of thyroidassociated orbitopathy in accra. middle east afr j ophthalmol. 2017; 24 (4): 183-189. 10. gharib s, moazezi z, bayani ma. prevalence and severity of ocular involvement in graves' disease according to sex and age: a clinical study from babol, iran. caspian j intern med. 2018; 9 (2): 178-183. 11. kinis v, ozbay m, bakir s, ediz y, ramazan g, mehmet a, et al. management of orbital complications of sinusitis in pediatric patients. j craniofac surg. 2013; 24 (5): 1706-1710. 12. de assis-costa, santos gs, maciel j, sonoda ck, de melo wm. odontogenic infection causing orbital cellulitis in a pediatric patient. j craniofac surg. 2013; 24 (5): e526-9. 13. nasa m, sharma z, lipi l, sud r. gastric angioinvasive mucormycosis in immunocompetent adult, a rare occurrence. j assoc physicians india. 2017; 65 (12): 103-104. 14. wong sj, levi j. management of pediatric orbital cellulitis: a systematic review. int j pediatr otorhinolaryngol. 2018; 110: 123-129. 15. tsirouki t, dastiridou ai, ibánez flores n, cerpa jc, moschos mm, brazitikos p, et al. orbital cellulitis. surv ophthalmol. 2018; 63 (4): 534-553. 16. olsen tg, heegaard s. orbital lymphoma. surv ophthalmol. 2019; 64 (1): 45-66. 17. zhu t, xi xy, dong hj. isolated myeloid sarcoma in the pancreas and orbit: a case report and review of literature. world j clin cases, 2018; 6 (11): 477-482. 18. barreau g, mounayer c, bédu a, pommepuy i, robert py. a newborn saved by embolisation and surgery of a giant teratoma of the orbit. j fr ophtalmol. 2017; 40 (4): e137-e139. 19. mici e, belli e. fibrous dysplasia: a complex maxillary reconstruction. j craniofac surg. 2018; 29 (7): e660-e661. 20. hayashi s, kurihara h, hirato j, sasaki t. solitary fibrous tumor of the orbit with extraorbital extension: case report. neurosurgery, 2001; 49 (5): 1241-1245. https://www.sciencedirect.com/science/article/abs/pii/s0248866318300043#! https://www.sciencedirect.com/science/article/abs/pii/s0248866318300043#! https://www.sciencedirect.com/science/article/abs/pii/s0248866318300043#! https://www.sciencedirect.com/science/article/abs/pii/s0248866318300043#! https://www.sciencedirect.com/science/article/abs/pii/s0248866318300043#! mohammad idris, et al 74 pak j ophthalmol. 2021, vol. 37 (1): 70-74 21. borni m, kammoun b, kolsi f, boudawara mz. l’esthésioneuroblastome pédiatrique: une lésion maligne exceptionnelle (à propos d’un cas et revue de la littérature) [pediatric esthesioneuroblastoma: an exceptional malignant lesion (a case study and literature review)]. pan afr med j. 2018; 31: 144. 22. lafford gh, eccles sj, haq j, orban n. sight preserving orbital decompression: a novel multidisciplinary approach to managing severe proptosis in neurofibromatosis type 2. bmj case rep. 2017; 2017: bcr2017221462. 23. johnson d, schweitzer k, sharma s. answer: can you identify this condition? can fam physician, 2009; 55 (6): 607. 24. griffin as, hoang jk, malinzak md. ct and mri of the orbit. int ophthalmol clin. 2018; 58 (2): 25-59. 25. pamukcu c, odabaşı m. acute retrobulbar haemorrhage: an ophthalmologic emergency for the emergency physician. ulus travma acil cerrahi derg. 2015; 21 (4): 309-314. authors’ designation and contribution mohammad idris; assistant professor: concepts, design, literature search, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. hasan yaqoob; associate professor: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing. muhammad adnan khan; vitreo retina fellow: literature search, data acquisition, analysis, manuscript preparation, manuscript editing. adnan zar; spr: literature search, data acquisition. saifullah; associate professor: data analysis, manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (1): 29-33 29 original article internal limiting membrane (ilm) peeling for macular edema secondary to branch retinal vein occlusion (brvo) hussain ahmad khaqan 1 , usman imtiaz 2 , hasnain muhammad baksh 3 hafiz ateeq-ur-rehman 4 , raheela naz 5 1-5 ameer-ud-din medical college pgmi lahore general hospital, lahore – pakistan abstract purpose: to find out the anatomic and functional outcomes of pars plana vitrectomy (ppv) and internal limiting membrane (ilm) peeling in patients with refractory macular edema associated with branch retinal vein occlusion (brvo). study design: interventional case series. place and duration of study: ophthalmology department, lahore general hospital, lahore from 2015 to 2019. methods: fifty-five eyes of patients presenting with refractory macular edema associated with branch retinal vein occlusion (brvo) were recruited for this study. they were treated using 23-gauge pars plana vitrectomy and brilliant blue green assisted internal limiting membrane peeling. pre-operative and post-operative best-corrected visual acuity (bcva) and macular edema were assessed by fluorescein angiography and optical coherence tomography (oct). monthly follow up was continued for one year. results: in 46 (83.6%) eyes, central macular thickness improved from 465 ± 91 µm at baseline to 295 ± 103 µm post-operatively, (p < 0.003) at one year follow up. in nine (16.3%) eyes, there was no improvement in central macular thickness. improvement in best-corrected visual acuity (bcva) was seen in 43 (78.1%) eyes. out of these 43 eyes, 37 (86%) eyes had mean 3 snellen lines improvement while six (13.9%) eyes had 2.4 snellen lines improvement. in 12 eyes (21.8%) bcva did not improve. no statistically significant difference was seen in post-operative bcva between ischemic and non-ischemic brvo (p > 0.05). conclusion: twenty-three gauge vitrectomy with brilliant blue green (bbg) assisted ilm peeling is effective in reducing refractory macular edema and improves visual acuity in ischemic and non-ischemic brvo. key words: internal limiting membrane, macular edema, retinal vein occlusion, brilliant blue green. how to cite this article: khaqan ha, imtiaz u, baksh hm, rehman ha, naz r. internal limiting membrane (ilm) peeling for macular edema secondary to branch retinal vein occlusion (brvo). pak j ophthalmol. 2021, 37 (1): 29-33. doi: https://doi.org/10.36351/pjo.v37i1.1144 correspondence: hussain ahmad khaqan ameer-ud-din medical college pgmi lahore general hospital, lahore. pakistan email: drkhaqan@hotmail.com received: october 13, 2020 accepted: november 23, 2020 introduction brach retinal vein occlusion (brvo) is a common vascular condition that leads to significant vision loss. 1 it is the second only to diabetes as a cause of vision loss and is three times more common than central retinal vein occlusion (crvo). brvo can be caused by both systemic factors, e.g. diabetes, high blood pressure and local factors such as raised intraocular pressure. 2 numerous factors are associated with vision hussain ahmad khaqan, et al 30 pak j ophthalmol. 2021, vol. 37 (1): 29-33 loss in brvo, the most common of which is macular edema. 3 macular edema in brvo is caused by break down of the blood-retinal barrier and increased vascular permeability. vascular occlusion leads to the expression of interleukin 6 (il-6) and vascular endothelial growth factor (vegf), both of which lead to the development of macular edema which reduces vision. 4 treatment has evolved significantly over the past few years with the aim of treating macular edema in branch retinal vein occlusion (brvo). grid laser photocoagulation was used to treat macular edema in a specific group of patients with brvo, while promising results were observed with intravitreal injections of anti-vegf (vascular endothelial growth factor) or steroids. 5-6 a conventional treatment for chronic or refractory macular edema (cme) with brvo is pars plana vitrectomy (ppv) with hyaloid removal, based on the hypothesis that vitreous traction on the macula causes fluid to accumulate. recently, the role of internal limiting membrane (ilm) peeling has been introduced as an adjunctive procedure to ppv. 7 ilm peeling in brvo associated macular edema is a new surgical technique that focuses on the hypotheses about the role of vitreoretinal interface abnormalities in the pathogenesis of macular edema. in recent years, ppv has been proved to be an effective technique for the management of macular edema. mandelcorn et al. have shown promising results from ilm peeling in cases of severe visual impairment due to macular edema caused by retinal vein occlusion. they proposed that vitrectomy along with ilm peeling resulted in dispersion of retained intraretinal extracellular fluid and blood into the vitreous through the retina from where ilm has been removed. 8 the purpose of our study was to find out the anatomic and functional outcomes of pars plana vitrectomy (ppv) and internal limiting membrane (ilm) peeling in patients with refractory macular edema associated with branch retinal vein occlusion (brvo). methods a prospective study was conducted at ophthalmology department of lahore general hospital, lahore, from 2015 to 2019. a total of 55 eyes with brvo (both ischemic and non-ischemic) with associated refractory macular edema of more than 6 months duration and confirmed by optical coherence tomography (oct) were included in the study. eyes with visually significant media opacities and evident macular traction on oct were excluded. eyes which required cataract surgery during ppv were also excluded. refractory macular edema was defined as edema in which all therapeutic options including grid laser photocoagulation (at least 3 months before vitrectomy) and three intravitreal injections of anti-vegf on monthly basis (with last injection at least one month before vitrectomy) had failed to reduce macular edema. patients were observed for one year postoperatively. the study was approved from the institutional ethical committee and informed consent was taken from every patient. twenty-three–gauge sutureless ppv with brilliant blue green (bbg) assisted removal of the ilm was performed. preoperative and post-operative complete eye examination including bcva, fundoscopy, fluorescein angiography, and oct were done in all patients. all surgeries were performed by the same surgeon. three ports 23-gauge ppv with ilm peeling assisted with brilliant blue green (bbg) was performed. after core vitrectomy, posterior vitreous detachment was done. air-fluid exchange was carried out after which, bbg was injected into the vitreous cavity on the macula and allowed to stain ilm for 3 minutes. under the fluid infusion, stained ilm was removed by ilm peeling forceps and isolated from the surface of the internal retina on the macular area to a point just outside the foveal avascular zone. none of the eyes was sutured to close the sclerotomy. postoperative follow up was performed every 4 weeks for one year. results in 46 (83.6%) eyes the central macular thickness improved from 465 ± 91 µm at baseline to 295 ± 103 µm (p < 0.003). in nine (16.3%) eyes, there was no improvement in central macular thickness. in 43 (78.1%) eyes, improvement in bcva was seen (p < 0.05). out of these 43 eyes, 37(86%) eyes gained 3 snellen lines of bcva while six (13.9%) eye gained 2.4 snellen lines. however, no statistically significant difference was seen in improvement of visual acuity between ischemic and non-ischemic brvo (p > 0.05). no eyes had recurrence of macular edema during the ilm peeling for macular edema secondary to branch retinal vein occlusion (brvo) pak j ophthalmol. 2021, vol. 37 (1): 29-33 31 follow-up period. there were no intraoperative complications. pre-operative and post-operative oct of two patients is shown below in figure 1 and 2. fig. 1a: pre-operative oct of a patient with branch retinal vein occlusion (brvo) associated with macular edema. fig. 1b: post-operative oct of the patient in “a”. fig. 2a: pre-operative oct of a patient with brvo associated with macular edema. fig. 2b: post-operative oct of the patient in “a”. discussion a number of treatment options have been proposed for the management of macular edema including macular grid laser photocoagulation, anti-vascular endothelial growth factor (vegf) and intravitreal steroids. 9-11 it takes time for macular edema to get resolved after treatment. this persistent macular edema can cause apoptosis of photoreceptors and can result in permanent vision loss. rapid regression of macular edema is necessary for visual acuity preservation. 12 ppv with ilm peel is based on the belief that by activating the release of extracellular fluid and blood into the vitreous, the normal thickness of the retina can be restored. this surgery also helps to reduce the intraretinal pressure around adjacent retinal capillaries that would help to reopen the occluded blood vessels. it is also documented that with ppv cytokines such as interleukin 6 (il-6) and vascular endothelial growth factor (vegf) are cleared from the eye and thus their adverse effects are canceled. 13-16 ppv also increases pre-retinal oxygen tension. in addition, ilm peeling helps in the absorption of the macular edema. eventually all of these events increase the pre-retinal oxygen stress and further stimulate the vasoconstriction, thereby reducing the hydrostatic vascular pressure and reducing edema. 17-20 previous studies have shown reduction in macular thickness after ppv in patients with brvo. sato et al conducted a study to find out the anatomical and functional outcomes of micro-incisional vitrectomy (mivs) surgery on 101 eyes of 101 patients to treat macular edema secondary to branch retinal vein occlusion (brvo). they also categorized the patients into ischemic and non-ischemic brvo. patients were evaluated at1, 3, 6 and 12 months after surgery. they concluded that mivs was effective in improving visual acuity and morphology of fovea with low recurrence rate of macular edema. 21 in another study, a 25-gauge ppv with intra vitreal triamcinolone acetonide and ilm peeling was done in 38 eyes with chronic cystoid macular edema and retinal vein occlusion. the study concluded that refractory macular edema in brvo was significantly reduced after surgery. 22 hariri et al reported that ppv with ilm peeling resulted in decreasing macular edema but the improvement in bcva was not statistically significant. 4 mandelcorn reported decrease in macular thickness within an average of 39 days after ppv and hussain ahmad khaqan, et al 32 pak j ophthalmol. 2021, vol. 37 (1): 29-33 ilm peeling. 20 long-term effects of ilm peeling were also reported by kumagai et al. there was no recurrence of macular edema at one year follow-up which is consistent with our study. 23 other researchers have also shown similar results. 24 outcomes of ppv with ilm peel were similar when macular edema in ischemic and non-ischemic brvo was compared. 12,20 this was observed in our study as well. sometimes visual acuity does not improve after ppv, which could be due to damage to the photoreceptor layer even after the resolution of macular edema. ota et al reported lack of highreflectance band on high-resolution oct, which correlated with a poor final visual acuity. 25 limitation of this study was small sample size. diabetic and hypertensive status of the patients were also not taken into account. conclusion twenty-three– gauge vitrectomy with brilliant blue green (bbg) assisted ilm peeling is effective in reducing refractory macular edema and improving visual acuity in ischemic and non-ischemic brvo. ethical approval the study was approved by the institutional review board/ ethical review board. (amc/pgmi/lgh/00-159-20) conflict of interest authors declared no conflict of interest references 1. sophie r, campochiaro p. treatment of macular edema following branch retinal vein occlusion. us ophthalmic review, 2013; 06 (02): 148. 2. hamid s, mirza sa, shokh i. branch retinal vein occlusion. j ayub med coll abbottabad. 2008 apr-jun; 20 (2): 128-132. 3. ehlers j, kim s, yeh s, thorne j, mruthyunjaya p, schoenberger s, et al. therapies for macular edema associated with branch retinal vein occlusion. ophthalmology, 2017; 124 (9): 1412-1423. 4. hariri a, baharivand n, javadzadeh, sadeghi, heidari. pars plana vitrectomy and internal limiting membrane peeling for macular edema secondary to retinal vein occlusion. clin ophthalmol. 2011; 5: 10891093. 5. rehak j, rehak m. branch retinal vein occlusion: pathogenesis, visual prognosis, and treatment modalities. curr eye res. 2008; 33 (2): 111-131. 6. parodi pm, bandello f. branch retinal vein occlusion: classification and treatment. ophthalmologica. 2009; 223 (5): 298-305. 7. ma j, yao k, zhang z, tang x. 25-gauge vitrectomy and triamcinolone acetonide-assisted internal limiting membrane peeling for chronic cystoid macular edema associated with branch retinal vein occlusion. retina, 2008; 28 (7): 947–956. 8. mandelcorn ms, nrusimhadevara rk. internal limiting membrane peeling for decompression of macular edema in retinal vein occlusion: a report of 14 cases. retina, 2004; 24 (3): 348–355. 9. varma r, bressler n, suñer i, lee p, dolan c, ward j, et al. improved vision-related function after ranibizumab for macular edema after retinal vein occlusion. ophthalmology, 2012; 119 (10): 2108-2118. 10. aref aa, scott iu. management of macular edema secondary to central retinal vein occlusion: an evidence-based. adv ther. 2011; 28 (1): 40–50. doi.org/10.1007/s12325-010-0089-3 11. argon laser photocoagulation for macular edema in branch vein occlusion. the branch vein occlusion study group. am j ophthalmol. 1984; 98 (3): 271-282. doi: 10.1016/0002-9394(84)90316-7. 12. liang xl, chen hy, huang ys, au eong kg, yu ss, liu x, et al. pars plana vitrectomy and internal limiting membrane peeling for macular oedema secondary to retinal vein occlusion: a pilot study. ann acad med singap. 2007; 36 (4): 293-297. 13. gandorfer a, messmer em, ulbig mw, kampik a. resolution of diabetic macular edema after surgical removal of the posterior hyaloid and the inner limiting membrane. retina, 2000; 20 (2): 126–133. 14. quinlan pm, elman mj, bhatt ak, mardesich p, enger c. the natural course of central retinal vein occlusion. am j ophthalmol. 1990; 110 (2): 118–123. 15. chen jc, klein ml, watzke rc, handelman il, robertson je. natural course of perfused central retinal vein occlusion. can j ophthalmol. 1995; 30 (1): 21–24. 16. suzuma k, kita m, yamana t, ozaki s, takagi h, kiryu j, et al. quantitative assessment of macular edema with retinal vein occlusion. am j ophthalmol. 1998 sep; 126 (3): 409-16. doi: 10.1016/s00029394(98)00096-8. 17. stefansson e. the therapeutic effects of retinal laser treatment and vitrectomy. a theory based on oxygen and vascular physiology. acta ophthalmol scand. 2001; 79 (5): 435–440. ilm peeling for macular edema secondary to branch retinal vein occlusion (brvo) pak j ophthalmol. 2021, vol. 37 (1): 29-33 33 18. leizaola-fernandez c, suarez-tata l, quirozmercado h, colina-luquez j, fromow-guerra j, jiménez-sierra j, et al. vitrectomy with complete posterior hyaloid removal for ischemic central retinal vein occlusion: series of cases. bmc ophthalmol. 2005; 5: 10. 19. tachi n, hashimoto y, ogino n. vitrectomy for macular edema combined with retinal vein occlusion. doc ophthalmol. 1999; 97 (3–4): 465–469. 20. mandelcorn m. vitrectomy with surgical macular decompression by internal limiting membrane removal. can j ophthalmol. 2007; 42 (4): 626. 21. sato s, inoue m, yamane s, arakawa a, mori m, kadonosono k. outcomes of microincision vitrectomy surgery with internal limiting membrane peeling for macular edema secondary to branch retinal vein occlusion. clin ophthalmol. 2015; 9: 439-444. 22. ma j, yao k, zhang z, tang x. 25-gauge vitrectomy and triamcinolone acetonide–assisted internal limiting membrane peeling for chronic cystoid macular edema associated with branch retinal vein occlusion. retina, 2008; 28 (7): 947-956. 23. kumagai k, furukawa m, ogino n, larson e, uemura a. long-term visual outcomes after vitrectomy for macular edema with foveal hemorrhage in branch retinal vein occlusion. retina, 2007; 27 (5): 584-588. 24. shirakata y, fukuda k, fujita t, nakano y, nomoto h, yamaji h, et al. pars plana vitrectomy combined with internal limiting membrane peeling for recurrent macular edema due to branch retinal vein occlusion after antivascular endothelial growth factor treatments. clin ophthalmol. 2016; 10: 277-283. doi: 10.2147/opth.s85751. 25. ota m, tsujikawa a, murakami t, kita m, miyamoto k, sakamoto a, et al. association between integrity of foveal photoreceptor layer and visual acuity in branch retinal vein occlusion. br j ophthalmol. 2007; 91 (12): 1644-9. doi: 10.1136/bjo.2007.118497. authors’ designation and contribution hussain ahmad khaqan; professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. usman imtiaz; vitreo retinal fellow: data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. hasnain muhammad baksh; vitreo retinal fellow: data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. hafiz ateeq-ur-rehman; post graduate resident: literature search, statistical analysis. raheela naz; post graduate resident: literature search, statistical analysis. .…  …. 183 pak j ophthalmol. 2021, vol. 37 (2): 183-187 original article frequency of diabetic retinopathy and factors for suboptimal diabetic control in type 2 diabetic patients in a trust hospital of pakistan sidrah riaz 1 , tehmina jahangir 2 , tariq khan 3 departments of ophthalmology, 1,3 akhtar saeed medical and dental college, lahore, 2 ameer ud din medical college, lgh abstract purpose: to find out the frequency of diabetic retinopathy and factors responsible for poor diabetic control in patients with type 2 diabetes in a trust hospital. place and duration of study: akhtar saeed medical college, from january 2018 to december 2019. study design: descriptive cross-sectional study. methods: total 395 diabetic patients belonging to lower socioeconomic class were included in the study. type 1diabetes, age below 20 years, high myopia, papilledema, dense cataract, corneal scar and patients on dialysis were excluded. age, gender, duration of disease, family history of diabetes, drugs used for diabetic control, compliance with drug, random serum sugar level at presentation, hba1c level, best corrected visual acuity, slit lamp and fundus findings were noted. results: there were 270 (68.4%) females and 125 (31.6%) males (total 395). random serum sugar was below 200mg/dl in 188 (47.6%). family history of diabetes was positive in 145 (36.7%). duration of diabetes was below ten years in 288 (73%). visual acuity was less than 6/60 in 36 (6.3%) patients. hba1c was within normal range in only 124 (31.4%). csmo was present in 199 (50.37%) patients. diabetic retinopathy was observed in 57 (14.43%) patients. patients using oral hypoglycemic agents were 225 (57%), on insulin 151 (38.23%) and19 (4.8%) were using both oral drugs and insulin. compliance was poor in 294 (74.4%). conclusion: poor monetary resources compounded with lack of knowledge about disease, misconceptions regarding insulin and imbalanced diet are big hurdles in achieving optimal glycemic control in lower socioeconomic class. key words: diabetic retinopathy, glycated hemoglobin (hba1c), blood serum sugar, clinically significant macular edema. how to cite this article: riaz s, jahangir t, khan t. frequency of diabetic retinopathy and factors for suboptimal diabetic control in type 2 diabetic patients in a trust hospital of pakistan. pak j ophthalmol. 2021, 37 (2): 183-187. doi: http://doi.org/10.36351/pjo.v37i2.1123 correspondence: sidrah riaz department of ophthalmology akhtar saeed medical and dental college lahore email: sidrah893@hotmail.com received: august 24, 2020 accepted: january 27, 2021 introduction diabetes mellitus is a chronic progressive disease whose prevalence is growing globally. 1 pakistan currently stands at 7 th position among countries with highest diabetic population as estimated by international diabetic federation (idf) database on diabetes and by 2025 it is estimated to be at 5 th position. 2 diabetes is not a simple disease; it is a http://doi.org/10.3352/jeehp.2013.10.3 frequency of diabetic retinopathy and factors for suboptimal diabetic control in type 2 diabetic patients in a trust hospital of pakistan pak j ophthalmol. 2021, vol. 37 (2): 183-187 184 syndrome, which affects whole human body from head to toe. the major organs affected by it are heart, eyes and kidneys as it is a microangiopathy. visual impairment due to diabetic retinopathy is not only most serious complication of diabetes but also a leading cause of blindness worldwide. 3 the longer the duration of diabetes more will be chances of diabetic retinopathy. 4 according to american diabetes association (ada) about 21% patients have diabetic retinopathy at time of diagnosis and 60% develop within a decade of diagnosis. 5 in 2015 five million diabetes related deaths were reported in low to middle income countries. 6 diabetic retinopathy is sight threatening microvascular complication affecting retina. 7-9 diabetic patients belonging to low socioeconomic status are more prone to have uncontrolled disease and ocular complications of disease. 10 diabetic retinopathy is classified based on absence or presence of new blood vessels. rationale of this study was to find out the frequency of diabetic retinopathy in patients presenting in a trust hospital and to find out the factors responsible for poor diabetic control in the lower socio-economic class. methods total three ninety-five (395) diabetic patients were included in the study. all patients were from lower socioeconomic class, which was defined as monthly family income of 20,000 or below. the previously undiagnosed diabetic patients, type 1 diabetes, age below 20 years, high myopia, papilledema, dense cataract or corneal opacities hindering fundal view and patients on dialysis were not included. the patients included in the study, either presented in eye opd with visual complaints or were referred by medical opd for fundus examination with history of diabetes. the study period was from january 2018 to december 2019. the pupil was dilated with tropicamide 1% and phenylephrine 10%. the pertinent age, gender, duration of disease, family history of diabetes were noted. they were enquired about drugs used for diabetic control, their compliance with drug and major reasons for poor diabetic control. the random blood sugar level at presentation, hba1c level, best corrected visual acuity, presence or absence of nvi’s, dilated fundus examination findings, presence or absence of clinically significant macular edema (csmo) and grade of diabetic retinopathy (npdr or pdr) were also noted. fundus examination was done using non-contact fundus lens (90 d; volk super field). these patients were advised about importance of good diabetic control, visual complications associated with longstanding disease and importance of regular clinical examination by internist and ophthalmologist. results out of 395 diabetic patients, 270 (68.4%) were females and 125 (31.6%) were males. the mean age of diabetic patients was 52.93 years, slightly more for male (55.20 years) patients than females (51.84 years). mean iop was 16.24 mmhg in the right eye and 16.54 mmhg in the left eye. history of laser treatment was seen in 2 (0.5%), avastin in 8 (2%) and both in 2 (0.5%). further detail is shown in table 1. table 1: details of the patients. gender male 125 31.65% female 270 68.35% compliance poor 294 74.43% good 101 25.57% treatment oral drugs 225 56.96% insulin 151 38.23% both 19 4.81% hba1c below 6 124 31.40% above 6 271 68.60% total 395 100% duration of disease above 10 years 107 27% below 10 years 288 73% total 395 100% bsr(random serum sugar) above 200 207 52.40% below 200 188 47.60% total 395 100.00% csmo absent 196 49.63% present 199 50.37% total 395 100% diabetic retinopathy none 338 85.60% mild npdr 40 10.10% moderate npdr 4 1.01% severe npdr 3 0.76% pdr 10 2.53% total 395 100% compliance with drugs good 101 25.60% poor 294 74.40% total 395 100% sidrah riaz, et al 185 pak j ophthalmol. 2021, vol. 37 (2): 183-187 discussion frequency of diabetic retinopathy in our study was 14.43%. other countries showed similar statistics i.e. 40% in egypt, 42% in oman, 25.9% in nepal, 3.7% in south korea, 27% in sri lanka, 17.6% in india and 37% in iran. 11 in a review article by hakeem r et al frequency of diabetic retinopathy was 7.6% to 11%. 12 diabetic retinopathy (dr) is one of the major causes of decrease vision among diabetic patients. in one study, the diabetic patients were the largest fraction attending eye hospital for visual complaints. 13 diabetic retinopathy was more in females in our study which was analogous to results of national diabetes survey of pakistan. 14 nearly one third of patients, 36.7% had positive family history of diabetes. it was also consistent with other studies in pakistan and lebanon, where 30.2% patients showed positive family history. 14,15 clinically significant macular edema (csmo) is the commonest cause of visual impairment in diabetic patients. 16 it was observed in 50% of known diabetic patients who presented in our eye opd. glycated hemoglobin (hba1c) is an important indicator to know about optimal diabetic control, which gives information about optimal glycemic control over last 3 months. 17,18 it was high in majority of our patients. the increased prevalence of diabetic retinopathy in socioeconomically deprived people was major concern for us. about 24% pakistani population is living below national poverty line; 31% in rural areas and 13% in urban areas. the systematic review by kashim et al found poor economy as a major risk factor for nonattendance of retinal clinic by known diabetic patients for regular fundoscopy. 19,20 even if they managed to attend the clinic, poor compliance with medical treatment was observed in 74% our patients. the patients were asked about the possible causes of poor diabetic control. the reasons were misconceptions regarding insulin, lack of knowledge about long term complications of diabetes and nonavailability of balanced diet. it was found that many patients thought that if insulin was suggested by physician for treatment of diabetes it meant that disease had aggravated. insulin injection storage was also a problem because refrigerator was not available in all homes or temperature maintenance was issues because of frequent power failures. lack of awareness about disease nature, course and complications was another issue. another cause of poor diabetic control was poor diet. the diabetic patients diet chart needs specific modification as they need relatively less carbohydrates (50 to 55%) in diet than normal nondiabetic person who needs 65 to 75%. 21,22 quality proteins and lipids intake was harder because of affordability issues. the two densely populated countries in asia are china and india. both got independence in 1949 and 1947 respectively and despite facing poverty as a major problem, both have a national plan for diabetic patients. 23,24 pakistan, with its 200 million people, lack national program for diabetes control which is detrimental for our national health and wellbeing. the national action plan on non-communicable diseases (ncd) including diabetes is agreed upon by central government but its implementation is still pending. furthermore after 18 th amendment in constitution in 2010, provinces are mainly responsible for forming own health policies and role of central government is only coordination. a combined effort by major stake holders; government, health professionals and community are need of time to tackle with diabetic population. measures should also be taken to deal with poverty at national level to improve people economic status. the limitations of study are single centered noncomparative study on limited number of patients. multicentric studies with larger number of diabetic patients are required. conclusion diabetes mellitus is not only a problem of elite class rather it is also prevalent in patients belonging to low socioeconomic status. poor monetary resources compounded with lack of knowledge about disease, misconceptions regarding insulin and imbalanced diet are big hurdles in achieving optimal glycemic control. ethical approval the study was approved by the institutional review board/ ethical review board. (m-19/045/-ophthal). conflict of interest authors declared no conflict of interest. frequency of diabetic retinopathy and factors for suboptimal diabetic control in type 2 diabetic patients in a trust hospital of pakistan pak j ophthalmol. 2021, vol. 37 (2): 183-187 186 references 1. akhtar s, nasir ja, abbas t, sarwar a. diabetes in pakistan: a systematic review and meta analysis. pak j med sci. 2019; 35 (4): 1173-1178. doi:10.12669/pjms 35.4.194. 2. international database federation atlas. 2006 showing prevalence of diabetes in 2007 and future projection for 2025. available from: http://www.atlas.idf.org/index1397.html. 3. jingi am, noubiaq jjn, ellong, bigna jjr, myogo ce. epidemiology and treatment outcomes of diabetic retinopathy in a diabetic population from cameroon. bmc ophthalmol. 2014: 19. doi: 10.1186/1471-241514-19. 4. lartey sy, aikins ak. visual impairment amongst adult diabetics attending a tertiary outpatient department clinic. ghana med j. 2018; 52 (2): 84-87. doi:10.4314/gmj. v52i2.4. 5. cho n, shaw j, karuranga s, huang y, da rocha fernandes j, ohlrogge a, et al. idf diabetes atlas: global estimates of diabetic prevalence for 2017 and projections for 2045. diabetes res clin pract. 2018; 138: 271-281. 6. world health organization (who) diabetes country profiles. 2016. available from: https://www.who.int/diabetes/countryprofiles/paken.pdf?ua=1. 7. sivaprasad s, gupta b, crosby-nwaobi r, evans j. prevalence of diabetic retinopathy in various ethnic groups: a worldwide perspective. surv. ophthalmol. 2012; 57: 347–370. doi: 10.1016/j.survophthal.2012.01.004. 8. yau jwy, rogers sl, kawasaki r, lamoureux el, kowalski jw, bek t, et al. global prevalence and major risk factors of diabetic retinopathy for the metaanalysis for eye disease (meta-eye) study group. diabetes care. 2012; 35: 556–564. doi: 10.2337/dc111909. 9. fenwick e, rees g, pesudovs k, dirani m, kawasaki r, wong ty, et al. social and emotional impact of diabetic retinopathy: a review. clin. exp. ophthalmol. 2012; 40: 27–38. doi: 10.1111/j.1442-9071.2011.02599.x. 10. hakeem r, awan z, memon s, shaikh sa, sheikh ma, ilyas s. diabetic retinopathy awareness and practices in low income suburban population in karachi, pakistan. j diabetol. 2017; 8: 49-55. doi: 10.4103/jod.jod_31_17. 11. mohan v, unnikrishnan r, shobana s, malavika m, anjana rm, sudha v. are excess carbohydrates the main link to diabetes & its complications in asians? indian j med res. 2018; 148 (5): 531-538. doi: 10.4103/ijmr.ijmr_1698_18. 12. hakeem r, fawwad a. diabetes in pakistan: epidemiology, determinants and prevention. j diabitol. 2010; 3: 4. 13. khan a, riaz q, soomro f, qidwai u, qazi u. frequency and patterns of eye diseases in retina clinic of a tertiary care hospital in karachi. pak j ophthalmol. 2011; 27: 155-159. 14. basit a, fawwad a, qureshi h, shera as. prevalence of diabetes, pre-diabetes and associated risk factors: second national diabetes survey of pakistan (ndsp), 2016-2017. bmj 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(2): 196-199. doi: 10.2174/1573399812666161129154559. 19. kashim rm, newton p, ojo o. diabetic retinopathy screening: a systematic review on patients' nonattendance. int j environ res public health, 2018; 15 (1): 157. doi:10.3390/ijerph15010157. 20. shaikh s, ursani tj, dhiloo kh, samuel r, talpur r, jawad m, et al. prevalence of diabetic retinopathy and related factors in patients with type 2 diabetes mellitus in hyderabad and adjoining areas. j entomol zool stud. 2017; 5 (6): 1755-1759. 21. chaudhury a, duvoor c, reddy dendi vs, kraleti s, chada a, ravilla r, et al. clinical review of antidiabetic drugs: implications for type 2 diabetes mellitus management. front endocrinal (lausanne), 2017; 8: 6. doi: 10.3389/fendo.2017.00006. 22. shaw je, sicree ra, zimmet pz. global estimates of prevalence of diabetes for 2010 and 2030. diabetes res clin pract. 2010; 87 (1): 4–14. doi 10.1016/j.diabres.2009.10.007. 23. mumtaz sn, fahim mf, arslan m, shaikh sa, kazi u, memon ms. prevalence of diabetic retinopathy in pakistan; a systematic review. pak j med sci. 2018; 34 (2): 493-500. doi: 10.12669/pjns.342.13819. https://www.who.int/diabetes/country-profiles/pak https://www.who.int/diabetes/country-profiles/pak sidrah riaz, et al 187 pak j ophthalmol. 2021, vol. 37 (2): 183-187 24. nishter s, boerma t, amjad s, alam ay, khalid f, ul haq i, et al. pakistan’s health system: performance and prospects after the 18th constitutional amendment. lancet 2013; 381: 2193-2206. doi 10.1016/so1406736(13)60019-7. authors’ designation and contribution sidrah riaz; associate professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript review. tehmina jahangir; associate professor: literature search, manuscript editing, manuscript review. tariq khan; professor: concepts, design, literature search. .…  …. 335 pak j ophthalmol. 2020, vol. 36 (4): 335-340 original article frequency of post-operative hypotony in 23 gauge and 25 gauge pars plana vitrectomy in advanced diabetic eye disease hussain ahmad khaqan 1 , usman imtiaz 2 , hasnain muhammad buksh 3 hafiz ateeq-ur-rehman 4 , raheela naz 5 1-5 department of ophthalmology, ameer-ud-din medical college pgmi, lahore general hospital, lahore, pakistan abstract purpose: to compare the frequency of post-operative hypotony between 23g ppv and 25g ppv in advanced diabetic eye disease. study design: quasi experimental study. place and duration of study: study was conducted at department of ophthalmology, lahore general hospital, lahore from 7 th april 2016 to 6 th october 2016. methods: total 100 cases of advanced diabetic eye disease with age ranging from 25 – 65 years and either gender were selected. patients with nystagmus and claustrophobia, lamellar macular holes, epiretinal membrane and neovascular glaucoma were excluded. patients were divided by lottery method into 2 groups. data of the patient i.e. name, age, sex, patient’s registration number and address was recorded. every patient had detailed preoperative work-up; including best corrected visual acuity by snellen’s chart, intraocular pressure by applanation tonometer, indirect ophthalmoscopy and b-scan for retinal status. group a underwent 23g ppv and group b underwent 25g ppv. patients were followed after 24 hours of surgery to measure intraocular pressure to access hypotony. results: mean age of patients in group a was 50.16 ± 10.40 years and in group b was 50.26 ± 9.91 years. out of 100 patients 57 (57.0%) were females and 43 (43.0%) were males, with female to male ratio of 1.1:1. post-operative hypotony was seen in 24 (48.0%) patients with 23g ppv and 02 (4.0%) patients with 25g ppv (p-value = 0.0001). conclusion: this study concluded that the frequency of post-operative hypotony in 23g pars plana vitrectomy was higher as compared to 25g pars plana vitrectomy in advanced diabetic eye disease. key words: diabetic retinopathy, pars plana vitrectomy, hypotony. how to cite this article: khaqan ha, imtiaz u, buksh hm, rehman ha, naz r. comparison of frequency of post-operative hypotony in 23 guage and 25 guage pars plana vitrectomy in advanced diabetic eye disease. pak j ophthalmol. 2020; 36 (4): 335-340. doi: https://doi.org/10.36351/pjo.v36i4.1016 correspondence: hussain ahmad khaqan ameer-ud-din medical college, lahore general hospital, lahore – pakistan email: drkhaqan@hotmail.com received: march 11, 2020 accepted: july 23, 2020 introduction diabetes mellitus (dm) is of three types. type i or insulin dependent dm or juvenile diabetes, type ii or non-insulin dependent dm or adult-onset diabetes and gestational diabetes which occurs when pregnant women without a previous diagnosis of diabetes develop a high blood glucose level. 1 incidence of mailto:drkhaqan@hotmail.com post-operative hypotony in 23 gauge and 25 gauge pars plana vitrectomy pak j ophthalmol. 2020, vol. 36 (4): 335-340 336 diabetes mellitus is 10 – 14% worldwide. diabetes mellitus type 2 (formerly non-insulin-dependent diabetes mellitus (niddm) or adult-onset diabetes) is a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency while in diabetes mellitus type 1, due to destruction of islet cells in the pancreas, there is an absolute insulin deficiency. 2 diabetes mellitus (dm) is one of the commonest world health problems affecting 92.4 million adults worldwide and its prevalence in pakistan is 13.4%. 3 among the large number of diabetic people, 35% develop some form of diabetic retinopathy and 10% progress to vision threatening stages and require treatment. 4 prevalence of diabetic retinopathy in pakistan was 28.76% in 2012. 3 diabetic retinopathy contributes 10.2% to total blindness worldwide. unfortunately, this blindness mostly affects the working age group of population. 4 although the exact mechanism of diabetic retinopathy is unclear, but several theories have been postulated to explain the course of disease. hyperglycemia alters blood vessel formation in retina of the eye, it can lead to blurring of vision and ultimately to blindness if left untreated. 5 patients with type 2 diabetes mellitus, due to its delayed diagnosis, already have diabetic complications at the time of diagnosis. duration of diabetes is directly proportional to the development of diabetic retinopathy. 6 prevalence of diabetic retinopathy in patients with type 2 diabetes at the time of diagnosis varies from 5 – 35%. 7 timely diagnosis of diabetic retinopathy and appropriate management can help delay the complications. initial stages of diabetic retinopathy can be treated with good systemic control of blood sugar levels by showing compliance to their physicians and laser photocoagulation of retina. however, advanced diabetic eye disease requires surgery. pars plana vitrectomy (ppv) remains the gold standard surgical treatment. 8 improving the surgical technique aiming towards a better visual outcome developed trans-conjunctival suture-less vitrectomy. this also provides better patient’s comfort during and after surgery. 9 a study comparing 23g ppv and 25g ppv for posterior segment disease revealed that post-operative hypotony was 41.3% with 23g ppv and none with 25g ppv. another study showed that eyes operated with 23g ppv present with intra-ocular pressure (iop) less than 6 mm hg (hypotony) more frequently when compared with eyes operated through 25g ppv (p = 0.034). this resulted in more frequent application of port sutures in eyes operated through 23g ppv (p = 0.014). 10 25g ppv may prove a good alternate to the traditionally used 23g ppv. giving the patient an extra benefit in the form of better comfort and earlier visual rehabilitation. smaller incision also allows better anatomical preservation of delicate ocular structures and lessens the risk of post-operative infections according to principles of minimum invasive surgery. 9 this study was conducted with the aim to compare post-operative hypotony in 23g and 25g ppv. currently both approaches of surgery are in use and according to the results of this study, better surgical approach can be adopted to avoid post-operative hypotony. methods this quasi experimental study was conducted at department of ophthalmology, lahore general hospital, lahore from 7th april 2016 to 6th october 2016. total of 100 patients were included in the study with 50 patients in each group. non-probability, consecutive sampling technique was used. patients from 25-65 years of age from both sexes, with diabetes for more than 5 years and diagnosed with advanced diabetic eye disease were included in the study. patients with nystagmus and claustrophobia and preoperative iop of less than 6 mm hg, patients who were unable to maintain supine posture, mentally handicapped patients, patients with neo-vascular glaucoma, epiretinal membrane and patients with lamellar macular holes were excluded from the study. informed consent was obtained from all patients. data of the patients including name, age, sex, patient’s registration number and address were recorded. every patient had detailed preoperative work-up which included best corrected visual acuity by snellen’s chart, intraocular pressure by applanation tonometer, indirect ophthalmoscopy and b-scan for retinal status. patients were divided by lottery method into 2 groups. group a underwent 23g ppv and group b underwent 25g ppv. intraocular pressure was measured by applanation tonometry on first post-operative day. data was recorded on a pre-designed proforma. 23g http://en.wikipedia.org/wiki/metabolic_disorder http://en.wikipedia.org/wiki/blood_glucose http://en.wikipedia.org/wiki/insulin_resistance http://en.wikipedia.org/wiki/insulin http://en.wikipedia.org/wiki/diabetes_mellitus_type_1 http://en.wikipedia.org/wiki/diabetes_mellitus_type_1 http://en.wikipedia.org/wiki/diabetes_mellitus_type_1 http://en.wikipedia.org/wiki/islets_of_langerhans http://en.wikipedia.org/wiki/pancreas http://en.wikipedia.org/wiki/retina http://en.wikipedia.org/wiki/blindness hussain ahmad khaqan, et al 337 pak j ophthalmol. 2020, vol. 36 (4): 335-340 and 25g ppv procedure are minimally invasive retinal surgeries to deal with retinal diseases through small trans-conjunctival scleral incisions at pars plana. these micro incisions facilitate the insertion of instruments e.g. vitrectomy cutter, endo-illuminator and fluid to maintain globe integrity and intraocular pressure. patients were followed after 24 hours of surgery to measure intraocular pressure to access hypotony. spss version 12.0 was used for statistical analysis of the data. results were shown as mean and standard deviation was used for quantitative variables i.e. age and post-operative intra-ocular pressure of patients. frequency and percentage were calculated for qualitative variables like gender and hypotony (present/absent). frequency of hypotony was compared in both groups by using chi square test with p-value ≤ 0.05 as significant. effect modifiers like age, gender and duration of dm were controlled through stratifications. post-stratification chi square was applied to see their effects on outcome and p value ≤ 0.05 was considered as significant. results in this study, the age ranged from 25 to 65 years with mean age of 50.21 ± 10.11 years. mean age of patients in group a was 50.16 ± 10.40 years and in group b was 50.26 ± 9.91 table 1: age distribution for both groups (n = 100). age (years) group a (n = 50) group b (n = 50) total (n = 100) no. of patients % age no. of patients % age no. of patients % age 25 – 40 11 22.0 10 20.0 21 21.0 41 – 55 18 36.0 20 40.0 38 38.0 56 – 65 21 42.0 20 40.0 41 41.0 mean ± sd 50.16 ± 10.40 50.26 ± 9.91 50.21 ± 10.11 table 2: distribution of patients according to duration of dm (n = 100). duration (years) group a (n = 50) group b (n = 50) total (n = 100) no. of patients % age no. of patients % age no. of patients % age 6 – 10 21 42.0 23 46.0 44 44.0 > 10 29 58.0 27 54.0 56 56.0 mean ± sd 8.24 ± 4.09 8.39 ± 4.18 8.32 ± 4.13 table 3: stratification of post-operative hypotony according to age. age of patients (years) group a (n = 50) group b (n = 50) p-value hypotony hypotony yes no yes no 25 – 40 04 (36.36%) 07 (63.64%) 00 (0.0%) 10 (100.0%) 0.034 41 – 55 09 (50.0%) 09 (50.0%) 01 (5.0%) 19 (95.0%) 0.002 56 – 65 11 (52.38%) 10 (47.62%) 01 (5.0%) 19 (95.0%) 0.001 table 4: stratification of post-operative hypotony according to gender. gender group a (n = 50) group b (n = 50) p-value hypotony hypotony yes no yes no male 12 (57.14%) 09 (42.86%) 01 (4.55%) 21 (95.45%) 0.000 female 12 (41.38%) 17 (58.62%) 01 (3.57%) 27 (96.43%) 0.001 table 5: stratification of post-operative hypotony according to duration of dm. duration group a (n = 50) group b (n = 50) p-value hypotony hypotony yes no yes no 6 – 10 years 10 (47.62%) 11 (52.38%) 00 (0.0%) 23 (100.0%) 0.000 > 10 years 14 (48.28%) 15 (51.72%) 02 (7.41%) 25 (92.59%) 0.001 post-operative hypotony in 23 gauge and 25 gauge pars plana vitrectomy pak j ophthalmol. 2020, vol. 36 (4): 335-340 338 years. 41.0% patients were between 56 to 65 years of age. out of 100 patients, 57 were females and 43 were males, with female to male ratio of 1.1:1. mean duration of diabetes mellitus in group a was 8.24 ± 4.09 years and in group b was 8.39 ± 4.18 years. most of the patients (56.0%) had >10 years of duration of diabetes mellitus. mean intra-ocular pressure was 9.41 ± 3.12 mm hg. post-operative hypotony was seen in 24 (48.0%) patients with 23g ppv and 02 (4.0%) patients with 25g ppv (p-value = 0.0001). stratification of post-operative hypotony with respect to age groups showed significant difference in postoperative hypotony in both groups. similarly, statistically significant difference was found in post-operative hypotony in both genders between both groups. for details see tables 1 to 5. discussion complicated vitreoretinal disease, such as advanced diabetic eye disease has been treated using 20-g or 23g ppv. however, in 2002, fujii described 25-g ppv, which has revolutionized the vitreoretinal surgeries. 11 the advantages include short duration of surgery, decreased inflammation, rapid visual recovery, comfortability, reduced rate of iatrogenic retinal breaks, preservation of limbal stem cells, and reduced corneal astigmatism. the indications for 25-g ppv are macular holes, idiopathic epiretinal membranes, refractory macular edema, and non-resolving vitreous hemorrhage. 12 the delicacy or limited variety of instrumentation for 25-g ppv has rendered its use limited for uncomplicated surgeries. 13,14,15 data has shown comparable outcomes and complication rates between 25-g ppv and 20-g or 23-g systems for complicated retinal surgeries like diabetic tractional retinal detachment. 16 a study comparing 23g ppv and 25g ppv for posterior segment disease revealed that post-operative hypotony was 41.3% with 23g ppv and none with 25g ppv. 17 another study showed that eyes operated with 23g ppv presented with intra-ocular pressure (iop) less than 6 mm hg (hypotony) when compared with eyes operated through 25 g ppv (p = 0.034). the aim of small gauge vitrectomy or minimally invasive vitreous surgery (mivs) is to minimize invasion with maximum success of the surgery. the much-criticized small gauge vitrectomy has now gained popularity. thus, instruments used in vitreoretinal surgery are now available in 23-g and 25-g sizes. initial success rate for 25-g vitrectomy has increased from 74% to 92.9% with gas as tamponade. 18 literature shows approximately up to 25% rates of hypotony following suture-free vitrectomy. the severity can range from mild and transient cases, which resolve after conservative management, to severe cases which could lead to hypotonic maculopathy, optic choroidopathy and large choroidal mounds. the following factors can lead to wound leakage and can result in hypotony; redo surgery on a vitrectomized eye, multiple instrumentation, young age, widespread dissection of vitreous base and wound construction alteration. 19 the two-step procedure is superior to one-step technique in terms of lower rates of wound leakage. technique of trocar insertion can influence the rate of hypotony. direct insertion of cannulais associated with higher rates of wound leakage 20 . oblique or obliqueparallel entry helps in scleral wound re-apposition, thus reducing wound leakage. retraction of the conjunctiva while trocar entry may be beneficial. 21 while using one-step technique, wound leakage is minimal for extreme oblique trocar entry and relatively higher for oblique and direct cannula entry. no difference was observed in wound leakage following 23-g and 25-g vitrectomies. 22 this is further supported by imaging of wound healing by optical coherence tomography of the anterior segment. after a 25-g vitrectomy, scleral wounds assessed by optical coherence tomography were closed at 60.5% at one month follow up and 63.9% at three month follow up. after a 23-g vitrectomy, 57.4% of scleral wounds were seen closed at one month and 61.1% at three months postoperatively 23 . in a study by bamonte et al, rate of hypotony after 25-g vitrectomy was 9.2%. 24 they also found that the rate of hypotony was higher in cases where fluid tamponade was used. on the whole, it was concluded that frequency of post-operative hypotony in 23 g ppv was higher compared to 25g ppv in advanced diabetic eye disease. conclusion this study concluded that the frequency of postoperative hypotony in 23g pars plana virectomy is higher when compared to 25g pars plana virectomy in advanced diabetic eye disease. hussain ahmad khaqan, et al 339 pak j ophthalmol. 2020, vol. 36 (4): 335-340 references 1. shoback, gardner dg, dolores. greenspan's basic & clinical endocrinology. 9th ed. new york: mcgrawhill medical, 2011; chap 17. 2. vijan s. type 2 diabetes. ann intl med. 2010; 152 (5): 31–15. 3. khanzada ma, siyal na, mirza sa, memon a, elmuttaqi a, mirza aa. frequency and types of diabetic maculopathy in type ii diabetes. pak j surg. 2013; 29 (2): 139-142. 4. ludwig j, sanbonmatsu l, gennetian l, adam e, duncan gj, katz lf, et al. neighborhoods, obesity, and diabetes--a randomized social experiment. n engl j med. 2011; 365 (16): 1509-1519. 5. yng w, lu j, weng j, jia w, xio j. prevalence of diabetes among men and women in china. n engl j med. 2010; 362 (12): 1092-1101. 6. zafar j, bhatti f, akhtar n, rasheed u, humayun s, waheed a, et al. prevalence and risk factors of diabetes mellitus in a selected urban population of a city in punjab. j pak med asso. 2011; 61: 40-47. 7. yau jw, rogers sl, kawasaki r, lamoureux el, kowalski jw, bek t, et al. global prevalence and major risk factors of diabetic retinopathy. dia care, 2012: 556-564. 8. memon wu, jadoon z, qidwai u, naz s, dawar s, hasan t. prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicenter diabetic clinic in karachi. p j ophthalmol. 2012; 28 (2): 99-104. 9. bxter sl, wormald rp, musa jm, patel d. blindness registers as epidemiological tools for public health planning: a case study in belize. epidemiol res int. 2014; 2014: 1-8. 10. ockrim z, yorston d. managing diabetic retinopathy. bmj. 2010; 341: c5400. 11. fujii gy, de juan e jr, humayun ms, pieramici dj, chang ts, awh c, et al. a new 25-gauge instrument system for transconjunctival sutureless vitrectomy surgery. ophthalmology. 2002; 109 (10): 1807-1812 12. khanduja s, kakkar a, majumdar s, vohra r, garg s. small gauge vitrectomy: recent update. oman j ophthalmol. 2013 jan; 6 (1): 3-11. 13. rizzo s, genovesi-ebert f, vento a, miniaci s, cresti f, palla m. modified incision in 25-gauge vitrectomy in the creation of a tunneled airtight sclerotomy: an ultrabiomicroscopic study. graefes arch clin exp ophthalmol. 2007 sep; 245 (9): 1281-1288. 14. hubschman jp, gupta a, bourla dh, culjat m, yu f, schwartz sd. 20-, 23-, and 25-gauge vitreous cutters: performance and characteristics evaluation. retina. 2008 feb; 28 (2): 249-257. 15. ahmad m, el-asrar a. advances in the treatment of diabetic retinopathy. saudi j ophthalmol. 2011; 25 (2): 113-122. 16. newman dk. surgical management of late complications of proliferative diabetic retinopathy. eye, 2010; 24: 441-449. 17. kayani h, ahmad a, jahangir k, rehman h, chauhan k. comparison between 23-guage and 25guage pars plana vitrectomy for posterior segment disease. pak j ophthalmol. 2013; 29: 42-45. 18. guther g, magbill h, steel hw. 23-guage versus 25guage vitrectomy for proliferative diabetic retinopathy: a comparison of surgical outcomes. ophthalmologica. 2015; 233: 104-111. 19. schrader wf. the options to minimize the surgical trauma to treat ocular diabetic complications. epma j. 2010; 1: 82-87. 20. cooper ma, hutfles s, segav dl, ibrahim a, lyu h, makary ma. hospital level underutilization of minimally invasive surgery in united states. bjm. 2014; 349: g4198. 21. teixeira a, allemann n, yamada ac, uno f, maia a, bonomo pp. ultrasound biomicroscopy in recently postoperative 23-gauge transconjunctival vitrectomy sutureless self-sealing sclerotomy. retina, 2009; 29: 1305–1309. 22. lópez-guajardo l, vleming-pinilla e, parejaesteban j, teus-guezala ma. ultrasound biomicroscopy study of direct and oblique 25-gauge vitrectomy sclerotomies. am j ophthalmol. 2007; 143: 881–883. 23. singh rp, bando h, brasil of, williams dr, kaiser pk. evaluation of wound closure using different incision techniques with 23-gauge and 25-gauge microincision vitrectomy systems. retina, 2008; 28: 242–248. 24. bamonte g, mura m, stevie tan h. hypotony after 25-gauge vitrectomy. am j ophthalmol. 2011; 151: 156–160. authors’ designation and contribution hussain ahmad khaqan; associate professor: concepts, designs, literature research, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. usman imtiaz; post graduate trainee: literature research, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. hasnain muhammad buksh; medical officer: literature research, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. post-operative hypotony in 23 gauge and 25 gauge pars plana vitrectomy pak j ophthalmol. 2020, vol. 36 (4): 335-340 340 hafiz ateeq-ur-rehman; post graduate trainee: data acquisition, data analysis, statistical analysis. raheela naz; post graduate trainee: data acquisition, data analysis, statistical analysis. .…  …. pak j ophthalmol. 2022, vol. 38 (1): 4-8 4 original article laser assisted in situ keratomileusis (lasik) versus trans epithelial photorefractive keratectomy (t-prk) in astigmatic patients mahar safdar ali qasim 1 , muhammad suhail sarwar 2 , maher mustansar ali qasim 3 1 riphah international university, 2 king edward medical university, mayo hospital, lahore 3 al-razi hospital, rawalpindi abstract purpose: to compare the results of lasik versus trans epithelial photorefractive keratectomy (t-prk) in correcting astigmatic refractive error. study design: quasi experimental study. place and duration of study: lahore medicare hospital from january to october 2018. methods: one hundred and twenty six eyes of 63 patients, age 18 to 35 years, either gender, presenting with astigmatism were enrolled in this study. myopes with spherical equivalent (se) ≤ -13.0 diopter sphere (ds), hyperopes with se ≤ +5.0 ds and astigmatism ≥ 1.5 d with visual acuity better or equal to 0.3 logmar were included. astigmatic eyes with < 1.5d and with any other ocular pathology were excluded. refractive status was assessed by canon autorefractor and heine retinoscope. average reading of both methods was taken. patients were divided into two groups (31: lasik; 32: trans-prk) by spin of a coin method. refractive surgery was done in both groups. data was analyzed by spss 20. normality of quantitative data was checked by shapiro wilk test. mann whitney-u test was used for non-parametric data. p-value ≤ 0.05 was taken as significant. results: mean age of the patients was 25.83 ± 3.09 years. the difference in residual sphere, amount of cylinder, axis of cylinder and cct (central corneal thickness) after surgery in two groups was insignificant. p values were as follows; for sphere p = 0.85, amount of cylinder p = 0.22, axis of cylinder p = 0.46 and cct p = 0.07. conclusion: both techniques are equally good in correcting astigmatism (p = 0.22). lasik or t-prk can be done alternatively in patients with astigmatism. key words: lasik, trans epithelial prk, astigmatism. how to cite this article: qasim msa, sarwar ms, qasim mma. laser assisted in situ keratomileusis (lasik) versus trans epithelial photorefractive keratectomy (t-prk) in astigmatic patients. pak j ophthalmol. 2022, 38 (1): 4-8. doi: 10.36351/pjo.v38i1.1250 correspondence: mahar safdar ali qasim riphah international university lahore – pakistan email: safdarkemu@gmail.com received: april 06, 2021 accepted: december 12, 2021 introduction the prevalence of astigmatic refractive error (defined as cylindrical error of more than 1.00 diopter) is between 15% and 34.3% worldwide. 1 it is 37.00% in pakistan. 2 large sample studies in pakistan have also shown a significant number of corneal astigmatism. 3 moderate to high astigmatism has been a challenge for practitioner to correct it through refractive surgery. 4 there are various factors that play role in the open access laser assisted in situ keratomileusis (lasik) versus trans epithelial photorefractive keratectomy (t-prk) pak j ophthalmol. 2022, vol. 38 (1): 4-8 5 compromised results of refractive surgery including degree of astigmatism, axis of cylinder, and centration of surgical ablation profile. chances of blur or haze formation after photorefractive keratectomy prk as compared to laser assisted in situ keratomileusis (lasik) can lead to regression of astigmatic error in long run 5 . refractive surgery is considered an advanced technique in the correction of refractive error. some people prefer this for cosmesis. 6 there are several procedures available for this purpose including laser assisted in situ keratomileusis (lasik), laser assisted sub-epithelial keratomileusis (lasek), transepithelial photorefractive keratectomy (t-prk) and epithelial photorefractive keratectomy. 7,8 in lasik, corneal epithelial flap is formed and thickness of the flap can be variable depending upon the refractive requirement. after ablation of cornea the corneal flap is replaced on that cornea. 9,10 trans epithelial photo keratectomy (t-prk) is another technique also used to correct myopia and hypermetropia. trans-prk is a comparatively newer method of the conventional prk in which corneal epithelial is removed by an excimer laser rather than alcohol and manual scraping. this is assumed that it creates a smoother surface that allows rapid healing of epithelium which results in quicker visual recovery and minimum pain and all procedure is done after instillation of anesthesia drop to overcome blinking and patient`s discomfort. after surgery contact lens is applied over corneal surface to assist regeneration of corneal epithelium and to minimize irritation and discomfort. 11-13 . as compared to the contact lenses especially (rgp) rigid gas permeable the vision quality is slightly less in laser corrective procedures as it needs more time to meet patient’s expectations. moreover prior to these procedures patient must discontinue using soft or rigid gas permeable lenses (one to four weeks) to stabilize corneal surface permitting accurate measurements. 14 we designed this study to compare the results of lasik and t-prk. the idea was to find out which procedure has better results in our part of the world. methods this was an experimental (quasi) study was conducted at lahore-medicare hospital. from january 2018 to october 2018 after obtaining ethical approval from university ethical committee and institutional review board of king edward medical university. using nonprobability convenient sampling technique, 126 eyes of 63 patients, age 18 – 35 years and presenting with astigmatism were included in the study. for the examination of anterior and posterior segments of the eye, retinal disorders and fundoscopy patients were dilated using 1.0% tropicamide eye drops and examination was done by an ophthalmologist. visual acuity was taken by using logmar visual acuity chart. auto-refraction was done using canon autorefractometer. retinoscopy was performed using heine retinoscopy at 2/3 of meter and average of both autorefractor reading and retinoscopy reading was taken. topography was done using schwind amaris topography apparatus and planned for refractive surgery either lasik or t-prk using schwind amaris model 500e apparatus. after one month of surgery patient`s visual status was recorded. all cylindrical values were recorded in minus cylinder. if an individual came with plus cylindrical value, his cylindrical value was transposed to get minus cylinder. individuals with minus cylindrical values were recorded with no change. data was entered and analyzed by statistical package for the social scientist (spss 20.00). quantitative variables like refractive errors were presented as mean ± standard deviation. qualitative variables like gender were presented as frequency and percentage. assumption of data`s normality was checked by kolmogorov-smirnov test and shapiro wilk test. all the variables were non-parametric as p-value was < 0.05 (table 1). comparison of two groups lasik and t-prk was carried out by applying mann whitney u test. p value ≤ 0.05 was taken as significant. results the clinical characteristics are listed in table 1 & 2. there was no significant difference between lasik and t-prk as regards spherical, cylindrical, axis and corneal thickness values pre and post operatively. there were 55.60% females (n = 35) and 44.40% were males (n = 28). mean age of the patients was 25.83 ± 3.09 years. further details are mentioned in tables 1, 2, 3 and 4. mahar safdar ali qasim, et al 6 pak j ophthalmol. 2022, vol. 38 (1): 4-8 table 1 showed mean values of sphere, cylinder and axis in lasik and t-prk groups. after refractive procedure, there were 44 and 61 eyes with mean ±0.25d and ± 0.50d residual cylinder in lasik group. in t-prk group 53 and 64 eyes had ± 0.25 and ± 0.50d residual cylinder. both groups did not show any major difference in residual refractive power. table 1: descriptive statistics of residual refractive errors in lasik vs. t-prk. residual (refractive errors) lasik (n = 62) mean t-prk (n = 64) mean sphere -0.08 -0.11 cylinder -0.22 -0.17 axis 31.84 30.11 p value p = .220 (p > 0.05) table 2: descriptive statics of different variables vs refractive procedure. range minimum maximum mean std. error of mean std. deviation lasik (n = 62 eyes) pre-operative sphere 17.00 -8.50 8.50 -1.64 0.53 4.14 cylinder 1.25 -2.75 -1.50 -1.92 0.04 0.30 axis 175.00 0.00 175.00 85.60 7.57 59.58 cct 104.00 460.00 564.00 547.06 1.66 13.09 post-operative sphere 1.75 -0.75 1.00 -0.08 0.05 0.42 cylinder 0.75 -0.75 0.00 -0.22 0.03 0.22 axis 177.00 0.00 177.00 31.84 6.28 49.45 cct 111.00 430.00 541.00 495.63 3.12 24.54 t-prk (n = 64 eyes) pre-operative sphere 17.00 -9.50 7.50 -2.19 0.51 4.08 cylinder 1.00 -2.50 -1.50 -1.85 0.03 0.27 axis 175.00 0.00 175.00 75.16 6.70 53.61 cct 24.00 540.00 564.00 549.58 0.70 5.63 post-operative sphere 1.50 -0.75 0.75 -0.11 0.05 0.37 cylinder 0.50 -0.50 0.00 -0.17 0.02 0.19 axis 175.00 0.00 175.00 30.11 6.52 52.17 cct 126.00 410.00 536.00 500.22 3.45 27.61 table 3: comparison of (cylinder) post lasik &post t-prk procedures. value of cylinder after surgery procedure cylinder frequency percent valid percent cumulative percent lasik -.75 1.00 1.60 1.60 1.60 -.50 17.00 27.40 27.40 29.00 -.25 18.00 29.00 29.00 58.10 .00 26.00 41.90 41.90 100.00 t-prk -.50 11.00 17.20 17.20 17.20 -.25 22.00 34.40 34.40 51.60 .00 31.00 48.40 48.40 100.00 table 4: comparison of residual cylinder in lasik vs. t-prk. hypothesis test summary null hypothesis test sig. decision the distribution of a_cyl is the same across categories of procedure independent sample mann-whitney u test .22 retain the null hypothesis there are no significant difference between lasik and t-prk groups as p value is ≥ 0.05 (p = 0.220). discussion this study showed the comparison of results of lasik vs. t-prk (in terms of cylindrical correction). laser assisted in situ keratomileusis (lasik) versus trans epithelial photorefractive keratectomy (t-prk) pak j ophthalmol. 2022, vol. 38 (1): 4-8 7 results showed no significant difference (equal visual results) as p value was > 0.05. a study conducted by american society of rs showed that lasik treated 98% of individuals within ± 0.50d emmetropia and tprk treated 96.4% of individuals within ± 0.50d emmetropia. this study includes all type of spherocylindrical errors correction. comparison of sphere, axis of cylinder and cct (central corneal thickness) before and after refractive surgery in lasik and t-prk groups showed no significant difference as p ≥ 0.05. 15 in contrast to our results, in another study eyes with low to moderate myopia were treated using different refractive procedures. t-prk provided slightly better visual outcomes than lasik or lasek. in eyes with high myopia, t-prk proved better than lasik while laser in situ keratomileusis was associated with the most major postoperative complications. 16 variable results have been reported in literature regarding these two procedures. in another study both trans-prk and lasik showed excellent efficacy, safety and predictability profiles. the results were comparable. 17 one year post operative follow up of t-prk was reported by luger et al. they showed that postoperative results of t-prk were equivalent to those of femtosecond-assisted lasik. they concluded that tprk was efficacious and safe with a disadvantage that this procedure was associated with longer recovery time. 18 in low to middle income countries cost of the procedure is also a matter of concern for the patients. in a local study from pakistan, although superior visual outcomes were reported with lasik but patients satisfaction rate was higher in simple prk due to the higher cost of lasik. 19 in t-prk and lasik, the difference in the cost is not very much. hence, satisfaction level of the patient is related with the visual outcome as compared to the cost. some authors have also considered high order aberrations in their studies. in one study, the results showed that although the visual outcomes were slightly better in the prk group, but aberrations showed better results in the lasik group. 20 limitations of this study are that we did not consider the higher order aberrations due to the technological deficiencies and duration of followup was short. patient satisfaction was also not taken into account. conclusion results of residual astigmatic sphero-cylindrical power, axis and central corneal thickness shows no significant difference in both refractive surgery procedures lasik and t-prk procedure. therefore both surgical procedures are useful in astigmatism correction. this study suggests that lasik and tprk has same results in correcting astigmatism. ethical approval the study was approved by the institutional review board/ethical review board (et/11/21). conflict of interest authors declared no conflict of interest. refrences 1. hassan h, akbar f, abbasi y, reza p, haadi o, mehdi k. global and regional estimates of prevalence of refractive errors: systemic overview and metaanalysis. j curr ophthalmol. 2018; 30 (1): 3-22. 2. ayesha s, hammad z, akram m, zahid a. prevalence of under-corrected refractive errors in adults aged 30 years and above in a rural population in pakistan. nih. 2015; 27 (1): 8-12. 3. saba a, anum i, aun r, quratulain z. frequency and amount and axis of astigmatism in subjects of rawalpindi pakistan. j pak med assoc. 2013; 63 (11): 4-9. 4. sugar a, rapuano cj, culbertson ww, huang d, varley ga, agapitos pj, et al. laser in situ keratomileusis for myopia and astigmatism: safety and efficacy: a report by the american academy of ophthalmology. ophthalmology, 2002; 109 (1): 175187. doi: 10.1016/s0161-6420(01)00966-6. pmid: 11772601. 5. salomão mq, wilson se. femtosecond laser in laser in situ keratomileusis. j cataract refract surg. 2010; 36 (6): 1024–32. pmid: 20494777. 6. alió jl, artola a, claramonte pj, ayala mj, sánchez sp. complications of photorefractive keratectomy for myopia: two year follow-up of 3000 cases. j cataract refract surg. 1998; 24 (5): 619-626. doi: 10.1016/s0886-3350(98)80256-3. pmid: 9610444. 7. spadea l, sabetti l, d'alessandri l, balestrazzi e. photorefractive keratectomy and lasik for the correction of hyperopia: 2-year follow-up. j refract surg. 2006; 22: 131-136. mahar safdar ali qasim, et al 8 pak j ophthalmol. 2022, vol. 38 (1): 4-8 8. douglas kd. excimer laser technology: new options coming to fruition, jcataract refract surg. 1997; 23 (10): 1429-1430. doi: 10.1016/s0886-3350(97)80001-6 9. vengris m, gabryte e, aleknavicius a, barkauskas m, ruksenas o, vaiceliunaite a, danielius r. corneal shaping and ablation of transparent media by femtosecond pulses in deep ultraviolet range. j cataract refract surg. 2010, 36: 1579–1587. doi: 10.1016/j.jcrs.2010.06.027 10. zheng y, zhou yh, zhang j, liu q, zhang l, deng zz, et al. comparison of visual outcomes after femtosecond lasik, wave front-guided femtosecond lasik, and femtosecond lenticule extraction. cornea. 2016; 35 (8): 1057-1061. 11. moussa s, dexl a, krall em, dietrich m, arlt em, grabner g, et al. comparison of short-term refractive surgery outcomes after wavefront-guided versus nonwavefront-guided lasik. european journal of ophthalmology, 2016; 26 (6): 529-535. 12. moshirfar m, shah tj, skanchy df, linn sh, kang p, durrie ds. comparison and analysis of fda reported visual outcomes of the three latest platforms for lasik: wavefront guided visx idesign, topography guided wavelight allegro contoura, and topography guided nidek ec-5000 catz. clin ophthalmol. 2017; 11 (1): 135-147. 13. nakamura y, hieda o, yamamura k, wakimasu k, yokota i, kinoshita s. comparative study of sevenyear outcomes following laser in situ keratomileusis with those of trans-epithelial photorefractive keratectomy. nippon ganka gakkai zasshi, 2016; 120 (7): 487-493. 14. nuzzi r, tridico f. comparison of visual outcomes, spectacles dependence and patient satisfaction of multifocal and accommodative intraocular lenses: innovative perspectives for maximal refractive-oriented cataract surgery. bmc ophthalmology, 2017; 17 (1): 12. 15. demill dl, moshirfar m, neuffer mc, hsu m, sikder s. a comparison of the american society of cataract and refractive surgery post-myopic lasi k/prk intraocular lens (iol) calculator and the ocular md iol calculator. clin ophthalmol. 2011; 5 (1): 1409-1414. 16. faisal g, ali a, michael d. laser in situ keratomileusis versus surface ablation: visual outcomes and complications. j cataract refract surg. 2007; 33 (12): 2041-2048. doi: 10.1016/j.jcrs.2007.07.026 17. gershoni a, mimouni m, livny e, bahar i. zlasik and trans-prk for correction of high-grade myopia: safety, efficacy, predictability and clinical outcomes. int ophthalmol. 2019; 39: 753–763. doi.org/10.1007/s10792-018-0868-4 18. michiel ha, tobias dipl-ing e, arba-mosquera, samuel. myopia correction with transepithelial photorefractive keratectomy versus femtosecond−assisted laser in situ keratomileusis: oneyear case-matched analysis, jcataract refract surg. 2016; 42 (11): 1579-1587. doi: 10.1016/j.jcrs.2016.08.025 19. hashmani n, hashmani s, ramesh p, rajani h, ahmed j, kumar j, et al. a comparison of visual outcomes and patient satisfaction between photorefractive keratectomy and femtosecond laserassisted in situ keratomileusis. cureus, 2017; 9 (9): e1641. doi:10.7759/cureus.1641 20. sajjadi v, ghoreishi m, jafarzadehpour e. refractive and aberration outcomes after customized photorefractive keratectomy in comparison with customized femtosecond laser. med hypothesis discov innov ophthalmol. 2015; 4 (4): 136-141. pmid: 27800501; pmcid: pmc5087100. authors’ designation and contribution mahar safdar ali qasim; assistant professor: concepts, design, literature search, data acquisition, data analyis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. muhamnmad suhail sarwar; principal and head of department: design, literature search, data acquisition, data analyis, statistical analysis, manuscript review. maher mustansar ali qasim; optometrist: literature search, data acquisition, data analyis, manuscript preparation, manuscript review. disclaimer it is testify that this is my m.phil. research product and that was conducted as a part of degree requirment in king edward medical university (kemu) and data was collected at lahore medicare hospital, lahore. all the authors were present in the said place during the conductio of study. .…  …. https://dx.doi.org/10.1016/j.jcrs.2010.06.027 https://dx.doi.org/10.1016/j.jcrs.2010.06.027 https://dx.doi.org/10.1016/j.jcrs.2010.06.027 https://doi.org/10.1007/s10792-018-0868-4 pak j ophthalmol. 2021, vol. 37 (2): 142-146 142 original article frequency of colour blindness amongst the young age group in a tertiary care eye hospital summaya khan 1 , aisha rafique 2 , muhammad azeem khizer 3 1-3 armed forces institute of ophthalmology, rawalpindi abstract purpose: to determine the frequency of color vision deficiency among young age groups visiting a tertiary care eye hospital for pre-employment health screening. study design: descriptive, cross sectional study. place and duration: armed forces institute of ophthalmology, rawalpindi, from june 2018 to december 2019. methods: data was collected using non-probability consecutive sampling technique. all candidates who appeared for medical fitness for pre-employment screening were included. candidates belonged to various regions of pakistan. informed consent was taken. complete history and ophthalmic examination including visual acuity, best corrected visual acuity, anterior segment examination and dilated posterior segment examination was performed. intra ocular pressure was measured by goldmann applanation tonometer. colour vision was checked before pupillary dilation using ishihara test plates. candidates were clearly instructed about test plates. candidates with ocular abnormality were referred to the specialized units. the data analysis was done by ibm spss 20 software. results: one thousand and five hundred (1500) candidates were screened. out of these, 88.3% (1325) were males and 11.6% (175) were females. mean age of the candidates was 20.35 ± 4.46 years. approximately five percent (4.8%, n = 73/1500) candidates had color vision deficiency. out of these, 94.52% (69) candidates were unaware of their condition. conclusions: color blindness in this study was 4.86%. majority of the color blind persons were males and most of them were unaware of their condition. key words: colour blindness, ishihara plates, x-linked, red green deficiency. how to cite this article: khan s, rafique a, khizer ma. frequency of colour blindness amongst the young age group in a tertiary care eye hospital. pak j ophthalmol. 2021, 37 (2): 142-146. doi: http://doi.org/10.36351/pjo.v37i2.1180 introduction colour blindness is a condition in which there is faulty development of one or more sets of retinal cone photoreceptors. in this condition there is complete absence or decreased perception of colour and hue correspondence: muhammad azeem khizer armed forces institute of ophthalmology, rawalpindi email: m.azeem7@gmail.com received: december 11, 2020 accepted: february 16, 2021 differences under normal illuminating conditions. there is variation in frequency of color blindness in different ethnic populations worldwide. humans have trichromatic colour vision. presence of three spectrally-distinct types of cone photoreceptors in retina leads to perception of this trichromatic colour vision. these various types of cones are maximally sensitive to light of different wave lengths. these wave lengths are 420, 530 and 560 nm. as a result, these cones are termed as short, middle and long wave length sensitive cones with respect to their sensitivity domain. 1 this distinct spectral sensitivity of cones leads to immaculate colour vision discrimination in http://doi.org/10.3352/jeehp.2013.10.3 summaya khan, et al 143 pak j ophthalmol. 2021, vol. 37 (2): 142-146 humans. colour vision deficiency is one of the commonest visual disorders and can be grouped as either congenital or acquired. mutations in x chromosome is the most common heritable pattern. xlinked red green deficiency is the most wide spread form of color vision impairment. it is therefore more common in males. colour vision deficiencies are due to mutations in the genes encoding the above mentioned three spectral sensitive cone pigments. 2 hybrid cone opsin gene undergoes a missense mutation. it leads to x-linked cone dystrophy. 3 the blue pigment gene is harboured on chromosome 7. long arm of the x-chromosome (xq28) entails red and green pigment genes for trichromatic vision. the carrier mothers of the abnormal gene renders a chance of 50% her of sons with anomalous colour vision. xchromosomes is transferred to daughters only by colour vision deficient fathers, rendering all daughters to be carriers of trait. however, sons have no difficulty in colour perception. 4 colour vision provides basic sensory information to organisms of their surroundings. it is one if the basic mechanisms of survival where we use our colour instincts to find food and water. although it is a common condition, still, most of the patients with colour vision deficiency are not aware of their condition and it remains an unnoticed problem. however, various problems such as disability in job (25%), career selection (33%), judgment in daily routine (75%) and traffic signal recognition (13%) are consequences of this condition. 5 colour vision standards are clearly identified and established in fighting arms, aviation and land communicating railway fields and are effectively employed in these fields. the reason for establishment of these clear protocols is due to the fact that these jobs are highly colour sensitive and colour dependent. one little misinterpretation of colour marking may lead to huge loss of lives and material. due to this, according to uk health and safety executive, normal colour vision is required for purpose of safety and quality. colour vision deficiency put an imminent risk in professions like army, aviation, navigation, police, pharmacists and firefighting services. in addition to this, colour blind individuals may decrease the quality of productivity in jobs like textile industry, fine arts and photography. there is scanty data available in pakistan and population based studies are lacking. we have an increase number of candidates who are referred for ocular assessment including colour vision as vital part of their pre-employment screening. in our study, we aim to assess the prevalence of colour vision impairment among pakistani population presenting for pre-employment medical examination in a tertiary eye care hospital. this study will provide basis to consider colour vision deficiency as an important ocular pathology which should be ruled out in candidates who appear for colour sensitive jobs. methods this study was conducted over a period one and a half year from june 2018 till dec 2019 in armed forces institute of ophthalmology. study was initiated after taking approval from hospital ethical review committee. in this cross-sectional study, a total of 1500 candidates were included using non probability consecutive sampling technique. sample size was calculated using who sample size calculator, keeping confidence interval of 95% and 5% error. the study included all candidates appearing for pre-employment ocular examination. individuals with history of ocular or neurologic surgery, trauma, anti-tuberculosis treatment or central nervous system drugs, prior history of intra ocular inflammation, candidates having systemic diseases like diabetes, hypertension and other organ systems were excluded. informed consent. unaided vision and best corrected visual acuity was assessed. colour vision was assessed with the best correction in trial frame. ishihara isochromatic colour plates were read by each candidate held at 75cm in front, perpendicular to the line of vision in a well illuminated place. each plate was presented for five to seven seconds and candidate was requested to read the number or recognize the pattern present on plate. the candidate who read all the plates properly were considered normal while those who could not read the plates accurately or confusingly were considered to be colour vision deficient. slit lamp examination of anterior and posterior segments along with intra ocular pressure measurement with goldmann applanation tonometer was carried out. individuals who were found to have ocular pathologies were referred to specialized units for further work up and treatment. data was entered and analyzed in spss version 20. descriptive statistics were used to calculate mean and standard deviation of age. percentage was calculated for the presence or absence of colour blindness and awareness of this ailment. frequency of colour blindness amongst the young age group in a tertiary care eye hospital pak j ophthalmol. 2021, vol. 37 (2): 142-146 144 results one thousand and five hundred (1500) candidates underwent ophthalmic medical fitness examination during june 2018 to december 2019. out of these, 88.3% (1325) were males and 11.6% (175) were females. mean age of the candidates was 20.35 ± 4.46 years. overall 4.8% (73/1500) of the candidates had vision deficiency. there were 94.6% (70) males and 4.1% (3) were females (table 1 and 2). out of them, 94.52% (69) candidates were unaware of their condition. table 1: frequency of colour blindness by age group. age group (years) number of candidates candidates with colour vision deficiency number percentage (%) out of screened candidates ≤ 20 370 (24.6%) 18 4.86 ≥ 21 1130 (75.4 %) 55 4.86 total 1500 73 4.86 table 2: frequency of colour blindness by gender. gender number of candidates candidates with colour vision deficiency number percentage (%) out of screened candidates male 1325 (88.4%) 70 5.28 female 175 (11.6%) 3 1.71 total 1500 73 4.86 discussion color vision was one of the basic strategy of survival of the fittest where our ancestors were able to differentiate between food for living and danger zones. colour vision deficiency is reduced or total absence of perception of colour. visual acuity is unaffected hence it is difficult to detect in routine ocular examination and often go unnoticed by individuals. however, preemployment screening is a helpful modality to identify individuals with such deficiencies. this also marks importance of maintaining safety and quality of jobs which requires intricate colour perception. moreover, colour deficient individuals in field of telecommunication put a hazard when they are unable to identify wiring of basic colour. there are various tests used for assessment of colour vision e.g. ishihara test plates, fransworth munsell 100 hue test and city university test. ishihara test can only differentiate congenital colour vision deficiency, it is user friendly, easier to understand and widely available thus it is the most common tool to detect abnormal colour vision. it has first plate which colour can be read by both normal and colour blind individuals. it is subsequently followed by 16 plates with colour coded numbers and patterns. unanimously colour vision deficiency is more prevalent in males as compared to females. this is because genes encoding for red green colour is passed down through x chromosome and males have only one x chromosome. prevalence of colour vision deficiency in european caucasians is about 8% in men and 0.4% in women. in chinese and japanese, it ranges between 4% to 6.5%. however, there is marked difference in prevalence of colour vision deficiency in males and females of europeans and asian population. 6 few prevalence studies have been reported from various regions of world. the estimated prevalence in turkey is 7.3%, iran 4.7%, india 2.8% to 8.2% (ethnic variations), saudi arabia 2.9%. 7,8 colour vision deficiency reported from various areas of pakistan has shown to be 5.1% in rawalpindi, 1.41% in karachi. 9 hamida et al reported overall colour vision deficiency to be 2.48% in the population of quetta and siddiqui et al however found colour vision deficiency among pakistani students from various institutions to be 2.75%. 10 these results are comparable to our study. colour blindness affects many people. mostly they are unaware of this trait as reflected in our study. it is manifested only when they undergo detailed ophthalmic checkup. specific jobs entities rely on normal colour perception and hence they get rejected. it renders them surprised to an extent that the person goes through an emotional setback. however behavioral therapies and aiding adaptation to daily life routine may help them. color vision defects also hamper health care workers in identifying general physical signs in body colour such as pallor, cyanosis, jaundice and erythema pertaining to life threatening diseases. 11 ophthalmic and otoscopic examinations or reading blood and urine test strips put them in confusing situation. 12,13 unfortunately there is no modality yet discovered which can reverse colour blindness. these difficulties are under reported. it is due to the lack of screening before selecting or initiating profession in health care. campbell determined that these health care providers summaya khan, et al 145 pak j ophthalmol. 2021, vol. 37 (2): 142-146 are a compromise to patients’ safety. 14 knowing of colour vision deficiency at earlier age can be helpful in selecting professions with less colour vision requirements. a study from iran found that colour vision deficient laboratory technicians end up making errors in lab tests. they should not be considered medically fit for such employment choices. 15 according to a report, 96% of the colour-blind students in middle school and 65% of the colour blind university students were totally unaware of their anomalous vision status. 16 in this study 94.52% of the candidates were unaware of their colour vision deficiency. this is comparable to an international study, which showed that 96% of colour blind students attending middle school were unaware of anomalous vision. 17 in another study it was found that 65% of the university students did not know about their anomalous vision. 18 congenital colour vision deficiency is nonprogressive and incurable. various therapies had been devised in the past like vitamin supplementation, electrical eye stimulation and iodine injection but those are ineffective. recent advances in technology has rendered user friendly applications in iphone and ipad allowing colour blind person to see in improved way. colour blind pal, colour filter, colour blind aid are the names of few such applications. there have been camera devices as well to aid colour blind individuals in their professions. recently, advancement in genetic engineering has emerged with promising future. few studies have been conducted on animals in which injecting a gene of missing photo pigment conferred colour vision. however, no such studies have been conducted on humans yet. 19, 20 screening of candidates or students make them aware of their limitations in power of colour observation hence enable them to device the ways to overcome them. this allows them to choose profession hence reducing anxiety and enhancing their confidence. limitation of this study is that it is a single center study, pedigree charts were not made and it did not take into account the type of color blindness. conclusion the screened population showed colour vision deficiency to be present in 4.86% of the candidates and most of the individuals were unaware of their deficiency. ethical approval the study was approved by the institutional review board/ ethical review board. (183/erc/afio). conflict of interest authors declared no conflict of interest. references 1. woldeamanuel gg, geta tg. prevalence of color vision deficiency among school children in wolkite, southern ethiopia. bmc res notes, 2018; 28; 11 (1): 838. doi: 10.1186/s13104-018-3943-z. 2. dohvoma va, mvogo sr, kagmeni g, emini nr, epee e, mvogo ce. colour vision deficiency among biomedical students: a cross-sectional study. clin ophthalmol. 2018; 12: 1121–1124. doi: 10.2147/opth.s160110 3. xiao f, cai g, zhang h. segregation analysis suggests that a genetic reason may contribute to "the dress" colour perception. plos one. 2016; 11 (10): e0165095. doi: 10.1371/journal.pone.0165095. 4. cole bl. assessment of inherited colour vision defects in clinical practice. clin exp optom. 2007; 90: 157– 175. 5. cole bl. the handicap of abnormal colour vision. clin exp optom. 2004; 87 (4-5): 258-275. 6. shah a, hussain r, fareed m, afzal m. prevalence of red-green colour vision defects among muslim males 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epidemiologic and social features of colour blindness. community genet. 1999; 2: 30–35. doi: 10.1159/000016181. 17. nathans j, thomas d, hogness ds. molecular genetics of human color vision: the genes encoding blue, green, and red pigments. science. 1986 apr 11; 232 (4747): 193-202. doi: 10.1126/science.2937147. pmid: 2937147. 18. chhipa sa, hashmi fk, ali s, kamal m, ahmad k. frequency of colour blindness in pre-employment screening in a tertiary health care center in pakistan. pak j med sci. 2017; 33 (2): 430-432. 19. birch j. worldwide prevalence of red-green colour deficiency. j opt soc am a opt image sci vis. 2012; 29 (3): 313-320. 20. gómez-robledo l, valero em, huertas r, martínez-domingo ma, hernández-andrés j. do enchroma glasses improve color vision for colorblind subjects? opt express. 2018; 26 (22): 28693-28703. doi:10.1364/oe.26.028693. authors’ designation and contribution summaya khan; consultant ophthalmologist: concepts, design, literature search, data acquisition, manuscript editing, manuscript review. aisha rafique; trainee ophthalmologist: concepts, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. muhammad azeem khizer; trainee ophthalmologist: literature search, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. .…  …. 85 pak j ophthalmol. 2022, vol. 38 (2): 85-90 original article partial coherence laser interferometry versus conventional a-scan acoustic biometry in intraocular lens power calculation – comparison of postoperative refractive error javeria muid 1 , farooq afzal 2 1 university hospital waterford, waterford, ireland, 2 shifa international hospital, islamabad, pakistan abstract purpose: to compare the post-operative residual refractive error in patients undergoing cataract surgery using partial coherence laser interferometry (pcli) versus a-scan applanation acoustic biometry. study design: quantitative experimental research. place and duration of study: shifa international hospital (sih), islamabad from november 2018 to august 2019. methods: total 254 patients were selected. group a included patients whose biometry was done using pcli method and group b included patients who had a-scan acoustic biometry. intraocular lens power calculation was done using srk/t formula. phacoemulsification surgery with foldable intraocular lens was performed. patients were called for follow-up visit the next day and then one month after surgery. postoperative refractive error was checked after one month. all data were entered and analyzed using spss version 21.0. descriptive statistics were used for qualitative as well as quantitative variables. we applied independent samples t-test to compare the mean postoperative refractive error in both groups. a p-value of less than 0.05 was considered significant. results: the mean age of patients was 65 ± 9.37 years. the preoperative mean axial length was 20.35 ± 1.1 mm in the pcli group and 21.54 ± 1.2 mm in the ultrasound group. mean absolute error (mae) of postoperative residual refractive error in the pcli group was 0.12 ± 0.13 mm (p = 0.003). the mae in the ultrasound group was 0.18 ± 0.12 mm (p = 0.02). conclusion: the non-contact optical biometry improves the mean absolute error for postoperative refraction and is a reliable tool for biometry in phakic eyes before surgery. key words: partial coherence laser interferometry; ultrasound a scan; biometry; a-constant; intraocular lens. how to cite this article: muid j, afzal f. partial coherence laser interferometry versus conventional a-scan acoustic biometry in intraocular lens power calculation – comparison of postoperative refractive error. pak j ophthalmol. 2022, 38 (2): 85-90. doi: 10.36351/pjo.v38i2.1364 correspondence: javeria muid university hospital waterford, waterford, ireland email: averiamuid90@gmail.com received: december 21, 2021 accepted: march 16, 2022 introduction according to world health organization (who), cataract is the commonest cause of reversible blindness in the world. 1 nowadays phacoemulsification is the standard method of treatment for cataract. 2,3 generally the opinion is that 85% of cataract surgeries should achieve a good visual outcome (presenting visual acuity [pva]: 6/18 or better) with fewer than 10% having borderline (< 6/18 – 6/60), and less than 5% having poor (< 6/60) outcomes. 4 the postoperative refractive outcome mainly depends on the accuracy of calculating power of the partial coherence laser interferometry versus conventional a-scan acoustic biometry pak j ophthalmol. 2022, vol. 38 (2): 85-90 86 intraocular lens, which depends on several factors including axial length (al) measurement, anterior chamber depth (acd), keratometry readings, intraocular implants calculation formulae and material of the intraocular lens. out of all these factors, imprecise al measurements have shown to be the major factor responsible for the surprised refractive outcome. studies show that an error of 100 micrometers in al measurement leads to a refractive error of 0.28 d when the mean absolute error (mae) in the partial coherence laser interferometry group is 0.52 ± 0.32 d and in the ultrasound group, is 0.62 ± 0.4 d. 5 there are currently two methods of biometry available worldwide: ultrasound and optical. studies have shown that a-scan al measurements are lower than that of iol master, the mean difference being 0.2 ± 0.44  mm. 6 ultrasound biometry uses the technique of echo delay time to measure ocular distances. it has a longitudinal resolution of 200 micrometers and a precision of 100–120 micrometers. it involves direct contact of the cornea with the probe using topical anesthetic drops. it is uncomfortable for the patient as well as it has the disadvantage of corneal indentation during measurement. 5 it requires a specially trained person to avoid errors due to excessive compression of the cornea by the ultrasound probe. on the other hand, the optical biometer works on the principle of partial coherence laser interferometry (pcli). the iol master operates as a modified michelson interferometer and uses infrared laser light (wavelength 780 nm) for precise al and anterior curvature of cornea measurements. 7 the eye to be measured and the photodetector are situated at each end of the interferometer. the signal is generated as a result of interference between the light reflected by the tear film over the cornea and that reflected by the retinal pigmentary epithelium and this signal goes to the photodetector. the position of the interferometer mirror is used to precisely measure the interference signal received by the photodetector. this gives us the optical length between the corneal surface and retina. this length is used to obtain intraocular distances by putting in the refractive indices of the respective ocular media (cornea, lens, aqueous humor, and vitreous). this method is reported to have a high resolution of about 12mm and an accuracy of 0.3 – 10mm. 5 perfect measurements by optical biometer require a signal-to-noise ratio of greater than 2.0. 8 the limitation of this optical biometer is its inability to measure the distances with accuracy in conditions; for example corneal opacities, dense vitreous hemorrhages, mature cataracts, and vitrectomised eye. 9 the purpose of doing this study was to document the results of comparison of two different techniques in a tertiary care facility of pakistan. the results of this study will help in predicting the post-operative visual improvement after cataract surgery in patients. methods ethical approval was obtained from the institutional review board and ethics committee sih, before the initiation of the research work. synopsis approval from the research evaluation unit (reu), (college of physicians and surgeons pakistan), was also taken. data was collected over a period of ten months after the date of approval. a consecutive non-probability sampling technique was used for data collection. the sample size was calculated using who sample size calculator. 5 the following parameters were taken. hypothesis tests for two population means (one-sided test), level of significance as 5%, power of the test as 80%, population standard deviation (0.36), population variance (0.1024), population mean in pcli group (0.52) and population mean in a-scan group (0.62). the sample size was 127 in each group. patients with age-related cataract of either gender were included. patients who did not give consent to be part of this study, patients with complicated cataract or any other significant ocular conditions e.g., ocular trauma, squint, amblyopia, diabetic retinopathy, agerelated macular degeneration, central serous chorioretinopathy, retinitis pigmentosa, keratoconus, viral keratitis, corneal dystrophies, corneal opacity, or any other corneal or macular disease were excluded from the study. patients with high myopia, hypermetropia i.e., greater than 5diopters, and astigmatism of greater than 2 diopters, patients with a history of any previous ocular surgery in the same eye for example refractive surgery, corneal transplant, or retinal surgery were also excluded. the patients were recruited by consecutive sampling technique from ophthalmology department of sih, islamabad. total 254 patients were selected. group a included patients whose biometry was done using pcli method and group b included patients who had a-scan acoustic biometry. javeria muid, et al 87 pak j ophthalmol. 2022, vol. 38 (2): 85-90 we used zeiss iol master 700 as an optical biometer and quantel compact touch as an a-scan biometer. biometry was performed by a single trained ophthalmic technician. intraocular lens power calculation was done using srk/t formula. this is the most commonly used formula that is used in both methods of biometry. we aimed for emmetropia for distance vision. after lens power calculation, phacoemulsification surgery with foldable intraocular lens (acrysof iq-monofocal) was performed. patients were called for a follow-up visit the next day and then one month after surgery. postoperative refractive error was checked after one month. all data were entered and analyzed using spss version 21.0. descriptive statistics were used for qualitative as well as quantitative variables. qualitative variables were gender, eye, type of refractive error and quantitative variables were age, pre-operative and post-operative visual acuity, bestcorrected pre-operative and post-operative visual acuity and refractive error. for qualitative variables, frequency and percentages were determined, and for quantitative variables data mean and standard deviation was ascertained. we applied independent samples t-test to compare the mean postoperative refractive error in both groups. type of refractive error, gender and the eye were used for stratification and post-stratification independent sample t-test. a pvalue of less than 0.05 was considered significant. results among the 254 patients included in the study, the mean age of participants was 65.54 ± 9.38 years. the minimum and maximum age of patients were 37 and 84 years respectively. there were 138 (54.3%) male and 116 (45.7%) female patients. there were 80 males and 47 females in group a while 58 males and 69 females in group b. distribution of study patients according to the type of refractive error is shown in (table-1). preoperative mean best corrected visual acuity according to log mar scale was 0.5220 ± 0.2289 and post-operative mean best corrected visual acuity was 0.0417 ± 0.089. the mean pre-operative al in the ultrasound group was 21.54 ± 1.2 mm, the mean error 0.07 ± 0.2 mm and mae of 0.18 ± 0.12 mm (p= 0.02). while the mean preoperative al in the pcli group was 20.35 ± 1.1 mm, the mean error −0.06 ±0.17 mm and mae of 0.12 ± 0.13 mm (p = 0.003). there was no statistically significant difference in preoperative al values in both the groups as shown in table-2. table 1: type of refractive error and distribution according to the groups. type of refractive error group a group b total p-value myopia yes 16 12 28 0.422 no 111 115 226 hypermetropia yes 40 11 51 0.00001 no 87 116 203 astigmatism yes 45 52 97 0.3659 no 82 75 157 nil yes 26 52 78 .0004 no 101 75 176 table 2: comparison between partial coherence laser interferometry and ultrasound biometry by application of independent t test. pcli mean ± sd ultrasound biometry mean ± sd p-value post–operative mean refractive error 0.42 ± 0.35 d 0.50 ± 0.4 d 0.003 postoperative mean axial length 20.35 ± 1.1 21.54 ± 1.2 0.02 p value 0.003 0.02 mean refractive error between groups alongside effect modifiers is explained in table-3. table 3: mean refractive error between groups alongside effect modifier. effect modifier group a group b pvalue mean refractive error (mean ± sd) gender male 0.041 ± 0.09 0.038 ± 0.08 0.714 female 0.087 ± 0.12 0.015 ± 0.05 age categories > 50 0 0.0167 ± 0.003 0.13 < 50 0.06 ± 0.11 0.03 ± 0.005 eye side right 0.035 ± 0.08 0.021 ± 0.06 0.01 left 0.086 ± 0.12 0.03 ± 0.07 discussion ocular biometry is fundamental to cataract surgery. pcli is a non-contact method and offers the ease of obtaining keratometry values, acd, and al measurements in a single sitting, which is a significant advantage when compared to ultrasound biometry. it is less time-consuming and has the advantage of improved precision, as compared to ultrasound partial coherence laser interferometry versus conventional a-scan acoustic biometry pak j ophthalmol. 2022, vol. 38 (2): 85-90 88 biometry, which demands topical anesthesia and is time-consuming. our study compared the refractive outcome between applanation acoustic biometry and pcli. it has shown significant improvement in iol power calculation using pcli compared with ultrasound (mean difference was 0.08 d). statistically significant differences (p < 0.05) were found in the mean values obtained using both techniques of measurement. pcli method can achieve reliable al measurements in phakic eyes, as observed in our study with a mean difference of 1.19 ± 0.1mm. it shows that pcli leads to statistically significant improvement for postoperative refraction when compared to a-scan using prospective iol power calculations in phakic eyes. from a theoretical point of view, the total error in iol power calculation may be expected to decrease significantly as a result of the decrease in the variability of al readings with pcli. if one assumes the small variation observed between preoperative and postoperative pcli measurements to reflect the total error originating from the axial length measurements, this source is shown to represent only 30–40% of the total prediction error, compared with 50–60% with ultrasound. 10 another study showed that the average absolute iol prediction error (observed minus expected refraction) was 0.65 d with ultrasound and 0.43d with pcli using the 5‐variable acd prediction method. 11 furthermore, the noncontact essentially operator-independent method, gave significantly more reliable biometry before cataract surgery, especially in the case of a less experienced operator. 12 rajan et al. found that the use of optical biometry offered a better predictive value than the use of applanation axial biometry measurements. 5 on the other hand, haigis et al., in their study of comparing the outcome of postoperative refraction measurements by two different methods (ultrasound vs. pcli), concluded that postoperative refraction was predicted accurately by the ultrasound method. 13 the influence of the operator's experience especially on the contact technique was emphasized by kittahaweesin. 14 he compared the acoustic biometry method with the immersion technique and found that the reproducibility of both techniques was similar when performed by an experienced operator, whereas, the less experienced operator had greater reproducibility with the immersion technique. he suggested that the immersion technique should be considered, particularly for less-experienced operators. 14 other studies showed that experienced operators had less difference and lower variability in the difference between applanation acoustic biometry and iol master readings for al and acd measurements. 15,16 there are variable conclusions about which technology has a better predictive value. our study has shown the iol prediction value accuracy of around 80% as compared to other studies, which have shown an improvement in predictive value up to 27%. 17 our study showed that the average absolute error inaccurate iol power prediction was found to decrease from 0.5 d with ultrasound to 0.4 d with pcli. both the groups were compared favorably with no significant difference in functional outcome. however, the patients who had pcli did better in reaching ± 1 d of the expected post-op refraction (80%) as compared to 87% shown by rajan et al. 5 they also showed that preoperative mean al was 23.47 ± 1.1 mm in the pcli group and 23.43 ± 1.2 mm in the ultrasound group (p > 0.05). the mae in the pcli group was 0.52 ± 0.32 d. the mae in the ultrasound group was 0.62 ± 0.4 d. these results are comparable to our study. in our study, the mean preoperative al in the pcli group was 20.35 ± 1.1 mm and in the ultrasound group, was 21.54 ± 1.2 mm. the mae in pcli group was 0.42 ± 0.35 d (p = 0.003) and ultrasound group was 0.50 ± 0.4 d (p = 0.02). rajan et al also studied the role of pcli in pseudophakic al measurement. it revealed a mean shortening of the eyes postoperatively in the pcli group. 5 the mean shortening encountered with pcli was seen to be most likely related to the group refractive index incorporated in the calculation, causing this systematic error. the a-constant needs to be altered to suit pcli to achieve better accuracy. 18,19 in contradiction to the above study, pcli was able to achieve reliable al measurements in pseudophakic eyes as observed in our study. this application becomes clinically relevant in evaluating pseudophakic eyes that might need a secondary piggyback iol. pcli relies on adequate foveal fixation eyes with corneal scarring, dense cataracts, posterior capsule plaque, macular degeneration and eccentric fixation fail to obtain reliable results. 20 furthermore, in the areas where hard cataracts are common, this optical method cannot work very well. on the other hand, pcli has an edge over acoustic biometry in measuring the al of eyes with silicone oil or posterior staphyloma. we also did not calculate the failure rate, javeria muid, et al 89 pak j ophthalmol. 2022, vol. 38 (2): 85-90 positive predictive value, and negative predictive value so we cannot compare these values with other studies. another limitation is that we did not compare the experienced operator with the less experienced operator in the case of acoustic biometry. furthermore, we had to choose the patients who did not have mature cataracts resulting in selection bias. some patients were lost to follow-up. a multicenter study with larger sample size is required to make the results more reliable and find out the importance of acd accuracy in the prediction of postoperative refraction when iol is implanted in cataract surgery. conclusion it is concluded that the non-contact optical biometry using the pcli principle reduces the mae of postoperative refraction after cataract surgery and is a more reliable tool in the measurement of intraocular lenses in cataractous eyes before surgery. the highly significant improvement of pcli over ultrasound found in the present paper might be reinforced in a highly controlled best-case study. these results support the likelihood that iol implantation after calculation of its value by a non-contact method is one of the most accurate methods. thus, an optical biometer, in the future can be the most precise tool in measurements of iol power in patients in which corneal power has been changed due to refractive surgery. ethical approval the study was approved by the institutional review board/ ethical review board (irb-952-227-2018). conflict of interest authors declared no conflict of interest. references 1. pascolini d, mariotti sp. global estimates of visual impairment: 2010. british j ophthalmol. 2012; 96: 614618. 2. bourne rr, flaxman sr, braithwaite t, cicinelli mv, das a, jonas jb, et al. magnitude, temporal trends, and projections of the global prevalence of blindness and distance and near vision impairment: a systematic review and meta-analysis. lancet glob health, 2017; 5: e888-897. 3. bowling b. kanski’s clinical ophthalmology. 8thed. london united kingdom: elsevier; june 2015: 281p. 4. ahmad k, zwi ab, tarantola dj, soomro aq, baig r, azam si. gendered disparities in quality of cataract surgery in a marginalized population in pakistan: the karachi marine fishing communities eye and general health survey. plos one, 2015; 10: e0131774. 5. rajan ms, keilhorn i, bell ja. partial coherence laser interferometry vs. conventional ultrasound biometry in intraocular lens power calculations. eye, 2002; 16: 552. 6. gaballa sh, allam rs, abouhussein nb, raafat ka. iol master and a-scan biometry in axial length and intraocular lens power measurements. delta j ophthalmol. 2017; 18: 13. 7. wang q, savini g, hoffer kj, xu z, feng y, wen d, et al. j. a comprehensive assessment of the precision and agreement of anterior corneal power measurements obtained using 8 different devices. plos one, 2012; 7: e45607. 8. nakhli fr. comparison of optical biometry and applanation ultrasound measurements of the axial length of the eye. saudi j ophthalmol. 2014; 28: 287291. 9. mcalinden c, wang q, pesudovs k, yang x, bao f, yu a, et al. axial length measurement failure rates with the iol master and lenstar ls 900 in eyes with cataract. plos one, 2015; 10: e0128929. 10. holladay jt, prager tc, ruiz rs, lewis jw, rosenthal h. improving the predictability of intraocular lens power calculations. arch ophthalmol. 1986; 104 (4): 539-541. doi: 10.1001/archopht.1986.01050160095020. pmid: 3954656. 11. olsen t. improved accuracy of intraocular lens power calculation with the zeiss iol master. acta ophthalmol scand. 2007; 85: 84–87. 12. findl o, kriechbaum k, sacu s, kiss b, polak k, nepp j, et al. influence of operator experience on the performance of ultrasound biometry compared to optical biometry before cataract surgery. j cataract refract surg. 2003 oct; 29 (10): 1950-5. doi: 10.1016/s0886-3350(03)00243-8. pmid: 14604716. 13. haigis w, lege b, miller n, schneider b. comparison of immersion ultrasound biometry and partial coherence interferometry for intraocular lens calculation according to haigis. graefes arch clinexp ophthalmol. 2000; 238 (9): 765-773. doi: 10.1007/s004170000188. 14. kitthaweesin k, mungsing w. agreement and reproducibility of contact and immersion techniques for axial length measurement and intraocular lens power calculation. j med assoc thai. 2009; 92: 1046e1049. 15. freudiger h, artaria l, niesel p. influence of intraocular lenses on ultrasound axial length measurement: in vitro and in vivo studies. j am intraocul implant soc. 1984 winter; 10 (1): 29-34. doi: 10.1016/s0146-2776(84)80073-7. partial coherence laser interferometry versus conventional a-scan acoustic biometry pak j ophthalmol. 2022, vol. 38 (2): 85-90 90 16. kiss b, findl o, menapace r, wirtitsch m, drexler w, hitzenberger ck, et al. biometry of cataractous eyes using partial coherence interferometry: clinical feasibility study of a commercial prototype i. j cataract refract surg. 2002; 28 (2): 224-9. doi: 10.1016/s08863350(01)01272-x. 17. prinz a, neumayer t, buehl w, kiss b, sacu s, drexler w, et al. influence of severity of nuclear cataract on optical biometry. j cataract refract surg. 2006; 32 (7): 1161-1165. doi: 10.1016/j.jcrs.2006.01.101. 18. chylack lt jr, wolfe jk, singer dm, leske mc, bullimore ma, bailey il, et al. the lens opacities classification system iii. the longitudinal study of cataract study group. arch ophthalmol. 1993; 111 (6): 831-6. doi: 10.1001/archopht.1993.01090060119035. 19. povazay b, hermann b, unterhuber a, hofer b, sattmann h, zeiler f, et al. three-dimensional optical coherence tomography at 1050 nm versus 800 nm in retinal pathologies: enhanced performance and choroidal penetration in cataract patients. j biomed opt. 2007; 12 (4): 041211. doi: 10.1117/1.2773728. 20. pearce e, sivaprasad s, chong nv. comparing fixation location and stability in patients with neovascular age-related macular degeneration treated with or without ranibizumab. eye (lond). 2011; 25 (2): 149-153. doi: 10.1038/eye.2010.167. authors’ designation and contribution javeria muid; consultant ophthalmologist: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, farooq afzal; professor: concepts, manuscript preparation, manuscript review. .…  …. pakistan journal of ophthalmology, 2020, vol. 36 (3): 191-193 191 editorial corona virus nanoparticles and enhanced respiratory protection for outpatient ophthalmic practice nick kopsachilis 1 , rashid zia 2 1 lead consultant ophthalmologist; east kent hospitals university foundation trust, united kingdom 2 lead new hayesbank ophthalmology services, ashford kent united kingdom the covid-19 pandemic has emerged rapidly and is now part of our everyday life and work. at the time of writing this script, all routine clinical activity and surgery that had previously been stopped is set for a phased reopening over the next 6 weeks to 6 months. extensive planning has been undertaken to cater to the significant backlog but the sword of damocles hangs over all of us as an imminent risk of a second peak and another lockdown looms. standard infection control precautions (sicps) and transmission-based precautions (tbps) must be used when managing patients with suspected or confirmed covid-19. public health england has advised, “sicps should be used by all staff, in all care settings, at all times, for all patients” 1 . at this stage, we believe it is extremely important to understand that the current discussion on using enhanced personal protective equipment (ppe) is to prevent specifically from corona infection and transmission. ophthalmologists, ophthalmic nurses and optometrists are at the frontline of this crisis and their work related risks are often undervalued. in its most recent guidelines, public health england (phe) has advised that “covid19 is how to cite this article: kopsachilis n, zia r. corona virus nanoparticles and requirement of enhanced respiratory protection for outpatient ophthalmic practice. pak j ophthalmol. 2020; 36 (3): 191-193. doi: 10.36351/pjo.v36i3.1079 correspondence to: rashid zia new hayesbank ophthalmology services, united kingdom email: rashidzia@nhs.net no longer categorised as a high consequence infectious disease and therefore enhanced ppe is not recommended” 1 and that ophthalmologists should wear standard ppe including a surgical fluid resistant mask, plastic apron, gloves and eye protection when examining covid positive patients 1 . as reassuring as this may sound, this recommendation is not scientifically backed by the literature citing systematic review on respiratory protection against airborne nanoparticles discussing nano particles’ behaviour and penetration of facial seals of masks. 2 corona particle is classified as a nanoparticle – an average diameter of the virus particles is around 125 nm (0.125 μm). 3,4 it may seem counter-intuitive that a 0.3 microns particle that is 30 times larger would be harder to capture than 0.1 micron size corona particle but the root of the problem is in our thinking that respiratory masks act like nets if a particle is smaller than the holes in the net, it gets through and the smaller the particle, the harder it is to capture. this logic works for particles bigger than 0.3 microns. such particles (i.e. > 0.3 microns) either cannot fit through or their inertia causes them to hit the filter fibres– a process called impaction and interception. nanoparticles under the 0.3 microns have very little mass and they are bounced around like a pinball when they hit gas molecules. this is known as brownian motion. these tiny particles are small enough to fit through 0.3 micron filters if they flow straight. as they fly in zigzag patterns, they end-up hitting the fibres and getting stuck. the smaller the particles, the fewer will slip through. 5 electrostatic attraction is another efficient method of capturing particles of various sizes from the airstream. this method incorporates electrically charged fibres or granules, which are mailto:rashidzia@nhs.net https://en.wikipedia.org/wiki/nanometre https://en.wikipedia.org/wiki/micrometre nick kopsachilis, et al 192 pakistan journal of ophthalmology, 2020, vol. 36 (3): 191-193 embedded in the filter to attract oppositely charged particles from the airstream. the attraction between the oppositely charged fibres and particles is strong enough to effectively remove the nanoparticles from the air. 6 hence, even masks with electret filters that may not be effective against 0.3 microns may be more effective in stopping nanoparticles. 6 all n95, ffp2, ffp3 and many surgical masks have electret filters of varying efficiencies. thus, phe guidelines of using simple masks may be protective against droplet and even against nanoparticles if they contain an electret filter. however, it completely ignores the increased risk of deadlier aerosol related infection via lack of facial seals in ordinary surgical masks. 7 phe recommends wearing a respirator mask and enhanced ppe when performing an aerosol generating procedure 1 yet it fails to recognize aerosol generation and prolonged exposure to the virus by ophthalmologists during common daily outpatient procedures and examinations. ophthalmic examination includes close working distance to our patients at the slit lamp (< 20 cm). many nasolacrimal outpatient procedures can easily convert into droplet infection and even aerosol i.e. refluxes from lacrimal washout. handling of cleaning tissues contaminated with tears and excessive eye drops is a particularly high risk for droplet infection. it is known that the viral load accumulation can increase the severity of the disease. 8 in addition, many slit lamp based procedures and examinations can lead to prolonged exposure and in some cases even aerosol generation. thus, loosely fitted surgical masks, despite their electret filter to trap nanoparticles may offer little or no protection at all. aerosol can be produced by talking alone and its contact with an exposed conjunctiva is known to cause infection. 9 furthermore, conjunctivitis can be the first manifestation of covid-19 without fever or coughing and ophthalmologists working in eye casualty can be caught off guard and be at increased risk of infection. it is probably not a coincidence that 3 out of 8 surgeons who died in wuhan were ophthalmologists. therefore, ophthalmology should be considered as a high risk category between healthcare workers because of prolonged exposure to the patients, droplets and aerosol generating outpatient procedures during the ophthalmic examination. to summarise, despite being significantly smaller than 0.3 microns (filtration limit of most masks including n95, ffp2 and ffp3), corona virus particles (0.1 micron ) can still be effectively filtered by all kind of masks with electret filters. however, none of the masks offer effective protection especially against aerosols unless fit tested. the evidence is overwhelming that ophthalmologists require enhanced ppes including surgical cap, gown, fit tested mask, gloves and goggles for all ophthalmic examinations. hesitation in implementing new ppe guidance for ophthalmology will probably cost lives. conflict of interest author declared no conflict of interest authors’ designation and contribution nick kopsachilis; consultant ophthalmologist: manuscript writing, literature review, final review. rashid zia; consultant ophthalmologist: manuscript writing, literature review, final review. references 1. covid-19: infection prevention and control guidance (2020). available from: https://assets.publishing.service.gov.uk/government/upl oads/system/uploads/attachment_data/file/886668/cov id19_infection_prevention_and_control_guidance_co mplete.pdf 2. ntlailane mgl, wichmann j. effectiveness of n95 respirators for nanoparticle exposure control (2000– 2016): a systematic review and meta-analysis. j nanopart res. 2019; 21 (8): 170. 3. goldsmith cs, tatti km, ksiazek tg, rollin pe, comer ja, lee ww, et al. ultrastructural characterization of sars coronavirus. emerg infect dis. 2004; 10 (2): 320-26. 4. fehr ar, perlman s. coronaviruses: an overview of their replication and pathogenesis. methods mol biol. 2015; 1282: 1-23. doi: 10.1007/978-1-4939-2438-7_1. 6. 5. shaffer re, rengasamy s. respiratory protection against airborne nanoparticles: a review. j nanopart res. 2009; 11 (7): 1661-1672. 6. sun q, leung ww. enhanced nano-aerosol loading performance of multilayer pvdf nanofiber electrets filters. sep purif technol. 2020; 240: 116606. 7. doremalen vn, bushmaker t, morris dh, holbrook mg, gamble a, williamson bn, et al. aerosol and surface stability of sars-cov-2 as compared with sars-cov-1.n engl j med. 2020; 382 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/886668/covid19_infection_prevention_and_control_guidance_complete.pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/886668/covid19_infection_prevention_and_control_guidance_complete.pdf 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protection for outpatient ophthalmic practice pakistan journal of ophthalmology, 2020, vol. 36 (3): 191-193 193 (16): 1564-1567. doi: 10.1056/nejmc2004973. epub 2020 mar 17. 8. liu y, yan lm, wan l, xiang tx, le a, liu jm. viral dynamics in mild and severe cases of covid-19. lancet infect dis. 2020; 20 (6): 656-657. doi: 10.1016/s1473-3099(20)30232-2. 9. lu cw, liu xf, jia zf. 2019-ncov transmission through the ocular surface must not be ignored. lancet. 2020; 395 (10224): e39. doi: 10.1016/s0140-6736(20)30313-5. .…  …. https://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20y%5bauthor%5d&cauthor=true&cauthor_uid=32199493 https://www.ncbi.nlm.nih.gov/pubmed/?term=yan%20lm%5bauthor%5d&cauthor=true&cauthor_uid=32199493 https://www.ncbi.nlm.nih.gov/pubmed/?term=wan%20l%5bauthor%5d&cauthor=true&cauthor_uid=32199493 https://www.ncbi.nlm.nih.gov/pubmed/?term=xiang%20tx%5bauthor%5d&cauthor=true&cauthor_uid=32199493 https://www.ncbi.nlm.nih.gov/pubmed/?term=le%20a%5bauthor%5d&cauthor=true&cauthor_uid=32199493 https://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20jm%5bauthor%5d&cauthor=true&cauthor_uid=32199493 https://www.ncbi.nlm.nih.gov/pubmed/32199493 https://www.ncbi.nlm.nih.gov/pubmed/?term=lu%20cw%5bauthor%5d&cauthor=true&cauthor_uid=32035510 https://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20xf%5bauthor%5d&cauthor=true&cauthor_uid=32035510 https://www.ncbi.nlm.nih.gov/pubmed/?term=jia%20zf%5bauthor%5d&cauthor=true&cauthor_uid=32035510 https://www.ncbi.nlm.nih.gov/pubmed/?term=2019-ncov+transmission+through+the+ocular+surface+must+not+be+ignored pak j ophthalmol. 2020, vol. 36 (4): 456-458 456 clinical practice article surgical approach to control advanced coats disease şengül özdek 1 , ahmet yücel üçgül 2 1 professor in ophthalmology, gazi university, school of medicine, ankara 2 abantizzet baysal university training and research hospital, bolu, turkey coats disease, first described by george coats in 1908, is commonly a unilateral clinical entity characterized by leaky telangiectatic vessels leading to progressive subretinal exudation and exudative retinal detachment (erd). 1 it is generally seen in pediatric population and has a distinct male predilection of over 90%. shields et al. classified coats disease into five stages as follows: stage 1: presence of retinal telangiectasia only, stage 2: telangiectasia and exudation (2a: extrafoveal exudation, 2b: foveal exudation), stage 3: exudative rd (3a: subtotal rd, 3b: total rd), stage 4: total rd and neovascular glaucoma, stage 5: advanced end-stage disease. 2 disease progression can be controlled with ablative therapies such as laser photocoagulation (lfk) and cryotherapy in the early stages of coats disease. however, ablative therapies are not effective in the late stages (stage 3 – 4) due to excessive subretinal exudation and erd. therefore, adjunctive surgical approaches have become popular in the treatment of advanced coats disease. this helps in effective ablation of leaky abnormal vessels. in the presence of erd, although some authors are of the opinion that laser energy could be absorbed by haemoglobin in the telangiectetic vessels on the how to cite this article: özdek ş, üçgül ay. surgical approach to control advanced coats disease. pak j ophthalmol. 2020; 36 (4): 456-458. doi: https://doi.org/10.36351/pjo.v36i4.1112 correspondence: şengül özdek gazi university, school of medicine, ankara, turkey e mail: sengulozdek@gmail.com received: june 20, 2020 accepted: july 29, 2020 detached retina. 3 however, we consider that external drainage of subretinal fluid and exudation is necessary because erd can obscure the visualization of the peripheral part of the retina. furthermore, the ablative therapies can be applied more effectivelywhen retina is attached, as retinal pigment epithelium (rpe) contains melanin which has a stronger ability of absorption of laser energy when compared to haemoglobin. transscleral drainage of subretinal fluid (tdsrf) enhances the visualization of the retina and contributes to more effective ablation by providing retinal reattachment prior to ablative therapies. another advantage of this surgical approach is the maintenance of retinal integrity (figure 1). up till now, favourable anatomic outcomes have been reported after the tdsrf, which was performed as an adjunct to ablative therapies. however, visual outcomes remained poor due to the presence of severe photoreceptor damage in advanced cases. 4 in the last decade, satisfactory outcomes have been reported after pars plana vitrectomy (ppv) surgery, which was performed to treat advanced coats disease. 5 the first purpose of ppv surgery is the removal of vascular endothelial growth factor (vegf) burden, which increases secondary to the retinal ischemia. the fig. 1: preoperative image of a 9-month-old baby having unilateral stage 3b coats-related exudative rd (a). external drainage together with cryotherapy combined with anti-vegf injection at the end of the surgery resulted in complete reattachment of the retina at one month (b) and 12 months follow-up visits (c). mailto:sengulozdek@gmail.com şengül özdek, et al 457 pak j ophthalmol. 2020, vol. 36 (4): 456-458 second aim of ppv is peeling of the posterior hyaloid membrane, which acts as a scaffold for potential subsequent pvr. although some surgeons performed an internal drainage retinotomy to drain the subretinal fluid and exudate and reported relatively successful outcomes after the surgery, 5,6 we consider that internal retinotomy can predispose to the development of proliferative vitreoretinopathy (pvr) and rhegmatogenous retinal detachment (rrd) in such an aggressive disease with excessive exudations. therefore, because the maintenance of the retinal integrity is crucial in advanced coats disease, we prefer to avoid internal drainage (figure 2). fig. 2: preoperative image of 12-year-old boy with stage 3a coats (a). there was limited subretinal fluid (no bullous rd) with subretinal hard exudates, old vitreous haemorrhage opacity in inferior vitreous cavity and epiretinal membranes. ppv with endolaser and cryotherapy to the temporal quadrants and anti-vegf injection without external subretinal fluid drainage was performed. retina was reattached with less subretinal exudates during the 1 st month visit (b) and there was subretinal fibrosis in the macula and temporal periphery with totally attached retina without significant exudate at the last visit, which was 12 th postoperative month (c). vitreoretinal fibrosis and tractional retinal detachment (trd) is not seen in the natural clinical course of coats disease. 7 it is accepted that trd develops secondary to the ablative therapies. in a large series of 351 cases, in which the potential risk factors for the development of trd were investigated, it was found that cryotherapy and anti-vegf therapy increased the risk of trd development in coats disease. 8 this poses two questions: does trd worsen the clinical course of advanced coats disease? does treatment of trd contributes positively to the clinical course of advanced coats disease? it is known that visual outcomes are poor due to severe photoreceptor damage secondary to excessive sub-foveal exudation in advanced coats disease. some authors consider that the clinical approach should be limited to observation in such cases with trd. 9 however, in advanced cases, although treatment of trd has a limited contribution to visual outcomes but it can slow the disease progression and reduce the need for further ablative therapy. therefore, we recommend ppv together with removal of posterior hyaloid when possible and other tractional membranes in advanced cases with trd. another important question is that; should ppv be combined with external drainage in advanced disease or it should be reserved when further trd develops? tdsrf is accepted by many surgeons for effective ablation of the abnormal leaky vessels in advanced coats disease. some cases, where tdsrf was performed as an adjunct to ablative therapies, developed trd secondary to cryotherapy and antivegf therapyin the long-term follow-up and these cases were treated with ppv. 10 our 10-year experience in the treatment of advanced coats disease has shown us that simultaneous surgeries of tdsrf and ppv protects from further development of trd. in cases, where tdsrf and ppv are performed, the need for further ablative therapy decreases (unpublished data). 11 fig. 3: preoperative image of 6-year-old girl, which shows total exudative retinal detachment in contact with the lens (a). external drainage together with ppv, endolaser & cryotherapy to telangiectasic areas combined with antivegf injection at the end of the surgery resulted in complete reattachment of the retina at 18 months follow-up visits. at last visit, retina seems to be attached completely, together with widespread subretinal fibrosis and subfoveal nodule (b). another preoperative image of 2-year-old girl, which shows total exudative retinal detachment and widespread abnormal telangiectatic vessel (c). the patient had an operation by the same surgical technique. at first year of the follow-up, retina seems to be attached completely, and ablated abnormal telangiectatic vessels seems to be under control without leaking (d). surgical approach to control advanced coats disease pak j ophthalmol. 2020, vol. 36 (4): 456-458 458 when tdsrf is performed alone, sub-retinal exudation may recur in the long term and erd may occur together with trd. consequently, although the first surgery is more invasive, there will be no need for a second surgery as the risk of subsequent trd development is eliminated in patients undergoing simultaneous surgeries of tdsrf and ppv (figure 3). in early stages (stage 1 – 2) of coats disease, effective ablation of leaky vessels could be achieved with application of laser photocoagulation and cryotherapy when necessary. furthermore, the use of anti-vegf agents also contributes to a decrease in macular oedema and subretinal fluid. however, patients with advanced coats disease require more than conventional ablative therapies. adjunctive surgical approaches include tdsrf and ppv. simultaneous surgeries of ppv and tdsrf are more successful, when compared with sequential surgeries. internal drainage should be avoided to decrease the risk of pvr and rrd development at a later date. conflict of interest authors declared no conflict of interest. references 1. coats g. forms of retinal diseases with massive exudation. roy lond ophthalmol hosp rep. 1908; 17: 440-525. 2. shields ja, shields cl, honavar sg, demirci h, cater j. classification and management of coats disease: the 2000 proctor lecture. am j ophthalmol. 2001; 131: 572–583. 3. nucci p, bandello f, serafino m, wilson me. selective photocoagulation in coats’ disease: ten-year follow-up. eur j ophthalmol. 2002; 12 (6): 501-505. 4. peng j, zhang q, jin h, fei p, zhao p. a modified technique for the transconjunctival and sutureless external drainage of subretinal fluid in bullous exudative retinal detachment using a 24-g i.v. catheter. ophthalmologica. 2017; 238 (4): 179-185. 5. karacorlu m, hocaoglu m, sayman muslubas i, arf s. long-term anatomical and functional outcomes following vitrectomy for advanced coats disease. retina, 2017; 37 (9): 1757-1764. 6. muftuoglu g, gulkilik g. pars plana vitrectomy in advanced coats' disease. case rep ophthalmol. 2011; 2 (1): 15-22. 7. shields ja, shields cl, honavar sg, demirci h. clinical variations and complications of coats disease in 150 cases: the 2000 sanford gifford memorial lecture. am j ophthalmol. 2001; 131 (5): 561-571. 8. shields cl, udyaver s, dalvin la, lim las, atalay ht, khoo ct, shields ja. coats disease in 351 eyes: analysis of features and outcomes over 45 years (by decade) at a single center. ind j ophthalmol. 2019; 67 (6): 772. 9. adeniran, janelle fassbender, nathan lambert n, ramasubramanian a. “treatment of coats' disease: an analysis of pooled results.” int j ophthalmol. 2019; 12 (4): 668. 10. li as, capone a, jr., trese mt, et al. long-term outcomes of total exudative retinal detachments in stage 3b coats disease. ophthalmology, 2018; 125 (6): 887-893. 11. ucgul ay, ozdek s, ertop m, atalay ht. surgical approaches as an adjunct to ablative therapy in advanced coats disease. toa 53 rd national congress. 2019; oral presentation. authors’ designation and contribution şengül özdek: professor; study design, manuscript preparation, final review. ahmet yücel üçgül: study design, manuscript preparation, final review. .…  …. https://pubmed.ncbi.nlm.nih.gov/?term=demirci+h&cauthor_id=11336931 https://pubmed.ncbi.nlm.nih.gov/?term=cater+j&cauthor_id=11336931 https://www.ncbi.nlm.nih.gov/pubmed/?term=lambert%20n%5bauthor%5d&cauthor=true&cauthor_uid=31024824 https://www.ncbi.nlm.nih.gov/pubmed/?term=ramasubramanian%20a%5bauthor%5d&cauthor=true&cauthor_uid=31024824 108 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology case report true exfoliation in a man with retinitis pigmentosa sana nadeem, shahzad waseem, b. a. naeem, rabeea tahira pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sana nadeem ophthalmology department fauji foundation hospital/ fumc, rawalpindi doctorsana@hotmail.com …..……………………….. true exfoliation is the term given to lamellar splitting of the anterior lens capsule. usually caused by exposure to infrared radiation, it may occur in uveitis, and rarely may be idiopathic. retinitis pigmentosa comprises a group of retinal dystrophies involving photoreceptors and retinal pigment epithelium characterized by night blindness and progressive visual field loss. we present a case of idiopathic true exfoliation of the lens discovered on routine slit lamp examination, in an elderly man, discovered to have bilateral classic retinitis pigmentosa as well. true exfoliation coexistent with retinitis pigmentosa has not been reported so far in literature. rue exfoliation or capsular delamination1 refers to thickening and splitting of superficial part the lens capsule from the deeper part with extension into the anterior chamber2. pathogenesis of this rare condition is unclear, and causes include exposure to intense heat or infrared rays, uveitis, cataract surgery or trauma2-7. idiopathic7,8 true exfoliation of the lens has long been under reported. retinitis pigmentosa (rp) 9 is the term used for a set of hereditary disorders of variable presentation, involving the photoreceptors and retinal pigment epithelium, resulting in progressive visual loss due to photoreceptor death, night blindness, and constriction of visual fields. true exfoliation has never been reported in a patient with retinitis pigmentosa. although, this combination could be a complete chance occurrence, but we decided to report this unique case. case report a 73 year old man presented to our outpatient department of fauji foundation hospital, rawalpindi, with complaints of gradual, progressive decrease in vision of the left eye for the past four months. he also gave a vague history of having difficulties in night vision. he had undergone cataract surgery in the right eye, one and a half year ago, and had no problems with it. otherwise, he had never had any eye problems. he did not have any co morbid systemic illness. family history was also negative for any ocular disease. he had never worked in a glass factory and did not give a history of exposure to infrared light or trauma. on examination, best corrected distance vision in the right eye was 6/6, and in the left eye 6/36. slit lamp examination revealed bilateral arcus senilis, bilateral mid-peripheral iris atrophy, pseudophakia od, and the left eye showed a diaphanous membrane arising from the anterior capsule; attached on one end, folding of the lamella on itself, and floating and undulating in the anterior chamber (figures 1 – 5). the lens had grade 3 nuclear sclerosis, and cortical cataract grade 2. the pupils dilated fully on mydriasis, with no signs what so ever of pseudoexfoliation. intraocular pressures were 17 mm hg od and 18 mm hg os. fundus examination revealed normal discs bilaterally, with a cdr of 0.2, bilateral mid-peripheral bony spicules of retinal pigment, beyond the arcades, retinal pigment epithelial atrophy extending from the midperiphery to the macular periphery, with relative preservation on the maculae and a dull foveal reflex. the vessels were attenuated (figures 6 – 8). gonioscopy was done which revealed grade iv angles by shaffer classification and prominent iris processes. t mailto:doctorsana@hotmail.com true exfoliation in a man with retinitis pigmentosa pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 109 fig. 1: slit lamp photograph showing the capsular delamination, with the rolled lamella projecting into the anterior chamber. fig. 2: the folded inferior part of the true exfoliation fig. 3: nuclear sclerosis grade 3 and margins of the split layer fig. 4: folded anterior capsule visible on nasal side fig. 5: retroillumination showing entire extent of the true exfoliation fig. 6: fundus photograph of the right eye showing classic retinitis pigmentosa, with midperipheral bony spicules, baring of rpe, vessel attenuation, and sparing of central macula. sana nadeem, et al 110 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology fig. 7: a superior view of the right fundus showing the mid-peripheral involvement fig. 8: fundus photograph of the left eye, showing retinitis pigmentosa, the view being hazy due to the cataract the history of night blindness and associated signs in the fundus led to a clinical diagnosis of classic rp, and since the maculae were spared, with good vision in the right eye, and because often patients of rp give a vague history of night blindness, and present to us when maculopathy occurs; no further investigation was deemed necessary by us. the midperipheral iris atrophy can also occur in elderly patients, and we consider it another chance occurrence, since there were no signs of either pigment dispersion or pseudoexfoliation. he underwent successful cataract surgery for the left eye, and best corrected distance vision is 6/6 to date. discussion true exfoliation is a so rare condition, that most textbooks do not explain it. it was described for the first time10 in 1922 by elschnig in glassblowers, and later by punder, who noticed floating anterior capsular folds in a patient with a complicated cataract. the pathogenesis of this entity is obscure. usually, it is classically seen in people who have been exposed to intense heat and infrared radiation over a long period, like glassblowers or blast furnace operators. this may result in rupture of the lens capsule. recently, true exfoliation has been associated with trauma, ocular inflammation, glaucoma, hypermetropia, senility, cataract surgery, and capsular protein abnormalities.27,10,11 however; no one has ever described an association with a pigmentary retinopathy. transmission electron microscopy (tem)11 has demonstrated loss of lens epithelial cells along with abnormal fibrils which indicated age related degeneration as a causative influence. heat activated proteolysis, abnormalities in capsular proteins and cellular abnormalities have been proposed as possible pathogenetic mechanisms2. true exfoliation needs differentiation12 from the more common pseudoexfoliation syndrome; the former being a splitting of the anterior capsule with serrated or glistening, curled or scrolled margins, and the latter being a dandruff like material deposited widely across the anterior segment, and associated more frequently with an open angle glaucoma. the term ‘retinitis pigmentosa’13 is a misnomer due to the absence of inflammation; and encompasses all retinal dystrophies with photoreceptor loss and pigmentary retinal deposits. it has a prevalence of around 1:3000 to 1:5000. it is typically characterized by the classic triad of waxy disc pallor, arteriolar attenuation, and bone – spicule retinal pigment. atypical rp has many forms: pericentral, central, sectorial, sine pigmento, rp puntata albescens, rp with exudative vasculopathy, and unilateral rp9, 13-15. diagnosis is established by the presence of night blindness, fundus changes, progressive visual field loss and diminished erg ‘a’ and ‘b’ waves. inheritance pattern of rp may be autosomal dominant, autosomal recessive, x-linked or digenic. ocular associations of rp are many fold being; posterior subcapsular cataract, open angle glaucoma, myopia, keratoconus, optic disc drusen, vitreous cells, and intermediate uveitis9, 13-15. true exfoliation in a man with retinitis pigmentosa pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 111 however our search of literature has revealed that true exfoliation has never been reported in a patient with rp, typical or atypical. although, this may very well be a chance occurrence, we believe that we are the first to report this instance. author’s affiliation dr. sana nadeem assistant professor ophthalmology department fauji foundation hospital / fumc rawalpindi dr. shahzad waseem assistant professor ophthalmology department fauji foundation hospital / fumc rawalpindi prof. dr. b. a. naeem professor and head, ophthalmology department ophthalmology department fauji foundation hospital / fumc rawalpindi dr. rabeea tahira ophthalmology department fauji foundation hospital / fumc rawalpindi references 1. brodrick jd, tate gw jr. capsular delamination (true exfoliation) of the lens. report of a case. arch ophthalmol. 1979 sep; 97 (9): 1693-8. 2. karp cl, fazio jr, culbertson ww, green wr. true exfoliation of the lens capsule. arch ophthalmol. 1999; 117: 1078-80. 3. yamamoto n, miyagawa a. true exfoliation of the lens capsule following uveitis. graefes arch clin exp ophthalmol. 2000; 238: 1009-10. 4. cashwell lf jr, holleman il, weaver rg, van rens gh. idiopathic true exfoliation of the lens capsule. ophthalmology. 1989; 96: 348-51. 5. tayyab a, dukht u, farooq s, jaffar s. spontaneous idiopathic true exfoliation of the anterior lens capsule during capsulorhexis. j pak med assoc. 2012; 62: 282-4. 6. oharazawa h, suzuki h, matsui h, shiwa t, takahashi h, ohara k. two cases of true exfoliation of the lens capsule after cataract surgery. j nippon med sch. 2007; 74: 55-60. 7. anderson il, van bockxmeer fm. true exfoliation of the lens capsule. a clinicopathological report. aust n z j ophthalmol. 1895; 13: 343-7. 8. majima k, kousaka m, kanbera y. a case of true exfoliation. ophthalmologica. 1996; 210: 341-3. 9. yanoff m, duker js. ophthalmology. third edition. mosby: elsevier. 2009; 550-9. 10. shentu xc, zhu yn, gao yh, zhao sj, tang yl. electron microscopic investigation of anterior lens capsule in an individual with true exfoliation. int j ophthalmol. 2013; 6: 5536. 11. riffle j. floating anterior lens capsule: an unusual case of true exfoliation. digit j ophthalmol. 2010; 16: 17-9. 12. theobold gd. pseudoexfoliation of the lens capsule: relation to true exfoliation of the lens capsule as reported in the literature and role in the production of glaucoma capsulocuticulare. am j ophthalmol. 1954; 37: 1-12. 13. hamel c. retinitis pigmentosa. orphanet j rare dis. 2006; 1: 40. 14. kanski jj, bowling b. clinical ophthalmology: a systematic approach. seventh edition. elsevier. 2011; 651-5. 15. regillo c, chang ts, johnson mw, kaiser pk, scott iu, spaide r, griggs pb. american academy of ophthalmology. basic and clinical science course. section 12: retina and vitreous. 2004; 207-11. 56 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology case report jalili syndrome tayyaba gul malik, muhammad khalil, shoaib alam shah, mian muhammad shafiq pak j ophthalmol 2016, vol. 32 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyaba gul malik associater professor ophthalmology lmdc email. tayyabam@yahoo.com received: december 28, 2015 accepted: march 09, 2016. …..……………………….. a thirty years old pakistani male was referred from university of lahore, pakistan for clinical evaluation and interpretation of his erg. clinical examination revealed cone – rod dystrophy. systemic examination showed discolored and abnormally shaped teeth. the patient was otherwise mentally and physically normal. his erg showed scotopic (rod responses) within upper normal limits in right eye while markedly reduced in the left eye. scotopic rod and cone combined responses (indicating generalized retinal functions) were also decreased. photopic (cone responses) were reduced in both eyes, with more marked fall in the left eye as compared to the right eye. key words: rod-cone dystrophy, amelogenesis imperfect, electro-retinogram, pigmentary retinopathy alili syndrome is a rare cone-rod dystrophy which is associated with amelogenesis imperfecta. few cases are reported in literature so far. the very first report of jalili syndrome was published in 1988 by an iraqi ophthalmologist named ismail k. jalili. jalili and smith reported 29 individuals from a single highly inbred arab family from the gaza strip. later, other families with this syndrome were reported mainly from middle east. only one case from north america and indian sub-continent are reported. we report a case of jalili syndrome from northern areas of pakistan. environmental factors and genetic association of this syndrome is also mentioned with reference to the hypotheses already presented in different papers globally. case report we present a case of thirty years old pakistani male, referred from university of lahore, pakistan for clinical evaluation and interpretation of his erg. for reporting of this case, informed consent was taken, according to the principles of the declaration of helsinki. the patient did not give consent to publish his face photographs but allowed the publication of fundus pictures and electro retinogram. history revealed that the patient complained of decreased visual acuity in both eyes since childhood. he was prescribed glasses but the compliance was poor. day and night vision were equally affected. there was no irritation and redness in both eyes. systemic history revealed discolored and abnormally shaped teeth. there was no history of any medicine intake specially tetracycline group of drugs. family consanguinity was positive but there was no history of such disease in any of the relatives. he had two brothers and one sister and all were normal with no ocular and systemic disease. on examination, he was an average built male who was well oriented in time and space. he was orthotropic. auto-refraction showed mild myopia. his best corrected visual acuity was finger counting in each eye. anterior segment showed no abnormality. on dilated fundus examination, there were tilted oval discs in both eyes. there was arteriolar attenuation and bone spicule pigmentation scattered all over the retina. pigmentation was also visible in the macular area. large choroidal vessels were visible. general physical examination showed normal vital signs. teeth were yellow in color and distorted in shape. clinical features led to the diagnosis of jalili syndrome. his erg showed scotopic (rod responses) within upper normal limits in right eye while markedly reduced in the left eye. scotopic rod and cone combined responses (indicating generalized retinal functions) were also decreased. photopic (cone j mailto:tayyabam@yahoo.com jalili syndrome pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 57 responses) were reduced in both eyes, with more marked fall in the left eye as compared to the right eye. fig. 1: cone rod dystrophy in a patient with jalili syndrome. macular excavation, arteriolar attenuation and pigmentary retinopathy. fig. 2a: light adapted erg. fig. 2b: light adapted flicker erg. discussion fig. 2c: dark adapted erg. fig. 2d: dark adapted erg + ops. fig. 2e: dark adapted 10 erg cone – rod dystrophies are part of a genetically diverse group of progressive photoreceptor disorders, which are categorized on the basis of the photoreceptor cells primarily involved in the disease process. three main groups are identified; cone-rod, rod-cone, and mixed receptors dystrophies. jalili tayyaba gul malik, et al 58 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology syndrome is a cone-rod dystrophy which is associated with amelogenesis imperfecta. amelogenesis was defined by crawford et al. as “a group of conditions of genetic origin that affect the structure and clinical appearance of enamel of all or almost all of the dentition, and that may be associated with morphological or biochemical changes in other parts of the body”.1 in cone-rod dystrophy, there is initial involvement of cone dysfunction; loss of central vision, color vision and photophobia.2 jalili syndrome was first reported in 1988 by an iraqi ophthalmologist named ismail k. jalili. jalili and smith reported 29 individuals from a single highly inbred arab family from the gaza strip. all patients had photophobia, loss of color vision but normal night vision. teeth of all the individuals were discolored and malformed from the very beginning.3 three phenotypic variations were identified in gaza strip. type a had early onset macular lesion leading to macular excavation and coloboma in early age. type b had more peripheral involvement and had resemblance to retinitis pigmentosa but without night blindness. third type c was similar to type a, but it appeared in late age. our patient had early onset of retinal signs and had excavated type of maculopathy similar to type a. initially, jalili syndrome was only found in the gaza strip and not in the west bank4. different environmental and genetic factors are described in literature which can lead to jalili syndrome. one such environmental factor is family consanguinity in people of gaza strip. our patient also had a strong history of intra family marriages. another important factor regarding the jalili syndrome was hypothesized to be high fluoride levels in ground water of gaza strip. this resulted in dental fluorosis5. literature shows that high fluoride levels in water are toxic and the toxicity is dose dependent.6 it was also hypothesized that a disrupted magnesium transport was involved in the development of the dental abnormalities observed in jalili syndrome7. unfortunately, we were not able to get the fluoride and magnesium levels in ground water of that area (our patient’s residence). genetic factors are well recognized for this disease. nine mutations are described in literature; three mis-sense changes, three termination mutations, two large deletions, and a single base insertion.8 recently, more cases were reported from other parts of the world. in 2013 first family of jalili syndrome was identified in north america.9 there was only one case of jalili syndrome reported from sub continent10. he had situs inversus totalis, keratoconus and ectopia lentis. he belonged to an area with high fluoride levels in the ground water and a positive history of consanguineous marriage among his family members. there were no such ocular abnormalities in our patient. another case of a 9-year-old child with neurofibromatosis type 1 (nf1) and jalili syndrome was reported in the literature11. similarly, different phenotypes were also seen in the same family in a study.12 the short comings in our case report were lack of genetic study and chemical analysis of ground water. conclusion our literature search found only one case reported from the indo-pak sub-continent. family consanguinity and environmental factors favor the prevalence of jalili syndrome in our part of the world but few reports might be because of under diagnosis of the disease. author’s affiliation dr. tayyaba gul malik associate professor lmdc dr. muhammad khalil associate professor lmdc dr. shoaib alam shah 1st year resident ghurki trust teaching hospital lahore dr. mian muhammad shafiq professor of ophthalmology ophthalmology lmdc lahore role of authors dr. tayyaba gul malik data collection and manuscript writing dr. muhammad khalil manuscript writing jalili syndrome pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 59 dr. shoaib alam shah data acquisition dr. mian muhammad shafiq manuscript review references 1. crawford pj m, aldred m, bloch-zupan a. amelogenesis imperfecta. orphanet journal of rare diseases, 2007; 2: 7. 2. michaelides m, bloch-zupan a, holder ge, hunt dm. moore at (2004). an autosomal recessive cone-rod dystrophy associated with amelogenesis imperfect. j med genet. 2004; 41: 468–73. 3. jalili ik, smith nj. a progressive cone-rod dystrophy and amelogenesis imperfecta: a new syndrome. j med genet. 1988; 25: 738–40. 4. bellamy rj, inglehearn cf, jalili ik, jeffreys aj, bhattacharya ss. increased band sharing in dna fingerprints of an inbred human population. human genet. 1991; 87: 341–7. 5. shomar b, müller g, yahya a, askar s, sansur r. fluorides in groundwater, soil and infused black tea and the occurrence of dental fluorosis among school children of the gaza strip. j water health. 2004; 2: 23– 35. 6. shailaja k, johnson me. fluorides in groundwater and its impact on health. j environ biol. 2007; 28: 331–2. 7. fewtrell l, smith s, kay d, bartram j. an attempt to estimate the global burden of disease due to fluoride in drinking water. j water health, 2006; 4: 533–42. 8. luder hu, gerth – kahlert c, ostertag – benzinger s, schorderet df. dental phenotype in jalili syndrome due to a c. 1312 dupc homozygous mutation in the cnnm4 gene. plos one 8:10 2013 pg e78529. am j hum genet. 2009, 13; 84 (2): 266–273. 9. doucette l et al. molecular genetics of achromatopsia in newfoundland reveal genetic heterogeneity, founder effects and the first cases of jalili syndrome in north america. ophthalmic genetics, 2013; 34: 119-29. 10. purwar p sareen s bhartiya k ) et al. jalili syndrome presenting with situs inversus totalis and keratoconus: the first case in the indian subcontinent. oral surgery, oral medicine, oral pathology and oral radiology, 2015; 120: 210-8. 11. zobor d, kaufmann dh, weckerle p, sauer a, wissinger b, wilhelm h, kohl s. cone-rod dystrophy associated with amelogenesis imperfecta in a child with neurofibromatosis type 1. ophthalmic genetics, 2012; 33: 34-8. 12. gerth – kahlert c, seebauer b, dold s, hanson jvm, wildberger h, spörri a, waes hv, berger w. intrafamilial phenotype variability in patients with jalili syndrome. eye, 2015; 29: 712-6. http://www.unboundmedicine.com/medline/?st=m&author=luder%20hu http://www.unboundmedicine.com/medline/?st=m&author=gerth-kahlert%20c http://www.unboundmedicine.com/medline/?st=m&author=ostertag-benzinger%20s http://www.unboundmedicine.com/medline/?st=m&author=schorderet%20df http://www.unboundmedicine.com/medline/?st=m&journal=plos%20one http://www.unboundmedicine.com/medline/?st=m&author=doucette%20l http://www.unboundmedicine.com/medline/?st=m&journal=ophthalmic%20genet http://www.unboundmedicine.com/medline/?st=m&author=purwar%20p http://www.unboundmedicine.com/medline/?st=m&author=sareen%20s http://www.unboundmedicine.com/medline/?st=m&author=bhartiya%20k http://www.unboundmedicine.com/medline/?st=m&journal=oral%20surg%20oral%20med%20oral%20pathol%20oral%20radiol http://www.unboundmedicine.com/medline/?st=m&journal=oral%20surg%20oral%20med%20oral%20pathol%20oral%20radiol http://www.unboundmedicine.com/medline/?st=m&author=zobor%20d http://www.unboundmedicine.com/medline/?st=m&author=kaufmann%20dh http://www.unboundmedicine.com/medline/?st=m&author=weckerle%20p http://www.unboundmedicine.com/medline/?st=m&author=sauer%20a http://www.unboundmedicine.com/medline/?st=m&author=wissinger%20b http://www.unboundmedicine.com/medline/?st=m&author=wilhelm%20h http://www.unboundmedicine.com/medline/?st=m&author=kohl%20s http://www.unboundmedicine.com/medline/?st=m&journal=ophthalmic%20genet pak j ophthalmol. 2021, vol. 37 (4): 428-430 428 brief communication excellent healing after severe lid injury by a bird tanveer chaudhry 1 , nida shamim 2 department of ophthalmology, 1 liaquat national hospital and medical college, karachi – pakistan 2 hashmani group of hospitals abstract eye lid lacerations secondary to penetrating trauma is quite common. most of the injuries occur due to animal bites, falls and collision with sharp objects. they may lead to partial or full thickness lid defects. we report a case of middle aged woman who was attacked by bird claws and sustained severe upper lid laceration that was immediately thoroughly investigated and then managed surgically resulting in excellent wound healing. ocular trauma from bird pecking injury can cause blindness in humans. the public should guard against feeding and keeping close with them. if immediate medical attention is given by the ophthalmologist and urgent primary repair is done there are high chances to save the eye from disastrous complications. key words: lid laceration, ocular trauma, penetrating injury. how to cite this article: chaudhry t, shamim n. excellent healing after severe lid injury by a bird. pak j ophthalmol. 2021, 37 (4): 428-430. doi: 10.36351/pjo.v37i4.1281 introduction though, birds are generally harmless creatures but if provokedcan be extremely dangerous, or show aggressive behavior when in state of hunger or breeding. they can easily cause harm to their prey using their sharp weapons that are claws, and beak. 1 here we highlight a case where a middle-aged woman was attacked by a kite (cheel), and sustained severe upper lid damage that was immediately repaired and followed up with excellent healing. reconstructing and initial management of eye lid lacerations has always been very challenging for the ophthalmologists due to its profuse blood supply thus preventing scar tissue formation is very essential for good cosmetic outcome. correspondence: tanveer chaudhry department of ophthalmology liaquat national hospital and medical college karachi – pakistan email:tchaudhry39@yahoo.com received: may 26, 2021 accepted: september 23, 2021 case presentation a 55 years old woman presented to us in the emergency department of a tertiary care hospital with complaints of profuse bleeding from her left eye and severe pain that was unbearable for half hour. on enquiry, she said that she was heading back home by foot after grocery shopping, she held in her hand shoppers containing meat and vegetables. suddenly, she noticed few kites that were hovering over her head, when one large bird tried to snatch the shopper from her hand. on a glimpse of a second the bird attacked her left eye with its claws and left her injured. she was immediately brought to the hospital.after giving her first aid including anti-tetanus prophylaxis and hemostasis, her eye was examined completely. on examination, there were superficial and deep lacerations involving the subcutaneous tissue, orbicularis muscle, tarsus and conjunctiva of x and t shape, involving full length of her left upper eyelid with irregular margins and ragged edges as shown in fig. 1. there were also bruises and scratches on the surrounding skin with edema of the lids. her vision was 20/20 with no anterior or posterior segment findings. her intraocular pressure was normal, and open access mailto:tchaudhry39@yahoo.com tanveer chaudhry, et al 429 pak j ophthalmol. 2021, vol. 37 (4): 428-430 extraocular movements were full.her right eye was 20l20 with normal examination. the patient was admitted for immediate surgery. she was given systemic antibiotics to prevent septicemia and systemic analgesics. after general examination, anesthetic fitness and all aseptic measures, she was operated under general anesthesia, her wound was copiously irrigated and any foreign body was removed, her wound was repaired layer by layer attempting the deeper tissues first. the orbital septum was carefully avoided in the repair process. primary repair of the posterior lamellae was done then the anterior lamella was professionally approximated and sutured with 6/0 prolene sutures shown in fig. 2. figure 1: trauma to the left eyelid by kite. figure 2: early post-operative. post operatively, oral antibiotics and analgesics were advised with proper cleaning of lid instructions with pyodine and the patient was discharged. on follow up one week later, there was no pain, edema and discharge. her wound was examined and sutures removed. on follow-up of 6 weeks, there was excellent recovery and rapid wound healing as shown in fig. 3. figure 3: late post-operative picture showing excellent healing. discussion there are very few cases reported of bird related traumas to human eye. literature review shows that there are few cases of bird trauma causing penetrating ocular injuries affecting the vision with disastrous complications involving anterior and posterior segment. 2 on comprehensive reviews of the pertinent literature in the past involving human eye related injuries by birds, it has been reported by duke-elder et al. and kühlapud collin that most human eye bird injuries are caused by owls, chicken and roosters. they found that attacks occur more commonly in the spring season, in their breeding time. the type of injury varied depending on the type of bird and shape of the beak. curved beak/claws injuries result in perforating corneal, scleral wounds leading to severe intraocular damage with poor prognosis. in contrast, birds with sharp straight beaks most likely cause clean corneal perforating injuries with preferably less intraocular damage and better visual prognosis. 3 the faceand eyes appear to be favored sites of a birds attack. possiblycornea, due to its color, shape and excellent healing after severe lid injury by a bird pak j ophthalmol. 2021, vol. 37 (4): 428-430 430 reflection of light, comparable to the rest of the face, becomes the target of attention. 4 our patient was attacked by the black kite (cheel), which is a medium to large-sized, predator that is considered to be the most successful raptor in the world. there are previous reports where kites aggressively snatch food from humans due to the presence of close proximity of their nests to human colonies. physical attacks dependon human activities such as unhygienic waste disposal near their nests, feeding of kites (practiced by some muslims), increasing human population near their breeding areas, and presence of a balcony near the nest, suggestive of an association between kite’s aggressive behavior and frequent-close exposure to humans. 5 these large birds can cause ocular and periocular damage to variable extents. according to a study, traumatic endophthalmitis was seenin 7% of penetrating ocular injuries. there is also a case report where an open globe injury wassustained leading to traumatic endophthalmitis following crane pecking injury in a twelve year old boy. in bird beak injuries, delay in immediate management can lead to deleterious effects on the anatomical and functional outcome. 6 commonly affected population is the pediatric age group. high pecking impact can cause blindness. 7 our patient sustained severe lid trauma that was immediately brought into attention of the ophthalmologist in the tertiary care hospital where the lesion was perfectly approximated and closed using prolene sutures. full understanding of the anatomy and vascular supply of the lid and periorbital structures play a crucial rule in the repair and healing process. proper planning of the technique of lid repair in the early period prevents excessive tissue loss, leaving no apparent scar mark. 8 there are certain principles of lid repair that need to be followed in order to attain good functional and cosmetic outcome. depending on the lamellae involved, repairing should be done layer by layer attempting the deeper tissues first. 9 conclusion mass awareness is needed to avoid such preventable injuries caused by birds. if they happen, immediate repair can lead to better results of surgery. conflict of interest none. references 1. chaudhry ia, al-sharif am, hamdi m. severe ocular trauma caused by an ostrich. br j ophthalmol. 2005; 89 (2): 250-251. 2. abdulla ha, alkhalifa sk. ruptured globe due to a bird attack. case reports in ophthalmol. 2016; 7 (1): 112-114. 3. al-sharif em, alkharashi as. an unusual case of penetrating eye injury caused by a bird: a case report with review of the pertinent literature. saudi j ophthalmol. 2019; 33 (2): 196-199. 4. young al, cheng ll, rao sk, lam ds. corneal laceration with total but isolated aniridia caused by a pecking injury. j cataract refract surg. 2000; 26 (9): 1419-1421. 5. kumar n, jhala yv, qureshi q, gosler ag, sergio f. human-attacks by an urban raptor are tied to human subsidies and religious practices. sci reports, 2019; 9 (1): 1-10. 6. baskaran p, ramakrishnan s, dhoble p, gubert j. traumatic endophthalmitis following a crane pecking injury – an unusual mode. gms ophthalmol cases, 2016; 6: doc 01. doi: 10.3205/oc000038. 7. ayanniyi aa, monsudi kf, danfulani m, jiya py, balarabe ha. uniocular blindness in a six-yearold boy following penetrating eye injury from a domestic hen peck. jrsm short reports, 2013; 4 (2): 1-3. 8. black e, nesi-eloff f, nesi fa. eyelid laceration and lid defects. in manual of oculoplastic surgery, springer, cham. 2018: pp. 39-45 9. tomy rm. management of eyelid lacerations. kerala j ophthalmol. 2018; 30 (3): 222. authors’ designation and contribution tanveer chaudhry; consultant ophthalmologist: concepts, design, data acquisition, data analysis, statistical analysis, manuscript editing, manuscript review. nida shamim; consultant ophthalmologist: design, literature search, data acquisition, manuscript preparation, manuscript editing. .…  …. 124 pak j ophthalmol. 2021, vol. 37 (1): 124-125 brief communication sars-cov2 source, control, conundrums victor leung 1 , hasan naveed 2 , rawya diab 3 , christopher liu 4 1 core extension health and safety, canada, 2,3,4 sussex eye hospital, london there have been several recent publications on the exposure and control options against covid-19. 1,2 effects of physical distancing, eye and respiratory protection and person to person spread of sars-cov2 have been extensively described in literature. 3 we would like to caution readers drawing causal conclusions based on statistical modelling alone for example, the beneficial effect of eye protection alone may not be biologically plausible. the major differences between surgical masks and respirators are shown in table 1. respirators have finer filters and seal against the wearer’s face but require mandatory fit testing, allowing for variations in face shape and size in different gender and ethnic groups. 4 once fit tested, a wearer should adhere to the same make and model and fit check before entering highrisk areas. 5 as surgical masks and respirators are in short supply worldwide, universal public masking for how to cite this article: leung v, naveed h, diab r, liu c. sars-cov2 source, control, conundrums. pak j ophthalmol. 2021, 37 (1): 124-125. doi: https://doi.org/10.36351/pjo.v37i1.1145 correspondence: hasan naveed sussex eye hospital, london email: hasan.naveed@nhs.net received: october 14, 2020 accepted: november 11, 2020 preventing spread should be with multi-layered cloth masks, preferably certified. 6 those with medical contraindications to mask wear may be placed at risk especially when conducting heavy work activities or exercise. three students in china died during intense physical exercise whilst observing mandatory mask wear. 7 droplets and aerosol are an artificial divide – particle sizes exist as a continuum. 8 a droplet can become aerosol with evaporation. the minimum infective dose of sars-cov2 is still unknown. the relative contributions from droplets, aerosol and indirectly via fomites is also uncertain. further, particle settling time and maximum travel distance in air will depend on prevailing wind, room size, amount of ventilation, air exchange, humidity and whether the particles were propelled by cough, sneeze and singing/ shouting. particle density also depends on the number of virus shedding occupants in the room. 8 should we observe physical distancing? physical distancing is sufficient for non-propelled droplets, but insufficient for aerosol and propelled droplets. nevertheless, it is highly protective when combined with universal mask wear to keep air and surfaces clean. it would be prudent to avoid repeated and lengthy exposure, and we should reduce aerosolgenerating activities such as talking, singing, and shouting during the pandemic. self-isolation of those with covid-19 symptoms, universal mask wear, hand hygiene, strict no touching of face and one another, and ventilation of closed spaces should allow society to reopen. 9 table: differences between surgical masks and respirators. surgical mask n95/ffp2/ffp3 respirators purpose primary use to prevent bio-aerosol spread from the wearer. primary use to protect wearer from exposure to inhaling bioaerosol from ambient air. intended use protection against expel of large droplets from wearer, and external splashes/sprays of bodily or other hazardous fluids. protection against inhaling particles including small particle aerosols up to muc* and external splashes/sprays of bodily or other hazardous fluids (only non-oil aerosols). protect against expel of large droplets from wearer with exception of respirator with exhaled valve. face seal fit loosefitting tight-fitting sars-cov2 source, control, conundrums pak j ophthalmol. 2021, vol. 37 (1): 124-125 125 fit-testing requirement no yes (n95) no (ffp2) yes (ffp3) ability for user fit-checking no yes filtration unreliable protection against airborne particle filtration and is not considered respiratory protection (n95) 95% (ffp2) 94% (ffp3) 99% leakage leakage occurs around the edge of the mask when user inhales when properly fitted and donned, minimal leakage occurs around edges of the respirator when user inhales clean-shaven requirement no yes *muc – maximum use concentration calculated as safe exposure concentration multiply by respirator assigned protection factor (apf). as there is no safe infection dose for sars-cov-2, the use of respirator only offers a relative exposure concentration reduction up to the apf of the selected properly fitted respirator. conflict of interest authors declared no conflict of interest. references 1. nocola m, o’neill n, sohrabi c, khan m, agha m, agha r. evidence based management guideline for the covid-19 pandemic review article. int j surg. 2020 may); 77: 206-216. doi: 10.1016/j.ijsu.2020.04.001. [accessed 19 th october 2020]. 2. us-osha safety & health topics: covid-19 control and prevention (2020). available at: https://www.osha.gov/sltc/covid19/controlprevention.html. [accessed on 19 th october 2020]. 3. chu dk, akl ea, duda s, solo k, yaaqub s, schunemann. physical distancing, face masks and eye protection to prevent person-to-person transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis. lancet. 2020; s0140-6736 (20): 3114231149. 4. centers for disease control and prevention and national institute of occupational safety and health. understanding the difference, surgical mask, n95 respiratory [online]. available at: https://www.cdc.gov/niosh/npptl/pdfs/understanddiffer enceinfographic-508.pdf [accessed on 20 th june 2020] 5. health and safety executive. rapid. review part 1. equivalence of n95 and ffp2 masks [online. 2020. available at: https://www.hse.gov.uk/news/assets/docs/face-maskequivalence-aprons-gown-eye-protection.pdf [accessed 20th june 2020]. 6. liu c, diab r, naveed h, leung v. universal public mask wear, design, rationale and acceptability. respirology, 2020; 25 (8): 895-897. doi:10.1111/resp.13892. 7. w zhang. after multiple deaths, official call for no masks in gym class [online]. sixth tone: fresh voices from today’s china. 2020. available at: https://www.sixthtone.com/news/1005609/aftermultiple-deaths%2c-officials-call-for-no-masks-ingym-class[accessed 20 th june 2020]. 8. wang jw, li y, eames i, chan pks, ridgway gl. factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises. j hosp infect. 2006; 64 (2): 100–114. 9. smieszek t, lazzari g, salathe m. assessing the dynamics and control of dropletand aerosol transmitted influenza using an indoor positioning system. scientific reports, 2019; 9: 2185. available at https://doi.org/10.1038/s41598-019-38825-y [accessed 19th october 2020]. authors’ designation and contribution victor leung; industrial hygienist: concepts, design, literature search, manuscript preparation, manuscript editing, manuscript review. hasan naveed; specialist registrar: concepts, literature search, manuscript editing, manuscript review. rawya diab; corneal fellow: concepts, literature search, manuscript editing, manuscript review. christopher liu; consultant ophthalmologist: concepts, design, literature search, manuscript preparation, manuscript editing, manuscript review. .…  …. https://dx.doi.org/10.1016%2fj.ijsu.2020.04.001 https://www.osha.gov/sltc/covid-19/controlprevention.html https://www.osha.gov/sltc/covid-19/controlprevention.html https://www.cdc.gov/niosh/npptl/pdfs/understanddifferenceinfographic-508.pdf https://www.cdc.gov/niosh/npptl/pdfs/understanddifferenceinfographic-508.pdf https://www.hse.gov.uk/news/assets/docs/face-mask-equivalence-aprons-gown-eye-protection.pdf https://www.hse.gov.uk/news/assets/docs/face-mask-equivalence-aprons-gown-eye-protection.pdf https://www.sixthtone.com/news/1005609/after-multiple-deaths%2c-officials-call-for-no-masks-in-gym-class https://www.sixthtone.com/news/1005609/after-multiple-deaths%2c-officials-call-for-no-masks-in-gym-class https://www.sixthtone.com/news/1005609/after-multiple-deaths%2c-officials-call-for-no-masks-in-gym-class https://doi.org/10.1038/s41598-019-38825-y 33 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology original article orbital tumors – retrospective study of 24 years faiz m. halepota, khalid iqbal talpur, mahesh kumar luhano, late sher muhammad shaikh, abdul rehman siyal pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: faiz m. halepota hayat medical centre satellite town mirpurkhas, sindh 6900 mklohana@yahoo.com …..……………………….. purpose: to evaluate incidence of uncommon tumors with unique clinical presentation and rising incidence of lymphomas. material and methods: this study was conducted at chandka medical college larkana, peopled medical college, nawabshah; liaquat university of medical and health sciences, eye hospital, hyderabad; and two private hospitals of sindh province namely hajiani hospital, pathan colony hyderabad; and, hayat medical center, satellite town mirpurkhas. a total of 42 cases and conditions simulating tumors were identified and in all cases diagnosis was confirmed by histology. results: a rising incidence of lymphoma, 06 cases (2.52%), followed by tumors of eyeball and lids (squamous cell ca, retinoblastoma) 06 cases each (2.52%) were noted. fibroangio sarcoma 03 (1.26%) lacrimal gland tumor 03 (1.26%), socket tumors 03 (1.26%) nerve sheath tumor 03 (1.26%) (schwannoma and neurofibroma) porocarcinoma and metastatic tumor one case each were identified (0.42%). miscellaneous non malignant lesions were 08 (3.36%) lymphoid hyperplasia of lacrimal gland 02 case (0.84%). conclusion: our study shows variety of tumors, few uncommon which affect orbit, with lately rising incidence of lymphomas, revealed by employing modern investigation techniques. ever increasing incidence of orbital lymphoma need to be confirmed by further studies in future. rbital tumors may be primary, secondary, metastatic extension from adjacent tissues – sinuses, lids, eye ball or manifestation of leukaemia. tumors may be benign or malignant; in children 90% are benign (cystic) and 10% malignant. studies by various authors have given variable incidence of different tumors, depending on age, race, region and study period. lymphoid tumors, inflammatory lesions (pseudotumor muccoele) vascular and cystic lesion (dermoid and epidermoid are most common1. there are conditions, which mimic orbital tumors such as thyroid ophthalmopathy usual presentation is axial proptosis, decreased vision, restriction of e.o.m, pain, inflammation and cosmetic disfigurement. the initial clinical evaluation of patient with orbital mass (lesion is frequently inclusive to arrive at corrective diagnosis clinical examination, blood tests, x-ray p.n.s and rhinological examination, b-scan ultrasound, ct scan and mri are done. biopsy remains gold standard; ultrasonography is a good diagnostic tool especially in tumors of solid, cystic variety and thyroid orbitopathy2. primary orbital tumors if not treated on time and adequately cause morbidity and mortality by local extension and systemic metastasis. material and methods this is a retrospective study includes all cases confirmed by histology. we excluded cases of thyroid ophthalmopathy, congenital bony anomalies, orbital varicose veins, pseudo tumors who responded to o orbital tumors retrospective study of 24 years pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 34 retrobulbar and systemic steroids. the cases where histopathological slides showed multi cellular and anaplastic cell appearance and diagnosis was speculative were also excluded. we sought opinion of paediatrition, radiologist and clinical pathologist where necessary biopsy was done in all cases. blood tests, ct scan, mri were done in selected cases to assess site, size, spread to surrounding structures and plan surgical approach. ct scan and mri helped clinically and morphologically to differentiate orbital infections from benign and malignant tumor of epithelial and connective tissue origin. tumor within muscle cone or advanced tumors invading sinuses on anterior cranial fossa were referred to ent and neuro surgeon respectively. results age of study cases varied from 6 months to 80 years and gender wise male were 23 and female 19 (table 1). the most common tumors were lymphoma, squamous cell carcinoma and retinoblastoma comprising 6 of each (table 2). while other tumors included fibro sarcoma, lacrimal gland tumor, socket tumor, tuberculous granuloma, neurofibromatosis (3 each), optic nerve meningioma, dermoid cyst, lymphoid hyperplasia of lacrimal gland (2 each) and schwannoma, metastatic tumor, porocarcinoma (1 each) (table 2). in squamous cell carcinoma 04 cases were extension from limbus (fig. 6) and 2 cases were direct spread from lid (fig 7). regarding fibrosarcoma, first case of two year old female child had grown to larger dimensions just within three months time. it shows rapid and aggressive growth in children1. in a second case of 24 year old male, it had grown slowly and was well differentiated. in a third case 55 year old woman, it had grown slowly over a period of 5 years and was painless (fig 3). on attempted exentration, it was massive growth which bled profusely and had eroded bony walls of maxillary sinus, lateral wall of nose and roof of orbital fossa. patient died three weeks post-operatively due to concurrent infection. as regards lacrimal gland tumor adenoid cyst carcinoma occurred in a 40 year old female. this tumor had local infiltrative and metastatic potential. it responds to radio therapy but is not radio curable1. rest three tumors were one case epidermoid carcinoma of lacrimal gland origin and two cases of lymphoid hyperplasia. 23 19 0 5 10 15 20 25 males females table 1: the gender breakup of cases 14% 14% 14% 7%7% 7% 7% 7% 5% 5% 5%3% 3%2% lymphoma squamous cell ca retinoblastoma fibrosarcoma lacrimal gland tumor socket tumor tb granuloma neurofibromatosis optic nerve meningioma table 2: the percentage of different types of tumors fig. 1: fibrsarcoma faiz m. halepota, et al 35 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology fig. 2: lymphoma h.e staining fig. 3: schwannoma h.e staining fig. 4: meningioma optic nerve fig. 5: schawanoma fig. 6: squamous cell carcinoma fig. 7: squamous cell carcinoma lid. orbital tumors retrospective study of 24 years pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 36 two cases of optic nerve menigioma were recorded. in both patients enucleation was done: one 24 year old male had progressive proptosis, pain, lid oedema, chemosis (figure 4), for such growths similar description has been described with age less than 10 years in literature11. regarding nerve sheath tumors, one schwannoma (neurolimoma) and two neurofibroma were recorded. schwannoma has been reported in two studies5,8 but without mention of histological pattern and duration of onset. our case (fig 3) with 5 year duration is unique: bulky mass and easily enucleated out without blood loss contrary to our expectations. microscopically both antoni a-spuidle cells in cords and whorls plus antoni b-stellate cells with mucoid stroma, coexisted in some cross sectional view1. a nine year old boy presented with painless proptosis of right eye of recent onset. after clinical examination retrobulbar leukaemia deposits were suspected. peripheral blood film revealed blast cells. patient was referred to hematologist and was lost to follow up. in 50 year old man with proptosis of few years duration exentration was done. a diagnosis of poro carcinoma was made by histopathologist after examination of orbital contents. incidentally secondary tumors with extension from adjacent sinuses, nose brain were not encountered in our collection of 24 years duration. discussion incidence of lymphoma was higher as reported in recent studies3,4 followed by squamous cell carcinoma and retinoblastoma (table 2). the two latter tumors are listed equal to lymphoma but are not primary tumors of orbit. out of lymphomas, 04 cases were non hodgkin’s (two large and two small) and 02 were hodgkin’s type. our incidence was 13% but 7 – 20% has been reported in literature and same reported by jawaid in his study5. however in hodgkin’s type search for extra orbital involvement was not attempted. one case of orbital burkitt’s tumor (b-cell) arising from ethmoid sinus was reported in a 5 year old boy6. in another report7 primary non hodgkin’s lymphoma which involved left orbit and upper lid in a 4 year old girl. editorial by awan8 quoted 24 year study (1962 – 1986) about 750 orbital tumors although there was no mention of burkitt’s tumor. he further stated that in early nineties 200 – 300 cases were reported annually and that such tumors were not recognized or misrecognized by the pathologists. both hodgkin’s and non hodgkin’s lymphoma have been reported in immuno deficiency syndrome9,10. out of 228 ophthalmic lymphoma adenexal and ocular reported1 during 1980 – 2005 more than 50% were located in orbit with rapid rising incidence. complete remission or significant reduction of lymphoma lesions following antibiotic therapy for chlamydia psittaca infection – suggest its role in aetiology of lymphoma11. some authors also noted higher incidence of non hodgkin’s lymphoma in asians than europeans and blacks. relationship between lymphoma and chlamydia psittaci with regard to aetiology and response to antibodies was previously reported by ferri a et al in two separate papers with different team of coauthors12,13. galieni et al.14 reported fifteen patients with localized orbital lymphoma and low grade mucosa associated lymphoid tumor (malt) which were treated with chemotherapy, radiotherapy and surgical excision with local relapse in three but disease spread was never recorded. hodgkin’s and non hodgkin’s classification depends on variable histological cellular pattern and morphology picture13-15. non hodgkin’s lymphomas are classified into b and t cells, b cells are much more common and consist of large b cells, small cells and marginal cells. burkitt’s tumor is composed of large b cells. biopsy is sent to molecular diagnostic laboratory and following methods applied.  immuno histochemistry with surface cell markers for b and t cells15.  florometry genetic study (chromosomal dependant) for definitive diagnosis and subtyping of lymphoma16,17. in our opinion, modern diagnostic techniques mentioned were non existent/non-available to pathologists of late 20th century, could explain lack of proper histological diagnosis typing and subtyping. conclusion the study revealed rising incidence and prevalence of orbital lymphoma. its incidence was even higher than that of reported. lymphoma tumor is localized, stationary, and occasionally assuming large size. faiz m. halepota, et al 37 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology modern laboratory techniques have revealed higher incidence as reported in resent international study. rising incidence and occurrence of this tumor need to be confirmed by further studies in future. author’s affiliation prof. faiz m. halepota department of ophthalmology muhammad medical college, mirpurkhas, sindh – pakistan. prof. khalid iqbal talpur chairman, department of ophthalmology liaquat university eye hospital hyderabad, sindh – pakistan dr. mahesh kumar luhano clinical pathologist, department of ophthalmology liaquat university eye hospital hyderabad, sindh – pakistan late sher muhammad shaikh department of pathology chandka medical college, larkana sindh – pakistan dr. abdul rehman siyal department of pathology muhammad medical college, mirpurkhas sindh – pakistan. acknowledgements authors extend thanks to dr. aijaz ali khooharo, associate professor and incharge director, advanced studies, sindh agriculture university tandojam for his input in interpretation of results. references 1. greer ocular pathology. 4. blackwell science; 1989. 241-57. 2. khalil m. diagnostic role of ultrasonography in orbital disorders. ophthalmology update 2010; 8: 17-21. 3. moslehi r, devesa ss, schairer c, fraumeni jf jr. rapidly increasing incidence of ocular non-hodgkin lymphoma. j natl cancer inst. 2006; 98: 936-9. 4. sjo ld, ralfkiaer e, prause ju, et al. increase incidence of ophthalmic lymphoma in denmark from 1980 to 2005. invest ophthalmol vis sci. 2008; 49: 3283-8. 5. jawaid ma. management of orbital tumors. pak j ophthalmol. 2005; 21: 44-8. 6. muhammad z, khan d. orbital burkitt’s lymphoma, arising from ethnoid sinus. pak j ophthalmol. 1991; 17: 87-9. 7. talpur ki. orbital – blephro lymphoma. pak j ophthalmol. 2001; 17: 134-6. 8. awan k. (editorial), burkitt’s lymphoma in pakistan. pak j ophthalmol. 1991; 7: 85-90. 9. park kl, gonis km. hodgkin lymphoma of orbit associated with acquired immunodeficiency syndrome. am j ophthal. 1993; 116: 111-2. 10. antle cm, white va, horsman de, rootman j. large cell orbital lymphoma in patient with acquired immunodeficiency syndrome. ophthalmology. 1990; 97: 1494-8. 11. american academy of ophthalmology 2006. ophthalmic pathology; intraocular tumors section 4. aao, san francisco. 209-10. 12. ferreri aj, guidobomi m, ponzoni m de conciliis c, dell'oro s, fleischhauer k, caggiari l, lettini aa, dal cin e, ieri r, freschi m, villa e, boiocchi m, dolcetti r. evidence for association between chlamydia psittachi and ocular adenexal lymphomas. j natl cancer inst. 2004; 96: 586-94. 13. ferreri aj ponzoni m, guidoboni m, de conciliis c, resti ag, mazzi b, lettini aa, demeter j, dell'oro s, doglioni c, villa e, boiocchi m, dolcetti r. regression of ocular adenexal lymphoma after chlamydia psittica eradicating antibiotic therapy. j clin oncol. 2005, 23: 5067-73. 14. galieni p, polito e, leccisotti a, marotta g, lasi s, bigazzi c, bucalossi a, frezza g, lauria f. localized orbital lymphoma. haematologica. 1997; 82: 436-9. 15. freedman as, nadler lm. immunologic markers in nonhodgkin’s lymphoma. hematol oncol clin north am. 1991; 5: 871-89. 16. clack c glaser sl, dorfman rf, bracci pm, eberle e, holly ea. expert view of non hodgkin lymphomas in population based cancer registry reliability of diagnosis and subtype classifications cancer epidermoid. biomarkers prev. 2004; 13: 138-43. 17. harris, n. jaffe es, stein h, banks pm, chan jk, cleary ml, delsol g, de wolf-peeters c, falini b, gatter kc, et al. a revised euro-american classification of lymphoid neoplasms: a proposal from the international lymphoma study group. blood. 1994; 84: 1361-92. 126 pak j ophthalmol. 2021, vol. 37 (1): 126-128 brief communication centrality of hirschberg reflex in young emmetropic population of pakistan zeeshan kamil 1 , qirat qurban 2 , khalid mahmood 3 1-3 khalid eye clinic, nazimabad, karachi abstract purpose: to find out the centrality of hirschberg reflex in young emmetropic females and to correlate it with asthenopia. study design: cross-sectional study place and duration of study: outpatients department of khalid eye hospital, karachi, from january to december 2019. methods: six hundred young emmetropic females 10 to 25 years of age were included. we performed the hirschberg test and jackson cross cylinder to assess the astigmatism and observed near point of convergence to find out convergence insufficiency. results: out of 600 young emmetropic females only one hundred and ninety had a central hirschberg corneal reflex along with an astigmatism of 0.25 to 0.50 which was observed in one hundred and sixty five patients. one hundred and twenty five had a receded near point of convergence. conclusion: acentrality of hirschberg can be a cause of asthenopia among young emmetropic females. key words: asthenopia, astigmatism, emmetropia, hirschberg corneal reflex. how to cite this article: kamil z, qurban q, mahmood k, centrality of hirschberg reflex in young emmetropic population of pakistan. pak j ophthalmol. 2021, 37 (1): 126-128. doi: 10.36351/pjo.v37i1.1156 introduction there are a number of methods available for assessing the ocular alignment and can be grouped into four basic types; hirschberg test, cover tests, dissimilar image test, dissimilar target test. 1 the hirschberg light reflex method is based on the contention that 1 mm of deviation of the corneal light reflection corresponds to approximately 7°, or 15δ, of ocular deviation of the visual axis. therefore, a light reflex at the pupillary margin is about 2 mm from the correspondence: zeeshan kamil department of outpatients, khalid eye hospital, karachi dr.zeeshankamil@yahoo.com received: november 2, 2020 accepted: december 4, 2020 pupillary center (with a 4-mm pupil), which corresponds to 15°, or roughly 30δ, of deviation. a reflex at the mid-iris region is about 4 mm from the pupillary center, which is around 30°, or 60δ, of deviation; similarly, a reflex at the limbus is about 45°,or 90δ, of deviation. 2 the angle kappa, which is made by the visual axis and the anatomical pupillary axis of the eye, can have an effect on the corneal light reflex measurements. if the fovea is temporal to the pupillary axis, which is normally the case, the corneal light reflection will be slightly nasal to the center of the cornea. this is termed positive angle kappa and simulates exodeviation. if the fovea is nasal to the pupillary axis, the corneal light reflection will be slightly temporal to the center of the cornea. this is called negative angle kappa and simulates esodeviation. an angle kappa does not affect the cover tests. centrality of hirschberg reflex in young emmetropic population of pakistan pak j ophthalmol. 2021, vol. 37 (1): 126-128 127 convergence insufficiency incidence has no major change with growing age up to the age of sixty years but increases significantly thereafter. augmented visual stress of school work and prolonged periods of reading aggravate symptoms in older children. the most common presentation encountered by a clinician is that of a high school or college student who develops symptoms when unwarranted demands are placed on the visual system during long periods of studying. lack of sleep, illness, and anxiety are also known to exacerbate the problem. 3 rarely, any previous research was done to focus exclusively on emmetropic young female population. the purpose of this observational study was to check the hirschberg reflex in young emmetropic females and to shed light on the non-refractive causes of ocular discomfort. methods this observational study was conducted at khalid eye hospital, karachi, from january 2019 to december 2019. it included six hundred emmetropic females between the ages of 10 to 25 years having gross visual acuity of 6/6 on snellen chart. the main complaint in this study group were headache, blurring of vision and double vision while reading. patients having refractive error, previous history of spectacles, history of excessive screen usage more than five hours a day, late night sleep habits, gross media opacity, or history of glaucoma were excluded from the study. a questionnaire/proforma was designed to record demographics, reason of visit in hospital, hirschberg test finding, visual acuity, subjective refraction, jackson cross cylinder test, slit lamp ocular examination, extraocular movement along with near point of convergence and accommodation. main outcome measures were acentrality of hirschberg light reflex, hidden minor astigmatism and receding near point of convergence. all recruited patients were informed about the study and study approval was obtained by the ethical review committee. data was analyzed through spss version 20 and frequency for age, and variables were obtained. results this observational study showed that four hundred ten (68.3%) out of six hundred females had non-central corneal light reflex, where as one hundred and ninety (31.7%) had a central reflex (p value < 0.005). out of four hundred ten females having non central reflex three hundred fifty (85.3%) had corneal reflex on the nasal side of cornea, where as sixty (14.7%) females had corneal reflex in the temporal side of cornea (p value < 0.005). astigmatism of 0.25 to 0.50 was observed in one hundred and sixty five (27.5%) patients. near point of convergence was more than 20 mm in one hundred and twenty five (20.8%) patients. discussion young female patients usually complain of tiredness, headache and blurred vision in the absence of any significant refractive error. the hidden causes of these symptoms in this age group could be convergence insufficiency, forcibly compensated phorias, muscle weakness and minor astigmatism which could be responsible for ocular discomfort in emmetropic population. 4,5 the miscellany in the reported standards of the convergence insufficiency in literature may be due to disparity in target populations, age groups, and facilities for visual assessment, interpupillary distances and geographical factors affecting the results. scheiman and colleagues suggested that refractive errors are not the only reason for causing abnormal near point of convergence. there are many other causes like phoria, tropias, injuries, trauma and psychological implications. 6,7 in this study we observed 20.8% patients had remote near point of convergence more than 20 mm, which could also be the major contributor of symptoms of asthenopia in this considerably emmetropic study group. it is not improbable that anemia can be casually related to convergence insufficiency in view of the frequency of various degrees of hypochromic anaemia in women of this age group. in many cases the onset of symptoms was a sequel to a hemorrhage or menstrual pathology causing anaemia. these situations must provide additional cause for a latent muscular imbalance to become manifest or for insufficiency to appear where no imbalance previously existed. 8 jonejo et al reported central hirschberg reflex in 17% of patients and also they reported high prevalence of non central corneal reflex in females. 9 in our study, central hirschberg was seen in 31% of cases although this study included only female patients. hikmatullah reported high incidence of convergence insufficiency in young females. 10 sidra reported high frequency of exophoria in convergence insufficiency patients zeeshan kamil, et al 128 pak j ophthalmol. 2021, vol. 37 (1): 126-128 mostly in females. 11 another study showed that individuals of 18 to 31 years with visual status of 6/9 to 6/6 found asthenopia in emmetropes. 12 saba also reported a relationship between asthenopia and convergence insufficiency. 7 in latent strabismus especially in exophoria, usual symptoms are headache, aching eyes, intermittent blurring of prints while reading and occasional diplopia. 13 a study found astigmatism to be the most frequent cause of asthenopia. female patients were more prone than male patients to complain of asthenopia, at the same time high school students were more likely than primary school children to complain of asthenopia. 14 limitation of this study was that it was a small scale study and not a true reflection of the whole population. however, it has highlighted the various hidden causes of symptoms of asthenopia in young emmetropic females. conclusion majority (85%) of non-central corneal reflex population having corneal reflection on the nasal side of the cornea, which also could be the possible cause of difficulty in near work or symptoms of asthenopia. ethical approval the study was approved by the institutional review board/ ethical review board. (erl-01-20) conflict of interest authors declared no conflict of interest. references 1. helveston e, moodley a. how to check eye alignment and movement. community eye health, 2019; 32 (107): 55. 2. coi ry, kushner bj. the accuracy of experienced strabismologists using the hirschberg and krimsky tests. ophthalmology, 1998; 105 (7): 1301–1306. 3. matiullah, khan b, durrani j. associations of convergence insufficiency in patients with myopia of age group 15-25 years. ophthalmology update, 2018; 16 (1): 470-473. 4. wee sw, moon nj, lee wk, et al. ophthalmological factors influencing visual asthenopia as a result of viewing 3d displays. british journal of ophthalmology, 2012; 96: 1391-1394. 5. cohen y, segal o, barkana y, lederman r, zadok d, pras e et al. correlation between asthenopic symptoms and different measurements of convergence and reading comprehension and saccadic fixation eye movements. optometry – journal of the american optometric association, 2010; 81 (1): 28-34. 6. scheiman m, mitchell gl, cotter s, cooper j, kulp m, rouse m, et al. a randomized clinical trial of treatments for convergence insufficiency in children. arch ophthalmol. 2005; 123 (1): 14-24. 7. akram s, qasim sma, saleemullah, choudry a. comparison of convergence insufficiency between different refractive status of the eye. ophthalmology pakistan, 2018; 8 (3): 28-32. 8. manson n. anaemia as an aetiological factor in convergence insufficiency. brit j. ophthal. 1962; 46: 674. 9. jonejo ay, hassan mu. strabismus and its type in children of age 6 to 15 years presenting at a public sector hospital of karachi. journal of dow university of health sciences, 2019; 13 (1): 24-29. 10. hikmatullah. to assess the accommodative insufficiency in patients of convergence insufficiency in age group 5-25 years at hayatabad medical complex, peshawar. ophthalmology update, 2019; 17 (2): 60-64. 11. sidra s. frequency of exophoria among the convergence insufficiency patients. international journal of science: basic and applied research (ijsbar) 2017; vol. 36 (3): 65-74. 12. cross fr. asthenopia and ocular headache. bristol med chir j. 1893; 11 (40): 73-84. 13. shakeel k, akram s, ullah s, qasim msa, arshad a. association of asthenopia, pre-presbyopia and refractive errors in workers involved in hand crafting. pak j ophthalmol. 2018; 34 (3): 201-206. 14. wajuihian so. frequency of asthenopia and its association with refractive errors. afr vision eye health, 2015; 74 (1): 293. author’s designation and contribution zeeshan kamil; consultant ophthalmologist: examiner, manuscript writer. qirat qurban; consultant ophthalmologist: data collection, manuscript writer. khalid mahmood; consultant ophthalmologist: data collection. .…  …. https://journals.lww.com/co-ophthalmology/fulltext/2015/09000/involutional_entropion___risk_factors_and_surgical.16.aspx#r7-16 https://journals.lww.com/co-ophthalmology/fulltext/2015/09000/involutional_entropion___risk_factors_and_surgical.16.aspx#r7-16 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7041817/ https://www.sciencedirect.com/science/journal/15291839 https://www.sciencedirect.com/science/journal/15291839 16 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology original article a long term follow up after limbal conjuctival autograft for recurrent pterygium jamshed ahmed, shehla dareshani pak j ophthalmol 2016, vol. 32 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: jamshed ahmed assistant professor ophthalmology department unit-2 dow university of health sciences karachi. email: jamshi62@yahoo.com received: november 04, 2015. accepted: march 15, 2016. …..……………………….. purpose: to find out the success rate at three year post surgery of limbal conjunctival auto-grafting after pterygium excision in patients with recurrent pterygium. study design: a prospective case study. place and duration of study: dow university of health sciences from june 2008 to may 2014. material and methods: we conducted this study at the department of ophthalmology, dow university of health sciences karachi from june 2008 to may 2014. the patients were selected from the outpatient department of civil hospital karachi and sindh govt. lyari general hospital karachi. thirty six patients were treated with pterygium excision and limbal conjunctival autograft with a history of previously failed pterygium surgery due to recurrence. patients were followed postoperatively at regular intervals for a period of at least three years to find recurrence of pterygium and complications. results: out of thirty six eyes, recurrence was observed in 05 (13.8%) patients over a period of three years of follow-up. intra-operative complications included button holing in 02 (5.5%) case that was sutured in the same setting. postoperative complications included. persistent graft edema over two weeks in 06 (16.5%) case, partial graft retraction in 04 (11.1%) cases, graft retraction in 2 (5.5%) cases, dellens in 5 (138%) and giant papillary conjunctivitis due to sutures 3 (8.3%) cases. conclusion: pterygium excision with limbal conjunctival auto grafting is a superior technique and results in lower recurrence rates. key words: pterygium, recurrence, limbal conjunctival grafting, autograft. terygium is a common condition resulting from defective limbal stem cell function usually at the medial aspect of limbal area.1 these defective limbal stem cell allow the formation of a triangular fibro-vascular wing shaped tissue that develops from the conjunctiva and encroaches on to the cornea.2 exposure to ultraviolet radiation is strongly associated with the pathogenesis of pterygium.3 global prevalence of pterygium has been reported from 1 to 25 percent. pterygium occurs more commonly in tropical regions in population with chronic sun exposure4. surgical removal of pterygium is indicated usually when visual axis is at risk, induced astigmatism, diplopia, cosmetic rehabilitation, periodic inflammation and evidence of cystic or malignant change.5 pterygium is managed conservatively because of high rates of recurrences after simple excision. the recurrence rates after bare sclera resection range from 24% to 89% and zero to 38% following bare sclera resection with mitomycin-c p a long term follow up after limbal conjuctival autograft for recurrent pterygium pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 17 application. these recurrences are 3 – 38% following pterygium resection with conjunctival graft placement.6 an advanced insight into the pathogenesis of pterygium led kenyon et al to create a barrier of limbal stem cell at the site of defective stem cell by implanting a limbal autograft.7 limbal conjunctival auto-grafting has promising results with no recurrence to as high as 15%. long surgical time warrant this technique to be adopted only for recurrent pterygia. in all these studies follow up was very short. in this study we documented the outcome after three years of follow up in all these cases. material and methods this prospective study was conducted at the departments of ophthalmology dow university of health sciences from june 2008 to may 2014. thirty six eyes of thirty four patients with a history of recurrence were included in this study. an informed consent was taken from the patient preoperatively. patients were operated on microscope under complete sterilization and aseptic measures. day care surgical procedure under topical and sub conjunctival infiltration anesthesia was used. local anesthesia with 2% lidocaine and 0.5% bupivacaine was injected beneath the pterygium. castroviejo eyelid speculum was used to ensure wide opening. a 6.0 vicryl suture at the lateral limbus was used to abduct the eye. conjunctiva was dissected from the body of the pterygium medially with a westcott scissors after making a vertical incision medial to its head. the head of the pterygium was dissected carefully to avoid corneal perforation. the abnormal fibro-vascular tissue beneath the conjunctiva was aggressively resected. the size of the conjunctival graft was measured by using castroviejo calipers. the supero-temporal conjunctiva was selected to obtain the limbal graft. once the limbus was reached the limbal area was carefully dissected 0.5 mm beyond the limbus to ensure stem cells inclusion. the conjunctival-limbal graft was slid onto the cornea by using a fine non toothed forceps and the graft was secured using interrupted 10 – 0 nylon sutures. the eye was patched firmly after instilling antibiotic eye ointment. topical antibiotic and steroid drops were used postoperatively every 2 hours for two weeks and then four times a day for four weeks along with antibiotic ointment at bed time for four weeks. sutures were removed after four weeks. follow up was instituted at monthly intervals for six months and after that after every six months. results age of the patients ranged from 25 to 64 with a mean of 42.08 years. most of the patients were in our study were between 25 and 45 years (66.7%). males 24 (66.7%) predominated over females 12 (33.3%). outdoor workers (34 eyes 94.4%) were seen to be greatly affected by pterygium. indication of surgery in our study included threatening of visual axes in 09 (25%) cases, recurrent inflammation in 07 (19.4%) cases, diplopia in 4 (11.1%) cases, cosmetic concern in 06 (16.7%) cases, astigmatism greater than 1.00 diopter in 9 (25%) cases and cystic changes in one (2.8%) case. most of the pterygia were progressive in nature. in a large number of cases, 29 (80.5%), have pterygia between limbus and undilated pupillary margins while in 07 (19.5%) cases pterygia were reaching or crossing the pupil. astigmatism with the rule greater than 1.0 diopter was present in 09 (25% cases. intraoperative complications included button holing in 02 (5.5%) case that was sutured in the same setting. postoperative complications included. persistent graft edema over two weeks in 06 (16.5%) case, partial graft retraction in 04 (11.1%) cases, graft retraction in 2 (5.5%) cases, dellens in 5 (138%) and giant papillary conjunctivitis due to sutures 3 (8.3%) cases. we followed all these cases for at least a period of 36 months (range 36 – 52 months) with a mean of 42.94 months. discussion pterygium excision with bare sclera technique has a high recurrence rate ranging from 30 to 70%9. different modalities like beta irradiation, mitomycin c and amniotic membrane graft have been used to decrease this high recurrence10. kenyon et al. in their study on conjunctival autograft on advanced and recurrent pterygium gave a recurrence rate of 5.3%7. high recurrence rates have been reported by other authors after the initial study. wahid in his study relates this to the accuracy with which the limbal area is included in the autograft11. low recurrences rates have been demonstrated by various others authors who have specifically described the inclusions of limbal tissue in the graft.7,12,13 anothers study by al. fayez also concludes that limbal transplantation appeared more effective than free conjunctional transplantation for treatment of recurrent pterygium14. in one study we found a male preponderance of (66.7%) males over females (33.3%). similar preponderance has also been reported by srinivas k. rao of 74.5% males over 25.4% females15. most of our jamshed ahmed, et al 18 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology patients were less than 40 years of age (66.7%). similarly srinivas has reported an age group of < 40 year in (59.6%) of his patients15. high incidence of pterygium is seen in outdoor patients 80%. most common post op complication encountered in our study was persistent graft edema in 6 (15.6%) cases over 2 weeks, edema resolved on medical treatment similar observation has been stated by kawana.16 significant improvement in astigmatism after surgery has been reported by some authors.8 similar improvement was seen in our 9 (25%) cases of astigmatism. conclusion limbal conjunctional autograft with inclusion of limbal cells although time consuming and tedious procedure, is a safe and effective adjuvant in preventing recurrence of pterygium and postoperative improvement in astigmatism. due to long surgical time this technique has to be reserved for recurrent pterygia. author’s affiliation dr. jamshed ahmed assistant professor ophthalmology department unit-2 dow university of health sciences karachi dr. shehla dareshani assistant professor department of ophthalmology unit-2 dow university of health sciences karachi role of authors dr. jamshed ahmed study design, manuscript writing dr. shehla dareshani data interpretation, manuscript review references 1. sandra s, zeljka j, zeljka v a, kristian s, ivana a. the influence of pterygium morphology on fibrin glue conjunctival autografting pterygium surgery. international ophthalmology, 2014; 34: 75-9. 2. chui j, coroneo mt, tat lt, crouch r, wakefield d, di girolamo n. ophthalmic pterygium: a stem cell disorder with premalignant features. the american journal of pathology 2011; 178: 817-27. 3. yam jc, kwok ak. ultraviolet light and ocular diseases. international ophthalmology. 2014; 34: 383400. 4. jacobs ds. uptodate. [homepage on the internet]. 2014 [cited 2015 feb 21]. available from: http://http:// www. uptodate. com /contents/pterygium. 5. twelker dl, baily il. clinical evaluation of pterygium. in hr taylor editor. pterygium. hague, netherland: kugkar publication, 2000: pp. 71-82. 6. sánchez-thorin j c, rocha g, yelin jb. meta-analysis on the recurrence rates after bare sclera resection with and without mitomycin c use and conjunctival autograft placement in surgery for primary pterygium. br j of ophthalmology, 1998; 82: 661-5. 7. kenyon kr, wagoner md, hettinger me. conjunctival autograft transplantation for advanced and recurrent pterygium. ophthalmology, 1985; 92: 1461-70. 8. patel d, vala r, shah h, brahmbhatt j, kothari r, rawal sv. efficacy of limbal conjunctival autograft surgery with stem cells in primary and recurrent pterygium. ijhsr, 2014; 4: 86-90. 9. sigh g, wilson mr, foster cs. long term follow up study of mitomycin as eye drops as adjunctive treatment for pterygia and it comparison with conjunctival autograft: cornea, 1990; 9: 331-4. 10. oguz h, kilitcioglu a, yasar m. limbal conjunctival autografting fro preventing recurrence after pterygium surgery. euro j ophthalmol. 2006; 16: 209-13. 11. abdulla wm. efficacy of limbal conjunctival autograft surgery with stem cells in pterygium treatment: middle east afr j. ophthalmol. 2009; 16: 260-2. 12. koch jm, mellin jb, wauble tn. the pterygium – autologous conjunctiva limbal transplantation as treatment-opthalmology, 1992; 89: 1436. 13. figueiredo rs, cohen ej, gomes jap, rapuano cj. laibson conjunctival autograft for pterygium surgery: how well does it prevent recurrences. ophthalmic surg lasers, 1997; 28: 99-104. 14. al fayez mf. limbal versus conjunctival autograft transplantation for advanced and recurrent pterygium: ophthalmology, 2002; 109: 1752-5. 15. srinivsa k rao, lekha t, mukesh bn, sitalakshmi g, padmanabhan p: conjunctival – limbal autograft for primary and recurrent pterygia: technique and results: indian j ophthalmol. 1998; 46: 203-9. 16. kawano h, kawano k, sakamoto t. separate limbal – conjunctival autograft transplantation on using inferior conjunctiva for primary pterygium. oman j ophthalmol. 2011; 4: 120-4. http://http:/%20www.%20uptodate.%20com%20/contents/pterygium http://http:/%20www.%20uptodate.%20com%20/contents/pterygium http://http:/%20www.%20uptodate.%20com%20/contents/pterygium http://www.ncbi.nlm.nih.gov/pubmed/?term=lekha%20t%5bauthor%5d&cauthor=true&cauthor_uid=10218302 http://www.ncbi.nlm.nih.gov/pubmed/?term=mukesh%20bn%5bauthor%5d&cauthor=true&cauthor_uid=10218302 http://www.ncbi.nlm.nih.gov/pubmed/?term=sitalakshmi%20g%5bauthor%5d&cauthor=true&cauthor_uid=10218302 http://www.ncbi.nlm.nih.gov/pubmed/?term=padmanabhan%20p%5bauthor%5d&cauthor=true&cauthor_uid=10218302 245 pak j ophthalmol. 2021, vol. 37 (3): 245-248 original article aesthetic appearance of external dacryocystorhinostomy scar: a comparison between w and c shaped incision zeeshan kamil 1 , qirat qurban 2 , khalid mahmood 3 1-3 khalid eye clinic, nazimabad, karachi – pakistan abstract purpose: to compare the post-operative appearance of external dacryocystorhinostomy scar resulting from w and c shaped incisions. study design: interventional case series. place and duration of study: khalid eye clinic, karachi, from july 2018 to june 2019. methods: we recruited ninety-six patients of nasolacrimal duct obstruction by convenience sampling technique. age ranged from 20 to 50 years and both genders were included. two groups were made. group a comprised of patients who underwent external dacryocystorhinostomy (ex-dcr) surgery through w shaped incision and group b patients underwent ex-dcr with curvilinear c shaped incision. main outcome measure was to observe minimal to no visible scarring at wound site after six months of follow up. all patients were explained about the difference in incision technique and consent was obtained from each patient. results: mean age was 34.3 ± 6.897 years. there were thirty-six (37.5%) males and sixty (62.5%) females. right side was affected in forty-six (47.9%) cases whereas left side was involved in fifty (52.1%) cases. in group a, 20 (41.6%) out of 48 patients, whereas in group b, 38 (79.2%) out of 48 patients had no visible scar at all and it was statistically significant with a p-value of < 0.05. suture abscess developed in four (8.3%) patients in group a, no other serious complications were observed in either group. conclusion: curvilinear c shaped incision in ex-dcr has better cosmetic outcome. key words: external dacryocystorhinostomy, c shaped incision, w shaped incision. how to cite this article: kamil z, qurban q, mahmood k. aesthetic appearance of external dacryocystorhinostomy scar: a comparison between w and c shaped incision. pak j ophthalmol. 2021, 37 (3): 245-248. doi: 10.36351/pjo.v37i3.1088 introduction external dacryocystorhinostomy (ex-dcr) was first performed in 1904 as an exterior approach to the sac via a skin incision in the medial canthus by toti. 1 it has since then been done as a cost effective, customary procedure in patients with nasolacrimal duct correspondence: zeeshan kamil khalid eye clinic, nazimabad, karachi – pakistan email: de.zeeshankamil@yahoo.com received: june 28, 2020 accepted: august 19, 2020 impediment with > 90% accomplishment rate depending upon the surgeon’s experience. 2 the chief downside of ex-dcr is the presence of a cosmetically unappealing blemish which may occur in up to 9 to 33% of the cases and is difficult to predict. 3 it is of great apprehension for both the surgeon and the patients and all efforts are made in order to curtail the appearance of an unsightly scar. factors that can influence the configuration of a scar include the site and shape of incision, careful surgical technique and blood free surgical field. 4 not many studies have been done to evaluate the visibility of ex-dcr surgical scars. a study done by devoto, showed that 9% of the patients who went through ex-dcr quantified the open access aesthetic appearance of external dacryocystorhinostomy scar between w and c shaped incision pak j ophthalmol. 2021, vol. 37 (3): 245-248 246 surgical scar as very perceptible and 26% graded it as moderately noticeable. 5 alternative procedures such as endonasal dcr have yet to progress to achieve equivalent success rates as ex-dcr, therefore it is desirable that a skin approach to dcr is planned that can productively conceal the visibility of the surgical scars. 6 the rationale of this study is to assess the consequence of incision shape along the skin tension lines, in effectively reducing the visibility of the scar tissue by using w and c shaped incisions in patients undergoing ex-dcr for nasolacrimal duct obstruction. methods this prospective interventional case series was carried out at khalid eye clinic, karachi, during the period of july 2018 to june 2019. it included ninety-six patients with nasolacrimal duct obstruction between the ages of 20 to 50 years. both genders were included in the study. patients were informed about the study dynamics and consent was taken from every patient. the purpose, method and basis of the study were conveyed to all the patients. the institutional ethical review committee approved the study. the exclusion criteria was presence of any concomitant pathology of intranasal cavity, obstruction of the canaliculi, trauma, dacryocystitis along with fistula, dermal disorder that might influence the course of wound remedial. the entire surgery of each patient was done under the influence of regional anesthesia along with sedation by a single oculoplastic surgeon. all patients were divided into two groups with forty eight patients each. diagnosis of nasolacrimal duct obstruction was established by lacrimal probing and syringing. group a included individuals who underwent ex-dcr through w shaped incision and group b patients underwent curvilinear c shaped incision (figure 1) ex-dcr. the exterior incisions were analyzed by the individuals themselves and two co-authors, six months after each procedure. main outcome measure was to observe minimal to no visible scarring after six months of follow up. data was analyzed via spss version 25.0 for statistical analysis. a p-value of < 0.01 was accepted statistically significant. all patients underwent ex dcr under local anesthesia. in the patients of group a, a w-shaped incision was fashioned by forming three uninterrupted triangles of 4 mm in length with two tips and one base adjacent to the medial canthus and was 12 mm in length. in patients of group b, a c shaped incision of 10mm x 8mm was constructed medial to the medial canthus. the surgical technique was otherwise same in all the patients. at the end of the surgery, the subcutaneous tissues and the dermal incisions were approximated with 6-0 vicryl. the w shaped incision was closed with interrupted sutures placed at the tips and gaps that had been formed by the incision whereas the c shaped incision was closed using interrupted sutures. there were no per-operative problems in any case, such as angular vessel damage leading to excessive bleeding or postoperative complications in either group. postoperatively, all patients received topical antibiotic drops and ointment for a period of 2 weeks and vasoconstrictor nasal spray. patients were followed-up on day 1 after surgery, then after 10 days, and later on at 1, 3 and 6 months. sutures were removed after 2 weeks of surgery. the scar analysis was performed under same light conditions and distance at each visit. co-authors and patients were asked to grade the scar visibility. if unable to see the scar, it was graded as 1. minimally perceptible scar was labeled as grade 2, reasonably visible scar was graded as 3, and easily noticeable scar was grade 4. results this one year interventional study was conducted on ninety six patients between the ages of 20 to 50 years. mean age was 34.3 ± 6.897 years. there were thirty six (37.5%) males and sixty (62.5%) females. right side was affected in forty six (47.9%) cases whereas left side was involved in fifty (52.1%) cases. in group a, 20 (41.6%) out of 48 patients, whereas in group b, 38 (79.2%) out of 48 patients had no visible scar at all (table 1). cross – tabulation for group outcomes was statistically significant with a p-value of < 0.01 (pearson chi-squared test). suture abscess developed in four (8.3%) patients in group a, no other serious fig. 1: w and c shaped incision markings before surgery. zeeshan kamil, et al 247 pak j ophthalmol. 2021, vol. 37 (3): 245-248 complications were observed in either group. mean follow up period was 188.2 ± 12.42 days. table 1: comparison between the two groups according to scar grading. scar grade group a group b total 1 20 38 58 2 3 5 8 3 10 3 13 4 15 2 17 48 48 96 discussion ex-dcr is a consistent but an intricate surgical technique requiring substantial surgical experience. the formation of scar at the surgical site is a chief disadvantage and a cosmetic blemish for patients undergoing ex dcr. many types of surgical incisions like curvilinear tear trough, sub-ciliary lower eyelid, w-shaped nasal, and trans-conjunctival subcarancular have been tried in different studies to reduce the visibility of scar. 6,7,8 we fashioned the incision contour in such a way that it takes into account the standard dermal tension lines, which effectively reduce the formation of a scar. a study done by langer highlighted the standard tensile dermal strength lines and stated that the incision line course was one of the most important factors in determination of the final scar configuration. 9 another study reported the significance of making an incision corresponding to the dermal tensile strength lines. 10 another study evaluated the significance of the ex dcr linear surgical scar as assessed by the patients. a total of 20.6% scars were felt to be visible (grade 4) by the patients, 10.5% were labeled as grade 1 and 4% were rated as grade 2. 11 in our study, 31.3% in group a (w shaped incision) and 4.2% in group b (c shaped incision) reported an easily visible scar tissue (grade 4). the aesthetic outcome of ex-dcr in another study following conventional ex dcr was 30% with no visibility of a scar. 12 similarly, another study reported that 40% of their patients did not see a visible scar at the end of the 6 months follow up period. 11 this study reported an improved aesthetic outcome of 41.6% in group a with w shaped incision and a very good cosmetic result of 79.2% in group b with c shaped incision with no visibility of a surgical scar. the mean age in our study was 34.3 ± 6.897 years which was lower than the study done by ekinci et al 7 (40.8 ± 14.3 years) and much lower than the studies done by devoto et al 5 (61 years), sharma et al 3 (67y) and kashkouli et al 13 (52.9y). studies have suggested that more prominent scarring in younger age group is due to the presence of smoother, less flawed skin, making the scar more conspicuous. 14,15 davis 4 concluded that scarring after c shaped incision during ex dcr is modestly noticeable to the surgeons and nearly indistinguishable to patients but the study did not have a comparison. the final follow up of the aforementioned study was 90 days, whereas in this study it was six months. the lower chance of scarring is based on a number of factors such as the use of anesthesia, surgical site and shape, incision direction, proper closure of wound and dermal flap approach. 16,17,18,19 in this study no significant alteration in scarring was noticed to occur between 3rd and 6th month of follow up, though both differed from the 1st month, concluding that the greatest scar development was achieved in the initial three months. it was also found that ex dcr with c shaped incision was cosmetically superior to w shaped incision (p < 0.05). the time required to carry out ex dcr with c shaped incision was also lesser than w shaped incision. the postsurgical scarring improved at the end of follow up period of six months. the percentage of patients having a visible scar mark was significantly lower in group b as compared to group a. dirim et al compared c and w shaped incisions and found no noteworthy disparity between the presence of scarring among both groups (40% in c shaped vs. 50% in w shaped). 20 scarring differs among different races and therefore our results are not universal. the limitation of this study is the simple grading system, which did not take into account the other characteristics of a scar such as width, height, pigmentation and colour of the suture marks. conclusion external dacryocystorhinostomy remains the successful gold standard surgery for the management of nasolacrimal duct obstruction and this study found that curvilinear c shaped incision in ex dcr is aesthetically more appealing and has a better cosmetic outcome as compared to a w shaped incision. aesthetic appearance of external dacryocystorhinostomy scar between w and c shaped incision pak j ophthalmol. 2021, vol. 37 (3): 245-248 248 ethical approval the study was approved by the institutional review board/ ethical review board. (erc-14-20) conflict of interest authors declared no conflict of interest. references 1. toti a. nuovometodoconservatore di curaradicaledellesuporazionichronichedel saccolacrimale. clin mod firenze 1904; 10: 385-389. 2. sobel rk, aakalu vk, wladis ej, bilyk jr, yen mt, mawn la. a comparison of endonasal dacryocystorhinostomy and external dacryocystorhinostomy: a report by the american academy of ophthalmology. ophthalmology, 2019; 126 (11): 1580-1585. doi: 10.1016/j.ophtha.2019.06.009. 3. sharma v, martin pa, benger r, danks jj, deckel y, hall g. evaluation of the cosmetic significance of external dacryocystorhinostomy scars. am j ophthalmol. 2005; 140: 359–362. 4. davies bw, mccracken ms, hawes mj, hink em, durairaj vd, pelton rw. tear trough incision for external dacryocystorhinostomy. ophthal plast reconstr surg. 2015; 31: 278–281. 5. devoto mh, zaffaroni mc, bernardini fp, de conciliis c. postoperative evaluation of skin incision in external dacryocystorhinostomy. ophthal plast reconstr surg. 2004; 20: 358–361. 6. qidwai n, dawood a, hussain m, inam m, jafri as, soomro f. results of external dacryocystorhinostomy with the subciliary incision. pak j ophthalmol. 2020, 36 (2): 141-145. doi: 10.36351/pjo.v36i2.973 7. ekinci m, caǧ atay hh, gokce g, ceylan e, keleş s, çakici o, et al. comparison of the effect of w shaped and linear skin incisions on scar visibility in bilateral external dacryocystorhinostomy. clin ophthalmol. 2014; 8: 415–419. 8. kaynak p, ozturker c, karabulut g, çelik b, yilmaz of, demirok a. transconjunctival dacryocystorhinostomy: long term results. saudi j ophthalmol. 2014; 28: 61–65. 9. langer k. on the anatomy and physiology of the skin. the cleavability of the cutis. br j plast surg. 1978; 31 (1): 3-8. 10. paul sp. biodynamic excisional skin tension lines for excisional surgery of the lower limb and the technique of using parallel relaxing incisions to further reduce wound tension. plast reconstruct surg. global open. 2017; 5 (12): e1614. doi: 10.1097/gox.0000000000001614 11. ekinci m, cag_atay hh, oba me. the long-term follow-up results of external dacryocystorhinostomy skin incision scar with ‘‘w incision’’. orbit. 2013; 32: 349–355. 12. mahfouz s, amin a, elessawy k, mahmoud m. aesthetic external dacryocystorhinostomy. egypt j hosp med. 2019; 76 (3): 3779-3790. 13. kashkouli mb, jamshidian-tehrani m. minimum incision no skin suture external dacryocystorhinostomy. ophthal plast reconstr surg. 2014; 30 (5): 405-409. 14. kearney cr, holme sa, burden ad, mchenry p. long term patient satisfaction with cosmetic outcome of minor cutaneous surgery. australas j dermatol. 2001; 42 (2): 102-105. 15. caesar rh, fernando g, scott k, mcnab aa. scarring in external dacryocystorhinostomy: fact or fiction. orbit. 2005; 24 (2): 83-86. 16. akaishi pm, mano jb, pereira ic. functional and cosmetic results of a lower eyelid crease approach for external dacryocystorhinostomy. arquivosbrasileiros de oftalmologia 2011; 74: 283–285. 17. kim jh, woo ki, chang hr. eyelid incision for dacryocystorhinostomy in asians. korean j ophthalmol. 2005; 19 (4): 243-246. 18. waly ma, shalaby oe, elbakary ma, hashish aa. the cosmetic outcome of external dacryocystorhinostomy scar and factors affecting it. indian j ophthalmol. 2016; 64: 261. 19. ganguly a, ramarao k, mohapatra s, rath s. transconjunctival dacryocystorhinostomy: an aesthetic approach. indian j ophthalmol. 2016; 64: 893. 20. dirim b, sendul sy, demir m, ergen e, acar z, olgun a, et al. comparison of modifications in flap anastomosis patterns and skin incision types for external dacryocystorhinostomy: anterior-only flap anastomosis with w skin incision versus anterior and posterior flap anastomosis with linear skin incision. sci world j 2015; 2015. https://doi.org/10.1155/2015/ 170841. authors’ designation and contribution zeeshan kamil; consultant ophthalmologist: concepts, design, literature research, data analysis, statistical analysis, manuscript preparation, manuscript editing. qirat qurban; consultant ophthalmologist: concepts, design, literature research, data analysis, statistical analysis, manuscript preparation, manuscript review. khalid mahmood; consultant ophthalmologist: data acquisition, manuscript review. https://pubmed.ncbi.nlm.nih.gov/?term=danks+jj&cauthor_id=16083840 https://pubmed.ncbi.nlm.nih.gov/?term=deckel+y&cauthor_id=16083840 https://pubmed.ncbi.nlm.nih.gov/?term=hall+g&cauthor_id=16083840 https://www.ncbi.nlm.nih.gov/pubmed/?term=ceylan%20e%5bauthor%5d&cauthor=true&cauthor_uid=24591810 https://www.ncbi.nlm.nih.gov/pubmed/?term=kele%26%23x0015f%3b%20s%5bauthor%5d&cauthor=true&cauthor_uid=24591810 https://www.ncbi.nlm.nih.gov/pubmed/?term=%26%23x000c7%3bakici%20%26%23x000d6%3b%5bauthor%5d&cauthor=true&cauthor_uid=24591810 pak j ophthalmol. 2022, vol. 38 (3): 199-204 199 original article correlation and comparison of anterior and posterior corneal surface parameters in healthy eyes muhammad suhail sarwar 1 , muhammad arslan ashraf 2 , faisal mehmood 3 , muhammad arbab azeem 4 , sobia yousaf 5 department of ophthalmology, 1,2,4,5 mayo hospital, lahore, 3 rashid latif medical college, lahore abstract purpose: to correlate and compare anterior and posterior corneal surface parameters like kflat, ksteep, kavg, r1, r2, ravg and astigmatism in healthy eyes. study design: descriptive correlational study. place and duration of study: this study was conducted at mayo hospital, lahore from june 2020 to dec. 2020. methods: this study included 176 subjects (86 males and 90 females) with mean age of 28.06 ± 9.68 and 28.13 ± 8.24 respectively. the data was collected through non-random convenient sampling technique by self-made proforma after taking patients’ consent. anterior and posterior corneal parameters (kflat, ksteep, kavg, r1, r2, ravg and astigmatism) were measured with galilei g4. pearson correlation test was used for correlation and independent sample t-test/mann-whitney u test was used for comparing means of anterior and posterior corneal parameters. data was entered and analyzed in spss-21. results: mean of anterior and posterior corneal curvatures was 44.21 ± 1.01 d and -6.22 ± 0.19 d [p < 0.001], kflat was 43.76 ± 0.99 d and -6.08 ± 0.19 d [p < 0.001] and ksteep was 44.66 ± 1.08 d, -6.34 ± 0.21 d, respectively [p < 0.001]. the anterior and posterior corneal curvature ravg was 7.63 ± 0.17 mm, 6.44 ± 0.200 mm [p < 0.001], mean r1 was 7.71 ± 0.17 mm, 6.58 ± 0.21 mm, [p < 0.001] and mean r2 was 7.56 ± 0.18 mm, 6.31 ± 0.21 mm, respectively [p < 0.001]. anterior posterior corneal astigmatism was 0.90 ± 0.55 d and -0.25 ± 0.11 d, respectively [p < 0.001]. anterior corneal parameters also show strong correlation with posterior corneal parameters. conclusion: there is significant difference between corneal parameters of anterior and posterior surface. strong correlation was also found in anterior and posterior corneal parameters except corneal astigmatism. key words: cornea, corneal curvature, corneal astigmatism, corneal topography. how to cite this article: sarwar ms, ashraf ma, mehmood f, azeem ma, yousaf s. correlation and comparison of anterior and posterior corneal surface parameters in healthy eyes. pak j ophthalmol. 2022, 38 (3): 199-204. doi: 10.36351/pjo.v38i3.1380 correspondence: muhammad arslan ashraf department of ophthalmology, mayo hospital, lahore email: rajkumararslan@yahoo.com received: march 10, 2022 accepted: june 9, 2022 introduction cornea which is an avascular tissue acts as a structural barrier and protects the eye from outer insults. 1 anterior refractive surface of the eye is also provided by pre-corneal tear film. the contribution of cornea in refractive power is about two third. 2 it is the most sensitive and highly innervated tissue in the body. 3,4 it measures 9 to 11 mm vertically and 11 to 12 mm horizontally. in males and females, the corneal average muhammad arslan ashraf, et al 200 pak j ophthalmol. 2022, vol. 38 (3): 199-204 diameter is 11.77 ± 0.37mm and 11.64 ± 0.47mm, respectively. 5,6 cornea has different power in various meridians which results in astigmatism. importance of corneal refractive power is that it is used in calculation of power of intraocular lens and in refractive surgeries. 7 non-contact devices like pentacam and galilei g4 make three dimension images of corneal anterior section, mark corneal topography and pachymetry. pentacam utilizes a rotating scheimpflug camera to make topographical images of anterior segment, a twofold scheimpflug camera and a placido topographical framework. likewise, there are different instruments used for corneal curvature measurements; orbscan, javal-schiotz keratometer, verion optical imaging system etc. 8-10 these parameters and their correlation are important in accurate measurement of different intraocular lens implants. 11,12 finding out concordance among different topographic and tomographic instruments is important in clinical practice. 13,14 current study deals with measuring corneal parameters of both anterior and posterior corneal surface. this study finds the correlation and comparison of corneal parameters of both sides of cornea, which will be helpful in understanding the effect of change of anterior or posterior corneal parameters on each other. methods this cross-sectional study was conducted at outdoor of eye department of mayo hospital and college of ophthalmology and allied vision sciences. non probability convenient sampling method was used. the study period was from june 2020 to december 2020 during which 176 eyes of 88 normal individuals were studied. there were 44 males and 44 females. data was collected through self-made proforma after taking patients’ consent. following parameters were studied; kflat, ksteep, kavg, r1, r2, ravg and astigmatism. galilei g4 was used for all these readings. healthy individuals between 11 to 60 years of age, myopic, hyperopic or emmetrope males and females were recruited for study. for coorelation between anterior and posterior corneal parameters pearson’s correlation test was applied. pearson value greater than 0.7 was considered as excellent correlation. quantitative variables like age, kflat, ksteep, kavg, r1, r2, ravg and astigmatism were presented with mean and standard deviation. independent sample t-test / mann-whitney u test were applied for comparing means of corneal parameters. pvalue less than 0.05 was considered significant. data was entered and analyzed by using spss-21. graphs were also made by using spss-21 software. for tabulation, microsoft excel-16 was used. the research protocol was approved by the ethical review board of college of ophthalmology and allied vision sciences. results anterior mean k showed strong negative correlation with posterior mean k and posterior mean r (-0.78). anterior flat k showed strong negative correlation with posterior flat k (-0.75). anterior steep k showed strong negative correlation with posterior steep k (-0.75). anterior mean r showed strong positive correlation with posterior mean r (0.78). anterior r1 showed strong positive correlation with posterior r1 (0.76). anterior r2 showed strong and positive correlation with posterior r2 (0.76). anterior astigmatism showed poor but negative correlation with posterior astigmatism (-0.33) (table 2). anterior and posterior corneal curvature mean k was 44.21 ± 1.01 d and -6.22 ± 0.19 d, respectively with p < 0.001. anterior and posterior corneal curvature kflat was 43.76 ± 0.99 d and -6.08±0.18 d, respectively with a difference of 49.84 d was noted (p < 0.001). anterior and posterior corneal curvature mean ravg was 7.64 ± 0.17 mm and 6.44 ± 0.200 mm, respectively with a difference of 1.19 mm was noted (p < 0.001). the mean r1 of anterior and posterior corneal curvature was 7.72 ± 0.17 mm and 6.58 ± 0.202 mm, respectively with a difference of 1.13 mm was noted (p < 0.001). likewise, anterior and posterior corneal curvature mean r2 was 7.56 ± 0.18 mm and 6.31 ± 0.211 mm, respectively. the difference of 1.24 mm was noted (p < 0.001). the steep k of anterior and posterior corneal curvature was 44.67 ± 1.09 d and -6.34 ± 0.21 d, respectively and a difference of 51.01 d was noted (p < 0.001). the astigmatism of anterior and posterior corneal curvature was 0.91 ± 0.55 d and -0.26 ± 0.11 d, respectively and a difference of 1.17 d was noted (p < 0.001) (table 3). correlation and comparison of anterior and posterior corneal surface parameters in healthy eyes pak j ophthalmol. 2022, vol. 38 (3): 199-204 201 table1: age gender distribution. descriptive statistics gender n minimum maximum mean std. deviation age male 172 11 54 28.06 9.653 female 180 11 50 28.13 8.215 table 2: table of correlation. correlations post_k post_flt pst_stp post_r post_r1 post_r2 post_ast sim_k -.778 ** -.773 ** -.757 ** -.784 ** -.775 ** -.755 ** -0.126 ant_flat -.741 ** -.754 ** -.702 ** -.747 ** -.757 ** -.700 ** -0.036 ant_stp -.756 ** -.736 ** -.754 ** -.761 ** -.737 ** -.753 ** -.199 ** ant_r .778 ** .774 ** .757 ** .784 ** .776 ** .756 ** 0.123 ant_r1 .743 ** .756 ** .702 ** .749 ** .758 ** .701 ** 0.034 ant_r2 .758 ** .738 ** .756 ** .764 ** .739 ** .756 ** .198 ** ant_ast -.148 * -0.085 -.218 ** -0.148 -0.082 -.219 ** -.328 ** **. correlation is significant at the 0.01 level (2-tailed). *. correlation is significant at the 0.05 level (2-tailed). table 3: table of comparison. category mean std. deviation std. error mean mean diff. p value mean k (d) anterior 44.21 1.01 0.08 50.43 < 0.001 posterior -6.22 0.19 0.01 flat k (d) anterior 43.76 0.99 0.08 49.84 < 0.001 posterior -6.08 0.18 0.01 mean r (mm) anterior 7.64 0.17 0.01 1.19 < 0.001 posterior 6.45 0.21 0.02 r1 (mm) anterior 7.72 0.17 0.01 1.13 < 0.001 posterior 6.58 0.20 0.02 r2 (mm) anterior 7.56 0.18 0.01 1.24 < 0.001 posterior 6.31 0.21 0.02 steep k (d) anterior 44.67 1.09 0.08 51.01 < 0.001 posterior -6.34 0.21 0.02 astigmatism (d) anterior 0.91 0.55 0.04 1.17 < 0.001 posterior -0.26 0.11 0.01 figure 1: scatter chart of anterior and posterior mean r (r 2 : 0.615). figure 2: scatter chart of anterior and posterior mean ksteep (r 2 : 0.569) muhammad arslan ashraf, et al 202 pak j ophthalmol. 2022, vol. 38 (3): 199-204 figure 3: scatter chart of anterior and posterior mean kflat (r2: 0.569). figure 4: scatter chart of anterior and posterior mean k (r 2 : 0.605). figure 5: scatter chart of anterior and posterior mean r2 (r 2 : 0.572). figure 6: scatter chart of anterior and posterior mean r1 (r 2 : 0.575). figure 7: scatter chart of anterior and posterior mean astigmatism (r 2 : 0.108). discussion with the advancement in medical sciences, proper preoperative evaluation of refractive surgeries has improved the surgical outcomes. imaging techniques in the field of ophthalmology played a key role for such purposes. corneal imaging techniques provide more precise information. raul montalban et al. conducted a study to correlate anterior and posterior corneal radius of curvature which showed correlation coefficient value of 0.86. 15 raúl montalbán et al. also found significant difference between anterior and posterior corneal surface in healthy subjects whereas, non-significant difference was found in patients with correlation and comparison of anterior and posterior corneal surface parameters in healthy eyes pak j ophthalmol. 2022, vol. 38 (3): 199-204 203 keratoconus. 16 faik orucoglu et al. also found similar results. 17 in another study, comparison of anterior and posterior corneal parameters were analyzed in five hundred and fifteen healthy subjects. the study found an average flat k of anterior and posterior corneal surface as 43.03 ± 1.57 d and -6.13 ± 0.26 d respectively, whereas ksteep was 44.17 ± 1.58 d and -6.41 ± 0.28 d respectively. 18 gender and age related changes of cornea were studied by another group of authors, which showed similar results. 19 the gullstrand eye model measured anterior radius of corneas as 7.8mm while 6.5 mm of posterior surface. by using the method of purkinje image, the ravg was 6.42 mm. eom eom y et al measured the astigmatism of anterior surface as 2.21 d and posterior corneal surface as 0.43 d. 20 yuta ueno et al. found a shift of against the rule astigmatism from with the rule with age. 21 this study also showed similar results. limitations of this study are that we did not compare the results of different age groups. similarly comparison among different refractive errors was not made. we included normal eyes in our study. further research can be done by comparing with the eyes with corneal ectasia. conclusion significant difference was found in anterior and posterior corneal parameters like kflat, ksteep, kavg, r1, r2, ravg and astigmatism in healthy cornea. a strong negative correlation was found between kflat, ksteep, and kavg of anterior and posterior corneal surface. whereas, a strong positive correlation was found in r1, r2, ravg of anterior and posterior corneal surface. astigmatism showed poor but negative correlation. conflict of interest: authors declared no conflict of interest. ethical approval the study was approved by the institutional review board/ethical review board (coavs/1061/22). references 1. del monte dw, kim t. anatomy and physiology of the cornea. j cataract refract surg. 2011; 37 (3): 588598.doi:10.1016/j.jcrs.2010.12.037. 2. shaheen bs, bakir m, jain s. corneal nerves in health and disease. surv ophthalmol. 2014; 59 (3): 263-285. 10.1016/j.survophthal.2013.09.002. 3. sridhar ms. anatomy of cornea and ocular surface. indian j ophthalmol. 2018; 66 (2): 190. doi: 10.4103/ijo.ijo_646_17. 4. eghrari ao, riazuddin sa, gottsch jd. overview of the cornea: structure, function, and development. progress molecular biology and translational science, 2015; 134: 7-23. doi: 10.1016/bs.pmbts.2015.04.001. 5. rüfer f, schröder a, erb c. white-to-white corneal diameter: normal values in healthy humans obtained with the orbscan ii topography system. cornea, 2005; 24 (3): 259-261. doi: 10.1097/01.ico.0000148312.01805.53. 6. ghezzi ce, rnjak-kovacina j, kaplan dl. corneal tissue engineering: recent advances and future perspectives. tissue engineering part b: reviews, 2015; 21 (3): 278-287. doi: 10.1089/ten.teb.2014.0397. 7. qian y, liu y, zhou x, naidu rk. comparison of corneal power and astigmatism between simulated keratometry, true net power, and total corneal refractive power before and after smile surgery. j ophthalmol. 2017; 2017. doi: 10.1155/2017/9659481. 8. leyland m. validation of orbscan ii posterior corneal curvature measurement for intraocular lens power calculation. eye (lond). 2004; 18 (4): 357-360. doi: 10.1038/sj.eye.6700659. 9. wang l, mahmoud am, anderson bl, koch dd, roberts cj. total corneal power estimation: ray tracing method versus gaussian optics formula. invest ophthalmol vis sci. 2011; 52 (3): 1716-1722. doi: 10.1167/iovs.09-4982. 10. lauschke jl, lawless m, sutton g, roberts tv, hodge c. assessment of corneal curvature using verion optical imaging system: a comparative study. clin exp ophthalmol. 2016; 44 (5): 369-376. doi: 10.1111/ceo.12687. 11. zhang b, ma j-x, liu d-y, guo c-r, du y-h, guo x-j, et al. effects of posterior corneal astigmatism on the accuracy of acrysof toric intraocular lens astigmatism correction. intern j ophthalmol. 2016; 9 (9): 1276.10.18240/ijo.2016.09.07 12. hua y, xu z, qiu w, wu q. precision (repeatability and reproducibility) and agreement of corneal power measurements obtained by topcon kr-1w and itrace. plos one, 2016; 11 (1):e0147086. doi: 10.1371/journal.pone.0147086 13. menassa n, kaufmann c, goggin m, job om, bachmann lm, thiel ma. comparison and reproducibility of corneal thickness and curvature readings obtained by the galilei and the orbscan ii analysis systems. j cataract refract surg. 2008; 34 (10): 1742-1747.doi: 10.1016/j.jcrs.2008.06.024 https://doi.org/10.1016/j.jcrs.2010.12.037 https://doi.org/10.1016/j.survophthal.2013.09.002 https://doi.org/10.4103/ijo.ijo_646_17 https://doi.org/10.1016/bs.pmbts.2015.04.001 https://doi.org/10.1097/01.ico.0000148312.01805.53 https://doi.org/10.1089/ten.teb.2014.0397 https://doi.org/10.1111/ceo.12687 https://doi.org/10.18240%2fijo.2016.09.07 https://doi.org/10.1371/journal.pone.0147086 https://doi.org/10.1371/journal.pone.0147086 https://doi.org/10.1371/journal.pone.0147086 https://doi.org/10.1016/j.jcrs.2008.06.024 muhammad arslan ashraf, et al 204 pak j ophthalmol. 2022, vol. 38 (3): 199-204 14. shirayama m, wang l, weikert mp, koch dd. comparison of corneal powers obtained from 4 different devices. am j ophthalmol. 2009; 148 (4): 528-535. e1.doi: 10.1016/j.ajo.2009.04.028 15. montalbán r, piñero dp, javaloy j, alió jl. scheimpflug photography–based clinical characterization of the correlation of the corneal shape between the anterior and posterior corneal surfaces in the normal human eye. j cataract refract surg. 2012; 38 (11): 1925-1933. 16. montalbán r, alio jl, javaloy j, piñero dp. comparative analysis of the relationship between anterior and posterior corneal shape analyzed by scheimpflug photography in normal and keratoconus eyes. graefes arch clin exp ophthalmol. 2013; 251 (6): 1547-1555. doi: 10.1007/s00417-013-2261-3 17. orucoglu f, toker e. comparative analysis of anterior segment parameters in normal and keratoconus eyes generated by scheimpflug tomography. j ophthalmol. 2015; 2015. doi: 10.1155/2015/925414. 18. orucoglu f, akman m, onal s. analysis of age, refractive error and gender related changes of the cornea and the anterior segment of the eye with scheimpflug imaging. contact lens and anterior eye, 2015; 38 (5): 345-350. doi: 10.1016/j.clae.2015.03.009. 19. nemeth g, berta a, lipecz a, hassan z, szalai e, modis jr l. evaluation of posterior astigmatism measured with scheimpflug imaging. cornea, 2014; 33 (11): 1214-1218. doi: 10.1097/ico.0000000000000238. 20. eom y, rhim jw, kang s-y, kim s-w, song js, kim hm. toric intraocular lens calculations using ratio of anterior to posterior corneal cylinder power. am j ophthalmol. 2015; 160 (4): 717-724. doi: 10.1016/j.ajo.2015.07.011. 21. ueno y, hiraoka t, beheregaray s, miyazaki m, ito m, oshika t. age-related changes in anterior, posterior, and total corneal astigmatism. journal of refractive surgery, 2014; 30 (3): 192-197. doi: 10.3928/1081597x-20140218-01. authors’ designation and contribution muhammad suhail sarwar; professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing. muhammad arslan ashraf; diagnostic oculist: literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. faisal mehmood; consultant ophthalmologist: literature search, manuscript preparation, manuscript editing, manuscript review. muhammad arbab azeem; diagnostic oculist: literature search, data acquisition, manuscript preparation. sobia yousaf; house officer: manuscript editing, manuscript review. .…  …. https://doi.org/10.1016/j.ajo.2009.04.028 https://doi.org/10.1007/s00417-013-2261-3 https://doi.org/10.1155/2015/925414 https://doi.org/10.1016/j.clae.2015.03.009 https://doi.org/10.1097/ico.0000000000000238 https://doi.org/10.1016/j.ajo.2015.07.011 https://doi.org/10.3928/1081597x-20140218-01 337 pak j ophthalmol. 2021, vol. 37 (3): 337-338 letter to editor dear sir! i would like to bring my few queries in your notice regarding a case report “polypoidal choroidal vasculopathy (pcv)” which is published in the recent issue of the journal, pak j ophthalmol. 2021; 37 (2). the author has diagnosed it with the case of right eye pcv. they have also mentioned the presence of drusens in an old-age female with unilateral disease (right eye). indocyanine green angiography (icga) was not done due to unavailability. my queries related to this case report are: 1. drusens are usually not present in pcv and presence of drusens are more indicative of choroidal neovasularization 2. pcv is usually present in young age. 3. pcv usually presents with asymmetrical bilateral disease. 4. icg is the diagnostic investigation for pcv and without it; it is only diagnosis of exclusion which is made after all other more common causes are ruled out. as in this case, presence of bilateral drusens in an old lady are suggestive of age related macular degeneration. 5. everest criteria which was a, phase 4 multi centered randomized active control double masked exploratory study, is not met for the diagnosis of pcv. i would appreciate if these queries are answered. regards dr. syed abdullah mazhar mbbs fcps mrcs (edin.uk) assistant professor rashid latif medical college, lahore response to letter to the editor it gives me great pleasure to share my thoughts on pcv and to be provided a platform for this, by the prestigious pakistan journal of ophthalmology. i would also like to thank the author for taking time to read my article and raise queries about this interesting entity. we believe pcv to be similar to the amd spectrum and its variant although different theories exist and there are different schools of thought. 1 it is not right to eliminate the presence of any entity in the diagnosis of any disease. the author believes that drusen cannot coexist with pcv, although there have been several studies mentioning the presence of drusen in coexistence with pcv. 2-4 contrary to the belief of the author of the letter, pcv is not seen in young age rather older age is a risk factor for pcv and is usually diagnosed between 60 – 70 years of age and a mean age of 68.4 years, although some believe it is earlier than amd. 5,6 i agree that pcv is asymmetrical and bilateral as mentioned in literature. icg angiography is mentioned to be the definitive diagnostic modality, but being ophthalmologists in a developing country we must accept our limitations and the lack of one investigation should not hold us back in reporting useful literature. ffa and oct are useful modalities in its diagnosis and are available. also, orange, aneurysmal dilatations can clearly be seen in the figure 1, which i have encircled now for more clarity. figure 1: orange aneurysmal lesions observed on fundus photography in the right eye. open access letter to editor pak j ophthalmol. 2021, vol. 37 (3): 337-338 338 moreover, such large pigment epithelial detachments are not seen in any other disorder rather than pcv, and what else could it be provided all the images and imaging modalities in the case report? the everest criteria again requires icg angiography, which we were unable to acquire as the icg dye was unavailable, but i am sure that if that was done, it would have yielded a diagnosis of pcv. oct has been deemed an excellent diagnostic modality with high sensitivity and specificity 7-9 and we have demonstrated its use in diagnosing the large, multiple peds as well as resolution following treatment with bevacizumab injections in the right eye. the rationale of publishing a case report is to help others come up with similar diagnoses in the event of paucity of multimodal imaging, especially in developing countries. this also helps in managing such patients. respectfully dr. sana nadeem assistant professor mbbs fcps acmed department of ophthalmology foundation university medical college & fauji foundation hospital, islamabad – pakistan email: sana.nadeem@fui.edu.pk how to cite this article: mazhar sa. letter to editor. pak j ophthalmol. 2021; 37 (3): 337-338. doi: 10.36351/pjo.v37i3.1251 references 1. chaikitmongkol v, cheung cmg, koizumi h, govindahar v, chhablani j, lai tyy. latest developments in polypoidal choroidal vasculopathy: epidemiology, etiology, diagnosis, and treatment. asia pac j ophthalmol (phila). 2020; 9 (3): 260-268. doi: 10.1097/01.apo.0000656992.00746.48. 2. iwama d, tsujikawa a, sasahara m, hirami y, tamura h, yoshimura n. polypoidal choroidal vasculopathy with drusen. jpn j ophthalmol. 2008; 52 (2): 116-121. doi: 10.1007/s10384-007-0503-9. 3. vella g, sacconi r, borrelli e, bandello f, querques g. polypoidal choroidal vasculopathy in a patient with early-onset large colloid drusen. am j ophthalmol case rep. 2021; 22.101085. https://doi.org/10.1016/j.ajoc.2021.101085. 4. singh sr, chakurkar r, goud a, rasheed ma, vupparaboina kk, chhablani j. pachydrusen in polypoidal choroidal vasculopathy in an indian cohort, indian j ophthalmol. 2019; 67 (7): 1121-1126. doi: 10.4103/ijo.ijo_1757_18 5. coscas g, lupidi m, coscas f, benjelloun f, zerbib j, ali dirani a, et al. toward a specific classification of polypoidal choroidal vasculopathy: idiopathic disease or subtype of age-related macular degeneration. invest ophthalmol vis sci. 2015; 56 (5): 3187-3195. doi: https://doi.org/10.1167/iovs.14-16236. 6. honda s, matsumiya w, negi a. polypoidal choroidal vasculopathy: clinical features and genetic predisposition. ophthalmologica. 2014; 231: 59-74. doi: 10.1159/000355488 6. anantharaman g, sheth j, bhende m, narayanan r, natarajan s, rajendran a, et al. polypoidal choroidal vasculopathy: pearls in diagnosis and management. indian j ophthalmol. 2018; 66 (7): 896908. doi: 10.4103/ijo.ijo_1136_17. 7. dansingani kk, gal-or o, sadda sr, yannuzzi la, freund kb. understanding aneurysmal type 1 neovascularization (polypoidal choroidal vasculopathy): a lesson in the taxonomy of 'expanded spectra' – a review. clin exp ophthalmol. 2018; 46 (2): 189-200. doi:10.1111/ceo.13114 8. chang ys, kim jh, kim jw, lee tg, kim cg. optical coherence tomography-based diagnosis of polypoidal choroidal vasculopathy in korean patients. korean j ophthalmol. 2016; 30 (3): 198-205. doi: 10.3341/kjo.2016.30.3.198 .…  …. https://doi.org/10.1016/j.ajoc.2021.101085 https://doi.org/10.1167/iovs.14-16236 4 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology original article intravitreal injection of lucentis and the vitreomacular relationship in patients with exudative amd: a prospective study tahir islam, salina siddiqui, murtaza mookhtiar, louise m. downey, mark t. costen pak j ophthalmol 2015, vol. 31 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tahir islam hull & east yorkshire nhs trust hull royal infirmary, anlaby road, hull united kingdom, hu3 2jz tahir.islam@ulh.nhs.uk or tahir.islam@nhs.net …..……………………….. purpose: this study aimed to investigate the relationship between intravitreal injections of lucentis and the vitreomacular surface. material and methods: central macular thickness (cmt), logmar visual acuity and the presence or absence of posterior vitreous detachment (pvd) were noted in lucentis eligible patients before commencing treatment, and 6 months after initial treatment prospectively. the paired sample t-test repeated measures anova were used. results: of 52 eyes analyzed, 70% were noted to have no pvd prior to injection. of these, 55% of eyes developed pvd. comparison of the change in cmt between pvd-induced eyes and pre-existing pvd eyes was statistically significant. pvd induction during treatment was associated with a greater reduction in cmt than in eyes with pre-existing pvd. conclusions: the induction of pvd may have an effect on cmt in eyes injected with lucentis, implying a potential therapeutic effect of pvd in exudative amd. key words: macular, neovascularization, age related macular degeneration, lucentis ge – related macular degeneration (amd) is the largest cause of blind registration in the western world. although clinically, both dry (atrophic) and exudative forms of amd are recognized, it is the choroidal neovascular membrane (cnv) that has been the focus of intensive research into agents which stabilize the disease process in what was previously an untreatable condition. there have been considerable advances in treatment of cnv over recent years, with the recent addition of antivascular endothelial growth factor (anti-vegf) agents to the armamentarium.1,2 much, however, remains obscure regarding the etiology of the disease. hereditary, inflammatory, degenerative and vascular factors have all been widely implicated, but clearly it represents a multifactorial disease.3 posterior vitreous detachment (pvd) describes the process of separation of the posterior hyaloid face of the vitreous from its attachments to the retina, notably around the optic disc and macula primarily. in humans this is a normal ageing process due to progressive liquefaction of the gel structure. there is an increasing incidence of pvd with age4. in some patients, such as those with diabetes, there are abnormally strong attachments, preventing complete pvd from occurring and resulting in persistent vitreoretinal traction. there is evidence from animal studies that experimental induction of pvd using intravitreal injection of microplasmin improves vitreous cavity, and therefore possibly inner retinal oxygenation5 and there are numerous clinical reports of reduced macular thickness in cases of macular oedema, after both vitrectomy and enzymatic vitreolysis.6-9 vitreoretinal adhesion in diabetic retinopathy is believed to promote angiogenesis10 and its role in the pathogenesis of amd disease is being studied with a intravitreal injection of lucentis and the vitreomacular relationship in patients with exudative amd pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 5 increasing interest. several studies have demonstrated that pvd is less prevalent in eyes with amd. krebs et al demonstrated, in a prospective study, that less than half of patients with cnv had pvd development when compared to age – matched controls, or fellow eyes.11,12 furthermore, a study of the role of vitrectomy for amd with vitreous hemorrhage has shown a reduction in cnv activity after pars plana vitrectomy, indicating the importance of vitreomacular traction in the pathophysiology of cnv in age – related macular degeneration.13 the major treatment for exudative amd involves sequential injection of small volumes of anti–vegf agent into the vitreous cavity. the effect of this treatment has shown significant improvement, both in terms of lesion characteristics and visual acuity.1,2 there is little data relating to the injection of a fluid bolus into the vitreous cavity, on the state of the posterior hyaloid. as amd treatment involves three or more sequential monthly injections, it is conceivable that pvd development occurs in these patients and thus contributes to the anatomical and visual results. macular complications due to peri-foveal vitreous detachment has been documented in literature.14-16 we aimed to investigate the relationship between lucentis injections & vitreomacular interface by analyzing the incidence of pvd in patients undergoing lucentis treatment for amd and how this correlated to the clinical outcomes of visual acuity and optical coherence tomography (oct) i.e. central macular thickness (cmt). material and methods after obtaining research and ethics (rec) approval we devised a prospective non-interventional study of patients undergoing intravitreal lucentis injection for amd for 6 months. b – scan ultrasonography (hiscan, optikon, alcon) and optical coherence tomography (oct) (time domain: zeiss stratus) were performed on consecutive patients listed for lucentis treatment for exudative macular degeneration in amd clinics at the hull & east yorkshire eye hospital, initially before commencing treatment, and then after 6 months of follow-up. pvd was recorded as present or absent on each occasion. central macular thickness (cmt) was taken as the central 1mm scan on a fast macular scan when accurate linear delineation by the oct of inner and outer retinal boundaries was demonstrated. patients were initiated with lucentis monotherapy with three initial monthly loading doses followed by an oct driven prn regime.17 best – corrected edtrs logmar acuities were recorded monthly. the main inclusion criterion was patients with active wet amd as per current nice criterion (i.e. evidence of wet amd worsening, best corrected visual acuity between 6/12 to 6/96 & no permanent damage to fovea/less than 12 disc diameter involvement), treated with intravitreal lucentis. patients with co-existent diabetic retinopathy, those with oct evidence of vitreomacular traction or high refractive error (less than 4 or more than +4 dioptres) were excluded from the study, as were patients with oct evidence of vitreomacular traction. the main outcome measures were the percentage of eyes with pvd prior to the commencement of treatment with intravitreal lucentis, and the percentage of eyes which developed pvd during treatment, based on clinical examination, b-scan ultrasonography and oct. the visual and anatomical outcomes of both pvd and non-pvd eyes were measured by logmar visual acuity and cmt respectively. the study was commenced following the local research ethics approval (rec) and adhered to the tenets of the declaration of helsinki. visual acuity was measured using the number of etdrs letters seen, and comparisons made using the paired sample t-test. macular thickness was quantified using oct data and analyzed using the paired sample t-test. a repeated measures anova was used to examine the effects over time of the pvd development on logmar acuity and cmt. results fifty – two eyes were analyzed. the age range was 6399 years (mean age 76, sd 7 years). 36/52 (70%) were noted to have pvd absent at the time of enrolment. 16/52 (30%) eyes had pvd at enrolment. 23 (44%) were left eyes and 29 (56%) were right eyes. the most prevalent type of cnv was occult which accounts for 57.5% of cases (n = 30). the remaining cases were classic 8% (n = 4), predominantly classic 17% (n = 9), minimally classic 13.5% (n = 7), two cases were unclassified. tahir islam, et al 6 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology the differences in va and cmt between the two groups at baseline were evaluated and did not reach statistical significance. 36 cases had no pvd at enrolment. one patient died prior to their follow up. of the 35 remaining cases with an absent pvd at enrolment, 19 cases (54%) developed pvd whilst 16 cases (46%) did not develop pvd after intra-vitreal injections. of the 22 fellow non-injected eyes with no pvd at enrolment, 2 (9%) developed pvd during the course of the study on the basis of oct data although these eyes did not undergo b-scan ultrasonography. logmar visual acuity prior to intravitreal injection was 24 – 76 letters (mean 52 letters), compared with 4 – 81 (mean 50 letters) 6 months post injection. the number of injections administered over the 6 months ranged from 3 – 6 (mean 4.1) and there was no significant difference in the number of injections between groups. a paired sample t-test was used to compare the va and oct cmt scores pre and post intravitreal injection for each individual in the group as a whole. there was a significant reduction in oct cmt between the pre and post measures for all patients, t (49) = 4.6 p < 0.001 (table 1). a significant reduction in oct cmt (table 2) was also noted for eyes where a pvd was induced during the study (n=19, mean cmt change = -165) t(18) = 4.5, p < 0.001. a repeated measure anova was used to examine the effects over time of the pvd first on va and oct cmt (figures 1a and b). the patients were assigned to one of 3 groups: those who had pvd at enrolment, those who developed a pvd and those who do not have a pvd. a series of paired sample t-tests were used to examine the differences between baseline and 6 month follow up measures of va and oct cmt in patients who developed pvd. there was a significant difference in oct cmt post intravitreal injection fig. 1: repeated measure anova showing the effects over time of pvd on 1a. va and 1b. oct cmt: compared with pre-injection. fig. 1a: effects of pvd on va over time. fig. 1b: effects of pvd on cmt over time. these results indicate that the reduction in cmt after pvd induction is significant. the reduction in cmt in patients with pvd present at enrolment and in those who did not develop a pvd did not reach statistical significance. although patients with pvd induction during the course of treatment show a slight trend towards better va (49.4 to 52.1=+2.74 logmar letters), the overall differences preand post-injection were not significant. overall visual acuity post treatment was intravitreal injection of lucentis and the vitreomacular relationship in patients with exudative amd pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 7 reduced slightly by 1.4 logmar letters amongst all groups this was not statistically significant. discussion studies show that the incidence of pvd is lower in patients with exudative amd and that persistent attachment of the vitreous cortex to the macula may be an additional risk factor in its development.11 furthermore, vmt is associated with greater severity of amd and operated eyes show a reduction in cmt and improvement in best corrected visual acuity following vitrectomy.18 there is also a demonstrated treatment effect of ppv in cnv regression in eyes without a pre-existing pvd.13 in our study, pvd induction was common after repeated intravitreal injection. although not formally compared, the apparent low level of pvd induction in untreated fellow eyes would seem to suggest a possible effect of the intravitreal injection on the state of the vitreous gel, either related to the fluid bolus, or the anti-vegf agent itself. there was a significant reduction in cmt when pvd was induced during the course of treatment with intravitreal injections. interestingly, this was also true of patients that did not develop a pvd at any point (see table 2) whereas the pre-existing pvd group did not demonstrate a significant reduction in cmt. although it is difficult to draw conclusions from such small subgroups, it does raise the possibility that there may be a differing pathophysiology of amd and its response to antivegf agents depending upon the state of the posterior hyaloid. the category with induced pvd fared slightly better from the point of view of improvement in visual acuity (49.4 to 52.1 = +2.74 logmar letters) although the difference was not statistically significant. there was no significant difference in the number of injections administered to each of the three groups. this study does have some limitations. the numbers were relatively small, and the results should therefore be interpreted with some caution. a larger data set would be required to definitively draw conclusions. additionally, the use of age-matched controls would be useful in further assessing the development of pvd spontaneously without intervention. visual acuity outcomes may be subject to other variables, including developing cataract. also, the response to lucentis in patients with wet amd is now known to be influenced by genotype.19-20 another reason for this slight decrease in overall mean va could be the wide variation of va at presentation & the extent of damage on the fovea prior to treatment as well as treatment failures, our study does not take account of these variables. multiple intravitreal injections may hasten pvd development. the relationship between the state of the posterior hyaloid and the change in cmt in our study suggests that the state of the posterior hyaloid, whether attached, or in the process of detaching, may have an impact on the effect of anti-vegf therapy. conclusion thus in conclusion it is possible that once a pvd has been induced, the course of a patient’s amd might fare better. further studies to investigate the therapeutic role of vitrectomy & pvd in wet amd are warranted. author’s affiliation mr. tahir islam hull & east yorkshire nhs trust hull royal infirmary, anlaby road, hull united kingdom, hu3 2jz miss. salina siddiqui hull & east yorkshire nhs trust hull royal infirmary, anlaby road, hull united kingdom, hu3 2jz mr. murtaza mookhtiar hull & east yorkshire nhs trust hull royal infirmary, anlaby road, hull united kingdom, hu3 2jz miss. louise m downey hull & east yorkshire nhs trust hull royal infirmary, anlaby road, hull united kingdom, hu3 2jz mr. mark t costen hull & east yorkshire nhs trust hull royal infirmary, anlaby road, hull united kingdom, hu3 2jz references 1. rosenfeld p, brown d, heier js, boyer ds, kaiser pk, chung cy, kim ry; marina study group ranibizumab for neovascular age-related macular degeneration. n engl j med. 2006; 355: 1419-31. 2. brown d, kaiser p, michels m. soubrane g, heier js, kim ry, sy jp, schneider s; anchor study group. ranibizumab versus verteporfin for neovascual agehttp://www.ncbi.nlm.nih.gov/pubmed/?term=heier%20js%5bauthor%5d&cauthor=true&cauthor_uid=17021318 http://www.ncbi.nlm.nih.gov/pubmed/?term=boyer%20ds%5bauthor%5d&cauthor=true&cauthor_uid=17021318 http://www.ncbi.nlm.nih.gov/pubmed/?term=kaiser%20pk%5bauthor%5d&cauthor=true&cauthor_uid=17021318 http://www.ncbi.nlm.nih.gov/pubmed/?term=chung%20cy%5bauthor%5d&cauthor=true&cauthor_uid=17021318 http://www.ncbi.nlm.nih.gov/pubmed/?term=kim%20ry%5bauthor%5d&cauthor=true&cauthor_uid=17021318 http://www.ncbi.nlm.nih.gov/pubmed/?term=marina%20study%20group%5bcorporate%20author%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=soubrane%20g%5bauthor%5d&cauthor=true&cauthor_uid=17021319 http://www.ncbi.nlm.nih.gov/pubmed/?term=heier%20js%5bauthor%5d&cauthor=true&cauthor_uid=17021319 http://www.ncbi.nlm.nih.gov/pubmed/?term=kim%20ry%5bauthor%5d&cauthor=true&cauthor_uid=17021319 http://www.ncbi.nlm.nih.gov/pubmed/?term=sy%20jp%5bauthor%5d&cauthor=true&cauthor_uid=17021319 http://www.ncbi.nlm.nih.gov/pubmed/?term=schneider%20s%5bauthor%5d&cauthor=true&cauthor_uid=17021319 http://www.ncbi.nlm.nih.gov/pubmed/?term=anchor%20study%20group%5bcorporate%20author%5d tahir islam, et al 8 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology related macular degeneration. n engl j med. 2006; 355: 1432-44. 3. spaide rf, armstrong d, browne r. choroidal neovascularisation in age-related macular degeneration what is the cause? retina. 2003; 23: 595-614. 4. yonemoto j, ideta h, sasaki k, tanaka s, hirose a, oka c. the age of onset of posterior vitreous detachment. graefes arch clin exp ophthalmol. 1994; 232: 67-70. 5. quiram p, leverenz v, baker r, dang l, fj giblin, trese m. microplasmin-induced posterior vitreous detachment affects oxygen vitreous levels. retina. 2007; 27: 1031-7. 6. murakami t, takagi h, ohashi h. role of posterior vitreous detachment induced by intravitreal tissue plasminogen activator in macular edema with central retinal vein occlusion. retina. 2007; 27: 1031-7. 7. yanyali a, horozoglu, celik e, nohutcu a. long-term outcomes of pars plana vitrectomy with internal limiting membrane removal in diabetic macular edema. retina. 2007; 27: 557-66. 8. yamamoto t, takeuchi s, sato y, yamashita h. longterm follow-up results of pars plana vitrectomy for diabetic macular edema. jpn j ophthalmol. 2007; 51: 285. 9. patel j, hykin p, schadt m, luong v, fitzke f, gregor z: pars plana vitrectomy with and without peeling of the internal limiting membrane for diabetic macular edema. retina. 2006; 26: 5-13. 10. takhashi m, trempe c, maguire k, mcmeel j. vitreoretinal relationship in diabetic retinopathy. arch ophthalmol. 1981; 99: 241-5. 11. krebs i, brannath w, glittenberg c, zeiler f, sebag j, binder s. posterior vitreomacular adhesion: a potential risk factor for exudative age-related macular degeneration? am j ophthalmol. 2007; 144: 741-6. 12. ondes f, yilmaz g, acar m, unlu n, kocaoglan h, arsan a. role of the vitreous in age-related macular degeneration. jpn j ophthalmol. 2000; 44: 91-3. 13. sakamoto t, sheu s-j, arimura n, sameshima s, shimura m, uemura a, et al. vitrectomy for exudative age related macular degeneration with vitreous haemorrhage. retina. 2010; 30: 856-65. 14. johnson mw. perifoveal vitreous detachment & its macular complications. trans am ophthalmol soc 2005; 103: 537-67. 15. johnson mw. posterior vitreous detachment and complications of its early stages:. am j ophthalmol. 2010; 149: 371-82. 16. pop m, gehorghe a. pathology of the vitreomacular interface. oftalmologica. 2014; 58: 3-7. 17. fung a, lalwani g, rosenfeld p, dubovy s, michels s, feuer w, et al. an optical coherence tomographyguided variable dosing regimen with intravitreal ranibizumab (lucentis) for neovascular age-related macular degeneration. am j ophthalmol. 2007; 143: 56683. 18. mojana f, cheng l, bartsch d-ug, silva ga, kozak i, nigam n, et al. a role of abnormal vitreomacular adhesion in age-related macular degeneration: spectral optical coherence tomography and surgical results. am j ophthalmol. 2008; 146: 218-27. 19. kloeckner-gruissem b, barthelmes d, labs s, schindler c, kurz levin m, michels s, et al. genetic association with response to intravitreal ranibizumab (lucentis®) in neovascular amd patients. iovs. 2011. 20. lee a, raya a, shiels a, brantley m. pharmacogenetics of complement factor h (y402h) and treatment of exudative age-related macular degeneration with ranibizumab. br j ophthalmol. 2009; 93: 610-3. 78 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology original article serum versus vitreous vegf a and central macular thickness in diabetic macular edema and the effect of intra-vitreal bevacizumab on these variables tayyaba gul malik, muhammad khalil, roquyya gul, syed shoaib ahmad, sania munawar pak j ophthalmol 2016, vol. 32 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyaba gul malik associate professor department of ophthalmology lmdc, lahore email. tayyabam@yahoo.com received: march 31, 2016 accepted: june 05, 2016 …..……………………….. purpose: to determine a relation among serum vegf a, vitreous vegf a and central macular thickness and the effect of intravitreal bevacizumab on these variables. study design: quasi – experimental study. place and duration of study: ghurki trust teaching hospital, lahore. 2014 to 2016. material and methods: fifty patients with clinically significant macular edema diagnosed with 78-d indirect ophthalmoscopy were recruited. optical coherence tomography (oct for macular thickness), serum vegf a and vitreous vegf a were analyzed at pre and post (four weeks) intra-vitreal bevacizumab injection. measurement of central sub field thickness, macular cube volume, cube average thickness, vitreous and serum vegf a levels one month after a single injection of intra-vitreal bevacizumab were the outcome variables. results: out of fifty patients, forty three patients were included with an average age of 56 years. mean pre-injection vegf a values were 347.8 ± 92 pg/ml which were reduced to 107.2 ± 16 pg/ml four weeks post intra-vitreal bevacizumab ( p = 0.000). mean pre-injection vegf a level in vitreous was 701.9 ± 145 pg/ml and post injection 82.66 ± 21 pg/ml (p = 0.000). pre and post injection central sub field thickness (cst) was 410 ± 24 µm and 299.6 ±15 µm respectively with p values of 0.000. mean pre injection cube volume (cv) and cube average thickness (cat) were 12 ± 0.36 mm 3 and 355.7 ± 10 µm which were reduced to 11± 0.26 mm 3 and 304 ± 9 µm after injection. conclusion: from this study, a direct relation of vitreous vegf a, serum vegf a and central sub field thickness is confirmed. statistically significant absorption of intra-vitreal bevacizumab occurs into the systemic circulation and effect of intra vitreal bevacizumab on the fellow eyes is an additional benefit. key words: vegf a, diabetic macular edema, bevacizumzb, central macular thickness, cube average volume. iabetic macular edema (dme) is the commonest cause of decreased visual acuity in diabetic patients. the role of vegf a in pathogenesis of diabetic macular edema is well documented1. vegf a is released in response to hypoxia and has an important role in increasing the permeability of retinal vessels. this, ultimately results in macular edema2,3,4. anti-vegf agents are now widely used all over the world for treating dme. many studies from pakistan are also available which d mailto:tayyabam@yahoo.com serum versus, vitreous vegf a and central macular thickness in dme and the effect of intravitreal bevacizumab pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 79 show an improvement in diabetic macular edema after intra-vitreal injection of anti-vegf agents.5,6 quantitative evidence of this improvement is possible with the help of oct which can give macular thickness in micrometers. in this study, we tried to find out the relation of serum and vitreous vegf a levels with macular thickness. effect of intra-vitreal bevacizumab on serum and vitreous vegf a and macular thickness of the treated and fellow eyes is also determined. materials and methods an interventional, time series study was designed, in which fifty diabetic patients with clinically significant macular edema (csme) were selected from ghurki trust teaching hospital, lahore, pakistan. the project was approved by institutional review board. patients with type 2 diabetes having diabetic macular edema were included in the study. the following patients were excluded: patients with type 1 diabetes, patients with any other systemic disease, elevated blood pressure, and evidence of vitreoretinal interface abnormality on sd-oct, and intra-vitreal corticosteroids or anti vegf a agents or laser photocoagulation during last 6 months. the primary outcome measures were a positive relation between high serum and vitreous vegf a levels with central sub field thickness. secondary outcomes were effects of intra-vitreal bevacizumab on the central sub field thickness of treated and fellow untreated eyes. clinical history, including ocular as well as systemic history was taken. ocular examination included distance and near visual acuity, pupillay reactions to light and accommodation, slit-lamp biomicroscopy and tonometry. csme was diagnosed with the help of +78d lens indirect ophthalmoscopy. macular thickness was measured using sd – oct. (carl zeiss, usa, model 4000). macular thickness parameters were; central subfield thickness, average cube thickness and macular volume. on the very next day of oct, blood and vitreous samples were drawn using strict aseptic techniques and bevacizumab 1.25 mg in 0.05 ml was injected in the vitreous cavity. patient was given topical antibiotics qid. oct was repeated after four weeks and blood and vitreous samples were drawn again. serum was separated from all blood samples and stored at -20°c. patient proforma and consent forms were filled before sampling. the methodology used in the current study to analyze vegf a in vitreous and serum samples was xmap flow cytometry and the kit used was human angiogenesis/growth factor magnetic bead panel. flow cytometry is a simultaneous measurement of multiple physical characteristics of a single cell as the cell flows in suspension through a measuring device. it measures the optical and fluorescence characteristics of a single cell. the statistical analysis was done by using spss version 21. asymptotic z test and wilcoxon signed rank tests were used for finding statistical significance. results average age of the patients was 56 years (39-75 years). there were 17 (39.5%) males and 26 (60.5%) females. 18 right and 25 left eyes were studied. mean preinjection vegf a values were 347.8 ± 92 pg/ml which were reduced to 107.2 ± 16 pg/ml four weeks after intra-vitreal bevacizumab ( p = 0.000). mean preinjection vegf a level in vitreous was 701.9 ± 145 pg/ml and post injection 82.66 ± 21 pg/ml (p = 0.000). pre and post injection central sub field thickness (cst) was 410 ± 24 µm and 299.6 ± 15 µm respectively with p values of 0.000. mean pre injection cube volume (cv) and cube average thickness (cat) were 12 ± 0.36 mm3 and 355.7 ± 10 µm which were reduced to 11 ± 0.26 mm3 and 304 ± 9 µm after injection. mean cst, cv and cat in the fellow non-treated eyes were 345.4 µm, 11.9 mm3 and 329.2 µm respectively. these parameters were also significantly changed after injection of bevacizumab in the other eye (cst = 282.8 µm, cv = 11.2 mm3, cat = 318.1 µm). for details refer to tables 1, 2 and figures 1, 2 and 3. discussion vascular endothelial growth factor (vefg), which, was previously known as vascular permeability factor is a key agent in the physiologic and pathologic angiogenesis7. the human vegf family is comprised of vegf-a, vegf-b, vegf-c, vegf-d and placental growth factor8,9. in addition to angiogenesis, vegf a (most commonly studied) causes increased vascular permeability, which is responsible for the development of dme. it mediates this action through activation of vascular endothelial growth factor receptor-2 (vegf-r2) and its permeability is 50,000 times more than histamine10. tayyaba gul malik, et al 80 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology table 1: pre and post injection parameters in the treated eyes. parameters mean median p value pre-injection post-injection pre-injection post-injection serum vegf a (pg/ml) 347.8 sd ± 608 107.2 sd ± 107 175.98 85 0.000 vitreous vegf a (pg/ml) 701.9 sd ± 944 82.7 sd ± 136.9 307.1 21.23 0.000 central macular sub field thickness (µm) 410 sd ± 158.99 299.6 sd ± 104.9 356 257 0.000 macular cube volume (mm3) 12 sd ± 2.4 11.4 sd ± 1.75 12.1 11 0.000 macular cube average thickness (µm) 355.7 sd ± 67.9 304.69 sd ± 59.22 336 302 0.000 table 2: effect of intra-vitreal bevacizumab on the macular oct of the other eye. parameters mean median p value pre-injection post-injection pre-injection post-injection central macular sub field thickness (µm) 345.42 sd± 143.95 282.8 sd ± 102.32 308 248 0.001 macular cube volume (mm3) 11.9 sd ± 2.61 11.2 sd ± 2.99 11.1 11.1 0.008 macular cube average thickness (µm) 329.2 sd ± 71.86 318.1 sd ± 63.6 309 309 0.001 to combat the deleterious effects of high vegf a levels, bevacizumab was introduced. it is a highly specific, 149 kda, recombinant, humanized monoclonal antibody that selectively binds to human vascular endothelial growth factor11. it was the first us fda approved drug to neutralize the biologic activity of vegf in cancer patients. the estimated half-life of bevacizumab is approximately 20 days12 (range 11 − 50 days). recently, it is widely used off – label for the treatment of many retinal conditions including dme. in vitreous, its half-life is 9.8 days13. in the current study, serum and vitreous vegf a levels were high in patients of dme and a direct effect of bevacizumab was seen on central sub field thickness of the injected and the fellow non-injected eyes. the results were in concordance with the existing studies5,14,15. in many of our patients, levels of fig. 1: mean serum and vitreous vegf a values before and four weeks after intra-vitreal bevacizumab injection. serum versus, vitreous vegf a and central macular thickness in dme and the effect of intravitreal bevacizumab pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 81 fig. 2: mean central subfield thickness (cst), mean cube volume (cv) and mean cube average thickness before and after intra-vitreal bevacizumab in the treated eyes. fig. 3: mean central subfield thickness (cst), mean cube volume (cv) and mean cube average thickness of the other untreated eyes before and after intra-vitreal bevacizumab in the treated eyes. vegf were in thousands pictograms; the highest vitreous vegf a value was 4469.76 pg/ml and in serum the highest recorded reading was 3867.5 pg/ml in our study. these vegf a levels in serum and vitreous were significantly reduced (p = 0.000) four weeks after intra-vitreal bevacizumab. this indicates the leakage of bevacizumab in the systemic circulation after intra-vitreal injection. it was similar to the previous studies in which the maximum reduction in serum vegf a was seen on the seventh day.16-18 in our patients, it was significantly high even after four weeks. to further prove the leakage of intra-vitreal bevacizumab into systemic circulation, some researchers labeled bevacizumab with 125-i and observed radioactivity in serum19,20. it was noted that there was more leakage of bevacizumab in systemic circulation in dme as compared to other diseases like neovascular age related macular degeneration21. this can be explained by the disturbance of blood retinal barrier in diabetic retinopathy. the fc fragment of bevacizumab is bound to vascular endothelium which increases the translocation across the blood-retina barrier and it also prevents elimination of bevacizumab from systemic circulation12,22. this results in increased half life of bevacizumab as compared to other anti-vegf agents like ranibizumab18. detailed review of serum vegf a in our study showed values distributed over a wide range. we compared them with other studies but absolute serum vegf values were found to differ dramatically17. one explanation found in literature is that the platelets contain large concentrations of vegf a. during sample collection and preservation, these platelets are broken down releasing vegf, which is responsible for the extra ordinary large values as seen in some cases23. in the current study, central sub field thickness, macular volume and cube average thickness in the fellow non-injected eyes were also taken into account. the results clearly consolidated the idea of significant systemic absorption of bevacizumab after intra-vitreal injection. this effect on the fellow non-injected eyes is also reported by other authors24,25. the proof of this finding was augmented by the animal studies, in which bevacizumab injected in one eye appeared in the fellow eye after sometime26 in contrast to this, laser photocoagulation in one eye does not cause a decrease in the vegf a of the fellow eyes. this shows intra-vitreal bevacizumab has an additional benefit when compared with laser photocoagulation. once the systemic absorption and its effects on serum vegf and macular thickness of other eyes is established, the question arises about the serious adverse events (sae) associated with bevacizumab. sea associated with bevacizumab are severe bleeding, including central nervous system hemorrhage, thrombo-embolic events gastrointestinal perforations, surgery and wound healing complications, hypertensive crisis, reversible posterior leukoencephalopathy syndrome, proteinuria and death with tayyaba gul malik, et al 82 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology systemic administration. although in all intra-vitreal anti-vegf registration trials, the incidence of these sae are negligible but caution should be exercised because bevacizumab has a cumulative effect due to its long half life12. there are certain shortcomings in this study. firstly, the functional endpoint (improvement in visual acuity) was missing in this study. visual results are dependent on many factors including status of photoreceptors and the duration of dme. we did not take into account the integrity of is/os layer which directly affects the visual outcome. further elaborative studies are required to see the effect of bevacizumab on the morphology of photoreceptor layer. secondly, the follow up duration was short. conclusion there is a direct relation of vitreous vegf a, serum vegf a and central sub field thickness. vitreous vegf a, serum vegf a and central sub field thickness decrease correspondingly after intra-vitreal bevacizumab. there is a statistically significant absorption of intra-vitreal bevacizumab into systemic circulation. hence, caution should be exercised in high-risk patients (ischemic heart disease, stroke etc.). it was also concluded that the effect of intra-vitreal bevacizumab on the fellow eyes is an additional benefit not seen with laser photocoagulation. acknowledgement this study was funded by osp lateef chaudhary research fund. author’s affiliation dr. tayyaba gul malik associate professor of ophthalmology lmdc, lahore dr. muhammad khalil associate professor lmdc, lahore dr. roquyya gul assistant professor crimm/ imbb the university of lahore dr. syed shoaib ahmad assistant professor crimm/ imbb the university of lahore dr. sania munawar medical officer ophthalmology ghurki teaching hospital role of authors: dr. tayyaba gul malik research design, data acquisition, analysis, data compiling and manuscript drafting dr. muhammad khalil research design, data analysis, interpretation and manuscript review dr. roquyya gul research design, data analysis, interpretation and manuscript review dr. syed shoaib ahmad data compiling and statistical analysis dr. sania munawar data acquisition references 1. selim km, sahan d, muhittin t, et al. increased levels of vascular endothelial growth factor in the aqueous humor of patients with diabetic retinopathy. indian j ophthalmol. 2010; 58: 375-9. 2. nguyen qd, shah sm, van ae, et al. supplemental inspired oxygen improves diabetic macular edema: a pilot study. invest ophthalmol vis sci. 2003; 45: 617-24. 3. ozaki h, hayashi h, vinores 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diabetes. 2012; 8: 237-46. 9. papadopoulos n, martin j, ruan q, et al. binding and neutralization of vascular endothelial growth factor and serum versus, vitreous vegf a and central macular thickness in dme and the effect of intravitreal bevacizumab pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 83 related ligands by vegf trap, raniibizumab and bevacizumab. angiogenesis 2012; 15: 171-85. 10. ferrara n, gerber hp, lecouter j. the biology of vegf and its receptors. nat med. 2003; 9: 669-76. 11. presta lg, chen h, o’connor sj, et al. humanization of an anti-vascular endothelial growth factor monoclonal antibody for the therapy of solid tumors and other disorders. cancer res 1997; 57: 4593-9. 12. avastin prescribing information. genentech, inc. september 2015. 13. krohne tu, liu z, holz fg, et al. intraocular pharmacokinetics of ranibizumab following a single intravitreal injection in humans. am j ophthalmol. 2012; 154: 682-6. 14. arevalo f, sanchez jg, wu l et al. primary intravitreal bevacizumab for diffuse diabetic macular edema. the pan-american collaborative retina study group at 24 months. ophthalmology 2009; 116: 1488-97. 15. seo jw, park iw. intravitreal bevacizumab for treatment of diabetic macular edema.korean j ophthalmol. 2009; 23: 17-22. 16. davidovic sp, nikolic sv, curic nj, et al. changes of serum vegf concentration after intravitreal injection of avastin in treatment of diabetic retinopathy. eur j ophthalmol. 2012; 22: 792-8. 17. inan uu, polat o, inan s, et al. alterations in vegf, pedf and pdgf levels of vitreous and blood in response to intravitreal anti-vegf therapy in patients with diabetic macular edema. investigative ophthalmology and visual science. 2015; 56: 4717. 18. zehetner c, kirchmair r, huber s, et al. plasma levels of vascular endothelial growth factor before and after intravitreal injection of bevacizumab, ranibizumab and pegaptanib in patients with age – related macular degeneration, and in patients with diabetic macular oedema. br j ophthalmol. 2013; 97: 454-9. 19. heiduschka p, fietz h, hofmeister s, et al. penetration of bevacizumab through the retina after intravitreal injection in the monkey. invest ophthalmol vis sci. 2007; 48: 2814-23. 20. julien s, heiduschka p, hofmeister s, et al. immunohistochemical localisation of intravitreally injected bevacizumab at the posterior pole of the primate eye: implication for the treatment of retinal vein occlusion. br j ophthalmol. 2008; 92: 1424-8. 21. choi yj, cho ih, lee sh, et al. changes in serum concentrations of vascular endothelial growth factor after consecutive intravitreal bevacizumab injection in diabetic macular edema and neovascular age – related macular degeneration. investigative ophthalmology and visual science. 2011; 52: 4870. 22. tolentino m. systemic and ocular safety of intravitreal anti-vegf therapies for ocular neovascular disease. surv ophthalmol 2011; 56: 95-113. 23. chakravarthy u, harding sp, rogers ca, et al. ranibizumab versus bevacizumab totreat neovascular age-related macular degeneration: one-year findings from the ivan randomized trial. ophthalmology. 2012; 119: 1399–411. 24. hanhart j, tiosano l, averbukh e, et al. fellow eye effect of unilateral intravitreal bevacizumab injection in eyes with diabetic macular edema. eye. 2014; 28: 646–53. 25. brit ia, zacharias lc, luis s, et al. fellow eye macular edema improvement after intravitreal bevacizumab for radiation retinopathy. ophthalmol med. 2015; 8. 26. sinapis ci, routsias jg, sinapis ai, sinapis di, agrogiannis gd, pantopoulou a, et al. pharmacokinetics of intravitreal bevacizumab in rabbits. clin ophthalmol. 2011; 5: 697-704. pak j ophthalmol. 2022, vol. 38 (3): 205-209 205 original article effectiveness of syntonic phototherapy in amblyopia in terms of improved visual acuity and contrast sensitivity shakila abbas 1 , malaika younus 2 , ayesha bukhari 3 , aalia iqrar 4 , mahnoor anwar 5 1-5 the university of faisalabad abstract purpose: to compare visual acuity and contrast sensitivity in different types of amblyopia and to see the effect of syntonic therapy on amblyopia in terms of visual acuity and contrast sensitivity. study design: a quasi experimental study. place and duration of study: madina teaching hospital faisalabad, from august 2021 to november 2021. methods: a total of 30 patients of either gender and age from 8 to 18 years were included. there were 15 patients with anisometropic amblyopia and 15 with strabismic amblyopia. the patients were recruited through non-probability purposive sampling technique. all the patients underwent assessment of visual acuity with log mar chart and contrast sensitivity with pelli-robsonchart. syntonic phototherapy with red filter glasses was prescribed for 4 weeks. after 4 weeks, patients returned and underwent post-therapy assessment of visual acuity and contrast sensitivity. paired sample t test and independent sample t test was used with the help of ibm spss23 to get a statistical result. results: syntonic phototherapy showed significant improvement in mean visual acuity of 0.223 (p = 0.00) and contrast sensitivity of -0.200 (p = 0.00) in amblyopia. anisometropic amblyopia showed better improvement in visual acuity (p = 0.016) and contrast sensitivity (p = 0.035) by syntonic phototherapy as compared to patients with strabismic amblyopia. conclusion: significant improvement was seen in visual acuity and contrast sensitivity in patients with amblyopia after syntonic phototherapy. anisometropic amblyopia showed better improvement as compared to strabismic amblyopia, in terms of visual acuity and contrast sensitivity. keywords: amblyopia, anisometropia, strabismic amblyopia, syntonic phototherapy. how to cite this article: abbas s, younus m, bukhari a, iqrar a, anwar m. effectiveness of syntonic phototherapy in amblyopia in terms of improved visual acuity and contrast sensitivity. pak j ophthalmol. 2022, 38 (3): 205-209. doi: 10.36351/pjo.v38i3.1355 correspondence to: shakila abbas the university of faisalabad email: shakila.abbass@tuf.edu.pk received: december 10, 2021 accepted: may 30, 2022 introduction amblyopia is reduction in visual acuity either unilateral or bilateral, caused by vision deprivation or binocular interaction for which no organic cause can be identified by physical examination of the eye. in appropriate cases, it is reversible by therapeutic measures if introduced early. 1 practically speaking, amblyopia is represented as two snellen line difference between the visual acuity of both eyes. 2 it is the major and merely frequent source of uniocular visual impairment in children as well as adults. 3 risk factors of amblyopia are positive family history of eye diseases, visual defects in infancy, mentally retarded children, congenital cataract, other media opacities, ptosis, corneal injury or dystrophy, premature birth, developmental and cognitive impairment, children with lesser birth weight along with anisometropia, hyperopia, myopia and strabismus. 4 aetiology of shakila abbas, et al 206 pak j ophthalmol. 2022, vol. 38 (3): 205-209 unilateral amblyopia include strabismus, anisometropia or composite of two, stimulus deprivation caused by media opacities like infantile cataract, ptosis, corneal opacities/opaque cornea, hyphaema, vitreous clouding or haemorrhages and prolonged uncontrolled patching or prolonged unilateral atropinisation. 5 bilateral amblyopia is caused by bilateral opacities (cataract of equal density), ametropia, astigmatism and motor type nystagmus. according to best corrected visual acuity, amblyopia has been divided into mild amblyopia (20/25 to 20/60), moderate amblyopia (20/70 to 20/100) and severe amblyopia (20/200 or worse). 6 amblyopia can be categorized into different types depending on etiology. refractive amblyopia is caused by uncorrected refractive error. it includes anisometropic amblyopia and isoametropic amblyopia. isoametropic amblyopia is originated by large degree of similar refractive error. aniso-hypermetropia occurs in the case of 1.0d to 1.5d difference in refractive error, aniso-astigmatism if more than 2d and anisomyopia in more than 3.0d to 4.0d difference between the two eyes. bilateral amblyopia occurs if hyperopia is more than 4.0d to 5.0d, 2.0d to 3.0d in case of astigmatism and 5.0d to 6.0d in myopia. 7 strabismic amblyopia is due to deviation, usually seen in unilateral constant squint where strong favour of one eye for fixation is present. prevalence of amblyopia is more in esotropic subjects in comparison to exotropic subjects. 8 amblyopia is diagnosed by different methods e.g. visual acuity assessment, neutral density filter test, contrast sensitivity testing, crowding phenomenon testing, fundoscopy, refraction, stereoacuity testing, central and eccentric fixation testing and tests for sensory abnormalities. 9 the earlier the treatment the better is the prognosis. 10 there are basically two ways to treat amblyopia, one is treating underlying aetiology while other is stimulating amblyopic eye. 11 treating underlying aetiology include refractive error, cataract and ptosis etc. for stimulating the weaker eye, multiple options like occlusion therapy, penalization, pleoptics, pharmacological interventions and cam stimulator are available. 12 syntonic phototherapy is a simple, non-invasive light therapy treatment that uses specific light colors, frequency and wavelength to improve the regulatory centers in the brain. colored light by different filters used in syntonic phototherapy stimulates visual system and also alters the biochemistry of the brain, thus improving the sympathetic and parasympathetic nervous systems and balance among them. 13 red filter absorbs all light except red, so red light stimulates the cones of the retina thus fovea with its exclusively cone component is predominant stimulated. 14 red light enhances cell membrane capacitance buildup of electrical charge before discharge that enhance the nerve cell charge to break through synaptic resistance to decrease amblyopia. 15 we conducted this study to evaluate the effectiveness of this therapy at our set up, as this area in amblyopia therapy is still void in pakistani literature. methods a quasi experimental study was conducted from august 2021 to november 2021 in madina teaching hospital faisalabad. permission from the ethical review board was sought. we recruited amblyopic patients from 8-18 years old through a non-probability purposive sampling technique. patients with strabismic and anisometropic amblyopia were included after informed consent. patients with ocular pathologies, positive squint surgery and other types of amblyopia were excluded from this study. total sample of 30 patients were included, out of which 15 were strabismic amblyopes and 15 were anisometropic amblyopes. after taking both verbal and written consent detailed history was taken. detailed history and complete ocular examination was performed to diagnose amblyopia and then categorized either into strabismic or anisometropic amblyopia. cover uncover test was used to confirm strabismic amblyopia. subjective plus objective refraction was done to confirm anisometropic amblyopia. visual acuity and contrast sensitivity were tested in all cases. visual acuity was tested by using log mar chart at 4-meter distance. contrast sensitivity was tested by using pellirobson chart. after initial assessment syntonic phototherapy with red filter was prescribed binocularly for 4 weeks with 5 sessions per week. patients wore their red filter glasses and were asked to fixate at a light source that provided 1.4 lux at the distance of 20 inches for 20 minutes in each session. the patient was kept in comfortable position throughout the sessions and were allowed to move eye if fatigued. after 4 weeks and total 20 sessions, visual acuity and contrast sensitivity were retested with log mar chart and pelli-robson chart respectively. after syntonic phototherapy in amblyopia pak j ophthalmol. 2022, vol. 38 (3): 205-209 207 the collection of data paired sample t test and independent sample t test were used with the help of ibm spss-23. results there were 12 (40%) males and 18 (60%) females with mean age 14.93 years. the mean value of visual acuity before syntonic therapy in amblyopes was 0.62 ± .33 and after syntonic therapy it was .40 ± .36. the result of this study shows that there is significant difference in visual acuity before and after syntonic phototherapy in amblyopes (p = 0.00). the mean value of contrast sensitivity before syntonic therapy in amblyopia was 1.20 ± .38 and after syntonic therapy was 1.40 ± .39. the result of this study shows that there is significant improvement in contrast sensitivity before and after syntonic phototherapy in amblyopes (p = 0.00). table 1 and 2 show the details. table 1: visual acuity and contrast sensitivity before and after syntonic therapy in amblyopia. paired sample t-test visual acuity mean std. deviation std. error mean before syntonic therapy .62 .33 .060 after syntonic therapy .40 .36 .065 contrast sensitivity mean std. deviation std. error mean before syntonic therapy 1.20 .38 .070 after syntonic therapy 1.40 .39 .071 table 2: visual acuity and contrast sensitivity before and after syntonic therapy in amblyopia. paired difference mean difference std. deviation std error mean sig (2tailed) visual acuity before and after syntonic therapy 0.22 .16 .029 0.00 contrast sensitivity before and after syntonic therapy -.20 .21 .038 0.00 independent t test was used to determine the effectiveness of syntonic phototherapy in different types of amblyopia. the result of this study shows that significant difference was present in visual acuity between anisometropic amblyopia patients and strabismic amblyopia patients after syntonic therapy, (p value = 0.016). anisometropic amblyopic subjects showed better improvement in visual acuity by syntonic phototherapy as compared to strabismic amblyopic patients. significant difference was also seen in contrast sensitivity between anisometropic amblyopic patients and strabismic amblyopic patients after syntonic therapy (p value = 0.035). anisometropic amblyopic patients showed better improvement in contrast sensitivity by syntonic phototherapy as compared to strabismic amblyopic patients. table 3: comparison of visual acuity and contrast sensitivity after syntonic therapy in strabismic and anisometropic amblyopia. independent sample test levene’s test for equality of variance t-test for equality of means f sig t df sig. (2tailed) mean difference std. error difference 95% confidence interval of the difference lower upper visual acuity equal variances assumed equal variances not assumed 2.61 .12 2.57 2.57 28 22.80 .016 .017 .309 .309 .120 .120 .063 .060 .56 .56 contrast sensitivity equal variances assumed equal variances not assumed .036 .85 -2.22 -2.22 28 27.46 .035 .035 -.303 -.303 1.37 1.37 -.58 -.58 -.02 -.02 shakila abbas, et al 208 pak j ophthalmol. 2022, vol. 38 (3): 205-209 discussion syntonic phototherapy with red light can be used as a treatment option for amblyopia. in 1920s clinical implementation of selected frequencies of light came in action. 16 present research on syntonic phototherapy was focused on visual acuity and contrast sensitivity of amblyopes as well as comparison of visual acuity and contrast sensitivity in different types of amblyopia. results demonstrated that syntonic phototherapy showed significant improvement of visual acuity (p = 0.00) and contrast sensitivity (p = 0.00) in amblyopes. anisometropic amblyopic subjects showed better improvement in visual acuity and contrast sensitivity as compared to strabismic amblyopes. in a study, 55 patients between 11 to 15 years of age and diagnosed with amblyopia were treated with full time occlusion of good eye until no further improvement in visual acuity was seen. all subjects had improved visual acuity after treatment. the mean improvement was of 0.46 log mar unit. 17 the result of present research also showed improvement in visual acuity in amblyopes. there was also improvement of contrast sensitivity in amblyopes. occlusion and penalization therapy of good eye had been gold standard for treatment of unilateral amblyopia. in one study, it took 6 months to show improvement. 18 studies found that severe amblyopia improved by an average of 4.8 lines of visual acuity over 4 months duration with 6 hours of patching/day and 62% of moderate amblyopes had improvement of 3 lines of visual acuity or visual acuity better than 20/32 after patching for two hours/day for four months. 19 in this particular research, only 20 sessions were enough to show significant improvement of visual acuity and contrast sensitivity. children were happy with the red filter glasses while their parents found syntonic therapy simple plus facile and gave good results. eye care practitioners must be familiar with this therapy and they should keep syntonic phototherapy in mind whenever they are dealing with amblyopic patients. recently use of ipad has also been used to treat amblyopia. however, results are not comparable to the occlusion therapy. 20 limitations of this study are small sample size, single center study and no comparison between the two groups of different treatment modalities. further research is needed to find out which therapy is better. conclusion visual acuity and contrast sensitivity increased significantly in patients with anisometropic and strabismic amblyopia after syntonic phototherapy. visual acuity and contrast sensitivity improved more significantly in anisometropic amblyopes as compared to strabismic amblyopes. conflict of interest: authors declared no conflict of interest. ethical approval the study was approved by the institutional review board/ethical review board (tuf/irb/004/2021). references 1. levi dm. linking assumptions in amblyopia. vis neurosci. 2013; 30 (5-6): 277-287. doi: 10.1017/s0952523813000023. 2. khurana ak. adaptations to strabismus and amblyopia. theory and practice of squint and orthoptics. 2nd ed. india: cbs publishers & distributors; 2013: p. 137-138. 3. pediatric eye disease investigator group. a randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. arch ophthalmol. 2002 mar; 120 (3): 268-278. doi: 10.1001/archopht.120.3.268. 4. pascual m, huang j, maguire mg, kulp mt, quinn ge, ciner e, et al. vision in preschoolers (vip) study group. risk factors for amblyopia in the vision in preschoolers study. ophthalmology, 2014; 121 (3): 622-629.e1. doi: 10.1016/j.ophtha.2013.08.040. 5. magdalene d, bhattacharjee h, choudhury m, multani pk, singh a, deshmukh s, et al. community outreach: an indicator for assessment of prevalence of amblyopia. indian j ophthalmol. 2018; 66 (7): 940-944. doi: 10.4103/ijo.ijo_1335_17. 6. williams c. amblyopia. bmj clin evid. 2009; 2009: 0709. pmid: 21726480; pmcid: pmc2907781. 7. weakley dr jr. the association between nonstrabismic anisometropia, amblyopia, and subnormal binocularity. ophthalmology, 2001; 108 (1): 163-171. doi: 10.1016/s0161-6420(00)00425-5. 8. lin lk, uzcategui n, chang el. effect of surgical correction of congenital ptosis on amblyopia. ophthalmic plast reconstr surg. 2008; 24 (6): 434-436. doi: 10.1097/iop.0b013e31818ab497. syntonic phototherapy in amblyopia pak j ophthalmol. 2022, vol. 38 (3): 205-209 209 9. sachdeva v, mittal v, gupta v, gunturu r, kekunnaya r, chandrasekharan a, et al. combined occlusion and atropine therapy" versus "augmented part-time patching" in children with refractory/residual amblyopia: a pilot study. middle east afr j ophthalmol. 2016; 23 (2): 201-207. doi: 10.4103/0974-9233.175892. 10. holmes jm, lazar el, melia bm, astle wf, dagi lr, donahue sp, et al. pediatric eye disease investigator group. effect of age on response to amblyopia treatment in children. arch ophthalmol. 2011; 129 (11): 1451-1457. 11. loudon se, simonsz hj. the history of the treatment of amblyopia. strabismus, 2005; 13 (2): 93-106. doi: 10.1080/09273970590949818. 12. holmes jm, kraker rt, beck rw, birch ee, cotter sa, everett df, et al. a randomized trial of prescribed patching regimens for treatment of severe amblyopia in children. ophthalmology, 2003; 110 (11): 2075-2087. 13. ray g, larry w. syntonic phototherapy. photomedlaser surg. 2019; 28: 449-452. doi: 10.1089/pho.2010.9933. 14. schmidt bp, sabesan r, tuten ws, neitz j, roorda a. sensations from a single m-cone depend on the activity of surrounding s-cones. sci rep. 2018; 8 (1): 8561. doi: 10.1038/s41598-018-26754-1. 15. ibrahimi d, mendiola-santibañez jd, cruzmartínez e, gómez-espinosa a, torres-pacheco i. changes in the brain activity and visual performance of patients with strabismus and amblyopia after a compete cycle of light therapy. brain sci. 2021; 11 (5): 657. doi: 10.3390/brainsci11050657. 16. friederichs e., wahl s. (re)-wiring a brain with light: clinical and visual processing findings after application of specific coloured glasses in patients with symptoms of a visual processing disorder (cvpd): challenge of a possible new perspective? med. hypotheses, 2017; 105: 49–62. doi: 10.1016/j.mehy.2017.06.006. 17. mohan k, saroha v, sharma a. successful occlusion therapy for amblyopia in 11to 15-year-old children. j pediatr ophthalmol strabismus, 2004; 41 (2): 89-95. doi: 10.3928/0191-3913-20040301-08. 18. kaur s, bhatia i, beke n, jugran d, raj s, sukhija j. efficacy of part-time occlusion in amblyopia in indian children. indian j ophthalmol. 2021; 69 (1): 112-115. doi:10.4103/ijo.ijo_1439_19. 19. repka mx, beck rw, holmes jm, birch ee, chandler dl, cotter sa, et al. pediatric eye disease investigator group. a randomized trial of patching regimens for treatment of moderate amblyopia in children. arch ophthalmol. 2003; 121 (5): 603-611. doi: 10.1001/archopht.121.5.603. 20. holmes jm, manh vm, lazar el, beck rw, birch ee, kraker rt, et al. pediatric eye disease investigator group. effect of a binocular ipad game vs. part-time patching in children aged 5 to 12 years with amblyopia: a randomized clinical trial. jama ophthalmol. 2016; 134 (12): 1391-1400. doi: 10.1001/jamaophthalmol.2016.4262. authors’ designation and contribution shakila abbas; lecturer: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. malaika younus; optometrist: concepts, design, data acquisition, data analysis, statistical analysis, manuscript preparation. ayesha bukhari; optometrist: concepts, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation. aalia iqrar; optometrist: design, literature search, data acquisition, data analysis, statistical analysis. mahnoor anwar; optometrist: design, literature search, data acquisition, data analysis, statistical analysis. .…  …. 409 pak j ophthalmol. 2021, vol. 37 (4): 409-412 clinical practice article surgical outcome of dacrystorhinostomy in fistulous dacryocystitis noman ahmed 1 , arsalan ahmed shaikh 2 , munawar ahmed 3 , ashok kumar narsani 4 muhammad luqman ali bahoo 5 1-4 department of ophthalmology, liaquat university of medical and health sciences, jamshoro, 5 cmh institute of medical sciences, bahawalpur abstract purpose: to study the surgical outcomes of dacryocystorhinostomy (dcr) in fistulous dacryocystitis. study design: quasi experimental study. place and duration of study: the detailed study was carried out in the institute of ophthalmology, liaquat university hospital jamshoro, between september 2018 to august 2020. material and methods: we analyzed the histories of 30 patients taking the dcr procedure and noted their mean age, standard deviation, follow-up time, complications and other details. we also reported the intraoperative anatomical results, postoperative analysis, and variable groups vs. outcomes post-surgery using spss version 20. results: the mean patient's age was 44.2 ± 4.13years, where males to female percentages were 27% to 73%. we noted significant changes in patients with a success rate of 87% displayed by no relieved epiphora and lacrimal patency in 1 month, 3 months, and 6 months. the mean time of the patients was 4 months varying between 1 to 8 (months) and the variable group values vs. surgical outcomes showed no significant association between the variables (p-value ranging from 0.195 to 0.935). conclusion: complications resulting in some patient’s post-surgery are manageable and the surgical technique has a good success rate. key words: (dcr) dacryocystorhinostomy, lacrimal patency, fistulous dacryocystitis, scarring. how to cite this article: ahmed n, shaikh aa, ahmed m, narsani ak, bahoo mla. surgical outcome of dacrycystorhinostomy in fistulous dacryocystitis. pak j ophthalmol. 2021, 37 (4): 409-412. doi: 10.36351/pjo.v37i4.1265 introduction according to chandler, the treatment of dacryocystitis dates backs to around 2000 years. 1 in the early days, a passage was created into the nose by making use of a correspondence: noman ahmed department of ophthalmology liaquat university of medical and health sciences, jamshoro email: drdnas@gmail.com received: may 06, 2021 accepted: august 13, 2021 hot cautery and puncturing the lacrimal bone. 2 however, research and development of nasal anatomy and physiology have widened our understanding of the disease, and, consequently, many new methods and techniques have emerged since then. 3 in 20 th century, dacryocystorhinostomy became the procedure of choice with favorable results. 4 dacryocystitis caused by nasolacrimal duct obstruction can be either chronic or acute. fistulous dacryocystitis usually occurs by inadequate or delayed treatment. 2 according to a study dacryocystitis occurs approximately one in a 3884 individuals. gender open access mailto:drdnas@gmail.com surgical outcome of dacrystorhinostomy in fistulous dacryocystitis pak j ophthalmol. 2021, vol. 37 (4): 409-412 410 difference shows that 75% of dacryocystitis patients are females. 5,6 in this particular case series, we tried to find out the results of dacryocystorhinostomy in patients with fistulous dacryocystitis. methods this interventional case series was carried out in liaquat university hospital, jamshoro. thirty patients with fistulous dacryocystitis were selected by convenient sampling from september 2018 to august 2020. acute as well as chronic cases were included in the study. patients with lacrimal sac abscess were also recruited. patients with a history of dacryocystorhinostomy, previous maxillofacial surgery, nasolacrimal trauma, lacrimal neoplasm, congenital anomalies of the lacrimal drainage system and patients with compromised immune system were excluded. all procedures were performed under local anesthesia. local anesthesia was given by injecting xylocaine 2% with adrenaline 1:100000. a curved incision was given at 1.3cm medial to the medial canthus. orbicularis muscle was dissected by blunt dissection. the skin and the orbicularis muscle were retracted with four retractable 4 – 0 silk sutures. lacrimal fossa was exposed and an osteotomy was created about 1.5 × 1.5 cm wide with bone puncher until nasal mucosa was exposed. the next step was to make an h-shaped incision in lacrimal sac and nasal mucosa. posterior flap of nasal mucosa was sutured with the posterior flap of the lacrimal sac with 6/0 vicryl suture. silicone tube intubation aided to suture the anterior fold of lacrimal sac with anterior nasal mucosa. the incision was closed in two layers. follow-up examinations were planned on first postoperative day, first, third and then sixth month. the data was collected and compiled. statistical analysis was done using spss version 20.chi-square test was used for statistical significance. results there were 27% male patients. mean age was 44.2 years ± 4.13. maximum age was 55 years and minimum was 38 years. the mean time for relief of epiphora was 4 ± 3.606 months. figure-1: age and gender versus outcome on 1st month, 3rd month and 6-month follow-up. about 87% patients (37% in 36 – 50 years old and 13% about 50yrs) of patients got relieved of epiphora and lacrimal patency in 1 month, three months, and six months with p-value being 0.399 in all respectively. however, gender wise in 1 st month 5% male and 63% females got relived with p-value being 0.935 and 3 rd month repeat values just as 1 st month were observed in male and female with p value being 0.935 which is not statistically significantly being more than 0.05.the surgery showed no complication in 70%, i.e., 21 cases out of 30, while 9 patients showed intraoperative hemorrhage (16.7%), laceration of the nasal mucosa (13.3%) (figure-2). figure-2: complication in fistulous patients. noman ahmed, et al 411 pak j ophthalmol. 2021, vol. 37 (4): 409-412 figure 3: postoperative success rate in fistula patients. we concluded the success rate by relieving epiphora and lacrimal patency at the end of the last follow-up to be 87%, while 13% showed recurrence (figure-3). discussion dacryocystorhinostomy has proved to be an effective procedure for treating chronic dacryocystitis. 7,8 in a previous study, fistula excision with external dcr proved to be an effective procedure for fistulous dcr. 9 in our study, mean age was 44.2 years. this was consistent with a previous study which showed a mean age of 42.4 ± 7.6 years. 9 there were 73% females in our study whereas islam et al had 62% females indicating female prepondrance. 10 the mean (average) time of the patients was 4 months (bracket 1 – 8 months), and the standard deviation was 3.606 months. another study by lee et al, recorded a post-operative follow-up period of 11.01 ± 16.3 months (ranging from 4 to 10.8). 11 the values of the post-surgery outcomes vs. patients gender and age showed no significant association between the variables (p-value ranging from 0.195 to 0.935) and similar was observed in one such study where p-value were insignificant ranging from 0.193 to 0.895. 12 the complication rate of the surgical procedure observed in our population was 30%, i.e., only 9 cases out of 30 showed complications from intraoperative hemorrhage (16.7%), laceration of the nasal mucosa (13.3%). however, elsewhere, a negligible complication rate of 28 %.was noted by rahman et al. 13 further to our findings, the success rate is seconded by the relief of epiphora and lacrimal patency at the end of the last follow-up in 87% of patients, while 13% showed recurrence. similar findings were done by khan et al, 14 found a 97.1% success rate in the dcr technique. in a local study by mumtaz and his friends the success rate was recorded at 94.7%. 15 similarly, pradhnya 16 and colleagues found a success rate of 82.61% cases after dcr technique. elsewhere when follow-up was taken for the surgical outcomes after 12 months, dcr cam successful both in the anatomy and functionality with success percentage of 94.7%. 17 one such local study of dcr conducted on 100 patients, showed scarring on 85 patients which was invisible and only 4 patients showing some visibility. 18 another research on 36 subject undergoing dcr technique showed 95% function success and no scars after 3 months’ follow-up. 19 akaishi et al, showed promising outcomes of dcr too. 20 a local study conducted on dcr on patients ageing 18 to 60 years showed successful lacrimal patency after 6 months follow-up. 21 conclusion dcr technique was noted to be a successful technique in treating chronic conditions, and complications are manageable, and therefore, the procedure is good.thus our success rate for the study suggests it is an efficient technique that takes reasonable operation time. however, there can be more improvement for better precision. ethical approval the study was approved by the institutional review board/ethical review board (lumhs/r.ec/i.o.l-07) conflict of interest authors declared no conflict of interest. references 1. ali, mohammad. lacrimal disorders and surgery: historical perspectives. international ophthalmology: september 2014; 34 (6): 240-263. surgical outcome of dacrystorhinostomy in fistulous dacryocystitis pak j ophthalmol. 2021, vol. 37 (4): 409-412 412 2. taylor rs, ashurst jv. dacryocystitis.]. in: stat pearls [internet]. treasure island (fl): stat pearls publishing; 2021 jun 26. available online at https://www.ncbi.nlm.nih.gov/books/nbk470565/ 3. weinberg, d, gupta r. dacryocystorhinostomy: an update. american academy of opthaomogly.jul 01, 2007. 4. herzallah i, alzuraiqi b, bawazeer n, marglani o, alherabi a, mohamed sk, al-qahtani k, al-khatib t, alghamdi a. endoscopic dacryocystorhinostomy (dcr): a comparative study between powered and nonpowered technique. j otolaryngol head neck surg. 2015 dec 22; 44: 56. 5. chen l, fu t, gu h, jie y, sun z, jiang d, yu j, zhu x, xu j, hong j. trends in dacryocystitis in china: a strobe-compliant article. medicine (baltimore). 2018 jun; 97 (26): e11318. 6. enright nj, brown sj, rouse hc, mcnab aa, hardy tg. nasolacrimal sac diverticulum: a case series and literature review. ophthalmic plast reconstr surg. 2019 jan/feb; 35 (1): 45-49. 7. mukhtar sa, jamil az, ali z. efficacy of external dacryocystorhinostomy (dcr) with and without mitomycin-c in chronic dacryocystitis. j coll physicians surg pak. 2014 oct; 24 (10): 732-5. 8. reddy, dalli. clinical study on surgical outcomes of endoscopic dacryocystorhinostomy (dcr) between powered and non-powered techniques. journal of evolution of medical and dental sciences: sept 2020; 9 (28): 6810-6811. 9. ari, suleyman & cingu, abdullah & şahin, alparslan & ozkök, a & caca, i. the outcomes of surgical treatment in fistulous dacryocystitis. european review for medical and pharmacological sciences: jan 2013; 17 (2): 243-246. 10. islam, akm & hossain, khandaker & or rashid, md & hossain, md. a study of conventional dacryocystorhinostomy operation without silicon tube intubation in a secondary hospital. faridpur medical college journal, 2016. 11. lee, m. j., kim, i. h., choi, y. j., kim, n., choung, h. k., & khwarg, s. i. relationship between lacrimal sac size and duration of tearing in nasolacrimal duct obstruction. canadian journal of ophthalmology, 2019; 54 (1): 111-115. 12. fugita r, santos c, ribeiro s. epidemiological profile of patients with fistula in ano. j. coloproctol. 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[internet], 2020 mar; 40 (1): 1-7. 13. rahman sh, tarafder kh, ahmed ms, et al. endoscopic dacryocystorhinostomy. mymensingh med j 2011; 20 (1): 28-32. 14. mkh, khan & ma, hossain & hossain, mohammed & mz, rahman. comparative study of external and endoscopic endonasal dacryocystorhinostomy for the treatment of chronic dacryocystitis. journal of armed forces medical college, bangladesh: april. 2012: 7. 15. mumtaz h, saleem a. saeed a. dcr (dacryocystorhinostomy) with or without intubation. annals of king edward medical university: july-sept. 1988; 4 (3): 34-36. 16. sen p, jain e, mohan a, kumar a. surgical outcome of external dacryocystorhinostomy with silicone intubation for recurrent lacrimal abscess in children younger than 6 years. pediatr ophthalmol strabismus, feb. 2019; 56 (3): 188–193. 17. fayers t, dolman pj. bicanalicular silicone stents in endonasal dacryocystorhinostomy: results of a randomized clinical trial. ophthalmology, 2016 oct; 123 (10): 2255-9. 18. qidwai n, dawood a, hussain m, inam m, jafri a, somro f. cosmetic and functional results of external dacryocystorhinostomy with the subciliary incision in a tertiary eye care hospital, karachi. pjo [internet]. 17 mar. 2020; 36 (2). 19. elbarbary he. evaluation of the cosmetic and functional outcomes of the subciliary incision for external dacryocystorhinostomy. j clin exp opthamol. 2018; 9 (720): 2. 20. akaishi pm, mano jb, pereira ic. functional and cosmetic results of a lower eyelid crease approach for external dacryocystorhinostomy. arquivos brasileiros de oftalmologia. 2011; 74 (4): 283-285. 21. shahis e, jafri a, fasih u, shaikh a. external dacryosystorhinostomy with intubation in shrunken fibrotic sac in chronic dacryocyctitis. pak l opthalmol. apr – jun. 2020; 36 (2): 23-5. authors’ designation and contribution noman ahmed; assistant professor: primary surgeon, concept, design, manuscript preparation. arsalan ahmed shaikh; associate professor: data analysis, statistical analysis, manuscript editing. munawar ahmed; associate professor: literature search, data acquisition, manuscript review and approval. ashok kumar narsani; professor: concept, design, manuscript review and approval. muhammad luqman ali bahoo; associate professor: manuscript editing, manuscript review. .…  …. https://journals.healio.com/doi/pdf/10.3928/01913913-20190228-01 https://journals.healio.com/doi/full/10.3928/01913913-20190228-01 https://journals.healio.com/doi/full/10.3928/01913913-20190228-01 https://journals.healio.com/doi/full/10.3928/01913913-20190228-01 https://journals.healio.com/doi/full/10.3928/01913913-20190228-01 pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 159 original article first crack guided conservative posterior capsulotomy using neodymium: yag laser syed imtiaz ali shah, shujaat ali shah, partab rai, safdar ali abbasi, naeem akhtar katpar pak j ophthalmol 2016, vol. 32, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: prof. syed imtiaz ali shah syed eye clinic, ratodero road larkana, sindh – pakistan email: syedimtiazalinaqvi@yahoo.com …..……………………….. purpose: to report a new method of nd: yag laser posterior capsulotomy (first crack guided conservative posterior capsulotomy). study design: prospective case series study. place and duration of study: from january 2001 to january 2015 at the department of ophthalmology, chandka medical college hospital, larkana, pakistan. material and methods: in this study, 670 eyes of 623 patients with clinically diagnosed posterior capsular opacification following extra capsular cataract extraction or phacoemulsification and posterior chamber iol implantation, were included. patients with aphakia, anterior chamber iol, high myopia, uveitis, uncontrolled glaucoma, maculopathies, optic nerve diseases and patients below 20 years of age were excluded from the study. pre-procedure best corrected visual acuity (bcva) and iop was noted and complete clinical examination was done. nd: yag laser posterior capsulotomy was performed. the patients were seen one hour after capsulotomy, then after 24 hours and then weekly for 3 weeks. post-procedure best corrected visual acuity (bcva) and any complications seen were recorded. spss version 20 was used for data entry and analysis. results: out of the total 623 patients 398 (63.88%) were males and 225 (36.12%) were females. mean age ± standard deviation was 55.39 ± 13.16 years and age range was 20 to 78 years. most of the patients belonged to the 51 – 60 years age group. interval between cataract surgery and nd: yag laser posterior capsulotomy ranged from 6 months to 60 months. 652 (97.31%) patients showed improvement of the best corrected visual acuity (bcva) after nd: yag laser posterior capsulotomy. most common complications seen after the procedure were transient uveal reaction, transient rise in iop and intra ocular lens (iol) pitting. conclusion: first crack guided conservative posterior capsulotomy using nd: yag laser has proved to be a quick, safe, efficient and cost effective method in our setting. keywords: cataract surgery, posterior capsule opacification, nd: yag laser, posterior capsulotomy, complications. osterior capsular opacification (pco) is the most common late onset post operative complication of standard cataract surgery including phacoemulsification1. it still remains the most challenging complication of modern cataract surgery despite significant improvements in the p mailto:syedimtiazalinaqvi@yahoo.com syed imtiaz ali shah, et al 160 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology techniques of surgery, iol materials and designs. posterior capsular opacification occurs due to proliferation of the left over lens epithelial cells after cataract extraction and a peculiar change occurring in them which turns them into myofibroblasts2. these myofibroblasts contract to cause thickening and wrinkling of the posterior capsule and as the process progresses further, the sheets of fibroblastic proliferation are seen entering into the central area (visual axis) that cause visual disturbance. the incidence of pco is reported to be as much as 100%5 in children, however most of the studies report pco incidence to be around 20% to 50%4,5. after being reported as a treatment modality for pco more than three decades ago3; nd: yag laser has taken over as the gold standard for performing posterior capsulotomy. the cutting effect is achieved by way of ionizing effect of the laser leading to plasma formation and photo-disruption of the target tissue. although it is accepted as an effective procedure for the management of posterior capsular opacification, nd: yag laser posterior capsulotomy can lead to sight – threatening complications11. several techniques have been used for performing nd: yag laser posterior capsulotomy, like cross pattern method6, can opener method7, inverted u method8, racquet shaped method9 and circular with vitreous strand cutting method10. all techniques have been employed to achieve maximum visual improvement with minimum complications but all of them have their advantages, limitations and drawbacks as well. in this research study we are reporting a new method of nd: yag laser posterior capsulotomy and we have termed it as “first crack guided conservative posterior capsulotomy”. material and methods this was a prospective case series study of 670 eyes of 623 patients, conducted from january 2001 to january 2015 at the department of ophthalmology, chandka medical college hospital, larkana, pakistan after approval from institutional ethical review committee. patients with pco following extra capsular cataract extraction or phacoemulsification and posterior chamber iol implantation were included in the study. definite diagnosis of pco was made clinically by senior ophthalmologist. patients below 20 years of age, patients with aphakia, anterior chamber iol, high myopia, uveitis, uncontrolled glaucoma, maculopathies and optic nerve diseases were excluded from the study. with the help of available data and history, actual dates of cataract surgery were noted and pre-procedure best corrected visual acuity (bcva) was also noted. slit lamp examination, applanation tonometry and fundoscopy was performed on all cases before patient was taken for nd: yag laser posterior capsulotomy. patient was seated comfortably in dimly lighted room of consultant for approximately one hour, while consultant kept on examining the other patients. this kept the patient awake and the pupil dilates physiologically. then the patient was taken to nd: yag laser equipment and the laser beam was focused on the posterior capsule at 12 o’clock position just inferior to the superior pupil margin. the posterior yag laser offset was kept on 150 µm in all cases, to avoid iol pitting. the nd: yag laser energy level was set at 1 millijoule and when the pupil was seen to acquire dilating phase of hippus, the first shot was fired. if crack was observed at 1 millijoule, the process was continued at the same energy level but if crack was not observed than the energy level was increased with 0.5 millijoule steps till crack was achieved fig. 1. the direction of first crack was observed and further shots were aimed in the line of dehiscence of the crack fig. 2. the line of crack usually advanced quickly with few shots and capsular flaps gave way. in some cases where crack remained as a cut fig. 3, few shots were given to the edges and an adequate opening was achieved quickly fig. 4. wherever needed, a few shots were aimed to displace the flaps downwards or sideways, away from the visual axis. the patients were seen one hour after capsulotomy, then after 24 hours and then weekly for 3 weeks. during these follow up examinations, postprocedure best corrected visual acuity (bcva) was recorded, patients were seen on slit lamp, applanation tonometry and detailed fundus examination was performed. increase in the best corrected visual acuity (bcva) of at least one line on the snellen’s chart was considered as improvement in visual acuity. any complications seen were recorded and treatment was prescribed accordingly. spss version 20 was used for data entry and analysis. results a total of 670 eyes of 623 patients were included in the study. out of these 623 patients 398 (63.88%) were males and 225 (36.12 %) were females (figure 2). mean age ± standard deviation was 55.39 ± 13.16 years and age range was 20 to 78 years. most of the patients belonged to the 51 – 60 years age group (table 1). iol material type used was hydrophobic acrylic in 214 first crack guided conservative posterior capsulotomy using neodymium: yag laser pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 161 fig. 1: fig. 2: (31.94%) eyes and polymethylmethacrylate (pmma) in 456 (68.06%) eyes (table 2). interval between cataract surgery and nd: yag laser posterior capsulotomy ranged from 6 months to 60 months in different patients, but the interval was 37 months to 48 months in majority 167 (24.9 %) of the patients (table 3). energy level used for the procedure ranged from 1 millijoule to 2.5 millijoule and the number of shots ranged from 3 to 19. maximum energy used in a case was 44.5 millijoule (range: 3 millijoule to 44.5 millijoule). 652 (97.31%) patients showed improvement of the best corrected visual acuity (bcva) after nd: yag laser posterior capsulotomy (figure 2). complications seen after the procedure were transient uveal reaction in 331 (49.4%) patients, transient rise in iop in 219 (32.7%) patients, intra ocular lens (iol) pitting in 53 (7.9%) patients, clinical macular edema in 18 (2.7%) patients and retinal detachment in 3 (0.4 %) cases (table 4). fig. 3: fig. 4: discussion nd: yag laser posterior capsulotomy is a quick and effective method for the treatment of posterior capsular opacification but some complications may occur. improvement in visual acuity after nd: yag syed imtiaz ali shah, et al 162 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology figure 5: table 1: age group no. of patients percentage 20 – 30 years 60 9.6% 31 – 40 years 23 3.7% 41 – 50 years 46 7.4% 51 – 60 years 291 46.7% 61 – 70 years 148 23.8% 71 – 78 years 55 8.8% total 623 100% figure 6: table 2: type of iol material no: of eyes percentage polymethylmethacrylate (pmma) 456 68.06 % hydrophobic acrylic material 214 31.94 % total no: of eyes 670 100 % table 3: interval between cataract surgery and capsulotomy no. of eyes percentage 6 – 12 months 125 18.7% 13 – 24 months 136 20.3% 25 – 36 months 149 22.2% 37 – 48 months 167 24.9% 49 – 55 months 87 13.0% 56 – 60 months 6 0.9% total no: of eyes 670 100% table 4: complications no. of eyes percentage transient rise in iop 219 32.7% transient uveal reaction 331 49.4% lens pitting 53 7.9% clinical macular edema 18 2.7% retinal detachment 3 0.4% laser posterior capsulotomy has been reported to be 96% by min jk et al10, 96.9% by khanzada ma et al12, 100% by zeki sm et al8 and it was 97.31% in our study. various complications after nd: yag laser posterior capsulotomy have been reported, like iol dislocation15, damage13, pitting12, increased iop14, uveitis15, cystoid macular edema16,17, rupture of anterior vitreous face18,19, hyphaema15, endophthalmitis15,21, aqueous misdirection syndrome20 and retinal detachment22,23. our study has also observed some of these complications, which are first crack guided conservative posterior capsulotomy using neodymium: yag laser pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 163 shown in table 4, but they were mild, transient and resolved with appropriate treatment. incidence of retinal detachment in our study was so low that any causal relationship between nd: yag laser posterior capsulotomy and retinal detachment seems unlikely, as has been suggested by nielsen ne et al25 as well. min jk et al10 have reported no complications in their study, probably due to preventive measures like use of steroids and iop lowering drugs. we did not use any drug post-procedure and prior to the development of complications, to observe the accurate effects of first crack guided conservative nd: yag laser posterior capsulotomy on the ocular structures. according to some studies, capsulotomy size and laser energy levels are directly proportional to the post-capsulotomy complications16,17,24. our method, “first crack guided conservative posterior capsulotomy” using nd: yag laser utilizes least energy as the crack is assisted by contractile forces of the posterior capsule and capsulotomy site and size is physiological owing to utilization of physiologically dilated pupil during the procedure. in other methods, where pharmacological mydriasis is used, there is a risk of performing an undesirably big and/or decentered capsulotomy. in our method, patient sitting in a dark room usually achieves maximum physiological dilatation of pupil within an hour and when the patient is taken to yag laser, the pupil starts contracting but the patient’s dilating phase of hippus is already facilitated and is utilized giving a physiologic capsular opening. as the crack line is followed in this method, the tear guides its own course and capsulotomy is achieved quickly with least number of shots and hence least amount of laser energy. this not only causes lesser number of complications but also prolongs the life of laser cavity of the machine. patient is comfortable before and after the procedure with quick visual recovery because less laser energy causes less pigment bleaching and there is no photophobia as pupil is not pharmacologically dilated. conclusion first crack guided conservative posterior capsulotomy using nd: yag laser has proved to be a quick, safe, efficient and cost effective method in our setting. it has the beauty of patient comfort and satisfaction, it is superior to other methods being utilized presently as it leads to perfectly centered capsulotomy, no photophobia and least complications due to least energy used inside the eye. authors affiliation syed imtiaz ali shah fcps, professor, department of ophthalmology, chandka medical college/smbb medical university larkana shujaat ali shah trainee registrar, department of ophthalmology, chandka medical college/smbb medical university larkana partab rai fcps, professor, department of ophthalmology, chandka medical college/smbb medical university larkana safdar ali abbasi ophthalmologist, department of ophthalmology, chandka medical college larkana naeem akhtar katpar ophthalmologist, department of ophthalmology, chandka medical college larkana role of authors: dr. syed imtiaz ali shah reviewed the case, images, and gave final approval of the manuscript to be published. dr. shujaat ali shah did literature search, drafted the manuscript, reviewed the case, images, and did the analysis. dr. partab rai reviewed the case, images, and revised the manuscript. dr. safdar ali abbasi involved in data collection and review of manuscript. dr. naeem akhtar katpar involved in data collection and review of cases. references 1. wormstone im. posterior capsule opacification: a cell biological perspective. exp eye res. 2002; 74 (3): 337-47. 2. nishi o, nishi k. intraocular lens encapsulation by shrinkage of the capsulorhexis opening. j cataract refract surg. 1993; 19: 544-5. 3. aron-rosa d, aron jj, griesemann m, thyzel r. use of the neodymium-yag laser to open the posterior capsule after lens implant surgery: a preliminary report. j am intraocul implant soc. 1980; 6 (4): 352-4. 4. nakazawa m, ohtsuki k. apparent accommodation in pseudophakic eyes after implantation of posterior chamber intraocular lenses. am j ophthalmol. 1983; 96(4): 435-8. syed imtiaz ali shah, et al 164 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology 5. kim mj, lee hy, joo ck. posterior capsule opacification in eyes with a silicone or poly methyl methacrylate intraocular lens. j cataract refract surg. 1999; 25 (2): 251-5. 6. levy jh, pisacano am. comparison of techniques and clinical results of yag laser capsulectomy with two qswitched units. j am intraocul implant soc. 1985; 11 (2): 131-3. 7. murrill ca, stanfield dl, van brocklin md. capsulotomy. optom clin. 1995; 4 (4): 69-83. 8. zeki sm. inverted u' strategy for short pulsed laser posterior capsulotomy. acta ophthalmol scand. 1999; 77 (5): 575-7. 9. shaikh ma, shah sia, siddiqui sj, shaikh ah, shaikh kr: the short term and long term complications of racquet shaped nd: yag posterior capsulotomy. ophthalmology update, 2014; 12 (4): 2702. 10. min jk, an jh, yim jh. a new technique for nd: yag laser posterior capsulotomy. int j ophthalmol. 2014; 7 (2): 345-9. 11. billotte c, berdeaux g. adverse clinical consequences of neodymium: yag laser treatment of posterior capsule opacification. j cataract refract surg. 2004; 30 (10): 2064-71. 12. khanzada ma, jatoi sm, narsani ak, dabir sa, gul s. is the nd: yag laser a safe procedure for posterior capsulotomy? pak j ophthalmol. 2008; 24 (2): 73-8. 13. newland tj, mcdermott ml, eliott d, hazlett ld, apple dj, lambert rj, barrett rp. experimental neodymium: yag laser damage to acrylic, poly methyl methacrylate, and silicone intraocular lens materials. j cataract refract surg. 1999; 25 (1): 72-6. 14. ge j, wand m, chiang r, paranhos a, shields mb. long-term effect of nd: yag laser posterior capsulotomy on intraocular pressure. arch ophthalmol. 2000; 118 (10): 1334-7. 15. khan b, alam m, shah ma, bashir b, iqbal a, alam a. complications of nd: yag laser capsulotomy. pak j ophthalmol. 2014; 30 (3): 133-6. 16. steinert rf, puliafito ca, kumar sr, dudak sd, patel s. cystoid macular edema, retinal detachment, and glaucoma after nd: yag laser posterior capsulotomy. am j ophthalmol. 1991; 112 (4): 373-80. 17. ari s, cingu ak, sahin a, inar yc, caca i. the effects of nd: yag laser posterior capsulotomy on macular thickness, intraocular pressure, and visual acuity. ophthalmic surg lasers imaging, 2012; 43 (5): 395-400. 18. harris ws, herman wk, fagadau wr. management of the posterior capsule before and after the yag laser. trans ophthalmol soc. 1985; 104: 533-5. 19. ficker la, steel ad. complications of nd: yag laser posterior capsulotomy. trans ophthalmol soc. 1985; 104: 529-32. 20. mastropasqua l, ciancaglini m, carpineto p. aqueous misdirection syndrome: a complication of neodymium: yag posterior capsulotomy. j cataract refract surg. 1994; 20 (5): 563-5. 21. carlson an, koch dd. endophthalmitis following nd:yag laser posterior capsulotomy. ophthalmic surg. 1988; 19 (3): 168-70. 22. raza a. complications after nd: yag posterior capsulotomy. j rawalpindi med coll. 2007; 11: 27-9. 23. burq ma, taqui am. frequency of retinal detachment and other complications after neodymium: yag laser capsulotomy. j pak med assoc. 2008; 58 (10): 550-2. 24. karahan e, er d, kaynak s. an overview of nd:yag laser capsulotomy. med hypothesis discov innov ophthalmol. 2014; 3 (2): 45-50. 25. nielsen ne, naeser k. epidemiology of retinal detachment following extracapsular cataract extraction: a follow-up study with an analysis of risk factors. j cataract refract surg. 1993; 19 (6): 675-80. 347 pak j ophthalmol. 2021, vol. 37 (4): 347-351 original article comparative analysis of retinal nerve fiber layer thickness between normal and mild to moderately myopic eyes gul nasreen 1 , shaheer suhail sarwar 2 , irfana bibi 3 , muhammad arslan ashraf 4 1-5 department of ophthalmology, king edward medical university, lahore abstract purpose: to determine the difference between mean retinal nerve fiber layer (rnfl) thickness in myopic eyes (up to -6.00d) and normal eyes. study design: descriptive observational study. place and duration of the study: eye department of mayo hospital lahore, from february 2019 to april 2019. methods: we compared the mean rnfl between 58 myopic eyes (up to -6.00 d) and age matched 60 normal eyes. the age of the participants was between 12 to 42 years. complete ocular examination was done and rnfl thickness was measured by using optical coherence tomography (nidex rs-33.0, software-ex 1.5.2).data was analyzed by independent sample t-test by using spss; with p < .05 as significant. results: the mean difference among these groups was 5.852 µm with (se: 1.929). mean rnfl thickness in myopic group was (95.93 ± 10.158µm) with (se: 1.334). the result for mean rnfl thickness in myopic eyes was distributed normally as p < .03. mean rnfl in normal group was (101.78 ± 10.774 µm) with (se: 1.391), and the result of mean rnfl thickness measured in normal eyes was not distributed normally as p < .20. the results showed that there is a statistically significant difference between mean rnfl thickness measured in normal versus myopic eyes as (p < .003). conclusion: there is a significance difference between mean rnfl thickness between myopic eyes and normal eyes as measured by oct. careful interpretation of rnfl data in myopic eyes is recommended to avoid misdiagnosis with glaucoma. key words: retinal nerve fiber layer thickness, myopia, optical coherence tomography. how to cite this article: nasreen g, sarwar ss, bibi i, ashraf ma. comparative analysis of retinal nerve fiber layer thickness between normal and mild to moderately myopic eyes. pak j ophthalmol. 2021, 37 (4): 347-351. doi: 10.36351/pjo.v37i4.1219 correspondence: gul nasreen department of ophthalmology king edward medical university lahore email: nasringojali@yahoo.com received: february 02, 2021 accepted: july 23, 2021 introduction myopia has appeared as a major health problem in east asia. the high occurrence of myopia in east asian cities is likely to be associated with increasing educational pressures and with other changes in life style, which have reduced the time children spend outdoors. 1 the prevalence of myopia has been increasing over the past decades, with a projected half of the world population estimated to be myopic by 2050. 1 this condition is especially very common in east asia, where the prevalence has been estimated to open access comparative analysis of retinal nerve fiber layer thickness between normal and mild to moderately myopic eyes pak j ophthalmol. 2021, vol. 37 (4): 347-351 348 be as high as 90%. myopia has been connected with an increased risk of different other ocular diseases, of which glaucoma remains one of the main ocular problems. 2 myopia is more common in children of urban area, chinese and asians. 3 percentages of myopia is high in east and southeast especially in young adults. 4 myopia is vision threatening if choroid neovascularization occurs which is considered to be a major risk factor for vision loss in pathologic myopia. 5 measuring rnfl thickness without testing refractive error or optical status of the eye may lead to misdiagnosis of glaucoma, especially in myopic eyes. disc changes in myopic eyes may make it difficult to distinguish glaucomatous optic neuropathy from the myopia-related optic nerve and retinal abnormalities that may complicate both the diagnosis and treatment of glaucomatous disease. 6 optical coherence tomography is used to measure per-papillary retinal nerve fiber layer thickness. it is a non-contact technique. 7 oct measurements are important and have become an essential part of diagnosis of different ocular conditions and assessing the prognosis and outcomes of surgery. 8 as myopia leads to decrease in rnfl thickness, it is important to differentiate between the rnfl thinning caused by myopia and glaucoma. rationale of the current study was to compare the mean rnfl thickness in myopic eyes with normal eyes and to interpret the effect of age on the physiological and structural changes of rnfl in myopic and normal eyes. methods it was a comparative cross-sectional study. sixty normal eyes and 58 myopic eyes were included in the study by convenient sampling technique, from outpatient department of ophthalmology, mayo hospital, lahore from february 2019 to april 2019.group 1 comprised of normal eyes and group 2 included myopic eyes with less than -6.00 diopters. age of the participants ranged between 12 – 42 years. individuals with history of any systemic disease, any organic ocular pathology, uncooperative individuals, glaucomatous eyes, high myopia above -6.00d and any other refractive error were excluded from the study. mild myopia was defined as myopia of -0.5d to ≤ 3 d and moderate as values between -3 d and < -6 d. 9 the mean rnfl thickness was defined according to the isnt rule; thickest inferior quadrant with rnfl = 126 ± 15.8 µm, superior rnfl = 117.2 ± 16.13 µm, nasal = 75 ± 13.9 µm and thinnest temporal quadrant with 70.6 ± 10.8µm. 10 relationship of mean the rnfl thickness of two groups was analyzed by independent sample t-test with p < 0.05 as significant. data collection was started after approval from the ethics committee. informed consent were obtained from the participants and a detailed history was taken along with a complete ophthalmological examination. auto refraction and retinoscopy was performed to check the amount of refractive error. retinal nerve fiber layer thickness measurement was performed by using oct (nidex rs-33.0, software-ex 1.5.2). data was analyzed using spss-23.quantitative variables (age) was shown as mean ± standard deviation. relationship of mean retinal nerve fiber layer thickness among two groups ‘myopic and normal’ eyes was analyzed by independent sample t-test with p value of 0.05 taken as significant. results the mean difference of rnfl between the two groups was 5.852 µm (se: 1.929). mean rnfl thickness in myopic group was 95.93 ± 10.158 µm (se: 1.334). mean value of rnfl thickness in myopic eyes was distributed normally as p < 0.03. mean rnfl in normal group was 101.78 ± 10.774 µm (se: 1.391) and it was not distributed normally as p < 0.20. the results showed statistically significant difference between mean rnfl thickness of normal and myopic eyes (p < 0.003). mean age of myopic group was 27.21 ± 7.360 years, with mean rnfl thickness of right eye as 95.276 ± 9.9135 µm, and left eye as 97.276 ± 10.853 µm. results showed that age has a weak positive correlation with mean rnfl thickness in myopic eyes as (r = 1.89, p < 1.66, n = 58.). age has a moderately positive correlation (r = .364, p = .0.01, n = 60.) with mean rnfl thickness in normal eyes. results table1. the normal distribution of data is tested by using shapiro-wilk test and kolmogorov-smirnov b https://www.sciencedirect.com/topics/medicine-and-dentistry/myopia gul nasreen, et al 349 pak j ophthalmol. 2021, vol. 37 (4): 347-351 test. the result for mean retinal nerve fiber layer thickness in myopic eyes was distributed normally as p < 0.05. table 1: tests of normality in myopic eyes. kolomogorov-simirnov b shapiro-wilk statistic df sig. statistics df sig. mean rnfl thickness .123 58 0.03 .965 58 .090 table 2: descriptive analysis of myopic eyes. descriptive analysis statistic std. error mean rnfl thickness mean 95.93 1.334 95% confidence interval for mean lower bound 93.26 upper bound 98.60 5% trimmed mean 95.65 median 95.00 variance 103.188 std. deviation 10.158 minimum 76 maximum 122 range 46 interquartile range 13 skewness .548 .314 kurtosis .329 .618 table 2: shows the descriptive analysis of mean rnfl recorded in myopic eyes. the mean retinal nerve fiber layer thickness was (95.93±10.16 mm) with (se: 1.33). table 3: descriptive analysis of normal eyes. statistic std. error mean rnfl thickness mean 101.78 1.391 95% confidence interval for mean lower bound 99.00 upper bound 104.57 5% trimmed mean 101.59 median 101.50 variance 116.071 std. deviation 10.774 minimum 81 maximum 127 range 46 interquartile range 17 skewness .214 .309 kurtosis -.582 .608 table 3 shows the descriptive analysis of mean rnfl recorded in myopic eyes. the mean retinal nerve fiber layer thickness was (101.9 ± 10.78 mm) with (se: 1.4). table 4: t test for group statistics. refractive status n mean std. deviation std. error mean mean rnfl thickness normal 60 101.78 10.774 1.391 myopia 58 95.93 10.158 1.334 table 4: shows comparison between normal subjects and subjects having myopia. independent t-test was applied. mean retinal nerve fiber layer in normal group was (101.78 ± 10.774mm) with (se: 1.391), and mean retinal nerve fiber layer thickness in myopic group was (95.93 ± 10.158mm) with (se: 1.334). table 5: independent sample t test. independent samples test levene's test for equality of variances t-test for equality of means f sig. t df sig. (2tailed) mean difference std. error difference 95% confidence interval of the difference lower upper mean rnfl thickness equal variances assumed 1.161 .283 3.034 116 .003 5.852 1.929 2.032 9.673 equal variances not assumed 3.037 115.930 .003 5.852 1.927 2.035 9.669 table 5: the above table shows comparison between normal subjects and subjects having myopia. independent sample levene’s test has been applied for equality variance and t-test done measure equality of mean. the results showed that there is significant difference comparing mean retinal nerve fiber layer thickness measured in normal and myopic eyes as p <.05. the mean differences among these groups are 5.852mm with (se: 1.929). comparative analysis of retinal nerve fiber layer thickness between normal and mild to moderately myopic eyes pak j ophthalmol. 2021, vol. 37 (4): 347-351 350 discussion the results of this cross-sectional study established that there was significant difference in mean rnfl thickness between myopic group and normal group. myopes have lower rnfl values and myopia is also a risk factor for primary open angle glaucoma. 11 myopia is not a simple refractive error, but an eyesightthreatening disease 12 . according to who, a large population of the world is going to be affected by myopia by 2050. 13 myopia presents a significant challenge to the ophthalmologists as myopic discs are often seen large, tilted, with deep cups and have a thinner neuro-retinal rim making diagnosis of glaucoma as a challenge. optic disc changes and malformations in myopic eyes may lead to progression of glaucoma. 14,15 a recent cohort study stated that myopia can significantly affect gcipl(ganglion cell inner plexiform layer) and rnfl thickness profiles, and optic disc size has a significant effect on rnfl thickness 16 . though the current study does not include a detailed evaluation of the optic nerve head and retina it evaluated average rnfl thickness of the four quadrants. it showed that mean rnfl thinning was seen in myopic eyes. atta allah and coworkers found that myopia has an effect on the retinal nerve fiber layer thickness distribution. patients with high myopia have characteristic altered distribution pattern of rnfl thinning. 17 high myopes were excluded from our study and we evaluated low to medium myopic eyes. kelly d and co-workers concluded from their study that oct measurements and evaluations of thickness of nerve fiber layer of the retina in patients with high myopia must be done carefully in order to avoid any misdiagnosis with glaucoma. 18 study by elm tai and et al suggested that status of refractive error must be evaluated with caution when evaluating or assessing oct report of individuals with myopia as nerve fiber layer of the retina and its thickness changes with the increase in myopia. 19 others suggested that eyes with high level of myopia have an unusual reduction of rnfl thickness in two years duration than in emetropes. 20 a study showed that in hyperopia the retinal thickness increases and it decreases in myopic eyes. 21 a significant change was seen when both myopic and hyperopic eyes were compared with normal group. the change in myopia was seen more significant (p = 0.001) than hyperopia (p = 0.031) 21 . optic disc tilt and torsion along with peri-papillary atrophyseen in myopic eyes makes detection of glaucomatous optic disc changes difficult. with increasing axial length, the optic disc alters in shape from an almost round one to a vertically oval structure. 22 another study from pakistan also showed similar effect of myopia on rnfl thickness. 23 studies on ganglion cell layer (gcl) thickness has revealed more thinning of the gcl in subject with high myopia than with low myopia and moderate myopia. 24 there are certain limitations of this study. we included all patients of mild to moderate myopia in this study and the type of myopia based on axial length, curvature of lens and cornea were not taken into account. myopic and normal individual outside 12 to 42 years of age were not studied. conclusion there is a significance difference between mean rnfl thickness between myopic eyes and normal eyes as measured by oct. careful interpretation of rnfl data in myopic eyes is recommended to avoid misdiagnosis with glaucoma. ethical approval the study was approved by the institutional review board/ ethical review board. (332/rc/kemu) conflict of interest authors declared no conflict of interest. references 1. morgan ig, ohno-matsui k, saw s-m. myopia. the lancet, 2012; 379 (9827): 1739-1748. 2. tai elm, ling jl, gan eh, adil h, wanhazabbah w-h. comparison of peripapillary retinal nerve fiber layer thickness between myopia severity groups and controls. intern j ophthalmol. 2018; 11 (2): 274. 3. chen s-j, lu p, zhang w-f, lu j-h. high myopia as a risk factor in primary open angle glaucoma. int j opthamol. 2012; 5 (6): 750. 4. mak c, yam jc, chen l, lee s, young al. epidemiology of myopia and prevention of myopia progression in children in east asia: a review. hong kong med j. 2018; 24 (6): 602-609. 5. soubrane g. choroidal neovascularization in pathologic myopia: recent developments in diagnosis and treatment. surv ophthalmol. 2008; 53 (2): 121138. gul nasreen, et al 351 pak j ophthalmol. 2021, vol. 37 (4): 347-351 6. porwal s, nithyanandam s, joseph m, vasnaik ak. correlation of axial length and peripapillary retinal nerve fiber layer thickness measured by cirrus hd optical coherence tomography in myopes. indian j ophthalmol. 2020; 68 (8): 1584-1586. 7. leung ck-s, mohamed s, leung ks, cheung cyl, chan sl-w, cheng dk-y, et al. retinal nerve fiber layer measurements in myopia: an optical coherence tomography study. invest ophthalmol vis sci. 2006; 47 (12): 5171-5176. 8. ng d, cheung c, luk f, mohamed s, brelen m, yam j, et al. advances of optical coherence tomography in myopia and pathologic myopia. eye (lond). 2016; 30 (7): 901. 9. varma r, bazzaz s, lai mi. optical tomography – measured retinal nerve fiber layer thickness in normal latinos. invest opthalmol vis sci. 2003; 44 (8): 3369-3373. 10. alasil t, wang k, keane pa, lee h, baniasadi n, de boer jf, et al. analysis of normal retinal nerve fiber layer thickness by age, sex, and race using spectral domain optical coherence tomography. j glaucoma, 2013; 22 (7): 532-541. 11. yokoyama y, aizawa n, chiba n, omodaka k, nakamura m, otomo t, et al. significant correlations between optic nerve head microcirculation and visual field defects and nerve fiber layer loss in glaucoma patients with myopic glaucomatous disk. clin opthalmol. 2011; 5: 1721. 12. wu pc, huang hm, yu hj, fang pc, chen ct. epidemiology of myopia. asia pac j ophthalmol (phila). 2016; 5 (6): 386-393. 13. resnikoff s, jonas jb, friedman d, he m, jong m, nichols jj, et al. myopia–a 21st century public health issue. invest ophthalmol vis sci. 2019; 60 (3). 14. tan ny, sng cc, ang m. myopic optic disc changes and its role in glaucoma. curr opin ophthalmol. 2019; 30 (2): 89-96. 15. williams km, bertelsen g, cumberland p, wolfram c, verhoeven vj, anastasopoulos e, et al. increasing prevalence of myopia in europe and the impact of education. j opthalmol. 2015; 122 (7): 14891497. 16. seo s, lee ce, jeong jh, park kh, kim dm, jeoung jw. ganglion cell-inner plexiform layer and retinal nerve fiber layer thickness according to myopia and optic disc area: a quantitative and three-dimensional analysis. bmc ophthalmology, 2017; 17 (1): 22. 17. attaallah hr, omar ian, abdelhalim as. evaluation of optic nerve head parameters and retinal nerve fiber layer thickness in axial myopia using sd oct. opthalmol ther. 2017; 6 (2): 335-341. 18. schweitzer kd, ehmann d, garcía r. nerve fibre layer changes in highly myopic eyes by optical coherence tomography. canadian journal of ophthalmology, 2009; 44 (3): e13-e16. 19. tai elm, ling jl, gan eh, adil h, wanhazabbah w-hi. comparison of peripapillary retinal nerve fiber layer thickness between myopia severity groups and controls. int j opthamol. 2018; 11 (2): 274. 20. lee m-w, kim j-m, shin y-i, jo y-j, kim j-y. longitudinal changes in peripapillary retinal nerve fiber layer thickness in high myopia: a prospective, observational study. j opthalmol. 2019; 126 (4): 522528. 21. sowmya v, venkataramanan v, prasad v. effect of refractive status and axial length on peripapillary retinal nerve fibre layer thickness: an analysis using 3d oct. jclin diagnost res. 2015; 9 (9): nc01. 22. jonas jb, ohno-matsui k, panda-jonas s. myopia: anatomic changes and consequences for its etiology. asia pac j ophthalmol (phila). 2019; 8 (5): 355-359. 23. mubashir a, khan ma, saeed s, irfan b, irfan o, niazi jh. mean retinal nerve fiber layer thickness in high myopics using optical coherence tomography in a tertiary care hospital in karachi, pakistan. pak j ophthalmol. 2018; 34 (1). 24. sezgin akcay bi, gunay bo, kardes e, unlu c, ergin a, editors. evaluation of the ganglion cell complex and retinal nerve fiber layer in low, moderate, and high myopia: a study by rtvue spectral domain optical coherence tomography. semin ophthalmol. 2017. authors’ designation and contribution gul nasreen; optometrist: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. shaheer suhail sarwar; assistant professor: concepts, manuscript review. irfana bibi; optometrist: statistical analysis, manuscript preparation. muhammad arslan ashraf; diagnostic oculist: manuscript preparation, manuscript editing, manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (3): 322-326 322 original article improving the outcomes of modified manual small incision cataract surgery using clinical audit muhammad ifraheem khan 1 , saba ali arif 2 , muhammad raja 3 , sheikh ijaz 4 , muhammad saeed khan 5 1 layton rehmatullah benevolent trust free eye hospital 2 pakistan institute of medical sciences, 3 james paget university hospitals nhs foundation trust, 4 east surrey hospital red hill. uk 5 layton rahmatulla benevolent trust abstract purpose: to use clinical audit in improving the outcomes of manual small incision cataract surgery technique study design: clinical audit. place and duration: layton rehmatullah benevolent trust eye hospital karachi, from september 2019 to december 2019. methods: two hundred patients who had undergone manual small incision cataract surgery were selected. cases with traumatic cataract, weak zonules, pseudoexfoliation, and more than 1 diopter difference in keratometric readings, corneal and retinal pathologies were excluded. surgical complications and visual outcomes were recorded on the 7th postoperative day. refractive data was recorded from subjective refraction. data was analyzed by university hospital bristol formula. standards were set using international literature. deficiencies were noted and technique was modified to improve the outcome. the audit was repeated after 2 months to see whether modifications had improved the outcome. results: in the first audit, posterior capsular rupture rate was 1%, corrected visual acuity of 6/12 or better was achieved in 85.36% and surgically induced cylinder of less than 2 dc was achieved in 75.60% of the patients. in the second audit all standards were achieved. posterior capsular rupture did not occur. corrected visual acuity of 6/12 or better was achieved in 90.50% and induced cylinder of less than 2 dc was achieved in 87.05% of the patients. conclusion: clinical audit of the surgical procedures is a good technique in improving the outcomes of manual small incision cataract surgery. key words: cataract extraction, clinical audit, posterior capsular rupture, astigmatism, visual acuity. how to cite this article: khan im, arif sa, raja m, ijaz s, khan ms. improving the outcomes of modified manual small incision cataract surgery using clinical audit. pak j ophthalmol. 2021, 37 (3): 322-326. doi: 10.36351/pjo.v37i3.1234 introduction the most common type cataract formation is the senile cataract which results from different biochemical and structural alterations in lens with advancing age. 1 correspondence: muhammad ifraheem khan layton rehmatullah benevolent trust free eye hospital email: ifraheem.khan@yahoo.com received: february 25, 2021 accepted: april 28, 2021 although exact pathogenesis is unclear, as the person ages, lens proteins breakdown and form clumps of high molecular weight materials which opacify and affect the visual quality. 2 other causes include trauma, drugs, metabolic disorders, radiation and congenital. cataract is the second most common cause (65.2 million people) of decreased vision and the most common cause of treatable blindness worldwide. 3 efforts are continuously made to improve the outcomes of cataract surgery for which new techniques are introduced and old are improvised. a cost effective alternative to phacoemulsification is manual small open access https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewj8m7kt87twahvkbc0khd6bbjqqfjaaegqiaxad&url=https%3a%2f%2fwww.jpaget.nhs.uk%2f&usg=aovvaw0s_wfj2-fcbg5surzidnz6 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewj8m7kt87twahvkbc0khd6bbjqqfjaaegqiaxad&url=https%3a%2f%2fwww.jpaget.nhs.uk%2f&usg=aovvaw0s_wfj2-fcbg5surzidnz6 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewj8m7kt87twahvkbc0khd6bbjqqfjaaegqiaxad&url=https%3a%2f%2fwww.jpaget.nhs.uk%2f&usg=aovvaw0s_wfj2-fcbg5surzidnz6 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewj8m7kt87twahvkbc0khd6bbjqqfjaaegqiaxad&url=https%3a%2f%2fwww.jpaget.nhs.uk%2f&usg=aovvaw0s_wfj2-fcbg5surzidnz6 muhammad ifraheem khan, et al 323 pak j ophthalmol. 2021, vol. 37 (3): 322-326 incision cataract surgery (msics) which has comparable best corrected visual acuity to phacoemulsification, but can produce higher induced astigmatism. phacoemulsification is gold standard for cataract surgery because of small incision size, faster visual recovery/rehabilitation and minimum surgically induced astigmatism, but is not available in all parts of the world because of high cost, longer learning curve and technical expertise. 4 extra capsular cataract extraction (ecce) is less favored because it requires large incision, suture closure of the wound and slow rehabilitation. 5 to judge the outcomes of a surgical procedure, clinical audit is a very effective tool in improving the quality. 6 generally speaking, there are 2 ways of audit. firstly to join an already organized audit and secondly to setup an audit yourself. 7 we used clinical audit cycle in this study to improve our surgical outcomes in terms of reducing posterior capsular rupture rate and visual status. we compared our results with internationally accepted standards. methods the first audit was done between 21 st september 2019 and 30 september 2019. we examined 100 consecutive surgeries of msics in july 2019 by one surgeon in layton rehmatullah benevolent trust eye hospital karachi. cases with traumatic cataract, weak zonules, pseudoexfoliation, and more than 1 diopter difference in keratometric readings, corneal and retinal pathologies were excluded. following standards were set (to compare the outcome) after reviewing the literature; 7,8,9,10 sn outcome proportion 1. posterior capsular rupture with vitreous loss 1.4% 2. over all best corrected snellen visual acuity of 6/12 or better 89.2% 3. surgically induced astigmatism of 2dc or less 85% msics was performed as follow; a straight, partial thickness incision was made about 1.5mm posterior to the limbus in conjunctiva and sclera superiorly centering at 12 o clock position. a tunnel entry of about 2.5mm long was made into the anterior chamber with 3.2mm keratome. after capsulorhexis (about 6mm), 3.2mm wide tunnel was extended by passing a 5.2mm keratome through it. intraocular pmma lens was implanted after nucleus delivery with wire vectus and lens matter removal with irrigation aspiration cannula. data was obtained from electronic patient record, patient files, surgical complication logbook, postoperative refraction and visual acuity (7th postoperative day) logbook. refractive data was recorded as subjective refraction (not keratometric readings) of patients on first follow up (1 week after surgery).recorded data was analyzed according to the formula developed by audit department of university hospital bristol 11 and results were compared with standards. after analysis, our results were presented in hospital meeting. deficiencies (detailed in table 1 & 2) were noted and discussed. after discussion, it was planned to apply some modification to the technique and do another audit after 2 months to see if modifications applied have improved the outcome. following modifications were made; main incision was moved from superior to superotemporal location and two side ports of about 2mm wide were made about 3 clock hours away from the center of main incision in clear cornea on each side to neutralize the astigmatism caused by the main incision. all steps of the main incision were completed with 3.2mm keratome (5.2mm keratome was not used). steps of the surgery are shown in figure 1and 2. the second audit was done in december 2019 in which 100 surgeries done between 01/11/2019 and 21/11/2019were evaluated to see whether applied modifications had improved the outcome. data collection and methods of analysis were same as for the first audit and results were compared with set standards (table 1 and 2). figure 1(a): entry into conjunctiva. (b, c): tunnel construction with sweeping movement of keratome. (d): anterior chamber entry. (e, f): nucleus delivery. improving the outcomes of modified manual small incision cataract surgery using clinical audit pak j ophthalmol. 2021, vol. 37 (3): 322-326 324 figure 2: diagram of the incision sites and sizes of modified technique. results patients included in this audit cycle ranged from 50 to 85 years of age. in the first audit, one posterior capsular rupture occurred while polishing the posterior capsule. anterior vitrectomy was done, iol was placed in the sulcus and center of the main incision was sutured. refractive and visual acuity data of 82 (82%) patients who came for follow up after 1 week was analyzed. one out of three set standards achieved were (detailed in table 1). out of 9 patients who had 6/18 snellen visual acuity, 2 had mild corneal edema (deep seated eyes), one had posterior capsular rupture during surgery, whereas surgically induced astigmatism (> 3d) was the cause in remaining 6 patients. one patient had age related macular degeneration (fundus not visible because of hypermature cataract during preoperative assessment) whose visual acuity was 6/36 (table2). seven patients had large mature nuclei which required about 7mm of scleral tunnel incision for delivery. these patients had 3dc or more of astigmatism post operatively. table 1: comparison of the audit results with set standards. results of the first audit targets standard personal achieved posterior capsular rupture 1.4% 1% yes corrected visual acuity 6/12 or better 89.2% 85.36% no astigmatism of <2dc 85% 75.60% no results of the re-audit targets standard personal achieved posterior capsular rupture 1.4% 0% yes corrected visual acuity 6/12 or better 89.2% 90.50% yes astigmatism of <2dc 85% 87.05% yes (dc = diopter cylinder) in the second audit (done after applying the modification) 85 (85%) patients came for follow up after 1 week and data analysis revealed that all standards were achieved. only one patient had visual acuity < 6/18 because of asteroid hyalosis. seven patients had 6/18 visual acuity because of > 3dc astigmatism (4 patients), mild corneal edema (1 patient), and in 2 patients no obvious reason could be identified. patients who had over 3 dc astigmatism required large scleral incision to deliver large nucleus. results summarized in (table 2). table 2: corrected visual acuity and surgically induced cylinder outcome of the first and second audit recorded on 7th postoperative day. outcome of the first audit corrected visual acuity surgically induced cylinder va 6/6 – 6/9 6/12 6/18 < 6/18 < 2dc 2.5 – 3 dc 3.25 – 4 dc number of patients 57 13 9 1 (6/36) 62 13 7 total (85.36%) (10.97%) (1.21%) 75.60% 15.85% 8.53% outcome of the re-audit corrected visual acuity surgically induced cylinder va 6/6 – 6/9 6/12 6/18 < 6/18 < 2dc 2.5 – 3 dc 3.25 – 4 dc #of patients 61 16 7 1 (6/24) 74 07 4 total (90.50%) (8.23%) (1.17%) 87.05% 8.23% 4.70% (va=visual acuity, dc=diopter cylinder) muhammad ifraheem khan, et al 325 pak j ophthalmol. 2021, vol. 37 (3): 322-326 discussion in our re-audit of msic technique, clear improvement in surgical outcome in terms of best corrected visual acuity and surgically induced astigmatism were observed after modifying the technique. reduction in surgically induced astigmatism has been observed by moving the incision from superior to superotemporal location in mics in many studies. 12,13 different changes have been introduced in mics technique since its introduction in terms of incision site, size and shape, tunnel length, number of side ports, their locations and purpose, methods of capsulorhexis and nucleus delivery to improve surgical outcome. chevron’s incision is reported to cause the least astigmatism compared to frown, straight and blumenthal incisions. 14 moreover, farther the incision from the limbus and smaller in size, lesser the astigmatism. side ports have been used for anterior chamber (ac) maneuvering and placement of ac maintainer. msics is better in terms of learning curve, surgical time, availability and affordability than phacoemulsification (gold standard) and has comparable results to it in terms of complication and long term visual outcome. whereas, astigmatism is less and rehabilitation is faster in phacoemulsification. several guidelines have been established to improve the cataract surgery by using audit as a tool. according to lindfield, it is important in clinical audit that if the initial results do not provide better results, further changes should be made for improvement. 15 thus, auditing and re-auditing is the key. a standardized audit system for cataract surgeons is the eurequo project which helps cataract surgeons to monitor their results and compare them against a europe-wide benchmark with the promise of improving the refractive results of cataract surgery. 16 retrospective manual auditing of cataract outcome is time consuming and many countries have adopted electronic system and it was recommended in the rcophth’s cataract surgery guidelines. 17 in pakistan, we lack far behind in audit system. few audits of cataract surgery are available but nonetheless, audit cycle is rarely carried out. 18,19,20 audit brings forth some interesting facts, which are generally overlooked. one study measured the number of times a sharp instruments was used in a modified mics technique (all steps of the main incision and side ports were made with 3mm keratome) in hiv patients and reported it to be 3 times (scissors for conjunctival peritomy, keratome for tunnel making and 25g needle for sub conjunctival medication), reducing the risk of transmission to a significant level. 21 in terms of limitations, postoperative data after 1 week of surgery was analyzed because follow-up dropped to less than 50% on second week due to logistic and cultural reasons, whereas 4 to 6 weeks postoperative visual outcome data was reported in the literature from which the standards were developed. secondly, all patients did not show up for follow up. these limitations may have affected the results, but lessons learned from this audit have improved the surgical outcome to a significant level. conclusion this audit has shown that a superiotemporal sclerocorneal, wedge shaped tunnel incision (with 2 side ports 3 clock hours away from its center) has visual outcome and posterior capsular rupture rate comparable to the internationally accepted standards. clinical audit is an effective tool to improve the outcomes of cataract surgery. acknowledgement special thanks to british pakistani ophthalmic society (bpos) for review and to mohammad hassan javed for helping with refractive data collection. ethical approval the study was approved by the institutional review board/ ethical review board. (smo-1/lrbt) conflict of interest authors declared no conflict of interest. references 1. bowling b. kanski’s clinical ophthalmology: a systematic approach. 8th ed. london, england: w b saunders; 2015. 2. denniston a, murray p. oxford handbook of ophthalmology. london, england: oxford university press; 2018. 3. vision impairment and blindness. available at: http://www.who.int/mediacentre/factsheets/fs282/en/ improving the outcomes of modified manual small incision cataract surgery using clinical audit pak j ophthalmol. 2021, vol. 37 (3): 322-326 326 4. signes-soler i, javaloy j, muñoz g, moya t, montalbán r, albarrán c. safety and efficacy of the transition from extracapsular cataract extraction to manual small incision cataract surgery in prevention of blindness campaigns. middle east afr j ophthalmol. 2016; 23 (2): 187-194. doi: 10.4103/0974-9233.175890. 5. rajkarnikar s, shrestha db, dhakal s, shrestha r, thapa k, gurung a. comparative study of extra capsular cataract extraction (ecce) and small incision cataract surgery (sics): experience on cataract surgery in a tertiary center of army hospital, kathmandu. nepal j ophthalmol. 2018; 10 (20): 162167. doi: 10.3126/nepjoph. 6. limb c, fowler a, gundogan b, koshy k, agha r. how to conduct a clinical audit and quality improvement project. int j surg oncol (n y). 2017; 2 (6): e24. doi: 10.1097/ij9.0000000000000024. 7. improvement plan, do, study, act (pdsa): nhs institute for innovation and improvement, 2008. available at: http://webarchive.nationalarchives.gov.uk/2012110807 4656/http://www.institute.nhs.uk/quality_and_service_i mprovement_tools/quality_and_service_improvement_t ools/plan_do_study_act.html. 8. henry p, donachie j, sparrow j. national ophthalmology database audit. 2nd ed. [ebook] london: royal college of ophthalmologists london. https://www.nodaudit.org.uk/resources/publicationsannual-report 9. venkatesh r, muralikrishnan r, balent lc, prakash sk, prajna nv. outcomes of high volume cataract surgeries in a developing country. br j ophthalmol. 2005; 89 (9): 1079-1083. 10. bigyabati r, victor r, rajkumari b. a comparative study of the amount of astigmatism following conventional extra capsular cataract extraction and manual small incision cataract surgery. j evid based med health, 2016; 3 (47): 2342-2345. clinical audit. available at: http://www.uhbristol.nhs.uk/for-clinicians/clinicalaudit/ 11. nikose as, saha d, laddha pm, patil m. surgically induced astigmatism after phacoemulsification by temporal clear corneal and superior clear corneal approach: a comparison. clin ophthalmol. 2018; 12: 65-70. https://doi.org/10.2147/opth.s149709 12. sharma u, sharma b, kumar k, kumar s. evaluation of complications and visual outcome in various nucleus delivery techniques of manual small incision cataract surgery. indian j ophthalmol. 2019; 67 (7): 1073. 13. singh k, misbah a, saluja p, singh ak. review of manual small-incision cataract surgery. indian j ophthalmol. 2017; 65 (12): 1281. 14. lindfield r. the value of clinical audit to improve cataract quality. community eye health, 2014; 27 (87): 55. 15. improving refractive results of cataract surgery through audit. available at: https://crstodayeurope.com/articles/2011feb/improving-refractive-results-of-cataract-surgerythrough-audit/ 16. the royal college of ophthalmologists. cataract surgery guidelines, 2004. http://www.rcophth.ac.uk/docs/publications/publishedguidelines/finalversionguidelinesapril2007updated.p df. 17. chaudhry rk, khan nq, dembra wk, riaz a, vickash g. pediatric cataract surgery audit at a tertiary care center in karachi, pak. j. ophthalmol. 2020; 36 (1): 38-42. https://doi.org/10.36351/pjo.v36i1.898. 18. chhipa sa, junejo mk. outcomes of cataract surgery at teaching hospital in karachi. j pak med assoc. 2018; 68 (1): 76-80. 19. paracha q. cataract surgery at marie adelaide leprosy centre karachi: an audit. j pak med assoc. 2011 jul; 61 (7): 688-90. pmid: 22204247. 20. giles k, domngang c, nguefack-tsague g, come em, wiedemann p. modified small incision cataract surgery and intraocular lens implantation in hiv patients. ophthalmol eye dis. 2015 nov 9; 7: 35-7. doi: 10.4137/oed.s31013. authors’ designation and contribution muhammad ifraheem khan; fellow pediatric: concepts, design, literature search, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. saba ali arif; medical officer: concepts, literature search, data acquisition, data analysis, manuscript preparation, manuscript review. muhammad raja; consultant ophthalmologist: concepts, design, data analysis, manuscript preparation, manuscript review. sheikh ijaz; consultant ophthalmologist: concepts, design, data analysis, manuscript preparation, manuscript editing, manuscript review. muhammad saeed khan; chief medical officer: design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation. .…  …. http://webarchive.nationalarchives.gov.uk/20121108074656/http:/www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html http://webarchive.nationalarchives.gov.uk/20121108074656/http:/www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html http://webarchive.nationalarchives.gov.uk/20121108074656/http:/www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html http://webarchive.nationalarchives.gov.uk/20121108074656/http:/www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html http://webarchive.nationalarchives.gov.uk/20121108074656/http:/www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html http://www.rcophth.ac.uk/documents.asp?section=39&sectiontitle=publications&let=c http://www.rcophth.ac.uk/documents.asp?section=39&sectiontitle=publications&let=c http://www.rcophth.ac.uk/documents.asp?section=39&sectiontitle=publications&let=c https://doi.org/10.36351/pjo.v36i1.898 microsoft word 8. asad azeem mirza mm 226 pakistan journal of ophthalmology, 2020, vol. 36 (3): 226-230 original article intra-operative and immediate post-operative complications of cataract surgery in an eye camp asad azeem mirza1, saba al-khairy2, mazhar-ul-hassan3, shahid azeem mirza4, saad aslam5 farnaz siddique6 1,2,3,5,6department of ophthalmology, dow international medical college, duhs 4department of ophthalmology, ghambat institute of medical sciences abstract purpose: to analyze the intra-operative and immediate post-operative complications in patients after cataract surgery in an eye camp. study design: descriptive cross-sectional study. place and duration of study: the study was conducted in a village of nawabshah, sindh, pakistan from 7th to 9th of february 2020. material and methods: fifteen hundred patients were screened for visual disabilities of which 150 were selected for the study. they had a visual acuity of less than 6/9 in one or both eyes and had a cataract. the selected patients were operated using either phacoemulsification, extracapsular cataract extraction ecce), intracapsular cataract extraction (icce) or small incision cataract surgery (sics). the immediate intra-operative as well as post-operative complications on day 1 after surgery were observed. results: one hundred and fifty patients were operated. age ranged from 14 years to 90 years, males were 58.7% and females were 41.3%. the most common procedure performed was phacoemulsification 51.3%, followed by ecce 30.0%, then sics 18.0% and icce 0.7%. the most common intra-operative complication was posterior capsule rent and the most common post-operative complication was striate keratopathy which was seen in 14.0% individuals. there was a significant association found for post-operative complications with gender with females having more post-operative complications as compared to males (p-value = 0.001 < 0.001). conclusion: camp surgeries when performed with strict sterilization and in experienced hands can play an important role in treating cataract, which is the commonest cause of preventable blindness in developing countries. key words: cataract, intra-ocular lens, phacoemulsification, extra capsular cataract extraction, corneal edema. how to cite this article: mirza aa, al-khairy s, hassan m, mirza sa, aslam s, siddique f. intra-operative and immediate post-operative complications in patients after cataract surgery in an eye camp. pak j ophthalmol. 2020; 36 (3): 226-230. doi: 10.36351/pjo.v36i3.1056 introduction according to a study out of 207.7 million people in ____________________________________________ correspondence to: asad azeem mirza dow international medical college, duhs email: asad_azim@hotmail.com received: april 23, 2020 revised: may 4, 2020 accepted: may 4, 2020 pakistan, 1.12 million were blind with their visual acuity less than 3/60, another 1.09 million [0.93 – 1.24] people were found to have severe vision loss (3/60 ≤ va < 6/60) and another 6.79 million [6.00– 7.74] people had moderate vision loss (6/60 ≤ va < 6/18)1. muhammed saleh memon organized the first national survey which was held between 1987–19902 to determine the prevalence and causes of blindness in intra-operative and immediate post-operative complications in patients after cataract surgery in an eye camp pakistan journal of ophthalmology, 2020, vol. 36 (3): 226-230 227 pakistan. a total of 29,157 subjects from all over pakistan were examined and the declared prevalence of blind people was 9.03%. there were varied causes of decreased vision but the most common was found to be due to cataract (66.7%). there was a study conducted between 2002 – 2004 and the analyzed data was published in two papers by dineen et al.3 and jadoon et al4. there is a serious lack of access to health care facilities in rural areas of pakistan predominantly due to lack of resources and technical infrastructure combined with reluctance of doctors and other health care personnel to work in these poorly developed areas. the main reason behind this is poor allocation of funds and resources to the health sector of pakistan.5,6 in order to provide health facilities to the people in far flung areas, camps are organized in many developing countries.7,8 the objective of our research was to perform different types of cataract surgeries feasible in low income countries and to document the intra-operative and post-operative complications so as to prevent them in future by taking appropriate measures. material and methods this study was conducted over a 3-day period at an eye camp located in nawabshah, sindh pakistan. patients of all ages were screened for cataract in opd in the morning hours from 9:00 am till 1:00 pm while surgeries were performed from 2:00 pm till 12:00 am. there was a total of 150 patients selected for cataract surgery. these patients underwent visual acuity assessment and examination of anterior segment and posterior segment. patients with diabetic retinopathy, age related macular degeneration, corneal opacity, advanced glaucoma, conjunctivitis, corneal degenerations and dystrophies, macular scars were all excluded from the study. the selected patients were then assessed for uncontrolled diabetes through a blood test for random blood glucose, high blood pressure and blood test for hepatitis b, hepatitis c and hiv viruses. those found to be positive for any of the above were excluded from the study. these patients underwent one of the four procedures phacoemulsification, extracapsular cataract extraction, intracapsular cataract extraction and small incision cataract surgery by four experienced qualified eye surgeons. any intra-operative complication was recorded during surgery and these patients were seen on post-operative day 1 and their ocular findings were recorded. the data was analyzed on ibm spss version 21.0 and the results were presented as mean ± standard deviation for age, frequency, and percentages for comorbids, gender, type of surgery, intra operative complications and post-operative complications. statistical association were performed between postoperative complication with age, comorbids, gender, type of surgery using chi-square and fisher’s exact test. a p-value of 0.05 or less was considered statistically significant. results total 150 subjects were analyzed. table 1 describes the descriptive statistics of all respondents. mean age was 68.5 ± 11.1 years. males were 88 (58.7%) and table 1: descriptive statistics for demographics. characteristics n = 150 (%) age in years (mean ± sd) 68.5 ± 11.1 gender male 88 (58.7%) female 62 (41.3%) comorbid none 135 (90%) dm 12 (8%) htn 02 (1.3%) both 01 (0.7%) type of surgery phaco 77 (51.3%) ecce 45 (30.0%) sics 27 (18.0%) icce 01 (0.7%) intra-operative complications 02 (1.3%) post-operative complications none 124 (82.7%) corneal edema 21 (14.0%) asad azeem mirza, et al 228 pakistan journal of ophthalmology, 2020, vol. 36 (3): 226-230 endophthalmitis 01 (0.7%) iris prolapse 01 (0.7%) others 03 (2.0%) females were 62 (41.3%). majority of the patients had no comorbidity i.e. 135 (90%) and few had diabetes mellitus i.e. 12 (8.0%). most common surgery performed was phacoemulsification 77 (51.3%) followed by ecce 45 (30.0%) and sics 27 (18.0%). regarding postoperative complications 124 patients were observed to have none while 21 (14.0%) were found to have corneal edema making it the most common postoperative complication. table 2 describes association of post-operative complication with age, comorbids, gender, type of surgery. there were 12 (8%) patients with dm, 02 (1.3%) patients with htn and one having both diabetes and hypertension. there was a significant association of diabetics with postoperative corneal edema. post-operative complications were significantly related with gender, age and diabetes (table 2). discussion we reported results of an eye camp that was held in a village where around 150 patients were operated for cataract. since cataract is the leading cause of blindness worldwide, a similar study was done in pakistan where cataract was found in 66% of patients.2 our study was aimed to analyze intra-operative and post-operative complications occurring due to cataract surgery. most common procedure performed table 2: association of post-operative complications with demographics. characteristics post-operative complications p-value none (n=124) corneal edema (n=26) total (n=150) age (years) 0.04*^ 10 < 40 02 (66.7%) 01 (33.3%) 03 40 < 70 63 (90%) 07 (10.0%) 70 ≥ 70 59 (76.6%) 18 (23.4%) 77 gender male 79 (89.8%) 09 (10.2%) 88 0.001** female 45 (72.6%) 17 (27.4%) 62 comorbid none 115 (85.2%) 20 (14.8%) 135 0.02*^ dm/htn/both 09 (60.0%) 06 (40.0%) 15 type of surgery phaco 62 (80.5%) 15 (19.5%) 77 0.10` ecce 41 (91.1%) 04 (8.9%) 45 sics 21 (75.0%) 07 (25.0%) 28 **significant at 1%, *significant at 5%, `chi-square test, ^fisher's exact test dm = diabetes mellitus, htn = hypertension worldwide is phacoemulsification followed by ecce, sics and icce. rates of complications in both males and females differ and so does the presence of comorbidities leading to increased complication rate. striate keratopathy (or corneal edema) was the most common post-operative complication observed in our study. this was consistent with another study done in a rural population in india.9,10 overall, 40% of patients with comorbidities developed corneal edema. many studies have also reported higher rates of endothelial loss and edema among diabetic patients, factor leading to delayed visual recovery.11,12 diabetic corneas do not recover as quickly as in normal persons because of the decreased regulation of fluid balance, enzymatic dysfunction of bicarbonate pump and involvement of aldose reductase with buildup of sorbitol in the corneal stroma. corneal edema was found in our patients as we examined them both intraoperatively as well as post-operatively and on day 1 of surgery as well while shakya k et al, also reported the presence of corneal edema even after 1 week post-operatively in diabetic patients.13 yang r et al, also reported that corneal endothelium in diabetic patients was more prone to damage from phacoemulsification.14 intra-operative and immediate post-operative complications in patients after cataract surgery in an eye camp pakistan journal of ophthalmology, 2020, vol. 36 (3): 226-230 229 however, based on demographics, it can be noted that increased age and female patients were more likely to develop corneal edema. a study done by hashemi h et al, in iran, highlighted the importance of demographics and development of outcomes of cataract surgery which showed females to be at a disadvantage, lower level of education and older age being the factors leading to post-operative complications.15 similar are the conditions in pakistan where lack of resources predominantly in rural areas along with the lack of health care access for patients leads to comorbidities.16 for several years, phacoemulsification has been the method of choice for cataract extraction in developed countries. but phaco is far more dependent on technology than the conventional extracapsular cataract extraction (ecce). therefore, it is scrutinized whether phaco is worth the cost especially in lowmiddle income countries like pakistan. as reported by ruit et al, in a randomized control trial in nepal on the efficacy of phacoemulsification vs. manual smallincision extra-capsular cataract surgery (msics) where they also compared the cost effectiveness of both the procedures.17 results found that mics was not only cost effective but also a well-suited option with excellent results in developing world where prevalence of cataract was the leading cause of blindness. in our study we employed all three techniques which best suited the patients. rate of post-operative corneal edema was less in ecce as compared to phaco. there were more patients who had phacoemulsification than ecce or sics but since factors such as the presence of comorbidities and other demographics contributed towards the development of post-operative complications in phacoemulsification. de silva et al, compared phacoemulsification and ecce in a cochrane review where a literature search comparing the two techniques was performed that included 11 randomized controlled trials, which included a total of 1228 participants.18 it reported better visual outcomes with phacoemulsification and complications were lower with this technique. however, ecce was cheaper and in lower income countries ecce may therefore have a role in maximizing the number of people that can be treated with limited resources.19,20 limitation of our study was that it was a single centered study. further studies are needed with data from multiple eye camps in the future. conclusion camp surgeries when performed with strict sterilization and in experienced hands can play an important role in treating cataract, which is the commonest cause of preventable blindness in developing countries. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors‘ designation and contribution asad azeem mirza; assistant professor: research planning & data collection. saba al-khairy; assistant professor: manuscript writing & manuscript drafting. mazhar-ul-hassan; professor & chairman: research design, final manuscript review & data analysis. shahid azeem mirza; professor: research planning & data collection. saad aslam; house officer: manuscript writing & literature search. farnaz siddique; associate professor: manuscript review. references 1. hassan b, ahmed r, li b, noor a, hassan zu. a comprehensive study capturing vision loss burden in pakistan (1990-2025): findings from the global burden of disease (gbd) 2017 study. plos one. 2019; 14 (5): e0216492. 2. memon ms. prevalence and causes of blindness in pakistan. j pak med assoc. 1992; 42: 196–198. pmid: 143380. 3. dineen b, bourne r, jadoon z, shah sp, khan ma, foster a, et al. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91 (8): 1005–10. pmid: 17229806. 4. jadoon mz, dineen b, bourne rr, shah sp, khan ma, johnson gj, et al. prevalence of blindness and visual impairment in pakistan: the pakistan national blindness and visual impairment survey. invest. ophthalmol. vis. sci. 2006; 47 (11): 4749–55. 5. basharat s, shaikh bt. healthcare system in pakistan. in: rout hs (ed.) healthcare system – a asad azeem mirza, et al 230 pakistan journal of ophthalmology, 2020, vol. 36 (3): 226-230 global survey. ed. 1st, new delhi: new century publications; 2011: 434-54. 6. government of pakistan, statistics division, federal bureau of statistics, islamabad, (2004 – 05). pakistan social and living standards measurement survey (round-1), 2004 – 05. (internet). cited on: 28/09/2016. available from url: http://www.pbs.gov.pk/sites/default/files/social_statistic s/publications/pslm200 4-05/pslms%202004-05.pdf 7. kapoor h, chatterjee a, daniel r. evaluation of visual outcome of cataract surgery in an indian eye camp. br j ophthalmology, 1999; 83: 343-346. 8. dandona l, dandona r, srinivas m. giridhar p, vilas k, prasad mn, et al. blindness in the indian state of andhra pradesh. invest ophthalmol vis sci. 2001; 42: 908–916. 9. kudva aa, lasrado as, hegde s, kadri r, devika p, shetty a. corneal endothelial cell changes in diabetics versus age group matched non-diabetics after manual small incision cataract surgery. indian j ophthalmol. 2020; 68 (1): 72–76. 10. hugod m, storr-paulsen a, norregaard jc, nicolini j, larsen ab, thulesen j. corneal endothelial cell changes associated with cataract surgery in patients with type 2 diabetes mellitus. cornea. 2011; 30: 749– 53. 11. aditya kelkar, jai kelkar, hetal mehta, and winfried amoaku. cataract surgery in diabetes mellitus: a systematic review. indian j ophthalmology,2018; 66 (10): 1401–1410. doi: 10.4103/ijo.ijo_1158_17. 12. el-agamy a, alsubaie s. corneal endothelium and central corneal thickness changes in type 2 diabetes mellitus. clin ophthalmol. 2017; 11: 481–6. 13. shakya k, pokharel s, karki kj, pradhananga c, pokharel rp, malla ok. corneal edema after phacoemulsification surgery in patients with type ii diabetes mellitus. nepal j ophthalmology, 2013; 5 (2): 2304. doi: 10.3126/nepjoph. v5i2.8734. 14. yang r, sha x, zeng m, tan y, zheng y, fan f. the influence of phacoemulsification on corneal endothelial cells at varying blood glucose levels. eye sci. 2011; 26 (2): 91-5. doi: 10.3969/j.issn.10004432.2011.02.018. 15. hashemi h, mohammadi sf, z-mehrjardi h, majdi m, ashrafi e, mehravaran s, mazouri a, roohipoor r, khabazkhoob m. the role of demographic characteristics in the outcomes of cataract surgery and gender roles in the uptake of postoperative eye care: a hospital-based study. ophthalmic epidemiol. 2012; 19 (4): 242-8. doi: 10.3109/09286586.2012.691600. 16. malik a r, qazi z a, gilbert c. visual outcome after high volume cataract surgery in pakistan. br j ophthalmol. 2003; 87: 937–940. 17. ruit s, tabin g, chang d, bajracharya l, kline dc, richheimer w, shrestha m, paudyal g. a prospective randomized clinical trial of phacoemulsification vs. manual suture less smallincision extra-capsular cataract surgery in nepal. (am j ophthalmology, 2007; 143: 32–38. doi: 10.1016/j.ajo.2006.07.023. 18. de silva sr, riaz y, evans jr. phacoemulsification with posterior chamber intraocular lens versus extracapsular cataract extraction (ecce) with posterior chamber intraocular lens for age-related cataract. cochrane database of systematic reviews 2014, issue 1: art. no.: cd008812. doi: 10.1002/14651858.cd008812.pub2. 19. gallup pakistan. short round up of health infrastructure in pakistan – 2000 – 2015. (internet) cited on: 28/09/2016. url: http://gallup.com.pk/wpcontent/uploads/2016/09/report-1short-roundup-ofhealth-infrastructure-in-pakistan1.pdf 20. bourne rr, dineen b, modasser ali s. the national blindness and low vision prevalence survey of bangladesh: research design, eye examination methodology and results of the pilot study. ophthalmic epidemiol. 2002; 91: 19–132. .……. pakistan journal of ophthalmology, 2020, vol. 36 (3): 318-323 318 original article deep sclerectomy with low-tension sutures versus tight-tension sutures without space-maintaining implant in controlling intraocular pressures rashid zia 1 , nikhil jain 2 , albena dardzhikova 3 1 , 3 east kent hospitals university nhs foundation trust, ashford, united kingdom 2 university college london hospitals nhs foundation trust, london, united kingdom abstract purpose: to compare the iop lowering effect and post-operative complications of low tension sutures versus tight tension sutures in deep sclerectomy. study design: quasi experimental study. place and duration of study: william harvey hospital, east kent hospitals university nhs foundation trust from 2015 to 2016 and kent and canterbury hospital, east kent hospitals university nhs foundation trust from 2016 to 2017. methods: twenty-seven eyes undergoing deep sclerectomy operation with normal strength sutures (ts) were compared with 21 eyes undergoing a modified technique in which low tension sutures were tied to only approximate anatomy (ls). both sets of patients were operated on by the same experienced surgeon with similar technique except for the tensile strength of suture; same anti-metabolite in similar concentration was used with identical pre and post-operative care. outcome measures were post-operative intraocular pressure, number of medications needed and complications. results: iop decreased significantly in both groups, in ts group by 12.6 mm hg (p < 0.001) and in the ls groups by 18.9 mm hg (p < 0.001). greater iop drop was seen in ls group versus ts group (p = 0.046). in ls group number of eye drops required post operatively were significantly less than ts group (p = 0.007). after follow up only one patient in the loose suture group still required iop-lowering medication. there were minimal complications in both groups, 1 patient in the ls group and 7 in ts group required a yag goniotomy. conclusion: using low tension sutures in deep sclerectomy increases the iop lowering effect of the surgery and reduces the number of medications the patient requires post operatively. key words: deep sclerectomy; glaucoma; sclerostomy, trabeculectomy. how to cite this article: rashid z, jain n, dardzhikova a. comparison of deep sclerectomy with low – tension sutures versus tight – tension sutures without space – maintaining implant in controlling intraocular pressures. pak j ophthalmol. 2020; 36 (4): 318-323. doi: https://doi.org/10.36351/pjo.v36i4.1031 correspondence: rashid zia leads new hayesbank ophthalmology services ashford kent united kingdom email: rashidzia@nhs.net received: march 23, 2020 accepted: may 21, 2020 introduction recent developments in glaucoma surgery have moved towards non-penetrating surgical techniques. deep sclerectomy (ds) has emerged as one of the more established of these procedures. there is ever increasing evidence to support its efficacy and safety profile with the latter being largely accepted as superior to many other alternatives 1 . this procedure https://meshb.nlm.nih.gov/record/ui?ui=d012599 https://meshb.nlm.nih.gov/record/ui?ui=d014130 mailto:rashidzia@nhs.net rashid zia, et al 319 pakistan journal of ophthalmology, 2020, vol. 36 (4): 318-323 entails removing the inner wall of schlemm's canal and juxta-canalicular trabecular meshwork and leaving intact a trabeculo-descemet's membrane (tdm) to control aqueous outflow through a filtration site 2 . the initial steps of the procedure involve creating a superficial and deep scleral flap. the tdm is created by extending the dissection used to create the deep flap while also gently detaching descemet‟s membrane. once the dissection is complete, the deep flap is excised and the inner wall of schlemm‟s canal and the juxta canalicular trabecular meshwork if peeled off. the superficial scleral flap is then attached using 10/0 nylon sutures 2 . in ds aqueous primarily drains through the anterior trabeculum and peripheral descemet‟s membrane 3,4 . in addition, after aqueous humor has percolated through the tdm, it reaches a scleral lake formed at the site of the sclerectomy, under the superficial scleral flap. this artificial space may act as a first, intrascleral filtration bleb. from there, studies have shown some degree of aqueous drainage occurs into the sub-choroidal space and as well as through the subconjunctival pathway into the filtration bleb 5 . traditionally, to keep the artificial intrascleral space patent, a space maintaining implant may be inserted in the scleral bed. superficial scleral flap sutures tend to be tight to allow for small egress of fluid. we present data on a modified deep sclerectomy (mds) whereby the operating steps are kept identical, but the sutures used to seal the superficial scleral flap are tied with less tension to approximate anatomy only. methods the patients were selected by convenient sampling from william harvey hospital, east kent hospitals university nhs foundation trust from 2015 to 2016 and kent and canterbury hospital, east kent hospitals university nhs foundation trust from 2016 to 2017. two groups of patients were analysed. twenty-seven eyes, that were operated on at one site, formed the „tight suture‟ (ts) group of patients; these patients had their procedure carried out according to the standard deep sclerectomy with normal strength sutures which allowed only a small egress of fluid. this data was contrasted against 21 eyes operated on at a second hospital, in which loose sutures were applied to approximate the anatomical structures; this formed the „loose suture‟ (ls) group. the sample sizes for both groups in our study was calculated as 19 participants for both groups by online rss research calculator while taking in account the primary end point of the study. all patients were operated under sub-tenon anaesthesia. topical glaucoma therapy was stopped 1 week before surgery to optimise the ocular surface for surgery. none of the patients had cataract surgery before or during the observation period of the study. intraocular pressures were controlled by systemic carbonic anhydrase inhibitors in the meantime. approximation of structures was done using 10/0 nylon sutures (ethilon, j & j, usa) in all patients and no spacer devices were used in either group. both sets of patients had 5fluorourasil (5-fu) 50 mg/ml, for 4 minutes on sponges before creating the superficial flap, as an anti-metabolite adjunct to the procedure. post-operatively, all patients had 2 hourly preservative free 0.1% dexamethasone eye drops tailed off over 2 months along with preservative free chloramphenicol eye drops for 2 weeks and use of preservative free 0.15% sodium hyaluronate eye drops qds. the primary outcome measure was change in intra-ocular pressure (iop). this was measured at 1day, 1 week, 1 month, 6-months and 1-year post operatively. however, for comparison, only 6 month and 1 year readings were analysed. the secondary outcome measure was the number of medications required by the patient post operatively to control their iop. the tertiary outcome measures were the percentage of patients who had an iop of less than 18 mm hg, less than 21 mm hg at follow up and an iop decrease of 30% or more. the patients were also followed up to see if there were any complications after the procedure and these were recorded as per recommendations of “guidelines on design and reporting glaucoma trials” published by world glaucoma association. in addition to this it was assessed how many patients required a yag goniotomy procedure post operatively. multiple statistical tests were used using spss version 23 to compare groups. a paired ttest was applied for comparison within each group. an unpaired t-test was done to find out any significant change in iop between the groups. chi-square test was used to assess significance for categorical data. a p value of < 0.05 was considered significant. deep sclerectomy with low–tension sutures versus tight–tension sutures pakistan journal of ophthalmology, 2020, vol. 36 (3): 318-323 320 results table 1 highlights the baseline iop and medications of both groups. there was no significant difference in these characteristics. there were no significant differences in medications required, iop measurements or complications at 1 year versus 6 months in either group. in both sets of patients the treatment regimen and disease had stabilised by 6 months. the data was analysed at 1 year follow-up. both treatments reduced the mean iop in the respective groups; the ts group by 12.6 mm hg (p < 0.001) and the ls group by 18.9 mm hg (p < 0.001). in addition, both treatments reduced the number of drugs required to control iop; by 1.8 (p < 0.001) in the ts group and by 3.6 (p < 0.001) in the ls group. (as summarised in table 1). when these means were contrasted between the groups, the difference in iop drop and the reduction in drugs was significant (p < = 0.046 and p = 0.007 respectively). this is highlighted in table 2. therefore, it can be inferred that each treatment reduces both the iop and number of drugs required to control iop after the operation and both of these effects are more substantial in the loose suture group. tertiary outcome measures were equivocal between the groups. in the ts group 26 out of 27 patients (96%) had a follow up iop of less than 18 mm hg and as well as less than 21 mm hg versus all 21 (100%) patients in the ls group (p-value 0.89). iop reduction of greater than 30% occurred in 24/27 (89%) patients of ts group and in 19/21 (90%) patients of the ls group (p-value 0.92). therefore, there was no significant difference in the number of patients that had an iop drop of more than 30% or a final iop less than 18 or 21 mm hg. as number of patients with iop of less than 18 mm hg were identical to those with number of patients with 21 mm hg or less hence only one group was used for statistical analysis. however, it should be noted that in the ls group this pressure was maintained without medication in almost all patient whereas eye drops were still required to control iop in the ts group. in both groups the average number of drugs required pre-operatively was between 3 and 4. of the 27 eyes in the ts group, 8 eyes required no drugs for iop post-operatively while 19 eyes still required some medication. of the 21 eyes in the ls group 19 required no medication at the last follow up and only 2 patients still needed eye drops to maintain iop within range. there were no cases in either group requiring more drugs than before the operation. however, statistical testing showed no significance in the number of patients requiring „no drugs‟ versus „fewer drugs‟ between groups (p = 0.197). this means that we can confidently say that both procedures reduce the number of dugs required by patients and those with loose sutures require fewer drugs; we cannot confidently say that loosening sutures will leave patients requiring no drugs post operatively. there were very few complications recorded in either group. in the ls group, one patient had corneal abrasion post operatively which healed with treatment and 1 needed a yag goniotomy procedure. in the ts group, 2 patients were reported to have hyphaema and 7 patients needed a yag goniotomy procedure 1 table 1: summary of the change in iop and drugs required within each group at 1-year follow up. p-values show that both parameters decreased significantly in the groups. technique pre-operative iop (mm hg) post-operative iop (mm hg) p value pre-operative medications post-operative medications p-value tight sutures 28.3 15.5 < 0.001 3.1 1.26 < 0.001 loose sutures 31.8 12.5 < 0.001 3.3 0.2 < 0.001 table 2: mean difference in iop and drugs required within each group and the significance of the difference between groups. also shows what percentage of patients had iop less than 18mmhg at follow up and a drop of 30% or more. outcomes tight sutures loose sutures difference between groups p value decrease in iop (mm hg) 12.6 19.3 6.3 0.046 decrease in medications required 1.8 3.1 1.3 0.007 percentage of patients with iop below 18 mm hg at follow-up 96% 100% 4% 0.89 percentage of patients with iop drop of more than 30% at follow-up 89% 90% 1% 0.92 rashid zia, et al 321 pakistan journal of ophthalmology, 2020, vol. 36 (4): 318-323 month after the operation. none of the patients had postoperative hypotony, leaking bleb or iris incarceration. cataract progression and endothelial cell loss were not observed. requirement for a yag goniotomy post operatively is not widely considered a complication of deep sclerectomy. it is more commonly thought of as a potential second step in a 2step operation; therefore, we did not include it as a complication. hence, there appears to be no long term effects in any of our patients. discussion adjunctive techniques are often used to increase the efficacy of ds. these include using intraoperative metabolites 6 , collagen implants 7 and yag goniotomy, should iop rise above the target range. given that, yag goniopuncture can be considered as an adjunct to ds and we did not consider it a complication. 8.9 it is nonetheless significant that only one case of the ls group required the procedure while just under a third of the ts group went on to the need of adjunctive procedure. according to some studies, the need for goniopuncture may be required in almost 40-60% of cases 8,9 . while it has been shown that complication rates are low after ds 4 our data would appear to suggest that these may be lower if loose sutures are applied, we likely need to look at a larger sample size to say this with confidence. the widely accepted marker of success in glaucoma treatments is iop less than 21 mm hg or a decrease in iop of 30% or greater. historically, the standard iop control of 21 mm hg is considered as the upper limit of the normal iop distribution from population-based studies and is used as cut off point 10 . in 1996, the 5 fluorouracil filtration surgery study group (5-fu study) 11 used this value as the cut off point for the upper limit of normal. it further categorized success and failure based on the need for postoperative supplemental medication, reoperation and sight threatening complications. “complete success” being defined as iop of 21 mm hg or lower without medication, reoperation or devastating complications. whereas “qualified success” was reserved for iop of 21 mm hg or lower with supplemental medication but without devastating complication. recent clinical trials have adopted lower iop cut off points of < 18 or < 15 mm hg including advanced glaucoma intervention study (agis) 12 , the collaborative initial glaucoma treatment study (cigts) 13 , the early manifest glaucoma trial (emgt) 14 , and the collaborative normal tension glaucoma study 15 . the association of international glaucoma societies published consensus series in 2005 which report life-table results for annual iop control under 18 mm hg for early damage and 15 mm hg for moderate to advance damage 10 . these varying criteria reflect the fact that different eyes require different degrees of iop lowering based on baseline untreated iop, the degree of glaucoma damage and other factors (trajectory of other eye, family history, life expectancy etc). thus, any broadly applied iop success criterion has limitations. our data would appear to show that there are no differences in either of these measures at follow up and therefore in terms of clinical benefit to the patients these two techniques are comparable. success in this technique comes from the total reduction in iop as well as the total cost of treating glaucoma and patient satisfaction and compliance. post-operative iop and post-operative drugs needed decreased significantly in the ls group versus the ts group. the reduction in drugs required to control iop is perhaps most striking. patients that undertake a regular deep sclerectomy operation still needed on average 2 different medications to be taken daily whereas in the ls group only 2 patients required eye drops at all. this has significant implications to patient satisfaction. the long-term ramifications of needing to take drops versus not doing so should not be underestimated. studies suggest that non-compliance or poor compliance with lifelong drops can range from 25 – 50% in patients with glaucoma 16-18 . studies with longer followup show poor adherence with drops in patients that have the deep sclerectomy surgery with tight suture and worsening of their glaucoma. evidence suggests that the fewer eye drops a patient is on, the more likely they are to be adherent to their regimen 17 . in addition to this, the total cost of treatment is reduced. patients with the tight suture requires more drugs and hence a greater cost. costs could also be reduced in terms of follow up appointments. all but one of ls patients were medication free at 6 months whereas the ts patients still required the same number of drugs postoperatively at a year as at 6 months. with implementation of the looser sutures technique it is likely that patients will need either fewer clinic follow ups or total appointments thereby also comparatively deep sclerectomy with low–tension sutures versus tight–tension sutures pakistan journal of ophthalmology, 2020, vol. 36 (3): 318-323 322 reducing the cost between groups. costs are also lowered if fewer patients require a yag goniotomy. future developments and improvements further to this adjustment could be sutureless deep sclerectomy. in a pilot study of 24 eyes followed up for a period of 6 months with a modified deep sclerectomy technique to eliminate sutures altogether found that patients had a statistically significant reduction in iop without extra complications 19 . while this technique mirrors our data. this study in combination with our study would suggest that tying sutures tightly and securely has a limiting effect on iop drop and on maintaining a low iop. studies have shown that deep sclerectomy is inferior to trabeculectomy but modifications in this technique can provide favourable results 20 . smalls sample size was the major limitation of our study. further studies involving multiple centres are required. conclusion using looser sutures to seal the superficial scleral flap towards the end of the standard deep sclerectomy operation increases the iop reduction, decreases the number of drugs patients require and has no increased rate of complications. this has significant ramifications for patient satisfaction and total healthcare costs. there is little or no benefit to applying tight sutures in the deep sclerectomy technique. list of abbreviations: ts tight suture group ls loose suture group iop intra-ocular pressure yag yttrium aluminium garnet ds deep sclerectomy tdm trabeculo-descemets membrane mds modified deep sclerectomy references 1. sarodia u, shaarawy t, barton k. nonpenetrating glaucoma surgery: a critical evaluation. curr opin ophthalmol. 2007; 18 (2): 152–158. 2. varga z, shaarawy t. deep sclerectomy: safety and efficacy. middle east afr j ophthalmol. 2009; 16 (3): 123–126. 3. vaudaux j, mermoud a. aqueous humor dynamics in nonpenetrating filtering surgery. ophthalmol practice, 998; 38: 51064. 4. mermoud a. sinusotomy and deep sclerectomy. eye (london). 2000; 14: 531-535. 5. marchini g, marraffa m, brunelli c. ultrasound biomicroscopy and intraocular pressure lowering mechanisms of deep sclerectomy with reticulated hyaluronic acid implant. j cataract refract surg. 2001; 27 (4): 507-517. 6. kozobolis vp, christodoulakis e v, tzanakis n, zacharopoulos i, pallikaris ig. primary deep sclerectomy versus primary deep sclerectomy with the use of mitomycin c in primary open-angle glaucoma. j glaucoma. 2002; 11 (4): 287–293. 7. karlen me, sanchez e, schnyder cc, sickenberg m, mermoud a. deep sclerectomy with collagen implant: medium term results. br j ophthalmol. 1999; 83 (1): 6–11. 8. mendrinos e, shaarawy t. the current situation in non-penetrating glaucoma surgery. eur ophthal rev. 2009; 2 (1): 35-38. 9. roy s, mermoud a. deep sclerectomy. dev ophthalmol. 2012; 50: 29-36. 10. mo, kass ma. the ocular hypertension treatment study: design and baseline description of the participants. arch ophthalmol. 1999; 117 (5): 573-583. 11. garway-heath df, quartilho a, prah p, crabb dp, cheng q, zhu h. evaluation of visual field and imaging outcomes for glaucoma clinical trials (an american ophthalmological society thesis). trans am ophthalmol soc. 2017; 115: t4. 12. the advanced glaucoma intervention study (agis): the relationship between control of intraocular pressure and visual filed deterioration. the agis investigators am j ophthalmology.2000;130(4):429-440. 13. lichter pr, musch dc, gillespie bw, guire ke, janz nk, wren pa, et al. interim clinical outcomes in the collaborative initial glaucoma treatment study comparing initial treatment randomized to medications or surgery. ophthalmology. 2001;108(11):1943-1953. 14. heijl a, leske mc, bengtsson b, hyman l, bengtsson b, hussein m. reduction of intraocular pressure and glaucoma progression: results from the early manifest glaucoma trial. arch ophthalmol. 2002:120(10):1268-1279. 15. the effectiveness of intraocular pressure reduction in the treatment of normal-tension glaucoma. collaborative normal-tension glaucoma study group. am j ophthalmol. 1998; 126 (4): 498-505. 16. varga z, shaarawy t. deep sclerectomy: safety and efficacy. middle east afr j ophthalmol. 2009; 16 (3): 123–126. rashid zia, et al 323 pakistan journal of ophthalmology, 2020, vol. 36 (4): 318-323 17. nordmann j-p, baudouin c, renard j-p, denis p, regnault a, berdeaux g. identification of noncompliant glaucoma patients using bayesian networks and the eye-drop satisfaction questionnaire. clin ophthalmol. 2010; 4: 1489–1496. 18. konstas agp, maskaleris g, gratsonidis s, sardelli c. compliance and viewpoint of glaucoma patients in greece. eye, 2000; 14 (5): 752–756. doi: https://doi.org/10.1038/eye.2000.197 19. abdelrahman am, eltanamly r, sabry m. sutureless deep sclerectomy: a preliminary report. j glaucoma. 2017; 26 (11). 20. sharifipour f, yazdani s, asadi m, saki a, nourimahdavi k. modified deep sclerectomy for the surgical treatment of glaucoma yazdani. j ophth vis res. 2019; 14: 144-150. authors’ designation and contribution rashid zia: consultant ophthalmologist; study design, manuscript writing, final review. nikhil jain: specialty trainee in ophthalmology; literature search, data analysis, manuscript preparation, manuscript editing, statistical analysis. albena dardzhikova: consultant ophthalmologist, literature search, manuscript preparation, manuscript editing, statistical analysis and review. .…  …. https://doi.org/10.1038/eye.2000.197 https://www.e-igr.com/abs/index.php?issue=202&page=authors&autid=74268 https://www.e-igr.com/abs/index.php?issue=202&page=authors&autid=35771 https://www.e-igr.com/abs/index.php?issue=202&page=authors&autid=94380 https://www.e-igr.com/abs/index.php?issue=202&page=authors&autid=95363 https://www.e-igr.com/abs/index.php?issue=202&page=authors&autid=26931 https://www.e-igr.com/abs/index.php?issue=202&page=authors&autid=26931 http://www.e-igr.com/abs/index.php?abid=81099&page=abstracts&issue=203 http://www.e-igr.com/abs/index.php?abid=81099&page=abstracts&issue=203 http://www.e-igr.com/abs/index.php?abid=81099&page=abstracts&issue=203 pak j ophthalmol. 2021, vol. 37 (1): 53-56 53 original article effect of trabeculectomy on corneal astigmatism: a hospital based study syed daniyal ali hashmi 1 , ume sughra 2 , sultana kausar 3 department of ophthalmology, 1-3 al-shifa trust eye hospital, rawalpindi abstract purpose: to find out the effect of trabeculectomy on corneal astigmatism among glaucoma patients. study design: interventional case series. place and duration of study: al-shifa trust hospital, from august 2015 to february 2016. methods: thirty patients of glaucoma who were advised trabeculectomy were included in the study. pre and post trabeculectomy data was collected by a structured clinical proforma. snellen chart was used to measure visual acuity. auto refracto-keratometer was used to find k-readings, corneal astigmatism and its axis. data was entered in spss version 22. descriptive analysis was done to report frequencies, percentages for qualitative variables and mean and sd for continuous variables. paired sample t test was applied after the preliminary analysis to compare the corneal astigmatism pre and post trabeculectomy. results: out of 30 patients, majority (76%) were males. there was no statistically significant change found in visual acuity pre and post trabeculectomy (p-value > 0.05). there was statistically significant difference of k1 (horizontal) and k2 (vertical) readings pre and post trabeculectomy (p < 0.05). there was a statistically significant increase in overall corneal astigmatic power (p < 0.05). approximately 1.20d of astigmatism developed after trabeculectomy. there was no statistically significant difference between pre (94.0 ± 49.6) and post-operative corneal axis of astigmatism (87.6 ± 64.1). conclusion: trabeculectomy results in a significant change of corneal curvature in both meridians. this causes a change in post-operative visual acuity which in turn may adversely affect the compliance of patient towards surgical treatment. key words: glaucoma, trabeculectomy, corneal astigmatism, visual acuity, keratometry. how to cite this article: hashmi sda, sughra u, kausar s. effect of trabeculectomy on corneal astigmatism: a hospital based study. pak j ophthalmol. 2021, 37 (1): 53-56. doi: https://doi.org/10.36351/pjo.v37i1.1136 introduction according to the world health organization (who) glaucoma is the second leading cause of blindness in the world. it affects approximately 2% of those over the age of 40 years and up to 10% over the age of 80 correspondence: sultana kausar department of ophthalmology, al shifa trust eye hospital, rawalpindi email: kausarsultana180@gmail.com received: september 21, 2020 accepted: november 11, 2020 years. fifty percent may remain undiagnosed. 1,2 openangle and angle-closure types of glaucoma are based on the mechanism by which aqueous outflow is impaired with respect to the anterior chamber angle configuration. 3 primary open angle (poag) is the most prevalent type of glaucoma, affecting approximately 1% of the general population over the age of 40 years. 4 trabeculectomy is the surgical procedure to reduce intraocular pressure (iop) of the eye. 5,6 in trabeculectomy the intra ocular pressure is lowered by creating new pathway in the sclera between anterior chamber and sub tenon space. 7 the success rate of trabeculectomy in poag is 86% to 98% with little dose of medication and 71% without syed daniyal ali hashmi, et al 54 pak j ophthalmol. 2021, vol. 37 (1): 53-56 additional anti-glaucoma medication. 8 the major complications of trabeculectomy are shallow anterior chamber, anterior uveitis, choroidal detachment and uncontrolled intraocular pressure. 9 after trabeculectomy, patients often complain of reduction in visual acuity for several months. this may be due to corneal astigmatism besides the other complications. post surgery astigmatism is an important concern because it has negative effect on the visual outcome. 10 in majority of cases, 87% of the patients have with the rule astigmatism while 13% have against the rule astigmatism postoperatively. astigmatism after trabeculectomy creates problem for both patients and surgeon. 11 international studies have reported that corneal astigmatism can develop after trabeculectomy. 12,3 purpose of the study was to find out the effect of trabeculectomy on corneal astigmatism among glaucoma patients in a tertiary care hospital. methods an interventional case series study was carried out from august 2015 to february 2016 in glaucoma department of al-shifa trust hospital, a tertiary eye care hospital of rawalpindi. patients of both gender, above 30 years of age, having primary open angle glaucoma and advised filtration surgery (trabeculectomy) were included by consecutive sampling. patients with congenital/juvenile glaucoma, previous intra ocular surgeries, significant corneal opacification, all type of lens induced and neo vascular glaucoma and patients not willingness to participate in the study were excluded. the study was conducted after taking approval from the hospital ethical review committee (erc no: 54/ast/15). interview based questionnaire along with clinical proforma was used for data collection. it consisted of two sections. first section contained patient’s personal profile. second section contained test investigations. questionnaire was validated for content validity and face validity by circulating them to field experts. verbal informed consent was taken from the patients who were advised trabeculectomy before including them in the study. purpose of the study was explained to them. no harm, confidentiality and anonymity were ensured to them. they were given the right to quit study whenever they wanted to. patient’s visual acuity was taken using snellen visual acuity chart. autokerato-refractrometer was used to measure the keratometric readings for horizontal meridian (k1) and vertical meridian (k2) of the eye before surgery. subjective refraction was done to confirm the power and axis of astigmatism. after surgery patient’s visual acuity, k-readings, power and axis of astigmatism were noted on 15 th day of followup with the same procedures that were done before trabeculectomy. data was entered and analyzed using spss software. descriptive analysis was done to express continuous variables as mean and ± s.d and categorical variables as frequencies and percentages. normality of data was checked by the histogram that was bell shaped. inferential analysis was done by applying the paired sample (dependent) t test to compare the mean values pre and post trabeculectomy. results out of 30 patients, majority were males (76%) and females were 24%. patients’ age distribution is shown in figure 1. 5 (16%) 6 (20%) 10 (32%) 6 (20%) 3 (12%) 0 2 4 6 8 10 12 31-40 41-50 51-60 61-70 71-80 fig. 1: distribution of participants with age groups (n = 30, 100%). table 1: visual acuity, k1 & k2 reading, astigmatism and axis (n = 30). measurements mean ± sd vision (log mar) pre trabeculectomy 0.81 ± 1.33 post trabeculectomy 0.84 ± 1.37 k 1 reading pre trabeculectomy 43.1 ± 2.0 post trabeculectomy 42.7 ± 1.9 k 2 reading pre trabeculectomy 44.6 ± 1.9 post trabeculectomy 45.5 ± 2.3 astigmatism pre trabeculectomy -1.6 ± 1.06 post trabeculectomy -2.8 ± 1.48 effect of trabeculectomy on corneal astigmatism: a hospital based study pak j ophthalmol. 2021, vol. 37 (1): 53-56 55 axis pre trabeculectomy 94.0 ± 49.6 post trabeculectomy 87.6 ± 64.1 there was no statistically significant change found in visual acuity pre and post trabeculectomy (p-value > 0.05). however, statistically significant difference of k1 (horizontal) and k2 (vertical) readings were seen pre and post trabeculectomy (p < 0.05). there was also a statistically significant increase in overall corneal astigmatic power (p < 0.05). approximately 1.20d of astigmatism developed after trabeculectomy. there was no statistically significant difference between pre (94.0 ± 49.6) and post-operative corneal axis of astigmatism (87.6 ± 64.1) (table 1 and 2 for details). table 2: comparison of corneal astigmatism’s parameters (visual acuity, k1 & k2 readings, astigmatism and axis) pre and post trabeculectomy using paired sample t test (n = 30). measurement mean difference (md) ± sd t(29) p-value md 95% ci lower upper vision (log mar) pre trabeculectomy -0.03 ± 0.04 -3.4 0.08 -0.23 -0.01 post trabeculectomy k 1 reading pre trabeculectomy 0.41 ± 0.9 2.167 0.04 0.02 0.80 post trabeculectomy k 2 reading pre trabeculectomy 0.88 ± 1.6 -2.7 0.11 -1.54 -0.22 post trabeculectomy astigmatism pre trabeculectomy 1.21 ± 1.6 3.7 0.001 0.54 1.88 post trabeculectomy axis pre trabeculectomy 6.4 ± 55.1 0.58 0.568 -16.38 29.18 post trabeculectomy discussion trabeculectomy has a dominant affect on corneal astigmatisms’ parameters. during trabeculectomy a surgical pathway is produced by making a scleral flap which is later closed with sutures. surgically induced astigmatism may be created due to the partial thickness scleral flap created during surgery. corneal astigmatism may be related to cautery used in surgery due to contraction of sclera. 14,15 the results of the current study are consistent with the study conducted by abolbashari et al who found that most of the subjects developed 1.50 to 2.50 diopters of steepening in the 90-degree meridian following trabeculectomy. 16 the findings of this study are also in accordance with the observations of alvani et al who reported 0.38-1.4 diopters (d) of with-the-rule (wtr) astigmatism after trabeculectomy. 17 some studies have reported superior steepening of the cornea that caused with the rule astigmatism of about 1d which persisted for 1 year following surgery. there are also reports of steeper meridian becoming steeper and flatter meridian becoming more flat. 18 vernon et al reported that small flap trabeculectomy produced smaller changes in corneal curvature that resolved earlier than the larger flap technique. 19 iwasaki et al discovered that the change in vertical corneal curvature after trabeculectomy resulted in with-the-rule change in corneal astigmatism. 20 this supports our findings as well. similarly, corneal curvature changes have been reported by kumari et al. 21 akhter et al discovered that there was a significant change found in the corneal astigmatism. these findings are in accordance with this study. 11 this research had few limitations due to shorter duration of research and single setting. long term studies are required to investigate whether these changes continue to evolve or not. conclusion trabeculectomy results in significant change of corneal curvature in both meridians. this could have impact on postoperative visual acuity which in turn may adversely affect the compliance of patients syed daniyal ali hashmi, et al 56 pak j ophthalmol. 2021, vol. 37 (1): 53-56 towards surgical treatment. patient should be informed and counseled about the possible visual outcomes after the trabeculectomy to preclude any distress that may occur following surgery. ethical approval the study was approved by the institutional review board/ ethical review board. (erc-54/ast-15) conflict of interest authors declared no conflict of interest. references 1. wright c, tawfik ma, waisbourd m. primary angleclosure glaucoma: an update. acta ophthalmol. 2016; 94: 217-225. 2. babar tf, saeed n, masud z, khan md. two years audit of glaucoma admitted patients in hayatabad medical complex, peshawar. pak j ophthalmol. 2003; 19: 32-39. 3. kanski jj, bowling b. glaucoma. in: clinical ophthalmology: a systemic approach.7th ed. london: elsevier saunders; 2011: 311-399. 4. anand a, negi s, khokhar s, kumar h, gupta sk, murthy gvs, et al. role of early trabeculectomy in primary open angle glaucoma in developing world, eye, 2007; 21 (1): 40-45. 5. fazle-hanan, shah ma, javaid m, mohammad s. effectiveness of trabeculectomy in primary open angle glaucoma. j postgrad med inst 2007; 21 (03): 209-211. 6. adegbehingbe b, majemgbasan t. a review of trabeculectomies at a nigerian teaching hospital. ghana med journal, 2007; 41 (4): 176-180. 7. american academy of ophthalmology. basic and clinical science course. section 10; 2011-12: 17-205. 8. bhatia j. outcome of trabeculectomy surgery in primary open angle glaucoma. oman med j. 2008; 23 (2): 86-89. 9. jalal t, mohammad s. three years retrospective study of patients undergone trabeculectomy in lady reading hospital peshawar. j postgrad med inst. 2004; 18: 487-494. 10. ashai m, ahmed a, ahsan m, imtiaz a. the effect of trabeculectomy on corneal astigmatism. jammu and kashmir practitioner; 2006; 13 (1): 27-29. 11. akhtar f. the effect of trabeculectomy on corneal curvature. pak j ophthalmol. 2008; 24 (3): 118-121. 12. delbeke h, stalmans i, vandewalle e, zeyen t. the effect of trabeculectomy on astigmatism. j glaucoma. 2016; 25: e308–e312. doi: 10.1097/ijg.0000000000000236. 13. chan hhl, kong yxg. glaucoma surgery and induced astigmatism: a systematic review. eye vis (lond). 2017; 4: 27. doi: 10.1186/s40662-017-0090. 14. el-saied hm, foad ph, eldaly ma, abdelhakim ma. surgically induced astigmatism following glaucoma surgery in egyptian patients. j glaucoma, 2014; 23: 190–193. doi: 10.1097/ijg.0000000000000035. 15. kumari r. keratometric astigmatism after trabeculectomy. nepal j ophthalmol. 2013; 5 (10): 215-219. 16. abolbashari f, ehsaei a, daneshvar r, abolbashari f, ehsaei a, daneshvar r, et al. the effect of trabeculectomy on contrast sensitivity, corneal topography and aberrations. int ophthalmol. 2019; 39 (2): 281-286. 17. alvani a, pakravan m, esfandiari h, safi s, yaseri m, pakravan p. ocular biometric changes after trabeculectomy. j ophthalmic vis res. 2016; 11 (3): 296-303. 18. law sk, mansury am, vasudev d, caprioli j. effects of combined cataract surgery and trabeculectomy with mitomycin c on ocular dimensions. br j ophthalmol. 2005; 89 (8): 1021-1025. 19. vernon s, zambarakji h, potgieter f. topographic and keratometric astigmatism up to 1 year following small flap trabeculectomy (microtrabeculectomy). br j ophthalmol. 1999; 83: 779-782. 20. iwasaki k, takamura y, arimura s, tsuji t, matsumura t, gozawa m, et al. prospective cohort study on refractive changes after trabeculectomy. j ophthalmol. 2019; 2019: 4731653. 21. kumari r, saha bc, puri lr. keratometric astigmatism evaluation after trabeculectomy. nepal j ophthalmol. 2013; 5 (2): 215-219. authors’ designation and contribution syed daniyal ali hashmi; optometrist & orthoptist: concepts, design, literature search, data acquisition, statistical analysis, manuscript preparation. ume sughra; associate professor: data acquisition, data analysis, statistical analysis, manuscript editing, manuscript review. sultana kausar; research assistant: literature search, statistical analysis, manuscript editing, manuscript review. .…  …. http://onlinelibrary.wiley.com/doi/10.1111/aos.12784/abstract;jsessionid=dddbcd879efa9c5c20ee5bda92324017.f04t01 http://onlinelibrary.wiley.com/doi/10.1111/aos.12784/abstract;jsessionid=dddbcd879efa9c5c20ee5bda92324017.f04t01 http://onlinelibrary.wiley.com/doi/10.1111/aos.12784/abstract;jsessionid=dddbcd879efa9c5c20ee5bda92324017.f04t01 microsoft word 13. mahtab mengal mm pakistan journal of ophthalmology, 2020, vol. 36 (3): 253-257 253 original article trabeculectomy in congenital glaucoma; experience in helpers eye hospital quetta mahtab mengal1, m. afzal khan2, aimal khan3, manzoor ahmed4, rabia khawar chaudhry5 nasar qamar khan6 1-4bolan university of medical and health sciences (bumhs), quetta, 5-6jinnah postgraduate medical centre (jpmc), karachi abstract purpose: to evaluate outcomes of trabeculectomy in terms of iop control and its safety in terms of peroperative and post-operative complications in primary congenital glaucoma. study design: interventional case-series. place and duration of study: helpers eye hospital, quetta, from june 2017 to december 2018. material and methods: thirty eyes of 17 patients were included in this case series after diagnosis of primary congenital glaucoma. patients with secondary congenital glaucoma due to trauma, surgery, inflammation, sturge weber syndrome, neurofibromatosis, cataract, uveitis, aphakia and pseudophakia were excluded from the study. informed consent was taken from parents. examination under anesthesia was done before surgery to record preoperative iop, corneal diameter and anterior and posterior segment abnormalities. primary trabeculectomy was done. post-operative iop and corneal diameter was recorded at 1st, 3rd and 6th month and every 6 months thereafter under general anesthesia. iop at 12th month of surgery was the final outcome which was considered significant if iop was less than 21 mm hg with stable corneal diameters. results: mean preoperative iop was 25.8 mm hg. twenty-three (76.66%) eyes out of 30 eyes were considered successful with mean iop of 15.3 mm hg at last follow-up while 7 (23.33%) cases of failure were observed with postoperative mean iop of 27.71 mm hg. these patients underwent additional surgeries to control iop. hyphema was the only complication observed in this study. postoperative cataract developed in 5 eyes. conclusion: primary trabeculectomy is an effective operation and safe surgery for primary congenital glaucoma. key words: primary congenital glaucoma, intra-ocular pressure, trabeculectomy. how to cite this article: mengal m, khan ma, khan a, ahmed m, chaudhry rk, khan nq. outcomes of trabeculectomy in congenital glaucoma; experience in helpers eye hospital quetta. pak j ophthalmol. 2020; 36 (3): 253-257. doi: 10.36351/pjo.v36i3.1043 introduction the commonest type of glaucoma in pediatric age group is primary congenital glaucoma (pcg) which correspondence to: mahtab mengal bolan university of medical and health sciences (bumhs), quetta. email: mengalmahtab@yahoo.com received: april 17, 2020 revised: may 4, 2020 accepted: may 4, 2020 accounts for 2.5-15% of all documented cases of blindness in children1,2 and occurs without any other ocular or systemic abnormalities. it is caused by abnormal development of the angle of anterior chamber2, which leads to raised iop, subsequently, opaque cornea, enlargement of eyeball, optic disc damage and permanent loss of vision. timely treatment can prevent permanent loss of vision and lifetime disability1. the incidence of pcg varies in different ethnic populations. in developed western countries it is mahtab mengal, et al 254 pakistan journal of ophthalmology, 2020, vol. 36 (3): 253-257 approximately 1 in 10,000 to 70,000 births1,3. in saudi arabia, southern india, slovakia, it is between 1:1,250 and 1:33004. in pakistani pediatric population incidence of pcg is nine times higher than that in caucasians5. in chinese population pcg constitutes 5.1%6. the higher rate of consanguinity is considered as the cause of this higher incidence of pcg3,7. the ultimate aim of treatment in congenital glaucoma is to control iop to restore vision7. the treatment of choice is surgical because medical therapy poorly controls the iop in congenital glaucoma1. the preferred surgical options are goniotomy, trabeculotomy, trabeculectomy, or combined trabeculotomy-trabeculectomy with or without mitomycin c8,9. according to previous reports success rate of goniotomy and trabeculotomy is 81 – 90% in western countries due to early presentations of pcg while low success rate in middle east10,11. in another report, 25% success rate of goniotomy was reported in pcg8. in developing countries, pcg patients present late with severe disease and cloudy cornea, in which goniotomy is not possible12,13. in such situations, trabeculectomy is the preferred procedure. different studies document the success rate of primary trabeculectomy varying from 54% to 92.3% in pcg11,14,15. another researcher reported 75% success rate of primary trabeculectomy in pcg16. there is limited local data available about trabeculectomy results in primary congenital glaucoma. the aim of this study was to evaluate the outcomes of trabeculectomy in terms of iop control and its safety in terms of per-operative and postoperative complications in balochistan region. material and methods this interventional case-series was conducted from june 2017 to december 2018 for duration of 1.5-years in eye department of helpers eye hospital, quetta. approval from the ethical committee of bolan medical complex hospital (bmch) was taken and informed consent was taken from parents (of all patients) before including them in study. the patients were included in this series and labeled as congenital glaucoma if the following features were present in the patient;  iop > 20 mm hg.  corneal diameter > 12 mm in any meridian.  cup disc ratio > 0.3.  corneal edema.  age: patients under 5 years.  either gender. exclusion criteria for this study were; patients having raised iop due to secondary causes, for example, history of ocular trauma, ocular surgery, inflammation, sturge weber syndrome, neurofibromatosis, cataract, uveitic glaucoma, aphakia and pseudophakia. total sample size was 30, which was calculated by non-probability consecutive sample technique using; confidence level = 95% absolute precision[d] = 0.10 anticipated population proportion [p] = 92.3%24,25,27. examination under anesthesia (eua) was done in every patient. during eua iop, corneal diameter, anterior segment examination, fundoscopy for optic disc assessment, b-scan, a-scan for axial length measurement and retinoscopy for refractive error (if media was clear) were recorded. surgery was performed by one surgeon. under general anaesthesia and aseptic technique, corneal stay suture was applied at 12 ‘o’clock using 6 – 0 vicryl (polyglactin) suture. a fornix-based conjunctival flap was lifted and cauterization of superficial scleral vessels was done to secure hemostasis. a partial thickness scleral flap of 4 × 4 mm size was dissected upto about 1 mm of clear cornea. the inner trabeculectomy groove of 2 × 2 mm was made. the inner block of tissue comprised of trabecular meshwork and scleral spur. peripheral iridectomy (pi) was done. the partial thickness scleral flap was sutured with 10–0 nylon. the conjunctival flap was closed with 8–0 continuous watertight sutures and at the end of the surgery, the patency of the pi and scleral flap was checked and watertight conjunctival bleb was assessed. combination of antibiotic and steroid (dexamethasone and gentamicin) were injected subconjunctivally. eye patch was applied at the end. all cases in this study had a follow up of minimum of 12 months. iop measurements (and corneal diameter) were recorded preoperatively and postoperatively at 1st, 3rd and 6th month and every 6 months thereafter under general anesthesia. intraoperative and postoperative complications were recorded. iop at 12th month of surgery was the final trabeculectomy in congenital glaucoma; experience in helpers eye hospital quetta pakistan journal of ophthalmology, 2020, vol. 36 (3): 253-257 255 outcome which was considered significant if iop was less than 21 mm hg. definition of surgical success was made on the basis of following criteria; iop⩽21 mm hg, stable corneal diameters and clear cornea at 12th month of surgery. while failure was defined as either need for reoperation for glaucoma, persistently raised iop over 20 mm hg despite topical iop lowering medications or persistent hypotony (iop < 5 mm hg). the indication of using anti-glaucoma eye drops was an iop > 21 mm hg on two consecutive follow up visits or continuous corneal edema postoperatively. use of anti-glaucoma postoperatively was not included in criteria of failure. results in this study, a total of 30 eyes of 17 patients were included. among them, there were 8 (47.05%) girls and 9 (52.94%) boys (table 1). table 1: comparison of preoperative and postoperative mean intraocular pressure. preoperative iop in all cases (30 eyes) 25.8 mm hg postoperative iop in successful cases (23 eyes – 76.66%) 15.3 mm hg postoperative iop in cases of failure (7 eyes – 23.33%) 27.7 mm hg before surgical intervention, mean preoperative iop was 25.8 mm hg and mean horizontal corneal diameter was 13.76 mm. fundus examination was possible in only in 17 eyes because of corneal edema. twenty-three eyes (76.66%) met the success criteria at the time of last follow-up. the mean postoperative intraocular pressure for all successful eyes was 15.3 mm hg. the postoperative intraocular pressures were considerably lower than the preoperative iop levels at all follow-up visits. complete success was obtained in 15 (65.21%) eyes without topical anti-glaucoma medication. a spike of raised iop was observed in 8 (34.78%) eyes at 3rd to 6th month of follow up visit, but stable values of iop were achieved in these eyes with the use of anti-glaucoma eye drops. there were 7 (23.33%) eyes with trabeculectomy failure. in these cases, mean postoperative iop was 27.71 mm hg in two consecutive follow-up visits even after the use of topical anti-glaucoma medications. these cases needed additional surgery to control iop (repeat trabeculectomy with mmc). the cause of failure in these cases was probably severe disease, late presentation and aggressive healing process in the pediatric population. in this series, small hyphema was noted in 3 cases (10%) which resolved completely within 3 days of procedure. other than this, there were no intraoperative and postoperative complications (like shallow anterior chamber, bleb leak, hypotony, choroidal detachment, retinal detachment and endophthalmitis) till 12 months of follow-up. 76.66% 23.33% complete success failure fig. 1: comparison of postoperative results at 12th month of follow-up visit. cataract developed in 5 (16.66%) eyes at 6th month of trabeculectomy and these cases underwent early cataract surgery with iol implantation to restore vision. topical anti-glaucoma therapy was used in early postoperative days of these cases to prevent any inadvertent spike of iop. discussion in pediatric population primary congenital glaucoma is found to be the most common type of glaucoma, which is the leading cause of blindness in this age group. anterior chamber angle anomaly is the underlying cause which subsequently results in raised intraocular pressure. it has been reported in literature that early treatment can prevent lifetime vision loss1,2. surgery is the treatment of choice and traditionally trabeculectomy is ideal choice after failure of angle surgeries, with aim to control intraocular pressure. aggressive healing response in this age group, challenges of poor compliance and insufficient comahtab mengal, et al 256 pakistan journal of ophthalmology, 2020, vol. 36 (3): 253-257 operation with examination, are possible reasons of poor outcomes in this age group17,18. in this study male predominance was observed with 52.94% boys. literature review showed male dominance with percentage of 65-80%19. in another report, 77.7% of total sample were male20. however, in japanese population female predominance was observed21. in our study, iop control after trabeculectomy was according to the desired level, average preoperative iop in this case series was 25.8 mm hg, while postoperative iop was 15.3 mm hg. overall surgical success was achieved in 23 eyes which is 76.66% of total sample. this is comparable to other international studies. a 75% success rate of primary trabeculectomy was documented by rao and his friends in their study16. many authors state that the factors influencing success rate of trabeculectomy are age at time of surgery, early stage of disease, corneal diameter at presentation, surgeon expertise and technique, patient compliance with follow up and prompt management of any complication. there were 7 eyes (23.33%) in our series in which trabeculectomy failed to control iop in spite of topical iop lowering medications. 27.7 mm hg was mean iop with vascularized flat bleb in these eyes at their last visit. eventually these patients underwent repeat trabeculectomy with mmc. four eyes of two patients who presented at 1st month of their neonatal life, had severe disease since birth, while remaining 3 eyes of other 3 patients presented after 24th month of age with severe disease. there were large corneal diameters, opaque corneas and high iop. beck and colleagues reported that patients less than 1 year at the time of surgery were associated with very high risk of failure22. corneal health (diameters and clarity) is also a factor of high surgical success rate. al-hazmi et al, had reported that a better surgical outcome of trabeculectomy could be achieved when preoperative corneal diameter was < 13 mm and patient was < 1 year of age9. we observed in our study that the patients who presented within 3 months to 18 months and who underwent early surgery showed better results than patients who presented with age under 1 month. these patients had untreated advanced disease with corneal diameters larger than 13.5 mm and age more than 24 months. according to many researchers, infancy was a significant risk factor for surgical failure. in literature, the outcomes of trabeculectomy in infants under one year of age varied between 15–43%15,23. this confirmed that early diagnosis of pcg and prompt surgical intervention are the gateway to successful treatment. in our study, cataract developed in 5 cases (16.66%) during postoperative 3rd to 6th month. it was comparable to existing literature for same duration of follow up (i.e. 11.5%)24. complications were minimal in our study except for small hyphema in 3 (10%) postoperative cases of trabeculectomy, which is less than internationally reported studies where it is documented as 19%1 and 27.4%25. the encouraging results of our study with fewer complications may be due to surgeon skills, patient compliance with follow up and postoperative medications. miller, another researcher, reported that use of anti-metabolites in primary trabeculectomy improved the success rate in those patients who were at higher risk of surgical failure, but their use is associated with many other serious complications9. limitation of our study was small sample size. the results of the study cannot be generalized because the study was conducted in a single center. conclusion primary trabeculectomy is an effective operation for primary congenital glaucoma when performed early and followed properly and regularly for any decompensation. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution mahtab mengal; senior registrar: concept, manuscript writing, data collection and analysis. m. afzal khan; assistant professor: data collection and final review. trabeculectomy in congenital glaucoma; experience in helpers eye hospital quetta pakistan journal of ophthalmology, 2020, vol. 36 (3): 253-257 257 aimal khan; assistant professor: data collection and final review. manzoor ahmed; senior registrar: data collection, literature search. rabia khawar chaudhry; paediatric ophthalmologist: manuscript writing, literature search. nasar qamar khan; consultant ophthalmologist: statistical analysis, final review refrences 1. huang jl, huang jj, zhong ym, guo xx, chen xx, xu xy, et al. surgical outcomes of trabeculotomy in newborns with primary congenital glaucoma. chin med j engl. 2016; 129 (18): 2178–83. 2. ho cl, walton ds. primary congenital glaucoma: 2004 update. j pediatr ophthalmol strabismus. 2019; 41 (5): 271-88 3. tamçelik n, atalay e, bolukbasi s, çapar o, ozkok a. demographic features of subjects with congenital glaucoma. indian j ophthalmol. 2014; 62 (5): 565–9. 4. alanazi ff, song jc, mousa a, morales j, al shahwan s, alodhayb s, et al. primary and secondary congenital glaucoma: baseline features from a registry at king khaled eye specialist hospital, riyadh, saudi arabia. am j ophthalmol. 2013; 155 (5): 882–889.e1. 5. bashir r, sanai m, azeem a, altaf i, saleem f, naz s. contribution of glc3a locus to primary congenital glaucoma in pakistani population. pakistan j med sci. 2014; 30 (6): 1341–5. 6. liu b, huang w, he m, zheng y. an investigation on the causes of blindness and low vision of students in blind school in guangzhou. yan ke xue bao – eye sci. 2007; 23 (2): 117–20. 7. chang tc, cavuoto km. surgical management in primary congenital glaucoma: four debates. j ophthalmol. 2013; 2013: 612708. 8. terraciano aj, sidoti pa. management of refractory glaucoma in childhood. curr opin ophthalmol. 2002; 13 (2): 97–102. 9. al-hazmi a, awad a, zwaan j, al-mesfer sa, aljadaan i, al-mohammed a. correlation between surgical success rate and severity of congenital glaucoma. br j ophthalmol. 2005; 89 (4): 449–53. 10. mcpherson sd, berry dp. goniotomy vs external trabeculotomy for developmental glaucoma. am j ophthalmol. 1983; 95 (4): 427–31. 11. debnath sc, teichmann kd, salamah k. trabeculectomy versus trabeculotomy in congenital glaucoma. br j ophthalmol. 1989; 73 (8): 608–11. 12. mullaney pb, selleck c, al-awad a, al-mesfer s, zwaan j. combined trabeculotomy and trabeculectomy as an initial procedure in uncomplicated congenital glaucoma. arch ophthalmol. 1999; 117 (4): 457–60. 13. mandal ak, bhatia pg, bhaskar a, nutheti r. long-term surgical and visual outcomes in indian children with developmental glaucoma operated on within 6 months of birth. ophthalmology. 2004; 111 (2): 283–90. 14. fulcher t, chan j, lanigan b, bowell r, o’keefe m. long-term follow up of primary trabeculectomy for infantile glaucoma. br j ophthalmol. 1996; 80 (6): 499–502. 15. al-hazmi a, zwaan j, awad a, al-mesfer s, mullaney pb, wheeler dt. effectiveness and complications of mitomycin c use during pediatric glaucoma surgery. ophthalmology, 1998; 105 (10): 1915–20. 16. rao k v, sai cm, babu b v. trabeculectomy in congenital glaucoma. indian j ophthalmol. 1984; 32 (5): 439–40. 17. gressel mg, heuer dk, parrish rk. trabeculectomy in young patients. ophthalmology, 1984; 91 (10): 1242–6. 18. beauchamp gr, parks mm. filtering surgery in children: barriers to success. ophthalmology, 1979; 86 (1): 170–80. 19. elder mj. congenital glaucoma in the west bank and gaza strip. br j ophthalmol. 1993; 77 (7): 413–6. 20. olusanya b, ugalahi m, malomo m, baiyeroju a. trabeculectomy for congenital glaucoma in university college hospital, ibadan: a 7 year review of cases. niger j ophthalmol. 2015; 23 (2): 44. 21. dickens cj, hoskins jr hd. epidemiology and pathophysiology of congenital glaucoma. vol. 2, the glaucomas, 1996: 729-738. 22. beck ad, wilson wr, lynch mg, lynn mj, noe r. trabeculectomy with adjunctive mitomycin c in pediatric glaucoma. am j ophthalmol. 1998; 126 (5): 648–57. 23. freedman sf, mccormick k, cox ta. mitomycin c-augumented trabeculectomy with postoperative wound modulation in pediatric glaucoma. j aapos off publ am assoc pediatr ophthalmol strabismus, 1999; 3 (2): 117–24. 24. jayaram h, scawn r, pooley f, chiang m, bunce c, strouthidis ng, et al. long-term outcomes of trabeculectomy augmented with mitomycin c undertaken within the first 2 years of life. ophthalmology, 2015; 122 (11): 2216–22. 25. tamcelik n, ozkiris a. long-term results of viscotrabeculotomy in congenital glaucoma: comparison to classical trabeculotomy. br j ophthalmol. 2008; 92 (1): 36–9. .……. 137 pak j ophthalmol. 2021, vol. 37 (2): 137-141 original article frequency of posterior segment pathologies in patients with ocular trauma using b-scan ultrasonography fatima sidra tanweer 1 , afia matloob rana 2 , waseem akhter 3 department of ophthalmology, 1,2 hbs medical and dental college, islamabad 3 rawal medical and dental college, islamabad abstract purpose: to determine the frequency of posterior segment pathologies caused by ocular trauma using b scan usg. study design: descriptive, cross-sectional study. place and duration of study: holy family hospital, rawalpindi, from september 2015 to march 2016. methods: one hundred patients of ocular trauma, 12 to 45 years of age were included in the study. patients who had any posterior segment pathology prior to the ocular trauma were excluded. b scan was performed in all patients. the data was collected and analyzed using spss version 17. for all the categorical variables like gender, type and site of ocular injury, the side of eye involved, type of posterior segment pathology as detected on b scan, frequencies and percentages were calculated. for the continuous variables like age and time since injury, mean and standard deviation were calculated. results: mean age was30.43 ± 9.58 years. majority of the patients (35.0%) were between 26 to 35 years of age. out of these 100 patients, 73 were males and 27 were females with male to female ratio of 2.7:1. vitreous hemorrhage was the most common and ocular pathology (38 patients). retinal detachment was seen in 21 patients. intra-ocular foreign bodies were seen in 12 patients. conclusion: vitreous hemorrhage was the most common posterior segment pathology in ocular trauma followed by retinal detachment and intra-ocular foreign bodies. key words: trauma, b-scan, vitreous hemorrhage, retinal detachment. how to cite this article: tanweer fs, rana am, akhter w. frequency of posterior segment pathologies in patients with ocular trauma using b-scan ultrasonography. pak j ophthalmol. 2021, 37 (2): 137-141. doi: http://doi.org/10.36351/pjo.v37i2.1197 introduction ocular trauma is one of the common reasons of preventable blindness. among all the patients correspondence: afia matloob rana department of ophthalmology, hbs medical and dental college, islamabad email: afiamatloob@yahoo.com received: january 9, 2021 accepted: february 22, 2021 presenting in ocular emergency, there are 39.7% related with ocular trauma. 1 half a million people are monocularly blind worldwide after ocular trauma. 2 much variation is present in the type and complexity of ocular injuries. it is not possible to visualize fundus of patients with opaque ocular media like those resulting from corneal opacity, vitreous hemorrhage, hyphema, lenticular and vitreous opacities. 3 these pathologies are common in cases of ocular trauma. early detection of these pathologies and appropriate management is the hope for suffering patients. b scan uses high frequency ultrasound waves (10 mhz) and it http://doi.org/10.3352/jeehp.2013.10.3 frequency of posterior segment pathologies in patients with ocular trauma pak j ophthalmol. 2021, vol. 37 (2): 137-141 138 has high resolution making it very important for scanning intraocular structures. 4 b scan is inexpensive, and serial echography allows us to follow the disease progression and regression. 5 blunt trauma to the eye causes distortion of globe which can result in more severe injuries than detected on slit lamp examination. 6 b-scan ultrasonography is also a useful imaging modality in the management of an open globe injury. it can offer both diagnostic and prognostic information and it is useful for both surgical planning and further medical management. 6 although there is abundant literature on the utility of b-scan in case of cataract and blast injuries but its utility in cases of severe ocular trauma with hazy media has not been adequately investigated. the aim of this study was to perform gentle b scan in posttraumatic eyes with hazy ocular media so that timely diagnosis and appropriate management could be done and also to find out the frequency of posterior segment pathologies related with ocular trauma. methods this study was conducted in the department of ophthalmology, holy family hospital, rawalpindi, from september 2015 to march 2016. we included both opd and emergency patients. it was a descriptive, cross-sectional study. the sample size was calculated using the reference value of expected proportion of posterior segment pathologies as 14.5%, 3 keeping confidence level at 95% and desired precision as 7%. one hundred patients were recruited using nonprobability, consecutive sampling. patients between 12 to 45 years of age and of either gender, with history of binocular or monocular trauma to the eye which made clinical assessment of posterior segment difficult were included in this study. patients with any known post segment pathology prior to ocular trauma and patients with history of diabetes and hypertension were excluded from the study. before the start of the study, approval was taken from ethical committee of the hospital. informed consent was taken from the adults and in case of patients younger than 18 years, parents were asked for consent. background information like history was taken on structured proforma. gentle b scan was performed. eye was anesthetized using local anesthetic. gel was applied on closed eye. transverse probe position was used. each quadrant of the eye was examined using limbus to fornix approach. the 12o'clock, 3-o'clock, 6-o'clock, and 9-o'clock positions, were examined carefully. the data was entered and analyzed using statistical package of social sciences software version 17. for all the categorical variables like gender, type and site of ocular injury, the side of eye involved, type of posterior segment pathology as detected on b scan, frequencies and percentages were calculated. for the continuous variables like age and time since injury, mean and standard deviation were calculated. effect modifiers like age, gender, site of injury, side of eye, time since injury were controlled by stratification. post stratification chi-square test was applied. p value < or equal to 0.05 was considered significant. results age range in this study was from 12 to 45 years with mean age of 30.43 ± 9.58 years. majority of the patients 35.0% were between 26 to 35 years of age. out of 100 patients, 73 were males and 27 were females with male to female ratio of 2.7:1. mean duration of injury was 2.27 ± 1.42 months with majority of patients i.e. 67 were between 0-3 months of duration. vitreous hemorrhage was the most common pathology seen in 38 patients. retinal detachment was seen in 21 patients and intra-ocular foreign bodies were seen in 12 patients. stratification of posterior segment pathologies with respect to age groups, gender, duration of trauma, side involved, type and site of trauma are given in table 1 and 2. table 1: stratification of posterior segment pathologies with respect to age groups. posterior segment pathologies 12-25 years (n = 31) 26-35 years (n = 35) 36-45 years (n = 34) p-value vitreous hemorrhage yes 11 (35.48%) 14 (40.0%) 13 (38.24%) 0.931 no 20 (64.52%) 21 (60.0%) 21 (61.76%) retinal detachment yes 08 (25.81%) 06 (17.14%) 07 (20.59%) 0.688 no 23 (74.19%) 29 (82.86%) 27 (79.41%) intra-ocular foreign bodies yes 02 (6.45%) 05 (14.29%) 05 (14.71%) 0.519 no 29 (93.55%) 30 (85.71%) 29 (85.29%) fatima sidra tanweer, et al 139 pak j ophthalmol. 2021, vol. 37 (2): 137-141 table 2: stratification of posterior segment pathologies with respect to gender, duration of trauma, side involved, type and site of trauma are given in table 2. posterior segment pathologies with respect to gender male (n = 73) female (n = 27) p-value vitreous hemorrhage yes 27 (36.99%) 11 (40.74%) 0.731 no 46 (63.01%) 16 (59.26%) retinal detachment yes 11 (15.07%) 10 (37.04%) 0.017 no 62 (84.93%) 17 (62.96%) intra-ocular foreign bodies yes 08 (10.96%) 04 (14.81%) 0.598 no 65 (89.04%) 23 (85.19%) posterior segment pathologies with respect to time since injury. 0-3 months (n = 67) 4-6 months (n = 33) p-value vitreous hemorrhage yes 22 (32.84%) 16 (48.48%) 0.130 no 45 (67.16%) 17 (51.52%) retinal detachment yes 13 (19.40%) 08 (24.24%) 0.576 no 54 (80.60%) 25 (75.76%) intra-ocular foreign bodies yes 08 (11.94%) 04 (12.12%) 0.979 no 59 (88.06%) 29 (87.88%) posterior segment pathologies with respect to side. right (n = 55) left (n = 45) p-value vitreous hemorrhage yes 21 (38.18%) 17 (37.78%) 0.967 no 34 (61.82%) 28 (62.22%) retinal detachment yes 11 (20.0%) 10 (22.22%) 0.786 no 44 (80.0%) 35 (77.78%) intra-ocular foreign bodies yes 07 (12.73%) 05 (11.11%) 0.805 no 48 (87.27%) 40 (88.89%) posterior segment pathologies with respect to site of injury. open globe (n = 53) closed globe (n = 47) p-value vitreous hemorrhage yes 23 (43.40%) 15 (31.91%) 0.238 no 30 (56.60%) 32 (68.09%) retinal detachment yes 14 (26.42%) 07 (14.89%) 0.158 no 39 (73.58%) 40 (85.11%) intra-ocular foreign bodies yes 09 (16.98%) 03 (6.38%) 0.104 no 44 (83.02%) 44 (93.62%) posterior segment pathologies with respect to type of trauma blunt (n = 61) penetrating (n = 39) p-value vitreous hemorrhage yes 18 (29.51%) 20 (51.28%) 0.029 no 43 (70.49%) 19 (48.72%) retinal detachment yes 11 (18.03%) 10 (25.64%) 0.362 no 50 (81.97%) 29 (74.36%) intra-ocular foreign bodies yes 06 (9.84%) 06 (15.38%) 0.405 no 55 (90.16%) 33 (84.62%) discussion global data suggest that each year more than a million people become blind due to ocular trauma. 7 early diagnosis and intervention is of utmost importance in preventing blindness in such cases. in developing countries like pakistan, the burden on healthcare system due to ocular trauma is overwhelming with around 7% admissions in ophthalmology ward related to ocular trauma. 8 such injuries can readily be investigated by ultrasound, which is of particular value when the light conducting media are opacified by hemorrhage or other injury. 9,10,11 b-scan is the most important routine investigation to be done in cases of blunt ocular trauma, especially in the presence of media opacities like hyphema, corneal edema, traumatic cataract which are very common findings after ocular trauma. 12 one of the most important roles for b-scan ultrasonography remains diagnosis and follow-up of ocular trauma. ultrasonography can be helpful not only to diagnose intraocular pathology immediately following ocular trauma when no additional imaging is possible but also during follow-up of cases in which view of posterior segment is obscured. 13 one study demonstrated 100% sensitivity and specificity for preoperative ultrasound diagnosis of retinal detachments and intraocular foreign bodies (iofbs) in 46 patients. 14 in addition, the article revealed retinal detachment, sub-retinal hemorrhage, and hemorrhagic choroidal detachment on imaging to be poor prognostic factors for visual outcome. however, the study population was limited in size and restricted to preoperative use of b-scan ultrasound. it was also seen that ultrasound had comparable results to ct scan in assessing ocular blast injuries in a military setting. 14 age range in our study was from 12 to 45 years with mean age of 30.43 ± 9.58 years. in another out of 128 eyes with ocular trauma, 83 eyes (64.84%) had open globe injury and 45 eyes (35.15%) had closed globe injury. b scan was normal in 35.15% eyes, the remaining 64.84% eyes had various posterior segment abnormalities detected on b scan, ranging from vitreous hemorrhage which was present in 42.18% eyes, retinal detachment found in 20.09% and intra ocular foreign body in 14.84% eyes. 3 in another study, with a sample size of 79, including 78 males (98.73%) and 1 female (1.26%), age ranged from 5 to 60 years with a mean of 23.43 ± 10.67 years. the interval between the time of injury and presentation to ophthalmologist ranged from 1 to 10 days in 44 patients (60 eyes) and was more than 10 days in 35 patients (48 eyes). ocular injury was frequency of posterior segment pathologies in patients with ocular trauma pak j ophthalmol. 2021, vol. 37 (2): 137-141 140 unilateral in 50 (63.29%) patients and bilateral in 29 (36.70%) eyes. forty one (37.96%) eyes had closed globe injury and 67 (62.03%) had open globe injury. the most common type of injury was corneal/scleral perforation (48.14%) followed by vitreous haemorrhage (38.88%) and traumatic cataract (30.55%). 3 bhatia et al reported vitreous membrane in 7 %, retinal detachment in 6%, vitreous hemorrhage in 4% and intra ocular foreign body in 4% cases. 15 in another study, ultrasonography revealed retinal detachment in 17 (13%), vitreous haemorrhage in 14 (10.7%), macular edema in 14 (10.7%), endophthalmitis in 12 (9.2%), pvd in 7 (5.4%) and panophthalmitis in 1 (0.7%) eye. 16 djosevska ed, in his study, detected vitreous hemorrhage in 20.9% eyes, retinal detachment in 4.4%, endophthalmitis in 3.3%, posterior vitreous detachment in 3.8%, intra ocular foreign body in 6.6% and choroidal detachment in 1.1% eyes on ultrasonography. 17 traumatic vitreous hemorrhage is seen after all sorts of traumatic insults (blunt, penetrating, surgical trauma, birth trauma, abusive head trauma, etc.). despite being uncommon, it accounts for the majority of vitreous hemorrhages in children and adolescents, ranging from 54.3 to 82.5% of all causes of vitreous hemorrhage. 18 incidence of vitreous hemorrhages in neonates is smaller (0.039%). 19 non-penetrating (blunt) trauma accounts for the majority of traumatic vitreous hemorrhage. it has a predominance of male patients age between 3 to 18 years (mean about 7 to 8 years). 18 the incidence of the traumatic retinal detachment is about 0.8% according to another study. 20 in the pediatric population, the incidence is even lower, ranging from 2.5 to 2.9 per 100,000 among children aged 10 to 19 years. 20 traumatic retinal detachment (rd) in children represents 3% to 6% of all causes of retinal detachment. 21 the most common type of retinal detachment after trauma is rhegmatogenous. in this age group, patients usually present with the worst visual acuity and the detachment has a longer evolution with a higher incidence of macular involvement and proliferative vitreoretinopathy (pvr). 20 retinal dialysis is the most common type of predisposing lesion, responsible for more than half of the traumatic retinal detachment. retinal tears are the second-most common predisposing lesion, responsible for about 20% of the traumatic retinal detachment. 22 in a study 23 on 72 traumatic eyes, the major causative agents in penetrating cases were pellet in 11.8%, metallic foreign body and road traffic accident in 9.8%. the major causative agents in blunt trauma was assault by fist/stick in (23.8%). 24 limitations of this study was its descriptive cross sectional design. interventional studies need to be done to see the outcomes of such injuries in different settings. conclusion vitreous hemorrhage was the most common posterior segment pathology in ocular trauma followed by retinal detachment and intra-ocular foreign bodies. bscan ultrasonography if carefully done, can be a very useful tool for proper evaluation of posterior segment pathologies. ethical approval the study was approved by the institutional review board/ ethical review board. (r-21/rmc/2015) conflict of interest authors declared no conflict of interest. references 1. baig r, ahmad k, zafar s, khan nu, ashfaq a. frequency of ocular emergencies in a tertiary care setting in karachi, pakistan it is time to reduce unnecessary visits. j pak med assoc. 2018; 68: 14931495. 2. nadeem s, ayub m, fawad h. visual outcome of ocular trauma. pak j ophthalmol. 2013; 29: 34-39. 3. alam m. khan a. b-scan ultrasonography in blast related posterior segment eye injuries. pak j ophthalmol. 2014; 30: 87-89. 4. kicova n. bertelmann t. irle s. sekundo w. evaluation of posterior viterous: a comparison of biomicroscopy, b scan ultrasonography and optical coherence tomography to surgical findings with chromodissection. acta ophthalmol. 2012; 90: 264268. 5. agarwal r, ahirwal s. view of a study of role of b scan ultrasound in posterior segment pathology of eye. int j med res rev. 2015; 3: 969-974. 6. satyajeet s, satish z, ojha s, bharadwaj n. role of b-scan ocular ultrasound in diagnosing posterior segment pathology in the event of non-visualization of fundus. intern j sci res. 2018; 7: 30-32. https://jpma.org.pk/article-details/8891 https://jpma.org.pk/article-details/8891 https://jpma.org.pk/article-details/8891 fatima sidra tanweer, et al 141 pak j ophthalmol. 2021, vol. 37 (2): 137-141 7. chen z, li sm. trauma of the globe: state of art in global and in china. chinese j traumatol. 2016; 19: 317-318. 8. babar tf, khan mt, marwat mz, shah sa, murad y, khan md. patterns of ocular trauma. j coll physicians surg pak. 2007; 17: 148–153. 9. chu hc, chan my, chau cwj, wong cp, chan hh, wong tw. the use of ocular ultrasound for the diagnosis of retinal detachment in a local accident and emergency department. hong kong j emerg med. 2017; 24: 263-267. 10. ibrahim em, mona am. use of ophthalmic b-scan ultrasonography in determining the causes of low vision in patients with diabetic retinopathy. eur j radiol open. 2018; 5: 79–86. 11. parchand s, singh r, bhalekar s. reliability of ocular ultrasonography findings for pre -surgical evaluation in various vitreo -retinal disorders. semin ophthalmol. 2014;29(4):236-41. doi: 10.3109/08820538.2013.821506. 12. sawyer mn. ultrasound imaging of penetrating ocular trauma. j emerg med. 2009; 36: 181–182. 13. rubsamen pe, cousins sw, winward ke, byrne sf. diagnostic ultrasound and pars plana vitrectomy in penetrating ocular trauma. ophthalmology, 1994; 101: 809–814. 14. ritchie jv, horne st, perry j, gay d. ultrasound triage of ocular blast injury in the military emergency department. mil med. 2012; 177: 174–178. 15. bhatia im, panda a, dayal y. role of ultrasonography in ocular trauma. indian j ophthalmol. 1983; 31: 495-498. 16. harshadbhai ht, tyagi m, jani s, thakkar j, sudhalkar a. paediatric ocular trauma and role of echography in evaluation of these cases. aioc proceedings. trauma session. 2010; 694-696. 17. djosevska ed. ultrasonography in ocular trauma. contributions sec med sci. 2013; 34: 105-112. 18. al-harkan dh, kahtani es, gikandi pw, abu elasrar am. vitreous hemorrhage in pediatric age group. j ophthalmol. 2014; 2014: 497083. 19. hinds t, shalaby-rana e, jackson am, khademian z. aspects of abuse: abusive head trauma. curr probl pediatr adolesc health care, 2015; 45: 71-79. 20. sarrazin l, averbukh e, halpert m, hemo i, rumelt s. traumatic pediatric retinal detachment: a comparison between open and closed globe injuries. am j ophthalmol. 2004; 137: 1042-1049. 21. weinberg dv, lyon at, greenwald mj, mets mb. rhegmatogenous retinal detachments in children: risk factors and surgical outcomes. ophthalmology, 2003; 110: 1708-1713. 22. sheard rm, mireskandari k, ezra e, sullivan pm. vitreoretinal surgery after childhood ocular trauma. eye, 2007; 21: 793-798. 23. rai p, shah sia, cheema am, niazi jh, sidiqui sj. usefulness of b-scan ultrasonography in ocular trauma. pak j ophthalmol. 2007; 23: 136-143. authors’ designation and contribution fatima sidra tanweer; registrar: concepts, design, data acquisition, manuscript review. afia matloob rana; assistant professor: literature search, data analysis, statistical analysis, manuscript review. waseem akhter; professor: manuscript preparation, manuscript editing, manuscript review. .…  …. https://www.sciencedirect.com/science/article/pii/s1008127516303662#! https://www.sciencedirect.com/science/article/pii/s1008127516303662#! https://www.ncbi.nlm.nih.gov/pubmed/?term=mohamed%20ie%5bauthor%5d&cauthor=true&cauthor_uid=30069496 https://www.ncbi.nlm.nih.gov/pubmed/?term=mohamed%20ma%5bauthor%5d&cauthor=true&cauthor_uid=30069496 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6066607/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6066607/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6066607/ 9 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology original article refractory diabetic macular edema in phakic patients looking for answer muhammad irfan karamat, asad aslam khan, nasir chaudhary, haroon tayyab pak j ophthalmol 20 1 8, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irfan karamat department of ophthalmology, kemu, mayo hospital lahore email: drirfankaramat@gmail.com …..……………………….. purpose: to evaluate the efficacy of intra-vitreal triamcinolone acetate (ta) in the treatment of macular edema secondary to diabetes mellitus, not responding to intra-vitreal bevacizumab injection. study design: quasi experimental study. place and duration of study: study was conducted in mayo hospital. study duration was six months from 1 st january to 30 th june 2017. material and methods: our study was prospective case series, which included 14 patients having diabetes and refractory diabetic macular edema, with history of 3 – 8 injections of intra-vitreal bevacizumab. patients included in the study underwent phacoemulsification along with intra-vitreal injection of triamcinolone acetate in a single sitting. best corrected visual acuity (bcva) and central macular thickness (cmt) was documented pre-op and post-op at 1, 4, 8 and 16 weeks. results: mean age of study population was 44.5 ± 4.94 years. out of 14 patients, 11 (78.6%) patients were males and 3 (21.4%) were females. results showed that 12 patients (85.7%) had improvement in bcva, one patient (7.1%) had no improvement in bcva while one patient (7.1%) had decrease in visual acuity from 0.2 log mar to 0.1 log mar. 12 (85.7%) patients showed decrease in cmt, while 2 (14.2%) showed increase in cmt. only 1 (7%) patient showed increase in iop which was outside normal limits. conclusion: intra-vitreal triamcinolone, when given in an appropriate dose is an effective treatment of refractory macular edema. cataract extraction can reduce steroid related complications; improve compliance and produce better visual outcome. key words: triamcinolone acetate, bevacizumab, macular edema, best corrected visual acuity, central macular thickness. iabetic eye disease, also known as diabetic retinopathy is the leading cause of blindness. prevalence of diabetic retinopathy among pakistani population is 56.9%1. in spite the fact that lasers, intra-vitreal injections and surgical interventions are frequently done in these patients, a significant number still remain untreated. clinically significant macular edema (csme) as defined by etdrs was based on the observation that retinal edema and exudates involving macula, especially fovea, threatens vision2. the extent and severity of edema is the basis of the international clinical macular edema disease severity scale which guides us regarding prognosis and management.3 both ocular and systemic measures are taken in order to treat diabetic macular edema. american diabetic association, united kingdom prospective diabetes study (ukpds), diabetic control and complications trial (dcct), action to control cardio-vascular risks in diabetes (accord) and other clinical trials strongly recommend hemoglobin a1c of 7%, systolic blood pressure of 150 mmm hg or less and a good control of d refractory diabetic macular edema in phakic patients looking for answer pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 10 cholesterol in order to treat dme4-8. focal/grid laser, intra-vitreal injection of anti-vegfs and vitrectomy are recommended treatment options for dme. data from etdrs tells us that at 3 years, eyes with mild to moderate non-proliferative diabetic retinopathy (npdr) and dme at base line treated with immediate focal/grid laser photocoagulation, shows 50% decrease in rate of moderate visual loss, still leaving 50% patients at risk apart from other laser induced complications like field defects, choroidal neovascularization (cnv) and sub-retinal fibrosis. one of the four sub-groups in diabetic retinopathy clinical research network (drcr.net; protocol i) evaluating intra-vitreal injection of ranibizumab showed 9 letters of improvement of snellen’s visual acuity at two years of follow-up, which includes 8 injections given to the patient during this time period9. a large clinical trial( drcr.net, protocol d) evaluating vitrectomy for dme showed improvement in visual acuity in 38% of patients, decrease in visual acuity in 22% patients whereas, 40% patients showed no improvement. out of 87 patients, 1 had endophthalmitis, 3 had retinal detachment, 5 had vitreous hemorrhage and 7 had raised intra-ocular pressure (iop)10. all these treatment modalities still leave a significant number of patients with refractory macular edema. results of drcr.net do not support intravitreal triamcinolone as first line therapy. however it shows promise as component of combination therapy, particularly in settings of dme refractory to other therapies and in settings of pseudophakia. a subgroup in clinical trial for dme, treating pseudophakic eyes with intra-vitreal triamcinolone with prompt laser showed comparable results to ranibizumab group and superior to laser group.11 major complications associated with intra-vitreal steroids are cataract formation and raised intra-ocular pressure (iop). in another study, a short term quantitative analysis of hard exudates in diabetic macular edema was done after giving intravitreal triamcinolone or dexamethasone implant or bevacizumab. it was observed that intravitreal steroids significantly reduced hard exudates on short term follow-up12.it was also observed that dexamethasone implant was beneficial for patients of diabetic macular edema with a good safety profile.13 the aim of our study was to evaluate efficacy of intra-vitreal triamcinolone acetate in the treatment of macular edema secondary to diabetes mellitus, not responding to intra-vitreal bevacizumab injection. material and methods after approval by the hospital ethical review committee, informed written consent was taken from the patients prior to inclusion in the study. patients from either gender, aged between 40-65 years, diagnosed with diabetic macular edema on the basis of visual acuity testing, fundus examination and oct findings were included in the study. the criteria also included diabetes mellitus for 5-30 years, good glycemic control confirmed with hba1c level, controlled blood pressure and serum hdl and ldl levels within normal range, and body mass index ranging from 20 – 35. patients having received intravitreal anti-vegf without significant improvement were also included in the study. only phakic patients were included in the study. patients with known history of posterior or anterior uveitis, glaucoma, prostaglandins use, or epiretinal membrane, taut posterior hyaloid or vitreomacular traction confirmed on oct were excluded. patients who had developed macular ischemia on ffa were also excluded. subjects fulfilling the inclusion criteria underwent ophthalmic examination including uncorrected and bcva measurement and slit lamp examination for iop measurement using goldmann applanation tonometry. after dilating pupils with one drop of 1% tropicamide, instilled three times, 10 minutes apart, fundus examination was performed to confirm macular edema and to rule out other causes. cmt was checked using sd oct (optovue rtvue fourier domain sd oct system). patients then underwent phacoemulsification surgery with implantation of iol. all patients received intra-vitreal triamcinolone injection (1 mg/0.01 ml) at the end of cataract surgery, in the same sitting. patients were asked to sit upright just after injection at-least for an hour in order to avoid macular staining. for evaluation, patients having complicated surgery were excluded from the study. bcva, iop and cmt were checked pre-operatively, 1 week, 4 week, 8 week and 16 weeks post-operatively. all investigations/ examinations and surgeries were undertaken by single researcher to eliminate observer bias. the predesigned proforma was completed endorsing subject’s demography, ocular examination and investigation findings. data was evaluated and analyzed using statistical program for social sciences (spss) version 17. mean and standard deviation was reported for continuous variables (age, duration of diabetes, number of previous injections, bcva, iop, cmt) while frequency and percentage for nominal/ordinal data (gender, history of laser). shapiro wilk’s test was muhammad irfan karamat et al 11 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology used to check normality of data. post normality testing, paired t test was used to compare change in bcva, iop and cmt from pre-operative value. a p value of ≤ 0.05 was considered statistically significant. results a total of 14 eyes of 14 patients were analysed. mean age of the study population was 44.5 ± 4.94 years (range 45 – 63 years). out of 14 patients, 11 (78.6%) patients were males and 3 (21.4%) were females. out of study population, 7 (50%) had undergone previous laser photocoagulation and 7 (50%) did not undergo previous photocoagulation, and there was no statistically significant difference between the two groups. demographic and clinical data of study population is given in table 1. mean pre-operative, 1 week, 4 weeks, 8 weeks and 16 weeks bcva, table 1: demography and clinical data of study population (n = 14). variable study population(n = 14) age (years) mean ± sd 54.5 ± 4.94 gender (male/female) 11/3 (78.6%)/(21.4%) laterality right/left 8/6 (57.1%)/(42.9%) previous iva (no of injections) mean ± sd 4.43 ± 1.65 previous laser history (yes/no) 7/7 (50%)/(50%) table 2: mean values of bcva, iop and cmt (n = 14). variable findings(n = 14) p value* pre-operative bcva (logmar) mean ± sd 0.15 ± 0.11 pre-operative iop (mmhg) mean ± sd 16.57 ± 2.24 pre-operative cmt (µm) mean ± sd 403.86 ± 103.80 week 1 bcva (logmar) mean ± sd 0.26 ± 0.14 .001 week 1 iop (mm hg) mean ± sd 17.36 ± 1.73 .127 week 1 cmt(µm) mean ± sd 414.64 ± 97.34 .033 week 4 bcva (logmar) mean ± sd 0.29 ± 0.15 .000 week 4 iop (mm hg) mean ± sd 17.29 ± 2.55 .231 week 4 cmt (µm) mean ± sd 391.64 ± 96.26 .075 week 8 bcva (logmar) mean ± sd 0.31 ± 0.14 .000 week 8 iop (mm hg) mean ± sd 17.29 ± 2.55 .286 week 8 cmt (µm) mean ± sd 369.08 ± 95.81 .003 week 16 bcva (logmar) mean ± sd 0.34 ± .16 .000 week 16 iop (mm hg) mean ± sd 17.86 ± 1.79 .036 week 16 cmt (µm) mean ± sd 335.71 ± 81.50 .001 *from pre-operative value using paired t test refractory diabetic macular edema in phakic patients looking for answer pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 12 iop and cmt are shown in table 2. out of study population, one patient (7.1%) had decrease in visual acuity from 0.2 log mar to 0.1 log mar. out of study population, 12 (85.7%) patients showed decrease in cmt, while 2 (14.2%) showed increase in cmt. both of these patients showed decrease in bcva as mentioned before. out of 14 patients, 3 (21.4%) patients showed decrease in iop, 2 (14.2%) patients had no effect on their iop, while 8 (57.1%) patients showed increase in iop but it was within normal range. only 1 (7%) patient showed increase in iop which was outside normal limits. difference in bcva from pre-operative value was significant at week 1, week 4, week 8 and week 16. difference in iop from pre-operative value was significant at week 16 (p = 0.03), while it was not significant at week 1, week 4 and week 8. difference in cmt from pre-operative value was significant at week 1, week 8 and week 16 while it was not significant at week 4 (p = 0.07). discussion intra-ocular use of steroids for different ocular pathologies is common and effective but not recognized as first line therapy in diabetic macular edema. role of steroids in dme is evolving from injections to implants as second line of treatment. multiple neurodegenerative and inflammatory pathways play their role in the development of macular edema. a cascade of events leads to chronic low grade inflammation of micro-vasculature leading to breakdown of tight junctions of blood retinal barrier. this in turn leads to increase in vascular permeability which results in macular edema. our study was based on the observation that corticosteroids inhibits prostaglandins, interleukin 6, vegf-α, leukotriene and block other pathways14. they also decrease paracellular permeability and increase tight junction integrity by restoring tight junction proteins at cell border15. a recent study was conducted by schmiteilenberger, analyzing the role of corticosteroids on refractory diabetic macular edema on 15 patients (n = 15) out of which 10 (66.6%) were pseudophakic16 all patients included in the study had a history of treatment failure. out of these patients 73% patients showed improvement in visual acuity. another case series published by elaraoud et al of 22 patients, who received fluocinolone acetate implant over 8 months period. all patients in this study were pseudophakic and all of them had history of intra-vitreal anti-vegf. six patients also had a history of intra-vitreal triamcinolone as well. after 3 months, mean reduction in central retinal thickness was 148 microns and average improvement in visual acuity was 6.4 letters. in this study, 68% patients showed reduction in central retinal thickness (crt) whereas 4 (18.18%) showed no improvement in cmt. two major complications of steroids in ocular treatment are cataract formation and rise of intraocular pressure.17 fame trial showed that 62% patients enrolled in the study were phakic. 82% of phakic patients developed cataract at 36 months period. after cataract surgery, overall visual benefit in these patients was similar to pseudophakic patients in the study. this shows us that use of steroids in pseudophakic patients is more productive18. a randomized controlled trial conducted by drcr.net showed that two sub-groups getting steroids for treatment of dme showed increase in iop. dme was treated by giving 1mg and 4 mg in these sub groups and increase in iop was noted in 16% and 33% patients respectively. even in fame trial increase in iop was observed in almost 45% of the patients19,20. what we believe from above discussion that if intra-vitreal steroid is given in appropriate dose and circumstances, it can be more effective and less damaging. as stated earlier, best eyes are pseudophakic eyes and low sustained dose is most effective. we selected phakic patients with a previous average history of 4.4 intra-vitreal avastin injections for dme. what we observed that almost all of them had nuclear sclerosis of grade 2 or more. so for treatment purposes we did cataract surgery along with steroid as combination therapy. advantage was two folds, cataract surgery not just gave an early improvement in visual function which helped us to build patient confidence and regular follow up but also reduced the fear of development of most common complication. steroid injection dose was 1 mg/0.05 ml. the incidence of rise in iop above the normal range with 1 mg was 16 % according to drcr.net. removal of cataract also reduces iop. both these factors helped to keep iop within normal limits. in our study we observed that at 16 weeks, out of 14 patients 9 (64.2%) patients showed increase in iop. 88.8% of these patients still had their iop within normal limit. only one patient (7.1%) showed iop more than 20 mmhg which was controlled through medication. this incidence of increase in iop outside normal limits muhammad irfan karamat et al 13 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology (7.1%) is less than the incidence of rise of iop in drcr.net (16%) and fame study 45%. our study revealed that there was an average decrease of 69 microns in cmt at end of 4 months. 12 (85.7%) patients showed decrease in cmt out of 14 which is even more than the international data we mentioned above (69%). average improvement in bcva was 1.8 log mar. 12(85.7 %) patients showed improvement in va which made it significant. our study was a prospective case series without any control group. all surgeries were performed by single surgeon; no patient was lost to follow-up. it was a pilot study with a small sample size and short follow up period. perhaps a large trial with a lengthy follow up is needed. conclusion intra-vitreal triamcinolone, when given in an appropriate dose is an effective treatment of refractory macular edema. cataract extraction can reduce steroid related complications, improve compliance and achieve better visual outcome. both these tools can be an effective combination therapy in order to treat refractory macular edema. author’s affiliation dr. m. irfan karamat mbbs, fcps, mrcs senior registrar kemu/mayo hospital, lahore prof. dr. asad aslam khan mbbs, ms, fcps, phd professor of ophthalmology kemu/mayo hospital, lahore dr. nasir chuadhry mbbs, fcps fellowship in vr assistant professor kemu/mayo hospital, lahore dr. haroon tayyab mbbs, fcps, fcps (vr) assistant professor kemu/mayo hospital, lahore role of authors dr. m. irfan karamat data collection, analysis, compilation, writing of manuscript. prof. dr. asad aslam khan critical review. dr. nasir chuadhry collection of data, writing of article, compilation. dr. haroon tayyab manuscript writing. references 1. mehreen s. prevalence of diabetic retinopathy among type – 2 diabetes patients in pakistan – vision registry. pak j ophthalmol. 2014, vol. 30, no. 4. 2. early treatment diabetic retinopathy research group. photocoagulation for diabetic macular edema. early treatment diabetic retinopathy study report no. 1. arch ophthalmol. 1985; 103: 1796-806. 3. wilkinson cp, ferries 3rd fl, klein re. proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales. ophthalmology, 2003; 110: 1677-82. 4. american diabetes association. standards of medical care in diabetes-2011 diabetes care, 2011: 34 (suppl 1): s11-61. 5. uk prospective diabetes study (ukpds) group. effect of intensive blood glucose control with metformin on complication in over weight patients with type 2 diabetes (ukpds 34). lancet, 1998; 352: 854-65. 6. diabetes control and complication trial research group. the relationship of glycemic exposure (hba1c) to the risk of development and progression of retinopathy in the diabetes control and complication trial. diabetes, 1995; 44: 968-83. 7. riddle mc. counterpoint: intensive glucose control and mortality in accordstill looking for clues. diabetes care, 2010; 33: 2722-4. 8. holmen rr, paul sk, bethel ma, et al. 10 year follow up of intensive glucose control in type 2 diabetes. n engl med. 2008; 359: 1577-89. 9. elman mj, aiello lp, beck rw, et al. randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. ophthalmology, 2010; 117: 1064-77 e35. 10. haller ja, qin h, apte rs. vitrectomy outcomes in eyes with diabetic macular edema and vitreo-macular traction. ophthalmology, 2010; 117: 1087-93 e3. 11. elman mj, bresseler nm, qin h, et al. expended two year follow up of ranizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. ophthalmology, 2011; 118: 609-14. 12. shin yu, hong eh, lim hw, kang mh, seong m, cho h. quantitative evaluation of hard exudates in diabetic macular edema after short-term intravitreal triamcinolone, dexamethasone implant or bevacizumab injections.bmc ophthalmol. 2017; 17: 182. 13. sacconi r1, battagliaparodi m, casati s, lattanzio r, marchini g, bandello f. dexamethasone implants in https://www.ncbi.nlm.nih.gov/pubmed/28974211 https://www.ncbi.nlm.nih.gov/pubmed/?term=sacconi%20r%5bauthor%5d&cauthor=true&cauthor_uid=28704825 https://www.ncbi.nlm.nih.gov/pubmed/?term=battaglia%20parodi%20m%5bauthor%5d&cauthor=true&cauthor_uid=28704825 https://www.ncbi.nlm.nih.gov/pubmed/?term=casati%20s%5bauthor%5d&cauthor=true&cauthor_uid=28704825 https://www.ncbi.nlm.nih.gov/pubmed/?term=lattanzio%20r%5bauthor%5d&cauthor=true&cauthor_uid=28704825 https://www.ncbi.nlm.nih.gov/pubmed/?term=marchini%20g%5bauthor%5d&cauthor=true&cauthor_uid=28704825 https://www.ncbi.nlm.nih.gov/pubmed/?term=bandello%20f%5bauthor%5d&cauthor=true&cauthor_uid=28704825 refractory diabetic macular edema in phakic patients looking for answer pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 14 diabetic macular edema patients with high visual acuity. ophthalmic res. 2017; 58: 125-130. 14. kern ts. contributions of inflammatory processes to the development of the early stages of diabetic retinopathy. exp diabetes res. 2007; 2007: 95103. 15. amoaku wm, saker s, stewart ea. a review of therapies for diabetic macular oedema and rationale for combination therapy. eye (lond). 2015; 29: 1115–1130. 16. tamura h, miyamoto k, kiryu j, et al. intravitreal injection of corticosteroid attenuates leukostasis and vascular leakage in experimental diabetic retina. invest ophthalmol vis sci. 2005; 46: 1440–1444. 17. felinski ea, antonetti da. glucocorticoid regulation of endothelial cell tight junction gene expression: novel treatments for diabetic retinopathy. curr eye res. 2005; 30: 949–957. 18. schmit-eilenberger vk. a novel intravitreal fluocinolone acetonide implant (iluvien®) in the treatment of patients with chronic diabetic macular edema that is insufficiently responsive to other medical treatment options: a case series. clin ophthalmol. 2015; 9: 801–811. 19. campochiaro pa, brown dm, pearson a, et al. fame study group. sustained delivery fluocinolone acetonide vitreous inserts provide benefit for at least 3 years in patients with diabetic macular edema. ophthalmology, 2012; 119: 2125–2132. 20. goñi fj, stalmans i, denis p, et al. elevated intraocular pressure after intravitreal steroid injection in diabetic macular edema: monitoring and management. ophthalmol ther. 2016; 5 (1): 47–61. https://www.ncbi.nlm.nih.gov/pubmed/28704825 microsoft word 7. munir amjad baig mm pakistan journal of ophthalmology, 2020, vol. 36 (3): 221-225 221 original article dry eye disease and diabetes mellitus munir amjad baig1, rabeeya munir2 1azad jammu kashmir medical college muzaffar abad, 2islamic international medical & dental college islamabad abstract purpose: to find out the frequency of dry eye disease in patients of type ii diabetes mellitus. study design: a hospital based descriptive cross sectional study. place and duration of study: federal government services hospital islamabad, from january 2015 to may 2016. material and methods: four hundred patients of type ii diabetes, diagnosed according to american diabetic association (ada) criteria, were selected by convenient sampling technique. patients with any ocular surgery, any systemic disease or medication affecting tear production, pregnancy, and contact lens users were excluded. clinical data was obtained by direct patient interviews and their medical records. basic demographics were recorded and a 6-item standardized dry eye questionnaire (deq-6) was administered by a trained researcher to all patients. detailed eye assessment was performed by a single surgeon under the same physical conditions. ded was assessed using dry eye workshops dews (2007) recommendations. results: participants had mean age of 55.6 ± 10.2 years. there were 61.5% males and 38.5% females. mean duration of diabetes was 12.02 ± 7.5 years. frequency of ded in this study was 58%. there were 19.7% patients who had an hba1c ≥ 9.0%. oral glucose lowering drugs (oglds) were used by 61% of the participants, while 22.5% were on insulin and 16.5% were on both. the most common symptom was burning and the most frequent sign was frothy discharge. tbut was positive in 43.5% patients. schirmer test was positive in 33.1% and corneal staining was present in 37% subjects. conclusion: dry eye disease is a common finding in diabetes mellitus which increases with the duration of diabetes. key words: diabetes mellitus, flourescein stain, dry eye, schirmer test, tear film breakup time. how to cite this article: baig ma, munir r. dry eye disease and diabetes mellitus. pak j ophthalmol. 2020; 36 (3): 221-225. doi: 10.36351/pjo.v36i3.1003 introduction dry eye disease (ded) is a multi-factorial disease of the tears resulting in tear-film instability with damage to the ocular surface1. about 4.7% of american men and 7.8% of women over 50 years have ded and 7–10 correspondence to: munir amjad baig azad jammu kashmir medical college, muzaffar abad e-mail: drmuniramjad@gmail.com received: february 9, 2020 revised: may 4, 2020 accepted: may 4, 2020 million americans use artificial tears consuming us $100 million/year2. a study in pakistan showed the de prevalence was 16%3. various risk factors influence ded like female sex, age, and hormones4. the word diabetes was used by arashes cappodocia (81-133 ad) and the word mellitus was used by thomas willis in 1675. egyptians, 3000 years ago, described dm and its clinical features5. type 2 diabetes, which accounts for nearly 90% of diabetes worldwide, is a chronic hyperglycaemia due to insulin deficiency, insulin resistance or both. it causes corneal neuropathy and corneal epithelium munir amjad baig, et al 222 pakistan journal of ophthalmology, 2020, vol. 36 (3): 221-225 dysfunction. human cornea contains both unmyelinated c and myelinated a-δ fibers6. the corneal complications like epithelial defects, trophic ulcers and superficial punctate keratopathy are caused by hyperglycemia all closely related with de6. a review of the literature showed that ded was present in more than half of diabetic patients. ded is present in 55% of people with type 2 diabetes compared to 27% people having type 1 and 29% of those having no diabetes.7 results also showed relations between diabetes duration and onset of diabetic retinopathy. it varied from 28.8% to 77.8% in persons having 5 years and 15 years duration respectively8. studies have shown that ded is correlated with glycated hemoglobin level; higher the level of hba1c, the higher is the ded symptoms9. the aim of this study is to know the effect of type 2 diabetes on tear film parameters. material and methods a descriptive cross sectional study was carried out among 400 type 2 diabetic patients attending diabetic eye clinic and referred from other departments of the federal government services hospital islamabad from january 2015 to may 2016. patients consent was taken and permission from ethical committee was sought. all cases of diabetes diagnosed according to the american diabetic association (ada) criteria, were consecutively selected. those with any surgery, any systemic disease or medication affecting tear production, pregnancy, and contact lens users were excluded. clinical data was obtained by direct patient interviews and their medical records. demographic data was recorded and a 6-item standardized de questionnaire (deq-6) was administered by a trained researcher to all the patients. detailed eye assessment including visual acuity, like slit-lamp biomicroscopy, dilated fundus examination for retinal status and various dry eye tests were performed by a single surgeon under the same physical conditions. early treatment diabetic retinopathy (etdrs) study criteria was used to grade diabetic retinopathy dr. subjects having 1 or more symptoms often or all the time, tear film break-up time (tbut) of < or = 10 seconds in 1 or both eyes, schirmer's test (st) < or = 5 mm in 5 min, corneal fluorescein staining (cfs) of > or = 1 for presence of conjunctival injection, punctate epithelial erosions (pee) and slit lamp examination of lid for mucous threads/telengiectasias and meibomian gland dysfunction (mgd) were positive signs according to japanese diagnostic criteria for dry eye. the diagnosis was made on the presence of three of five de tests. suspected dry eyes based on symptoms like ocular discomfort, burning, redness, itchiness/gritty sensation, blurred vision which improved with blinking, excessive watering and confirmed by tbut and st test values were diagnosed as de patients. data was analyzed for frequencies/percentages using spss version 20. results a total of 400 type 2 diabetic patients of varying duration, age ranging from 38-78 years, mean age 55.6 ± 10.2 years, were screened for ded. there were 246 (61.5%) male and 154 (38.5%) females and the mean duration of diabetes was 12.02 ± 7.5 years. frequency of ded in this study was 58% (232/400), 56.0% male, 43.9% female and was found to increase with age 58–67 years’ group and with duration of diabetes 15–19 years’ group. the majority of our subjects were male (61.5%) who were in the age group of 48–57 years. table 1: baseline characteristics (n = 400) 38 – 78 years. demographics respondents (%) age group (years) 38 – 47 98 24.5% 48 – 57 127 31.7% 58 – 6 7 104 26% 68 or above 71 17.8% total 400 100% sex male 246 61.5% female 154 38.5% urban 281 70.2% rural 119 29.8% family history 136 34% smokers >5 years 111 28% glasses 82 20.5% computer users 141 35.2% 218 (54.5%) patients had diabetic retinopathy, 89 (40.8%) had mild changes, 91 (41.7%) had moderate and 38 (17.4%) had severe form of retinopathy. 37% (148) subjects had peripheral neuropathy (pn), 24.5% (98) had diabetic nephropathy. 35.5% (142) subjects had hba1c value below 7.0% and 19.7% (97) had an hba1c ≥ 9.0%. oral glucose lowering drugs (oglds) were used by 61% of the participants, while 22.5% dry eye disease and diabetes mellitus pakistan journal of ophthalmology, 2020, vol. 36 (3): 221-225 223 were on insulin and 16.5% were on both. 34% 136 patients had positive family history of diabetes. the most common symptom was burning (51%) and the least common symptom was lids stuck together in the mornings (23%). the most frequently observed sign was frothy discharge in 67 (16.7%) patients. tbut was positive in 101 (43.5%) patients, schirmer test (st) was positive in 77 (33.1%), corneal staining was present in 86 (37%) subjects and 117 (50.4%) had telengiectasias and plugging of meibomian openings and/or mucous threads. decreased tear film function was found in patients with table 2: dry eye symptoms after smoking. symptoms never rarely sometimes often all the time % age burning/dryness 89 54 53 75 129 51% f.b. sensations 92 90 56 69 93 40.5% redness 108 91 67 58 76 33.5% watering 122 104 61 68 45 28.2% discharge 120 132 56 53 39 23% table 3: ded detection by deq5, positive results of tfbut, schirmer test, fluorescein staining, lid pathology. deq6 tfbut schirmer test fluorescein staining lid pathology dry eye disease (n = 232) 7 (20.2%) 101 (43.5%) 77 (33.1%) 86 (37%) 117 (50.4%) normal (n=168) 21 (12.5%) 48 (28.5%) 33 (19.6%) 8 (5%) 20 (11.1%) table 4: ded related to duration of diabetes. duration total no. dry eyes % frequency 1 – 5 years 89 34 38.2% 6 – 10 years 110 63 57.2% 11 – 15 years 130 81 62.3% 16 – 20 years 71 54 76% total 400 232 58% dr than in those with non-dr. discussion in pakistan, about 10 percent of the population suffer from diabetes and the incidence of blindness is similar to other studies (5.5% and 3.6% in nigeria and barbados respectively) as reported by world health organization (who)10. another study in pakistan, showed that the prevalence of type 2 diabetes mellitus was 11.7% over 25 years of age which was higher in males than females and was more common in urban than the rural areas11 similar to our study. the frequency of ded among diabetic patients in our study was 58%, is consistent with manaviat et al8, najafi et al9 and seirfart and strempel who had found a it to be 54.3%, 53% and 52.8% respectively among their diabetic population. out of 58% (232/ 400) patients who had ded, males were 56.0% while females were 43.9%. this is contrary to other study12 that showed females were more prone to ded. some authors13 showed that de incidence rises in women due to the low levels of protective hormones like androgens. other studies in diabetics negate gender relation in diabetic keratoconjunctivitis sicca14. majority of our subjects were in the age group of 48 – 57 years. there was an increase in ded with age (59 – 68 year group), which is comparable to chia et al15 who found higher ded prevalence with age in diabetics. liu et al16 also found that diabetes and increased age were risk factors for dry eye. contrary to that, manaviat et al.8 denied older age as a risk factor for ded in diabetics. in our study, decreased tfbut and st values with advancing age were consistent with another study11 which showed that with increasing age there was decrease in aqueous part of tear film causing symptoms of ded. thirty-four percent patients had positive family history in this study. patients with a family history of diabetes were also prone to ded is consistent with other study17. zhang et al, showed that 33% of diabetic patients exhibited lower values of schirmer test than normal18. in a series by gupta and dogru, 22.7% to 34% of eyes had lower schirmer values19. in our study, 218 (54.5%) subjects had diabetic retinopathy, 89 (40.8%) had mild changes, 91 (41.7%) had moderate and 38 (17.4%) had severe form of retinopathy similar to other study showing 28.8% to 77.7% dr prevalence during five to over 15 years duration20. in our study 38 (17.4%) subjects with munir amjad baig, et al 224 pakistan journal of ophthalmology, 2020, vol. 36 (3): 221-225 proliferative diabetic retinopathy (pdr) showed decreased tear film function than those with non-pdr is consistent to other study showing that both tbut and st values were decreased in the pdr group compared to the non-dr group21. in our study there was an interesting relation between sex and grades of dr. lower grades of dr was common in women and more severe form of dr was common in men, similar relation was found in rema et al22 study. another interesting observation was that most of the ded patients had diabetes for longer duration 10-14 years and the decreased tear film function was present in patients with pdr than npdr similar to studies of chen et al17 and manaviat et al8 while imam et al mentioned fewer dry eye symptoms23 in those with longer duration of diabetes. the most commonly reported symptom in this study was burning (61% of diabetics) and the least reported was eyelids stuck together in the morning. the study by chia et al15 found that itchiness was the most commonly reported symptom. in our study, 37% of subjects had peripheral neuropathy (pn) leading to ded. this is consistent to nakata et al24 showing that diabetic neuropathy may be an important risk factor for lacrimal gland dysfunction. dry eye incidence is related with the level of glycated hemoglobin; higher the glycated hemoglobin level, the higher is the ded. in our study ded symptoms were related to hba1c but najafi et al9 did not find the relationship while zia et al25, found more use of artificial tears among diabetics with a higher hba1c. strength of our study is that we used 6-items questionnaire to detect de symptoms. a single trained researcher helped reducing the scoring bias. our results were closer to those studies utilizing the questionnaires similar to present study. conclusion there is a link between dry eye disease and diabetes. ded is both public health and economic burden suggesting that dry eye tests must be part of the ocular examinations among diabetics. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest author’s designation and contribution munir amjad baig; associate professor: study design, data collection, manuscript writing. rabeeya munir; demonstrator: data collection, manuscript writing. references 1. lemp ma, foulks gn. the definition and classification of dry eye disease: report of the definition and classification subcommittee of the international dry eye workshop. ocul surf. 2007; 5: 75– 92. 2. miljanović b, dana r, sullivan da, schaumberg da. impact of dry eye syndrome on vision-related quality of life. am j ophthalmol. 2007; 143 (3): 409– 415. 3. cheema a, aziz t, mirza sa, siddiqi a, maheshwary n, khan ma. sodium hyaluronate eye drops in the treatment of dry eye disease: an open label, uncontrolled, multicentre trial. j ayub med coll abbottabad, 2012; 24 (3-4). 4. le q, zhou x, ge l, wu l, hong j, xu j. impact of dry eye syndrome on vision-related quality of life in a non-clinic-based general population. bmc ophthalmol. 2012; 12: 22. 5. ahmed am. history of diabetes mellitus. saudi med j 2002; 23: 373-8. 6. liu h., sheng m., liu y., et al. expression of sirt1 and oxidative stress in diabetic dry eye. international journal of clinical and experimental pathology, 2015; 8 (6): 7644–7653. 7. fuerst n, langelier n, massaro-giordano m, pistilli m, stasi k, burns c, et al. tear osmolarity and dry eye symptoms in diabetics. clin ophthalmol. 2014; 8: 507–515. 8. manaviat mr, rashidi m, afkhami-ardekani m, shoja mr. prevalence of dry eye syndrome and diabetic retinopathy in type 2 diabetic patients. bmc ophthalmol. 2008; 8: 10. doi: 10.1186/1471-2415-810. 9. najafi l, malek m, valojerdi ae, aghili r, khamseh me, fallah ae, et al. dry eye and its correlation to diabetes microvascular complications in people with type 2 diabetes mellitus. j diabetes complicat. 2013; 27: 459–462. 10. who diabetes geneva switzerland: world health organization, 2016. [cited 2016 january 14]. 1- available. --from: http://www.who.int/diabetes/facts/world_figures/en/ind ex2.html dry eye disease and diabetes mellitus pakistan journal of ophthalmology, 2020, vol. 36 (3): 221-225 225 11. meo sa, zia i, bokhari ia, arain sa. type 2 diabetes mellitus in pakistan: current prevalence and future forecast. j pak med assoc. 2016; 66 (12): 16371642. 12. beckman k. a. characterization of dry eye disease in diabetic patients versus non-diabetic patients. cornea, 2014; 33 (8): 851–854. 13. misra sl, craig jp, patel dv, mcghee cn, pradhan m, ellyett k, kilfoyle d, braatvedt gd. in vivo confocal microscopy of corneal nerves: an ocular biomarker for peripheral and cardiac autonomic neuropathy in type 1 diabetes mellitus. invest ophthalmol vis sci. 2015; 56 (9): 5060–5065. 14. achtsidis v, eleftheriadou i, kozanidou e, voumvourakis k, stamboulis e, theodosiadis pg, et al. dry eye syndrome in subjects with diabetes and association with neuropathy. diabetes care, 2014; 37 (10): e210–e211. 15. chia em, mitchell p, rochtchina e, lee aj, maroun r, wang jj. prevalence and associations of dry eye syndrome in an older population: the blue mountains eye study. clin exper ophthalmol. 2013; 31 (3): 229-232. 16. liu nn, liu l, li j, sun yz. prevalence of and risk factors for dry eye symptom in mainland china: a systematic review and meta analysis. j ophthalmol. 2014; 2014: 748654. 17. chen l, magliano dj, zimmet pz. the worldwide epidemiology of type 2 diabetes mellitus–present and future perspectives. nat rev endocrinol. 2012; 8: 228– 236. doi: 10.1038/nrendo.2011.183. 18. zhang x, zhao l, shijing deng s, xuguang sun x, and ningli wang n. dry eye syndrome in patients with diabetes mellitus: prevalence, etiology, and clinical characteristics. j ophthalmol. 2016: article id 8201053, 7 pages. 19. gupta p. k. vickers l. a. the future of dry eye treatment: a glance into the therapeutic pipeline. ophthalmology and therapy, 2015; 4 (2): 69–78. 20. messmer em, von lindenfels v, garbe a, kampik a. matrix metalloproteinase 9 testing in dry eye disease using a commercially available point-of-care immunoassay. ophthalmology, 2016; 123: 2300–2308. 21. ang l, jaiswal m, martin c, pop-busui r. glucose control and diabetic neuropathy: lessons from recent large clinical trials. curr diab rep. 2014; 14: 528. 22. rema m, premkumar s, anitha b, deepa r, pradeepa r, mohan v. prevalence of diabetic retinopathy in urban india: the chennai urban rural epidemiology study (cures) eye study. invest ophthalmol vis sci. 2005; 46: 2328–2333. 23. imam s, elagin rb, jaume jc. diabetes-associated dry eye syndrome in a new humanized transgenic model of type 1 diabetes. molecular vision, 2013; 19: 1259–1267. 24. nakata m., okada y., kobata h, shigematsu t, reinach ps, tomoyose k, saika s. diabetes mellitus suppresses hemodialysis-induced increases in tear fluid secretion. bmc research notes, 2014; 7 (1): 78. 25. zia a, bhatti a. prevalence of type 2 diabetes– associated complications in pakistan. int j diabetes dev c. 2016; 36 (2): 179–188. .……. deq 6 1. do your eyes ever feel dry? 2. do you ever feel a gritty or sandy sensation in your eye? 3. do your eyes ever have a burning sensation? 4. are your eyes ever red? 5. do you notice much crusting on your lashes? 6. do your eyes ever get stuck shut in the morning? possible answers to the questions were 'none', 'rarely or sometimes', and 'often or all the time'. subjectively dry eye was defined as having one or more symptoms 'often or all the time'. pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 25 original article visual outcome of traumatic cataract at holy family hospital, rawalpindi muhammad imran janjua, ali raza, tariq shakoor pak j ophthalmol 2016, vol. 32 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad imran janjua postgraduate trainee ophthalmology holyfamilyhospital, rawalpindi email: janjua.doc@gmail.com received: october 29, 2015. accepted: december 01, 2015. …..……………………….. purpose: to evaluate the visual outcome of patients with secondary extraction of traumatic cataract with iol implantation. study design: prospective case series. place and duration of study: department of ophthalmology, holy family hospital, rawalpindi from january 2014 to july 2015. materials and methods: 38 eyes of 38 patients with traumatic cataract were managed with cataract extraction with iol implantation. the patients were followed up for six months post operatively and final best corrected visual acuity was determined. results: 38 eyes of 38 patients were studied and there was a male predilection of 3.2:1. the most common age group affected was between 4 and 20 years (50%). blunt trauma was the cause in 11 (28.9%) patients and penetrating trauma in 27 (71.1%). more than 88% of patients had pre-op bcva of 6/60 or less. residual corneal scar due to trauma was present in 24 (63.2%) patients. the final bcva at 6 months post-op was 6/6 – 6/9 in 11 (28.9%), 6/12 – 6/18 in 21 (55.3%) and 6/24 – 6/36 in 6 (15.8%) patients. conclusion: traumatic cataract is a major cause of ocular morbidity in younger age groups and males are commonly affected. if properly managed, good final visual outcome can be achieved in such patients. key words: traumatic cataract, visual acuity, intraocular lens implantation. cular trauma is a leading cause of ocular morbidity and is one of the commonest causes of monocular blindness worldwide.1 approximately 0.5 million people suffer from blinding ocular injuries every year and more than 2 million people are bilaterally visually impaired owing to ocular trauma.2 in the developed country like us, the incidence of ocular injuries ranges from 8 to 13 per 1000 population.2 a previous study shows that from india the reported incidence is 20.53% and from pakistan it is 12.9%.1 ocular injuries commonly affect younger age group and hence of great public health importance in terms of significant and often unnecessary toll in terms of medical care, human suffering, long-term disability, productivity loss, rehabilitation services, and socioeconomic cost.3 cataract formation is a common complication of blunt or penetrating ocular trauma resulting in visual impairment.1-4 the methods used for evaluation of visual outcome of traumatic cataract are similar to those used for other types of cataract3 but the management needs special consideration because of associated injuries to other ocular structures1. the final visual outcome may be compromised by such injuries3 but if the cataract extraction is carried out as a secondary procedure the outcome is improved1. hence the purpose of this study was to evaluate the visual outcome of patients with secondary extraction of traumatic cataract with iol implantation. o muhammad imran janjua, et al 26 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology material and methods this prospective study was carried out at the department of ophthalmology, holy family hospital, rawalpindi from january 2014 to july 2015. all the patients presenting with unilateral traumatic cataract were included in the study. patients with associated injuries to the posterior segment e.g. retinal detachment and retained intra-ocular foreign body (iofb) which could affect the final visual outcome were excluded from our study. patient’s data including demographic details, mode of injury, pre-operative visual acuity, operative procedure, type of iol, presence or absence of corneal scar and final visual outcome was noted. cataract extraction with iol implantation in the capsular bag was performed as a separate procedure after initial management of the patients for the primary ocular injury. the preoperative assessment of the patients included slit lamp biomicroscopy of the anterior segment with examination of the fundus where possible owing to media clarity. in patients with obscured fundus view, b-scan was performed to rule out any iofb or other pathology like retinal detachment etc. best corrected visual acuity was also noted. biometry was performed for the calculation of iol power. in cases with corneal scar, the keratometric readings of contralateral eye were used. three types of operative procedures were used i.e. irrigation and aspiration i&a, phacoemulsification and ecce, and either rigid or foldable posterior chamber iol was placed. the patients were followedup regularly for post op recovery and final best corrected visual acuity (bcva) was recorded 6 months after surgery. the data was analyzed by statistical package for social sciences (spss) version 20.0 and values were expressed in terms of frequencies, percentages and means. results the study included 38 eyes of 38 patients who presented with unilateral traumatic cataract. out of these, 29 (76.3%) were males and 9 (23.7%) were females with a male to female ratio of 3.2: 1. the age ranged between 4 and 65 years (mean age: 22.68 ± 14.6 years). half of the patients (50%) ranged between 4 and 20 years. 39.5% patients were between 21 to 40 years. the rest (10.5%) were from 41 to 65 years. the table 1: demographic details (n=38). parameters n (%) age distribution 4 – 20 19 (50) 21 – 40 15 (38.5) 41 – 65 4 (10.5) gender male 29 (76.3) female 9 (23.7) eye right 18 (47.4) left 20 (52.6) mode of injury blunt 11 (28.9) penetrating 27 (71.1) table 2: pre-op bcva, procedure and type of iol (n=38) parameters n (%) pre-op bcva 6/6 – 6/9 0 (0%) 6/12 – 6/18 0 (0%) 6/24 6/36 4 (10.5) 6/60 1/60 17 (44.7) < 1/60 17 (44.7) procedure i&a 17 (44.7) phaco 15 (39.5) ecce 6 (15.8) type of iol rigid 16 (42.1) foldable 22 (57.9) visual outcome of traumatic cataract at holy family hospital, rawalpindi pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 27 table 3: corneal scar and post-op bcva (n=38). parameters n (%) corneal scar absent 14 (36.8) present 24 (63.2) post-op bcva 6/6 – 6/9 11 (28.9) 6/12 – 6/18 21 (55.3) 6/24 – 6/36 6 (15.8) 6/60 – 1/60 0 < 1/60 0 right eye was involved in18 (47.4%) patients whereas left eye was involved in 20 (52.6%) patients. the mode of injury was blunt trauma in 11 (28.9%) patients and penetrating trauma in 27 (71.1%). table1 shows these figures. 4 (10.5%) patients had a pre-operative best corrected visual acuity (bcva) of 6/24-6/36 and 17 (44.7%) had visual acuity of 6/60 – 1/60, whereas 17 (44.7%) patients had a visual acuity of <1/60. 17(44.7%) patients were operated by i&a, phacoemulsification was done in 15 (39.5%) and ecce in 6 (15.8%) patients. rigid lens was placed in 16 (42.1%) and foldable lens in 22 (57.9%) patients (table2). residual corneal scar due to trauma was not present in 14 (36.8%) patients whereas 24 (63.2%) patients had corneal scar. the post-operative best corrected visual acuity (bcva) at 6 months was found to be 6/6 – 6/9 in 11 (28.9%), 6/12 – 6/18 in 21 (55.3%) and 6/24 – 6/36 in 6 (15.8%) patients (table3). discussion this study included 38 eyes with traumatic cataract that presented to and managed at department ofophthalmology, holyfamilyhospital, rawalpindi from january 2014 to july 2015. more than 75% of table 4: different parameters according to age (n=38). age groups total (n=38) n (%) 4 – 20 years (n=19) n (%) 21 – 40 years (n=15) n (%) 41 – 65 years (n=4) n (%) mode of injury pre op vision procedure post op vision blunt 4 (21.1) 5 (33.3) 2 (50) 11 (28.9) penetrating 15 (78.9) 10 (66.7) 2 (50) 27 (71.1) 6/6 – 6/9 0 (0) 0 (0) 0 (0) 0 (0) 6/12 – 6/18 0 (0) 0 (0) 0 (0) 0 (0) 6/24 – 6/36 3 (15.8) 0 (0) 1 (25) 4 (10.5) 6/60 – 1/60 6 (31.6) 11 (73.3) 0 (0) 17 (44.7) < 1/60 10 (52.6) 4 (26.7) 3 (75) 17 (44.7) i & a 15 (78.9) 2 (13.3) 0 (0) 17 (44.7) phaco 1 (5.3) 11 (73.3) 3 (75) 15 (39.5) ecce 3 (15.8) 2 (13.3) 1 (25) 6 (15.8) 6/6 – 6/9 3 (15.8) 6 (40) 2 (50) 11 (28.9) 6/12 – 6/18 11 (57.9) 9 (60) 1 (25) 21 (55.3) 6/24 – 6/36 5 (26.3) 0 (0) 1 (25) 6 (15.8) 6/60 – 1/60 0 (0) 0 (0) 0 (0) 0 (0) < 1/60 0 (0) 0 (0) 0 (0) 0 (0) muhammad imran janjua, et al 28 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology patients were males. a previous study from karachi, pakistan in 2011 showed a male to female ratio of 4:1.2another study from italy in 2008 showed male predilection of 5.5:1.5 this is due to involvement of males in hazardous outdoor activities like sports and work1-3, 6. younger age groups were mostly involved and 50% patients were from 4 to 20 years of age. another 39.5% were between 21 to 40 years. this pattern of younger age group involvement is also shown in many local and foreign studies1,3,6-8. this shows that ocular trauma is a major cause of visual morbidity in productive age groups. about two – thirds of patients in this study were affected by penetrating trauma. this is consistent with previous studies which showed open globe injuries in 70 to 80 percent of patients.1,3,6,7 more than 88% of patients had a pre-op bcva of 6/60 or less with only 10% with a bcva of 6/36 or better. a previous study in singapore reported pre-op bcva of less than 6/60 in about 70% of patients of traumatic cataract9. as most of the patients were young with soft cataracts so i&a was performed in about 45% patients. phacoemulsification was done in 39% and ecce in the remaining 16% patients. posterior chamber iol was placed in all 38 patients as it is the standard method to overcome aphakia in patients operated for cataract, and results in good visual outcome.2 the post-operative bcva checked at 6 months was satisfactory in this study. about 30% of patients had a vision of 6/9 or better and 85% achieved a final visual acuity of 6/18 or better. in a study conducted in africa two – thirds of patients had a visual outcome of 6/18 or better.8two previous local studies showed a visual outcome of 6/36 or better in more than 90% patients.2,6 a foreign study from italy reported a final bcva of 6/12 or better in 48% of patients.5another study from singapore demonstrated a final bcva of 6/12 or better in 35% of patients9. this study and previous studies show that good visual outcome can be achieved by removal of traumatic cataract and implantation of posterior chamber iol. another point to consider is that ocular injuries are a major cause of significant morbidity not only in terms of physical and psychological stress but also a great economic burden. the cost is estimated to be almost 3 billion dollars annually.5 the limitations in this study were a small sample size and a fixed followup period. this was mainly due to the fact that we excluded patients who had posterior segment involvement or a retained iofb and secondly, most patients were from far flung areas and it was not convenient for them to come for longer follow-ups. conclusion to conclude, it has been observed in this as well as previous studies that ocular trauma mostly affects young males and it is a major cause of physical, psychological and economic burden. though good visual outcome can be achieved in most patients by proper management but efforts should be made to create awareness about strategies to prevent ocular morbidity due to ocular trauma and traumatic cataract. the importance of eye protection should be emphasized to the high risk population through continuous and persistent health education. the limitations of this study were a small sample size and limited follow up period. with further studies including more patients and a longer follow up period, more elaborate results can be obtained. author’s affiliation dr. muhammad imran janjua postgraduate trainee ophthalmology holyfamilyhospital, rawalpindi dr. ali raza professor and head of ophthalmology rawalpindi medical college and allied hospitals dr. tariq shakoor armed forces institute of ophthalmology rawalpindi role of authors dr. muhammad imran janjua study conception, data collection, analysis, drafting dr. ali raza study conception, analysis, overall supervision dr. tariq shakoor critical review, analysis references 1. memonmn, narsaniak, nizamaninb. visual outcome of unilateral traumatic cataract. jcpsp, 2012; 22: 497-500. 2. garg a, moreno jmr. clinical diagnosis and management of ocular trauma. jaypee; 2009. 3. shah ma, shah sm, shah sb, patel ua. effect of interval between time of injury and timing of visual outcome of traumatic cataract at holy family hospital, rawalpindi pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 29 intervention on final visual outcome in cases of traumatic cataract. eur j ophthalmol. 2011; 21: 760-5. 4. ahmed n, aziz t, akram s. visual outcome afterprimary iol implantation for traumatic cataract. pak j ophthalmol. 2011; 27: 152-4. 5. cillino s, casuccio a, di-pace f, pillitteri f, cillino g. a five-year retrospective study of the epidemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in a mediterranean area. bmc ophthalmology, 2008: 8. 6. zaman m, iqbal s, sanaullah, khan md. frequency and visual outcome of traumatic cataract. jpmi, 2006; 20: 330-4. 7. serna ojc, cordova cj, lopez sm, abdalafac, jimenez ca, matiz mh, chavez-mondragon e. management of traumatic cataract in adults at a reference center in mexico city. intophthalmol. 2015; 35: 451-8. 8. rogers g, mustak h, hann m, steven d, cook c. sutured posterior chamber intraocular lenses for traumatic cataract in africa. j cataract refract surg. 2014; 40: 1097-101. 9. adlinaar, chong yj, shatriahi. clinical profile and visual outcome of traumatic paediatric cataract in suburban malaysia: a ten – year experience. singapore med j. 2014; 55: 253-6. 10. benezra d, cohen e, rose l. traumatic cataract in children: correction of aphakia by contact lens or intraocular lens. american journal of ophthalmology, 1997; 123 (6): 773-82. 11. chuang lh, lai cc. secondary intraocular lens implantation of traumatic cataract in open-globe injury. canadian journal of ophthalmology, 2005; 40 (4): 454-9. 12. rumelt s, rehany u. the influence of surgery and intraocular lens implantation timing on visual outcome in traumatic cataract. graefe's archive for clinical and experimental ophthalmology, 2010; 248 (9): 1293-7. 13. fagerholm pp, philipson bt. human traumatic cataract. actaophthalmologica. 1979; 57 (1): 20-32. 14. lam ds, tham cc, kwok ak, gopal l. combined phacoemulsification, pars planavitrectomy, removal of intraocular foreign body (iofb), and primary intraocular lens implantation for patients with iofb and traumatic cataract. eye, 1998; 12: 395-8. 15. churchill aj, noble ba, etchells de, george nj. factors affecting visual outcome in children following uniocular traumatic cataract. eye, 1995; 9: 285-291. 16. yasukawa t, kita m, honda y. traumatic cataract with a ruptured posterior capsule from a nonpenetrating ocular injury. journal of cataract & refractive surgery, 1998; 24 (6): 868-9. 17. loncar vl, petric i. surgical treatment, clinical outcomes, and complications of traumatic cataract: retrospective study. croatian medical journal, 2004; 45 (3): 310-3. 18. fagerholm pp. the response of the lens to trauma. transactions of the ophthalmological societies of the united kingdom, 1981; 102: 369-74. 19. shah ma, shah sm, shah sb, patel cg, patel ua, appleware a, gupta a. comparative study of final visual outcome between open-and closed-globe injuries following surgical treatment of traumatic cataract. graefe's archive for clinical and experimental ophthalmology, 2011; 249 (12): 1775-81. 20. kuhn f.traumatic cataract: what, when, how. graefe's archive for clinical and experimental ophthalmology, 2010; 248 (9): 1221-3. http://www.ncbi.nlm.nih.gov/pubmed/?term=chavez-mondragon%20e%5bauthor%5d&cauthor=true&cauthor_uid=25028216 451 pak j ophthalmol. 2020, vol. 36 (4): 451-455 review article current trends in treating acanthamoeba keratitis: a brief narrative review mauro salducci 1 1 department of ophthalmology, sapienza university of rome (italy) abstract the author, after examining the historical evolution of scientific knowledge and treatment of severe acanthamoebic keratitis, presents this brief review on the treatment of this serious eye disease, relatively frequent in patients with corneal contact lenses. therapy of acanthamoeba keratitis is always very long and demanding. its management requires adequate experience because it is not always easy to evaluate the response to treatment and complications can be very serious and difficult to manage. resistance to therapy can also occur during treatment and must be distinguished from drug-induced toxicity. in cases where no improvement is obtained with maximum medical therapy, it is advisable to repeat the corneal sampling and proceed to new laboratory tests for acanthamoeba, bacteria and fungi. prevention, which always remains of fundamental importance, is practically based on avoiding contact of the corneal lens with contaminated water, since this acanthamoeba has a ubiquitous diffusion. it is therefore recommended to always avoid the use of corneal contact lenses in the pool or in the shower, not to wash them under running tap water and to frequently replace the relative container of these lenses. key words: acanthamoeba keratitis, corneal ulcer, contact lenses. how to cite this article: mauro. current trends in treating acanthamoeba keratitis: a brief narrative review. pak j ophthalmol. 2020; 36 (4): 451-455. doi: https://doi.org/10.36351/pjo.v36i4.1068 introduction since 1973, it has been recognized that acanthamoeba microorganism, which is part of the amoeba family, causes severe keratitis which can lead to blindness. the characteristic symptoms include severe eye pain, paracentral annular stromal infiltrates, epithelial ulcers and resistance to most antibiotics. 1 number of recognized cases of acanthamoeba keratitis has increased steadily in recent years for various reasons. these include increased awareness of ophthalmologists, increase in the number of contact correspondence: mauro salducci department of ophthalmology, sapienza university of rome (italy) email:mauro.salducci@uniroma1.it received: may 18, 2020 accepted: july 27, 2020 lens wearers, lack of proper care in contact lens hygiene and availability of rapid diagnostic tests that allow confirmation of acanthamoeba infection. acanthamoeba is a ubiquitous microorganism that can be isolated from a wide variety of environments, especially from ponds, swimming pools, reservoirs, sea, hot tubs, salt water, bottled water and saline solutions for contact lenses. as a pathogen, acanthamoeba can cause a form of chronic granulomatous encephalitis and skin amoebiasis in immunocompromised individuals, as well as a severe form of chronic keratitis in the healthy population. 2 corneal infection is often associated with the use of contact lenses, which in fact represents the most important risk factor. some studies have shown that more than 80% of cases of acanthamoeba keratitis occur in contact lens wearers. 3 acanthamoeba exists in two forms, quiescent cyst and active trophozoite form. under unfavorable current trends in treating acanthamoeba keratitis: a brief narrative review pak j ophthalmol. 2020, vol. 36 (4): 451-455 452 conditions, trophozoites are encysted. the cyst has a double wall containing cellulose with a diameter of 10 – 25 μm; it is extremely resistant to extreme conditions, such as changes in osmolarity, ph, drying, freezing or antimicrobial chemical agents. although the clinical symptoms of acanthamoeba keratitis can be controlled by various pharmacological agents, parasites can encyst in the corneal stroma and remain in a quiescent form. a corneal transplant can thus activate the quiescent cysts in the limbus and cause a resurgence of keratitis. 4 brief review the first case of acanthamoeba keratitis was described by jones in 1975. only 10 cases of acanthamoeba keratitis were reported between 1975 and 1981. since 1981 the number of cases has increased gradually and more than 100 cases have been reported in the united states in recent years. 5 in great britain, about 400 cases of acanthamoeba keratitis have been reported since 1977, but the real incidence of acanthamoeba keratitis is unknown. 6 more than 750 cases have been diagnosed worldwide. however authoritative authors suggest that the incidence of acanthamoeba keratitis can be 1 per 10,000 contact lens wearers per year. theoretically speaking, as there are 1,800,000 contact lens wearers in italy, infections with acanthamoeba would be around 180 per year. 7 acanthamoeba keratitis occurs in young and immunocompetent individuals, most of whom are contact lens wearers and it equally affects men and women. the pathology occurs more frequently unilaterally, although bilateral cases have also been observed and the main risk factors that seem to be implicated in the onset of acanthamoeba keratitis are; previous corneal trauma, cleaning of contact lenses with tap water or a solution contaminated with acanthamoeba and the use of contact lenses. 8 from the point of view of clinical signs, one of the most important symptoms in case of acanthamoeba keratitis is severe pain, which is very disproportionate to the clinical aspect, especially in the early stage of infectious process. this is linked to perineural infiltration. early infection can be confined to epithelium, which shows irregularities. another important feature is represented by the dendritic form corneal lesions. late manifestations include stromal infiltrates and a characteristic ring infiltrate. recurrent corneal erosions, ring infiltrates, corneal abscesses often develop that lead to an incorrect diagnosis of herpetic keratitis, satellite lesions and in severe cases hypopyon, nodular or diffuse anterior scleritis or posterior scleritis. 9,10 it is therefore essential to obtain a laboratory diagnosis as soon as possible since a delayed therapy can negatively alter the visual outcome. 8 corneal scrapings should be performed for staining and culture of epithelial or subepithelial lesions. if epithelial disease is small and stromal infection predominates, a biopsy should be considered followed by staining with methenamine silver, hematoxylin, eosin and periodic acid–schiff (pas). tissues from scraping or biopsy should be transported to the laboratory in saline along with samples taken from the contact lens box and cleaning solutions, if of course they are available. the latter must be inoculated on a lawn of escherichia coli on non-nourishing agar, so that the amoebae, which consume e. coli, form identifiable traces. 6 electron microscopy and confocal microscopy can also be used to identify parasites in corneal tissues, while phase contrast microscopy can be used to identify trophozoites furniture that has a large karyosome and a contractile vacuole. 8 as for the treatment of this serious keratopathy, the suggested antimicrobials include; membrane antiseptics (chlorhexidine and polyhexamethylene biguanide, phmb) which inhibit membrane function, aromatic diamonds (hexamidine, pentamidine isothotate, propamidine isothionate) which inhibit dna synthesis, aminoglycosides (neomycin and paromomycin) which inhibit protein synthesis and imidazoles (clotrimazole, fluconazole, ketoconazole, miconazole), which destabilize cell walls. the most commonly used drugs are propamidine isothionate (brolene, not available in italy but still supplied at the vatican city pharmacy) and chlorhexidine gluconate (visiodose eye drops), which are easily available in france and republic of san marino. 11,12,13 therapy combines antimicrobial agents that have different and additive or synergistic mechanisms. cationic antiseptics have a good general anti-amoebic activity, so, as an initial approach, chlorhexidine or phmb is recommended in combination with neomycin and/or propamidine isothionate. if necessary, imidazole can be added as a third agent. 14,15 once the diagnosis is made, the drops are used every hour for 48 hours, the frequency of dropping is mauro salducci 453 pak j ophthalmol. 2020, vol. 36 (4): 451-455 gradually reduced at night while administration is maintained every hour during the day. as inflammation and infection decreases, the frequency can be reduced within a few weeks to 4 times a day, a dosage, which is then maintained for many months. the role of corticosteroids in the treatment of acanthamoebic infection is still controversial. corticosteroids suppress the host's immune and inflammatory responses and reduce the severity of inflammation. although topical corticosteroid therapy improves the clinical picture of acanthamoeba keratitis, both worsening and side effects may occur during the execution of this therapy. 16 in the early stage of infection, de-epithelialization is effective, if used in combination with anti-amoebic therapy. this procedure appears to increase the penetration of drugs into the cornea and facilitate the removal of pathogenic microorganisms from the lesion. corneal cryotherapy has also been used both as a single procedure and in combination with keratoplasty. cryotherapy is performed at the time of perforating keratoplasty to destroy and confine parasites outside the transplanted flap. the rationale for this procedure is to eliminate relapses in recipients. 17 in vitro, trophozoites have been shown to be killed when exposed to temperatures between -50° c and -130°c. however, the cysts survive. it is important to note that cryotherapy can cause extensive corneal damage. cryotherapy therefore represents an ineffective therapeutic procedure in the treatment of acanthamoeba keratitis. 18 lamellar or perforating keratoplasty is recommended in case of progression of the disease, despite the therapeutic regimen, in the event of imminent danger of corneal perforation. 19 however, the timing of this surgery is still controversial. most of the published work shows that keratoplasty is used only in an advanced stage of pathology, that is, when limbus and sclera may already be involved or when corneal perforation has occurred. in fact, the results are often disappointing. the biggest problem is the recurrence of infection and inflammation with cataract complicated by secondary hypertonicity, intraocular inflammation, secondary limbal deficit and rejection. for this reason, some authors suggest early keratoplasty so as to be sure of eradicating the disease. 20 another subject of discussion is the choice of the type of keratoplasty; penetrating or lamellar. deep lamellar keratoplasty is indicated in cases where the cornea is not perforated. the advantages of this technique are the lower risk of rejection in these inflamed eyes and a reduced risk of endophthalmitis, being a closed bulb surgical procedure. 21 the disadvantage is the possibility that infected fibers remain in the residual stroma, a risk that is reduced with the use of deep keratoplasty techniques, in which the whole stroma is removed. in any case, if a lamellar keratoplasty fails, a penetrating keratoplasty can always be used. 8 if there is an imminent danger of corneal perforation, lamellar keratoplasty must be done. in this procedure, it is essential that the infected corneal region is entirely included in the donor flap, otherwise the infection can often reappear at the transplant-host interface with drastic consequences. therapy of acanthamoeba keratitis is always very long and demanding and its management requires adequate experience because it is not always easy to evaluate the response to treatment and complications can be very serious and difficult to manage. resistance to therapy can also occur during treatment and must be distinguished from drug-induced toxicity. in the event of deterioration during treatment, any therapy can be stopped and the response observed: if the clinical picture improves, it can be concluded that it was drug toxicity and replace one of the drugs used with an analogue (e.g., phmb with chlorhexidine or vice versa) or reduce the number of administrations. in the event of failure to improve, it must be concluded that it was resistance; in this regard, you can replace a drug with an analogue (as above) or increase its concentration. 22,23,24 phmb is also tolerated at the concentration of 0.04% and 0.06%. although the mechanism of action of phmb is similar to that of chlorhexidine, in a case of resistance to both drugs, confirmed by the positivity to culture after repeated sampling, combination of the two drugs may resolve the infection. the effect of the association of the two biguanides could be the same as that obtained with the increase in the concentration reported above. with regard to the suspension of treatment, it must be remembered that, unlike bacterial and even fungal infections, the progression of amoebic infection is very slow, so there is no risk in temporarily stopping therapy. the temporary suspension of anti-amoebic drugs has also been proposed as "pulsed" therapy, in current trends in treating acanthamoeba keratitis: a brief narrative review pak j ophthalmol. 2020, vol. 36 (4): 451-455 454 order to encourage the passage of the parasite from the cystic, more resistant, to the vegetative form, which is much more sensitive to drugs. in cases where there is no improvement despite all these manouvers, it is advisable to repeat the corneal sampling and proceed to new laboratory tests for acanthamoeba, bacteria and fungi. another technique in cases of progressive worsening despite therapy is the conjunctival grafting. it has been shown that blood supply with conjunctival tissue can have a positive effect on both the colliquative necrosis and the infectious component. prevention, which always remains of fundamental importance, is practically based on avoiding contact of the corneal lens with contaminated water, since this acanthamoeba has a ubiquitous diffusion. it is therefore recommended to always avoid the use of corneal contact lenses in the pool or in the shower, not to wash them under running tap water and to frequently replace the relative container of these lenses. 8 conflict of interest authors declared no conflict of interest. references 1. puig m, weiss m, salinas r, johnson da, kheirkhah a. etiology and risk factors for infectious keratitis in south texas. j ophthalmic vis res. 2020; 15 (2): 128-137. doi: 10.18502/jovr.v15i2.6729. 2. nayeri t, bineshian f, khoshzaban f, asl ad, ghaffarifar f. evaluation of the effects of rumex obtusifolius seed and leaf extracts against acanthamoeba: an in vitro study. infect disord drug targets, 2020 apr 22. 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https://www.ncbi.nlm.nih.gov/pubmed/31850183 microsoft word 19. uzma hamza mm 282 pakistan journal of ophthalmology, 2020, vol. 36 (3): 282-286 original article vitreo-macular interface abnormalities in diabetic and non-diabetic patients using optical coherence tomography uzma hamza1, waqas asghar2, qasim lateef chaudhry3, muhammad hassaan ali4, sana jahangir5 1-5department of ophthalmology, allama iqbal medical college, jinnah hospital, lahore abstract purpose: to study the frequency of vitreomacular interface abnormalities (vias) in diabetic and non-diabetic patients presenting in a tertiary care hospital. study design: comparative cross-sectional study. place and duration of study: jinnah hospital, lahore from may 2013 to june 2016. methods: the frequency of vitreomacular interface abnormalities (vias) was assessed among 278 patients, who presented in outpatient department of our hospital. patients were categorized into diabetic and non-diabetic groups on the basis of hemoglobinhba1c. patients with altered macular reflex on slit lamp examination underwent spectral domain (sd) optical coherence tomography (oct) of macula to determine vias. results: there were 278 patients in the study with mean age 59.7 ± 11.7(range: 40 – 65) years and male to female ratio of 1:1.06. prevalence of vias was observed to be higher among diabetic patients than non-diabetics in all age groups (p-value < 0.05). overall frequency of different vias was found to be 10.7% for epiretinal membrane, 6.4% for posterior vitreous detachment, 6.1% for macular edema/macular cyst, 4.3% for vitreomacular traction, 1.8% for full thickness macular holes and 0.71% for partial thickness macular holes. macular edema/macular cystwas the most common. via was more commonly observed in diabetic patients (17.2%). except for erm, all lesions of vias were significantly more prevalent in females as compared to males. conclusion: vias are found in significantly larger number in diabetics compared to non-diabetic patients. female gender with advancing age is associated with a higher frequency of vias. key words: vitreomacular interface abnormalities, optical coherence tomography, epiretinal membrane, vitreomacular traction. how to cite this article: hamza u, asghar w, chaudhry ql, ali mh, jahangir s. frequency of vitreomacular interface abnormalities in diabetic and non-diabetic patients using optical coherence tomography. pak j ophthalmol. 2020; 36 (3): 282-286. doi: 10.36351/pjo.v36i3.1018 introduction vitreomacular interface abnormalities (vias) are most commonly seen in patients with diabetic correspondence to: waqas asghar eye department, jinnah hospital, lahore email: waqasasghar2008@gmail.com received: march 14, 2020 revised: may 4, 2020 accepted: may 4, 2020 retinopathy1,2,3. apart from triggering diabetic macular edema, these lesions contribute to the development of advanced stages of diabetic retinopathy4,5,6. vias include epiretinal membrane (erm), partial thickness macular hole (ptmh), full thickness macular hole (ftmh), vitreomacular traction (vmt), macular cyst or macular hole (mc/mh) and posterior vitreous detachment (pvd). symptoms vary from mild metamorphopsia to severe visual deterioration. lesions like ptmh and ftmh always result in visual vitreomacular interface abnormalities in diabetic and non-diabetic patients using optical coherence tomography pakistan journal of ophthalmology, 2020, vol. 36 (3): 282-286 283 deterioration, therefore the techniques that can diagnose their precursor lesions are very useful in clinical practice7. after the advent of ocular coherence tomography (oct), vias have attracted significant clinical attention. virgili et al have shown the value of spectral-domain oct (sd-oct) for excellent visualization of vias which could potentially be missed on direct ophthalmoscopy or slit lamp biomicroscopy8. sd-oct provides higher resolution and greater scanning speed than the time domain (td)-oct. duker et al showed that sd-oct has enabled ophthalmologists to visualize and monitor the vitreomacular interface with better accuracy and repeatability9. the rationale of the study was to find the reason for unexpected visual loss in patients with diabetic retinopathy. the objective was to compare frequency and pattern of various vias in diabetic and nondiabetic patients in our local population. material and methods this comparative cross-sectional study was conducted at department of ophthalmology, jinnah hospital, lahore, pakistan from may 2016 to june 2019. the study was conducted after approval from ethical review board of the same institution and adhered to the principles of ethical medical practice as laid down in declaration of helsinki 2011. patients were recruited from outpatient department of jinnah hospital after obtaining informed written consent. patients of both genders and above 40 years of age were included in the study and divided into two groups: diabetics and non-diabetics on the basis of hemoglobin hba1c levels. the diabetes mellitus was defined as hba1c  6.2%. patients with history of vitreoretinal surgery and retinal vascular disorders like retinal vein occlusion were excluded from the study. after taking detailed ophthalmic history, detailed ophthalmic examination was performed which included assessment of unaided and best corrected visual acuity, pupillary examination, anterior segment examination using slit lamp biomicroscope and intraocular pressure measurement using applanation tonometer. the pupils were pharmacologically dilated using 1% tropicamide and 1% cyclopentolate eye drops. dilated fundus examination was performed using slit lamp biomicroscope with 90d and 66d lenses. patients with altered macular reflex on slit lamp bio-microscopy were referred for oct test. macular scans were acquired using standard 6×6 mm protocol on cirrus hd-oct 500 by zeiss, usa. presence of any via was recorded and categorized into erm, ptmh, ftmh, pvd, vmt and mc/mh. record of each patient including demographic data, ocular and oct findings were recorded in a pre-designed proforma. data was analyzed using statistical package for social sciences (spss, ibm statistics, chicago, il, usa version 23.0). mean ± sd was calculated for numerical variables like age and duration of diabetes mellitus whereas frequencies and percentages were calculated for qualitative variables like gender and various vias. the statistical significance of differences between various numerical and qualitative variables was calculated using t-test and chi-square test respectively. the p-value < 0.05 was considered statistically significant. results the study included 278 patients with mean age of 59.7 ± 11.7 (range: 40 – 65) years (table 1). there were 135 males and 143 females in the study (table 2). among 278 patients, 151 were diabetics and 127 were non diabetics. the mean duration of diabetes mellitus was 12.3 ± 5.2 years with 55 patients diagnosed with diabetes mellitus within last 5 years and 96 patients had diabetes for more than 5 years. prevalence of vias was observed to be higher among diabetic patients (66 patients) than non table 1: distribution of patients in different age groups. age (years) diabetic n non-diabetic n total n 40-54 33 37 70 55-64 46 40 86 >65 72 50 122 total 151 127 278 n: number of patients table 2: gender distribution of study population. diabetic n non-diabetic n total n p-value female 81 54 135 0.071 male 70 73 143 total 151 127 278 n: number of patients uzma hamza, et al 284 pakistan journal of ophthalmology, 2020, vol. 36 (3): 282-286 table 3: various vitreomacular interface abnormalities seen in diabetic and non-diabetic patients in different age groups. via diabetic patients (n) non-diabetics (n) total (n) 45-54 55-64 ≥65 total 45-54 55-64 ≥65 total erm 4 6 8 18 2 3 5 10 28 ptmh 1 0 0 1 0 1 0 1 2 ftmh 0 2 1 3 0 1 1 2 5 vmt 1 3 3 7 1 2 2 5 12 mc/me 7 8 11 26 2 2 2 6 32 pvd 3 4 4 11 3 2 3 8 19 total 16 23 27 66 8 11 13 32 98 n: number of patients diabetics (32 patients) in all age groups (table 3). the frequency of vias increased with age (table 3). overall frequency of different vias was found to be 10.7% for epiretinal membrane, 6.4% for posterior vitreous detachment, 6.1% for macular edema/macular cyst, 4.3% for vitreomacular traction, 1.8% for full thickness macular holes and 0.71% for partial thickness macular holes. macular edema/ macular cyst were the most common. vias were more commonly observed in diabetic patients (17.2%). except for erm, all lesions of vias were significantly more prevalent in females (table 4). table 4: frequency of various vitreomacular interface abnormalities in males and females. vias male female total erm 20 8 28 ptmh 0 2 2 ftmh 1 4 5 vmt 4 8 12 mc/me 14 18 32 pvd 8 11 19 vias 47 51 98 erm: epiretinal membrane ptmh: partial thickness macular hole ftmh: full thickness macular hole vmt: vitreomacular traction mc/ me: macular cyst/ macular edema pvd: posterior vitreous detachment vias: vitreoretinal interface abnormalities discussion our study found frequency of various vias on sdoct in diabetic and non-diabetic patients who presented to us with altered macular reflex. overall, the commonest via was erm in this study. however, macular edema and macular cysts were the commonest vias in diabetic patients. we also observed that, except for erm, all vias were significantly more prevalent in female patients. the prevalence of vias increased with advancing age of the patients. oct provides high resolution cross-sectional scans of retina that is used to identify pathological changes at vitreoretinal interface7. there are different conventional methods for assessment of retinal pathologies which include slit lamp bio-microscopy, indirect ophthalmoscopy, fluorescein angiography and fundus stereo-photography. sd-oct is a new modality that allows excellent visualization of vitreomacular interface, thus enabling us to study the vitreomacular abnormalities with high precision8. the pathophysiology of most of the vias is based on changes in vitreous with age. with advancing age, vitreous liquifies and collapses, thus causing complete or incomplete posterior vitreous detachment. incomplete posterior vitreous detachment is associated with abnormal vitreomacular adhesions, which can become symptomatic and can lead to the development of vias such as vitreomacular traction and an operculum9. similarly, epiretinal membrane can lead to development of partial or full thickness macular hole and macular edema or cyst9,10. the symptoms of the patients can vary from metamorphopsia to severe visual deterioration. furthermore, vias not only trigger other retinal pathologies like myopic tractional maculopathy but also contribute to the development of severe diabetic retinopathy11,12. unlike the current study, which utilized sd-oct for classification of various vias, previous studies have reported prevalence of various vias on the basis of clinical diagnosis made on clinical examination and/or grading of fundusphotograph11,12,13,14. however, beaver dam eye study, handan eye study and maastricht study used oct imaging to report high resolution images of vitreoretinal interface16,17,18. the beaver dam and handan eye studies did not compare prevalence of vias in diabetic and non-diabetic vitreomacular interface abnormalities in diabetic and non-diabetic patients using optical coherence tomography pakistan journal of ophthalmology, 2020, vol. 36 (3): 282-286 285 patients16,17. maastricht study calculated the prevalence of all vias and stratified them according to the age, sex and diabetics status18. in our study we observed prevalence of erm to be 10.7%. this prevalence was higher in diabetic patients (6.4%) as compared with non-diabetics (3.5%). the prevalence of erm was reported to be 6.1% and 3.4% in maastricht and handan studies respectively16,18. the beaver study reported much higher prevalence of erm (34.1%)17. all studies confirmed that the frequency of erm increased with age. our results are consistent with maastricht study as we also found significantly higher prevalence of erm in diabetics versus non-diabetics. the frequency of vitreomacular traction was found to be 4.3% in this study which is in accordance with the results of the maastricht study18 (7.0%) but differ from the findings of beaver dam study17 (26%). an earlier study reported prevalence of vmt to be 23.9% in patients with diabetic macular edema which is significantly higher than our finding (4.3%)15,19,20,21. this implies that patients with diabetic macular edema have higher chances of developing vitreomacular tractions and should undergo oct testing to check for macular pathology early in the course of the disease. the frequency of macular hole in our study was found to be 1.79% with females affected 4 times more than males (2.69% versus 0.69%). results of an earlier study showed prevalence of macular hole to be 0.5%. similarly, we found prevalence of lamellar hole to be 0.71%, which is consistent with results of the maastricht study (0.9%) but less than the findings of the beaver dam study (3.6%)17,18. the frequency of macular edema, macular cyst and posterior vitreous detachment were found to be significantly higher in diabetic patients when compared to non-diabetics (p-value < 0.05). this shows that the suspicion for diagnosing vias should be kept high in diabetic patients and where needed, oct imaging should be done to acquire high resolution images of the vitreomacular interface for early diagnosis of various macular pathologies. the limitation of this study is the small number of patients and a larger study is required to be done to confirm the results in the general population. conclusion vias were found in significantly larger number in diabetics compared to non-diabetic patients and female gender with advancing age is associated with a higher frequency of vias. optical coherence tomography proved to be a viable tool for the detection of various vitreomacular interface abnormalities. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution uzma hamza; assistant professor: study design, data collection, critical analysis, statistical analysis, manuscript writing. waqas asghar; medical officer: data collection, critical analysis, statistical analysis, manuscript writing. qasim lateef chaudhry; associate professor: concept, design, statistical analysis, final review. muhammad hassaan ali; senior registrar: data collection, statistical analysis, final review sana jahangir; vitreoretina fellow: data collection, analysis, final review. references 1. tabish sa. is diabetes becoming the biggest epidemic of the twenty-first century? int j health sci. 2007; 1 (2): 5-8. 2. copete s, martí-rodrigo p, muñiz-vidal r, pastoridoate s, rigo j, figueroa ms et al. preoperative vitreomacular interface 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traction. retina. 2019; 39 (6): 1054-60. 22. brinkhues s1, dukers-muijrers nhtm, hoebe cjpa, van der kallen cjh, koster a, henry rma, et al. social network characteristics are associated with type 2 diabetes complications: the maastricht study. diabetes care, 2018 aug; 41 (8): 1654-1662. doi: 10.2337/dc17-2144. epub 2018 jun 15. .……. 269 pak j ophthalmol. 2021, vol. 37 (3): 269-273 original article trickle down effects of covid-19 on glaucoma patients amna rizwan 1 , mahmood ali 2 , farah akhtar 3 , ume sughra 4 , syed ali hasan naqvi 5 1-5 department of ophthalmology, al-shifa trust eye hospital, rawalpindi abstract purpose: to report the adherence of glaucoma patients to anti-glaucoma medical therapy during lockdown period of covid-19 and to evaluate the factors that lead to non-adherence to medical therapy. study design: cross sectional survey. place and duration of study: al-shifa trust eye hospital, rawalpindi from august 2020 to october 2020. methods: a total of 210 patients diagnosed with glaucoma were included. exclusion criteria was newly diagnosed cases of glaucoma and patients who were non-compliant before lockdown. patients’ age, gender, marital status, occupation, residence, monthly income bracket, type of glaucoma, duration of glaucoma, number and type of anti-glaucoma medication and any other co-morbidity like diabetes or hypertension were asked from the patient. the patients were evaluated for best corrected visual acuity (bcva), intraocular pressure (iop) and retinal nerve fiber layer thickness (rnfl). before lockdown, bcva, iop and rnfl thickness were taken from computerized data of our hospital. patients were asked about the compliance of the anti-glaucoma therapy and the factors that lead to non-compliance (if any). results: out of 210 individuals, there were 131 (62.4%) males and 79 (37.6%) females. about 169 (80.5%) patients reported non-compliance to anti-glaucoma drugs during the lockdown period. non-availability of medicines was the most common reason given by 77 (57.5%) individuals, followed by lack of money by 44 (32.8%) patients. conclusion: a high proportion of non-compliance to anti-glaucoma therapy was seen in glaucoma patients during pandemic. low literacy rate, non-availability of medicines and lack of money were major reasons for noncompliance. key words: covid-19, glaucoma, intra ocular pressure. how to cite this article: rizwan a, ali m, akhtar f, sughra u, naqvi sah. trickle down effects of covid-19 on glaucoma patients. pak j ophthalmol. 2021, 37 (3): 269-273. doi: 10.36351/pjo.v%vi%i.1184 introduction glaucoma is one of the leading causes of blindness worldwide. it is a chronic vision threatening disease correspondence: amna rizwan department of ophthalmology, al-shifa trust eye hospital, rawalpindi email: aamnarizwan@hotmail.com received: december 24, 2020 accepted: january 30, 2021 that causes progressive optic neuropathy and visual field defects. it normally goes unnoticed at onset as it is asymptomatic unless at an advanced stage. 1 the global prevalence of glaucoma is 3.54%. 2 in pakistan, according to one study, 1.8 million cases were reported to have glaucoma. half of these cases have already lost vision. 3 loss of vision causes a significant burden on healthcare system. 4 the treatment regimen for glaucoma is unforgiving. normally topical antiglaucoma, surgery or laser therapy is done in these patients. 5 so far, the most common modality of glaucoma treatment is open access mailto:aamnarizwan@hotmail.com amna rizwan, et al pak j ophthalmol. 2021, vol. 37 (3): 269-273 270 topical anti-glaucoma therapy. however, they do have the problem that they may need a sustained use of up to three to four drugs at one time, with lack of consistency a major cause of failure in the treatment. 6 the novel corona virus disease 19 (covid 19), which hit pakistan on 26 february 2020, is the newest global challenge to healthcare. 7 this pandemic has put a lot of stress on the healthcare system. the long-term effects of this pandemic on chronic conditions is worth considering, especially the possible mismanagement of the same during the lockdown period. 8 chronic diseases require continuous use of medications and non-adherence to these medications can cause progression of the disease and other harmful effects on whole body. this pandemic has affected individuals by causing anxiety, depression, fear and financial problems. adherence to anti-glaucoma medications has always been an issue especially in people of third world countries, which ultimately leads to irreversible damage to optic nerve. 9 the current pandemic have led to worsening of this situation. we have investigated the effects of this pandemic on the patient’s ability to effectively continue with their anti-glaucoma regimen. methods this observational cross-sectional study was conducted at the department of glaucoma, al-shifa trust eye hospital, rawalpindi from august 2020 to october 2020, after approval from the institutional ethics review committee. non-probability convenient sampling was used. inclusion criteria was all patients presenting to glaucoma department with a confirmed diagnosis of glaucoma and who were already on antiglaucoma treatment. newly diagnosed cases of glaucoma and patients who were non-compliant before lockdown were excluded from the study. noncompliance before lockdown was assessed by computerized records of the patients. written informed consent was taken from all patients. patients’ age, gender, marital status, occupation, residence, monthly income bracket, type of glaucoma, duration of glaucoma, number and type of antiglaucoma medications and any other co-morbidity like diabetes or hypertension were asked from the patients. the patients were assessed for best corrected visual acuity (bcva), intraocular pressure (iop), retinal nerve fiber layer thickness (rnfl) and fundus evaluation to see cup-disc ratio (cdr). before lockdown, bcva, iop and rnfl thickness were taken from computerized data of our hospital. patients were enquired about the compliance to the antiglaucoma drugs and the factors that lead to noncompliance. non-compliance was defined as missing topical drops for more than 3 consecutive days. for statistical analysis, paired t-test was applied to compare the pre and post lockdown parameters of glaucoma patients. p-value ≤ 0.05 was taken statistically significant at 95% confidence interval. data analysis was done using spss 21. results of 210 individuals, there were 131 (62.4%) males and 79 (37.6%) females. the mean age of the patients was 57.8 years, ranging from 18 to 86. half of the individuals (50%) were illiterate, 62 (29.5%) were educated up to the primary level, 37 (17.6%) were up to the secondary level and only 6 (2.8%) had university level qualifications. one hundred and seventy four 174 (82.8%) people had a monthly income of less than 20 thousand, 25 (11.9%) were earning between 21 and 40 thousand, 8 (3.8%) were earning 41 to 60 thousands and only 39 (1.4%) were earning above 60 thousand rupees per month. majority were house wives (31.4%), 12.4% were retired personnel, 12.4% were laborers, 8.6% were shopkeepers and 12.9% were unemployed. we found compliance to anti-glaucoma therapy to be strongly correlated with education with a spearman coefficient of +1.00 at a (p < 0.01). there were 71 (33.8%) patients with only 1 seeing eye. fifty people (23.8%) were using topical antiglaucoma drugs for right eye, 47 (22.4%) for the left eye, while 113 (53.8%) individuals were using it in both eyes. about 180 (85.7%) individuals were being treated for primary open angle glaucoma, 17 (8.1%) for primary angle closure glaucoma, and 13 (6.2%) for secondary glaucoma. fifteen (7.1%) individuals had isolated diabetes, while 39 (18.6%) patients had isolated hypertension, with 19 (9%) individuals having both. after preliminary analysis of normality, paired sample t test was applied to compare the iop, rnfl and visual acuity before and after lockdown among glaucoma patients. details are shown in table 1 and 2. no statistically significant association was found among non-compliance with age, gender, duration of glaucoma, number of anti-glaucoma drops or only eyed patients. trickle down effects of covid-19 on glaucoma patients 271 pak j ophthalmol. 2021, vol. 37 (3): 269-273 table 1: comparison of glaucoma assessment parameters before and after lockdown (n=210).iop= intraocular pressure, rnfl= retinal nerve fiber layer. variables before lockdown (mean ± sd) after lockdown (mean ± sd) mean difference t (df) p-value 95% confidence interval of the difference lower upper visual acuity right eye 0.51 ±0.29 0.47 ± 0.29 -2.012 -4.75 < 0.001 -2.849 -1.176 visual acuity left eye 0.49 ± 0.30 0.48 ± 0.30 -1.962 -4.70 < 0.001 -2.786 -1.139 iop right eye 14.15 ± 3.75 16.13 ± 5.88 2.061 5.18 < 0.001 1.276 2.846 iop left eye 14.34 ± 3.80 16.31 ± 5.95 2.431 6.39 < 0.001 1.681 3.182 rnfl thickness right eye 68.69 ± 22.68 66.63 ± 22.64 .03496 5.73 < 0.001 .02292 .04700 rnfl thickness left eye 66.89 ± 22.71 64.46 ± 23.69 .02677 4.02 < 0.001 .01361 .03993 table 2: visual and iop parameters. visual acuity (va) before lockdown n(%) after lockdown n(%) iop (mmhg) before lockdown n(%) after lockdown n(%) right eye va 6/6 – 6/12 83 (50.9%) 74 (45.4%) right eye 15 or less 112 (68.7%) 92 (56.4%) mild (6/12 – 6/18) 23 (14.1%) 25 (15.3%) >15 – 20 42 (25.7%) 48 (29.4%) moderate (6/18 – 6/60) 45 (27.6%) 49 (30%) >20 – 25 7 (4.3%) 9 (5.5%) va < 6/60 12 (7.4%) 15 (9.2%) >25 – 30 1 (0.6%) 7 (4.3%) >30 1 (0.6%) 7 (4.3%) total 163 (100%) 163 (100%) total 163 (100%) 163 (100%) left eye va 6/6 – 6/12 76 (47.5%) 73 (45.6%) left eye 15 or less 110 (68.7%) 90 (56.2%) mild 6/12 – 6/18 31 (19.3%) 26 (16.25%) >15 – 20 44 (27.5%) 44 (27.5%) moderate 6/18 – 6/60 44 (27.5%) 46 (28.7%) >20 – 25 3 (1.9%) 14 (8.7%) va < 6/60 9 (5.6%) 15 (9.4%) >25 – 30 2 (1.2%) 5 (3.1) >30 1 (0.6%) 7 (4.4%) total 160 (100%) 160 (100%) total 160 (100%) 160 (100%) table 3: reasons for non-compliance during lockdown. isolated reasons frequency n(%) combined reasons/frequency n(%) a. lack of knowledge 2 (1.4%) a+e 1 (2.8%) b. lack of money 44 (32.8%) a+b 6 (17.1%) c. loss of job 2 (1.4%) a+f 3 (8.6%) d. did not want to leave home 4 (2.9%) b+d 1 (2.8%) e. lack of health care facility 3 (2.2%) b+e 1 (2.8%) f. unavailability of medicine 77 (57.5%) b+c 2 (5.7%) g. side-effects of drops 1 (0.7%) b+f 19 (54.3%) h. transport problem 1 (0.7%) c+f 2 (5.7%) total 134 35 discussion covid-19 pandemic has emerged as a singular healthcare challenge confronting the global citizenry both in terms of its colossal impact on the healthcare system and as a micro and macroeconomic catastrophe. 10 in terms of attention to patient health, chronic disease management has suffered as healthcare systems are overwhelmed with treating covid-19 patients. the health care providers are less able to track the progression of conditions such as diabetes, kidney diseases, cardiovascular conditions, and glaucoma, etc. this apathy to chronic diseases, displayed by both healthcare systems and individuals, may lead to worsening of these conditions and lead to serious complications. 11 this study was conducted to determine the status of non-compliance to anti-glaucoma treatment in patients as a result of a four-month lockdown in pakistan. during this period ophthalmology clinics remained essentially closed. more affluent patients may still had limited recourses to medical facilities in terms of private clinics, but the more deprived majority may have suffered adverse complications. in our study, we included those patients only that were properly compliant with their glaucoma treatment regimen to get results that more or less reflected non-compliance only due to covid-19 pandemic. the main findings of our survey are the relatively high noncompliance rates (80.5%). this is understandably higher than noncompliance rate in a study conducted in israeli arab patients before the amna rizwan, et al pak j ophthalmol. 2021, vol. 37 (3): 269-273 272 times of covid where noncompliance rate was 53.6% with noncompliance primarily attributed to a poor understanding of the disease. 12 in another study by tamrat et al in 2015, about 67.5% patients were reported non-adherent to anti-glaucoma treatment which again is not as high as in our study. 13 we find that the leading causes for non-compliance in our patients were unavailability of medications due to the lockdown (77 individuals,57.5%) followed by lack of financial resources to acquire the medications (44 patients, 32.8%). this, as expected, are different from leading causes cited by patients in a similar study conducted pre-covid in the year 2016 in pakistan where the leading causes were identified as a difficult follow up regimen in terms of a variety of medications to be self-administered and various side effects that prompted patients to take their glaucoma medication intermittently. 14 we have found a strong statistically significant correlation (p < 0.01) between education level and compliance to anti-glaucoma therapy by utilizing the spearman test that resulted in a correlation coefficient of +1.00. this is consistent with the findings of an earlier study, where the authors reported compliance to be strongest in educated patients and non-compliance to be highest in the least educated patients. 15 we do not find the number of eyes drops to be correlated to noncompliance with glaucoma therapy which is inconsistent with the findings of hasebe et al and lulu et al. 16,17 there was no statistically significant correlation between glaucoma therapy compliance and patient’s age. this contradicts the findings of tadesse et al, who found younger patients to be more compliant. this may be the result of an overwhelmingly large number of less educated patients in our study whereas tadesse et al might had found compliance in younger generation due to better access to education leading to a better understanding of the disease. 18 while it may seem counterintuitive, we did not find any association of glaucoma noncompliance with patients who had one seeing eye versus two. the primary strength of our study is that it was initiated under unique conditions of lockdown due to the covid-19 pandemic and is certainly one of a kind considering noncompliance rates of glaucoma and resulting effects on pakistani patients. the main limitation of this study was that some results were based on a questionnaire where patients’ recall-bias as well as bias to please the physician may contribute to incorrect reporting of glaucoma medication noncompliance. however, we do have an independent check on the disease progression in terms of va, iop control and rnfl thickness. we have seen in this study that there is a very strong correlation between educational attainment and compliance with glaucoma regimen. 19,20 further, the biggest hurdle faced by the patients in this pandemic was the timely availability of proper medication. we recommend that in times of pandemic the state can do a better job of educating the masses regarding various chronic conditions and counsel them via mass media to stick to their medication regimen. extraordinary efforts are needed to ensure that individuals' chronic conditions do not worsen in times of pandemic. this includes, but is not limited to, consultation via phone and other media and medicines delivery at the doorsteps. at a very minimum, drug availability at pharmacies must be ensured, with the possibility of obtaining continuing medicines for chronic conditions from primary healthcare facilities. conclusion the covid-19 pandemic has caused a statistically significant increase in the rate of non-compliance to glaucoma medication principally resulting from nonavailability of medications and lack of financial resources. low literacy resulting in poor understanding of the disease probably compounded the situation. this non-compliance has resulted in a statistically significant increase in iop and decrease in va and rnfl thickness\ compared with the prepandemic situation among patients presenting to our tertiary care facility. ethical approval the study was approved by the institutional review board/ ethical review board. (erc-52/ast-20) conflict of interest authors declared no conflict of interest. references 1. kastner a, king aj. advanced glaucoma at diagnosis: current perspectives. eye (lond). 2020; 34 (1): 116128. doi:10.1038/s41433-019-0637-2. 2. khandelwal rr, raje dv, khandelwal r. clinical profile and burden of primary glaucoma in rural camp patients attending a tertiary care center in india. j clin ophthalmol res. 2019; 7: 55-60. doi:10.4103/jcor.jcor79-18. https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.4103%2fjcor.jcor_79_18 https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.4103%2fjcor.jcor_79_18 trickle down effects of covid-19 on glaucoma patients 273 pak j ophthalmol. 2021, vol. 37 (3): 269-273 3. khan l, ali m, qasim m, jabeen f, hussain b. molecular basis of glaucoma and its therapeutical analysis in pakistan: an overview. biomed res ther. 2017; 4 (03): 1210-1227. doi: 10.15419/ bmrat. v4i03.158. 4. williams am, huang w, muir kw, stinnett ss, stone js, rosdahl ja. identifying risk factors for blindness from primary open-angle glaucoma by race: a case–control study. clin ophthalmol. 2018; 12: 377383. doi: 10.2147/opth.s143417. 5. motlagh bf. medical therapy versus trabeculectomy in patients with open-angle glaucoma. arq bras oftalmol. 2016; 79 (4): 233-237. doi:10.5935/0004-2749.20160067. 6. butt nh, ayub mh, ali mh. challenges in the management of glaucoma in developing countries. taiwan j ophthalmol. 2016; 6 (3): 119-122. doi: 10.1016/j.tjo.2016.01.004. 7. waris a, atta uk, ali m, asmat a, baset a. covid-19 outbreak: current scenario of pakistan. new microbe new infect. 2020; 35: 100681. doi: 10.1016/j.nmni.2020.100681. 8. chudasama yv, gillies cl, zaccardi f, coles b, davies mj, seidu s, et al. impact of covid-19 on routine care for chronic diseases: a global survey of views from healthcare professionals. diabetes metab syndr. 2020; 14 (5): 965-967. doi: 10.1016/j.dsx.2020.06.042. 9. rajurkar k, dubey s, gupta pp, john d, chauhan l. compliance to topical anti-glaucoma medications among patients at a tertiary hospital in north india. j curr ophthalmol. 2018; 30 (2): 125-129. doi: 10.1016/j.joco.2017.09.002. 10. kamran m, jafri w. severity of disease from covid-19 in patients with obesity and mafld: is there an association? j coll physicians surg pak. 2020; 30 (9): 891-893. doi: 10.29271/jcpsp.2020.09.891. 11. liu n, huang r, baldacchino t, sud a, sud k, khadra m, et al. telehealth for noncritical patients with chronic diseases during the covid-19 pandemic. j med internet res. 2020; 22 (8): e19493. doi: 10.2196/19493. 12. abu hussein nb, eissa im, abdel-kader aa. analysis of factors affecting patients' compliance to topical antiglaucoma medications in egypt as a developing country model. j ophthalmol. 2015; 2015: 234157. doi:10.1155/2015/234157. 13. tamrat l, gessesse gw, gelaw y. adherence to topical glaucoma medications in ethiopian patients. middle east afr j ophthalmol. 2015; 22 (1): 59-63. doi:10.4103/0974-9233.148350. 14. khan h, mahsood yj, gul n, ilyas o, jan s. factors responsible for non-compliance of glaucoma patients to topical medications in our setup. pak j ophthalmol. 2018; 34 (4): 265-271. doi:10.36351/pjo.v34i4.266. 15. abu hussein nb, eissa im, abdel-kader aa. analysis of factors affecting patients’ compliance to topical antiglaucoma medications in egypt as a developing country model. j ophthalmol. 2015; 2015: 234157. doi:/10.1155/2015/234157. 16. hasebe y, kashiwagi k, tsumura t, suzuki y, yoshikawa k, suzumura h, et al. changes in adherence and associated factors among patients on newly introduced prostaglandin analog and timolol fixed-combination therapy. patient prefer adherence. 2018; 12: 1567-77. doi:/10.2147/ppa.s168921. 17. lulu-bahiyya ui, sreeja pa. assessment of topical glaucoma side effects and adherence to the glaucoma medications in eye care centres at palakkada prospective study. int j pharm pharm res. 2017; 9 (3): 234-243. 18. tadesse f, mulugeta a. compliance to topical antiglaucoma medication among glaucoma patients at menelik ii tertiary hospital, addis ababa, ethiopia. ethiop j health dev. 2015; 29 (1): 31-36. 19. rudd p. in search of the gold standard for compliance measurement. archives of internal medicine. 1979; 139 (6): 627-628. 20. konstas ag, maskaleris g, gratsonidis s, sardelli c. compliance and viewpoint of glaucoma patients in greece. eye, 2000; 14 (5): 752-756. authors’ designation and contribution amna rizwan; registrar: concepts, design, literature search, data acquisition, data analysis, manuscript review. mahmood ali; associate professor: manuscript editing, manuscript review. farah akhtar; professor: concepts, design, literature search, manuscript review. ume sughra; associate professor: data analysis, statistical analysis, manuscript review. syed ali hasan naqvi; medical officer: data analysis, manuscript review. .…  …. https://doi.org/10.15419/ https://doi.org/10.2147/opth.s143417 https://doi.org/10.2196/19493 https://doi.org/10.36351/pjo.v34i4.266 https://doi.org/10.1155/2015/234157 https://doi.org/10.2147/ppa.s168921 102 pak j ophthalmol. 2021, vol. 37 (1): 102-108 original article computer vision syndrome (cvs) and its associated risk factors among undergraduate medical students in midst of covid-19 khola noreen 1 , kashif ali 2 , kausar aftab 3 , muhammad umar 4 1,4 rawalpindi medical university, rawalpindi, 2 combined military hospital, panu aqil 3 gujranwala medical college, gujranwala abstract purpose: to determine the frequency of computer vision syndrome and its associated risk factors among under graduate medical students. study design: descriptive cross–sectional study. place and duration of study: gujranwala medical college and rawalpindi medical university, pakistan from 5 th august to 28 th august, 2020. methods: a validated self-designed questionnaire was used for this study. the survey instrument was tailored from a published questionnaire which comprised of questions on demographics, frequency of symptoms of computer vision syndrome, pattern of computer usage and ergonomic practices. final analysis was run on 326 undergraduate medical students. results: there were 228 (69%) females and 98 (30%) males with age range between 17 to 25 years. overall frequency of cvs was found to be 98.7%. twenty-nine percent students experienced extra ocular complaints and 71% had ocular symptoms. symptoms of cvs were more commonly observed among those using desktop/laptop at less than forearm length (p = 0.001). distance of < 12 inches from mobile phone was found to be associated with eye irritation and neck shoulder pain (p = 0.001). frequency of break of more than 60 minutes was found to be significantly associated with eye irritation (p = 0.002) and excessive blinking and light sensitivity (p = 0.001). the students not using ergonomically designed work station were found to suffer with more symptoms of cvs as compared to those using ergonomically designed work station (p = 0.049). conclusion: health issues related to excessive use of digital devices has become alarmingly high during covid-19 pandemic. symptoms of cvs are significantly associated with distance from digital device and less frequent break intervals. key words: covid-19, computer vision syndrome, digital eye syndrome, ergonomics, visual display terminals. how to cite this article: noreen k, ali k, aftab k, umar m. computer vision syndrome (cvs) and its associated risk factors among undergraduate medical students in midst of covid-19.. pak j ophthalmol. 2021, 37 (1): 102-108. doi: https://doi.org/10.36351/pjo.v37i1.1122 correspondence: khola noreen rawalpindi medical university rawalpindi email: khauladr@gmail.com received: august 27, 2020 accepted: november 9, 2020 introduction prolonged and rampant use of visual display terminals (vdts) during pandemic has predisposed our young generation to a variety of health issues not limited only to visual problems but also including various musculoskeletal problems. since the report of first cluster of covid -19 (corona virus) cases around the end of december 2019 in china, it has shown rapid spread over short span of time. 1 on 30 th january 2020, international health regulations emergency computer vision syndrome (cvs) and its associated risk factors pak j ophthalmol. 2021, vol. 37 (1): 102-108 103 committee meeting regarding the outbreak of novel corona virus (2019-ncov) declared it as global public health emergency of international concern (pheic). on 11 th february 2020, virus was labelled by who as „severe acute respiratory tract coronavirus-2‟ (sars-cov-2; also referred to as 2019-ncov) and disease as „covid-19‟. 2 on 11 th march, 2020 this outbreak was declared as global pandemic by who. 3 the global pandemic has imposed cataclysmic impacts on almost every aspect of life. “spatial distancing” 4 became one of the strongly recommended practice around the globe and it involves creating and maintaining safe social distance which has ultimately moved the world away from public spaces and shared locations to isolation. 4 this practice led to implementation of variety of regulation and recommendations that has resulted in shutting down of all major areas involving public gathering and human interaction including schools, colleges, offices, air ports, railway stations, shopping malls, mosques, temples, sports arena and has affected almost every field of life. under such unprecedented circumstances work from home (remote working practices) has become obligatory practice and human life has become dependent on technology as it serves as a crucial requirement for linkage to the external world. 5 technology has become sole enabling tool for people to interact, communicate and continue their responsibilities. the human interaction has become virtual in the form of online meetings, audio, video conferencing, recreational activities like online gaming, blogging, social networking resulting in rapid upsurge in increased digitalization in every aspect of human life. education sector is another domain in which long standing educational practices were disrupted and elicited the need to look for alternate educational strategies to be adopted during pandemic. the e-learning strategy emerged as alternative solution to continued education. the educational institutions around the globe have started using different educational platforms like google classroom, zoom, and microsoft teams. rapid upsurge in internet traffic has also been observed on these platforms. 6 rapid increase in digitalization during pandemic has resulted in increased time spent in front of video display terminals including desktops, computers, laptops, smart phones and e-readers. increased use of video display terminals (vdts) predisposes to variety of health problems restricted not only to visual problems but also include various musculoskeletal problems, collectively known as digital eye strain (des) or computer vision syndrome. 7 american optometric association defined computer vision syndrome as “a complex of eye and vision problems related to activities, which stress the near vision and which are experienced in relation or during the use of the computer”. 8 symptoms related to cvs have been divided as: (i) symptoms related to ocular-surface like dry eye, excessive watering, eye irritation (ii) asthenopic-eye fatigue, eye strain, sore eyes (iii) visual related problems like double vision, difficulty in focus change, blurred vision (iv) extra ocular symptoms including back, neck pain and headache. 9 the massive increase in digitalization during this pandemic has predisposed million of the individuals around the globe to increased risk of digital eye syndrome. as pandemic escalated quickly without any prior warning there was little reaction time available for preparedness and other mitigation measures. under such unanticipated circumstances digital eye syndrome may turn up as an emerging public health issue which can be responsible not only for substantial health problems but might have significant economic impact also and its deleterious consequences may continue even when pandemic is over. the objective of this study was to determine the frequency of computer vision syndrome and its associated risk factors among under graduate medical students during covid-19. this study would provide baseline data to public health professionals to devise effective strategies to mitigate this emerging public health issue. methods a cross-sectional survey was conducted from 5 th august to 28 th august, 2020 after seeking ethical approval from university ethical review board. sample size was calculated using who sample size calculator taking prevalence as 74.3% from a recent study. 10 estimated sample size was found to be 295. however, estimated sample size was inflated to cater for nonresponses and to assess a large number of participants and gather maximum possible data and enhance generalizability. data was collected from two different medical universities to attain required sample size and statistical power. students within age range of 18 – 25 years, using computer since last 3 months or since educational institutes were closed due to lock down (whichever khola noreen, et al 104 pak j ophthalmol. 2021, vol. 37 (1): 102-108 was earlier) were selected for this study. students with underlying systemic illness like hypertension, diabetes, tuberculosis, endocrine, metabolic disorders, autoimmune disorders using medication having visual side effects (bisphosphonates, cyclosporines, tetracyclines, hydroxychloroquine, antituberculosis, anticholinergics), topical eye drops were excluded. the study participants were asked about the presence of symptoms of cvs during the previous 3 months or since the closure of academic institutions. symptoms of computer vision syndrome are broadly classified into four categories: i) asthenopic – sore eyes, eye strain, (ii) ocular surface relateddry eye, irritation, watering, (iii) visual – double vision, blurred vision, slowness of focus change iv) extra ocular – shoulder pain, neck pain, back ache.symptoms that lasted for at least one week during this time period were considered as presence of symptoms of cvs. study was started after approval from institutional review board. the data collection was in accordance with the helsinki declaration and according to the national ethical guidelines. anonymity and confidentiality of data was maintained. since the students were subjected to observe social distancing, all educational institutes were temporarily closed and routine educational activities were suspended due to lock down, the data was collected using online questionnaire which was shared electronically. questionnaire was prepared using online google forms and shared through social networking sites for data collection. before filling the form, students were given brief description about the purpose of study, its objectives and brief instructions to fill the questionnaire. students were allowed to proceed only if they agreed to participate in the survey. the students were allowed to withdraw themselves at any stage if they were not willing to proceed. there was also an option of skipping any questions if they did not feel comfortable in providing particular information. data collection tool was developed after extensive literature search of already published studies and according to guidelines of american optometric association. 11 first draft was validated by two senior faculty members, one from ophthalmology department and other from public health. after initial review, draft was revised and necessary alterations were made to finalize the tool. after finalization, pilot study was carried out on 30 students to check for its understanding. statistical analysis was performed by spss 25. mean and standard deviation was calculated for quantitative variables and for categorical variables, frequencies and percentages were estimated. chi square test was applied to find statistical association, p-value < 0.05 was taken as significant. results a total of 343 students were enrolled in the study. final analysis was run on 326 undergraduate medical students. females were 228 (69%) and 98 (30%) were males. age of the participants ranged between 17 to 25 years, mean age of the participants was 21.41 years. out of total 326 students, 322 claimed that they had experienced at least one symptom of computer vision syndrome since last three months. overall prevalence was found to be 98.7%. complaints associated with computer vision syndrome are broadly classified into two categories, ocular and extra ocular (musculoskeletal) complaints. out of 322 students affected, total 29% students experienced extra ocular complaints, out of which 43 (13%) suffered musculoskeletal complaints and 52 (16%) had headache while rest of 227 (71%) had ocular symptoms. the frequency of ocular complaints in this study included irritation of eyes 25 (7.7%), blurred vision 21 (6.4%), redness of eyes 14 (4.3%), eye strain 17 (5.2%), excessive watering 7 (2.1%), increased sensitivity to light 5 (1.5%). most commonly employed ergonomic practice was controlling light and glare. rest of the details of ergonomic practices are shown in fig. 1. symptoms of cvs were more commonly observed among those using desktop/laptop at less than forearm length (p = 0.001). distance of < 12 inches from mobile phone was found to be associated with eye irritation and neck shoulder pain (p = 0.001). rest of details are shown in table 1. frequency of break of more than 60 minutes was found to be significantly associated with eye irritation (p = 0.002) and excessive blinking and light sensitivity (p = 0.001). the students not using ergonomically comfortable chair were found to suffer more with symptoms of cvs as compared to those using ergonomically designed chair (p = 0.049). details are shown in table 2. computer vision syndrome (cvs) and its associated risk factors pak j ophthalmol. 2021, vol. 37 (1): 102-108 105 fig. 1: preventive strategies adapted by students during using digital devices. table 1: association of computer usage with symptoms of computer vision syndrome. variable group eye irritation pvalue blurring of vision pvalue excessive blinking pvalue sensitivity to light pvalue pain in neck & back pvalue distance from laptop/ desktop <forearm 182 (56) 0.001 124 (91) 0.001 143 (44) 0.418 96 (54.8) 0.001 122 (89.6) 0.890 >forearm 143 (44) 11 (8.1) 162 (48) 62 (45.9) 158 (89.3) distance from mobile phone <12inch 93 (68.9) 0.001 123 (91.1) 0.431 82 (59.9) 0.418 62 (45.9) 0.418 122 (90.4) 0.001 12-16 inch 74 (42.8) 158 (91.3) 74 (42.8) 74 (42.8) 134 (79) >16 inch 6 (54.5) 10 (90.9) 6 (54.5) 6 (54.5) 8 (72.7) time spent in using digital device <2 hrs 1 (16.7) 0.036 0 (0) 0.01 7 (93) 0.598 1 (16.7) 0.144 6 (98) 0.276 2-4 hrs 19 (7.5) 1 (4.8) 34 (85) 19 (47.5) 34 (85) 4-6 hrs 49 (40.8) 5 (9.3) 110 (91.7) 49 (40.8) 110 (91.7) 6-8 hrs 83 (57.8) 21 (33.7) 79 (87.8) 43 (47.8) 79 (87.8) >8 hrs 91 (67.7) 56 (86.2) 58 (89.2) 31 (47.7) 58 (89.2) table 2: pattern of computer usage with symptoms of computer vision syndrome. variable group eye irritation pvalue blurring of vision pvalue excessive blinking pvalue sensitivity to light pvalue pain in neck & back pvalue frequency of break > 60 mins 99 (47.2) 0.002 94 (87) 0.667 182 (56) 0.001 64 (59.9) 0.001 94 (87) 0.667 < 60 min 44 (40.5) 188 (90.4) 143 (44) 109 (52.4) 188 (90.3) posture mostly lying 20 (33.3) 0.159 52 (86.1) 0.465 20 (33.3) 0.418 20 (45.9) 0.418 56 (93.4) 0.470 mostly sitting 38 (48.8) 67 (90.3) 36 (48.8) 74 (42.8) 66 (89.2) both 87 (45.5) 176 (92.1) 87 (45.5) 6 (54.5) 168 (88) using ergonomically designed station yes 14 (31.7) 0.049 221 (89.5) 0.429 14 (31.8) 0.045 1 (16.7) 0.044 42 (95.5) 0.667 no 112 (45.5) 42 (95.5) 112 (45.5) 19 (47.5) 218 (88.3) may be 149 (45.2) 29 (13.5) 14 (45.2) 49 (40.8) 28 (90.7) khola noreen, et al 106 pak j ophthalmol. 2021, vol. 37 (1): 102-108 discussion in this particular study, out of total 326 under graduate medical students, 322(98.7%)reported that they had experienced at least one symptom of cvs in last 3 months. this figure is remarkably high as compared to previous studies as the result of the study conducted on medical students of karachi reported prevalence of 68%. 12 similarly, study conducted on government office workers of ethiopia reported 69.5% 13 , survey of university students of uae reported 72% 14 and students of engineering university of india reported 80.3%. 15 other studies showed 67.4% in office workers of sri lanka 16 and 89.9% in malaysian students. 17 however, report of recent study conducted in jeddah, saudi arabia showed consistent results in which prevalence of computer vision syndrome was reported to be 97.3%. 18 in most of the previous studies, there was no specification of duration or categorization of symptoms of cvs and all the symptoms even transient ones lasting less than one week were included in criteria of cvs. in our study, the participants were asked about symptoms they experienced during the previous 3 months. symptoms lasting for at least one week were considered as symptom of cvs. this high frequency points towards the increased use of digital devices during pandemic. possible reason for increased frequency could be that we conducted or study during covid-19 pandemic when increased digitalization has been observed in every field of life. students are subjected to the use these devices for long time without break as they were shifted to online teaching. there has also been increased digitalization for recreational purposes. 19 in our study the most common symptoms of cvs in order of severity were irritation of eyes, blurred vision, redness of eyes, eye strain, excessive watering and increased sensitivity to light respectively. while in ethiopia the commonest symptom was blurred vision, eyestrain and followed by eye irritation. 13 results of recent study conducted in saudi arabia reported feeling of temporary long or short-sightedness (65%), itchy eyes (63%) and burning sensation of eyes (62%) as the most common symptoms. 20 underlying mechanism involved in appearance of ocular symptoms during excessive use of digital devices could be the constantly changing focus. since images and font size on computer tend to change rapidly, eye needs to focus and refocus constantly which stresses eye muscles leading to various ocular symptoms related to eye strain. 21 reduced blink rate is also associated with asthenopic sore eyes and eye strain. it has been reported that blink rate during computer use reduces to 3.6 blinks/min as compared to normal mean blink rate i.e. 18.4 blinks/ min 11 . in our study headache was reported as the most common extra ocular symptom followed by back and neck pain due to poor posture which were also reported in previous studies. 16,17 in our study distance from both laptop/desktop (< forearm) and distance from mobile phone (<12 inch) was found to be significantly associated with cvs symptoms. similar results were reported by previous studies in which distance of < 20 inch was significantly associated with cvs symptoms. 15 moreover, american optometric association has also recommended the minimum viewing distance to be 20–28 inches. 11 results of another study also showed that distance of 10 inches was associated with symptoms of cvs. 22 in our study there was a significant association between duration of digital device usage and symptoms of cvs. these results are consistent with results of a recent study. 18 however, in contrast to this, another study showed that symptoms of cvs were not significantly associated with increased duration of use of digital device. 20 results of previous studies also reported that more than 4 hours of digital device usage was associated with increased risk of symptoms of computer vision syndrome. 15 similar findings are supported by american optometrist association. 11 in our study, frequency of break more than 60 minutes was found to be significantly associated with symptoms of computer vision syndrome. results of study conducted by hassan et al also reported similar results. 23 our study also determined the use of ergonomic practices during digital work. it was found that symptoms of cvs were found pronounced among the students who were not using ergonomically designed work station. students were only practicing control of excessive light and glare while using digital devices. study carried out by straker et al found consistent results. 24 best strategy to prevent computer vision syndrome is to limit screen time but this might not be possible in current unanticipated circumstances. current pandemic has disrupted the long standing educational practices and elicited the need to adopt alternate online teaching strategy. it is the need of hour that we must sensitize computer vision syndrome (cvs) and its associated risk factors pak j ophthalmol. 2021, vol. 37 (1): 102-108 107 our students regarding detrimental health effects associated with rapid digitalization, specially students must be familiar with recommendations by american optometrist association for prevention of computer vision syndrome. these recommendations include keeping the computer screen 4 – 5 inches below eye level and distancing the screen at least 25 inches, using anti-glare screen filter, calibration of the monitor to avoid excessive light and darkness and maintaining the seating position by ergonomically designed chair. it is also recommended to have a 20 seconds break to look at something 20 feet away every 20 minutes. limitation of this study was that it was done only in the undergraduate medical students. other population groups were not included. total hours of study were not considered in this study. since data was collected using self-reported questionnaire, it can be potential source of bias. moreover, as it was a cross sectional study so it was difficult to establish causal association between risk factors and disease. even then, the results of our study can provide baseline data to stakeholders to devise effective strategies to reduce its rapid upsurge during pandemic. conclusion computer vision syndrome is highly prevalent among undergraduate medical students. health issues related to excessive use of digital devices is alarmingly high due to the current pandemic. symptoms of cvs are significantly associated with distance from digital device, less frequent break intervals and among students not following ergonomic practices. there is dire necessity to address this burning public health issue by sensitizing our young generation about deleterious health effects associated with excessive use of digital devices. there is urgent need to make an institutional policy involving all stakeholders to devise effective strategies to prevent young generation from its detrimental health effects of excessive digitalization during the pandemic. ethical approval the study was approved by the institutional review board/ ethical review board. (222/gmc) conflict of interest authors declared no conflict of interest. references 1. zhu n, zhang d, wang w, li x, yang b, song j, et al. a novel coronavirus from patients with pneumonia in china, 2019. n eng j med. 2020; 382: 727-733. 2. sohrabi c, alsafi z, o'neill n, khan m, kerwan a, al-jabir a, et al. world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19). international journal of surgery, 2020; 76: 71–76. 3. ghebreyesus, ta. who director-general‟s opening remarks at the media briefing on covid-19-11 march 2020. world health organization, 2020. https://www.who.int/dg/speeches/detail/who-directorgeneral-s-opening-remarks. accessed on 4 november 2020. 4. abel t, mcqueen d. the covid-19 pandemic calls for spatial distancing and social closeness: not for social distancing. int j public health, 2020; 65: 231. 5. ayittey fk, ayittey mk, chiwero nb, kamasah js, dzuvor c. economic impacts of wuhan 2019‐ncov on china and the world. journal of medical virology, 2020; 92 (5): p. 473-475. 6. moorhouse bl. adaptations to a face-to-face initial teacher education course „forced‟ online due to the covid-19 pandemic. j edu teach. 2020: 1-3. 7. madhan m. computer vision syndrome. nurs j ind. 2009; 100 (10): p. 236. 8. sheppard al, wolffsohn js. digital eye strain: prevalence, measurement and amelioration. bmj open ophthalmology, 2018; 3 (1). 9. blehm c, vishnu s, khattak a, mitra s, yee r. computer vision syndrome: a review. survophthalmol. 2005; 50 (3): 253-262. 10. sánchez-brau m, domenech-amigot b, brocalfernández f, quesada-rico ja, seguí-crespo m.prevalence of computer vision syndrome and its relationship with ergonomic and individual factors in presbyopic vdt workers using progressive addition lenses. int j env res public health, 2020; 17 (3): 1003. 11. association ao. the effects of computer use on eye health and vision. internet: http://www. aoa. org/documents/effects computer use. pdf [02 august 2011], 1997. accessed on 4 november 2020. 12. noreen k, batool z, fatima t, zamir t.prevalence of computer vision syndrome and its associated risk factors among under graduate medical students of urban karachi. pak j ophthalmol. 2016; 32 (3): 140-146. 13. dessie a, adane f, nega a, wami sdw, chercos dh. computer vision syndrome and associated factors among computer users in debre tabor town, northwest ethiopia. j env public health, 2018; 2018. https://www.ncbi.nlm.nih.gov/pubmed/?term=alsafi%20z%5bauthor%5d&cauthor=true&cauthor_uid=32112977 https://www.ncbi.nlm.nih.gov/pubmed/?term=o%27neill%20n%5bauthor%5d&cauthor=true&cauthor_uid=32112977 https://www.ncbi.nlm.nih.gov/pubmed/?term=khan%20m%5bauthor%5d&cauthor=true&cauthor_uid=32112977 https://www.ncbi.nlm.nih.gov/pubmed/?term=kerwan%20a%5bauthor%5d&cauthor=true&cauthor_uid=32112977 https://www.ncbi.nlm.nih.gov/pubmed/?term=al-jabir%20a%5bauthor%5d&cauthor=true&cauthor_uid=32112977 https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks https://onlinelibrary.wiley.com/action/dosearch?contribauthorstored=ayittey%2c+matthew+k https://onlinelibrary.wiley.com/action/dosearch?contribauthorstored=chiwero%2c+nyasha+b https://onlinelibrary.wiley.com/action/dosearch?contribauthorstored=kamasah%2c+japhet+s https://onlinelibrary.wiley.com/action/dosearch?contribauthorstored=dzuvor%2c+christian https://pubmed.ncbi.nlm.nih.gov/?term=vishnu+s&cauthor_id=15850814 https://pubmed.ncbi.nlm.nih.gov/?term=khattak+a&cauthor_id=15850814 https://pubmed.ncbi.nlm.nih.gov/?term=mitra+s&cauthor_id=15850814 https://pubmed.ncbi.nlm.nih.gov/?term=yee+rw&cauthor_id=15850814 http://www/ khola noreen, et al 108 pak j ophthalmol. 2021, vol. 37 (1): 102-108 14. shantakumari n. computer use and vision. related problems among university students in ajman, united arab emirate. ann med health sci. res. 2014; 4 (2): 258-263. 15. logaraj m, madhupriya v, hegde s. computer vision syndrome and associated factors among medical and engineering students in chennai. ann med health sci res. 2014; 4 (2): 179-185. 16. ranasinghe p, wathurapatha ws, perera ys, lamabadusuriya da, kulatunga s, jayawardana n, et al.computer vision syndrome among computer office workers in a developing country: an evaluation of prevalence and risk factors. bmc research notes, 2016; 9 (9): 150. 17. reddy sc, low ck, lim yp, low ll, mardina f, nursaleha mp. computer vision syndrome: a study of knowledge and practices in university students. nepalese journal of ophthalmology, 2013; 5 (2): 161168. 18. altalhi a, khayyat w, khojah o, alsalmi m,almarzouki h.computer vision syndrome among health sciences students in saudi arabia: prevalence and risk factors. cureus, 2020; 12 (2):e7060. 19. király o, potenza mn, stein dj, king dl, hodgins dc, saunders jb, et al. preventing problematic internet use during the covid-19 pandemic: consensus guidance. comprpsychiatr. 2020; 100: 152180. 20. abudawood ga, ashi hm, almarzouki nk. computer vision syndrome among undergraduate medical students in king abdulaziz university, jeddah, saudi arabia. jophthalmol.2020: 2789376. https://doi.org/10.1155/2020/2789376 21. yan z, hu l, chen h, lu f. computer vision syndrome: a widely spreading but largely unknown epidemic among computer users. comput. hum. behav. 2008; 24 (5): 2026-2042. 22. chiemeke sc, akhahowa ae, ajayi ob. evaluation of vision-related problems amongst computer users: a case study of university of benin, nigeria. in world congress on engineering. 2007. 23. hassan a, mmk b. prevalence of computer vision syndrome (cvs) amongst the students of khyber medical university, peshawar. in islamabad congress of ophthalmology, 2017. 24. straker lm, smith aj, bear n, o'sullivan pb, de klerk nh. neck/shoulder pain, habitual spinal posture and computer use in adolescents: the importance of gender, ergonomics. 2011; 54 (6): 539-546. doi: 10.1080/00140139.2011.576777 authors’ designation and contribution khola noreen; assistant professor: concepts, design, manuscript preparation. kashif ali; consultant ophthalmologist: literature search, data analysis. kausaraftab; assistant professor: data acquisition, statistical analysis. muhammad umer; professor: manuscript editing, manuscript review. .…  …. https://www.cureus.com/users/144014 https://www.cureus.com/users/148877 https://www.cureus.com/users/138512 https://www.cureus.com/users/122267 https://doi.org/10.1155/2020/2789376 https://doi.org/10.1080/00140139.2011.576777 microsoft word 6. adnan ahmad 250 pak j ophthalmol. 2022, vol. 38 (4): 250-256 original article comparison of intravitreal diclofenac-sodium versus intravitreal triamcinolone in diabetic macular edema adnan ahmad1, mubashir rehman2, hamid rehman3 department of ophthalmology, 1,2nowshera medical college, nowshera 3bannu medical college, bannu abstract purpose: to compare the effectiveness of intra-vitreal diclofenac-sodium (iv-d) versus intra-vitreal triamcinolone acetonide (iv-t) in the treatment of diabetic macular edema (dme). study design: quasi experimental study. place and duration of study: qazi hussain medical complex, nowshera from october 2020 to april 2021. methods: we recruited 40 eyes with diabetic macular edema (dme). two groups were made. one group was assigned to 4 mg/0.1 cc of iv-t and the other group received 0.5 mg/0.1 cc of iv-d. there were 20 eyes in each group. pre and post-op best corrected visual acuity (bcva), intra-ocular pressure (iop), and central subfield thickness of macula (csft) were documented and analysed in both groups. the patients were followed up for 3 months after injection. results: both treatment arms displayed marked decrease in csft (iv-t with p = 0.03 and iv-d with p = 0.02), but the difference between groups were not statistically significant. statistically significant improvement in bcva was seen in iv-t from the baseline (p = 0.04). however, difference between the two groups regarding bcva was not statistically significant. transient increase in iop occurred in 20% of iv-t. in iv-d reduction in iop was observed that achieved the level of statistical significance (p = 0.03). conclusion: iv-d was better in management of dme in terms of iop after intravitreal injection and iv-t showed superior results in bcva. however, both iv-t and iv-d showed similar efficacy in reduction of csft. key words: diabetic macular edema, diclofenac sodium, intra-vitreal injections, triamcinolone acetonide, intraocular pressure, central macular thickness. how to cite this article: ahmad a, rahman m, rehman h. comparison of intravitreal diclofenac-sodium versus intravitreal triamcinolone in diabetic macular edema. pak j ophthalmol. 2022, 38 (4): 250-256. doi: 10.36351/pjo.v38i4.1365 correspondence: adnan ahmad department of ophthalmology, nowshera medical college, nowshera email: dradnanahmad82@gmail.com received: january 05, 2022 accepted: august 20, 2022 introduction intra-vitreal triamcinolone acetonide (iv-t) is an established therapy for reduction of macular edema caused by various pathologies including diabetic macular edema (dme). this results in improvement in visual acuity.1 despite its good response in cases of macular edema, its benefits need to be weighed against its harmful effect on intraocular pressure (iop) and lens opacification.2,3 anti vascular endothelial growth factors (anti–vegf) have shown promising results in macular edema caused by various diseases.4,5 however, several trials have shown that their effect vanishes after 4 weeks and repeated injections are required.6 in some studies, bevacizumab did not show promising results in reduction of dilatation and tortuosity of retinal vessels as compared to its effect on angiogenesis.7 topical non-steroidal anti-inflammatory drugs (nsaids) have been used as a monotherapy or in comparison of intravitreal diclofenac-sodium versus intravitreal triamcinolone in diabetic macular edema pak j ophthalmol. 2022, vol. 38 (4): 250-256 251 combination with iv-t/bevacizumab for the management of long standing macular edema with better effects on vision and additionally causing marked reduction in macular thickness.8 literature shows topical nsaids have less side effects as compared to steroids.9 in some interventional studies, raised iop and lens opacification was not observed with intra-vitreal nsaids.10 the rationale of this work is to undertake a comparative analysis between intra-vitreal diclofenac sodium (iv-d) and iv-t in terms of effectiveness as well as safety in the management of diabetic macular edema which is one of the most common sight threatening complication of diabetic retinopathy. methods it was a quasi experimental study which included 40 eyes of 40 patients with diffuse dme. the study was conducted from october 2020 to april 2021 at qazi hussain ahmad medical complex, nowshera. the sample size was calculated by online sample size calculator by keeping into consideration the prevalence of disease and power of study was set at 80%. the study was conducted according to the guidelines of declaration of helsinki. prior to the study an informed consent was acquired from the participants and another informed consent was obtained about the off label use of diclofenac sodium and its possible side effects, an approval was granted by the institutional ethical review board (ierb) before the commencement of trial. all the participants underwent a complete ophthalmic examination, including best-corrected visual acuity (bcva) by snellen chart which was converted into log mar. iop, slit-lamp biomicroscopy, fundus photographs and fundus fluorescein angiography (fa) were performed in all cases. macular thickness was measured in a circle (4mm diameter) centred on the fixation point. mean thickness on the 1-mm circle centred on the fovea (central subfield thickness, csft) was recorded as a measure of central macular thickness (csft) and considered for statistical analysis by using spectraldomain optical coherence tomography (sd-oct). patients with diabetic macular oedema, (> 400 µm thickness on oct) and patients with macular oedema (> 400 µm) and no response to grid laser (done more than 4 months back), were enrolled in the study. diabetic macular oedema was defined on clinical grounds as thickening of macula (4mm in diameter) with foveal involvement and cystic morphology apparent on fundoscopy. on oct, it was characterised by thickened foveal and peri-foveal zones i.e. within 1mm and 4mm diameter circle respectively. eyes with macular ischemia on fa defined as an enlarged foveal avascular zones (faz) i.e. 1500 µm, or broken perifoveal capillary rings at margins of the faz, with clearly delineated regions of non-perfused capillaries (with-in 1.5mm area of fovea), macular oedema due to aetiologies other than diabetes, past intra-vitreal injections (within 6 months) or vitreoretinal surgeries, vitreomacular traction (vmt), glaucomatous eyes and intra-ocular inflammatory disorders were excluded. eyes were assigned to one of the following treatment modalities; intra-vitreal injection of 4 mg/ 0.1 cc of triamcinolone acetonide (injection tricort 40 mg/ml, akhai pharma, pak. n = 20) or intra-vitreal injection of 0.5mg/0.1cc of commercially available diclofenac sodium preparation primarily for intramuscular use (injection voren 75mg/3ml; asian continental pharma, pak. n = 20). after aspiration of 1 ml (containing 25 mg), it was diluted with 4ml of distilled water so that 5 mg of diclofenac sodium was present in each 1 ml. hence, 0.1 cc of the above preparation contained 0.5 mg of diclofenac, which was given intravitreally. all procedures were performed under strict aseptic environment of operation theatre. topical proparacaine 1%was followed by 5% povidone–iodine in inferior conjunctival fornix after 05 minutes. each eye received either 0.1 cc of triamcinolone acetonide/iv-t (4 mg) or 0.1 cc of diclofenac sodium/iv-d (500 µg) by 27g needle in the superotemporal quadrant approximately 4mm from the limbus via pars plana route. after the intervention topical antibiotics were prescribed for 02 days in quid regimen. the following day patients were assessed for bcva, iop, evidence of any infection/ inflammation and other adversities (endophthalmitis, retinal detachment, raised iop and vitreous haemorrhage). topical anti-glaucoma drugs were given only when iop was more than 21 mmhg on applanation tonometry. follow ups were done at 2nd week, 4th week and 12th week post injection. an increase in bcva of 1 snellen line was taken as an improvement. oct was performed after 2 weeks to observe an initial response and then at 4th and 12th week. similarly, eyes were specially examined for lens opacification and adnan ahmad, et al 252 pak j ophthalmol. 2022, vol. 38 (4): 250-256 redo fa if deemed necessary. statistical analysis was done using spss 19.0. the primary outcome was diminution in central macular thickness, while bcva and iop were taken as secondary and tertiary variables for analysis. preinjection and post-injection bcva, iop, and csft were compared between iv-t and iv-d groups by repeated measure anova test. chi-square test was used for qualitative variables and wilcoxon signed rank test was applied for within group analysis. statistical significance was taken at a p value of < 0.05 with the confidence interval of 95%. results the study included 40 eyes of 40 subjects with mean age of 56 years (range = 38–66 years). there were 26 males and 14 females. table 1 shows pre-treatment variables of both groups. in iv-t group, csft central macular thickness reduced till the end of 12th week (figure 1). mean csft reduced from 440.7 ± 76.2 µm to 278.3 ± 38.2 µm at 4th week and to 244.3 ± 54.2 µm at 12th week. this difference was statistical significance at both intervals (p = 0.03). in contrast, csft between week 4 and 12 did not show a level of statistical significance (p = 0.08 by wilcoxon rank test). post-operative mean percent decrease in csft was 45% (figure 2). table 1: preliminary characteristics of the study participants in both groups. iv-t group iv-d group pvalue total no. of eyes 20 20 participants mean age 56.5 54.5 0.52 duration of diabetes (years) 10.0 ± 3.1 12.0 ± 2.6 0.12 female: male 08:14 06:12 1.42 iop (mmhg) 15.2 ± 1.8 15.5 ± 1.6 0.06 visual acuity (logmar) 0.11 ± 0.09 0.13 ± 0.07 0.41 central sub-field thickness (µm) 440.7 ± 76.2 419.8 ± 94.2 0.58 post-operatively mean percent csft reduction was 40% in iv-d and 45% in iv-t group (figure 2). statistically insignificant difference (p = 0.42) was observed between both groups in terms of mean percent csft reduction. in both groups, subtle leakage on fa was evident till 12th week. table 3 depicts visual outcome in both treatment arms. in the iv-t group, visual improvement was attained in 69.5% of eyes (figure 3) and visual deterioration was not observed in any patient. the difference between pre and post intervention mean bcva was statistical significance (p = 0.04). in the ivd group, visual improvement was attained in 50% of eyes (figure 3) and no visual deterioration was table 2: central subfield thickness on oct at different times of study. data values iv-t (n =20) iv-d (n = 20) p-value central subfield thickness (μm) at baseline 440.7 ± 76.2 419.8 ± 94.2 0.582 central subfield thickness (μm) at 4th week 278.3 ± 38.2 323.5 ± 63.2 0.256 central subfield thickness (μm) at 12th week 244.3 ± 54.2 271.1 ± 52.9 0.372 central macular thickness reduction at 12th week in % 45% 40% 0.420 p-value within group 0.03 0.02 figure 1: csft between the groups. figure 2: reduction in csft at 12th week. comparison of intravitreal diclofenac-sodium versus intravitreal triamcinolone in diabetic macular edema pak j ophthalmol. 2022, vol. 38 (4): 250-256 253 observed in this group. however, the difference between pre and post-intervention mean bcva was not statistically significant (p = 0.20). there was no statistically significant difference between both groups in terms of post-injection bcva (p = 0.10), mean line improvement (p = 0.09) and percentage of eyes with improved bcva (p = 0.07). table 3: comparison of visual acuity after iv-t and ivd. iv-t group iv-d group pvalue mean baseline va 0.11 ± 0.09 0.13 ± 0.07 0.41 mean bcva at 12 week 0.24 ± 0.20 0.18 ± 0.14 0.10 p-value (within groups) 0.04 0.20 mean snellen lines improvement 1.9 ± 1.2 1.1 ± 1.4 0.09 eyes with improved va (%) 69.5 50 0.07 1snellen line 8 (40%) 7 (35%) 2 snellen line 4 (20%) 2 (10%) > 2 snellen line 2 (10%) 1 (05%) stable va 6 (30%) 10 (50%) figure 3: comparison of bcva between the two groups. in iv-t group, temporary increase in iop (26–34 mmhg) was observed in 4 (20%) eyes, which was treated with anti-glaucoma medications. in iv-d group, difference between pre and post-injection iop reduction achieved statistical significance (p = 0.03). visually disabling cataract was not observed during the follow-ups in both groups during the follow up period. similarly, no, serious post-operative side effects were observed in both groups (endophthalmitis, retinal detachment or vitreous haemorrhage etc.). discussion various intra-vitreal agents are used either as monotherapy or combination therapy for the management of dme.11,12 in the current study, marked reduction in csft was observed in iv-t (45%) and iv-d (40%) groups. in 2008, diabetic retinopathy clinical research network (drcr.net) compared preservative-free iv-t with focal/grid laser for diabetic macular oedema. the proportion of patients requiring cataract extraction within three years was 30% in laser, 45% in 1mg and 82% in 4mg triamcinolonegroup.13 similarly iop elevated by 12 mmhg at any visit in 5% cases in laser, 19% in 1mg and 34% in 4mg triamcinolone group. however, we did not observe these side effect due to short duration of 3months of follow up. various studies have emphasized the role of inflammatory mediators in pathogenesis of dme.14 based upon previous studies, we used nsaids as an adjunctive agent in the management of macular oedema. in one of the case series, topical nepafenac 0.1% was used in patients with macular oedema for 24 weeks. results showed reduction in macular thickness with visual improvement by 3 lines.15 shimura et al,16 reported that post cataract extraction increase in macular thickness in diabetic patients cannot be completely ameliorated either by topical nepafenac or steroids. nevertheless, topical nepafenac prevented early post-operative cystoid macular edema. in our study, although more reduction in csft was achieved with iv-t than iv-d, however the reduction didnot reach the level of statistical significance. in one pilot study on 12 eyes with macular edema due to different pathologies, soheilian et al observed visual improvement after iv-d, but no marked csft reduction was achieved.17 however, by including various types of macular edema with different pathophysiological mechanisms might actually underrate the effects of diclofenac sodium on macular thickness. steroids decrease macular edema by affecting inflammatory cascade which involves the inhibition of both lipo-oxygenase and cyclo-oxygenase pathways.17 steroids may also down regulate the level of vascular endothelial growth factors (vegfs) involved in the pathogenesis of dme, resulting in reduction of macular oedema.18 steroids in experimental models have shown to decrease the disruption of blood–retinal barrier. nsaids act primarily through one adnan ahmad, et al 254 pak j ophthalmol. 2022, vol. 38 (4): 250-256 mechanism, which is by inhibiting the production of prostaglandins (pgs) synthesis via blocking of cyclooxygenases.19 interestingly it is also an established fact that diclofenac sodium can also block the lipooxygenase pathway in inflammatory cascade. this special ability makes it almost similar to steroids. that is why we did not observe any statistically significant difference between both groups as far as mean reduction in csft was concerned. warren et al,20 reported that topical nsaids increased the efficacy of intra-vitreal steroids and anti-vegfs for long standing pseudo-phakic macular oedema. they observed that topical diclofenac sodium had a sustained effect on csft for about 06 weeks. in the current study, decrease in csft was sustained for about 12 weeks in iv-d group. such a difference might be explained by using different routes of administration. topical nsaids cannot effectively accumulate in the posterior segment, while intra-vitreal route allows greater bioavailability and efficacy of the drug at the target sites in tissues.21 visual improvement was achieved in both groups, but only iv-t group attained a level of statistical significance. no correlation was observed between visual improvement and reduction in macular thickness in our study. soheilian et al, observed visual improvement in 72% of patients for up to 10 weeks after intra-vitreal diclofenac sodium.17 steroids may also cause visual improvement via its effect on muller cells, retinal astrocytes, neuronal synapses and rods/ cones.22 nevertheless, loss of vision contributed by increased fluid in the macula is attributed to the liberation of inflammatory mediators by the retinal cells, hence diclofenac sodium cause visual improvement via its anti-inflammatory effects.8 temporary increase of iop developed in 20% of eyes in iv-t group. in contrast, patients in iv-dgroup attained significant reduction of iop (p = 0.03), however unexplainable but may be due to alteration in the intraocular levels of prostaglandins (pg). shimura et al16 observed sufficient iop reduction with topical diclofenac sodium in post cataract extraction cases in 48 diabetics with no/mild non-proliferative retinopathy. contrary to that pressure in the topical steroid treated eyes were high. the possible explanation for reduction of iop in nsaids treated eyes could be due to the fact that intraocular pg can regulate the pressure via its adhesion to pg-receptors. these receptors can be either agonist or antagonist. hence, intraocular pgs can cause either reduction or elevation of eye pressure.23 intra-vitreal diclofenac sodium may preferably activate the agonistic response, resulting in decreased iop. this fact is explored by costagliola et al,24 who found that diclofenac sodium potentiates the iop lowering effect of prostaglandin analogues without influencing efficacy of beta blockers. limitation of our study is small sample size and limited duration of follow up. lens opacification did not develop in the iv-t group due to relatively short duration of study period. numerous studies showed that cataract does not become visually significant until 26 to 52 weeks after steroid injection.3,13 however, adequate dose of intra-vitreal diclofenac sodium (500 µg) have not yet been associated with lens opacification or glaucoma in various trials.25 conclusion intra-vitreal diclofenac sodium was effective in management of diabetic macular oedema that lasted 3 months. both iv-t and iv-d have shown similar efficacy in macular oedema. however, visual improvement was superior with triamcinolone. ethical approval the study was approved by the institutional review board/ethical review board (1322/r&d/ierb/nmc). conflict of interest: authors declared no conflict of interest. references 1. gao l, zhao x, jiao l, tang l. intravitreal corticosteroids for diabetic macular edema: a network meta-analysis of randomized controlled trials. eye vis (lond). 2021; 8 (1): 35. doi: 10.1186/s40662-02100261-3. 2. karakurt y, ucak t, taslı g, agcayazı b, i̇cel e, yılmaz h. the effects of intravitreal ranibizumab, aflibercept or dexamethasone implant injections on intraocular pressure changes. med sci monit. 2018; 24: 9019-9025. doi: 10.12659/msm.910923. 3. gillies mc, simpson jm, billson fa, luo w, penfold p, chua w, et al. safety of an intravitreal injection of triamcinolone: results from a randomized clinical 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1755.e1. doi: 10.1016/j.ophtha.2008.04.023. 7. ameri h, chader gj, kim jg, sadda sr, rao na, humayun ms. the effects of intravitreous bevacizumab on retinal neovascular membrane and normal capillaries in rabbits. invest ophthalmol vis sci. 2007; 48 (12): 5708-5715. doi: 10.1167/iovs.070731. 8. warren ka, bahrani h, fox je. nsaids in combination therapy for the treatment of chronic pseudophakic cystoid macular edema. retina, 2010; 30 (2): 260-266. doi: 10.1097/iae.0b013e3181b8628e. 9. saade js, istambouli r, abdulaal m, antonios r, hamam rn. bromfenac 0.09% for the treatment of macular edema secondary to noninfectious uveitis. middle east afr j ophthalmol. 2021; 28 (2): 98-103. doi: 10.4103/meajo.meajo_134_21. 10. shen wy, constable ij, chelva e, rakoczy pe. inhibition of diclofenac formulated in hyaluronan on angiogenesis in vitro and its intraocular tolerance in the rabbit eye. graefes arch clin exp ophthalmol. 2000; 238 (3): 273-282. doi: 10.1007/s004170050353. 11. jonas jb, kreissig i, söfker a, degenring rf. intravitreal injection of triamcinolone for diffuse diabetic macular edema. arch ophthalmol. 2003; 121 (1): 57-61. 12. ahmadieh h, ramezani a, shoeibi n, bijanzadeh b, tabatabaei a, azarmina m, et al. intravitreal bevacizumab with or without triamcinolone for refractory diabetic macular edema; a placebocontrolled, randomized clinical trial. graefes arch clin exp ophthalmol. 2008; 246 (4): 483-489. doi: 10.1007/s00417-007-0688-0. 13. diabetic retinopathy clinical research network. a randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. ophthalmology, 2008; 115 (9): 14471449, 1449.e1-10. doi: 10.1016/j.ophtha.2008.06.015 14. wilkinson-berka jl. vasoactive factors and diabetic retinopathy: vascular endothelial growth factor, cycoloxygenase-2 and nitric oxide. curr pharm des. 2004; 10 (27): 3331-3348. doi: 10.2174/1381612043383142. 15. hariprasad sm, callanan d, gainey s, he yg, warren k. cystoid and diabetic macular edema treated with nepafenac 0.1%. j ocul pharmacol ther. 2007; 23 (6): 585-590. doi: 10.1089/jop.2007.0062. 16. shimura m, nakazawa t, yasuda k, nishida k. diclofenac prevents an early event of macular thickening after cataract surgery in patients with diabetes. j ocul pharmacol ther. 2007; 23 (3): 284291. doi: 10.1089/jop.2006.134. 17. soheilian m, karimi s, ramezani a, peyman ga. pilot study of intravitreal injection of diclofenac for treatment of macular edema of various etiologies. retina, 2010; 30 (3): 509-515. doi: 10.1097/iae.0b013e3181bdfa43. 18. nauck m, roth m, tamm m, eickelberg o, wieland h, stulz p, et al. induction of vascular endothelial growth factor by platelet-activating factor and platelet-derived growth factor is downregulated by corticosteroids. am j respir cell mol biol. 1997; 16 (4): 398-406. doi: 10.1165/ajrcmb.16.4.9115750. 19. schalnus r. topical nonsteroidal anti-inflammatory therapy in ophthalmology. ophthalmologica. 2003; 217 (2): 89-98. doi: 10.1159/000068563. 20. warren ka, bahrani h, fox je. nsaids in combination therapy for the treatment of chronic pseudophakic cystoid macular edema. retina, 2010; 30 (2): 260-266. doi: 10.1097/iae.0b013e3181b8628e. 21. rabiah pk, fiscella rg, tessler hh. intraocular penetration of periocular ketorolac and efficacy in experimental uveitis. invest ophthalmol vis sci. 1996; 37 (4): 613-618. 22. larsson j, zhu m, sutter f, gillies mc. relation between reduction of foveal thickness and visual acuity in diabetic macular edema treated with intravitreal triamcinolone. am j ophthalmol. 2005; 139 (5): 802806. doi: 10.1016/j.ajo.2004.12.054. 23. nakajima t, matsugi t, goto w, kageyama m, mori n, matsumura y, et al. new fluoroprostaglandin f(2alpha) derivatives with prostanoid fp-receptor agonistic activity as potent ocular-hypotensive agents. biol pharm bull. 2003; 26 (12): 1691-1695. doi: 10.1248/bpb.26.1691. 24. costagliola c, parmeggiani f, antinozzi pp, caccavale a, cotticelli l, sebastiani a. the influence of diclofenac ophthalmic solution on the intraocular pressure-lowering effect of topical 0.5% timolol and 0.005% latanoprost in primary open-angle glaucoma patients. exp eye res. 2005; 81 (5): 610-615. doi: 10.1016/j.exer.2005.03.020. adnan ahmad, et al 256 pak j ophthalmol. 2022, vol. 38 (4): 250-256 25. age-related eye disease study research group. risk factors associated with age-related nuclear and cortical cataract : a case-control study in the age-related eye disease study, areds report no. 5. ophthalmology, 2001; 108 (8): 1400-1408. doi: 10.1016/s0161-6420(01)00626-1. authors’ designation and contribution adnan ahmad; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. mubashir rehman; associate professor: literature search, data acquisition, data analysis, statistical analysis, manuscript review. hamid rehman; assistant professor: data acquisition, data analysis, statistical analysis, manuscript preparation. .……. pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 38 original article frequency of retinopathy in newly diagnosed patients of type 2 diabetes mellitus kashif jamil, yasir iqbal, sohail zia, qaim ali khan pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: kashif jamil department of medicine punjab medical college unit iv dhq hospital faisalabad …..……………………….. purpose: to find out the frequency of retinopathy in newly diagnosed patients of type 2 diabetes mellitus. material and methods: after the approval of the hospital ethical committee and informed verbal consent of the patients the study was conducted in the out patients department of medicine, dhq hospital, faisalabad. all patients of either sex (non-probability consecutive sampling) were included, who were diagnosed within two months as type 2 diabetes mellitus. diagnosis of diabetes was done by reports of > 200 mg/dl on two consecutive base line random blood sugar (rbs), fasting blood sugar (fbs) and glycosylated hemoglobin (hba1c). all the patients underwent dilated retina examination with +90 diopter lens on biomicroscopic slit lamp and diabetic retinopathy was labeled on the basis of presence of fundus findings. results: the study was completed in a period of 7 months from sep 2010 to march 2011. a total of 196 patients fulfilling the criteria were included. age range was 31 to 60 years with a mean age of 50.95 ± 10.12 years. diabetic retinopathy was observed in 25 (12.75%) patients with newly diagnosed type 2 diabetes mellitus. the hba1c (%) was found to be 9.5 ± 1.6 in the patients with diabetic retinopathy and 7.4 ± 2.5 in patients without diabetic retinopathy. conclusion: we found that the frequency of retinopathy in newly diagnosed patients of type 2 diabetes mellitus is 12.75% and we stress the value of in depth ophthalmic assessment of every patient of diabetes at the time of diagnosis. iabetes mellitus is a global epidemic. it is estimated that 171 million people are suffering from this disease throughout the world which is increasing in number every year. diabetic retinopathy (dr) is one of its frequent and serious complications and is among the leading causes of blindness worldwide. a patient can be suffering from type 2 diabetes mellitus well before clinical diagnosis and usually has diabetic retinopathy at the time of his diagnosis. diabetic retinopathy (dr) is defined as damage to retinal microvascular system due to prolonged hyperglycemia. major risk factors are duration of diabetes, degree of glycemic control and hyperlipidemia. in type 2 diabetic subjects diabetic retinopathy has been associated with increase in arterial stiffness and thickness of the intima-media suggesting that a common pathophysiology might be leading to diabetic microangiopathy1. diabetics are 25 times more likely to become blind than non-diabetics due to diabetic retinopathy. for this it is vital to increase the awareness about the complications of diabetic retinopathy by educating the patients through the health care professionals and public seminars3. over the past 20 years, eight population-based studies have suggested that the prevalence of diabetic retinopathy is close to 28.7% in diabetic patients2. a study conducted in karachi among the newly d kashif jamil, et al 39 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology diagnosed cases of type 2 diabetes mellitus reported 15% of the patients had diabetic retinopathy4. we conducted a similar study to determine the frequency of retinopathy in newly diagnosed diabetic type 2 patients in order to see the magnitude of the problem in local population compared to the available statistics. by doing so one would be able to suggest more meticulous primary and secondary preventive strategies that would ultimately decrease the morbidity of such patients. material and methods after the approval of the hospital ethical committee and informed verbal consent of the patients the study was conducted in the medical out patients departments of dhq hospital, faisalabad. the purpose of research was explained to the patients. all patients of either sex (non-probability consecutive sampling) were included, who were diagnosed within two months as type 2 diabetes. diagnosis of diabetes was done by reports of > 200 mg/dl on two consecutive base line random blood sugar (rbs), fasting blood sugar (fbs) and glycosylated hemoglobin (hba1c) on the following set criteria as defined by world health organization (who) in 1999 and revised in 20065. patients having associated hypertension, renal disease, corneal opacity, mature cataract, hazy vitreous and or uncooperative due to any reason, were excluded from study. the pupil was dilated after instillation of one drop of tropicamide in each eye. all the patients underwent dilated retina examination with +90 diopter lens on biomicroscopic slit lamp for the presence of diabetic retinopathy. the patients requiring further evaluation or treatment were referred to the ophthalmology department after entering the data into a proforma. the data was analyzed by using spps – 11. descriptive statistics were calculated for all the variables. mean and standard deviation was calculated for the quantitative variables that is age in years. frequency and percentage were calculated for the qualitative variables that is genders, presence and type of retinopathy. results the study was completed in a period of 7 months from sep 2010 to march 2011. a total of 196 patients fulfilling the criteria were included. (as calculated by who sample size calculator by keeping p = 15%4, margin of error = 5% and confidence interval = 95%). age range was 31 to 60 years; majority of them belonged to 4th decade (table 1) with a mean age of 50.95 ± 10.12 years. 64.28% patients were males and 35.71% were females (table 2). diabetic retinopathy was observed in 25 (12.75%) patients with newly diagnosed type 2 diabetes mellitus. out of these, 15 were males and 10 were females (table 3). 16 (8.16%) patients among 12.75% were found to have background retinopathy, 6(3%) had pre proliferative and 3 (1.53%) had proliferative retinopathy (fig. 1). the hba1c (%) was found to be 9.5 ± 1.6 in the patients with diabetic retinopathy and 7.4 ± 2.5 in patients without diabetic retinopathy (table 4). frequency of retinopathy in newly diagnosed patients of type 2 diabetes mellitus pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 40 out of the 16 patients with background retinopathy, 10 were males and 6 were females, whereas 4 males and 2 females had preproliferative retinopathy and 2 males and 1 female had proliferative retinopathy (table 5). 0 2 4 6 8 10 12 14 16 18 background preproliferative proliferative fig. 1: types of retinopathy in study group: n = 196. discussion diabetes mellitus is the most common endocrine metabolic disorder. the true frequency of patients having diabetes mellitus is difficult to ascertain because of differing standards of diagnosis but various studies have reported that prevalence of diabetes mellitus in pakistan is around 5 – 7%6. similarly it was estimated that in pakistan the prevalence of diabetic retinopathy (dr) in diabetic patients is 12%7 whereas others have reported the rates to be as high as 15%8 to 19.9%9. dr is a major cause of blindness in those suffering from type 2 diabetes. it is assumed globally that diabetic retinopathy (dr) will be one of the most important causes of blindness in the future. we conducted a prospective study among the newly diagnosed patients of type 2 diabetes mellitus and found that the diabetic retinopathy was present among 12.75% of the patients. a study done in southern parts of pakistan showed 15% of newly diagnosed diabetics had retinopathy at the time of diagnosis4. similarly a study from india reported this figure to be 10.2%10 whereas in united kingdom the prevalence of diagnosed retinopathy was reported to be 19%11. these differences could probably be because of ethnic variations, different gender and age groups presentations. this is evident by comparing our results with a similar study done in abbottabad12. they found the frequency to be 17% while their study group was with mean age of 45.1 ± 3.2 years consisting of predominantly females whereas in our settings the mean age was 50.95 ± 10.12 years and was predominantly male. we found retinopathy predominantly to be background (8.16%), then pre-proliferative (3%) and proliferative (1.53%). these results are comparable to the findings of hayat et al.12 in our study group hba1c (%) was found to be 9.5 ± 1.6 and the fasting plasma glucose level was 221 ± 35.6 in the patients with diabetic retinopathy. these findings augment the association of hba1c and fasting plasma glucose in patients with retinopathy as suggested by abdollahi a13 and rema m et al10. denmark14 also suggested a strong correspondence of period of diabetes, hba1c levels and systolic blood pressure with the severity of retinopathy. the importance of eye examination of all diabetic patients at the time of diagnosis in preventing the blinding complications of dr. it further shows that age, gender, and glycemic control are associated with the onset and progression of dr. conclusion the frequency of retinopathy in newly diagnosed patients of type 2 diabetes mellitus is 12.75% and stress the value of in depth ophthalmic assessment of every patient of diabetes at the time of diagnosis. author’s affiliation dr. kashif jamil department of medicine punjab medical college unit iv dhq hospital, faisalabad kashif jamil, et al 41 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology dr. yasir iqbal asst. prof. ophthalmology iimc-t pakistan railways hospital, rawalpindi dr. sohail zia asst. prof. ophthalmology iimc-t pakistan railways hospital, rawalpindi dr. qaim ali khan asst. prof. ophthalmology poonch medical college, rawalakot, ajk. references 1. rema m, pradeepa r. diabetic retinopathy: an indian perspective. india j med res. 2007; 125: 297-310. 2. kamal a, kamal a, nazir a, qaisera s. assessment of awareness regarding diabetic retinopathy among patients visiting diabetic clinic sir ganga ram hospital, lahore. esculapio j services inst med sci. 2008; 3: 10-3. 3. delcourt c, massin p, rosilo m. epidemiology of diabetic retinopathy: expected vs. reported prevalence of cases in the french population. diabetes metab. 2009; 35: 431-8. 4. wahab s, mahmood n, shaikh z, kazmi hw. frequency of retinopathy in newly diagnosed type 2 diabetes patients. j pak med assoc. 2008; 58: 557-61. 5. world health organization. the who diagnostic criteria of diabetes of 1999 as revised in 2006 at the 19th world diabetes conference [internet]. [updated 2009]. 6. shera as, jawad f, maqsood a. prevalence of diabetes in pakistan. diabetes res clin pract. 2007; 76: 219–22. 7. wahab s, mehmood n, shaikh z, kazmi h. frequency of retinopathy in newly diagnosed type 2 diabetes patient. j pak med assoc. 2008; 58: 557. 8. jamal-u-din, qureshi mb, khan aj, khan md, ahmad k. prevalence of diabetic retinopathy among individuals screened positive for diabetes in five community-based eye camps in northern karachi. j ayub med coll abbottabad. 2006; 18: 1-13. 9. al-maskari f, el-sadig m. prevalence of diabetic retinopathy in the united arab emirates: a cross-sectional survey. bmc ophthalmology. 2007; 7: 11-9. 10. reema m, deepa r, mohan v. prevalence of retinopathy at diagnosis among type 2 diabetic patients attending a diabetic centre in south india. br j ophthalmol. 2000; 84: 1058-60. 11. kostev k, rathmann w. diabetic retinopathy at diagnosis of type 2 diabetes in the uk: a database analysis. diabetologia. 2013; 56: 109-11. 12. hayat as, khan aq, baloch gh, sheikh n. frequency and pattern of retinopathy in newly diagnosed type 2 diabetic patients at tertiary care settings in abbottabad. j ayub med coll abbottabad. 2012; 24: 87-9. 13. abdollahi a, malekmadani mh, mansoori mr, bostak a, abbaszadeh mr, mirshahi a. prevalence of diabetic retinopathy in patients with newly diagnosed type ii diabetes mellitus. acta medica iranica. 2006; 44: 415–9. 14. klein r, klein be, moss se, linton kl. the beaver dam eye study. retinopathy in adults with newly discovered and previously diagnosed diabetes mellitus. ophthalmology 1992; 99: 58–62. pak j ophthalmol. 2021, vol. 37 (1): 1-3 1 editorial artificial intelligence in ophthalmology tayyaba gul malik 1 1 department of ophthalmology, rashid latif medical college, lahore many of us have read or heard the famous story of novel “frankenstein” written in 1818 by mary shelley. 1 the story was about an artificial human or a human-like creature made by a young scientist. although this creature had nothing similar to today‟s artificial intelligence (ai), but that can be referred to as the first ai in fiction stories. this was the time when the first industrial revolution (1760–1840) was taking place with new materials made of iron and steel. later, ai took the form of machines and robots. starting from movie by the name of “metropolis” in 1927 to the latest movie released in 2020 by the name of “super intelligence” there is a long journey of fiction stories on artificial intelligence. however, it is no longer a fiction in the twenty first century. in the real world of science, the word „artificial intelligence‟ was introduced 70 years back in 1950s. it was a software, which had the capability of learning from experience and problem solving by processing and recognizing different patterns of huge amounts of data. 2 before the role of ai in ophthalmology could be talked about, it is pertinent to know the different types of ai. the simplest example of ai is the google browser system. google search engine gives recommendations once you type a word in the search bar. it depends on a set of input data on the basis of which, outcome is predicted. these predictions are based on the information that it collects from our search history, location and age. machine learning (ml) and deep learning (dl) are other frequently how to cite this article: malik tg. artificial intelligence in ophthalmology. pak j ophthalmol. 2021, 37 (1): 1-3. doi: https://doi.org/10.36351/pjo.v37i1.1170 correspondence: tayyaba gul malik department of ophthalmology, rashid latif medical college, lahore email: tayyabam@yahoo.com used terms in ai. machine learning refers to a process by which we feed data into a machine and the machine devices a strategy on its own to perform a certain task. in health care system, we can give example of 2d or 3d images of patients (retinal cameras, x-rays, ct scans etc.) which are called inputs or training datasets. on the basis of these inputs, machine trains itself to make a diagnosis in the form of outputs. in comparison to ml, dl works just like human brain by using complex neural network (cnn) after receiving multiple input data. examples include recognition of objects in images, language translation in real-time, manipulation of electronic devices by speech and so on and so forth. a larger set of data is required in this case. in simplest terms, the difference between ml and dl is that ml consists of input and output while dl comprises of input, hidden layer/layers (which carry out various computations) and then output. 3 different models of ai are identified. the fullyautomated and semi-automated models are the two frequently used ones. in fully automated model, the machine identifies a disease and suggests the referral or further monitoring by its own. however, in semiautomated models, a human grader is needed to suggest intervention, referral or monitoring. use of ai in ophthalmology involves different algorithms and many of which are in the experimental phase to help in screening, diagnosing and monitoring major eye diseases. the whole process of identification of disease can be categorized into four steps. collection of large amount of images and input data is the kick-off step. second step involves labelling of ocular lesions by the ophthalmologists. in the third step, the computer program extracts salient features of the disease from the images or data provided. fourth and the final step is to give an output. by 2018, pubmed library showed 243 articles of ai application in diagnosing ocular diseases. 4 although literature describes various fields of ophthalmology in which ai is being tried, system for tayyaba gul malik 2 pak j ophthalmol. 2021, vol. 37 (1): 1-3 diabetic retinopathy (dr) was the first to be approved by fda in april 2018 (idx-dr system). this device has a sensitivity and specificity of 87.3% and 89.5%, respectively. use of this device can help in increasing the number of patients who can get screened at primary care. although some data shows that ai performs better than ophthalmologists in early detection of dr but more clinical data is still needed to prove that. 5 other areas include age-related macular degeneration, retinopathy of prematurity, glaucoma, keratoconus, retinal detachment, retinal vascular occlusions, cataract, squint, refractive errors, and ocular oncology. 6,7 in early 2020, i-rop received breakthrough device status by fda. it has been claimed that i-rop is capable of identifying plus disease better than the expert ophthalmologist. for diagnosis of glaucoma, ai dl models use fundus images with optic disc changes, oct scans, result of visual fields, intraocular pressure and corneal thickness. 8 detection and grading of cataract has also been made possible by using ml programs. res net system is a unique model capable of identifying referable cataracts. there is another program called cc-cruiser, which is based on slit lamp photographs to identify the density and degree of congenital cataract. role of ai in calculating iol is also commendable. the common example is hill-rbf formula, which uses axial length, central corneal thickness, anterior chamber depth, lens thickness, corneal diameter, and keratometry measurements to calculate the lens power with great accuracy. 9 ai has also made striking progress in ocular oncology. it has been employed to predict the results of periocular reconstruction in cases of bcc, which helps in decision making after removal of tumor. some ai models can help to prognosticate the outcomes of choroidal melanoma using demographic data and oncologic history. another development in ocular oncology is the non-invasive detection of ocular surface squamous neoplasia by making use of multispectral auto-fluorescence imaging. 10 a deep learning algorithm for the assessment of strabismus using photographic images of patients is also being tried. similarly, detection of refractive errors can also be possible with ai techniques one of which is based on brückner pupil red reflex imaging. 11.12 work on retinal vein occlusion is also underway and the initial results are very encouraging. ai has revolutionized the medical field during the last decade but its accuracy depends on the input data. „garbage in garbage out‟ phenomenon holds true for it. that is not all, development of an algorithm requires huge costs and experience. thus, right now such investments can only be made for very common diseases with high morbidity and mortality. similarly, as the ai is based on the input data and there are variations in different disease presentations in different populations, the data cannot be generalized. for accurate results whole set of new data from different population has to be incorporated into the machine. similarly, any variation of a disease, which is not included in the input data will be missed by the machine. variations in the geographical areas with unequal facilities of healthcare is another hurdle in implementation of ai. 13 another concern is that an ophthalmologist sees a patient for all kinds of ocular diseases. however, when it was tried to incorporate more diseases into a single machine, the accuracy of detection was decreased. a particular algorithm is designed to detect only one disease at a time. for example, a model which is designed for rop will fail to detect glaucoma as a disease or abnormality. in future these problems will be solved. although application of ai has facilitated tele health programs and has overcome the issue of shortage of specialists, there are liability issues as well. most important is the case if an error is made, would the clinician be liable or the ai technology programmer. such questions need to be answered and laws are yet to be made before widespread implementation of ai. there are other issues related with the consent, privacy and security of the patients as well. advent of ai has revolutionized the field of medicine and further work is being done for refining the results and decreasing the dependency on humans, but somehow some kind of human intervention will always be needed. conflict of interest authors declared no conflict of interest. references 1. frankenstein. available at: https://en.wikipedia.org/wiki/frankenstein. accessed on 19. november 2020. https://en.wikipedia.org/wiki/frankenstein artificial intelligence in ophthalmology pak j ophthalmol. 2021, vol. 37 (1): 1-3 3 2. kapoor r, walters sp, al-aswad la. the current state of artificial intelligence in ophthalmology. surv ophthalmol. 2019; 64 (2): 233-240. doi:10.1016/j.survophthal.2018.09.002 3. ting dsw, peng l, varadarajan av, keane pa, burlina pm, chiang mf, et al. deep learning in ophthalmology: the technical and clinical considerations. prog retin eye res. 2019. doi: 10.1016/j.preteyeres.2019.04.003 4. lu w, tong y, yu y, xing y, chen c, shen y. applications of artificial intelligence in ophthalmology: general overview. j ophthalmol. 2018; 5278196: 15. https://doi.org/10.1155/2018/5278196 5. abràmoff md, lavin pt, birch m, shah n, folk jc. pivotal trial of an autonomous ai-based diagnostic system for detection of diabetic retinopathy in primary care offices. npj digit med. 2018; 1: 39. doi: 10.1038/s41746-018-0040-6 6. hwang dk, hsu cc, chang kj, chao d, sun ch, jheng yc, et al. artificial intelligence-based decisionmaking for age-related macular degeneration. theranostics, 2019; 9: 232-245. 7. brown jm, campbell jp, beers a, chang k, ostmo s, chan rvp, et al. automated diagnosis of plus disease in retinopathy of prematurity using deep convolutional neural networks. jama ophthalmol. 2018; 136 (7): 803-810. doi: 10.1001/jamaophthalmol.2018.1934 8. schmidt-erfurth u, sadeghipour a, gerendas bs, waldstein sm, bogunović h. artificial intelligence in retina. prog retin eye res. 2018; 67: 1-29. 9. liu x, jiang j, zhang k, et al. localization and diagnosis framework for pediatric cataracts based on slit-lamp images using deep features of a convolutional neural network. plos one, 2017; 12 (3): e0168606. doi: 10.1371/journal.pone.0168606 10. habibalahi a, bala c, allende a, anwer ag, goldys em. novel automated non invasive detection of ocular surface squamous neoplasia using multispectral autofluorescence imaging. ocul surf. 2019; 17 (3): 540-550. doi: 10.1016/j.jtos.2019.03.003 11. chen z, fu h, lo w-l, chi z. strabismus recognition using eye-tracking data and convolutional neural networks. j healthc eng. 2018; 2018: 7692198. doi: 10.1155/2018/7692198 12. reid je, eaton e. artificial intelligence for pediatric ophthalmology. curr opin ophthalmol. 2019; 30 (5): 337-346. doi: 10.1097/icu.0000000000000593 13. du xl, li wb, hu bj. application of artificial intelligence in ophthalmology. int j ophthalmol. 2018; 11 (9): 1555-1561. doi: 10.18240/ijo.2018.09.21. .…  …. https://doi.org/10.1155/2018/5278196 431 pak j ophthalmol. 2021, vol. 37 (4): 431-435 case report loss of vision after laser peripheral iridotomy: a case report p s mahar 1 , asma rahman 2 , abdul sami memon 3 1-3 department of ophthalmology, aga khan university hospital, karachi abstract laser peripheral iridotomy (lpi) is a common laser procedure carried out in patients with narrow or occluded irido-corneal angles at risk of developing angle closure glaucoma. nd-yag and argon laser are used sequentially in our local population to create an iridotomy. posterior segment complications are rare after this procedure and generally can occur due to direct laser induced damage. we report a 44-year old patient, who had lpi performed on his both eyes. post laser patient complained of reduced vision in his left eye and was evaluated in our glaucoma clinic. on examination, his vision was 20/25 unaided in his right eye and 20/60 in his left eye with no further improvement. optical coherence tomography (oct) revealed presence of cystoid macular edema (cme) in his left eye responsible for his reduced vision. key words: laser peripheral iridotomy, cystoid macular edema, argon laser. how to cite this article: mahar ps, rahman a, memon as. loss of vision after laser peripheral iridotomy: a case report. pak j ophthalmol. 2021, 37 (4): 431-435. doi: 10.36351/pjo.v37i4.1268 introduction laser peripheral iridotomy (lpi) is the procedure of choice in patients with primary angle closure glaucoma (pacg), primary angle closure (pac) and primary angle closure suspects (pacs). 1 the procedure is also carried out in eyes with secondary causes of iridocorneal angle closure. 2 lpi creates an alternative route for aqueous escape from posterior to anterior chamber thus relieving the relative pupillary block. 3 in light colored eyes, ndyag, can work fine but in brown asian eyes due to heavily pigmented iris, combined argon and yag iridotomy remains the treatment of choice. 4 correspondence: p s mahar department of ophthalmology aga khan university hospital, karachi email: salim.mahar@aku.edu received: may 07, 2021 accepted: september 23, 2021 although the procedure is commonly practiced in glaucoma clinics universally, it is not free of side effects and complications. several possible post-laser complications have been reported following this procedure including transient rise in intraocular pressure, posterior synechiae formation, transient blurred vision, choroidal effusion, formation of focal lens opacities, corneal decompensation, aqueous misdirection, retinal hemorrhages and choroidal and retinal detachment. 5 we report here a case of patient who developed blurred vision in his left eye after getting lpi in his both eyes simultaneously. case report a 44-year-old male attended our glaucoma clinic with complaint of blurred vision in his left eye for last 2 weeks. he had been diagnosed with glaucoma and was using fixed combination of timolol 0.5% and dorzolamide 2% twice a day in his both eyes. his open access mailto:salim.mahar@aku.edu loss of vision after laser peripheral iridotomy: a case report pak j ophthalmol. 2021, vol. 37 (4): 431-435 432 figure 1: above: anterior segment of right and left eye showing iridotomies; middle: fundus photographs of right and left eyes; below: optic discs of both eyes. p. s. mahar, et al 433 pak j ophthalmol. 2021, vol. 37 (4): 431-435 oct rnfl left eye figure 2: optical coherence tomography of right and left eye showing retinal nerve fiber layer analysis (rnfl). right rnfl appears normal while there is thinning of rnfl in supero-temporal quadrant in left eye. treating physician advised him for lpi which was carried out simultaneously on his both eyes under topical anesthesia. the details of the procedure were not known. after the laser, he complained of blurred vision in his left eye. he did not have family history of glaucoma and no significant past and present medical or surgical history. on examination in our clinic, his best corrected visual acuity (bcva) was 20/25 unaided in the right eye and 20/60 in the left eye with no further improvement. his intraocular pressures with goldmann applanation tonometer (gat) were 16 mm hg in his right and left eye. his corneas were clear and pupils round and reacting. his central corneal thickness (cct) was 525 microns in his right eye and 530 microns in his left eye. gonioscopy revealed iridocorneal angles grade ii in all quadrants by shaffer’s classification. he had two iridotomies present at 10’o and 2’ o clock position in both eyes and were patent (figure 1). media were clear and the dilated fundus examination with 90 ds volk lens showed a cup disc ratio of about 0.3 with healthy rims in his right eye while it was calculated at 0.6 in the left eye (figure 1). left macular reflex appeared dull on further examination. optical coherence tomography (oct) of retinal nerve fiber layer (rnfl) and macula was requested. right rnfl analysis was within normal limits while left eye showed early thinning in superior-temporal area (figure 2). macular scans measuring 6.6 mm x 6.6 mm of right eye was normal while it showed presence of cystoid macular edema with central macular thickness (cmt) of 630 microns (figure 3). this patient was advised intravitreal injection of bevacizumab (avastin – genintech, usa) in dose of 1.25 mg/0.05 ml in his left eye. this was carried out in the operating room under sterile condition. with patient’s history of glaucoma, he was given 2 tablets of acetazolamide 250 mg, 6 hours before injection. at 4 weeks postoperative, patient’s vision had recovered to 20/25 in his left eye unaided and a repeat oct scan of macula showed flat retina (figure 3). discussion cystoid macular edema (cme) after lpi is one of the most uncommon complications of this procedure. medline and pubmed search found only 2 reports of this complication. the first one reported in literature was in 1983 by choplin. 6 this has been followed by another report of delayed appearance of cme after lpi by yang and colleagues published in 2018. 7 though irrvine – gass syndrome remains the loss of vision after laser peripheral iridotomy: a case report pak j ophthalmol. 2021, vol. 37 (4): 431-435 434 figure 3: optical coherence tomography of left macula showing presence cystoid macular edema. optical coherence tomography of left macula 1 month after intravitreal bevacizumab. common cause of cme after cataract surgery, 8 there are numerous other conditions described with this clinical appearance of fluid filled cystoid spaces in macular area elegantly seen on the macular scan. there are several mechanisms postulated for the development of the cme. the diffusion of inflammatory mediators such as prostaglandins can cause increased permeability of retinal blood vessels resulting in outpouring of fluid. 9 this theory is supported by the evidence that cyclooxygenase inhibitors such as non-steroidal anti-inflammatory drugs reduce the incidence of cme. we can theorize that laser application to the iris can cause release of such mediators causing cme in our patient. as this p. s. mahar, et al 435 pak j ophthalmol. 2021, vol. 37 (4): 431-435 patient had lpi performed simultaneously on both eyes, this theory does not hold good. the patient developed cme only in one eye. the vitreo-macular traction (vmt) is another factor which can cause stress at the muller cells and feet exerting traction force with release of basic fibroblastic growth factor (bfgf), vascular endothelial growth factor (vegf) and platelet-derived growth factor (pdgf). 10 this results in blood retinal barrier breakdown with development of edema. however, no sign of vmt was evident on patient’s retinal examination. however, dispersion of normal vitreo-macular interface can occur due to the laser energy resulting in release of mediators leading to breakdown of blood retinal barrier with clinical appearance of cme. vascular disorders such as diabetic retinopathy (dr) and branch retinal vein occlusion (brvo) are one of main group condition, which can result in cme. 11 our patient did not fall in any of these groups. conclusion cystoid macular edema in a patient after simultaneous laser peripheral iridotomy in both eyes is a rare entity. multiple hypotheses can be formulated to explain it. however, to prove it further work has to be done. references 1. quigley ha. angle-closure glaucoma–simpler answers to complex mechanisms: lxvi edward jackson memorial lecture. am j ophthalmol. 2009; 148 (5): 657-669. 2. prum be jr, herndon lw jr, moroi se, mansberger sl, stein jd, lim mc, et al. primary angle closure preferred practice pattern guidelines. ophthalmol. 2016; 123: p1–p40. 3. lam dsc, tham ccy, congdon ng, baig n. peripheral iridotomy for angle closure glaucoma. glaucoma elsevier; 2015: pp 708-715. 4. mirza aa, nizamani nb, khanzada ma, talpur ki. efficacy and complications of modified laser iridotomy in primary angle closure glaucoma. pak journal ophthalmol. 2016; 32 (4): 195-200. 5. saha bc, rashmi k, sinha bp, ambasta a, kumar s. laser in glaucoma: an overview. int ophthalmol 2021; 41: 1111-1128. 6. choplin nt, bene ch. cystoid macular edema following laser iridotomy. ann ophthalmol. 1983; 15 (2): 172-173. 7. yang ay, kempton j, liu j. delayed cystoid macular oedema after uncomplicated laser peripheral iridotomy. clin exp ophthalmol. 2018; 46 (7): 823824. 8. benitah nr, arroyo jg. pseudophakic cystoid macular edema. int ophthalmol clin. 2010; 50 (1): 139-153. 9. shelsta hn, jampol lm. pharmacologic therapy of pseudophakic cystoid macular edema, 2010 update. retina, 2011; 31 (1): 4-12. 10. bottos j, elizalde j, maia m. classifications of vitreomacular traction syndrome: diameter vs. morphology. eye, 2014; 28 (12): 1107-1112. 11. spaide rf. retinal vascular cystoid macular edema: review and new theory. retina, 2016; 36 (10): 18231842. authors’ designation and contribution p s mahar; professor & section head: manuscript writing and final review. asma rahman; senior medical officer: data collection abdul sami memon; clinical assistant professor: data analysis and final review. .…  …. pak j ophthalmol. 2020, vol. 36 (4): 408-411 408 original article color vision defects among textile mill workers in lahore qazi muhammad omair 1 , hifza imtiaz 2 , maryam iqbal 3 1-3 department of optometry & vision sciences, university of lahore abstract purpose: to find out the color vision defects among textile mill workers in lahore. study design: descriptive cross sectional study. place and duration of study: university of lahore from june 2019 to december 2019. methods: study was done at different textile mills in lahore, pakistan. self-designed proforma was used to record data including age, gender, occupation, any medication or surgery. the workers with best corrected visual acuity of 6/6 and refractive error less than 3.00 d of sphere or astigmatism less than 1 d of cylinder with no history of ocular surgeries were included in the study. color vision was assessed binocularly with the best correction in a trial frame using ishihara isochromatic color plates (38 plates) held at about 40 cm from the worker. examination of the anterior segment and posterior segment was done by using slit lamp biomicroscopy and 90 d of condensing lens. data was entered and analyzed using the spss version 22. results: during this study 1,250 textile mill workers fulfilled the inclusion criteria. there were six hundred and fifty males and 600 females who had an assessment of their colour vision. only 10 workers were found to be suffering from color vision deficiency, which was 0.8% of the total sample size. all of the color vision deficiency patients were male of different age group. conclusion: colour vision defects were found in small percentage of textile mill workers as there is no proper color vision examination in pre-employment examination at public and private textile industry. how to cite this article: omair qm, imtiaz h, iqbal m. color vision defects among textile mill workers in lahore. pak j ophthalmol. 2020; 36 (4): 408-411. doi: https://doi.org/10.36351/pjo.v36i4.1100 introduction the human eye has unique characteristics of having trichromatic vision and capability to differentiate between dissimilar wavelengths of light. this is because of three unique types of retinal cones which function to detect the colors. according to certain theories, there are red green and blue cones correspondence: qazi muhammad omair department of optometry & vision sciences university of lahore email: qazi.omair@ahs.uol.edu.pk received: july 14, 2020 accepted: september 5, 2020 with specific pigments. the functions of these cones are to detect an appropriate mixture of red, green and blue lights, which enables the eye to match any color which is visible to it. when this normal trichromatic vision is absent in a person he or she is labeled as having abnormal color vision, color vision deficiency or simply color blind. 1 the x linked red green deficiency affects approximately 8% of male population and 0.4% of females in most of the western countries. 2 color vision deficiency has been reported in different parts of the world and the prevalence in different countries is nearly close to one another. color vision deficiency is found in 4.7% of irani population. 3 in united kingdom the prevalence is 6.7%, 8.5% in qazi muhammad omair, et al 409 pak j ophthalmol. 2020, vol. 36 (4): 408-411 mediterranean croatia and 8.9% in croatia. 3 the rate of dichromacy was higher in mediterranean croatia (2.40%), while the rate of anomalous trichromacy was greater in inland croatia (6.93%). 4 a higher number of color vision deficiency is found in australia and turkey which is 7.4% and 7.3% respectively. 5 however, color vision deficiency in saudia arabia and pakistan are 2.90% and 2.75% respectively. 6 color vision deficiency in all over the world is taken as an occupational hazard as it is creating hazardous troubles in daily life activities. most of the patients having color vision deficiency are unaware of their deficiency which results in various mishaps. 7 the problems these persons face include career selection (33%), disability in job (25%), traffic signal recognition (13%) and judgment in daily routines (75%). 8 according to a study in uk, some medical practitioners were unable to detect red blood or rash in a given photograph and they had no idea of having color vision deficiency. 2 color vision patient have difficulty in conducting daily routine activities. most of the patients are unaware of their condition which lead them to many handicaps. 6 the purpose of the study was to find out the frequency of colour vision deficiency in textile mill workers in lahore region. methods the study was a cross sectional descriptive study, with non probability convenient sampling technique. it was done at different textile mills in lahore, pakistan. the principles outlined in the declaration of helsinki (2008) were followed for the conduction of study and a formal approval from the ethical review committee was obtained for the conduction of study. with informed consent, the data was collected among workers working at different textile mills in lahore. proforma was designed which was used to take history of the workers and other parameters including age, gender, occupation, any medication or surgery. visual acuity was measured using snellen chart. the workers with best corrected visual acuity of 6/6 after refraction and a refractive error of less than 3.00 d of sphere or astigmatism less than 1 d of cylinder, with no history of ocular surgeries or pathologies, age between 20 – 40 years were included in the study. examination of the anterior segment and posterior segment was done by using slit lamp biomicroscopy and 90 d condensing lens. color vision was assessed binocularly with the best correction in a trial frame using ishihara isochromatic color plates (38 plates). the color vision plates were held at about 40 cm from the worker. each ishihara plate was shown to the patient for 10 seconds and they were asked to read the numbers and patterns shown on the plate. the response was compared with chart key and color vision deficiency was screened out. data was entered and analyzed using the spss version 22. results during the study 1,250 textile mill workers fulfilled the inclusion criteria and among them 650 were males and 600 were females. among sample size of 1,250 only 10 workers were suffering from color vision deficiency, which was 0.8% of the total sample size. all of the color vision deficiency patients were males of different age groups. discussion color vision deficiency is a genetic disorder. different studies have been conducted for the treatment of color vision deficiency. a study based on laboratory experiments showed that monocular filters could improve color discrimination in dichromats. 9 formankiewicz and mollon conducted a study and predicted that deutronope may be helped by monocular long band lens to discriminate color along deutan axis (colours of equal luminance that lie along a deutan axis in colour space look indistinguishable to a deuteranopic observer). 10 color vision defects can be treated by gene therapy. different studies have been conducted on mice and they suggested different reasons for color blindness. a study revealed that adeno-associated virus can act as a transmission vector in rod monochromacy. 11 improvement of cone function was observed both electrophysiologically and behaviourally in almost all treated animals. however, the reason remained unclear as to in which stage the improvement of vision can be achieved during developmental stages. alteration was observed in inner retinal structure, photoreceptor mosaic and in reorganization of the visual cortex. 12,13,14 the studies showed that these changes alone would have an impact on visual function. textile mills are working as a backbone in the economical sector of a country. pakistan’s textile industry is the 8 th largest exporter of the textile color vision defects among textile mill workers in lahore pak j ophthalmol. 2020, vol. 36 (4): 408-411 410 products in asia. it provides more than 60 percent to the total country’s exports and support 8.5 percent of country gdp. 15,16 our study showed that 0.8% of the textile mill workers are suffering from color vision defects and the patients are unaware of this deficiency. textile mills are totally dependent on color vision. a study was conducted in united kingdom in which colour vision assessment was conducted among different professionals. 7 they observed that no color vision defect was found in textile mill workers because they have a proper colour vision screening protocol during hiring. color vision deficiency is the among the largest problems which leads to results in various industrial mishaps. 7 the patients are unaware of this deficiency and this leads to problems in textile works. in pakistan different professionals are totally unaware of this disease. in united kingdom, this defect was found in medical practitioners and they were unable to detect red blood or rash in a photograph given to them and they were even having no idea of being color vision deficient. 2 a comparison of color vision deficiency was done among medical and non-medical students, students of baqai medical university, karachi were compared with nadirshaw edulji dinshaw university of engineering and technology and the results showed there was no significant difference (p = 0.125) in color vision defects between medical students and non medical students. 6 colour vision deficiency was found in 3.7% of 1 st year mbbs students of different medical colleges at faisalabad. 17 in railway lines, 1.3% of employees had color vision defect. 18 a study conducted at combined military hospital (cmh) bahawalpur, included all individuals who applied for medical fitness examination at eye department. color vision deficiency was 3.1% and among them 93.54% were unaware that they had color vision deficiency. 19 the results of our study were similar to the study done at agha khan university hospitals karachi, where colour vision deficiency was 0.9% among tertiary health care workers. 20 these studies showed that color vision defects are found in all groups; whether they are students, professional, or uneducatedand most of them are unaware of their condition. conclusion although textile industry is based on colors, there is no proper color vision examination in our textile sector. colour vision deficiency awareness should be increased so that everyone in the community is well aware of it. the test of color vision must be made compulsory in pre-employment examination at public and private sector at every level. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. holroyd e, hall dmb. a re-appraisal of screening for colour vision impairments. child care health dev. 1997; 23 (5): 391-398. 2. campbell jl, griffin l, spalding jab, mir fa. the effect of abnormal colour vision on the ability to identify and outline coloured clinical signs and to count stained bacilli in sputum. clin exp optom. 2005; 88 (6): 376-381. doi: 10.1111/j.1444-0938.2005.tb05103.x 3. hashemi h, khabazkhoob m, pakzad r, yekta a, heravian j, nabovati p, et al. the prevalence of color vision deficiency in the northeast of iran. j curr ophthalmol. 2019; 31 (1): 80–85. 4. rogošić v, bojić l, karaman k, pleština-borjan i, rogošić lv, titlić m, et al. comparative follow-up study of unselected male population with congenital defective color vision from inland and mediterranean areas of croatia. acta medica croat. 2011; 65 (1): 1924. 5. citirik m, acaroglu g, batman c, zilelioglu o. congenital color blindness in young turkish men. ophthalmic epidemiol. 2005; 12 (2): 133–137. 6. siddiqui qa, shaikh sa, qureshi tz, subhan mm. a comparison of red-green color vision deficiency between medical and non-medical students in pakistan. saudi med j. 2010; 31 (8): 895–899. 7. cumberland p, rahi js, peckham cs. impact of congenital colour vision defects on occupation. arch dis child, 2005; 90 (9): 906–908. 8. rich dc. color vision, by leo m. hurvich. sinauer associates, sunderland, ma, 1981, color res appl. 1982: pp328. 9. knoblauch k, mcmahon mj. discrimination of binocular color mixtures in dichromacy: evaluation of the maxwell–cornsweet conjecture. j opt soc am a. 1995. 10. formankiewicz ma, mollon jd. the psychophysics of detecting binocular discrepancies of luminance. vision res. 2009; 12: 2219-2229. qazi muhammad omair, et al 411 pak j ophthalmol. 2020, vol. 36 (4): 408-411 11. alexander jj, umino y, everhart d, chang b, min sh, li q, et al. restoration of cone vision in a mouse model of achromatopsia. nat med. 2007; 13 (6): 685687. doi: 10.1038/nm1596. 12. varsányi b, somfai gm, lesch b, vámos r, farkas á. optical coherence tomography of the macula in congenital achromatopsia. investig ophthalmol vis sci. 2007; 48 (5): 2249-2253. doi: 10.1167/iovs.06-1173. 13. carroll j, choi ss, williams dr. in vivo imaging of the photoreceptor mosaic of a rod monochromat. vision res. 2008; 48 (26): 2564–2568. 14. baseler ha, brewer aa, sharpe lt, morland ab, jaägle h, wandell ba. reorganization of human cortical maps caused by inherited photoreceptor abnormalities. nat neurosci. 2002; 5 (4): 364-370. doi: 10.1038/nn817. 15. khan aa, khan m. pakistan textile industry facing new challenges. © res j internatıonal studıes-issue, 2010; 14: 21-29. 16. tanveer ma, zafar s. the stagnant performance of textile industry in pakistan. eur j sci res. 2012; 77 (3): 362-372. 17. mughal ia, ali l, aziz n, mehmood k, afzal n. colour vision deficiency (cvd) in medical students. pak j physiol. 2013; 9 (1): 19–21. 18. iqbal y, watim m, watim am. color vision deficiency in pakistan railways employees, pak j ophthal 2016; 32 (4): 226-230. 19. access o, blindness c, article o, armed p, med f, munawar t, et al. frequency of color blindness amongst the youngest age group in southern punjab province of pakistan. pak. armed forces med. j 2018; 68 (5): 1190–1193. 20. chhipa sa, hashmi fk, ali s, kamal m, ahmad k. frequency of color blindness in pre-employment screening in a tertiary health care center in pakistan. pakistan j med sci. 2017; 33 (2): 430–432. authors’ designation and contribution qazi muhammad omair; academic coordinator: concepts, statistical analysis, manuscript preparation. hifza imtiaz; research coordinator: design, literature research, manuscript editing. maryam iqbal; senior lecturer: data acquisition, data analysis, manuscript review. .…  …. https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18499214 15 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology original article comparison of recurrence after pterygium excision with amniotic membrane graft versus stem cell graft nukhba zahid, irfan qayyum, ayesha hanif pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. nukhba zahid dhq teaching hospital, gujranwala email: nukhba.zahid@gmail.com …..……………………….. purpose: to compare the recurrence of pterygium with amniotic membrane versus stem cell graft techniques after pterygium excision. study design: quasi experimental study. place and duration of study: study was conducted at dhq teaching hospital, gujranwala, for duration of 12 months from july 2016 june 2017. material and methods: this was a quasi experimental study where two surgical procedures were opted for pterygium excision. the patients were divided into two equal groups. one group had pterygium excision with stem cells grafting and the other group had pterygium excision with amniotic membrane grafting. patients of both gender, above 18 years of age with grade 2-3 of pterygium causing discomfort, visual impairment or cosmetic disfigurement were included in the study. whereas patients with id abnormalities, lacrimal sac infection, dry eye syndrome, pseudo pterygium and patients with recurrent epithelial erosions were excluded from the study results: out of 60 patients, 38 (63.3%) were males and 22 (36.7%) were females in this study. the mean age was 42 ± 9.3 years. recurrence rate with amniotic membrane grafting was 10 % and with stem cell grafting it was 3.3%. conclusion: stem cell grafting has less recurrence and better cosmetic appearance than amniotic membrane graft. key words: amniotic membrane graft, pseudo pterygium, surgical procedures, stem cell graft. terygium is a fibrovascular conjunctival tissue, which invades the cornea1. it is three sided in shape and is more often located nasally than temporally2. the most common clinical symptoms of pterygium are ocular irritation, hyperemia and vision loss3. conjunctival or limbal auto grafts, amniotic membrane grafts, application of mitomycin c, postoperative beta irradiation, postoperative thiotepa application, buccal mucus membrane grafting etc. are major adjuvants for prevention of pterygium recurrence4-10. although many other therapeutic modalities have been proposed8,11,12, further studies on their efficacy and safety are required. the purpose of this study was to compare the recurrence of pterygium with amniotic membrane versus stem cell graft techniques after pterygium excision. also, the efficacy and outcomes of pterygium excision were also considered postoperatively. material and methods this was a quasi experimental study where two surgical procedures were opted for pterygium excision for two groups of patients. each group comprised of 30 patients. patients were randomly divided in two groups by using random number table. the treatment p comparison of recurrence after ptrygium excision with amniotic membrane graft verses stem cell graft pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 16 modality in group a was pterygium excision with amniotic membrane grafting whereas in group b it was stem cell grafting. the venue of this study was dhq university teaching hospital, gujranwala. the duration of the study was twelve months starting from july 2016. the patients were selected through nonprobability, purposive sampling method. patients of both gender, above 18 years of age with grade 2 3 of pterygium causing discomfort, visual impairment or disfigurement were included in the study. approval from ethical committee of hospital was taken. demographic and clinical characteristics were noted for each patient. an informed consent was taken from each patient in which the purpose and procedure was explained and confidentiality of information was ensured. both the procedures were done under subconjunctival anesthesia. a 0.5 cc injection xylocaine with 1:100,000 adrenaline was given into the head of the lesion. the pterygium mass along with overlying conjunctiva was excised. in group a, amniotic membrane grafting was done. the membrane was taken from human placenta after hep b, hep c and hiv screening. it was then soaked in antibiotics (gentamycin and fluconazole) for about 1 hour. after taking measurement of the bare sclera with calipers, a graft of the same size was sutured with 10/0 nylon. in group b, after excision of the ptergyium bare area was measured with calipers. then conjunctival stem cell autograft was taken from the superior limbus and stitched to the bare area at the limbus. at the end of the procedure, a combination of topical steroid and antibiotic drops were prescribed and an eye pad was applied for 72 hours. these drops were used four times a day for 1 month and then tapered off. follow up was done after 3 days, 2 weeks, 1 month, 3 months and 6 months post operatively for pterygium recurrence (fibro-vascular re-growth crossing limbus by 1 mm or more). all the collected data was stored electronically & analyzed later by using spss version 20. descriptive statistics were applied to calculate mean and standard deviation. frequency distribution and percentages were calculated for qualitative variables like gender, level 2 and 3 pterygium. p value less than 0.05 was considered statistically significant. results the mean age was 42 ± 9.3 years. there were 38 (63.3%) males and 22 (36.7%) females in this study. the size of pterygium invasion outside limbus ranged from 2 4 mm. the distribution of pterygium grades among groups is given in table 1. table 1: pterygium grades distribution among groups. pterygium grades group a group b grade 2 15 (50%) 12 (40%) grade 3 15 (50%) 18 (60%) all the patients were operated with their allotted surgical treatment and observed postoperatively. corneal epithelial defects were observed in almost all patients, which healed after one week of operation. no corneal staining with fluorescein was observed in any group, although few complaints like foreign body sensation and watering were seen in some patients of group a & b. none of the patients had grafting edema in group a which was operated with amniotic membrane graft whereas 4 (13.3%) patients had edema in group b which was operated with stem cell graft. the difference between both groups was insignificant (p > 0.05) for all complications. the details of other postoperative complications are given in figure 1. in our study, recurrence rate was 10% with amniotic membrane grafting while recurrence rate of 3.3% was seen with stem cell graft. (p > 0.05). fig. 1: postoperative complication of both groups. discussion it is well known that pterygium is a multifactorial disorder, which is degenerative in nature13-15. the excision of the pterygium has complications and nukhba zahid, et al 17 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology recurrence, which is more difficult to control. the underlying recurrence mechanism had been attributed to trauma, inflammation, and proliferation of fibroblasts and deposition of extracellular matrix16-19. in our study, we selected 60 patients with pterygium and divided them into two groups of 30 patients each. the age range in the study was 18 to 58 years. the mean age was 42 ± 9.3 years. maximum patients (65%) presented between ages 34 49 years. among all the patients 38 (63.3%) were males and 22 (36.67%) were females. among 38 male patients, 19 were treated by pterygium excision with amniotic membrane grafting and other 19 by pterygium excision with stem cell grafting. female patients were 11 in each group. the recurrence rate following pterygium excision with amniotic membrane graft was found to be 10% and with stem cell graft it was 3%. among 19 male patients in group a, 2 had recurrence whereas in group b, 1 patient had recurrence while no recurrence was noted in female patients. recurrence was noted in patients between 39 45 years of age. other published studies support our findings13-15. one of the researches claimed a recurrence rate of 27%, which is comparatively very high. the study findings of nakamura et al16 recorded no recurrence in follow up period. moreover, some vision threatening side effects such as scleral ulceration, cataract formation and glaucoma have been reported20. in literature many researchers have provided evidence of its functional importance20. it is also well known that the conjunctiva and the limbus are important in maintenance and integrity of the corneal epithelium21. the current study presents only minor postoperative complications like hemorrhage and graft edema. these results are supported by various available published studies15,22. compared with the bare sclera method, conjunctival autograft is a more technically demanding procedure. surgeon factors (experience, technique, etc) may have a profound influence on the recurrence rate. moreover, conjunctival grafts including limbus generally yield better results, because in addition to the contact inhibition effect on residual abnormal tissue by conjunctival graft, the former may also contain limbal stem cells which help to restore the limbal barrier, and this in turn inhibits pterygium recurrence and retards recurrence time20,23,24. soliman and bhattia reported that there were no recurrences of pterygium growth except in 2 cases (4.75%) following stem cell graft with pterygium excision25. the limitation of the study is the small sample size and larger study is needed to assess the safety profile and low recurrence rate of pterygium excision. conclusion no major post‐operative complications following stem cell graft with pterygium excision were seen in our study. based on results of our study we recommend that stem cell grafting gives less recurrence and better cosmetic appearance than amniotic membrane graft. author’s affiliation dr. nukhba zahid medical officer mbbs ophthalmology department dhq teaching hospital, gujranwala. dr. irfan qayyum associated professor mbbs, fcps, fvr ophthalmology department dhq teaching hospital, gujranwala. dr. ayesha hanif medical officer mbbs ophthalmology department dhq teaching hospital, gujranwala. role of authors dr. nukhba zahid study design, manuscript writing & surgeon. dr. irfan qayyum manuscript review and critical analysis. dr. ayesha hanif data collection and surgeon. references 1. american academy of ophthalmology. basic and clinical science course. section 8, external disease and cornea. san francisco: american academy of ophthalmology, 2004: 344. 2. khamar b, khamar m, trivedi n. degenerative conditions of the conjunctiva. in: dutta lc, dutta nk, eds. modern ophthalmology, 3rd ed. new delhi: jaypee. 2005: 127-30. comparison of recurrence after ptrygium excision with amniotic membrane graft verses stem cell graft pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 18 3. gupta v, tandon r, vajpayee rb. disorders of conjunctiva. in: agarwal s, agarwal a, apple dj, burato l, alio jl, panday sk, eds. textbook of ophthalmology, vol-2. lids, adnexa and orbit external eye diseases, cornea and refractive surgery. 1sted. new delhi: jaypee brothers, 2002: 862-9. 4. okoye o, nc oguego, chukaokosa c m, ghanta m. short term results of pterygium surgery with adjunctive amniotic membrane graft. niger j clin pract. 2013; 16: 356-9. 5. hussain a alhammami. amniotic membrane transplantation for primary pterygium surgery, med j babylon. 2012; 9 (4): 734-738. 6. sangwan vs, burman s, tejaswani s, mahesh sp, murthy r. amniotic membrane transplantation, a review of current indications in management of ophthalmic disorders, indian j ophthal 2007; 55: 251-60. 7. zhao f, et al. clinical observation on fresh amniotic membrane transplantation for treatment of recurrent pterygium, article in chinese, 2002; 18 (4); 220-2. 8. goldberg l, david r. pterygium and its relationship to the dry eye in bantu.br j ophthalmol. 1976; 60: 720-1. 9. alemworie m, abebe b, menen a. prevalence of pterygium in a rural community of meskan district, southern ethiopia. ethio j health dev. 2008; 22: 191‐4. 10. asokan r, venkatasubbu rs, velumuri l, lingam v, george r. prevalence and associated factors for pterygium and pingencula in 
south indian population. ophthalmic physiol opt. 2012; 32: 3944. 11. hirst lw. the treatment of pterygium. surv ophthalmol. 2003; 48: 145-77. 12. fernandes m, sangwan vs, gangopadhyay n, sridhar ms, garg p, aasuri mk, et al. outcome of pterygium surgery: analysis over 14 years. eye, 2005; 19: 1182‐90. 13. kucukerdonmez c, akova ya, altinors dd. comparison of conjunctival autograft with amniotic membrane transplantation for 
pterygium surgery: surgical and cosmetic outcome. cornea, 2007; 26: 407. 14. allan bd, short p, crawford gj, barret gd, constable ij. pterygium excision with conjunctival autografting: an effective and safe 
technique. br j ophthalmol. 1993; 77: 698‐701. 15. luanratanakorn p, ratanapakrm t, suwan‐apichon d, chuck rs. randomised controlled study of conjunctival autogaft versus 
amniotic membrane graft in pterygium excision. br j ophthalmol. 2006; 90: 1476‐80. 16. nakamura t, inatomi t, sekiyama c, ang lp, yokoi n, kinoshita s. clinical application of sterilized freeze‐dried amniotic 
membrane to treat patients with pterygium. acta ophthalmol scand 2006; 84: 401‐5. 17. ma dh, see lc, liau sb, tsai rj. amniotic membrane graft for pterygium. br j ophthalmol. 2000; 84: 973‐8. 18. mastropasqua l, carpineto p, ciancaglini m, enrico gallenga p. long term results of intraoperative mitomycin c in the treatment 
of recurrent pterygium. br j ophthalmol. 1996; 80: 288‐91. 19. buratto l, phillips r l, carito g. pterygium surgery. nj: slack: slack incorporated; 2000. 20. prabhasawat p, barton k, burkett g. comparison of conjunctival autograft, amniotic membrane grafts, and primary closure for 
pterygium excision. ophthalmology, 1997; 104: 974-85. 21. baradaran‐rafii ar, aghayan hr, arjmand b, javadi ma. amniotic membrane transplantation. iran j ophthalmic res. 2007; 2: 58‐75. 22. essex rw, snibson gr, daniell m, tote dm. amniotic membrane grafting in the surgical management of primary pterygium. clin experiment ophthalmol. 2004; 32: 1‐4. 23. riordan-eva p, kielhorn i, ficker la, et al. conjunctival autografting in the surgical management of pterygium. eye, 1993; 7: 634–8. 24. rao sk, lekha t, sitalakshmi g, et al. conjunctival autograft for pterygium surgery: how well does it prevent recurrence? ophthalmic surg lasers, 1997; 28: 875–6. 25. soliman mahdy ma, bhatia j. treatment of primary pterygium: role of limbal stem cells and conjunctival autograft transplantation. eur j ophthalmol. 2009; 19 (5): 729-32. pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 147 original article ectopia lentis – etiology and management in children seema qayyum, ajmal chaudhary pak j ophthalmol 2016, vol. 32 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: seema qayyum department of pediatric ophthalmology the children’s hospital, lahore e.mail: seemaqayyum@gmail.com …..……………………….. purpose: to study the etiology, mode of presentation and management strategies of ectopia lentis in children less than 10 years of age. study design: interventional case series. place and duration of study: the children’s hospital and institute of child health, lahore and department of ophthalmology, kemu, lahore from january 2010-january 2015. material and methods: all patients diagnosed as having non-traumatic ectopia lentis were included in the study. the children were evaluated for vision threatening complications of ectopia lentis. a complete systemic examination was done by the pediatrician to diagnose any associated inherited systemic syndrome. the family members of the child were also examined for ectopia lentis. surgery was planned in all eyes where there was displacement of the lens in anterior chamber with or without pupil block. results: a total of 54 eyes of 27 patients diagnosed as having non-traumatic ectopia lentis were included in the study. there were 15 males, 12 female patients with 24 patients falling in the age bracket of 0 – 7 years. seventeen out of the twenty – seven patients were diagnosed as having inherited systemic syndrome, marfan being the most common. majority of the patients presented to the eye department only when there was pain in the eye due to increase in iop. conclusion: every child patient with ectopia lentis is a candidate for a thorough ocular and systemic examination for early recognition of vision threatening as well as life threatening systemic problems. the importance of involvement of parent with amblyopia management cannot be overemphasized for visual rehabilitation of the child. key words: ectopia lens, subluxation of lens, lensectomy. ctopia lentis means partial displacement or complete dislocation of the lens from its normal position, trauma being the most common cause1. non-traumatic ectopia lentis can occur as an isolated entity or may be part of the spectrum of a variety of inherited disorders2,3. in familial or idiopathic ectopia lentis there are no associated systemic or ocular findings4. high refractive errors and optical aberrations because of the lens not being in place reduce vision5. when there is a uniform loosening of the lens zonules a change in the shape of the lens results in myopia. anterior dislocation of the lens may cause pupil block and an increase in iop. a posteriorly displaced lens has the potential of causing damage to the retina. the ocular complications related to ectopia lentis can result in permanent decrease in vision, especially if this occurs in amylogenic age. prompt recognition and treatment are required to decrease the burden of blindness from complicated ectopia lentis. when a pediatric ophthalmologist comes across a child with ectopia lentis, he/she should consider the wide spectrum of inherited disorders associated with this entity2,6. the child should be referred to appropriate e seema qayyum, et al 148 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology subspecialty so as to address the possible life – threatening disease. the child should be monitored for amblyopia, and should be kept on a close follow-up with frequent cycloplegic refraction and correction of the visual error with appropriate glasses. in cases of marked lens displacement surgical intervention should be considered followed by visual rehabilitation. material and methods a prospective interventional study was conducted in the department of ophthalmology, kemu and department of pediatric ophthalmology, children’s hospital & institute of child health (ch-ich), lahore from january 2010 – january 2015. patients were seen either at kemu or ch&ich and were managed respectively in either of the two institutes. all patients who presented with non-traumatic ectopia lentis were included the study. patient demographic information recorded on the prescribed form included age, gender and ethnicity. after complete ocular and systemic examination, note was made of the mode of presentation, bcva, state and position of the lens, and underlying etiology. the patient was referred to the department of pediatric medicine for systemic evaluation and appropriate management. conservative management was done in nonsignificant subluxation of lens, cycloplegic refraction was done and appropriate glasses prescribed. the parents were counseled as regards the vision threatening potential of the disease and importance of follow-up. surgical management: surgery was planned in all eyes where there was displacement of the lens in anterior chamber with or without pupil block. relevant specialty was kept on board. within the bag lensectomy followed by anterior vitrectomy was the procedure of choice. postoperatively a close watch was kept on the signs of any complication. the parents of the child were advised as regards use of topical antibiotics, steroids and cycloplegic drops. at the time of discharge, the patients were given appropriate glasses. a follow-up schedule was given to the parents. results a total of 27 patients age 3 months to 11 years were included in the study, mean age being 4.27 years with a standard deviation of 2.2. male were 56% whereas females were 44%, (graph 1). seventeen patients (62.9%) were diagnosed as having inherited systemic syndrome, marfan being the most common (9 patients) (table 1). most of the patients presented to the eye department only when there was pain in the eye due to increase in iop (31 eyes – 57.4%) (graph 3). table 1: underlying etiology of ectopia lentis. underlying etiology n (patients) n (%) marfan syndrome 9 (33.33) weil marchesani 5 (18.5) homocystinuria 3 (11.11) idiopathic 6 (6.8) table 2: ocular associations ocular associations n (eyes) n (%) axial myopia 18 (33.33) glaucoma 8 (14.8) cataract 4 (7.4) aniridia 2 (3.7) table 3: management strategies of ectopia lentis management n (eyes) n (%) conservative 21 (38.8) pars plana lensectomy 27 (50) irrigation aspiration with iol 3 (5.5) irrigation aspiration with ctr+iol 3 (5.5) discussion ectopia lentis is the second most common congenital lenticular anomaly resulting in compromised vision. there is disruption of the zonular fibers resulting in subluxation of the crystalline lens7. genetic alterations being a frequent cause of ectopia lentis8. ectopia lentis – etiology and management in children pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 149 fig. 1: protocol of ectopia lentis management. graph 1: gender distribution. graph 2: age range. this entity can be isolated or associated with inherited systemic syndromes such as marfan syndrome9, weill marchesani syndrome10, homocystinuria, hyperlysinemia and sulfite oxidase seema qayyum, et al 150 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology graph 3: mode of presentation. graph 4: pre and post management visual acuity. deficiency accounting for 75% of the cases. marfan syndrome however, the most common cause of inherited ectopia lentis, is caused by a mutation in fbn1,11,12. in accordance with literature in this series inherited systemic disorders account for 63% of cases, marfan’s syndrome (33%) being most common of all systemic association. there have been reports in the literature of its association with ehler – danlos syndrome, sturge – weber syndrome, and stickler syndrome13.in this study however, no patient was found to be effected with these entities. the most common mode of presentation in our series in decreasing order of frequency was anteriorly dislocated lens (43%) with and without pupil block, followed by subluxation of lens (37%). a high percentage of patients reported only when they developed severe ocular pain (57.4%). this may be due to the fact that majority come from far-flung areas having limited access to health facilities. when dealing with a patient with ectopia lentis it is essential to make a comprehensive plan regarding diagnosis, management, visual rehabilitation and follow-up14. all the relevant subspecialties should be taken on board for timely diagnosis and management of associated systemic problems. the biggest challenge a pediatric ophthalmologist faces is when to plan for surgery and how to manage the visual rehabilitation of the compromised eye of the child. if there is a possibility of achieving visual improvement and maturation in the very sensitive amblyogenic age of the child with glasses, surgery can be delayed or even avoided. despite maximum conservative management romano et al, report ametropic amblyopia in 50% of patients with familial ectopia lenses15.in our series 31.4% eyes had vision less the 6/24. in cases where the vision is severely compromised surgical removal of the culprit lens should be planned16. a thorough ocular examination should be undertaken prior to surgery. looking at the lens under undilated and dilated condition would help the surgeon assess the direction and location of the zonular dysfunction as well as degree and direction of subluxation. retina should be carefully examined for any associated pathology especially in cases of marfan syndrome17. in the pre-automated vitrectomy era, surgery for ectopia lentis in small eyes was met with high rates of complications e.g. vitreous loss followed by retinal detachment. since the availability of the close system, automated, irrigation – vitrectomy there has been a remarkable improvement in the methodology and outcome with minimum complications in the hands of an experienced surgeon. both limbal, anterior approach as well as pars plana approach has been advocated by researchers18. the key to the success of the surgical procedure is the meticulous removal of vitreous gel and to make sure that there is no incarceration of the vitreous in the wound. in our series no significant postsurgical complication was noted. postoperatively the pediatric ophthalmologist is faced with the next big challenge of visual rehabilitation19. various options include aphakic glasses, contact lens, angle supported anterior chamber iol implant, posterior chamber iris fixated iol implant, posterior chamber capsule placed iol with or without capsular tension ring. however, each ectopia lentis – etiology and management in children pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 151 of these modalities has its inherent limitations and complications. in our series 88% of patients showed improvement in bcva of 6/18 or better. the role of proper counseling and involvement of parents and compliance with amblyopia therapy cannot be overemphasized20. conclusion ectopia lentis should not be considered as an isolated entity. the child patient should be taken as a whole in order to rule out the presence of associated systemic problems so as to decrease the morbidity and mortality author’s affiliation dr. seema qayyum associate professor & hod pediatric ophthalmology the children’s hospital and institute of child health, lahore dr. ajmal chaudhary assistant professor pediatric ophthalmology king edward medical university role of authors: dr. seema qayyum conception of research question, formulating the protocol, collection of data, data analysis, writing of manuscript dr. ajmal chaudhary conception of research question, collection of data, data analysis references 1. scothorn dm, sporn a, terry je. ectopia lentis secondary to physical abuse in a traumatized, elderly individual. j am optom assoc. 1991; 62: 630-3. 2. shortt aj, lanigan b, o’keefe m. pars plana lensectomy for the management of ectopia lentis in children. j pediatr ophthalmol strabismus, 2004; 41: 289–94. 3. chandra a, charteris d. molecular pathogenesis and management strategies of ectopia lentis. eye (lond), 2014; 28:162–8. 4. sadiq ma, vanderveen d. genetics of ectopia lentis. semin ophthalmol, 2013; 28: 313–20. 5. wen y, wu-chen, robert d, letson m. functional and stuctural outcomes following lensectomy for ectopia lentis. j americn assoc pediatr ophthalmol strabismus, 2005; 9:353–7. 6. hsu hy, sean l. edelstein jtl. surgical management of non-traumatic pediatric ectopia lentis: a case series and review of the literature. saudi j ophthalmol. 2012; 3: 315–21. 7. ahram d, sato ts, kohilan a, tayeh m, chen s, leal s, et al. a homozygous mutation in adamtsl4 causes autosomal recessive isolated ectopia lentis. am j hum genet. 2008; 84: 274–8. 8. neuhann tm. hereditary ectopia lentis . klin monbl augenheilkd, 2015; 232: 259–65. 9. zadeh n, bernstein ja, niemi ak, dugan s, kwan a, liang d, et al. ectopia lentis as the presenting and primary feature in marfan syndrome. am j med genet part a. 2011; 155: 2661–8. 10. chu bs. weill-marchesani syndrome and secondary glaucoma associated with ectopia lentis. clin exp optom. 2006; 89: 95–9. 11. kainulainen k, karttunen l, puhakka l, sakai l, peltonen l. mutations in the fibrillin gene responsible for dominant ectopia lentis and neonatal marfan syndrome. nat genet, 1994; 6: 64–9. 12. chandra a, patel d, aragon-martin ja, pinard a, collod-broud g, comeglio p, et al. the revised ghent nosology; reclassifying isolated ectopia lentis. clin genet. 2015; 87: 284–7. 13. chandra a aragon martin ja; child,ah arno g; charteris d et. al. alternative diagnoses with ectopia lentis. eye (lond). 2012; 26: 481–2. 14. hoffman rs, snyder me, devgan u, allen qb, yeoh r, braga-mele r. management of the subluxated crystalline lens. j cataract refract surg. 2013; 39: 1904– 15. 15. romano pe., kerr nc hgm. bilateral ametropic functional amblyopia in genetic etopia lenti:its relation to the amount of subluxatio, an indicator for early surgical management. binocul vis strabismus, 2002; 17: 235–41. 16. neely de, plager da. management of ectopia lentis in children. ophthalmol clin north am. 2001; 14: 493–9. 17. nahum y, spierer a. ocular features of marfan syndrome: diagnosis and management. isr med assoc j, 2008; 10: 179–81. 18. simon ma, origlieri ca, dinallo am, forbes bj, wagner rs, guo s. new management strategies for ectopia lentis. j pediatr ophthalmol strabismus, 2015; 52: 269–81. 19. melissa a. simo, catherine a, anthony m. dinallo, forbes pj, wagner rs. suqin guo m. new management strategies for ectopia lentis. j pediatr ophthalmol strabismus, 2015; 52: 269–81. 20. epley k.d., shainberg mj., lueder gttl. pediatric secondary lens implantationin the absence of capsular support. j aapos. 2001; 5: 301–6. 375 pak j ophthalmol. 2021, vol. 37 (4): 375-378 original article results of rectangular and triangular shaped scleral flaps in trabeculectomy in terms of control of intra ocular pressure (iop) and complications qirat qurban 1 , zeeshan kamil 2 , khalid mahmood 3 1-3 khalid eye clinic, nazimabad karachi abstract purpose: to compare between the results of rectangular and triangular shaped scleral flaps in trabeculectomy for primary open angle glaucoma. study design: quasi experimental study place and duration of study: khalid eye clinic, karachi, from july 2018 to june 2019. methods: this study included 24 patients of either gender and age from 40 to 65 years. patients with a diagnosis of primary open angle glaucoma refractory to medical treatment were included by convenient sampling technique. they were divided into two groups. group a underwent trabeculectomy with rectangular shaped scleral flap whereas group b underwent trabeculectomy with triangular shaped scleral flap. the main outcome measures were intraocular pressure reduction, anterior chamber depth and post-operative complications. all patients were followed up for a period of two months. results: mean age was 52.1± 6.72 years. mean pre-operative intraocular pressure in group a was 24.4±2.13 mmhg and 23.5±1.64 mmhg in group b. mean post-operative iop was 11.6±1.51 mmhg in group a and 13.4±1.67 mmhg in group b with p-value of 0.11. pre-operative anterior chamber depth (acd) was grade 4 both groups. it remained same in all patients of group a but two patients of group b changed to grade 3 acd. two patients of group b developed hypotony on the first post-operative day. they did not require revision suturing and were managed conservatively. conclusion: both types of scleral flap are effective in reducing iop but rectangular scleral flap reduced iop more as compared to triangular scleral flap but the difference was not statistically significant. keywords: trabeculectomy, intra ocular pressure, open angle glaucoma. how to cite this article: qurban q, kamal z, mahmood k. comparison of rectangular and triangular shaped scleral flaps in trabeculectomy in terms of control of intra ocular pressure (iop) and complications. pak j ophthalmol. 2021, 37 (4): 375-378. doi: 10.36351/pjo.v37i3.1089 introduction trabeculectomy is considered as the gold standard surgical technique for medically uncontrolled correspondence: qirat qurban khalid eye clinic, nazimabad karachi email: khalid eye clinic, nazimabad karachi received: june 28, 2020 revised: january 2021 accepted: june 07, 2021 through which aqueous humor can traverse within the sclera from the anterior chamber into the subconjunctival space preventing damage to the optic nerve. 1 the long term success rate of trabeculectomy in controlling iop ranges from 48% to 98%. 2,3 owing to the complications related to the early post-operative intraocular pressure control with full thickness glaucoma surgeries, non-penetrating filtration surgery was developed. 4 the designing of the sclera flaps of partial thickness over inner sclerostomy has helped to improve the outflow of aqueous humor with better open access qirat qurban, et al pak j ophthalmol. 2021, vol. 37 (4): 375-378 376 intraocular pressure outcome ensuing decreased chances of developing hypotony and its consequences such as shallowing of the anterior chamber depth, collapse of the blood aqueous barrier, bleeding in the anterior chamber, choroidal effusion, hypotony maculopathy, formation of cataract, suprachoroidal haemorrhage and misdirection of the aqueous humor during the first few days after surgery. 5,6 the designing of the original scleral flap in trabeculectomy comprised of formation of a rectangular shaped partial thickness scleral flap along with the excision of an elongated block of trabecular tissue, which has since then been modified accordingly in an effort to preserve a sufficient level of intraocular pressure in the long run and prevent the occurrence of complications. 7,8 the modifications over time have included limbal or fornix-based conjunctival flaps, adjuvant anti metabolite therapy, change in shape and size of the scleral flap and inner sclerostomy as well as the level of tightness in approximation of scleral flap closure with the help of sutures, which can be adjusted or lysed and help affirm a consistent management of aqueous flow thereby reducing the risk of early post operative hypotony. 9,10 apart from all the aforementioned modifications to help maintain an adequate intraocular pressure over a longer duration of time, iop control is mainly dependent upon the subconjunctival healing response as well. 11,12 despite the presence of various modifications, few studies have been conducted which compare the effectiveness and superiority between scleral flaps of different shapes. 7,8,13 we carried out this study to compare the outcomes of trabeculectomy with two different types of flaps, in terms of intraocular pressure management and anterior chamber depth. methods this study was carried out at khalid eye clinic, karachi from july 2018 to june 2019 and included 24 patients of either gender with an age range of 40 to 65 years. patients with a diagnosis of primary open angle glaucoma and refractory to medical therapy were included in this study. surgical procedure was explained to the patients and informed consent was obtained. study was approved from the ethical review committee. data was collected and documented including demographic information, comorbidities, duration of glaucoma, eyelid opening, presence of eyelid deformity and current medications used. patients who underwent previous ocular surgery and secondary glaucoma were excluded from the study. patients were divided into two groups. group a underwent trabeculectomy with rectangular scleral flaps whereas group b underwent trabeculectomy with triangular scleral flap. rest of the technique was similar in both groups. surgery was done under general anaesthesia. after ensuring a stable iop, limbal-based incision was made in all the patients. the overlying conjunctiva and episcleral tissue was removed from one quadrant and site cleared for the procedure. partial thickness scleral incision in a rectangular fashion (4 x 3 mm with 3 mm base) was made in group a and triangular flap (3 mm each side) was fashioned in group b behind the limbus tangentially with the help of baever blade. the anterior chamber was entered by making a central slit in the peripheral cornea using a blade under the base of the scleral flap. an elongated trabecular tissue block was removed and peripheral iridectomy was performed. sutures were placed to approximate the scleral flaps with the rest of the sclera to make sure that the scleral flap was well positioned and sitting symmetrically within its bed. in group a, two sutures were placed diagonally through each corner of the rectangular flap. in group b, two sutures were placed through each side of the triangle close to the apex. the conjunctiva was sutured back over the scleral flap making sure no free space remained between the adjacent sutures. all surgeries were done by a single surgeon. patients were followed for a period of up to two months. it was made sure that scleral flap was between one-half and two-thirds thickness in its entirety, sclerostomy was placed with a diameter of no greater than 1 mm and scleral flap was positioned with each corner well placed into the corresponding corner of the scleral bed with equal tightness of the sutures in all the surgeries. the main outcome measures were intraocular pressure reduction, anterior chamber depth and post-operative complications. results this study included 24 patients distributed into two groups. each group contained twelve patients. there were fifteen (62.5%) males and nine (37.5%) females. age ranged from 40 to 65 years with a mean age of 52.1 ± 6.72 years. there was involvement of the right eye in seventeen (70.8%) individuals and left eye in seven (29.2%) patients. pre-operative mean intraocular pressure in patients of group a was 24.4 ± 2.13 rectangular and triangular shaped scleral flaps in trabeculectomy 377 pak j ophthalmol. 2021, vol. 37 (4): 375-378 mmhg, whereas in group b it was 23.5 ± 1.64 mmhg (p-value 0.238 between two groups by independent sample t test). iop dropped down to 11.6 ± 1.51 mmhg in group a and 13.4 ± 1.67 mmhg in group b (p-value 0.11). anterior chamber depth (acd) was grade 4 (von herrick method) in patients of both groups pre-operatively. post-operatively it remained the same in all patients of group a but two patients of group b changed to grade 3. as far as complications were concerned, none of the patients of group a developed any post-operative hypotony, infection, or bleb leakage, where as two patients of group b developed hypotony on the first post-operative day. they did not require revision suturing and were managed conservatively. mean follow up period was 59 ± 2 days post operatively. discussion in trabeculectomy, presence of scleral flap poses a significant resistance to the outflow of aqueous humor in the initial period thereby making scleral flap a key controller of iop and influencing the risk of hypotony. if it is inappropriately constructed, it may cause a decreased reduction in iop. 14 the outflow of aqueous humor through a scleral flap depends upon multiple factors such as the formation of scleral tunnel, approximation of the scleral flap to the underlying scleral bed and its ability to lift to aid in drainage which depends on its elasticity as predicted by the scleral flap thickness, tension, position and tightness of the sutures placed. 15,16 keeping this in mind, this study was designed to observe the outcomes of two different shaped scleral flaps (rectangular versus triangular) and their effect on post operative intraocular pressure and anterior chamber depth. scleral flaps of adequate size and thickness were created, since too thick or too thin flaps would result in resistance to aqueous outflow and flap dehiscence leading to uncontrolled iop. 17,18 a study was conducted in which rectangular shaped scleral flaps of 3 × 2 mm were created. 8 the average iop reduction was at least two-thirds of baseline. this study also showed that the size of sclerostomy did not increase the possibility of postoperative flat anterior chamber nor did it affect the long-term iop control. 8 another study assessed the outflow of aqueous humor in relation to the formation of scleral flap and sclerostomy made during trabeculectomy. 19 increasing the size of the scleral flap was linked to an increase in aqueous outflow. it also found that square shaped scleral flap augmented the drainage of aqueous humor as compared to triangular shaped scleral flap of same size. it also concluded that thinner scleral flap enhanced the outflow of aqueous humor but thinner than half the thickness resulted in hypotony. 19 in another study, the pressure drop was greater across thinner flaps owing to less rigidity and resistance. 7 a bigger scleral flap and lesser number of sutures led to a greater reduction in intraocular pressure. a comparison between rectangular and triangular shaped scleral flap was done, similar to this study, over a period of 12 months among patients of ages 40 to 76 years old. 20 patients with angle closure glaucoma were included. it was reported that the iop reduction was equally significant among both the techniques with hypotony being found in two patients who underwent triangular shaped scleral flap and one patient who underwent rectangular shaped scleral flap, which resolved on its own within a week. the findings of the aforementioned studies correlated with the observations made in our study with the exception that patients of primary open angle glaucoma were recruited in this study and categorized into two groups. however, the reduction in iop among both the groups was significant and rectangular technique turned out to be more effective in the significant reduction of iop and maintenance of anterior chamber although not statistically significant. the follow up period in our study was two months as compared to the longer duration in the previous studies. the patients of group b observed a shallowing of anterior chamber depth, which could be due to the triangular design or inaccurate thickness of the scleral flap leading to increased outflow. the hypotony was managed conservatively and none of the patients required any revision surgery. the limitation of this study is the small sample and the follow up was of short duration. longer follow up to see the long-term effects of both shapes of flaps is needed. conclusion rectangular shaped scleral flap reduced iop more as compared to triangular shaped scleral flap but the difference was not statistically significant. patients who underwent trabeculectomy with rectangular shaped scleral flap did not show any change in the anterior chamber depth nor developed any postoperative complications. qirat qurban, et al pak j ophthalmol. 2021, vol. 37 (4): 375-378 378 ethical approval the study was approved by the institutional review board/ethical review board (erc-26-20). conflict of interest authors declared no conflict of interest. references 1. kirwan jf, lockwood aj, shah p, macleod a, broadway dc, king aj, et al. trabeculectomy outcomes group audit study group. trabeculectomy in the 21st century: a multicenter analysis. ophthalmology, 2013; 120 (12): 2532-2539. doi: 10.1016/j.ophtha.2013.07.049. 2. yuasa y, sugimoto y, hirooka k, ohkubo s, higashide t, sugiyama k, et al. effectiveness of trabeculectomy with mitomycin c for glaucomatous eyes with low intraocular pressure on treatment eye drops. acta ophthalmol. 2020 feb; 98 (1): e81-e87. doi: 10.1111/aos.14195. 3. gedde sj, feuer wj, lim ks, barton k, goyal s, ahmed iik, et al. primary tube versus trabeculectomy study group. treatment outcomes in the primary tube versus trabeculectomy study after 3 years of follow-up. ophthalmology, 2020; 127 (3): 333-345. doi: 10.1016/j.ophtha.2019.10.002. 4. binibrahim ih, bergström ak. the role of trabeculectomy in enhancing glaucoma patient's quality of life. oman j ophthalmol. 2017; 10 (3): 150-154. 5. walkden a, au l, fenerty c. trabeculectomy training: review of current teaching strategies. adv med educ pract. 2020; 11: 31-36. 6. ghazala t, imran g, riaz a. the effectiveness of conventional trabeculectomy in controlling intraocular pressure in our population. pak j ophthalmol. 2013; 29: 26–30. 7. samsudin a, eames i, brocchini s, khaw pt. the influence of scleral flap thickness, shape, and sutures on intraocular pressure (iop) and aqueous humor flow direction in a trabeculectomy model. j glaucoma, 2016; 25 (7): e704-12. doi: 10.1097/ijg.0000000000000360. 8. tse km, lee hp, shabana n, loon sc, watson pg, thean sy. do shapes and dimensions of scleral flap and sclerostomy influence aqueous outflow in trabeculectomy? a finite element simulation approach. br j ophthalmol. 2012; 96 (3): 432-437. doi: 10.1136/bjophthalmol-2011-300228. 9. o’brart dp, shiew m, edmunds b. a randomised, prospective study comparing trabeculectomy with viscocanalostomy with adjunctive antimetabolite usage for the management of open angle glaucoma uncontrolled by medical therapy. br j ophthalmol. 2004; 88: 1012–1017. 10. mahadevappa k, prasanna n, channabasappa ra. trends of various techniques of tubectomy: a five year study in a tertiary institute. j clin diagn res. 2016; 10 (1): qc04-qc7. 11. sheha, hosam. update on modulating wound healing in trabeculectomy, 2011. doi: 10.5772/23062. 12. yamanaka o, kitano-izutani a, tomoyose k. pathobiology of wound healing after glaucoma filtration surgery. bmc ophthalmol. 2015; 15: 157. https://doi.org/10.1186/s12886-015-0134-8 13. dhingra s, eames i, nicolle a, taban v, brocchini s, khaw pt. the effect of scleral flap shape and size on aqueous flow and pressure following trabeculectomy: implications from mathematical and physical modelling. invest. ophthalmol. vis. sci. 2011; 52 (14): 651. 14. megan ar, maharaj a. a review of scleral flap shape on trabeculectomy outcomes. vision panamerica, panam j ophthalmol. 2016; 15: 70-74. 15. chowdhury ur, hann cr, stamer wd, fautsch mp. aqueous humor outflow: dynamics and disease. invest. ophthalmol. vis. sci. 2015; 56 (5): 2993-3003. 16. swaminathan ss, oh dj, kang mh, rhee dj. aqueous outflow: segmental and distal flow. j cataract refract surg. 2014; 40 (8): 1263-1272. 17. vijaya l, manish p, ronnie g, shantha b. management of complications in glaucoma surgery. indian j ophthalmol. 2011; 59 (1): s131-s140. doi:10.4103/0301-4738.73689 18. henderson hw, ezra e, murdoch ie. early postoperative trabeculectomy leakage: incidence, time course, severity, and impact on surgical outcome. br j ophthalmol. 2004; 88: 626–629. 19. birchall w, bedggood a, wells ap. do scleral flap dimensions influence reliability of intraocular pressure control in experimental trabeculectomy? eye, 2007. 21: 402–407. 20. sharma a, adhikari s, das h, lavaju p, bijay s. a randomised clinical trial comparing the outcome of trabeculectomy using triangular versus rectangular scleral flaps. nepalese j ophthalmol. 2010; 1 (1): 2024. authors’ designation and contribution qirat qurban; consultant ophthalmologist: concepts, design, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing. zeeshan kamil; consultant ophthalmologist: consultant ophthalmologist: concepts, design, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing. khalid mahmood; consultant ophthalmologist: data acquisition, manuscript review. https://doi.org/10.1186/s12886-015-0134-8 cataract extraction through small pupil 16 pak j ophthalmol. 2022, vol. 38 (1): 16-20 original article sutureless manual extracapsular cataract extraction with club mahfooz hussain 1 , homaira iqbal khan 2 , tahir ali 3 , muhammad aftab 4 , adnan alam 5 1 euro eye clinic, 2 kabir medical college, 3, 4,5 lady reading hospital, peshawar abstract purpose: to evaluate the efficacy and safety of cataract extraction through small pupil with the help of a specially designed instrument called club. study design: interventional case series. place and duration of study: euro eye clinic from january 2019 to december 2019. methods: seventeen consecutive patients with pupil diameter of <4mm after maximal pharmacological dilatation were recruited for study. inclusion criteria was patients with less than 4mm pupil size after maximum pharmacological dilation. patient with previous anterior segment surgery and small pupil with posterior synechea were excluded. the instrument (club) was originally designed for breaking posterior synechae. sutureless manual extracapsular cataract extraction (smece), more commonly known as msics, was performed in all cases. after tunnel formation and capsulotomy, club was used to bring lens edge out in pupillary margin. lens was then maneuvered into anterior chamber and expressed out. results: all 17 patients had successful smece. in one patient pupil was stretched before applying instrument. none of the patients had posterior capsular rupture or hyphaema. conclusion: this instrument designed in center of ophthalmic instrument and equipment designing (coied) is very useful, safe and cost effective. in extra capsular cataract extraction (ecce) or smece, surgeons usually do keyhole iridotomy, mechanical stretching or multiple sphincterotomies for managing small pupil. with this new instrument, cataract extraction can be done without surgical trauma to the pupil, thus preserving pupil shape. key words: sutureless manual extra capsular cataract extraction (smece), manual small incision cataract surgery (msics), miosis. how to cite this article: hussain m, khan hi, ali t, aftab m, alam a. sutureless manual extracapsular cataract extraction with club. pak j ophthalmol. 2022, 38 (1): 16-20. doi: 10.36351/pjo.v38i1.1252 introduction in developing countries sutureless manual extracapsular cataract extraction (smece) is widely correspondence: mahfooz hussain department of ophthalmology, euro eye clinic email: mahfoozhussain@hotmail.com received: april 18, 2021 accepted: november 26, 2021 used. 1,2 it is more commonly known as manual small incision cataract surgery (msics) but incision is no way small and smece appears to be more appropriate name for this surgery. 3 smece (new name for msics) has been proved to be as effective as phacoemulsification. 4,5 it has been shown to be better than extra capsular cataract extraction. 6,7 small pupil is a common problem faced by cataract surgeons and increases chances of intra operative complications particularly posterior capsular rupture and iris damage. 8,9 the causes of small pupil open access sutureless manual extracapsular cataract extraction with club pak j ophthalmol. 2022, vol. 38 (1): 16-20 17 are pseudoexfoliation, posterior synechae secondary to uveitis or previous surgery, tonic pupil, diabetic iridopathy, iris sphincter sclerosis from ageing, chronic miotic therapy and iridoschisis. 10 doing phacoemulsification through small pupil is possible but it becomes easier with the help of various mechanical pupil dilating devices. 11-13 on the other hand performing smece through small pupil is more traumatic. normally smece surgeons do multiple iris sphincterotomies to enlarge small pupil, to make it big enough to bring lens into anterior chamber, before expressing it out of eye. the objective of study was to do cataract extraction in small pupil without damaging sphincter. club was designed in center of ophthalmic instrument and equipment designing (coied). club has same angles as chopper but end is round like small ball which gives it shape of club (figure) and hence the name. club gets lens out of capsular bag and brings lens edge in pupil. this way lens can be brought in anterior chamber without damaging pupil and postoperatively pupil stays round without any damage to pupil sphincter. methods it was a prospective interventional case series. patients were recruited from ist january 2019 to 31 december 2019. inclusion criteria was patients with less than 4mm pupil size after maximum pharmacological dilation. patients with previous anterior segment surgery and small pupil with posterior synechea were excluded. seventeen consecutive patients with pupil diameter < 4 mm after maximal pharmacological dilatation were recruited for study. causes of small pupil in this study were pseudoexfoliation (n = 9), rigid tonic pupil (n = 3), diabetic iridopathy (n = 2) and sphincter sclerosis from ageing (n = 3). patients with coexisting anterior segment pathologies like glaucoma or uveitis were not included in study. all patients were operated by smece with club. after tunnel formation and capsulotomy, club was used to bring lens edge in pupillary margin. lens was then maneuvered into anterior chamber and expressed out of the eye with the help of ocular viscoelastic device (ovd). intraoperative complications like difficulty in bringing out lens into anterior chamber, posterior capsular rupture, zonular dehiscence or hyphema were not noted. postoperative examination was done at day one, one week, one month and three month. visual acuity, intraocular pressure (iop), lens position and anterior chamber inflammation was noted on all visits. standard postoperative regimen was topical steroid and antibiotic eye drops one hourly for one day, followed by 6 times a day for a week and then four times a day for another 4 weeks. frequency of this regimen was changed when needed and topical cyclopentolate and iop lowering medications were added when needed. at 10th week, all patients had stopped using eye drops. after superior peritomy, 6-6.5 mm frown shaped incision was given 2 mm behind the limbus. scleral tunnel was made with crescent blade extending up to 12 mm on internal edge and 2 mm in front of limbus. side port was made and ovd was injected into anterior chamber. ovd was used to lift iris away from lens to create more space between iris and anterior surface of lens. 24-gauge needle was used to do canopener anterior capsulotomy. capsulotomy needle was taken underneath the iris to do as big capsulotomy as possible. 3.2 mm phaco knife was used to enter anterior chamber through tunnel but the incision was not enlarged on both sides as done in routine cases. this keeps anterior chamber formed deep during use of club. hydrodissection was done using 20 gauge cannula. for softer cataract, hydro-delineation was also done to separate central hard part of lens, which could easily be grabbed by club. ovd was injected back into eye to inflate anterior chamber. sinski hook was introduced through the side port with left hand. sinski hook was used not only to stabilize the lens but also to press it down. at this stage of operation club was used. this device has a small ball at its end which swipes underneath lens. this brings superior lens margin into pupillary area (figure 1). figure 1: using club for nucleus expression. mahfooz hussain, et al 18 pak j ophthalmol. 2022, vol. 38 (1): 16-20 after the lens edge was popping out of the bag, ovd was injected underneath the lens to push posterior capsule backwards and to push lens forward. lens was rotated to bring it into anterior chamber. ovd was injected at 5 and 7 o’clock position in anterior chamber and in front of the lens. eye was held at 6 o’clock position with toothed forceps and pressure was applied at 12° clock to express the lens. irrigation and aspiration of soft lens matter was done with simcoe cannula. a 6.5 mm single piece pmma posterior chamber intraocular lens (iol) was implanted in all patients. after aspirating ovd, conjunctiva was opposed with bipolar cautery. results all the patients had successful surgery with no specific problems regarding use of this new instrument. all the patients had pupil diameter of <4mm at the time of surgery. none of the patients had posterior capsule rupture, iris trauma or hyphaema. only in one patient pupil margin was damaged. in this patient pupil was sclerosed and we had to stretch pupil. postoperative inflammation was usual for a routine cataract extraction. all the patients were off postoperative treatment at 2 months time. intra ocular pressure (iop) was high in 3 patients. iop was controlled with topical beta blockers in 2 patients and only one patient had acetazolamide 250 mg tablets for 3 days. all glaucoma treatment was stopped at 8 weeks and iop was normal in all patients at 3 months. average postoperative vision with correction was 6/9, ranging from 6/24 to 6/6. the instrument is not expensive and reusable and there is no extra cost per surgery. introduction of club into eye and inserting it under lens is safe because of its round edge. rest of the operation before and after this step was as per routine. discussion many patients presenting for cataract surgery have pupils that do not dilate to desired levels with pharmacological mydriatic agents used topically. 14 the causes of small pupil in this study were pseudoexfoliation, rigid tonic pupil, diabetic iridopathy and ageing pupillary sclerosis. phacoemulsification with the help of iris retraction hooks was my procedure of choice in cases of small pupil. then i designed a hook and used it for lens extraction in pupil. 15 this new instrument, club, is even better and more easy to use than previously designed hook. now with the help of club i performed smece with more ease and without any extra cost, which is particularly useful for countries where cost of surgery is big issue. i classify cataract extraction through small pupil into four possible ways. the first method is mechanically stretching method. the second method is iris cutting method. the third method is iris retainer method and the fourth method is cataract extraction through small pupil without any dilatation. the first three methods are by dilating pupil as described by kershner 16 and the fourth method is cataract extraction through small pupil without any mechanical dilatation. phacoemulcification through small pupil has been described but in this study i have described a new method in which pupil is not dilated for extracapsular cataract extraction and pupil is only stretched by lens itself when it comes into anterior chamber. commonly used method for extracapsular cataract extraction through small pupil is bimanual stretching of pupil. 17 though the pupil with this method is dilated but still remains small enough and it remains difficult for lens to pop out into anterior chamber. the other disadvantages of this method are intraoperative hyphaema, iris sphincter damage, pigment dispersion and malfunctioning pupil postoperatively. the second method commonly used for small pupil is multiple sphincterotomies to enlarge pupil. 18 this makes smece easy through small pupil but the scissors used for cutting iris can damage corneal endothelium. this also leaves an irregular and enlarged postoperative pupil which does not give acceptable cosmetic result and postoperatively patient also feels trouble from glare. another way of managing small pupil in smece is doing keyhole iridotomy and then applying iris suture at the end of operation to restore iris shape. all these methods cause irreversible damage to pupil sphincter and leave pupil dilated postoperatively in some cases. the third method is pupil expanding devices. these small pupil dilating devices are iris retraction hooks, polymethyl methacrylate (pmma) pupil dilator-ring, perfect pupil expansion device and greather pupil expander. 19,20 these devices have only been tried for successfully managing small pupil in phacoemulcification though iris retraction hooks have been used in smece. in smece these devices are very likely to touch corneal endothelium. touching of corneal endothelium can particularly happen when sutureless manual extracapsular cataract extraction with club pak j ophthalmol. 2022, vol. 38 (1): 16-20 19 anterior chamber is likely to collapse which is during expressing lens out of the bag and during expressing lens out of the eye. the device is simple and safe to use. this is a reusable instrument and there is no extra cost per surgery. there were no particular intraoperative or postoperative complications in our study. conclusion this instrument designed in coied is very useful, safe and cost effective. in smece surgeons usually do key hole iridotomy, mechanical stretching or multiple sphincterotomies for managing small pupil. with this new instrument cataract extraction can be done without surgical trauma to pupil, thus preserving pupil shape. there were no cases of posterior capsular rupture or papillary sphincter damage and no extra cost to surgery with minimal added time for surgery. minimal postoperative inflammation was probably because of minimal trauma to iris. ethical approval the study was approved by the institutional review board/ethical review board (osp-irb-/2021/007). conflict of interest authors declared no conflict of interest. references 1. ruit s, paudyal g, gurung r, tabin g, moran d, brian g. an innovation in developing world cataract surgery: sutureless extracapsular cataract extraction with intraocular lens implantation. clin exp ophthalmol. 2000; 28: 274-279. 2. gogate p. clinical trial of manual small incision cataract surgery and standard ecce. community eye health j. 2003; 48: 54-55. 3. hussain m. cataract extraction through small pupil without mechanical dilatation. ophthalmol update, 2010; 8 (1): 9-11. 4. ruit s, tabin g, chang d, bajracharya l, kline dc, richheimer w, et al. a prospective randomized trial of phacoemulsification vs. manual sutureless small-incision extracapsular cataract surgery in nepal. am j ophthalmol. 2007; 143 (1): 32-38. 5. gogate pm, kulkarni sr, krishnaiah s, deshpande re, joshi sa, palimkar a, et al. safety and efficacy of phacoemulsification compared with manual smallincision cataract surgery by a randomized controlled clinical trial: six week results. ophthalmology. 2005; 112 (5): 869-874. 6. huang fc, tseng sh. comparison of surgically induced astigmatism after sutureless temporal clear corneal and scleral frown incisions. j cataract refract surg. 1998; 24: 477-481. 7. olsen t, dam-johansen m, bek t, hjortdal jo. corneal versus scleral tunnel incision in cataract surgery: a randomized study. j cataract refract surg. 1997; 23 (3): 337-341. doi:10.1016/s0886-3350(97)80176-9. pmid: 9159676. 8. guzek jp, holm m, cotter jb, cameron ja, rademaker wj, wissinger dh, tonjum am, sleeper la. risk factors for intraoperative complications in 1000 extracapsular cataract cases. ophthalmology, 1987; 94 (5): 461-466. doi:10.1016/s0161-6420(87)33424-4. pmid: 3601359. 9. fine ih, hoffman rs. phacoemulsification in the presence of pseudoexfoliation. j cataract refract surg. 1997; 23: 160-165. 10. halkiadakis i, chatziralli i, drakos e, katzalkis m, skouriots s, patsea e, et al. causes and management of small pupil in patients with cataract. oman j ophthalmol. sep-dec. 2017; 10 (3): 220-24. 11. vasavada a, singh r. phacoemulsification in eyes with small pupil. j cataract refract surg. 2000; 26 (8): 1210-1218. 12. goldman jm, karp cl. adjunct devices for managing challenging cases in cataract surgery; pupil expansion and stabilization of the capsular bag. curr opin ophthalmol. 2007; 18 (1): 44-51. 13. grzybowski a, kanclerz p. methods for achieving adequate pupil size in cataract surgery. curr opin ophthalmol. 2020; 31 (1): 33-42. 14. malyugin be. recent advances in small pupil cataract surgery. curr opin ophthalmol. 2018; (1): 40-47. 15. hussain m. cataract extraction through small pupil without mechanical dilatation. ophthalmol update, 2010; 8 (1): 9-11. 16. kershner rm. management of small pupil for clear corneal cataract surgery j cataract refract surg. 2002; 28 (10): 1826-1831. 17. basckulin a, kundt g, guthoff r. efficiency of pupillary stretching in cataract surgery. eur j ophthalmol. 1998 oct-dec; 8 (4): 230-3. 18. cole md, brown r, ridgeway ae. role of sphincterotomy in extracapsular cataract surgery. br j ophthalmol. 1986 sep; 70 (9): 692-5. 19. birchall w, spencer af. misalignment of flexible iris hook retractors for small pupil cataract surgery: effects on pupil circumference j cataract refract surg. 2001 jan; 27 (1): 20-4. 20. graether jm. graether pupil expander for managing the small pupil during surgery j cataract refract surg. 1996 jun; 22 (5): 530-35. https://pubmed.ncbi.nlm.nih.gov/?term=halkiadakis+i&cauthor_id=29118499 https://pubmed.ncbi.nlm.nih.gov/?term=chatziralli+i&cauthor_id=29118499 https://pubmed.ncbi.nlm.nih.gov/?term=drakos+e&cauthor_id=29118499 https://pubmed.ncbi.nlm.nih.gov/?term=grzybowski+a&cauthor_id=31743155 https://pubmed.ncbi.nlm.nih.gov/?term=kanclerz+p&cauthor_id=31743155 https://pubmed.ncbi.nlm.nih.gov/?term=malyugin+be&cauthor_id=29059105 mahfooz hussain, et al 20 pak j ophthalmol. 2022, vol. 38 (1): 16-20 authors’ designation and contribution mahfooz hussain; consultant ophthalmologist: concept, design, manuscript preparation, manuscript editing, manuscript review. homaira iqbal khan; associate professor: literature search, manuscript preparation. tahir ali; vr fellow: data acquisition, data analysis, statistical analysis. muhammad aftab; vr fellow: data acquisition, data analysis, statistical analysis. adnan alam; vr fellow: literature search, manuscript preparation. .…  …. pak j ophthalmol. 2022, vol. 38 (1): 43-47 43 original article outcomes of maximum levator resection in severe upper eyelid ptosis at a tertiary oculoplastic service mohammad idris 1 , hassan yaqoob 2 , hadia sabir 3 , hera fahim 4 , muhammad jamshed 5 1,3,4,5 lady reading hospital, medical teaching hospital, 2 north west teaching hospital, peshawar abstract purpose: to investigate the surgical outcomes of maximum levator resection in cases of severe upper eyelid ptosis at a tertiary oculoplastic service. study design: interventional case series. place and duration of study: department of ophthalmology, lady reading hospital, medical teaching hospital, peshawar january 2013 to december 2017. methods: one hundred and twenty three eyes of 107 patients, who underwent maximum levator resection for severe congenital ptosis were included. patients with missing or incomplete notes, patients with previous ptosis surgery and ptosis other than congenital were excluded. maximum levator resection of the muscle above the whitnall ligament was performed under local/general anesthesia. all patients had a minimum of 6 months and maximum of 5 years followup. the postoperative complications were recorded and followed. post operative followup was done at day one, week one and at four weekly intervals till the end of the study. results: out of 123 eyes, satisfactory results (excellent or good) were obtained in 111 (90.1%) eyes. majority of the patients (56.09%) were females. mean preoperative levator function was 2.3 ± 1.1mm. mean preoperative mrd1 was −0.1 ± 1.5 mm and mean postoperative mrd1 was 3.9 ± 01.0 mm. the commonest complication was over correction which occurred in 5 (4.06%) cases, under correction in 4 (3.25%), crease abnormality in 2 (1.62%) cases and entropion was seen in only one (0.81%) case. success rate was 90.1% at 6 months to 5-years followup. key words: blepharoptosis; levator resection; levator function. how to cite this article: idris m, yaqoob h, sabir h, fahim h, jamshed m. outcomes of maximum levator resection in severe upper eyelid ptosis at a tertiary oculoplastic service. pak j ophthalmol. 2022, 38 (1): 4347. doi: 10.36351/pjo.v38i1.1284 correspondence: mohammad idris department of ophthalmology lady reading hospital medical teaching hospital, peshawar email: idrisdaud80@gmail.com received: june 1, 2021 accepted: november 12, 2021 introduction ptosis is a common and challenging oculoplastic procedure because of cosmetic and physiological implications, which depend on surgeon’s own experience when deciding about choice of procedure. greek word “ptosis” means falling and refers to drooping of eyelid when eye is in primary position. 1 one of the commonest causes is simple congenital ptosis but sometimes it is associated with a lifethreatening condition. 2 most of the cases referred to open access mailto:idrisdaud80@gmail.com mohammad idris, et al 44 pak j ophthalmol. 2022, vol. 38 (1): 43-47 our oculoplastic clinic are benign but systemic examination is important to exclude any systemic disease; for example myasthenia gravis and horner syndrome. 3 ptosis is not only a major cosmetic concern but it can be an important cause of amblyopia in young children as well. 4 decision in such cases is based on severity of ptosis. severe ptosis need early correction to prevent sight-threatening amblyopia. severe congenital ptosis with poor levator function of ≤ 4 mm is not easy for the oculoplastic surgeon to deal with. 5 the type of surgery for the correction of congenital ptosis is based on surgeon’s choice which may be frontalis suspension (fs) or mlr, different studies are available which support both types. 6 in both choices, the surgery is a challenge because of cosmetic and physiological implications. 7 fs with different synthetic material is used to lift the droppy eyelid. this procedure is simple but there are certain issues which include bilateral surgery for symmetrical results, lack of crease formation, use of synthetic material in very young children and significant lagophthalmos leading to exposure. 8 mlr is useful alternative in selected patients with severe ptosis which refers to resection of the muscle above the whitnall ligament. 9 in our present analysis, maximum levator resection (mlr) was done by a single surgeon. rationale was to investigate the results of mlr in our set up. such type of surgical audit is a useful tool to assess shortcomings and are important source to guide and improve results. 10 it is beneficial both for the surgeon as well as the patients. we compared our results with different studies. methods one hundred and twenty three eyelids of 107 patients, who underwent maximum levator resection for severe congenital ptosis at oculoplastic service were included in this study. twenty-one patients were lost to followup and excluded. informed consent was taken. newly diagnosed patients were included. complete history and ocular examination was performed. a single consultant performed all the surgeries. maximum levator resection of the muscle above the whitnall ligament was performed under local/general anesthesia. the end-point of the surgery was to have the eyelid margin rest 1 to 2 mm below the super limbus with the patient under general anesthesia. all the patients had a minimum of 6 months and maximum of 5 years followup. their success rate, postoperative complications and final outcome were assessed. satisfactory surgical outcome was defined as postoperative mrd1 of 3 mm in each eye and difference in mrd1 of 1 mm between the two eyes at 6months after surgery. the postoperative complications were recorded and followed. success of surgery was defined on the basis of absent complications like lid abnormality, over or under correction and lid elevation with 1mm lid covering the limbus at least at 6 months. sutures were removed after two weeks. complicated cases were assessed as to whether further surgery is required or not. post operatively followup was done at day one, week one and at four weekly intervals till the end of the study. results out of 123 eyes, satisfactory results (excellent or good result) were obtained in 111 (90.1%). sixteen cases were bilateral and 91 were unilateral out of 123 (107 patients) eyelids. majority of patients 56.09 % (n = 69) were females and males were 43.90% (n = 54). patients were divided into three age groups. maximum patients were in the age group of 7 – 27 years (55.28%, n = 68), patients of age 28 – 48 years were 34.95% (n = 43), while age groups > 48 years were 9.75% (n = 12) patients. preoperative and postoperative lid measurements for maximal levator resection was noted (table 1). different postoperative table 1: eye lid measurements before and after maximal levator resection in millimeter. s. no. upper eyelid measurements mean ± sd 1. preoperative lf 2.3 ± 1.1 mm 2. preoperative mrd1 −0.1 ± 1.5 mm 3. postoperative mrd1 3.9 ± 01.0 mm lf = levator function, mm = millimeter, lf = levator function, mrd1 = upper lid marginal reflex distance, sd = standard deviation complications are shown in table 2 and the commonest complication was over correction which occurred in 5 (4.06%) cases. successful cases were 90.1%. these results were shown and compared with published literature (table 3). outcomes of maximum levator resection in severe upper eyelid ptosis at a tertiary oculoplastic service pak j ophthalmol. 2022, vol. 38 (1): 43-47 45 table 2: frequency of complications and successful cases (n = 123. post-op complication frequency percent under correction 4 3.25 over correction 5 4.06 abnormal crease 2 1.62 upper lid entropion 1 0.81 successful cases 111 90.1 total 123 100 table 3: comparison of our results with previous studies. s. no. author followup no. of cases success rate 1 cruz, et al 11 5 – 85 months 35 91.4 2 mauriello, et al 12 18 months 32 87.5 3 press and hübner 13 na 44 81.8 4 al-mujaini and wali 14 2 – 24 months 7 100 5 decock, et al 15 > 1 year 11 63.6 6 mete, et al 16 10 – 36 months 29 69.6 7 lee, et al 17 40.9 months 210 93.0 8 present study 6 months – 5 years 123 90.1 na = not available figure 1: common postoperative complications: a) lagophthalmos in the early postoperative period, b) over correction at one month followup. figure 2. a) right severe congenital ptosis, b) first postoperative day, c) at one month after surgery. figure 3: severe congenital ptosis before and after surgery. discussion in a study by bernardini et al, 9 amount of levator resection was based on the severity and levator muscle function. the aim was to keep eyelid margin 1 to 2 mm below the super limbus with the patient under general anesthesia and concluded that supra-maximal levator resection has become the procedure of choice for unilateral, poor levator function congenital ptosis.” this audit was used to assess outcome of this procedure which is beneficial for both surgeon and patient as surgical repair of upper lid ptosis correction is a challenging oculoplastic procedure. we compared our results with similar cases in published literature. according to these studies, mlr for severe ptosis was found favorable option with good cosmetic and functional outcome. mohammad idris, et al 46 pak j ophthalmol. 2022, vol. 38 (1): 43-47 cruz et al 11 studied 35 cases of severe ptosis after mlr with a success rate of 91.4%. similarly, mauriello et al, 12 press and hübner, 13 al-mujaini and wali 14 , decock et al 15 and mete et al, 16 have results of successful outcome ranging from 63.6 to 100%. the largest cases operated were by lee et al, 17 who operated on 210 cases with a success of 93% at followup of 40.9 months. in the present audit, which included 123 eyelids operated by mlr, success rate was 90.1 % after 6 month to 5 years followup. these results are comparable to the above mentioned studies. both fs and mlr have postoperative complications. in a study by gazzola r et al, 18 mlr had fewer complications as compared to fs. similar finding in favor of mlr was mentioned by young sm et al. 19 according to lee et al, 6 common postoperative complications were exposure keratopathy, lid crease asymmetry, entropion, overcorrection, eyelash ptosis, temporal eyelid droop, suture abscess and conjunctival prolapse. with proper followup, most of such complications can be managed. in our present audit, 12 cases had different complications. most common was, overcorrection and under correction. these cases were later managed with conservative treatment and secondary surgery performed to get satisfactory outcome. finally long-term followup is important in these cases as postoperative lagophthalmos is common, and needs to be treated at proper time. 20 lagophthalmos and exposure keratopathy are common problems after surgery. commonly known risk factors for lagophthalmos after levator surgery are the severity of the ptosis, lf, and degree of levator complex resection. 21,22 young sm et al, concluded that mlr was an effective alternative to fs in congenital ptosis with poor lf. 19 the risk of postoperative lagophthalmos was related to postoperative lid height rather than preoperative lf. no case of lagophthalmos developed significant exposure keratopathy in the present analysis. cases with mild lagophthalmos in initial postoperative period were advised lubricants and massage to reduce over correction. conclusion maximum levator resection for congenital severe ptosis is a safe and cosmetically acceptable procedure. followup is important to address postoperative complications at an early time to improve success rate of surgery. ethical approval the study was approved by the institutional review board/ethical review board (ref: no.14). conflict of interest authors declared no conflict of interest. references 1. koka k, patel bc. ptosis correction. in: statpearls. treasure island (fl): statpearls publishing; 2021 jan–. pmid: 30969650. 2. yadegari s. approach to a patient with blepharoptosis. neurol sci. 2016; 37 (10): 1589-1596. doi: 10.1007/s10072-016-2633-7. 3. marenco m, macchi i, macchi i, galassi e, massaro-giordano m, lambiase a. clinical presentation and management of congenital ptosis. clin ophthalmol. 2017; 11: 453-463. doi: 10.2147/opth.s111118. 4. zikić z, ljutica m, karabeg r, stamenkovic m. outcomes of early correction of congenital myogenic ptosis using transconjunctival levator plication. med arch. 2020; 74 (3): 205-209. doi: 10.5455/medarh.2020.74.205-209. 5. lee jh, kim yd. surgical treatment of unilateral severe simple congenital ptosis. taiwan j ophthalmol. 2018; 8 (1): 3-8. doi: 10.4103/tjo.tjo_70_17. 6. lee jh, aryasit o, kim yd, woo ki, lee l, johnson on 3rd. maximal levator resection in unilateral congenital ptosis with poor levator function. br j ophthalmol. 2017; 101 (6): 740-746. doi: 10.1136/bjophthalmol-2016-309163. 7. jubbal kt, kania k, braun tl, katowitz wr, marx dp. pediatric blepharoptosis. semin plast surg. 2017; 31: 58–64. 8. shah kp, mukherjee b. efficacy of frontalis suspension with silicone rods in ptosis patients with poor bell's phenomenon. taiwan j ophthalmol. 2017; 7 (3): 143-148. doi: 10.4103/tjo.tjo_36_17. 9. bernardini fp. supramaximal levator resection for poor function congenital ptosis, ophthal plast reconstr surg. 2019; 35 (5): e126. doi: 10.1097/iop.0000000000001341 10. rakha tm, el saadani aeki, awara am, mandour ss. evaluation of intraoperative lagophthalmos formula for levator resection in congenital ptosis in egyptian patients. eur j ophthalmol. 2020 aug. 17: 1120672120951760. doi: 10.1177/1120672120951760. outcomes of maximum levator resection in severe upper eyelid ptosis at a tertiary oculoplastic service pak j ophthalmol. 2022, vol. 38 (1): 43-47 47 11. cruz aa, akaishi pm, mendonça ak, bernadini f, devoto m, garcia dm, et al. supramaximal levator resection for unilateral congenital ptosis: cosmetic and functional results. ophthal plast reconstr surg. 2014; 30: 366-371. 12. mauriello ja, wagner rs, caputo ar, natale b, lister m. treatment of congenital ptosis by maximal levator resection. ophthalmology, 1986; 93: 466-469. 13. press up, hübner h. maximal levator resection in the treatment of unilateral congenital ptosis with poor levator function. orbit, 2001; 20: 125-129. 14. al-mujaini a, wali uk. total levator aponeurosis resection for primary congenital ptosis with very poor levator function. oman j ophthalmol. 2010; 3: 122-125. 15. decock ce, shah ad, delaey c, forsyth r, bauters w, kestelyn p, et al. increased levator muscle function by supramaximal resection in patients with blepharophimosis-ptosis-epicanthus inversus syndrome. arch ophthalmol. 2011; 129: 1018-1022. 16. mete a, cagatay hh, pamukcu c, kimyon s, saygılı o, güngör k, et al. maximal levator muscle resection for primary congenital blepharoptosis with poor levator function. semin ophthalmol. 2017; 32: 270-275. 17. lee jh, aryasit o, kim yd, woo ki, lee l, johnson on 3rd, et al. maximal levator resection in unilateral congenital ptosis with poor levator function. br j ophthalmol. 2017; 101: 740-746. 18. gazzola r, piozzi e, vaienti l, wilhelm baruffaldi preis f. therapeutic algorithm for congenital ptosis repair with levator resection and frontalis suspension: results and literature review. semin ophthalmol. 2018; 33 (4): 454-460. doi: 10.1080/08820538.2017.1297840. 19. young sm, imagawa y, kim yd, park jw, jang j, woo ki. lagophthalmos after congenital ptosis surgery: comparison between maximal levator resection and frontalis sling operation. eye (lond). 2021; 35 (4): 1261-1267. doi: 10.1038/s41433-020-1081-z. 20. mokhtarzadeh a, bradley ea. safety and long-term outcomes of congenital ptosis surgery: a populationbased study. j pediatr ophthalmol strabismus, 2016; 53 (4): 212-217. doi: 10.3928/01913913-20160511-02. 21. berry-brincat a, willshaw h. paediatric blepharoptosis: a 10-year review. eye, 2009; 23: 1554– 1559. 22. iljin a, loba a, omulecki w, zielin ˜ski a. congenital blepharoptosis: part i. evaluation of the results of surgical treatment for congenital blepharoptosis. acta chir plast. 2003; 45: 8–12. authors’ designation and contribution mohammad idris; assistant professor: concepts, design, literature search, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. hassan yaqoob; associate professor: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing. hadia sabir; trainee: literature search, data acquisition, statistical analysis, manuscript preparation, manuscript editing. hera fahim; trainee: literature search, data acquisition. muhammad jamshed; trainee: data analysis, manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (4): 352-355 352 original article relationship between hba1c levels and severity of diabetic retinopathy saima jamshaid 1 , ayesha hanif 2 , irfan qayyum malik 3 , nukhba zahid 4 , hafiza sadia imtiaz 5 1-5 department of ophthalmology, dhq teaching hospital, gujranwala abstract purpose: to determine the relationship between hba1c and severity of retinopathy in diabetic patients. study design: cross sectional study. place and duration of study: eye department of dhq-uth gujranwala, from july 2020 to dec 2020. methods: an observational cross-sectional study including 100 patients was conducted at eye department of dhq-uth gujranwala from january 2018 to december 2018. after approval from institutional review board, written informed consent with demographic variables was collected from every patient. patients of either gender between 40-80 years of age with both types i and type ii diabetes were included in this study. complete ophthalmic examination including best corrected visual acuity, slit lamp biomicroscopy, goldmann applanation tonometry and fundus examination carried out. diabetic retinopathy was classified from grade 0 to grade 5. results: out of 100 patients, 46 (46%) were males and 54 (54%) were females. mean age was 60 ± 2.4 years with a range of 40 – 80 years among males and 40 – 70 years among females. forty patients presented with grade 1 diabetic retinopathy and 4% presented with grade 5. thirty two patients had good glycemic control while 20% had glycemic control of grade iii. patients with grade 4 diabetic retinopathy had the worst glycemic control of hba1c level of 11.5. conclusion: this study concluded that patients with poor glycemic control had severe diabetic retinopathy as compared to the patients with good diabetic control. there is a direct relation between hba1c level and severity of diabetic retinopathy. key words: hba1c, diabetic retinopathy, non proliferative diabetic retinopathy, proliferative diabetic retinopathy, vitreous hemorrhage. how to cite this article: jamshaid s, hanif a, malik iq, zahid n, imtiaz hs. relationship between hba1c levels and severity of diabetic retinopathy. pak j ophthalmol. 2021, 37 (4): 352-355. doi: 10.36351/pjo.v37i4.1210 introduction diabetes mellitus is a metabolic syndrome characterized by an absolute or relative lack of insulin. it can damage every organ system of body causing correspondence: saima jamshaid department of ophthalmology dhq teaching hospital, gujranwala email: drsaimali@yahoo.com received: january 24, 2021 accepted: september 03, 2021 impaired quality of life and burden to local community and economy. 1 according to global data, 451 million people were suffering from diabetes mellitus in 2017, which is expected to increase to 693 million by 2045. 2 diabetic retinopathy is a very common complication of diabetes mellitus. it is the leading cause of blindness in working age group of 20 – 65 years. 3 diabetic retinopathy is present in up to 40% of both type i and type ii diabetic patients while type 1 patients are affected more. 4 proliferative diabetic retinopathy affects 5 – 10% of diabetic patients. severity of diabetic retinopathy open access saima jamshaid, et al 353 pak j ophthalmol. 2021, vol. 37 (4): 352-355 depends upon many factors e.g. duration of diabetes, glycemic control, hypertension, nephropathy, smoking and cataract surgery etc. 5-8. another important factor which has a strong relationship with progression of diabetic retinopathy is microalbuminuria. microalbuminuria of higher grades pose a great risk factor for severity of diabetic retinopathy. 9 in this study we reported relationship of severity of diabetic retinopathy with glycemic control via hba1c level. regarding treatment of proliferative diabetic retinopathy and macular edema, lasers, intraocular steroid and anti vascular endothelial growth factor injection are less destructive to retina than lasers. 10 this study was carried out at a tertiary care hospital to find out a relationship between the control of diabetes and severity of diabetic retinopathy. methods after approval from institutional review board, written informed consent was taken and demographic data was collected. patients of either gender between 40 – 80 years of age with both type i and type ii diabetes were included in this study. across-sectional study including 100 patients was conducted at eye department of dhq-uth gujranwala from january 2018 to december 2018. complete ocular examination including best corrected visual acuity, slit lamp biomicroscopy, goldmann applanation tonometry and ophthalmoscopy was carried out. diabetic retinopathy was classified from grade 0 to grade 5 as follow; grade 0 no diabetic changes grade 1 mild to moderate npdr grade 2 npdr with csme grade 3 pdr grade 4 advanced dr (rd + vit hge) grade 5 nerve palsies, crvo, crao hba1c levels were classified in 3 grades as follow; grade i 5 – 8 grade ii 8 – 12 grade iii 12 – 15 data was collected on specially designed proforma and analyzed using spss version 20. frequency and percentages were used for categorical data while mean ± sd was determined for numerical data. results out of 100 patients, 46% were males and the remaining 54% were females. mean age was 60 ± 2.4 years. figure 1 shows a bar chart with number of patients on y-axis with diabetic retinopathy grades on x-axis. maximum number of patients presented with grade 1 (40%) while minimum number of patients presented with grade 5diabetic retinopathy (4%). figure 1: number of patients with different grades of diabetic retinopathy. table 1: hba1c and severity of diabetic retinopathy. hba1c grading total no. of patients diabetic retinopathy severity grade – i (5 – 8) 32 (32%) grade 0 = 5% grade 1 = 13% grade 2 = 6% grade 3 = 3% grade 4 = 5% grade 5 = 0% grade – ii (8 – 12) 48 (48%) grade 0 = 0% grade 1 = 24% grade 2 = 13% grade 3 = 7% grade 4 = 3% grade 5 = 1% grade – iii (12 – 15) 20 (20%) grade 0 = 0% grade 1 = 3% grade 2 = 6% grade 3 = 4% grade 4 = 4% grade 5 = 3% patients were also divided according to their glycemic control with 32% having good glycemic control of grade i, 48% with poor glycemic control of grade ii and 20% with worst glycemic control of grade iii (table 1). correlation between diabetic retinopathy grading and hba1c levels was also assessed and documented relationship between hba1c levels and severity of diabetic retinopathy pak j ophthalmol. 2021, vol. 37 (4): 352-355 354 by line chart, which showed that patients with grade 4 diabetic retinopathy had the worst glycemic control of 11.5 hba1c level (figure 2). figure 2: correlation between diabetic retinopathy grading and hba1c levels. discussion diabetic retinopathy is a serious cause of blindness causing a major burden to ophthalmic society. it is very important to determine the risk factors exacerbating the progression of diabetic retinopathy. in this study, we have evaluated the relationship between hba1c levels and severity of diabetic retinopathy. hba1c levels depict glycemic control of diabetic patient which is very important factor towards development and progression of diabetic retinopathy. 11,12 maximum number of male patients were between 51 – 55 years of age while in female group, maximum number of patients were in 46 – 50 years of age depicting an earlier age of presentation among females. a similar study was carried out in indian population and it reported higher prevalence in males (68%) compared to females (32%) and majority of their patients belonged to 61 – 70 years of age. 13 in our study, most patients presented with grade 1 diabetic retinopathy that is mild to moderate npdr making up of 40% of total patients. total patients belonged to npdr grade were 65% while to pdr grade were only 14%. these values are comparable with findings of sewak et al. while determining the association of hba1c levels with severity of diabetic retinopathy. 14 out of 100 patients, only 5 patients presented with grade 0(no dr) and grade 1 hba1c levels with mean value of 5.7% that is slightly lower than the cut-off value determined by a study carried out on 3403 adults in south korea. 15 mostly of the patients with npdr (grade 1 and grade 2) had hba1c levels of grade 2 (8 – 12). majority of the patients with grade 5 diabetic retinopathy had hba1c levels of grade iii (12 – 15). prasad et al. reported mean hba1c levels of 9.25 + 1.59 and revealed an increasing trend in the severity of retinopathy with a rise in hba1c levels. 16 a similar study was carried out in saudi arabia and it concluded that patients who had uncontrolled diabetes (high hba1c levels) had 66.61% chance of developing diabetic retinopathy. 17 relationship between diabetic retinopathy and hba1c levels showed that severity of retinopathy increased as hba1c levels were raised and this is also supported by many other similar studies. 18-21 a study conducted by rebecka andreasson et al in sweden showed similar results in children with type 1 diabetes. increase in hba1c levels corresponded to the severity of diabetic retinopathy. 22 in another study conducted in china by valencia foo et al, showed that increase in hba1c levels and systolic bp was directly related to severity of diabetic retinopathy in type 2 diabetes. 23 limitations of this study are that it was a single center study with limited number of patients. multicenter study is suggested to further support relationship of hba1c levels and severity of diabetic retinopathy. conclusion patients with poor glycemic control have severe diabetic retinopathy as compared to patients with good diabetic control. it suggests a direct relationship between hba1c level and severity of diabetic retinopathy. ethical approval the study was approved by the institutional review board/ethical review board. (admn.292/gmc) conflict of interest authors declared no conflict of interest. references 1. alrashedi m, alshaban j, alshamdin t, alharbi m, morsi o, alharby m. the incidence of diabetic retinopathy in diabetic patients attending the ophthalmic clinic in khayber general hospital, medinah region. intern j med developing countries, 2019: 289-293. saima jamshaid, et al 355 pak j ophthalmol. 2021, vol. 37 (4): 352-355 2. shah a. prevalence of diabetic retinopathy in the united states, 2011 – 2014. value in health, 2016; 19 (3): a199. 3. cho n, shaw j, karuranga s, huang y, da rocha fernandes j, ohlrogge a, et al. idf diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. diab res clin pract. 2018; 138: 271-281. 4. nojomi m. study of diabetic retinopathy and its risk factors in diabetic patients, ahvaz, iran. j diab metab. 2016; 07 (09). 5. shrote a. clinical evaluation of correlation between diabetic retinopathy with modifiable, non-modifiable and other independent risk factors in tertiary set-up in central rural india. j clin diag res. 2015; 9 (10): 10-14. 6. rawat d. retinopathy and its associated factors in type 2 diabetes mellitus in rural population of central india. j med sci clin res. 2019; 7 (6): e69. 7. phillips k, clarke-farr p, matsha t, meyer d. biomarkers as a predictor for diabetic retinopathy risk and management: a review. african vis eye health, 2018; 77 (1): 1-5. 8. niveditha h, yogitha c, liji p, sundeep shetty, n.v.v. himamshu, vinutha bv, et al. clinical correlation of hba1c and diabetic nephropathy with diabetic retinopathy. j evol med dent sci. 2013; 2 (49): 9430-9435. 9. garg p, misra s, yadav s, singh l. correlative study of diabetic retinopathy with hba1c and microalbuminuria. intern j ophth res. 2018; 4 (2): 282-286. 10. cheung n, mitchell p, wong ty. diabetic retinopathy. lancet, 2010; 376 (9735): 124-136. doi: 10.1016/s0140-6736(09)62124-3. epub 2010 jun 26. 11. kim y, kim j, lee j, lee k, joe s, park j, et al. development and progression of diabetic retinopathy and associated risk factors in korean patients with type 2 diabetes: the experience of a tertiary center. j korean med sci. 2014; 29 (12): 1699-1705. 12. bagzai d. correlation between severity of diabetic retinopathy with hba1c in type ii diabetic patients. j med sci clin res. 2019; 7 (3). 13. lokesh s, shiwaswamy s. study of hba1c levels in patients with type 2 diabetes mellitus in relation to diabetic retinopathy in indian population. intern j adv med. 2018; 5 (6): 1397-1401. 14. sewak s, solanki y, gupta c. association of level of hba1c with severity of diabetic retinopathy. j med sci clin res. 2018; 6 (1): 32538-32543. 15. cho n, kim t, woo s, park k, lim s, cho y, et al. optimal hba1c cutoff for detecting diabetic retinopathy. acta diabetologica, 2013; 50 (6): 837-842. 16. prasad r, nayana g. association of diabetic retinopathy in type ii diabetes mellitus with hba1c levels: a study. iosr j dent med sci. 2016; 15 (07): 48-53. 17. alabdulwahhab k. relationship between diabetic retinopathy and hba1c in type 2 diabetics, kingdom of saudi arabia. j res med dent sci. 2019; 7 (5): 1-4. 18. parasar v, mohan n, kumari r, sinha b. to evaluate the relationship of hba1c levels and serum magnesium in patients with type ii diabetes and its correlation with diabetic retinopathy. j med sci clin res. 2019; 7 (7): 277-281. 19. sigamani v, devi kanagaraj n, kuppuswamy rajagantham v. the association between poor glycaemic control (hba1c levels ≥ 7%) and higher incidence of diabetic retinopathy in small group of type 2 diabetes mellitus patients attending mahatma gandhi memorial government hospital, trichy. j evo med dent sci. 2017; 6 (66): 4761-4764. 20. memon wr, lal b, sahto aa. diabetic retinopathy; frequency at level of hba1c greater than 6.5%. prof med j. 2017; 24 (02): 234-238. 21. hoque s, muttalib m, islam m, khanam p, choudhury s. evaluation of hba1c level and other risk factors in diabetic retinopathy: a study of type 2 diabetic patients attending in a tertiary level hospital. kyamc journal, 2017; 6 (2): 614-619. 22. andreasson r, ekelund c, landin-olsson m, nilsson c. hba1c levels in children with type 1 diabetes and correlation to diabetic retinopathy. j pediatr endocrinol metab. 2018; 31 (4): 369-374. doi: 10.1515/jpem-2017-0417 23. foo v, quah j, cheung g, tan nc, ma zar kl, chan cm, et al. hba1c, systolic blood pressure variability and diabetic retinopathy in asian type 2 diabetics. j diabetes, 2017; 9 (2): 200-207. doi: 10.1111/1753-0407.12403. authors’ designation and contribution saima jamshaid; consultant ophthalmologist: concepts, literature search, data analysis, statistical analysis, manuscript preparation. ayesha hanif; senior registrar: manuscript review. irfan qayyum malik; associate professor: design, manuscript review. nukhba zahid; women medical officer: data acquisition. hafiza sadia imtiaz; postgraduate trainee: manuscript editing. .…  …. 112 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology case report kayser-fleischer rings in wilson’s disease hannan masud, tariq bashir pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hannan masud classified ophthalmologist combined military hospital pano aqil, sindh …..……………………….. purpose: the kayser fleischer ring is the hallmark of wilson’s disease. we present a case of wilson’s disease with neurological manifestations and kayserfleischer ring without chronic hepatic involvement. material and methods: a male patient, 31 years of age, presented with two weeks history of difficulty in speaking and tremors of hands. he was married and had two healthy daughters. his parents were alive and healthy. he was conscious, well oriented and had stable vital signs. neurological examination revealed mask like facies with a vacuous smile, dysarthria and bradykinesia. kayser – fleisher rings were seen on slit lamp examination. there was no clinical evidence of chronic liver disease. the laboratory investigations showed haemoglobin 13.9 g/dl, platelet count 161x10 9 /l, wbc 6.5x10 9 /l, serum alt 17 u/l ( 9-43 u/l), serum alkaline phosphatase 332 u/l (80-306 u/l), total bilirubin 23 umol/l (<19 umol/l), urea 4.4 mmol/l (3.2-6.7 mmol/l) and creatinine 105 umol/l (53-120 umol/l). serum ceruloplasmin was 10 mg/dl (19-57 mg/dl). mri brain showed hyperintense signals in caudate nuclei, lentiform nuclei, thalami and brainstem on t2w images and flair. result: a diagnosis of wilson’s disease was made and penicillamine (vistamine) with oral zinc was started. follow up after 3 months showed improvement in clinical features and laboratory results. follow up planned at 6 months and 12 months after treatment. conclusion: a high index of suspicion is required for early detection of wilson’s disease in adolescents and young adults with neurological disorders. initiation of treatment at an early stage can prevent complications. ilson’s disease (hepatolenticular degeneration) is an autosomal recessive disease of copper metabolism due to mutation in atp7b gene1,2. the genetic defect causes excessive copper accumulation in the liver, brain and other body tissues. the prevalence of wilson’s disease is one in 30,000 people worldwide and corresponding carrier frequency is one in 903. clinically, it presents as liver disease or neurological / neuropsychiatric disorder in different age groups (table 1)4. it manifests as liver disease in children and young adults, typically between the ages of 6 and 45 years. neurological and psychiatric symptoms are seen in adults in their twenties and older5,6. the identification of kayser – fleischer ring is helpful in the diagnosis of wilson’s disease. patients suspected of this disease are referred to ophthalmologist for identification of kayser – fleischer ring by slit-lamp examination and gonioscopy. it is a rare disease and few ophthalmologists have ever seen a true kayser – fleischer ring. it is reported that often the kayser – fleischer rings of one patient are seen by multiple ophthalmologists in the department, so the total number of patients diagnosed is less than the total number of reported cases seen7. we present a case of wilson’s disease with neurological manifestations and kayser – fleischer ring without chronic hepatic involvement. this case has classic clinical features of the disease and typical w kayser-fleischer rings in wilson’s disease pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 113 kayser – fleischer rings in the cornea. the ophthalmologist has an important role in identification of this disease in suspected cases but he is not directly involved in the treatment of such cases. it is considered appropriate to report this case and discuss clinical features, current status of management and prognosis of the disease so that they feel confident in management of this disease. fig. 1: a mask like facies with a vacuous smile, dysarthria and bradykinesia. fig. 2: arrows indicate greenish brown kayser fleisher ring in descemet membrane of cornea. case report a male patient, 31 years of age, presented with two weeks history of difficulty in speaking and tremors of hands. he was married and had two healthy daughters. his parents were alive and healthy. he was conscious, well oriented and had stable vital signs. neurological examination revealed mask like facies with a vacuous smile, dysarthria and bradykinesia (fig 1). kayser fleisher rings were seen on slit lamp examination (fig. 2). there was no clinical evidence of chronic liver disease. the laboratory investigations showed haemoglobin 13.9 g/dl, platelet count 161 × 109/l, wbc 6.5 × 109/l, serum alt 17 u/l (9 43 u/l), serum alkaline phosphatase 332 u/l (80 306 u/l), total bilirubin 23 umol/l (< 19 umol/l), urea 4.4 mmol/l (3.2 6.7 mmol/l) and creatinine 105 umol/l (53 120 umol/l). serum ceruloplasmin was 10 mg/dl (19 57 mg/dl). mri brain showed hyper intense signals in caudate nuclei, lentiform nuclei, thalami and brainstem on t2w images and flair (fig. 3). a diagnosis of wilson’s disease was made and penicillamine (vistamine) with oral zinc was started. follow up after 3 months showed improvement in clinical features, serum alkaline phosphatase 309 u/l (80 306 u/l), total bilirubin 21 (< 19 umol/l), urea 4.3 mmol/l (3.2 6.7 mmol/l) and creatinine 96 umol/l (53 120 umol/l) and serum ceruloplasmin was 11.9 mg/dl (19 57 mg/dl). follow up planned at 6 months and 12 months after treatment. fig. 3: mri brain shows hyperintense signals in caudate nuclei, lentiform nuclei, thalami and brainstem on t2 w images and flair. discussion samuel alexander kinnier wilson (1878 1937) described this condition in 1912. the neurological form of wilson’s disease is also known as westphal strumpell pseudosclerosis. hannan masud, et al 114 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology table 1: clinical features in wilson’s disease 3 hepatic asymptomatic hepatomegaly splenomegaly persistently elevated serum aminotransferase activity (ast, alt) fatty liver acute hepatitis / resembling autoimmune hepatitis cirrhosis: compensated or decompensated acute liver failure neurological movement disorders (tremor, involuntary movements) drooling, dysarthria rigid dystonia pseudobulbar palsy dysautonomia migraine headaches seizures psychiatric depression neurotic behaviours / psychosis personality change other symptoms ocular: kayser fleischer rings, sunflower cataracts cutaneous: lunulae ceruleae renal abnormalities: aminoaciduria & nephrolithiasis skeletal abnormalities: premature osteoporosis and arthritis pancreatitis hypothyroidism menstrual irregularities: infertility, repeated miscarriages wilson’s disease manifests as neurological disease in adults8. it can present as movement disorders or rigid dystonias. movement disorders appear earlier as tremors, poor coordination, loss of fine-motor control, micrographia, chorea and / or choreoathetosis. spastic dystonia disorder manifests as mask-like facies, rigidity and gait disturbances5. pseudobulbar involvement is more common in older individuals and presents as dysarthria, drooling and difficulty in swallowing. table 2: diagnostic tests of wilson’s disease 12 kayser-fleischer rings low serum ceruloplasmin levels (<0.20 g/l, normal is 0.20 to 0.40 g/l) 24 hour urinary copper excretion (>100 µg/day or 1.0 mol/day) 24 hour urinary copper excretion after dpenacillamine (>25 mol/day) hepatic copper level on liver biopsy (>250 µg/g dry weight, normal is< 50 µg/g dry weight) genetic mutation in atp7b gene the neurologic findings in patients with hepatic presentation may be subtle. mood disturbance, depression and changes in school performance may be observed5. the psychiatric manifestations are variable. pure psychotic disorders are uncommon. the kayser – fleischer ring is the hall mark of wilson’s disease9. the copper deposition in descemet’s membrane of the cornea appears as kayser-fleischer ring and indicates a high level of copper in the body10. it appears as a golden brown ring in the peripheral cornea, extending from schwalbe’s line to less than 5 mm on to the cornea. it can be greenish yellow, ruby red or bright green in colour. it is almost always bilateral. initially, it appears superiorly, then inferiorly, and later becomes circumferential. gonioscopy is often required in early stages of disease but it can be seen in torch light in advanced disease. it is seen in about 85 – 100% patients with neurological and/or psychiatric manifestations, 33 – 86% patients with hepatic disease and up to 59% in asymptomatic patients11. with treatment, it disappears in 85 – 90% of patients12,13. sunflower cataract appears as a late manifestation of neurological form of wilson’s disease. in torch light, it appears as greenish disc in the centre of the pupil and on slit – lamp examination, it appears as brown / green pigmentation of the anterior and posterior lens capsule14. the presence of kayser-fleischer rings, neurological symptoms and low serum ceruloplasmin are considered diagnostic of wilson’s disease15. further tests are advised where indicated (table 2)7. wilson’s disease is suspected in close relatives of the patient kayser-fleischer rings in wilson’s disease pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 115 and relevant clinical feature. in neurolocial symptoms, mri brain shows hyperintensities in the basal ganglia in the t2 setting. it may show the characteristic 'face of the giant panda’ sign16. liver biopsy is the gold standard test and more than 250ug of copper per gram of dried liver tissue confirms wilson’s disease. mutation analysis of the atp7b gene may be performed1,2. if confirmed, family members can be screened as part of clinical genetic family counseling. these patients are advised to take a diet low in copper – containing foods and avoid mushrooms, nuts, chocolates, dried fruits, liver and shell fish. they need a life-long treatment and it should not be discontinued. symptomatic patients are treated with chelating agents17,18. penicillamine is advised as tablet d-penicillamine by mouth 2 or 3 times a day19. pyridoxine must be given with it. full blood count and urinalysis is monitored regularly. 24 hours urinary copper values should be 5 – 10 times normal to confirm chelation and increased urinary excretion of copper. lower values suggest non-compliance or body stores may have been adequately depleted. serious side effects are seen in up to 30% patients and include severe thrombocytopenia, leucopenia, aplastic anemia, proteinuria, nephritic syndrome, polyserositis, goodpasture syndrome and severe skin reactions. if side effects occur, tablet d-penicillamine is substituted with tablet trientine hydrochloride as an alternate treatment. if it is not available, these adverse events might be manageable with co-administration of steroids. almost 50% patients with neurological disorder experience a paradoxical worsening in their symptoms with penicillamine. once laboratory investigations are within normal limits, zinc therapy is given to maintain stable copper levels20. tablet zinc acetate (galzin) is advised at least 2 – 3 time daily before meals. it stimulates metallothionein which is a protein in gut cells that binds copper and prevents its absorption and transport to the liver. the kayser – fleischer rings can be identified accurately by an ophthalmologist by using a slit lamp. the presence of kayser-fleischer rings, neurological symptoms and low serum ceruloplasmin are helpful in diagnosis of wilson’s disease. a high index of suspicion is required for early detection of wilson’s disease in adolescents and young adults with neurological disorders. initiation of treatment at an early stage can prevent complications. author’s affiliation dr. hannan masud classified ophthalmologist cmh pano aqil sindh dr. tariq bashir classified medical specialist cmh pano aqil sindh references 1. gromadzka g, schmidt hh, genschel j, bochow b, rodo m, tamacka b, litwin t, chabik g, czlonkowska a. p.h1069q mutation in atp7b and biochemical parameters of copper metabolism and clinical manifestation of wilson’s disease. mov disord. 2006; 21: 245-8. 2. huster d, kühne a, bhattacharjee a, raines l, jantsch v, noe j, schirrmeister w, sommerer i, sabri o, berr f, mössner j, stieger b, caca k, lutsenko s. diverse functional properties of wilson disease atp7b variants. gastroenterology. 2012; 142: 947-56. 3. olivarez l, caggana m, pass ka, ferguson p, bremer gj. estimate of the frequency of wilson’s disease in the us caucasian population: a mutation analysis approach. ann hum genet. 2001; 65: 459-63. 4. roberts ea, schilsky ml. diagnosis and treatment of wilson disease: an update. hepatology. 2008; 47: 2089–211. 5. coffey aj, durkie m, hague s, mclay k, emmerson j, lo c, klaffke s, joyce cj, dhawan a, hadzic n, mieli-vergani g, kirk r, elizabeth allen k, nicholl d, wong s, griffiths w, smithson s, giffin n, taha a, connolly s, gillett gt, tanner s, bonham j, sharrack b, palotie a, rattray m, dalton a, bandmann o. a genetic study of wilson's disease in the united kingdom. brain. 2013; 136: 1476-87. 6. kumar mk, kumar v, singh pk. wilson’s disease with neurological presentation, without hepatic involvement in two siblings. j clin diagn res. 2013; 7: 1476-8. 7. birkholz es, oettingta. kayser-fleischer ring: a systems based review of the ophthalmologist’s role in the diagnosis of wilson’s disease. eye rounds.otg. 2009. 8. svetel m, kozic d, stefanova e, semnic r, dragasevic n, kostic vs. dystonia in wilson’s disease. mov disord. 2001; 16: 719-23. 9. liu m, cohen ej, brewer gj, laibon pr. kayser fleischer ring as the presenting sign of wilson disease. am j 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disease. hepatology. 1992; 15: 609-61. 16. kuruvilla a, joseph s. 'face of the giant panda' sign in wilson's disease revisited. neurol india. 2000; 48: 395. 17. roberts ea, schilsky ml. diagnosis and treatment of wilson’s disease: an update. hepatology. 2008; 47: 2089-111. 18. european association for study of liver; easl clinical practice guidelines: wilson’s disease. j hepatol. 2012; 56: 67185. 19. durand f, bernuau j, giostra e, mentha g, shouval d, degott c, benhamou jp, valla d. wilson’s disease with severe hepatic insufficiency: beneficial effects of early administration of d-penicillamine. gut. 2001; 48: 849-52. 20. brewer gj. zinc acetate for the treatment of wilson’s disease. expert opin pharmacother. 2001; 2: 1473-7. 24 pak j ophthalmol. 2021, vol. 37 (1): 24-28 original article preferences and trends in management of rhegmatogenous retinal detachment in pakistan muhammad amer awan 1 , javeria muid 2 1 department of ophthalmology, shifa international hospital h-8/4 islamabad 2 royal victoria eye and ear hospital, dublin ireland abstract purpose: to report the preferences and trends in managing rhegmatogenous retinal detachment (rrd) in pakistan. study design: cross sectional survey. place and duration of study: shifa international hospital, islamabad, from december 2018 to january 2019. method: an online survey was conducted in which the practicing vitreoretinal (vr) surgeons, who were registered with vitreoretinal society of pakistan were included. they were asked to respond to 10 questions to assess their practice and management strategies in treating rrd. the survey included general questions regarding their primary practice, preference of anaesthesia and type of vitrectomy machine they used and specific questions consisting of different scenarios of rrd. results: sixty-two vr surgeons of pakistan responded to this survey. most of the vr surgeons belonged to punjab (56%) followed by sindh (25%). regarding their primary practice setting 50% of vr surgeons worked both in government and private practice, 30% practiced in academic/university hospital and 20% of them had only private practice. seventy percent of vr surgeons in pakistan preferred local anaesthesia. in non-posterior vitreous detachment (pvd) rrd, majority (69%) performed segmental buckling (sb) with or without encirclement. in pseudophakic superior macula on rrd with a single retinal tear 50% preferred pars plana vitrectomy (ppv) followed by sb in 25% and pneumatic retinopexy in 18%. in inferior macula off rrd with a retinal tear at 7 0’clock position, 56% of the vr surgeons performed ppv alone or combined with sb. conclusion: there is an increased trend towards ppv as a primary procedure for rrd in pakistani vr surgeons. local anaesthesia is the preferred anesthesia. key words: rhegmatogenous retinal detachment, retinal break, pars plana vitrectomy, pneumatic retinopexy. how to cite this article: awan ma, muid j. preferences and trends in management of rhegmatogenous retinal detachment in pakistan. pak j ophthalmol. 2021, 37 (1): 24-28. doi: https://doi.org/10.36351/pjo.v37i1.1157 introduction rhegmatogenous retinal detachment (rrd) is a sight correspondence: javeria muid royal victoria eye and ear hospital, dublin ireland email: javeriamuid90@hotmail.com received: november 3, 2020 accepted: november 26, 2020 threatening retinal condition that requires urgent management and can lead to blindness if left untreated. 1,2 prevalence of rrd is from 6.3 to 17.9 per 100,000 people per year and has a lifetime risk of 0.06% approximately. 3,4 there are various conditions that can lead to rhegmatogenous retinal detachment such as, tractional force of posterior vitreous detachment (pvd) that produces a retinal tear, allowing the fluid to access the sub retinal space through the break. 5 various predisposing factors are increasing age, previous cataract surgery, diabetes, https://doi.org/10.36351/pjo.v37i1.1157 preferences and trends in management of rhegmatogenous retinal detachment in pakistan pak j ophthalmol. 2021, vol. 37 (1): 24-28 25 blunt ocular trauma and myopia. 6,7,8,9 the main aim of treatment is to identify the retinal breaks, seal them (with laser photocoagulation/cryopexy) and release any traction on the edges of the breaks. 10 various treatment modalities are available for this purpose for example, pneumatic retinopexy (pr), scleral buckle (sb), pars plana vitrectomy (ppv) and combined sb and ppv. 11,12 these approaches are used throughout the world with the primary success rate of around 90%. 4 ppv is reported to be the most common method of rrd repair. a study showed the primary reattachment rate of 95.6% with 27g ppv for primary rrd. 12 the purpose of this survey was to report the current trends and preferences in managing different types of rrd in pakistan. we also aim to compare our national management trends with international standards. methods institutional review board and ethics committee at shifa tameer-e-millat university and shifa international hospital approved this study and the study was performed in accordance with the relevant guidelines and regulation. this was an online cross-sectional survey that involved the vitreo-retinal (vr) surgeons of pakistan. duration of the survey was one month from 16 th december 2018 to 15 th january 2019. the practicing vitreoretinal (vr) surgeons, who were registered with vitreoretinal society of pakistan were included. they were asked to respond to 10 questions to assess their practice and management strategies in treating rrd. the survey included general questions regarding their primary practice, preference of anaesthesia and type of vitrectomy machine they used and specific questions consisting of different scenarios of rrd and vr surgeons were asked to give their opinions in that specific scenario. the data was collected and analyzed using microsoft excel version 2016. qualitative variables were presented as frequency and percentages. results sixty-two vr surgeons responded to the survey questionnaire in the specified time from different areas of pakistan. fifty-six percent vr surgeons (34 of 62) who responded to the survey belonged to punjab, followed by sindh with 25% (15 of 62) and islamabad with 10% (6 of 62). regarding their primary practice setting, half of the total vr surgeons worked in both government and private practice, one third (18 of 62) practiced in academic/ university hospitals while, one fifth of them (13 of 62) had only private practice. furthermore, most of the surgeons preferred to perform rd surgery in local anaesthesia (70%). preferences about the type of vitrectomy machine being used by most of the surgeons revealed that constellation by alcon was the most popular choice (43%), being used by 27 surgeons, followed by dorc eva & associate in 12 out of 62 (28%) vr surgeons in pakistan. when asked about the preferences of procedure in different types of rrds. graph 1 shows the preferred choice of procedure in a 25 years old male patient with non-pvd, macula on rd, with multiple retinal holes anterior to equator in supero-temporal quadrant. segmental buckling was the preferred choice. fig. 1: second scenario included a patient with superior pseudophakic macula-on rd with a single retinal tear at 10 o’ clock anterior to equator, in 65 years old female with -2.5 myopia. graph 2 shows the response preference. third scenario was about the inferior macula-off rrd with a retinal tear at 7 o’clock in a 55-year old male. this question showed interestingly different results with no single popular choice by the vr surgeons. graph 3. muhammad amer awan, et al 26 pak j ophthalmol. 2021, vol. 37 (1): 24-28 fig. 2: fig. 3: the results also showed that the trend of performing sb has decreased as 75% of the respondents were doing scleral buckling in only 1120% of their patients with rrd. while 18% surgeons performed this procedure in 21-40% of their patients. preferred choice of tamponade in ppv for rrd with retinal tear in superior half was gas, being chosen by 60% vr surgeons (26% sf6, 26%c3f8 and 8% c2f6) and 30% used 1000 centistokes silicone oil. in rrd with breaks in inferior half, 74% preferred silicone oil (1000 centistokes, 5000 centistokes or densiron) and the remaining used medium (c2f6) or long acting gas (c3f8). discussion in this study, we described the recent preferences and trends in the management of rrd in pakistan. ppv is becoming the most popular choice to treat different types of rrd throughout pakistan as well as internationally. it has gained worldwide popularity due to variety of reasons. recent developments and advancements in mechanical and technical fields such as micro incision vitrectomy systems, high speed cutters, wide angle viewing systems and utilization of perfluorocarbon liquids led to better visibility and fewer complications in retinal reattachment surgery in comparison to the past decade. in modern training programs retinal surgeons are getting more exposure to ppv that has made them more comfortable with ppv than sb. on the other hand, the indications for ppv have been expanded to include spectrum of vitreo retinal diseases such as macular hole, epiretinal membrane and diabetic retinopathy whereas sb is only performed in rrd. the appropriate treatment depends upon various factors such as: age of the patient, presence of pvd, complexity of detachment, whether breaks are anterior or posterior and surgeon's preference as well. 13 in simple detachment sb, pr and ppv are options depending on pvd and complex detachments require internal surgical approach. 14 a study in us, in which 12779 patients of rrd were evaluated, it was found that treatment approaches were not only decided on the basis of patient-level characteristics but physician variations also made a huge difference. geographical variations least affected the management approach. 15 in 2012 us medicare survey showed that 74%, 11% and 15% of primary rrd were repaired by ppv, sb and pr respectively. 16 the preferences and trends (pat) survey of 2015 showed that 67% of the vitreoretinal surgeons placed sb in 11% of rrds, while 24% placed sb in 41% rrds. 17 fischer et al. did a survey in august 2018 and showed that the surgeons were less willing to perform sb when multiple co-factors were present. 18 for example, if two adjacent retinal breaks were present which could still be treated with sb only approximately 57% would perform sb while the rest would simply go for ppv. 18 they also compared their results with a survey done in 2001 which showed that there was a marked increase in trend towards ppv even in pseudophakic eyes. we also compared our results with the international studies. regarding superior rrd, in preferences and trends in management of rhegmatogenous retinal detachment in pakistan pak j ophthalmol. 2021, vol. 37 (1): 24-28 27 korean study 74% surgeons chose to do sb, 16% preferred pr and 10% went for ppv in 2013. 19 in american society of retina specialists survey, only 6% would do sb, 68% of them favored ppv followed by pr in 26%. 20 our survey has shown that ppv was the preferred choice in pakistan. however, one fourth of the respondents would do sb in our study. eibenberger et al also stated that from 2009 to 2015 there was an increased trend towards performing ppv in primary rrds as is seen in our survey in the case of pvd related rrds. 20 minihen et al. retrospectively compared rrd surgeries, performed 20 years apart, in a single center located in london, uk. 21 they reported that 63% patients with primary rrd were treated by ppv in 1999; in contrast, only one case was managed by ppv in 1979 and 1980. in contrast to this, with latest developments in cutters, fluidics and adjuncts, there is marked shift towards vitrectomy in simple and complex rrd. on comparison with international trends shown by international surveys, there are some similarities as well as few differences. popularity of pr is decreasing in recent times even in the case of uncomplicated primary rrd that was previously considered as a good indication. pr has few advantages over other procedures i.e. ppv and sb. these include shorter operating time, cost-effectiveness and availability as an outpatient-based procedure. the disadvantage of this procedure is that it is mandatory to have a second retinopexy procedure, such as laser photocoagulation. furthermore, it requires maintaining a certain posture after the procedure for at least several days or weeks which can be very difficult for old, asthmatic and obese patients. moreover, missed or new breaks and higher probability of needing a second operation decreased its popularity. there are some limitations of the study. there was a selection bias as all the respondents were the member of pakistan vitreo-retinal society. furthermore, not all members of vitreoretinal society responded in the given duration. in addition, the scenarios presented were simple rrd with location of breaks either in upper half or lower half of retina; however, in real world, there are variety of clinical variables in an eye with rrd. adding on, we did not include questions regarding the complications during or after the surgery, rate of reattachment after first surgery and rrd surgery in children. in future we can have participation of more vr surgeons and this data will be available for comparison. conculsion there is an increased trend towards ppv as a primary procedure for rrd. most of the vr surgeons in pakistan prefer local anaesthesia over general anaesthesia. in non-pvd rd, sb is preferred by most of vr surgeons. however, in superior rd with pvd, ppv is considered as a procedure of choice and gas is selected as a preferred tamponade. in inferior rd most of the respondents preferred silicone oil. ethical approval the study was approved by the institutional review board/ ethical review board. (167-987-2020) conflict of interest authors declared no conflict of interest references 1. lumi x, lužnik z, petrovski g, petrovski bé, hawlina m. anatomical success rate of pars plana vitrectomy for treatment of complex rhegmatogenous retinal detachment. bmc ophthalmology, 2016; 16 (1): 216. 2. feltgen n, walter p. rhegmatogenous retinal detachment—an ophthalmologic emergency. dtsch ärzteblint. 2014; 111 (1-2): 12. 3. nemet a, moshiri a, yiu g, loewenstein a, moisseiev e. a review of innovations in rhegmatogenous retinal detachment surgical techniques. j ophthalmol. 2017; 2017: 4310643. 4. hatef e, sena df, fallano ka, crews j, do dv. pneumatic retinopexy versus scleral buckle for repairing simple rhegmatogenous retinal detachments. cochrane database syst rev. 2015; (5): cd008350. 5. kuhn f, aylward b. rhegmatogenous retinal detachment: a reappraisal of its pathophysiology and treatment. ophth res. 2014; 51 (1): 15-31. 6. norregaard jc, thoning h, andersen tf, bernthpetersen p, javitt 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medicare advantage patients, 2003-2016. am j ophthalmol. 2018; 196: 82-90. 12. shinkai y, oshima y, yoneda k, kogo j, imai h, watanabe a, et al. 27g vitrectomy study group. multicenter survey of sutureless 27-gauge vitrectomy for primary rhegmatogenous retinal detachment: a consecutive series of 410 cases. graefes arch clin exp ophthalmol. 2019; 257 (12): 2591-2600. 13. awan a. primary rhegmatogenous retinal detachment surgery in modern era. pak j ophthalmol. 2018; 34 (2): 70-73. 14. chneider ew, geraets rl, johnson mw. pars plana vitrectomy without adjuvant procedures for repair of primary rhegmatogenous retinal detachment. retina, 2012; 32 (2): 213-219. 15. vail d, pershing s, reeves mg, afshar ar. the relative impact of patient, physician, and geographic factors on variation in primary rhegmatogenous retinal detachment management. ophthalmology, 2020; 127 (1): 97-106. 16. hwang jc. regional practice patterns for retinal detachment repair in the united states. am j ophthalmol. 2012; 153 (6): 1125-1128. 17. pat survey. asrs (american society of retina specialists). available at: https://www.asrs.org/asrscommunity/pat-survey. accessed 16 september 2020. 18. fischer cv, kulanga m, hoerauf h. trends in retinal detachment surgery: what has changed compared to 2001? ophthalmologe. 2018; 115 (8): 669. 19. cho ge, kim sw, kang sw. changing trends in surgery for retinal detachment in korea. korean j ophthalmol. 2014; 28 (6): 451–459. 20. eibenberger k, georgopoulos m, rezar-dreindl s, schmidt-erfurth u, sacu s. development of surgical management in primary rhegmatogenous retinal detachment treatment from 2009 to 2015. curr eye res. 2018; 43 (4): 517-525. 21. minihan m, tanner v, williamson th. primary rhegmatogenous retinal detachment: 20 years of change. british journal of ophthalmology, 2001; 85 (5): 546-548. authors’ designation and contribution muhammad amer awan; consultant ophthalmologist: wrote the introduction, discussion, results and references, approved the final version. javeria muid; postgraduate trainee: helped with discussion, figures and results, helped with final review of the study, approved the final version. .…  …. https://www.asrs.org/asrs-community/pat-survey https://www.asrs.org/asrs-community/pat-survey pak j ophthalmol. 2021, vol. 37 (4): 404-408 404 original article effect of online classes on dry eye disease in children: a hospital based survey sangameshwarayya salimath 1 , salma sultana 2 , brijesh appasaheb patil 3 , kalpana kulkarni 4 shishir k nyamagoudar 5 1-5 s.nijalingappa medical college & hsk hospital & research abstract purpose: to determine the effect of online classes on dry eye disease in children. study design: cross sectional study. place and duration of study: department of ophthalmology hsk hospital, navanagar, bagalkot, india, from october 2020 to november 2020. methods: a total of 454 students attending online classes between the ages of 3 – 18 years were selected. questionnaire was presented which included name, age, sex, residence, duration of online studies and duration in hours per day along with the various signs and symptoms according to speed questionnaire. statistical analysis was performed using the ibm spss version 17. quantitative variables were presented as mean ± standard deviation, while qualitative data was presented as frequency and percentages and compared by chi square test. p-value of < 0.005 was considered as significant. results: of the 454 responses, 316 (69.6%) had symptoms of dry eye disease, of which 159 were girls and 157 boys. there was no significant difference between boys and girls. children taking online classes for 2 – 3 hours and for 4 to 6 months duration were more affected by the dry eye disease. based on severity of grading system, 246 (84.2%) had mild symptoms, 42 (9.3%) had moderate symptoms and 28 ([6.2%) had severe symptoms. one hundred and twenty children visited ophthalmologist and 28.5% had their treatment of dry eye started. conclusion: online classes have resulted in increase in the frequency of dry eye disease in children. proper education about the usage of screen time and educating parents about early treatment is essential. key words: dry eye disease, symptoms, headache, online learning. how to cite this article: salimath s, sultana s, patil ba, kulkarni k, nyamagoudar sk. effect of online classes on dry eye disease in children: a hospital based survey. pak j ophthalmol. 2021, 37 (4): 404-408. doi: 10.36351/pjo.v37i4.1322 introduction dry eye disease (ded) is a chronic ocular disease and a major global health problem that manifests as a group of symptoms such as burning, photophobia, correspondence: salma sultana s. nijalingappa medical college & hsk hospital & research email: drsultanasalma@gmail.com received: july 26, 2021 accepted: september 23, 2021 tearing, and grittiness. patients with ded experience problems in their routine activities and compromising their quality of life. 1 the symptoms and irritation felt by the person with ded hardly match up with the intended clinical tests. 2 other factors for example topographical location, atmospheric conditions, and living style of the population also affect the ded. 3-5 there is a need to expand epidemiological studies of ded using standardized questionnaires and uniform diagnostic criteria. some studies are available from the subcontinent with variable prevalence of up to 33%. 6-10 the dry eye disease is noticed much less frequently in open access salma sultana, et al 405 405 pak j ophthalmol. 2021, vol. 37 (4): 404-408 pediatric population but it has become a matter of concern when the children develop clinical symptoms and signs. the problem has increased nowadays because of the online classes, which have changed the norms all over the world. ded if present in children below 5 years of age it is due to some congenital or related systemic illnesses such as sjögren’s syndrome, steven jonson syndrome, juvenile rheumatoid arthritis or it may be due to increased exposure to screen. however diagnosing dry eye is much more cumbersome in pediatric age group, because of non-compliance of children. usually the parents notice excessive blinking, itching of eyes and excessive rubbing leading to infections of eyes and meibomian gland dysfunction. 11 they might even develop astigmatism due to excess rubbing of eyes. decreased outdoor activities and increased indoor activities have also led to the excessive use of mobile and computer screens. for the diagnosis of dry eye, taking an accurate medical history of the patient is critical. for this purpose, the ocular surface disease index (osdi) can be regarded as the established standard questionnaire but the standard patient evaluation of eye dryness (speed) questionnaire has recently been developed. the advantages of the speed questionnaire are the lower number of questions and easier interpretability. 12 over the time speed questionnaire has proved to be a sound measure for dry eye symptoms even in epidemiological studies and clinical practice for dry eye symptom assessment. 13 we performed this study to find out the frequency of ded in children attending online classes. the results can be helpful in modifying the virtual classes and taking preventive measures before ded takes the form of epidemic. methods this cross-sectional survey was conducted by department of ophthalmology hsk hospital, navanagar, bagalkot, india, from 12/10/2020 to 11/11/2020. online classes had been started in the month of june. informed consent was obtained from all participants. institutional ethics committee approval was obtained and this study was done according to the tenets of declaration of helsinki. all students attending online classes between the age group of 3 – 18 years were selected irrespective of the gender and social status. patients more than 18 and less than three years of age were excluded. as this was an online survey, ocular examination was not carried out. questionnaire was presented which included name, age, sex, residence, duration of online studies and duration in hours per day along with the various signs and symptoms according to speed questionnaire. a pilot study was done, based on symptoms of dry eye disease. by taking p = 70%, 5% error at 95% confidence interval and using open epi version 2 software we got a sample size of n = 323. as we got 454 responses in duration of 1 month the data was analyzed and results tabulated. all the data that was collected from the respondents was exported as microsoft excel sheets from the google drive link, and statistical analysis was performed using the ibm spss version 17. quantitative variables were presented as mean ± standard deviation, while qualitative variables were presented as numbers and percentages. qualitative data like gender was presented as frequency and percentages and compared by chi square test. p-value of < 0.005 was considered as significant. results of the 454 responses, 316 (69.6%) had symptoms of dry eye disease, of which 159 were girls and 157 boys. there was no significant difference between boys and girls. majority of students were between 9 – 14 years (chart: 1). children taking online classes for 2 – 3 hours and for 4 to 6 months duration were more affected by the dry eye disease (chart: 2). there was a significant statistical association between symptoms of dry eye and duration of exposure, with a significance of 0.000 in pearson chi square test in our study (table 2). two hundred and eighty children had gritting and itching sensation in eyes, 263 had burning sensation in eyes and 268 had headache. based on severity grading system, designed by korb and blakie in order to quickly track progression scores given from 0 – 28. mild is 0 – 4, moderate is 4 – 8, > 8 as severe, 14 we classified the responses accordingly. of the 316 (69.9%) symptomatic children, 246 (84.2%) had mild symptoms, 42 (9.3%) had moderate symptoms and 28 ([6.2%) had severe symptoms. one hundred and twenty children visited ophthalmologist and 28.5% had their treatment of dry eye started. effect of online classes on dry eye disease in children: a hospital based survey pak j ophthalmol. 2021, vol. 37 (4): 404-408 406 table 1: age-wise distribution of the symptoms of dry eye disease. age asymptomatic symptomatic total chi-square tests point probability < 6 years 37 14 51 pearson chi-square 6 – 8 years 23 38 61 likelihood ratio 8 – 10 years 28 62 90 fisher's exact test 10 – 12 years 12 71 83 linear-by-linear association .000 c 12 – 14 years 24 69 93 n of valid cases 14 – 16 years 12 55 67 16 years 2 7 9 total 138 316 454 table 2: duration of online learning and symptoms of dry eye disease. duration in hours asymptomatic symptomatic total value df asymp. sig. (2-sided) exact sig. (2-sided) exact sig. (1-sided) pearson chi-square 61.619a 3 0.000 0.000 1 – 2 hr 47 21 68 likelihood ratio 57.952 3 0.000 0.000 2 – 3 hr 47 115 162 fisher's exact test 57.308 0.000 3 – 4 hr 29 101 130 linear-by-linear association 44.260b 1 0.000 0.000 0 > 4 hrs 15 79 94 n of valid cases 454 total 138 316 454 discussion covid-19 pandemic has resulted in life-style changes throughout the world. there has been nationwide lockdowns in different countries in order to maintain social distance and as a means to halt the spread of covid-19. this has affected education of about 1.5 billion students world-wide. 15 in our study the mean age of participants was 9-14 yrs. the frequency of ded in our study was 69.6% which is higher than the study conducted by amit m et al, which is 50.2%. 16 there was no gender difference regarding ded in our study. however, visual symptom scores in digital device users were higher among females than males in a study done by shima et al. 17 when duration of online study was analyzed, our results showed that children who used online sources for 2 to 4 hours per day were maximally affected with ded. a study conducted by ichhpujani p, reported that the prevalence of des was significantly higher in individuals who spent > 4 h per day on digital devices. 18 similar results were found in another study, conducted by kanitkar k et al, which reported that the duration in front of a screen was directly proportional to the des symptoms. 19 there is even a significant salma sultana, et al 407 407 pak j ophthalmol. 2021, vol. 37 (4): 404-408 statistical association between symptoms of dry eye and duration of exposure, with a significance of 0.000 in pearson chi square test in our study. a recent meta-analysis reported that the pooled prevalence of des was 19.7% in children. 20 in a study conducted in the private schools of west india, it was reported that the prevalence of des was 17.9%. 18 it was comparable to our study where it showed 15.5% prevalence of moderate to severe disease in children. in our study, pearson chi-square test shows significant association that is 0.000 between dry eyes related with age, probably because, as the age increases, duration of exposure to online classes is also increased. in a study conducted by moon et al. it was pointed out that symptoms of dry eye diseases were higher in the children of older age group. it was because of spending more hours on smart phone use, which may lead to a higher ded prevalence in older children. 21 shortening the duration of digital device use has a significant effect on the symptoms of des. the 20/20/20 rule proposed by misawa t et al should be taught to reduce asthenopic symptoms during computer use. after every 20 minutes of digital device use, look at a distance of 20 feet for at least 20 seconds. 22 children should be instructed to blink while using screens. the device should be held at least at an arm’s length away from the eyes. regular eye checkups has to be recommended for early diagnosis and treatment. there are certain limitation of this study. as the survey was done online, we were unable to examine the participants. conclusion the results of this study emphasizes the importance of early diagnosis of ded in children involved in online classes. proper education about the usage of screen time and educating parents about early treatment is essential. ethical approval the study was approved by the institutional review board/ethical review board (snmc/iechsr/20212022/a-6/1.1) conflict of interest authors declared no conflict of interest. references 1. miljanović b, dana r, sullivan da, schaumberg da. impact of dry eye syndrome on vision-related quality of life. am j ophthalmol. 2007; 143: 409-415. 2. nichols kk, mitchell gl, zadnik k. the repeatability of clinical measurements of dry eye. cornea, 2004; 23: 272-285. 3. the epidemiology of dry eye disease: report of the epidemiology subcommittee of the international dry eye workshop (2007). ocul surf. 2007; 5: 93-107. 4. mccarty ca, bansal ak, livingston pm, stanislavsky yl, taylor hr. the epidemiology of dry eye in melbourne, australia. ophthalmology, 1998; 105: 1114-1119. 5. lin py, tsai sy, cheng cy, liu jh, chou p, hsu wm, et al. prevalence of dry eye among an elderly chinese population in taiwan: the shihpai eye study. ophthalmology, 2003; 110: 1096-1101. 6. gupta n, prasad i, jain r, d’souza p. estimating the prevalence of dry eye among indian patients attending a tertiary ophthalmology clinic. ann trop med parasitol. 2010; 104: 247-255. 7. basak sk, pal pp, basak s, bandyopadhyay a, choudhury s, sar s, et al. prevalence of dry eye diseases in hospital-based population in west bengal, eastern india. j indian med assoc. 2012; 110: 789-794. 8. rege a, kulkarni v, puthran n, khandgave t. a clinical study of subtype-based prevalence of dry eye. j clin diagn res. 2013; 7: 2207-2210. 9. sahai a, malik p. dry eye: prevalence and attributable risk factors in a hospital-based population. indian j ophthalmol. 2005; 53: 87-91. 10. shah s, jani h. prevalence and associated factors of dry eye: our experience in patients above 40 years of age at a tertiary care center. oman j ophthalmol. 2015; 8: 151-156. 11. bhatt r, prajapati v, viramgami u. evaluation of the prevalence and risk factors of dry eye in young population m & j western regional institute of ophthalmology, ahmedabad, gujarat, india. dehli j ophthalmol. 2020; 8: 123-126. 12. finis d, pischel n, könig c, hayajneh j, borrelli m, schrader s, et al. comparison of the osdi and speed questionnaires for the evaluation of dry eye disease in clinical routine. ophthalmologe, 2014; 111 (11): 1050-1056. 13. asiedu k, kyei s, mensah sn, ocansey s, abu ls, kyere ea. ocular surface disease index (osdi) versus the standard pattern evaluation of eye dryness (speed): a study of a nonclinical sample. cornea, 2016; 35 (2): 175-180. 14. ngo w, situ p, keir n, korb d, blackie c, simpson t. psychometric properties and validation of standard patient evaluation of eye dryness questionnaire. cornea, 2013; 32 (9): 1204-1210. effect of online classes on dry eye disease in children: a hospital based survey pak j ophthalmol. 2021, vol. 37 (4): 404-408 408 15. global education coalition. available from: https://en.unesco.org/covid19/educationresponse/global coalition. accessed on: july 28, 2021. 16. amit m, pradhnya s, chintan s, elesh j, swapnil j. prevalence and risk factor assessment of digital eye strain among children using online e-learning during the covid-19 pandemic, indian j ophthalmol. 2021; 69 (1): 140-144. 17. shima m, nitta y, iwasaki a, adachi m. investigation of subjective symptoms among visual display terminal users and their affecting factorsanalysis using log-linear models nippon eiseigaku zasshi. 1993; 47: 1032–1040. 18. ichhpujani p, singh rb, foulsham w, thakur s, lamba as. visual implications of digital device usage in school children: a cross-sectional study bmc ophthalmol. 2019; 19: 76. 19. kanitkar k, carlson an, richard y. ocular problems associated with computer use: the everincreasing hours spent in front of video display terminals have led to a corresponding increase in visual and physical ills rev ophthalmol e-newsletter, 2005: 12. 20. vilela ma, pellanda lc, fassa ag, castagno vd. prevalence of asthenopia in children: a systematic review with meta-analysis j pediatr brazil, 2015; 91: 320–325. 21. moon jh, kim kw, moon nj. smartphone use is a risk factor for pediatric dry eye disease according to region and age: a case control study bmc ophthalmol. 2016; 16: 188. 22. misawa t, yoshino k, shigeta s. an experimental study on the duration of a single spell of work on vdt (visual display terminal) performance sangyo igaku. 1984; 26: 296–302. authors’ designation and contribution sangameshwarayya salimath; assistant professor: concepts, design, literature search, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. salma sultana; post graduate trainee: concepts, design, literature search, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. brijesh appasaheb patil; professor: concepts, design, literature search, data analysis, manuscript preparation, manuscript editing, manuscript review. kalpana kulkarni; statistician: concepts, data analysis, manuscript preparation, manuscript editing, manuscript review. shishir k nyamagoudar; post graduate trainee: concepts, literature search, data acquisition, manuscript preparation, manuscript editing. .…  …. https://en.unesco.org/covid19/educationresponse/globalcoalition https://en.unesco.org/covid19/educationresponse/globalcoalition pak j ophthalmol. 2020, vol. 36 (4): 418-422 418 original article role of thyroid stimulating immunoglobulins (tsi) in early diagnosis of patients with euthyroid graves’ ophthalmopathy mohammad idris 1 , muhammad zubair umer 2 , eemaz nathaniel 3 , muhammad iqbal 4 , adnan zar 5 1,5 lady reading hospital, medical teaching institute (mti), peshawar, 2 mardan medical complex, mardan, 3 rehman medical college, peshawar, 4 pinum cancer hospital, faisalabad abstract purpose: to determine the role of thyroid stimulating immunoglobulin (tsi) in early diagnosis of patients with euthyroid graves’ ophthalmopathy visiting oculoplastic service of a tertiary care centre. study design: descriptive cross sectional study. place and duration of study: oculoplastic service, outpatient department of ophthalmology, lady reading hospital, peshawar, pakistan, from august 2015 to august 2016. methods: patients of both gender, and all ages with any one of the signs and symptoms of grave’s ophthalmopathy at any stage and of any severity of disease, but normal thyroid functions, were included in the study. patients were selected by non-probability purposive sampling technique. one-way anova test was done to find out relationship of tsi with age and gender. results: among 90 patients included in the study there were 68.9% females and 31.1% males. maximum number of patients were between 41 and 55 years (37.8%). thyroid stimulating immunoglobulin (tsi) test was positive in 84% patients out of which 55.6% were females and 28.9% were males. age group of 41 – 55 years had maximum number of positive tsi (32.2%) and > 56 years age group had 2 nd most positive tsi (26.7%) with the overall significance of 0.969. the association of tsi with gender showed higher significance than age with p values of 0.142 and 0.908 respectively. conclusion: tsi is positive in majority of female euthyroid graves’ ophthalmopathy patients in age between 41 and 55 years. early diagnosis with the help of tsi in euthyroid graves’ disease can prevent ocular complications by timely referral to the endocrinologist. key words: euthyroid graves’ ophthalmopathy, thyroid stimulating immunoglobulin, thyroid function tests. how to cite this article: idris m, umer mz, nathaniel e, iqbal m, zar a. role of thyroid stimulating immunoglobulins (tsi) in early diagnosis of patients with euthyroid graves’ ophthalmopathy. pak j ophthalmol. 2020, 36 (4): 418-422. doi: https://doi.org/10.36351/pjo.v36i4.1113 correspondence: mohammad idris lady reading hospital, medical teaching institute (mti), peshawar email: idrisdaud80@gmail.com received: july 29, 2020 accepted: september 6, 2020 introduction thyroid eye disease is a common reason for many patients visiting oculoplastic clinics because of its cosmetic and vision related problems. graves’ disease is by far the most common cause of hyperthyroidism, with more than 1% prevalence in the general population. 1 thyroid related disorders are more common in females than males and increase with mohammad idris, et al 419 pak j ophthalmol. 2020, vol. 36 (4): 418-422 increasing age. 2 the peak incidence of graves’ disease (gd) occurs among patients of 30 – 60 years age, with an increased incidence among african americans. 3 the euthyroid graves’ ophthalmopathy occurs in 510% of patients, which is mostly bilateral. 4 thyroid associated ophthalmopathy (tao) is an organ specific, autoimmune process, in which the thyroid gland is over stimulated, causing hyperthyroidism. the extra ocular muscles (eom) and thyroid gland have same antigenic nature that is recognized by the antibodies. antibodies bind to the eom and cause swelling behind the eyeball. the orbital and periorbital tissues are involved leading to swelling which has also been reported to be the result of mucopolysaccharide deposition posterior to the eyes, a symptom indirectly associated with graves’ disease. the “orange peel” skin has been attributed to the infiltration of antibodies beneath the skin, causing an inflammatory response and subsequent fibrous plaques. euthyroid graves’ ophthalmopathy causes the characteristic eye symptoms of graves’ ophthalmopathy, also known as thyroid eye disease (ted) without thyroid dysfunction. the clinical features of graves’ eye disease involve eyelid retraction, proptosis, conjunctival chemosis, periorbital swelling and in advanced cases may result in loss of sight as a result of optic nerve compression. 5 there is normal thyroid function tests (free t3, free t4, tsh) and elevated thyroid stimulating immunoglobulin (tsi) levels, in patients with euthyroid graves’ ophthalmopathy. 6 euthyroid graves’ ophthalmopathy results in an immune response in soft tissues of the orbit especially muscles and these abnormal changes result in typical features of thyroid eye disease. 7 therefore, tsi is a good indicator of progress of thyroid disease. 8 tao is a common but still least understood element of graves’ disease, which involves inflammation, congestion and soft tissue remodeling of the orbit and unlike majority of autoimmune disorders, has variable severity and a predictable course. 6 the tsi measurement is a clinically important indicator of disease severity even in chronic quiescent stage of the disease. 9 the best management strategy of any disease is to timely treat the cause or underlying mechanism. the timely detection of thyroid stimulating immunoglobulin can be helpful in early diagnosis and management of graves’ eye disease before it worsens clinically and affects vision. the rationale of the study was to improve the scarce data about this disease in pakistan. the purpose of the study was to determine the role of thyroid stimulating immunoglobulin (tsi) in early diagnosis of patients with euthyroid graves’ ophthalmopathy visiting oculoplastic service of a tertiary care centre. methods this was a cross sectional descriptive study conducted at the oculoplastics service, outpatient department of ophthalmology of a tertiary care hospital of peshawar, pakistan. the total duration of the study was one year from august, 2015 to august, 2016. informed consent was taken from all the patients. patients of both gender, and all ages with any one of the signs and symptoms of graves’ ophthalmopathy at any stage and of any severity of disease, but normal thyroid functions, were included in the study. all patients having abnormal biochemical profile of thyroid functions (having high or low levels of t3, t4, and tsh level) or significant renal diseases, hepatic diseases, pulmonary diseases, patients on immunosuppressive therapy and patients having autoimmune diseases were excluded from the study. patients who received any medical or surgical treatment in the past for any thyroid disorder were also excluded from the study. the study was conducted after approval from hospital ethical and research committee. all patients presented to the oculoplastic service, out patient department of ophthalmology, lady reading hospital peshawar, who met the inclusion criteria and who were willing to participate in the study were examined. graves’ ophthalmopathy was diagnosed on the basis of eye examination by a consultant ophthalmologist (assistant professor or above with at least five years of professional experience). an informed written consent was obtained from all patients who were included in this study. all patients had normal biochemical profile of thyroid gland (t3, t4, and tsh). the tsi was calculated by using fully automated chemistry analyzer hplc (high performance liquid chromatography). the values of tsi was expressed in terms of percentage estimating camp accumulated in the presence of test immunoglobulin, in comparison with camp accumulated in the presence of normal immunoglobulin. data was entered and analyzed http://en.wikipedia.org/wiki/extraocular_muscles thyroid stimulating immunoglobulins in euthyroid graves’ ophthalmopathy pak j ophthalmol. 2020, vol. 36 (4): 418-422 420 through spss version 22. mean and standard deviations were calculated for numerical data like age. the frequency and percentage were calculated for presence of tsi in the euthyroid graves’ ophthalmopathy. all results were presented in the form of tables and graphs. stratification was done with regard to the age, gender, duration and severity of disease to see the effects on these variables. one-way anova test was also done for tsi with age groups and gender. results a total of 90 patients were selected. females were more than males, 68.9% and 31.1% respectively. four age groups were made in which age group of 41 – 55 years had 37.8% patients and more than 56 years of age group had 32.2% patients (table 1). among the 90 patients, 84% had their thyroid stimulating immunoglobulin (tsi) test positive. cross tabulation was performed for tsi with gender. among all patients, 84.4% of the males and females had their tsi positive. out of these, 55.6% females and 28.9% males had positive tsi with a p value of 0.139 (figure 1). maximum number of positive tsi were among the age groups 41 – 55 years (32.2%). patients with more than 56 years had second high percentage of positive tsi (26.7%), with the overall significance of 0.969 (table 1). one-way anova test was also done for tsi with age groups and gender. the association of table 1: distribution of thyroid stimulating immunoglobulin among age groups. age in years thyroid stimulating immunoglobulin total p value yes no 11 – 25 (9) 10.0% (2) 2.2% (11) 12.2% 0.969 26 – 40 (14) 15.6% (2) 2.2% (16) 17.8% 41 – 55 (29) 32.2% (5) 5.6% (34) 37.8% > 56 (24) 26.7% (5) 5.6% (29) 32.2% total (76) 84.4% (14) 15.6% (90) 100.0% table 2: one – way anova for age groups and gender with tsi. n mean s. d sig. age in years yes 76 2.89 .988 .908 no 14 2.93 1.07 total 90 2.90 .995 gender yes 76 1.66 .478 .142 no 14 1.86 .363 total 90 1.69 .466 tsi with gender showed higher significance than age with p values of 0.142 and 0.908 respectively (table 2). 28.90% 2.20% 55.60% 13.30% 84.40% 15.60% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% male female total present absent fig. 1: gender distribution of thyroid stimulating immunoglobulin (p = 0.139). discussion graves' ophthalmopathy (also known as thyroid eye disease, ted, dysthyroid/thyroid-associated orbitopathy (tao), graves' orbitopathy) is an autoimmune inflammatory pathology which affects the orbit around the eye, identified by upper eyelid retraction, swelling (edema), redness (erythema), conjunctivitis, and proptosis. 10 it is thus a cosmetic as well as a sight threatening condition and one of the common reasons for visiting oculoplastic clinic. graves' ophthalmopathy is easily diagnosed in a patient with confirmed thyrotoxicosis, positive tsi. 11 graves’ disease is the most frequent cause of hyperthyroidism in areas with iodine deficiency, with 20 – 30 cases annually per 100,000 individuals. 1 the logical consequence is that patients with graves’ hyperthyroidism, especially elderly, should be given particular attention by general practitioners and thyroid specialists. 12 it is component of a systemic course with variable expression in the eyes, thyroid and skin, due to binding of auto-antibodies to tissues in these organs. these auto-antibodies target the fibroblasts of eye muscles, which can transform into fat cells (adipocytes). fat cells and muscles enlarge and become inflamed. compression of veins fails to drain fluid, resulting in edema. 10 presence of tsi among gender http://en.wikipedia.org/wiki/autoimmune http://en.wikipedia.org/wiki/orbit_%28anatomy%29 http://en.wikipedia.org/wiki/edema http://en.wikipedia.org/wiki/erythema http://en.wikipedia.org/wiki/conjunctivitis http://en.wikipedia.org/wiki/proptosis http://en.wikipedia.org/wiki/edema mohammad idris, et al 421 pak j ophthalmol. 2020, vol. 36 (4): 418-422 annual incidence is 16/100,000 in females, 3/100,000 in males. in 3 to 5% of patients, the disease is severe with intense pain, and sight threatening corneal ulceration or compression of the optic nerve. tobacco smoking, related with many autoimmune disorders, increases the incidence to 7.7 fold. 10 mild disease mostly resolves by using artificial tears and quitting smoking by reducing dryness and discomfort. treatment of severe cases includes glucocorticoids and occasionally cyclosporine. 13 some anti-inflammatory biological mediators, like infliximab, etanercept, and anakinra have been tried, but none of randomized controlled trials have demonstrated effectiveness. early diagnosis and timely management can prevent or lessen the complications of this thyroid eye disease. some patients may present with any one or more features of this thyroid associated ophthalmopathy with thyroid dysfunctions. some patients although having thyroid functions within normal limits may present with graves’ ophthalmopathy and in some cases, the disease is unilateral. for this presentation patient moves from physician to physician and unnecessary and expensive invasive and non invasive investigations are carried out and all are in vain. the patient thinks that she or he is suffering from some rare disease, which cannot be diagnosed by routine knowledge and investigations. due to this delay in treatment, some patient undergoes psychological issues and depression, although it is a treatable disease. majority of signs and symptoms regress and complications are prevented. by evaluating tsi in these euthyroid patients, which is almost 88.6% positive in euthyroid graves’ ophthalmopathy, the early diagnosis and timely treatment can lessen the morbidity. the sensitivity and specificity of tsi is 100%. accuna et al 14 in their study on 49 patients with euthyroid graves’ ophthalmopathy, found positive tsi in 65% of cases which is lower than our study. possible explanation for this is that we used patients of of all ages and both gender at any stage of the disease. kraiem et al 15 had 72% positive tsi and again it is lower than in our study. possible explanation can be better diagnostic tools and newer method of detection. emphasis should be given to early diagnosis and timely management of the patients. by estimating tsi, further unnecessary and expensive invasive and noninvasive investigations can be avoided. 16 in our study, tsi was present in 88.6% patients of euthyroid graves’ ophthalmopathy (sensitivity & specificity of tsi is 100%), and majority of the patients were above 60 years and the duration of disease did not have any effect on severity of disease. oculoplastic surgeons in particular should be aware of the diagnostic value of tsi to prevent the cosmetic as well as sight threatening complications of this disease by early diagnosis and referral to endocrinologist especially when the disease is in acute stage. circulating anti-thyroglobulin (anti-tg) antibodies are also present in graves’ disease but antitg antibodies can be present in individuals without any other evidence of thyroid dysfunction. 17 another important clinical use tsi determinations is their value in predicting the relapse of hyperthyroidism in treated patients. 18 there are some conflicting reports in the literature regarding tsi levels and graves’ ophthalmopathy. 19 in a study on children, the authors did not find a relationship between tsi levels and presence of graves’ ophthalmopathy. 20 limitation of this study is that it is a single center study and we cannot generalize the results. further studies are required across pakistan so that this test can be added in the routine protocol of management of a patient with clinically diagnosed euthyroid graves’ disease. conclusion tsi is positive in majority patients of euthyroid graves’ ophthalmopathy, which is a sight-threatening condition in patients visiting oculoplastic clinics and can be diagnosed early with the help of tsi without any expensive investigations even when other thyroid function tests are normal. the association of tsi with gender showed higher significance than age. early diagnosis can prevent complications by timely referral to the endocrinologist. references 1. smith tj, hegedüs l. graves' disease. n engl j med. 2016; 375 (16): 1552-1565. 2. de leo s, lee sy, braverman le. hyperthyroidism. lancet. 2016; 388 (10047): 906‐918. 3. kahaly gj, bartalena l, hegedüs l, leenhardt l, poppe k, pearce sh. 2018 european thyroid association guideline for the management of graves' hyperthyroidism. eur thyroid j. 2018; 7 (4): 167‐186. http://en.wikipedia.org/wiki/glucocorticoid http://en.wikipedia.org/wiki/cyclosporine http://en.wikipedia.org/wiki/infliximab http://en.wikipedia.org/wiki/etanercept http://en.wikipedia.org/wiki/anakinra http://en.wikipedia.org/wiki/randomized_controlled_trial thyroid stimulating immunoglobulins in euthyroid graves’ ophthalmopathy pak j ophthalmol. 2020, vol. 36 (4): 418-422 422 4. arslan e, yava åÿoäÿlu i, cilda äÿ bm, kocatürk t. unilateral optic neuropathy as the initial manifestation of euthyroid graves’ disease. intern med. 2009; 48 (22): 1993-1994. 5. weiler dl. thyroid eye disease: a review. clin exp optom. 2017; 100 (1): 20‐25. 6. suzuki n, noh jy, kameda t, yoshihara a, ohye h, suzuki m, et al. clinical course of thyroid function and thyroid associated-ophthalmopathy in patients with euthyroid graves' disease. clin ophthalmol. 2018; 12: 739‐746. 7. khanzada tw, memon w, kumar b, samad a. thyroid scintigraphy: an overused investigation. gomal j med sci. jan – jun. 2009; 7 (1): 39-41. 8. tay wl, chng cl, tien cs, loke ks, lam ww, fook-chong sm, et al. high thyroid stimulating receptor antibody titre and large goitre size at firsttime radioactive iodine treatment are associated with treatment failure in graves' disease. ann acad med singapore, 2019; 48 (6): 181‐187. 9. woo yj, jang sy, lim th, yoon js. clinical association of thyroid stimulating hormone receptor antibody levels with disease severity in the chronic inactive stage of graves' orbitopathy. korean j ophthalmol. 2015; 29 (4): 213‐219. 10. grebe skg. thyroid disease. in the genetic basis of common diseases. second edition. edited by ra king, ji rotter, ag motulsky. new york, oxford university press, 2002: pp 397-430. 11. subekti i, pramono la. current diagnosis and management of graves' disease. acta med indones. 2018; 50 (2): 177‐182. 12. bartalena l, chiovato l, marcocci c, vitti p, piantanida e, tanda ml. management of graves' hyperthyroidism and orbitopathy in time of covid-19 pandemic [published online ahead of print, 2020 may 21]. j endocrinol invest. 2020: 1‐3. 13. cakir m. euthyroid graves' ophthalmopathy with negative autoantibodies. j natl med assoc. 2005; 97 (11): 1547-1549. 14. acuna om, athannassaki i, paysse ea. association between thyroid-stimulating immunoglobulin levels and ocular findings in pediatric patients with graves disease. trans am ophthalmol soc. 2007; 105: 146‐151. 15. kraiem z, glaser b, pauker j, sadeh o, sheinfeld m. bioassay of thyroid stimulating immunoglogulin in cryopreserved human thyroid cells: optimization and clinical evaluation. j clin chem. 1988; 34 (2): 244-249. 16. kiran z, rashid o, islam n. typical graves' ophthalmopathy in primary hypothyroidism. j pak med assoc. 2017; 67 (7): 1104-1106. 17. hollowell jg, staehling nw, flanders wd, hannon wh, gunter ew, spencer ca, et al. serum tsh, t(4), and thyroid antibodies in the united states population (1988 to 1994): national health and nutrition examination survey (nhanes iii). j clin endocrinol metab. 2002; 87 (2): 489-499. 18. pinchera a, fenzi gf, macchia e, bartalena l, mariotti s, monzani f. thyroid-stimulating immunoglobulins. horm res. 1982; 16 (5): 317-328. doi: 10.1159/000179520. 19. dragan lr, seiff sr, lee dc. longitudinal correlation of thyroid-stimulating immunoglobulin with clinical activity of disease in thyroid-associated orbitopathy. ophthal plast reconstr surg. 2006; 22: 13–19. 20. shibayama k, ohyama y, yokota y, ohtsu s, takubo n, matsuura n. assays for thyroidstimulating antibodies and thyrotropin-binding inhibitory immunoglobulins in children with graves' disease. endocr j. 2005; 52 (5): 505-510. authors’ designation and contribution mohammad idris; assistant professor: concepts, design, literature research, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review muhammad zubair umer; assistant professor pathology: concepts, design, literature research, data acquisition, manuscript preparation, manuscript editing eemaz nathaniel; editor jrmi: literature research, data acquisition, statistical analysis, manuscript preparation, manuscript editing muhammad iqbal; consultant ophthalmologist: literature research, data acquisition adnan zar; spr: data analysis, manuscript review. .…  …. file:///f:\pubmed file:///f:\pubmed file:///f:\pubmed https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=loke+ks&cauthor_id=31377762 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=lam+ww&cauthor_id=31377762 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=fook-chong+sm&cauthor_id=31377762 https://www.ncbi.nlm.nih.gov/pubmed/28770897 https://www.ncbi.nlm.nih.gov/pubmed/28770897 https://reference.medscape.com/viewpublication/6441 https://reference.medscape.com/viewpublication/6441 https://reference.medscape.com/viewpublication/6441 a case of acute rhino-orbital-cerebral mucormycosis in an adult with covid-19 76 pak j ophthalmol. 2022, vol. 38 (1): 76-79 brief communication acute rhino-orbital-cerebral mucormycosis in a patient with covid – 19 warda ali naqvi 1 , muhammad javid bhutta 2 , ejaz ahmed khan 3 , aftab akhtar 4 , sania raza 5 1-5 shifa international hospital, islamabad abstract covid-19 patients are known to have immunosuppression due to decreased lymphocytes and increased susceptibility to co-infections (bacterial and fungal). we present a case of 61-year-old patient who had diabetes, hypertension and ischemic heart disease with covid-19 infection admitted after rt-pcr positive result. he developed rhino-orbital mucormycosis during treatment. he received remdesivir with parenteral methylprednisolone and meropenem. while admitted in the ward, he developed signs of orbital cellulitis. magnetic resonance imaging (mri) of the brain, orbits, and paranasal sinuses revealed right frontal, ethmoidal, and maxillary sinusitis with the extension of the sinisuidal disease to the orbit. a nasal biopsy revealed broad a septate filamentous fungal hyphae suggestive of mucormycosis. long-term use of steroids/monoclonal antibodies/broadspectrum antibiotics may contribute to the predisposition to fungal disease. early diagnosis and prompt management are warranted to avoid morbidity. key words: mucormycosis, covid – 19, orbital cellulitis. how to cite this article: naqvi wa, bhutta mj, khan ea, akhtar a, raza s. acute rhino-orbital-cerebral mucormycosis in a patient with covid 19. pak j ophthalmol. 2022, 38 (1): 76-79. doi: 10.36351/pjo.v38i1.1301 introduction patients of covid – 19 suffer immunosuppression due to decreased lymphocytes and hence they have an increased susceptibility to other infections. published data shows that diabetes mellitus, lung diseases, old age and critically ill patients requiring ventilator support are more prone to fungal and bacterial coinfections. 1,2 aspergillosis is widely suspected among fungal infections in covid-19 patients. however, covid – 19 associated mucormycosis (cam) are often under diagnosed and need to be understood with respect to the clinical features, outcomes, and risk factors for the early diagnosis of this lethal condition. 3 correspondence: warda ali naqvi shifa international hospital, islamabad email: warda.ali91@yahoo.com received: june 15, 2021 accepted: december 5, 2021 mucormycosisisis a lethal, opportunistic, and invasive fungal infection seen in immunocompromised individuals. around 30 to 50% of diabetic patients develop rhino-orbital–cerebral form (rocm). however, the mortality due to extension to brain is about 100%. 3 tissue necrosis in mucormycosis causes poor penetration of the antifungal therapy at the lesion site attributing to delayed treatment response. the prerequisites for diagnosing mucormycosis are; a high index of suspicion and prompt assessment of clinical manifestations. 2 so there is a need for early diagnosis of this highly deadly disease. 4 recently, there is a rise in fungal infections which is associated with covid – 19. pakistan shows a 15% increase in fungal complications of covid – 19 1 and warrants algorithms for early diagnosis and management of fungal infections, especially the lifethreatening rocm. 1 here we present a patient with multiple comorbidities and covid – 19, who developed acute rhino-orbital mucormycosis, which open access acute rhino-orbital-cerebral mucormycosis in a patient with covid – 19 pak j ophthalmol. 2022, vol. 38 (1): 76-79 77 disseminated to the brain and caused death of the patient. case presentation a 61-year-old male patient was admitted to the covid – 19 critical ward with an eight-day history of shortness of breath, fever and dry cough. he had taken one dose of tocilizumab before admission with seven days history of azithromycin and doxycycline use. he was a longstanding case of hypertension and diabetes (> 10 years), taking insulin (aspart and glargine) and antihypertensive treatment (carvedilol). he also had a history of percutaneous coronary intervention for the last two years and was using amlodipine with aspirin. on examination, his pulse rate was 124/minute, blood pressure was 130/78 mmhg, respiratory rate was 22/minute with an oxygen saturation of 82% on room air which improved to 93% on 5 liters/minute with rebreather mask and he was a febrile on admission. the relevant physical examination revealed bilateral crepitation at the lung bases and no cardiovascular or neurological abnormalities. a reverse-transcriptase polymerase chain reaction (rt-pcr) was positive for the sars-cov-2 virus. there were bilateral non-homogeneous opacifications on the chest x-ray and computed tomography (ct) scan of the chest showed multifocal, multi-lobar peripheral ground-glass opacities typical for covid 19. intravenous methylprednisolone (40 mg twice daily), intravenous meropenem (1g 8 hourly) and intravenous remdesivir (200 mg for one day and 100 mg per day as maintenance dose) were started. his pre-meal blood sugar was set at 180 – 200 mg/dl with insulin using sliding scale method. subcutaneous enoxaparin (40 mg/0.4 ml) once daily and three doses of 6 mg ivermectin were also given as per the institution guidelines. his oxygen demand gradually increased to 15 liters/min on rebreather mask over the next few days, upon which bipap was started with an increase in intravenous methylprednisolone (60 mg twice daily). on day seven, the patient improved and was shifted to a regular covid – 19 ward with oxygen 15 liters/min on the non-rebreather mask. rest of the treatment was continued as before. on day 9, the patient experienced severe headache associated with right eyelid swelling, proptosis and pain radiating to the forehead. he was advised topical moxifloxacin and radiological tests by an ophthalmologist. the next day, an mri and ct scan of the brain, orbits, and paranasal sinuses revealed right frontal, ethmoidal and maxillary sinusitis with mild thinning of the right-sided lamina papyracea of the ethmoid sinus. the disease had also extended to the orbit. after the infectious diseases consult, empiric treatment was initiated with liposomal amphotericin b (300 – mg/day). isavuconazole (200 mg twice a day for 48 hours followed by 200 mg once daily) was also added later on. after two days, the right eye showed proptosis with periorbital edema and conjunctival congestion. the left eye appeared normal. gross visual acuity was intact and ocular movements showed mild restriction in extremes of all gazes on the right side. ct scan was repeated which revealed the disease extent to the orbital apex with possible thrombosed right ophthalmic artery and small orbital abscess along the superomedial wall. ent team did an urgent functional endoscopic sinus surgery (fess) and orbital decompression on day 13 th . histology and fungal cultures revealed broad a septate hyphae branching at 90 degrees, suggestive of mucor species confirmed on a sabourauds dextrose agar culture. fig. 1a: intraoperative aspect: extensive necrosis and hemorrhage in the right ethmoid sinus. tissue cultures also revealed growth of escherichia coli. intravenous meropenem was increased to 2g three times a day. mri brain and orbits with contrast after four days showed worsening of the warda ali naqvi, et al 78 pak j ophthalmol. 2022, vol. 38 (1): 76-79 figure 1b and 1c: a septate hyphae branching at 90 degrees, suggestive of rhizopusspecies. lesion with intracranial extension and asymmetric enhancement of dura on the right side, while intraorbital contents on the left side did not show any pathology. meningio-encephalitis and involvement of the right cavernous sinus and the ophthalmic veins were also noted. the patient continued to deteriorate, developed hypertensive emergency and was intubated for ventilator support. later he required inotropic support over the next couple of days. he also developed renal failure. due to multi-organ failure and the spread of the disease to the brain the patient expired on day thirty-six of admission. discussion the purpose of presenting this case is to highlight the challenging possibility of opportunistic fungal infections in covid-19 cases and its management. our patient not only had diabetes to contribute towards acquiring rocm but also had hypertension, covid19 and ihd. rhino-orbital-cerebral mucormycosis is the most common disease form affecting up to 55% of the diabetic patients with covid-19. 2 there has been a marked increase in mucormycosis in diabetic patients who develop covid-19. 5,6 werthman-ehrenreich a 4 reported a case of a 33year-old covid-19 positive female with altered mental status and proptosis who had developed orbital mucormycosis. it was suggested to highlight the early identification of this high morbidity disease for better outcomes. other factors predisposing to mucormycosis in covid positive patients include prolonged steroid treatment and immunomodulatory drugs. mehta s et al. shared a case of a 66-year-old male who had covid-19 and developed rhino-orbital mucormycosis after steroids therapy. 1 in covid-19, the reduced numbers of t lymphocytes, cd4+t, and cd8+t cells, may alter innate immunity, causing predisposition to fungal infections along with the effects of the drugs. another case was reported by waizel-haiat s et al, in which a young patient with covid, developed rhino-orbital mucormycosis. 7 they proposed that in diabetic patients, symptoms such as cranial nerve palsy, mid-facial pain, diplopia, proptosis, apex orbital syndrome, periorbital edema and palatine ulcer raise the red flags for rocm. in another case report, the authors discussed the importance of early diagnosis and treatment of fungal co-infections in covid-19.the prompt recognition of this complication and initiation of anti-fungal therapy are essential to decrease morbidity owing to fungal coinfections and extension into the adjoining structures. 8 other authors have also described the importance of early diagnosis, start of antifungal treatment and acute rhino-orbital-cerebral mucormycosis in a patient with covid – 19 pak j ophthalmol. 2022, vol. 38 (1): 76-79 79 surgical debridement to prevent morbidity and mortality. 9,10 early administration of liposomal amphotericin through a retrobulbar injection with accompanied systemic antifungals in the setting of rhino-orbital-mucormycosis can also help patient survival. conclusion our report highlights the importance of early diagnosis of challenging possibility of rocm which can help in starting prompt therapy resulting in better patient outcomes. early diagnosis of rocm through warning signs, ophthalmological symptoms can help initiation of early treatment. conflict of interest authors declared no conflict of interest. references 1. mehta s, pandey a. rhino-orbital mucormycosis associated with covid-19. cureus, september 30, 2020; 12 (9): e10726. doi:10.7759/cureus.10726 2. ashraf dc, idowu oo, hirabayashi ke, kalinhajdu e, grob sr, winn bj, et al. outcomes of a modified treatment ladder algorithm using retrobulbar amphotericin b for invasive fungal rhino-orbital sinusitis. am j ophthalmol. 2021 jun. 8: s0002-9394 (21): 00319-6. doi: 10.1016/j.ajo.2021.05.025. epub ahead of print. pmid: 34116011. 3. bartoletti m, pascale r, cricca m, rinaldi m, maccaro a, bussini l, et al. predico study group. epidemiology of invasive pulmonary aspergillosis among intubated patients with covid-19: a prospective study. clin infect dis. 2021 dec. 6; 73 (11): e3606-e3614. doi: 10.1093/cid/ciaa1065. pmid: 32719848; pmcid: pmc7454393. 4. werthman-ehrenreich a. mucormycosis with orbital compartment syndrome in a patient with covid-19. am j emerg med. 2021 apr; 42: 264.e5-264.e8. doi: 10.1016/j.ajem.2020.09.032. epub 2020 sep 16. pmid: 32972795; pmcid: pmc7493738. 5. fouad ya, abdelaziz tt, askoura a, saleh mi, mahmoud ms, ashour dm, et al. spike in rhinoorbital-cerebral mucormycosis cases presenting to a tertiary care center during the covid-19 pandemic. front med (lausanne). 2021 may 28; 8: 645270. https://doi.org/10.3389/fmed.2021.645270 6. john tm, jacob cn, kontoyiannis dp. when uncontrolled diabetes mellitus and severe covid-19 converge: the perfect storm for mucormycosis. j fungi (basel). 2021 apr. 15; 7 (4): 298. doi: 10.3390/jof7040298. pmid: 33920755; pmcid: pmc8071133. 7. waizel-haiat s, guerrero-paz ja, sanchez-hurtado l, calleja-alarcon s, romero-gutierrez l. a case of fatal rhino-orbital mucormycosis associated with new onset diabetic ketoacidosis and covid-19. cureus. 2021 feb; 13 (2): e13163. doi:10.7759/cureus.13163 8. maini a, tomar g, khanna d, kini y, mehta h, bhagyasree v. sino-orbital mucormycosis in a covid-19 patient: a case report. int j surg case rep. 2021 may; 82: 105957. doi: 10.1016/j.ijscr.2021.105957 9. ahmadikia k, hashemi sj, khodavaisy s, getso mi, alijani n, badali h, et al. the double-edged sword of systemic corticosteroid therapy in viral pneumonia: a case report and comparative review of influenza-associated mucormycosis versus covid-19 associated mucormycosis. mycoses, 2021 aug; 64 (8): 798-808. doi: 10.1111/myc.13256. epub 2021 mar 5. pmid: 33590551; pmcid: pmc8013756. 10. emilin pandian md. the role of retrobulbar liposomal amphotericin in orbital apex syndrome in a covid–19 positive diabetic. j med clin case repo. 2021; f650: 804-9270. author’s designation and contribution warda ali naqvi; medical officer: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. muhammad javid bhutta; consultant infectious diseases: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. ejaz ahmed khan; consultant infectious diseases: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. aftab akhtar; head of department: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. sania raza; associate consultant: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. .…  …. https://doi.org/10.3389/fmed.2021.645270 https://dx.doi.org/10.1016%2fj.ijscr.2021.105957 160 pak j ophthalmol. 2022, vol. 38 (3): 160-164 original article strabismus as a psychosocial disease in pakistani cultural context ayesha jabeen 1 , rabia khadim 2 , mahnoor azhar 3 , ushna farrukh 4 1-4 university of management & technology, lahore abstract purpose: to find out the relationship between psychosocial issues, self-concept, and interpersonal difficulties in patients with strabismus. study design: descriptive observational study. place and duration of study: this study is conducted in university of management and technology from september 2019 to january 2020. method: this study included 100 participants (male to female ratio of 1:1), recruited from one government and two semi-government eye hospitals of lahore, through purposive sampling technique. a demographic sheet including the information about the participant’s age, gender, marital status, family system, reason of strabismus, and duration of strabismus were included in the study. the measures of the study included the indigenous psychosocial issues scale, self-concept scale, and interpersonal difficulties scale. results: the mean age of the patients was 24.5 ± 2.17. among 100 patients, 41% were married and 64% were living in a nuclear family system. there were 21% with matriculation, 24% had intermediate and 55% had graduation or masters level of education. the cause of strabismus was genetic (20%), congenital (16%), and due to different health issues such as diabetes (63%). the analysis was carried out by using pearson product-moment correlation analysis which showed that psychosocial problems (psp) had a significant positive relation with interpersonal difficulty (id) (r = .51, p < 0.001) and negative self-concept (nsc) (r = .55, p < 0.001), and a nonsignificant relationship with positive sc (r. 08 = p > 0.05). the most frequently reported psychosocial verbatim were crying behavior (72%), difficulty in finding a job (72%) and feeling worthless (69%). conclusion: the results of the study revealed that negative self-concept contributes to causing interpersonal difficulties in persons with strabismus. keywords: strabismus, pakistan, interpersonal difficulties, psychosocial issues, self-concept. how to cite this article: jabeen a, khadim r, azhar m, farrukh u. strabismus as a psychosocial disease in pakistani cultural context. pak j ophthalmol. 2022, 38 (3): 160-164. doi: 10.36351/pjo.v38i3.1385 correspondence: ayesha jabeen university of management & technology, lahore email: ayesha.jabeen@umt.edu.pk received: march 3, 2022 accepted: june 6, 2022 introduction eyes are highly developed sensory organs, through which one perceives almost 80% of the information. 1 eyes can capture and interpret beyond one million pulse signals per millisecond and communicate to the brain. healthy eyesight plays a vital role in learning multiple skills and contributing towards growth and development. any defect in the eyes can lead towards multiple eye diseases. strabismus is one of the most challenging subspecialties encountered in the field of ophthalmology. worldwide prevalence of strabismus is 2 to 6%. 2 there are chances to get it developed at any age but it commonly develops during childhood. during adulthood, it frequently occurs secondary to either systemic disease or mechanical damage such as trauma or brain tumor. 3 strabismus is not only a biological disease causing visual disruption but also a psycho-social problem. it has been observed that individuals with strabismus strabismus as a psychosocial disease in pakistani cultural context pak j ophthalmol. 2022, vol. 38 (3): 160-164 161 may develop appearance concerns in their physiognomy, troubling their self-esteem, self-concept and ultimately, they suffer from high lebels of anxiety and depression. 4 in an attempt to belong to the society, get accepted, and fitting in, in terms of social roles and developments, extreme attention is rewarded to the body image, perceived by others. the misaligned eyes directly impact the way one views himself because they do not look normal and they are more prone to get rejected and discriminated. 5 a study has revealed that individuals with strabismus stated lower self-identity as compared to non-strabismus persons. statistically significant differences were found in subjectivity, initiative, self-acceptance, and familiarity. 6 specifically, this decline in self-identity on the initiative and familiarity sub-sections is found consistent with a general decline in self-esteem and difficulties in interpersonal relationships and social activity. individuals start to make fun of or taunting a child suffering from strabismus, result in the separation or aggression of children with strabismus. difficulty in finding a partner is a most common complaint in strabismus adults. they have difficulties in making and maintaining relationships, more specifically with the opposite gender ultimately shattering their selfconfidence. 7,8 the adverse effects of strabismus are not limited to psychological aspects but prevail over too many debilitating consequences: education, quality of life, mental health, possibly affecting all. they also struggle hard in gaining employment. their cross-eyes mean to be so detrimental in achieving the employment milestones such as promotion and developing their careers to the next level. 7 the people with strabismus, experiencing communication difficulties and problems in interaction with others, may experience impairments in social functioning, experiencing social anxiety, social phobia, negatively affecting their mental health. 9 there is a scarcity of literature on psychological issues of persons with strabismus in the pakistani cultural context. therefore, the present study aimed to find out the relationship between psychosocial issues, self-concept, and interpersonal difficulties. it is hypothesized that psychosocial problems in individuals with strabismus will positively correlate with negative self-concept and interpersonal difficulties. methods this cross-sectional study was carried out from september 2019 to january 2020. the institutional ethical committee approved the project. written consent was taken from the hospital authorities and verbal consent was taken from the participants before administering the research protocol. participants were informed about the aim and objectives of the study and they were given the right to withdraw at any time. a demographic sheet including the information about the participant’s age, gender, marital status, family system, reason of strabismus, and duration of strabismus were included in the study. strabismus psychosocial problem scale (sps) was used to find and assess the psycho-social problems of individuals with strabismus. 10 it was designed to assess the psychosocial problems of individuals with strabismus. it consisted of twenty-five items, each pointing to the psycho-social problems, frequency, and distress level associated with daily functioning. the reliability of the scale was found to be .92. it consisted of two factors namely self-related and daily difficulties. self-concept scale was developed by hussain and rizvi (ssc; 2016). 11 the scale consists of 38 items with 5 points; never, sometimes, donot know, to some extent, and very much. the scale was based on two factors in which the first factor was named positive self-concept and the second-factor was negative selfconcept. the reliability of the scale was found to be .90. interpersonal difficulty scale (ids) was developed by saleem and mahmood. 12 it was used in the current study to find out the interpersonal difficulties of the individuals with strabismus during daily life activities. the scale consists of 31 items with 5 response points; never, sometimes, donot know, to some extent, and very much. the scale was based on six factors; (dominated by others, low self-confidence, mistrust, lack of assertiveness, lack of boundaries, and unstable relationships). the ids begins with brief instructions. this scale examines different questions like exactly how the individual faces interpersonal difficulties in their daily life. the data was collected from one government and two semi-government eye hospitals of the city of ayesha jabeen, et al 162 pak j ophthalmol. 2022, vol. 38 (3): 160-164 lahore. the inclusion criteria were (i) individuals with strabismus (ii) both married and unmarried (iii) patients who were treated in standard outpatient and inpatient eye units. participants with any other medical condition such as diabetes, hypertension and patients who belonged to rural areas were excluded from the study. the protocol was administered in a one-to-one session after building a rapport with the patient. they were also debriefed about the implications of the study. results the sample of the study consisted of 100 men and women with an equal percentage. the age ranged between 18 to 30 years (mean = 24.5 ± 2.17). forty one percent were married and 59% were unmarried with 64% living in a nuclear family system. participants with education upto matric was 21%, 24% were educated upto intermediate level and 55% had done graduation or masters. the cause of strabismus was reported to be genetic (20%), by birth (16%), and due to different health issues such as diabetes (63%). 86% of the participates reported to have “no other disease”. the analysis was carried out by use pearson product-moment correlation analysis which showed that psychosocial problems (psp) had a significant positive relation with interpersonal difficulty (id) (r = .51, p < 0.001) and negative self-concept (nsc) (r = .55, p < 0.001), and a non-significant relationship with positive sc (r.08 = p > 0.05). mediation analysis was carried out using process macro 3.5 with a 95% confidence interval. psychosocial problems were taken as an independent variable, negative self-concept was taken as a mediator and interpersonal difficulties were taken as a dependent variable. results have shown that the total effect of psp on id was significant (β = .55, t = 6.46, p = 0.001) with the inclusion of mediating variable sc, the impact of psp on id remains significant (β = .27, t = 3.05, p = 0.001). the indirect effect of independent variable on dependent variable through a mediator is partially mediating and is significant. the results of table 1 have shown that negative self-concept positively mediates the relationship between psychosocial issues and interpersonal difficulties. the higher is the negative self-concept more will be interpersonal difficulties. table 2 shows that there is a high percentage of persons with strabismus who experience psychosocial issues. these psychosocial problems depict two dimensions i.e. one that relates to the inner world and another that relates to the outer world. table 1: regression coefficient, standard error and model summary information for psychosocial issues and negative self-concept faced by strabismus patients. antecedents consequents m(nsc) y(ids) β se p β se p psp(x) a .55 3.12 .001*** c' -.27 .07 .01** nsc(m) ---b1 .49 .14 .001*** r 2 =.30 f (1,98) =43.31 p =.001*** r 2 =.55 f (2,97) =43.12, p =.001*** note. psp = psychosocial problems, nsc = negative self-concept strabismus as a psychosocial disease in pakistani cultural context pak j ophthalmol. 2022, vol. 38 (3): 160-164 163 table 2: percentage of reported psychosocial problems reported by strabismus patients (n=100) sr# behaviors % 1. crying behavior 72 2. difficulty in getting job 72 3. feel worthless 69 4. financial issues 67 5. nausea while working 67 6. fear of losing eyesight 65 7. anger 63 8. self-pity 62 9. feel incomplete 60 10. difficulty in making friends 60 11. hesitant to take initiative 60 12. feel less beautiful than others 67 13. low-self confidence 54 14. complaining god 57 15. irritation 59 16. suicidal ideation 58 17. difficulty in carrying out house hold chores 57 18. feel bad about oneself percentage of most frequently reported physical complaints by strabismus patients 57 19. blurred vision 69 20. headache 67 21. nausea 65 22. pain in eyes 65 23. weak eyesight 47 discussion the present study aimed to find out the relationship between psychosocial issues, self-concept, and interpersonal difficulties in persons with strabismus. according to the bio-psycho-social model, there is an interplay between the biological and social factors within a person that determine the functionality of the individual. 13 living in a “beauty-conscious” society minor physical impairment may bring great challenges for the individuals. strabismus is an obvious defect that may generate low self-confidence. such individuals experience distress, loss of self-esteem, and interpersonal issues in their work and social circumstances; due to which they are less likely to take initiative and enjoy their relations. 14 in our study, crying behavior came out to be one of the significant psychosocial complaints by the participants. crying is a maladaptive coping mechanism and is the characteristic feature of emotional coping strategies. the verbatim feeling worthless, anger, and feeling incomplete also reflected a loss of control over the circumstances resulting in hopelessness. physical complaints like blurred vision, headache, and nausea are the typical consequences of misalignment caused due to the interference in the control and functioning of extraocular muscles. 15 living in a collectivistic culture not only helps in the provision of social support but also puts forth multiple challenges. for many individuals, minor physical defects sometimes become a reason for the proposal rejection during pre-marital life years. lack of empathy is observed when people use different titles such as “bhenga (cross-eyed)” sarcastically. these experiences become not only the source of low self-confidence but also hinder such individuals to form social interactions with others. the corrective medical procedures not only improve the quality of life but significantly impact the positive self-concept. the results of the current study correlate with the previous literature on self-concept and psychosocial issues of strabismus. 16 in another study, the patients were reported to have non-specific negative feelings (88%), general disability (88%), appearance to others (people notice my eyes; 77%). 17 due to this reason some patients find that getting a normal appearance is much essential due to social reactions to misaligned eyes. the prevalence of strabismus in pakistan is reported to be 5% 6%. 18 several studies have been carried out in pakistan however, their focus remained to determine the rate of strabismus or to find out the efficacy of medical-based management procedures. 19,20 this study highlights the implications of strabismus in the health psychology domain in general and contribute specifically towards the psychosocial literature of strabismus in pakistan. the bio-psychosocial model has emphasized how psychological factors may exacerbate the physical symptoms of a disease and vice versa. therefore, there is a dire need to develop psychological-based disease-specific assessment and treatment procedures. the major limitation of the study was that only urban population was included which cannot be generalized to the rural population. a comparative study would have given the differential impact of psychological factors on both samples. conclusion it can be concluded that negative self-concept was not only positively correlated with interpersonal difficulties in persons with strabismus but, also positively mediated the relationship between psychosocial stressors and interpersonal difficulties. ayesha jabeen, et al 164 pak j ophthalmol. 2022, vol. 38 (3): 160-164 the study has also revealed the expression and percentage of problems experienced by persons with strabismus where “crying” and “difficulties in getting a job” were the highest reported problems. conflict of interest: authors declared no conflict of interest. ethical approval the study was approved by the institutional review board/ ethical review board (icpy/20/131). references 1. hutmacher f. why is there so much more research on vision than on any other sensory modality? front psychol. 2019; 10: 2246. doi: 10.3389/fpsyg.2019.02246. 2. bruce a, santorelli g. prevalence and risk factors of strabismus in a uk multi-ethnic birth cohort. strabismus, 2016; 24 (4): 153-160. doi: 10.1080/09273972.2016.1242639. 3. aragaw ka, melkamu tt, natnael la betelhem ty. knowledge towards strabismus and associated factors among adults in gondar town. j ophthalmol. 2020: 3639273 https://doi.org/10.1155/2020/3639273 4. ritchie a, colapinto p, jain s. the psychological impact of strabismus: does the angle really matter? strabismus, 2013; 21 (4): 203-208. doi: 10.3109/09273972.2013.833952. 5. youngjun k, cheron k, seongjae k, yongseop h, inyoung c, seongwook s, et al. difference of selfidentity levels between strabismus patients and normal controls. korean j ophthalmol. 2016; 30 (6): 410–415. doi: 10.3341/kjo.2016.30.6.410 6. jackson s, morris m, gleeson k. the long-term psychosocial impact of corrective surgery for adults with strabismus. br j ophthalmol. 2013; 97: 419– 422.10.1136/bjophthalmol-2012-302983 7. mona s k, sarah al-ghamdi, alaydarous s, jumanah jh, alhasan a, alsubaie s, et al. knowledge and attitude toward strabismus in western province saudi arabia. cureus, 2020; 12 (1): 6571. doi:10.7759/6571 8. xu m, yu h, chen y, xu j, zheng j, yu x. longterm quality of life in adult patients with strabismus after corrective surgery compared to the general population. plos one. 2016; 11 (11). https://doi.org/10.1371/journal.pone.0166418 9. mao d, lin j, chen l, luo j, yan j. health-related quality of life and anxiety associated with childhood intermittent exotropia before and after surgical correction. bmc ophthalmol. 2021; 21 (1): 270. doi: 10.1186/s12886-021-02027-w. 10. azhar m, jabeen a. psycho-social distress, selfconcept and interpersonal difficulties in persons with strabismus (unpublished thesis). university of management and technology. 2019 11. hussain s, rizvi m. self-concept scale (unpublished thesis). university of management and technology, 2016. 12. saleem s, ihsan z, mahmood z. development of interpersonal difficulties scale for university students. pak j psychol res. 2014; 29 (2): 277-297. doi:10.1037/t54691-000 13. plakun em. psychodynamic psychiatry, the biopsychosocial model, and the difficult patient. psychiatr clin north am. 2018; 41 (2): 237-248. doi: 10.1016/j.psc.2018.01.007 14. durnian j, noonan c, marsh ib. the psychosocial effects of adult strabismus – a review. br j ophthalmol. 2011; 95 (4): 450. doi:10.1136/bjo.2010.188425 15. bommireddy t, taylor k, clarke mp. assessing strabismus in children. pediatr child health, 2019; 1418. doi 10.1016/j.paed.2019.10.003 16. liu ss, shteynberg g, morris mw, yang q, galinsky ad. how does collectivism affect social interactions? a test of two competing accounts. pers soc psychol bull. 2021; 47 (3): 362-376. doi: 10.1177/0146167220923230. 17. hatt sr, leske da, kirgis pa, bradley ea, holmes jm. the effects of strabismus on quality of life in adults. am j ophthalmol. 2007; 144 (5): 643-647. doi: 10.1016/j.ajo.2007.06.032. 18. azam p, nausheen n, fahim mf. prevalence of strabismus and its type in pediatric age group 6 – 15 years in a tertiary eye care hospital, karachi. biom biostat int j. 2019; 8 (1): 24-28. doi:10.15406/bbij.2019.08.00265 19. siddiqui ah, raza sa, ghazipur a, hussain ma, iqbal s, ahsan k, et al. analysis of association between type of amblyopia and gender at a tertiary care hospital in karachi. j pak med assoc. 2016; 66: 545-548. 20. ahmed n, shaheer m, zahoor s, hamza s, asim s. practice patterns in the management of strabismus in pakistan. pak j ophthalmol. 2020, 36 (2): 115-119. doi: 10.36351/pjo.v36i2.889 authors designation and contribution ayesha jabeen; assistant professor: concepts, design, manuscript editing. rabia khadim; lecturer: literature search, manuscript preparation, manuscript review. mahnoor azhar; clinical psychologist: literature search, data acquisition, data analysis. ushna farrukh; counselling coordiator: data analysis, statistical analysis, manuscript review. https://doi.org/10.1155/2020/3639273 https://www.ncbi.nlm.nih.gov/pubmed/?term=kim%20y%5bauthor%5d&cauthor=true&cauthor_uid=27980359 https://dx.doi.org/10.3341%2fkjo.2016.30.6.410 https://doi.org/10.1136/bjophthalmol-2012-302983 https://www.ncbi.nlm.nih.gov/pubmed/?term=khojah%20ms%5bauthor%5d&cauthor=true&cauthor_uid=31949996 https://www.ncbi.nlm.nih.gov/pubmed/?term=al-ghamdi%20s%5bauthor%5d&cauthor=true&cauthor_uid=31949996 https://dx.doi.org/10.7759%2fcureus.6571 https://doi.org/10.1371/journal.pone.0166418 http://dx.doi.org/10.1037/t54691-000 https://doi.org/10.1016/j.psc.2018.01.007 http://dx.doi.org/10.1136/bjo.2010.188425 295 pak j ophthalmol. 2021, vol. 37 (3): 295-299 original article comparison of central corneal thickness measurements using specular microscope, optical biometer and corneal topographer madiha waseem 1 , mehvash hussain 2 , muhammad muneer quraishy 3 , zaheer sultan 4 1-4 department of ophthalmology, dow university of health sciences, karachi abstract purpose: to compare the central corneal thickness (cct) measurements by three different devices in normal eyes. study design: cross sectional observational study. place and duration of study: dow university of health sciences and dr. ruth k.m. pfau civil hospital, karachi, from october 2020 to january 2021. methods: 80 eyes of healthy subjects aged between 20 to 50 years were included in the study. patients with corneal pathologies, systemic disease, history of ocular surgery or trauma, high intraocular pressure and high refractive error were excluded. subjects underwent full ophthalmic examination. central corneal thickness was measured by specular microscope (shin-nippon spm-700; rexxam co. ltd, takamatsu, japan), optical biometer (al-scan; nidek, gamagori, japan) and corneal topographer (tms-5; tomey corporation, nagoya, japan). all data entry and analysis was done on spss version 23. for correlation among devices, pearson correlation coefficient was used. scatter plot was drawn for graphical presentation. results: 80 eyes of 80 healthy subjects (50 males, 30 females) were recruited in the study by convenient sampling. the mean age was 37.76 ± 8.35 years. mean central corneal thickness values were 515.57 ± 31.54 µm, 510.21 ± 30.11 µm, 522.03 ± 29.78 µm with specular microscope, optical biometer and corneal topographer respectively. measurements by these devices strongly correlate with each other using pearson correlation coefficient (r = 0.927 to 0.966, p ≤ 0.001). conclusion: the results of central corneal thickness measurements obtained from these three devices positively correlate with each other so any of these devices can be used for its measurement. key words: central corneal thickness (cct), specular microscope, optical biometer, corneal topographer. how to cite this article: waseem m, hussain m, quraishy mm, sultan z. comparison of central corneal thickness measurements using specular microscope, optical biometer and corneal topographer. pak j ophthalmol. 2021, 37 (3): 295-299. doi: 10.36351/pjo.v37i3.1236 correspondence to: madiha waseem department of ophthalmology dow university of health sciences karachi email: madiha.waseem@gmail.com received: march, 05, 2021 accepted: april 28, 2021 introduction corneal deturgescence by endothelial pump is indicated by corneal thickness. 1 normal central corneal thickness is 540 μm. 2 central corneal thickness evaluates corneal pathologies like keratoconus and corneal dystrophies. 3 it is a key determinant of intraocular pressure and prevents misdiagnosis of glaucoma. 4 error of 3.4mm of hg in iop measurement occurs with 10% difference in open access central corneal thickness using specular microscope, optical biometer and corneal topographer pak j ophthalmol. 2021, vol. 37 (3): 295-299 296 central corneal thickness. 5 it evaluates cornea for refractive procedures. 6 it is important in various disorders such as contact lens complications and diabetes mellitus. 7 various modalities are used for the measurement of corneal thickness. contact methods include confocal microscopy and ultrasound pachymetry. 8 noncontact methods such as topography, optical coherence tomography and specular microscopy are also used. 9 corneal topography by scheimpflug camera and scanning slit system provides corneal thickness map. 10 scheimpflug imaging devices include tomey, galilei, pentacam, and sirius. 11 optical biometer like al-scan uses diode laser of 830nm and works on scheimpflug principle for central corneal thickness measurement. 12 specular microscope analyzes corneal endothelial cell count. it is also used for the measurement of corneal thickness. 13 it uses light reflections to differentiate layers of cornea for the measurement of corneal thickness. 14 the current study was undertaken to compare the central corneal thickness measurement by specular microscope, optical biometer and corneal topographer. methods this comparative study was done in the department of ophthalmology, dow university of health sciences and dr. ruth k.m. pfau civil hospital, karachi from 15 th october 2020 to 30 th january 2021. it included 80 right eyes of 80 healthy individuals aged 20 to 50 years, of both sexes, with refractive error of ≤ ± 1.5 diopters, healthy cornea and normal intraocular pressure of ≤ 21 mmhg and normal fundus. this study adhered to the declaration of helsinki. written and informed consent was obtained. all subjects underwent full ophthalmic examination including refraction, slit lamp biomicroscopy, measurement of intraocular pressure and fundoscopy. exclusion criteria comprised of patients with corneal pathologies, systemic diseases such as diabetes mellitus, contact lens wearers, history of ocular surgery or trauma, intraocular pressure > 21 mm hg and refractive error > ± 1.5 diopters. central corneal thickness (cct) was assessed using specular microscope (shin-nippon spm-700; rexxam co. ltd, takamatsu, japan), optical biometer (al-scan; nidek, gamagori, japan) and corneal topographer (tms-5; tomey corporation, nagoya, japan). all the readings were taken from the right eye by a single investigator in the morning between 10:00 am and 1:00 pm to avoid diurnal variation. specular microscope determines corneal thickness in the range of 400 – 750 µm by using light reflections from the anterior and posterior surface of the cornea. al-scan optical biometer uses scheimpflug imaging technique to measure central corneal thickness. tomey corneal topographer tms-5 combines scheimpflug and placido disc principle. it uses 25 – 31 rings capturing 256 point per ring and measurement time is around 1 second. the patients were asked to blink before each measurement and then fixate at the target after head positioning. central zone of 3.0 mm of cornea was used. three measurements were taken. the images were captured and analyzed with each device. an interval of 5 minutes was taken between measurements with the devices. selection of devices was in random order as all of them were noncontact methods. data analysis was done on spss version 23. qualitative data including gender was presented as frequency and percentage. mean ± standard deviation (sd) was calculated for age of the patients and central corneal thickness (cct). pearson’s correlation coefficient (r) was used to show strength of relation among three devices for cct measurement. r > 0.7 indicates strong positive correlation between devices. scatter plot was used for graphical presentation of correlation among the three devices. p ≤ 0.001 was considered significant statistically. results the study included 80 eyes of healthy subjects. the age ranged from 20 to 50 years. the mean age was 37.76 ± 8.35 years. there were 50 (62.5%) males and 30 (37.5%) females. table 1 shows mean central table 1: central corneal thickness (cct) measurements (µm), n = 80. method mean standard deviation specular microscope 515.57 31.545 optical biometer 510.21 30.114 corneal topographer 522.03 29.789 corneal thickness (cct) using different devices. there was strong positive correlation among all devices with pearson correlation coefficient (r) more between specular microscope and optical biometer (r = 0.966) than between specular microscope and corneal topographer (r = 0.946) and between optical biometer madiha waseem, et al 297 pak j ophthalmol. 2021, vol. 37 (3): 295-299 and corneal topographer (r = 0.927) as shown in table 2. however, all three methods had strong correlation (p ≤ 0.001). the scatter plots showed highest linear correlation (r²) of cct readings between specular microscope and optical biometer (r² = 0.934) in figure 1 followed by the correlation between specular microscope and corneal topographer (r² = 0.895) in figure 2 and between optical biometer and corneal topographer (r² = 0.860) in figure 3. table 2: correlation among specular microscope, optical biometer and corneal topographer. method specular microscope optical biometer corneal topographer specular microscope pearson correlation 1 .966 ** .946 ** sig. (2-tailed) .000 .000 n 80 80 80 optical biometer pearson correlation .966 ** 1 .927 ** sig. (2-tailed) .000 .000 n 80 80 80 corneal topographer pearson correlation .946 ** .927 ** 1 sig. (2-tailed) .000 .000 n 80 80 80 **. correlation is significant at the 0.01 level (2-tailed). figure 1: scatter plot of central corneal thickness measurements by specular microscope with optical biometer. figure 2: scatter plot of central corneal thickness measurements by specular microscope with corneal topographer. figure 3: scatter plot of central corneal thickness measurements by optical biometer with corneal topographer. discussion measurement of cct may be undertaken by ultrasonic pachymetry, confocal microscopy, corneal topography or optical coherence tomography. 15 central corneal thickness is an important component in the diagnosis of glaucoma and assessment of corneal disease. 16 it is required for reliable preoperative assessment of candidates for keratorefractive surgery as corneal thickness of less than 500 µm is a relative contraindication for lasik. 17 increased corneal thickness may indicate early corneal decompensation. 18 bourges et al observed that noncontact methods for cct measurement can be used interchangeably with each other. 19 in our study, mean cct values were 515.57 ± 31.54 µm, 510.21 ± 30.11 µm, 522.03 ± 29.78 µm central corneal thickness using specular microscope, optical biometer and corneal topographer pak j ophthalmol. 2021, vol. 37 (3): 295-299 298 when measured by specular microscope, optical biometer and corneal topographer respectively. different methods are available for central corneal thickness (cct) estimation and several studies have compared the accuracy of various devices. 20 mean cct using scheimpflug analyzer was 536.4 ± 35.77 µm in a study conducted in pakistani population which was comparable to our results and also reported positive correlation among different devices for cct measurement (r = 0.804 to r = 0.949). 1 in a study by chen et al, mean cct with scheimpflug imaging was 521.7 ± 27.62 μm which relates to our study. 21 according to sadik and rahmi study, the mean cct was 542 ± 46 μm with specular microscope. 22 other studies reported mean cct of 518.53 ± 34.96 and 520 ± 29 with specular microscope which corresponds to our result. 23, 24 jiang et al demonstrated that the mean cct by specular microscope was 532.6  ±   40.0  μm. there was good correlation in scatter plot (r  =  0.954) between specular microscope and optical biometer. 13 the mean cct for the alscan optical biometer and corneal topographer was 554.6 ± 30.9 μm and 570.7 ± 30 μm respectively. 15 in the present study, there was strong linear correlation with pearson correlation coefficient ranged from r = 0.927 to r = 0.966 when all three methods were compared. many studies support our result. ozyol et al in his study concluded that cct measurements by optical biometer and scheimpflug system are comparable with each other. 25 our study results are in accordance with the study by reem which had positive correlation of cct measurements between specular microscope and scheimpflug topographer (r = 0.949). 26 khaja w et al, study found linear correlation between specular microscope (r 2 =0.98) and corneal topographer (r 2 = 0.96) 9 . luisa observed high correlation coefficient (r = 0.852 to 0.995) among different instruments for central corneal thickness. 16 with the current pandemic of covid-19 corona virus disease, these methods of measuring central corneal thickness are probably safer to use as all of them are non-contact methods. limitations of this study is the small sample size. comparison between different age groups and different ethnic groups were also not made. further study to address these issues are needed. conclusion in normal eyes, cct measurements by all three devices show strong linear correlation and these modalities can be used correspondingly for the measurement of central corneal thickness. ethical approval the study was approved by the institutional review board/ ethical review board. 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opin ophthalmol. 2017; 28: 120–126. 21. chen s, huang j, wen d, chen w, huang d, wang q. measurement of central corneal thickness by highresolution scheimpflug imaging, fourier-domain optical coherence tomography and ultrasound pachymetry. acta ophthalmol. 2012; 90 (5): 449-455. 22. cevik sd, rahmi r, cevik mt, kivanc sa. comparison of central thickness estimates by an ultrasonic pachymeter and non-contact specular microscopy. arq bras oftalmol. 2016; 79 (5): 312-314. 23. almubrad tm, osuagwu ul, alabbadi i, ogbuehi kc. comparison of the precision of the topcon sp3000p specular microscope and an ultrasound pachymeter. clin ophthalmol. 2011; 5: 871–876. 24. ogbuehi kc, osuagwu ul. repeatability and interobserver reproducibility of artemis – 2 high – frequency ultrasound in determination of human corneal thickness. clin ophthalmol. 2012; 6: 761-769. 25. ozyol e, ozyol p. comparison of central corneal thickness with four noncontact devices: an agreement analysis of swept-source technology. indian j ophthalmol. 2017; 65 (6): 461–465. 26. azzam ri, kasem ma, khattab a, el-fallal hm. measurement of central corneal thickness by different techniques. j egypt ophthalmol soc. 2017; 110: 114117. authors’ designation and contribution madiha waseem; consultant ophthalmologist: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing. mehvash hussain; assistant professor: data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. muhammad muneer quraishy; professor: design, literature search, manuscript preparation, manuscript review. zaheer sultan; consultant ophthalmologist: search, data acquisition, data analysis, manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (3): 274-277 274 original article comparison of quadrantic retinal nerve fiber layer thickness between glaucoma patients and age matched controls nargis nizam ashraf 1 , nisar ahmed siyal 2 , muhammad ibrahim 3 department of ophthalmology, 1-3 dow university of health sciences, karachi abstract purpose: to compare the quadrantic retinal nerve fiber layer thickness between the glaucoma patients and agematched controls. study design: descriptive observational study. place and duration of study: eye department of civil hospital karachi, from january 2018 to december 2020. methods: two hundred and fifty eyes were included in this study. there were 128 eyes of the glaucoma patients and 122 eyes were age-matched controls. after complete ocular examination, all participants underwent optical coherence tomography and retinal nerve fiber layer thickness measurement in four quadrants. prior quadrants were subsequently analyzed. heidelberg 3-d optical coherence tomography 2017, spectr04859 was used. readings were saved on excel sheet and analyzed on spss version 25. for descriptive statistics the mean and standard deviations were calculated for each quadrant and for inferential statistics the data was first checked for the normality. comparison of the quadrants was done using non-parametric paired sample t-test (wilcoxon signed rank test). results: out of 250. form which 128 (51%) eyes were those of glaucoma patients and 122 (49%) eyes were of non-glaucoma patients. the mean difference between the glaucomatous and non-glaucomatous eyes were statistically significant in all four quadrants (p > 0.05). conclusion: glaucomatous eyes had reduced rnfl thickness in all quadrants. the thickness of the inferior quadrant was more as compared to the other quadrants in both glaucoma and control groups. whereas the least thickness was that of the temporal quadrant. key words: retinal nerve fiber layer, optical coherence tomography, glaucoma. how to cite this article: ashraf nn, siyal na, ibrahim m. comparison of quadrantic retinal nerve fiber layer thickness between glaucoma patients and age matched controls. pak j ophthalmol. 2021, 37 (3): 274-277. doi: 10.36351/pjo.v37i3.1199 correspondence: nargis nizam ashraf eye unit dow university of health sciences karachi email: nargis.ashraf99@hotmail.com received: january 21, 2021 accepted: may 3, 2021 introduction the main diagnostic tools used to examine and analyze optic nerve and retinal nerve fiber layer (rnfl) are disc photography, confocal scanning laser ophthalmoscopy and ocular coherence tomography. 1 it is possible to observe and analyze the objective and quantitative details of retinal layers with spectral domain oct. this is done by means of automated algorithms. 2 delay in echo-time and quantity of reflected light are put to use through interferometry for open access mailto:nargis.ashraf99@hotmail.com nargis nizam ashraf, et al 275 pak j ophthalmol. 2021, vol. 37 (3): 274-277 3 d analysis. 3 additional information is obtained with swept source (ss) oct which has a much faster speed than conventional oct and also has a longer wave length. 4 the effect of age-related thinning of rnfl should be taken into account when assessing for glaucomatous changes. 5 literature shows that rnfl thinning was more prominent in the superior and inferior quadrants in patients with glaucoma. 6 when the superior and inferior quadrants of the disc are involved there are more chances of profound visual field defects. this is explained by the arrangement of axons of ganglion cells in the disc. nowadays ganglion cell complex is also taken into account and the ideal area is around the optic disc. it is here that the ganglion cells converge and exit from the eye. 7 in this study, we compared the quadrantic thickness of rnfl between normal controls and glaucoma patients in a tertiary care hospital of karachi. methods patients with clinical findings of glaucoma were included in the study by convenient sampling technique. patients with ocular diseases other than glaucoma were excluded. sample size was calculated by open epi program and came out to be 250 eyes. out of these, 128 eyes were those of glaucoma patients and 122 eyes were non-glaucomatous controls. after complete ocular examination including visual acuity, intraocular pressures, slit lamp examination and fundoscopy, oct was done for rnfl thickness. thickness of all four quadrants; superior, inferior, nasal and temporal was documented.heidelberg 3-d optical coherence tomography 2017, spec-tr-04859 was used. the patients’ pupils were dilated with tropicamide eye drops. statistical analysis was doneby spss version 25. sample t–test was performed for comparison of data of normal subjects with that of glaucoma patients. frequencies were checked and cross tabulation was done for descriptive analysis. for descriptive statistics the mean and standard deviations were calculated for each quadrant and for inferential statistics the data was first checked for the normality and based on the p-values it was found that data is significantly deviated from the normal distribution (p < 0.05). therefore, the comparison of the quadrants was done using non-parametric paired sample t-test (wilcoxon signed rank test). results the mean difference between the glaucomatous and non-glaucomatous eyes are shown in table 1. temporal quadrant was the thinnest in glaucomatous eyes while superior quadrant was thinnest in controls. inferior quadrant was the thickest in both glaucomatous eyes as well as controls. table 1: comparison of total number of cases in term of quadrants. quadrants mean p-value superior quadrant glaucomatous eye 56.5 ± 15.2 0.001 control 126.1 ± 30.4 inferior quadrant glaucomatous eye 57.8 ± 18 0.001 control 131.2 ± 47.5 nasal quadrant glaucomatous eye 56.1 ± 16.9 0.001 control 127.5 ± 39.2 temporal quadrant glaucomatous eye 55.7 ± 16.2 0.001 control 127.1 ± 38.6 discussion the technology of oct is evolving. the spectral domain oct has much higher scanning speed that is 25,000 a scans per second compared to time domain oct. it produces a 3 d image of the retina. 8 the advantage of oct over other investigation techniques is that it is non-invasive, analyzes rnfl in all four quadrants. rnfl thickness varies under the influence of age, gender, axial length, optic disc size and refractive error. 9 in our study we analyzed the retinal nerve fiber layer thickness in 4 quadrants.in a study by kausar a and akhtar n, the isnt rule applied to the rnfl thickness. 10 rnfl thickness is also being studied in cases of neurological diseases including alzheimer and multiple sclerosis etc. 11-13 in a crosssectional study it was observed that retinal nerve fiber layer thickness diminished by 0.16 0.26 micrometer every year, indicating the effect of age on rnfl. 14 the temporal and nasal quadrants were assessed by hwang and kim, especially the neuro-retinal rim on oct. 15 in our study when means were compared of normal and glaucoma patients, it was seen that the most decreased thickness was that of the temporal quadrant. in another study, it was observed that about 6 years before onset of changes in fields, retinal nerve fiber layer thinning had started. 16 the thickness of the retinal nerve fiber layer at the outset determines the course the disease. another factor determining rnfl thickness is myopia. the greater the myopia the lesser quadrantic retinal nerve fiber layer thickness in glaucoma patients and age matched controls pak j ophthalmol. 2021, vol. 37 (3): 274-277 276 the thickness. in studies done in individuals with myopia, the average measurement of rnfl came out to be 107.49. in yet another research the average thickness came out to be 105 micrometers. 17 in a study at karachi, rnfl was of greatest thickness at the inferior pole. 3 most of the studies have concentrated on the parapapillary measurement of rnfl on oct and on fundoscopy. however, other areas give useful information especially oct of 6 by 6 mm square optic disc cube scan. 18 in another study conducted in spain on relation of rnfl defects to cardiovascular conditions, it was noted that atherosclerosis in right carotid artery led to decreased thickness of superior rnfl. 19 other conditions leading to superior quadrant changes are ocular ischemic syndrome, neovascular glaucoma and central retinal vein occlusion. when optical coherence tomography of cigarette smokers was done it was observed that thickness of nasal quadrant was decreased. 12 another way of assessing glaucomatous damage is analyzing retinal ganglion cells. the best area to study retinal ganglion cells is the macula, their greatest number being at this area. when the efficacy of analyzing retinal nerve fiber layer was compared to that of ganglion cells by saha and karti in their research, both were equally reliable. 20,21 this was converse to what was observed by kaushik and kataria, they found retinal nerve fiber layer thickness to be a more reliable indicator of glaucoma progression than the retinal ganglion cell analysis. 7 this could be because of the distribution of the different type of ganglion cells in the retina. ganglion cells are analyzed at the macula, here p type of ganglion cells are in majority. for early diagnosis of glaucoma m type ganglion cell analysis is more reliable, which are not in the foveal region. limitation of this study is that it is a single center study and sample size is small. all patients with glaucoma were included irrespective to the stage of disease. conclusion when quadrantic analysis was done on oct in our population, the difference was most in the inferior quadrant. this is different from studies done in other populations in which nasal and temporal quadrants were more affected. this needs to be assessed with further studies in our population. ethical approval the study was approved by the institutional review board/ethical review board (osp-irb/2021/001). conflict of interest authors declared no conflict of interest. references 1. optic nerve and retinal nerve fiber imaging. available from: https://eyewiki.aao.org/optic_nerve_and_retinal _nerve_fiber_imaging 2. mariottoni eb, jammal aa, urata cn, berchuck si, thompson ac, estrela t, et al. quantification of retinal nerve fibre layer thickness on optical coherence tomography with a deep learning segmentation-free approach. sci rep. 2020; 10 (1): 402. doi: 10.1038/s41598-019-57196-y. 3. hashmani n, hashmani s. three-dimensional mapping of peripapillary retinal layers using a spectral domain optical coherence tomography. clin ophthalmol. 2017; 11: 2191-2198. 4. hondur g, göktaş e, al-aswad l, tezel g. agerelated changes in the peripheral retinal nerve fiber layer thickness. clin ophthalmol. 2018; 12: 401-409. doi: 10.2147/opth.s157429. 5. jeong d, sung kr, jo yh, yun sc. age-related physiologic thinning rate of the retinal nerve fiber layer in different levels of myopia. j ophthalmol. 2020; 2020: 1873581. doi: 10.1155/2020/1873581. 6. hood dc, slobodnick a, raza as, de moraes cg, teng cc, ritch r. early glaucoma involves both deep local, and shallow widespread, retinal nerve fiber damage of the macular region. invest ophthalmol vis sci. 2014; 55 (2): 632-649. doi: 10.1167/iovs.1313130. 7. kaushik s, kataria p, jain v, joshi g, raj s, pandav ss. evaluation of macular ganglion cell analysis compared to retinal nerve fiber layer thickness for preperimetric glaucoma diagnosis. indian j ophthalmol. 2018; 66 (4): 511-516. doi: 10.4103/ijo.ijo_1039_17. 8. sung kr, kim js, wollstein g, folio l, kook ms, schuman js. imaging of the retinal nerve fibre layer with spectral domain optical coherence tomography for glaucoma diagnosis. br j ophthalmol. 2011; 95 (7): 909-914. doi: 10.1136/bjo.2010.186924. epub 2010 oct 28. pmid: 21030413; pmcid: pmc3421150. 9. tatham aj, medeiros fa. detecting structural progression in glaucoma with optical coherence tomography. ophthalmology, 2017; 124 (12s): s57s65. doi: 10.1016/j.ophtha.2017.07.015. https://eyewiki.aao.org/optic_nerve_and_retinal_nerve_fiber_imaging https://eyewiki.aao.org/optic_nerve_and_retinal_nerve_fiber_imaging nargis nizam ashraf, et al 277 pak j ophthalmol. 2021, vol. 37 (3): 274-277 10. kausar a, akhtar n, afzal f, ali k. effect of refractive errors/axial length on peripapillary retinal nerve fibre layer thickness (rnfl) measured by topcon sd-oct. j pak med assoc. 2018; 68 (7): 1054-1059. 11. martinez-lapiscina eh, arnow s, wilson ja, saidha s, preiningerova jl, oberwahrenbrock t, et al. retinal thickness measured with optical coherence tomography and risk of disability worsening in multiple sclerosis: a cohort study. lancet neurol. 2016; 15 (6): 574-584. doi: 10.1016/s1474-4422(16)00068-5. . 12. larrosa jm, garcia-martin e, bambo mp, pinilla j, polo v, otin s, et al. potential new diagnostic tool for alzheimer's disease using a linear discriminant function for fourier domain optical coherence tomography. invest ophthalmol vis sci. 2014; 55 (5): 3043-3051. doi: 10.1167/iovs.13-13629. 13. young jb, godara p, williams v, summerfelt p, connor tb, tarima s, et al. assessing retinal structure in patients with parkinson's disease. j neurol neurophysiol. 2019; 10 (1): 485. doi: 10.4172/21559562.1000485. 14. hirasawa h, tomidokoro a, araie m, konno s, saito h, iwase a, et al. peripapillary retinal nerve fiber layer thickness determined by spectral-domain optical coherence tomography in ophthalmologically normal eyes. arch ophthalmol. 2010; 128 (11): 1420-1426. doi: 10.1001/archophthalmol.2010.244. 15. hwang yh, kim yy. glaucoma diagnostic ability of quadrant and clock-hour neuroretinal rim assessment using cirrus hd optical coherence tomography. invest ophthalmol vis sci. 2012; 53 (4): 2226-2234. doi: 10.1167/iovs.11-8689. 16. banitt mr, ventura lm, feuer wj, savatovsky e, luna g, shif o, et al. progressive loss of retinal ganglion cell function precedes structural loss by several years in glaucoma suspects. invest ophthalmol vis sci. 2013 mar; 54 (3): 2346-2352. doi: 10.1167/iovs.12-11026. 17. murugan c, golodza bz, pillay k, mthembu bn, singh p, maseko ks, et al. retinal nerve fibre layer thickness of black and indian myopic students at the university of kwazulu-natal. afr vision eye health, 2015; 74: 24. 18. zhang x, dastiridou a, francis ba, tan o, varma r, greenfield ds, et al. advanced imaging for glaucoma study group. baseline fourier-domain optical coherence tomography structural risk factors for visual field progression in the advanced imaging for glaucoma study. am j ophthalmol. 2016; 172: 94103. doi: 10.1016/j.ajo.2016.09.015. 19. wang d, li y, zhou y, jin c, zhao q, wang a, et al. asymptomatic carotid artery stenosis and retinal nerve fiber layer thickness. a community-based, observational study. plos one. 2017; 12 (5): e0177277. doi: 10.1371/journal.pone.0177277. 20. saha m, bandyopadhyay s, das d, ghosh s. comparative analysis of macular and peripapillary retinal nerve fiber layer thickness in normal, glaucoma suspect and glaucomatous eyes by optical coherence tomography. nepal j ophthalmol. 2016: 8: 110-118. 21. karti o, yuksel b, uzunel ud, karahan e, zengin mo, kusbeci t. the assessment of optical coherence tomographic parameters in subjects with a positive family history of glaucoma. clin exp optom. 2017; 100 (6): 663-667. doi: 10.1111/cxo.12523. authors’ designation and contribution nargis nizam ashraf; assistant professor: concepts, design, literature search, manuscript preparation, manuscript editing, manuscript review. nisar ahmed siyal; associate professor: concepts, design, manuscript review. muhammad ibrahim; technologist: data acquisition, manuscript review. .…  …. 79 pakistan journal of ophthalmology, 2020, vol. 36 (1): 79-82 original article fibrin glue versus autologous serum for conjunctival autograft fixation in pterygium surgery abdul rafe 1 , muhammad tariq munawar 2 , saquib naeem 3 1-3 department of ophthalmology, combined military hospital (cmh), kharian abstract purpose: to compare the outcomes of conjunctival autograft fixation using autologous serum vs fibrin glue to cover the bare sclera in pterygium excision surgery. study design: quasi experimental study. place and duration of study: ophthalmology department of cmh kharian from april 2018 to november 2018. material and methods: forty patients with primary pterygium were selected by convenient sampling technique. patients with recurrent pterygia and moderate to severe dry eyes, keratitis or secondary to trauma were excluded. the patients were divided into two groups, group a treated with fibrin glue and group b treated with autologous serum technique. all patients underwent pterygium excision under topical anaesthesia. the conjunctival autograft was removed from superior temporal bulbar conjunctiva to cover the scleral bed produced by pterygium excision. post operatively the patients were followed-up for three months to assess the fixation or otherwise. data was noted and analysed by using spss version 23. results: the patients were followed up for three months after surgery. the graft was taken-up nicely in most of the cases. the frequency of graft lost in group a and group b was noted as n = 8 (40%) and n = 1 (5%), respectively (p = 0.008). the only other complication was recurrence of pterygium which was n = 5 (25%) and n = 3 (15%), in group a and group b, respectively (p = 0.429). no case of infection was noted. conclusion: fixation of conjunctival autograft with autologous serum is a safe and effective method and potential alternative of fibrin glue technique. keywords: conjunctival autograft, pterygium, autologous serum, fibrin glue. how to cite this article: rafe a, naeem s, munawar t. fibrin glue versus autologous serum for conjunctival autograft fixation in pterygium surgery, pak j ophthalmol. 2020, 36 (1): 79-82. doi: 10.36351/pjo.v36i1.1007. introduction pterygium is a wing shaped triangular encroachment of vascularised conjunctival tissue onto the cornea in the palpebral fissure area. its prevalence ranges from 0.7% to 33% globally 1 . it is a fairly common condition seen in our part of the world because of excessive uv correspondence to: abdul rafe consultant ophthalmologist, cmh, kharian email: mabdulrafe@yahoo.com light, hot and dry climate, especially in rural areas 2 . pterygia that extend onto the cornea cause visual problems due to induced astigmatism and obstructing the visual axis along with cosmetic disfigurement 3 . since the medical management of this condition is unsatisfactory hence it needs surgical removal. surgical techniques have evolved from bare sclera technique, autorotation of conjunctival graft, use of amniotic membrane graft to the development of conjunctivo-limbal autograft 4,5,6 . one of the popular techniques used is excision of pterygium is covering mailto:mabdulrafe@yahoo.com fibrin glue versus autologous serum for conjunctival autograft fixation in pterygium surgery pakistan journal of ophthalmology, 2020, vol. 36 (1): 79-82 80 the defect with conjunctival autograft, which is either sutured or fixed with fibrin glue 7 . fixing the graft with fibrin glue reduces operative time, gives good cosmetic results and causes less post operative discomfort however like any other surgical procedure it has some disadvantages like increased cost, graft loss, granuloma formation and transmission of infection to mention a few. another technique is to use patients own serum as an adhesive agent. this has some valuable advantage of being easily available and less costly with minimum risk of transmission of infection 8 . it also reduces operative time and causes less post-operative discomfort being suture less 9 . the above mentioned qualities of autologous serum prompted us to conduct a study to assess and compare fibrin glue vis a vis patient’s own serum as a fixating agent. material and methods the study was conducted at ophthalmology department cmh kharian from april 2018 to november 2018. ethical permission was obtained from hospital ethical review board. informed written consent was obtained from patients. nonprobability consecutive sampling technique was used. the inclusion criteria were unilateral and primary pterygium. those with recurrent pterygia and moderate to severe dry eyes, younger than 25 years or older than 65 years and pterygia associated with blepharitis, sjogren’s syndrome, keratitis or secondary to trauma were excluded. patients were divided into two groups (group a and group b). patients in group a were treated with fibrin glue and in group b were treated with autologous serum. patients in group b were sent to lab before surgery where serum from their blood was removed under aseptic conditions and handed over to them. all surgeries were performed by an experienced ophthalmic surgeon. periocular skin was scrubbed with povidone iodine 1%. topical proparacaine was instilled to provide topical anaesthesia and the eye was opened by a self-retaining speculum. lignocaine with adrenaline was injected in the bed of pterygium to ensure satisfactory anaesthesia and to dissect the pterygium from the underlying sclera. pterygium was excised using no. 15 bp knife. the defect in the conjunctiva so produced was measured by a calliper. a conjunctival graft 1mm larger than the scleral bed was fashioned from the superior temporal bulbar conjunctiva taking care to avoid incorporating any tenon tissue. in group a patients the graft was immediately placed on the scleral bed after sprinkling 3 to 4 drops of fibrin glue, while in group b patients, same amount of autologous serum was sprayed on the scleral bed before placing the graft. care was taken to keep the epithelial side of the graft superficially, and a cotton tipped applicator was held gently onto the graft surface for 5 minutes followed by waiting of seven minutes for adherence of the graft. the eye pad was applied for twenty-four hours. oral nsaid were given for 24 hours to manage pain. the patients were followed on day 1, day 15 and then three months after surgery. spss version 23 was used for data analysis. numerical data was analysed and presented as mean and standard deviation like mean graft size. frequency and percentages were calculated and presented for qualitative data like gender, graft loss, recurrence and graft retraction. student t-test was applied for numerical variables and chi-square test was applied for qualitative variables to see association among variables. p value ≤ 0.05 was considered significant. results forty eyes were included, in this study. the patients were divided into two groups as group a and group b having 20 eyes each. mean age, gender distribution and graft size are shown in table 1. in group a there were 14 (70%) left eyes and 6 (30%) right eyes, while, in group b, there were 10 (50%) left eyes and 10 (50%) right eyes. lost graft was the commonest complication seen in both groups. it was noted in 8 eyes (40%) in group a and one eye (5%) in group b. the difference was statistically significant, (p = 0.008). recurrence was also higher in group treated with fibrin glue, being n = 5 (25%) whereas it was n = 3 (15%) in those treated with autologous serum, however the difference table 1: demographic characteristics and mean graft size of both groups. variable age (years) group a (n = 20) 50.81 ± 3.64 group b (n = 20) 47.89 ± 4.33 male n = 11 (55%) n = 10 (50%) female n = 9 (45%) n = 10 (50%) left n = 14 (70%) n = 10 (50%) right n = 6 (30%) n = 10 (50%) mean graft size mm 2 40.02 ± 4.09 41.45 ± 2.32 rafe a, et al 81 pakistan journal of ophthalmology, 2020, vol. 36 (1): 79-82 table 2: comparison of complications between two the groups variable group a n = 20 group b n = 20 p-value graft lost n = 8 (40%) n = 1 (5%) 0.008 recurrences n = 5 (25%) n = 3 (15%) 0.429 was statistically insignificant, (p = 0.429). no case of infection or anaphylaxis was noted. discussion pterygium is a very common condition seen in our country because of lot of sun light, dust, smoke and hot and dry climate. surgical excision with conjunctival auto-graft is the treatment of choice 10 . this technique was first described by kenyon et al in 1985 11 . since then this procedure is under continuous modification to improve cosmetic results and reduce recurrence 12 . suturing the graft was the initial practice. this was also shown by prabhaswat et al 13 who reported that conjunctival autograft was associated with minimum side effects and better outcomes. it has few drawbacks like longer operation time, irritation in post-operative periods and a higher incidence of granuloma formation, which is seen due to the use of sutures. our study aimed to assess methods of fixing the conjunctival graft, other than suturing. fibrin glue and autologous serum are the two popular methods serving this objective. in a study by koranyi et al 14 , fibrin glue technique was reported to be a good alternative to suturing which was associated with reduced surgical time, and fewer complications and discomfort after surgery. however, it is not free of side effects like transmission of infection, as was reported by foroutan et al 15 . de wit et al, 16 conducted a study and reported that anaphylactic reactions may occur with use of fibrin glue. in our study we did not observe any anaphylactic reaction or any case of infection. ayala et al, 17 reported in his study that recurrence rate was higher in fibrin glue group as compared to autologous serum group. this finding is in conformity with our study. they found that other complications were also higher in fibrin glue technique. farid et al, 18 also conducted a study in 2009 and reported that recurrence rate in fibrin glue group was higher however there was no case of anaphylactic reaction, a finding consistent with the observations in our study. srinivasan et al, 19 in his study published in 2009 also found a higher recurrence rate with fibrin glue technique along with poor attachment, whereas sati et al, 20 also conducted a similar study but reported contrary finding to our study and previous studies that graft loss and recurrence rate was similar in both techniques. he observed that the higher rate of graft rejection might be because of graft size rather than the technique of fixation. there are other studies which have shown that none of the techniques has advantage over the other as was shown by kurian et al, 21 who found that percentage of graft loss was same in both fibrin glue and autologous blood group. malik et al, 22 were also of the same view and found that there was no advantage of fibrin glue over the autologous serum. however, we found in our study that autologous serum group had fewer complications and overall better results compared to fibrin glue group. it is obvious from the above mentioned studies as well as our study that both the autologous serum and fibrin glue are promising methods for fixing autograft after pterygium excision. our study has shown slightly better results with autologous serum, moreover it is cheap, easily available and safe. our study has few limitations including relatively small sample size, shorter period of follow up and single centre study. further studies are needed to establish a definite superiority of one over the other. conclusion pterygium excision with conjunctival autograft gives better results. fixation of conjunctival autograft with autologous serum is a safe and potential alternative of fibrin glue technique, however more studies are needed to assess and recommend the better option in our part of the world. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution abdul rafe; consultant ophthalmologist: research planning, manuscript writing, final review. fibrin glue versus autologous serum for conjunctival autograft fixation in pterygium surgery pakistan journal of ophthalmology, 2020, vol. 36 (1): 79-82 82 muhammad tariq munawar; consultant ophthalmologist: research planning, final review. saquib naeem; consultant 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68-72. 12. zein h, ismail a, abdelmongy m, elsherif s, hassanen a, muhammad b et al. autologous blood for conjunctival autograft fixation in primary pterygium surgery: a systematic review and metaanalysis. current pharm des. 2018; 24 (35): 41974204. 13. prabhasawat p, barton k, burkett g. comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. ophthalmology, 1997; 104 (6): 974-85. 14. koranyi g, seregard s, kopp ed. the cut-and-paste method for primary pterygium surgery: long-term follow-up. acta ophthalmol scand. 2005; 83 (3): 298301. 15. foroutan a, beigzadeh f, ghaempanah mj, eshghi p, amirizadeh n, sianati h. efficacy of autologous fibrin glue for primary pterygium surgery with conjunctival autograft. iranian j ophthalmol. 2011; 23 (1): 39-47. 16. wit-d, athanasiadis i, sharma a. suture less and glue-free conjunctival autograft in pterygium surgery: a case series. eye, 2010; 24 (9): 1474-7. 17. ayala m. results of pterygium surgery using a biologic adhesive. cornea, 2008; 27 (6): 663-7. 18. farid m, pirnazar jr. pterygium recurrence after excision with conjunctival autograft: a comparison of fibrin tissue adhesive to absorbable sutures. cornea, 2009; 28 (1): 43-5. 19. srinivasan s, dollin m, mc callum p. fibrin glue versus sutures for attaching the conjunctival autograft in pterygium surgery: a prospective observer masked clinical trial. br j ophthalmol. 2009; 93 (2): 215-8. 20. sati a, shankar s, jha a. comparison of efficacy of three surgical methods of conjunctival autograft fixation in the treatment of pterygium. int ophthalmol. 2014; 34 (6): 1233-9. 21. kurian a, reghunadhan i, nair kg. autologous blood versus fibrin glue for conjunctival autograft adherence in suture less pterygium surgery: a randomised controlled trial. br j ophthalmol. 2015; 99 (4): 464-70. 22. malik kp, goel r, gutpa a, gupta sk, kamal s, mallik vk. efficacy of suture less and glue free limb conjunctival autograft for primary pterygium surgery. nepal j ophthalmol. 2012; 4 (2): 230-5. .…  …. 103 pak j ophthalmol. 2022, vol. 38 (2): 103-108 original article to compare the day-time phasing with one-time supine position iop in patients with primary open angle glaucoma and normal tension glaucoma aneeq ullah baig mirza 1 , asim mehboob 2 , muhammad usman arshad 3 , sohail zia 4 , aamir asrar 5 1,2,3,4 islamic international medical college, riphah university rawalpindi, 5 amanat eye hospital, rawalpindi abstract purpose: to compare the intraocular pressure (iop) during 12 hour day-time phasing with one-time supine position iop. study design: prospective, observational. place and duration of study: glaucoma clinic of a tertiary eye – care center in rawalpindi, pakistan, from september 2020 to february 2021. methods: forty two eyes of 21 participants with primary open angle and normal tension glaucoma were included in the study by convenient sampling technique. three hourly diurnal applanation tonometry was performed in sitting position from 9:00 am to 9:00 pm. mean iop and standard deviations were calculated. one-time supine position iop was taken by perkins tonometer at 9:10 pm. mean iop at 9:00 pm in sitting position was compared with the mean iop in supine position. results: there were 15 males (71.42%) and 6 females (28.58%) in the study. means of sitting position iop during different times of the day ranged between 16.64 and 18.16 mmhg. the mean of iop measured at 9:00am, 12:00 pm, 3:00 pm, 6:00 pm and 9:00 pm was 17.62 ± 4.04 mmhg. mean supine position iop at 9:10 pm was 22.38 ± 5.92 mmhg. mean difference between supine and sitting position iop was 4.75 ± 3.65 mmhg. this was statistically significant p-0.001.direct comparison between sitting and supine iop at 9:00 pm and 9:10 pm revealed the values to be 17.88 and 22.38 mmhg respectively (p < 0.001). conclusion: one-time supine position iop gives a higher value than any one – time of iop recorded during 12hour diurnal phasing performed in sitting position. key words: intra ocular pressure, diurnal phasing, primary open angle glaucoma, normal tension glaucoma. how to cite this article: mirza aub, mehboob a, arshad mu, zia s, asrar a. to compare the day-time phasing with one-time supine position iop in patients with primary open angle glaucoma and normal tension glaucoma. pak j ophthalmol. 2022, 38 (2): 103-108. doi: 10.36351/pjo.v38i2.1356 correspondence: aneeq ullah baig mirza islamic international medical college, riphah university, rawalpindi email: aneeqmirza07@gmail.com received: december 12, 2021 accepted: february 16, 2022 introduction intra ocular pressure (iop) is a dynamic parameter, which undergoes constant variations during 24 hour time period which are determined by circadian rhythm and body posture. 1,2 it is a well-known fact that a higher iop constitutes a major risk for glaucomatous damage. 3 clinical tonometry involves sitting position iop only. it does not take into account the variations in response to posture, muscular effort, deep respiration, wearing swimming goggles, repeated eye touching, rubbing etc. there are four different types of iop fluctuations; instantaneous, diurnal-nocturnal, short-term and longterm. instantaneous iop fluctuations occur within seconds e.g. saccades, blinking, eye rubbing etc. there is no evidence that instantaneous iop fluctuations lead day-time phasing versus one-time supine position iop in patients with primary open angle glaucoma pak j ophthalmol. 2022, vol. 38 (2): 103-108 104 to glaucoma progression. diurnal-nocturnal iop fluctuations occur over 24 hour time period e.g. variations with blood pressure and episcleral venous pressure, changes with body posture, fluctuations in cortisol levels, rate of aqueous production, environment light and dark cycles and seasonal influences. 4 evidence indicates that 24 hour iop fluctuations leads to glaucoma progression. de moraes et al 5 found that the number of larger peaks in iop and the mean-peak ratio (mean peak height to the time to peak) could very well indicate the chances of accelerated glaucomatous damage. short-term fluctuations occur over days to weeks and long-term fluctuations occur over months to years. there are four characteristics of a patient’s iop which are associated with glaucoma progression i.e. a higher base-line iop, a higher mean iop, a higher peak iop and increased iop fluctuation. 6 short-term iop fluctuations can predict long-term fluctuations. 7 continuous monitoring of iop fluctuations can be done with contact lens sensor. it can measure the changes in the corneo-scleral limbal circumference with changes in iop. 8,9 the iop measurement with contact lens sensor has proven to be correct and can be taken without interrupting the patient’s sleep and provides reproducible results. 10,11 contact lens sensor is not widely available in ophthalmic centers across the world. literature suggests diurnal/24 hour phasing of iop in sitting position, which is a very unreliable method because it does not take into account the iop changes associated with lying down posture. 12 besides, it is time consuming for both the patient and the doctor. our study focused on the assumption that a single supine position iop reading might give a higher value than 12 hour phasing. if it does, then it would provide a better picture about two important factors leading to glaucoma or its progression i.e. the peak and mean iop. methods a study of diurnal and one-time supine position iop was carried out in 42 eyes (21 patients) at amanat eye hospital, rawalpindi, from september 2020to february 2021. patients with poag (primary open angle glaucoma) and ntg (normal tension glaucoma) were included. ethical committee approved the study. a self-designed proforma was completed by researcher endorsing subject’s demography and ocular examination findings. informed consent was received from the patient and confidentiality of the patient’s record was maintained. diurnal iop readings were taken with applanation tonometer in sitting position at 9.00 am, 12.00 noon, 3.00 pm, 6.00 pm and 9.00 pm. their mean and sd (standard deviation) were calculated. after the last reading at 9.00 pm, the patients were laid in supine position. 10 minutes later, iop was checked by perkins tonometer, in supine position. the mean iop and standard deviations were calculated. for each case, the calibration of perkins tonometer was checked (in sitting position) and confirmed by comparing with applanation tonometer. statistical package for social sciences (spss 20.0) for windows was used for statistical analysis. descriptive statistics i.e. mean ± standard deviation for quantitative values (age, iop) and frequencies along with percentages for qualitative variables (gender, laterality of eyes, over/under estimation) were used to describe the data. shapiro wilk test was used to test normality of data. post normality testing, paired ‘t’ test was used to compare mean iop measurement during sitting positions with mean iop measured during supine position. p value of < 0.05 was considered statistically significant. results there were 15 males (71.42%) and 6 females (28.58%) in the study. the age ranged from 20 to 90 years. out of 21 patients, 18 fell into the 40-70 years age group. a total of 42 eyes of 21 patients were evaluated. laterality of eyes was thus equal (50% right and 50% left).there were 13 poag, 5 ntg and 3 ocular hypertension patients. on diurnal phasing, mean iop showed a slight elevation at 9.00 am, a fall at 12.00 noon, a rise again at 3.00 pm, followed by a fall at 6.00 pm and then a rise at 9.00 pm (table 1). mean iop ranged between 16.64 to 18.16 mmhg during the day-time phasing (table 1). table 1: mean intraocular pressure in upright position with standard deviation. obs. no. time of the day mean intraocular pressure (mmhg) standard deviation 1. 9.00 am 18.00 4.2138 2. 12.00 pm 17.4524 4.27815 3. 3.00 pm 18.1667 3.88189 4. 6.00 pm 16.6429 4.81776 5. 9.000 pm 17.881 4.58099 aneeq ullah baig mirza, et al 105 pak j ophthalmol. 2022, vol. 38 (2): 103-108 overall mean of iop measured at 9am, 12pm, 3pm, 6pm, and 9pm (calculated for ease of comparison) was 17.62 ± 4.04 mmhg. mean iop measured in supine position was 22.38 ± 5.92 mmhg (figure 1). mean difference of supine position iop and day – time sitting position iop was 4.75 ± 3.65 mmhg which was statistically significant p < 0.001. on direct comparison in the evening time, mean iop in upright position at 9:00 pm was 17.88 mmhg (sd 4.58099) while mean iop in supine position at 9.10 pm was 22.38 mmhg (sd 5.92206). this difference was statistically significant p < 0.001. the highest iop was recorded in 35.7% eyes at 9.00 am, 31% eyes at 3.00 pm, 19% eyes at 9.00 pm and 7.1% eyes at 12.00 noon and 6.00 pm. the lowest iop was recorded in 31% eyes at 6.00 pm, 26.2% eyes at 12.00 noon, 21.4% eyes at 9.00 am, 16.7% at 9.00 pm and 4.8% at 3.00 pm. mean change in iop from maximum observed iop in sitting position to supine position was 3.07 ± 3.92 mmhg while the mean change from minimum observed iop in sitting position to supine position was 6.57 ± 4.06 mmhg. this signifies the fluctuations in iop. majority of the cases (18 eyes) had the difference between means of upright position phasing iop and supine position iop in the range of 2 – 4 mmhg. (table 2). figure 1: comparison of means of diurnal upright phasing with one-time supine position iop. table 2: mean upright phasing iop and supine position iop difference versus number of eyes. iop difference (mmhg) no. of eyes (42) ˂2 8 2 – 4 18 5 – 9 11 ˂10 5 discussion phasing is a dynamic observation of iop. our study showed that one-time supine position iop at 9.10 pm gave a higher value than 3 hourly phasing in sitting position. this difference was statistically significant. mean iop at 9.00 pm in sitting position was 17.88 mmhg and at 9.10 pm in supine position was 22.38 mmhg. the literature says that on assuming supine position, the iop rises within 2 minutes. 13 if the day-time supine position iop is significantly higher than the day-time sitting position iop, we may presume that the same phenomenon works at night time and during sleep. one of the studies of 177 patients with normal tension glaucoma has shown that night-time habitual position iop is significantly higher than night-time sitting position iop. 14 however, no correlation was found between iop and visual field damage. in contrast, our study included both poag and ntg. however, the number of cases was much less and visual field correlation was not determined. both studies showed elevation of iop on assuming supine position. the ideal method of studying 24-hour iop behavior in patient’s physiological conditions is by using the triggerfish contact lens. this can help in diagnosing the true ntg patients. researchers in toyama university, japan studied the 24 hour iop fluctuations between 14 ntg and 12 non-glaucoma patients by sensimed triggerfish contact lens. 15 they discovered that iop fluctuations were significantly higher in ntg patients (p-0.007). this higher range of iop fluctuations among ntg patients could be the reason behind progressive visual field deterioration in these patients. our study highlights the significance of combined diurnal phasing and supine iop in the absence of availability of triggerfish contact lens to observe the iop behavior in ntg cases. generally, the at-risk glaucoma patients require 24-hour iop monitoring, especially those who show progression despite treatment. due to its practical difficulties, a surrogate method can be adopted. this includes diurnal iop readings and a single morning supine position iop measurement. the supine position iop elevation may represent the nocturnal iop. 16 in our study, a single supine iop was recorded at 9.10 pm. if it was recorded in the morning, the iop might have been even higher as the normal diurnal fluctuation shows a higher iop in early morning. the hindrance was availability of patients and the staff day-time phasing versus one-time supine position iop in patients with primary open angle glaucoma pak j ophthalmol. 2022, vol. 38 (2): 103-108 106 during early morning hours. supine position iop elevation reverses 10 minutes after resuming the erect position. supine measurement of iop in office hours can improve the estimate of maximum iop during 24 hours period in patients with glaucoma. 13 fogagnolo p et al 13 concluded that the collection of supine and sitting office-hour measurements help in estimation of 24 hour iop characteristics in both control subjects and glaucoma patients. only a minority of patients require 24 hour phasing. the implications of our study are similar to their findings. in a study of healthy volunteers and untreated poag patients regarding 24-hour iop fluctuation, it was revealed that nocturnal supine iop was higher than the day-time sitting and supine iop. 17 their study contradicts our assumption that day – time supine iop represents nocturnal supine iop. we did not determine the nocturnal supine iop. however, both studies strengthen the significance of supine iop. supine daily iop measurements may estimate the peak nocturnal iop better than the sitting position iop. 18 one of the studies on patients of pigment dispersion syndrome and glaucoma has shown a significant increase in iop on posture change from recumbent to lateral decubitus and more so in prone position. it implies that dependency enhances iop elevation. 19 just like our study, this fact is also proven in similar studies for other conditions. 20,21 change in neck position may affect the internal carotid artery and internal jugular vein thus resulting in raised episcleral venous pressure. 22 on recumbent position, episcleral venous pressure rises suddenly due to absence of valves in orbital veins. 23 even if we know that supine position iop is higher than the sitting position iop, the question is; does it really lead to glaucomatous damage? in one of the studies performed on ntg patients, it was seen that the eyes with higher recumbent position iop showed a greater visual field loss on humphrey field analyzer as increasing mean deviation and decreasing visual field index. 24 the focus of our study was on supine iop rather than visual field changes. in a questionnaire about the preferred lateral decubitus position during sleep, it was observed that it correlated with asymmetric and more visual field loss, in eyes with ntg and poag. 21 short-term recumbent position iop studies (5 – 30 min) have not shown significant ocular perfusion pressure changes, which makes this position vulnerable to glaucomatous damage. 25 inclusion of supine position iop provides a closer picture of the mean iop, which is one of the major factors determining glaucomatous damage. conventional day-time phasing in sitting position gives a very limited information and can misdiagnose a lot of poag as ntg cases. our study highlights the significance of supine iop. we recommend that supine iop be included in the routine ophthalmic examination for the diagnosis of ntg and unexplained visual loss in poag patients who are apparently controlled on anti-glaucoma therapy. for cases with advanced glaucoma, diurnal phasing and supine position iop should be combined in order to get a better picture of mean iop and fluctuations. the weakness of our study is that comparative 3 hourly supine position iop was not taken. if that is included in further studies, we can get information about the maximum fluctuation that is possible between the lowest and the highest iop. further studies should be carried out on larger population samples to compare the supine iop with phasing, determine the effects of supine position on nocturnal iop and consequent visual field changes. conclusion one time supine position iop gives a higher value than any one time of iop reading in sitting position in day-time phasing. supine iop measurement gives a better information for diagnosis of normal tension glaucoma. moreover, for patients with unexplained visual loss but normal sitting iop during diurnal phasing, supine iop should be obtained. combined sitting iop in phasing and supine iop measurement should be conducted in high risk cases to obtain better information about mean iop and fluctuations in 24 hours. ethical approval the study was approved by the institutional review board/ ethical review board (ripah/irc/20/218). conflict of interest authors declared no conflict of interest. aneeq ullah baig mirza, et al 107 pak j ophthalmol. 2022, vol. 38 (2): 103-108 references 1. quaranta l, katsanos a, russo a, riva i. 24-hour intraocular pressure and ocular perfusion pressure in glaucoma. surv ophthalmol. 2013; 58 (1): 26-41. 2. liu jhk, zhang x, kripke df, weinreb rn. twenty four hour intraocular pressure pattern associated with early glaucomatous changes. invest ophthalmol vis sci. 2003; 44 (4): 1586-1590. 3. leske mc, heijl a, hussein m, bengtsson b, hyman l, komaroff e. factors for glaucoma progression and the effect of treatment: the early manifest glaucoma trial. arch ophthalmol. 2003; 121: 48-56. 4. kim jh, caprioli j. intraocular pressure fluctuation: is it important? j ophthalmic vis res. 2018; 13 (2): 170-174. 5. de moraes cg, jasien jv, simon-zoula s, liebmann jm, ritch r. visual field change and 24hour iop-related profile with a contact lens sensor in treated glaucoma patients. ophthalmology, 2016; 123: 744-753. 6. komori s, ishida k, yamamoto t. results of longterm monitoring of normal-tension glaucoma patients receiving medical therapy: results of an 18-year follow-up. graefes arch clin exp ophthalmol. 2014; 252 (12): 1963-1970. 7. tojo n, abe s, miyakoshi m, hayashi a. correlation between short-term and long-term intraocular pressure fluctuation in glaucoma patients. clin ophthalmol. 2016 sep 2; 10: 1713-7. doi: 10.2147/opth.s116859. pmid: 27621590; pmcid: pmc5015882. 8. mansouri k, shaarawy t. continuous intraocular pressure monitoring with a wire-less ocular telemetry sensor: initial clinical experience in patients with open angle glaucoma. br. j ophthalmol. 2011; 95 (5): 627-629. 9. leonardi m, pitchon em, bertsch a, renaud p, mermoud a. wire-less contact lens sensor for intraocular pressure monitoring: assessment on enucleated pig eyes. acta 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ophthalmology, 2006; 113 (12): 2150-2155. day-time phasing versus one-time supine position iop in patients with primary open angle glaucoma pak j ophthalmol. 2022, vol. 38 (2): 103-108 108 25. buys ym, alasbali t, jin yp, smith m, gouws p, geffen n, et al. effect of sleeping in a head-up position on intraocular pressure in patients with glaucoma. ophthalmology, 2010; 117 (7): 1348-1351. authors’ designation and contribution aneeq ullah baig mirza; professor: concepts, design, literature search, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. asim mehboob; consultant ophthalmologist: design, data analysis, statistical analysis. muhammad usman arshad; assistant professor: design, literature search, data analysis. sohail zia; associate professor: design, literature search, data acquisition, manuscript review. aamir asrar; consultant ophthalmologist: design, literature search, data acquisition, manuscript review. .…  …. pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 9 original article effectiveness of intralesional triamcinolone acetonide in the treatment of chalazion mohammad zeeshan tahir, mubashir rehman, imran ahmad., asif aqbal, ibrar hussain pak j ophthalmol 2015, vol. 31 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mubashir rehman department of ophthalmology lady reading hospital peshawar. dr_mubashir@yahoo.com …..……………………….. purpose: to determine the effectiveness of intralesional injection of triamcinolone acetonide in the treatment of chalazion. material and methods: all patients meeting the inclusion criteria were included in the study through opd. chalazion was diagnosed on the basis of presence of painless and non tender nodule in the eye lid with size of between 2 mm to 11 mm. under strict aseptic technique 0.1 to 0.2 ml of triamcinolone acetonide (40 mg/ml) was injected intralesionally by an expert ophthalmologist. follow up visit was done at two weeks to determine effectiveness in term of reduction in size of chalazion by 2 mm. results: the mean pre-operative size of chalazion among all patients was 5.1 ± 2.1 mm. at 2 weeks follow up, the successful results (reduction in at least 2 mm size of chalazion from pre-operative size) of intralesional triamcinolone injection were achieved in 92% of patients with 95% in females and 96% in males. conclusion: intralesional injection of triamcinolone acetonide is highly effective in the treatment of chalazion with size between 2 mm to 11 mm with high effectiveness rates in sizes less than 6 mm. key words: chalazion intralesional triamcinolone meibomian gland. ocal swelling of the eyelid is a common complaint that is seen in the primary care or urgent care setting. often, the swelling can be identified as either a hordeolum (stye) or a chalazion, although several other benign and malignant processes can be mistaken for these two.1 chalazia are the most common inflammatory lesions of the eyelid. a chalazion is a slowly enlarging nodule on the eyelid that is formed by inflammation and obstruction of meibomian glands. chalazia can further be categorized into superficial or deep, depending on which glands are blocked.2 different teatment options for chalazion include conservative management such as hot compresses and topical antibiotics, incision and curettage and intralesional steroid injection.3 chalazia can reoccur, and those that do should be evaluated for malignancy.2, 3 incision and curettage is one of the most commonly performed effective surgical procedure for chalazion.4 triamcinolone acetonide has been effectively used in the ocular therapeutics for over 50 years; its use has increased dramatically in recent years for periocular and intraocular treatment5. intralesional triamcinolone acetonoid have also been tried as a treatment of chalazion6 and it had showed a success rate of 62%7, 89.6%8 and 76%.9 intralesional triamcinolone acetonoid injection is an effective and safe alternative procedure to surgical incision and curettage for the treatment of chalazion.7 in primary and recurrent chalazion it is effective in achieving lesion regression and it may be considered as a first line treatment in cases where the diagnosis is straight forward.10-12 material and methods this study was conducted at department of f javascript:showrefcontent('refrenceslayer'); mohammad zeehan tahir, et al 10 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology ophthalmology, eye “b” unit khyber teaching hospital peshawar from 1st dec, 2010 to 31st may, 2011. sample size was 142, which was calculated on the basis of following assumptions using who sample size calculator: 62% effectiveness of triamcinolone acetonide,7 95% confidence interval and 8% margin of error. all patients presented with chalazion with size between 2 mm to 11 mm diagnosed on the basis of history and clinical examination under slit lamp biomicroscopy of any age group from both genders were included in the study through opd. patients with infected chalazion, multiple chalazion, very large chalazion > 11 mm and those with a history of prior treatment to chalazion whether surgical or conservative were excluded from the study. chalazion was diagnosed on the basis of presence of painless and non tender nodule in the eye lid with size of between 2 mm to 11 mm measured with caliper. the purpose and benefits of the study were explained to all patients, the patients were assured that the study is done purely for research and publication and a written informed consent was obtained from all patients who were included in the study. all patients were worked up with complete history and complete systemic and ophthalmologic examination. under strict aseptic technique 0.1 to 0.2 ml of triamcinolone acetonide (40 mg/ml) was injected intralesionally by an expert ophthalmologist. the patient was kept under observation in the opd for 30 minutes and was advised to go home. follow up visit was done at two week to determine effectiveness in terms of reduction in size of the chalazion by at least 2 mm. strictly exclusion criteria were followed to control confounders and bias in the study results. data was analyzed in spss version 10 for windows. mean and sd was calculated for quantitative variable like age and pre and post injection size of chalazion. frequency and percentages were calculated for categorical variables like sex and effectiveness. effectiveness was stratified among age, sex and pre injection size of chalazion to see the effect modification. results in this study, 142 patients with chalazion had been included, in which 88 (61.97%) were male and 54 (38.03%) were female patients. male to female ratio was 1.62:1. patients age was divided in four categories, out of which most presented in young age i.e. less than or equal to 30 years which were 77 (54.2%) while 50 (35.2%) patients were in the age range of 31 – 40 years, 4 (2.8%) were of age range 41-50 years and 11 (7.7%) presented at age more than 50 years. the study included age ranged from 22 up to 59 years. average age was 32.29 years + 8.4 sd table 1. table 1: age wise distribution of the patients. age in years no. of patients n (%) cumulative percent <= 30 77 (54.2) 54.2 31 40 50 (35.2) 89.4 41 50 4 (2.8) 92.3 51+ 11 (7.7) 100.0 total 142 (100) over all efficacy of the intralesional injection of triamcinolone acetonide in the treatment of chalazion was 91.5%. age wise distribution of efficacy results shows that majority of the efficacy 72 (55.4%) were found in less than or equal to 30 years of age, 43 (33.1%) patients have age groups of 31 – 40 years, 4 (3.1%) have age range of 41 – 50 years and 11 (8.5%) cases have age range of more than 50 years of age table 2. table 2: age wise distribution of efficacy. age (in years) efficacy total n (%) yes n (%) no n (%) <= 30 72 (55.4) 5 (41.7) 77 (54.2) 31 – 40 43 (33.1) 7 (58.3) 50 (35.2) 41 50 4 (3.1) 0 (.0) 4 (2.8) 50 + 11 (8.5) 0 (.0) 11 (7.7) total 130 (100) 12 (100) 142 (100) effectiveness of intralesional triamcinolone acetonide in the treatment of chalazion pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 11 average pre-injection size of chlazion was 5.1mm + 2.1 sd with a range of 2 – 11 mm. efficacy wise distribution shows that 100% efficacy was seen in the range of 2 – 6 mm. in chalazion 6.01 – 9 mm in size injection of triamcinolone was effective in 26 (74.32%) patients, while in chalazion above 9 mm it was effective in 13 (81.2%) patients. 74.32% (26 patients) efficacy was observed in 6.01-9 mm while 81.2% (13 patients) efficacy was observed in above 9 mm size of chalazion table 3. table 3: pre-injection size of chlazion wise distribution of efficacy. pre-injection size of chlazion efficacy total n (%) yes n (%) no n (%) 2 6.00 91 (100) 0 (.0) 91 (100) 6.01 – 9.00 26 (74.3) 9 (25.7) 35 (100) 9.01+ 13 (81.2) 3 (18.8) 16 (100) total 130 (91.5) 12 (8.5) 142 (100) table 4. pre-injection size of chlazion wise distribution of gender pre-injection size of chlazion gender total n (%) female n (%) male n (%) 26.00 42 (77.8) 49 (55.7) 91 (64.1) 6.01-9.00 8 (14.8) 27 (30.7) 35 (24.6) 9.01+ 4 (7.4) 12 (13.6) 16 (11.3) total 54 (100) 88 (100) 142 (100) the majority of females i.e. 77.8% presented with chalazion between size 2 mm 6 mm, who presented with size above 6 mm up to 9 mm were only 14.8% and the left over were only 7.4% of females; who presented with chalazion with a pretreatment size of above 9 mm table 4. discussion localized swelling of the eyelid is one of the common conditions with which patients presents to ophthalmology department3. chalazion is the most common lesion responsible for focal swelling of the eyelid. it is a slowly enlarging nodule which occur as a result of meibomian gland inflammation and obstruction.13 the treatment of chalazia consists of frequent daily use of warm compresses, eyelid hygiene, and topical anti-inflammatory medications in the acute inflammatory phase.14 antibiotic therapy may be necessary in case of a secondary bacterial infection.15 if these measures fail, then surgical incision and curettage or intralesional corticosteroid injection may be necessary. however, the steroid therapy is most effective when the chalazion has not been secondarily infected. if this has already happened surgery is the method of choice.16, 17 intralesional steroid injection for the treatment of chalazion was described first by leinfelder 1964,10 since then many studies proclaimed the efficacy of intralesional corticosteroid injection. our study was designed to determine the effectiveness of intralesional triamcinolone in the treatment of chalazion with a range in size between 2 mm to 11 mm. the successful treatment was set at the reduction in size of chalazion of at least 2 mm from baseline pre treatment size of the chalazion. intralesional triamcinolone acetonide injection was an effective, safe and rapid form of treatment. most of the patients displayed prompt and lasting resolution within 2 weeks after 1 injection. the results were astonishing and much more comparable to previous studies. in our study the overall effectiveness of intralesional triamcinolone acetonide using only one injection was observed in 92% of patients with failure in only 8% of patients who were later referred for incision and curettage under local anesthesia. this was not surprising since the association of chalazion with cosmetic disfigurement among females was an issue they wanted to address quickly. among males, 55% of them presented with chalazion between size 2 mm – 6 mm, 29% presented with size above 6mm and up to 9 mm and only 21% of males presented with size above 9 mm up to 11 mm. although the overall effectiveness of the intralesional triamcinolone injection was 92% in our study, but it was observed that the results are even better and conclusive in the patients who presented with size between 2mm-6mm with the success rate of javascript:showrefcontent('refrenceslayer'); mohammad zeehan tahir, et al 12 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology 100%. among patients who presented with size above 6mm to 9mm the success rate was 97% and even lower among patients who presented with size above 9mm up to 11mm with success rate of 90%. a study conducted to determine effectiveness of chalazion (a reduction in size of chalazion of at least 2mm from baseline pre operative size was considered effective.) among children by thabit et al showed that the mean age group in his study was 9.5 years with 50% males and 50% females, the results showed that 75%18 of chalazia resolved after 2 weeks of injection of triamcinolone acetonide. in his study, although the overall efficacy was somehow different from our study, but he concluded since chalazia are quite common in younger age groups and so as the efficacy of the triamcinolone injection. he also concluded that the efficacy didn’t vary between genders although younger females present at early stages. the results of our study were not much different from his study, in his study the efficacy of intralesional triamcinolone among females was 88%18 with 90%18 males showing successful results after 2 weeks, same was found in our study that the efficacy of intralesional triamcinolone acetonide among females was 95% with 96% among male gender. since the chalazion is not common in older age groups, most of the patients presenting in our study with chalazion had a mean age of 31 + 7.8 years and almost similar age group was observed in a study conducted by dhaliwaal ms reporting a mean age group of patients presenting with chalazion was 35.1 years19. chalazion can also vary in size, but the time of presentation depends upon how the patient cares about it and especially the pain associated with it if it is secondarily infected.15 in our study, most of the patients presented with a range in size between 2 mm to 6mm with 77% females and 55% males. in a study conducted by jakko palwa, he also reported that 45% of overall patients presented with size less than 6 mm.20 the results are much closer to what was done in previous studies. ammyanah et al reported the success rate of intralesional triamcinolone acetonide injection to be 84%21 however the only difference in his and our study was that he followed the patients for 3 weeks but in our study the maximum follow up to determine the effectiveness was set at 2 weeks. similarly the study reported by gil a et al concluded that the effectiveness of intralesional triamcinolone is even more successful if combined with incision and curettage and he reported it to be 96%,22 although much closer to the effectiveness of our study but it can lead to opening of further research work to be done over combined treatment approach. however the results of our study are little different from one study conducted by watsan p concluding that the success of the injection of triamcinolone is only achieved in 77%23 of cases as compared to 92% in our study. the results of a study conducted by colonel jorma castrén were also in close approximation to our study, in his study he reported a success rate of intralesional triamcinolone acetonide to be 88%24 even much closer to 92% achieved in our study. however, the literature about efficacy is so vast that the variable results have been coated by different authors. in a study conducted by pizzarello ld concluded his study with the success rate of only 65%25 and lung hang reported it to be 60%26 while watson ap showed effectiveness of 77%27 and dr hetal k reported success rate of intralesional triamcinolone acetonide of 70%28 much lower to what was achieved in our study of 92%. kim yw in his study reported slightly better success rate of intralesional triamcinolone for chalazion and concluded his study at 80%29 of success with one injection at 2.5 weeks follow up getting closer to results of our study and even a higher success rate was reported by somdutt prasad of 94.1%30. chung cf, concluded in his study that the success rate of intralesional triamcinolone was 93.8% with mean prior duration of chalazion before treatment was significantly shorter in success cases than in failed cases.31 the success rate is quite closer to our study but the only difference was that in our study we didn’t take data regarding the pre treatment duration of chalazion. conclusion this study was designed to determine the effectiveness of intralesional triamcinolone injection in the treatment of chalazion. the study proved that the intralesional triamcinolone is an effective treatment of chalazion. especially considering the size of chalazion, the intralesional injection of triamcinolone is found to be heavily effective among patient presenting with size less than 6mm with little failure rates in the sizes above 6mm. so from this study the http://www.ncbi.nlm.nih.gov/pubmed?term=%22pizzarello%20ld%22%5bauthor%5d effectiveness of intralesional triamcinolone acetonide in the treatment of chalazion pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 13 conclusion can be drawn that for chalazion with sizes less than 6mm the intralesional injection of triamcinolone can be used as a first line therapy keeping other treatment modalities considered with sizes above 6mm. author’s affiliation dr. mohammad zeeshan tahir medical officer, department of ophthalmology lady reading hospital, peshawar dr. mubashir rehman medical officer, department of ophthalmology lady reading hospital, peshawar dr. imran ahmad assistant professor jinnah medical college, peshawar dr. asif aqbal vitreeoretina trainee department of ophthalmology hayatabad medical complex, peshawar dr. ibrar hussain professor, eye “b” unit department of 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http://www.ncbi.nlm.nih.gov/pubmed?term=%22ho%20sy%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22lai%20js%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed/11861988 http://www.ncbi.nlm.nih.gov/pubmed/11861988 http://www.ncbi.nlm.nih.gov/pubmed/11861988 http://www.ncbi.nlm.nih.gov/pubmed?term=%22mohan%20k%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22dhir%20sp%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22munjal%20vp%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22jain%20is%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed/3592474 http://www.ncbi.nlm.nih.gov/pubmed/3592474 http://www.ncbi.nlm.nih.gov/pubmed/3592474 329 pak j ophthalmol. 2020, vol. 36 (4): 329-334 original article histopathological features of group e retinoblastoma eyes after upfront enucleation muhammad usman viyani 1 , jamal mughal 2 , muhammad owais arshad 3 , anum javed 4 , javeria nasir 5 , muhammad hanif chatni 6 1-6 department of ophthalmology, patel hospital, karachi abstract purpose: to study histopathological features of eyes with intraocular group e retinoblastoma primarily treated by enucleation at a tertiary care centre in karachi, pakistan. study design: retrospective histopathological study. place and duration of study: department of ophthalmology, patel hospital, karachi, january 2012 to august 2019. methods: seventy five eyes of children diagnosed with group e retinoblastoma, on clinical examination, examination under general anaesthesia along with mri and then enucleated were examined histopathologically after being primarily enucleated. histological features were enlisted for the presence of choroidal invasion, extent of optic nerve invasion, anterior chamber involvement, scleral and extra-scleral invasion along with tumour differentiation. demographic variables (age at presentation, gender, laterality of the disease, median follow-up) and the histopathological features of tumour along with high risk features were assessed using spss version 24. results: out of 75 eyes, 48 (64%) eyes showed high risk histopathological features including post lamina cribrosa involvement, choroidal invasion, scleral involvement, anterior chamber involvement (angle, iris, ciliary body). all high risk features were significantly more in the poorly differentiated group of tumours. all patients showing high risk features were given post enucleation systemic chemotherapy accordingly. median follow-up was 40 months (3 – 100 months). adjuvant chemotherapy was given in 48 (64%) patients who showed high risk histopathological features. conclusion: by identifying the histopathological pattern and high risk features, we can decrease the chances of metastasis, recurrence, mortality and morbidity of these children which pose an overwhelming physical, psychological, social and financial burden on our society as a whole. key words: retinoblastoma, enucleation, chemotherapy. how to cite this article: viyani mu, mughal j, arshad mo, javed a, nasir j, chatni mh. histopathological features of group e retinoblastoma eyes after upfront enucleation. pak j ophthalmol. 2020; 36 (4): 329-334. doi: https://doi.org/10.36351/pjo.v36i4.1057 introduction it is well established that retinoblastoma is the most common primary intra-ocular tumour in young correspondence: anum javed department of ophthalmology, patel hospital, karachi email: anum.javed1989@gmail.com received: april 25, 2020 accepted: july 23, 2020 children with worldwide prevalence of 1:15000 – 20000 live births. 1 pakistan ranks 6 th in the list of countries with high incidence of retinoblastoma. around 66% of children are “diagnosed” before their second birthday according to world health organization (who), while 95% are “diagnosed” before the age of five years. presenting complaints of retinoblastoma include white reflex, red eye and proptosis, strabismus. 2 retinoblastoma may be unilateral or bilateral. a mutation in the rb1 gene histopathological features of group e retinoblastoma eyes after enucleation pak j ophthalmol. 2020, vol. 36 (4): 329-334 330 holds responsible for both heritable and non-heritable forms. 3 in spite of good understanding about the clinico-pathological features of retinoblastoma, the survival rate in asia is comparatively low. 4 majority of the tumours are diagnosed at an advanced stage and those with metastatic retinoblastoma die within 6 months of time. 5 the international intraocular retinoblastoma classification (iirc) is used for grouping of retinoblastoma. according to the iirc, group e eyes are destined for enucleation despite significant advancements in the treatment modalities available. histopathology shows the characteristics of the tumour, growth pattern and the extent of invasion by tumour. the histopathology of enucleated eyes serves to be an indicator for malignant potential of the tumour, including higher chances of orbital recurrence and metastasis. 6 there is lack of general consensus on the identified high risk histopathology features among several researchers of enucleated eyes across the globe. 7 however, residual tumour at the cut end of the optic nerve is unanimously agreed upon as a high risk feature. with this study, the authors wish to share the histopathology features of group e eyes from this part of the world and establish a relationship between age, tumour differentiation and high risk features. methods this is a retrospective study of 75 eyes that were diagnosed as group e retinoblastoma on clinical examination, examination under general anaesthesia along with mri. approval from ethical review board was sought. informed consent was taken from the parents and the eyes were enucleated primarily at patel hospital, a tertiary care centre, in karachi, pakistan from january, 2012 to august, 2019. files and histopathological documents were reviewed by the investigators. all slides were reviewed for tumour differentiation and high risk features. their age, gender, laterality of the tumour, age at presentation and age at enucleation were noted. median follow-up, number of deaths and extra-ocular metastasis with or without the presence of secondary tumours was also recorded. histological features were enlisted for the presence of choroidal invasion, extent of optic nerve invasion, anterior chamber involvement, scleral and extra-scleral invasion along with tumour differentiation. eyes that were pathologically proven as intraocular retinoblastoma group e and treated with enucleation as their primary treatment without any other local therapy, chemotherapy or radiation therapy, were included in the study. eyes which had any other iirc group or eyes that received treatment other than enucleation such as local laser treatment (cryotherapy, argon laser), chemotherapy and radiation therapy before undergoing enucleation were excluded from the study. we performed enucleation only for eyes that were group e according to iirc. high risk histopathological features were defined as choroidal invasion, invasion of the lamina cribrosa, tumour at the cut-end of the optic nerve, scleral infiltration and involvement of the anterior chamber by the tumour. choroidal invasion is the term used for tumour cells invading the choroid with resultant compressive effects and infiltrative borders. similarly, the extent of optic nerve involvement was grouped as no optic nerve invasion, pre-laminar optic nerve invasion, and post-laminar optic nerve invasion. level of differentiation was categorized as welldifferentiated to moderately differentiated tumours (comprising of small, circular, blue cells, showing features of differentiation in the form of flourettes, flexner-wintersteiner or homer-wright rosettes, staining with synaptophysin), and as poorly differentiated tumours (tumours that had small, circular blue cells but no features of rosettes formation). adjuvant chemotherapy (carboplatin, etoposide, and vincristine) was planned for those enucleated patients, who had high risk histopathological features such as optic nerve involvement posterior to lamina cribrosa, massive choroidal invasion along with any gross choroidal and optic nerve involvement and tumour seeding in anterior chamber or neovascular glaucoma. spss version 24 descriptive statistics were used to summarize the data with mean ± standard deviation or mean for quantitative variables, taking p-value < 0.05 as statistically significant. frequencies and percentages were tabulated for categorical variables. results there were 50 (66.7%) males and 25 (33.3%) females. median age at the time of presentation was 24 months (mean 26 months, range 3 to 72 months). median age muhammad usman viyani, et al 331 pak j ophthalmol. 2020, vol. 36 (4): 329-334 at the time of enucleation was 24 months (mean 27 months, range 3 to 73 months). details are shown in table 1. table 1: demographics, presenting complains and follow-up. demographics n (percentages) number of patients 75 number of eyes 75 family history positive 10 (13.3%) males 50 (66.7%) females 25 (33.3%) laterality bilateral 11 (14.7%) unilateral 64 (85.3%) age n (months) median age at presentation 24 months (3 – 72 months) median age at enucleation 24 months (3 – 73 months) presentation signs n (percentages) leukocoria 55 (73.3%) squint 12 (16% proptosis 6 (8%) hyphema 2 (2.7%) icrb group: n group e 75 grades of differentiation well-differentiated 23 (30.7%) moderately-differentiated 27 (36) poorly differentiated 25 (33.3) growth pattern endophytic 47 (62.7%) exophytic 22 (29.3%) mixed 6 (8%) necrosis and calcification 47 (62.7%) optic nerve cut end not involved 26 (34.7%) metastasis or death 0 follow-up in months, median 40 the most prevalent high risk features in our study were choroidal involvement. other features are depicted in table 2. no one received external beam radiotherapy (ebrt). median follow-up was 40 months (3 – 100 months). adjuvant chemotherapy was given in 48 (64%) patients who showed high risk histopathological features. no evidence of tumour metastasis, recurrences or deaths were recorded for any patient during the study period. table 2: high risk features on histopathology of well/ moderately differentiated and poorly differentiated tumours. high risk features well/moderately differentiated n (percentages) poorly differentiated n (percentages) optic nerve cut end involved 18 (36%) 8 (32%) post lamina cribrosa involvement 19 (38%) 11 (44%) choroidal invasion 28 (56%) 18 (72%) scleral involvement 13 (26%) 9 (36%) anterior segment involvement angle iris ciliary body 5 (10%) 3 (6%) 1 (2%) 14 (28%) 4 (16%) 5 (20%) 3 (12%) 12 (48%) fig. 1: specimen showing pre-laminar optic nerve invasion. fig. 2: specimen showing homer wright rosettes and flexner wintersteiner rosettes. histopathological features of group e retinoblastoma eyes after enucleation pak j ophthalmol. 2020, vol. 36 (4): 329-334 332 fig. 3: specimen showing necrosis and few calcifications. discussion retinoblastoma can often lead to death in children if the disease is left untreated. outcomes of retinoblastoma vary among the developed and developing countries. in countries like pakistan, delay in seeking specialist health care and refusal of treatment further leads to higher mortality. hindrances encountered while handling the histopathological specimens and an avid lack of awareness about the disease further add to the overall disease burden. this delay in seeking medical and/or ophthalmological advice could be a possible cause of increased chances of retinoblastoma when compared to the developed countries including europe and north america. in this study we reviewed the records of 75 enucleated eyes of retinoblastoma patients. we found high risk histopathological features in 46 eyes postenucleation. a precise definition of high risk features has been argued and disputed variably but an acceptable one includes gross choroidal invasion with post-laminar optic nerve involvement, tumour present at the cut end of the optic nerve and scleral invasion. these are the features that are associated with a high risk of metastatic disease and require further treatment. 8 various studies have been conducted on the incidence and implications of high risk histopathological features worldwide. 10 – 40% of advanced intraocular disease (group d and group e) is suggested to be associated with high risk histopathology at diagnosis. post-laminar optic nerve invasion and massive choroidal invasion constitute the most common features, similar to the findings of kim and colleagues. 9 the median age of diagnosis was 24 months which was consistent with the findings of other researchers from subcontinent. subramaniam et al found that the mean age at diagnosis was between 23 – 24 months of age whereas in the western literature, mean age at diagnosis is reported as 18 months. 10 our results concluded that irrespective of laterality, poorly differentiated cases presented late, compared to those that were well to moderately differentiated, which were similar to the works of eagle et al 11 and madhavan et al. 12 necrosis was found along with calcification in 47 (62.7%) cases. it was observed in our study that the more the necrosis in the tumour, the higher the chance of invasion beyond the lamina cribrosa of the optic nerve. histopathological high risk features in our group of patients, were found to be similar to other studies from india. 13 the reported incidence of choroidal invasion varies from 12% to 41% while optic nerve involvement with resection end range from 6.5% to 40%, discussed by yousef et al. 14 similarly, current study showed majority (61.4%) of the eyes had choroidal invasion. in our study, younger patients were found to have well-differentiated tumours in contrast to older patients, which are often associated with poorly differentiated tumours. there were low to intermediate features of histopathology in younger patients as opposed to those who were enucleated at an older age (> 2.5 years). these findings were consistent with the study of kaliki et al, suggesting that welldifferentiated tumours present earlier than poorly differentiated tumours. this may be related to varying retinal cell affection with development and dedifferentiation of tumours with age. 15 there was no evidence of extraocular disease on mri prior to enucleation. histopathology remains the gold standard in identifying high risk features. however, de jong et al studied the significance of mri addressing the high risk features. identification of these features on mri assists greatly in making the choice of enucleation versus globe-salvage therapy. it is believed that mri findings should not, however, be the basis of taking the final decision of enucleation. hence, it is suggested that vigilant and thorough screening prior to the surgical procedure of enucleation should be employed. 16 none of the patients received any form of treatment before enucleation. as studied by zhao et al, muhammad usman viyani, et al 333 pak j ophthalmol. 2020, vol. 36 (4): 329-334 the authors believe that chemotherapy offered before enucleation to group e eyes with advanced tumour, may alter the pathological features and down stage the disease. 17 this can have a masking effect on the possible risk of metastasis and even death. more than half of the eyes were well to moderately differentiated while the rest were poorly differentiated. this could partly be explainable due to the early decision for upfront enucleation of group e eyes in our setup. however, in our neighbouring countries, as discussed by kashyap et al, most of the tumours were poorly differentiated, owing to late presentation and delayed referral among medical personals. 18 during our study period, there was no evidence of metastasis, recurrence of disease or deaths recorded due to the fact that they were given timely chemotherapy. moreover, this could be due to almost similar age at presentation and prompt decision for upfront enucleation based in our results. the epitome of successful retinoblastoma treatment revolves around saving the life of the patient, decreasing and/or eliminating the risk of metastasis, salvaging the globe and vision, along with an overall improvement in the quality of life of those afflicted with this debilitating and fatal disease. 19 various researches across the globe have debated over high risk features from developed and developing countries. however, there are very few studies available from pakistan about high risk features of retinoblastoma afflicted group e enucleated eyes. 20 the limitation of our study was the limited number of cases studied. to establish a consensus, we need further multi-centre studies with larger sample size, which may offer a better understanding and better insight about histopathological trends of retinoblastoma in pakistan. there is scarcity of published data from our part of the world. conclusion by identifying the high grade histopathological features we can manage and devise a strategy to deal with this unprecedented disease. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. jain m, rojanaporn d, chawla b, sundar g, gopal l, kheta v. retinoblastoma in asia. eye, 2019; 33 (1): 87-96. 2. zia n, hamid aa, iftikhar s, qadri mh, jangda a, khan mr. retinoblastoma presentation and survival: a four-year analysis from a tertiary care hospital. pak j med sci. 2020; 36 (1): s61. 3. nawaiseh i, al-hussaini m, alhamwi a, meyar m, sultan i, alrawashdeh k, et al. the impact of growth patterns of retinoblastoma (endophytic, exophytic, and mixed patterns). j. pathol. 2015; 31 (1): 45-50. 4. kivelä t. the epidemiological challenge of the most frequent eye cancer: retinoblastoma, an issue of birth and death. br j ophthalmol. 2009; 93 (9): 1129-1131. doi:https://doi.org/10.1136/bjo.2008.150292. 5. dimaras h, kimani k, dimba ea, gronsdahl p, white a, chan hs, et al. retinoblastoma. the lancet. 2012; 379 (9824): 1436-1446. 6. singh l, kashyap s. update on pathology of retinoblastoma. int. j. ophthalmol. 2018; 11 (12): 2011. 7. aerts i, sastre-garau x, savignoni a, lumbroso-le rouic l, thebaud-leculée e, frappaz d, et al. results of a multicenter prospective study on the postoperative treatment of unilateral retinoblastoma following primary enucleation. j clin oncol. 2013; 31: 1458-1463. 8. chévez-barrios p, eagle jr rc, krailo m, piao j, albert dm, gao y, et al. study of unilateral retinoblastoma with and without histopathologic high-risk features and the role of adjuvant chemotherapy: a children’s oncology group study. j. clin. oncol. 2019; 37 (31): 2883-2891. 9. kim jw, shah sn, green s, o'fee j, tamrazi b, berry jl. tumour size criteria for group d and e eyes in the international classification system for retinoblastoma: effects on rates of globe salvage and high‐risk histopathologic features. acta ophthalmologica, 2020; 98 (1): e121-125. 10. subramaniam s, rahmat j, rahman na, ramasamy s, bhoo-pathy n, pin gp, et al. presentation of retinoblastoma patients in malaysia. asian pac j cancer prev. 2014; 15 (18): 7863-7867. 11. eagle jr rc. high-risk features and tumor differentiation in retinoblastoma: a retrospective histopathologic study. arch. pathol. lab. med. 2009; 133 (8): 1203-1209. 12. madhavan j, ganesh a, roy j, biswas j, kumaramanickavel g. the relationship between tumor cell differentiation and age at diagnosis in retinoblastoma. j pediat ophth strab. 2008; 45 (1): 2225. histopathological features of group e retinoblastoma eyes after enucleation pak j ophthalmol. 2020, vol. 36 (4): 329-334 334 13. kashyap s, meel r, pushker n, sen s, bakhshi s, sreenivas v, et al. clinical predictors of high risk histopathology in retinoblastoma. pediatr blood cancer, 2012; 58 (3): 356-361. 14. yousef ya, hajja y, nawaiseh i, mehyar m, sultan i, deebajah r, et al. a histopathologic analysis of 50 eyes primarily enucleated for retinoblastoma in a tertiary cancer center in jordan. j. pathol. 2014; 30 (3): 171-177. 15. kaliki s, gupta s, ramappa g, mohamed a, mishra dk. high-risk retinoblastoma based on age at primary enucleation: a study of 616 eyes. eye, 2019; 25: 1-8. 16. de jong mc, van der meer fj, göricke sl, brisse hj, galluzzi p, maeder p, et al. diagnostic accuracy of intraocular tumor size measured with mr imaging in the prediction of postlaminar optic nerve invasion and massive choroidal invasion of retinoblastoma. radiology, 2016; 279 (3): 817-826. 17. zhao j, dimaras h, massey c, xu x, huang d, li bchan hs, et al. pre-enucleation chemotherapy for eyes severely affected by retinoblastoma masks risk of tumor extension and increases death from metastasis. j clin oncol. 2011; 29 (7): 845-851. 18. kashyap s, sethi s, meel r, pushker n, sen s, bajaj ms, et al. a histopathologic analysis of eyes primarily enucleated for advanced intraocular retinoblastoma from a developing country. arch. pathol. lab. med. 2012; 136 (2): 190-193. 19. kaliki s, mittal p, mohan s. chattannavar g, divya s, jajapuram, et al. bilateral advanced (group d or e) intraocular retinoblastoma: outcomes in 72 asian indian patients. eye, 2019; 33: 1297–1304. https://doi.org/10.1038/s41433-019-0409-z 20. khan a, bukhari m, mehboob r. association of retinoblastoma with clinical and histopathological risk factors. natural science. 2013; 5: 437-444. doi: https://doi.org/10.4236/ns.2013.54056. authors’ designation and contribution muhammad usman viyani; consultant ophthalmologist: concepts, design, literature research, statistical analysis, manuscript editing, manuscript review. jamal mughal; consultant ophthalmologist: concepts, design, manuscript editing, manuscript review. muhammad owais arshad; senior registrar: literature research, data acquisition, data analysis, statistical analysis, manuscript editing, manuscript review. anum javed; post graduate trainee: literature research, data acquisition, data analysis, statistical analysis, manuscript editing, manuscript review. javeria nasir; registrar: literature research, data acquisition, data analysis, statistical analysis, manuscript editing, manuscript review. muhammad hanif chatni; director eye department: concepts, design, manuscript preparation, manuscript editing, manuscript review. .…  …. javascript:; javascript:; http://dx.doi.org/10.4236/ns.2013.54056 pak j ophthalmol. 2021, vol. 37 (2): 134-136 134 editorial visual rehabilitation in corneal blindness alfonso vasquez-perez 1 , christopher liu 2 1 moorfields eye hospital, london, 2 brighton and sussex medical school, brighton, uk blindness from corneal diseases remain a major ophthalmic health problem worldwide second only to cataract. 1 the spectrum of corneal blindness is quite different in developing and developed countries and encompasses a wide variety of infectious and inflammatory diseases. although scarred corneas from preventable diseases like trachoma and malnutrition are rarely seen in developed countries, they remain prevalent in regions with poor health environment. on the other hand, autoimmune conditions such as stevens johnson syndrome (sjs) and ocular mucous membrane pemphigoid (mmp) as well as chemical injuries are seen worldwide and often present the most challenging situations for corneal specialists. eyes with severe corneal scarring in the context of ocular surface failure could just be able to distinguish light from dark and such a scenario is devastating when both eyes are affected. blindness has not only a negative impact in the quality of life but also causes a considerably economic burden affecting the individuals, their families, and society. the main challenges from diseases causing corneal blindness are ocular surface scarring, dryness and stem cell deficiency, because such conditions prevent long-term survival of a corneal transplant. thus, in these cases the only hope for visual restoration is to bypass the ocular surface and cornea with an artificial cornea or keratoprosthesis (kpro). 2,3 how to cite this article: perez av, liu c. visual rehabilitation in corneal blindness. 2021, 37 (2): 134136. doi: 10.36351/pjo.v37i2.1186 correspondence: alfonso vasquez-pere moorfields eye hospital, london, uk email: alest99@gmail.com received: december 28, 2020 accepted: january 28, 2021 over the past five decades multiple kpros have been pioneered and developed but most of them just had temporary existence, reflecting the complexity and challenges in the pursuit of a successful artificial cornea. currently only two principal kpro devices are used in clinical practice: the boston kpro type i (massachusetts eye & ear infirmary, boston, ma, usa) and the osteo-odonto-keratoprosthesis known as “ookp” (originally described by strampelli and later modified by falcinelli). 2,4 the boston type i is a synthetic kpro and is the most common device implanted worldwide. 5 the current design of the boston type i kpro is composed by a front plate with an optical polymethyl acrylate (pmma) stem and a titanium back plate. a donor cornea is sandwiched between the plates and it is the carrier cornea button which is sutured onto the eye. the presence of a wet ocular surface is paramount when considering boston type i kpro implantation: both adequate tear production and intact blinking mechanism are necessary. as such this kpro is primarily an alternative to high-risk penetrating keratoplasty. other indications for boston type i kpro include chemical injuries, primary congenital glaucoma with corneal decompensation, aniridia, irido-corneal syndrome and gelatinous drop-like dystrophy. the boston type ii kpro is another design in which the optic is implanted through the closed eyelid. this device is indicated in end-stage ocular disease with dryness and or adnexal abnormalities. 6 however careful patient selection must be done as severe dryness and contracted lid fornices are accompanied by chronic inflammation which implicates high risk of failure for both boston 1 and 2 kpro. 5,6 hence in patients with advanced stage of stevens johnson syndrome, chemical injuries or ocular pemphigoid, only biological kpro scan provide long-term survival. the ookp and the tibial bone osteokeratoprosthesis are the two well-known biological alfonso vasquez-perez, et al 135 pak j ophthalmol. 2021, vol. 37 (2): 134-136 kpros. despite both have reported favourable anatomical and functional success, the ookp have proved to have achieved better long-term outcomes. 7 the ookp is a two-stage procedure and uses the patient’s own tooth and alveolar bone to create a frame (osteo-odonto-lamina) that carries a pmma optical cylinder. after its initial preparation, the lamina is implanted in a submuscular pocket for nourishment and growth of surrounding connective tissue. at the same time the ocular surface is covered by a buccal mucosa; graft (stage 1). three to four months later the lamina is retrieved and then sutured onto the sclera after central cornea trephination and removal of iris, lens, and anterior vitreous (stage 2). the buccal mucosa that was initially reflected will now cover all the lamina except the central optic cylinder through which patients see. the unique autologous biological composition confers the ookp excellent bio-integration and no immunological rejection. the boston type i and type ii kpro are both onestage procedure, however the ookp is a more complex multistage procedure and is available only in a handful of centres around the world. in general patients who are considered for a kpro should have bilateral blindness and commit to lifelong follow-up. they need to be highly motivated to comply with postoperative care and particularly in the case of the ookp must be prepared for the altered cosmetic appearance. bypassing an opaque cornea improves vision with all types of kpro, but the amount of improvement is determined by the status of the retina and optic nerve. it is not meaningful to compare the anatomical retention outcomes between the boston type i and the ookp as the indications for each kpro are different. but despite better results due to modifications in its design and improvements in postoperative management with the boston type i, the long-term anatomical retention rate (five or more years) in sjs and severe chemical burns remains below 50%. 8 similar retention rate is also achieved by the boston type ii kpro which has comparable indications to the ookp. 6 in contrast the reported long-term anatomical retention rate from the ookp in all studies is above 80% (even at the 20 year time point) with more than half of the patients achieved vision better than 6/18. 2,9 thus, in such truly challenging cases of corneal blindness the ookp has proved the most effective in restoring sight and the most endurable keratoprosthesis. 2,4,7 complications are not uncommon in keratoprostheses. the most common long-term blinding complication of all kpros is glaucoma, which can affect two thirds of cases and be a pre-existing condition in more than one third. 5-7 in addition to the challenges of estimating intraocular pressure in kpro eyes, topical medications are not absorbed through buccal mucosa in ookp eyes and not all patients can tolerate oral acetazolamide. glaucoma in kpro eyes usually requires surgical implantation of tubes which have variable results but commonly fail in the longterm. endophthalmitis is the most feared complication in kpro and has been reported in less than 20% of cases, being lower in the ookp (0-8%). 5-7 other complications seen are retroprosthetic membranes, retinal detachment, keratolysis in boston type i and lamina exposure in ookp due to buccal mucosa defects. in summary, patients considered for a kpro must be carefully assessed for an appropriate decision whether this treatment should be offered as well as the type of device required for each case. they also should be aware that long-term success is not guaranteed, and that the treatment is not reversible in the case of ookp. future improvement of the ophthalmic use of stem cells may allow to regenerate the ocular surface restoring corneal transparency or providing appropriate environment for a corneal graft. but in the meantime, for the most challenging cases of corneal blindness, keratoprosthesis is the only hope for visual rehabilitation. conflict of interest authors declared no conflict of interest references 1. whitcher jp, srinivasan m, upadhyay mp. corneal blindness: a global perspective. bull world health organ, 2001;79 (3): 214-221. 2. zarei-ghanavati m, avadhanam v, vasquez perez a, liu c. the osteo-odonto-keratoprosthesis. curr opin ophthalmol 2017; 28 (4): 397-402. 3. vasquez-perez a, zarei-ghanavati m, avadhanam v, liu c. osteo-odonto-keratoprosthesis in severe thermal and chemical injuries. cornea, 2018; 37 (8): 993-999. 4. falcinelli g, falsini b, taloni m. modified osteoodonto-keratoprosthesis for treatment of corneal blindness: long-term anatomical and functional outcomes in 181 cases. arch ophthalmol. 2005; 123 (10): 1319-1329. visual rehabilitation in corneal blindness pak j ophthalmol. 2021, vol. 37 (2): 134-136 136 5. aldave aj, kamal km, vo rc, yu f. the boston type i keratoprosthesis: improving outcomes and expanding indications. ophthalmology, 2009; 116 (4): 640-651. 6. lee r, khoueir z, tsikata e, chodosh j, dohlman ch, chen tc. long-term visual outcomes and complications of boston keratoprosthesis type ii implantation. ophthalmology, 2017; 124 (1): 27-35. 7. de la paz mf, de toledo j, charoenrook v, sel s, temprano j, barraquer ri, et al. impact of clinical factors on the long-term functional and anatomic outcomes of osteo-odonto-keratoprosthesis and tibial bone keratoprosthesis. am j ophthalmol. 2011; 151 (5): 829-839.e1. 8. nonpassopon m, niparugs m, cortina ms. boston type 1 keratoprosthesis: updated perspectives. clin ophthalmol. 2020; 14: 1189-1200. 9. tan a, tan dt, tan xw, mehta js. osteo-odonto keratoprosthesis: systematic review of surgical outcomes and complication rates. ocul surf. 2012; 10 (1): 15-25. .…  …. 161 pak j ophthalmol. 2021, vol. 37 (2): 161-167 original article awareness regarding primary eye care among primary healthcare workers of pakistan: a way to revitalize health for all! noor-ur-rehman 1 , hina sharif 2 1-2 department of ophthalmology, al-shifa trust and eye hospital, karachi abstract purpose: to assess awareness regarding primary eye care among (primary healthcare workers) phcws and also intended to identify its determinants. study design: descriptive cross-sectional study. place and duration of study: all primary healthcare facilities of tehsil kallar syedan, from october 2019 to december 2019. methods: the calculated sample size was 115. data was collected from primary health care workers (phcws). data was collected through a structured questionnaire with both open-ended and close-ended questions. questions were made using simple language and were also translated in urdu. questionnaire was adapted from two articles and some questions were made after reading the components of national programme for prevention and control of blindness (punjab, pakistan).chi-square test of independence was used for finding associations. results: fifty-four percent phcws had poor awareness regarding primary eye care. majority of the phcws, n = 64 (55.7%) identified just the names of common eye diseases. cataract was identified with correct treatment by 88% primary healthcare workers. age, education, designation were significantly associated with awareness of phcws. conclusion: the study concluded that more than half of phcws had low awareness regarding pec. all of them mentioned that there was a need of improving and refreshing their knowledge related to primary eye care. this will definitely help to reduce pressure on secondary and tertiary healthcare workers. key words: primary eye care, primary healthcare workers, primary healthcare facilities, pakistan. how to cite this article: rehman n, sharif h. awareness regarding primary eye care among primary healthcare workers of pakistan: a way to revitalize health for all! pak j ophthalmol. 2021, 37 (2): 161-167. doi: http://doi.org/10.36351/pjo.v37i2.1146 introduction primary eye care (pec) is an essential part of primary healthcare (phc), which involves methods and correspondence: hina sharif department of ophthalmology, al-shifa trust and eye hospital, karachi email: pcc4u@hotmail.com received: october 15, 2020 accepted: february 1, 2021 techniques for promotion of healthy eyes and provision of pec to the community and involves primary healthcare workers. pakistan has huge burden of eye diseases for which primary eye care is an important element of primary health care. the concept of primary eye care (pec) was born as a consequence of the alma ata meeting in 1978, which highlighted the tenets of primary health care (phc). 1 who reports on universal eye health (global action plan 2014-2019) states that more than 2.2 billion people have vision impairment globally. of those at least 1 billion people have preventable vision http://doi.org/10.3352/jeehp.2013.10.3 awareness regarding primary eye care among primary healthcare workers of pakistan pak j ophthalmol. 2021, vol. 37 (2): 161-167 162 impairment. 2 the basic elements of phc include water supply, sanitation, nutrition, immunization against infectious diseases, maternal and child health, treatment of common diseases, prevention and control of common diseases and injuries, provision of adequate drugs and health education. 3 majority of the people with treatable blindness cannot access eye care services because of lack of awareness regarding available services. 4 the primary factors which influence the uptake of eye care services are availability, accessibility and affordability. 5 primary health care workers (phcws) are the main personnel to link the chain between primary health care facilities and rural community. early detection of common diseases and timely referral can reduce the burden of avoidable blindness. this can be achieved if phcws are properly equipped with adequate knowledge, tools and supported by a good referral system including regular interaction and coordinated team work between full time eye workers, integrated eye workers and community eye worker. 6,7 pakistan has a strong structure of primary healthcare in the form of basic health units (bhus) and rural health centers (rhcs). lady health workers (lhws), lady health visitors (lhvs) and lady health supervisors (lhss) are the backbone of this globally acknowledged structure. this was fundamentally constructed to shift burden of higher tiers of healthcare (secondary and tertiary) towards primary; so that people can have awareness and treatment at their doorsteps. pakistan has also huge burden of eye diseases therefore, primary eye care always remains as an important element of primary health care. this study aimed to assess awareness regarding pec among phcws and also intended to identify its determinants. methods a quantitative cross-sectional study was conducted within the duration of three months starting from october 2019 to december 2019 in all primary healthcare facilities of tehsil kallar syedan, pakistan. the study population was phcws including lady healthcare workers (lhw), lady healthcare visitors (lhv) and lady healthcare supervisors (lhs). the sample size was calculated with the help of an online software open-epi by taking population size of lhw, lhv and lhs to be 150, prevalence taken was 50% and 5% margin of error. the calculated sample size was 115. the sampling frame of all phcws was obtained and data was collected from lhw, lhv and lhs. data was collected through a structured questionnaire with both open-ended and close-ended questions. questions were made using simple language and were also translated in urdu. the validity of questionnaire was checked before starting data collection by performing a pilot study on lhw. questionnaire was adapted from two articles: knowhow of primary eye care among health extension workers in southern ethopia 7 and awareness of eye health and diseases among the population of the hilly region of nepal 8 and some questions were made after reading the components of national programme for prevention and control of blindness (punjab, pakistan). 3 validity was checked for english version with the help of subject specialist. later on, after translation into urdu, validity was rechecked to ensure same meaning of translated words. reliability was checked with the help of chronbach’s alpha and it was 0.69. data was analyzed by using statistical software spss version-20.0. qualitative variables were given numbers and percentages. scale of awareness was computed and categorized into poor and good awareness by taking median. chi-square test of independence was used for finding association between outcome variable and independent variable. this test was applied on all independent variables and outcome variables. a significance level of 5% was used for all inferential statistics. the study was conducted after approval from institutional review board (irb) of al-shifa trust eye hospital. all the respondents were included after taking verbal consent from them. results mean age of the participants 44 ± 7.85 years. majority of the respondents (86%) were lady healthcare workers (lhw’s). table1: sociodemographic characteristics. demographics frequency(n) percentage (%) education (years) 8 15 13 10 69 60 12 25 21.7 14 5 4.3 marital status single 7 6.1 married 108 93.9 experience (years) 5 – 15 47 40.9 noor-ur-rehman, et al 163 pak j ophthalmol. 2021, vol. 37 (2): 161-167 16 – 25 66 57.4 > 25 2 1.7 currently working as lady healthcare supervisor 8 7 lady healthcare worker 99 86.1 lady healthcare visitor 8 7 previous eye training yes 103 89.6 no 12 10.4 no. of training never 10 8.7 once 21 18.3 twice 35 30.4 3 – 4 times eye patients seen in a month 1 – 5 6 – 10 > 11 48 70 29 11 41.7 60.9 25.2 9.6 majority of the phcws, n = 64 (55.7%) identified just the names of common eye diseases (cataract, red eye, glaucoma). further information regarding their knowledge of eye diseases in mentioned in graph 1. graph 1: eye diseases identified by primary healthcare workers (phcw’s). basic knowledge about the eye disease is depicted in table 2. table 2: awareness about primary eye care among phcws. variables frequency (n) percentage (%) pec definition: maintain personal and ocular hygiene correctly defined 53 46.1 not correctly defined 62 53.9 can identify and refer the common eye diseases yes 52 45.2 no 63 54.8 can you measure visual acuity? yes 113 98.3 no 2 1.7 is pec essential part of phc? yes 106 92.2 no 4 3.5 i don’t know 5 4.3 when should eye-specialist be visited? in case of any eye problem 28 24.3 once a year 57 49.6 twice a year 30 26.1 what does white pupillary reflex show? night blindness 7 6.1 glaucoma 3 2.6 cataract 89 77.4 i don’t know 16 13.9 what do infectious misdirected lashes indicate? cataract 3 2.6 trachoma 56 48.7 conjunctivitis 30 26.1 i don’t know 25 21.7 what are the risk factors for trachoma? unhygienic environment yes 78 67.8 no 36 31.3 malnutrition yes 30 26.1 no 85 73.9 which food items contain vitamin-a? green leafy vegetables, yellow fruits 101 87.8 cereals, rice, bread 5 4.3 others 4 3.5 don’t know 4 3.5 what is the age for cataract? old age individuals only 42 36.5 new borns only 63 55.3 other age group 9 7.9 how can diabetes be managed? diet yes 69 60 no 46 40 walking yes 50 43.5 no 65 56.5 medicines yes 53 46.1 no 62 53.9 what are risk factors for vitamin-a deficiency? pregnant women 35 30.4 children with measles and diarrhea 40 35.1 both of above factors 23 20.2 others 16 13.9 how can you prevent vitamin-a deficiency? maternal and child vit-a supplementation yes 81 70.4 no 33 28.7 awareness regarding primary eye care among primary healthcare workers of pakistan pak j ophthalmol. 2021, vol. 37 (2): 161-167 164 measles vaccination yes 13 11.3 no 101 87.8 balanced diet and clean water yes 44 38.3 no 70 60.9 what is the cause of night blindness mother is malnutritioned 25 21.7 vitamin-a deficiency 67 58.3 both above factors 7 6.2 other factors 6 5.2 i don’t know 9 7.8 what is treatment of conjunctivitis? medicine 20 17.4 advise patient to maintain hygiene 42 36.8 refer to hospital/doctor 26 22.6 both above along with refer 26 22.6 is there any need of eye training for lhw? yes 111 96.5 no 3 2.6 how can we improve eye-care awareness? provision of medicines by government yes 35 30.4 no 79 68.7 provide eye training for lhw yes 86 74.8 no 28 24.3 arrange awareness programs for public yes 34 29.6 no 80 69.6 provision of balanced diet yes 5 4.3 no 109 94.8 all questions of outcome were computed and then by using median (md = 64), it was categorized into binary variable i.e. low awareness and high awareness. chi square test of association was conducted to check the association between outcome variable i.e. awareness and the independent variables i.e. age, educational level, experience, previous eye care training and currently how they are working (table 3). 87.80% 60.90% 70.40% 86% 82.60% 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% c a ta ra c t t ra c h o m a v it a m in -a d e fi c ie n c y t ra u m a b le e d in g e y e graph 2: diseases identified by phcws with correct treatment. primary eye care awareness of primary healthcare workers 54% 46% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% low aw areness high aw areness graph 3: primary eye care awareness of phcw’s table 3: associated factors with awareness of phcws about primary eye care. variables awareness about eye care chi-square (df) p-value low high age (years) ≤ 44 27 (45%) 33 (55%) 4.01 (1) 0.045 > 44 35 (63.6%) 20 (36.4%) education (years) ≤ 10 51 (60%) 34 (40%) 4.86 (1) 0.028 > 10 11 (36.7%) 19 (63.3%) experience (years) 5-15 26 (55.3%) 21 (44.7%) 0.063 (1) 0.801 > 15 36 (52.9%) 32 (47.1%) designation lhs and lhv 3 (18.8%) 13 (81.2%) 9.25 (1) 0.002 lhw 59 (59.6%) 40 (40.4%) previous eye-care training yes 59 (57.3%) 44 (42.7%) 4.50 (1) 0.34 no 3 (25%) 9 (75%) no. of eye-care never 3 (30%) 7 (70%) 8.84 (4) 0.065 noor-ur-rehman, et al 165 pak j ophthalmol. 2021, vol. 37 (2): 161-167 training once 9 (42.9%) 12 (57.2%) twice 25 (71.4%) 10 (28.6%) 3-4 times 25 (53.2%) 22 (46.8%) no. of eye patients seen in a month 1-5 44 (62.9%) 26 (37.1%) 5.56 (3) 0.135 6-10 11 (37.1%) 18 (62.1%) 11-15 5 (45.5%) 6 (54.5%) discussion a total of 115 phcws were included in the study, among them 99 were lhws, 8 lhs and 8 lhvs. according to the present study, 54% phcws had low awareness of pec, although most of the phcw’s (89.6%) had done previous training in primary eye care. the study established the significant relationship of level of awareness with the age, education and the job description of phcws. a previous study conducted in southern ethiopia showed that the knowledge about blinding eye disease did not significantly vary with the years of experience or previous healthcare training. 7 our study also showed non-significant association of level of awareness with years of experience or previous eye care training. this consistent finding emphasized need of the assessment of quality of eye care training being provided to healthcare workers. in a study conducted in india showed a remarkable improvement in knowledge among teachers after pec training. 9 other studies in pakistan showed that 35% of teachers in rawalpindi had knowledge about eye conditions and 32.8% of general population in azad kashmir showed awareness about eye care services. 10,11 provision of pec to the community is strongly associated with phcws particularly lady healthcare workers (lhws). lhws are given training for 15 months which include first 3 months of classroom training and 12 months on-the-job training about prevention and control of common illnesses. 12 pakistan is facing a double burden of disease (bod), the burden is higher in the poor, and many of these can be controlled at relatively low cost interventions and best practices through primary and secondary care levels. 13 a recent report of national eye health committee indicates that pakistan achieved a national cataract surgical rate (csr) of 5253 (with ajk included). 14 a report on rapid assessment of refractive error in children in pakistan (2016-2017) by brien holden vision institute showed the prevalence of significant refractive error is 5.4% in the age of 5 to 15 years. 15 common diseases should be identified at the phc. concept of pec and school health in india (2019) suggested that the trained teachers in schools could manage red eyes, loss of vision and pain in the eye by timely referral. 16 in our study, majority of phcws (77.4%) had awareness of white reflex of pupil and decreased vision in cataract. previous studies also showed good knowledge about cataract i.e. 55.7% in kenya and malawi, 17 72.3% in nigeria 6 and 67.3% in tanzania. 18 our research showed that 88% of phcws had knowledge of treatment options for cataract while previous studies showed this percentage to be 96.4% 7 and 63.2%. 18 this finding is also justifiable on the basis of high prevalence of cataract all over the world therefore; training regarding eye care is always focused on this disease. trachoma was identified by 48.7% of phcws and 60.9% considered that by improving environmental and personal hygiene trachoma can be cured similarly a study performed in southern ethiopia, 7 96% of health extension workers knew that trachoma could cause blindness and 13.5% considered face washing could eliminate the risk of trachoma. all the phcws had awareness of conjunctivitis being contagious. among all the phcws 86% correctly identified the management of superficial foreign body similarly a previous study had 69.3% phcws who could manage this. 18 vitamin-a deficiency causes serious effects on eyes, majority of the phcws (87.8%) correctly mentioned the food items that contained vitamin-a. according to 70.4% phcws vitamin-a deficiency could be prevented by providing vitamin-a supplements to mothers and children. more than half of phcws (58.3%) knew that vitamin-a deficiency was the cause of night blindness among children. a study was conducted in nigeria among phcws, stated that 28% of phcws correctly identified the common features of vitamin-a deficiency. 6 the dissimilarity between both studies can be due to demographic and contextual differences. majority of the phcws (92.2%) were aware of the fact that pec was an essential part of phc and 96.5% accepted that there awareness regarding primary eye care among primary healthcare workers of pakistan pak j ophthalmol. 2021, vol. 37 (2): 161-167 166 was further need of providing pec training to them. this finding proved the need of reinforcing primary eye care to make primary healthcare more useful for community. 19 the low awareness of pec among phcws shows that there is a need of providing primary eye care training to them with regular intervals of time. awareness programs and eye-camps should be arranged for phcws. phcws being the frontline health workers should be equipped with adequate knowledge so that they can provide effective primary eye care to the community at the earliest time. the method of teaching and training phcws should involve the eye-models and colored pictures of diseases to make them visualize and understand the diseases in a better way. 20 the limitations of this study was that it was conducted in a short period of time i.e. from october, 2019 to december, 2019. only those phcws were included in the study that were available at the time of visit to bhus. majority of phcws were lady healthcare workers (86%), therefore the results cannot be generalized to all the primary healthcare workers. conclusion the study concluded that more than half of phcws had low awareness regarding pec. all of them mentioned that there was a need of improving and refreshing their knowledge related to primary eye care. this can definitely reduce pressure on secondary and tertiary healthcare workers. ethical approval the study was approved by the institutional review board/ ethical review board. (pio/trg/19) conflict of interest authors declared no conflict of interest. references 1. courtright p, seneadza a, mathenge w, eliah e, lewallen s. primary eye care in sub-saharan african: do we have the evidence needed to scale up training and service delivery? ann trop med parasitol. 2010; 104 (5): 361–367. 2. what is universal eye health? iapb available from: https://www.iapb.org/advocacy/global-action-plan2014-2019/what-is-universal-eye-health/ accessed on 25 th may 2020. 3. minimum services delivery standards. available at: https://phc.org.pk/cati_hce.aspx accessed on 25 th may 2020. 4. primary eye care framework. clinical council for eye health commissioning 2018, available at: http://www.ccehc.org.uk. accessed on 25 th may 2020. 5. etim ba, ibanga aa, udoh me, okonkwo sn, agweye ct, utam ua, et al. eye care cadre utilization and knowledge about eye care professionals among university students in calabar, nigeria. j adv med res. 2018; 28 (2): 1–6. 6. abdulrahman aa, rabiu mm, alhassan mb. knowledge and practice of primary eye care among primary healthcare workers in northern nigeria. trop med int heal. 2015; 20 (6): 766–772. 7. hailu y, tekilegiorgis a, aga a. know-how of primary eye care among health extension workers (hews) in southern ethiopia. ethiop j heal dev. 2009; 23 (2): 127-132. 8. shrestha g, sigdel r, shrestha j, sharma a, shrestha r, mishra s, et al. awareness of eye health and diseases among the population of the hilly region of nepal. j ophthalmic vis res. 2018; 13 (4): 461. 9. screening e, dist i, budh g, agrawal d, tyagi n, nagesh sr. awareness levels of school teachers regarding healthy vision. nat j comm med. 2020; 9 (8): 7–10. 10. ahmad ss. glaucoma suspect : a pratical approach. taiwan j ophthalmol. 2017; 8: 53–55. 11. ashraf f, mobeen r. status of awareness of optometry and primary eye care services among common population in district bhimber, azad kashmir, ophthalmol pak. 2016; (04): 15–18. 12. zhu n, allen e, kears a, gaglia j, atun r. lady health workers in pakistan improving access to health care for rural women and families. 2014;11. available from: https://cdn2.sph.harvard.edu/wpcontent/uploads/sites/32/2014/09/hsph-pakistan5.pdf. accessed on 25 th may 2020. 13. ministry of planning d & reform. p. national health vision pakistan 2016-2025. 2016; 3–17. available from: www.https://extranet.who.int/countryplanningcycles/sit es/default/files/planning_cycle_repository/pakistan/nati onal_health_vision_2016-25_30-08-2016.pdf. accessed on 30 may 2020. 14. bourne r, dineen b, jadoon z, lee ps, khan a, johnson gj, et al. outcomes of cataract surgery in pakistan: results from the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91 (4): 420-426. doi: 10.1136/bjo.2006.106724. noor-ur-rehman, et al 167 pak j ophthalmol. 2021, vol. 37 (2): 161-167 15. yasmin s, saifullah k, minto h. developing an integrated school eye health programme in pakistan. community eye heal. 2017; 30 (98): s8–11. 16. giri a, behera s, galhotra a. concept of primary eye care & school health in india. indian j community fam med. 2018; 4 (2): 55. 17. kalua k, gichangi m, barassa e, eliah e, lewallen s, courtright p. skills of general health workers in primary eye care in kenya, malawi and tanzania. hum resour health, 2014; 12 (1): 4–9. 18. byamukama e, courtright p. knowledge, skills, and productivity in primary eye care among health workers in tanzania: need for reassessment of expectations? int health, 2010; 2 (4): 247–252. 19. sharon l, lindner h, mathews r, morris s, wells l, litt j, et al. what skills do primary health care professionals need to provide effective selfmanagement support ? seeking consumer perspectives. aust j prim health, 2009; 15: 37–44. 20. murthy gvs, raman u. perspectives on primary eye care. comm eye health j. 2009; 22 (69): 10. authors’ designation and contribution noor-ur-rehman; student: concepts, design, literature search, data acquisition, manuscript preparation. hina sharif; senior lecturer: data analysis, statistical analysis, manuscript editing, manuscript review. .…  …. microsoft word 20. muhammad sharjeel mm pakistan journal of ophthalmology, 2020, vol. 36 (3): 287-291 287 original article efficacy of local anesthesia during external dacryocystorhinostomy with 1:200,000 adrenaline versus 1:50,000 adrenaline muhammad sharjeel1, mehr-un-nisa2, usama iqbal3, rafay razzaq wattoo4 1gomal medical college, dera ismail khan, 2,3department of ophthalmology, dhq-uth, gujranwala 4department of ophthalmology, lakson medical trust, sahiwal abstract purpose: to compare the efficacy of local anesthesia during dacryocystorhinostomy using xylocaine with 1:200,000 adrenaline versus with 1:50,000 adrenaline. study design: quasi experimental study. place and duration of study: dhq hospital, dera ismail khan, from january to december 2019. material and methods: we compared two different formulations of local anesthesia during dacryocystorhinostomy in terms of efficacy of per-operative pain, bleeding and effectiveness of anesthesia. 50 patients fulfilling our inclusion criteria were divided in two groups each containing 25 patients. in group a patients underwent dacryocystorhinostomy under local anesthesia using bupivacaine and the commercially available xylocaine with 1:200,000 adrenaline while patients in the group b underwent surgery using bupivacaine, xylocaine with 1:50,000 adrenaline. per-operative pain, bleeding and effectiveness of anesthesia were measured on a numeric scale. means of pain score, bleeding score and anesthesia effectiveness score were computed and were compared. results: in group a, 84% patients were females and 16% were male. in group b, 80% were females and 20% were males. mean age of patients was 41.04 ± 6.84 and 40.80 ± 8.563 years in group a and b respectively. mean pain score in group a was 2.20 while in group b was 1.72. mean bleeding score in group a was 1.84 while in group b was 1.24. mean anesthesia effectiveness score in group a was 2.08 while in group b was 2.76. conclusion: local anesthesia with concentrated adrenaline (in patients with no cardiac disease or other major co-morbidity) provides a better control of per-operative pain, bleeding and better anesthesia. key words: dacryocystorhinostomy, epiphora, xylocaine, bupivacaine, anesthesia, nasolacrimal duct obstruction, adrenaline, epinephrine. how to cite this article: sharjeel m, nisa mu, iqbal u, wattoo rr. comparison of efficacy of local anesthesia during external dacryocystorhinostomy with 1:200,000 adrenaline versus 1:50,000 adrenaline. pak j ophthalmol. 2020; 36 (3): 287-291. doi: 10.36351/pjo.v36i3.1032 introduction epiphora is one of the most common complaints ____________________________________________ correspondence to: usama iqbal dhq-uth, gujranwala email: usamaiqbal@gmail.com received: march 31, 2020 revised: april 23, 2020 accepted: mat 4, 2020 presenting to the ophthalmology department, and one of the most common reasons for referral to the oculoplastic units. persistent epiphora can be attributed to reflex tearing or poor tear outflow. the latter can be associated with naso-lacrimal duct obstruction (nldo) which can be congenital, acquired or idiopathic1. treatment of epiphora due to congenital nldo is therapeutic lacrimal probing if spontaneous resolution does not occur beyond nine month of age2. muhammad sharjeel, et al 288 pakistan journal of ophthalmology, 2020, vol. 36 (3): 287-291 unlike congenital nasolacrimal duct obstruction in which lacrimal probing and syringing has a high success rate, acquired nasolacrimal duct obstruction in adults gets minimal benefit from probing and syringing in terms of treatment3. most of the patients need surgical intervention to overcome the obstruction4. external dacryocystorhinostomy (dcr) was introduced in 1904 by a french ophthalmologist, adeototi5. since then different ophthalmologists have developed various techniques for this procedure. external dcr remains the most commonly performed surgery for this purpose and is considered a gold standard technique6. success rate of external dcr is upto 91% as compared to 63 – 75% for endonasal dcr7. external dcr is not performed routinely in private sector hospitals. this procedure is mostly performed in public sector hospitals. to deal with large number of patients with complaint of epiphora presenting to public sector hospitals, it is often required to perform this procedure in local anesthesia (la). there are certain drawbacks of performing this procedure in la8. the most problematic per-operative complication during external dcr is bleeding from the highly vascular nasolacrimal apparatus, which prolongs the surgical time and reduces patient comfort. another troublesome complication during the surgery is ineffective analgesia. to overcome these complications various techniques have been employed like use of a vasoconstrictive agents e.g. adrenaline, raising the head end of the table, good nasal packing or using cautery9. use of adrenaline along with the local anesthetic has beneficial effects in terms of reduced per-operative bleeding and more concentration of the local anesthetic at the place of interest10. in this study we intend to compare two different concentrations of adrenaline used along with local anesthetic, in terms of their beneficial outcomes in the form of reduced pain, per-operative bleeding and effectiveness of anesthesia. material and methods this study started after approval from the ethical committee of dhq hospital dera ismail khan. 50 patients presenting to the outpatient ophthalmology department who were diagnosed as cases of primary nasolacrimal duct obstruction were selected. patients suffering from any kind of cardiovascular disease, acute infection, having history of previous dcr and those not willing to participate in the study or refusing surgery under local anesthesia were excluded from our study. all the patients were adults from 18-60 years old. patients participating in our study were divided in two groups. first 25 patients booked for dcr surgery were allocated to group a, next 25 patients during study period were allotted to group b. all the patients had complete ophthalmic examination before surgery. general physical health of the patients was also assessed in terms of hypertension and diabetes. those having uncontrolled hypertension and poor glycemic control were excluded from our study. patients in group a underwent dcr under local anesthesia i.e. 5 ml anesthetic formulation made by 2.5 ml of 2% bupivacaine and 2.5 ml of commercially available 2% xylocaine, with 1:200,000 adrenaline (0.005 mg/ml); whereas those in group b had their surgery done under local anesthesia with 2.5 ml of 2% bupivacaine, 2.4 ml of 2% xylocaine and 0.1 ml of 1:50,000 adrenaline (0.02 mg/ml). injection of local anesthetic was given at three points; supratrochlear block, infra-trochlear block and 10 mm from medical canthus. no sedative or intra muscular analgesics were used in any case. except for the concentration and formulation of local anesthesia, there was no difference in the surgical technique in both groups and all surgeries were performed by the same surgeon. per-operative pain, bleeding and effectiveness of anesthesia were noted in both the groups and were compared. scoring of pain, bleeding and anesthesia effectiveness was done using the scoring table shown below (table 1). pain was assessed on a numeric scale by asking the patient during the procedure and postoperatively. peroperative bleeding was scored on the basis of number of gauze packs (one gauze pack contain 10 gauze pieces) used during procedure. effectiveness of anesthesia was measured in terms of number of doses required during the surgery. data was recorded in excel spreadsheets and analyzed using spss version 20. descriptive statistics were used to describe the data. means of pain score, bleeding score and anesthesia effectiveness score for both groups were compared. results in group a, 21 (84%) patients were females and 4 (16%) were males. in group b 20 (80%) patients were efficacy of local anesthesia during external dacryocystorhinostomy with 1:200,000 adrenaline versus 1:50,000 adrenaline pakistan journal of ophthalmology, 2020, vol. 36 (3): 287-291 289 females and 5(20%) were males. mean age of patients in group a was 41.04 ± 6.84 years and in group b was 40.80 ± 8.563 years. epiphora with discharge was the chief presenting complaint in the patients of both the groups. regurgitation test was positive in all the patients of both the groups. intra operative complications were failure to suture nasal mucosa and lacrimal sac flaps in one patient of group a because of damage to lacrimal mucosa during osteotomy. most common postoperative finding was periorbital swelling followed by table 1: scoring of pain, bleeding and effectiveness of anesthesia. grade of pain score no pain 0 mild pain 1 moderate pain ( controllable) 2 severe pain (uncontrollable) 3 bleeding score minimal ( 2 gauze packs used) 1 moderate (2-5 gauze packs used) 2 massive (more than 5 gauze packs used) 3 effectiveness of anesthesia score no additional dose required 3 control with 1 additional dose 2 control with >1 additional dose 1 table 2: pain, bleeding and anesthesia in group a and b. group a group b n min max mean std. dev min max mean std. dev pain 25 1 3 2.20 .500 1 3 1.72 .542 bleeding 25 1 3 1.84 .473 1 2 1.24 .436 anesthesia effect 25 1 3 2.08 .640 2 3 2.76 .436 2.2 1.72 1.84 1.24 2.08 2.76 0 1 2 3 pain bleeding anesthesia group a group b fig. 1: difference in pain, bleeding and anesthesia between group a and b. ecchymosis. descriptive statistics of pain, bleeding and effectiveness of anesthesia scores of the group a and b are shown in table 2. discussion external dcr is the gold standard procedure for nld blockage in adults. this procedureis not performed routinely in private sector hospitals. because of this reason there is increase burden of nld blockage patients presenting to public sector hospitals. because of long surgical booking time and increased burden of patients, it is often required to perform this procedure in local anesthesia (la). xylocaine 1%–2% without and with adrenaline (1:100,000 or 1:200,000) is available commercially. it is the local anesthetic most commonly used for surgical procedures11. addition of adrenaline decreases systemic absorption and also provides good anesthesia and better control of bleeding11. xylocaine is mostly given in a preparation combined with bupivacaine, which is a long acting local anesthetic12. it has been observed by shoroghi et al. that increasing the concentration of adrenaline during dermatologic surgery reduces the surgical time and also reduces the per-operative bleeding13. adrenaline in a concentration of 10µg/ml (1:100,000) in the local anesthetic is under use for different oculoplastic procedures14. there is no enough evidence available on its use in a concentration of 20 µg/ml (1:50,000) in ophthalmic surgery. adrenaline in a concentration of 20 µg/ml (1:50,000) is used for many day care dental procedures. the maximum recommended dose (mrd) of adrenaline in la formulations for healthy adults is 0.2 mg per visit15. based on this recommendation, the maximum safe dose of xylocaine in ml with adrenaline 20µg/ml (1:50,000), is 10 ml16. in our study 6 patients (n = 25) in group b received 10 ml of muhammad sharjeel, et al 290 pakistan journal of ophthalmology, 2020, vol. 36 (3): 287-291 xylocaine w/adrenaline 20 µg/ml (1:50,000). no patient required more than 1 dose of local anesthetic. it is important to mention that adrenaline has a relatively narrow therapeutic window17. adverse effects which can occur include restlessness, agitation, anxiety, tremulousness, headache, dizziness, pallor, palpitation, and tachycardia. these side effects have been reported even with the administration of recommended therapeutic doses18. in our study no major side effects were noted. complaint of headache and tachycardia was noted in a few patients, but it was attributed to be post-surgical effect. in high-risk cardiac patients lower dose of adrenaline is recommended. it ranges from 0.02 – 0.05 mg19,20. in our study patients with cardiac disease were excluded. patients in group b in our study had better analgesia as compared to group a. this resulted in short duration of surgery and more patient satisfaction. the control of bleeding was also better in group b, which provided benefit in terms of better tissue identification and surgical results. there was also low incidence of post-operative periorbital ecchymosis in group b patients. limitation of this study was that it was a single centre study with small sample size. patients with comorbid conditions were excluded in this study. multicentre studies with large sample size are required to report safety profile of adrenaline use is high concentration with local anesthesia. conclusion use of more concentrated adrenaline during external dcr is an effective measure in terms of reducing peroperative complications in patients who have no significant contraindications to the use of concentrated adrenaline. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution dr. muhammad sharjeel; senior registrar: data collection, manuscript review. dr. mehr-un-nisa; postgraduate trainee: manuscript writing and review. dr. usama iqbal; postgraduate trainee: manuscript writing, data analysis, data entry. dr rafay razzaq wattoo; consultant ophthalmologist: manuscript writing, literature review, final review. references 1. shen gl, ng jd, ma xp. etiology, diagnosis, management and outcomes of epiphora referrals to an oculoplastic practice. int j ophthalmol. 2016; 9 (12): 1751–1755. doi: 10.18240/ijo.2016.12.08. 2. qamar rmr, latif e, tahir my, moin m. outcome of delayed lacrimal probing in congenital obstruction of nasolacrimal duct. pak j ophthalmol. 2011; 27 (4): 3. vagge a, ferro desideri l, nucci p, 1, giannaccare g, lembo a, et al. congenital nasolacrimal duct obstruction (cnldo): a review. diseases, 2018; 6 (4): 96. doi: 10.3390/diseases6040096. 4. sathiamoorthi s, frank rd, mohney bg. spontaneous resolution and timing of intervention in congenital nasolacrimal duct obstruction. jama ophthalmol. 2018; 136 (11): 1281–1286. doi: 10.1001/jamaophthalmol.2018.3841. 5. toti a. new radical conservative method of chronic suppurations of the lacrimal sac (dacryocystorhinostomy). cli. mod firenze. cli. mod firenze. 1904; 10: 385-9. 6. wadwekar b, hansdak a, nirmale sd, ravichandran k. cutaneous scar visibility after external dacryocystorhinostomy: a comparison of curvilinear and w shaped incision. saudi j ophthalmol. 2019; 33 (2): 142–147. doi:10.1016/j.sjopt.2019.01.009. 7. ghasemi h, asghariasl s, yarmohammadi me, jafari f, izadi p. external dacryocystorhinostomy; success rate and causes of failure in endoscopic and pathologic evaluations. iran j pathol. 2017; 12 (3): 189–194. 8. kasaee a, ghahari e, tabatabaie s z, mohtaram r, rajabi m t. external dacryocystorhinostomy: local versus general anesthesia. iran j ophthalmol. 2010; 22 (1): 27-30. 9. burket, c. n., 2019. eye wiki. available at: https://eyewiki.aao.org/dacryocystorhinostomy 10. managutti a, prakasam m, puthanakar n, menat s, shah d, patel h. comparative analysis of local anesthesia with 2 different concentrations of adrenaline: a randomized and single blind study. j intern oral health, 2015; 7 (3): 24. efficacy of local anesthesia during external dacryocystorhinostomy with 1:200,000 adrenaline versus 1:50,000 adrenaline pakistan journal of ophthalmology, 2020, vol. 36 (3): 287-291 291 11. ing eb, philteos j, sholohov g, kim dt, nijhawan n, mark pw, gilbert j. local anesthesia and anxiolytic techniques for oculoplastic surgery. clin ophthalmol. (auckland, nz). 2019; 13: 153. 12. karm mh, kim m, park fd, seo ks, kim hj. comparative evaluation of the efficacy, safety, and hemostatic effect of 2% lidocaine with various concentrations of epinephrine. j dent anesth pain med. 2018; 18 (3): 143-9. 13. shoroghi m, sadrolsadat sh, razzaghi m, farahbakhsh f, sheikhvatan m,sheikhfathollahi m, abbasi a. effect of different epinephrineconcentrations on local bleeding and hemodynamics during dermatologicsurgery. acta dermatovenerol croat. 2008; 16 (4): 209-14. 14. sheikh r, dahlstrand u, memarzadeh k, blohmé j, reistad n, malmsjö m. optimal epinephrine concentration and time delay to minimize perfusion ineyelid surgery: measured by laser-based methods and a novel form ofextended-wavelength diffuse reflectance spectroscopy. ophth plast reconstr surg. 2018; 34 (2): 123-9. 15. chernow b, balestrieri f, ferguson cd, et al. local dental anesthesia with epinephrine. minimal effects on the sympathetic nervous system or on hemodynamic variables. arch intern med. 1983 nov; 143 (11): 21413. 16. kemp sf, lockey rf, simons fe. world allergy organization ad hoc committee on epinephrine in anaphylaxis. epinephrine: the drug of choice for anaphylaxis-a statement of the world allergy organization. world allergy organ j. 2008; 1 (7 suppl): s18-26. doi: 10.1097/wox.0b013e31817c9338. 17. kemp sf, lockey rf, simons fe. world allergy organization ad hoc committee on epinephrine in anaphylaxis. epinephrine: the drug of choice for anaphylaxis. a statement of the world allergy organization. allergy, 2008; 63 (8): 1061-70. 18. managutti a, prakasam m, puthanakar n, menat s, shah d, patel h. comparative analysis of local anesthesia with 2 different concentrations of adrenaline: a randomized and single blind study. j int oral health. 2015; 7 (3): 24-27. 19. gerlach rf, santos jetd, escobar cab. the use of epinephrine-containing anesthetic solutions in cardiac patients: a survey. revista de odontologia da universidade de são paulo. 1998; 12 (4): 349-353. 20. kothari d, abbas h. how safe is therapeutic dose of lignocaine with epinephrine: an overview. natl j maxillofac surg. 2015; 6 (1): 132. doi: 10.4103/09755950.168230. .……. outcme of amniotic membrane transplant in persistant corneal epithelial defects 52 pak j ophthalmol. 2022, vol. 38 (1): 52-57 original article outcome of amniotic membrane transplant in persistent corneal epithelial defects tiabbah saleem 1 , syeda aisha bokhari 2 1 sir syed college of medical sciences, sir syed hospital, 2 the eye center, south city hospital, karachi abstract purpose: to determine the outcome of amniotic membrane transplant in patients with ocular surface disease. study design: interventional case series study. place and duration of study: layton rahmatullah benevolent trust eye hospital, korangi 2½, karachi, from january, 2019 to july 2019. methods: patients with an age range of 20 – 45 years, either gender and who had persistent corneal epithelial defects as a consequence of keratitis, chemical injuries, bullous keratopathy and mooren’s ulcers were included. informed consent was obtained. preserved amniotic membrane was used in all patients and they were followed at 1 week, 1, 3 and finally at 6 months and results were evaluated in terms of stable, healed and pain-free cornea. results: mean age of the patients was 37.94 ± 6.78 years. majority of the patients (60.0%) were less than 40 years of age. out of 58 patients, 45 (77.6%) were males and 13 (22.4%) were females. mean duration of injury was 7.67 ± 2.28 weeks with majority of patients i.e. 62% were with less than 8 weeks of duration. most common cause of persistent corneal epithelial defect was bacterial keratitis (17.2%) followed by vegetative trauma (13.8%). successful surgical outcome as healed cornea was observed in 53 (91.4%) patients. conclusion: amniotic membrane transplant is an effective treatment for persistent corneal epithelial defects unresponsive to standard medical treatment. this surgical technique is effective in terms of healing and resolving the inflammation and preserving the useful vision. key words: persistant corneal epithelial defect, amniotic membrane, bullous keratopathy. how to cite this article: saleem t, bokhari sa. outcome of amniotic membrane transplant in persistent corneal epithelial defects. pak j ophthalmol. 2022, 38 (1): 52-57. doi: 10.36351/pjo.v38i1.1340 introduction amniotic membrane forms the innermost layer of placenta and consists of a thick basement membrane correspondence: tiabbah saleem sir syed college of medical sciences sir syed hospital karachi email: staibbah@gmail.com received: october 6, 2021 accepted: december 7, 2021 that promotes epithelial cell migration and adhesion and an avascular stromal matrix that reduces inflammation, fibrosis and neovascularization. certain characteristics make the amniotic membrane ideally suited to its application in ocular surface reconstruction. it can be easily obtained and its availability is nearly unlimited. the tissue can be preserved at -80℃ for several months, allowing sufficient time to plan surgery or consider a trial of other options. 1 amniotic membrane does not express hla-a, b or dr antigens and hence immunological rejection after its transplantation cannot occur. transplantation of preserved amniotic membrane can open access outcome of amniotic membrane transplant in persistent corneal epithelial defects pak j ophthalmol. 2022, vol. 38 (1): 52-57 53 be considered one of the major developments in ocular surgery. although the first ophthalmological use of amniotic membrane documented in the international literature, was almost 70 years ago, amniotic membrane transplantation has been performed in large number of patients since 1995 with promising results. it has been used in the treatment of conjunctival disorders, persistent corneal epithelial defects and painful bullous keratopathy and prone to perforate corneal ulcers. 2,3 clinical trials suggest that amniotic membrane transplantation promotes epithelialization and differentiation of the epithelium of the ocular surface. 4 the most important growth factors that promote wound healing are epidermoid growth factor and keratocyte growth factor, which have been isolated mainly from the amniotic membrane epithelium and stroma. 5 the normal ocular surface is covered by corneal, limbal and conjunctival epithelial cells. the limbal stem cells give rise to the corneal epithelium and therefore are especially important for maintenance of a smooth, clear corneal surface. these cells together with a stable tear film maintain the health of the ocular surface and therefore, contribute towards improved visual acuity. damage to these cells from certain systemic inflammatory diseases or primary ocular diseases or trauma such as stevens johnson syndrome, ocular cicatricial pemphigoid, rheumatoid arthritis, herpes zoster ophthalmicus, surgically induced neurotrophic keratitis, chemical or thermal injuries and infective keratitis may lead to the state of limbal stem cell deficiency. the result is breakdown of ocular surface and corneal epithelial defects that may become chronic if normal epithelialization process fails. conjunctival epithelium may replace corneal epithelium resulting in loss of corneal transparency. chronic inflammation may occur characterized by neovascularization, corneal scarring and opacification, corneal thinning and possible corneal perforation, all of which may lead to loss of visual acuity. 6 structural proteins such as laminin and type vii collagen in the amniotic basement membrane explain the observed epitheliotropic effects. intrinsic neurotropic substances make amniotic membrane an ideal substrate for reconstruction of the epithelium of the ocular surface. amniotic membrane has been used to treat persistent non-healing corneal ulcers and surface problems with favorable outcomes of healed, stable and pain-free corneal surface. 7 methods this study was conducted at lrbt, which is a tertiary care teaching eye hospital, karachi, from january 2019 to june 2019. it was an interventional case series. the sample size was calculated using reference value of expected proportion of successful outcome as 81.8%, keeping confidence level at 95% and desired precision as 7%. fifty-eight (58) patients were recruited using non-probability, consecutive sampling. both male and female with an age range of 20–45 years, who had persistent epithelial defect as a consequence of keratitis, chemical injuries, bullous keratopathy and mooren’s ulcers were included. information regarding demographic data, history of disease, side involved and ophthalmic examination findings were noted. examination included visual acuity, slit lamp examination to note extent of damage of corneal epithelial defect measured in two dimensions with mm scale on slit lamp, limbal ischemia, conjunctival involvement in the form of necrosis, lime deposits, tear film assessment by schirmer test with and without anesthesia and fundus examination, wherever possible. exclusion criteria of the study was history of previous ocular surgeries (e.g. cataract surgery) or intraocular injection, intraocular inflammation, penetrating ocular trauma, diabetes, hypertension and patients who lost to follow up before completion of 6 months duration after treatment. hospital ethical review committee gave the approval for study and informed consent was obtained from all the patients. preserved amniotic membrane was used in all the patients and they were followed at 1 week, 1, 3 and finally at 6 months and results were evaluated in terms of stable, healed cornea and painfree cornea of level 0 and 1 according to visual analogue scale. at the time of surgery, patient’s eye was scrubbed with 10% povidine solution and draped, eye speculum was placed and 5% povidine-iodine solution was applied to the ocular surface. amniotic membrane was thawed at room temperature just before its use, and the membrane was rinsed three times in balanced salt solution. hand-held corneal trephines of different sizes were used to cut the amniotic membrane according to size of wound, to get regular margins of the applied tissue and for applying neat and equally spaced radial sutures according to anatomical shape of cornea. the membrane was then gently separated from the nitrocellulose paper with blunt forceps. the amniotic membrane was then gently spread on to the ocular surface and trimmed to the tiabbah saleem, et al 54 pak j ophthalmol. 2022, vol. 38 (1): 52-57 appropriate size and shape. in cases of corneal pathologies other than chemical injuries, the membrane was secured in place using 10/0 nylon interrupted sutures to the cornea with shiny epithelial surface placing upward. in cases of chemical injuries, as well as mooren’s ulcer (corneal/limbal disease) a membrane much larger than the affected area was needed. in these cases, a combination of interrupted 10/0 nylon sutures to the conjunctiva/episclera and an 11/0 nylon continuous suture (i.e. purse string bedding suture just outside the limbus) was applied. bandage contact lens (bcl) was routinely used, at the end of the operation, to protect and keep the amniotic membrane in place and for comfort. the sutures and contact lens were removed after 2 to 4 weeks. recommended post-operative topical treatment consisted of preservative-free antibiotic and corticosteroid drops. fig. 1: 1st layer of amniotic membrane (am) secured with continuous suture. fig. 2: 2nd layer of am with interrupted sutures. fig. 3: rt. descemdocele. fig. 4: decemetocele resolved (8 weeks post-operative). fig. 5: pre-operative left corneal epithelial defect. fig. 6: am in place, conjunctival inflammation resolved. outcome of amniotic membrane transplant in persistent corneal epithelial defects pak j ophthalmol. 2022, vol. 38 (1): 52-57 55 results the age of patients in this study ranged between 20 to 45 years with mean age of 37.94 ± 6.78 years. majority of the patients 60.0% were less than 40 years of age. out of 58patients, 45 (77.6%) were males and 13 (22.4%) were females. mean duration of symptoms was 7.67 ± 2.28 weeks with majority of the patients i.e. 62% were with less than 8 weeks of duration. most common cause of persistent corneal epithelial defect was bacterial keratitis (17.2%) followed by vegetative trauma (13.8%). stable healed cornea was observed in 53 (91.4%) and 54 (93.1%) patients were pain-free after treatment. effect modifiers like age, gender, duration of disease and side of eye were controlled through stratification. post stratification chi-square test was applied. p-value ≤ 0.05 was taken as significant. table 1: frequency distribution of healed cornea according to gender, age, duration and eye. modifiers healed cornea p-value yes no gender male 40 5 0.209 females 13 0 age < 40 32 3 0.987 > 40 21 2 duration (weeks) < 8 32 4 0.387 > 8 21 1 eye side right 27 2 0.640 left 26 3 table 2: frequency distribution of pain free cornea according to gender, age, duration and eye. modifiers pain-free cornea yes no gender male 43 2 0.17 female 11 2 age (years) < 40 32 3 0.535 > 40 22 1 duration (weeks) < 8 34 2 0.606 > 8 20 2 eye side right 28 1 0.300 left 26 3 discussion there are multiple ways to manage persistent corneal epithelial defects. amniotic membrane transplant is one of the successful methods to treat these cases. 8-10 our preference to use amniotic membrane transplant was to see its effectiveness in our setup. traditional amniotic membrane transplant involves application of sterilized and preserved amniotic membrane patch, cutting it with scissors and applying over the defect site according to the size of defects and securing it with sutures. after that bandage contact lens (bcl) is applied to allow good approximation of graft to the host surface. we performed amniotic membrane transplant in multi layers depending upon the thinning and severity of defect. peraka rp et al described the integration of multilayer amniotic membrane graft (mamg) in the corneal stroma around the full thickness corneal defect. 11 similarly, healing effect of amniotic membrane described by lavaris and colleagues support the effectiveness of mamg in treatment of corneal epithelial defect. 12 the application of bcl over the am provides better approximation and contact of the am graft with the corneal surface and protects from retraction of graft with blinking and reduces the duration of healing. xia zhang and colleagues reported that the healing time of patients with bcl application over amniotic membrane transplant after pterygium excision was 3.43 ± 1.03 days, as compared to the group without bcl of 5.13 ± 1.16 days. 13 most of the patients included in our study responded within 1 to 2 weeks with healed corneal surface. there was no corneal staining and there was decrease in associated ocular inflammation. the patients with mooren’s ulcer responded with decrease in severity of pain, while surface reconstruction required additional scleral tectonic graft in the areas of severe thinning. a study conducted by lee sh supported the idea that amniotic membrane transplantation may be considered as an alternative method for treating persistent epithelial defects and sterile ulceration that are refractory to conventional treatment. he suggested that am transplant should be considered before planning treatment with conjunctival flaps or tarsorrhaphy. ten out of 11 patients healed in 3.9 ± 2.3 weeks (p < .01) without recurrence for 9.0 ±5.9 months. one patient failed to heal because of preexisting corneal perforation pursuant to severe rheumatoid arthritis. 14 hanada k and colleagues performed amt in three different surgical procedures in 95 patients. am patch, for the promotion of corneal re-epithelialization was performed in 14 cases, 13 out of them were healed. there were no complications due to the am transplantation during the course of treatment in any of the 95 cases. 15 tiabbah saleem, et al 56 pak j ophthalmol. 2022, vol. 38 (1): 52-57 treatment of neuropathic corneal pain (ncp) remains complex and challenging, and involves a long-term combined multistep approach. the selfretained cryop reserved amniotic membrane (prokera®, bio-tissue, miami, fl) has been utilized for multiple ocular surface disorders. 16 amniotic membrane transplant did not produce successful results in cases of perforated corneas where tarsorrhaphy should be the preferred procedure. 17 alina gheorghe and colleagues reported three cases treated with amniotic membrane transplant. they concluded that the tissue was very conducive to epithelial cell migration and attachment. keratocytes re-populate the amnion stroma, thus building corneal stromal tissue. the mechanism of action of the membrane was attributed to its physical structure and its molecular constituents. 18 amt should be considered for ocular surface reconstruction and also in limbal stem cell deficiency of various severity in conjunction with other novel procedures like kerato-limbal allograft and autograft. le q and colleagues concluded that the surgical approaches to treat lscd (limbal stem cell deficiency) vary depending on the severity of lscd. the transplantation of am alone seems to have limited long term effect. amt combined with various types of lsc transplantation is commonly performed based on the presumption that am provides biological and mechanical support, and protection to the transplanted tissues and cells. although few studies are available but large population studies are lacking to support the efficacy of amt in lsc transplantation. 19,20 limitation of the study was that it was a single centered study. the follow up was of short duration. conclusion amniotic membrane transplant is a very effective treatment modality for persistent corneal epithelial defects not responding to conventional medical treatment. it has additional benefit of reducing associated conjunctival inflammatory response, may reduce the risk of severe limbal cell deficiency, preserving the vision from deterioration and preventing the patient from cosmetically less acceptable procedures. however, wide use of amniotic membrane transplant in occular surface disorders needs to be optimized widely and its efficacy evaluated by conducting wide spread trials. ethical approval the study was approved by the institutional review board/ethical review board. (lrbt/fbeh/wec/3297/17). conflict of interest authors declared no conflict of interest. references 1. jirsova k, jones gl. amniotic membrane in ophthalmology: properties, preparation, storage and indications for grafting a review. cell tissue bank, 2017; 18 (2): 193-204. 2. siu gd, kam kw, young al. amniotic membrane transplant for bullous keratopathy: confocal microscopy & anterior segment optical coherence tomography. semin ophthalmol. 2019; 34 (3): 163167. 3. hossain l, arifuzzaman m, diba f, siddika a, adnan mh, akhtar n, et al. human amniotic membrane preparation, preservation and clinical application using various techniques for the treatment of ophthalmic dysfunctions. preprints, 2018: 10.0321.v1. doi: 10.20944/preprints201810.0307.v1 4. malhotra c, jain ak. human amniotic membrane transplantation: different modalities of its use in ophthalmology. world j transplant. 2014; 4 (2): 111. 5. koob tj, rennert r, zabek n, massee m, lim jj, temenoff js, et al. biological properties of dehydrated human amnion/chorion composite graft: implications for chronic wound healing. int wound j. 2013; 10 (5): 493-500. 6. tseng sc. hc-ha/ptx3 purified from amniotic membrane as novel regenerative matrix: insight into relationship between inflammation and regeneration. invest ophthalmol & vis sci. 2016; 57 (5): orsfh 18. 7. kruse fe, cursiefen c. surgery of the cornea: corneal, limbal stem cell and amniotic membrane transplantation. dev ophthalmol. 2008; 41: 159-170. doi: 10.1159/000131087. 8. paolin a, cogliati e, trojan d, griffoni c, grassetto a, elbadawy hm, et al. amniotic membranes in ophthalmology: long term data on transplantation outcomes. cell tissue bank, 2016; 17 (1): 51-58. 9. monteiro bg, loureiro rr, cristovam pc, covre jl, gomes já, kerkis i. amniotic membrane as a biological scaffold for dental pulp stem cell transplantation in ocular surface reconstruction. arq bras oftalmol. 2019; 82 (1): 32-37. outcome of amniotic membrane transplant in persistent corneal epithelial defects pak j ophthalmol. 2022, vol. 38 (1): 52-57 57 10. korittum as, kassem mm, adel a, gaith aa, elhabashi n. effect of human amniotic membrane transplantation in reconstruction of canine corneal wound. alex. j vet sci. 2019; 60 (2). 11. peraka rp, kalra p. multilayered amniotic membrane transplantation in a case of chronic corneal fistula. br. med. j case rep. 2020; 13 (9): e237369. 12. lavaris a, elanwar mf, al-zyiadi m, xanthopoulou pt, kopsachilis n. glueless and sutureless multi-layer amniotic membrane transplantation in a patient with pending corneal perforation. cureus, 2021; 13 (7): e16678. doi:10.7759/cureus.16678 13. zhang x, tang q, qian xu. effect of pterygium transplantation combined with amniotic membrane transplantation plus bandage contact lenses for pterygium. int j ophthalmol. 2018; 18 (6): 1146-1148. 14. lee sh, tseng sc. amniotic membrane transplantation for persistent epithelial defects with ulceration. am j ophthalmol. 1997; 123 (3): 303-312. 15. hanada k, nishikawa n, ishii n, utsunomiya t, yoshida a. amniotic membrane transplantation for corneal and conjunctival diseases: classification of application and outcomes from analysis of 95 cases. nippon ganka gakkai zasshi. 2017; 121 (4): 359. 16. alder j, mertsch s, menzel-severing j, geerling g. aktuelle und experimentelle therapieansätze bei neurotropher keratopathie [current and experimental treatment approaches for neurotrophic keratopathy]. ophthalmologe. 2019; 116 (2): 127-137. german. doi: 10.1007/s00347-018-0843-5. pmid: 30707284. 17. patel n, erickson b, lee ww. eyelid: temporary tarsorrhaphy. in: rosenberg e., nattis a., nattis r. (eds) operative dictations in ophthalmology. springer, cham. 2017: 513-515. https://doi.org/10.1007/978-3319-45495-5_119 18. gheorghe a, rosoga at, mrini f, vărgău i, gherghiceanu f. various therapies for ocular surface diseases. rom j ophthalmol. 2018; 62 (1): 83. 19. le q, deng sx. the application of human amniotic membrane in the surgical management of limbal stem cell deficiency. the ocular surface, 2019; 17 (2): 221229. 20. qihua le, sophie x. deng. the application of human amniotic membrane in the surgical management of limbal stem cell deficiency. the ocular surface, 2019; 17 (2): 221-229. https://doi.org/10.1016/j.jtos.2019.01.003. authors’ designation and contribution tiabbah saleem; senior registrar: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. syeda aisha bokhari; consultant ophthalmologist: concepts, design, data acquisition, manuscript editing, manuscript review. .…  …. microsoft word 12. saif hassan al-rasheed mm pakistan journal of ophthalmology, 2020, vol. 36 (3): 247-252 247 original article clinical characteristics of patients presenting with headache at binocular vision clinic: a hospital based study saif hassan al-rasheed1 1department of optometry, qasim university, saudi arabia and department of binocular vision, alneelain university, khartoum, sudan abstract purpose: to assess the clinical characteristics of patients presenting with headache at binocular vision clinic. place and duration of study: al-neelain eye hospital, khartoum, sudan, from february to october 2018. study design: descriptive cross-sectional study. material and methods: one hundred fifty patients with history of headache were included in study. detailed ocular examination was performed. dissociated heterophoria was measured using maddox wing and maddox rod. associated heterophoria was assessed by the mallett unit fixation disparity and fusional vergence was measured using a prism bar. data was analyzed using spss, version 25. the relationship between measures was determined using the chi-squared analysis. for all statistical determinations, significance levels were set at p < 0.05. results: mean age was 25 ± 3.5 years. 86.7% patients with headache had visual acuity of 6/6. females constituted 78% and headache was significantly associated with females (p < 0.0001). majority of patients (82%) presented with exophoria (mean = 4.74 ± 0.75 δ base-in) at near fixation, 10.7% were orthophoric and 7.34percentage were esophoric (mean = 3.24 ± 0.5 δ base-out). the association between near heterophoria and headache was statically significant (χ2 = 7.426; p = 0.001). association between distance heterophoria and headache was not statistically significant (χ2 = 22.172; p = 0.265). the association between headache and positive fusional vergence at near fixation was statically significant (p = 0.03). leading cause of headache was convergence weakness exophoria (39.3%; p = 0.001), followed by convergence insufficiency (24%; p = 0.02). conclusion: headache was more common in females and was associated with exophoria, convergence insufficiency and inadequate positive fusional vergence at near fixation. key words: headache, binocular vision, exophoria, convergence insufficiency. how to cite this article: al-rasheed sh. clinical characteristics of patients presenting with headache at binocular vision clinic: a hospital based study. pak j ophthalmol. 2020; 36 (3): 247-252. doi: 10.36351/pjo.v36i3.1046 introduction headache is one of the commonest health complaints and it affect approximately half of world population. it correspondence to: saif hassan al-rasheed college of applied medical sciences, qasim university, saudi arabia, email: saif.alrasheed@yahoo.com received: april 18, 2020 revised: may 4, 2020 accepted: may 4, 2020 has significant effect on work productivity and quality of life1. the problem may arise from conditions that range from benign to catastrophic. quick and accurate diagnosis is an important step for successful management of headache2,3. a review of studies conducted globally, estimated the prevalence of headache as 58.4% among school-going children and 46% in adult population2,3,4. it is commonly believed saif hassan al-rasheed, et al 248 pakistan journal of ophthalmology, 2020, vol. 36 (3): 247-252 that refractive errors and binocular vision anomalies can lead to headache among young individual4. eye care professional reported that headache is a common patient complaint5,6,7. international headache society reported that the diagnostic criteria of headache associated with refractive errors is as follows: a) uncorrected refractive errors such as hypermetropia, astigmatism, presbyopia, or wearing incorrect glasses, b) mild headaches in the frontal region and in the eyes, c) pain absent on awakening and worse by prolonged visual tasks at distance or near8. in a masked case control study, to assess the relation between headache and binocular vision anomalies it was concluded that people suffering from headache had higher prevalence of heterophoria, associated phoria and reduced stereopsis compared with controls. the study found that there was strong association between exophoria and complaint of headache9. another study have indicated that the positive fusional reserve should be at least twice the magnitude of an exophoria to be compensated (without symptoms)10. binocular visual dysfunctions such as convergence insufficiency (ci) affects young people and is characterised by the inability to accurately converge, or sustain accurate convergence when focusing at near targets. it is associated with symptoms such as headache, blurry vision, eyestrain, and double vision10. headache may also be due to different ocular diseases such as acute glaucoma, optic neuritis, uveitis, and visual anomalies such as uncorrected refractive errors, accommodative and vergence dysfunctions. the most common eye condition leading to headache after refractive errors is binocular vision anomalies11. there is a general increase in the number of people suffering from headaches. in addition, headaches have a significant negative impact on the quality of life and productivity. therefore, the current study was conducted to assess the clinical characteristics of patients suffering from headaches who attended the binocular vision clinic at al-neelain eye hospital khartoum, sudan. material and methods one hundred and fifty patients suffering from headache and referred by ophthalmologists to the binocular vision clinic were selected by convenient sampling technique, from february to october 2018. patients with other ocular or systemic diseases were excluded from the study. all selected patients underwent detailed ocular examinations by trained ophthalmologists. the patients were then referred to the orthoptic clinic for binocular vision assessment. optometry graduate research assistants with experience in clinical optometry assisted with data collection. the data collectors underwent training in the study protocol procedures. ethical approval for study was obtained from al-neelain university. to facilitate a better understanding of the procedures and conditions of involvement in the study, an information document detailing the nature of the study was provided to all the patients. participation in the study was voluntary and patients were informed that they could withdraw from the study at any time without giving any reason. all forms and data sheets were shredded as soon as it is entered into database system for analysis. the demographic information was collected from all the participants followed by measurement of visual acuity at distance using snellen tumbling e-chart. amplitude of accommodation and near point of convergence were measured using raf rule. cover test was conducted at 33 cm for near and 6-meter for distance with the patients fixating on one line above the best visual acuity of the poor eye. the subjects underwent motility tests to assess the integrity of the eye muscles. objective refraction was assessed using retinoscopy (neitzrx, japan) while dissociated heterophoria was measured using maddox wing and maddox rod at near and distance fixation, respectively. associated heterophoria was assessed by the mallett unit fixation disparity while the positive and negative fusional vergence were measured using a prism bar at 33 cm and 6 meter for near and distance respectively. the data was entered in microsoft excel spreadsheet and analyzed using spss software, version 25 (spss, inc., chicago, il). the data were analysed descriptively using standard deviations and percentages. the relationship between measures was determined using the chi-square analysis. significance levels were set at p < 0.05. results a total of 150 patients who attended al-neelain eye hospital complaining of headaches were included in this study. the age of the participants ranged between 10 and 35 years with a mean age of 25.0 ± 3.5 years. clinical characteristics of patients presenting with headache at binocular vision clinic: a hospital based study pakistan journal of ophthalmology, 2020, vol. 36 (3): 247-252 249 seventy-one percent were between 15-20 years, followed by age groups (21–25) representing 57 (38%). one hundred and seventeen (78%) patients who complained of headache were females. association of headache with females was statistically significant (χ2 = 149.18, p < 0.0001). association of decreased vision with headache was not statistically significant (χ2 = 4.082, p = 0.850), as shown in table 1. the association between headache and types of refractive errors was not statistically significant (χ2 = 2.05; p = 0.562) as illustrated in table 2. majority of the patients (82%) presented with exophoria (mean = 4.74 ± 0.75δ base-in) at near. the association between near heterophoria and headache was statistically significant (χ2 = 7.426; p = 0.001) as shown in table 3. the association between distance heterophoria and headache was not statistically significant (χ2 = 22.172; p = 0.265) as shown in table 3. association between near point of convergence and headache was not statistically significant (χ2 = 3.04; p = 0.836). table 3. 72.7% patients presented without an associated phoria. association between headache and associated phoria was statistically significant. (χ2 = 13.837; p = 0.001) as shown in table 4. 59.3% patients presented with weak positive fusional vergence at near fixation (2 – 14δ base-out). the association between headache and weak positive fusional vergence at near fixation was statistically significant χ2 = 10.726; p = 0.03) as illustrated in table 5. table 1: visual acuity (va) among patients complaining of headache (χ2 = 4.082 p = 0.850). age of participants mean sd (25.0 ±3.5 years) va of participants total n (%) 6/6 n % 6/9 n % ≤ 6/12 n % 10 – 14 11 (7.3) 0 (0.0) 0 (0.0) 11 (7.3) 15 – 20 61 (40.7) 5 (3.3) 5 (3.3) 71 (47.3) 21 – 25 48 (32.0) 3 (2.0) 6 (4.0) 57 (38.0) 26 – 30 8 (5.3) 1 (4.6) 0 (0.0) 9 (6.0) 31 – 35 2 (1.3) 0 (0.0) 0 (0.0) 2 (1.3) total 130 (86.7) 9 (6.0) 11 (7.3) 150 (100) table 2: distribution of refractive error among participants. age of participants mean sd (25.0 ±3.5 years) refractive error of participants total n (%) emmetropia n (%) hypermetropia n (%) myopia n (%) astigmatism n (%) 10 – 14 8 (5.3) 0 (0.0) 1 (0.6) 2(1.3) 11 (7.3) 15 – 20 62 (41.3) 1 (0.6) 6 (4.0) 2(1.3) 71 (47.3) 21 – 25 52 (34.7) 0 (0.0) 1 (0.6) 4(2.7) 57 (38.0) 26 – 30 6 (4.0) 1 (0.6) 1 (0.6) 1(0.6) 9 (6.0) 31 – 35 1 (0.6) 1 (0.0) 0 (0.0) 0(0.0) 2 (1.3) total 129 (86.0) 3 (2.0) 9 (6.0) 9(6.0) 150 (100) (χ2 = 2.05; p = 0.562) table 3: near and distance dissociated heterophoria among the participants. heterophoria gender of participants total n (%) p-value male n (%) female n (%) near dissociated phoria orthophoria 5 (3.3) 11 (7.3) 16 (10.7) exophoria 25 (16.7) 98 (65.3) 123 (82) 0.001 esophoria 3 (2.0) 8 (5.3) 11 (7.3) distance dissociated phoria orthophoria 21 (14.0) 89 (59.3) 110 (73.3) exophoria 9 (6.0) 25 (16.7) 34 (22.7) 0.265 esophoria 3 (2.0) 3 (2.0) 6 (4.0) total 33 (22.0) 117 (78.0) 150 (100) table 4: distribution of associated phoria among the participants. associated phoria gender of participants total n (%) p-value male n (%) female n (%) near associated phoria orthophoria 19 (12.7) 90 (60.0) 109 (72.7) base-in 14 (9.3) 17 (11.3) 31 (20.7) 0.001 base-out 0 (0.0) 10 (5.3) 11 (6.6) total 33 (22.0) 117 (78.0) 150 (100) (χ2 = 13.837; p = 0.001) table 5: fusional vergence among participants suffering from headache. fusional vergence gender of participants total n (%) p-value male n (%) female n (%) positive fusional vergence weak (2 – 14 base-out δ) 19 (12.7) 70 (46.6) 89 (59.3) strong (16 – 35 base-out δ) 14 (9.4) 47 (31.3) 61 (40.7) 0.03 negative fusional vergence weak (2 – 4 base-in δ) 8 (5.3) 16 (10.7) 24 (16.0) strong (6 – 15 base-in δ) 25 (16.7) 101 (67.3) 126 (84.0) 0.534 total 33 (22.0) 117 (78.0) 150 (100) saif hassan al-rasheed, et al 250 pakistan journal of ophthalmology, 2020, vol. 36 (3): 247-252 with respects to negative fusional vergence, most of the patients (84%) had strong negative fusional vergence at near fixation (6 – 15δ base-in). the association between headache and weak negative fusional vergence at near fixation was not statistically significant (χ2 = 2.139; p = 0.534) as shown in table 5. binocular vision anomalies among patients complaining of headache is shown in table 6. the association between headache and table 6: binocular vision anomalies among patients complaining from headache. binocular vision anomalies gender of participants total n (%) p-value male n (%) female n (%) convergence weakness exophoria 10 (6.7) 49 (32.6) 59 (39.3) 0.001 convergence insufficiency 8 (5.3) 28 (18.7) 36 (24) 0.02 weak fusional vergence 4 (2.7) 15 (10.0) 19 (12.7) 0.124 divergence excess exophoria 5 (3.3) 13 (8.7) 18 (12.0) 0.131 convergence excess esophoria 4 (2.7) 7 (4.6) 11 (7.3) 0.423 divergence weakness esophoria 2 (1.3) 5 (3.4) 7 (4.7) 0.658 total 33 (22.0) 117 (78.0) 150 (100) convergence weakness exophoria was statistically significant p = 0.001. the association between headache and convergence insufficiency was also statistically significant p=0.02. discussion headache is a common health complaint and is considered a public health problem. it has significant effect on public health as well as personal health. however, diagnosis of headache and its management is not always easy because the list of differential diagnosis of headache is one of longest in all of the diseases. majority of the patients complaining of headache are referred to eye care professionals, ophthalmologist or optometrist for further diagnosis and management. when headache is a sign of a central nervous system disease, an ophthalmologist can offer valuable information about the nature and localization of the lesion to the neurologists12. in the current study, percentage of females presenting with headache was more than males. this was in accordance with a study in which it was reported that headache was three times more prevalent in females than males particularly during the reproductive age5. similar results were published in other studies13,14,15. the commonest age group suffering from headaches was 15 – 20 years, representing 47.3%. the reason behind this could be more near tasks like reading and writing, in this age group. jain et al12 also reported that headache was more prevalent among young age group and the authors concluded that it could be due to psychological stress caused by educational pressures, emotional factors, and family conflicts. the current study revealed that the association between headache and near exophoria was statistically significant (χ2 = 12.726; p = 0.001). this is in agreement with harle et al9, who reported that there was a strong association between exophoria and headache. evans16 reported that symptoms of exophoria were likely to include headache, which was associated with prolonged use of eyes in near task. this may be due to inadequate positive fusional vergence to compensate the degree of exophoria at near fixation. another study suggested that the positive relative convergence (positive fusional reserve) should be at least twice the magnitude of an exophoria to be compensated17. this is supported by the result of the present study where the majority of patients suffering from headaches presented with weak positive fusional vergence at near fixation. the association between headache and weak positive fusional vergence at near fixation was statistically significant (χ2 = 4.584; p = 0.03). gargetal11 reported that the insufficient positive fusional vergence was more common among patients suffering from headaches. however, in this study there were only 7.3% esophoric patients who complained of headaches. rabbetts reported that the symptoms of esophoric patients were frontal headaches, which might occur after prolonged use of eyes18. the association between near heterophoria and headache was also statistically significant (χ2 = 7.426; p = 0.001). however, the association between distance heterophoria and headache was not statistically significant (χ2 = 22.172; p = 0.265). this could be due to the fact that, at distance fixation, visual axis need less convergence effort, resulting in less ocular deviation compared to near fixation tasks such as reading and chatting on the smart phone. almost 27.4% of patients suffering from headache presented with associated heterophoria (aligning clinical characteristics of patients presenting with headache at binocular vision clinic: a hospital based study pakistan journal of ophthalmology, 2020, vol. 36 (3): 247-252 251 prism). several authors19-23 reported that patients with a fixation disparity (associated heterophoria) on the near mallett unit were likely to have symptoms such as headache and eye strain. with regards to final diagnosis the leading cause of headache among the patients referred to the binocular vision clinic was convergence weakness exophoria which was statistically significant (χ2 = 13.426; p = 0.001). it was followed by convergence insufficiency (χ2 = 6.483; p = 0.02). rouse et al24 defined convergence insufficiency as a syndrome based on near exophoria, low positive fusional reserves (e.g. failing sheard’s criterion) and near point of convergence more remote than 7.5 cm. in a study to assess the association between binocular vision anomalies and headache, it was revealed that the common binocular vision anomaly found in patients with headache was convergence insufficiency 39.19%.11 this was supported by the fact that majority of patients in this study had near exophoria and weak positive fusional vergence. the current study has some limitations. the sample size was small and stereopsis was not assessed in the patients suffering from headache. this was a cross sectional study and the effects of management on headache were also not studied. conclusion headache is more common in females than males, with convergence weakness exophoria and convergence insufficiency being the most common binocular vision anomalies in patients with headache. weak positive fusional vergence at near fixation and associated phoria was common among patients suffering from headache. acknowledgement we are grateful to the staff of al-neelain eye hospital department of binocular vision for helping in data collection process. we would also like to thank all the patients who participated in this study. our thanks to the students of the faculty of optometry and visual science, al-neelain university, who participated in data collection. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. author’s designation and contribution saif hassan alrasheed; optometrist: study design, data collection, and manuscript writing. references 1. sohail s, nakigozi g, anok a, batte j, kisakye a, mayanja r, et al. headache prevalence and its functional impact among hiv-infected adults in rural rakai district, uganda. j neurovirol. 2019; 25 (2): 248-53. 2. abu-arafeh i, razak s, sivaraman b, graham c. prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies. dev 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original article effect of intravitreal bevacizumab on the optic nerve head perfusion in patients with diabetic macular edema nida usman 1 , muhammad ali haider 2 department of ophthalmology, 1-2 al-ehasan welfare eye hospital, lahore abstract purpose: to find out the effect of intravitreal bevacizumab on optic nerve head perfusion using ocular coherence tomography angiography (octa) in patients with diabetic macular edema (dme). study design: interventional case series. place and duration of study: ophthalmology department, mayo hospital, lahore from june 2018 to january 2020. methods: in this study 57 eyes of patients fulfilling the inclusion criteria were selected from the outpatient department. after informed consent, detailed history and ocular examination was performed. baseline octa was done in all cases. the patients received intravitreal bevacizumab (1.25 mg in 0.05 ml). octa was repeated three weeks after injection. both the pre and post injection onh perfusion was compared and analyzed using spss. demographic characteristics like age and gender were calculated. paired sample t-test was applied to check the significance of difference between pre and post injection values. p-value of < 0.05 was considered significant. results: there were 16 (28.1%) males and 41 (71.9%) females. mean age of the patients was 53.54 ± 7.00 years. pre injection blood flow was 56.11 and post injection was significantly reduced to 52.69. the mean difference between was 3.423 and confidence interval of the difference was (2.5755-4.2701). p-value 0.000 was < 0.05 which showed significant reduction in perfusion of onh. conclusion: intravitreal bevacizumab decreases the optic nerve head blood flow and should be used with care in patients having reduced blood flow states and also in patients with advanced glaucomatous optic neuropathy. key words: diabetic macular edema, intravitreal bevacizumab, optical coherence tomography angiography, diabetic retinopathy, optic nerve head, vascular endothelial growth factor. how to cite this article: usman n, haider ma. effect of intravitreal bevacizumab on the optic nerve head perfusion in patients with diabetic macular edema. pak j ophthalmol. 2022, 38 (3): 181-185. doi: 10.36351/pjo.v38i3.1368 correspondence: muhammad ali haider al-ehasan welfare eye hospital, lahore email: alihaider_189@yahoo.com received: january 20, 2022 accepted: june 4, 2022 introduction diabetic macular edema (dme) is one of the major complications causing visual loss in diabetic retinopathy. 1 it is characterized by occlusion and loss of normal macular capillary network. 2 lntravitreal antivascular endothelial growth factor (anti-vegf) has been commonly used for the treatment of diabetic macular edema. off-label intravitreal bevacizumab is the commonest drug in this regard. anti-vegf injections are used to treat various retinal vascular disorders including diabetic macular edema. 3 these agents not only affect dme but also have influence on optic nerve head blood flow. 4,5 optical coherence tomography angiography (octa) is one of the latest techniques that can be used noninvasively to detect perfusion of the optic nerve head at the capillary level. 6,7 octa allows to study retinal microvasculature by calculating the difference mailto:alihaider_189@yahoo.com muhammad ali haider, et al 182 pak j ophthalmol. 2022, vol. 38 (3): 181-185 between a static tissue (vessel) and a dynamic one (red blood cells). 8 red blood cells movement in the retinal capillaries is used as an intrinsic contrast medium to generate flow imaging and it is independent of the direction of movement of cells, with the removal of all static (structural) information by the software. 9 this study was conducted to evaluate the changes in the onh perfusion before and after an intravitreal injection using octa in patients having diabetic macular edema (dme) with moderate to severe nonproliferative diabetic retinopathy (npdr). methods this interventional case series was conducted from june 2018 to january 2020 in ophthalmology department of mayo hospital, lahore. fifty seven patients of 20 to 60 years of age, with moderate and severe non-proliferative diabetic retinopathy. npdr with dme, no previous history of any other ocular disease, no previous ocular surgery or trauma were included. patients with proliferative diabetic retinopathy (pdr), any other ocular pathology, previous history of treatment for any type of diabetic retinopathy were excluded. after approval from ethical review board, the study was started and informed consent was taken from every patient. complete history and examination including vision, intra ocular pressure (iop), refraction, detailed anterior and posterior segment evaluation were performed in every patient. octa was performed to measure the blood flow of onh. all patients received intravitreal bevacizumab (1.25 mg in 0.05 ml), 3.5mm behind the limbus in the infrotemporal quadrant, using all the standard protocals in the hands of a single experienced surgeon. octa was repeated after three weeks. scanning protocol was 200×200 sampling points over 6×6 mm 2 area centered on optic disc to check the changes in blood flow of onh through vessel area density. pre and post injection scans were compared and analyzed using spss. demographic characteristics like age and gender were calculated. paired sample t-test was applied to check the significant difference between pre and post injection perfusion. p-value of < 0.05 was considered significant. figure 1: octa scan showing the blood flow at optic nerve head. effect of intravitreal bevacizumab on the optic nerve head perfusion in patients with diabetic macular edema pak j ophthalmol. 2022, vol. 38 (3): 181-185 183 results there were 16 males (28.1%) and 41 (71.9%) females. mean age was 53.54 ± 7 years. in this study, out of 57 eyes 50 eyes had decrease in onh perfusion, five eyes had slight increase and two eyes showed no change in perfusion. the mean difference between pre and post injection perfusion was 3.423 and confidence interval of the difference was (2.5755 – 4.2701). p-value was 0.000 which is < 0.05 and showed the significant difference between pre and post injection perfusion of onh (table 1). table 1: pre and post avastin perfusion of onh. mean mean difference confidence interval p-value pre-avastin 56.11 3.423 2.5755-4.2701 0.000 post-avastin 52.69 discussion this study showed a statistically significant decrease in onh perfusion after intravitreal injection of bevacizumab. the results correlate with another study which showed transient effect on optic nerve perfusion in response to iop increase due to intravitreal injection. 10 however, our results showed decreased perfusion of onh even after three weeks. numerous studies are available showing the effect of intravitreal anti-vegf on choriodal circulation and retinal circulation using different techniques but our study just shows its effect on onh and uses octa to measure the blood flow. 11,12,13 fukami et al. studied the effects of ranibizumab injection in eyes with macular edema in retinal vein occlusion and found that the injection led to vasoconstriction of retinal vessels and reduction of retinal blood flow. 14 similarly, sugimoto et al. accessed the effects of unilateral intravitreal ranibizumab on ocular circulation of patients treated for dme. they showed a decrease of mean blood flow rate of onh after treatment in the affected eye, but not in the fellow eye which was untreated. 15 nitta et al. showed a comparison between dme patients and patients with branch retinal vein occlusion (brvo) and concluded that mean blood flow did not change significantly after intravitreal bevacizumab in the brvo group, on the other hand in dme group it had decreased. 16 in another study, intravitreal injection of bevacizumab was seen to significantly affect the ocular hemodynamic parameters of both the injected and the un-injected fellow eyes with neovascular age-related macular degeneration. 17 we studied the effect of a single anti-vegf injection in dme. similarly there are other studies showing decrease in retinal arteriolar, choroidal and onh perfusion after intravitreal anti-vegf. 18,19 contradictory to these there is evidence of shortterm reduction in perfusion only in the treated eye which was independent from iop, indicating a direct pharmacological effect. no changes in choroidal perfusion were observed during the first 45 min after the injection. 20 whether this significant decrease in onh perfusion as imaged on octa, leads to any long-term tissue damage remains to be seen. however, clinicians performing these injections should be well aware of these findings and carefully monitor the optic nerve in patients undergoing antivegf injections. limitations of this study are small sample size and short follow up. the additive effect of repeated injections could be measured in case of longer follow ups. moreover, a comparison with other antivegf drugs such as ranibizumab and aflibercept could disclose other ocular blood flow changes. conclusion intravitreal bevacizumab decreases the optic nerve head blood flow and should be used with care in patients having reduced blood flow state especially in patients with advanced glaucoma. conflict of interest: authors declared no conflict of interest. ethical approval the study was approved by the institutional review board/ethical review board (coavs: 114/2022). references 1. klein r, knudtson md, lee ke, gangnon r, klein be. the wisconsin epidemiologic study of diabetic retinopathy: xxii the twenty-five-year progression of retinopathy in persons with type 1 diabetes. ophthalmology, 2008; 115 (11): 18591868. doi: 10.1016/j.ophtha.2008.08.023. muhammad ali haider, et al 184 pak j ophthalmol. 2022, vol. 38 (3): 181-185 2. gundogan fc, yolcu u, akay f, ilhan a, ozge g, uzun s. diabetic macular edema. pak j med sci. 2016; 32 (2): 505-510. doi: 10.12669/pjms.322.8496. 3. pham b, thomas sm, lillie e, lee t, hamid j, richter t, et al. anti-vascular endothelial growth factor treatment for retinal conditions: a systematic review and meta-analysis. bmj open, 2019; 9: e022031. doi: 10.1136/bmjopen-2018-022031. 4. elnahry ag, abdel-kader aa, raafat ka, elrakhawy k. evaluation of changes in macular perfusion detected by optical coherence tomography angiography following 3 intravitreal monthly bevacizumab injections for diabetic macular edema in the impact study. j ophthalmol. 2020; 2020. 5. wen jc, chen cl, rezaei ka, chao jr, vemulakonda a, luttrell i, et al. optic nerve head perfusion before and after intravitreal antivascular growth factor injections using optical coherence tomography-based microangiography. j glaucoma, 2019; 28 (3): 188-193. doi: 10.1097/ijg.0000000000001142. 6. chen c-l, bojikian kd, gupta d, wen jc, zhang q, xin c, et al. optic nerve head perfusion in normal eyes and eyes with glaucoma using optical coherence tomography-based microangiography. quant imaging med surg. 2016; 6: 125–133. 7. chen c-l, bojikian kd, xin c, wen jc, gupta d, zhang q, et al. repeatability and reproducibility of optic nerve head perfusion measurements using optical coherence tomography angiography. j biomed opt. 2016; 21: 65002. 8. hagag am, gao ss, jia y, huang d. optical coherence tomography angiography: technical principles and clinical applications in ophthalmology. taiwan j ophthalmol. 2017; 7 (3): 115-129. doi: 10.4103/tjo.tjo_31_17. 9. or c, sabrosa as, sorour o, arya m, waheed n. use of octa, fa, and ultra-widefield imaging in quantifying retinal ischemia: a review. asia-pac. j. ophthalmol. 2018; 7: 46–51. 10. makedonsky k, wu c, durbin m, ray s. optic nerve head and macula perfusion in diabetics after anti-vegf injection. invest ophthalmol vis scie. 2019; 60 (9): 3076-3076. 11. okamoto m, yamashita m, ogata n. effects of intravitreal injection of ranibizumab on choriodal structure and blood flow in eyes with diabetic macular edema. graefe arch clin exp ophthalmol. 2018; 256 (5): 885-892. 12. ponticorvo a, cardenas d, dunn ak, ts'o d, duong tq. laser speckle contrast imaging of blood flow in rat retinas using an endoscope. j biomed opt. 2013; 18 (9): 090501. doi: 10.1117/1.jbo.18.9.090501. 13. sugiyama, t, araie m, riva ce, schmettere l, orgul s. use of laser speckle flowgraphy in ocular blood flow research. acta ophthalmologica. 2010; 88 (7): 723-729. 14. fukami m, iwase t, yamagata k, kaneko h, yasuda s, terasaki h. changes in retinal microcirculation after intravitreal ranibizumab injection in eyes with macular edema secondary to branch retinal vein occlusion. invest ophthalmol vis sci. 2017; 58 (2): 1246-1255. 15. sugimoto m, nunome t, sakamoto r, kobayashi m, kondo m. effect of intravitreal ranibizumab on the ocular circulation of untreated fellow eye. graefes arch clin exp ophthalmol. 2017; 255 (8): 1543-1550. 16. nitta f, kunikata h, aizawa n, omodaka k, shiga y, yasuda m, et al. the effect of intravitreal bevacizumab on ocular blood flow in diabetic retinopathy and branch retinal vein occlusion as measured by laser speckle flowgraphy. clin ophthalmol. 2014; 11; 8: 1119-1127. doi: 10.2147/opth.s62022. 17. hosseini h, lotfi m, esfahani mh, nassiri n, khalili mr, razeghinejad mr, et al. effect of intravitreal bevacizumab on retrobulbar blood flow in injected and uninjected fellow eyes of patients with neovascular age-related macular degeneration. retina, 2012; 32 (5): 967-971. doi: 10.1097/iae.0b013e31822c28d6. 18. calzetti g, mora p, borrelli e, sacconi r, ricciotti g, carta a, et al. short-term changes in retinal and choroidal relative flow volume after antivegf treatment for neovascular age-related macular degeneration. sci rep. 2021; 11 (1): 23723. doi: 10.1038/s41598-021-03179-x. 19. najafi a. the quantitative measurements of vascular density and flow area of optic nerve head using optical coherence tomography angiography. j glaucoma, 2018; 27 (2): e51-e52. doi: 10.1097/ijg.0000000000000850. 20. mursch-edlmayr as, luft n, podkowinski d, ring m, schmetterer l, bolz m. short-term effect on the ocular circulation induced by unilateral intravitreal injection of aflibercept in age-related maculopathy. acta ophthalmol. 2019; 97 (6): e927e932. doi: 10.1111/aos.14098. effect of intravitreal bevacizumab on the optic nerve head perfusion in patients with diabetic macular edema pak j ophthalmol. 2022, vol. 38 (3): 181-185 185 authors’ designation and contribution nida usman; consultant ophthalmologist: designs, data acquisition, statistical analysis, manuscript preparation, manuscript editing, manuscript review. muhammad ali haider; consultant ophthalmologist: concepts, design, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. disclaimer this research study was conducted at kemu and all authors were present in the said place during the conduct of the study. .…  …. microsoft word 18. qirat qurban mm pakistan journal of ophthalmology, 2020, vol. 36 (3): 277-281 277 original article treatment of entropion – a modified technique qirat qurban1, zeeshan kamil2, muhammad tanweer hassan khan3 1-3lrbt teaching tertiary care hospital korangi 2½, karachi – pakistan abstract purpose: to study the results of a modified technique of entropion correction at a tertiary care hospital. study design: quasi experimental study. place and duration of study: layton rahmatullah benevolent trust (lrbt), a tertiary care teaching eye hospital, korangi, karachi, for a duration of six months, from january 2018 to june 2018. material and methods: patients with senile entropion were included in the study. patients with recurrent entropion, cicatricial entropion, chronic/acute ocular and adnexal infection were excluded. three equally spaced double-armed 6–0 vicryl horizontal mattress sutures were used to close the skin and orbicularis muscle of the wound with a bite of the retractors in the center and a 5 mm silicone tube bolster place in the superior loop. postoperative treatment of antibiotics, anti-inflammatory drugs and topical lubricant eye gel were given. patients were examined on 11stpost operative day and then weekly interval for up to one month and thereafter every month for up to six months. results: there were 40 eyes of 30 patients with ages ranging from 50 to 65 years. twenty (66%) patients had unilateral repair and 10 (33%) had bilateral repair done. no recurrence was seen in 39 (97.5%) eyes at the end six months after surgery. out of the 40 patients, only 2 (5%) patients complained of heaviness which went away eventually with the disintegration of the external tamponade. conclusion: this modified technique of entropion repair using skin excision with retractor plication in the wound has a favorable outcome with minimum recurrences and complications. key words: entropion, entropion repair, wies procedure, external tamponade. how to cite this article: qurban q, kamil z, khan mth. treatment of entropion – a modified technique. pak j ophthalmol. 2020; 36 (3): 277-281. doi: 10.36351/pjo.v36i3.1020 introduction entropion is of four types; congenital, acute spastic, involutional and cicatricial. it may occur unilaterally or bilaterally and tends to affect the lower eyelid more commonly than the upper eyelid. it is also found to be more prevalent among women (2.4%) than men correspondence to: dr. qirat qurban lrbt teaching tertiary care hospital korangi 2½, karachi, pakistan email: qirat_89@hotmail.com received: march 16, 2020 revised: may 4, 2020 accepted: may 4, 2020 (1.9%) and has a prevalence of 2.4% in whites and 0.8% in blacks.1 entropion is also more common in asians2. since, multiple anatomical defects are involved in causing entropion, numerous surgical techniques have been described to correct them, the most consistent anatomical factor discussed in the literature are horizontal eyelid laxity, lower eyelid retractor disinsertion and orbicularis oculi muscle override3. the horizontal eyelid stability of the lower lid is derived from the underlying orbicularis oculi, lower eyelid retractors, tarsus and canthal tendons. laxity of these structures leads to the rotation of the lid margin. analogous to the levator aponeurosis and muller's muscle in the upper lid, the lower eyelid retractors qirat qurban, et al 278 pakistan journal of ophthalmology, 2020, vol. 36 (3): 277-281 provide vertical stability and the capsulopapebral head of these retractors surrounds the inferior oblique muscle, forming part of the lockwood ligament, and fuse with the septum at the inferior border of the tarsal plate. since, most traction on the lid is provided by the posterior layer of the lower lid retractors, laxity of these vertical stabilizing structures causes the lid to rotate inward.the extent of laxity which contributes to entropion is accessed via a pinch test which was described by nishimoto et al4. asamura et al assessed the overriding of preseptal orbicularis muscle onto the pretarsal in asian patients5. entropion is managed according to the specific etiology, which includes conservative medical management and surgical management. the aim of medical management is to counter the adverse effects of misdirected lashes causing ocular surface damage secondary to irritation and includes the use of lubricants, contact lenses and botulinum toxin. definitive treatment includes surgical management and temporary office based procedure such as quickert sutures, in which the surgeon explores and repairs the lower eyelid retractors via a skin incision. alternatively, transconjunctival approach can be done to support the inferior border of the tarsus.6 a little amount of pretarsal orbicularis oculi can be removed to prevent further overriding of the tarsus. if only horizontal eyelid laxity is involved, a medial or lateral canthal tightening procedure can be done. a lateral tarsal strip operation or wedge resection overcomes all three etiologic factors in involution entropion (horizontal lid laxity, attenuation or disinsertion of the eyelid retractors, and overriding by the preseptal orbicularis oculi muscle). we describe a modified surgical technique for senile entropion done at a tertiary care hospital. material and methods this quasi experimental study was conducted at lrbt tertiary teaching eye hospital, karachi, from january 2018 to june 2018. thirty patients were enrolled in this study with age ranging from 50-65 years (58.57 ± 2.1). inclusion criteria were patients between 50 – 65 years of age attending hospital outpatient department with senile entropion. exclusion criteria were recurrent entropion, cicatricial entropion, congenital entropion, chronic/acute ocular and adnexal infections. informed consent was obtained from all the patients. a proforma was used to record information. diagnosis of senile entropion was made on the basis of clinical examination. history of previous surgery, trauma or skin disease was specifically sought. patients were enquired about their occupation, previous recurrent conjunctivitis, history of ocular diseases and surgeries, use of topical ocular medication, diabetes and hypertension. best corrected visual acuity (bcva) was recorded after refraction. local examination of the entropion included medial and lateral canthal tendon laxity as well as the extent of horizontal lid laxity. slit lamp examination included thorough examination of the palpebral conjunctiva, tear film, inferior corneal surface irregularities, as well as flourescein staining of cornea. iop measurement and fundus examination was carried out as part of the general ophthalmic examination. after examination, all the surgeries were performed under the microscope using local anesthesia by a single surgeon. after all aseptic measures, a skin incision was marked 3 mm inferior to the lashes. local anesthesia was induced across the whole length of the eyelid. a lid guard was placed to protect the globe. the lower eyelid was stabilized with '4–0' silk traction suture and clamped to the guard and drape. a partial-thickness incision was made and a 2-3 mm strip of skin, depending upon the laxity, was removed along the entire length of the lower lid. the inferior fat pad was exposed with blunt dissection behind the preseptal orbicularis oculi muscle. the lower eyelid retractors were identified as a visible white fibrous tissue layer between the inferior fat pad and the conjunctiva. three equally spaced double-armed 6–0 vicryl horizontal mattress sutures were used to close the skin and orbicularis muscle of the wound with a bite of the retractors in the center. a 5 mm silicone tube was introduced through each of the 3 suture arms initially. at the end both arms of the sutures were at the same level and were tied to each other. these sutures acted as an external tamponade. these sutures absorbed over the course of 3 to 4 weeks and the tubes disintegrated, leaving a good cosmetic appearance. post-operative treatment comprised of systemic antibiotics and anti inflammatory drugs along with the topical lubricant eye gel at night. all the patients were examined on 1st post-operative day and then weekly interval for up to one month and thereafter every month for up to six months. total duration of followup in this study was six months. post-operative complication was observed in 2 (5%) patients, which included heaviness of lid margin; treatment of entropion – a modified technique pakistan journal of ophthalmology, 2020, vol. 36 (3): 277-281 279 which resolved spontaneously after disintegration of external tamponade. data collection and recording was done using spss 21. results forty eyes of thirty patients underwent lower lid entropion repair via a modified technique. twenty (66%) patients had unilateral repair and ten (33%) had bilateral repair done. most of the patients in this study were between 50 – 65 years of age. mean age was 58.57 ± 2.1 years. twenty (66.6%) patients were male and ten (33%) were females. 39 (97.5%) eyes showed no recurrence (figure 1) at the end of the follow-up fig. 1: horizontal mattress sutures with silicone bolster superiorly. fig. 2: pre and postoperative appearance. period. one (2.5%) patient ended up with recurrence of previous disease, who was re-operated after three months of initial surgery. only 2 (5%) patients complained of heaviness of lid margin until the external tamponade disintegrated. discussion senile entropion is most commonly defined as a form of spastic entropion occurring in the lower eyelid of elderly people, attributed to the spasm of orbicularis muscle frequently causing significant ocular discomfort. the aim of entropion correction is directed towards the prevention of ocular irritation, recurrent bacterial conjunctivitis, reflex tear hyper secretion, superficial keratopathy and risk of ulceration and microbial keratitis7,8. jones narrated lower eyelid retractor plication and advancement as a surgical treatment for entropion. jones also suggested that lower eyelid retractor laxity was analogous to a levator aponeurosis dehiscence9. collin and rathbun studied patients with entropion versus normal eyelids evaluating the lower lid retractors on the basis of histology. in the specimens of entropion patients, they found that the lower lid retractors and orbital septum only came to within 3.5 mm of the inferior border of the tarsus versus 1.5 to 2.5 mm in normal lids10. moreover, a larger amount of orbital fat was present in the entropion samples compared to the normal lids indicating a retractor dehiscence11. the tarsal plate has been shown to invert in entropion where the lower border rotates superiorly and anteriorly and the upper border rotates inward10. in a number of patients, the junction of the inferior border of the tarsus with the lower lid retractors has an acute angulation as compared to a normal eyelid. it was the physicians’ knowledge of the involutional pathophysiological and anatomical changes of the inward rotation of the lower lid margin, that was dictating the current clinical and surgical repair practice prior to the publication of high level evidence12. various methods have been described for treating involutional entropion13,14,15. wies, in 1954, introduced his procedure for vertical lid laxity but this resulted in over correction of 10% and recurrence of 11% at the end of 6 months follow up.8 carrol et al combined above procedure with horizontal shortening which resulted in almost no recurrence at follow up of 33 months16. some authors, such as collin stated a qirat qurban, et al 280 pakistan journal of ophthalmology, 2020, vol. 36 (3): 277-281 3.7% recurrence rate for the combined procedure17 and rougraff observed a recurrence of 1.6% for indirect retractor attachment with everting sutures combined with the tarsal strip procedure18. dryden reported recurrence rate of 2/12 patients who underwent correction of vertical lid laxity in the form of retractor plication with the jones procedure19. in this study, a modified surgical technique was performed for the repair of senile entropion which showed 2.5% recurrence at the end of follow up period, whereas, sobky et al20 shows 7.1% recurrence rate. baboridis et al21 mentioned recurrence rate of 17%. males were predominant over females in this study, whereas in several other studies by baboridis, females were predominant. damasceno et al showed that prevalence of females was 2.4% as compared to males, which was 1.9%22. on the contrary, abdel fatteh et al showed 20 male patients in comparison to 6 female patients23. in this current study, no overcorrection was encountered whereas sobky et al20 ended up in 6.7% rate of overcorrection. limitation of our study is that it was a small scale study and the follow up period was only six months. larger sample size with longer duration of follow up will further prove the efficiency of this procedure. conclusion this modified technique of entropion repair using skin excision with retractor plication in the wound has a favorable outcome with minimum recurrences and complications. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest authors’ designation and contribution qirat qurban; associate professor: concept, study design, manuscript writing. zeeshan kamil: senior consultant ophthalmologist: concept, study design, final review. muhammad tanweer hassan khan; consultant ophthalmologist: concept, study design, data collection, final review. references 1. damasceno rw, osaki mh, dantas pe, belfort r. involutional entropion and ectropion of the lower eyelid: prevalence and associated risk factors in the elderly population. ophthalmic plast reconstr surg. 2011; 27 (5): 317-20. 2. carter sr, chang j, aguilar gl. involutional entropion and ectropion of the asian lower eyelid. ophthal plast reconstr surg. 2000; 16: 45–49. 3. marcus mm, paul po, jimmy sml. involutional entropion: risk factors and surgical remedies curr opin ophthalmol. 2015; 26 (5): 416–421. 4. nishimoto h, takahashi y, kakizaki h. relationship of horizontal lower eyelid laxity, involutional entropion occurrence, and age of asian patients. ophthal plast reconstr surg. 2013; 29: 492–496. 5. asamura s, kakizaki h, shindou e, itani y, isogai n. what is the best strategy for asians with involutional entropion? j craniofac surg; 2014; 25: 972–975. 6. quickert mh, rathbun e. suture repair of entropion. arch ophthalmol. 1971; 85 (3): 304–305. 7. bergstrom r, czyz cn. entropion eyelid reconstruction. pmid: 29262117, 2018. 8. wies fa. surgical treatment of entropion. j int collsurg. 1954; 21 (6): 758–760. 9. jones lt, reeh mj, tsujimura jk. senile entropion. am j ophthalmol. 1963; 55 (3): 463–469. 10. collin jro, rathbun je. involutional entropion: a review with evaluation of a procedure. arch of ophthalmol 1978; 96(6): 1058–1064, 11. quickert mh. malpositions of the eyelid. in: modern ophthalmology, a. sorsby, ed. butterworths, london, uk, 1972; 2nd edition: pp. 941–943. 12. boboridis kg, bunce c. interventions for involutional lower lid entropion. cochrane database of systematic reviews 2011, issue 12. art. no.: cd002221. 13. cook t, lucarelli mj, lemke bn, dortzbach rk. primary and secondary transconjunctival involutional entropion repair. ophthalmology, 2001; 108: 989–993. 14. rainin e. senile entropion. arch ophthalmol 1979; 97: 928–930. 15. dryden r, leibson j, wobig j. senile entropion. pathogenesis and treatment. arch ophthalmol. 1978; 96: 1883–1885. 16. caroll r, allen se. combined procedure for repair of involutional entropion. ophthal plast reconstr surg. 1991; 7: 273–277. 17. collin j. a manual of systemic eyelid surgery. edinburgh: churchill livingstone; 1989: 7–26. treatment of entropion – a modified technique pakistan journal of ophthalmology, 2020, vol. 36 (3): 277-281 281 18. rougraff p, tse d, johnson t, feuer w. involutional entropion repair with fornix sutures and lateral tarsal strip procedure. ophth plast reconstr surg. 2001; 17 (4): 281–7. 19. dryden rm, leibsohn j, wobig j. senile entropion. pathogenesis and treatment. archives of ophthalmology, 1978; 96 (10): 1883–5. 20. el-sobky hmk, mandour ss, allam mmm. wies procedure versus jones procedure in the surgical correction of acquired lower eyelid involutional entropion, menoufia med j. 2017; 30 (2): 507-511. doi: 10.4103/1110-2098.215452, 2017. 21. boboridis k, bunce c, rose ge. a comparative study of two procedures for repair of involutional lower lid entropion. ophthalmology, 2000; 107: 959–961. 22. damasceno rw, osaki mh, dantas pe, belfort rjr. involutional entropion and ectopion: clinicopathologic correlation between horizontal eyelid laxity and eyelid extracellular matrix. ophthal plast reconstr surg. 2011; 27: 321–326. 23. abdel fattah me, el-sayed emeh, abdel kader ksed, abdel badia sm. wies operation with horizontal shortening versus retractor tightening with horizontal shortening for management of lower eyelid senile entropion. discussed thesis in zagazig university, egypt 2007. available from: http://www.publications.zu.edu.eg/pages/pubshow.asp x?id=18624&&pubid=19. .……. pak j ophthalmol. 2021, vol. 37 (1): 17-23 17 original article clinical outcomes of low vision aids for enhancement of residual vision in diabetic retinopathy mufarriq shah 1 , muhammad tariq khan 2 1-2 department of ophthalmology, hayatabad medical complex, peshawar abstract purpose: to investigate the clinical outcomes of low vision aids for enhancement of residual vision in patients with diabetic retinopathy (dr). study design: cross-sectional study. place and duration of study: hayatabad medical complex peshawar, from january 2018 to december 2019. methods: consecutive patients with dr having poor visual acuity were assessed in a low vision clinic for vision rehabilitation. data regarding distance and near visual acuity (va), refractive error, types of low vision aids (lvas), va with best correction and with lvas were collected and analyzed. results: eighty-one patients with mean age of 58.48 ± 13.54 years were included in the study out of which 63% were male. there were 29.6% insulin dependent and 70.4% non-insulin dependent diabetics with mean duration of 12.6 years of diabetes. at presentation, 63% had moderate vision impairment (va <0.5 and > 1.0), 14.8% had severe vision impairment (va <1.0 and > 1.3) and 22.2% had blindness (va < 1.3). with lvas, 97.5% achieved distance va of log mar 0.4 or better. mean improvement in distance va with lvas was log mar 0.95 ± 0.19 (p = 0.000; 95% ci). near va improved significantly with lvas and the number of participants who could see 1m or better with their own glasses increased from 7.4% to 97.5% (p < 0.001). binocular telescopes 2.1x were the most preferred low vision device for distance vision and prismatic magnifying spectacles for near vision. conclusion: visual rehabilitation through the use of lvas was very helpful in patients with low vision caused by diabetic retinopathy. key words: diabetic retinopathy, blindness, visual rehabilitation, low vision aids. how to cite this article: shah m, khan mt. clinical outcomes of low vision aids for enhancement of residual vision in diabetic retinopathy. pak j ophthalmol. 2021, 37 (1): 17-23. doi: https://doi.org/10.36351/pjo.v37i1.1138 introduction vision impairment and blindness due to diabetic retinopathy (dr) is a major public health problem. 1,2 correspondence: mufarriq shah department of ophthalmology hayatabad medical complex, peshawar email: mufarriq1@hotmail.com received: august 24, 2020 accepted: november 11, 2020 there is a significant increase in the number of people with vision loss due to dr over the last two decades. 3 globally in 2010, dr accounted for 2.6% of all blindness and 1.9% of all moderate and severe vision impairment (msvi). 3 in india, the prevalence of vision impairment and blindness due to type 2 diabetes in people of 40 years age and above was reported to be 4% and 0.5% respectively. 4 vision loss resulting from dr is also likely to increase in lowand middleincome countries with the continued diabetes epidemic. 3 mufarriq shah, et al 18 pak j ophthalmol. 2021, vol. 37 (1): 17-23 worldwide prevalence of diabetes is rising and is expected to increase by 20% in developed countries and 69% in developing countries by 2030. 5 the prevalence of dr varies in different countries and is reported to be 19% in bangladesh 6 , 21% in china 7 , 28.3% in taiwan 8 , and 37% in iran. 9 the prevalence of dr amongst people with diabetes in pakistan ranges from 17% to 26%. 10,11 people with vision loss due to dr contribute significantly to the number of people with low vision. 12,13 all people with dr are at risk of vision loss. despite advancements in eye-care service delivery through innovation in medical and surgical management, it is unlikely to restore vision loss due to dr. it is evident that low-vision rehabilitation of people with vision loss through enhancing residual vision with the use of optical and non-optical low vision aids are successful to improve various aspects of visual performance such as improving distance visual acuity, near visual acuity and reading ability. 14,15 the purpose of low-vision assessment is to evaluate the individual’s functional use of the residual vision. low-vision rehabilitation aims to help people with impaired vision to learn making the most of a person's residual vision in order to perform activities of daily livings in a better way. 14,16 according to the world health organization, a person with low vision is one who has best corrected distance visual acuity less than 6/18 in the better-seeing eye or a visual field of less than 20 degree in the largest diameter in the better-seeing eye even after treatment. 17 majority of people with diabetes seek eye care services only after they have lost their vision due to dr. 18 vision loss can lead to loss of productivity and has enormous medical, social, financial and psychological implications. 19,20 it necessitates the provision of low-vision rehabilitation services to people with vision loss due to dr when medical or surgical treatments are unsuccessful. 14,16 this study aimed to investigate clinical outcomes of provision of low vision aids for enhancement of residual vision in people with dr in a tertiary eye care center of pakistan. methods this study included 81 patients with diabetic retinopathy (dr), who were assessed for low-vision rehabilitation at a low vision clinic (lvc), hyatabad medical center, peshawar between january 2018 and december 2019. this is a tertiary eye care institute in pakistan. patients with dr in whom therapeutic interventions could not play a significant role in improving their vision were referred from various hospitals in the province to our lvc for low-vision rehabilitation. patients with dr included in this study had already been treated medically with intra-vitreal anti-vegf injections and laser photo-coagulation. patients who had some residual vision that could be enhanced with the use of low vision devices were included in the study. patients with best corrected visual acuity (va) equal to or better than 6/18 in the better seeing-eye at the time of presentation were excluded from this study. patients with other pathologies or having multiple causes for vision loss were also excluded from this study. institutional ethical committee approval was obtained to collect and analyze the hospital-based data and was conducted in accordance with the declaration of helsinki. at the lvc all these participants with dr underwent detailed assessment for visual functions and trial of low vision aids by experienced optometrist. methods and procedures employed for low vision assessment of these patients included: detailed history of the patient including information about their visual difficulties and previous history of low vision assessment; presenting distance and near visual acuity was recorded in logarithm of the minimum angle of resolution (log mar) using a bailey-lovie visual acuity assessment chart with five optotypes on each line and final log mar distance and near visual acuity with low vision devices. distance va in the better-seeing eye was classified as per who classification 21 : no impairment (distance va 6/18 or better or log mar 0.5 or better); moderate vision impairment (distance va 6/18 to 6/60); severe vision impairment (distance va 6/60 to 3/60) and blindness (distance va worse than 3/60). near va was classified in three groups on the basis of reading text size; less than 3.2m, 3.2m to less than 1m, and 1m (newspaper size) or better and were recorded for each eye separately. 13 for each patient, the target near visual acuity to achieve with low vision devices was defined on the basis of the text size the patient wanted to read or need of the patient. the text size the patient wanted to read, the distance of eye from the print, equivalent viewing distance (evd) and equivalent viewing power (evp) for calculating required magnification and selection of optical devices were noted. clinical outcomes of low vision aids in diabetic retinopathy pak j ophthalmol. 2021, vol. 37 (1): 17-23 19 single or multiple optical low vision devices were used for assessment of distance and near visual acuities of patients with low vision. this included monocular and binocular telescopes of varying magnification, ocutech telescope, reading cap with telescope, clip-on filters for patients with photophobia, hand-held and stand magnifiers. details of the low vision devices used for low vision assessment at the lvc were as follows: a. max tv binocular telescopes (eschenbach, germany) are spectacle model telescopes with 2.1 x magnification. binocular telescopes are mostly suitable for students for watching black board in the classroom as well as for recognizing faces and watching television in adult population. b. monocular telescope ranged from 3x to 8x magnification provided from low vision resource centre hong kong society for the blind [lvrc-hksb] used for spotting distant objects. c. the ocutech vision enhancing system (ves) (ocutech inc.) make hands-free magnified vision possible. various types of ocutech bioptic telescope have range of magnification from 1.7x (sight scope, galilean telescope design) to 6x (ves-sport, keplerian telescope design). reading caps are also available with ocutech bioptic telescopes for reading text. d. half-eye spectacles up to +10.0 diopters (d) with incorporated base-in prism. these are hand-free magnifiers that allow both the eyes to read together providing greater field of view. these also make the reader more comfortable to write at greater working distance. high-powered single vision reading glasses for better seeing-eye for reading small print size. e. hand-held magnifiers ranged from 6d to 48d [lvrc-hksb]. these portable magnifiers are available with and without illumination and are more comfortable for seeing and spotting at a greater working distance. pocket hand-held magnifiers [lvrc-hksb] are smaller in size with a wide range of magnification. these are available with and without illumination and mostly used for spotting near tasks. f. stand and dome magnifiers [lvrc, hksb]. stand magnifiers are available in a wider range of magnification for seeing very small print size but with limited field of view. dome magnifiers are available with limited range of magnification. these have brighter view and are more comfortable for adult population for continuous reading tasks. g. closed-circuit television (cctv). it has a wide range of magnification from ×2 to ×25 and offers the option of contrast change, and freezing of images. most participants with severe vision impairment due to dr needed multiple devices (optical and nonoptical) for better improvement in their vision to perform multiple tasks. trial of single or combination of low vision devices was given to each patient depending on their presenting visual acuity and required task. detailed explanation and training of use of the low vision device was given to each patient. the maximum improvement in the distance and near visual acuity and types of low vision devices was noted. spss (statistical package for social sciences) version 19 (ibm corp, armonk, ny, usa) was used for analysis of the data. for statistical differences such as between visual acuity prior and with the provision of low vision devices, paired samples t-test was conducted. a p-value of less than 0.05 was considered as level of significance. data was presented descriptively as mean values and standard deviation. results out of 81 participants assessed for low vision rehabilitation, 63% (n = 51) were male. mean age of the participants was 58.48 ± 13.54 years (range: 27 to 80 years). amongst participants, 29.6% (n = 24) had insulin dependent diabetes while 70.4 % (n = 57) had non-insulin dependent diabetes. mean duration of diabetes was 12.6 ± 6.72 years. regarding literacy, 29.6% (n = 24) were educated and could read and write. illiterate counted 11.1% (n = 9) while 59.3% (n = 48) could read only but could not write. participants who could read only but could not write asked for low vision aids (lvas) to help them read the holy books and use them in other routine near tasks. all these participants were not satisfied from their own spectacles and wanted improvement in their distance and near vision. none of these participants had received low vision rehabilitation services earlier. the refractive errors of participants were taken as spherical equivalent. amongst participants, 48.1% (n = 39) had hypermetropia (+0.50d or more), 40.7% (n = 33) had myopia (-0.50d or less) and 11.1% mufarriq shah, et al 20 pak j ophthalmol. 2021, vol. 37 (1): 17-23 table 1: age wise distribution of participants based on levels of vision impairment. levels of vision impairment distance visual acuity (log mar) age groups in years total less than 30 30 to 39 40 to 49 50 to 59 60 and older mvi va <0.5 & ≥ 1.0 3 0 9 15 24 51 svi va <1.0 & ≥ 1.3 0 0 3 3 6 12 blind va < 1.3 0 0 3 3 12 18 total 3 3 15 18 42 81 legends: mvi = moderate vision impairment; svi = severe vision impairment (n = 9) had no refractive error. mean spherical equivalent refractive error was -0.25 ± 3.72d in right eyes and 0.10 ± 3.55d in left eyes. the larger value of sd showed the larger spread of refractive error data ranging from -11.0d to +9.0d in right eyes and -9.50d to +9.75d in left eyes. the difference in the means of spherical equivalent refractive error in right and left eyes of these participants was -0.352d (-0.739, 0.359; 95% ci). at the time of presentation, 63% had moderate vision impairment (distance va less than log mar 0.5 to 1.0), 14.8% had severe vision impairment (distance va less than log mar 1.0 to 1.3) and 22.2% had blindness (distance va less than log mar 1.3). about half of the participants were age 60 years and above of whom more than one-fourth were in the blind category. age wise distribution of participants based on level of vision impairment at the time of presentation is given in table 1. mean log mar distance visual acuity prior to the introduction of low vision aids (lvas) was 1.10 ± 0.21. with the provision of lvas the mean distance va improved significantly (log mar 0.15 ± 0.14; p < 0.00). mean improvement in distance va with lvas was log mar 0.95 ± 0.19 (p = 0.000; 95% ci). with the provision of lvas, 96.3% (n = 78) of participants could improve to distance va log mar 0.4 or better. at the time of presentation, 20% (n = 6) amongst female participants and 23.5% (n = 12) amongst male participants were in the blind category. with the provision of lvas, none of the participants remained in the blind or severe vision impairment categories. gender wise distribution of participants on the basis of levels of vision impairment at the time presentation and improvement with lvas are detailed in table 2. the overall improvement in near visual acuity with lvas was statistically significant (p < 0.001). with the provision of lvas for enhancement of near va, there was an increase in the number of participants who could discern 1m text size. prior to provision of lvas for near, 7.4% (n = 6) of participants could discern 1 m text size with their own glasses for near. with the provision lvas, 97.5% (n = 79) of participants achieved near va 1 m or better while 2.5% (n = 2) had near va less than 1 m. table 2: gender wise distribution of participants based on levels of vision impairment. levels of vision impairment distance visual acuity (log mar) at presentation with lvas male n female n male n female n normal 0.5 or better 0 0 48 30 mvi va <0.5 & ≥1.0 33 18 3 0 svi va <1.0 & ≥1.3 6 6 0 0 blind va < 1.3 12 6 0 0 total 51 30 51 30 legends: mvi = moderate vision impairment svi = severe vision impairment all of the 51 participants who were in the moderate vision impairment group at presentation were able to discern 1m or better with lvas. amongst 18 participants in the blind group (va < log mar 1.3), two could not discern 1m with lvas. thus participants who had moderate vision impairment at the time presentation achieved better improvement in near vision with lvas. conventional glasses were prescribed to 88.8% (n = 72) of participants. for distance vision, 2.1x max tv binocular telescope was the most commonly (n = 17) prescribed low vision device. amongst the participants 38.3% (n = 31) did not want any telescope for distance. table 3 show low vision aids prescribed to patients for distance vision. prismatic magnifying spectacles (up to +10.0d with base in prism incorporated) were the most accepted low vision device for near vision and were prescribed to 21 participants followed by high plus monocular spectacle lenses (n = 19). eleven participants did not want any device for near vision clinical outcomes of low vision aids in diabetic retinopathy pak j ophthalmol. 2021, vol. 37 (1): 17-23 21 table 3: low vision aids prescribed for distance vision. types of low vision aids number 2.1 x max tv binocular 17 3x binocular telescope 10 4x hand held telescope 9 6x hand held telescope 6 filters 7 ocutech telescope 1 nil (did not want any telescope) 31 saying that they did not need. for enhancement in near vision, some participants needed more than one device to perform different tasks. the details of lvds prescribed for near vision are given in table 4. table 4: low vision aids prescribed for near vision. types of low vision aids number prismatic magnifying spectacles 21 high plus monocular spectacle lenses 19 illuminated hand-held magnifiers 16 pocket magnifiers 11 bar magnifier 6 dome magnifier 4 cctv system 1 nil lvas for near vision 11 discussion findings from this study show that majority (63%) of people with diabetic retinopathy (dr) had moderate vision impairment at the time of presentation. there was a significant improvement in both distance and near visual acuities of participants with the provision of lvas. optical low vision devices were the major type of low vision aids dispensed and accepted by people with dr. participants with moderate vision impairment achieved normal near visual acuity with lvas. the most preferred low vision devices were 2.1x max tv binoculars for distance vision and prismatic magnifying spectacles for near vision. all these participants visited for seeking low vision services for the first time. similar to the results of this study, the predominance of moderate vision impairment in people with dr has also been reported in other studies. 12,14 due to progressive nature of dr, this predominance of moderate vision impairment amongst these people with dr may not sustain. vision may deteriorate with the passage of time and number of people with moderate vision impairment may decline with an increase in number of people with severe vision impairment and blindness. 3,22 however, early visual rehabilitation is important to reduce the degree of handicap and strengthen their visual abilities enabling them to manage with vision loss and continue their activities of daily living. 23 the findings from the present study proved the effectiveness of optical devices for enhancement of distance and near vision in people with dr. similar to the results of this study, other researcher reported successful use of lvas as an effective way to help people manage their vision related problems. 13,14 despite strong evidence for the effectiveness of low vision devices, it is also evident from this study that 38.3% (n = 31) of participants with dr deny accepting lvas. many factors contributed to their denial such as illiteracy, finances and stigma associated with the usage of low vision aids. in the light of global epidemic of diabetes and expected increase in number of people with vision loss due to dr, the role of low vision rehabilitation services is pivotal for maintaining independence in activities of daily livings. 5 findings from the present study show that none of these participants visited low vision services before. similar results had been reported in literature indicating most of people with dr were not using low vision services. 24 these facts indicate that awareness of patients with dr and of their health care providers about the availability of such services is of utmost importance and a key predictor of the use of these services as reported in literature. 25 various types of lvas are available to help people with low vision to cope better with their everyday activities. however, acceptance of type of lvds is based on individual’s preference and needs. results from this study showed that prismatic magnifying spectacles were the most preferred (n = 21) lva followed by high plus monocular spectacle lenses (n = 19), illuminated hand-held magnifiers (16) and pocket magnifier (n = 11) for performing near task. the preference of these lvas indicated that older people mostly prefer simpler and cheaper rather than complex and expensive lvas. similar results have been reported in other studies. 12,14 amongst the participants in our study, only one person was benefited with cctv while other studies reported greater number of cctv to participants with vision loss. 14 in this study, non-affordability was the major obstacle in accepting cctv for reading purpose. mufarriq shah, et al 22 pak j ophthalmol. 2021, vol. 37 (1): 17-23 an important aspect of this study was that more than half of the participants (59.3%; n = 48) in our study wanted to read the holy books. the needs and expectations of these participants could be different than those of the literate people. therefore, findings from our study could be different from other studies. a limitation of this study was that we aimed to quantify the improvement in distance and near visual acuity with the provision of suitable low vision aids in people with dr but could not assess the impact of these lvas on quality of life of these people. another limitation is that we did not investigate levels of patient’s satisfaction about the vision rehabilitation services. in addition, we could not investigate the factors hindering the acceptance of use of prescribed aids. further research is needed to explore these factors. conclusion visual rehabilitation through the use of lvas proved to be successful in people with diabetic retinopathy. prismatic magnifying spectacles were the most preferred lva for near tasks. awareness about lvas in people with dr and their eye and health care practitioners is crucial for utilization of low vision services. ethical approval the study was approved by the institutional review board/ ethical review board. 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outcomes of low vision aids in diabetic retinopathy pak j ophthalmol. 2021, vol. 37 (1): 17-23 23 15. dunbar hmp, crossland md, bunce c, egan c & rubin gs. the effect of low vision rehabilitation in diabetic eye disease: a randomised controlled trial protocol. ophthalmic physiol opt. 2012; 32: 282–293. doi: 10.1111/j.1475‐ 16. hooper p, jutai jw, strong g, russell-minda e. age-related macular degeneration and low-vision rehabilitation: a systematic review. can j ophthalmol. 2008; 43 (2): 180-187. 17. world health organization. the management of low vision in children. report of a who consultation: bangkok, july 1992. geneva: world health organization, 1993: who/pbl/93.27. 18. murthy gv, gilbert ce, shukla r, vashist p, shamanna br. situational analysis of services for diabetes and diabetic retinopathy and evaluation of programs for the detection and treatment of diabetic retinopathy in india: methods for the india 11-city 9state study. indian j endocrinol metab. 2016; 20 (suppl. 1): s19-25. doi: 10.4103/2230-8210.179770. 19. sj leat. a proposed model for integrated low-vision rehabilitation services in canada. optom vis sci. 2016; 93: 77-84. 20. joshi mr, yamagata y, akura j, shakya s. the efficacy of low vision devices for students in specialized schools for students who are blind in kathmandu valley, nepal. j vis impair blind. 2008; 102 (7): 430-435. 21. keeffe je, taylor hr, fotis k. prevalence and causes of vision loss in southeast asia and oceania: 1990– 2010. br j ophthalmol. 2014: bjophthalmol-2013304050. 22. hinds a, sinclair a, park j, suttie a, paterson h, macdonald m. impact of an interdisciplinary low vision service on the quality of life of low vision patients. br j ophthalmol. 2003; 87 (11): 1391-1396. 23. o'connor pm, mu lc, keeffe je. access and utilization of a new low-vision rehabilitation service. clin experiment ophthalmol. 2008; 36 (6): 547-552. 24. adam r, pickering d. where are all the clients? barriers to referral for low vision rehabilitation. j visual impair res. 2007; 9 (2-3): 45-50. authors’ designation and contribution mufarriq shah; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. muhammad tariq khan; associate professor: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. .…  …. 140 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology original article prevalence of computer vision syndrome and its associated risk factors among under graduate medical students khola noreen, zunaira batool, tehreem fatima, tahira zamir pak j ophthalmol 2016, vol. 32 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: khola noreen assistant professor community health sciences bahria university medical and dental college, karachi email: dr_khaula@yahoo.com …..……………………….. purpose: to determine the prevalence of computer vision syndrome and its associated risk factors among undergraduate medical students. study design: descriptive cross – sectional study. place and duration of study: bahria university medical and dental, karachi, pakistan from 15 th january, 2016 to 15 th july 2016. material and methods: this institution based cross sectional study was carried out on 198 undergraduate medical students of bahria university medical and dental, karachi, pakistan. all the students within age group 17-25 years and who have used computer in 1 month preceding the date of the study were included in the study. students who were using medication that affect visual health, diagnosed with underlying systemic disease like diabetes, hypertension, having preexisting eye diseases and those who do not give inform written consent were excluded from study. chi-square test was used to prove associations between categorical variables. data was analyzed using the standard statistical software packages (v 21) results: mean age of 20.16 ± 3.81 years. out of 198 respondents 133 (67.2%) claimed that they have experienced at least (headache, eye fatigue, burning sensation, eye irritation, neck shoulder pain) related to computer vision syndrome. ocular symptoms of computer user ranged from eye irritation (48%), burning sensation (33%), eye fatigue (15%). extra ocular complaints include neck shoulder pain (21.8%) to headache (38%) problems. eye fatigue and headache was significantly associated with computer usage time (240 min/ 4 hrs). conclusion: computer vision syndrome is a very frequent condition among undergraduate medical students. key words: computer vision syndrome, prevalence, ocular complaints, extra ocular symptoms ith the advent of modern technology use of computer devices and gadgets has almost become indispensible in every aspect of life. these devices are considered as necessity of 21st century. they are not only being used at work places offices, academic institutions but there usage is also very much common even at recreational places and homes1. a computer screen is commonly known as video display terminal (vdt). computers, tablets, ereaders, smart phones and other electronic devices are included in it. it is estimated that approximately 45 million workers directly use computers by staring into vdts for hours continuously2. no doubt the advent of modern technology has revolutionized the world and benefited the society as these devices are w mailto:dr_khaula@yahoo.com prevalence of computer vision syndrome among under graduate medical students pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 141 indispensable source of information to greater extent and these are easy accessible and available3. it has been documented that 75% of all the daily activities involves the use of computer4. in the present era of prolong and rampant computer usage, there has been rapid upsurge in computer related health problems. prolonged exposure to vdts has been the cause of a visual and ergonomic disorder called “computer vision syndrome” (cvs).5 american optometric association defined computer vision syndrome as “a complex of eye and vision problems related to activities, which stress the near vision and which are experienced in relation or during the use of computer”6. visual problems are reported to be most frequently occurring health problem associated with excessive computer usage. most commonly reported visual complaints include redness, dry eyes, burning sensation and blurring of vision. ergonomic problems associated with computer use include muscular stiffness, cervical pain, headache, numbness of the fingers7. symptoms of computer vision syndrome are broadly classified into four categories: i) asthenopic – sore eyes, eye strain, (ii) ocular surface relateddry eye, irritation, watering, (iii) visual – double vision, blurred vision, slowness of focus change iv) extra ocular – shoulder pain, neck pain, back ache8. globally, nearly 60 million people are suffering from cvs and approximately million new cases occur every year9. in united states more than 143 million people work on computer everyday10. south asian region has undergone rapid socioeconomic and technological development for past few decades. owning to rapid advancement in science and technology, computer has become integral part of everyday life. excessive use of technology has lead to increase prevalence of cvs with resultant loss of productivity and hampered quality of life. but unfortunately there is dearth of literature and only few studies are available in this regard. there is no national representative survey and available literature is of the studies conducted on small scale and mostly single institutional based11. cvs is growing public health issue and contributing significantly towards reducing quality of life and productivity at work place. according to report of american optometric association, nearly 14% of patients report for ocular examination because of computer vision syndrome and such effected individuals are not even aware that they are suffering from this condition12. the objective of this study is to determine the prevalence of computer vision syndrome and its associated risk factors among undergraduate medical students. it will help the public health professionals and all the stakeholders to take measures to reduce this public health issue and help to create awareness among public regarding health hazards of computers and digital electronic devices. material and methods this institution based cross sectional study was carried out from 15th january to 15th july, 2016 on undergraduate medical students of bahria university medical and dental college, karachi. study participants were enrolled by non-probability convenience sampling. sample size was calculated by taking the prevalence of computer vision syndrome as 80%13, margin of error 5%, estimated sample was found to be 245. all the students within age group 17-25 years and those who have used computer in 1 month preceding the date of the study were included in the study. students who were using medication that affect visual health like (anti tuberculosis treatment, steroids and immunosuppressant), those diagnosed with underlying systemic disease like diabetes, hypertension, having preexisting eye diseases and those who do not give informed written consent were excluded from study. chi-square test was used to prove associations between categorical variables. data was analyzed using the standard statistical software packages. all those students having the symptoms of computer vision syndrome either intermittently or continuously for at least one week during last six months were included in the diagnostic criteria of computer vision syndrome. the cvs related symptoms include irritation of eyes, eye fatigue, burning sensation, and headache and neck shoulder pain. the participants were surveyed using a pre-tested structured questionnaire, which included the basic demographic profile, time spend on video display terminal, distance from screen, symptoms experienced after viewing screen, frequency of break while khola noreen, et al 142 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology working on computers, symptoms aggravated by posture and potential risk factors during its usage. questionnaire was prepared after expert opinion regarding cvs from consultant ophthalmologist and adapted from the literature research on previous study2,4,8. informed written consent was taken from every participant before study. study approval was taken from institution ethical review committee of bahria university medical and dental college. results overall, 245 participants were enrolled in study. 212 questionnaires were returned. 14 were discarded because they were filled incompletely. finally, at the end of study 198 participants (69% females and 31% males) were included in study. the age range between 17 to 25 years with mean age of 20.16 ± 3.81 years. out of 198 respondents 133 (67.2%) claimed that they have experienced at least one symptoms related to computer vision syndrome. fig. 1: frequency of ocular complaints in students. complaints associated with computer usage are broadly categorized into two categories, ocular and non ocular or muscular skeletal problems. out 133 (67.2%) affected, 28 students (55%) experienced ocular complaints while 6 students (12%) were having extra ocular complaints including headache and musculoskeletal problems. the frequency distribution of ocular morbidities in the study include 95 (48%) irritation of eyes, 65 (33%) burning sensation and 30 (15%) experience eye fatigue (figure 1). extra ocular complaints range from neck shoulder pain 43 (21.8%) to headache 75 (38%) problems (fig. 2). cvs symptoms were commonly observed among the students 64.36% who used computers for more than 4 hours (240 min) as compared to 34.4% of participants who spend less than 4 hours (240 min) (p = 0.003) similar trend was seen on finding association between cvs symptoms and duration of mobile phone usage time (p = 0.012). significant association was seen for laptop and phone usage time (> 240 min/4 hours) with eye fatigue and headache (p < 0.05). details are shown in table 1. fig. 2: frequency of extra ocular complaints in student. headache was experienced by 35% of the students in lying position, 55% in sitting and in 15% using both method (p = 0.006). headache significantly occurs in 55% students using computer in sitting position. similarly, neck shoulder pain is also more commonly observed in 64% of students in sitting position as compared to 42% in lying and 12% in both sitting and lying position (p = 0.003). details are mentioned in table 2. symptoms of cvs get worsen with less frequent breaks. there was no significant association of cvs symptoms with frequency of breaks. however, all the symptoms associated with computer vision syndrome improve after increasing the intervals of break. details are shown in table 2. discussion the present study was conducted on the medical students of university and prevalence of computer vision syndrome was found to be 67%. study conducted on medical students of chennai reported high prevalence as compared to our study as 78.6%13. prevalence of computer vision syndrome among under graduate medical students pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 143 table 1: association of computer usage with symptoms of computer vision syndrome. variables group eye fatigue headache neck/shoulder pain irritation of eyes n/(%) p n/(%) p n/(%) p n/(%) p laptop time ≤ 240 min 68/(34.4) 0.003 18/(9.1) 0.031 37/(18.6) 0.489 14/(7.07) 0.554 >240 min 127/(64.3) 69/(34.8) 28/(14.1) 9/(4.5) phone time ≤ 240 min 23/(11.6) 0.012 30/(15.15) 0.026 34/(17.7) 0.412 11/(5.5) 0.852 >240 min 71/(35.8) 90/(45.45) 44/(22.1) 15/(7.5) distance from desktop/ laptop < forearm length 29/(14.6) 0.841 39/(19.6) 0.997 36/(18.1) 0.255 50/(25.2) 0.628 > forearm length 24/(12.1) 31/(15.6) 29/(14.6) 46/(23.2) distance from mobile phone < 12 inches 30/(15.1) 0.775 43/(21.7) 0.068 31/(15.7) 0.903 12/(6.1) 0.808 12 – 16 inches 19/(9.59) 35/(17.6) 24/(12.1) 8/(4.2) > 16 inches 4/(2.07) 33/(16.6) 6/(3.03) 5/(2.5) table 2: pattern of computer usage with symptoms of computer vision syndrome. variable groups eye fatigue headache neck/shoulder pain irritation of eyes n/% p n/% p n/% p n/% p posture mostly sitting 17/(8.58) 0.283 55/(27.7) 0.006 64/(32.2) 0.003 3/(1.50) 0.898 mostly lying 19/(9.59) 35/(17.6) 42/(21.20) 4/(2.2) sitting/lyin g both 14/(7.07) 15/(7.57) 12/(6.06) 2/(1.1) symptoms aggravated by improper illumination yes 39/(19.8) 0.155 53/(26.7) 0.082 41/(20.7) 0.053 18/(9.1) 0.147 no 35/(17.6) 41/(20.7) 39/(19.7) 13/(6.5) frequency of breaks ≤ 60 min 40/(20.2) 0.064 52/(26.2) 0.911 46/(23.2) 0.679 17/(8.3) 0.740 >60 min 38/(19.1) 49/(24.7) 41/(20.7) 15/(14.5) in this study all the symptoms even transient one were considered to meet the criteria of cvs while in our study symptoms lasting for at least one month duration were considered this can be reason for overestimation of prevalence in former study. study conducted on university students of malaysia reported high prevalence of cvs as compared to our study 89.9%14. study conducted in nigeria reported the prevalence as 74%15. in our study most frequent ocular complaint reported was 48% irritation of eyes, then burning sensation 33% followed by eye fatigue 15%.while in extra ocular symptoms , most common symptom was headache (38%) then neck shoulder pain was experienced by 21% individual. in study carried out in iran, most frequent ocular problem was pain in eyes khola noreen, et al 144 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology (41%) then excessive watering (18%) followed by then burning and itching in eyes (15%). in extra ocular symptoms, 38% students suffered headache and 19% shoulder pain. in our study headache was reported by 41% and neck shoulder pain was experienced by 21% participants16. extra ocular symptoms were in accordance to our study. in our study, burning sensation was reported by 33% students this is in accordance to the study conducted in india where burning sensation was experienced by 32% medical students17. another study conducted in india by talwar et al reported relatively low prevalence of burning sensation as it was experienced by 28.9% of the participants18. while in contrast study conducted among call center workers report high prevalence of burning sensation as it was experienced by 54.6%19. the duration of computer work is directly related to eye symptoms, longer duration tends to result in long-lasting complaints even after the work is finished. in our study duration of computer work (both mobile phone and laptop time is found to be directly associated with symptoms of computer vision syndrome. computer usage time more than 4 hour (240 minutes) is found to be significantly associated with visual symptoms. statistical significant association was observed for headache and eye fatigue. study conducted by shrivastava et al also reported that the visual symptoms aggravated with increase duration of hours spend on computer20 rahman and sanip in their study documented that more than 7 hours of computer usage is significantly associated with symptoms of cvs21. another study done in india reported the results in accordance with our study in which the ocular symptoms including eye strain itching and burning are more common in computer users more than 6 hours22. while stella et al. reported that cvs symptoms are more common in people using computer for more than 8 hours daily23. in our study, the participants who take break experience less frequent symptoms however; there was no significant association between frequency of breaks and relief of symptoms. latest research has also supported the evidence that taking break do not relief the symptoms associated with cvs.24 in contrast, several studies have supported that without taking breaks visual symptoms of cvs get aggravated. 14, 21.study conducted by straker et al also document that musculoskeletal symptoms get aggravated by sitting posture25. our study fairly highlighted this public health issue and identified the risk factors associated with computer vision syndrome. however, there are certain limitations to our study. since it was the cross sectional study it limits the establishment of the casual association between identified risk factors and cvs. it was a single centered study and symptoms of cvs were self reported. in future, prospective studies with follow ups should be designed to establish the causal inference. it is recommended to follow the rule of 20/20/20 to reduce the symptoms of computer vision. rule of 20/20/20 states that one should sit 20 feet away; take 20 min break after 20 minutes of computer use2. conclusion this study concludes that computer vision syndrome is a highly frequent condition among undergraduate medical students. it is evident from our study that computer related health problems now become a significant public health issue. there is dire need to create public health awareness by organizing awareness lectures in order to make general public sensitize about deleterious health effects of computer usage. young generation should be addressed by organizing health awareness lectures at academic institutes to make youth aware of health problems associated with computer usage. this is multi disciplinary task and there is need of integration of all concerned stake holders in order to make effective strategies to halt this problem. all concerned authorities should collaborate to make effective implementation of preventive strategies and ergonomics. periodic monitoring and medical examinations should be arranged to avoid complications and to limit disability. author’s affiliation dr khola noreen assistant professor community health sciences bahria university medical and dental college karachi zunaira batool final year mbbs student bahria university medical and dental college karachi prevalence of computer vision syndrome among under graduate medical students pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 145 tehreem fatima final year mbbs student bahria university medical and dental college, karachi dr tahira zamir assistant professor pharmacology department bahria university medical and dental college karachi role of authors dr. khola noreen analysis and interpretation of data. dr. zunaira batool. conception and design dr. tehreem fatima collection and assembly of data. dr tahira zamir statistical analysis. references 1. singh h, tigga mj, laad s, et al. prevention of ocular morbidity among medical students by prevalence assessment of asthenopia and its risk factors. j. evid. based med. healthc. 2016; 3: 532-6. 2. gangamma mp, rajagopala m. a clinical study on" computer vision syndrome" and its management with triphala eye drops and saptamrita lauha. ayu (an international quarterly journal of research in ayurveda). 2010; 31: 236. 3. hayes jr, sheedy je, stelmack ja, heaney ca. computer use, symptoms, and quality of life. optom vis sci. 2007; 84: 738–44. 4. logaraj m, priya vm, seetharaman n, hedge sk. practice of ergonomic principles and computer vision syndrome (cvs) among under graduates students in chennai. nat j commun med. 2013; 3: 111–6 5. bali j, navin n, thakur br. computer vision syndrome: a study of the knowledge, attitudes and practices in indian ophthalmologists. indian j ophthalmol. 2007; 55: 289-94. 6. computer vision syndrome (cvs). american optometric association. available from: http://www.aoa.org/x5374.xml. 7. shantakumari n, eldeeb r, sreedharan j, gopal k. computer use and vision – related problems among university students in ajman, united arab emirate. annals of medical and health sciences research. 2014; 2: 258–63. 8. akinbinu tr, mashalla yj. impact of computer technology on health: computer vision syndrome (cvs). medical practice and reviews. 2014; 5: 20-30. 9. sen a, richardson s. „a study of computer-related upper limb discomfort and computer vision syndrome‟, j. human ergol. 2007; 36: 45-50. 10. lpp 2006, structured surveys and data collection methods, viewed 5 june 2011. http:// www.smallstock.info/issues/structured.htm>. 11. ranasinghe p, wathurapatha ws, perera ys, lamabadusuriya da, kulatunga s, jayawardana n, et al. computer vision syndrome among computer office workers in a developing country: an evaluation of prevalence and risk factors. bmc research notes. [journal article], 9 (1): 1. 12. erven. computer vision syndrome in 21 century. j am optom assoc., 10: 15-20. 13. logaraj m, madhupriya v. hegde scomputer vision syndrome and associated factors among medical and engineering students in chennai. ann med health sci res. 2014; 4: 179-85. 14. reddy sc, low ck, lim yp, low ll, mardina f, nursaleha mp. computer vision syndrome: a study of knowledge and practices in university students. nepalese journal of ophthalmology, 2013; 23: 161-8. 15. akinbinu tr, mashalla y. knowledge of computer vision syndrome among computer users in the workplace in abuja, nigeria. pretoria: university of south africa; 2012. 16. ghassemi – broumand m, ayatollahi m. evaluation of the frequency of complications of working with computers in a group of young adult computer users. pak j med sci. 2008; 24: 702-6. 17. klamm j, tarnow kg. computer vision syndrome: a review of literature. medsurg nurs. 2015; 24: 89–93. 18. talwar r, kapoor r, puri k, bansal k, singh sa. study of visual and musculoskeletal health disorders among computer professionals in ncr delhi. indian j community med. 2009; 34: 326-8. 19. sa ec, ferreira junior m. rocha le risk factors for computer visual syndrome (cvs) among operators of two call centers in são paulo, brazil, 2012; 41: 3568. 20. shrivastava sr, bobhate ps. computer related health problems among software professionals in mumbai: a cross-sectional study. int j health sci. 2012; 1: 74–8. 21. rahman za, sanip s. computer user: demographic and computer related factors that predispose user to get computer vision syndrome. int j bus humanit technol. 2011; 1: 84–91. 22. agarwal s, goel d, sharma a. evaluation of the factors which contribute to the ocular complaints in computer users. j clin diagn res. 2013; 7: 331-5. 23. chiemeke sc, akhahowa ae, ajayi ob. evaluation of vision – related problems amongst computer users: a case study of university of benin, nigeria. in: proceedings of the world congress on engineering, vol i. london: international association of engineers; 2007. 24. ranasinghe p, wathurapatha ws, perera ys, lamabadusuriya da, kulatunga s, jayawardana n, katulanda p. computer vision syndrome among http://www.aoa.org/x5374.xml khola noreen, et al 146 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology computer office workers in a developing country: an evaluation of prevalence and risk factors. bmc research notes, 2016; 9: 1. 25. straker lm, smith aj, bear n, o'sullivan pb, de klerk nh. neck/shoulder pain, habitual spinal posture and computer use in adolescents: the importance of gender. ergonomics, 2011; 54: 539-46. pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 42 original article timing of closed intubation in recurrent epiphoric children abdul rehman, irfan qayyum, ali zain-ul-abidin, najam iqbal, javed iqbal, mumtaz hussain pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: m. abdul rehman eye department mayo hospital, lahore …..……………………….. purpose: to determine the most appropriate time for closed intubation in recurrent epiphoric patients. material and methods: this was an interventional retrospective study which was conducted in the eye unit ii, institute of ophthalmology, mayo hospital, lahore, from january 2005 to january 2011. we performed closed intubation in 200 children up to four years of age, where syringing and probing failed twice at least. all patients were closed intubated with crawford silicon tube under general anaesthesia. epiphora and discharge was noted pre and post operatively at 1 month, 3 months and 6 months follow-up. results: in this study there were 111 males and 89 females ranging from 1 to 4 years of age. in these 200 cases, 172 were relieved from epiphora and discharge while 28 patients had persistent epiphora. failure as compared to age presentation observed during this period was as follows; 20 (71.4%) in 3-4 years of age; 6 (22.2%) in 2-3 years of age; 2 (7.4%) in 1 – 2 years of age. conclusion: closed intubation with silicon tube is an effective treatment modality for children of age between 1 to 4 years. acrimal drainage system obstruction may be present in approximately 50% of newborn infants congenitally. mostly obstructions opened spontaneously within 4 – 6 weeks after birth. the newborn with epiphora presented at 3 – 4 weeks of age, mostly unilaterally and sometimes bilaterally. approximately 90% resolved within 1st year of life, with or without massaging or topical antibiotic drops. if epiphora persisted, then probing and syringing was optional, non-invasive treatment. but some children present again with epiphora and discharge. and the next option remains the eternal dcr or the closed intubation. the aim of our study was to avoid the external dcr and relief of symptoms of epiphora and discharge with closed intubation in children up to 4 years of age. material and methods this was an interventional retrospective hospital based study. patients were selected from the outpatient department of mayo hospital lahore, kemu. all 200 children up to 4 years of age who have had failed probing and syringing once or twice and presented with epiphora discharge and mucocele formation, were included in this study. patients were given general anaesthesia. after draping both the puncti were dilated with punctum dilator. then, probing and syringing was done up to the level of inferior opening of nasolacrimal duct into the inferior turbinate of the nose. then crawford silicon tube was passed through the same anatomical passage. tube is appreciated in the nose then pulled from the nose with artery forceps. the same procedure was repeated from the upper punctum and both ends of crawford silicon tube were tied in the nose. patient was discharged on topical and systemic antibiotics and nsaids. followup was done at the interval of 1 month, 3 months and 6 months. then the tube was removed under general anaesthesia after 6 to 8 months. results there were 111 (55.5%) male and 89 (44.5%) females. l abdul rehman, et al 43 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology the age range was 1-4 years. among these, 89 (44.5%) were 1-2 years of age, 68 (34%) were 2-3 years of age, 43 (21.5%) were 3-4 years of age. preoperatively all the children had epiphora and discharge with failed probing and syringing once or twice. postoperative follow-up was done at the interval of 1 month, 3 months and 6 months, during which 172 (86%) had no epiphora and discharge whereas 28 (14%) presented with epiphora and discharge. failure as compared to age presentation observed during this period was as follows; 20 (71.4%) in 3-4 years of age; 6 (22.2%) in 2-3 years of age; 2 (7.4%) in 1-2 years of age. complication noted with silicon tube were, cheese wiring of canaliculli and pulling out of tubes. discussion congenital naso-lacrimal duct obstruction is a common congenital anomaly even in full term infants presenting age chart failure age ratio chart fig. 1: 1st post op day. fig. 2: after 3 months. fig. 3: crawford tube with olive tip. and is due to delay in the normal development of the system. neonates have tear secretion at birth and 96% to 98% have a totally patent and functional drainage system at birth. the 2% to 4% who do not have an 44.5 34 21.5 1-2 years 2-3 years 3-4 years 71.4 22.2 7.4 sales 3-4 years 2-3 years 1-2 years timing of closed intubation in recurrent epiphoric children pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 44 intact lacrimal drainage system, have a thin residual membrane at the distal end of the naso-lacrimal duct. this membrane dissolves spontaneously in 80% to 90% of infants within the first few months of life1, either spontaneously or with medical treatment and massage2-3. the obstruction and the resultant continued tearing and discharge are not only unsightly and a potential source of ocular infection, it also causes a lot of anxiety to young parents who are inexperienced and apprehensive about their newborn babies4. in the majority of cases, the cause of failure of conservative treatment is an improper technique of lacrimal sac massage5. surgical intervention in the form of probing and irrigation of the naso-lacrimal duct is required in the cases not responding to medical treatment and massage. we included the epiphoric children in our study where probing and syringing didn't work at least twice. the aim of our study was to avoid external dcr & relief of symptoms of epiphora and discharge with closed intubation in children up to 4 years of age.in our study out of 200 patients 111 (55.5%) were male while 89 (44.5%) were females. the age range was 1 – 4 years. among these, 89 (44.5%) were 1 – 2 years of age, 68 (34%) were 2 – 3 years of age, 43 (21.5%) were 3 – 4 years of age. preoperatively all the children had epiphora and discharge with failed probing and syringing once or twice. postoperative follow-up was done at the interval of 1 month, 3 months and 6 months, during which 172 (86%) had no epiphora and discharge whereas 28 (14%) presented with epiphora and discharge. failure to age ratio observed during this period was as follows; 20 (71.4%) in 3 – 4 years of age; 6 (22.2%) in 2 – 3 years of age; 2 (7.4%) in 1 – 2 years of age. other complication noted with silicon tube were 1. cheese wiring of canaliculi 2. pulling out of tubes probing of the naso-lacrimal duct is the first line of treatment. however probe failure increases with age and is known to double every 6 months. for this reason and in cases of persistent epiphora, a second probing two to four months later is advocated. in failed cases with persistent epiphora and recurrent infection, it may be necessary to perform a dacryocystorhinostomy (dcr) or closed intubation. in our study we did closed intubation in all cases with aiming to avoid the patients from major surgery of dcr. in our study the success rate was 86% which is almost consistence with the studies done in the past. it is quiet safe and effective and the results are almost identical to dcr surgery. and the main thing is that there is no external scar. conclusion closed intubation with silicon tube is an effective treatment modality for children with age between 1 to 4 years. and it is also noted that as the age increases the failure rate increases. author’s affiliation dr. muhammad abdul rehman akram medical officer eye department, mayo hospital lahore dr. irfan qayyum eye department, mayo hospital lahore dr. ali zain ul abidin medical officer eye department, mayo hospital lahore dr. najam iqbal ahmad senior registrar eye department, mayo hospital lahore dr. javed iqbal chaudhry assistant professor eye department, mayo hospital lahore dr. mumtaz hussain professor of ophthalmology eye department, mayo hospital lahore references 1. petersem ra, robb rm. the natural course of congenital obstruction of the naso-lacrimal duct. j pediat ophthal strabismus. 1978; 15: 246-50. 2. muhammad z, khan md. timing of probing in naso-lacrimal duct obstruction in infants and children. pak j ophthalmol. 1994; 10: 82-4. 3. mehmood t. watery eyes, pak j ophthalmol. (editorial), 2006; 22: 58-9. 4. nasir j, mohyuddin m, bhatti sa. non massaging management of congenital and infantile naso-lacrimal duct obstruction. pak j ophthalmol 2007; 23: 84-6. 5. khan n, khan mn, jan s, mohammad s. congenital nasolacrimal duct obstruction: presentation and management. pak j ophthalmol. 2006; 22: 74-8. pak j ophthalmol. 2021, vol. 37 (3): 336 336 letter to editor dear prof. mohammad moin assalamo alaikum thank you for sending me the 36th and 37th, 2021 volumes of pjo. i went through both volumes with a lot of interest and enjoyed reading every article. both volumes have generously covered the diagnostic, therapeutic, and interventional aspects of current ophthalmology. i took great pleasure in reading your article on medical education and tayyaba gul's article on artificial intelligence. all the other articles met international standards in terms of contents, style, language, and grammar. i was delighted to see that ophthalmologists from abroad have started sending you articles for publication in your esteemed journal. the credit for achieving such a high standard goes to you and your dedicated team. i know you have spent many long hours of your precious time to achieve your ultimate goal, "achieving the highest possible standard for pakistan journal of ophthalmology." i take great pleasure in congratulating you and your team for achieving such a noble goal. with profound regards professor mohammad daud khan founder vice chancellor khyber medical university peshawar email: profmdkhan@gmail.com how to cite this article: khan md. letter to the editor. pak j ophthalmol. 2021; 37 (3): 336. doi: 10.36351/pjo.v37i3.1304 .…  …. open access pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 1 editorial anti-vegf therapy: proactive or reactive? one of the greatest breakthroughs in ophthalmology occurred only ten years ago following the first publication of the use of intravitreal bevacizumab to treat choroidal neovascularisation.1 since then the use of anti-vegf agents bevacizumab, ranibizumab and aflibercept has spread on a massive scale throughout the world and patients are benefiting from sightsaving therapy for diseases which previously had limited or no effective therapy. for most patients commencing anti-vegf therapy the treatment course can last many years and maintaining the early benefit gained from treatment is a challenge for clinicians. some patients may discontinue therapy due to lack of effect, progression of untreatable aspects of the disease such as atrophy and ischaemia or other systemic problems may prevent ability to attend for treatment. however, for many there may be an initial positive treatment benefit which is lost over time. the reasons for this may naturally reflect the differences in patient response when compared to clinical trials but real world data is emerging indicating response may also be variable depending on treatment approach. the landmark studies of ranibizumab (anchor, marina) in wet amd showed mean gain in vision maintained for two years on monthly treatment. when monthly treatment was discontinued and a more reactive clinician guided approach of review and treatment as required was used, over the subsequent two years (horizon study) there was a gradual reduction in mean vision gain. this trend continued in the further long term follow-up (seven-up) study.2 the landmark studies of aflibercept (view) also showed good maintenance of vision gain using a proactive treatment approach in the first year; monthly treatment for three months followed by bimonthly and in the second year a prn approach being used but capped so that treatment was given at twelve weeks even if the patient was stable and not strictly needing a treatment according to the prn approach.3 in routine clinical practice a reactive clinical approach is commonly used to try and limit the number of intravitreal injections used for an individual patient whilst trying to maintain treatment effect. this has partly been driven by cost and capacity. although it is possible to achieve good visual results from a prn approach as shown in the catt study which compared prn bevacizumab and ranibizumab with monthly treatment, this was achieved through tight monthly monitoring, a very low retreatment threshold and a relatively high number of treatments in the prn arms.4 longer term results of anti-vegf treatments for wet amd in real world clinical practice using a prn approach appear to be showing that this approach can lead to a gradual loss of treatment effect in the longer term. the uk emr study of 12951 eyes receiving 92976 injections showed an initial visual again after a loading dose of three injections but then a gradual reduction of visual acuity to below baseline over the course of three years5. this was also shown in a crosscountry comparison in the international aura study in which the uk fared better but had the highest overall number of injections and patient visits.6 in contrast a proactive approach using aflibercept using a fixed dosing treatment protocol as in the view studies showed good results in routine clinical practice.7 these trends towards lack of maintenance of efficacy in routine clinical practice with a reactive approach could be explained by the damaging effect of the underlying disease process. a study measuring aqueous vegf levels showed that vegf suppression is lost before detectable recurrence of disease on oct scan and this precedes visual acuity loss. at any time that recurrence is detected at a routine review appointment the disease will inevitably have been active for a variable period of time during which damage may have been occurring which could affect response to treatment and future visual outcomes. a treatment approach which attempts to take a more proactive approach and tailor the treatment to the response of an individual patient is the concept called “treat and extend” (tae). this approach already very popular in the us and australia and evidence is building for its efficacy in the clinical trial setting and real world clinical practice. this approach involves commencing treatment using a fixed monthly sajjad mahmood 2 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology dosing approach until a dry retina or disease stability is achieved. the treatment is then continued and the review interval is extended sequentially at each visit in up to 12 weeks if there is disease stability. if signs of disease activity increase, the treatment interval is reduced. all visits therefore become treatment visits and vary not in deciding whether treatment is required but at what interval to review the patient. the lucas study compared bevacizumab and ranibizumab for wet amd patients using a tae approached and showed increase in best-corrected visual acuity va of 7.9 and 8.2 letters, respectively, after 1 year of treatment.8 real world data has been published in an australian study reviewing results from 1198 eyes of 1101 patients treated according to a tae approach. mean visual acuity improved by 6.5 letters in the first year and was maintained at 5.3 in the second year with an overall mean of 13.0 injections over two years and 14.8 clinic visits.9 potential criticisms of this approach include the possibility of over-treating a dry retina, an increased risk of atrophy, greater cost and need for exit criteria. at present the evidence for atrophy risk is inconclusive and has to be weighed against the risk to the eye of damage from repeated recurrent disease. although on average more treatments may seem to be required in the first year, the treatment number in reported studies is comparable with patients managed more intensively using a prn approach without the need for intervening monitoring visits. over-treatment can be minimised by excluding particularly good responders. in the sustain study which used a prn approach, approximately 20% of patients did not require an injection after the first three treatments10. patients responding so well to treatment could therefore be excluded from the tae approach and continued prn if needing infrequent treatment but if disease recurrence occurs within a three month timescale, treat and extend could be implemented for patients from that point. exit could be an option when a patient has been extended up to a 12 week interval and remains dry at 2 – 3 consecutive visits although in patients with a high risk from recurrent disease e.g. those on treatment in their better eye long term treatment may be preferred to the risking recurrent disease. implementing tae also requires a modification of staff and patient psychology and expectations need to be set so a patient expects treatment at each visit and discontinuing treatment is not perceived to be a success and continuing treatment a failure. the tae approach has been reported most for wet amd patients. data is limited for retinal vein occlusion. for diabetic macular oedema there appears to be less detriment from allowing fluid to recur for a period and long term results from a prn approach used in drcr.net study protocol11 and restore study12 show an average reduction in injection requirement year on year to very low levels after the second year from initiating treatment. in the first two years though a tae approach may help manage capacity by reducing monitoring visit requirements as shown in the retain study.13 although particularly good responders requiring few treatments may be seen in all disease types treated with anti-vegf therapy in the majority of cases chronic disease requires long term therapy and a proactive approach makes sense to achieve the best long term outcomes for patients. reference 1. rosenfeld pj, moshfeghi aa, puliafito ca. optical coherence tomography findings after an intravitreal injection of bevacizumab (avastin) for neovascular agerelated macular degeneration. ophthalmic surg lasers imaging, 2005; 36: 331-5. 2. rofagha s, bhisitkul rb, boyer ds, sadda sr, zhang k. seven-up study group. seven-year outcomes in ranibizumab-treated patients in anchor, marina, and horizon: a multicenter cohort study (sevenup). ophthalmology, 2013; 120: 2292-9. 3. schmidt-erfurth u, kaiser pk, korobelnik jf, et al. intravitreal aflibercept injection for neovascular agerelated macular degeneration: ninety-six-week results of the view studies. ophthalmology, 2014; 121: 193-201. 4. catt research group. ranibizumab and bevacizumab for treatment of neovascular age – related macular degeneration: two-year results. ophthalmology, 2012; 119: 1388-98. 5. writing committee for the uk age-related macular degeneration emr users group. the neovascular agerelated macular degeneration database: multicenter study of 92 976 ranibizumab injections. report 1: visual acuity. ophthalmology. 2014;-:1e10 a 2014 by the american academy of ophthalmology. 6. hykin p, chakravarthy u, lotery a, mckibbin m, napier j, sivaprasad s. a retrospective study of the real – life utilization and effectiveness of ranibizumab therapy for neovascular age – related macular degeneration in the uk. clin ophthalmol. 2016; 10: 8796. 7. talks js, lotery aj, ghanchi f, sivaprasad s, johnston rl, patel n, mckibbin m, bailey c, mahmood s. united kingdom aflibercept users group. first – year visual acuity outcomes of providing aflibercept according to the view study protocol for age – anti-vegf therapy: proactive or reactive? pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 3 related macular degeneration. ophthalmology, 2016; 123: 337-43. 8. berg k, pedersen tr, sandvik l, bragadóttir r. comparison of ranibizumab and bevacizumab for neovascular age – related macular degeneration according to lucas treat-and-extend protocol. ophthalmology, 2015; 122: 146-52. 9. arnold jj, campain a, barthelmes d, et al. fight retinal blindness study group. two – year outcomes of "treat and extend" intravitreal therapy for neovascular age – related macular degeneration. ophthalmology, 2015; 122: 1212-9. 10. holz fg, amoaku w, donate j, guymer rh, kellner u, schlingemann ro, weichselberger a, staurenghi g. sustain study group. safety and efficacy of a flexible dosing regimen of ranibizumab in neovascular age-related macular degeneration: the sustain study. ophthalmology, 2011; 118: 663-71. 11. diabetic retinopathy clinical research network (drcr.net), bressler sb et al. five year outcomes of ranibizumab with prompt or deferred laser versus laser or triamcinolone plus deferred ranibizumab for diabetic macular edema. am j ophthalmol. 2016; 20. 12. schmidt-erfurth u, lang ge, holz fg, schlingemann ro, lanzetta p, massin p, gerstner o, bouazza as, shen h, osborne a, mitchell p. restore extension study group. three-year outcomes of individualized ranibizumab treatment in patients with diabetic macular edema: the restore extension study. ophthalmology. 2014; 121: 1045-53. 13. prünte c, fajnkuchen f, mahmood s, ricci f, hatz k, studnička j, bezlyak v, parikh s, stubbings wj, wenzel a, figueira j. the retain study group. ranibizumab 0.5 mg treat-and-extend regimen for diabetic macular oedema: the retain study. ranibizumab 0.5 mg treat-and-extend regimen for diabetic macular oedema: the retain study. br j ophthalmol. 2015 oct 9. pii: bjophthalmol-2015-307249. sajjad mahmood consultant ophthalmologist, medical retina specialist clinical lead, macular treatment centre, manchester royal eye hospital, uk received: february 15, 2016: accepted: march 14, 2016. 80 pak j ophthalmol. 2022, vol. 38 (1): 80-81 letter to editor eye camp surgery ahmad zeeshan jamil 1 , muhammad luqman ali bahoo 2 1 sahiwal medical college, sahiwal, 2 cmh institute of medical sciences, bahawalpur cataract surgery is the most frequently performed operative procedure in the human body. 1 in pakistan, we have very meagre trained human resources and equipment. 2 at onetime, eye-camp surgery was promoted by the government to tackle the growing burden of cataract-related blindness. as time passed on, we developed public and private health care delivery services. now we have ample resources to deal with an ever-growing number of cataracts. in the current scenario, eye camp surgery is not justified. but it seems as if government and regulatory bodies have no intentions to focus on this point. we researched eye camps in our region. majority of eye camp surgeries were organized by notables of the area. influential person usually has political or religious affiliation and eye camp surgeries are usually a way of brand publicity. in most cases, organizers know nothing about heath care. they hire semitrained health care workers who have some experience of work, but they have no formal training or education. these health care workers contract with notables to do a certain number of surgeries in a minimum number of days. doctors who are usually novices in their field are invited to do surgeries in these camps. sometimes these doctors are given a small amount of money. as everyone wants numbers so each person walking across the front street is a potential surgery. surgeries are planned and then performed without proper preoperative evaluation. operation theatre can be any place including kitchen, laundry, cattle shed, a tent erected in the centre of the village, etc. 3 lowquality smuggled medicines are used. the same instruments are used in multiple surgeries. to reduce the time per surgery, the surgeon tends to be reckless. per operative complication rate is high, and no one is accountable. patients never know the type of surgery, surgeon's name and follow-up schedule. after achieving desired numbers, the eye camp is closed until the next season. patients are left at no one’s care. in case of any serious complication, the grave prognosis is the patients’ fate. in pakistan, we have health care delivery facilities ranging from basic health units up to medical universities. we have enough resources to do all cataract surgeries in these facilities. it is the responsibility of health bureaucracy, health care commission (hcc) and pakistan medical commission (pmc) to take strict measures to stop eye camps that do not meet the minimal service delivery standards. meanwhile, ophthalmological society of pakistan (osp) that is the representative society of ophthalmologists should come forward to raise awareness amongst the masses about having standard health care services. osp should prepare preferred practice patterns for doctors as to the minimal standard of eye surgeries. these standards may be utilized by hcc, pmc, and health bureaucracy as a steering wheel to drive the eye care services. if eye camp surgery is to be done at all there must be some minimal standards that encompass the provision of dedicated infrastructure, equipment, trained staff, and doctors along with proper follow-up of patients. in that way, a dream of health for all can be fulfilled with a healthy nation and a prosperous pakistan. how to cite this article: jamil az, bahoo mla. eye camp surgery. pak j ophthalmol. 2022, 38 (1): 80-81. doi.10.36351/pjo.v38i1.1329 correspondence: ahmad zeeshan jamil sahiwal medical college, sahiwal email: ahmadzeeshandr@gmail.com received: august 14, 2021 accepted: december 12, 2021 references 1. thompson j, lakhani n. cataracts. primary care, 2015; 42 (3): 409-423. open access eye camp surgery pak j ophthalmol. 2022, vol. 38 (1): 80-81 81 2. achakzai j. pakistan among countries with highest cataract surgical rate. international the news. december 22, 2019. available at: https://www.thenews.com.pk/print/586935-pakistanamong-countries-with-highest-cataract-surgical-rate. accessed online on september 28, 2020. 3. rathore ah. eye camp surgery: an old tradition which should come to an end. pulse. available at: http://www.pulsepakistan.com/index.php/main-newsmay-1-17/2067-eye-camp-surgery-an-old-traditionwhich-should-come-to-an-end. accessed on 09/05/2021. .…  …. https://www.thenews.com.pk/print/586935-pakistan-among-countries-with-highest-cataract-surgical-rate https://www.thenews.com.pk/print/586935-pakistan-among-countries-with-highest-cataract-surgical-rate http://www.pulsepakistan.com/index.php/main-news-may-1-17/2067-eye-camp-surgery-an-old-tradition-which-should-come-to-an-end http://www.pulsepakistan.com/index.php/main-news-may-1-17/2067-eye-camp-surgery-an-old-tradition-which-should-come-to-an-end http://www.pulsepakistan.com/index.php/main-news-may-1-17/2067-eye-camp-surgery-an-old-tradition-which-should-come-to-an-end pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 53 case report conjunctivoblepharon; a variant of ankyloblephron munawar ahmed pak j ophthalmol 2016, vol. 32 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: munawar ahmed department of ophthalmology liaquat university of medical and health sciences jamshoro/ hyderabad email: munawar_404@yahoo.com received: october 27, 2015 accepted: december 01, 2015. …..……………………….. we report a patient seen with an unusual condition affecting the eyelids and conjunctiva seen in 2015 at the department of ophthalmology liaquat university of medical and health sciences jamshoro. affected patient was reviewed for his clinical history, examination findings, external photographs, and the result of treatment. this is a new ocular problem in which tarsal conjunctiva of upper and lower lid is fused and can be called conjunctivoblepharon. key words: eye lids, conjunctiva, vision, primary position. ye lid adhesions between upper and lower lids may be congenital or acquired. the congenital adhesions may be associated lip or cleft palate.1 ankyloblepharon filiforme adnatum (afa) is a rare but potentially ambylogenic congenital abnormality of the eyelids, in which single or multiple bands of tissue join the upper and lower eyelid. afa is also important, as it can be associated with several disorders, such as trisomy 18 (edward's syndrome), hay-wells syundrome (ankyloblepharon – ectodermal dysplasia – clefting syndrome, curly hairankyloblepharon nail dysplasia syndrome, and cleft lip and palate.2 conjunctivoblepharon; this problem is limited to conjunctiva and eye lids only. no systemic anomaly is identified because this condition seems to be acquired and not congenital. case report an 18 years male resident of rural area of sindh, presented with obstruction of left eye vision in primary position from ten years. he was not having any eye problem in early child hood. no history of physical or chemical trauma. he noticed adhesion between upper and lower lids of his left eye in the morning after overnight sleep. he was not able to see with left eye in primary positions. he was able to see with both eyes in left or right positions of gaze. he was having this problem for the last 10 years but he had not consulted with any eye specialist. fig. 1: preoperative picture. a triangular fleshy sheet, extending between central part of upper and lower lid was visible. the e mailto:munawar_404@yahoo.com munawar ahmed 54 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology base of this triangular sheet was attached to lower lid tarsal conjunctiva 2mm away from posterior lid margin and apex to the upper lid tarsal conjunctiva 2mm away from posterior lid margin. posterior layer of sheet was continuous with the conjunctiva of lower fornix. in primary position visual acuity in right was 6/6 and left eye hm. as this triangular sheet was not attached with the cornea or eye ball so globe movements were normal and in right or left gaze the visual acuity in left eye was 6/9 unaided. fig. 2: per operative picture. double layered tubular structure triangular in shape with base down extending from lower tarsal conjunctiva to the upper tarsal conjunctiva. both anterior and posterior layers were attached to upper tarsal conjunctiva close to each other 2 mm away from posterior lid margin, occupying central 6mm of lid margin length. in lower tarsal the anterior layer of this fleshy sheet was attached 2 mm away from posterior lid margin occupying two third of lid margin length, where as posterior layer was continuous with lower forniceal conjunctiva. both anterior and posterior surfaces of sheet were pinkish, glistening and vascularized. after removal of this structure eye appeared normal with clear cornea. discussion adhesions between upper and lower lids may be congenital (isolated or associated with systemic condition) or acquired (chemical burns, from drug reactions, acute infections) ocular complications of stevens – johnson syndrome can result in ankyloblepharon and symblepharon.3 in ankyloblepharon filiforme adnatum full eyelid opening may be impaired and make interpalpebral aperture narrow4. in this condition partial fusion of upper and lower eyelids by single or multiple bands of tissue join the upper and lower eyelids either unilaterally or bilaterally. lower eyelid retractor laxity combined with a temporary adhesion between the upper and lower lid can be observed in sticky eyelid syndrome.5 our case is different from all these conditions and do not fit in any existing ophthalmic conditions. evaluation of case indicates that condition is acquired not congenital. as conjunctiva is involved, it can be taken as new form of symblepharon, but it is not attached to bulbar conjunctiva or cornea. furthermore normal conjunctiva is a translucent structure whereas this fleshy sheath is opaque. it is away from posterior lid margin and occupies the central part of the upper and lower lids. it is possible that sever conjunctivitis and chemosis resulted in adhesion at posterior lid margins during sleep but due to growth of tarsal plates the point of adhesion shifted away from posterior lid margins over a long period. gradually the lower tarsal/forniceal conjunctiva has been pulled up and resulted in triangular fleshy mass with base of this triangular sheet downward attached at equal distance away from posterior lid margins of upper and lower lids. no any systemic abnormality was noted in this patient. we have never seen such a condition before and such a problem of conjunctiva is not present in the literature. author’s affiliation dr. munawar ahmed assistant professor ophthalmology liaquat university of medical and health sciences jamshoro/hyderabad role of authors dr. munawar ahmed data collection and manuscript writing references 1. farrington f, lausten l. oral findings in ankyloblepharon – ectodermal dysplasia-cleft lip/palate (aec) syndrome. am j med genet a. 2009; 149: 1907-9. conjunctivoblepharon; a variant of ankyloblephron pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 55 2. willium ma, white st, ginnity g mc. ankyloblepharon filiforme adnatum arch dis child, 2007; 92: 73–4. 3. ukponmwan cu, njinaka i, ehimiyen efe t. ocular complications of stevens-johnson syndrome and toxic epidermal necrolysis trop doct. 2010; 40: 167-8. 4. ioannides a, georgakarakos n d. management of ankyloblepharon filiforme adnatum eye, 2011; 25: 823. 5. kortvelesy js, george f, burger jr. sticky eyelid syndrome american journal of ophthalmology, 2004; 138: 882-4. pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 117 abstracts edited by dr. qasim lateef chaudhry vitrectomy with internal limiting membrane peeling versus no peeling for idiopathic fullthickness macular hole cornish ks, lois n, scott nw, burr j, cook j, boachie c, tadayoni r, cour m, christensen u, kwok akh ophthalmology 2014; 121: 649-55. kurt et al conducted a systematic review and individual participant data (ipd) meta-analysis under the auspices of the cochrane eyes and vision group to determine whether internal limiting membrane (ilm) peeling improved anatomic and functional outcomes of full-thickness macular hole (ftmh) surgery when compared with the no-peeling technique. only randomized controlled trials (rcts) were included in this study. all patients with idiopathic stage 2, 3, and 4 ftmh undergoing vitrectomy with or without ilm peeling and gas endotamponade were enrolled. primary outcome was best-corrected distance visual acuity (bcdva) at 6 months postoperatively. secondary outcomes were bcdva at 3 and 12 months; best-corrected near visual acuity (bcnva) at 3, 6, and 12 months; primary (after a single surgery) and final (after > 1 surgery) macular hole closure; need for additional surgical intervenetions; intraoperative and postoperative complications; patient-reported outcomes (pros) (euroqol-5d and vision function questionnaire-25 scores at 6 months); and cost-effectiveness. four rcts were identified and included in the review. all rcts were included in the meta-analysis; ipd were obtained from 3 of the 4 rcts. no evidence of a difference in bcdva at 6 months was detected (mean difference, −0.04; 95% confidence interval [ci], −0.12 to 0.03; p = 0.27); however, there was evidence of a difference in bcdva at 3 months favoring ilm peeling (mean difference, −0.09; 95% ci, −0.17 to −0.02; p = 0.02). there was evidence of an effect favoring ilm peeling with regard to primary (odds ratio [or], 9.27; 95% ci, 4.98–17.24; p < 0.00001) and final macular hole closure (or, 3.99; 95% ci, 1.63 – 9.75; p = 0.02) and less requirement for additional surgery (or, 0.11; 95% ci, 0.05 – 0.23; p < 0.00001), with no evidence of a difference between groups with regard to intraoperative or postoperative complications or pros. the ilm peeling was found to be highly cost-effective. the authors concluded that available evidence supports ilm peeling as the treatment of choice for patients with idiopathic stage 2, 3, and 4 ftmh. collaborative retrospective macula society study of photodynamic therapy for chronic central serous chorioretinopathy lim ji, glassman ar, aiello lp, chakravarthy u, flaxel cj, spaide rf ophthalmology 2014; 121: 1073-8. jennifer et al did a retrospective case series to assess the visual and anatomic outcomes of central serous chorioretinopathy (csc) after verteporfin photodynamic therapy (pdt). members of the macula society were surveyed to retrospectively collect data on pdt treatment for csc. patient demographic information, pdt treatment parameters, fluorescein angiographic information, optical coherence tomography (oct) metrics, preand post-treatment visual acuity (va), and adverse outcomes were collected online using standardized forms. the main outcome measures were visual acuities over time and presence or absence of sub retinal fluid (srf). data were submitted on 265 eyes of 237 patients with csc with a mean age of 52 (standard deviation [± 11]) years; 61 were women (26%). mean baseline logarithm of the minimum angle of resolution (logmar) va was 0.39 ± 0.36 (20/50). baseline vas were ≥ 20/32 in 115 eyes (43%), 20/40 to 20/80 in 97 eyes (37%), and ≤ 20/100 in 47 eyes (18%). normal fluence was used for pdt treatment in 130 treatments (49%), halffluence was used in 128 treatments (48%), and very low fluence or missing information was used in 7 treatments (3%). the number of pdt treatments was 1 in 89%, 2 in 7%, and 3 in 3% of eyes. post-pdt followup ranged from 1 month to more than 1 year. postpdt va was correlated with baseline va (r = 0.70, p < 0.001). visual acuity improved ≥3 lines in < 1%, qasim lateef chaudhry 118 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology 29%, and 48% of eyes with baseline va ≥ 20/32, 20/40 to 20/80, and ≤ 20/100, respectively. sub retinal fluid resolved in 81% by the last post pdt visit. there was no difference in the response to pdt when analyzed by age, race, fluence setting, fluorescein angiography (fa) leakage type, corticosteroid exposure, or fluid location (sub retinal or pigment epithelial detachment; all p > 0.01). complications were rare: retinal pigment epithelial atrophy was seen in 4% of patients, and acute severe visual decrease was seen in 1.5% of patients. the authors concluded that photodynamic therapy was associated with improved va and resolution of srf. adverse side effects were rare. antibiotic choice for the prophylaxis of postcataract extraction endophthalmitis rudnisky cj, wan d, weis e ophthalmology 2014; 121: 835-41. christopher et al conducted this case control study to determine the 8-year incidence of endophthalmitis after cataract surgery and to determine which surgical practices were associated with higher rates of endophthalmitis. a total of 75 318 eyes undergoing cataract extractions, performed by 26 different surgeons at 4 public hospitals and 5 nonhospital surgical facilities were included. cases of endophthalmitis were acquired using a detailed, prospectively designed demographic database. controls were tabulated using volume data available from the provincial health care system. the primary outcome was the development of endophthalmitis. a total of 23 cases (13 with culture-positive results) of postoperative endophthalmitis occurred, yielding an overall 8 year incidence of 0.03%. the incidence of endophthalmitis varied between surgeons from 0% to 0.20%. two surgeons had higher rates than the rest of the group: 1 high-volume surgeon (1059.4 ± 231.9 mean cases per year) with an incidence of 0.08% (n = 7; p = 0.004) and 1 low – volume surgeon (123.5 ± 44.8 mean cases per year) with an incidence of 0.20% (n = 2; p = 0.002). on univariate analysis, the rate of endophthalmitis was not influenced by the use of intracameral (0.898) or sub conjunctival antibiotics (0.331), whereas the use of moxifloxacin was associated with a lower rate of endophthalmitis (p = 0.029). surgery at 1 private facility (p = 0.046) and the use of timolol at the end of the procedure (p = 0.007) were associated with a higher rate of endophthalmitis. multivariate analysis demonstrated that the odds of endophthalmitis was lower if a second-generation (p = 0.02) or fourth generation (p = 0.008) fluoroquinolone antibiotic was used after surgery. in contrast, the odds of endophthalmitis occurring was higher if timolol (p = 0.0002) was used at the end of the procedure or if the surgery was performed at one of the private facilities (p = 0.009). in conclusion the rate of endophthalmitis was lower if a fluoroquinolone was used after surgery. in contrast, endophthalmitis was more likely to occur if timolol was used at the end of the procedure. collagen cross-linking in progressive keratoconus; three year results wittig-silva c, chan e, islam fma, wu t, whiting m, snibson gr ophthalmology 2014; 121: 812-21 three year results to report the refractive, topographic, and clinical outcomes after corneal collagen cross linking (cxl) in eyes with progressive keratoconus in this prospective, randomized controlled trial were published by christine et al. one hundred eyes with progressive keratoconus were randomized into the cxl treatment or control groups. cross-linking was performed by instilling riboflavin 0.1% solution containing 20% dextran for 15 minutes before and during the 30 minutes of ultraviolet air radiation (3 mw/cm2). follow-up examinations were arranged at 3, 6, 12, 24, and 36 months. the primary outcome measure was the maximum simulated keratometry value (kmax). other outcome measures were uncorrected visual acuity (ucva; measured in logarithm of the minimum angle of resolution [logmar] units), best spectacle – corrected visual acuity (bscva; measured in logmar units), sphere and cylinder on subjective refraction, spherical equivalent, minimum simulated keratometry value, corneal thickness at the thinnest point, endothelial cell density, and intraocular pressure. the results from 48 control and 46 treated eyes were reported. in control eyes, kmax increased by a mean of 1.20 ± 0.28 diopters (d), 1.70 ± 0.36 d, and 1.75 ± 0.38 d at 12, 24, and 36 months, respectively (all p < 0.001). in treated eyes, kmax flattened by 0.72 ± 0.15 d, 0.96 ± 0.16 d, and 1.03 ± 0.19 d at 12, 24, and 36 months, respectively (all p < 0.001). the mean change in ucva in the control group was + 0.10 ± 0.04 logmar (p ¼ 0.034) at 36 months. in the treatment group, both ucva (0.150.06 logmar; p 0.009) and bscva (0.090.03 logmar; p ¼ abstracts pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 119 0.006) improved at 36 months. there was a significant reduction in corneal thickness measured using computerized video keratography in both groups at 36 months (control group: 17.013.63 mm, p < 0.001; treatment group: 19.525.06 mm, p < 0.001) that was not observed in the treatment group using the manual pachymeter (treatment group: þ 5.864.30 mm, p ¼ 0.181). the manifest cylinder increased by 1.17 ± 0.49d (p ¼ 0.020) in the control group at 36 months. there were 2 eyes with minor complications that did not affect the final visual acuity. in conclusion at 36 months, there was a sustained improvement in kmax, ucva, and bscva after cxl, whereas eyes in the control group demonstrated further progression. 433 pak j ophthalmol. 2020, vol. 36 (4): 433-439 original article ocular manifestations and viral prevalence in conjunctival secretions of patients with covid 19 – a meta–analysis ayisha shakeel 1 , sharjeel sultan 2 , syed imtiaz ali 3 1-3 al nafees medical college and hospital, isra university, islamabad, 2 dow university of health sciences, karachi abstract pubmed was searched using key words “covid-19”, “coronavirus”, and “sars cov-2” in conjunction with “ophthalmology” and “eye” on 17 th may 2020. total 483 articles were identified. after screening eleven articles were included in the analysis. the frequencies of ocular manifestations and the presence of virus in conjunctiva were analyzed and the final results were compiled. ten out of eleven articles were analyzed for ocular manifestations. in our analysis a total of 2115 cases had covid 19, out of which 77 patients developed ocular manifestations (3.64%, 95% ci 2.88 – 4.53). the most common being conjunctival congestion. twelve patients had sars – cov-2 in their ocular secretions confirmed by rt pcr test (2.61%, 95% ci 1.36 – 4.52). this metaanalysis concludes that conjunctiva is neither a preferred site of infection nor a preferred gateway for entry of sars cov-2 in the body. as a low risk of infection does exist, eye protective equipment should be used when treating covid – 19 patients. key words: sars cov 2, covid 19, conjunctiva, ophthalmology. how to cite this article: ocular manifestations and viral prevalence in conjunctival secretions of patients with covid 19 – a meta – analysis. pak j ophthalmol. 2020; 36 (4): 433-439. doi: https://doi.org/10.36351/pjo.v36i4.1126 introduction human race since its existence has been threatened by many deadly pandemics. the most recent pandemic caused by a corona virus has very quickly spread through the entire world and has affected millions of individuals. 1 since its beginning earlier this year there have been more than 4.6 million confirmed cases and around 300000 deaths worldwide. 2 corona viruses are single stranded rna enveloped viruses. they were first identified in 1960s and were considered to cause mild flu like symptoms in humans until more recently correspondence: ayisha shakeel al nafees medical college and hospital, isra university, islamabad email: ayishashakeel@gmail.com received: september 3, 2020 accepted: september 6, 2020 since the emergence of sars cov in 2002 and mers cov in 2012. the latter two viruses can cause severe lower respiratory tract infection proceeding to pneumonia and even death. 3 the latest pandemic is caused by a novel corona virus now named as sars cov2. like its predecessors, it can cause a highly infectious pneumonia called corona virus disease or covid 19. the sars cov-2 has a mortality much lower than the mortality of sars cov and mers cov but it is considered to be more contagious. 4,5 interest of ophthalmology began in this disease since the first doctor to notice this different kind of flu was an ophthalmologist. dr li wenliang was working in wuhan, china when he noticed these patients. he unfortunately contracted the disease from one of his patients and died later on. 6 since then, two more ophthalmologists have died in wuhan due to occupational exposure and a pulmonologist developed conjunctivitis while treating his patients. the only mailto:ayishashakeel@gmail.com ocular manifestations and viral prevalence in conjunctival secretions of patients with covid 19 pak j ophthalmol. 2020, vol. 36 (4): 433-439 434 exposed part of his face were his eyes thus leading to the speculation that ocular entry could be the cause of infection. 5 due to close proximity to the patients as a job requirement, ophthalmologists are at greater risk of catching or transmitting the disease. 7 since then many studies and case reports have been published with involvement of eyes of covid 19 patients. 8,9,10 the most common ocular symptoms were hyperemia, chemosis, lacrimation and increased secretion while none of the patient experienced blurred vision. 11 the sars cov-2 spreads through respiratory droplets and by direct contact with virus contaminated fomites. 12 eye due to exposure to the environment can come in contact with these virus particles. the virus has been sequenced and is found to be 75 – 80% similar to sars cov and 40% similar to mers cov. 13 it is therefore possible that sars cov-2 shares the same mechanism to gain access in the human cells. the virus gains entry into human cells by binding to certain proteins on the cell surface. two of such key proteins, angiotensin converting enzyme 2 (ace 2) and transmembrane serine protease 2 (tmprss 2) are the key proteins for entry in host cells. animal models have shown that in the eye their highest expression is in conjunctiva and cornea. 14 ace 2 and tmprss 2 are found in human conjunctival cells and corneal limbal stem cells. ace 2 are also present in other parts of the eye like trabecular meshwork, aqueous humor, iris, ciliary body, nonpigmented ciliary epithelium, and retina. 15 human eye is also connected to the nasopharynx by the constant draining of tears through the nasolacrimal duct. it is therefore, possible that there may be two routes of entry of virus through the eye. one is by binding to the ocular surface cells and the other is by being drained into the nasopharynx with tears. 16 although the possibility of spread exists, the eyes are rarely involved in covid 19. 17 this suggests that the eye is neither a preferred organ for human coronavirus infection nor a preferred gateway of entry that enables human coronaviruses to infect the respiratory tract. 12 since the emergence of this disease, a lot of information is coming up on daily basis about covid 19 and its involvement of the eye. in ophthalmology, the main focus is on two things. firstly, the ocular manifestations of covid 19 and secondly how is the eye involved in transmission and infection of this disease. a number of studies have come up in literature to answer these questions with varying opinions. in this paper, we try to sum up the findings of literature by performing a systematic review and meta-analysis with special focus on ocular manifestations and presence of virus in the conjunctiva of patients with possible transmission through the eye. the objective of this analysis was to find out the ocular manifestations of covid – 19 and presence of virus in the conjunctival secretions of these patients. methods this meta-analysis was carried out according to the fundamentals laid in the preferred reporting items for systematic reviews and meta‐analysis (prisma) statement. 18 the objective of this analysis was to find out the ocular manifestations of covid19 and presence of virus in the conjunctival secretions of these patients. in the meta-analysis only comparative studies (both prospective and retrospective observational studies) and randomized controlled trials since the start of corona virus pandemic till 17 th may 2020 were included. the participants in all these studies were laboratory confirmed covid – 19 patients. ocular symptoms of conjunctival hyperemia, discharge, watering, foreign body sensation, itching and chemosis were all included. reverse transcriptasepolymerase chain reaction test (rt-pcr) was performed on the conjunctival swabs of all patients with ocular symptoms for presence of sars – cov-2. pubmed database was searched for relevant articles using the keywords “covid – 19”, “coronavirus”, and “sarscov-2” in conjunction with “ophthalmology” and “eye”. a total of 483 articles were identified through database searching till 17 th may 2020. however, by following the flow diagram of prisma guidelines for meta-analysis, 97 articles were identifiedafter removal of duplicates and irrelevant articles. further screening removed 41 more articles (editorials, communication, case reports, case series) leaving 56 behind to be assessed for eligibility. these full text articles were then assessed for eligibility under the criteria set in the beginning of the article. thirty-one did not fulfill the criteria and were removed leaving behind 25 articles for qualitative analysis. the results of these articles were assessed and out of these articles, 11 articles were included for meta-analysis. the whole process is shown in fig. 1. for statistical data analysis, frequencies were calculated in terms of percentages to identify the most ayisha shakeel, et al 435 pak j ophthalmol. 2020, vol. 36 (4): 433-439 fig. 1: flow chart. common ocular manifestations and presence of virus in the conjunctiva of patients based upon which, final conclusions were drawn. results after following the guidelines of prisma for metaanalysis a total of 11 articles were finally included in the meta-analysis. based on the available data ten articles were included to analyze the ocular manifestations in patients with covid – 19, while eight articles were included to assess the prevalence of virus in ocular secretions in such patients (table 1). the ten studies analyzed for ocular manifestations had a total of 2115 confirmed cases of covid 19. out of the total 2115 confirmed cases, 77 patients developed ocular manifestations (3.64%, 95% ci 2.88 – 4.53) of different kind. the most common ocular manifestations and viral prevalence in conjunctival secretions of patients with covid 19 pak j ophthalmol. 2020, vol. 36 (4): 433-439 436 ocular manifestations were conjunctival congestion (09 studies) followed by increased secretions (7 studies), itching (4 studies), foreign body sensation (2 studies), dry eyes (2 studies), chemosis, blurred vision and floaters (1 study each). for details see table 2. the eight studies analyzed for prevalence of virus in ocular secretions had a total of 459 confirmed cases of covid – 19. out of the total 459 confirmed cases, 12 patients had sars-cov 2 in their ocular secretions confirmed by rt pcr test (2.61%, 95% ci 1.36 – 4.52). table 3 shows the details. table 1: studies included in meta-analysis. author type of study sample size age gender (m, f) patients with ocular manifestations patients with positive conjunctival secretion yunyun zhou et al 19 retrospective 67 35.7 ± 10.6 25, 42 1 3 nang hong et al 20 cross sectional 56 48 ± 21.1 31, 25 15 ping wu et al 11 retrospective 38 65.8 ± 16.6 25, 13 12 2 wei-jie guan et al 17 retrospective 1099 47 (35 – 58) 58.1%, 41.9% 9 jianhua xia et al 21 interventional case series 30 54.5 ± 14.17 27, 3 1 1 xian zhang et al 22 cross sectional 72 58.68 ± 14.81 36, 36 2 1 yunyun zhou et al 23 cross sectional 121 48 53, 68 8 3 lan qianqian et al 24 prospective 81 41.69 ± 18.6 33, 48 3 0 ivan yu jun seah et al 25 prospective 17 1 0 hua-tao xie et al 26 retrospective 33 57.6 ± 14 22, 11 2 liwen chen et al 27 cross sectional 534 45 260, 274 25 table 2: studies included in analysis of ocular manifestations in covid – 19 patients. author type of study sample size age gender (m, f) no of patients with ocular manifestations percentage of ocular symptom 95% ci yunyun zhou et al 19 retrospective 67 35.7 ± 10.6 25,42 1 1.49% 0.04 – 8.04 nang hong et al 20 cross sectional 56 48 ± 21.1 31, 25 15 26.79% 15.83 – 40.3 ping wu et al 11 retrospective 38 65.8 ± 16.6 25, 13 12 31.58% 17.5 – 48.65 wei-jie guan et al 17 retrospective 1099 47 (35 – 58) 58.1%, 41.9% 9 0.82% 0.38 – 1.55 jianhua xia et al 21 prospective 30 54.5 ± 14.17 27, 3 1 3.33% 0.08 – 17.22 xian zhang et al 22 cross sectional 72 58.68 ± 14.81 36, 36 2 2.78% 0.34 – 9.68 yunyun zhou et al 23 cross sectional 121 48 53, 68 8 6.61% 2.91 – 12.61 lan qianqian et al 24 prospective 81 41.69 ± 18.6 33, 48 3 3.70% 0.77 – 10.4 ivan yu jun seah et al 25 prospective 17 1 5.80% 0.15 – 28.65 liwen chen et al 27 cross sectional 534 45 260,274 25 4.68% 3.05 – 6.83 total patients 2115 77 3.64 2.88 – 4.53 table 3: studies with sars – cov-2 in ocular secretions. author type of study sample size age gender m, f no of patients with sars cov2 in conjunctival secretions % age of ocular symptoms 95% ci ping wu et al 11 retrospective 38 65.8 ± 16.6 25, 13 2 5.26% 0.64 – 1.77 yunyun zhou et al 19 retrospective 67 35.7 ± 10.6 25, 42 3 4.48% 0.093 – 12.5 jianhua xia et al 21 prospective 30 54.5 ± 14.17 27, 3 1 3.33% 0.08 – 17.22 xian zhang et al 22 cross sectional 72 58.68 ± 14.8 36, 36 1 1.39% 0.03 – 7.5 yunyun zhou et al 23 cross sectional 121 48 53, 68 3 2.48% 0.51 – 7.07 lan qianqian 24 prospective 81 41.69 ± 18.6 33, 48 0 0.00% 0 – 4.45 ivan yu jun seah et al 25 prospective 17 0 0.00% 0 – 19.5 hua-tao xie et al 26 retrospective 33 57.6 ± 14 22, 11 2 6.06% 0.74 – 20.23 total patients 459 12 2.61% 1.36 – 4.52 ayisha shakeel, et al 437 pak j ophthalmol. 2020, vol. 36 (4): 433-439 discussion the results of this meta-analysis shows that overall 3.64% (95% ci 2.88 – 4.53) patients with covid – 19 presented with ocular manifestations. this is slightly higher than another meta-analysis by loffredo et al in which 1.1% patients of covid 19 had ocular manifestations. 28 the reason could be that the number of studies in our meta-analysis were ten as compared to only three in the other meta-analyses. with more and more studies being published the rate and manifestations of the disease will change. loffredo et al has also mentioned two groups of patients with covid – 19 and the rate of ocular manifestations in patients with severe disease was 3%. the rate of ocular manifestations in covid 19 patients has varied among individual studies. initial studies by huang, chan and chen from wuhan did not mention any ocular manifestations at all. 29,30,31 later on multiple studies emerged which mentioned ocular manifestations as symptoms of covid – 19. a study by guan et al with a sample size of 1099 patients mentioned ocular manifestations in only 0.82% (95%ci 0.38 – 1.55) of the patients. 17 on the contrary, a retrospective analysis of 38 patients by wu et al reported ocular manifestationsas high as 31.8% (95% ci 17.5 – 48.65). 11 as covid – 19 is a new disease and humanity is battling with its effect on the human body, it is not surprising that we will find different features in different reports. the most common ocular manifestation in our analysis was conjunctival congestion, which was present in 82% of our studies. this was followed by increased ocular secretions which was mentioned in 64% of our studies. the next most common manifestations were itching and ocular discomfort or foreign body sensation in around 36% of our studies. dry eye was another manifestation, which the patients had experienced in 18% of our analyzed studies. the least common ocular manifestations were chemosis, floaters and blurred vision, which were mentioned in only one out of eleven studies (9%). most of the studies except one did not mention reduced or blurred vision as an ocular manifestation of covid – 19. these findings were almost similar to the reported literature on ocular manifestations of covid – 19 in which conjunctival congestion, hyperemia, increased tearing and foreign body sensations were the most common manifestations in the eye. in a case report from france by navel et al the patient presented with hemorrhagic conjunctivitis with pseudo memebranes. 8 in another case report by chen et al a patient developed redness, foreign body sensation and tearing during the course of the disease. 9 a case report by cheema et al from canada mentioned conjunctivitis as the primary presentation of covid – 19. 10 another report by daruich et al also mentioned ocular redness and foreign body sensation as the primary presentation of the disease. 32 corona viruses have been reported to cause retinal vasculitis, retinal degeneration and breakdown of blood retinal barriers in animal models in the past. 33 the sars cov-2 virus uses ace2 receptors to get attached to the host cells and ace 2 receptors have been identified in human retina. therefore, the possibility of retinal manifestation exists in covid – 19. a recent case series reported some retinal findings in the patients of covid 19 possibly due to sars-cov-2. 34 as case reports were excluded from this analysis, these diverse retinal findings could not be found in these cross sectional and retrospective studies. further studies are required to fully understand the spectrum of ocular manifestations in covid – 19 patients. in this meta-analysis we also looked into the presence of sars cov-2 virus in ocular secretions. out of the eleven studies, eight studies analyzed ocular secretions for the presence of sars cov-2 by rt pcr tests. in these studies, a total of 459 patients with confirmed covid – 19 were analyzed. out of these, 12 were found to have sars cov-2 in their ocular secretions (2.61%, 95% ci 1.36 – 4.52). two of the studies in this meta-analysis did not show viral shedding in ocular secretions at all. 24,25 the highest rate of viral shedding in ocular secretions was in a study by xie et al which was 6.06%. 26 as the knowledge about the disease is evolving the varying rates of viral shedding is not surprising. respiratoryrelated public health events, such as sars, were reported to be associated with ophthalmology. 35 corona virus or ebola virus had been detected in the tears of patients with sars and ebola. 36 a case report by hu et al detected not only sars cov-2 but also hsv1 and hhv6b in ocular secretions 2 weeks after the nasopharyngeal swab became negative. 37 this was not found in the studies under review. shedding of virus in the ocular secretions of patients who does not have conjunctivitis pose a public health risk of transmission. an article by liu et al mentioned that ocular route is not the preferred route for virus transmission and respiratory route was the most preferred route. 38 although it seems, at the ocular manifestations and viral prevalence in conjunctival secretions of patients with covid 19 pak j ophthalmol. 2020, vol. 36 (4): 433-439 438 moment, that there is a low risk of coronavirus spreading through tears, it may survive for a long time or replicate in the conjunctiva, even in the absence of conjunctivitis signs, indicating that eye protection (e.g., protective goggles alone or in association with face shield) is advisable to prevent contamination from external droplets and aerosol. conclusion the current analysis indicate that ocular manifestations are not very common in patients with covid-19. this meta-analysis concludes that conjunctiva is neither a preferred site of infection nor a preferred gateway for entry of sars cov-2 in the body. as a low risk of infection does exist, eye protective equipment should be continued when treating covid-19 patients. conflict of interest none to declare. funding disclosure none to declare. references 1. cucintta d, vanelli m. 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[published online ahead of print, 2020 may 14]. doi: 10.1111/aos.14456. 38. liu z, sun cb. conjunctiva is not a preferred gateway of entry for sars-cov-2 to infect respiratory tract j med virol. 2020; 10.1002/jmv.25859. [published online ahead of print, 2020 apr 10]. doi: 10.1002/jmv.25859. author’s designation and contribution ayisha shakeel; assistant professor: concepts, design, literature research, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review sharjeel sultan; assistant professor: design, literature research, data acquisition, statistical analysis, manuscript preparation syed imtiaz ali; professor: concepts, design, data analysis, manuscript preparation, manuscript review. .…  … https://doi.org/10.1101/2020.03.12.20034678 243 pak j ophthalmol. 2021, vol. 37 (2): 243-246 case report choroidal osteoma in a young female – a case report mehr-un-nisa 1 , usama iqbal 2 , irfan qayyum malik 3 , hira kanwal 4 1-4 department of ophthalmology, gujranwala medical college, gujranwala abstract we present a case of23 year old female, who presented with history of decreased central vision in the right eye for 3 months. best corrected visual acuity was 6/36 od and 6/9 os. anterior segment was normal ou. fundus examination revealed a yellowish white peripapillary lesion extending up to the macula in the right eye. a similar lesion was seen in the left eye. oct macula showed central macular thickness of 193 – 323 µm with cystoid spaces and 290 – 436 µm with serous retinal detachment in the right and left eye respectively. ct scan showed a hyper dense opacity similar to the bony tissue ou. all lab investigations were normal. the patient was diagnosed as a case of bilateral choroidal osteoma. after 6 months no progression or complication was noted. key words: choroid, osteoma, choroidal neoplasm. how to cite this article: nisa m, iqbal u, malik iq, kanwal h. choroidal osteoma in a young female – a case report. pak j ophthalmol. 2021, 37 (2): 243-246. doi: http://doi.org/10.36351/pjo.v37i2.1158 introduction choroidal osteoma is a rare benign tumour that arises in the choroid. it can cause visual loss and is found mostly near the optic nerve head. as choroid is the source of nutrition for retina, replacement by bony structure impedes the blood supply of retina leading to retinal ischemia, retinal atrophy and retinal neovascularisation. 1 it was first described by van dyk at verhoeff society meeting in 1975. 2 the condition is rarely reported, with the largest case series reporting only 61 patients at a major tertiary center in 26 years. 3 choroidal osteoma is unique as it affects otherwise healthy eyes. most of the affected individuals are reported to be young females in the 2 nd or 3 rd decade but it can also affect males and patients as young as 2 correspondence: usama iqbal department of ophthalmology gujranwala medical college, gujranwala email: usamaiqqbal@gmail.com received: november 3, 2020 accepted: january 29, 2021 months and as old as 67 years. 3 morbidities which can complicate a choroidal osteoma are neovascularization, hemorrhage from the neovessels, accumulation of srf, degeneration of overlying rpe, calcification and decalcification and vision loss can be due to rpe degeneration, hemorrhage due to cnvs or macular involvement. 4,5 we report a case of choroidal osteoma presenting to our department with decreased visual acuity. case history a 25 year old lady from a rural area of gujranwala, punjab presented in out-patient department of dhq teaching hospital, gujranwala with complaint of decreased central vision and distorted images in right eye for last three months. there was no significant previous medical and ocular history. her visual acuity was 3/60 in right eye and 6/9 in left eye measured on snellen’s visual acuity chart at the time of presentation and metamorphopsia was noted by the patient on amsler grid. cycloplegic retinoscopy was done and best corrected visual acuity was 6/36 in right eye with -2.00 ds. anterior segment was normal in both eyes. fundus examination of the right eye http://doi.org/10.3352/jeehp.2013.10.3 choroidal osteoma in a young female – a case report pak j ophthalmol. 2021, vol. 37 (2): 243-246 244 revealed a white-yellow peripapillary lesion, extending to macula with sharp round borders and hyperpigmented lesions in the foveal region and periphery. fundoscopy of the left eye revealed a juxtapapillary lesion extending along vascular arcades sparing the macula but with macular puckering. fundus photograph is show in (fig. 1). disc appeared swollen and to rule out any space occupying lesion in the brain, ct scan was done which was normal for brain but a hyper-dense (resembling bone) opacity was noted in both eyeballs more prominent in the right eye (fig. 2). fig. 1: fundus photographs. the patient had no other significant associated ocular symptoms except for mild irritation in both eyes on and off. family history was insignificant for the related symptoms and no systemic complaint was reported. all the systemic investigations were also normal. oct macula of both eyes was done which showed decreased thickness of macula in the centre and increased in the periphery in right eye (190 – 323 µm) with few cystic spaces whereas the left eye showed macular oedema (thickness 290 – 436 µm) and a serous retinal detachment in extrafoveal region. visual fields was done on medmont automated perimeter which showed significant field loss in the right eye whereas central vision was preserved in the left eye which only showed loss of the peripheral field. this can be attributed to the relative macular sparing in the left eye. fig. 2: axial section-ct scan of orbits. b-scan right eye showed minimal echoes in the vitreous cavity and a hype reflective shadow just near the optic disc whereas left eye showed hyper reflective echoes near the optic disc and a dark void behind the lesion causing the characteristic pseudo-optic nerve appearance of a choroidal osteoma (figure 3). ffa showed mottled hyper-fluorescence in the areas of lesion in the choroidal phase and masking of background choroidal vasculature by the bony lesions in both eyes. after all the investigations and imaging modalities, a diagnosis of bilateral choroidal osteoma was made. the patient was called for a follow up visit after 6 months. no change in signs or symptoms were noted. it was planned to follow up the patient annually to see if any visually debilitating complication develops so that timely management can be done when needed. mehr-un-nisa, et al 245 pak j ophthalmol. 2021, vol. 37 (2): 243-246 fig. 3: b scan ultrasound showing choroidal osteoma. discussion choroidal osteoma is a rare tumour and cause is not known. it has been postulated that the lesion is a choristoma of the choroid. it can be an incidental finding because many of the patients are asymptomatic. the patients may present with blurry vision, metamorphopsia or scotomas depending on the location of the tumour and associated complications. vision loss in choroidal osteoma may be gradual or sudden due to retinal pigment epithelium degeneration, cnv or macular involvement by the lesion. 4,5 the case discussed above is even rarer as in 75% of the patients choroidal osteoma is unilateral. 6. our patient had bilateral choroidal osteoma although the symptoms and clinical findings were asymmetrical with the right eye being more severely affected than the left eye. ocular morbidities in choroidal osteoma are due to sensory retinal degeneration and neovascularization, which can be complicated by haemorrhage, cnvm and srf accumulation. the tumour is slow growing and in the largest cohort, tumour growth was noted in 51% of the cases whereas decalcification which hinders further growth was noted in 50% of the total cases at 10 years. 3,6 vision loss over 10 years has been reported up to 20/200 or less in 58% of the cases. 7 treatment options for choroidal osteoma are basically concerned with treatment of cnvs and the associated complications. treatment modalities mentioned in literature include photocoagulation, photodynamic therapy (pdt) and intravitreal anti-vascular endothelial growth factor (vegf) injection alone or in combination with pdt. 8,9,10 all these treatment options have been reported to give promising results in terms of visual acuity improvement in case of extrafoveal lesions. there are limited options for degenerated lesions or lesions involving the macular area. observation is recommended for asymptomatic patients and lesions which are stationary without cnvs or are decalcified. it is also important to differentiate this tumour from similar lesions like amelanotic melanoma of the choroid, choroidal metastases, idiopathic sclerachoroidal calcification, choroidal granuloma etc., so that proper management could be done. in this particular case, no cnvs or visual deterioration were observed over a follow up of 6 months. therefore, no active management was done. the future plan is to observe the patient annually to look for any deterioration of symptoms or growth of cnvs. conclusion choroidal osteoma can be complicated by vision threatening complications. proper assessment of the lesion using different imaging modalities and observation is indicated, so that any complication can be picked up and timely management can be done. conflict of interest authors declared no conflict of interest. references 1. browning dj. choroidal osteoma: observations from a community setting. ophthalmology, 2003; 110: 13271334. 2. gass gd, guerry rk, jack rl, harris g. choroidal osteoma. arch ophthalmol. 1978; 96 (3): 428–435. 3. shields cl, sun h, demirci h, shields ja. factors predictive of tumor growth, tumor decalcification, choroidal neovascularization, and visual outcome in 74 eyes with choroidal osteoma. arch ophthalmol. 2005; 123: 1658-1666. choroidal osteoma in a young female – a case report pak j ophthalmol. 2021, vol. 37 (2): 243-246 246 4. chen j, lee l, gass jd. choroidal osteoma: evidence of progression and decalcification over 20 years. clin exp optom. 2006; 89: 90–94. 5. cherian t, paulose rm, reesha kr. antivascular endothelial growth factor in treatment of choroidal osteoma not associated with choroidal neovascular membrane. kerala j ophthalmol. 2017; 29: 237-239. 6. fine hf, ferrara dc, ho iv, takahashi b, yannuzzi la. bilateral choroidal osteomas with polypoidal choroidal vasculopathy. retinal cases brief rep. 2008; 2: 15–17. 7. singh ad, talbot jf, rundle pa, rennie ig. choroidal neovascularization secondary to choroidal osteoma: successful treatment with photodynamic therapy. eye (lond). 2005; 19: 482-484. 8. ahmadieh h, vafi n. dramatic response of choroidal neovascularization associated with choroidal osteoma to the intravitreal injection of bevacizumab (avastin) graefes arch clin exp ophthalmol. 2007; 245: 1731– 1733. 9. blaise p, duchateau e, comhaire y, rakic jm. improvement of visual acuity after photodynamic therapy for choroidal neovascularization in choroidal osteoma. acta ophthalmol scand. 2005; 83: 515–516. 10. sharma s, sribhargava n, shanmugam mp. choroidal neovascular membrane associated with choroidal osteoma (co) treated with trans-pupillary thermo therapy. indian j ophthalmol. 2004; 52: 329– 330. authors’ designation and contribution mehr-un-nisa; postgraduate resident: literature search, manuscript writing. usama iqbal; postgraduate resident: manuscript writing. irfan qayyum malik; associate professor: supervisor and critical analysis of literature and manuscript. hira kanwal; investigative & ophthalmic technician: imaging and visual field analysis, review. .…  …. department of ophthalmology pak j ophthalmol. 2021, vol. 37 (3): 242-244 242 editorial fungal keratitis; new horizons mahfooz hussain 1 , pablo goldschmidt 2 1-2 department of ophthalmology, lady reading hospital, peshawar fungal keratitis remains most challenging to understand, diagnose and treat for ophthalmologists. terminology of fungus is confusing and adds to the difficulty. current management is still based on traditional diagnosis and limited options of treatment. fortunately, there are newer ways to diagnose and treat fungal keratitis which i call new horizons to look for in fungal keratitis. for an ophthalmologist, fungi should be classified on the basis of microscopic characteristics, which make it easy to understand and remember. on microscopy, fungi can be seen as unicellular yeasts or as multicellular molds which are in the form of filaments/hyphae/mycelium or branches. most common fungi are fusarium and aspergillus (both molds) in developing countries with candida (yeast) as less common while in developed countries candida is more common because of contact lens use. in following classification first three are multicellular molds and fourth one is the unicellular yeast. 1. filamentous septate non pigmented (hyaline): means molds with filaments which have septa and are non-pigmented. fusarium and aspergillus are most common species. 2. filamentous septate pigmented (dematiacious/ phaeoid) means molds with filaments and same as first one except pigmented and now second how to cite this article: hussain m, goldshmidt p. fungal keratitis; new horizons. pak j ophthalmol. 2021, 37 (3): 242-244. doi: 10.36351/pjo.v37i3.1253 correspondence: mahfooz hussain department of ophthalmology lady reading hospital, peshawar email: mahfoozhussain@hotmail.com received: april 18, 2021 accepted: may 27, 2021 common cause of fungal keratitis in developing world. curvalaria and alternaria are most common species 3. filamentous non septate: these are molds with filaments but no septa and most common species is mucor causing mucormycosis. 4. yeast which is unicellular and common species is candida and zygomycetes. diagnosis is based on clinical picture, traditional microscopy, culture and latest technologies with my emphasis on later. 1 these newer techniques are practically possible and not that expensive as normally thought. initial diagnosis of fungal keratitis is mainly clinical. 2 clinically fungal keratitis can have one or more of peculiar features 2 like satellite lesions, infiltrate, feathery or hyphate margins, spikes on surface, elevated edges, rough surface, gritty appearance on scrapping, endothelial or posterior plaque, immobile convex cheesy hypopyon, greyish brown pigmentation, collar button appearance and wessely immune ring. 3 traditionally and most commonly fungi are diagnosed by simple microscopy by using gram, giemsa and koh staining and culture. microscopy can easily differentiate between filamentous septate, filamentous non septate and unicellular yeasts. cultures like sebouraud dextrose agar can be used to grow fungi but it takes many days to grow and keratitis gets worse during this time. one should be careful in taking sample for microscopy and culture, as fungi are usually deep in cornea. superficial exudates should be removed before taking sample. in case of negative results but strong clinical suspicion, corneal biopsy can be taken and sent to laboratory. i am very strong advocate of small ophthalmic laboratory in ophthalmic department for microscopy slides and culture media inoculation at least. confocal microscopy is another way to diagnose fungi. 4 it can differentiate between molds and yeast open access mahfooz hussain 243 pak j ophthalmol. 2021, vol. 37 (3): 242-244 and also can diagnose acanthamoeba but not good for bacteria. other newer techniques 5 like polymerase chain reaction (pcr) 6 , metagenomic deep sequencing (mds) 7 and matrix assisted laser desorption ionization time of flight mass spectrometry (maldi tof ms) 8 can diagnose keratitis in up to 2 hours though these tests do not give drug sensitivity. these techniques not only differentiate between bacteria, fungus and amoeba but can also diagnose exact form of fungus so exact and proper treatment can be started same day. maldi tof and mds are expensive though mdt can identify any organism in sample but pcr is more economical and practical in developing countries. pcr is perhaps most practical and relatively economical test as compared to other new tests. advantages of pcr are handling of small samples, high sensitivity, high specificity and quick results. its particular advantage in ophthalmology is that it amplifies the pathogen. so, even very tiny specimens give positive results; actually, sensitivity is so high that theoretically even single organism can be detected. because of high specificity we can detect exact genotype. speed of test is well known and results can be as quick as 2 hours. pcr is considered expensive but after establishment of service, it is cost effective because of its advantages. it does need welltrained and dedicated staff. at times one may have false positive results because of amplification. in house pcr is more versatile and economical though there is initial high cost. pcr laboratory not only gives quick results to ophthalmologist for keratitis and endophthalmitis but also helps other department to diagnose conditions like meningitis. one can design range of primers of common pathogens and within two hours, diagnosis of exact species of fungus, bacteria, virus or acanthamoeba can be made. treatment was mainly topical drops for long time and even that with limited options. now newer antifungals have added to armory. in addition, ophthalmologists now have other non-surgical and surgical options. two main classes of antifungals are polyenes and azoles. the polyenes are natamycin and amphotecin b while azoles are further divided into amidazoles and trizoles. imidazoles are ketaconazole, and miconazole while trizoles are fluconazoles, voriconazole and posaconazole. other new treatments include antimicrobial peptides (amps), terbinafine, micafungin (mcfg), caspofungin, immunosuppressant like tacrolimus (fk506) and vitamin d receptor agonist (vdra). 9 natamycin works well against molds but only available in topical form and does not penetrate to deeper layers of cornea. voriconazole is effective against both molds and yeast. fluconazole is mainly effective against candida but it is also effective against molds in high concentration. amphoteracin b acts mostly against candida with variable action against molds. fluconazole and voriconazole drops might have been a leap forward but mycotic ulcer treatment trial 1 (mutt 1) showed that even the topical voriconazole was not more effective than topical natamycin. in mycotic ulcer treatment trial 2 (mutt 2) voriconazole was not of any benefit as oral adjuvant to topical therapy. systemic antifungal therapy has limited role in fungal keratitis but intrastromal and intracameral use of antifungals are showing promising results. voriconazole is the most commonly used intrastromal antifungal because of its wide spectrum against molds and yeasts but amphotericin b and fluconazole are equally good if causative is agent is known. doses and techniques of intrastromal and intracameral antifungals can be downloaded from osp app on your mobile phone, which is developed by ophthalmological society of pakistan. corneal cross linking (cxl) was developed for treating corneal ectasia particularly keratoconus. 10 ultraviolet light used in cxl is known for its microbicidal effect and this effect was used to treat microbial keratitis. this was later named as photoactivated chromophore for infectious keratitis – corneal collagen cross linking (pack-cxl). the antimicrobial effect of cxl is because of ultraviolet (uv) light and riboflavin used in procedure. uv light can directly damage dna and rna in microbes including fungi. on other hand, riboflavin can release reactive oxygen species (ros) when activated, which then interacts with cell membranes and nucleic acids of microbe. the combined effect of uv light and riboflavin increases effect 10 folds as compared to uv light alone. in addition, photoactivated collagen fibers become more resistant to enzymatic degradation by microbes. however, pack-cxl has been shown to be more effective for superficial ulcer and more effective for bacterial than fungal keratitis. fungal keratitis; new horizons pak j ophthalmol. 2021, vol. 37 (3): 242-244 244 randomized clinical trials also showed that antimicrobial treatment and pack-cxl had similar results as the antimicrobial treatment alone. however, majority of evidence shows that pack-cxl improves outcome along with antimicrobial treatment. other surgical options are partial keratectomy, amniotic membrane, conjunctival flap and penetrating keratoplasty (pk). pk should be reserved as the last resort as chances of graft infection are very high. in conclusion most common fungi in mycotic keratitis are fusarium and aspergillus in developing countries with candida as less common. clinical diagnosis can be made in 60% cases, which should be confirmed by diagnostic test like pcr being more specific and quicker. new drugs, intrastromal injections, pack-cxl have improved management of fungal keratitis. tertiary care centers should invest in setting up pcr laboratories and cxl facility. conflict of interest authors declared no conflict of interest. references 1. goldschmidt p, degorge s, benallaoua d, semoun o, borsali e, le bouter a, et al. new strategy for rapid diagnosis and characterization of keratomycosis. ophthalmology, 2012; 119: 945–950. 2. mahmoudi s, masoomi a, ahmadikia k, tabatabaei sa, soleimani m, rezaie s, et al. fungal keratitis: an overview of clinical and laboratory aspects. mycoses, 2018; 61: 916–930. 3. dalmon c, porco tc, lietman tm, prajna nv, prajna l. the clinical differentiation of bacterial and fungal keratitis: a photographic survey. investig. ophthalmol. vis. sci. 2012; 53: 1787–1791. 4. chidambaram jd, prajna nv, palepu s, lanjewar s, shah m, elakkiya s, et al. in vivo confocal microscopy cellular features of host and organism in bacterial, fungal, and acanthamoeba keratitis. am j ophthalmol. 2018; 190: 24-33. doi: 10.1016/j.ajo.2018.03.010. 5. kuo mt, chen jl, hsu sl, chen a, youint hl. an omics approach to diagnosing or investigating fungal keratitis j. mol. sci. 2019; 20: 3631. 6. gaudio, pa, gopinathan u, sangwan v, hughes te. polymerase chain reaction based detection of fungi in infected corneas. br j ophthalmol. 2002; 86: 755– 760. 7. ahmed a. analysis of metagenomics next generation sequence data for fungal its barcoding: do you need advance bioinformatics experience? front. microbiol. 2016; 7: 1061. 8. de carolis e, vella a, florio ar, posteraro p, perlin ds, sanguinetti m, et al. use of matrix-assisted laser desorption ionization-time of flight mass spectrometry for caspofungin susceptibility testing of candida and aspergillus species. j clin. microbiol. 2012; 50: 2479–2483. 9. ghosh a, basu s, datta h, chattopadhyay d. evaluation of polymerase chain reaction-based ribosomal dna sequencing technique for the diagnosis of mycotic keratitis. am. j. ophthalmol. 2007; 144: 396–403. 10. erdem e, harbiyeli ii, boral h, ilkit m, yagmur m, ersoz r. corneal collagen cross-linking for the management of mycotic keratitis. mycopathologia. 2018; 183: 521–527. .…  …. 249 pak j ophthalmol. 2021, vol. 37 (3): 249-253 original article optical coherence tomography angiography in retinal vein occlusion: correlation between foveal avascular zone area and visual acuity lubna feroz 1 , najia uzair 2 , mariam shamim 3 , shahab-ul-hassan siddiqui 4 , syed asad mehmood 5 department of ophthalmology, 1-5 layton rehmatullah benevolent trust free eye hospital abstract purpose: to find out correlation between visual acuity and deep capillary plexus (dcp) in foveal avascular zone (faz) area using octa in patients with retinal vein occlusion (rvo). study design: descriptive observational study. place and duration of study: layton rehmatullah benevolent trust free eye hospital, from september 2018 to december 2019. methods: this observational study included 50 eyes of 50 patients, who were treated with intra-vitreal anti-vegf for macular edema secondary to retinal vein occlusion. we excluded patients with macular edema due to other ocular diseases. octa was performed in every patient to measure the size of foveal avascular zone. faz area of 0.6mm 2 or less was taken as normal and any value above that was considered to be larger faz. ibm spss version 25 was used to analyze the data. frequencies with percentages were used to present qualitative variables and mean ± sd were calculated for the quantitative variables. p-value ≤ 0.005 was taken as significant. results: mean age was 58.38 ± 7.51 years. there were 28 males and 22 females. mean best-corrected visual acuity was 0.62 ± 0.26 logmar. the patients with normal faz area in dcp showed a mean bcva of 0.51 ± 0.265 logmar in comparison to those who had larger faz in dcp, where the mean bcva was 0.75 ± 0.204 logmar. dcp was larger in patients with crvo than brvo. conclusion: octa is a good diagnostic tool for qualitative and quantitative evaluation of the deep capillary plexus. improvement in visual acuity is related with the size of the dcp in faz. key words: retinal vein occlusion, foveal avascular zone, optical coherence tomograghy angiography. how to cite this article: feroz l, uzair n, shamim m, siddiqui sh, mehmood sa. optical coherence tomography angiography in retinal vein occlusion: correlation between foveal avascular zone area and visual acuity. pak j ophthalmol. 2021, 37 (3): 249-253. doi: 10.36351/pjo.v37i2.1102 introduction after diabetic retinopathy, retinal vein occlusion is the second most common retinal vascular disorder. the leading cause of decrease vision in patients with correspondence: lubna feroz department of ophthalmology, layton rehmatullah benevolent trust free eye hospital email: lubna_mallick@live.com received: july 18, 2020 revised: april 20, 2021 accepted: may 2, 2021 retinal vein occlusion (rvo) is cystoid macular edema (cme). 1,2 there are many treatment options for macular edema which include intra-vitreal anti-vegf, laser and intra-vitreal steroids. they all have been reported to be effective in reducing macular edema and improving vision. however, intra-vitreal antivegf is found to be superior in treating central macular edema. 3 it has been observed that in many patients there is a poor visual recovery despite complete resolution of macular edema. thus, there is a need to improve our understanding of pathophysiologic mechanism and anatomically correlate the fovea with its physiological function. open access octa in retinal vein occlusion pak j ophthalmol. 2021, vol. 37 (3): 249-253 250 fundus fluorescence angiography (ffa) has been the gold standard in rvo diagnosis for many decades. it cannot be denied that it has certain serious adverse reactions including anaphylactic reactions which may range from skin rash and itching to severe anaphylactic shock. 4 moreover, ffa can evaluate only the superficial layer of the faz while studies support that deep capillary plexus (dcp) correlates more significantly with the visual status of the patient. 5 therefore, there was a search for a non-invasive technique which at the same time achieves noninferior diagnostic accuracy. optical coherence tomography angiography (octa) is a non-invasive diagnostic technique for the evaluation of micro perfusion in both retina andchoroid. 6,7 the spectralis oct-a provides three-dimensional visualization of perfused vasculature of the retina and choroid. it not only analyses the intensity of reflected light but also the temporal changes in the reflection caused by moving particles, such as erythrocytes moving through vessels. such changes are detected by repeatedly capturing images at each point on the retina and allowing for the creation of image contrast between perfused vessels and static surrounding tissues. this technique enables a depth selective view of blood flow in different retinal layers. 8 the spectralis oct-a divides the retinal image into different slabs on the basis of capillary plexus which are superficial capillary plexus, intermediate and deep capillary and avascular layer. thus, octa can be utilized to assess the deeper layer capillaries around fovea instead of only superficial plexus as in ffa. 9,10 most important vascular changes occur in the dcp, and decreased perfusion and dcp ischemia have significant role in poor visual status. therefore, the aim of this study was to assess the correlation between visual acuity and deep capillary plexus in the faz using octa in rvo patients. methods this observational study included 50 eyes of 50 patients, who were treated with intra-vitreal antivegf for macular edema secondary to retinal vein occlusion. patients with more than eighteen years of age were enrolled using non-probability consecutive sampling technique. subject recruitment started from 1 st september 2018 to 31 st december 2019. the hospital ethics committee approval was taken prior to the commencement of this study. we excluded patients with macular edema due to other ocular diseases (such as diabetic retinopathy, and stage 4 hypertensive retinopathy, diagnosed with fundoscopic examination and sd-oct); those with history of ocular surgery, laser treatment for macular edema, age-related macular degeneration, epiretinal membrane, vitreous hemorrhage, and uveitis; and those with complications of high myopia or with significant media opacities. we also excluded data from those with poor quality images (defined as scan quality < 6/10 or presence of significant artifacts). rvo diagnoses were based on medical and ophthalmic history and complete ophthalmic examination including best corrected visual acuity (bcva)using a snellen chart which was converted to logarithm of the minimal angle of resolution (logmar) unit, slit-lamp biomicroscopic and fundus examinations.in our study, visual acuity equal to or better than 6\24was considered good. spectral domain optical coherence tomography (spectralis, heidelberg engineering) was used to confirm macular edema. octa was performed in every patient to measure the size of foveal avascular zone. written informed consent was taken from the patients who fulfilled the criteria for the study. we evaluated 3×3mm oct angiograms for the measurement of faz (mm 2 ) in the dcp (automated segmentation selecting area between inner plexiform layer and outer plexiform layer) by two trained independent graders. faz area of 0.6mm 2 or less was taken as normal and any value above it was considered to be larger faz. 11 the scans with poor image quality were repeated and the ones with persistent low-quality images were excluded. ibm spss version 25was used to analyze the data. frequencies with percentages were used to present qualitative variables and mean ± sd were calculated for the quantitative variables. visual status was stratified with respect to foveal avascular zone. independent t-test was applied to determine the significance of difference in bcva with respect to deep capillary plexus in faz. p-value ≤ 0.005 was taken as significant. results there were 50 eyes of 50 patients with resolved macular edema. they underwent octa to measure deep capillary plexus in faz. among 50 eyes there were 17 crvo and 33 brvo. the mean age was 58.38 ± 7.51 years. out of them, 28 were males and 22 females. the patients presented with mean bestlubna feroz, et al 251 pak j ophthalmol. 2021, vol. 37 (3): 249-253 corrected visual acuity of 0.62 ± 0.26 logmar. dcp was evaluated using oct-a manually by two independent observers. it was observed that patients with good bcva had normal faz area as compared to those who had poor bcva (shown in table 1). it was also found that the patients with normal faz area in dcp showed a mean bcva of 0.51±0.265 logmar (equal to 6/19 snellen notation) in comparison to those who had increase faz in dcp, where the mean bcva was 0.75 ± 0.204 logmar (equal to 6/30 snellen notation). independent t test was applied and the difference in bcva was found to be statistically significant (p-value = 0.001), shown in table 2. it was also seen that dcp was larger in patients with crvo than brvo. table 1: correlation between faz and bcva. bcva correlated with faz area faz area total ≤ 0.60 > 0.60 bcva 6\6p 2 0 2 6\9p 2 0 2 6\12 3 1 4 6\12p 7 0 7 6\18 2 4 6 6\24 3 3 6 6\24p 1 5 6 6\36 2 1 3 6\36p 2 5 7 6\60 2 5 7 total 26 24 50 table 2: difference in bcva. difference in bcva with respect to faz faz n mean std. deviation std. error mean bcva ≤ 0.60 26 .508 .2652 .0520 > 0.60 24 .746 .2043 .0417 discussion we investigated the patients of retinal vein occlusions with resolved macular edema and measured their deep capillary plexus in faz and correlated it with their best corrected visual acuity. we found that those patients who had poor visual acuity despite completely resolved macular edema, actually had larger faz in deep capillary plexus. the results of our study are supported by manuel et al., and others who reported a reduction in vascular densities in both the superficial capillary plexus (scp) and dcp, correlating faz areas and visual acuities. 12,13,14 this is explained by the ischemia in the deep capillary plexus area which has resulted in increase in size of faz. 15 thus, causing decline in the visual status of the patient.moreover, it was also observed that the patients with crvo had larger faz than in brvo. it is because of the fact that ischemia is more pronounced in crvo than brvo. 16 in this study, we found that oct-a is a valuable tool in investigating the foveal avascular zone, where it is a quick and non-invasive technique. moreover, it does not require any pre-requisite as in ffa and is capable of evaluating the deeper layer of capillaries in comparison to ffa. 17,18 in another study it was seen that faz was irregular and larger in sizein eyes with brvo after cme was resolved. 19 our study has several limitations. firstly, it was an observational study and the patients were evaluated at different time after the diagnosis and treatment of rvo. number of injections were not considered. furthermore, projection artifacts were commonly encountered, although these were tackled by means of post processing system incorporated in spectralis octa. 20 finally, the small scan window (3x3 mm) allows accurate evaluation of the central macula but visualization of more peripheral fundus changes is hampered. nevertheless, our study has the major advantage of the quantitative analysis of angiographic data using octa, which has been shown to be reliable. in summary, we have shown that an enlarged faz area is correlated significantly with poorer visual outcomes. optical coherence tomography–a can supply additional information in the evaluation of patients with rvo and can help us predict patient’s long-term visual prognosis. conclusion octa is a good diagnostic tool which enables qualitative and quantitative evaluation of the deep capillary plexus during the follow-up of patients treated for rvo. improvement in visual acuity is related with the size of the dcp in faz. ethical approval the study was approved by the institutional review board/ethical review board. (lrbt/tteh/erc/2722/07) conflict of interest authors declared no conflict of interest. octa in retinal vein occlusion pak j ophthalmol. 2021, vol. 37 (3): 249-253 252 references 1. glanville j, patterson j, mccool r, ferreira a, gairy k, pearce i. efficacy and safety of widely used treatments for macular oedema secondary to retinal vein occlusion: a systematic review. bmc ophthalmol. 2014; 14 (1): 7. 2. ons j, pfau m, wirth m, freiberg f, becker m, michels s. optical coherence tomography angiography of the foveal avascular zone in retinal vein occlusion. ophthalmologica. 2016; 235 (4): 195– 202. doi:10.1159/000445482 3. campochiaro a, heier s, feiner l. ranibizumab for macular edema following branch retinal vein occlusion: six month primary end point results of a phase iii study. ophthalmology, 2010; 117: 1102–1112. 4. la mantia a, kurt ra, mejor s, egan ca, tufail a, keane pa, et al. comparing fundus fluorescein angiography and swept-source optical coherence tomography angiography in the evaluation of diabetic macular perfusion. retina, 2018. doi:10.1097/iae.0000000000002045. 5. ciloglu e, dogan n. optical coherence tomography angiography findings in patients with branch retinal vein occlusion treated with anti-vegf. arq bras oftalmol. 2020; 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161: 160–171. 15. farinha c, marques jp, almeida e, baltar a, santos ar, melo p, et al. treatment of retinal vein occlusion with ranibizumab in clinical practice: longer term results and predictive factors of functional outcome. ophthalmic res. 2015; 55: 10–18. 16. seknazi d, coscas f, sellam a, rouimi f, coscas g, souied e, et al. optical coherence tomography angiography in retinal vein occlusion. correlations between macular vascular density, visual acuity, and peripheral non-perfusion area on fluorescein angiography. retina, 2018; 38: 1562–1570. 17. díez-sotelo m, díaz m, abraldes m, gómez-ulla f, penedo mand, ortega m. a novel automatic method to estimate visual acuity and analyze the retinal vasculature in retinal vein occlusion using swept source optical coherence tomography angiography. j. clin. med. 2019; 8: 1515. doi:10.3390/jcm8101515. 18. corvi f, pellegrini m, erba s, cozzi m, staurenghi g, giani a. reproducibility of vessel density, fractal dimension, and foveal avascular zone using 7 different optical coherence tomography angiography devices. am j ophthalmol. 2018; 186: 25-31. https://doi.org/10.1016/j.ajo.2017.11.011 19. brar m, sharma m, grewal sps, grewal ds. quantification of retinal microvasculature and neurodegeneration changes in branch retinal vein occlusion after resolution of cystoid macular edema on optical coherence tomography angiography. indian j ophthalmol. 2019; 67 (11): 1864-1869. doi: 10.4103/ijo.ijo_1554_18. 20. samara wa, shahlaee a, sridhar j, khan ma, ho ac, hsu j. quantitative optical coherence tomography angiography features and visual function in eyes with branch retinal vein occlusion, am j ophthalmol. 2016; 166: 76-83. doi: 10.1016/j.ajo.2016.03.033. https://doi.org/10.1016/j.ajo.2017.11.011 lubna feroz, et al 253 pak j ophthalmol. 2021, vol. 37 (3): 249-253 authors’ designation and contribution lubna feroz; consultant ophthalmologist: concepts, literature search, manuscript preparation. najia uzair; consultant ophthalmologist: design, data acquisition, review. mariam shamim; consultant ophthalmologist: data analysis, manuscript review. shahab ul hassan siddiqui; senior consultant ophthalmologist: data analysis, statistical analysis, manuscript review. syed asad mehmood; consultant ophthalmologist: manuscript editing, manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (3): 262-268 262 original article evaluation of the effect of suprachoroidal triamcinolone injection on refractory diabetic macular edema tehmina jahangir 1 , sidrah riaz 2 , arooj amjad 3 1,3 ameer-ud-din medical college pgmi lahore general hospital, 2 akhtar seed medical and dental college, lahore abstract purpose: to assess the safety and efficacy of supra choroidal triamcinolone injection (sct) in cases of refractory diabetic macular oedema. study design: interventional case series. place and duration of study: lahore general hospital, lahore, from july to december 2019. methods: a total of 22 eyes of patients above 18 years of age, with either type-1 or type-2 diabetes mellitus and treatment resistant central diabetic macular edema (dme) of 320 um or more (measured on zeiss cirrus hd-oct) and best corrected visual acuity (bcva) of less than or equal to 20/40 were included in the study. bcva, intra ocular pressure (iop) and central subfield thickness (cst) was recorded. after supra-choroidal triamcinolone (scta), patients were followed up at one and three months and same clinical parameters were recorded and the results were analysed. results: out of 22 patients, 10 (45.45%) were males and 12 (54.54%) were females. mean pre injection cst was 615.5 ± 200.28 um and log mar bcva was 0.9 ± 0.20. mean post injection cst at one and three months was 302.45 ± 52.45 and 301.66 ± 55.82 um. mean post injection log mar bcva at one and three months was 0.52 ± 0.3 and 0.40 ± 0.22. the results were statistically significant for pre and post injection cst at both one and three months (p-value < 0.00001). pre and post injection bcva was also statistically significant (p-value < 0.05). conclusion: cst is a safe and effective means to reduce refractory diabetic macular edema and improve oct macular thickness. key words: diabetic macular edema, suprachoroidal triamcinolone, central sub-field thickness. how to cite this article: jahangir t, riaz s, amjad a. evaluation of the effect of suprachoroidal triamcinolone injection on refractory diabetic macular edema. pak j ophthalmol. 2021, 37 (3): 262-268. doi: 10.36351/pjo.v37i3.1171 introduction diabetic macular edema (dme) results from hyperglycemia induced breakdown of the blood-retina correspondence: tehmina jahangir ameer-ud-din medical college pgmi lahore general hospital, lahore email: tehminajahangir@gmail.com received: september 24, 2020 accepted: march 05, 2021 barrier, which leads to fluid extravasation from the retinal vessels into the surrounding neural retina. a diagnosis of dme is made when retinal thickening that involves the macula is present. central subfieldinvolved dme that affects the fovea is a common cause of vision loss in diabetic patients. in contrast, non-center-involving dme is unlikely to affect vision unless it progresses to center involvement. dme can be present in any severity level of diabetic retinopathy. current algorithms for pharmacologic intervention in dme use a simple, oct based classification to open access tehmina jahangir, et al 263 pak j ophthalmol. 2021, vol. 37 (3): 262-268 classify dme as center-involved or non-center involved. in center-involved dme, the central retinal subfield appears thickened on oct scans. dme that does not affect the central subfield is termed noncenter-involved. 1 anti-vegf drugs are now the first-line therapy for most eyes with center-involved dme, especially those with vision impairment caused by dme. commonly used anti vegf agents are eylea® (bayer, leverkusen, germany), lucentis® (novartis, basel, switzerland) and avastin® (genentech inc., san francisco, ca, usa). 2 despite their approval by food and drug administration (fda), not all patients are responsive to this therapy. 3,4 corticosteroids are also useful as alternative agents for eyes that are not candidates for anti-vegf therapy or that were incompletely responsive to previous anti-vegf treatment. 5 for a long time, intravitreal triamcinolone acetonide (ivta) has been an alternative drug for cases not responsive to anti vegf agents; or wherecompliance has been an issue. although, ivta has very good effect in reversing macular edema and re-establishing the compromised blood retinal barrier; its use has been plagued by certain non-desirable effects. most notable among them is the need for repeated injections due to the waning effect of ivta and rebound macular edema. its use also leads toelevated intraocular pressure (iop) and cataract formation. 6 the use of locally given steroids has proven their efficacy in certain clinical situations asfirst line treatment. dme with pseudophakia responds equally well to steroids and ranibizumab as illustrated by protocol i of diabetic retinopathy clinical research network (drcr.net). 7 however, it showed clinically significant rise of iop in patients receiving ivta. 7 recently, the interest in steroids has increased as the researchers have come up with novel ways of delivering steroids in the eye. the most notable of these are ozurdex® and iluvein®. ozurdex® (allergan, inc., irvine, usa) is a dexamethasone implant designed to stay in vitreous cavity for six months and then biodegrade. it slowly releases the steroid invitreous cavity. it had been approved by fda and in most european countries for use in patients with dme. use of ozurdex® is also associated with increase in iop and it has been documented by many researchers. 8 cost and availability are other important issues that limit its use in pakistan. corticosteroids injected into the suprachoroidal space may achieve therapeutic levels in the retina while decreasing the same in the anterior part of the globe. this has the potential to provide efficacy for the treatment of posterior segment pathologies while minimising the risk of intraocular pressure elevation and cataract acceleration associated with intravitreal corticosteroid injection. 9,10 the rationale of this study was to see the safety and efficacy of supra-choroidal route of triamcinolone acetonide in patients with treatment resistant diabetic macular edema. methods this was a prospective interventional case series conducted in the vitreoretinal department of lahore general hospital, lahore from july 2019 to december 2019.this study was approved by ethical committee of the hospital. informed consent was taken from all the participants. a total of 22 patients were included in this study. the selection of patients was by convenient sampling. all the patients included in this study were 18 years or more ofage, having type-1 or type-2 diabetes mellitus. they had treatment resistant central diabetic macular edema (dme) of 320 um or more (zeiss cirrus hd-oct) with best corrected visual acuity (bcva) of less than or equal to 20/40. patient with macular edema secondary to any other cause, iop of more than 21 mmhg, history of previousintraocular surgery or treatment naïve patientsof dme, uveitis, ocular hypertension, cataractand macular ischemia (documented on fundusfluorescein angiography) were excluded. patientswho had history of periocular or intravitrealtriamcinolone acetonide treatment within the last6 months and/or prior anti-vegf treatment within 90 days were also excluded. treatment resistance was defined as dmefailing to respond to three anti vegf injections (any type) spaced at one month apart. failureto respond was decided on bcva and/or central subfield thickness (cst) on spectral domain optical coherence tomography (zeiss cirrus hd-oct). at one month after the third anti-vegf, if bcva did not improve by 5 letters onearly treatment diabetic retinopathy study (etdrs) chart or the cst did not decrease by 50 um or 10% from baseline, then the case waslabelled as resistant dme. at the timeof initial assessment, all participants underwentcomplete ocular examination that included, iopmeasurement (applanation method) effect of suprachoroidal triamcinolone injection on refractory diabetic macular edema pak j ophthalmol. 2021, vol. 37 (3): 262-268 264 and anterior/posterior segment examination. the patients were followed for three months after injection and their follow up visits were scheduled at oneweek, one month and three months after injection. at each follow-up visit, bcva, iop and cst wasrecorded for final data analysis. the primary efficacy end points were change in bcva and cst from the baseline at the end of three months. data was analyzed using spss 20.0. we used paired t-test and wilcoxon signed-ranked test astest of significance for normally distributed and skewed continuous data respectively. a p-valueof 0.05 was taken as statistically significant. a total of 22 eyes of 22 patients were included. baseline best corrected visual acuity (bcva), intra ocular pressure (iop) and central subfield thickness (cst) were recorded. after scta, patient was followed-up at one and three months and same clinical parameters were recorded again and results were analysed. we used an improvised technique for scta injection with 30 gauge1cc insulin syringe (bd insulin syringe with bd ultrafine needle; becton, dickinson and company, nj, usa). other dispensable included 24 gauge intravenous branula and injection triamcinolone acetonide (ta) 40 mg/ml (kenakort a by glaxo smith kline brentford, middlesex, tw89gs, united kingdom). all patients were dilated before scta and indirect ophthalmoscope was placed at hand to examine fundus after injection. needle was withdrawn from branula and branula was cut in such a way that only 1000 um of insulin syringe was exposed from the edge of branula. ta was filled in the syringe up-to the mark of 0.1 ml. the eye was painted with 10% povidone iodine solution and 5% of this solution was instilled infornices and left there for 30 seconds. the eye was draped in a manner similar to any intraocular procedure. we marked 3.5mm from the limbusin suprotemporal quadrant. after marking, 4 mg of triamcinolone acetonide (0.1 ml) was injected in suprachoroidal space by inserting the needle perpendicular to sclera and bevel pointing backwards at the distance of 3.5 mm from limbus inthe said quadrant. needle was slowly withdrawn and cotton tipped applicator was applied at the site of injection to ensure minimal reflux. immediately after this, indirect ophthalmoscopy was performed to ensure patency of central retinal artery and to document any spillage of drug invitreous cavity. in case, central retinal artery was found to be occluded, then anterior chamber paracentesis was performed with 15 degrees’ phacoemulsification incision knife. after the procedure, a single drop of routinely used antibiotic was instilled in the eye. results a total of 22 eyes of 22 patients were enrolled in this study. out of 22 patients, 10(45.45%) were males and 12(54.54%) were females. mean ageof the patients was 53.2917 ± 6.24 years. mean number of previous injections received were 5.95. maximum injections received by a patient was 11 and minimum were four. mean pre injection cst was 615.5 ± 200.28 um. mean post injection cst at one and three months was 302.45 ± 52.45 and 301.66 ± 55.82 um. there was statistically significant difference between pre and one-month post injection cst with p-value of < 0.00001. at three months’ postinjection, the difference between pre and post injection cst was maintained with p-value of < 0.00001.mean pre injection and post injection (at one and 3 months) cst is shown in fig.1. mean pre-injection log mar bcva was 0.9 ± 0.20. mean post injection log mar bcva at one and three months was 0.52 ± 0.3 and 0.40 ± 0.22. the results were statistically significant for pre and post injection cst at both one and three months (p-value < 0.00001). pre and post-injection bcva was also statistically significant (p-value < 0.05). mean pre injection and post injection bcva (at 1 and 3 months) is shown in fig.2. mean pre injection iop was 14.25± 3.13 mmhg. intraocular pressure at one and three months after injection was 14.87 ± 3.41 mmhg and 14.52 ± 3.12 mmhg respectively. the result of bcva at three months was also statistically significant (p-value < 0.05) from the baseline. there was no difference between pre injection and post injection (one and three months) iop when measured individually. p-value at one month was 0.131 and at three months was 0.711.we did not encounter any complication or unwanted sequel in our limited follow-up period. tehmina jahangir, et al 265 pak j ophthalmol. 2021, vol. 37 (3): 262-268 fig. 3: pre and post scta injection sd-octs showing marked reduction in central subfield thickness. fig. 4: pre and post-scta injection sd-octs showing marked reduction in central subfield thickness. discussion although intravitreal anti-vegf agents have been very useful for the treatment of diabetic macular edema (dme) but it does not eliminate edema in all patients suggesting that mechanisms other than vegf are at play in the pathogenesis of dme. studies have shown that the average number of anti-vegf injections required for resolution of dme in a single effect of suprachoroidal triamcinolone injection on refractory diabetic macular edema pak j ophthalmol. 2021, vol. 37 (3): 262-268 266 patient ranged from 9 to 11 in the first year to 17 over five years. 11,12 there has been considerable success in treating both refractory and naive dme with ozurdex. 13 however, its use has also been plagued with a considerable rise in intraocular pressure (iop). 14,15 the efficacy of ivta in treating dme is well proven over the last several years. however, repeated studies have shown very high occurrence of cataract formation and increased iop over time.this is especially true when multiple serial injections are used to control chronic dme. 16 delivery of corticosteroids to the suprachoroidal space has a therapeutic effect similar to that of intravitreal delivery. however, suprachoroidal delivery is associated with extended half-life and less incidence of iop rise. the drug has a very low anterior chamber presence as opposed to the intravitreal route. 17,18 very recently, the hulk trial; n = 20 was carried out which assessed the safety and efficacy of scta for dme in treatment naïve and previously treated eyes. 18 in the hulk trial’s previously treated group, the mean number of injections was 21.6 whereas in our study this figure was 7.4. there are certain key differences between our study and the hulk trial. we did not include treatment naïve patients. we also did not combine the first injection of scta with aflibercept. the mean pre-treatment cst in the previously treated arm of the hulk trial was 473 microns whereas in our study it was 615.5 ± 200.28 um. at 6 months, the mean cst in hulk reduced to 369 um whereas in our study the mean cst at 3 months was 301.66 ± 55.82 um. the initial cst in our study was more than the hulk trial, the cmt achieved at the end of the follow-up period in our study was less than the hulk trial. we did not reinject scta in any of our patients as opposed to the hulk trial in which they re-injected scta when needed. after a 3-month follow-up, a mean increase of 7 letters from the baseline was reported in the hulk study while our study revealed a mean increase of 11 letters from the baseline. this is probably because the initial bcva in our study was worse than the hulk trial. the mean iop was 13.8 mmhg at baseline and it was 14.2 mmhg at 6 months of hulk trial. the hulk trial reported two cases where iop was raised and required topical anti-glaucoma treatment. in a similar study, no case of raised iop was detected. 19 hulk report one incidence of inadvertent intravitreal spillage of triamcinolone where as we had no such incidence. overall, the efficacy and safety of scta are very much comparable in both the studies despite some differences in patient selection and follow-up duration. in the dogwood trial scta was used for posterior uveitis of non-infectious etiology; there was sustained reduction in terms of central subfield thickness and improvement in bcva. 20,21 other studies like peachtree have been conducted to assess the efficacy and safety of scta with favourable outcomes. 22 the suprachoroidal mode of triamcinolone delivery has also been used in cases of macular edema secondary to retinal vascular occlusion (rvo) and posterior uveitis. in the tanzanite study, intravitreal aflibercept efficacy was compared with that of scta in cases of macular edema secondary to retinal venous occlusion. the results have been very encouraging in terms of improved visual outcomes with reduced number of injections hence sustained edema resolution. 23 there is a local study conducted by haroon et al with favourable visual oct outcomes. 24 the main advantage of using the suprachoroidal space for delivery of drugs is that it leads to a more posterior distribution with higher concentrations available for the retina, choroid and retinal pigment epithelium with simultaneous lesser exposure to the structures in the anterior segment. 25 this in turn reduces the side effects of triamcinolone in anterior segment like cataract formation and raised iop.this has been shown in similar studies like hulk, dogwood and tanzanite studies. limitation of this study include a small sample size and lack of a control group. there was short duration of follow-up. however, this novel route of drug administration appears to be effective and safe for pathologies other than diabetic macular edema. however, cautions and controlled use is recommended, that too in carefully selected cases. it is imperative that surgeon is comfortable with the use of this injection technique before venturing on its widespread use. conclusion there was anatomical as well as functional improvement following a single injection of triamcinolone acetonide (ta). sct is a safe and tehmina jahangir, et al 267 pak j ophthalmol. 2021, vol. 37 (3): 262-268 effective means to reduce refractory diabetic macular edema and improve oct macular thickness. ethical approval the study was approved by the institutional review board/ethical review board. (amc/pgmi/lgh/00/06/2021) conflict of interest authors declared no conflict of interest. references 1. browning dj, stewart mw, lee c. diabetic macular edema: evidence-based management. indian j ophthalmol. 2018; 66 (12): 1736-1750. doi:10.4103/ijo.ijo_1240_18 2. schmidt-erfurth u, garcia-arumi j, bandello f, berg k, chakravarthy u, gerendas bs, et al. guidelines for the management of diabetic macular edema by the european society of retina specialists (euretina). ophthalmologica. 2017; 237 (4): 185222. doi: 10.1159/000458539 3. blinder kj, dugel pu, chen s, jumper jm, walt jg, hollander da, et al. anti-vegf treatment of diabetic macular edema in clinical practice: effectiveness and patterns of use (echo study report 1). clin ophthalmol. 2017; 11: 393-401. doi: 10.2147/opth.s128509 4. he y, ren xj, hu bj, lam wc, li xr. a metaanalysis of the effect of a dexamethasone intravitreal implant versus intravitreal anti-vascular endothelial growth factor treatment for diabetic macular edema. 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slow and sustained drugrelease for retina drug delivery. expert opin drug deliv. 2019; 16 (7): 679-686. doi: 10.1080/17425247.2019.1618829 21. shatz w, aaronson j, yohe s, kelley rf, kalia yn. strategies for modifying drug residence time and ocular bioavailability to decrease treatment frequency for back of the eye diseases. expert opin drug deliv. 2019; 16 (1): 43-57. doi: 10.1080/17425247.2019.1553953 22. clearside biomedical. suprachoroidal injection of clsta in subjects with macular edema associated with non-infectious uveitis (peachtree). nlm identifier: nct02595398. available from: https://clinicaltrials.gov/ct2/show/nct02595398 (accessed may 25, 2017). 23. campochiaro pa, wykoff cc, brown dm, boyer ds, barakat m, tanzanite study group, et al. suprachoroidal triamcinolone acetonide for retinal vein occlusion: results of the tanzanite study. ophthalmol retina, 2018; 2 (4): 320-328. doi: 10.1016/j.oret.2017.07.013 24. tayyab h, ahmed cn, sadiq caa. efficacy and safety of suprachoroidal triamcinolone in cases of resistant diabetic macular edema. pak j med sci. 2020; 36 (2): 25. patel sr, prausnitz mr. targeted drug delivery within the eye through the suprachoroidal space. j ocul pharmacol ther. 2016; 32 (10): 640-641. doi:10.1089/jop.2016.0158 authors’ designation and contribution tehmina jahangir; professor: concepts, design, data acquisition, data analysis, manuscript preparation. sidrah riaz; associate professor: concepts, design, manuscript review, arooj amjad; assistant professor: data acquisition, manuscript preparation. .…  …. 423 pak j ophthalmol. 2020, vol. 36 (4): 423-427 original article surgical outcomes of combined phacoemulsification and silicone oil removal in post retinal detachment surgery patients uzma haseeb 1 , muhammad haseeb 2 , aziz-ur-rehman 3 1-3 department of ophthalmology, al ibrahim eye hospital, karachi, 2 al-ain institute of eye diseases, karachi abstract purpose: to evaluate the surgical outcomes of combined phacoemulsification with iol implantation and silicone oil removal in patients with previous retinal detachment surgery. study design: interventional case series. place and duration of study: al-ibrahim eye hospital karachi from january 2019 to december 2019. methods: patients who had previous retinal detachment surgery with silicone oil used as an internal tamponade with post-operative cataract formation and attached retina confirmed by indirect ophthalmoscopic examination or b scan depending on media clarity were included in the study. the time interval between the two surgeries was 8 to 10 months. phacoemulsification with iol implantation was done followed by silicone oil removal using 23gauge pars plana method. post-operative follow-ups were done at day 1, 1 month and at 6 months to record visual acuity and retinal status. results: thirty eyes of 30 patients between ages of 25 to 65 years were included in the study best corrected visual acuity was recorded pre and post-operatively using snellen chart. pre-operatively visual acuity was 6/60 in 12 patients, 6/95 in 12 patients and 6/120 in 6 patients. there was improvement of 2 lines of visual acuity post operatively as recorded by snellen chart. retina was attached in 28 (93.33%) patients while 2 (6.66%) patients had re-detached retina at the end of 6 months. conclusion: combined phacoemulsification with silicone oil removal is a useful method that is associated with good visual and anatomical outcomes and it eliminates the need for third surgery for cataract extraction. key words: retinal detachment, phacoemulsification, silicon oil. how to cite this article: haseeb u, haseeb m, rehman a. surgical outcomes of combined phacoemulsification and silicone oil removal in post retinal detachment surgery patients. pak j ophthalmol. 2020; 36 (4): 423-427. doi: https://doi.org/10.36351/pjo.v36i4.1116 introduction proliferative vitreoretinopathy (pvr) is one of the complications of rhegmatogeneous retinal detachment. correspondence: uzma haseeb department of ophthalmology al-ibrahim eye hospital, karachi email: uzma_123us@yahoo.com received: august 5, 2020 accepted: september 5, 2020 silicone oil is used as an internal tamponade to reduce the rate of retinal re-detachment (rrd). in complicated cases of retinal detachment such as in giant retinal tears, trauma, proliferative vitreoretinopathy (pvr), and diabetic tractional retinal detachment silicone oil is used as an effective tamponade. silicone oil gives better view for retinal examination while it is impossible if gas or air is used as tamponade in eye. after silicone oil removal the incidence of retinal re-detachment (rrd) vary widely from 6% to 28%. phacoemulsification and silicone oil removal in post retinal detachment surgery patients pak j ophthalmol. 2020, vol. 36 (4): 423-427 424 one of most important risk factor for retinal redetachment is previously unsuccessful surgery. 1 most common complication that can occur after cataract surgery including phacoemulsification is retinal detachment (rd). although with each passing day new advances had been introduced in vitreoretinal surgery but still rd can cause severe visual loss and thus leads to blindness. after phacoemulsification the risk of rd is 0.32% to 1.17%. 2 in general population the incidence of rrd is between 0.01% and 0.02% and is more common in males. around the sixth decade of life the incidence of rrd is at its peak and right eye is more affected then left eye. 3 risk of rrd differs with ethnicity, it is tenfold more in caucasians than african populations. 4 in asian population the incidence is variable but more in young age group. east asians are at same risk as caucasians 5 but risk of rrd is lower in south asians, which is threefold less than caucasians. common risk factors associated with rrd are myopia, fellow eye rrd, trauma and proliferative diabetic retinopathy. previously nd: yag laser capsulotomy was considered as one of risk factor for rrd but this has been questioned recently and is under debate. 6 posterior vitreous detachment (pvd) associated with retinal tear or break can lead to rd in 80 – 90% of cases. around 60 to 70 years of age there is increased liquefaction of vitreous gel, which is natural and age related process and can lead to pvd. at the time of cataract surgery complete pvd without rd is considered beneficial because it gives protection against rd. 7 in posterior segment surgery silicone oil (so) is used as an endo tamponade to flatten retina and to maintain intraocular pressure (iop). however, silicone oil emulsification, secondary glaucoma, cataract, and corneal degeneration are vision threatening complications of so. that is why it is preferred to remove so from eye after its tamponading effects are no more required. silicone oil when comes in contact with lens leads to formation of posterior sub capsular cataracts, mostly 6 – 12 months after surgery. after development of secondary cataract in so filled eye combination surgery including cataract extraction with removal of so is advisable. 8 this study was designed to evaluate the rate of retinal re-detachment and visual outcomes after combined phacoemulsification and iol implantation and silicone oil removal in patients who had previously undergone retinal detachment surgery. methods this was an interventional case series with nonprobability convenience sampling technique. study was carried out at al-ibrahim eye hospital, karachi from january 2019 to december 2019. a prior ethical approval was taken from the institutional review board of isra postgraduate institute of ophthalmology, alibrahim eye hospital, karachi. informed written consent was taken from all the study participants. patients who had previous retinal detachment surgery with silicone oil used as an internal tamponade with post-operative cataract formation and attached retina confirmed by indirect ophthalmoscopic examination or b scan depending on media clarity were included in the study. indications of retinal detachment surgery with use of so in these patients were rhegmatogeneous retinal detachment (rd) 13 (43.33%) patients, tractional rd 13 (43.33%) patients and combined tractional + rhegmatogeneous rd 4 (13.33%) patients. patients’ age was 25 years or above with no discrimination of gender. exclusion criteria were retinal detachment surgery with tamponading agents other than silicone oil, other ocular pathology, aphakia, pseudophakic eyes, and post traumatic eyes with retinal detachment. a well trained vitreoretinal surgeon performed all the surgeries to reduce chances of bias. phacoemulsification with iol implantation was done first, followed by removal of silicone oil through 23 g pars plana technique. fluid-air exchange was done at least two times. follow-up of all patients was planned at first day of surgery then first month, and sixth month after surgery. at each follow-up best-corrected visual acuity, slit lamp 90 d fundus examination, intra ocular pressure and anatomical retinal attachment were assessed. if retina was completely attached at last follow-up (6 months), it was considered as anatomically attached retina. if ongoing (pvr) proliferative vitreoretinopathy or the contractions of the retina leading to rd within six months of so removal was detected, it was considered as anatomically detached retina meaning failed surgery. statistical package for social sciences (spss) version 23.0 was used for statistical analysis. quantitative variables like age, duration between two surgeries, and intraocular pressure were presented as mean ± sd. the data for gender, reason for previous surgery, tamponade, visual acuity (pre-operative and at uzma haseeb, et al 425 pak j ophthalmol. 2020, vol. 36 (4): 423-427 6 month follow-up) and state of retina were described by frequency and percentages. results in this study total 30 patients are recruited. mean age of patients was 52.35 ± 9.8 with minimum age of 25 and maximum age of 65 years. there were 20 (66.66%) male and 10 (33.33%) female patients. visual acuity was recorded pre-operatively and postoperatively by snellen chart. for details see table 1. table 1: pre-operative visual acuity no of patients (%) post op visual acuity at 6 month 6/60 12 (40%) all 12 patients improved to va = 6/38 6/95 12 (40%) 6 patients improved to va = 6/75 6 patients improved to va = 6/60 6/120 6 (20%) 3 patients improved to va = 6/75 3 patients improved to va = 6/60 status of retina was also assessed at the end of 6 months. twenty-eight (93.33%) patients had attached retina while 2 (6.66%) of them presented with retinal re-detachment (graph 1). fig. 1: status of retinal at follow-up. discussion in complicated cases of rd three port pars plana vitrectomy with silicone oil as internal tamponade is extensively used to flatten retina. most frequent long term ocular complications of so are cataract, glaucoma and band keratopathy. 9 the longer the duration of so in the eye the higher will be the chances of development of cataract and glaucoma. 10 in some cases, even very short duration of intraocular silicone oil tamponade can cause cataract formation. 11 the mechanical effect of silicone oil in cataract formation is more than the toxic effect of silicone oil. 12 it has been shown that mechanical energy from intraocular instruments causes emulsification of silicone oil. 13 it seems reasonable to do combined procedure including cataract extraction with so removal in one sitting. measures should be adopted for safe removal of silicone as sometimes removal of silicone oil can lead to retinal re-detachment. combining the two surgeries leads to shortened total surgical time. 14 visual outcomes are also good when two surgical procedures are done at the same time. on the other hand, this combined procedure is associated with some potential disadvantages like difficulty in intraocular lens power calculation. silicone oil contact with corneal endothelium during surgery can lead to corneal damage and dislocation of intraocular lens in posterior segment of the eye can also occur if the posterior capsulorhexis is too large. there are several methods of this combined procedure in literature. these methods usually differ from each other in silicone oil removal technique. some of these are removal of silicone oil through a planned posterior capsulorhexis and removal of silicone oil through a trans-scleral approach. 15.16,17 in the present study, visual acuity was documented pre and post-operatively which showed improvement in majority of patients. antoun et al reported similar results in patients and showed better visual outcomes or better post-operative visual acuity. 18 ramezani et al stated that more patients had an increased or unchanged visual acuity (va) at the last follow-up visit. rate of retinal re-detachment was low at 6 month follow-up. 19 in the current study, all patients had previous retinal detachment surgery with so used as an internal tamponade. in comparison to our study, study done by nagpal et al showed detachment to be 12.7%. 20 phacoemulsification and silicone oil removal in post retinal detachment surgery patients pak j ophthalmol. 2020, vol. 36 (4): 423-427 426 another study by jain et al documented 11.6% redetachment rate. 21 furthermore, different studies by mancino r et al 22 reported 20.2% and choudhary mm et al 23 reported 27.6% re-detachment. yu j et al reported that 81.3% of the patients after removal of silicone oil were observed to have retinal redetachment in first 10 days. 24 the most common cause after so removal of rrd in first 10 days was residual vitreoretinal tractions at the vitreous base. caramoy et al stated that so used as endotamponade after vitrectomy could lead to temporary increase in iop and did not cause any damage on removal of so. 25 limitation of this study is the small sample size and shorter duration of follow-up. retention of so in eye for long duration does not give any additional advantages to the eye. although there is still a risk of retinal re-detachment after silicone oil removal so strict follow-up is the main element in these cases. conclusion visual outcomes were found to be good with low rate of retinal re-detachment after 6 month follow-up of combined phacoemulsification with iol implantation followed by silicone oil removal. combined phacoemulsification with silicone oil removal is a preferred method that is associated with better visual and anatomical outcomes. this also eliminates the chances of patients undergoing third surgery for cataract extraction. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. rhatigan m, mcelnea e, murtagh p, stephenson k, harris e, connell p, et al. final anatomic and visual outcomes appear independent of duration of silicone oil intraocular tamponade in complex retinal detachment surgery. intern j ophthalmol. 2018; 11 (1): 83. 2. grzybowski a, kanclerz p. does nd: yag capsulotomy increase the risk of retinal detachment? asia-pac j ophthalmol. 2018; 7 (5): 339-344. 3. mitry dcd, yorston d, siddiqui ma, campbell h, murphy al, fleck bw, et al. scottish rd study group. the epidemiology and socioeconomic associations of retinal detachment in scotland: a twoyear prospective population-based study. investig ophthalmol vis sci. 2010; 51: 4963–4968. 4. bechrakis ne, dimmer a. rhegmatogenous retinal detachment: epidemiology and risk factors. der ophthalmologe. 2018; 115 (2): 163-178. 5. kirin m, chandra a, charteris dg, hayward c, campbell s, celap i, et al. genome-wide association study identifies genetic risk underlying primary rhegmatogenous retinal detachment. hum mol genet. 2013; 22 (15): 3174–3185. 6. liu x, wang q, zhao j. acute retinal detachment after nd: yag treatment for vitreous floaters and posterior capsule opacification: a case report. bmc ophthalmology, 2020; 20 (1): 1-4. 7. mahroo oa, dybowski r, wong r, williamson th. characteristics of rhegmatogenous retinal detachment in pseudophakic and phakic eyes. eye, 2012; 26 (8): 1114-1121. 8. al-wadani sf, abouammoh ma, abu el-asrar am. visual and anatomical outcomes after silicone oil removal in patients with complex retinal detachment. int ophthalmol. 2014; 34 (3): 549-556. 9. yang jy, kim hk, kim sh, kim ss. incidence and risk factors of cystoid macular edema after vitrectomy with silicone oil tamponade for retinal detachment. korean journal of ophthalmology, 2018; 32 (3): 204210. 10. jiang y, oh dj, messenger w, lim ji. outcomes of 25-gauge vitrectomy with relaxing retinectomy for retinal detachment secondary to proliferative vitreoretinopathy. journal of vitreoretinal diseases, 2019; 3 (2): 69-75. 11. dhalla k, kapesa i, odouard c. incidence and risk factors associated with retinal redetachment after silicone oil removal in the african population. international ophthalmology, 2017; 37 (3): 583-589. 12. zhang x, pan y, song z. trocar opening: a novel management strategy for silicone oil removal with phacoemulsification and iol implantation. j clin exp ophthalmol. 2018; 9 (6): 1000772. 13. francis jh, latkany pa, rosenthal jl. mechanical energy from intraocular instruments causes emulsification of silicone oil. br j ophthal. 2017; 91: 818-821. 14. feng x, li c, zheng q, qian x, shao w, li y, et al. risk of silicone oil as vitreous tamponade in pars plana vitrectomy: a systematic review and meta-analysis. retina, 2017; 37 (11): 1989-2000. uzma haseeb, et al 427 pak j ophthalmol. 2020, vol. 36 (4): 423-427 15. xu w, cheng w, zhuang h, guo j, xu g. safety and efficacy of transpupillary silicone oil removal in combination with micro-incision phacoemulsification cataract surgery: comparison with 23-gauge approach. bmc ophthalmology, 2018; 18 (1): 200. 16. zhou c, qiu q. 360° versus localized demarcation laser photocoagulation for macular‐sparing retinal detachment in silicone oil‐filled eyes with undetected breaks: a retrospective, comparative, interventional study. lasers surg med. 2015; 47 (10): 792-797. 17. romano mr, vinciguerra r, vinciguerra p. sutureless silicone oil removal: a quick and safe technique. retina, 2013; 33 (5): 1090–1091. 18. antoun j, azar g, jabbour e, kourie hr, slim e, schakal a, et al. vitreoretinal surgery with silicone oil tamponade in primary uncomplicated rhegmatogenous retinal detachment. retina, 2016; 36 (10): 1906-1912. 19. ramezani a, ahmadieh h, rozegar a, soheilian m, entezari m, moradian s, et al. predictors and outcomes of vitrectomy and silicone oil injection in advanced diabetic retinopathy. korean j ophthalmol. 2017; 31 (3): 217-229. 20. nagpal mp, videkar rp, nagpal km. factors having implications on retinal detachments after silicone oil removal. indian j ophthalmol. 2012; 60 (6): 517–520. 21. jain n, mccuen bw, mruthyunjaya p. unanticipated vision loss after pars plana vitrectomy. surv ophthalmol. 2012; 57 (2): 91–104. 22. mancino r, aiello f, ciuffoletti e, di carlo e, cerulli a, nucci c. inferior retinotomy and silicone oil tamponade for recurrent inferior retinal detachment and grade c pvr in eyes previously treated with pars plana vitrectomy or scleral buckle. bmc ophthalmology, 2015; 15 (1): 173. 23. choudhary mm, choudhary mm, saeed mu, ali a. removal of silicone oil: prognostic factors and incidence of retinal re-detachment. retina, 2012; 32 (10): 2034-2038. 24. yu j, zong y, jiang c, zhu h, deng g, xu g. silicone oil emulsification after vitrectomy for rhegmatogenous retinal detachment. j ophthalmol. 2020; 2020: 1-6. 25. caramoy a, kearns vr, chan yk. development of emulsification resistant heavier-than-water tamponades using high molecular weight silicone oil polymers. j biomater appl. 2015; 30 (2): 212-220. authors’ designation and contribution uzma haseeb; assistant professor: concepts, design, literature research, data acquisition, data analysis, manuscript preparation, manuscript editing. muhammad haseeb; consultant ophthalmologist: design, literature research, manuscript preparation. aziz-ur-rehman; professor: manuscript preparation, manuscript editing, manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (3): 312-316 312 original article comparison of endonasal endoscopic dacryocystorhinostomy with external dacryocystorhinostomy muhammad tariq 1 , ahmad zeeshan jamil 2 , shahid ali 3 , muhammad khalid 4 , ali akash 5 1-5 district headquarter teaching hospital & sahiwal medical college, sahiwal abstract purpose: to compare anatomical and functional success of endonasal dacryocystorhinostomy (dcr) with that of external dacryocystorhinostomy. study design: quasi-experimental study. place and duration of study: department of ophthalmology and otolaryngology, district headquarter teaching hospital, sahiwal, from july 2018 to july 2019. methods: sixty patients with nasolacrimal duct obstruction were selected by convenient sampling technique and were divided into two groups. group 1 underwent endonasal dcr while group 2 underwent external dcr. detailed history with regard to symptoms and duration of the obstruction was taken. detailed ophthalmological and otolaryngological examination was performed. patients were followed up for three months. chi-square test was used to compare the success between two groups. confidence level of 95% was used and p value of less than 0.05 was considered significant. results: male to female ratio was 4:11. the most common presenting symptoms was epiphora that was present in all patients. regurgitation of lacrimal sac was present in 75%, conjunctivitis was present in 53.33% and dacryocystitis was present in 41.66% patients. anatomical success rate for endonasal dcr was 25 (83.33%) and for external dcr was 27 (90%). functional success rate for endonasal dcr was 23 (76.67%) and for external dcr was 22 (73.33%). there was no statistically significant difference in the short term success of surgery between the two groups. conclusion: endonasal dcr offers minimal invasive approach with comparable anatomical and functional results to the external dcr. key words: conjunctivitis, dacryocystorhinostomy, dacryocystitis, epiphora. how to cite this article: tariq m, jamil az, ali s, khalid m, akash a. comparison of endonasal endoscopic dacryocystorhinostomy with external dacryocystorhinostomy. pak j ophthalmol. 2021, 37 (3): 312-316. doi: 10.36351/pjo.v37i3.1226 introduction tears have important role in ocular surface wellbeing. correspondence: ahmad zeeshan jamil district headquarter teaching hospital & sahiwal medical college, sahiwal email: ahmadzeeshandr@gmail.com received: february 11, 2021 accepted: april 28, 2021 drainage of tears from the conjunctival sac through the lacrimal passages into the nose is important as it prevents stagnation of the tears. blockage in the drainage of tears through the lacrimal passages not only causes discomforting epiphora but it can also lead to infections. 1 restoring patency of the lacrimal drainage system into the nose relieves the agonizing epiphora and stops occurrence of recurrent infections. dacryocystorhinostomy (dcr) is creating a fistula between the lacrimal sac and the nasal cavity. for the open access mailto:ahmadzeeshandr@gmail.com muhammad tariq, et al 313 pak j ophthalmol. 2021, vol. 37 (3): 312-316 first time dcr was performed via intranasal approach in nineteenth century. 2 in the twentieth century dcr was performed by toti by a novel technique. in that procedure external skin incision was used to approach the lacrimal sac and an opening was made to the nasal cavity. 3 endoscopic assisted transnasal dcr was first concocted by mcdonogh and meiring in 1989. 4 with the development of better visualization systems, small guage instruments and introduction of lasers in the field of surgery, more emphasis is given towards minimally invasive surgical approaches. as a result, endonasal dcr is gaining popularity. with the increasing experience of the surgeons, results of endonasal dcr are coming close to the results of external dcr. 5 endonasal dcr offers the advantage of no skin scar, preservation of lacrimal part of orbicularis oculi, less operative time once the learning curve of surgeon has plateaued and faster recovery of the patient. moreover, endonasal dcr can be done in the setting of active infection. 6 external dcr is considered a gold standard. its main advantages include no dependency on expensive instrumentation, lacrimal sac direct approach for examination, treatment of intra-sac pathologies and capability of creation and suturing of lacrimal sac and nasal mucosal flaps. 7 in the current study we have compared success of endonasal dcr with that of conventional external dcr. the idea was to see whether endonasal dcr is as promising a technique as external dcr with less morbidity to the patient and faster postoperative recovery. methods this prospective quasi-experimental study was conducted from july 2018 to july 2019. departments of ophthalmology and otolaryngology of district headquarter teaching hospital, sahiwal, contributed to this study. institutional review board approval was sought before the start of the study. informed consent was taken from all the patients included in the study. patients were selected from outpatient department of ophthalmology. diagnosis of nasolacrimal duct obstruction was made on the basis of symptoms, presence of regurgitation test and by probing and syringing of the lacrimal passages. inclusion criteria were patients with age ranging from 20 years to 60 years, both genders and presenting with chronic dacryocystitis. exclusion criteria comprised of obstruction of lacrimal passages proximal to the lacrimal sac, previous history of dacryocystorhinostomy, history of trauma, presence of nasal pathologies obstructing lacrimal drainage pathway, hypersecretion of tears, lower lid laxity manifested by lateral distraction of more than 5 mm, punctal eversion and conjunctivochalasis. detailed history was obtained from all the patients with respect to duration and severity of the symptoms. detailed ophthalmological and otolaryngological examination were performed. ct scan of paranasal sinuses and orbit was obtained for all the patients. all the patients were operated under general anesthesia. patients were divided into two groups. group 1 patients were operated by endonasal approach while group 2 patients were operated by external approach. in the external dcr group, local infiltration of the medial canthus and lower lid region was done with 5 ml of 2% lidocaine and 1:100,000 epinephrine solution. nasal cavity was packed with dressing soaked in a solution of 2% lidocaine and 1:100,000 epinephrine. skin incision was given over the side of the nose 10 mm away from the medial canthus. periosteum over the anterior lacrimal crest was approached by dissecting the soft tissue. lacrimal sac was exposed by elevating the periosteum. bone was removed with the help of kerrison bone rongeur. lacrimal sac and nasal mucosal flaps were fashioned. nasal packing was removed. silicon tube was passed through the superior and inferior canaliculus into the nasal cavity and tied by square knots. anterior flaps of lacrimal sac and nasal mucosa were sutured together. cut ends of orbicularis oculi muscle were sutured together. sub cuticle suture was used to close the skin incision. nasal packing soaked in 1:100,000 adrenaline was put. nose was packed with ribbon gauze soaked in 1:100,000 adrenaline solution. in endonasal dcr group, nasal mucosa was infiltrated with 1:100,000 adrenaline and 2% lidocaine solution. with the help of endoscope, inspection of nasal cavity was performed and nasal mucosa was incised. kerrison bone rongeur was used to remove the bone until lacrimal sac was exposed. twenty three gauge light pipe used in vitreoretinal surgery was passed through one of the canaliculus into the lacrimal sac. trans-illumination helped in the identification of lacrimal sac. lacrimal sac was opened with the help of blade. silicon tube was passed through upper and lower canaliculus into the nasal cavity. two ends of the silicon tube were secured with the help of surgical comparison of endonasal endoscopic dacryocystorhinostomy with external dacryocystorhinostomy pak j ophthalmol. 2021, vol. 37 (3): 312-316 314 stapler. nasal mucosa was approximated with lacrimal sac mucosa. nasal packing with alginate foam soaked in triamcinolone was done at the end of the procedure. all patients were prescribed topical antibiotics and steroids eye drops and decongestant nasal spray. all patients were followed up at 1 week, 1 month and 3 months. in both groups, silicon tube was removed at 12 weeks after the surgery. patients were followed up for 3 months. patency of lacrimal drainage system was checked by irrigating with florescence-stained normal saline at 2 weeks, 1 month and 3 months. functional success of the procedure was judged on the basis of relief of symptoms and anatomical success was based on patency of lacrimal passage on irrigation. data was entered in statistical package for social sciences version 23. chi-square test was used to compare the success between two groups. p value equal to or less than 0.05 was considered significant. results in this quasi-experimental study, there were 30 patients in each group. distribution of cases in both groups and presenting symptoms are given in table number 1. symptoms were present for less than 6 months in 17 (28.3%). in 12 (20%) symptoms were present for 6 to 12 months. in 19 (31.7%) cases symptoms were present for one year to two years. in 12 (20%) cases symptoms were present for more than 2 years. anatomical and functional success in both groups is given in table number 2. there was no statistically significant difference in anatomical and functional success between the two groups. table 1: demographic characteristics of patients and presenting symptoms in two groups. group male female age epiphora regurgitation dacryocystitis conjunctivitis endonasal 7 (23.3%) 23 (76.67%) 42.40 ± 12.67 30 (100%) 24 (80%) 11 (36.67%) 14 (46.67%) external 9 (30%) 21 (70%) 41 ± 11.67 30 (100%) 21 (70%) 14 (46.67%) 18 (60%) table 2: anatomical and functional success. group anatomical success chisquare/ p-value functional success chisquare/ p-value endonasal 25(83.33%) 0.577/0.35 23(76.67%) 0.089/0.50 external 27(90%) 22(73.33%) discussion external dcr has been considered as the gold standard for the treatment of nasolacrimal drainage system blockage beyond common canaliculus. recent advances in endoscopic visualization system, surgical instrumentation and growing expertise of surgeons have paved the way to the minimal invasive surgical approach. as a result, endonasal dcr is gaining popularity. 8 likewise, in our institution there is a growing trend in transition to the minimally invasive surgical approach whereby more and more patients are being offered endonasal dcr. dcr is all about creating a fistula between lacrimal sac and nasal cavity. making window in the bony wall of nose is essential part of this procedure. the most common cause of failure of dcr surgery is closure of the bony ostium into the bony wall of the nose. intraoperative tissue damage leading to postoperative scarring is one the main contributing factors in the closure of the opening of bony ostium. 9 interestingly initial size of the bony ostium is not related to the postoperative final size of bony opening. 10 more emphasis is given on minimizing surgical trauma to prevent postoperative scarring of the ostium. better visualization with the help of endoscopes and minimal tissue dissection with fine surgical instrumentation is the key concept behind minimally invasive surgical techniques. 11 approximation of lacrimal sac and nasal mucosa appears to offer the best result in maintaining the patency of bony opening in dcr surgery. 12,13 in the present study, meticulous care was taken to approximate the flaps of lacrimal sac and nasal mucosa. at the same time unnecessary dissection and cautery was avoided in both groups to minimize postoperative scarring. anatomical success rate for endonasal dcr was 25 (83.33%) and for external dcr was 27 (90%). functional success rate for endonasal dcr was 23 (76.67%) and for external dcr was 22 (73.33%). the success rate of endonasal dcr in the current study is comparable to the results of herzallah et al. where success rate was 87.88%. 8 in a study done by muhammad tariq, et al 315 pak j ophthalmol. 2021, vol. 37 (3): 312-316 hartikainen and colleagues external dcr was successful in 91% cases while endonasal dcr was successful in 63% cases. 14 in another study done by the same author endonasal endoscopic dcr success rate was 75% and external dcr success rate was 91% at the end of one year. 15 javate and coauthors performed a longitudinal study comparing the success rate of endonasal dcr with that of external dcr. success rate of endonasal dcr was 90% as compared to 94% for external dcr. 16 study done by hii et al. showed success rate of 92.1% for endonasal dcr and 91.7% for external dcr. 17 in a study done by walker and colleagues endonasal dcr success rate was 90.2% and external dcr success rate was 89.8%. 18 su and colleagues compared the anatomical and functional success rate between endonasal and external dcr. in their study no significant difference was noted in the success between the two groups. anatomical success for endonasal and external dcr was 93.5% and 95.8% respectively. functional success for endonasal and external dcr was 90.7% and 90.1% respectively. 19 ben and colleagues study demonstrated a significantly higher success rate of endonasal dcr (84%) as compared to external dcr (70%). 20 in another study conducted by karim and coauthors success rate of endonasal and external dcr was 82.4% and 81.6% respectively. 21 jain et al study showed equal success rate of 87% in endonasal versus external dcr. 22 success rate of external and endonasal dcr was 90.9% and 91.3% in study of gupta. 23 it was 94% and 86% in a study of leong. 24 results of all studies show equal and reasonably higher success rate of endonasal and external dcr. results of our study are comparable to all those results. endonasal dcr with less manipulation of tissue and less extensive dissection theoretically promotes healing with primary intension. this leads to less formation of granulation tissue and subsequent scarring and stenosis of internal ostium. 25 limitation of the current study was small sample size, shorter follow up and being conducted in a single center. in future large scale multi-center study with long term follow up is required to conclude the outcome of endo nasal dcr. conclusion endonasal dcr offers minimal invasive approach with comparable anatomical and functional results to the external dcr. ethical approval the study was approved by the institutional review board/ethical review board. 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dacryocystitis with lacrimal sac abscess formation: a randomized clinical trial. jama ophthalmology, 2017; 135 (12): 1361-1366. 7. amadi aj. endoscopic dcr vs. external dcr: what's best in the acute setting? j ophthalmic vis res. 2017; 12 (3): 251. 8. herzallah i, alzuraiqi b, bawazeer n, marglani o, alherabi a, mohamed sk, et al. endoscopic dacryocystorhinostomy (dcr): a comparative study between powered and non-powered technique. j otolaryngol head neck surg. 2015; 44: 56. doi 10.1186/s40463-015-0109-z 9. kim sy, paik js, jung sk, cho wk, yang sw. no thermal tool using methods in endoscopic dacryocystorhinostomy: no cautery, no drill, no illuminator, no more tears. eur arch otorhinolaryngol. 2013; 270 (10): 2677-2682. 10. linberg jv, anderson rl, bumsted rm, barreras r. study of intranasal ostium external dacryocystorhinostomy. arch ophthalmol. 1982; 100 (11): 1758–1762. comparison of endonasal endoscopic dacryocystorhinostomy with external dacryocystorhinostomy pak j ophthalmol. 2021, vol. 37 (3): 312-316 316 11. codère f, denton p, corona j. endonasal dacryocystorhinostomy: a modified technique with preservation of the nasal and lacrimal mucosa. ophthalmic plast reconstr surg. 2010; 26 (3): 161– 164. 12. mann bs, wormald pj. endoscopic assessment of the dacryocystorhinostomy ostium after endoscopic surgery. laryngoscope, 2006; 116 (7): 1172-1174. 13. ullrich k, malhotra r, patel bc. dacryocystorhinostomy. in: stat pearls. treasure island (fl): stat pearls publishing; 2020 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk557851/ 14. hartikainen j, grenman r, puukka p, seppä h. prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy. ophthalmology. 1998;105(6): 1106-1113. 15. hartikainen j, antila j, varpula m, puukka p, seppä h, grénman r. prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. laryngoscope, 1998; 108 (12): 1861-1866. 16. javate rm, campomanes jr bs, co nd, dinglasan jr jl, go cg, tan en, tan fe. the endoscope and the radiofrequency unit in dcr surgery. ophthalmic plastic and reconstructive surgery, 1995; 11 (1): 5458. 17. hii bw, mcnab aa, friebel jd. a comparison of external and endonasal dacryocystorhinostomy in regard to patient satisfaction and cost. orbit, 2012; 31 (2): 67e76. 18. walker ra, al-ghoul a, conlon mr. comparison of non-laser non-endoscopic endonasal dacryocystorhinostomy with external dacryocystorhinostomy. can j ophthalmol. 2011; 46 (2): 191e195. 19. su py. comparison of endoscopic and external dacryocystorhinostomy for treatment of primary acquired nasolacrimal duct obstruction. taiwan j ophthalmol. 2018; 8 (1): 19e23. 20. simon gj, joseph j, lee s, schwarcz rm, mccann jd, goldberg ra. external versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. ophthalmology, 2005; 112 (8): 1463-1468. 21. karim r, ghabrial r, lynch t, tang b. a comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. clin ophthalmol. 2011; 5: 979e989. 22. jain s, ganguly a, singh s, mohapatra s, tripathy d, rath s. primary non-endoscopic endonasal versus delayed external dacryocystorhinostomy in acute dacryocystitis. ophthalmic plast reconstr surg. 2017; 33 (4): 285-288. 23. gauba v. external versus endonasal dacryocystorhinostomy in a specialized lacrimal surgery center. saudi j ophthalmol. 2014; 28 (1): 36e39. 24. leong sc, karkos pd, burgess p, halliwell m, hampal s. a comparison of outcomes between nonlaser endoscopic endonasal and external dacryocystorhinostomy: single-center experience and a review of british trends. am j otolaryngol. 2010; 31 (1): 32-37. 25. bharangar s, singh n, lal v. endoscopic endonasal dacryocystorhinostomy: best surgical management for dcr. indian j otolaryngol head neck surg. 2012; 64 (4): 366-369. authors’ designation and contribution muhammad tariq; professor: concepts, design, manuscript preparation. ahmad zeeshan jamil; associate professor: literature search, drafting of article, critical revision. shahid ali; assistant professor: manuscript writing, critical revision. muhammad khalid; professor: literature search, statistical analysis. ali akash; postgraduate resident: literature search, drafting of article. .…  …. pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 95 #original article outcome of external dacryocystorhinostomy with adjunctive mitomycin c in tertiary care hospital narain das, shakir zafar, farhan amjad jafri, syed fawad rizvi pak j ophthalmol 2016, vol. 32 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: narain das fcps ophthalmologist lrbt free base eye hospital korangi no 2 ½ karachi email: narainpagarani@yahoo.com received: november 03, 2015 accepted: june 08, 2016 …..……………………….. purpose: to evaluate the role of intra-operative mitomycin c in external dcr in cases of recurrent (previously treated medically) and chronic dacryocystitis. study design: interventional case series. place and duration of study: from may 2012 to november 2014 in lrbt free base eye hospital korangi no. 2½ karachi, a tertiary care hospital in pakistan. material and methods: 150 patients (males 62, females 88), age of patients ranged from 22 to 56 years were included in the studies. all patients underwent external dcr with intubation with the adjunctive use of topical mitomycin c primarily. all patients underwent the same surgical procedure performed by two surgeons with average follow up period of 12 months. success was assessed objectively by irrigation of punctae, with absence of regurgitation, and subjectively by absence of epiphora and discharge. results: out of 150 patients, 138 patients (92%) remained symptom free, while 12 patients (8%) complained of persistent watering and discharge despite an uncomplicated surgical procedure postoperatively, however out of these 12 patients, 3 patients dislodged the tube prematurely 4 months after surgery. the average operative time was 45 (sd 7.48) minutes. one patient had excessive bleeding during surgery while 3 patients were noted with delayed wound healing and 2 patients with peri-orbital ecchymosis postoperatively. conclusion: external dacryocystorhinostomy (dcr) with intra-operative mitomycin c shows promising results. key words: mitomycin c, external dacryocystorhinostomy, epiphora. acryocystitis is the infection of lacrimal sac most often as a result of obstruction of nasolacrimal duct. watering from the eye is the presenting complain of chronic dacryocystitis. a swelling at the inner canthus, that is usually painless, is often the presenting sign in chronic dacryocystitis. sometimes swelling may not be obvious but pressure over the lacrimal sac can result in regurgitation of mucopurulent discharge through the canaliculi. most ophthalmic surgeons accept dcr as a highly successful procedure in managing epiphora due to nasolacrimal duct obstruction. from previous studies, it appears that the success rate for this procedure in adult is 90%1. fibrous tissue growths in the flap anastomosis, obstruction at common canalicular end and closure of osteotomy site constitute the most common causes of failure of external dcr. success rate can be increased if growth of fibrous tissue is prevented. this goal can be achieved by applying antifibrotic agents like mitomycin c over the anastomosed flaps and osteotomy site2. mitomycin c derived from soil bacterium streptomyces caespitosus, is an alkylating antibiotic. it reduces fibroblast collagen synthesis by inhibiting d mailto:narainpagarani@yahoo.com narain das, et al 96 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology dna dependent rna synthesis and can suppress cellular proliferation in any period of cell cycle. it is used intravenously to treat upper gi tumors, anal cancer, breast cancer and bladder tumors. mitomycin c has also been used topically rather than i/v in several areas like bladder cancers and intraperitoneal tumors. it is now well known that a single instillation of this agent within 6 hours of bladder tumor resection can prevent recurrence. in esophageal and tracheal stenosis, application of mitomycin c onto the mucosa immediately following dilatation will decrease restenosis by decreasing the production of fibroblasts and scar tissue. in eye surgery, it is applied topically to prevent recurrence in pterygium surgery, to prevent scarring in glaucoma filtering surgery and haze after prk and lasik. mitomycin c was first used in ophthalmology in 1969 in japan where recurrent pterygium was successfully treated with the drug3. its use and application in ophthalmology has been increasing in recent years because of its modulatory effects on wound healing. in our study, we evaluate the long term success rate of dacryocystorhinostomy with intubation with adjunctive intraoperative mitomycin c in a group of patients presenting with a complaint of epiphora and having chronic recurrent dacryocystitis material and methods this prospective interventional study was conducted from may 2012 to november 2014. average follow up period was 12 months. 150 consecutive primary cases (previously no surgical intervention) of chronic dacryocystitis with or without mucocele of adult age (22 years to 56 years) of both genders were selected from outpatient department of lrbt free base eye hospital korangi. a complete history and thorough clinical examination were performed in each case. inclusion criteria were adult patients between 22 years and 56 years of age of either gender, primary cases of chronic dacryocystitis. exclusion criteria included acute on chronic dacryocystitis, previous failed dcr, punctual agenesis, common or individual canalicular obstruction, external fistula in chronic dacryocystitis, trauma, and nasal or paranasal sinuses pathology. a proforma was maintained for all the registered patients to assess post-operative results. all patients (underwent) same surgical procedures performed by two surgeons. preoperatively, a detailed history regarding watering, mucopurulent discharge, swelling near the medial canthus was obtained. history of eye drugs such as adrenaline or phospholine iodide and anticoagulants was also taken. ocular as well as nasal examination was performed in all the patients. ocular examination was done to assess entropion, trichiasis or blepharitis, punctual malposition, stenosis, agenesis or accessory puncta, canaliculitis, fistula near medial canthus, conjunctivitis, keratitis. regurgitation test was performed and reflux of mucus and mucopurulent material through the canaliculu and puncta was noted. assessment of tear film meniscus height, dye disappearance test, jones i and ii and dacryocystogram were performed to assess patency of lacrimal drainage system. probing and then syringing was performed in all the case. failure of saline to reach the throat (i-e complete nld block) and regurgitation of mucoid and mucopurulent through cancliculi and puncti (i.e. patent canaliculi) material was noted in all the patients. nasal cavity was examined in all the patients to exclude any nasal disease. preoperatively patients were investigated for any bleeding diathesis, complete blood picture, esr, blood sugar levels, bleeding and clotting time. hbsag and anti hcv and other relevant investigations if needed were done also. standard surgical technique of external dcr was used in all the patients. all operations were conducted under local anesthesia. local infiltrative anesthesia, consisting of 2% lignocaine (lidocaine) and 1:100000 adrenaline (epinephrine) was administered in the region of the medial canthus and lower lid. with the patients under local anaesthesia, the nasal cavity of the operable side was decongested for 10 minutes with cotton pledgets soaked in 2% lidocaine and 1:100000 adrenaline and packed with gauze piece. after using all aseptic measures and draping the surgical area, a curvilinear skin incision was made at the level of medial canthal tendon extending into the thin skin of the lower lid for approximately 10 – 12 mm. blunt dissection was done to reach the periostium overlying the anterior lacrimal crest. exposed periostium was incised parallel to the anterior lacrimal crest and an osteotomy of 12x12 mm wide was created with bone punch. the lacrimal sac was opened to form anterior and posterior flaps. the nasal mucosa was cut in a similar fashion to the lacrimal sac. then, the posterior nasal and lacrimal sac flaps were joined with 5/0 vicryl suture. a silicone tube was used to intubate the lacrimal system and passed through the osteotomy in front of posterior flap into the nostril and it was tied to each other with 4/0 silk suture in the nasal cavity. then a piece of cotton pledget soaked with 0.2 mg/ml outcome of external dacryocystorhinostomy with adjunctive mitomycin c in tertiary care hospital pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 97 mitomycin c was placed over the anastomosed posterior flaps and osteotomy site. after 10 minutes of application the cotton pledget soaked with mitomycin c was removed and the area was irrigated with normal saline. the anterior nasal mucosal and lacrimal sac flaps were sutured together. periostium and orbicularis muscles were closed in separate layers. the skin incision was sutured with 6/0 prolene suture and then nasal packing soaked with antibiotic ointment was applied. systemic oral antibiotic and topical antibiotic drops were administered to the patients in the postoperative period. the nasal packings were removed on the second postoperative day. skin sutures were removed after one week postoperatively. the silicone tubes were removed at 6 months postoperatively in all the patients. during surgery bleeding was measured by attaching a collection jar to the suction tube. mean intraoperative bleeding was 50.5 ml (range 15 to 60 ml). bleeding more than 60 ml was labeled as “excessive bleeding”. postoperatively skin sutures were removed after 7 days. at the time of suture removal if wound was healed and the edges were approximated properly it was considered as “normal wound healing”. wound disruption during suture removal was noted in few cases and was considered as “delayed wound healing”. follow up was maintained up to 12 months for the evaluation of abnormal over flow of tears and the patency of lacrimal drainage system by syringing. the 1st follow up was done on day one after surgery and then after one week and then at 1st, 3rd, 6th, 9th and 12th month postoperatively. nasal packings of all the patients were removed on 1st postoperative day. the skin sutures were removed on 1st postoperative week. outcome of the surgery was measured on the basis of the subjective and objective findings. the surgery was considered successful if the patients had no symptoms of tearing and lacrimal drainage system was proved to be patent by irrigation with normal saline at the final follow up. patients with persistent epiphora with nonpatent lacrimal drainage system were classified as failed dacryocystorhinostomy (dcr). at the end of follow up period of 12 months results were compiled and compared with national and international data. results 150 surgeries were performed in this study. females (58.66%) outnumbered males (41.33%). the mean age group was 39 (sd 9.18) years. out of 150 patient’s 138 patients remained symptom free and showed patency with irrigation at the end of 12 months after surgery which shows that success rate was 92%. remaining 12 (8%) patients complained of persistent watering and not successfully irrigated at final follow up which shows that the failure rate was 8%. out of 12 failed surgeries, 3 (2%) patients dislodged the tube before 4 months after surgery. during surgery one (0.66%) patient had excessive bleeding. 5(3.33%) patients noted with early postoperative complications in which 2 (1.33%) patients had periorbital ecchymosis noted on 1st postoperative day which later resolved and 3 (2%) patients showed delayed wound healing. fortunately, the wound healed within 2-3 weeks after dcr surgery leaving a barely visible scar with a successful result. discussion external dacryocystorhinostomy is highly successful procedure in managing epiphora secondary to nasolacrimal duct obstruction4,5. the reported success rate varies between 85% and 99%.6 in our study the success rate of dcr with mmc and intubations was found to be 92%. various other studies have previously been conducted to assess the surgical outcome of dcr with silicone tube. zaman m et al showed success rate of 97.5%7 whereas iliff reported 90%8 and tarbatand custer reported 95% success results9. in a comparative study hussain et al10 reported 94.7% success results in intubated series. similarly advani et al11, reported success rate of 95% in intubated cases. a study by ym denaley and r khooshabeh showed that patent dcr system to irrigation and a positive dye test was achieved in 90% of procedures12. nawaz et al were successful by 93.33%13. the dcr with mmc group showed a success rate of 95.4% and failure rate of 4.6%. from amongst the various studies previously conducted to assess the surgical outcome of dcr with mmc, shu l liao et al showed 95.5% success rate2, yildrim et al gave a success rate of 95% and rehman et al achieved a success rate 97.7%14,15. kao et al showed 100% success with mmc in maintaining patency and a large osteotomy site.7 in other studies conducted by you in 2001, roozitalab in 2004 and akhund in 2005 applied mmc over the anastomosed flaps and achieved success rate of 100%, 90.50% and 99% respectively16,17. our study also compared with previous studies of endoscopic dcr. selig et al (2000) reported 87.5% success rate in endoscopic dcr, with application of topical mitomycin c, but the series was a small one and did not have any control18. liao et al, (2000) found 95.5% success rate with topical mitomycin c, as narain das, et al 98 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology compared to 70.5% in non-mitomycin group and have strongly recommended its use14. zilelioglu et al (1998), on the other hand, reported 77.3% success in mitomycin group 77.8% in non-mitomycin group.19 liu et al (2003) and beloglazov et al (1999) also noted similar observations with no beneficial effects of mitomycin c and hence have not recommended its use20,21. our study showed better results (92%) as compared to above endoscopic dcr studies. they observed that with appropriate operative techniques and in experienced hands the success rates of endodcr are practically equal to those of classical external approach. the major advantages of endo-dcr are shorter operative times, lower complication rates, reduced patient morbidity and absence of external scars. in our study, there were 52.6% females. in the study by zamanet al there were 62% females7, by rehman et al there were 76% females15, by ali et al, there were 79% females22. the female preponderance is possibly due to the narrow lumens of bony lacrimal canals and nld in women, osteoporosis, hormonal changes and heightened immune response23. many complications due to mitomycin c application have been reported in both pterygium and glaucoma filteration operations. severe secondary glaucoma, corneal perforation, corectopia, secondary cataract and scleral calcification are documented as complications in using topical mitomycin c as a medical adjunct to pterygium surgery24. hypotony related maculopathy, infection and endophthalmitis have been found in patients undergoing glaucoma surgery after exposure to mitomycin c25. in our study, one patient had excessive bleeding during surgery. five patients were noted with postoperative complications out of which two patients had periorbital ecchymosis noted on 1st postoperative day which later resolved. periorbital ecchymosis may be due to excessive manipulation during surgery. three patients showed delayed wound healing. wound disruption was noted during skin suture removal about seven days after surgery, it may be due to the result of accidental contact of mitomycin c soaked sponge on the skin wound could have been prevented by carefully managing the sponge. conclusion dcr with intraoperative mitomycin c soaking over the osteotomy site and anastomosed flaps can minimize the adhesion around the septo-osteotomy as well as the opening of the common canaliculus. mitomycin c soaking during dcr surgery is a useful modified procedure to improve the success rate of external dcr. author’s affiliation dr. narain das fcps ophthalmologist lrbt free base eye hospital korangi no 2 ½ karachi dr. shakir zafar lrbt free base eye hospital dr. farhan amjad jafri lrbt free base eye hospital korangi no 2 ½ karachi dr. syed fawad rizvi lrbt free base eye hospital korangi role of authors: dr. narain das study design & surgery dr. shakir zafar manuscript review, compilation, surgery dr. farhan amjad jafri data collection and results dr. syed fawad rizvi manuscript review references 1. tarbet kj, custer pl. external dacryocystorhinostomy: surgical success, patient satisfaction economic cost. ophthalmology. 1995: 102: 1065-7. 2. liao sl, kao scs, tseng jhs, chen ms, hou pk. results of intraoperative mitomycin-c application in dacryocystorhino-stomy. br j ophthalmol. 2000; 84: 9036. 3. kunitomoro n, mori s. studies on pterygium: part 4,a treatment of pterigium by mitomycin-c installation. acta soc ophthalmol jpn. 1969; 67: 601-7. 4. tarbet kj, cluster pl. external dacryocystorhinostomy: surgical success, patient satisfaction and economic cost. 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edward med uni. 1998; 4: 34-6. 11. advani rk, halepota fm, shah sia, et al. comparative results of dacryocystorhinostomy with and without silicon intubation. pak j ophthalmol. 2004; 86: 533-5. 12. khushabeh r. external dacryocystorhinostomy for the treatment of acquired partial nasolacrimal duct obstruction in adults. br j ophthalmol. 2002; 86: 533-5. 13. nawaz m, sultan ms, hanif q et al. dacryocystorhinostomy; a comparative study of the results with and without silicon intubation in pakistani patients of chronic dacryocystitis. professional med j mar. 2008; 15: 81-6. 14. yildrim c, yaylali v, esme a. long-term results of rahman a, channa s, niazi jh, et al. dacryocystorhinostomy without intubation with intraoperative mitomycin-c. j coll physicians surg pak. 2006; 16: 4768. 15. rahman a1, channa s, niazi jh, memon ms. dacryocystorhinostomy without intubation with intraoperative mitomycin-c. j coll physicians surg pak. 2006; 16: 476 16. you ya, fang ct. intraoperative mitomycin c in dacryocystorhinostomy. ophthalplast recons surge. 2001; 17: 115-9. 17. roozitalab mh, amirahmedi m, namazi mr. results of the application of intraoperative mitomycin-c in dacryocystorhinostomy. eur j ophthalmol. 2004; 14: 461-3. 18. selig yk, biesmanbs, rebeiz ee. (2000): topical application of mitomycin c in endoscopic dacryocystorhinostomy. am j rhinol. 2000; 14: 205-7. 19. zilelioglu g, ugurbas sh, anadolu y, akiner m, akturk t. adjunctive use of mitomycin c on endoscopic lacrimal surgery. br. j. ophthalmol. 1998; 82: 636. 20. liu d, bosley tm. silicone nasolacrimal intubation with mitomycin ca prospective, randomized, doublemasked study. ophthalmology. 2003; 110: 306-10. 21. beloglazov vg, grusha ov, saad-ey din nm, alkova el, malaeva lv. the prevention and treatment of recurrences after dacryocystorhinostomies. vestin oftalmol. 1999; 115: 14-7. 22. ali a, ahmed t. dacryocystorhinostomy (a review of 51 cases). pak j ophthalmol. 2001; 17: 122-8. 23. mortimore s1, banhegy gy, lancaster jl, karkanevatos a. endoscopic dacryocystorhinostomy without silicon stenting. j r coll. surg edinb. 1999; 44: 371-3. 24. rubinfeld rs1, pfister rr, stein rm, foster cs, martin nf, stoleru s, talley ar, speaker mg. serious complications of topical mitomycin-c after pterygium surgery. ophthalmology, 1992; 99: 1647-54. 25. kupin th, juzych ms, shin dh, khatana ak, olivier mm. adjunctive mitomycin c in primary trabeculectomy in phakic eyes. am j ophthalmol. 1995; 119: 30-9. http://www.ncbi.nlm.nih.gov/pubmed/?term=rahman%20a%5bauthor%5d&cauthor=true&cauthor_uid=16827960 http://www.ncbi.nlm.nih.gov/pubmed/?term=channa%20s%5bauthor%5d&cauthor=true&cauthor_uid=16827960 http://www.ncbi.nlm.nih.gov/pubmed/?term=niazi%20jh%5bauthor%5d&cauthor=true&cauthor_uid=16827960 http://www.ncbi.nlm.nih.gov/pubmed/?term=memon%20ms%5bauthor%5d&cauthor=true&cauthor_uid=16827960 http://www.ncbi.nlm.nih.gov/pubmed/?term=mortimore%20s%5bauthor%5d&cauthor=true&cauthor_uid=10612959 http://www.ncbi.nlm.nih.gov/pubmed/?term=banhegy%20gy%5bauthor%5d&cauthor=true&cauthor_uid=10612959 http://www.ncbi.nlm.nih.gov/pubmed/?term=lancaster%20jl%5bauthor%5d&cauthor=true&cauthor_uid=10612959 http://www.ncbi.nlm.nih.gov/pubmed/?term=karkanevatos%20a%5bauthor%5d&cauthor=true&cauthor_uid=10612959 http://www.ncbi.nlm.nih.gov/pubmed/?term=rubinfeld%20rs%5bauthor%5d&cauthor=true&cauthor_uid=1454338 http://www.ncbi.nlm.nih.gov/pubmed/?term=pfister%20rr%5bauthor%5d&cauthor=true&cauthor_uid=1454338 http://www.ncbi.nlm.nih.gov/pubmed/?term=stein%20rm%5bauthor%5d&cauthor=true&cauthor_uid=1454338 http://www.ncbi.nlm.nih.gov/pubmed/?term=foster%20cs%5bauthor%5d&cauthor=true&cauthor_uid=1454338 http://www.ncbi.nlm.nih.gov/pubmed/?term=martin%20nf%5bauthor%5d&cauthor=true&cauthor_uid=1454338 http://www.ncbi.nlm.nih.gov/pubmed/?term=stoleru%20s%5bauthor%5d&cauthor=true&cauthor_uid=1454338 http://www.ncbi.nlm.nih.gov/pubmed/?term=talley%20ar%5bauthor%5d&cauthor=true&cauthor_uid=1454338 http://www.ncbi.nlm.nih.gov/pubmed/?term=speaker%20mg%5bauthor%5d&cauthor=true&cauthor_uid=1454338 http://www.ncbi.nlm.nih.gov/pubmed/?term=khatana%20ak%5bauthor%5d&cauthor=true&cauthor_uid=7825687 http://www.ncbi.nlm.nih.gov/pubmed/?term=olivier%20mm%5bauthor%5d&cauthor=true&cauthor_uid=7825687 http://www.ncbi.nlm.nih.gov/pubmed/?term=olivier%20mm%5bauthor%5d&cauthor=true&cauthor_uid=7825687 http://www.ncbi.nlm.nih.gov/pubmed/?term=olivier%20mm%5bauthor%5d&cauthor=true&cauthor_uid=7825687 157 pak j ophthalmol. 2022, vol. 38 (2): 157-161 original article early removal of scleral buckle nida usman 1 , muhammad ali haider 2 department of ophthalmology, 1-2 al-ehsan welfare eye hospital abstract purpose: to study the outcomes of early removal of segmental buckle on visual acuity, retinal status, and astigmatism. study design: interventional case series place and duration of study: mayo hospital, from february 2018 to july 2018. methods: ten patients fulfilling the inclusion criteria were recruited. all the patients underwent segmental radial sponge with cryoretinopexy, with or without drain and intraocular gas tamponade as per need. post-operative follow ups were at 1 st week, 4 th week and 6 th week. sponge was removed at 6 th week after making sure that the retina was attached. follow ups after buckle removal were planned at 1 st week, 1 st month and 3 rd month. improvement in va, retinal status and astigmatism were noted. the commonest reason for the explant removal was infection followed by pain. normality was checked through shapiro-wilk’s w-test and the normality criteria was met so paired sample t-test was used to assess the significance of astigmatism pre and post-surgery. results: the average age was 32.30 ± 16.75 years (range, 03 – 61 years). anatomical success was achieved in 100%. visual acuity improved in all patients. moreover, early removal of buckle reduced astigmatism and further improvement in vision was also noted. pre and post-surgical vision improvement was statistically significant with p-value of 0.000. after removal of buckle, improvement of astigmatism was also statistically significant p-value 0.004. conclusion: the early removal of scleral explant not only provides symptomatic relief to the patients, but is also associated with marked improvement in visual acuity was noted. key words: visual acuity, astigmatism, retinal detachment, segmental scleral buckle. how to cite this article: usman n, haider ma. early removal of scleral buckle. pak j ophthalmol. 2022, 38 (2): 157-161. doi: 10.36351/pjo.v38i2.1357 correspondence: nida usman al ehsan eye hospital, lahore email: dr.nidausman@yahoo.com received: december 11, 2021 accepted: march 16. 2022 introduction scleral buckling (sb) has always been an important procedure for the management of retinal detachment and provides comparable results with primary pars plana vitrectomy. 1,2 pars plana vitrectomy is increasingly used for repair of rhegmatogenous retinal detachment (rrd)and is the most popular method of management nowadays. the importance of conventional method with cryotherapy and scleral implant cannot be put aside. 3 buckling not only provides very good vision but also gives anatomical stability to the retina. 4 scleral buckle is removed at 6 months after surgery or in some cases not removed at all. 5 segmental scleral buckle is an extremely effective technique for the repair of retinal detachments, especially in young and phakic eyes with fresh rrd. 6 its initial success rates are higher than pneumatic retinopexy and are comparable with vitrectomy and combined approach in selected cases. 7 segmental buckle is a fast, simple and cost effective procedure. it eliminates the restriction of positioning and decreases risk of cataract formation with minimal astigmatism. it also reduces the risk of iop rise and there is faster visual rehabilitation with no risk of travelling. on the nida usman, et al pak j ophthalmol. 2022, vol. 38 (2): 157-161 158 other hand because of more chances of infection, extrusion, and astigmatism, with more implication of time and effort and more difficult training, its usage has become limited with the passage of time. 8 this study was conducted to evaluate anatomical and functional outcomes of early removal of segmental scleral buckle, chances of re-detachments and changes in the refractive status of the eye. methods ten patients fulfilling the inclusion criteria were taken from the outdoor of mayo hospital. phakic patients with fresh rhegmatogenous retinal detachment, single break or multiple breaks involving 1 clock hour and pvr a or b were included. pseudophakic patients with old rrd, multiple breaks or breaks involving 2 or more clock hours and pvr c were excluded. the data was collected from february 2018 to july 2018. initial evaluation included: visual acuity (va), auto refraction (ar), intra ocular pressure (iop) and detailed anterior and posterior segment evaluation. all the patients underwent segmental radial sponge (507 or 509) with cryo, with or without sub-retinal fluid drainage and intraocular gas tamponade (c3f8) when needed. post-operative visits were planned at 1 st week, 4 th week (laser augmentation if needed) and 6 th week. removal of sponge was done at 6 th week after making sure the stability of retina. follow up after buckle removal was planned at 1 st week, 1 st month and 3 rd month. improvement in va, retinal status and astigmatism were noted. data was collected and analyzed using spss version 25. the shapiro-wilk’s w-test was applied for checking normality assumptions. paired sample t-test was used to check the significance of results, the pvalue of ≤0.05 was considered as statistically significant. results average age of the patients was 32.30 ± 16.75 years (range, 03–61 years). functional success was 100% as visual acuity was improved in all the patients. further improvement in visual acuity was observed after the removal of buckle. anatomical success rate was also 100%. mean duration of explant was 06 weeks and mean follow-up was 06 months. in all the 10 patients, radial silicone explants was applied. the commonest reason for the explant removal was infection. followed by pain. symptomatic relief was achieved in 100% of patients. no patient suffered from retinal redetachment after removal of explant till the last followup. normality was checked through shapiro-wilk’s w-test and the normality criteria was met so paired sample t-test was used to assess the significance of astigmatism pre and post-surgery and friedman test was applied to check the significance of visual improvement. results showed that the pre and postsurgical vision improved significantly with p-values < 0.05. after removal of buckle, improvement in astigmatism was also significant p-value 0.004. table 1: pre and post-surgical visual improvement. visual acuity log units no. of patients percentage pre surgery 1.00 2 20.0 1.50 1 10.0 1.60 7 70.0 total 10 100.0 post buckle (2 nd week) 0.30 2 20.0 0.50 3 30.0 0.60 4 40.0 1.00 1 10 total 10 100 post buckle removal (6 th week) 0.10 2 20.0 0.30 2 20.0 0.40 2 20.0 0.50 1 10.0 0.60 2 20.0 0.70 1 10.0 total 10 100.0 table 2: pre and post-surgical astigmatism. astigmatism dioptres (d) no. of patients percentage before buckle removal 0.90 1 10.0 1.20 4 40.0 1.40 1 10.0 1.70 3 30.0 2.20 1 10.0 total 10 100 after buckle removal 0.40 1 10.0 0.70 1 10.0 0.90 3 30.0 1.20 2 20.0 1.40 2 20.0 1.70 1 10.0 total 10 100.0 early removal of scleral buckle 159 pak j ophthalmol. 2022, vol. 38 (2): 157-161 table 3: early removal of scleral buckle impacts. total no. of patients minimum maximum mean std. deviation pvalue visual acuity va pre surgery 10 1.00 1.60 1.4700 .24967 0.000* va post surgery pre-buckle removal 10 .30 1.00 .5500 .19579 va post buckle removal 10 .10 .70 .4000 .20548 astigmatism astigmatism pre surgery 10 .90 2.20 1.4400 .38064 0.004* astigmatism post surgery 10 .40 1.70 1.0700 .38312 *shows significant p-value, va = friedman test was applied, astigmatism = paired sample t-test figure 1: functional success. figure 2: post buckle improvement of astigmatism in individual patients. discussion the aim of our study was to find out the functional and anatomical success in case of early removal of scleral buckle, which was carried out at 6 th week. we had a close eye on patients on the 1 st week and kept on checking until 4 th week to see if the patient needed any laser augmentation, laser was applied to three patients who needed augmentation at the site of the break and after complete satisfaction we went for the removal of buckle at 6 th week post operative. only two of our patients showed slight infection of the sponge in late 5 th week and their buckle was also removed at 6 th week. all of our patients showed 100% success as not only the vision of our patients improved but when these patients were followed up later at 6 th months and one year interval none of them showed any redetachment. not only did we measure betterment in the va due to retinal attachment but we also calculated the degree of astigmatism induced due to buckle and when the buckle was removed astigmatism improved as well as the va in most of our cases making it significant finding that early removal of buckle helps reduce astigmatism as well. deokule investigated in his study that the commonest reason for explant removal was extrusion followed by pain, scleritis, infection and foreign body sensation but we only faced minor explant infection at the end of 5 th week for which we removed the implant at 6 th week. retina was attached in 88.8% of his patients but we achieved the 100% success. he did not calculate the improvement in astigmatism after the removal of buckle but we calculated and showed significant improvement in astigmatism. 9 there are other studies which showed some of the major complications following scleral buckling. 10-13 these included extrusion, 10 fistula formation, 11 rejection 12 and intrusion of the sponge. 13 however, in our study only two patients got minor infection in the 5 th week which came better as soon as we removed the sponge by the end of 6 th week. by early removal of buckle we can avoid all of these complications and relieve our patients from the complications of buckle. 14 in previous studies, the usual time of removal of scleral buckle ranged from 03 – 80 months. 15,16,17 moisseiev et al, studied the effects and indications of implant removal. 16 he experienced explant extrusion as the commonest reason for buckle removal. however, in our study infection was the commonest reason and we did not have extrusion in any case. in his study the improvement in va was not significant but our patients showed marked improvement in va. it might be because of the different patient selection criteria as we included only fresh detachments in our study. different types of explants were studied by different authors but we used only radial silicone sponge. 18,19 singh s has shown a rare case of buckle infection with curvularia species. 19 park sw et al. described nida usman, et al pak j ophthalmol. 2022, vol. 38 (2): 157-161 160 that patient selection was a very important criteria in case of scleral buckling in the management of rhegmatogenous retinal detachment and its outcomes. 20 limitations of our study was that it was a case series with only limited follow up. large number of patients with longer follow ups and multi-center data are required to further prove the results of this particular study. conclusion early removal of scleral buckle at 6 weeks not just gives anatomical but functional success as well with minimal chances of post-operative infections. the discomfort that patients experience in case of buckle (sponge) is also reduced. ethical approval the study was approved by the institutional review board/ ethical review board (coavs/817/2020). conflict of interest authors declared no conflict of interest. disclaimer this research study was conducted at kemu and all authors were present in the said place during the conduct of the study. references 1. schwartz sg, flynn hw. pars plana vitrectomy for primary rhegmatogenous retinal detachment. clin ophthalmol. 2008; 2 (1): 57-63. doi: 10.2147/opth.s1511. 2. falkner-radler ci, myung js, moussa s, chan rv, smretschnig e, kiss s, et al. trends in primary retinal detachment surgery: results of a bicenter study. retina. 2011; 31 (5): 928-936. doi: 10.1097/iae.0b013e3181f2a2ad. 3. heimann h, bartz–schmidt ku, bornfeld n, hilgers rd, nodov m, weiss c, et al. results of the scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (spr study). invest. ophthalmol. vis. sci. 2006; 47 (13): 2690. 4. kazi ms, sharma vr, kumar s, bhende p. indications and outcomes of scleral buckle removal in a tertiary eye care center in south india. oman j ophthalmol. 2015; 8 (3): 171-174. doi: 10.4103/0974-620x.169891. 5. smiddy we, miller d, flynn hw jr. scleral buckle removal following retinal reattachment surgery: clinical and microbiologic aspects. ophthalmic surg. 1993; 24 (7): 440-445. pmid: 8351089. 6. thanos a, papakostas td, young lh. scleral buckle: does it still have a role in retinal detachment repair? int ophthalmol clin. 2015; 55: 147-156. doi: 10.1097/110:0000000000000085. 7. paulus ym, leung ls, pilyugina s, blumenkranz ms. comparison of pneumatic retinopexy and scleral buckle for primary rhegmatogenous retinal detachment repair. ophthalmic surg lasers imaging retina. 2017; 48 (11): 887-893. doi: 10.3928/23258160-20171030-03 8. schwartz sg, flynn hw. primary retinal detachment: scleral buckle or pars plana vitrectomy? curr opin ophthalmol. 2006; 17 (3): 245-250. doi: 10.1097/01.icu.0000193097.28798.fc. 9. deokule s, reginald a, callear a. scleral explant removal: the last decade. eye (lond). 2003; 17 (6): 697-700. doi: 10.1038/sj.eye.6700491. 10. khan aa. transpalpebral extrusion of a solid silicone buckle. oman j ophthalmol. 2009; 2: 89-90. doi: 10.410/0974-620x.53040. 11. ozgur ok, modjtahedi sp, lin lk. eyelid fistula caused by a scleral buckle. ophthal plast reconct surg. 2010; 26: 369-371. doi:10.1097/iop.0b013e3181c78326. 12. russo ce, ruiz rs. silicone sponge rejection. early and late complications in retinal detachment surgery. arch ophthalmol. 1971; 85: 647-650. doi: 10.1001/archipelago. 1971.00990050649001. 13. shami mj, abdul rahim as. intrusion of a scleral buckle: a late complication of retinal reattachment surgery. retina (philadelphia, pa) 2001; 21: 197. doi: 10.1097/00006982-200104000-00027. 14. voegtle r, laplace o, metge f, nordmann jp. cutaneous extrusion of a silicone sponge explanation retina (philadelphia pa). 2001; 21: 565-566. doi: 10.1097/00006982-200110000-60035. 15. tsui i. scleral buckle removal: indications and outcomes. surv ophthalmol. 2012; 57 (3): 253-263. doi: 10.1016/j.survophthal.2011.11.001. 16. moisseiev e, fogel m, fabian id, barak a, moisseiev j, alhalel a. outcomes of scleral buckle removal: experience from the last decade. curr eye res. 2017; 42 (5): 766-770. doi: 10.1080/02713683.2016.1245423. 17. rasouli m, khuthaila m, spirn mj, garg sj, greve md, hsu j. outcomes of scleral buckle removal with and without concurrent prophylactic laser retinopexy. can j ophthalmol. 2014; 49 (1): 30-34. doi: 10.1016/j.jcjo.2013.07.011. early removal of scleral buckle 161 pak j ophthalmol. 2022, vol. 38 (2): 157-161 18. shrivastav a, kumar s, singh s, agarwal m, sapra n, gandhi a. microbiological profile and antibiotic susceptibility of scleral buckle infection in north india. indian j ophthalmol. 2019; 67 (5): 644. doi:10.4103/ijo.ijo_1094_18. 19. singh s, shrivastav a, agarwal m, gandhi a, mayor r, paul l. a rare case of scleral buckle infection with curvularia species. bmc ophthalmol. 2018; 18: 35. https://doi.org/10.1186/s12886-018-06954 20. park sw, lee jj, lee je. scleral buckling in the management of rhegmatogenous retinal detachment: patient selection and perspectives. clin ophthalmol. 2018; 12: 1605-1615. published 2018 aug 30. doi:10.2147/opth.s153717 authors’ designation and contribution nida usman; consultant ophthalmologist: concepts, design, literature search, data acquisition, manuscript preparation. muhammad ali haider; assistant professor: data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (3): 300-305 300 original article inter-observer reproducibility of axial ocular measurements with non-contact haag-strait biometer muhammad suhail sarwar 1 , sehrish shahid 2 , muhammad arslan ashraf 3 , shaista kanwal 4 1-4 department of ophthalmology, mayo hospital, lahore abstract purpose: to check inter observer reproducibility of axial ocular measurements i.e. central corneal thickness (cct), anterior chamber depth (acd), aqueous depth (ad), lens thickness (lt), anterior segment lens (asl), vitreous length (vl) and axial length (al) with non-contact haag-strait biometer. study design: comparative reproducibility analysis. place and duration of study: college of ophthalmology and allied vision sciences (coavs), mayo hospital, lahore. methods: this study included 66 healthy students (132 eyes). data was collected through self-designed proforma by 2 operators independently. spss 21 was used for data analysis. interclass correlation was applied for agreement between the two readings. interclass coefficient (icc) value greater than 0.7 was considered as excellent correlation. results: the mean cct, ad, acd, lt, asl, vl, and al were 526.47 ± 35.72 µm and 526.47 ± 36.06 µm (icc = 0.92); 2.93 ± 0.29 mm and 2.93 ± 0.29 mm (icc = 0.81); 3.45 ± 0.30 mm and 3.46 ± 0.30 mm (icc = 0.79); 3.58 ± 0.28 mm and 3.56 ± 0.22 mm (icc = 0.76); 7.03 ± 0.30 mm and 7.02 ± 0.27 mm (icc = 0.80); 16.56 ± 0.85 mm and 16.62 ± 0.81 mm (icc = 0.72); and 23.59 ± 0.85 mm and 23.64 ± 0.87 mm (icc: 0.76) of observer 1 and 2, respectively. conclusion: non-contact biometer (haag-strait) has high inter-observer reproducibility with strong interclass coefficient of greater than 0.72. key words: biometry, axial length, central corneal thickness, anterior chamber depth. how to cite this article: sarwar ms, shahid s, ashraf ma, kanwal s. inter-observer reproducibility of axial ocular measurements with non-contact haag-trait biometer. pak j ophthalmol. 2021, 37 (3): 300-305. doi: 10.36351/pjo.v37i3.1239 introduction in last few decades, modernizations such as phacoemulsification, ocular biometry and intraocular lens (iol) power estimate formulas have improved the correspondence: muhammad arslan ashraf department of ophthalmology, mayo hospital, lahore email: rajkumararslan@yahoo.com received: march 08, 2021 accepted: may 10, 2021 refractive outcomes of cataract surgery. 1-3 to encounter these prospects, consideration to precise biometry reading is critical. in recent cataract surgery and corneal refractive surgery, the biometric parameters like corneal curvature, cct (central corneal thickness), acd (anterior chamber depth), lt (lens thickness) and al (axial length), asl, vl are the most significant to achieve good refractive results. 4,5 like contact biometer, optical biometry gives iol power calculation which is the key to get an emmetropic outcome after the surgery. 6-10 open access muhammad suhail sarwar, et al 301 pak j ophthalmol. 2021, vol. 37 (3): 300-305 non-contact optical biometry devices use the principle of partial coherence interferometry (pci). it uses a 780-nm semiconductor diode laser. besides al, it can also measure acd and keratometry (k) based on 6 points of reference in a 2.3 mm zone. it has an accuracy of ± 0.02 mm for al measurement; with excellent reproducibility compared with ultrasound devices. 11 it also measures cct which is important in vision improvement surgeries e.g. laser in situ keratomileusis (lasik), as well as in glaucoma diagnosis and other corneal diseases. in addition, it can also provide measurements for lt. 11-13 this non-contact technique is associated with increased patient comfort and decreased risk for corneal complications when compared with immersion ultrasound biometry. it also allows for patient fixation during the measurement process, which increases the likelihood of the al measurement being directly aligned to the fovea. however, obtaining measurements can be tough and less reliable in the human eyes with corneal opacities, dense posterior sub-capsular cataracts (psc), macular disease, and poor fixation. 11,14 this study was done to find out the repeatability of axial ocular measurements i.e. cct (central corneal thickness), acd (anterior chamber depth), lt (lens thickness), anterior segment lens (asl), vitreous length (vl) and al (axial length) measured with noncontact biometer in patients visiting mayo hospital lahore. methods it was a comparative reproducibility analysis and 132 was the sample size of healthy individuals who were students of college of ophthalmology and allied vision sciences (coavs), mayo hospital, lahore. the mean age of males was 20.73 ± 2.337 and females was 21.17 ± 2.514 (table 1). the sampling technique used in this study was non-probability convenient sampling. patients with poor fixation, any opacity other than cataract or any other ocular pathology were excluded. equipment used was pen torch, slit lamp and noncontact biometer (haag streit model: ls 900). log mar visual acuity chart was used for visual acuity. patients with visual acuity of 0.5 log mar or better were included. age, gender and literality were independent variables while axial ocular parameters like cct, acd, ad, lt, asl, vl and al were dependent variables. quantitative variables like age, cct, ad, acd, lt, asl, vl and al were presented as mean ± sd. spss 21 software was used for data analysis. interclass correlation was applied for agreement between the two readings. interclass coefficient (icc) value greater than 0.7 was considered as excellent correlation. results table 2 shows the mean axial ocular measurements, measured by observer 1 and 2. interclass correlation showed excellent correlation between the two cct readings (0.921), as well as between two readings of ad (0.813), acd (0.792), lt (0.757), asl (0.795), vl (0.719) and al readings (0.759). table 1: descriptive statistics of age distribution among gender. descriptive statistics gender n minimum maximum mean std. deviation statistic statistic statistic statistic std. error statistic female age 74 18 28 20.73 .272 2.337 male age 58 18 28 21.17 .330 2.514 inter-observer reproducibility of axial ocular measurements with non-contact haag-strait biometer pak j ophthalmol. 2021, vol. 37 (3): 300-305 302 table 2: descriptive statistics of cct, ad, acd, lt, asl, vl and al measured by observer i and ii. descriptive statistics minimum maximum mean std. deviation intra-class correlation mean diff. std. deviation statistic statistic statistic std. error statistic single measures average measures cct1 432 601 526.4697 3.10887 35.71824 .921 a .959 c 0 14.355 cct2 430 610 526.4697 3.13861 36.05984 ad1 2.23 3.84 2.935 0.02529 0.29052 .813 a .897 c 0.001 0.17912 ad2 2.25 3.86 2.934 0.02552 0.29322 acd1 2.49 4.37 3.4522 0.02574 0.29574 .792 a .884 c -0.008 0.18911 acd2 2.72 4.38 3.4602 0.02518 0.28932 lt1 2.7 4.43 3.5752 0.02062 0.23693 .757 a .862 c 0.0135 0.16016 lt2 3.06 4.43 3.5617 0.01935 0.22237 asl1 5.65 7.92 7.0273 0.02596 0.29826 .795 a .886 c 0.0055 0.18216 asl2 6.32 7.99 7.0219 0.02337 0.26847 vl1 14.28 18.75 16.5575 0.07441 0.85495 .719 a .837 c -0.0574 0.62425 vl2 15.32 18.94 16.6148 0.0706 0.81115 al1 21.63 25.71 23.58482 0.07425 0.853064 .759 a .863 c -0.0519 0.59786 al2 21.99 25.8 23.6367 0.07568 0.86948 a. the estimator is the same, whether the interaction effect is present or not. b. type a intra-class correlation coefficients using an absolute agreement definition. c. this estimate is computed assuming the interaction effect is absent, because it is not estimable otherwise. figure 1: scatter chart showing regression value (0.846), strong relationship between both measurements of cct. figure 2: scatter chart showing regression value (0.676), moderate relationship between both measurements of acd. muhammad suhail sarwar, et al 303 pak j ophthalmol. 2021, vol. 37 (3): 300-305 figure 3: scatter chart showing regression value (0.576), moderate relationship between both measurements of al. figure 4: scatter chart showing regression value (0.575), moderate relationship between both measurements of lt. figure 5: scatter chart showing regression value (0.519), moderate relationship between both measurements of vl. figure 6: scatter chart showing regression value (0.637), moderate relationship between both measurements of asl. discussion optical biometry is being widely used by ophthalmologists to measure axial ocular measurement of eyes and to calculate the intraocular lens power excluding 5 to 10 percent of those eyes with dense cataract or poor fixation. with the help of biometer we can measure the cct, ad, lt, al and iol power of eye. the accuracy of all parameters that can be measured by optical biometer is imperative for exact intraocular lens power calculation. in this study, like in some previous studies cct, ad, acd, asl, vl and al measurements have been performed by 2 observers. andrew kc et al. showed a study to assess the repeatability and accuracy of non-contact device. the al and acd were measured by two practitioners independently by using non-contact biometer followed by ultrasound. there was good repeatability of al and acd. there was no difference on al and acd between the two practitioners. 15 andrew carkeet et al. also found the al and acd measurements with noncontact showed better repeatability. the mean difference of al and acd between the readings 2 and 1 was -0.006 mm and 0.009 mm, respectively. 16 l p j cruysberg and co-workers evaluated the reproducibility with non-contact biometer of the inter-observer reproducibility of axial ocular measurements with non-contact haag-strait biometer pak j ophthalmol. 2021, vol. 37 (3): 300-305 304 lenstar ls 900. cct, acd, lt and al were attained to regulate the reproducibility of the lenstar. the reproducibility of the lenstar was more than 0.9%; for cct, acd, lt, k values and al measurements. even though all correlations were highly significant (p, 0.001). the reproducibility of the lenstar was excellent. 17 in another study, the exactness of axial length measurements was tremendously high with icc of 0.759. 18 some of the measurements can be little different when taken by different instruments and technicians, but some of these measurements should be firmly checked in cases like central corneal thickness and cases of glaucoma or refractive surgery evaluation. this study measured the mean cct of observer 1 and 2 as 526.47 ± 35.72 µm and 526.47 ± 36.06 µm, respectively. interclass correlation (icc) showed excellent correlation between the two reading (icc: 0.921). ramazan yagc et al, also reported that the assortment of agreement for reproducibility was great for the measurements of central corneal thickness (1.610 and 3.077 for normal eyes and for the eyes with keratoconus, respectively). 18 bengu e. found correlation coefficient to be 99.3% for lenstar and 99.2% for up (ultrasound pachymetry). the measurements taken by the two different technicians seemed to agree in a high level for both lenstar (r = 0.993) and ultrasound pachymetry (r = 0.957). the actual importance of this study was that sample size was large and the interobserver unpredictability was estimated for both olcr (optical low-coherence reflectometry) and up (ultrasound pachymetry). 19 in our study, mean ad was 2.9350 ± 0.291 mm and 2.934 ± 0.293 mm of observer 1 and 2, respectively. icc showed excellent correlation between two reading (icc: 0.813). the mean acd of observer 1 and 2 was 3.452 ± 0.296 mm and 3.460 ± 0.289 mm of observer 1 and 2, respectively. icc showed excellent correlation between two reading (icc: 0.792). according to a former study of lenstar device, the accuracy of measurement of anterior chamber depth was high and the assortment of agreement was 0.025 millimeter and 0.069 millimeter in normal (emmetropic) eye and the eye with keratoconus, respectively. according to the assessment of haigis formula, which uses the preoperative measurement of anterior chamber depth in the calculation of intraocular lens power, a difference of 0.06 millimeter in acd affects the ultimate refraction by only 0.05 d. 18 j. s shammas et al. also found that, with icc of 0.946 the accuracy of the acd measurements was high. 20 in our study, icc showed excellent correlation between two lt readings (icc: 0.757). h. john shammas found high accuracy of the measurement of lt, with an icc of 0.963. ramazan yagc et al, found that the non-contact biometer attained brilliant reproducibility for the measurements of axial length (assortment of agreement 0.038 and 0.041 for normal eyes and eyes having keratoconus, respectively). in a usual eye, a difference of 0.04 millimeter affects the final refraction by almost 0.10 d. 18 limitation of this study are small sample size and it was a single center study. more data for our population is needed for further evaluation. this study can be improved with the participation of more than two observers. moreover, comparison of reproducibility and repeatability of non-contact with contact biometer can also be done. conclusion it is concluded that non-contact biometer (haigstrait) has high reproducibility. the interclass coefficient value for cct, ad, acd, lt, asl, vl and al is greater than 0.7. ethical approval the study was approved by the institutional review board/ ethical review board. 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al-mohtaseb m, mitchell p. weikert m. updates in biometry. intern ophthalmol clin. 2017; 57 (3): 115-124. 12. huang j, lu w, savini g, chen h, wang c, yu x, et al. comparison between a new optical biometry device and an anterior segment optical coherence tomographer for measuring central corneal thickness and anterior chamber depth. j ophthalmol. 2016; 2016. 13. ashraf ma, sarwar ms, afzal ma, khalid i, shahid s. comparison of axial ocular measurements with contact and non-contact biometry. pak j ophthalmol. 2020; 36(1). doi: https://doi.org/10.36351/pjo.v36i1.922 14. de souza rg, de oca im, esquenazi i, al-mohtaseb z, weikert mp. updates in biometry. intern ophthalmol clin. 2017; 57 (3): 115-24. 15. lam ak, chan r, pang pcjo, optics p. the repeatability and accuracy of axial length and anterior chamber depth measurements from the iolmaster™. ophthalmic physiol opt. 2001; 21 (6): 477-483. 16. carkeet a, saw s-m, gazzard g, tang w, tan dtjo. repeatability of iol master biometry in children. optom vis sci. 2004; 81 (11): 829-834. 17. cruysberg lp, doors m, verbakel f, berendschot tt, de brabander j, nuijts rm. evaluation of the lenstar ls 900 non-contact biometer. br j ophthalmol. 2010; 94 (1): 106-110. 18. yağcı r, güler e, kulak ae, erdoğan bd, balcı m, hepşen i̇f. repeatability and reproducibility of a new optical biometer in normal and keratoconic eyes. jcataract refract surg. 2015; 41 (1): 171-177. 19. koktekir be, gedik s, bakbak b. comparison of central corneal thickness measurements with optical low-coherence reflectometry and ultrasound pachymetry and reproducibility of both devices. cornea, 2012; 31 (11): 1278-1281. 20. shammas hj, hoffer kj. repeatability and reproducibility of biometry and keratometry measurements using a noncontact optical lowcoherence reflectometer and keratometer. am j ophthalmol. 2012; 153 (1): 55-61. e2. authors’ designation and contribution muhammad suhail sarwar; ms: concepts, design, manuscript preparation, manuscript review. sehrish shahid; consultant ophthalmologist: literature search, data acquisition, data analysis, manuscript preparation, review. muhammad arslan ashraf; consultant ophthalmologist: literature search, data acquisition, data analysis, statistical analysis, manuscript review.. shaista kanwal; consultant ophthalmologist: data acquisition, manuscript preparation, manuscript review. .…  …. https://doi.org/10.36351/pjo.v36i1.922 173 pak j ophthalmol. 2021, vol. 37 (2): 173-178 original article treatment of severe recalcitrant fungal keratitis using subconjunctival fluconazole as an adjunctive therapy ambreen gul 1 , fuad ahmad khan niazi 2 , ali raza 3 1-3 department of ophthalmology, holy family hospital, rawalpindi medical university, rawalpindi abstract purpose: to evaluate the safety and effectiveness of 2% subconjunctival injection of fluconazole as an adjunctive treatment in severe recalcitrant fungal keratitis. study design: interventional case series. place and duration of study: ophthalmology department of holy family hospital, rawalpindi medical university, from january 2019 to august 2019. methods: the study included 18 eyes of 18 patients with severe resistant fungal corneal ulcer.we excluded those cases who had known hypersensitivities to fluconazole. these ulcers were refractory toprimary conventional antifungal therapy with topical natamycin, topical and systemic fluconazole. sample for culture was taken with sterile cotton bud and scraping was taken with kimura spatula. all resistant cases were given1.0 ml of 2% subconjunctival fluconazole injection once a day for at least one week. after that depending upon the condition, the injections were givenonalternate days for 2 weeks. results: average age of the patients was 35.22 years (sd ± 10.42). among total 18 patients, six (33.33%) were females and 12 (66.67%) were males. thirteen (72.22%) cases showed absolute response after one week and 5 (27.77%) cases needed more injections. four (22.22%) of these 5 cases partiallyimproved andone case failed to show improvement. final vision varied in different cases according to the position of the residual scar. five cases ended up in keratoplasty. local or systemic toxicity was not seen in any case. conclusion: subconjunctival injection of 2% fluconazole can be used as an adjunctive therapy for severe fungal keratitis without any toxic complications. key words: keratomycosis, evisceration, keratoplasty. how to cite this article: gul a, niazi fak, raza a. treatment of severe recalcitrant fungal keratitis using subconjunctival fluconazole as an adjunctive therapy. pak j ophthalmol. 2021, 37 (2): 173-178. doi: http://doi.org/10.36351/pjo.v37i2.1081 introduction globally, one of the common reasons of unilateral correspondence: ambreen gul department of ophthalmology, holy family hospital, rawalpindi medical university, rawalpindi email: amber-gul@hotmail.com received: june 13, 2020 accepted: march 2, 2021 blindness is keratitis. in majority of the cases, corneal infections are treatable or avoidable.¹ in developing countries like pakistan, the second most common cause of visual impairment is central corneal opacity, cataract being the first. 2 keratitis can be secondary to infectious agent or trivial trauma to eye. infectious keratitis, a sight threatening inflammation and necrosis of stromal layer of cornea, is commonly correlated with micro pathogens like bacteria, virus or fungus. 3 microbial keratitis leads to irreversible loss of vision due tosequel like suppuration, corneal melting, http://doi.org/10.3352/jeehp.2013.10.3 treatment of severe recalcitrant fungal keratitis using subconjunctival fluconazole as an adjunctive therapy pak j ophthalmol. 2021, vol. 37 (2): 173-178 174 vascularization and opacification of cornea. 4 of all the infectious keratitis pathogens, fungi have been reported to be the most virulent and intangible, posing a diagnostic and therapeutic challenge to ophthalmic clinicians worldwide, particularly in tropical countries with temperate warm zones. 5 mycotic keratitis is accounted to be roughly 44% among all other causes of keratitis in developing countries. 6 precipitating factors leading to increased incidence includeinjury to eye especially vegetative, contact lenses usage, immunosuppression caused by steroids and antibiotics usage and systemic illnesses like diabetes and agricultural occupation. 7 these pathogens invade the defective epithelium leading to penetration of corneal stroma causing immunologic inflammation and destruction leading to devastating tissue injury and scarring. 8 keratitis which is refractory to medical treatment leads to progressive disease like perforated corneal ulcers at presentation. in 15 – 27% of fungal infections the outcome is surgical intervention like keratoplasty, evisceration or enucleation. 9 majority of therapeutic keratoplasties are performed for severe, advanced and non-healing ulcers. 9 numerous types of fungi such as yeast like candida albicans, dimorphic and filamentous pathogens like fusarium and aspergillus are responsible for fungal keratitis. etiologyof fungal keratitis and prevalence ofparticularmicrobes in specific geographic areas demonstrates inconsistency. other robust pathogens include mucor and alternaria. 10 early detection of fungal keratitis and referral along with justified medical treatment are imperative for favorable prognosis. reasons for medical treatment failure include difficulty in availability of antifungal agents, limited penetration of the drugs, cost and toxic side effects. despite advances in medical treatment, cure of fungal keratitis is complex. one of the reasons is that majority of the antifungal drugs are fungi static and not fungicidal. 11 treatment modalities based on routesof administering drugs are direct topical, intra stromal, intracameral, subconjunctival, intravitreal and systemic antifungal agents. there are various therapeutic drug regimens but all groups have their own benefits and side effects. 12 commonly used drugs are polyenes such as amphotericin, natamycin and azoles like fluconazole, itraconazole. choice of agent and route depends on severity and type of fungal infection. first line of treatment is with topical polyenes. if keratitis is deep with full thickness stromal or endothelial involvement and aqueous or anterior chamber invasion, subconjunctival, intra-cameral or intra-stromal routes are preferred. intravitreal injections are reserved for keratitis related endophthalmitis. systemic antifungals are used for scleritis or endophthalmitis but their efficacy is not clear. 13 advanced drugs like azoles are superior to polyenes in better penetration,broad antifungal spectrum, less toxicity and are relatively cheaper. fluconazole is the first generation bistriazole with added benefit of less protein binding, slow metabolism and fewer side effects. due to better ocular penetration, it achieves higher levels in anterior chamber for longer duration. 14,15 sub-conjunctival injection of highly toxic drugs like amphotericin and natamycin is discouraged due to thinning of sclera and necrosis of conjunctiva. 16 sub-conjunctival injection of 2% fluconazole has been shown to offer pharmacokinetic benefits as well as broad spectrum coverage. 17 the rationale of the present study is to scrutinize and report the effectiveness and safety of subconjunctival injection of 2% fluconazole in treating severe recalcitrant fungal keratitis, refractory to conservative antifungal treatment regimens. methods after taking approval from the institutional review board, current study enrolled eighteen patients with clinical diagnosis of severe fungal keratitis. the patients were of the grade 2 or 3 jones criteria (mentioned in table 1) and not responding to or deteriorating on conservative topical and systemic antifungal medication. we excluded those cases who had known hypersensitivities to fluconazole. informed written consent was obtained regarding the drug injection and its reported pros and cons. after detailed history and demographic data entry, we examined the patients in cornea clinic and slit lamp biomicroscopy was done. corneal culturewas taken with sterile cotton bud and scraping was taken with kimura spatula and put on sterile glass slide. the samples were sent to microbiology laboratory. microscopic inspection of hyphae or pseudohyphae was set as a diagnostic criteriafor fungal keratitis. hyphae were considered as molds and pseudohyphae as yeast by microscopic analysis. in those patients, who had both negative stain and culture, aqueous tap was done and sent for culture sensitivity. all patients were admitted in hospital and ambreen gul, et al 175 pak j ophthalmol. 2021, vol. 37 (2): 173-178 advised first-line therapy of natamycin eye drops four hourly, topical fluconazole 2% eye drops one hourly, atropine 1% eye drops twice a day and moxifloxacin eye drops to prevent secondary bacterial keratitis. if the ulcer worsened and showed no response to conventional regimen, oral fluconazole was added (200 mg) on day 1 then 100 mg daily for two weeks after assessing liver function tests.in patients who failed to respond after 14 days, sub-conjunctival fluconazole injection was started. the intravenous solution of fluconazole 2%, up to 1.0 ml, was injected sub-conjunctivaly in infero-temporal fornix once daily for at least 7 days. all injections were given by single consultant ophthalmologist under topical anesthesia. after the first week, those cases who still had hypopyon or stromal infiltration, sub-conjunctival injections were continued on alternate days for 2 weeks. the patients were followed up for six months after discharge to observe recurrent infection. patients were divided into three groups on the basis of response to treatment. group a cured patientswho showed absolute response to the treatment with complete resolution of corneal stromal/endothelial infiltrates and hypopyon following 2% sub-conjunctival fluconazole injection for 7 days. group b incomplete response was defined as partial resolution of primary infection including infiltrates and hypopyon after 7 days of 2% sub-conjunctival fluconazole injection. group c noresponse was defined as not responding primary infectionandadvanced endophthalmitis leading to surgical intervention. table 1: jones grading criteria. factor grade 1 grade 2 grade 3 location non axial central or peripheral central or peripheral area 2 mm 2 – 6mm > 6mm depth superficial one third superficial two third extending to inner one third anterior segment inflammation mild moderate severe hypopyon/ fibrionus exudate results average age of the patientswas 35.22 years (sd ± 10.42) with a range of 16 to 60 years. among 18 patients, six (33.33%) were women and 12 (66.67%) were men.culture sensitivity results are shown in figure 1.four (22.22%) patients had diabetes mellitus; two (11.11%) had tuberculosis, two (11.11%) had rheumatoid arthritis, rest of the patients had no systemic risk factors. eleven eyes (61.11%) had history of vegetative trauma along with organic foreign body. four eyes (22.22%) had history of longterm use of topical corticosteroid or corticosteroidantibiotic combination therapy. eight (44.44%) patients were agriculturists and fieldworkers. peripheral corneal ulcer was present in 13 (72.22%) patients while 5 (27.77%) patients had central keratitis. size of the infiltrate was 3mm in 3 (16.66%) cases,36mm in 11 (61.11%) cases and > 6mm in 4 (22.22%) cases. depth of infiltration was superficial 2/3 rd in 13 (72.22%) cases and extending to inner 1/3 rd leading to endothelial plaque in 5 (27.77%) cases. 4 (22.22%) cases had corneal thinning with impending perforation and 1 case had descemetocele at presentation. total of 17 cases showed effective response. thirteen were cured with complete resolution of infection and fourpatients partially responded requiring repeated injections. one patient of our series showed no response and underwent evisceration. in 13 cases sub-conjunctival injection of fluconazole 2% 1ml was given for 7 days. five patients required repeated injections. hypopyon resolved after repeated sub-conjunctival fluconazole therapy within mean 6.23 days. one patient with descemetocele did not show any signs of improvement in primary infection figure 1: culture sensitivity and staining results. treatment of severe recalcitrant fungal keratitis using subconjunctival fluconazole as an adjunctive therapy pak j ophthalmol. 2021, vol. 37 (2): 173-178 176 or hypopyon. ulcer healed within 4.8 weeks. four cases ultimately required penetrating keratoplasty for severe corneal scarring and it was done 6 months after ulcer resolution. three patients presented with recurrent fungal keratitis within 4 weeks of last subconjunctival fluconazole. they were managed with repeated subconjunctival fluconazole injections and they showed partial response. only ocular side effect reported was sub-conjunctival hemorrhage. patients were kept on follow-up for at least 6 months for side effects or recurrence. pre-treatment and post-treatment visual acuity is shown in table 2. table 2: pre-treatment and post treatment visual acuity. presenting visual acuity no of cases post treatment visual acuity no of cases perception of light 3 no perception of light 1 hand movements 9 hand movements 1 counting fingers 6 counting finger-6/60 3 6/60-6/24 6/36-6/24 9 6/18-6/12 6/18-6/12 4 discussion prevalence of fungal keratitis is high in tropical and subtropical developing countries leading to severe ocular morbidity. it is one of the principle causes of blindness with strikingly poorer prognosis than other infectious keratitis. majority of the cases are associated with vegetative traumain field workers from rural areas and delayed presentation often results in advanced complicated cases. 1,5 in pakistan, the reported incidence of fungal keratitis cases was38.45% according to a study conducted in a tertiary care centre in larkana. 18 this reported incidence is comparable to 44.1% amongst mettapracharak patients and also identical to that reported china. 19 on account of narrow spectrum, medical therapy failure often leads to call for early surgical intervention like penetrating keratolpasty and enucleation/evisceration. in a study carried out by xie l et al, 35.1% of fungal keratitis patients received keratoplasty treatment for not responding to medical therapy. although therapeutic pkp is effective in curing and preserving the eye along with visual rehabilitation but it is also associated with complications like recurrent fungal keratitis, graft rejection and failure requiring intensive antifungal therapy. 8,9 availability of good grafts is a limitation in our setups. it is said that one cornea is available for 70 patients who require corneal graft, leading to severe imbalance between global supply and demand. majority of the patients with advanced complicated fungal keratitis end up in evisceration before getting access to corneal transplant. 20 for deep fungal keratitis with hypopyon, higher concentrations of drug isrequired in the anterior chamber for longer duration and that can be achievedwith sub-conjunctival injections. problem with sub-conjunctival administration of antifungal agents is toxicity especially polyenes. azoles group of antifungal drugs have enhancedocular penetration against several fungal pathogens. 21 fluconazole 2% solution is used as topical agent as well. in comparison to amphotericin b it has been recognized to have very low ocular toxicity and superior ocular penetration. intact epithelium leads to lesser penetration of antifungal agents but epithelial debridement in already thin corneas can lead to progression or worsening of ulcer along with risk of perforation. fluconazole has been reported to show equal penetration in debrided and non-debrided corneas of fungal keratitis. 22 role of sub-conjunctival fluconazole has been reported in few clinical studies of fungal keratitis not responding to conventional antifungal agents. however, there are no clear guidelines for dosage and frequency of administration. yilmaz et al conducted a study on role of 2% subconjunctival fluconazole 1mltwice a day for 5 days initiallyand then once a day for 2 weeksin 13 patients and they found that 12 patients healed and one patient required enucleation. 23 sachin dev et al reported a study of 33 patients who received 0.5 ml of 0.2% subconjunctival fluconazole once a day. out of total 33 patients, 18 responded to treatment. they reported that subconjunctival injection was safer for a maximum of 60 days. 24 isipradit s et al reported 50 percent cure rate and 83.3% successful treatment in a study of 6 patients who received 0.5 ml of 0.2% subconjunctival fluconazole twice a day for initial 5 days then once a day for 14 days along with intracameral amphotericin b and topical antifungal and oral itraconazole. 25 in the current study, signs of clinical improvement as hypopyon resolution or decrease in size of infiltrate was seenas early as 3 rd day after first injection in eyes with candidainfection. in eyes with fusarium, mucor and aspergillus, response was seen as late as 12 days after first subconjunctival injection. yilmaz et al reported healing after 10 injections and seven patients required 5 – 14 days of additional injections. 23 ambreen gul, et al 177 pak j ophthalmol. 2021, vol. 37 (2): 173-178 limitations of our study are small sample size and negative cultures in many cases. it could be due to scrapping done superficially because of corneal thinning and melting, but inner 1/3 rd of stroma was also involved in many cases. it could also be due to the fact that patients were already taking antifungal before referral to our hospital. conclusion prompt and timely diagnosis of fungal keratitis along with combined fortified antifungal agents and subconjunctival fluconazole 2% for grade 2 and 3 fungal keratitis is a good strategy for non-responding ulcers. ethical approval the study was approved by the institutional review board/ ethical review board. (86/iref/rmu/2019). conflict of interest authors declared no conflict of interest. references 1. acharya y, acharya b, karki p. fungal keratitis: study of increasing trend and common determinants. nepal j epidemiol 2017; 7 (2): 685-693. 2. dineen b, bourne ra, jadoon z. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91 (8): 1005-1010. 3. srigyan d, gupta m, behera hs. keratitis: an inflammation of cornea. ec ophthalmol. 2017; 6 (6): 171-177. 4. austin a, lietman t, rose-nussbaumer j. update on the management of infectious keratitis. ophthalmology, 2017; 124 (11): 1678-1689. 5. manikandan p, abdel-hadi a, singh yrb. fungal keratitis: epidemiology, rapid detection, and antifungal susceptibilities of fusarium and aspergillus isolates from corneal scrapings. bio med res intern. 2019: 6395840. 6. saha s, banerjee d, khetan a. epidemiological profile of fungal keratitis in urban population of west 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j ophthalmol. 2016; 64 (5): 346-357. doi: 10.4103/0301-4738.185592. 14. savani dv, perfect jr, cobo lm, durack dt. penetration of new azole compounds into the eye and efficacy in experimental candida endophthalmitis. antimicrob agents chemother, 1987; 31: 6 –10. 15. foster cs. miconazole therapy for keratomycosis. am j ophthalmol, 1981; 91: 622–629. 16. shu th, hussein a, kursiah mr. conjunctiva necrosis following subconjunctival amphotericin b injection in fungal keratitis. cureus, 2019; 11 (9): e5580. 17. el-sayed sh, wagdy fm, el-hagaa aa, mottawea ef. topical amphotericin b versus subconjunctival fluconazole injection in the management of fungal keratitis. menoufia med j. 2016; 29 (3): 601-605. 18. shah sia, shah sa, rai p, abbasi sa, fatima h, soomroet aa. etiology of infectious keratitis as seen at a tertiary care center in larkana, pakistan. pak j ophthalmol. 2016; 32 (1): 48-52. 19. ausayakhun s, chaidaroon w. suppurative keratitis: clinical analysis of 224 cases. thai j ophthalmol. 1992; 6: 1-7. 20. wong kh, kam kw, chen lj, young al. corneal blindness and current major treatment concern-graft scarcity. int j ophthalmol. 2017; 10 (7): 1154-1162. 21. yee rw, cheng cj, meenakshi s, ludden tm, wallace je, rinaldi mg. ocular penetration and pharmacokinetics of topical fluconazole. cornea, 1997; 16: 64–71. 22. behrens-baumann w, klinge b, ruchel r. topical fluconazole for experimental candida keratitis in rabbits. br j ophthalmol. 1990; 74: 40–42. 23. yilmaz s, maden a. severe fungal keratitis treated with subconjunctival fluconazole. am j ophthalmol. 2005; 140: 454-458. 24. dev s, rajaraman r, raghavan a. severe fungal keratitis treated with subconjunctival fluconazole. am j ophthalmol. 2006; 141: 783-784. treatment of severe recalcitrant fungal keratitis using subconjunctival fluconazole as an adjunctive therapy pak j ophthalmol. 2021, vol. 37 (2): 173-178 178 25. isipradit s. efficacy of fluconazole subconjunctival injection as adjunctive therapy for severe recalcitrant fungal corneal ulcer. j med assoc thai. 2008; 91 (3): 309-315. authors’ designation and contribution ambreen gul; senior registrar: concepts, design, literature search, final review. fuad ahmad khan niazi; professor: concepts, design, final review. ali raza; professor: concepts, design, final review. .…  …. 371 pak j ophthalmol. 2020, vol. 36 (4): 371-375 original article intra-operative and immediate post-operative complications in a high volume cataract surgery center muhammad ali haider 1 , uzma sattar 2 , muhammad amjad 3 department of ophthalmology, 1 al-ehsan eye hospital, 2 rahbar medical & dental college lahore, 3 huddersfield royal infirmary, uk abstract purpose: to find out the frequency of complications in a high volume phacoemulsification set up at a tertiary care eye hospital in lahore. study design: quasi experimental study. place and duration of study: al-ehsan eye hospital, lahore, from july 2017 to june 2019. methods: surgical outcomes of 6,902 patients who had undergone phacoemulsification were included. patients were excluded if they had ocular infections, lid margin diseases, adnexal diseases, those requiring a secondary anterior chamber surgery and those unfit for the procedure due to medical grounds. every patient underwent a detailed history and complete clinical examination. all patients underwent standard phacoemulsification technique with intraocular lens implantation in most of the cases. complications encountered during high volume cataract surgery were recorded and their percentages were calculated. results: a total of 6.902 patients underwent cataract surgery with 2.66% intra-operative and 6.94% immediate post-operative complications. the most common intra-operative complication was posterior capsular rupture (1.15%). in patients with capsular rupture the intra ocular lens was implanted within the sulcus in 61 cases (0.88%) while in 12 cases (0.17%) anterior chamber lens was implanted because of lack of capsular support. during the surgery intra ocular lens could not be implanted in 7 cases (0.10%) and they were left aphakic. the commonest immediate post-operative adverse outcome was corneal edema with striate keratopathy and decements folds in 197 cases (2.85%). conclusion: high volume cataract surgery using appropriate techniques and sterilization does not compromise the quality of outcomes. key words: cataract, phacoemulsification, vitreous loss. how to cite this article: haider ma, sattar u, amjad m. intra-operative and immediate post-operative complications in high volume cataract surgery center. pak j ophthalmol. 2020; 36 (4): 371-375. doi: https://doi.org/10.36351/pjo.v36i4.1059 correspondence: muhammad ali haider department of ophthalmology al-ehsan eye hospital, lahore email: alihaider_189@yahoo.com received: april 28, 2020 accepted: july 21, 2020 introduction there are multiple etiologies that can cause formation of cataracts. 1,2 numerous medications were investigated to treat cataract; including sorbitollowering agents, aspirin, glutathione-raising agents and antioxidant vitamins c and e. 3 the definite treatment of cataracts still remains removal through surgery and implantation of an intra-ocular lens. 4,5,6 with an advancing age and early presentation, the intra-operative and immediate post-operative complications in cataract surgery pak j ophthalmol. 2020, vol. 36 (4): 371-375 372 disease burden has increased in recent years and despite the advancements in surgical techniques and equipment it poses a significant challenge to the health services. 7,8,9 this is especially a problem in the developing world where lack of disease awareness, lack of education, under developed health services, financial constraints all add up and compound the problems. high volume cataract surgery is now a common practice in most parts of the developing world. 10,11 high volume phacoemulsification is a routine at al-ehsan eye hospital, lahore. a large proportion of patients presenting at the hospital are diagnosed with cataracts and undergo phacoemulsification. in the light of this practice, a study was conducted at the hospital where cases operated by a high volume surgeon were analyzed for per-operative and post-operative complications. methods al-ehsan eye hospital, lahore is a tertiary care eye hospital with a large outpatient and surgical volume. the study was conducted during the period from july 2017 to june 2019. the patients were operated by a single qualified surgeon who operated more than eighty (80) cases per week. ethical approval was sought and consent was taken from every patient before surgery. this study included all patients between 20 and 90 years, whose best corrected visual acuity did not improve by refraction. other indications for cataract surgery included diagnosis and treatment of any associated underlying retinal pathology, performing relevant posterior segment investigations such as oct, ffa, visual fields etc. patients were excluded from study if they had underlying ocular infections, lid margin diseases, associated adnexal diseases, those requiring a secondary anterior chamber surgery and those deemed unfit to undergo the procedure on medical grounds. all patients were recruited from the outpatient department at the hospital. patients underwent a standard protocol from advice of procedure to surgery. every patient on presentation underwent a detailed examination that included a brief history, refraction, anterior segment examination and iop measurement followed by detailed fundus examination. all patients underwent baseline blood tests, viral serology with elisa and biometry with iol master for iol power calculations. all patients were prepped with disposable surgical caps and gowns, vitals were recorded, eyes were marked, pupils were dilated using the 2.5% phenylephrine and 1% mydriacyl eye drops and patients were then taken to the surgical operating room for surgery. the surgery was performed by the surgeon using two fully equipped eye surgical stations. each stationed was manned by an assisting nurse for the surgical trolley and two supporting staff members who assisted in shifting of the patients, providing consumables to the assisting nurse and the surgical team. each station was equipped with an operating microscope, phacoemulsification machine, operating table and surgeon chair. a strict sterilization protocol was followed for the instrument sterilization. the eye to be operated was cleaned with povidone iodine solution before the surgery by the assisting nurse. patients with negative serology for hepatitis b and c viruses were operated first followed by those with positive blood tests for hepatitis b and c viruses. the surgeon switched in between the two operating stations where the prepared patients were ready for surgery. all patients underwent the standard phacoemulsification technique and at the end of each surgery, subconjunctival injections of dexamethasone and gentamycin were given to the patients. any per-operative event was documented after the surgery. all eyes were covered with an eye pad and all patients prescribed steroid and antibiotics eye drops. the patients were instructed to remove the eye pads four hours after surgery and start the drops at two hourly intervals. the patients were examined on the next day in outpatient department by the operating surgeon who documented any post-operative complications in the cases. results the per-operative complications encountered during the high volume surgery varied in spectrum. the most common intra-operative complication recorded was posterior capsular rupture in 80 cases (1.15%). vitreous loss with posterior capsular rupture requiring anterior vitrectomy was encountered in 63 cases (0.91%) while 17 cases (0.24%) had no vitreous prolapse. in patients with capsular rupture the intra ocular lens was implanted within the sulcus in 61 cases (0.88%) while in 12 cases (0.17%) anterior chamber lens was implanted. lens matter drop into the posterior muhammad ali haider, et al 373 pak j ophthalmol. 2020, vol. 36 (4): 371-375 vitreous cavity was encountered in 4 cases (0.05%) that had capsular rupture. two cases (0.002%) had nucleus drop during the surgical procedure. during the surgery intra ocular lens could not be implanted in 7 cases (0.10%) and they were left aphakic. while preforming phacoemulsification iris was damaged in 9 cases (0.13%). per operative surgical hyphema secondary to mechanical trauma was encountered in 5 cases (0.05%). in 4 cases (0.05%) the lens haptics were damaged that required replacement (table1) table 1: frequency of per-operative complications during high volume cataract surgery (percentage). intra-operative complications complication no of patients percentage posterior capsular rupture with vitreous loss 63 0.91% posterior capsular rupture with no vitreous loss 17 0.24% iol implant in sulcus 61 0.88% ac iol implant 12 0.17% posterior capsular rupture with lens matter drop in vitreous 4 0.05% nucleus drop 2 0.002% aphakia 7 0.10% iris chop 9 0.13% surgical hyphema 5 0.07% broken haptic 4 0.05% post-operatively the most common adverse outcome was corneal edema with striate keratopathy and decements folds in 197 cases (2.85%). this adverse outcome was associated with hard cataracts that required excessive chamber manipulation during chopping and phacoemulsification. the most serious complication was intense anterior chamber activity with residual hypopyon in 3 cases (0.04%) on the immediate post-operative day. these patients were promptly treated on the treatment guidelines of postoperative endophthalmitis (table 2). table 2: immediate post-operative complications in high volume cataract surgery. complication no of patients percentage corneal edema + striate keratopathy and dm folds 197 2.85% anteriorchamber reaction (> + 2 cells) 167 2.41% corneal edema 83 1.20% displaced iol requiring repositioning 11 0.15% wound leak + shallow 6 0.08% anterior chamber residual cortex/lens matter 7 0.10% hyphema 5 0.07% hypopyon 3 0.04% discussion cataract is the commonest cause of decreased vision in older age in developing countries like pakistan. 4 in developing countries the increased number of patients with cataract is due to lack of education, lack of disease awareness, under-developed health facilities and financial constrain. in such circumstances, high volume cataract surgery is now a common practice in most parts of the developing world. the same high volume surgical approach was adopted in our surgical setting where we focused on different intra-operative and post-operative complications encountered during high volume cataract surgery operated by a single surgeon. 12 the average surgery time was approximately 3 minutes and approximately 8 – 10 surgeries were performed in a single hour. venkatesh et al. documented 1.9% intraoperative and 12.6% immediate postoperative complications of three high volume surgeons in a community based hospital. their average surgical time was 3.75 minutes per case. 13 in a population based analysis in ontario, canada the association of annual surgeon volume of cataract procedures with their risk of post-operative adverse events was documented. there were 284 797 cataract surgeries in patients older than 20 years performed at 70 hospitals or eye surgery centers. fewer than 1 in 200 patients experienced an adverse event (range 0.33% – 0.41%). surgeons performing 50 to 250 cataract surgeries per year had an adverse event rate of 0.8%. surgeons performing 251 to 500 cataract surgeries per year had an adverse event rate of 0.4%. surgeons performing 501 to 1000 cataract surgeries per year had an adverse event rate of 0.2% and surgeons performing more than 1000 cataract surgeries per year had an adverse event rate of 0.1%. 14 in our study over a course of two years the intraoperative and immediate post-operative complications rate in surgeries performed by a single surgeon was 2.78% and 6.94% respectively. the most common problem faced after the cataract extraction was corneal edema with striate keratopathy and folds in decements membrane in approximately 1.39%. it occurred due to excessive chamber manipulation during chopping of intra-operative and immediate post-operative complications in cataract surgery pak j ophthalmol. 2020, vol. 36 (4): 371-375 374 the lens. this settled approximately after 2 weeks by using intensive steroid therapy every 2 hours in the first week followed by four times a day in the 2 nd week. the commonest intra-operative complication recorded was posterior capsular rupture in total of 80 cases (1.15%). the capsular rupture was dealt most commonly with lens implanted in sulcus (0.88%). 15 the modified sterilization and asepsis protocol adopted to facilitate high-volume cataract surgery in our clinical setting appeared to be safe and effective in preventing postsurgical endophthalmitis with a very low frequency comparable to other studies. 16 in a study conducted at aravind eye hospital on more than 42,000 consecutive cases of high volume cataract surgery, the incidence of endophthalmitis was 0.09% after using a standardized sterilization and prophylaxis protocol. 17 our study shows that by using appropriate sterilization and asepsis protocol, in the hands of an experienced surgeon, high volume cataract surgery does not compromise the surgical outcome with a very low rate of complications that are comparable to other studies. 18 high volume cataract surgeries are affordable, cost effective and if made a standard practice can help in tackling high levels of preventable blindness in the developing countries. 19,20 thus, more data should be collected to develop standard protocols for high volume cataract surgeries. conclusion high volume cataract surgery using appropriate sterilization techniques does not compromise quality of outcomes. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. lundström m, barry p, henry y, rosen p, stenevi u. visual outcome of cataract surgery; study from the european registry of quality outcomes for cataract and refractive surgery. j cataract refract surg. 2013; 39 (5): 673-679. 2. yan x, guan c, mueller a, iezzi b, he m, liang h, et al. outcomes and projected impact on vision restoration of the china million cataract surgeries program. ophthalmic epidemiol. 2013; 20 (5): 294– 300. 3. hashemi h, mohammadi sf, z-mehrjardi h, majdi m, ashrafi e, mehravaran s, et al. the role of demographic characteristics in the outcomes of cataract surgery and gender roles in the uptake of postoperative eye care: a hospital-based study. ophthalmic epidemiol. 2012; 19 (4): 242-248. 4. matta s, park j, subash p, shantha g, khanna rc, rao gn. cataract surgery visual outcomes and associated risk factors in secondary level eye care centers of l v prasad eye institute, india. plos one, 2016; 11 (1): e0144853. 5. chaudhary c, bahadhur h, gupta n. study of cystoid macular edema by optical coherent tomography following uneventful cataract surgery. int ophthalmol. 2015; 35 (5): 685-691. 6. haripriya a, chang df, reena m, shekhar m. complication rates of phacoemulsification and manual small-incision cataract surgery at aravind eye hospital. j cataract refract surg. 2012; 38 (8): 1360-1369. 7. world health organization. programme for the prevention of deafness. global initiative for the elimination of avoidable blindness. available at: http://www.who.int/iris/handle/10665/63748 (2000). accessed january 2, 2018. 8. conrad-hengerer i, hengerer fh, joachim sc, schultz t, dick hb. femtosecond laser-assisted cataract surgery: how far have we come? j cataract refract surg. 2015; 41 (9): 1833-1838. 9. dick hb, conrad-hengerer i, schultz t. intraindividual capsular bag shrinkage comparing standard and laser-assisted cataract surgery. j refract surg. 2014; 30 (4): 228-233. 10. gaskin gl, pershing s, cole ts, shah nh. predictive modeling of risk factors and complications of cataract surgery. eur j ophthalmol. 2016; 26 (4): 328-337. 11. lundström m, goh pp, henry y, salowi ma, barry p, manning s, et al. the changing pattern of cataract surgery indications: a 5-year study of 2 cataract surgery databases. ophthalmology, 2015; 122 (1): 3138. 12. ti se, yang yn, lang ss, chee sp. a 5-year audit of cataract surgery outcomes after posterior capsule rupture and risk factors affecting visual acuity. am j ophthalmol. 2014; 157 (1): 180-185. 13. venkatesh r, muralikrishnan r, balent lc, prakash sk, prajna nv. outcomes of high volume cataract surgeries in developing countries. br j ophthalmol. 2005; 89 (9): 1079–1083. muhammad ali haider, et al 375 pak j ophthalmol. 2020, vol. 36 (4): 371-375 14. gonzález n, quintana jm, bilbao a, vidal s, de larrea nf, díaz v, et al. factors affecting cataract surgery complications and their effect on the postoperative outcome. can j ophthalmol. 2014; 49 (1): 72-79. 15. hashemi h, mohammadpour m, jabbarvand m, nezamdoost z, ghadimi h. incidence of and risk factors for vitreous loss in resident-performed phacoemulsification surgery. j cataract refract surg. 2013; 39 (9): 1377-1382. 16. asencio ma, huertas m, carranza r, tenias jm, celis j, gonzalez-del valle f. a case-control study of post-operative endophthalmitis diagnosed at a spanish hospital over a 13-year-period. epidemiol infect. 2015; 143 (1): 178-183. 17. haripriya a, chang df, reena m, shekhar m. complication rates of phacoemulsification and manual small-incision cataract surgery at aravind eye hospital. j cataract refract surg. 2012; 38 (8): 1360-1369. 18. erie j. rising cataract surgery rates: demand and supply. ophthalmology, 2014; 121 (1): 2-4. 19. klein be, howard kp, lee ke, klein r. changing incidence of lens extraction over 20 years: the beaver dam eye study. ophthalmology, 2014; 121 (1): 5-9. 20. lewallen s, courtright p. gender and use of cataract surgical services in developing countries. bull world health organ, 2002; 80 (4): 300-303. authors’ designation & contribution muhammad ali haider; assistant professor: study design, data collection, write manuscript. uzma sattar; optometrist: result, data analysis, final review. muhammad amjad; consultant ophthalmologist: editing, manuscript review. .…  …. microsoft word 5. asma shams mm pakistan journal of ophthalmology, 2020, vol. 36 (3): 211-215 211 original article efficacy of microwave pulse diode laser and argon laser trabeculoplasty in patients with primary open angle glaucoma asma shams1, narain das2, noman rashid3, m. nasir bhatti4, beenish khan5, jai kumar6 1,2,4,5,6departments of ophthalmology and 3phsiology, shaheed mohtarma benazir bhutto medical college lyari 5um & dc, karachi abstract purpose: to compare the efficacy of the microwave pulse diode laser and argon laser trabeculoplasty in primary open angle glaucoma. study design: quasi experimental study. place and duration of study: shaheed mohtarma benazir bhutto medical college lyari and sindh government lyari general hospital, karachi, from october, 2017 to march, 2018. material and methods: one hundred and sixty patients, between 42 to 61 years with visual acuity of perception of light to 6/36 were enrolled. patients diagnosed with poag were included and patients with intraocular pressure of more than 40 mm hg, previous glaucoma surgery or laser treatment and narrow angle on gonioscopy were excluded. ophthalmic examination included visual acuity, slit lamp examination, fundus examination and visual field status using humphrey perimeter. patients were divided into two groups. group a received microwave pulse diode laser (810) and group b received argon laser trabeculoplasty. average follow up period was 6 months. success was assessed objectively by measuring intra ocular pressure and subjectively by visual acuity. results: the average time-period for each procedure was 15 ± 5 minutes. in group a, mean iop at first week, first month, third month and sixth month was 20.79, 16.34, 16.21and 16.09 mm hg respectively. while in group b, iop at first week, first, third and sixth month was 16.52, 15.76, 13.62, and 12.54 mm hg at (p < 0.001 in both groups). conclusion: both microwave pulse diode laser and argon laser trabeculoplasty are effective in lowering intra ocular pressures in patients with primary open angle glaucoma. key words: open angle glaucoma, argon laser trabeculoplasty, diode laser trabeculoplasty, intra ocular pressure (iop). how to cite this article: shams a, das n, rashid n, bhatti mn, khan b, kumar j. to compare the efficacy of the microwave pulse diode laser and argon laser trabeculoplasty in patients with primary open angle glaucoma. pak j ophthalmol. 2020; 36 (3): 211-215. doi: 10.36351/pjo.v36i3.1008 introduction glaucoma is the second most common cause of ____________________________________________ correspondence to: asma shams shaheed mohtarma benazir bhutto medical college lyari, karachi email: dr.shaikh82@yahoo.com received: march 3, 2020 revised: may 4, 2020 accepted: may 4, 2020 blindness in the world, while it is 3rd most common blinding disease in pakistan1-2. according to who program of blindness, 16% of total blindness for year 2020 will be from glaucoma3. glaucoma affects an estimated 67 million people, most of them are not aware of the disease4. glaucoma is a threatening eye disorder in which the permanent optic nerve damage may occur and results in visual field loss5. early therapeutic intervention is pivitol for stopping asma shams, et al 212 pakistan journal of ophthalmology, 2020, vol. 36 (3): 211-215 complete blindness. glaucoma is diagnosed on the basis of intra ocular pressure, visual field testing and optic nerve appearance on ophthalmoscopy. in glaucoma, retinal ganglions cells axons are lost causing thinning or atrophy of retinal nerve fiber layer in superior and inferior arcuate bundles with exposed smaller retinal vessels. primary open angle glaucoma (poag) accounts for about 50% of glaucoma blindness6. the first line of treatment for glaucoma is medical therapy in the form of eye drops7. several anti glaucoma medications are effective in lowering the iop and thus preventing the optic nerve damage. failure of medical treatment leads to interventional laser trabeculoplasty or trabeculectomy8. over the years, ophthalmologists are trying to achieve an ideal treatment for glaucoma and the role of microwave pulse diode laser trabeculoplasty (mdlt) and argon laser trabeculoplasty (alt) in management of poag. it is a procedure in which tiny holes are created in trabecular meshwork with the help of laser thereby which improves the facility of out flow. both argon and microwave pulse diode lasers have been used for this purpose. it is reported that alt success rate is 90%9. a study regarding mdlt has shown success rate to be 75%10. purpose of our study was to compare the efficacy of alt and mdlt in a tertiary care hospital of pakistan. material and methods the study was conducted at shaheed mohtarma benazir bhutto medical college lyari and sindh government lyari general hospital, karachi for duration of six months from october, 2017 to march, 2018. the study was approved from institutional review committee. one hundred and sixty patients were selected from glaucoma clinic. patients diagnosed with poag, both gender and age > 40 years and < 70 years were included. patients with intraocular pressure of more than 40 mm hg, previous glaucoma surgery or laser treatment and narrow angle on gonioscopy were excluded from the study. patients were divided into two groups. group a was treated with microwave pulse diode laser while group b was treated with argon laser. the data regarding reduction in iop < 21 mm hg and efficacy were entered in already designed proforma. all patients were evaluated by taking thorough history and examination. general physical examination was carried out in all patients. ophthalmic examination included, record of visual acuity, slit lamp examination of the anterior segment, fundus examination with slit lamp using +90 d lens to assess neuroretinal rim, cd ratio, vascular status and macula. visual field status was analyzed using humphrey perimeter. the procedure was explained to all the patients with its benefits and complications. informed written consent was taken. iop was measured before the procedure. the patients were seated comfortably. topical proparacaine 0.5% eye drops were instilled in the eye to be treated. ritch trabeculoplasty lens was filled with hydroxy propyl methyl cellulose and applied. alcon ophthalmus 532 eyelite frequency doubled nd-yag laser photocoagulator was used. the aiming beam was focused at the junction of pigmented and non pigmented trabeculum. the ideal reaction was transient blanching or the appearance of a minute gas bubble at the point of impact. forty to sixty burns were applied at regularly spaced interval. single drop of topical diclofenac sodium 0.1% was instilled into the eye after procedure. iop was checked 3 hours after the procedure. all patients were prescribed diclofenac sodium 0.1% eye drops 4 times a day for 5 days to control inflammatory response. all patients were followed up regularly at 1 week, 4 weeks and 6 months after the procedure. at each visit, iop was measured, gonioscopy was done and fundus examination was performed with slit lamp using 90 d lens. the final outcome was monitored at 6 months. the treatment was labeled successful if iop was < 21 mm hg at 6th month. cases failed to reduce to that level were labeled failed and were treated with either additional laser application sessions or antiglaucoma drugs. results male to female ratio was 2:1. mean age of the patients was 55.69 years (range 41 – 69 years). table 1 shows the distribution of patients by gender and age group in each intervention group. according to sample size, 80 eyes of 73 patients were examined and treated in the group a with microwave pulse diode laser (810). there were 57 (71.3%) males and 23 (28.8%) females in this group. the mean age of the patients in this group was 55.8 years (range 42 – 69). the mean pre efficacy of the microwave pulse diode laser and argon laser trabeculoplasty in patients with primary open angle pakistan journal of ophthalmology, 2020, vol. 36 (3): 211-215 213 treatment iop of 80 eyes (of 73 patients) was 31.8 ± 5.32 mm hg. the mean iop was 19.24+4.9 mm hg at 6 months postoperatively. group b was treated with argon laser trabeculoplasty. there were 56 (70%) males and 24 (30%) females in this group. the mean age of patients was 55.56 years (range 41 – 69 years). mean pre-treatment iop of 80 eyes (of 77 patients) was 30.6 ± 5.32 mm hg. there was mean drop of iop to 17.63 ± 4.6 mm hg at 6 months postoperatively. table 2 gives a comparison of the mean iop before and after intervention in the two groups. table 1: gender distribution in each group according to age group (n= 160, 80 in each group). age (years) group a (n = 80) male female total group b (n = 80) male female total total no. of eyes 41 – 50 18 11 29 16 08 24 55 51 – 60 25 10 35 31 09 40 56 61 – 70 12 04 16 10 06 16 49 total 55 25 80 57 23 80 160 table 2: comparison of pre treatment and post treatment (after 6 months) intra ocular pressure (iop). diode laser (group a) mean ± sd mmhg (n = 80) argon laser (group b) mean ± sd mmhg (n = 80) pre-treatment iop 31.79 ± 5.38 30.66 ± 4.63 post treatment iop (six months after treatment) 19.24 ± 4.99 (p < 0.001) 17.63 ± 3.65 (p < 0.001) discussion primary argon laser trabeculoplasty has a definite role in the management of primary open angle glaucoma. it is useful in decreasing the number of medications and delays the surgical intervention11. the other major advantage of argon laser trabeculoplasty in addition to intraocular pressure reduction is to reduce the spikes of the diurnal variation of intraocular pressure. laser therapy causes shrinkage of trabecular beams and necrosis of cells resulting in widening of spaces12. the mechanism of action of both procedures are comparable13. in our study, argon laser trabeculoplasty as a primary therapy was useful in controlling the intra ocular pressure in 90% of patients after 6 months follow up. it caused mean reduction of intra ocular pressure measuring at 12.5 mm hg at the final follow up. agarwal9 in a study done in indian population, reported a success rate of 90% at 6 months. odberg and saduik14 reported from norway that there was mean reduction in iop of 8.8 mm hg at 1 month after primary argon laser trabeculoplasty therapy with success rate without medication of 77% after 2 years, 67% after 5 years and 67% after 8 years. our study showed mean reduction of iop after six months to be 12.54 mm hg. another report from india found the effect of argon laser trabeculoplasty in indian eyes which were not controlled on maximum medical treatment15. there were 93% patients who were controlled at 3 months and 72.7% at 1 year, but only 9.2% were controlled at the end of 4 years. ingvoldstad et al16 and colleagues presented a study at the 2005 arvo meeting. they showed the results of alt and mdlt during a three-month follow-up. they noticed similar reduction in iop with these two procedures. there was 18.9% decrease with alt and 18.3% with mdlt. diode laser produces histological changes comparable to the argon laser, and early clinical trials have shown it to be an effective instrument for performing photocoagulation of the trabecular meshwork but in current study we did not compare such changes in both groups. the similarity of lesions produced by current laser modalities, and the advantages of diode lasers regarding their portability and reliability, certainly will stimulate further interest in their therapeutic potential for the treatment of glaucoma. we found from our study that lt yields excellent results in controlling rise in iop. lt has its own advantages. the overlying conjunctiva does not require breaching as in trabeculectomy surgery therefore it is painless and does not cause bleeding. the risk of infection and conjunctival scarring are minimized and strict aseptic techniques are not required. topical antibiotics or corticosteroid are not required after laser trabeculoplasty. the disadvantages encountered with laser trabeculoplasty are that it causes iritis, transient rise in iop and peripheral anterior synechiae. we used asma shams, et al 214 pakistan journal of ophthalmology, 2020, vol. 36 (3): 211-215 topical nsaids to all our patients for a period of 1 week to help relieve the mild discomfort and inflammation induced by laser. age selection in our study was between 51 – 60 years with an average of 53 years. other studies showed a similar age group selection14-16. a study was published in american journal of ophthalmology17which showed that the diode laser patients had mean intraocular pressure of 21.6 ± 2.0 mm hg before procedure and 19.0 ± 3.3 mm hg (or a 2.4% ± 16.9% mean reduction) at 3 months after procedure. in the argon laser patients, mean intraocular pressure was 24.4 ± 3.5 mm hg and 15.5 ± 1.2 mm hg (or a 30.0% ± 16.5% mean reduction) at 3 months after laser treatment. the difference between the two techniques in reduction of intra ocular pressure was statistically significant at 3 months (p < 0.05) after treatment. another research18 reported the results of argon laser trabeculoplasty in 211 eyes of primary open angle glaucoma. the success rate was 81% at 1 year, 48% at 5 years and only 11% at a ten years. few other studies have also shown mdlt is not as effective as alt. a recent study published in acta ophthalmologica suggested that 180º mdlt is a safe but less effective treatment in patients with open angle glaucoma19. these similar results were found in our study. there are some studies which show that mdlt efficacy equivalent to alt at a lower cost with less inflammation and less risk of complications. a study using sub-threshold micropulse laser protocols have reported successful outcomes for primary open angle glaucoma20. another study suggested that hypotensive effects and success rates of diode laser trabeculoplasty were comparable to argon laser trabeculoplasty (alt)21. the results shown in the current study has a larger impact as compared to other studies in our region as the occurrence of glaucoma induced blindness is higher in south asian region. limitation of our study is that it was a single center study and results cannot be generalized to whole population. further research at other centers will add to the results obtained in our study. conclusion both alt and mdlt are effective in controlling iop in poag. however, alt is more effective in controlling iop then microwave diode laser trabeculoplasty. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution asma shams; senior registrar: study design and procedures. narain das; assistant professor: compilation of data and procedures. noman rashid; associate professor: manuscript writing and review. m. nasir bhatti; professor: manuscript review. beenish khan; assistant professor: statistical analysis and results. jai kumar; consultant ophthalmologist: data collection. references 1. resnikoff s, pascolini d, etya’ale d, kocur i, pararajasegaram r, pokharel gp, mariotti sp. global data on visual impairment in year 2002. bull world health organ, 2004; 82 (11): 844-551. 2. mahar ps, jamali kk. argon laser trabeculoplasty as primary therapy in open angle glaucoma. j coll physici surg pak. 2008; 18: 102-4. 3. ali n, wajid sa, saeed n, khan md. the relative frequency and risk factor of poag and angle closure glaucoma. pak j ophthalmol. 2007; 23: 117-21. 4. oberacher-velten i, hoffmann e, helbig h. glaucoma a common disease. ophthalmologe. 2016; 113 (9): 746-51. 5. sugisaki k, asaoka r, inoue t, yoshikawa k, kanamori a, yamazaki y, et al. predicting humphrey 10 – 2 visual field from 24 – 2 visual field in eyes with advanced glaucoma. br j ophthalmol. 2020; 104 (5): 642-647. doi: 10.1136/bjophthalmol-2019-314170. 6. quigley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006; 90: 262-7. 7. occhiutto ml, maranhão rc, costa vp, konstas ag. nanotechnology for medical and surgical efficacy of the microwave pulse diode laser and argon laser trabeculoplasty in patients with primary open angle pakistan journal of ophthalmology, 2020, vol. 36 (3): 211-215 215 glaucoma therapy-a review. adv ther. 2020; 37 (1): 155-199. doi: 10.1007/s12325-019-01163-6. 8. goldberg i. argon laser trabeculoplasty in open angle glaucoma. long term follow-up. aust new zeal j ophthalmol. 1985; 13: 243-248. 9. agarwal hc, sihota r, das c, dada t. role of argon laser trabeculoplasty as primary and secondary therapy in open angle glaucoma in indian patients. br j ophthalmol. 2002; 86: 733-6. 10. fea am, bosone a. microwave pulse diode laser trabeculoplasty, a phase 2 clinical study with 12 months follow-up. clin ophthalmol. 2008; 2: 247-55. 11. greslechner r, spiegel d. laser trabeculoplasty in modern glaucoma therapya review. klin monbl augenheilkd. 2019; 236 (10): 1192-1200. doi: 10.1055/a-0577-7925. 12. rodrigues mm, speath gl, donohoo p. electron microscopy of argon laser therapy in phakic open-angle glaucoma. ophthalmology, 1982; 89: 198-210. 13. erichev vp, poleva rp. diode and argon trabeculoplasty in primary open-angle glaucoma treatment. vestn oftalmol. 2019; 135 (4): 103-107. 14. odberg t, sandvik l. the medium and long term efficacy of primary argon laser trabeculoplasty in avoiding topical medication in open angle glaucoma. acta ophthalmol scand. 1999; 77: 176-81. 15. gosh b, gupta a. argon laser trabeculoplasty for uncontrolled open angle glaucoma in indian eyes. ann ophthalmol. 1996; 28: 263-8. 16. ingvoldstad dd, krishna r and willoughby l. micro-pulse diode laser trabeculoplasty versus argon laser trabeculoplasty in the treatment of open angle glaucoma. invest ophthalmol vis sci. 2005; 46 (13): 123. 17. brancato r, carassa r, and trabucchi g. diode laser compared with argon laser for trabeculoplasty. am j ophthalmol. 1991; 4: 112: 50. 18. moulin f, haut j. argon laser trabeculoplasty: a 10 year follow-up. ophthalmologica. 1993; 207: 1996201. 19. rantala, e. and valimali, j. micropulse diode laser trabeculoplasty 180-degree treatment. acta ophthalmologica. 2010: 1755-3768. 20. sivaprasad s, elagouz m, mchugh d, shona o, dorin g. micropulsed diode laser therapy: evolution and clinical applications. surv ophthalmol. 2010; 55: 516-30. 21. moriaarty ap, mchugh jd, ffytche tj, marshall j, hamilton am. long-term follow-up of diode laser trabeculoplasty for primary open-angle glaucoma and ocular hypertensions. ophthalmology, 1993; 100: 14614-8. .……. 152 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology original article retinal disorders in a tertiary eye centre in nigeria iyiade adeseye ajayi, olusola joseph omotoye, kayode olumide ajite, oluwole oluseye ajogbasile pak j ophthalmol 2016, vol. 32, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: iyiade adeseye ajayi consultant ophthalmologist ekiti state university teaching hospital ado-ekiti, nigeria e-mail: iyiseye2005@gmail.com …..……………………….. purpose: to review the types of retinal disorders in patients seen at the retinal clinic of a tertiary eye centre in southwestern nigeria. study design: observational descriptive study. place and duration of study: ekiti state university teaching hospital, nigeria over a 2½ year period from july 2013 to january 2016 was reviewed. materials and methods: all patients seen in the clinic had documentation of their demographic characteristics, visual acuity at presentation, findings on dilated fundus examination, slit lamp biomicroscopy and diagnosis. investigations such as fundus fluorescein angiography (ffa) and ocular coherence tomography (oct) were recorded. results: a total of 405 patients constituting 10.4% of the total patient load had retinal disorders during the period of study. the mean age was 56.95 ± 20.8 years. more than half (68.5%) of the patients were aged 50 years and above. the presenting visual acuity was < 3/60 in 135 (33.3%) of cases. age related macular degeneration was the leading eye disorder seen in 18.2% followed closely by diabetic retinopathy in 16.3%. retinitis pigmentosa was the leading cause of bilateral blindness. optical coherence tomography (67.4%) and fundus fluorescein angiography (61.73%) were the leading investigations ordered in the retinal clinic. conclusion: age related macular degeneration and diabetic retinopathy were the leading eye disorders in our centre. limited access to investigative facilities is a major challenge in the management of retinal disorders in our centre. keywords: retinal disorders, tertiary eye, retinal investigations. iseases affecting the retina vary in types and frequencies depending on the geographic location. the causes include congenital and developmental disorders, inflammations, vascular, age related degenerative conditions, heredity and other disorders due to effect of systemic diseases like diabetes mellitus, hypertension, sickle cell disease among others. the impact on quality of vision vary in magnitude depending on the type and severity of the condition. retinal disorders account for 13% of eye disorders according to report in a neighbouring state by onakpoya et al1. nwosu in a study in south eastern nigeria reported an incidence of 8.1%2. the equipments required for evaluation, diagnosis and treatment of retinal disorders are expensive to procure and maintain3. data on the types of retinal disorders in our eye – care facility will assist in planning for a more efficient eye – care delivery for our patients with retinal disorders. a review like this has not been done in our state. our centre is the only centre with an established retinal care delivery in the state. most of the incidence reports in our country were done over a decade ago in some other states of the country. materials and methods ekiti state university teaching hospital has an established tertiary eye care service with a retina d retinal disorders in a tertiary eye centre in nigeria pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 153 subspecialty clinic where all patients with retinal diseases are seen on a scheduled weekday clinic. these patients are either referred from our general ophthalmology clinic or other ophthalmologists from eye care centres in the neighbouring states. the retinal clinic also offer diabetic retinopathy screening service to all the diabetics sent in routinely from the endocrinology unit of our hospital. only diabetics with retinal disorders were included in the record of the retinal clinic where records of all patients with retinal diseases were kept from the inception of the clinic. the retinal subspecialty unit offers medical retinal services including intravitreal injections and lasers while patients requiring vitreoretinal surgical interventions are referred to other centres where vitreoretinal surgical services are provided. approval was obtained from the ethics and research committee of our centre. the record kept over a 2½ year period from july 2013 to january 2016 was reviewed. data obtained include demographic characteristics, visual acuity at presentation, and final diagnosis after detailed dilated ocular examination with binocular indirect ophthalmoscope and slit lamp biomicroscopy with +78d or +90d lenses. visual acuity was graded according to who guideline with ≥ 6/18 as normal, < 6/18 to > 3/60 as visual impairment and < 3/60 to no light perception as blindness. in patients with bilateral disorders the visual acuity of the worse hit eye was considered as the visual acuity of the affected eye. patients uptake of required investigations and treatment offered were also assessed. data was analysed using statistical package for social sciences 20.0 (spss inc., chicago, il). means (standard deviations) were used to describe the distributions of continuous variables. categorical variables were described in percentages. comparisons of categorical data was performed with the use of pearson's chisquare test and statistical significance was inferred at p < 0.05. results a total of 405 new patients were diagnosed with one form of retinal disorder or the other. this constitutes 10.4% of 3881 total patients seen in the eye clinic over the study period. the mean age was 56.95 ± 20.80 years. the age range was 5 – 120 years. there were 180 (44.4%) males and 225 (55.6%) females giving a male to female ratio of 1:1.3. one hundred and ninety one cases (47.2%) had unilateral eye disorder while 214 (52.8%) had bilateral retinal disorders. two hundred and seventy six (68.15%) of the patients were aged above 50 years with greater proportion of females in this age group (chi square 8.471, p = 0.003 rr = 1.876 (95% ci: 1.225 – 2.873) ([figure 1]. from table 1 above the presenting visual acuity in figure 1: age – sex distribution of patients. figure 2: causes of bilateral blindness. keys: armd: (age related macular degeneration), dr: (diabetic retinopathy), crvo: (central retinal vein occlusion), ipcv: (idiopathic polypoidal choroidal vasculopathy), rheg rd: rhegmatogenous retinal detachment. the affected eye was < 3/60 in 135 (33.3%) of the patients, 104 (25.67%) had unilateral blindness while iyiade adeseye ajayi, et al 154 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology table 1: laterality vs presenting visual acuity in the affected eye. 6/6 – 6/18 < 6/18 – 6/60 < 6/60 – 3/60 < 3/60 unilateral 40 49 25 77 bilateral 70 55 31 58 total 110 104 56 135 chi sq=10.573 p=0.014 table 2: uptake of requested retinal investigations. retinal investigations requested n (% total) done n (% requested) oct 273 (67.41) 21 (7.7) ffa 250 (61.73) 2 (0.8) erg 72 (17.78) 0 (0) icg 28 (6.91) 0 (0) table 3: types of retinal diseases. number (%) age related macular degeneration (amd) 73 (18.02) diabetic retinopathy 66 (16.3) retinal vein occlusion 40 (9.9) chorioretinitis (toxoplasma) 37 (9.1) retinitis pigmentosa 24 (5.9) retinal detachment 21 (5.2) pathological myopia 17 (4.2) full thickness macular hole 17 (4.2) posterior vitreous detachment 16 (3.95) macular scar 12 (2.96) parafoveal telangiectasia 9 (2.2) idiopathic parafoveal choroidal vasculopathy (ipcv) 8 (1.98) macular dystrophy 6 (1.5) cellophane maculopathy 6 (1.5) neovascular glaucoma 6 (1.5) traumatic vitreous hemorrhage 6 (1.5) central serous chorioretinopathy 3 (0.74) hypertensive retinopathy (grade 4) 4 (0.99) intermediate uveitis 2 (0.49) familial exudative vitreoretinopathy 1 (0.25) angioid streaks 1 (0.25) sickle cell retinopathy 3 (0.74) sub hyaloid hemorrhage 4 (0.99) central retinal artery occlusion 2 (0.49) cystoid macula edema 2 (0.49) retinal arterial macroaneurysm 4 (0.99) coloboma 1 (0.25) morning glory anomaly 1 (0.25) myelinated retinal fibres 2 (0.49) arteritic ischemic optic neuropathy 3 (0.74) optic nerve head avulsion 1 (0.25) optic neuritis 1 (0.25) 31 (7.65%) had bilateral blindness. unilateral disorders accounted for 77 (57.04%) of blind eyes and 74 (46.25%) of mild – moderate visual impairment. visual acuity was found to be normal in 110 (27.16%) of the patients. the rate ratio of blindness in the unilateral to bilateral disorders was 1.817 (ci: 1.196 – 2.758) p = 0.003. table 4: treatment offered. medical (oral and/or topical drugs) 117 (28.9) optical low vision aids 104 (25.68) intravitreal antivegf 52 (12.84) reassurance 49 (12.1) laser 48 (11.85) vitreoretinal surgical intervention 42 (10.4) retinal disorders in a tertiary eye centre in nigeria pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 155 of the patients with bilateral blindness, retinitis pigmentosa accounted for 9 (29.0%) followed by armd 7 (22.6%) and macular scar presumably due to toxoplasmosis in 6 (19.4%). others were diabetic retinopathy 3 (9.7%), central retinal vein occlusion and pathological myopia 2 (6.5%) each, ipcv and retinal detachment 1 (3.2%) each. the causes of unilateral blindness were retinal vascular occlusion 23 (29.9%), rhegmatogenous rd 14 (18.2%), chorioretinitis 5 (6.5%), full thickness macular hole 4 (5.2%) and traumatic vitreous hemorrhage 3 (3.9%). the investigations required are as shown in table 2 with optical coherence tomography (67.41%) and fundus fluorescein angiography (61.73%) being the 2 leading investigations ordered and indocyanine green angiography the least ordered. only 7.7% of our patients were able to do the oct. table 3 shows the types of retinal diseases seen. the leading eye disorder was amd (18.02%) followed closely by diabetic retinopathy (16.3%). retinal vein occlusion accounted for 9.9% of the disorders followed closely by retinitis pigmentosa. systemic and/or topical drugs were the treatment offered in 117(28.9%) of cases. some patients utilized more than one treatment options. disscussion there were a total of 405 patients constituting 10.4% of the 3881 outpatient population of our eye care centre within the period of study. this implies that on the average one out of every 10 patients seen in our eye centre had some form of retinal disorder. other studies have reported retinal disorders constituting 3.9% – 13% of the eye disorders in some other centres in nigeria1-5. we can therefore say that retinal diseases are not as uncommon as they had been perceived to be6. a female preponderance was observed in our study contrary to other studies where male preponderance2,3 and equal proportion of male to female4 have been reported. a statistically significant pronouncement of the female preponderance after age of 50 years was observed (chi square 8.471, p value 0.003, rr 1.876 ci: 1.225 – 2.873), the reason for which is not obvious from the study but a possibility of the diseases observed occurring more commonly among females cannot be completely ruled out. lewallen et al opined a greater likelihood of women to seek eye care than men7. about 68% of our patients were aged 50 years and above with a mean age of about 57 ± 20.8 years and a mode of 60 years. despite a mean age higher than reported by others in different parts of the country, we all have a common mode1-5,6. the observed mean age was however lower (40 years) in the studies by onakpoya1 and eze4. about 1/3 of our patients were blind in the affected eye at presentation. another 1/3 had visual impairment. this lends credence to the report of retina diseases having a huge contribution to blindness and visual impairment in nigeria2,3. the rate ratio of blindness in the unilateral to bilateral disorders was 1.817 (ci – 1.196 – 2.758) p = 0.003. the increased rate of blindness among unilateral disorders may be explained by possibility of a late detection due to compensatory effect of the other seeing eye. age related macular degeneration (armd) was the leading disorder in our study. although it was previously considered an uncommon condition among people of african descent8 it has been subsequently reported over time to be an increasingly important cause of poor vision in the southwestern3 and southeastern9 parts of our nation. some authors have explained that the increasing prevalence of armd is due to increasing number of older people due to higher survival rate from improved health facilities and improved diagnostic facilities and skill from subspecialisation in the developing countries10. having been reported to be a common form of retinal diseases among the elderlies we were not taken aback when we found amd to be the second leading (22.6%) cause of bilateral blindness in our study after retinitis pigmentosa. the observed rate is higher than reports from independent authors with rates of 12.8%11, 14.5%12. diabetic retinopathy was the second leading retinal disorder in this study having been diagnosed in 16.3% of the total retinal cases. this rate is lower than the 24.9% reported in southeastern nigeria4 but similar to the ibadan study3 where diabetic retinopathy was found to be one of the significant retina diseases. it is however higher than the 9.6% rate in another southwestern nigeria tertiary eye care centre1. visual loss from diabetic retinopathy has been predicted to have a likelihood of an upward trend with the maturing epidemic of diabetes unless there is an improvement in early detection and treatment13. in this study the high rate of diabetic retinopathy could be partly due to the compulsory dilated eye examination offered as part of our retinal services to the diabetic patients receiving care from the endocrinology department of our hospital. diabetic retinopathy accounted for 9.7% of cases of bilateral iyiade adeseye ajayi, et al 156 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology blindness in our study. it has been reported to contribute 5% to global blindness14 and a major cause of blindness in an onitsha hospital –based study.2 retinal vascular disorders, the 3rd leading retinal disorder in our study accounted for 29.9% of cases of unilateral blindness at presentation. retinal vein occlusions (rvos) are the second most common blinding vascular retinal disorder after diabetic retinopathy and is a frequent cause of vision loss and blindness15. a rate of 7.4% was reported in southsouth nigeria16. a study in south-eastern nigeria reported retinal vein occlusion as one of the leading retinal disorders2. another study in benin city on the other hand reported a low incidence of retinal vascular occlusion17. toxoplasma retinochoroidits was also a common eye disorder found among 9.1% of our patients. it has been reported to be responsible for majority of infectious uveitis (intraocular inflammation) cases8,19. while some authors opined that the diagnosis is usually accomplished serologically because symptoms are very non specific20. some others have reported that the presence of anti t. gondii igg antibodies does not confirm toxoplasmic etiology as it can often persist at high titres for years after acute infection with a high prevalence of the antibodies in the general population21 and the marked individual variations in the time elapsing between the onset of clinical symptoms and the activation of specific antibody production giving rise to a resultant high proportion of false negative results.22 none of our patients had serologic testing for anti-toxoplasmosis antibodies or polymerase chain reaction because of the lack of the diagnostic kits in our laboratory facility like most centres in our developing country. the diagnosis of toxoplasma chorioretinitis were made based on clinical examination finding of focal chorioretinitis with overlying vitritis23. it was found to account for 6.5% of unilateral blindness in this study. the risk of morbidity in toxoplasma retinochoroiditis has been found to increase if the disease extends to structures critical for vision like the macula and the optic disc and other complications like retinal detachment or neovascularisation.24 the diagnosis of retinitis pigmentosa was made in 5.9% of our patients. this rate is lower than the 11.1% reported in ibadan3. retinitis pigmentosa in this study accounted for 29.03% of cases of bilateral blindness. 54.2% of the cases were blind at presentation while 33.3% had low vision. it was found to be one of the major causes of bilateral blindness and visual impairment in south east nigeria2. the high degree of visual loss in patients with this condition have been related to the long duration of the disease and age of the patients at presentation.25 retinal detachment, pathological myopia, full thickness macular hole, posterior vitreous detachment, macular scar and parafoveal telangiectasia were also common disorders found among our patients. all these disorders contribute to the burden of blindness and visual impairment through various mechanisms especially when there are delays in presentation and treatment. it is not therefore too surprising to find out that about 26% of our patients had to be referred for optical low vision aids. all others benefitted from one intervention or the other ranging from drugs (28.9%), intravitreal antivegf (12.84%), reassurance (12.10%, laser (11.85%) to surgical intervention in 10.4% of cases. optical coherence tomography (oct) and fundus fluorescein angiography (ffa) were the most frequently requested investigations for our patients. the role of oct and ffa in the management of retinal disorders in a centre like ours can therefore not be overemphasized. fundus fluorescein angiography have been described as a safe invasive outpatient procedure which will enhance more specific diagnosis, treatment decisions and progress monitoring in vast majority of patients with vitreo-retinal diseases1,3,6. the high cost of procurement and maintenance of these equipment have made them scarce in our country2,3 and where available in few private settings the costs are rather out of reach for the common man. it was observed from this study that only 7.7% of the patients who needed oct for diagnosis and follow up carried out the test. this was due to financial constraints mainly as most of the patients needed to travel to a private facility in another state to carry out the required test. worse still was a lower uptake of 0.8% for fundus fluorescein angiography. erg and icg could not be done as the facilities for them were not available in the country. this leaves us to rely more on clinical judgment for the treatment and follow up of most patients. this finding however shows an improvement over the studies by oluleye3 and onakpoya1 carried out about a decade earlier where none of their patients had any of the investigations. the challenge with this is that patients who require more frequent investigations for follow up are unlikely to have it done. the treatments offered revealed in table 4 that topical and oral medicines ranked top most on the list. retinal disorders in a tertiary eye centre in nigeria pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 157 about ¼ of the patients could only be helped by referral for optical low vision aids. this is as a result of the majority of these patients presenting at an advanced stage of the disease when permanent damage has been caused to the retina. late presentation at advanced stages of posterior segment disorders have been found to be a common practice in developing countries like ours6. this calls for an intensified health talk to increase awareness of retinal disorders among the people of ekiti and the need for early presentation once a reduction or impaired vision is observed. another reason for this could be the non availability of an established retinal care unit in our centre until the time of commencement of this study. about 13% of our patients had intravitreal anti-vegf injection while another 12% had laser intervention. these rates are lower than reported rates by oluleye and ajaiyeoba3 but a build up on the report by onakpoya1 where the services were not available at the time of their study. conclusion considering the enormous magnitude of retinal disorders as revealed in various studies in different parts of our nation and the scarcity and high cost of investigative facilities we would like to solicit that the government of our nation pay more attention to the procurement and maintenance of these equipments even if it would mean that special investaigation centres be made available in each geopolitical region of the country at subsidized rate in order to further enhance the achievement of the millenium development goals and reduce the burden of blindness from retinal diseases. authors affiliation iyiade adeseye ajayi consultant ophthalmologist ekiti state university teaching hospital ado-ekiti, nigeria olusola joseph omotoye consultant ophthalmologist ekiti state university teaching hospital ado-ekiti, nigeria kayode olumide ajite consultant ophthalmologist ekiti state university teaching hospital ado-ekiti, nigeria oluwole oluseye ajogbasile ophthalmologist in training ekiti state university teaching hospital ado-ekiti, nigeria role of authors: iyiade adeseye ajayi conception, design, data collection, literature search, writing and editing. olusola joseph omotoye literature search, data collection, editing. kayode olumide ajite data collection, editing. oluwole oluseye ajogbasile data collection, literature search. references 1. onakpoya oh, olateju so, ajayi i a. retinal diseases in a tertiary hospital: the need for establishment of a vitreo-retinal care unit. j natl med assoc. 2008; 100 (11): 1286-1289. 2. nwosu sn. prevalence and pattern of retinal diseases at the guiness eye hospital, onitsha, nigeria. ophthalmic epidemiol. 2000; 7: 41-48. 3. oluleye ts, ajaiyeoba ai. retinal diseases in ibadan. eye, 2006; 10: 1-2. 4. eze bi, uche jn, shiweobi jo. the burden and spectrum of vitreo-retinal diseases among ophthalmic patients in a resource – deficient tertiary eye care setting in south eastern nigeria. middle east afr j ophthalmol. 2010; 17: 246-249. 5. abiose a. pattern of retinal diseases in lagos. ann ophthalmol. 1979; 11: 1067-72. 6. yorston d. retinal diseases and vision 2020. commun eye health, 2003; 46: 19-20. 7. lewallen s and courtright p. recognising and reducing barriers to cataract surgery. commun eye health, 2000; 13: 20-21. 8. friedman ds, katz j, bressler nm, rahmani b, tielsch jm: racial differences in the prevalence of age – related macular degeneration in the baltimore eye survey ophthalmology, 106 (6): 1049-1055. 9. nwosu sn. low vision in persons aged 50 and above in the onchocercal endemic communities of anambra state, nigeria. west afr j med. 2000; 19 (3): 216-219. 10. oluleye tunji sunday. is age – related macular degeneration a problem in ibadan sub-saharan africa? clin. ophthalmol. 2012; 6: 561-4. 11. sijuwola o, fasina o. etiology of visual impairment among ophthalmic patients at federal medical centre, abeokuta, nigeria. j west afr coll surg. 2012; 2 (4): 3850. iyiade adeseye ajayi, et al 158 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology 12. nwosu sn. age – related macular degeneration in onitsha nigeria niger j clin pract. 2011; 14 (3): 327-31. 13. fatima kyari, abubakar tafida, selvaraj sivasubrananiam, gudlavalleti vs murthy, tunde peto. clare e gilbert and the nigeria national blindness and visual impairment study group. bmc public health, 2014; 14: 1299. 14. foster a, resnikoff s. the impact of vision 2020 on global blindness. eye, 2005; 19: 1133-1135. 15. shahid h, hossain p, amoaku wm: the management of retinal vein occlusion: is interventional ophthalmology the way forward? br j ophthalmol. 2006; 90: 627–639. 16. fiebai b, ejimadu cs, komolafe rd. incidence and risk factors for retinal vein occlusion at the university of port harcourt niger j clin pract. 2014; 17 (4): 462-6. 17. odarosa m uhumwangho, darlingtess oronsaye. retinal vein occlusion in benin city, nigeria. niger j surg. 2016; 22 (1): 17-20. 18. lopez a, dietz vj, wilson m, navin tr, jones jl. preventing congenital toxoplasmosis mmwr recomm rep. 2000; (49rr-2): 59-68. 19. soheilian m, heidari k, yazdani s, shahsavari m, ahmadieh h, dehghan m. pattern of uveitis in a tertiary eye care center in iran. ocul immunol infalmm. 2004; 12: 297-310. 20. remington j.s and montoya j.g. laboratory test for the diagnosis of toxoplasmosis, a guide for clinicians. palo. alto. med. found, 2009. 21. ongkosuwito jv, bosch – driessen eh, kijlstra a. rothova a. serologic evaluation of patients with primary and recurrent ocular toxoplasmosis for evidence of recent infection. am j ophthalmol. 1999; 128: 407-412. 22. garweg jg. department of determinants of immunodiagnostics success in human ocular toxoplasmosis. parasite immunol 2005; 27: 61-68. 23. bosch – driessen le, berendschot tt. ongkosuwito jv et al. ocular toxoplasmosis: clinical features and prognosis of 154 patients. ophthalmology, 2002; 109 (5): 869-78. 24. alessandra g commodaro, rubens n belfort, luis vicente rizzo, cristina muccioli, claudio silveira, miguel n burnier jr, rubens belfort jr. ocular toxoplasmosis – an update and review of the literature. mem inst oswaldo cruz, rio de janeiro, 2009; 104 (2): 345-350. 25. ukponmwan cu, atamah a. retinitis pigmentosa in benin, nigeria east afr med j. 2004; 81 (5): 254-7. 203 pak j ophthalmol. 2021, vol. 37 (2): 203-207 original article orbital hydatid cyst: an interventional case series tajamul khan 1 , ibrar hussain 2 , zaman shah 3 1-3 department of ophthalmology, khyber teaching hospital, peshawar pakistan abstract purpose: to find out the demographics, presentation, and outcome of surgical treatment in patients of orbital hydatid cyst. study design: interventional case series. place and duration of study: khyber teaching hospital peshawar, pakistan from 2009 to 2019. methods: this study included 11 patients with orbital hydatid cyst who presented in khyber teaching hospital, peshawar. detailed history, ocular examination and orbital imaging (ophthalmic b-scan, ct scan and/or mri) was performed. the patients underwent orbitotomy, cyst extirpated and sent for histopathology. albendazole was given to the patients for 12 weeks after surgery. the preoperative and postoperative data until last follow-up was analyzed. results: male to female ratio was 5:6 and the mean age of the patients was 18.17 ± 17.4 years. mean amount of proptosis was 26.27 ± 2.05mm and visual acuity was 0.23 ± 0.33 decimal in the affected eye at presentation. eight patients (72.8%) had relative afferent pupillary defect with swollen discs. after imaging studies, presumptive diagnosis of hydatid cyst was made. histopathology confirmed the diagnosis of hydatid cyst in all cases. mean proptosis at the last follow up improved to 19.04 ± 1.45mm (p value = 0.00) and visual acuity to 0.47 ± 0.22 decimals (p value = 0.048). only one patient (9.1%) had an associated hydatid cyst in the lung. there was no recurrence until last follow-up. conclusion: hydatid cyst should be considered in differential diagnosis of proptosis in patients under 20. surgical excision followed by a course of oral albendazole is effective for the treatment of orbital hydatid cyst. key words: orbital hydatid cyst, proptosis, orbitotomy. how to cite this article: khan t, hussain i, shah z. orbital hydatid cyst: an interventional case series. pak j ophthalmol. 2021, 37 (2): 203-207. doi: http://doi.org/10.36351/pjo.v37i2.1147 introduction orbital hydatid cyst is a rare disease accounting for about 1% of the total cases of hydatid disease. 1 it is caused by a tapeworm echinoccocus granulosus and human is the accidental intermediate host. orbital hydatid cyst may occur alone or as a part of systemic correspondence: tajamul khan department of ophthalmology, khyber teaching hospital, peshawar – pakistan email: drtajamul@yahoo.com received: october 15, 2020 accepted: february 18, 2021 disease where cysts may be found in liver, lungs or other parts of the body. 2 it is usually located in intraconal compartment of the orbit mostly occupying the superomedial or superolateral part of the orbit. rarely, it occupies the floor of the orbit, pushing the eyeball forward and superiorly. 2 the most common presentation of orbital hydatid cyst is progressive unilateral painless proptosis. mechanical effect of large cyst in a limited space of bony orbit may cause compression of the optic nerve and limitation in ocular movements. imaging studies especially the magnetic resonant imaging (mri) can help in diagnosis but definitive diagnosis is done by histopathology. the ultimate treatment of orbital hydatid cyst is surgical excision, followed by oral http://doi.org/10.3352/jeehp.2013.10.3 orbital hydatid cyst: an interventional case series pak j ophthalmol. 2021, vol. 37 (2): 203-207 204 albendazole (10mg/kg) for 12 weeks. the surgical approach depends upon size and location of the cyst. in this article, we present a series of 11 patients of orbital hydatid cyst, who presented in our department between 2009 and 2019. methods it is a retrospective case series where record of 11 cases of orbital hydatid cyst was evaluated and analyzed. these patients were admitted in “orbit and oculoplastics” department of khyber teaching hospital peshawar, pakistan between 2009 to 2019. after detailed history and examination, each patient underwent imaging study (b-scan, ct scan and/or mri orbit), chest x-ray, abdominal ultrasound and complete blood examination. pulmonologist and general surgeon were also consulted. depending upon presumptive diagnosis of orbital hydatid cyst on imaging studies, all patients underwent orbitotomy and cyst extirpated. all cysts ruptured during removal and field irrigated with hypertonic saline. the cyst walls were sent for histopathological examination and results came positive for hydatid cyst in all cases. postoperative follow-up of the patients was between 03 months and one year. nine out of eleven patients came from afghanistan which is a war-affected area and patients could not come back for long term regular follow-up. various variables including age, gender, preoperative and postoperative amount of proptosis, visual acuity, extraocular movement, pupillary reaction and surgical techniques were recorded and analyzed using spss – version 25. mean with standard deviations were derived for numerical variables like age, amount of proptosis and visual acuity (in decimals) and frequencies were calculated for categorical variables like gender and pupillary reaction. paired samples t-test was applied to calculate p-value to compare preoperative and postoperative proptosis and visual acuity. results in the period from 2009 to 2019, eleven cases of orbital hydatid cysts were admitted and operated in our department. male to female ratio was 5:6. the mean age of the patients was 18 ± 17.4 years and 9 out of 11 patients had age 20 years or below. all patients presented with moderately progressive unilateral painless proptosis. mean amount of proptosis was 26.27 ± 2.05mm in the affected eye, while mean difference of proptosis between the affected and nonaffected eye was 7.25 ± 2.05mm. mean visual acuity in the affected eye was 0.23 ± 0.33 decimal at presentation. eight patients (72.8%) had relative afferent pupillary defect (rapd) with swollen optic discs and one (9.1%) had afferent pupillary defect (apd) with no perception of light. fundus was not visible in this case due to hazy media. rest 3 (27.3%) eyes had normal pupillary reaction. imaging study of all patients was performed including mri in 9 (81.8%) cases. preliminary diagnoses of hydatid cyst was made on peculiar features on mri and other imaging studies in all cases. in 9 (81.8%) cases cyst was intraconal and in 2 (18.2%) it was extraconal. all patients underwent surgical orbitotomy to excise the cyst, the approach depending upon cyst location. at one week postoperatively mean proptosis improved to 19.82 ± 2.14mm from 26.27 ± 2.05mm (p value = .000) and mean visual acuity improved to 0.28 ± 0.17 decimals (p value = 0.513). mean proptosis at last follow-up was 19.04 ± 1.45mm (p value = 0.000) while difference of proptosis between affected and unaffected eye improved to 0.91 ± 0.14mm from 7.25 ± 2.05mm (p value = 0.000). all patients took albendazole 10 mg/kg for 12 weeks. the mean visual acuity at last follow up in the affected eye improved to 0.47 ± 0.22 decimals (p value = .048). all of our patients had isolated orbital involvement except one (9.1%) case in which a hydatid cyst was found concomitantly in the right lung. the excised cysts were sent for histopathology and all were confirmed to be hydatid cysts. one cyst from the old man (case 11) was calcified. the individual details of the cases are shown in table 1. table 1: demographics, clinical presentation and post-operative findings. s/n age gender laterality pre-operative visual acuity preoperative proptosis pupil cyst location visual acuity at last followup proptosis at last follow-up pupil at last follow-up 1 15 f l 0.1 30 rapd intraconal 0.67 22 n 2 15 m r 0.1 27 rapd intraconal 0.69 20 n tajamul khan, et al 205 pak j ophthalmol. 2021, vol. 37 (2): 203-207 3 3 f l un-cooperative 30 rapd intraconal uncooperative 18 n 4 17 f l 0.08 28 rapd intraconal 0.5 18 n 5 28 f r 0.05 26 rapd intraconal 0.5 19 n 6 19 m l 0.05 29 rapd intraconal 0.17 19 rapd 7 20 f l 0.67 26 n extraconal 0.67 19 n 8 6 m r 1.00 22 n intraconal 0.5 18 n 9 6 m r 0.1 25 rapd intraconal 0.5 19 n 10 5 m l 0.1 21 rapd intraconal 0.5 17 n 11 65 m l 0 25 apd extraconal 0 21 apd apd = afferent pupillary defect, f = female, l = left, m = male, n = normal, r = right, rapd = relative afferent pupillary defect figure: 1a. left proptosis at presentation. b. b-scan left eye. c. t1 weighted axial mr scan. d. t1 weighted sagital mr scan. e. t2 weighted sagital mr scan. f. t2 weighted axial mr scan. g. excised cyst wall. h. first postop day. discussion orbital hydatid cyst is caused by a tapeworm called echinococcus granulosus. this disease is endemic in certain areas such as in australia, new zealand, middle east, south america and mediterrian region. 3 dog is a definitive host and adult tapeworm lives in dog’s intestine. eggs are shed infeces, which are taken-up by cattle (sheep, cows, etc.). cattle is the intermediate host and hydatid cysts are formed in various organs of the cattle. dogs get infection by ingesting the cyst containing organs of intermediate host. human is an aberrant intermediate host and gets infection by ingesting raw vegetables contaminated with e. granulosus eggs. oncospheres hatch from the orbital hydatid cyst: an interventional case series pak j ophthalmol. 2021, vol. 37 (2): 203-207 206 eggs in the human intestine. these penetrate the intestinal wall and enter the circulation to reside in variety of organs including liver, lung, brain, bone and rarely in the orbit. 4 orbital involvement comprises less than 1% of the total incidence. 1 in endemic areas orbital hydatid cyst comprised 5 – 18% of orbital space occupying lesions. 5 in a study on cystic lesions in the orbit from an endemic area, hydatid cyst comprised 25.8% of the cystic orbital lesions, second to dermoid cysts which was 29.7%. 6 in literature, it is mentioned that it affects mainly the left orbit, which can be explained by path of left carotid artery. 7 in our case series, the ratio of left and right orbit involvement is 7:4 i.e. two third involving the left orbit. in our study, the youngest patient was of 3 years age and median age was 15 years (figure: 1). it is consistent with the age found in international literature. 8 no gender predilection is reported so far which is consistent with our case series. unilateral progressive proptosis is the most frequent presenting feature and proptosis is usually quite significant (figure: 2a). due to progressive enlargement of the cyst in a limited space of bony orbit, there is increasing intra orbital pressure and compression of the optic nerve which leads to swollen optic disc, decrease in vision and rapd. in our study, 9 (81.8%) eyes presented with compressed optic nerve with rapd and decreased visual acuity (mean visual acuity 0.23 ± 0.33 decimals) in affected eyes. in a study from morocco on 10 patients, 90% of patients had visual loss at presentation. 9 in a meta-analysis from turkey, 48% patients had visual impairment. 10 imaging studies including b-scan, ct-scan and mri of the orbit help in presumptive diagnosis. b-scan shows a characteristic “double wall” sign in orbital hydatid cyst. 11 (figure:2b). ct-scan shows a welldefined hypodense mass with perilesional rim of hyperdensity. 5 mri demonstrate a homogeneous lesion, which is hypo-intense on t1 weighted images and hyper-intense on t2 weighted images. 5 (figure:2c-f). in our study, presumptive diagnosis of hydatid cyst was accurate in 10 (90.9%) cases on imaging study. in one (9.1%) case, the cyst was calcified and diagnosis was made on histopathological examination. calcification of the cyst wall when present indicate dead organism. 12 total calcification of the cyst in liver can also occur. regarding location of the hydatid cyst in the orbit, it was intraconal in 9(81.9%) cases and extraconal in 2 (18.2%) cases. even in the intraconal location, the main bulk of the cyst was occupying different locations in the orbit. in literature it is mentioned that most of the cysts are intraconal. 13 in a study from iran on 8 patients, 2 cysts were extraconal, 3 intraconal, 1 in lacrimal gland, 1 in medial rectus and 1 intraosseous in lateral orbital wall. 14 kiratli h. reported a case of intramuscular hydatid cyst in medial rectus muscle. 15 it shows that although more common site in the orbit is intraconal, almost any part of the orbit can be involved. there are also some case reports on subretinal hydatid cyst. 16 different approaches and excision methods are described in the literature. neurosurgeons approach through craniotomy and orbitotomy and the orbital surgeons perform orbitotomy. 17 the classical surgical method for removal of hydatid cyst is described in “mansons tropical diseases”. the contents of the cysts are sucked out with a wide bore needle. then 10% formalin is injected in the cyst, left for 5 minutes and then aspirated. then the cyst wall is excised. 18 into to excision of the cyst without rupture is another way of cyst removal. aspiration of the cyst, followed by removal of the germinal layer of cyst by holding it with cryo probe is another procedure. 19 some authors described a simpler technique by draining the cyst percutaneously under ultrasound guidance, refilled it with 15% hypertonic saline and re-aspirated after 10 minutes. 20 limitation of this study is the small sample size and lack of long term follow-up. majority of the participants were from afghanistan and they could not make up follow-up visits. conclusion although rare, orbital hydatid cyst should be considered in differential diagnosis of unilateral proptosis, especially in children. imaging studies including b-scan, ct-scan and mri can give presumptive diagnosis of hydatid cyst in more than 90% of cases. treatment of choice is surgical excision and postoperative results are excellent, provided surgical excision in done earlier followed by oral albendazole for 12 weeks. ethical approval the study was approved by the institutional review board/ ethical review board. (667/dme/kmc). tajamul khan, et al 207 pak j ophthalmol. 2021, vol. 37 (2): 203-207 conflict of interest authors declared no conflict of interest. references 1. lentzsch am, göbel h, heindl lm. primary orbital hydatid cyst. ophthalmology, 2016l; 123 (7): 1410. doi: 10.1016/j.ophtha.2016.02.042. 2. kahveci r, sanli am, gürer b, sekerci z. orbital hydatid cyst. neurosurg pediatrics, 2012; 9: 42–44. 3. aksoy fg, tanrikulu s, kosar u. inferiorly located retrobulbar hydatid cyst: ct and mri features. comput med imaging graph. 2001; 25 (6): 535–540. 4. berradi s, hafidi z, lezrek o, lezrek m, daoudi r. orbital hydatid cyst. qjm: an intern j med. 2015; 108 (4): 343-344. 5. ciurea av, giuseppe g, machinis tg, coman tc, fountas kn. orbital hydatid cyst in childhood: a report of two cases. south med j. 2006; 99 (6): 620625. 6. al-muala hd, sami sm, shukri ma, hasson hk, alaboudy at. orbital hydatid cyst. ann maxillofac surg. 2012; 2 (2): 197-199. doi: 10.4103/2231-0746.101365. 7. limaiem f, bellil s, bellil k. primary orbital hydatid cyst in an elderly patient. surg infect (larchmt), 2010; 11: 393–395. 8. somay h, emon st, orakdogen m, berkman mz. a primary orbital hydatid cyst. j clin neurosci. 2012; 19 (6): 898–900 9. benazzou s, arkha y, derraz s, el-ouahabi a, elkhamlichi a. orbital hydatid cyst: review of 10 cases. j cranio-maxillofac surg. 2010; 38 (4): 274-278. 10. turgut at, turgut m, koşar u. hydatidosis of the orbit in turkey: results from review of the literature 1963–2001. intern ophthalmol. 2004; 25 (4): 193-200. 11. betharia sm, sharma v, pushker n. ultrasound findings in orbital hydatid cysts. am j ophthalmol. 2003; 135 (4): 568-570. 12. malik a, chandra r, prasad r, khanna g, thukral bb. imaging appearances of atypical hydatid cysts. indian j radiol imag. 2016; 26 (1): 33. 13. chtira k, benantar l, aitlhaj h, abdourafiq h, elallouchi y, aniba k. the surgery of intra-orbital hydatid cyst: a case report and literature review. pan afr med j. 2019; 33: 167. doi: 10.11604/pamj.2019.33.167.18277. 14. rajabi mt, bazvand f, makateb a, hosseini s, tabatabaie sz, rajabi mb. orbital hydatid cyst with diverse locality in the orbit and review of literatures. arch iran med. 2014; 17 (3): 207–210. 15. kıratlı h, bilgiç s, öztürkmen c, aydın ö. intramuscular hydatid cyst of the medial rectus muscle. am j ophthalmol. 2003; 135 (1): 98-99. 16. muftuoglu g, cicik e, ozdamar a, yetik h, ozkan s. vitreoretinal surgery for a subretinal hydatid cyst. am j ophthalmol. 2001; 132 (3): 435-437. 17. hammoud m, benzagmout m, lakhdar f, chakour k, chaoui mf. fronto orbital approach for primary orbital hydatid cyst: case report. j neurol stroke, 2020; 10 (1): 53-56. doi: 10.15406/jnsk.2020.10.00410. 18. wilcocks c, manson-bahr pec. chapter 13, cestode infections. in: manson’s tropical diseases. 17th ed. london, england: bailliere tindall. 1972: 342-346. 19. kaymaz m, dogulu f. orbital hydatid cyst. j neurosurg. 2002; 97: 724. 20. xiao a, xueyi c. hydatid cysts of the orbit in xinjiang: a review of 18 cases. orbit. 1999; 18 (3): 151-155. authors’ designation and contribution tajamul khan; professor: concepts, literature search, data acquisition, data analysis, statistical analysis, manuscript editing, manuscript review. ibrar hussain; professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation. zaman shah; associate professor: literature search, manuscript editing, manuscript review. .…  …. 45 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology original article effect of incision site on pre-existing astigmatism in phaco-emulsification akbar khan, mumtaz alam, muhammad rafiq afridi, imran ahmad pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: akbar khan house no 310, street no 5, sector e-4, phase 7, hayatabad peshawar …..……………………….. purpose: the purpose of the study was to determine the mean change in preexisting astigmatism, by site of incision in phacoemulsification. material and methods: it was a prospective study, conducted at ophthalmology department, khyber teaching hospital peshawar, from march 1 st 2012 to august 31 st 2012. all cases were operated by phacoemulsification with intraocular lens implantation keeping 3.2 mm incision perpendicular to steep meridian of cornea. astigmatism was measured in diopters by keratometry preoperatively and at 6 weeks post-operatively. results: total number of patients included in the study was 113. the mean pre-operative astigmatism was 1.90 ± 0.49 diopters with a range from 1.20 to 3.25 diopters. the astigmatism decreased in 105 eyes (92.92%), remained unchanged in 4 eyes (3.53%) and increased in 4 eyes (3.53%). the mean reduction in astigmatism at the end of study was 0.54 ± 0.27 diopters. this difference in preoperative and postoperative was statistically significant (p value = 0.0001). conclusion: a 3.2 mm perpendicular incision at the steep meridian of cornea is effective in reducing the pre-existing astigmatism. ataract affects approximately 20 million people worldwide and this figure is expected to reach 50 million by the year 20201. in pakistan cataract accounts for 66.7% of the total blindness2 and cataract surgery is the most commonly performed ocular surgery3. small incision cataract surgery doesn’t require suturing of wound, has low risk of intra operative and postoperative complications and results in rapid visual rehabilitation4. phacoemulsification results in better postoperative visual acuity (va) than extra capsular cataract extraction (ecce) at all postoperative intervals5. therefore, phacoemulsification is almost universally preferred nowadays6. spectacles or contact 5 lenses can be used to correct astigmatism. spectacles wear for correction of astigmatism can cause various optical aberrations. contact lens wear has a number of side effects such as risk of infection, mechanical and hypoxic keratitis, immune response keratitis and giant papillary conjunctivitis7. correction of preexisting astigmatism simultaneously with cataract surgery is attempted nowadays. different methods of reducing astigmatism during cataract surgery include keratotomy, toric intraocular lens (iol) implantation, opposite clear corneal incision (occi) and limbal relaxing incisions or corneal relaxing incisions5. a clear corneal incision given during phacoemulsification at the steep meridian of cornea reduces preexisting astigmatism8,9. limbal relaxing incisions performed during phacoemulsification are also very safe, stable and effective in reducing pre-existing corneal astigmatism9. the objective of the study was to determine the mean change in pre-existing astigmatism, by site of incision in phacoemulsification as altering the incision site may help in reducing pre-existing astigmatism. material and methods it was a prospective study conducted at ophthalmology department, khyber teaching hospital c effect of incision site on pre-existing astigmatism in phaco-emulsification pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 46 peshawar, from march 1st 2012 to august 31st 2012. all patients with age related cataract with pre existing astigmatism of 1d or more were included in the study. patients having irregular astigmatism and astigmatism due to pterygium, previous history of any surgery in same eye, corneal opacity and those having traumatic or complicated cataract were excluded from the study. sampling technique was non-probability consecutive sampling. approval was taken from the hospital ethical committee before starting the study and written informed consent was taken from the patients. preoperatively detailed history was taken and complete systemic and ocular examination was done, including keratometry for the type and degree of astigmatism. all cases were operated by phacoemulsification with iol implantation keeping 3.2mm incision at the limbus perpendicular to steep meridian of cornea. after viscoelastic material was injected, a continuous curvilinear capsulorhexis, hydro dissection, phacoemulsification, aspiration of cortex and capsular bag refilling with viscoelastic solution was performed. a foldable acrylic iol was implanted in the capsular bag. viscoelastic material was removed and anterior chamber formed with ringer’s lactate. wound was tested for water tightness. in all eyes phaco power, viscoelastic gel, irrigation solution (ringer’s lactate) and iol were kept constant. all surgeries were performed by the same surgeon. postoperatively each patient received 0.3% ofloxacin eye drops and 0.1% dexamethasone eye drops 4 times / day. steroid eye drops were tapered in 4 – 6 weeks. analgesics were used whenever required. post-operatively the patients were followed up after 6 weeks. at follow up visit, keratometry was performed to see the effect of incision site in the form of correction of pre-existing astigmatism. all the relevant data was recorded in a pre-designed proforma. all the collected data was analyzed using spss version 10.0. results the number of patients included in our study was 113. patient’s age ranged from 41 to 84 years with a mean of 59.36 ± 10.08 years. 62 patients (54.86 %) were male and 51 (45.13%) were female. all the patients underwent phacoemulsification and iol implantation through a 3.2 mm wide incision perpendicular to the steep meridian of cornea. right eye was operated in 59 (52.21%) cases and left eye was operated in 54 (47.78%) cases. pre-operative astigmatism in all the patients was measured in diopters (table 1). the mean preoperative astigmatism was 1.90 ± 0.49 diopters with a range from 1.20 to 3.25 diopters. all patients were followed up at 6th week postoperatively and post-operative astigmatism was recorded (table 2). the mean post-operative astigmatism was 1.36 ± 0.53 diopters with a range from 0.50 to 2.80 diopters. akbar khan, et al 47 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology difference between pre-operative and postoperative astigmatism was noted at 6 weeks (table 3). the change in astigmatism was ranging from -1.25 d to + 0.25 diopters with a mean of -0.54 ± 0.27 diopters. the astigmatism decreased in 105 eyes (92.92%), remained unchanged in 4 eyes (3.53%) and increased in 4 eyes (3.53%). the mean change in astigmatism at the end of my study was 0.54 ± 0.27 diopters. student t test was applied for significance of change in astigmatism after the surgery. the p value was 0.0001 and this difference was considered to be statistically significant. discussion modern cataract surgery aims at achieving a good refractive outcome postoperatively with minimal postoperative astigmatism10. postoperative astigmatism depends on the site, width and architecture of the incision and suturing technique11,12. even with small incision cataract surgery using foldable iol the visual outcome may vary greatly due to pre-existing astigmatism. placing the incision on the steepest meridian results in decreased refractive power in that meridian and an increased refractive power in the meridian perpendicular to it13. in our study this concept was utilized in eyes with pre-operative astigmatism of 1.00 d or more. in this study a 3.2 mm self-sealing incision was given perpendicular to the steep axis of cornea to assess the effect of a site of incision on neutralizing the pre-existing astigmatism. this study shows that by placing a 3.2 mm incision perpendicular to the steeper axis, it is possible to reduce the amount of astigmatism in eyes with preoperative astigmatism of 1.00 d or more. lever and dahan14 reported in their study that a 3.5 mm opposite clear corneal incision in the steep meridian was effective in reducing pre-existing corneal astigmatism by a mean value of 2 diopters. corresponding figures have been reported to be 0.5 diopters by tadros15 and 1.5 diopters by khokhar.8 in one study,16 in patients who underwent conventional small incision cataract surgery (sics), eyes with superior incisions had 1.92 ± 0.53 d “against the rule” astigmatism and eyes with temporal incisions had 1.57 ± 0.24 d “with the rule” astigmatism at 90 days. in patients who underwent phacoemulsification, 1.08 ± 0.36 d astigmatism was seen with clear corneal incision and 1.23 ± 0.71 d astigmatism was seen with corneo-scleral incision. in the study of george et al17, mean astigmatism after conventional ecce, manual sics and phacoemulsification surgery was 1.77 d, 1.17 d and 0.77 d respectively (p = 0.001). in our study a 3.2 mm clear corneal incision was given in all cases, in the steep meridian. post-operative keratometry was done 6 weeks after the surgery, to give time for complete wound healing and stabilization of refraction. the decrease in astigmatism at the follow up was 0.54 ± 0.27 diopters. the difference between pre-operative and post-operative astigmatism was statistically significant (p value = 0.0001). however, placing the corneal incision in the steep meridian alone may not fully correct high astigmatism and this may have to be combined with other procedures5 or the residual astigmatism may have to be corrected with glasses post-operatively. conclusion a 3.2 mm wide incision for phacoemulsification placed perpendicular to steep axis of cornea is effective in reducing the pre-existing corneal astigmatism. author’s affiliation dr. akbar khan eye surgeon khyber eye foundation, peshawar dr. mumtaz alam senior registrar ophthalmology department kuwait teaching hospital, peshawar effect of incision site on pre-existing astigmatism in phaco-emulsification pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 48 dr. muhammad rafiq afridi assistant professor ophthalmology department rehman medical institute, peshawar dr. imran ahmad medical officer khyber teaching hospital, peshawar references 1. zaman m, iqbal s, khan ym, khan mt, jadoon mz, qureshi mb, safi ma, khan md. manual small incision cataract surgery (msics). review of first 500 cases operated in microsurgical training center. pak j ophthalmol. 2006; 22: 1422. 2. khan aq, qureshi b, khan md. rapid assessment of cataract blindness in age 40 years and above in district skardu, baltistan, northern areas of pakistan. pak j ophthalmol. 2003; 19: 84-9. 3. qazi za. corneal endothelium tissue that demands respect. pak j ophthalmol. 2003; 19: 1-2. 4. ahmad a, ahmad j. combined phacoemulsification, intraocular lens implantation and trabeculectomy. pak j ophthalmol. 2000; 16: 26-8. 5. yi dh, sullivan br. phacoemulsification with indocyanine green versus manual expression extracapsular cataract extraction for advanced cataract. j cataract refract surg. 2002; 28: 2165-9. 6. chakrabarti a, singh s. phacoemulsification in eyes with white cataract. j cataract refract surg. 2000; 26: 1041-7. 7. kanski jj. cornea. in: kanski jj clinical ophthalmology. a systemic approach 7th ed. butterworth heinemann elsevier 2007; 167-238. 8. khokhar s, lohiya p, murugiesan v, panda a. corneal astigmatism correction with opposite clear corneal incisions or single clear corneal incision: comparative analysis. j cataract refract surg. 2006; 32: 1432-7. 9. altan – yaycioglu r, akova ya, akca s, gur s, oktem c. effect on astigmatism of the location of clear corneal incision in phacoemulsification of cataract. j cataract refract surg. 2007; 23: 515-8. 10. rainer g, menapace r, vass c. corneal shape changes after temporal and superolateral 3.0 mm clear corneal incisions. j cataract refract surg. 1999; 25: 1121-6. 11. roman sj, auclin fx, chong-sit da, ullern mm. surgically induced astigmatism with superior and temporal incisions in cases of with-the-rule preoperative astigmatism. j cataract refract surg. 1998; 24: 1636-41. 12. simsek s, yasar t, demirok a, cinal a, yilmaz of. effect of superior and temporal clear corneal incisions on astigmatism after sutureless phacoemulsification. j cataract refract surg. 1998; 24: 515-8. 13. elkington ar, frank hj, greaney mj. refractive surgery. in: clinical optics. 3rd edition. 1999; 242-54. 14. lever j, dahan e. opposite clear corneal incision to correct preexisting astigmatism in cataract surgery. j cataract refract surg. 2000; 26: 803-5. 15. tadros a, habib m, tejwani d, lany hv, thomas p. opposite clear corneal incisions on the steep meridian in phacoemulsification: early effects on the cornea. j cataract refract surg. 2004; 30: 414-7. 16. reddy b, raj a, singh vp. site of incision and corneal astigmatism in conventional sics versus phacoemulsification. ann ophthalmol. 2007; 39: 209-16. 17. george r, rupauliha p, sripriya av, rajesh ps, vahan pv, praveen s. comparison of endothelial cell loss and surgically induced astigmatism following conventional extracapsular cataract surgery, manual small – incision surgery and phacoemulsification. ophthalmic epidemiol. 2005; 12: 293-7 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22altan-yaycioglu%20r%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22akova%20ya%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22akca%20s%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22gur%20s%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22oktem%20c%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstractplus javascript:al_get(this,%20'jour',%20'j%20refract%20surg.'); 186 pak j ophthalmol. 2022, vol. 38 (3): 186-192 original article intravitreal triamcinolone acetonide and bevacizumab versus intravitreal bevacizumab and posterior subtenon triamcinolone acetonide in refractory diabetic macular edema ambreen gul 1 , fuad ahmad khan niazi 2 , ali raza 3 1,2 holy family hospital, rawalpindi medical university, rawalpindi 3 al-nafees medical college & hospital, islamabad abstract purpose: to compare the effects of combined simultaneous injection of intravitreal triamcinolone acetonide and bevacizumab with intravitreal bevacizumab and posterior subtenon triamcinolone acetonide in treatment of refractory diabetic macular edema. study design: quasi experimental study. place and duration of study: rawalpindi medical university from january 2019 to december 2019. methods: forty pseudophakic diabetic patients with refractory diabetic macular edema with central retinal thickness (crt) of > 350 ɥm on oct were included in the study. group a was given simultaneous injection of intravitreal bevacizumab 1.25 mg/0.05 ml with posterior sub-tenon triamcinolone 40mg while group b had intravitreal bevacizumab with simultaneous intravitreal triamcinolone 2 mg/0.05 ml. changes in the bcva, iop and crt were evaluated in both groups. results: group b showed a more significant decrease in the median crt at 1 month (p = 0.0002). after 3 months, the reduction in crt was not statistically different between the two groups (p > 0.05). both groups had significant improvement in bcva compared to pre-injection baseline visual acuity. five eyes in group b and none in group a developed iop beyond 22 mmhg. at 12 weeks, 7 patients of group a and 6 of group b developed recurrent macular edema and required repeated injections. conclusion: posterior subtenon triamcinolone is as effective as intravitreal triamcinolone in conjunction with intravitreal bevacizumab in reducing crt and improving and stabilizing bcva. posterior subtenon injection is safer as compared to intravitreal injection in terms of rise of iop. key words: diabetic macular edema, intravitreal injection, posterior subtenon injection, central retinal thickness, optical coherence tomography. how to cite this article: gul a, niazi fak, raza a. intravitreal triamcinolone acetonide and bevacizumab versus intravitreal bevacizumab and posterior subtenon triamcinolone acetonide in refractory diabetic macular edema. pak j ophthalmol. 2022, 38 (3): 186-192. doi: 10.36351/pjo.v38i3.1400 correspondence: ambreen gul holy family hospital, rawalpindi medical university, rawalpindi email: amber-gul@hotmail.com received: april 11, 2022 accepted: june 9, 2022 introduction diabetes mellitus is a metabolic disorder with multiple complications involving end organs like retina. diabetic retinopathy (dr) is leading cause of visual disturbance among diabetics. 1 neovascularization of retina and diabetic macular edema (dme) are major clinical manifestations of diabetic retinopathy potentially adding to visual loss.¹ ocular factors mailto:amber-gul@hotmail.com simultaneous injection of intravitreal triamcinolone acetonide and bevacizumab versus intravitreal bevacizumab and posterior subtenon pak j ophthalmol. 2022, vol. 38 (3): 186-192 187 affecting this morbidity are severity of diabetic retinopathy and systemic factors like type, duration and poor control of diabetes leading to higher hemoglobin a1c levels. 2 despite availability of several treatment options for dme, it is one of the principal causes of visual disability among diabetic patients. the prevalence of dme is 2.7-11% and 30% particularly in diabetics with duration of ailment for more than 20 years. 1-3 pathogenesis of dme is multifaceted and intricate. it is not entirely understood because of several etiologic agents. leakage of exudates from retinal capillary hyper permeability, leukostasis, ischemia and pro inflammatory reactions play role. inflammatory mediators like enzymes, growth factors such as vegf, interleukins, and cytokines like tnf, tgf-beta and certain metabolic changes result in loss of tight junctions between endothelial cells. it leads to disruption of inner blood retinal barrier and interstitial edema. 4 early dme occurs due to inflammation and vascular dysfunction and in long standing persistent dme, anatomical changes occur in harmony with neurotoxic effects. most important test in diagnosing and monitoring progression of dme is oct. persistent refractory diabetic macular edema is one of the most frequent and untreatable causes of visual loss among diabetics. macular edema not responding to anti vegf agents is refractory or resistant macular edema. 4 the frequency of resistant or refractory dme is approximately 50%. 5 there is no clear cut off value in definition of refractory dme in published literature. parameters used in labeling dme as recalcitrant include; no gain in visual acuity, reduced anatomical responses or frequent requirement of injections. dme refractory to medical or laser treatment is a challenge for ophthalmologists. different types of interventions are proposed for resistant dme like intravitreal steroids, newer anti-vegf agents, and combination drugs. sequence of treatment regimens and shift from one regimen to another is also not clearly understood. 6 pars plana vitrectomy with or without ilm peeling and laser photocoagulation is another option to treat dme. laser photocoagulation was considered to be the gold standard in improving vision but has definite side effects like macular scarring and fibrosis along with visual field defects. now-a-days anti vegf agents have become gold standard for treatment of dme. newer agents like monthly injections of intravitreal ranibizumab and aflibercept have shown promising results in treatment of dme; however, cost is an issue in this treatment. 6 moreover, all diabetic patients with dme do not demonstrate favorable and optimal response to intravitreal anti-vegf agents. almost 50% of patients showed post treatment crt of more than 275 ɥm when treated with intravitreal ranibizumab in restore study. 7 anti vegf agents block the production of vegf responsible for chronic low grade inflammatory and metabolic changes leading to macular edema. they need to be given repeatedly due to which risk of ocular and systemic side effects are high along with compliance problems. 7 intravitreal steroids are second line treatment particularly in pseudo phakic eyes due to side effects of cataract and intraocular pressure elevation. corticosteroid options include triamcinolone acetonide, dexamethasone implant and flucinolone acetonide insert. neurodegenerative and inflammatory pathways leading to breakdown of inner blood retinal barrier and vascular hyper-permeability are inhibited by corticosteroids. 8 they also recover the integrity of blood retinal barrier by restoring proteins at cellular border, consequently a neuroprotective effect on retina. 9 intravitreal triamcinolone acetonide is effective in treating dme but its limitations are glaucoma and cataract. with any intravitreal injection there is risk of iatrogenic vitreous hemorrhage, retinal tear or detachment and endophthalmitis (sterile or infectious). posterior sub tenon injection of ta is mostly used in treatment of intermediate uveitis and post cataract surgery cystoids macular edema. it is less invasive technique than intravitreal injections and its comparable therapeutic concentrations are achieved in vitreous and delivered to macula. posterior subtenon injection has shown promising results in treatment of persistent refractory dme. 10 in refractory or resistant cases, there is generally need for repetitive injections to maintain their therapeutic effect due to prolonged clinical course of dme. the debate is going on whether single or combined simultaneous agents would be sufficient in limiting the disease with respect to safety, economy and effectiveness. purpose of discovering treatments of combined therapies in resistant cases is to increase the duration of effective role of these agents; hence to eliminate the necessity for repeated injections intimidating complications along with benefit of cost effectiveness. the aim and objectives of present study were to evaluate and compare the effects of intravitreal triamcinolone acetonide versus posterior sub-tenon ambreen gul, et al 188 pak j ophthalmol. 2022, vol. 38 (3): 186-192 triamcinolone acetonide in conjunction with intravitreal bevacizumab in treatment of persistent refractory dme after repeated monotherapy failure with ivb. methods this quasi-experimental study of 12 months duration was conducted at ophthalmology department of rawalpindi medical university. after approval from institutional ethical board of university, we explained objectives of this study to patients enrolled in this study. patients were registered from diabetic retinopathy project in the dr clinic of department from january 2019 to december 2019. informed written consent was obtained from all patients along with details of interventional treatment given to them and its possible side effects. we included 40 pseudophakic eyes of diabetic patients in current study. inclusion criteria was patients exclusively diagnosed with refractory diabetic macular edema with mean crt of ≥ 350 ɥm on oct with a minimum (< 15%) or no reduction in crt for the last 6 months. most of these cases had been given ≥ 3 consecutive ivb injections in normal dosage of 1.25mg/0.05ml at intervals of 4 or 6 weeks. furthermore, they showed an increase or no decrease in crt after ivb monotherapy before switching to other regimen. patients who were steroid responders showing an increase in iop, previous intraocular surgery or laser treatment within three months, previous corticosteroids treatment for dme, known case of glaucoma, ischemic cardiovascular or cerebrovascular events in last 6 months, ischemic maculopathy or vitreomacular adhesion were excluded. we divided patients into two groups. group a was given intravitreal injection of bevacizumab 1.25 mg/0.05 ml in conjunction with 40mg of posterior subtenon injection of triamcinolone acetonide in the same sitting. group b was given intravitreal injection of bevacizumab 1.25 mg/0.05 ml in conjunction with 2 mg/0.05 ml intravitreal injection of triamcinolone acetonide in the same sitting. all patients received detailed ophthalmic examinations at baseline in dr clinic. best corrected visual acuity by snellen decimal chart was measured. after assessing the iop by goldman applanation tonometry and pupil reaction to rule out any rapd; dilated fundus evaluation was done on slit lamp biomicroscope with 90 d lens and staging of diabetic retinopathy was recorded. all patients had baseline spectral domain oct for crt. ffa was done to rule out ischemic maculopathy. changes in the bcva (snellen decimal fraction), iop, and crt were reevaluated in both groups at subsequent follow-up visits planned at 1, 2 and 3-months post treatment. retreatment was performed at 6 weeks interval whenever indicated by oct. repeated treatment with combined simultaneous injections was only suggested for cases who responded to first injection with decrease in crt by at least 10-15%. if an eye showed an increase in crt after first combined injection, additional treatment was suspended. combined simultaneous injection of ivb and ivta to group a patients were given under strict aseptic measure in operation room by a single consultant ophthalmologist. after povidone iodine scrubbing and sterile draping of eye, 1.25mg/0.05ml of intravitreal bevacizumab was injected then intravitreal triamcinolone acetonide 2mg in 0.05 ml was injected in the same fashion. after injection, if any sign of central retinal artery compression was seen; anterior chamber paracentesis was done immediately. post injection iop was checked after 4 hours and at day 1. patients were given topical moxifloxacin eye drops one day before injection and 4 hourly for seven days after injection to protect against endophthalmitis. if any raised iop was documented, topical antiglaucoma medications were started. group b was given intravitreal bevacizumab and posterior subtenon triamcinolone acetonide (psta).psta was given in dosage of 40 mg of ta in 1ml with 27-gauge needle. patient was asked to look down and needle was penetrated into conjunctiva in superotemporal fornix with bevel downwards. then needle was advanced under tenon along the contour of globe with side to side movements to test for engagement of globe or sclera in tip of needle and drug was injected. all patients were followed on day 1, 7 and 14 for complications due to raised intraocular pressure or endophthalmitis. primary outcome measure was crt reduction on oct (anatomical success) and secondary outcome measures were bcva (functional visual acuity improvement), number of patients requiring repeated injections and side effects of treatment like elevated iop. statistical analysis was done by spss software version 21. comparative analysis of crt, bcva and iop was done at baseline (pre-injection), 1 and 3 months (post-injection) by paired sample t test and p simultaneous injection of intravitreal triamcinolone acetonide and bevacizumab versus intravitreal bevacizumab and posterior subtenon pak j ophthalmol. 2022, vol. 38 (3): 186-192 189 value less than 0.05 was taken as statistically significant. qualitative variables like gender, type of diabetes, control of diabetes and staging of diabetic retinopathy were expressed as percentages and frequencies. quantitative variables such as age, duration of diabetes, crt, bcva and iop were expressed as mean ± sd. results mean age in group a was 59.9 ± 9.12 with a range of 42 – 75 years. duration of diabetes was 7 – 22 years with a mean duration of 13.1 ± 4.30. right and left eye was involved in 10 patients each. there were 50% males and 50%females. four (20%) patients had type 1 diabetes and 16 patients (80%) had type 2 diabetes. nine patients (45%) had uncontrolled diabetes and 11 (55%) patients had controlled diabetes. in group a, 14 (70%) patients had npdr and 6 (30%) had pdr. mean age in group b was 63.6 years ± 9.39 with a range of 47 – 78 years. mean duration of diabetes was 13.85 ± 5.98 with a range of 6 – 26 years. right eye was involved in 11 and left eye in 9 patients. there were 45% males and 55% females. three patients (15%) had type 1 diabetes and 17 (85%) patients had type 2 diabetes. five patients (25%) in group b had uncontrolled diabetes and 15 (75%) patients had controlled diabetes. in group b, 5 patients (25%) had pdr and 15 (75%) had npdr. considering the demographic variables both groups were well matched in terms of age, gender, type, duration, control of diabetes and staging of diabetic retinopathy. the difference in demographic variables was not statistically significant between two groups (p > 0.05). mean baseline bcva in group a was 0.100±0.04 with a range of 0.03 – 0.16 by snellens decimal visual acuity chart. mean baseline crt was 449.5 ɥm ± 101.18 with a range of 375 – 716 ɥm. mean baseline iop was 15.2 mmhg ± 2.66 with a range of 11 – 20 mmhg. there was significant reduction in mean crt of 286.45 ɥm ± 5.735 with a range of 269 – 298.00 ɥm in group a at 1 month after combined injection of ivb and psta (p value 0.001). mean bcva was 0.21 ± 0.12 with a range of 0.05 – 0.50, this illustrated an obvious improvement in bcva from baseline (p value 0.002). mean iop was 17.3 ± 2.31 mmhg with a range of 13 – 21 mmhg, which demonstrated a slight rise in iop from baseline but none of the patients showed a glaucomatous rise in iop beyond borderline of 21 mmhg. mean crt at 3 months after treatment was 288.20 ɥm ± 36.96 with a range of 212 – 388 ɥm which was considerably less than baseline but there was no statistically significant difference from crt reduction at 1 month (p value > 0.05). mean bcva at 3 months was 0.46 ± 0.32 with a range of 0.05 – 0.8 snellens decimal chart. there was evident improvement in bcva from baseline. mean iop was 14.8 mm hg ± 2.36 with a range of 10–18 mm hg at 3 months post injection. iop showed no statistically significant difference from baseline iop (p value > 0.05) and was closer to baseline iop. extrafoveal hard exudates were present in 16 (70%) patients and subfoveal hard exudates in 4 (30%) patients in group a. mean baseline bcva in group b was 0.091 ± 0.043 with a range of 0.01 – 0.16 by snellens decimal visual acuity chart. mean baseline crt was 500.95±103.67ɥm with a range of 389–709ɥm. mean baseline iop was 14.95 mmhg ± 2.60 with a range of 10 – 19 mmhg. there was significant reduction in mean crt of 263.45 ɥm ± 20.89 sd with a range of 220 – 283 ɥm in group b at 1 month after combined simultaneous injection of ivb and ivta (p value of 0.0002). mean bcva at end of 1 st month in group b was 0.24 ± 0.13 with a range of 0.03 – 0.50. this showed an improvement in bcva from baseline. mean iop after 1 month of injection was 20.4 ± 3.01 mmhg with a range of 17 – 26 mmhg, which revealed a significant rise in intraocular pressure from baseline (p value 0.042). five out of 20 patients showed a glaucomatous rise in iop beyond borderline of 21 mmhg which was treated with antiglaucoma medications. mean crt at 3 months after treatment was 289.4 ɥm ± 25.89 with a range of 261 – 328 ɥm which was considerably less than baseline but showed a slight increase compared to cst at 1 month. mean bcva at 3 months was 0.43 ± 0.30 with a range of 0.03 – 0.8 snellens decimal chart. there was marked improvement in bcva (p value = 0.000). mean iop was 16.15 mmhg ± 1.56 with a range of 14 – 20 mmhg at 3 months post injection. this iop was comparable to baseline iop (p value 0.49) which means there was transient increase in iop at 1 month, which returned to baseline at an interval of 12 weeks. extrafoveal hard exudates were present in 15 (75%) patients and subfoveal hard exudates in 5 (25%) patients in this group b. ambreen gul, et al 190 pak j ophthalmol. 2022, vol. 38 (3): 186-192 figure 1: mean crt comparison between two groups’ preinjection, 1 and 3 months. 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 group a group b bcva preinjection bcva 1 month bcva 3 months figure 2: mean bcva comparison between two groups’ preinjection, 1 and 3 months. figure 3: mean iop comparison between two groups’ pre-injection, 1 and 3 months. both groups showed a reduction in crt in all 40 (100%) patients. group a showed improvement in bcva in 16 (70%) patients and stabilization in bcva in 4 (30%) patients. group b showed an improvement in bcva in 17 (85%) patients and stabilization in bcva in 3 (15%) patients. bcva changes in both groups were significantly better than baseline bcva (p value < 0.05) but between two groups changes were not statistically significant. at 12 weeks, 7 patients in group a and 6 patients in group b developed recurrent macular edema and required repeated injections. illustration of mean crt, bcva and iop of both groups’ pre-injection, 1 and 3 months are shown in figure 1, 2 and 3 respectively. discussion combined injections of anti vegf and corticosteroids have been intended to treat refractory persistent dme both by inhibiting vegf production and proinflammatory mediators that cause vascular hyperpermeability. current study showed significant improvement in refractory macular edema with reduction in crt in all 40 patients (100%) from baseline at 1 and 3 months (p value < 0.05). group a showed an improvement in bcva in 70% while group b showed an overall improvement in bcva in 85%. freeman et al showed that superotemporal injection of steroids results in more precise delivery closer to macula by b-scan ultrasonography. 11 geroski et al concluded that trans-scleral route was beneficial in placement of drug in retina. 12 weijtens et al reported peribulbar injection of corticosteroids provided higher intravitreal concentrations. 13 summarizing all these reports effective concentrations of ta in retina can be attained through sub-tenon route. ohguro et al reported the positive effect of psta in diffuse dme in eyes that had not shown significant response to vitrectomy. 14 bakri and kaiser conducted a study on refractory dme patients with psta injection and they found substantial improvement in va after 1 month of injection and this effect was sustained for one year. so they proposed that psta was an alternative in treating dme. 15 chan et al illustrated the effect of triple therapy that is psta in high dosage of 75 mg, ivb and argon laser photocoagulation in patients of refractory dme. 16 choi yj et al conducted a study of intravitreal versus posterior subtenon injection of triamcinolone acetonide in cases of dme and concluded that psta had an equivalent effect to ivta and showed less risk of iop elevation. 17 these studies indicate that the subtenon route provided therapeutic concentration of drugs to retina in a safer way. current study also proved safety of psta route compared to ivta. kim et al compared monotherapy of ivb,psta with combination of ivb-psta (4.0 mg) and they found superior anatomical (clinical) outcomes particularly at end of 1 month in combination group compared to monotherapy group. 18 aly mm et al simultaneous injection of intravitreal triamcinolone acetonide and bevacizumab versus intravitreal bevacizumab and posterior subtenon pak j ophthalmol. 2022, vol. 38 (3): 186-192 191 proposed considerable improvement in mean cmt in all eyes and improvement in visual acuity in 83.3% of eyes with persistent dme with a combined ivb and psta. 19 wang ys et al compared single ivb with combined ivb-ivta for dme and they found favorable effects with combined injection but significant effect was not permanent. 20 esfahani mr et al conducted a study in centre involving macular edema and compared the results of ivb given alone and combined ivb-ivta injection. they reported a significant reduction in macular thickness in combined ivb-ivta group but visual acuity enhancement was better in ivb alone. combination therapy decreases the number of injections required. 21 tsilimbaris mk et al found out major decrease in central macular thickness and superior best corrected visual acuity in group with combined ivb-ivta and showed this therapy to be very effective. 22 in all of these studies, results are comparable to our study supporting combined simultaneous use of bevacizumab with corticosteroids to be more favorable with better outcomes. cardillo et al did a comparative trial of intravitreal and posterior subtenon triamcinolone and found out ivta more beneficial than psta in cases of diffuse dme in each eye of one patient. study had limitations of small sample size. 23 bonini filho et al compared both intravitreal and posterior subtenon triamcinolone injections in refractory dme and reported ivta more approving than psta. 24 both these studies differ from current study which showed both ivta and psta were equally effective in treating refractory dme in term of anatomical and visual (functional) outcomes. psta was safer as compared to ivta in terms of iop elevation. this disparity could be due to relatively short follow-up in our study. their results are also relatively non-comparable to current study because combined simultaneous injections were given in our study. more studies are needed long follow-up to confirm long term effectiveness and safety of combined simultaneous injections. conclusion combined simultaneous injections of ivb-psta and ivb-ivta are cost effective and evenly beneficial in treating persistent refractory dme but in terms of safety, ivb-psta is considered to be less harmful with fewer to no complication or side effects. conflict of interest: authors declared no conflict of interest. ethical approval the study was approved by the institutional review board/ethical review board (136/iref/rmu/2018). references 1. wang w, lo acy. diabetic retinopathy: pathophysiology and treatments. int j mol sci. 2018; 19 (6): 1816. doi: 10.3390/ijms19061816. 2. liu y, yang j, tao l, lv h, jiang x, zhang m, et al. risk factors of diabetic retinopathy and sightthreatening diabetic retinopathy: a cross-sectional study of 13 473 patients with type 2 diabetes mellitus in mainland china. bmj open, 2017; 7 (9): e016280. doi: 10.1136/bmjopen-2017-016280. 3. browning dj, stewart mw, lee c. diabetic macular edema: evidence-based management. indian j ophthalmol. 2018; 66 (12): 1736-1750. doi: 10.4103/ijo.ijo_1240_18. 4. haritoglou c, maier m, augustin a. pathophysiology of diabetic macular edema – a background for current treatment modalities. exp rev ophthalmol. 2018; 13 (5): 273-281. doi: 10.1080/17469899.2018.1520634. 5. torabi h. management of refractory diabetic macular edema: a review article. int j med rev. 2018; 5 (1): 2734. 10.29252/ijmr-050105. 6. stefanini fr, badaró e, falabella p, koss m, farah 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after periocular injection. am j ophthalmol. 1987; 103 (3pt 1): 281-288. https://doi.org/10.1080/17469899.2018.1520634 https://doi.org/10.1159/000499540 ambreen gul, et al 192 pak j ophthalmol. 2022, vol. 38 (3): 186-192 12. geroski dh, edelhauser hf. transscleral drug delivery for posterior segment disease. adv drug deliv rev. 2001; 52 (1): 37-48. doi: 10.1016/s0169-409x(01)00193-4. 13. weijtens o, van der sluijs fa, schoemaker rc, lentjes eg, cohen af, romijn fp, et al. peribulbar corticosteroid injection: vitreal and serum concentrations after dexamethasone disodium phosphate injection. am j ophthalmol. 1997; 123 (3): 358-463. doi: 10.1016/s0002-9394(14)70131-x. 14. ohguro n, okada aa, tano y. trans-tenon's retrobulbar triamcinolone infusion for diffuse diabetic macular edema. graefes arch clin exp ophthalmol. 2004; 242 (5): 444-445. doi: 10.1007/s00417-003-0853-z. 15. bakri sj, kaiser pk. posterior subtenon triamcinolone acetonide for refractory diabetic macular edema. am j ophthalmol. 2005; 139 (2): 290-294. doi: 10.1016/j.ajo.2004.09.038. 16. chan ck, lai ty, mohamed s, lee vy, liu dt, li cl, et al. combined high-dose sub-tenon triamcinolone, intravitreal bevacizumab, and laser photocoagulation for refractory diabetic macular edema: a pilot study. retina, 2012; 32 (4): 672-678. doi: 10.1097/iae.0b013e31823043c6. 17. choi yj, oh ik, oh jr, huh k. intravitreal versus posterior subtenon injection of triamcinolone acetonide for diabetic macular edema. korean j ophthalmol. 2006; 20 (4): 205-209. doi: 10.3341/kjo.2006.20.4.205. 18. kim hd, kang kd, choi ks, rhee mr, lee sj. combined therapy with intravitreal bevacizumab and posterior subtenon triamcinolone acetonide injection in diabetic macular oedema. acta ophthalmol. 2014; 92 (7): e589-590. doi: 10.1111/aos.12420. 19. aly mm, abd elmagid m. combined intravitreal bevacizumab and posterior sub-tenon’s triamcinolone acetonide injections for persistent diabetic macular edema. delta j ophthalmol. 2017; 18 (3): 149. 20. wang ys, li x, wang hy, zhang zf, li mh, su xn. intravitreal bevacizumab combined with/without triamcinolone acetonide in single injection for treatment of diabetic macular edema. chin med j (engl). 2011; 124 (3): 352-358. 21. riazi-esfahani m, riazi-esfahani h, ahmadraji a, karkhaneh r, mahmoudi a, roohipoor r, et al. intravitreal bevacizumab alone or combined with 1 mg triamcinolone in diabetic macular edema: a randomized clinical trial. int ophthalmol. 2018; 38 (2): 585-598. doi:10.1007/s10792-017-0496-4. 22. tsilimbaris mk, pandeleondidis v, panagiototglou t, arvanitaki v, fragiskou s, eleftheriadou m, et al. intravitreal combination of triamcinolone acetonide and bevacizumab (kenacort-avastin) in diffuse diabetic macular edema. semin ophthalmol. 2009; 24 (6): 225230. doi: 10.3109/08820530903389775. 23. cardillo ja, melo la jr, costa ra, skaf m, belfort r jr, souza-filho aa, et al. comparison of intravitreal versus posterior sub-tenon's capsule injection of triamcinolone acetonide for diffuse diabetic macular edema. ophthalmology, 2005; 112 (9): 15571563. doi: 10.1016/j.ophtha.2005.03.023. 24. bonini-filho ma, jorge r, barbosa jc, calucci d, cardillo ja, costa ra. intravitreal injection versus sub-tenon's infusion of triamcinolone acetonide for refractory diabetic macular edema: a randomized clinical trial. invest ophthalmol vis sci. 2005; 46 (10): 3845-3849. doi: 10.1167/iovs.05-0297. authors designation and contribution ambreen gul; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. fuad ahmad khan niazi; professor: concepts, design, literature search, manuscript preparation, manuscript editing, manuscript review. ali raza; professor: concepts, design, manuscript editing, manuscript review. .…  …. https://link.springer.com/article/10.1007/s10792-017-0496-4 pak j ophthalmol. 2022, vol. 38 (2): 140-146 140 original article clinical effectiveness and local side effects of topical 0.05% cyclosporine in treatment of children with severe vernal keratoconjunctivitis adnan ahmad 1 , mubashir rehman 2 , muhammad farhan 3 , jawad humayun 4 department of ophthalmology, 1-3 nowshera medical college, nowshera 4 khyber teaching hospital, peshawar abstract purpose: to evaluate the therapeutic response of topical cyclosporine (cys-a) in patients with vernal keratoconjunctivitis (vkc), resistant to topical mast cell stabilizer (mcs) and anti-histamine therapy. study design: quasi experimental study. place and duration of study: qazi hussain ahmad medical complex, nowshera, from april 2019 to august 2019. methods: forty patients, 30 males and 10 females, less than 18 years of age and diagnosed with vernal keratoconjunctivitis were enrolled in the study. all participants were graded based upon severity of the disease at presentation with a score of 0 for normal, 1 for mild, 2 for moderate and 3 for severe, for both symptoms and signs. each patient received topical cys-a 0.05%in qid regimen in addition to lubricating tear substitute. followup was done for 04 months. results: clinical scoring was done at baseline and at the 1 st , 2 ndand 4 th month following therapy. after 4 months of topical application, not only the patients improved symptomatically but their clinical signs also improved, which achieved a level of statistical significance (p < 0.05). all participants completed the follow-up duration of therapy. although horner tranta’s dot showed improvement, but comparison of baseline with 1 st month values were statistically non-significant (p = 0.048). however, during 2 nd and 4 th month, the improvement achieved statistical significance (p = 0.013 and p = 0.006 respectively). none of the participants reported any bothersome local side effect. conclusion: topical cyclosporine 0.05% is effective in alleviating the symptoms and signs without any local side effects in resistant vkc. key words: vernal keratoconjunctivitis, cyclosporine, cobblestone papillae. how to cite this article: ahmad a, rehman m, farhan m, humayun j. clinical effectiveness and local side effects of topical 0.05% cyclosporine in treatment of children with severe vernal keratoconjunctivitis. pak j ophthalmol. 2022, 38 (2): 140-146. doi: 10.36351/pjo.v38i2.1288 correspondence: adnan ahmad department of ophthalmology, nowshera medical college, nowshera email: dradnanahmad82@gmail.com received: june 04, 2021 accepted: november 6, 2021 introduction vernal keratoconjunctivitis (vkc) is a serious allergic eye disorder, with aggravation during spring and summer seasons, affecting adolescent population in particular. 1 vernal keratoconjunctivitis typically begins after 04 years of age and wanes in the late teens in majority of the patients. 2 the disease affects the daily activities of adolescents including schooling and socialization which make their parents worried. clinically vkc manifests itself in the form of excessive light sensitivity, lacrimation, ocular irritation, secretion, cobble-stone papillae, vernal clinical effectiveness and local side effects of topical 0.05% cyclosporine in treatment of severe vernal keratoconjunctivitis 141 pak j ophthalmol. 2022, vol. 38 (2): 140-146 keratopathy, horner tranta’s dots, bulbar conjunctiva hyperemia/congestion, limbus edema, shield corneal ulcers and pannus. 3 in addition to steroid induced raised intraocular pressure (iop) and lens opacification, structural damages occur to the ocular surface permanently, such as conjunctival fibrosis, corneal structural instability and shield ulcer develops during the acute phase and may cause profound vision loss. 4 histo-pathological specimens have shown the accumulation of th-2 subset of t lymphocytes i.e. helper t-cells in tears and biopsy specimens from conjunctiva in vkc patients with abundance of activated mast cells and eosinophils identified in conjunctival scrapings. 5,6 different types of interleukins particularly interleukine-5 and gmcs factors are expressed in conjunctival eosinophils. 7 steroids in the topical form is the most efficacious therapy for vkc, suppressing the inflammatory pathways and inhibiting the phagocytic responses. 8 some serious adverse effects, including steroid induced increased iop, lens opacification, corneal infections with opportunistic organisms and reactivation of herpetic eye diseases are the consequences of prolonged topical steroid therapy. 3 as a result of serious side effects, steroids are not indicated for long term in vkc. topical mcs, topical anti-histamines and non-steroidal anti-inflammatory agents are other therapeutic options available in the management of mild to moderate vkc. however, these are less effective in severe form of the disease. 9-10 cys-a is an immunosuppressive agent that inhibits th-4 lymphocyte multiplication and il-2 formation. in addition, cys-a blocks the release of histamine from mast cells and basophils. 11-13 however, cys-a doesnot have adverse ophthalmic consequences like cataract or steroid induced glaucoma. 14 several studies have reported the usefulness of topical cys-a therapy in vkc in various strengths. 15,16 in this study, we evaluated the effectiveness of topical cys-a 0.05% (ropsol, atco inc. khi. pak.) in pediatric age group with vernal keratoconjunctivitis who were resistant to topical mcs and anti-histamines. methods forty patients with vkc were chosen, consecutively by non-probability sampling in a retrospective design by review of their medical records, they were subjected to topical cyclosporine 0.05% for at least 04 months. the study was conducted at an eye out patient department, qazi hussain ahmad medical complex, nowshera, from april 2019 to august 2019. study was approved by the institutional ethical review board. we adhered to the tenets of declaration of helsenki and guidelines of good clinical practice for the study. participants with documented allergies to tacrolimus (tcl) or cyclosporine (cys-a), ocular infections and diseases like glaucomatous eyes, intraocular inflammatory disorders, any keratitis, systemic inflammatory disorders other than atopic disorders, and age more than 18 years were screened out. we enrolled 30 males and 10 females, with a mean age of 12.0 ± 3.5 years. all the participants were previously treated with either mcs or combination drugs (olopathidine) for at least 04 weeks prior to initiation of topical cys-a therapy but the response was minimal. the parents/guardians and where necessary participants were informed about the possible side effects and an informed consent was obtained prior to the study. participants underwent thorough ocular assessment, including best-corrected visual acuity (snellen chart) and slit lamp biomicroscopy. subjective symptoms such as ocular irritation, foreign body sensations, light sensitivity and lacrimation were recorded. patients were asked to grade their symptoms as follows; 0 = normal, 1 = mild, 2 = moderate and 3 = severe. ocular signs were also graded as above. the objective signs were tarsal conjunctival congestion, upper tarsal conjunctival papillae, limbal hypertrophy, horner trantas dots and superficial punctate keratitis (table 1a & 1b). participants were started on topical cys-a 0.05% (ropsol, atco inc.khi. pak.) in a four times a day regimen along with ocular lubricants. clinical scoring for the symptoms and signs were documented at baseline and at 1 st , 2 nd and 4 th month after treatment. data analysis was performed using the spss 19.0. continuous data variables were expressed as mean ± standard deviation (sd). descriptive variables such as symptoms and signs of vkc were represented in percentages, 1-month, 2 nd month and 4 th month data values comparison was undertaken by using the wilcoxon signed ranked analysis. p < 0.05 was taken as significant. adnan ahmad, et al pak j ophthalmol. 2022, vol. 38 (2): 140-146 142 table 1a: score grading system for symptoms in vernal keratoconjunctivitis. symptoms 0 (normal) 1 (mild) 2 (moderate) 3 (severe) irritation no occasional itching frequent itching constant itchy eyes foreign body sensation no occasional frequent constant light sensitivity not at all slightly bothersome using tinted glasses for eyes comfort marked not relieved with sun glasses lacrimation normal fullness with no overflow on lid margins occasional over-flowing on the lid margins constant or frequent overflow of tears secretion no secretions small amount in lower fornix present both in lower fornix and marginal tear strip, crusts on eye lashes upon awakening eyelids tightly matted together upon awakening, warm soaks necessary to clean eyelids during day. table 1b: score grading system for signs in vernal keratoconjunctivitis. signs 0 (normal) 1 (mild) 2 (moderate) 3 (severe) tarsal conjunctival congestion none several vessels dilated numerous vessels dilated individual blood vessels indistinguishable upper tarsal conjunctival papillae none diameter 0.1 – 0.2mm diameter 0.3 – 0.5mm diameter > 0.6 mm limbal hypertrophy none less than half limbus involved more than half of the limbus involved annular limbal involvement horner trantas dots none 1 – 3 4 – 7 > 8 superficial punctate keratitis none superficial punctuate keratitis desquamatory superficial punctuate keratitis shield ulcer or epithelial erosion results clinical scoring for different ocular symptoms of 40 patients at baseline and at follow-up visits (1 st , 2 nd and 4 th month) are depicted in table 1a and b. all the participants completed the follow-up. slight irritation on topical application was taken as insignificant. clinical scoring for symptoms including ocular irritation, lacrimation, foreign body sensation, secretion and light sensitivity reduced significantly as compared to baseline at each follow-up visit during 04 months of cys-a therapy (p < 0.0001, for each). shown in table 2. table 3 shows that ocular signs improved which achieved a level of statistical significance throughout the follow-up period of 4 months (p < 0.05). although horner trantas dots showed improvement, but comparison of baseline with 1 st month values were statistically non-significant (p= 0.048). however, during 2 nd and 4 th month, the improvement achieved statistical significance (p = 0.013 and p = 0.006 respectively). clinical effectiveness and local side effects of topical 0.05% cyclosporine in treatment of severe vernal keratoconjunctivitis 143 pak j ophthalmol. 2022, vol. 38 (2): 140-146 table 2: score wise distribution of patients for clinical symptoms. symptoms 0 (n) 1 (n) 2 (n) 3 (n) pvalue irritation baseline 1 st month 2 nd month 4 th month 08 24 14 26 12 10 26 o6 04 30 ref. 0.0001% 0.0001% 0.0001% foreign body sensation baseline 1 st month 2 nd month 4 th month 06 10 34 05 14 26 06 15 20 04 20 ref. 0.0001% 0.0001% 0.0001% light sensitivity baseline 1 st month 2 nd month 4 th month 05 05 26 34 10 25 10 06 20 10 04 05 ref. 0.0001% 0.0001% 0.0001% lacrimation baseline 1 st month 2 nd month 4 th month 01 04 12 28 05 12 26 10 14 22 02 02 20 ref. 0.0001% 0.0001% 0.0001% secretion baseline 1 st month 2 nd month 4 th month 02 10 26 34 08 24 12 06 18 06 02 12 ref. 0.0001% 0.0001% 0.0001% table 3: score wise distribution of patients for clinical signs. ocular signs 0 (n) 1 (n) 2 (n) 3 (n) pvalue tarsal conjunctival congestion baseline 1 st month 2 nd month 4 th month 18 26 15 20 14 16 20 08 24 05 ref. 0.0001% 0.0001% 0.0001% upper tarsal conjunctival papillae baseline 1 st month 2 nd month 4 th month 02 04 08 20 06 08 22 18 10 24 08 02 22 04 02 ref. 0.0001% 0.0001% 0.0001% limbal hypertrophy baseline 1 st month 2 nd month 4 th month 08 18 02 10 20 18 16 26 10 04 22 04 02 ref. 0.0001% 0.0001% 0.0001% horner tranta’s dots baseline 1 st month 2 nd month 4 th month 26 28 30 34 04 06 08 06 06 04 02 04 02 ref. 0.048% 0.013% 0.006% superficial punctate keratitis baseline 1 st month 2 nd month 4 th month 06 16 26 20 24 18 12 16 08 05 02 04 02 01 ref. 0.0001% 0.0001% 0.0001% discussion vernal keratoconjunctivitis (vkc) is a sightthreatening inflammatory disease of the conjunctiva and cornea. although vkc is classified as an allergic adnan ahmad, et al pak j ophthalmol. 2022, vol. 38 (2): 140-146 144 ocular disorder, the role of allergens as inducers is unclear. the pathophysiology of vkc involves ige, cytokines, chemokines and inflammatory cells (t and b lymphocytes, mast cells, basophils, neutrophils, and eosinophils), with liberation of their granular factors, multiplication of fibrocytes and formation of excessive amount of collagen fibrils in the conjunctiva. mild disease of vkc tends to remit with non-specific and supportive therapy. on the other hand, severe cases are usually more prolonged, with remissions and flare-ups over a long duration. in patients with severe vkc, treatment with topical anti-histamines and mcs is usually insufficient. these patients need topical steroids therapy during flare ups of the disease. however, due to their adverse effects, topical steroids are not used for long duration, particularly in pediatric population. in this study, we used topical 0.05% cys-a in 40 patients for up to 04 months. the patients improved both symptomatically and clinically. numerous trials have reported that topical cys-a 2% is effective in vkc, requiring less need for topical steroids. 15,16 cyclosporine a (cys-a) is an immune-modulatory agent that blocks the multiplication and stimulation of t-cells. ben ezra et al treated 21 children with severe vkc resistant to steroids and 2% di-sodium cromoglycate with cyclosporine 2% eye drops in oil solution. 17 symptoms such as redness, irritation, light sensitivity, watering, discomfort, mucinous secretions and difficulty in routine activities were documented. eighty six percent of the participants improved symptomatically after 02 weeks of therapy. in addition to that, use of topical and systemic steroids was reduced significantly in majority of the patients. 17 studies have shown that cys-a 2% in qid dose is effective in controlling vkc. 18 in a double-masked, randomized control trial, 2% cys-a was topically applied to 24 patients with severe vkc and 5 to 15years of age. 18 most of the effects of topical cyclosporine 2% on ocular symptoms and signs were achieved after 14 days of therapy. a short course of topical steroids were needed in few patients while rest were stabilized with cys-a 2%. it was deducted from the trial that cys-a 2% strength was safe and efficacious in the management of refractory vkc. 18 in another study, topical cys-a1% strength was given to 195 children with resistant vkc for about 16 weeks. 19 ocular symptoms and signs were graded on a 4-point scale at baseline, 2 weeks, 4 weeks and 16 weeks after treatment. the mean score for severity of symptoms and clinical signs reduced 02 weeks post treatment. cyclosporine serum values were nondetectable at the end of treatment, they also did not observe any corneal endothelial cell loss with therapy. spadaveccia et al evaluated the effectiveness of 1.25% versus 1% cys-ain children with severe/ resistant form of vkc. 20 in each group, the mean score for ocular symptoms and clinical signs were significantly reduced on day 14 and then 16 weeks post-treatment. the investigators concluded that 1% concentration of cys-a might be minimally effective strength for controlling the symptoms and clinical signs of severe form of vkc. the most likely local reaction with 2% cys-a were redness and stingy ocular sensation after couple of minutes of topical application. 17,18 despite the local stinging sensations after topical applications, most of the patients continued the treatment due to improvement in symptoms of vkc. feeling of ocular burning and watering soon after the application of 1.25% cys-a were also noted in some patients. 20,21 topical cys-a has also proved to be effective in the treatment of corneal-shield ulcers in chronic resistant types of vkc. 21 four patients with cornealshield ulcers, who were non-responders to topical steroids, h1-blockers and mcs were treated with 0.05% – 2% strengths of topical cys-a in qid doses. the concentration entration was titrated to the severity of clinical signs, beginning with 2% and finally at the end of the study it was concluded that the minimally effective concentration entration was 1%. ozcan et al 22 gave topical cys-a in 0.05% concentration twice or 4 times daily in 10 patients of pediatric age group with severe ocular allergic disorder not responding to topical steroids. six patients had vernal keratoconjunctivitis, while four patients had atopic keratoconjunctivitis. all the participants of the study were symptomatic at the time of recruitment despite being on topical steroids. the investigators observed that by adding topical cys-a in 0.05% strength, a significant improvement was seen. in addition, the requirement for topical steroids were decreased or even stopped. 22 severe vkc effectively responds to topical cys a and tacrolimus (tcl), normally within 04 weeks post treatment. long-term use of cysa and tcl in vkc is safe and tolerated by most of the patients without having any serious side effects. 23 topical cys-a, at either 1% or 2% concentration was safe and effective clinical effectiveness and local side effects of topical 0.05% cyclosporine in treatment of severe vernal keratoconjunctivitis 145 pak j ophthalmol. 2022, vol. 38 (2): 140-146 for long-term therapy of vkc in 160 children. ophthalmic assessment at regular intervals and systemic evaluation tests at certain intervals allowed investigators to rule out the possibility of local or systemic adverse effects over a time span of 7 years. 24 similarly, in a case report, a 6 years old child with severe vkc was treated effectively with oral cyclosporine. it was impossible to control the patient’s symptoms with topical steroids, cys-a and mcs. the patient responded dramatically with oral cyclosporine therapy. 25 in this study, we used topical cys-ain 0.05% strength in 40 children with resistant form of vkc for 04 months in qid regimen. the clinical signs and ocular symptoms responded effectively with cys-a therapy, not a single patient in our study needed topical steroids for controlling the disease. similarly, no patient in our study reported any serious side effects from topical application resulting in cessation of therapy. the reason could be due to lower strength of cys-a i.e. 0.05% used in our study. the limitations of our study are its retrospective design, lack of masking in the study, small sample size and relatively short follow-up period. further doubleblinded, randomized control clinical trials with larger sample size and long-term follow-up are needed to explore the efficacy of topical cys-a and the minimal strength needed for controlling the disease. conclusion it is concluded that topical cys-ain 0.05% concentration is safe and efficacious in the management of resistant vkc. not only the patients improved symptomatically but also the clinical signs improved with therapy without having serious local adverse reactions. the topical therapy also reduces the need for topical steroids in controlling the disease hence, preventing the local adverse effects of steroids such as cataract and glaucoma. further doubleblinded, randomized control clinical trials are needed to unveil the mystery of topical cys-a in vkc. ethical approval the study was approved by the institutional review board/ ethical review board (0921/ r&d/ ierb/ nmc). conflict of interest authors declared no conflict of interest. references 1. al-yaqout f, feteih a. ocular allergy. in: the manual of allergy and clinical immunology, 2022 (pp. 23-30). crc press. 2. singhal d, sahay p, maharana pk, raj n, sharma n, titiyal js. vernal keratoconjunctivitis. surv ophthalmol. 2019; 64 (3): 289-311. 3. zicari am, capata g, nebbioso m, de castro g, midulla f, leonardi l, et al. vernal keratoconjunctivitis: an update focused on clinical grading system. italian j pediatr. 2019; 45 (1): 1-6. 4. özkaya d, usta g, karaca u. a case of shield ulcer due to vernal keratoconjunctivitis. iran j allergy asthma immunol. 2021: 1-4. 5. maggi e, biswas p, del prete g, parronchi p, macchia d, simonelli c, et al. accumulation of th-2like helper t cells in the conjunctiva of patients with vernal conjunctivitis. j immunol. 1991; 146 (4): 11691174. pmid: 1825106. 6. leonardi a, defranchis g, zancanaro f, crivellari g, de paoli m, plebani m, et al. identification of local th2 and th0 lymphocytes in vernal conjunctivitis by cytokine flow cytometry. invest ophthalmol vis sci. 1999; 40: 3036-3040. 7. hingorani m, calder v, jolly g, buckley rj, lightman sl. eosinophil surface antigen expression and cytokine production vary in different ocular allergic diseases. j aller clin immunol. 1998; 102: 821-830. 8. kaan g, özden ö. therapeutic use of topical cyclosporine. ann ophthalmol. 1993; 25: 182-186. 9. avunduk am, avunduk mc, kapicioglu z, akyol n, tavli l. mechanisms and comparison of antiallergic efficacy of topical lodoxamide and cromolyn sodium treatment in vernal keratoconjunctivitis. ophthalmology, 2000; 107: 1333-1337. 10. roumeau i, coutu a, navel v, pereira b, baker js, chiambaretta f, et al. efficacy of medical treatments for vernal keratoconjunctivitis: a systematic review and meta-analysis. j allergy clin immunol. 2021 apr 2. 11. chatterjee a, bandyopadhyay s, bandyopadhyay sk. efficacy, safety and steroid-sparing effect of topical cyclosporine a 0.05% for vernal keratoconjunctivitis in indian children. j ophthalmic vis res. 2019; 14 (4): 412. 12. sperr wr, agis h, czerwenka k, virgolini i, bankl hc, müller mr, et al. effects of cyclosporin a and fk-506 on stem cell factor-induced histamine secretion and growth of human mast cells. j allergy clin immunol. 1996; 98 (2): 389-399. doi: 10.1016/s00916749(96)70163-x. pmid: 8757216. adnan ahmad, et al pak j ophthalmol. 2022, vol. 38 (2): 140-146 146 13. caputo r, marziali e, de libero c, di grande l, danti g, virgili g, et al. long-term safety and efficacy of tacrolimus 0.1% in severe pediatric vernal keratoconjunctivitis. cornea, 2021; 40 (11): 1395-401. 14. tabbara kf. ocular complications of vernal keratoconjunctivitis. can j ophthalmol. 1999; 34: 8892. 15. bremond-gignac d, doan s, amrane m, ismail d, montero j, németh j, et al. vektis study group. twelve-month results of cyclosporine a cationic emulsion in a randomized study in patients with pediatric vernal keratoconjunctivitis. american journal of ophthalmology, 2020; 212: 116-126. 16. hossain it, sanghi p, manzouri b. pharmacotherapeutic management of atopic keratoconjunctivitis. expert opinion on pharmacotherapy, 2020; 21 (14): 1761-1769. 17. ben ezra d, pe’er j, brodsky m, cohen e. cyclosporine eye drops for the treatment of severe vernal keratoconjunctivitis. am j ophthalmol. 1986; 101: 278-282. 18. yücel oe, ulus nd. efficacy and safety of topical cyclosporine a 0.05% in vernal keratoconjunctivitis. singapore med j. 2016; 57 (9): 507-510. doi:10.11622/smedj.2015161 19. tesse r, spadavecchia l, fanelli p, rizzo g, procoli u, brunetti l, et al. treatment of severe vernal keratoconjunctivitis with 1% topical cyclosporine in an italian cohort of 197 children. pediatr allergy immunol. 2010; 21 (2 pt 1): 330-335. doi: 10.1111/j.1399-3038.2009.00948.x. epub 2009 oct 15. pmid: 19840298. 20. spadavecchia l, fanelli p, tesse r, brunetti l, cardinale f, bellizzi m, et al. efficacy of 1.25% and 1% topical cyclosporine in the treatment of severe vernal keratoconjunctivitis in childhood. pediatr allergy immunol. 2006; 17 (7): 527-532. doi: 10.1111/j.1399-3038.2006.00427.x. pmid: 17014629. 21. çetinkaya a, akova y, dursun d, pelit a. topical cyclosporine in the management of shield ulcers. cornea, 2004; 23: 194-200. 22. ozcan aa, ersoz tr, dulger e. management of severe allergic conjunctivitis with topical cyclosporine a 0.05% eye drops. cornea, 2007; 26: 1035-1038. 23. vichyanond p, kosrirukvongs p. use of cyclosporine a and tacrolimus in treatment of vernal keratoconjunctivitis. curr allergy asthma rep. 2013; 13: 308-314. 24. pucci n, caputo r, mori f, de libero c, di grande l, massai c, et al. long-term safety and efficacy of topical cyclosporine in 156 children with vernal keratoconjunctivitis. int j immunopathol pharmacol. 2010; 23 (3): 865-871. doi: 10.1177/039463201002300322. pmid: 20943058. 25. gokhale ns, samant r, sharma v. oral cyclosporine therapy for refractory severe vernal keratoconjunctivitis. indian j ophtalmol. 2012; 90: 461-464. authors’ designation and contribution adnan ahmad; assistant professor: concepts, design, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. mubashir rehman; associate professor: concepts, design, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. muhammad farhan; senior registrar: concepts, design, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. jawad humayun; pg trainee: literature search, statistical analysis, manuscript review. .…  …. 399 pak j ophthalmol. 2021, vol. 37 (4): 399-403 original article impact of covid-19 virus on ophthalmology residents and fellows in a tertiary care hospital maryum nawaz department of ophthalmology, hayatabad medical complex, peshawar abstract purpose: to determine the impact of covid-19 pandemic on the training of ophthalmology residents and fellows in a tertiary care hospital. study design: cross sectional survey. place and duration of study: the study was conducted in a tertiary care hospital, peshawar from august 1 st to august 20 th 2020. methods: a self-designed questionnaire was distributed among 50 ophthalmology residents and fellows. undergraduate students, house officers and post-graduate trainees from other specialties were excluded. questions comprised of demographic data, and questions which were meant to investigate the changes experienced by the trainees during covid-19. the data was analyzed by spss software (version 19). results: among 50 participants of this study, 16 (32%) were females and 34 (68%) were males. the age ranged from 27 to 35 years. there was no statistically significant difference in the perspectives of resident trainees and fellows regarding negative impact of covid-19 on their training. ninety-five percent of the residents and fifty five percent of the fellows had effect on their clinical skills with p values of less than 0.05. hundred percent residents agreed that online case presentation could not replace the traditional long rounds and simulator based training could improve the surgical skills in pandemic. twenty five (60.97%) trainees and 6 (66.66%) fellows mentioned that pandemic affected them psychologically and they felt fear while working. conclusion: covid-19 has adversely affected the training of post graduate trainees. training directors should ensure to provide modern technological tools to improve trainees’ clinical and surgical skills until the crisis is over. key words: covid-19, ophthalmology, training, conference. how to cite this article: nawaz m. impact of covid-19 virus on ophthalmology residents and fellows in a tertiary care hospital. pak j ophthalmol. 2021, 37 (4): 399-403. doi: 10.36351/pjo.v37i4.1189 correspondence: maryum nawaz hayatabad medical complex, peshawar email: shinwari139@yahoo.com received: december 29, 2020 revised: april 20, 2021 accepted: september 03, 2021 introduction the world health organization was alerted by chinese authorities on the 31st of december 2019 of a number of pneumonia cases in wuhan city. 1 a new virus, coronavirus, was found to be the culprit of the pneumonia and it was phylogenetically similar to sars-cov. 2 it was declared pandemic by world health organization on march 11, 2020. 3 till august 15 th , 2020, 216 countries were affected with more than 21.29 million people infected and more than 0.7 million deaths worldwide. 4 first two cases in pakistan were reported on 26 th february, 2020 among the pilgrims from iran. 5 the overall case fatality rate (cfr) of covid-19 is approximately 6.36% that is preceded by severe acute respiratory syndrome open access impact of covid-19 virus on ophthalmology residents and fellows in a tertiary care hospital pak j ophthalmol. 2021, vol. 37 (4): 399-403 400 (sars) (9.6%) and middle east respiratory syndrome (mers) (34.4%). 5 ophthalmology is among the specialties with the highest proportion of residents with confirmed covid-19 and at high risk of exposure to other viruses as well. 6 it is due to the nature of their work being in close contact with the patients during routine ophthalmic examination. dr. li wenliang, an ophthalmologist, first recognized the symptoms of severe acute respiratory syndrome coronavirus in seven of his patients and then developed the disease himself. he passed away on 7 th february 2020 due to covid-19 infection. this explains the role and risk of ophthalmologists in an infectious disease pandemic. 7 first vaccine against covid-19 was introduced in market in december 2020 but the evidence that shows the duration of the immune coverage and the need for booster is still lacking. 8 the study was conducted specifically addressing the ophthalmology residents and fellows, aiming to assess the changes they have experienced in ophthalmology training related to the current covid19 pandemic. based on their responses, we have tried to propose potentially beneficial long-term changes in the training. methods it was a cross-sectional survey that included 50ophthalmology postgraduate trainees and fellows of a teaching hospital. a self-designed questionnaire was distributed among ophthalmology residents and fellows in august 2020. the principles of declaration of helsinki were followed in the study. the purpose and benefits of the study were explained to the participants and a verbal consent was obtained before filling the questionnaire. the participants’ identity was concealed, and a single investigator collected the data. under-graduate students, house officers and postgraduate trainees from other specialties were excluded. questions comprised of demographic data (age, gender, year of residency) and a set of closed-ended questions which were meant to investigate the changes experienced by the trainees in three areas (clinical activity, surgical practice, and online teaching). their perception about the impact of pandemic on their training and suggestions for future potential modifications were also sought. the data was analyzed by spss software (version 19). post stratification chi square was applied and p value of ≤ 0.05 was considered significant. frequencies and percentages were calculated for categorical variables like age and gender. all the results were presented in the form of tables. results among 50 participants f this study, 16 (32%) were females and 34 (68%) were males. the age ranged from 27 to 35 years. there were 41 (82%) residents and 9 (18 %) were fellows in different subspecialties of ophthalmology. there was no statistically significant difference in the perspectives of resident trainees and fellows regarding negative impact of covid-19 on their training. however, there was a difference between residents and fellows regarding impact on the clinical skills. ninety five percent of the residents and fifty five percent of the fellows had effect on their clinical skills with p values of less than 0.05 (table 1). similarly, surgical skills were also significantly affected. regarding online teaching and learning, there was significant difference between residents and fellows where 100% residents agreed that online case presentation could not replace the traditional long rounds. however, they agreed that simulator based training could improve the surgical skills in pandemic. majority of the participants were economically affected by the pandemic. twenty five (60.97%) trainees and 6 (66.66%) fellows mentioned that pandemic affected them psychologically and they felt fear while working. however, no trainee or fellow was infected during their ophthalmological duties (table 3). maryum nawaz 401 pak j ophthalmol. 2021, vol. 37 (4): 399-403 table 1: residents’ and fellows’ perspective of covid-19 impact. residents total n = 41 fellows total n = 9 p value have you performed duty in covid-19 screening? yes 13 (31.70%) 2 (22.22%) .574 if yes, were your services effective for the patients? yes 11 (84.61%) 2 (100%) .986 have you performed duty in covid 19 ward? yes 25 (60.97%) 5 (55.55%) .764 if yes, was your service productive? yes 4 (16 %) 2 (40 %) .716 have you stayed in isolation for 2 weeks after your duty in covid screening or ward? yes 38(100%) 7 (100%) .177 did you get infected with covid-19 while performing the duty? yes 1 (2.63%) 1 (2.63%) .229 has the pandemic affected your clinical skills? yes 39 (95.12%) 5 (55.55%) .000 how much are your surgical skills affected? .009 mild 1 (2.43%) moderate 5 (12.19%) 6 (66.66%) severe 35 (85.36%) 3 (33.33%) which of the following procedures you did in last 4 months? primary ocular repair 30 (73.17%) 2 (22.22%) .022 lid repair 11 (26.82%) 1 (11.11%) intravitreal injections 10 (24.39%) 1 (11.11%) how many surgeries you performed in last 4 months? 0 – 4 31 (75.6%) 9 (100%) .098 5 – 8 10 (24.4%) 0 (0%) how many surgeries you used to perform monthly before the pandemic? 0 – 10 13 (31.7%) 0 (0%) .119 11 – 20 19 (46.3%) 7 (77.8%) 21 – 25 9 (22.0%) 2(22.2%) table 2: showing effect on teaching/learning during pandemic. residents total n = 41 fellows total n = 9 p value have you attended any web based lectures before the pandemic? yes 3 (7.31%) 2 (22.22%) .704 are you attending online classes in the pandemic? yes 39 (95.12%) 8 (88.88%) .476 do you think online lectures and webinars and conferences are effective? yes 27 (65.85%) 5 (55.55%) .231 do you think online case presentations can replace traditional long rounds? yes 0 (0%) 2 (22.22%) .002 do you think the simulator based training can improve your surgical skills in the pandemic? yes 37 (90.24%) 7 (77.77%) .030 table 3: economic impact of covid-19 on residents and fellows wellbeing. residents total n= 41 fellows total n=9 p value are you affected economically by the pandemic? yes 37 (90.24%) 6 (66.66%) .003 do you feel drained at the end of the day? yes 3 (7.3%) 2 (22.22%) .177 do you feel fear while performing duty in the pandemic? yes 25 (60.97%) 6 (66.66%) .963 has the fear compromised your work? yes 20 (73 %) 6 (66.66%) .269 had you been infected with covid-19 virus while working in ophthalmology unit? yes 0 (0%) 0 (0%) discussion the cross sectional survey in peshawar specifically investigated the impact of covid-19 on ophthalmology residents’ clinical and surgical training and highlighted the uncertainty, anxiety and higher stress levels among ophthalmology trainees due to the disruption of training program schedules. all the trainees and fellows should quarantine for 2 weeks after their duties in covid areas, as recommended by the accreditation council for graduate medical education in the united states. 9 with the rising scores of infected medical personnel, it has become a necessity to modify the training protocols. in a correspondence published in royal college of ophthalmologists, it was stated that ophthalmologists could learn basic ventilator parameters and modes after guidance. 10 impact of covid-19 virus on ophthalmology residents and fellows in a tertiary care hospital pak j ophthalmol. 2021, vol. 37 (4): 399-403 402 it was also recommended by the american college of surgeons that all elective procedures should be cancelled until the infection is controlled. 11 this resulted in reduction in the number of surgeries and hence adversely affecting the surgical skills of the trainees. this particular study showed that number of surgeries reduced by more than 60%, a similar reduction was noted in a study published in acta med port. 12 during the lockdown, there has been a surge in the number of online classes and webinars in ophthalmology. this survey showed that 27 (65.85%) trainees and 5 (55.55%) fellows found ophthalmic classes and webinars being conducted useful. conferences are an essential part of medical training and continuing education as it presents an opportunity to know new advances in the field around the world and opinions on how to improve in the field. many conferences across the globe have been cancelled or postponed. however, some societies very successfully conducted online conferences to overcome the gap produced by this pandemic. one of the many examples is the world ophthalmic congress. 13 a positive impact of these virtual conferences was that the trainees who could not afford to travel were able to attend these meetings without bearing the expenses of travel and accommodation. this is an undeniable fact that there is no substitute for learning and practicing clinical examination techniques on patients and surgical procedures in real life. as elective procedures and routine clinical examinations are not possible in pandemic, medical simulators came out as very useful tool of training. 14 in this particular study, 37 (90.24%) post-graduate trainees and 7 (77.77%) fellows suggested that the simulators could help improve their skills in this era. many ophthalmologists around the world have proposed that for surgical skill refinement, besides wet laboratory training, simulators may be used to recreate the surgical experience. 15,16 moreover, a study done by co m, et al, showed no difference between surgical techniques taught to students face to face and web based surgical skill learning session. 17 unfortunately, there is no simulator available at our tertiary care hospital. the hospital needs to invest in simulators in such draining time to prepare better ophthalmologists for future. not only the training of the residents and fellows affected in this pandemic, extreme psychological burden was also noticed in frontline health care workers. 18,19 majority of participants of our study reported that they felt fear of getting the virus and ultimately infecting their families. appropriate psychological training can improve to reduce this fear as shown by a study published in european journal of ophthalmology in which the ophthalmology trainees’ anxiety and fear reduced significantly after appropriate training. 20 training institutes must offer psychological counselling and psychiatric support to those who are combating on front line. in this study, participants reported that the pandemic had enormously affected the surgical and clinical skills of the trainees and fellows. a study conducted by hussain rohan, sing b, shah n et al stated that the trainees in the start of their training were more affected than their seniors. 21 in another study published in plos one, the residents were affected both economically and psychologically by the pandemic and not only by the training gaps. 22 leaders and hospital authorities should implement measures to promote the well-being of the health care workers who are exposed to covid-19. enough ppes should be provided so that the front liners may be able to combat the pandemic without worrying about acquiring the virus. 23 the study has several limitations. firstly, the duration of study was short, that is, 20 days due to continuous changes in the situation. secondly, only one tertiary care hospital was included in the study. however, it every effectively highlights the importance of urgent steps which need to be taken for the learning and training of doctors. conclusion covid-19 has adversely affected the training of postgraduate trainees. training directors should ensure to provide modern technological tools to improve trainees’ clinical and surgical skills until the crisis is over. ethical approval the study was approved by the institutional review board/ethical review board (1012/eye/2021/hmc). conflict of interest authors declared no conflict of interest. maryum nawaz 403 pak j ophthalmol. 2021, vol. 37 (4): 399-403 references 1. seah i, su x, lingam g. revisiting the dangers of the coronavirus in the ophthalmology practice. eye (lond). 2020; 34 (7): 1155-1157. doi: 10.1038/s41433-0200790-7. 2. zhu n, zhang d, wang w, li x, yang b, song j, et al. china novel coronavirus investigating and research team. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med. 2020; 382 (8): 727-733. doi: 10.1056/nejmoa2001017. 3. wan kh, lin tph, ko cn, lam dsc. impact of covid-19 on ophthalmology and future practice of medicine. asia pac j ophthalmol (phila). 2020; 9 (4): 279-280. doi: 10.1097/apo.0000000000000305. 4. world health organization. corona. available from: https://www.who.int/health-topics/coronavirus 5. noreen n, dil s, niazi suk, naveed i, khan nu, khan fk, et al. covid-19 pandemic & pakistan; limitations and gaps. global biosecurity, 2020; 2 (1): doi: http://doi.org/10.31646/gbio.63 6. breazzano mp, shen j, abdelhakim ah, glass lrd, horowitz jd, xie sx, et al. residency program directors covid-19 research group. new york city covid-19 resident physician exposure during exponential phase of pandemic. j clin invest. 2020; 130 (9): 4726-4733. doi: 10.1172/jci139587. 7. chatziralli i, ventura cv, touhami s, reynolds r, nassisi m, weinberg t, et al. transforming ophthalmic education into virtual learning during covid-19 pandemic: a global perspective. eye, 2021; 35 (5): 1459-1466. 8. wang c, wang z, wang g, lau jy, zhang k, li w. covid-19 in early 2021: current status and looking forward. signal transduct target ther. 2021; 6 (1): 14. 9. potts jr. residency and fellowship program accreditation: effects of the novel coronavirus (covid19) pandemic. j am coll surg. 2020; 230 (6): 10941097. 10. harvey jp, sinclair vf. preparing ophthalmologists for the use of mechanical ventilation during the covid-19 pandemic. eye, 2020; 13: 1-2. 11. clinical issues and guidance. from american college of surgeons. available at: https://www.facs.org/covid19/clinical-guidance 12. silva n, laiginhas r, meireles a, breda jb. impact of the covid-19 pandemic on ophthalmology residency training in portugal. acta médica portuguesa. 2020; 33 (10): 640-648. 13. world ophthalmology congress. 2020. available at: https://icowoc.org/ 14. zarei-ghanavati m, liu gp, naveed h, diab ra, liu c. ophthalmology education in the postcoronavirus disease 2019 era. journal of current ophthalmology, 2020; 32 (4): 307. 15. bakshi sk, ho ac, chodosh j, fung at, chan rvp, ting dsw. training in the year of the eye: the impact of the covid-19 pandemic on ophthalmic education. br j ophthalmol. 2020; 104 (9): 1181-1183. doi: 10.1136/bjophthalmol-2020-316991. 16. mccannel ca. simulation surgical teaching in ophthalmology. ophthalmology, 2015; 122 (12): 23712372. 17. chung ph, chu km. online teaching of basic surgical skills to medical students during the covid-19 pandemic: a case – control study. surg today, 2021: 16. 18. lai j, ma s, wang y, cai z, hu j, wei n, et al. factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. jama network open, 2020; 3 (3): e203976-. 19. si my, su xy, jiang y, wang wj, gu xf, ma l, et al. psychological impact of covid-19 on medical care workers in china. infectious diseases of poverty, 2020; 9 (1): 1-3. 20. lim c, de silva i, moussa g, islam t, osman l, malick h, et al. redeployment of ophthalmologists in the united kingdom during the coronavirus disease pandemic. eur j ophthalmol. 2020 aug 27: 1120672120953339. doi: 10.1177/1120672120953339. 21. hussain r, singh b, shah n, jain s. impact of covid-19 on ophthalmic specialist training in the united kingdom-the trainees' perspective. eye (lond). 2020; 34 (12): 2157-2160. doi: 10.1038/s41433-0201034-6. erratum in: eye (lond). 2020 jul 8;: pmid: 32572183; pmcid: pmc7307645. 22. kannampallil tg, goss cw, evanoff ba, strickland jr, mcalister rp, duncan j. exposure to covid-19 patients increases physician trainee stress and burnout. plos one, 2020; 15 (8): e0237301. 23. ahmed j, malik f, bin arif t, majid z, chaudhary ma, ahmad j, et al. availability of personal protective equipment (ppe) among us and pakistani doctors in covid-19 pandemic. cureus, 2020; 12 (6): e8550. doi: 10.7759/cureus.8550. pmid: 32670687; pmcid: pmc7357309. authors’ designation and contribution maryum nawaz; concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. .…  …. http://doi.org/10.31646/gbio.63 https://icowoc.org/ microsoft word 13. saliha zaman 286 pak j ophthalmol. 2022, vol. 38 (4): 286-288 case report retinal detachment in dengue fever – a case report saliha zaman1, eileen samuel2, qasim lateef chaudhry3 department of ophthalmology, 1,3lahore medicare hospital, 2shaukat khanam hospital, lahore abstract a 20 years old female came to our hospital with sudden painless loss of vision in her right eye for two days. she was diagnosed with dengue fever two and a half weeks back and was managed conservatively. ocular examination showed mid-dilated pupils with sub-conjunctival hemorrhage, lens opacity, vitreous hemorrhage and haze, sub-retinal hemorrhage and retinal detachment. visual acuity in right eye was perception of light only. ultrasound revealed moderate number of low to moderately reflective vitreous echoes and a highly reflective membrane attached to the disc suggesting retinal detachment. an urgent ophthalmologist opinion was sought followed by pars plana vitrectomy with silicon oil. she was lost to follow up after surgery. key words: dengue fever, dengue hemorrhagic fever, retinal detachment. how to cite this article: zaman s, samuel e, lateef q. retinal detachment in dengue fever – a case report. pak j ophthalmol. 2022, 38 (4): 286-288. doi: 10.36351/pjo.v38i4.1390 correspondence: saliha zaman lahore medicare hospital, lahore email: zaman.saliha@yahoo.com received: march 28, 2022 accepted: august 20, 2022 introduction dengue flavi virus is a common cause of fever and acute systemic illness in the tropics. it is endemic in south-east asia including pakistan. the principal vector is the aedes aegypti mosquito. globally cases have exceeded to 100 million per year.1 despite a risk of infection existing in 129 countries, 70% of the actual burden is in asia.2 one estimate indicates 390 million dengue virus infections per year, of which 96 million manifest clinically (with any severity of disease).2 however, among these 0.5 million cases of dengue hemorrhagic fever (dhf) and dengue shock syndrome (dss) require hospitalization each year with an average death rate of 5% according to who statistics.3 the largest number of dengue cases ever reported globally was in 2019, in which united states of america alone reported 3.1 million cases, with more than 25,000 classified as severe, whereas argentina had more than 92.229 dengue suspected cases.4 dengue infection has a wide range of clinical presentation, patient can either be completely asymptomatic or present with typical or atypical features. characteristic features include fever with myalgias and fatigue, retro-orbital pain, bony pain and papules. in addition to these, keratitis, uveitis, subconjunctival hemorrhage, corneal erosion, maculopathy, retinal hemorrhages, retinal vascular occlusion and serous retinal detachment are also reported. panophthalmitis, periorbital ecchymosis and hemorrhagic complications may occur in severe cases5. we present a case of dengue fever who had retinal detachment as a major complication of it. case presentation a 20 years old female came to our hospital with sudden painless loss of vision in her right eye for two days. she was initially presented to regional hospital with high grade fever and diagnosed with hemorrhagic dengue fever 2.5 weeks back. she had multiple platelet transfusions with conservative management by antibiotics and steroids for her dengue hemorrhagic fever. on examination her right pupil was mid-dilated and sluggishly reacting to light with subconjunctival retinal detachment in dengue fever – a case report pak j ophthalmol. 2022, vol. 38 (4): 286-288 287 hemorrhage. her visual acuity in right eye was only perception of light and was not improving with any lens. on further investigation her intra ocular pressure was 25 mm of hg by goldmann applanation tonometer. on examination of the affected eye, lens opacity, vitreous hemorrhage, sub-retinal hemorrhage and retinal detachment were also seen. ultrasound of the right eye was performed and illustrated 1 moderate number of reflective vitreous echoes 2, a high reflective membrane echo attached to the disc with poor after movements gain further both suggesting retinal detachment (figure 1). an urgent ophthalmologist opinion was made and we explained her intent of treatment and poor prognosis of disease in detail. she then underwent vitrectomy and oil injection. post operatively she did well but was lost of follow-up after discharge. figure 1: b-scan showing hemorrhagic retinal detachment. discussion dengue fever is often self-limiting infection and treatment is symptomatic. dhf is a severe and potentially fatal form of dengue fever. dhf is defined by who as df associated with thrombocytopenia (< 100 × 109 cells/l) and hemo-concentration (hematocrit > 20% above baseline). the early phase of dhf is indistinguishable from df. visual impairment by dengue fever can be detected by various ophthalmological techniques including slit lamp examination, optical coherence tomography (oct) imaging, fluorescein fundus angiographic (ffa), visual field analysis (vfa), and electroretinography. steroids can be given in case of active infection either tropically, orally, intravitreally or intravenously.6 there are four serotypes of dengue virus, all producing a similar clinical syndrome; homotypic immunity after infection with one of the serotypes is life-long, but heterotypic immunity against the other serotypes lasts only a few months after infection. the pathogenesis is still uncertain for ocular manifestations of dengue but an immune-mediated inflammatory process is proposed.7 this inflammatory process typically affects immunocompetent adults, who often present at the nadir of thrombocytopenia with visual impairment. the onset and severity of ocular complication depends on the grades of thrombocytopenia. seet et al reported leucopenia and hypoalbuminemia as the risk factors for development of ocular manifestations.8 the diagnosis is confirmed by either fourfold rise in igg antibody titres or isolation of dengue virus from blood or detection of virus rna by polymerase chain reaction (pcr). retinal detachment (rd) has multiple etiologies and is one of the ubiquitous complications of dengue. prompt treatment requirement is indicated as it can lead to permanent vision loss and blindness. symptoms of retinal detachment including the appearance of floaters flashes of light and vision deterioration can occur between 0 – 30 days after the onset of fever.9 similar cases have been reported globally. in germany, a patient complained of blurring of vision, 4 days after returning from a 20-day vacation in vietnam and cambodia. on investigation he was diagnosed with retinal detachment.10 moreover a case report on dengue fever leading to retinal detachment was published in india in 2019.9 a study including 197 participants in singapore showed the prevalence of dengue maculopathy to be as high as 10% among seropositive patients.6 close observation with regular monitoring of vitals, blood counts and ocular exams is usually recommended. as thrombocytopenia resolves, ocular signs show improvement. steroids have been used in various delivery modes depending upon ocular pathology with reliable results and duration of treatment. in severe cases pneumatic retinopexy, scleral buckling or vitrectomy with air, gas or silicone oil injection are considered. limitation of this case report is that the patient was lost to follow up. conclusion the dengue fever can be completely asymptomatic or can present with classical clinical signs. dengue saliha zaman, et al 288 pak j ophthalmol. 2022, vol. 38 (4): 286-288 hemorrhagic fever is a serious complication of dengue fever. retinal detachment is one of the ocular complications of dengue hemorrhagic fever. blurring of vision typically coincides with the nadir of thrombocytopenia. detailed ocular examination is recommended in patients who present with decreased vision with a history of dengue fever. in severe case, pneumatic retinopexy, scleral buckling or vitrectomy with air, gas or silicone oil injection are considered. conflict of interest: authors declared no conflict of interest. references 1. bhatt s, gething pw, brady oj, messina jp, farlow aw, moyes cl, et al. the global distribution and burden of dengue. nature, 2013; 496 (7446): 504507. doi: 10.1038/nature12060. 2. brady oj, gething pw, bhatt s, messina jp, brownstein js, hoen ag, et al. refining the global spatial limits of dengue virus transmission by evidencebased consensus. plos negl trop dis. 2012; 6 (8): e1760. doi: 10.1371/journal.pntd.0001760. 3. duong v, lambrechts l, paul re, ly s, lay rs, long kc, et al. asymptomatic humans transmit dengue virus to mosquitoes. proc natl acad sci usa. 2015; 112 (47): 14688-14693. doi: 10.1073/pnas.1508114112. 4. dengue and severe dengue. who. int. 2022. https://www.who.int/news-room/factsheets/detail/dengue-and-severe-dengue. accessed 23 july 2022 5. chan dp, teoh sc, tan cs, nah gk, rajagopalan r, prabhakaragupta mk, et al. eye institute denguerelated ophthalmic complications workgroup. ophthalmic complications of dengue. emerg infect dis. 2006; 12 (2): 285-289. doi: 10.3201/eid1202.050274. 6. su dh, bacsal k, chee sp, flores jv, lim wk, cheng bc, et al. dengue maculopathy study group. prevalence of dengue maculopathy in patients hospitalized for dengue fever. ophthalmology, 2007; 114 (9): 1743-1747. doi: 10.1016/j.ophtha.2007.03.054. 7. gubler dj. dengue and dengue hemorrhagic fever. clin microbiol rev. 1998 jul; 11 (3): 480-496. doi: 10.1128/cmr.11.3.480. 8. seet rc, quek am, lim ec. symptoms and risk factors of ocular complications following dengue infection. j clin virol. 2007; 38 (2): 101-105. doi: 10.1016/j.jcv.2006.11.002. 9. abhishek v, manmath d. hemorrhagic retinal detachment following severe dengue fever: a case report. dehli j ophthalmol. 2019; 29: 52-53. doi: http://dx.doi.org/10.7869/djo.419 10. heinemann m, bigdon e, veletzky l, jordan s, jochum j, knospe v, et al. case report: acute vision loss in a young returning traveler with dengue fever. am j trop med hyg. 2020; 103 (5): 2026-2028. doi: 10.4269/ajtmh.20-0562. authors’ designation and contribution saliha zaman; optometrist: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. eileen samuel; resident: literature search, manuscript preparation, manuscript editing. qasim lateef chaudhry; professor: concepts, manuscript review. .……. pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 15 original article to assess the efficacy and safety of tacrolimus skin cream, 0.03% in moderate to severe vernal keratoconjunctivitis sameera irfan, arsalan ahmed, faiza rasheed pak j ophthalmol 2015, vol. 31 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sameera irfan mughal eye trust hospital 301, h3/a, johar town, lahore. sam.irfan48@gmail.com …..……………………….. purpose: to determine the efficacy and safety of tacrolimus skin cream (ecczemus 0.03%) in the resolution of moderate to severe vernal keratoconjuctivitis (vkc). material and methods: a prospective clinical trial was conducted at the oculoplastics department of a tertiary care centre, from sep 2013 – oct 2014. in this, 54 consecutive cases (108 eyes) with moderate to severe vkc, between the ages of 4 – 18 (mean 7 years) years were included. there were 13 newly diagnosed cases and 41 recurrent. after discontinuing their previous medications, they were treated with tacrolimus skin cream, 0.03% applied into the lower conjunctival fornix twice a day along with lubricants for a period of 4 – 8 months. clinical signs and symptoms were recorded at the beginning of the treatment and at all follow-ups which were conducted weekly for one month and then every month for one year. results: the duration of therapy was 4 – 8 months (mean 6 months). the patients were followed-up for a mean duration 10 ± 1.5 months. there was marked subjective as well as objective improvement in all cases within one month of therapy. there was no need for any additional therapy. no toxic effects of tacrolimus were observed in any case. conclusion: it can be concluded that tacrolimus skin cream (0.03%) is an effective therapy for moderate to severe cases of vernal keratoconjuctivitis. it acts as a safe alternative to topical steroids. key words: tacrolimus vernal keratoconjunctivitis, allergy ernal keratoconjunctivitis (vkc)is an acute – on – chronic inflammatory disease of the conjunctiva and cornea,1,2encountered usually in the first decade of life .in children. the patients are visually handicapped because of intense burning and itching along with lacrimation, a stringy mucoid discharge, photophobia and heaviness of eyelids due to involvement of the tarsal conjunctiva. the symptoms are accentuated when patient goes to a warm, humid environment. mild cases of vkc show improvement with nonspecific, supportive therapy. but severe cases show frequent remissions and relapses, run a protracted course, and if not treated properly, usually result in sight–threatening complications3 over a period of time. vkc starts as a type i (immediate) hypersensitivity reaction4 (histamine mediated). this occurs when a sensitized individual comes into contact with a specific antigen resulting in degranulation of mast cells in the conjunctiva and the release of histamine. histamine causes watery, red eyes with intense itching in children; later there is super-imposed involvement of t lymphocytes2,4 which results in chronicity of the disease, corneal and tarsal conjunctival signs. there is involvement of both eyes which may be asymmetrical. the disease is notorious for recurrence when the treatment is stopped. it needs to be differentiated from seasonal allergic conjunctivitis which is an acute type 1 hypersensitivity reaction and involves only the conjunctiva. in comparison to vkc, it shows marked v http://en.wikipedia.org/wiki/lacrimation http://en.wikipedia.org/wiki/photophobia sameera irfan, et al 16 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology chemosis, conjunctival injection and eyelid edema due to the release of histamine from conjunctival mast cells resulting in .increased vascular permeability. patients with vkc exhibit large amounts of circulating immunoglobulin e (ige); the cross-linking of 2 adjacent ige molecules by the antigen triggers mast cell degranulation. this releases various preformed mediators of the inflammatory cascade like histamine, prostaglandins, leukotrienes, tryptase, chymase, heparin and chondroitin sulfate. these mediators cause increase vascular permeability with migration of eosinophils, polymorphs, t and b lymphocytes and proliferation of fibroblasts which lay down of exuberant amounts of collagen in conjunctival tissue. hence the ocular tissues exhibit the following changes : conjunctiva shows cellular infiltration with hyperplasia of epithelium and dilatation of conjunctival vessels along with increased permeability. the upper tarsus is typically affected by the proliferation of fibrous layer of conjunctiva and its hyalinization resulting in the formation of giant papilla, more than 0.3 mm in diameter, giving the classic 'cobble – stone' appearance. in severe cases, these papillae may hypertrophy producing cauliflower-like excrescences (giant papillae) which may produce mechanical ptosis. these giant papillae are randomly distributed over the whole tarsus while those resulting from wearing of hard contact lenses are present only at the edge of the tarsus. the limbal involvement comprises of papillae which are thick, gelatinous along with multiple white spots which are collections of degenerated epithelial cells and eosinophils called horner – trantas dots. they do not last longer than a week from their initial presentation as they .undergo rapid dissolution. the corneal involvement is variable: it may show punctate epithelial keratopathy (pek) due to toxic effect of inflammatory mediators released from the conjunctiva. these fine punctate erosions coalesce, resulting in larger erosions or a shield ulcer, which is typically shallow with white irregular epithelial borders. the giant tarsal papillae are a major contributing factor in its development by causing chronic mechanical irritation. vernal pseudogerontoxon, a degenerative lesion in the peripheral cornea resembling corneal arcus, may be seen. keratoconus is a frequent complication in chronic cases, due to chronic eye rubbing and superimposed corneal thinning by injudicious use of topical steroids. corneal vascularizuation or pannus formation may also be seen. in the acute but milder form of vkc, topical antihistamines, mast cell stabilizers, mucolytics, ansaids and lubricants are used as the first line of therapy. however, in the severe and chronic disease, corticosteroids 5 have to be added and they have to be used for a long term to control the symptoms; corticosteroid withdrawal leads to clinical worsening while their long term use is associated with sideeffects like cataract, glaucoma, corneal thinning, corneal ectasia / keratoconus. hence a marked ocular morbidity results from the prolonged use of steroids topically. immuno-modulators have been introduced for the past two decades into the armamentarium of drugs for the management of vkc.6 they are mainly used as steroid – sparing drugs. tacrolimus7,8 is one such immunomodulating drug, the other being cyclosporin eye drops. tacrolimus is known to be 10 – 100 times more potent than cyclosporin. it is a macrolide, discovered in 1984 from the bacteria streptomyces tsukubaensis. it is very affective in suppressing the activation and proliferation of b & t lymphocytes and formation of inflammatory mediators like cytokines, especially interleukin2. at first tacrolimus was used as an immunosuppressant in liver transplants and subsequently in other solid – organ transplants. for more than 10 years it has been used in the treatment of skin disorders such as vitiligo and atopic dermatitis etc. it is available as a skin cream 0.03% and 0.1% for the treatment of atopic dermatitis (eczema), vitiligo. it suppresses inflammation as affectively as topical steroids, with the major advantage for not causing skin thinning (atrophy) and other steroid related side-effects. on initial applications, it can produce mild burning or itching sensation, with increased sensitivity to sunlight and heat.; no other side effects have been reported. patients should minimize or avoid exposure to natural or artificial light. there may be an increased risk of activation of skin infections which should be cleared up prior to its application. according to numerous clinical studies,9-12 tacrolimus has been successfully used in the treatment of autoimmune diseases of the ocular surface such as dry eyes, mooren’s ulcer, scleritis, cicatricial conjunctivitis atopic and vkc. its ophthalmic preparation is not available in pakistan so we http://en.wikipedia.org/wiki/hyperplasia http://en.wikipedia.org/wiki/epithelium http://emedicine.medscape.com/article/1194693-overview http://en.wikipedia.org/wiki/atopic_dermatitis http://en.wikipedia.org/wiki/eczema http://en.wikipedia.org/wiki/vitiligo http://en.wikipedia.org/wiki/steroid http://en.wikipedia.org/wiki/atrophy to assess the efficacy and safety of tacrolimus skin cream, 0.03% in moderate to severe vernal pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 17 conducted this study to find out the efficacy and safety of tacrolimus skin cream 0.03% (ecczemus, brooke pharma) applied in the lower conjunctival fornix in treating moderate to severe vkc. material and methods a prospective clinical trial was conducted at the oculoplastics department of mughal eye trust hospital, lahore, pakistan, from sep 2013 – o ct 2014. this is a tertiary referral centre. 54 consecutive cases with moderate to severe vkc (108 eyes), between the ages of 4 – 18 years were included. the male to female ratio was 2:1. there were 13 newly diagnosed cases and 41 recurrent, being refractory to their previous therapy consisting of topical antihistamines, mast cell stabilizers and steroids. the study inclusion criteria was moderate to severe cases of vkc presenting with the symptoms of chronic, recurrent, bilateral red eyes with itching, redness, watering and mucus discharge with papillae found on the upper tarsal conjunctiva, along with limbal changes. study exclusion criteria were cases of seasonal allergic conjunctivitis (histamine mediated) and mild vkc with only palpebral conjunctivitis; patients who had received systemic or sub-conjunctival corticosteroids, glaucoma or ocular hypertension due to previous therapy, developmental cataract or any systemic illness. before starting the trial, all patients were given a questionnaire to grade the severity of their symptoms of itching, redness, watering, mucus discharge, photophobia and a foreign body sensation (table 1), as 0 (none), 1 for mild (occasional symptoms), 2 for moderate (frequent symptoms), and 3 for severe (constant symptoms). they all underwent a thorough ophthalmic examination including the measurement of best spectacle-corrected visual acuity (bscva), slitlamp biomicroscopy, conjunctival/corneal fluorescein staining and applanation tonometry. the clinical signs like conjunctival injection, limbitis, papillary hypertrophy or giant papillae, punctate corneal erosions, corneal pannus formation were graded (table 2 and 3) as 0 (none), 1 (mild), 2 (moderate), 3 (severe). the patients and / or their parents were fully explained the advantages and disadvantages of the treatment and a verbal consent was obtained. after discontinuing the previous medications in recurrent cases, all were treated with tacrolimus skin cream, 0.03% applied into the lower conjunctival fornix twice a day along with lubricants (visol eye gel 4 × / day and lacrilube eye ointment at night) for a period of 4 8 months (mean of 6 months). efficacy of treatment was evaluated subjectively by assessing patient's symptoms and objectively by noting an improvement in the clinical signs. the need for any additional therapy was noted. any side effects of the treatment particularly ocular discomfort were specifically asked and possible complications such as intraocular pressure, lens opacification, secondary bacterial infections were noted. all these findings were recorded at the beginning of the treatment and at all follow-ups conducted weekly for the first month and then after every month, for 1 year. any recurrence of symptoms and / or signs after stopping all therapy was also noted during the follow-up period. sameera irfan, et al 18 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology results in all 54cases (108 eyes) included in the study, the commonest presenting symptom was itching and watering of eyes in addition to other symptoms shown in table1. papillary hypertrophy was noted in all cases while giant papillae were found only in 25 recurrent cases (moderate = 24 eyes and severe = 26 eyes), table 2. limbitis was found in all cases (mild = 12, to assess the efficacy and safety of tacrolimus skin cream, 0.03% in moderate to severe vernal pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 19 moderate = 42, severe = 54 eyes), corneal involvement in the form of punctate erosions was seen in all cases (mild = 15, moderate = 52, severe = 41 eyes), corneal pannus in 42 cases (62 eyes) and shield ulcer, unilateral, in 2 cases. after starting 0.05% tacrolimus skin cream, the patients were followed up for 8 – 12 months (mean duration 10 ± 1.5 months). all symptoms significantly improved after treatment though itching was the first to be relieved. percentage improvement of symptoms after treatment has been shown in table 1. by 1 month after treatment, the residual symptoms only included mild redness in ten eyes (90.74% improvement), mild photosensitivity in 6 eyes and mild foreign body sensation in 5 eyes which disappeared after a further one month's therapy. the patients remained mostly symptom-free during the remaining period of therapy. however, when tacrolimus was stopped after 2 – 3 months of continuous use, almost all of them had a recurrence of the disease though in a milder form. hence it was continued for a further 2 months and then tapered gradually over another one month. after stopping all treatment, 26 cases developed mild recurrence after 3 – 4 months during the follow-up period which was of mild severity and was managed with anti-histamine eye drops only. while during treatment with tacrolimus, none of the cases needed additional medications like topical steroids, antihistamines or mast-cell stabilizers, for symptomatic relief. marked improvement was noted objectively, table 2; conjunctival injection was the first sign to show improvement in all cases within two weeks of therapy. in addition, conjunctival papillary hypertrophy showed improvement in all eyes. all 25 cases (50 eyes) with moderate to severe giant papillae, all showed reduction in size of the papillae as early as 2 weeks of therapy which flattened by1 month and disappeared by the end of 4 months of therapy. there was improvement in limbitis (limbal papillary hypertrophy) in all 54 cases (108 eyes), corneal punctate epithelial erosions in 54 cases (mild = 15 moderate = 52, severe = 41 eyes), and corneal pannus in 42 cases (62 eyes) after one month treatment which cleared fully after 2 months of therapy. both cases (2 eyes) with a shield ulcer healed after two months therapy. all cases showed improvement in visual acuity by two snellen’s lines. only three cases complained of mild discomfort on instillation of the cream; the remaining 51 cases did not complain of any discomfort or burning sensation when asked specifically. intraocular pressure remained normal in all cases and no other ocular complication related to tacrolimus skin cream was seen in any case. no patient had to discontinue the medication due to any adverse effect. discussion since vkc is an immune – mediated disease with marked ocular morbidity, the use of an immunomodulating drug to control the debilitating symptoms of itching and watering in children becomes necessary in moderate to severe cases. the disease is known for its recurrence when therapy is stopped, hence the medications have to be used on a long – term basis. topical steroids have been the preferred choice to – date to control symptoms in such cases, but their prolonged use results in vision-threatening complications like glaucoma, cataracts, corneal thinning and ectasia. hence tacrolimus has emerged as a very safe and effective steroid-sparing option which inhibits all immune reactions responsible for the pathogenesis of vkc.9-12 though an ophthalmic preparation is not available in pakistan; this study confirms that tacrolimus skin cream (0.03%) in such a mild concentration is a safe and effective therapeutic alternative to topical steroids for moderate to severe vkc. we opted for tacrolimus after its effectiveness in vkc has been demonstrated in other studies. tacrolimus 0.1% ‘skin’ cream applied to the skin of lower eyelid in previous studies13,14 had effectively controlled vkc. sengoku et al15 used 0.01 – 1% eye drops in an animal study for ocular allergy while ohashi et al16 used an 0.1% ophthalmic suspension in another clinical study. this study shows that not only there was an effective control of patient's symptoms in all cases (table 1) but a subjective improvement was also noted soon after starting the treatment (table 2). conjunctival injection was the first sign to show improvement within 2 weeks of therapy while conjunctival papillary hypertrophy also improved in all eyes within one month of therapy. a similar improvement was noted in giant papillae which started regressing after one month of therapy and disappeared after 4 months in all case. corneal signs like punctate epithelial erosions, pannus, and to some degrees, the opacities in corneal stromal showed improvement. similar results have been shown in a study by ohashi et al16 kymionis et al17 who used an sameera irfan, et al 20 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology ophthalmic preparation. 2 cases in our series had a shield ulcer which also resolved after treatment with tacrolimus and lubricants as has been reported previously18. improvement in bscva in 21 out of 27 cases, who had an initial bscva less than 6/18, was seen due to the improvement of corneal status and ocular surface in general. however, the 6 cases which did not show improvement in va had keratoconus which was confirmed by an orbscan (due to constant rubbing of eyes and a thinned cornea due to previous use of topical steroids). in our study, an attempt to discontinue tacrolimus after 2 – 3 months of continuous use resulted in recurrence of a milder form of vkc hence they were asked to use it for at least 4 – 5 months and then gradually taper it over a further one month. in other studies, topical tacrolimus has been stopped after 4 weeks in vkc and no recurrence was documented.15,16 in a study by miyazaki et al,18 topical tacrolimus was continued for 7 months while in another study, in patients with akc,13,18 it was used for up to 42 months and no side effects were reported. in our study, none of our cases needed additional medications like anti-histamines or mast cell stabilizers. since its long-term use has been shown to be safe, it can be used as a prophylactic drug in less severe disease as well to prevent its aggravation during the hot, humid season of the year. upon initial application of tacrolimus, a local burning sensation has been reported,16-18 it was seen in only 4 cases in our study and it disappeared after one week of therapy. during the follow-up period of 8 – 12 months (mean duration 10 ± 1.5 months), none of the cases developed any other side effects. however, because of its local immunosuppressive effect, it may result in activation of viral infections. hence we excluded patients from our study who gave a history of previous herpes infection. conclusion the use of tacrolimus eye drops / ointment in the treatment of vkc has been a topic of extensive research. consistent with previous reports, we found out that tacrolimus skin cream 0.03% used twice daily in the lower conjunctival fornix shows marked improvement in vkc; all patients had an effective relief of their symptoms within one month of therapy. since the nature of the disease requires long term usage, it was safe and easy to taper off the dosage and eventually stop it after 6 months with no adverse effects. there was no need to add additional medications like antihistamines or steroids in any case during the study. author’s affiliation dr. sameera irfan consultant oculoplastic surgeon mughal eye trust hospital 301, h3/a, johar town, lahore dr. arsalan ahmed mughal eye trust hospital 301, h3/a, johar town, lahore dr. faiza rasheed mughal eye trust hospital 301, h3/a, johar town, lahore references 1. bonini s, coassin m, aronni s, et al. vernal keratoconjunctivitis. eye (lond) 2004; 18: 345–51. 2. kumagai n, fukuda k, fujitsu y, et al. role of structural cells of the cornea and conjunctiva in the pathogenesis of vernal keratoconjunctivitis. progretin eye res 2006; 25: 165–87. 3. kumar s. vernal keratoconjunctivitis: a major review. acta ophthalmo. 2009; 87: 133–47. 4. barney np. vernal and atopic keratoconjunctivitis. in: krachmer jh, mannis mj, holland ej, eds. cornea: fundamentals, diagnosis and management. 3nd ed. philadelphia, pa, elsevier/mosby, 2011, pp 1–2 5. carnahan mc, goldstein da. ocular complications of topical, peri-ocular, and systemic corticosteroids. curr opin ophthalmol. 2000; 11: 478–83. 6. kino t, hatanaka h, hashimoto m, et al. fk-506, a novel immunosuppressant isolated from a streptomyces. i. fermentation, isolation, and physicchemical and biological characteristics. j antibiot (tokyo). 1987; 40: 1249–55. 7. bertelmann e, pleyer u. immunomodulatory therapy in ophthalmology: is there a place for topical application? ophthalmologica. 2004; 218: 359–67. 8. joseph ma, kaufman he, insler m. topical tacrolimus ointment for treatment of refractory anterior segment inflammatory disorders. cornea 2005; 24: 417–20. 9. zhai j, gu j, yuan j, et al. tacrolimus in the treatment of ocular diseases. bio drugs. 2011; 25: 89–103. 10. kheirkhah a, zavareh mk, farzbod f, et al. topical 0.005% tacrolimus eye drop for refractory vernal keratoconjunctivitis. eye (lond). 2011; 25: 872–80. 11. lee yj, kim sw, seo ky. application for tacrolimus ointment in treating refractory inflammatory ocular surface diseases. am j ophthalmol. 2013; 155: 804–13. to assess the efficacy and safety of tacrolimus skin cream, 0.03% in moderate to severe vernal pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 21 12. müller gg, josé nk, castro rs de. topical tacrolimus 0.03% as sole therapy in vernal keratoconjuctivitis. eye contact lens. 2014; 40: 79-83. 13. virtanen hm, reitamo s, kari m, kari o. effect of 0.03%tacrolimus ointment on conjunctival cytology in patients with severe atopic blepharoconjunctivitis: a retrospective study. acta ophthalmol scand. 2006; 84: 693–5. 14. zribi h, descamps v, hoang-xuan t, crickx b, doan s. dramatic improvement of atopic keratoconjunctivitis after topical treatment with tacrolimus ointment restricted to the eyelids. j eur acad dermatol venereol. 2009; 23: 489–90. 15. sengoku t, sakuma s, satoh s, kishi s, ogawa t, ohkubo y, et al. effects of fk506 eye drops on late and delayed-type responses in ocular allergy models. clin exp allergy.2003; 33: 1555–60. 16. ohashi y, ebihara n, fujishima h, fukushima a, kumagai n, nakagawa y, et al. a randomized, placebo-controlled clinical trial of tacrolimus ophthalmic suspension 0.1% in severe allergic conjunctivitis. j ocul pharmacol ther. 2010; 26: 165–74. 17. kymionis gd, goldman d, ide t, yoo sh. tacrolimus ointment 0.03% in the eye for treatment of giant papillary conjunctivitis. cornea. 2008; 27: 228–29. 18. myazakai, vichyanond p, tantimongkolsuk c, dumrongkigchaiporn p, jirapongsananuruk o, visitsunthorn n, kosrirukvongs p. vernal keratoconjunctivitis: result of a novel therapy with 0.1% topical ophthalmic fk-506 ointment. j allergy clin immunol. 2004; 113: 355–8. pak j ophthalmol. 2020, vol. 36 (4): 360-364 360 original article treatment of medial canthal tumor by rotation flap qirat qurban 1 , zeeshan kamil 2 , khalid mahmood 3 1-3 khalid eye clinic, nazimabad, karachi – pakistan abstract purpose: to describe the cosmetic outcome after repairing medial canthal defects via glabellar rotation flaps in patients undergoing wide clear margin excision of medial canthal tumour. study design: interventional case series. place and duration of study: this study was conducted at khalid eye clinic, nazimabad, karachi, from march 2019 to august 2019. methods: eleven patients of both genders with clinically suspected medial canthal tumor were included in the study. study approval was obtained from the ethical review committee. patients who underwent previous treatment such as radiation, cryotherapy or surgery were excluded. all surgeries were done to remove the tumor along with surrounding wide clear margins followed by reconstruction of the defect of the medial canthus area with the help of a rotation flap. patients were followed for a period of up to six months post operatively for any wound related problems or recurrence. all patients were informed about the study and consent was obtained from each of them. results: all eleven patients of this study were satisfied at the end of the follow-up period with the final cosmetic outcome. seven out of eleven patients were males and the remaining four were females, which also highlighted a greater incidence of medial canthal tumors in the male gender. conclusion: glabellar rotation flap is a suitable procedure for the medial canthal area restoration after the tumor excision and can be customized as per the characteristics of the surrounding skin as well as the site, dimensions, and profundity of the defect. key words: medial canthal tumor, glabellar rotation flap, medial canthus. how to cite this article: qurban q, kamil z, mahmood k. treatment of medial canthal tumor by rotation flap. pak j ophthalmol. 2020; 36 (4): 360-364. doi: https://doi.org/10.36351/pjo.v36i4.1047 introduction medial canthal region is often a favourable location for the development of malignant skin tumours, most commonly basal cell carcinoma, owing to an increased ultraviolet light exposure. 1 due to the presence of minimal skin and subcutaneous tissue at the multi correspondence: qirat qurban khalid eye clinic, nazimabad, karachi – pakistan email: qirat_89@hotmail.com received: april 18, 2020 accepted: july 29, 2020 contoured medial canthal region, tumor extension may involve the underlying structures such as orbicularis muscle, medial canthal ligament, periosteum along with lacrimal puncta and the eyelids, making reconstruction a challenge after the tumor is excised. 2 current surgical strategies for repairing and reconstructing medial canthal region defects incorporate direct closure, free dermal grafts and flaps. 3 the surgical medial canthal region differs from the anatomical medial canthus in terms of size and extension since it lengthens perpendicularly into the region below the brow, to the nasal side close to the midline medially, and on top of the cheek inferiorly. 4, 5 removal of the medial canthal tumour results in a http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 qirat qurban, et al 361 pak j ophthalmol. 2020, vol. 36 (4): 360-364 cosmetically disfiguring defect. hence, it is of utmost importance that a careful surgery is planned for adequate tumour excision and to reduce the functional and cosmetic consequences of surgery in order to restore the colour, continuity, consistency and depth of the dermal tissue for the maintenance of a more natural symmetrical external appearance. this is best done with the help of a flap contiguous to the defect such as glabellar flap transposition, which matches the tissue characteristics and maintains a good vascular supply important for the viability of the flap. 6 this study aims at sharing our reconstructive strategy to provide an acceptable cosmetic outcome after repairing medial canthal defects via glabellar rotation flaps in patients undergoing wide clear margin excision of medial canthal tumours. methods this interventional case series was conducted at khalid eye clinic, nazimabad, karachi, from march 2019 to august 2019 and included eleven patients of both genders with age ranging from 55 to 65 years, having clinically suspected medial canthal tumor. surgical procedure was explained to the patients and informed consent was obtained. study approval was obtained from the ethical review committee. each patient’s data was collected and documented including demographic information, co-morbidities, size of the lesion, duration of the lesion, location of the lesion, size of the resulting defect, type of reconstructive surgery, eyelid opening, presence of eyelid deformity and aesthetic symmetry. patients who underwent previous treatments such as radiation, cryotherapy or surgery were excluded from the study. surgery was done under general anaesthesia. all surgeries were done to remove the medial canthal tumor along with surrounding wide clear margins and restoration of the medial canthus area with the help of a glabellar rotation flap by a single oculoplastic surgeon. patients were followed for a period of up to six months post operatively and any recurrence, epiphora, wound related problems and cosmetic outcome was noted. all the postoperative follow-up and result of the surgery was assessed by another co-author. after all aseptic measures, surgical site was marked by a sterile marker and suspected tumour along with wide clear margin (3-4 mm from the tumor edge) was excised and sent for histopathological analysis to validate the presence of margin clarity. the size, location, depth of the tissue deficiency and integrity of the lacrimal duct arrangement was assessed and glabellar rotation flap of adequate size was made on the adjacent area of the skin. injection bupivacaine 0.5% with 2% adrenaline was injected subcutaneously followed by physical pressure on the site of injection for 5 minutes to maintain hemostasis. the margins of the flap were incised using a scalpel followed by dissection with blunt scissors underneath the flap and transversely on the dorsum of the nose along the horizontally oriented relaxed skin tension lines. 7 the flap was raised, mobilized and placed onto the defect. the proportion of flap to defect size was reserved at 3:1 to ensure a good supply of blood into the flap. the margins of the nasal skin were then sutured with interrupted 6 – 0 prolene and the lid skin was closed with 6-0 vicryl sutures to develop the concavity of the medial canthal region. the area was double padded with ocular dressing to attain sufficient compression to prevent formation of hematomas and help to establish the shape of medial canthal region. patients were called for follow-up for the removal of sutures following healing of the sutured skin margins. the results were classified as satisfactory if there was complete lid closure and unsatisfactory if there was any resultant exposure of the ocular surface. topical antibiotic ointment and systemic antibiotic were prescribed twice daily for 7 days with digital pressing of the flap until removal of the sutures for a duration of minimum two months. results mean age of the patients was 59.2 ± 4.76 years. seven (63.6%) patients were males and four (36.3%) were females. at the end of the mean follow-up period of 185 ± 11.3 days, all patients of this study were satisfied with the cosmetic outcome with complete lid closure and formation of an acceptable medial canthal contour (figure 1). during the course of follow-up, one (9.09%) out of eleven patients developed pyrexia with slight inflammation of the flap which settled with oral antibiotic and antipyretics. another patient (9.09%) developed misdirection of lashes medially, which was treated by electrolysis. three (27.3%) out of the eleven patients, as a consequence of tumor excision, resulted in compromised lacrimal drainage system. out of those three patients, one patient complained of watering and further treatment with lester jones dacryocystorhinostomy was planned. rest of the patients did not develop any infection, http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 treatment of medial canthal tumor by rotation flap pak j ophthalmol. 2020, vol. 36 (4): 360-364 362 bleeding, graft loss, necrosis, or reappearance of the tumor tissue throughout the duration of follow-up. picture 1: immediate post operative and at the end of follow-up period. discussion malignant tumors of the eyelid constitute about 40% of all soft tissue tumors around the orbital region. 8 in this part of the world, occurrence and conclusion of an assortment of tumors of the eyelid fluctuate considerably owing to the diverse geographical locations, hereditary backdrop, and social and financial standing of the affected patients. 9 risk factors such as chronic uv exposure, slow tumor growth, resemblance to benign lesions, along with unawareness, negligence to seek medical advice in time and lack of healthcare infrastructure are some of the reasons which result in delay in presentation and diagnosis. when there is a clinical suspicion of a tumor at the medial canthus, the tumor as well as the surrounding tissue needs to be removed with wide clear margins to make sure that no cancer cells or tumor tissue is left behind. reconstruction of full-thickness defects is complex if done in a single surgical procedure. wide excision is followed by reconstruction of the medial canthal region. as a consequence of this surgical procedure, the conjunctiva, lacrimal puncta, canaliculi, caruncle, ligament of the medial canthus and the lacrimal sac may get sacrificed. 10 there are various techniques available for the repair of medial canthal region including direct closure, flaps and grafts. no ideal procedure exists; therefore, each of the techniques has its own advantages and disadvantages. 11 in 1993, spinelli et al recommended that for the medial canthus restoration, local skin flap proved to be excellent. 12 another study by onishi showed that for rebuilding of the medial canthal area, for deficit extending further ahead than the medial canthus onto the upper and lower eyelid’s lateral side could be restored by rotating the apex of the glabellar flap. 13 in this study we performed the glabellar rotation flap for the treatment of patients presenting with clinically suspected tumor of the medial canthal region after they underwent wide clear margin tumor excision. a surgeon ought to evaluate the depth, consistency and flexibility of the skin, underlying subcutaneous tissue, muscles, amount of the tissue to be rotated onto the defect and normal dermal tension lines while assessing a flap. 10 the glabellar rotation flap comprises of a skin flap and underlying subcutaneous tissue that is transposed about a hinge position onto the neighboring medial canthal deficit. the idea behind selecting a rotation flap and not a free skin graft was due to the fact that, full-thickness skin graft may result in inadequate filling of defect volume, graft shrinkage leading to distortion, cosmetically unsatisfactory as compared to an adjacent flap, presence of color mismatch (hyperpigmentation or hypopigmentation with time) and necrosis from an impaired local blood supply. 14 flaps have their own blood supply, resulting in rapid healing with decreased risk of infection and necrosis, as well as a single operative site is required. additional benefits of a glabellar rotation flap include a short operation time, less invasive with less obvious scarring as compared to a free skin graft. the cosmetic outcome is excellent since the ensuing blemish is concealed in a stress-free dermal tension line and becomes inconspicuous with time. like any surgical procedure, reconstruction using a rotation flap is not entirely free from complications. some of the common problems which may be encountered subsequently include disparity in skin color, texture, poor eyelid motility, medial canthal concavity volume loss which may be cosmetically obvious, restricted globe motility from a cicatricial conjunctiva and constant watering, which possibly occurs as a consequence of inadequate corneal http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 qirat qurban, et al 363 pak j ophthalmol. 2020, vol. 36 (4): 360-364 coverage, anomalous eyelid placement or injury to the nasolacrimal drainage structure. 15 sokol et al reported a greater preponderance of medial canthal tumour in the male gender, which was also found in present study. 16 at the end of six months follow-up period in this study, all the patients were content with the cosmetic result having no inconvenience with the eyelid motility and complete lid closure. misdirection of lashes medially was experienced by one patient (9.09%), which was treated by electrolysis. rafael et al noted ectropion in his study. 17 three (27.3%) out of the eleven patients in this study, consequently resulted in compromised lacrimal drainage system. the raised skin caused by the flap pedicle passing the dorsum of the nasal area was not apparent and showed significant enhancement in the flap mass at follow-ups, tolerable to the patients since it was explained to each patient prior to the surgery. lykoudis 18 and chao 19 demonstrated the employment of glabellar flap and observed it to be straightforward, dependable and aesthetically acceptable for reconstruction of medial canthus deficits. timm a et al suggested that glabellar flap could be applied for the repair of defects measuring up to 30 × 25 mm. 20 they also showed that this method was also appropriate for deeper defects in this area. the flap is also suitable if a patient has a recurrence of tumour. limitation of the study was small number of patients and only six months follow-up. conclusion glabellar rotation flap is a suitable method for the renovation of medial canthus area after the removal of tumor and can be customized according to the characteristics of the skin surrounding the orbit and the site, dimensions, and profundity of the deficit. it can be performed with good grace, has its own blood supply, is aesthetically pleasing owing to it following the dermal stresslines of the bridge of the nasal region and the glabellar region in addition to providing excellent skin shade, tissue depth and consistency match and does not necessitate asubsequent surgical process. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. lin hy, cheng cy, hsu wm, kao wh, chou p. incidence of eyelid cancers in taiwan: a 21-year review. ophthalmology, 2006; 113: 2101-2107. 2. chiarelli a, forcignanb r, boatto d, zuliani e, bisazza s. reconstruction of the inner canthus region with a forehead muscle flap: a report on three cases. br j plast surg. 2001; 54 (3): 248-252. 3. bertelmann e, rieck p, guthoff r. medial canthal reconstruction by a modified glabellar flap. ophthalmologica. 2006; 220: 368-371. 4. corredor-osorio r. rhomboid flap: an option to medial canthal reconstruction. our dermatol online, 2017; 8: 329-332. 5. maloof aj, leatherbarrow b. the glabellar flap dissected. eye, 2000; 14: 597-605. 6. akihiro o, kiyoshi o, emi o, miho n. medial canthal reconstruction with multiple local flaps. jpras open, 2018; 15: 4–9. 7. metha js, olver jm. infra glabellar trans nasal bilobed flap in the reconstruction of medial canthal defects. arch ophthalmol. 2006; 124: 111-115. 8. wójcicki p, zachara m. surgical treatment of eyelid tumors. j craniofac surg. 2010; 21: 520-525. 9. deprez m, uffer s. clinicopathological features of eyelid skin tumors. a retrospective study of 5504 cases and review of literature. am j dermatopathol. 2009; 31: 256-262. 10. mustarde jc. surgery of the medial canthus. in: mustarde jc, editor. repair and reconstruction in the orbital region. 3rd ed. edinburgh: churchill livingstone; 1991: pp. 255–281. 11. bertelmann e, rieck p, guthoff r. medial canthal reconstruction by a modified glabellar flap. ophthalmologica. 2006; 220: 368-371. 12. spinelli hm, jelks gw. periocular reconstruction; a systemic approach. plast reconstr surg. 1993; 91: 1017–1024. 13. onishi k, maruyama y, okada e, ogino a. medial canthal reconstruction with glabellar combined rintala flaps. plast reconstr surg. 2007; 119: 537–541. 14. collin jr. eyelid reconstruction and tumour management. in: collin jr. a manual of systematic eyelid surgery. 2nd ed. edinburgh, scotland: churchill livingstone; 1989: 73-74. http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 http://www.jnsmonline.org/article.asp?issn=2589-627x;year=2019;volume=2;issue=2;spage=81;epage=85;aulast=baabdullah#ref16 https://www.ncbi.nlm.nih.gov/pubmed/16962174 https://www.ncbi.nlm.nih.gov/pubmed/16962174 https://www.ncbi.nlm.nih.gov/pubmed/16962174 https://www.ncbi.nlm.nih.gov/pubmed/20216443 https://www.ncbi.nlm.nih.gov/pubmed/20216443 https://www.ncbi.nlm.nih.gov/pubmed/19384066 https://www.ncbi.nlm.nih.gov/pubmed/19384066 https://www.ncbi.nlm.nih.gov/pubmed/19384066 https://www.ncbi.nlm.nih.gov/pubmed/19384066 treatment of medial canthal tumor by rotation flap pak j ophthalmol. 2020, vol. 36 (4): 360-364 364 15. madge sn, malhotra r, thaller vt, davis gj, kakizaki h, mannor ge, et al. a systematic approach to the oculoplastic reconstruction of the eyelid medial canthal region after cancer excision. int ophthalmol clin. 2009; 49 (4): 173–194. 16. sokol i, ina k, erisa k. choosing the appropriate reconstructive technique for eyelid defects after tumor excision. j surg curr trend innov. 2019; 3: 023. doi: 10.24966/scti-7284/100023. 17. rafael co, gabriela mcm, gabriela bcv. the transnasal bilobed flap for medial canthal reconstruction. heighpubs otolaryngol and rhinol. 2017; 1: 088-091. doi: 10.29328/journal.hor.1001014. 18. lykoudis eg, lykoudis ge, alexiou ga. “pickaxe” double flap: a useful “tool” for reconstruction of deep large medial canthal defects-5-year experience and brief literature review. aesth plast surg. 2015; 39: 410–413. 19. chao y, xin x, jiangping c. medial canthal reconstruction with combined glabellar and orbicularis oculi myocutaneous advancement flaps. j plast reconstr aesthet surg. 2010; 63: 1624–1628. 20. timm a, vick h, guthoff r. glabellar transposition flap for medial canthal reconstruction after tumour excision. klin monatsbl augenh, 2002; 219 (10): 740744. authors’ designation and contribution qirat qurban; consultant ophthalmologist: data collection, manuscript writer, final review. zeeshan kamil; consultant ophthalmologist: examiner, manuscript writer, final review. khalid mahmood; consultant ophthalmologist: helped in data collection, final review. .…  …. http://dx.doi.org/10.24966/scti-7284/100023 341 pak j ophthalmol. 2020, vol. 36 (4): 340-347 original article clinical outcome of pars plana vitrectomy with or without intravitreal bevacizumab as a pre-treatment in advanced diabetic eye disease ambreen gul 1 , sairam ahmed 2 , fuad ahmad khan niazi 3 , ali raza 4 1-4 holy family hospital, rawalpindi medical university, rawalpindi abstract purpose: to find out the clinical outcome of pars plana vitrectomy with and without intravitreal bevacizumab as a pretreatment in advanced diabetic eye disease. place and duration of study: ophthalmology department, holy family hospital rawalpindi, from january 2018 to december 2018. methods: sixty patients with advanced proliferative diabetic retinopathy were included. patients were divided into two groups. in group a, patients had pars plana vitrectomy with pre procedure injection of intravitreal bevacizumab and group b had vitrectomy without pre procedure intravitreal bevacizumab. amount of bleeding during vitrectomy, surgical time and rate of iatrogenic tears were noted in both groups. outcome measures were post operative best corrected visual acuity at 6 months and post operative recurrent vitreous hemorrhage. results: patients had a mean age of 63.83 ± 7.314 years. in group a, mild bleeding was seen in 33%, moderate in 6.7% and severe in 0%. in group b, mild bleeding was seen in 13.3%, moderate in 46.7%, and severe bleeding in 40%. after 6 months, 27 (90%) patients in group a showed improvement in best corrected visual acuity while it was seen in 12 (40%) patients in group b. iatrogenic tears were seen in 10% in group a and 36% in group b. mean time of surgery in group a was 59.27 ± 6.823 minutes and in group b was 77.87 ± 9.637 minutes. rate of recurrent vitreous hemorrhage after vitrectomy was 6.7% in group a and 40% in group b. conclusion: intravitreal injection of bevacizumab is helpful in reducing surgical time and also decreases intraoperative and post operative bleeding. key words: bevacizumab, vitrectomy, proliferative diabetic retinopathy. how to cite this article: gul a, ahmed s, niazi fak, raza a. clinical outcome of pars plana vitrectomy with or without intravitreal bevacizumab as a pretreatment in advanced diabetic eye disease. pak j ophthalmol. 2020; 36 (4): 341-347. doi: https://doi.org/10.36351/pjo.v36i4.1036 introduction diabetes mellitus is a metabolic disease. 1 in islamic republic of pakistan, prevalence of diabetes is correspondence: ambreen gul holy family hospital rawalpindi medical university, rawalpindi email: amber-gul@hotmail.com received: april 4, 2020 accepted: july 21, 2020 reported to be nearly 9% especially in individuals in third decade of life. 2 diabetic retinopathy is amongst the foremost reasons of visual deterioration in 2 nd to 6 th decade. 3 according to different studies, the incidence of diabetic retinopathy is approximated to be 15.3% to 28.9%. 4 in a study in gaddap, a prevalence of 1.74% of advanced manifestations of proliferative diabetic retinopathy was seen. 2 the risk of developing retinopathy is proportional to the time period of diabetes. majority of type 1 diabetic individuals and 60% of type 2 diabetics develop retinopathy following pars plana vitrectomy with or without intravitreal bevacizumab in diabetic eye disease pak j ophthalmol. 2020, vol. 36 (4): 340-347 342 a time period of 15 – 20 years. 5 dense non clearing vitreous hemorrhage (vh) and tractional retinal detachment (trd) are the outcomes of advanced diabetic eye disease (aded). 6,7 vitreous gel is an avascular structure and vh develops due to leakage of blood into vitreous from damaged vessels. causes of vh include proliferative diabetic retinopathy, retinal tear, retinal vascular disorders, posterior vitreous detachment and eye trauma. 8 vh that obscures fundus view, is generally caused by a retinal tear or retinal vasculopathy posing a typical clinical dilemma. 9 vasculopathy in diabetes results in retinal ischemia and sequentially, release of vascular endothelial growth factor (vegf). vegf expression is the core reason for retinal neo-vessels. these pathophysiological changes provide the ground for employment of anti-vegf therapies in retinal neovascularization diseases. 10 bevacizumab (avastin) is an effective anti-vegf. it is a recombinant humanized monoclonal antibody effective for all forms of vegf. its anti-angiogenic potential efficiently reduces neo-vessels on iris and retina in proliferative stages and is also useful in the treatment of advanced diabetic eye disease. it also treats intraocular hemorrhages by stimulating retinal neovessels degeneration. 11 pars plana vitrectomy (ppv) was started in 1970 for vitreous hemorrhage due to proliferative diabetic retinopathy. 12 ppv plays a vital role in treating complicated aded. trd is outlined as tractional bands causing retinal elevation either clinically or spotted on b-scan ultrasound signifying a principal problem. non-resolving vh is defined as bleed in the vitreous cavity that is constant (for a minimum of 3 months) or is recurrent. 13 the aim of ppv in advanced diabetic eye disease is to refurbish vision by clearing blood in vitreous cavity and removing proliferative tractional fibrovascular membranes. it is also aimed to alleviate the retinal neovascularization by retinal endo laser photocoagulation. 14 key alarms in vitrectomy for complicated proliferative diabetic retinopathy are surgical complications like prolonged surgical time due to intra-operative bleeding, iatrogenic retinal tears, post-operative recurrent vitreous hemorrhage and neovascular glaucoma. they result in poor visual and anatomical outcomes. 15 currently, surgical outcomes of intravitreal bevacizumab (ivb) as an add-on to ppv in managing diabetic eye disease have been unfolded in several trials. hence, it was proposed that administration of ivb preoperatively can be beneficial to decrease per operative bleeding in aded. the utilization of antivegf agents few days before diabetic vitrectomy also ends up in better improvement in postoperative best corrected visual acuity (bcva), and reduces frequency of recurrent vh. recurring vitreous hemorrhage is a frequent cause for reoperation. in majority of cases, recurrent hemorrhage in vitreous cavity is reported at some point within the initial six months postoperatively but may occur long duration afterward. 16,17 however, its use remains controversial as some studies have mentioned a rapid progression of tractional detachment after ivb. 18 rationale of this study was to relinquish ample information regarding effectiveness of avastin injection given as an intravitreal adjunct prior to ppv for the surgical management of proliferative diabetic retinopathy. this prospective study was conducted to scrutinize, explore and compare the effect and success of ivb as an add-on in patients planned for three port ppv with aded. methods after approval by hospital ethical review committee, the study was conducted at department of ophthalmology, holy family hospital, rawalpindi medical university from january to december 2018. sample size was drawn from the software by taking the statistical conditions of 95% confidence interval with 5% margin of error. sample included sixty eyes of sixty patients of either gender aging between 45 – 75 years with advanced diabetic ocular disease. the patients underwent pars plana vitrectomy. only those patients who had trd threatening macula, trd with vh or non-clearing vh of a minimum of three months duration having good metabolic and hypertensive control were included in the study. patients who had vitreoretinal or any intraocular surgery within 6 months or who had received avastin within 6 weeks were excluded. we also excluded patients with known coagulation abnormalities or on anticoagulants. patients were enrolled through dr (diabetic retinopathy) clinic, department of ophthalmology holy family hospital. detailed informed consent was sought from all patients. self-designed proforma was used to enter data. total 60 patients were divided into two groups; group had 30 cases. patients of group a underwent ppv with ivb of 1.25 mg/0.05 ml, 1 week (7 days) before surgery. group b had 23 gauge ambreen gul, et al 343 pak j ophthalmol. 2020, vol. 36 (4): 340-347 vitrectomy with no intravitreal avastin injection preoperatively. these patients were operated by single experienced vitreoretinal surgeon. data including patient demographics, duration and category of diabetes (type 1 or 2) were recorded. every patient underwent detailed ophthalmic examination including best-corrected visual acuity (bcva) with snellen decimal chart and slit lamp bio-microscopy and fundoscopy with 90 d lens. fundus images were taken by non-mydriatic fundus camera. intra-ocular pressure (iop) was taken by gat goldman applanation tonometer. b-scan ultrasonography was done preoperatively to find out the condition of retina in cases of intense vh. a 10% povidone-iodine swab stick was applied to coat the injection site. after sterilized preparation, bevacizumab (avastin) in dosage of 1.25 mg/0.05 ml was injected intravitreally in the operation theatre under topical proparacaine drops. injection site was marked with calipers at 4 mm in phakic and 3.5 mm in pseudophakic eyes, posterior to the limbus. prophylactic topical antibiotic (moxifloxacin) was started one day before the procedure. drops were continued for a week after avastin injection. group a patients had ppv one week after injection by the same consultant surgeon under local anaesthesia. all vitrectomies were done using feros vitrectomy machine (oertli, switzerland). after local anesthesia, surgical scrubbing and draping was done. conjunctival peritomy was done 360 degrees. sclerotomy ports were made using 23gauge micro-vitreoretinal knife. core vitrectomy was carried out employing a vitreous cutter of high velocity (cut rate of 3000 cycles/minute). after intravitreal triamcinolone acetonide injection, residual vitreous was visualized along with epiretinal and vitreoretinal proliferation adhesions. tangential and anterior-posterior traction was alleviated by cutting the peripheral vitreous. all tangential traction including proliferative epiretinal fibrous membrane was relieved as much as possible by segmentation, dissection and delamination with the help of vitreoretinal endo forceps and scissors. scleral depression was done to aid 360 degree peripheral vitreous gel removal by shaving. a binocular indirect ophthalmo-microscope (biom) was employed in all cases consequently after adequate clearance of the vitreous hemorrhage to permit revelation of the posterior pole when required. high-speed 23-gauge cutter (up to 2500 cuts/min) was accustomed to cut membranes very near to the retina. no ilm peeling was done. with cautious lifting of the posterior hyaloid and indenting the periphery with muscle hook, scrupulous shaving of the vitreous base was done to eliminate the maximum amount of remaining blood as possible. full attention was paid to alleviate traction. panretinal photocoagulation was done with endolaser. silicone oil 5000 cst was used for internal tamponade. all ports of sclera and peritomy incisions were closed with 6/0 vicryl. sub-conjunctival injection of steroid-antibiotic was given and eye pad was applied. one week face down posturing was done in all cases that had undergone air/fluid exchange. hemostasis was maintained by raising ocular infusion pressure or by administering endo-diathermy. amount of bleeding during vitrectomy surgery was observed by trained assistant and it was categorized as mild, moderate, severe or none. no bleeding, if none occurred during surgery, mild if bleed was stopped by increasing the ocular perfusion pressure, moderate if bleeding was stopped by increasing iop for longer time, and severe, if endodiathermy was necessitated. both groups a and b were compared for total bleed during surgery. none to mild bleeding cases were put in the category of successful response to ivb treatment. all patients were examined at 1 st , 7 th , and 14 th day post operatively and followed up after every month till six months. early postoperative vh was defined as vitreous bleed within a month post vitrectomy. patients were followed up for at least 6 months. computer software package spss version 23.0 was used to analyze data. for quantitative variables like age, duration of diabetes, time of surgery; mean ± s.d was calculated. for qualitative variables like gender, type of diabetes, bleeding during surgery, iatrogenic retinal tear and frequency (percentage) was calculated. student t-test was used to compare statistical significance between two groups. p value less than 0.05 was considered statistically significant. primary clinical outcomes was flat retina postoperatively and visual outcome was bcva at six months. intraoperative complications including bleeding during surgery, necessity for endo-cautery to stop bleed, mean time of surgery and iatrogenic tears in retina were analyzed and compared in both groups. results there were 60 patients with 30 in each group a and b. mean age in group a was 63.73 ± 8.387 years and pars plana vitrectomy with or without intravitreal bevacizumab in diabetic eye disease pak j ophthalmol. 2020, vol. 36 (4): 340-347 344 in group b was 63.83 ± 7.314 years. among 60 patients there were 27 (45%) males and 33 (55%) females. there were 13 males and 17 females in group a and 14 males and 16 females in group b. mean duration of diabetes was17.50 ± 5.111 years in group a and 14.43 ± 3.626 in group b. in group a, (iddm) insulin dependent diabetes mellitus was seen in 4 patients and (niddm) non insulin dependent diabetes mellitus was seen in 26 patients while in group b, iddm was seen in 3 patients and niddm was seen in 27 patients. the difference between two groups was not statistically significant as regards to demographic details (age, gender, type and duration of diabetes) as p value was more than 0.05. intraoperative bleeding quantity was less in group-a as compared to group-b (p value 0.001). comparison between two groups for per operative bleeding is shown in table 1. table 1: intraoperative bleeding in avastin group a and control group b. intraoperative bleeding total none mild moderate severe group a(avastin group) 18 10 2 0 30 b(control group) 0 4 14 12 30 total 18 14 16 12 60 the rate of iatrogenic tears in group a was 10% and in group b was 36% with a p value of 0.015 which was statistically significant. mean time of surgery in group a was 59.27 ± 6.823 minutes and in group b was 77.87 ± 9.637 minutes. meantime of surgery (mean ± s.d) of group-a was appreciably less in comparison to group b (p = 0.001). in group a, 28 (93.3%) patients had no vh up to 6 months; whereas, in group b, 18 (60%) patients had no vh up to 6 months with asignificant p-value of 0.002. the rate of recurrent bleed in vitreous cavity was 6.67% in group a and 40% in group b post operatively. there was statistically significant difference between two groups (p value 0.001). postoperative rubeosis iridis was seen in 3.33% patient in group a as compared to 23.3% patients in group b (p = 0.003). anatomical success was seen in 90% patients in group a and 60% of patients in group b (p = 0.001). in this study, visual outcome of bcva at 6 months was measured in terms of stable, improved or worse visual acuity. at 6 months, 27 (90%) cases in group a showed improved bcva whereas in group b, 12 (40%) cases had improved bcva, p value of 0.001. the results are shown in table 2 and figure 1 as under. table 2: post operative bcva in avastin group a and control group b. post operative best corrected va group total avastin group a control group b post operative bcva 6/6 to 6/18 (1.00 – 0.33) 5 1 6 6/24 to 6/60 (0.25 – 0.1) 22 11 33 less than 6/60 or counting fingers (0.08 – 0.03) 3 18 21 total 30 30 60 fig. 1: postoperative bcva in avastin group a and control group b. discussion this study found that ppv with pre-operative use of ivb can be beneficial in reducing the risk of intraoperative hemorrhage, reducing the surgical time, decreasing the chance of postoperative hemorrhage and improving bcva. in pakistan, diabetic patients present in late complicated stages due to lack of understanding about complications of the disease, poor socioeconomic status of patients leading to poor acquiescence with medications which results in developing advanced form of diabetic eye disease. in a study done by rizzo et al patients had a mean age of 52 years. 10 yeoh et al reported a mean age of 46 years. 19 haseeb et al reported most of patients in the range of 56 – 65 years 20 and in a study done by faisal et al, age ranged from 47 – 65 years with a mean of ambreen gul, et al 345 pak j ophthalmol. 2020, vol. 36 (4): 340-347 58.1 years. 21 different studies have shown different ages of patients with diabetic retinopathy. in our study, advanced disease was seen in sixth decade. mean duration of disease of diabetes mellitus in our study was 17.50 years in avastin group and 14.43 years in control group. avery et al conducted a trial in which the mean duration of disease was 15 years. 22 prevalence of advanced diabetic eye disease increases as duration of diabetes increases. faisal et al reported a comparatively shortermean duration of disease 21 , which can be attributed to poor compliance of patientsto medications leading to rapid progression of proliferative retinopathy. in proliferative diabetic retinopathy, dissection of adherent proliferative fibrovascular membrane leads to repetitive intraoperative hemorrhage which obscures visibility and hence lengthening surgery time. increased use of endo-diathermy for intraoperative bleeding also induces a high risk of inflammatory membrane and postoperative uveitis. decreased circulation to the optic disc and corneal edema can be caused by elevated ocular perfusion pressure for prolonged duration to control intra operative hemorrhage. pre-ppv intra-vitreal avastin facilitates easy separation of proliferative fibrovascular membranes from retina with less intraoperative bleeding. this occurs as a result of degeneration of vascular complex of fibrovascular membranes aiding segmentation and dissection. clear view during surgery reduces the duration of surgery. 5,7,8,10 . rizzo et al reported no intra-operative hemorrhage in 54% cases in group that received avastin as compared to 18% in the group that had not received avastin. 10 in a similar study conducted by faisal et al in non-avastin group no bleeding was observed in only 7.1% and severe in 71.4%. in avastin group no bleeding was seen in 60.7% andsevere in only 17.9% of cases. 21 el-batarny reported severe bleeding in all 15 cases in non avastin group. in group with pre vitrectomy avastin, no bleeding was seen in 13.3% and severe in 26.6%. 23 ivb also decreases post-ppv vitreous hemorrhage. dissected and segmented fibrovascular complexes typically re-bleed in 7 days of surgery. nevertheless, the cause of immediate post vitrectomy hemorrhage in vitreous cavity is generally hard to determine. in the current study, patients were examined postoperatively at 1 month, 3 months and 6 months for recurrent vitreous hemorrhage. the incidence of post vitrectomy recurrent hemorrhage in vitreous cavity in the avastin group was significantly low. haseeb et al reported no vh in avastin group upto 6 months. 20 similar results have been reported by cooper et al. 24 in our study mean time of surgeryin group a was 59.27 mins ± 6.82 and in group b was 77.87 mins ± 9.63. difference in mean time of surgery was quite evident between two groups. rizzo et al., reported 57 minutes in group with avastin and 83 minutes in nonavastin group. 10 faisal et al reported 64 ± 10.35 minutes in avastin group and 80.5 ± 10.22 minutes in non-avastin group. 21 in another study done by elbatarny, mean surgical time was 93.3 ± 11.6 minutes in non-avastin group as compared to 61.6 ± 14.5 minutes in avastin group. 23 the reasons for reduction in the operating time and facilitation of surgery were easier dissection of membranes owing to the lack of bleeding during surgery simplifying surgical technique with fewer exchanges of instruments and clear view. greater intraoperative bleeding hinders the surgical field, hence chances of inducing intraoperative iatrogenic retinal tears are also higher. rizzo et al, reported no iatrogenic retinal tear in avastin group and 36.3% in non-avastin group. 10 faisal et al reported retinal tears in 7.1% in avastin group as compared to 18.6% in non-avastin group. 21 el-batarny reported increased frequency of iatrogenic retinal tears in group given avastin as compared to non-avastin group. 23 although it is presumed that trd increases in patients receiving avastin, it can be reduced by giving ivb 2 – 7 days before surgery. in the current study, 27 (90%) patients in group a had improvement in best corrected visual acuity in comparison to 12 (40%) patients in group b at six months post operatively.this is comparable to study by haseeb et al in which avastin group had 70% patients who showed improved va. 20 el-batarny reported improved visual acuityin 87% patients with ivb group. 23 likewise, ahmadieh had better best corrected visual acuity in avastin group in contrast to group with no preoperative ivb. 14 iqbal et al reported improvement of vision in 82% patients, stablein 10%, and worse in 8% in avastin group. 25 primary retinal reattachment rate significantly differed between two groups as well (90% in group a versus 60% in group b). in our study, postoperative rubeosisiridis or hyphaema was seen in very few (3.33%) patients in group a compared to 23.3% patients in group b. elbatarny also stated a similar results. 23 ischemic retina leads to agreater release of vegf in vitreous cavity, pars plana vitrectomy with or without intravitreal bevacizumab in diabetic eye disease pak j ophthalmol. 2020, vol. 36 (4): 340-347 346 whereas intravitreal bevacizumab leads to suppression of vegf expression causing pharmacological involution of retinal and iris neovascularisation. conclusion intravitreal bevacizumab prior to ppv for advanced diabetic eye disease is a useful adjunct in offering success both anatomically and visually. this reduces intraoperative bleeding, resulting in less need for hemostatic techniques with fewer intraoperative complications and lesser risk of post operative vitreous hemorrhage and rubeosis iridis. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. american diabetes association (ada), position statement; standards of medical care in diabetes. diabetes care, 2013: 36 (suppl1): s11-66. 2. mahar ps, awan mz, manzar n, memon ms. prevalence of type-ii diabetes mellitus and diabetic retinopathy: the gaddap study. j coll physicians surg pak. 2010; 20 (8): 528-532. 3. cheung n, mitchell p, wong ty. diabetic retinopathy. lancet, 2010; 376: 124-136. 4. shaikh a, shaikh f, shaikh za, ahmed j. prevalence of diabetic retinopathy and influence factors among newly diagnosed diabetics in rural 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prospective case series. clin exp ophthalmol. 2008; 36: 449-454. 20. haseeb u, rehman au, haseeb m. visual outcomes of pars plana vitrectomy alone or with intra vitreal bevacizumab j coll physicians surg pak, 2019; 29 (8): 728-731. 21. faisal sm, tahir ma, cheema am, anjum mi. pars plana vitrectomy in vitreous hemorrhage with or without intravitreal bevacizumab: a comparative overview. pak j med sci. 2018; 34 (1): 221-225. https://www.ncbi.nlm.nih.gov/pubmed/?term=baz%20%26%23x000d6%3b%5bauthor%5d&cauthor=true&cauthor_uid=28058164 https://www.ncbi.nlm.nih.gov/pubmed/?term=%26%23x000c7%3bi%26%23x000e7%3bek%20u%5bauthor%5d&cauthor=true&cauthor_uid=28058164 https://www.ncbi.nlm.nih.gov/pubmed/?term=%26%23x000c7%3belik%20b%5bauthor%5d&cauthor=true&cauthor_uid=28058164 http://www.njcponline.com/searchresult.asp?search=&author=k+hassan&journal=y&but_search=search&entries=10&pg=1&s=0 http://www.njcponline.com/searchresult.asp?search=&author=a+ijasan&journal=y&but_search=search&entries=10&pg=1&s=0 https://pubmed.ncbi.nlm.nih.gov/?term=vento+a&cauthor_id=18286296 https://pubmed.ncbi.nlm.nih.gov/?term=miniaci+s&cauthor_id=18286296 https://pubmed.ncbi.nlm.nih.gov/?term=williams+g&cauthor_id=18286296 https://pubmed.ncbi.nlm.nih.gov/?term=mei+y&cauthor_id=27034822 https://pubmed.ncbi.nlm.nih.gov/?term=lei+h&cauthor_id=27034822 https://pubmed.ncbi.nlm.nih.gov/?term=liu+j&cauthor_id=27034822 https://pubmed.ncbi.nlm.nih.gov/?term=monshizadeh+r&cauthor_id=19699531 https://pubmed.ncbi.nlm.nih.gov/?term=romano+mr&cauthor_id=23791371 https://pubmed.ncbi.nlm.nih.gov/?term=falavarjani+kg&cauthor_id=23791371 https://pubmed.ncbi.nlm.nih.gov/?term=ahmadieh+h&cauthor_id=23791371 https://pubmed.ncbi.nlm.nih.gov/?term=bergstrom+c&cauthor_id=19584650 https://pubmed.ncbi.nlm.nih.gov/?term=srivastava+sk&cauthor_id=19584650 https://pubmed.ncbi.nlm.nih.gov/?term=yan+j&cauthor_id=19584650 https://pubmed.ncbi.nlm.nih.gov/?term=buttery+r&cauthor_id=18942219 https://pubmed.ncbi.nlm.nih.gov/?term=chiu+d&cauthor_id=18942219 https://pubmed.ncbi.nlm.nih.gov/?term=clark+b&cauthor_id=18942219 ambreen gul, et al 347 pak j ophthalmol. 2020, vol. 36 (4): 340-347 22. avery rl, pearlman j, pieramici dj, rabena md, castellarin aa, nasir ma, et al. intravitreal bevacizumab (avastin) in the treatment of proliferative diabetic retinopathy. ophthalmology, 2006; 113 (10): 1695. 23. el-batarny am. intravitreal bevacizumab as an adjunctive therapy before diabetic vitrectomy. clin ophthalmol. 2008; 2 (4): 709-716. 24. cooper b, shah gk, grand mg, bakal j, sharma s. visual outcomes and complications after multiple vitrectomies for diabetic vitreous haemorrhage. retina, 2004; 24: 19-22. 25. iqbal a, orakzai ok, khan mt, sanaullah j. visual outcome after pars plana vitrectomy in diabetic vitreous haemorrhage. j pak med inst. 2016; 30: 23-9. authors’ designation and contribution ambreen gul; senior registrar: preparing the manuscript, data collection, writing the article, protocols and designs to be followed in the study. sairam ahmed; resident: data analysis, manuscript writing and review. fuad ahmad khan; associate professor: data analysis, manuscript writing and review. ali raza; professor and head of department: data analysis, manuscript writing and review. .…  …. https://pubmed.ncbi.nlm.nih.gov/?term=rabena+md&cauthor_id=17011951 https://pubmed.ncbi.nlm.nih.gov/?term=castellarin+aa&cauthor_id=17011951 https://pubmed.ncbi.nlm.nih.gov/?term=nasir+ma&cauthor_id=17011951 https://pubmed.ncbi.nlm.nih.gov/?term=bakal+j&cauthor_id=15076939 https://pubmed.ncbi.nlm.nih.gov/?term=sharma+s&cauthor_id=15076939 151 pak j ophthalmol. 2022, vol. 38 (2): 151-156 original article the association between attendance and academic performance of mbbs students of a private medical college in the subject of ophthalmology sidrah riaz 1 , mariam sheikh 2 , muhammad tariq khan 3 , ambreen mumtaz 4 , muhammad saghir 5 1-5 akhtar saeed medical and dental college, lahore abstract purpose: to study the association between attendance and academic performance of mbbs students belonging to a private medical college in the subject of ophthalmology. study design: cross sectional observational study. place and duration of study: akhter saeed medical and dental college of lahore, from january 2021 to october 2021. methods: a total of 152 students were included in study. the attendance record and test records of students in the subject of ophthalmology was retrieved. both class test and ward tests included short essay questions and multiple choice questions. relationship between the attendance and test results was compared by using pearson correlation. results: among 152 students, 62.5%were females and 37.5% were males. the mean attendance in 3 rd year was 55.73 ± 20.44 and in 4 th year was 77.25 ± 19.03. during 3 rd year mbbs, 80.92% students had attendance below 75% and in 4 th year 32.24% had below 75%. passed students had mean attendance of 56.82% in 3 rd year and 78.74% in 4 th year. failed students had mean attendance of 49.27% in 3 rd year and 40% in 4 th year. regarding ward test, students who passed their batch test in first attempt had mean attendance of 60.92% and 83.54% in 3 rd year and 4 th year respectively. positive relationship between pass candidates in send up exams and ward tests was demonstrated by pearson correlation, showing significant results at 0.01. conclusion: the academic performance of students is directly related with class attendance. the students with better class performance had better percentage of attendance and vice versa. key word: medical students, attendance, academic performance. how to cite this article: riaz s, sheikh m, khan mt, mumtaz a, saghir m. the association between attendance and academic performance of mbbs students of a private medical college in the subject of ophthalmology. pak j ophthalmol. 2022, 38 (2): 151-156. doi: 10.36351/pjo.v38i2.1369 correspondence: sidrah riaz akhtar saeed medical and dental college, lahore email: sidrah893@yahoo.com received: january23, 2022 accepted: march 16, 2022 introduction professional education especially medical education is demanding and getting admission in institutes of professional education is tough because of competition. 1 it is also associated with economical concerns related to higher education. 2 the admission in medical college and successful completion of mbbs is not an easy job. to ensure producing a professionally competent and a good quality doctor, examining university has to set certain parameters to ensure professional competency standards. attendance criteria is one of them and for medical students, a minimum of 75% attendance is mandatory to appear in exit exams. over the decades, it has been observed that students with better grades are more regular in their sidrah riaz, et al pak j ophthalmol. 2022, vol. 38 (2): 151-156 152 theory and clinical classes and vice versa. 3 it is also documented that class attendance is a significant determinant of academic performance. 4-6 from technical point of view, a missed day is missed opportunity for a student to learn something new. there are number of factors, which determine students’ attendance. studies have shown that not only at university level but a primary school level, kids with absenteeism in school is associated with poor academic achievement and deficient general knowledge later in life. 7 in private medical institutions of pakistan, attendance of the students has always been the issue of great concern. local data regarding this issue is scarce. this study was designed to see address this issue providing a preliminary data which can help the policy makers in further refining the quality standards. methods total 152 students, who were promoted to 4 th year mbbs class after passing 3 rd professional university exam held in november 2020, were included in study. the students belonged to akhtar saeed medical and dental college (amdc), lahore. the attendance record of the students in 3 rd year in the subject of ophthalmology was also noted from previous records (2020) and 4 th year attendance of lectures and clinical classes was noted over the year (february to october 2021). the attendance of students was either marked by the teacher himself/herself or collected in the form of individually signed paper circulated in class during lecture and counter checked at the end of the class. this was done by getting the signatures of each student in front of his or her mentioned roll number. the attendance record was sent daily to medical education department of the college for computerized records. there were two lectures of ophthalmology of 40 minutes duration per week and a clinical batch class consisting of 20 to 25 students, 5 days a week for 3 hours. the academic performance of the students was noted in the form of class tests and ward test results. there were three (3) class tests held every 3 months which included all chapters at the end of 03 months. the class was divided in 08 clinical batches, which were rotated among different clinical subjects (ophthalmology, ent, community medicine, pathology, gynae obs, surgery and medicine) over the academic year. the ward test was taken at the end of each clinical ward rotation of ophthalmology. both class test and ward test included short essay question and multiple choice question papers and pass marks were 50%. the students who were not able to pass their ward test in first attempt or absent on the day of test were given a second chance to clear their test, as it was mandatory to appear in send up examination. no second chance was provided to students who failed the send up examination or were absent. they were not eligible to appear in the fourth professional examination. seventy five percent attendance was mandatory criteria set by the university to appear in exams at the end of session. the parents and students were also given three monthly reminders in the form of mobile messages and letters, if their attendance was less than 75%. results among the 152 students included in the study, 93 (62.5%) were females and 57 (37.5%) were males. the mean attendance in 3 rd year was 55.73 ± 20.44, 63.05% for females and 43.55% for males. mean attendance for 4 th year students was 77.25 ± 19.03, 83.11% for females and 67.48% for males (table 1). during 3 rd year mbbs class 123 (80.92%) students had attendance below 75% and 29 (19.08%) above it (graph 1). in 4 th year mbbs 49 (32.24%) students had attendance below 75% and 103 (67.76%) had above it (graph 2). the students who passed their send up examination had mean attendance of 56.82% in 3 rd year and 78.74% in 4 th year. students who failed in send up examination had mean attendance of 49.27% in 3 rd year and 40% in 4 th year. regarding ward test, students who passed their batch test in first attempt had mean attendance of 60.92% and 83.54% in 3 rd year and 4 th year respectively. failed students who re appeared in second attempt had attendance of 48.08% in 3 rd year and 68.83% in 4 th year (table 2). in the first class-test, students who appeared and declared successful had attendance of 61.59% in 3 rd year and 83.97% in 4 th year. further details are found in table 3. the positive relationship between pass candidates in send up exams and ward tests was demonstrated by pearson correlation, showing significant test at 0.01 level (2 tailed) shown in table 4. the association between attendance and academic performance of mbbs students of a private medical college 153 pak j ophthalmol. 2022, vol. 38 (2): 151-156 table 1: send up results and mean attendance of students. attendance mbbs class mean attendance female male send up exam result pass fail absent mean attendance 3 rd year 55.73% 63.05% 43.55% 56.82% 40.00% 16.07% 4 th year 77.25% 83.11% 67.48% 78.74% 49.27% 39.03% table 2: send up & ward results and mean attendance of students. ward tests attempt/absent send up results 3 rd year mbbs mean attendance 4 th year mbbs mean attendance female male female male female male ward test passed in first attempt pass 71 31 66.75% 47.35% 86.64% 76.79% fail 0 1 0.00% 67.86% 0.00% 73.17% absent 0 0 0.00% 0.00% 0.00% 0.00% ward test passed in second attempt pass 20 19 54.64% 42.67% 76.71% 60.59% fail 0 1 0.00% 35.71% 0.00% 58.54% absent 1 0 32.14% 0.00% 78.05% 0.00% absent in ward test pass 2 2 33.93% 30.36% 46.34% 53.66% fail 1 2 57.14% 19.65% 39.02% 37.81% absent 0 1 0.00% 0.00% 0.00% 0.00% 95 (62.5%) 57 (37.5%) 152 (100%) table 3: 1 st , 2 nd & 3 rd class test results and mean attendance of students. mbbs academic year first class test results second class test results third class test results appeared in test and pass appeared in test and failed absent appeared in test and pass appeared in test and failed absent appeared in test and pass appeared in test and failed absent third year mbbs attendance (mean) 61.59% 57.38% 32.59% 66.65% 51.52% 46.04% 58.85% 46.31% 26.19% forth year mbbs attendance (mean) 83.97% 79.85% 49.29% 86.94% 78.05% 64.00% 82.17% 61.71% 37.40% table 4: showing correlation between attendance and academic performance. pearson’s correlations 3 rd year attendance 4 th year attendance send-up results ward-test results 3 rd -year attendance pearson correlation 1 .581 ** -.268 ** -.419 ** sig. (2-tailed) .000 .001 .000 n 152 152 152 152 4 thyearattandance pearson correlation .581 ** 1 -.354 ** -.566 ** sig. (2-tailed) .000 .000 .000 n 152 152 152 152 send up exam pearson correlation -.268 ** -.354 ** 1 .379 ** sig. (2-tailed) .001 .000 .000 n 152 152 152 152 ward test pearson correlation -.419 ** -.566 ** .379 ** 1 sig. (2-tailed) .000 .000 .000 n 152 152 152 152 **.correlation is significant at the 0.01 level (2-tailed). sidrah riaz, et al pak j ophthalmol. 2022, vol. 38 (2): 151-156 154 graph 1: detail of %age attendance of student in 3 rd year mbbs. graph 2: detail of % age attendance of student in 4 th year mbbs. discussion this particular study showed that students are more likely to pass their examinations if they attend school regularly. existing data has revealed that class attendance is a useful, effective and valuable indicator of successful attainment of any academic degree. 8-11 the association between attendance and academic performance of mbbs students of a private medical college 155 pak j ophthalmol. 2022, vol. 38 (2): 151-156 the reasons why regulatory bodies are interested in attendance of medical students, are professional development and performance, as attendance is considered as its integral part. 12,13 another logic is that attendance is the only variable that can be monitored, tracked and regulated to achieve good academic performance. a study from denmark with data of nearly1000 undergraduate students strongly correlated attendance with academic performance. 8 on the contrary, some studies have provided clue that good academic performance was not related with optimal roll call. 14 other studies have shown that absenteeism affected students in an adverse way. in addition to falling behind in academics, students who were not in school on a regular basis were more likely to get into trouble with the law and cause problems in their communities. 15 studies also indicate that chronic absenteeism was also linked with less academic achievement, social withdrawal and isolation among students. 16,17 this particular study showed that female medical students were more regular in attending the classes than their male counterparts. there mean attendance was 63.05% in 3 rd year and 83.11% in 4 th year mbbs class whereas boys had 43.55% and 67.48% in 3 rd and 4 th year respectively. it may be related to more female students in class. there were 93 females in the class of 152. boys also had more outdoor interests like sports and social activities as compared to girls. 18,19 overall, girls showed more serious behaviour toward attendance rules and remained abide by the regulations more proficiently. the students showed 55.73% mean attendance in the subject of ophthalmology during 3 rd year mbbs class, that was less than 75%, as compared to 77.25% mean attendance in 4 th year as it was examination subject in 4 th year and not in 3 rd year. therefore students were less serious about its attendance in third year. in 3 rd year, 9 (5.92%) students had attendance below 10% and 17 (1118%) had below 30%. in 4 th year the students of the same class showed only 2 (1.32%) students below 10% and 5 (3.29%) below 30%. another study from a private medical college showed similar results. 20 there are different factors, which cause absenteeism among students. 21 when enquired about its reason, poor time management, working against nature’s clock and being awake till late night leading to difficulty in early rising were told by the students in general discussion. as attendance is considered an important predictor of pedagogical success, so a designated cell, under department of medical education, collects students’ attendance of lectures and clinical classes, updates students and their parents regularly and maintains a smooth record. different institutes have adopted different systems to mark attendance of students but our college has approved manual and biometric methods. the timely reminder about students’ attendance, academic results, grades and missed assignments at regular intervals to their parents or guardians has reduced course failures and motivates pupils too to increase class attendance. 22 it is emphasized that lectures should be interesting and ward classes should be more practical to maintain interest of students. limitations of the study are that only a single subject was considered in this study. it was a private college and public sector data was not included in the study. basic sciences were also not taken into account. conclusion the academic performance of students when assessed over the year was directly related with class attendance. the students with better class performance had better percentage of attendance and vice versa. ethical approval the study was approved by the institutional review board/ethical review board (m-21/74/ophthalmology). conflict of interest authors declared no conflict of interest. references 1. fatimah n, hasnain nadir m, kamran m, shakoor a, mansoor khosa m, raza wagha m, et al. depression among students of a professional degree: case of undergraduate medical and engineering students. int j ment health psychiatry, 2016; 2: 2. doi:10.4172/2471-4372.100012. 2. stanca l. the effects of attendance on academic performance: panel data evidence for introductory microeconomics. j econ educ. 2006; 37 (3): 251-266. sidrah riaz, et al pak j ophthalmol. 2022, vol. 38 (2): 151-156 156 3. fadelelmoula t. the impact of class attendance on student performance. int res j med sci. 2018; 6 (2): 47-49. doi: 10.30918/irjmms.62.18.021. 4. bamuhair ss, al farhan ai, althubaiti a, ur rahman s, al-kadri hm. class attendance and cardiology examination performance: a study in problem-based medical curriculum. int j gen med. 2016; 9: 1-5. 5. westerman jw, perez-batres la, coffey bs, pouder rw. the relationship between undergraduate attendance and performance revisited: alignment of student and instructor goals. decision sci j innov educ. 2011; 9 (1): 49–67. https://doi.org/10.1111/j.15404609.2010. 00294. 6. crede´ m, roch sg, kieszczynka um. class attendance in college a meta-analytic review of the relationship of class attendance with grades and student characteristics. rev educ res. 2010; 80 (2): 272–295. https://doi.org/10.3102/0034654310362998 7. romero m, lee y. a national portrait of chronic absenteeism in the early grades. new york, ny: the national center for children in poverty. columbia academic commons, 2007. https://doi.org/10.7916/d89c7650. 8. kassarnig v, bjerre-nielsen a, mones e, lehmann s, lassen dd. class attendance, peer similarity, and academic performance in a large field study. plos one, 2017; 12 (11): e0187078. https://doi.org/10.1371/journal.pone.0187078. 9. romer d. do students go to class? should they? j econ perspectives. 1993; 7 (3): 167–174. https://doi.org/10.1257/jep.7.3.167. 10. deane rp, murphy dj. student attendance and academic performance in undergraduate obstetrics/ gynaecology clinical rotations. j am med assoc. 2013; 310 (21): 2282-2288. doi:10.1001/jama.2013.282228. 11. kauffman ca, derazin m, asmar a, kibble jd. relationship between classroom attendance and examination performance in a second year medical pathophysiology class. adv physiol educ. 2018; 42 (4): 593-598. doi: 10.1152/advan.00123.2018. 12. hamdy h, prasad k, anderson mb, scherpbier a, williams r, zwierstra r, et al. beme systematic review: predictive values of measurements obtained in medical schools and future performance in medical practice. medteach. 2006; 28 (2): 103-116. 13. smith lb. medical school and on-line learning: does optional attendance create absentee doctors? med educ. 2012; 46 (2): 137-138. 14. eisen d, schupp c, isserof r, ibrahimi o, ledo l, armstrong a. does class attendance matter? results from a second-year medical school dermatology cohort study. int j dermatol. 2015; 54: 807–816. 15. bauer l, liu p, schanzenbach dw, shambaugh j. reducing chronic absenteeism under the every student succeeds act. brookings institution, 2018 apr. 16. gottfried, m. chronic absenteeism and its effects on student’s academic and socioemotional outcomes. j educ for stud placed risk, 2014; 19: 53-75. doi:10.1080/10824669/2014.952696. 17. gottfried ma. chronic absenteeism in the classroom context: effects on achievement. urban education, 2019; 54 (1): 3-4. 18. cortright rn, lujan hl, cox jh, dicarlo se. does sex (female versus male) influence the impact of class attendance on examination performance? adv physiol educ. 2011; 35 (4): 416-420. 19. horton dm, wiederman sd, saint da. assessment outcome is weakly correlated with lecture attendance: influence of learning style and use of alternative materials. adv physiol educ. 2012; 36 (2): 108-115. 20. khan yl, lodhi sk, bhatti s, ali w. does absenteeism affect academic performance among undergraduate medical students? evidence from "rashid latif medical college (rlmc).". adv med educ pract. 2019; 10: 999-1008. doi: 10.2147/amep.s226255. 21. cohall dh, skeete d. the impact of an attendance policy on the academic performance of first year medical students taking the fundamental of disease and treatment course. caribbean teaching scholar, 2012; 2 (2): 115-123. 22. bergman, p, chan ew. leveraging parents: the impact of high-frequency information on student achievement. teachers college, columbia university, 2017. retrieved from http://www.columbia. edu/~psb2101/parentrct. authors’ designation and contribution sidrah riaz; associate professor: design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing. mariam sheikh; associate professor: data acquisition, data analysis, statistical analysis, manuscript editing, manuscript review. muhammad tariq khan; professor: concepts, manuscript editing, manuscript review. ambreen mumtaz; professor: data acquisition, manuscript editing, manuscript review. muhammad saghir; registrar: data acquisition, manuscript editing, manuscript review. .…  …. https://doi.org/10.1111/j.1540-4609.2010.%2000294 https://doi.org/10.1111/j.1540-4609.2010.%2000294 https://doi.org/10.3102/0034654310362998 https://doi.org/10.7916/d89c7650 pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 59 editorial recent advances in medical education exciting and needed advances in medical education are occurring around the world. i think the three main paradigm shifts are competency – based training, a team approach to medical care and increased emphasis on the crucial “soft skills” of professionalism and effective communication. competency-based training is a shift from the old paradigm of showing that training programs are capable of teaching to showing that trainees can actually do what is expected of them. not just the ability to do, but to do it well. in ophthalmology this has necessitated development of new valid and reliable competency assessment tools.1 importantly, these tools provide a more objective assessment of competence and serve as teaching tools as well. most countries do not use assessment tools to determine resident competence in surgical procedures and those that do still rely on minimum numbers of cases as a measure of competence. this system must be replaced by valid and reliable measures of competence rather than simply by subjective impression and the number of cases performed. many of these assessment tools are available in multiple languages on the international council of ophthalmology’s website (www.icoph.org). to facilitate competency attainment, the united states has recently instituted the “milestones project” designed to closely follow a resident as they achieve competency milestones throughout their training.2 objective assessments are used when possible to gauge progress and prompt remediation in a more timely fashion. in addition, internationally validated competency – based curricula have been produced to guide ophthalmic education.3 these curricula are meant to be adapted for local use based on the needs of the population. the second paradigm shift is the team approach to medical care. in a lancet commissioned paper, frenk and associates note “glaring gaps and inequities in health persist both within and between countries”4 one of their conclusions is that the team approach to medical care is essential and team training will facilitate this. they advocate “promotion of interprofessional education that breaks down professional silos while enhancing collaborative and nonhierarchical relationships in effective teams.” thus, physician led teams with appropriate delegation of duties are essential to effectively provide efficient medical care. clearly this applies to ophthalmology. we know from recent work by resnikoff and associates that there is a widening gap between numbers of ophthalmologists and the future need5. they conclude that we must “aggressively train eye care teams to alleviate the current and anticipated deficit of ophthalmologists worldwide.” there is also data to show that utilization of ophthalmic allied personnel allow ophthalmologists to be more efficient.6 nevertheless, some countries do not utilize or even recognize this important eye care cadre. the world health organization (who) in their recent universal eye health document include objective 2.3 as the need to “develop and maintain a sustainable workforce for the provision of comprehensive eye care services as part of the broader human resources for health”.7 the international council of ophthalmology (ico) and the international joint commission on allied health personnel in ophthalmology (ijcahpo) have recognized this need and are working on both an advocacy position paper and a “starter kit” for creation of new ophthalmic allied personnel training programs. in addition allied ophthalmic personnel and refractionist competencybased curricula have been produced to facilitate training of team members. more effective use of the ophthalmologist led team must occur if we are to meet the world’s eye care needs. finally, increased emphasis has been placed on the multiple characteristics of the “good” physician. in the late 1990s the accreditation council for graduate medical education (acgme) in the united states and the royal college of physicians in canada proclaimed the need to teach and assess other relevant physician competencies such as professionalism and communication skills. these “soft – skills” were felt to be essential competencies of the effective physician. this has led to worldwide interest in developing teaching and assessing methods in these previously relatively neglected areas. in the past these competencies were taught primarily by role modeling. however, role modeling occurs whether the student is observing good or bad behavior and it may not be http://www.icoph.org karl golnik 60 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology clear to the learner when a particular behavior is desirable. in ophthalmology, this has led to other modes of teaching including discussion of standardized written vignettes8 and online ethics modules. assessment of these competencies traditionally has been with senior physicians who are likely to observe the resident on their best behavior. multisource (360 degree) tools are needed to provide residents feedback regarding professionalism and communication skills. questions on a multi-source assessment tool are tailored to the assessor. thus a nurse or assistant would not rate a physician’s medical knowledge but rather their professionalism and communication skills. probyn and associates used such a tool and also asked for resident selfassessment9. they found self – assessment scores were significantly lower than multisource scores. interestingly, but not surprisingly, a teaching physician was more likely to rate the resident highly than a secretary or program assistant. this emphasizes the importance of obtaining information about professionalism and communication skills from someone other than the resident’s supervisor. these recent advances in medical education have let to increasing emphasis on the physicians’ teaching effectiveness. yet, ophthalmic educators are rarely taught how to teach. ico is emphasizing this educational disconnect through a variety of initiatives aimed at improving ophthalmic education and thus patient care. the ico teaching the teachers program includes regional courses for residency program directors; world ophthalmology educational colloquium (woec) at the world ophthalmology congress; conferences for ophthalmic educators occurring during supra-national ophthalmic meetings; and ophthalmic surgical competency assessment rubrics (oscars). the ico’s center for ophthalmic educators website (https://educators.icoph.org.) provides myriad resources for ophthalmic educators to improve their educational effectiveness. references 1. golnik kc. assessment principles and tools. meajo. 2014; 21: 109-13. 2. lee ag, arnold ac. the acgme milestone project in ophthalmology. surv ophthalmol. 2013; 58: 3590369. 3. lee ag, chen y. structured curricula and curriculum development in ophthalmology residency. meajo. 2014; 21: 103-8. 4. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet. 2010; 376: 1923-58. 5. resnikoff s, felch w, gauthier tm, spivey b. the number of ophthalmologists in practice and training worldwide: a growing gap despite more than 200,000 practitioners. br j ophthalmol. 2012; 96: 783-8. 6. woodworth ke, donshik pc, ehlers wh, pucel dj, anderson ld, thompson na. a comparative study of the impact of certified and noncertified ophthalmic medical personnel on practice quality and productivity. eye contact lens. 2008; 34: 28034. 7. available at: http://www.who.int/blindness/ zerodraftactionplan2014-19.pdf. accessed april 29, 2015. 8. khan r, lee a, golnik k, paranilam j. residency education professionalism vignettes. ophthalmology 2013; 120: 874. 9. probyn l, lang cl, tomlinson g, bandiera g. multisource feedback and self-assessment of the communicator, collaborator, and professional canmeds roles for diagnostic radiology residents. can assoc radiol j. 2014; 65: 379-84. karl golnik, md, med http://www.who.int/blindness/%20zerodraftactionplan2014-19.pdf http://www.who.int/blindness/%20zerodraftactionplan2014-19.pdf http://www.who.int/blindness/%20zerodraftactionplan2014-19.pdf 459 pak j ophthalmol. 2020, vol. 36 (4): 459-460 letter to editor dear sir i read the article published in your journal from authors mahtab mengal et al 1 on the subject of trabeculectomy in congenital glaucoma. i have a keen interest in the subject they worked on and i appreciate authors’ hard work. the strength of the study was their very strict success criteria, which added a lot to my knowledge. however, there are few points i would like to get views from the authors’ for my better understanding. 1. in material and methods, they stated the inclusion criteria and definition of congenital glaucoma as one entity. did all or few or one of the features contributed to the diagnosis, because as much we know gender is never in definition of congenital glaucoma. kindly comment. 2. for sample size calculation why absolute precision of 0.10 was taken? similarly, why anticipated population proportion of 92.3% was taken because the references they mentioned have no such figures. moreover, reference no. 25 of their citation is not study about trabeculectomy so how they included it in the sample size calculation. 2 how will they respond to this query? 3. the authors have made some mistake in references, total references are 25 in their article but the attribution is of 27. how will they explain this? i hope, you will get me these answers for updating my knowledge and better understanding. how to cite this article: mahsood yj. letter to editor. pak j ophthalmol. 2020, 36 (4): 459-460. doi: https://doi.org/10.36351/pjo.v36i4.1103 correspondence to: yousaf jamal mahsood assistant professor glaucoma department of ophthalmology khyber girls medical college, peshawar email: yousaf82@hotmail.com references 1. mengal m, khan ma, khan a, ahmed m, chaudhry rk, khan nq. outcomes of trabeculectomy in congenital glaucoma; experience in helpers eye hospital quetta. pak j ophthalmol. 2020; 36 (3): 253-257. 2. tamcelik n, özkiris a. long-term results of viscotrabeculotomy in congenital glaucoma: comparison to classical trabeculotomy. br j ophthalmol. 2008; 92 (1): 36-39. reply we are glad to have received your response and appreciation, and i am thankful for the interest that you have shown in this topic. we will try to answer your questions, hopefully to your satisfaction, in the same order as you have put them before us. 1. as for the first question, since our study was designed to recruit only patients with congenital glaucoma as participants, the operational definition of congenital glaucoma became the inclusion criteria as well. the reason for clearly stating that gender would not be a deciding factor within the inclusion criteria was to avoid any confusion among the research team during the recruitment process. 2. since cases of congenital glaucoma are not too frequent, and not all parents agree to have their children undergo trabeculectomy, therefore we decided that it would be adequate to have results that were precise within 10 percentage points 95% of the time. this was the reason for keeping the absolute precision value at 0.10 while the confidence interval remained 95%. the anticipated population proportion was chosen to be 92.3% based on available regional data, the referencing in the material and methods section however was failed to be updated along with the rest of the article and this has resulted in the wrong citation for the given value. the actual article for this number can be found in the reference number 14 of the published article, which has been correctly cited for the figure of 92.3% in the introduction section of the published article. we are grateful to you for having raised this issue, and we will mailto:yousaf82@hotmail.com letter to editor pak j ophthalmol. 2020, vol. 36 (4): 459-460 460 update the citation numbers for the material and methods section. 3. for the last point, we would again like to express our gratitude at having brought up this point, and as mentioned, we will update the citation numbers for the material and methods section accordingly. we hope that your queries have been answered to your satisfaction, and that all the points that were raised have been clarified adequately. the points you raised have been most pertinent and have helped us to rectify an oversight in our article. mahtab mengal bolan university of medical and health sciences (bumhs), quetta email: mengalmahtab@yahoo.com .…  …. pak j ophthalmol. 2021, vol. 37 (1): 57-61 57 original article comparative study of intraocular pressure measurements with airpuff, icare and goldmann applanation tonometers umair tariq mirza 1 , m. usman sadiq 2 , m. irfan sadiq 3 , ali raza 4 , waseem ahmed khan 5 1-4 mohi-ud-din islamic medical college, mirpur azad kashmir 5 mohtarma benazir bhutto shaheed medical college abstract purpose: to compare the difference in intraocular pressure (iop) measurements by airpuff, icare and goldmann applanation tonometers (gat). study design: comparative analytical study. place and duration of study: department of ophthalmology, mohi-ud-din teaching hospital, mirpur azad kashmir, from june 2020 to august 2020. methods: twenty-five patients (50 eyes) were included in this study. iop was measured in each eye firstly by airpuff tonometery, then by icare tonometery and lastly by goldmann applanation tonometer. three consecutive readings were taken in each eye. if there was a difference of 2 mm hg or more among the readings, measurement was repeated. once we got three readings, their average was taken and analyzed. comparison of iop readings between these tonometers was done. results: mean iop was 15.84 ± 2.736 mm hg with airpuff tonometer, 14.48 ± 2.435 mm hg with icare tonopen and 14.74 ± 2.489 mm hg with goldman applanation tonometer. the difference between the mean airpuff and goldman applanation tonometer readings was 1.10 mm hg which was not statistically significant (p-value = 0.083). the difference between the mean goldman applanation tonometer and icare tonopen readings was 0.26 mm hg which is also not statistically significant (p-value = 0.867). but, the difference between the mean icare tonopen and airpuff tonometer readings was -1.36 mm hg which was statistically significant (p-value = 0.02). conclusion: it is concluded that iop readings taken by icare tonopen and airpuff tonometer are comparable to those taken by goldman applanation tonometer and icare tonopen underestimates the iop when compared with airpuff tonometer. key words: airpuff tonometer, glaucoma, goldmann applanation tonometer, icare tonometer, intraocular pressure. how to cite this article: mirza ut, sadiq mu, sadiq mi, raza a, khan wa. comparative study of intraocular pressure measurements with airpuff, icare and goldmann applanation tonometers. pak j ophthalmol. 2021, 37 (1): 57-61. doi: https://doi.org/10.36351/pjo.v37i1.1139 correspondence: umair tariq mirza mohi-ud-din islamic medical college mirpur azad kashmir email: utmirza@gmail.com received, september 21, 2020 accepted, november 20, 2020 introduction intraocular pressure (iop) is the aqueous pressure determined by the equilibrium between the amount of aqueous humor produced, by the ciliary body, and drained through the trabecular meshwork. 1 tonometry is the method by which iop is measured and its umair tariq mirza, et al 58 pak j ophthalmol. 2021, vol. 37 (1): 57-61 accurate measurement is necessary in evaluation of patients at risk of glaucoma. 2 an accurate iop measurement is mandatory component of ophthalmological examination in clinical practice. the range of iop in the general population is about 11–21 mm hg. 3 in some cases, glaucomatous changes are noticed even with iop values less than 21 mm hg i.e. normal tension glaucoma (ntg). 4 while in other cases with iop more than 21 mm hg, no glaucomatous changes are detected i.e. ocular hypertension. 5 there are some factors, which influence iop value, one of most important such factor is central corneal thickness (cct). 6 glaucoma can be classified in different ways. 7 there are many methods to measure iop. in airpuff tonometery, the central corneal surface is flattened by a jet of air and time needed to do so is directly proportional to iop. as it is done without topical anesthesia and there is no contact made with the eye, it is ideal for community screening. for more accurate readings, at least three readings are taken to get an average. 8 icare tonopen is based on rebound tonometry in which there is a thin wire with attached 1.8 mm plastic ball, when probe decelerates upon corneal contact, the magnitude of deceleration is directly proportional to iop. 9 no anesthesia is needed in this procedure as well, thus it is also helpful for community screening. while in goldmann applanation tonometry (gat), imbert–fick principle is applied according to which the pressure (p) inside a dry thinwalled sphere is equal to the force (f) needed to flatten its surface divided by the area (a) which is flattened (i.e. p = f/a). this requires topical anesthesia and there is corneal contact made. for this reason disinfection between patients is needed thus it is not suitable for mass screening. 10 disposable tonometer prisms and caps can also be used to address the need of repeated disinfection between patients. the objective of this study was to compare the iop measurements by airpuff tonometer, icare tonometer and goldmann applanation tonometer (gat) and to evaluate the accuracy and reliability of the three iop measurement methods. methods this study was carried out at the department of ophthalmology, mohi-ud-din teaching hospital, mirpur azad kashmir. study period was from 1 st june 2020 to 31 st august 2020. ethical approval was obtained from the ethical committee of the hospital. informed written consent was obtained from all patients and detailed counseling was done about the procedure and results. twenty-five patients (50 eyes) were included in this study out of which 15 were males and 10 were females. mean age of the participants was 30.36 ± 5.376 years. the sample size was calculated using who sample size calculator on the basis of recent study. 11 all patients were enrolled from ophthalmology out-patient department (opd), mohiud-din teaching hospital, the affiliated hospital of mohi-ud-din islamic medical college, mirpur azad kashmir. any patient with central corneal opacity, corneal astigmatism, nystagmus, ocular surface disease i.e. dry eyes and conjunctivitis, ocular trauma was excluded from the study. history of contact lens use and refractive or intraocular surgery was also taken into consideration while setting exclusion criteria. all enrolled patients were examined using slit lamp. iop measurements were taken using airpuff – icare – gat sequence while in the sitting position. all tonometers were properly calibrated before taking readings and there was a gap of 10 minutes maintained between each iop measurement to reduce any after measurement fluctuation. tonometery was first performed in each patient with an airpuff tonometer (nidek rkt 7700, nidek corporation, japan). three consecutive readings were taken in each eye. if there was difference of 2 mm hg or more among the readings, measurement was repeated. once we got three readings, their average was taken and analyzed. after ten minutes, iop measurement was done with icare pro (icare finland oy, helsinki, finland). it has a single use/disposable probe, loaded into the instrument and was aligned 4-8 mm vertical to the central corneal surface. after six measurements were taken, the highest and lowest values were automatically discarded and the average iop was calculated from the remaining four values by the built-in software. at the end goldmann applanation tonometry was performed using gat at900, haag streit, koniz, switzerland installed on a slit–lamp biomicroscope. three iop readings were taken after instillation of a drop of 0.5% proparacaine hydrochloride (alcaine) and 0.25% fluorescein in each eye. the final iop was taken from the average value of these three measurements provided that there was no difference of 2 mm hg or more among these three values. all the measurements were taken by same comparative study of iop measurements with air puff, icare and goldman applanation tonometers pak j ophthalmol. 2021, vol. 37 (1): 57-61 59 ophthalmologist. measurements by airpuff tonometery, icare tonometer, goldmann applanation tonometer (gat) were analyzed and compared with each other. data was entered and analyzed using statistical package for social sciences (spss) version 21. mean and standard deviation were calculated for quantitative variable i.e. age. qualitative variable like gender and eye involved were calculated by frequency and percentage. one way anova and tukey test were used to see the difference in intraocular pressure readings in all measurement methods. p-value of < 0.05 was considered significant. results a total of 25 patients (50 eyes) were included in this study. mean age of the patients was 30.36 ± 5.376 years (21 – 39). there were 15 male patients and 10 female patients in the study (figure 1). out of 50 eyes, 25 were right eyes and 25 were left eyes. overall the iop measured by all instruments was 15.02 ± 2.607 mm of hg. the iop averages measured with all instruments are shown in table 1. mean iop reading with airpuff tonometer 15.84 ± 2.736 mm hg, with icare tonopen it 14.48 ± 2.435 mm hg and with goldman applanation tonometer was 14.74 ± 2.489 mm hg. table 1: average iop in each method with one way anova test (p value = 0.021). method n iop (mm of hg) p value airpuff tonometer 50 15.84 ± 2.736 (10 – 21) 0.021 goldmann applanation tonometer 50 14.74 ± 2.489 (10 – 20) icare tonopen 50 14.48 ± 2.435 (9 – 19) total 150 15.02 ± 2.607 (9 – 21) table 2: differences in intraocular pressure (iop) measurement methods using tukey test. variable mean difference (mm of hg) p value airpuff tonometer – goldman applanation tonometer 1.10 0.08 goldman applanation tonometer icare tonopen 0.26 0.87 icare tonopen – airpuff tonometer -1.36 0.02 overall, the difference was statistically significant with p value = 0.021. table 2 shows the differences between iop measurement methods. discussion goldmann applanation tonometry has been considered as a gold standard for iop measurement for a long time. 12,13 however, there are some instances in which iop measurement by gat is not possible or very difficult, for example in children and in bed ridden cases. 14 recent advancements have introduced many instruments and methods for measuring iop. 15 the reliability and accuracy of these instruments is comparable to gat. 16 airpuff tonometer and a recently introduced icare tonometer are some alternatives which can be used to measure iop in challenging cases. 17 in a recent study by demirci et al 16 , measurements by rebound tonometer, non-contact airpuff tonometer and goldmann applanation tonometer were compared in three groups of healthy subjects based upon the age i.e. group 1 (7 – 17 years), group 2 (18 – 40 years) and group 3 (41 – 75 years). central corneal thickness was also measured by ultrasonic pachymeter. according to their study, airpuff tonometer readings were significantly higher than both goldmann applanation tonometer and rebound tonometer measurements in all groups. there was no statistically significant difference between goldmann applanation tonometer and rebound tonometer measurements in group 1 (p = 0.248), group 2 (p = 0.63), and group 3 (p = 0.126). in our study, we did not group the subjects on the basis of age. rather we only included subjects aged between 21 and 39 years with healthy eyes. moreover, we did not perform pachymetry in our subjects. erdogan et al 18 conducted a study to compare intraocular pressure (iop) measurements by noncontact tonometer (nct), goldmann applanation tonometry with fluorescein (fgat), and gat without fluorescein (ngat). they also assessed the effect of central corneal thickness (cct) and keratometric values on iop. one hundred and eighty eight eyes of 94 healthy subjects were included in the study. their study showed that there were statistically insignificant differences in iop values by ngat and fgat (p > 0.05), and were correlated positively with nct readings. iop readings were independent of cct and keratometry readings. whereas in our study we did not umair tariq mirza, et al 60 pak j ophthalmol. 2021, vol. 37 (1): 57-61 compare the iop values obtained by gat done with and without fluorescein. our sample size was 25 as compared to 94 in their study. in another study, grewal et al 19 investigated the correlation among intraocular pressure (iop) values, in 50 eyes of 50 patients who already had undergone vitreoretinal surgery, obtained by icare rebound tonometer, tonopen, and gat. however, in our study, we only included subjects with healthy eyes with no previous history of trauma or surgery. mean iop values obtained by icare, tonopen, and goldmann were 15.9 ± 8.9, 16.9 ± 6.2, and 16.0 ± 7.3 mm hg, respectively. they concluded that, post vitreoretinal surgery, there is excellent agreement among iop values obtained by icare rebound tonometer, tonopen, and gat. they also concluded that icare overestimated iop when iop was ≥ 23 mm hg and underestimated the iop when iop was < 10 mm hg. we, in our study, did not assess the effect of low or high iop on icare tonopen values. in another study by takenaka et al 20 , comparison was done among the iop values measured by nct, gat, icare tonometer and the tonopen xl while wearing soft contact lenses (scls). iop was measured in twenty-six healthy subjects, wearing scls of -5.00 d, -0.50 d and +5.00 d, using nct, gat, icare, and the tono-pen xl. using gat, while wearing +5.00 d lenses, iop readings were higher than those of the naked eyes. whereas, when measured by icare, iop readings were almost same as measured over scls ranging from −5.00 d to +5.00 d and were also comparable with values obtained by gat in the naked eyes. thus, it was concluded that to measure iop through scls, nct and icare were best alternatives. tonopen xl was not included in our study. raina et al 21 in their study compared the iop values obtained by gat, tono-pen and noncontact tonometer in children. they had a sample size of 200 eyes of indian children (aged 8 – 18 years). iop was measured by using above-mentioned three tonometers. effect of cct on iop was also analyzed. the mean iop was 14.38 with nct, 15.63 with tonopen, and 12.44 mm hg with gat i.e. lowest with gat and highest with tonopen. these results contradict the results of our study as mean iop in our study was 15.84 ± 2.736 mm hg with airpuff tonometer, 14.48 ± 2.435 mm hg with icare tonopen and 14.74 ± 2.489 mm hg with gat i.e. lowest with icare tonopen and highest with airpuff nct. therefore, there was some ambiguity regarding the iop values obtained by different tonometers. limitation of our study was that we did not assess the effect of central corneal thickness (cct) on iop values obtained by different tonometers. the effect of very low and high iops on the measurements was also not investigated with three tonometers. conclusion iop readings taken by icare tonopen and airpuff tonometer are comparable to those taken by goldmann applanation tonometer and icare tonopen underestimates the iop when compared with airpuff tonometer. thus icare rebound tonometry and airpuff tonometry are reliable alternatives to goldmann applanation tonometery and both of these can be used to measure iop in challenging cases. ethical approval the study was approved by the institutional review board/ ethical review board. (1-2/20-mimc/erb/0018) conflict of interest authors declared no conflict of interest. references 1. kim yw, park kh. exogenous influences on intraocular pressure, 2019; 103 (9): 1209-1216. 2. de moraes cg, liebmann jm, levin la. detection and measurement of clinically meaningful visual field progression in clinical trials for glaucoma. progress in retinal and eye research, 2017; 56: 107-147. 3. wang yx, xu l, wei wb, jonas jb. intraocular pressure and its normal range adjusted for ocular and systemic parameters. the beijing eye study, 2011. 2018; 13 (5): e0196926. 4. trivli a, koliarakis i, terzidou c, goulielmos gn, siganos cs, spandidos da, et al. normal-tension glaucoma: pathogenesis and genetics. exp ther med. 2019; 17 (1): 563-574. 5. gordon mo, kass ma. what we have learned from the ocular hypertension treatment study. am j ophthalmol. 2018; 189: 226-227 6. sng cc, ang m, barton k. central corneal thickness in glaucoma. curr opin ophthalmol. 2017; 28 (2): 120126. 7. foster pj, buhrmann r, quigley ha, johnson gj. the definition and classification of glaucoma in prevalence surveys. br j ophthalmol. 2002 feb; 86 (2): 238-42. comparative study of iop measurements with air puff, icare and goldman applanation tonometers pak j ophthalmol. 2021, vol. 37 (1): 57-61 61 8. maczynska e, rzeszewska-zamiara j, jimenez villar a, wojtkowski m, kaluzny bj, grulkowski i. air-puff-induced dynamics of ocular components measured with optical biometry. invest ophthalmol vis sci. 2019; 60 (6): 1979-1986. 9. lovecchio f, salveson p, mulrow m, malashock h. icare vs. tono-pen in the ed. am j emer med. 2016; 34 (3): 670-673. 10. ragan a, cote sl, huang jt. disinfection of the goldman applanation tonometer: a systematic review. canadian j ophthalmol. 2018; 53 (3): 252-259. 11. wong b, parikh d, rosen l, gorski m, angelilli a, shih c. comparison of disposable goldmann applanation tonometer, icare ic100, and tonopen xl to standards of care goldmann nondisposable applanation tonometer for measuring intraocular pressure. j glaucoma, 2018; 27 (12): 1119-1124. 12. tejwani s, dinakaran s, joshi a, shetty r, sinha roy a. a cross-sectional study to compare intraocular pressure measurement by sequential use of goldman applanation tonometry, dynamic contour tonometry, ocular response analyzer, and corvis st. ind j ophthalmol. 2015; 63 (11): 815-820. 13. yildiz a, yasar t. comparison of goldmann applanation, non-contact, dynamic contour and tonopen tonometry measurements in healthy and glaucomatous eyes, and effect of central corneal thickness on the measurement results. medicinski glasnik: official publication of the medical association of zenica-doboj canton, bosnia and herzegovina. 2018; 15 (2): 152157. 14. aceituno paredes sc, asturias de león al, barnoya pérez j. rebound tonometry with resterilised tips versus goldmann applanation tonometry in children. archivos de la sociedad espanola de oftalmologia. 2020; 95 (7): 322-326. 15. pahlitzsch m, brünner j, gonnermann j, maier ab, torun n, bertelmann e, et al. comparison of icare and iopen vs. goldmann applanation tonometry according to international standards 8612 in glaucoma patients. intern j ophthalmology, 2016; 9 (11): 16241628. 16. demirci g, erdur sk, tanriverdi c, gulkilik g, ozsutçu m. comparison of rebound tonometry and non-contact airpuff tonometry to goldmann applanation tonometry. ther adv ophthalmol. 2019; 11: 2515841419835731. 17. rödter th, knippschild s, baulig c, krummenauer f. meta-analysis of the concordance of icare(®) probased rebound and goldmann applanation tonometry in glaucoma patients. eur j ophthalmol. 2020; 30 (2): 245-252. 18. erdogan h, akingol z, cam o, sencan s. a comparison of nct, goldman application tonometry values with and without fluorescein. clin ophthalmol. (auckland, nz). 2018; 12: 2183-2188. 19. grewal ds, stinnett ss, folgar fa, schneider ew, vajzovic l, asrani s, et al. a comparative study of rebound tonometry with tonopen and goldmann applanation tonometry following vitreoretinal surgery. am j ophthalmol. 2016; 161: 22-8.e1-8. 20. takenaka j, kunihara e, rimayanti u, tanaka j, kaneko m, kiuchi y. intraocular pressure readings obtained through soft contact lenses using four types of tonometer. clin ophthalmol. (auckland, nz). 2015; 9: 1875-1881. 21. raina uk, rathie n, gupta a, gupta sk, thakar m. comparison of goldmann applanation tonometer, tono-pen and noncontact tonometer in children. oman j ophthalmol. 2016; 9 (1): 22-26. authors’ designation and contribution umair tariq mirza; assistant professor: concepts, design, data acquisition, manuscript editing, manuscript review. m. usman sadiq; assistant professor: concepts, design, data acquisition, data analysis, statistical analysis, manuscript review. m. irfan sadiq; assistant professor: concepts, design, literature search, manuscript preparation, manuscript editing, manuscript review. ali raza; professor: concepts, design, manuscript preparation, manuscript review. waseem ahmed khan; professor: literature search, manuscript preparation, manuscript review. .…  …. 210 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology original article evaluation of the frequency of posterior segment pathologies determined by b-scan ultrasonography in patients with congenital cataract piyya muhammad musammat rafi, muhammad rizwan khan, muhammad naeem azhar pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: piyya muhammad musammat rafi bahawal victoria hospital bahawalpur …..……………………….. purpose: to evaluate the frequency of posterior segment pathologies determined by b-scan ultrasonography in patients with congenital cataract. material and methods: 204 patients with congenital cataract admitted in ophthalmology department in bahawal victoria hospital bahawalpur were included in the study. study period was six months with non probability consecutive sampling. age range was from new born to five years. patients having cataract underwent b-mode ultrasonography. b-mode ultrasonography was done with hiscan (optikon), by 4 th year resident under supervision of consultant ophthalmologist. outcome variables like vitreous disorders, retinal detachment and intraocular tumours were measured. results: ninety female and 114 male patients (total 237 eyes) were analysed. on b-scan ultrasonography seventeen eyes (7.17%) showed finding suggestive of posterior segment pathology while two hundred and twenty (92.83%) eyes showed no pathology in posterior segment in patient with congenital cataract. the most common finding was in the vitreous. five (2.5%) eyes showed persistent fetal vasculature (phpv) and three (1.5%) showed haemorrhage. intraocular tumour was present as elevated fundus lesion in 3 (1.5%) eyes. retinal detachment was present in one (0.5%) eye. detectable optic nerve lesions were present in four eyes; in 1 eye (0.5%) there was optic disc drusen, elevated optic disc was present in 2 (1%) and one eye (0.5%) showed cupping. other demonstrable findings were posterior staphyloma in one (0.5%) eye. conclusion: b-scan ultrasonography proves accurate and beneficial in opaque ocular media to detect posterior segment pathologies. there is possibility that some kind of other pathology might be present behind the cataract. b-mode ultrasonography should be included as essential investigating tool in evaluation of eyes undergoing cataract surgery in paediatrics population. -mode ultrasonography is used to investigate and diagnose variety of ocular conditions. bmode (brightness mode) ultrasonography is of great help when optical methods fail to give clear view of posterior segment of the globe1. b-scan ultrasonography uses high frequency (10mhz) sound waves to produce echoes as they strike interfaces between acoustically distinct structures2. b-scan two dimensional usg (ultrasonography) provides topographic information concerning the size, shape and quality of a lesion as well as its relationship to other structures2. the ability to examine the posterior segment of the eye accurately in patient with opaque media is essential for good surgical care of the cataract patient. sometime congenital cataract is associated with posterior segment pathologies like vitreous disorder, b evaluation of the frequency of posterior segment pathologies determined by b-scan ultrasonography pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 211 retinal detachment, intraocular tumour, and intraocular foreign body. the imaging modality that is simple, cheap and employed globally in this regard is b-scan ultrasonography. it is routinely used and recommended for use in patient with dense cataract3. now, even a variety of studies have been undertaken that review the presence of posterior segments pathologies in adults3, no trial has so far demonstrated such findings in children suffering from congenital cataract, especially in our country. it therefore remains to be established that what kind of common pathologies are present in posterior segments that we routinely miss in children with congenital cataract. these common posterior segment pathologies have a significant impact in the clinical course and visual development of patients with congenital cataract. this study will demonstrate the frequency of these pathologies in cataract patients of this age group in our part of the world, so that appropriate planning in such patients could be done. material and methods this cross sectional study was carried out in department of ophthalmology, bahawal victoria hospital bahawalpur. study was conducted for a period of six months from 27th may 2012 to 28th november 2012. 237 eyes were included in this study. hypothesized % frequency of outcome factor in the population (p): 4%+/-2.5 confidence limits as % of 100(absolute +/%) (d): 2.5%. design effect (for cluster surveys-deff): 1. non probability consecutive sampling technique was adopted. all children with positive congenital cataract up to the age of 5 years were included in this study because of late pursuance of congenital cataract cases in our settings. following children were excluded from our study; individual with history of trauma to the globe any time after birth, individuals with uveitis, cases with known glaucoma and previous ocular surgery. data analysis all the data was computerized and spss version 10 was used for analysis of data. descriptive statistics was used to analyse the data. quantitative variables like age was measured by mean and standard deviation. qualitative variables like gender and posterior segment pathologies including vitreous disorders (haemorrhage), retinal detachment, and intraocular tumours were measured by frequency and percentage. confounding variables like age, was controlled by making cross matched stratified tables. the chi-square test was used for analysis and the value of p< 0.05% was considered significant. results two hundred and thirty seven eyes of two hundred and four patients were included in the study. ninety (44.1%) were female and one hundred and fourteen (55.9%) were male patients. age range was from seven days to five years. mean age was four years with piyya muhammad musammat rafi, et al 212 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology standard deviation 3.23. below one year were 72 (35.3%), from one year to three years were 83 (40.7%), and from three years to five years were 49 (24%). on b-scan ultrasonography seventeen eyes (7.17%) showed finding suggestive of posterior segment pathology while two hundred and twenty (92.83%) eyes showed no pathology in posterior segment in patient with congenital cataract. the most common finding was in the vitreous. five (2.5%) eyes showed persistent fetal vasculature and three (1.5%) showed haemorrhage. intraocular tumours were present as elevated fundus lesion in 3 (1.5%) eyes. retinal detachment was present in one (0.5%) eye. detectable optic nerve lesions were present in four eyes; in 1 eye (0.5%) was optic disc drusen, elevated optic disc was present in 2 (1%) and one eye (0.5%) showed cupping. other demonstrable findings were posterior staphyloma in one (0.5%) eye. statistically the value of the test of significance (p value) is of the order of >0.05 for all variables, which shows that the relationships of various outcome variables with different age groups and gender of the patients are insignificant. discussion over the last 30 years, ultrasonography has greatly advanced which has enabled us to study posterior segment of the eye even in the presence of opaque media like dense cataract. cataract is a one of the leading cause of treatable blindness in developing countries. many of these cases have advanced cataracts that preclude visualization of fundus prior to cataract surgery. such visualization is considered important to provide accurate prognosis for vision after cataract surgery. under such circumstances ultrasonographic examination can provide information regarding such abnormalities4. in this study high percentage (3.37%) of findings were present in the vitreous cavity; including two patients with vitreous haemorrhage and one with nonspecific homogenous hyper-echoic vitreous (1.5%), other five patients showed bands and membrane consistent with persistent hyperplastic vitreous (2.5%). persistent hyperplastic primary vitreous is often associated with cataract in children. only one eye in this study showed characteristics of retinal detachment (0.5%) on b-scan usg. frequency of retinal detachment differ in traumatic and non traumatic eyes of patients as well as with the age of patients. qureshi ma et al found retinal detachment in non-traumatic cataract patients was (1.47%) and (21.12%) in traumatic cataract patients7. along with three primary variables (retinal detachment, intraocular tumours and vitreous disorders) there were other findings detectable by bmode usg, these broadly classified into optic disc lesions and miscellaneous lesions. optic disc swelling was present in 1%, cupping in 0.5% and drusens in 0.5%. shaikh et al8 in their study of 227 eyes found similar optic disc findings. optic disc edema was 0.45%, retinal detachment in 0.9%, vitreous hemorrhage in 1.32% and posterior staphyloma in 3.52%. conclusion b-scan ultrasonography proves accurate and beneficial in opaque ocular media to detect posterior segment pathologies. there is possibility that some kind of other pathology might be present behind the cataract. b-mode ultrasonography should be included as essential investigating tool in evaluation of eyes undergoing cataract surgery in paediatrics population. author’s affiliation dr. piyya muhammad musammat rafi medical officer bahawal victoria hospital bahawalpur dr. muhammad rizwan khan medical officer bahawal victoria hospital bahawalpur dr. muhammad naeem azhar ophthalmologist lrbt free eye hospital, lahore references 1. ehlers jp, shah cp, fenton gl, hoskins en, shelsta hn. pediatrics. in: the wills eye manual, office and emergency room diagnosis and treatment of eye disease. new delhi: wolters kluwer health. 2008: 17981. 2. kanski jj. imaging techniques. in: clinical ophthalmology, a systemic approach. london: butterworth – heinemann. 2007: 44-5. 3. aironi vd, gandage sg. pictorial essay: b-scan ultrasonography in ocular abnormalities. indian j radiol imaging. 2009; 19: 109-15. 4. salman a, palmer p, vanila cg, thomas pa, nelson jesudasan ca. is ultrasonography essential before surgery in eyes with advanced cataracts, jpgm. 2006; 52: 19-22. evaluation of the frequency of posterior segment pathologies determined by b-scan ultrasonography pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 213 5. dawood z, mirza sa, qadeer a. role of b-scan ultrasonography for posterior segment lesions. pak j lumhs. 2008; 07: 07–12. 6. ahmed j, shaikh ff, rizwan a, memon mf. evaluation of vitro-retinal pathologies using b-scan ultrasound. pak j ophthalmol. 2009; 25: 4. 7. qurshi ma, laghari k. role of b-scan ultrasonography in pre-operative cataract patients. int j health sci (qassim). 2010 january; 4 (1): 31–7. 8. shaikh fu, narsani ak, jatoi sm, shaikh za. preoperative posterior segment evaluation by ultrasonography in dense cataract. pak j ophthalmol. 2009; 25: 135-8. pak j ophthalmol. 2022, vol. 38 (2): 130-134 130 original article delayed surgical management of the patients with chronic dacryocystitis: a cross sectional survey bazla batool 1 , usama iqbal 2 , hamza iqbal 3 , irfan qayyum malik 4 , aamna jabran 5 department of ophthalmology, 1,2,4,5 dhq teaching hospital, gujranwala, 3 mayo hospital, lahore abstract purpose: to determine the factors that cause delay in dacryocystorhinostomy in patients with chronic dacryocystitis. study design: cross sectional survey. place and duration of study: ophthalmology department dhq teaching hospital gujranwala from february 2021 to may 2021 methods: sixty five ophthalmologists were included in this study. questionnaire was designed on google forms and it composed of four parts. first part included the title and purpose of this study. second part included professional information regarding qualification and place of practice. third part included 18 questions that were divided in three sub-sections in terms of factors related to the patient (5 questions), ophthalmologist (9 questions), and health resources provided (4 questions). responses were recorded in yes/no answers. last part comprised of blank space for remarks. the electronic link of questionnaire was shared with the participants of ophthalmology educational groups on whatsapp, facebook and e-mail. data was analyzed using spss 23.00 software and results were derived based on questionnaire. results: out of 65 ophthalmologists, 48 (72.7%) agreed that patients suffered from delay in surgical management. among the hospital related factors, 45 (69.23%) ophthalmologists believe that busy out patient department accounted for most of the delay. among patient related factors, 51 (78.46%) ophthalmologists were of the view that patients took the disease lightly as it was not vision-threating. forty one ophthalmologists (63.07%) reported that there was lack of surgical exposure during training years to learn dcr. conclusion: there are various patient related, surgeon related and hospital related factors which play a significant role in delay of surgical management of chronic dacryocystitis. key words: dacryocystitis, dacryocystorhinostomy, epiphora. how to cite this article: batool b, iqbal u, iqbal h, malik iq, jabran a. delayed surgical management of the patients with chronic dacryocystitis: a cross sectional survey. pak j ophthalmol. 2022, 38 (2): 130-134. doi: 10.36351/pjo.v38i2.1305 correspondence: usama iqbal dhq teaching hospital, gujranwala email: usamaiqqbal@gmail.com received: june 18, 2021 accepted: january 6, 2022 introduction tear film stability plays a key role in maintaining normal vision. improper drainage of the tears lead to epiphora. 1 epiphora can affect a patient’s quality of life (qol) in many ways. it not only compromises visual acuity but can also lead to peri-orbital skin soreness and splattered glasses. in some cases it can be a cause of social embarrassment because epiphora give resemblance to constant crying. daily routine activities like reading, driving, working at computer and outdoor activities are affected by poor drainage of tears. 2 causes of epiphora can be classified in different ways. it can be due to obstruction of the lacrimal drainage system or reflex tearing. another classification is congenital and acquired. the most common cause of epiphora in adult population is usama iqbal, et al 131 pak j ophthalmol. 2022, vol. 38 (2): 130-134 nasolacrimal duct (nld) obstruction. 3 most of the patients with nld obstruction suffer from chronic dacryocystis, with off and on super added acute attacks. chronic dacryocystitis affects 72.5% of female patients. 4 treatment of nld obstruction is dacryocystorhinostomy (dcr). patient’s quality of life (qol) improve significantly following dcr, as reported in studies which assessed patients’ qol using patients reported outcome measure (prom) questionnaires. 5,6 success rate of dacryocystorhinostomy ranges from 63% to 97%. 5 despite these benefits of dcr, majority of the patients present with the complications of chronic dacryocystitis due to delay in surgery. dcr is often delayed due to multiple factors. on patient’s behalf they might take this complaint lightly at initial stages. fear of surgery and post-operative pain add up to delayed decision about surgery. on behalf of ophthalmologists, most of the eye practitioners especially in non-teaching institutes, private setups and primary health care are not willing to do dcr. possible reasons include busy outdoors and operation theatre lists because of cataract surgery patients. there is fear about unpredictable surgical outcomes of this procedure. due to these reasons, there are a significant number of epiphora patients who are using multiple topical medications injudiciously, suffering from social stigma and consequent complications as well. in this study, we intend to identify the factors contributing to delayed surgery in patients with chronic dacryocystitis. this would help to address the factors for the betterment of community. methods after approval from institutional review board, gujranwala medical college (admn.321/gmc), a cross sectional study was designed. total 65 eye practitioners were included in this study. as previous literature showed no study regarding factors causing delay in dcr surgery, a self-designed questionnaire was developed for this study. questionnaire was designed based on author’s personal experiences, taking into consideration important responsible factors. questionnaire was designed electronically on google forms and it was composed of four parts. first part included the title and purpose of this study. in this part participants were also assured about the confidentiality of the survey. informed consent was also part of this section. second part included professional information regarding qualification (mcps/doms/fcps/ms) and place of practice. third part included 18 questions that were divided in three sub-sections in terms of factors related to the patient (5 questions), ophthalmologist (9 questions), and health resources provided (4 questions). responses were recorded in yes/no answers. last part comprised of blank space for remarks. participants were thanked and again assured about their privacy at the end. authors were enrolled as key persons for data collection. the electronic link of questionnaire was shared with the participants of ophthalmology educational groups on whatsapp, facebook and via e-mail. data was analyzed using spss 23.00 software and results were derived based on questionnaire. results total no of ophthalmologist were 65. detailed information about place of practice and professional qualification is shown in table 1. table 1: professional information of participating ophthalmologists. current place of work frequency (n = 65) public sector 41 private sector 24 total 65 qualification frequency (n = 65) fcps/ms/frcs 32 mcps/doms 8 post graduate residents 25 total 65 table 2 shows the percentage wise response of the participants and questions included in this survey. among all the factors mentioned above, top three factors causing delay in surgery are related only to patient’s decision of surgery. 78.46% ophthalmologists believed the patients did not consider chronic dacryocystitis as sight threatening disease, 76.92% of ophthalmologists believed that patients had fear of surgery and 75.38% of ophthalmologist believed that patients were reluctant for surgery due to cosmetic reasons leading to delay in management. delayed surgical management of the patients with chronic dacryocystitis: a cross sectional survey pak j ophthalmol. 2022, vol. 38 (2): 130-134 132 table 2: questionnaire and participants responses. sr. no questions yes no patient related factors 01. cosmetic reasons and surgical incision mark make patients reluctant 75.38 % (49) 24.61%(16) 02. patients have misconception of vision loss after surgery 21.53% (14) 78.46%(51) 03. patients are reluctant for surgery under local anesthesia 73.84% (48) 26.15%(17) 04. disease is not sight threatening so patients take it lightly 78.46% (51) 21.53%(14) 05. patient’s fear of surgery 76.92% (50) 23.07%(15) ophthalmologist related factors 06. lack of interest in oculoplastic surgery 27.69% (18) 72.30%(47) 07. different management approach 30.76% (20) 69.23% (45) 08. lack of interest in dacryocystorhinostomy 21.53% (14) 78.46% (51) 09. lack of surgical exposure for learning dcr surgery 63.07% (41) 36.92% (24) 10. sufficient skill for dcr but lack of interest in dcr 58.46% (38) 41.53% (27) 11. low cost surgery make surgeon reluctant for surgery 50.76% (33) 49.23% (32) 12. unpredictable surgical outcomes make surgeon reluctant for surgery 53.84% (35) 46.15% (30) 13. surgeon’s fear of bleeding during surgery make them reluctant 55.38% (36) 44.61% (29) 14. general anesthesia complications make surgeon reluctant 49.23% (32) 50.76% (33) factors related to health facility provided 15. busy opd routine 69.23% (45) 30.76% (20) 16. busy operation theater due to cataract surgery 52.30 %(34) 47.69% (31) 17. non availability of general anesthesia in operation theaters 64.61% (42) 35.38% (23) 18. medico legal issues related to surgery 30.76% (20) 69.23% (45) discussion most of the previous studies on chronic dacryocystitis only show its gender predisposition, epidemiological background and surgical benefits of dcr but literature shows no study on factors that cause delay in surgical management of these patients. 4 in our study, we summarized all these factors under three domains: 1. patient related factors. 2. ophthalmologist related factors. 3. factors related to health resources. a study by coats dk et al on factors responsible for delayed surgical management in adult strabismus, concluded that strabismus surgery was never offered by eye care specialist in 27% cases and surgery was offered but declined by the patient in 23% cases. 7 a study by naik vd et al from india showed that delay in surgical management of cataract patients was due to public unawareness, economical challenges and distrust in surgery. 8 regarding surgical delay in chronic dacryocystitis patients, our study showed that 78.46 % of the ophthalmologists were of the view that patients did not consider chronic dacryocystitis as a sight threatening disease and were reluctant for surgery. busy opd routine 69.23% (among the hospital related factors), followed by lack of surgical exposure of surgeons during their residency 63.07% (among the surgeon related factors) are other factors which are responsible for this delay in surgery. in ophthalmological practice surgeons are more concerned about the visual prognosis of patient. cataract is one of the major cause of visual impairment around the globe. 9 among other causes are age related macular degeneration (amd), diabetic retinopathy, glaucoma and trachoma. 10 all the above mentioned diseases burden the heath sector causing delay in dcr surgery. therefore chronic dacryocystitis when untreated can complicate into acute or chronic dacryocystitis, lacrimal abscess, and lacrimal fistula. it can also cause conjunctivitis, corneal ulcers, orbital cellulitis leading to blindness, moreover psychological stress and social embarrassment due to continuous watering. dcr is the treatment of choice for chronic dacryocystitis. 11,12 traditional approach is external dcr with or without mitomycin c. 13 new modality is endonasal dcr alone or with mmc. 14 probing can also have a role in patients with chronic dacryocystitis. 15 probing with mmc also have promising outcomes. literature shows only a few cases (04 cases) of dacryocystitis that caused visual impairment. 16 therefore, it is generally believed that chronic dacryocystitis is not sight threating and usama iqbal, et al 133 pak j ophthalmol. 2022, vol. 38 (2): 130-134 patients show reluctance regarding surgical management. cosmesis and psychological stress are other reasons behind delayed surgery. 17 our study also relates that patients delay dcr due to cosmetic issues, though this issue has been resolved by endonasal dcr. 18 previous studies also showed that workload can affect the potential of health professionals towards the patient management. 19,20,21 in our study, ophthalmologists believed that 69.23% of patients got delay in surgery due to busy opd and 52.3% of the patients got delayed due to busy ot schedule. previous literature shows no study regarding the relationship of non-availability of general anesthesia, its complications and fear of bleeding during dacryocystorhinostomy causing delay in dcr surgery. this study showed a direct relationship. we could not find relationship of delayed dcr with the surgeon related factors (described above) in literature. however, in our study surgeons believed in their direct relationship. limitations of this survey are small sample size and not considering the patients’ reviews regarding delay in their surgical management. although this study involves ophthalmologist working in different setups but statistics cannot be generalized. health professionals should take their responsibilities towards delay in surgical management of nld block. these factors should be addressed. moreover, education of patients, improvement of hospital based care and provision of health facilities in hospital can improve the patient management towards his particular problem. conclusion there are various patient related, surgeon related and hospital related factors which play a significant role in delay of surgical management of chronic dacryocystitis. these factors should be tackled by the ophthalmic community in our part of the world. ethical approval the study was approved by the institutional review board/ethical review board (admn.321/gmc). conflict of interest authors declared no conflict of interest. references 1. shin j-h, kim y-d, woo kijbo. impact of epiphora on vision-related quality of life. bmc ophthalmol. 2015; 15 (1): 1-6. 2. jutley g, karim r, joharatnam n, latif s, lynch t, olver jj. patient satisfaction following endoscopic endonasal dacryocystorhinostomy: a quality of life study. eye, 2013; 27 (9): 1084-1089. 3. sipkova z, vonica o, olurin o, obi ee, pearson ar. assessment of patient-reported outcome and quality of life improvement following surgery for epiphora. eye (lond). 2017 dec; 31 (12): 1664-1671. doi: 10.1038/eye.2017.120. epub 2017 jun 16. pmid: 28622317; pmcid: pmc5733284. 4. majidaee m, mohammadi m, sheikh mr, khademlu m, gorji mh. patients undergoing dacryocystorhinostomy surgery in northern iran: an epidemioloic study. ann med health sci res. 2014 may; 4 (3): 365-368. doi: 10.4103/2141-9248.133461. pmid: 24971210; pmcid: pmc4071735. 5. pokharel sm, chaudhary s, chaurasiya bd. factors affecting the success rate of external dacryocystorhinostomy at bp koirala institute of health sciences, dharan, nepal. birat j health sci. 2017; 2 (2): 196-200. 6. kubba h, swan ir, gatehouse s. the glasgow children's benefit inventory: a new instrument for assessing health-related benefit after an intervention. ann otol rhinol laryngol. 2004 dec; 113 (12): 980986. doi: 10.1177/000348940411301208. pmid: 15633901. 7. coats dk, stager dr sr, beauchamp gr, stager dr jr, mazow ml, paysse ea, felius j. reasons for delay of surgical intervention in adult strabismus. arch ophthalmol. 2005 apr; 123 (4): 497-499. doi: 10.1001/archopht.123.4.497. pmid: 15824223. 8. naik vd, usgaonkar up, albal vh. reasons for delay of surgical treatment among patients with senile mature cataract in goa.int j community med public health, 2018; 5 (6): 2529. 9. resnikoff s, pascolini d, etya'ale d, kocur i, pararajasegaram r, pokharel gp, mariotti sp. global data on visual impairment in the year 2002. bull world health organ. 2004 nov; 82 (11): 844-851. epub 2004 dec 14. pmid: 15640920; pmcid: pmc2623053. 10. schuster ak, erb c, hoffmann em, dietlein t, pfeiffer n. the diagnosis and treatment of glaucoma. deutsches arzteblatt international, 2020; 117 (13): 225-234. 11. erdöl h, akyol n, imamoglu hi, sözen e. longterm follow-up of external dacryocystorhinostomy and the factors affecting its success. orbit. 2005 jun; 24 (2): 99-102. doi: 10.1080/01676830590926693. pmid: 16191796. delayed surgical management of the patients with chronic dacryocystitis: a cross sectional survey pak j ophthalmol. 2022, vol. 38 (2): 130-134 134 12. pandya vb, lee s, benger r, danks jj, kourt g, martin pa, et al. external dacryocystorhinostomy: assessing factors that influence outcome. orbit. 2010; 29 (5): 291-297. 13. feng yf, yu jg, shi jl, huang jh, sun yl, zhao ye. a meta-analysis of primary external dacryocystorhinostomy with and without mitomycin c. ophthalmic epidemiol. 2012 dec; 19 (6): 364-370. doi: 10.3109/09286586.2012.733792. pmid: 23171205. 14. dolmetsch am. nonlaser endoscopic endonasal dacryocystorhinostomy with adjunctive mitomycin c in nasolacrimal duct obstruction in adults. ophthalmology, 2010 may; 117 (5): 1037-1040. doi: 10.1016/j.ophtha.2009.09.028. epub 2010 jan 15. pmid: 20079535. 15. agrawal gj. clinical outcome and complications of therapeutic nasolacrimal duct probing in adult cases of chronic dacryocystitis. int j cur res rev. 2017; 9 (18): 26. 16. pfeiffer ml, hacopian a, merritt h, phillips me, richani k. complete vision loss following orbital cellulitis secondary to acute dacryocystitis. case rep ophthalmol med. 2016; 2016: 9630698. doi: 10.1155/2016/9630698. epub 2016 oct 10. pmid: 27803829; pmcid: pmc5075612. 17. al shehri f, duan l, ratnapalan s. psychosocial impacts of adult strabismus and strabismus surgery: a review of the literature. can j ophthalmol. 2020 oct; 55 (5): 445-451. doi: 10.1016/j.jcjo.2016.08.013. epub 2016 nov 8. pmid: 33131636. 18. gauba v. external versus endonasal dacryocystorhinostomy in a specialized lacrimal surgery center. saudi j ophthalmol. 2014; 28 (1): 3639. 19. zavala am, day ge, plummer d, bamford-wade a. decision-making under pressure: medical errors in uncertain and dynamic environments. aust health rev. 2018 aug; 42 (4): 395-402. doi: 10.1071/ah16088. pmid: 28578757. 20. prints m, fishbein d, arnold r, stander e, miller k, kim t, et al. understanding the perception of workload in the emergency department and its impact on medical decision making. the am j emerg med. 2020; 38 (2): 397-399. 21. qureshi sm, purdy n, mohani a, neumann wp. predicting the effect of nurse-patient ratio on nurse workload and care quality using discrete event simulation. j nurs manag. 2019; 27 (5): 971-980. authors’ designation and contribution bazla batool; postgraduate resident: literature search, data analysis, statistical analysis, manuscript preparation. usama iqbal; postgraduate resident: concepts, design, data acquisition, manuscript editing, manuscript review. hamza iqbal; house officer: data acquisition, data analysis, manuscript preparation. irfan qayyum malik; associate professor: concepts, design, literature search, manuscript editing, manuscript review. aamna jabran; assistant professor: concepts, design, manuscript editing, manuscript review. .…  …. pak j ophthalmol. 2021, vol. 37 (1): 109-114 109 original article pattern of intra ocular foreign bodies in a tertiary care hospital of punjab usama iqbal 1 , irfan qayyum malik 2 , zeeshan hameed 3 , sadia hameed 4 1-3 department of ophthalmology, gujranwala medical college, gujranwala 4 departmwent of microbiology, sheikh zayed hospital, lahore abstract purpose: to find the epidemiological characteristics, management strategies and outcomes of intraocular foreign bodies (iofb) in a tertiary care setup of punjab. study design: descriptive retrospective study. place and duration: department of ophthalmology, gujranwala medical college/teaching hospital, from january 2017 to december 2019. methods: a retrospective review, of all the patients who had iofb removal, was performed. information regarding the nature and circumstances of injury, types of iofb, operative procedure performed and patient’s preoperative and post-operative best corrected visual acuity (bcva) were analyzed. x-ray orbit was advised to all the patients with ocular trauma having suspicion of any iofb while ct scan was done in patients with negative xray. descriptive statistics were used for analysis of data. results: record of 22 patients was retrieved out of which 18 (81.81%) were male and 4 (18.18%) were female with a mean age of 27.95 ± 9.325 years. occupational trauma was the leading cause of injury (66.6%). metallic objects were among the most common type of iofb (66.6%) followed by glass, concrete stone (each 13.3%) and lead pencil (6.6%). serious complications seen due to retained iofb were phthisis bulbi (9.09%), retinal detachment (13.63%) and endophthalmitis (9.09%). on follow-up, 10 patients had bcva less than hand movement (hm), 5 patients had bcva of cf to 6/60, 3 patients had bcva of 6/60-6/24 and 4 patients had bcva better than 6/18. conclusion: occupational trauma in young age group of working class was the most common cause of iofb. treatment delay and complications contributed to poor visual prognosis. key words: intra-ocular foreign body, retinal detachment, phthisis bulbi. how to cite this article: iqbal u, malik iq, hameed z, hameed s. pattern of intra ocular foreign bodies in a tertiary care hospital of punjab. pak j ophthalmol. 2021, 37 (1): 109-114. doi: https://doi.org/10.36351/pjo.v37i1.1071 introduction intraocular foreign bodies (fb) are more commonly encountered in males in working age group. 1 injuries correspondence: usama iqbal department of ophthalmology gujranwala medical college, gujranwala email: usamaiqqbal@gmail.com received: 2021 accepted: 2021 to eye occur either by primary or secondary impact. primary impact is direct mechanical injury while secondary impact is either introduction of infection in the eye or fb substance associated specific effects. 1 introduction of a fb in the eye can cause disturbing health issues ranging from transient ocular irritation to complete vision loss. ocular fbs can be classified in a number of ways. they are classified as extra ocular (eofb) or intra ocular (iofb) depending on whether fb is inside or outside the eyeball. 2 this classification system seems mailto:usamaiqqbal@gmail.com usama iqbal, et al 110 pak j ophthalmol. 2021, vol. 37 (1): 109-114 simple. on the basis of exact location of fb, new classification systems evolved with time. these systems also include the terminology of adnexal foreign bodies (orbit, eyelids, conjunctiva, and lacrimal system) and intramural foreign bodies (imfb) which are embedded within the layers of cornea or sclera and are neither iofb nor eofb. 3 iofbs are mainly chips of iron, copper, steel, glass, stones, lead and wood particles etc. the visual prognosis is dependent on multiple factors including age, extent of wound, time between injury and repair, size of fb, and complications such as, retinal detachment and endophthalmitis. 4 a complete history and examination is usually required to determine the type and location of retained iofb. imaging plays a vital role in the diagnosis of iofbs. plain x-ray orbital radiography can be used for screening all the patients with penetrating eye injury. 5 additionally, ultrasound and b-scan are also important modes of investigation, which can detect the size, location, nature of iofb and complications caused by that fb. ct scan will detect small iofbs and remains the investigation of choice when iofb is not visible clinically. 5 mri is generally avoided especially if magnetic fb is suspected. 6 among penetrating ocular injuries, 18 – 40% present with retained iofb. 7,8 in majority of cases, injury is mainly due to occupational trauma in adults and unsafe games in children. 9 keeping in view the modes of injury, majority of these injuries seem to be preventable and thus a number of people can be saved from getting blind through precautionary measures. 9 in this article, we describe epidemiological characteristics and visual outcomes of patients with iofb presenting to ophthalmology department of gujranwala medical college/teaching hospital during a period of 2 years. this study will be helpful in highlighting the importance of ocular safety measures. methods our study area was gujranwala city, which is situated 96.7 km north of the city of lahore in pakistan. gujranwala is the 5 th most populous district of pakistan. 10 it is an industrial city with a large proportion of population working in industries and the who are at high risk for ocular trauma. after permission from institutional review board, a retrospective case review study was conducted in which data of the patients from 1st th january 2017 to 31 th december 2019 was analyzed. all patients who were operated in ophthalmology department for iofb removal were included in the study. ophthalmology department gujranwala medical college/teaching hospital is the only ophthalmic unit in its locality providing 24/7 emergency cover to the patients of ocular trauma. plain x-ray orbit was advised to all the patients with ocular trauma having suspicion of any iofb (figure 1). fig. 1: plain x-ray orbit showing iofb. pattern of intra ocular foreign bodies in a tertiary care hospital of punjab pak j ophthalmol. 2021, vol. 37 (1): 109-114 111 fig. 2: ct scan orbit axial view showing r iofb. ct-scan was advised in those cases, which involved negative findings on x-ray orbit but with clinical signs suggestive of ocular fb (figure 2). name, age, gender, contact details, occupation and clinical information like; nature and type of injury, type of tear, type of fb, other ocular findings, surgical procedure, pre and post-operative bcva, duration of hospitalization, and impact of trauma on personal life were recorded. fig. 3: image showing different removed metallic iofbs. results total numbers of patients included in the study were 22. mean age of the patients was 27.95 ± 9.325 years. patients were categorized into three age groups (table 1). table 1: frequency distribution of gender and age. frequency (n = 22) percentage gender male female total 18 04 22 81.81% 18.18% 100.0% age groups 1-18 years 18-35 years > 35 years total 3 15 4 22 13.63% 68.18% 18.18% 100.0% on the basis of location 14 patients (63.63%) had iofb in posterior segment while 8 patients (36.36 %) had iofb in anterior segment (figures 4 & 5). magnetic metallic objects were the commonest type of iofb (66.6%), followed by glass, concrete stone (each 13.3%) and lead pencil (6.6%). one aspect of injury was the involvement of visual axis. in 14 patients (63.63%) visual axis was involved while in remaining 8 patients (36.36%) there was no involvement of visual axis. usama iqbal, et al 112 pak j ophthalmol. 2021, vol. 37 (1): 109-114 fig. 4: iofb removed from anterior chamber (ac) with the help of forceps. fig. 5: posterior segment iofb engaged with the help of endomagnet and removed through corneal incision with the help of forceps. corneal entry wound was seen in 10 individuals (46.45%), scleral entry in 6 patients (27.27%) and corneo-scleral entry in 6 individuals (27.27%). left eye was involved in 13 patients (60%) and right eye in 9 patients (40%). causes of trauma are shown in table 2. table 2: frequency distribution of cause of injury. cause of injury frequency percentage occupational trauma 13 59.09 accidents 6 27.27 others 3 13.63 total (n = 15) 22 100.0 gap between time of presentation and surgical intervention greatly affects the visual prognosis. for details refer to table 3. table 3: frequency distribution of patient’s time of presentation. time of presentation frequency percentage within 1 hour 3 13.63 124 hours 6 27.27 2448 hours 5 22.72 2 days – 1 week 7 31.81 1 week – 1 month 1 4.5 total 22 100.0 iofb was successfully removed in all patients. 23guage pars plana vitrectomy was performed in 14 patients. in 12 patients, iofb was removed with the help of endo-magnet, 2 patients had non-magnetic or large sized iofb which was grabbed with vitrectomy forceps and then removed through anterior segment. silicon oil was injected in all the 14 patients who had iofb removed from posterior segment. endo-laser was applied in all the patients who had retinal break per-operatively. most common location of retinal break was at 6’o clock position. anterior segment iofbs were removed through the corneal incision. corneal tear repair was performed in 8 patients, corneo-scleral tear repair in 6 patients and scleral tear repair in 6 patients. two patients had self-healing corneal entry wounds. traumatic cataract was removed in 5 patients. serious complications of iofb were phthisis bulbi in 2 patients (9.09%), retinal detachment in 3 patients (13.63%) and endophthalmitis in 2 patients (9.09%). the main criterion of prognostic measure in follow-up was best corrected visual acuity (bcva). for details see table 4. table 4: frequency distribution of bcva at follow-up. patient’s bcva frequency (n = 22) percentage no perception of light (npl) 2 9.09% perception of light 3 13.63% hand movements 5 22.72% cf-6/60 5 22.72% 6/60 – 6/24 3 13.63% 6/18 to 6/9 4 18.18% discussion our study comprised of a total of 22 patients. most of the studies published for epidemiological characteristics and management outcomes of iofbs are retrospective. 6,11,12 in our study design, data was also collected in retrospective manner. majority of pattern of intra ocular foreign bodies in a tertiary care hospital of punjab pak j ophthalmol. 2021, vol. 37 (1): 109-114 113 injuries (81.81%) occurred in male group. mean age of presentation was 27 years. liu et al described similar trends with male predominance but mean age was 38 years. 4 in another study, done for iofbs in new york, male predominance with mean age of above 30 years was reported. 13 local authors have also reported mean age above 30 years. 6,14 young age group in our study might be because of small sample size. it can also be because of the reason that the study area was an industrial city with most of the laborers belonging to the age group of 20 to 30 years. regarding the type of iofb, magnetic metals are the most common reported in literature which is also depicted in our study. 15,16 a retrospective analysis of 1340 cases of iofbs over 10 years period, reported farming as the most common profession. 11 in other reports industrial workers were the most common patients presenting with iofb. 4,16 hammer and chisel is also reported as the leading cause by some authors. 15 in our study occupational trauma related to ceramic and utensil making industry, was the leading cause; followed by accidental injuries which included hammering related trauma to eye. the cause can vary from region to region. it depends on the type of study area and its population. none of the patients presented to us were using eye safety googles at the time of trauma. most common point of entry was cornea. overall corneal involvement was seen in 73.72% cases. other local authors have also reported cornea as the most common entry point for iofb. 15,17 some authors reported corneal involvement as high as 88%. 13 in our study all the patients with clinical signs suggestive of iofb were advised plain orbital x-ray. the sensitivity of plain orbital x-rays for radio-opaque foreign bodies ranges from 70–90% and ct-scan remains the gold standard investigation for iofb. 5 in our study only one patient was diagnosed with iofb on ct-scan with no finding on plain x-ray. time of presentation to emergency ophthalmic unit and timely intervention is the most important factor, which can affect the visual prognosis. only 13% patients presented within the first one hour. idris et al., reported 27% patients presenting to eye care facility after ocular trauma. 6 the type of instrument to be used for removal of posterior segment iofb depends on the location, size and nature of iofb. 18 poor presenting visual acuity is regarded as the most important factor which determines the final visual outcome. 19,20 other factors which influence final va include the size of iofb, age of patient and associated complications (retinal break, endophthalmitus, retinal detachment). 4 decision regarding removal of difficult iofb keeping in mind the risk of surgery can vary from case to case. with improvement in surgical techniques and surgical devises, the decision to plan for removal of iofb is now easier. some authors recommend removal of iofb in all cases regardless of its location and inertness. 21 limitations of our study include its retrospective design and small sample size. information regarding instruments and exact surgical technique used for removal of iofb were also not available. conclusion ocular trauma leading to intra ocular foreign bodies is one of the major challenges faced by an eye surgeon. since occupational trauma is the leading cause of such injuries especially in young age group, so proper care during working hours can reduce the risk of trauma to a great extent. ocular safety measures and protective equipment should be provided to all the industrial workers who are at high risk of ocular trauma and its related complications. the licensing agencies regulating these industries should also ensure the availability of safety equipment for the workers. ethical approval the study was approved by the institutional review board/ ethical review board. (admn.112/gmc) conflict of interest authors declared no conflict of interest. references 1. pandey an. ocular foreign bodies: a review. j clin exp ophthalmol. 2017; 8: 1-5. 2. duke-elder s, macfaul pa. system of ophthalmology. part i. 1st ed. london: henry kimpton; 1972: e451-501. 3. shukla b. new classification of ocular foreign bodies. chin j traumatol. 2016; 19 (6): 319-321. 4. liu y, wang s, li y, gong q, su g, zhao j. intraocular foreign bodies: clinical characteristics and prognostic factors influencing visual outcome and globe survival in 373 eyes. j ophthalmol. 2019; 2019. usama iqbal, et al 114 pak j ophthalmol. 2021, vol. 37 (1): 109-114 5. saeed a, cassidy l, malone de, beatty s. plain xray and computed tomography of the orbit in cases and suspected cases of intraocular foreign body. eye, 2008; 22 (11): 1373-1377. 6. idris m, ayaz s, yaqoob h. demographic characteristics of cases with iofb presented to a tertiary care centre. pak j ophthalmol. 2015; 31 (1): 22-26. 7. loporchio d, mukkamala l, gorukanti k, zarbin m, langer p, bhagat n. intraocular foreign bodies: a review. surv ophthalmol. 2016; 61 (5): 582-596. 8. han s, wang t, jia j, sun s, fan y, yang g, et al. visual outcomes and prognostic factors of intralenticular foreign bodies in a tertiary hospital in north china. j ophthalmol. 2019; 2019: 4964595. doi.org/10.1155/2019/4964595 9. romaniuk vm. ocular trauma and other catastrophes. emerg med clin n am. 2013; 31 (2): 399-411. doi: 10.1016/j.emc.2013.02.003. 10. iqbal u, malik iq, iqbal h. epidemiology of ocular trauma in a tertiary hospital setting. pak j ophthalmol. 2019; 35 (1): 47-54. 11. li l, lu h, ma k, li yy, wang hy, liu np. etiologic causes and epidemiological characteristics of patients with intraocular foreign bodies: retrospective analysis of 1340 cases over ten years. j ophthalmol. 2018; 2018: 6309638. 12. luo z, gardiner m. the incidence of intraocular foreign bodies and other intraocular findings in patients with corneal metal foreign bodies. ophthalmology, 2010; 117 (11): 2218–2221. 13. chae b, cohen ej, cymerman rm, park l. epidemiology, clinical characteristics and complications in ocular foreign body injuries. invest ophthalmol vis sci. 2014; 55 (13): 4713. 14. ademola iw, naha n, boladale ia. clinical and demographic characteristics of intraocular foreign body injury in a referral center: 3 years’ experience. pak j ophthalmol. 2016; 32 (4): 205-209. 15. khan n, waheed k, siddiq s, tayyib m. visual outcome and complications in intra ocular foreign bodies. pak armed forces med j. 2014; 64 (4): 509513. 16. napora kj, obuchowska i, sidorowicz a, mariak z. intraocular and intraorbital foreign bodies characteristics in patients with penetrating ocular injury. klinika oczna. 2009; 111 (10-12): 307-312. 17. memon aa, iqbal ms, cheema a, niazi jh. visual outcome and complications after removal of posterior segment intraocular foreign bodies through pars plana approach. j coll physicians surg pak. 2009; 19 (7): 436-439. 18. jahangir t, qureshi bz, chaudhry ql, khan aa. ease of removal of posterior segment metallic intraocular foreign body with intraocular forceps vs endomagnet plus forceps. pak j ophthalmol. 2014; 30 (2): 95-98. 19. valmaggia c, baty f, lang c, helbig h. ocular injuries with a metallic foreign body in the posterior segment as a result of hammering: the visual outcome and prognostic factors. retina. 2014; 34 (6): 111611122. 20. ma j, wang y, zhang l, chen m, ai j, fang x. clinical characteristics and prognostic factors of posterior segment intraocular foreign body in a tertiary hospital. bmc ophthalmology, 2019; 19 (1): 1-6. 21. jastaneiah ss. long-term corneal complication of retained anterior chamber-angle foreign body. saudi j ophthalmol. 2010; 24 (3): 105-108. authors’ designation and contribution usama iqbal; post graduate resident: permission from institutional review board, manuscript writing, final review and correspondence. irfan qayyum malik; associate professor: supervised the whole project, formulated the study design and performed surgeries of posterior segment iofb presented in this study, review the final manuscript. zeeshan hameed; house officer: data collection, data entry and manuscript writing. sadia hameed; post graduate resident: final review, statistical analysis and data handling. .…  …. https://doi.org/10.1155/2019/4964595 pak j ophthalmol. 2020, vol. 36 (4): 312-314 312 editorial objective structured clinical examination (osce); strengths and hurdles in implementation muhammad moin 1 1 director medical education, head of the ophthalmology department ameer-ud-din medical college, postgraduate medical institute, lahore objective structured clinical examination (osce) was established by harden in 1975 to assess performance in a simulated environment within a specified time. 1 there are many variations to this original technique. in pakistan osce and later task oriented assessment of clinical skills (toacs) was introduced by the college of physicians and surgeons (cpsp) in postgraduate examinations in 1990s and this was later implemented at the undergraduate level by pakistan medical and dental council as objective structured practical examination (ospe). 2 it has been used to assess wide range of topics including history, examination, radiological investigations, blood reports and counselling. assessment methods in most of the postgraduate programs are designed to check the competence of students at the end of their training in the form of summative exit examinations. in the miller’s pyramid ‘knows’ is typically checked by using mcqs while ‘knows how’ is checked by case presentations and essays. ospe on the other hand assesses the performance of the student at the ‘shows how’ level of the miller’s pyramid. ‘does’ is checked by work based assessments or direct observation of procedural skills. most of the undergraduate and how to cite this article: moin m. objective structured clinical examination (osce); strengths and hurdles in implementation. pak j ophthalmol. 2020; 36 (4): 312-314. doi: https://doi.org/10.36351/pjo.v36i4.1129 correspondence: muhammad moin head of the ophthalmology department, ameer-ud-din medical college, postgraduate medical institute, lahore email: mmoin7@gmail.com received: august 12, 2020 accepted: september 14, 2020 postgraduate examinations assess their students up to the 3 rd level (shows how) as the feasibility to check the highest level (does) is not good. 3 long and short case examination used to be the gold standard of assessment for a long time. the major drawback of this method was the subjectivity of the examination. teachers had the power to pass or fail a student by assessing his performance on a few cases which did not cover majority of the topics in the specialty being examined. students always felt that they were at the mercy of the bad examiners because of the poor inter rater reliability of this assessment method. 4 osce was introduced to counter these weaknesses and now has become the new gold standard for assessing the clinical competence of students with a very high reliability of 0.91. 5 it is now used as a method to assess all the 3 domains of learning in addition to the long case and short case. it has two major underlying principles which include objectivity and structure. the objectivity depends upon standardization of the answering rubrics and trained examiners. each station has a standardized design which assesses a specific clinical task which is blue printed against the curriculum. more centers are using standardized cases to further improve the objectivity of this method. these characteristics have shown that osce has very high validity and reliability which can assess all three domains of learning including cognition, skill and affect. 6 feasibility of ospe has shown that it is more resource intensive as compared to other techniques of assessment. organization of an osce is time consuming and when conducted in the recommended manner it incurs huge costs for the medical institutions. engaging multiple trained examiners for all the stations is a difficult task as well. 7 proper examination stations are required to maintain confidentiality of each station. usually 8 – 16 stations are included with a time duration of 5 minutes for each station. usually 70 to 160 minutes are mailto:mmoin7@gmail.com muhammad moin 313 pak j ophthalmol. 2020, vol. 36 (4): 312-314 required for one round of ospe with multiple examiners at all the stations. 8 multiple stations allow assessment of performance in different areas of the specialty in a short period of time. mujumdar et al in a study of 52 final year students and 22 examiners found that majority of the students gave positive feedback about the osce examination held in their university in trinidad. the attributes (fairness, structure, administration, sequence, structure and coverage of knowledge/skills), reliability, validity, organization (time table, announcements, room quality) were all rated well by the students. however, they felt that the environment was stressful and the difficulty level of some stations was difficult. majority of the examiners were satisfied with the process, administration and organization of the ospe examination. 9 khan et al conducted a study of 250 final year students at khyber medical college, peshawar and found that the exam was found to be fair and comprehensive by 88% of the students, it was believed to be more stressful and tough mentally by 94% students, it was felt to be reliable and valid by 96% of the students and it was found to be an appropriate examination to assess clinical competency by 87% of the students. 2 in pakistan there are many challenges in assurance of quality in medical education. 10 this has led to a decline in the quality of assessment using osce over the years. the international association of medical education (amee) has published guidelines for organization and administration of osce. the objectives have been developed to elaborate the essential steps to ensure quality of osce. according to the guidelines the reliability is compromised if the coaching of standardized patients is deficient, examiners are not trained adequately, quality of questions and answering rubric are poor. the validity is also affected if the questions are not according to the learning outcomes and are unrealistic. 11 unfortunately examples of lapses in such quality assurance steps are seen in our system of medical education. these include the introduction of many static stations instead of interactive stations during this exam. these stations do not assess the performance but just the knowledge which can be assessed by using other techniques. time duration of the stations is manipulated by the examiners reducing the reliability of the examination. some places lack proper stations for ospe thereby encouraging the students to get help from their colleagues. this happens due to short distances between stations without any visual barriers thereby allowing the students to easily visualize the answer sheets of their colleagues. in some institutions even short cases are included as some ospe stations. these stations with short cases do not include a rubric thereby leading to reduced objectivity in the examination and inadequate assessment of the students due to shortage of time at each station. answering rubrics used for ospe do not have a penalty for the incorrect sequence of response from the students. this allows the student to give multiple responses incoherently but as they are included in the key the examiners have the leverageto mark the responsesas correct. training of examiners is deficient in undergraduate examination due to the large number of examiners required by the universities. simulated patients are an asset to the exam because they improve objectivity by giving the same response to the students all the time. unfortunately, many institutions do not have a large pool of simulated patients. question banking with item analysis of each station is required to improve the quality of ospe in each examination. 12 some institutions have this facility but it is lacking in other medical colleges. osce is a valuable tool to assess performance of students in a simulated environment. 13 we need to take necessary steps to improve the standards of osce in pakistan by improving the validity, reliability, cost efficiency and acceptability of the test. the universities conducting examination of multiple medical colleges need to make sure that a central osce is developed rather than asking each institution to develop their own osce stations independently without any quality control. training and certification of assessors is an essential step in quality control. use of trained simulated patients is becoming essential to check certain skills with high reliability. the validity can be improved by ensuring the blue printing of osce stations. all institutions should develop dedicated examination halls to conduct osce for all specialties. this would reduce the burden on each specialty to develop stations in their department with compromised facilities. feedback from students, examiners and patients’ needs to be taken to continuously improve the stations every year. it has been shown that students pass the examination even if they do not know certain essential skills asked at a station because of compensation from other stations. this reduces the assessment of competency of the students. therefore, passing the stations having objective structured clinical examination (osce); strengths and hurdles in implementation pak j ophthalmol. 2020, vol. 36 (4): 312-314 314 essential skill assessment should be made compulsory in all osce.realization of these realities about osce in our country is essential and we should strive to bring it to international standards. references 1. harden rm, stevenson m, downie ww, wilson gm. assessment of clinical competence using objective structured examination. br med j. 1975; 1: 447–451. doi:10.1136/bmj.1.5955.447. 2. khan a, ayub m, shah z. an audit of the medical students’ perceptions regarding objective structured clinical examination. educ res int. 2016: article id 4806398:4. doi: 10.1155/2016/4806398. 3. khan kz, ramachandran s, gaunt k, pushkar p. the objective structured clinical exam (osce): amee guide no. 81—part i: an historical and theoretical perspective. med teach. 2013; 35 (9): e1437– e1446. doi: 10.3109/0142159x.2013.818634. 4. troncon lea, dantas ro, figueiredo jfc, ferriolli e, moriguti jc, martinelli alc, et al. a standardized, structured long-case examination of clinical competence of senior medical students, medical teacher, 2000; 22 (4): 380-385. doi: 10.1080/014215900409483. 5. sloan d, donnelly mb, schwartz r, strodel w. the objective structured clinical examination – the new gold standard for evaluating postgraduate clinical performance. ann surg. 1995; 222 (6): 735–742. 6. moeen-uz-zafar a, shammari o, aljarallah b. evaluation of interactive osce for medical students in the subject of medicine; reliability and validity in the setting of internal vs. external examiners. ann public health res. 2015; 2 (4): 1030. 7. harden rm. misconceptions and the osce. med teach. 2015; 37 (7): 608–610. doi: 10.3109/0142159x.2015.1042443. 8. heal c, d’souza k, banks j, malau-aduli bs, turner r, smith j et al. a snapshot of current objective structured clinical examination (osce) practice at australian medical schools, medical teacher, 2019; 41 (4): 441-447. doi: 10.1080/0142159x.2018.1487547. 9. mujumdar maa, kumar a, krishnamurthy k, ojeh n, adams op, sa b. an evaluative study of objective structured clinical examination (osce): students and examiners perspectives. adv med educ pract. 2019; 10: 387-397. doi: 10.2147/amep.s197275. 10. khan aw, sethi a, wajid g, yasmeen r. challenges towards quality assurance of basic medical education in pakistan. pak j med sci. 2020; 36 (2): 4-9. doi: https://doi.org/10.12669/pjms.36.2.1319. 11. khan kz, gaunt k, ramachandran s, pushkar p. the objective structured clinical examination (osce): amee guide no. 81. part ii: organisation& administration, medical teacher, 2013; 35 (9):e1447e1463, doi: 10.3109/0142159x.2013.818635. 12. pell g, fuller r, homer m, roberts t. how to measure the quality of the osce: a review of metrics – amee guide no. 49, medical teacher, 2010; 32 (10): 802-811. doi: 10.3109/0142159x.2010.507716. 13. gormley g. summative osces in undergraduate medical education. ulster med j. 2011; 80 (3): 127-32. .…  …. https://doi.org/10.1080/014215900409483 https://doi.org/10.1080/0142159x.2018.1487547 https://doi.org/10.12669/pjms.36.2.1319 https://doi.org/10.3109/0142159x.2013.818635 https://doi.org/10.3109/0142159x.2010.507716 pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 27 original article comparison of central corneal thickness measurement using non-contact and contact pachymetry devices in normal eyes qamar-ul-islam, sidra malik pak j ophthalmol 2015, vol. 31 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: surg cdr qamar ul islam classified eye spec /asst prof pns shifa /bahria university med & dental college (bumdc) karachi qamarulislam71@gmail.com …..……………………….. purpose: to compare central corneal thickness (cct) in normal population using contact and non-contact pachymetry devices and to assess the intra operator repeatability of measurement with each device. materials and methods: this prospective, cross sectional comparative study evaluated 30 healthy subjects fulfilling the inclusion criteria reporting in afio rawalpindi. cct was measured in both eyes of subjects using noncontact specular microscope, dual scheimpflug analyzer and contact ultrasound pachymeter by a single investigator at the same time of the day. pearson’s correlation coefficient test was performed to ascertain correlation between pachymetry devices. intra operator repeatability was analysed using within subjects coefficient of variation/repeatability (cov) and intra class correlation coefficient (icc). results: sixty eyes of 30 male subjects were analysed. mean age of study population was 31.03 ± 10.30 years. mean cct values were 536.48 ± 35.77 µm, 498.62 ± 34.70 µm and 526 ± 37 µm with dual scheimpflug analyzer , specular microscope and ultrasonic pachymeter respectively (p < 0.01). there was significant linear co relation between all measurement modalities (r = 0.804 to r = 0.949) (p < 0.01). intra operator repeatability was excellent for all devices as indicated by low cov values (< 0.80%) and high icc values (> 0.90). conclusion: all three devices showed excellent intra operator repeatability for cct measurement making them reliable tools for cct measurement. key words: central corneal thickness, pachymetry, repeatability, microscopy. orneal thickness is a sensitive indicator of corneal hydration and patency of corneal endothelial pump. accurate central corneal thickness (cct) measurement (pachymetry) has diagnostic and therapeutic implications in various conditions like ectatic corneal dystrophies (keratoconus, pellucid marginal degeneration), contact lens related problems, dry eyes, diabetes mellitus, glaucoma and refractive surgery (lasik).1,2 an ideal method of pachymetry should be accurate, safe, repeatable, reproducible, easy and quick to perform.3 over a period of time, many methods have been devised for pachymetry such as ultrasound pachymetry, ultrasound bio microscopy, slit scanning corneal topography, confocal microscopy, optical biometry, scheimpflug system, specular microscopy, spectral domain oct and very high frequency ultrasound scanner (vhfus).2,3 for years, ultrasound pachymetry remains the gold standard method for measurement of cct due to c mailto:qamarulislam71@gmail.com qamar-ul-islam, et al 28 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology its high degree of intra operator and inter operator reproducibility.4 but the potential disadvantages of this method include possibility of probe malplacement and malalignment, inadvertent indentation leading to slightly thinner readings, patient’s discomfort, need for topical anaesthesia, epithelial damage and risk of infection.1,4-8 in the current era, newer non-invasive methods of pachymetry have been thoroughly evaluated for accuracy, precision, repeatability, reproducibility, and agreement between these new devices and gold standard ultrasound pachymeter. many studies have demonstrated acceptable repeatability and reproducibility of various noncontact pachymetry equipments and conformed agreement between cct measurements with noncontact methods and contact ultrasound methods.1,4, 7,9,10 the objective of this study was to compare cct measurements in healthy volunteers using contact ultrasound pachymeter, noncontact dual scheimpflug analyzer and non-contact specular microscope and to assess the intra operator repeatability of measurement with each device. material and methods this prospective, cross sectional comparative study enrolled 30 consecutive healthy subjects (staff members, candidates for medical examination and attendants of patients) reporting in armed forces institute of ophthalmology (afio) rawalpindi between 21 june 2013 to 30 aug 2013. subjects with ocular or systemic disease, history of ocular surgery or trauma, intraocular pressure (iop) > 21 mm hg, refractive error ≥ ± 1.5 dioptres, contact lens wearers and those using any topical ocular medications were excluded. the study was conducted in accordance with the ethical considerations given in helsinki declaration and written and informed consent was obtained from each subject before examination. comprehensive ophthalmic examination including visual acuity, refraction, slit lamp examination and fundus examination was carried out in each subject. cct was measured in both eyes of subjects using noncontact specular microscope (sp 3000 p; topcon, japan), dual scheimpflug analyzer (galilei™ g4; ziemer, switzerland) and contact ultrasound pachymeter (iopac® advanced; reichert). all the readings were taken by a single investigator at the same time of the day between 1000 – 1400 hours to avoid diurnal variation of pachymetry readings. for each subject all the measurements were performed within a 45 minute period. cct readings were first taken by non-contact method (specular microscope or dual scheimpflug analyzer). ten readings were recorded for each eye with a gap of 30 seconds after each reading and fresh alignment of equipment was done each time. following measurements with both non-contact equipments, cornea was anaesthetized with topical 0.5% proparacaine hydrochloride (alcaine) eye drops and 10 readings on each eye were taken with ultrasound pachymeter by placing the sterile ultrasound probe perpendicular to the centre of cornea and asking the patient to blink before each new reading. all the measurements were endorsed on a pre-devised proforma. statistical analysis of the data was done using spss version 13.0. all the data were tested for normality before analysis. descriptive statistics i.e. means ± standard deviation (sd) for quantitative variables and frequencies and percentages for quailtative variables were used. inter device differences were analysed using paired sample ‘t’ test. pearson’s correlation coefficient test was performed to compare the mean cct values obtained from non-contact equipment with contact ultrasound pachymeter. a p value of ≤ 0.05 was considered significant. intra operator repeatability was analysed using within subjects coefficient of variation / repeatability (cov) and intra class correlation coefficient (icc). cov was defined as the sd values divided by the mean result. the lower the cov and higher the icc the more repeatable the measurements were. for repeatability assessment 10 readings of right eye of 10 randomly selected subjects were used. results sixty eyes of 30 healthy volunteer male subjects fulfilling the inclusion criteria were analysed. mean age of study population was 31.03 ± 10.30 years (range: 1650 years) with 33.33% of subjects were in 3rd decade of life. mean cct values were 536.48 ± 35.77 µm , 498.62 ± 34.70 µm and 526 ± 37 µm with galilei™ g4 dual scheimpflug analyzer , sp 3000 specular microscope and iopac advanced ultrasonic pachymeter respectively (p < 0.01). mean cct values for right and left eyes were comparable for each measurement modality (p > 0.05) (table 1). inter device comparison results showed that mean cct values obtained by specular microscope and ultrasound pachymeter were 7.05% and 1.90% lower comparison of central corneal thickness measurement using non-contact and contact pachymetry pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 29 than galilei analyzer values, while cct measurement obtained by specular microscope were 5.25% lower than those from ultrasound method (p < 0.01). there was strong linear co relation between all measurement modalities with pearson co relation coefficient ranging from r = 0.804 to r = 0.949 (p <0.01) (table 2). the coefficient of variation (cov) and intra class correlation coefficient (icc) for cct measurement from different methods is given in table 3. agreement for successive measurements performed was excellent for all devices as indicated by low cov values (< 0.80%) and high icc values (> 0.90). galilei dual scheimpflug analyzer produced lowest cov (0.406%) and specular microscope gave highest icc values (0.996) indicating a high degree of intra operator repeatability of these equipments. discussion importance of cct measurement in various domains of ophthalmology including diagnosis of glaucoma, cataract and refractive surgery cannot be undermined. availability of a precise and accurate non-contact pachymetry device with high intra operator repeatability eliminates the need of conventional ultrasonic pachymeter with its potential contact hazards. most of the studies on cct measurements in pakistan have been done using various contact ultrasound pachymeter. mean cct values in our study were 526.27 ± 37 µm using ultrasonic pachymeter that were comparable to cct values of 535.68, 531.08 and 540.60 µm quoted in various studies on pakistani population.11-13 in our study, mean cct values using galilei dual scheimpflug analyzer, spqamar-ul-islam, et al 30 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology 3000 specular microscope and ultrasonic pachymeter were 536.48 ± 35.77 µm , 498.62 ± 34.70 µm and 526 ± 37 µm respectively. a lot of work has been published in international literature regarding cct measurement by different devices in various ethnic and racial groups (table 4). most of the results from these studies are comparable to our results, whereas, observed differences from our results may possibly be due to racial differences, variation in study settings and measurement methods. overall, inter device comparison in our study showed mean paired differences of cct values being statistically significant between devices (p < 0.01). however, pairwise comparison of all devices demonstrated significantly strong linear correlation with pearson correlation coefficient ranged from r = 0.804 to r =0.949. study by ou th et al, showed significant good linear correlation between ultrasound pachymeter orbscan ii (r = 0.793, p < 0.001) and ultrasound pachymeter – sp 3000 specular microscope (r = 0.890, p < 0.001) for cct measurement in eyes with glaucoma or glaucoma suspect.5 over a period of last decade, various computerized corneal tomography devices were developed based on the principle of placido disc and slit scanning (orbscan ii), single rotating scheimpflug camera (pentacam) and dual scheimpflug and placido disc (galilei) that provide more reliable pachymetry data apart from providing accurate curvature and topographic analysis of cornea. in a study by crawford az et al orbscan ii measured significantly lower cct values (524 ± 36 µm) compared with galilei (542 ± 26 µm) and pentacam (544 ± 26 µm).18 however, cct values obtained by galilei dual scheimpflug analyzer were comparable with our results. in our study, cct values obtained by specular microscope were significantly lower than both ultrasound pachymeter and galilei analyzer (p = <0.01). but this pattern of significantly lower cct measurements obtained by specular microscopy as compared to other modalities had been reported in other studies as well.1,5,14,15 the difference between specular microscope pachymetry and other two methods used in our study was probably due to different operating principles. the non-contact specular microscopy is based on reflection of light, while ultrasonic pachymetry depends on reflection of ultrasonic waves from anterior and posterior corneal surfaces and galilei dual scheimpflug analyzer uses two rotating scheimpflug cameras 180 apart along with placido imaging. comparing repeatability of the instruments is essential because it reflects amount of agreement that is possible between instruments. we used coefficient of variation (cov) and intra class correlation coefficient (icc) to ascertain intra operator repeatability and our results suggested excellent agreement of repeated measurements for all devices as indicated by low cov values (< 0.80%) and high icc values (> 0.990). in our study galilei analyzer produced lowest cov (0.40%) and specular microscope gave highest icc (0.996) indicating high comparison of central corneal thickness measurement using non-contact and contact pachymetry pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 31 degree of repeatability of these instruments. weerawat k et al, reported high intra operator repeatability (icc = 0.985) for cct measurement by ultrasonic pachymeter that was comparable to our repeatability results using ultrasonic pachymeter (icc = 0.995).19 various studies demonstrated high intra operator repeatability of various non-contact pachymetry devices (galilei, orbscan, specular microscope and sd oct) and ultrasonic pachymeter for cct measurement as reflected by low cov (between 0.33 – 0.93%) and high icc values (> 0.978).3-4,10,15,18 discrepancies between studies may be due to several factors, including statistical method, subject characteristics, and the definition of acceptable agreement. subject characteristics also may influence the interpretation of agreement. one of the limitations of our study was that we examined both eyes of each subject. although this increases the sample size, it raises the fundamental issue of inter eye correlation. the use of both eyes of each subject therefore may account for some of the differences reported between studies. in the current study, the pachymetry values obtained by the galilei, specular microscope, and ultrasonic pachymeter were sufficiently disparate that the 3 devices could not be considered equivalent. as the true gold standard for cct measurement is not yet established, it is difficult to conclude which device obtains the most accurate measurements, and therefore it is not possible to recommend one device absolutely over the others at the present time. conclusion both non-contact devices showed excellent intra operator repeatability for cct measurement that was comparable to contact method in normal eyes making them reliable tools for cct measurement providing better patient comfort. although, all three devices showed strong linear correlation , they are not inter changeable as mean cct measurement values differ significantly between instruments. author’s affiliation dr. qamar ul islam classified eye spec /assistant professor pns shifa /bahria 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central corneal thickness measurements with three new optical devices and a standard ultrasonic pachymeter. intl j ophthalmol. 2014; 7: 302-8. 11. ahmed j, memon mf. central corneal thickness and its relationship with myopia. jlumhs. 2008; jan-apr: 4-6. 12. channa r, mir f, shah mn, ali a, ahmad k. central corneal thickness of pakistani adults. jpma. 2009; 59: 225-9. 13. akram s, anklesaria zh, ahmad k. correlation between central corneal thickness measurements using two different ultrasonic pachymeters. pak j ophthalmol. 2013; 29: 214-6. 14. ogbuehi kc, osuagwu ul. repeatability and interobserver reproducibility of artemis – 2 high – qamar-ul-islam, et al 32 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology frequency ultrasound in determination of human corneal thickness. clinical ophthalmology. 2012; 6: 7619. 15. bao f, wong q, chong s, savini g, lu w, feng y, et al. comparison and evaluation of central corneal thickness using 2 new noncontact specular microscopes and 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jan – mar, 2014 pakistan journal of ophthalmology editorial the role of ocular coherence tomography in glaucoma diagnosis and management new technologies bring with them new hope and often unrealistic expectations. optical coherence tomography (oct) is no exception. the use of oct has led to a much better understanding of the structure of the retina. it has, within the space of a few years, become irreplaceable in the management of retinal disorders. therapy for macular diseases is now guided by oct findings. glaucoma is a chronic slowly progressive neuropathy of the optic nerve and presents a different challenge. screening tests generate a large number of false positives and frequently miss early cases. recent large scale studies have shown that the mean intraocular pressure (iop) at diagnosis is around 20 mm hg making it a very poor screening tool1,2. linking structural changes on the optic nerve head (onh) to characteristic, functional changes in the field of vision is the cornerstone of glaucoma diagnoses and its management by lowering iop. in general structural changes appear earlier than changes in visual fields. in the ocular hypertension study (ohts), more than half the patients who developed glaucoma from ocular hypertension, did so optic disc changes3. unfortunately our current examination techniques and tests do not allow us to detect the disease early and we often rely on changes of visual field to diagnose glaucoma. it is estimated that at least 35% of the retinal ganglion cells have to be lost before any vf loss appears. traditionally, changes on the optic nerve head have been assessed by ophthalmoscopy. optic disc stereo-photography is considered the gold standard for assessing optic discs. however, the limitations of photography preclude its universal adoption. these include the need for skilled technicians to take photographs and poor inter-observer agreement, even amongst experts4. retinal nerve fibre layer defects may precede onh and visual field changes by 4-7 years but their detection via ophthalmoscopy and photographs is difficult with advancing age and in myopia5. confocal scanning laser ophthalmoscopy (cslo, heidelberg retina tomograph) to assess the onh and scanning laser polarimetry (slp, gdx nerve fibre layer analyser), to assess the peripapillary nerve fibre layer have been available for assessing structure in glaucoma for more than a decade. studies indicate that both have good diagnostic ability to detect glaucoma. the adoption of both the technologies has not been wide spread as their findings often do not correlate to the clinical and functional assessment. rapid advances in image acquisition technology have made oct reliable and reproducible for retinal imaging. current fourier domain octs (fd-oct) acquire 25 76,000 a scans per second and have superseded the slower time-domain octs (400 scans/ sec). what are we looking for with oct scans in glaucoma? oct findings in glaucoma are more subtle than in retinal disease. onh changes and retinal nerve fibre layer (nfl) thinning due to loss of ganglion cell soma at the macula occur. visible nfl defects involve a loss of 12,500 axons (1% of normal total) and measure about 21 – 47 μm in depth (ref). fdoct has a resolution of 5 – 10 µm and scans can detect nfl defects earlier than red-free photography. oct for glaucoma involves detection and segmentation of the retinal layers and is essentially quantitative. the thickness of the nfl can be compared between hemispheres and eyes and the detected asymmetry in thinning may be due to a pathologic process, not necessarily glaucoma. for the optic disc the software measures the neuroretinal rim below an arbitrary plane and in most often doesn’t coincide with the true neuroretinal rim. the thickness of various parameters is then compared to a normative database. unfortunately segmentation algorithms in different scanners are mutually exclusive and are not comparable. therefore long-term assessments need to be with the same oct scanner and this is a serious limitation. the first practical application of oct in glaucoma was published in 1997 where time domain – oct was shown to be useful in detecting glaucoma in an eye with optic nerve head drusen6. it became evident that retinal thinning could be topographically correlated to visual sensitivity in glaucoma7. however scanning for glaucoma was limited by the slow speed of scanning the role of ocular coherence tomography in glaucoma diagnosis and management pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 2 and motion artefacts by the time domain oct. extensive research has been done on oct – derived nfl thickness and macular thickness. oct – detected macular changes have led to a better understanding of the structure-function relationship in glaucoma. early work indicated that macular thinning was a less accurate measure for glaucoma detection than tdoct peripapillary nfl thickness and that inner macular thickness which included the ganglion cell layer has a higher diagnostic power8. oct – derived optic disc parameters have so far not proved to be reliable indicators of the disease. recently chauhan et al have proposed that an onh parameter, the bruch’s membrane opening – minimum rim width is a reliable indicator for glaucoma9. furthermore chauhan and burgoyne have proposed a radical re-think in the way oct assessment for glaucoma is done. they suggest that the oct scan output should be reviewed like a chest x-ray rather than trying to fit the oct scan outcomes to the clinical appearance of the disc. this is because in glaucoma, often the clinical disc margin doesn’t coincide with that determined by the oct10. is the oct suitable as a ‘stand alone’ device to detect glaucoma? unfortunately there appears to be no single device or test which can diagnose the disease with certainty. in normal human retinas and optic nerves, retinal ganglion cells count show a two-fold or greater variability. there is significant intra-session variability in oct – measured rnfl thickness11. very few studies have looked at the diagnostic capabilities of the oct in ‘real – life’ scenarios. one such study from hungary looked into the diagnostic accuracy of a commercially available fd – oct in an unselected population. normality was decided by the softwareprovided classification. sensitivity was 73.6% for the optic nerve head parameters, and 62.7% for the other parameters. specificity was high (94.6 – 100%) for most rnfl thickness and inner macular thickness parameters, but low (72.0 – 76.3%) for the optic disc parameters12. this study implies that the diagnosis of glaucoma cannot be made simply because the oct is normal or abnormal. the detection of glaucomatous progression is a critical aspect of glaucoma management but difficult to ascertain reliably. corroborative change with different tests can be used as an alternative to singletest confirmation to detect glaucomatous progression. for example, if we are using three methods to detect progression (e.g. cslo, oct and perimetry) the detection of a concomitant change by oct and hrt (preferably spatially correlated) allows earlier detection of progression compared to repeating a corroborative change result with any of these two tests. the oct has a significant advantage over other methods. consistent and spatially correlated change in two oct parameters, rfnl and macular thickness would confirm progression. cslo and slp have helped significantly but often there is disconnect between progression as determined by these devices and that by visual fields. this may be due to ‘noise’ in both structural and functional tests. the hope is that with oct there would be a greater degree of coherence between structural and functional progression. this has been confirmed in some recent studies, where the fd-oct performed significantly better than the cslo, slp and the time-domain oct in detecting progression13-15. does the oct have any drawbacks? the adage ‘rubbish in, rubbish out’ is very apt for oct assessment for glaucoma. it is essential to ensure that the scan is of good quality. head tilt and microsaccades may result in poor quality scans. low signal scans due to media opacities may lead to a significant underestimation of nfl thickness. artefacts due to incorrect segmentation of the retina may occur in 5-10% of cases. diseases like myopia and epiretinal membranes confuse the software. technological advances in oct continue at a rapid pace. eye-tracking enables reliable oct scans in eyes with poor fixation and accurate and repeatable alignment of oct and fundus images. the enhanced depth imaging oct allows for visualisation of the lamina cribrosa16. swept source oct which uses longer wavelengths than fd – oct and scan twice as fast (100,000 scans/sec) allows for simultaneous scanning of retina, optic nerve and choroid17. another exciting prospect is that it can accurately scan the anterior chamber angle. this allows for accurate localisation and quantification of extent of iridotrabecular contact and peripheral anterior synechiae in angle closure glaucoma18. the oct has improved our diagnostic capabilities for glaucoma and allows for earlier detection of progression. for once the early promise in a new technology has been vindicated. this is evidenced by the rapid and widespread adoption in routine glaucoma practise in the usa and europe. however it is important to remember it is not a substitute to meticulous clinical and perimetric assessment of glaucoma. nitin anand 3 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology reference 1. leske mc, heijl a, hyman l, bengtsson b. early manifest glaucoma trial: design and baseline data. ophthalmology. 1999; 106: 2144-53. 2. lascaratos g, garway – heath df, burton r, bunce c, xing w, crabb dp, russell ra, shah a; united kingdom glaucoma treatment study group. the united kingdom glaucoma treatment study: a multicenter, randomized, double-masked, placebo-controlled trial: baseline characteristics. ophthalmology 2013, 120: 2540-5. 3. gordon mo, beiser ja, brandt jd, heuer dk, higginbotham ej, johnson ca, keltner jl, miller jp, parrish rk 2nd, wilson mr, kass ma. the ocular hypertension treatment study: baseline factors that predict the onset of primary openangle glaucoma. arch ophthalmol. 2002; 120: 714-20. 4. breusegem c, fieuws s, stalmans i, zeyen t. agreement and accuracy of non-expert ophthalmologists in assessing glaucomatous changes in serial stereo optic disc photographs. ophthalmology. 2011; 118: 742-6. 5. sommer a, miller nr, pollack i, maumenee ae, george t. the nerve fiber layer in the diagnosis of glaucoma. arch ophthalmol. 1977; 95: 2149-56. 6. roh s, noecker rj, schuman js. evaluation of coexisting optic nerve head drusen and glaucoma with optical coherence tomography. ophthalmology. 1997; 104: 1138-44. 7. zeimer r, asrani s, zou s, quigley h, jampel h. quantitative detection of glaucomatous damage at the posterior pole by retinal thickness mapping. a pilot study. ophthalmology. 1998; 105: 224-31. 8. tan o, chopra v, lu at, schuman js, ishikawa h, wollstein g, varma r, huang d. detection of macular ganglion cell loss in glaucoma by fourier – domain optical coherence tomography. ophthalmology. 2009; 116: 2305-14. 9. chauhan bc, o'leary n, almobarak fa, reis as, yang h, sharpe gp, hutchison dm, nicolela mt, burgoyne cf. enhanced detection of open-angle glaucoma with an anatomically accurate optical coherence tomography-derived neuroretinal rim parameter. ophthalmology. 2013; 120: 535-43. 10. chauhan bc, burgoyne cf. from clinical examination of the optic disc to clinical assessment of the optic nerve head: a paradigm change. am j ophthalmol. 2013; 156: 218-27. 11. wessel jm, horn fk, tornow rp, schmid m, mardin cy, kruse fe, juenemann ag, laemmer r. longitudinal analysis of progression in glaucoma using spectral-domain optical coherence tomography. invest ophthalmol. vis. sci. 2013; 54: 3613-20. 12. garas a, vargha p, hollo g. diagnostic accuracy of nerve fibre layer, macular thickness and optic disc measurements made with the rtvue-100 optical coherence tomograph to detect glaucoma. eye (lond). 2011; 25: 57-65. 13. xu g, weinreb rn, leung ck. retinal nerve fiber layer progression in glaucoma: a comparison between retinal nerve fiber layer thickness and retardance. ophthalmology. 2013; 10. 14. leung ck, liu s, weinreb rn, lai g, ye c, cheung cy, pang cp, tse kk, lam ds. evaluation of retinal nerve fiber layer progression in glaucoma a prospective analysis with neuroretinal rim and visual field progression. ophthalmology. 2011; 118: 1551-7. 15. leung ck, chiu v, weinreb rn, lai g, ye c, cheung cy, pang cp, tse kk, lam ds. evaluation of retinal nerve fiber layer progression in glaucoma: a comparison between spectral – domain and time-domain optical coherence tomography. ophthalmology. 2011; 118: 1558-62. 16. park hy, park ck. diagnostic capability of lamina cribrosa thickness by enhanced depth imaging and factors affecting thickness in patients with glaucoma. ophthalmology. 2013; 120: 745-52. 17. takayama k, hangai m, kimura y, morooka s, nukada m, akagi t, ikeda ho, matsumoto a, yoshimura n. three – dimensional imaging of lamina cribrosa defects in glaucoma using swept-source optical coherence tomography. invest ophthalmol. vis. sci. 2013; 54: 4798-807. 18. lai i, mak h, lai g, yu m, lam ds, leung ck. anterior chamber angle imaging with swept-source optical coherence tomography: measuring peripheral anterior synechia in glaucoma. ophthalmology. 2013; 120: 1144-9. nitin anand calderdale & huddersfield nhs trust west yorkshire, uk anand1604@gmail.com http://www.ncbi.nlm.nih.gov/pubmed?term=bengtsson%20b%5bauthor%5d&cauthor=true&cauthor_uid=10571351 http://www.ncbi.nlm.nih.gov/pubmed?term=lascaratos%20g%5bauthor%5d&cauthor=true&cauthor_uid=24126032 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http://www.ncbi.nlm.nih.gov/pubmed?term=akagi%20t%5bauthor%5d&cauthor=true&cauthor_uid=23778878 http://www.ncbi.nlm.nih.gov/pubmed?term=ikeda%20ho%5bauthor%5d&cauthor=true&cauthor_uid=23778878 http://www.ncbi.nlm.nih.gov/pubmed?term=matsumoto%20a%5bauthor%5d&cauthor=true&cauthor_uid=23778878 http://www.ncbi.nlm.nih.gov/pubmed?term=yoshimura%20n%5bauthor%5d&cauthor=true&cauthor_uid=23778878 http://www.ncbi.nlm.nih.gov/pubmed?term=lai%20i%5bauthor%5d&cauthor=true&cauthor_uid=23522970 http://www.ncbi.nlm.nih.gov/pubmed?term=mak%20h%5bauthor%5d&cauthor=true&cauthor_uid=23522970 http://www.ncbi.nlm.nih.gov/pubmed?term=lai%20g%5bauthor%5d&cauthor=true&cauthor_uid=23522970 http://www.ncbi.nlm.nih.gov/pubmed?term=yu%20m%5bauthor%5d&cauthor=true&cauthor_uid=23522970 http://www.ncbi.nlm.nih.gov/pubmed?term=lam%20ds%5bauthor%5d&cauthor=true&cauthor_uid=23522970 http://www.ncbi.nlm.nih.gov/pubmed?term=leung%20ck%5bauthor%5d&cauthor=true&cauthor_uid=23522970 pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 19 original article awareness of retinopathy of prematurity (rop) amongst pediatricians in pakistan muhammad moin, nasira inayat, umar k. mian, ayesha khalid, agha shabbir ali pak j ophthalmol 2016, vol. 32 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: prof. m. moin dept of ophthalmology ameer-du-din medical college, postgraduate medical institute, lahore general hospital, lahore email: mmoin7@gmail.com received: november 03, 2015. accepted: march 09, 2016. …..……………………….. purpose: to find the awareness of rop among neonatologists in pakistan. study design: quantitative and qualitative survey. place and duration of study: national pediatric conference held at lahore in march 2014. material and methods: a questionnaire was given to all the pediatricians and neonatologists at a national pediatric conference held at lahore in march 2014. the answering pediatricians/neonatologists were divided into two groups. group i consisted of 28 pediatricians who had worked for less than 5 years, and in group ii, there were 34 pediatricians who had worked for more than 5 years. this questionnaire was especially constructed to assess knowledge, attitude, and practice (kap) of retinopathy among participants attending the conference. results: a total number of 62 pediatricians/neonatologists participated in the study majority of the 58pediatricians (93%) had heard about retinopathy of prematurity and 43 (69.4%) agreed that the infants must be checked for rop. a few participants 15 (24%) stated that there is a rop screening criteria, 44 (71%) responded negatively and 3 (4.8%) responded that there may be a criteria present. forty eight (77.4%) stated that they did not have an ophthalmologist for rop screening while 11 (17%) had an ophthalmologist. thirty five (56.5%) agreed that there are treatment options for rop but 20 (32.3%) were not sure about such treatment options. thirty two (51%) agreed that a patient should be given reappointment within 3 days once he missed one. rop was an important issue for 40 (64%) of doctors while 16 (25%) were not sure about this. there was insignificant difference with respect to years of experience as pediatrician and the questions asked. conclusion: rop awareness should be raised at a national level to improve the development of rop screening and treatment services in pakistan. keywords: retinopathy of prematurity, awareness, screening, neonatologist. etinopathy of prematurity (rop), is a proliferative retinopathy that develops in preterm infants. as the survival rate of premature infants is increasing worldwide, rop is emerging as an important cause of preventable blindness. different criteria are set for the high, middle and low – income countries.1 screening for middleincome countries like india and pakistan is recommended in infants with a birth weight of less than 2000 grams, gestational age of less than 35 weeks, multiple births, and eventful postnatal period like oxygenation, sepsis, respiratory distress syndrome and blood transfusions.2 at least 50,000 children are blind due to rop throughout the world3 and in india alone, which is a country like our socioeconomic background, 500 children are estimated to become blind every year.4 as the survival rate of premature infants is improving, the blindness due to rop is increasing in r m. moin, et al 20 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology children especially in the developing countries; this is referred as “third epidemic” of rop.5,6 in pakistan, neonatal death rate was 82.5 percent in the year 2000, which dropped to 61.3 percent in 2012, showing a slow improvement over twelve years.7 with this slight improvement in survival rate, the incidence of blindness due to rop increased. a referral system was then developed by the leading agha khan university hospital, karachi.8 a key strategy used for rop screening programs is recognition and an early referral of high risk infants.9 one study carried out by aga khan university hospital, karachi; states that a significantly high number of children attending the hospital had turned blind because, as infants, they were not screened or referred to the ophthalmologists for the management of rop.10 in india, ten year data was collected to find out the incidence of rop in asian indian premature babies.11, and world-wide.12 the initial screening guidelines given by the american academy of pediatrics, and american association for pediatrics and strabismus in 2006.13 these guidelines recommend screening for the infants “with a birth weight of less than 1500g or a gestational age of 32 weeks or less and selected infants with a birth weight 1500 and 2000g or gestational age of more than 32 weeks with an unstable clinical course, including those requiring cardio-respiratory support and those who are believed by their attending pediatrician or neonatologist to be at high risk, should have retinal screening examination performed after pupillary dilation using binocular indirect ophthalmoscopy to detect retinopathy of prematurity (rop).” neonatologists / pediatricians play a vital role in identification and referral of neonates to the ophthalmologists.9,10 thus, it is essential that neonatologists/pediatricians should be aware of rop screening guidelines, risk factors, referral indications and resource availability.14 the present study is carried to find out the level of knowledge amongst this group of doctors. material and methods a questionnaire was given to the pediatricians and neonatologists who had come to attend a national pediatric conference held at lahore in march 2014. a total number of 62 doctors answered the questionnaire. the answering pediatricians/ neonatologists were divided into two groups. group i consisted of pediatricians who had worked for less than 5 years, and in group ii, pediatricians had worked for more than 5 years. this questionnaire was especially constructed to assess knowledge, attitude, and practice (kap) of retinopathy among participants attending the conference (fig 1.) six questions were about the profile of the doctors attending the conference. twelve questions were formulated for the knowledge, attitude and practice (kap) study. these consisted of 9 open – ended and 3 closed – ended questions. the rop related questionnaire included questions for collecting information about their educational and practice profile, knowledge about rop screening guidelines, risk factors and treatment guidelines. attitude assessment included questions about knowing if infants needed their eyes examined by the ophthalmologists and a comprehensive question about the time of referral if the infant missed one appointment. practice based questions included if they had taken care of infants with rop, was there an ophthalmologist attending their neonatal intensive care unit, and if there was a screening criterion practiced at their unit. results a total number of 62 pediatricians/neonatologists participated in the study. group i consisted of 28 pediatricians who had an experience of less than five years in their field. group ii consisted of those 34 pediatricians who had a work experience of more than five years in their respective field. majority of the 58 (93%) had heard about the retinopathy of prematurity and 43 (69.4%) agreed that the infants must be checked for rop while 18 (29%) further specified that only certain babies need to be checked. rop can cause blindness was highlighted by 60 (96%) of neonatologists. there was a little difference between the doctors who had taken care of the infant with rop previously as frequency of positive responders was 25 (40%) while negative responders were 37 (59%). when inquired about the screening criteria for rop few 15 (24%) stated that there is a criteria, 44 (71%) responded negatively and 3 (4.8%) responded that there may be a criteria present. majority of the doctor 48 (77.4%) stated that they did not have an ophthalmologist for nicu infants and just 11 (17%) had an ophthalmologist. 35 (56.5%) agreed that there are treatment options for rop but 20 (32.3%) were not sure about such treatment options. there was almost awareness of retinopathy of prematurity (rop) amongst pediatricians in pakistan pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 21 table 1: distribution with respect to awareness to rop. question answer, n (%) answer, n (%) answer, n (%) have you heard about rop? yes, 58 (93.5) no, 2 (3.2) may be, 2 (3.2) do infants need their eyes examination for rop? yes, 43 (69.4) no 1 (1.6) only certain baby 18 (29) can rop cause blindness? yes, 60 (96.8) not sure, 2 (3.2) have you taken care of a baby with rop? yes, 25 (40.3) no, 37 (59.7) is there a screening criterion for rop? yes, 15 (24.2) no, 44 (71) may be, 3 (4.8) do you have an ophthalmologist who comes to your nicu for screening rop? yes, 11 (17.7) no, 48 (77.4) may be, 3 (4.8) is there any treatment for rop? yes, 35 (56.5) no, 7 (11.3) not sure, 20 (32.3) please state the criteria for treatment of rop? laser therapy, 5 (8.1) depending on stage, 5 (8.1) oxygen therapy, 1 (1.6) if appointment is missed, next appointment must be within? 3 days, 32 (51.6) 1 week, 13 (21) 2 – 3 week, 7 (11.3) 1 month, 4 (6.5) other, 6 (9.7) is rop is an important disease in pakistan? yes, 40 (64.5) no, 6 (9.7) not sure, 16 (25.8) table 2: comparative opinion of doctors for rop on basis of experience. question answer < 5 years in practice n (%) > 5 years in practice n (%) p-value have you heard about rop? yes 24 (41.4) 34 (58.6) 0.259 no 0 (0) 2 (100) may be 0 (0) 2 (100) do infants need their eyes examination for rop? yes 15 (34.9) 28 (65.1) 0.350 no 1 (100) 0 (0) only certain baby 8 (44.4) 10 (55.6) can rop cause blindness? yes 24 (40) 36 (60) 0.518 not sure 0 (0) 2 (100) have you taken care of a baby with rop? yes 7 (28) 18 (72) 0.190 no 17 (45.9) 20 (54.1) is there a screening criterion for rop? yes 4 (226.7) 11 (73.3) 0.369 no 18 (40.9) 26 (59.1) may be 2 (66.7) 1 (33.3) do you have an ophthalmologist who comes to your nicu for screening rop? yes 4 (36.4) 7 (63.6) 0.962 no 19 (39.6) 29 (60.4) m. moin, et al 22 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology may be 1 (33.3) 2 (66.7) is there any treatment for rop? yes 16 (45.7) 19 (54.3) 0.076 no 0 (0) 7 (100) not sure 8 (40) 12 (60) please state the criteria for treatment of rop? laser therapy 2 (40) 3 (60) 0.730 depending on stage 2 (40) 3 (60) oxygen therapy 0 (0) 1 (100) if appointment is missed, next appointment must be within? 3 days 12 (37.5) 20 (62.5) 0.986 1 week 5 (38.5) 8 (61.5) 2 – 3 week 3 (42.9) 4 (57.1) 1 month 2 (50) 2 (50) other 2 (33.3) 4 (66.7) is rop is an important disease in pakistan? yes 16 (40) 24 (60) 0.696 no 3 (50) 3 (50) not sure 5 (31.3) 11 (68.8) equal distribution for the selection of various techniques for treatment of rop. most of the doctors 32 (51%) agreed upon that a patient should be given reappointment within 3 days once he missed one, 13 (21%) agreed for 1 week delay, 7 (11.3%) for 2-3 week delay and just 4 (6.5%) agreed for delay in repeat appointment for 1 month. for 40 (64%) of doctors rop was an important issue while 16 (25%) were not sure about this. there was insignificant difference with respect to years of experience as practicing pediatrician and the questions asked (table 2). knowledge of pediatricians / neonatologists about criteria for screening of rop patients is given in table 3. discussion it was encouraging to find out that 93.5% of the neonatologists and pediatricians were aware of rop. the results are similar to the knowledge attitude practice (kap), study done in south india4, where 97.4% of the 38 participants were aware of the disease. our sample is double to that of the study mentioned. table 3: criteria for rop screening. state the criteria for screening. criteria group i (n=28) group ii (n=34) rop screening at 6 weeks of age 2 (5.9) < 1.5 kg, < 32 wks. gestation, receiving high flow oxygen 2 (7.1) 1 (2.9). premature babies receiving oxygen/mechanical ventilation. 2 (7.1) every premature child 2 (7.1) 1 (2.9) all babies < 1.5 kg to be screened. 1 (2.9) < 32 wks, within 1st. month of birth 1 (2.9) premature babies receiving oxygen / mechanical ventilation. 2 (7.1) awareness of retinopathy of prematurity (rop) amongst pediatricians in pakistan pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 23 although 98.8% thought that rop could cause blindness, only 29% said that only certain babies should be examined by the ophthalmologists, the majority, (71%), thought that all infants needed an ophthalmic screening. when asked about screening criteria, 79% did not answer. as time is a crucial parameter in rop screening, it is currently recommended that a uniform screening protocol should be followed.15 “20thday screening strategy” for the babies born at less than 30 weeks gestational age to detect acute posterior rop at the earliest, and “30th day screening strategy” for infants born between 30 and 35 weeks.11-15 about 50% of the participants had never taken care of an infant with rop. this figure was higher in the young pediatricians, i.e.; 70.8%. there was a screening criterion in 24.2% of the institutions where the participants had come from. although, the survival rate of neonates has increased in pakistan, 16in our survey only twenty one percent of the pediatricians had an ophthalmologist visiting their institution. in the present study, 56.5% agreed that a treatment for rop was available, but when asked about the treatment criteria, 82.2% did not answer at all. only 8% of the doctors knew about laser therapy. these results indicate that the awareness was good, whereas the depth of knowledge, attitude and practice had a lot of room for improvement. partnership groups, like “no rop group5” should work together to improve screening of rop, and, hence treatment and prevention of blindness in premature babies. there should be a consensus amongst ophthalmologists and neonatologists about the screening programs throughout pakistan. availability of the referral services is important on a country based level. in our study, only 21% of the pediatricians had an ophthalmologist visiting their nicu for screening purposes.17 this stresses a need to increase referral services. in a study done by kemper et al.12 the most important barrier for rop screening was „lack of availability of eye care specialists‟. finding barriers is essential for formulating any successful screening program. barriers like „parents not willing‟ and „unaware of referral services‟ were found even in the developed countries like usa.18 the most important factor responsible for the development of rop is the gestational age and birth weight.9risk factors such as supplemental oxygen, sepsis, respiratory distress and anaemia were not significantly associated with rop. cerman e et al19 have divided their results into 3 groups including premature babies less than 28 weeks, those between 29 and 32 weeks and those between 33 and 37 weeks. majority of the pediatricians in our study knew about the risk factors for the development of rop. low birth weight (80.6%), prematurity (75.8%), and high oxygen therapy (85.5%) were the most feared risk factors by the pediatricians.20,21 till date, no study has been published on kap for rop amongst pediatricians in pakistan. the study was done on one of the largest gathering of pediatricians / neonatologist who had come to attend the national conference in lahore, and hence the results cannot be extrapolated to the entire population of pediatricians. conclusion rop awareness should be raised at a national level to improve the development of rop screening and treatment services in pakistan. author’s affiliation prof. muhammad moin dept of ophthalmology ameer-du-din medical college, postgraduate medical institute, lahore general hospital, lahore dr. nasira inayat dept of ophthalmology ameer-du-din medical college, postgraduate medical institute, lahore general hospital, lahore dr. umar k mian department of opthalmology and visual sciences montefiore medical center/albert einstein college of medicine new york, usa dr. ayesha khalid department of pediatrics ameer-du-din medical college, postgraduate medical institute. prof. agha shabbir ali department of pediatrics ameer-du-din medical college, postgraduate medical institute. role of authors prof. muhammad moin data collection, result compilation m. moin, et al 24 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology dr. nasira inayat data collection, manuscript writing dr.umar k mian made questionnaire paper, manuscript review dr. ayesha khalid data collection prof. agha shabbir ali data collection and manuscript review references 1. jalali s, hussain a, matalia j, anand r. modification of screening criteria for india and other middle – income group countries. am j ophthalmol. 2006; 141: 966-8. 2. jalali s, anand r, kumar h, gopal l. programme planning and screening strategy in retionopathy of prematurity. indian j ophthalmol. 2003; 51: 89-97. 3. zin a, gole ga. retinopathy of prematurity-incidence today .clin perinatol. 2013: 40; 185-200. 4. rani p, jalali. knowledge, attitude and practice study of retinopathy of prematurity amongst pediatricians attending a neonatal ventilation workshop in south india. world j of retina & vit. 2011; 1 (1): 9-13. 5. gilbert c. retinopathy of prematurity: a global perspective of epidemics, population of babies at risk and implications for early control. early hum dev. 2008; 84: 77-82. 6. gibson dl, et al. retinopathy of prematurity: a new epidemic? pediatrics. 1989; 83: 486-89. 7. taqui am, et al. retinopathy of prematurity: frequency and risk factors in a tertiary care hospital in karachi, pakistan. jr pak med assoc. 2008; 58: 186-90. 8. hashmi fk, chaudary ta, ahmad k. an evaluation of referral system for retinopathy of prematurity in leading health centers across karachi, pakistan. jr pak med assoc. 2010; 60: 840. 9. gilbert c, fielder a, gordillo l, semiglia r, visintin p, et al. characteristics of infants with severe retinopathy of prematurity in countries of low, moderate, and high levels of development: implications for screening programs. pediatrics, 2005: 518-25. 10. umar k. et al. retinopathy of prematurity and pakistan; an epidemic coming. pak j ophthalmol. 2014; 30: 60-62. 11. vinekar a, et al. retinopathy of prematurity in asian indian babies weighing greater than 1250 g at birth: ten year data from a tertiary care center in a developing country. indian j ophthalmol. 2007; 55: 331-336. 12. kemper ar, freedman sf, wallace dk. retinopathy of prematurity care: patterns of care and workforce analysis. j aapos, 2008; 12: 344-8. 13. kemper ar, wallace dk. neonatologists‟ practices and experiences in arranging retinopathy of prematurity screening services. pediatrics, 2007; 120: 527-31. 14. amer m, et al. retinopathy of prematurity: are we missing any infant with retinopathy of prematurity? br j ophthalmol. 2012; 96: 1052-5. 15. chow lc, write kw, sola a. can changes in clinical practice decrease the incidence of severe retinopathy of prematurity in very low birth weight infants? pediatrics, 2003; 111: 339-45. 16. binkhathlan aa, et al. retinopathy of prematurity in saudi arabia: incidence, risk factors, and the applicability of current screening criteria. br j ophthalmol. 1008; 92: 167-169. 17. chaudary ta, et al. retinopathy of prematurity: an evaluation of existing screening criteria in pakistan. br j ophthmol. 2013; 30: 4018. 18. attar ma, lang sw, bratton sl. barriers to screening infants for retionopathy of prematurity after discharge or transfer from a neonatal intensive care unit. j perinatal. 2005; 25: 36-40. 19. cerman e, balci sy, yenice os. retinopathy of prematurity: dealing with the risk factors. clin perinatol. 2006; 45: 120-126. 20. saugated od. oxygen and retinopathy of prematurity. jr of perinatology. 2006; 26: 46-50. 21. hutchinson ak, saunders ra, o’ neil jw, et el. timing of initial screening examination for retinopathy of prematurity. arch ophthalmol. 1998; 116 (5): 608-612. outcome of cataract surgery at secondary eye hospital 119 pak j ophthalmol. 2022, vol. 38 (2): 119-124 original article outcome of cataract surgery at secondary eye care facility in karachi mahpara mangi 1 , muhammad khizar bashir 2 , mujahid inam 3 department of ophthalmology, 1-3 al-baseer eye hospital, karachi abstract purpose: to find out visual outcome of cataract surgery at secondary eye care hospital in karachi, pakistan. study design: surgical audit. place and duration of study: al-baseer eye hospital, karachi from january 2019 to january 2021. methods: a total of 1540 cataract surgeries were performed. patients referred from distant eye camps (outside of city limits) were not included. data collection was done using hospital medical records on patient’s age, sex, pre-operative best-corrected visual acuity (bcva), surgical complications, visual acuity(va) at 1 st post-operative day, 1, 3 and 4 – 16 post-operative weeks, bcva at 4 – 16 post-operative weeks and causes of poor visual outcome (bcva worse than 6/60) at 4 – 16 post–operative weeks. for data analysis, ibm spss statistics 23 was used. results: out of 1540 cataract surgeries, 81% (1248) cases underwent phacoemulsification with intraocular lens implantation. mean age at the time of surgery was 56.24 ± 11.45 years. males were 54.9% (845) while 45.1% (695) were females. rate of intraoperative complications was 0.9% (14 cases). posterior capsule rupture occurred in 0.8% (13 cases), and zonular disinsertion in 0.1% (1 case). at 4 – 16 weeks post-operatively, follow– up rate was 53.8% (828 patients); and the percentages of patients with good, borderline and poor bcva were 94.7% (784 cases), 2.3% (19 cases), and 3.0% (25 cases) respectively. conclusion: good visual outcome can be obtained after cataract surgery at a secondary eye hospital, provided the surgeons and operating room team are trained, well equipped and follow aseptic measures. key words: phacoemulsification, cataract, posterior capsule, blindness. how to cite this article: mangi m, bashir mk, inaam m. outcome of cataract surgery at secondary eye care facility in karachi. pak j ophthalmol. 2022, 38 (2): 119-124. doi: 10.36351/pjo.v38i2.1341 correspondence: mahpara mangi department of ophthalmology, al-baseer eye hospital, karachi email: mahpara.mangi02@gmail.com received: october 09, 2021 accepted: january 1, 2022 introduction blindness due to cataract is a major health problem in many countries. due to ageing and population growth, the number of cataract patients are expected to increase in coming years. 1 standard treatment is surgical removal of cataract via phacoemulsification/extra-capsular cataract extraction (ecce) or intra-capsular cataract extraction, with intraocular lens implantation or aphakic correction. 2 unless the cataract surgery services are increased and improved, more and more people will continue to suffer from cataract-related visual impairment or blindness. 3 despite advancements in the surgical management of cataract, many patients fear having surgery due to poor visual outcomes, especially in many developing countries. 3 with increase in number of cataract surgery service providers, the need for routine monitoring of outcomes and complication rate is crucial. maintaining and improving quality of surgery will produce better results, and motivate more patients to get early outcome of cataract surgery at secondary eye care facility in karachi pak j ophthalmol. 2022, vol. 38 (2): 119-124 120 treatment. world health organization (who) recommends that the visual outcome is recorded in three groups; good vision (≥ 6/18), borderline vision (6/24 – 6/60), poor vision (worse than 6/60) anywhere between discharge and 12 weeks postoperatively. 3 data from the tertiary care and free eye camps are easily available but surgical outcomes and complication rate at secondary eye hospitals is scarce. this study was conducted to find out if outcomes of cataract surgery at such facility meet who recommendations. methods the study was conducted after obtaining permission and ethical approval from al-baseer eye hospital (erb/04-21/001). we retrieved two years data from the hospital record of al-baseer eye hospital, karachi from january 2019 to january 2021. this secondary eye hospital provides community eye health services and standard cataract surgery facility at subsidized rates or free-of–cost for non-affording individuals. patients referred from distant eye camps (i.e. outside karachi) were not included in this study because they are lost to follow up. all patients underwent routine eye examination, including refraction, slit-lamp examination and fundoscopy. distance visual acuity (va) was measured using snellen chart. blood tests (random blood sugar level, screening for hepatitis b and c, and hiv), blood pressure and cardiac status were checked. biometry was done by a trained staff. patients who were fit for surgery were operated after written consent. after all aseptic measures, operation was done under local or topical anaesthesia by skilled surgeons. depending on case, foldable (single/multipiece) or rigid intraocular lens was implanted. patients were asked to follow up next day for eye examination. topical antibiotics and corticosteroids were prescribed for a month and then gradually tapered. topical nsaids (nepafenac 0.1%), hypertonic saline 5% or beta blocker (levobunolol 0.5%) were advised as per need. subsequent check-ups were done after 1 week and 4 – 16 weeks postoperatively. in patients, who had ecce, bestcorrected visual acuity was recorded 1week after suture removal. data collection was done using previous hospital medical records on patient’s age, sex, pre-operative bcva, intraoperative surgical complications, va at 1st post-operative day, 1 – 3 post-operative weeks, 4 – 16 post-operative weeks and bcva at 4 – 16 postoperative weeks. visual outcome was recorded in three groups; good vision (≥ 6/18), borderline vision (6/24 – 6/60), and poor vision (worse than 6/60). causes of poor visual outcome (bcva worse than 6/60) at 4 – 16 post–operative weeks were found and recorded. causes of poor vision were surgery (due to intraoperative or immediate post-operative complications), spectacles (due to inadequate optical correction) or sequel (due to late postoperative complications). early post-operative complications noted on 1 st post-operative day were also evaluated. for data analysis, ibm spss statistics 23 was used. analyzed data was presented in form of charts, graphs and tables as necessary. results total 1540 cataract surgeries were performed (figure 1). mean age at the time of surgery was 56.24 ± 11.45 years (ranging from 20 to 96 years). there were 54.9% (845) males while 45.1% (695) were females. percentage of intraoperative complications was 0.9% (14 cases). posterior capsule rupture occurred in 0.8% (13 cases) and zonular disinsertion with vitreous presentation in 0.1% (1 case). all cases with posterior capsule rupture with vitreous loss were managed with anterior vitrectomy and intraocular lens placement either in posterior or anterior chamber. one patient figure 1: type of surgery. mahpara mangi, et al 121 pak j ophthalmol. 2022, vol. 38 (2): 119-124 was left aphakic due to insufficient capsular, zonular and iris support. the patient was later referred to tertiary eye hospital for secondary scleral fixation intraocular lens placement. figure 2: comparison between pre-operative bcva and postoperative bcva. follow–up rate fell from 81% (1248 cases) from 1st post-operative day to 53.8% (828 cases) at 4 – 16 weeks post-operatively. among follow-up patients at 1 st post-operative day, presenting va was good in 905 (72.5%), borderline in 146 (11.7%), and poor in 197 (15.8%) cases, while at 4 – 16 weeks post-operatively, the same variables were seen in 742 (89.6%), 52 (6.3%) and 34 (4.1%) cases respectively. with bestcorrection, cases with good vision increased to 784 (94.7%). in 41 (5%) patients visual outcome was borderline/poor due to residual refractive errors and good va was achieved with spectacles (table 1). comparison between pre-operative bcva and postoperative bcva is shown in figure 2. causes of poor bcva at 4 – 16 post-operative weeks were pre-existing eye disease in 22 (88%) cases, and late s complications in 3 (12%) cases. preexisting eye diseases and late post-operative complications are shown in table 2. early post-operative complications were noted in 147(11.7%) depicted in table 3. majority of the complications were successfully managed medically. surgical intervention was done where required. no case of acute endophthalmitis was seen. table 1: post–operative visual acuity. table 1 (post–operative visual acuity) presenting va at 1st post-operative day presenting va at 1-3 post-operative weeks presenting va at 416 post-operative weeks best-corrected vision at 4-16 post-operative weeks good vision (≥ 6/18) 905 (72.5%) 914 (81.2%) 742 (89.6%) 784 (94.7%) borderline vision (6/24 – 6/60) 146 (11.7%) 110 (9.8%) 52 (6.3%) 19 (2.3%) poor vision (worse than 6/60) 197 (15.8%) 101 (9.0%) 34 (4.1%) 25 (3.0%) total no. of patients at follow-up visits 1248 1125 828 828 table 2: causes of poor bestcorrected vision at 4 – 16 post-operative weeks. pre-existing eye diseases post-operative complications optic atrophy 6 (24.0%) persistent corneal edema 2 (8.0%) glaucoma 3 (12.0%) dense posterior capsule opacification 1 (4.0%) maculopathy (cnv, atrophy) 6 (24.0%) macular hole 2 (8.0%) retinitis pigmentosa 1 (4.0%) diabetic retinopathy 1 (4.0%) corneal opacity/degeneration 1 (4.0%) amblyopia 2 (8.0%) total 22 (88.0%) 3 (12.0%) (total number of patients with poor bcva at 4 – 16 weeks postoperatively = 25) (cnv = choroidal neovascularization) table 3: frequency of early post-operative complications noted on 1 st post-operative day. table 3 (frequency of early post-operative complications noted on 1 st post-operative day). striate keratopathy 120 (9.6%) tass (toxic anterior segment syndrome) others 19 (1.5%) 8 (0.6%) uveitis early pco residual cortical matter anterior chamber shallowing hyphema exposure keratitis 2 2 1 1 1 1 total cases 147 (11.7%) discussion cataract, which is opacification of natural lens, is affecting approximately 65.2 million people outcome of cataract surgery at secondary eye care facility in karachi pak j ophthalmol. 2022, vol. 38 (2): 119-124 122 worldwide. 1 according to global burden of disease 2017 study, blindness (va 3˂/60) and severe vision loss (va 6/60-3/60) contributes 5% to total burden of vision loss in pakistan; with cataract being the most common cause ( 5˂0%) especially in aged 60 years and above. the burden of vision loss is estimated to further increase by 2025. 4 studies suggest that gender disparity, sub-standard cataract surgery services for marginalized communities, lack of trained eye-care workforce with experience or access to advance technology and inadequate pre and post-operative assessment, are most likely reasons for cataract and cataract surgery related vision impairment in developing countries. 5 hence, to reduce back-log, there is need for upgrading quantity and quality of cataract surgery service providers. improving quality of surgery by auditing surgical outcome periodically will produce better results, and motivate more patients to get early treatment. limburg h had suggested certain parameters useful in monitoring quality of outcomes as per who guidelines. 1. percentage of surgical complications should be less than 10%. 2. posterior capsule rupture and vitreous loss should be less than 5%. 3. at discharge, va should be good in 5˂0% of cases, and poor should be less than 10%. 4. at 4 weeks or more post-operatively, presenting va should be good in atleast 80% of cases, and poor should be less than 5%. 5. at 4 weeks or more post-operatively, bcva should be good in more than 90% of cases, and poor should be less than 5%. if not, then causes of suboptimal results should be analyzed, and corrected. 2,6 the audit showed that the hospital fulfilled the 1 st , 2 nd , 4 th and 5 th criteria as mentioned above completely. however, 3 rd criterion was partially fulfilled. ideally, at discharge, ˂ 50 % of cases should have good va and less than 10% poor outcome. according to this study, at 1 st post-op day, though the percentage of good vision was 5˂0% (72.5%) but that of poor outcome was higher than 10% (15.8%), which reduced to 4.1% at ≥ 4 weeks post-operatively. in many patients, significant visual improvement was seen after resolution of striate keratopathy and/or removal of tight sutures. percentage of intraoperative complications was 0.9%. most common was posterior capsule rupture (0.8 %), which is lesser than that reported in other studies (0.99% 4.8%). 7-10 rate of zonular dehiscence found in this study (0.1%) is also slightly lesser than that reported by paracha and sanaullah et al. (0.2%). 9,10 the most common early post-operative complication seen at 1 st post-op day was striate keratopathy (9.6%), rate of which is lower than that observed by paracha (10.7%) and mirza et al. 9,11 second most common complication was toxic anterior segment syndrome tass (1.5%) which occurred in clusters. this could be due to intra operative factors (surgical instruments or intraocular medications/ solutions/iol) or post-operative topical medications toxicity. further studies are recommended to find and address causes for such complications. kk shoaib had reported outbreak of tass in 14.8% of his patients in two months. exact cause could not be found. however, increased vigilance resulted in cessation of such cases. 12,13 the conclusive finding of this study was the percentage of best-corrected good vision at ≥ 4 weeks postoperatively which was 94.7%.good visual outcome of our study was higher than that reported in a national survey of pakistan 2007 (50.1% ≥ 6/18 with best-correction), lrbt free eye hospital in lahore (68%), khalifa gul nawaz teaching hospital, kpk (80.5%), aga khan university hospital, karachi (93.3% and 94.5%), punjab eye camps conducted by surgeons from hamdard university hospital(21.4%), and lower dir district malakand (40.5%), 5,10,14-17 but lower than that reported at marie adelaide leprosy centre karachi (97.2%). 9 studies conducted in other developing countries showed good visual outcome in 91.7 %in india,78.8 % in ibadan (nigeria), 26.6% in ethiopia, and 89 % at a regional hospital in ghana. 18-21 causes for poor bcva at 4 – 16 post-op weeks were mostly due to selection (88%) followed by sequel (12%).similar findings were reported by paracha and fk hashmi et al, where majority of cases with poor/borderline bcva had pre-existing ocular diseases. 9,15 three patients suffered from poor bcva due to late post-operative complications. out of two patients with persistent corneal edema, one was referred to cornea specialist. the other patient had coexisting optic atrophy and was kept on topical medications. mahpara mangi, et al 123 pak j ophthalmol. 2022, vol. 38 (2): 119-124 third patient with dense posterior capsule opacification, was lost to follow-up, though he was counselled about the need for capsulotomy at postoperative visit. percentage of follow–up visit was 53.8% (828 patients) at 4 – 16 weeks post-operatively as depicted in table 1. possible reasons for decrease in follow-up could be good vision, travel restrictions due to covid-19 pandemic, unstable health or socioeconomic conditions. however a study by limburg h. suggested that those returning for follow up were representative of the total, and that at ≥ 6 months postoperatively, the outcome data for the non-attenders did not differ remarkably from those who did attend. 22 in light of this, we can reasonably extrapolate our results to those who did not follow-up. inspite of good results, surgeons and associated team members should not stay complacent, rather work harder to maintain, and to increase cataract services effectiveness and efficiency. low follow-up rate at 4-16 weeks post-operatively was a limitation of this study. single-centre study, results from one secondary eye hospital cannot be generalized for other similar centres. subjective refraction done using snellen chart instead of logarithm of the minimal angle of resolution (logmar). literature shows that logmar chart is recommended in research studies as it is more reliable than snellen. 23 objective residual refractive errors were not analyzed as patients with good vision (6/18 – 6/9) may require glasses to attain va of 6/6. lateonset complications occurring beyond 4 16 weeks post-operatively were not evaluated. conclusion good visual outcome as per who recommendations can be obtained after cataract surgery at secondary eye hospital; provided that the surgeons and operating room team are trained, well equipped, and follow aseptic measures. routine monitoring by hospitals and surgeons using who guidelines will help in assessing quality of cataract surgery services over time. acknowledgment authors would like to acknowledge al-baseer eye hospital administration and staff for their cooperation. ethical approval the study was approved by the institutional review board/ethical review board (abeh-erb/04-21/001). conflict of interest authors declared no conflict of interest. references 1. world health organization. world report on vision: executive summary. who; 2019. 2. world health organization. informal consultation on analysis of blindness prevention outcomes. geneva: who; 1998. 3. foster a. cataract and ―vision 2020—the right to sight‖ initiative. br j ophthalmol. 2001; 85: 635-637. 4. hassan b, ahmed r, li b, noor a, hassan zu. a comprehensive study capturing vision loss burden in pakistan (1990 – 2025): findings from the global burden of disease (gbd) 2017 study. plos one, 2019; 14 (5): e0216492. 5. bourne r, dineen b, jadoon z, lee ps, khan a, johnson gj, et al. outcomes of cataract surgery in pakistan: results from the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91 (4): 420-426. 6. limburg h. monitoring cataract surgical outcomes: methods and tools. community eye health, 2002; 15 (44): 51-53. 7. aaronson a, viljanen a, kanclerz p, grzybowski a, tuuminen r. cataract complications study: an analysis of adverse effects among 14,520 eyes in relation to surgical experience. ann transl med. 2020; 8 (22). 8. chhipa sa, junejo mk. outcomes of cataract surgery at teaching hospital in karachi. j pak med assoc. 2018; 68 (1): 76. 9. paracha q. cataract surgery at marie adelaide leprosy centre karachi: an audit. j pak med assoc. 2011; 61 (7): 688-690. 10. sanaullah ms, murtaza b, muhammad r, akhtar s. visual outcome of cataract surgery after phacoemulsification. pak j ophthalmol. 2017; 33 (4). 11. mirza aa, al-khairy s, hassan m, mirza sa, aslam s, siddique f. intra-operative and immediate post-operative complications in patients after cataract surgery in an eye camp. pak j ophthalmol. 2020; 36 (3): 226-230. 12. sengillo jd, chen y, garcia dp, schwartz sg, grzybowski a, flynn jr hw. postoperative endophthalmitis and toxic anterior segment syndrome prophylaxis: 2020 update. ann transl med. 2020; 8 (22). outcome of cataract surgery at secondary eye care facility in karachi pak j ophthalmol. 2022, vol. 38 (2): 119-124 124 13. shoaib kk. features, causes and prevention of toxic anterior segment syndrome (tass)-an outbreak investigation. pak j ophthalmol. 2013; 29 (2). 14. malik ar, qazi za, gilbert c. visual outcome after high volume cataract surgery in pakistan. br j ophthalmol. 2003; 87 (8): 937-940. 15. hashmi fk, khan qa, chaudhry ta, ahmad k. visual outcome of cataract surgery. j coll physicians surg pak. 2013; 23 (6): 448. 16. ahmed t, ahmed t, ghaffar z, ali a, shadmani s. evaluation of visual outcome of cataract surgery in five consecutive rural eye camps. pak j surg. 2012; 28 (1): 57-59. 17. shaikh sp, aziz tm. rapid assessment of cataract surgical services in age group 50 years and above in lower dir district malakand, pakistan. j coll physicians surg pak. 2005; 15 (3): 145-148. 18. matta s, park j, palamaner subash shantha g, khanna rc, rao gn. cataract surgery visual outcomes and associated risk factors in secondary level eye care centers of lv prasad eye institute, india. plos one, 2016; 11 (1): e0144853. 19. olawoye oo, ashaye ao, bekibele co, ajayi bg. visual outcome after cataract surgery at the university college hospital, ibadan. ann ib postgrad med. 2011; 9 (1): 8-13. 20. hussen ms, gebreselassie kl, seid ma, belete gt. visual outcome of cataract surgery at gondar university hospital tertiary eye care and training center, north west ethiopia. clin optom (auckl). 2017; 9: 19. 21. kobia-acquah e, pascal tm, amedo a, koomson ny. visual outcome after cataract surgery at the sunyani regional hospital, ghana. ec ophthalmol. 2018; 9: 181-188. 22. limburg h, foster a, gilbert c, johnson gj, kyndt m. routine monitoring of visual outcome of cataract surgery. part 1: development of an instrument. br j ophthalmol. 2005; 89 (1): 45-49. 23. patel h, congdon n, strauss g, lansingh c. a need for standardization in visual acuity measurement. arq bras oftalmol. 2017; 80 (5): 332-337. authors’ designation and contribution mahpara mangi; consultant ophthalmologist: literature search, data acquisition, data analysis, statistical analysis, manuscript preparation. muhammad khizar bashir; consultant ophthalmologist: concepts, design, data acquisition, manuscript editing, manuscript review. mujahid inam; consultant ophthalmologist: literature search, manuscript preparation, manuscript editing, manuscript review. .…  …. 327 pak j ophthalmol. 2021, vol. 37 (3): 327-329 brief communication acute macular neuro-retinopathy: a rare retinal disorder, presenting as paracentral scotoma royala zaka 1 , yasir khan 2 , zaki-ud-din ahmed sabri 3 1-3 prevention of blindness a trust based hospital, karachi – pakistan abstract acute macular neuro-retinopathy (amn) is a rare clinical entity. we present a case of 26 years old male who presented with one-week old history of sudden onset of decrease vision in left eye associated with paracentral scotomas. dilated fundus examination of the left eye showed multiple reddish brownish petalloid para-foveal lesions with apex pointing toward the fovea. oct showed hyper-reflective bands in the outer nuclear layer and outer plexiform layer along with disruption of ellipsoid zones. amsler grid drawn by the patient and the visual field showed scotoma corresponding to the macular lesion. the cause turned out to be undiagnosed essential hypertension. purpose of presenting this case is that high definition optical coherence tomography (sd-oct) makes diagnosis of some rare conditions easy and fast for an ophthalmologist, that might be misdiagnosed or missed with conventional oct and ffa imaging test. key words: acute macular neuro-retinopathy, spectral domain optical coherence tomography, paracentral scotoma. how to cite this article: zaka r, khan y, sabri zda. acute macular neuro-retinopathy: a rare retinal disorder, presenting as paracentral scotoma. pak j ophthalmol. 2021, 37 (3): 327-329. doi: 10.36351/pjo.v37i3.1225 introduction bos and deutman in 1975 were the first to describe acute macular neuro-retinopathy (amn). 1 since then, one hundred and fifty six cases of amn have been reported till 2016. 2,3 five cases of amn, reportedly caused by non-ocular trauma, were studied on oct first by nentwich et al, that showed the defect in the outer retina supporting the gillies et al work. 4,5 based on oct findings, there are 2 types of amn, type 1 the classic amn points to hyperreflective bands in the outer plexiform layer along with ellipsoid disruption and outer nuclear layer and type 2 amn refers to hyper-reflective bands in the correspondence: royala zaka prevention of blindness a trust based hospital, karachi – pakistan email: drroyala@hotmail.com received: february 09, 2021 accepted: april 28, 2021 outer plexiform and inner nuclear layer. 6 deep retinal capillary plexus ischemia is thought to be associated with both types. 7 we describe a case of amn in a 26-year old male who presented with paracentral scotoma and on oct it was diagnosed as amn. case presentation a 26-year old man presented in eye out patient department with history of decrease vision in left eye that was sudden along with paracentral scotoma for 1 week. there was no history of smoking, drugs, trauma, surgery, hypotension, caffeine or fever, flu or sinus infection. best-corrected visual acuity (bcva) measured 20/20 od and 20/30 os, and intraocular pressures were within normal limits ou. pupillary examination and anterior segment was unremarkable in both the eyes done by slit lamp biomicroscopy. dilated fundus examination showed multiple perifoveal petalloid shaped lesion with the apex pointing towards the fovea in left eye. (figure 1 color open access acute macular neuro-retinopathy: a rare retinal disorder, presenting as paracentral scotoma pak j ophthalmol. 2021, vol. 37 (3): 327-329 328 fundus photograph and infrared imaging that highlights the lesion and figure 2 of optical coherence tomography shows hyper-reflective bands in the outer nuclear layer and outer plexiform layer, along with disruption of ellipsoid and inter-digitation zones). the right eye fundus was normal. amsler grid showed scotoma corresponding to the macular lesion drawn by the patient and so did the visual field of the left eye as shown in the figure 3a of visual field and 3 bamsler grid. patient’s consent was sought before preparation of case report. figure 1: color and infrared fundus photo of the left eye demonstrating a reddish brownish petalloid lesion on the macula. the right-most image shows mild recovery after 5 months of follow up. figure 2: oct showshyper-reflective bands in the onl and opl, along with disruption of ellipsoid and interdigitation zones. figure 3: visual field and amsler grid shows paracentral lesion corresponding to the scotoma and the retinal lesion on the of figure 1. discussion we found the typical clinical features of amn in our patient. infrared clearly highlights the features of amn in more detail. hyper-reflective bands in the outer nuclear layer and outer plexiform layer with ellipsoid and interdigitation zone disruption showed that it was a classic type 1 amn. earlier a case of amn was seen in a woman using oral contraceptive pills. 6 other conditions like dengue fever, cocaine use, trauma, shock, eclampsia, epinephrine, sympathomimetic use, hypovolaemia, heavy coffee or caffeine intake and systemic lupus erythematosus are also reported to be associated with amn. the two types of amn have been recently described by rahimsy and colleagues as two separate entities. 8 the one, involving the outer retina as in our patient is considered as classic type 1 and paracentral acute middle maculopathy pamm type 2 based on oct results. 8 it was seen that although there are no signs of hypertensive retinopathy but our patient found to have essential hypertension. we counselled and referred the patient to the internist to control his blood pressure. however, on his second follow up visit after https://www.karger.com/article/fulltext/496144#f01 royala zaka, et al 329 pak j ophthalmol. 2021, vol. 37 (3): 327-329 3 months, his findings remained more or less the same and scotoma persisted. that could be because of the thinning of the retinal layers/outer nuclear layer that is involved by the lesion. 9 conclusion amn is a rare disease entity and in our case it was associated with essential hypertension that the patient was unaware of. it is very important to diagnose rare cases using relevant investigation to save unnecessary time and money of the institute and the patient. conflict of interest authors declared no conflict of interest. disclaimer this case report has been presented as a poster in 35th singapore malaysia joint meeting in ophthalmology in conjunction with 1st asia pacific ocular imaging society meeting 17-19th jan 2020. references 1. bos pjm, deutman af. acute macular neuroretinopathy. am j ophthalmol. 1975; 80 (4): 573584. 2. bhavsar kv, lin s, rahimy e, joseph a, freund kb, sarraf d, et al. acute macular neuroretinopathy: a comprehensive review of the literature. surv ophthalmology, 2016; 61 (5): 538-565. 3. kim se, lee se, kim y-y. a case of acute macular neuroretinopathy after non-ocular trauma. j korean ophthalmol. 1970; 57 (12): 1970-1975. 4. kuriakose rk, chin ek, almeida drp. an atypical presentation of acute macular neuroretinopathy after non-ocular trauma. case rep ophthalmol. 2019; 10 (1): 1-4. 5. gillies m, sarks j, dunlop c, mitchell p. traumatic retinopathy resembling acute macular neuroretinopathy. aust n z j ophthalmol. 1997; 25: 207-210. 6. kumar v, tewari r, yadav d, vikas sj. acute macular neuroretinopathy in a young hypertensive patient. clin exp optom. 2017; 100 (3): 288-290. 7. yu s, pang ce, gong y, freund kb, yannuzzi la, rahimy e, et al. the spectrum of superficial and deep capillary ischemia in retinal artery occlusion. am j ohthalmol. 2015; 159 (1): 53-63. e2. 8. rahimy e, kuehlewein l, sadda sr, sarraf d. paracentral acute middle maculopathy: what we knew then and what we know now. retina. 2015; 35 (10): 1921-1930. doi: 10.1097/iae.0000000000000785. 9. fawzi aa, pappuru rr, sarraf d, le pp, mccannel ca, sobrin l, et al. acute macular neuroretinopathy: long-term insights revealed by multimodal imaging. retina, 2012; 32 (8): 1500-1513. authors’ designation and contribution royala zaka; consultant ophthalmologist: concepts, design, literature search, data analysis, manuscript preparation. yasir khan; consultant ophthalmologist: data acquisition, statistical analysis, manuscript editing. zaki-ud-din ahmed sabri; consultant ophthalmologist: literature search, manuscript editing, manuscript review. .…  …. 242 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology abstracts edited by dr. qasim lateef chaudhry role of corneal collagen cross-linking in pseudophakic bullous keratopathy a clinico pathological study arora r, manudhane a, saran rk, goyal j, goyal g, gupta d ophthalmology 2013; 120: 2413-8. in this randomized, prospective, interventional study ritu et al evaluated the clinical and histopathologic changes induced by collagen cross–linking (cxl) in twenty–four pseudophakic bullous keratopathy (pbk) patients. these patients with pbk underwent cxl followed by keratoplasty at 1 or 3 months. twelve patients underwent penetrating keratoplasty 1 month after cxl (group a) and the remaining 12 patients underwent penetrating keratoplasty 3 months after cxl (group b). the main outcome measures were assessed at 1 week and 1 month for all patients and at 3 months for 12 patients only. the corneal buttons underwent histopathologic and immune fluorescence evaluation. the main outcome measures were visual acuity, ocular discomfort (tearing, redness, pain), corneal haze, central corneal thickness, histopathologic evaluation, and immune fluorescent microscopy. mean visual acuity showed a significant improvement after cxl, from 1.925 0.173 before surgery to 1.75 0.296 at 1 month after surgery (p¼ 0.010), but deteriorated to 1.81 0.23 at 3 months. symptomatic relief after cxl was at a maximum at 1 month, with a worsening trend at 3 months. eighteen patients showed a reduction in corneal haze 1 month after cxl. the effect was maintained in 9 of 12 patients at 3 months. the mean central corneal thickness decreased significantly from 846.46 88.741 to 781.0 98.788 mm at 1 month (p<0.01) after cxl, but increased to 805.08 136.06mm at 3 months. immunofluorescence microscopy revealed anterior stromal compaction in 7 of 12 patients (58.3%) in group a and in 5 of 12 patients (41.6%) in group b. staining of keratocyte nuclei with 40, 6-diaminido-2-phenylindole dihydrochloride (molecular probes, carlsband, ca) revealed a relative uniform distribution throughout the stroma. the authors concluded that collagen cross– linking causes symptomatic relief and a decrease in central corneal thickness and anterior stromal compaction in pbk. however, the effect decreases with time and depends on disease severity. twenty – four hour efficacy with preservative free tafluprost compared with latanoprost in patients with primary open angle glaucoma or ocular hypertension konstas agp, quaranta l, katsanos a, riva i, tsai jc, giannopoulos t, voudouragkaki ic, paschalinou e, floriani i, haidich ab br j ophthalmol. 2013; 97: 1510-15. anastasios et al compared 24 h intraocular pressure (iop) control obtained with preservative free (pf) tafluprost 0.0015% versus branded preservative containing latanoprost 0.005% administered as first choice monotherapy in patients with primary open angle glaucoma (poag) or ocular hypertension (oht) in this prospective, observer-masked, crossover study including consecutive newly diagnosed patients with poag or oht, and baseline iop between 24 and 33mm hg. qualifying patients underwent baseline untreated 24 h iop monitoring in habitual positions, with goldmann tonometry at times 10:00, 14:00, 18:00 and 22:00, and perkins supine tonometry at times 02:00 and 06:00. they were then randomised to either latanoprost or tafluprost, administered in the evening, for 3 months and then switched to the opposite therapy for another 3 months. 24 h monitoring was repeated at the end of each treatment period. 38 patients completed the study. mean untreated 24 h iop (24.9 mm hg) was significantly reduced with both prostaglandins (p<0.001). tafluprost demonstrated similar mean 24 h efficacy compared with latanoprost (17.8 vs 17.7 mm hg; p=0.417). latanoprost demonstrated significantly better 24 h trough iop (15.9 vs 16.3 mm hg; p=0.041) where as tafluprost provided significantly lower 24 h iop fluctuation (3.2 vs 3.8 mm hg; p=0.008). no significant difference existed between the two prostaglandins for any adverse event. the authors concluded that pf tafluprost achieved similar 24 h iop reduction to branded latanoprost. abstracts pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 243 spontaneous vitreous hemorrhage in children sudhalkar a, chhablani j, jalali s, mathai a, pathengay a am j ophthalmol. 2013; 156: 1267-71. aditya et al conducted this retrospective computer – assisted chart review study to determine the clinical profile, causes, and outcomes of ‘‘spontaneous’’ vitreous hemorrhage in children (<18 years). charts of 124 eyes of 76 children who presented with non traumatic, non surgical vitreous hemorrhage between 2002 and 2012 were reviewed. all children underwent an appropriate ocular and systemic examination. data collected included demographics, visual acuity, cause of ‘‘spontaneous’’ vitreous hemorrhage, ocular and systemic findings at presentation and at last follow-up, investigations, management details, and visual outcomes. the median age was 153.45 ± 56.19 months and there were 39 female and 37 male patients in this study. forty-eight patients had bilateral vitreous hemorrhage. the most common presenting complaints were diminished vision (96.45%) and behavioral changes (87.24%). the mean baseline bcva in logmar was 2.25 ± 1.11. the most common causes included vasculitis (34.6%) and hematologic disorders (27.4%). patients were given medical therapy (topical and/or systemic) or underwent laser photocoagulation (29%) and/or surgery (55.6%). twenty-nine eyes (23.3%) did not require any intervention. the mean number of surgeries was 1.89 ± 1.45 (range 1-4 surgeries). the mean final visual acuity was 0.76 ± 0.58 logmar and was significantly better than the baseline (p <.001). the best anatomic and visual outcomes were seen in vasculitis, whereas congenital disorders such as retinoschisis had the worst. the authors concluded that spontaneous pediatric vitreous hemorrhage has a diverse etiology, vasculitis being the most common cause in this series. a comprehensive evaluation (systemic and ocular) is required to ensure that vision and life-threatening conditions are not missed. persistent outer retinal fluid following nonposturing surgery for idiopathic macular hole rahman r, oxley l, stephenson j br j ophthalmol. 2013; 97: 1451-4. rubina et al presented the anatomical and visual outcomes of patients with hypo-reflective cystic defects in outer fovea (outer foveal defect; ofd) in macular holes repaired with non-posturing vitrectomy and short term gas tamponade. this prospective consecutive case series study of 58 patients undergoing macular hole surgery also identified the incidence and risk factors for developing ofd. two week post operative optical coherence tomography (oct) was done in all patients and ofd was measured. in these patients oct was performed monthly until resolution of ofd. 27 eyes (46.6%) had an outer defect at 2 weeks, the presence of which was significantly associated with macular holes with larger base diameters preoperatively (p = 0.006). all defects closed spontaneously without further intervention, and the final vision was not affected by the presence of an ofd. visual recovery was only slightly (and not significantly) delayed by the presence of an outer defect. in this first study of outcomes of ofds following macular hole surgery in patients who did not posture postoperatively the authors concluded that ofds are common but do not adversely affect visual outcomes. 223 pak j ophthalmol. 2021, vol. 37 (2): 223-227 original article factors predisposing to rhegmatogenous retinal detachment in a tertiary care hospital of pakistan sahira wasim 1 , imran ghayoor 2 , munira shakir 3 , ronak afza 4 , waqas ali 5 1-5 department of ophthalmology, liaquat national university hospital, karachi abstract purpose: to find out the factors predisposing to rhegmatogenous retinal detachment. study design: descriptive cross sectional study. place and duration of study: liaquat national hospital, karachi, from october 2017 to april 2018. methods: after approval from ethical review committee 117 patients presenting with rhegmatogenous retinal detachment (rrd) were included in the study. a detailed history was taken including previous surgery and trauma. complete ocular examination was performed including dilated fundus examination. data was analyzed using spss version 21. mean and standard deviation were computed for quantitative variable i.e. age and frequency. percentages were calculated for qualitative variables i.e. gender, eye involved, lattice degeneration, trauma and intraocular surgery. stratification was done with regards to age, gender, eye involved to see the effect of these modifiers on individual factor (lattice degeneration, trauma, intraocular surgery) by using chi square test and considering p value ≤ 0.05 as significant. results: there were 117 patients including 91 males and 26 females. sixty four were right eyes and fifty three were left eyes. mean age was 37.30 ± 8.97 years. lattice degeneration was observed in 29.1% patents, trauma was 37.6% and intraocular surgery was observed in 33.3% patients. there was a significant association of age with trauma (p = 0.045) and intraocular surgery (p = 0.001), which had statistically significant association with rrd. conclusion: intraocular surgery, trauma were significantly associated with age and rrd. however, although lattice degeneration is an established risk factors for rhegmatogenous retinal detachment it was not associated with increased age. key words: rhegmatogenous retinal detachment, lattice degeneration, trauma, intraocular surgery. how to cite this article: wasim s, ghayoor i, shakir m, afza r, ali w. factors predisposing to rhegmatogenous retinal detachment in a tertiary care hospital of pakistan. pak j ophthalmol. 2021, 37 (1): 223-227. doi: http://doi.org/10.36351/pjo.v37i2.1172 introduction in rrd longer duration of detached retina involving correspondence: sahira wasim department of ophthalmology, liaquat national university hospital, karachi email: sahirawasim@gmail.com received: november 26, 2020 accepted: february 10, 2021 the macula and foveal center causes profound vision loss in the affected eye leading to complete blindness if not treated in time. 1,2 according to some reports, the annual incidence of rd is between 6 to 12 per 100,000 population per year. 3 rd is classified into three types on the basis of clinical appearance. rhegmatogenous retinal detachment (rrd), tractional retinal detachment (trd) and exudative/serous retinal detachment. 4 rhegmatogenous retinal detachment is an ophthalmic surgical emergenc, 5 and also the most http://doi.org/10.3352/jeehp.2013.10.3 mailto:sahirawasim@gmail.com factors predisposing to rhegmatogenous retinal detachment in a tertiary care hospital of pakistan pak j ophthalmol. 2021, vol. 37 (2): 223-227 224 commonly seen type. 6,7 it is caused by liquefied vitreous which leads to traction forces producing a retinal break. fluid gains access into the sub-retinal space and leads to rrd. 8 it is a common sightthreatening condition. 9 a study from singapore reported an annual incidence of rrd as 10.5 per 100 000. 10 trd and exudative/serous retinal detachment are less common. common factors contributing to development of rrd are lattice degeneration, trauma and intraocular surgery. 11,12 the aim of our study was to evaluate the frequency of common factors in our population as local data is scarce. it can be helpful in reducing the incidence and potential complications caused by rrd. in high risk cases, regular follow up will help in early detection to prevent delay in treatment and better surgical outcome can be achieved. methods the study was conducted in department of ophthalmology, liaquat national hospital, karachi, from 31 st october 2017 to 30 th april 2018, after approval from hospital ethical review committee. sample size was calculated by who software for sample size. by taking prevalence of lattice degeneration = 18.1%, d = 7%, and 95% confidence level, the calculated sample size was 117 eyes. nonprobability consecutive sampling technique was used. inclusion criteria was patients presenting with rrd, diagnosed by consultant ophthalmologist, age 20years and above and either gender. patients with tractional and exudative/serous detachments and rrd with vitreous hemorrhage were excluded. verbal informed consent was obtained for all patients before data collection. all demographic information like name, age, gender were recorded. a detailed history was sought. history of cataract surgery was confirmed on examination. slit lamp and dilated fundus examination was done pre-operatively to identify type of retinal detachment and associated factors as mentioned above. all information were collected on especially designed performa. data was analyzed by using spss version 21. mean and standard deviation were computed for quantitative variable i.e. age. frequency and percentage were calculated for qualitative variables i.e. gender, eye involved, lattice degeneration, trauma, intraocular surgery. stratification was done with regards to age, gender, eye involved to see the effect of these modifiers on individual factors (lattice degeneration, trauma, intraocular surgery) by using chi square test and considering p value ≤ 0.05 as significant. results total 117 patients of either gender with age more than 20 years were included. out of total study subjects, 91 (77.8%) were males and 26 (22.2%) were females. there were 64 (54.7%) right and 53 (45.3%) left eyes (table-1). mean age of the subjects was 37.30 ± 8.97 years. age was stratified into two groups. age was further evaluated according to stratified groups. it was observed that mean age of patients with age ≤ 35 years was 28.12 ± 4.52 years and it was 44.15 ± 3.87 years among patients with age > 35 years. the detailed descriptive statistics of age are presented in table-1. fig. 1: histogram presenting distribution of age (n = 117). table 1: descriptive statistics of patients under study. variable frequency (%) age (mean ± sd) 37.30 ± 8.97 age ≤35 years 50 (42.7%) >35 years 67 (57.2%) gender male 91 (77.8) female 26 (22.2) eye involved right 64 (54.7) left 53 (45.3) sahira wasim, et al 225 pak j ophthalmol. 2021, vol. 37 (2): 223-227 lattice degeneration yes 34 (29.1) no 83 (70.9) trauma yes 44 (37.6) no 73 (62.4) intraocular surgery yes 39 (33.3) no 78 (66.7) it was observed that lattice degeneration was observed in 29.1%, history of trauma was present in 37.6% and history of intraocular surgery was present in 33.3%. the detailed descriptive statistics are presented in table-2. stratification with respect to gender, age, and eye involved was done to observe the effect of these modifiers on individual factors using chi square test. p-value ≤ 0.05 was considered significant. the results showed that there was significant association of age with trauma (p = 0.045) and intraocular surgery (p = 0.001). the detailed results are presented in table-2. table 2: association of demographic findings with lattice degeneration, trauma and intraocular surgery. lattice degeneration p-value trauma p-value intraocular surgery p-value yes no yes no yes no age ≤ 35 years 18 (36) 32 (64) 0.153** 24 (48) 26 (52) 0.045* 8 (16) 42 (84) 0.001* > 35 years 16 (23.9) 51 (76.1) 20 (29.9) 47 (70) 31 (46.3) 36 (53.7) gender male 26 (28.6) 65 (71.4) 0.828** 35 (38.5) 56 (61.5) 0.721** 30 (33) 61 (66.7) 0.828** female 8 (30.8) 18 (69.2) 9 (34.6) 17 (65.4) 9 (34.6) 17 (65.4) eye involved right 21 (33.3) 42 (66.7) 0.226** 20 (31.7) 43 (68.3) 0.226** 22 (34.9) 41 (65.1) 0.638** left 12 (23.1) 40 (76.9) 24 (46.2) 28 (53.8) 16 (30.8) 36 (69.2) chi-square test is applied. *significant at p-value < 0.05 **insignificant at p-value > 0.05 discussion our study findings showed more male patients than females with mean age 37.30 ± 8.97 years with range of 20 to 50 years. there were more right eyes which had rrd. other studies have shown that 3.1% cases rrd had history of trauma. in ethopia, cases of rrd had history of trauma. this percentage was 30% in south africa and 8% in kenya. 4 risk of rrd with cataract surgery was 19% from minnesota studies, 30.8% in swedish and 10% in chinese reports. this association is also reported in uk and south american studies. 10 a higher proportion of lattice degeneration was found in japanese studies (60 – 65%). 10 laser photocoagulation and cryotherapy are effective in preventing rrd if holes are detected earlier. due to the patient’s unawareness and on-going pre/intra/sub-retinal fibrosis there is development of proliferative vitreoretinopathy (pvr), making the surgical correction a difficult procedure and worsening the visual outcomes. our study showed that majority of the detachments were found around 50 years of age. it was also seen as males were more commonly affected with rrd than females. the reason could be outdoor activities make the males more prone to trauma. in third world countries there seemed to be a trend towards delayed presentation of retinal detachments to retina specialists. 12 lack of education and limited clinical resources are the likely contributory factors. average presentation time in these patients was 97.24 ± 16.95 days. this much time considerably compromises visual and anatomical surgical success rates. 13 the major risk factors associated with increased incidence of rrd were intraocular surgery, 14 trauma and peripheral lattice degeneration in decreasing order of frequency. 15 in another study, among 107 operated eyes, there were 44.8% myopic eyes and lattice degeneration was present in 39.5% of the myopic eyes. however, we did not study this factor in our study. a uk based study reported an overall, mean prevalence of lattice degeneration to be 45.7 ± 20.3% and of myopia to be 47.28 ± 12.59%. 10 in a study majority of the myopic detachments (45 of 48) were present in phakic eyes depicting their early age wise occurrence before patients usually undergo senile cataract surgery. 11 factors predisposing to rhegmatogenous retinal detachment in a tertiary care hospital of pakistan pak j ophthalmol. 2021, vol. 37 (2): 223-227 226 burton reported that patients between 40 and 60 years of age with premature posterior vitreous separation and tractional tears are found among those with lattice degeneration and low to moderate degrees of myopia leads to detachments. 16 similar presentation of 37% of total rrd in phakic and aphakic eyes in a total of 114 eyes has been reported in india by rajendran. 17 studies from pakistan reported 95% macula-off detachments in a series of 45 cases 18 and 80% in another series of 175 cases of rrd. 19 inferior as compared to superior half and temporal as compared to nasal half were observed to be more frequently affected. 11 sometimes no break is identified in rrd. factors contributing to inability to find out primary breaks in aphakic/pseudophakic eyes include small size of break, peripherally located breaks, poor visualization on indirect ophthalmoscopy due to distortions by intraocular lens and obscuration by peripheral capsular opacification. 20 in 38.3% eyes only one break could be identified and in 29.9% eyes two or more breaks were present. majority of the primary breaks were horseshoe tears. 21 the main limitation of our study was the small sample size. it was a single-center experience and descriptive cross sectional study design. only few factors were studied. further studies addressing other factors need to be done from other centers. conclusion trauma with 37.6% was the commonest factor followed by intraocular surgery with 33.3% and lattice degeneration with 29.1%. age was found as a significant factor for trauma and intraocular surgery. ethical approval the study was approved by the institutional review board/ ethical review board. (0350-2017-lnh-erc). conflict of interest authors declared no conflict of interest. references 1. steel d. retinal detachment. bmj clin evid. 2014; 2014: 0710. 2. caiado rr, magalhaes jr o, badaro e, maia a, novais ea, stefanini fr, et al. effect of lens status in the surgical success of 23-gauge primary vitrectomy for the management of rhegmatogenous retinal detachment: the pan am. collaborative retina study (pacores) group results. retina. 2015; 35 (2): 326-333. 3. khanzada ma, wahab s, hargun ld. impact of duration of macula off rhegmatogenous retinal detachment on visual outcome. pak j med sci. 2014; 30 (3): 525. 4. solomon b, teshome t. factors predisposing to rhegmatogenous retinal detachment among ethiopians. ethiop j health dev. 2011; 25 (1): 31-34. 5. feltgen n, walter p. rhegmatogenous retinal detachment — an ophthalmologic emergency. deut arztebl int. 2014; 111 (1-2): 12. 6. tareen s, tahir ma, cheema am. surgical audit of outcome of rhegmatogenous retinal detachment repair at vitreoretinal unit jpmc in year 2014. pak j med sci. 2016; 32 (1): 101. 7. poulsen cd, peto t, grauslund j, green a. epidemiologic characteristics of retinal detachment surgery at a specialized unit in denmark. acta ophthalmologica. 2016; 94 (6): 548-555. 8. lumi x, luznik z, petrovski g, petrovski be, hawlina m. anatomical success rate of pars planavitrectomy for treatment of complex rhegmatogenous retinal detachment. bmc ophthalmol. 2016; 16 (1): 216. 9. mitry d, singh j, yorston d, siddiqui mr, wright a, fleck bw, et al. the predisposing pathology and clinical characteristics in the scottish rd study. ophthalmology, 2011 jul; 118 (7): 1429-1434. 10. mitry d, charteris dg, fleck bw, campbell h, singh j. the epidemiology of rhegmatogenous retinal detachment: geographical variation and clinical associations. br j ophthalmol. 2010; 94 (6): 678-684. 11. jamil mh, farooq n, khan mt, jamil az. characteristics and pattern of rhegmatogenous retinal detachment in pakistan. j coll physicians surg pak. 2012; 22 (8): 501-504. 12. yorston d, jalali s. retinal detachment in developing countries. eye, 2002; 16: 353-358. 13. james m, o'doherty m, beatty s. the prognostic influence of chronicity of rhegmatogenous retinal detachment on anatomic success after re-attachment surgery. am j ophthalmol. 2007; 143: 1032-1034. 14. ripandelli g, coppé am, parisi v, olzi d, scassa c, chiaravalloti a, et al. posterior vitreous detachment and retinal detachment after cataract surgery. ophthalmol. 2007; 114: 692-697. 15. gariano rf, kim ch. evaluation and management of suspected retinal detachment. am fam physician 2004; 69: 1691-1698. sahira wasim, et al 227 pak j ophthalmol. 2021, vol. 37 (2): 223-227 16. burton tc. the influence of refractive error and lattice degeneration on the incidence of retinal detachment. trans am ophthalmol soc. 1989; 87: 143-157. 17. rajendran b, pradeep b, sitaramanjaneyulu b. retinal detachments in phakics and aphakics: a clinical study. indian j ophthalmol. 1983; 31: 1060-1063. 18. jan s, iqbal a, saeed n, ishaq a, khan md. conventional retinal re-attachment surgery. j coll physicians surg pak. 2004; 14: 470-473. 19. adhi mi, jan ma, ali a, rizvi f, aziz mu, hasan ks. retinal detachment surgery by scleral buckling procedure: experience in 175 cases. pak j ophthalmol. 1996; 12: 85-90. 20. lee jy, min s, chang wh. clinical characteristics of traumatic rhegmatogenous retinal detachment. j korean ophthalmolsoc.2009; 50: 1207-1214. 21. solomon sd, dong lm, haller ja, gilson mm, hawkins bs, bressler nm. risk factors for rhegmatogenous retinal detachment in the submacular surgery trials: sst report no. 22. retina, 2009; 29 (6): 819-824. authors’ designation and contribution sahira wasim; resident: concepts, design, literature search, data acquisition, manuscript preparation, manuscript editing, manuscript review. imran ghayoor; professor: concepts, design, manuscript preparation, manuscript editing, manuscript review. munira shakir; associate professor: manuscript preparation, manuscript editing, manuscript review. ronak afza; resident: literature search, data acquisition, data analysis, statistical analysis. waqas ali; resident: literature search, data analysis, statistical analysis, manuscript review. .…  …. 179 pak j ophthalmol. 2020, vol. 36 (2): 179-188 review article neuroimaging in neuro-ophthalmology (systematic review) tayyaba gul malik 1 , khalid farooq 2 1 department of ophthalmology, rashid latif medical college/arif memorial teaching hospital, lahore 2 department of radiology, lahore medical and dental college/ghurki trust teaching hospital, lahore abstract there are quite a number of neurological diseases, which initially present to the ophthalmologists. based on the proper history and clinical findings ophthalmologist have to suggest the ancillary neuro-imaging to support their provisional diagnosis and reach the site of lesion. unless the ophthalmologists are aware of the right imaging at right time and at right area to focus, there are many pitfalls. mri and ct of the brain and orbit are important investigations in neuro-ophthalmology which if intelligently ordered can add to the diagnostic and management process. in general, mri is the most commonly ordered investigation in neuro-ophthalmology with so many additional sequences as flair, gre, diffusion weighted imaging, spectroscopy, in addition to t1 and t2 weighted imaging. having said that ct scan has its advantages in cases of bony pathologies and acute brain hemorrhages. this article reviews the indications and importance of different neuro-imaging techniques, based on the previous studies from 1997 to 2019. key words: neuro-ophthalmology, magnetic resonance imaging, optic neuritis, papilledema, visual pathway, optic tract, optic nerve, meningioma, glioma. how to cite this article: malik tg, farooq k. neuroimaging in neuro-ophthalmology (systematic review). pak j ophthalmol. 2020, 36 (2): 179-188. doi: 10.36351/pjo.v36i2.1026 introduction neuro-imaging is an important part of neuroophthalmology but it cannot replace a thorough clinical examination. rather ordering a relevant neuroimaging test depends upon a detailed history and thorough evaluation in the clinics. suggesting a right investigation at a right time can save time as well as money. it is very important for the ophthalmologists to have sufficient knowledge about which investigation is required in a particular case, when to use contrast, which views (coronal, axial, sagittal) are important in which case and which sequence is necessary. keeping correspondence: tayyaba gul malik department of ophthalmology, rashid latif medical college/arif memorial teaching hospital, lahore received: january 1, 2020 accepted: march 20, 2020 a radiologist fully informed about the positive clinical findings and the provisional diagnosis along with the area of interest in neuro-imaging is also a mandatory part of neuro-imaging, failing which can lead to pitfalls in diagnosis. at times, the definite clinical findings are not supported by neuro-imaging, in which case it is important to have a detailed discussion of the case with the radiologist. sometimes very thin slices of a particular area of interest are required and which are missed in general thick slice scans. at other times, some additional investigation is needed to prove a definite clinical diagnosis. the purpose of this review article was to find out which neuro-imaging tests are commonly used in neuro-ophthalmology and what were the presenting complaints of the patients for which these investigations were suggested. keeping in view the published data an exercise is done to make clear when neuroimaging in neuro-ophthalmology pak j ophthalmol. 2020, vol. 36 (2): 179-188 180 to order which of the neuro-imaging test to save time and money by avoiding wrong investigation or right investigation in wrong time and area. methods prisma guidelines were followed for this systematic review. a literature search was conducted on the 11 th november 2019. ncbi pubmed database was used with search terms „neuroimaging‟ and „neuroophthalmology‟ (1997 to 2019). one hundred and eighteen results were found. articles with unaccessible full articles, duplicates and irrelevant articles were excluded. we were left with 70 items. this produced a list of 19 review articles, 19 original articles and 29 case reports or case series. review articles were not included in this review. studies, which did not use neuro-imaging in diagnosis of neuro-ophthalmology cases, were excluded from our study. we also excluded articles, which were published only as abstracts or were presented only in conferences without publication. one of the study was also removed because it did not mention the type of imaging used in the study. the flow chart for data retrieval is shown below. results in 19 original articles, total number of patients were 1350 (858 females and 492 males), with age ranging from 1 year to 81 years. there were 14 retrospective studies, 2 case control studies, 2 cross sectional studies and 1 interventional study. there were 29 case reports/case series, which included 72 patients (45 females and 27 males) with age ranging from 3 months to 89 years. neuro-imaging was done for complaints of diplopia, decreased vision, visual field defects, swollen optic discs, headache, pulsatile tinnitis, nausea, vomiting associated with headache, ocular motor nerve palsies, horner syndrome, nystagmus, presumed cortical blindness, supranuclear gaze palsy, ptosis and as part of investigation in cases of neurofibromatosis. the final diagnoses included idiopathic intracranial hypertension, meningioma, glioma of visual pathway, multiple sclerosis, trochlear headache, pituitary adenoma, craniopharyngioma, ischemic strokes, hemorrhages, aneurysms, herpes simplex encephalitis, stenosis of dural sinuses and cerebral venous sinus thrombosis. diagnoses of case reports and series included; hair dresser syndrome, pseudotumor cerebri, horner syndrome, tolosa-hunt syndrome, sixth nerve palsy, migraine, amyloidosis, encephalopathy syndrome, orbital apex syndrome, behr syndrome, optic nerve hypoplasia, 4th nerve palsy, pituitary apoplexy, eight and a half syndrome, cholesterol granuloma of the sphenoidal sinus, craniopharyngioma and alzheimers disease. other neuro-imaging results included arnold chiari malformation, carotico-cavernous fistula, vertebrobasilar ischemia, cerebral edema, nonhodgkin's lymphoma, ectopic posterior pituitary gland, rathke's cleft cyst, carcinomatous meningitis secondary to metastatic breast cancer, neurosarcoidosis and carotid artery dissection. mri scan was the most commonly ordered investigation followed by ct scan. other ancillary sequences were done when initial mri and ct were normal. the investigations, which were done in decreasing order of frequency were as follows: mri, ct, mrv, ct angiography, mra, flair, pet, dti and diffusion tensor tractography, arteriography. after excluding review articles, we were left with 19 original articles and 29 case reports/ case series. medline search was done on 11 th november 2019 with words „neuro-imaging‟ and „neuroophthalmology‟ (data between 1997 to 2019). 118 articles found. articles with un-accessible full articles, duplicates and irrelevant articles were excluded. tayyaba gul malik, et al 181 pak j ophthalmol. 2020, vol. 36 (2): 179-188 table 1: details of original articles (neuro-imaging in neuro-ophthalmology from 1997 to 2019). author study design sample size provisional diagnosis neuroimaging findings gondi kt, et al, 13 2019 case control study 53 iih (idiopathic intracranial hypertension) mri, ct, mrv empty sella, globe flattening, prominent perioptic cerebrospinal fluid, venous sinus stenosis park ka, et al, 14 2019 retrospective 127 ocular motor nerve palsies mri inflammatory lesions and neoplasms koytak pk, et al, 15 2018 retrospective 35 optic nerve sheath meningioma mri diagnosis of optic nerve sheath meningioma was confirmed bursztyn llcd, et al, 16 2018 retrospective 92 optic neuritis mri 83.7% positive results for on mri khadse r et al, 17 2017 retrospective 40 optic neuritis mri isolated optic nerve enhancement, demyelinating foci in frontal lobe and parieto-occipital lobe kowal et al, 18 2017 retrospective 24 optic tract lesions mri, flair ischemic strokes, tumors, hemorrhages, vascular malformation, demyelination, encephalitis aguilar-pérez m et al, 19 2017 retrospective 51 iih mri, mrv empty sella, stenotic dural sinuses chang ro, et al, 20 2016 retrospective 12 iih mri empty sella ming ge, et al, 21 2015 interventional 11 optic pathway gliomas diffusion tensor tractography diagnosis of optic nerve gioma was confirmed j. h. smith, et al, 22 2014 retrospective 25 trochlear headaches mri and ct normal imaging balk lj, et al, 23 2014 case control study 222 ms mri, flair, dti integrity of the optic radiations (fa) was significantly impaired in patients with ms. atrophy of the visual cortex, grey and white matter. kennedy de blank pm, et al, 24 2013 retrospective 50 optic pathway gliomas mri /dti optic nerve axons and myelin sheath integrity was disturbed mehta et al, 25 2012 retrospective 157 optic neuropathy and cranial nerve palsies. ct, cta, mri, mra, mrv 28.9% of neuroimaging tests requested by neuro-ophthalmologists resulted in an abnormal finding s. ambika, et al, 26 2010 retrospective 50 iih ct, mri, mrv 25 normal, others had empty sella and stenotic dural sinus agarwal p, et al, 27 2010 retrospective 308 iih mri, mrv 35 patients had cerebral venous sinus thrombosis wolfe s, et al, 28 2008 cross sectional 125 miscellaneous conditions mri, ct .18% positive imaging lee ag, et al, 29 2005 retrospective 91 optic tract lesions mri, ct 93 normal, lesions found in 18 cases mcfadzean r, et al, 30 1998 cross sectional 100 isolated 3rd nerve palsy cta 72 were normal, aneurysm in 18 and 10 had other abnormalities jacobson dm, 31 1997 retrospective 71 parieto occipital lobe lesions mri parieto occipital lobe lesions confirmed table 2: details of case reports/case series (neuro-imaging in neuro-ophthalmology; 1997 to2019). authors no. of cases diagnosis neuroimaging findings jonathan a, et al, 32 2019 3 hair dresser syndrome ct/cta or mri/mra) vertebrobasilar ischemia tommy l.h. et al, 33 2018 3 iih mri, mrv bilateral dural venous sinus stenosis karti dt, et al, 4 2018 1 horner syndrome ct, mri (cervical) multiple spinal root cysts between c7 and t1 segments ravindran k, et al, 35 2017 1 tolosa–hunt syndrome mri/cerebral angiogram inflammatory stranding of the right orbital apex and extension into the lateral wall of the right cavernous sinus neuroimaging in neuro-ophthalmology pak j ophthalmol. 2020, vol. 36 (2): 179-188 182 authors no. of cases diagnosis neuroimaging findings brandon j, et al, 36 2017 1 sixth nerve palsy mri and mra normal nadha a, et al, 37 2017 1 migraine mri, ct normal oana m, et al, 38 2017 1 amyloidosis cta/mra/ mri multifocal patchy and confluent vasogenic edema in the cerebral hemispheres, hemosiderin deposition from microhemorrhages chou mc, et al, 39 2017 1 encephalopathy syndrome mri/mra/ct/ flair hyperintense signal change at periventricular, parietooccipital, cerebellar, and brainstem areas visualised in flair carlen a, et al, 40 2017 1 orbital apex syndrome ct retrro-orbital mass. excision biopsy showed nonhodgkin's lymphoma hidehiro oku, et al, 41 2016 1 sixth nerve palsy mri and mra aneurysm of intracavernous carotid artery raoof n, et al, 42 2015 1 sixth nerve palsy mri and ct skull base endochondroma kleffner i, et al, 43 2015 2 behr syndrome mri bilateral hypointense signals in the globus pallidus, the putamen, and the substantia nigra as well as a cerebellar atrophy vaphiades ms, et al, 44 2015 1 progressive supranuclear palsy-like syndrome mri/mri tractography/ (fmri), normal koukkoulli a, et al, 45 2015 1 ophthalmoplegia with lid scc mri perineural spread of cutaneous squamous cell carcinoma cheng hc, et al, 46 2015 5 optic nerve hypoplasia mri ectopic posterior pituitary gland, agenesis of septum pellucidum, rathke's cleft cyst madgula, et al, 47 2014 1 4th nerve palsy mri metastatic breast cancer berkenstock m, et al, 48 2014 1 pituitary apoplexy mri and mra pituitary adenoma with haemorrhage bansal s, et al, 49 2014 1 third nerve palsy mri neurosarcoidosis rosini f, et al, 50 2013 1 8 ½ syndrome with hemiparesis and hemihypesthesia: the nine syndrome? mri ischemia of right pons involving the abducens nucleus, adjacent medial longitudinal fasciculus(mlf), and facial colliculus, extending to the ipsilateral mediallemniscus and corticospinal tract pehere n, et al, 51 2011 1 cholesterol granuloma of the sphenoidal sinus mri a homogenous t1 and t2 hyperintense lesion causing expansion of sphenoidal sinus reyes kb, et al, 52 2011 1 craniopharyngioma mri suprasellar cystic lesion compressing the chiasm, flattening the pituitary gland raghavendra s, et al, 53 2010 1 4th nerve palsy mri mid brain hemorrhage sánchez vm, et al, 54 2006 1 alzheimer's disease pet scan parietal-occipital bilateral hypo-metabolism andrew gl, et al, 55 2004 8 alzheimer's disease mri and pet hypoperfusion in the parieto-occipital areas.mri showed pariet-occipital atrophy freedman ka, et al, 56 2004 1 nonketotic hyperglycemic patient mri normal madhura a. et al, 57 2004 2 third nerve palsy mri and mra internal carotid artery aneurysm and arteriovenous fistula arising parsa cf, et al, 58 2001 13 optic nerve gliomas ct and mri gliomas of optic nerve and chiasma andrew gl, et al, 59 2000 8 acute optic neuropathy mri 3 sarcoidosis, 4 meningioma, metastasis mark l, et al, 60 1998 9 miscellaneous mri, ct, arteriography carotid artery dissection, pituitary tumour, ischemic occipital lobe injury, arnold chiari malformation, ccf, carotid stenosis, ms, optic nerve sheath meningioma tayyaba gul malik, et al 183 pak j ophthalmol. 2020, vol. 36 (2): 179-188 fig. 1: axial t2 images; 1) eyeball, 2) lateral rectus, 3) medial rectus 4) optic nerve. fig. 2: coronal t1 images through orbit; 1) optic nerve 2) medial rectus 3) superior rectus 4) lateral rectus 5) inferior rectus 6) optic chiasm. fig. 3: coronal t2 images; 1) eyeball, 2) optic nerve, 3) medial rectus, 4) inferior rectus, 5) lateral rectus, 6) superior rectus 7) superior oblique 8) optic chiasm. fig. 4: sagittal t1 images; 1) eyeball, 2) superior rectus, 3) optic nerve, 4) inferior rectus. fig. 5: gadolinium contrast with fat suppression showing enhancement of optic nerve sheath. fig. 6: axial flair images; 1) eyeball, 2) optic nerve, 3) medial rectus 4) lateral rectus, 5) optic chiasma. discussion in this systematic review only ncbi pubmed database was used with search terms neuroimaging and neuroophthalmology (1997 to 2019). the details of the studies and case reports are depicted in table 1 and 2. when we searched pakistan journal of ophthalmology website from 2006 to 2019, only 14 articles were found related to neuro-ophthalmology. after excluding the articles, which did not include neuro-imaging, we were left with 5 case reports and 5 original articles. case reports included csf rhinorrhea, ewing sarcoma, optic disc drusen, traumatic optic neuropathy and tuberous sclerosis. 1-5 neuroimaging in neuro-ophthalmology pak j ophthalmol. 2020, vol. 36 (2): 179-188 184 original articles included headache, head trauma, meningiomas of visual pathway, retinoblastoma and systemic associations of optic nerve diseases. 6-10 . in the following paragraphs, the commonly used neuro-imaging techniques and important sequences are discussed based on the articles reviewed through pubmed search. magnetic resonance imaging (mri) the basic mechanism of mri is the rearrangement of charged hydrogen ions after exposure of a tissue to a short electromagnetic pulse. relaxation times of the tissues depend upon their characteristics and a tissue may be t1 weighted or t2 weighted. the magnetic field in mri is expressed in tesla (t). the commonly used field is 1.5t to 3.0t. 11 in t1 weighted images, csf and vitreous appear dark and it is good for studying normal anatomy. in t2 weighted images, water appears hyperintense. hence, the edematous tissues will be differentiated from the surrounding tissues as hyperintense. optic nerve gliomas can be seen as tubular or fusiform enlargement of the nerve, which appear isointense to hypointense when compared with the adjacent tissues on t1-weighted mri and enhance after gadolinium injection. 12 optic nerve meningiomas appear separate from the optic nerve on coronal views. it is visible in the form of a concentric ring around the nerve. in patients with idiopathic intracranial hypertension (iih), t1-weighted images of the brain may show an empty sella turcica while axial t2weighted mri images of the orbit show distension and tortuosity of the optic nerve sheaths. flattening of the posterior globe is also an mri sign of iih. 12 afferent and efferent visual pathways are also best detected by mri studies (figures 1, 2, 3, 4). however, in the presence of acute hemorrhage and bony abnormalities, ct is a better option. gadolinium contrast studies is a special contrast medium, which shows up when placed in a magnetic field. when given through intravenous route, it remains inside the vessels unless there is a defect in the blood brain barrier. it is used with t1 weighted images. it helps in enhancing the brightness of tumour images and inflammatory lesions. sellar masses are also best visualized with contrast enhanced t1 weighted images. postcontrastt1-weighted images can be helpful in diagnosing giant cell arteritis, in which case there is increased vessel wall thickness and edema. fat-suppression techniques are used in various conditions including orbital pathologies. orbital fat on conventional t1-weighted imaging makes it difficult to differentiate from other normal tissues (optic nerve and extraocular muscles), tumors, inflammatory lesions and vascular malformations. there are two types of fat-suppression sequence used in neuroophthalmology. 1. t1 weighted images with gadolinium contrast and fat suppression allows the optic nerve sheath lesions to be enhanced. 12 2. stir (short t1 inversion recovery) is used without contrast and is quite optimal sequence for diagnosing intrinsic lesions of the intraorbital optic nerve (e.g. optic neuritis). inflammation of the optic nerve sheath is better detected by gadolinium-enhanced fat-saturated t1weighted mri, in which they appear as circumferential optic nerve sheath enhancement and on axial views these are seen as tram-track sign (figure 5). fat suppression techniques are also useful in confirming the fat-containing lesions, such as dermoid cysts and lipomas. thus for optic nerve sheath and optic nerve lesions, fat suppression is a gold standard. diffusion-weighted imaging diffusion-weighted imaging (dwi) is a special mri technique that is based on the microscopic random brownian motion of water. it is useful in detecting acute ischemic strokes. this technique is useful in very early stage of ischemic stroke when the changes are undetectable on t1 and t2 weighted mri. 12 as different stages of infarction can also be identified by dwi, this technique is helpful in distinguishing vasogenic reversible ischemia from irreversible ischemia in patients with cortical blindness and brainstem ischemia. (flair) sequence as csf is bright ont2-weighted images, it becomes difficult to differentiate periventricular lesions from csf signal. in fluid-attenuated inversion recovery, a t2-weighted image of csf signal is suppressed to allow better detection of adjacent pathology. flair sequences also help to highlight inflammatory changes 12 (figure 6). tayyaba gul malik, et al 185 pak j ophthalmol. 2020, vol. 36 (2): 179-188 gradient recalled echo (gre) or susceptibilityweighted imaging (swi) is helpful in diagnosing micro hemorrhages (within the first few hours) (figure 2). fiesta and ciss (fast imaging employing steady-state acquisition and constructive interference in steady-state). the structures surrounded by csf and isodense to csf in t1 and t2 weighted images are better visualized by this technique. orbital masses, which arise from the orbital nerves can be better detected with this technique. magnetic resonance venography (mrv) and magnetic resonance arteriography (mra) mra is a very good technique, which has reduced dependency on conventional invasive angiography. mra relies on blood flow within the vessels and hence contrast is not required. however, the thrombosed aneurysm and small aneurysms are missed. mrv is used to detect venous sinus thrombosis or venous stenosis. 11 diffusion tensor imaging and diffusion tensor tractography dti and dtt can be helpful in visualizing the axon and myelin integrity. data from dti is used to reconstruct a 3d images in dtt. magnetic resonance spectroscopyis capable of detecting brain metabolites and hence help in distinguishing between neoplasms, demyelinating lesions, radiation necrosis, inflammatory lesions and mitochondrial disorders that can affect the visual pathways. limitations of mri include bony defects and acute haemorrhages, which are not detected on mri. magnetic foreign bodies, cardiac pace markers, ferromagnetic aneurysm clips are contraindications for mri. the test is also not suitable for claustrophobic patients. computed tomography (ct) uses x-rays to obtain images, which are then computed to form crosssectional images. white is the maximum density of the tissue as in bones and black is the minimum density as in air. iodinated contrast is used to improve the visualization of structures but allergy to iodine and renal failure are contraindications. use of contrast in acute hemorrhage, bony injury and in case of foreign bodies, can mask the visibility. optic nerve head drusen and tumours that show calcification e.g., craniopharyngiomas, meningiomas and retinoblastomas can be detected with ct scan. especially in cases of optic nerve sheath meningioma, ct shows perineural calcification in the form of “tram-tracking”. hyperostosis of the neighboring bones is also a diagnostic sign. 12 in cases of traumatic optic neuropathy, ct scan can help in detecting the optic canal fracture, edema (or blood) within the optic canal (or optic nerve sheath), intraconal hematoma, or foreign body/fracture fragments causing impingement on the optic nerve. fludeoxy glucose (fdg)–pet: positron emission tomography (pet) is a sequence, which is used in diagnosing inflammatory and/or neoplastic processes. fluorodeoxy glucose (fdg) is a metabolic marker. greater uptake of glucose by the inflammatory and neoplastic lesions can be helpful in diagnosis. large vessel vasculitis in gca and extraocular muscle inflammation in graves disease is detected by this technique. 12 computed tomographic angiography and venography (cta, ctv): extremely thin slices of brain are taken to investigate intracranial aneurysms. ctv is a good diagnostic technique for cerebral venous sinus thrombosis. contrast is injected and the patient is exposed to radiations. conventional catheter angiography was once the only diagnostic test for intracranial aneurysm but now cta and mra have surpassed its use and it is only reserved for the patients in which the cta and mra are not diagnostic. 12 limitation of this systematic review is the use of only one database (pubmed). other databases and gray literature/unpublished data were also not included. conclusion relevant history with detailed clinical examination along with the provisional diagnosis and the area of interest for neuro-imaging must be included in the investigation form. in case of any confusion, it is better to consult a radiologist, for the best interest of the patient, before filling the investigation form rather than writing a wrong investigation. neuroimaging in neuro-ophthalmology pak j ophthalmol. 2020, vol. 36 (2): 179-188 186 references 1. malik tg, khalil m, ain q. chronic rhinorrhea. pak j ophthalmol. 2016; 32 (4): 238-240. 2. abbasi s, cheema a. ewing sarcoma of orbit with intracranial extension. pak j ophthalmol. 2015; 31 (2): 111-114. 3. memon gm, zafar s, shakir m, kamil z, bokhari sa. bilateral optic disc drusen in hypermetropic children of a family. pak j ophthalmol 2012; 28 (3): 163-165. 4. awan ah. traumatic optic neuropathy. pak j 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https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5602716/ https://dx.doi.org/10.1016%2fj.tjo.2014.11.001 neuroimaging in neuro-ophthalmology pak j ophthalmol. 2020, vol. 36 (2): 179-188 188 54. asensio-sánchez vm, torreblanca-agüera b, martínez-calvo s, calvo mj, rodríguez r. visual symptoms as the first manifestation of alzheimer‟s disease. arch soc esp oftalmol. 2006; 81: 169-172. 55. lee ag, martin co. neuro-ophthalmic findings in the visual variant of alzheimer‟s disease. ophthalmology, 2004; 111: 376–381. 56. freedman ka, polepalle s. transient homonymous hemianopia and positive visual phenomena in nonketotic hyperglycemic patients. am j ophthalmol. 2004; 137: 1122–1124. 57. tamhankar ma, liu gt, young tl, sutton ln, hurst rw. acquired, isolated third nerve palsies in infants with cerebrovascular malformations. am j ophthalmol. 2004; 138 (3): 485-486. 58. parsa cf, hoyt cs, lesser rl, weinstein jm, strother cm, mendoza rm et al. spontaneous regression of optic gliomas: thirteen cases documented by serial neuroimaging. arch ophthalmol. 2001; 119 (4): 516–529. 59. lee ag, lin dj, kaufman m, golnik kc, vaphiades ms, eggenberger e. atypical features prompting neuroimaging in acute optic neuropathy in adults. can j ophthalmol. 2000; 35: 325-330. 60. moster ml, johnson mh. a neuro-ophthalmologist‟s perspective on neuro-radiology. seminars in ultrasound, ct and mri, 1998; 19 (3): 216-225. authors’ designation and contribution tayyaba gul malik; professor: study design, literature search, data acquisition, data analysis, manuscript writing, final review. khalid farooq; professor: study design, data acquisition, final review. .…  …. pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 116 editorial minimally invasive glaucoma surgery: principles shaping glaucoma surgery for the future over the last half century, open-angle glaucoma management has revolved mainly around topical medical treatment with or without laser trabeculoplasty, with gold standard trabeculectomy kept back for patients with advanced and progressing glaucoma. keeping in mind the possible complications associated with trabeculectomy and glaucoma valves,1 these are usually kept for late glaucoma treatment algorithm. development of new topical medications has actually reduced the rate of trabeculectomy remarkably.2 the mostrecent interest in glaucoma surgery has been in minimally invasive glaucoma surgery (migs) with excellent results in mild to moderate glaucoma. these are designed to improve the safety of surgical intervention for glaucoma. although initially coined minimally invasive, the term micro seems more appropriate because it truly differentiates these microscopic ophthalmic procedures from other minimally invasive surgical procedures (i.e., general surgery). most migs procedures enhance physiologic outflow and are aimed at a different patient population than traditional filtration surgery. as opposed to competing with traditional filtering surgery, migs seems to be more of an alternative to medical therapy in an effort to address adherence challenges, adverse events, and quality-of-life (qol) issues with topical medications. a common misperception of migs is that it needs to be compared with the gold standard of mitomycin c trabeculectomy to show its effectiveness. this inappropriateinterpretation is based on the idea that migs procedures are designed to replace conventional filtering surgery. in fact, migs devices are designed to address the treatment gap that exists between medical therapy and more aggressive traditional surgical options. migs devices are not a replacement for trabeculectomy or glaucoma valves. many migs procedures have been studied and are used in conjunction with cataract surgery. many patients (up to 15% 20%)3 undergoing cataract surgery already have glaucoma. cataract surgery provides an opportunity to perform a migs procedure in which the risks of an intraocular procedure already have been accepted by the patient. performing an adjunctive migs procedure therefore is accomplished with minimal additional risk, thus reducing the risk and costs of these migs procedures comparedwith when they are performed as a stand–alone procedure. however, knowing that phacoemulsification also lowers iop4 creates a significant confounder that must be considered when designing studies. ultimately, migs is all about safety due to its noninvasiveness, permitting its use in non-refractory glaucoma and much earlier in the glaucoma treatment algorithm. what’s out there and the outcomes: trabectome: (neomedix, tustin, ca) has manufactured this new surgical system. since its launch in 2014 it lets you perform a trabeculotomy using an internal approach. a path for aqueous humor drainage is created by cutting a piece of trabecular meshwork and the sclemm’s canal inner wall5. the trabectome is made up a single use, disposable hand piece which is used for aspiration, irrigation and electrocautery. formation of a direct passage to schlemm's canal by bypassing the trrabecular meshwork is the key feature of this surgery. there is no formation of bleb and the conjunctiva is not disturbed and it is possible to combine it with phacoemulsfication for cataract. general drawbacks include paucity of flow circumferentially, closure of cleft and limitation of iop reduction by resistance of schlemm's canal and episcleral venous pressure.6 istent: fda approved the istent trabecular micro-bypass stent (glaukos, laguna hills, ca) in 2012. it is non-ferromagnetic, heparin coated stent with the shape of a snorkel to help in implantation.a mohammed sohaib mustafa 117vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology disposable, sterile inserter is used to place the device through a 1.5 mm incision of the cornea. being 1 mm in length and 0.3 mm in height the istent is the smallest device which has been approved by the fda. augustinus et al,7 has shown that implantation of the istent with phacoemulsification results in remarkably lower, long-term reduction of iop and number of medications being used compared to only phacoemulsification with no significant complications. cypass micro-stent: it was manufactured by transcend medical inc. and compass clinical study is currently evaluating it as a method in the united states. clinical trials in europe have been studying it since 2009. ab-interno approach is used for the insertion of the device and it is itself a polymide, supraciliary device. controlled cyclodialysis is created with stented aqueous outflow to the supracilary space. it has an outer diameter of 0.51 mm and is 6.35 mm long. initial trials have shown that with the device there can be remarkably reduction in the number of drugs being used and marked reduction in uncontrolled iop or maintenance of a controlled iop. moreover, it has very little side effects and a high safety record. xen glaucoma implant: this implant (aquesys implant) was developed by aquesysinc and is a device in investigational phase that is undergoing clinical trials at the moment. it is non-inflammatory because it has been manufactured with soft, collagenderived, gelatin which does not induce inflammation. the aim of the device is to make an aqueous humor outflow path connecting the anterior chamber to the subconjunctival space. an injector is used to insert the implant through a small corneal incision similar to iol implantation. like other implants, it can be implanted simultaneously during cataract surgery. trials in usa are currently underway but limited data from international trials has been provided by the company. hydrusmicrostent: this device was developed by ivantis inc. and fda has approved it for phase iv clinical trials currently. it is made from a super-elastic, biocompatible, nickel-titanium alloy (nitinol) and is 8mm in size. the “intracanalicular scaffold” is inserted into schlemm’s canal so that patency can be maintained and outflow established. the stent can be placed simultaneously with cataract surgery and utilizes the same incision of the cornea.8 in a european study both hydrus implantation alone and combined with cataract surgery showed reduction in intraocular pressure and medication burden. more trials in usa are currently under way.8 many physicians and patients are long awaiting a new class of glaucoma interventions that can address an expansive gap in therapy. ultimately, migs may help to fill that gap. the first-generation migs devices will pave the way for even safer and effective options. however, that journey will require more work to understand, substantiate, and individualize fully the role for migs. basic science, clinical, qol, and economic evaluations are underway to provide these much-needed data with migs, to determine its success in a larger range of glaucoma patients, particularly those with higher iops and to ensure a transparent and comprehensive evaluation of migs devices. the worldwide glaucoma fraternity goal is 10, 10, 10 by 2020. we need a procedure that can be done in 10 minutes, give a target pressure of 10mmhg and last for 10 years. migs is not the complete answer. however it is a step in the right direction for stem cell technology and immune – inflammatory modulation to be amalgamated with the principle of migs to reach this end point. references 1. gedde sj, herndon lw, brandt jd, budenz dl, feuer wj, schiffman jc. postoperative complications in the tube versus trabeculectomy (tvt) study during five years of follow-up. am j ophthalmol. 2012; 153: 804–14. 2. ramulu py, corcoran kj, corcoran sl, robin al. utilization of various glaucoma surgeries and procedures in medicare beneficiaries from 1995 to 2004. ophthalmology 2007; 114: 2265–70. 3. tseng vl, yu f, lum f, coleman al. risk of fractures following cataract surgery in medicare beneficiaries. jama 2012; 308: 493–501. 4. mansberger sl, gordon mo, jampel h, brandt jd, wilson b, kass ma. reduction in intraocular pressure after cataract extraction: the ocular hypertension treatment study. ophthalmology 2012; 119: 1826–31. 5. francis ba, singh k, lin sc, hodapp e, jampel hd, samples jr, smith sd. novel glaucoma procedures: a report by the american academy of ophthalmology. ophthalmology. 2011; 118: 1466-80. 6. maeda m, watanabe m, ichikawa k. evaluation of trabectome in open – angle glaucoma. j glaucoma. 2013; 22: 205-8. 7. francis ba, minckler d, dustin l, kawji s, yeh j, sit a, mosaed s, johnstone m. combined cataract extraction and trabeculotomy by the internal approach http://www.ncbi.nlm.nih.gov/pubmed/?term=brandt%20jd%5bauthor%5d&cauthor=true&cauthor_uid=22608478 http://www.ncbi.nlm.nih.gov/pubmed/?term=brandt%20jd%5bauthor%5d&cauthor=true&cauthor_uid=22608478 http://www.ncbi.nlm.nih.gov/pubmed/?term=brandt%20jd%5bauthor%5d&cauthor=true&cauthor_uid=22608478 http://www.ncbi.nlm.nih.gov/pubmed/?term=wilson%20b%5bauthor%5d&cauthor=true&cauthor_uid=22608478 http://www.ncbi.nlm.nih.gov/pubmed/?term=kass%20ma%5bauthor%5d&cauthor=true&cauthor_uid=22608478 http://www.ncbi.nlm.nih.gov/pubmed/?term=kawji%20s%5bauthor%5d&cauthor=true&cauthor_uid=18571075 http://www.ncbi.nlm.nih.gov/pubmed/?term=yeh%20j%5bauthor%5d&cauthor=true&cauthor_uid=18571075 http://www.ncbi.nlm.nih.gov/pubmed/?term=sit%20a%5bauthor%5d&cauthor=true&cauthor_uid=18571075 http://www.ncbi.nlm.nih.gov/pubmed/?term=sit%20a%5bauthor%5d&cauthor=true&cauthor_uid=18571075 http://www.ncbi.nlm.nih.gov/pubmed/?term=sit%20a%5bauthor%5d&cauthor=true&cauthor_uid=18571075 http://www.ncbi.nlm.nih.gov/pubmed/?term=mosaed%20s%5bauthor%5d&cauthor=true&cauthor_uid=18571075 http://www.ncbi.nlm.nih.gov/pubmed/?term=johnstone%20m%5bauthor%5d&cauthor=true&cauthor_uid=18571075 minimally invasive glaucoma surgery: principles shaping glaucoma surgery for the future pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 118 for coexisting cataract and open-angle glaucoma: initial results. j cataract refract surg; 34: 1096-1103. 8. arriola-villalobos p, martínez-de-la-casa jm, díazvalle d, fernández-pérez c, garcía-sánchez j, garcíafeijoó j. combined i stent trabecular micro-bypass stent implantation and phacoemulsification for coexistent open-angle glaucoma and cataract: a longterm study. br j ophthalmol. 2012; 96: 645-9. 9. pfeiffer n, lorenz k, ramirez m, et al. 6 month results from a prospective, multicenter study of a nickeltitanium schlemm's canal scaffold for iop reduction after cataract surgery in open-angle glaucoma. american glaucoma society annual meeting. new york, ny. march 1-4, 2012. dr. mohammed sohaib mustafa consultant ophthalmologist glaucoma, cataract and refractive surgeon moorfields eye hospital dubai honorary consultant at moorfields london pak j ophthalmol. 2020, vol. 36 (4): 440-444 440 original article indications and outcomes of penetrating keratoplasty at a tertiary hospital in bangladesh a.s.m. moin-ud-din 1 , chandana sultana 2 , m. a. muntakim shahid 3 mohammed rashed 4 , mohammad shamsal islam 5 1-4 ispahani islamia eye institute and hospital, bangladesh, 5 orbis international bangladesh country office abstract purpose: to study the indications and outcomes of penetrating keratoplasty at a tertiary eye hospital in dhaka, bangladesh. study design: retrospective hospital based study. place and duration of study: ispahani islamia eye institute and hospital, dhaka, bangladesh from july 2011 and july 2018. methods: in this study, data was collected from the records of patients, who came for treatment at the cornea unit. pre-operative evaluation and post-operative follow-up record was analyzed. patents’ demographic information, visual acuity, management, pre and post-operative complications, follow-up visits and outcomes were recorded. a technical research team headed by a senior consultant determined the content validity and their comments were incorporated in finalizing the research instruments. results: a total of 213 penetrating keratoplasties (pk) were performed during the study period. the main indications were keratoconus (8.28%), corneal scarring (41.42%), adherent leucomas (25.59%), corneal dystrophy (3.84) and bullous keratopathy (7.25%). rejection rates at 8 years were 5.62%. keratoconus showed the best graft survival (79%). the percentage of patients with post-transplant best-corrected visual acuity of 6/36 at 8 years was 52%. there was a statistically significant reduced rejection rate in males. conclusion: penetrating keratoplasty is an effective treatment option for improving visual outcomes for people with visual impairment. there are many co-factors involved in quality outcome of patients with penetrating keratoplasty such as immunological rejection, microbial keratitis and level of patient awareness, which continue to limit the success. key words: penetrating, keratoplasty, bangladesh, keratoconus, corneal dystrophy. how to cite this article: din asmm, sultana c, shahid mam, rashed m, islam ms. indications and outcomes of penetrating keratoplasty at a tertiary hospital in bangladesh. pak j ophthalmol. 2020; 36 (4): 440-444. doi: https://doi.org/10.36351/pjo.v36i4.1117 correspondence to: a.s.m. moin-ud-din ispahani islamia eye institute and hospital dhaka bangladesh email: moin.uddin@islamia.org.bd received: august 6, 2020 accepted: september 5, 2020 introduction penetrating keratoplasty (pk) is an advanced surgical treatment for corneal disorders secondary to trauma, chemical burns and infectious diseases, as well as congenital disorders of cornea. pk is considered as a good option for management of corneal opacity. 1 it is the most common tissue transplant technique in the developed countries and this treatment has become popular in developing countries as well due to significantly high percentage of visual impairment and a.s.m. moin-ud-din, et al 441 pak j ophthalmol. 2020, vol. 36 (4): 440-444 blindness in these countries. recent evidence shows that corneal transplantation has good outcomes among pediatric patients. 2-4 outcomes of pk depend on graft survival times, graft survival rates and other significant prognostic factors. 5-7 very recent studies in pakistan showed that keratoconus was the most common indication for pkp, followed by fuch’s endothelial dystrophy, bullous keratopathy, viral keratitis, other corneal dystrophies, and mechanical trauma. 8 in earlier studies, the prognostic factors for the visual outcome were age, time of primary graft, surgical indication, unilateral versus bilateral grafts, other ocular surgeries and follow-up timing. 9 in this study, we have evaluated the indications and outcomes of pk in bangladeshi population. methods this was a retrospective hospital based study and data was collected from the records of patients, who came for treatment at the cornea unit between july 2011 and july 2018. ethical review committee of the hospital unanimously approved the proposal. a total of 213 eyes were included in this study. hospital information system and international classification of diseases (icd) were used to retrieve medical records of the patients. the study was under taken in the cornea unit of the ispahania islamia eye institute and hospital, dhaka, bangladesh. pre-operative evaluation and 60 months post-operative follow-up record was analyzed. a total 213 patients with age ranging from 3 to 77 years were included in the study. patents demographic information, visual acuity, management, pre and postoperative complications, follow-up visits and outcomes were recorded in the self-designed proforma. a technical research team headed by a senior consultant determined the content validity and their comments were incorporated in finalizing the research instruments. all patients who had undergone pk and had full pre-operative evaluation and post operative follow-up records of at least 12 months were included. we excluded the patients who had undergone lamellar kp, therapeutic keratoplasy, repeat kp, dalk, cosmetic keratoplasy and lack of follow-up record. the outcomes of graft transparency were recorded and visual acuity was classified according to the world health organization (who) recommended categories of visual loss. blindness was defined as vision of less than 6/60 to perception of light. spss version 24 was used for analyzing the data. the qualitative data was manually analyzed. quantitative data was entered into the computer for analysis. both univariate and bivariate tables were used. frequency distribution, measurement of central tendency (mean, median, and mode), measures of dispersion (standard deviation), and non-parametric tests (chi-square, cramer’s v) were recorded. the level of significance was set at 0.05. results the study included both male and female patients but male patients were more (69%) than the female patients (31%). the mean age was 34.75 (±) years (table 1). the graft survival rates were highest among male patients (55.42%) compared to females (24.41%). table 2 shows the indications for surgery and table 3 shows details of the results. there was at least six-month follow-up available for 91% (n = 193) patients and maximum follow-up of 8 years was available for only 7% (n = 13) patients. avascular recipient cornea had the best 8-year survival rate. recipient with age younger than 50 years showed better 8-year survival rate as compared to recipients older than 50 years. keratoconus had best graft survival. a significant correlation was observed between graft-rejection and age (r   =   0.153; r 2   =   0.023; p   =   .048), with a mean age of 10.84 + 4.80 years at rejection. the average donor graft diameter was 8 mm (range 7 mm to 8.50 mm). majority of the grafts were performed with an interrupted suture technique. fiftythree patients had concurrent extra-capsular cataract extraction at the time of keratoplasty, an additional 12 had intraocular lens (iol) exchange and one patient table 1: percentage distribution of age of the pk surgery patients by sex. age categories male n = 148 female n = 65 total = 213 percentage percentage percentage 3 – 18 years 19.10 25.50 17.40 19 – 35 years 36.30 33.80 40.30 36 – 60 years 26.10 38.90 32.90 61+ years 18.50 1.8 9.40 total 100.0 100.0 100.0 mean 17.68 11.76 st. deviation 7.17 14.22 12.22 x 2 = 23.782; gamma v = .229; df = 13; gamma = -0.321; sig; p = < .05 penetrating keratoplasty; indications and outcomes pak j ophthalmol. 2020, vol. 36 (4): 440-444 442 had iol explanation. the most common intraoperative complication was vitreous loss. best corrected visual acuity is shown in table 4. considering the univariate analysis, preservation status and time between death and transplant showed a significant effect for pk. donor age, donor sex, and time between death and enucleation showed no significant influence. both graft diameter and effect of combined surgery were significant in univariate analysis. graft diameter between 7.0 and 7.5 mm as well as between 8.0 and 8.50 mm showed the best 8 table 2: indications for penetrating keratoplasty (n = 213). indication percent (%) corneal scarring (trauma related) 41.42 adherent leukomas 25.59 keratoconus 8.28 bullous keratopathy 7.25 corneal dystrophy 3.84 pseudophakic 5.81 congenital hereditary endothelial dystrophy 6.00 dmd 1.81 total 100 table 3: percentage distribution of gender wise graft survival, graft rejection and graft failure. types of graft male female total = 213 percentage percentage percentage graft survival 55.42 (n = 117) 24.41 (n = 52) 79.83 (n = 169) graft rejection 3.75 (n = 8) 1.87 (n = 4) 5.62 (n = 12) graft failure 6.57 (n = 14) 7.80 (n = 16) 14.35 (n = 30) total 65.74 (n = 139) 33.79 (n = 72) 100 (n = 213) mean 21.91 11.26 st. deviation 23.72 9.54 x 2 = 26.66 gamma v = .492; df = 9; sig; p = < .002 table 4: post-operative best corrected visual acuity (bcva). best corrected visual acuity (bcva) percent (%) 6/6 – 6/12 38.00 6/18 – 6/36 14.75 6/60 – fc 22.56 hm 20.23 pl 4.46 total 100 x 2 =14.28, df = 25, sig. = .05 year survival estimate, followed by diameters of 7.5 to 8.00 mm. discussion penetrating keratoplasty in developing countries is a challenging surgery, not only regarding the surgical procedure, but also during follow-up and rehabilitation. the patients of penetrating keratoplasty tend to be young, with a mean age of 17.68 years (range 3–77 years). the high prevalence of allergic eye disease and use of contact lens wear in the dry and dusty conditions in our region are factors which account in part for the great preponderance of keratoconus patients. the graft survival rate at one and two years after surgery is around 80% and 67%, respectively. 10 reports on 5 – year graft survival range from 50% to 91%, depending on the series. 11 in our study, 2 – year graft survival was 73%, and 5 – year graft survival was 44%, which is consistent with the graft survival rates reported in other tertiary eye care centers. 12 similarly, our graft survival rate for keratoconus was higher compared with the rest of indications (p   =   .0001). graft survival rates for keratoconus patients varied between genders in the first 3 years: females presented a higher graft rejection with a peak at 24 months after the procedure; nevertheless, at 28 months this difference was no longer observed. 13,14 a gender difference in the survival of graft in children has not been reported although there are some studies showing significant adult differences. the australian corneal graft registry and the canadian corneal graft outcome study reported statistically significant gender differences in adults, showing that females were more likely to have a rejection event compared with males. 15 however, the causes of these differences were not discussed. another proposed explanation is the augmented activity of the immune system in females that increases the incidence of autoimmune conditions. 16 one possible mechanism to understand why there are higher numbers of rejection events among young women could be the mismatching between donor gender and recipient. a study published in the american journal of transplantation indicated poorer outcomes in women who received corneas from males. 17 the study explained that this effect, only observed in females, could be a consequence of h-y antigen incompatibility related to the y chromosome. lack of y chromosome allows compatibility from female donors to male recipients. 18 a.s.m. moin-ud-din, et al 443 pak j ophthalmol. 2020, vol. 36 (4): 440-444 in addition, steroid hormones are implicated in the susceptibility of female graft rejection. regarding indications for keratoplasty, similar to other series, keratoconus was the leading indication for transplant in over half of the patients. 19 literature shows that less frequent pathologies like peters anomaly, sclerocornea, and axenfeld–rieger syndrome had the worst outcomes with high rejection rates. 20 age is another important factor associated with success or failure of penetrating keratoplasty. it has been established that older children have a better prognosis. limitation of our study was the retrospective design. surgeries were not performed by a single surgeon which can be a cause of bias. more prospective trials are needed to better identify the indications, prognostic factors and outcomes of kp. conclusion penetrating keratoplasty has been considered effective treatment option for improving visual outcomes for people with visual impairment. there are many cofactors involved with a quality outcome of patients with penetrating keratoplasty such as immunological rejection, microbial keratitis and level of patient awareness, which continues to limit the success. acknowledgements we thank all respondents for providing all essential information. we also would like to thank ispahani islamia eye institute and hospital authority to support for conducting this study. ethical approval all study materials, including research protocols, were approved by the research committee of ispahani islamia eye institute and hospitals. conflict of interest authors declared no conflict of interest. references 1. ganekal s, gangangouda c, dorairaj s, jhanji v. early outcomes of primary pediatric keratoplasty in patients with acquired, atraumatic corneal pathology. j aapos. 2011; 15: 353–355. 2. karadag r, chan tc, azari aa, nagra pk, kristin m., hammersmith km, et al. survival of primary penetrating keratoplasty in children. am j ophthalmol. 2016; 171: 95–100. 3. majander a, kivelä tt, krootila k. indications and outcomes of keratoplasties in children during a 40-year period. acta ophthalmol. 2016; 94: 618–624. 4. low jr, anshu a, tan ac, htoon hm, tan dth. the outcomes of primary pediatric keratoplasty in singapore. am j ophthalmol. 2014; 158: 496–502. 5. hovlykke m, hjortdal j, ehlers n, nielsen k. clinical results of 40 years of paediatric keratoplasty in a single university eye clinic. acta ophthalmol. 2014; 92: 370–377. 6. rao kv, fernandes m, gangopadhyay n, vemuganti gk, krishnaiah s, sangwan vs. outcome of penetrating keratoplasty for peters anomaly. cornea, 2008; 27: 749–753. 7. basdekidou c, dureau p, edelson c, de meux p, caputo g. should unilateral congenital corneal opacities in peters' anomaly be grafted? eur j ophthalmol. 2011; 21: 695–699. 8. chaudhry t, sadiq sn, sirang z, syed ma, kamal m, ahmad, k. a 10 – year review of indications for penetrating keratoplasty in a tertiary care setting in karachi pakistan. j pak med assoc. 2016; 66 (10): s84-s86. 9. dana mr, moyes al, gomes ja, rosheim km, schaumberg da, laibson pr, et al. the indications for and outcome in pediatric keratoplasty. a multicenter study. ophthalmology, 1995; 102: 1129–1138. 10. thompson rw, price mo, bowers pj. long-term graft survival after penetrating keratoplasty. ophthalmology, 2003; 110: 1396–1402. 11. sharma n, prakash g, titiyal js, tandon r, vajpayee rb. pediatric keratoplasty in india: indications and outcomes. cornea, 2007; 26: 810–813. 12. oertelt-prigione s. the influence of sex and gender on the immune response. autoimmun rev. 2012; 11: a479–485. 13. hopkinson cl, romano v, kaye ra, steger b, stewart rmk, tsagkataki m, et al. the influence of donor and recipient gender incompatibility on corneal transplant rejection and failure. am j transplant. 2017; 17: 210–217. 14. haskova z, filipec m, holan v. the significance of gender incompatibility in donors and recipients and the role of minor histocompatibility antigens in corneal transplantation. cesk slov oftalmol. 1997; 53: 128– 135. 15. costenbader kh, gay s, alarcon-riquelme me, iaccarino l, doria a. genes, epigenetic regulation and environmental factors: which is the most relevant in developing autoimmune diseases? autoimmun rev. 2012; 11: 604–609. https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=nagra+pk&cauthor_id=27590122 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=hammersmith+km&cauthor_id=27590122 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https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=laibson+pr&cauthor_id=9097737 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=tandon+r&cauthor_id=17667614 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=vajpayee+rb&cauthor_id=17667614 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=steger+b&cauthor_id=27412098 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=stewart+rm&cauthor_id=27412098 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=tsagkataki+m&cauthor_id=27412098 penetrating keratoplasty; indications and outcomes pak j ophthalmol. 2020, vol. 36 (4): 440-444 444 16. patel hy, ormonde s, brookes nh, moffatt ls, mcghee cnj. the indications and outcome of paediatric corneal transplantation in new zealand: 1991 – 2003. br j ophthalmol. 2005; 89: 404–408. 17. groh mj, gusek-schneider gc, seitz b, schönherr u, naumann go. outcomes after penetrating keratoplasty in congenital hereditary corneal endothelial dystrophy (ched). report on 13 eyes]. klin monbl augenheilkd. 1998; 213: 201–206. 18. erlich cm, rootman ds, morin jd. corneal transplantation in infants, children and young adults: experience of the toronto hospital for sick children, 1979–1988. can j ophthalmol. 1991; 26: 206–210. 19. hong jx, xu jj, sheng mj, zhu yll. pediatric penetrating keratoplasty in shanghai: a retrospective multiple centre study from 2003 to 2007. chin med j (engl). 2008; 121: 1911–1914. 20. lowe mt, keane mc, coster dj, williams ka. the outcome of corneal transplantation in infants, children, and adolescents. ophthalmology, 2011; 118: 492–497. authors’ designation and contribution a.s.m. moin uddin; consultant ophthalmologist: concept and design, acquisition of data, analysis and interpretation of data and drafting of the manuscript. chandana sultana; consultant ophthalmologist: concept and design, acquisition of data, analysis and interpretation of data and drafting of the manuscript. m. a. muntakim shahid; consultant ophthalmologist: acquisition of data, analysis and interpretation of data and drafting of the manuscript. critical revision of the manuscript for important intellectual content. mohammed rashed; consultant ophthalmologist: acquisition of data, analysis and interpretation of data and drafting of the manuscript. critical revision of the manuscript for important intellectual content. mohammad shamsal islam; research consultant: concept and design, acquisition of data, analysis and interpretation of data and drafting of the manuscript. .…  …. https://www.ncbi.nlm.nih.gov/pubmed/?term=moffatt%20ls%5bauthor%5d&cauthor=true&cauthor_uid=15774913 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=sch%c3%b6nherr+u&cauthor_id=9848064 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=naumann+go&cauthor_id=9848064 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=zhu+l&cauthor_id=19080123 https://pubmed.ncbi.nlm.nih.gov/?sort=date&term=williams+ka&cauthor_id=20932584 36 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology original article external dacryocystorhinostomy under local anesthesia qaim ali khan, sohail zia, yasir iqbal pak j ophthalmol 2016, vol. 32 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: yasir iqbal assistant professor ophthalmology/islamic international medical college trust pakistan railways hospital rawalpindi e.mail: yasir.iqbal@riphah.edu.pk received: december 04, 2015 accepted: march 09, 2016. …..……………………….. purpose: to document the results of external dacryocystorhinostomy (ex-dcr) under local anesthesia with sedation for treatment of nasolacrimal duct (nld) obstruction. study design: interventional study case series. place and duration of study: conducted at a private clinic in gilgit pakistan over a 3 year period. materials and methods: data was prospectively collected on all patients who underwent ex-dcr. the indication for surgery was a blocked nasolacrimal duct obstruction. patients underwent irrigation of the nasolacrimal drainage systems, fluorescein dye disappearance test, and intranasal examination. patients with previous dacryocystorhinostomy surgery to the same eye were excluded from the study. ex-dcr was performed under local anesthesia with sedation on outpatient basis by a single surgeon having expertise in the technique. follow up was at day 1, 1st week and on 6th month for. during postoperative visits, patients were asked about symptomatic resolution of epiphora and assessed with patency on irrigation, fluorescein dye disappearance test, and intranasal examination. all patients were followed up for at least 6 months. surgical success was defined by patient’s resolution of symptoms with patency on irrigation. results: 61 patients were included in the study with a mean age of 37.16 ± 12 years. most of the operated patients were females (77.05%) with a nearly equal distribution between left and right eyes. intraoperative complications were unable to suture posterior flap (4.92%), excessive bleeding above 100ml in one patient, snipping of puntum one patient and unable to pass dcr tube in one patient. none of the patients had uncontrolled intranasal bleeding, cardiovascular event or local anesthesia toxicity during the surgery. all of the patients had a successful outcome which was determined by patent syringing. the most common post-operative complication was ecchymosis in 14.75%. conclusion: in order to avoid the risks of general anesthesia, ex-dcr under la with sedation is a safe and highly effective alternative technique in terms of surgical outcome. key words: dacryocystorhinostomy, local anesthesia, nasolacrimal duct obstruction. piphora is a common ophthalmic problem which may be either due to congenital or acquired nasolacrimal duct obstruction. for many decades the gold standard treatment for nasolacrimal duct obstruction has been external dacryocystorhinostomy (ex-dcr) surgery .it was first described by addeo toti in 19041 and gained popularity due to its efficacy and relatively low complication rates. the endonasal approach for lacrimal surgery was first introduced in 1893 by e external dacryocystorhinostomy under local anesthesia pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 37 caldwell.2 however it is in recent time endoscopic endonasal dcr has been employed for the treatment of nasolacrimal duct obstruction. the internal approach of endoscopic / endonasal dacryocystorhinostomy (endo-dcr) gained popularity because of having advantages of decreased morbidity, decreased post operative and reduced recovery time.3 however its disadvantages having steep learning curve, difficulty in manipulations in the narrow nasal cavity, use of general anesthesia and the expense of equipment for endoscopic techniques make it impractical in under developed areas.4 the majority of ex-dcrs are being done under general anesthesia (ga) but published works have shown success using local anesthesia (la) in elderly patients5 and youth6. la requires less ancillary and specialized staff and a shorter hospital stay. in this study, we aimed to document the results of ex-dcr performed under local anesthesia with sedation. material and methods the principles outlined in the declaration of helsinki (2008) were followed for the conduction the study7. data was prospectively collected on all patients who underwent ex-dcr at a private clinic in gilgit pakistan over a 3 year period (aug 2009 until aug 2012). all of the patients above the age of 15 years in whom surgery was indicated were selected. the indication for surgery was a blocked nasolacrimal duct obstruction (nld). patients underwent ophthalmic examinations including irrigation of the nasolacrimal drainage systems, fluorescein dye disappearance test, and intranasal examination. documented obstruction on syringing and probing were included whereas patients with previous dcr surgery to the same eye were excluded from the study. the patients signed informed consent for the procedure opting not be operated under general anesthesia but if deemed necessary were to be given general anesthesia. all surgical procedures were performed on an outpatient basis by a single surgeon having expertise in the technique. one hour before starting surgery, intragluteal 30mg pentazocine in 1ml (narcotic analgesic) mixed with 50 mg dimenhydrinate in 1 ml (antiemetic) and 75 mg diclofenac sodium intramuscularly separately in order to prevent crystallization (usually in the arm or contra lateral gluteous) were administered. an intravenous injection of 250 mg tranexamic acid (an anti-fibrinolytic) in 5 ml was given preoperatively. for local anesthesia, 10 ml of a 50/50 mixture of 2% lidocaine with adrenaline 1/200,000 and bupivicaine hcl 50 mg/10 ml was made. first, it was injected 5ml near the supraorbital foramen, directing the needle towards the medial canthus and the area was infiltrated resulting in raised skin. next, 5ml was injected near the infraorbital foramen and again infiltrated this area up to the medial canthus. proparacaine hcl 0.5% ophthalmic drops were placed in the conjunctival sac and benzocaine 20% was sprayed to anesthetize nasal mucosa. before surgery, the nasal mucosa was packed with 2% lidocaine and 1/200,000 epinephrine left over from the 10 ml vial. after swabbing the nose and orbital area skin with povidone iodine 10%, a sterile field was created expositing the medial canthal tendon. a vertically inferior, temporally angled skin incision 5-8mm long was made. the incision began just below the half way mark between the nose and medial canthus and following the angle formed by the nasal and lacrimal bones. the incision was extended to bone depth with an effort to spare the angular vein to avoid excessive bleeding. then a self-retaining retractor was placed. after some blunt dissection to free up the skin and the orbicularis oculi muscle, periosteal elevator was used to reflect the periosteum off the lacrimal bone medially and laterally. this separated the lacrimal sac from its bony fossa. after breaking through the thin part of the lacrimal bone separating the nasal mucosa from the sac, the nasal mucosa was elevated from the bone. next with the kerrison rongeur the bony stoma was enlarged. the lacrimal sac and nasal mucosa were then cut vertically in an “i” configuration and both posterior flaps were sutured together using 6.0 vicryl. after dilating the puncta and intubating the canaliculi with the dcr tube, the dcr tube was prepared by making three to four knots at different places. ultimately, it was passed through the medial meatus. then the anterior mucosal flaps were sutured with 6.0 vicryl and the wound was closed layer by layer. the skin was then approximated using a subcutaneous running 6.0 vicryl stitch and the nose was repacked with gauze soaked in lidocaine and epinephrine overnight. intraoperative complications if occurred were noted on a proforma. post-operatively, 250mg ampicillin plus 250 mg cloxacillin tid for 5 days, serratiopeptidase 5 mg tid×10 days (anti-inflammatory and anti-tumefacient) and paracetamol 500 mg × 2 tid for pain were administered. on the first post-operative day the nasal packing was removed. dexamethasone 0.1% qid with chloramphenicol 0.5% qid ophthalmic solution for the qaim ali khan, et al 38 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology eye, as well as dexamethasone 0.1% with chloramphenicol 0.5% ointment bid × one month for the wound were prescribed to all the patients. follow up was at day 1, 1st week to remove the skin stitch, after one month and on 6th month for dcr tube removal. during postoperative visits, patients were asked about symptomatic resolution of epiphora and assessed with patency on irrigation, fluorescein dye disappearance test, and intranasal examination. all patients were followed up for at least 6 months. surgical success was defined by patient’s resolution of symptoms with patency on irrigation. surgical failure was defined as no symptomatic reduction in epiphora and/or an inability to irrigate the lacrimal system postoperatively. complaints and complications, if any, were noted on all visits. results a total of 61 patients were included in the study with a mean age of 37.16 ± 12 years. most of the operated patients were females (77.05%) with a nearly equal distribution between left and right eyes. one patient (male) was operated bilaterally on separate dates. most common presenting complaint of the patients was epiphora (67.21%) then intermittent pus (31.14%), pain/burning (11.48%), itching (8.2%), morning stickiness (6.56%), and swelling (4.92%). the intraoperative complications were unable to suture posterior flap in 3 patients (4.92%), excessive bleeding above 100ml in one patient, snipping of puntum one patient and unable to pass dcr tube in one patient. none of the patients had uncontrolled intranasal bleeding, cardiovascular event or local anesthesia toxicity during the surgery. table 1: post operative complications of dcr. post operative complications no. of patients (n = 61) ecchymosis 14.75% infection of the wound site 3.27% epiphora 3.27% prolapsed tube 3.27% bleeding 1.63% primary open angle glaucoma 1.63% stoma and common canaliculus fibrosis 1.63% 18.03% patients complained of pain on the 1st day and 1st week follow up. one patient complained of pain on 1 month follow up. complaint of epiphora was noted in two patients (3.27%); one at 1st month and one at 6 month follow up. syringing was done and in both cases patency was positive. the most common post-operative complications noted in follow up visits was ecchymosis in 14.75% (table 1). among the prolapsed tube, one tube was pushed back through the stoma; the other was not and was removed at 1.5 months. in all cases of possible failure because of complication (infection, prolapsed tube, stoma fibrosis), patency was evaluated and determined to be patent. bleeding was either wound hemorrhage or epistaxis which was treated conservatively, including nasal spray and/or packing. homeostasis was achieved with no secondary hemorrhage requiring surgical intervention. the operation was declared successful by the objective demonstration of a patent nasolacrimal system through irrigation. anatomical patency and symptom relief was achieved in all patients. discussion in areas of the world where post-operative follow-ups can be few or non-existent, a practical and economical surgical technique with a high percentage of success is very important. the health and economic benefits of external techniques over endoscopic has been described 8 and this is especially true in rural and developing areas. mcnab9 has shown ex-dcr under la with sedation to be quite effective and ciftci6 also showed success without sedation. in an effort to streamline protocol and make every patient as comfortable as possible with little or no complications, we chose to use sedation. 3.27% of our patients returned with complaints of epiphora and 1.63% returned with stoma scarring. according to ben simon10 characteristics of surgical failure in dcr include (1) no marked improvement in tearing (2) any episode of postoperative dacrocystitis (3) inability to irrigate the lacrimal system postoperatively (4) postoperative nasal endoscopy with scarring in the intranasal osteotomy or no visualization of fluorescein dye. this gives a surgical success rate of at least 95% in our study. our level of 95% can even be debated under part (1) of the definition because epiphora had improved in these patients since the operation. in addition to surgical success of outcome, the external dacryocystorhinostomy under local anesthesia pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 39 choice of nerve blocks/infiltrations sets our procedure apart from those published previously. ciftci6 used five separate blocks, whereas in our study we anesthetized three nerves in one injection. we found no need for the block of the external nasal branch of the infraorbital nerve due to lidocaine nasal packing and overlap with our infraorbital block. bleeding precautions are of importance during ex-dcr procedures11 and we feel use of lidocaine 2% with 1:200,000 adrenaline provides adequate vasoconstriction. hosal et al12 showed that 3% lidocaine and oxyetazoline was effective and ciftci6 used 3% lidocaine with 1:100,000 epinephrine with good effect. in contrast to ga where coughing, retching, airway obstruction and the use of vasoactive medications can cause an increase in venous pressure,13 la remains devoid of such issues and has lower amounts of blood loss when even the same agents are used.6 prevention of secondary hemorrhage after exdcr is a concern, and successful precautions have been addressed in previous works.14 we noted zero cases of secondary hemorrhage which is similar to previously published reports of 3.9%15 and under 1%.6 one post-operative complication of note was our inability to suture the posterior flap in 4.92% of patients. differing reports have been noted in the past16, 17, but the report from a head to head trial is that double-flap anastomosis has no advantage over dcr with only anterior flaps, and is easier to perform.17 three of our patients who did not have the posterior flap closed also did well with no complications. another interesting complication of note was primary open angle glaucoma requiring trabeculectomy at 1.5 months post-op from the dcr. this patient had elevated pressures pre-operatively and the need for surgery is most likely unrelated, especially taking into account the high rate of glaucoma in the patient population of the northern areas. yet still, dcr might have complicated issues post-operatively. retrospectively the dcr could have been postponed until after the trabeculectomy. one prior case report of closed – angle glaucoma has been reported in the literature,19 but no prior cases of openangle as a result of dcr surgery were found. the complication of post-operative infection was managed by ciprofloxacin 500mg bid for 10 days for one patient presenting on post-op 1st week (ciprofloxacin was given again plus doxycycline 100 mg bid for ten days when the patient presented again at 6 months) while another was given amoxicillin on presentation at post-op 1.5 months. of note, one infection was a patient noted to be in poor hygiene and non-compliant in wound – care. all complications were evaluated for patency as mentioned in the results and were determined to be patent. the fact our procedure is outpatient in nature emphasizes our cost efficacy. previous reports published hospital stays of 1 – 3 days on average6 adding unwanted cost to the system and to the patients. also of note were the demographics of this study. our patient’s mean age was 37.16 years old and 77.05% of them were women. other reports have noted a similar predominance of women.6,9 previous reports of the age of patients undergoing dcr (using studies which included the general population) documented 645, and 59.69 years which were considerably older then our cohort. the lower age of our patients could be due to genetics or the unhygienic, dry, dusty conditions in the northern areas. both genetics and/or environmental factors could exacerbate a nldo to present earlier in life.20 conclusion if en-dcrs are not recommended because of the risks of ga or simple impracticality, ex-dcr under la with sedation is a safe and highly effective alternative technique in terms of surgical outcome. author’s affiliation dr qaim ali khan assistant professor ophthalmology/poonch medical college rawalakot, ajk dr. sohail zia assistant professor ophthalmology/islamic international medical college-trust pakistan railways hospital rawalpindi dr yasir iqbal assistant professor ophthalmology/islamic international medical college trust pakistan railways hospital rawalpindi role of authors dr. qaim ali khan operation surgeon, data collection qaim ali khan, et al 40 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology dr. sohail zia result formulation, statistics analysis dr. yasir iqbal result formulation, statistics analysis references 1. toti a. nuovo metodo conservatore di cura radicale delle suprorazioni chroniche del sacco lacrimale. clin mod firenze. 1904; 10385-9. 2. lynch tf, tang b. a comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. clinical ophthalmology. 2011; 5: 979-89. 3. khawaja k s, salahuddin a, muhammad m, sabihuddin a, iftikhar a syed n h. problems / complications, success rate – endoscopic dacryocystorhinostomy .pak j ophthalmol. 2012; 28: 17-21. 4. razavi me, noorollahian m, eslampoor a. nonendoscopic mechanical endonasal dacryocystorhinostomy. j ophthalmic vis res. 2011; 6: 219–24. 5. kratky v, hurwitz jj, ananthanerayan c, avram dr. dacryocystorhinostomy in elderly patients: regional anesthesia without cocaine. can j ophthalmol. 1994; 29: 13-6. 6. ciftci f, pocan s, karadayi k, gulecek o. local versus general anesthesia for external dacryocystorhinostomy in young patients. opthal plast reconst surg. 2005; 21: 201-6. 7. krleža-jerić k, lemmens. t 7th revision of the declaration of helsinki: good news for the transparency of clinical trials. croat med j. 2009; 50: 105–10. 8. karim r, ghabrial r, lynch tf, tang b. a comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. clin ophthalmol. 2011; 979–89. 9. mcnabb aa, simmie rj. effectiveness of local anesthesia for external darcryocystorhinostomy. clin exp ophthalmology, 2002; 30: 270-2. 10. ben simon gj, joseph j, lee s, schwarcz rm, mccann jd, goldberg ra. external versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. ophthalmology, 2005; 112: 1463-8. 11. chan, w., fahlbusch, d., dhillon, p., & selva, d. assisted local anesthesia for powered endoscopic dacryocystorhinostomy, orbit. 2014; 33: 416-20. 12. hosal bm, hosal sa, hurwitz jj, freeman jl. a rationale for the selection of nasal decongestants in lacrimal drainage surgery. opthal plast reconst surg. 1995; 11: 215-20. 13. maheshwari r. single-prick infiltration anesthesia for external dacryocystorhinostomy. orbit. 2008; 27: 79-82. 14. mcmurray cj, mcnab aa, selva d. late failure of dacryocystorhinostomy. ophthalmic plastic and reconstructive surgery, 2011; 27: 99-101. 15. ben simon gj, joseph j, lee s, schwarcz rm, mccann jd, goldberg ra. external versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. ophthalmology, 2005; 112: 1463-8. 16. elwan s. a randomized study comparing dcr with and without excision of the posterior mucosal flap. orbit. 2003; 22: 7-13. 17. baldeschi l, macandie k, hintschich cr. the length of unsutured mucosal margins in external dacryocystorhinostomy. am j ophthalmol. 2004; 138: 840-4. 18. serin d, alagoz g, karslioglu s, celebi s, kukner s. external dacryocystorhinostomy: double-flap anastomosis or excision of the posterior flaps? ophth plastic and reconstr surg. 2007; 23: 28-31. 19. wilcsek ga, vose mj, francis ic, sharma s, corneo mt. acute angle closure glaucoma following the use of intranasal cocaine during dacryocystorhinostomy. brit journ of ophthalmol. 2002; 86: 1312. 20. rose ge, verity dh. functional nasolacrimal duct obstruction–a nonexistent condition? concepts in lacrimal dynamics and a practical course of treatment. expert review of ophthalmology. 2011 dec 1; 6 (6): 60310. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22ben+simon+gj%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22joseph+j%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22lee+s%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22schwarcz+rm%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22mccann+jd%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22mccann+jd%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22mccann+jd%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22goldberg+ra%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22ben+simon+gj%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22joseph+j%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22lee+s%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22schwarcz+rm%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22mccann+jd%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22mccann+jd%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22mccann+jd%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=search&itool=pubmed_abstractplus&term=%22goldberg+ra%22%5bauthor%5d pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 111 original article ocular manifestations associated with head injury kanwal zareen abbasi, baseerat qadeer, ali raza pak j ophthalmol 2016, vol. 32 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: kanwal zareen abbasi senior registrar ophthalmology department benazir bhutto hospital rawalpindi email: dr_ maninoor_abbasi @yahoo.com received: january 26, 2016 accepted: may 13, 2016 …..……………………….. purpose: to evaluate the pattern of ocular manifestations in patients of head injury. study design: prospective cross sectional study. place and duration of study: study was carried out at district headquarter hospital, rawalpindi, from 1 st january 2013 to 30 th june 2013. material and methods: 152 patients, diagnosed with head injury along with ocular manifestations were included in this study. these head injured patients with ocular morbidity were analyzed for age, sex, cause of injury and types of ocular and head injuries. to evaluate these parameters, detailed history was taken followed by detailed anterior and posterior segment slit lamp examination, checking of extra ocular movements and optic nerve functions. diagnostic investigations carried out included computed tomography scanning/ magnetic resonance imaging of brain and orbit, gonioscopy, diplopia charting, and measurement of intraocular pressure. results: among 152 patients, 108 were males and 44 were females. causes of head injury were traffic accidents 56.5%, fall from height 25.0%, assault 13.8%, and gunshot 4.6%. maximum head and ocular injuries were in age group of 1120 years. most frequent soft tissue injury was periorbital echymosis (85 patients). most frequent neuro-ophthalmic manifestation was abducent nerve palsy (12 patients). orbital fracture with ruptured globe was encountered in 2 patients. conclusion: injury to the globe, adenexae and ocular cranial nerve palsies constitute the most common oculovisual complications following head injury. keywords: ocular, visual, complications, head injury. ead injuries are frequently associated with ophthalmic manifestations and consequent morbidity1. head injuries cause the hospitalization of 200 – 300 persons per 100,000 populations per year, and about 25% of these are associated with ocular and visual defects2. the role of ocular injuries secondary to head trauma in the causation of blindness has become a subject of immense importance.3 the manifestations of head injury and its numerous other systemic complications are so compelling that damage to the visual system is most likely to be ignored. mostly, when the eye is examined as part of neurological assessment of a patient with head injury, the purpose is mainly to gauge the severity of the head injury itself3. with respect to soft – tissue injuries to the globe and adenexae in the anterior segment of the eye, one hypothesis suggested that energy is transferred to these structures from the sturdy frontal bones to the orbit and from the lateral orbital margin to contiguous facial structures during the impact following head injury4. disorders of eye movement are thought to result from direct trauma to orbital contents, cranial nerves, and other brain areas5. the aim of this study was to evaluate the pattern and clinical profile of ocular and visual complications h kanwal zareen abbasi, et al 112 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology in patients hospitalized and managed for head injury at dhq hospital, rawalpindi. material and methods the study comprised a prospective analysis of 152 patients diagnosed as having head injury along with ocular manifestations by the neurosurgery and ophthalmology department on the basis of history, neurological and ophthalmological findings at the time of admission. they were hospitalized for varying periods between 1st january 2013 and 30th june 2013 at the dhq hospital, rawalpindi. we reviewed these patients and did follow ups for signs and symptoms of ocular morbidity which were present subsequently. detailed anterior and posterior segment slit lamp examination was done. extraocular movements, optic nerve function tests were checked. diagnostic investigations carried out included computed tomography scanning and/or magnetic resonance imaging of brain and orbit, gonioscopy, diplopia charting, and measurement of intraocular pressure. according to requirement, we assessed the visual acuity (va) using the snellen's chart. then we transferred the findings into a questionnaire format, which included patients' sociodemographic data, mode of head trauma, and findings on neurological and ophthalmic evaluations. ocular and visual complications were grouped into three main classes of abnormalities of the visual system: soft-tissue injuries to the globe and adenexae, neuro-ophthalmic abnormalities, and injuries to the bony orbit and other skull bones. ophthalmology and neurosurgery departments managed the patients according to their respective diagnoses and referred those who presented with multiple organ involvement to the appropriate specialties at the same hospital. results ocular and visual complications occurred in 152 headinjured individuals managed during the period under consideration. they were 108 (71.0%) male and 44 (28.9%) female subjects. at presentation, the youngest and oldest patients were 6 years and 63 years old, respectively. ophthalmic complications peaked at the second decade of life, and thereafter declined (fig. 1). patients encountered multiple ocular injuries involving both anterior and posterior segments of the eye. the causes of head injury are itemized in table 1 and traffic accidents were the most common cause of ocular disorder (56.6%), fall from height (25%) and assault (13.8%) accounted for head and ocular injuries, while gunshot injury to the head was responsible in 7 patients (4.6%). of the traffic related accidents, passengers were most frequently affected (65.0%) than pedestrians (26.0%) and cyclists (9%), shown in fig. 2. fig. 1: age and sex distribution in 152 patients manifesting ocular and visual complications of head injury. fig. 2: people affected in traffic accidents. table 2 shows the ocular and visual complications of head injury observed in 152 cases. one very important case found was a patient who developed carotid cavernous fistula bilaterally shown in figures 3, 6 (features were more prominent on left side). other frequent complications included soft-tissue injuries to the globe and adenexae, neuro-ophthalmic abnormalities, and fracture of the orbit with rupture of ocular manifestations associated with head injury pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 113 the globe. the most frequent soft – tissue injuries were periorbital echymosis (85 patients), sub-conjunctival haemorrhage (62 patients), lid oedema (52 patients), chemosis (16 patients),black eye (18), lid laceration (14 patients), corneoscleral laceration (06 patients) shown in figure 4, vitreous haemorrhage (05 patients). the most frequently encountered neuroophthalmic manifestation was abducens nerve palsy. it occurred in 12 patients and was the most common ocular motor nerve palsy, followed by oculomotor 10 patients, trigeminal 4 patients, trochlear 4 patients and facial nerve palsy 2 patients. one patient developed aberrant regeneration of third nerve. another neuro-ophthalmic complication observed fig. 3: ct angiography brain showing dilated cavernous sinuses due to carotid cavernous fistula. fig. 4: right eye corneo-scleral tear with uveal tissue prolapsed. table 1: causes of head injury causes male female no of patients n (%) traffic accidents 58 28 86 (56.6) assault 16 5 21 (13.8) falls from height 30 8 38 (25.0) gunshot 4 3 7 (4.6) total 108 44 152 (100) table 2: ocular complications of head injury injury type no. of patients a. soft – tissue injury to the globe and adenexae periorbital ecchymosis laceration of eyelids lid oedema corneoscleral laceration subconjunctival haemorrhage unilateral bilateral chemosis brow tear vitreous haemorrhage black eye unilateral bilateral b. orbital fracture with rupture globe c. neuro-ophthalmic complications cranial nerve injury abducens oculomotor trochlear trigeminal facial traumatic optic neuropathy aberrant regeneration of third nerve papillodema carotid cavernous fistula 85 14 52 06 62 44 18 16 02 05 18 08 10 02 12 10 04 04 02 10 01 10 01 kanwal zareen abbasi, et al 114 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology was papillodema in 10 patients which is not uncommon to be found in cases of head injury. table 3: ct scan findings of head injured patients (bony and soft tissue injuries). according to ct-scan findings (table 3) the most commonly fractured bone was frontal bone (20) followed by parietal bone (08), occipital bone (04), basal skull fracture (04) and temporal bone fracture in (02) patients. subdural haemorrhage occurred in (30) patients followed by sub-arachanoid (22), extra-dural (16) and intra-cerebral bleed in (10) patients. multiple brain contusions occurred in (16) patients. discussion in our study we have assessed different ocular manifestations which we found in patients of head injury. it is not surprising that traffic accidents were responsible for the greater proportion of head injuries associated with ocular manifestations. in many series worldwide, traffic accident constitutes the leading cause of head injury which is shown in study of odebode et al,3 kulkarni et al5, masila et al6, sabates et al7 and in our study again, it is the leading cause 56.6%. in our setting, motorized transportation has been on the rise in recent years and this is not without the attendant risk of increased auto accidents. this is worst in those parts of the world like ours, where traffic regulations and speed limits are not strictly observed and unlicensed careless driving is treated with levity. the lids and conjunctiva in the anterior segment of the eye were more commonly involved in head injuries than the posterior segment, ocular cranial nerves, or the bony orbit. injuries to this segment result from direct impact on the rigid frontal bones and orbital margins, producing periorbital echymosis, lid laceration, and subconjunctival haemorrhage, and chemosis3. same is true for our study. the eyes are often involved in head injury (directly and indirectly) with neuro-ophthalmic deficits7,8,9,10,11,12. in our study, of the neuro-ophthalmic complications, traumatic ocular motor abnormality was the most frequent and among cranial nerve palsies the abducens being the most commonly affected cranial nerve (41%) followed by oculomotor, trigeminal, trochlear and facial being least affected nerve. the incidence of abducens nerve palsy in odebode et al study, in severe head injuries has been reported as 27%3. the mechanism of its palsy, secondary to severe head injuries, has been attributed to avulsion or contusion of the nerve at the base of the posterior clinoid process, where it lies beneath the rigid petrospheniod (gruber's) ligament, medial to the sensory root of the fifth nerve at the apex of the temporal bone3. eye injuries remain the most common cause of monocular blindness, a life-long disability, and when the outcome is less serious than blindness extensive medical care, including surgery, hospitalization, and repeated treatments over long periods may be required. inspite of this, majority of the past reviews on this subject have focused on specific aspects of the visual anatomy, such as the ocular cranial nerves, optic nerves, or the posterior visual pathways13,14,15,16, rather than a complete overview of the manner in which head injury affects the visual system. our study has added to the latter list and has given credibility to a few previous findings. as we have discussed previously that abducent nerve is the most commonly damaged cranial nerve, it is usually damaged when a basilar fracture crosses the petrous ridge and a clear relationship can usually be established with facial paralysis and deafness16. this makes the seventh and eighth cranial nerve damage a common association with head injuries associated with ocular manifestations as observed in this series. abducens palsy could also derive from sufficient middle cranial fossa haemorrhage causing compression and pressure paralysis on one or both sides16. fractures number frontal bone parietal bone 0ccipital bone temporal bone basal skull 20 08 04 02 04 haemorrhages sub-dural haemorrhage sub-arachanoid haemorrhage extra-dural haemorrhage intra-cerebral bleed 30 22 16 10 multiple brain contusions 16 ocular manifestations associated with head injury pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 115 visual loss resulting from globe rupture and traumatic optic nerve damage associated with head injury in this series should be regarded as the most significant disability. in our study there were 10 cases of traumatic optic neuropathy. trauma-induced injury to the optic nerve can occur anywhere along the nerve’s intraorbital to intracranial length. radiological investigations (ct scan/mri) has confirmed the presence of dural haemorrhage, interstitial nerve haemorrhage, shearing lesions, as well as localized ischaemia and oedema, which are considered as secondary events to initiate neuropathy. according to rush et al16, such injuries are ordinarily self-limiting with improvements occurring in 3 – 4 days. however, when they do persist, corticosteroid therapy or optic nerve decompression has been advocated17. currently endoscopic optic nerve decompression by an intranasal or trans-ethmoidal or trans-sphenoid approach is gaining a popular support. in our study, aberrant regeneration of third nerve was detected in a young male, 25 years of age, who had road traffic accident with resultant left frontal bone fracture with underlying extra-dural and subarachanoid haemorrhages, along with that he had 3rd, 5th (ophthalmic branch), 6th nerve palsies and papillodema at time of admission, during regular follow up, at 3 month he was found to have signs similar to adie’s pupil i.e. light near – dissociation and vermiform movements (seen on slit lamp examination). traumatic third nerve palsy may result in aberrant regeneration of the third cranial nerve. the full blown features of this syndrome may or may not be present18 and the same problem can occur after orbital trauma19. another important case in our study was traumatic carotid cavernous fistula, who was a 65 year old female patient and had history of fall from roof with resultant occipital epidural hematoma and basal skull fracture. she was managed conservatively after admission and was discharged after 3 days of admission. 5 months after injury she presented via eye opd with pain left eye. on examination she had bilateral episcleral congestion (l > r) left corneal oedema, fixed dilated pupil, intraocular pressure at eye 18 mm hg, lt eye 70 mm hg, left fundal view was hazy showing disc hyperemia. features of pupil involving left 3rd nerve palsy were also there. initially raised iop was managed with topical, oral and intravenous anti-glaucoma therapies and with full conservative management, intraocular pressure was reduced to 32 mm hg in left eye. our provisional diagnosis was carotid cavernous fistula which was confirmed on ct angiography and so patient was referred to neurosurgery department dhq rawalpindi for further management. a relatively high incidence of traumatic carotid cavernous fistula was been reported in patients with basal skull fracture (mainly middle cranial fossa)20. prompt diagnosis and early intervention may significantly improve the patient outcome20. as far as skull fractures are concerned, frontal bone fracture was most common in our study (51%) which is comparable with rupani et al21 study (56.7%) where again it was most common. among intracranial bleeds, subdural haemorrhage was most of all (30.1%) noted in perel et al22 study and same is true for our study where it is 38.1%. conclusion injury to the globe, adenexae and ocular cranial nerve palsies constitute the most common oculovisual complications associated with head injury, so every patient with head injury should also be examined for eye signs along with routine management for head injury and this should be practiced not only on first presentation but also on follow up visits. author’s affiliation dr. kanwal zareen abbasi senior registrar ophthalmology department benazir bhutto hospital rawalpindi dr. baseerat qadeer postgraduate trainee ophthalmology department benazir bhutto hospital rawalpindi professor dr. ali raza head of ophthalmology department, rawalpindi medical college and allied hospitals rawalpindi role of authors: dr. kanwal zareen abbasi data collection, review of literature, paper writing dr. baseerat qadeer data collection kanwal zareen abbasi, et al 116 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology professsor dr. ali raza manuscript review references 1. van stavern gp, biousse v, lynn mj, simon dj, newman nj. neuro-ophthalmic manifestations of head trauma. j neuro-ophthalmol. 2001; 21: 112–7. 2. baker rs, epstein ad. ocular motor abnormalities from head trauma. survey ophthalmol. 1991; 35: 245−67. 3. odebode to, ademola-popoola ds, ojo ts, ayanniyi aa. ocular and visual complications of head injury. eye 2005; 19: 561–6. 4. duke elder s, wybar kc. the anatomy of the visual system. eye and sport medicine. 1961; 2: 559−67. 5. kulkarni ar, aggarwal sp, kulkarni rr, deshpande d, walimbe 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insufficiency in brain – injured patients. brain injury. 1989; 3: 187−91. 14. ramsay jh. optic nerve injury in the fracture of the canal. br j ophthalmol. 1979; 63: 607–10. 15. shifrin, louise z md. bilateral abducens nerve palsy after cervical spine extension injury: a case report. spine, march 1991; 16: 374-5. 16. rush ja, younge br. paralysis of cranial nerves iii, iv and vi. cause and prognosis in 1,000 cases. arch ophthalmol. 1981; 99: 76-9. 17. waga s, kubo y, sakakura m. transfrontal intradural microsurgical decompression for traumatic optic nerve injury. acta neurochir. 1998; 91: 42–46. 18. sayed sa, rabea m. aberrant regeneration of the third cranial nerve.journal of the egyptian ophthalmology society. 2013; 106: 150-2. 19. sebag j, sadun aa. aberrant regeneration of third cranial nerve following orbital trauma, arch neurol. 1983; 40: 762-4. 20. liang w, xiaofeng y, weiguo l. traumatic carotid cavernous fistula accompanying basal skull fracture. j trauma. 2007; 63: 1014-20. 21. rupani r, verma a, rathore s. patterns of skull fractures in cases of head injury by blunt force. acad forensic med. 2013; 35. 22. perel p, roberts i, bouamra o, woodford m, mooney j, lecky f. intracranial bleeding in patients with traumatic brain injury: a prognostic study. bmc emergency medicine. 2009; 9. pak j ophthalmol. 2021, vol. 37 (4): 366-369 366 original article frequency of different ocular conditions leading to ocular morbidity in pediatric age group at dow university hospital madiha jawaid 1 , mazhar-ul-hassan 2 , saba al-khairy 3 , farnaz siddiqui 4 , asad azeem 5 1-5 department of ophthalmology, dow university hospital, ojha campus abstract purpose: to determine the frequency of different ocular conditions leading to ocular morbidity in a tertiary care hospital. study design: descriptive cross sectional study. place and duration of study: study was done in dow university of medical sciences, from may 2018 to october 2018. methods: a total of 278 patients presenting in the eye out-patient department were included. patients with unaided visual acuity of 6/6 in both eye and no ocular abnormality were excluded from the study. children with congenital syndromes like down’s syndrome, etc. leading to eye diseases were also excluded. all children underwent complete ocular examination. data was analyzed by using spss version 22. frequency and percentages were computed for gender and different ocular diseases e.g., myopia, hypermetropia, strabismus, vernal kerato-conjunctivitis, astigmatism, red eye, subconjunctival hemorrhage etc. post-stratification chi-square test was applied with p-value ≤ 0.05. results: out of 278 participants of the study, there were 154 (55.4%) males and 124 (44.6%) females. average age of the patients was 11.15 ± 3.44 years. myopia and red eyes were the major causes of pediatric ocular morbidity i.e. 33.81% and 26.6% respectively. comparison between two age groups showed that myopia was higher in children with 11 to 15 years. myopia and astigmatism were more common in females while subconjunctival hemorrhage was more in males. conclusion: refractive errors are the commonest cause of childhood visual impairment in our setup. correcting these preventable diseases can have a positive impact on the performance of children at school. key words: visual acuity, pediatric, myopia, hypermetropia, kerato-conjunctivitis. how to cite this article: jawaid m, hassan m, al-khairy s, siddiqui f, azeem a. frequency of different ocular conditions leading to ocular morbidity in pediatric age group at dow university hospital. pak j ophthalmol. 2021, 37 (4): 366-369. doi: 10.36351/pjo.v37i4.1202 correspondence: madiha jawaid department of ophthalmology dow university hospital ojha campus email: madihajawaid88@gmail.com received january 14, 2021 accepted: july 24, 2021 introduction decreased vision, whether congenital or acquired can negatively affect the learning of a child. it not only leads to bad quality of life but also has detrimental effects on the person’s self-esteem caused by lack of employment opportunities and other social stigmatization. 1 according to who, about 5 percent of the global blind population comprises of children (approximately open access madiha jawaid, et al 367 pak j ophthalmol. 2021, vol. 37 (4): 366-369 1.5 billion). the burden of blindness in the third world countries of africa and asia is three to four folds as compared to developed countries, contributing to 8090% of the number of blind children worldwide. 2 every year, 5,000,000 children become blind and it is found that the majority of cases are caused by preventable ailments. 3 the most common cause of visual impairment, all over the world, is refractive error. 4 according to the pakistani data, the ratio of blindness among children was 1 per 10,000 children, which accumulated the total to 60,000 blind children. a possible contributing factor of congenital visual impairment is consanguineous marriages and maternal infections. 5 among the visually impaired people in pakistan, 66.7% are caused by cataracts. 6 the range of ocular morbidity shows regional disparity, at a national level and sub-national level, often with respect to racial and genetic make-up. in the united states, squint, amblyopia and refractive error were the most common causes of visual disability in school going children. 7 while in nigeria, refractive error accounts for 25.7%, allergic conjunctivitis makes up to 25.3%, ocular trauma about 13.3% and corneal infections 12.5%. 8 although in ethiopia, the most frequent reason of ocular diseases among kids was trachoma (33.7%), while refractive errors came out to be 6.3% and nontrachomatous conjunctivitis was about 5.9%. 9 in india, about 30% of the visually impaired people acquire this disability before 20 years of age. 10 ocular morbidities, in order of their prevalence included refractive error (23.6%), vernal conjunctivitis (17.32%) and infection of eye (15.13%). 11 the rationale of this study was to find out the causes of vision impairment in dow university hospital so that preventable diseases of pediatric age group could be tackled in time to avoid blindness. methods it was a descriptive cross sectional study done at dow university hospital, karachi, from may 2018 to october 2018. the sample size was calculated by open epi calculator with prevalence of most common morbidity of refractive error as 23.67%. 11 with margin of error as 5% and 95% confidence interval, the sample size came out to be 278. all patients of 5 to 15 years of age were included in this study. patients belonging to either gender, presenting in the opd for eye related problems were included. all patients, who had unaided visual acuity of 6/6 in both eye and no ocular abnormality detected on detailed examination were excluded from the study. children with congenital syndromes like down’s syndrome, etc. leading to eye diseases were also excluded. after written informed consent from the parents of the children, all children underwent autorefractrometery (using rm8800 topcon) by a trained optometrist. visual acuity was checked with snellen chart. cycloplegic refraction (by using cyclopentolate hydrochloride 1.0% drops) was done in patients with visual acuity of less than 6/9 in the worse eye. detailed examination of anterior segment and fundus of the eye was done with slit lamp biomicroscope (topcon sl-3c) and +90 diopter by a trainee ophthalmologist. the information collected from the patients was entered in a pre-designed performa. data was analyzed by using spss version 22. mean with standard deviation was calculated for age. frequency and percentages were computed for gender, ocular morbidity e.g., myopia, hypermetropia, strabismus, vernal kerato-conjunctivitis, astigmatism, red eye, subconjunctival hemorrhage etc. effect modifiers like age and gender were addressed through stratification. post-stratification chi-square test was applied with p-value ≤ 0.05. results out of 278 participants of the study, there were 154 (55.4%) males and 124 (44.6%) females. average age of the patients was 11.15 ± 3.44 years. myopia and red eyes were the major causes of pediatric ocular morbidity i.e. 33.81% and 26.6% respectively. for detailed causes of visual impairment refer to table 1. some patients had more than ocular diseases. table 1: most common ocular morbidity in childhood (n = 278). cause of vision impairment percentage myopia 33.81% red eye 26.6% astigmatism 12.95% hypermetropia 6.47% vernal kerato-conjunctivitis 6.12% sub-conjunctival hemorrhage 4.68% strabismus 1.44% frequency of different ocular conditions leading to ocular morbidity in pediatric age group pak j ophthalmol. 2021, vol. 37 (4): 366-369 368 comparison between two age groups is shown in table 2. myopia was higher in age group with 11 to 15 years. all the other ocular diseases were similarly common in both age groups. gender difference indicated that rate of decrease vision, myopia, astigmatism and sub-conjunctival hemorrhage were also statistically significantly different between male and female as shown in table 3. table 2: ocular morbidity with respect to pediatric age groups. ocular morbidity age groups (years) p-value 5 – 10 n = 105 11 – 15 n = 173 decrease vision 56 (53.3%) 111 (64.2%) 0.074 myopia 21 (20%) 73 (42.2%) 0.0005* hypermetropia 9 (8.6%) 9 (5.2%) 0.268 strabismus 3 (2.9%) 1 (0.6%) 0.122 vernal keratoconjunctivitis 9 (8.6%) 8 (4.6%) 0.183 astigmatism 18 (17.1%) 18 (10.4%) 0.105 red eye 32 (30.5%) 42 (24.3%) 0.257 sub-conjunctival hemorrhage 6 (5.7%) 7 (4%) 0.523 table 3: ocular morbidity with respect to gender n = 278. ocular morbidity gender pvalue male n = 154 female n = 124 decrease vision 81 (52.6%) 86 (69.4%) 0.005* myopia 43 (27.9%) 51 (41.1%) 0.021* hypermetropia 13 (8.4%) 5 (4%) 0.138 strabismus 2 (1.3%) 2 (1.6%) 0.827 vernal keratoconjunctivitis 10 (6.5%) 7 (5.6%) 0.769 astigmatism 14 (9.1%) 22 (17.7%) 0.033* red eye 51 (33.1%) 23 (18.5%) 0.06 sub-conjunctival hemorrhage 11 (7.1%) 2 (1.6%) 0.030* discussion visual disabilities of children affect their ability to learn, their wisdom, studying power and behavior. statistics on diagnosis of ocular diseases in kids is the key for to carry out preventive and curative facilities. in the present study, the average age of the patients was 11.15 ± 3.44 years. in a study by mehari et al, the mean (sd) age of the study population was about 9.37 (4.95) years. 12 biswas et al had 714 patients including 416 (58.26%) males and 298 (41.74%) females. all the patients were divided into three broad groups, that is, 0–4, 5–9, and 10–14 years. majority, that is, 70.73% of the study subjects were in the 10–14 years of age group. 11 different studies had been done which concluded the burden of ocular morbidity among pediatric population. one of the study from nigeria found that refractive error was the most common (25.7%) while the vernal conjunctivitis was second commonest cause of visual morbidity. 13 in another study in tikrit, iraq, allergic conjunctivitis (27%) came out to be most prevalent and the second most common was refractive errors (14.6%) followed by ocular trauma (13.8%), infection (12.7%), squint (12.1%) and nasolacrimal duct obstruction (nldo, 5.2%). 14 active trachoma (51.6%) was the most common in central ethiopia in children under 10 years of age. 15. in another study, refractive error was the commonest cause of decrease vision in children. 16 this was consistent with our results. different studies show a variability in the prevalence of refractive error from 12% to 31%. 17,18 higher prevalence of refractive errors is seen among older age group of children which also endorse the results of our study. this could be because of lack of awareness among caretakers to recognize visual problem at an earlier stage. in india, the prevalence of refractive errors ranges between 21% and 25% in india. 19 similar prevalence of refractive errors has been observed among different studies in shimla, kolkata and also in ahmedabad. 20 data on prevalence of different causes of ocular morbidity from a particular region is a pre-requisite for planning preventive and curative services. there are insufficient data regarding hospital based studies on childhood ocular morbidity. to combat this, school eye screening programs should be strengthened so that visual impairment due to refractive errors could be reduced. majority of the causes of ocular morbidity are preventable. limitations of this study are a single centered study with limited data. measure to tackle these problems were also not included in this research. large scale data from different provinces is required to make standard operating procedures to reduce ocular morbidity in the pediatric age group. conlcusion refractive errors is the commonest cause of childhood visual impairment, which can be easily handled. early detection and management can have a positive impact on the performance of children at school. the problem can be solved by simple spectacle correction. ongoing madiha jawaid, et al 369 pak j ophthalmol. 2021, vol. 37 (4): 366-369 repeated inspection platforms should be implemented to trim down the prevalence of ocular diseases in children. ethical approval the study was approved by the institutional review board/ethical review board. (osp-irb/2021/006) conflict of interest authors declared no conflict of interest. references 1. mehari za. pattern of childhood ocular morbidity in rural eye hospital, central ethiopia. bmc ophthalmol. 2014; 14 (1): 50. 2. kishore s, aggrawal p, muzammil k, singh s, bhaskar y, bhaskar r. ophthalmic morbidity in school children in hilly areas of uttarakhand. indian j community health, 2014; 26 (1): 56-60. 3. saxena a. nema a, deshpande a. “prevalence of refractive errors in school-going female children of a rural area of madhya pradesh, india.” j clin ophthalmol res. 2019: 45-49. 4. kumari vk, lakshmi ms. screening for simple myopia among high school children in hyderabad city. j evid based med. 2016; 3: 1097-1091. 5. farrukh s, latif ma, klasra ah, ali m. pattern of pediatric eye diseases. pakistan j ophthalmol. 2015; 31 (3): 148. 6. jadoon mz, dineen b, bourne rr, shah sp, khan ma, johnson gj, et al. prevalence of blindness and visual impairment in pakistan: the pakistan national blindness and visual impairment survey. arvo. 2006; 47 (11): 4749-4755. 7. american foundation for the blind, "statistical snapshots from the american foundation for the blind." retrieved from: http://www.afb.org/info/blindness-statistics/2. 8. achigbu e, oguego n, achigbu k. spectrum of eye disorders seen in a pediatric eye clinic south east nigeria." nigerian j. 2017; 23 (2): 125. 9. mohammed s, abebe b. common eye diseases in children of rural community in goro district, central ethiopia. ethiopia j health dev. 2005; 19: 148-152. 10. gupta m, gupta bp, chauhan a, bhardwaj a. ocular morbidity prevalence among school children in shimla, himachal, north india. indian j opthalmol. 2009; 57 (2): 133. 11. biswas j, saha i, das d, bandyopadhyay s, ray b, biswas g. ocular morbidity among children at a tertiary eye care hospital in kolkata, west bengal. intern j pub health, 2012; 56 (4): 293. 12. mehari za. pattern of childhood ocular morbidity in rural eye hospital, central ethiopia. bmc ophthalmology, 2014; 14: 50. 13. olusanya ba, ugalahi mo, ogunleye ot, baiyeroju am. refractive errors among children attending a tertiary eye facility in ibadan, nigeria: highlighting the need for school eye health programs. ann ib postgrad med. 2019; 17 (1): 49-59. 14. salmansheaps ms. pediatric eye diseases among children attending outpatient eye department of tikrit teaching hospital. tikrit j pharm sci. 2010; 7 (1): 95– 103. 15. abebe b, wondu a. prevalence of trachoma and its determinants in dalocha district, central ethiopia. ophthalmic epidemiol. 2001; 8 (2–3): 119–125. 16. paudel p, ramson p, naduvilath t, wilson d, phuong ht, ho sm, et al. prevalence of vision impairment and refractive error in school children in ba ria – vung tau province, vietnam. clin exp ophthalmol. 2014 apr; 42 (3): 217-226. doi: 10.1111/ceo.12273. 17. salma kcr, hari t, malla ba. clinical profile of pediatric ocular morbidity in a tertiary eye care centre in western region of nepal. ann pediatr child health, 2015; 3: 1070. 18. gupta m, gupta pb, chauhan a, bhardwaj a. ocular morbidity prevalence among school children in shimla, himachal, north india. indian j ophthalmol. 2009; 57: 133-138. 19. kumar r, dabas p, mehra m, ingle gk, saha r, kamlesh. ocular morbidity amongst primary school children in delhi. health popul perspect issues, 2007; 30: 222-229. 20. santos-bueso e, dorronzoro-ramírez e, gegúndez fernández ja, vinuesa-silva jm, vinuesa-silva i, garcía-sánchez j. causes of childhood blindness in a developing country and an underdeveloped country. j fr ophtalmol. 2015; 38 (5): 427-430. authors’ designation and contribution madiha jawaid; senior medical officer: concepts, design, literature search, data acquisition, data analysis, manuscript editing, manuscript review. mazhar-ul-hassan; professor: data analysis, manuscript editing, manuscript review. saba al-khairy; assistant professor: statistical analysis, manuscript editing. farnaz siddiqui; assistant professor: manuscript preparation. asad azeem; assistant professor: data acquisition, data analysis. .…  …. http://www.who.int/mediacentre/factsheets/fs282/en/ http://www.afb.org/info/blindness-statistics/2 https://go.gale.com/ps/advancedsearch.do?method=dosearch&searchtype=advancedsearchform&usergroupname=anon%7e66997a7b&inputfieldnames%5b0%5d=au&prodid=hrca&inputfieldvalues%5b0%5d=%22ngozi+oguego%22 https://go.gale.com/ps/advancedsearch.do?method=dosearch&searchtype=advancedsearchform&usergroupname=anon%7e66997a7b&inputfieldnames%5b0%5d=au&prodid=hrca&inputfieldvalues%5b0%5d=%22kingsley+achigbu%22 pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 154 original article frequency of common eye diseases in pediatric outpatient department of a tertiary care hospital kaneez fatima, erum shahid, arshad shaikh pak j ophthalmol 2015, vol. 31 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: kaneez fatima department of ophthalmology abbasi shaheed hospital karachi email: kf_sajjad@hotmail.com …..……………………….. purpose: to determine the frequency of common eye diseases in children attending outpatient department of a tertiary care hospital. material and methods: a total of 186 patients with complaints of reduced vision, redness, itching and watering of eyes were included in this study. detailed examination was done at department of ophthalmology, abbasi shaheed hospital, karachi. six months from 1 st august 2013 to 31st january 2014. refraction was performed under cycloplegia. anterior segment was examined with the help of direct ophthalmoscope and slit lamp. posterior segment examination was performed after dilating pupil with mydriatic drops using direct and indirect ophthalmoscopes. intraocular pressure was checked where needed. all information was entered in proforma. data was analyzed on spss 10. mean and standard deviation were computed for age. frequency and percentages were computed for categorical variables like conjunctivitis, vernal keratoconjunctivitis, nasolacrimal duct blockage, hypermetropia and myopia. results: frequency of commonest eye disease was conjunctivitis i.e. 41.3% followed by nasolacrimal duct blockage 25.8%, vernal keratoconjunctivitis 16.1%, hypermetropia 9.1% and myopia 7.5%. conclusion: the most common eye problem was conjunctivitis. nasolacrimal duct blockage presented the second most common cause of pediatric ophthalmic disorder. males were more affected than females. key words: eye diseases, conjunctivitis, nasolacrimal, keratoconjunctivitis. ye diseases are very common in every part of the world and in all age groups they affect quality of life. frequency of ocular diseases not only varies country to country but also from region to region in the same country. it may be due to environmental, climatic, racial, socioeconomic and literacy factors.1 the eye diseases that cause visual problems are different in different age groups. in adults most of the visual problems are caused by diabetes, hypertension, and age related cataract but in children congenital and infective problems are more common. pediatric ophthalmic disorders are important because of their impact on child’s development, education, future work and quality of life. their early diagnosis and initiation of treatment may reduce the incidence of blindness in later life. in infants and children common eye diseases include conjunctivitis, vernal keratoconjunctivitis, nasolacrimal duct blockage, refractive errors like hypermetropia and myopia. prompt diagnosis and treatment of these problems is must as they can lead to permanent visual loss in later life.2 global incidence of conjunctivitis is 42.5%2 vernal keratoconjunctivitis is 27%,3 nasolacrimal duct blockage is 30%,4 hypermetropia is 8.4%5 and myopia is 6.3%,6 an international survey revealed that among 45 million people who were blind in year 2000, 1.4 million were children and unfortunately majority would be living in poorest regions of asia and africa.6 e kaneez fatima, et al 155 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology in pakistan childhood eye disease remains a significant public health issue as children under 12 years contribute 42% of total population.7 clinically no published data is available on this very important health issue however it has frequently been reported from other regions of the world. this study will help to generate local data and will contribute to evaluate the burden of this problem in our society. the objective of our study was to determine the frequency of common eye diseases in children attending outpatient department of a tertiary care hospital. material and methods this study was a cross sectional descriptive study. it was conducted in the department of ophthalmology, abbasi shaheed hospital, karachi from 1st august 2013 to 31st january 2014. sample size calculated was 186 6 with 3.5% margin of error ,95% confidence interval and proportion of myopia is taken as 6.35. sampling technique was non probability consecutive sampling. children of 12 or less than 12 years of age, both gender coming to an out-patient department of ophthalmology, abbasi shaheed hospital, karachi with any of these complains like reduce vision, redness, itching and watering of eyes were included. children having visual impairment due to ocular trauma, history of ocular surgery, using topical or systemic steroid for at least 1 week were excluded from the study. as steroids can mask various diagnostic signs and raise intraocular pressure. patients fulfilling inclusion criteria were approached through outpatient eye department of abbasi shaheed hospital. detail history was taken and detail examination was done after obtaining a full informed consent from parents. refraction was performed under cycloplegia where required. anterior segment was examined with the help of direct ophthalmoscope and slit lamp. posterior segment examination was performed after dilating pupil with mydriatic drops using direct and indirect ophthalmoscopes and fundus contact lenses e.g. 90 diopter lens. squint assessment was done using test for version and ductions, hirschberg’s test and coveruncover test. outcome variables like conjunctivitis, vernal keratoconjunctivitis, nasolacrimal duct blockage, hypermetropia and myopia were measured as per operational definitions. all information was entered in proforma. the collected data was entered in spss (version 10) and analyzed. male to female ratio was computed along with gender distribution. mean and standard deviation was computed for age. frequency and percentages were computed for categorical variables like conjunctivitis, vernal keratoconjunctivitis, nasolacrimal duct blockage, hypermetropia and myopia. result a total of 186 patients were included in this study. there were 105 (56.45%) males and 81 (43.55%) females. male to female ratio was 1.29:1. the average age of the children between 1 to 12 years of age was 7.17 ± 2.79 years (95%ci: 6.76 to 7.57) as shown in table 1. twenty seven children (14.52%) were between 1 to 4.9 years, 97(52.15%) were between 5 to 8.9 years of age and 62 (33.33%) were 9 to 12 years of age as presented in fig. 1. frequency of commonest eye disease was conjunctivitis i.e.77 (41.3%) followed by nasolacrimal duct blockage 48 (25.8%), vernal keratoconjunctivitis 30 (16.1%), hypermetropia 17(9.1%) and myopia 14 (7.5%) as presented in table 2. all of these diseases were slightly more common in boys than girls table 3. table 1: descriptive statistics of age of the children. male 105 (56.45%) female 81 (43.55%) mean age 7.17 ± 2.79 minimum age 1 maximum age 12 discussion pediatric ophthalmic disorders are important because of their impact on child’s development, education, future work, opportunities and quality of life. the global prevalence of blindness is 0.78/1000 and there are estimated 1.5 million blind children. approximately 500,000 children becoming blind every year, one every minute and half of them die within one to two years of becoming blind. in pakistan childhood eye disease remains a significant public health issue as children under 12 years contribute to 42% of total population.7 according to an international frequency of common eye diseases in pediatric outpatient department of a tertiary care pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 156 survey among 4.5 million people who were blind in year 2000, 1.4 million were children. unfortunately majority of them reside in poorest region of asia and africa.6 fig. 1: age distribution of the study children (n = 186). in present study frequency of commonest eye disease was conjunctivitis i.e. 77 (41.3%) followed by nasolacrimal duct blockage 48 (25.8%), vernal keratoconjunctivitis 30 (16.1%), hypermetropia 17 (9.1%) and myopia 14 (7.5%). in sethi et al study2 conjunctiva was involved in 42.5%, vernal keratoconjunctivitis was 35.6% children followed by refractive errors involving 12.8% children. in a survey among school children aged 6-10 years in south africa revealed a prevalence of vernal keratoconjunctivitis to be 11.8% in boys and 8.3% in girls.10 corneal diseases accounted for 4.9% of pediatric ophthalmic disorders11. refractive errors which account mostly for low vision and visual handicap are the third largest cause of curable blindness in pakistan12. in one study it was found out that refractive errors account for 8% cases of uniocular blindness in north west frontier province13. squints accounted for 11.8% of the pediatric ophthalmic disorders. there is variability in the prevalence of hypermetropia worldwide, from 0.7% in rural india14, 21 to 21.6% for 5–7-year olds in chile.15 in this study myopia was high among boys. ojaimi et al,16 also studied school children in australia and found an overall myopia prevalence of 1.4%. they found a significant difference between white european children (0.79%) and those belonging to other ethnicities (2.73%). in another polish study in semirural population of children, the prevalence of myopia was slightly higher: 11.3% in those aged 10 years to 14.4% in those aged 12 years.17,18 the pattern of underlying causes of childhood blindness varies considerably between developed and developing countries. in industrialized countries the main cause of childhood blindness are cataract, glaucoma, retinopathy of prematurity, genetic diseases and congenital anomalies. in developing countries blindness in children is usually caused by conditions which cause scarring of the cornea such as vitamin a deficiency, measles, infection, conjunctivitis of newborn and harmful traditional eye practices. all of these are preventable causes of blindness. we need to work on elimination of those causes in collaboration with government and private sector, also by creating awareness among masses. conclusion the leading causes of eye diseases in children coming to eye opd were conjunctivitis followed by nasolacrimal duct blockage, vernal keratoconjunckaneez fatima, et al 157 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology tivitis, hypermetropia and myopia. males were more commonly affected than females. author’s affiliation dr. kaneez fatima department of ophthalmology abbasi shaheed hospital karachi dr. erum shahid senior registrar department of ophthalmology abbasi shaheed hospital karachi dr. arshad shaikh head of department department of ophthalmology abbasi shaheed hospital karachi role of authors dr. kaneez fatima study design, concept, data collection, data analysis, manuscript writing and critical review. dr. erum shahid study design, concept, part of manuscript writing and critical review. dr. arshad shaikh study design, concept and critical review. references 1. william c, north stone k, howard m. prevalence and risk factors for common vision problems in children. br j ophthalmology. 2008; 92: 959-64. 2. sadia s, junaid s, nasir s, naimatullah k. pattern of common eye disease in children attending outpatient eye department khyber teaching hospital. pak j ophthalmology. 2008; 24: 166-71. 3. lambiase a, minchiotti s, leonardi a, secchi ag, ronaldo m. prospective, multicentered demographic epidemiological study on vernal keratoconjunctivitis. ophthalmic epidemiology. 2009; 16: 38-41. 4. maheshwari r, maheshwari s. late probing for congenital nasolacrimal duct obstruction. jcpsp. 2007; 17: 41-3. 5. jenny m, dana r, paul m. prevalence of hypermetropia under 12 years in unscreened population of australian children. american j opthalmol. 2008; 115: 678-85. 6. polling jr, loudon se, klaver cc. prevlence of amblyopia and refractive errors in an unscreened population of children. optom vis sci. 2012; 89: 44-9. 7. ayesha m. paediatric and adult health survey of suburban areas of punjab. jpma. 2011; 6: 42-6. 8. awais sm, sheik a. morbidity of vernal keratoconjunctivitis. pak j ophthalmol. 2001; 17: 120-3. 9. khan md, kundi nk. study of 530 cases of vernal conjunctivitis from north west frontier province. pak j ophthalmol. 1986; 2: 111-4. 10. forrer a. vernal keratoconjunctivitis. bullitin medicus mandi. 1995; 56: 37-42. 11. taylar ki, taylor hr. distribution of azithromycin for treatment of trachoma. br j ophthalmol. 1999; 83: 134-5. 12. durani j. blindness statistics for pakistan. pak j ophthalmol. 1999; 15: 1-2. 13. khan ma, gullab a, khan md. prevalence of blindness and low vision in north west frontier province of pakistan. pak j ophthalmol. 1994; 10: 39-42. 14. dandona r, srinvas minhaj a. refractive error study in children in rural population in india. investigat ophthalmol visual sciences. 2002; 43: 615-22. 15. maul e, barroso s, munoz sr. refractive error study in children: results from la florida, chile. am j ophthalmol. 2000; 129: 445–54. 16. ojaimi e, rose ka, morgan ig, smith w, martin fj, kifley a, robaei d, mitchell p. distribution of ocular biometric parameters and refraction in a populationbased study of australian children. invest ophthalmol vis sci. 2005; 46: 2748-54. 17. czepita d, mojsa a, zejmo m. prevalence of myopia and hyperopia among urban and rural school children in poland. ann acad med stetin. 2008; 54: 17-21. 18. czepita d, zejmo m, mojsa a. prevalence of myopia and hyperopia in a population of polish school children. ophthalmic physiol opt. 2007; 27: 60-5. pak j ophthalmol. 2020, vol. 36 (4): 428-432 428 original article the effect of phacoemulsification on corneal endothelial cells morphology and thickness raghda faisal abdelfatah mutwali 1 , abd elaziz mohamed elmadina 2 , saif hassan alrasheed 3 mustafa abdu 4 , manzoor ahmad qureshi 5 1 alahlyya amman university (jordon) and al-neelain university, khartoumsudan 2 department of optometry college of applied medical science, qassim university, saudi arabia 3 department of optometry college of applied medical science, qassim university, saudi arabia 4 faculty of applied medical sciences, university of jeddah, jeddah – saudi arabia 5 liaquat university of medical and health sciences, jamshoro – pakistan abstract purpose: to compare the corneal endothelial cells morphology and central corneal thickness (cct) before and after phacoemulsification in sudanese population. place and duration of study: al-neelain eye hospital, khartoum, sudan, from january 2018 to may 2018. study design: observational longitudinal study. methods: one hundred and forty eyes of 140 patients with immature senile cataract were selected by convenient sampling. the age ranged from 40 to 85 years. the patients underwent complete ocular examination including morphology of corneal endothelial cells and cct using computerized non-contact specular microscope. inclusion criteria for the study was eyes with normal corneal endothelial cells and cell density more than 1000 cells/mm 2 . we excluded patients with ocular or systemic diseases, previous history of intraocular surgery, refractive surgery or trauma as well as contact lenses wear. the patients underwent phacoemulsification by a single surgeon. the examination parameters were repeated one month after surgery. descriptive and comparative statistical analyses were performed using spss for windows version 21.0. results: there was significant reduction in mean endothelial cells density after phacoemulsification compared to baseline with p < 0.001. there was also significant post-operative reduction in mean endothelial cells number as compared to baseline (p value < 0.001). mean endothelial cells hexagonality was reduced after surgery with p value of 0.003. no significant difference was found between mean coefficient variation of endothelial cells size before and after phacoemulsification (p = 0.55). central corneal thickness showed significant increase postoperatively, p = 0.003. conclusion: phacoemulsification causes significant damage to corneal endothelium cells, including decrease in corneal endothelial cell density, hexagonality and cell number. key words: corneal endothelium, endothelial cell density, central corneal thickness, phacoemulsification. how to cite this article: mutwali rfa, elmadina aem, alrasheed sh, abdu m, qureshi ma. the effect of phacoemulsification on corneal endothelial cells morphology and thickness: a hospital based study. pak j ophthalmol. 2020; 36 (4): 428-432. doi: https://doi.org/10.36351/pjo.v36i4.1092 correspondence: abd elaziz mohamed elmadina al-neelain university, khartoumsudan; department of optometry, college of applied medical science, qasim university, saudi arabia email: almadina67@gmail.com received: july 2, 2020 accepted: august 28, 2020 introduction visual impairment and blindness are major public health problems in developing countries where there is limited health-care service. senile cataract is a leading cause of visual impairment among different raghda faisal abdelfatah mutwali, et al 429 pak j ophthalmol. 2020, vol. 36 (4): 428-432 communities. the crystalline lens loses its natural transparency resulting in misty vision and eventually gradual loss of vision. age-related cataract is commonest type of acquired cataract affecting persons above 50 years and responsible for over 47% of blindness globally. 1 phacoemulsification is one of the choices of surgical treatment of cataract. it affects the corneal structure, which may change the corneal endothelium that has important role in keeping cornea transparent. a significant change in endothelial cells, corneal thickness and corneal endothelial cell density occurs during cataract surgery, resulting in prolonged corneal oedema. some patients with senile cataract come with corneal oedema after phacoemulsification surgery which may develop to corneal opacity that result in irreversible visual impairment. several studies clearly showed that there is reduction in corneal endothelial cell count as well as increased central corneal thickness after phacoemulsification. 2 since no study was conducted in sudan to assess the corneal morphological changes after phacoemulsification, we carried out this research to evaluate corneal endothelium morphological and central thickness changes pre-operatively and postoperatively among sudanese patients. the results represent a crucial role towards understanding how phacoemulsification surgery may affect habitual corneal endothelial cells morphology and central corneal thickness among sudanese. methods this longitudinal observational study evaluated 140 sudanese patients who underwent phacoemulsification surgery in one eye during from january 2018 to may 2018 at al-neelain university eye hospital, sudan. inclusion criteria for the study was eyes with normal corneal endothelial cells and cell density more than 1000 cells/mm 2 . eyes with anterior chamber depth of more than 2.5mm and normal iop (10–22 mmhg) were included. the study excluded any patients with ocular or systemic diseases, history of previous intraocular surgery, refractive surgery or trauma as well as contact lenses wear. ethical approval for study was obtained from al-neelain university and was conducted according to the declaration of helsinki guidelines. a comprehensive eye examination was performed including detailed history, refraction using topcon autorefractometer and best corrected visual acuity (bcva, decimal notation).slit lamp examination and fundus examination were carried out and b-scan was used when retina was not visible. corneal endothelial profile was performed with topcon computerized noncontact specular microscope (sp 3000) which included endothelium cell density (ecd), hexagonality (hex.), cell number (cn), coefficient variance of cells size (cv), and central corneal thickness(cct) before and one month after phacoemulsification. all phacoemulsification surgeries were performed by the same surgeon using same technique. the surgical technique included supero-temporal small incision with ultrasound energy that varied from 30-60 hertz per seconds depending on the cataract density. descriptive and comparative statistical analyses were performed using spss for windows version 21.0 (spps inc., chicago, il, usa). all data were reported as means ± standard deviations (sd). a paired sample t-test was used to compare between variables pre and post-operatively. independent sample t test was also used to compare means between different study groups. p value of < 0.05 was considered statistically significant. results a total 140 consecutive eyes of 140 patients who underwent phacoemulsification surgery were included in this study. among them77 (55%) were males and 63 (45%) were females with mean age of 61.3 ± 9.3 years (range: 40 – 85). mean best corrected visual acuity (bcva), mean ecd, cv, hex, cn and cct before and after surgery are shown in table 1. using paired sample t test, mean bcva was found significantly improved one-month post-surgery (0.72 ± 0.27) compared to that measured before operation (0.09 ± 0.14) with p value of < 0.001. further analysis yielded no significant differences between both gender in term of mean age that was 61.6 ± 8.3 and 61 ± 10.5 for males and females respectively with p value of 0.72. independent sample t test also showed no significant mean differences between males and females regarding pre-operative ecd, cn, hex, cv and cct with p values of 0.62, 0.67, 0.10, 0.56 and 0.17 respectively. the test also yielded no significant differences in all parameters evaluated between both gender post-operation with p value of > 0.05 (see table 2). effect of phacoemulsification on corneal morphology and thickness pak j ophthalmol. 2020, vol. 36 (4): 428-432 430 table 1: pre-operative and post-operative comparison of variables. variable (n = 140) pre-operative mean ± sd post-operative mean ± sd average changes % p value ecd = endothelial cells density, cn = cells number, hex = hexagonality, cv = coefficient variation of endothelial cells size, cct = central corneal thickness. ecd (cells/mm 2 ) 2225 ± 469 1497 ± 670 32.7% < 0.001 cn 58.6 ± 28 37.9 ± 24.8 35.3% < 0.001 hex (%) 42.7 ± 31.3 32.4 ± 23.1 24.1% 0.003 cv (%) 39.2 ± 9.5 40 ± 11.4 2% 0.55 cct (µm) 481 ± 34 492 ± 41 2.3% 0.003 table 2: comparison of variables among male and females. variable pre-operative mean ± sd post-operative mean ± sd gender (n = 140) males (n = 77) females (n = 63) p value males (n = 77) females (n = 63) p value ecd (cells/mm 2 ) 2207 ± 465 2246 ± 476 0.62 1383 ± 516 1371 ± 541 0.89 cn 59.5 ± 28.4 57.4 ± 27.7 0.67 37.8 ± 25.8 38 ± 24.3 0.96 hex (%) 38.8 ± 17.9 47.4 ± 41.9 0.10 31.6 ± 23.5 33.4 ± 22.6 0.65 cv (%) 38.8 ± 10.5 39.8 ± 8.01 0.56 40.5 ± 12 39.3 ± 10.7 0.55 cct (µm) 484.6 ± 36.9 476.6 ± 29.9 0.17 494.3 ± 44.8 488.5 ± 36.9 0.41 ecd = endothelial cells density, cn = cells number, hex = hexagonality, cv = coefficient variation of endothelial cells size, cct = central corneal thickness. discussion the corneal endothelium plays a crucial role in maintaining the dehydrated state and the transparency of the cornea. 3 although, some degree of endothelial cell loss invariably occurs in all types of cataract surgery but the amount of endothelial cell loss varies according to the surgical technique. 4,5,6 central corneal thickness and corneal endothelial cell density are the two important parameters in functional assessment of cornea for diagnostic purposes. corneal endothelium cells have a limited capacity for repair, therefore damage to corneal endothelial cells is compensated by a combination of cell enlargement and cell spread to cover up for lost cells, resulting in a gradual decrease in endothelial cell density, which may lead to compromised functions of these cells. 6,7 the results of the present study showed statistically significant decrease in endothelium cells density with a value of 32.7% for mean endothelial cell loss after phacoemulsification as compared to that assessed before the procedure. this reduction can be compared to several published studies that reported loss of 11.4% and 15.3%. 8,9 several published studies conducted among different countries with different ethnic groups and various surgical techniques reported wide range of endothelial cell loss. 10-13 this higher loss affects the function of the endothelial cells, consequently the patients are at higher risk of corneal oedema after phacoemulsification surgery that finally leads to corneal opacity and visual impairment. the higher loss of endothelium cell in the current study could be attributed to difference in surgical technique, patient populations, and time points of evaluation after surgery, in addition tolower quality of materials, longer duration of surgery as well as inaccurate measurement because the study was conducted in poor nation with limited eye care resources. ultrasound energy during phacoemulsification results in endothelial cell damage due to mechanical trauma from sonic waves and from thermal injury. 14 in addition to endothelial cells loss, the hexagonal shape of individual endothelial cell is decreased with mean total loss of about 24.1% and the mean coefficient of variation of cell size is increased after phacoemulsification. these changes in shape and size are attributed to enlargement of endothelial cells in order to fill the gaps as a result of endothelium cell damage. previous studies also support these findings. , this result in agreement with that reported in literature. 5,7 the present study showed significant increase in mean central corneal thickness after phacoemulsification. this could be attributed to corneal oedema occurring as a result of changes in corneal endothelium. this finding is also in agreement with several previous reports. 13,14 the current increase in corneal thickness is higher compared to some studies conducted in iran and pakistan that reported an increase of 1.8% and 0.7% respectively. 8,15 on the other hand, other studies reported higher increase than https://www.sciencedirect.com/topics/nursing-and-health-professions/central-corneal-thickness https://www.sciencedirect.com/topics/nursing-and-health-professions/central-corneal-thickness https://www.sciencedirect.com/topics/nursing-and-health-professions/central-corneal-thickness https://www.sciencedirect.com/topics/medicine-and-dentistry/endothelial-cell https://www.sciencedirect.com/topics/medicine-and-dentistry/corneal-endothelium https://www.sciencedirect.com/topics/medicine-and-dentistry/cell-enlargement raghda faisal abdelfatah mutwali, et al 431 pak j ophthalmol. 2020, vol. 36 (4): 428-432 the current findings. 16 it has also been reported that besides the effect of phacoemulsification, postoperative cornel oedema could be due to many other factors such as patient’s age, previous corneal pathology and a postoperative increase in intraocular pressure. 8,17,18 the present study also showed no significant mean differences in term of endothelial cells changes between both gender, which is also found congruent with studies by others researchers. 19,20 conclusion phacoemulsification causes significant damage to corneal endothelial cells, resulting in reduced corneal endothelial cell density and hexagonality and also induces differences in cells size as well as corneal oedema. acknowledgement we are grateful to the staff of al-neelain eye hospital department of ophthalmic medical photography for helping in data collection process. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. references 1. lee cm, afshari na. the global state of cataract blindness. curr opin ophthalmol. 2017;28(1):98-103. doi: 10.1097/icu.0000000000000340. 2. rosado-adames n, afshari na. the changing fate of the corneal endothelium in cataract surgery. curr opin ophthalmol. 2012; 23: 3–6. 3. erika fm, zamora-ortiz r, gonzalez-salinas r. endothelial cell density changes in diabetic and nondiabetic eyes undergoing phacoemulsification employing phaco-chop technique. intern ophthalmol. 2019; 39.8: 1735-1741. 4. parikshit g. commentary: corneal endothelial cell changes in diabetics versus age-group matched nondiabetics after manual small incision cataract surgery (sics). indian j ophthalmol. 2020; 68 (1): 2196-2201. 5. islam qu, saeed mk, mehboob ma. age related changes in corneal morphological characteristics of healthy pakistani eyes. saudi j ophthalmol. 2017;31 (2): 86-90. 6. arıcı c, arslan os, dikkaya f. corneal endothelial cell density and morphology in healthy turkish eyes. j ophthalmol 2014; 2014. 7. ewete t, ani eu, alabi as. normal corneal endothelial cell density in nigerians. clin ophthalmol. (auckland, nz). 2016; 10: 497. 8. bamdad s, bolkheir a, sedaghat mr, motamed m. changes in corneal thickness and corneal endothelial cell density after phacoemulsification cataract surgery: a double-blind randomized trial. electron physician. 2018; 10 (4): 6616. 9. thakur sk, dan a, singh m, banerjee a, ghosh a, bhaduri g. endothelial cell loss after small incision cataract surgery. nepalese j ophthalmol. 2011; 3 (2): 177-180. 10. bourne rr, minassian dc, dart jk, rosen p, kaushal s, wingate n. effect of cataract surgery on the corneal endothelium: modern phacoemulsification compared with extracapsular cataract surgery. ophthalmology, 2004; 111 (4): 679-685. 11. faramarzi a, javadi ma, karimian f, jafarinasab mr, baradaran-rafii a, jafari f, et al. corneal endothelial cell loss during phacoemulsification: bevelup versus bevel-down phaco tip. j cat refract surg 2011; 37 (11): 1971-1976. doi: 10.1016/j.jcrs.2011.05.034. 12. yamazoe k, yamaguchi t, hotta k, satake y, konomi k, den s, et al. outcomes of cataract surgery in eyes with a low corneal endothelial cell density. j cat refract surg 2011; 37 (12): 2130-2136. doi: 10.1016/j.jcrs.2011.05.039. 13. mencucci r, ponchietti c, virgili g, giansanti f, menchini u. corneal endothelial damage after cataract surgery: microincision versus standard technique. j cat refract surg 2006; 32 (8): 1351-1354. doi: 10.1016/j.jcrs.2006.02.070. 14. walkow t, anders n, klebe s. endothelial cell loss after phacoemulsification: relation to preoperative and intraoperative parameters. j cat refract surg 2000; 26 (5): 727-732. doi: 10.1016/s0886-3350(99)00462-9. 15. wali fs, ali surhio s, talpur r, jawed m, shujaat s. change in central corneal thickness after phacoemulsification. pak j ophthalmol, 2020; 36 (1). 16. behndig a, lundberg b. transient corneal edema after phacoemulsification: comparison of 3 viscoelastic regimens. j cat refract surg 2002; 28 (9): 1551-1556. doi: 10.1016/s08863350(01)01219-6. 17. kim j, jo m, brauner s, ferrufino-ponce z, ali r, cremers s, et al. increased intraocular pressure on the first postoperative day following resident-performed cataract surgery. eye, 2011; 25 (7): 929-36. effect of phacoemulsification on corneal morphology and thickness pak j ophthalmol. 2020, vol. 36 (4): 428-432 432 18. glasser db, schultz ro, hyndiuk ra. the role of viscoelastics, cannulas, and irrigating solution additives in post-cataract surgery corneal oedema: a brief review. lens eye tox res 1992; 9 (3-4): 351-359. pmid: 1301791. 19. george r, rupauliha p, sripriya av, rajesh ps, vahan pv, praveen s. comparison of endothelial cell loss and surgically induced astigmatism following conventional extracapsular cataract surgery, manual small-incision surgery and phacoemulsification. ophthalmic epidemiol. 2005; 12 (5): 293-297. 20. maggon r, bhattacharjee r, shankar s, kar rc, sharma v, roy s. comparative analysis of endothelial cell loss following phacoemulsification in pupils of different sizes. indian j ophthalmol. 2017; 65 (12): 1431. disclaimer: the corresponding author declares that the authors in this article had worked jointly in the same hospital when the study was conducted. authors’ designation and contribution raghda faisal abdelfatah mutwali; assistant professor: concepts, design, literature research. abd elaziz mohamed elmadina; assistant professor: literature research, data analysis, statistical analysis. saif hassan alrasheed; assistant professor: literature research, manuscript preparation, manuscript editing. mustafa abdu; associate professor: data analysis, manuscript editing, manuscript review. manzoor ahmad qureshi; assistant professor: design, manuscript editing, manuscript review. .…  …. 72 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology original article early detection of primary open angle glaucoma by using optical coherence tomography (oct) abdul majeed malik, saima irum, kashif ali pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: abdul majeed malik prof of (0phthalmolgy bum & dc) classified eye specialist pns shifa naval hospital karachi mail: majeed2413@hotmail.com …..……………………….. purpose: to measure and analyze thickness of retinal nerve fiber layer using optical coherence tomography (oct). material and methods: this study was conducted in ophthalmology department pns shifa, karachi. from march 2013 to jan 2015 for 23 months. a total of 350 glaucoma suspect patients were selected. a detailed history of ocular or systemic diseases was taken. intraocular pressure (iop) was measured using goldmann applanation tonometer. optical coherence tomography (oct) images were taken using heidelberg hra + oct spectralis machine. results: patients with a mean age of 35 ± 12 years were included. out of 350 patients, 140 (40%) patients were female and 210 (60%) were male. mean iop was 25 ± 5 mm hg, mode was 23 mm hg and median 26 mm hg. out of these 350 suspects, only 28 patients were found to have nerve fiber layer thickness outside the normal limits i.e. decreased in half a quadrants or more. conclusion: ocular coherence tomography nerve fiber layer thickness analysis is a quick and effective method to diagnose early and borderline cases of glaucoma. key words: optical coherence tomography (oct), retinal nerve fiber layer (rnfl), glaucoma, intraocular pressure (iop). laucoma is an optic neuropathy characterized by ganglion cell death that manifests clinically as characteristic optic nerve head (onh) and retinal nerve fiber layer (rnfl) changes with correlating visual field defects. early diagnosis of glaucoma and the early detection of glaucomatous progression is a challenge. optical coherence tomography (oct), first described in 1991, is a noncontact, noninvasive imaging technique that can reveal layers of the retina by looking at the interference patterns of reflected laser light.1 automated software segmentation algorithms are able to outline the retinal nerve fiber layer with much precision, which is relevant in glaucoma since this layer is thinned as ganglion cells are lost. it is well known that significant structural rnfl loss occurs prior to the development of functional visual field loss.2 spectral domain oct (sd-oct) is a recent technique that enables the imaging of ocular structures with higher resolution and faster scan rate compared with the previous version of this technology. several studies have been performed to assess the diagnostic capability of sd-oct in perimetric glaucoma. one representative study compared the diagnostic capability of sd-oct to td-oct rnfl thickness scans in subjects with early and moderate glaucoma as well as normal age-matched subjects. when using the average rnfl thickness at the 5% level compared to the normative database (yellow coloring on rnfl deviation map), sd-oct had a sensitivity of 83% and a specificity of 88% compared to 80% and 94% g mailto:majeed2413@hotmail.com early detection of primary open angle glaucoma by using optical coherence tomography (oct) pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 73 respectively for td-oct. when using the average rnfl thickness at the 1% level (red coloring on rnfl deviation map), the specificity for both sd-oct and td-oct was 100% but the sensitivity was only 65% in sd-oct and 61% in td-oct.3 onh parameters have also been found to have excellent ability to discriminate between normal eyes and eyes with even mild glaucoma. the parameters found to have the greatest diagnostic capability are vertical rim thickness, rim area, and vertical cup to disc ratio. these onh parameters were found to be as good as rnfl thickness parameters in diagnosing glaucoma.4 standard automated perimetry, (sap) the once gold standard to evaluate glaucomatous neuropathy and to monitor disease progression has poor sensitivity for detecting early glaucoma. material and methods this cohort observational study was carried out at the department of ophthalmology pns shifa, karachi, extending over 23 months from 1st march 2013 to 31 jan 2015. non probability consecutive sampling was done. a total of 350 patients were enrolled in our study so fulfilling the criteria of preliminary glaucoma suspect (n = 350), with optic c:d ratio of more than 0.6 at least in one eye, intra ocular pressure (iop) higher than 20 mm hg, and age more than 20 years. subjects previously diagnosed as cases of glaucoma (poag, pacg and secondary glaucomas), previous intra ocular surgery, and optic neuropathy due to other causes were excluded. systemic diseases were also ruled out .permission was taken from hospital ethical committee. written informed consent was taken. both iop and oct images were taken on the same day with calibrated instruments. intraocular pressure of both eyes was measured with help of goldmann applanation tonometer using 2% fluorescein eye drops by the same physician to avoid inter examiner and inter tonometer variation, between 9 to 11 am to minimize the effect of diurnal variation. central corneal thickness was also measured. three readings of each eye were taken at 30 minutes interval and mean calculated. oct images were taken using heidelberg hra+oct spectralis by a single person to avoid inter examiner error. results patients had a mean age of 35 ± 12 years. out of 350 patients, 140 (40%) patients were female and 210 (60%) were male. mean iop was 25 ± 5. mode was 23 and median 26. out of these 350 suspects, only 28 (8.0%) patients were found to have nerve fiber layer thickness outside normal limits i.e. decreased in half a quadrant or more. they were further investigated and documented with visual field analysis and iop phasing. 60% 40% female / male 1 2 fig. 1: male female percentages. fig. 2: iop distribution. fig. 3: total glaucoma suspects = 350 glaucoma patients = 28 (8%) non glaucomatous = 322 (92%) abdul majeed malik, et al 74 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology discussion glaucoma is a progressive disease characterized by death of ganglion cells and degeneration of retinal nerve fiber layer leading to irreversible loss of vision. although automated perimetry has been the standard method for detecting progressive disease, it is known that many patients can have progressive structural damage that precedes detectable associated changes in the visual field. there are three main parameters relevant to the detection of glaucomatous loss i.e. retinal nerve fiber layer, optic nerve head, and the “ganglion cell complex.” latest spectral domain ocular coherence tomography (sd-oct) was used to measure retinal nerve fiber layer (rnfl) thickness around optic nerve head. sd-oct can directly measure and quantify rnfl thickness by calculating the area between the internal limiting membrane (ilm) and rnfl border (how the edge of the rnfl is determined and how blood vessels are handled is different between different machines, which do not have interchangeable measurement outputs).5 its software was used to see any abnormality in retinal nerve fiber layer thickness in different quadrants around optic nerve by comparing with normative preloaded data in the software. sd-oct is a superior technology than conventional time domain (tdoct) with reference to scanning speed up to 200 times faster and higher axial resolution (3 to 6 μm). progressive rnfl thinning measured on sd-oct can often be used to detect progressive disease. the top three rnfl progression patterns are: widening of an existing rnfl defect, deepening without widening of an existing rnfl defect, or development of a new rnfl defect. in one study, the inferotemporal quadrant was the most frequent location for rnfl progression6. in such pre perimetric disease, sd-oct rnfl is especially useful in helping to diagnose glaucoma prior to the onset of visual field loss. in the presence of perimetric disease, finding rnfl bundle loss on sdoct with a corresponding abnormality in the visual field served by those retinal ganglion cells can help confirm the diagnosis of glaucoma. in early to moderate glaucoma, progressive thinning of rnfl thickness measured by sd-oct is a very useful tool to judge progression of disease. at advanced stages however, sd-oct is less clinically useful due to a “floor effect” of rnfl thickness. with advanced loss, rnfl thickness levels off, rarely falling below 50 µm and almost never below 40 µm due to the assumed presence of residual glial or non-neural tissue including blood vessels.7 at this level of disease, serial visual fields are more useful to judge progression. scanning laser polarimetry (slp), provides quantitative estimates of the thickness of the rnfl with potential use for diagnosis and follow-up of glaucoma patients. it is based on the principle that polarized light passing through the rnfl undergoes a measurable phase shift, known as retardation, which is linearly related to histologically measured rnfl tissue thickness. myopic eyes have thinner rnfl measurements, which can confound comparisons to the normative database. additionally, myopic eyes can have unique distributions of rnfl bundles. with increasing myopia, the superotemporal and inferotemporal rnfl bundles tend to converge temporally.8 this may result in the temporal shift of the superior and inferior rnfl bundle peaks of normal magnitude. while the limitations of the normative database may hinder the utility of sd-oct in diagnosing glaucoma using a single scan, serial sd-oct scans can be very useful to judge glaucomatous progression by setting a baseline scan against which to judge progressive thinning on subsequent scans. therefore, each patient can be his or her own “normative database” to diagnose glaucoma in such difficult settings as high myopia. with this approach, clinicians should be aware that rnfl thickness decreases with age in normal, healthy individuals. based on a longitudinal study, the age-related rate of reduction in rnfl thickness has been estimated to be -0.52 µm/ year, -1.35 µm/year, and -1.25 µm/year for average, superior, and inferior rnfl respectively.9 in one study, artificially defocusing an image scan by +2 diopters resulted in an artifactual 10 µm thinning of the rnfl.10 similarly, a 9.3% increase in mean average rnfl thickness was seen after cataract surgery in a study of 45 patients.11 it is important to look at the segmentation lines produced by any sd-oct machine’s software algorithm to ensure that they are appropriately placed. lines should not come together (go to zero). occasionally, one will find that the segmentation lines are misplaced along the retina leading to errors in the calculation of rnfl thickness. these segmentation errors are more common in the presence of poor signal strength, tilted discs, staphylomas, large peripapillary atrophy, epiretinal membranes, and posterior vitreous detachments. studies have found a decreased incidence of such segmentation errors in sd-oct compared to tdearly detection of primary open angle glaucoma by using optical coherence tomography (oct) pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 75 oct12. cataracts can affect rnfl thickness measurements. one study found a 4.8 µm increase in rnfl thickness measurement after cataract surgery. this effect was most pronounced in cortical cataracts, followed by posterior subcapsular cataracts. interestingly, nuclear cataracts were not found to affect signal strength or rnfl thickness measurements.13 conclusion glaucoma can be easily screened by routine ophthalmoscopy done by general medical practitioner. any glaucoma suspect can be diagnosed early by using new imaging technique like ocular coherence tomography nerve fiber layer thickness analysis by an ophthalmologist. doubtful cases of glaucoma should be further investigated and documented with visual field analysis and iop phasing. sd-oct is a powerful objective structured assessment tool that can greatly assist clinicians in diagnosing and managing glaucoma (especially early disease), when used in conjunction with visual field testing and clinical examinations. author’s affiliation prof. dr. abdul majeed malik prof (0phthalmolgy bum & dc) / classified eye specialist pns shifa naval hospital, karachi dr. saima irum classified ophthalmologist cmh cherat dr. kashif ali classified ophthalmologist pns shifa karachi references 1. aref aa, budenz dl. spectral domain optical coherence tomography in the diagnosis and management of glaucoma. ophthalmic surg lasers imaging. 2010; 41: s15-27. 2. quigley ha, dunkelberger gr, green wr. retinal ganglion cell atrophy correlated with automated perimetry in human eyes with glaucoma. am j ophthalmol. 1989; 107: 453–64. 3. chang rt, knight oj, feuer wj, budenz dl. sensitivity and specificity of time-domain vs spectraldomain optical coherence tomography in diagnosing early to moderate glaucoma. ophthalmology. 2009; 116: 1257-63. 4. mwanza jc, durbin mk, budenz dl, sayyad fe, chang rt, neelakantan a, godfrey dg, carter r, crandall as. glaucoma diagnostic accuracy of ganglion cell-inner plexiform layer thickness: comparison with nerve fiber layer and optic nerve head. ophthalmology. 2012; 119: 1151-8. 5. leite mt, rao hl, weinreb rn, zangwill lm, bowd c, sample pa, tafreshi a, medeiros fa. agreement among spectral-domain optical coherence tomography instruments for assessing retinal nerve fiber layer thickness. am j ophthalmlol. 2011; 151: 85-92. 6. leung ck, yu m, weinreb rn, lai g, xu g, lam ds. retinal nerve fiber layer imaging with spectral – domain optical coherence tomography: patterns of retinal nerve fiber layer progression. ophthalmology. 2012; 119: 185866. 7. hood d, kardon r. a framework for comparing structural and functional measurements of glaucomatous damage. prog retin eye res. 2007; 26: 688710. 8. leung ck, yu m, weinreb rn, mak hk, lai g, ye c, lam ds.. retinal nerve fiber layer imaging with spectral-domain optical coherence tomography: interpreting the rnfl maps in healthy myopic eyes. invest ophthalmol vis sci. 2012; 53: 7194-7200. 9. leung ck, yu m, weinreb rn, ye c, liu s, lai g, lam ds. retinal nerve fiber layer imaging with spectraldomain optical coherence tomography: a prospective analysis of age – related loss. ophthalmology 2012; 119: 731-7. 10. balasubramanian m, bowd c, vizzeri g, weinreb rn, zangwill lm. effect of image quality on tissue thickness measurements with spectral – domain optical coherence tomography. opt express. 2009; 17: 4019-36. 11. mwanza jc, bhorade am, sekhon n, mcsoley jj, yoo sh, feuer wj, budenz dl. effect of cataract and its removal on signal strength and peri-papillary retinal nerve fiber layer optical coherence tomography measurements. j glaucoma. 2011; 20: 37-43. 12. ho j, sull ac, vuong ln, chen y, liu j, fujimoto jg, schuman js, duker js. assessment of artifacts and reproducibility across spectraland time-domain optical coherence tomography devices. ophthalmology. 2009; 116: 1960–70. 13. lee dw, kim jm, park kh. effect of media opacity on retinal nerve fiber layer thickness measurements by optical coherence tomography. j ophthalmol vis res. 2010; 5: 151-7. 14. savini g, barboni p, parisis v, carbonelli m. the influence of axial length on retinal nerve fibre layer thickness and optic-disc size measurements by spectraldomain oct. br j ophthalmol. 2012; 96: 57-61. 15. mwanza jc, chang rt, budenz dl, durbin mk, gendy mg, shi w, feuer wj.. reproducibility of peripapillary retinal nerve fiber layer thickness and optic nerve head parameters measured with cirrus hdoct in glaucomatous eyes. invest ophthalmol vis sci 2010; 51: 5724-30. 16. kontas a g p, irkec m t, teuas m a, cvenckle b, astakhov y s, sharpe e d, hollo g, mylopoulos n, http://www.ncbi.nlm.nih.gov/pubmed/?term=sayyad%20fe%5bauthor%5d&cauthor=true&cauthor_uid=22365056 http://www.ncbi.nlm.nih.gov/pubmed/?term=chang%20rt%5bauthor%5d&cauthor=true&cauthor_uid=22365056 http://www.ncbi.nlm.nih.gov/pubmed/?term=neelakantan%20a%5bauthor%5d&cauthor=true&cauthor_uid=22365056 http://www.ncbi.nlm.nih.gov/pubmed/?term=godfrey%20dg%5bauthor%5d&cauthor=true&cauthor_uid=22365056 http://www.ncbi.nlm.nih.gov/pubmed/?term=carter%20r%5bauthor%5d&cauthor=true&cauthor_uid=22365056 http://www.ncbi.nlm.nih.gov/pubmed/?term=crandall%20as%5bauthor%5d&cauthor=true&cauthor_uid=22365056 http://www.ncbi.nlm.nih.gov/pubmed/?term=zangwill%20lm%5bauthor%5d&cauthor=true&cauthor_uid=20970108 http://www.ncbi.nlm.nih.gov/pubmed/?term=bowd%20c%5bauthor%5d&cauthor=true&cauthor_uid=20970108 http://www.ncbi.nlm.nih.gov/pubmed/?term=bowd%20c%5bauthor%5d&cauthor=true&cauthor_uid=20970108 http://www.ncbi.nlm.nih.gov/pubmed/?term=bowd%20c%5bauthor%5d&cauthor=true&cauthor_uid=20970108 http://www.ncbi.nlm.nih.gov/pubmed/?term=sample%20pa%5bauthor%5d&cauthor=true&cauthor_uid=20970108 http://www.ncbi.nlm.nih.gov/pubmed/?term=tafreshi%20a%5bauthor%5d&cauthor=true&cauthor_uid=20970108 http://www.ncbi.nlm.nih.gov/pubmed/?term=medeiros%20fa%5bauthor%5d&cauthor=true&cauthor_uid=20970108 http://www.ncbi.nlm.nih.gov/pubmed/?term=lai%20g%5bauthor%5d&cauthor=true&cauthor_uid=22677426 http://www.ncbi.nlm.nih.gov/pubmed/?term=xu%20g%5bauthor%5d&cauthor=true&cauthor_uid=22677426 http://www.ncbi.nlm.nih.gov/pubmed/?term=lam%20ds%5bauthor%5d&cauthor=true&cauthor_uid=22677426 http://www.ncbi.nlm.nih.gov/pubmed/?term=mak%20hk%5bauthor%5d&cauthor=true&cauthor_uid=22997288 http://www.ncbi.nlm.nih.gov/pubmed/?term=lai%20g%5bauthor%5d&cauthor=true&cauthor_uid=22997288 http://www.ncbi.nlm.nih.gov/pubmed/?term=ye%20c%5bauthor%5d&cauthor=true&cauthor_uid=22997288 http://www.ncbi.nlm.nih.gov/pubmed/?term=lam%20ds%5bauthor%5d&cauthor=true&cauthor_uid=22997288 http://www.ncbi.nlm.nih.gov/pubmed/?term=ye%20c%5bauthor%5d&cauthor=true&cauthor_uid=22264886 http://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20s%5bauthor%5d&cauthor=true&cauthor_uid=22264886 http://www.ncbi.nlm.nih.gov/pubmed/?term=lai%20g%5bauthor%5d&cauthor=true&cauthor_uid=22264886 http://www.ncbi.nlm.nih.gov/pubmed/?term=lam%20ds%5bauthor%5d&cauthor=true&cauthor_uid=22264886 http://www.ncbi.nlm.nih.gov/pubmed/?term=lam%20ds%5bauthor%5d&cauthor=true&cauthor_uid=22264886 http://www.ncbi.nlm.nih.gov/pubmed/?term=lam%20ds%5bauthor%5d&cauthor=true&cauthor_uid=22264886 http://www.ncbi.nlm.nih.gov/pubmed/?term=weinreb%20rn%5bauthor%5d&cauthor=true&cauthor_uid=19259243 http://www.ncbi.nlm.nih.gov/pubmed/?term=zangwill%20lm%5bauthor%5d&cauthor=true&cauthor_uid=19259243 http://www.ncbi.nlm.nih.gov/pubmed/?term=mcsoley%20jj%5bauthor%5d&cauthor=true&cauthor_uid=20179622 http://www.ncbi.nlm.nih.gov/pubmed/?term=yoo%20sh%5bauthor%5d&cauthor=true&cauthor_uid=20179622 http://www.ncbi.nlm.nih.gov/pubmed/?term=yoo%20sh%5bauthor%5d&cauthor=true&cauthor_uid=20179622 http://www.ncbi.nlm.nih.gov/pubmed/?term=yoo%20sh%5bauthor%5d&cauthor=true&cauthor_uid=20179622 http://www.ncbi.nlm.nih.gov/pubmed/?term=feuer%20wj%5bauthor%5d&cauthor=true&cauthor_uid=20179622 http://www.ncbi.nlm.nih.gov/pubmed/?term=budenz%20dl%5bauthor%5d&cauthor=true&cauthor_uid=20179622 http://www.ncbi.nlm.nih.gov/pubmed/?term=chen%20y%5bauthor%5d&cauthor=true&cauthor_uid=19592109 http://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20j%5bauthor%5d&cauthor=true&cauthor_uid=19592109 http://www.ncbi.nlm.nih.gov/pubmed/?term=fujimoto%20jg%5bauthor%5d&cauthor=true&cauthor_uid=19592109 http://www.ncbi.nlm.nih.gov/pubmed/?term=schuman%20js%5bauthor%5d&cauthor=true&cauthor_uid=19592109 http://www.ncbi.nlm.nih.gov/pubmed/?term=duker%20js%5bauthor%5d&cauthor=true&cauthor_uid=19592109 http://www.ncbi.nlm.nih.gov/pubmed/?term=carbonelli%20m%5bauthor%5d&cauthor=true&cauthor_uid=21349942 http://www.ncbi.nlm.nih.gov/pubmed/?term=durbin%20mk%5bauthor%5d&cauthor=true&cauthor_uid=20574014 http://www.ncbi.nlm.nih.gov/pubmed/?term=gendy%20mg%5bauthor%5d&cauthor=true&cauthor_uid=20574014 http://www.ncbi.nlm.nih.gov/pubmed/?term=shi%20w%5bauthor%5d&cauthor=true&cauthor_uid=20574014 http://www.ncbi.nlm.nih.gov/pubmed/?term=feuer%20wj%5bauthor%5d&cauthor=true&cauthor_uid=20574014 http://www.ncbi.nlm.nih.gov/pubmed/?term=hollo%20g%5bauthor%5d&cauthor=true&cauthor_uid=17917683 http://www.ncbi.nlm.nih.gov/pubmed/?term=mylopoulos%20n%5bauthor%5d&cauthor=true&cauthor_uid=17917683 abdul majeed malik, et al 76 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology bozkurt b, pizzamiglio c, potyomkin vv, alemu am, nasser qj, stewart ja, stewart wc. mean intraocular pressure and progression based on corneal thickness in patients with hypertension. eye 2009; 23: 73-8. http://www.ncbi.nlm.nih.gov/pubmed/?term=bozkurt%20b%5bauthor%5d&cauthor=true&cauthor_uid=17917683 http://www.ncbi.nlm.nih.gov/pubmed/?term=pizzamiglio%20c%5bauthor%5d&cauthor=true&cauthor_uid=17917683 http://www.ncbi.nlm.nih.gov/pubmed/?term=potyomkin%20vv%5bauthor%5d&cauthor=true&cauthor_uid=17917683 http://www.ncbi.nlm.nih.gov/pubmed/?term=alemu%20am%5bauthor%5d&cauthor=true&cauthor_uid=17917683 http://www.ncbi.nlm.nih.gov/pubmed/?term=nasser%20qj%5bauthor%5d&cauthor=true&cauthor_uid=17917683 http://www.ncbi.nlm.nih.gov/pubmed/?term=stewart%20ja%5bauthor%5d&cauthor=true&cauthor_uid=17917683 http://www.ncbi.nlm.nih.gov/pubmed/?term=stewart%20wc%5bauthor%5d&cauthor=true&cauthor_uid=17917683 pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 243 abstracts edited by dr. qasim lateef chaudhry a randomized clinical trial comparing methotrexate and mycophenolate mofetil for noninfectious uveitis rathinam sr, babu m, thundikandy r, kanakath a, nardone n, esterberg e, lee sm, enanoria wta, porco tc, browne en, weinrib r, acharya nr ophthalmology 2014; 121: 1863–70. sivakumar et al compared the relative effectiveness of methotrexate and mycophenolate mofetil for noninfectious intermediate uveitis, posterior uveitis, or panuveitis in this multicenter, block randomized, observer masked clinical trial. eighty patients with noninfectious intermediate, posterior, or panuveitis requiring corticosteroid sparing therapy at aravind eye hospitals in madurai and coimbatore, india were enrolled in this study. patients were randomized to receive 25 mg weekly oral methotrexate or 1 g twice daily oral mycophenolate mofetil and were monitored monthly for 6 months. oral prednisone and topical corticosteroids were tapered. masked examiners assessed the primary outcome of treatment success, defined by achieving the following at 5 and 6 months: (1) ≤0.5+ anterior chamber cells, ≤0.5+ vitreous cells, ≤0.5+ vitreous haze and no active retinal/choroidal lesions in both eyes, (2) ≤10 mg of prednisone and ≤ 2 drops of prednisolone acetate 1% a day, and (3) no declaration of treatment failure because of intolerability or safety. additional outcomes included time to sustained corticosteroid sparing control of inflammation, change in best spectacle corrected visual acuity, resolution of macular edema, adverse events, subgroup analysis by anatomic location, and medication adherence. forty one patients were randomized to methotrexate and 39 to mycophenolate mofetil. a total of 67 patients (35 methotrexate, 32 mycophenolate mofetil) contributed to the primary outcome. sixty nine percent of patients achieved treatment success with methotrexate and 47% with mycophenolate mofetil (p = 0.09). treatment failure from adverse events or tolerability was not different by treatment arm (p = 0.99). there were no differences between treatment groups in time to corticosteroid sparing control of inflammation (p = 0.44), change in best spectacle corrected visual acuity (p = 0.68), or resolution of macular edema (p = 0.31). the authors concluded that there was no statistically significant difference in corticosteroid sparing control of inflammation between patients receiving methotrexate or mycophenolate mofetil. however, there was a 22% difference in treatment success favoring methotrexate. post-cataract prevention of inflammation and macular edema by steroid and nonsteroidal antiinflammatory eye drops a systematic review kessel l, tendal b, jørgensen kj, drmedsci, erngaard d, flesner p, andresen jl, hjortdal j. ophthalmology 2014; 121: 1915-24. line et al compared the efficacy of topical steroids with topical nonsteroidal anti-inflammatory drugs (nsaids) in controlling inflammation and preventing pseudophakic cystoid macular edema (pcme) after uncomplicated cataract surgery in patients undergoing uncomplicated surgery for age related cataract. the authors performed a systematic literature search in medline, cinahl, cochrane, and embase databases to identify randomized trials published from 1996 onward comparing topical steroids with topical nsaids in controlling inflammation and preventing pcme in patients undergoing phacoemulsification with posterior chamber intraocular lens implantation for age related cataract. postoperative inflammation and pseudophakic cystoid macular edema was taken as main outcome measure. fifteen randomized trials were identified. postoperative inflammation was less in patients randomized to nsaids. the prevalence of pcme was significantly higher in the steroid group than in the nsaid group: 3.8% versus 25.3% of patients, risk ratio 5.35 (95% confidence interval, 2.94e9.76). there was no statistically significant difference in the number of adverse events in the 2 treatment groups. the authors found low to moderate quality of evidence that topical nsaids are more effective in controlling postoperative inflammation after cataract surgery. qasim lateef chaudhry 244 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology they also concluded that topical nsaids are more effective than topical steroids in preventing pcme and the use of topical nsaids was not associated with an increased events thus recommending using topical nsaids to prevent inflammation and pcme after routine cataract surgery. cost evaluation of surgical and pharmaceutical options in treatment for vitreomacular adhesions and macular holes chang js, smiddy we ophthalmology 2014; 121: 1720-6. jonathan et al evaluated cost effectiveness and cost utilities for treatment options for vitreomacular adhesions (vmas) and full thickness macular holes (mhs) in this markov model of cost effectiveness and utility. outcomes of published clinical trials (index studies) of surgical treatment of vmas and mhs and a prospective, multicenter clinical trial of pharmaceutical vitreolysis with intravitreal ocriplasmin with saline control were used to generate a model for costs of treatment and visual benefits. all techniques were assumed to result in a 2.5 line visual benefit if anatomy was resolved. markov analysis, with cost data from the centers for medicare and medicaid services, was used to calculate imputed costs for each primary treatment modality in a facility setting, with surgery performed in a hospital serving as the highest end of the range and nonfacility setting with surgery performed in an ambulatory surgery center serving as the lowest end of the range. imputed costs of therapy, cost per line saved, cost per line year saved, cost per quality adjusted life years (qalys) were taken as main outcome measure. when pars plana vitrectomy (ppv) was selected as the primary procedure, the overall imputed cost ranged from $5802 to $7931. the cost per line was $2368 to $3237, the cost per line year saved was $163 to $233 and the cost per qaly was $5444 to $7442. if intravitreal injection of ocriplasmin was the primary procedure, the overall imputed cost was $8767 to $10 977. the cost per line ranged from $3549 to $4456, the cost per line year saved was $245 to $307, and the cost per qaly was between $8159 and $10 244. if intravitreal saline injection was used as a primary procedure, the overall imputed cost was $5828 to $8098. the cost per line was $2374 to $3299, the cost per line year saved was $164 to $227, and the cost per qaly was $5458 to $7583. the authors concluded that is a primary procedure, ppv was the most cost effective therapy in this model. the other treatments had similar costs per qaly saved and compare favorably with costs of therapy for other retinal diseases. retinal nerve fibre layer and macular thickness analysis with fourier domain optical coherence tomography in subjects with a positive family history for primary open angle glaucoma rolle t, dallorto l, briamonte c, penna rr br j ophthalmol 2014; 98: 1240-4. this study was conducted to detect early structural changes of retinal nerve fibre layer (rnfl) and macular ganglion cell complex (gcc) in subjects with a positive family history for primary open angle glaucoma (poag) using fourier domain optical coherence tomography (fd-oct) (rtvue-100). in this cross sectional observational study first and second degree relatives of poag patients, healthy subjects, and subjects with preperimetric glaucoma (ppg) without a family history for glaucoma, were enrolled. all participants underwent complete ophthalmic examination, visual field test and fd-oct (rtvue100) imaging. average rnfl and gcc thicknesses were measured and a pattern analysis was applied to the gcc map. analysis of variance (anova), least significant difference post-hoc test, and multiple anova were used. the final analysis included 271 eyes divided into several groups: 163 eyes of first and second degree relatives (85 healthy, 40 with ocular hypertension and 38 with ppg); and 108 eyes of subjects without a positive family history (60 healthy and 48 ppg). rnfl and gcc thickness values of these five groups were statistically different (p<0.001). rnfl superior, gcc average, gcc superior, and gcc inferior were found to be significantly thinner and the global loss volume was higher in normal relatives than in healthy subjects without a positive family history of poag (p=0.04, p=0.001, p=0.005, p=0.004, p=0.009). rnfl and gcc thicknesses obtained by dividing the family members by the degree of consanguinity showed statistically significant thinning in siblings of glaucomatous subjects than in offspring. the authors concluded that the eyes of subjects with a positive family history for poag have significantly thinner rnfl and gcc than normal eyes and a more accurate follow-up has to be performed. http://bjo.bmj.com/search?author1=teresa+rolle&sortspec=date&submit=submit http://bjo.bmj.com/search?author1=laura+dallorto&sortspec=date&submit=submit http://bjo.bmj.com/search?author1=cristina+briamonte&sortspec=date&submit=submit http://bjo.bmj.com/search?author1=rachele+roberta+penna&sortspec=date&submit=submit pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 56 abstracts edited by dr. qasim lateef chaudhry descemet's membrane endothelial keratoplasty: clinical results of single versus triple procedures (combined with cataract surgery) chaurasia s, price fw, gunderson l, price mo. ophthalmology 2014; 121: 454-8. in this retrospective, comparative, interventional case series the outcomes of triple descemet's membrane endothelial keratoplasty (dmek) versus dmek alone in pseudophakic eyes were compared. patients with fuchs' endothelial dystrophy, secondary corneal edema, and prior failed endothelial keratoplasty with or without prior cataract extraction were included. outcomes of 492 dmek procedures performed between april 2010 and august 2012 were reviewed; 292 pseudophakic eyes underwent dmek (group 1) and 200 eyes had concurrent cataract surgery with dmek (group 2). corrected distance visual acuity, endothelial cell loss, immediate and early postoperative complications were taken as main outcome measures. the mean age at the time of surgery was 70 years (range, 47 – 94 years) in group 1 and 64 years (range, 46 – 90 years) in group 2 (p < 0.0001). at 6 months, the median corrected distance visual acuity was 20/25 (range, 20/16 – 20/80; n = 164) in group 1 and 20/20 (range, 20/16 – 20/100; n = 121) in group 2 (p < 0.0001), excluding 21 eyes with retinal or optic nerve problems. the dmek graft failed to clear in 9 eyes (3.1%) in group 1 and 7 eyes (3.5%) in group 2 (p = 0.34); all were re-grafted successfully with dmek. no further graft failures occurred during the follow-up period. the air reinjection rate was 30% in group 1 and 29% in group 2 (p = 0.69). the air reinjection rate dropped significantly in both groups, from 45% to 16%, after use of viscoelastic was eliminated during the tissue insertion step. the median endothelial cell loss at 3 to 6 months did not differ significantly between groups (26% in both). the authors concluded that triple dmek was not associated with any higher risk of complications than dmek alone. compared with sequential management of patients with concomitant cataract and endothelial dysfunction, triple dmek is an effective strategy in rapid visual rehabilitation and offers the advantage of a 1-stage procedure, with reduced risks and costs. management and outcome of retinoblastoma with vitreous seeds manjandavida fp, honavar sg, reddy vap, khanna r. ophthalmology 2014; 121, 517-24. fairooz et al reported the treatment response of retinoblastoma with vitreous seeds to high – dose chemotherapy coupled with periocular carboplatin in this retrospective, interventional case series. consecutive patients with retinoblastoma with vitreous seeds managed over 10 years at a comprehensive ocular oncology center and followed up for at least 12 months after the completion of treatment were included in this study. institutional review board approval was obtained and high-dose chemotherapy with a combination of vincristine, etoposide, and carboplatin in patients with focal vitreous seeds and additional concurrent periocular carboplatin in patients with diffuse vitreous seeds was given. main outcome measures noted were tumor regression, vitreous seed regression, and eye salvage. after excluding the better eye of bilateral cases, 101 eyes of 101 patients were part of the final analysis. all the patients belonged to reese-ellsworth group vb, but on the international classification of retinoblastoma (icrb), 21 were group c, 40 were group d, and 40 were group e. the mean basal diameter of the largest tumor was 11.8±4.7 mm. mean tumor thickness was 7.5 ± 4.0 mm. vitreous seeds were focal in 21 eyes and diffuse in 80 eyes. chemotherapy cycles ranged from 6 to 12 (median, 6). seventy-three eyes with diffuse vitreous seeds received a 15 mg posterior subtenon carboplatin injection (range, 1 – 13 mg; median, 6 mg). follow-up duration ranged from 13.4 to 129.2 months (median, 48 months). external beam radiotherapy (ebrt) was necessary in 33 eyes with residual tumor, vitreous seeds, or both. in all, 20 eyes (95%) with icrb group c retinoblastoma, 34 eyes (85%) with group d retinoblastoma, and 23 eyes (57.5%) with group e retinoblastoma were salvaged. of 77 eyes that were salvaged, 74 (96%) had visual acuity of 20/200 or better. twenty four of 33 chemotherapy failures (73%) regressed with ebrt. none of the patients demonstrated second malignant neoplasm or systemic metastasis. factors predicting tumor regression and eye salvage were bilateral http://www.aaojournal.org/issues?issue_key=s0161-6420(13)x0013-2 http://www.aaojournal.org/article/s0161-6420(13)00816-6/abstract http://www.aaojournal.org/article/s0161-6420(13)00816-6/abstract http://www.aaojournal.org/article/s0161-6420(13)00816-6/abstract http://www.aaojournal.org/article/s0161-6420(13)00816-6/abstract qasim lateef chaudhry 57 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology retinoblastoma and absence of subretinal fluid. factors predicting vitreous seed regression were absence of subretinal fluid and subretinal seeds. the authors concluded that intensive management with primary high dose chemotherapy and concurrent periocular carboplatin, and ebrt selectively in chemotherapy failures, provides gratifying outcome in retinoblastoma with vitreous seeds. cost – effectiveness of femtosecond laser – assisted cataract surgery versus phacoemulsification cataract surgery affiliations abell rg, vote bj ophthalmology 2014; 121: 10-6. robin et al performed a comparative cost-effectiveness analysis (cea) of femtosecond laser-assisted cataract surgery (lcs) and conventional phacoemulsification cataract surgery (pcs) using a retrospective cea using computer-based econometric modeling. the study included hypothetical cohort of patients undergoing cataract surgery in the better eye based on a review of the current literature and direct experience of authors using lcs. a cost-effectiveness decision tree model was constructed to analyze the costeffectiveness of lcs compared with pcs. complication rates of cataract surgery were obtained from a review of the current literature to complete the cohort of patients and outcomes. this data was incorporated with time trade-off utility values converted from visual acuity outcomes. improvements in best-corrected visual acuity obtained from the literature were used to calculate the increase in quality adjusted life years (qalys) in a hypothetical cohort between 6 months and 1 year after cataract surgery. this was combined with approximate costs in a cost utility analysis model to determine the incremental cost – effectiveness ratios (icers). based on the simulated complication rates of pcs and lcs and assuming resultant visual acuity outcome improvement of 5% in uncomplicated cases of lcs, the cost-effectiveness (dollars spent per qaly) gained from lcs was not cost – effective at $9,286 australian dollars. the total qaly gain for lcs over pcs was 0.06 units. multivariate sensitivity analyses revealed that lcs would need to significantly improve visual outcomes and complications rates over pcs, along with a reduction in cost to patient, to improve cost effectiveness. modeling a best – case scenario of lcs with excellent visual outcomes (100%), a significant reduction in complications (0%) and a significantly reduced cost to patient (of $300) resulted in an icer of $20,000. the authors concluded that laser cataract surgery, irrespective of potential improvements in visual acuity outcomes and complication rates, is not cost effective at its current cost to patient when compared with cost-effectiveness benchmarks and other medical interventions, including pcs. a significant reduction in the cost to patient (via reduced consumable / click cost) would increase the likelihood of lcs being considered cost effective. intravitreal aflibercept injection for macular edema resulting from central retinal vein occlusion korobelnik jf, holz fg, roider j, ogura y, simader c, schmidt – erfurth u, lorenz k, honda m, vitti r, berliner aj, hiemeyer f, stemper b, zeitz o, sandbrink r. ophthalmology 2014; 121: 202-8. the gallileo study group evaluated the efficacy and safety of intravitreal aflibercept injections for treatment of macular edema secondary to central retinal vein occlusion (crvo) in a randomized, multicenter, double-masked phase 3 study. a total of 177 treatment-naive patients with macular edema secondary to crvo were randomized in a 3:2 ratio. patients received either 2 mg intravitreal aflibercept or sham injections every 4 weeks for 20 weeks. from week 24 to 48, the aflibercept group received aflibercept as needed (pro re nata prn), and the sham group continued receiving sham injections. the primary efficacy end point was the proportion of patients who gained 15 letters or more in bestcorrected visual acuity (bcva) at week 24. this study reported week 52 results including the proportion of patients who gained 15 letters or more in bcva and the mean change from baseline bcva and central retinal thickness. at week 52, the mean percentage of patients gaining 15 letters or more was 60.2% in the aflibercept group and 32.4% in the sham group (p¼ 0.0004). aflibercept patients, compared with sham patients had a significantly higher mean improvement in bcva (þ16.9 letters vs. þ3.8 letters, respectively) and reduction in central retinal thickness (-423.5 mm vs. -219.3 mm, respectively) at week 52 (p < 0.0001 for both). aflibercept patients received a mean of 2.5 injections (standard deviation, 1.7 injections) during prn dosing. the most common ocular adverse events in the aflibercept group were related to the injection procedure or the underlying disease, and included abstracts pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 58 macular edema (33.7%), increased intraocular pressure (17.3%), and eye pain (14.4%). the study concluded that treatment with intravitreal aflibercept provided significant functional and anatomic benefits after 52 weeks as compared with sham. the improvements achieved after 6 monthly doses at week 24 largely were maintained until week 52 with as-needed dosing. this new drug was also generally well tolerated. pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 217 letter to editor dear editor in chief, i have the following observations on original article “assessment of “imtiaz sign” for early detection of hypovitaminosis a”, vol. 31, no. 3, jul – sep, 2015. starting from the title the word “assessment of” is superfluous. there is not a single reference of surma which is the main topic. (ref 1 – 6). in material & methods it is mentioned about a dot and dots, which are these dots? it is mentioned that the surma stains the dots, the color of staining is not mentioned. the bitot’s spots get stained with surma, was it excluded? quantity of surma used in one application is not mentioned. does any topical drugs (vitamin a preparations) were used? time duration of application is not mentioned. dyeing or staining end point in not mentioned. chemical composition of surma is not at all discussed, since the surma is of many types, few of them are fe3o4, zno, pbs, pb3o4 which type of surma was used in the study. in material & methods, authors have mentioned that other signs of hypovitaminosis a were noted. contrary to this authors mention in results section that other sign of hypovitaminosis a were not observed because of early stage of disease. which statement should be taken under consideration? only 81% cases were proven for malnourishment by labs and rest were assumed to be malnourished but not proven in any case for vitamin a deficiency. authors mention that all patients (100%) responded for direct question of visual difficulty in dim light (nyctalopia). while 24% patients were in age group 5 – 10 years and another 46% were between 11 – 20 years of age. how these young patients responded to questions of night blindness in very early stage. dark adaptation threshold and x ray of long bone have been done in how many cases and why? there is no mention as to how it is determined that “imtiaz sign” occurs before bitot’s spot. how a study can be scientific where laboratory test were done on selected cases only. was hepatitis b & c excluded in this study which is prevalent in the area of study. how it is concluded that sub clinical deficiency of vitamin a gets stained with surma. in this study, were the same patients given vitamin a were stained again with surma to confirm its logic. it is not mentioned in the study of 650 patients that how many had bitot’s spot. how 650 patients were graded of vitamin a deficiency by who criteria. references 1. vaishnav r. an example of the toxic potential of traditional eye cosmetics. indian j. pharmacol.2001;33:46– 8. 2. sweha f. kohl along history in medicine and cosmetics. hist sci med. 1982; 17: 182– 3. 3. hardy ad, farrant aj, rollinson g, barss p, vaishnav r. a study of the chemical composition of traditional eye cosmetics (“kohls”) used in qatar and yemen. j cosmet sci. 2008; 59: 399–418. 4. al-hazzaa sa, krahn pm. kohl: a hazardous eyeliner. int ophthalmol. 1995;19:83–8. 5. mahmood za, zoha sm, usmanghani k, hasan mm, ali o, jahan s, et al. kohl (surma): retrospect and prospect. pak j pharm sci. 2009;22:107–22. 6. u.s. food and drug administration. kohl, kajal, alkahal, or surma: by any name, a source of lead poisoning. available from: http://www.fda.gov/cosmetics/productandingredien tsafety/productinformation/ucm137250.htm [last accessed on 2010 feb 25] prof. shahid wahab karachi author’s response my this communication is in response to the letter to editor by prof shahid wahab. it seems that prof. wahab misunderstood the very perspective of this scientific paper. this paper is purely a scientific work to help and save ailing humanity particularly in underdeveloped world to prevent unnecessary blindness and death1. 1. he says the word “assessment” is superfluous? the word assessment means “analysis of the letter to editor 218 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology security, effectiveness, and potential of an existing or planned intelligence activity”2. 2. he has wrongly interpreted that “surma” is the main topic, he has missed the other staining material “kajal” which is mentioned in the article. 3. he has raised question about stained dot or dots, which is clearly mentioned that due to deficiency of vitamin a in the body, epithelia are affected including epithelium of conjunctiva. the epithelial defects take up stain which indicate vitamin a deficiency in the body. there is no existing sign which can pick up vitamin a deficiency in the body at this early and reversible stage. 4. he has raised the question of topical use of vitamin a in the eye which is not relevant as this negligible amount of vitamin a in the eye ointment cannot be considered for replenishing vitamin a stores in the body. 5. he has raised the question of quantity of surma used in one application, whereas it is described clearly in the paper that “staining of a dot or few dots of nasal or mostly temporal conjunctiva with surma (eyelash dye used for religious belief in men, women and children particularly in muslims) or kajal (eyelash dye used for cosmetic purpose) indicates early / subclinical stage of vitamin a deficiency.” these materials were not used by authors but by patients themselves. 6. he has raised the question of time duration of application which is not applicable as these stains were used by the patients themselves and not by the authors. 7. he has raised the chemical composition of surma and types of surma utilized in the study, however it is clearly mentioned that both stains “surma and kajal” were utilized by patients themselves and not by authors who picked up the sign only. however if he is interested to find different chemical compositions of surma or kajal being utilized by people in pakistan, he may conduct this study and add in our knowledge. 8. he has raised the question of dyeing and staining end point which is not relevant as these stains were used by the patients themselves and not by the authors. 9. he has raised the question of contradiction in the methods and results regarding signs of vitamin a deficiency but he has misunderstood the sentence, the signs mentioned in methods were to be noted if present in the patients under study but were not present as mentioned in the results. interestingly this very important point is emphasized in the study which makes “imtiaz’s sign” useful. 10. he has raised the question regarding the diagnosis of remaining 19% of cases of vitamin a deficiency as only lab. evidence of 81% is mentioned in the study, however he has forgotten that remaining 19% patients had nyctalopia and they improved with vitamin a supplements which was taken up as therapeutic test (diagnostic evidence) already mentioned in the article. 11. he has raised the question of how night blindness was picked up in age group 5 years to 20 years but he has forgotten that this is verbal age group and they can tell themselves about their difficulty in dim light, however to make it more clear to him, parents of those children were the source of information who could not express themselves. 12. he has raised the question as to why dark adaptation threshold and x-ray of long bones was performed? however it is clearly mentioned in the paper that " dark adaptation threshold3,4 and xray of long bones6 were performed to determine excessive deposition of periosteal bone5 which is sign of vitamin a deficiency. 13. he has raised the question that “there is no mention as to how it is determined that imtiaz’s sign occurs before development of bitot’s spot”. however he has forgotten that this study is emphasizing this very point from beginning to the end and i hope that he does not want us to leave the patients to develop the late signs like bitot’s spot. 14. he has raised the question that whether hepatitis b & c were excluded in the study? however it is clearly mentioned in the article that liver disease was excluded. 15. he has raised the question that whether staining with surma was done after vitamin a was given? however it is mentioned clearly that the stains were used by the patients themselves and “administration of dietary or therapeutic supplements of vitamin a quickly resolved these stained areas and also resolved associated symptoms of vitamin a deficiency”. as the patients using these stains for religious or cosmetic purpose keep on using these stains but after letter to editor pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 219 vitamin a use they no more encounter “imtiaz sign”. 16. he has raised the question that "it is not mentioned in the study of 650 patients that how many had bitot’s spot/ ”but the article mentions that "650 patients, 152 (23.38%) males and 498 (76.62%) females were identified as cases of hypovitaminosis a on the basis of presence of imtiaz’s sign” and not on the basis of late signs including bitot’s spot, therefore there is no question of presence of bitot’s spot in the study. 17. he has raised the question that “how 650 patients were graded of vitamin a deficiency by who criteria?” however, this study is specifically conducted to document the earliest sign of vitamin a deficiency which is not included in who criteria and has been reported recently therefore will take some time to be included hopefully in who criteria. references 1. mayo-wilson e, imdad a, herzer k, yakoob my, bhutta za. vitamin a supplements for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis. bmj. 2011 aug 25. 343: d5094. 2. assessment – definition of assessment by the free dictionary http://www.thefreedictionary.com/ assessment. 3. rubino p, mora p, ungaro n, gandolfi sa, orsoni jg. anterior segment findings in vitamin a deficiency: a case series. case rep ophthalmol med. 2015; 2015: 181267. 4. makhoul z, taren d, duncan b, pandey p, thomson c, winzerling j et al. risk factors associated with anemia, iron deficiency and iron deficiency anemia in rural nepali pregnant women. southeast asian j trop med public health. 2012; 43 (3): 735-46. 5. sommer a. vitamin a deficiency and clinical disease: an historical overview. j. nutr. 2008; 138 (10): 1835-39. 6. mellanby e. vitamin a and bone growth: the reversibility of vitamin a-deficiency changes. j physiol. 1947; 105 (4): 382-99. prof. syed imtiaz ali shah larkana http://www.ncbi.nlm.nih.gov/pubmed/?term=rubino%20p%5bauthor%5d&cauthor=true&cauthor_uid=26509090 http://www.ncbi.nlm.nih.gov/pubmed/?term=mora%20p%5bauthor%5d&cauthor=true&cauthor_uid=26509090 http://www.ncbi.nlm.nih.gov/pubmed/?term=ungaro%20n%5bauthor%5d&cauthor=true&cauthor_uid=26509090 http://www.ncbi.nlm.nih.gov/pubmed/?term=gandolfi%20sa%5bauthor%5d&cauthor=true&cauthor_uid=26509090 http://www.ncbi.nlm.nih.gov/pubmed/?term=orsoni%20jg%5bauthor%5d&cauthor=true&cauthor_uid=26509090 http://www.ncbi.nlm.nih.gov/pubmed/26509090 http://www.ncbi.nlm.nih.gov/pubmed/?term=makhoul%20z%5bauthor%5d&cauthor=true&cauthor_uid=23077854 http://www.ncbi.nlm.nih.gov/pubmed/?term=taren%20d%5bauthor%5d&cauthor=true&cauthor_uid=23077854 http://www.ncbi.nlm.nih.gov/pubmed/?term=duncan%20b%5bauthor%5d&cauthor=true&cauthor_uid=23077854 http://www.ncbi.nlm.nih.gov/pubmed/?term=pandey%20p%5bauthor%5d&cauthor=true&cauthor_uid=23077854 http://www.ncbi.nlm.nih.gov/pubmed/?term=thomson%20c%5bauthor%5d&cauthor=true&cauthor_uid=23077854 http://www.ncbi.nlm.nih.gov/pubmed/?term=thomson%20c%5bauthor%5d&cauthor=true&cauthor_uid=23077854 http://www.ncbi.nlm.nih.gov/pubmed/?term=thomson%20c%5bauthor%5d&cauthor=true&cauthor_uid=23077854 http://www.ncbi.nlm.nih.gov/pubmed/?term=winzerling%20j%5bauthor%5d&cauthor=true&cauthor_uid=23077854 http://www.ncbi.nlm.nih.gov/pubmed/23077854 http://www.ncbi.nlm.nih.gov/pubmed/23077854 http://www.ncbi.nlm.nih.gov/pubmed/23077854 http://jn.nutrition.org/search?author1=alfred+sommer&sortspec=date&submit=submit http://www.ncbi.nlm.nih.gov/pubmed/?term=mellanby%20e%5bauth%5d 22 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology original article demographic characteristics of cases with iofb presenting to a tertiary care centre mohammad idris, sadia ayaz, hassan yaqoob, zubairullah, mir ali shah pak j ophthalmol 2015, vol. 31 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mohammad idris ophthalmology unit, pgmi, lrh peshawar email idrisdaud80@gmail.com …..……………………….. purpose: to determine the demographic characteristics of iofb presenting to a tertiary care centre of khyber pakhtunkhwa for management. material and methods: the study was carried out at department of ophthalmology, govt. lady reading hospital, peshawar from july 2011 to jan 2013. we received 37 cases from outdoor department for management and were admitted for management. patients were examined after detailed history and important findings noted. data was collected on special proforma and was analyzed with the help of spss version16. results: the study population comprised of 37 cases. male were 26 (70.2%). . mean age was 33 ± 12 years. hammering a chisel was the main cause and it was seen in 15 (40.5%) cases. labor was the commonest occupation which was seen in 18 (48.6%) cases. no perception of light vision was noted in 11 (29.7%) cases and 09 (24.32 %) cases presented with perception of light vision. counting finger or better vision was noted in 17 (46%) cases. left eye was affected in 25 (67.6%) cases. conclusion: duration of trauma was linearly proportion with prognosis for vision. visual progression was poor in majority of the eyes; delayed presentation and bbi were the top reasons. key words: iofb, ocular trauma, visual outcome. n certain parts of the world, trauma is one of the most common causes of visual morbidity and ocular problems especially when associated with iofb.1 its incidence is on the rise due to increase use of weapons and wars especially in our part of the world.2 traumas whether blunt or penetrating results in series of ocular structure damage which at times becomes irreversible and may result in blindness. penetrating trauma is even more dangerous because it gives rise to numerous ocular complications like endophthalmitis, vitreous hemorrhage, retinal detachment, optic nerve damage, mainly due to penetration of intraocular foreign body (iofb).3 there are various reasons, why a foreign body (fb) gets entry into the body. in our part of the world, bomb blast injuries, working while chiseling or hammering and accidental entry of stones etc are the most common reasons for iofb.4,5 there are different types of iofb, metal, wood, stone, plastic and even hair can enter the globe and cause serious damage. every iofb can cause complications.6 timely repair of the defect, removal of iofb and treatment of complications of iofb are the key factors on which prognosis for vision depends along with type of iofb.7 different techniques are available to detect iofb. the most important step in detecting the characteristics of iofb is proper history and examination of globe. in most of the time history is diagnostic and will give us the clue for presence of iofb. occupation, age, gender, area of accident, all give valuable information about the different characteristics of iofb like nature, location, size, shape and even prognosis about vision.8 i demographic characteristics of cases with iofb presenting to a tertiary care centre pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 23 imaging plays a vital role in the management of iofb. ultrasound and b – scan is a simple and easy diagnostic test which not only detects the presence of iofb but also gives us the exact size, nature and location of iofb. it gives information about complication of fb as well as vitreous hemorrhage, retinal detachment and globe integrity. ct scan is particularly useful for detection of metallic and small fbs.9 x-ray orbit will give a rough idea about detection of iofb. mri should be avoided especially when there are clues in favor of magnetic iofb. most of the victims are male and young patients working on fields which are exposed because of their occupations. in this regard, lack of awareness regarding protective goggles and early referral to eye specialist for urgent management is lacking.10,11 causes of iofb are also important. metals, infected foreign bodies and organic foreign bodies have worse progressive. bbi victims have multiple injuries and complicated trauma and are especially the risk group.4 every penetrating trauma patient should be properly managed. the most important step is to take proper history and detailed clinical examination of the globe so that the presence of any iofb should be excluded. neglected iofb which are left undetected in the globe results in disastrous complications and even loss of whole eye and represent a challenge to the ophthalmologist.12 the aim of the study is to give data about demographic features of the patients who suffer from iofb in open globe injuries to highlight the importance of proper assessment of penetrating trauma so that any iofb if detected should be managed on time. material and methods the study was carried out at department of ophthalmology, govt. lady reading hospital, peshawar from july 2011 to jan 2013. we received 37 cases from outdoor department and were admitted for management. this was a prospective, interventional case series of consecutive patients with iofbs. patients were examined after detailed history and important findings noted. patients were recalled for a comprehensive examination. the following variables were recorded for the purpose of the study: age, gender, cause of trauma, occupation, complications, presenting best – corrected visual acuity (bcva), slit lamp and fundus examination, ultrasound examination when ophthalmoscopy was not possible, foreign body localization based on orbital ct scan, size, site, and type of the foreign body, consequences of retained iofb including complications, time interval since injury, details were recorded. all patients underwent surgical removal of the iofb. final visual acuity at 6 month follow up visit was noted. data was collected on special proforma and was analyzed with the help of spss version 16. non probability consecutive sampling technique was used. patients were enrolled during the study period. inclusion criteria: patients with history of intraocular foreign body. patients with history of ocular disease especially diabetic retinopathy, high myopia, past ocular surgery and bleeding disorders were excluded as these factors can introduce bias in the study results. results we evaluated thirty seven cases of intraocular foreign body admitted with us from january 2012 to july 2013. for ease of description we divided the age of the patients into three groups in years (table 1). age ranged from five years to sixty three years. age was divided and in first group age ranged from five to twenty years. in the second group it is ranging from twenty one to forty years and in the third group from forty one to sixty three years. majority of the patients belonged to second group and there were 21 (56.7%) patients in group one, 7 (19%) patients in group two and 10 (27.02%) patients in group three. mean age was 33 ± 12 years. so majority of our patients were young who spent life in outside environment. 26 (70.2%) patients were male and only 11 (29.8%) were female (table 2). different causes of the iofb were determined. hammering a chisel was the main cause and it was seen in 15 (40.5%) cases. bomb blast injury was seen in 13 (35.1%) patients and sports or accidents were seen in 4 (10.8%), while other causes reported unknown by the patients were 5 (13.5%) cases (table 3). different people involve in different sort of occupations who get iofb labor was the commonest occupation which was seen in 18 (48.6%) cases. sports and defense related people were seen in 11 ( 29.7%), students and children in 5 ( 13.5%) and others / accidental cases were only 3 ( 8.1%) (table 4). mohammad idris, et al 24 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology in our study right eye was affected in 12 (32.4%) cases. left eye was affected in 25 (67.6%) cases. no case of bilateral iofb was seen (table 5). 10 (27.02%) cases presented less than one hour after the incidence of trauma, one hour to 24 hours were 10 (27.02%), less than one week 9 (24.3%) while 8 (21.62%) cases presented later than one week after trauma. it is these patients whose prognosis and results of surgery were good which were presented early (table 6). finally visual progress at six month follow up was determined. most cases end up in poor vision. 11(29.7%) cases have no perception of light vision. 09(24.32 %) cases got perception of light vision only. counting finger or better vision was noted in 17 (46%) cases. bbi and late presentation were the common reason for poor visual outcome (table 7). discussion with successive wars in the twentieth century, there has been a relative increase in injuries to the eye compared to injuries of other parts of the body. the main causes of eye injury have changed with advances demographic characteristics of cases with iofb presenting to a tertiary care centre pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 25 in techniques and weaponry of warfare, with blast fragmentation injuries accounting for 50 – 80% of cases.13 in our study, mostly victims are those working in the field and exposed to environment. the most common causes of open globe injury are domestic accidents and occupational injuries. significant prognostic factors for final visual outcome in patients with open globe injury are initial visual acuity, posterior extent and length of wound, presence of hyphema and presence of vitreous prolapse. awareness of the factors predicting a poor visual outcome may be helpful during counseling of patients with open globe injuries.14 in our study, mostly patients were those working in the field and exposed to environment. labor was the commonest occupation and these were the main victims of iofb. according to different studies 4,13,15 despite early referral, bbis were having worse prognosis and despite proper management and early intervention, results and final visual outcome were poor and disappointing. it was mainly because of multiple as well as complex type of injuries and severe ocular damage. several studies confirm that trauma of any type is common in male.16 in our study male were in majority. similarly young to middle age people are the common group of people exposed to both accidental as well as occupational trauma.10,11 in our study most of our patients were less than 40 years age. in eye injury patients, the nature of the foreign body determines the clinical behavior; inert objects such as steel and glass may not cause significant inflammation to warrant their removal. removal of organic foreign bodies, however, is mandatory since these objects usually lead to secondary infection, like endophthalmitis.18 in our study, the final visual acuity was hand motion vision in majority (60%) of the cases and main reason besides endophthalmitis was bbi and late presentation as well as postoperative complications resulted in an attempt to remove iofbs from the globe. several studies have shown that the visual prognosis is poor. in a study, patients (63%) had final visual acuity of less than 5/200 at final follow-up19. in another study, visual acuity on admission between 6/60 to pl comprises highest number (64%) and also on discharge between 6/60 to pl comprises highest number of cases (50%).17 in our study, the average final visual acuity we got was pl in 56% cases and cf or better in 44% cases at 6 months follow up. we lost 05 patients at follow up. as mentioned earlier, the late presentation and bbi were main reasons for poor visual outcome. so majority have poor final vision even after treatment. conclusion in ocular trauma, iofb is a common and important clinical problem. majority of victims were children and young in their productive life. mostly left eye involved. most serious cause of iofb was bbi. duration of trauma was linearly proportion with prognosis for vision. visual progression was poor in majority of the eyes; delayed presentation and bbi were the top reasons. author’s affiliation dr. mohammad idris medical officer ophthalmology unit, pgmi, lrh, peshawar dr sadia ayaz house officer ophthalmology pgmi, lrh, peshawar dr hassan yaqoob consultant, ophthalmology north west general hospital, peshawar dr. zubairullah incharge, eye unit mission hospital, peshawar dr mir ali shah associate professor ophthalmology pgmi, lrh, peshawar references 1. lam sr, devenyi rg, berger ar, dunn w. visual outcome following penetrating globe injuries with retained intraocular foreign bodies. can j ophthalmol. 1999; 34: 389-93. 2. thach ab, ward tp, hollifield rd, cockerham k, birdsong r, kramer kk. eye injuries in a terrorist bombing: dhahran, saudi arabia, june 25, 1996. ophthalmology. 2000; 107: 844-7. 3. de souza s, howcroft mj. management of posterior segment intraocular foreign bodies: 14 years' experience. can j ophthalmol. 1999; 34: 23-9. 4. wightman jm, gladish sl. explosions and blast injuries. ann emerg med. 2001; 37: 664-78. 5. quayum ma, akhanda ah. pattern of ocular trauma http://www.ncbi.nlm.nih.gov/pubmed?term=lam%20sr%5bauthor%5d&cauthor=true&cauthor_uid=10649580 http://www.ncbi.nlm.nih.gov/pubmed?term=devenyi%20rg%5bauthor%5d&cauthor=true&cauthor_uid=10649580 http://www.ncbi.nlm.nih.gov/pubmed?term=berger%20ar%5bauthor%5d&cauthor=true&cauthor_uid=10649580 http://www.ncbi.nlm.nih.gov/pubmed?term=dunn%20w%5bauthor%5d&cauthor=true&cauthor_uid=10649580 http://www.ncbi.nlm.nih.gov/pubmed/10649580 http://www.ncbi.nlm.nih.gov/pubmed?term=thach%20ab%5bauthor%5d&cauthor=true&cauthor_uid=10811072 http://www.ncbi.nlm.nih.gov/pubmed?term=ward%20tp%5bauthor%5d&cauthor=true&cauthor_uid=10811072 http://www.ncbi.nlm.nih.gov/pubmed?term=hollifield%20rd%5bauthor%5d&cauthor=true&cauthor_uid=10811072 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http://www.ncbi.nlm.nih.gov/pubmed?term=akhanda%20ah%5bauthor%5d&cauthor=true&cauthor_uid=19182740 mohammad idris, et al 26 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology admitted in a tertiary hospital. mymensingh med j. 2009; 18: 1-6. 6. slusher mm. intraretinal foreign bodies. management and observations. retina. 1990; 1: s50-4. 7. erakgun t, egrilmez s. prognostic factors in vitrectomy for posterior segment intraocular foreign bodies. j trauma. 2008 ; 64: 1034-7. 8. woodcock mg, scott ra, huntbach j, kirkby gr. mass and shape as factors in intraocular foreign body injuries. ophthalmology. 2006; 113: 2262-9. 9. briscoe d, geffen n, assia ei, yaffe d. determining size and characteristics of metal intraocular foreign bodies using helical ct scan. eur j ophthalmol. 2009; 19: 861-5. 10. han sb, yu hg. visual outcome after open globe injury and its predictive factors in korea. j trauma. 2010; 69: e66-72. 11. yalcin tök o, tok l, eraslan e, ozkaya d, ornek f, bardak y. prognostic factors influencing final visual acuity in open globe injuries. j trauma. 2011; 71: 1794800. 12. mcgimpsey sj, rankin sj. presentation of intraocular foreign body 25 years after the event. clin experiment ophthalmol. 2005; 33: 665-6. 13. wong ty, seet mb, ang cl. eye injuries in twentieth century warfare: a historical perspective. surv ophthalmol. 1997; 41: 433-59. 14. madhusudhan al, evelyn-tai lm, zamri n, adil h, wan-hazabbah wh. open globe injury in hospital universiti sains malaysia a 10-year review. int j ophthalmol. 2014; 7: 486-90. 15. barak a, verssano d, halpern p, lowenstein a. ophthalmologists, suicide bombings and getting it right in the emergency department. graefes arch clin exp ophthalmol. 2008; 246: 199-203. 16. kinderan yv, shrestha e, maharjan im, karmacharya s. pattern of ocular trauma in the western region of nepal. nepal j ophthalmol. 2012; 4: 5-9. 17. hossain mm, mohiuddin aa, akhanda ah, hossain mi, islam mf, akonjee ar, ali m. pattern of ocular trauma. mymensingh med j. 2011; 20: 377-80. 18. karcioglu za, nasr am. diagnosis and management of orbital inflammation and infections secondary to foreign bodies: a clinical review. orbit. 1998; 17: 247-69. 19. groessl s, nanda sk, mieler wf. assault-related penetrating ocular injury. am j ophthalmol. 1993; 116: 26-33 http://www.ncbi.nlm.nih.gov/pubmed/19182740 http://www.ncbi.nlm.nih.gov/pubmed?term=slusher%20mm%5bauthor%5d&cauthor=true&cauthor_uid=2191382 http://www.ncbi.nlm.nih.gov/pubmed/2191382 http://www.ncbi.nlm.nih.gov/pubmed?term=erakgun%20t%5bauthor%5d&cauthor=true&cauthor_uid=18404071 http://www.ncbi.nlm.nih.gov/pubmed?term=egrilmez%20s%5bauthor%5d&cauthor=true&cauthor_uid=18404071 http://www.ncbi.nlm.nih.gov/pubmed/18404071 http://www.ncbi.nlm.nih.gov/pubmed/18404071 http://www.ncbi.nlm.nih.gov/pubmed/18404071 http://www.ncbi.nlm.nih.gov/pubmed?term=woodcock%20mg%5bauthor%5d&cauthor=true&cauthor_uid=17157134 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http://www.ncbi.nlm.nih.gov/pubmed?term=mieler%20wf%5bauthor%5d&cauthor=true&cauthor_uid=8328539 http://www.ncbi.nlm.nih.gov/pubmed/8328539 134 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology original article surgical management of optic disc pit maculopathy haroon tayyab, tehmina jahangir, akhwand abdul najeed jawad pak j ophthalmol 2016, vol. 32 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: harron tayyab ophthalmology department sharif medical and dental college, lahore e.mail: haroontayyab79@gmail.com …..……………………….. purpose: to evaluate the structural and functional outcome of pars plana vitrectomy combined with ilm peel, endo-photocoagulation and gas tamponade for optic disc pit associated maculopathy. study design: prospective interventional case series place and duration of study: jinnah hospital lahore and al-ehsan eye hospital lahore material and methods: seven consecutive patients with unilateral maculopathy associated with optic disc pit underwent pars plana vitrectomy combined with ilm peel, endo-photocoagulation and gas tamponade. patients were followed up for 6 months after treatment. main outcomes were determined by optical coherence tomography (oct) and best – corrected visual acuity (bcva). results: treatment with c3f8 tamponade followed by laser photocoagulation in odp maculopathy patients resulted in resolution of sub-retinal and/or intraretinal fluid in six out of seven patients at the end of six month follow up. the remaining one patient had significant reduction in retinoschisis, as determined by oct, and fundoscopy, as well as an improvement in anatomical architecture. there was statistically significant improvement in visual acuity in four eyes, remained stable in two eyes and deteriorated in one eye in which we were not able to achieve complete macular reattachment at the end of six months. central visual field loss after photocoagulation was not clinically appreciable. no postoperative complications of maculopathy occurred during the follow-up period. conclusion: given the myriad underlying pathology of sub retinal and intra retinal fluid secondary to optic disc pit associated maculopathy, a complete procedure of pars plana vitrectomy combined with ilm peel, endophotocoagulation and gas tamponade proved to be an efficient procedure to achieve satisfactory structural and functional out come. key words: optic disc pit maculopathy, retinoschisis, photocoagulation, pars plana vitrectomy, internal limiting membrane. ptic nerve pits are congenital colobomatous malformation of optic nerve head with a reported incidence of 1 in 11000 patients1,2. this condition was first described by wiethe in 18823. although some patients remain asymptomatic but maculopathy has been reported in up to 25% – 75% of the patients in different case series and studies4. visual loss secondary to maculopathy involving optic nerve pit is mainly caused by serous macular detachment and retinoschisis. the source and flow of fluid and pathogenesis of maculopathy remain controversial and various clinical mechanisms have been proposed to describe these dilemmas surrounding optic pit maculopathy. one such proposition was given by lincoff that schisis cavities are initially formed that lead to outer macular hole formation; thus resulting in conduit of fluid from intra-retinal space to sub retinal space5. however, optical coherence tomography o surgical management of optic disc pit maculopathy pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 135 (oct) based studies have concluded that there can be a collection of sub retinal fluid in the absence of retinoschisis in cases of optic pit maculopathy6. the theory of vitreous origin of fluid has been supported by various previous clinical and histopathology studies like alcain blue staining of vitreous followed by presence of mucopolysaccharides in optic disc pit; videos showing bubbles coming out of the pit after pars plana vitrectomy (ppv) and intraocular gas tamponade; similarly silicone oil has also been described emerging from pit after intraocular tamponade7-9. cerebrospinal fluid has also been implicated as a potential source of sub retinal fluid and this observation has been substantiated by few observations. mri contrast dye has been reported to pass into sub retinal space and intraocular silicone oil has been found in intracranial cavity in mri documented cases10,11. recent oct findings have suggested a 3 way connection between intraretinal space, sub retinal space, perineurial space and vitreous cavity; flow and trajectory of fluid may vary among various patients. this hints towards the origin of myriad of surgical options available; all being partially successful and thus the lack of standard surgical approach for optic disc pit maculopathy12. spontaneous resolution of optic pit maculopathy has been reported in up to 25% of patients but one may encounter macular hole formation, degenerative cystic changes and retinal pigment epithelium degeneration leading to more severe visual loss in the absence of intervention. therefore, to avoid these sequel observed in the natural course of disease, surgical intervention has been recommended by most investigators12-14. the basic surgical procedure for optic disc pit maculopathy is ppv and intraocular gas tamponade; this procedure has been supplemented with internal limiting membrane (ilm) peel and endolaser photocoagulation to temporal margin of disc15,16. macular buckle, optic nerve sheath fenestration and intra / sub retinal fluid aspiration (recent description) have also been employed as additional procedures with varying functional and anatomic outcomes17. in this study, we report the outcome of 7 cases of optic disc pit maculopathy after ppv, ilm peel, endo laser and intraocular gas tamponade. material and methods this study was conducted at jinnah hospital lahore and al-ehsan eye hospital, lahore from february 2013 to december 2015 after seeking approval from hospital ethics committee and all patients were enrolled in this study after obtaining informed consent. seven eyes of 7 patients under went standard 23g, 3 port ppv, ilm peel, endolaser and intraocular gas tamponade for optic disc pit associated maculopathy. all surgeries were performed by the same vitreoretinal surgeon. optic disc pit maculopathy was diagnosed after detailed slit lamp examination, patients complaints, clinical signs and relevant oct observations. oct and fundus photographs were taken pre and post operatively. after standard 3 ports 23g ppv, additional procedures if ilm peel and endo laser were also performed. ilm peel was assisted by brilliant peel 0.025% (fluoron/geuder, heidelberg, germany) dye that preferentially stains ilm without staining cortical vitreous and epiretinal membrane. the nasal extent if ilm peel was till the optic disc margin.two rows of frequency doubled nd: yag laser were applied around the temporal border of optic disc covering the margins of retinal elevation just adjacent to optic disc. grade i reactions were achieved after applying burns at the level of rpe. after fluid air exchange, a 14% mixture of c3f8 and air were used as final endotamponade. all 23g ports were secured using 6 0 vicryl sutures. all patients underwent post operative examination at 1st post operative day, 7th post operative day and at 1st, 3rd and 6th post operative month. all patients examined at 1st, 3rd and 6th post operative months were evaluated after documenting their best corrected visual acuity (bcva) and observations on oct (stratus oct carl zeiss meditec inc., dublin, ca, usa) and (3d oct – 1 maestro; topcon corporation®, itabashi, tokyo, japan). spss statistical software version 16.0 (spss inc., chicago, il, usa) was used for data analysis. preoperative and post-operative best corrected visual acuity (bcva) in log mar were statistically analysed using wilcoxon signed rank test. spearman rank correlation test was used to find relationship between postoperative anatomic and functional results and other relevant parameters. p-value <0.05 was taken as statistically significant. results we had 4 male and 3 female patients with mean age of 28.88 +/14.55 years (age range 19-66 years). duration harron tayyab, et al 136 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology of loss of vision was between 18 days and 24 months (mean 8.42 +/6.03 months. range of preoperative bcva was from logmar 0.3 to 1.30 (mean logmar 1.00 +/0.43). location wise, 5 pits were located inferotemporally, 1 pit was located surepotemporally and 1 pit was central in location (fig. 1). fig. 1: location of optic disc pit. 0 1 3 4 5 6 macular reattachment in 3 months macular reattachment in 6 months no macular reattachment numbers fig. 2: time needed before compete macular attachment. complete macular reattachment as observed on oct was achieved in 5 out of 7 eyes in 3 months. one patient achieved macular reattachment at 5th post operative month and 1 patient failed to achieve complete macular reattachment at the end of 6 months follow-up (figure 2). by the end of 6 months followup, bcva improved by at least 2 lines in 4 out of 7 patients. two patients fig.3a: pre-operative oct and fundus photo of optic disc pit with sensory macular detachment and showing communication between sub retinal space and optic disc pit. fig. 3b: pre-operative oct and fundus photo of optic disc pit with retinoschisis. had stable bcva where as in 1 patient, bcva deteriorated as compared to her bcva at the time of presentation. out of these 2 patients, one patient has an unsuccessful anatomic outcome at the end of 6 months (figure 3a, 3b, 3c and 3d). over all, 6 months post operative bcva ranged from logmar1. 34 to 0.24 (mean 0.64 +/0.54. these finding showed a statistically significant (p-value < 0.005) improvement in bcva after 6 months of surgical intervention. spearman’s bivariate correlation concluded that final bcva was negatively correlated with patients age and duration of symptoms at presentation (p = 0.005, r = 0.6 and p = 0.004, r = 0.63). however, there was no statistically significant correlation between duration of symptoms and pre operative bcva. surgical management of optic disc pit maculopathy pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 137 fig. 3c: 6 months post-operative oct and fundus photo of optic disc pit where macula has failed to reattach completely despite block of communication between optic disc pit and sub retinal space after argon laser photocoagulation. fig.3d: 6 months post-operative oct and fundus photo showing complete resolution of retinoschisis but sensory macular elevation persists. discussion optic disc pit presents clinically as a grey round to oval excavation in optic nerve head. its occurrence is due to lack of perfect closer of embryonic fissure18. as our understanding of maculopathy associated with optic disc pit has increased, so have been the options and recommendations for its treatment. surgeons have tried gas tamponade with or without endolaser barrage, pars plana vitrectomy with or without laser and with or without ilm peeling with varying success rates19. different patterns of maculopathy also influence the anatomical and visual outcome after surgical intervention. one such observation is the presence of multilayer schisis cavities which renders the intervention with poor visual outcome as compared to serous retinal detachment type of maculopathy20. although incomplete understanding of mechanism and management of maculopathy associated with optic disc pit, still 74% of patients with optic disc pit have been found to have certain level of vitreous abnormalities like condensed vitreous strongly attached to pit, vitreomacular traction or incomplete vitreous detachment21. therefore pars plana vitrectomy aided with tamponade, laser or ilm peeling has been widely adopted as a technique to counter this maculopathy with varying success rates. in our study, we employed the surgical technique of pars plana vitrectomy with ilm peel, endorser and intraocular gas tamponade for treating optic disc pit associated maculopathy. although if maculopathy is left alone and allowed to follow its natural course, reattachment of macula has been reported but visual outcome is usually very poor22,23. researchers have reported a relatively higher incidence of recurrence after gas tamponade or laser when done alone24. pars plana vitrectomy with or without its adjuncts has been used widely but there are risks associated with pars plana vitrectomy as well (macular hole formation)13. in one report, scanning laser ophthalmoscope (slo) showed a cyst like structure above the pit; and dynamic movement of eyes seemed to exert traction on the pit and may be responsible for development of serous macular detachment associated with optic disc pit26. these observations along with above mentioned abnormal vitreous traction role explains why pars plana vitrectomy has become a preferred procedure for optic disc pit maculopathy. in our study, complete macular attachment was observed in 5 out of 7 patients (72%) at 3 months and 6/7 (86%) at the end of 5 months. our anatomic results are comparable to avci et al, who achieved macular reattachment in 11/13 (84%) at the 16 month follow up. our functional results showed 57% patients had improvement in bcva of 2 lines or more where as acvi had such improvement in 84% in his subjects. just like in our study, he concluded a negative correlation between durations of symptoms and final bcva17. the main difference between the to study groups was that we preferred ilm peeling as an adjunct where as acvi did his intervention just like us harron tayyab, et al 138 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology but omitting ilm peeling. another study showed that 7/8 eyes (87%) achieved retinal reattachment after pars plana vitrectomy and induction of pvd alone without ilm peel, gas tamponade or endophotocoagulation; but complete retinal reattachment in this study was achieved after 1 year as compared to our patients where 6/7 patients achieved complete retinal attachment at end of 6 months. although size of macular detachment, presence and severity of retinoschisis and size of optic disc pit may be important factors influencing the therapeutic outcomes of intervention, our study shows that early diagnosis and treatment are fundamental to achieving good functional and anatomic results. conclusion we have presented a study with good functional and structural outcome for optic disc pit associated maculopathy treated by pars plana vitrectomy, endo laser, ilm peel and gas endotamponade. this combination procedure has been effective and we encountered minimal side effects of this procedure. although, the results cannot be generalised due to limited sample size, further similar studies can further support the therapeutic approach we adopted for this pathology. despite the difficulty in conducting randomised clinical trial for optic disc pit maculopathy because of its very low incidence, we still need further scientific evidence to tailor our approach in finding the best procedure to address this pathology completely. author’s affiliation dr. haroon tayyab assistant professor sharif medical and dental college lahore dr. tehmina jahangir senior registrar jinnah hospital, lahore dr. akhwand abdul najeed jawad medical officer smdc, lahore role of authors dr. haroon tayyab surgeon and study design. dr. tehmina jahangir patient evaluation and literature search. dr. akhwand abdul najeed jawad statistical analysis and discussion writing. references 1. postel ea, pulido js, mcnamara ja, johnson mw. the etiology and treatment of 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two cases simulating malignant melanoma of the choroid. arch ophthalmol. 1963; 70: 346-57. 8. akiba j, kakehashi a, hikichi t, trempe cl. vitreous findings in cases of optic nerve pits and serous macular detachment. am j ophthalmol. 1993; 116: 38-41. 9. johnson tm, johnson mw. pathogenic implications of subretinal gas migration through pits and atypical colobomas of the optic nerve. arch ophthalmol. 2004; 122: 1793-800. 10. chang s, haik bg, ellsworth rm, st louis l, berrocal ja. treatment of total retinal detachment in morning glory syndrome. am j ophthalmol. 1984; 97: 596-600. 11. kuhn f, kover f, szabo i, mester v. intracranial migration of silicone oil from an eye with optic pit. graefes arch clin exp ophthalmol. 2006; 244 rence tomography morphology in optic disc pit associated maculopathy. indian j ophthalmol. 2014; 62: 777-81. 12. sandali o, barale po, bui quoc e, belghiti a, borderie v, laroche l, sahel ja, monin c. long-term results of the treatment of optic disc pit associated with serous macular detachment: a review of 20 cases. j fr ophtalmol. 2011; 34: 532-8. 13. shukla d, kalliath j, tandon m, vijayakumar b. vitrectomy for optic disk pit with macular schisis and outer retinal dehiscence. retina. 2012; 32: 1337-42. 14. georgalas i, petrou p, koutsandrea c, http://www.ncbi.nlm.nih.gov/pubmed/?term=postel%252520ea%25255bauthor%25255d&cauthor=true&cauthor_uid=10360283 http://www.ncbi.nlm.nih.gov/pubmed/?term=pulido%252520js%25255bauthor%25255d&cauthor=true&cauthor_uid=10360283 http://www.ncbi.nlm.nih.gov/pubmed/?term=mcnamara%252520ja%25255bauthor%25255d&cauthor=true&cauthor_uid=10360283 http://www.ncbi.nlm.nih.gov/pubmed/?term=johnson%252520mw%25255bauthor%25255d&cauthor=true&cauthor_uid=10360283 http://www.ncbi.nlm.nih.gov/pubmed/?term=tzu%252520jh%25255bauthor%25255d&cauthor=true&cauthor_uid=23355772 http://www.ncbi.nlm.nih.gov/pubmed/?term=flynn%252520hw%252520jr%25255bauthor%25255d&cauthor=true&cauthor_uid=23355772 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http://www.ncbi.nlm.nih.gov/pubmed/?term=shukla%252520d%25255bauthor%25255d&cauthor=true&cauthor_uid=22481474 http://www.ncbi.nlm.nih.gov/pubmed/?term=kalliath%252520j%25255bauthor%25255d&cauthor=true&cauthor_uid=22481474 http://www.ncbi.nlm.nih.gov/pubmed/?term=tandon%252520m%25255bauthor%25255d&cauthor=true&cauthor_uid=22481474 http://www.ncbi.nlm.nih.gov/pubmed/?term=vijayakumar%252520b%25255bauthor%25255d&cauthor=true&cauthor_uid=22481474 http://www.ncbi.nlm.nih.gov/pubmed/?term=georgalas%252520i%25255bauthor%25255d&cauthor=true&cauthor_uid=19253260 http://www.ncbi.nlm.nih.gov/pubmed/?term=petrou%252520p%25255bauthor%25255d&cauthor=true&cauthor_uid=19253260 http://www.ncbi.nlm.nih.gov/pubmed/?term=koutsandrea%252520c%25255bauthor%25255d&cauthor=true&cauthor_uid=19253260 surgical management of optic disc pit maculopathy pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 139 papaconstadinou d, ladas i, gotzaridis e. optic disc pit maculopathy treated with vitrectomy, internal limiting membrane peeling, and gas tamponade: a report of two cases. eur j ophthalmol. 2009; 19: 324-6. 15. theodossiadis g. evolution of congenital pit of the optic disk with macular detachment in photocoagulated and nonphotocoagulated eyes. am j ophthalmol. 1977; 84: 620-31. 16. hirakata a1, okada aa, hida t. long-term results of vitrectomy without laser treatment for macular detachment associated with an optic disc pit. ophthalmology, 2005; 112: 1430-5. 17. avci r, yilmaz s, inan uu, kaderli b3, kurt m, yalcinbayir o, yildiz m, yucel a. long-term outcomes of pars planavitrectomy without internal limiting membrane peeling for optic disc pit maculopathy. eye (lond). 2013; 27: 1359-67. 18. halbertsma kt. crater-like hole and coloboma of the disc associated with changes at the macula. br j ophthalmol. 1927; 11: 11-7. 19. georgalas i, ladas i, georgopoulos g, petrou p. optic disc pit: a review. graefes arch clin exp ophthalmol. 2011; 249: 1113-22. 20. skaat a, moroz i, moisseiev j. macular detachment associated with an optic pit: optical coherence tomography patterns and surgical outcomes. eur j ophthalmol. 2013; 23: 385-93. 21. theodossiadis pg, grigoropoulos vg, emfietzoglou j, theodossiadis gp. vitreous findings in optic disc pit maculopathy based on optical coherence tomography. graefes arch clin exp ophthalmol. 2007; 245: 1311-8. 22. vedantham v, ramasamy k. spontaneous improvement of serous maculopathy associated with congenital optic disc pit: an oct study. eye (lond). 2005; 19: 596-9. 23. sobol wm, blodi cf, folk jc, weingeist ta. longterm visual outcome in patients with optic nerve pit and serous retinal detachment of the macula. ophthalmology. 1990; 97: 1539-42. 24. theodossiadis g. treatment of retinal detachment with congenital optic pit by krypton laser photocoagulation. graefes arch clin exp ophthalmol. 1988; 226: 299. 25. gandorfer a, kampik a. role of vitreoretinal interface in the pathogenesis and therapy of macular disease associated with optic pits. ophthalmologe. 2000; 97: 2769. http://www.ncbi.nlm.nih.gov/pubmed/?term=papaconstadinou%252520d%25255bauthor%25255d&cauthor=true&cauthor_uid=19253260 http://www.ncbi.nlm.nih.gov/pubmed/?term=ladas%252520i%25255bauthor%25255d&cauthor=true&cauthor_uid=19253260 http://www.ncbi.nlm.nih.gov/pubmed/?term=gotzaridis%252520e%25255bauthor%25255d&cauthor=true&cauthor_uid=19253260 http://www.ncbi.nlm.nih.gov/pubmed/?term=theodossiadis%252520g%25255bauthor%25255d&cauthor=true&cauthor_uid=930990 http://www.ncbi.nlm.nih.gov/pubmed/?term=hirakata%252520a%25255bauthor%25255d&cauthor=true&cauthor_uid=16024082 http://www.ncbi.nlm.nih.gov/pubmed/?term=okada%252520aa%25255bauthor%25255d&cauthor=true&cauthor_uid=16024082 http://www.ncbi.nlm.nih.gov/pubmed/?term=hida%252520t%25255bauthor%25255d&cauthor=true&cauthor_uid=16024082 http://www.ncbi.nlm.nih.gov/pubmed/?term=avci%252520r%25255bauthor%25255d&cauthor=true&cauthor_uid=24037231 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http://www.ncbi.nlm.nih.gov/pubmed/?term=theodossiadis%252520g%25255bauthor%25255d&cauthor=true&cauthor_uid=3402755 http://www.ncbi.nlm.nih.gov/pubmed/?term=gandorfer%252520a%25255bauthor%25255d&cauthor=true&cauthor_uid=10827464 http://www.ncbi.nlm.nih.gov/pubmed/?term=kampik%252520a%25255bauthor%25255d&cauthor=true&cauthor_uid=10827464 126 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology case report bilateral irreversible blindness following urine therapy to the eyes fadamiro, christianah olufunmilayo pak j ophthalmol 2018, vol. 34, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: fadamiro, christianah olufunmilayo fwacs (ophthal), fmc (ophthal) ophthalmologist ophthalmology/ ekiti state university teaching hospital, ado-ekiti email: joechrisdamiro @yahoo.com …..……………………….. this is a case report of a 36-year-old nigerian photographer who suffered irreversible blindness following the use of urine as therapy for red eyes, the aftermath was devastating to the eyes, despite the resultant visual loss, and the eyes were disfigured due to bilateral anterior staphyloma. this is an avoidable case of blindness due to use of toxic agent on the eyes and calls for need of public enlightenment and eye health education on the use of self remedies for eye ailments and its untoward effects. keywords: blindness, urine therapy, self-remedy. he use of toxic agents on the eyes for ailments is a common practice in developing countries13. the effect of such agents is usually devastating to the ocular tissues and can invariably lead to blindness or disfigurement of the eyes4,5. such toxic agents vary from one environment to the other. it can be chemical in nature or products from animals or human beings6-8. this case report is to highlight the disastrous effect of the use of urine on the eyes and sensitize the public on the need to avoid self-remedy for eye disorders especially toxic agents. case report a 36 year old male photographer presented to the eye clinic of ekiti state university teaching hospital on 12 september 2017 with loss of vision in both eyes with associated bulging of the eyes of six months’ duration. he claimed he initially had pain, redness and discharge of both eyes of a few days’ duration for t bilateral irreversible blindness following urine therapy to the eyes pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 127 which he applied some medications, which he could not ascertain. when he realized there was no improvement, he decided to be applying his personal urine; he was questioned on why he applied urine, and the reasons given bordered solely on ignorance and misinformation. when he realized that he could no longer see with the eyes following the application of the urine for some days, he decided to visit the primary health centre in his village and was given some eye medication, which he used for some months to no avail. he also sought spiritual help where he was given anointed olive oil without improvement. he was consequently brought to our clinic by one of our patients who had successful cataract surgery some years back. clinical examination revealed an anxious looking blind young man, his visual acuity in both eyes were hand movement. the eyes were examined using both pen light and slit lamp microscope, the conjunctiva were moderately injected, the two eyes had anterior staphyloma with disorganization of the anterior segment, no further details of the other structures in the eyes. he was placed on gutt ciprofloxacin 8 hourly, oc chloramphenicol 12 hourly to both eyes, oral vitamin figure a anterior view of the patient. figure b lateral view of the patient fig. a & b: photographs of the patient’s eyes showing bilateral anterior staphyloma. 128 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology a 200,000, iu daily and vitamin c 200 mg tab 8 hourly for 2 weeks as palliatives, after which he was asked to come for follow-up. at follow up, the patient was less anxious, even though there was no visual improvement or resolution of the anterior staphyloma. he was counseled and referred to the blind institution in the state for further rehabilitation. discussion the use of toxic agents as remedy for some eye conditions have been reported by various authors worldwide1-4 such remedies are often fraught with complications that can either lead to visual loss or impairment4-7. common agents used as remedy include; chemical substances, homemade remedy, plant extracts and animal’s products, such as urine4,7-9 the use of urine on the eye can transform a mild ocular infection into a devastating one as in this case because urine itself has ammonia which is toxic aside from the fact that the patient may be harboring some pathogenic bacterial in his urine which will further compound the keratitis. reasons why patients indulge in this unwholesome act include ignorance, poverty, inaccessibility to an eye care facility and some local beliefs7, 8, 10. in this case, the patient resides in a village where there is no eye care facility and having used some selfprescribed medication without prompt relief, he resulted into the use of personal urine, which was recommended by a family member with the belief that it will ameliorate the eye condition. the resultant effect of visual loss coupled with disfigurement of the eye, which is a cosmetic embarrassment to this patient is avoidable. this kind of harmful practice is a common trend in the environment7, 8, 9 and there is need to institute actions that will forestall it. conclusion there is need to create public awareness on the danger of using harmful agents and other inappropriate medication as remedy for eye ailment. this can be achieved through public media and educating people in some large gathering such as schools, churches and mosques. furthermore there is need to incorporate primary eye care in all available primary health care facilities and motivate people to utilize them. author’s affiliation dr. fadamiro, christianah olufunmilayo fwacs (ophthal), fmc (ophthal) ophthalmologist ophthalmology/ekiti state university teaching hospital, ado-ekiti. role of author dr. fadamiro, christianah olufunmilayo 100% contribution by the sole author. references 1. prajna vn, pillai mr, manimegali tk, srinivasan m. use of traditional eye medicines by corneal ulcer patients presenting to a hospital in south india. ind. j. ophthalmol. 1999; 47 (1): 15-18. 2. carvalho rs, kara jose n, temorini er, kara-junior n, noma-campos r. self-medication: initial treatments used by patients seen in an ophthanmologic emergency room. clinics. 2009; 64 (8): 735-41. 3. courtright p, lawallen s, kanjaloti s, divala dj. traditional eye medicine use among patients with corneal disease in rural malawi. br. j. ophthalmol. 1994; 78: 810-812. 4. ukponmwan cu, momoh n. incidence and eye complications of traditional eye medications in a nigeria teaching hospital. middle east afr. j. ophthalmol. 2010; 17 (4): 315-319. 5. osahon ai. consequences of traditional eye medication in ubth, benin city. nigeria j. ophthalmol. 1995; 3: 51-4. 6. jaya y. masanganise r. the prevalence, types and effect of traditional eye medicine use among newly presenting patients at sekuru kaguvi hospital eye unit in harare zimbabwe. cent. afr. j. med. 2014; 60: 36-44. 7. ayanniyi aa. a 39 years old man with blindness following the application of raw cassava extract to the eyes. digit j ophthalmol, 2009; 15: 2. 8. eze bi, chuka-okosa cm, uche jn. traditional eye medicine use by newly presenting ophthalmic patients to a teaching hospital in south-eastern nigeria; sociodemographic and clinical correlates. bmc complement altern med. 2009; 9: 40. 9. ajite ko, fadamiro co. prevalence of harmful/ traditional medication use in a traumatic eye injury. glob j health sci, 2013; 5 (4): 55-59. 10. nwosu s, obidiozor ju. incidence and risk factors for traditional eye medicine use among patients at a tertiary eye hospital in nigeria. niger. j. clin. pract 2011; 14: 405-7. 129 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology 4 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology original article relationship between body mass index and intraocular pressure in diabetic and hypertensive adults farnaz siddiqui, saba alkhairy, mazhar-ul-hassan, darshan kumar pak j ophthalmol 2016, vol. 32 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: farnaz siddiqui department of ophthalmology dow international medical college (dimc) dow university hospital (duh) dow university of health sciences (duhs) karachi. email: siddiqui.farnaz@gmail.com received: november 11, 2015 accepted: march 14, 2016 …..……………………….. purpose: to evaluate the relationship between body mass index and intraocular pressure in diabetic and hypertensive adults presenting to the out patient department of dow international medical college. study design: descriptive cross – sectional study. place and duration of study: department of ophthalmology, dow university hospital (ojha campus) of dow international medical college, dow university of health sciences, karachi, pakistan from 15 march 2015 to 15 april 2015. material and methods: this study done in the department of ophthalmology, dow university hospital (ojha campus) of dow international medical college, dow university of health sciences, karachi, pakistan from 15 march 2015 to 15 april 2015. 101 patients were included in the study group who were known diabetics with or without hypertension. height, weight, blood pressure and intraocular pressure (iop) were recorded in these patients. iop was measured using the goldmann applanation tonometer. the correlation between body mass index (bmi) and iop was calculated and the statistical analysis was done by spss version 21. results: 101 patients were examined, 45 were males and 56 were females. mean bmi was 29.86 ± 5.87 in patients having diabetes with hypertension and 27.49 ± 4.99 in only diabetic patients. the mean iop was found to be 16.34 ± 0.34 in diabetic and hypertensive patients and 15.98 ± 0.43 in diabetic patients. bmi was significantly correlated with iop in both diabetic with or without hypertensive adults. conclusion: these results show a correlation between bmi and iop in both diabetic patients with or without hypertension. increase in bmi is strongly associated with increase in iop. key words: body mass index, diabetes, hypertension, intraocular pressure, glaucoma. ntraocular pressure (iop) is pressure within the eye ball and is determined by production, circulation and drainage of ocular aqueous humor. parameters involved in the maintenance of intraocular pressure are aqueous flow, outflow facility, uveoscleral out flow and episcleral venous pressure. increase in iop associated with glaucomatous optic nerve damage and leads to subsequent detonation in vision.1,2 iop is currently the only modifiable risk factor for glaucoma.3 iop has been associated with different systemic, familial, anthropometric and demographic factors by several studies4. several epidemiological studies have shown an association between obesity and iop in adults.5,6 obesity is one of the most prevalent disorders of the world. it is an important risk factor for several i relationship between body mass index and iop in diabetic and hypertensive adults pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 5 diseases like hypertension, diabetes, stroke etc. obesity increases blood viscosity through increasing red cell count, hemoglobin and hematocrit and consequently, increased outflow resistance of episcleral veins occur. iop is high in diabetics as compared to non-diabetics and an increase in iop is seen to be associated with increasing body mass index (bmi) and there is a positive correlation between bmi and iop in diabetics.7 hypertension is defined as systolic blood pressure (sbp) ≥ 140 mm hg or diastolic blood pressure (dbp) ≥90 mm hg and has an increased prevalence in individuals with a body mass index (bmi) of overweight (bmi 25.0 – 29.9) or obese (bmi ≥ 30).8 to explain the relationship between blood pressure (bp) and iop there are two theories that have been proposed.9 the first theory states that the autonomic nervous system, which is mainly involved in the regulation of bp, may affect the circadian rhythm of aqueous mainly involved in the regulation of bp, may affect the circadian rhythm of aqueous humor secretion, which would then result in corresponding changes in iop10. the second theory states that angiotensin converting enzyme (ace) may bring about changes in iop as it is involved in the renin angiotensin system by mechanisms such as blocking the action of cholinesterase or by up regulating prostaglandin production.11 glaucoma and diabetes mellitus (dm) are seen to run in families and the first degree relatives are at higher risk of acquiring the disease. also glaucoma is often symptomless and goes undetected until patients start to experience significant decrease in vision and difficulty with their daily activities. obesity is one of the other risk factor for both iop and other systemic vascular abnormalities such as hypertension and arteriosclerosis. in this study we aim to analyses the effect of bmi on elevation of intraocular pressure in diagnosed diabetic patients with or without associated hypertension. material and methods this study was conducted over a one month period in the ophthalmology department of dow international medical college, karachi pakistan. a total of 101 patients were analyzed after obtaining an informed consent. 57 subjects were diabetics with associated hypertension while 44 subjects were those without hypertension. individuals that were aged 20 – 70 years, both genders, having diabetes alone or with hypertension were included in the study. candidates that were taking any iop lowering agent, active eye infection, recent eye surgery and patients using steroids in any form were excluded from the study. the subjects went through detailed examination in which there was measurement of blood pressure, measurement of height, tonometry and ocular examination including fundoscopy. measurement of iop in both eyes was done with a goldmann applanation tonometer. iop measurements were always performed between 9:00 am – 12:00 pm by goldmann tonometer so as to reduce the diurnal variation bias. subject’s height was measured using a standard scale, weight using a standard weighing machine, blood pressure using a sphygmomanometer and pulse rate. bmi was calculated as weight in kilogram/height in metre.2,12 we reported frequencies and percentages for categorical variables and reported mean and standard deviation (sd) for continuous variables. we performed non parametric tests to find the association between means. associations between two independent means were calculated by using the mann – whitney test and the associations between more than two independent means were calculated by using the kruskal – wallis test. we used spss version 21 for data analysis, and p-value ≤ 0.05 was taken as significant level. results the subjects were divided into two groups. one group had diabetes with hypertension while the other group was diabetic without hypertension. all individuals were aged above 20 years, ranging from 20-70 years. among these patients 45 were males and 56 were females. gender distribution of bmi and iop is given in table 1. the mean bmi in the diabetic with hypertensive subjects was 29.86 ± 5.87 while in diabetic without hypertensive subject was 27.49 ± 4.99 with p-value of 0.027 (table 2) which is statistically significant. the mean iop of both eyes in diabetic with hypertensive subject was 16.34 ± 0.34, while in diabetic without hypertensive subject was 15.98 ± 0.43 with p-value of 0.579 (table 2). the association between the bmi and iop was evaluated. there was a significant increase in iop with increase in bmi in both groups (p value = 0.006, p value = 0.001) table 3. increase in iop was strongly associated with increase in bmi in both diabetic with or without associated hypertensive adults. farnaz siddiqui, et al 6 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology table 1: age, bmi and mean iop distribution according to gender (n = 101). characteristics total male n (%) female n (%) age (years) < 25 4 1 (25.0) 3 (75.0) 25 – 44 19 8 (42.1) 11 (57.9) 45 – 64 65 28 (43.1) 37 (56.9) ≥ 65 13 8 (61.5) 5 (38.5) body mass index (kg/m2) < 24.9 28 15 (53.6) 13 (46.4) 25 – 29.9 35 18 (51.4) 17 (48.6) ≥ 30 38 12 (31.6) 26 (68.4) mean intra ocular pressure (mmhg) < 15 28 15 (53.6) 13 (46.4) 15 – 19 56 24 (42.9) 32 (57.1) ≥ 20 17 6 (35.3) 11 (64.7) table 2: comparison of bmi and mean iop within diabetic and diabetic hypertensive patients. (n = 101). d/ht d/nht pvalue* body mass index (kg/m2) mean ± sd 29.86 ± 5.87 27.49 ± 4.99 0.027 mean intra ocular pressure (mmhg) mean ± sd 16.34 ± 0.34 15.98 ± 0.43 0.579 d/ ht – diabetes mellitus with hypertension d/nht diabetes mellitus without hypertension *p-value calculated using mann – whitney test discussion the iop values increased with increasing age. various studies have shown a positive association between increasing age and iop13-15 however a study done on japanese population16,17 showed a negative correlation. in another study done in pakistan, iop progressively table 3: association of mean iop and bmi in diabetic and diabetic hypertensive group. (n=101) mean intra ocular pressure (mmhg) body mass index (kg/m2) d/ht d/nht n mean ± sd n mean ± sd < 24.9 15 13.2 ± 0.8 13 12.5 ± 1.3 25 29.9 34 16.6 ± 1.2 22 16.4 ± 1.4 ≥ 30 8 20.6 ± 1.2 9 20.0 ± 1.2 p-value* 0.006 0.001 d/ ht – diabetes mellitus with hypertension d/nht diabetes mellitus without hypertension *p-value calculated using kruskal – wallis test increased with age in both sexes, and amongst the two sexes it was seen to increase more in females 18 which matches with our study. a study done on korean population showed the mean iop of men was 15.8 ± 3.3 mmhg and 15.7 ± 3.3 mmhg for right and left eyes respectively, which was significantly higher than women (15.1 ± 3.1 mmhg).19 another study conducted on a taiwanese population reported that intraocular pressure showed a significant reduction with aging in men but not in women.20 the blue mountains eye study”,21 the “baltimore eye survey”22 and the “barbados eye study“23 have studied the relationship between iop and diabetes mellitus. the barbados eye study have also showed the relationship of iop with increase of arterial blood pressure. this study showed the relationship of systemic factors such as diabetes and hypertension to increase in iop in an african population and results concluded that elevated iop in groups that had increased prevalence of diabetes and hypertension.23 barbara e. k. klein, ronald klein, and karhryn l. p. linton et al conducted the beaver dam eye study24 and they found an association of iop with systolic and diastolic blood pressures, body mass index, hematocrit, serum glucose, glycohemoglobin, cholesterol level, nuclear sclerosis, season, and time of day of measurement. another study showed that the iop values increased progressively in hypertensive patients without retinopathy, to the hypertensive with relationship between body mass index and iop in diabetic and hypertensive adults pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 7 retinopathy and diabetic hypertensive with retinopathy. this shows the increasing association between raised intra ocular pressure and evolution of systemic hypertensive disease and association with diabetes mellitus.25 in our study the mean iop of both groups (i.e diabetes mellitus with hypertension and diabetes mellitus without hypertension) were 16.34 ± 0.34 and 15.98 ± 0.43 respectively with p-value of 0.579 which is not statistically significant. this might be because of small sample size of our study and need more crosssectional studies of larger sample size to evaluate the statistically significant relation between the iop with diabetic and hypertensive subjects. various studies have shown that obesity is an independent risk factor for increased iop and there is a positive relationship with iop26-28. in our study there is also strong association of iop and bmi in both diabetic hypertensive and only diabetic group with statistically significant p-value of 0.006 and 0.001 respectively. obesity leads to increased intra orbital adipose tissue which causes a raised episcleral venous pressure. this in turn will reduce drainage of the aqueous humour. other factors that come into play include an increased blood viscosity through elevated blood cell count, hemoglobin and hematocrit. both these factors contribute to increasing impedance in aqueous humour outflow.29 a relation between obesity and iop was also found in studies by shiose et al18, klein et al30and bulpitt et al31 (japanese, american and british populations, respectively). another study done on the korean population showed that the mean bmi was 23.9 for men and 23.7 for women, and was positively associated with iop after adjusting for age, sex and mean blood pressure.19 conclusion there is positive association between increase bmi with increase iop in both diabetic with or without associated hypertension. author’s affiliation dr. farnaz siddiqui assistant professor department of ophthalmology dow international medical college (dimc), dow university hospital (duh) dow university of health sciences (duhs) karachi dr. saba alkhairy assistant professor department of ophthalmology dow international medical college (dimc), dow university hospital (duh) dow university of health sciences (duhs) karachi dr. mazhar-ul-hassan professor of ophthalmology dow international medical college (dimc), dow university hospital (duh) dow university of health sciences (duhs karachi dr. darshan kumar assistant professor department of nide dow international medical college (dimc), dow university hospital (duh) dow university of health sciences (duhs) karachi role of authors dr. farnaz siddiqui manuscript writing dr. saba alkhairy research design dr. mazhar-ul-hassan research design dr. darshan kumar manuscript review references 1. mackanzie p, cioffi g. how does lowering of intraocular pressure protect the optic nerve? surv ophthalmol. 2008; 53: 39-43. 2. coleman al, kodjebackeva g. risk factors for glaucoma needing more attention. 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population. arq. bras. oftalmol. 2000; 63: no.3 sao paulo. 26. gherghel d, orgül s, gugleta k, flammer j. retrobulbar blood flow in glaucoma patients with nocturnal over – dipping in systemic blood pressure. am j ophthalmol. 2001; 132: 641–7. 27. kohli pg, kaur h, maimi s. relation of body mass index with intraocular pressure. indian j of basic and applied medical research, 2014; 3: 679-81. 28. baisakhiya s, surjit s, mushtaq f. correlative study of intraocular pressure and blood pressure in north indian subjects. int j med health science, 2015; 4: 453-6. 29. nyamdorj r, qiao q, söderberg s, pitkäniemi j, zimmet p, shaw j, alberti g, nan h, uusitalo u, pauvaday v, chitson p, tuomilehto j. comparison of body mass index with waist circumference, waist-to-hip ratio, and waist-to-stature ratio as a predictor of hypertension incidence in mauritius. j hypertens. 2008; 26: 866-70. 30. klein bek, klein r, linton kl. intraocular pressure in an american community: the beaver dam eye study. invest ophthalmol vis sci. 1992; 33: 2224–8. 31. bulpitt cj, hodes c, everitt mg. intraocular pressure and systemic blood heart study. am. j. epidemiol. 1977; 106: 33–41. http://www.ncbi.nlm.nih.gov/pubmed/?term=shimokata%20h%5bauthor%5d&cauthor=true&cauthor_uid=12187477 http://www.ncbi.nlm.nih.gov/pubmed/?term=miyake%20y%5bauthor%5d&cauthor=true&cauthor_uid=12187477 http://www.ncbi.nlm.nih.gov/pubmed/?term=javitt%20jc%5bauthor%5d&cauthor=true&cauthor_uid=7831041 http://www.ncbi.nlm.nih.gov/pubmed/?term=sommer%20a%5bauthor%5d&cauthor=true&cauthor_uid=7831041 pakistan journal of ophthalmology, 2020, vol. 36 (3): 197-204 197 special report ophthalmological society of pakistan (osp), beyond 2016 mohammad daud khan 1 1 founder vice chancellor, khyber medical university, peshawar this report highlights recent developments in osp in the field of ophthalmic medical education including professionalism, research and development, publications and eye health care service delivery system. in the year 2016, prof. ziaul islam was elected as the new president of osp. in the inaugural meeting of the central council, chaired by the newly elected honorable president, it was observed that despite achieving major milestones since the birth of the country in 1947 and the birth of the ophthalmological society in 1957, there are still serious gaps in eye care in pakistan in terms of equitability, cost, uptake, comprehensiveness, quality and sustainability. after detailed discussion, the honorable president appointed a committee under the chairmanship of prof. m.d.khan with four terms of reference. 1. redraft osp vision, mission and values. 2. revamp and remodel the osp health and education foundation. 3. recommend smart future plan to bridge the gaps. 4. submit the report to osp central council for thorough examination, adoption and implementation. the committee critically examined the issue and tried to find answers to four important questions. how to cite this article: khan md. ophthalmological society of pakistan (osp), beyond 2016. pak j ophthalmol. 2020, 36 (3): 197-204. doi: 10.36351/pjo.v36i3.1082 mohammad daud khan founder vice chancellor, khyber medical university, peshawar email: profmdkhan@gmail.com 1. where we were? 2. where are we now? 3. where do we need to go? 4. how should we reach there? 1. where we were? at the time of birth of pakistan in 1947, pakistan inherited 78 registered medical doctors and only few nurses. health services in general and eye health services in particular were very rudimentary 1 . apart from some eye care services at mayo hospital lahore acivil hospitalkarachi and few cottage hospitals in punjab, the rest of the population in the entire country was served by few christian missionary hospitals run by two very dedicated missionary groups. sir henry holland and his family covered the south, with two major facilities, one at quetta for baluchistan andthe other at shikarpur for sindh. dr. novel christy and his associates served the north from their hq at taxilla. by 1950/60, new eye departments came up in public sector at karachi, multan and peshawar. few new eye departments were also opened in military hospitals in major cities. however, 80% population had no access to organized eye care services 2 . in response to a letter from dr william john holmes of honolulu, on december 19, 1957, a meeting of ophthalmologists was convened in lahore where the formation of ophthalmological society of pakistan (osp) wasapproved. lt general burki was elected as the founder president and professor raja mumtaz as thefirst secretary general of the society.osp was soon affiliated to apao. later on it was also affiliated to international federation of ophthalmological societies, afro-asian mohammad daud khan 198 pakistan journal of ophthalmology, 2020, vol. 36 (3): 197-204 academy of ophthalmology (aaao), the american academy of ophthalmology (aao), saarc academy of ophthalmology (sao) and international council of ophthalmology (ico) 2,3 . in 1979, the 7 th apao meeting was held in karachi, pakistan. the then president of pakistan general mohammad zia-ul-haq was invited as chief guest on this occasion. he took keen interest in the affairs of vision and its protection. soon after this meeting in 1980, who country office invited professor hugh taylor as who shortterm consultant to report on the current status of eye health in pakistan. the major findings of the report were; 1. prevalence of blindness in the country is over 2%. 2. there are only 80 ophthalmologists to take care of a population of 100 million. 3. 45 out of 64 districts are without ophthalmologist. 4. there is no concept of eye care team. 5. there is gross mismatch in human resource. 4 the report proved to be wakeup call for osp and the entire country. osp used the report as a major tool for advocacy. the following steps were taken with the help of government of pakistan, who and the international non government developmental organizations (indgos). national committee for prevention of blindness (pbl) was notified in the late nineties. prof. saleh memon, a highly talented, honest and upright ophthalmologist who was already working as a national coordinator since 1987/88 was appointed as the 1 st chairman of the committee. he succeeded in undertaking the monumental task of the 1 st national blindness prevalence survey in198788. the survey reconfirmed the findings of the who report, 1980. 5 in the early nineties, efforts were made to create an osp foundation to promote ophthalmic research and development and ophthalmic medical education for all cadres and for all levels. many senior ophthalmologists and some members of the pharmaceutical industry played a key role in the financial support of this foundation. in 1994 prof. m. d. khan was appointed as the new chairman of pakistan national pbl committee. district based national comprehensive eye care program was developed in close collaboration of vision 2020: who/iapb, the right to sight initiative. for implementation we followed the who six building blocks and the v.2020 threecore strategies; disease control, appropriate human resource development (hrd) and infrastructure and appropriate technology development 6 . the program was developed incrementally in close collaboration of who and sight savers international (ssi). the concept was first tested in an artificial district in kpk, then in one real district (district bannu 7 ) and finally in ten districts. 8 after thorough evaluation at each stage, it was finally rolled over to the entire country through two consecutive five years national eye health development programs.cbm, fred hollows foundation and many other small organizations joined ssi, to support the project. the total cost incurred on developing 100 districts along with four provincial eye care hrd centers and the pakistan institute of community ophthalmology (pico) at peshawar amounted to 13 million usds. the entire developmental cost was borne by the consortium of indgos 6 . large number of centers of excellence for human resource development and sophisticated eye care interventions were opened in government and nongovernment sectors across the country. college of physicians and surgeons of pakistan (cpsp), international council of ophthalmology (ico), london school of tropical medicine and hygiene and international joint commission of allied health in ophthalmology (ijcapo), played a key role in training, evaluation and certification of ophthalmologists, community ophthalmologists and ophthalmic allied health personnel including ophthalmic nurses. the 2nd national blindness prevalence survey was undertaken in collaboration with london school of tropical medicine and hygiene and the ingdos consortium in the years 2003 – 2004 9 . the following were the salient features of the results of the 2 nd survey. the prevalence of overall blindness dropped from 1.78% to 0.9%. the number of ophthalmologists shot up from 80 in 1980 to > 2000 in 2004. the number of cataract surgeries shot up from 50,000 in 1980 to 500,000 in 2004. the cataract surgical rate (csr) shot up from 1115/m in 1980 to 4000/m in 2004. ophthalmological society of pakistan (osp), beyond 2016 pakistan journal of ophthalmology, 2020, vol. 36 (3): 197-204 199 a mix of over 900 optometrists, orthoptists, over 200 ophthalmic nurses and over 2000 ophthalmic technicians were added to the eye care human resource 9 . the result of the pakistan 2 nd national blindness prevalence survey was announced in geneva in 2004. on the same day, the results of indian and bangladesh blindness prevalence surveys were also announced. the result showed that pakistan had achieved the best results. at this moment of great joy, the pakistan health minster, there and then announced to spend additional 46 million usds to further strengthen the pakistan national eye health program. in 2006, prof. asad aslam khan was appointed as the new chairman of the national pbl committee. prof. asad aslam khan made significant contributions by strengthening all tertiary health care centers across the country. 2. where we are now? we are blessed with a very vibrant national ophthalmological society. it is led by very competent and committed leaders. we have a strong national eye care network. we have a national hrd program for ophthalmologists, ophthalmic subspecialists and allied health personnel including nurses. we have centers for research and development and sophisticated eye care interventions. we have strong national and international linkages and collaborations. however, we still have some serious weaknesses and gaps in eye care systems. our population is not only rapidly increasing; it is also aging. there is therefore, constant mismatch between the health care needs and supply. (37.54 m in 1950 & 220.039 m in 2020) 10 . our literacy rate is still very low. (82.5% males, 59.8% females) 11 . our maternal and infant mortality rates are unacceptably high. (infant mortality rate; 57.2 deaths per 1,000 live births). (maternal mortality rate, 178 deaths per 100,000 live births). 12 we face serious challenge of malnutrition; stunting (45%), acute under nutrition (16%), underweight (40%) and wasting (9%) 13 . we face serious challenges of air, food and water pollution and contamination. an estimated 70 percent of households drink bacterially contaminated water 14 . we have an unacceptably high rate of road traffic accidents. we have high rates of drug abuse and also serious drug induced complications. we have poor control on unnecessary use or abuse of explosive devices. our health care services are not truly integrated. our primary health care system is very weak. our school health system is dysfunctional. we have a very poor referral system. our district health system needs to be further decentralized and strengthened. our tertiary care system is overburdened. we have to increase the centers of excellence and ensure its equitable distribution across the country. we still have serious gaps in health care delivery through a strong and well-coordinated team. our health management systems are very weak. our health services are neither comprehensive nor sustainable. there is very little emphasis on health education, disease prevention and rehabilitation. we have a very strong national tv network, but there is not a single dedicated channel for public awareness, health education and health promotion. 3. where do we need to go? we have to generate some fresh data on the most common causes of blindness in the country. we have to come up with a health delivery system which is equitable, people friendly, integrated, of high qualityand comprehensive. we must ensure the availability of who six building blocks for any new health initiative, (advocacy, user friendly physical infrastructure, essential human resource, technology, management and collaboration. mohammad daud khan 200 pakistan journal of ophthalmology, 2020, vol. 36 (3): 197-204 our primary health care system must be changed to a strong family health care system. we must have a robust referral system. our health care approach must be holistic and multidimensional. we therefore musttake on board the ministries of population, law, environment, water and sanitation, education and disaster management and rehabilitations during the health policy formulation. 4. how do we reach there? the committee came up with following three important recommendations to achieve the osp desired goals. 1. rename the board. call it oreef (osp research, education and eye care delivery foundation). 2. revisit and redefine the osp vision, mission and values. 3. constitute a management board assisted by five task forces to efficiently and effectively manage the board and achieve the society’s ultimate intervention goals. a. osp vision, mission and values. 1. vision; osp will be a strong advocate and partner with government of pakistan and other national and international developmental agencies to promote eye care, prevent eye diseases and ensure provision and equitable distribution of high quality, integrated, comprehensive and sustainable eye care services across the country so that nobody goes or remain blind because of lack, access or cost of services. the society will try its best to ensure that those who are blind or suffer from severe visual impairment, get maximum medical and social services support to enable them to lead a life of full potential and good quality. 2. mission: osp will take all necessary measures including strong advocacy, essential research, provision and access to necessary resources, (money, manpower, materials and management) and national and international collaboration to make eye care services available, accessible, affordable and sustainable without compromising on quality. 3. values: 1. lifelong commitment to service, quality care and compassion. 2. lifelong commitment to excellence in teaching, training and evaluation. 3. lifelong commitment to sustainable institutional development and capacity building. 4. lifelong commitment to knowledge, scholarship, wisdom and creativity. (hrd with strong emphasis on research and development and cme, cpd & ced). 5. lifelong commitment to development of strong and courageous leadership with excellent skills in advocacy, communications and quality management. 6. strong team spirit with interpersonal relationships based on dignity, honor and mutual trust and respect. 7. equity and justice with passion to serve the un-served and underserved populations. 8. strong commitment to honesty, integrity, ethical values and professionalism. 9. patience and perseverance with advance problem solving skills. 10. strong national and international linkages and collaboration. b. oreef management board and the five task forces: prof. m. lateef chaudhry chairman prof. m. daud khan executive vice chairman prof. shad mohammad secretary prof. hamid m. butt chairman education & hrd prof. shahid wahab chairman r&d ophthalmological society of pakistan (osp), beyond 2016 pakistan journal of ophthalmology, 2020, vol. 36 (3): 197-204 201 prof. mohammad moin chairman publication wing prof. nadeem hafeez butt chairman fund raising, professionalism and leadership development prof. asad aslam khan chairman, eye health care delivery and management members; 14 from across the country tors: • generate, invest and manage funds efficiently and effectively. • approve annual budget of the foundation. • allocate money for research, publications and education. • decide on the scope and purpose of ophthalmic research and education. • prioritize areas of research and development in terms of society’s current and future emerging needs. • ensure access, relevance and quality in education, research and patient care and treatment. • ensure regular annual financial audit. • quality assurance across the board. • ensure strong coordination between ophthalmic research, education, publication and health delivery and eye care management sectors. • ensure strong national and international linkages and collaboration. • ensure efficiency of the foundation through excellent management systems. • performance audit of all relevant sectors, education, research and development, hrd, publications, health care delivery and eye care management. • generate an annual report for osp central council. c: the oreef five task forces: 1. ophthalmic education (hrd). chairman: prof. hamid mahmood butt executive director: col. shahzad eight members from across the country tors: come out with smart strategies to adequately meet all the human resource needs in the form of an excellent eye care team, properly trained, wellmotivated, well mixed and properly distributed to ensure integrated, high quality comprehensive eye care delivery at all levels 15,16 . run all the affairs of the task force efficiently and effectively with honesty and integrity. prepare strategic annual plan for eye health education (with inbuilt mechanisms for monitoring and evaluation) in consultation of oreef board. (need, relevance (eye care team) & quality). prepare annual budget. get the budget approved. ensure national and international collaboration. prepare a comprehensive annual report for the board under the following heads. o a: internal & external financial audit report. o b: internal and external performance audit report. o c: internal quality assurance report. 2. ophthalmic research and development. chairman: prof. shahid wahab executive director: prof. mahfooz hussain eight members from across the country come out with smart strategies to adequatelymeet all the r&d needs of the society. run all the affairs of the task force efficiently and effectively with honesty and integrity. prepare strategic annual ophthalmic research implementation plan (with inbuilt mechanisms for monitoring and evaluation) in consultation of oreef board. ensure need, relevance, validity, quality and prioritization. types; basics, clinical, epidemiological, technological, clinical trials, quality of care and quality of life. prepare annual budget. haq’ health care access & quality index mohammad daud khan 202 pakistan journal of ophthalmology, 2020, vol. 36 (3): 197-204 get the budget approved. ensure national and international collaboration. prepare a comprehensive annual report for the board under the following heads. o internal & external financial audit report. o internal and external performance audit report. o internal quality assurance report. 3. publications chairman: prof. mohammad moin executive director: prof. tayyaba gul malik eight members from across the country come out with smart strategies to meet the publication needs of osp members, both quantitatively and qualitatively. make all-out effort to attain the highest standard of the journal. run all the affairs of the task force efficiently and effectively with honesty and integrity. prepare strategic annual ophthalmic research publication plan (with inbuilt mechanisms for monitoring and evaluation) in consultationwith oreef board. (need, relevance, quality and strong ethical values). prepare annual budget. get the budget approved. ensure national and international collaboration. prepare a comprehensive annual report for the board under the following heads. o a: internal financial audit report. o b: internal performance audit report. o c: internal quality assurance report. 4. eye health care delivery and management. chairman: prof. asad aslam khan executive director: dr. ali ayaz sadiq eight members from across the country • come out with smart strategies to work closely with government and non-government agencies at all levelsto ensure that; 1. the population’s current and future emerging needs in terms of access, cost and relevance are adequately met: 2. the system is well integrated, equitable, sustainable and of high quality. 3. it is efficiently connected through a robust referral system. 4. there is enough emphasis on health promotion, disease prevention and rehabilitation. • run all the affairs of the task force efficiently and effectively with honesty and integrity. • prepare strategic annual eye health care delivery and management plan (with inbuilt mechanisms for monitoring and evaluation) in consultation of oreef board. (needs, rights, relevance, quality and equitability). • prepare annual budget. • ensure national and international collaboration. • prepare a comprehensive annual report for the board under the following heads. • a: internal financial audit report. • b: internal performance audit report. • c: internal quality assurance report. 5. fund raising, professionalism, leadership development and national/international linkages and collaboration. chairman: prof. nadeem hafeez butt executive director: dr. qasim lateef chaudhry eight members from across the country come out with smart strategies to adequately meet the osp current and future emerging needs in the above mentioned areas with special emphasis on; o leadership development o promotion of ethics and professionalism in hrd, r&d and health care delivery system. negotiate with ministries of education, health and information to invest heavily in public health education, health promotion and disease ophthalmological society of pakistan (osp), beyond 2016 pakistan journal of ophthalmology, 2020, vol. 36 (3): 197-204 203 prevention through efficient utilization of all available media of information 17,18 . run all the affairs of the task force efficiently and effectively with honesty and integrity. prepare strategic annual plan for fund generation to adequately meet the task forces needs. prepare annual budget. get the budget approved. prepare a comprehensive annual report for the board under the following heads. a: internal financial audit report. b: internal performance audit report. c: internal quality assurance report. the oreef board will ensure that the task forces come out with strategic plans to ensure that; 1. all members of the foundation must have strong advocacy skills for negotiation with government and non-government developmental organizations for establishing equitable, sustainable and high quality patient friendly eye care services at all levels. 2. the board needs to pay special attention to health education, health promotion and disease prevention. 3. the board also needs to pay very special attention to rehabilitate people with severe visual impairment and those who are blind. 4. we make sure that the foundation has enough funds to meet the annual needs of the task forces in a sustainable manner. 5. all members of the eye health care delivery team are well trained, well-motivated, well mixed and optimally distributed. 6. apart from necessary knowledge and skills, the curricula for all cadres must have ample opportunities for teaching, training and evaluating professionalism. 7. the board must ensure strong emphasis on all aspect of research and development in ophthalmology including quality of care and quality of life. 8. all services must be integrated, people centered, comprehensive and sustainable. primary care must be converted to family care. there must be a robust referralsystem between all the three/four tier eye health care delivery system. 9. osp must have a strong national leadership development program (ldp). 10. service delivery must be regularly monitored and periodically evaluated through an efficient management system. 11. osp must be a strong partner in the national eye care program. osp therefore must ensure strong national linkages with; a. government of pakistan through ministries of health and education, pakistan medical and dental council (pmdc), pakistan medical research council (pmrc), higher education commission (hec), national and provincial universities and college of physicians and surgeons of pakistan (cpsp), the civil society, and the private and charitable health and educational institutions. b. international linkages and collaborations with institutions like who, unicef, british royal colleges, aao, regional ophthalmological societies, international council of ophthalmology, international universities and international agency for prevention of blindness(iapb) and c. national and international non-government developmental organizations. (ngdos & ingdos). d. expected national outcomes: • quality of ophthalmic medical education for all cadres and for all levels will improve. • relevance, validity, quantity and quality of ophthalmic research and development will also improve. • high quality integrated eye care services will become accessible, affordable and sustainable. • for people with marked visual impairment or blindness, strong rehabilitation services will become easily available, accessible and affordable. • quality of patient carewill improves at all levels. • patient level of satisfaction will improve. • high quality accessible eye care services will have a very positive impact on the quality of life of the affected individuals. mohammad daud khan 204 pakistan journal of ophthalmology, 2020, vol. 36 (3): 197-204 • prevalence and incidence of blindness and visual impairment will further drop down in pakistan. • high quality accessible eye care services will also have a very positive impact on national economy. • pakistan will become an epicenter for eye health tourism in the region. • pakistan will become a champion of who integrated; people centered eye health care (ipcec). references 1. regional health systems observatory-emro. available from: http://www.emro.who.int/pak/who-presence-inpakistan/. [accessed 9 june 2020]. 2. asia pacific academy of ophthalmology. apao congress 2007. available from: https://www.apaophth.org/apao-congress-2007/. [accessed 9 june 2020]. 3. memon s. pakistan national blindness survey. j pak med assoc. 1992: 196–198. 4. vision 2020, the who/ iapb initiative; https://www.iapb.org/vision-2020/[accessed 9 june 2020]. 5. gilbert c. the epidemiology of eye disease. br j vis impair. 1999; 17 (2): 79-82. https://doi.org/10.1177/026461969701700209 6. khan, m. the duke elder lecture: the challenge of equitable eye care in pakistan. eye. 2011; 25: 415–424. https://doi.org/10.1038/eye.2010.186 7. national program for prevention of blindness. 1st five year plan: 1994–1998. ministry of health, special education and social welfare: islamabad. 8. national program for prevention of blindness. 2nd five year plan: 1999–2003. ministry of health, special education and social welfare: islamabad. 9. jadoon mz, dineen b, bourne rr, et al. prevalence of blindness and visual impairment in pakistan: the pakistan national blindness and visual impairment survey. invest ophthalmol vis sci. 2006; 47 (11): 4749-4755. doi: 10.1167/iovs.06-0374. 10. pakistan population live available from: https://www.worldometers.info/worldpopulation/pakistan-population/[accessed 9 june 2020] 11. federal ministry of education. available from: https://en.wikipedia.org/wiki/education_in_pakistan. [accessed 9 june 2020] 12. pakistan demographic and health survey 2017 – 2018 key indicators report. 13. healthcare in pakistan. available from: https://en.wikipedia.org/wiki/healthcare_in_pakistan [accessed 10 june 2020] 14. wash: wash, sanitation and hygiene. available from:https://www.unicef.org/pakistan/wash-watersanitation-and-hygiene-0 [accessed 10 june 2020]. 15. sapkota yd. human resources for eye health in south asia, comm. eye health, 2018; 31 (102). 16. gullapali n. human resource development vision 2020: the right to sight, community eye health, 2000; vol. 13, no .35. 17. brennan md. the role of professionalism in clinical practice, medical education, biomedical research and health care administration. j transl int med. 2016; 4 (2): 64–65. 18. dissanayake mm. professionalism and ethics in ophthalmology. j coll ophthalmol sri lanka, 2014; 20: 71-73. .…  …. http://www.emro.who.int/pak/who-presence-in-pakistan/ http://www.emro.who.int/pak/who-presence-in-pakistan/ https://www.apaophth.org/apao-congress-2007/ https://www.iapb.org/vision-2020/ https://doi.org/10.1177%2f026461969701700209 https://www.worldometers.info/world-population/pakistan-population/ https://www.worldometers.info/world-population/pakistan-population/ https://en.wikipedia.org/wiki/education_in_pakistan http://www.nips.org.pk/abstract_files/pdhs%20-%202017-18%20key%20indicator%20report%20aug%202018.pdf http://www.nips.org.pk/abstract_files/pdhs%20-%202017-18%20key%20indicator%20report%20aug%202018.pdf https://en.wikipedia.org/wiki/healthcare_in_pakistan https://www.unicef.org/pakistan/wash-water-sanitation-and-hygiene-0 https://www.unicef.org/pakistan/wash-water-sanitation-and-hygiene-0 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5290899/ 214 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology original article correlation between central corneal thickness measurements using two different ultrasonic pachymeters sharmeen akram, zarksis h. anklesaria, khabir ahmad pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sharmeen akram section of ophthalmology, department of surgery, aga khan university, stadium road, p.o. box 3500, karachi 74800, sharmeen.akram@aku.edu …..……………………….. purpose: to assess correlation between central corneal thickness measurements using two different ultrasonic pachymeters. material and methods: this prospective study involved normal subjects aged 16 to 45 years. central corneal thickness was measured in 47 eyes by two ultrasonic pachymeters – tomey sp – 100 and sonomed 300 ap. correlations between cct measurements assessed by the two pachymeters were tested by pearson correlation. results: forty seven eyes were included in the study. the mean (± sd) age of the subjects was 27.79 years (± 6.88).the mean (± sd) tomey pachymeter cct was 536.45 m (34.37) and the mean (sd) sonomed cct was 540.64 m (33.48).cct measurements by the two modalities were very strongly correlated (r = 0.98; p <0.0001). conclusions: in healthy individuals, tomey pachymeter measurements of corneal thickness were highly correlated with those obtained using sonomed pachymeter, and hence the two may be used interchangeably. pplanation ultrasound (us) pachymetry is the gold standard for corneal thickness (cct) measurement, which is an important step in ophthalmic evaluations prior to refractive procedures such as laser in situ keratomelisus (lasik)1. this approach uses the ultrasonic principle to determine cct and requires both topical anesthesia and contact of the probe with the cornea. in the literature, a variety of methods of measuring cct have been described2. these include contact methods, such as ultrasound and confocal microscopy, or noncontact methods such as optical pachymetry with scheimpflug cameras, optical coherence tomography and optical coherence pachymetry. in this study, we aimed to assess the correlation between cct measurements using two different ultrasonic pachymeters (sonomed pachymeter 300 ap and tomey sp-100 handy pachymeter) in normal subjects. material and methods this prospective study was conducted at laser vision center, karachi during june 2012 to 30 jan 2013. healthy individuals aged 16 to 45 years with refractive errors were included in the study. those with corneal abnormalities like corneal scars were excluded. after informed consent, cct was measured. all readings were taken with tomey sp-100 handy pachymeter first followed by sonomed pachymeter 300 ap with an interval of 24 hours. the specifications of both pachymeters are shown in table 1. for both machines measurements, the cornea was anesthetized with topical proparacaine hydrochloride 1% (alcaine). the calibrated us probe was used to obtain 5 measurements from the central cornea. the highest and the lowest values were excluded, and the mean of the remaining 3 was used for analysis. data were entered and analyzed using spss v.19 (ibm corp, armonk, ny). correlations between a correlation between central corneal thickness measurements using two different pachymeters pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 215 sonomed pachymeter 300 ap and tomey sp – 100 handy pachymeter cct measurements were tested by pearson correlation. to assess if the two methods may be used interchangeably, bland-altman analysis was performed (figure 2). a p value < 0.05 was considered statistically significant. results forty seven eyes (20 male eye and 27 female eyes) of 24 patients were included in the study. the mean (± sd) age of the subjects was 27.79 years (± 6.88). of the selected eyes, 23 (48.9%) were right and 24 (51.1%) were left. the mean (± sd) tomey pachymeter cct was 536.45μm (34.37) and the mean (sd) sonomed cct was 540.64μm (33.48). as shown in table 2, cct measurements by the two pachymeters were very strongly correlated (r = 0.98, 95% ci 0.97, 0.9; p <0.0001). bland-altman plot showed that the average discrepancy between the two pachymeters was not large enough to be important. tomey s o n o m e d 400 450 500 550 600 650 450 500 550 600 650 fig. 1: scatter plot of cct measurements between ``sonomed 300 ap and tomey sp-100 500 550 600 650 -20 -10 0 10 20 tomey-sonomed average (µ) t o m e y -s o n o m e d d if fe re n c e (µ ) fig. 2: bland – altman plot of the difference in cct measurements versus average cct measurements discussion to the best of our knowledge, this is the first study to assess the correlation between cct measurements using two different ultrasonic pachymeters (sonomed pachymeter 300 ap and tomey sp-100 handy pachymeter) in normal subjects in a pakistani population. our study showed that both the measurements were highly correlated and hence the two pachymeters may be used interchangeably. comparative data is limited as most previous studies have compared pachymeters that use different principles (ultrasonic and optical) to use to measure cct. accurate measurement of cct is important for detection, evaluation, and treatment of many eye conditions. key diagnostic and therapeutic decisions are made based on these readings. accurate sharmeen akram, et al 216 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology measurement of cct is also important before refractive procedures to minimize the risk of iatrogenic keratectasia which is one of the most dreaded complications of lasik procedure3. as mentioned earlier both contact and non-contact methods of measuring cct have been described including ultrasonic pachymetry, optical pachymetry by rotating scheimpflug camera, corneal con focal microscopy, and oct4,5. studies have shown difference in measurements between optical and ultrasonic pachymetry which is currently considered the gold standard6-8. however, this kind of contact examination still has some problems, including the need to anesthetize the cornea, corneal indentation during measurement, and corneal epithelial damage and cross infections9. despite these problems, the measurements of cct by means of ultrasonic pachymetry are very accurate and highly reproducible, with a low intra-observer and interobserver and variability. hence it is still the most common method for measuring corneal thickness. although several different models of ultrasonic pachymeters are available, they all work on the same principle, are inexpensive and easy to use. the two most commonly used such pachymeters in our setting are tomey and sonomed and we conducted this study to see if the two could be used interchangeably. our results showed that readings of the two pachymeters were highly correlated. conclusion in healthy individuals, there is a high co-relation between cct measurements of tomey sp-100 and sonomed 300 ap pachymeters, and hence the two may be used interchangeably. author’s affiliation dr. sharmeen akram section of ophthalmology, aga khan university department of surgery, karachi dr. zarksis h. anklesaria laser vision center dr. s. d. anklesaria eye clinic and hospital, karachi dr. khabir ahmad section of ophthalmology, aga khan university department of surgery, karachi references 1. beutelspacher sc, serbecic n, scheuerle af. assessment of central corneal thickness using oct, ultrasound, optical low coherence reflectometry and scheimpflug pachymetry. european journal of ophthalmology. 2011; 21: 132-7. 2. grewal ds, brar gs, grewal sp. assessment of central corneal thickness in normal, keratoconus, and post-laser in situ keratomileusis eyes using scheimpflug imaging, spectral domain optical coherence tomography, and ultrasound pachymetry. journal of cataract and refractive surgery 2010; 36: 954-64. 3. randleman jb, russell b, ward ma, thompson kp, stulting rd. risk factors and prognosis for corneal ectasia after lasik. ophthalmology. 2003; 110: 267-75. 4. foster cs, azar dt, dohlman ch, editors. smolin and thoft's: the cornea, scientific foundations and clinical practice. 4th ed. philadelphia: lippincott williams & wilkins; 2005. 5. krachmer jh, mannis mj, holland ej. cornea 2nd edition. philadelphia: elsevier mosby, 2005. 6. chaidaroon w. the comparison of corneal thickness measurement: ultrasound versus optical methods. journal of the medical association of thailand. 2003; 86: 462-6. 7. chakrabarti hs, craig jp, brahma a, malik ty, mcghee cn. comparison of corneal thickness measurements using ultrasound and orbscan slitscanning topography in normal and post-lasik eyes. journal of cataract and refractive surgery. 2001; 27: 18238. 8. buehl w, stojanac d, sacu s, drexler w, findl o. comparison of three methods of measuring corneal thickness and anterior chamber depth. american journal of ophthalmology. 2006; 141: 7-12. 9. solomon od. corneal indentation during ultrasonic pachymetry. cornea. 1999; 18: 214-5. 244 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology letter to the editor pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . dr. daljit singh (amritsar) daljits1@gmail.com i have been working on the fluid movement in the anterior segment through lymphatics. the standard teaching is that there are no lymphatics in the eye. i wish to start my association with pjo by attaching a self explanatory picture of the limbus showing lymphatics. if the ophthalmologists start looking at the limbus under high power of slit lamp microscope, they shall get a gold mine of information on lymphatics. once you understand their importance, you shall not like to hurt them during any surgery especially during glaucoma surgery. during my recent visit to pakistan, i had an opportunity to go to fauji hospital in rawalpindi and mughal hospital in lahore. we do not have a single charitable hospital of such grandeur in our punjab, in public or private sector. there must be many others too, which i have not seen. i saw the surgeons perform in excellent operation theater environment, which is superior to ours. my congratulations to pakistani ophthalmologists who made that possible. reply: it is interesting to know that you are working on fluid movements in the anterior segment through lymphatics. we would suggest you to publish your article in pjo. so that our readers become aware of your research. we appreciate your interest and for your views for pakistani hospitals and doctors. prof. shahid wahab editor in chief (advisor) pakistan journal of ophthalmology aims to improve quality and standard of the journal to promote research in the field of ophthalmology and in this regard pjo invites our valuable readers to submit letter to editor with their ideas, suggestions and positive scientific criticism with reference not more than 300 words long for possible publication. pakistan journal of ophthalmology reserves the right to edit letters and may publish them in upcoming issues in print and electronic media (website). submission of a letter implies consent for publication unless otherwise indicated in the letter. all letters must include the correspondent's name and address and are subject to editing to meet style, clarity, and space requirements. we shall highly appreciate if letters may be sent to pjoosp@gmail.com. please include “letter to editor” in the subject line and address your typed letter to: editor, osp house, 4 – a lda flats lawrence road, lahore – pakistan. please include your name and address. mailto:daljits1@gmail.com mailto:pjoosp@gmail.com pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 77 original article limbal relaxing incision during phacoemulsification for the correction of astigmatism mehvash hussain, mohammad muneer quraishy pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mehvash hussain doctors plaza room no 542 karachi …..……………………….. purpose: to determine the difference in mean post-operative astigmatism of patients having limbal relaxing incisions with phacoemulsification as compared to phacoemulsification alone for the correction of pre-existing corneal astigmatism. material and methods: this study was conducted in the civil hospital karachi eye unit ii, from 1 st december 2009 1 st december 2010, for duration of 12 months. patients enlisted for phacoemulsification cataract surgery with coexisting astigmatism were recruited and divided into two groups. eyes that underwent cataract surgery with limbal relaxing incisions (cataract lri group) and eyes that underwent cataract surgery only (control group). all patients underwent a comprehensive baseline ophthalmic examination that included uncorrected visual acuity (ucva) and best corrected visual acuity (bcva), manifest refraction, anterior segment slit – lamp examination, 90 d examination of fundus, keratometry and ultrasound biometry. patients were evaluated at 1 st day, 1 st month and 3 rd month postoperatively post-operative examination included bcva, anterior segment slit-lamp microscopy and keratometry. the data thus obtained was analyzed on spss 17. results: a total of 50 eyes (29 right eyes and 21 left eyes) of 44 patients were included in the study. mean patients age was 61 yrs ± 11.3 yrs (range: 30 to 80) in the lri group and 57 yrs ± 11.8 yrs (range 30 to 80) in the control group. data analysis demonstrated statistically significant reduction in the mean postoperative astigmatism in the lri eyes from 1.78 ± 0.81 d@125° (range: 0.75 to 3.70 d) preoperatively to 0.73 ± 0.71 d @ 130° (range: 0.0 to 2.70) in the 3 rd postoperative month as compared to control group from 1.28 ± 0.41 d @ 145° (range: 0.75 to 1.97 d) preoperatively to 1.17 ± 0.57 d @ 144° (range: 0.10 to 2.30) p-value 0.021. there were no intraoperative complications or postoperative subjective complaints (such as halo or glare) in our patients. conclusion: limbal relaxing incisions performed during phacoemulsification surgery appear to be safe and effective procedure to reduce pre-existing corneal astigmatism. key words: limbal relaxing incision, phacoemulsification, astigmatism. ataract surgery is the most successful and most commonly performed ophthalmic procedure in the modern medical world.1,2 an increasingly important goal of modern cataract and lens implantation surgery is to obtain the most desirable refractive outcomes for the patients. as this trend continues, we are faced with addressing the obstacles to spectacle independence. there are an estimated 15 – 20% of individuals with greater than 1.5d of cylinder and a much higher percentage with less than 1.5 d of cylinder.3 novel techniques of cataract surgery to correct preexisting astigmatism are presented. hence, the uncorrected visual outcome of cataract patients has been improved and better c mehvash hussain, et al 78 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology refractive correction is possible now.4,5 in order to achieve better visual results, the effect of pre-operative corneal astigmatism should be minimized through one of the several techniques including placement of clear corneal incisions(cci), limbal relaxing incisions (lri), toric intraocular lens implants (iol) or postoperative vision correction by ablative refractive surgery by excimer laser; each with its own advantages and disadvantages.6-8 herein, we report the efficacy of limbal relaxing incisions (lris) for correction of pre-existing corneal astigmatism during phacoemulsification. material and methods this study was conducted at the department of ophthalmology, dow university of health sciences, civil hospital karachi from 1st december 2009 – 1st december 2010, for duration of 12 months. study approval was obtained from the ethics committee of dow university of health sciences and informed consent was obtained from all study participants. patients admitted in the inpatient department of ophthalmology unit 11 civil hospital having cataract and co-existing astigmatism of 0.75 d to 3.75 d were selected and randomly divided into two groups. inclusion criteria were all patients undergoing cataract surgery from all age groups and from both sexes, patients having pre-existing astigmatism 1 to 3.75 d. exclusion criteria was patients having any corneal opacity, degenerations or dystrophies, any retinal vascular diseases or retinal detachment, any macular pathology, glaucoma or patients with any other ocular co-morbidity. eyes that underwent cataract surgery with limbal relaxing incisions (cataract lri group) and eyes that underwent cataract surgery only (control group). fifty eyes of forty four patients (mean age 59 years ± 11.6 range 30 to 80 years) were included. youngest patient was 30 years while the oldest being 80 years of age. all patients underwent a comprehensive baseline ophthalmic examination that included uncorrected visual acuity (ucva) and best corrected visual acuity (bcva), manifest refraction, anterior segment slitlamp examination, 90 d examination of fundus, keratometry and ultrasound biometry. patients were evaluated at 1st day, 1st month and 3rd month postoperatively post-operative examination included ucva, anterior segment slit-lamp microscopy and keratometry. all surgeries were performed by one surgeon. srk-t formula was used for all patients for iol power calculation. cataract surgery was performed under topical anesthesia. acrylic foldable iols (alcon, sa 60 at, usa) were implanted through a 2.75 mm temporal clear corneal incision in r eyes and nasal in l eyes without enlarging the incision using the injector for all eyes. in the cataract lri group before surgery, the steepest meridian was marked with the patient in supine position based on corneal topography on which lris were made according to the nichamin nomogram (table 2). all lris were placed inside the surgical limbus at a depth of 600 μm with lri knife determined for 600 μm. for patients with against-the-rule astigmatism the temporal hinge incision for phacoemulsification was oriented to align with placement of the lri. a second lri was performed on the nasal side before phacoemulsification. after iol implantation and before removal of viscoelastic material, the original minimal lri was extended according to the nomogram. in eyes with the rule astigmatism, paired lris were placed on the steep meridian before phacoemulsification as dictated by the nomogram. the collected data was analyzed by using spss version 17.0. the results of the study were presented through tables. the success of the procedure was evaluated by comparing preand post-operative keratometry readings. effectiveness was analysed by comparing the arithmetic mean and standard deviation of the post-operative keratometric astigmatism between the groups. independent sample t-test was used to check the difference between the two groups with level of significance of ≤ 0.5. all post-operative complications and subjective symptoms were recorded. stratification was done to age and gender to see the impact of these on the outcome. results lri with phacoemulsification was performed on 25 eyes whereas 25 eyes underwent phacoemulsification alone. total of 50 eyes were included (29 right eyes and 21 left eyes) of 44 patients. there was no significant difference in the mean age of the patients in limbal relaxing incision during phacoemulsification for the correction of astigmatism pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 79 the two groups. mean age was 61 years ± 11.3 yrs (range: 30 to 80) in the lri group and 57 years ± 11.8 years (range 30 to 80) in the control group. 0 2 4 6 8 10 12 14 16 female male lri control fig. 1: gender distribution in cases (n = 50). out of 25 patients of lri group nine (2.25%) were females and sixteen (4%) were males whereas in the control group sixteen (4%) were females and nine (2.25%) were males. data analysis demonstrated statistically significant reduction in the mean post-operative astigmatism in the lri eyes as compared to control group. mean decrease in the lri group was 1.04 ± 0.87 d while in the control group was 0.10 ± 0.53 d. lri group showed reduction from 1.78 ± 0.81 d @ 1250 (range: 0.75 to 3.70 d) preoperatively to 0.73 ± 0.71 d @ 130° (range: 0.0 to 2.70 d) in the 3rd postoperative month whereas the control group showed reduction from 1.28 ± 0.41 d @ 145° (range: 0.75 to 1.97 d) preoperatively to 1.17 ± 0.57 d @ 144° (range: 0.10 to 2.30 d) in the 3rd postoperative month p-value 0.021. there were no intraoperative complications or postoperative subjective complaints (such as halo or glare) in our patients. discussion visual recovery and satisfaction of patients who underwent phacoemulsification is closely related to the appropriate iol power calculation and management of postoperative astigmatism.9-11 among patients undergoing cataract surgery, 15 20% have significant corneal astigmatism ranging from 1 to 3 d. with the introduction of aspherical intraocular lens (iols) as an integral part of cataract surgery, better formulae for iol power calculation, and eliminating lenticular astigmatism by removing the lens by cataract extraction, the major source of postoperative refractive astigmatism is the corneal astigmatism. there are several options to reduce the preoperative astigmatism including intraoperative relaxing incisions, toric iol implantation or postoperative vision correction by ablative refractive surgery by excimer laser each with its own benefits and drawbacks. toric iols are rather expensive. moreover, if postoperative rotation of the iol occurs, there would be a significant induced astigmatism. excimer laser vision correction after cataract surgery needs an additional operation with high expenses, possible complications and limitations in patients with thin cornea.12-13 lris have been used to correct preexisting astigmatism at the time of cataract surgery. simultaneously, one can benefit from lower costs and easy performance with minimal learning curve, without overcorrection. however, the predictability, stability and range of correction are rather limited. according to gills and guyton lris are more effective in eyes with low to moderate, rather than high astigmatism. lris also appear to cause less distortion and irregularity at the limbus. they can provide more rapid postoperative visual acuity (va) as compared to clear corneal incisions with less risk of glare and discomfort. in this study, the use of limbal relaxing incisions during phacoemulsification significantly reduced preexisting corneal astigmatism. astigmatism correction is evaluated by comparing the pre-operative and postoperative mean keratometry effectiveness of lri’s was evaluated by using mean and standard deviation of the post-operative astigmatism between the groups. based on the results obtained we reject the null hypothesis which stated that there was no difference in the mean post-operative astigmatism of patients having lri with phacoemulsification as compared to phacoemulsification alone. phacoemulsification and lens implantation were performed through a 2.75mm temporal incision to mehvash hussain, et al 80 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology table 2: nichamin nomogram. limbal relaxing incision during phacoemulsification for the correction of astigmatism pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 81 avoid inducing astigmatism. according to fine14 a temporal incision might minimize the astigmatism induced by phacoemulsification due to a number of factors such as an incision architecture that maximizes the distance from the limbus to the central cornea, the lack of action of the superior rectus muscle, and the alignment of the incision with the action of superior eyelid and gravitational pull. induced astigmatism is likely related to the creation and manipulation of the incision during surgery.15 induction of astigmatism may be averted by prevention of thermal damage to the incision by the phaco tip and the correct iol implantation.16-19 our study demonstrated that use of lris during phacoemulsification significantly reduces corneal astigmatism; however, there was a trend for under correction. under correction was not uncommon in previous reports.20-21 budak et al, studied 22 patients. they found a 44% reduction of astigmatism in eyes treated with lri during phacoemulsification using the gills nomogram.22 in another study of 12 eyes of 11 patients that underwent phacoemulsification and limbal relaxing incision budak et al, found 75% of the eyes were under corrected. in study of carvalho et al,9 a statistically significant reduction in the mean topographic astigmatism was seen in the cataract lri eyes from 1.93 ± 0.58 d preoperatively to 1.02 ± 0.60 d 6 months postoperatively (p < 0.05). multiple factors might cause under correction of astigmatism in patients who are treated with phacoemulsification and lris. we minimized the surgeon factor by performing all operations by only one surgeon. another cause may be the improper position of blade (oblique incision rather than perpendicular incision on the limbus, that may result in the wrong depth causing under correction).23 under correction may be related to area of limbal incision that is far from the corneal center.24 however, more central clear corneal incisions may cause more glare and higher order aberrations for the patients. in summary, when combined with the accurate identification of the steep meridian of corneal astigmatism, limbal relaxing incisions are safe and efficacious for correcting corneal astigmatism during phacoemulsification. conclusion in our study 25 eyes that were operated with lris during phacoemulsification surgery. limbal relaxing incisions appear to be safe and fairly effective to correct mild to moderate amounts of corneal astigmatism. under correction is a common limitation that may be further managed by modified nomograms in future studies adjusted by the surgeon factors. apart from the patient age, multiple factors including ethnicity, gender, corneal limbal thickness, course of postoperative steroid regimen and surgeon factors should be considered for adjustment of future nomograms. it seems that lri incisions cannot fully correct but would cause more acceptable reduction in the preoperative corneal astigmatism. author’s affiliation dr. mehvash hussain doctors plaza, karachi prof. mohammad muneer quraishy civil hospital, karachi references 1. kershner rm. refractive cataract surgery. curr opin ophthalmol. 1998; 9: 46-54. 2. nichamin ld. treating astigmatism at the time of cataract surgery. curr opin ophthalmol. 2003; 14: 35-8. 3. hoffer kj. biometry of 7,500 cataractous eyes. am j ophthalmol. 1980; 90: 360-8. 4. nichamin ld. astigmatism control. ophthalmol clin north am. 2006; 19: 485-93. 5. alastrué v, calvo b, peña e, doblaré m. biomechanical modeling of refractive corneal surgery. j biomech eng. 2006; 128: 150-60. 6. morlet n, minassian d, dart j. astigmatism and the analysis of its surgical correction. br j ophthalmol. 2001; 85: 1127-38. 7. kaufmann c, peter j, ooi k , phipps s, cooper p, goggin m, et al. limbal relaxing incisions versus on axis incision to reduce corneal astimatism at the time of cataract surgery. j cataract refract surg. 2005; 31: 22615. 8. carvelho mj, suzuki sh, freitas ll, branco bc, schor p, lima al. limbal relaxing incision to correct corneal astigmatism during phacoemulsification. j refract surg. 2007; 23: 499-504. 9. oshika t, yoshitomi f, fukuyama m, hara y, shimokawa s, shiwa t, sakabe i. radial keratotomy to treat myopic refractive error after cataract surgery. j cataract refract surg. 1999; 25: 50-5. 10. packer m, fine ih, hoffman rs, coffman pg, brown lk. immersion a-scan compared with partial coherence interferometry: outcomes analysis. j cataract refract surg. 2002; 28: 239-42. http://www.ncbi.nlm.nih.gov/pubmed?term=%22hara%20y%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22shimokawa%20s%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22shiwa%20t%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22sakabe%20i%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22coffman%20pg%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22brown%20lk%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22brown%20lk%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22brown%20lk%22%5bauthor%5d mehvash hussain, et al 82 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology 11. murphy c, tuft sj, minassian dc. refractive error and visual outcome after cataract extraction. j cataract refract surg. 2002; 28: 62-6. 12. bayramlar hh, daglioglu mc, borazan m. limbal relaxing incisions for primary mixed astigmatism and mixed astigmatism after cataract surgery. j cataract refract surg. 2003; 29: 723-8. 13. gills jp, gayton jl. reducing pre-existing astigmatism. in: gills jp, fenzle r, martin rg, eds, cataract surgery; the state of the art. thorofare, nj, slack. 1998; 53-66. 14. fine ih. architecture and construction of a self sealing incision for cataract surgery . j cataract refract surg. 1991; 17: 672-6. 15. steinert rf, deacon j. enlargement of incision width during phacoemulsification and folded intraocular lens implant surgery. opthalmology. 1996; 103: 220-5. 16. majid ma, sharma mk, harding sp. corneosclral burn during phacoemulsification surgery. j cataract refract surg. 1998; 24: 1413-5. 17. sugar a, schertzer rm. clinical course of phacoemulsification wound burns. j cataract refract surg. 1999; 25: 688-92. 18. mamalis n. incision width after phacoemulsification with foldable intraocular lenses. j cataract refract surg. 2000; 26: 237-41. 19. kohen t, lambert rj, koch dd. insicion sizes for foldable intraocular lenses. ophthalmol. 1997; 104: 127786. 20. osher rh. paired transverse relaxing keratotomy: a combined technique for reducing astigmatism. j cataract refract surg. 1989; 15: 32-7. 21. oshika t, shimazaki j, yoshitomi f, oki k, sakabe i, matsuda s, et al. arcuate keratotomy to treat corneal astigmatism after cataract surgery: a prospective evaluation of predictability and effectiveness. ophthalmology. 1998; 105: 2012-6. 22. budak k, yilmaz g, aslan bs, duman s. limbal relaxing incisions in congenital astigmatism: 6 month follow-up. j cataract refract surg. 2001; 27: 715-9. 23. akura j, matsuura k, hatta s, otsuka k, kaneda s. a new concept for the correction of astigmatism: full-arc, depth – dependent astigmatic keratotomy. ophthalmology, 2000; 107: 95-104. 24. waring go 3rd, lynn mj, mcdonnell pj. results of the prospective evaluation of radial keratotomy (perk) study 10 years after surgery. arch opthalmol. 1994; 112: 1298-308. http://www.ncbi.nlm.nih.gov/pubmed?term=%22oki%20k%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22sakabe%20i%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22otsuka%20k%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22kaneda%20s%22%5bauthor%5d microsoft word 14. yasir iqbal malik mm 258 pakistan journal of ophthalmology, 2020, vol. 36 (3): 258-262 original article association of serum vitamin d levels with senile cataract yasir iqbal malik1, aqsa malik2, atteya zaman3, rabia shabbir4, masooma talib5 1,5watim medical college, rawat, islamabad, 2mohtarma benazir bhutto shaheed medical college mirpur-ajk, 3federal medical and dental college, islamabad, 4hitec medical and dental college, wah cantt, abstract purpose: to determine vitamin d levels in patients of senile cataract and compare them with age related control patients. study design: case control observational study. place and duration of study: naseer memorial hospital, dadhyal azad kashmir from march 2016 to june 2017. material and methods: three hundred patients were selected and two groups were designed for the study. group i included patients having senile cataract of any morphological type. the inclusion criteria were age of 50 years or more. group ii was control in which age matched controls that had no cataract were enrolled from the outpatient clinic. vitamin d levels were measured by radioimmunoassay technique with diasorin sr® kit following the user’s manual. the collected data was entered in the statistical package for social sciences (spss) version 21 for analysis. independent t –test was used to determine the significant difference of means between controls and patients. p value less than 0.05 was considered as significant. results: group i consisted of 65.33 % females and 35.66% males whereas in group ii were 68% females and 32% males. the mean age of patients was 63.20 ± 9.5 years in group i and 65.5 ± 8.9 years in group ii. statistically no significant difference (p>0.05) was found between mean vitamin d levels in cataract patients (25.95 ± 3.75 ng/ml vs. and age matched control (29.02 ± 5.11ng/ml). conclusion: there was no statistically significant difference between the vitamin d levels of cataract patients and the age matched controls. key words: vitamin d, cataract, oxidative stress. how to cite this article: malik yi, malik a, zaman a, shabbir r, bilal m. association of vitamin d levels with senile cataract. pak j ophthalmol. 2020; 36 (3): 258-262. doi: 10.36351/pjo.v36i3.1037 introduction cataract is a one of the leading causes of reversible blindness and is estimated to be affecting 94 million people of the world population1. in pakistan, it was the correspondence to: yasir iqbal malik watim medical college, rawat, islamabad email: yazeriqbal@gmail.com received: april 13, 2020 revised: may 4, 2020 accepted: may 4, 2020 leading cause of severe visual loss in year 2017 according to the statistics of the global burden of disease (gbd)2. the treatment of cataract is surgical removal with implantation of artificial intraocular lens, which is the commonest procedure being performed in all ophthalmic centers.3 cataract is defined as any opacification or cloudiness in the otherwise clear crystalline ocular lens. the normal lens is made up of water and protein fibers and when these proteins clump together an opacity is formed which affects the lens ability to association of serum vitamin d levels with senile cataract pakistan journal of ophthalmology, 2020, vol. 36 (3): 258-262 259 refract light. the causes of cataract are multiple. it can be senile due to normal aging process or secondary to trauma, drugs, ocular diseases, systemic diseases, ultraviolet light exposure and oxidative stress4. alcohol abuse, smoking and obesity lead to an increase in oxidative stress and this increase in oxidative stress is a preventable cause of cataract5. like all cellular cytoplasm of the body, oxidation is being inhibited in the lens and it is kept in a reduced environment but it can be oxidized6. ultraviolet light absorption from sunlight can create free radicals such as hydrogen peroxide and hydroxyl radical leading to increased oxidative damage and cataract formation. this free radical formation can be prevented by nutritional factors such as vitamin c, vitamin e and xanthine6. vitamin d, once a vitamin, has now been declared as a hormone due to its proven anti-inflammatory properties and immune regulation. researchers have found association of vitamin d in cardiovascular diseases, neurogenesis, autoimmune disorders and infectious diseases in preventing oxidative stress7. due these properties researchers have debated its role in prevention of senile cataract by preventing oxidative stress. the source of vitamin d is dual. most of it is synthesized in the skin after being exposed to ultraviolet light and the rest is from dietary source8. vitamin d after absorption in the intestines and synthesis by skin is converted into 25(oh) d in the liver which is the measuring parameter of vitamin d. the subject is considered to be vitamin d deficient if the serum 25 (oh) d levels are less than 30ng/ml8. to find out whether serumvitamin d levels are related tocataract formation or not we measured vitamin d levels in patients of senile cataract and compared them with age-matched controls. material and methods this comparative prospective observational study was conducted at naseer memorial hospital, dadyal, azad jammu and kashmir during a period of one year and three months after approval from the ethical review committee and following the guidelines of declaration of helsinki. three hundred patients were selected by convenient non-probability sampling technique and two groups were designed for the study. group i included patients having senile cataract of any morphological type. the inclusion criterion was age of 50 years or older and of any gender. the exclusion criteria were history of smoking, alcohol use, cataract secondary to ocular or systemic disease, having glaucoma or any other retinal pathology, history of ocular surgery, oral steroid or calcium supplements use, any history of ocular trauma or any systemic disease. group ii was control in which age matched subjects who had no cataract were enrolled from the outpatient clinic having the same exclusion criteria. the patients underwent complete eye examination like visual acuity assessment with the snellen chart, pupillary reflexes, slit lamp examination, intraocular pressure measurement with applanation tonometry and detailed biomicroscopic fundoscopy. cataract diagnosis and grading was done by lens opacity classification system (locs) on slit lamp using retroillumination technique. for the assessment of vitamin d levels 3 ml peripheral venous blood sample was collected from 300 patients of both groups in the laboratory. serum was obtained after centrifugation of whole blood, after clot formation had taken place at 3000 rpm for 5 minutes and were stored at −20 °c for further analysis. 25-oh d levels were measured by radioimmunoassay technique with diasorin sr® kit following the user’s manual. the collected data was entered in the statistical package for social sciences (spss) version 21 for analysis. gender was expressed as percentages and frequency whereas numerical variable e.g. age was expressed as mean and standard deviation. independent t–test was used to determine the significant difference of means between controls and patients. p value less than 0.05 was considered significant. results the study was completed in 1 year and 3 months. during the study period 24,759 patients were examined out of which 1,874 (7.5%) patients were diagnosed with cataract. cataract patients consisted of 956 (51.01%) males with mean age of 57 ± 11.4 years and 918 (48.9%) females with mean age of 55 ± 8.4 years. for the study one hundred and fifty patients, fulfilling the inclusion and exclusion criteria, were included in the group i from these diagnosed patients having cataract. in group i, we found cataract involving the right eye in 29.3% males vs. 22.6% females. bilateral yasir iqbal malik, et al 260 pakistan journal of ophthalmology, 2020, vol. 36 (3): 258-262 cataract was seen in 16.8% males and 8% females. morphological classification revealed that majority of the patients had nuclear cataract (37.3% in males vs. 34.6% in females) followed by posterior subcapsular cataract (8% in males vs. 13.3% in females) with no significant statistical difference (table 1). group i consisted of 65.33% females and 35.66% males table 1: morphological types of cataract in group i (n = 150). cataract males females type cortical 4% 2.6% nuclear 37.3% 34.6% posterior subcapsular 8% 13.3% unilateral right 29.3% 22.6% left 8% 15.3% bilateral 16.8% 8% whereas in group ii there were 68% females and 32% males. the mean age of patients was 63.20 ± 9.5 years in group i and 65.5 ± 8.9 years in group ii. patients in both groups were matched for age and gender revealing no significant difference (table 2). table 2: descriptive statistics of cataract and control group. group i (cataract) n = 150 group ii (control) n = 150 p value mean age (years ± sd) 63.20 ± 9.5 65.5 ± 8.9 0.94 gender female 65.33% 68% 0.414 male 34.66% 32% 0.617 serum vitamin d levels (ng/ml) 25.95 ± 3.75 29.02 ± 5.11 0.921 statistically no significant difference was found between mean 25-oh d levels in cataract patients (25.95 ± 3.75ng/ ml vs. 29.02 ± 5.11 ng /ml) and age matched control. discussion cataract has a high reported incidence worldwide which has been related to oxidative stress induced by light with photochemical generation of reactive oxygen species such as superoxide, hydrogen peroxide and hydroxyl radical.9 we found frequency of cataract as 7.5% but during a survey it has been reported as high as 20.9% in pakistan1. similarly, in another study, cataract was reported as 4% and 50% in the ages of 50-65 years and 75 – 85 years respectively2. cataract not only makes the patient himself handicapped but adds people to the non functional community. it is a burden for the developing world for its increasing incidence10. we found bilateral cataract in 16.8% males and 8% females compared to a study conducted in chakwal district reporting prevalence of bilateral cataract in 5.1% of the study group11. similarly, different prevalence of cataract has been reported according to morphology. naseer1 reported posterior sub capsular cataracts as being the most common in 56.8% of the study group, followed by nuclear cataract in 26.4% and cortical cataract in 16.8% whereas we found nuclear cataract (37.3% in males vs. 34.6% in females) followed by posterior subcapsular cataract (8% in males vs. 13.3% in females). the variation in frequency of cataract may be attributed to variation in sample sizes and settings of the studies. this was endorsed by a study by sasaki h et al12 who reported more percentage of cortical cataract in northern region of japan and china while nuclear cataracts predominating in the southern regions. according to the guidelines of the endocrine society, serum vitamin d levels less than 30 ng/dl is declared as vitamin d deficiency13. in our study we found vitamin d levels as 25.95 ± 3.75 ng/ml in patients with cataract and as 29.02 ± 5.11ng/ml in the control group falling in the vitamin d deficiency group. this finding is in correspondence to reports by other researches done in our settings. according to mansoor s et al14 90% of the employees in a tertiary care unit had low vitamin d levels in his study. iqbal r et al15 also reported prevalence of vitamin d deficiency in 74% of the study group. this deficiency in vitamin d levels has been equated to a worldwide epidemic and has been postulated to be due to decrease in outdoor activities and sun exposed work professions16. furthermore, people have become more inclined to television, computer usage and deliberate sun prevention16. vitamin d, a new revolution in hormone therapy, is a breakthrough for the medical community. numerous systemic diseases of the body are proven to be associated with vitamin d levels like the skeletal system, teeth and the cardiovascular system.17 vitamin d has been detected in aqueous and vitreous humor of the eye and because of its antioxidant properties by preventing free radical formation, it has been associated to uveitis18, macular degeneration19 and dry eye syndrome20. researchers are exploring association association of serum vitamin d levels with senile cataract pakistan journal of ophthalmology, 2020, vol. 36 (3): 258-262 261 of vitamin d with cataract formation but there are conflicting results. in our study we found no statistically significant difference in levels of vitamin d in control and cataract patients and found no role of vitamin d in cataract development. this is in accordance to the findings of rao p et al21who also stated that vitamin d levels were not related to cataract. on the other hand, park s22 reported that serum vitamin d levels were inversely associated to the risk of developing cataract. similarly, jee d23 reported that age related cataracts were significantly decreased in patients with high serum vitamin d levels. supporters of vitamin d deficiency leading to cataract have postulated some pathways. according to brown cj16 vitamin d regulating systemic calcium also regulates calcium levels in aqueous humor. vitamin d levels were negatively correlated to parathyroid. cataract is associated with parathyroid hormone disorders; therefore, when vitamin d levels decrease, parathyroid hormone levels are increased leading to cataract formation.16 another pathway is disruption of calcium homeostasis caused by vitamin d deficiency producing lens opacification by lens protein aggregation and abnormal differentiation of lens epithelial cells into fibrocytes24. limitations of our study were that it was an observational study and it was confined to a particular area. confounders like time spent outdoors, sunlight exposure, dietary habits and ethnicity were not taken into account. furthermore, linear analysis was not done but we still we feel that this study will be a new milestone in cataract and vitamin d association. conclusion there was no statistically significant difference between the vitamin d levels of cataract patients and the age matched controls. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution yasir iqbal malik; associate professor: concept and drafting of article, manuscript review. aqsa malik; assistant professor: manuscript review. atteya zaman; assistant professor: interpretation of data, manuscript review. rabia shabbir; assistant professor: interpretation of data, manuscript review. masooma bilal; assistant professor: critical appraisal of findings with literature, manuscript review. references 1. alam m, idris m, hussain m. frequency of different types of age related cataracts (study of 250 cases). ophthalmology update, 2013; 11 (1): 25. 2. hassan b, ahmed r, li b, noor a, ul hassan z. a comprehensive study capturing vision loss burden in pakistan (1990-2025): findings from the global burden of disease (gbd) 2017 study. plos one, 2019; 14 (5). 3. iqbal y, zia s, khan qa. post operative anterior chamber reaction in adult cataract surgery after adding heparin in irrigating solution. pak j ophthalmol. 2014; 30 (4). 4. garcía-layana a, ciufo g, toledo e, martínezgonzález ma, corella d, fitó m, et al. the effect of a mediterranean diet on the incidence of cataract surgery. nutrients, 2017; 9 (5): 453. 5. kuruvilla a. background causes of human cataract. indian japp res. 2019; 10; 9 (7). 6. rakete s, nagaraj rh. uva light‐mediated ascorbate oxidation in human lenses. photochem photobiol. 2017; 93 (4): 1091-5. 7. hussain f, malik a, qureshi ms, imran m, waquar s, shafique h, et al. homeostatic relevance of vitamin d in maintaining male fertility in human: down–regulation of oxidative stress and up-regulation of anti-oxidative defense and steroidal hormones. asian pac j reprod. 2018; 7 (2): 56. 8. udani sk, qureshi sa, lateef t, jafri l, effendi mu, raheem a, et al. vitamin d and bone metabolism in breast cancer patients in karachi, pakistan. pak j pharm sci. 2019; 32 (2) (supplementary): 875-880. 9. varma sd, kovtun s, hegde kr. role of uv irradiation and oxidative stress in cataract formation. medical prevention by nutritional antioxidants and metabolic agonists. eye contact lens, 2011; 37 (4): 233. 10. baig ma, mahmood s, munir r, shahid s. to study the visual outcome and complications of small incision cataract extraction (sics) with intra ocular lens implantation (iol). pak j med health sci. 2017; 11 (1): 237-9. 11. haider s, hussain a, limburg h. cataract blindness in chakwal district, pakistan: results of a survey. ophth epidemiol. 2003; 10 (4): 249-58. 12. sasaki h, jonasson f, shui yb, kojima m, ono m, katoh n, cheng hm, et al. high prevalence of yasir iqbal malik, et al 262 pakistan journal of ophthalmology, 2020, vol. 36 (3): 258-262 nuclear cataract in the population of tropical and subtropical areas. dev ophthalmol. 2002; 35: 60-9. 13. holick mf, binkley nc, bischoff-ferrari ha, gordon cm, hanley da, heaney rp, et al. weaver cm. evaluation, treatment, and prevention of vitamin d deficiency: an endocrine society clinical practice guideline. j clin endocrinol metab. 2011; 96: 19111930. 14. mansoor s, habib a, ghani f, fatmi z, badr-uddin s, mansoor s, et al. prevalence and significance of vitamin d deficiency and insufficiency among apparently healthy adults. clin biochem. 2010; 43 (18): 1431-5. 15. iqbal r, jafri l, haroon a, habib a. illuminating the dark side-vitamin d status in different localities of karachi. j coll phys surg. 2013; 23 (8): 604. 16. brown cj, akaichi f. vitamin d deficiency and posterior subcapsular cataract. clin ophthalmol. (auckland, nz). 2015; 9: 1093. 17. jee d, kang s, yuan c, cho e, arroyo jg. epidemiologic survey committee of the korean ophthalmologic society. serum 25-hydroxy vitamin d levels and dry eye syndrome: differential effects of vitamin d on ocular diseases. plos one. 2016; 11 (2): e0149294. 18. grotting la, davoudi s, palenzuela d, papaliodis gn, sobrin l. association of low vitamin d levels with noninfectious anterior uveitis. jama ophthalmology, 2017; 135 (2): 150-3. 19. millen ae, voland r, sondel sa, parekh n, horst rl, wallace rb, et al. vitamin d status and early agerelated macular degeneration in postmenopausal women. archive ophthalmol. 2011; 129 (4): 481-9. 20. yildirim p, garip y, karci aa, guler t. dry eye in vitamin d deficiency: more than an incidental association. int j rheum dis. 2016; 19 (1): 49-54. 21. rao p, millen ae, meyers kj, liu z, voland r, sondel s, et al. the relationship between serum 25hydroxyvitamin d levels and nuclear cataract in the carotenoid age-related eye study (careds), an ancillary study of the women's health initiative. invest ophthalmol vis sci. 2015; 56 (8): 4221-30. 22. park s, choi nk. serum 25-hydroxy vitamin d and age-related cataract. ophth epidemiol. 2017; 24 (5): 281-6. 23. jee d, kim ec. association between serum 25hydroxy vitamin d levels and age-related cataracts. j cat refract surg. 2015; 41 (8): 1705-15. 24. vrensen gf, de wolf a. calcium distribution in the human eye lens. ophth res. 1996; 28 (suppl. 2): 7885. .……. 222 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology editorial childhood glaucoma p. s. mahar pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . hildhood glaucoma is a heterogeneous cluster of disorders occurring in early years of life. according to the american academy of ophthalmology1, congenital glaucoma is present at birth or diagnosed up to 12 months of life. infantile glaucoma is present from 1 year to 3 years and after 3 years onwards, it is termed as juvenile glaucoma. this division however can be arbitrary in our country where child is brought often too late for clinical advice. most of the pediatric glaucoma have no specific identifiable cause and are considered as primary glaucoma. however, when glaucoma is associated with some specific disease, it is called as secondary glaucoma. some of the disorders associated with childhood glaucoma include axenfeld – rieger syndrome, sturge-weber syndrome, aniridia and neurofibromatosis. the chronic use of topical steroids, trauma and cataract surgery remain the other associated factors. about 10% of primary congenital/infantile glaucoma are inherited with specific gene mutation. the secondary glaucoma associated with neurofibromatosis and aniridia are inherited by autosomal gene, which can be passed on to 50% of affected children2. the prevalence of primary congenital glaucoma (pcg) is not known in this country but it occurs in about 1:10,000 live births in usa3. in saudi arabia pcg is estimated to have a prevalence up to 10 times higher than in usa occurring in 1:2500 to 3000 live births4. the condition is usually managed surgically. the surgical techniques are designed to eliminate the resistance of aqueous outflow created by the structural abnormalities in the anterior chamber angle. these congenital changes include presence of non-permeable barkan’s membrane covering the trabecular meshwork and anterior insertion of ciliary body and iris, overlapping the trabecular meshwork5,6. childhood glaucoma poses a huge diagnostic challenge, as young children are uncooperative and difficult to examine in routine setup. the intraocular pressure (iop) reading can be difficult to obtain even under sedation as these sedating agents can influence the readings of iop so these children should be examined and referred to a special unit equipped with handheld tonometer, portable slit lamp and anesthetic facilities. managing childhood glaucoma is one of difficult tasks for glaucoma specialist. the goal of treatment should be better control of iop and preservation of vision. glaucoma surgery remains the eventual treatment. anti-glaucoma drops are used to stabilize the iop until surgery is scheduled. because of serious side effects of medical therapy in the young age, topical drops are carefully chosen. usually betablockers and alpha agonists are avoided because of their potential harmful side effects. broadly, the surgical treatment is divided into 3 categories. 1. angle surgeries like goniotomy and trabeculotomy are meant to enhance the aqueous outflow pathway. goniotomy is usually preferred if cornea is clear. in case of hazy cornea when angle structures cannot be visualized, trabeculotomy is the procedure of choice. it is generally accepted that success rate of these 2 procedures is similar with same degree of disease severety7,8,9. however, advocates of goniotomy argue in its favor when considering the long-term effect especially for future glaucoma surgery such c childhood glaucoma pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 223 as trabeculectomy as conjunctiva and sclera remains untouched, increasing the future success of drainage surgery. with the availability of antifibrotic mitomycin c (mmc), this may not be the case10. recently 360 degrees canaloplasty is taking momentum, which can be performed from outside or inside the eye. the success rate of circumferential 360 degrees trabeculotomy in eyes with pcg varies from 77% – 92% after 1 – 4 years11,12,13. 2. the second set of surgical category is to create external outflow like trabeculectomy or placement of glaucoma drainage devices (gdd). the result of trabeculectomy in children has been poor but with the advent of adjunctive use of mmc, surgical outcome has improved. our results with mmc augmented trabeculectomy in pcg has shown that 58% of children up to 3 years of age maintained the iop of less than 15 mm hg at the end of 1 year follow-up14. molteno first published his results of use of gdd in children in 197315. since then several researchers have used ahmed glaucoma valve and baerveldt implant in children. at 1 to 2 years follow-up, many workers have reported a success rate of 80% but this has reduced to 50% in long-term follow-up16,17. if one looks at the literature, there is no superiority of one device over other. however, baerveldt implant may provide slight better long-term iop control but ahmed implant has shown lesser complications18,19. 3. the third category is procedures causing reduction of aqueous production. this includes cyclo-destructive procedures usually carried out with trans-scleral diode laser of 810 nm. this procedure is traditionally reserved for refractory cases where routine surgery has failed. however, accurate laser application in big eyeball with distorted landmarks can be extremely difficult. endoscopic diode laser can be used in these cases but its use in phakic eyes remains controversial. the best surgical procedures in childhood glaucoma should consider age of the patient, underlying cause of glaucoma, associated ocular factors, any previous ocular surgery, and extent of visual damage and above all surgical expertise of treating specialist and facilities available locally. the diagnosis of childhood glaucoma not only affects the child and parents emotionally but also can hinder child’s education in long term and also can be burden on the family to finance multiple surgeries and hospital costs. in these cases, it may be prudent for primary physician to refer such child to an institute where these factors can be addressed. author’s affiliation prof. dr. p.s. mahar frcs, frcophth professor of ophthalmology & dean isra postgraduate institute of ophthalmology consultant eye surgeon, director glaucoma service aga khan university hospital, karachi. financial interest: none. conflict of interest: none. references 1. american academy of ophthalmology, basic and clinical sciences course. section 6. pediatric ophthalmology & strabismus, 2009 – 2010. 2. stoilov i, akarsu an, sarfarazi m. identification of three different truncating mutations in cytochrome ps501b1 (cyp1b1) as the principal cause of primary congenital glaucoma (buphthalmos) in families linked to the glc3a locus on chromosome 2p21. human mol genetics, 1997; 6 (4): 641-647. 3. hoskins hd jr, shaffer rn, hetherington j. anatomical classification of developmental glaucomas. arch ophthalmol. 1984; 102: 1331-1337. 4. malik r, khandekar r, boodhna t, et al. eradicating primary congenial glaucoma for saudi arabia. the case for a national screening program. saudi j ophthalmol. 2017; 31 (4): 247-249. 5. beauchamp gr, parks mm. filtering surgery in children. barriers to success. ophthalmology. 1979; 86: 170-180. 6. cadera w, pachtman m. filtering surgery in childhood glaucoma, ophthalmic surg. 1984; 15: 319-322. 7. shaffer rn. prognosis of goniotomy in primary infantile glaucoma (trabeculodysgenesis) trans am ophthalmol soc. 1982; 26: 321-325. 8. mcpherson sd, jr, mcfarland d. external trabeculectomy for developmental glaucoma. ophthalmology, 1980; 87: 302-305. 9. dietlein ts, jacobi pc, krieglstein gk. prognosis of primary ab externo surgery for primary congenital glaucoma. br j ophthalmol. 1999; 83: 174-179. 10. mendal ak, walton ds, john t, jayagandan a. mitomycin c – augmented trabeculectomy in refractory congenital glaucoma. ophthalmology, 1997; 104: 9961001. 11. girkin ca, rhodes l, mcgwin g, marchase n, cogen ms. goniotomy versus circumferential trabeculotomy with an illuminated microcatheter in congenital glaucoma. j aapos. 2012; 16: 424-427. p. s. mahar 224 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology 12. mendicino me, lynch mg, drack a, beck ad, harbin t, pollard z, et al. long-term surgical and visual outcome in primary congenital glaucoma: 360 degree trabeculotomy versus goniotomy. j aapos. 2000; 4: 205-210. 13. beck ad, lynn mj, crandall j, mobin-uddin o. surgical outcomes with 360-degree suture trabeculotomy in poor-prognosis primary congenital glaucoma and glaucoma associated with congenital anomalies or cataract surgery. j aapos. 2011; 15: 54-58. 14. mahar ps, memon as, bukhari s, bhutto ia. outcome of mitomycin – c augmented trabeculectomy in primary congenital glaucoma. pak j ophthalmol. 2012; 28 (3): 136-139. 15. molteno a. children with advanced glaucoma treated by draining implants. s afr arch ophthalmol. 1973; 1: 55-62. 16. ei sayed y, awadein a. polypropylene vs silicone ahmed valve with adjunctive mitomycin c in pediatric age group: a prospective controlled study. eye, 2013; 27: 728-734. 17. ishida k, mandal ak, netland pa. glaucoma drainage implants in pediatric patients. ophthalmol clin north am. 2005; 18: 431-442. 18. al-mobarak f, khan ao. two-year survival of ahmed valve implantation in the first 2 years of life with and without intraoperative mitomycin – c. ophthalmology, 2009; 116: 1862-1865. 19. tsai jc, grajewski al, parrish rk. surgical revision of glaucoma shunt implants. ophthalmic surg lasers, 1999; 30: 40-46. pak j ophthalmol. 2022, vol. 38 (1): 1-3 1 editorial what should be the earliest age for clinical trials of corneal cross linking for keratoconus? ksenia denisova 1 , roy s. chuck 2 1,2 department of ophthalmology and visual sciences albert einstein college of medicine, montefiore medical center, nyc, ny keratoconus is often diagnosed in the second or third decade of life, with a younger mean age at diagnosis, in patients of middle eastern and asian descent. 1 patients with severe forms of keratoconus present at a younger age (usually in the second decade of life), and these patients have more rapid progression of the disease. pediatric keratoconus is generally attributed to disease manifesting in patients less than 18 years of age. however, studies that looked at progression in different age groups used varying age criteria. léonimesplié et al. found that keratoconus is often more advanced in children (defined as ≤ 15 years) than in adults (≥ 27 years) at the time of diagnosis. 2 while tuft et al. found that patients ≤ 18 years at the time of diagnosis progressed to transplantation faster than the patients >18 years of age. 3 another study found that the rate of change in corneal curvature was substantially greater in patients < 20 years old and slowed down dramatically after that. 4 until the late 1990s when corneal cross-linking (cxl) was initially developed, there were no effective means to halt or slow progression and keratoplasty was the definitive treatment. there was some assertion in literature that certain contact lenses and intracorneal rings may help slow progression but no definitive evidence was ever presented. 5 ring segments have been shown to improve best-corrected visual acuity as well as contact lens tolerance but do not alter progression of disease. 5 how to cite this article: denisova k, chuck rs. what should be the earliest age for clinical trials of corneal cross linking for keratoconus? pak j ophthalmol. 2022, 38 (1): 1-3. doi: 10.36351/pjo.v38i1.1346 keratoconus is one of the most common indications for keratoplasty in patients ≤ 18 years of age, accounting for 39 – 86% of all corneal transplants for that age group. 6 pakistan, along with india and saudi arabia, has the highest prevalence and incidence of keratoconus in the world. 1 unfortunately, in pakistan corneal transplantation may not always be an option for many patients due to the lack of donor corneal tissue and relatively new eye banking infrastructure. in 2019, pakistan’s first eye bank was established as part of a new national eye banking network. more widespread application of cxl in pakistan is certainly warranted; however, cxl is a relatively new modality and is not yet globally practiced. 7 cxl utilizes ultraviolet light and photosensitizing riboflavin eyedrops to increase the bio-mechanical strength of the cornea via formation of chemical bonds and received u.s. food and drug administration (fda) approval in 2016. currently, the only crosslinking system approved by fda is avedro-glaukos’ kxl system (glaukos, san clemente, california, usa). the procedure is performed in patients with 14 years of age or older. as keratoconus has been diagnosed in children as young as 4 years old, the question arises about the younger patients, who often progress faster and have more severe disease at diagnosis. until recently, majority of clinical trials that examined the efficacy of different cxl systems involved adults over the age of 18. 8 similarly, trials testing different treatment protocols were also focused on adult populations. even in trials with a lower age cutoff, adolescents (ages 10–19 years) constituted a minority of the data points. for example, although the united states clinical trial of corneal collagen cross open access https://doi.org/10.36351/pjo.v38i1.1346 ksenia denisova, et al 2 pak j ophthalmol. 2022, vol. 38 (1): 1-3 linking for keratoconus treatment, (a phase iii multicenter clinical trial), included patients 14 years or older, the mean age of participants was 33 years, with a standard deviation of 10.9 years. 8 the first randomized controlled trial of progressive keratoconus (keralink) in 10–16 years old patients was published this year. 9 sixty eyes with progressive keratoconus (defined as having an increase in the mean corneal power in the steepest meridian or maximum keratometry in the steepest corneal power over at least 3 months, of ≥ 1.5 d) were randomized to either cxl plus standard care or standard care alone. keralink found that cross-linking had an average of 3d decrease in steep keratometry and achieved significantly better visual acuity than those treated with standard care alone at 18 months. however, it must be noted that the outcome measure used in this trial, steep keratometry (k2) over 18 months, is different than the outcome measure used in most other trials, which was maximum keratometry (kmax) at 12 or more months. 9 therefore, this data must be interpreted cautiously. data on how these children fare long term will be key to understanding the benefits of cross-linking. advances in techniques for cross-linking are a rapidly expanding area of research. many involve variations on the standard epithelium-off technique, which has the drawbacks of postoperative discomfort, delayed healing and risk of stromal haze and infection. variations on this protocol include accelerated approaches, transepithelial or epithelium-on cross linking with various formulations of riboflavin, iontophoresis-assisted methods to increase intrastromal riboflavin penetration as well as techniques to increase oxygen availability including supplemental oxygen and pulsed light delivery. 10-12 chemical cross linking, using eye drops to induce cross linking pharmacologically and bypassing the uv light and riboflavin altogether, is also an active area of development. 13 new investigative devices, such as a wearable scleral contact lens which delivers uv light directly onto the cornea and tracks the change in corneal rigidity in real time, have recently emerged. 14 computational simulations modelling the outcomes of cxl in keratoconus with the goal of optimizing outcomes have shed light on customized cross-linking treatment algorithms. 15 these advances will likely be key in adapting this procedure for younger patients by increasing efficiency, accuracy, and patient comfort. in conclusion, present data on cxl for the pediatric population is promising. cxl should be made available for children with progressive keratoconus as young as 10 years old for disease stabilization. more clinical trials regarding the longterm effects of cxl specifically in the adolescent and pediatric age group (18 and younger) are needed, since these patients are both the most vulnerable to disease progression and have among the worst prognoses. acknowledgement the authors would like to acknowledge research funding support for the einstein-montefiore department of ophthalmology and visual sciences from the irving and branna sisenwein, and lewis henkind endowments. references 1. kok yo, tan gf, loon sc. keratoconus in asia. cornea, 2012; 31 (5): 581-593. 2. léoni-mesplié s, mortemousque b, touboul d, malet f, praud d, mesplié n, et al. scalability and severity of keratoconus in children. am j ophthalmol. 2012; 154 (1): 56-62. 3. tuft sj, moodaley lc, gregory wm, davison cr, buckley rj. prognostic factors for the progression of keratoconus. ophthalmology, 1994; 101 (3): 439-447. 4. mcmahon tt, edrington tb, szczotka-flynn l, olafsson he, davis lj, schechtman kb. clek study group. longitudinal changes in corneal curvature in keratoconus. cornea, 2006; 25 (3): 296305. 5. garcia-ferrer fj, akpek ek, amescua g, farid m, lin a, rhee mk, et al. corneal ectasia preferred practice pattern. ophthalmology, 2019; 126 (1): 170215. 6. lowe mt, keane mc, coster dj, williams ka. the outcome of corneal transplantation in infants, children, and adolescents. ophthalmology, 2011; 118 (3): 492497. 7. khan wa, zaheer n, khan s. corneal collagen cross-linking for keratoconus: results of 3-year followup in pakistani population. canadian j ophthalmol. 2015; 50 (2): 143-150. 8. hersh ps, stulting rd, muller d, durrie ds, rajpal rk, binder ps, et al. united states multicenter clinical trial of corneal collagen cross linking for keratoconus treatment. ophthalmology, 2017; 124 (9): 1259-1270. earliest age for clinical trials of corneal cross linking pak j ophthalmol. 2022, vol. 38 (1): 1-3 3 9. larkin df, chowdhury k, burr jm, raynor m, edwards m, tuft sj, et al. effect of corneal crosslinking versus standard care on keratoconus progression in young patients: the keralink randomized controlled trial ophthalmology, 2021; 128 (11): 15161526. 10. price mo, fairchild k, feng mt, price jr fw. prospective randomized trial of corneal cross-linking riboflavin dosing frequencies for treatment of keratoconus and corneal ectasia. ophthalmology, 2018; 125 (4): 505-511. 11. faramarzi a, hassanpour k, rahmani b, yazdani s, kheiri b, sadoughi mm. systemic supplemental oxygen therapy during accelerated corneal cross linking for progressive keratoconus: randomized clinical trial. j cataract refract surg. 2021; 47 (6): 773-779. 12. mazzotta c, traversi c, paradiso al, latronico me, rechichi m. pulsed light accelerated cross linking versus continuous light accelerated cross linking: oneyear results. j ophthalmol. 2014; (2014): 604731. 13. paik dc, solomon mr, wen q, turro nj, trokel sl. aliphatic β-nitroalcohols for therapeutic corneoscleral cross-linking: chemical mechanisms and higher order nitroalcohols. invest ophthalmol vis sci. 2010; 51 (2): 836-843. 14. dackowski ek, logroño jb, rivera c, taylor n, lopath pd, chuck rs. transepithelial corneal cross linking using a novel ultraviolet light-emitting contact lens device: a pilot study. trans vis sci technol. 2021; 10 (5): 5. 15. roy as, dupps wj. patient-specific computational modeling of keratoconus progression and differential responses to collagen cross-linking. invest ophthalmol vis sci. 2011; 52 (12): 9174-9187. .…  …. 188 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology original article role of topical travoprost in non syndromic (simple) axial myopia in young persons munawar ahmed, m. arshad mahmood, atif mansoor ahmed, murtaza sameen, arshad ali, noman ahmed pak j ophthalmol 2015, vol. 31 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: munawar ahmed department of ophthalmology liaquat university of medical & health sciences jamshoro munawar_404@yahoo.com …..……………………….. purpose: to evaluate the role of topical travoprost 0.004% eye drops in reducing simple axial myopia in young patients. material and methods: this case and control study was conducted on 45 young patients of either sex from 18 to 25 years old, who were selected by independent random sampling technique. patients having best corrected visual acuity of 6/6 in both eyes, axial length more than 24 mm, myopia of -1.0 d to -4.0 d, and intraocular pressure of 16 to 20 mm hg were registered for the study. after informed consent, slit lamp examination of anterior and posterior segment was done. intra-ocular pressure and axial length were measured. travoprost .004% eye drops were used in one eye once daily in the evening for four months. the fellow eye was kept as control. follow up was done every month up to six months. on each visit best corrected visual acuity, axial length, and iop were examined. any complaint or complication was also noted and results were compiled. results: in these forty five patients reduction of myopia in treated eye was seen in 24 (53.33%), stabilization of myopia in 13 (28.88%), and increase in myopia was seen in 08(17.77%) patients. in these patients iop 7.2445 mm hg, axial length 0.2089 mm, and myopia -0.4444 d was reduced (p-value less than .05, as compared to fellow control eye where axial length and myopia increased by 0.1423 mm and -0.0478 d respectively. despite iop decreased by 1.0889 mm hg. p-value was again less than .05. temporary headache in 8 (17.77%), conjunctival congestion in 16(35%) patients. complication of darkening and lengthening of lashes were noted to variable degree in all treated eyes. conclusions: topical travoprost 0.004% eye drops is effective in reducing axial myopia in young persons. key words: myopia, refraction, axial length, iop, travoprost eye drops, young patients. yopic refractive errors are the most common eye conditions in the world. it is more common in whites than in blacks, in females than in males and more common in educated than illiterates1. highest prevalence is observed in some east asian populations reaching over 90%. genetics clearly have an important role but type of visual environment also influences the onset, progression, and cessation of myopia2. myopia can be physiological or pathological differentiated by the presence of degenerative changes and the level of the refractive error. depending on age, myopia can divided into youth – onset (less than 20 years old), early adult-onset (20 to 40 years) and late m role of topical travoprost in non syndromic (simple) axial myopia in young persons pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 189 adult-onset myopia (above 40 years). other classifications include: axial and non-axial myopia; low myopia (-0.25 to –3.0 d), moderate myopia (–3 to –6 d) and high myopia (–6.0 d). myopia is also divided into syndromic and non-syndromic types. non-syndromic myopia can be further divided into two types: myopia having complex traits which is determined by genetic and environmental factors; and myopia showing a mendelian pattern of inheritance (autosomal dominant, autosomal recessive), which is caused by genetic mutations3. non-syndromic myopia typically begins in childhood, with the condition progressing throughout the high school and college years. adults in the past didn't frequently develop myopia, but computer use seems to have increased the incidence of adult first time eye glass or contact lens wearers. it is now widely accepted that the development of myopia is related to the genetic and environmental factors. genetics plays a role in the growth of the eye and near work (especially reading) is important environmental factor that can result in myopia. for both european and east asian children, myopia is more common in the inner city region (8.1% and 55.1%, for european and east asian, respectively)4. in young adults with moderate to severe myopia iop increases at night, but level of the increase is significantly low than in the age-matched control subjects. blindness due to malignant myopia is more common in persons living near the sea than in the persons living far away from sea coast5. intra ocular pressure in upper normal limits (16 mm hg or more) and weaker accommodation can result in progression of myopia in younger age group6. reduction of iop with anti-glaucoma drugs contributes in reduction of spherical myopic errors even after kerato-refractive surgery7. material and methods this study was conducted in department of ophthalmology, liaqat university of medical and health sciences, jamshroo hyderabad. in this control case study 45 patients were selected by independent random sampling method, 18 to 25 years old of either sex having best corrected visual acuity 6/6 in both eyes with normal appearing fundus, simple axial myopia from -1.0 to -4.0 d, intra-ocular pressure 16-20 mm hg, axial length more than 24 mm, were enrolled for study (table 1). after informed consent complete slit lamp examination of anterior and posterior segment was done. any intraocular pathology like stickler’s syndrome, marfan’s syndrome, ehler danlos syndrome, intraocular inflammation and media opacity were excluded. best corrected visual acuity and iop was noted, axial length was measured with a-scan and reading less than 0.1 standard deviation was noted. travoprost .004% (travatan) eye drops were used once daily in the evening in more myopic eye with higher iop, or in right eye in case of equal pressure in both eyes. travoprost eye drops were used for four months. the fellow eye was kept as control. follow up was done every month up to six months. after four months all patients were fully corrected for their refractive errors (equally readable in red and green on duochrome test) and travoprost was discontinued. on each visit visual acuity, refraction, axial length, and iop were examined. any complain or complication was also noted and results were compiled. in results only 45 cases were considered who completed follow up for six months completely. spss (statistical package for social sciences) version 14 was used to analyze the result of 45 patients who completed the recommended follow up period. paired t-test was used to assess change in iop, axial length and spherical myopia before and after treatment with travoprost on treated as well as on control eyes. for data analysis refraction was used in diopters after refining the refraction as full correction for far vision at 6 meters (equally readable in red and green on duoch-rome test). independent sample test was performed to see significant difference before and after treatment. results out of forty-five patients who completed required follow up; travoprost eye drops were effective in reducing iop, axial length and myopia in 24 (53.33%) patients in treated eye. in these patients whose initial iop was 16-20 mm hg; mean initial iop was 17.7778 mm hg standard deviation 1.14592. after one month reduction of iop was 3 – 4 mm hg (21 – 25%) (due to travoprost) and after three to four months iop reduced by 6 – 8 mm hg (37.5% to 40.0%) to the base line iop 10 – 12 mm hg. after treatment the mean iop 10.5333 mm hg and standard deviation was 0.66058. average reduction of iop was 7.2445 mm hg. this further reduction of iop was due to active accommodation which resulted due to change in refractive status from under correction to over munawar ahmed, et al 190 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology correction of myopia for the far vision. mean initial axial length in treated eye was 24.7778 mm and standard deviation was 0.14016. after treatment mean initial axial length was 24.5689 mm, standard deviation 0.12133, and average reduction of axial length was 0.2089 mm. mean initial myopia in treated eye -2.7222 d standard deviation was 1.05828. mean myopia after treatment was -2.2778 d, standard deviation 0.80697 and average reduction of myopia was −0.4444 d after four months treatment and maintained till last follow up at six months. there was significant reduction in myopia after treatment with travoprost. the results were two tailed and p value was less than 0.05 (table 2). in these 24 patients ocular refraction from myopia (under correction) changed to hyperopia (over correction) due to reduction in axial length and patient was complaining of eye strain. in these patients refraction was reviewed to full correction which relieved the eye strain. in 13 (28.88%) patients reduction of iop was 3 4 mm hg and there was no change in axial length or refractive state of eye. in remaining 08 (17.77%) patients, increase in axial length (0.1mm) and myopia 0.25d was observed despite reduction of 3 4 mm hg iop. these patients were initially 4.0 d myopic. in the fellow control eyes initial mean iop 17.5111 mm hg and standard deviation was 1.17980. after six months mean iop was 16.4222 mm hg, standard deviation 1.35661, and average decrease in iop was 1.0889 mm hg. initial mean axial length 24.7733 mm and standard deviation was 0.12804. after six months mean axial length 24.9156, standard deviation 0.11763 and increase in axial length was 0.1423 mm. initial mean myopia -2.6833 d, and standard deviation was 1.01326. after six months mean myopia -2.7311d, standard deviation 1.06958 and increase in myopia was -0.0478d mainly during early follow up period. increase in axial length and myopia was more common in patients under 20 years of age. fellow eye acted as partially control eye due to reduction of iop because of systemic absorption of travoprost eye drops. even then this increase was significant and pvalue was less than 05 (table 3). in treated eye best corrected visual acuity improved (from 6/6 to 6/5 partial) in 15 (33.33%) patients than in fellow (control) eye, the reason is not known, it might have increased retinal circulation. conjunctival congestion in treated eye (fig. 1) and to lesser degree in fellow eye was noted in 16 (35%) of patients which decreased within two month. conjunctival congestion in the fellow eye was due to systemic absorption. temporary headache occurred in 8 (17.77%) patients. complication of darkening and lengthening of lashes was noted to variable degree in all treated eyes (fig. 2). no case of macular edema in these young patients was seen. table 1: demographic information of patients male 09 female 36 range of age 18-25 present residency urban range of refractive error −1.0 d to −4.0 d education students of class xii to university level socioeconomic poor to middle class fig. 1: travoprost used in right eye (conjunctival congestion in both eyes) fig. 2: lengthening of eye lashes in right eye after 4 months use of travoprost role of topical travoprost in non syndromic (simple) axial myopia in young persons pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 191 discussion trend in the change of lifestyle, increased educational competition in younger age students, and relatively high iop is increasing the incidence of myopia. variable accommodation also plays important role in lowering the intraocular pressure. when accommodation is totally relaxed in myopic persons, mainly when myopia is more -2.0d, aqueous out flow through trabecular meshwork is decreased resulting in slight increase in intraocular pressure. if this change of iop occurs at younger age it stretches the immature eye ball tissue, increases axial length, and myopia. mean refractive shift per year in myopic children is −0.30 d/yr. reduced ocular rigidity, increased wall stress due to relatively high intra-ocular pressure, and scleral thinning play important role in myopia progression in young persons8. the average intraocular pressure in twenty four hours is slightly high in the myopic than in emmetropics9. although most of the refractive errors can be corrected by optical or surgical methods, but these methods cannot stop or retard the progression of myopia. these treatments also have some drawbacks and pose a large economic burden. travoprost 0.004% has no affect on ciliary body muscle in relation to contraction or relaxation as it does not affect aqueous production, and has no effect on nutrition of intraocular structures. travoprost increases uveoscleral out flow and its maximum stable affect (25% – 30%) is achieved within two weeks. in our study 40% reduction of intraocular pressure was observed. this reduction of iop was in two steps; in first 15 days intraocular pressure was reduced due to travatan, and in second to third month of treatment further reduction of intraocular pressure was due to active accommodation within 6 meter distance. when eye under treatment, became 0.25d to 0.5d hyperopic due to decreased iop and axial length and further 10munawar ahmed, et al 192 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology 15% reduction of iop was observed. patient also felt heaviness in eye under treatment due to mild hyperopia and the refraction was then under corrected on duochrome test. again 10-15% iop increased. it was also observed that target pressure between 10 – 12 mm hg is required to reduce the myopia and 14.0 mm hg target iop required to stop its progression. role of active accommodation have also been observed by other researchers. in the fellow control eye 2-3 mm hg reduction of iop was also observed but this small reduction did not reduce the axial length or myopia but progression of myopia was reduced. this reduction of iop in fellow eye was due to systemic absorption. change in near work habit, full correction of refractive error, and lowering of iop with travatan eye drops can control or reduce axial myopia. it has also been observed that intra-ocular pressure is lowered more after repeated accommodation than after static accommodation. pattern of near work therefore also affects intra-ocular pressure10. the developing eye experiences a number of changes that lead to adjustment of its optical components in accordance with the natural trend to emmetropia and the sometimes conflicting intervention of environmental influences. it is well established that central corneal thickness also affects iop measurements. iop was also found to be associated with amplitude of accommodation but only in males. as the amplitude of accommodation is known to decrease with age and the iop was shown to rise in the first decade of life. the fact that males and females vary in significance of associations between iop and amplitude of accommodation may result from the differences in the iop changes with age and the deviation of the trends after 12 years of age. differences between males and females have been noted by pensiero but the greatest deviations were noted before the age of 6 in the previous study11. mean iop is higher by 3 mm hg in myopic than in emmetropic eye. therefore, relatively elevated iop (16 or more) and poor accommodation can be the risk factor in myopia progression in young age group12. in pathological myopia, continuous thinning occurs in the sclera, choroid (from 250 to <10  μm), and secondary defects in the bruch’s membrane, loss of retinal pigment epithelium, choriocapillaris, and retinal photoreceptors with maximal thinning observed at the posterior pole13. conclusions topical travoprost and full correction of refractive error is effective in reducing axial myopia. it is therefore recommended that myopia should be fully corrected for the far vision to facilitate aqueous out flow to maintain target iop (10 – 12mm hg) which if maintained at early age can prevent progression of myopia in young persons. author’s affiliation dr. munawar ahmed assistant professor department of ophthalmology liaquat university of medical & health sciences jamshoro prof. muhammad arshad mahmood prof. & hod university college of medicine the university of lahore dr. atif mansoor ahmed associate professor sheikh zayed medical complex, lahore dr. murtaza sameen liaquat university of medical & health sciences jamshoro dr. arshad ali lodhi liaquat university of medical & health sciences jamshoro dr. noman ahmed liaquat university of medical & health sciences jamshoro role of authors dr. munawar ahmed conducted the main research guided and informed the patients about the research procedure, it’s duration, number of follow up, and it’s beneficial and possible worse effects. observation of effects and side effects of drug used for research purpose and compiled the results and discussed with the second author. prof. muhammad arshad mahmood partially conducted the research on some patients adopting the same research protocol, helped in writing and compiling the results. dr. atif mansoor ahmed provided guide lines about research procedures and selection of patients. role of topical travoprost in non syndromic (simple) axial myopia in young persons pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 193 dr. murtaza sameen helped in data collection and arranged the drug used for research. dr. arshad ali lodhi helped in literature search. dr. noman ahmed helped in data collection and informed the patients about research procedure. references 1. sun j, zhou j, zhau p, lian j, zhu h, zhou y. high prevalence of myopia and high myopia in 5060 chinese university students in shanghai. invest. ophthalmol. vis. sci, 2012; 53: 7504-9. 2. aller ta. clinical management of progressive myopia. eye, 2014; 28: 147-53. 3. meng w, butterworth j, malecaze f, calvas p. axial length of myopia: a review of current research. ophthalmologica. 2011; 225: 127–34. 4. jenny m. ip, kathrin a. rose, ian g. morgan, george burlutsky, paul mitchell. myopia and the urban environment: findings in a sample of 12-year-old australian school children. invest. ophthalmol. vis. sci. 2008; 49: 3858-63. 5. daubas jg. some geographic, environmental and nutritive concomitants of malignant myopia. ophthalmic physiol opt. 1984; 4: 143-9. 6. svirin av, lapocdhkin, khashem ab. statistical evaluation of the role of elevated intraocular pressure and weakened accommodation in progressive acquired myopia. vestn opftalmol. 1990; 106: 36-8. 7. kamiya k, aizawa d, igarashi a, komatsu m, shimizu k. american journal of ophthalmology, 2008; 145: 233-8. 8. schmid kl, li rwh, edwards mh, lew jkf. the expandability of the eye in childhood myopia. curr eye res. 2003; 26: 65-71. 9. liu jhk, daniel f, ke k, twa md, gokhale pa, jones ei, park eh, meehan je, weinreb nr. twenty four hour pattern of intraocular pressure in young adults with moderate to severe myopia. invest ophthalmol vis sci. 2002; 43: 2351-5. 10. jenssen f, krohn j. effects of static accommodation versus repeated accommodation on intraocular pressure. j glaucoma. 2012; 21: 45-8. 11. dusek wa, pierscionek bk, clelland j f mc. age variations in intraocular pressure in a cohort of healthy austrian school children. eye. 2012; 26: 841-5. 12. svirin av, lapochkin vi, khashem ab. statistical evaluation of the role of elevated intraocular pressure and weakened accommodation in progressive acquired myopia. vestn oftalmol. 1990; 106; 36-8. 13. lxu jbj. histological changes of high axial myopia. eye 2014; 28: 113-7. pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 142 original article awareness of glaucoma in different groups of urban population nasira inayat, muhammad moin, asif manzoor pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nasira inayat department of ophthalmology, lahore general hospital, lahore e-mail: nasira_dr@hotmail.com …..……………………….. purpose: to evaluate the level of glaucoma awareness among different groups of urban population material and methods: a survey was conducted by ophthalmology unit-ii, ameer-ud-din medical college / post graduate medical institute / lahore general hospital, lahore; pakistan. survey was conducted in three different groups of civilians using non probability, purposive sampling. group i consisted of 150 medical students of first and second year in their mbbs; group ii comprised of 115 student nurses; and group iii was composed of 150 adults from all public sectors. this study is an observational and cross sectional study. results: a total of 415 adults answered the questionnaire made for awareness of glaucoma. in group i, 13.3% stated that they did not know what glaucoma meant. all in group ii answered as to what glaucoma meant; whereas, 48.7% in group iii had not heard about glaucoma. in group i, 36% said that it was raised intra ocular pressure, 21.3% said it was an eye disease, 16.7% thought that it was another name for blindness, 8% wisely answered it as an optic neuropathy, 2.3% translated the word glaucoma in their local language (urdu) as ‘kalamotia’, 1.3% students thought that it was a glucose related disorder, or a form of diabetes and 0.7% thought that it was a name given to blindness due to diabetes mellitus. in group ii, 80.9% nurses stated that the term ‘glaucoma’ meant a raised intraocular pressure, 15.7% thought that glaucoma meant blindness, 2.6% stated that it was an optic neuropathy and 0.9% wrote that glaucoma meant headache and vomiting. in group iii, 24% participants said glaucoma meant loss of vision, 22% stated it was an eye disease, 4.7% knew that it was due to raised intraocular pressure, and 0.7% said that glaucoma meant watering from the eye. conclusion: the awareness of glaucoma is low in the general public. an efficient information, education and communication strategy needs to be designed for early detection and treatment of glaucoma to prevent blindness. key words: glaucoma, blindness, intraocular pressure. laucoma is the second leading cause of blindness in the world1. the incidence of glaucoma ranges between 6.5 to 7.5% indifferent parts of the world.2,3 with such a high incidence of a blinding disease, early detection of glaucoma is essential to prevent blindness. public awareness of this almost silent disease plays a pivotal role in bringing the high risk patients to the ophthalmologists, and hence, preventing the dreadful results. spreading knowledge about the disease not only helps to prevent blindness but also reduces the economic burden of the disease4. report of glaucoma awareness surveys in different parts of the world have been used to identify least knowledgeable subgroups in order to most effectively use the resources for public education.5,6 no such survey has been previously published from pakistan before. therefore we carried out survey to find out the awareness level of glaucoma in medical students, nurses and general public in lahore. the most common source of g nasira inayat, et al 143 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology information has been found to be doctors in a study done in ethiopia7. three groups were used in the survey to estimate the level of knowledge among group of people with different levels of education. material and methods a survey was conducted by ophthalmology unit-ii amee-rud-din medical college / post graduate medical institute / lahore general hospital, lahore; pakistan. survey was conducted in three different groups of civilians using non probability, purposive sampling. group i consisted of 150 medical students of first and second year in their mbbs; group ii comprised of 115 student nurses; and group iii was composed of 150 adults from all public sectors. the following were included in the study. any one above age 18 years irrespective of the gender was included. first group (medical students): all medical students of 1st and 2nd year from ameer-ud-din medical college, having no clinical exposure to patients. these students were attending their basic sciences lectures. second group (nursing students): all student nurses from nursing school, lahore general hospital, lahore; who also had some clinical exposure during ward duties in addition to lectures on basic sciences. third group (general public): people belonging to any field of life whether educated or not but had never received any medical education were included in this group. the following were excluded from the study. first group (medical students): all graduates, students of 3rd year and above and anyone having clinical exposure (electives).third group (general public): anyone who had any sort of diploma / degree in medical education. survey data was collected through a performa having both open ended and close ended questions. all those who fulfilled inclusion criteria filled survey form themselves anonymously (except those who were uneducated or had language problem). survey questions were asked in simple language (table 1) and their answers recorded. results a total of 415 adults answered the questionnaire made for awareness of glaucoma. group i, comprising of 150 medical students had a mean age of 19 years. male students were 40.9% and females were 59.3%. group 11 had a mean age of 22 years and all participants were females. in group iii, mean age was 39 years, where 63.3% were male participants and 36.7% were females. in group i, 13.3% stated that they did not know what glaucoma meant. all in group ii answered as to what glaucoma meant; whereas, 48.7% in group iii had not heard about glaucoma. in group i, 36% said that it was raised intra ocular pressure, 21.3% said it was an eye disease, 16.7% thought that it was another name for blindness, 8% wisely answered it as an optic neuropathy, 2.3% translated the word glaucoma in their local language (urdu) as ‘kalamotia’, 1.3% students thought that it was a glucose related disorder, or a form of diabetes and 0.7% thought that it was a name given to blindness due to diabetes mellitus. in group ii, 80.9% nurses stated that the term ‘glaucoma’ meant a raised intraocular pressure, 15.7% thought that glaucoma meant blindness, 2.6% stated that it was an optic neuropathy and 0.9% wrote that glaucoma meant headache and vomiting. in group iii, 24% participants said glaucoma meant loss of vision, 22% stated it was an eye disease, 4.7% knew that it was due to raised intraocular pressure, and 0.7% said that glaucoma meant watering from the eye. in response to question about the source of information; in group i, 27.3% had gathered information from the basic sciences’ lectures in the college, 10.7% read about glaucoma in different books, 6.7% gathered information from the internet, 3.3% had read about it in a medical dictionary, 2% were informed about glaucoma from the television and only 0.7% was informed by another patient and 0.7% was a patient himself. 24% of the general public did not answer the question in this group. in group ii, 72.2% of the nurses stated books as their source of information, 25.2% had known about it from the dictionary, 0.9% got information from the doctors in the ward, 0.9% from the internet and 0.9% was a patient herself. there was no source of information about glaucoma in 62% of the general public participants in group iii. 13.3% knew about the disease from involved family members, 12% had friends suffering from glaucoma, 9.3% were told about glaucoma by a doctor, 1.3% were patients themselves, 1.3% read about glaucoma in a book and 0.3% were informed through media. as an answer to the question if someone could have glaucoma without symptoms; in group i, 23.3% awareness of glaucoma in different groups of urban population pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 144 nasira inayat, et al 145 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology said yes, 34% said no and 44.7% were not sure. in group ii, 23.48% said yes, 66.1% said no, and 10.4% were not sure. in group iii, 19.3% said yes, 10.7% said no, and 70% were not sure. the next question was if the blindness from glaucoma was reversible? in group i, 20.7% of the medical students said that yes it was reversible, 38% said it was not reversible and 41.3% were not sure. in group ii, 20% i of the nurses thought blindness because of glaucoma was reversible and 80% wrote that it was irreversible. in response to the risk factors associated with glaucoma, in group i, 18.7% thought family history was important, 36.7% thought old age and 44.7% were not sure. in group ii, 19.1% thought family history as a risk factor, 51.3% old age as a risk factor and 29.6%. in response to the question about what was the perceived risk of getting glaucoma in patients at risk; in group i, 32% thought that there was a high risk, 10% answered that there no risk and 58% were not sure. in group ii, 94.8% stated that there was a high risk, 0.9% said there was no risk at all and 4.3% were not sure. in group iii, 16% said there was a high risk of getting glaucoma in the particular group, 0.7% said there was no risk at all and 83% were not sure. discussion although different awareness studies have been carried out in the developing world to find out the level and depth of knowledge about glaucoma in the general public,7,8 we decided to include the awareness level of medical students and nurses for a comparison. in the study mention above7, the most common source of information among the public were the ophthalmologists attending to the glaucoma patients. in our study 4.7% of the general population of the city of lahore knew about glaucoma to the extent that it was a raised intraocular pressure that caused blindness. this figure is almost double to what was found in the urban population of ethiopia 2.4%7, and in the urban population of india 2.3%8. but our sample size is small. 150 civilians from all classes ranging from house maids and domestic guards to house wives and high class office bearers, only seven knew what glaucoma meant. there was no difference between the awareness levels in both genders, which is similar to the studies done in the western world.9-13,16 we found that the awareness about glaucoma was depressingly low in the general public but those who had heard about glaucoma also had a good knowledge about it. this is in contrast to two studies of glaucoma carried out in australia where a reasonable portion of population had heard about glaucoma but only a few had knowledge about it.10,13 in chennai, india14, a similar survey was carried out, where it was found that rate of awareness about glaucoma in rural population was 13.3%. 0.5% had a good knowledge, 4% had a fair knowledge and 4.2% only knew that glaucoma was an eye disease. this is again a very dissimilar result as compared to our result. ophthalmologists were found to be the most important source of information in our study, whereas, friends were the main source of information in a german survey11, and media was reported to be the most important in rural india14. information from the close acquaintances was apparently the only source in southwestern ethiopia10. it was particularly observed that health information about ophthalmological diseases was scanty on the media, while information campaigns on diseases like dengue fever were very successfully carried out through media. awareness of glaucoma in different groups of urban population pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 146 educating people about the glaucoma is mostly being carried out by the ophthalmologists themselves, which is only limited to the patients attending the ophthalmology clinics and tertiary hospitals. nurses, medical students and media should be used to spread the awareness about the disease. all those who are suffering from the disease should be convinced to get their relatives screened for glaucoma. free screening services should be available to those coming for screening, as it is carried out in the developed countries16. although our sample size is small, but it has given us a rough idea that to improve awareness of the disease we can effectively use nurses and medical students in helping the general awareness of the disease. media is another very important and completely neglected source, that can play a vital role in bringing the suspects of glaucoma to screening centers and hence an early diagnosis. conclusion the awareness of glaucoma is low in the general public. our sample size is small but similar results can be suspected in larger population group studies. it was satisfactory to find the level of knowledge in the nurses, who can be effectively used for spreading awareness. an efficient information, education and communication strategy needs to be designed for early detection and treatment of glaucoma to prevent blindness. author’s affiliation dr. nasira inayat senior registrar in ophthalmology lahore general hospital, lahore prof. muhammad moin department of ophthalmology lahore general hospital, lahore dr. asif manzoor post graduate trainee, department of ophthalmology, lahore general hospital, lahore references 1. resnilkoff s, pascolini d, etya’ale d. global data on visual impairment in year 2002. bull world health org. 2004, 82: 84451. 2. d grosvenor, a hennis: incidence of glaucoma. west indian med j. 2011; 60: 3. mehar p, shahzad a: glaucoma burden in a public sector hospital. pak. j ophthalmol. 2008; 24: 112-7. 4. noertjojo k, mabertey d, courtright p. awareness of eye diseases and risk factors: identifying needs for health education and promotion in canada. can j ophthalmol. 2006, 41: 617-23. 5. javitt jc. preventing blindness in americans: the need for eye health education. surv ophthalmol. 1995; 40: 41-4. 6. deokule s, shah s. chronic open angle glaucomaawareness of the nature of the disease, topical medication, compliance and the prevalence of systemic symptoms. ophthalmol physiol opt 2004; 24: 9-15. 7. tenkir a, soloman b, deribew a. glaucoma awareness among people attending ophthalmic outreach service in southwestern ethiopia. bmc ophthalmol. 2010; 10: 17. 8. dandona l, dandona k, jhon r, mccarty c, rao g. awareness of eye diseases in an urban population in southern india. bull world health org. 2001; 79: 96-102. 9. gasch at, wang p, pasquale lr. determinants of glaucoma awareness in a general eye clinic. ophthalmology. 2000, 107: 303-8. 10. attebo k, mitchell p, cumming r, smith w: knowledge and beliefs about common eye diseases.aust n z j ophthalmol. 1997; 25: 283-7. 11. pfeiffer n, krieglstein gk, stegan w: knowledge about glaucoma in the unselected population: a german survey. j glaucoma. 2002; 11: 458-63. 12. mansouri k, orgul s, gibbons f, mermoud a: awareness about glaucoma and related eye health attitudes in switzerland: a survey of general public.ophthalmologica. 2006, 220: 101-8. 13. livingston pm, et al: knowledge of glaucoma and its relationship to self care practices, in a population sample. br j ophthalmol, 1998; 82: 789-5. 14. ramesh v, pradeep g, gonnie g, et al. determents of glaucoma awareness and knowledge in urban chennai. indian j ophthalmol. 2009; 57: 355-60. 15. krishnalah s, koval v, srinivas m, shamanna b, rao g, ravi t: awareness of glaucoma in the rural population of southern india. indain j ophthalmol. 2005; 53: 205-8. 16. eke t, reddy ma, karwatowski ws: glaucoma awareness and screening updates in relatives of glaucoma. eye 1999; 13: 647-9. pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 213 original article frequency and visual outcome of choroidal tubercles with miliary tuberculosis mirza shafiq ali baig, muhammad masroor, jameel a. burney, farnaz siddiqui, mazhar-ul-hassan, sarfaraz nawaz, syed muhammad adnan pak j ophthalmol 2014, vol. 30 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mirza shafiq ali baig department of ophthalmology dow university hospital dow international medical college (dimc), dow university of health sciences (duhs), karachi email: drshafiqbaig@gmail.com …..……………………….. purpose: to determine the frequency and visual outcome of choroidal tubercles in diagnosed cases of miliary tuberculosis. material and methods: a prospective study was conducted at department of ophthalmology and institute of chest disease (oicd) dow university hospital (duh), dow international medical college (dimc) and dow university of health sciences (duhs) karachi, 24 th april, 2010 to 23 rd november, 2013. two hundred and seventy two (272) diagnosed cases of miliary tuberculosis referred from ojha institute of chest disease (oicd) to our department were included in the study. detailed examination at the first visit was conducted and then after 2 months and 6 months. complete examination including visual acuity, color vision, refraction, slit lamp examinations, intraocular pressure (iop), and posterior segment evaluation after pupil dilatation was performed. fundus photographs were also taken. data was recorded and analyzed in spss version 16. frequencies and percentages were calculated for age, gender and visual outcome. results: two hundred and seventy two (272) cases were included in the study. age ranges from 10 to 80 years with mean age being 45 years. there were 140 (51.41%) female and 132 (48.53%) males. among these two hundred and seventy two (272) cases, 14 (5.14%) had choroidal tubercles. they were all on anti tuberculous treatment. visual acuity improved from less than 6/60 to 6/9 or 6/6 in majority of cases after completion of treatment and healing of choroidal tubercles was also noted. conclusion: the study is unique and done for the first time in pakistan. frequency of choroidal tubercles with diagnosed cases of miliary tuberculosis is 5.14% with gender distribution female to male was 8:6. visual outcome is better if the patient is screened early and treated promptly. key words: choroidal tubercles, miliary tuberculosis, visual outcome uberculosis (tb) is the leading infectious cause of morbidity and mortality worldwide.1-2 it is one of the major public health problems in pakistan and ranks fifth among tb high-burden countries worldwide. the incidence of tb in pakistan by world health organization is 231 / 100,000. in 2012, the number of tb cases diagnosed increased from 20,707 in 2001 to 26, 7 912 in 2010.3 tb is caused by mycobacterium tuberculosis (mtb). it primarily affects the lungs but can affect other organs including the eye.4-5 tb in eyes can affect lids, conjunctiva, cornea, iris, choroid and retina. involvement of tb in choroid appears as choroidal tubercles. . if choroidal tubercles are untreated, it can lead to blindness. involvement of both lungs with military infiltrates is known as m.t .in miliary tuberculosis, whole body is studded with similar infiltrates. the diagnosis of choroidal tubercle is mainly based on clinical findings. both clinical and histopathological descriptions are available in t mirza shafiq ali baig, et al 214 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology fig. a: re – treatment (initial) fundus photograph fig. a1: right eye: choroidal tubercle of about 3 disc diameter with exudative retinal detachment at macula fig. a2: left eye pre treatment (initial): small choroidal lesion inferior to the disc of about 1/2 disc diameter fig. b: post-treatment fundus photograph first follow up at two months fig. b1: right eye: resolution of choroidal tubercle with exudative retinal detachment fig. b2: left eye: inactive choroidal tubercle below the disc at two months literature.13,14-16 culture or direct histopathological examination of infected tissue can provide definitive proof but it is highly associated with risk of intraocular infection in cases of active ocular inflammation. all our cases were diagnosed clinically, radiologicaly and by laboratory investigation in ojha institute of chest diseases (oicd). all patients were assigned to standard treatment protocol consisting of two months intensive phase followed by 4 to 6 months of consolidation phase. the first phase drugs were rifampicin, isoniazid, ethambutol and pyrazinamide. during consolidation phase patients received rifampicin and isoniazid. dose was adjusted according to patients’ weight. patients were followed both by treating physician and eye department. serum uric acid and liver function test were followed during 1st two months. visual outcome is better if the patient is screened early and treated promptly. however increase in number of cases of tb worldwide with ocular symptoms needs thorough investigations to rule out choroidal tuberculosis. visual outcome is better if the patient is screened early and treated promptly. due to its effects on eye sight and increase in the incidence rate of miliary tuberculosis patients in pakistan, we conducted this study in our department to find out the frequency and visual outcome. frequency and visual outcome of choroidal tubercles with miliary tuberculosis pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 215 fig. c: post – treatment fundus photograph second follow up at six months fig. c1: right eye: complete regression of choroidal tubercle with pigmentary changes at macula fig. c2: left eye: inactive choroidal tubercle below the disc at six months material and methods two hundred and seventy two (272) cases were included in the study referred from ojha institute of chest disease (oicd) karachi with confirmed diagnosis of miliary tuberculosis. all patients above 10 and below 80 years of age with diagnosis of miliary tuberculosis were included in the study. patients already taking treatment for over one month excluded. patients with glaucoma, maculopathy, media opacities (cornea or vitreous) cataract and visual pathway problem, patients with acute anterior uveitis, diabetes with advanced retinopathy, irregular anitubercular treatment, ,poor follow up and patients with previous ocular trauma were excluded from study. freshly diagnosed cases of mtb were included in the study. this observational, descriptive study was conducted at department of ophthalmology from 24th april 2010 to 23rd november 2013. diagnosed cases of miliary tuberculosis referred from oicd were included in the study. a total of 272 cases were enrolled. a careful history was taken from each patient and recorded on a performa which included: name, age, gender, address, presenting complaints and their duration. complete ocular examination was done and findings were recorded on a performa, which included uncorrected and corrected visual acuity, slit lamp examination, tonometry, fundoscopy and fundus photography. the diagnosis of choroidal tubercle in our cases is mainly based on clinical finding as both clinical and histopathological descriptions are available in literature.13,14-16 also the cases in our study were all diagnosed cases of miliary tuberculosis referred from ojha institute of chest diseases (oicd). their diagnosis were made on clinical examination, radiological findings and laboratory investigations. choroidal tubercles in number, site and size were noted. record of visual acuity at the beginning and completion of treatment as mentioned in the introduction, were noted at follow up visits. results total of 272 patients were included in the study. among these cases, 14 (5.14%) had choroidal tubercles with male to female ratio was 8:6. they were all on anti tuberculous treatment. in majority of cases choroidal tubercles were unilateral and ranged in size from 1 to 2 disc diameter (dd). they were mostly localized at the posterior pole. the lesions number ranged from 5 to 10. the appearance initially was yellow and pigmentation occured later on. in one case choroidal tubercles were associated with serous retinal detachments. pretreatment fundus photography of patient with choroidal tubercles given in figure a. (a1, a2) post mirza shafiq ali baig, et al 216 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology treatment fundus photography of patient with choroidal tubercles in first and second follow up visit given in figure b (b1, b2) and figure c (c1, c2). all cases had a best corrected visual acuity of 6/9 or better after six months treatment with anti tubercular therapy. discussion tuberculosis is one of the leading infectious causes of morbidility and mortality worldwide. miliary tuberculosis is a complication of pulmonary tuberculosis. unfortunately pakistan is also facing this major health problem and stand among the five high burdened countries in the world. according to world health organization the incidence of tb is increasing day by day. the recognized association of tb with eye complications dates back to the 17th century, when iris lesions in tb patients were described.6 recognition of choroidal tubercles in the medical literature was first noted between 1830 and 1844.7 it is estimated that 1.4% of persons with pulmonary tb (ptb) develop ocular manifestations8,9 but many patients with ocular tb have no evidence of ptb.10–12 the diagnosis of ocular tb is important because prompt treatment may improve the individual patient’s outcome. delayed diagnosis can lead to pain, vision loss, and systemic complications of the infection. extensive literature and studies are available on miliary tuberculosis and its ocular involvement. however, to our knowledge, there is no study in pakistan so far to determine frequency of choroidal tubercles and visual out-come in diagnosed cases of miliary tuberculosis. in our study all 272 patients were diagnosed cases of miliary tb and referred from ojha institute of chest disease (oicd) karachi. they were all taking standard anti tuberculous treatment regularly. we only confined our study on frequency of choroidal tubercles and their visual outcome. among 272 cases only 14 (5.4%) patients were found to have choroidal tubercles. all patients having choroidal tubercles had decreased vision improved on completion of treatment as shown in table 2. choroidal tubercles are seen in 1.4% to 60% of patients with different forms of tb reported in many studies.18,19 in malawi, africa, a 2.8% incidence of choroidal granuloma in 109 patients with fever and tuberculosis was reported in a prospective study in 2002.20 frequency and visual outcome of choroidal tubercles with miliary tuberculosis pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 217 the frequency with which various investigators21 found choroidal tubercle is given in the table 4. our study correlates with the above mentioned studies. however our study is from a single center and city. therefore we suggest that the scope of the study in future must be multi center and involves various parts of the country. choroidal tubercles are the most recognized lesions in intraocular tb, with both clinical and histopathologic descriptions available in the literature13,14–16. the tubercles are located deep in the choroid, presenting unilaterally (more commonly) or bilaterally as yellowish lesions, discrete with illdefined borders and typically elevated centrally. most commonly situated in the posterior pole, these are solitary or few in number. inflammatory cells may be present in the anterior chamber or vitreous cavity. subretinal fluid may be present. histological examination reveals granulomatous inflammation, caseation necrosis and acid fast bacilli (afb). varying degrees of marginal pigmentation and scar formation occured with their healing.17 if untreated, a choroidal tubercle may grow into a large tumor-like mass called tuberculoma. it is seen as a yellowish, elevated mass-like lesion mimicking an abscess that is subretinal, with surrounding retinal detachment. choroidal tubercles are localized in the choroid, but may rarely rupture the bruch's membrane, and invade the subretinal space and the vitreous cavity, causing widespread intraocular inflammation, necessitating vitrectomy.16 poor vision at presentation may be due to tubercles located in and around the macula with surrounding subretinal fluid. peripheral tubercles are usually asymptomatic unless associated with anterior segment inflammation. conclusion the study is unique and done for the first time in pakistan. frequency of choroidal tubercles with diagnosed cases of mliary tuberculosis is 5.14%, with gender distribution female to male was 8:6. visual outcome is better if the patient is screened early and treated promptly author’s affiliation prof. dr. mirza shafiq ali baig professor & head department of ophthalmology dow international medical college (dimc) dow university hospital (duh) dow university of health sciences (duhs) karachi prof. muhammad masroor principal dow international medical college (dimc) director ojha institute of chest disease (oicd) head department of medicine dow university hospital (duh) dow university of health sciences (duhs) karachi dr. jameel a. burney chief ophthalmologist department of ophthalmology sindh govt. qatar hospital orangi town, karachi dr. farnaz siddiqui assistant professor department of ophthalmology dow international medical college (dimc) dow university hospital (duh) dow university of health sciences (duhs) karachi dr. mazhar ul hassan assistant professor department of ophthalmology dow international medical college (dimc) dow university hospital (duh) dow university of health sciences (duhs) karachi javascript:newshowcontent('active','references'); mirza shafiq ali baig, et al 218 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology dr. sarfaraz nawaz senior medical officer department of ophthalmology dow international medical college (dimc) dow university hospital (duh) dow university of health sciences (duhs) karachi syed muhammad adnan bio-statistician national institute of diabetes and endocrinology (nide) dow university of health sciences (duhs) karachi references 1. schlossberg d, maher d. the global epidemic of tuberculosis: a world health organization perspective in tuberculosis and nontuberculous mycobacterial infections. ed schlossberg d (philadelphia wb saunders), 1999; 10: 104–15. 2. dye c, scheele s, dolin p, et al. consensus statement. global burden of tuberculosis: estimated incidence, prevalence, and mortality by country. who global surveillance and monitoring project. jama 1999; 282: 677–86. 3. who emro stop tuberculosis programmes pakistan. the global plan to stop tb. 2011-2015. 4. thompson mj, albert dm. ocular tuberculosis. arch ophthalmol. 2005; 123: 844. 5. yeh s, sen hn, colyer m, et al. update on ocular tuberculosis. curr opin ophthalmol. 2012; 23: 551. 6. maitre-jan a. traite des maladies des yeux. 1711, troyes. 456. in: helm cj, holland gn, ocular tuberculosis. surv ophthalmol. 1993; 38: 229–56. 7. wecker lv. die erkrankungen des uvealtractus und des glaskorpers. tuberkeln der choroidea. chloroiditis tuberculosis, in graefe a, saemisch t, eds. handbuch der gesammten augenheilkunde. 1874; 4: 642–648. 8. gupta a, gupta v. tubercular posterior uveitis. int ophthalmol clin. 2005; 45: 71–8. 9. biswas j, badrinath ss. ocular morbidity in patients with active systemic tuberculosis. int ophthalmol. 1996; 19: 293-8. 10. morimu ra y, okada aa, kawahara s, et al. tuberculin skin testing in uveitis patients and treatment of presumed intraocular tuberculosis in japan. phthalmology. 2002; 109: 851–7. 11. sarvananthan n, wiselka m, bibby k. intraocular tuberculosis without detectable systemic infection. arch ophthalmol. 1998; 116: 1386-8. 12. shome d, honavar s, vemuganti g, et al. orbital tuberculosis manifesting with endophtalmos and causing a diagnostic dilemma. ophthal plast reconstr surg. 2006; 22: 219–21. 13. gupta v, gupta a, rao na. intraocular tuberculosis – an update. surv. ophthalmol. 2007; 52: 561-87. 14. helm cj, holland gn. ocular tuberculosis. surv. ophthalmol. 1993; 38: 229–56. 15. gupta v, gupta a, sachdeva n, arora s, bambery p. successful management of tubercular sub-retinal granulomas. ocul. immunol. inflamm. 2006; 14: 35–40. 16. biswas j, madhavan hn, gopal l, badrinath ss. intraocular tuberculosis. clinicopathologic study of five cases. retina. 1995; 15: 461-8. 17. mehta s. healing patterns of choroidal tubercles after antitubercular therapy: a photographic and oct study. j. ophthalmic inflamm. infect. 2012; 2: 95–7. 18. biswas j, badrinath ss. ocular morbidity in patients with active systemic tuberculosis. int of ophthalmol. 1995-1996; 19: 293-8. 19. illingworth rs, lorber j. tubercles of the choroid. arch dis child. 1956; 31: 467-9. 20. beare na, kublin jg, lewis dk, et al. ocular disease in patients with tuberculosis and hiv presenting with fever in africa. br j ophthalmol. 2002; 86: 1076-79. 21. ronald s. illingworth, trevor wright. tubercle of the choroid. british medical journal. 1948; 21. 22. debre r, st thieffry, brissaud; nonfflard h. british medical journal. 1974; 21: 899. 23. moore r. medical ophthalmology blakeston phikadepphia. f. 1922; p. 198. 24. groenouw a. beziehungen and krankheiten des sehorganes. berlin. 1920; 3rd ed. p. 1079. 25. marple w. ophthalmoscope. b 1912; 10: 559 26. carpenter g, stepherson s. ophthalmoscope. 1905; 3: 375. 27. litten m. samml klin vortr. 1877; 119. quoted by bredeck 1916. http://www.uptodate.com/contents/tuberculosis-and-the-eye/abstract/1 http://www.uptodate.com/contents/tuberculosis-and-the-eye/abstract/1 http://www.uptodate.com/contents/tuberculosis-and-the-eye/abstract/2 http://www.uptodate.com/contents/tuberculosis-and-the-eye/abstract/2 186 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology erratum conservative management of congenital eversion of the upper lid in a nigerian child c.o. omolase, o.t. ogunleye, b.o. omolase, a. ogedengbe pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . in pjo vol. 28; issue 4; 2012 the fig 1 was replicate in fig 2. the corrected figures are given below. fig. 1: congenital upper eye lid eversion before commencement of management fig. 2: normal eyelids 4 days after treatment author’s affiliation dr. c. o. omolase department of ophthalmology federal medical centre, owo ondo state, nigeria dr. o. t. ogunleye department of ophthalmology federal medical centre, owo ondo state, nigeria dr. b. o. omolase department of ophthalmology federal medical centre, owo ondo state, nigeria dr. a. ogedengbe department of family medicine federal medical centre, owo ondo state, nigeria pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 4 original article sight threatening diabetic retinopathy in type – 2 diabetes mellitus mohammad memon, sajjad ali surhio, shahzad memon, noor bakht nizamani, khalid iqbal. talpur pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: noor bakht nizamani, department of ophthalmology, liaquat university eye hospital, jail road, hyderabad, 71000, sindh, …..……………………….. purpose: to determine the proportions of proliferative diabetic retinopathy (pdr) and clinically significant macular edema (csme) in patients with known type–2 diabetes mellitus. material and methods: a prospective study was conducted at ophthalmology department, liaquat university of medical and health sciences, hyderabad, pakistan. duration of study was one year, starting from 1 st january 2010 till 31 st december 2010. two hundred consecutive type – 2 diabetics diagnosed with diabetic retinopathy were classified according to the most severe changes in the worse eye into the following three stages based on edtrs classification. 1) patients with non–proliferative diabetic retinopathy (npdr). 2) patients with csme stage (in the presence of npdr). 3) patients with pdr stage (irrespective of presence or absence of csme). results: the mean age of patients with diabetic retinopathy was 51.7 ± 9.4 years. 62 (31%) patients had pdr, and another 66 (33%) patients had csme. 51.6% of patients with pdr were in the age group of 40 – 49 years and 56% of patients with csme were 50 – 59 years. patients presented with pdr were significantly younger (p–value < 0.001) than patients with csme and npdr. 51% of patients had dm for 15.7 ± 6.1 years; with a mean age of 30.5 ± 4.6 years at diagnosis with type – 2 dm. conclusion: 64% of patients had sight – threatening stages of diabetic retinopathy, and 34.4% of them were 40 – 49 years of age. iabetes mellitus (dm) is a chronic, costly and potentially disabling disease due to its severe complications. there are 285 million adults worldwide with dm; having a prevalence of 6.4% among adults aged 20 – 79 years.1 pakistan has the 7th largest population of dm with 7.1 million people; having a prevalence of 9% among adults ≥ 25 years of age1,2. diabetic retinopathy is one of the common micro vascular complications of dm. the risk of developing diabetic retinopathy increases with the duration of dm. 3 the prevalence of diabetic retinopathy among diabetic subjects varies between 15.3% and 28.9% in various studies conducted in pakistan4,5. diabetic retinopathy progresses from the asymptomatic non-proliferative diabetic retinopathy (npdr); characterized by increased vascular permeability and progressive vascular closure, to the sight – threatening proliferative diabetic retinopathy (pdr); characterized by growth of new blood vessels on the retina3,6. the new blood vessels in pdr may bleed causing vitreous hemorrhage with sudden loss of vision, or may lead to tractional retinal detachment and neovascular glaucoma. meanwhile; clinically significant macular edema (csme) can develop during any stage of diabetic retinopathy, and it is characterized by retinal thickening from leaky blood vessels causing slow and gradual blurring of vision3,6. more than 90% of cases of diabetes worldwide are type – 2 dm. type – 2 dm occurs at a relatively younger age in the indian subcontinent than elsewhere in the world7. basit et al8 in a study on 2199 type – 2 diabetics had observed that; the age at onset of dm was < 40 years in 46.3% of type – 2 diabetics. d mohammad memon, et al 5 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology early onset type – 2 dm may cause diabetic retinopathy to develop at a relatively younger age. the aim of this study was to determine the proportions of proliferative diabetic retinopathy (pdr) and clinically significant macular edema (csme) in patients with known type – 2 dm. material and methods this cross sectional study was carried out at department of ophthalmology, liaquat university of medical and health sciences, hyderabad, pakistan, from 1st january 2010 to 31st december 2010. the sample size was calculated using computer software open epi version 2. a sample of 200 diabetics with retinopathy was required for 15.3% prevalence at 95% confidence interval and absolute precision of ± 5% (based on 15.3% prevalence of diabetic retinopathy in the diabetic subjects of the pakistan national blindness and visual impairment survey)4. diabetic retinopathy screening was performed in all known as well as newly diagnosed type – 2 diabetics (already on oral hypoglycemic drugs or on insulin) coming to our hospital for routine checkup with or without complain of decreased vision or any other ocular symptom. detailed history was taken including name, age, gender, duration of dm and the mode of treatment (oral hypoglycemic drugs or insulin). detailed ocular examination was performed including best corrected visual acuity (bcva), anterior segment examination and fundus examination. patients were excluded if fundus details were not visible due to cataract or corneal opacity. the patients were divided according to the most severe diabetic retinopathy changes in the worse eye into the following three groups based on edtrs classification: a) patients with npdr stage b) patients with csme stage (in the presence of npdr) c) patients with pdr stage (irrespective of presence or absence of csme). also; the patients were stratified according to their age into the following five age groups: below 30 years, 30 – 39 years, 40 – 49 years, 50 – 59 years and above 59 years of age. the data was analyzed using spss version 11 software. the descriptive statistics obtained were; the age distribution, the proportion of various stages of diabetic retinopathy, and the distribution of stage of retinopathy by the age of patients. the mean and standard deviation (sd) for the age at presentation with diabetic retinopathy, the duration of dm, and the estimated age at onset of dm were compared; between different stages of diabetic retinopathy using one way anova test. p – value < 0.05 was taken as significant. results in this study; 200 consecutive type – 2 diabetics diagnosed with diabetic retinopathy were included. 121 (60.5%) patients had presented with an ocular symptom, meanwhile; the remaining 79 (39.5%) patients were referred for diabetic retinopathy screening by physicians. over 52% of our patients were females with mean age of 50.4 ± 9.7 years. males were significantly older with mean age of 53.1 ± 8.8 years (p – value = 0.043). males also had a significantly longer duration of dm (p – value < 0.001); the duration of dm in males was 14.6 ± 7.4 years, while females had a mean duration of 11.9 ± 4 years. table 1 shows the overall demographic features of our patients along with difference in demographics of patients with different stages of diabetic retinopathy. the difference in the mean duration of dm in patients with different stages of diabetic retinopathy was statistically insignificant (p – value = 0.083). however; patients with pdr were significantly younger at the time of diagnosis with dm than other patients (p – value < 0.001) (fig. 1). in 51% of patients the age at diagnosis with dm was < 40 years; and they were considered to have early onset type – 2 dm. 40.2% (41/ 102) of patients with early onset type – 2 dm had already been shifted from oral hypoglycemic drugs to insulin by their physicians to control their dm. meanwhile; 17.3% (17 / 98) of patients with late onset type – 2 dm were on insulin. because of early onset type – 2 dm in our patients; 58.1% (36 / 62) of patients with pdr were < 50 years of age. table 2 shows an overall comparison between patients with early onset type – 2 dm v/s late onset type – 2 dm. table 3 shows detailed comparison between patients with early onset type – 2 dm v/s late onset type – 2 dm; presented with different stages of diabetic retinopathy. discussion the prevalence and severity of diabetic retinopathy increases with the duration of dm and age of the patients, along with; poor metabolic control. but sight threatening diabetic retinopathy in type – 2 diabetes mellitus pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 6 traditionally; the age has been coupled to the duration of dm and was not regarded as an independent risk factor3. niazi et al9 and chaudhary5 reported that only the longer duration of dm was proved to be an independent risk factor for both type and progression of diabetic retinopathy. al – maskari and el – sadig10 observed an increase in the prevalence of diabetic retinopathy with increasing age (p = 0.004) and disease duration (p = 0.0001). similar results were reported in several studies11,12. in this study; the mean age of patients presenting with diabetic retinopathy was 51.7 ± 9.4 years, which is consistent with other national5,13–15, and mohammad memon, et al 7 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology international studies11,16–18. thirty one percent of our patients had the sight threatening pdr, and similar results were reported in literature2,13,14,16–18. meanwhile, other studies had reported lower prevalence of pdr among patients with any type of diabetic retinopathy, i.e. 11.7% (111 / 946) was reported by chaudhary gm5, 20.9% (163 / 780) by khan aj15, and 14.6% (172 / 1176) was reported by agrawal et al11. this lower prevalence of pdr might be related to the difference in the duration of dm. the short duration of ≤10 years of dm; was observed in 60.5% by chaudhary gm5, in 52.2% by khan aj 15, and in 42.4% by agrawal et al11. whereas in this study, only 35% of patients had dm for ≤10 years. the prevalence of the sight – threatening csme among our patients with npdr was 47.8% (66/138), this is consistent with literature12,14,18,19. however sight threatening diabetic retinopathy in type – 2 diabetes mellitus pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 8 fig. 1: diabetic retinopathy and age at diagnosis with diabetes mellitus lower prevalence of csme (15-22%)16,20 has been reported among patients with npdr, which could be related to the difference in the duration of dm. in the aforementioned studies 53.7%20 and 49.6%16 patients had ≥ 11 years duration of dm, while 65% of our patients had that much duration, which might explain the higher prevalence of csme with npdr. the sight– threatening diabetic retinopathy (either pdr or csme) was observed in 64% (128/200) of our patients. this high prevalence may be due to the selection bias, and; it is one of the disadvantages of a tertiary hospital – based study like ours. the mean age of our patients with csme was 53.4 ± 8.7 years, and; 56.0% of them were 50 – 59 years, while; 18.2% were 40 – 49 years. similarly; aziz-urrahman et al 21 had reported that; 41.5% (34/82) of patients with diabetic maculopathy were 51 – 60 years and 30.5% (25/82) were 41 – 50 years of age. meanwhile; the mean age of our patients with pdr was 47.0 ± 8.8 years with 58.1% being < 50 years of age, which is younger age comparatively15. we observed that, 51% of our patients with diabetic retinopathy had early onset type – 2 dm (< 40 years of age at diagnosis with dm), and among them; 33.3% had presented with pdr, and another 27.5% had csme. the trend of early onset type – 2 dm in pakistan had been reported previously2,8,22. there is an evidence suggesting that microvascular complications may develop and progress more rapidly in patients with early onset type – 2 dm, and that is due to an increased tissue susceptibility to the damaging effects of hyperglycemia at a younger age23. similarly it has been reported that patients with dm diagnosed at < 45 years of age had a higher prevalence and more severe grades of diabetic retinopathy than those diagnosed later, despite matched duration of dm and glycemic control24. the younger age at onset of type – 2 dm is an independent risk factor for the development of diabetic retinopathy (the odds ratio for diabetic retinopathy was 1.9, 1.1, and 1; when age at onset of dm was < 45, 45 – 55 and > 55 years respectively)24. early detection of diabetic retinopathy in diabetic patients should be planned in liaison with local general medical practioners. arranging screening programs for all ages especially between 40-60 years at the time of diagnosis and thereafter annually. conclusion over 51% patients in our study had diabetic retinopathy on diagnosis with a mean age of 30.5± 4.6 years. majority of the patients with type-2 dm (64%) had sight threatening proliferative diabetic retinopathy with or without csme on presentation ranging mostly in < 50 years age group. there is a higher prevalence of sight threatening dr (pdr or csme) in our patients with earlier presentation. early onset of type-2 dm is related to greater prevalence of sight threatening dr. author’s affiliation dr. mohammad memon department of ophthalmology, liaquat university of medical and health sciences, jamshoro/hyderabad, pakistan dr. sajjad ali surhio department of ophthalmology, liaquat university of medical and health sciences, jamshoro / hyderabad, pakistan dr. shahzad memon department of ophthalmology, liaquat university of medical and health sciences, jamshoro / hyderabad, pakistan dr. noor bakht nizamani department of ophthalmology, liaquat university of medical and health sciences, jamshoro / hyderabad, pakistan mohammad memon, et al 9 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology dr. khalid iqbal. talpur department of ophthalmology, liaquat university of medical and health sciences, jamshoro / hyderabad, pakistan references 1. shaw je, sicree ra, zimmet pz. global estimates of the prevalence of diabetes for 2010 and 2030. diabetes res clin pract. 2010; 87: 4-14. 2. mahar ps, awan z, manzar n, memon s. prevalence of type-2 diabetes mellitus and diabetic retinopathy: the gaddap study. j coll physicians surg pak. 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al–maskari f, el–sadig m. prevalence of diabetic retinopathy in the united arab emirates: a cross – sectional survey. bmc ophthalmol. 2007; 7: 11. 11. agrawal rp, ranka m, beniwal r, gothwal sr, jain gc, kochar dk, et al. prevalence of diabetic retinopathy in type 2 diabetes in relation to risk factors: hospital based study. int j diab dev ctries. 2003; 23: 16-9. 12. khandekar r, al lawatii j, mohammed aj, al raisi a. diabetic retinopathy in oman: a hospital based study. br j ophthalmol. 2003; 87: 1061-4. 13. kayani h, rehan n, ullah n. frequency of retinopathy among diabetics admitted in a teaching hospital of lahore. j ayub med coll abottabad. 2003; 15: 53-6. 14. siddiqui sj, shah sia, shaikh aq, depar my, abbassi sa. study of 189 cases of diabetic retinopathy at cmc larkana. pak j ophthalmol. 2007; 23: 92-6. 15. khan aj. age, sex and duration relationships and prevalence of diabetic retinopathy in pakistani population. pak j ophthalmol. 1990; 6: 6-8. 16. javadi ma, katibeh m, rafati n, dehghan mh, zayeri f, yaseri m et al. prevalence of diabetic retinopathy in tehran province: a population – based study. bmc ophthalmol. 2009; 9: 12. 17. el haddad oa, saad mk. prevalence and risk factors for diabetic retinopathy among omani diabetics. br j ophthalmol. 1998; 82: 901-6. 18. bamashmus ma, gunaid aa, khandekar rb. diabetic retinopathy, visual impairment and ocular status among patients with diabetes mellitus in yemen: a hospital-based study. indian j ophthalmol. 2009; 57: 293-8. 19. narendran v, john rk, raghuram a, ravindran rd, nirmalan pk, thulasiraj rd. diabetic retinopathy among self reported diabetics in southern india: a population based assessment. br j ophthalmol. 2002; 86: 1014-8. 20. ishaque n, rahman n. prevention of significant visual loss in diabetic macular edema by early laser photocoagulation. pak j ophthalmol. 1998; 14: 73-6. 21. aziz-ur-rahman, aziz tm, niazi jh. use of diode laser in diabetic maculopathy. pak j ophthalmol. 2001; 17: 43-7. 22. iqbal f, naz r. patterns of diabetes mellitus in pakistan: an overview of the problem. pak j med res. 2005; 44: 59-64. 23. song sh, hardisty ca. early onset type 2 diabetes mellitus: a harbinger for complications in later years--clinical observation from a secondary care cohort. qjm. 2009; 102: 799-806. 24. wong j, molyneaux l, constantino m, twigg sm, yue dk. timing is everything: age of onset influences long-term retinopathy risk in type 2 diabetes, independent of traditional risk factors. diabetes care. 2008; 31: 1985-90. pak j ophthalmol. 2021, vol. 37 (1): 75-82 75 original article types of pattern strabismus and their surgical outcomes after adjustable strabismus surgery sana nadeem 1 1 department of ophthalmology, foundation university medical college & fauji foundation hospital, rawalpindi abstract purpose: to study the different types of pattern strabismus and their surgical outcomes after adjustable strabismus surgery. study design: prospective, interventional study. place and duration of study: eye department, fauji foundation hospital, rawalpindi (june, 2016 to march, 2019). methods: a total of 40 consecutive patients with pattern strabismus were included in the study. after complete orthoptic assessment, the patients underwent either rectus muscle transposition or oblique muscle surgery, by adjustable squint surgery. the pre-operative evaluation of different strabismus patterns, deviations, and postoperative results were measured and analyzed. the amount of postoperative pattern change was measured at 6 weeks postoperatively, to assess the success of the surgeries. results: out of 40 patients, 33 were females and 7 were males. the age ranged from 7 to 69 years (mean 18.05 ± 9.6). all patients were operated by using adjustable suture technique.“v” pattern was seen in 26 cases (65%) and “a” pattern was seen in 12 (30%) cases. the mean preoperative pattern was 13.2 ± 8.09 pd (prism diopters), and the mean postoperative pattern was 2.05 ± 2.96 pd. surgical success was defined as the amount of pattern collapse at 6 weeks, the period at which a stable alignment was achieved. the difference between the preoperative and postoperative pattern deviation was statistically significant (p=0.000). correction of the pattern was seen in 92.5% of patients at average follow up of 50.87±14.02 days. conclusions: pattern strabismus can be corrected by varying rectus muscle transpositions or oblique muscle surgery during routine adjustable strabismus surgery. key words: strabismus, v pattern, a pattern, y pattern, x pattern, lambda pattern, muscle transposition. how to cite this article: nadeem s. types of pattern strabismus and their surgical outcomes after adjustable strabismus surgery. pak j ophthalmol. 2021, 37 (1): 75-82. doi: https://doi.org/10.36351/pjo.v37i1.1049 introduction strabismus patterns are a common occurrence in routine strabismus patients, although discussed correspondence: sana nadeem department of ophthalmology, foundation university medical college & fauji foundation hospital, rawalpindi email: sana.nadeem018@gmail.com received: april 19, 2020 accepted: october, 29, 2020 scarcely. these include the frequently occurring “a” and “v” patterns, and also the not so common “y”, “λ” (lambda), “x”, and “↓” (arrow) patterns. the “v” pattern was the first of its kind to be described in 1897, by duane in a patient with bilateral superior oblique palsy. 1.2 years later, in 1948, urrets-zavalia described the deviation in upgaze and downgaze, and bought attention to the “a” and “v” patterns, the terms coined by urist in 1951. 1,2 typically, a “v” pattern describes horizontal strabismus, with vertical incomitance in upgaze and sana nadeem 76 pak j ophthalmol. 2021, vol. 37 (1): 75-82 down gaze of 15 prism diopters (pd) or greater, or more esotropia and less exotropia in down gaze when compared in upgaze. the “a” pattern is defined converse to the “v” pattern with a difference between upgaze and down gaze of 10 pd or more, with more esotropia and less exotropia in upgaze relative to down gaze. minimal change in down gaze to primary position, but exotropia (divergence) in upgaze, defines a “y” pattern, seen usually in duane and brown syndromes. this is usually caused by bilateral inferior oblique over action in congenital horizontal strabismus. a lambda (“λ”) pattern is converse to the “y” pattern, in which divergence is maximum between primary position and down gaze. this is observed in bilateral superior oblique over action or inferior rectus under action. an “x” pattern denotes divergence in both upgaze and down gaze, and the exotropia may be controlled in primary position by fusion. this is caused by all four oblique over action. an arrow (“↓”) pattern, describes maximum convergence in primary and down gaze positions, typically observed in bilateral superior oblique palsy. 3 pathophysiological mechanisms for pattern strabismus, though unclear, have been attributed both to mechanical (peripheral) and neural (central) factors; the former occurring as a result of oblique muscle under or overaction, ectopic muscle pulleys or orbital deformities in craniofacial dysostosis, hydrocephalus or plagiocephaly; and the later being caused by loss of fusion with abnormal torsion, abnormal supranuclear circuits or vestibular hypofunction. transposition of the horizontal rectii is a reasonable approach for correcting about 15-20 pd of pattern, in the absence of oblique over action; larger amounts require oblique weakening if over action is present; bilateral inferior oblique weakening corrects 15-25 pd, whereas bilateral superior oblique weakening can correct as much as 40 pd. 2,3 it is important for the strabismus surgeon to recognize both common and rare patterns in strabismus and to correct them accordingly, to provide maximum cosmesis to the patient. the purpose of our study was to identify any patterns occurring in strabismus patients, and to correct them during routine adjustable strabismus surgery. methods a total of 40 consecutive patients were included in this study carried out in the department of ophthalmology, fauji foundation hospital, rawalpindi, a tertiary care teaching hospital affiliated with the foundation university medical college. the study was carried out from june, 2016 to march, 2019. approval from the ethical committee was taken. horizontal, vertical and complex strabismus cases were included. patients with previous history of strabismus surgery were also included. all surgeries were performed by the same surgeon. myasthenia gravis, pattern less than 5 pd and uncooperative children less than 7 years of age were excluded. a detailed ocular assessment was done for every case. best-corrected visual acuity was documented and refractive correction was given to patients prior to the surgery. the preoperative angle of deviation was assessed by the prism cover test with the refractive correction in place, for both near and distance in primary gaze position, as well as in 25° of upgaze (chin down) and 35° of down gaze (chin up) 1 , right and left gaze, and head tilt in cases of paralytic strabismus. in certain cases of sensory strabismus with poor fixation, the krimsky test was used for analysis of the angle or a pen torch was used as a target for near and distance. the distance angle in primary position with refractive correction in place was considered as the angle of deviation in all cases, and the surgical alignment was sought to correct this angle, although at the time of suture adjustment, both near and distance alignment was corrected. exception to this was accommodative refractive esotropia, for which the near deviation with distance spectacles in place was considered for correction of the alignment. measurements were taken by the operating surgeon and repeated one day prior to surgery, to obtain maximum cosmesis. extraocular motility was checked with muscle over-action graded from +1 to +4 and under-action graded from -1 to -5. binocular vision and stereopsis were assessed by the titmus fly test and worth-four-dot test, for every case as a routine. a thorough eye examination was performed including fundus examination and intraocular pressures. in case of significant oblique over-action or vertical strabismus, fundus torsion was assessed with the indirect ophthalmoscope. all surgeries were performed under general anesthesia. a drop of phenylephrine 10% (ethifrin ® ) was instilled into the conjunctival fornix at the beginning of surgery in each eye. the fornix approach for strabismus surgery was used in every case. each muscle was hooked, and then secured with a double surgical outcomes of different types of pattern strabismus pak j ophthalmol. 2021, vol. 37 (1): 75-82 77 fig. 1: (a-b) correction of pattern for an “a” pattern strabismus (a): displacement of the lateral rectus away from the apex 5 mm or half tendon width. (b): displacement of the medial rectus 5 mm towards the apex. this is irrespective of whether the rectus muscle is recessed or resected. (c-e): inferior oblique myectomy. (c): inferotemporal fornix incision and exposure of inferior oblique with two squint hooks. (d): clamping of each end with artery forceps and cutting it between them. (e): cautery to cut ends of muscle. armed 6-0 vicryl, which was passed through the sclera at its insertion, or transposed above or below the insertion in case of “a” or “v” patterns, in a „hangback‟ fashion. the medial rectii were transposed towards the apex of the pattern, and the lateral rectii were transposed away from the apex of the pattern (figure 1 a-b) (figure 2: a-d). the amount of transposition varied from 1mm to 5mm, the latter being the standard half tendon width. this depended upon the amount of pattern noted and increased with increasing pattern. in case of significant inferior oblique over-action or dvd (dissociated vertical deviation), inferior oblique myectomy (figure 1 c-e) or anteriorization respectively, were done to correct the pattern. the recessed muscles were mostly placed for adjustable purpose, with the required recession held in place by guyton‟s modification of the sliding noose knot, which was fashioned with a 6-0 vicryl suture. the amount of „hang-back‟ recession was calculated for each patient using standard tables. the traction suture for holding the sclera for postoperative adjustment was created with ethibond 5-0 in every case. for the non-adjustable recessions, the muscle was tied and allowed to „hang-back‟ from its insertion, with the required amount of recession calculated as required. for resections, the amount of resection was overcorrected by 2 mm, and allowed to „hang-back‟ for this distance, to be adjusted if required postoperatively. at least one muscle was kept on an adjustable sliding noose knot per case; with complex strabismus, all muscles were kept on adjustable sutures. all patients were assessed for alignment and final adjustment at least 1 hour or more after surgery, in the recovery room, to allow for the effects of general anesthesia to wear off. the eyes were anesthetized topically with alcaine ® (proparacaine hydrochloride 0.5%) eye drops. the patients were assessed with the cover-uncover test at distance and near, with a torch sana nadeem 78 pak j ophthalmol. 2021, vol. 37 (1): 75-82 light for distance if the vision was blurred, or a distance readable target, and for near an accommodative target was used. if the alignment was satisfactory, with no movement on cover testing, the sutures were tied off in their existing position, held in place by the sliding noose, which was removable after tying the ends of the muscle sutures. thereafter, the traction knot was cut, and the conjunctiva was sutured with at least one 6-0 vicryl suture. the final tying off point was orthotropia or maximum possible undercorrection as required. in cases of exotropia, the goal was orthotropia or mild esotropia. in cases of esotropia, the goal was either orthotropia, if achieved, or slight under-correction. the transpositions were not adjustable, but were predetermined, and so were the inferior oblique weakening procedures. the superior oblique muscle was not operated upon in any case. in five cases of small degrees of patterns, only routine adjustable surgery was performed. the alignment was noted postoperatively, the next day, at 2 weeks follow up, and then at 6 weeks after surgery. the patients were given postoperative topical steroids and antibiotic drops twice a day and ointment at night for a minimum of 2 weeks. surgical success or primary outcome measure was defined in terms of amount of collapse of the pattern as compared to pre-operative pattern, at the end of at least 6 weeks after surgery. this is the time at which a stable alignment is achieved and this usually correlates with long-term success. although both horizontal, vertical and complex strabismus were included in our study, the horizontal alignments preoperatively and postoperatively, were mainly assessed except for 2 cases of monocular elevation deficiency, in which the hypotropia was assessed for success of adjustable strabismus surgery. horizontal deviations were assessed and analyzed for pattern strabismus collapse after surgery. the results were noted, tabulated and analyzed using the spss version 20. frequencies were calculated for age, gender, type and pattern of strabismus, surgical procedure performed, as well as the follow up period. the difference between the preoperative and postoperative deviation and patterns was analyzed by the wilcoxon signed ranks test, with a significance of less than 0.05. results a total of 40 consecutive patients with pattern strabismus presenting to us were included in this study. the mean age was 18.05 ± 9.6 years (range 769). there were 33 (82.5%) females and the 7 males, (n = 7, 17.5%). the type of deviation in the majority of patients was exotropia in 17 (42.5%) cases (table 1). the pre-operative and post-operative patterns are detailed in table 2, with the majority being “v” patterns in 26 (65%) cases and “a” pattern in 12 (30%) cases (figure 2). table 1: type of deviation. type of deviation frequency(percent) pattern preoperative pattern postoperative v a x y v a y none exotropia 17(42.5) 15 2 0 0 6 3 2 6 esotropia 9(22.5) 3 6 0 0 0 4 0 5 exotropia & dvd ɸ 2(5.0) 1 0 1 0 1 0 1 0 esotropia & dvd ɸ 2(5.0) 1 1 0 0 1 0 0 1 exotropia & hypertropia 4(10.0) 4 0 0 0 1 0 0 3 esotropia & hypertropia 1(2.5) 0 1 0 0 0 1 0 0 esotropia & hypotropia 4(10.0) 2 1 0 1 1 1 0 2 exotropia & hypotropia 1(2.5) 0 1 0 0 0 1 0 0 horizontal 18(45.0) 12 6 0 0 4 5 2 7 horizontal and vertical 6(15.0) 5 0 1 0 2 1 0 3 complex € 10(25.0) 4 5 0 1 3 4 0 3 horizontal & complex € 4(10.0) 3 1 0 0 1 0 0 3 horizontal, vertical & complex € 2(5.0) 2 0 0 0 0 0 1 1 ɸ dissociated vertical deviation € sensory, monocular elevation deficit, paralytic strabismus, nystagmus or dvd surgical outcomes of different types of pattern strabismus pak j ophthalmol. 2021, vol. 37 (1): 75-82 79 table 2: pattern of strabismus. pre-operative patterns post-operative residual patterns pattern frequency percent pattern frequency percent v pattern 26 65.0 none 17 42.5 a pattern 12 30.0 v pattern 10 25.0 x pattern 1 2.5 a pattern 10 25.0 y pattern 1 2.5 y pattern 3 7.5 fig. 2: a. left esotropia of 80 pd with an “a” pattern of 25 pd, with bilateral duane syndrome type i. b. post-operative appearance at 6 weeks, after bi-medial recessions 7 mm od and 10 mm os and 5 mm upward transposition of each. c. alternate exotropia of 70 pd and a “v” pattern of 32 pd; managed by bilateral lateral rectus recessions of 7 mm and a right medial rectus resection of 6 mm, and bilateral inferior oblique myectomies. d. postoperative appearance. table 3: details of surgical procedures. surgical procedures for pattern deviations surgical procedures for horizontal and vertical deviation surgery for pattern correction frequency (percentage) horizontal muscle surgery frequency (percent) vertical muscle surgery frequency (percent) no surgery performed 5 (12.5) blrc ¶ 10 (25) none 22(55) 1 mm transposition β 1 (2.5) bmrc § 10 ( 25) unilateral io α myectomy 4(10) 2 mm transposition β 5 (12.5) bmrs ¥ 1 (2.5) bilateral io α myectomies 7(17.5) 3 mm transposition β 3 (7.5) mrc ¤ + lrs × 1 (2.5) io α anteriorization 1(2.5) 4 mm transposition β 1 (2.5) mrs ø + lrc ħ 10 (25) sr ω transposition 1(2.5) 4.5 mm transposition β 1 (2.5) blrc ¶ + mrs ø 2 (5) bilateral io myectomies + src ʃ 1(2.5) 5 mm (1/2 tendon) transposition β 10 (25) bmrc § + lrs × 2 (5) irc ϡ + src ʃ 3(7.5) unilateral io myectomy 4 (10) mrc ¤ 2 (5) irc ϡ 1(2.5) bilateral io myectomy 9 (22.5) lrc ħ 1(2.5) io anteriorization 1 (2.5) lrc ħ +mrs ø + mrc ¤ 1 (2.5) α inferior oblique β transposition of medial rectus towards apex of pattern and lateral rectus towards empty space of pattern ¶ bilateral recessions § bimedial recessions ¥ bimedial resections ¤ unilateral medial rectus recession × unilateral lateral rectus resection ø unilateral medial rectus resection ħ unilateral lateral rectus recession α inferior oblique ω superior rectus ʃ superior rectus recession ϡ inferior rectus recession table 3 outlines a list of surgeries performed for correction of the patterns and other primary deviations. the average number of muscles operated upon for each patient were 2.92 ± 1.09 (range 2-6). the mean pre-operative pattern deviation was 13.2 ± 8.09 pd (prism diopters) with a range from 5 to 35 pd. the mean post-operative pattern deviation was 2.05 ± 2.96 pd [range 0-12 pd] at 6 weeks. surgical sana nadeem 80 pak j ophthalmol. 2021, vol. 37 (1): 75-82 success or collapse of the pattern was seen in 92.5% of patients. five cases of small patterns in which no surgery for the pattern was undertaken were also observed for post-operative pattern collapse; in one case, the pattern persisted, in three cases, it disappeared completely, and in another one case, it increased. inferior oblique anteriorization to treat dvd, accentuated the pattern slightly, but treated the dvd. inferior oblique myectomy was effective in all cases. the wilcoxon signed ranks test was used to analyze the pre-operative pattern and post-operative pattern collapse, and the difference between the two was found to be statistically significant [p=0.000]. the mean preoperative deviation was 49.02 ±17.63 pd (range 20-83 pd), and the mean postoperative deviation was 2.53 ±4.42 pd [range 020 pd]. the wilcoxon test was also used to compare the preoperative and postoperative deviation, to assess for success of our adjustable strabismus technique, which was highly significant (p=0.000). the success rate of adjustable strabismus surgery in the short term (6 weeks postoperatively) for these patients was also 92.5%, in whom a postoperative deviation within ≤10 pd of orthotropia was achieved. the average follow-up was 50.87±14.02 days (range 38-94 days). discussion alphabet patterns in strabismus are important aspects of strabismus management that need to be assessed carefully during workup of routine strabismus patients. ignoring these patterns may lead to under or over corrections, with subsequent disappointment for both patient and surgeon. 4 around 12-87% of strabismus patients have an “a” or “v” pattern. 1,2,4 the mechanism of pattern strabismus is still unclear. many theories have been put forward regarding its etiology. the most popular theory to date was proposed by knapp, who listed oblique muscle dysfunction as the prime cause, with overacting inferior obliques in “v” patterns, and overacting superior obliques in “a” patterns. 2 deng et al 5 supported this theory by strongly correlating fundus intorsion, and superior oblique over action with “a” patterns, and fundus extorsion and inferior oblique over action with “v” patterns. kushner 6 suggested the role of ocular torsion as a cause of these patterns, as it can cause vertical displacement of rectus insertions. craniofacial dysmorphisms, orbital pulley heterotopias or laxity, as well palpebral fissure slanting can contribute to such patterns. 2 they can also arise iatrogenically. 7 there are numerous studies where patterns of strabismus have been studied and a variety of surgical procedures have been employed over the years for their correction. conventionally, in the absence of oblique over action, horizontal rectii are displaced, with medial rectus towards the apex of the pattern and lateral rectus away. 8-11 monocular surgery with vertical displacement of the horizontal rectii was studied by metz and schwartz 8 with satisfactory results, and no subsequent torsional symptoms. these are good options for small patterns. 9 oya 10 et al showed that the amount of correction corresponds to the size of the pattern. we found that varying horizontal rectus transpositions during routine adjustable strabismus surgery is very effective in reducing pattern strabismus postoperatively. depending upon the size of the pattern, we varied our transpositions from 1mm to 5mm, and all the horizontal rectus muscles involved during surgery were transposed (range 2-3). we believe that patterns of less than 5 pd may resolve on their own, and may not need transposition, and did not include them in our study. some surgeons have opted out horizontal muscle transposition in “sub-a” or “sub-v” patterns in exotropia, and claimed that routine muscle surgery corrected these patterns post operatively. sub-patterns were less than the classical definition of “a” or “v” patterns i.e. < 10 pd or < 15 pd respectively. we have observed that leaving sub-patterns as such with no surgery performed for their correction is risky, and patterns more than 5 pd may not correct without transposition, and may even increase after standard strabismus surgery. insertion slanting recessions or resections have historically been described for the treatment of these patterns, but were not considered to be of much effect. 2,3,12 recently, these procedures are again being advocated for treatment of “a” or “v” patterns with comparable success with transposition. 12-13 we did not slant any muscle insertion during our study. van der meulen-schot et al 14 demonstrated partial tenotomy of the horizontal rectiias the effective treatment option for pattern strabismus. in case of significant inferior oblique muscle over action as a cause of pattern strabismus or if the pattern is very large, weakening procedures like graded recession, myectomy or anterior transposition are good surgical outcomes of different types of pattern strabismus pak j ophthalmol. 2021, vol. 37 (1): 75-82 81 options. 15-17 minguini 18 et al compared anterior transposition to graded recession and found equal effectiveness. kumar 19 et al advocated hang-back inferior oblique recession for v-pattern therapy. a bilateral oblique weakening procedure was expected to give greater success than unilateral surgery. 20 we preferred myectomy of the inferior oblique, in case of “v” patterns with significant inferior oblique over action, and we found it immensely effective in all 13 (32.5%) cases in collapsing the pattern. inferior oblique anteriorization, however may not be as effective, as in our only case of dvd, which increased the “v” pattern slightly. akar 21 et al demonstrated effectiveness of graded anterior transposition of the inferior obliques on “v” pattern. caldeira et al 22 noted the development of a vertical imbalance in 1/5 of the cases, after bilateral graded inferior oblique recession for “v” esotropia. superior oblique tuck 2 may also be used to treat “v” pattern. in case of “a” patterns with large bilateral superior oblique over action, posterior 7/8 tenectomy is successful in pattern collapse of all magnitudes as reported by ranka and coworkers. 23 nasal tenectomy, disinsertion, tendon spacer or graded recession have all been tested and tried. 24 however, caution is advised in superior oblique surgery, as it may induce bothersome torsional diplopia. ron 25 et al prefer ztenotomy combined with horizontal muscle surgery. in case of “x”, “y”, “λ”, or “↓” patterns, similar principles of surgery are indicated depending on rectus or oblique over action, and these can be corrected accordingly. strength of our study was that this study had a very good success rate both for pattern correction and for the primary deviation. classical patterns as well as sub-patterns have been included and managed. the patients were all happy and no further repeat surgery was needed in any case, either to correct residual strabismus or pattern. limitations of our study are that it reflects the preference of a single center only, and that other centers may differ in their techniques for pattern correction. torsional outcomes of pattern correction were not noted by us, nor reported by any patient. superior oblique surgery was not done in any case. future work required is a multi-centered, large scale study for a more comprehensive analysis of pattern correction. conclusion rectus muscle transpositions can be varied to treat alphabet pattern strabismus, along with oblique muscle surgery, during adjustable strabismus surgery. with good techniques, patterns can be successfully eliminated to enhance the postoperative cosmetic outlook. ethical approval the study was approved by the institutional review board/ethical review board. 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oblique muscle over action. arch ophthalmol. 2010; 128 (6): 712-718. 7. khawam e, jaroudi m, abdulaal m, massoud v, alameddine r, maalouf f. major review: management of strabismus vertical deviations, aand v-patterns and cyclotropia occurring after horizontal rectus muscle surgery with or without oblique muscle surgery. binocul vis strabolog q simms romano. 2013; 28 (3): 181-192. 8. metz hs, schwartz l. the treatment of a and v patterns by monocular surgery. arch ophthalmol. 1977; 95 (2): 251-253. 9. garrido jt, goldchmit m, souza-dias cr. vertical transposition of medical rectus muscles for correction of a-pattern anisotropia. binocul vis strabismus q. 2004; 19 (4): 207-215. sana nadeem 82 pak j ophthalmol. 2021, vol. 37 (1): 75-82 10. oya y, yagasaki t, maeda m, tsukui m, ichikawa k. effects of vertical offsets of the horizontal rectus muscles in v-pattern exotropia without oblique dysfunction. j aapos. 2009 dec; 13 (6): 575-577. 11. awadein a, fouad hm. management of large vpattern exotropia with minimal or no inferior oblique overaction. j aapos. 2013; 17 (6): 588-593. 12. kushner bj. insertion slanting strabismus surgical procedures. arch ophthalmol. 2011; 129 (12): 16201625. 13. mostafa am, kassem rr. a comparative study of medial rectus slanting recession versus recession with downward transposition for correction of v-pattern esotropia. j aapos. 2010; 14 (2): 127-131. 14. van-der-meulen-schot hm, van-der-meulen sb, simonsz hj. caudal or cranial partial tenotomy of the horizontal rectus muscles in a and v pattern strabismus. br j ophthalmol. 2008; 92 (2): 245-251. 15. monteiro-de-carvalho km, minguini n, dantas fj, lamas p, jose nk. quantification (grading) of inferior oblique muscle recession for v-pattern strabismus. binocul vis strabismus q. 1998; 13 (3): 181-184. 16. polati m, gomi c. recession and measured, graded anterior transposition of the inferior oblique muscles for v-pattern strabismus: outcome of 44 procedures in 22 typical patients. binocul vis strabismus q. 2002; 17 (2): 89-94. 17. caldeira ja. some clinical characteristics of v-pattern exotropia and surgical outcome after bilateral recession of the inferior oblique muscle: a retrospective study of 22 consecutive patients and a comparison with vpattern esotropia. binocul vis strabismus q. 2004: 19 (3): 139-150. 18. minguini n, de-carvalho km, de araújo l, crosta c. anterior transposition compared to graded recession of the inferior oblique muscle for v-pattern strabismus. strabismus. 2004; 12 (4): 221-225. 19. kumar k, prasad hn, monga s, bhola r. hangback recession of inferior oblique muscle in v-pattern strabismus with inferior oblique over action. j aapos. 2008; 12 (4): 401-404. 20. nowakowska o, broniarczyk-loba a, loba pj. the reduction of a-v patterns with oblique muscles overaction in unilateral and bilateral surgery. kiln oczna. 2008; 110 (10-12): 361-363. 21. akar s, gökyiğit b, yilmaz of. graded anterior transposition of the inferior oblique muscle for vpattern strabismus. j aapos. 2012; 16 (3): 286-290. 22. caldeira ja. v-pattern esotropia: a review; and a study of the outcome after bilateral recession of the inferior oblique muscle: a retrospective study of 78 consecutive patients. binocul vis strabismus q. 2003; 18 (1): 3548. 23. ranka mp, liu gt, nam jn, lustig mj, schwartz sr, hall ls. bilateral posterior tenectomy of the superior oblique muscle for the treatment of a-pattern strabismus. j aapos. 2014; 18 (5): 437-440. 24. ung t, raoof n, burke j. effect of superior oblique weakening on vertical alignment and horizontal and vertical incomitance in patients with a-pattern strabismus. j aapos. 2011; 15 (1): 9-13. 25. ron y, snir m, axer-seigel r, friling r. z-tenotomy of the superior oblique tendon and the horizontal rectus muscle surgery for a-pattern horizontal strabismus. j aapos. 2009; 13 (1): 27-30. author’s designation and contribution sana nadeem; assistant professor: concepts, design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. .…  …. pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 41 original article orbitofacial anthropometry in a pakistani population saba alkhairy, farnaz siddiqui, mazhar-ul-hassan pak j ophthalmol 2016, vol. 32 no. 1 . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: saba alkhairy fcps, assistant professor dimc, duhs e.mail: doweyedepartment@gmail.co m received: january 16, 2016. accepted: march 07, 2016. …..……………………….. purpose: to demonstrate the anthropometric variations in head circumference, inner and outer canthal distances and interpupillary distance in pakistani population. study design: cross sectional study. place and duration of study: the data was collected for a period of three months from august 2015 to october 2015 at the opd of the dow university of health science, dow international medical college, karachi, pakistan. material and methods: a total of 500 patients were recruited from an outpatient ophthalmology department of dow university of health science, dow international medical university. icd(inter canthal distance) was measured between the medial angles of the palpebral fissures and the ocd(outer canthal distance) from the lateral canthus of each eye using a metal rule .the head circumference was measured using an inch tape and the ipd(inter pupillary distance) was measured using an autorefractrometer. each of the measurements were done twice to the nearest 0.5 mm by two different researchers and an average was taken of these two measurements. results: total 500 subjects were used. males were 227 (45.4%) and female were little more 273 (54.6%). the mean values for the parameters measured are as following: head circumference (mean: 55.0cm ± 1.8cm), inner canthal distance (mean: 3.4cm ± 0.4cm), outer canthal distance (mean: 10.7cm ± 3.9cm), inter pupillary distance (mean: 61.4mm ± 4.3mm). overall there is no mean difference found by gender or age group separately except difference in age groups for inter pupillary distance. conclusion: this study shows that anthropometric variations for head circumference, inner canthal distance, outer canthal distance and the interpupillary distance are seen with age and gender. standard baseline values should be defined for these parameters and these should be considered when classifying a patient with hypertelorism, hypotelorism or telecanthus or when planning an orbital surgery. keywords: anthropometry, inner canthal distance (icd), outer canthal distance (ocd), interpupillary distance (ipd) and head circumference (hc). nthropometry is the study in which we measure the different components of the human body in order to estimate their relative parts.¹ medical craniofacial anthropometry methods are different from those of classical physical anthropology, in such a way that there are increased number of craniofacial landmarks and measurements. also there are more ways used to make some measurements, and in the interpretation of the findings. there are different ways to take measurements in medical anthropology. these comprise of direct anthropometry (in which measurements are taken directly from the subject) and three indirect anthropometric methods: photogrammetry, soft-tissue a http://www.cpcjournal.org/keyword/anthropometry http://www.cpcjournal.org/keyword/canthal%20distance http://www.cpcjournal.org/keyword/interpupillary%20distance saba alkhairy, et al 42 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology facial-profile cephalometry, and computer-imaged three-dimensional (3d) craniofacial surface scans. nevertheless, these methods have some things in common. they all require identification of the craniofacial surface landmarks, execution of measurements, and assessment of the data comparing the results to the normal population.² a careful evaluation of the orbital region of the face is an integral part in the description of phenotypic anomalies, which can be classified as qualitative or quantitative anomalies. qualitative anomalies are described as being present or not present in comparision to a normal human phenotype. the rationale of conducting this study is that we are able to deduce basic standard values of anthropometric measurements in a given population so that quantitative anomalies such as hypertelorism can be identified.³ fronto-occipital circumference, inner canthal distance, outer canthal distance and interpupillary distance are important measurements in the evaluation of several systemic syndromes and craniofacial abnormalities and in the surgical treatment of posttraumatic telecanthus.³,4 the interpupillary distance (ipd) is the distance measured between the centers of the pupils, and it is important for the creation of the stereoscopic vision, which results in a single tridimensional image.5 canthus is either corner of the eye where the upper and lower eyelids meet. the inner canthus is called as nasal or medial cantus while outer canthus is known as lateral or temporal canthus.6 studies on anthropometry have revealed variations in craniofacial features as well as in body attributes amongst people belonging to different racial background7. earlier many researchers have studied craniofacial parameters and come up with standard formulations based on ethnic or racial data.8-11 the objective of the study is to determine basic standard values for the inter pupillary distances, inner and outer canthal distances and head circumference measurements and to study the differences in these anthropometric values with variation of gender and age in the pakistani population. material and methods all patients were recruited from the ophthalmology department of dow university of health science, dow international medical college through convenience sampling. the patients were aged between 5 and 60 years younger subjects were not taken due to lack of cooperation while subjects older than 75 years years were also not taken due to arrest of craniofacial development. also subjects with cranio facial anamolies, telecanthus, epicanthus, strabismus were omitted. after taking informed consent each measurement was taken by two expert ophthalmologists and an average value of the two readings was noted. the measurements that were taken included the head circumference, the inner canthal distance, the outer canthal distance and the inter pupillary distance. all measurements were taken with the patient seated comfortably sitting in an upright position in a well illuminated room. the head circumference was measured using an inch tape drawn across the head over the occipital protuberance posteriorly and over the supra orbital ridges anteriorly. the female subjects with buns and braids were asked to let their hair down before the measurements were taken. the inner canthal distance was measured using a non stretchable ruler from one medial canthus to the other with the patient seated comfortably and instructed to look straight ahead.the outer canthal distance was measured from one lateral canthus to another using the same millimeter ruler with the patient looking upward. the inter pupillary distance was measured in millimeters using an autorefractometer.(rm 8800 topcon,tokyo,japan). fig. 1: details of measurements. the data was analyzed on ibm spss version 22.0 and the results were presented as mean ± sd with confidence interval. statistical comparisons were performed using first factorial design for the each response variable with age groups and gender as independent variables to see which covariate or interaction effect significance. if it is significant than for comparisons of gender by each age group which interaction effect significant we use bonferroni post hoc test due to the assumption of non-normal data. a orbitofacial anthropometry in a pakistani population pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 43 p-value of 0.05 or less was considered statistically interaction or covariate significance. however, for each pair of interaction p-value revised due to the bonferroni test and a p-value of 0.036 or less was considered statistically significant. results total 500 subjects were enrolled. males were 227 (45.4%) and female were little more 273 (54.6%). there were gradually increasing number of subjects in age groups, for 5 to 15 group 46 (9.2%), 16 to 30 group 131 (26.2%) and most population was found in 31 to 75 age group 323 (64.6%). table 1 describe the descriptive statistics for head circumference, inner canthal distance, outer canthal distance, all measured in centimeters except inter pupillary distance which was measured in millimeters. for head circumference (mean ± sd: 55.0cm ± 1.8cm), inner canthal distance (mean ± sd: 3.4cm ± 0.4cm), outer canthal distance (mean ± sd: 10.7cm ± 3.9cm), inter pupillary distance (mean ± sd: 61.4mm ± 4.3mm). overall there was no mean difference found by gender or age group separately except difference in age groups for inter pupillary distance. these means are unadjusted means and no involvement of any covariate. table 1: mean (sd) of hc, icd, opd, ipd for age groups and gender characteristics no. of patients n (%) hc (cm) icd (cm) ocd (cm) ipd (mm) overall 500 55.0 (1.8) 3.4 (0.4) 10.7 (3.9) 61.4 (4.3) gender female 273 (54.6) 54.7 (1.7) 3.4 (0.4) 10.5 (0.8) 61.3 (4.1) male 227 (45.4) 55.4 (1.8) 3.5 (0.5) 10.9 (5.7) 61.5 (4.6) age groups 5 – 15 46 (9.2) 54.1 (2.2) 3.4 (0.4) 10.5 (1.0) 58.7 (4.7) 16 – 30 131 (26.2) 54.9 (1.6) 3.5 (0.4) 10.7 (0.9) 62.2 (3.3) 31 – 75 323 (64.6) 55.2 (1.7) 3.4 (0.5) 10.7 (4.8) 61.5 (4.5) hc: head circumference; icd: inner canthal distance ocd: outer canthal distance; ipd: inter pupillary distance table 2: head circumference (cm) for different age groups characteristics no. of patients meana (sd) 95% c.i p-value 5 15 (n = 46) female 23 53.8 (2.0) (53.1 , 54.5) < 0.99 male 23 54.3 (2.4) (53.6 , 55.0) 16 30 (n = 131) female 74 54.7 (1.6) (54.3 , 55.1) < 0.99 male 57 55.2 (1.6) (54.7 , 55.6) 31 75 (n = 323) female 176 54.8 (1.6) (54.6 , 55.1) < 0.001** male 147 55.7 (1.8) (55.4 , 55.9) **significant at 0.036, bonferroni post hoc test a: adjusted means with covariate inner canthal distance saba alkhairy, et al 44 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology table 3: inner canthal distance (cm) for different age groups characteristics no. patients mean (sd) 95% c.i p-value 5 15 (n = 46) 0.747 female 23 3.4 (2.0) (3.2 , 3.6) male 23 3.5 (2.4) (3.3 , 3.6) 16 30 (n = 131) female 74 3.4 (1.6) (3.3 , 3.5) male 57 3.5 (1.6) (3.4 , 3.6) 31 75 (n = 323) female 176 3.4 (1.6) (3.3 , 3.5) male 147 3.4 (1.8) (3.4 , 3.5) b: adjusted means with covariate head circumference table 4: outer canthal distance (cm) for different age groups characteristics no. of patients mean (sd) 95% c.i p-value 5 15 (n = 46) 0.747 female 23 10.4 (1.0) (8.8 , 12.0) male 23 10.6 (1.1) (9.0 , 12.2) 16 30 (n = 131) female 74 10.6 (0.9) (9.7 , 11.5) male 57 10.9 (0.9) (9.9 , 11.9) 31 75 (n = 323) female 176 10.5 (0.8) (9.9 , 11.1) male 147 11.0 (7.0) (10.4 , 11.7) table 2 to 5 shows our comparison of male and female by age groups. for each response variable we calculated their mean, standard deviation and 95% confidence interval and presented in a separate table. we have just shown results for three pair comparison although total fifteen pairs were there. there was no mean difference found in all combination of groups for each response variable except just one i.e. 31 to 75 age group male and female head circumference mean to was different statistically. however, it may not be a large clinical difference. a little bit adjustment for the means were reported in table 2 and 3 since effect of the covariate inner canthal distance and head circumference. there was similar mean of inner canthal distance for males and females. i.e. 3.4cm or 3.5cm. a similar high mean value was found of males compared to females for outer canthal distance and inter pupillary distance. for outer canthal distance, maximum mean was 11.0cm for male (31 to 75 age group) and 10.6cm for female (16 to 30 age group). for inter pupillary distance, maximum mean was 62.8mm for male (16 to 30 age group) and 61.7mm for female in the same age group. orbitofacial anthropometry in a pakistani population pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 45 discussion there are many studies done to measure the anthropometric parameters in adults.12,13,14 the anthropometric parameters differ in measurements in individuals due to several factors that include hereditary factors, inadequate nutrition in growth years and endurance of the human body on the physical activity it is subjected to. the inter pupillary distance is the distance between the center of a pupil in one eye to the center of the pupil in the other eye with the patient looking straight ahead. there are four objective methods of assessment for inter pupillary distance. they include the victorian method, the pupillometer method, corneal reflection and the autorefractrometer. we used the autorefractrometer in our study as this was used to measure ipd and refractive errors at the same time. our study showed that the mean ipd values measured amongst males were larger than females in all age groups. in iran the mean ipd in females was 61.1 ± 3.5 mm in females and 63.6 ±3.9mm in males15. in another study on caucasians the ipd was also larger in male subjects versus female subjects16. in the turkish population evereklioglu et al showed that in the study conducted in turkish population aged between 7 and 40 years the overall mean ipd values for distance in males were 60.76 ± 4.04 in males and 59.46 ± 3.51 in females.17we also studied the ipd in relation to age and divided our subjects into three groups. the age groups were 5 – 15 years, 16 – 30 years and 31 – 75 years. the ipd increased from 58.7 ± 4.7 mm in the age group of 5 – 15 years (table 1) to 62.2 ± 3.3mm in the age group 16 – 30 years and there was no further increase noted with age as the mean value of ipd was 61.5 ± 4.5 mm in individuals aged between 31 – 70 years. craniofacial anthropometry is an important asset to both clinical genetists and ophthalmologists. in a study done on 1000 subjects from ljaw within the age range of 3–21 years found the mean inner inter canthal distance for male and female subjects are 28.30 ± 4.16 mm and 28.15 ± 2.75 mm respectively and the outer mean canthal distance for males and females was 92.49 ± 6.30 mm and 91.96 ± 5.81 mm respectively18. in a study done on a nigerian population the mean icd for males and females were 43.90 ± 4.11mm and 41.77 ± 3.37mm respectively while the mean ocd for males and females is 118.34 ± 0.66 mm and 114.76 ± 0.34 mm respectively.19in our study done on 500 subjects the mean icd in males and females was 35mm ± 5 mm and 34mm ± 4mm respectively. thus the mean icd value in our subjects was less as compared to the nigerian population and more as compared to the ljaws however the latter can be due to younger subjects that were recruited with age range between 3 and 21 years. in our study the icd and the ocd in males are larger than those of females which is consistent with the study done on the ljaws, turks, nigerians, and latvians20. another study done on 1000 subjects in chattisgarh region of india showed that the table 5: inter pupillary distance (mm) for different age groups. characteristics no. of patient mean (sd) 95% c.i p-value 5 15 (n = 46) <0.99~ female 23 58.6 (5.4) (56.8 , 60.3) male 23 58.8 (4.0) (57.1 , 60.6) 16 30 (n = 131) female 74 61.7 (3.2) (60.7 , 62.6) male 57 62.8 (3.3) (61.7 , 63.9) 31 75 (n = 323) female 176 61.5 (4.1) (60.9 , 62.1) male 147 61.5 (4.9) (60.8 , 62.1) ~three above pairs are not significant except other possible pairs. saba alkhairy, et al 46 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology measured parameters were higher in males than females but the difference was not statistically significant(p value ≥ 0.001)21. this was in contrast to a study on a mixed european population where the mean icd of 32.00 was observed and there was no difference in gender22. a study done on harvani adults showed that the average values for head circumference in male subjects was 55.91 cm while in female subjects it was 54.61cm which clearly shows that harvani males had a slight increased head circumference as compared to their female counterparts23. this was consistent with our study in which the mean head circumference was observed to be slightly higher in males as compared to females. maximum mean was 55.7cm for male (31 to 75 age group) and 54.8cm for female (31 to 75 age group) in our study. another similar study done on 408 adults by ahmet riffat et al showed mean hc in men 55.90 ± 1.85 and 54.57 ± 1.61 in women24. another study done on canadian male adults aged between 18 to 71 years showed them to have a mean value of head circumference of 56.69cm25. the data of our study will be helpful to anthropologists and orbital surgeons. short comings of our study included a small sample size which is not a true representation of the pakistani population and also there was no study done on the racial differences of these parameters in the given population as pakistan is a multiracial country and comprises of a very large population. we hope to conduct studies in future in regard to the above mentioned points. conclusion this study shows that anthropometric variations for head circumference, inner canthal distance, outer canthal distance and the interpupillary distance are seen with age and gender. standard baseline values should be defined for these parameters and these should be considered when classifying a patient with hypertelorism, hypotelorism or telecanthus or when planning an orbital surgery. author’s affiliation dr. saba alkhairy fcps, assistant professor dimc, duhs dr. farnaz siddiqui fcps, assistant professor dimc, duhs dr. mazhar-ul-hassan fcps, professor & hod dimc, duhs role of authors dr. saba alkhairy manuscript writing. dr. farnaz siddiqui data collection and study design. dr. mazhar-ul-hassan manuscript review. references 1. kolar jc, salter em. craniofacial anthropometry practical measurements of the head and face for clinical, surgical and research use. charles thomas publisher ltd. usa 1996. 2. g leslie,k curtis. antgropometric determination of craniofacial morphology. am j of medical genetics 1996; 65: 1-4. 3. dollfus h, verloes a. dysmorphology and the orbital region: a practical clinical approach. surv ophthalmol. 2004; 49: 547– 61. 4. laestadius, aase ndjm, smith dw. normal inner canthal and outer orbital dimensions. j pediatr. 1979; 74: 465–468. 5. aslankurt m, aslan l, aksoy a, ozdemir m. dane, “laterality does not affect the depth perception, but interpupillary distance,” journal of ophthalmology. 2013; article id 485059, 5. 6. spencer f. ed. history of physical anthropology. gerland, newyork and london. 1997; pp-80. 7. farkas lg, katic mj, forrest cr. international anthropometric study of facial morphology in various ethnic groups/races. the journal of craniofacial surgery. 2005; 16: 616–46. 8. pryor hb. objective measurements of interpupillary distance. pediatrics. 1969; 44: 973-7. 9. singh jr, banerjee s. normal values for interpupillary, inner canthal and outer canthal distances in an indian population. hum hered 1983; 33: 326-8. 10. fledelius hc, stubgaard m. changes in eye position during growth and adult life as based on exophthalmometry, interpupillary distance and orbital distance measurements. acta ophthalmol. 1986; 64: 4816. 11. sanchez-andres a, mesa ms. heritabilities of morphological and body composition characteristics in a spanish population. anthropol anzeiger. 1994; 52: 341-9. 12. nellhaus g. composite international and interracial graphs. pediatrics. 1968; 41: 106-10. 13. farkas lg, posnic jc, hreczko tm. anthropometric orbitofacial anthropometry in a pakistani population pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 47 growth study of the head. cleft palate-craniofacial j. 1992; 29: 303-8. 14. murphy wk, laskin dm, richmond ms. intercanthal and interpupillary distance in the black population. oral surg oral med pathol. 1990; 69: 676–80. 15. fesharaki h, rezaei l, farrahi f, banihashem t, jahanbakhshi a. normal interpupillary distance values in an iranian population. j ophthalmic vis res. 2012; 7: 231–4. 16. pointer js. the interpupillary distance in adult caucasian subjects, with reference to „readymade‟ reading spectacle centration. ophthalmic physiol opt. 2012; 32: 324–31. 17. evereklioglu c, doganay s, er h, gündüz a. distant and near interpupillary distance in 3448 male and female subjects: final results. turgut özal tip merkezi dergisi. 1999; 6: 84–91. 18. e.a osunwoke, b.c didia, e.j, otutu, a.h yerikema. a study on the normal values of inner and outer canthal distance, inter papillary distance and head circumference of 3-21 years ijaws. am j of scientific and industrial research. 2012, 3: 441-5. 19. oa egwu, eo ewunonu et al. normal values of inner and outer canthal distance in a study population in south east nigeria. int. j. biol. chem. sci. 2008; 2: 355-8. 20. naegles e. craniofacial anthropometry in a group of healthy latvian residents. actamedica lituanica, 2005; 12: 47-53. 21. j agrawal, as yogesh, ck shukla et al. orbitofacial anthropometric assessment of inter-canthal and outer canthal distance measurement in chattisgarh region. biomed res-india 2013; 24: 365-9. 22. er mohammed, jalalifar s. correlation between interpupillary distance and inner-outer distances in individuals younger than 20. jr of ophthalmic and vision research. 2008; 3: 16-22. 23. k mahesh, l mohd muzzafar. a study of sexual dimorphism in stature and horizontal head circumference among haryanvi adults. int. j. rec. biotech. 2013; 1: 1-4. 24. riffat oa. adult head circumferences and centiles. jr of turgut özal medical center. 197; 4: 261-4. 25. nguyen akd, simard-meilleur, berthiaume aa et al. head circumference in canadian male adults: development of a normalized chart. int. j. morphol. 2012; 30: 1474-80. pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 167 original article diabetic retinopathy in diabetic patients with diabetic nephropathy noor muhammad, sher akbar khan, muhammad waqas khan, akhtar ali, shad muhammad pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sher akbar khan medical teaching institute lady reading hospital peshawar email: urhumbleme@yahoo.com objective: the aim of this study was to discover the stages of diabetic retinopathy in patients with diabetic nephropathy. study design: descriptive cross sectional study. place and duration: it was conducted in medical teaching institute lady reading hospital peshawar. duration of study was from october 2015 to 0ctober 2016. material and methods: 208 participants with type 1 and 2 diabetes having diabetic nephropathy were included in the study. patients either requiring or not requiring hemodialysis, were also included. the data was analyzed with statistical package for the social sciences (spss) 16.0. frequency of different variables was calculated in percentage. results: non-proliferative diabetic retinopathy (npdr) were found in 102 cases (49%) while proliferative diabetic retinopathy (pdr) was in 79 cases (38%) and normal fundi were found in 27 patients (13%). among 69 patients who required hemodialysis, 65.2% were having pdr, 31.88% having npdr and 2.89% normal fundi. among 139 patients who were stable 34 had pdr (24.46%). npdr was seen in 80 (57.55%) and normal fundi were observed in 25 (17.98%) patients. among 184 hypertensive patients 41.84% had pdr, 54.34% had npdr and 3.80% had normal fundi. out of 24 normotensive patients 8.33% had pdr, 8.33% had npdr and 83.33% had normal fundi. in 32 type 1 diabetic patients, 62.50% had pdr, 25% had npdr and 12.5% had normal fundi. out of 176 type 2 diabetic patients 33.52% had pdr, 53.40% npdr and 13.06% normal fundi. conclusion: most of the diabetic patients who had nephropathy had diabetic retinopathy. key words: diabetic nephropathy; diabetic retinopathy; hemodialysis; non proliferative diabetic retinopathy; proliferative diabetic retinopathy. iabetes is a group of chronic diseases, that occurs when the body does not produce any or enough insulin. in modern health system, there is a variety of lifestyle and pharmaceutical interventions used for preventing and controlling diabetes1. the development of chronic complications of diabetes are closely related to glycemic control. micro and macro vascular pathological complications can involve various organs and tissues resulting in significant morbidity and mortality2. as the number of people with diabetes are increasing the development of microvascular complications like retinopathy, nephropathy and neuropathy are also rising3. diabetic nephropathy and retinopathy are the two most serious complications of diabetes mellitus leading to blindness. as the patient advances to end stage renal disease and blindness, the socioeconomic and medical cost burden increases on patient as well d noor muhammad, et al 168 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology as health care system4. there is a close relationship between diabetic retinopathy and nephropathy. microangiopathy is the underlying disorder with a histopathological corelation with each other5. changes in the microcirculation result in the increase of blood viscosity and platelet aggregation leading to retinal capillary wall thickening. microangiopathy leads to hyper-permeability and ischemia of retinal vessels6. the most important cause of end stage renal disease is diabetic nephropathy2. diabetic retinopathy is a diagnostic and screening tool for diabetic nephropathy in type 2 diabetic patients with renal disease. proliferative diabetic retinopathy may be a highly specific indicator for diabetic nephropathy7. the annual incidence of proliferative diabetic retinopathy is 10-15% in early nephropathy compared to only 1% in patients without nephropathy. long-term improvement of metabolic control by using insulin infusion pumps and antihypertensive especially ace inhibitors seems to stop the further progression of early nephropathy and significantly improves the clinical outcome8. the aim of this study was to find out the diabetic retinopathy and its stages in patients with diabetes having diabetic nephropathy. material and methods the study was carried out in lady reading hospital in the department of nephrology with the collaboration of ophthalmology department from october 2015 to 0ctober 2016. it was descriptive cross sectional study and comprised of 208 participants with diabetes having diabetic nephropathy. male and female patients of all age groups were included in the study. both type 1 and type 2 diabetics were included. these patients were further stratified as those that required hemodialysis and those who were stable, patients who were hypertensive and patients who were normotensive. all type 2 diabetics who had nephropathy were included irrespective of time duration. while diabetic nephropathy patients who had type 1 diabetes of less than 5 years duration were excluded. written consent was taken from all patients, bio data was entered on prescribed proforma. variables were entered in spss 16.0. variables were name, age, sex, duration and type of diabetes, blood pressure, urea creatinine, fundoscopy findings, dialysis received or not was recorded. fundoscopy findings broadly categorized as non-proliferative diabetic retinopathy, proliferative and normal fundi. results total number of patients was 208. age ranged from 20 years to 83 years. mean age was 53.40 years with standard deviation of ± 12.26. male were 113 (54.3%) while females were 95 (45.7%). type 1 diabetics were 32 (15.4%) while type 2 diabetics were 176 (84.6%). total number of hypertensives were 184 (88.5%) while normotensives were 24 (11.5%). non-proliferative diabetic retinopathy (npdr) was found in 102 cases (49%) while proliferative diabetic retinopathy (pdr) was seen in 79 cases (38%) and normal fundi were found in 27 patients (13%). hemodialysis was done in 69 patients (33.2%) while 139 patients (66.8%) were stable not requiring renal replacement therapy. among the patients that required hemodialysis, 45 (65.21%) had proliferative diabetic retinopathy, 22 (31.88%) were having non-proliferative diabetic retinopathy and 2 (2.89%) had normal fundi. those who were stable and not required dialysis were 139 in number having pdr in 34 (24.46%) patients, npdr in 80 (57.55%) and normal fundi in 25 (17.98%). 184 patients were found hypertensive. among these hypertensive patients, 41.84% were having pdr, 54.34% were having npdr, and 3.80% had normal fundi. out of 24 normotensive patients, 8.33% had pdr and the same percentage of patients had npdr table 1: demographics. total number of patients 208 age 20-83 years mean age 53.40 years standard deviation ± 12.26 male 113 (54.3%) female 95 (45.7%) type1 32 (15.4%) typ2 176 (84.6%). hypertension 184 (88.5%) normotensive 24 (11.5%). npdr 102 (49%) pdr 79 (38%) normal fundi 27 (13%) dialysis 69 (33.2%) stable patients 139 (66.8%) diabetic retinopathy in diabetic patients with diabetic nephropathy pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 169 table 2: percentages of patients with different stages of diabetic retinopathy in people with diabetes having diabetic nephropathy, further stratified in hypertensive and normotensive, type i and type ii diabetics and those who require hemodialysis and stable (does not require hemodialysis. hemodylasis n =( 69) stable n = (139) hypertensive n = (184) normotensive n = (24) type 1 n = (32) type 2 n = (176) pdr 45 (65.21%) 34 (24.46%) 77 (41.84%) 2 (8.33%) 20 (62.50) 59 (33.52%) npdr 22 (31.88%) 80 (57.55%) 100 (54.34%) 2 (8.33%) 8 (25%) 94 (53.40%) normal fundus 2 (2.89%) 25 (17.98%) 7 (3.80%) 20 (83.33%) 4 (12.50%) 23 (13.06%) while 83.33% had normal fundi. out of 32 type 1 diabetic patients, 62.50% patients had pdr, 25% had npdr and 12.5% had normal fundi. out of 176 patients of type 2 diabetes, 33.52% patients had pdr, 53.40% patients had npdr and 13.06% had normal fundi. discussion the three microvascular complications of diabetes are diabetic retinopathy, diabetic nephropathy and diabetic neuropathy9. some recent studies have shown that diabetic retinopathy is a risk factor for diabetic nephropathy and especially the proliferative stage of diabetic retinopathy may be a very high specific indicator of the diabetic nephropathy10,11,12 but not an exclusion criterion for non-diabetic renal disease13. therefore, diabetic retinopathy may be useful in diagnosing and screening for the diabetic nephropathy. in this study we have examined people with diabetes having nephropathies. we also found whether these patients had diabetic retinopathies or not and the stages of retinopathies in terms of normal fundi, having no retinopathy and non-proliferative retinopathy and proliferative retinopathy. we also studied these stages in the diabetic retinopathy patients who were hypertensive and normotensive patients, and also in those patients who required dialysis and in those who did not require dialysis and were stable. finally we examined these diabetic retinopathy stages in diabetic nephropathy patients in type 1 and type 2 diabetic patients. we found that most of the diabetic patients having nephropathies also had retinopathies either in non-proliferative or in proliferative stages and only few had normal fundi. the same findings were shown in the trial to reduce cardiovascular events with aranesp therapy (treat) study, which stated that dr was common in diabetic patients having nephropathy14. those patients who required dialysis had proliferative diabetic retinopathies and only a small number of patients had normal fundi. while those who were stable had mainly non proliferative diabetic retinopathy, (however these had more patients having normal fundi than in those who required dialysis). our study findings are similar to a recent study by lee et al15 who showed a direct association between dr and ckd and the presence of ckd and dr was associated with a more rapid reduction in renal function and greater mortality in this group of patients who might benefit from more aggressive treatment. those who are hypertensive have more npdr and pdr while negligible amount of patients have normal fundi. those who are normotensive have high number of patients having normal fundi than npdr and pdr. in higher number of people with type 1 diabetes and nephropathy have pdr than npdr and little number of patients have normal fundi. in higher number of people with type 2 diabetes and nephropathy has npdr than pdr and little number of patients have normal fundi. these results are also comparable to previous study, which established a higher incidence of npdr than pdr in cases of type 2 diabetes10. so from the above discussion, it is now obvious that diabetic patients having nephropathy have high likelihood that these patients would have diabetic retinopathy. therefore, diabetic patients who present to nephrologist or physician first should also be referred to ophthalmologist to have his or her eyes checkup so that they should be promptly and timely treated. when these patients present to ophthalmologist for the first time, they should be referred to physician or nephrologist. it is also found in this study that the severe the renal disease higher will be the stage of the diabetic retinopathy and vice versa. type 1 diabetes and hypertension are also associated with higher stage of diabetic retinopathy. it is uncertain from this study that hypertension along with nephropathy is responsible for this higher number of patients in pdr, or is this the hypertension noor muhammad, et al 170 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology alone which poses a high risk for retinopathy progression. another study is required to find out this relationship. however other studies have shown that hypertension leads to progression of kidney disease and retinopathy and pharmacologic lowering of blood pressure was shown to slow progression of kidney failure and reduce the risk of progression of diabetic retinopathy and vision loss16,17. another drawback of this study is that it is also possible that the nephropathy of some of these patients may not be due to diabetes and it may be a coincidence that these patients would have non-diabetic nephropathy and having diabetes especially in those patients who have normal fundi. so, those patients having normal fundi and having nephropathy should be further investigated to find out some other cause of nephropathy. however, previous meta-analyses demonstrated that dr could differentiate dn from ndrd with a pooled sensitivity of 0.65 and a pooled specificity of 0.75,18. when diabetic retinopathy coexists with albuminuria, the likelihood of diabetic nephropathy is very high 19 and lack of retinopathy suggests a non-diabetic etiology for persistent albuminuria in diabetic patients20. conclusion this study concluded that diabetic patients having nephropathy also have diabetic retinopathy. most of the diabetic patients with nephropathy who require hemodialysis have proliferative diabetic retinopathy and those who do not require dialysis have nonproliferative diabetic retinopathy. most of type 1 diabetic patients with nephropathy have proliferative diabetic retinopathy, most of the type 2 diabetic patients with nephropathy have non-proliferative diabetic retinopathy and most of the hypertensive diabetic patients with nephropathy have proliferative diabetic retinopathy. author’s affiliation dr noor muhammad fcps, assistant professor nephrology nephrology medical teaching institute, lady reading hospital peshawar dr. sher akbar khan fcps, assistant professor ophthalmology ophthalmology medical teaching institute, lady reading hospital peshawar muhammad waqas khan medical student ophthalmology medical teaching institute lady reading hospital peshawar dr akhtar ali fcps, professor of nephrology nephrology medical teaching institute, lady reading hospital peshawar dr. shad muhammad fcps, assistant professor nephrology medical teaching institute, lady reading hospital peshawar role of authors dr. noor muhammad concept and design, data collection, assembly dr. sher akbar khan concept and design, statistical analysis, literature search, critical revision muhammad waqas khan literature search, data entry, statistical analysis dr. akhtar ali concept and design, critical revision dr. shad muhammad data collection, assembly references 1. flower mj. microvascular and macrovascular complications. clinical diabetes, 2011 jul; 29 (3): 116122. 2. shera as1, jawad f, maqsood a, jamal s, azfar m, ahmed u. ahmad. pravelence of chronic complications and associated factors in type2 diabetes. j pak med assoc. 2004 feb; 54 (2): 54-9. 3. rani pk1, raman r, gupta a, pal ss, kulothungan v, sharma t. albuminuria and diabetic reinopathy in type 2 diabetes mellitus. diabetol metab syndr. 2011 may 25; 3 (1): 9. 4. java a, kcomot j. fonseca va. diabetic nephropathy and retinopathy .us national library of medicine, national institute of 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diabetologia. 1983; 25: 496–501. 12. gall ma, rossing p, skott p,damsbo p, vaag a. prevalence of microand macroalbuminuria, arterial hypertension, retinopathy and large vessel disease in european type 2 (non-insulin-dependent) diabetic patients. diabetologia. 1991; 34: 655–661. 13. christensen pk, larsen s, horn t, olsen s, parving hh. causes of albuminuria in patients with type 2 diabetes without diabetic retinopathy. kidney int. 2000; 58: 1719–31. 14. bello na, pfeffer ma, skali h, mcgill jb, rossert j, olson ka et al. .retinopathy and clinical outcomes in patients with type 2 diabetes mellitus, chronic kidney disease, and anemia.bmj open diabetes res care, 2014 ; 2 (1): e000011. 15. lee wj, sobrin l, kang mh, seong m, kim yj, yi jh, miller jw, cho hy. ischemic diabetic retinopathy as a possible prognostic factor for chronic kidney disease progression. eye (lond). 2014 ; 28 (9): 1119-25. 16. parving hh, andersen ar, smidt um, svendsen pa. early aggressive antihypertensive treatment reduces rate of decline in kidney function in diabetic nephropathy. lancet. 1983 may 28; 1 (8335): 1175-9. 17. brenner bm, cooper me, de zeeuw d, keane wf, mitch we, parving hh, remuzzi g, snapinn sm, zhang z, shahinfar sn. effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. renaal study investigators. n engl j med. 2001; 345 (12): 861-9. 18. liang, s. xue-guang z, guang-yan c, han-yu z, jianhui z, jie w et al. identifying parameters to distinguish non-diabetic renal diseases from diabetic nephropathy in patients with type 2 diabetes mellitus: a metaanalysis. plos one, 2013; 8 (5): e64184. 19. schwartz mm, lewis ej, leonard-martin t, lewis jb, batlle d. renal pathology patterns in type ii diabetes mellitus: relationship with retinopathy. the collaborative study group. nephrol dial transplant. 1998; 13 (10): 2547-52. 20. parving hh, gall ma, skott p, jorgensen he, lokegaard h, jorgensen f, nielsen b, larsen s. prevalence and causes of albuminuria in non-insulindependent diabetic patients. kidney int. 1992; 41 (4): 758-62. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4911847/ https://www.ncbi.nlm.nih.gov/pubmed/?term=cavalieri%20gc%5bauthor%5d&cauthor=true&cauthor_uid=27847639 https://www.ncbi.nlm.nih.gov/pubmed/?term=lima%20mc%5bauthor%5d&cauthor=true&cauthor_uid=27847639 https://www.ncbi.nlm.nih.gov/pubmed/?term=nazario%20no%5bauthor%5d&cauthor=true&cauthor_uid=27847639 https://www.ncbi.nlm.nih.gov/pubmed/?term=lima%20gc%5bauthor%5d&cauthor=true&cauthor_uid=27847639 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5088444/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5088444/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5088444/ https://www.ncbi.nlm.nih.gov/pubmed/?term=bello%20na%5bauthor%5d&cauthor=true&cauthor_uid=25452859 https://www.ncbi.nlm.nih.gov/pubmed/?term=pfeffer%20ma%5bauthor%5d&cauthor=true&cauthor_uid=25452859 https://www.ncbi.nlm.nih.gov/pubmed/?term=skali%20h%5bauthor%5d&cauthor=true&cauthor_uid=25452859 https://www.ncbi.nlm.nih.gov/pubmed/?term=mcgill%20jb%5bauthor%5d&cauthor=true&cauthor_uid=25452859 https://www.ncbi.nlm.nih.gov/pubmed/?term=olson%20ka%5bauthor%5d&cauthor=true&cauthor_uid=25452859 https://www.ncbi.nlm.nih.gov/pubmed/25452859 https://www.ncbi.nlm.nih.gov/pubmed/23691167 pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 245 letter to the editor pakistan journal of ophthalmology aims to improve quality and standard of the journal to promote research in the field of ophthalmology and in this regard pjo invites our valuable readers to submit letter to editor with their ideas, suggestions and positive scientific criticism with reference not more than 300 words long for possible publication. pakistan journal of ophthalmology reserves the right to edit letters and may publish them in upcoming issues in print and electronic media (website). submission of a letter implies consent for publication unless otherwise indicated in the letter. all letters must include the correspondent's name and address and are subject to editing to meet style, clarity, and space requirements. we shall highly appreciate if letters may be sent to pjoosp@gmail.com. please include “letter to editor” in the subject line and address your typed letter to: editor, osp house, 4 – a lda flats lawrence road, lahore – pakistan. please include your name and address. mailto:pjoosp@gmail.com 93 pak j ophthalmol. 2020, vol. 36 (2): 93-95 editorial clear lens extraction in glaucoma (is it still a controversy?) syed shoeb ahmad 1 1 ibn-e-sina academy, dodhpur, aligarh-202001, india the lens appears to play a strategic role in the etiopathogenesis of glaucoma. this is not a new concept. in 1891 priestley smith had noted that some patients diagnosed with glaucoma demonstrated shallow anterior chambers even before the development of the disease (glaucoma). he concluded that this feature could be attributed to the disproportion between the size of the eyeball and the lens. 1 lowe (1969) mentioned that the anatomical basis of primary angle closure glaucoma (pacg) lies in two important “constitutional” factors (lens position and thickness) and two other factors of lesser importance related to advanced age (increase in lens thickness and anterior lens displacement). 2 recently it has been mentioned that apart from age-related progressive growth in lens volume, another factor called lens vault is involved in the pathogenesis of angle closure, especially in women in the 3 rd or 4 th decade. 3 lens vault is defined as the part of the lens situated anterior to a plane drawn across the scleral spurs. in cases where the part of the lens anterior to its normal position becomes more protruded, in other words increased lens vault, there is direct narrowing of the anterior chamber angle. it also aggravates iridolenticular contact, which may eventually worsen pupillary block. studies have shown that after a successful peripheral iridotomy (pi), there can be a gradual increment in lens vault which can key words: lens, glaucoma, angle closure, cataract. how to cite this article: ahmad ss. clear lens extraction in glaucoma (is it still a controversy?). pak j ophthalmol. 2020; 36 (2): 93-95. doi: 10.36351/pjo.v36i2.1025 correspondence: syed shoeb ahmad ibn-e-sina academy, dodhpur, aligarh-202001, india email: syedshoebahmad@yahoo.com cause re-closure of the pi. 4 in certain eyes the thickened lens may cause pupillary/angle closure through intumescence, even though it could be a clear lens. other clear lens related factors such as subluxed lenses and spherophakia may also contribute to glaucoma. 5 therefore, identification of these clinical features in a patient with glaucoma/ocular hypertension (oht) may help decide the best course of action. with this understanding of the lens as a strategic factor in the development of glaucoma there is wider acceptance of lens-based surgeries for the management of certain forms of primary angle closure disease (pacd). a number of studies have been performed previously to assess the role of cataract extraction in glaucoma. it was probably guyton (1945) who first gave the concept of lens extraction in glaucoma. 6 subsequently, a number of clinicians reported good control of iop, reduction in glaucoma medications, better visual gains and lesser complications using this modality. in a report published by the american academy of ophthalmology, the authors accessed pubmed and cochrane databases to review the effect of phacoemulsification on iop in glaucoma patients. the study reported the procedure was successful in reducing iop by 13% in primary open angle glaucoma patients, by 20% in psuedoexfoliative glaucoma, in acute pacg by 71% and in chronic pacg by 30%. 7 while cataract extraction for management of glaucoma is already an established mode of treatment, it is the new “avatar” of this procedure which finds itself in a storm of controversy. this technique is “clear lens extraction” (cle) for glaucoma. these patients have no visual symptoms, there are inherent risks of intraand post-operative complications, loss of accommodation following the procedure and the increased costs of surgery. these factors have opened cle as a subject of debate. clear lens extraction in glaucoma pak j ophthalmol. 2020, vol. 36 (2): 93-95 94 in the last few years a few studies have been published on the role of cle in glaucoma. tham et al. have compared cle with trabeculectomy. they reported marginally better iop control with trabeculectomy in comparison to cle (36% vs. 34%). however, trabeculectomy operated eyes had more frequent surgical complications (46% vs. 4%. p = .0001). 8 dada et al. in their study performed cle for primary angle closure (pac) patients. they reported significant reduction in iop and increase in the angle opening distance (aod) as well as in trabecular-iris angle and reduction in glaucoma medications following the procedure. 9 in another study, cle was compared with trabeculectomy and there was slightly better lowering of iop in the trabeculectomy group. finally, the most extensive analysis of cle was performed in “the effectiveness in angle-closure glaucoma of lens extraction” (eagle) study. in a large multi-center trial conducted in 30 hospitals across five countries patients with pac/pacg underwent cle. the procedure was performed on 208 individuals who were followed up for three years. at the end of the study, mean iop was 1 mm hg lower in the cle group compared to the standard-care group (medications and pi). further treatment was required in 21% patients who underwent cle compared to 61% in the other group. the cle group also reported less frequent need for surgical intervention (one vs. 24 in the standard-care group). 10 while undeniably there are multiple advantages of cle it is necessary to emphasize that this procedure is not a one-stop solution for all cases of pacg. the possibility of trabecular meshwork dysfunction and post-trabecular mechanisms for the development of glaucoma have to be kept in mind. cle may not be effective in such cases. the management of pacd depends upo1n a number of aspects including the stage of the disease and correctly identifying the underlying mechanisms. the surgical option should be dictated by a holistic consideration of all factors and not just lowering of iop. cle alone may possibly be an alternative to trabeculectomy as an initial surgical option in medically uncontrolled, iridotomized eyes without cataract. it is debatable if cle can be an alternative to iridotomy. cle can be preferred in patients prone to or who cannot accept the potential complications of trabeculectomy with anti-fibrotic agents such as mitomycin-c. in situations which require a more urgent need to reduce the number of medications it is advisable to opt for glaucoma filtering surgery rather than cle. 11 the ideal candidate for cle is someone having only mild damage and whose iop is within target range on well tolerated glaucoma medications. certain factors have to be considered while deciding for cle vs. combined surgery vs. trabeculectomy alone. these include: patient characteristics, severity of glaucoma, the potential visual outcome after lens extraction and target iop to be achieved. in certain cases, minimally invasive glaucoma surgery (migs) or goniosynechialysis can be combined with cle.preexisting structural trabecular damage in pacg eyes may not lead to effective lowering of iop after lens extraction alone. such patients would do better with combined phaco-trabeculectomy. cle can be considered if there is increased lens thickness or lens vault and no significant trabecular dysfunction or glaucomatous optic nerve degeneration is present. in such situations cle may prove curative. 12 lens extraction is the only surgical modality that changes the anatomy of the angle, which is a predisposing factor for angle closure. lens removal deepens the anterior chamber and thereby relieves angle crowding. 13 shingleton has mentioned that cataract extraction should not replace combined surgery in the glaucoma population; instead it can be an appropriate choice in a compliant glaucoma patient on one or two medications pre-operatively with otherwise stable visual fields and optic nerves. 14 cle can be considered if topical treatment does not control iop and pi does not have a positive effect on the angle closure. this is especially effective if there is only appositional angle closure and anterior segment imaging shows the lens contributing significantly to the angle closure. it is essential to weigh the benefits of cle with disadvantages such as loss of accommodation, stress of surgical intervention on the patient and surgeon, technical difficulties and the intraand post-operative complications which may occur more frequently in this group compared to normal eyes. 15 in conclusion, there appears to be widening acceptance of cle in selected cases. glaucoma management has to be individualized and when situation demands such techniques can be successfully employed. the procedure is relatively safe, validated by our experience of clear lens exchange for refractive errors, effective and shows a positive impact on the quality of life of the individual by reducing dependence on glaucoma medications. there is need syed shoeb ahmad 95 pak j ophthalmol, 2020, vol. 36 (2): 93-95 to further develop and refine the indications for cle so that it can be utilized as an adjunct approach for glaucoma management in the near future. conflict of interest author declared no conflict of interest. references 1. smith p. on the pathology and treatment of glaucoma. churchill. london, 1891.p 153 2. lowe rf. causes of shallow anterior chamber in primary angle closure glaucoma. ultrasonic biometry of normal and angle closure glaucoma eyes. am j ophthalmol. 1969; 67: 87-93. 3. vasile p, catalina c. the role of clear lens extraction in angle closure glaucoma. rom j ophthalmol. 2017; 61: 244-248. 4. lee ks, sung kr, shon k, sun jh. longitudinal changes in anterior segment parameters after laser peripheral iridotomy assessed by anterior segment optical coherence tomography. invest ophthalmol vis sci. 2013; 3; 54: 3166-3170. 5. trikha s, perera sa, husain r, aung t. the role of lens extraction in the current management of primary angle-closure glaucoma. curr opin ophthalmol. 2015; 26: 128-134. 6. guyton js. choice of operation in eyes with primary glaucoma and cataracts. trans am acad ophthalmol otolaryngol. 1945; 49: 216-224. 7. chen pp, lin sc, junk ak, radhakrishnan s, singh k, chen tc. the effect of phacoemulsification on intraocular pressure in glaucoma patients. ophthalmology, 2015; 122: 1294–1307. 8. tham ccy, kwong yyy, baig n, leung dy, li fc, lam ds. phacoemulsification versus trabeculectomy in medically uncontrolled chronic angle closure glaucoma without cataract. ophthalmology, 2013; 120: 62-67. 9. dada t, rathi a, angmo d, agarwal t, vanathi m, khokhar sk, et al. clinical outcomes of clear lens extraction in eyes with primary angle closure. j cataract refract surg. 2015; 41: 1470-1477. 10. azuara-blanco a, burr j, ramsay c, cooper d, foster pj, friedman ds, et al. effectiveness of early lens extraction for the treatment of primary angleclosure glaucoma (eagle): a randomized controlled trial. lancet. 2016; 388: 1389-1397. 11. baig n, kam k-w, tham ccy. managing primary angle closure glaucomathe role of lens extraction in this era. open ophthal j. 2016; 10 (suppl. 1: m6): 8693. 12. ling jd, bell np. role of cataract surgery in the management of glaucoma. int ophthalmol clin. 2018; 58: 87-100. 13. thomas r, walland mj, parikh rs. clear lens extraction in angle closure glaucoma. curr opin ophthalmol. 2011; 22: 110-114. 14. shingleton bj, gamell ls, o’donaghue mw, baylus sl, king r. long-term changes in intraocular pressure after clear corneal phacoemulsification: normal patients versus glaucoma suspect and glaucoma patients. j cataract refract surg. 1999; 25: 885-890. 15. eid tm. primary lens extraction for glaucoma management: a review article. saudi j ophthalmol. 2011; 25: 337-345. .…  …. microsoft word 15-retracted note manzoorquereshi final 59 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology retraction note retracted article: prevalence of incidental amblyopia in buraidah city manzoor ahmed qureshi, mohammad ijaz ahmed, yousef hamood al-debasi, vishakh nair pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . received: 30 may 2012 / accepted: 04 november 2012 pak j ophthalmol 2012, vol. 28, no. 3 retraction statement the article has been retracted by agreement between the authors and the editors. the reasons for retraction are twofold: 1. first author mr. manzoor ahmed qureshi failed to get permission from the qassim university, kingdom of saudi arabia to publish the data which was supervised and analysed by dr. yousaf aldebasi. 2. the head of optometry department, qassim university, kingdom of saudi arabia asked mr. manzoor qureshi to retract the article as he was the first author. all listed authors agree on the fact that the article should be retracted due to contention of authorship. therefore this publication should be ignored. dr. manzoor apologizes to all authors and to the editors and readership of the pakistan journal of ophthalmology. the article has been retracted by agreement between the authors and the editors. the reasons for retraction are specified in the retraction statement that replaces the original publication. author’s affiliation dr. manzoor ahmed qureshi department of optometry college of applied medical sciences qassim university, kingdom of saudi arabia dr. mohammad ijaz ahmed department of optometry college of applied medical sciences qassim university, kingdom of saudi arabia dr. yousef hamood al-debasi department of optometry dean, college of applied medical sciences qassim university, kingdom of saudi arabia dr. vishakh nair department of optometry college of applied medical sciences qassim university, kingdom of saudi arabia 119 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology original article assessment of “imtiaz’s sign” for early detection of hypovitaminosis a syed imtiaz ali shah, shujaat ali shah, partab rai, shahid jamal siddiqui, safdar ali abbasi, shabir ahmad bhutto pak j ophthalmol 2015, vol. 31 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syed imtiaz ali shah department of ophthalmology chandka medical college larkana email: syedimtiazalinaqvi@ yahoo.com …..……………………….. purpose: to identify and document the earliest diagnostic sign of vitamin a deficiency (imtiaz's sign). material and methods: this prospective case series study was conducted from september 1999 to september 2014 at ophthalmology department chandka medical college and syed eye clinic, larkana, pakistan. patients identified clinically as cases of hypovitaminosis a on the basis of presence of “imtiaz’s sign” were included in the study. patients with retinitis pigmentosa, glaucoma, chronic liver disease and malabsorption syndrome were excluded from the study. imtiaz's sign of vitamin a deficiency and nyctalopia were noted and relevant laboratory investigations available were also done on selected patients. patients were given therapeutic doses of vitamin a and improvement was observed to see resolution of imtiaz’s sign of vitamin a deficiency and remission of nyctalopia. results: 650 patients, 152 (23.38%) males and 498 (76.62%) females were identified as cases of hypovitaminosis a on the basis of presence of imtiaz’s sign. age of the patients ranged from 5 to 43 years and the mean age (± standard deviation) was 18.15 ± 10.20 years. all patients replied positively for nyctalopia; however other signs, except imtiaz’s sign, were not observed due to the early stage of vitamin a deficiency. relevant laboratory investigations were performed on selected cases which showed that 45.68% of them had iron deficiency, 40.74% of them had hypoalbuminemia and 13.58% had disturbed lfts. this shows that most of the patients suffering from vitamin a deficiency were victims of malnourishment. conclusion: imtiaz’s sign is an early and effective clinical diagnostic sign to identify vitamin a deficiency at an early phase. it requires no costly tools for application, is safe and can be easily recognized and treated by vitamin a supplements. such a diagnostic ocular sign is desirable to avoid morbidity and mortality related to vitamin a deficiency. keywords: blindness, malnutrition, vitamin a deficiency, xerophthalmia. itamin a, a fat soluble vitamin, was the first vitamin to be discovered in 1913.1 chemically it is a retinol, and is the immediate precursor of two very important metabolites, retinal and retinoic acid. retinal is a very important component of rhodopsin which is mandatory for functioning of photoreceptors and retinoic acid has a vital role to play as messenger during transcription of a number of genes. vitamin a is essential to human body as it is an important part of visual purple of both rods and cones and serves both night and day vision. as the rods are affected first in hypovitaminosis a, night blindness has become a famous feature of vitamin a deficiency. vitamin a also maintains epithelia of skin and mucous membranes all over the body and is also needed for spermatogenesis, female reproductive cycle and v assessment of “imtiaz’s sign” for early detection of hypovitaminosis a pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 120 skeletal development and maintenance. its immune strengthening function has led to the popularity of this vitamin as anti-infective.2 approximately one third of the world’s preschool-age population is estimated to be suffering from hypovitaminosis a; with the highest prevalence (44-50%) being reported from south – east asia and africa.3 one of the earliest studies carried out in indonesia showed that children with night blindness were almost three times more likely to die as compared to those from the same community without night blindness, and children with both night blindness and bitot's spots were almost nine times more likely to die.4 a study from bangladesh showed that almost two-thirds of children with keratomalacia had died within a few months5. these facts clearly indicate that irreversible damage has been done by the time the ocular signs develop. the different ocular signs and symptoms of vitamin a deficiency, as graded by the who7, are: night blindness. conjunctival xerosis. bitot's spots. corneal xerosis. corneal ulcer covering less than 1/3 of the cornea. corneal ulcer covering at least 1/3 of the cornea, defined as keratomalacia. corneal scarring. it is vital to realize that many patients especially children who are vitamin a deficient will not have these documented ocular signs. this means that patients with the ocular signs are only the tip of the iceberg; there will be many others in the community who are vitamin a deficient but still have apparently normal eyes. objective of this research study was to document a diagnostic sign which can identify vitamin a deficiency in its initial stage before irreversible and irreparable damage was done. material and methods this prospective case series study was conducted from september 1999 to september 2014 at ophthalmology department chandka medical college and syed eye clinic, larkana, pakistan. patients identified clinically as cases of hypovitaminosis a on the basis of presence of “imtiaz’s sign”, were included in the study during this period. imtiaz’s sign fig. 1 was described by professor syed imtiaz ali shah in pakistan,14 who explained that the staining of a dot or few dots of nasal or mostly temporal conjunctiva with surma (eyelash dye used for religious belief in men, women and children particularly in muslims) or kajal (eyelash dye used for cosmetic purpose) indicates early / subclinical stage of vitamin a deficiency. patients with retinitis pigmentosa, glaucoma, chronic liver disease and malabsorption syndrome were excluded from the study. associated symptoms and signs of vitamin a deficiency were noted. relevant laboratory investigations available were also done on selected patients for the assessment of vitamin a deficiency like, serum iron level, serum albumin level and lft (liver function tests). serum retinol level (vitamin a level) was very costly and not available in many countries including pakistan and serum rbp (retinol binding protein) level was relatively less costly but was also not available in pakistan. dark adaptation threshold and x-ray of long bones to determine excessive deposition of periosteal bone were also performed. patients were given therapeutic doses of vitamin a (2000 to 8000 iu daily in children and 10000 iu daily in adults) orally and improvement was observed. resolution of symptoms or signs, including imtiaz’s sign of vitamin a deficiency was taken as a therapeutic test. results 650 patients, 152 (23.38%) males and 498 (76.62%) females (fig. 2) were identified as cases of hypovitaminosis a on the basis of presence of imtiaz’s sign. age of the patients ranged from 5 years to 43 years and the mean age (± standard deviation) was 18.15 ± 10.20 years. patients were divided into four different age groups (fig. 3 and table 1), 156 (24%) patients belonged to the 5 – 10 years age group. 299 (46%) patients were in the age group of 11-20 years, 88 (13.54%) patients were in the 21 – 30 years age group and 107 (16.46%) patients were in the 31 – 43 years age group. all patients replied positively for nyctalopia; however other signs (e.g. conjunctival xerosis, bitot's spots, corneal xerosis, keratomalacia, corneal scarring), except imtiaz’s sign, were not observed due to the early stage of vitamin a deficiency. relevant laboratory investigations were performed in 81 patients, 37 (45.68%) of them showed iron deficiency, 33 (40.74%) of them had hypoalbuminemia and 11 (13.58%) of them had disturbed lfts (fig 4). this shows that most of the patients suffering from vitamin a deficiency were victims of malnourishment. syed imtiaz ali shah, et al 121 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology fig. 1: imtiaz’s sign. fig. 2: gender distribution. fig. 3: age distribution. fig. 4: laboratory investigations. discussion estimates show that 1.02 billion people in the world are severely affected by micronutrient deficiencies and vitamin a is the most deficient nutrient in the body.6 xerophthalmia and keratomalacia are recognized as chronic manifestations of severe deficiency of vitamin a12. xerophthalmia is the leading cause of preventable childhood blindness with its earliest manifestations known are night blindness and bitot's spots, followed by blinding keratomalacia13. according to who, 140 250 million children are at risk of vitamin a deficiency disorders (vadd) and increased morbidity and mortality even in the absence of ocular signs8. therefore better signs for assessing vitamin a status are needed to identify vitamin a deficiency at an early stage. bitot’s spots are the buildup of keratin located superficially in the conjunctiva usually in the form of triangular foamy lesion with base towards limbus. in 1863, pierre bitot (1822 1888), a french physician, first described these spots in debilitated orphans.9 since then these spots have turned into the hallmark ocular sign of hypovitaminosis a. but several studies assessment of “imtiaz’s sign” for early detection of hypovitaminosis a pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 122 suggest that administration of vitamin a fails to abolish these spots10,11 and permanent damage to the body tissues occur if delay in diagnosis is allowed for appearance of bitot's spots. imtiaz’s sign is the staining of a dot or few dots of conjunctiva with surma or kajal and is the earliest diagnostic sign of vitamin a deficiency. due to sub clinical deficiency of vitamin a rough areas of conjunctiva are produced which get the natural stain of kajal or surma used for cosmetic or religious purpose. these patients who are in the early phase of vitamin a deficiency often confirm visual difficulty in dim light reacting to a leading question, which indicates forthcoming nyctalopia. administration of dietary or therapeutic supplements of vitamin a quickly resolves these stained areas and also resolves associated symptoms of vitamin a deficiency. conclusion due to non-availability of specific laboratory tests to assess vitamin a levels in the blood in most of the countries across the world, presence of an early and effective clinical diagnostic sign is desirable to avoid morbidity and mortality related to vitamin a deficiency. imtiaz’s sign is the diagnostic sign to identify vitamin a deficiency in its initial stage, when the sign and symptoms are reversible. imtiaz’s sign requires no costly tools for application, is safe and can be easily recognized and confirmed by therapeutic test of vitamin a supplements. author’s affiliation professor syed imtiaz ali shah department of ophthalmology chandka medical college, larkana dr. shujaat ali shah trainee registrar department of ophthalmology chandka medical college, larkana professor partab rai department of ophthalmology chandka medical college, larkana dr. shahid jamal siddiqui professor and chairman department of ophthalmology chandka medical college, larkana dr. safdar ali abbasi registrar department of ophthalmology chandka medical college, larkana dr. shabir ahmad bhutto assistant professor department of ophthalmology chandka medical college, larkana role of authors dr. syed imtiaz ali shah reviewed the study and images. dr. shujaat ali shah did the analysis and reviewed the manuscript. prof. partab rai revised the manuscript and reviewed the images. dr. shahid jamal siddiqui substantial contribution to conception and design, acquisition of data or analysis and interpretation of data. dr. safdar ali abbasi involved in drafting the manuscript and revising it critically. dr. shabir ahmad bhutto final approval of the study to be published. references 1. rosenfeld l. vitamine--vitamin. the early years of discovery. clin chem. 1997; 43: 680-5. 2. gerster h. vitamin a-functions, dietary requirements and safety in humans. internat j vit nutr res. 1997; 67: 71-90. 3. world health organization (who). global prevalence of vitamin a deficiency in populations at risk 1995-2005. who global database on vitamin a deficiency. geneva: who; 2009. 4. sommer a, tarwotjo i, hussaini g, susanto d. increased mortality in children with mild vitamin a deficiency. lancet. 1983;2(8350): 585-8. 5. cohen n, rahman h, sprague j, jalil ma, leemhuis de regt e, mitra m. prevalence and determinants of nutritional blindness in bangladeshi children. world health stat q. 1985; 38: 317-30. 6. nair h, arya g, vidnapathiranad j, tripathi s, talukder sh, srivastava v. improving neonatal health in south-east asia. public health. 2012; 126: 223-6. 7. gilbert c. the eye signs of vitamin a deficiency. community eye health. 2013; 26: 6-67. 8. underwood b a. vitamin a deficiency disorders: international efforts to control a preventable “pox”. j nutr. 2004; 134: 231s-6s. 9. shukla m, behari k. congenital bitot spots. ind j ophthalmol. 1979; 27: 63-4. 10. mclearen ds. bitot’s spots: a review of their significance after 100 years. br med j. 1963; 2: 892, 926. http://www.ncbi.nlm.nih.gov/pubmed/?term=rosenfeld%20l%5bauthor%5d&cauthor=true&cauthor_uid=9105273 http://www.ncbi.nlm.nih.gov/pubmed/9105273 http://www.ncbi.nlm.nih.gov/pubmed/?term=cohen%20n%5bauthor%5d&cauthor=true&cauthor_uid=3878045 http://www.ncbi.nlm.nih.gov/pubmed/?term=rahman%20h%5bauthor%5d&cauthor=true&cauthor_uid=3878045 http://www.ncbi.nlm.nih.gov/pubmed/?term=sprague%20j%5bauthor%5d&cauthor=true&cauthor_uid=3878045 http://www.ncbi.nlm.nih.gov/pubmed/?term=jalil%20ma%5bauthor%5d&cauthor=true&cauthor_uid=3878045 http://www.ncbi.nlm.nih.gov/pubmed/?term=leemhuis%20de%20regt%20e%5bauthor%5d&cauthor=true&cauthor_uid=3878045 http://www.ncbi.nlm.nih.gov/pubmed/?term=leemhuis%20de%20regt%20e%5bauthor%5d&cauthor=true&cauthor_uid=3878045 http://www.ncbi.nlm.nih.gov/pubmed/?term=leemhuis%20de%20regt%20e%5bauthor%5d&cauthor=true&cauthor_uid=3878045 http://www.ncbi.nlm.nih.gov/pubmed/?term=mitra%20m%5bauthor%5d&cauthor=true&cauthor_uid=3878045 http://www.ncbi.nlm.nih.gov/pubmed/?term=mclearen%20ds%5bauth%5d syed imtiaz ali shah, et al 123 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology 11. darby wj, mcganity wj, mclaren ds, paton d, alemu z, medhen mg. bitot’s spots and vitamin a deficiency. public health rep. 1960; 75: 738-43. 12. sommer a. xerophthalmia and vitamin a status. prog retin eye res. 1998; 17: 9-31. 13. akhtar s, ahmed a, randhawa ma, atukorala s, arlappa n, ismail t et al. prevalence of vitamin a deficiency in south asia: causes, outcomes, and possible remedies. j health popul nutr. 2013; 31: 41323. 14. shah sia: assessment of imtiaz sign for early detection of hypovitaminosis a: scientific presentation: 27th annual congress of ophthalmological society of pakistan, lahore, pakistan, volume: souvenir. http://www.ncbi.nlm.nih.gov/pubmed/?term=sommer%20a%5bauthor%5d&cauthor=true&cauthor_uid=9537797 http://www.ncbi.nlm.nih.gov/pubmed/9537797 http://www.ncbi.nlm.nih.gov/pubmed/9537797 http://www.ncbi.nlm.nih.gov/pubmed/9537797 http://www.ncbi.nlm.nih.gov/pubmed/?term=atukorala%20s%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=arlappa%20n%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=ismail%20t%5bauth%5d 156 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology original article role of intravitreal bevacizumab before pars plana vitrectomy in patients with vitreous hemorrhage due to proliferative diabetic retinopathy aimal khan, umair qidwai, umer kazi, arif rabbani pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: aimal khan …..……………………….. purpose: to investigate the role of bevacizumab as an adjunct to the management of patients with proliferative diabetic retinopathy undergoing pars plana vitrectomy. material and methods: hundred and eight eyes of 108 patients with proliferative diabetic retinopathy scheduled for surgery were included in the study. they were randomized to vitrectomy with preoperative ivb (group 1) or standard vitrectomy (group 2). group 1 underwent a single intra-vitreal injection of bevacizumab 1.25 mg /0.05ml one week prior to vitrectomy. main outcome measures were best corrected visual acuity (bcva) after surgery, post-operative complications. results: mean age of the patients was 52.07±5.54 years (range 39-67). at 6 months, 40 patients in group 1 had bcva better than baseline as compared to 24 patients in group 2. in group 1, only one patient had early post-operative vitreous hemorrhage, whereas 22 patients in group 2 had early vitreous hemorrhage. conclusion: pre-operative ivb is helpful in improving bcva post operatively, reducing the time of surgery, decreasing the incidence of intraoperative and postoperative bleeding and reducing the frequency of rubeosis and hyphaema. he aim of vitrectomy in proliferative diabetic retinopathy is to re-establish visual acuity through removal of vitreous blood, removal of fibrovascular proliferation causing traction and to stabilize the neovascular process through panretinal endophotocoagulation of ischemic retina. intravitreal bevacizumab (ivb) has been shown to effectively reduce rubeosis and retinal neovascularization in proliferative diabetic retinopathy (pdr).1,2 also, administration of ivb prior to diabetic vitrectomy may reduce intraoperative bleeding and post-operative complications in patients with tractional retinal detachment (trd).3 recurrent vitreous hemorrhage is a common indication for reoperation. most of the hemorrhages occur during the first 6 months but may occur years later.4 bevacizumab (avastin) a full length humanized monoclonal antibody to vascular endothelial growth factor (vegf), initially approved by the us food and drug administration (fda) for the treatment for metastatic colorectal cancer, has now been used in age-related macular degeneration and proliferative diabetic retinopathy (pdr).2,5 it has also been shown to clear the vitreous hemorrhage rapidly and induce regression of retinal neovascularization6. this prospective study was conducted to investigate the effect of ivb prior to diabetic vitrectomy and on its postoperative course. material and methods hundred and eight of 108 patients were recruited in t role of intravitreal avastin before pars plana vitrectomy in patients with vitreous hemorrhage pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 157 the study. the study was approved by the institutional review board. study duration was one year i.e. from 1st september 2010 to 31st august 2011. the study was conducted at isra postgraduate institute hyderabad, al ibrahim eye hospital, karachi and jinnah postgraduate medical center. these patients were diagnosed with proliferative diabetic retinopathy (pdr) and were advised to undergo pars plana vitrectomy (ppv). they were randomized into two categories. in group 1, intravitreal bevacizumab (ivb) was injected 5 to 7 days prior to surgery (60 patients) and group 2 underwent standard ppv (48 patients). all treatment options and the off-label use of intravitreal bevacizumab were discussed with the patient; all patients provided written consent. the inclusion criteria were non clearing vitreous hemorrhage of at least one month, tractional retinal detachment (trd) involving or threatening the macula, and pre-retinal subhyaloid bleeding covering the macula. preoperative assessment included best-corrected visual acuity (bcva), funduscopy with 90d lens and b-scan ultrasonography in 18 patients was used as fundus was not visualized clinically. four patients had visually significant cataract leading to inability to visualize the fundus thus b-scan ultrasonography was used in such patients. all patients were followed up postoperatively at day 1, day 7, day 14, and then monthly up to 6 months. the main outcome measures were improvement of bcva after surgery, postoperative complications hyphema and rubeosis and frequency of vitreous hemorrhage. early postoperative vitreous hemorrhage was taken as vitreous hemorrhage occurring within four weeks after surgery. all cases completed a minimum follow up of 6 months. the patients in group 1 underwent a single injection of ivb one week prior to vitrectomy. after sterile preparation and draping, 1.25 mg / 0.05 ml bevacizumab (avastin, genentech) was injected intravitreally in the operating theatre under topical anesthesia. topical antibiotic (moxifloxacin) was started a day before the procedure and was continued for 3 days post injection. best corrected visual acuity (bcva) and ophthalmic evaluation were done on each visit pre and post operatively. all surgeries were performed by a single senior vitreo-retina specialist with experience of over 4 years in performing vitrectomies and similar vitreo-retinal surgeries. postoperative assessment was also done by a single examiner with over 5 years of experience in diagnostics in vitreo-retina. this observer was kept blind about the group of patient being examined in order to prevent examination bias. standard 20 gauge 3-port ppv was performed using alcon accurus surgical system. tractional membranes were removed using peeling, segmentation, delamination and en bloc dissection. pan retinal photocoagulation (prp) was done at the end of surgery. internal tamponade used was either gas or silicone oil 5000 cst. around 15 patients were lost (from both the groups) to follow up and thus were not included in the data. results hundred and eight eyes of 108 patients were included in the study. mean age of the patients was 52.07 ± 5.54 years (range 39 – 67). there were 64 males and 44 females. out of 108 eyes, 70 (64.8%) had no tamponade used while in rest of the 38 (35.2%) eyes, silicone oil was used. post-operative bcva is shown in (table i). change in bvca was categorized as improvement, deterioration or no change. patients in the group 1 had much better visual acuity than patients in group 2. most of the patients 36(75%) had their bcva in the range of 6/60 or better compared to group 2 where only 28 (46%) patients had bcva better than or equal to 6/60. in group 1, 40 (83%) patients had visual improvement while 6 (13%) had no change and only 2 (4%) had worsening of bcva. on the other hand in group 2, 24 (40%) patients had improvement in bcva while 32 (53%) had no change and 2 (7%) had worsening of bcva (table 2). no significant difference was observed in the frequencies of postoperative rubeosis and hyphema among the groups (table 4). in group 1, only 6 (12.5%) patients had vitreous hemorrhage, 4 of them had it in later stage. in group 2, 40 (60%) patients had vitreous hemorrhage. out of these, 22 had it in early post-operative period. the difference in both groups was statistically significant with p value of 0.0021, using independent t test. discussion in our study, patients in the group 1, who had ivb before ppv had much better post-operative visual aimal khan, et al 158 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology acuity than patients in group 2 who had had standard ppv alone. this is comparable to the study by elbatarny where vision improved in 87% in ivt with ppv group and 80% in standard ppv group.7 similarly in another study by ahmadieh, bcva was better in the ivb group at 1 month compared with the control group (p<0.004).8 the incidence of early postoperative vitreous hemorrhage was very low in group 1 where only 6 patients had vitreous hemorrhage. in the other group, 40 patients had vitreous hemorrhage, out of these 22 had it in early post-operative period. it has been shown in a number of studies that ivb may reduce the incidence of intraoperative and postoperative hemorrhage in diabetic vitrectomy.3,9-11 it is usually difficult to determine the source of early postoperative vitreous hemorrhage. surgeons believe that dissected fibrovascular membranes are the source of bleeding which typically bleed within one week of surgery.12 in our avastin-treated group, only 6 cases of postoperative bleeding were noticed. ivb was given only once in group 1 patients at least 7 days before surgery to give enough time to had its effects on high levels of vegf. exact mechanism of how it reduces the re-bleeding after surgery is not clear. furthermore, ivb prior to surgery significantly reduced the duration of surgery. easier dissection due to the absence of intraoperative bleeding and clear view seem to be the reasons for the reduction in the operating time. fewer cases in avastin group had postoperative rubeosis or hyphaema. el-batarny also reported a similar finding7. retinal ischemia leads to an increased production of intravitreal vegf, while inhibition of vegf activity via ivb decreases vegf levels and inhibits retinal and iris neovascularisation.13,14 conclusion intravitreal bevacizumab reduces retinal neovascularization,2 thus resulting in better visual acuity postoperatively and reduction in intra and post operative complications when it is used preoperatively in pars plana vitrectomy surgery in patients with proliferative diabetic retinopathy. more studies with adequate sample size are required to confirm this effect. author’s affiliation dr. aimal khan (fcps, frcs) consultant ophthalmologist helpers eye hospital quetta dr. umair qidwai. ( fcps ) alibrahim eye hospital karachi dr. umer kazi (fcps) consultant ophthalmologist alibrahim eye hospital karachi dr. arif rabbani (fcps) jpmc karachi role of intravitreal avastin before pars plana vitrectomy in patients with vitreous hemorrhage pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 159 references 1. oshima y, sakaguchi h, gomi f, tano y. regression of iris neovascularization after intravitreal injection of bevacizumab in patients with proliferative diabetic retinopathy. am j ophthalmol. 2006; 142: 155–8. 2. avery rl. regression of retinal and iris neovascularisation after intravitreal bevacizumab (avastin) treatment. retina. 2006; 26: 352–4. 3. avery rl, pearlman j, pieramici dj. intravitreal bevacizumab (avastin) in the treatment of proliferative diabetic retinopathy. ophthalmology. 2006; 113: 1695– 1705. 4. tolentino fl, cajita vn, gancayco t. vitreous hemorrhage after closed vitrectomy for proliferative diabetic retinopathy. ophthalmology. 1989; 96: 1495– 1500. 5. spaide rf, fisher yl. intravitreal bevacizumab (avastin) treatment of proliferative diabetic retinopathy complicated by vitreous hemorrhage. retina 2006; 26: 275-8. 6. chen e, park ch. use of intravitreal bevacizumab as a preoperative adjunct for tractional retinal detachment repair in severe proliferative diabetic retinopathy. retina 2006; 26: 699–700. 7. el-batarny am. intravitreal bevacizumab as an adjunctive therapy before diabetic vitrectomy. clin ophthalmol. 2008; 2: 709-16. 8. ahmadieh h, shoeibi n, entezari m, monshizadeh r. intravitreal bevacizumab for prevention of early post vitrectomy hemorrhage in diabetic patients: a randomized clinical trial. ophthalmology. 2009; 116: 1943-8. 9. moradian s, ahmadieh h, malihi m. intravitreal bevacizumab in active progressive proliferative diabetic retinopathy. graefes arch clin exp ophthalmol. 2008; 246: 1699–1705. 10. romano mr, gibran sk, marticorena j. can a preoperative bevacizumab injection prevent recurrent postvitrectomy diabetic vitreous haemorrhage? eye. 2009; 19: 618-21. 11. rizzo s, genovesi-ebert f, di bartolo e. injection of intravitreal bevacizumab (avastin) as a preoperative adjunct before vitrectomy surgery in the treatment of severe proliferative diabetic retinopathy (pdr). graefes arch clin exp ophthalmol. 2008; 246: 837-42. 12. lee ms, abrams gw. membrane dissection in proliferative diabetic retinopathy. in: peyman ga, ameffert s, conway md, et al. (eds). vitreoretinal surgical techniques. london: martin dunitz ltd. 2001: 251-66. 13. aiello lp, avery rl, arrigg pg. vascular endothelial growth factor in ocular fluid of patients with diabetic retinopathy and other retinal disorders. n eng j med 1994; 331: 1480–7. 14. mahar ps, hanfi an, khan a. angiogenesis and role of antivegf therapy. pak j ophthalmol. 2009; 25 (3): 170-4 pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 89 original article adjustable strabismus surgery: an early glance sana nadeem, b.a naeem, farman khan pak j ophthalmol 2018, vol. 34, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sana nadeem eye department fauji foundation hospital, rawalpindi email: sana.nadeem018@gmail.com …..……………………….. purpose: to assess the short term success rate of adjustable suture technique on rectus muscle strabismus surgery in terms of postoperative alignment study design: prospective, interventional study place and duration of study: eye department, fauji foundation hospital, rawalpindi, from 25 th june, 2016 to 25 th december, 2017 material and methods: we carried out a study using the fornix approach for adjustable squint surgery, in mainly horizontal strabismus in adults and cooperative children, to finely tune the postoperative alignment. the preoperative deviation, strabismus type, patterns, were measured and analyzed. the early postoperative alignment was measured at 6 weeks postoperatively, to assess the success of the adjustable suture technique. a sliding noose knot was used to adjust the sutures, 1 hour postoperatively under topical proparacaine anesthesia, after the effects of general anesthesia had worn off. results: 31 patients were included in this study. the majority were female being 23 (74.5%). the age ranged from 9 to 37 years, with the mean age 16.87 ± 5.5 years. all consenting adults and teenagers, with strabismus were included in this study and operated via the adjustable suture technique. the mean preoperative deviation was 49.38 ± 16.29 δ prism diopters, and the mean postoperative deviation was 3.5 ± 5.42δ prism diopters. the difference between the two was statistically significant (p < 0.05), using the wilcoxon signed ranks test (p = 0.000). early surgical success defined as alignment within ± 10δ (prism diopters) of orthotropia at the end of 6 weeks after surgery, was found in 27 (87.1%) of our strabismus cases. conclusion: adjustable strabismus surgery is associated with excellent shortterm postoperative outcomes in terms of alignment and patient satisfaction. adjustable sutures should be considered in all strabismus cases, whether adults or children. key words: short term, success, adjustable, strabismus, fornix approach, alignment. djustable strabismus surgery1 is an art, dating back to 1907, with the ideation of bielchowsky, o’connor and harms who first introduced this technique to refine postoperative alignment. jampolsky1 later re-introduced the adjustable suture technique to achieve stable motor alignment and sensory improvement. although most strabismus surgeons who use adjustable sutures, including me, would prefer them for all their patients regardless of the cause of strabismus, or age of the patient; there are certain indications2 where they are necessary for good cosmetic results: restrictive strabismus including thyroid myopathy, anesthetic myotoxicity, scleral buckles, paralytic strabismus, and diplopia to name a few. this art however, has failed to gain universal acceptance so far, and especially in a sana nadeem, et al 90 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology pakistan3. strabismus surgery can be tricky3 in terms of its outcomes, despite accurate measurements and nomograms followed, and may yield different results in different patients, in spite of the same amount of alignment. thus, the need arises, to adjust the eyes postoperatively, to maximize the chances of success. adjustable sutures give the operating surgeon a ‘second chance’ at achieving a stable alignment4. in june 2016, we started doing adjustable strabismus surgery, and found it to achieve superior cosmesis, and improve binocular vision and diplopia5. since we are relatively new at this technique, we decided to review and share our early postoperative alignment at six weeks6 postoperatively, as this is the time, which reflects the chance of the patient achieving eventual long term stable alignment of eyes. the aim of this study is to describe the adjustable suture technique and to assess its effectiveness and success in the early postoperative period, prospectively, in addition to highlight the importance and benefits of postoperative adjustment on postoperative outcomes. the importance of sharing our experiences with others is to benefit those who want to help their patients in achieving the best postoperative cosmetic results. material and methods all consenting adults and co-operative teenagers with strabismus were included in this ongoing study, reaching 31 patients. this study was carried out in the department of ophthalmology, fauji foundation hospital, rawalpindi, which is a tertiary care, teaching hospital affiliated with foundation university medical college; from 25th june 2016 to 25th december 2017. approval from the ethical committee was taken. the strabismus cases included both horizontal and vertical strabismus, with only one horizontal muscle being used for adjustment. patients with previous history of strabismus surgery were also included. the first author performed all surgeries. restrictive strabismus, myasthenia gravis, and uncooperative children less than 9 years of age were excluded. visual acuity was documented for every case with a refractive correction given to patients prior to consideration for surgery. the type of strabismus was noted for each patient. the preoperative angle of deviation was assessed by the prism cover test for both near and distance with the refractive correction in place. in certain cases of sensory strabismus with poor fixation, the krimsky test was used for analysis of the angle or a pen torch used as a target for near and distance. the angle of deviation was measured for both near and distance as well as in up gaze, downgaze, right and left gaze. however, the distance angle with refractive correction in place was considered as the angle of deviation in all cases, and the surgical alignment was sought to correct this angle. at the time of suture adjustment, though, both near and distance alignment was corrected. exception to this was accommodative refractive esotropia, for which the near deviation with distance spectacles in place was considered for correction of the alignment. a plus sign (+) was assigned to an exotropic angle and a negative sign (-) was assigned to an esotropic angle. the measurements were taken by the operating surgeon and a certified orthoptist, and repeated by the operating surgeon one day prior to surgery, to obtain maximum cosmesis. binocular vision and stereopsis were assessed by the titmus fly test and worth fourdot test, routinely by the orthoptist preoperatively. a thorough eye examination was performed including fundus and intraocular pressures, and was documented. all surgeries were performed under general anesthesia. a drop of phenylephrine 10% (ethifrin®) were instilled into the conjunctival fornix at the beginning of surgery in each eye. the fornix approach for strabismus surgery was used in every case. each muscle was hooked, and then secured with a double armed 6-0 vicryl (polyglactin 910) absorbable suture, which was passed through the sclera at its insertion, or transposed above or below the insertion in case of ‘a’ or ‘v’ patterns, in a ‘hang-back’7,8 fashion. the medial recti were transposed towards the apex, and the lateral recti were transposed away from the apex, in case of ‘a’ or ‘v’ patterns. the recessed muscles were mostly placed for adjustable purpose, with the required recession held in place by guyton’s9 modification of the sliding noose knot, which was fashioned with a 6-0 vicryl suture. the amount of ‘hang-back’ recession was calculated for each patient using standard tables4,10,11. the traction suture for holding the sclera for postoperative adjustment was created with ethibond 5-0 in every case. for the non-adjustable recessions, the muscle was tied and allowed to ‘hangback’ from its insertion, with the required amount of recession calculated as required. resections were also put up for adjustment in one case only, but avoided mostly, as they tend to cause more pain. for resections, the amount of resection is overcorrected by 2 mm, and allowed to ‘hang-back’ for this distance, to adjustable strabismus surgery: an early glance pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 91 be adjusted if required postoperatively. only one muscle was kept on an adjustable sliding noose knot per case. all patients were assessed for alignment and final adjustment at least 1 hour or more after surgery, in the recovery room, to allow time for the effects of general anesthesia to wear off12. the eyes were anesthetized topically with alcaine® (proparacaine hydrochloride 0.5%) eye drops. the patients were assessed with the cover-uncover test at distance and near, with a torch light for distance if the vision was blurred (due to viscoelastic, antibiotic/steroid drops placed postoperatively or pupillary dilatation with phenylephrine or general anesthesia), or a distance readable target, and for near an accommodative target was used. if the alignment was satisfactory, with no movement on cover testing, the sutures were tied off in their existing position, held in place by the sliding noose, which was removable after tying the ends of the muscle sutures. thereafter, the traction knot was cut, and the conjunctiva was sutured with at least one 6-0 vicryl suture. the final tying off point was orthotropia or maximum possible under-correction as required. in cases of exotropia, the goal was orthotropia or mild esotropia. in cases of esotropia, the goal was either orthotropia, if achieved, or slight under-correction. the alignment was noted postoperatively the next day, at 2 weeks and 6 weeks after surgery. the patients were given postoperative topical steroid and antibiotic drops twice a day and ointment at night for a minimum of 2 weeks. the follow up is being continued to assess long term postoperative alignment as well. early surgical success was defined as alignment within ± 10δ (prism diopters) of orthotropia at the end of 6 weeks after surgery. this postoperative residual deviation was the average of the distance and near deviations noted on prism cover testing. although both horizontal, vertical and complex strabismus were included in our study, the horizontal alignments preoperatively and postoperatively, were mainly assessed and analyzed for surgical success purpose. the results were noted, tabulated and analyzed using the spss statistics version 20. frequencies were calculated for age, gender, type and pattern of strabismus, surgical procedure performed, as well as the follow-up. statistical analysis of success rate was done, and assessment of statistically significant differences between the preoperative and postoperative strabismus deviations was analyzed by the wilcoxon signed ranks test. the success rate was compared and analyzed for the type of strabismus as well. results 31 patients were included in this study, with predominantly 23 (74.2%) females and 8 (25.8%) males. the mean age was 16.87 ± 5.5 years with a range from 9 years to 37 years. the early postoperative alignment was measured at 6 weeks follow up, and the average follow up was 52.7 ± 13.76 days, with an actual range from 38 to 94 days. the patients were classified based on type of deviation and the majority of them were exotropic with 16 (51.6 %) cases [table 1]. table 1 categorizes the patients based on type of strabismus, with predominance of purely horizontal cases in 17 (54.8 %) cases; the rest being a combination of horizontal, vertical and/or complex strabismus. associated patterns, a, v, x, y were tabulated in table 2, with predominance of v-pattern. table 1: type of strabismus. deviation type frequency (percent) exotropia 16 (51.6) esotropia 6 (19.4) exotropia & dvd ɸ 2 (6.5) esotropia & dvd ɸ 1 (3.2) exotropia & hypertropia 5 (16.1) esotropia & hypertropia 1 (3.2) horizontal 17 (54.8) horizontal and vertical 7 (22.6) horizontal & complex€ 4 (12.9) horizontal, vertical & complex€ 3 (9.7) ɸ dissociated vertical deviation € sensory, paralytic strabismus or dvd table 2: pattern of strabismus if present. pattern frequency (percent) v-pattern 20 (64.5) a-pattern 4 (12.9) none 7 (22.6) sana nadeem, et al 92 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology table 3: surgical procedure performed. surgical procedure frequency (percent) blrc¶ 12 (38.7) bmrc§ 5 (16.1) bmrs¥ 1 (3.2) mrc¤ + lrs× 1(3.2) mrsø + lrcħ 6 (19.4) blrc¶ + mrsø 4 (12.9) bmrc§ + lrs× 1 (3.2) mrc¤ 1 (3.2) ¶ bilateral recessions § bimedial recessions ¥ bimedial resections ¤ unilateral medial rectus recession × unilateral lateral rectus resection ø unilateral medial rectus resection ħ unilateral lateral rectus recession the various surgical procedures performed to correct horizontal component of strabismus are listed in table 3. associated vertical deviations were addressed with concurrent procedures on the vertical recti or obliques, which are listed in table 4. a summary of the data in accordance with the type of deviation is elaborated in table 5. the mean preoperative deviation was 49.38 ± 16.29δ (prism diopters), with a range from 23 to 85δ. the mean postoperative deviation was 3.5 ± 5.42δ (prism diopters), with a range from zero to 20δ. the difference between the preoperative and postoperative deviation was analyzed by the wilcoxon signed ranks test and found to be statistically significant (p = 0.000) [table 6]. early surgical success defined as satisfactory alignment within ± 10δ (prism diopters) of orthotropia at the end of 6 weeks after surgery, was found in 27 (87.1%) of our strabismus cases, and were tabulated for each deviation type [table 7], and under corrections were found in 3 (9.6%) cases of exotropia and 1 (3.2%) case of esotropia only. figures 1-3 depict our post-operative success. reoperation has not been required in any of these cases so far. no complication was encountered in any patient during suture adjustment and all proceeded smoothly with minimal patient discomfort. table 4: surgery on vertical recti & obliques. surgery on vertical recti & obliques frequency (percent) unilateral ioα myectomy 3 (9.7) bilateral ioα myectomies 6 (19.4) ioα anteriorization 1 (3.2) srβ transposition 1 (3.2) bilateral ioα myectomies + src ʃ 1 (3.2) none 19 (61.3) α inferior oblique β superior rectus ʃ superior rectus recession table 5: data analysis according to deviation type. type of deviation age in years (mean ± sd) gender preoperative angle (pd) (mean ± sd) ω postoperative angle (pd) (mean ± sd) pattern male female vpattern apattern exotropia 19.06 ± 6.18 4 12 48.1 ± 16.7 4.46 ± 6.77 9 2 esotropia 14.17 ± 4.4 2 4 60.1 ± 13.3 2.58 ± 4.34 4 2 exotropia & dvd ɸ 13.5 ± 4.9 1 1 34 ± 8.4 1.00 ± 1.41 2 0 esotropia & dvd ɸ 15.0 1 0 70 0 1 0 exotropia & hypertropia 15.0 ± 3.53 0 5 47.8 ± 10.7 2.30 ± 2.58 4 0 esotropia & hypertropia 16.0 0 1 23 8 ± 3.50 0 0 pd prism diopters sd standard deviation ω distance deviation in all cases except accommodative esotropia in which near deviation with distance correction was taken adjustable strabismus surgery: an early glance pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 93 table 6: preoperative and postoperative deviations. descriptive statistics mean std. deviation minimum maximum percentiles 25th 50th (median) 75th preoperative deviation (pd) 49.3871 16.29249 23.00 85.00 40.0000 45.0000 65.0000 postoperative deviation (pd) at 6 weeks 3.5000 5.42525 .00 20.00 .0000 1.0000 6.0000 pd prism diopters test statisticsa postoperative deviation at 6 weeks preoperative deviation (prism diopters) z -4.862b asymp. sig. (2-tailed) .000 a. wilcoxon signed ranks test b. based on positive ranks. table 7: surgical success. surgical success with postoperative deviation within 10 prism diopters yes no total 31 27 (87.1) 4 (12.9) deviation type exotropia 13 (41.9) 3(9.6) esotropia 5 (16.1) 1 (3.2) exotropia & dvd ɸ 2 (6.4) 0 esotropia & dvd ɸ 1 (3.2) 0 exotropia & hypertropia 5 (16.1) 0 esotropia & hypertropia 1 (3.2) 0 ɸ dissociated vertical deviation fig. 1 (a): 20 year old girl with congenital alternate esotropia of 70δ, a left hypertropia of 8δ, and a v-pattern of 15δ. bimedial recessions of 7mm od and 8 mm os after adjustment and a left inferior oblique myectomy was done. sana nadeem, et al 94 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology fig. 1 (b): postoperatively, she is well aligned. fig. 2 (a): a 15-year-old girl with an alternate exotropia of 70δ and a v-pattern of 32δ was managed by bilateral lateral rectus recessions of 7mm and a right medial rectus resection of 6 mm, and bilateral inferior oblique myectomies. no adjustment was needed postoperatively and the sutures were tied off. fig. 2 (b): postoperatively she is orthotropic. adjustable strabismus surgery: an early glance pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 95 fig. 3 (a): a 12 year old boy with an alternate exotropia of 40δ and a v-pattern of 20δ was managed with bilateral lateral rectus recessions 6mm od and 8 mm os after adjustment, along with a half tendon width upward transposition of both muscles was done. fig. 3 (b): postoperatively, he is orthotropic, with resolution of the v-pattern. discussion in our study, we found adjustable strabismus surgery to be highly effective for postoperative satisfactory alignment with a high success rate of 87.1%. the patients experienced no adverse effects or complications during the adjustable procedure, and did not report much discomfort during suture tying. we minimized patient discomfort by putting only one muscle on an adjustable noose knot per procedure, and this too has borne fruitful results. suture adjustment was needed in the majority of patients postoperatively, amounting to 26 (83.8%) cases, and no adjustment was required for 5 (16.1%) cases, thus indicating the need to fine tune the postoperative alignment to achieve orthotropia and better surgical outcomes, because the nomograms and tables may not be appropriate for each individual case. thus, our study findings indicating positive and encouraging outcomes with the adjustable suture technique are consistent with numerous studies worldwide, which report high success rates with the likes of wisnicki, repka and guyton13, who reported a huge success rate of this adjustable procedure in a massive 290 patients, and rate of reoperation in just 9.7%. eino et al14, reported a success rate of 91.7% in 109 patients, and tripathi et al15, observed a higher success rate with adjustable versus non-adjustable surgery in 443 total cases. engel et al16 reported a high short-term success rate of 88% in their adjustable suture technique in 61 children, and so did awadein and guyton12, with their study on children and infants using propofol anesthesia, who noted a success rate of 79%. nihalani and hunter16 also noted a high success rate for both vertical and horizontal muscle surgery sana nadeem, et al 96 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology using a short tag noose technique. budning et al17 developed a short adjustable suture with high success in 304 patients. locally, a study done by shakir et al18 at lrbt free base eye hospital in karachi, reported a success rate of 88% in 18 exotropic subjects with adjustable technique. several other authors park et al19 and bishop et al20, have contrasting evidence in their reported studies, where they did not find any difference in surgical success, when comparing adjustable versus non-adjustable techniques. the strengths of our study are its success in terms of surgical results. there are both vertical and horizontal strabismus patients included along with complex cases like consecutive strabismus, dvd, patterns, and one case of a sixth nerve palsy. transpositions were also performed during surgery on these patients. the surgeries were carried out in a single step to restore ocular alignment, rather than splitting the large alignments at a second stage. a few limitations of our study are a relatively small sample size, because we wanted to share our early postoperative results, and we do intend to add more patients to this study with time. strabismus patients are not that frequent in our set up and using this technique on more patients is our priority, for the interest of the patients. four of our patients did not have a successful postoperative alignment, and we could attribute it to measurement errors21,22, or muscle abnormalities, hypoplasia or pulley anomalies, which can be assessed preoperatively with neuroimaging23. also early alignment may vary from subsequent longterm alignment, which is more important to the patient especially, and to the operating surgeon, although we have observed them to be quite similar in many of the cases. in addition, we used only one muscle per patient for the adjustable suture technique both to avoid excessive discomfort, and to save time. others2 recommend using adjustable sutures on all muscles, except on the inferior oblique, in order to adjust the muscles symmetrically and achieve a balanced alignment between the two eyes. we intend to broaden our experience on adjustable strabismus, to include all cases including children, to offer our patients a better chance of success. some patients have not returned for a follow up, which we had to exclude from the study, decreasing our eventual total number of cases. future work required is a large-scale study with more subjects, which we are recruiting, and assessment of long-term outcomes at one year postoperatively and beyond. using the adjustable suture on multiple or all muscles may further enhance the success rate of this procedure. infants and children12 also need to be given a chance at better postoperative success with the use of propofol anesthesia. superior oblique adjustment can also be done with this technique, if the need arises to operate on this muscle. the need arises to encourage strabismus surgeons, to use this adjustable technique to maximize the chances of their surgical success, and to reduce the number of reoperations needed to satisfy the patients. conclusion adjustable strabismus surgery has been found to yield excellent short-term postoperative outcomes in terms of alignment and patient satisfaction. the adjustable suture technique should be considered in all strabismus cases, whether horizontal, vertical or cyclovertical; simple or complex strabismus, and irrespective of the subjects being adults or children. author’s affiliation dr. sana nadeem assistant professor ophthalmology department fauji foundation hospital/fumc, rawalpindi prof. dr. b.a naeem professor and head ophthalmology department fauji foundation hospital/fumc, rawalpindi farman khan orthoptist ophthalmology department fauji foundation hospital/fumc, rawalpindi role of authors dr. sana nadeem principle author, performed all surgeries, orthoptic assessment & evaluation of all patients, data analysis. prof. dr. b.a naeem reviewing author, opinion about patient management, head of department farman khan orthoptic assessment & fusion of all the patients adjustable strabismus surgery: an early glance pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 97 references 1. vasconcelos gc, guyton dl. adjustable sutures in strabismus surgery: why surgeons either love them or hate them after three decades. editorial. arc bras oftalmol. 2014 aug; 77 (4): 5-6. 2. guyton dl. adjustable sutures. in: clinical atlas of procedures in ophthalmic and oculofacial surgery. second ed. oxford university press: usa, 2011: p 592. 3. nihalani br, hunter dg. adjustable suture strabismus surgery. eye. 2011 oct; 25 (10): 1262-1276. 4. coats dc, olitsky se. strabismus surgery and its complications. springer: berlin, 2007: p 37-39. 5. ferdi a, kelly r, logan p, dooley i. outcomes of adjustable strabismus surgery an irish university hospital. int ophthalmol. 2016 nov 8; 37 (5): 1215-1219. 6. liebermann l, hatt sr, leske da, holmes jm. adjustment versus no adjustment when using adjustable sutures in strabismus surgery. j aapos. 2013 feb; 17 (1): 38-42. 7. capó h, repka mx, guyton dl. hang-back lateral rectus recessions for exotropia. j pediatr ophthalmol strabismus, 1989; 26: 31-4. 8. repka mx, guyton dl. comparison of hangbackmedial rectus recession with conventional recession. ophthalmology, 1988; 95: 782-7. 9. deschler ek, irsch k, guyton kl, guyton dl. a new, removable, sliding noose for adjustable-suture strabismus surgery. j aapos. 2013 oct; 17 (5): 524-7. 10. lueder gt, archer sm, hered rw, karr dj, kodsi sr, kraft sp, et al. pediatric ophthalmology and strabismus. section 6. basic and clinical science course. american academy of ophthalmology. san francisco, 2015-2016: p 182. 11. yanoff m, duker js. ophthalmology. third edition. mosby: st. louis, 2009: p 1331-1338. 12. awadein a, sharma m, bazemore gm, saeed ha, guyton dl. adjustable suture strabismus surgery in infants and children. j aapos. 2008; 12: 585-590. 13. wisnicki hj, repka mx, guyton dl. reoperation rate in adjustable strabismus surgery. j pediatr ophthalmol strabismus, 1988; 25: 112-114. 14. eino d, kraft sp. postoperative drifts after adjustable suture strabismus surgery. can j ophthalmol. 1997; 32: 163-169. 15. tripathi a, haslett r, marsh ib. strabismus surgery: adjustable good for all? eye, 2003; 17: 739-742. 16. nihalani br, whitman mc, salgado cm, loudon se, hunter dg. short tag noose technique for optional and late suture adjustment in strabismus surgery. arch ophthalmol. 2009 dec; 127 (12): 1584-1590. 17. budning as, day c, nguyen a. the short adjustable suture. can j ophthalmol. 2010; 45: 359-362. 18. shakir m, kamil z, zafar s, bokhari sa, rizvi f. adjustable sutures in constant exotropia. pak j ophthalmol. 2013; 29 (4): 192-196. 19. park yc, chun by, kwon jy. comparison of the stability of postoperative alignment in sensory exotropia: adjustable versus non-adjustable surgery. korean j ophthalmol. 2009; 23: 277-280. 20. bishop f, doran rm. adjustable and non-adjustable strabismus surgery: a retrospective case-matched study. strabismus, 2004; 12: 3-11. 21. pediatric eye disease investigator group. inter-observer reliability of the prism and alternate cover test in children with esotropia. arch ophthalmol. 2009 jan; 127 (1): 59-65. 22. thompson jt, guyton dl. ophthalmic prisms. measurement errors and how to minimize them. ophthalmology, 1983 mar; 90 (3): 204-210. 23. patel jr, gunton kb. the role of imaging in strabismus. curr opin ophthalmol. 2017 sep; 28 (5): 465-469. microsoft word 15. obituary sah 128 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology   obituary prof. syed ali haider (1962 – 2013) on a bright morning of 18th february 2013 we lost a renowned and talented vitreo retinal surgeon prof. syed ali haider along with his younger son murtaza haider from the crown of pakistani ophthalmology. nobody even, who met him once, can forget the energy and sincerity in handshake of this handsome man. he was an intuitive leader, excellent ophthalmic surgeon and exquisite medical teacher. born in 1962, he belonged to a family of accomplished physicians. his mother, prof. tahira bokhari; a professor of anatomy, while his father prof. syed zafar haider; a renowned general surgeon and teacher of innumerous doctors placed around the world. after his schooling at multan he joined king edward medical college, lahore, in 1981. his father paid special attention towards his grooming and asked ali to either push bicycle or use public transport to the educational institute, despite couple of vehicles in the portico. after graduation he decided to specialize in ophthalmology and moved to united kingdom, where he got through his professional examinations with laurels. he completed 4 year training in britain and was the first pakistani to have fellowship training in vitreo-retinal surgery from oxford, uk. with distinguished credentials he could have reached pinnacle of success in any rich country, but he was a patriotic pakistani and moved back to motherland in 1996. he started service in government sector at mayo hospital, lahore and gradually moved up the ladder. the highlight of his professional career was when he became associate and later professor of ophthalmology at postgraduate medical institute / lahore general hospital. there initially he received a couple of ruined wards, few medical officers and broken equipments. he took up this challenge and showed utmost qualities of leadership. he invited trained medical faculty to join hands with him. he raised millions of rupees to acquire expensive electro-medical ophthalmic equipment. he motivated the ngos to repair building, fund investigations and support treatment, not only for ophthalmic but also other disciplines. he was an institution maker and played pivotal role in development of dr. ameer din medical college, ophthalmic oncology service of shaukat khanum memorial hospital, postgraduate medical institute lahore. he was life member and held office as general secretary, ophthalmological society of pakistan, lahore branch (2006-07). he was secretary of vitreo-retinal association of pakistan (vrap) and supervisor/examiner of fcps vitreo-retina (college of physicians & surgeons pakistan). he was editor in chief of pjo 2011-12 and editor ppmj 2009-12. based on his scientific publications (23), presentations (approximately 60) and tireless services to thousands of needy patients seeking cure from vitreo-retinal disorders he was awarded prof. m lateef chaudhry osp gold medal in 2009. he was kindhearted towards patients and would go to any extent to help them out. his professional manners were praised equally by his patients, students and colleagues. his enthusiasm towards teaching was unmatched and he took part in training of hundreds of postgraduate students in ophthalmology. he was a popular vitreo-retina trainer and at the time of his demise, fellowship training slots for him were booked for 2 years. his special personality attribute was to speak his mind, even in the highest office. his inside was even shinier than the grey hair on his head. he was polite in etiquettes to everybody. however, he could enter into a obituary sah pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 129 hot debate where interest of deserving person is at stake. ali had quite a broad knowledge of english / urdu literature. he was an eloquent speaker and could articulate at length on any topic. he loved riding bicycle and travelled through european mountains with friends on push – bikes. he was married to dr. fatima haider, who herself is very compassionate and runs a free medical centre for the needy persons at lahore. he was a loving father of two sons and a 6 month old daughter. he was role model as a father to groom the children. despite all his engagements, ali was unique, as he found time to accompany his sons while at work or would join them at riding lessons etc. he is separated from the medical fraternity but his legacy would always prevail and will be beacon of light in any moments of darkness. may allah swt rest his soul in eternal peace. zahid kamal siddiqui       microsoft word 01-editorial 1 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology editorial ophthalmic challenges in our community there are many issues related to ophthalmic community, to our trainees and patients. are these persons getting the best from us? we must ponder on these issues and try to solve them. ophthalmic state of affairs in pakistan needs prompt attention. patient’s expectation for proper treatment for their ailment at reasonable cost in private sector is their right. patients pay handsome amount under the head of various treatment modalities like anti vegf / laser, different types of intra ocular lenses and for varying investigations such as oct / ffa. concept of quality practices should be propagated among all of us. now ophthalmology is evidence based1 and some uniformity in the treatment should be sought out for keeping socio-economic affordability of patient and nation. diabetic eye disease is an emerging challenge. we should plan for its prevention and keep our self ready for future work load. awareness for preventive ophthalmology amongst the doctors should be sought. public counseling about diabetic eyes disease is very important. role of tele-ophthalmology should be evaluated to solve the issues in rural areas. advanced technology has greatly increased the cost of practice. in short duration new versions of equipment has wondered everyone in the practice. federal government took initiative of making centers of excellence in every province. in many public hospitals state of art equipments are lying without the basic equipments. to cope with technology influx one should consult people who have vision and experience in health economics2. wise decision is required for buying advanced equipment, knowing its proper need and utilization. the role of ngos is also very important. comprehensive planning and liaison should be sought to achieve maximum benefits of their investments and services. charitable eye hospitals are delivering good services. now we should think about improving the outcome of their work. availability of new drugs in the market had helped the ophthalmic physicians to treat various entities medically without embarking upon surgical intervention. many local drug companies have minimized the cost to the benefit of patients. doctors must recognize their noble profession and ethical practices must be warranted3. sub-standard drugs must be discouraged by asking their official registration and licensure by drug regulating or enforcing agencies. the liaison between drug license issuing authorities and body / council of ophthalmic representatives of the country must be recognized so as legislation and its implementation for fair practices can be ensured. the role of ophthalmological society of pakistan in this context is quite obvious. minimum standards of practice (sop) must be identified. each hospital / institute must develop and follow sops institution should display sops for every medical or surgical entity so as trainees can build their reflexes towards ethical practices. once they learn what to use, when to use and when not to use, will ultimately bring sops in their routine practices. efforts and financial resources are required for education and training of an ophthalmic surgeon. great consideration is required for post graduate training in general ophthalmology and sub specialty programs. selection of compatible candidate for pg ship and their dedication must be watched along and comprehensive training schedule should be implemented in true letter and spirit. we should provide better environment and opportunities to them. ophthalmological society of pakistan (osp) is sending doctors to attend overseas scientific conferences. in all national ophthalmic conferences every osp branch is giving incentives to junior doctors for best papers. pakistan journal of ophthalmology also gives cash prize of pkr 50,000/to best paper in each issue. this is a good start and we should also arrange scholarships for overseas training of doctors in new disciplines of ophthalmology. we should develop a registry in which we should report all cases like endophthalmitis, trauma and retinoblastoma4. most important area of research is highly ignored by our busy experts in every specialty. data recording is the main stay of any scientific work. it is important not only for research but legal aspects could not be denied. plenty of data is available and we should take time to compile or document it. a little effort in this regard can bring good research articles of international standards. proper surveys should be conducted to identify the gravity of situation and thereby comprehensive planning can be tailored. ophthalmic challenges in our community pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 2 references 1. wormald r. what is evidence–based ophthalmology? introducing the cochrane eyes and vision group. community eye health. 2003; 16 (48): 60. 2. smith af, brown gc. understanding cost effectiveness: a detailed review. br j ophthalmol 2000; 84: 794-798. 3. ahmed m. code of ethics of pakistan ophthalmic society. available from: www.ospcentre.org/ 4. rich iii wl. ophthalmic clinical registry would enhance compliance, outcomes and revenues. available from: http://www.healio.com/ophthalmology/practicemanagement/news/online/ prof. shahid wahab 68 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology original article ocular emergencies in a rural hospital: a 5 year retrospective clinical audit subhasis jana, saumen kumar chaudhuri, asim kumar dey, purban ganguly, mousumi bandopadhyay, subrata dutta pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: subhasis jana 3 nd year ms pgt dept. of ophthalmology, burdwan medical college, burdwan p.o. rajbati, pin: 713104 india …..……………………….. purpose: to study the magnitude of the ocular emergencies and to explain the health professional about its prevention and better management. material and methods: this retrospective clinical audit was conducted over a period of 5 years from 1 st january 2008 to 31 st december 2012 at the department of ophthalmology, burdwan medical college and hospital, burdwan, west bengal. a comprehensive review of the record available for ocular emergencies was carried out. results: total 5674 patients were attended admitted in the ophthalmology emergency. male and female were 3764 and 1910 respectively. male: female ratio was 1.97:1. traumatic ocular emergencies were 4071 (71.75%) and nontraumatic ocular emergencies were 1603 (28.25%). most common cause of traumatic ocular emergency was extra-ocular foreign body 1848 (45.40%) followed by open globe injury 976 (23.97%). in traumatic ocular emergencies male and female were 3044 (74.77%) and 1027 (25.22%) respectively. most common presented age group was third and fourth decade. among the open globe injury (n=976) 825 (84.53%) episodes were due to accidents. common source of open globe injury was due to stone 450 (54.55%). corneal ulcer 341 (21.27%) and acute glaucomas 311 (19.4%) were the leading causes of nontraumatic group. minor ocular injuries were managed as day care basis. open globe ocular injuries were managed with primary repair. others ocular emergencies were given conservative medications. conclusions: increased public health awareness will prevent inadvertent incidences of ocular emergencies in the community. early intervention of all ocular morbidities in the community will help reduce the burden of non-traumatic ocular emergencies. he word audit is “a mean of quality control for medical practice by which the profession shall regulate its activities with the intention of improving overall patient care”1. an audit of clinical practice is the analysis of the data either prospectively or retrospectively to determine both quantitatively and qualitatively of the work load of an institution or individual department. it includes numbers of admissions, patients’ demographics, various complications and mortality2. previously published literatures have shown that traumatic ocular injury was more common in males3.they have also reported that open globe injury was the most prevalent ocular emergency. it has been found that younger workers (25 – 44) are more susceptible to severe trauma4. it has been further reported that in india and other developing countries corneal abrasion in agriculture-worker is a major risk factor for causation of microbial keratitis5. ocular emergency cases are of varied nature, from accidental foreign body injury to severe sight threatening perforation of globe. in – spite of significant prevalence of ocular emergency in burdwan region no recent data is available. a five year retrospective t ocular emergencies in a rural hospital: a 5 year retrospective clinical audit pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 69 clinical audit from january 2008 to december 2012 is presented in this study to evaluate the patients attending in the emergency department for ocular emergency services. the aim of this audit is to determine the prevalence and causes of emergency ocular problems in a medical college and hospital in rural setup. material and methods a comprehensive observational retrospective audit was done in the department of ophthalmology burdwan medical college from january 2008 – december 2012. the data was collected from emergency inpatients registers, indoor admission registers, out patients registers and minor operation theater registers of the department of ophthalmology. data on patient age, gender, occupation, date of admission, etiology of disease / trauma if any, presenting complains, and the treatment offered to them were analyzed. from the above database, patients were classified into traumatic and non-traumatic ocular emergencies. age and sex distribution was studied among both the groups. according to the nature of trauma the traumatic emergencies were further classified into: extra-ocular foreign body induced injuries, open globe injuries and closed globe injuries. non traumatic ocular emergencies were further classified according to the nature of the disease. among the non traumatic group, corneal ulcers were further sub-classified according to etiological agent. results between january 2008 – december 2012, the department of ophthalmology, burdwan medical college provided general and specialized emergency services to 5,674 patients in total. therefore on average 1,135 patients per year and about 3.15 patients/day attended the emergency department of ophthalmology of burdwan medical college and hospital. total 5,674 patients were seen / admitted in the ophthalmology emergency. among them male and female were 3,764 and 1,910 respectively. male: female ratio was 1.97:1. the youngest patient in this audit was 6 months old and the eldest was 90 years and the peak age group was 2nd and 3rd decades of life. traumatic ocular emergency cases were 4071 (71.75%) and non-traumatic cases were 1603 (28.25%). the most common traumatic ocular emergency was extra-ocular foreign body 1848 (45.40%) followed by open globe injury 976 (23.97%). in traumatic ocular emergency male and female were 3,044 (74.77%) and 1,027 (25.22%) respectively. among extra-ocular foreign body, the most common site of foreign body lodgment was cornea 1,280 (76%) followed by tarsal plate 202 (11.99%) and iron 1,125 (66.80%) was the most common foreign body followed by sand 286 (16.98). among the open globe injury 825 (84.53%) episodes were due to accidents. common source of accidental open globe injury was due to stone 450 (54.55%) (fig.2). most common site of open globe injury was cornea 632 (62.94%) followed by scleracorneal junction with uveal prolapse 223 (22.21) (table 5). among closed globe injury cases 421 (10.34%) hyphema 214 (50.83%) was the most common presentation (table 6). corneal ulcer 341 (21.27%) and acute glaucomas 311 (19.4%) were the leading causes of non-traumatic group. bacterial etiology 198 (58.06%) was the most common cause followed by viral 94 (27.56%) (fig. 1). bacteria fungus virus fig. 1: showing etiology of corneal ulcer among patients in non-traumatic group (n = 341) age and sex distribution of non-traumatic and traumatic groups were shown in (table 1, 2) respectively. the frequencies of non-traumatic and traumatic ocular emergencies were shown in (table 3, 4) respectively. discussion an audit of surgical outcome can be seen as the final step in what had been termed the “journey of care” for both the individual patient and for the population as a etiology of corneal ulcer subhasis jana, et al 70 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology whole6. ocular emergency cases remain the serious clinical problem and if not managed properly it could be sight threatening. in our study majority of the patients of nontraumatic ocular emergencies were middle aged. this could be explained by the fact that certain diseases of older age groups present as ocular emergency, such as lens induced glaucoma (lig), and angle closure glaucoma (acg). male predominance was seen in both groups. in this study we found that almost 1/3rd patient out of the total ocular emergency was due to trauma. trauma was a common ocular morbidity and damage may be immediately apparent or may develop after the injury as a secondary complication. however ocular trauma is mostly preventable by the use of suitable eye protection7. ocular trauma had greater potential to cause permanent visual or cosmetic defect for rest of the life in the affected individuals and was a major cause of monocular blindness and visual impairment throughout the world, although little is known about its epidemiology or associated visual ocular emergencies in a rural hospital: a 5 year retrospective clinical audit pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 71 outcome in developing countries8. khattak et al reported that trauma as a common cause of unilateral blindness9. a national population based survey of blindness in nepal found a blindness prevalence rate of 0.8% and trauma was responsible for 7.9% of monocular blindness10. in our study majority of the patients belonged to 2nd-3rd decades, in which 2/3rd of the total patients were males in the traumatic group. this finding correlates with the finding of al–rajhi, et al, they reported that 77% of ocular trauma occurred in males11. stone (54.55%) iron (20.97%) road traffic accident (19.03%) wood (17.21%) sharp instrument (16.48%) fall (16.12%) fig. 2: showing sources of accidental traumatic open globe injury (n = 825) in the present study commonest site of lodgment of extra-ocular foreign body was cornea. iron was the commonest foreign body followed by sand and agricultural matter in order of decreasing incidence. in traumatic open globe injury cornea was the most common affected part of eye followed by scleracorneal rupture with uveal – prolapse. asaminew t et al reported that cornea was the most common affected part of the eye i.e. 63.2%, cornea – scleral injury 14.8%, and uveal – prolapse or damage were 8.9%12. accidental open globe rupture being the most common which is similar to the findings with vats s et al, who reported that 87.1% episodes were due to accidents, 10.4% due to alleged assault, and 2.5% were self-inflicted13. we also found that hyphema was the most common presentation among the traumatic closed globe injury. according to fasih u et al 22.2% of the patients presented with hyphema in their study14. chemical injuries, though relatively less frequent are very devastating to the eye. in our study it was not possible to classify the chemical induced injuries according to the nature of the chemicals because no such documentation for such cases was available. ramakrishnan et al has shown that accidental chemical injury at the work place is most common in the group of 19 – 30 years15. majority of the extra ocular foreign bodies were removed. closed globe and chemical injuries were managed medically. in all cases of open globe injury, primary repair was done. valid estimation of the annual incidence of infective ulceration was difficult to obtain in most countries8. in our study we found that corneal ulcer was the most common non-traumatic ocular emergency. gonzales ca et al reported that annual incidence of corneal ulcer in madurai district, south india was 11.3 per 10,000 population16. bacteria were the most common etiologic agent followed by virus and fungus. iqbal a et al in their study reported that bacterial corneal ulcer were the most frequent causes i.e. 63.4% followed by fungal 21.2% and viral ulcer were 12.1%9. bharathi mj et al found that 32.77% were bacterial and 34.4% were fungal corneal ulcer in their study17. these findings also support our findings. in all cases of non-traumatic ocular emergencies, conservative medical management was given. conclusion this study indicates that ocular trauma is a significant cause of mono-ocular and sometimes bi-nocular visual loss in all age groups. many injuries and their visual outcome may be prevented through education and prompt, appropriate medical care. health education and safety strategies can prevent most serious ocular emergencies both at home and place of work. the incidence of occupational ocular injuries can be reduced by mandatory use of protective goggles and alcohol free environment at work place. majority of the non-traumatic ocular emergencies were corneal ulcers, mostly due to bacterial etiology. this indicates that public health awareness about ocular hygiene and early intervention of all cases of red eyes can considerably reduce the burden of nontraumatic ocular emergencies. a 5 year retrospective clinical audit of ocular emergencies in a rural hospital will definitely enable future health managers and clinicians to formulate comprehensive strategies for prevention and management of ocular emergencies both at the level of communities as well as health care delivery units. subhasis jana, et al 72 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology author’s affiliation dr. subhasis jana ms (final year) pgt department of ophthalmology burdwan amaedical college burdwan, west bengal, india p.o. rajbati. pin: 713104 dr. saumen kumar chaudhuri assistant professor department of ophthalmology burdwan amaedical college burdwan, west bengal, india p.o. rajbati. pin: 713104 dr. asim kumar dey associate professor department of ophthalmology burdwan amaedical college burdwan, west bengal, india p.o. rajbati. pin: 713104 dr. purban ganguly ms (first year) pgt department of ophthalmology burdwan amaedical college burdwan, west bengal, india p.o. rajbati. pin: 713104 dr. mousumi bandyopadhyay professor and head, dept. of ophthalmology burdwan amaedical college burdwan, west bengal, india p.o. rajbati. pin: 713104 dr. subrata dutta professor department of ophthalmology calcutta national medical college kolkata, india references 1. alam sn, rehman s, raza sm, manzar s. audit of a general surgical unit: need for self evaluation. pak j of surgery. 2007; 23: 141-4. 2. bilal a, salim m, muslim m, israr m. two years audit of thoracic surgery department at peshwar. pak j med sci. 2005; 21: 12-6. 3. karman k, antunica ag, perk sr. epidemiology of adult eye injuries in split-dalmatian county. croatian medical journal 2004; 45: 304-9. 4. fea a, bosone a, rolle t, grignolo fm. eye injuries in an italian urban population: report of 10, 620 cases admitted to an eye emergency department in torino. graefes arch clin exp ophthalmol. 2008; 246: 175-9. 5. chaudhuri sk, jana s, biswas j, bandyopadhya. modes and impacts of agriculture related ocular injury. int j health sci res. 2014; 4: 108-11. 6. herbert ma, prina sl, william sjl. are unaudited records forming an outcome registry database accurate? ann thorac surg. 2004; 77: 1960-4. 7. iqbal a, jan s, khan mn, khan s, muhammad s. admitted ocular emergencies: a four year review. pak j ophthalmol. 2007; 23: 58-64. 8. jackson h. bilateral blindness due to trauma in combodia. eye 1996; 10: 517-20. 9. khattak mnk, khan md, mohammad s, mulk ra. untreatable monocular blindness in pakistani eye patients. pak j ophthalmol. 1992; 8: 3-5. 10. khatry sk, lewis ae, schein od, et al. the epidemiology of ocular trauma in rural nepal. br j ophthalmol. 2004; 88: 456-60. 11. al-rajhi aa, awad a, badeeb o, bwchari a. causes of blindness in students attending schools for the blind in saudi arabia. saudi j ophthalmol. 2003; 17: 276-80. 12. asamanew t, gelaw y, alemseged f. a 2-year review of ocular trauma in jimma university specialized hospital. ethiop j health sci. 2009; 19: 67-74. 13. vats s, murthy gvs, chandra m, gupta sk, vashist p, gogoi m. epidemiological study of ocular trauma in an urban slum population in delhi, india. indian j ophthalmol. 2008; 56: 313-6. 14. fasih u, shaikh a, fehmi ms. occupational ocular trauma (causes, management and prevention). pak j ophthalmol. 2004; 20: 65-73. 15. ramakrishnan km, mathivanan t, jayaraman v, babu m, shankar j. current scenario in chemical burns in a developing country: chennai, india. ann burns fire disasters. 2012; 25: 812. 16. gonzales ca, srinivasan m, whitcher jp. incidence of corneal ulceration in madurai district, south india. ophthal epidemiol 1996; 3: 156-66. 17. bharathi mj, ramakrishnan r, vasu s, meenakshi r, shivkumar c, palaniappan r. epidemiology of bacterial keratitis in a referral centre in south india. indian journal of medical microbiology. 2003; 21: 239-45. pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 185 editorial updates in the management of retinoblastoma retinoblastoma is the commonest childhood intraocular malignant tumour, with an approximate incidence of 1 in 15,000–20,000 live births worldwide. advances in treatment over the last quarter century have led to a survival rate that is over 90% in developed countries1. while paradigm shifts have occurred in conservative treatment, enucleation (removal of the eye) remains the mainstay for treatment for advanced disease. with improved survival rates, there has been an impetus to treat retinoblastoma without removal of the eye and to preserve vision. previously external beam radiotherapy (ebr) was extensively used to avoid enucleation. however well recognised side effects such as second cancers in the field of radiation, particularly if given in the first year of life, have limited its use to salvage treatment in order to avoid enucleation.2 recently there is a trend away from enucleation and external beam radiotherapy towards focal conservative treatments. this is reflected in the reeseellsworth classification, which predicted chance of eye salvage by ebr, being replaced by the international intraocular retinoblastoma classification (iirc).3 such conservative treatments include primary intravenous chemotherapy followed by tumour consolidation with focal measures such as thermotherapy, cryotherapy, and plaque radiotherapy.4 the most commonly used chemotherapy drugs include carboplatin, etoposide, and vincristine (cev) given every 3 weeks through central venous access line. this regimen has become the standard primary treatment for iirc groups b, c, and d, though variations in protocols exist amongst specialist centres.3,5 concerns about the side-effects of multidrug systemic chemotherapeutic agents including bone marrow suppression, hearing loss and acute myeloid leukaemia stimulated the development of novel approaches for selectively delivering chemotherapy to the globe to avoid the potential complications of systemic drugs. intra-ophthalmic artery chemotherapy (intra-arterial chemotherapy/ ophthalmic artery chemosurgery; oac) has received much recent attention. it was first performed in 1954 by reese in new york, usa followed by the japanese group led by kaneko in 1993, who delivered the chemotherapy drug, melphalan, into the internal carotid artery using a balloon to prevent spread into the brain. in 2006, abramson and colleagues modified the technique and introduced direct intra-ophthalmic artery catheterisation to treat patients with retinoblastoma, using a microcatheter placed at the ostium of the ophthalmic artery rather than directly into the ophthalmic artery to get a higher concentration of the chemotherapeutic agent into the ophthalmic artery.6 this technique showed promise in curing eyes with large retinal tumours. the treatment can be given as a primary treatment or as salvage treatment to prevent enucleation or external beam therapy. the iirc group e (most advanced) eyes are a clinical spectrum, and although group e eyes have been treated with this modality as a primary treatment, these were not buphthalmic nor did they have high intraocular pressures. eyes with such advanced features should still be treated by enucleation. tumours that seed into the vitreous cavity or subretinal space are still difficult to control. ocular salvage at four years follow-up was achieved in 58% of eyes that had previous treatment failure with intravenous chemotherapy and/or ebr.6 the greatest concern about using this method for advanced retinoblastoma (group d or e eyes) is that it does not prevent potential metastatic disease and it has its own complications. in a report of 78 patients undergoing oac, there were 2 that developed metastases requiring aggressive systemic chemotherapy.6 in addition, radiation is used to visualise the position of the catheter and provide an angiogram of the ophthalmic artery in this technique. although this is a low dose, it is essential to minimise radiation for patients with genetic retinoblastoma. systemic complications e.g. severe vasovagal response from catheterisation and local effects such as choroidal ischaemia have been reported.7 the position of the catheter, the dose of melphalan and previous radiation (either brachytherapy or ebr) shabana chaudhry, et al 186 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology can limit vision in patients with previously healthy foveolas.8 most reports have used melphalan as a chemotherapeutic agent but topotecan has also been recently used as an adjunct drug.6 vitreous seeds are the most difficult tumour feature to control and various strategies have been employed from radiotherapy, second line chemotherapy to enucleation. intravitreal chemotherapy melphalan via specific safety-enhancing injection techniques (intravitreal melphalan injection, 20-30 µg, by transconjunctival pars plana route with concomitant triple-freeze cryotherapy at the injection site during needle withdrawal for prevention of extraocular seeding in a hypotensive eye) has also been tried with good outcomes for persistent vitreous seeds.9 intra-ophthalmic artery chemotherapy and intravitreal chemotherapy offer weapons in the arsenal of therapies that might save the eye in patients with retinoblastoma. however, there are still potential complications to consider, and, consequently, these procedures should be performed at institutions with expertise in the care of patients with retinoblastoma. multicentre prospective studies with large numbers are essential in order to predict which patients will benefit long term from attempts at eye salvage. references 1. maccarthy a, birch jm, draper gj, hungerford jl, kingston je, kroll me, stiller ca, vincent tj, murphy mf. retinoblastoma: treatment and survival in great britain 1963 to 2002. br j ophthalmol. 2009; 93: 38–9. 2. chan mp, hungerford jl, kingston je, plowman pn. salvage external beam radiotherapy after failed primary chemotherapy for bilateral retinoblastoma: rate of eye and vision preservation. br j ophthalmol. 2009;93: 891-4. 3. linn murphree. a intraocular retinoblastoma: the case for a new group classification. ophthalmol clin north am, 2005; 18: 41-53. 4. shields cl, de potter p, shields ja. chemoreduction in the initial management of intraocular retinoblastoma. arch ophthalmol. 1996; 114: 1330–8. 5. chan hs, deboer g, thiessen jj, budning a, kingston je, o'brien jm, et al. combining cyclosporin with chemotherapy controls intraocular retinoblastoma without requiring radiation. clin cancer res. 1996; 2: 1499-508. 6. gobin yp, dunkel ij, marr bp, brodie se, abramson dh. intra-arterial chemotherapy for the management of retinoblastoma: four-year experience. arch ophthalmol. 2011; 129: 732-7. 7. muen wj, kingston je, robertson f, brew s, sagoo ms, reddy ma. efficacy and complications of super-selective intraophthalmic artery melphalan for the treatment of refractory retinoblastoma. ophthalmology. 2012:119: 611-6. 8. tsimpida m, thompson da, liasis a, smith v, kingston je, sagoo ms, reddy ma. visual outcomes following intraophthalmic artery melphalan for patients with refractory retinoblastoma and age appropriate vision. br j ophthalmol. 2013; 97: 1464-70. 9. munier fl, gaillard mc, balmer a, soliman s, podilsky g, moulin ap, beck-popovic m. intravitreal chemotherapy for vitreous disease in retinoblastoma revisited: from prohibition to conditional indications. br j ophthalmol. 2012; 96: 1078-83. dr. shabana chaudhry clinical fellow in paediatric ophthalmology with special interest in retinoblastoma, royal london hospital, barts nhs trust hospitals uk honorary clinical fellow in paediatric ophthalmology moorefields eye hospital, london, uk dr. mandeep s. sagoo consultant ophthalmic surgeon in retinoblastoma ocular oncology & medical retina st. bartholomew’s and royal london hospitals london moorfields eye hospital, london, uk senior lecturer ucl institute of ophthalmology dr. m. ashwin reddy consultant paediatric ophthalmologist and retinoblastoma surgeon lead for paediatric ophthalmology and retinoblastoma services, barts health nhs trust paediatric service director, moorfields eye hospital nhs foundation trust 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http://www.ncbi.nlm.nih.gov/pubmed/?term=comlications+of+intra+arterial+chemotherapy+in+retinoblastoma+-tsimpida http://www.ncbi.nlm.nih.gov/pubmed?term=munier%20fl%5bauthor%5d&cauthor=true&cauthor_uid=22694968 http://www.ncbi.nlm.nih.gov/pubmed?term=gaillard%20mc%5bauthor%5d&cauthor=true&cauthor_uid=22694968 http://www.ncbi.nlm.nih.gov/pubmed?term=balmer%20a%5bauthor%5d&cauthor=true&cauthor_uid=22694968 http://www.ncbi.nlm.nih.gov/pubmed?term=soliman%20s%5bauthor%5d&cauthor=true&cauthor_uid=22694968 http://www.ncbi.nlm.nih.gov/pubmed?term=podilsky%20g%5bauthor%5d&cauthor=true&cauthor_uid=22694968 http://www.ncbi.nlm.nih.gov/pubmed?term=moulin%20ap%5bauthor%5d&cauthor=true&cauthor_uid=22694968 http://www.ncbi.nlm.nih.gov/pubmed?term=beck-popovic%20m%5bauthor%5d&cauthor=true&cauthor_uid=22694968 http://www.ncbi.nlm.nih.gov/pubmed/22694968 pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 259 original article measurement of optic disc diameter and cd ratio using oct imaging and fundus stereo-biomicroscopy to find an agreement between the two shaheryar ahmed khan, louise mason pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: shaheryar ahmed khan ophthalmology department, north devon district hospital, raleigh park, barnstaple ex31 4jb. email: javakhan@hotmail.com …..……………………….. purpose: to compare the clinician disc assessment findings with oct estimation and to assess the agreement. study design: observational study. place and duration of study: north devon district hospital, uk from january 2017 and april 2017. material and methods: this is an observational study of 100 eyes of 50 consecutive patients. all patients and eyes were examined by one single clinician. vertical disc height was measured by the clinician using the slit lamp narrow beam of light. cd ratio was estimated by comparing the cupped area of the optic disc with the neuro-retinal rim of the optic disc considering the overall optic disc size. oct was used for automated disc examination and to assess disc parameters. the agreement between the two methods was analyzed statistically by intraclass correlation coefficient (icc). results: there was a good correlation seen between the two methods while assessing vertical disc diameters and cd ratio (r = 0.65, 0.66 respectively). there was a substantial strength of agreement (according to icc agreement criteria) in both clinician and oct estimated values in the measurement of vertical disc diameter and cd ratio. the icc values were 0.77 (ci = 0.66, 0.84) and 0.70 (ci = 0.28, 0.85) respectively. conclusion: in this study, the agreement is much greater for both important disc parameters between oct and clinician methods and clearly it is substantial but still not perfect. oct and clinician measured observations for optic disc measurements are still not interchangeable in clinical practice. keywords: cd ratio; oct; vertical disc diameter. ptic disc examination is an important part of glaucoma assessment for its screening and monitoring in routine ophthalmology clinical practice. it has played a pivotal role historically in the diagnosis and management of glaucoma. generally, the optic disc size is measured on fundoscopy by the clinician along with the estimation of cup to disc ratio (cd ratio) and optic disc rim thickness. usually the vertical optic disc height and cd ratio is measured on the slit lamp however along with it, heidelberg retinal tomography (hrt) and more recently optical coherence tomography are being utilized more routinely for such measurements of the optic disc for diagnosis as well as follow up of glaucoma patients routinely. previously, studies have been carried out to compare the measurements of optic disc performed by o shaheryar ahmed khan, et al 260 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology the clinicians fundus examination with that of hrt1,2. some researchers have used digital stereo optic disc camera (discam) and hrt in measuring the cd ratio3. however, to our best knowledge there has been no comparative study in the literature, which assessed both these disc parameters (cd ratio & vertical disc diameter) in a single study comparing the agreement between the oct disc measurements with the clinicians’ slit lamp bio-microscopy disc measurements. hence, we have carried out this study on these two important optic disc parameters to compare the clinicians disc assessment findings with oct estimation and to assess the agreement or otherwise between the two. study design observational study of the patients examined for glaucoma assessment in the eye clinic in a district regional hospital. material and methods this is an observational study of 100 eyes of 50 consecutive patients attending the glaucoma assessment clinic at north devon district hospital between january 2017 and april 2017. all patients in the clinic were referred with a query of glaucoma by the community opticians but not already diagnosed with glaucoma. the research was approved by north devon district hospital nhs trusts ethics committee. the protocol and methods undertaken in the study for patients were followed in accordance with the tenets of the declaration of helsinki. patients included in the study were adults with snellen chart visual acuity of 6/24 or better and those who had good quality images of their optic discs with oct scan. patients with previous ocular trauma and with dense media opacities like corneal scarring, dense brown or white cataracts or vitreous haze due to any other cause limiting the fundal view for slit lamp examination and oct imaging were excluded from the study. high myopic (-6d or greater) individuals were also excluded from the study. patients were examined in the eye clinic thoroughly with focus on the fundal optic disc examination. all patients and eyes were examined by one single clinician. haag streit slit lamp (haag streit bm 900, switzerland) was used for examination and all patients were examined with dilated pupils using mydriatic drops for pupil dilation. +60 diopters double aspherical fundus (volk opticals) lens was used to assess the optic disc. correction factor was not required for slit lamp biomicroscopy disc height measurements as +60 dioptres lens does not require a correction factor. vertical disc height was measured by the clinician, using the slit lamp narrow beam of light. the vertical length of the slit lamp beam of light coinciding with the optic disc margin vertically was recorded from the millimeter scale of the slit lamp. cd ratio was estimated by comparing the cupped area of the optic disc with the neuro-retinal rim of the optic disc considering the overall optic disc size. topcon 3doct 2000 model was used for automated disc examination and to assess disc parameters. oct is beginning to be widely used for assessing optic disc parameters in glaucoma clinical practice. oct works on the principle of using low coherence interferometry and produce in-vivo cross sectional scans of retinal structures4,5,6. oct has been used by researchers to assess the retinal nerve fiber layer and to assess the topography of the optic disc5,6. patients were registered on the topcon oct individually and each patient had individual oct assessment of their optic disc. based on the edges of the rpe of each b-scan, the oct software automatically estimates the optic disc margin. vertical as well as horizontal optic disc diameters and cd ratios were obtained from oct measurement options for each patient. oct uses the cross points of the reference plane and the internal limiting membrane of the retina for estimating cd ratios. the data of 100 eyes obtained from slit lamp biomicroscopy and from the oct scanning was analyzed with spss version 10 and microsoft office excel version 2010. the agreement between the two methods for measuring the vertical disc diameter and cd ratio parameters was analyzed statistically by intraclass correlation coefficient (icc) and pearson correlation coefficient (r) was used for correlation. fleiss and cohen have described the icc as a measure of reliability for assessing the level of agreement for quantitative data6. landis and koch have interpreted the icc in table-1 by describing the relevant strength of agreement for categorical data7. we also used a statistical analysis using graphical methods for agreement which is described by bland and altman8. paired t tests were carried out to find a statistically significant difference between the two methods of measurements and a p-value < 0.05 was considered significant. measurement of optic disc diameter and cd ratio using oct imaging and fundus stereobimicrosopy to find pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 261 results the mean vertical disc diameter of 100 patients recorded by the clinician on slit lamp fundoscopy was 1.76 mm, while oct scanning estimated it to be 1.80 mm and the mean clinician cd ratio was 0.56 while oct estimated it to be 0.68 as mentioned in table 2. the mean difference of values by the two methods was 0.04 (95% ci = 0.001, 0.08) for vertical disc diameter where oct measured the disc diameter to be slightly larger than clinician (p < 0.05, paired t test) and 0.11 (95% ci = 0.08, 0.14) for cd ratio where oct measured the cd ratio to be significantly larger than the clinician (p < 0.0001, paired t test). bland altman plots of differences of the optic disc diameter values and cd ratios against the average of these two parameters in oct and clinician measurements are shown in figures 1 and 2 respectively. there was a good correlation seen between the two methods while assessing vertical disc diameters and cd ratio (r = 0.65, 0.66 respectively) as shown in figure 3 and 4 respectively. there was a substantial strength of agreement (according to icc agreement criteria) in both clinician and oct estimated values in the measurement of vertical disc diameter and cd ratio. the icc values were 0.77 (ci = 0.66, 0.84) and 0.70 (ci = 0.28, 0.85) respectively. table 1: agreement measures for categorical data. intraclass correlation coefficient (icc) strength of agreement < 0.00 poor 0.00-0.20 slight 0.21-0.40 fair 0.41-0.60 moderate 0.61-0.8 substantial 0.81-1.00 almost perfect table 2: mean and difference (with 95% ci) of oct and slit lamp clinician values of vertical disc diameter and cd ratio. mean clinical vertical disc diameter in mm (95% ci) mean oct vertical disc diameter in mm (95% ci) differenceclinician & oct vertical disc diameter in mm (95% ci) mean clinician cd ratio (95% ci) mean oct cd ratio (95% ci) differenceclinical & oct cd ratio (95% ci) 1.76 (1.72, 1.80) 1.80 (1.75, 1.85) 0.04(0.001, 0.08) 0.56 (0.53,0.59) 0.68 (0.64,0.72) 0.11 (0.08,0.14) fig. 1: bland and altman plot for agreement between clinician stereo-biomicroscopy and oct vertical disc diameters. fig. 2: bland and altman plot for agreement between clinician stereo-biomicroscopy and oct cup disc ratios. shaheryar ahmed khan, et al 262 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology fig. 3: graph showing correlation between clinician and oct vertical disc diameter. fig. 4: graph showing correlation between clinician and oct cup disc ratios. discussion optic nerve assessment in general and estimation of optic disc diameter and cd ratio in particular are very important parts of glaucoma assessment and management. researchers have previously shown that glaucomatous visual field loss is preceded by optic disc damage9,10. reproducibility of retinal nerve fibre layer analysis and optic disc parameter measurements using oct modality has been established previously by researchers11,12. there has been studies, which have utilized different methods to assess the optic disc parameters and to compare the different methods of assessment. most of these studies have compared the cd ratio using hrt as one of the methods of assessment to find an agreement between hrt values with other methods, mainly slit lamp biomicrocopy2,3,13,14. however, far less number of studies have assessed the optic disc diameter for this purpose. optic disc diameter is the most important disc parameter and has a pivotal role in determining other disc parameters, e.g., the size of both optic disc rim and cd ratio parameters are very much linked and dependent on it15,16,17. watkins et al. assessed vertical cd ratio to study the agreement between direct ophthalmoscopic, fundus bio-microscopic and hrt estimated values14. they found a moderate agreement between clinician values and hrt in their work, however in our study, we found a better, substantial agreement for cd ratio estimation between the fundus bio-microscopy and oct estimated values. some researchers have assessed the vertical disc diameters by fundoscopy using 60, 78 and 90 d lenses with that of hrt for finding a correlation between them18. in their study the correlation was substantially good between the two methods when using 60 d lens however it reduced with 90 d lens (r = 0.80 with 60d lens and r = 0.59 with 90d lens). in our study, oct and 60 d lens values for vertical disc diameter correlated well. however, in contrast there was a substantive agreement for vertical disc diameter (icc = 0.77) in our study. agreement was not analyzed in their study as they only studied the correlation (r = 0.65). bl rao et al. have assessed the disc diameters of small, average and large optic discs estimated by clinician stereo-biomicroscopy and hrt to find an agreement1. in their study, the icc for measurements by clinical method and hrt for vertical disc diameter was 0.487, which was a moderate agreement in contrast to a substantially strong agreement (icc measurements of 0.77) in the current study when comparing oct and clinicians’ vertical disc diameter values. the mean difference between the clinical and hrt measurements found by them was 0.22 (mm) for vertical disc diameter which seems to be markedly different and unlike our study in which the mean difference between the clinical and oct measurements for disc diameter was only slightly different (0.04 mm). moghimi et al. assessed the optic disc size and cd ratio parameters comparing spectral domain (sd) oct and hrt evaluated readings in their study. they found that hrt overestimated optic disc area as compared to sd-oct17. however, in our study, the clinician has slightly underestimated the optic disc size as compared to oct. there is another study, which has shown a poor correlation and agreement for vertical cd ratio measured using hrt-3, oct and clinical grading19. correlation and agreement of cd ratio in contrast is very good in our study using oct measurement of optic disc diameter and cd ratio using oct imaging and fundus stereobimicrosopy to find pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 263 and clinical grading. to mention the merits of our study, we have compared and assessed both the important parameters of optic disc, i.e., vertical optic disc diameter and cd ratio. secondly, oct has been utilized in this study to compare both the disc parameters (disc diameter and cd ratio) with clinicians’ disc findings. however, oct has been used for disc topography measures and for its comparison with other methods20,21,22. comparison of oct, fundus photography and clinicians’ stereo bio-microscopy findings for analyzing only the cd ratio parameter for agreement between these methods has also been studied previously by prof. meenakshi et al23. furthermore, we have not only used icc and bland altman method for finding an agreement between the two methods but we have also shown correlation between them. our study is limited in the fact that we have estimated and assessed the agreement of only vertical disc diameter by the two different methods rather than assessing both horizontal and vertical disc diameters. it is thought that vertical disc diameter is mainly measured in a routine clinical practice and is more important of the two. the patients selected in this study were referred from community opticians to the glaucoma clinics, for assessment but not already diagnosed with it. one of the other limitations of this study was that the optic disc size was not classified in our study and optic discs were not grouped into different categories according to their size. we felt this was not an adequate sample size for that type of descriptive study and this would not have affected the results to a great extent. however, this was a study with an adequate sample size for finding an agreement between the two different methods. the study is also lacking in not providing the diagnosis or a break up of glaucoma diagnosis as the patients were selected from screening clinic. it was considered that this would not reflect greatly and would not change the agreement very much, as this was a head to head comparison of two different methods of same optic discs with same underlying diagnosis if any. the study is limited by utilizing only one clinical observer. further studies with oct are required using more observers with different experience in optic disc assessment to explore further and to find a better agreement between the systems. we found that there was a slight difference in the vertical disc diameter values in both methods but more difference was observed for cd ratio values in the two methods. clinicians underestimated the values in the measurement of both optic disc parameters in our study, perhaps more training is required for measurements and standardization of estimation of optic disc parameters clinically which may improve the agreement further in the future. conclusion in summary, the agreement is much greater for both important disc parameters between oct and clinician methods and clearly it is substantial but still not perfect. clinical significance of this study is that the mean estimated values are statistically different in both methods hence we conclude that oct and clinician measured observations for optic disc measurements are still not interchangeable in clinical practice. author’s affiliation dr. shaheryar ahmed khan mrcsed ophthalmology north devon district hospital, raleigh park, barnstaple. louise mason bsc optometry optometry department north devon district hospital, raleigh park, barnstaple. role of authors dr. shaheryar ahmed khan concept, planning, design, data analysis, literature search, manuscript preparation & write up, manuscript editing, guarantor. louise mason data acquisition, manuscript review, manuscript editing, guarantor. references 1. harsha b l rao, g c sekhar, ganesh j babu, and rajul s parikh. clinical measurement and categorization of optic disc in glaucoma patients. indian j 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optom vis sci. 2003; 80: 454–9. 15. caprioli j miller jm. optic disc rim area is related to disc size in normal subjects. arch ophthalmol. 1987; 105: 1683–1685. 16. vernon sa, hawker mj, ainsworth g, hillman jg, macnab hk, dua hs. laser scanning tomography of the optic nerve head in a normal elderly population: the bridlington eye assessment project. invest ophthalmol vis sci. 2005; 46: 2823–2828. 17. zangwill lm, weinreb rn, berry cc. racial differences in optic disc topography. arch ophthalmol. 2004; 122: 22–28. 18. lim cs, o'brien c, bolton nm. a simple clinical method to measure the optic disk size in glaucoma. j glaucoma. 1996; 5: 241–245. 19. perera sa et al. cup-to-disc ratio from heidelberg retina tomograph 3 and high-definition optical coherence tomography agrees poorly with clinical assessment. j glaucoma. 2016 feb; 25 (2): 198-202. 20. moghimi s et al. measurement of optic disc size and rim area with spectral-domain oct and scanning laser ophthalmoscopy. invest ophthalmol. vis sci. 2012; vol. 53: 4519-4530. 21. schuman js, wollstein g, farra t, hertzmark e, aydin a, fujimoto jg, paunescu la. comparison of optic nerve head measurements obtained by optical coherence tomography and confocal scanning laser ophthalmoscopy. am j ophthalmol. 2003 apr; 135 (4): 504-12. 22. ramakrishan r, kader ma, budde wm. optic disc morphometry with optical coherence tomography: comparison with planimetry of fundus photographs and influence of parapapillary atrophy and pigmentary conus. indian j ophthalmol. 2005; 53:187-91. 23. dhar m, jayachandran i, raju b, deepa pa. comparison of results of optic disc analysis using stereoscopic biomicroscopy, stereo fundus photography and optical coherence tomography. kerala j ophthalmol. 2007; 19(3): 276-281 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1771020/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1771020/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1771020/ https://www.ncbi.nlm.nih.gov/pubmed/25827299 https://www.ncbi.nlm.nih.gov/pubmed/?term=schuman%20js%5bauthor%5d&cauthor=true&cauthor_uid=12654368 https://www.ncbi.nlm.nih.gov/pubmed/?term=wollstein%20g%5bauthor%5d&cauthor=true&cauthor_uid=12654368 https://www.ncbi.nlm.nih.gov/pubmed/?term=farra%20t%5bauthor%5d&cauthor=true&cauthor_uid=12654368 https://www.ncbi.nlm.nih.gov/pubmed/?term=hertzmark%20e%5bauthor%5d&cauthor=true&cauthor_uid=12654368 https://www.ncbi.nlm.nih.gov/pubmed/?term=aydin%20a%5bauthor%5d&cauthor=true&cauthor_uid=12654368 https://www.ncbi.nlm.nih.gov/pubmed/?term=aydin%20a%5bauthor%5d&cauthor=true&cauthor_uid=12654368 https://www.ncbi.nlm.nih.gov/pubmed/?term=aydin%20a%5bauthor%5d&cauthor=true&cauthor_uid=12654368 https://www.ncbi.nlm.nih.gov/pubmed/?term=fujimoto%20jg%5bauthor%5d&cauthor=true&cauthor_uid=12654368 https://www.ncbi.nlm.nih.gov/pubmed/?term=paunescu%20la%5bauthor%5d&cauthor=true&cauthor_uid=12654368 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2804124/ pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 189 editorial recent advancements in management of uveitis uveitis is a sort of “umbrella term” that encompasses many different diseases, with different etiologies, treatment and prognosis. however, there is a common denominator among them: the potential, more or less important, to produce severe and permanent deficit in visual acuity and/or visual function.1 this concept should be kept in mind whenever we face a patient with uveitis and need to establish the treatment modality. this patient will be most of times young and in working age. disease’s impact on his life and his social circle should not be underestimated, nor the impact of uveitis as a cause of morbidity and socioeconomic blindness within the society.2 in recent years, much emphasis has been put to define, specifically, each clinical entity. results of this effort are the criteria for the diagnosis of behcet's disease3,4, sarcoidosis5 or vogt-koyanagi-harada syndrome.6 the sun criteria (standardization of uveitis nomenclature), although wider, also help in defining a particular clinical picture, esential step before choosing diagnostic and therapeutic strategies and comparing results among different centers.7 speaking the same "language" shortens distances and facilitates experience exchanges. different uveal diseases appear in different geographic regions and genetic backgrounds; epidemiological knowdelge about uveitis in the part of the world we are working will render our task easier. major emphasis should be put on epidemiologic research everywhere, but specially in countries of the so called developing world: appraisal of our patient population is key when taking decisions, mainly in a context where resources are far to be unlimited. during the last years, we have been privileged witness of a breakthrough in ancillary tests for disease diagnosis. just as an example, in 1948, posner and schlossman described for the first time the clinical picture of hypertensive cyclitis that bears their names.8 their original description of a benign and recurrent syndrome is far from the current understanding of this form of infectious, hypertensive and severe uveitis. sixty years passed and thousands of molecular techniques were developed and applied to aqueous humor analysis. our knowledge of uveitic entities moved steadily from the description of biomicroscopic findings to the molecular and imaging characterization of each syndrome. the arrival of spectral domain optical coherence tomography (sdoct) shed light on various posterior uveitic diseases, mainly the group of the so called white dot syndromes: the almost histological resolution of images combined with the non-invasive acquisition mode render this tool esential in the diagnosis and monitoring of the disease.9 the near future is the enhanced depth imaging oct (edi-oct), which will “remove the veil” from the choroid, a so frequent target within the spectrum of uveitis.10 how to define the active or quiescent nature of uveitis remains crucial and difficult to implement. how to predict which patients will have a more torpid evolution or will develop complications more often, how to know who will respond less to treatment.... the quantification of proteins in the anterior chamber using the laser flare meter (lfm) technology represents a great improvement for disease activity assesment, objectively measured in terms of bloodaqueous barrier rupture.11 the method proved to be useful in the management of juvenile idiopathic arthritis (jia) – associated uveitis and was a good predictor of progression to more severe forms of the disease.12 similarly, the indocyanine green (icga) angiography allowed us to "see" choroidal inflammation, to defined choroidal tissue as the primary site of inflammation in many entities and to monitor treatment response.13 the concept of recurrence in vkh syndrome, for example, traditionally considered as an anterior uveitis requiring topical treatment, radically changed due to icg angiography: we know now that disease reactivation involves also the primary site of the autoimmune insult and that treatment should be systemic.14 perhaps the greatest progress (and also the next frontier) has to do with treatment. the development of biological drugs in the field of rheumatology and oncology allowed us to benefit our patients with a better treatment targetted to the molecular level. the shift from systemic to intraocular delivery, whenever karina j. 190 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology possible, is by far our great contribution. the family of tumor necrosis factor (tnf) alpha blockers proved to be important agents in the treatment of uveitis and showed interesting differences between uveal inflammation and inflammation affecting elsewhere in the body: etanercept, for example, although very useful in cases of arthritis, spondylitis, or psoriasis, presents few advantages (if any) in the management of uveitis.15 is the intraocular approach really superior to systemic immunosuppression? even though it seems its advantages are clear, this issue is still a matter of discussion. surprisingly, the must (multicenter uveitis steroid treatment trial) study did not find clear benefits from local therapy with the retisert implant compared to systemic corticosteroid administration (with immunosuppressants if needed).16 the goal of therapy is to achieve as many periods of remission as possible with the lowest doses and the least adverse effects (ocular or systemic). keeping this in mind, we are still waiting for more results of the ozurdex implant.17 in short time, uveitis has moved from being considered a purely infectious disease, mainly linked to tuberculosis or syphilis, to represent a wide and diverse group of diseases, infectious, autoimmune or autoimmune infectiously triggered. from being considered a guarded prognosis disease, where the balance between the damage from disease itself and the one related to steroid therapy was difficult to establish, to be thought as a group of very different entities, each one with specific challenges and molecularly targeted treatments. the genetic pathway (and the differences in treatment response according to genetic polymorphisms in each different patient) is still waiting to be explored. and even more important, in the era of globalization of disease management, in a world where frontiers are difficult to establish and knowledge is global, resources are far away of being homogeneously distributed. how to bring the gold standard of care to every patient suffering from uveitis, regardless where he is, represents definitely our next big challenge. references 1. durrani om, meads ca, murray pi. uveitis: a potentially blinding disease. ophthalmologica. journal international d'ophtalmologie. international journal of ophthalmology. zeitschrift fur augenheilkunde. 2004; 218 (4): 223-236. 2. durrani om, tehrani nn, marr je, moradi p, stavrou p, murray pi. degree, duration, and causes of visual loss in uveitis. the british journal of ophthalmology. 2004; 88 (9): 1159-1162. 3. criteria for diagnosis of behcet's disease. international study group for behcet's disease. lancet. 1990; 335 (8697): 1078-1080. 4. okada aa, stanford m, tabbara k. ancillary testing, diagnostic / classification criteria and severity grading in behcet disease. ocular immunology and inflammation. 2012; 20 (6): 387-393. 5. herbort cp, rao na, mochizuki m. members of scientific committee of first international workshop on ocular s. international criteria for the diagnosis of ocular sarcoidosis: results of the first international workshop on ocular sarcoidosis (iwos). ocular immunology and inflammation. 2009; 17 (3): 160-169. 6. read rw, holland gn, rao na, et al. revised diagnostic criteria for vogt-koyanagi-harada disease: report of an international committee on nomenclature. american journal of ophthalmology. 2001; 131 (5): 647652. 7. khairallah m. are the standardization of the uveitis nomenclature (sun) working group criteria for codifying the site of inflammation appropriate for all uveitis problems? limitations of the sun working group classification. ocular immunology and inflammation. 2010; 18 (1): 2-4. 8. posner a, schlossman a. syndrome of unilateral recurrent attacks of glaucoma with cyclitic symptoms. arch ophthal. 1948; 39 (4): 517-535. 9. onal s, tugal tutkun i, neri p, c ph. optical coherence tomography imaging in uveitis. international ophthalmology. 9 2013. 10. fung at, kaliki s, shields cl, mashayekhi a, shields ja. solitary idiopathic choroiditis: findings on enhanced depth imaging optical coherence tomography in 10 cases. ophthalmology. 2013; 120 (4): 852-858. 11. herbort cp, guex-crosier y, de ancos e, pittet n. use of laser flare photometry to assess and monitor inflammation in uveitis. ophthalmology. 1997; 104 (1): 64-71; discussion 71-62. 12. davis jl, dacanay lm, holland gn, berrocal am, giese mj, feuer wj. laser flare photometry and complications of chronic uveitis in children. american journal of ophthalmology. 2003; 135 (6): 763-771. 13. herbort cp, mantovani a, papadia m. use of indocyanine green angiography in uveitis. international ophthalmology clinics. 2012; 52 (4): 13-31. 14. bouchenaki n, herbort cp. indocyanine green angiography guided management of vogt-koyanagiharada disease. journal of ophthalmic & vision research. 2011; 6 (4): 241-248. 15. kakkassery v, mergler s, pleyer u. anti-tnf-alpha treatment: a possible promoter in endogenous uveitis? observational report on six patients: occurrence of uveitis following etanercept treatment. current eye research. 2010; 35 (8): 751-756. 16. kempen jh, altaweel mm, holbrook jt, jabs da, louis ta, sugar ea, thorne je. randomized recent advancements in management of uveitis pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 191 comparison of systemic anti-inflammatory therapy versus fluocinolone acetonide implant for intermediate, posterior, and panuveitis: the multicenter uveitis steroid treatment trial. ophthalmology. 2011; 118 (10): 1916-1926. 17. lowder c, belfort r, jr., lightman s, et al. dexamethasone intravitreal implant for noninfectious intermediate or posterior uveitis. archives of ophthalmology. 2011; 129 (5): 545-553. karina julian, md uveitis – instituto de la visión ophthalmology department, austral university hospital austral university – school of medicine buenos aires – argentina pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 10 original article pattern of common paediatric diseases at spencer eye hospital uzma fasih, atiya rahman, arshad shaikh, m.s fahmi, m. rais pak j ophthalmol 2014, vol. 30 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: uzma fasih spencer eye hospital unit 2 karachi medical & dental college …..……………………….. purpose: to determine the pattern of common paediatric ocular diseases presenting at outpatient department of spencer eye hospital. material and methods: it was a hospital based descriptive cross sectional type of study carried out at opd of spencer eye hospital from march 2012 – may 2012 and included 370 patients. a detailed history was taken regarding the ocular disease and examination was carried out in detail on slit lamp, direct and indirect fundoscopy was done where required. refraction was done and examination under anesthesia was done if required. diagnosis was established and recorded. patients were managed accordingly. data analysis was done on spss programme version 14. results: we studied 370 patients from march 2012 – may 2012. there were 220 (59.50%) male patients and 150 (40.5%) female patients. most frequent presenting age group was 6 – 10 years (41.62%). mean age of the patients was 8.24 ± 3.7 years. bacterial conjunctivitis was most frequently found ocular disease (26.77%) followed by trachoma (20%) while vernal catarrh was present in 9.73% patients. refractive errors were present in 8.11% patients and ocular trauma in 6.76% patients. congenital cataract presented in 5.68% of patients. squint was found in 3.51% of patients. presentation of corneal ulcer was in 2.70% patients. congenital diseases were not much prevalent. conclusion: paediatric ocular disorders are of utmost importance. their early diagnosis is greatly helpful in reduction of preventable childhood blindness. electronic media should educate about the importance of paediatric ocular disorders. ediatric ocular diseases are of prime importance. most of these diseases are treatable up to a specific age and if left untreated may have a disastrous effect on functional abilities of child. more specialized curative services are required by the child population 1.it was reported that there are 135 million people with true low vision in the world and among them 7 million are children (quantitatively a person is said to have true low vision when he or she has visual acuity of 6/18 to light perception or visual field of less than 10 degrees from point of fixation but uses or is potentially able to use vision for planning and execution of a task)2. approximately 1.3 million children in the world are blind, half of these cases are preventable and treatable3. about 60 – 80% children die within 2 years of onset of blindness either due to underlying cause of blindness (general ailment or hereditary or systemic disease) or due to lack of support for survival4.various studies have reported that pediatric ocular diseases and cause of visual loss in children varies from place to place and greatly depends on socioeconomic conditions of the area.5 in countries with low socioeconomic strata and inadequate healthcare systems, malnutrition and infections form major part of the etiology; while in industrialized countries common pediatric diseases are cataract, glaucoma, retinopathy of prematurity, genetically transmitted diseases and congenital abnormalities5. p uzma fasih, et al 11 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology in addition childhood blindness has direct effect not only on the functional abilities of child and education but also indirectly effects family and community. this has drawn the attention of world health organization's vision 2020 program which included “childhood blindness” as one of its major targets. material and methods it was a hospital based descriptive cross sectional study. the study was carried out at opd of spencer eye hospital karachi from march 2012 – may 2012. it included 370 patients of age from 1 day to 14 years through non-probability consecutive sampling technique. sample size was calculated by using open epi sample size calculators for demographic studies. population size taken was 10,000, while keeping confidence interval 95%, margin of error 5% and prevalence of conjunctivitis (p) 42%; the calculated sample size was 370. informed consent was taken and anonymity and confidentiality of the patient was maintained throughout the study. a detailed history was taken regarding the ocular disease and examination was carried out in detail on slit lamp, direct and indirect fundoscopy was done where required. refraction was done and examination under anesthesia was done if required. diagnosis was established and recorded. patients were managed accordingly. data analysis was done on spss programme version 14. descriptive statistics were used to calculate mean and standard deviation for age. frequencies were calculated for ocular diseases along with the percentages. results we studied 370 patients from march 2012 – may 2012. there were 220 (59.50%) male patients and 150 (40.50%) female patients. bacterial conjunctivitis was most frequently found ocular disease (26.77%) followed by trachoma (20%) while vernal catarrh was present in 9.73% patients. refractive errors were present in 8.11% patients and ocular trauma in 6.76% patients. congenital cataract presented in 5.67% patients. squint was found in 3.51% patients. presentation of corneal ulcer was in 2.7% patients. congenital diseases were not much prevalent for e.g. coloboma iris (1.08%) congenital glaucoma (0.81%), congenital ptosis (0.8%), dermoid cyst (0.54%), cogenital entropion (0.27%) and collodion baby (0.27%). it was observed that conjunctivitis (m = 80, f = 93), stye (m = 6, f = 9) and chalazion (m = 3, f = 5) are more prevalent among female children and vernal catarrh (m = 28, f = 8), refractive errors (m = 28, f = 2) and ocular trauma (m = 19, f = 6) are more prevalent among male children. discussion a male preponderance was seen 59.50% while female patients were 40.50%, this finding was very similar to a study conducted at eye department khyber teaching hospital where male patients were 68.9% and female patients were 31.1%.6 this could be due to the fact that preference is given to male children in poor society. most frequently reported disease in our study was infectious conjunctivitis 26.77% and trachoma 20%. a study conducted by qureshi h m and et al reported7 prevalence of trachoma among children less than 10 years of age up to 48.98%. this is higher than our study perhaps due to the fact that this study was conducted in rural areas of upper sindh where poverty and poor sanitation are responsible for high prevalence of this disease. stye and chalazion were seen in 4.05% and 2.16% children respectively. spencer eye hospital is located in an old town of lyari where pattern of common paediatric diseases at spencer eye hospital pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 12 the hygienic conditions are not satisfactory and socioeconomic conditions are also poor but not as worse as rural areas of sindh. these factors may play a significant role in high prevalence of infectious eye diseases in this area. poor sanitation, ignorance and poor hand washing practices due to deficiency of water are additive factors. prevalence of vernal catarrh was 9.72% and a male preponderance was seen. sethi s et al reported 35.6% prevalence of vernal catarrh with a male preponderance6. their results were noticeably different from ours perhaps due to geographical and dry climatic conditions of that region. refractive errors were found in 8.11% patients. uncorrected refractive errors have a direct effect on learning capabilities of the children and their education9. according to another study it was reported that refractive errors are third largest cause of curable blindness in pakistan10. in a study conducted by sethi s6, prevalence of refractive errors was 12.8% which is quite closer to the finding of our study. in another study conducted in nwfp it was found that refractive errors were responsible for 8% uniocular blindness and amblyopia11. children who presented with ocular trauma were 6.76%. most of these cases presented with corneal cuts and prolapse of uveal tissue. lack of transportation was one of the major causes of delayed presentation of these cases and poor prognosis. sethi and et al reported in their study that trauma accounted for half of peadiatric corneal disorders in their study6. another study reported that ocular uzma fasih, et al 13 vol. 30, no. 1, jan – mar, 2014 pakistan journal of ophthalmology trauma forms 8 – 14% of total injuries suffered by children12. children are more prone to ocular injuries due to their inability to avoid hazards13. afghani t reported in his study on causes of childhood blindness that 6% of childhood blindness was due to postnatal causes and major underlying pathology in his study was ocular trauma14. presentation of congenital cataract was 5.68%.more than 50% of these cases were due to congenital rubella and about 30% were familial with a positive family history. no cause could be established in few cases. sethi s et al reported in their study that lens disorders are responsible for 8.9% of the paediatric ocular disorders quite similar to our study and among them bilateral congenital cataract is the most common cause6. another study by sethi and khan reported 4.91% prevalence of bilateral congenital cataract15. rahi and sripathi have reported that 20-30% of childhood blindness is due to cataract. majority cases of bilateral congenital cataract in developing countries are due to congenital rubella16. patients with nasolacrimal duct obstruction were 4.05%. sethi et al reported 5.07% of these cases in their study which is quite similar to our study. 80 – 90% of these patients responded well to syringing and probing. presentation of children with squint was 3.51%. majority of them had esotropia. a study conducted in nepal reported 1.6% prevalence of squint16 and a tanzanian study reports 0.5% prevalence of squint17. presence of a well developed squint clinic may be helpful in early diagnosis and management of strabismus as esotropia may have an amblyopic potential. vitamin a deficiency has a major contribution towards preventable corneal blindness and there is a great variation in its prevalence in same region as well as region to region. in our study ocular involvement due to vitamin a deficiency was 2.97%.these children were severely malnourished. afghani t reported this prevalence up to 12%15. another study conducted at lasbela baloshistan reported the same 3.29%20 while the prevalence reported from india was 26%16. presentation of children with corneal disorders was 2.70%. greater presentation was of bacterial corneal ulcers. many of them presented as post measles corneal ulcers. sethi and et al reported 4.9% the prevalence of corneal diseases16. they reported the same prevalence in another study conducted at khyber teaching hospital peshawar6. these findings are almost 50% greater than that of our study. in another survey by afghani t corneal diseases formed 12% of all the pediatric diseases14. most of these causes are responsible for preventable blindness. our study reported 0.81% cases of congenital glaucoma which is quite similar to the study conducted at khyber teaching hospital where it was reported 0.99%6. while another study conducted, these cases present so late that many children have become blind. poverty, ignorance, illiteracy and lack of transport facilities are responsible for such cases of preventable blindness. prevalence of congenital ptosis was 0.54%. the study showed 0.12% prevalence of congenital ptosis. severe cases of ptosis require early treatment as chances of development of amblyopia are greater in severely drooped eyelid. congenital diseases were not much prevalent for e.g. congenital glaucoma (0.81%), congenital ptosis (0.54%), dermoid cyst (0.54%), cogenital entropion (0.27%) and collodion baby (0.27%). it was observed that conjunctivitis, stye and chalazion are more prevalent among female children and vernal catarrh, refractive errors and ocular trauma are more prevalent among male children. a very interesting entity was of collodion baby 0.27% who presented to us on 2nd day of his life. the term collodion baby is used for newborns in which all the body surface is covered by thick skin sheets, so called “collodion membrane”. in almost all of the collodion membrane cases an autosomal recessive ichthyosi form disease is implicated20. the eyelids and the lips may be everted and tethered (ectropion and eclabion). in such cases loss of proper management can result with keratitis due to xerophthalmia and eventually blindness21-24). conclusion paediatric ocular disorders are of utmost importance. their early diagnosis and prompt treatment is greatly helpful in reduction of preventable causes of childhood blindness. ignorance, illiteracy, poverty and lack of transport facilities are mainly responsible for these situations. such outcomes directly affect the functional abilities of the child and his education and indirectly his family and community. it should be the responsibility of electronic media to educate people about the importance of various pediatric diseases. pattern of common paediatric diseases at spencer eye hospital pakistan journal of ophthalmology vol. 30, no. 1, jan – mar, 2014 14 author’s affiliation dr. uzma fasih associate professor spencer eye hospital unit 2 karachi medical & dental college dr. atiya rahman assistant professor spencer eye hospital unit 2 karachi medical & dental college dr. arshad shaikh prof.r and head of ophthalmology department karachi medical & dental college dr. m. s. fahmi professor and incharge spencer eye hospital unit 2 karachi medical & dental college dr. m. rais senior registrar spencer eye hospital unit 2 karachi medical & dental college references 1. qayyum z, khan am. causes of low vision among children and adult patients presenting at low vision clinic of mayo hospital, lahore ophthalmology pakistan. 2008; 1: 34-370 2. chaudhry m. low vision aids ist edition india japee brothers; world health organization. prevention of childhood blindness. geneva who. 1992; 2006: 63. 3. gilbert ce, foster a, negral ad, thylefors b. childhood blindness a new form of recording visual loss in children bull world health organ ization. 1993; 71: 485-9. 4. rahi j s, sripathi s, gilbert c e, foster a. childhood blindness due to vitamin a deficiency in india: regional variations arch. dis child. 1995; 72: 330-3. 5. gilbert ce, canvas r, foster a. causes of blindness and sever visual impairment in children in chile. dev med cild neurol. 1994; 36: 326-33. 6. sethi s, sethi jm, saeed n, kundi kn. pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital. pak j ophthalmol. 2008; 24: 166-70. 7. qureshi mh, siddiqui js, pechuho am, shaikh d, shaikh aq. prevalence of trachoma in upper sindh. pak j ophthalmol. 2010; 26: 118-21. 8. garcia – ferrer fj, ivan r, vaughn dg. general ophthalmology, mc graw hill lange company 2008; 17: 103-14. 9. negral ad, maul ep. pokheral, zhap refractive error study in children: sampling and measurement methods for a multicountry survey. am j ophthalmol. 2000; 129: 421-6. 10. durrani j., blindness statistics for pakistan pak j ophthalmol. 1994; 10: 39-42. 11. khan ma, gullab a, khan md. prevalence of blindness and low vision in north west frontier province of pakistan. pak j ophthalmol. 1999; 15: 1-2. 12. scribano pv, midelfart, nance m, reilly p. peadiatric non powderfire arm injuries. outcomes in urban peaditrric setting. peadiatrics 1997; 100: 5. 13. negral ad, thlefors b. the global impact of eye injuries. ophthalmic epidemiology. 1998; 5: 143-69. 14. afghani t. causes of childhood blindness and severe visual impairment. pak j ophthalmol. 2000; 16: 4-26. 15. sethi s, khan md. survey of blind schools in north west frontier province. pak j ophthalmol. 2001; 17: 90-6. 16. rahi js, sripathi s, gilbert ce. the importance of perinatal factors in childhood blindness in india. developmental medicine and child neurology. 1997; 39: 449-55. 17. nepal bp, koirala s, adhi ks. ocular morbidity in school children in khatmandu. br j ophthalmol. 2003; 87: 531-4. 18. wener susamme hw, david ar. rebecca b et al. prevalence of eye diseases in primary school children in rural areas of tanzania br j ophthalmol. 2000; 84: 1291-97. 19. khalil a, lakho m, jadoon z. pattern of ocular problem in school going children of district lasbela, balochistan. pak j ophthalmol. 2012; 28: 200-5. 20. tüzün y, i̇şçimen a, pehlivan o. collodion baby j turk acad dermatol. 2008; 2: 82201. 21. judge mr. collodion baby and harlequin ichthyosis. harper j, oranje a, prose n. textbook 0f pediatric dermatology. second edition. malden, blackwell publishing. 2006; 118-25. 22. shwayder t, akland t. neonatal skin barrier: structure, function and disorders. dermatol therapy. 2005; 18: 87-103. 23. judge mr, mclean whi, munro cs. disorders of keratinization. burns t, breathnach s, cox n, griffiths c. rook's text book of dermatology. 7th ed. malden, blackwell publishing. 2004; 34: 1-34. 24. fleckman p, digovanna jj. the ichthyoses. klaus w, goldsmith la, katz si, gilchrest ba, paller as, leffell dj. fitzpatrick’s dermatology in general medicine. 7th edition. new york, mcgraw – hill medical. 2008; 401-24. pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 131 15 march 2018 letter to editor dear editor in chief, it is in reference to pjo vol.33, issue no.4 oct to dec 2017. following are my observation regarding article “comparison of complication between forceps and injector delivery for acrylic multi piece iol”. study does not justify this topic. conclusion is also questionable since literature proves otherwise. astigmatism & endothelium count is more important in this study. this topic requires to focus on power of iol as well. since 26 d lens is quite thicker than 14 d lens. there is no mention of dioptric power in this study. how 3.0 mm wound was enlarged to 4.00 mm. descemet’s member tear & corneal edema is not accounted for on first day on slit lamp examination. no mention of hydration or stich to 4.00 mm wound. limitations in study are not mentioned. the acrys ma 60 ac was introduced in 2003 in pakistan. but this study started in year 2002. in introduction section author told about advancement in cataract surgery while the references are of year 1999. statement given (cataract surgery during past decades) does not match with study quoted in reference 4. reference 3&5 sequence not shown anywhere in the text. “hyrophobic acrylic iol with square edge design produces the least posterior capsular opacification” (8 & 9 reference). this is an irrelevant statement to the study topic with unmatched quoted references. statement for reference no 6 & 7 do not matched with the actual studies quoted. the rationale of the study described is actually the purpose of the study, hence rationale is not actually justified. in the material method. study is approved by ethical board of which hospital? author stated that all data was recorded in the electronic records of the patient. how performa was designed electronically for individual patients. was this a retrospective or prospective study? (15 years electronic recorded data). students “t” test with p value was applied (as per stated in material & method) for the statistical analysis. but in the result section, it was not mention anywhere. in the result average age was stated, which is actually the mean age with standard deviation. does this enlargement of incision up to 4.00 mm caused any astigmatism? as author agreed in discussion that enlargement of incision badly effect the amount of post-operative astigmatism. percentages were shown in the text only, not in tables. in table 1, total iol placed in the sulcus were shown 16 while the total comes 17. how does this happened? in the text section of the result 04 iols were shown flipped back to front while in the table ii only two iol were shown front to back. similarly, only two optic & haptic damage were mentioned in the text of results, while in table ii, 3 iol seems damaged. at various places author agreed with the more benefits of injector (see page no 204 of introduction & 306 of discussion) as compared with forceps delivery of iol. author also seems convinced about surgical induced astigmatism by enlarging incision (see reference 8 & 9) but did not mentioned this important observation/ complication anywhere in the results. irrelevant references are given in the text with entirely wrong sequence. out of 22 references, 11 (50%) are older than year 2000. letter to editor 132 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology in material & method, which viscoelastic is used since it is discussed in discussion section iol was folded under microscope or under naked eye. in reference 5, 9 &14 there are typographical mistakes. author recommended wet lab practice for injector delivery of the multi piece iols. although similar practice is also required for forceps delivery for the beginners as well. so how this could be the conclusive statement. prof. shahid wahab chairman ophthalmic research & education foundation, pakistan. reply letter to editor dear editor in chief, it is in reference to pjo vol.33, issue no.4 oct to dec 2017. following are the answers to the letter to the editor regarding the article “comparison of complication between forceps and injector delivery for acrylic multi piece iol”. study does not justify this topic. reply: the study was focused on intra-operative complications between two types of iols and is discussed completely in the text. conclusion is also questionable since literature proves otherwise.reply: conclusion is according to the personal experience of the author and true results of the study. astigmatism & endothelium count is more important in this study. reply: this was not the scope of the study. these are other angles to write this research which are also interesting. this topic requires to focus on power of iol as well. since 26 d lens is quite thicker than 14 d lens. there is no mention of dioptric power in this study. reply: data is available with authors on power of the lens and will be given in reply to the letter to the editor. how 3.0 mm wound was enlarged to 4.00 mm.reply: the wound was marked with caliper to 4 mm and enlarged with a 2.75 mm keratome. descemet’s member tear & corneal edema is not accounted for on first day on slit lamp examination. reply: the scope of the paper was to study the complications while injecting the iol intra-operatively. other studies can be done to assess these variables. no mention of hydration or stich to 4.00 mm wound.reply: data is available with authors regarding this. as the study was limited to only problems with injecting the iol that is why it has not been mentioned. limitations in study are not mentioned. reply: we had a fairly large sample size so this a fairly generalizable study. the acrys ma 60 ac was introduced in 2003 in pakistan. but this study started in year 2002.reply: the first lens was implanted by the author on 8th october 2002 according to the electronic medical record. in introduction section author told about advancement in cataract surgery while the references are of year 1999.reply: the advancement in small incision cataract surgery had started in that year so the reference is quoted. statement given (cataract surgery during past decades) does not match with study quoted in reference 4.reply: the study quoted is from local reference in 1996 so that is 2 decades from this study. reference 3&5 sequence not shown anywhere in the text.reply: this was a printing during printing. “hyrophobic acrylic iol with square edge design produces the least posterior capsular opacification” (8 & 9 reference). this is an irrelevant statement to the study topic with unmatched quoted references.reply: the title reference does not match the text but the quoted article had mentioned this in the discussion. letter to editor pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 133 statement for reference no 6 & 7 do not matched with the actual studies quoted.reply: the title reference does not match the text but the quoted article had mentioned this in the discussion. the rationale of the study described is actually the purpose of the study, hence rationale is not actually justified.reply: the rationale of the study was to identify problems in new injecting systems for intraocular lenses. in the material method. study is approved by ethical board of which hospital? reply: the study is approved by the ethical board of lahore general hospital, where the author is working. the committee was kind enough to approve ethical concerns for this study. author stated that all data was recorded in the electronic records of the patient. how performa was designed electronically for individual patients. reply: the performa was designed using microsoft access. the author has a dedicated electronic medical record for this purpose and records are available for review. was this a retrospective or prospective study? (15 years electronic recorded data). reply: this was a retrospective study. students “t” test with p value was applied (as per stated in material & method) for the statistical analysis. but in the result section, it was not mention anywhere.reply: the t test was applied on initial submission but later was omitted after revision. in the result average age was stated, which is actually the mean age with standard deviation.reply: average and arithmetic mean are the same as verified by research. does this enlargement of incision up to 4.00 mm caused any astigmatism? as author agreed in discussion that enlargement of incision badly effect the amount of post-operative astigmatism.reply: data on astigmatism is available with author but the study was only focused on per operative complications therefore it was not mentioned. in discussion with other studies these facts are highlighted. percentages were shown in the text only, not in tables.reply: this was to prevent duplication. in table 1, total iol placed in the sulcus were shown 16 while the total comes 17. how does this happened?reply: there has been a typing mistake in the table and the total should be 17 in table and text. in the text section of the result 04 iols were shown flipped back to front while in the table ii only two iol were shown front to back.reply: there has been a typing mistake in the table and it should read same as in text. similarly, only two optic & haptic damage were mentioned in the text of results, while in table ii, 3 iol seems damaged.reply: in text only the haptic and optic damage in iol in the bag have been mentioned. at various places author agreed with the more benefits of injector (see page no 204 of introduction & 306 of discussion) as compared with forceps delivery of iol. author also seems convinced about surgical induced astigmatism by enlarging incision (see reference 8 & 9) but did not mentioned this important observation / complication anywhere in the results.reply: this was recorded by the author but as long term follow up was not available for all patients that is why it was not studied specifically. irrelevant references are given in the text with entirely wrong sequence.reply: the reference sequence missing are 3 & 5 due to printing error. the references have discussed the topics in their discussions. out of 22 references, 11 (50 %) are older than year 2000.reply: pjo requires some references to be new but not all and there is no ratio defined. this was a study of long duration which required old references therefore they have been quoted. in material & method, which viscoelastic is used since it is discussed in discussion section iol was folded under microscope or under naked eye.reply: methylcellulose was used in all cases and iol was folded under microscope. in reference 5, 9 & 14 there are typographical mistakes. reply: the space between two letter has been omitted due to problems with the printer and formatting done by him. author recommended wet lab practice for injector delivery of the multi piece iols. although similar practice is also required for forceps delivery for the beginners as well. so how this could be the conclusive statement.reply: wet lab can be used for both techniques. the author feels that as he encountered more complications with the injector other surgeons learning the technique would benefit more from wet lab in the injector technique as it has more complicated steps and maneuvers. prof. muhammad moin dr. asif manzoor authors pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 38 original article intermediate uveitis: causes and systemic associations nazli gul, sana ullah jan, yousaf jamal mahsood, tariq shanam, tahir ali pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. nazli gul department of ophthalmology, khyber teaching hospital, peshawar email: drnazli83@gmail.com purpose: the purpose of this study was to analyze the patients for the etiologies/ systemic associations of intermediate uveitis (iu) at a single center. study design: descriptive case series. place and duration of the study: department of ophthalmology, hayatabad medical complex, peshawar from 1 st august 2010 to 31 st july 2012. materials and methods: data collected included demographics such as gender, age at presentation, complete ocular examination including intraocular pressure. systemic examination including central nervous, respiratory, gastrointestinal and cardiovascular systems was also performed. relevant investigations such as full blood count (fbc) with erythrocyte sedimentation rate (esr), syphilis serology (venereal disease research laboratory (vdrl) test), rheumatoid factor (rf), antinuclear antibodies (ana), toxoplasma antibodies (igm, igg), mantoux test and chest x-rays with radiology report were performed. spss version 16 was used for data analysis. results: the study included 21 eyes of 21 patients with iu. mean age of patients was 34.7 years with male to female ratio of 15:6. the disease was bilateral in 6 patients (28.6%). nineteen cases (90.5%) were idiopathic with no systemic association. two patients (9.5%) with iu were diagnosed with tuberculosis. conclusion: infectious causes must be ruled out in all cases of iu. key words: intermediate uveitis, systemic associations, tuberculosis. ntermediate uveitis (iu) is defined as uveitis in which vitreous is the major site of inflammation with or without peripheral vascular sheathing and macular edema1. the international uveitis study group (iusg) described iu to be an idiopathic inflammatory syndrome which mainly involves the anterior vitreous, ciliary body and peripheral retina with minimal or no anterior and chorioretinal signs2. the incidence is similar in both genders with no racial predilection3. it can affect any age group but is commonly found in third and fourth decades3. diagnosis of iu is usually clinical. patients usually present with decreased visual acuity and/or floaters. there is no pain, redness or photophobia. there are vitreous cells which outnumber anterior chamber cells and pars plana exudates. usually iu is less commonly associated with a systemic disorder and most of the cases remain idiopathic2,4-5. however, with laboratory investigations and ancillary tests we may exclude an associated disorder. it has got associations with systemic infectious diseases such as tuberculosis, syphilis, htlv-1, toxocariasis, sarcoidosis and multiple sclerosis6. cause and any systemic association need to be determined for proper management. incomplete or improper management is associated with higher incidence of ocular complications. proper management is required to save vision as well as life of the patients. that’s why we conducted this study to reach to any cause or systemic association for proper vision and life saving management. i nazli gul, et al 39 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology materials and methods this descriptive case series was conducted at ophthalmology department of hayatabad medical complex from 1st august 2010 to 31st july 2012. the diagnosis of iu was made clinically and its systemic associations were investigated according to standard criteria described by the standardization of uveitis nomenclature (sun) working group1. all patients underwent standardized thorough clinical history, complete ophthalmological examination with systemic review, laboratory and radiological investigations. laboratory investigations included full blood count (fbc) with erythrocyte sedimentation rate (esr), syphilis serology (venereal disease research laboratory (vdrl) test), rheumatoid factor (rf), antinuclear antibodies (ana), toxoplasma antibodies (igm, igg) and mantoux test and chest x-rays with a radiology report. cases of iu without a specific systemic disease were labeled as idiopathic. more than +3 vitreous cells were described as severe vitritis. data included gender, age, eye/eyes affected, clinical ocular & systemic examination, chest x-rays findings and laboratory investigations. medical history and other systemic co-morbidities were also recorded. iu in both genders with age 16 years or more with best corrected visual acuity of less than 6/12 on snellen’s visual acuity chart were included in the study. patients with anterior uveitis, posterior uveitis and pan uveitis were excluded from the study. patients who fulfill the inclusion criteria were selected in this study via opd. after the approval of the study by ethical board, informed consent was taken from all patients. spss version 16 was used for data analysis. results table 1: total number of patients (n) 21 mean age (years) 34.7 (min.17, max. 60, sd ± 1.07) male versus female 15 versus 6 (71.4% vs 28.6%) laterality at initial presentation unilateral: 15 (71.4%) bilateral: 6 (28.6%) n = number, min = minimum, max = maximum, % = percentage the demographic data is given in table 1. nineteen patients (90.5%) had idiopathic disease. the systemic examination and laboratory work up was unremarkable in these patients. two patients (9.5%) had pulmonary tuberculosis based on chest x-rays and positive mantoux test of 15 mm induration. they had presenting best corrected visual acuity of 1.30 log mar (snellen equivalent: 6/120) in comparison to 1.00 log mar (6/60) in idiopathic cases which is statistically significant (p < 0.05). the disease was bilateral in both cases. they had severe vitritis with snow balls, macular edema and peripheral retinal periphlebitis. there were no choroidal lesions which are associated with intraocular tuberculosis. discussion usually iu is autoimmune in nature in the developed world while the situation in developing countries is different7. there is limited data of infectious associations especially tuberculosis with iu in the developed world8-10. in our study tuberculosis was main association which is consistent with our high tuberculosis incidence rate. we had 9.5% of cases with tuberculosis as etiology of iu which is higher than japan and usa with an incidence of 6.9% and 7.0% respectively5,11. a study by parchand et al showed an association of 46.7% with tuberculosis in iu7. a local study also showed association with tuberculosis12. in our study tuberculosis associated iu has similar incidence in both gender with a ratio of 1:1. both patients with tuberculosis associated iu presented in their 4th decades with a positive family history of tuberculosis. this could be due to the living conditions and low socioeconomic status of our study population. tuberculosis associated iu presented with worse mean best corrected visual acuity than idiopathic cases. this could be due to associated macular edema. peripheral periphlebitis usually occurs with multiple sclerosis13. we experienced its occurrence in our cases associated with tuberculosis. none of the idiopathic cases had periphlebitis. tuberculosis association with posterior uveitis (choroiditis) or panuveitis is more common than with iu in international studies14-18. in endemic areas like pakistan, tuberculosis should be excluded as a cause of iu. many ophthalmologists may not routinely investigate these patients for tuberculosis which can lead to prolonged disease course with frequent recurrences. significant reduction in recurrences of tuberculosis associated iu can be achieved by prompt diagnosis & treatment. it intermediate uveitis: causes and systemic associations pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 40 should be a multidisciplinary approach to treat iu by ophthalmologist, infectionists & immunologists with uveitis experience for better management, prognosis and course of the disease. multiple sclerosis has a strong association with iu in the western population19-20. but in our study no systemic findings warrant mri or csf analysis. we did not perform mri for patients with uveitis keeping in mind the low prevalence of multiple sclerosis in our population. ana & rf were negative in all patients. in our study most cases were idiopathic like other studies in asia & western countries. the prevalence of idiopathic iu is 70 – 90% in africa, europe and usa11, 18-21. in spite of using all the investigating tools for systemic associations, there is still commonly a local pathological process than systemic in iu. with improved newer diagnostic tools the proportion of idiopathic iu will be reduced22. patients having visual acuity of < 0.3 logmar (< 6/12 on snellen’s visual acuity chart) used to be usually treated12. now more aggressive treatment is advocated. various treatment options are local steroids (periocular or intravitreal), oral steroids, immunomodulatary therapy, cryotherapy or indirect laser photocoagulation to peripheral affected retina, pars plana vitrectomy with induction of posterior hyloid separation and peripheral laser photocoagulation to pars plana snow banks.12 periocular injections are the preferred route of treatment12. intravitreal triamcinolone acetonide (ivta) is used to treat inflammation and cystoid macular edema associated with iu which achieves high vitreous concentration as compared to periocular route23. all our iu patients received ivta. in addition to ivta, iu patients having associated tuberculosis also received anti tuberculosis drugs for 9 months. they showed good response to anti tuberculosis drugs with vitreous activity reduction to < +1 cells and resolution of macular edema at final follow up visit at 120th day of starting treatment. peripheral peribhlebitis also showed resolution. our study has limitations due to small sample size of patients. secondly, referral bias as we got all these patients from certain specific areas which didn’t show the true population representation. the strong thing is that we got patients from all ethnic groups to our tertiary care teaching hospital. however the results of our study were comparable with the studies in other part of our region or the world which is quite significant. conclusion it is recommended that in endemic areas like pakistan, high vigilance should be done to find out the infective causes of iu especially tuberculosis. this will prevent visual loss associated with systemic disease recurrences and decrease the disease burden, morbidity and cost of management. author’s affiliation dr. nazli gul specialist registrar, department of ophthalmology, khyber teaching hospital (kth), peshawar dr. sanaullah jan fcps, frcs (edin), frcs (glasgow) professor, khyber institute of ophthalmic medical sciences (kioms), hayatabad medical complex (hmc), peshawar dr. yousaf jamal mahsood fcps, fico, frcs assistant professor, lady reading hospital, peshawar dr. tariq shahnam fcps, frcs, assistant professor, peshawar institute of medical sciences (pims), peshawar dr. tahir ali fcps, vitreo retina trainee, lady reading hospital (lrh), peshawar role of authors dr. nazli gul proposed topic, basic study design, methodology, manuscript writing, date collection. dr sanaullah jan date collection, statistical analysis and interpretation of results. dr yousaf jamal mahsood statistical analysis and interpretation of results. dr tariq shahnam statistical analysis and interpretation of results. dr tahir ali literature review & referencing and quality insurer. nazli gul, et al 41 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology references 1. wakabayashi t, morimura y, miyamoto y, okada aa. changing patterns of intraocular inflammatory diseases. ocul immunol inflamm. 2003; 11: 277– 286. 2. bloch me, nussenblatt rb. international uveitis study group recommendations for the evaluation of intraocular inflammatory disease. am j ophthalmol. 1987; 103: 234–235. 3. rathinam sr, namperumalsamy p. global variation and pattern changes in epidemiology of uveitis in an urban population in southern india. indian j ophthalmol. 2007; 55 (3): 173-83. 4. talin ba, saskia mm, lamiss m, wolfgang e, klaus m, herbert a. uveitis a rare disease often associated with systemic diseases and infectionsa systematic review of 2619 patients. orphanet j rare diseases, 2012; 7: 57. 5. jabs da, nussenblatt rb, rosenbaum jt. standardization of uveitis (sun) working group. standardization of uveitis nomenclature for reporting clinical data. results of the first international workshop. am j ophthalmol. 2005; 140: 509–516. 6. zierhut m, foster cs. multiple sclerosis, sarcoidosis and other diseases in patients with pars planitis. dev ophthalmol. 1992; 23: 41–47. 7. parchand s, tandan m, gupta v, gupta a. intermediate uveitis in indian population. j ophthal inflamm infect. 2011; 1: 65–70. 8. donaldson mj, pulido js, herman dc, diehl n, hodge d. pars planitis: a 20-year study of incidence, clinical features, and outcomes. am j ophthalmol. 2007; 144: 812–817. 9. de boer j, berendschot tt, van der dp, rothova a. long-term follow-up of intermediate uveitis in children. am j ophthalmol. 2006; 141: 616–621. 10. biswas j, sudharshan s. intermediate uveitis. in: gupta a, gupta v, herbort cp, khairallah m (eds) uveitis text and imaging. jaypee brothers medical publishers, new delhi, 2009. 11. smit rl, baarsma gs, de vries j. classification of 750 consecutive uveitis patients in the rotterdam eye hospital. int ophthalmol. 1993; 17: 71–75. 12. iqbal a, jan s, saeed n, khan md. two years audit of admitted uveitis patients. pak j ophthalmol. 2003; 19 (4): 108-12. 13. manohar b, rathinam sr. intermediate uveitis. indian j ophthalmol. 2010; 58 (1): 21-27. 14. chang jh, wakefield d. uveitis: a global perspective. ocul immunol inflamm. 2002; 10: 263–279. 15. cimino l, herbort cp, aldigeri r, salvarani c, bolardi l. tuberculous uveitis, a resurgent and underdiagnosed diasease. int ophthalmol. 2009; 29: 67–74. 16. bodaghi b, lehoang p. ocular tuberculosis. curr opin ophthalmol. 2000; 11: 443–448. 17. hamade ih, tabbara kf. complications of presumed ocular tuberculosis. acta ophthalmol. 2010; 88: 905–909. 18. davis ej, rathinam sr, okada aa, tow sl, petrushkin h, et al. clinical spectrum of tuberculous optic neuropathy. j ophthalmic inflamm infect. 2012; 2: 183–189. 19. raja sc, jabs da, dunn jp, fekrat s, machan ch, et al. pars planitis: clinical features and class ii hla associations. ophthalmology, 1999; 106: 594–599. 20. malinowski sm, pulido js, folk jc. long-term visual outcome and complications associated with pars planitis. ophthalmology, 1993; 100: 818–824. 21. khairallah m, yahia sb, ladjimi a, messaoud r, zaouali s, et al. pattern of uveitis in a referral centre in tunisia, north africa. eye, 2007; 21: 33–39. 22. sengun a, karadag r, karakurt a, saricaoglu ms, abdik o, et al. causes of uveitis in a referral hospital in ankara, turkey. ocul immunol inflamm. 2005; 13: 45– 50. 23. sallam a, richard mc, john hc, john rg, richard a, peter jm, susan l. short-term safety and efficacy of intravitreal triamcinolone acetonide for uveitic macular edema in children. arch ophthalmol. 2008; 126 (2): 2005. microsoft word 1. editorial 62 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology editorial cataract and refractive surgery the last quarter of a century showed tremendous innovations and improvements in medical science in general and ophthalmology in particular. the ophthalmic conditions once thought to be dreadfully blinding are now tackled effectively after better understanding of the disease process. these improvements involve practically all areas in ophthalmology from anterior to posterior segment, orbital to adnexal sub specialty of ophthalmology where better understanding of the subject has lead to better management, revolutionizing the treatment plan of the disease and the patients. cataract, the most commonly occurring senile ailment is most widely studied, improvised and improved management wise. from the days of surgical management by couching, this condition is now tackled with utmost precision through image enhancement, microsurgical techniques and lens replacement with state of the art lenses available today for total glasses freedom and independence. like the great idea of intra ocular lens in 1949 by sir harold ridley,1 the invention of phacoemulsification method by george kelman in sixties has totally changed the outcome and the outlook of this sometime thought to be a permanently disabling condition operated or unoperated wise.2 the skills for managing cataract nowadays are improved with immediate and perfect results achievable through better technology and experience. needless to mention the role of all the stake holders in building the foundations at which ophthalmology is standing right now.2 the technique of cataract surgery is improving further, day by day over the platform of phacoemulsification cataract surgery. new machines are coming every now and then with better control over the process at the same time avoiding possible complications to produce better results. the work is mainly focused in achieving better results using minimum energy, hence complication rates are reduced. the fluid management system can now work more efficiently and effectively with control over the dynamic rise taking the best benefits out of this technique. the oscillation motion now available prevents occlusion thereby reducing the risk for posterior capsule rupture, the most unpleasant complication a phaco surgeon can think of. the recent advances have remarkably reduced the phaco time needed to effectively emulsify even a denser. introduction of femtosecond laser as a cutting tool for those aiming at high precision is a remarkable. this machine transforms the most delicate steps of cataract surgery into simple maneuvers avoiding the complications and adding success to the outcome3. the laser corrective surgery for refractive error is changing fast since its introduction and, it can tackle a refractive error from +6 dioptres of hyperopia to -10 dioptres of myopia with up to 4 cylinders of astigmatism. excimer laser refractive surgery techniques in current use include: photorefractive keratectomy (prk), laser epithelial keratomileusis (lasek) and laser in-situ keratomileusis (lasik). new modalities both in terms of technology development as well as treatment options based on the research data is responsible for controlled, long lasting and better results.4 the introduction of intraocular lenses like phakic iol for accommodation correction, astigmatic correcting5 lenses for astigmatism, multifocal lenses for distance and near distance correction and multifocal astigmatic aspheric lenses for correcting astigmatism distance and near distance correction are few of the technologies available now and are responsible for total glasses freedom for patients with cataracts. these lenses when planned for a patient require lot of workup and careful selection in order to avoid difficulties post operatively which may come in due course. once a patient is carefully selected, briefed, counseled and the procedure is done successfully, the outcome and patient’s satisfaction is remarkable. not all the patients are candidate for the above mentioned lenses, a careful selection criteria is to be met before offering these lenses to the patients. results with multifocal lenses are very good so are the results with toric astigmatic correcting lenses. learning the new lens technology, calculation of the power and selecting lens type for your patient and placements require understanding and practice. much is done but a lot has to be done in this important field cataract and refractive surgery pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 63 which is the present and the final frontier in the field of surgical ophthalmology.6 references: 1. ridley h. intra-ocular acrylic lenses after cataract extraction. 1952. bull world health organ. 2003; 81 (10): 758–761. 2. linebarger ej, hardten dr, shah gk, lindstrom rl. phacoemulsification and modern cataract surgery. surv ophthalmol. 1999 sep-oct; 44 (2): 123-47. 3. zacharias j. jackhammer or cavitation: the final answer. video presented at: the ascrs film festival; march 1722, 2006; san francisco, ca. 4. loughnan m; laser refractive surgery, australian family physician 1998; 27 (3): 154-158. 5. holladay jt, van dijk h, lang a, portney v, willis tr, sun r, oksman hc. optical performance of multifocal intraocular lenses. journal of cataract and refractive surgery 1990; 16 (4): 413-422. 6. bruno zuberbuhler, theo signer, richard gale, eduard haefliger rotational stability of the acrysof sa60tt toric intraocular lenses: a cohort study bmc ophthalmology 2008, 8: 8. professor jamshed nasir 209 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology original article comparison of central corneal thickness in type 2 diabetic patients versus healthy subjects sana jahangir, haroon tayyab, tehmina jahangir pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. haroon tayyab assistant professor – vitreoretina college of ophthalmology & allied vision sciences king edward medical university, lahore e-mail: haroontayyab79@gmail.com …..……………………….. purpose: to compare the mean central corneal thickness in type ii diabetics and non diabetics. study design: case control study. place and duration of study: department of ophthalmology, unit ii, jinnah hospital lahore. the study was carried out over a period of six months from 10-07-2011 to 09-01-2012. material and methods: a total of 120 patients (60 in each group) were included in this study. these patients were divided into two groups a and b. patients with type ii dm were assigned in group a and age matched controls were assigned in group b. cct was measured in both groups using alcon ocu scan rxp pachymeter and average of 10 consecutive readings from each eye were recorded in micrometers. results: mean age of the patients in group-a was 57.9 ± 10.4 and in groupb was 56.1 ± 11.3 years. in this study, 35 patients (58.3%) and 37 patients (61.7%) were male in group-a and b, respectively. in group-a 25 patients (41.7%) and in group-b 23 patients (38.3%) were females. when comparison was made in terms of central corneal thickness, group-a (diabetics) showed mean cct 567.53 ± 15.37 µm and group-b (nondiabetics) mean cct was 532.69 ± 9.40 µm. statistically significant difference was noted between two groups (p < 0.001). conclusion: it is concluded that diabetic patients exhibit a greater statistically significant average central corneal thickness than non-diabetics. key words: diabetes mellitus, central corneal thickness, pachymetry, glaucoma. iabetes mellitus is a very common disease worldwide, having a considerable impact on society, not only due to its high prevalence, but also due its complications and high morbidity and mortality related to it1. it is clinically divided into insulin dependent diabetes mellitus (iddm) and non insulin dependent diabetes mellitus (niddm)2. common pathologies include diabetic retinopathy, maculopathy, cataract, optic neuropathy, paretic muscle disorders and diabetic keratopathy3. diabetic keratopathy includes corneal epitheliopathy and corneal endotheliopathy. corneal endothelial pump dysfunction results in alterations in central corneal thickness (cct) and endothelial cell morphology4. cct is an important indicator of corneal endothelial pump function5. cct in an adult eye of caucasian population is 550 ± 33 µm with a range of 472 – 651 µm5. in one study, mean cct of adult pakistanis was 531 ± 33.37 µm6. dm has been shown to d comparison of central corneal thickness in type 2 diabetic patients versus healthy subjects pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 210 affect corneal biomechanics, resulting in higher cct values than those in healthy control subjects7. in one study, diabetic corneas were significantly thicker (p = 0.019); the mean cct was 530.3 ± 35.9 µm in the control group and 548.7 ± 33.0 µm in the diabetic group8. cct is an important parameter in various diagnostic and therapeutic modalities like evaluation of corneal degeneration and dystrophies, glaucoma, ocular hypertension, refractive surgery and contact lens use4. there is a strong positive correlation between increased cct and elevated intraocular pressure (iop)7. patients with both these findings are sometimes wrongly treated as cases of glaucoma. the literature suggests that diabetics have a tendency to have increased cct as compared to non diabetics. some clinicians prescribe anti-glaucoma medications based on iop readings. these medications are lifelong with considerable cost implications and side effects, therefore, it is of paramount importance to understand that these raised iop readings are reflecting thickened corneas and not indicating a glaucomatous process. the rationale of this study is to highlight the importance of cct measurement in diabetic patients as labeling a patient with glaucoma has significant implications on his life style. material and methods this was a case control study conducted in department of ophthalmology, unit ii, jinnah hospital lahore – a tertiary care hospital. study was carried out over a period of six months from 10-072011 to 09-01-2012. this study included 120 patients divided in 2 equal groups of 60 patients each. patients were included in this study through non-probability purposive sampling. an informed consent was taken from all the participants of this study. permission from hospital ethics committee was sought before commencement of this study. patients with following characteristics were included; age 25 years or more, both genders, type ii diabetes mellitus of 2 or more years duration, diagnosed at jinnah hospital lahore with supporting medical record visiting eye department for screening of diabetic retinopathy (known diabetic or fbs > 126 mg/dl), age matched controls visiting eye department with complaints other than mentioned in excluding criteria. the following patients were excluded from the study; history of or ongoing glaucoma, history of previous corneal (refractive surgery) or intraocular surgery (cataract extraction) and trauma, corneal ectasias (keratoconus, keratoglobus, pellucid degeneration) and past or ongoing corneal/ocular surface disease assessed on eye examination, history of contact lens wear less than 1 month before cct evaluation, systemic connective tissue diseases i.e. rheumatoid arthritis, systemic lupus erythematosis, polyarteritis nodosa assessed on systemic examination, systemic metabolic disorders i.e. mucopolysccaridosis, wilsons disease, multiple myeloma, cystinosis on systemic examination, high body mass index (bmi) of more than 27%. sixty type ii diabetic patients and 60 age matched controls meeting the above mentioned criteria were referred from out-patient department (opd) for pachymetry. these patients were divided into two groups a and b. patients with type ii dm were assigned to group a and age matched controls assigned to group b. cct was measured after instillation of local anaesthetic in both groups using alcon ocu scan rxp pachymeter and average of 10 consecutive readings from each eye were recorded in micrometers by the researcher. also, the mean of the readings were recorded for that patient. single dose of broad spectrum antibiotic was instilled immediately after the procedure. information was recorded using a predesigned proforma. data were analyzed by computer software spss version 10.0. quantitative variables like age, cct and duration of diabetes were presented as mean and standard deviation. qualitative variables such as gender were presented as percentages and frequencies. mean cct of each eye was calculated separately. comparison of cct between the two groups was done using t-test. p value (one tailed) of < 0.05 was considered as significant. results age distribution of the patients is described in table 1. mean age of the patients in group-a was 57.9 ± 10.4 and in group – b was 56.1 ± 11.3 years (table 1). the gender distribution is given in table 2. when comparison was made in terms of cct, group – a (diabetics) showed mean cct 567.53 ± 15.37 µm and group-b (non-diabetics) mean cct was 532.69 ± 9.40 µm. statistically significant difference was noted between two groups (p < 0.001) (table 3). sana jahangir, et al 211 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology table 1: distribution of patients by age (n = 120). age (year) group – a (diabetics) group – b (non-diabetics) no. % no. % 30 – 50 17 28.3 22 36.7 51 – 70 35 58.3 31 51.7 71 – 85 08 13.4 07 11.6 total 60 100.0 60 100.0 mean ± sd 57.9 ± 10.4 56.1 ± 11.3 table 2: distribution of patients by gender (n = 120). gender group – a (diabetics) group – b (nondiabetics) no. % no. % male 35 58.3 37 61.7 female 25 41.7 23 38.3 total 60 100.0 60 100.0 table 3: comparison of central corneal thickness (n = 120. group mean standard deviation group – a (diabetic) 567.53 15.37 group – b (non-diabetic) 532.69 09.40 t value 14.97 p value p < 0.001 discussion diabetes is a common disease. the current worldwide prevalence is estimated to be approximately 250 x 106, and it is expected to reach 380 x 106 by 20259,10. approximately 13 % of people are effected by diabetes mellitus world wide11. occasionally, diabetes mellitus is diagnosed after its onset and many symptoms may go unnoticed12. it is estimated that nearly 50% of diabetics are undiagnosed at the moment10. therefore it is imperative that early diagnosis of diabetes is made so that end organ damage can be avoided and morbidity and mortality of this disease is reduced1. one of the most common ocular morbidity associated with diabetes is diabetic retinopathy. other problems associated with diabetes are cataract and glaucoma. it is estimated that diabetic retinopathy is second most common cause of blindness in working age group10,12. diabetic keratopathy mostly involves the corneal epithelium and endothelium that may manifest as punctate epithelial erosions and decreased pumping ability of endothelial cells. clinically, this may manifest as altered corneal transparency and fluctuating vision13,14. in the current study, mean cct in diabetic patients was 567.53 ± 15.37 µm while in non-diabetic patients, it was noted to be 532.69 ± 9.40 µm. a statistically significant difference between two groups was observed with p value of p < 0.001. similar data has been reported by herse, lam and douthwaite15,16. it has been implicated that hyperglycaemia is the main reason for altering biomechanics of cornea. that may result in changes in corneal endothelial morphology and thus varying central corneal thickness17. sonmez et al suggested that hyperglycaemia is responsible for inducing refractive changes in cornea which have been manifested in altered keratometric readings18. in another study, it was shown that different stages of hypoxia effected corneal endothelial permeability as well19. this emphasizes the need of assessing corneal endothelial function before performing intraocular and corneal surgery in patients with long term diabetics20. it has also been reported that variations in central corneal thickness may be one of the earliest clinical signs in diabetic eye disease21. el-agamy stated long term history of diabetes mellitus is associated with changes in corneal morphology and central corneal thickness 22. conclusion thus we conclude from this study that diabetes mellitus is correlated with increasing central corneal thickness. further studies are needed to assess the relationship of diabetes and its effect on corneal endothelium and its association with corneal comparison of central corneal thickness in type 2 diabetic patients versus healthy subjects pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 212 thickness. this may influence our protocols regarding intraocular surgery in diabetics. authors affiliation dr. sana jahangir assistant professor ophthalmology sharif medical & dental college, lahore dr. haroon tayyab assistant professor vitreo-retina collage of ophthalmology & allied vision sciences king edward medical university, lahore dr. tehmina jahangir assistant professor ophthalmology jinnah hospital, lahore role of authors dr. sana jahangir study concept and data collection. dr. haroon tayyab review of literature. dr. tehmina jahangir statistical analysis and proof reading. references 1. peterson sr, silva pa, murtha tj, sun jk. cataract surgery in patients with diabetes: management strategies. semin ophthalmol. 2017; 16: 1-8. 2. sapozhnikova ie, zotina en. the attitude of patients with types 1 and 2 diabetes mellitus towards having the disease.ter arkh. 2017; 89 (10): 22-7. 3. hafner j, ginner l, karst s, leitgeb r, unterluggauer m, sacu s, et al. regional patterns of retinal oxygen saturation and microvascular hemodynamic parameters preceding retinopathy in patients with type ii diabetes. invest ophthalmol vis sci. 2017 oct. 1; 58 (12): 5541-7. 4. gao f, lin t, pan y. effects of diabetic keratopathy on corneal optical density, central corneal thickness, and corneal endothelial cell counts. exp ther med. 2016 sep; 12 (3): 1705-10. 5. rapauno cj, beling mw, wachler bb, donnenfield ed, feder rs, rosenfeild si. refractive surgery basic and clinical science course. san francisco: am acad ophthalmol. 2009: p. 47-9. 6. channa r, mir f, shah mn, ali a, ahmed k. central corneal thickness of pakistani adults. j pak med assoc. 2009; 59: 225–8. 7. su dh, wong ty, wong wl, saw sm, tan dt, shen sy, et al. diabetes, hyperglycemia and central corneal thickness: the singapore malay eye study. ophthalmology, 2008; 115: 964–8. 8. goldich y, barkana y, gerber y, rasko a, morad y, harstein m, et al. effect of diabetes mellitus on biomechanical parameters of cornea. j cataract refract surg. 2009; 39: 715-9. 9. sacks db, arnold m, bakris gl, bruns de, horvath ar, kirkman ms, et al. executive summary: guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. clin chem. 2011 jun; 57 (6): 793-8. 10. williams r, airey m, baxter h, forrester j, kennedy martin t, girach a. epidemiology of diabetic retinopathy and macular oedema: a systematic review. eye, 2004; 18: 963-83. 11. demmer rt, zuk am, rosenbaum m, desvarieux m. prevalence of diagnosed and undiagnosed type 2 diabetes mellitus among us adolescents: results from the continuous nhanes, 1999–2010. am j epidemiol. 2013 oct. 1; 178 (7): 1106–13. 12. kart ö, mevsim v, kut a, yürek i̇, altın aö, yılmaz o. a mobile and web-based clinical decision support and monitoring system for diabetes mellitus patients in primary care: a study protocol for a randomized controlled trial.bmc med inform decis mak. 2017 nov. 29; 17 (1): 154. 13. kramerov aa, ljubimov av. stem cell therapies in the treatment of diabetic retinopathy and keratopathy. exp biol med (maywood). 2016 mar; 241 (6): 559-68. 14. wang y, zhou q, xie l2. diabetic keratopathy: new progresses and challenges. zhonghua yan ke za zhi. 2014 jan; 50 (1): 69-72. 15. herse p, yao w. variation of corneal thickness with age in young new zealanders. acta ophthalmol (copenh) 1993; 71: 360-4. 16. lam ak, douthwaite wa. the corneal – thickness profile in hong kong chinese. cornea, 1998; 17: 384-8. 17. nishitsuka k1, kawasaki r, kanno m, tanabe y, saito k, honma k, et al. determinants and risk factors for central corneal thickness in japanese persons: the funagata study. ophthalmic epidemiol. 2011 oct; 18 (5): 244-9. 18. sonmez b, bozkurt b, atmaca a, irkec m, orhan m, aslan u. effect of glycemic control on refractive changes in diabetic patients with hyperglycemia. cornea, 2005; 24: 531-37. 19. weston bc, bourne wm, polse ka, hodge do. corneal hydration control in diabetes mellitus. invest ophthalmol vis sci. 1995; 36: 586-95. 20. dhasmana r, singh ip, nagpal rc. corneal changes in diabetic patients after manual small incision cataract surgery. j clin diagn res. 2014 apr; 8 (4): vc03-vc06. 21. sahu pk, das gk, agrawal s, kumar s. comparative evaluation of corneal endothelium in patients with diabetes undergoing phacoemulsification. middle east afr j ophthalmol. 2017 apr – jun; 24 (2): 74-80. 22. el-agamy a, alsubaie s. corneal endothelium and central corneal thickness changes in type 2 diabetes mellitus. clin ophthalmol. 2017 mar. 2; 11: 481-6. https://www.ncbi.nlm.nih.gov/pubmed/?term=peterson%20sr%5bauthor%5d&cauthor=true&cauthor_uid=29144826 https://www.ncbi.nlm.nih.gov/pubmed/?term=silva%20pa%5bauthor%5d&cauthor=true&cauthor_uid=29144826 https://www.ncbi.nlm.nih.gov/pubmed/?term=murtha%20tj%5bauthor%5d&cauthor=true&cauthor_uid=29144826 https://www.ncbi.nlm.nih.gov/pubmed/?term=sun%20jk%5bauthor%5d&cauthor=true&cauthor_uid=29144826 https://www.ncbi.nlm.nih.gov/pubmed/?term=sapozhnikova%20ie%5bauthor%5d&cauthor=true&cauthor_uid=29171466 https://www.ncbi.nlm.nih.gov/pubmed/?term=zotina%20en%5bauthor%5d&cauthor=true&cauthor_uid=29171466 https://www.ncbi.nlm.nih.gov/pubmed/?term=hafner%20j%5bauthor%5d&cauthor=true&cauthor_uid=29075765 https://www.ncbi.nlm.nih.gov/pubmed/?term=ginner%20l%5bauthor%5d&cauthor=true&cauthor_uid=29075765 https://www.ncbi.nlm.nih.gov/pubmed/?term=karst%20s%5bauthor%5d&cauthor=true&cauthor_uid=29075765 https://www.ncbi.nlm.nih.gov/pubmed/?term=leitgeb%20r%5bauthor%5d&cauthor=true&cauthor_uid=29075765 https://www.ncbi.nlm.nih.gov/pubmed/?term=unterluggauer%20m%5bauthor%5d&cauthor=true&cauthor_uid=29075765 https://www.ncbi.nlm.nih.gov/pubmed/?term=unterluggauer%20m%5bauthor%5d&cauthor=true&cauthor_uid=29075765 https://www.ncbi.nlm.nih.gov/pubmed/?term=sacu%20s%5bauthor%5d&cauthor=true&cauthor_uid=29075765 https://www.ncbi.nlm.nih.gov/pubmed/?term=gao%20f%5bauthor%5d&cauthor=true&cauthor_uid=27588090 https://www.ncbi.nlm.nih.gov/pubmed/?term=lin%20t%5bauthor%5d&cauthor=true&cauthor_uid=27588090 https://www.ncbi.nlm.nih.gov/pubmed/?term=pan%20y%5bauthor%5d&cauthor=true&cauthor_uid=27588090 https://www.ncbi.nlm.nih.gov/pubmed/21617153 https://www.ncbi.nlm.nih.gov/pubmed/21617153 https://www.ncbi.nlm.nih.gov/pubmed/21617153 https://www.ncbi.nlm.nih.gov/pubmed/?term=kart%20%c3%96%5bauthor%5d&cauthor=true&cauthor_uid=29187186 https://www.ncbi.nlm.nih.gov/pubmed/?term=mevsim%20v%5bauthor%5d&cauthor=true&cauthor_uid=29187186 https://www.ncbi.nlm.nih.gov/pubmed/?term=kut%20a%5bauthor%5d&cauthor=true&cauthor_uid=29187186 https://www.ncbi.nlm.nih.gov/pubmed/?term=y%c3%bcrek%20%c4%b0%5bauthor%5d&cauthor=true&cauthor_uid=29187186 https://www.ncbi.nlm.nih.gov/pubmed/?term=alt%c4%b1n%20a%c3%96%5bauthor%5d&cauthor=true&cauthor_uid=29187186 https://www.ncbi.nlm.nih.gov/pubmed/?term=y%c4%b1lmaz%20o%5bauthor%5d&cauthor=true&cauthor_uid=29187186 https://www.ncbi.nlm.nih.gov/pubmed/?term=y%c4%b1lmaz%20o%5bauthor%5d&cauthor=true&cauthor_uid=29187186 https://www.ncbi.nlm.nih.gov/pubmed/?term=kramerov%20aa%5bauthor%5d&cauthor=true&cauthor_uid=26454200 https://www.ncbi.nlm.nih.gov/pubmed/?term=ljubimov%20av%5bauthor%5d&cauthor=true&cauthor_uid=26454200 https://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20y%5bauthor%5d&cauthor=true&cauthor_uid=24709136 https://www.ncbi.nlm.nih.gov/pubmed/?term=zhou%20q%5bauthor%5d&cauthor=true&cauthor_uid=24709136 https://www.ncbi.nlm.nih.gov/pubmed/?term=xie%20l%5bauthor%5d&cauthor=true&cauthor_uid=24709136 https://www.ncbi.nlm.nih.gov/pubmed/?term=nishitsuka%20k%5bauthor%5d&cauthor=true&cauthor_uid=21961514 https://www.ncbi.nlm.nih.gov/pubmed/?term=kawasaki%20r%5bauthor%5d&cauthor=true&cauthor_uid=21961514 https://www.ncbi.nlm.nih.gov/pubmed/?term=kanno%20m%5bauthor%5d&cauthor=true&cauthor_uid=21961514 https://www.ncbi.nlm.nih.gov/pubmed/?term=tanabe%20y%5bauthor%5d&cauthor=true&cauthor_uid=21961514 https://www.ncbi.nlm.nih.gov/pubmed/?term=saito%20k%5bauthor%5d&cauthor=true&cauthor_uid=21961514 https://www.ncbi.nlm.nih.gov/pubmed/?term=saito%20k%5bauthor%5d&cauthor=true&cauthor_uid=21961514 https://www.ncbi.nlm.nih.gov/pubmed/?term=honma%20k%5bauthor%5d&cauthor=true&cauthor_uid=21961514 https://www.ncbi.nlm.nih.gov/pubmed/?term=dhasmana%20r%5bauthor%5d&cauthor=true&cauthor_uid=24959498 https://www.ncbi.nlm.nih.gov/pubmed/?term=singh%20ip%5bauthor%5d&cauthor=true&cauthor_uid=24959498 https://www.ncbi.nlm.nih.gov/pubmed/?term=nagpal%20rc%5bauthor%5d&cauthor=true&cauthor_uid=24959498 https://www.ncbi.nlm.nih.gov/pubmed/?term=sahu%20pk%5bauthor%5d&cauthor=true&cauthor_uid=28936050 https://www.ncbi.nlm.nih.gov/pubmed/?term=das%20gk%5bauthor%5d&cauthor=true&cauthor_uid=28936050 https://www.ncbi.nlm.nih.gov/pubmed/?term=agrawal%20s%5bauthor%5d&cauthor=true&cauthor_uid=28936050 https://www.ncbi.nlm.nih.gov/pubmed/?term=kumar%20s%5bauthor%5d&cauthor=true&cauthor_uid=28936050 https://www.ncbi.nlm.nih.gov/pubmed/?term=el-agamy%20a%5bauthor%5d&cauthor=true&cauthor_uid=28280298 https://www.ncbi.nlm.nih.gov/pubmed/?term=alsubaie%20s%5bauthor%5d&cauthor=true&cauthor_uid=28280298 pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 77 original article limbal relaxing incision during phacoemulsification for the correction of astigmatism mehvash hussain, mohammad muneer quraishy pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mehvash hussain doctors plaza room no 542 karachi …..……………………….. purpose: to determine the difference in mean post-operative astigmatism of patients having limbal relaxing incisions with phacoemulsification as compared to phacoemulsification alone for the correction of pre-existing corneal astigmatism. material and methods: this study was conducted in the civil hospital karachi eye unit ii, from 1 st december 2009 1 st december 2010, for duration of 12 months. patients enlisted for phacoemulsification cataract surgery with coexisting astigmatism were recruited and divided into two groups. eyes that underwent cataract surgery with limbal relaxing incisions (cataract lri group) and eyes that underwent cataract surgery only (control group). all patients underwent a comprehensive baseline ophthalmic examination that included uncorrected visual acuity (ucva) and best corrected visual acuity (bcva), manifest refraction, anterior segment slit – lamp examination, 90 d examination of fundus, keratometry and ultrasound biometry. patients were evaluated at 1 st day, 1 st month and 3 rd month postoperatively post-operative examination included bcva, anterior segment slit-lamp microscopy and keratometry. the data thus obtained was analyzed on spss 17. results: a total of 50 eyes (29 right eyes and 21 left eyes) of 44 patients were included in the study. mean patients age was 61 yrs ± 11.3 yrs (range: 30 to 80) in the lri group and 57 yrs ± 11.8 yrs (range 30 to 80) in the control group. data analysis demonstrated statistically significant reduction in the mean postoperative astigmatism in the lri eyes from 1.78 ± 0.81 d@125° (range: 0.75 to 3.70 d) preoperatively to 0.73 ± 0.71 d @ 130° (range: 0.0 to 2.70) in the 3 rd postoperative month as compared to control group from 1.28 ± 0.41 d @ 145° (range: 0.75 to 1.97 d) preoperatively to 1.17 ± 0.57 d @ 144° (range: 0.10 to 2.30) p-value 0.021. there were no intraoperative complications or postoperative subjective complaints (such as halo or glare) in our patients. conclusion: limbal relaxing incisions performed during phacoemulsification surgery appear to be safe and effective procedure to reduce pre-existing corneal astigmatism. key words: limbal relaxing incision, phacoemulsification, astigmatism. ataract surgery is the most successful and most commonly performed ophthalmic procedure in the modern medical world.1,2 an increasingly important goal of modern cataract and lens implantation surgery is to obtain the most desirable refractive outcomes for the patients. as this trend continues, we are faced with addressing the obstacles to spectacle independence. there are an estimated 15 – 20% of individuals with greater than 1.5d of cylinder and a much higher percentage with less than 1.5 d of cylinder.3 novel techniques of cataract surgery to correct preexisting astigmatism are presented. hence, the uncorrected visual outcome of cataract patients has been improved and better c mehvash hussain, et al 78 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology refractive correction is possible now.4,5 in order to achieve better visual results, the effect of pre-operative corneal astigmatism should be minimized through one of the several techniques including placement of clear corneal incisions(cci), limbal relaxing incisions (lri), toric intraocular lens implants (iol) or postoperative vision correction by ablative refractive surgery by excimer laser; each with its own advantages and disadvantages.6-8 herein, we report the efficacy of limbal relaxing incisions (lris) for correction of pre-existing corneal astigmatism during phacoemulsification. material and methods this study was conducted at the department of ophthalmology, dow university of health sciences, civil hospital karachi from 1st december 2009 – 1st december 2010, for duration of 12 months. study approval was obtained from the ethics committee of dow university of health sciences and informed consent was obtained from all study participants. patients admitted in the inpatient department of ophthalmology unit 11 civil hospital having cataract and co-existing astigmatism of 0.75 d to 3.75 d were selected and randomly divided into two groups. inclusion criteria were all patients undergoing cataract surgery from all age groups and from both sexes, patients having pre-existing astigmatism 1 to 3.75 d. exclusion criteria was patients having any corneal opacity, degenerations or dystrophies, any retinal vascular diseases or retinal detachment, any macular pathology, glaucoma or patients with any other ocular co-morbidity. eyes that underwent cataract surgery with limbal relaxing incisions (cataract lri group) and eyes that underwent cataract surgery only (control group). fifty eyes of forty four patients (mean age 59 years ± 11.6 range 30 to 80 years) were included. youngest patient was 30 years while the oldest being 80 years of age. all patients underwent a comprehensive baseline ophthalmic examination that included uncorrected visual acuity (ucva) and best corrected visual acuity (bcva), manifest refraction, anterior segment slitlamp examination, 90 d examination of fundus, keratometry and ultrasound biometry. patients were evaluated at 1st day, 1st month and 3rd month postoperatively post-operative examination included ucva, anterior segment slit-lamp microscopy and keratometry. all surgeries were performed by one surgeon. srk-t formula was used for all patients for iol power calculation. cataract surgery was performed under topical anesthesia. acrylic foldable iols (alcon, sa 60 at, usa) were implanted through a 2.75 mm temporal clear corneal incision in r eyes and nasal in l eyes without enlarging the incision using the injector for all eyes. in the cataract lri group before surgery, the steepest meridian was marked with the patient in supine position based on corneal topography on which lris were made according to the nichamin nomogram (table 2). all lris were placed inside the surgical limbus at a depth of 600 μm with lri knife determined for 600 μm. for patients with against-the-rule astigmatism the temporal hinge incision for phacoemulsification was oriented to align with placement of the lri. a second lri was performed on the nasal side before phacoemulsification. after iol implantation and before removal of viscoelastic material, the original minimal lri was extended according to the nomogram. in eyes with the rule astigmatism, paired lris were placed on the steep meridian before phacoemulsification as dictated by the nomogram. the collected data was analyzed by using spss version 17.0. the results of the study were presented through tables. the success of the procedure was evaluated by comparing preand post-operative keratometry readings. effectiveness was analysed by comparing the arithmetic mean and standard deviation of the post-operative keratometric astigmatism between the groups. independent sample t-test was used to check the difference between the two groups with level of significance of ≤ 0.5. all post-operative complications and subjective symptoms were recorded. stratification was done to age and gender to see the impact of these on the outcome. results lri with phacoemulsification was performed on 25 eyes whereas 25 eyes underwent phacoemulsification alone. total of 50 eyes were included (29 right eyes and 21 left eyes) of 44 patients. there was no significant difference in the mean age of the patients in limbal relaxing incision during phacoemulsification for the correction of astigmatism pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 79 the two groups. mean age was 61 years ± 11.3 yrs (range: 30 to 80) in the lri group and 57 years ± 11.8 years (range 30 to 80) in the control group. 0 2 4 6 8 10 12 14 16 female male lri control fig. 1: gender distribution in cases (n = 50). out of 25 patients of lri group nine (2.25%) were females and sixteen (4%) were males whereas in the control group sixteen (4%) were females and nine (2.25%) were males. data analysis demonstrated statistically significant reduction in the mean post-operative astigmatism in the lri eyes as compared to control group. mean decrease in the lri group was 1.04 ± 0.87 d while in the control group was 0.10 ± 0.53 d. lri group showed reduction from 1.78 ± 0.81 d @ 1250 (range: 0.75 to 3.70 d) preoperatively to 0.73 ± 0.71 d @ 130° (range: 0.0 to 2.70 d) in the 3rd postoperative month whereas the control group showed reduction from 1.28 ± 0.41 d @ 145° (range: 0.75 to 1.97 d) preoperatively to 1.17 ± 0.57 d @ 144° (range: 0.10 to 2.30 d) in the 3rd postoperative month p-value 0.021. there were no intraoperative complications or postoperative subjective complaints (such as halo or glare) in our patients. discussion visual recovery and satisfaction of patients who underwent phacoemulsification is closely related to the appropriate iol power calculation and management of postoperative astigmatism.9-11 among patients undergoing cataract surgery, 15 20% have significant corneal astigmatism ranging from 1 to 3 d. with the introduction of aspherical intraocular lens (iols) as an integral part of cataract surgery, better formulae for iol power calculation, and eliminating lenticular astigmatism by removing the lens by cataract extraction, the major source of postoperative refractive astigmatism is the corneal astigmatism. there are several options to reduce the preoperative astigmatism including intraoperative relaxing incisions, toric iol implantation or postoperative vision correction by ablative refractive surgery by excimer laser each with its own benefits and drawbacks. toric iols are rather expensive. moreover, if postoperative rotation of the iol occurs, there would be a significant induced astigmatism. excimer laser vision correction after cataract surgery needs an additional operation with high expenses, possible complications and limitations in patients with thin cornea.12-13 lris have been used to correct preexisting astigmatism at the time of cataract surgery. simultaneously, one can benefit from lower costs and easy performance with minimal learning curve, without overcorrection. however, the predictability, stability and range of correction are rather limited. according to gills and guyton lris are more effective in eyes with low to moderate, rather than high astigmatism. lris also appear to cause less distortion and irregularity at the limbus. they can provide more rapid postoperative visual acuity (va) as compared to clear corneal incisions with less risk of glare and discomfort. in this study, the use of limbal relaxing incisions during phacoemulsification significantly reduced preexisting corneal astigmatism. astigmatism correction is evaluated by comparing the pre-operative and postoperative mean keratometry effectiveness of lri’s was evaluated by using mean and standard deviation of the post-operative astigmatism between the groups. based on the results obtained we reject the null hypothesis which stated that there was no difference in the mean post-operative astigmatism of patients having lri with phacoemulsification as compared to phacoemulsification alone. phacoemulsification and lens implantation were performed through a 2.75mm temporal incision to mehvash hussain, et al 80 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology table 2: nichamin nomogram. limbal relaxing incision during phacoemulsification for the correction of astigmatism pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 81 avoid inducing astigmatism. according to fine14 a temporal incision might minimize the astigmatism induced by phacoemulsification due to a number of factors such as an incision architecture that maximizes the distance from the limbus to the central cornea, the lack of action of the superior rectus muscle, and the alignment of the incision with the action of superior eyelid and gravitational pull. induced astigmatism is likely related to the creation and manipulation of the incision during surgery.15 induction of astigmatism may be averted by prevention of thermal damage to the incision by the phaco tip and the correct iol implantation.16-19 our study demonstrated that use of lris during phacoemulsification significantly reduces corneal astigmatism; however, there was a trend for under correction. under correction was not uncommon in previous reports.20-21 budak et al, studied 22 patients. they found a 44% reduction of astigmatism in eyes treated with lri during phacoemulsification using the gills nomogram.22 in another study of 12 eyes of 11 patients that underwent phacoemulsification and limbal relaxing incision budak et al, found 75% of the eyes were under corrected. in study of carvalho et al,9 a statistically significant reduction in the mean topographic astigmatism was seen in the cataract lri eyes from 1.93 ± 0.58 d preoperatively to 1.02 ± 0.60 d 6 months postoperatively (p < 0.05). multiple factors might cause under correction of astigmatism in patients who are treated with phacoemulsification and lris. we minimized the surgeon factor by performing all operations by only one surgeon. another cause may be the improper position of blade (oblique incision rather than perpendicular incision on the limbus, that may result in the wrong depth causing under correction).23 under correction may be related to area of limbal incision that is far from the corneal center.24 however, more central clear corneal incisions may cause more glare and higher order aberrations for the patients. in summary, when combined with the accurate identification of the steep meridian of corneal astigmatism, limbal relaxing incisions are safe and efficacious for correcting corneal astigmatism during phacoemulsification. conclusion in our study 25 eyes that were operated with lris during phacoemulsification surgery. limbal relaxing incisions appear to be safe and fairly effective to correct mild to moderate amounts of corneal astigmatism. under correction is a common limitation that may be further managed by modified nomograms in future studies adjusted by the surgeon factors. apart from the patient age, multiple factors including ethnicity, gender, corneal limbal thickness, course of postoperative steroid regimen and surgeon factors should be considered for adjustment of future nomograms. it seems that lri incisions cannot fully correct but would cause more acceptable reduction in the preoperative corneal astigmatism. author’s affiliation dr. mehvash hussain doctors plaza, karachi prof. mohammad muneer quraishy civil hospital, karachi references 1. kershner rm. refractive cataract surgery. curr opin ophthalmol. 1998; 9: 46-54. 2. nichamin ld. treating astigmatism at the time of cataract surgery. curr opin ophthalmol. 2003; 14: 35-8. 3. hoffer kj. biometry of 7,500 cataractous eyes. am j ophthalmol. 1980; 90: 360-8. 4. nichamin ld. astigmatism control. ophthalmol clin north am. 2006; 19: 485-93. 5. alastrué v, calvo b, peña e, doblaré m. biomechanical modeling of refractive corneal surgery. j biomech eng. 2006; 128: 150-60. 6. morlet n, minassian d, dart j. astigmatism and the analysis of its surgical correction. br j ophthalmol. 2001; 85: 1127-38. 7. kaufmann c, peter j, ooi k , phipps s, cooper p, goggin m, et al. limbal relaxing incisions versus on axis incision to reduce corneal astimatism at the time of cataract surgery. j cataract refract surg. 2005; 31: 22615. 8. carvelho mj, suzuki sh, freitas ll, branco bc, schor p, lima al. limbal relaxing incision to correct corneal astigmatism during phacoemulsification. j refract surg. 2007; 23: 499-504. 9. oshika t, yoshitomi f, fukuyama m, hara y, shimokawa s, shiwa t, sakabe i. radial keratotomy to treat myopic refractive error after cataract surgery. j cataract refract surg. 1999; 25: 50-5. 10. packer m, fine ih, hoffman rs, coffman pg, brown lk. immersion a-scan compared with partial coherence interferometry: outcomes analysis. j cataract refract surg. 2002; 28: 239-42. http://www.ncbi.nlm.nih.gov/pubmed?term=%22hara%20y%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22shimokawa%20s%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22shiwa%20t%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22sakabe%20i%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22coffman%20pg%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22brown%20lk%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22brown%20lk%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22brown%20lk%22%5bauthor%5d mehvash hussain, et al 82 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology 11. murphy c, tuft sj, minassian dc. refractive error and visual outcome after cataract extraction. j cataract refract surg. 2002; 28: 62-6. 12. bayramlar hh, daglioglu mc, borazan m. limbal relaxing incisions for primary mixed astigmatism and mixed astigmatism after cataract surgery. j cataract refract surg. 2003; 29: 723-8. 13. gills jp, gayton jl. reducing pre-existing astigmatism. in: gills jp, fenzle r, martin rg, eds, cataract surgery; the state of the art. thorofare, nj, slack. 1998; 53-66. 14. fine ih. architecture and construction of a self sealing incision for cataract surgery . j cataract refract surg. 1991; 17: 672-6. 15. steinert rf, deacon j. enlargement of incision width during phacoemulsification and folded intraocular lens implant surgery. opthalmology. 1996; 103: 220-5. 16. majid ma, sharma mk, harding sp. corneosclral burn during phacoemulsification surgery. j cataract refract surg. 1998; 24: 1413-5. 17. sugar a, schertzer rm. clinical course of phacoemulsification wound burns. j cataract refract surg. 1999; 25: 688-92. 18. mamalis n. incision width after phacoemulsification with foldable intraocular lenses. j cataract refract surg. 2000; 26: 237-41. 19. kohen t, lambert rj, koch dd. insicion sizes for foldable intraocular lenses. ophthalmol. 1997; 104: 127786. 20. osher rh. paired transverse relaxing keratotomy: a combined technique for reducing astigmatism. j cataract refract surg. 1989; 15: 32-7. 21. oshika t, shimazaki j, yoshitomi f, oki k, sakabe i, matsuda s, et al. arcuate keratotomy to treat corneal astigmatism after cataract surgery: a prospective evaluation of predictability and effectiveness. ophthalmology. 1998; 105: 2012-6. 22. budak k, yilmaz g, aslan bs, duman s. limbal relaxing incisions in congenital astigmatism: 6 month follow-up. j cataract refract surg. 2001; 27: 715-9. 23. akura j, matsuura k, hatta s, otsuka k, kaneda s. a new concept for the correction of astigmatism: full-arc, depth – dependent astigmatic keratotomy. ophthalmology, 2000; 107: 95-104. 24. waring go 3rd, lynn mj, mcdonnell pj. results of the prospective evaluation of radial keratotomy (perk) study 10 years after surgery. arch opthalmol. 1994; 112: 1298-308. http://www.ncbi.nlm.nih.gov/pubmed?term=%22oki%20k%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22sakabe%20i%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22otsuka%20k%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22kaneda%20s%22%5bauthor%5d pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 217 original article surgically induced corneal astigmatism in conventional 20 – gauge versus transconjunctival sutureless 23 – gauge vitrectomy syed raza ali shah, tehseen mehmood mahju, qasim lateef chaudry, asad aslam khan, chaudry nasir ahmad, zoya raza pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syed raza ali shah associate professor ophthalmology, king edward medical university. vitreoretinal fellow, college of ophthalmology & allied visual sciences / mayo hospital lahore. drrazaalishah14@gmail.com …..……………………….. purpose: the purpose of the study was to evaluate and compare the effects of 23g (gauge) tran-sconjunctival pars plana vitrectomy (ppv) with conventional 20g ppv in inducing corneal astigmatism. material and methods: this was comparative, consecutive interventional study done at institute of ophthalmology mayo hospital lahore from january 2011 till june 2011. 40 patients were selected and divided into two equal groups. group i patients underwent 23g trans-conjunctival ppv while patients in group ii were operated by conventional 20g ppv. evaluation was done on 1 st postoperative day, the 1 st follow-up visit (after one week), 2 nd follow up visit (after one month), 3 rd follow-up visit (2 months post-op) and on fourth follow-up visit (after 3 months). on each visit keratometry (huvitz keratometer) along with anterior segment examination, posterior segment examination and intraocular pressure measurement were performed. results: there were total of forty patients divided into two equal groups, 22 were males and 18 females. group-i was operated by trans-conjunctival 23g ppv whereas the group ii underwent conventional 20g ppv. the surgically induced corneal astigmatism was lower at one week postoperatively in the 23g group (p = .006) compared with the 20g group (p = .001). one month postoperatively, the surgically-induced corneal astigmatism was still lower in the 23g group (p = 01). conclusion: 23g ppv induces much less surgically induced corneal astigmatism in comparison to 20g ppv. pv was developed by robert machemer, and it was performed using a 14-gauge instrument (2.1-mm diameter). 20g vitrectomy remained in vogue in the last two decades of the 20th century. peyman developed a 23-g ppv probe in 19901, primarily for vitreous and retinal biopsy. hilton also described an office-based sutureless-vitrectomy system. fujii and associates2,3, modified vitrectomy instruments and introduced 25-g ppv with sutureless self-sealing sclerotomies. reduction in postoperative discomfort along with short surgical and recovery time, are few advantages of 23g over 20g ppv4-7. the 23-g ppv induces no corneal astigmatism and there is very significant stability for all the measured parameters between the preoperative and the postoperative conditions8,9. the self-sealing sclerotomies and the sutureless scleral and conjunctival incisions explain the corneal curvature stability after the procedure. by contrast, the conventional 20-gauge vitrectomy is responsible for significant corneal topographic changes in the first preoperative days or weeks10. the purpose of the study was to compare the preoperative and post-operative corneal astigmatism and p file:///c:\users\user\appdata\users\dell\desktop\munib\comparison%20of%20one-year%20outcomes%20between%2023-%20and%2020-gauge%20vitrectomy%20for%20preretinal%20membrane.htm%23bib2 file:///c:\users\user\appdata\users\dell\desktop\munib\comparison%20of%20one-year%20outcomes%20between%2023-%20and%2020-gauge%20vitrectomy%20for%20preretinal%20membrane.htm%23bib3 http://www.nature.com/eye/journal/v23/n12/full/eye2008431a.html#bib27 http://www.nature.com/eye/journal/v23/n12/full/eye2008431a.html#bib26 http://www.nature.com/eye/journal/v23/n12/full/eye2008431a.html#bib27 syed raza ali shah, et al 218 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology hence assess corneal stability in 20g sutured versus 23g sutureless vitrectomy. material and methods the study was carried out at college of ophthalmology and allied vision sciences / king edward medical university, mayo hospital lahore. the patients were admitted from eye opd of mayo hospital lahore. study was of six months duration from january 2011 till june 2011. there were 40 eyes included in this study and 20 each were assigned to 20g & 23g group. sampling technique was a comparative, consecutive and interventional study. patients were selected randomly in both groups. those included in the study had epiretinal membranes (erm), macular hole, nonclearing vitreous hemorrhage, retained lens fragments, vitreomacular traction, diabetic macular edema and tractional retinal detachment (trd). the patients who required cataract surgery per operatively or had a corneal pathology were excluded. patients who required relaxing incisions to cornea, removal of intraocular foreign body, repair of rhegmatogenous retinal detachment or silicone oil insertion were also excluded from the study. forty consecutive eyes of patients presenting in vitreo-retina out-patient department of the institute of ophthalmology, mayo hospital, lahore, from 1st january 2011 to 31st march were included in our study. examination of the eyes included the recordings of corneal astigmatism, keratometric readings [m2], slitlamp examination of anterior segment, fundus examination, b scan, oct and ffa if required. all data including preoperative, operative and post operative recordings were collected. follow up period was extended over 3 months with visits on day 1, 7, 30, 60 and 90. outcome variables included preoperative and post-operative corneal keratometric readings (astigmatism) on each follow-up visit. data was entered and analyzed using computer program epi info version “10” to find out frequencies and percentages. descriptive statistics ware applied to determine the mean and standard deviation (sd) for variables like keratometric readings and hypotony. chi-square test was applied to evaluate the results. pvalue ≤0.05 was considered significant. results in 20g group 11 were males and 9 were females whereas in 23g group 10 were males and 10 females. in 20g group 14 had vitreous haemorrhage, 2 had macular hole and 4 had dropped lens in the vitreous whereas in 23-g group 10 had vitreous haemorrhage, 9 had macular hole and 1 had erm (macular pucker). posterior vitreous detachment (pvd) had to be created intra-operatively in 10 (50%) of 20 eyes in the 23g group and 6 (30%) of 20 eyes in the 20g group. retinal breaks associated with the maneuvers performed to create a pvd occurred in 1 (10%) of 10, and 1 (16.6%) of 6 eyes in the 23g and 20g groups, respectively, and were treated effectively with photocoagulation intra-operatively. no retinal detachments developed. no severe postoperative hypotony developed in either group, although in 23g group-1 eye had iop less than 7 mm hg 1stday postoperatively which increased to more than 10-mm hg in 2 days and no surgical intervention was required. there was no significant difference in complications in either group preoperatively and postoperatively. no choroidal detachment or bacterial endophthalmitis developed in either group. the corneal induced astigmatism was lower 1 week postoperatively in the 23g group (p=.006) as compared with the 20g group (p = .001). one month postoperatively, the surgically induced corneal astigmatism was still lower in the 23-gauge group (p = .01). astigmatism in 20g group on first day had ranged from 2.5 d to 3.5 d with a mean of 3.25d, which reduced to a mean of 2 d on the 7th post operative day, 1.25 d after one month, 0.75 d by 2 months and 0.5 to 0.6 d by 3 months whereas astigmatism in 23g group on 1st post-operative day ranged from 0.25 d to 0.75 d with mean of 0.6 d, 0.5 d on 7th post operative day, 0.4 d after 1 month, 0.3 d after 2 months and 0.25 d after 3 months. discussion in our study there had been very rapid improvement and very low surgically induced astigmatism one week after surgery in patients undergoing 23-g ppv as compared with those undergoing 20-g ppv. less surgically induced astigmatism in patients who underwent 23-g ppv had earlier visual rehabilitation with maximum vision improvement in the first couple of weeks. although much work has been done on 25-g ppv and its role in surgically induced astigmatism, only limited studies are available regarding surgically induced astigmatism in 20-g and especially 23-g ppv. our study shows that in the early post-operative surgically induced corneal astigmatism in conventional 20-g vs. 23-g vitrectomy pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 219 period, 23-g trans-conjunctival surgery is comparable to 25-g ppv with much less post-operative astigmatism, proving these techniques to be superior to the 20-g ppv. complications, although occasionally common with 20-g ppv, were not observed in patients undergoing 23-g ppv. a patient had post-operative hypotony and a couple of patients had flare in anterior chamber after 23-g ppv, who recovered early with treatment. fig. 1: indications for 20 g ppv fig. 2: indications for 23 g ppv graph: surgically induced corneal astigmatism in 23g and 20g ppv domniz and associates described that the induced astigmatism in patients undergoing 20-guage vitrectomy, usually transient, may be attributed to suturing at the entry ports. slusher et al reported that the lysis of the sutures after ppv reduce postoperative corneal astigmatism by more than 5.0 d. bergmann et al reported that scleral cautery near the incisions changed corneal curvature by causing thermal contracture of the treated tissue and immediate central steepening. wimpissinger and associates who compared the sutureless 23-g system with the standard 20-g system in ppv for various vitreoretinal disorders, randomly divided 60 patients into 2 groups and reported that the opening and closure times were significantly shorter and the duration of the vitrectomy was significantly longer in the 23-gauge system compared with the 20-gauge vitrectomy group. however, the degree of retinal manipulation and the overall duration of surgery did not differ significantly between the groups. vitreous surgery for pre-retinal membranes can be a good indication for using the sutureless-trans-conjunctival 23g system to capitalize on the merits of and decrease the disadvantages of the surgical system. conclusion the 23-gauge procedure resulted in less corneal astigmatic changes as compared to conventional 20gauge vitrectomy. author’s affiliation dr. syed raza ali shah associate professor king edward medical university/ mayo hospital lahore, vr fellow, college of ophthalmology and allied visual sciences institute of ophthalmology dr. tehseen mehmood mahju senior registrar and vr fellow college of ophthalmology and allied visual sciences, institute of ophthalmology, king edward medical university / mayo hospital lahore dr. qasim lateef chaudry assistant professor college of ophthalmology and allied visual sciences institute of ophthalmology, king edward medical university / mayo hospital lahore prof. asad aslam khan professor of ophthalmology, king edward medical university / mayo hospital lahore, director general college of ophthalmology and allied visual sciences institute of ophthalmology dr. chaudry nasir ahmad assistant professor college of ophthalmology and allied visual sciences institute of ophthalmology, king edward medical university / mayo hospital lahore syed raza ali shah, et al 220 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology ms. zoya raza statistical analyst lahore school of economics, lahore references 1. peyman ga. a miniaturized vitrectomy system for vitreous and retinal biopsy. can j ophthalmol. 1990; 25: 285–6. 2. fujii gy, de juan jr e, humayun ms, chang ts, pieramici dj, barnes a, et al. initial experience using the trans-conjunctival sutureless vitrectomy system for vitreoretinal surgery. ophthalmology. 2002; 109: 1814-20. 3. fine hf, iranmanesh r, iturralde d, spaide rf. outcomes of 77 consecutive cases of 23-gauge transconjunctival vitrectomy surgery for posterior segment disease. ophthalmology 2007; 114: 1197-1200. 4. oshima y, ohji m, tano y. surgical outcomes of 25gauge trans-conjunctival vitrectomy combined with cataract surgery for vitreoretinal diseases. ann acad med singapore. 2006; 35: 175-80. 5. lakhanpal rr, humayun ms, de juan jr e, lim ji, chong lp, chang ts et al. utcomes of 140 consecutive cases of 25-gauge trans-conjunctival surgery for posterior segment disease. ophthalmology. 2005; 112: 817-24. 6. jackson t. modified sutureless sclerotomies in pars plana vitrectomy. am j ophthalmol. 2000; 129: 116-7. 7. assi ac, scott ra, charteris dg. reversed self-sealing pars plana sclerotomies. retina. 2000; 20: 689-92. 8. domniz yy, cahana m, ayni i. corneal surface changes after pars plana vitrectomy and scleral buckling surgery. j cataract refract surg. 2001; 27: 868-72. 9. slusher mm, ford jg, busbee b. clinically significant corneal astigmatism and pars plana vitrectomy. ophthalmic surg lasers. 2002; 33: 5-8. 10. bergmann mt, koch dd, zeiter jh. the effect of scleral cautery on corneal astigmatism in cadaver eyes. ophthalmic surg. 1988; 19: 259-62. 11. hubschman jp, gupta a, bourla dh, culjat m, yu f, schwartz sd. 20, 23, and 25 gauge vitreous cutters: performance and characteristics evaluation. retina. 2008; 28: 249-57. 12. wimpissinger b, kellner l, brannath w, krepler k, stolba u, mihalics c, binder s. twenty-three-gauge versus 20-gauge system for pars plana vitrectomy: a prospective randomized clinical trial. br j ophthalmol. 2008; 92: 1483-7. pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 83 original article glaucoma and ocular hypertension in pseudoexfoliation syndrome azfar ahmed mirza, noor bakht nizamani, mariya nazish memon, sajjad ali surhio, khalid i. talpur pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: noor bakht nizamani department of ophthalmology liaquat university eye hospital jail road, hyderabad, 71000, sindh email: noorniz@hotmail.com …..……………………….. purpose: to assess the frequency of glaucoma and ocular hypertension in pseudoexfoliation syndrome. material and methods: this study was conducted in the department of ophthalmology, liaquat university eye hospital, hyderabad, pakistan from june 2011 to december 2011. hundred confirmed cases of pseudoexfoliation syndrome (pxs) were included in the study by non-probability convenience sampling. tonometry, gonioscopy, ophthalmoscopy and visual field analysis were carried out to determine glaucoma. data was collected by specially designed proforma and analyzed by using statistical program for social sciences (spss, version 16.0 for windows). the frequencies and percentage were recorded and any association with predisposing factors was statistically analyzed on chi square test. p-value of <0.001 was considered significant with a confidence interval (ci) of 95%. results: out of the 100 pxs patients, 16% patients were diagnosed with pseudoexfoliation glaucoma (pxg) (ci 95%): 12% with open angle glaucoma and 4% narrow angle glaucoma. ocular hypertension without glaucomatous changes was detected in 9% (ci 95%) of the patients (p <0.001). pxg was more common after 50 years of age while ocular hypertension occurred earlier i.e. 40 years. gender (p=0.45), locality (p=0.725) and family history of glaucoma (p=0.95) were statistically insignificant risk factors for development of glaucoma in pxs patients. increased age, intraocular pressure and cup-disc ratio (16%) were significant risk factors for development of pxg (p <0.001 ci 95%). conclusion: increasing age, intraocular pressure and cup disc ratio are significant risk factors for development of glaucoma in pxs. it is recommended that patients over 50 years should be actively examined for glaucoma particularly those with pxs. keywords: pseudoexfoliation syndrome, glaucoma, ocular hypertension. seudoexfoliation syndrome (pxs) is a complex systemic age-related disorder characterized by the accumulation of an extracellular material in various parts of the body including lungs, skin, liver, heart, kidney, gallbladder, blood vessels, eyes and meninges.1 in the eye, fibrillar material is deposited all over the anterior segment, particularly over the anterior lens capsule in characteristic double concentric ring pattern with clear zone in between the rings.1 pxs is the most common cause of secondary open angle glaucoma; pseudoexfoliation glaucoma (pxg), caused by clogging of the trabecular meshwork by pseudoexfoliation material.2,3 cataract is also an important association of pxs particularly cortical and nuclear cataract.4 pxs may complicate cataract surgery with poor mydriasis, zonular dehiscence, corneal endothelial dysfunction, phacodonesis, vitreous loss and capsular phimosis. 5 other ocular manifestations of pxs include iris depigmentation, transillumination defects, hyperpigmentation of trabecular meshwork and iridonesis.2 p mailto:noorniz@hotmail.com azfar ahmed mirza, et al 84 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology the prevalence of pxs in pakistan is 6.45%, while there is variable prevalence worldwide ranging between 0.5% and 33%, increasing with age.1,6,7 glaucoma is present in 14.2% patients of pxs, with up to threefold higher risk of open angle glaucoma.8 the purpose of this study was to assess the frequency of glaucoma and ocular hypertension in pxs. material and methods this cross sectional study was carried out at eye unit iii, department of ophthalmology, liaquat university eye hospital, hyderabad, from june 2011 to december 2011. a total of 100 patients, 40 years and above attending the outpatient department for various ocular problems were screened for pseudoexfoliation syndrome (pxs). the initial examination consisted of slit lamp biomicroscopy for the evidence of pseudoexfoliation material on the edge of pupil or lens in the undilated state and in those having suspicion of disease, the pupil was dilated and repeat slit lamp examination was performed. the patients having pxs were then further examined in detail according to an examination protocol and all the findings were recorded and entered in specially designed proforma for this study. the examination included complete history, general physical and systemic examination and full ocular examination. the ocular examination included visual acuity testing, slit lamp examination of the anterior segment, transillumination, gonioscopy, applanation tonometry and fundus examination. the patients were further divided into glaucoma or ocular hypertension on the basis of raised iop and visual fields. written informed consent was taken before proceeding for the recording of information and confidentiality was ensured. data was entered and analyzed by using statistical program for social sciences (spss version 16.0 for windows software). the frequencies and percentage were recorded and any association with predisposing factors was statistically analyzed on chi square test. the risk factors of pex glaucoma and ocular hypertension were statistically analayzed and compared using chi square test to compare the significance between the two groups. based on intraocular pressure the patients were further divided into subgroups of < 21 mm hg, 21-25 mm hg, 26 – 30 mm hg, 31 – 35 mm hg and 36 – 40 mm hg. the characteristics of these groups were compared by the chi square test. p-value of < 0.001 was taken as significant with a confidence interval (ci) of 95%. results in this study 100 consecutive patients of pseudoexfoliation syndrome (pxs) were included. 54% of our patients were males while 46% were females with mean age of 62.6 ± 9.7 years (table 1). the mean intraocular pressure was 16.3 ± 4.9 mm hg, ranging from 9 to 38 mm hg. table 1 shows the overall characteristics of our patients. during the initial assessment, majority (71%) of the patients with pxs did not have glaucoma or ocular hypertension (table 2). sixteen percent patients were diagnosed with pseudoexfoliation glaucoma (pxg): glaucoma and ocular hypertension in pseudoexfoliation syndrome pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 85 12% with open angle glaucoma and 4% narrow angle glaucoma. ocular hypertension without glaucomatous changes was detected in 9% of the patients (p <0.001 ci 95%). 4% patients had raised iop but could not be classified as pxg or ocular hypertension due to dense cataract (table 2). pxg was more common in males (9%) after 60 years of age while ocular hypertension occurred frequently in females (6%) and earlier i.e. 40 years (table 2). most of the patients had intraocular pressure ranging between 20 – 30 mm hg in both pxg and ocular hypertension. increased age and increased intraocular pressure (16%) (iop) were associated with increased risk of development of glaucoma (p < 0.001 ci 95%) (fig. 1). gender (p = 0.45), locality (p = 0.725) and family history of glaucoma (p = 0.95) were statistically insignificant risk factors for development of glaucoma in pxs patients (table 3). increased cup-disc ratio was azfar ahmed mirza, et al 86 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology a significant risk factor for development of pxg (p <0.001 ci 95%). discussion pxs is of particular importance as it is associated with a wide range of ocular manifestations specifically glaucoma and cataract.2,4 in addition it also tends to complicate intraocular surgery.5 there has been a great variability in the prevalence of pxs ranging from 0.5% up to 33%.1,7 the variability has been defined across different populations like japanese9 and south indian10 with 3.4% and 3.8% prevalence respectively while the icelandic and finnish had greater prevalence (17.7% and 33%).1,11 similar variability has been observed in local studies between 1.9% and 6.45%.6,12 pxs has been more prevalent in females worldwide while males are more affected in the pakistani glaucoma and ocular hypertension in pseudoexfoliation syndrome pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 87 population.8,13 similar to our study, increasing age has been universally accepted as a significant risk factor for development of pxs.8,9 0 5 10 15 20 25 30 < 21 mm hg 21-25 mm hg 26-30 mm hg 31-35 mm hg 36-40 mm hg 40-49 50-59 60-69 70-79 > 80 years fig. 1: relationship between intraocular pressure and different age groups (p-value < 0.001). 0 5 10 15 20 25 30 35 40 < 21 mm hg 21-25 mm hg 26-30 mm hg 31-35 mm hg 36-40 mm hg males females fig. 2: relationship between intraocular pressure and gender. pxg has been a hazardous association of pxs, which is difficult to treat. 16% of our patients had pxg which is significantly more than reported in literature.14,15 the blue mountains eye study8 conducted on australian population reported a prevalence of 13.4% which is comparable to our figures, while the american population had a significantly lower prevalence of 3% and 10%.14,15 pxs is the most common cause of secondary open angle glaucoma. the risk of developing open angle glaucoma is increased three times in pxs patients,8 consistent with this open angle glaucoma was more prevalent (12%) in our patients compared to angle closure glaucoma (4%). we found a greater prevalence of ocular hypertension (9%) than reported in literature (3.7%).16 there was no statistically significant increase with age or gender in the ohtn group.8,16 it was observed that pxg was more common in males and ohtn was frequently found in females. gender, locality and family history did not seem to be a significant risk factor for developing glaucoma in pxs patients.8 increasing age, intraocular pressure and cup-disc ratio were significant risk factors for development of glaucoma in pxs.8,17 conclusion increased age, intraocular pressure and cup disc ratio are significant risk factors for development of glaucoma in pxs. it is recommended that patients over 50 years should be actively examined for glaucoma particularly those with pxs. author’s affiliation dr. azfar ahmed mirza department of ophthalmology liaquat university of medical and health sciences jamshoro / hyderabad dr. noor bakht nizamani department of ophthalmology liaquat university of medical and health sciences jamshoro / hyderabad dr. mariya nazish memon department of ophthalmology liaquat university of medical and health sciences jamshoro / hyderabad dr. sajjad ali surhio department of ophthalmology liaquat university of medical and health sciences jamshoro / hyderabad dr. khalid i. talpur department of ophthalmology liaquat university of medical and health sciences jamshoro / hyderabad references 1. elhawy e, kamthan g, dong cq, danias j. pseudoexfoliation syndrome, a systemic disorder with ocular manifestations. hum genomics. 2012; 6: 22-31. 2. schlotzer-schrehardt u, naumann go. ocular and systemic pseudoexfoliation syndrome. am j ophthalmol. 2006; 141: 921–37. 3. cobb cj, blanco gc, spaeth gl. exfoliation syndrome angle characteristics: a lack of correlation with amount of disc damage. br j ophthalmol. 2004; 88: 1002-3. azfar ahmed mirza, et al 88 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology 4. kanthan gi, mitchell p, burlutsky g, rochtchina e, wang jj. pseudoexfoliation syndrome and the longterm incidence of cataract and cataract surgery: the blue mountains eye study. am j ophthalmol. 2013; 155: 83-8. 5. idris m, jawad m, ali a, ali s, hussain j, alam m. what for we are looking in pseudoexfoliation: a clinical presentation of the patients. ophthalmology update. 2014; 12:113-6. 6. rao rq, arain tm, ahad ma. the prevalence of pseudoexfoliation syndrome in pakistan. hospital based study. bmc ophthalmol. 2006; 6: 27. 7. schumacher s, schlotzer-schrehardt u, martus p, lang w, naumann go. pseudoexfoliation syndrome and aneurysms of the abdominal aorta. lancet. 2001; 357: 359-60. 8. mitchell p, wang jj, hourihan f. the relationship between glaucoma and pseudoexfoliation syndrome: the blue mountains eye study. arch ophthalmol. 1999; 117: 1319-24. 9. miyazaki m, kubota t, kubo m, kiyohara y, iida m, nose y, ishibashi t.. the prevalence of pseudoexfoliation syndrome in a japanese population: the hisayama study. j glaucoma. 2005; 14: 482-4. 10. arvind h, raju p, paul pg, baskaran m, ramesh sv, george rj, et al. pseudoexfoliation in south india. br j ophthalmol. 2003; 87: 1321–3. 11. arnarsson am. epidemiology of exfoliation syndrome in the reykjavik eye study. acta ophthalmol. 2009; 87: 1-17. 12. shafiq i, sharif-ul-hassan k. prevalence of pseudoexfoliation (pex) syndrome in a given population. pak j ophthalmol. 2004; 20: 49-52. 13. jawad m, nadeem a, khan a, aftab m. complications of cataract surgery in patients with pseudoexfoliation syndrome. j ayub med coll abbottabad. 2009; 21: 33-6. 14. ritch r. exfoliation syndrome. focal points. 1994; 12: 112. 15. cashwell lf jr, shields mb. exfoliation syndrome: prevalence in a southeastern united states population. arch ophthalmol. 1988; 106: 335-6. 16. mitchell p, smith w, attebo k, healey pr. prevalence of open – angle glaucoma in australia: the blue mountains eye study. ophthalmology. 1996; 103: 16619. 17. vinita r, mariam d, girish r. prevalence and prognosis of pseudoexfoliation glaucoma in western india. asia – pacific j of ophthalmology, 2015; 2: 121127. http://www.ncbi.nlm.nih.gov/pubmed/?term=kiyohara%20y%5bauthor%5d&cauthor=true&cauthor_uid=16276281 http://www.ncbi.nlm.nih.gov/pubmed/?term=iida%20m%5bauthor%5d&cauthor=true&cauthor_uid=16276281 http://www.ncbi.nlm.nih.gov/pubmed/?term=nose%20y%5bauthor%5d&cauthor=true&cauthor_uid=16276281 http://www.ncbi.nlm.nih.gov/pubmed/?term=ishibashi%20t%5bauthor%5d&cauthor=true&cauthor_uid=16276281 microsoft word 12. noor bakht nazamani case report 224 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology case report idiosyncratic topiramate – induced high myopic shift with angle closure glaucoma noor bakht nizamani, khalid i. talpur pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: noor bakht nizamani, department of ophthalmology, liaquat university eye hospital jail road, hyderabad, 71000 sindh, pakistan …..……………………….. purpose: a case of idiosyncratic topiramate induced acute high myopic shift with bilateral choroidal effusion and angle closure glaucoma. material and methods: a 24 year old female presented with severe bilateral visual loss after taking a single dose of topiramate. her visual acuity was counting finger and intraocular pressure was 32 mm hg in both eyes, with conjunctival congestion, very shallow anterior chambers, forward displacement of iris – lens diaphragm and normal pupils. there was acute high myopic shift of up to – 12.00, which resolved completely and patient became 6/6 bilaterally 9 days after cessation of topiramate. conclusion: topiramate may induce acute myopia and angle closure glaucoma. cession of treatment lead to complete resolution. opiramate (tpm) is an anti-epileptic drug which has recently gained popularity after being approved by food and drug administration (fda) for the use of prevention of migraine.1 although the prophylactic role of tpm cannot be denied, the main predicament arises with its off-label use in treating migraine, leading to a number of side effects. the ocular side effects include angle closure glaucoma, myopic shift and suprachoroidal effusion.2 we report a case of tpm induced acute high myopia with bilateral choroidal effusion and angle closure glaucoma. the uniqueness of our case is that it has the highest myopic shift to be reported to date, with complete resolution in a short span of 9 days. case report a 24 year old female presented to the emergency department with severe headache and sudden painful decreased vision in both eyes (ou) for few hours. headache was continuous and was associated with nausea and vomiting while visual acuity (va) was counting finger (cf) ou. patient’s past history was significant for migraine. previously there was no history of allergy or adverse drug reaction and she was emmetrope with no ocular disease. on slit lamp examination (table i), bilaterally there was conjunctival congestion, very shallow anterior chambers, forward displacement of iris-lens diaphragm, normal pupils and fundi with intraocular pressure (iop) of 32 mm hg (ou). she was given mannitol 20% 500 ml intravenously over forty minutes and 500 mg acetazolamide orally stat but there was no effect on the iop. to further manage the iop, bilateral yag (yttrium aluminium garnet) laser peripheral iridotomies were performed and the iop reduced to 22 mm hg and 18 mm hg, in right (od) and left eye (os) respectively. patient was prescribed oral acetazolamide 250 mg, topical pilocarpine 2%, glantrim (dorzolamide and timolol maleate, atco laboratories limited, pakistan), maxidex (dexamethasone, alcon scientific service, pakistan) and followed closely as a case of atypical narrow angle glaucoma. on first two days refraction was not possible as there was error on autorefractometer (mr-3100, huitz, korea). on fourth day (table i) patient had a high myopic refractive error of -10.00 / -5.25 × 103° od and -12.25/ -5.75 × 61° os with va of cf ou. she was followed carefully to evaluate her acute myopia and atypical narrow angle glaucoma. on further enquiry she revealed that she took a single dose of topiramate 25 mg (zopir, gltiz pharma, pakistan) for her migraine, few hours before her presentation. she did not take any further dose after that. on the very t idiosyncratic topiramate – induced high myopic shift with angle closure glaucoma pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 225 fig. 1: day 9 a & b: slit lamp photographs of right and left eyes showing normal anterior segment with slight forward displacement of iris. c & d: ultrasound biomicroscopy images showing forward displacement of iris root in both eyes. figure 2: day 9 b-scan ultrasonography. a: right eye showing slight superior choroidal effusion (red asterisk) remaining. b: left eye completely resolved choroidal effusion next day her myopia reduced to -6.50/ -0.25 × 108° od and -7.50/ -0.50 × 112° os with va of 3/60 od and 2/60 os. the iop was 14 mm hg od and 12 mm hg os thereafter all anti-glaucoma medications were stopped and she was kept under observation. on the ninth day (table i) patient recovered to emmetropia with mild astigmatism of +0.00 / -0.50 × 179° od and +0.00 / +0.75 × 99° os, and va of 6/6 ou. ocular examination was normal with slight iris displacement in the right eye (figure 1a and 1b) while ultrasound biomicroscopy revealed forward displacement of iris in both eyes indicating that there was significant displacement in early stages of the event (figure 1c and 1d). b-scan ultrasonography showed minor superior choroidal effusion remaining in the right eye while left eye was normal (figure 2a and 2b). on one month follow up patient had normal visual status. she was counseled on trigger control of migraine and was doing well without any medications. discussion transient myopia can occur due to diabetes mellitus, ectopia lentis, contact lens wear and drug use. our case did not have any of the aforementioned noor bakht nizamani, et al 226 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology conditions except drug use. a number of drugs have been reported to cause transient acute myopia but most common are the sulfa group drugs including topiramate (tpm)3. in literature, most of the cases of topiramate induced myopic shift (tims) presented 8.59 ± 7.24 days after taking tpm, (4) while our case presented on first day after taking single dose of tpm. the exact mechanism of tims is not known but it has been hypothesized that the choroidal effusion leads to anterior rotation of ciliary body and forward displacement of the iris-lens diaphragm. the severity of symptoms is independent of the dose of tpm5 but over 70% patients were taking 50 mg or more.4 our patient took just 25 mg of tpm, favoring the dose independence and idiosyncratic mechanism. topiramate induced myopic shift of up to 5.66 ± 1.57 has been reported in literature4. the highest myopic shift reported so far is -10.00 in a 34 year old male with topiramate induced angle closure glaucoma6. to our knowledge we are the first to report the tpm induced myopic shift of -12.00. the management typically involves discontinuing tpm nevertheless until a definite diagnosis is reached the iop may be controlled with conventional therapy. our patient had reversal to emmetropia and normal angle status within 9 days of stopping topiramate. conclusion this case highlights the significance of idiosyncratic ocular side effects of topiramate. cession of treatment leads to complete resolution of ocular side effects with retrieval of normal visual status. author’s affiliation dr. noor bakht nizamani department of ophthalmology, liaquat university of medical and health sciences, jamshoro / hyderabad, pakistan prof. khalid i. talpur department of ophthalmology, liaquat university of medical and health sciences, jamshoro / hyderabad, pakistan references 1. ramadan nm, buchanan tm. new and future migraine therapy. pharmacol ther. 2006; 112: 199–212. 2. fraunfelder fw, fraunfelder ft, keates eu. acute topiramate associated bilateral, secondary angle – closure glaucoma. ophthalmology. 2004, 111: 109-11. 3. chen tc, chao cw, sorkin ja. topiramate induced myopic shift and angle closure glaucoma. br j ophthalmol. 2003; 87: 648-9. 4. abtahi ma, abtahi sh, fazel f, et al. topiramate and vision: a systematic review. clin ophthalmol. 2012: 6 117–31. 5. natesh s, rajashekhara sk, rao as, et al. topiramateinduced angle closure with acute myopia, macular striae. oman j ophthalmol. 2010; 3: 26–8. 6. spaccapelo l, leschiutta s, aurea c, et al. topiramateassociated acute glaucoma in a migraine patient receiving concomitant citalopram therapy: a case – report. cases j. 2009; 2: 87. microsoft word 16-news and events vol 29;issue 1; 2013 pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 60 news and events vol. 29, 1, 2013 xi biennial congress of saarc academy of ophthalmology and 16th islamabad conference of osp federal branch date: 03-06 october, 2013 venue: pc bhurban contact: mr. muhammad mohsin phone: +92-323-5542666 email: ospfederaleye@gmail.com web: http://saarccongress2013.com american society of cataract and refractive surgery (ascrs) / american society of ophthalmic administrators (asoa) symposium and congress date: 19 23 april, 2013 venue: san francisco web: www.ascrs.org the association for research in vision and ophthalmology (arvo) annual meeting 2013 seattle washington, united states date: 5-9 may, 2013 venue: seattle, washington web: www.arvo.org 26th asia-pacific association of cataract & refractive surgeon annual meeting 2013 (apacrs 2013) date: 11-14 july, 2013 venue: suntec singapore international convention centre, singapore web: www.apacrs.org 34th world ophthalmology congress (woc) & the 29th asia-pacific academy of ophthalmology (apao) congress date: 2 6 april, 2014 venue: tokyo, japan web: www.apaophth.org 11th european glaucoma society conference date: 7-11 june 2014 venue: nice, france web: www.eugs.org xxi biennial meeting of international society for eye research date: 20-24 jul, 2014 venue: san francisco, california web: www.iser.org institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091 – 9217376 – 80 fax: 92 – 42 – 36363326 email: pico@pes.comsats.net.pk college of ophthalmology and allied vision sciences lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042 – 37355998 fax: 042 – 37248006 email: pipo@brain.net.pk news and events 61 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology pakistan institute of ophthalmology, al – shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al – shifa trust eye hospital, jhelum road, rawalpindi – pakistan phone: 92 – 51 – 5487830, 5487820 – 25 fax: 92 – 51 – 5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt 4-a lda flats lawrence road, lahore phone: 92 – 42 – 36363326 email: pjoosp@gmail.com 147 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology original article control of raised intraocular pressure after intravitreal triamcinolone acetonide p. s. mahar, a. sami memon pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p. s. mahar isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi cell: 03008284837 …..……………………….. purpose: to determine the various treatment options including anti-glaucoma medication, laser and surgery to control the intraocular pressure (iop) rise after intravitreal triamcinolone acetonide (ivta). material and methods: this prospective, interventional case series was carried out at isra postgraduate institute of ophthalmology, karachi from may 2007 to april 2009. patients with various choroidal and retinal vascular disorders, who were given ivta in a dose of 4 mg / 0.1 ml and developed raised iop ( > 21 mm hg) were included in the study and followed up for one year. results: two hundred thirty seven eyes of 180 patients received ivta during the study period. the mean age of patients was 50.86 ± 10.62 years with gender distribution of 99 male and 81 female. one hundred seventeen (49.36%) out of 237 eyes showed raised iop after ivta. fifty two (21.94%) eyes showed an iop between 25-30 mmhg while 65 (27.42%) had iop of > 30 mm hg. successful control of iop was defined as an iop of less than 21 mm hg. thirty-four (29.05%) eyes were controlled with single beta-blocker therapy (timolol maleate 0.5%) and 69 (58.97%) eyes were brought into control with combination therapy (timolol maleate 0.5% + dorzolamide 2%). additional 4 (3.41%) eyes required prostaglandin analogue (latanoprost 0.005%) along with combination therapy for iop control. another 4 (3.41%) eyes were controlled with argon laser trabeculoplasty and full medical treatment and remaining 6 (5.12%) eyes settled down with trabeculectomy with adjunctive mitomycin-c. conclusion: although ivta is a cost-effective therapeutic agent against various choroidal and retinal disorders, 50% of the patients developed raised iop > 21 mm hg. half of these patients required multiple drugs and almost 5% needed surgical intervention to control iop under 21 mm hg. key words: triamcinolone acetonide, intraocular pressure, glaucoma. riamcinolone acetonide is a major therapeutic agent given intravitrealy in various retinal and choroidal vascular disorders.1-7 the raised intraocular pressure (iop) is a major concern of this procedure. the reported incidence of increase in iop varies from 27-50% in various studies published in literature.8-12 intravitreal triamcinolone acetonide (ivta) causes secondary open angle type of glaucoma. the exact mechanism of rise in iop is not known but it can be caused by cortisone crystals blocking the trabecular meshwork or steroid related decreased phagocytosis of extracellular matrix in meshwork by macrophages. corticosteroids are believed to decrease aqueous outflow by inhibiting degradation of extracellular matrix material in trabecular meshwork, leading to an excessive amount of debris within the outflow channels with subsequent increase in outflow resistance.13,14 steroid induced glaucoma after ivta is usually of transient nature but can run a chronic course in certain patients. patients having iop of more than 16 mm hg, with family history of glaucoma or having diabetes mellitus are at increased risk of developing full – fledged disease15, 16. an increase in iop after ivta may take up to six t control of raised intraocular pressure after intravitreal triamcinolone acetonide pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 148 months to present12. the rise in iop can be variable after ivta, ranging from 22 mm hg to more than 40 mmhg, failing to control with medical therapy and eventually requiring drainage surgery. we undertook this study to determine the various treatment options and their effectiveness in controlling iop in cohort of patients who received ivta because of their choroidal and retinal vascular problems and developed raised iop > 25 mm hg. material and methods this was a prospective interventional case series conducted at isra postgraduate institute of ophthalmology/al-ibrahim eye hospital, karachi. permission to conduct the research was taken by the ethics committee of the hospital. the study design and details of the procedures are described elsewhere12. briefly, 237 eyes of 180 patients received ivta (4 mg / 0.1 ml) from may 2007 to april 2009 with various choroidal and retinal vascular disorders (table 1). patients having iop of > 20mm hg and already receiving anti-glaucoma medication were excluded from the study. after informed consent, a detailed ocular examination was carried out, including best corrected visual acuity, anterior segment biomicroscopy, iop measurement, gonioscopy and fundus examination using +90 ds lens. all intravitreal injections were given under sterile conditions in operating theatre with patients receiving ciprofloxacin 0.3% drops (ciloxin – alcon, belgium) one day prior to injection and continuing for 3 days afterwards. all patients were followed at day 1, 1 week, 1 month, 3 months and 6 months subsequently with mean follow up of one year. at each follow up visit, patients had charting of vision, iop measurement and fundus examination. a major aim of this study was to determine the proportion of eyes that had uncontrolled iop (> 21 mm hg) after the injection and the type and effectiveness of the iop – lowering treatment they received. the rise in iop was noticed at 1 week of post injection period but peaked to highest level at 3 months and continued to show an increase up to 6 months. statistical analysis for data analysis, spss (statistical package for social sciences) version 17.0 was used. the frequency and percentages were computed for categorical variables including gender and diagnosis. for continuous variable iop, data was shown in mean ± standard deviation. results two hundred thirty seven eyes of 180 patients received ivta during the study period. the mean age of patients was 50.86 ± 10.62 years with gender distribution of 99 male and 81 female. out of 237 eyes, 117 (49.36%) eyes showed an increase in iop > 21 mmhg (fig. 1). the iop increased from 13.76 ± 2.79 mmhg to a mean of 15.73 ± 4.5 mm hg post injection after 1 week. at 1 month, iop was increased to 17.3 ± 6.8 mm hg. after 3 months, iop increased to 19.08 ± 8.6 mm hg and after 6 months iop was 14.38 ± 4.9 mm hg (p < 0.0001). fifty two (21.94%) eyes showed an iop of 21-30 mm hg. all these eyes were commenced on timolol maleate 0.5% (betalol – sante, pak), one drop twice a day. thirty four (14.34%) eyes had controlled iop < 21 mm hg, while 18 (7.59%) eyes still had uncontrolled eye pressure. sixty five (27.42%) eyes out of 117 eyes had an initial iop measured > 30 mm hg. these eyes along with 18 eyes not controlled on single beta blocker therapy (65 + 18 = 83 eyes) were initiated on combination therapy of timolol maleate 0.5% + dorzolamide 2% (co-dorzal – sante, pak). out of total 85 eyes, 69 (29.11%) eyes responded well on combination therapy bringing iop < 21 mm hg while 14 eyes (5.90%) still had an elevated iop of > 25 mm hg. four (1.68%) eyes had a further drop in iop < 21 mm hg with addition of latanoprost 0.005% (vislat – sante, pak). out of remaining 10 (4.21%) eyes, argon p. s. mahar, et al 149 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology laser trabeculoplasty (alt) was performed, controlling iop in further 4 (1.68%) eyes. the remaining 6 (2.53%) eyes with uncontrolled iop of > 25 mm hg with combination therapy, prostaglandin analogue and alt were subjected to trabeculectomy with adjunctive use of mitomycin-c. all these eyes remained within range of normal iop between 10-20 mmhg at mean follow up of one year (table 2). 28 21 29 39 0 5 10 15 20 25 30 35 40 45 1st week 1st month 3rd month 6th month fig. 1: raised iop in total number of eyes following intravitreal triamcinolone acetonide. total eyes 237, raised iop in 117 (49%) eyes. in essence, out of 117 eyes showing raised iop after ivta, 34 (29.05%) eyes were controlled with single beta-blocker therapy, 69 (58.97%) eyes were brought into control with combination therapy. additional 4 (3.41%) eyes required prostaglandin analogue along with combination therapy for iop control. another 4 (3.41%) eyes were controlled with alt and full medical treatment and remaining 6 (5.12%) eyes settled down with drainage surgery. discussion intravitreal triamcinolone acetonide (ivta) can be a therapeutically option for the treatment of various intraocular pathologies including neovascular, oedematous and proliferative disease involving choroid and retina. it can also be used as an angiostatic agent in eyes with iris neovascularization, proliferative diabetic retinopathy and wet age related macular degeneration. an increase in iop is a common side effect with the use of ivta. the rise in iop can occur from one week to 6 months post injection. the amount of iop increase can range from 22-40 mm hg. (the raise in iop can be between 22 and 40 mm hg) there are certain number of patients who cannot be controlled on medical therapy and go on to have drainage surgery. an iop elevation after ivta was reported in 40% of 305 eyes by jonas and coworkers17. thirty nine percent of these eyes were controlled below 21 mm hg on topical anti-glaucoma medication and systemic carbonic anhydrase inhibitors with 1% (03) eyes required drainage surgery. kocaboraet al8 reported 40 (27%) eyes out of 147 eyes, showing an increase in iop of > 25 mm hg after ivta. thirty – three (22.44%) eyes were controlled below 21 mm hg on combination treatment of timolol maleate and dorzolamide drops, while 7 (4.7%) eyes required drainage surgery. park10 and colleagues reported 26, out of 60 (43.3%) eyes having elevated iop after 4mg of ivta. intraocular pressure was not controlled despite full anti-glaucoma medication in 7 (11.7%) eyes. these eyes underwent filtering surgery. in another study bashshur18 reported 59 (26.1%) of 226 eyes having iop higher than 21 mm hg after ivta in 4mg dosage. fifteen eyes (6.63%) had iop of > 25 mm hg treated with combination therapy of dorzolamide and timolol maleate, while 3 (1.32%) n u m b e r o f r a is e d i o p control of raised intraocular pressure after intravitreal triamcinolone acetonide pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 150 eyes required surgery. compared to these studies, in our cohort of patients receiving ivta, 117 out of 237 eyes showed raised iop of > 21 mm hg. out of these, 34 (29.05%) eyes were controlled with single beta-blocker, 69 (58.97%) eyes were brought in to control with combination therapy, while 4 (3.41%) eyes required prostaglandin analogue along with combination therapy for iop control. another 4 (3.41%) eyes were controlled with additional alt and remaining 6 (5.12%) eyes settled down with drainage surgery. severe and intractable iop elevation can occur even with full medical treatment after ivta, with certain patients necessitating trabeculectomy. this, therefore requires careful indication of ivta and long follow up. conclusion the benefit of intravitreal triamcinolone acetonide therapy should be weighed against the risk of increased iop, as 50% of our patient receiving ivta developed raised iop > 21 mm hg. half of these patients required multiple drugs and almost 5% needed drainage surgery to control iop. author’s affiliation prof. p. s. mahar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, karachi dr. a. sami memon isra postgraduate institute of ophthalmology al-ibrahim eye hospital, karachi references 1. karacorlu m, ozdemir h, karacorlu s, alacali n, mudun b, burumceke. intravitreal triamcinolone as a primary therapy in diabetic macular oedema. eye 2004; 19: 382-6. 2. hayashi k, hayashi h. intravitreal versus retrobulbar injections of triamcinolone for macular edema associated with branch retina vein occlusion. am j ophthalmol. 2005; 139: 97282. 3. williamson th, o’donnela. intravitreal triamcinolone acetonide for cystoid macular edema in nonischemic central retinal vein occlusion. am j ophthalmol. 2005; 139: 860-6. 4. park ch, jaffe gj, fekrat s. intravitreal triamcinolone acetonide in eyes with cystoid macular edema associated with central vein occlusion. am j ophthalmol. 2003; 136: 419-25. 5. martidis a, duker js, greenberg pb, rogers ah, puliafito ca, reichel e, baumalc. intravitreal triamcinolone for refractory diabetic macular edema. ophthalmology. 2002; 109: 920-927. 6. jonas jb, kreissig i, hugger p, sauder g, panad-jonas s, degenring r. intravitreal triamcinolone for exudative age related macular degeneration. br j ophthalmol. 2003; 87: 462-8. 7. rechtman e, danis rp, pratt lm, harris a. intravitreal triamcinolone with photodynamic therapy for subfovealchoroidal neovascularization in age related macular degeneration. br j ophthalmol. 2004; 88: 344-7. 8. kocabora ms, yilmazli c, taskapili m, gulkilik g, durmaz s. development of ocular hypertension and persistent glaucoma after intravitreal injection of triamcinolone. cl ophthalmol 2008; 2: 167-71. 9. jonas jb, degenring rf, kreissig i, akkoyun i, kamppler ba. intraocular pressure elevation after intravitreal triamcinolone acetonide injection. ophthalmology. 2005; 112: 593-98. 10. park hy, yi k, kim hk. intraocular pressure elevation after intravitreal triamcinolone acetonide injection. korean j ophthalmol. 2005; 19: 122-7. 11. jonas jb, kreissig i, degenring r. intraocular pressure after intravitreal injection of triamcinolone acetonide. br j ophthalmol. 2003; 87: 24-7. 12. mahar ps, memon as. frequency and management of raised intraocular pressure following intravitreal triamcinolone acetonide. jcpsp 2012; 22 (11): 699-702. 13. renfro l, snow js. ocular effects of topical and systemic steroids. dermatolcli. 1992; 10: 505-10. 14. wordinger rj, clark af. effect of glucocorticoids on the trabecular meshwork: towards a better understanding of glaucoma. prog retina eye res. 1999; 18: 629-67. 15. rhee dj, peck re, belmont j, martidis a, liu m, chang j et al. iop alterations following intrvitreal triamcinolone acetonide. br j ophthalmol. 2006; 90: 999-1003. 16. chang yc, wu w. elevation of iop after intravitreal injection of triamcinolone acetonide in taiwanese patients. kaohsiung j med sci. 2008; 24: 27-7. 17. jonas jb, degenring rf, kreissig i, akkoyum i, kamppeter ba. intraocular pressure elevation after intravitreal triamcinolone acetonide injection. ophthalmology. 2005; 112: 593-8. 18. bashshur zf, terro am, el-haibi cp, halawi am, schakal a, noureddin bn. intravitreal triamcinolone acetonide: pattern of secondary iop rise and possible risk factors. clin ophthalmol. 2008; 2: 269-74. microsoft word 4. kashif jahangir pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 127 original article retinal redetachment after silicone oil removal kashif jahangir pak j ophthalmol 2012, vol. 28 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: kashif jahangir d-149, dha eme sector multan road lahore …..……………………….. purpose: this study was conducted on 50 patients who underwent pars plana vitrectomy with silicone oil tamponade (1000 cs) for retinal detachment. the objective of this study was to analyze and evaluate in terms of retinal redetachment, surgical technique, visual acuity, and intraocular pressure after silicone oil removal. material and methods: a total of 50 patients who underwent 3-port parsplana vitrectomy with silicone oil was used as an internal tamponade were enrolled in this study. the study was conducted from march 2005 to april 2006, with a follow up period of six months after silicone oil removal. silicone oil of 1000 centistokes viscosity had been used in these patients. forty seven patients completed their six-month follow up. all the patients were selected by a convenience type of non-probability purposive sampling. results: out of a total of 47 eyes, 14 (29.8%) developed retinal re-detachment, which was within the first 3 months of silicone oil removal. the iop of the patients decreased significantly with a mean decrease of 4mmhg after silicone oil removal. out of 33 patients with attached retina after silicone oil removal 12 had improvement in snellen visual acuity of two lines or more where as 21 had no improvement in their vision. we observed that the duration of silicone oil as an endotemponade had no significant affect on the rate of retinal redetachment after its removal. conclusion: retinal redetachment is a common finding after silicone oil removal, which, in our study more than half of re-detachment occurred in the first month of oil removal. a mean of 4mmhg drop in the intraocular pressure was observed in our study after silicone oil removal. the visual acuity improved in only 12 (36%) patients after silicone oil removal with attached retina. aul cibis first described silicone oil use for the treatment of otherwise inoperable retinal detachment1. ever since, the silicone oil has been used as an internal temponade after the removal of stiff retinal folds during pars plana vitrectomy. retinal detachment is a separation of the sensory retina from the retinal pigment epithelium by sub retinal fluid, which may be either rhegmatogenous or nonrhegmatogenous2. machemer and colleagues developed the technique of pars plana vitrectomy (ppv) for the treatment of complicated retinal detachment and proliferative vitreoretinopathy3. ppv has been used successfully for the management of posterior segment disease like rhegmatogenous retinal detachment with proliferative vitreoretinopathy (pvr)4, proliferative diabetic retinopathy with vitreous hemorrhage or tractional retinal detachment, removal of intraocular foreign bodies, eales disease, release of vitreoretinal tractions by epiretinal membranes and removal of dislocated lens from the vitreous cavity. p kashif jahangir 128 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology intravitreal silicone oil use as an internal tamponade can lead to complications such as cataract, glaucoma5, and band keratopathy and oil emulsification6. these complications are partly related to the duration of intraocular tissue exposure to silicone oil. these complications may or may not be reversible once the oil has been removed from the eye. therefore it has been recommended that the oil should be removed as soon as a stable retinal situation ha been achieved i.e. a period of 3-6 months7. silicone oil removal is a procedure that carries a definite risk of retinal redetachment. recurrence of retinal detachment has been reported to occur in 20-40%8-10 cases due to reproliferation of epiretinal membranes and increasing traction on the retina. retinal redetachment is independent of duration of silicone oil in an eye and similarly the technique used for its removal. objectives we conducted this study to assess the time interval of recurrent retinal detachment after removal of silicone oil. our secondary objectives were to assess the association between the length of oil retention and incidence of recurrent retinal detachment after oil removal, the change of iop after removal of oil and to record the visual acuity after removal of silicone oil in eyes with attached retina. material and methods the study was conducted at the department of ophthalmology, fatima jinnah medical college / sir ganga ram hospital, lahore. the study was conducted from march 2005 to march 2006, with a follow up of six months. the study included fifty eyes of 50 patients of both genders in which pars plana vitrectomy with silicone oil (1000 cs) as an endotamponade was used. the patients were examined with indirect ophthalmoscope and retina was thoroughly scanned, with and without scleral indentation to locate for any fresh retinal breaks and residual tractions. in phakic and pseudophakic patients with silicone oil in the vitreous cavity a standard two port system was established after sclerotomies 3.5mm away from the limbus; one at the inferotemporal quadrant for infusion cannula and the other at the superonasal quadrant for oil removal cannula. fluid was irrigated continuously through the infusion port for at least fifteen minute with removal of silicone oil from the other port and after proper evaluation of the retinal status and the absence of any residual oil in the vitreouscavity the ports were sutured with a 6/0 vicryl. in aphakic patients a posterior capsulotomy was performed and in patients with inverse hypopyon the silicone oil was removed through a limbal incision, with fluid irrigation through an infusion cannula at the inferotemoral quadrant. each patient was examined on the first postoperative day, at one week, one month, 3 months and 6 months. on each visit the patient was examined for visual acuity, slit lamp examination, iop and anatomical attachment of the retina. anatomical success was defined as a completely flat retina that remained attached till the last follow-up. retinal redetachment due to ongoing proliferative vitreoretinopathy (pvr) or intrinsic contraction of retina within six months of removal of silicone oil was considered a failure. results fifty patients were initially enrolled in this study. three patients did not complete their follow up and thus had to be excluded from the study. forty-seven patients completed their 6 months follow up. the mean duration of intraocular silicone oil tamponade ranged from 3 months to 48 months. the ages of patients ranged from 21 to 80 years. mean age was 46.85 (±13.6sd). out of 47, 32 (68%) were male patients and 15 (32%) female patients. of the 47 patients who underwent 3 port parsplana vitrectomy with silicone oil as an internal temponade, 20 eyes had pvr, 4 eyes had giant retinal tear, 17 eyes had advanced diabetic eye disease, 2 had eye trauma and 4 eyes had eale’s disease. out of the total 47 patients, 16 (34%) underwent pars plana vitrectomy with silicone oil as an initial attachment surgical procedure, in which 6 patients developed recurrent detachment and 10 patients had attached retina, after silicone oil removal. 19 (40.4%) patients had combined scleral buckling, pars plana vitrectomy with silicone oil, in which 5 patients had recurrent detachment and 14 patients had attached retina after oil removal. in the remaining, 11 patients (23.4%) out of 47, with advanced diabetic retinopathy, had barrier argon laser therapy after pars plana vitrectomy with silicone oil, out of which 3 patients had redetachment, and the retina remained attached in the remaining 8 patients in the six months follow up. retinal redetachment after silicone oil removal pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 129 this result showed that the different initial surgical procedure used for attachment surgery did not have statistically significant results in terms of preferential procedure in prevention of retinal redetachment, after silicone oil removal. (p≥0.05) (table i). fisher exact test was used to analyse the stastical results. out of a total of 47 patients, the silicone oil was removed through pars plana in 33 patients, out of which 11 (33.3%) eyes had recurrent detachment after oil removal and in 22(66.6%) eyes the retina remained attached. the remaining 14 patients had silicone oil removed through pars plana and limbus amongst which 3(21%) had redetachment where as in 11(79%) the retina remained attached after silicone oil removal. the results were found statistically insignificant in relevance to the technique used for removal of silicone oil.(p≥0.05) (table 2). 14 eyes (30%) developed recurrent rd whereas in 33 eyes (70%), the retina remained attached in the 6 months follow up period after silicone oil removal. (table 3). the duration of recurrent detachment after removal of silicone oil was found to be within the first 3 months of follow up period in our study. four patients (28.5%) had redetachment on the first day, 7 patients (50%) at one month and 3 patients (21.5%) at three months follow up (table 4). out of47, 28 patients had intraocular silicone oil temponade for less than nine months period, in which 9 (32%)had recurrent detachment after oil removal where as in the 19 patients with oil temponade more than 9 months 5(35%) had recurrent detachment after silicone oil removal. the intraocular pressure of the patients decreased significantly after removal of silicone oil with a mean preoperative iop of +18.36mmhg (± 3.74sd) and post operative mean of +14.21 mmhg (±4.61 sd). this was statistically significant. (p≤ 0.05) (table 5). the visual acuity was measured with a snellen chart, which was found dependent on the preoperakashif jahangir 130 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology tive visual status. out of 33 patients with attached retina after oil removal, 15 patients who had a visual acuity of 6/60 or better before silicone oil removal,7 (47%) patients had an improvement of vision of two lines or more after oil removal, where as in the remaining 8 (53%) the visual acuity remained the same. in 18 patients with vision worse than 6/60 before oil removal, only 5 patients (28%) had post operative improvement in their final corrected visual acuity whereas 13 patients (72%) had no improvement in vision. (table 6). discussion combined with vitreoretinal surgery with silicone oil injection is a standard technique and improves the prognosis of complex retinal detachment associated with proliferative vitreoretinopathy, giant retinal tears, proliferative diabetic retinopathy, or ocular trauma. unfortunately silicone oil is not without significant ocular complications including cataract, glaucoma, peri-silicone epiretinal membrane proliferation, emulsification, and keratopathy. silicone oil removal is a procedure that carries a definite risk of retinal redetachment, due to reproliferation of epiretinal membranes and increasing traction on the retina, especially in the presence of peripheral recurrent detachment before oil removal, requiring further surgery involving complex rebuckling procedures, repeated membrane dissection, and retinectomies. since the retinal re-detachment rate does not appear to be influenced by the duration of intraocular oil, it seems reasonable to remove the oil as early as possible to avoid the initiation or worsening of oil associated complications. we prefer to have the oil removed in all patients after three months. in this study we observed that the duration of silicone oil as an endotemponade had no significant affect on the rate of retinal redetachment. the intraocular oil time interval ranged from three months to even 48 months in this study. the result showed that in the patients with intraocular silicone oil for a period more than one year had the same outcome as in patients with as early removal as three months in terms of retinal attachment. p ≥ 0.05. in the light of the following results we came to a conclusion that the longer time duration of silicone oil within the eye had no extra benefit, rather has the demerit of having more chance of silicone oil induced complications. similar results were achieved by falkner and colleagues conducted a study to evaluate the outcome of silicone oil removal7. the silicone study report conducted by hutton and colleagues in 1994 also gave the results that there was no association between the length of oil retention and incidence of recurrent retinal detachment after oil removal10. heij and ellenin their study concluded that despite the acceptable risk of recurrent retinal detachment, the early removal of silicone oil may yield a lower rate of anterior segment complications and an increase in visual acuity in approximately half the eyes6. the present study was conducted to assess the time interval of retinal redetachment after silicone oil removal, which was not more than three months. this led us to a conclusion that any retina, which has a tendency to re-detach will do so in the early post operative period of oil removal. hence it is necessary to have a careful follow up of all the patients undergoing such surgery especially in the first three post operative months. unluet al found that retina redetached in the first 10 days in 81.3% of patients after silicone oil removal. the residual vitreoretinal traction especially at the vitreous base is the most likely reason for retinal redetachment after silicone oil removal, which is most commonly seen during the first 10 days11. patients had a significant drop in iop after removal of silicone oil with a mean range of drop of retinal redetachment after silicone oil removal pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 131 4.13 mmhg. two of the eyes even went into hypotony with one patient having a post-operative choroidal detachment, in which we had to refill the eye with silicone oil. suic12 in his study revealed that elevation of intraocular pressure following vitrectomy with silicone oil tamponade had a temporary effect, as it did not lead to permanent intraocular pressure elevation but regressed after silicone oil removal from the eye. the visual acuity of patients with attached retina after silicone oil removal in this study had the final outcome in relevance to their preoperative visual status. there was no significant change in visual improvement noted in patients who had a visual acuity of counting finger or less before the removal of silicone oil. some patients with 6/60 or better vision had an increase in their best-corrected va after the removal of silicone oil. the eleventh silicone study report published in 1997 stated that compared with oil-retained eyes, oilremoved eyes had a visual acuity of 5/200 or better (p<.001)13. in conclusion recurrent retinal detachment is the most important complication that may occur after silicone oil removal with a 30% rate in this study. the duration of intraocular siliconeoil tamponade had no significant effect on the rate of postoperative retinal redetachment (p≥0.05).it was observed that the rate of retinal redetachment after silicone oil removal was independent of the technique of silicone oil removal (p≥0.05).there is a fall in iop after removal of silicone oil (p≤0.05). improvement in vision was dependent on the preoperative visual status of the patient. author’s affiliation dr. kashif jahangir senior registrar department of ophthalmology fatima jinnah medical college/ sir ganga ram hospital, lahore reference 1. steel dhw, weir p, james crh. silicone assisted, argon laser confinement of recurrent proliferative vitreoretinopathy related retinal detachment: a technique to allow silicone oil removal in problem eyes. br j ophthalmol. 1997; 81: 765-70. 2. sharma a, grigoropoulos v, williamson th. management of primary rhegmatogenous retinal detachment with inferior breaks. br j ophthalmol. 2004; 88: 1372-5. 3. lean js. proliferative vitreoretinopathy. in: albert dm, jakobiec fa. principles and practice of ophthalmology. philadelphia: wb saunders co. 1994: 1147-55. 4. soheilian m, mazareei m, pour m, et al. comparison of silicon oil removal with various viscosities after complex retinal detachment surgery: bmc ophthalmol. 2006; 6: 21. 5. wahab s, mahmood n. removal of silicone oil from the anterior chamber: new technique. pak j ophthalmol. 2007; 23: 4. 6. heij l, ellen c, fred mdh, et al. results and complications of temporary silicone oil tamponade in patients with complicated retinal detachments. retina. 2001; 21: 107-14. 7. falkner ci, binder s, kruge a. outcome after silicone oil removal. br j ophthalmol. 2001; 85: 1324-7. 8. jiang f, krause m, ruprecht kw, et al. risk factors for anatomical success and visual outcome in patients undergoing silicone oil removal. eur j ophthalmol. 2002; 12: 293–8. 9. jonas jb, knorr hl, rank rm, et al. retinal redetachment after removal of intraocular silicone oil tamponade. br j ophthalmol. 2001; 85: 1203-7. 10. hutton wl, azen sp, blumenkranz ms, et al. the effects of silicone oil removal. silicone study report 6. arch ophthalmol. 1994; 112: 778–85. 11. ünlü n, kocaolan h, acar ma, et al. outcome of complex retinal detachment surgery after silicone oil removal. inter ophthalmol. 2004; 25: 33-6. 12. suic ps, sikic j, pokupec r. intraocular pressure values following vitrectomy with silicone oil tamponade. acta med croatica. 2005; 59: 143-6. 13. abrams gw, azen sp, mccuen bw, et al. vitrectomy with silicone oil or long-acting gas in eyes with severe proliferative vitreoretinopathy: results of additional and long-term followup. silicone study report 11. arch ophthalmol. 1997; 115: 33544. pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 42 original article comparison of measurement of intraocular pressure between goldmann applanation tonometer and non-contact air puff tonometer attaullah shah bukhari, abdul haleem mirani, muhammad ali shar, shahid jamal siddiqui liaquat ali shah pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. attaullah shah bukhari flat no: b2 doctor residence civil hospital, khairpur email: drattaullahbukhari@yahoo.com purpose: to compare measurement of intraocular pressure between goldmann applanation tonometer and non-contact air puff tonometer. study design: clinical observational study. place and duration of study: this study was carried out at outpatient department of ophthalmology, khairpur medical college hospital, khairpur from january 2017 to march 2017. material and methods: in this study intra ocular pressures of 400 eyes of 200 patients, male 125 (250 eyes) and female 75 (150 eyes) with age ranging from 20 to 70 years, were measured by goldmann applanation tonometer (gat) and non-contact air puff tonometer (apt), results and differences were noted. results: the mean iop was 16 mm hg (sd = 6 mm hg) measured by apt and 13 mm hg (sd = 3 mm hg) measured by gat. the calculated difference between apt and gat was 3 ± 2.5 mm hg. pressure taken by apt was slight high (i.e. around 3 mm hg). conclusion: air puff tonometry gives slightly higher results (about 3 mm attaullah shah bukhari, et al 43 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology …..……………………….. hg) but is safe and easy than goldmann applanation tonometer. there is no fear of spread of infection and can be used easily in mass screening programs. key words: goldmann applanation tonometer, air-puff non-contact tonometer, intraocular pressure, glaucoma. ncrease in intraocular pressure is one of the risk factors in the development and progression of glaucoma1-2. control and reduction in iop is the main goal in treatment of glaucoma3. there are various methods to measure iop like schoitz tonometer, goldmann applanation tonometer (gat), perkins applanation tonometer, air puff non-contact tonometer, tonopen, pascal dynamic contour tonometer, i care tonometer. gat is worldwide used for measurement of iop and is gold standard.4 gat has many factors to affect its accuracy like thickness of central cornea5, however normal central corneal thickness (cct) has been documented from 427µm to 670 µm6, if we consider 520 µm as standard7. if central corneal thickness is more than 520 µm, it overestimates iop and if it is thinner than 520 µm, it underestimates8-9. various corrective factors have been proposed ranging from 0.19 to 0.7 mm for each 10 µm difference in central corneal thickness from mean value8-10. this relationship between cct and iop has clinical implications especially in the diagnosis of ocular hypertension (oht). researchers have documented thicker cct in oht subjects and suggested that some are misclassified due to thicker cornea producing an artificially raised iop11,12,13. conversely, subjects with thicker corneas have been shown to have a lower rate of progression to glaucomatous damage14. gat has double prism and 3.06 mm area of cornea is applanated using imbert fick principle. it is done under local anesthesia and also requires slit lamp.15apt is based on principle of applanation, but instead of using prism, the central part of the cornea is flattened by a jet of air. the time acquired to sufficiently flatten the cornea relates directly to the level of iop. in apt, there is no need of local anesthesia and no contact with cornea, so it prevents spread of infection. it may be portable and nonportable16. this study was conducted to find out the accuracy of apt to the gold standard gat. material and methods a comparative randomized study conducted in the ophthalmology department of khairpur medical college hospital. there were 400 eyes of 200 patients (125 males and 75 females) with age ranging from 20 to 70 years. adult co-operative patients visiting the outpatient department were included. uncooperative patients and patients with severe vision loss, who were unable to keep fixation of eye ball and patients with history of refractive surgery were excluded from the study. iop using apt was taken using tonometer nct10 shin-nippon (made in japan) and later iop was measured using gat with cso model: a 900 tonometer (made: in italy). proparacaine eye drops were put in eyes for anesthesia and fluorescein strips were used for staining of cornea. results the study included 400 eyes of 200 patients i.e. males 125 (250 eyes) and females 75 (150 eyes), with mean age of 54.12 ± 13.56 years (range 20 – 70 years (table 1). in 40 (10%) eyes, iop taken by apt was equal to gat. in 20 eyes (5%), iop with apt was below gat and in 340 (85%) eyes iop was higher than gat. the mean iop measured by apt was 16 ± 6 mm hg and mean iop measured by gat was 13 ± 3 mm hg. the calculated difference between apt and gat was 3 ± 2.5 mm hg (table 2). table 1: characteristics of study population (n = 400). age in years range 20 – 70 years (mean 54.12 ± 13.56 years) male 125 (250 eyes) female 75 (150 eyes) table 2: iop values measured by gat as related to iop measured by apt. i comparison of measurement of intraocular pressure between goldmann applanation tonometer pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 44 iop measurement by air puff tonometer patients % equal to gat measurement 40 (10%) higher than gat measurement 340 (85%) lower than gat measurement 20 (5%) discussion air puff tonometer and goldman applanation tonometer are common devices to measure iop. pressure recorded by ap tonometer is slightly higher. many studies have compared iop between gat and apt17-18. friat et al17 study revealed that gat results are slight lower than non-contact tonometer. martinezde-la-casa et al19 concluded that results of ap tonometer were higher than gat. tonnuet al20 showed that difference in iop between two methods was 0.7 mm hg. rao21 states that when iop was < 20 mm hg, it was more accurate with apt. lagerlof21 revealed that iop > 20 and 30 mm hg measured by apt is unreliable. a study was conducted by bang et al, comparing intraocular pressures, measured by three different non-contact tonometers and goldmann applanation tonometer, for non-glaucomatous subjects. they stated that there was statistically significant correlation between three non-contact tonometers and goldmann applanation tonometer. they said that iop measured with nidek nt-530p was lower than gat while iop taken by topcan ct-ip and canon t x 20p was higher than goldmann applanation tonometer22. study conducted by javed ahmed et al revealed that goldmann applanation tonometer was more accurate but air puff tonometer was good and easy for screening purposes23. study conducted by josphine wachtl et al proved that iop taken by gat in thin corneas and advanced glaucoma gave unpredictable measurement errors24. study conducted by sana naeem et al, showed that measurement of intraocular pressure by three different tonometers was comparable with good relation in normal adults. apt can be used as a good screening device to rule out glaucoma in patients25. study conducted by dibaji et al stated that non-contact air puff tonometer was quick for screening purposes but measurement should be confirmed by goldmann applanation tonometer26. study conducted by toprak et al showed that iop values obtained by nct 1 (non-contact tonometer with 1-puff) and nct 3 (3puffs) appeared to be similar with gat measurement. wide range of loa might limit the use of this nct (both 1-puff and 3puffs) and gat interchangeably in primary open angle glaucoma patients27. sood a and his colleague studied the clinical estimation of intraocular pressure with a non-contact tonometer and goldman applanation tonometer as a tool for mass screening and its correlation with central corneal thickness. both the methods of iop measurement showed positive corelation with central corneal thickness. the nct was more influenced by cct than gat for every 10 micron cct change. the iop change expected with nct was 0.47 mm hg and gat was 0.29 mm hg28. conclusion iop with apt is slight higher about 3 mm hg but is safe and easy than gat tonometry. there is no fear of spread of infection and it can be used in mass screening program author’s affiliation dr. attaullah shah bukhari assistant professor department of ophthalmology khairpur medical college khairpur mir’s. dr. abdul haleem mirani assistant professor department of ophthalmology gmmc sukkur dr. muhammad ali shar ophthalmologist kmc hospital khairpur mir’s prof. shahid jamal siddiqui head department of ophthalmology khairpur medical college khairpur mir’s dr. liaquat ali shah chief ophthalmologist civil hospital khairpur role of author’s dr. attaullah shah bukhari attaullah shah bukhari, et al 45 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology substantial and direct intellectual conception, design, analysis, collection and interpretation of data. dr. abdul haleem mirani collection of data, and references. dr. muhammad ali shar collection of data, and references. prof. shahid jamal siddiqui intellectual conception, design, interpretation and final review. dr. liaquat ali shah collection of data, and references. references 1. kass ma, heuer dk, higginbotham ej, et al. the ocular hypertension treatment study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. arch ophthalmol. 2002; 120: 701-13. 2. heijl a, leske mc, bengtsson b, et al. reduction of intraocular pressure and glaucoma progression: results from the early manifest glaucoma trial. arch ophthalmol 2002; 120: 1268–79. 3. realini t, weinreb rn, hobbs g. correlation of intraocular pressure measured with goldmann and dynamic contour tonometry in normal and glaucomatous eyes. j glaucoma, 2009; 18 (2): 119-23. 4. halkiadakis i, patsea e, chatzimichali k, et al. comparison of dynamic contour tonometry with goldmann applanation tonometry in glaucoma practice. acta ophthalmol. 2009; 87: 323-8. 5. whitacre mm, stein r. sources of error with use of goldmann-type tonometers. surv ophthalmol. 1993; 38 (1): 1–30. 6. hansen fk. a clinical study of the normal human central corneal thickness. acta ophthalmologica. 1971; 49 (1): 82–99. 7. goldmann v, schmidt t. uber applanations tonometrie. ophthalmologica. 1957; 134: 221–42. 8. johnson m, kass ma, moses ra, & grodzki wj. increased corneal thickness simulating elevated intraocular pressure. arch ophthalmol. 1978; 96: 664-5. 9. doughty mj, zaman ml. human corneal thickness and its impact on intraocular pressure measures: a review and meta-analysis approach. surv ophthalmol. 2000; 44: 367-408. 10. wolfs rc, klaver cc, vingerling jr, grob-bee de, hofman a & de jong pt. distribution of corneal central thickness and its association with intraocular pressure: the rotterdam study. am j ophthalmol. 1997; 123: 76772. 11. copt rp, thomas r, mermoud a. corneal thickness in ocular hypertension, primary open-angle glaucoma, and normal tension glaucoma. arch ophthalmol. 1999; 117 (1): 14–6. 12. bron am, creuzot-garcherc, goudeau-boutillon s, d’athis p. falsely elevated intraocular pressure due to increasedcentral corneal thickness. graefes arch clin exp ophthalmol. 1999; 237 (3): 220–4. 13. herndon lw, choudhri sa, cox t, damji kf, shields mb, allingham rr. central corneal thickness in normal, glaucomatous, and ocular hypertensive eyes. arch ophthalmol. 1997; 115 (9): 1137–41. 14. gordon mo, beiser ja, brandt jd, heuer dk, higginbotham ej, johnson ca et al. the ocular hypertension treatment study: baseline factors that predict the onset of primary open-angle glaucoma. arch ophthalmol. 2002; 120 (6): 714–20. 15. morrison jc, pollack ip, editors. glaucoma science and practice. new york, ny: thieme medical publishers; 2003: 60–4. 16. kanski jj, bowling b. clinical ophthalmology: a systematic approach, 7th ed. philadelphia: elsevier; 2011: 315–644. 17. firat pg, cankaya c, doganay s, et al. the influence of soft contact lenses on the intraocular pressure measurement. eye (lond). 2012; 26 (2): 278–82. 18. lagerlöf o. airpuff tonometry versus applanation tonometry. acta ophthalmol (copenh). 1990; 68 (2): 2214. 19. martinez-de-la-casa jm, jimenez-santos m, saenzfrances f et al. performance of the rebound, noncontact and goldmann applanation tonometers in routine clinical practice. acta ophthalmol. 2011; 89 (7): 676–80. 20. tonnu pa, ho t, sharma k, white e, bunce c, garway-heath d. a comparison of four methods of tonometry: method agreement and interobserver variability. br j ophthalmol. 2005; 89 (7): 847–50. 21. rao bs. clinical evaluation of the non-contact tonometer and comparison with goldmann applanation tonometer. indian j ophthalmol. 1984; 32 (5): 432–4. 22. seung pil bang chong eun lee and yu cheol kim. bmc ophthalmology, 2017; 17: 199. 23. javied a, muhammad rk, muhammad na, tariq ma, qazi za. accuracy of iop measured by noncontact (air – puff) tonometer compared with goldmann applanation tonometer pak j ophthalmol 2014, vol. 30, no. 1. 24. wachtl j, harms mt, frimmel s, roos m, kniestedt c tonometry. uncorrected and corrected goldmann applanation tonometry, and stage of glaucoma jama ophthalmol. 2017; 135 (6): 601-608. 25. nadeem s, naeem ba, tahira r, khalid s, hannan a. comparison of goldmann applanation, diaton transpalpebral and air puff tonometers, pak j ophthalmol. 2015, vol. 31, no. 1: 33-39. 26. dibaji m, shaikh rm. study of accuracy of intraocular pressure measured by non-contact (air puff) tonometer comparison of measurement of intraocular pressure between goldmann applanation tonometer pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 46 confirmed by goldmann applanation tonometer pjmhs. jul – sep 2016; vol. 10, no. 3: 972-974. 27. toprak i, kilic d. effects of puff times on intraocular pressure agreement between non-contact and goldmann applanation tonometers. guoji yanke zazhi (int eye sci.) 2014; 14 (7): 1186-1189. 28. sood a, nazir a, runyal f, mohiudin s, sadiq t. clinical estimation of intraocular pressure with a noncontact tonometer and goldman applanation tonometer as a tool for mass screening and its correlation with central corneal thickness: a comparative hospital based study gjmedph. 2015; vol. 4, issue 4. microsoft word 1. a.p. siddiqui 172 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology original article citicoline treatment of children with visual impairment; a pilot study a. p. siddiqui, g. lennerstrand, t. pansell, a. rydberg pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: a.p. siddiqui 296 ashby road, scunthorpe dn16 2ar united kingdom …..……………………….. purpose: to determine the use of citicoline in children with visual impairment and its result in improvement of high and low contrast acuity, and to see, if citicoline effects were different in children with low vision due to retinal/optic nerve disease and central visual deprivation. material and methods: the twenty-two children in this study were divided into a group of eleven with visual deprivation amblyopia (vda) and eleven with peripheral visual impairment (pvi). each child received 10 intramuscular injections containing 1 g of citicoline. changes in visual acuity were assessed with high contrast and low contrast acuity tests applied at baseline (day 1), day 30 and day 90. statistical analysis was done with an anova model to analyze both the within and between group effects of the citicoline-treatment. results: visual acuity increased in both groups of children but the changes were not statistically significant. clinical assessment of acuity changes showed more rapid improvement in the vda than in the pvi group. decline of acuity 90 days after treatment was more often seen in the vda than in the pvi group conclusions: treatment with citicoline for a short period can improve contrast visual acuity in children with visual impairment. further work is needed to determine the clinical relevance of citicoline treatment in visual impairment. iticoline has been used in treatment of neurological disease with minimal side effects, and it appears to improve functional outcome and reduce neurological deficit in acute stroke1,2. citicoline is an intermediate metabolite in the major pathway for the synthesis of the membrane phospholipids, phosphatidylcholine, which is important for the maintenance of cell-membrane fluidity and cellular integrity. citicoline can support cell-membrane repair, particularly neuronal cell membranes that have been damaged by trauma, ischemic events, toxins, infections or neural degeneration3. patients in the studies of neurological impairment also have reported that colours were brighter and that visual contrast was enhanced, which have led to investigations of citicoline in various ophthalmic conditions. studies in patients with glaucoma have suggested that citicoline repairs damage to the optic nerve and the retina4. animal studies have shown that citicoline raised the retinal dopamine concentration in the retina4. citicoline was found to significantly improve visual acuity in patients with amblyopia5, 6. further investigations showed that both high and low contrast acuity was improved, mainly in the amblyopic eye, but some increase in contrast vision was reported in the better eye as well7. in view of the findings of citicoline effects on retinal and optic nerve function in glaucoma and visual cortical function in amblyopia, we have examined the effects of citicoline on visual acuity in children with severe visual handicap. two different populations of visually impaired children were studied, one group with visual impairment mainly due to vision deprivation disease and the other group due to retinal or optic nerve disease. both high and c citicoline treatment of children with visual impairment; a pilot study pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 173 low contrast visual acuity was assessed, using cardboard letter charts8,9. previous studies in children with visual impairment had shown that visual function assessment with these tests corresponded quite well with assessment of the functional ability of the children11. the aim of the study was to see if contrast acuity could be improved by treatment with citicoline, if the effects were different for high and low contrast acuity, if there are differences in the effects related to the type of visual impairment, and if the response did vary with time after treatment. material and methods visual impairment according to who is defined as a presenting visual acuity of 6/18 to 3/60. “severe visual impairment” is less than 6/60 and more than or equal to 3/60, and “moderate visual impairment” less than 6/18 and more than 6/60). in this study most of the visual impairment is in the category of severe visual impairment but we shall use the term visual impairment to describe all the children10. twenty-two children with severe visual impairment at the al maktoom school for the visually impaired, islamabad, pakistan were included in the study. the research followed the tenets of the world medical association declaration of helsinki on ethical principles for medical research involving human subjects. the children were divided into two groups of 11 children in each group. one group consisted of eleven children with visual impairment due to vision deprivation by bilateral congenital cataract, operated later than 1 year of age and other conditions blurring/opacifying the optical media (table 1a). this group we hypothesized to have vision deprivation amblyopia (vda). the other group consisted of eleven children with visual impairment due to retinal or optic nerve disease representing peripheral visual impairment (pvi) (table 1a). children in the vda group were on an average older than children in the pvi group (11.9 years compared with 10.0 years) and they were also more likely to be female (64 % compared with 36 %). the groups were not significantly different with regard to age, but with regard to sex. each child received an intramuscular injection of 1 g of intramuscular citicoline for 10 consecutive days starting from day 1. discomfort at injections was expressed by the children. any other side effects were registered at the time of follow-ups. a. p. siddiqui, et al 174 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology visual acuity was determined with lea symbol test charts of high contrast (>85%) and low contrast (2.5%) (fig. 1). the instructions supplied with the test were followed. the high contrast visual acuity (hca) and the low contrast visual acuity (lca) was defined as the line of optotypes on which at least three of the five symbols were read correctly, and if the line was read twice, at least four of the symbols were required to be correct.11 in this children population with visual impairment, the testing was done binocularly, at a viewing distance of one meter and the acuity values were re-calculated for the ordinary testing distance of three meters. visual acuity was recorded using decimal notations, which was then converted into logmar values. if the child could not see even the largest optotypes at one meter, this was marked as “no response” and given an arbitrary acuity value of 2.0 logmar in the statistical analysis. the visual acuity was measured at baseline (day 1), on day 30 and on day 90. the examiner was not aware of the results of the previous assessments. (lh testing protocol) the changes in visual function were also assessed with subjective methods. the children were asked the following two questions: do you notice any brightening or darkening of the light around you? 1. do you think that the colours around you appear less or clearer and brighter? in addition, an assessment was made of the degree of improvement or decline in hca and lca, using ordinary clinical measures. improvement of visual acuity is generally estimated from the change in acuity level during or after treatment, and measured as the change in number of lines on the visual acuity chart. an increase in acuity of two or three lines on the chart was considered a relevant improvement, and was defined in this study as a moderate improvement of visual acuity. an increase of four lines or more was considered a marked improvement. a reduction of visual acuity was measured in the same manner and a decline of acuity of two to three lines was regarded as citicoline treatment of children with visual impairment; a pilot study pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 175 fig. 1. lea’s symbol (a) high contrast tests. (b) low contrast tests fig. 2a&b: visual acuity testing in individual children of the two groups and at different times are shown in figure 2a and b for hca and lca respectively. solid line indicate vda group and interrupted line pvi group. fig. 3: mean values of hca and lca in all children. fig. 4: mean values in visual acuity for the hca (fig. a) and for lca (fig. b). moderate and four lines or more as marked. the number of children with moderate and marked increase and decrease in visual acuity were recorded for the different groups of visual handicap, and for the high and low contrast testing levels. an anova for repeated measures analysis was performed on the visual acuity data. the within-effect of contrast (high contrast and low contrast) and the effect of time during treatment (base line, 30 days and 90 days) as well as the between-effect of the groups vda and pvi was assessed in the anova model. the data were further analyzed for trends with a linear contrast analysis, which is a planned comparison (post test) to evaluate if there is a trend in the measured response. the variables were analyzed by mauchley's test of sphericity for compound symmetry and the results were adjusted by the huynh-feldt correction paradigm. all analyses were done with the statistica (data analysis software system), version 7. statsoft, inc. a p-value of ≤ 0.05 was regarded as statistically significant. results subjective visual assessment the first signs of improvement in the visual functions after citicoline treatment were observed in the subjective assessments. all children except two, both in the pvi group, reported that the surroundings looked brighter and colour clearer during in the treatment with intramuscular injections of citicoline while they were receiving the injections and till almost 30 days from start of treatment. a. p. siddiqui, et al 176 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology visual acuity assessment the results of visual acuity testing in individual children of the two groups and at different times are shown in figure 2a and b for hca and lca respectively. there were no significant differences between the two groups at baseline with respect to either hca (t-test, p=0.12) or lca (t-test, p=0.62). in many children of the vda group the visual acuity had increased at the 30 day testing and stayed at the same level or declined during the following period. in the pvi group the changes were more irregular, but often an increase was seen in the lca testing. the mean values of hca and lca in all children are shown in figure 3. it is seen that treatment with citicoline had a positive effect on visual acuity when considering all children over time but the effect was not statistically significant [f(2,40)=1.74, p=0.188)]. a linear contrast analysis revealed a close to significant increase in visual acuity in the pvi group (p=0.09) and a less significant effect for the vda group (p=0.41). the mean values for the two groups are shown in figure 4a for hca and in figure 4b for lca. the values for the vda group was higher than the values for the pvi group but no significant difference could be found when analyzing the acuity-change to treatment between the groups [f(1,20)=0.69, p=0.41]. in the vda group the increase in hca and lca occurred at 30 days and declined slightly at 90 days. in the pvi group the increase was more marked at 90 than at 30 days. however, these differences were not statistically significant between groups. clinical visual assessment the improvement or decline in visual acuity after citicoline treatment was recorded as the change in the number of lines that could be recorded on the visual acuity chart. the number of children with improvement in hca and lca at different periods of measurement is shown in table 2a for the vda and the pvi groups, and the number of children with decline in table 2b. as seen in table 2a moderate and marked increase of hca was seen in 6/11 of subjects in the vda group and in 3/11 in the pvi group, and moderate or marked increase of lca was seen in 4/11 subjects of the vda group but in only one subject of the pvi group. the improvement in vda patients seemed to occur mainly during the early phases (0 – 30 days), while the pvi patients often showed improvement over a longer period, up to 90 days. as seen in table 2 b, a moderate or marked decline of hca was noted in 2/11 children with vda and in 3/11 children with pvi, and a decline in lca in 2/11 children with vda and 2/11 children with pvi. discussion we found that children with visual impairment experienced subjective improvement of visual function and often also showed improvement of visual acuity after treatment with citicoline administered intramuscularly for 10 days. no side effects were noted which is in agreement with previous studies in children5-7. most of the children of course noticed there arm being sore for the duration of the treatment especially at the injection site. however, there was no mention of nausea, vomiting or feeling of unwell being. testing of visual acuity using charts containing both high and low contrast optotypes is possible in children with visual impairment as shown by siddiqui, rydberg & lennerstrand11. a strong positive correlation between contrast acuity and a functional assessment of visual ability was reported11. in the present study we have used the lea symbol test charts with high and low contrast optotypes. these charts gave reliable results and were well accepted by the children. in this study of the effect of citicoline on visual function of visually impaired children, the subjects were divided into two groups with respect to the cause of the impairment. we hypothesized that: visual impairment due to congenital cataract or other opacities of the optical media, and treated with surgery later than one year of age would represent amblyopia related to vision deprivation, the vda group of children12, 13. visual impairment due to congenital diseases of the retina and the optic nerve would be connected with defects in the peripheral visual elements of the retina / macula and optic nerve, the pvi group of children. assuming that the site of the damage to the visual system was different, it would be possible that the effects on visual function by treatment with citicoline would vary in the two groups both with regard to level and time course of change. an increase of visual acuity was seen in many of citicoline treatment of children with visual impairment; a pilot study pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 177 the children after citicoline treatment. the changes were most prominent for the high contrast acuity, but were noted also for low contrast testing. in a small number of children a reduction of acuity was recorded. statistical analysis showed that the changes were not significant when values for the two groups were compared at the different testing times. in clinical practice the improvement and reduction of visual acuity by different treatment modalities has been estimated as the change in the number of lines recorded with the visual acuity chart. such an approach has acceptance in the clinical literature on for example amblyopia treatment.5, 6 modern acuity charts are arranged with a logarithmic scale and each step on the chart represents the same change in visual resolution independent of the level of visual acuity. we have defined a moderate improvement in visual acuity after treatment as a difference of two to three lines and a change of more than three lines as a marked improvement. estimated in this way, improvement of acuity after citicoline treatment occurred more often in children with vda than in children with pvi. further the improvement was seen mainly during the first 30 days in the vda children, whereas in the pvi group the improvement appeared more often in the later part of the follow-up period, i.e. from day 30 to day 90. however, the effect of citicoline did not seem to last more that about 1 month, and a decline of visual acuity was often noted at the end of the observation period of 3 months. this corresponds to the findings in studies of citicoline effects in amblyopia where a reversion of visual acuity levels has been observed after about 4 months5,6. citicoline has been found to improve visual performance in amblyopia when measured by visual acuity, contrast sensitivity and visual evoked potential7. the effect of citicoline could in amblyopia conditions be attributed to modifications of neuronal mechanisms in the geniculate body and the visual cortex where the functional and morphological changes in amblyopia are known to occur12-14. this may also be the basis for improvement of hca and lca in the vda group. in glaucoma, the improvement of vision by citicoline has been suggested to be due to repair of retinal and optic nerve elements4, 15. in the pvi group citicoline might have affected the function of the retina and the optic nerve as well as the higher levels of the visual pathways. it is also possible that the increase in visual acuity may have been related to improvement of accommodative ability or parts of the oculomotor system involved in fixation, since testing was done at the distance of 1m, which requires a slight accommodative effort in addition to control of fixation. the change in visual acuity induced by citicoline would probably lead to improvement in the visual performance of the children, since visual acuity measured with high and low contrast charts have been shown to correspond with measures of functional capabilities of the children.12 treatment with citicoline in children with visual impairment could be useful in improving their visual capacity, but this study is only a preliminary one and extended investigations are needed in order to establish the dosage, the length of treatment and other parts of the protocol of treatment with citicoline in visual dysfunction. oral medication has recently been reported useful in children with amblyopia,16 and might also be tried in a group of children with visual impairment. author’s affiliation dr. a.p. siddiqui scunthorpe general hospital scunthorpe, united kingdom dr. g. lennerstrand bernadotte laboratories s:t erik eye hospital and karolinska institutet stockholm, sweden dr. t. pansell bernadotte laboratories s:t erik eye hospital and karolinska institutet stockholm, sweden dr. a. rydberg bernadotte laboratories s:t erik eye hospital and karolinska institutet stockholm, sweden references 1. clark, wm, warach sj, pettigrew, lc, et al. a randomized dose-response trial of citicoline in acute ischemic stroke patients. citicoline stroke study group. neurology. 1997, 49: 671-8. 2. clark, wm, williams bj, selzer ka, et al. a randomized efficacy trial of citicoline in patients with acute ischemic stroke. stroke. 1999; 30: 2592-7. 3. andersen m, overgaard k, meden p, et al. effects of citicoline combined with thrombolytic therapy in a rat embolic stroke model. stroke, 1999; 30: 1464-71. a. p. siddiqui, et al 178 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology 4. rejdak r, toczoowski j, solski j, et al. citicoline treatment increases retinal dopamine content in rabbits, ophthalmic res. 2002; 34: 146–9. 5. campos ec, schiavi c, benedetti p, et al. effect of citicoline on visual acuity in amblyopia: preliminary results. graefes arch clin exp ophthalmol. 1995; 233: 307-12. 6. campos ec, bolzani r, sciavi c, et al. cytidin-5diphosphocholine enhances the effect of part time occlusion in amblyopia. doc ophthalmol. 1997; 93: 247-63. 7. porciatti v, schiavi c, benedetti, p, et al. cytidine-5'diphosphocholine improves visual acuity, contrast sensitivity and visually – evoked potentials of amblyopic subjects, curr eye res. 1998; 17: 141-8. 8. hyvärinen l, moiotanen i, rovamo j, et al. clinical assessment of contrast sensitivity. acta ophthalmol, (kbh). 1990; 68: 83-9. 9. rydberg a, han y. contrast sensitivity in children with normal and subnormal vision. strabismus. 1997; 7: 7995. 10. action plan for the prevention of avoidable blindness and visual impairment, wha 62 – 1 english. 2009 – 2013. 11. siddiqui ap, rydberg a, lennerstrand gl. visual contrast functions in children with severe visual impairment and the relation to functional ability. j visual impairment research. 2005; 7: 43-52. 12. von noorden gk. experimental amblyopia in monkeys. further behavioral observations and clinical correlations. invest ophthalmol. 1973a; 12: 721–6. 13. von noorden gk. histological studies of the visual system in monkeys with experimental amblyopia. invest ophthalmol. 1973b; 12: 727–38. 14. mendola jd, conner i, roa a, et al. voxel based analysis of mri detects abnormal visual cortex in children and adults with amblyopia. human brain mapping. 2005; 25: 222–36. 15. parisi v, manni g, colacino g, et al. cytidine-5’ diphosphocholine (citicoline) improves retinal and cortical responses in patients with glaucoma. ophthalmology. 1999 106: 1126-34. 16. fresina m, dickmann a, salerni a, et al. 2008 effect of oral cdp – choline on visual function in young amblyopic patients. graefe's archive for clinical and experimental ophthalmology. 2008; 246: 143-50. pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 225 original article smart phone: a smart technology for fundus photography in diabetic retinopathy screening ahmad zeeshan jamil, luqman ali, muhammad younis tahir, fazal shah shirazi pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ahmad zeeshan jamil assistant professor of ophthalmology, sahiwal medical college, sahiwal. email: ahmadzeeshandr@yahoo.com …..……………………….. purpose: to find the reliability of fundus photography using smart phone in diabetic patients compared to slit lamp biomicroscopic examination. study design: comparative cross sectional. place and duration of study: this study was conducted in district headquarter teaching hospital affiliated with sahiwal medical college, sahiwal from january 2017 to december 2017. material and methods: 250 eyes of 125 diabetic patients visiting outpatient department were examined for diabetic retinopathy by smart phone fundus photography and slit lamp biomicroscopy b 2 independent ophthalmologiss. examination was performed after dilatation of the pupil. diabetic retinopathy changes were noted and graded by each observer for the same patient on a form. age and gender were recorded for all patients. results: there was high degree of agreement in findings of the smart phone and the slit lamp which was used as a gold standard. the kappa value was found to be 0.87 between the two methods of diagnosing clinically significant macular oedema (csme). sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of smart phone fundus photography in diagnosis of csme was 82.6%, 99.55%, 95%, 98.26% and 98%. conclusion: smart phone fundus photography shows reasonable agreement with slit lamp microscopy for the diagnosis of diabetic retinopathy and can be used for the screening purposes. key words: diabetic retinopathy, macular oedema, slit lamp microscopy, smart phone, telemedicine. ccording to 2017 census, pakistan is the 6th most populous country of the world with population of 207,774,5201. according to who, prevalence of diabetes mellitus in pakistan is 9.8% and pakistan has seventh largest diabetic patients in the world2,3. the prevalence of diabetic retinopathy in pakistan is 28.78% among the diabetic population4. management of diabetic retinopathy requires longterm patient’s education and comprehensive eye care to prevent vision impairment. imaging has unique and widespread role in the field of ophthalmology. imaging is widened to diagnosis, treatment, documentation, research and learning purposes. imaging is extensively used for screening purpose of eye diseases. this is especially true for various retinal conditions5. it is very expensive a ahmad zeeshan jamil, et al 226 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology and technically demanding to get good quality ophthalmic images through dedicated workstations and image capturing units in hospital environment. recent development in the hardware and software of smart phones has spread their use widely. like all other professionals, ophthalmologists are not lagging behind in adopting this revolutionary technology. smart phones have found their valuable use in the field of ophthalmology. they are readily available, handy, easy to use and have great capability for connectivity wirelessly6. apart from their conventional role of phone calls and text messaging smart phones are now able to do multiple tasks like video recording, running soft-wares and applications, remote connectivity with internet.7,8,9. coupled with their portability and connectivity with other gadgets, smart phone acceptability in the professional use in the field of ophthalmology is ever increasing10. use of smart phone photography is as useful in hospital setting as is in the remote community setting. for the screening and diagnosis of retinal diseases particularly diabetic retinopathy by utilizing smart phone, different modalities are being used. various attachments have been developed to help smart phone getting images of the retina. alternatively, a high power condensing lens can be used on the principle of indirect ophthalmoscopy to capture retinal images11,12. this novel use of smart phone can overcome constrains of socioeconomic and cultural barriers in providing eye care facilities to areas where comprehensive eye care facilities are non-existing13. many eye diseases causing blindness are preventable like morbidity related to diabetic retinopathy, glaucoma and age related macular degeneration14. effective screening is the key to prevention15. screening protocols should address the community as most of the population never visits hospital before there is permanent damage. utilization of smart phone fundus photography to screen and diagnose these crippling diseases has a great potential. high quality fundus images can be captured and transferred to distant specialized centres for expert opinion. this tele-ophthalmic use of smart phone is widely utilized, and there is much more to come in the future16. the rationale of the study was to find a cheap, easy to use and reliable tool for screening of diabetic retinopathy. the purpose of the present study was to compare the reliability of fundus photography with smart phone in the screening of diabetic retinopathy with slit lamp microscopy, which is the gold standard. material and methods this prospective study was conducted in ophthalmology department of district head quarter teaching hospital affiliated with sahiwal medical college sahiwal from january 2017 to december 2017. the study was approved by the ethical committee of the institution. consent was obtained from all patients who were included in the study. diabetic patients coming in outpatient department were included in the study. this was cross sectional study and sampling technique was purposive sampling. all diabetic patients older than 15 years of both genders were included. patients with media opacity were excluded from the study. pupillary dilatation was achieved by instilling 1% tropicamide and 10% phenylephrine eye drops that were repeated twice after five minutes interval. after full dilatation of the pupil fundus photographs were taken with the help of smart phone and 20 diopter condensing lens. images of posterior pole, superior, nasal, inferior and temporal periphery were captured. smart phone used for this purpose was samsung galaxy n9000. images were taken using a resolution of 1920×1080. afterwards patients went through comprehensive eye examination on slit lamp. fundus photographs taken by smart phone were sent by whatsapp to one specialist (ml). slit lamp examination was performed by another specialist (az). findings were recorded according to a specially designed proforma. both specialists were unaware of each other’s findings. findings were categorized on the presence or absence of microaneurysms, exudates, retinal thickening, haemorrhages, intra-retinal micro-vascular changes, neovascularization of retina and optic disc. each specialist individually placed patients into following categories based on his findings: no diabetic retinopathy, non-proliferative diabetic retinopathy, proliferative diabetic retinopathy and clinically significant macular oedema. age was presented as mean and standard deviation while gender was presented as percentage. ƙ statistics was used to assess agreement between smart phone and slit lamp findings. sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were calculated using slit lamp examination as gold standard. statistical analysis smart phone: a smart technology for fundus photography in diabetic retinopathy screening pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 227 was performed using statistical programme for social sciences (spss version 21). results there were 250 eyes of 125 diabetic patients in the present study. mean age was 52.11 ± 11.33 years. there were 136 (54.4%) males and 114 (45.6%) females. table 1 shows frequency of findings along with agreement value between the two groups. table 2 gives the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy by using smart phone fundus photography for diagnosis of diabetic retinopathy with slit lamp examination as gold standard. table 1: frequency of findings along with agreement value between slit lamp and smart phone. diabetic retinopathy non-proliferative diabetic retinopathy proliferative diabetic retinopathy clinically significant macular oedema yes no yes no yes no yes no slit lamp 67 (26.2%) 183 (73.2%) 55 (22%) 195 (78%) 22 (8.8%) 228 (91.2%) 23 (9.2%) 227 (90.8%) smart phone 61 (24.4%) 189 (75.6%) 53 (21.2%) 197 (78.8%) 19 (7.6%) 231 (92.4%) 20 (8%) 230 (92%) ƙ(agreement) 0.916 0.787 0.814 0.873 table 2: sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy by using smart phone fundus photography for diagnosis of diabetic retinopathy with slit lamp examination as gold standard. diabetic retinopathy non-proliferative diabetic retinopathy proliferative diabetic retinopathy clinically significant macular oedema sensitivity 89.5% 81.81% 77.27% 82.60% specificity 99.45% 95.89% 99.12% 99.55% positive predictive value 98.36% 84.90% 89.47% 95.0% negative predictive value 96.29% 94.92% 97.83% 98.26% diagnostic accuracy 96.8% 92.8% 97.2% 98% discussion diabetic retinopathy is a potentially blinding condition. timely diagnosis and appropriate treatment is of paramount importance to lessen the morbidity of this disease. traditional fundus imaging cameras are costly, and they require dedicated environment for their operation17. there is a need for some alternative that is cheap, readily available, practical in community settings and has connectivity through telemedicine to specialist centres if we want to extend our health care services to underserved areas of the community18. in the present study, 250 eyes of 125 diabetic patients were screened with the help of smart phone fundus photography. slit lamp examination was used as gold standard to diagnose diabetic retinopathy. sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of smart phone fundus photography in diagnosis of clinically significant macular oedema was 82.6%, 99.55%, 95%, 98.26% and 98%. our findings are comparable to the results presented by russo a and co-authors. they reported 81% sensitivity and 98% specificity of diagnosing clinically significant macular oedema with the help of smart phone. in their study, agreement between examined techniques was 0.79 as compared to 0.87 in our study. however, russo and co-authors used d-eye system as smart phone camera attachment as compared to 20 diopter condensing lens used in our study. our approach utilized the principle of indirect ophthalmoscopy to capture retinal images. flashlight of smart phone provided the light source to illuminate the retina. work of maamari et al17 showed the quality of retinal images captured with the help of smart phone ahmad zeeshan jamil, et al 228 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology using 20 diopter condensing lens were of high quality to detect retinal changes. smart phone fundus imaging yields high quality photographs that are comparable to that obtained through fundus camera19. like any other skill quality of images captured with smart phone improves with practice and experience of the examiner. light exposure by smart phone camera is very less as compared to indirect ophthalmoscope light, making it a safe technique in terms of retinal light toxicity20. this decreased light intensity is more comforting for the patient but at the same time, it makes it difficult to get fundus images in the presence of media opacity. advantages of capturing retinal images with smart phone are many. smart phone is an economical device that is readily available in almost every setting of our community. moreover, its acceptability among doctors and public is very high. it needs no extra expensive attachments. it is true when high power condensing lens is used to take photographs. nurses, community health workers and paramedics can be trained to capture images and send these images through whatsapp or email to retinal specialist located in specialist centres for expert opinion. there are limitations of our study. the field of view by smart phone fundus imaging is less as compared to that obtained by slit lamp fundus examination that is gold standard. stereopsis is lacking in fundus images by smart phone. moreover, examiner practice is required before getting high quality images by smart phone. patient’s cooperation is very important in getting good images. nonetheless smart phone fundus photography is a promising technique that makes it possible to get high quality retinal images to detect retinal changes in population of remote and less served areas. use of tele-ophthalmology in combination with smart phone fundus imaging can open a new prospect for screening and diagnosis of potentially blinding diabetic retinopathy. author’s affiliation dr. ahmad zeeshan jamil mbbs, mcps, fcps, frcs, fcps (vro) associate professor of ophthalmology, sahiwal medical college, sahiwal. dr. luqman ali mbbs, fcps, fellowship refractive and cornea surgery assistant professor of ophthalmology, shahida islam medical college, lodhran. dr. muhammad younis tahir mbbs, fcps, fellowship in vitreoretina assistant professor of ophthalmology, quaid e azam medical college, bahawalpur. dr. fazal shah shirazi mbbs, doms, mcps consultant ophthalmologist, district head quarter teaching hospital sahiwal role of authors dr. ahmad zeeshan jamil concept and design of study, interpretation of data dr. luqman ali drafting and critical version of intellectual content dr. muhammad younis tahir statistical analysis, manuscript writing, proof reading dr. fazal shah shirazi literature search and drafting of article references 1. pakistan bureau of statistics. province wise provisional results of census – 2017. available at: http://www.pbs.gov.pk/sites/default/files/pakista n%20tehsil%20wise%20for%20web%20census_ 2017.pdf [accessed on 25/05/2018]. 2. pakistan-world health organization-diabetes country profiles, 2016. available at: http://www.who.int/diabetes/countryprofiles/pak_en.pdf?ua=1 [accessed on 26/05/2018] 3. shera as, jawad f, maqsood a. prevalence of diabetes in pakistan. diabetes res clinical prac 2007; 76 (2): 21922. 4. mumtaz sn, fahim mf, arslan m, shaikh sa, kazi u, memon ms. prevalence of diabetic retinopathy in pakistan: a systematic review. pak j med sci. 2018; 34 (2): 493-500. 5. nazari kh, nakatsuka a, el-annan j. smart phone fundus photography. journal of visualized experiments: 2017; (125) :55958. 6. lord rk, shah va, san filippo an, krishna r. novel uses of smart phones in ophthalmology. ophthalmology, 2010; 117 (6): 1274-.e3. 7. zvornicanin e, zvornicanin j, hadziefendic b. the use of smart phones in ophthalmology. acta informatica medica. 2014; 22 (3): 206-9. 8. tahiri hr, el sanharawi m, dupont-monod s, baudouin c. smart phones in ophthalmology. journal francais d'ophtalmologie. 2013; 36 (6): 499-525. 9. bastawrous a, cheeseman rc, kumar a. iphones for eye surgeons. eye, 2012; 26 (3): 343-54. http://www.who.int/diabetes/country-profiles/pak_en.pdf?ua=1 http://www.who.int/diabetes/country-profiles/pak_en.pdf?ua=1 smart phone: a smart technology for fundus photography in diabetic retinopathy screening pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 229 10. russo a, morescalchi f, costagliola c, delcassi l, semeraro f. comparison of smart phone ophthalmoscopy with slit-lamp biomicroscopy for grading diabetic retinopathy. am j ophthal 2015; 159 (2): 360-4.e1. 11. haddock lj, kim dy, mukai s. simple, inexpensive technique for high-quality smart phone fundus photography in human and animal eyes. j ophthalmol. 2013; 2013: 518479. 12. myung d, jais a, he l, blumenkranz ms, chang rt. 3d printed smart phone indirect lens adapter for rapid, high quality retinal imaging. j mob technol med. 2014; 3 (1): 9–15. 13. chow sp, aiello lm, cavallerano jd, katalinic p, hock k, tolson a, et al. comparison of non-mydriatic digital retinal imaging versus dilated ophthalmic examination for non-diabetic eye disease in persons with diabetes. ophthalmology, 2006; 113 (5): 833-40. 14. mohamed q, gillies mc, wong ty. management of diabetic retinopathy: a systematic review. jama 2007; 298 (8): 902–916. 15. cheung n, mitchell p, wong ty. diabetic retinopathy. lancet. 2010; 376 (9735): 124–136. 16. chhablani j, kaja s, shah v. smart phones in ophthalmology. indian j ophthal, 2012; 60 (2): 127-31. 17. maamari rn, keenan jd, fletcher da, margolis tp. a mobile phone-based retinal camera for portable wide field imaging. br j ophthal, 2014; 98 (4): 438-41. 18. shanmugam m, mishra d, madhukumar r, ramanjulu r, reddy s, rodrigues g. fundus imaging with a mobile phone: a review of techniques. indian j ophthal, 2014; 62 (9): 960-2. 19. adam mk, brady cj, flowers am, juhn at, hsu j, garg sj, et al. quality and diagnostic utility of mydriatic smart phone photography: the smart phone ophthalmoscopy reliability trial. ophthalmic surgery, lasers & imaging retina, 2015; 46 (6): 631-7. 20. kim dy, delori f, mukai s. smart phone photography safety. ophthalmology, 2012; 119 (10): 2200-1; author reply 1. annexure fig. 1: retinal thickening, hard exudates and clinically significant macular oedema fig. 2: neo vascularization elsewhere and laser marks. ahmad zeeshan jamil, et al 230 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology fig. 3: fibrous tractional fold at disc and macula along with neo vascularization at disc. fig. 4: in a silicone oil filled eye there is neo vascularization at disc and neo vascularization elsewhere. fig. 5: massive plaque exudative maculopathy. fig. 6: asteroids hyalosis. microsoft word 12. imran ghayoor case report pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 105 case report yag laser for macular subhyaloid hemorrhage imran ghayoor, syed irshad haider, sharif hashmani, sadaf shah pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: imran ghayoor liaqat national hospital karachi …..……………………….. ubhyaloid hemorrhage is defined as a localized detachment of vitreous from the retina caused by the accumulation of blood, which can lead to sudden and severe loss of vision, when it takes place in the macular area. premacular subhyaloid hemorrhage may occur in retinal vascular disorder such as proliferative diabetic retinopathy, branch retinal vein occlusion, macro aneurysm, and age-related macular degeneration, hematological disorders such as leukemia1 and chemotherapy induced pancytopenia, following laser in situ keratomileosis (lasik)3 because of rapid release of the microkeratome vacume pressure or after retinal vascular rupture associated with physical exertion (valsalva retinopathy),2. terson’s syndrome4. purtscher’s retinopathy5. sub-hyloid haemorrhage can be managed either conservatively or by vitrectomy6. hyloidectomy of the posterior hyloid face is another option7,8. material and methods two patients with subhyloid macular haemorrhage were selected to undergo yag laser treatment. we used 3 mirror contact lens and started power setting 6 mj and used a maximum of 10 mj till hole is achieved in the posterior hyloid and one can see blood coming out like a tail of a rat. case1 a 32 years old man referred to the hospital with history of sudden visual loss to hand movement in left eye 5 day’s ago. there was no history of systemic or ocular disorders, trauma, or surgery. no further identifiable cause for subhyaloid hemorrhage was found upon systemic evaluation. the right eye had visual acuity 6/6 with correction. the left eye was hm with or without glasses. anterior segment of both eyes were normal. on fundoscopy of left eye revealed a round, well circumscribed, dome shaped hemorrhage with a convex surface overlying the posterior pole, extending between the temporal vascular arcade, consistent with a sub-hyaloid or sub internal limiting membrane hemorrhage. q-switched neodyminium yttrium-aluminum garnet (nd-yag laser) laser was performed on the posterior hyaloid of the left eye over the dark brown hemorrhage, via the transcorneal route with full pupillary dilatation using a goldmann-3-mirror contact lens. the aiming beam was precisely focused on the surface of the posterior hyaloid membrane at the inferior edges of the sub-hyaloid hemorrhage to facilitate gravity-induced drainage. at the end of the procedure, the hemorrhage spontaneously drained into vitreous cavity and resorbed after a mean period of 9 to 16 days. s imran ghayoor, et al. 106 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology fig.1: subhyaloid hemorrhage fig. 2: blood drainage into vitreous cavity after yag laser visual acuity in the affected eye improved to 6/6 after yag laser. case – 2 37 years old insulin dependent diabetic male was referred to the hospital with sudden loss of vision in left eye of one week duration, on examination he was found to have proliferative diabetic retinopathy with large subhyaloid hemorrhage covering the macula. after explaining the situation he underwent prp in both eyes. to relieve the large subhyaloid hemorrhage. yag laser was attempted with central part of goldmann three mirror fundus contact lens. a break in the hyaloid face, which resulted in drainage of blood. the blood drained gradually with mild inflammation, hyphaema and rise in iop, which resolved spontaneously after six weeks. the vision improved from hm to 6\12 on 6 week, in between he also received one inj avastin [bevacizumab] and later macular grid laser, to complete the laser. discussion we wanted to report two of our cases of posterior subhyloid hemorrhage in which sudden visual loss could be reverted to fair visual recovery without reverting to extensive surgery or prolong conservative treatment. in our 1st case we could not find any causes although valsalva retinopathy9 is a possibility. in our second case the comparatively young gentleman had iddm with proliferative diabetic retinopathy. the most interesting thing in him was that his subhyloid hemorrhage drained through to the anterior segment. he did not have rubeosis, the mild inflammation seems to result from the trauma of the procedure and the prp which he received 2 days earlier. yag laser for macular subhyaloid hemorrhage pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 107 fig.1: subhyaloid hemorrhage, cotton wool fig. 2: blood drainage into vitreous spot and exudation. proliferative diabetic retinopathy cavity after yag laser we have been experimenting with different contact lenses available with yag. we wanted to report the use of goldmann three mirror lens and its central part as none of reported cases mentions the lens used. we found that central portion of goldmann three mirror lens works well with yag and easy to focus the aiming beam, and does achieve the break required to drain the blood. conclusion nd – yag laser hyaloidotomy in pre-macular subhyaloid hemorrhage is simple, inexpensive outpatient procedures, which results in rapid visual recovery and is relatively safe. further controlled clinical trials are recommended. author’s affiliation dr. imran ghayoor liaqat national hospital karachi syed irshan haider hashmanis hospital karachi dr. sharif hashmani hashmanis hospital, karachi dr. sadaf shah medical officer hashmanis hospital karachi reference 1. gass jdm. stereoscopic atlas of macular diseases.3rd ed. st louis: cv mosby. 1987. 2. duane td. valsalva hemorrhagic retinopathy. trans am ophthalmol soc. 1972; 70: 298 313. 3. mansour am, ojeimi gk. premacular subhyaloid hemorrhage following laser in situ keratomileusis. jrefract surg. 2000; 16: 371–2. 4. kuhn f, morris r, mester v, et al. terson's syndrome. results of vitrectomy and the significance of vitreous hemorrhage in patients with subarachnoid haemorrhage. ophthalmology 1998; 105: 472-7. 5. agarwal a, mckibbin m. purtscher's retinopathy: epidemiology, clinical features and outcome. br j ophthalmol. 2007; 91: 1456-9. 6. ramsay rc, knobloch wh, cantrill hl. timing of vitrectomy for active proliferative diabetic retinopathy. ophthalmology. 1986; 93: 283-9. imran ghayoor, et al. 108 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology 7. ulbig mw, mangouritsas g, rothbacher hh, et al. long-term `results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed nd: yag laser. arch ophthalmol. 1998; 116:1465-9. 8. ulbig mw, mangouritsas g, rothbacher hh, et al. long-term results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed nd: yag laser. arch ophthalmol. 1998; 116:1465-9. 9. tabatabaee sa, solaimani m, mohammad-reza mansouri mr, et al. purtscher retinopathy associated with valsalva retinopathy after accident. iranian journal of ophthalmology. 2009; 21: 70-2. pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 219 original article frequency of retinopathy and its different grades among type ii diabetic patients with metabolic syndrome in our population mohammad asghar, mubashir rehman, mohammad zahid khan, muhammad abdur rehman, mohammad zeeshan tahir pak j ophthalmol 2014, vol. 30 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mohammad asghar medical officer medical “a” unit lady reading hospital peshawar. …..……………………….. purpose: to determine the frequency of retinopathy and its different grades among type ii diabetic patients with metabolic syndrome material and methods: this study was conducted in the department of medicine, lady reading hospital peshawar from march 2011 to august 2011. through a descriptive cross sectional study design, a total of 201 patients with diabetes mellitus having metabolic syndrome were selected in a consecutive manner from the opd and fundoscopy was performed to detect and grade diabetic retinopathy and results were recorded. results: the mean age of patients was 39 ± 12.2 years with 54.7% female and 45.3% male gender. on fundoscopy, diabetic retinopathy was found in 35 (17.4%) of patients with most of the patients with retinopathy lying in older age group i.e. 34.6% in the age group 60+ years and 20% in the age group 50-59 years. on grading of diabetic retinopathy, 40% were in the mild to moderate non proliferative diabetic retinopathy (npdr) group, 37.1% in the severe non proliferative diabetic retinopathy (npdr) group and 22.9% were in the proliferative diabetic retinopathy (pdr) group. conclusion: diabetic retinopathy is a common sequalae of diabetes in patients with metabolic syndrome with non-proliferative diabetic retinopathy more common than proliferative diabetic retinopathy. it necessitates regular follow up of these patients to prevent development of proliferative disease and its complications. more studies are recommended before making recommendations for modifications in principles of its management. key words: frequency, metabolic syndrome, retinopathy etabolic syndrome (ms) is a common condition occurring in diabetic patients and is characterized by the presence of glucose intolerance, hypertension, central obesity, low high density lipoproteins (hdl) and high triglycerides. over-secretion of insulin with peripheral resistance to insulin action is believed to underlie this syndrome. the micro-vascular changes associated with ms include diabetic retinopathy, nephropathy and neuropathy.1,2,3 metabolic syndrome (md) is not an uncommon condition in diabetic patients and approximately 7080% of diabetics develop metabolic syndrome (ms) in their life.2 in indian population the prevalence of ms is 73.3% in comparison to the indian immigrants in usa who have 77% prevalence.4 in japanese and western population the prevalence of ms is reported to be 58.5% and 77.6% respectively.5,6 the prevalence is higher in women (83.3%), compared to men (65.3%). diabetic retinopathy is an important feature of metabolic syndrome in patients with diabetes with a prevalence of 16.9%.2 the correlation between the micro-vascular complications of diabetes and metabolic syndrome m mohammad asghar, et al 220 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology including diabetic retinopathy are well documented.5,7 however not enough literature and data is available in asian population. it has been found that in metabolic syndrome (ms) the risk factors for retinopathy is elevated hba1c level, and duration of diabetes, while nephropathy include hypertension and increased body mass index as risk factors in addition to elevated hba1c level, and duration of diabetes.2 in a study from faisalabad, the frequency of retinopathy among patients with diabetes mellitus and metabolic syndrome was found to be 41.4%8, while in another study from lahore it was 25%.9 the rationale of our study is to find out the prevalence of diabetic retinopathy in our local population with type 2 diabetes mellitus having metabolic syndrome. although local studies are available in literature but most of them are either comparative in nature or having controversial results as mentioned above (studies from lahore and faisalabad). we also tried to generate local statistics about the magnitude of the retinopathy among diabetic people living with metabolic syndrome. the results of this study will be compared with already available local and international literature and if found to be significantly high, will be shared with local health professionals to device future recommendations for the prevention and control of the problem. also this study will provide us frequency of different grades of retinopathy which has not been studied locally and will provide us with current statistics about the most common grade of retinopathy among patients with type ii diabetes and metabolic syndrome. material and methods the study was conducted in medical department, post graduate medical institute, lady reading hospital peshawar from march 2011-august 2011. it was a descriptive cross sectional study, and sampling technique used was consecutive non-probability sampling. a written permission from the hospital ethical committee was obtained. all patients presenting to the medical outpatient department (opd) of lrh with diabetes of minimum five years duration were worked up thoroughly for metabolic syndrome by clinical examination & investigations. those patients found to have metabolic syndrome were included in the study and were dealt with on opd basis or admitted to the medical ward where routine investigations as full blood count, urea, blood sugar, electrolytes, ecg and echocardiography were done. already diagnosed cases of retinopathy like; vasculitis, rheumatoid, systemic lupus erythematosis, radiation retinopathy, and systemic disease that will affect visual acuity evaluation (for example: cva), opaque cornea and vitreous were excluded from the study. a written informed consent was obtained from all the patients. fundoscopy of all patients was performed either on opd basis or after the admission to detect retinopathy and its different grades. all the fundoscopies were performed by senior ophthalmologist having got minimum of 5 years experience in ophthalmology. all the information is recorded on preformed proforma. an exclusion criterion was followed strictly to control confounding variables and bias in the study result. the data was analyzed in spss for windows version 10.0. continuous variables like age and duration of diabetes were presented as mean + standard deviation. qualitative variables like gender, retinopathy and its grades are presented as frequency and percentages. retinopathy was stratified among age, gender and duration of diabetes to see the effect modifications. all the results are presented as tables and graphs. results the study comprised a total of 201 patients of type ii diabetes mellitus, having minimum 5 years duration of diabetes. the mean age of diabetic patients were 39 ± 12.2 years. the minimum age in our study was 30 years and maximum age was 70 years. distributing the sample in different age groups, we found that 35 (17.4%) were in the age group 30-39 years, 70 (34.8%) were in the age group 40-49 years, 70 (34.8%) were in the age group 50-59 years while 26 (12.9%) were in the age group 60+ years. considering the duration of diabetes condition among subjects recruited, in this study, participants were grouped into: > 5–10 years with 61 (30.3%) of the sample, 11-15 years with 75 (37.3%) of the sample while in the group with duration of diabetes of 15+ years we had 65 (32.3%) of the overall sample of 201. while distributing the sample with regards to gender, we found that male gender contributed 91 (45.3%) of the sample and female gender contributed frequency of retinopathy and its different grades among type ii diabetic patients with metabolic syndrome pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 221 110 (54.7%) of the overall sample. on fundoscopic examination of all the diabetic individuals included in the study, diabetic retinopathy (dr) was observed in 35 (17.4%) of the patients (table 1). while looking into the gender wise stratification of the dr, we found that out of total 91 males, 13 (14.3%) had dr and out of total 110 females, 22 (20%) had dr. stratifying the dr with regards to age groups, we found that most of the dr were observed in older age groups, out of 35 in the age group 30-39 years 4 (11.4%) had dr, out of 70 in the age group 40-49 years 8 (11.4%) had dr, out of 70 in the age group 50-59 years 14 (20%) had dr and out of 26 in the age group 60+ years 9 (34.6%) had dr (table 2). while stratifying the diabetic retinopathy with regards to duration of diabetes, we found that most patients of diabetes were in the prolonged duration of diabetes suggesting that as the diseases progresses, the chances of developing diabetic retinopathy becomes higher. out of 61 patients in the group >5–10 years with 7 (11.5%) had dr, in the group with duration of diabetes 11-15 years out of 75, 13 (17.3%) had dr while in the group with duration of diabetes of 15+ years out of 65 patients, 15 (23%) had dr (table 3). the grades of retinopathy are also studied in this research project and it was seen that out of total 35 patients with diabetic retinopathy, 14 (40%) were in the mild to moderate non proliferative diabetic retinopathy (npdr) group, 13 (37.1%) were in the severe non proliferative diabetic retinopathy (npdr) group and remaining 8 (22.9) were in the proliferative diabetic retinopathy (pdr) group (table 4). discussion metabolic syndrome (ms) is a specific disease entity as reported by national cholesterol education program’s atp iii report. patients with this syndrome shows increased incidence of micro-vascular diseases.10 many studies showed association between hypertension, diabetes, cardiovascular diseases and micro-vascular retinal disease.11-16 in our study we addressed the frequency of diabetic retinopathy in diabetic patients with metabolic syndrome. the study conducted by fisbee jc showed experimentally in rats having obesity, diabetes and metabolic syndrome that they have narrow skeletal muscle arterioles and impaired arteriolar reactivity to vaso-active stimuli.17 while study conducted by irnving rj and serne eh et al14-16 showed changes in the structure and function of microcirculation in skin http://www.iovs.org/content/45/9/2949.full#ref-21 mohammad asghar, et al 222 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology and skeletal muscles in patients with metabolic syndrome. after 20 years, nearly 60% people with type-1 diabetes and around 40% with type-2 diabetes have proliferative diabetic retinopathy. in diabetic patients there is venular dilatation resulting in hyperperfusion which inturn causes hypoxia and lactic acidosis.18, 19 this venular dilatation is related to the duration of diabetes, raised hba1c level and high body mass index as shown by winconsin epidediologic study.20, 21 on the basis of all these facts, diabetic retinopathy can be explained in metabolic syndrome (ms) as a consequence of micro-vascular changes associated with inflammation and endothelial dysfunction resulting in decrease perfusion and hypoxia. our study showed relationship between metabolic syndrome (ms) and diabetic retinopathy. in our study, the prevalence of diabetic retinopathy among diabetics with metabolic syndrome was 17.4% which is lower than that (21-60 %) reported in other studies conducted in karachi and other cities in pakistan.22 the reason behind these differences could be that most of those studies were done on inadequate sample size while our study took 201 patients. it may have caused an overrepresentation of diabetics in the sample because several eye diseases are more prevalent among diabetics than their non-diabetic counterparts. second, a third of diabetics did not participate in the screening for diabetic retinopathy which may have either overestimated or underestimated the prevalence of diabetic retinopathy, depending on the rates of diabetic retinopathy among non-respondents. in our study, women had a slightingly greater prevalence of diabetic retinopathy than men (20% vs. 14.3%). the most prevalent type of diabetic retinopathy is our study was mild to moderate non proliferative diabetic retinopathy (npdr) which accounted for 40% of the cases. in a study by khan in karachi,22 background diabetic retinopathy accounted for 79.1% of the cases compared with 92%, 89.3-94.0% and 69.8% in studies conducted in australia, india and oman, respectively. severe proliferative diabetic retinopathy (npdr) was not so far in the race and the reported frequency in our study was 37.1%. this is lower than those reported in hospital based studies in pakistan and elsewhere. the severity of retinopathy is primarily related to the duration of diabetes, and exposure to various internal and external ocular factors. this lower prevalence of proliferative dr can be explained by the fact that majority of our participants were young. many studies have found duration of diabetes to be an important predictor of diabetic retinopathy.23, 24 the strength of our study includes large sample size (201) and the objective documentation of signs by both ophthalmologists and physicians. however considering the limitations of our study it is important to mention that our study was cross-sectional and prospective data are needed to document the relationship between the micro-vascular changes including diabetic retinopathy and metabolic syndrome. to conclude our study, we documented crosssectional association between diabetic retinopathy and metabolic syndrome (ms) in diabetic patients. we recommend further prospective studies to clearly establish association between metabolic syndrome (ms) and micro-vascular abnormalities in diabetic patients. conclusion diabetic retinopathy is the commonest cause of visual impairment in diabetic patients with metabolic syndrome with non-proliferative diabetic retinopathy more common than proliferative diabetic retinopathy. it necessitates regular follow up of these patients to prevent development of proliferative disease and its complications. more studies are recommended before making recommendations for modifications in principles of its management. author’s affiliation dr. mohammad asghar medical officer medical “a” unit lady reading hospital, peshawar dr. mubashir rehman medical officer department of ophthalmology lady reading hospital, peshawar dr. mohammad zahid khan medical officer department of endocrinology lady reading hospital, peshawar dr. muhammad abdur rehman assistant professor medical “a” unit lady reading hospital, peshawar frequency of retinopathy and its different grades among type ii diabetic patients with metabolic syndrome pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 223 dr. mohammad zeeshan tahir medical officer department of ophthalmology lady reading hospital, peshawar references 1. muhammad a, gamal n, fawaz n. increased prevalence of micro vascular complications in type 2 diabetes patients with the metabolic syndrome imaj. 2006; 8: 378–82. 2. raman r, gupta a, pal ss, ganesan s, venkatesh k, kulothungan v, sharma t. prevalence of metabolic syndrome and its influence on micro vascular complications in the indian population with type 2 diabetes mellitus. 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microvascular function relates to insulin sensitivity and blood pressure in normal subjects. circulation. 1999; 99: 896–902. 17. frisbee jc. remodeling of the skeletal muscle microcirculation increases resistance to perfusion in obese zucker rats. am j physiol. 2003; 285: 104–11. 18. skovborg f, nielsen av, lauritzen e, hartkopp o. diameters of the retinal vessels in diabetic and normal subjects. diabetes. 1969; 18: 292–8. 19. grunwald je, dupont j, riva ce. retinal haemodynamics in patients with early diabetes mellitus. br j ophthalmol. 1996; 80: 327–31. 20. klein r, klein bek, moss s, wong ty, hubbard ld, cruickshanks kj. retinal vascular abnormalities in persons with type 1 diabetes. the wisconsin epidemiological study of diabetic retinopathy. ophthalmology. 2003; 110: 2118–25. 21. wong ty, shankar a, klein r, klein be. retinal vessel diameters and the incidence of gross proteinuria and renal insufficiency in people with type 1 diabetes. diabetes. 2004; 53: 179–84. 22. khan mna, khan fa, sultana s, dilawar m, ijaz a, khan mja, et al. impact of new diagnostic criteria of diabetes mellitus. j coll physicians surg pak 2007; 17:327–30. 23. massin pa, erginay b, haouchine ab, mehidi m. retinal thickness in healthy and diabetic subjects measured using optical coherence tomography mapping software. eur j ophthalmol. 2008; 12: 102-12. 24. yamamoto tn, akabane s. vitrectomy for diabetic macular edema: the role of posterior vitreous detachment and epimacular membrane. am j ophthalmol. 2007; 132: 69-97. http://www.ncbi.nlm.nih.gov/pubmed?term=sharma%20t%5bauthor%5d&cauthor=true&cauthor_uid=21067623 http://www.ncbi.nlm.nih.gov/pubmed?term=chambless%20le%5bauthor%5d&cauthor=true&cauthor_uid=10845884 http://www.ncbi.nlm.nih.gov/pubmed?term=cooper%20ls%5bauthor%5d&cauthor=true&cauthor_uid=10845884 http://www.ncbi.nlm.nih.gov/pubmed?term=hubbard%20ld%5bauthor%5d&cauthor=true&cauthor_uid=10845884 http://www.ncbi.nlm.nih.gov/pubmed?term=evans%20g%5bauthor%5d&cauthor=true&cauthor_uid=10845884 http://www.ncbi.nlm.nih.gov/pubmed?term=schmidt%20mi%5bauthor%5d&cauthor=true&cauthor_uid=12020333 http://www.ncbi.nlm.nih.gov/pubmed?term=pankow%20js%5bauthor%5d&cauthor=true&cauthor_uid=12020333 http://www.ncbi.nlm.nih.gov/pubmed?term=couper%20dj%5bauthor%5d&cauthor=true&cauthor_uid=12020333 http://www.ncbi.nlm.nih.gov/pubmed?term=klein%20be%5bauthor%5d&cauthor=true&cauthor_uid=12020333 http://www.ncbi.nlm.nih.gov/pubmed?term=hubbard%20ld%5bauthor%5d&cauthor=true&cauthor_uid=12020333 http://www.ncbi.nlm.nih.gov/pubmed?term=duncan%20bb%5bauthor%5d&cauthor=true&cauthor_uid=12020333 http://www.ncbi.nlm.nih.gov/pubmed?term=duncan%20bb%5bauthor%5d&cauthor=true&cauthor_uid=14970147 http://www.ncbi.nlm.nih.gov/pubmed?term=couper%20dj%5bauthor%5d&cauthor=true&cauthor_uid=14970147 http://www.ncbi.nlm.nih.gov/pubmed?term=klein%20be%5bauthor%5d&cauthor=true&cauthor_uid=14970147 http://www.ncbi.nlm.nih.gov/pubmed?term=hubbard%20ld%5bauthor%5d&cauthor=true&cauthor_uid=14970147 http://www.ncbi.nlm.nih.gov/pubmed?term=nieto%20fj%5bauthor%5d&cauthor=true&cauthor_uid=14970147 http://www.ncbi.nlm.nih.gov/pubmed?term=ter%20wee%20pm%5bauthor%5d&cauthor=true&cauthor_uid=10027812 http://www.ncbi.nlm.nih.gov/pubmed?term=rauwerda%20ja%5bauthor%5d&cauthor=true&cauthor_uid=10027812 http://www.ncbi.nlm.nih.gov/pubmed?term=donker%20aj%5bauthor%5d&cauthor=true&cauthor_uid=10027812 http://www.ncbi.nlm.nih.gov/pubmed?term=gans%20ro%5bauthor%5d&cauthor=true&cauthor_uid=10027812 172 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology original article role of intravitreal bevacizumab (avastin) in diffuse diabetic macular edema rafeen talpur, muhammad jawed, fariha s. wali, faisal taqvi, shehnilla shujaat pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. muhammad jawed department of ophthalmology, sindh institute of ophthalmology and visual sciences hyderabad, pakistan. e-mail: jawedbiotech@yahoo.com …..……………………….. purpose: to observe the changes in best corrected visual acuity (va) and central macular thickness after intravitreal injection of bevacizumab (avastin) in patients suffering from diffuse macular edema. study design: observational study. place and duration of study: sindh institute of ophthalmology and visual sciences, hyderabad, sindh. from july 2017 to december 2017. material and methods: 50 eyes from 29 patients suffering from diffuse diabetic macular edema (dme) were given intravitreal bevacizumab. patients with va ≤ 20/60, hba1c ≤ 7.5 % were included. while, patients with high diabetic profile, high blood pressure, increased blood urea and creatinine level and past history of stroke were excluded. slit-lamp examination was performed to observe the number of anterior chamber cells. best corrected va investigated by early treatment diabetic retinopathy study (etdrs) chart and complete ocular examination was performed on each patient. swept source optical coherence tomography (oct) was used for the measurement of central macular thickness (cmt). results: 50 eyes of 29 patients between 35 and 75 years of age (mean 49.28 ± 8.16 years) were given intravitreal injection of bevacizumab. the base line va & central macular thickness mean were noted, significant increase in va & decrease in macular thickness after 3 months of 3 rd administration of injection avastin was confirmed by oct. two way anova was used to analyze the data. conclusion: bevacizumab plays an important role in reducing diabetic macular edema and improving vision. stability and increase in va was observed and cmt in diabetic macular edema was decreased after intravitreal injection of bevacizumab. key words: bevacizumab, diabetic macular edema, vascular endothelial growth factor. iabetic retinopathy (dr) is one of the major causes of visual disorders in actively working population in the world1. moreover, in developing countries dr has been demonstrated as a chief cause of blindness. leakage of macular capillaries results in diabetic macular edema (dme) which is the main reason of visual impairment in proliferative and non-proliferative dr2,3. vascular permeability factor, also known as vascular endothelial growth factor (vegf), is a single protein which causes the phosphorylation of tight proteins that stimulates the formation of blood vessels and hence increases the permeability of retinal vessels4. similarly, vegf gene is known to induce its transcription by hypoxia and has been reported to be a major inducer of vegf gene transcription5,6. patients suffering from proliferative diabetic retinopathy (pdr) have been found with higher levels of vegf in ocular d mailto:jawedbiotech@yahoo.com role of intravitreal bevacizumab (avastin) in diffuse diabetic macular edema pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 173 fluids7. in addition, when normal eyes of experimental animals were inoculated with vegf, they resulted with micro aneurysm formation and higher vascular permeability which are the same pathological conditions seen in the patients of diabetic retinopathy8,9. retinal neovascularization and macular edema have also been shown to be affected by vegf10,11. treatments with anti vegf drugs have been proved as a substitute for the management of diffuse diabetic macular edema (dme)12and retinal neovascularization (rn)13. bevacizumab (avastin) is a drug used in the treatment of diabetic eye diseases, age related macular degeneration (amd) and other retinal disorders. it is a full length protein which binds to all families of vegf and has been used systemically in tumor therapy14. intravitreal injection of avastin has been reported as a useful drug in the suppression of choroidal neovascularization, macular edema due to central retinal vein occlusion (crvo), vascular permeability and fibro-vascular proliferation. furthermore, intravitreal injection of avastin does not seem to be harmful at high concentration in the retina of albino rabbit18. compared with laser, anti vegf drugs have been reported more effective. avastin is extensively used off-label as an intravitreal management of macular edema due to other causes10. in the following study, we investigated the role of anti vegf bevacizumab (avastin) in patients suffering from dme wherein, vegf is the main mediator of vascular permeability and plays a key role in the catabolism of retinal blood barrier. material and methods 50 eyes of 29 patients of diffuse dme were recruited in this study. it was accepted by institutional review board (irb) of siovs. the diagnosis of diffuse dme was investigated by swept source oct. inclusion criteria comprised of best-corrected va ≤ 20/60, glycated hemoglobin ≤ 7.5%, any gender, patients with type 2 diabetes mellitus, aging between 35 to 75 years. diffuse dme criteria was defined as hard retinal exudates within 500µm of the macular center, 1 disc diameter or greater retinal edema, any part of which was under the limit of 1 disc diameter of center of macular area. exclusion criteria comprised of patients with bleeding disorders, any infection of cornea, former treatment of avastin, recent history of heart attack, hypertension and former history of laser either focal or grid. all patients were selected through retina clinic of sindh institute of ophthalmology & visual science (siovs), hyderabad, after fulfilling the inclusion criteria. objectives and methods of study were explained and then consent form was signed from each individual. slit lamp examination was done in each patient. swept source oct was performed for assessment of macular thickness before administration of avastin. anti vegf bevacizumab (avastin, 1.25 mg/ 0.05 ml) was injected intravitreal by monthly interval for three months. it was injected after local anesthesia, 3.5 mm in pseudophakic and 4 mm in phakic patients away from limbus. swept source oct was performed on all patients 3 months after anti vegf injection. outcome was observed on the basis of decrease in central macular thickness (cmt) and improvement in visual acuity. swept source oct was performed to confirm the effect of anti vegf (avastin) in diffuse dme. data was analyzed using spss version 24. results a total of 50 eyes of 29 patients were selected during this study. among whom, 32 eyes were from males and 18 from females. avastin was injected intravitreal in all 50 eyes of 29 patients. patients’ ages ranged between 35 and 75 years (mean 49.28 ± 8.16 years). all patients selected in this study were non-insulin dependent diabetic (niddm), had diffuse dme, which was confirmed by swept source oct. the baseline va mean & cmt mean were noted, significant increase in va & decrease in macular thickness after 3 months of 3rd administration of injection avastin was confirmed by oct. during this 3 months study, there were no complains of intraocular irritation, endophthalmitis, enhanced iop and detachment of retina. statistical analysis of oct and visual acuity (va) are described in table1 and table 2, respectively. rafeen talpur, et al 174 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology table1: descriptive statistics of oct at baseline and after 3 months of intravitreal injection of avastin. n cmt (µm) minimum cmt (µm) maximum mean sd baseline 50 300 595 372.14 77.60 1 month 50 250 389 323.19 73.82 3 months 50 166 498 278.94 75.86 p value 0.03904* cmt – central macular thickness sd – standard deviation analysis was performed in spss version 24.0 *represents a significant difference table 2: descriptive statistics of visual acuity (va) at baseline and after 3 months of intravitreal injection of avastin. n minimum maximum mean sd va pre 50 0.3 1.0 0.692 0.1915 et1 50 0.2 1.0 0.540 0.2306 et3 50 0.2 1.0 0.438 0.2423 p value 0.02804* va pre – baseline etdrs visual acuity, et1 – etdrs visual acuity at one month, et3 – etdrs visual acuity after three months sd – standard deviation analysis was performed in spss version 24.0 * represents a significant difference discussion the most frequent complication in diabetic patients is diffuse dme, which is a significant cause of visual impairment in these patients. due to increase in extracellular fluid, the level of vision decrease, as a result barriers within the retinal blood vessels due to accumulation of this extracellular fluid. it has been reported that dme and vegf are affected by retinal hypoxia, which increases vascular permeability of macula, leads to dme in patients of diabetes. bevacizumab is known to produce quick result in recovery of macular edema. as demonstrated in the section ‘results’, a total of 50 eyes from 29 patients were examined during this research. all the eyes were given intravitreal injection of avastin, which lead to functional and physiological betterment. central macular thickness (cmt) before administration of injection avastin ranged from 300 to 595 µm with a mean of 372.14 µm. fig. 1: comparison of visual acuity (va); va pre – at baseline. va1 – va after 1 month, va3 – va after 3 months. as shown in figure 1, after one month of administration of avastin, significant decrease in visual acuity was observed with a mean of 0.540 µm. on the other hand, mean cmt decreased noteworthy up to 323.19 ± 32.58 µm ranging from 250.78 to 389.76 µm. 46 eyes showed increased in va, while 4 eyes showed no difference in va. role of intravitreal bevacizumab (avastin) in diffuse diabetic macular edema pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 175 fig. 2: comparison of central macular thickness at baseline (before) and after three months of injection avastin. after three months of the treatment with injection avastin, there was a noteworthy decrease in cmt, ranging from 166 to 498 µm in all 50 patients with a mean of 278µm measured from swept source oct (fig. 2). 47 eyes showed reduction in macular thickness and only 3 eyes showed minor increase in macular thickness. mean va before injected injection avastin was 0.692. during this study, no systemic side effects were noticed and bevacizumab was well tolerated. there was no evidence of ocular inflammation, correspondingly, optical tolerance was also good. as compared with the study reported by haritoglou et al.20 our research proved noteworthy decease in cmt and improvement in visual acuity. recently, chen et al described the mechanism and fig. 3(a): central macular thickness before injection avastin 474µm, measured by swept source 3d optical coherence tomography. fig. 3(b): central macular thickness after 3rd intravitreal injection of avastin was 218 µm showing significant improvement. degenerative effects of intravitreal ranibizumab in 10 different eyes in patients suffering from macular edema21. on the other hand, our study showed improvement in oct findings and va in comparatively more patients (fig. 3). conclusion anti vegf injection of bevacizumab (avastin) proved to be capable for the management of diabetic macular edema and improving vision. at the doses of 1.25 mg/0.05 ml, it provided significant increase in va and helps in decreasing cmt in dme. we may assume without any harm that the rate of visual complications were managed with no significant side effects. acknowledgement this study was conducted at sindh institute of ophthalmology and visual sciences, hyderabad, under directorship of professor dr. khalid iqbal talpur. financial support and sponsorship nil. conflict of interest there are no conflicts of interest author’s affiliation dr. rafeen talpur fcps, ophthalmology, assistant professor department of ophthalmology, sindh institute of ophthalmology and visual sciences hyderabad. dr. muhammad jawed ph.d biochemistry and molecular biology research associate scientific ophthalmic research and pathology laboratory, sindh institute of ophthalmology and visual sciences hyderabad dr. fariha s. wali fcps, ophthalmology, assistant professor department of ophthalmology, sindh institute of ophthalmology and visual sciences hyderabad. dr. faisal taqvi fcps, frcs, ophthalmology, assistant professor rafeen talpur, et al 176 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology department of ophthalmology, sindh institute of ophthalmology and visual sciences hyderabad. dr. shehnilla shujaat ms, ophthalmology, senior registrar department of ophthalmology, sindh institute of ophthalmology and visual sciences hyderabad. role of authors dr. rafeen talpur primary investigator dr. muhammad jawed data analysis, formatting and correspondence dr. fariha s. wali co-investigator dr. faisal taqvi co-investigator dr. shehnilla shujaat co-investigator references 1. 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diabetic macular edema pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 177 castellarin aa, nasir maa, et al. intravitreal bevacizumab (avastin) in the treatment of proliferative diabetic retinopathy. ophthalmology, 2006; 113 (10): 1695-705.e6. 20. neubauer as, kook d, haritoglou c, priglinger sg, kampik a, ulbig mw, et al. bevacizumab and retinal ischemia. ophthalmology, 2007; 114 (11): 2096-.e2. 21. chun dw, heier js, topping tm, duker js, bankert jm. a pilot study of multiple intravitreal injections of ranibizumab in patients with center-involving clinically significant diabetic macular edema. ophthalmology, 2006; 113 (10): 1706-12. 246 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology indexes (volume 29, 2013) no.1. january.…………………………………………….. page 1-61 no.2. april…………………………………………………. page 62-130 no.3. july……………………………………………….…. page 131-188 no.4 october……………………………………………… page 189-252 subject index abstracts: 29: 57-8, 124-5, 184-5, 242-3. adnexa conservative management of congenital eversion of the upper lid in a nigerian child 29: 186. frontalis suspension for unilateral ptosis with poor levator function 29: 3-7. obituary prof. syed ali haider (1962 -2013) cataract congenital cataract: morphology and management 29: 151-5. prevalence of hepatitis b and c in urban patients undergoing cataract surgery 29: 147-50. cataract surgery intraocular pressure after iol implantation with hydroxypropylmethylcellulose 2% vs hydroimplantation 29: 12-5. negative dysphotopsia after uncomplicated phacoemulsification 29: 53-6. community correlation between axial length and retinal nerve fiber layer thickness in myopic eyes 29: 169-72. conjunctival leiomyoma “a case report” 29: 1779. endophthalmitis in immunocompromised patient 29, 238-41. features, causes and prevention of toxic anterior segment syndrome (tass) – an outbreak investigation 29, 100-5. prevalence of hepatitis b and hepatitis c in elective ocular surgery (rural origin) at shifa eye hospital, khanpur 29, 31-3. review of outpatient department spencer eye hospital (a study of 1900 patients) 29, 16-20. tuberculosis (tb) – an ophthalmic perspective 29, 46-9. conjunctiva comparison between topical olopatadine hydrochloride 0.1% and ketotifen fumarate 0.025% for the relief of symptoms of vernal keratoconjunctivitis (vkc) 29, 202-5. use of silver nitrate in superior limbic keratoconjunctivitis 29, 180-3. cornea can subconjunctival bevacizumab injection regress corneal neovascularization? 29, 21-5. complications of contact lenses; a clinicoexperimental study to evaluate the effects of bacterial contamination 29, 137-46. correlation between central corneal thickness measurements using two different ultrasonic pachymeters 29, 214-7. descemet’s membrane detachment repair with sodium hyaluronate after phacoemulsification 29, 110-5. efficacy of sub-conjunctival bevacizumab in high risk cornel transplantations 29, 206-9 epidemiology of microbial keratitis in a tertiary care center in karachi 29, 94-9. lasik in hyperopic eyes with congenital nystagmus: a case report 29, 106-9. prophylactic use of mitomycin – c on haze formation in photorefractive keratectomy 29, 1346. role of topical human milk in the treatment of neurotrophic corneal opacity 29, 192-7. surgically induced corneal astigmatism in conventional 20 – gauge versus trans-conjunctival sutureless 23 – gauge vitrectomy 29, 228, 31. editorial cataract and refractive surgery 29: 62-3. ophthalmic challenges in our community 29: 1-2. recent advancements in management of uveitis 29, 189-91. the basics of research in ophthalmology 29, 132-3. indexes pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 247 glaucoma comparison of changes in intraocular pressure after subtenon triamcinolone acetonide and topical dexamethasone 29, 160-3. needle revision of failed drainage blebs with mitomycin – c 29: 64-7. the effectiveness of conventional trabeculectomy in controlling intraocular pressure in our population 29, 26-30. news and events: 29: 60-1, 130, 187, 245. orbit cryo assisted minimally invasive surgery for the treatment of orbital cavernous haemangiomas 29, 116-23. retina alcohol related toxic optic neuropathy case series 29, 173-6. association between hyperhomocysteinemia and diabetic retinopathy 29, 197-201. bilateral symmetric retinal pigmentation versus heterochromia: a case of waardenburg syndrome 29, 50-2. retinal detachment surgery in oculocutaneous albinos patient 29, 235-7. sclera role of topical cyclosporin in scleritis: a case series 29, 68-72. squint adjustable sutures in constant exotropia 29, 192-6. trauma a clinico-epidemiological study of ocular trauma in indian university students 29, 80-8. epidemiology of age related macular degeneration (amd) and it’s associated ocular conditions and concomitant systemic diseases cataract 29, 210-3. non-surgical management of traumatic nonpenetrating hyphaema among nigerian ophthalmologists 29, 89-93. non-penetrating eye injuries in victims of bomb blasts and mine blasts 29, 8-11. non-penetrating eye injuries in victims of bomb blasts and mine blasts 29, 127. visual outcome of ocular trauma 29, 34-9. vitreous comparison between 23 – gauge and 25 – gauge pars plana vitrectomy for posterior segment disease 29, 40-5. effectiveness of intravitreal bevacizumab in various ocular diseases 29, 73-9. role of intravitreal bevacizumab before pars plana vitrectomy in patients with vitreous hemorrhage due to proliferative diabetic retinopathy 29, 156-9. safety of 23 gauge transconjunctival sutureless 3 port pars plana vitrectomy for vitreoretinal diseases 29, 164-8. author index ahmad a: comparison between 23 – gauge and 25 – gauge pars plana vitrectomy for posterior segment disease 29, 40-5. ahmad cn: safety of 23 gauge transconjunctival sutureless 3 port pars plana vitrectomy for vitreoretinal diseases 29, 164-8. ahmad cn: surgically induced corneal astigmatism in conventional 20 – gauge versus trans-conjunctival sutureless 23 – gauge vitrectomy 29, 228,-31. ahmad i: correlation between axial length and retinal nerve fiber layer thickness in myopic eyes 29, 169-72. ahmad k: lasik in hyperopic eyes with congenital nystagmus: a case report 29, 106-9. ahmad k: correlation between central corneal thickness measurements using two different ultrasonic pachymeters 29, 214-7. ahmed m: role of topical human milk in the treatment of neurotrophic corneal opacity 29, 192-7. ahmad mi: complications of contact lenses; a clinicoexperimental study to evaluate the effects of bacterial contamination 29, 137-46. ahmad n: surgically induced corneal astigmatism in conventional 20-gauge versus trans-conjunctival sutureless 23-gauge vitrectomy 29, 217-20. ahmad n: safety of 23 gauge transconjunctival sutureless 3 port pars plana vitrectomy for vitreoretinal diseases 29, 164-8 ahmad r: the effectiveness of conventional trabeculectomy in controlling intraocular pressure in our population 29, 26-30. ahmad s: cryo assisted minimally invasive surgery for the treatment of orbital cavernous haemangiomas 29, 116-23. afaq a: effectiveness of intravitreal bevacizumab in various ocular diseases 29, 73-9. akram s: lasik in hyperopic eyes with congenital nystagmus: a case report 29, 106-9. akram s: correlation between central corneal thickness measurements using two different ultrasonic pachymeters 29, 214-7. indexes pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 248 alam m: non-penetrating eye injuries in victims of bomb blasts and mine blasts 29, 8-11. alam m: erratum: non-penetrating eye injuries in victims of bomb blasts and mine blasts 29, 127. alam m: erratum: non-penetrating eye injuries in victims of bomb blasts and mine blasts 29, 127. alam m: comparison of changes in intraocular pressure after subtenon triamcinolone acetonide and topical dexamethasone 29, 160-3. aldebasi yh: complications of contact lenses; a clinico-experimental study to evaluate the effects of bacterial contamination 29, 137-46. aly sm: complications of contact lenses; a clinicoexperimental study to evaluate the effects of bacterial contamination 29, 137-46. amin f: epidemiology of age related macular degeneration (amd) and it’s associated ocular conditions and concomitant systemic diseases cataract 29, 221-5. anklesaria zh: lasik in hyperopic eyes with congenital nystagmus: a case report 29, 106-9. anklesaria zh: correlation between central corneal thickness measurements using two different ultrasonic pachymeters 29, 214-7. ansari msa: comparison between topical olopatadine hydrochloride 0.1% and ketotifen fumarate 0.025% for the relief of symptoms of vernal keratoconjunctivitis (vkc) 29, 202-5. arain tm: comparison between topical olopatadine hydrochloride 0.1% and ketotifen fumarate 0.025% for the relief of symptoms of vernal keratoconjunctivitis (vkc) 29, 202-5. arif m: surgically induced corneal astigmatism in conventional 20 – gauge versus trans-conjunctival sutureless 23 – gauge vitrectomy 29, 228-31. ashraf km: intraocular pressure after iol implantation with hydroxypropylmethylcellulose 2% vs hydro-implantation 29, 12-5. asif gh: descemet’s membrane detachment repair with sodium hyaluronate after phacoemulsification 29, 110-15. awan ah: prophylactic use of mitomycin – c on haze formation in photorefractive keratectomy 29, 134-6. ayub m: visual outcome of ocular trauma 29, 34-9. ayub m: congenital cataract: morphology and management 29, 151-5. aydin r: can subconjunctival bevacizumab injection regress corneal neovascularization? 29, 21-5. azhar mn: comparison between topical olopatadine hydrochloride 0.1% and ketotifen fumarate 0.025% for the relief of symptoms of vernal keratoconjunctivitis (vkc) 29, 202-5. bhatti n: efficacy of sub-conjunctival bevacizumab in high risk cornel transplantations 29, 206-9 bhatti n: epidemiology of microbial keratitis in a tertiary care center in karachi 29, 94-9. bhutto ia: needle revision of failed drainage blebs with mitomycin – c 29: 64. bhushan p: a clinico-epidemiological study of ocular trauma in indian university students 29, 80-8. bokhari sa: adjustable sutures in constant exotropia 29, 192-6. butt hm: news and events: 29: 60-1, 130, 187, 245. chaudhry ql: abstracts: 29: 57-8, 124-5, 184-5, 242-3. chaudry ql: safety of 23 gauge transconjunctival sutureless 3 port pars plana vitrectomy for vitreoretinal diseases 29, 164-8. chaudry ql: surgically induced corneal astigmatism in conventional 20 – gauge versus trans-conjunctival sutureless 23 – gauge vitrectomy 29, 217-20. chauhan k: comparison between 23-gauge and 25 – gauge pars plana vitrectomy for posterior segment disease 29, 40-5. chinedu ac: non-surgical management of traumatic non-penetrating hyphaema among nigerian ophthalmologists 29, 89-93. chuka om: non-surgical management of traumatic non-penetrating hyphaema among nigerian ophthalmologists 29, 89-93. daulat naghza: epidemiology of age related macular degeneration (amd) and it’s associated ocular conditions and concomitant systemic diseases cataract 29, 221-5. dawood a: frontalis suspension for unilateral ptosis with poor levator function 29, 3-7. durak i: can subconjunctival bevacizumab injection regress corneal neovascularization? 29, 21-5. fasih u: review of outpatient department spencer eye hospital (a study of 1900 patients) 29, 16-20. farooq o: cryo assisted minimally invasive surgery for the treatment of orbital cavernous haemangiomas 29, 116-23. fawad h: visual outcome of ocular trauma 29, 34-9. fawad h: congenital cataract: morphology and management 29, 151-5. fawad u: epidemiology of microbial keratitis in a tertiary care center in karachi 29, 94-9. fehmi ms: review of outpatient department spencer eye hospital (a study of 1900 patients) 29, 16-20. indexes pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 249 fasih u: prevalence of hepatitis b and c in urban patients undergoing cataract surgery 29, 147-50. fidelis mc: non-surgical management of traumatic non-penetrating hyphaema among nigerian ophthalmologists 29, 89-93. ghayoor i: alcohol related toxic optic neuropathy case series 29, 173-6 ghayoor i: the effectiveness of conventional trabeculectomy in controlling intraocular pressure in our population 29, 26-30. ghayoor i: association between hyperhomocysteinemia and diabetic retinopathy 29, 197-201. hashmi a: surgically induced corneal astigmatism in conventional 20 – gauge versus trans-conjunctival sutureless 23 – gauge vitrectomy 29, 217-20. hasan m: epidemiology of microbial keratitis in a tertiary care center in karachi 29, 94-9. heidari e: bilateral symmetric retinal pigmentation versus heterochromia: a case of waardenburg syndrome 29, 50-2. huda w: prevalence of hepatitis b and c in urban patients undergoing cataract surgery 29, 147-50. hussain m: efficacy of sub-conjunctival bevacizumab in high risk cornel transplantations 29, 206-9. hussain m: correlation between axial length and retinal nerve fiber layer thickness in myopic eyes 29, 169-72. iqbal h: role of topical cyclosporin in scleritis: a case series 29, 68-72. iqbal m: erratum: non-penetrating eye injuries in victims of bomb blasts and mine blasts 29, 127. iqbal m: non-penetrating eye injuries in victims of bomb blasts and mine blasts 29, 8-11. iqbal y: intraocular pressure after iol implantation with hydroxypropylmethylcellulose 2% vs hydroimplantation 29, 12-5. irfan s: role of topical cyclosporin in scleritis: a case series 29, 68-72. jafri shr: frontalis suspension for unilateral ptosis with poor levator function 29, 3-7. jafri a: alcohol related toxic optic neuropathy case series 29, 173-6 jahangir k: comparison between 23-gauge and 25gauge pars plana vitrectomy for posterior segment disease 29, 40-5. jameel n: prevalence of hepatitis b and c in urban patients undergoing cataract surgery 29, 147-50. janjua ta: cryo assisted minimally invasive surgery for the treatment of orbital cavernous haemangiomas 29, 116-23. janicijevic k: endophthalmitis in immunocompromised patient 29, 238-41. jovanovic p: endophthalmitis in immunocompromised patient 29, 238-41. kamil z: adjustable sutures in constant exotropia 29, 192-6. karam n: epidemiology of age related macular degeneration (amd) and it’s associated ocular conditions and concomitant systemic diseases cataract 29, 221-5. karina j. recent advancements in management of uveitis 29, 189-91. kadri wm: descemet’s membrane detachment repair with sodium hyaluronate after phacoemulsification 29, 110-5. kayani h: comparison between 23-gauge and 25gauge pars plana vitrectomy for posterior segment disease 29, 40-5. kazi a: efficacy of sub-conjunctival bevacizumab in high risk cornel transplantations 29, 206-9. kazi u: role of intravitreal bevacizumab before pars plana vitrectomy in patients with vitreous hemorrhage due to proliferative diabetic retinopathy 29, 156-9. khalil m: use of silver nitrate in superior limbic keratoconjunctivitis 29, 180-3. khan aa: surgically induced corneal astigmatism in conventional 20 – gauge versus trans-conjunctival sutureless 23 – gauge vitrectomy 29, 217-20. khan dh: epidemiology of age related macular degeneration (amd) and it’s associated ocular conditions and concomitant systemic diseases cataract 29, 221-5. khan sd: epidemiology of age related macular degeneration (amd) and it’s associated ocular conditions and concomitant systemic diseases cataract 29, 221-5. khan dr: epidemiology of age related macular degeneration (amd) and it’s associated ocular conditions and concomitant systemic diseases cataract 29, 221-5. khan mr: comparison between topical olopatadine hydrochloride 0.1% and ketotifen fumarate 0.025% for the relief of symptoms of vernal keratoconjunctivitis (vkc) 29, 202-5. khan a: role of intravitreal bevacizumab before pars plana vitrectomy in patients with vitreous hemorrhage due to proliferative diabetic retinopathy 29, 156-9. khan aa: safety of 23 gauge transconjunctival sutureless 3 port pars plana vitrectomy for vitreoretinal diseases 29, 164-8. indexes pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 250 khan h: comparison of changes in intraocular pressure after subtenon triamcinolone acetonide and topical dexamethasone 29, 160-3. khan md: the basics of research in ophthalmology 29, 132-3. laghari da: needle revision of failed drainage blebs with mitomycin – c 29, 64. mahmood ma: role of topical human milk in the treatment of neurotrophic corneal opacity 29, 192-7. mahmood r: prevalence of hepatitis b and hepatitis c in elective ocular surgery (rural origin) at shifa eye hospital, khanpur 29, 31-3. mahju tm: surgically induced corneal astigmatism in conventional 20 – gauge versus trans-conjunctival sutureless 23 – gauge vitrectomy 29, 217-20. mal w: retinal detachment surgery in oculocutaneous albinos patient 29, 235-7. mahar ps: needle revision of failed drainage blebs with mitomycin – c 29, 64. mahar ps: negative dysphotopsia after uncomplicated phacoemulsification 29, 53-6. malik iq: correlation between axial length and retinal nerve fiber layer thickness in myopic eyes 29, 169-72. malik tg: use of silver nitrate in superior limbic keratoconjunctivitis 29, 180-3. maurya rp: a clinico-epidemiological study of ocular trauma in indian university students 29, 80-8. memon as: needle revision of failed drainage blebs with mitomycin – c 29, 64. memon s: alcohol related toxic optic neuropathy case series 29, 173-6. memon m: alcohol related toxic optic neuropathy case series 29, 173-6. mirza a: intraocular pressure after iol implantation with hydroxypropylmethylcellulose 2% vs hydroimplantation 29, 12-5. munawar s: use of silver nitrate in superior limbic keratoconjunctivitis 29, 180-3. nadeem s: congenital cataract: morphology and management 29, 151-5. nadeem s: visual outcome of ocular trauma 29, 34-9. nasir j: editorial: cataract and refractive surgery 29, 62. nizamani nb: alcohol related toxic optic neuropathy case series 29, 173-6. niazi mk: cryo assisted minimally invasive surgery for the treatment of orbital cavernous haemangiomas 29, 116-23. obizoba ol: non-surgical management of traumatic non-penetrating hyphaema among nigerian ophthalmologists 29, 89-93. ozbek z: can subconjunctival bevacizumab injection regress corneal neovascularization? 29, 21-5. petrovic maj: endophthalmitis in immunocompromised patient 29, 238-41. qazi za: comparison between topical olopatadine hydrochloride 0.1% and ketotifen fumarate 0.025% for the relief of symptoms of vernal keratoconjunctivitis (vkc) 29, 202-5. qidwai u: efficacy of sub-conjunctival bevacizumab in high risk cornel transplantations 29, 206-9 qidwai u: role of intravitreal bevacizumab before pars plana vitrectomy in patients with vitreous hemorrhage due to proliferative diabetic retinopathy 29, 156-9. qidwai n: frontalis suspension for unilateral ptosis with poor levator function 29, 3-7. rabbani a: role of intravitreal bevacizumab before pars plana vitrectomy in patients with vitreous hemorrhage due to proliferative diabetic retinopathy 29, 156-9. rais m: review of outpatient department spencer eye hospital (a study of 1900 patients) 29, 16-20. rauf a: frontalis suspension for unilateral ptosis with poor levator function 29, 3-7. raza z: surgically induced corneal astigmatism in conventional 20-gauge versus trans-conjunctival sutureless 23-gauge vitrectomy 29, 217-20. rehman a: review of outpatient department spencer eye hospital (a study of 1900 patients) 29, 16-20. rehman a: prevalence of hepatitis b and c in urban patients undergoing cataract surgery 29, 147-50. rehman a: epidemiology of microbial keratitis in a tertiary care center in karachi 29, 94-9. rehman h: comparison between 23 – gauge and 25 – gauge pars plana vitrectomy for posterior segment disease 29, 40-5 rehman ma: correlation between axial length and retinal nerve fiber layer thickness in myopic eyes 29, 169-72. rehman m: surgically induced corneal astigmatism in conventional 20-gauge versus trans-conjunctival sutureless 23-gauge vitrectomy 29, 217-20. riaz q: epidemiology of microbial keratitis in a tertiary care center in karachi 29, 94-9. rizvi f: adjustable sutures in constant exotropia 29, 192-6. rizvi sf: retinal detachment surgery in oculocutaneous albinos patient 29, 235-7. saeed m: role of topical human milk in the treatment of neurotrophic corneal opacity 29, 192-7. indexes pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 251 sarwar s: correlation between axial length and retinal nerve fiber layer thickness in myopic eyes 29, 169-72. sarwar s: surgically induced corneal astigmatism in conventional 20 – gauge versus trans-conjunctival sutureless 23 – gauge vitrectomy 29, 228-31. sarenac – vulovic t: endophthalmitis in immunocompromised patient 29, 238-41. saatci ao: can subconjunctival bevacizumab injection regress corneal neovascularization? 29, 21-5. selver ob: can subconjunctival bevacizumab injection regress corneal neovascularization? 29, 21-5. selver ma: can subconjunctival bevacizumab injection regress corneal neovascularization? 29, 21-5. shah sra: surgically induced corneal astigmatism in conventional 20 – gauge versus trans-conjunctival sutureless 23 – gauge vitrectomy 29, 217-20. shakir m: adjustable sutures in constant exotropia 29, 192-6. shahid e: effectiveness of intravitreal bevacizumab in various ocular diseases 29, 73-9. sharif ul hasan k: effectiveness of intravitreal bevacizumab in various ocular diseases 29, 73-9. shoaib kk: features, causes and prevention of toxic anterior segment syndrome (tass) – an outbreak investigation 29, 100-5. shoaib kk: tuberculosis (tb) – an ophthalmic perspective 29, 46-9. shah sra: safety of 23 gauge transconjunctival sutureless 3 port pars plana vitrectomy for vitreoretinal diseases 29, 164-8. shafique mm: use of silver nitrate in superior limbic keratoconjunctivitis 29, 180-3. shaikh a: review of outpatient department spencer eye hospital (a study of 1900 patients) 29, 16-20. shaikh ar: frontalis suspension for unilateral ptosis with poor levator function 29, 3-7. shaikh a: prevalence of hepatitis b and c in urban patients undergoing cataract surgery 29, 147-50. siddiqui sh: retinal detachment surgery in oculocutaneous albinos patient 29, 235-7. siddiqui zk: obituary: prof. syed ali haider (1962 – 2013) 29, 128, 239-41. siddiqui s: association between hyperhomocysteinemia and diabetic retinopathy 29, 197-201. sinha k: a clinico-epidemiological study of ocular trauma in indian university students 29, 80-8. singh vp: a clinico-epidemiological study of ocular trauma in indian university students 29, 80-8. singh mk: a clinico-epidemiological study of ocular trauma in indian university students 29, 80-8. soomro fa: frontalis suspension for unilateral ptosis with poor levator function 29, 3-7. soomro mz: prevalence of hepatitis b and hepatitis c in elective ocular surgery (rural origin) at shifa eye hospital, khanpur 29, 31-3. surhio sa: alcohol related toxic optic neuropathy case series 29, 173-6. tabassum g: alcohol related toxic optic neuropathy case series 29, 173-6 tabassum g: the effectiveness of conventional trabeculectomy in controlling intraocular pressure in our population 29, 26-30. talpur ki: alcohol related toxic optic neuropathy case series 29, 173-6. tahir my: surgically induced corneal astigmatism in conventional 20-gauge versus trans-conjunctival sutureless 23-gauge vitrectomy 29, 228-31. tabssum g: association between hyperhomocysteinemia and diabetic retinopathy 29, 197-201. vujic d: endophthalmitis in immunocompromised patient 29, 238-41. vulovic d: endophthalmitis in immunocompromised patient 29, 238-41. wahab s: editorial: ophthalmic challenges in our community 29, 1-2. yaghoobi g: bilateral symmetric retinal pigmentation versus heterochromia: a case of waardenburg syndrome 29, 50-2. yaqub ma: cryo assisted minimally invasive surgery for the treatment of orbital cavernous haemangiomas 29, 116-23. yousif a: surgically induced corneal astigmatism in conventional 20-gauge versus trans-conjunctival sutureless 23-gauge vitrectomy 29, 217-20. zafar s: adjustable sutures in constant exotropia 29, 192-6. zafar s: retinal detachment surgery in oculocutaneous albinos patient 29, 239-41. zaka m: epidemiology of age related macular degeneration (amd) and it’s associated ocular conditions and concomitant systemic diseases cataract 29, 221-5. zia s: intraocular pressure after iol implantation with hydroxypropylmethylcellulose 2% vs. hydroimplantation 29, 12-5. zubair f: alcohol related toxic optic neuropathy case series 29, 173-6. indexes pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 252 abstracts index cornea corneal cross – linking as a treatment for keratoconus four – year morphologic and clinical outcomes with respect to patient age 29, 124. corneal collagen cross-linking with riboflavin and ultraviolet a irradiation for keratoconus 29, 184. effect of corneal collagen cross – linking on corneal innervation, corneal sensitivity, and tear function of patients with keratoconus 29, 124. long-term rejection incidence and reversibility after penetrating and lamellar keratoplasty 29, 57. role of corneal collagen cross-linking in pseudophakic bullous keratopathy a clinico pathological study 29, 243. glaucoma detection of glaucomatous progression by spectral-domain optical coherence tomography 29, 185. the effect of an ahmed glaucoma valve implant on corneal endothelial cell density in children with glaucoma secondary to uveitis 29, 58. twenty-four hour efficacy with preservative free tafluprost compared with latanoprost in patients with primary open angle glaucoma or ocular hypertension 29, 243. lacrimal incidence of canalicular closure with endonasal dacryocystorhinostomy without intubation in primary nasolacrimal duct obstruction 29, 185. retina displacement of the retina and its recovery after vitrectomy in idiopathic epiretinal membrane 29, 125. persistent outer retinal fluid following nonposturing surgery for idiopathic macular hole 29, 244. surgical management of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled trials 29, 184. treatment of coats’ disease with intravitreal bevacizumab 29, 57. tumor lesions simulating retinoblastoma (pseudoretinoblastoma) in 604 cases results based on age at presentation 29, 57. vitreous spontaneous vitreous hemorrhage in children 29, 244. microsoft word 5. murina shakir 72 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology original article corneal graft in children munira shakir, syeda aisha bokhari, shakir zafar, zeeshan kamil, syed fawad rizvi pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: munira shakir house no. 61 l.r.b.t free base eye hospital, karachi korangi 21/2, karachi. postal code74900 …..……………………….. purpose: to share our experience of penetrating keratoplasty in children at a tertiary care hospital material and methods: in this study, records of pediatric keratoplasty performed on 90 eyes in 85 children of less than 14 years of age at the pediatric department of lrbt free base eye hospital karachi, for the period of 3 years from january 2006 to december 2008 were reviewed. results: out of 85 patients, 45 (52.94%) were boys and 40 (47.05%) were girls. indications were scarring after keratitis in 16 (17.7%) eyes, traumatic corneal scarring in 16 (17.7%), corneal dystrophies 22 (24.4%), keratoconus and hydrops in 26 (28.8%), chemical injury in 8 (8.8%) and congenital glaucoma in 2 (2.2%). total 65 out of 90 (72%) eyes showed clear cornea at final follow up. grafts performed for keratoconus were the most successful in terms of graft survival, which accounted for 23 out of 26 (88.46%) eyes. improvement in visual acuity was recorded in 64 out of 90 (71.11%) eyes. best corrected visual acuity of 6/24 or better was achieved in 22 out of 90 (24.44%) patients. conclusion: in conclusion, our experience of keratoplasty in pediatric age group yielded promising results. eratoplasty is one of the world’s most widely practiced human organ and tissue transplanttation method1. corneal grafting is usually indicated for optical reason to restore vision occasionally it may be performed for cosmetic appearance of the eye2. modern day success in transplantation is attributed to eye banking, storage techniques, ocular pharmacology, equipment and modern surgical techniques3. paedriatic keratoplasty is a difficult undertaking, which presents a wide range of challenges pre-operatively, intra-operatively and postoperatively4. successful restoration of vision with paediatric keratoplasty has only been achieved in the past two to three decades5. previously pediatric corneal transplantation was considered contraindicated in children,6 because of the technical challenges in pediatric anterior segment surgery created by low scleral rigidity and forward displacement of lens-iris diaphragm. in children, the potential for post-surgical anterior segment inflammation may lower scleral rigidity which increases the likelihood of significant refractive errors after corneal transplantation. the underlying disease process will also influence the timing of surgery,5 presence of amblyopia, associated ocular pathology, and greater severity of the diseased may significantly limit visual outcome4. the upper age limit used to define the pediatric population varies among experts and may include adolescents up to the age of 21 which is consistent with the definition foundin several well-known sources7,8. the surgical procedure is technically more complex owing to the decreased rigidity and increased elasticity of the infant cornea and sclera, the smaller size of the infant eye, the increased intraoperative fibrin formation and the positive vitreous pressure4. postoperative follow up and management may be more complicated, and graft rejection is often difficult to detect and treat4. material and methods this retrospective case series reviewed 90 eyes of 85 patients, who underwent penetrating keratoplasty k munira shakir, et al. pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 73 from january 2006 to december 2008 in pediatric department lrbt free base eye hospital, karachi. out of 85 patients, 45 (52.94%) were boys and 40 fig. 1 fig. 2: fig. 3: fig. 4: (47.05%) were girls. inclusion criteria included patients with age ranging from 6 to 14 years with no sex predeliction; patients diagnosed with traumatic corneal scarring,corneal dystropies, keratoconus and hydrops, chemical injury and congenital glaucoma. exclusion criteria included combined non-corneal procedures,herpetic keratitis, patients with age below 6 years and patients who were lost to follow up.minimum follow up was 6 months while mean follow up was 15 months.preoperatively all patients underwent a complete ocular examination which included visual acuity assessment, intraocular pressure measurement, slit lamp and dilated fundus examination, a and b scan if needed. at the end of surgery all patients received systemic and topical steroids to decrease inflammatory reaction. topical cycloplegics, steroids and antibiotic eye drops were administered postoperatively. follow up examinations were performed consisting of visual acuity assessment and slit-lamp examination, intraocular pressure, fundus examination and if needed ultrasonic examinations. in the eyes with amblyopia, occlusion or atropinization of the good eye was conducted postoperatively. early optical correction with spectacles or contact lenses was pursued as aggressively as possible. data was analysed on spss (version 13). frequency and percentages were calculated for age, gender, best corrected visual acuity, graft survival and failure. chi-square test and fisher exact test were applied to calculate p-value and p< 0.005 was taken as statistically significant. surgical technique all penetrating keratoplasty surgeries were done by the same surgeon, under general anesthesia. standard corneal graft in children 74 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology table 1: graft failure and survival in different groups and their statistical significance (p<0.005) disease number n graft survival n graft failure n p-value keratitis 16 8 8 0.016 corneal scarring 16 12 4 1 dystrophies 26 16 10 0.088 keratoconus 26 25 1 0.0014 congenital glaucoma 2 1 1 0.4566 chemical injury 6 3 3 0.181 total 88 65 23 surgical technique was used throughout. source of graft was from eye bank of canada. prior to surgery donor’s cornea were stored in mc carey kaufman storage medium. the donor corneal button was trephined from the endothelial surface of the corneoscleral button. the diameter of the corneal button was 0.25-0.5mm larger than that of the recipient bed. the donor cornea was sutured to the recipient cornea with 10-0 nylon interrupted sutures. the mean diameter of the donor corneal button was 7.5mm (range 7.0-8.0 mm), and the mean diameter of the recipient bed was 7.0mm (range 6.5-7.5 mm). the mean time of sutures removal after keratoplasty was 10±4 months. earlier suture removal was performed in case of loosening of the sutures and increased vascularization of the host cornea. results this study included 90 eyes of 85 patients out of which, 45 (52.94%) were boys and 40 (47.05%) were girls. the mean age at the time of penetrating keratoplasty was 10 years (ranged from 6 to 14 years). minimum follow up was 6 months while mean follow up was 15 months. preoperative best corrected visual acuity ranged from light perception and hand movement to 6/60. postoperative visual acuity improvement was recorded in 64 (71%) out of 90 eyes. visual acuity improvement ranged from counting finger to 6/12 partial. twenty two (24.44%) out of 90 patients achieved a best corrected visual acuity of 6/24 or better. graft failures was defined as irreversible loss of corneal clarity. overall 65 (72.22%) out of 90 eyes showed clear cornea at final follow up. most grafts failed because of allograft rejection that is 13 (56.52%) out of 23, secondary infection was noted in 08(34.78%) out of 23 and secondary glaucoma was found in 2 (8.69%) out of 23. two patients were lost to follow up. graft survival was seen in a total of 65 (73.86%) out of 88 patients of which 8 (50%) out of 16 patients were of keratitis, 12 (75%) out of 16 patients were of corneal scarring, 16 (61.5%) out of 26 patients were of dystrophies, 25 (96.15%) out of 26 patients were of keratoconus, 1 (50%) out of 2 patients were of congenital glaucoma and 3 (50%) out of 6 patients were of chemical injury. grafts performed for keratoconus were most successful in terms of graft survival 23 (88.46%) out of 26 (p=0.0014), table 1. intraoperative complications were raised intraocular pressure seen in 4 (4.44%) eyes, iris injury in 1 (1.11%), bleeding from vascularized cornea 2 (2.22%) and decentration in 1 (1.11%) eye. postoperative complications were suture related corneal infiltrates in 6 (6.66%) eyes, acute uveitis in 1 (1.11%) case post traumatic adherent leucoma 1 (1.11%) eye, peripheral anterior synechiae in 2 (2.22%) eyes, secondary glaucoma was noted in 4 ( 4.44%), persistent epithelial defect in 5 ( 5.55%) and development of cataract in 2 ( 2.22%) eyes. discussion corneal grafting is a simple surgical procedure, which is most of the time straight forward. however, the rehabilitation time after surgery is long because of a slow healing process and many of the factors that affect visual outcome are uncertain. it is therefore; especially important with this procedure to try to understand more about what may be achieved in the long term. the success rate of penetrating keratoplasty in children is not as high as it is in adults. the reasons munira shakir, et al. pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 75 for the poorer prognosis are technically difficult surgery and irreversible amblyopia9. penetrating keratoplasty in children is generally considered a high risk procedure, because surgery in a small eye can lead to a sclera collapse. moreover, the iris is more adherent and the vitreous more tenacious in children than in adults9. improved results have been attributed in part to the advantages in surgical technique, improved donor-storage media and development of viscoelastics. therefore, the rate of intraoperative complications has been significantly declined.9despite all the developments, the incidence of inflammatory reaction and immunological rejection is still significant. the prognosis for graft clarity in children is poorer because of the high bioreactivity and healing potential of a child’s eye, which is very rapid and causes sutures to loosen quickly10. in this series overall graft survival at the end of follow up was 65 out of 90 (72.22%). graft performed for keratoconus were most successful in terms of graft survival which was seen in 23 out of 26 (88.46%). gabric n et all reported 64% graft survival in their series of corneal transplantation, with best prognosis in graft for keratoconus and congenital dystrophy11. overall 5-year graft survival was 82%, with keratoconus and corneal dystrophy as reported by rehman i et all12. dandona l et al also reported 46.5% graft survival in their study, with highest rate of graft survival for keratoconus13. patel hy, documented 82% graft survival at the end of one year14. in this study postoperative visual acuity improvement was recorded in 64 out of 90 (71.11%) eyes. visual acuity improvement ranged from counting finger to 6/12 partial. 22 out of 90 (24.44%) patients achieved a best corrected visual acuity of 6/24 or better. mcclellan et al reported improvement in visual acuity better than 6/60 in only 14% of cases15. xu-jia h et al reported improvement in visual acuity by 6/18 or better in 13% of cases1. conclusion in this study 72.22% eyes showed clear cornea postoperatively with improvement in visual acuity seen in 71.11%. most successful results were seen in eyes with keratoconus in which graft survival was observed in 88.46% cases. keeping the above findings in view, we conclude that keratoplasy is a safe and effective treatment in pediatric age-group. further clinical trials are required to establish these findings. author’s affiliation dr. munira shakir consultant ophthalmologist l.r.b.t free base eye hospital, karachi korangi 2 1/2, karachi. postal code74900 dr. syeda aisha bokhari associate ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi. postal code74900 dr. shakir zafar consultant ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi. postal code74900 dr. zeeshan kamil associate ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi postal code74900 dr. syed fawad rizvi chief consultant ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi postal code74900 reference 1. xu hj, jiang xj, jie sm, et al. pediatric penetrating keratoplasty in shanghai: a retrospective multiple centre study from 2003 to 2007. chin med j. 2008; 121: 1911-4. 2. corneal and refractive surgery. in: kanski jj. clinical ophthalmology a systemic approach. london: butterworth heineman: 2011. 239-50. 3. mc neill ji. pentrating keratoplasty: preoperative considerations, indications and outcomes. in krachker jh, mannis mj, holland ej (eds). mosby: cornea, st louis. 1997; 3: 1551-61. 4. vajpayee rb, ramu m, panda a et al. oversized grafts in children. ophthalmology. 1999; 106: 829-32. 5. pediatric penentrating keratoplasty. in: krachmer jh, mannis mj, holland ej, cornea: surgery of the cornea and conjunctiva. st louis: mosby year book. 1997; 1731-56. 6. leigh ag. corneal grafting. br j clin pract. 1958; 12: 329. 7. berham re, kliegman r, arvin am, et al. nelson textbook of pediatrics, 15thed, philadelphia: w.b saunders company; 1996. 8. rudolph am. rudolph’s pediatrics, 21st ed. ny: mcgraw-hill; 2002. 9. stulting rd. penetrating keratoplasty in children. in: brightbill, f.s., (ed.): corneal surgery. (mosby st. louis, missouri, 1993). 10. dana, mr, schaumberg da, moyes al, et al. gomes jap, ophthalmology. 1997; 104: 1580. corneal graft in children 76 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology 11. gabric n, dekaris i, vojnikovic b, et al. corneal transplantation in children. coll antropol 2001; 25: 17-22. 12. rahman i, carley f, hillarby c, et al. penetrating keratoplasty: indications, outcomes, and complications. eye. 2009; 23: 1288-94. 13. dandona l, naduvilath t, janarthanan m, et al. survival analysis and visual outcome in a large series of corneal transplants in india. 14. patel hy, ormonde s, brookes nh, et al. the indications and outcome of paediatric corneal transplantation in new zealand: 1991-2003. br j ophthalmol. 2005: 89: 404-8. 15. mcclellan k, lai t, grigg j, et al. penetrating keratoplasty in children: visual and graft outcome. br j ophthalmol. 2003; 87: 1212-4. pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 33 original article comparison of goldmann applanation, diaton transpalpebral and air puff tonometers sana nadeem, b. a. naeem, rabeea tahira, shizza khalid, abdul hannan pak j ophthalmol 2015, vol. 31 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sana nadeem department of ophthalmology foundation university medical college/fauji foundation hospital, rawalpindi doctorsana@hotmail.com …..……………………….. purpose: to compare the intraocular pressure (iop)) measurements in normal subjects, between the newly developed, transpalpebral tonometer (diaton®), goldmann applanation tonometer (gat), and air-puff tonometer (apt), and to assess agreement between the three devices. material and methods: a total of 400 eyes of 200 random subjects were included in this cross-sectional, comparative study. iop was measured with apt (canon full auto tonometer tx-f®), followed by diaton®, and lastly gat (haag streit at 900® tonometer) in both eyes. the mean iops and the differences between iops of the tonometers were calculated by the paired t-tests. their correlations were calculated using the pearson correlation coefficients, mean differences were analyzed by one-way analysis of variance, and agreement was analyzed by the bland-altman method. results: the mean iops noted for diaton, gat, and apt were 14.78 ± 3.22, 14.62 ± 3.01, and 14.42 ± 3.22 mm of hg, respectively. the pearson’s correlation coefficient (r) between diaton and gat was 0.314, between diaton and apt; 0.334, and between gat and apt; was 0.745. hence, the strongest correlation was between gat and apt, followed by moderate correlation of diaton with apt, and least between diaton and gat. however, correlations between all three tonometers were significant at the 0.01 level. bland-altman analysis revealed that the mean differencesbetween diaton and gat measurements was 0.16 ± 3.6 mm hg, between gat and apt was 0.20 ± 2.2 mm hg, and between diaton and apt was 0.36 ± 3.7 mm hg. the 95 % limits of agreement were smallest between gat and apt, as compared to the other two pairs. thus good agreement was observed between gat and apt, and there was fair agreement of diaton with both gat and apt. conclusion: measurement of intraocular pressures by all three tonometers was comparable with good correlation in normal adults. there was good agreement between gat and apt, and fair agreement of diaton with gat and apt. apt can be used as a screening device for patients. however, diaton is not a very useful device for screening purpose, because of wider variations. key words: intraocular pressure, transpalpebral tonometry, goldmann applanation tonometer, air-puff tonometry. laucoma is a leading cause of irreversible blindness worldwide. intraocular pressure (iop) is a monumental parameter in the diagnosis and monitoring of glaucoma. accurate measurement of iop is the hallmark for the management of glaucoma patients. iop is the sole g mailto:doctorsana@hotmail.com sana nadeem, et al 34 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology modifiable risk factor; the reduction of which is known to slow the progression of this potentially blinding condition.1-6 goldmann applanation tonometer (gat) is considered the „gold standard‟ in iop measurement being the most accurate and reliable of all the tonometers invented so far. this slit-lamp mounted device is based on the imbert-fick2, 7 principle, which states that the pressure (p) inside an ideal, dry thinwalled sphere is equal to the force (f) required to applanate its surface, divided by the area (a) {3.06 mm} of flattening (p=f/a). air puff tonometers (apt) are non-contact devices that applanate the cornea by a puff of air and measure iop by the time required to flatten a given area of the cornea. due to wide variations in readings, they are used largely for screening purposes.7 transpalpebral tonometers like diaton have been developed recently and considered by some8,9 to be well-tolerated, portable, user-friendly, light weight instruments that do not need topical anesthesia. whenever a new tonometer is developed, it is routine practice to compare it to the existing, reliable tonometers. no local studies have been performed on this transpalpebral tonometer to compare it with other devices. hence, we embarked on a study to assess this transpalpebral tonometer, in terms of practicality and accuracy of iop measurements, and compared it with the precise and renowned goldmann tonometer; used routinely in glaucoma patients, and with our air-puff tonometer used for routine screening of every patient arriving at our out – patient department. material and methods a total of 400 eyes of 200 random subjects were included in this cross-sectional, comparative study carried out in the last two weeks of november, 2013. the subjects included consenting presumably normal adults attending our out-patient department, their attendants, hospital staff and doctors volunteering for the study, 16 years of age and above (range 16-67). exclusion criteria included uncooperative patients to any method of tonometry, previously known glaucomatous patients, history of antiglaucoma drugs, trauma, ocular disease, scarred corneas, or intraocular or refractive surgery, astigmatism2 of 3 diopters or more by autorefraction, diabetes or other serious systemic ailments. air-puff tonometry, followed by diaton tonometry, and lastly applanation tonometry was performed in both eyes, to prevent applanation induced lowering of iop. the air-puff tonometer that used was canon full auto tonometer tx-f®. apt was done first by a single observer and a mean of three readings was taken (fig. 1). then transpalpebral tonometry using the diaton® tonometer (fig. 2) was done by two observers with comparable readings. this instrument is based on the principle10 of determining the acceleration of a rod during free fall, with a definite weight on interactive with the elastic eyeball through the lids.the patient must be sitting in a chair with the head in horizontal position, and the eyes gazing at the patient‟s thumb used for fixation at 45° angle. the observer should be at the side of the patient. the tonometer must be vertical when switched on. the upper eyelid should be manually retracted 1 mm above the limbus, and three readings should be taken with the tonometer tip touching the lid parallel to the lid margin, and the mean iop is read on the scale (fig. 3). lastly, applanation tonometry was done by a single observer using the same goldmann tonometer (haag streit at 900®) (fig. 4). the instrument was calibrated according to the manufacturer‟s instructions. the eye was anaesthetized with alcaine® (proparacaine hydrochloride 0.5 %) eye drops (alcon) and a fluorescein strip was placed in the inferior conjunctival fornix to stain the tear film. three consecutive iop readings were taken for each eye, with aseptic precautions and the mean was calculated for each eye. all types of tonometry were performed between 8:00 a.m. to 2:00 p.m. the difference in iop readings were compared between the three tonometers. the data was collected on a performa noting the age, gender, and iop measurements of all three tonometers in a tabulated form. data was analyzed by spss version 20. mean iops and the differences between iops of the tonometers were calculated using the paired t-tests. the correlations between the tonometers were calculated using the pearson correlation coefficients and the mean differences between the tonometers was analyzed by one-way analysis of variance. the agreement between the devices was analyzed by the bland-altman method and plots were constructed between the means of iops (x axis), and the difference of iops (y axis), between the pairs of devices. the mean iop difference (bias) and the 95% limits of agreement; which represent the range in which 95% of comparison ofgoldmann applanation, diaton transpalpebral and air puff tonometers pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 35 fig. 1: the air puff tonometer. fig. 2: the diaton tonometer. the differences between iop measurements by the instruments would occur; were analyzed for each pair. linear regression analysis was conducted on the iop measurements of the three devices, and regression based limits of agreement were analyzed. fig. 3: procedure of diaton tonometry. fig. 4: the goldmann applanation tonometer. results the average age of subjects enrolled in the study was 36.44 ± 13.76 years (range 16-67). there were 70 (35%) sana nadeem, et al 36 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology males and 130 (65%) females. the mean iops noted for diaton, gat, and apt were 14.78 ± 3.22 mm hg (range 8-23 mm hg), 14.62 ± 3.01 mm hg (range 8.6-25 mm hg), and 14.42 ± 3.22 mm of hg (range 7.5-24.4 mm hg), respectively (table 1). the difference of mean iops between gat and diaton was 0.16 ± 3.65 mm hg, between diaton and apt was 0.36 ± 3.72 mm hg, and between gat and apt was 0.20 ± 2.23 mm hg. the mean diaton iop was higher than gat, while mean apt iop was lower than gat. diaton was seen to overestimate iop in 195 (48.8%) eyes, in comparison to goldmann iop, underestimate iop in 174 (43.5%), and gave equivalent iop in 31 (7.8%) eyes. the apt was found to be underestimating iop in 204 (51%) eyes as compared to gat, overestimating in 179 (44.8%) eyes, and equal iop in 17 (4.3%) eyes. the pearson‟s correlation coefficient (r) between diaton and gat was 0.314, between diaton and apt was 0.334, and between gat and apt was 0.745 (table 2). hence, the strongest correlation was between gat and apt, followed by diaton and apt, and least between diaton and gat. however, correlations between all three tonometers were significant at the 0.01 level. agreement between the three devices was analyzed by the bland-altman analysis, which revealed the mean difference (bias) between diaton and gat measurements to be 0.16 ± 3.6 mm hg (+7.33 to -7.01 mm hg) (fig. 5), and the mean difference between gat and apt was 0.20 ± 2.2 mm hg (+ 4.57 to -4.17mm hg) [fig. 6], and between diaton and apt was 0.36 ± 3.7 mm hg (+7.65 to -6.93mm hg) (fig. 7). this shows good agreement between gat and apt, and fair agreement of diaton with both gat and apt. linear regression analysis (table 3) was done which revealed r2 values between gat and diaton, gat and apt, and apt and diaton to be 0.05, 0.01, and 0.00 respectively, indicating comparable performance between the three. analysis of variance between the three tonometers, showed that gat and apt could be used interchangeably (p=0.03) (table 2). discussion accuracy of iop measurement is the need for doctors managing glaucoma patients. goldmann applanation tonometer has surpassed all other tonometers in terms of reliability, accuracy, and is the benchmark of iop measurement. it is precise, easy to use with the slit lamp, and has low intraand inter-observer variability11. however, the effect of central corneal thickness, astigmatism, and corneal curvature, on influencing iop measurements with gat, is wellknown.2,7,12-15a thick central cornea leads to overestimating of the iop, and vice versa. the iop is underestimated for with-the-rule astigmatism and overestimated for against-the-rule astigmatism.16 tonometers that have been developed over the years have often been compared to this indisputable tonometer. our study shows that iops measured with gatand apt have good correlation, while both apt and diaton, and gat and diaton have moderate correlations; with the least correlation was found between gat and diaton. amongst the three devices, good agreement was seen between gat and apt, and comparison ofgoldmann applanation, diaton transpalpebral and air puff tonometers pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 37 fig. 5: agreement between gat and diaton (blandaltman plot). difference between goldmann applanation tonometer (gat) and diaton transpalpebral tonometer plotted against mean iop. the middle line indicates the estimated mean gat diaton difference. the upper and lower lines represent the 95% limits of agreement for the difference (+7.33 to -7.01 mm hg). fig. 6: agreement between gat and apt (blandaltman plot). difference between goldmann applanation tonometer (gat) and air puff tonometer (apt) plotted against mean iop. the middle line indicates the estimated mean gat-apt difference. the upper and lower lines represent the 95% limits of agreement for the difference (+4.57 to -4.17mm hg). fig. 7: agreement between diaton and apt (bland altman plot). difference between diaton and air puff tonometer (apt) plotted against mean iop. the middle line indicates the estimated mean diaton apt difference. the upper and lower lines represent the 95% limits of agreement for the difference (+7.65 to -6.93mm hg). there was fair agreement of diaton with both gat and apt. studies carried out by doherty,8 bali,17 li18 and lösch19 et al, showed that diaton and other transpalpebral tonometer measurements did not correlate much with gat, and the two devices had poor agreement. the mean iop difference was 1.62 ± 3.60 mm hg in the study by li,18 and in numerous other studies, the limits of agreement were found to be very wide, + 8.4 to – 9.6 observed by doherty8 et al, + 4.4 to -11.8 seen by losch19, and -9.9 to + 11.2 in bali‟s study.17 similarly, studies19 carried out by troost20 et al revealed transpalpebral tonometry to significantly underestimate iop compared to gat, with the effect being more pronounced as the iop rises. this contrasts with our study, in which diaton overestimated iop in the majority of eyes. sandner21 and toker22 et al have showed moderate correlation between gat and lid tonometry, with a wide variation21 in iop noted with the latter. we too noted the wide variation in iop measured by diaton. the above, in their experience recommend lid tonometry as a screening tool or, in cases where gat is not possible like scarred corneas. however, we would not recommend usage of diaton in routine clinical practice and do not consider it to be a useful device. sana nadeem, et al 38 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology numerous studies have been carried out comparing the air-puff tonometers with gat. a study carried out in bahawalpur23 listed the accuracy of apt as 49.7% with greater accuracy in the lower iop range, when compared to gat. similarly, a study conducted in north india24 shows a fair agreement between apt and gat when the iop is in the lower range (mean iop 1.2 mm hg with limits of agreement +4.7 to –2.3), but a high correlation, similar to our study. here too, the air puff was found to underestimate iop in the majority of cases, like we noted in our study. salim25 et al in their study in usa found a mean difference of -0.3 with limits of agreement of +6.8 to -7.4, and parker26 et al in uk noted mean iop of –0.11 mm hg (limits +2.10 to –2.33)thus revealing comparable performance of apt with gat, with good agreement in the normal iop range; however the variation began with higher iop range. on the contrary, a study carried out in iraq by farhood27 et al, found significant differences between the two devices, with apt overestimating iop in as many as 74% cases with a mean difference of 2.72 ± 2.34 mm hg. a major limitation of our study is that we have carried out the study on presumably normal subjects because we wanted to compare iop measurement by the three devices, in the normal range of iop. a few subjects with high iops were eventually diagnosed as glaucomatous later on. this prevents us from comparing the devices in the higher range of iops. because of the smaller sample size, we were unable to assess the above. we believe a larger scale study would be needed to assess the devices in extremes of iop. another limitation is our lack to assess the central corneal thickness of our subjects, and to evaluate its effect on the three individual devices. we plan to investigate the above at a later stage, in a separate study. some may consider transpalpebral tonometry to be useful for screening purposes, because it is portable, user friendly, and non-contact, but we do not deem it very useful in our practice, due tovariability of iop, difficult positioning of the patient, and wide variation in measurement. also, the slit-lamp mounted applanation tonometer is far more useful, accurate and convenient for us to use. the air-puff tonometer has been used and recommended largely for screening of patients, and has good agreement with gat, so we consider it to be a useful tonometer in our out-patient department for screening of every patient presenting to us. however, we do confirm the iop by gat in cases of glaucoma and when suspicion may arise. conclusion compared to goldmann tonometry, both air-puff tonometer and diaton have good correlation; however, only apt has good agreement with gat, while diaton has fair agreement with the two devices. apt is a useful tool for screening of iop, but diaton cannot be recommended as an accurate screening tool, due to wider variations in iop. author’s affiliation dr. sana nadeem assistant professor department of ophthalmology foundation university medical college / fauji foundation hospital, rawalpindi dr. b.a. naeem professor and head department of ophthalmology, foundation university medical college/ fauji foundation hospital, rawalpindi dr. rabeea tahira postgraduate trainee, department of ophthalmology foundation university medical college/ fauji foundation hospital, rawalpindi dr. shizza khalid house surgeon, department of ophthalmology foundation university medical college/ fauji foundation hospital, rawalpindi dr. abdul hannan post-graduate trainee al-shifa trust eye hospital, 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diatontonometry: an assessment of validity and preference against goldmann tonometry. clin experiment ophthalmol. 2012; 40: 171-5. 9. waisbourd m, shemesh g, top lb, lazar m, loewenstein a. comparison of the transpalpebral tonometer tgdc-01 with goldmann applanation tonometry. eur j ophthalmol. 2010; 20: 902-6. 10. troost a, yun sh, specht k, krummenauer f, schwenn o. transpalpebral tonometry: reliability and comparison with goldmann applanation tonometry and palpation in healthy volunteers. br j ophthalmol. 2005; 89: 280–3. 11. dielemans i, vingerling jr, hofman a,grobbee de, de jong pt. reliability of intraocular pressure measurement with the goldmann applanation tonometer in epidemiological studies. graefes arch clin exp ophthalmol. 1994; 232: 141-4. 12. mark hh, mark tl. corneal astigmatism in applanation tonometry. eye, 2003; 17: 617-8. 13. rask g, behndig a. effects of corneal thickness, curvature, astigmatism and direction of gaze on goldmann applanation tonometry readings. ophthalmic res. 2006; 38: 49-55. 14. whitacre mm, stein ra, hassanein k. the effect of corneal thickness on applanation tonometry. am j ophthalmol. 1993; 115: 592-6. 15. lleó a, marcos a, calatayud m, alonso l, rahhal sm, sanchis – gimeno ja. the relationship between central corneal thickness and goldmann applanation tonometry. clin exp optom. 2003; 86: 104-8. 16. akram a, yaqub a, dar aj, fiaz. pitfalls in intraocular pressure measurement by goldmann – type applanation tonometers. pak j ophthalmol. 2009; 25: 22-4. 17. bali sj, bhartiya s, sobti a, dada t, panda a. comparative evaluation of diaton and goldmann applanation tonometers. ophthalmologica. 2012; 228: 42-6. 18. li y, shi j, duan x, fan f. transpalpebral measurement of intraocular pressure using the diaton tonometer versus standard goldmann applanation tonometry. graefes arch clin exp ophthalmol. 2010; 248: 1765-70. 19. lösch a, scheuerle a, rupp v, auffarth g, becker m. transpalpebral measurement of intraocular pressure using the tgdc-01 tonometer versus standard goldmann applanation tonometry. graefes arch clin exp ophthalmol. 2005; 243: 313-6. 20. troost a, specht k, krummenauer f, yun sh, schwenn o. deviations between transpalpebral tonometry using tgdc-01 and goldmann applanation tonometry depending on the iop level. graefes arch clin exp ophthalmol. 2005; 243: 853-8. 21. sandner d, böhm a, kostov s, pillunat l. measurement of the intraocular pressure with the “transpalpebral tonometer” tgdc-01in comparison with applanation tonometry. graefes arch clin exp ophthalmol. 2005; 243: 563-9. 22. toker mi, vural a, erdogan h, topalkara a, arici mk. central corneal thickness and diaton transpalpebral tonometry. graefes arch clin exp ophthalmol. 2008; 246: 881-9. 23. ahmad j, khan mr, azhar mn, arain tm, qazi za. accuracy of iop measured by non-contact (air – puff) tonometer compared with goldmann applanation tonometer. pak j ophthalmol. 2014; 30: 20-3. 24. mohan s, tiwari s, jain a, gupta j, sachan sk. clinical comparison of pulsair non-contact tonometer and goldmann applanation tonometer in indian population. journal of optometry. 2014; 7: 86-90. 25. salim s, lin dj, echols ii jr, netland pa. comparison of intraocular pressure measurements with the portable pt100 noncontact tonometer and goldmann applanation tonometry. clinical ophthalmology 2009; 3: 341–4. 26. parker va, herrtage j, sarkies njc. clinical comparison of the keeler pulsair 3000 with goldmann applanation tonometry. br j ophthalmol. 2001; 85: 1303– 4. 27. farhood qk. comparative evaluation of intraocular pressure with an air–puff tonometer versus a goldmann applanation tonometer. clinical ophthalmology. 2013; 7: 23–7. https://www.ncbi.nlm.nih.gov/pubmed/9780094 https://www.ncbi.nlm.nih.gov/pubmed?term=heijl%20a%5bauthor%5d&cauthor=true&cauthor_uid=12365904 https://www.ncbi.nlm.nih.gov/pubmed?term=leske%20mc%5bauthor%5d&cauthor=true&cauthor_uid=12365904 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https://www.ncbi.nlm.nih.gov/pubmed?term=rahhal%20sm%5bauthor%5d&cauthor=true&cauthor_uid=12643806 https://www.ncbi.nlm.nih.gov/pubmed?term=sanchis-gimeno%20ja%5bauthor%5d&cauthor=true&cauthor_uid=12643806 https://www.ncbi.nlm.nih.gov/pubmed/12643806 pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 234 original article visual outcome of cataract surgery after phacoemulsification sanaullah, muhammad saim khan, bilal murtaza, rafiq muhammad, syed akhtar pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad saim khan mbbs, fcps, mph khalifa gul nawaz teaching hospital, bannu email: saim_amc@hotmail.com …..……………………….. purpose: to observe the effect of phacoemulsification cataract surgery on visual acuity as well as record the frequency of complications associated with this procedure. study design: observational study. place and duration of study: the study was conducted at khalifa gul nawaz teaching hospital (kgnth), bannu, pakistan from jan. 2014 to dec. 2016. material and methods: patients who had significant senile cataract affecting quality of life were included in the study. patients suffering from congenital, traumatic, secondary cataract amblyopia, corneal opacity, uncontrolled glaucoma, uncontrolled diabetes, severe diabetic retinopathy, diabetic macular edema or other retinal diseases were also excluded. all the included patients underwent assessment of their preoperative unaided visual acuity (ucva) and best corrected visual acuity (bcva). detailed slit lamp examination including both anterior and posterior segments was carried out. patients were reviewed on day 1, 14 and then at 01 month. postoperative ucva and bcva were noted at 04 weeks. results: a total of 1061 eyes of 772 patients suffering from senile cataract were included in the study. mean age of patients was 63.77 ± 5.27 years, 56% (594) of the patients were females while 44% (467) were males. all the surgeries were performed under local anesthesia. 54% (622) of the eyes were right while 46% (439) were left. good final visual outcome was seen in 80.5% of the cases. intraoperative complications occurred in 5.4% (60) eyes of patients and posterior capsular rupture seen in 3.01% (32). conclusion: phacoemulsification is safe and effective procedure with good visual outcome if performed in experienced hands under meticulous disinfection and aseptic measures. keywords: phacoemulsification, cataract surgery, visual outcome, posterior capsular rupture. ge related cataract is one of the leading cause of reversible blindness all over the world and its treatment can be traced back to 4000 years ago in ancient egypt1,2. cataract surgery is one of the commonest surgical procedure carried out all over the world and the number of cataract patients undergoing surgery are about 19 million per year and this number is expected to reach about 30 million by 20203,4. standard surgical procedure for cataract extraction is phacoemulsification, which utilizes ultrasonic waves to emulsify the cataract. although this procedure is simple, safe, quick, and induces lesser amount of corneal astigmatism as compared to manual extracapsular cataract surgery (ecce) it can be associated with complications such as corneal edema, posterior capsular rupture, macular edema a sanaullah, et al 235 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology and endophthalmitis5,6,7. the clinical and refractive outcome of phacoemulsification and the associated risk of complications has largely been improved over the last decade with new machines and advent of premier intraocular lenses. the advancements in the evolution of latest techniques of cataract surgery has led us to the point that patients as well as surgeon have started expecting emmetropia after surgery8,9. in conventional phacoemulsification, manual creation of incision, capsulorhexis and phacoemulsification can affect the clinical as well as refractive outcome of surgery and the results can vary among the surgeons. the final visual acuity is the prime outcome measure which define the success of cataract surgery. world health organization (who) has categorized postoperative visual outcome of cataract surgery into three groups; good vision (6/6 6/12), impaired vision (6/18 – 3/60) and poor vision (< 3/60)10. various studies has been conducted across the globe on assessing postoperative visual outcome of cataract surgery. many authors concluded that 21 – 50% of patients have unaided visual acuity (va) of worse than 6/18 and 11-25% have best corrected visual acuity (bcva) of worse than 6/60 after cataract surgery11,12. the visual outcome of cataract surgery is dependent upon variety of preoperative factors such as selection of patients, visual potential, technique of cataract surgery, intraoperative complications and postoperative care13,14. most of these factors are modifiable and can be improved which can therefore, improve the visual outcome and patients’ satisfaction. the rationale of conducting this study is to do a clinical audit of this tertiary care hospital and measure the outcome of cataract surgery. this will help us understand and improve upon our surgical practices for management of patients. methodology this was an observational study that was conducted at army field hospital, kgnth district bannu, pakistan from jan. 2015 to dec 2016. all those patients who had significant senile cataract affecting quality of life were included in the study. patients suffering from congenital, traumatic or secondary cataract were excluded from the study. patients suffering from visual morbidity due to causes other than senile cataract such as amblyopia, corneal opacity, uncontrolled glaucoma, uncontrolled diabetes, severe diabetic retinopathy, diabetic macular edema or other retinal diseases were also excluded. ethical approval was obtained from ethical review board of army field hospital, khalifa gul nawaz teaching hospital (kgnth), bannu. informed consent was taken from all the patients. who calculator was used to measure the sample size which appeared to be about 500 eyes. each eye of the patient was given separate consideration. all the included patients were registered the preoperative unaided visual acuity (ucva), best corrected visual acuity (bcva) and demographic details were noted. detailed slit lamp examination including both anterior and posterior segments along with intraocular pressure measurement was carried out by consultant ophthalmologist. postoperatively patients were reviewed on day 1, 14 and then at 01 month. intraoperative complications such as corneal burns, posterior capsular rupture, supra choroidal hemorrhage and postoperative complications such as endophthalmitis or corneal decompensation were documented. postoperative ucva and bcva were noted at 04 weeks postoperatively. all the patients underwent phacoemulsification cataract surgery with intraocular lens (iol) implantation under peribulbar local anesthesia. phaco machine (visalis 100 virgin 1 zeis) was used to perform all the surgeries by one surgeon. meticulous sterilization measures were observed and 5% pyodine was instilled in conjunctival sac for 3 mins. main corneal incision was made at 12 o clock with 2.75 mm knife while two other incisions 1.5 mm were made at 10 and 2 o’clock positions. after removal of nucleus with phacoemulsification, two way simcoe cannula was used to remove cortical matter. after insertion of iol with injector, the incisions were hydrated and intra-cameral moxifloxacin was injected. patients were prescribed oral analgesics and antibiotics for 05 days while topical steroids and antibiotics were advised for 04 weeks. statistical package for social sciences (spss 21.0) was used to perform statistical analysis. both categorical and continuous variables were analyzed. mean and standard deviation were measured for continuous variables such as age, while frequency distribution was measured for ucva, bcva, gender and other categorical variables. results a total of 1245 eyes of 842 patients were operated for cataract during the study period, however, only 1061 visual outcome of cataract surgery after phacoemulsification pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 236 eyes of 772 patients suffering from age related cataract were included in the study. age of the patients ranged from 55 to 74 years with a mean age of 63.77 ± 5.27 years. 594 (56%) of the patients were females while 467 (44 %) were males. all the surgeries were performed under local anesthesia. 54% of the eyes were right while 46% were left (table 1). mean unaided visual acuity (va) and bcva before and 04 weeks after the surgery is given in fig 1 (p = 0.001). the percentage of operative and postoperative complications are given in table 2. table 1: age and gender based distribution of patients. variable subgroups proportion of patients percentage gender female 594 56% male 467 44% laterality right eye 622 58.6% left eye 439 41.3 % fig. 1: shows percentage of the visual outcome before and after cataract surgery. table 2: frequency distribution of various operative and postoperative complications. complications no of patients (n = 1061) percentage uneventful 1001 94.44 % suprachoroidal hemorrohage 02 0.25 pcr with nucleus/part of nucleus drop 7 0.6 % pcr with pc iol 32 3.01 % pcr with aci ol 6 0.5% zonular dialysis 2 0.2 % sanaullah, et al 237 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology aphakia 5 0.5% cmo 3 0.3% endophthalmitis 2 0.2 % discussion the continuous development of the techniques of cataract surgery over the past few decades has led us to the age of ultrasonic phacoemulsification which is the gold standard treatment for cataract treatment15. the visual outcome of cataract surgery has been variable in different parts of the world. in our study 39.0% of the patients had good visual outcome with an unaided visual acuity of 6/18 or better while after correction with spectacles 80.5% of the patients finally had vision of 6/18 or better. out of total 8.1% patients sustained poor visual outcome with visual acuity of worse than 6/60 despite spectacle correction. malik et al in their study conducted in pakistani population also found a good visual outcome of 6/18 or better in 71.8% of the patients which improved to 92.3% with refraction and spectacle correction. they also found poor visual outcome in 7.7% of their cases13. bourne et al in their study in bangladeshi population found out a good visual outcome (va better than 6/18) in 53.8% of patients while 3.5% patients had poor visual outcome14. many authors believe that postoperative visual acuity is the best parameter to assess the visual outcome and they concluded that more than half of the patients have visual acuity better than 6/18 while only 11 – 25% have visual acuity worse than 6/6016,17,18,19. poor visual outcome of patients after cataract surgery is dependent on many preoperative, intraoperative and postoperative factors. like bourne and malik, the most common reason for reduced vision was refractive error in our study as evidenced in table 2. the second common reason for unfavorable visual outcome was due to complications related with posterior capsular rupture (pcr) during surgery such as vitreous loss, tilted iol, cystoid macular edema, persistent uveitis, anterior chamber iol leading to raised iop, corneal edema. the incidence of intraoperative and postoperative complications in our study was 5.56 %while thanigasalam et al found out this to be 21.0% which is much higher than our study10. the probable reason for this is the patient selection whereby we excluded all predisposing factors and comorbidities associated with peroperative complications such as uncontrolled diabetes, uncontrolled glaucoma, phakodonesis.20 in a study conducted by hosemi h and his colleagues in iran the rate of intraoperative complications during phacoemulsification was estimated to be 3.1% which is comparable to our study21. pcr was seen in 3.01% of our patients, however other authors found this to be 10% and 11.3% in african populations and 4.4% in an national survey conducted in uk22,23. although, visual outcome of our patients was comparable to other published studies in the same population, the incidence of endophthalmitis was 0.2% which is slightly lower than the study conducted by kim et al24. the incidence of cmo was just 0.3% which is less than expected. the probable explanation for this is the time of review of patients after surgery. cmo is believed to occur 4 – 6 weeks after cataract surgery while we examined our patients at the end of 01 month, so this can probably explain its lower incidence in our study25. in this clinical audit, we found out our practices of cataract surgery to be satisfactory and comparable to other published literature in similar population22,23,24,25. conclusion it is concluded that patients’ selection, detailed history and examination is necessary before considering the patient for cataract surgery. phacoemulsification is safe and effective procedure with good visual outcome if performed in experienced hands under meticulous disinfection and aseptic measures. conflict of interest: nil. funding sources: nil. authors affiliation dr. sanaullah mbbs, fcps, mph khalifa gul nawaz teaching hospital bannu. dr. muhammad saim khan mbbs, fcps, fico, mrcsed khalifa gul nawaz teaching hospital bannu. visual outcome of cataract surgery after phacoemulsification pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 238 dr. bilal murtaza, mbbs khalifa gul nawaz teaching hospital bannu. dr. rafiq muhammad, mbbs khalifa gul nawaz teaching hospital bannu. dr. syed akhtar, mbbs khalifa gul nawaz teaching hospital bannu. role of authors dr. sanaullah conception and critical review. dr. muhammad saim khan conception and drafting. dr. bilal murtaza conception, review. dr. rafiq muhammad data collection. dr. syed akhtar data collection. references 1. pizzarello l, abiose a, ffytche t, duerksen r, thulasiraj r, taylor h, et al. vision 2020: the right to sight: a global initiative to eliminate avoidable blindness. arch ophthalmol. 2004; 122: 615–620. 2. mahmoud ao. traditional operative couching is not a safe alternative procedure for cataract surgery in northern nigeria. saudi med j. 2005; 8: 30–32. 3. savage-smith e. thepractice of surgery in islamic lands: myth and reality. soc hist med. 2000 aug; 13 (2): 307-2. 4. uy, h. s., edwards, k. & curtis, n. femtosecond phacoemulsification: the business and the medicine. curr opin ophthalmo. 2012; 23: 33–39. 5. devgan, u. surgical techniques in phacoemulsification. curr opin ophthalmol. 2007; 18: 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alaeddini f, fotouhi a. six year trend in cataract surgical techniques in iran. middle east afr j ophthalmol. 2011 apr; 18 (2): 150-3. 22. de silva sr, riaz y, evans jr. phacoemulsification with posterior chamber intraocular lens versus extracapsular cataract extraction (ecce) with posterior chamber intraocular lens for age-related cataract. the cochrane database of systematic reviews, 2014 (1): cd008812. 23. kim bz, patel dv, mcghee cn. auckland cataract study 2: clinical outcomes of phacoemulsification cataract surgery in a public teaching hospital. clinical & https://www.ncbi.nlm.nih.gov/pubmed/?term=thepractice+of+surgery+in+islamic+lands%3amyth+and+reality%2c%e2%80%9d+social+history+of+medicine https://www.ncbi.nlm.nih.gov/pubmed/?term=the+relationship+between+capsulorhexis+size+and+anterior+chamber+depth+relation%2c%e2%80%9d+ophthalmic+surgery+and+lasers 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f, carricondo pc, olivalves e, hirata ce, yamamoto jh. outcomes of phacoemulsification in patients with uveitis at a tertiary center in sao paulo, brazil: a review of cases from 2007 to 2012. arquivosbrasileiros de oftalmologia. 2017; 80 (2): 104-7. 98 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology original article subjective quality of vision before and after cataract surgery at holy family hospital, rawalpindi muhammad imran janjua, ali raza pak j ophthalmol 2018, vol. 34, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad imran janjua department of ophthalmology, holy family hospital, rawalpindi email: janjua.doc@gmail.com …..……………………….. objective: to determine mean change in subjective quality of vision in patients undergoing cataract surgery at holy family hospital, rawalpindi. study design: quasi experimental. place and duration of study: department of ophthalmology, holy family hospital, rawalpindi, over a period of six months, from april, 2015 to october, 2015. materials and methods: 60 patients, between the age of 30 to 70 years with bilateral cataract diagnosed by slit lamp examination, undergoing cataract surgery with phacoemulsification + iol at holy family hospital, rawalpindi were included in this study. patients were interviewed one day before surgery and their responses filled in the questionnaire. they were operated the next day by consultant ophthalmologist and then followed up for one month for uneventful recovery after cataract surgery. the patients were interviewed again using the same questionnaire. the mean pre-operative and post-operative scores were compared. results: a total of 60 patients were included in the study. out of these 25 (41.7%) were males and 35 (58.3%) were females. the mean age was 56.15 ± 4.90 years (mean ± s.d). the right eye was operated in 32 (53.3%) patients and the left eye in 28 (46.7%). the average pre-operative score was 19.60 ± 2.12 (mean ± s.d). at one month, post-operatively the mean score was 29.68 ± 2.66 (mean ± s.d). there was an average difference of 10.08 ± 2.16 (mean ± s.d) between the pre and post-operative scores which was statistically significant (p = 0.00). conclusion: cataract surgery is an extremely effective and economical procedure, which has far greater implications for the lives of patients that cannot be measured on a visual acuity chart. efforts should be made to educate people about the effectiveness and success of cataract surgery. key words: cataract, phacoemulsification, subjective visual recovery. ataract is one of the important causes of reversible blindness in the world1. cataract surgery is amongst the most frequently performed surgeries worldwide2. cataract causes impairment in visual function of patients, which has a negative impact on daily activities3. it also negatively affects patient‟s physical and mental health2. visual improvement is by far the most common indication for cataract surgery. operation is indicated when the opacity develops to a degree sufficient to cause difficulty in performing essential daily activities4. advances in the methods to perform cataract surgery in the last two decades have improved the visual outcome post operatively4. c subjective quality of vision before and after cataract surgery at holy family hospital, rawalpindi pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 99 phacoemulsification with placement of posterior chamber intraocular lens has become the procedure of choice for cataract extraction4. the subjective quality of vision and patient satisfaction is a very important indicator for measuring the outcome of cataract surgery5. patients ask for treatment not because of the result of any objective measurement but for their subjectively experienced problems 6. a previous study showed that there is significant improvement in visual function after cataract surgery as measured by the catquest-9sf questionnaire7. the purpose of cataract surgery should not only be to improve the visual acuity of patients but also, and more importantly, to enhance the subjective quality of vision. this study was conducted to determine the change in quality of vision before and after cataract surgery at holy family hospital, rawalpindi, so that deficiencies could be addressed in future and the patient morbidity is decreased. material and methods this quasi-experimental study was conducted from april 2015 to october 2015 at the department of ophthalmology, holy family hospital, rawalpindi. non-probability consecutive sampling was done to recruit the patients. all patients, both male and female, between the age of 30 to 70 years with bilateral cataract diagnosed by slit lamp examination, undergoing cataract surgery with phacoemulsification + iol at holy family hospital, rawalpindi were included in the study. patients with post traumatic cataract, those suffering from any other eye disease that causes decrease in visual function e.g. any macular pathology, glaucoma or moderate or severe diabetic or hypertensive retinopathy and patients having any complication during or after surgery e.g. posterior capsular rupture with vitreous loss, iol placed at any site other than the capsular bag or postsurgical infection were excluded. after taking informed consent, demographic data and contact number was taken to ensure follow up. patients were interviewed one day before surgery and their responses filled in the questionnaire. they were operated the next day and then followed-up for one month for uneventful recovery after cataract surgery. consultant ophthalmologist performed operation. after one month of surgery the patients were interviewed again using the same questionnaire. the mean pre-operative and post-operative scores were compared. all the data was entered and analyzed in statistical package for the social sciences (spss). for the categorical variables like gender, frequencies along with percentages were calculated. for the continuous variables like age and pre and post-operative scores, means and standard deviations were calculated. to determine any statistical difference between the pre op and post op mean scores, paired t-test was applied at 5% level of significance. effect modifiers like age, gender etc. were controlled by stratification. post stratification paired sample ttest was applied. results a total of 60 patients were included in the study. 25 (41.7%) were males and 35 (58.3%) were females (fig. 1). the mean age was 56.15 ± 4.90 years (mean ± s.d). (table-1).the right eye was operated in 32 (53.3%) patients and the left eye was operated in 28 (46.7 %) patients. 58.3% 41.7% males = 25 females = 35 fig. 1: gender distribution of study patients (n = 60). table 1: age of patients (n = 60). minimum age (years) maximum age (years) mean age (years) s.d. 45 65 56.15 4.90 the minimum pre-operative score was 14 and maximum score was 23. the average score was 19.60 ± 2.12 (mean ± s.d). at one-month post operatively the minimum score was 27 and maximum score was 33. the mean post-operative score was 29.68 ± 2.66 (mean ± s.d). the difference between post op and pre op gender muhammad imran janjua, et al 100 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology table 2: scores of patients (n = 60). pre op score post op score difference in score (post op – pre op) p-value minimum 14 27 5 0.00 maximum 23 33 15 mean 19.60 29.68 10.08 s.d. 2.12 2.66 2.16 table 3: score of patients according to gender (n = 60). gender (n) pre op score post op score p value mean s.d. mean s.d. males (25) 19.56 2.00 30.04 2.70 0.00 females (35) 19.63 2.22 29.43 2.64 0.00 table 4: score of patients according to age (n = 60). age (n) pre op score post op score p value mean s.d. mean s.d. 45 – 55 (23) 20.30 2.24 30.43 2.76 0.00 56 – 65 (37) 19.16 1.93 29.22 2.52 0.00 score was calculated and the minimum difference was 5 and maximum difference was 15. there was an average difference of score of 10.08 ± 2.16 (mean ± s.d). this difference between the post op and pre op score was statistically significant (p = 0.00) (table 2). the patients‟ age and gender did not have any significant effect on the results. after stratification according to age and gender, paired sample t-test was applied and there was significant difference between pre op and post op scores of patients (p = 0.00) (table 3 & 4). this shows that cataract surgery resulted in a significant improvement of subjective quality of vision in cataract patients. discussion cataract surgery in the developed world has undergone a revolution over the last 20 years. an operation, which used to require a stay in hospital and long visual rehabilitation, is now a quick day-case procedure with immediate benefits. there is now the potential to provide cataract surgery at an earlier stage of cataract maturation and save patients from a period of severe visual impairment8. lens opacities in the eye are inevitable in later life. the word „„cataract‟‟ is originally translated from greek “down rush” or latin “waterfall”9. a cataract is a symptomatic lens opacity that obstructs the passage of light and causes a reduction of vision. poor vision has a great impact on patient‟s lives. decreased visual function, regardless of cause, is associated with diminished quality of life and general functional living activities. although visual acuity is used as an objective measure when considering cataract surgery, it is standard practice to select patients on their symptoms of visual function and quality of life rather than purely on their visual acuity10,11. patients have widely differing visual demands and it is vital to take these into account when considering surgery. this study consisted of 60 cataract patients. all had visual symptoms and subjectively decreased quality of vision. they had difficulties in performing routine activities of daily life. when they were operated and after removal of cataract, the intraocular lens was implanted, they all had improvement in their visual quality and were able to carry out their everyday activities without difficulty. the overall benefits of cataract surgery on visual subjective quality of vision before and after cataract surgery at holy family hospital, rawalpindi pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 101 function have been demonstrated by many studies. previous studies showed that visual function and patient‟s quality of life were significantly improved by cataract surgery12. a study from the uk showed that even in patients with unilateral cataract, who had previously undergone uncomplicated contralateral cataract extraction with posterior chamber lens implantation, there was a significant improvement in the quality of vision after second eye cataract extraction with intraocular lens implant 13,14. a study from india showed that the long-term visual outcome of cataract surgery largely depends on the intra and post-operative complications like vitreous loss, post-operative corneal decompensation, retinal detachment etc. and other associated ocular diseases like optic atrophy, glaucoma, age related macular degeneration etc. another significant factor of surgical outcome is the experience of the operating surgeon15. keeping this in mind, the complicated cases and those with pre-existing ocular pathologies other than cataract were excluded from this study and only those patients were interviewed who had uneventful cataract surgery and post op recovery. consultant ophthalmologists performed the surgeries. cataract surgery can benefit older age groups in improving their quality of life as shown by a study from the usa16. majority of patients in my study belonged to middle and old age, and by offering them a quick and effective remedy for their cataracts, their visual quality was significantly improved. another study showed that even in early cataracts the patients can have significant subjective visual symptoms like glare and decreased contrast sensitivity and these can be effectively overcome by offering them early cataract surgery with implantation of posterior chamber intraocular lens17. another study from australia showed that patients‟ satisfaction and perceived improvement in their symptoms largely depends on their expectations18. cataract surgery is one of those procedures where patients can have immediate results and their visual symptoms and quality of life can be significantly improved19, 20. conclusion cataract surgery is an extremely effective and economical procedure, which has far greater implications for the lives of patients that cannot be measured on a visual acuity chart. the continuing false assumption by many patients and physicians that a cataract should not be extracted until “ripe” is depriving many people of an enhanced quality of life. efforts should be made to educate people about the effectiveness and success of cataract surgery and that cataract surgery not only provides functional benefit in terms of improved vision but also significantly improves the subjective quality of life of patients. author’s affiliation dr. muhammad imran janjua fcps, senior registrar, ophthalmology shifa college of medicine shifa tameer-e-millat university islamabad prof. dr. ali raza mcps, fcps, professor and head of department department of ophthalmology rmc and allied hospitals rawalpindi role of authors dr. muhammad imran janjua study conception, data collection and analysis, article drafting and formatting prof. dr. ali raza critical analysis, data review, overall supervision. references 1. eirini s, colm m, konrad p, silvio p, jyoti k, giuseppe r. subjective quality of vision before and after cataract surgery. arch ophthalmol. 2012; 130 (11): 1377-82. 2. erik jg, lin l, marisa s, steven rt, robert mk, theodore gg. measuring the impact of cataract surgery on generic and vision-specific quality of life. qual life res. 2013; 22: 1405–14. 3. lee bs, mouoz be, west sk, gower ew. functional improvement after oneand two-eye cataract surgery in the salisbury eye evaluation. ophthalmology, 2013; 120: 949–55. 4. kanski jj, bowling b. clinical ophthalmology. 7th edi. london; elsevier saunders; 2011: 273-98. 5. lundstrom m, pesudovs k. catquest-9sf patient outcomes questionnaire nine-item short-form raschscaled revision of the catquest questionnaire. j cataract refract surg. 2009; 35: 504–13. 6. lundstrom m, pesudovs k. questionnaires for measuring cataract surgery outcomes. j cataract refract surg. 2011; 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with standard extracapsular cataract surgery: postoperative astigmatism and visual recovery. eye, 1992; 6: 626-629. 13. edwards m, rehman s, hood a, stirling r, noble b. discharging routine phacoemulsification patients at one week. eye, 1997; 11: 850-853. 14. laidlaw a, harrad r. can second eye cataract extraction be justified? eye, 1993; 7: 680-686. 15. anand r, gupta a, ram j, singh u, kumar r. visual outcome following cataract surgery in rural punjab. indian j ophthalmol. 2000; 48: 153-158. 16. owsley c, mcgwin gj, scilley k, meek gc, seker d, dyer a. impact of cataract surgery on health-related quality of life in nursing home residents. br j ophthalmol. 2007; 91: 1359-1363. 17. adamsons ia, vitale s, stark wj, rubin gs. the association of postoperative subjective visual function with acuity, glare, and contrast sensitivity in patients with early cataract. arch ophthalmol. 1996; 114 (5): 529536. 18. pager ck. randomised controlled trial of preoperative information to improve satisfaction with cataract surgery. br j ophthalmol. 2005; 89: 10-13. 19. brian g, taylor h. cataract blindness – challenges for the 21st century. bullet who. 2001; 79: 249-256. 20. hennig a, kumar j, yorston d, foster a. sutureless cataract surgery with nucleus extraction: outcome of a prospective study in nepal. br j ophthalmol. 2003; 87: 266-270. pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 247 indexes (volume 30, 2014) no.1. january……………………………………………..page 159 no.2. april………………………………………………. .page 60-120 no.3. july……………………………………………… …page 122-184 no.4 october…………………………………………… page 185-253 subject index abstracts: 30: 56-8, 117-9, 183-4, 243-4. adnexa cryptophthalmos syndrome: a case report 30: 173-5. cataract comparison of pre and postoperative astigmatism after cataract extraction by phacoemulsification through a 3.2 mm clear corneal superotemporal incision 30: 157-61. complications of nd: yag laser capsulotomy 30: 34-7. congenital cataracts; its laterality and association with consanguinity 30: 187-92. effect of incision site on pre-existing astigmatism in phacoemulsification 30: 45-8. neonatal screening for leukocoria 30: 232-6. outcomes of congenital cataract surgery in a tertiary care hospital 30: 28-32. post operative anterior chamber reaction in adult cataract surgery after adding heparin in irrigating solution 30: 237-40. pre-operative diclofenac sodium eyedrops vs intra-operative adrenaline irrigation in mantaining mydriasis during extracapsular cataract extraction 30: 199-203. peribulbar versus topical anesthesia for cataract surgery: patient’s satisfaction 30: 63-7. community early presbiopia a psychosomatic disorder 30: 162-6. physical and physiological changes with presbyopia 30: 78-81. lightning induced ocular complications: a case report 30: 49-52. ocular emergencies in a rural hospital: a 5 year retrospective clinical audit 30: 68-72. risk factors involved in pterygium recurrence after surgical excision 30: 73-7. subconjunctival loa loa worm: a case report 30: 241-2. congenital disorder a case series on waardenberg syndrome 30: 176-8. cornea kayser-fleischer rings in wilson’s disease 30: 112-6. role of sub-conjunctival bevacizumab in regression of corneal neovascularization 30: 99-102. to assess the efficacy of chemical corneal tattooing for unsightly corneal scars 30: 152-6. choroid frequency and visual outcome of choroidal tubercles with miliary tuberculosis 30: 213-8. choroidal melanoma, a rare condition in asians: a case report 30: 237-40. editorials new perspectives in the management of diabetic macular edema 30: 122-4. retinopathy of prematurity and pakistan an epidemic coming 30: 60-2. the role of ocular coherence tomography in glaucoma diagnosis and management 30: 1-3. updates in the management of retinoblastoma 30: 185-6. glaucoma accuracy of iop measured by non-contact (air–puff) tonometer compared with goldmann applanation 30: 20-3. awareness of glaucoma in different groups of urban population 30: 143-7. control of raised intraocular pressure after intravitreal triamcinolone acetonide 30: 148-51. causes of blindness in patients with open angle glaucoma, an alarming situation 30:24-7. indexes 248 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology diode laser trans-scleral cycloablation as surgical treatment for primary open-angle glaucoma after maximum tolerated medical therapy 30:90-4. estimation of range of intraocular pressure in normal individuals by puff tonometer30:130-3. the role of ocular coherence tomography in glaucoma diagnosis and management 30: 1-3. trabeculotomy in primary congenital glaucoma at pediatric eye department, bolan medical college, quetta 30: 125-9. letter to the editor: 30: 245. news and events: 30: 59, 184, 246. orbit orbital fungal myositis; a case report 30: 179-82. peads oph. pattern of common paediatric diseases at spencer eye hospital 30: 10-4. pattern of common eye diseases in children in a tertiary eye hospital, karachi 30: 193-8. timing of closed intubation in recurrent epiphoric children 30: 42-4. retina b-scan ultrasonography in blast related posterior segment eye injuries 30: 87-9. comparison of brilliant blue g and trypan blue during vitrectomy for macular hole surgery 30: 227-31. frequency of retinopathy in newly diagnosed patients of type 2 diabetes mellitus 30: 38-41. frequency of retinopathy and its different grades among typeii diabetic patients with metabolic syndrome 30: 219-23. four cases of xeroderma pigmentosum in a pakistani family 30: 224-6. masquerade syndrome: retinoblastoma presenting as sympathetic ophthalmia 30: 53-5. modified scleral buckling technique using endoillumination and non contact wide angle viewing system 30: 103-7. new perspectives in the management of diabetic macular edema 30: 122-4. prevalence of diabetic retinopathy among type-2 diabetes patients in pakistan-findings of the vision registry 30: 204-12. retinopathy of prematurity and pakistan an epidemic coming 30: 60-2. sight threatening diabetic retinopathy in type2 diabetes mellitus 30: 4-9. true exfoliation in a man with retinitis pigmentosa 30: 108-11. updates in the management of retinoblastoma 30: 185-6. vitrectomy combined with scleral buckling in patients with inferior retinal breaks 30: 82-6. sclera trans-scleral effect of mitomycin-c on ciliary body epithelium 30: 15-9. trauma ease of removal of posterior segment metallic intraocular foreign body with intraocular forceps vs endomagnet plus forceps 30: 95-8. epidemiological survey of traumatic eye injury in a southwestern nigeria tertiary hospital 30: 138-42. orbital tumors-retrospective study of 24 years 30: 33-7. vitreous visual outcome and complications of 23 g versus 20 g vitrectomy in cases of diabetic vitreous haemorrhage 30: 167-72. author index a nitin: the role of ocular coherence tomography in glaucoma diagnosis and management 30: 1-3. abdelbagi e: physical and physiological changes with presbyopia 30: 78-81. abstracts: 30: 56-8, 117-9, 183-4, 243-4. adnan sm: frequency and visual outcome of choroidal tubercles with miliary tuberculosis 30: 213-8. aftab m: vitrectomy combined with scleral buckling in patients with inferior retinal breaks 30: 82-6. afridi mr: effect of incision site on pre-existing astigmatism in phacoemulsification 30: 45-8. aftab am: role of sub-conjunctival bevacizumab in regression of corneal neovascularization 30: 99-102. ahmad a: cryptophthalmos syndrome: a case report 30: 173-5. ahmad a: diode laser trans-scleral cycloablation as surgical treatment for primary open-angle glaucoma after maximum tolerated medical therapy 30:90-4. ahmad cn: comparison of brilliant blue g and trypan blue during vitrectomy for macular hole surgery 30: 227-31. ahmad i: causes of blindness in patients with open angle glaucoma, an alarming situation 30: 24-7. indexes pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 249 ahmad i: effect of incision site on pre-existing astigmatism in phacoemulsification 30: 45-8. ahmad i: pre-operative diclofenac sodium eyedrops vs intra-operative adrenaline irrigation in mantaining mydriasis during extracapsular cataract extraction 30: 199-203. ahmad j: accuracy of iop measured by non-contact (air-puff) tonometer compared with goldmann applanation 30: 20-3. ahmad k: retinopathy of prematurity and pakistan an epidemic coming 30: 60-2. ajayi ia: epidemiological survey of traumatic eye injury in a southwestern nigeria tertiary hospital 30: 138-42. ajite ko: epidemiological survey of traumatic eye injury in a southwestern nigeria tertiary hospital 30: 138-42. akhtar p: neonatal screening for leukocoria 30: 232-6. akhter w: congenital cataracts; its laterality and association with consanguinity 30: 187-92. alam a: complications of nd: yag laser capsulotomy 30: 134-7. alam m: effect of incision site on pre-existing astigmatism in phacoemulsification 30: 45-8. alam m: complications of nd: yag laser capsulotomy 30: 134-7. alam m: b-scan ultrasonography in blast related posterior segment eye injuries 30: 87-9. ali z: estimation of range of intraocular pressure in normal individuals by puff tonometer 30: 130-3. ali abm: physical and physiological changes with presbyopia 30: 78-81. amir m: subconjunctival loa loa worm: a case report 30: 241-2. anwar ms: comparison of pre and postoperative astigmatism after cataract extraction by phacoemulsification through a 3.2 mm clear corneal superotemporal incision 30: 157-61. ashraf a: subconjunctival loa loa worm: a case report 30: 241-2. asghar m: frequency of retinopathy and its different grades among type ii diabetic patients with metabolic syndrome 30: 219-23. arain tm: accuracy of iop measured by non-contact (air-puff) tonometer compared with goldmann applanation 30: 20-3. arsalan four cases of xeroderma pigmentosum in a pakistani family 30: 224-6. azhar mn: accuracy of iop measured by non-contact (air-puff) tonometer compared with goldmann applanation 30: 20-3. baig msa: frequency and visual outcome of choroidal tubercles with miliary tuberculosis 30: 213-8. baloch ra: trabeculotomy in primary congenital glaucoma at pediatric eye department, bolan medical college, quetta 30: 125-9. bandopadhyay m: ocular emergencies in a rural hospital: a 5 year retrospective clinical audit 30: 68-72. bashir b: complications of nd: yag laser capsulotomy 30: 134-7. bashir t: kayser-fleischer rings in wilson’s disease 30: 112-6. burney ja: frequency and visual outcome of choroidal tubercles with miliary tuberculosis 30: 213-8. butt jby: cryptophthalmos syndrome: a case report 30: 173-5. butt jby: diode laser trans-scleral cycloablation as surgical treatment for primary open-angle glaucoma after maximum tolerated medical therapy 30:90-4. chakraborti c: lightning induced ocular complications: a case report 30: 49-52. chaudhry ql: abstracts 30: 56-8, 117-9, 183-4, 243-4. chaudhry qa: ease of removal of posterior segment metallic intraocular foreign body with intraocular forceps vs endomagnet plus forceps 30: 95-8. chaudhry s: updates in the management of retinoblastoma 30: 185-6. chaudhury sk: ocular emergencies in a rural hospital: a 5 year retrospective clinical audit 30: 68-72. chaudhry t: retinopathy of prematurity and pakistan an epidemic coming 30: 60-2. chaudhry ta: four cases of xeroderma pigmentosum in a pakistani family 30: 224-6. cheema a: a case series on waardenberg syndrome 30: 176-8. dey ak: ocular emergencies in a rural hospital: a 5 year retrospective clinical audit 30: 68-72. dutta s: ocular emergencies in a rural hospital: a 5 year retrospective clinical audit 30: 68-72. ejaz u: peribulbar versus topical anesthesia for cataract surgery: patient’s satisfaction 30: 63-7. fahmi ms: pattern of common paediatric diseases at spencer eye hospital 30: 10-4. fahmi ms: early presbiopia a psychosomatic disorder 30: 162-6. farooq a: peribulbar versus topical anesthesia for cataract surgery: patient’s satisfaction 30: 63-7. farooq m: neonatal screening for leukocoria 30: 232-6. fasih u: early presbiopia a psychosomatic disorder 30: 162-6. fasih u: pattern of common paediatric diseases at spencer eye hospital 30: 10-4. ganguly p: ocular emergencies in a rural hospital: a 5 indexes 250 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology year retrospective clinical audit 30: 68-72. haider ma: modified scleral buckling technique using endoillumination and non contact wide angle viewing system 30: 103-7. halepota fm: orbital tumors retrospective study of 24 years 30: 33-7. hashmi f: retinopathy of prematurity and pakistan an epidemic coming 30: 60-2. hayat n: a case series on waardenberg syndrome 30: 176-8. hussain i: role of sub-conjunctival bevacizumab in regression of corneal neovascularization 30: 99-102. hussain m: timing of closed intubation in recurrent epiphoric children 30: 42-4. hassan m: frequency and visual outcome of choroidal tubercles with miliary tuberculosis 30: 213-8. idrees n: four cases of xeroderma pigmentosum in a pakistani family 30: 224-6. iqbal j: timing of closed intubation in recurrent epiphoric children 30: 42-4. iqbal n: timing of closed intubation in recurrent epiphoric children 30: 42-4. iqbal y: frequency of retinopathy in newly diagnosed patients of type 2 diabetes mellitus 30: 38-41. iqbal y: post operative anterior chamber reaction in adult cataract surgery after adding heparin in irrigating solution 30: 237-40. iqbal a: complications of nd: yag laser capsulotomy 30: 134-7. iqbal z: visual outcome and complications of 23 g versus 20 g vitrectomy in cases of diabetic vitreous haemorrhage 30: 167-72. inayat n: awareness of glaucoma in different groups of urban population 30: 143-7. irfan s: to assess the efficacy of chemical corneal tattooing for unsightly corneal scars 30: 152-6. jahangir s: modified scleral buckling technique using endoillumination and non contact wide angle viewing system 30: 103-7. jahangir t: ease of removal of posterior segment metallic intraocular foreign body with intraocular forceps vs endomagnet plus forceps 30: 95-8. jamil az: estimation of range of intraocular pressure in normal individuals by puff tonometer 30: 130-3. jamil k: frequency of retinopathy in newly diagnosed patients of type 2 diabetes mellitus 30: 38-41. jana s: ocular emergencies in a rural hospital: a 5 year retrospective clinical audit 30: 68-72. kashif a: pattern of common eye diseases in children in a tertiary eye hospital, karachi 30: 193-8. khan a: b-scan ultrasonography in blast related posterior segment eye injuries 30: 87-9. khan a: effect of incision site on pre-existing astigmatism in phacoemulsification 30: 45-8. khan aa: ease of removal of posterior segment metallic intraocular foreign body with intraocular forceps vs endomagnet plus forceps 30: 95-8. khan b: complications of nd: yag laser capsulotomy 30: 134-7. khan bs: causes of blindness in patients with open angle glaucoma, an alarming situation 30: 24-7. khan j: pre-operative diclofenac sodium eyedrops vs intra-operative adrenaline irrigation in mantaining mydriasis during extracapsular cataract extraction 30: 199-203. khalid k: orbital fungal myositis; a case report 30: 179-82. khan da: peribulbar versus topical anesthesia for cataract surgery: patient’s satisfaction 30: 63-7. khan mt: diode laser trans-scleral cycloablation as surgical treatment for primary open-angle glaucoma after maximum tolerated medical therapy 30: 90-4. khan mt: cryptophthalmos syndrome: a case report 30: 173-5. khan mr: accuracy of iop measured by non-contact (air-puff) tonometer compared with goldmann applanation 30: 20-3. khan mz: frequency of retinopathy and its different grades among type 2 diabetic patients with metabolic syndrome 30: 219-23. khan qa: frequency of retinopathy in newly diagnosed patients of type 2 diabetes mellitus 30: 3841. khan qa: post operative anterior chamber reaction in adult cataract surgery after adding heparin in irrigating solution 30: 237-40. khatri b: pattern of common eye diseases in children in a tertiary eye hospital, karachi 30: 193-8. khatri sf: choroidal melanoma, a rare condition in asians: a case report 30: 237-40. lakho ka: physical and physiological changes with presbyopia 30: 78-81. latif k: outcomes of congenital cataract surgery in a tertiary care hospital 30: 28-32. luhano mk: orbital tumors retrospective study of 24 years 30: 33-7. mahar ps: control of raised intraocular pressure after intravitreal triamcinolone acetonide 30: 148-51. mahar ps: risk factors involved in pterygium recurrence after surgical excision 30: 73-7. mahar ps: trans-scleral effect of mitomycin-c on ciliary body epithelium 30: 15-9. mahmood sa: visual outcome and complications of 23 g versus 20 g vitrectomy in cases of diabetic indexes pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 251 vitreous haemorrhage 30: 167-72. mal w: visual outcome and complications of 23 g versus 20 g vitrectomy in cases of diabetic vitreous haemorrhage 30: 167-72. malik tm: peribulbar versus topical anesthesia for cataract surgery: patient’s satisfaction 30: 63-7. malik am: peribulbar versus topical anesthesia for cataract surgery: patient’s satisfaction 30: 63-7. manzar n: risk factors involved in pterygium recurrence after surgical excision 30: 73-7. masroor m: frequency and visual outcome of choroidal tubercles with miliary tuberculosis 30: 213-8. masud h: kayser-fleischer rings in wilson’s disease 30: 112-6. manzoor a: awareness of glaucoma in different groups of urban population 30: 143-7. memon m: sight threatening diabetic retinopathy in type-2 diabetes mellitus 30: 4-9. memon s: sight threatening diabetic retinopathy in type-2 diabetes mellitus 30: 4-9. memon as: control of raised intraocular pressure after intravitreal triamcinolone acetonide 30: 148-51. mian uk: retinopathy of prematurity and pakistan an epidemic coming 30: 60-2. moin m: news and events 30: 59, 184, 246. moin m: vitrectomy combined with scleral buckling in patients with inferior retinal breaks 30: 82-6. moin m: awareness of glaucoma in different groups of urban population 30: 143-7. moin m: orbital fungal myositis; a case report 30: 17982. mukhtar sa: estimation of range of intraocular pressure in normal individuals by puff tonometer 30: 130-3. nadeem s: neonatal screening for leukocoria 30: 2326. naeem ba: neonatal screening for leukocoria 30: 2326. nawaz s: frequency and visual outcome of choroidal tubercles with miliary tuberculosis 30: 213-8. nadeem s: true exfoliation in a man with retinitis pigmentosa 30: 108-11. naeem ba: true exfoliation in a man with retinitis pigmentosa 30: 108-11. naz s: outcomes of congenital cataract surgery in a tertiary care hospital 30: 28-32. nizamani nb: masquerade syndrome: retinoblastoma presenting as sympathetic ophthalmia 30: 53-5. nizamani nb: sight threatening diabetic retinopathy in type – 2 diabetes mellitus 30: 4-9. omotoye oj: epidemiological survey of traumatic eye injury in a southwestern nigeria tertiary hospital 30: 138-42. qayyum i: timing of closed intubation in recurrent epiphoric children 30: 42-4. qayyum a: trabeculotomy in primary congenital glaucoma at pediatric eye department, bolan medical college, quetta 30: 125-9. qazi za: accuracy of iop measured by non-contact (air – puff) tonometer compared with goldmann applanation 30: 20-3. qureshi bz: ease of removal of posterior segment metallic intraocular foreign body with intraocular forceps vs endomagnet plus forceps 30: 95-8. qureshi bz: modified scleral buckling technique using endoillumination and non contact wide angle viewing system 30: 103-7. qureshi tm: diode laser trans-scleral cycloablation as surgical treatment for primary open-angle glaucoma after maximum tolerated medical therapy 30:90-4. qureshi tm: cryptophthalmos syndrome: a case report 30: 173-5. rana am: congenital cataracts; its laterality and association with consanguinity 30: 187-92. rashid f: to assess the efficacy of chemical corneal tattooing for unsightly corneal scars 30: 152-6. rais m: early presbiopia a psychosomatic disorder 30: 162-6. rahman a: early presbiopia a psychosomatic disorder 30: 162-6. rafiq m: causes of blindness in patients with open angle glaucoma, an alarming situation 30: 24-7. rais m: pattern of common paediatric diseases at spencer eye hospital 30: 10-4. rahman a: pattern of common paediatric diseases at spencer eye hospital 30: 10-4. rahman a: timing of closed intubation in recurrent epiphoric children 30: 42-4. rahman m: causes of blindness in patients with open angle glaucoma, an alarming situation 30: 24-7. rahman m: pre-operative diclofenac sodium eyedrops vs intra-operative adrenaline irrigation in mantaining mydriasis during extracapsular cataract extraction 30: 199-202. rahman m: frequency of retinopathy and its different grades among type ii diabetic patients with metabolic syndrome 30: 219-23. rahman ma: frequency of retinopathy and its different grades among type ii diabetic patients with metabolic syndrome 30: 219-23. raza a: congenital cataracts; its laterality and association with consanguinity 30: 187-92. shaheer m: comparison of brilliant blue g and trypan blue during vitrectomy for macular hole surgery 30: indexes 252 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology 227-31. rizvi sf: visual outcome and complications of 23 g versus 20 g vitrectomy in cases of diabetic vitreous haemorrhage 30: 167-72. rizvi sf: outcomes of congenital cataract surgery in a tertiary care hospital 30: 28-32. riaz n: vitrectomy combined with scleral buckling in patients with inferior retinal breaks 30: 82-6. saleem z: vitrectomy combined with scleral buckling in patients with inferior retinal breaks 30: 82-6. shahzad i: to assess the efficacy of chemical corneal tattooing for unsightly corneal scars 30: 152-6. shaikh a: pattern of common paediatric diseases at spencer eye hospital 30: 10-4. shaikh a: early presbiopia a psychosomatic disorder 30: 162-6. shaikh as: subconjunctival loa loa worm: a case report 30: 241-2. shah ma: complications of nd: yag laser capsulotomy 30: 134-7. shaikh sm: orbital tumors retrospective study of 24 years 30: 33-7. shakir m: outcomes of congenital cataract surgery in a tertiary care hospital 30: 28-32. siddiqui f: frequency and visual outcome of choroidal tubercles with miliary tuberculosis 30: 213-8. siddiqui mar: new perspectives in the management of diabetic macular edema 30: 122-4. siyal ar: orbital tumors retrospective study of 24 years 30: 33-7. sohail m: prevalence of diabetic retinopathy among type-2 diabetes patients in pakistan-findings of the vision registry 30: 204-12. surhio sa: masquerade syndrome: retinoblastoma presenting as sympathetic ophthalmia 30: 53-5. surhio sa: sight threatening diabetic retinopathy in type – 2 diabetes mellitus 30: 4-9. syed zulfiqarud din: peribulbar versus topical anesthesia for cataract surgery: patient’s satisfaction 30: 63-7. tahir mz: frequency of retinopathy and its different grades among type ii diabetic patients with metabolic syndrome 30: 219-23. tahir z: pre-operative diclofenac sodium eyedrops vs intra-operative adrenaline irrigation in mantaining mydriasis during extracapsular cataract extraction 30: 199-203. tahira r: true exfoliation in a man with retinitis pigmentosa 30: 108-11. talpur ki: sight threatening diabetic retinopathy in type – 2 diabetes mellitus 30: 4-9. talpur ki: orbital tumors retrospective study of 24 years 30: 33-7. talpur ki: masquerade syndrome: retinoblastoma presenting as sympathetic ophthalmia 30: 53-5. tayyab h: modified scleral buckling technique using endoillumination and non contact wide angle viewing system 30: 103-7. waseem s: true exfoliation in a man with retinitis pigmentosa 30: 108-11. zafar s: visual outcome and complications of 23 g versus 20 g vitrectomy in cases of diabetic vitreous haemorrhage 30: 167-72. zafar s: outcomes of congenital cataract surgery in a tertiary care hospital 30: 28-32. zain-ul-abidin a: timing of closed intubation in recurrent epiphoric children 30: 42-4. zia s: frequency of retinopathy in newly diagnosed patients of type 2 diabetes mellitus 30: 38-41. zia s: post operative anterior chamber reaction in adult cataract surgery after adding heparin in irrigating solution 30: 237-40. abstracts index cataract antibiotic choice for the prophylaxis of postcataract extraction endophthalmitis 30: 118. cost-effectiveness of femtosecond laserassisted cataract surgery versus phacoemulsification cataract surgery affiliations 30: 57. post-cataract prevention of inflammation and macular edema by steroid and nonsteroidal anti-inflammatory eye drops a systematic review 30: 243. community a randomized clinical trial comparing methotrexate and mycophenolate mofetil for noninfectious uveitis 30: 243 the utility of routine tuberculosis screening in county hospital patients with uveitis 30: 183. cornea collagen cross-linking with photoactivated riboflavin (pack-cxl) for the treatment of advanced infectious keratitis with corneal melting 30: 182. collagen cross-linking in progressive keratoconus; three year results 30: 118. descemet’s membrane endothelial keratoplasty 30: 56. indexes pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 253 retina changes in postoperative refractive outcomes following combined phacoemulsification and pars plana vitrectomy for rhegmatogenous retinal detachment 30: 183. management and outcome of retinoblastoma with vitreous seeds 30: 56. collaborative retrospective macula society study of photodynamic therapy for chronic central serous chorioretinopathy 30: 117. intravitreal aflibercept injection for macular edema resulting from central retinal vein occlusion 30: 57. intravitreal aflibercept injection for macular edema due to central retinal vein occlusion (two-year results from the copernicus study) 30: 182. vitrectomy with internal limiting membrane peeling versus no peeling for idiopathic fullthickness macular hole 30: 117. retina/glaucoma retinal nerve fibre layer and macular thickness analysis with fourier domain optical coherence tomography in subjects with a positive family history for primary open angle glaucoma 30: 244. vitreous cost evaluation of surgical and pharmaceutical options in treatment for vitreomacular adhesions and macular holes 30: 244. 164 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology original article safety of 23 gauge transconjunctival sutureless 3 port pars plana vitrectomy for vitreoretinal diseases syed raza ali shah, nadeem ahmad, qasim lateef chaudry, chaudary nasir ahmad, asad aslam khan pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syed raza ali shah, associate professor, ophthalmology department, king edward medical university, vitreoretinal fellow, college of ophthalmology & allied visual sciences, mayo hospital lahore. …..……………………….. purpose: to evaluate the safety of 3 port pars plana 23 gauge transconjunctival sutureless vitrectomy for vitreoretinal diseases. material and methods: a prospective study was conducted at the institute of ophthalmology, mayo hospital lahore from july 2010 to december 2010. all patients were admitted in the eye ward from the outpatients department. total 30 patients were included in the study. male to female ratio was 70:30. mean age of patients was 45.5 years. those included had idiopathic epiretinal membrane (erm), diabetic vitreous hemorrhage, traumatic vitreous haemorrhage, vitreous haemorrhage secondary to eale’s disease, diabetic macular edema, macular hole, diabetic (tractional retinal detachment) trd and dislocated lens. outcome measures were recorded at baseline, 1 day, 1 week and 1 month, 2 months and 3 months post operatively. applanation tonometery, intra & post-operative complications, ancillary tests such as ocular coherence tomography (oct) and ultrasound were done as required. results: intra-operative complications noted were retinal tear 9% (2.7 patients), lens touch 4% (1.2 patients), sclerotomy leak requiring stitches 35% (10.5 patients), conjunctival hemorrhage 31% (9.3 patients), cannula slippage 13% (3.9 patients), entry site break 4% (1.2 patients) and retinal touch 4% (1.2 patients). first day post-operative complications were hypotony 20%, conjunctival inflammation 30%, mild eye discomfort 23.3% & corneal edema 13.3%. no complication was noted on 7 th post operative day. conclusion: this study showed that procedure is safe and can be adopted in different vitreoretinal procedures. it is minimally invasive surgical technique that enhances the postoperative recovery and outcomes by simplifying the surgical procedure. wenty-three gauge instrumentation offer advantages in fluidics, providing retinal stability in all of the surgeries. the benefits of patient comfort are important. however, anatomic and visual outcomes, which are superior after this surgery, are even more important. the first – generation 23-g trocar-cannulas had high insertion force, which created stabilization issues. the second-generation trocar-cannulas have low insertion force, roughly equivalent to that of a 20-g microvitreoretinal (mvr) blade, so stabilization of the eye is no longer a problem.1 the surgeon clearly benefits from these smaller – gauge systems compared to the more invasive systems. the capabilities of the systems have t safety of 23 gauge transconjunctival sutureless 3 port pars plana vitrectomy for vitreoretinal diseases pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 165 evolved significantly, specifically the rigidity of instrumentation and the lighting. surgery with 23-g instruments, however, is very similar to surgery with 20-g instruments.2 23-g system addresses many of the initial concerns, which have been related to instrument availability and sclerotomy site closure.3 the advantages of 23 – gauge sutureless trans-conjunctival vitrectomy compared to conventional 20 – gauge vitrectomy are shorter surgical4,5,6 and recovery time4 and less postoperative discomfort. the purpose of the study was to describe the initial experience, effectiveness and safety profile of 23 gauge transconjunctival sutureless vitrectomy for various vitreo-retinal diseases. safety was defined as the incidence of peroperative complications such as lens touch, entry site retinal break, retinal touch, sclerotomy site requiring stitches, choroidal detachment, cannula slippage , conjunctival haemorrhage, incidence of post-operative complications such as hypotony, corneal edema, endophthalmitis, conjunctival scarring and eye discomfort. material and methods this study was carried out at college of ophthalmology and allied vision sciences / king edward medical university, mayo hospital lahore from july 2010 till december 2010. the patients were admitted from eye opd of mayo hospital lahore. thirty eyes were included in this study using nonprobability convenience sampling technique. it was prospective, non-comparative, interventional study. those included in the study had epiretinal membranes (idiopathic erm), macular hole, non-clearing vitreous hemorrhage, lens or fragments dislocated in the vitreous, vitreomacular traction and diabetic macular edema. those excluded were patients with trd, intra ocular foreign body and rhegmatogenous rd and those requiring silicon oil injection. equipment used was muller’s microscope / leica’s microscope with biom, accurus / millennium vitrectomy machines, 23 – gauge system (infusion cannula, fiberoptic endoilluminator, vitrectomy cutter, trocar cannulas set, mvr blade) and gas (c3f8 / sf6). informed consent was taken before surgery. data abstract included patient’s age, sex, date of admission, date of operation, date of discharge, address, presenting complaints, pre-operative record, indication for surgery, investigations, probable diagnosis, incidence of intra-operative complications such as lens touch, entry site retinal break, retinal touch, sclerotomy site requiring stitches, choroidal detachment, cannula slippage and conjunctival haemorrhage, incidence of post-operative complications such as hypotony, corneal edema, endophthalmitis, conjunctival scarring and eye discomfort. these post-operative complications were noted on post-operative day 1, 1st week, 1st month, 2nd month and 3rd month. a 23 – gauge 3 – port vitrectomy setup was used for all cases. a drop of adrenaline was instilled to prevent conjunctival haemorrhage as vessels got blanched. the conjunctiva was displaced with the tooth forceps and to make eye stable. the 23 – gauge mvr keratome was inserted through the conjunctiva and sclera, parallel to the limbus, at an angle of approximately 20° to the sclera, 3.5/4.0mm posterior to the limbus. on the blunt micro trocar 6 mm cannula was fixed and inserted through the hole already made by 23g mvr blade while maintaining apposition of the conjunctival and scleral openings. 6 mm cannula was inserted and micro trocar removed. that produced a tunnel incision through the sclera. after the distal part of the blunt trocar was inserted, the direction of the trocar was angled to be normal with the eye, and the cannula was fully inserted. it was very important to look through the pupil for proper entry. once cannula was properly inserted, infusion line was opened that prevented hypotony while making 2nd and 3rd sclerotomy ports. in a similar fashion 2ndsclerotomy port was made 3.5/4.0mm from the limbus just superior to the infusion cannula. after injecting the 2nd 6mm cannula it was again visualized for proper placement. it was plugged to prevent hypotony when 3rd sclerotomy port was made. three port trans-conjunctival sutureless pars plana vitrectomy was done and in the end the cannulas were removed and wound secured. results thirty eyes of 30 patients were operated at the institute of ophthalmology, mayo hospital lahore. the average age of the patients was 45.5 years ranging from 10 years to 80 years. male to female ratio was 70:30. total mean hospital stay was 3 days ranging from 2 to 4 days. the patients selected for surgery had different indications, idiopathic erm 1 eye, diabetic vitreous hemorrhage 12 eyes, traumatic vitreous haemorrhage in 2 eyes, vitreous haemorrhage secondary to eale’s disease in 1 eye, diabetic macular edema was present in 3 eyes, macular hole 7 eyes, diabetic trd 3 eyes and dislocated lens in one eye. syed raza ali shah, et al 166 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology fig. 1: shows the maximum number of cases were of diabetic vitreous haemorrhage (12), followed by macular hole (7), 3 cases each for dme and diabetic trd, 2 having traumatic vitreous haemorrhage and 1 each having dislocated lens, idiopathic erm and vitreous haemorrhage secondary to eales disease. fig. 2: intra operative complications. shows 35% (8 cases) required sclerotomy stitches, 31% (7 cases) had sub-conjunctival haemorrhage, 13% (3 cases) had cannula slippage, 9% (2 cases) retinal tear, 4% (1 case) each had lens touch, entry site break and retinal touch fig. 3: post op complications on day 1. shows the post op complications 1st post op day. conjunctival inflammation was noted in 9 cases (30%), mild eye discomfort noted in 7 cases (23.3%), 6 eyes (20%) had each iop < 7 mmhg and hypotony and 4 cases (13.3%) had corneal edema. all eyes were normal on 7th post op day. fig. 4: iop 1stpost operative day. shows only 6 cases had iop below 7mm hg on 1st post op day and all of them settled the very next day and no suture was required. fig. 5: corneal edema 1st post op day. show that 13% (4 cases) had corneal edema on 1st post op day. all of them settled on 7th post op day. fig. 6: shows conjunctival inflammation 1 day and 7 day post operatively safety of 23 gauge transconjunctival sutureless 3 port pars plana vitrectomy for vitreoretinal diseases pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 167 intra-operative complications noted were retinal tear in 2 eyes, lens touch in 1 eye, sclerotomy leak requiring stitches in 8 eyes, conjunctival hemorrhage in 7 eyes, cannula slippage in 3 eyes, entry site break in 1 eye and retinal touch in 1 eye. post operative complications noted were hypotony at 1st day in 6 eyes (having iop less than 7 mm of hg) which resolved spontaneously in all eyes. conjunctival inflammation was noticed in 9 eyes and ocular discomfort was of mild nature was noted in 7 eyes at 1st postoperative day, which was not seen after 1 week in any of the cases. no case developed endophthalmitis. fig 1: indications for surgery. discussion in our study, 6 out of 30 eyes (20%) received a gas tamponade, 35% (8 eyes) required suture to the 23 – gauge sclerotomy site at the time of surgery due to leakage of gas / air, 13% (3 eyes) had cannula slippage during surgery, 31% (7 eyes) had sub-conjunctival haemorrhage which settled on 7th post op day, 9% (2 eyes) retinal tear which required silicon oil injection, 4% (1 eye) had crystalline lens touch from the infusion cannula. the patient was operated for cataract surgery 2 months following vitrectomy, 1 eye had entry site break for which cryo was applied and retina was stable after 3 months of follow-up. one eye had retinal touch in which endolaser with gas temponade was given with face down position for 5 days, retina remained stable after 3 months follow-up. six eyes had hypotony on postoperative day 1(having iop less than 7 mm of hg) and on 2nd day hypotony settled and no surgical intervention was required. no eyes developed choroidal effusions or endophthalmitis. two eyes were treated with topical and / or oral medications for relatively high postoperative pressures secondary to intraocular gas tamponade or from use of topical prednisolone acetate. two eyes required one of the sclerotomies to be converted to 20 gauge for injection of silicon oil. these 2 eyes were those which had iatrogenic retinal tears during segmentation of diabetic trd. conjunctival inflammation was noted in 30% (9 eyes), which settled on 7th postoperative day. eye discomfort was of mild nature noted in 23% (7 eyes) at 1st postoperative day, which was not seen after 1 week in any of the eyes. of the 30 eyes, 17 eyes were phakic, 10 eyes were pseudophakic, 1 eye was aphakic and 2 had cataract. per-operatively cataract was removed and iol was implanted in them to get clear retinal view. total mean hospital stay of patients was 3 days ranging from 2 to 4 days. the patients selected for surgery had different indications, idiopathic erm 1 patient, diabetic vitreous hemorrhage 12 patients, traumatic vitreous haemorrhage in 2 eyes, vitreous haemorrhage secondary to eale’s disease in 1 patient, diabetic macular edema was present in 3 patients, macular hole 7 patients, diabetic trd 3 patients and dislocated lens in vitreous 1 patient. howard f. fine5in their study showed 2 patients had hypotony on postoperative day 1, 1 patient required suturing of sclerotomy peroperatively, and no patient developed choroidal effusions. ashraf m et al8 in his study showed that 4 eyes (13.3%) required suturing of sclerotomy intraoperatively, conversion to 20-gauge was done in one eye (3.3%), hypotony was reported in one eye (3.3%) postoperatively & subconjunctival silicone oil was reported in one eye (3.3%). sutureless posterior segment surgery provides numerous potential advantages over traditional 20gauge vitrectomy, including faster wound healing, diminished conjunctival scarring, improved patient comfort, decreased postoperative inflammation, and reduced postoperative astigmatic change.9-17 conclusion the transconjunctival 23-gauge vitrectomy approach appears effective for sutureless transconjunctival posterior segment surgery with an acceptable safety profile. rates of sclerotomy leakage, hypotony, and choroidal detachment were favorable compared with previously published data. rates of intraoperative and postoperative retinal tears and detachments also appeared comparable to rates for 23-gauge systems. the 23-gauge transconjunctival sutureless vitrectomy system is an effective and safe technique for a number of vitreoretinal procedures that enhances the postoperative recovery by simplifying the surgical procedure. it appears to be a less traumatic and more convenient alternative to 20-gauge vitrectomy. author’s affiliation dr. syed raza ali shah college of ophthalmology & allied visual sciences, institute of ophthalmology, king edward medical university / mayo hospital lahore http://www.ophsource.org/periodicals/ophtha/article/piis0161642007002023/fulltext## http://www.ophsource.org/periodicals/ophtha/article/piis0161642007002023/fulltext## http://www.nature.com/eye/journal/v22/n1/full/6702987a.html#bib1#bib1 http://www.nature.com/eye/journal/v22/n1/full/6702987a.html#bib1#bib1 syed raza ali shah, et al 168 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology dr. nadeem ahmad college of ophthalmology & allied visual sciences, institute of ophthalmology, king edward medical university / mayo hospital lahore dr. qasim lateef chaudry college of ophthalmology & allied visual sciences, institute of ophthalmology, king edward medical university / mayo hospital lahore dr. chaudary nasir ahmad college of ophthalmology & allied visual sciences, institute of ophthalmology, king edward medical university / mayo hospital lahore prof. asad aslam khan college of ophthalmology & allied visual sciences, institute of ophthalmology, king edward medical university / mayo hospital lahore references 1. charles s. innovative approaches to small-gauge vitrectomy surgery. retinal physician. 2007. 2. fang sy, deboer cm, humayun ms. performance analysis of new – generation vitreous cutters. graefes arch clin exp ophthalmol. 2007; 18. 3. timothy g murray. innovative approaches to smallguage vitrectomy surgery. retinal physician. 2007. 4. chen e. 25 – gauge transconjunctival sutureless vitrectomy. curr opin ophthalmol. 2007; 18: 188–193. 5. fine hf, iranmanesh r, iturralde d, spaide rf. outcomes of 77 consecutive cases of 23-gauge transconjunctival vitrectomy surgery for posterior segment disease. ophthalmology. 2007; 114: 1197–1200. 6. oshima y, ohji m, tano y. surgical outcomes of 25gauge transconjunctival vitrectomy combined with cataract surgery for vitreoretinal diseases. ann acad med singapore. 2006; 35: 175–80. 7. lakhanpal rr, humayun ms, de juan jr e, lim ji, chong lp, chang ts et al. outcomes of 140 consecutive cases of 25-gauge transconjunctival surgery for posterior segment disease. ophthalmology. 2005; 112: 817–24. 8. ashraf m. el-batarny department of ophthalmology, magrabi eye and ear hospital, muscat, sultanate of oman. 2009 web published “transconjunctival sutureless 23 – gauge vitrectomy for vitreoretinal diseases: outcome of 30 consecutive cases”. 9. chen jc. sutureless pars plana vitrectomy through selfsealing sclerotomies. arch ophthalmol. 1996; 114: 1273– 5. 10. milibak t, suveges i. complications of sutureless pars plana vitrectomy through self-sealing sclerotomies. arch ophthalmol. 1998; 116: 119. 11. kwok ak, tham cc, lam ds, li m, chen jc. modified sutureless sclerotomies in pars plana vitrectomy. am j ophthalmol. 1999; 127: 731–3. 12. schmidt j, nietgen gw, brieden s. self-sealing, sutureless sclerotomy in pars plana vitrectomy. klin monatsbl augenheilkd. 1999; 215: 247-51. 13. jackson t. modified sutureless sclerotomies in pars plana vitrectomy. am j ophthalmol. 2000; 129: 116–7. 14. assi ac, scott ra, charteris dg. reversed self-sealing pars plana sclerotomies. retina. 2000; 20: 689–92. 15. rahman r, rosen ph, riddell c, towler h. self – sealing sclerotomies for sutureless pars plana vitrectomy. ophthalmic surg lasers. 2000; 31: 462–6. 16. theelen t, verbeek am, tilanus ma, van den biesen pr. a novel technique for self – sealing, wedge – shaped pars plana sclerotomies and its features in ultrasound biomicroscopy and clinical outcome. am j ophthalmol. 2003; 136: 1085–92. 17. fujii gy, de juan e, humayun ms, et al. initial experience using the transconjunctival sutureless vitrectomy system for vitreo-retinal surgery. ophthalmology. 2002; 109: 1814-20. http://www.ncbi.nlm.nih.gov/pubmed?term=li%20m%5bauthor%5d&cauthor=true&cauthor_uid=10372891 http://www.ncbi.nlm.nih.gov/pubmed?term=chen%20jc%5bauthor%5d&cauthor=true&cauthor_uid=10372891 microsoft word 2. oaps mahr 64 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology original article needle revision of failed drainage blebs with mitomycin-c p. s. mahar, a. sami memon, israr a. bhutto, dilshad a. laghari pak j ophthalmol 2013, vol. 29 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: prof. p.s mahar aga khan university hospital karachi …..……………………….. purpose: to assess the outcome of needle revision of failed drainage blebs with regard to decrease in intraocular pressure (iop) of < 20 mmhg over mean follow up of 1 year and to observe the complication associated with the procedure. material and methods: this non-comparative, interventional case series of 46 eyes (46 patients) with iop of > 25 mmhg after trabeculectomy were subjected to needle revision with mitomycin-c (mmc) from january 2007 to december 2010. thirty four patients were male and 12 were female with age ranging from 47 to 72 years. results: twenty six patients (26 eyes) out of 46 patients (46 eyes) showed improvement in iop of < 20 mmhg, achieving success at 57%. the preoperative mean iop of our patients was 26.7 ± 6 mmhg (95% confidence interval 25.16 – 28.23), while post-operative mean iop was 13.5 ± 4 mmhg (95% confidence interval 12.47 – 14.5) at the mean follow up of 1 year. transient hyphema was noticed in 1 patient (2.17%) and 2 patients (4.34%) went into hypotony with iop of < 6 mmhg. all these eyes resolved spontaneously with no additional treatment. conclusion: needle revision of drainage blebs with mmc revived failed filtration procedure in 57% of our patients at the mean follow up of 1 year with minimal complications. he partial thickness trabeculectomy (trab) was first described by cairns1 in 1968 and still remains the gold standard in the patients who fail to have their intraocular pressure (iop) controlled on maximal medical therapy. although success of trab has increased with the use of topical mitomycin-c (mmc) as an adjunctive therapy since its first use by chen et al,2 its failure rate is still significant ranging from 20 – 50% with long standing followup.3-6 the primary reason for long term failure is due toepiscleral fibrosis or conjunctival thickening overlying the area of filtration. this process of wound healing and tissue remodeling continues to occur indefinitely after the initial surgery. the failure of trab with flat filtration bleb and raised iop therefore requires several options such as addition of medical therapy, repeat trab, drainage implants, revision of existing bleb and cyclodestructive procedures. needle revision of failing drainage bleb is performed to separate and lyse the fibrous tissue bands in the scleral flap and inconjunctival bleb, to increase the surface area for filtration. it was first described by mardelliet al7 in 1996 and is subsequently popularized by other workers.8-11 the procedure can be performed at the slit lamp or in the operating theatre. the technique involves external revision, internal revision via anterior chamber (ac), with or without anti-fibrotic agents. we performed needle revision of failed filtering blebs with adjunctive use of mmc in cohort of patients who presented in glaucoma clinic with iop of >25 mmhg. the purpose of our study was to assess the outcome of needle revision with regard to decrease in iop of < 20 mmhg with mean follow up of one year and to observe the complications associated with the procedure. t needle revision of failed drainage blebs with mitomycin-c pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 65 material and methods this study is retrospective, non-comparative, interventional case series of 46 eyes (46 patients), who presented with iop of >25 mmhg after going under trab at isra postgraduate institute of ophthalmology and aga khan university hospital, karachi, due to initial diagnosis of primary open angle glaucoma (poag) or primary angle closure glaucoma (pacg). all surgeries were performed earlier with the adjunctive use of mmc. a total of 61 eyes of 61 patients had needle revision from january 2007 to december 2010. all needle revisions were performed from 2 weeks to 1 year post trabeculectomy. all patients had argon laser suture lysis before needle revision and were naïve to any anti-glaucoma medication. patients with repeated trab and other glaucoma procedures were excluded from the study. fifteen patients were lost to the follow up or had follow up of < 6 months which were not included in the study. gender distribution showed 34 male and 12 female patients. patient’s age ranged between 47 to 72 years with median age of 58 years. technique conjunctiva was anesthetized with several drops of proparacaine 0.5% (alcaine – alcon, belgium), followed by one drop of 5% povidone-iodine. two percent lignocaine (0.1ml) and mmc in concentration of 0.2mg/ml (0.1ml) was drawn into tuberculin syringe with 27 gauge needle and was given subconjunctivally in the superior fornix above the bleb (fig. 1 and 2). closed eye massage was done to diffuse the given solution (fig. 3). patient was positioned on the slit lamp and wired speculum was placed to open the eye lids. a tuberculin syringe with 27 gauge was introduced under the conjunctiva as far away as possible from bleb and advanced to the scleral flap. with slow motion all the adhesions between conjunctiva and episclera were separated. the needle was further introduced under the scleral flap and with side motions episcleral adhesions are broken down (fig. 4). in the pseudophakic patients, needle was advanced through the internal osteum into the anterior chamber. once the bleb is reformed, needle was gently removed (fig. 5). the iop was rechecked postoperatively and patients were commenced on topical moxifloxacin 0.5% (vigamox – alcon, belgium), 1 drop 4 times a day for 1 week and dexamethasone 0.1% (maxidex – alcon, belgium), 1 drop 4 times a day for 4 weeks. patients were followed at day 1, 1 week, 1 month and at 3 months subsequently. mean follow up of all patients was up to 13 months (range 6 – 18 months). the successful outcome of the needle revision was defined as iop between 6 mmhg to 20 mmhg without any anti-glaucoma medication. all immediate and post-operative complications were recorded. the data analysis was carried out on spss for windows version 17. a p-value of < 0.05 was considered statistically significant. the base line and follow up iops were compared with paired sample t test. results twenty six patients (26 eyes) out of 46 patients (46 eyes) showed improvement in iop of < 20 mmhg, achieving success at 57%. the pre-operative mean iop of our patients was 26.7 ± 6 mmhg(95% confidence interval 25.16 – 28.23), while post-operative mean iop was 13.5 ± 4 mmhg (95% confidence interval 12.47 – 14.5) at the mean follow up of 1 year. all patients had small areas of subconjunctival hemorrhage at the point of entry of needle. transient hyphema was noticed in 1 (2.17%) patient and 2 (4.34%) patients went into hypotony with iop of < 6 mmhg. all these eyes resolved spontaneously with no additional treatment. the risk factors for failure to achieve iop of < 20 mmhg in our series was pseudophakia, female gender and needle revision carried out within one month of trabeculectomy. discussion needle revision of the failed drainage bleb after trabeculectomy, offers several advantages over repeat trab or insertion of setons. it is a simple technique, which can be performed on the slit lamp in the examination room on outpatient basis. it spares conjunctiva from any trauma to make it suitable for any repeat procedure and it also reduces the cost of the operating theatre. the success rate of this procedure in our series of 46 patients was at 57%, reducing iop to <20 mmhgin 23 patients. one of our patients developed hyphema (2.17%) and two (4.34%) went into hypotony postoperatively. in mardelli’s series published in 19967, 62 eyes were reported for bleb needle revision. although he achieved 75.8% success in reducing iop of < 18 mmhg, there were averagely 2 needling procedures p. s. mahar, et al 66 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology fig. 1: entry of needle subconjunctivally fig. 2: injection of lignocaine with mmc fig. 3: closed lid massage fig. 4: cutting of adhesions fig. 5: formation of bleb performed per patient. he also used 0.03ml of mixture of 0.004mg of mmc mixed with bupivacaine 0.75% with epinephrine. ten eyes developed choroidal detachment, one eye had suprachoroidal hemorrhage, 5 eyes had bleb leaks and 2 eyes developed hyphema. shetty and coworkers11 carried out similar procedure in 44 patients and reported 64% of their patients achieving iop between 4 to 22 mmhg. however they also included patients in their successful outcome who either had repeated needling or required anti glaucoma medication. they also used mmc at higher concentration of 0.4 mg/ml. the complications in their study includedhypotony (2 eyes), hyphema (5 eyes) and bleb leak (1 eye), all resolving within couple of weeks. pasternack12 in consecutive bleb revision of 77 eyes, reported 52% patients achieving iop of 11.3 ± 3 needle revision of failed drainage blebs with mitomycin-c pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 67 mmhg at the mean follow up of 29.6 ± 14.4 months. however, subconjuctival 5 – fluorouracil (5fu) was used as an antifibrotic agent. only 2 eyes developed suprachoroidal hemorrhage and 1 eye developed kissing choroidals requiring surgical drainage in their series. the risk factors for failure in their patients included previous argon laser trabeculoplasty (alt), number of previous surgeries, previous combined phaco-trab and previous use of mmc. shin et al13using 5-fu with needle revision reported 45% success rate at the end of 1 year in cohort of 64 patients. their study suggested that, use of mmc in initial trab increased the success rate in revision. greenfield et al14 reported outcome of needle revision in 63 eyes with mmc. they also injected 5-fu subconjunctivally in inferior fornix with number of injections, depending upon the degree of inflammation. the overall success rate was achieved at 78% (iop < 22 mmhg) with or without anti-glaucoma medication at 12 months. the direct comparison of various studies on needle revision, reported in literature is difficult, given the different demographics, type of glaucoma, severity of glaucoma, timing of needle revision, varying quantity and concentration of mmc and type of antifibrotic agent used. there is limitation of our study due to its retrospective nature, lack of control and a small sample size. fifteen of our patients had inadequate follow up or were lost to the follow up, which may have influenced the final outcome. with the remaining 46 patients, fulfilling our criteria of inclusion, it has been showed that by carrying out a simple procedure, we can achieve an iop of < 20 mmhg in more than 50% of patients, avoiding any further surgery. conclusion needle revision of drainage blebs with mmc can revive failed filtration procedure in at least half of the cases, avoiding invasive repeat surgery or commencing patients again on anti-glaucoma therapy. author’s affiliation prof. p. s. mahar aga khan university hospital karachi dr. a. sami memon isra postgraduate institute of ophthalmology karachi dr. israr a. bhutto isra postgraduate institute of ophthalmology karachi dr. dilshad a. laghari isra postgraduate institute of ophthalmology karachi references 1. cairns je. trabeculectomy-preliminary report of a new method. am j ophthalmol. 1968; 5: 673-7. 2. chen c, huang h, bair j, lee c. trabeculectomy with simultaneous topical application of mitomycin-c in refractory glaucoma. j ocul pharmacol. 1990; 6: 175-82. 3. palmer ss. mitomycin as adjunct chemotherapy with trabeculectomy. ophthalmology. 1991; 98: 317-21. 4. stone rt, herndon lw, allinghan rr, shield mb. results of trabeculectomy with 0.3ml / mitomycin-c titrating exposure times based on risk factor for failure. j glaucoma. 1998; 7: 39-44. 5. singh k, mehta k, shaikh n. trabeculectomy with intraoperative mitomycin-c versus fluorouracil. prospective randomized clinical trial. ophthalmology. 2000; 107: 2305-9. 6. fontana h, nouri-madhavi k, lumba j, ralli n, caprioli j. trabeculectomy with mitomycin-c. outcomes and risk factors for failure in phakic openangle glaucoma. ophthalmology. 2006; 113: 930-6. 7. mardelli pg, lederer cm jr, murray pl. slit lamp needle revision of failed filtering blebs using mitomycin-c. ophthalmology. 1996; 103: 1946-55. 8. greenfield ds, miller mp, suner ij. needle elevation of the scleral flap for failing filtration blebs after trabeculectomy with mitomycin-c. am j ophthalmol. 1996; 122: 195-204. 9. ben-simon gj, glovinsky y. needle revision of failed filtering blebs augmented with subconjunctival injection of mitomycin-c. ophthalmic surg lasers imaging. 2003; 34: 94-9. 10. broadway dc, bloom pa, bunce c. needle revision of failing and failed trabeculectomy blebs with adjunctive 5-fluorouracil: survival analysis. ophthalmology. 2004; 111: 665-73. 11. shetty rk, wartluft l, moster mr, ibraham d. slitlamp needle revision of failed filtering blebs using highdose mitomycin-c. j glaucoma. 2005; 14: 52-6. 12. pasternack jj, wand m, shields mb, ibraham d. needle revision of failed filtering blebs using 5fluorouracil and a combined ab-externo and ab-interno approach. glaucoma 2005; 14: 47-51. 13. shin dh, kim yy. risk factors for failure of 5fluorourcil needling revision for failed conjunctival filtration blebs. am j ophthalmol. 2001; 132: 875-880. 14. greenfield ds, miller mp. needle elevation of the scleral flap for failing filtration blebs after trabeculectomy with mitomycin-c. am j ophthalmol. 1996; 122: 195-204. microsoft word 13. abstracts 28-4-12 pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 227 abstracts edited by dr. qasim lateef chaudhry grid laser photocoagulation for macular edema due to branch retinal vein occlusion in the age of bevacizumab? results of a prospective study with crossover design leitritz ma, gelisken f, ziemssen f, szurman p, bartz – schmidt ku, jaissle gb br j ophthalmol. 2013; 97: 215–9. martin et al aimed to investigate the long term effectiveness of grid laser photocoagulation (glp) versus intravitreal bevacizumab (bev) in macular edema (mo) secondary to branch retinal vein occlusion (brvo). in this prospective interventional consecutive case series, previously untreated eyes with perfused mo were enclosed over a period of 16 months for bev and for 29 months for glp. the follow-up period was 1 year. patients with persistent mo after 12 months of bev were offered glp and vice versa, and were followed-up for another 12 months. both bev (23 eyes) and glp (21 eyes) caused a significant (p < 0.05) reduction in central retinal thickness (crt) at 12 months although this was delayed with glp. however, bev revealed a signifycantly better best corrected visual acuity (bcva) compared with glp (0.2 vs 0.5 logmar; p < 0.04). switching therapy for non-responders revealed a reduced crt at another 12 months, although this was not significant. so the authors concluded that functionally and anatomically, bev appears to be more effective than glp for the therapy of mo due to brvo. bcva is significantly better after1 year and the anatomical response of the mo is faster. further more, non-responders with persistent mo despite bev or glp treatment might benefit from switching therapy. phacoemulsification versus trabeculectomy in medically uncontrolled chronic angle – closure glaucoma without cataract tham ccy, kwong yyy, baig n, leung dyl, li fch, lam dsc. ophthalmology 2013; 120: 62–7. clement et al compared phacoemulsification versus trabeculectomy with adjunctive mitomycin c in medically uncontrolled chronic angle – closure glaucoma (cacg) without cataract in this prospective, randomized clinical trial comprising of fifty medically uncontrolled cacg eyes without cataract of 50 patients. patients were randomized into undergoing either phacoemulsification or trabeculectomy with adjunctive mitomycin c. after surgery, patients were followed up every 3 months for 2 years. the main outcome measures noted were intraocular pressure (iop) and requirement for glaucoma drugs. twenty-six cacg eyes were randomized to receive phacoemulsification, and 24 eyes underwent trabeculectomy with mitomycin c. phacoemulsification and trabeculectomy resulted in significant and comparable iop reduction at 24 months after surgery (reduction of 8.4 mmhg or 34% for phacoemulsification vs. 8.9mmhg or 36% for trabeculectomy; p 0.76). over first 24 months, trabeculectomy treated eyes required on average 1.1 fewer drugs than phacoemulsification treated eyes (p 0.001). however, trabeculectomy was associated with significantly more surgical complications than phacoemulsification (46% vs. 4%; p 0.001). eight (33%) of 24 trabeculectomy eyes demonstrated cataract during follow-up. the authors concluded that both phacoemulsification and trabeculectomy are effective in reducing iop in medically uncontrolled cacg eyes without cataract. although trabeculectomy is more effective than phacoemulsification in reducing dependence on glaucoma drugs it is associated with more complications. long – term visual acuity and the duration of macular detachment: findings from a prospective population-based study mitry d, awan ma, borooah s, syrogiannis a, limfat c, campbell h, wright af, fleck bw, charteris dg, yorston d, singh j. br j ophthalmol. 2013; 97: 149–152 the authors report the long-term visual outcome of amulticenter prospectively recruited cohort of maculaoff rhegmatogenous retinal detachments (rrd). the scottish retinal detachment study was a prospectively recruited study that recruited all incident cases of primary rrd in scotland over a 2-year period (2007 – 2009). all patients with a macula-off rrd fromfour participating sites were invited for clinical examinaqasim lateef chaudhry 228 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology tion at 6 weeks, 3 months, 6 months and 1 year after the initial surgery. using a join point model they estimated the effect of duration of macular detachment on final visual outcome. in total, there were 291 patients with macula off rrd without pre-existing retinal disease who had successful repair after one operation. 65.9% achieved a final visual acuity (va) of 0.48 log mar (6/18). they identified two time points (day 8 (95% ci 3 to 15 days) and (day 21 (95% ci 6 to 26 days)) after which there was a statistically significant worsening in final va. in conclusion the authors suggested that that the majority of patients with macula – off rrd successfully repaired with one operation will achieve a va of 6/18 or better at final follow-up. after 8 days of macular detachment, the final visual outcome may be adversely affected and, thus, operative repair within this period is desirable. duration of macular detachment of ≤ 8 days demonstrated a continuing improvement in va for up to 1 year, a finding which was not found in macula detachments of longer duration. visual outcomes and safety of a refractive corneal inlay for presbyopia using femtosecond laser limnopoulou al, bouzoukis di, kymionis gd, panagopoulou si, pallikaris ai, feingold v; pallikaris ig journal of refractive surgery 2013; 29: 12-8. aliki et al conducted this study to evaluate the outcomes and safety of a refractive inlay (flexivue micro – lens, presbia coöperatief u.a.) for the corneal compensation of presbyopia. this prospective, intervenetional clinical study comprised of 47 emmetropicpresbyopes with a mean age of 52 ± 4 years (range: 45 to 60 years). the inlay was inserted, centered on the line of sight, inside a corneal pocket created in the patient’s non dominant eye, using a femtosecond laser. follow-up was 12 months. visual acuity, corneal topography, wave frontaberrometry, contrast sensitivity, structural corneal alterations, and questionnaires were evaluated. twelve months after surgery, uncorrected near visual acuity was 20/32 or better in 75% of operated eyes, whereas mean uncorrected distance visual acuity (udva) of operated eyes was statistically significantly decreased from 0.06 ± 0.09 log mar (20/20) (range: −0.08 to 0.26) preoperatively to 0.38 ± 0.15 log mar (20/50) (range: 0.12 to 0.8) (p < .001), and mean binocular udva was not significantly altered (p = .516). seventeen patients lost one line of corrected distance visual acuity in the operated eye. no patient lost 2 lines in cdva in the operated eye. overall, higher order aberrations increased and contrast sensitivity decreased in the operated eye. no tissue alterations were found using corneal confocal microscopy. no intraor postoperative complications occurred. so the authors concluded that after twelve months post implantation, the flexivue micro-lens intracorneal refractive inlay seems to be an effective method for the corneal compensation of presbyopia in emmetropicpresbyopes aged between 45 and 60 years old. microsoft word 09-oa sana nadeem pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 34 +original article visual outcome of ocular trauma sana nadeem, muhammad ayub, humaira fawad pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sana nadeem ophthalmology department fauji foundation hospital rawalpindi …..……………………….. purpose: to evaluate the causes and visual outcome of ocular trauma threatening vision. material and methods: this study was conducted at the department of ophthalmology, holy family hospital, rawalpindi, from 1st november, 2011 to 30th september, 2012. visually significant ocular trauma included all cases with any decrease in vision at presentation. a detailed history with complete ocular examination was undertaken and relevant investigations were done as necessary. patients were treated medically or surgically as the case may be. follow up ranged from 1 month to 10 months. results: our study found a male preponderance in ocular trauma patients, with a male to female ratio of 4.92:1.the commonest agents responsible being stones and wooden sticks, both constituting 10 (12%) cases each. unilateral involvement occurred in 82 (98.8%) cases. blunt trauma cases were the most frequent, pertaining to 47 (56.6%) cases. the anterior segment was predominantly involved with 55 (66.3%) cases. complex patterns of trauma were observed. the post-operative best corrected visual outcome was statistically significant to the pre-operative visual acuity with 24 (28.9%) eyes attaining a visual acuity of 6/6 (p = 0.000). the greatest number of cases were managed conservatively with medical treatment i.e. 36 (43.4%), and the rest required surgeries. conclusion: ocular trauma is a great threat to vision. early recognition of the severity, adequate evaluation, and appropriate management lead to a better visual outcome. cular trauma is a significant cause of preventable visual impairment and unilateral visual loss worldwide. epidemiology of ocular trauma and visual outcome in developing countries is little known. nearly half a million people are blind monocularly as a result of ocular trauma worldwide according to a survey.1 approximately, 75% of the populations suffering ocular trauma are monocularly blind.2 one out of twenty patients presenting to the ophthalmologist has an ocular injury.3 ocular injuries vary greatly in type and complexity. the etiology of ocular trauma is diverse and varies in different geographical locations. despite causing structural and functional visual loss, ocular trauma has profound social, economical, occupational and medico-legal consequences. early detection and management hold the key to trauma management and prevention of further complications. prevention is always better than cure: measures to create awareness about ocular trauma and preventive measures would result in a great decrease in ocular morbidity and mortality due to trauma. we conducted this study to determine the etiology, pattern and extent of ocular trauma presenting to us, and manage it appropriately and abruptly, and evaluate the subsequent visual outcome. we also sought to find out the factors that affect the final visual outcome, and how to manage trauma patients more effectively in future. material and methods this prospective, interventional case series was carried out at the department of ophthalmology, holy family o sana nadeem, et al 35 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology hospital from 1st november, 2011 to 30th september, 2012. all cases of ocular trauma causing decreased vision at presentation were included in the study. exclusion criteria included sole lid lacerations, minor trauma like conjunctival tears and superficial metallic corneal or conjunctival foreign bodies, superficial corneal abrasions not causing decreased vision, subconjunctival hemorrhage and periorbital ecchymosis. orbital fractures causing no visual loss were also excluded, along with very old cases of trauma. a detailed history with ocular examination was performed. snellen visual acuity was performed in each case. with children less than 2 years, fixation and follow test patterns were used and in older children picture snellen chart was used. all patients were examined under the slit-lamp, direct ophthalmoscope or indirect ophthalmoscope. tonometry was done as per requirement. eua (examination under anesthesia) was done for small, non-cooperative children or retarded / handicapped patients. traumatic iritis was treated with topical steroids and cycloplegics and intraocular pressure (iop) lowering agents. hyphema was managed along similar lines with best rest and head elevation. corneal tears and scleral tears were sutured with 10/0 nylon and 6/0 vicryl respectively. sutures were removed later after adequate wound healing, and the time period varied with each case. severely disfigured globes with no vision were eviscerated primarily after appropriate consent. a ruptured lens associated with a corneal / corneoscleral tear was treated via irrigation and aspiration primarily, with secondary intraocular lens (iol) implantation with posterior capsulotomy or anterior vitrectomy if needed, 6 – 8 weeks later. rigid 6.5 mm pmma (polymethyl–methacrylate) intraocular lenses (iols) or foldable hydrophilic acrylic lenses were used. vitreoretinal cases were referred to a vitreoretina facility elsewhere, due to lack of such a facility at our hospital. final visual acuity was measured according to the case managed. data analysis was done using spss version 16. frequencies and percentages were calculated for age, gender, laterality, causative agent, type, extent, pattern, and management. chi square test was employed to compare preand post-operative visual acuity, with a p value of less than 0.05 being considered significant. results a total of 83 patients were included in the study. the mean age was 23.3 ± 17.3 years with a range from 8 months to 80 years. there was a male preponderance with 69 (83.1%) male and 14 (16.9%) female patients with a male to female ratio of 4.92:1. right eye involvement occurred in 53 (63.9%) cases, left in 29 (34.9%) cases, and bilateral visual outcome of ocular trauma pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 36 involvement occurred in 1 (1.2%) case only. the causative agents involved are shown in the table (table 1). the most common agent being stones and wooden sticks, both constituting 10 (12%) cases each, followed by vegetative agents 7 (8.4%), then metal rods 6 (7.2%), and balls and glass pieces accounting for 5 (6%) cases each. we classified trauma into five types, with blunt trauma cases being the most frequent; 47 (56.6%), penetrating; 27 (32.5%), perforating; 2 (2.4%), penetrating/perforating with intraocular foreign body (iofb) fig. 1-3; 5 (6%), and chemical injury accounting for only 2 (2.4%) cases (table 2). we also analyzed the extent of ocular trauma fig. 4 with the greatest number of cases pertaining to the anterior segment i.e. 55 (66.3%), the posterior segment involved in 5 (6%) cases, both anterior and posterior segment involvement in 23 (27.7%), and orbital fracture in only 2 (2.4) cases. complex patterns of trauma were observed and documented in a tabulated form (table 3). the pre-operative visual acuity (table 4) and postoperative visual acuity (table 5) were compared and analyzed with the chi square test, and the visual outcome of our management was found to be statistically significant (p=0.000). management of these diverse cases varied profoundly (table 6). the greatest number of cases were managed conservatively with medical treatment i.e. 36 (43.4%), simple corneal repair was required in 9 (10.8%) cases, with another 9 (10.8%) cases requiring a corneoscleral repair with iris repositioning, 8 (9.6%) patients treated by a corneal repair with iris repositioning, with 3 (3.6%) cases requiring a phacoemulsification with posterior capsulotomy / anterior vitrectomy and an sana nadeem, et al 37 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology iol implant, primary evisceration done also in 3 (3.6%) cases with unsalvageable globes, and 3 (3.6%) were referred to a vitreo-retina facility elsewhere, with a loss of follow up. 2 (2.4%) cases each required a corneal repair with primary lens matter aspiration (lma) due to a ruptured lens, scleral repair, phacoemulsification with iofb removal with iol implant for traumatic cataracts, intracapsular cataract extraction (icce) with anterior chamber iol (aciol), and corneal foreign body removal. corneal repair with lma with primary iol implant was done in 1 (1.2%) case, and so was phacoemulsification with iol. secondary surgeries were required in 16 (19.2%) cases. discussion ocular trauma is a leading cause of ocular morbidity in children and young adults with a male preponderance; the former accounting for 20% to 50% of all ocular injuries1, 3-9. a review, undertaken for planning purposes in the who programme for the prevention of blindness, suggests that around 55 million eye injuries responsible for restricting activities for more than one day, occur annually; they account for 750,000 hospitalized cases each year. these include approximately 200,000 open-globe injuries; with around 1.6 million people blind from such injuries, 2.3 million people with bilateral low vision from this cause, and almost 19 million people with unilateral blindness or low vision10. in our study, males were found to be at a greater risk of ocular injury, with a male to female ratio of 4.92:1. this is consistent with local studies carried out in lahore7,8 and karachi6, and internationally as well in india2,4,11. australia5, nepal12, uk3, 13 and egypt14. the major objects causing ocular trauma were stones, wooden sticks, vegetative foreign bodies, metal rods, balls and glass pieces. this is consistent with local studies with vegetative material being the commonest in a study carried out at al-ibrahim hospital6, and sticks and pencils at sir ganga ram hospital8, and hammer on metal injuries at jinnah hospital, lahore7. unilateral involvement occurred in 82 (98.8%) cases. bilateral ocular injury is rare6,7,14. blunt trauma cases were the most frequent type, pertaining to 56.6% of the cases, as observed by bukhari6 et al and guly3 et al in their trauma studies. on the contrary, lacerating injury was found to be predominant in other studies carried out in lahore7,8, peshawar14, egypt15 and nepal12. penetrating trauma constituted 32.5% and true perforating injuries accounted for 2.4% only. six (6)% of the patients were found to have an intraocular foreign body and chemical injury accounted for only 2.4% cases. the anterior segment was predominantly involved in 66.3% of the cases. complex patterns of trauma visual outcome of ocular trauma pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 38 were observed with multiple structures involved. the post-operative best corrected visual outcome was statistically significant as compared to the preoperative vision with 28.9% eyes attaining a visual acuity of 6/6. in other studies carried out in karachi6, a good visual outcome was obtained; however, the opposite is true for a study in lahore8. the greatest numbers of cases were managed conservatively with medical treatment (43.4%), and the rest required surgeries. fig. 1: antero-posterior radiograph of a 60 year old female hit with a grinder blade accidentally, which was protruding from her left eye and embedded in the orbital floor. the eye was primarily eviscerated. fig. 2: lateral radiograph of the same patient. factors predicting final visual outcome after open globe trauma include mechanism or type of injury, preoperative visual acuity, time lag between trauma and surgery, relative afferent pupillary defect, size and location of the wound, hyphema, lens rupture, vitreous loss, vitreous hemorrhage, retinal detachment, intraocular foreign body4,6,11,12. the “golden hour” in trauma is broadly defined as the first sixty minutes and is vital that the patient should be transferred to a trauma facility, antibiotics started and appropriate investigations undertaken to treat it adequately, either medically or surgically. fig. 3: an intra-lenticular metallic foreign body in the left eye of a patient with occupational trauma. best corrected vision was 6/36. fig. 4: pie chart illustrating extent of trauma limitations of study are many. this study is a small scale study and does not reflect the epidemiological aspects of ocular trauma. some of the patients were lost to follow up and this could affect sana nadeem, et al 39 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology the overall visual outcome. our hospital lacked a vitreo-retina facility and thus patients referred were eventually lost. in a developing country, compliance to treatment, counseling and follow up are difficult due to ignorance, carelessness and illiteracy of the patients and their relatives; most patients would not comply to a follow up, once useful vision is attained. hence, long term results of such patients are hard to obtain. the tremendous impact of ocular trauma, on needs of medical care, loss of income and cost of rehabilitation, significantly enhances the need for the strengthening of preventive measures. a clear understanding of the mechanism of ocular injuries ensures prompt detection, treatment and prevention. parents and teachers should be counseled regarding availability and use of potentially traumatic objects by children, along with close supervision. sportsmen and employers and workers in hazardous industries need education regarding use of protective and safe eye gear at all times. conclusion ocular injury is a very grave cause of ocular morbidity and mortality. prevention is always better than cure, so appropriate preventive measures should be employed at potentially hazardous places. prompt transfer to a good eye facility, early investigations and management are key features to prevent permanent visual loss. author’s affiliation dr. sana nadeem senior registrar ophthalmology department fauji foundation hospital rawalpindi dr. muhammad ayub senior registrar ophthalmology department holy family hospital rawalpindi dr. humaira fawad consultant ophthalmologist ophthalmology department district headquarters hospital rawalpindi references 1. thylefors b. epidemiological patterns of ocular trauma. aust n z j ophthalmol http://www.ncbi.nlm.nih.gov/pubmed/ 1389141. 1992; 20: 95-8. 2. vats s, murthy gvs, chandra m, gupta sk, vashist p, gogoi m. epidemiological study of ocular trauma in an urban slum population in delhi, india. indian j ophthalmol. 2008; 56: 313-6. 3. guly cm, guly hr, bouamra o, gray rh, lecky fe. ocular injuries in patients with major trauma. emerg med j. 2006; 23: 915–7. 4. agarwal r, rao g, naigaonkar r, ou x, desai s. prognostic factors for vision outcome after surgical repair of open globe injuries. indian j ophthalmol. 2011; 59: 465-70. 5. thompson cg, kumar n, bilson fa, martin f. the aetiology of perforating ocular injuries in children. br j ophthalmol. 2002; 86: 920-2. 6. bukhari s, mahar ps, qidwai u, bhutto ia, memon as. ocular trauma in children. pak j ophthalmol. 2011; 27: 208-13. 7. jahangir t, butt nh, hamza u, tayyab h, jahangir s. pattern of presentation and factors leading to ocular trauma. pak j ophthalmol. 2011; 27: 96-102. 8. arfat my, butt hm. visual outcome after anterior segment trauma of the eye. pak j ophthalmol. 2010; 26: 74-8. 9. vafaee i, nobar mb, goldust m. etiology of ocular trauma: a two years cross-sectional study in tabriz, iran. [letter to the editor] j coll physicians surg pak. 2012; 22: 344. 10. négrel ad, thylefors b. the global impact of eye injuries. ophthalmic epidemiol. 1998; 5: 143-69. 11. narang s, gupta v, simalandhi p, gupta a, raj s, dogra mr. paediatric open globe injuries. visual outcome and risk factors for endophthalmitis. indian j ophthalmol. 2004; 52: 29-34. 12. khatry sk, lewis ae, schein od, thapa md, pradhan ek, katz j. the epidemiology of ocular trauma in rural nepal. br j ophthalmol. 2004; 88: 456-60. 13. eagling em. ocular damage after blunt trauma to the eye. its relationship to the nature of the injury. br j ophthalmol. 1974; 58: 126-40. 14. babar tf, khan mt, marwat mz, shah sa, murad y, khan md. patterns of ocular trauma. j coll physicians surg pak. 2007; 17: 148–53. 15. el-mekawey he, abu el einen kg, abdelmaboud m, khafagy a, eltahawy em. epidemiology of ocular emergencies in the egyptian population: a five-year retrospective study. clin ophthalmol. 2011; 5: 955-60. pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 124 original article effect of topical latanoprost 0.005% drops on central corneal thickness in patients with primary open angle glaucoma akhunzada mohammad aftab, mubashir rehman, sher akbar khan, farooq khan, awais rauf pak j ophthalmol 2014, vol. 30, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mubashir rehman medical officer department of ophthalmology, lady reading hospital, peshawar email:dr_mubashir@yahoo.com …..……………………….. purpose: to determine the effect of topical 0.005% latanoprost on central corneal thickness in patients with primary open angle glaucoma. material and methods: this study was conducted at eye “a” unit, khyber teaching hospital, peshawar. total sample size was 139 eyes. baseline iop measurement was taken with goldman applanation tonometer. central corneal thickness was measured by a single trained doctor using the quantel ® pachymeter. all patients were prescribed latanoprost 0.005% eye drops once daily in the evening. follow up was at 2 weeks and 8 weeks. results: mean age was 52 years with sd ±2.71. sixty nine (55%) patients were male and 56 (45%) were female. mean difference between baseline cct and cct after eight weeks was 4% as mean baseline cct level was 538 μm with sd ± 1.87 and mean cct level after 8 weeks was 534 μmwith sd ±2.12. efficacy of effect of latanoprost on central corneal thickness of patients with primary open angle glaucoma was analyzed as latanoprost was effective in reducing cct in 104 eyes (75%) of 94 patients and was not effective in 35 eyes (25%) of 31 patients. conclusion: our study concludes that topical 0.005% latanoprost eye drops reduces the central corneal thickness, so latanoprost therapy requires careful monitoring while treating patients with primary open angle glaucoma. however this reduction in cct was not ≥ 25 µm from base line reading which is not significant enough and hence did not have an effect on iop reading using goldman applanation tonometer. key words: latanoprost, central corneal thickness, primary open angle glaucoma. glaucoma has become an important cause of blindness worldwide especially in the aging age group. new statistics gathered by the who show that glaucoma is now the second leading cause of blindness globally.1 it is the fourth commonest cause of blindness in pakistan.2 glaucoma affects about 60 million people globally and is the causative factor of 12% of global blindness.3, 4 more than 3 million people are bilaterally blind from poag worldwide, and more than 2 million people will develop poag each year.5 intra ocular pressure (iop) measurement is one of the key steps in diagnosis and monitoring and the gold standard is goldman applanation tonometry (gat). a linear correlation between central corneal thickness (cct) and iop measured by goldman applanation tonometer has been described by several groups suggesting that goldman applanation tonometry results in under estimation in thin corneas and overestimation in thick corneas.6 to prevent glaucoma progression and to preserve vision, mean intraocular pressure should be decreased g akhunzada mohammad aftab, et al 125 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology to a patient dependent target pressure.7 the current treatment modalities for glaucoma include medical, laser (usually trabeculoplasty) and surgical (usually trabeculectomy).8 regarding medical therapy prostaglandin analogues are more cost-effective than beta-blockers for any stage of poag.9 latanoprost is a prostaglandin f2α analogue. latanoprost 0.005% decreases iop by increasing outflow of aqueous humor through uveoscleral pathways.8 common side effects include conjunctival irritation and hyperemia, eyelash changes (increased length, thickness, pigmentation, and number of lashes), eyelid skin darkening, intraocular inflammation (iritis / uveitis), iris pigmentation changes, and macular edema, including cystoid macular edema.8 evaluation of corneal thickness have been done in several populations. comparison among different populations is difficult due to different measurement techniques and missing data. aghaian et al. evaluated differences in central corneal thickness, and showed that the cct of japanese was significantly lower than that of caucasians, filipinos, chinese, and hispanics, and greater than that of african americans., african americans have thinner corneas compared to white subjects. 10 in a study conducted on pakistani population the mean (sd) cct measurements were 531.08 +/33.37) and 531.29 +/33.33 micrometers in the right and left eyes respectively and were not significantly different from each other.11 since no study has been done to look into the effects of topical latanoprost therapy on cct in our population, this study will help to prove or disprove effect of topical latanoprost therapy on central corneal thickness. if found to cause reduction, it would be interesting to see whether this decrease in cct significantly affects the iop readings done by goldman applanation tonometer. it would also prove beneficial in determining whether serial cct measurement should be a part of monitoring effects of latanoprost therapy. material and methods it was a descriptive cross sectional study conducted at department of ophthalmology, eye “a” unit khyber teaching hospital peshawar from april 2013 to october 2013. the total sample size was 139 eyes. sample size was calculated by who software for sample size calculation using 77.10% proportion of decrease in cct and 95% confidence interval and a 7% margin of error. before starting study, approval was taken from hospital’s ethical committee. patients were selected from outpatient department, department of ophthalmology, khyber teaching hospital, peshawar. all newly diagnosed primary open angle glaucoma patients from either gender within 20-60 years age group were selected. patients in whom prostaglandin analogues are contraindicated e.g. patients with known allergy to prostaglandin analogues, patients with uveitis and other ocular inflammatory conditions, patients who require multiple drug therapy and patients with previous ocular surgery or corneal refractive surgery were excluded from the study. written informed consent was taken from the patient. detailed history was taken followed by complete examination including assessment of best corrected visual acuity (bcva), anterior segment examination with slit – lamp, baseline iop measurement with goldman applanation tonometer and fundus examination with 90 d lens. humphrey standard perimetry was performed. central corneal thickness was measured in all patients by a single trained doctor using the quantel® pachymeter. the mean of 3 measurements was taken for analysis. all patients were prescribed latanoprost 0.005% eye drops once daily in the evening. patients were advised to come for follow up at 2 weeks and 8 weeks. repeated central corneal thickness readings were taken after 8 weeks by the same method as discussed above. cct measurement was performed in the morning to avoid any possible alteration due to day – time fluctuations. those patients who develop drug side effects and those who don’t come for follow up were omitted from the study. latanoprost will be said to be efficacious in causing change in cct if a difference in cct was observed after 8 weeks of initiation of therapy compared to baseline value of cct. this change in cct would be considered significant if it was ≥25µ as correction factor need to be applied then. spss version 20.0 was used for analysis of data. quantitative variables include age and cct (base line and after 8 weeks); and qualitative variables include gender and involvement of eye. mean ± standard deviation was calculated for quantitative variables; percentage and proportion was calculated for qualitative variables. efficacy was stratified among age, gender and baseline cct to see effect modifiers. effect of topical latanoprost 0.005% drops on central corneal thickness in patients with poag pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 126 table 1: base line cct (n = 139 eyes). base line cct frequency total right eye left eye both eyes < 500 μm 5 (4%) 5 (4%) 3 (2%) 13 (10%) 500 525 μm 15 (11%) 15 (11%) 9 (6%) 39 (28%) 525 555 μm 22 (16%) 23 (17%) 13 (9%) 58 (42%) 555 570 μm 14 (10%) 12 (8%) 3 (2%) 29 (20%) total 56 (40%) 55 (40%) 28 (20%) 139 (100%) mean baseline cct level was 538 μm with sd ± 1.87 table 2: cct at eight weeks (n = 139 eyes). cct at eight weeks frequency total right eye left eye both eyes < 500 μm 6 (4%) 7 (5%) 4 (3%) 17 (12%) 500 -525 μm 19 (11%) 17 (11%) 6 (6%) 42 (30%) 525 -555 μm 20 (14%) 19 (14%) 16 (12%) 55 (40%) 555 -570 μm 10 (7%) 9 (7%) 6 (4%) 25 (18%) total 56 (40%) 55 (40%) 28 (20%) 139 (100%) mean cct level after 8 weeks was 534 μm with sd ± 2.12 table 3: comparison of base line cct and cct at eight weeks. baseline cct cct at 8 weeks mean 538 534 standard deviation 1.87 2.12 ttest was applied in which p value was 0.0001 results a total of 139 eyes of 125 patients were observed to determine the effect of topical 0.005% latanoprost on central corneal thickness in patients with primary open angle glaucoma and the results were analyzes as: age distribution among 125 patients (139 eyes), was analyzed as 2(2%) patients were in age range 20 – 30 years, 5(4%) patients were in age range 31 – 40 years, 30 (24%) patients were in age range 41 – 50 years and 88 (70%) patients were in age range 51 – 60 years. mean age was 52 years with sd ± 2.71. gender distribution among 125 patients was analyzed as 69 (55%) patients were male while 56(45%) patients were female. involvement of eye among 125 patients was analyzed as 56 (45%) patients had right eye affected, 55 (44%) patients had left eye affected and 14 (11%) patients had both eyes (14 × 2 = 28 eyes) affected. base line cct among 139 eyes was analyzed as 13 (10%) eyes had cct level < 500 μm, 39 (28%) eyes had akhunzada mohammad aftab, et al 127 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology table 4: efficacy and stratification with involvement of eye (n = 139 eyes). efficacy involvement of eye total right eye left eye both eyes yes 42 (30%) 42 (30%) 20 (15%) 104 (75%) no 14 (10%) 13 (9%) 8 (6%) 35 (25%) total 56 (40%) 55 (40%) 28 (20%) 139 (100%) chi square test was applied in which p value was 0.032 cct level ranged from 500 – 525 μm, 58 (42%) eyes had cct level ranged from 525 – 555 μm and 29 (20%) eyes had cct level ranged from 555 – 570 μm. mean cct level was 538 μm with sd ± 1.87 (as shown in table 1). cct at eight weeks among 139 eyes was analyzed as 17 (12%) eyes had cct level < 500 μm, 42 (30%) eyes had cct level ranged from 500 – 525 μm, 55 (40%) eyes had cct level ranged from 525 – 555 μm and 25 (18%) eyes had cct level ranged from 555 – 570 μm. mean cct level was 534 μm with sd ± 2.12 (as shown in table 2). mean difference between baseline cct and cct after eight weeks was 4% as mean baseline cct level table 5: efficacy and stratification with gender (n = 139 eyes). efficacy gender total male female yes 56(40%) 48(35%) 104(75%) no 20(15%) 15(10%) 35(25%) total 76(55%) 63(45%) 139(100%) chi square test was applied in which p value was 0.047 table 6: efficacy and stratification with age distribution (n = 125 patients). efficacy age distribution total 20 – 30 years 31 – 40 years 41 – 50 years 51 – 60 years yes 1 (1%) 5 (4%) 19 (15%) 69 (55%) 94 (75%) no 1 (1%) 1 (1%) 13 (10%) 16 (13%) 31 (25%) total 2 (2%) 6 (5%) 32 (25%) 85 (68%) 125 (100%) chi square test was applied in which p value was 0.021 was 538 μm with sd ±1.87 and mean cct level after 8 weeks was 534 μm with sd ±2.12. p value has been calculated for pre-treatment and post-treatment cct using t-test and is found to be less than 0.0001. by conventional criteria this difference is considered to be extremely statistically significant (table 3). efficacy of latanoprost in causing a reduction of central corneal thickness of patients with primary open angle glaucoma among 139 eyes was analyzed as latanoprost was effective in reducing cct of 104 (75%) eyes and in 35(25%) eyes, there was no change in cct (as shown in table 4). stratification of efficacy of latanoprost in causing cct reduction with involvement of eye was analyzed as in 104 effective cases of latanoprost therapy, 42 patients had right eye affected, 42 patients had left eye effect of topical latanoprost 0.005% drops on central corneal thickness in patients with poag pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 128 affected and 20 patients had both eyes affected (as shown in table 4). stratification of efficacy of latanoprost causing reduction of cct with gender distribution was analyzed as in 104 effective cases of latanoprost, 56 eyes belonged to males, and 48 eyes belonged to females (as shown in table 5). stratification of efficacy of latanoprost causing reduction of cct with age distribution was analyzed as in 94 effective cases of latanoprost (104 eyes), 1 patient was in age rage 20 – 30 years, 5 patients were in age rage 31 – 40 years, 19 patients were in age rage 41 – 50 years and 69 patients were in age rage 51 – 60 years (as shown in table 6). discussion open angle glaucoma is silent killer of vision. it is slowly progressive and remains asymptomatic until it is very advanced and severe and irreversible damage has usually occurred in one or both eyes. it is the second leading cause of blindness worldwide.12 there are a number of risk factors for glaucoma but currently iop is the only modifiable risk factor that can be used to prevent progressive optic neuropathy. the early – manifest glaucoma treatment study showed that iop reduction by at least 25% reduced disease progression from 62 to 45% in the treated group compared to an untreated group.13,14 to prevent glaucoma progression and to preserve vision, mean intraocular pressure should be decreased to a patient dependent target pressure. the target pressure depends on a number of factors, including age of patient, baseline iop at which the damage occurred, structural damage (status of optic disc and rnfl), functional damage (assessed on perimetry) and the presence of additional risk factors for glaucomatous damage.15 the aim of glaucoma management is to preserve the visual functions and quality of life of the individual. our objective should be not just to treat the intraocular pressure (iop), but to treat the patient as a whole so as to provide maximum benefit with minimal side effects. medical treatment is the mainstay of glaucoma management, particularly of open angle glaucoma. a number of intraocular pressure-lowering agents are available which act either by decreasing aqueous secretion or by enhancing the aqueous outflow. the goal of medical treatment is to obtain 24 – hour iop control with the minimum concentration and number of medications, as well as minimal local and systemic side effects.16 latanoprost was well tolerated at all concentrations, with no differences between doses groups with respect any of the adverse events, including conjunctival hyperemia. there were two reports of iris darkening and 11 reports of eyelash growth, but there was no dose association for either of these events. both are well recognized side effects of prostaglandin analog therapy.17 after a single topical dose of latanoprost 0.005%, iop reduction is maximal within 8 to 12 hours and iop remains below pretreatment level for at least 24 hours. in 24-hour iop measurements, latanoprost administered once a day in the evening induces a constant iop reduction, although the hypotensive effect seems to be greatest during the day.16,17 in patients with glaucoma or ocular hypertension (iop ≥ 21), a number of studies, between 1 and 12 months’ treatment, report a reduced iop level, from 22% to 39%.18 our study shows that topical 0.005% latanoprost eye drops reduces the central corneal thickness as the mean cct was observed (538  ± 1.87 μm vs. 534   ± 2.1 2 μm) in 75% eyes in 8 weeks follow up. similar results were found in other studies as hatanaka m et al in a controlled trial have shown that latanoprost 0.005% showed reduction of 0.86% in cct from a baseline level of 548.57 μm ± 32.4 to 543.88 μm ± 35.6 after 8 weeks of use.17 xhong. y, et al reported a decrease in cct of 15.73 ± 3.25µm following latanoprost monotherapy.19 a statistically significant reduction in the mean cct was observed in the latanoprost group (535.5   ±  37.9  μm vs. 530.1  ±  36.4 μm) in 77.10% eyes 24 months following initiation of therapy by a similar study conducted by kim hj and cho bj.19 another study conducted by sen e, et al21 revealed a 1.9 ± 2.4% reduction in cct from a mean baseline cct value of 559.5 ± 35.3 μm, 12 months following latanoprost therapy. a meta – analysis of randomized clinical trials widely estimated the iop reduction achieved by the most frequently prescribed glaucoma drugs and a placebo and pointed out that prostaglandin analogs are the most effective group for lowering iop by mono therapy in primary open angle glaucoma (poag) or ocular hypertensive patients, with a relative change of −31% (at peak) and −28% (at trough) for latanoprost. akhunzada mohammad aftab, et al 129 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology after a long-term treatment, since latanoprost has no clinically significant effect on the permeability of the blood–aqueous barrier, iop will return to pretreatment levels within a few weeks, indicating that latanoprost is safe for long-term treatments. conclusion our study concludes that topical 0.005% latanoprost eye drops reduces the central corneal thickness as the mean cct was observed (538  ± 1.87 μm vs. 534 ± 2.12 μm) in 75% eyes in 8 weeks follow up, so latanoprost therapy requires careful monitoring while treating patients with primary open angle glaucoma. however this reduction in cct was not ≥ 25 µm from base line readingwhich is not significant enough and hence did not have an effect on iop reading using the goldman applanation tonometer. author’s affiliation dr. akhunzada mohammad aftab junior registrar, eye “a” ward, khyber teaching hospital, peshawar dr. mubashir rehman medical officer, department of ophthalmology, lady reading hospital, peshawar dr. sher akbar khan consultant ophthalmologist, medical rehabilitation complex, charsaddah dr. farooq khan trainee medical officer, department of ophthalmology, khyber teaching hospital, peshawar dr. awais rauf trainee medical officer, department of ophthalmology, khyber teaching hospital, peshawar role of authors dr. akhunzada mohammad aftab patients’ selection, data collection and data analysis. dr. mubashir rehman patients’ selection, data collection and data analysis. dr. sher akbar khan patients’ selection, data collection and data analysis. dr. farooq khan literature search and references. dr. awais rauf literature search and references. refrences 1. kumarasamy na, lam fs, wang al, theoharides tc. glaucoma: current and developing concepts for inflammation, pathogenesis and treatment. eur j inflamm. 2006; 4: 129-37. 2. quiiqley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol 2006; 90: 262-7. 3. dineen b, bourne rr, jadoon z. causes of blindness and visual impairment in pakistan. br j ophthalmol. 2007; 91: 1005-10. 4. hazin r, hendrick am, kahook my. primary openangle glaucoma: diagnostic approach and management. j nati med assoc. 2009; 101: 46-50. 5. kanski jj. glaucoma. in: kanski jj clinical ophthalmology. a systemic approach 6th ed. butterworth heinemann elsevier. 2007: 371-440. 6. izzotti a, bagnis a, saccà sc. the role of oxidative stress in glaucoma. mutat res. 2006; 612: 105-14. 7. theelen t, meulendij cf, geurts de. impact factors on intraocular pressure measurement in healthy subjects. br j ophthalmol. 2004; 88: 1510-1. 8. lodhi aa, talpur ki, khanzada ma. latanoprost 0.005% v/s timolol maleate 0.5% pressure lowering effect in primary open angle glaucoma. pak j ophthalmol. 2008; 24 (2): 68-72. 9. macleod sm, clark r, forrest j, bain m, bateman n, azuara – blanco a. a review of glaucoma treatment in scotland 1994-2004. eye, 2004; 22 (2): 251-5. 10. hoffmann em, lamparter j, mirshahi a, elflein h, hoehn r, wolfram c, lorenz k, adler m, wild ps, schulz a, mathes b, blettner m, pfeiffer n. distribution of central corneal thickness and its association with ocular parameters in a large central european cohort: the gutenberg health study. plos one, 2013; 8 (8): 118-21. 11. channa r, mir f, shah mn, ali a, ahmad k. central corneal thickness of pakistani adults. j pak med assoc. 2009; 59 (4): 225-8. 12. patel ss, spencer cm. latanoprost. a review of its pharmacological properties, and tolerability in the management of primary open-angle glaucoma and ocular hypertension. drugs aging, 1996; 9: 363-78. 13. rulo ah, greve el, hoyng pf. additive ocular hypotensive effect of latanoprost and acetazolamide: a short-term study in patients with elevated intraocular pressure. ophthalmology, 1997; 104: 1503-7. 14. novack gd, o'donnell mj, molloy dw. new glaucoma medications in the geriatric population: efficacy and safety. j am geriatr soc. 2002; 50: 956-62. 15. orzalesi n, rossetti l, invernizzi t, bottoli a, autelitano a. effect of timolol, latanoprost, and dorzolamide on circadian iop in glaucoma or ocular hypertension. invest ophthalmol vis sci. 2000; 41: 256673. 16. johnstone ma. hypertrichosis and increased pigmentation of eyelashes and adjacent hair in the http://www.ncbi.nlm.nih.gov/pubmed/?term=hoffmann%20em%5bauthor%5d&cauthor=true&cauthor_uid=23936291 http://www.ncbi.nlm.nih.gov/pubmed/?term=lamparter%20j%5bauthor%5d&cauthor=true&cauthor_uid=23936291 http://www.ncbi.nlm.nih.gov/pubmed/?term=mirshahi%20a%5bauthor%5d&cauthor=true&cauthor_uid=23936291 http://www.ncbi.nlm.nih.gov/pubmed/?term=elflein%20h%5bauthor%5d&cauthor=true&cauthor_uid=23936291 http://www.ncbi.nlm.nih.gov/pubmed/?term=hoehn%20r%5bauthor%5d&cauthor=true&cauthor_uid=23936291 http://www.ncbi.nlm.nih.gov/pubmed/?term=wolfram%20c%5bauthor%5d&cauthor=true&cauthor_uid=23936291 http://www.ncbi.nlm.nih.gov/pubmed/?term=lorenz%20k%5bauthor%5d&cauthor=true&cauthor_uid=23936291 http://www.ncbi.nlm.nih.gov/pubmed/?term=adler%20m%5bauthor%5d&cauthor=true&cauthor_uid=23936291 http://www.ncbi.nlm.nih.gov/pubmed/?term=wild%20ps%5bauthor%5d&cauthor=true&cauthor_uid=23936291 http://www.ncbi.nlm.nih.gov/pubmed/?term=schulz%20a%5bauthor%5d&cauthor=true&cauthor_uid=23936291 http://www.ncbi.nlm.nih.gov/pubmed/?term=mathes%20b%5bauthor%5d&cauthor=true&cauthor_uid=23936291 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3, jul – sep, 2015 130 region of the ipsilateral eyelids of patients treated with unilateral topical latanoprost. am j ophthalmol. 1997; 124: 544-7. 17. hatanaka m, vessani rm, elias ir, morita c, susanna r, jr. the effect of prostaglandin analogs and prostamide on central corneal thickness. j ocul pharmacol ther. 2009; 25 (1): 51-3. 18. watson p, stjernschantz j. a six – month, randomized, double – masked study comparing latanoprost with timolol in open – angle glaucoma and ocular hypertension. ophthalmology, 1996; 103: 126-37. 19. xhong y, shen x, yu j, tan h, cheng y. the comparison of the effects of latanoprost, travoprost and bimetaprost on central corneal thickness. cornea, 2011; 30 (8): 861-4. 20. kim hj, cho bj. long term effect of latanoprost on central corneal thickness in normal tension glaucoma. j ocul pharmacol ther. 2011; 27 (1): 73-6. 21. sen e, nalcacioqlu p, yazici a, aksakal fn, altonok a, tuna t, koklu g. comparison of the effects of latanoprost and bimetaprost on central corneal thickness. j glaucoma, 2008; 17 (5): 398-402. pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 187 original article congenital cataracts; its laterality and association with consanguinity afia matloob rana, ali raza, waseem akhter pak j ophthalmol 2014, vol. 30 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: afia matloob rana ophthalmology department holy family hospital, rawalpindi satellite town, rawalpindi email: afiamatloob@yahoo.com …..……………………….. purpose: to study the frequency of laterality (bilateral vs. unilateral) and its importance among congenital cataracts. we also investigated consanguinity as a risk factor in congenital cataract cases. material and methods: this study was conducted in ophthalmology department, holy family hospital, rawalpindi, from 2 nd january 2013 to 2 nd february 2014. a total of 112 eyes and 86 patients in age range from 3 months to 26 years and all types of visually significant congenital cataracts total or partial without prior history of ocular trauma and syndromic association were recruited for the study. frequency distribution, test of significance was carried out using statistical package for social sciences version 20.0. results: a total of 112 cases (61 males, 51 females) were recruited in the study. there was no statistically significant difference between different age groups and gender (p=0.2). the unilateral cases were 19.6% and bilateral were 80.4%. consanguinity was present in 69.6% (n=78) and absent in 30.4% (n=34). the difference was statistically significant (p=0.00). conclusion: bilateral congenital cataract is a more common presentation as compared to unilateral cataract. consanguinity is an important risk factor for congenital cataract especially bilateral cataracts. key words: congenital cataracts; ocular trauma, syndromic association ongenital cataract is an important cause of preventable visual deprivation in children accounting for 5%-20% of blindness in children worldwide.1,2 world – wide, the number of children who are blind is estimated to be 1.4 million, 190,000 of them from cataract.3 cataract in children can be classified as congenital, developmental or traumatic.4 congenital cataract presents either from birth or shortly thereafter, while developmental cataract usually refers to cataract that appears after the age of two5. pediatric cataracts are responsible for more than 1 million childhood blindness in asia.6 the prevalence of cataract in children has been estimated about 3 in 10,000 live births.7 ocular morbidity is mainly caused by obstruction to development of the visual system and it has great physical, social economical and psychological impact. prevention of visual impairment and blindness in childhood due to congenital and infantile cataract is an important international goal4 and is a priority for vision 2020.8 epidemiology of congenital cataract is not fully understood because it’s not a specific entity but combination of multiple factors, including many associated ocular pathologies. density and laterality of congenital cataract are one of the most important parameters in terms of visual outcome, others are type of cataract, associated ocular pathology and delay in presentation to hospital. unilateral dense cataract is a definite indication for early cataract surgery (preferably within days) which is followed by aggressive amblyopia treatment, even then the results mostly remain poor.9 unilateral cataracts are generally sporadic, with no family history of cataract or systemic illness, and affected infants have history of full-term and normal health.9 c mailto:afiamatloob@yahoo.com afia matloob rana, et al 188 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology genesis of congenital cataract is still not explored well and very little is known because of modern techniques, long term accurate data needed and lack of sensitive investigative procedures. genetic factors are important in the etiology of congenital cataract, up to half of childhood cataracts are genetic in origin10. nearly, one-third of total congenital cataract cases are familial.11 these types of cases are mainly because of genetically induced developmental alterations among the crystalline lens and surrounding tissues. there are a lot of ongoing epidemiological studies to find out risk factors like intrauterine infections, certain enzymes deficiency, and sporadic. the knowledge about the causes is important to develop appropriate planning strategies, which are not available for many regions of the world and where these are available, has been obtained mostly from studies of selected populations, or from routine sources which are often based on small numbers of cases.12 routine ocular examination of young infants is widely recommended to ensure that treatment, genetic counseling, and other advice and support are offered at the earliest opportunity. the parents and any siblings should be examined thoroughly even in the absence of positive family history. in this study we are trying to analyse frequency of laterality among congenital cataract and to investigate consanguinity as risk factor among hospital data of congenital cataract in patients attending our ophthalmology department. material and methods our study includes patients with congenital / infantile cataract presenting to ophthalmology department, holy family hospital, newly diagnosed during the 12month period from 2nd january 2013 to 2nd february 2014 identified prospectively. it include 112 eyes and 86 patients in age ranging from 3 months to 26 years and including all types of visually significant cataracts total or partial without prior history of ocular trauma and syndromic association. all affected individuals underwent a detailed history and ophthalmological examination. morphological details of cataract including other ocular associations and also detailed dilated fundus examination where possible were recorded. informed consent was obtained and detailed medical and family history with especial emphasis on consanguinity was obtained by taking detailed history from parents or guardian of children on admission using a standardized questionnaire. ophthalmic examination included assessment of the pupillary red reflex with a direct ophthalmoscope, visual acuity or fixation and following behavior checked according to age of patients, complete anterior segment examination with slit lamp and retinoscopy was done, b-scan was also done where required. all patients underwent irrigation and aspiration of cataract with or without iol followed by aphakic correction where required according to latest recommendations. laterality and association of consanguinity with congenital cataract was noted and assessed. statistical analysis was performed using statistical package for social sciences version 20. fisher exact test was performed to determine statistically significant differences in the gender of the population. a p value of <0.05 was taken to be significant in all analysis. results congenital cataract characteristics and demographics of the cases are shown in table 1 while table 2 shows laterality with age distribution, picture 1 showing consanguinity with laterality while picture 2 showing different morphological presentations of congenital cataract with gender distribution. a total of 112 cases (61 males, 51 females) were recruited in the study. the distribution of congenital cataract cases for different age groups in our study was as follows for less than 1 year age group 24.4% (n=15 males, n=11 females), age group 1–5 years 25% (n=19 males, n=7 females), age group 6–10 years 19.6% (n=12 males, n=10 females), age group 11–15 years 17.9% (n=8 males, n=12 females), age group 16–20 years 9.8% (n=4 males, n=7 females) and age group more than 20 years 6.3% (n=3 males, n=4 females). there was no statistically significant difference between different age groups and gender (p=0.2). the bilateral cataracts (n=90) included 48 (53.33%) males and 42 (46.66%) females, while unilateral cataract (n=22) comprised of 13 (59.09%) male and 9 (40.91%) female cases. in both bilateral and unilateral cataract groups males were more as compare to females. this difference was not statistically significant (p=0.093). the cumulative unilateral cases were 19.6% and bilateral were 80.4%. in age group less than 1 year 18% were unilateral and 24% were bilateral, in group 1-5 years unilateral were 9% and bilateral were 26%, in age group 6-10 years unilateral was 23% and bilateral were 18%, in age group 11-15 years unilateral were 18% and bilateral were 18%, in age group 16 – 20 years unilateral were 14% and bilateral were 9%, in age group more than 20 years unilateral were 18% and congenital cataracts; its laterality and association with consanguinity pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 189 fig. 1: fig. 2: bilateral were 3%, there was no statistical significance (p=0.093) between age of presentation of congenital cataract and laterality. consanguinity was present in 69.6% (n=78) and absent in 30.4% (n=34). the difference was statistically significant (p=0.00). out of total cases with positive consanguinity 18% (n=14) were unilateral and 82% (n=64) were bilateral while with absent consanguinity 24% (n=8) were unilateral and 76% (n=26) were bilateral. there was no statistically significant difference between the two groups (p=0.49). in our study we also observed different morphologies of cataracts. the frequencies of different types of congenital cataract were; dense nuclear cataract 15.2% (n=11 males, n=6 females), predominantly nuclear cataract 19.6% (n=16 males, n=6 females), predominantly lamellar cataract 12.5% (n=7 males, n=7 females), lamellar cataract with riders 6.3% (n=5 males, n=2 females) f, predominantly blue dot cataract 9.8% (n=3 males, n=8 females), posterior sub-capsular cataract 15.2% (n=5 males, n=12 females), sutural cataract 2.7% (n=3 males, n=0 females), anterior sub-capsular cataract 0.9% (n=1 males, n=0 females), posterior polar 1.8% (n=1 males, n=1 females) , sub-capsular coronary cataract 0.9% (n=0 males, n=1 females) , total mature cataract 7.1% (n=2 males, n=6 females), cortical cataract 1.8% (n=0 males, n=2 females) , cortical cataract with wrinkle 4.5% (n=5 males, n=0 females), and membranous cataract 1.8% (n=2 males, n=0 females). there was statistically significant difference between gender and morphology of cataract (p =0.01). afia matloob rana, et al 190 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology discussion congenital cataract is a major cause of blindness in children. congenital cataract is important in the regards that it blurs the retinal image as well as disrupts the development of the visual pathways in the central nervous system. congenital cataract is a rare disease, but it is a major cause of low vision or blindness among both developed13 and developing14 countries. the causes for most of the congenital cataracts remained unknown.15,16 prevention of visual impairment due to congenital and infantile cataract is an important component of world health organization’s international program for elimination of avoidable blindness by 202017. surgical removal of the opacified lens with and without intraocular lens implantation is the only treatment available for congenital cataract.18 in our study male were 55% (n=61) and females were 45% (n=51). male to female ratio was similar to the study of mwende j et all19, who had 55% (n=99) males and 45% (n=81). in the same study bilateral cataracts were 66% and unilateral were 34%, while in our study it was 80.4% and 19.6% respectively. rahi js et all20. in their study also the same ratio of laterality 66% and 34% was observed respectively. the difference was not statistically significant in both studies. the difference between our study and the two groups was because of the included age group which was more in our study from 3 month to 26 years while in the rest of the two studies it was 1 year of age. ruddle jb et al,21 also observed in their study that there was no significant difference between laterality of cataract (bilateral 45.5% vs. unilateral 55.5%) or gender (p  =  0.068). laterality is one of the most important parameters in terms of management. unilateral cataracts have poor prognosis as there are much more chances of amblyopia as compare to bilateral. in unilateral congenital cataract prognosis for visual outcome after cataract surgery depends on early clearance of visual axis, aphakic correction, and aggressive amblyopia treatment. congenital cataracts ideally should be operated before three months of age.19 in our study cases presented before one year of age group was 24.4% including 18% unilateral and 24% bilateral. after one year of age 75.6% cases presented including 82% unilateral and 76% bilateral. as we observed in our study that small number of cases presented before one year of age and unilateral cataracts were less in numbers. the reason was the early appreciation of reduced vision in bilateral cases. management of congenital cataract depends on the etiology, degree of visual interference and laterality of cataract. the outcome of cataract surgery after congenital cataract is 20 times worse than developmental cataracts, especially for those cases which are operated after one year of age.22 the visual system can get the opportunity to develop and mature after surgery while its progress remains halted by the development of cataract and visual system cannot develop at all in presence of dense congenital cataract 23. that’s why early cataract surgery is important in congenital cataract. especially for severe bilateral cataracts which are causing significant obscuration of the visual axis, surgery is recommended as early as possible. in developing countries delay in presentation and inadequate use of surgical services are the major causes of blindness secondary to congenital cataract24. the visual outcome depends upon the duration between onset of visual impairment and surgery, the shorter the duration, higher likelihood of good visual outcome. early presentation is important for visual outcome, regardless the type of cataract. the reasons of excessive delay of presentation in our study population were few barriers to presentation, which include lack of awareness about the disease, difficult access to health services, or acceptance of services (lack of education). in the language of clinical genetics, a consanguineous marriage is defined as a union between two individuals who are related to each other as second cousins or closer, with the inbreeding coefficient (f) equal or higher than 0.0156, where (f) is a measure of proportion of loci at which the offspring is expected to inherit identical gene copies from both partners. among arabs and south indian communities the inbreeding coefficient (f) is highest where it reaches up to 0.125.25 in our study we observed statistically significant high rate of positive history of first cousin marriage and among the positive cases bilateral cataracts were more common as compare to unilateral cataracts. this high rate of observed consanguinity may be considered as one of the risk factor for congenital cataract. at the same time this aspect could not be overlooked that consanguinity is very common in pakistani families and this relationship of consanguinity with congenital cataract as risk factor may be an incidental finding as number of our patients were limited. congenital cataracts; its laterality and association with consanguinity pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 191 a significant positive association has been consistently demonstrated between consanguinity and morbidity, although consanguinity associated blindness is less frequent but an increased rate of congenital cataracts has been reported in several populations.26 one billion people are currently living in those countries where consanguineous marriages are customary, and among them, one in every three marriages is cousin marriage, with a deeply rooted social trend. public awareness is rising about preventive measures of congenital disorders which has led to a trend that the number of couples who are seeking for preconception and premarital counseling on consanguinity are increasing gradually.27 the morphology of congenital cataracts is also very helpful in establishing their etiology and prognosis. congenital cataract is inherited in all three mendelian forms: autosomal dominant, autosomal recessive, and x-linked. in view of association of congenital cataract with consanguinity in literature, and the need to identify and delineate the variability in congenital cataract, the present study was undertaken to ascertain the role of consanguinity in congenital cataract patients. the prospective study of laterality and consanguinity in congenital cataract has several limitations. although we believe that all patients included in our study had congenital cataract not all patients were seen from time of birth .these cataracts showed many different patterns. the underlying and associated factors in patients with congenital cataract in this study were diverse. this complex pattern including variable differences between unilateral and bilateral cataracts has implication for further etiological research. conclusion bilateral congenital cataract is a more common presentation as compare to unilateral congenital cataract.. consanguinity is an important risk factor for congenital cataract especially for bilateral cataracts. author’s affiliation dr. afia matloob rana post graduate resident ophthalmology department holy family 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congenital and developmental cataracts in young children in south india and causes of poor outcome. indian j ophthalmol. 2013; 61: 65-70. 24. waddel km. childhood blindness and low vision in uganda. eye. 1998; 12: 184–92. 25. hamamy h, antonarakis se, cavalli-sforza ll, temtamy s, romeo g, kate lp. consanguineous marriages, pearls and perils: geneva international consanguinity workshop report. genet med. 2011; 13:841-47. 26. bittles ah, black ml. the impact of consanguinity on neonatal and infant health. early hum dev. 2010; 86:737-41. 27. hamamy h. consanguineous marriages. j community genet. 2012; 3:185-92. http://www.ncbi.nlm.nih.gov/pubmed?term=hamamy%20h%5bauthor%5d&cauthor=true&cauthor_uid=21555946 http://www.ncbi.nlm.nih.gov/pubmed?term=antonarakis%20se%5bauthor%5d&cauthor=true&cauthor_uid=21555946 http://www.ncbi.nlm.nih.gov/pubmed?term=cavalli-sforza%20ll%5bauthor%5d&cauthor=true&cauthor_uid=21555946 http://www.ncbi.nlm.nih.gov/pubmed?term=temtamy%20s%5bauthor%5d&cauthor=true&cauthor_uid=21555946 http://www.ncbi.nlm.nih.gov/pubmed?term=romeo%20g%5bauthor%5d&cauthor=true&cauthor_uid=21555946 http://www.ncbi.nlm.nih.gov/pubmed?term=kate%20lp%5bauthor%5d&cauthor=true&cauthor_uid=21555946 213 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology original article change in central corneal thickness after trabeculectomy mustafa kamal junejo, ps mahar pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. p.s mahar frcs, professor & dean isra postgraduate institute of ophthalmology karachi email: salim.mahar@aku.edu …..……………………….. purpose: to determine the change in central corneal thickness after trabeculectomy. study design: prospective interventional study. place and duration of study: isra postgraduate institute of ophthalmology, alibrahim eye hospital, karachi. january 2014 to june 2016. materials and methods: one hundred thirty eyes of 113 glaucoma patients who underwent trabeculectomy were assessed for the change in central corneal thickness from january 2014 to june 2016. the study approval was granted by the institutional ethical review committee. patients’ characteristics, including demographics, clinical details and management were recorded in a detailed proforma. results: the mean age of our patients was 53.3 ± 12.3 years (range 13 to 84 years). the mean cct before trabeculectomy was 524.25 ± 38.53 µm. after 12 months follow-up the mean cct was 521.95 ± 38.25 µm with correlation of 0.855 which was not statistically significant. conclusion: in our study there was no statistically significant change in central corneal thickness after trabeculectomy at the mean follow-up of 12 months. keywords: central corneal thickness, trabeculectomy, mitomycin c. ntraocular pressure (iop) is an important factor in the management of glaucoma. therefore, it is necessary that it should be measured using a technique with a high degree of accuracy. as goldman applanation tonometry (gat) is most commonly used and currently being the “gold standard”for iop measurement1, the variations in readings of iop measured with gat are proportional to the central corneal thickness (cct). however, multiple studies have proven that there is variation in the mean cct among individuals with healthy eyes2,3, in patients suffering from different types of glaucoma and due to presence of pseudo-exfoliation4. in the absence of corneal disease, goldman and schmidt very rarely observed significant cct changes, thus assumed a normal cct of 520 μm for their instrument5. the corneal thickness can help to identify the glaucoma suspects among primary open angle glaucoma (poag), ocular hypertension (oht) and normal tension glaucoma (ntg)6. as cct is a predictive factor for the conversion of oht to poag that is why its measurement has been recommended by the ocular hypertension treatment study (ohts)7. central corneal thickness can help to diagnose the likelihood of disease progression8. there are multiple treatment options available for the management of glaucoma. although medical therapy in the form of topical eye drops is considered to be the treatment of choice9, surgical intervention remains popular in selective cases. in developing countries, where patients’ follow-up is poor and standard preparations of topical medications are not available or expensive, surgery remains the first line in management strategy10. the most common glaucoma surgery performed is trabeculectomy, a type of drainage surgery. the use of i change in central corneal thickness after trabeculectomy pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 214 anti-metabolites adjuncts like mitomycin – c (mmc) has led to its improved success rate, but it is not without its risks and complications11. various randomized trials have demonstrated the loss of corneal endothelial cells after mmc – augmented trabeculectomy. the combined effect of mmc and peroperative surgical trauma may lead to endothelial cell compromise, resulting in subtle corneal edema, and subsequent alteration in cct12. if this is proven then the need for adjustment in postoperative iop values corresponding to cct change, or use of dynamic contour tonometry (dct) which is less affected by alteration in cct, can be recommended13. the aim of our study was to determine the change in cct after mmcaugmented trabeculectomy in pakistani population. to the best of our knowledge no study till date has depicted the effect of trabeculectomy on cct in our population and with this sample size. materials and methods this prospective single group cohort study involving patients who underwent trabeculectomy for the different types of glaucoma was carried out from january 2014 to june 2016 at isra postgraduate institute of ophthalmology/al-ibrahim eye hospital, karachi. all phakic patients who underwent trabeculectomy during study period were included in the study. those patients who had history of ocular trauma, any corneal disease, or those who underwent any other ocular surgery were excluded from the study. patients who underwent combined phacoemulsification and trabeculectomy procedure and those who had per-operative complications were also excluded from the study. cairns-type trabeculectomy was performed in all cases. a detailed proforma was generated with preoperative details of patients’ demographics, best corrected visual acuity as recorded by snellen’s chart, iop measurement using goldman’s applanation tonometer (gat), anterior segment examination with gonioscopy and dilated fundus examination (+ 90 d and + 78 d) with emphasis on optic disc evaluation. central corneal thickness was measured in all patients by ultrasonic pachymetry (us 800 nidek). topical proparacaine (alcain-alcon) was used to anaesthetize the eye before the procedure. on an average 10 readings of central cornea were taken as the reference cct of patients. all the measurements were taken between 9:00 am and 11:00 am by the same technician. similar details were recorded at 1, 6 and 12 months postoperatively after trabeculectomy. the statistical analysis was done using spss program, version 19.0. categorical variables like gender were described in terms of frequencies and percentages. continuous variables like age and cct were described in terms of mean ± standard deviation. paired t-test was used to analyze the change in central corneal thickness measured pre-operatively and postoperatively. p value of < 0.05 was considered to be statistically significant. results one hundred thirty (130) eyes of 113 patients were included in the study. the mean age of patients was 53.3 ± 12.3 (range 13 – 84 years). out of 113 patients 66.2% were male and 33.8% were female. the preoperative characteristics including age, refractive error and gender are summarized in table 1. table 1: biographic data, frequency of eyes, gender predilection, refractive error n = 130. frequency percentage eye right 64 49.2 left 66 50.8 gender male 86 66.2 female 44 33.8 refractive error emmetropia 01 0.8 myopia 84 64.6 hypermetropia 45 34.6 the mean cct of our study population before trabeculectomy was 524.25 ± 38.53 µm. the mean cct postoperatively was 523.75 ± 38.12 µm, 521.53 ± 37.95 µm and 521.95 ± 38.25 µm at 1, 6 and 12 months respectively. using paired t-test the p value of 0.855 was obtained, suggesting that the difference between cct measurement before and after surgery at 12 months follow-up was not statistically significant. the results are summarized in table 2. mustafa kamal junejo, et al 215 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology the preoperative iop in our group of patients was 25.4 ± 8.0 with range of 16 – 39 mmhg. the mean iop at 12 months follow-up was 12.9 ± 4.0 with range of 8 – 19 mmhg. using paired sample t-test p value of 0.0003 was obtained which is statistically significant (table 3). discussion the corneal thickness has been reported to change with the age and after intraocular procedures such as cataract surgery. multiple intraocular surgeries are also shown to cause changes in cct14. however, there are scanty reports in the literature about changes in cct after mmc augmented trabeculectomy. since 2002 when ohts was carried out, apart from the other factors, thin corneas were labeled as poor prognostic factor for the progression of glaucoma15. in 2007, a report by american academy of ophthalmology concluded that cct is a risk factor for progression from ocular hypertension to poag16. it is now well recognized table 2: pre-operative and post-operative central corneal thickness change. pre-operative mean cct 524.25 ± 38.53 µm post-op visit mean cct p value 1 month 523.75 ± 38.12 µm 0.855 6 months 521.53 ± 37.95 µm 12 months 521.95 ± 38.25 µm table 3: pre-operative and post-operative intra ocular pressure change. iop (sd) mm hg mean range p value pre-operative (sd) 25.4 ± 8.0 16 – 39 0.0003 post-operative (sd) 12.9 ± 4.0 8 – 19 that abnormally thick corneas (> 530 µm) can overestimate the iop and thin corneas (< 520 µm) can erroneously register less iop. it has been observed that cct is greater in the early morning at the wakeup time due to possible hydration of the cornea during the night but it goes back to its normal thickness 2 hours after eye opening17. for this reason, in our study cct measurements were taken between 9 am to 11 am to avoid any diurnal variation. multiple authors have investigated the effect of iop lowering drugs on the cct. sen et al18 in their study of group of patients using latanoprost and bimatoprost found mean reduction of 2.7 ± 6.9 µm at 6 months, 6.6 ± 7.4 µm at 12 months and 10.7 ± 14.2 µm at the end of 24 months follow-up in patients using latanoprost. the amount of cct reduction for bimatoprost group at same visits were 6.8 ± 5.7 µm, 11.3 ± 11.9 µm and 15.8 ± 10.2 µm. lass and colleagues19 found the decrease of approximately 6 µm in cct with the use of latanoprost and fixed combination of timolol and latanoprost at the end of 12 months follow-up. whether decrease in cct by antiglaucoma medication is due to direct effect of the compound or due to lowering of the iop is not known. if the change in cct is due to lowering of the iop then this should also occur after trabeculectomy. in our cohort of 113 patients, however, there was no change in the cct at the end of 12 months follow-up irrespective of postoperative iop variation. williams and coworkers20 postoperatively evaluated patients undergoing primary or repeat trabeculectomy with measurement of cct and corneal endothelial cell count. their conclusion was that neither cct nor endothelial cell count changed to statistically significant degree as compared to their pre-operative value. a study by wickham and colleagues21 has shown that the measurement of cct requires multiple readings to avoid any significant variability. for this reason, an average of 10 readings was taken for our patients. ultrasonic pachymetry has been shown to be accurate and reliable22. as it can be subject to inter observer bias so all our cct readings were carried out by the same technician. soro-martinez et al23 assessed cct changes in 80 eyes of 62 patients between 60 to 83 years of age. mean (± sd) cct was 542 ± 38.15 µm in the control group and 522 ± 34.70 µm, 540 ± 34.22 and 51.9 ± 32.91 in group i (trabeculectomy), group ii (combined trabeculectomy with phacoemulsification) and group iii (trabeculectomy followed by phacoemulsification). there was no significant difference between all groups showing changes in cct postoperatively. storrchange in central corneal thickness after trabeculectomy pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 216 paulsen and coworkers24 looked at 14 eyes of 14 patients undergoing mmc augmented trabeculectomy in regard to change in the corneal endothelial cell density and cct. the pre-operative value of cct was 527 ± 32 µm and remains at 531 ± 30 µm at 12 months after surgery suggesting no significant difference statistically. though there was significant decrease in iop in our patients at 12 months follow -up but this was not related to the change in cct. conclusion in our prospective study we found that at 12 months follow-up there was no statistically significant change in central corneal thickness. as this is a single center study, we think that similar studies should be conducted onlarge number of patients’population and in coalition with other centers to confirm our findings. author’s affiliation dr. mustafa kamal junejo mrcs, senior instructor/ assistant clinical & academic coordinator. dr. p.s mahar frcs, professor & dean role of authors dr. mustafa kamal junejo data collection & writing part of manuscript. statistical analysis dr. p.s mahar all glaucoma surgery & writing part of manuscript. references 1. brandt j, beisser j, gordon m. central corneal thickness in ocular hypertension treatment study (ohts). ophthalmology, 2001, 108 (10): 1779-1788. 2. cockburn dm. effects of corneal thickness on iop measurement. clin exp optom. 2004; 87 (3): 185-186. 3. la rosa f, gross r, orengo-nania s. central corneal thickness of caucasians and african–americans in glaucomatous and non-glaucomatous populations. arch ophthalmology, 2001; 119 (1): 23–27. 4. ventura ac, bohnke m, mojon ds. central corneal thickness measurements in patients with normal tension glaucoma, primary open angle glaucoma, pseudo exfoliation glaucoma or ocular hypertension. br j ophthalmol. 2001; 85 (7): 792–795. 5. goldman h, schmidt t. uber applanations tonometrie. ophthalmologica. 1957; 134: 221-42. 6. shetgar ac, mulimani mb. the central corneal thickness in normal tension glaucoma, 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https://www.ncbi.nlm.nih.gov/pubmed/?term=fakhraie%20g%5bauthor%5d&cauthor=true&cauthor_uid=26730310 https://www.ncbi.nlm.nih.gov/pubmed/?term=eslami%20y%5bauthor%5d&cauthor=true&cauthor_uid=26730310 https://www.ncbi.nlm.nih.gov/pubmed/?term=moghimi%20s%5bauthor%5d&cauthor=true&cauthor_uid=26730310 https://www.ncbi.nlm.nih.gov/pubmed/?term=mohammadi%20m%5bauthor%5d&cauthor=true&cauthor_uid=26730310 https://www.ncbi.nlm.nih.gov/pubmed/?term=abdollahi%20a%5bauthor%5d&cauthor=true&cauthor_uid=26730310 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4687258/ https://www.ncbi.nlm.nih.gov/pubmed/?term=realini%20t%5bauthor%5d&cauthor=true&cauthor_uid=19225347 https://www.ncbi.nlm.nih.gov/pubmed/?term=weinreb%20rn%5bauthor%5d&cauthor=true&cauthor_uid=19225347 https://www.ncbi.nlm.nih.gov/pubmed/?term=hobbs%20g%5bauthor%5d&cauthor=true&cauthor_uid=19225347 https://www.ncbi.nlm.nih.gov/pubmed/19225347 mustafa kamal junejo, et al 217 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology combination latanoprost-timolol and tomolol: a double-masked, randomized, one-year study. ophthalmology, 2001; 108 (2): 264-71. 20. williams aj, song j, allingham rr, herndon l. central corneal thickness change with intraocular pressure lowering. invest ophthalmol & vis sci. 2004; 45: 4459-60. 21. wickham l, edmunds b, murdoch le. central corneal thickness: will one measurement suffice. ophthalmology, 2005; 112 (2): 225-228. 22. rashid rf, farhood qk. measurement of central corneal thickness by ultrasonic pachymeter and oculus pentacam in patients with well-controlled glaucoma: hospital-based comparative study. clin ophthalmol. 2016; 10: 359-364. 23. soro-martínez mi, villegas-pérez mp, sobrado-calvo p et al. graefes arch clin exp ophthalmol. 2010; 248: 1185-89. 24. storr-paulsen t, norregaard jc, ahmeds, allan md. corneal endothelial cell loss after mitomycin caugmented trabeculectomy. j glaucoma, 2008; 17 (8): 654-657. http://journals.lww.com/glaucomajournal/toc/2008/12000 http://journals.lww.com/glaucomajournal/toc/2008/12000 192 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology original article adjustable sutures in constant exotropia munira shakir, zeeshan kamil, shakir zafar, syeda aisha bokhari, fawad rizvi pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. munira shakir d-80 street # 8 naval housing society karsaz stadium road, karachi. dr_munirasz@yahoo.com …..……………………….. purpose: to evaluate the use of adjustable sutures in constant exotropia. material and methods: the study was conducted in lrbt free base eye hospital karachi from april 2010 to march 2011. this was a retrospective study of eighteen patients who were operated for strabismus by adjustable suture technique. preoperative assessment and postoperative results, all were reviewed from hospital record. all patients included in this study were exotropic preoperatively. after the surgery, adjustment of sutures was done after the effect of anesthesia wore off. the main outcome measures were a need for reoperation, patients’ satisfaction with regard to final cosmetic appearance, and change in angle of deviation at the end of follow up. follow up period was six months. results: eighteen eyes of eighteen patients who were operated for exotropia out of which 72.2% were male and 27.7% were female. mean change in angle of deviation at the end of follow up was from 60.55 ± 11.75 pd to 15.22 ± 5.15 pd with a percentage change of 74.62% (p= 0.000).sixteen out of eighteen (88.8%) patients were satisfied with their cosmetic appearance. conclusions: adjustment strabismus surgery is an easy, tolerable and effective surgery, and is recommended for patients who are cooperative. trabismus is misalignment of eyes resulting in failure of the two eyes to simultaneously focus on the same image, leading to loss of binocular single vision1. the incidence of adult strabismus is estimated to be 4%2. strabismus may be present in adults for a variety of reasons, including uncorrected or consecutive childhood strabismus, thyroid eye disease, decrease vision in one eye, and surgical trauma to the extra ocular muscles. strabismus in adults may be associated with diplopia, torticollis, impaired stereopsis, and negative psychosocial effects3. strabismus surgery in adults has a high rate of success and has been shown to be beneficial in improving diplopia, binocular fusion, and psychosocial well being4. furthermore, adult strabismus surgery has been shown to be cost effective, with a cost equivalent to cataract surgery5. unusual results after strabismus surgery have been frustrating for both surgeon and patient. the adjustable suture surgical technique offers the surgeon the opportunity to place the eye in the required position within one day to few hours after surgery6. this technique allows the surgeon to fine adjust ocular alignment in the period just after surgery while patient is awake and free of the effects of anesthesia gases. the improved adjustable suture technique has improvised surgical results in strabismus patients and has markedly reduced the number of redo’s, especially in more complicated cases7. the adjustable suture technique is most effective in patients with complicated strabismus such as paralytic strabismus, large angle strabismus, reoperations, thyroid myopathy, and advancement of a lost or slipped muscle. in contrast, the adjustable suture technique has limited application in the patient with restrictive strabismus secondary to fat adherence syndrome, in which scarring of the globe or eye muscle causes the strabismus8. selection of patient is important, if not crucial, for successful implementation of the adjustable suture technique. the adjustment procedure is somewhat uncomfortable and in some patients evokes substantial s adjustable sutures in constant exotropia pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 193 anxiety. the cotton-swab test, which consists of touching a cotton swab to the medial or lateral aspect of the bulbar conjunctiva, is a simple yet accurate way of identifying patients who will be suitable for the adjustment procedure. if the patient is able to tolerate manipulation of the bulbar conjunctiva without topical anesthetic, then he or she should do well with the adjustment procedure. other indications of a patient’s suitability for the adjustable suture technique include his or her facility with contact lenses, ability to undergo applanation tonometry, facility with topical drops, or cooperation with forced duction testing. it is mandatory to advise patients that the adjustment procedure will be uncomfortable, and it is best to avoid patients who are unwilling or fearful of the procedure9. in this study all operations were performed under general anesthesia and the adjustment was done in the recovery room after 6 hours. material and methods the research ethical committee of lrbt free base eye hospital, karachi approved this study. a retrospective record review was done of all the patients who had undergone strabismus surgery by adjustable suture technique for exotropia in the practice of one surgeon (ms) from april 2010 to march 2011. the data collection was performed by two investigators (zk and sab) independently of the surgeon. there were 13 (72.2%) males and 5 (27.7%) females out of 18 patients. age ranged from 16-30 years ± 4.30. all patients had exotropia (fig 1) with a range of deviation from 30 prism dioptres to 80 prism dioptres with a mean of 60 prism dioptres. patients having previous strabismus surgery, congenital sixth nerve palsy were excluded from the study. all the patients had a preoperative ocular examination and orthoptic assessment, including angle of deviation for near (1/3m) and distant vision (6m) with and without correction, and measurement by prism cover test. fusional ranges were also measured by prism. written consent was obtained from all patients or first degree relatives. all patients were followed up to 6 months. the main outcome measures were a need for reoperation, patients’ satisfaction with regard to final cosmetic appearance and change in angle of deviation at the end of follow up. the statistical analysis of the data was done by the software statistical package for social sciences (spss) version 17. descriptive statistics were calculated in terms of mean, standard deviation, minimum, maximum and range. mean and standard deviation were calculated for quantitative variable like age of the patients. frequency and percentage were calculated for gender, cosmetic appearance and rate of reoperations. paired sample test was used to calculate pvalue, and p-value of < 0.005 was considered significant. surgical technique the eye was prepared and draped in the usual ophthalmic manner. two fixation sutures with 6-0 silk were inserted near limbus at the points perpendicular to the muscles to be operated upon (that is, at 12 and 6 o’clock for horizontal muscle operation). recession was done first. a limbal conjunctival approach was used with radial relaxing incisions. a double-armed 60 vicryl suture on a fine spatulaled needle was placed near its insertion and locked at the sides with a double-throw knot to prevent bunching up of the muscle. the muscle was then cut. the arms of the suture were passed through the scleral tunnel starting near each end of insertion and emerging 1.5 mm apart. the suture was then secured with a double throw knot followed by half bow. any redundant suture was shortened. subsequent adjustment in all cases is eased by ability to fix globe which is best done with the aid of a bucket – handle suture with 6 – 0 vicryl placed in the sclera at or near the insertion. resection of the antagonist if indicated was done as in conventional strabismus surgery. the patient was seated up on the table after the general anesthesia effect wore off. the deviation was measured for near and far distant vision by a prism cover test by an orthoptist (fig. 2). propracaine1% eye drops were instilled and adjustment was made until the deviation was less than 15 pd in the primary position, with no abnormal head posture (fig. 3). the conjunctival incision was closed and the eye was padded for one more hour. results eighteen eyes of eighteen patients who were operated for exotropia ranging from 30 pd to 80 pd with a mean of 60 pd by adjustable suture technique in lrbt free base eye hospital karachi. there were 13 (72.2%) males and 5 (27.7%) females out of 18 patients. sixteen out of eighteen (88.8%) patients were satisfied with their cosmetic appearance (table 1). one out of eighteen (5.55%) patients needed reoperation because munira shakir, et al 194 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology fig. 1: right eye exotropia (pre-operative) fig. 2: post-surgery orthoptic assessment fig. 3: post-adjustment of residual exotropia of 30 pd (table 2). mean change in angle of deviation at the end of follow up was from 60.55 ± 11.75pd to 15.22 ± 5.15 pd with a percentage change of 74.62% (p= 0.000). the paired sample test, statistics and correlations are illustrated in table 3, 4 and 5 respectively. discussion adjustable strabismus surgery first described by jampolsky10, it has the advantage of decreasing the redo surgeries and increasing the accuracy of end point in strabismus correction which has resulted in more surgeons opting for this technique in cooperative patients11. the post operative adjustment of the rectus muscle in two stages is commonly used, while an intra operative adjustment in one stage under local anesthesia is less commonly done12. intra operative one stage adjustment has been limited in literature to few patients because it is a lengthy and tedious task & requires an experienced surgeon, as well as a cooperative candidate.13 however, in a two stage adjustment procedure, there is usually time gap between surgery and starting adjustment. some surgeons do adjustable surgery using retrobulbar anesthesia rather than general anesthesia, but the patient and surgeon should wait until the anesthetic effect wears away6. in this study all operations were performed under general anesthesia and the adjustment was done on recovery room after 6 hours. in this study mean change in angle of deviation at the end of follow up was 74.62%, whereas in another study average change in angle of deviation was 87.5%14. melhuish and kemp presented a series of 20 patients operated using adjustable sutures and claiming an 85% success rate15. zhang m s also reported 74.8% success rate in patients undergoing strabismus surgery by adjustable suture method.16 in this study sixteen out of eighteen (88.8%) patients were satisfied with their cosmetic adjustable sutures in constant exotropia pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 195 appearance, tripathi a reported 96% of cosmetically satisfied patients with their appearance in his study14. one out of eighteen (5.55%) patients needed reoperation because of residual exotropia of 30 pd in this study, where as in the study of tripathi a, 8.51% patients needed a reoperation14. it is worth nothing, however, that adjustable suture strabismus surgery requires extra time and staff as well as additional recovery room space for orthoptic assessment and further adjustment, but on other hand it reduces the rate of reoperations. conclusion in conclusion, adjustable suture surgery allows the surgeon the ability to place the eye in a desired position within a few hours after surgery with the patient fully awake and free of the effects of anesthesia. it has improved surgical results in our strabismus patients and has markedly reduced the number of redo surgeries. author’s affiliation dr. munira shakir consultant ophthalmologist l.r.b.t free base eye hospital, karachi korangi 2½, karachi – 74900 dr. zeeshan kamil ophthalmologist l.r.b.t free base eye hospital, karachi korangi 2½, karachi – 74900 dr. shakir zafar consultant ophthalmologist l.r.b.t free base eye hospital, karachi korangi 2½, karachi – 74900 dr. syeda aisha bokhari associate ophthalmologist l.r.b.t free base eye hospital, karachi korangi 2½, karachi – 74900 dr. fawad rizvi consultant ophthalmologist l.r.b.t free base eye hospital, karachi references 1. iqbal s, naz j, ahmed m, shah a s., khalil z m. etiology of strabismus in ophthalmology department, hayatabad medical complex, peshawar pakistan. ophthalmology update. 2012; 10: 34-40. 2. beauchamp gr, black bc, coats dk, enzenauer rw, hutchinson ak, saunders ra, simon jw, stager dr, stager dr jr, wilson me, zobal-ratner j, felius j. the management of strabismus in adults-i. clinical characteristics and treatment. j aapos. 2003; 7: 233-40. http://www.ncbi.nlm.nih.gov/pubmed?term=beauchamp%20gr%5bauthor%5d&cauthor=true&cauthor_uid=12917608 http://www.ncbi.nlm.nih.gov/pubmed?term=black%20bc%5bauthor%5d&cauthor=true&cauthor_uid=12917608 http://www.ncbi.nlm.nih.gov/pubmed?term=coats%20dk%5bauthor%5d&cauthor=true&cauthor_uid=12917608 http://www.ncbi.nlm.nih.gov/pubmed?term=enzenauer%20rw%5bauthor%5d&cauthor=true&cauthor_uid=12917608 http://www.ncbi.nlm.nih.gov/pubmed?term=hutchinson%20ak%5bauthor%5d&cauthor=true&cauthor_uid=12917608 http://www.ncbi.nlm.nih.gov/pubmed?term=saunders%20ra%5bauthor%5d&cauthor=true&cauthor_uid=12917608 http://www.ncbi.nlm.nih.gov/pubmed?term=simon%20jw%5bauthor%5d&cauthor=true&cauthor_uid=12917608 http://www.ncbi.nlm.nih.gov/pubmed?term=stager%20dr%5bauthor%5d&cauthor=true&cauthor_uid=12917608 http://www.ncbi.nlm.nih.gov/pubmed?term=stager%20dr%20jr%5bauthor%5d&cauthor=true&cauthor_uid=12917608 http://www.ncbi.nlm.nih.gov/pubmed?term=wilson%20me%5bauthor%5d&cauthor=true&cauthor_uid=12917608 http://www.ncbi.nlm.nih.gov/pubmed?term=zobal-ratner%20j%5bauthor%5d&cauthor=true&cauthor_uid=12917608 http://www.ncbi.nlm.nih.gov/pubmed?term=felius%20j%5bauthor%5d&cauthor=true&cauthor_uid=12917608 munira shakir, et al 196 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology 3. hatt sr, leske da, kirgis pa, bradley ea, holmes jm. the effects of strabismus on quality of life in adults. am j ophthalmol. 2007; 144: 643-7. 4. mills md, coats dk, donahue sp, wheeler dt. ophthalmic technology assessment committee pediatric ophthalmology panel. strabismus surgery for adults: a report by the american academy of ophthalmology. ophthalmolgy. 2004; 111: 1255-62. 5. beauchamp cl, beauchamp gr, stager dr sr, brown mm, brown gc, felius j. the cost utility of strabismus surgery in adults. j aapos. 2006; 10: 394–9. 6. weston b, enzenauer rw, kraft sp, gayowsky gr. stability of the postoperative alignment in adjustablesuture strabismus surgery. j pediatr ophthalmol strabismus. 1991; 28: 206-11. 7. wisnicki hj, repka mx, guyton dl. reoperation rate in adjustable strabismus surgery. j pediatr ophthalmol strabismus. 1988; 25: 112-4. 8. parks mm. causes of the adhesive syndrome. in: symposium on strabismus, transactions of the new orleans academy of ophthalmology. st louis: cv mosby. 1978: 269-79. 9. kenneth w, wright md. practical aspects of the adjustable suture technique for strabismus surgery jampolsky a. current techniques of adjustable strabismus surgery. am j ophthalmol. 1979; 88: 406-18. 10. wright kw. color atlas of ophthalmic surgery: strabismus. philadelphia: jb lippincott co; 1991; 87-124. 11. rauz s, govan ja. one stage vertical rectus muscle recession using adjustable sutures under local anesthesia. br j ophthalmol. 1996; 80: 713-8. 12. klyve p, nicolaissen b jr. topical anesthesia and adjustable sutures in strabismus surgery. acta ophthalmologica 1992; 70: 637-40. 13. tripathi a, haslett r, marsh ib. strabismus surgery: adjustable suture-good for all? eye. 2003; 17: 739-42. 14. melhuish ja, kemp eg. the routine use of adjustable sutures in a adult strabismus surgery. jr coll surg edinburg. 1993; 38: 134-37. 15. zhang ms, hutchinson ak, drack av, cleveland j, lambert sr. improved ocular alignment with adjustable sutures in adults undergoing strabismus surgery. ophthalmology. 2012; 119: 396-402. http://www.ncbi.nlm.nih.gov/pubmed?term=hatt%20sr%5bauthor%5d&cauthor=true&cauthor_uid=17707329 http://www.ncbi.nlm.nih.gov/pubmed?term=leske%20da%5bauthor%5d&cauthor=true&cauthor_uid=17707329 http://www.ncbi.nlm.nih.gov/pubmed?term=kirgis%20pa%5bauthor%5d&cauthor=true&cauthor_uid=17707329 http://www.ncbi.nlm.nih.gov/pubmed?term=bradley%20ea%5bauthor%5d&cauthor=true&cauthor_uid=17707329 http://www.ncbi.nlm.nih.gov/pubmed?term=holmes%20jm%5bauthor%5d&cauthor=true&cauthor_uid=17707329 http://www.ncbi.nlm.nih.gov/pubmed?term=holmes%20jm%5bauthor%5d&cauthor=true&cauthor_uid=17707329 http://www.ncbi.nlm.nih.gov/pubmed?term=holmes%20jm%5bauthor%5d&cauthor=true&cauthor_uid=17707329 http://www.ncbi.nlm.nih.gov/pubmed?term=beauchamp%20cl%5bauthor%5d&cauthor=true&cauthor_uid=17070471 http://www.ncbi.nlm.nih.gov/pubmed?term=beauchamp%20gr%5bauthor%5d&cauthor=true&cauthor_uid=17070471 http://www.ncbi.nlm.nih.gov/pubmed?term=stager%20dr%20sr%5bauthor%5d&cauthor=true&cauthor_uid=17070471 http://www.ncbi.nlm.nih.gov/pubmed?term=brown%20mm%5bauthor%5d&cauthor=true&cauthor_uid=17070471 http://www.ncbi.nlm.nih.gov/pubmed?term=brown%20mm%5bauthor%5d&cauthor=true&cauthor_uid=17070471 http://www.ncbi.nlm.nih.gov/pubmed?term=brown%20mm%5bauthor%5d&cauthor=true&cauthor_uid=17070471 http://www.ncbi.nlm.nih.gov/pubmed?term=brown%20gc%5bauthor%5d&cauthor=true&cauthor_uid=17070471 http://www.ncbi.nlm.nih.gov/pubmed?term=felius%20j%5bauthor%5d&cauthor=true&cauthor_uid=17070471 http://www.ncbi.nlm.nih.gov/pubmed?term=zhang%20ms%5bauthor%5d&cauthor=true&cauthor_uid=22036633 http://www.ncbi.nlm.nih.gov/pubmed?term=hutchinson%20ak%5bauthor%5d&cauthor=true&cauthor_uid=22036633 http://www.ncbi.nlm.nih.gov/pubmed?term=drack%20av%5bauthor%5d&cauthor=true&cauthor_uid=22036633 http://www.ncbi.nlm.nih.gov/pubmed?term=cleveland%20j%5bauthor%5d&cauthor=true&cauthor_uid=22036633 http://www.ncbi.nlm.nih.gov/pubmed?term=lambert%20sr%5bauthor%5d&cauthor=true&cauthor_uid=22036633 http://www.ncbi.nlm.nih.gov/pubmed/?term=zhang+ms%2c+hutchinson+ak%2c+drack+av%2c+et+al.+improved+ocular+alignment+with+adjustable+sutures+in+adults+undergoing+strabismus+surgery.+ophthalmology+2011 pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 73 original article risk factors involved in pterygium recurrence after surgical excision p. s. mahar, nabeel manzar pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p.s. mahar department of surgery aga khan university hospital stadium road, karachi 74800 pakistan …..……………………….. purpose: to assess the influence of size and type of growth, age and gender of the patient and the duration of intraoperative mitomycin-c (mmc) application, on the recurrence of pterygium after surgical excision. material and methods: this retrospective, descriptive case series was carried out at the department of ophthalmology, aga khan university hospital, karachi. one hundred forty seven patient’s (147 eyes) data files were analyzed from 1999 to 2009, who underwent surgical removal of pterygium using bare sclera method with mmc in concentration of 0.2 mg / ml (0.02%) with variable exposure time of 1-5 minutes. ninety nine male and 48 female with mean age of 46.4 years (range 16 to 60 years) were included in the study. the classification of subjects was done according to the age, gender, mmc application time and type and size of pterygium. the main outcome measure was comparison of pterygium affected eye for any kind of recurrence after a minimum of 12 months of the follow up. results: the pterygium recurrence rate was 8.8% in our case series at the mean follow of 1 year. the factors such as younger age (< 50 years) at presentation (p = 0.04, pearson chi square test) and the presence of secondary pterygium (p = 0.05) correlated significantly with the recurrence of pterygium. there was a definite trend of lesser recurrence seen with mmc application time of greater than 3 minute as well as for a lesser size of the pterygium. however, statistical significance could not be achieved because of the small sample size. conclusions: these results suggest that a younger age of < 50 years coupled with increased size as well as history of multiple recurrences and mmc application time of less than 3 minutes are risk factors for pterygium recurrence after surgical excision. terygium is one of the most common conjunctival surface degenerative disorders seen in subtropical and tropical areas1-3. apart from causing cosmetics blemish, it alters the smoothness of the anterior surface of the eye ball with disruption of the normal tear film. it can also induce corneal astigmatism and if allowed to proceed over the pupillary area, reduces the vision2. a number of different surgical approaches have been proposed for the treatment of pterygium. the most common method has been the bare scleral excision technique, first described by ombrian4. however, the major limitation to simple excision is the high rate of postoperative recurrence5. therefore a number of adjunct therapies have been advocated along with excision to varying levels of success during the last three decades. the use of topical mitomycin c (mmc) as an adjunct therapy to prevent pterygium recurrence has considerably increased since its first introduction by kunitomo and mori of japan6 and its subsequent usage in us by singh and associates7. a number of research studies have been carried out to document the appropriate dosage and efficacy of mmc in treating pterygium and preventing its recurrence. however relatively few studies have evaluated the role of other factors such as age, gender, mmc exposure time, as well as the size and extent of p p. s. mahar, et al 74 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology pterygium encroaching on the cornea8-10. hence to prove the hypothesis that the above mentioned factors also play an important role in pterygium recurrence, we undertook this study to evaluate the role of these factors. material and methods this retrospective, case series study was carried at ophthalmology department, aga khan university hospital (akuh), karachi – pakistan. the patient’s data files were analyzed starting from the period of 1999 till 2009. only those patients fulfilling the following criteria were enrolled in the study, informed consent from the patient, individuals of all ages with established diagnosis of either unilateral or bilateral progressive pterygia of different sizes, supervised surgical excision by bare scleral technique and mmc administration, with minimum follow-up period of 12 months. the patients lost to the follow up or having any suspicious growth other than the pterygia and corneal scarring were excluded. all patients had their detailed medical history taken, with complete ocular examination including best corrected visual acuity (bcva), slit-lamp examination of anterior segment with goldman applanation tonometry and fundus examination with +90 ds lens. the pterygia were classified either as primary or secondary on the basis of first time episode or recurrence respectively. the pterygium size was graded depending on the extent of corneal involvement: grade 1 – pterygium encroaching over cornea for 2 mm. grade 2 – head of the pterygium covering cornea of more than 2 mm but sparing the visual axis and grade 3–involving the visual axis. a total of 147 patients (147 eyes) based on our inclusion criteria were incorporated in the study who had minimum follow up of 12 months, while 26 patients were lost to the follow-up, during the study period were excluded from the study. ninety-nine male and 48 female (male to female ratio 2:1) aged between 16 and 60 years (mean age 46.4 years) were included in the study. primary pterygium was present in 120 patients while secondary pterygium was diagnosed in 27 patients. one hundred two eyes (69.4%) were affected by grade 1 pterygium, 24 eyes (16.3%) had grade 2 and 21 eyes (14.3%) were having grade 3 pterygium. in 129 eyes (87.7%), pterygium was located on the nasal side, with 16 eyes (10.9%) had it on the temporal side and 2 eyes (1.4%) were affected on the either side. out of 147 eyes with pterygium, 66 belonged to the right eye and 81 to the left eye. the baseline characteristics of patients are shown in (table 1). pterygium excisions were performed on an outpatient basis by the same surgeon using the same technique11. after excision with bare scleral technique under topical anesthetic (proparacaine – alcon belgium), a sterile sponge (5x5 mm) soaked in 8 – 10 drops of 0.2 mg/ml mmc (0.02%) (mitomycin – c, kyowa – japan) was applied over corneo-sclera and the area from where pterygium was excised with variable duration of 1 – 5 minutes. the sponge was removed and eye irrigated with 20 ml of normal saline 0.9%. this was followed by topical administration of dexamethasone 0.1% + tobramycin 0.3% (tobradex-alcon, belgium) and hydroxypropyl methylcellulose (tear naturale ii – alcon, belgium) four times a day for 4 weeks. the dosage of mmc was calculated in line with the international recommendations12-14. patients were regularly followed up at the interval of 3 months after the procedure. any adverse effect or physical findings were noted on each visit for a minimum of one year period. the recurrence of pterygium was defined as an encroachment of fibrovascular connective tissue across the limbus and onto the cornea for any distance in the position of the previous lesion. the classification of subjects was done according to the age, gender, mmc application time, type and grading of the pterygium. subjects were divided into two age groups (1) ≤ 50 years in age (2) > 50 years. the time duration of topical application of mmc was divided into five groups, ranging from 1 to 5 minutes. the potential factors were also classified accordingly (table 2). the study protocol was reviewed and approved by an ethics committee at the study centre and the study was carried out in accordance with the declaration of helsinki of 1975 as revised in 1983. the primary outcome measure was the comparison of pterygium affected eye for any kind of recurrence after excision, along with the assessment of the potential role of mmc and grading of the pterygium with other factors in pterygium recurrence after a minimum of 12 months of follow up. the data was entered in statistical package for social sciences (spss) version 16 and analyzed using frequencies, proportions, group means, standard deviation, pearson chi square test and fisher exact risk factors involved in pterygium recurrence after surgical excision pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 75 test. alpha level of 0.05, confidence interval of 95% and power of 0.8 were selected for the analysis. results out of 147 eyes (147 patients), the recurrence of pterygium was seen in 13 eyes (8.8%) of 13 patients with mean time of recurrence of 6.77 months. out of 13 recurrences, 12 patients were in the age group below 50 years (p = 0.04, pearson chi square test). similarly there was a higher tendency of recurrence in male (10.1%) as compared to female (6.2%) though this was not statistically significant (p = 0.547). most of the recurrence was seen on the nasal side (9.3%) while 6.2% of pterygia recurred on either side (p = 1.00). in the group with recurrent pterygia, the recurrence rate was greater (18.5%) than in the group with primary pterygium (6.7%) (p = 0.05) with mean (std.dev) time of 3.20 months as compared to 9.00 months. a definite trend of recurrence was also noted on further stratification of the subjects on the basis of the corneal involvement, with a higher rate of recurrence seen in subjects with higher grades of p. s. mahar, et al 76 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology corneal involvement (p = 0.06). similarly, when subjects with primary pterygia were graded according to the size, there was a highly significant recurrence seen with higher grades of pterygium (p = 0.008). however, the same was not seen in participants with secondary pterygia (p = 0.334). the role of pterygium grading in recurrence of pterygiais shown in table 3. mitomycin – c application time was also noted for its relevance to the recurrence and there was a decreased rate of recurrence from 50% in 1 minute group to no recurrence seen in 5 minutes group (p = 0.213). corneal nebular opacity was the frequent finding seen in most patients postoperatively with one patient developing conjunctival cyst at the site of excision. no major complication like scleral thinning, ulceration or necrosis was seen in our patients discussion the recurrence of the pterygium remains an important health care issue in patients1 in asian countries. the present study was motivated by the invariably high recurrence of pterygium not only in pakistan but world over5, 15. the recurrence rate of pterygium in the present study was 8.8%. in a recent clinical trial carried out in the pakistani population, rahman et al16 estimated a recurrence of pterygia in 10% of the population. in another prospective study, cheng et al17 observed a recurrence of 7.9% in subjects with primary pterygia and a recurrence of 19.2% in subjects with recurrent pterygia. however comparison between our study and others is likely to be biased attributed to the different study population, setting and criteria used for grading pterygium. the age was significantly related to recurrence of pterygium in our study, with rising cases of recurrence in younger age groups of < 50 years. similar conclusions have been drawn from various studies carried throughout the globe18-20. the female gender was not related to recurrence in the target group, presumably due to the fact that women in pakistan are most of the time housewives whereas men are commonly exposed to the occupational and environmental hazards, leading to higher rate of recurrence. the site of the pterygium was also investigated for its role in recurrence, mainly because of the fact that in most of the cases, pterygia is always present on the nasal side; however there was no significance of site with recurrence. the secondary pterygium has been recognized as a risk factor for higher recurrence in various studies17, 18, 19. similarly, in the present study a highly significant rate of recurrence of 18.5% was observed in the secondary recurrent group as compared to 6.7% in the primary pterygium group. in a recent prospective study carried out by diaz et al21, no recurrence was observed on follow-up in group of patient with previous recurrent pterygia treated with intraoperative mmc. a lot of grading systems are currently being used for grading pterygium but in our study we have used the grading system based on the extent of corneal involvement by the fibrous pterygium. there was a higher tendency of recurrence seen in participants with higher grades of corneal involvement with rate of recurrence of 5.9% in 1° group as compared to 21% in 2° group. similar results have been obtained in studies across europe where a high rate of recurrence has been associated with increased fleshiness of the pterygia22, though the grading system used in these studies is slightly different, with translucency and vascularity being used as a criterion for grading. nonetheless in both the studies, a higher grade is increasingly being recognized as a risk factor for recurrence. in the secondary pterygium group, the same results could not be achieved, though a definite trend has been noted possibly due to the small sample size. the possible difference in the effect on recurrence of pterygium by the application of intra-operative topical mmc can be attributed to the difference in concentration as well as its application time. in a dose response study related to mmc, robin et al23 have shown that duration of exposure appears to be more important than the concentration of mmc. in the present study, there was no recurrence seen in patients risk factors involved in pterygium recurrence after surgical excision pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 77 treated with topical mmc for 5 minutes, however a high recurrence rate of 50% was seen in patients treated for 1 minute. other groups had a recurrence rate in between these two extremities. similar results were also documented in a randomized trial carried out by lam et al15. in their work, at a mean follow-up time of 30 months, a recurrence rate of 8.3% was seen in the patients applied 0.02% mmc for 5 minutes as compared to 42.9% seen in the group applied 0.02% mmc for 3 minutes. though there was no recurrence seen in the 5 minute mmc application group, most cases of corneal nebular opacity were seen among these patients. the results of our study hold important implications for further work on mmc, as probably, duration of administration of mmc, holds the key in its effect on pterygium recurrence. conclusion our study found significant associations of recurrence with higher grade as well as with secondary pterygia. there was a lesser recurrence with old age. the results of this study, suggests using mmc application time of greater than 3 minute for high risk recurrent 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treatment for pterygium. ophthalmology. 1988; 95: 813–21. 8. qing-feng l, liang x, xiu-ying j, qi-sheng y, xiao-hui y, tong-tong c. epidemiology of pterygium in aged rural population of beijing, china. chinese medical journal. 2010, 123: 1699-1701. 9. bradley jc, yang w, bradley rh, reid tw, schwab ir. the science of pterygia. br j ophthalmol. 2010; 94: 815-20. 10. gazzard g, saw sm, farook m, koh d, widjaja d, chia se et al. pterygium in indonesia: prevalence, severity and risk factors. br j ophthalmol. 2002; 86: 1341-6. 11. mahar ps, nwokora ge. role of mitomycinc in pterygium surgery. br j ophthalmol. 1993; 77: 433-5. 12. hayasaka s, noda s, yamamoto y, setogawa t. postoperative instillation of low dose mitomycin-c in the treatment of primary pterygium. am j ophthalmol. 1988; 106: 715–8. 13. rachmiel r, leibe h, levartovsky s. results of treatment with topical mitomycin c 0.02% following excision of primary pterygium. br j ophthalmol. 1995; 79: 233–9. 14. panda a, das g k, tuli s w, kumar a. randomized trial of intra-operative mitomycin c in surgery for pterygium. am j ophthalmol. 1998; 125: 59-63. 15. lam ds, wong ak, fan ds, chew s, kwok ps, tso mo. intraoperative mitomycin c to prevent recurrence of pterygium after excision: a 30-month follow-up study. ophthalmology. 1998; 105: 901-4. 16. rahman a, yahya k, sharif ul hasan k. recurrence rate of pterygium following surgical excision with intra operative versus postoperative mitomycin-c. j coll physicians surg pak 2008; 18: 489-92. 17. cheng hc, tseng sh, kao pl, chen fk. low-dose intra operative mitomycin c as chemo adjuvant for pterygium surgery. cornea. 2001; 20: 24-9. 18. chen pp, ariyasu rg, kaza v, labree ld, mcdonnell pj. a randomized trial comparing mitomycin c and conjunctival autograft after excision of primary pterygium. am j ophthalmol. 1995; 120: 151-60. 19. mastropasqua l, carpineto p, ciancaglini m, enrico gallenga p. long term results of intraoperative mitomycin c in the treatment of recurrent pterygium. br j ophthalmol. 1996; 80: 288-91. 20. mahar ps. role of mitomycin-c in reducing the recurrence of pterygium after surgery. pak j ophthalmol. 1996; 12: 91-4. 21. díaz l, villegas vm, emanuelli a, izquierdo nj. efficacy and safety of intra operative mitomycin c as adjunct therapy for pterygium surgery. cornea. 2008; 27: 1119-21. 22. tan dth, chee sp, dear kbg, lim as. effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. arch ophthalmol. 1997; 115:1235-40. 23. robin a, ramakrishnan r, krishnadas r, smith sd, katz jd, selvaraj s, skuta gl, bhatnagar r. a long-term dose-response study of mitomycin in glaucoma filtration surgery. arch ophthalmol. 1997; 115: 969-74. http://www.ncbi.nlm.nih.gov/pubmed?term=setogawa%20t%5bauthor%5d&cauthor=true&cauthor_uid=3143266 http://www.ncbi.nlm.nih.gov/pubmed?term=enrico%20gallenga%20p%5bauthor%5d&cauthor=true&cauthor_uid=8703875 http://www.ncbi.nlm.nih.gov/pubmed?term=enrico%20gallenga%20p%5bauthor%5d&cauthor=true&cauthor_uid=8703875 http://www.ncbi.nlm.nih.gov/pubmed?term=enrico%20gallenga%20p%5bauthor%5d&cauthor=true&cauthor_uid=8703875 http://www.ncbi.nlm.nih.gov/pubmed?term=smith%20sd%5bauthor%5d&cauthor=true&cauthor_uid=9258217 http://www.ncbi.nlm.nih.gov/pubmed?term=katz%20jd%5bauthor%5d&cauthor=true&cauthor_uid=9258217 http://www.ncbi.nlm.nih.gov/pubmed?term=selvaraj%20s%5bauthor%5d&cauthor=true&cauthor_uid=9258217 http://www.ncbi.nlm.nih.gov/pubmed?term=skuta%20gl%5bauthor%5d&cauthor=true&cauthor_uid=9258217 http://www.ncbi.nlm.nih.gov/pubmed?term=bhatnagar%20r%5bauthor%5d&cauthor=true&cauthor_uid=9258217 pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 166 original article visual outcome and complications of 23 g versus 20 g vitrectomy in cases of diabetic vitreous haemorrhage washoo mal, shakir zafar, zafar iqbal, syed fawad rizvi, syed asad mahmood pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: washoo mal lrbt free base eye hospital korangi 2 ½, karachi postal code: 74900 e-mail: dr.wash_72@yahoo.com …..……………………….. purpose: to compare post-operative visual outcome and complications of 23gauge versus 20-gauge pars plana vitrectomy in cases of vitreous haemorrhage secondary to proliferative diabetic retinopathy. material and methods: randomized clinical trial conducted at lrbt, free base eye hospital, karachi, from january 2010 to june 2012. two hundred sixty patients of vitreous haemorrhage secondary to proliferative diabetic retinopathy (type – l diabetes mellitus) were randomly selected, age range between 30 – 70 years, 23 – gauge (n = 130) group a; males 73 (56.16%), females 57 (43.85%) and 20 – gauge pars plana vitrectomy (n = 130) group b; males 70 (53.85%), females 60 (46.15%). post-operative follow up were at day one, 1 week, 1 month, 2 month, 3 month and final 6 month. data was analyzed and compared for post-operative best corrected visual acuity (bcva) and complications between two groups. results: visual acuity significantly improved in majority of patients in both groups. in group a 65.38% (85 patients) achieved between 6/6 6/24 and in group b 63.85% (83 patients) in same range when measured finally at 6 month post-operative. post operative complications in group a were transient hypotony 10.77% (14 eyes), recurrent vitreous haemorrhage 6.15% (8 eyes), raised iop 3.08% (4 eyes), cataract 3.84% (5 eyes), itrogenic tear 9.23% (12 eyes), vitreous show (prolapsed) 3.84% (5 eyes) and 1 patient (0.76%) developed endophthalmitis which was treated successfully. while in group b transient hypotony 6.15% (8 eyes), recurrent vitreous haemorrhage 18.46% (24 eyes), raised iop 7.69% (10 eyes), cataract 3.84% (5 eyes), itrogenic tear 7.69% (10 eyes) and phthisis bulbus 0.76% (1 eye), corneal edema 6.92% (9 eyes), and conjunctival granuloma at surgical wound 2.30% (3 eyes) observed. conclusion: 23 – gauge micro-incision vitrectomy system mivs and 20-gauge pars plana vitrectomy showed improvement in best corrected visual acuity (bcva) while early visual recovery and less complications rate seen in patients of 23 – gauge group. key words: vitrectomy, diabetic retinopathy, vitreous haemorrhage. t has been estimated that 8.5 – 12% population pakistan suferring from diabetes mellitus, type-ll is more common and prevalence of proliferative diabetic retinopathy 2.65 – 5% in our country.1,2 vitreous haemorrhage due to proliferative diabetic retinopathy (pdr) is one of major cause of visual impairment and due to emergence of vitrectomy system and rapid advancement in surgical techniques for posterior segment pathologies led to improvement in visual outcome after surgery. pars plana vitrectomy (ppv) is one of the most commonly performed surgical procedure for i washoo mal, et al 167 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology treatment of various vitreo-retinal diseases. machemer et al introduced ppv in 19713. more than last 30 years, the 3-port 20-gauge ppv remained the standard vitreoretinal surgery4. pars plana vitrectomy involves conjunctival incision, sclerotomies and suturing but now-a-day’s 20-gauge ppv is also performed transconjunctivally to make entry wound through the conjunctiva and sclera together, which does not required conventional suturing. these sutureless self sealing sclerotomies for ppv were first designed by chen in 19965. in 2002, fujil et al introduced the 25-gauge transconjunctival sutureless micro-incision vitrectomy surgery (mivs).6,7 after few years, in 2005 eckardt developed the 23-gauge transconjunctival vitrectomy system8. though the advances in surgical equipments and techniques, the vitrectomy procedure requires a skilled and experienced surgeon. conventional 3-port 20-gauge ppv need 1.2 mm wide sclerotomies, performed after conjunctival peritomy and surgical wound secured with sutures that may cause subconjunctival haemorrhage, congestion and foreign body sensation responsible for post-operative discomfort as well as prolong surgical time9. in recent years, the 23-gauge transconjunctival sutureless vitrectomy (tsv) has become the preferred mivs system of vitreo-retinal surgeons because of its smaller sclerotomies of 0.72 mm width and leads decrease surgical trauma, minimum post-operative inflammaion, faster healing and due to its sutureless, shortens the surgical time.10-12 the 23-gauge vitrectomy system has advantage to overcome the excessive flexibility of instruments used in smaller diameter 25-gauge mivs, which may cause hindrance in maneuvering the globe during surgery13. the rationale of this study is to compare postoperative visual outcome and complications between 23–gauge mivs and 20–gauge pars plana vitrectomy. material and methods in this prospective, randomized clinical trial of 260 patients of vitreous haemorrhage secondary to proliferative diabetic retinopathy (fig. 1) were randomly selected for 23 – gauge mivs (n = 130) and 20 – gauge ppv (n = 130) for indication of diabetic vitreous haemorrhage during period of january, 2010 to june, 2012, carried out in lrbt, free base eye hospital, karachi. all surgeries were carried out by one vitreoretinal surgeon (sz). the data acquisition was performed by two investigators (zi) independently of surgeon, while literature was reviewed by doctor (wm). the study was conducted under the supervision of hospital incharge (sfr). the study was approved by institutional ethical review committee, and informed consent was taken from each patient. cases of diabetic vitreous haemorrhage secondary to type – ii diabetes mellitus, without significant cataract and patients with pseudophakia were included in this study while patients associated with advanced or complicated pdr like retinal detachment, proliferative vitreo-retinopathy, uveitis, dense cataract and previous history of vitreo-retinal surgery were excluded from study and in invisible fundi dynamic bscan ultrasound carried out to rule out retinal detachment or any significant fibrotic bands. preoperative ocular & systemic examination of all patients done, including: visual acuity (snellen’s chart), ocular adnexa, anterior segment examination, intra ocular pressure, crystalline lens for opacities (cataract) and dilated fundal examination with +90 d lens at bio-microscopic slit lamp, indirect ophthalmoscopy, blood pressure, fasting blood sugar and hba1c were checked. all patients were informed about the procedure and written consent taken. surgeries were performed by using vitrectomy system) and non-contact viewing system (ebios) for visualization and illumination provided by xenon light. the rationale of this study is to compare postoperative visual outcome and complications between 23-gauge mivs and 20-gauge pars plana vitrectomy. surgical technique all surgeries done under local anaesthesia preferably retrobulbar with 2 ml of lidocain 2% and 2 ml of bupivacain 0.75% were used. all surgeries were carried out under strict aseptic measures using povidone iodine 5-10% for periocular paint and conjunctival fornices with 5% same solution. after applying eye speculum, self-retaining trocar/cannulae inserted transconjunctivally after 1.5-2 mm displacing conjunctiva laterally at supero-temporal, supero-nasal and infero-temporally about 3.5 mm away from the limbus, 300 obliquely to have sclera tunnel in all phakic patients. the infusion line was connected to infero-temporal cannula while superior two cannulae for illumination and vitrectomy cutter, after complete vitreous cleaning, the retina was examined and pan retinal photocoagulation was done using endolaser (fig: 2). balance salt solution was used as internal tamponade. at the completion of vitrectomy the visual outcome and complications of 23 g versus 20 g vitrectomy in cases of diabetic vitreous haemorrhage pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 168 fig. 1: pre operative fundus photograph of vitreous haemorrhage fig. 2: fundus photograph after pars plana vitrectomy with endolaser superior cannulae were plugged and infusion line was stopped. initially superior cannulae were removed with observing the repositioning of conjunctiva covering the sclerotomies finally infero-temporal cannula with infusion line removed and observed repositioning of conjunctiva; finally the sclerotomies in group a, of 23-gauge mivs left sutureless. (no any patient required suturing in group ain group b, 20gauge sclerotomies were done with mvr blade and infero-temporally infusion canula was sutured with vicryl 6/0. at end of surgery, the sclerotomies and conjunctiva were sutured with vicryl 6/0 (ethicon, johnson and johnson). the data was collected for variables like, age, gender, best corrected visual acuity (bcva). preoperatively and post-operatively follow up were at day one, 1 week, 1 month, 2 month, 3 month and finally at the end of 6 months visual acuity measured with snellen’s chart followed by refraction (where needed) and various post-operative complications were evaluated. variables were statistically analyzed by wilcoxon test for pre & post operative bcva and chi-square’s test and fisher’s exact test where applied for comparison two groups. a p-value ≤ 0.05 considered statistically significant. results data of two hundred sixty eyes of 260 patients were analyzed, 130 in each group a for 23-gauge mivs and group b for 20-gauge ppv. age range was 30 to 70 years, 73 (56.15%) males and 57 (43.85%) females in group a while 70 (53.85%) males and 60 (46.15%) females in group b. bcva of two groups were analysed by applying wilcoxon test (npar) to compare pre and post bcva of two groups, that showed significant improvement (p-value 0.0001). bcva differences in patients of two groups were insignificant when measured finally at 6 months postoperatively shown in table 1. in group a 85 (65.38%) improved between 6/6 6/24, 6/36 24 (18.46%), 6/60 11 (8.46%), cf 6 (4.61%), hm 4 (3.10%); whereas group b improved 83 (63.85%) 6/6 6/24, 22 (16.92%) 6/36, 13 (10%) 6/60, 7 (5.38%) cf, 5 (3.85%) -hm (hm due to ischemic maulopathy proven by ffa and recurrent vitreous haem:). p-value of bcva between two groups remained insignificant. early visual recovery observed in group a that might be due to lesser manipulation. post-operative complications are summarized the table 2. only one patient (0.76%) in group a developed endophthalmitis which was successfully treated with standard intra-vitreal, topical and systemic antibiotics and one eye (0.76%) in group b end up into phthisis bulbus. inspite of itrogenic tears, no any patient developed retinal detachment. because confluent lasers were applied around tears. discussion in this study post operatively bcva of both groups at 6 months significantly improved shown in (table 1) from hand movement to between 6/6 to 6/24 in 65.38% (85/130 patients) in 23-gauge group and 63.85% (83/130 patients) in 20-gauge group; which shows insignificant statistical difference between two groups. a study of kim jm et al shows bcva 6/6 to 6/24 in 72.72% in cases of vitreous haemorrhage 23washoo mal, et al 169 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology gauge vitrectomy which is much better improvement than this study14. this difference in visual outcome is due to variation in case selection. nataraj ams mentioned significant bcva improvement in his study of 23-gauge and 20-gauge technique with insignificant statistical difference in two groups, which is comparable to this study15. complications summarized in table 2, showing hypotony (defined as ≤ 5 mm hg intraocular pressure)16 occurred in 10.77% (14/130 eyes) in 23gauge and 6.15% (8/130 eyes) in 20 – gauge groups which was normalized in 2 weeks with use of topical steroids and cycloplegics. woo sj et al noted postoperative hypotony in 11.3% in 23-gauge vitrectomy17 and these results are comparable to this study. related to this multiple studies and literature shows increase incidence of post-operative hypotony in sutureless vitrectomy.6,11,18 intraocular pressure ≥ 30 mm hg was observed in 3.08% (4/130 eyes) in 23-gauge and 7.69% (10/130 eyes) in 20 – gauge groups. this would be due to suturing of sclerotomies in respective groups. misra a et al mentioned raise iop 8% (4/50 eyes) in 20gauge vitrectomy, that incidence is matched to this study. iatrogenic retinal breaks in 23-gauge and 20gauge groups are 10.77% (14/130 eyes) and 9.23% (12/130 eyes) respectively. misra a et al also shows iatrogenic breaks 14% and 12% in 23 – gauge and 20 – gauge respectively which is higher than this study19. as the 23-gauge vitrectomy is sutureless nature of surgery is vulnerable to most serious complication visual outcome and complications of 23 g versus 20 g vitrectomy in cases of diabetic vitreous haemorrhage pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 170 the endophthalmitis, kunimote et al in one large retrospective case series has shows incidence of endophthalmitis after sutureless 25 gauge (mivs) is 12 times higher than conventional 20-gauge vitrectomy20. however in subsequent case series of hu ay et al and parolini b et al have shows no increase incidence of endophthalmitis in 25 – gauge and 23-gauge compared with 20-gauge vitrectomy21,22. in this study single case developed endophthalmitis, this was successfully treated with intravitreal, topical and systemic antibiotics. the cause of post surgical endophthalmitis might have involved factors other than sutureless vitrectomy. misra a et al and romano mr mentioned in their studies that sutureless vitrectomy theoretically may be at greater risk of this dangerous complication.19,23 recurrent vitreous hemorrhage noticed in 8% (21 cases in both groups) more probably due to underlying basic pathology of proliferative diabetic retinopathy. conclusion this study concludes that 23 – gauge mivs and 20 – gauge pars plana vitrectomy showed improvement in best corrected visual acuity (bcva), while low rate of complications seen in 23 – gauge mivs except hypotony is higher due to sutureless surgery and preferably mivs should be considered first choice where ever possible. author’s affiliation dr. washoo mal associate ophthalomologist lrbt free base eye hospital korangi 2 ½, karachi postal code: 74900 dr. shakir zafar consultant ophthalmologist lrbt free base eye hospital korangi 2 ½, karachi postal code: 74900 dr. zafar iqbal consultant ophthalmologist lrbt free base eye hospital korangi 2 ½, karachi postal code: 74900 dr. syed fawad rizvi chief consultant ophthalmologist lrbt free base eye hospital korangi 2 ½, karachi postal code: 74900 dr. syed asad mahmood resident medical officer lrbt free base eye hospital korangi 2 ½, karachi postal code: 74900 references 1. memon wu, jadoon z, qidwai u, naz s, dawar s, hasan t. prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicentre diabetic clinics in karachi. pak j ophthalmol. 2012; 28: 99-104. 2. hussain f, arif m, ahmad m. the prevalence of diabetic retinopathy in faisalabad, pakistan: a population-based study. turk j med sci. 2011; 41: 735-42. 3. machemer r, buettner h, norton ew, parel jm. vitrectomy: a pars plana approach. trans am acad ophthalmol otolaryngol. 1971; 75: 813-20. 4. o’malley c, heintz rm sr. vitrectomy with an alternative instrument system. ann ophthalmol. 1975; 7: 585-8. 5. chen jc. sutureless pars plana vitrectomy through self-sealing sclerotomies. arch ophthalmol. 1996; 114: 1273-5. 6. fujii gy, de juan e jr , humayun ms, pieramici dj, chang ts, awh c, ng e, barnes a, wu sl, sommerville dn. a new 25-gauge instrument system for transconjunctival sutureless vitrectomy surgery. ophthalmology. 2002; 109: 1814-20. 7. fujii gy, de juan e jr, humayun ms, chang ts, pieramici dj, barnes a, kent d. initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery. ophthalmology. 2002; 109: 1814-20. 8. eckardt c. transconjunctival sutureless 23-gauge vitrectomy. retina. 2005; 25: 208-11. 9. jackson t. modified sutureless sclerotomies in pars plana vitrectomy. am j ophthalmol. 2000, 129: 116-7. 10. meyer ch, rodrigues eb, schmidt jc, horle s, kroll p. sutureless vitrectomy surgery. ophthalmology. 2003; 110: 2427-8. 11. soni m, chhugh d. 23-gauge transconjunctival sutureless vitrectomy: a way forward. eye news. 2007; 14: 18-20. 12. lakhanpal rr, humayun ms. de juan e jr, lim ji, chong lp, chang ts, javaheri m, fujii gy, barnes ac, alexandrou tj. outcomes of 140 consecutive cases of 25-gauge transconjunctival surgery for posterior segment disease. ophthalmology. 2005; 112: 817-24. 13. nam y, chung h, lee jy, kim jg, yoon yh. comparison of 25 and 23-gauge sutureless micronicision vitrectomy surgery in the treatment of various vitreoretinal diseases. eye 2010; 24: 869-74. 14. kim jm, park hk, hwang mj, yu gh, suk y, yu, chung h. the safety and efficacy of transconjunctival sutureless 23-gauge vitrectomy. korean journal of ophthalmology. 2007; 21: 201-7. 15. nataraj ams. comparison between 20 – gauge and 23-gauge vitrectomy in diabetic patients. kerala journal of ophthalmology. 2011; 23: 293-7. 16. kanski jj, bowling b. editors. acquired macular disorders. in: clinical ophthalmology a systemic approach. edinburg: elsevier; 2011;.594-646. 17. woo sj, park kh, hwang jm, kim jh, yu ys, chung h. risk factors associated with sclerotomy leakage and postoperative hypotony after 23-gauge transconjunctival sutureless vitrectomy. retina. 2009; 29: 456-63. 18. fine hf, iranmanesh r, iturralde d, spaide rf. outcomes of 77 consecutive cases of 23-gauge transconjunctival vitrectomy http://www.ncbi.nlm.nih.gov/pubmed?term=javaheri%20m%5bauthor%5d&cauthor=true&cauthor_uid=15878061 http://www.ncbi.nlm.nih.gov/pubmed?term=fujii%20gy%5bauthor%5d&cauthor=true&cauthor_uid=15878061 http://www.ncbi.nlm.nih.gov/pubmed?term=barnes%20ac%5bauthor%5d&cauthor=true&cauthor_uid=15878061 http://www.ncbi.nlm.nih.gov/pubmed?term=alexandrou%20tj%5bauthor%5d&cauthor=true&cauthor_uid=15878061 http://www.ncbi.nlm.nih.gov/pubmed?term=alexandrou%20tj%5bauthor%5d&cauthor=true&cauthor_uid=15878061 http://www.ncbi.nlm.nih.gov/pubmed?term=alexandrou%20tj%5bauthor%5d&cauthor=true&cauthor_uid=15878061 http://www.ncbi.nlm.nih.gov/pubmed?term=kim%20jh%5bauthor%5d&cauthor=true&cauthor_uid=19174725 http://www.ncbi.nlm.nih.gov/pubmed?term=yu%20ys%5bauthor%5d&cauthor=true&cauthor_uid=19174725 http://www.ncbi.nlm.nih.gov/pubmed?term=chung%20h%5bauthor%5d&cauthor=true&cauthor_uid=19174725 washoo mal, et al 171 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology surgery for posterior segment disease. ophthalmology. 2007; 114: 1197-1200. 19. misra a, ho-yen g; burton rl. 23-gauge suturless vitrectomy and 20-gauge vitrectomy: a case series comparison. eye. 2009; 23:1187-91. 20. kunimoto dy, kaiser rs. wills eye retina service. incidence of endophthalmitis after 20 and 25-gauge vitrectomy. ophthalmology. 2007; 114: 2133-7. 21. hu ay, bourges jl, shah sp, gupta a, gonzales cr, oliver sc, schwartz sd. endophthalmitis after pars plana vitrectomy a 20 and 25 – gauge comparison. ophthalmology. 2009; 116: 1360-5. 22. parolini b, romanelli f, prigione g, pertile g. incidence of endophthalmitis in a large series of 23 – gauge and 20-gauge transconjunctival pars plana vitrectomy. greafes arch clin exp ophthalmology. 2009: 247: 1711-2. 23. romano mr, das r, groenwald c, stapler t, marticorena j, valldeperas x, wong d, heimann h. primary 23-gauge sutureless vitrectomy for rhegmatogenous retinal detachment. indian j ophthalmol. 2012; 60: 29-33. http://www.ncbi.nlm.nih.gov/pubmed?term=gupta%20a%5bauthor%5d&cauthor=true&cauthor_uid=19576499 http://www.ncbi.nlm.nih.gov/pubmed?term=gonzales%20cr%5bauthor%5d&cauthor=true&cauthor_uid=19576499 http://www.ncbi.nlm.nih.gov/pubmed?term=oliver%20sc%5bauthor%5d&cauthor=true&cauthor_uid=19576499 http://www.ncbi.nlm.nih.gov/pubmed?term=oliver%20sc%5bauthor%5d&cauthor=true&cauthor_uid=19576499 http://www.ncbi.nlm.nih.gov/pubmed?term=oliver%20sc%5bauthor%5d&cauthor=true&cauthor_uid=19576499 http://www.ncbi.nlm.nih.gov/pubmed?term=schwartz%20sd%5bauthor%5d&cauthor=true&cauthor_uid=19576499 pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 221 original article epidemiology of age related macular degeneration (amd) and it’s associated ocular conditions and concomitant systemic diseases daulat naghza, naureen karam, fatima amin, marriam zaka, daulat haleem khan, shujaud din khan, daulat raheem khan pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: daulat naghza department of pharmacy lahore college for women university, lahore 54000 …..……………………….. purpose: to find the prevalence of amd and its accompanying ocular or systemic diseases. material and methods: epidemiological survey was conducted amongst the patients presented at different ophthalmology clinics in lahore. data was collected from amd patients (n=100) through prescribed forms and was analysed for statistical significance. results: dry amd (82%) was more prevalent than wet amd (18%). women (66%) seemed to be affected more than men (34%). in majority, amd was found associated with other ocular conditions like cataract (78%), pseudophakia (27%), glaucoma (2%) and vitreous degeneration (3%). interestingly, a high proportion of systemic diseases accompanied amd like hypertension-hypercholesterolemia (72%), obesity (40%) and depression (90%). ophthalmologists usually adopted preventive interventions against further vision loss like vitamins and minerals for dry amd. likewise, in wet amd anti-vegf, laser photocoagulation or photodynamic therapies were implied. conclusion: amd had a high prevalence and was often observed with other ocular conditions. moreover, an effect of age, gender and cardiovascular diseases seemed to exist as the predisposing factors in amd development. this study opens perspectives to conduct research to develop effective therapies for amd. ge – related macular degeneration (amd) is the deterioration of “macula” which is responsible for the central vision. there are two types of macular degeneration: first, dry or nonneovascular macular degeneration which is characterized by the formation of drusens (fat deposits) on retina and second, wet or neovascular macular degeneration which is developed due to the formation of abnormal blood vessels underneath the retina. each type of amd has its associated clinical manifestations like dry amd causes blurring of vision which includes inability to recognize faces and blank spot in central vision. likewise, the wet amd causes distorted vision which consists of the appearance of straight lines as bent, crooked or irregular1 amd may only be diagnosed by an ophthalmologist through clinical examination and in certain cases by additional complementary tests, particularly, fluorescein angiography, indocyanine green angiography and/or an optical coherence tomography2,3. at the moment, the exact cause for amd is not known. however, few factors are thought to contribute towards amd development like age, gender, genetics, life style and exposure to the a daulat naghza, et al 222 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology sunlight4. amd is a debilitating disease which usually affects patients over 50 years5,6 and has been considered to be a significant cause of blindness in united states7. although the prevalence of amd is the highest among caucasians in western countries, its prevalence among asians is also quite high8. in pakistan, however, little information is available on the epidemiology of amd. this study provides a) the prevalence of amd amongst the ophthalmic cases presented at ophthalmology clinics in pakistan, b) the diseases most commonly associated with amd and c) the different treatments and/or management options followed by the ophthalmologists in this condition. additionally, a corollary objective was to elucidate the role of pharmacist at the ophthalmology clinics – a comparatively less focused domain by the health professionals. material and methods in this study we carried out a cohort survey to observe the prevalence of amd and analyzed the management options followed by the ophthalmologists to treat amd. this project was primarily based upon collection of data from the patients presenting at the ophthalmology clinics and who were diagnosed to have amd by an ophthalmologist. the sample population followed up in this study included the ophthalmic patients of three hospitals in urban area of lahore district. the information from these patients was obtained by filling up a previously designed “data collection form”. later on this information was critically analyzed and conclusions were drawn. clinical observations first amd was diagnosed on the basis of clinical signs and symptoms and then fluorescein angiography was performed. a bolus injection of sodium fluorescein (3ml) was injected intravenously to the patients. the photos of retina were taken when the dye reached the ocular circulation (nearly 10 seconds after injection). statistical analysis in order to observe any significant results one way anova was performed through the use of spss software. results the results of this retrospective survey study indicate that amd had a high rate of prevalence amongst the patients (5%) presenting at the ophthalmology clinics. most of these cases (82%) were having dry form, while an important proportion was also having wet amd (18%). interestingly, women constituted a higher proportion (66%) of amd patients compared to men (34%). in majority of patients the onset of condition was progressive (82%) while an important population had an abrupt onset (18%) with either one (18%) or both eyes affected (82%). fig. 1: ocular conditions observed with amd in this study we observed that amd is associated with other ocular conditions like cataract (78%), pseudophakia (27%), glaucoma (2%) and vitreous degeneration (3%). the loss of vision cause severe psychological disturbances in affected people. in addition to the associated ocular disorders, we observed that a high proportion of amd patients had accompanying systemic diseases (70%). these conditions included hypertension, hypercholesterolemia (72%), obesity (40%) and depression (90%). the clinicians mostly used supportive therapies to avoid further vision loss in affected subjects. these treatments included vitamins and minerals (72%) for dry amd and in wet amd anti-vegf (10%) and laser photocoagulation (10%). however, these treatments did not contribute towards the improvement of vision already lost. epidemiology of age related macular degeneration (amd) & it’s associated ocular conditions pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 223 discussion age – related macular degeneration (amd) affects a significant percentage of the population and was considered to be the most significant cause of acquired blindness in united states involving more than 8 million people9. in this study we observed a high proportion of amd among ophthalmic patients (nearly 5%) and they reported a problem of significant vision loss elderly subjects had a higher incidence than the young. this is the most significant factors which also lead to assign the name of condition as “age – related” degeneration. the patients included men and women. however, women seemed to be more prone to amd. this sex predilection is unexplained so far, however, an association with cyclic hormonal changes or the use of contraceptives may be found. we observed that most of these cases were having dry amd (82%), while a comparatively smaller population had wet amd (18%). this is consistent with earlier findings. moreover, dry amd, if not treated, leads to the wet form which explains a higher proportion of dry form. the exact etiology of amd is difficult to be attributed; however, various predisposing factors are known. for instance, in our study we observed most of patients were taking a high fat diet which contained a lesser portion of betacarotene and leutin (data not shown). the deficiency of these two compounds is associated with development of dry amd. interestingly, amd was associated with other ocular conditions in most of the cases. the most common condition was cataract which probably is also manifestation of older age like amd. pseudophakia, or the ocular surgery mostly in cataract, was another important condition associated with amd. in fact, cataract surgery involves intra ocular lens implantation, which might not contain yellow chromophore responsible for blue light absorption. this inflicts regular apoptosis inhibition in eye cells causing drusen formation and hence, leads to amd. in the present study we observed amd was associated with other systemic diseases in addition to the ocular problems. depression was most common condition observed in patients reporting amd. this is in concordance with previous reports10. this is probably due to a fear factor of becoming blind forever. in fact, greater attention from families, physicians, and society to the mental health needs and also alleviation of mobility challenges may help improve the condition. the most striking feature of this study was the identification of hypertension as the second most common concomitant disease. interestingly, an association between amd and cardiovascular disease has been proposed; however, case control and genetic analyses have been quite ambiguous. however, chronic hypertension and various environmental risk factors like smoking have strongly been associated with ocular conditions including amd. it is observed that antihypertensive drugs like systemic beta blockers reduce lysozyme levels and they reduce the requirement for intravitreal anti-vegf injections in patients with wet amd. this is an interesting observation which opens the way for further research in the development of cardiovascular treatments which may prevent amd incidence11. conclusion the presented study provides a preliminary report on a major ophthalmic condition (amd) in pakistan. this study highlights that amd is a multifactor problem which may be associated with other ocular or systemic diseases. the improved efficiency of amd treatment in the patients receiving the cardiovascular medicines suggests existence of similar pathological mechanisms and highlights the significance of development of hypertension therapies which help improve amd as well. author’s affiliation daulat naghza department of pharmacy lahore college for women university lahore 54000 naureen karam department of pharmacy lahore college for women university lahore 54000 fatima amin department of pharmacy lahore college for women university lahore 54000 marriam zaka department of pharmacy lahore college for women university lahore 54000 daulat haleem khan department of pharmacy government college university faisalabad 38000 daulat naghza, et al 224 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology dr. shujaud din khan department of ophthalmology pakistan railways cairns hospital lahore 54000 dr. daulat raheem khan crbr, département des sciences animales université laval, québec, qc canada references 1. lim ls, mitchell p, seddon jm, holz fg, wong ty: age related macular degeneration. lancet. 2012; 379: 1728-38. 2. bischoff pm, flower rw: ten years’ experience with choroidal angiography using indocyanine green dye: a new routine examination or an epilogue? doc ophthalmol. 1985; 235-91. 3. regillo cd, benson we, maguire ji, annesley wh jr: indocyanine green angiography and occult choroidal neovascularization. ophthalmology. 1994; 280-8. 4. evans jr: risk factors for age – related macular degeneration. prog retin eye res 2001; 227-53. 5. ambati j, ambati bk, yoo sh, ianchulev s, adamis ap: age – related macular degeneration: etiology, pathogenesis, and therapeutic strategies. surv ophthalmol. 2003; 48: 257-93. 6. ambati j, anand a, fernandez s, sakurai e, lynn bc, kuziel wa: an animal model of age – related macular degeneration in senescent ccl-2or ccr-2-deficient mice. nat med. 2003; 1390-7. 7. leibowitz hm, krueger da, maunder ra: an ophthalmological study of cataract, glaucoma, diabetic retinopathy, macular degeneration and visual acuity in a general population of 2631 adults. surv ophthalmol. 1980; 335--610. 8. wong ty, loon s-c, saw sm: the epidemiology of age related eye diseases in asia. brit ophthalmol. 2006; 50611. 9. friedman ds, o'colmain bj, munoz b: prevalence of age – related macular degeneration in the united states. arch ophthalmol. 2004; 122: 564-72 10. popescu ml, boisjoly h, schmaltz h, kergoat mj, rousseau j, moghadaszadeh s, djafari f, freeman ee: explaining the relationship between three eye diseases and depressive symptoms in older adults. invest ophthalmol vis sci. 2012: 2308-13. 11. montero ja, ruiz – moreno jm, sanchis – merino e, perez – martin s: systemic beta-blockers may reduce the need for repeated intravitreal injections in patients with wet age – related macular degeneration treated by bevacizumab. retina. 2012; 24. http://www.ncbi.nlm.nih.gov/pubmed?term=lim%20ls%5bauthor%5d&cauthor=true&cauthor_uid=22559899 http://www.ncbi.nlm.nih.gov/pubmed?term=mitchell%20p%5bauthor%5d&cauthor=true&cauthor_uid=22559899 http://www.ncbi.nlm.nih.gov/pubmed?term=seddon%20jm%5bauthor%5d&cauthor=true&cauthor_uid=22559899 http://www.ncbi.nlm.nih.gov/pubmed?term=holz%20fg%5bauthor%5d&cauthor=true&cauthor_uid=22559899 http://www.ncbi.nlm.nih.gov/pubmed?term=wong%20ty%5bauthor%5d&cauthor=true&cauthor_uid=22559899 pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 158 case report sheep in the skin of a wolf, an unusual sub-retinal lesion tayyaba gul malik, muhammad khalil, afzal hussain pak j ophthalmol 2015, vol. 31 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyaba gul malik ophthalmology department lahore medical and dental college email: tayyabam@yahoo.com …..……………………….. purpose: to describe a case of sub retinal hemorrhage mimicking as uveal tumour. material and methods: although new diagnostic techniques are emerging every now and then, indirect ophthalmoscopy is still a gold standard in the diagnosis of retino-choroidal lesions. problems arise when media is not clear. oct, ffa are not possible in hazy media and fine needle aspiration cytology carries a risk of seeding. there are other conditions like choroidal naevi, choroidal hemangiomas and hemorrhages which can observed, but when it comes to choroidal melanoma, it becomes very important to diagnose it in time to prevent metastatic complication and death. a case of an 81 years old male is presented who had vitreous hemorrhage and a sub retinal mass. age of the patient, size of the mass and b scan were quite confusing to exclude a choroidal malignancy. pars plana vitrectomy was performed and the mass proved to be a sub retinal hemorrhage secondary to exudative age – related macular degeneration. key words: choroidal melanoma, sub retinal hemorrhage, intra gel hemorrhage, choroidal lymphoma, choroidal metastasis, choroidal naevus. xudative type of age related macular degeneration is one of the commonest causes of irreversible vision loss. sometimes rupture of choroidal neovascular membrane can lead to hemorrhagic retinal and retinal pigment epithelial detachments that, may be mistaken for choroidal melanoma which is the most common primary malignant intra ocular tumor and the second most common primary malignant melanoma of the body. it has a high mortality rate and the collaborative ocular melanoma study (coms) has reported a misdiagnosis rate of 0.48%. there are reports in which benign choroidal lesions came out to be malignant and vice versa. one such case is discussed in relation to literature review. case report an 81 years old male presented with history of sudden loss of vision in his left eye. he was a known case of diabetes and hypertension. both conditions were well controlled on insulin and antihypertensive agents respectively. he had several injections of intravitreal avastin in left eye for exudative age related macular degeneration. on examination, there was visual acuity of projection of light in right eye and finger counting in left eye. intra ocular pressures were normal. slit lamp examination revealed nuclear sclerosis in right eye and pseudo-phakia in left eye. fundoscopy showed macular disciform scar in right eye and vitreous hemorrhage in left eye. b-scan of left eye showed moderately dense intra gel hemorrhage with freely mobile afibrotic posterior vitreous detachment. inferotemporal area showed solid retinal detachment. all other structures were normal. there was medium reflectivity. an acoustic quiet zone at the base of the elevation could be seen. orbital shadowing was absent (figures 1-2) the differential diagnosis in our minds were sub retinal hemorrhage, choroidal melanoma, choroidal metastasis, choroidal osteoma and choroidal hemangioma. pars plana vitrectomy (ppv) was e mailto:tayyabam@yahoo.com tayyaba gul malik, et al 159 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology performed. a large yellowish white sub-retinal mass, more than 8 disc diameters was seen in the macular area and extending inferior to the inferior temporal vascular arcade (figure 3). fig. 1 & 2: b-scan showing intra gel hemorrhage and solid retinal detachment fig. 3: post ppv fundus photograph post ppv picture was more like amelanotic melanoma or choroidal lymphoma. sd-oct showed normal choroidal contours with no evidence of excavation. systemic investigations were performed to rule out choroidal metastasis from other organs especially lungs and prostate. choroidal osteoma was already ruled out on b scan. owing to the presence of disciform scar in the other eye and history of intra ocular avastin for amd in the same eye the patient was followed up for any change in size of the mass. after one month, the mass considerably reduced in height and width. diagnosis of large sub retinal hemorrhage was made and follow up was continued. discussion the importance of correct diagnosis of sub retinal mass cannot be overlooked. certain conditions for example choroidal melanoma requires prompt intervention while some others need either medical therapy (e.g, lymphoma) or just wait and observe strategy (haemangioma and sub retinal hemorrhage). there are cases where choroidal melanoma turns out to be some benign condition usually referred to as pseudo melanomas. in a study by shields, about 40 different conditions were described which simulated melanoma. the common ones included suspicious choroidal nevus, disciform degeneration, congenital hypertrophy of the retinal pigment epithelium and choroidal hemangioma. such a large number of differential diagnosis reflect the clinical problem confronted by ophthalmologist.1,2 in the early seventies the percentage of misdiagnosis of choroidal melanoma was as high as 20%. this percentage has fallen considerably with the improvement in diagnostic techniques over the past years. current diagnosis of choroidal melanoma is based on clinical findings including indirect ophthalmoscopy, a and b scan ultrasonography, and fundus fluorescein angiography. however, invasive procedures like fnac are not indicated. with clear media, 95% cases are correctly diagnosed by indirect ophthalmoscopy.3 the single most important technique to rule out a choroidal melanoma is indirect ophthalmoscopy associated with biomicroscopy of the fundus.4 according to coms, accuracy of clinical diagnosis for choroidal melanoma was more than 99% (confirmed by histopathology).5 but it should be noted that the study excluded patients with cloudy media which could have interfered with the ophthalmoscopic examination, fluorescein angiography and optical coherence tomography. another study reported that approximately 30% of patients referred to an ocular oncology service with the diagnosis of choroidal melanoma had an incorrect diagnosis.6 our patient had vitreous hemorrhage that made diagnosis a bit difficult. gunduz k and colleagues had described a healthy 31 years old man who had loss of vision in right eye. he had yellow white juxta papillary choroidal mass with vitreous hemorrhage. later on it turned out to be a choroidal granuloma7. another report described unilateral intraschisis sheep in the skin of a wolf, an unusual sub-retinal lesion pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 160 hemorrhage which closely mimicked a choroidal melanoma.8 our patient was found to be a case of exudative amd. literature shows that choroidal nevus is the commonest condition which simulates melanoma. only 4% patients of pseudomelanoma have amd.9 amoli fa has described non-hodgkin lymphoma (nhl) as a masquerade syndrome of choroidal melanoma.10 another differential diagnosis of our patient was circumscribed choroidal hemangioma, which often appears as a subtle red-orange mass or as a grayish lesion in the posterior choroid.11 the color of lesion in this particular patient and b scan was highly against hemangioma. sometimes limited choroidal hemorrhages are mistaken for a choroidal melanoma. morgan cm described three cases with an unusual localized posterior choroidal hemorrhage. these patients were thought to be cases of choroidal melanomas and were referred for proton beam irradiation. later, they turned out to be hemorrhagic choroidal detachments.12 contrary to these, there are reports in which presumed benign choroidal lesions later on proved to be choroidal melanoma. melanomas in the macular region can further jeopardize the diagnosis. they mimic exudative amd and if left as such, they can be fatal.13 in cases where ocular media is clear, sd-oct provides useful information to observe and document suspicious choroidal lesions and help differentiate choroidal nevus from malignant melanoma. our patient underwent ppv and sd-oct showed normal choroid and the lesion was purely sub retinal hemorrhage.14 although clear media is a pre-requisite for sdoct, it is very helpful in very small tumours which are not detectable by b scan.15 it is not necessary that subretinal hemorrhages should be darker red in color. this particular patient had yellowish white subretinal mass. when hemoglobin undergoes metabolism, there are spectrum of colors seen through this process. it is believed that the greenish hue originates from the retinal nerve fiber layer, which becomes stained by the breakdown products of hemoglobin. there are macrophages, which convert heme into biliverdin (water – soluble green compound) and bilirubin (water insoluble yellow compound). conclusion even with the advent of new technology, certain cases still prove to be backbreaking and challenging. ophthalmologists should be vigilant in making a final verdict. sometimes innocuous lesions turn out to be fatal and conversely, apparently blatant lesions prove benign. author’s affiliation dr. tayyaba gul malik associate professor of ophthalmology lahore medical and dental college email: tayyabam@yahoo.com dr. muhammad khalil associate professor of ophthalmology lahore medical and dental college email: mkhalil64pk2002@yahoo.com dr. afzal hussain eye consultant national eye center, lahore role of authors dr. tayyaba gul malik patient management and manuscript writing. dr. muhammad khalil patient management and manuscript writing. dr. afzal hussain patient management and manuscript writing. references 1. shields ja, augsburger jj, brown gc, stephens rf. the differential diagnosis of posterior uveal melanoma. ophthalmology. 1980; 87: 518-22. 2. shields cl, manalac j, das c, ferguson k, shields ja. choroidal melanoma: clinical features, classification, and top 10 pseudomelanomas. curr opin ophthalmol. 2014; 25: 177-85. 3. char dh, stone rd, irvine ar, crawford jb, hilton gf, lonn ll, et al. diagnostic modalities in choroidal melanoma. am j ophthalmol. 1980; 89: 223-30. 4. de laey jj. diagnosis and differential diagnosis of malignant melanomas of the choroid. bull soc belge ophtalmol. 1993; 248: 6-10. 5. the collaborative ocular melanoma study group. accuracy of diagnosis of choroidal melanomas in the collaborative ocular melanoma study. coms report no. 1. arch ophthalmol. 1990; 108: 1268-73. 6. khan j, damato be. accuracy of choroidal melanoma diagnosis by general ophthalmologists: a prospective study. eye (lond). 2007; 21: 595-7. mailto:tayyabam@yahoo.com mailto:mkhalil64pk2002@yahoo.com http://www.ncbi.nlm.nih.gov/pubmed?term=shields%20ja%5bauthor%5d&cauthor=true&cauthor_uid=7413140 http://www.ncbi.nlm.nih.gov/pubmed?term=augsburger%20jj%5bauthor%5d&cauthor=true&cauthor_uid=7413140 http://www.ncbi.nlm.nih.gov/pubmed?term=brown%20gc%5bauthor%5d&cauthor=true&cauthor_uid=7413140 http://www.ncbi.nlm.nih.gov/pubmed?term=stephens%20rf%5bauthor%5d&cauthor=true&cauthor_uid=7413140 http://www.ncbi.nlm.nih.gov/pubmed/7413140 http://www.ncbi.nlm.nih.gov/pubmed?term=shields%20cl%5bauthor%5d&cauthor=true&cauthor_uid=24614143 http://www.ncbi.nlm.nih.gov/pubmed?term=manalac%20j%5bauthor%5d&cauthor=true&cauthor_uid=24614143 http://www.ncbi.nlm.nih.gov/pubmed?term=das%20c%5bauthor%5d&cauthor=true&cauthor_uid=24614143 http://www.ncbi.nlm.nih.gov/pubmed?term=ferguson%20k%5bauthor%5d&cauthor=true&cauthor_uid=24614143 http://www.ncbi.nlm.nih.gov/pubmed?term=shields%20ja%5bauthor%5d&cauthor=true&cauthor_uid=24614143 http://www.ncbi.nlm.nih.gov/pubmed/24614143 http://www.ncbi.nlm.nih.gov/pubmed?term=de%20laey%20jj%5bauthor%5d&cauthor=true&cauthor_uid=8044333 http://www.ncbi.nlm.nih.gov/pubmed/8044333 http://www.ncbi.nlm.nih.gov/pubmed/8044333 http://www.ncbi.nlm.nih.gov/pubmed/8044333 http://www.ncbi.nlm.nih.gov/pubmed?term=khan%20j%5bauthor%5d&cauthor=true&cauthor_uid=16470216 http://www.ncbi.nlm.nih.gov/pubmed?term=damato%20be%5bauthor%5d&cauthor=true&cauthor_uid=16470216 http://www.ncbi.nlm.nih.gov/pubmed/16470216 tayyaba gul malik, et al 161 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology 7. gündüz k, shields cl, shields ja, schubert h. presumed choroidal granuloma with vitreous hemorrhage resembling choroidal melanoma. ophthalmic surg lasers. 1998; 29: 422-5. 8. hayyam kıratlı. persistent intraschisis hemorrhage simulating choroidal melanoma. jpn j ophthalmol. 2002; 46: 222–5. 9. shields ja, mashayekhi a, ra s, shields cl. pseudomelanomas of the posterior uveal tract: the 2006 taylor r. smith lecture. retina. 2005; 25: 767-71. 10. amoli fa, rajabi mt, esfahani mr, sadeghi a. nonhodgkin lymphoma (nhl) is also one of the masquerade syndromes of malignant melanoma. primary choroidal malignant lymphoma: report of a case and review of literature. acta medica iranica. 2006; 44: 145-50. 11. khuu t, hoffman dj. circumscribed choroidal hemangioma: a case report and review of the literature. optometry. 2006; 77: 384-91. 12. morgan cm, gragoudas es. limited choroidal hemorrhage mistaken for a choroidal melanoma. ophthalmology. 1987; 94: 41-6. 13. trzaska ka. differential diagnosis of exudative age – related macular degeneration with posterior pole choroidal tumours klin oczna. 2005; 107: 147-55. 14. sayanagi k, pelayes de, kaiser pk, singh ad. 3d spectral domain optical coherence tomography findings in choroidal tumors. eur j ophthalmol. 2011; 21: 271-5. 15. torres vl, brugnoni n, kaiser pk, singh ad. optical coherence tomography enhanced depth imaging of choroidal tumors. am j ophthalmol. 2011; 151: 586-93. http://www.ncbi.nlm.nih.gov/pubmed?term=g%c3%bcnd%c3%bcz%20k%5bauthor%5d&cauthor=true&cauthor_uid=9599367 http://www.ncbi.nlm.nih.gov/pubmed?term=shields%20cl%5bauthor%5d&cauthor=true&cauthor_uid=9599367 http://www.ncbi.nlm.nih.gov/pubmed?term=shields%20ja%5bauthor%5d&cauthor=true&cauthor_uid=9599367 http://www.ncbi.nlm.nih.gov/pubmed?term=schubert%20h%5bauthor%5d&cauthor=true&cauthor_uid=9599367 http://www.ncbi.nlm.nih.gov/pubmed/9599367 http://www.ncbi.nlm.nih.gov/pubmed?term=shields%20ja%5bauthor%5d&cauthor=true&cauthor_uid=16141866 http://www.ncbi.nlm.nih.gov/pubmed?term=mashayekhi%20a%5bauthor%5d&cauthor=true&cauthor_uid=16141866 http://www.ncbi.nlm.nih.gov/pubmed?term=ra%20s%5bauthor%5d&cauthor=true&cauthor_uid=16141866 http://www.ncbi.nlm.nih.gov/pubmed?term=shields%20cl%5bauthor%5d&cauthor=true&cauthor_uid=16141866 http://www.ncbi.nlm.nih.gov/pubmed/16141866 http://www.ncbi.nlm.nih.gov/pubmed?term=khuu%20t%5bauthor%5d&cauthor=true&cauthor_uid=16877203 http://www.ncbi.nlm.nih.gov/pubmed?term=hoffman%20dj%5bauthor%5d&cauthor=true&cauthor_uid=16877203 http://www.ncbi.nlm.nih.gov/pubmed/16877203 http://www.ncbi.nlm.nih.gov/pubmed?term=morgan%20cm%5bauthor%5d&cauthor=true&cauthor_uid=3550566 http://www.ncbi.nlm.nih.gov/pubmed?term=gragoudas%20es%5bauthor%5d&cauthor=true&cauthor_uid=3550566 http://www.ncbi.nlm.nih.gov/pubmed/3550566 http://www.ncbi.nlm.nih.gov/pubmed?term=kubicka-trzaska%20a%5bauthor%5d&cauthor=true&cauthor_uid=16052829 http://www.ncbi.nlm.nih.gov/pubmed/16052829 http://www.ncbi.nlm.nih.gov/pubmed?term=sayanagi%20k%5bauthor%5d&cauthor=true&cauthor_uid=21038307 http://www.ncbi.nlm.nih.gov/pubmed?term=pelayes%20de%5bauthor%5d&cauthor=true&cauthor_uid=21038307 http://www.ncbi.nlm.nih.gov/pubmed?term=kaiser%20pk%5bauthor%5d&cauthor=true&cauthor_uid=21038307 http://www.ncbi.nlm.nih.gov/pubmed?term=singh%20ad%5bauthor%5d&cauthor=true&cauthor_uid=21038307 http://www.ncbi.nlm.nih.gov/pubmed/21038307 http://www.ncbi.nlm.nih.gov/pubmed?term=torres%20vl%5bauthor%5d&cauthor=true&cauthor_uid=21257150 http://www.ncbi.nlm.nih.gov/pubmed?term=brugnoni%20n%5bauthor%5d&cauthor=true&cauthor_uid=21257150 http://www.ncbi.nlm.nih.gov/pubmed?term=kaiser%20pk%5bauthor%5d&cauthor=true&cauthor_uid=21257150 http://www.ncbi.nlm.nih.gov/pubmed?term=singh%20ad%5bauthor%5d&cauthor=true&cauthor_uid=21257150 http://www.ncbi.nlm.nih.gov/pubmed/21257150 microsoft word 12. imran ghayoor case report pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 105 case report yag laser for macular subhyaloid hemorrhage imran ghayoor, syed irshad haider, sharif hashmani, sadaf shah pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: imran ghayoor liaqat national hospital karachi …..……………………….. ubhyaloid hemorrhage is defined as a localized detachment of vitreous from the retina caused by the accumulation of blood, which can lead to sudden and severe loss of vision, when it takes place in the macular area. premacular subhyaloid hemorrhage may occur in retinal vascular disorder such as proliferative diabetic retinopathy, branch retinal vein occlusion, macro aneurysm, and age-related macular degeneration, hematological disorders such as leukemia1 and chemotherapy induced pancytopenia, following laser in situ keratomileosis (lasik)3 because of rapid release of the microkeratome vacume pressure or after retinal vascular rupture associated with physical exertion (valsalva retinopathy),2. terson’s syndrome4. purtscher’s retinopathy5. sub-hyloid haemorrhage can be managed either conservatively or by vitrectomy6. hyloidectomy of the posterior hyloid face is another option7,8. material and methods two patients with subhyloid macular haemorrhage were selected to undergo yag laser treatment. we used 3 mirror contact lens and started power setting 6 mj and used a maximum of 10 mj till hole is achieved in the posterior hyloid and one can see blood coming out like a tail of a rat. case1 a 32 years old man referred to the hospital with history of sudden visual loss to hand movement in left eye 5 day’s ago. there was no history of systemic or ocular disorders, trauma, or surgery. no further identifiable cause for subhyaloid hemorrhage was found upon systemic evaluation. the right eye had visual acuity 6/6 with correction. the left eye was hm with or without glasses. anterior segment of both eyes were normal. on fundoscopy of left eye revealed a round, well circumscribed, dome shaped hemorrhage with a convex surface overlying the posterior pole, extending between the temporal vascular arcade, consistent with a sub-hyaloid or sub internal limiting membrane hemorrhage. q-switched neodyminium yttrium-aluminum garnet (nd-yag laser) laser was performed on the posterior hyaloid of the left eye over the dark brown hemorrhage, via the transcorneal route with full pupillary dilatation using a goldmann-3-mirror contact lens. the aiming beam was precisely focused on the surface of the posterior hyaloid membrane at the inferior edges of the sub-hyaloid hemorrhage to facilitate gravity-induced drainage. at the end of the procedure, the hemorrhage spontaneously drained into vitreous cavity and resorbed after a mean period of 9 to 16 days. s imran ghayoor, et al. 106 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology fig.1: subhyaloid hemorrhage fig. 2: blood drainage into vitreous cavity after yag laser visual acuity in the affected eye improved to 6/6 after yag laser. case – 2 37 years old insulin dependent diabetic male was referred to the hospital with sudden loss of vision in left eye of one week duration, on examination he was found to have proliferative diabetic retinopathy with large subhyaloid hemorrhage covering the macula. after explaining the situation he underwent prp in both eyes. to relieve the large subhyaloid hemorrhage. yag laser was attempted with central part of goldmann three mirror fundus contact lens. a break in the hyaloid face, which resulted in drainage of blood. the blood drained gradually with mild inflammation, hyphaema and rise in iop, which resolved spontaneously after six weeks. the vision improved from hm to 6\12 on 6 week, in between he also received one inj avastin [bevacizumab] and later macular grid laser, to complete the laser. discussion we wanted to report two of our cases of posterior subhyloid hemorrhage in which sudden visual loss could be reverted to fair visual recovery without reverting to extensive surgery or prolong conservative treatment. in our 1st case we could not find any causes although valsalva retinopathy9 is a possibility. in our second case the comparatively young gentleman had iddm with proliferative diabetic retinopathy. the most interesting thing in him was that his subhyloid hemorrhage drained through to the anterior segment. he did not have rubeosis, the mild inflammation seems to result from the trauma of the procedure and the prp which he received 2 days earlier. yag laser for macular subhyaloid hemorrhage pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 107 fig.1: subhyaloid hemorrhage, cotton wool fig. 2: blood drainage into vitreous spot and exudation. proliferative diabetic retinopathy cavity after yag laser we have been experimenting with different contact lenses available with yag. we wanted to report the use of goldmann three mirror lens and its central part as none of reported cases mentions the lens used. we found that central portion of goldmann three mirror lens works well with yag and easy to focus the aiming beam, and does achieve the break required to drain the blood. conclusion nd – yag laser hyaloidotomy in pre-macular subhyaloid hemorrhage is simple, inexpensive outpatient procedures, which results in rapid visual recovery and is relatively safe. further controlled clinical trials are recommended. author’s affiliation dr. imran ghayoor liaqat national hospital karachi syed irshan haider hashmanis hospital karachi dr. sharif hashmani hashmanis hospital, karachi dr. sadaf shah medical officer hashmanis hospital karachi reference 1. gass jdm. stereoscopic atlas of macular diseases.3rd ed. st louis: cv mosby. 1987. 2. duane td. valsalva hemorrhagic retinopathy. trans am ophthalmol soc. 1972; 70: 298 313. 3. mansour am, ojeimi gk. premacular subhyaloid hemorrhage following laser in situ keratomileusis. jrefract surg. 2000; 16: 371–2. 4. kuhn f, morris r, mester v, et al. terson's syndrome. results of vitrectomy and the significance of vitreous hemorrhage in patients with subarachnoid haemorrhage. ophthalmology 1998; 105: 472-7. 5. agarwal a, mckibbin m. purtscher's retinopathy: epidemiology, clinical features and outcome. br j ophthalmol. 2007; 91: 1456-9. 6. ramsay rc, knobloch wh, cantrill hl. timing of vitrectomy for active proliferative diabetic retinopathy. ophthalmology. 1986; 93: 283-9. imran ghayoor, et al. 108 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology 7. ulbig mw, mangouritsas g, rothbacher hh, et al. long-term `results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed nd: yag laser. arch ophthalmol. 1998; 116:1465-9. 8. ulbig mw, mangouritsas g, rothbacher hh, et al. long-term results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed nd: yag laser. arch ophthalmol. 1998; 116:1465-9. 9. tabatabaee sa, solaimani m, mohammad-reza mansouri mr, et al. purtscher retinopathy associated with valsalva retinopathy after accident. iranian journal of ophthalmology. 2009; 21: 70-2. 134 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology editorial subthreshold macular laser treatment defne kalayc pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . he conventional continous wave (cw) laser photocoagulation, applied either as focal or grid pattern, using green argon laser (514 nm) was shown by the early treatment diabetic retinopathy study (etdrs) to reduce the risk of moderate vision loss (3 lines or more on the etdrs chart) by 50% and has been the standard of care for dme (diabetic macular edema) since the mid-80s1. although the etdrs demonstrated that focal/grid photocoagulation improves visual outcome in dme, it should be emphasized that the benefit was in reducing the frequency of visual loss and not in improving visual acuity. more than 3 lines (> 15 letters) of improvement in 3 years has been reported to be only 3% by the etdrs report2. moreover, conventional laser treatment may be associated with significant destruction of retinal tissue, and heat conduction to the nerve fiber layer and photoreceptors may result in the irreparable thermal destruction. this may cause side effects such as loss of macular sensitivity on microperimetry, progressive enlargement of laser scars towards the fovea, choroidal neovascularisation, epi-submacular fibrosis, iatrogenic foveal coagulation, increased macular edema and central visual acuity loss3-6. with anti-vegf therapy while untoward effects of laser were overcome, it has also been shown to stabilize and increase vision in a significant proportion of patients7,8. nevertheless macular laser is still a choice of therapy because of the following reasons: 1. anti-vegf therapy is not without problems. because of the temporary effectiveness of the injected anti-vegf drug, repeated intravitreal injections are required which pose the risk of endophthalmitis9. moreover, these repeated injections are a burden for both the patient and the physician. 2. anti-vegf therapy is more expensive. 3. major studies of diabetic macular edema treatment with intravitreal anti-vegf agents have reported that rescue laser treatment was needed in 20 – 56% of patients10,11. 4. in patients with clinically significant macular edema (csme) without central involvement, focal laser therapy is still the first line of treatment. 5. there are patients that decline intravitreal injections. 6. there may be systemic factors which anti-vegf agents may pose risks and preclude anti-vegf therapy. recent understanding of the mechanism of the therapeutic effect of laser photocoagulation has changed. previously thermal damage to the retinal pigment epithelium (rpe) and photreceptors was desired to decrease the metabolic load and hypoxia and therefore decrease secretion of angiogenic factors from ischemic retina. it is now believed that the therapeutic effect of laser is mediated by the healing response of the rpe to thermal injury and the useful therapeutic cellular cascade is activated, not by laserkilled rpe cells, but by the still-viable rpe cells surrounding the burned areas that are affected by the heat diffusion at sublethal thermal elevation12,13. what are the cascade of events triggered by macular laser photocoagulation and leading to the resolution of edema? it was thought that absorption of laser energy within the retinal capillaries had a direct occlusive effect on leaky microaneurysms, however the exact role of grid laser has not been understood. more recently, it has been recognized that the therapeutic effect of laser results from sublethal irradiation of the rpe followed by the release and/or downregulation of various t subthreshold macular laser treatment pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 135 factors from recovering rpe cells. these factors are cytokines, vegf, heat shock protein, pigment epithelium-derived factor (pedf), and matrix metalloproteinases (mmps). laboratory studies have shown that subsequent to laser irradiation, within 7 days rpe cell migration and enzyme release occurs which facilitates removal of debris from bruch’s membrane and increases transport processes. rpe cell division occurs by 7 – 14 days and is associated with release of cytokines, which trigger vascular endothelial cell division which strengthen the neuroretinal capillaries, leading to increased water outflow from the retina and reduced water inflow into the retina inducing reduction of retinal edema14,15. new understanding of the therapeutic effects of laser treatment have brought the concept of new modalities of laser treatment without damaging the retina. all new modalities intend to create subthreshold treatment. subthreshold photocoagulation is defined as laser treatment which produces absolutely no retinal damage detectable by any method including ffa (fundus fluorescein angiography) and newer high-resolution retinal imaging methods such as faf (fundus autofluorescence) and sd-oct (spectral domain-optical coherent tomography) at the time of treatment or anytime thereafter16. subthreshold laser modalities (table 1.): • subthreshold diode micropulse laser (sdmpl). (manufacturing companies:iridex, quantel). • yellow wavelength subthreshold micropulse laser (manufacturing companies:iridex, quantel, odos). sdmpl (subthreshold diode micropulse laser) is the laser technique that has been on the market the longest and has been used the most. recently yellow wavelength micropulse mode has also become available. in 1990, pankratov reported development of a new laser modality designed to deliver laser energy in short pulses (“micropulses”) rather than as a continuous wave17. micropulse laser uses a laser beam that is chopped into short, repetitive microsecond pulses, aiming tissue to cool between pulses and reducing thermal buildup. the laser “on” time is the duration of each micropulse, the “off” time is the time between micropulses that allows for heat reduction and thermal isolation of each pulse. the ratio between “on” and “off” time is the duty cycle. the lower the duty cycle is, the greater the heat reduction is. duty cycle can be adjusted and is commonly set at 5%. pulse duration of 200ms with 5% duty cycle means: an envelope of 100 x (100 µsn on +1900 µsn off) laser pulses. there are small scale randomised controlled clinical trials as evidence comparing subthreshold micropulse to conventional macular laser. most studies have found better visual results and equal efficacy for macular edema18-22. there is also a metaanalysis of those randomised controlled clinical trials which has found slightly better visual outcomes with subthreshold micropulse laser and similar effect on central macular thickness23. mpl is applied in a grid pattern with no spacing between spots, spot size is usually 160 – 200 µ, distance from foveal center is 500 microns. usually using 5% duty cycle, the energy needed for a barely visible treatment effect, which is the threshold energy is determined and half of the energy needed for a threshold burn is used for treatment. treatment parameters like duty cycle, spot size and the method of determination of the threshold energy whether by using continuous wave laser and then switching to micropulse mode or by using micropulse mode to determine threshold energy may differ among published studies. table 1: subthreshold lasers. laser type mode wavelength subthreshold micropulse* pulsed diode(810nm), yellow (577 nm) non damaging retinal laser therapy (nrt) continuous yellow (577nm) retina rejuvenation therapy (2rt) pulsed frequency doubled nd: yag laser 532 nm selective retinal therapy (srt)# pulsed frequency doubled nd: ylf laser 527 nm legend for table 1: *: also named as micropulse, subliminal, micro second according to manufacturing company. #: although reported as subthreshold, treatment effect can be determined by ffa. https://www.ncbi.nlm.nih.gov/pubmed/27096529 defne kalayc 136 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology fig. 1: legend for fig. 1: dashed lines, corresponding to different clinical grades, differ by an order of magnitude in arrhenius integral x. the red area corresponds to the damaging settings and green to the nondamaging range of hsp expression; blue is below the threshold for cell response. titration of 100% corresponds to barely visible lesion (bv) observed at 3 seconds. lavinsky d, wang j, huie p, et al. nondamaging retinal laser therapy:rationale and applications to the macula. invest ophthalmol vis sci.2016;57:2488–2500. (content is licensed under a creative commons attribution 4.0 international licence. https://creativecommons.org/licenses/by/4.0/) fig. 2: legend for figure 2: fundus autofluorescence image of a patient treated with nrt. white arrows demonstrate hyperfluorescent test spots. no treatment effect is seen at the macula. non-damaging retinal laser therapy (nrt) (previously named epm) (manufacturing company: topcon) heating of biomolecules by laser energy leads to protein denaturation as a temperature dependent chemical reaction. above a certain threshold cellular necrosis and coagulation occurs. the technique nrt is based on the arrhenius equation which is a computational tissue temperature model that was obtained by animal experiments. by the arrhenius equation it has been shown that at a certain pulse duration, 30% of the barely visible treatment effect which is termed as the threshold energy has been shown to be the highest non damaging and also the level that has therapeutic effect illustrated by the green shaded area (fig. 1). above 30% of the threshold energy has been shown to be damaging and below 30% of the threshold energy has been shown to be subtherapeutic24. by animal experiments of retinal laser therapy and immuno-histochemical staining for heat shock proteins (hsp), it has been shown that with 100% threshold energy, no hsp expression is seen over the laser treated area demonstrating cell death over the laser treated area with hsp expression sorrounding the laser burn, implying there has been sublethal thermal elevation sorrunding the laser burns. with 30% threshold energy, as hsp is expressed over the laser spots, it is shown that cells are not damaged over the laser treated areas. laser induction of hsp by thermal stress, is thought to rejuvenate rpe cells and restore their function25,26. promising results have been reported for chronic central serous chorioretinopathy and mactel type 2 but there has been limited experience24. nrt is applied in a grid pattern with 0.25 spot spacing between spots, spot size is 200µ, duration is 15ms. distance from foveal center is 500 – 700 microns. the energy needed for a barely visible treatment effect, which is the threshold energy is determined and 30% of the energy needed for a threshold burn is used for treatment. retina rejuvenation therapy (2rt) (manufacturing company:ellex) with 2rt, laser mode is discontinuous and the pulse duration is even shorter, it has been reduced to 3ns. subthreshold laser power is used. this results in https://creativecommons.org/licenses/by/4.0/ subthreshold macular laser treatment pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 137 damage from cavitation rather than thermal interaction, only few rpe cells are damaged without causing bruch’s membrane rupture. each of the dead rpe cell is surrounded by unaffected rpe cells. the overlying photoreceptors do not undergo secondary cell death. a pilot clinical study about the technique has been published, reporting visual acuity improvement and reduction in macular thickness27. selective retinal therapy (srt) (manufacturing companies:medical laser center, lumenis) srt has been developed to further improve selectivity by using a much shorter pulse duration of 1.7 μs, and consequently a higher irradiance. it has been demonstrated in animal studies that selective treatment of the rpe is achieved using microsecond pulse durations, and the follow-up showed that the rpe regenerates with survival of the adjacent photoreceptors28. there are few clinical studies evaluating srt in diabetic macular edema. stabilisation of visual acuity or improvement in over 80% of patients have been reported. this treatment although described as subthreshold, has ffa findings indicating rpe damage29. limitations of subthreshold lasers the primary limitation is the absence of a visible end point during treatment and determination of threshold energy out of the macular area which leads to concerns of under treatment. for micropulse lasers the lack of standardized treatment parameters are other major limitations as laser settings can be different depending on the study, with various duty cycles, spot sizes, and durations. large scale randomised controlled trials are required for comparison with conventional laser, anti-vegf treatment and combined anti-vegf with subthreshold laser therapy to find out the actual role of these several techniques of subthreshold laser treatment in various causes of macular edema and macular pathologies. author’s affiliation defne kalayc md prof of ophthalmology health sciences university, ankara numune research and training hospital, ankara, turkey. dakalayci@hotmail.com references 1. early treatment diabetic retinopathy study research group: photocoagulation for diabetic macular edema: early treatment diabetic retinopathy study report number 1. arch ophthalmol. 1985; 103: 1796–1806. 2. early treatment diabetic retinopathy study research group: early 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phototherapy: dynamic range of heat shock protein expression. invest ophthalmol vis sci. 2011 (52); 3: 1780-1787. 27. pelosini l, hamilton r, mohamed m, hamilton am,marshall j. retina rejuvenation therapy for diabetic macular edema: a pilot study. retina, 2013 (33); 3: 54858. 28. schuele g, rumohr m, huettmann g, brinkmann r. rpe damage thresholds and mechanisms for laser exposure in the microsecond-to-millisecond time regimen. invest ophthalmol vis sci. 2005(46); 2: 714-719. 29. park yg, kim jr, kang s, seifert e, theisen-kunde d, brinkmann r, roh yj. safety and efficacy of selective retina therapy (srt) for the treatment of diabetic macular edema in korean patients. graefes arch clin exp ophthalmol. 2016 (245); 9: 1703-1713. https://www.ncbi.nlm.nih.gov/pubmed/?term=diabetic%20retinopathy%20clinical%20research%20network%5bcorporate%20author%5d https://www.ncbi.nlm.nih.gov/pubmed/?term=diabetic%20retinopathy%20clinical%20research%20network%5bcorporate%20author%5d 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https://www.ncbi.nlm.nih.gov/pubmed/?term=brinkmann%20r%5bauthor%5d&cauthor=true&cauthor_uid=15671304 https://www.ncbi.nlm.nih.gov/pubmed?term=invest+ophthalmol+vis+sci+%5bjour%5d+and+46%5bvolume%5d+and+714%5bpage%5d+and+2005%5bpdat%5d&cmd=detailssearch https://www.ncbi.nlm.nih.gov/pubmed/?term=park%20yg%5bauthor%5d&cauthor=true&cauthor_uid=26803489 https://www.ncbi.nlm.nih.gov/pubmed/?term=kim%20jr%5bauthor%5d&cauthor=true&cauthor_uid=26803489 https://www.ncbi.nlm.nih.gov/pubmed/?term=kang%20s%5bauthor%5d&cauthor=true&cauthor_uid=26803489 https://www.ncbi.nlm.nih.gov/pubmed/?term=seifert%20e%5bauthor%5d&cauthor=true&cauthor_uid=26803489 https://www.ncbi.nlm.nih.gov/pubmed/?term=theisen-kunde%20d%5bauthor%5d&cauthor=true&cauthor_uid=26803489 https://www.ncbi.nlm.nih.gov/pubmed/?term=brinkmann%20r%5bauthor%5d&cauthor=true&cauthor_uid=26803489 https://www.ncbi.nlm.nih.gov/pubmed/?term=roh%20yj%5bauthor%5d&cauthor=true&cauthor_uid=26803489 https://www.ncbi.nlm.nih.gov/pubmed?term=graefes+arch+clin+exp+ophthalmol+%5bjour%5d+and+254%5bvolume%5d+and+1703%5bpage%5d+and+2016%5bpdat%5d&cmd=detailssearch https://www.ncbi.nlm.nih.gov/pubmed?term=graefes+arch+clin+exp+ophthalmol+%5bjour%5d+and+254%5bvolume%5d+and+1703%5bpage%5d+and+2016%5bpdat%5d&cmd=detailssearch https://www.ncbi.nlm.nih.gov/pubmed?term=graefes+arch+clin+exp+ophthalmol+%5bjour%5d+and+254%5bvolume%5d+and+1703%5bpage%5d+and+2016%5bpdat%5d&cmd=detailssearch pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 83 original article glaucoma and ocular hypertension in pseudoexfoliation syndrome azfar ahmed mirza, noor bakht nizamani, mariya nazish memon, sajjad ali surhio, khalid i. talpur pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: noor bakht nizamani department of ophthalmology liaquat university eye hospital jail road, hyderabad, 71000, sindh email: noorniz@hotmail.com …..……………………….. purpose: to assess the frequency of glaucoma and ocular hypertension in pseudoexfoliation syndrome. material and methods: this study was conducted in the department of ophthalmology, liaquat university eye hospital, hyderabad, pakistan from june 2011 to december 2011. hundred confirmed cases of pseudoexfoliation syndrome (pxs) were included in the study by non-probability convenience sampling. tonometry, gonioscopy, ophthalmoscopy and visual field analysis were carried out to determine glaucoma. data was collected by specially designed proforma and analyzed by using statistical program for social sciences (spss, version 16.0 for windows). the frequencies and percentage were recorded and any association with predisposing factors was statistically analyzed on chi square test. p-value of <0.001 was considered significant with a confidence interval (ci) of 95%. results: out of the 100 pxs patients, 16% patients were diagnosed with pseudoexfoliation glaucoma (pxg) (ci 95%): 12% with open angle glaucoma and 4% narrow angle glaucoma. ocular hypertension without glaucomatous changes was detected in 9% (ci 95%) of the patients (p <0.001). pxg was more common after 50 years of age while ocular hypertension occurred earlier i.e. 40 years. gender (p=0.45), locality (p=0.725) and family history of glaucoma (p=0.95) were statistically insignificant risk factors for development of glaucoma in pxs patients. increased age, intraocular pressure and cup-disc ratio (16%) were significant risk factors for development of pxg (p <0.001 ci 95%). conclusion: increasing age, intraocular pressure and cup disc ratio are significant risk factors for development of glaucoma in pxs. it is recommended that patients over 50 years should be actively examined for glaucoma particularly those with pxs. keywords: pseudoexfoliation syndrome, glaucoma, ocular hypertension. seudoexfoliation syndrome (pxs) is a complex systemic age-related disorder characterized by the accumulation of an extracellular material in various parts of the body including lungs, skin, liver, heart, kidney, gallbladder, blood vessels, eyes and meninges.1 in the eye, fibrillar material is deposited all over the anterior segment, particularly over the anterior lens capsule in characteristic double concentric ring pattern with clear zone in between the rings.1 pxs is the most common cause of secondary open angle glaucoma; pseudoexfoliation glaucoma (pxg), caused by clogging of the trabecular meshwork by pseudoexfoliation material.2,3 cataract is also an important association of pxs particularly cortical and nuclear cataract.4 pxs may complicate cataract surgery with poor mydriasis, zonular dehiscence, corneal endothelial dysfunction, phacodonesis, vitreous loss and capsular phimosis. 5 other ocular manifestations of pxs include iris depigmentation, transillumination defects, hyperpigmentation of trabecular meshwork and iridonesis.2 p mailto:noorniz@hotmail.com azfar ahmed mirza, et al 84 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology the prevalence of pxs in pakistan is 6.45%, while there is variable prevalence worldwide ranging between 0.5% and 33%, increasing with age.1,6,7 glaucoma is present in 14.2% patients of pxs, with up to threefold higher risk of open angle glaucoma.8 the purpose of this study was to assess the frequency of glaucoma and ocular hypertension in pxs. material and methods this cross sectional study was carried out at eye unit iii, department of ophthalmology, liaquat university eye hospital, hyderabad, from june 2011 to december 2011. a total of 100 patients, 40 years and above attending the outpatient department for various ocular problems were screened for pseudoexfoliation syndrome (pxs). the initial examination consisted of slit lamp biomicroscopy for the evidence of pseudoexfoliation material on the edge of pupil or lens in the undilated state and in those having suspicion of disease, the pupil was dilated and repeat slit lamp examination was performed. the patients having pxs were then further examined in detail according to an examination protocol and all the findings were recorded and entered in specially designed proforma for this study. the examination included complete history, general physical and systemic examination and full ocular examination. the ocular examination included visual acuity testing, slit lamp examination of the anterior segment, transillumination, gonioscopy, applanation tonometry and fundus examination. the patients were further divided into glaucoma or ocular hypertension on the basis of raised iop and visual fields. written informed consent was taken before proceeding for the recording of information and confidentiality was ensured. data was entered and analyzed by using statistical program for social sciences (spss version 16.0 for windows software). the frequencies and percentage were recorded and any association with predisposing factors was statistically analyzed on chi square test. the risk factors of pex glaucoma and ocular hypertension were statistically analayzed and compared using chi square test to compare the significance between the two groups. based on intraocular pressure the patients were further divided into subgroups of < 21 mm hg, 21-25 mm hg, 26 – 30 mm hg, 31 – 35 mm hg and 36 – 40 mm hg. the characteristics of these groups were compared by the chi square test. p-value of < 0.001 was taken as significant with a confidence interval (ci) of 95%. results in this study 100 consecutive patients of pseudoexfoliation syndrome (pxs) were included. 54% of our patients were males while 46% were females with mean age of 62.6 ± 9.7 years (table 1). the mean intraocular pressure was 16.3 ± 4.9 mm hg, ranging from 9 to 38 mm hg. table 1 shows the overall characteristics of our patients. during the initial assessment, majority (71%) of the patients with pxs did not have glaucoma or ocular hypertension (table 2). sixteen percent patients were diagnosed with pseudoexfoliation glaucoma (pxg): glaucoma and ocular hypertension in pseudoexfoliation syndrome pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 85 12% with open angle glaucoma and 4% narrow angle glaucoma. ocular hypertension without glaucomatous changes was detected in 9% of the patients (p <0.001 ci 95%). 4% patients had raised iop but could not be classified as pxg or ocular hypertension due to dense cataract (table 2). pxg was more common in males (9%) after 60 years of age while ocular hypertension occurred frequently in females (6%) and earlier i.e. 40 years (table 2). most of the patients had intraocular pressure ranging between 20 – 30 mm hg in both pxg and ocular hypertension. increased age and increased intraocular pressure (16%) (iop) were associated with increased risk of development of glaucoma (p < 0.001 ci 95%) (fig. 1). gender (p = 0.45), locality (p = 0.725) and family history of glaucoma (p = 0.95) were statistically insignificant risk factors for development of glaucoma in pxs patients (table 3). increased cup-disc ratio was azfar ahmed mirza, et al 86 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology a significant risk factor for development of pxg (p <0.001 ci 95%). discussion pxs is of particular importance as it is associated with a wide range of ocular manifestations specifically glaucoma and cataract.2,4 in addition it also tends to complicate intraocular surgery.5 there has been a great variability in the prevalence of pxs ranging from 0.5% up to 33%.1,7 the variability has been defined across different populations like japanese9 and south indian10 with 3.4% and 3.8% prevalence respectively while the icelandic and finnish had greater prevalence (17.7% and 33%).1,11 similar variability has been observed in local studies between 1.9% and 6.45%.6,12 pxs has been more prevalent in females worldwide while males are more affected in the pakistani glaucoma and ocular hypertension in pseudoexfoliation syndrome pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 87 population.8,13 similar to our study, increasing age has been universally accepted as a significant risk factor for development of pxs.8,9 0 5 10 15 20 25 30 < 21 mm hg 21-25 mm hg 26-30 mm hg 31-35 mm hg 36-40 mm hg 40-49 50-59 60-69 70-79 > 80 years fig. 1: relationship between intraocular pressure and different age groups (p-value < 0.001). 0 5 10 15 20 25 30 35 40 < 21 mm hg 21-25 mm hg 26-30 mm hg 31-35 mm hg 36-40 mm hg males females fig. 2: relationship between intraocular pressure and gender. pxg has been a hazardous association of pxs, which is difficult to treat. 16% of our patients had pxg which is significantly more than reported in literature.14,15 the blue mountains eye study8 conducted on australian population reported a prevalence of 13.4% which is comparable to our figures, while the american population had a significantly lower prevalence of 3% and 10%.14,15 pxs is the most common cause of secondary open angle glaucoma. the risk of developing open angle glaucoma is increased three times in pxs patients,8 consistent with this open angle glaucoma was more prevalent (12%) in our patients compared to angle closure glaucoma (4%). we found a greater prevalence of ocular hypertension (9%) than reported in literature (3.7%).16 there was no statistically significant increase with age or gender in the ohtn group.8,16 it was observed that pxg was more common in males and ohtn was frequently found in females. gender, locality and family history did not seem to be a significant risk factor for developing glaucoma in pxs patients.8 increasing age, intraocular pressure and cup-disc ratio were significant risk factors for development of glaucoma in pxs.8,17 conclusion increased age, intraocular pressure and cup disc ratio are significant risk factors for development of glaucoma in pxs. it is recommended that patients over 50 years should be actively examined for glaucoma particularly those with pxs. author’s affiliation dr. azfar ahmed mirza department of ophthalmology liaquat university of medical and health sciences jamshoro / hyderabad dr. noor bakht nizamani department of ophthalmology liaquat university of medical and health sciences jamshoro / hyderabad dr. mariya nazish memon department of ophthalmology liaquat university of medical and health sciences jamshoro / hyderabad dr. sajjad ali surhio department of ophthalmology liaquat university of medical and health sciences jamshoro / hyderabad dr. khalid i. talpur department of ophthalmology liaquat university of medical and health sciences jamshoro / hyderabad references 1. elhawy e, kamthan g, dong cq, danias j. pseudoexfoliation syndrome, a systemic disorder with ocular manifestations. hum genomics. 2012; 6: 22-31. 2. schlotzer-schrehardt u, naumann go. ocular and systemic pseudoexfoliation syndrome. am j ophthalmol. 2006; 141: 921–37. 3. cobb cj, blanco gc, spaeth gl. exfoliation syndrome angle characteristics: a lack of correlation with amount of disc damage. br j ophthalmol. 2004; 88: 1002-3. azfar ahmed mirza, et al 88 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology 4. kanthan gi, mitchell p, burlutsky g, rochtchina e, wang jj. pseudoexfoliation syndrome and the longterm incidence of cataract and cataract surgery: the blue mountains eye study. am j ophthalmol. 2013; 155: 83-8. 5. idris m, jawad m, ali a, ali s, hussain j, alam m. what for we are looking in pseudoexfoliation: a clinical presentation of the patients. ophthalmology update. 2014; 12:113-6. 6. rao rq, arain tm, ahad ma. the prevalence of pseudoexfoliation syndrome in pakistan. hospital based study. bmc ophthalmol. 2006; 6: 27. 7. schumacher s, schlotzer-schrehardt u, martus p, lang w, naumann go. pseudoexfoliation syndrome and aneurysms of the abdominal aorta. lancet. 2001; 357: 359-60. 8. mitchell p, wang jj, hourihan f. the relationship between glaucoma and pseudoexfoliation syndrome: the blue mountains eye study. arch ophthalmol. 1999; 117: 1319-24. 9. miyazaki m, kubota t, kubo m, kiyohara y, iida m, nose y, ishibashi t.. the prevalence of pseudoexfoliation syndrome in a japanese population: the hisayama study. j glaucoma. 2005; 14: 482-4. 10. arvind h, raju p, paul pg, baskaran m, ramesh sv, george rj, et al. pseudoexfoliation in south india. br j ophthalmol. 2003; 87: 1321–3. 11. arnarsson am. epidemiology of exfoliation syndrome in the reykjavik eye study. acta ophthalmol. 2009; 87: 1-17. 12. shafiq i, sharif-ul-hassan k. prevalence of pseudoexfoliation (pex) syndrome in a given population. pak j ophthalmol. 2004; 20: 49-52. 13. jawad m, nadeem a, khan a, aftab m. complications of cataract surgery in patients with pseudoexfoliation syndrome. j ayub med coll abbottabad. 2009; 21: 33-6. 14. ritch r. exfoliation syndrome. focal points. 1994; 12: 112. 15. cashwell lf jr, shields mb. exfoliation syndrome: prevalence in a southeastern united states population. arch ophthalmol. 1988; 106: 335-6. 16. mitchell p, smith w, attebo k, healey pr. prevalence of open – angle glaucoma in australia: the blue mountains eye study. ophthalmology. 1996; 103: 16619. 17. vinita r, mariam d, girish r. prevalence and prognosis of pseudoexfoliation glaucoma in western india. asia – pacific j of ophthalmology, 2015; 2: 121127. http://www.ncbi.nlm.nih.gov/pubmed/?term=kiyohara%20y%5bauthor%5d&cauthor=true&cauthor_uid=16276281 http://www.ncbi.nlm.nih.gov/pubmed/?term=iida%20m%5bauthor%5d&cauthor=true&cauthor_uid=16276281 http://www.ncbi.nlm.nih.gov/pubmed/?term=nose%20y%5bauthor%5d&cauthor=true&cauthor_uid=16276281 http://www.ncbi.nlm.nih.gov/pubmed/?term=ishibashi%20t%5bauthor%5d&cauthor=true&cauthor_uid=16276281 193 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology editorial who is the real author? tayyaba gul malik pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iterary meanings of an author is “a writer of a book, article, or document” or “someone who writes books” or “an originator of a plan or idea”. earlier in the eighteenth century till the start of twentieth century, single authorship was the rule that prevailed. in this new era of scientific research and development, importance of research papers cannot be overlooked. hence, ethical issues regarding authorship arose. this problem posed a great threat to public health and a fraud in research field. to combat such ethical issues, international committee of medical journal editors (icmje) made recommendations for standardizing the ethics, preparation and formatting of manuscripts submitted for publication by biomedical journals. its initial version was called “uniform requirements for manuscripts” (urms) and was submitted to biomedical journals in 1978. urms was revised in 1997 and some of the sections were updated in may 1999 and may 2000. now it has been renamed as “recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals”. this document was revised in 2013, 2014, 2015 and 2016. the members of icmje meet annually and discuss the matters related with publications. the icmje recommends that authorship be based on the following 4 criteria: substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; and drafting the work or revising it critically for important intellectual content; and final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. all four criteria must be met to get a designation of an author. those who meet lesser criteria should be acknowledged or included in the list of contributors. with the new standard definition of “authorship” other terminologies of authorship were also introduced; which included, ghost authorship, honorary authorship, guest authorship and gift authorship. unfortunately, these terms are not very well known to the authors in our part of the world. ghost authors are the persons who have worked in research planning, data collection, data analyzing and manuscript writing, but their names are not written in the list of authors. these authors may take their origin in one of the following forms. firstly, junior colleagues and workers, who are the real authors but their names do not appear in the list of authors because their seniors want their own names to be credited instead of the real authors. second type of ghost authors are the personal writers of researchers, they write the manuscript and save researcher’s time. third one is the most notorious in which, a pharmaceutical company hires some writers to write a research paper and after that, name of a well known scientist is used as author, who didn’t even know the real work. this is the most dangerous form of ghost authorship. gotzsche1 found that 75% of the pharmaceutical company sponsored trials were written by ghost authors, which is a serious concern. most of the time, such trials are in favor of the sponsor and patient’s benefit is kept at a side. contrary to that there are honorary authors, who are not involved in any of the activities of paper writing but they are given credit as a coauthor. guest and gift authorship come under the heading of honorary authorship. guest authors do not have any contribution in the paper writing but they are considered coauthors for example, junior colleagues add the names of their seniors to gain some extra l who is the real author? pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 194 benefits, or to increase the chance of publication. the guest authorship is very common in our part of the world where head of the department or institution expect and pressurize their juniors to write their names to get false credit of something that they do not even know or as a part of “you write my name, i write yours” process. there is another authorship called gift authorship in which, authors have some relationship with the study or have contributed to a level which does not meet the criteria of authorship by international committee of medical journal editors (icmje) guidelines. co-authorship is gifted to those persons who have done non-author tasks such as reviewing or approving manuscript before submission or data collection. in pakistan, ghost authorship is not a problem, as clinical trials by pharmaceutical companies are not very common. however, honorary authorship has become a nuisance. so much so, if a departmental head allows access to the patients, there is a demand to add his name as a coauthor. this does not end here. sometimes the heads of departments try to influence the list of authors. they think it their right to be in the list of first three authors. these unethical issues arise because honorary authors want authorships for their promotions or peer recognition. lack of interest in research, lack of basic knowledge of paper writing and lack of incentives and funds in the research field has led to increase in the number of honorary authors. the result is a long list of authors. this phenomenon of long list of authors is not only endemic in our settings, rather it has acquired the shape of a pandemic. not far in the past, a paper on drosophila was published in “g3: genes, genomics, genetics” with 1014 authors2. in the same year, world-record was made for the largest number of contributors in a research paper with 5154 authors. in this 33 page article, 24 pages were meant to mention the contributors and their institutions. such kind of studies were justified by the authors as these were joint ventures with large number of people working on a single large project. this cannot be applied in our setups where a single case report has so many authors. in the post icmje era, prevalence of articles with honorary and guest authorship was reduced from 29.2% in 1996 to 21%. ghost authorship was reduced from 11.5% in 1996 to 7.9% in 20114. icmje recommendations have their pros and cons. the advantage was that the number of authors was reduced. the disadvantage was that the persons who did not meet all the four criteria were denied of their due credit. this problem was addressed by paneth who suggested that there should be categories of persons involved in paper writing5. those who meet all four criteria should be called authors, those who satisfy less than 4 criteria should be listed as contributing authors, and those who qualify only one criterion should be called acknowledged contributors. the problem, no doubt, is there. the question is; what is the solution? the responsibility lies in the hands of the pmdc, editors of journals, institutions and at the individual level as well. recently, pmdc has decided to give equal credit to the first three authors. no credit is given to the authors after three. although, it is a good step to discourage honorary authorship but problem still exists when multiinstitutional studies have more than three persons who qualify authorship criteria but will be denied of any credit at pmdc level. this gives rise to unfairness. the departmental head or the senior uses his or her influence to get his name written in the first three authors and the juniors who deserve the authorship are left unaccredited. on part of the journal editors, restricting the author count can be helpful but again it raises the possibility of injustice against true authors, especially if the study is done at multiple centers. ethical issues are best tackled by good grooming. hence, the heads of the institutions and departments should adopt a fair way by not pressurizing their juniors for writing their names as authors. setting good examples by the seniors will bring about a definite and long lasting change. author’s affiliation dr. tayyaba gul malik fcps, professor of ophthalmology rashid latif medical college, lahore. references 1. gotzsche pc, hrobjartsson a, johansen hk, haahr mt, altman dg, chan aw. ghost authorship in industry-initiated randomised trials. plos med. 2007 jan; (4): e19. 2. sarah elgin et al. drosophila muller f elements maintain a distinct set of genomic properties over 40 million years of evolution. g3: genes, genomes. genetics, 2017 mar; (7). tayyaba gul malik 195 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology 3. ad g. et al. atlas collaboration, cms collaboration. phys. rev. lett. 2015; 114: 191803. 4. wislar js, flanagin a, fontanarosa pb, deangelis cd. honorary and ghost authorship in high impact biomedical journals: a cross sectional survey. bmj. 2011: 343. 5. paneth n. authorship: readers and editors respond. am j public health, 1998; 88: 824–826. 194 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology original article pain perception during laser in situ keratomileusis sharmeen akram, salman naveed sadiq, khabir ahmad pak j ophthalmol 2015, vol. 31 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sharmeen akram section of ophthalmology department of surgery aga khan university stadium road, p.o. box 3500, karachi 74800, sharmeen.akram@aku.edu …..……………………….. purpose: to compare pain severity during laser in situ keratomileusis (lasik) between firstand second – eye surgery in a pakistani population. material and methods: this was a prospective cohort study. 31 individuals eligible for lasik in both eyes were recruited at a laser clinic between june 2012 and november 2015. all underwent surgery using microkeratome and customvis solid state laser. after completion of the procedure, patients rated severity of their pain during lasik on a 4 – point scale (e.g. none, mild, moderate, severe pain) for each eye separately. wilcoxon signed – rank test was used to compare pain severity between firstand second – eye surgery. results: a total of 31 patients (62 eyes) were enrolled in the study. 16 (51.6%) patients perceived more pain in the second eye and 6 (19.4%) in the first one. there were 9 (29.0%) ties. the wilcoxon signed – rank test showed a statistically significant change in pain perception in the second eye (z =-2.343; p = 0.019). conclusions: patients undergoing lasik perceived more pain in the second eye. larger studies are needed to investigate this finding further, and to identify factors influencing this change in pain perception. aser in situ keratomileusis (lasik) is a common refractive surgical procedure performed worldwide.1 it is a relatively painless procedure compared with its predecessor; photorefractive keratectomy.2 it is generally performed under topical anesthesia. during this procedure, a significant proportion of patients report a certain degree of pain which can vary significantly between the two eyes. in a study by el rami et al.3, patients (n = 154) reported more pain during lasik in the second eye. the mean pain score during second eye surgery was 0.93 ± 0.51 compared with 0.63 ± 0.35 in the first eye. in addition, 74% patients perceived more pain in the second-eye, 2% reported more pain in the first eye and 24% reported equal pain in both eyes. pain perception can vary across cultures, space and time4. the purpose of the current study was to compare pain severity during lasik between first and second-eye surgery in a pakistani population. material and methods this prospective cohort study involved all patients aged ≥ 18 years who underwent bilateral lasik by a single surgeon in the same setting (laser vision center, karachi) during june 2012 to november 2015. standard pre-lasik screening was performed on each patient. informed consent was taken regarding the procedure and participation in the study. both eyes of each patient underwent lasik sequentially during a single session. both eyes were anesthetized using topical anesthesia: 1 drop of proparacaine hydrochloride 0.5% every 5 minutes. after the laser system was calibrated, each patient was placed in the supine position and draped. povidone iodine 5% was instilled in the conjunctival sac and irrigated with saline solution. corneal marker was applied. in each eye, a corneal flap with a nasal hinge was prepared with the l pain perception during laser in situ keratomileusis pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 195 nidek mk-2000 microkeratome. after the flap was lifted, a scanning laser system (customvis, australia) was used with a frequency of 300 hz and wavelength of 213 nm for ablation. after the completion of each bilateral procedure, patients were asked to complete a questioner pertaining to the timing and severity of pain during lasik. they were asked to rate severity of pain on a 4-point scale (0 = no pain; 1 = mild pain; 2 = moderate pain; 3 = severe pain). postoperatively, eye lubricants (artificial tears), corticosteroid eye drops (fluorometholone 0.1%) and topical antibiotic (moxifloxacin 0.5%) were advised as per protocol. all data were entered and analyzed using spss software (version 19.0 for windows). continuous variables were expressed as means and standard deviations, whereas categorical variables as frequencies and percentages. wilcoxon signed-rank test was used to compare pain severity between first and second eye surgery. a p value of < 0.05 was taken as statistically significant. results a total of 31 patients (62 eyes) were enrolled in the study. twelve (38.7%) were males and 19(61.3%) were females. in 23 patients, right eye was operated first while in the other 8 the left. overall, 16 (51.6%) patients perceived more pain in the second eye. only 6 (19.4%) patients perceived more pain in the first eye. there were 9 (29.0%) ties (figure 1). the wilcoxon signed-rank test showed a statistically significant change in pain perception in the second eye (z =-2.343; p = 0.019). the mean pain score was 0.74±0.73 in the first eye and 1.16 ± 0.73 in the second eye (table 1). in a subgroup analysis of patients who underwent their left eye lasik first, the mean pain score for the second eye was 1.25 ± 0.71. in terms of severity of pain, the frequency (%) of no, mild and moderate pain in the first eye was 13 (41.9%), 13 (41.9%), and 5 (16.1%), respectively. for the second eye, these values were: 6 (19.4%), 14 (45.2%), and 11 (35.5%). fig. 1: doughnut chart showing proportion of patients perceiving more pain in the first or second eye (n = 62 eyes) discussion our study indicates that patients undergoing lasik reported more pain in the second eye. these findings are consistent with el rami et al3. in our study, half of the patients (51.6%) perceived more pain in the second eye while only 6 (19.4%) reported more pain in the first one. in their study,3 74% and 2% patients perceived more pain in the second eye and the first eye, respectively. 24% reported equal pain in both eyes. it remains unclear why patients perceived more pain in the second eye.3 ursea et al,7 suggested that during second-eye surgery, patients were generally more aware of the ongoing procedure, which might explain their enhanced pain perception. their study was focused on pain in cataract surgery though. lasik is routinely performed under topical anesthesia. the main site of anesthetic action is the nerve cell membrane where it blocks axonal sodium channels hence eliminating propagation of action potential. anesthetic effect begins within 30 seconds of administration of eye drops and persists for 10–20 minutes.5 noxious stimuli to ocular nocicepters result in hypersensitization to inflammatory and pain mediators released in the extracellular space such as sharmeen akram, et al 196 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology bradykinin, histamine, neurotrophins and cytokines. these cause changes in membrane permeability of ions leading to lowering of the membrane threshold potential of potential of a neuron.6 it can be postulated that in response to noxious stimuli during lasik in the first eye, inflammatory and pain mediator levels increase in both eyes resulting in hyper-sensitization and hyperalgesia experienced by the second eye. measuring levels of these mediators/neurotransmitters can provide reasonably strong evidence to support the above hypothesis. in conclusion, our study supports the results of el rami et al.3 that patients undergoing lasik perceive more pain in the second eye. further studies are needed to identify factors associated with change in pain perception. author’s affiliation dr. sharmeen akram section of ophthalmology department of surgery aga khan university stadium road, p.o. box 3500 karachi-74800 dr. salman naveed sadiq section of ophthalmology department of surgery aga khan university stadium road, p.o. box 3500 karachi-74800 dr. khabir ahmad section of ophthalmology department of surgery aga khan university stadium road, p.o. box 3500 karachi-74800 role of authors dr. sharmeen akram substantial contributions to the conception and design of the work; acquisition of data; drafting the manuscript with sn sadiq and revising it critically for important intellectual content; and final approval of the version to be published. dr. salman naveed sadiq substantial contributions to the conception and design of the work; data entry; drafting the manuscript with s akram and revising it critically for important intellectual content; and final approval of the version to be published. dr. khabir ahmad substantial contributions to the conception and design of the work; analysis and interpretation of the data; and drafting and revising the draft critically for important intellectual content; and final approval of the version to be published. references 1. lombardo aj, lindstrom rl. demographics of refractive surgery patients and market trends http://www.aao.org/vp/edu/refract/v1m5/us_statisti cs.cfm (accessed. 2. shortt aj, allan bd, evans jr. laser-assisted in-situ keratomileusis (lasik) versus photorefractive keratectomy (prk) for myopia. cochrane database syst rev; 1: cd005135. 3. el rami h, fadlallah a, fahd d, fahed s. patientperceived pain during laser in situ keratomileusis: comparison of fellow eyes. j cataract refract surg. 38: 453-7. 4. free mm. cross-cultural conceptions of pain and pain control. proc (bayl univ med cent) 2002; 15: 143-5. 5. bartlett jd, jaanus sd. clinical ocular pharmacology. 5th ed: elsevier: 90-1. 6. mizumura k. peripheral mechanism of hyperalgesiasensitization of nociceptors. nagoya j med sci. 1997; 60: 69-87. 7. ursea r, feng mt, zhou m, lien v, loeb r. pain perception in sequential cataract surgery: comparison of first and second procedures. journal of cataract & refractive surgery 2011; 37(6): 1009-14. http://www.aao.org/vp/edu/refract/v1m5/us_statistics.cfm http://www.aao.org/vp/edu/refract/v1m5/us_statistics.cfm 272 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology original article subconjunctival bevacizumab as an adjunct to 5-fluorouracil enhanced trabeculectomy: short term results sana nadeem pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sana nadeem assistant professor, department of ophthalmology, foundation university medical college/ fauji foundation hospital, rawalpindi. e-mail: sana.nadeem018@gmail.com …..……………………….. purpose: to compare the results of trabeculectomy with subconjunctival bevacizumab and 5-fluorouracil (5-fu); with trabeculectomy with 5-fluorouracil alone in the short term (i.e. 3 months). study design: prospective, interventional study place and duration of study: department of ophthalmology, fauji foundation hospital, rawalpindi, from 18 th december 2013 till 16 th august 2018. material and methods: a total of 30 eyes (15 in each group) in patients above 40 years of age with primary glaucoma, underwent trabeculectomy with 5fluorouracil (5-fu) (50 mg/ml) applied for 5 minutes. at the end of surgery, subconjunctival bevacizumab (avastin® 2.5 mg in 0.1 ml) was injected in one group. the postoperative iop, bleb configuration, and complications at 1 day, 1 week, 1 month, and then monthly for 3 months was observed for both groups. results: the mean pre-operative iop in the 5-fu group was 30.6 ± 17.1 mm hg compared to 28.9 ± 18.9 mm hg in the 5-fu + bevacizumab group. the mean iop of the 5-fu group at 3 months was 13.8 ± 4.25 mm hg, compared to 12.5 ± 3.37 mm hg in 5-fu + bevacizumab group, comparison of the mean iop between the two groups revealed lower mean iop in the 5-fu group at day 1 (p = 0.556) , week 1 (p = 0.872), and month 1 (p = 0.042), but higher at month 3 (p = 0.339). bleb morphology between the two groups was statistically insignificant (p = 0.405). conclusion: there is no added benefit of subconjunctival bevacizumab used as an adjunct to 5-fu enhanced trabeculectomy in the short term. key words: trabeculectomy, 5-fluorouracil, bevacizumab, glaucoma, intraocular pressure. uccess of trabeculectomy for glaucoma may be limited by gradual subconjunctival and episcleral scarring, which causes its failure. the use of antimetabolites like 5-fluorouracil (5-fu) and mitomycin c (mmc) has long been attributed to decrease post-operative scarring1. these, too have not been entirely satisfactory. however; the need arises for a newer agent which may enhance the effect of these drugs. vascular endothelial growth factor (vegf) is a cytokine, known to be elevated in patients with glaucoma and to promote scarring and angiogenesis during wound healing1,2. bevacizumab (avastin®) is a full length monoclonal antibody against all isoforms of vegf-a and has been studied scantily to assess its anti-angiogenic and inhibitory effects on fibroblast proliferation, postoperative scarring and eventual success in glaucoma filtration surgery.3 few of those who have studied its effect have presented encouraging results and safety4,5. the rationale of this study was to assess the effect of anti-vegf on the success of trabeculectomy in our local population. s mailto:sana.nadeem018@gmail.com subconjunctival bevacizumab as an adjunct to 5-fluorouracil enhanced trabeculectomy: short term pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 273 the aim of this study is to compare the effect of subconjunctival bevacizumab as an adjunct to 5-fu enhanced trabeculectomy to the effect of 5-fu alone, mainly in terms of intraocular pressure (iop) lowering, bleb formation, and complications, in the short term (i.e. three months), and to see if it gives an added benefit. material and methods a total of 30 eyes in consecutive patients with glaucoma presenting to the operating surgeon, were included in this ongoing study (15 in each group), carried out in the department of ophthalmology, fauji foundation hospital, rawalpindi, which is a tertiary care, teaching hospital affiliated with foundation university medical college; from 18th december, 2013 to 16th august, 2018. approval from the ethical committee was taken. inclusion criteria were, patients above 40 years of age with primary open angle glaucoma (poag) or primary angle closure glaucoma (pacg), and pseudoexfoliative glaucoma (pxf), with uncontrolled iop after maximally tolerated medical therapy, or noncompliance, or advanced glaucomatous damage at presentation, or as a combined procedure for cataract and glaucoma if on multiple medications. patient preference for trabeculectomy as a treatment option was also considered if on 2 or more topical antiglaucoma medications. exclusion criteria were young patients with glaucoma, congenital, juvenile, secondary, uveitic, traumatic, neovascular, aphakic or patients with ocular surface disease. pre-operatively, a thorough slit lamp examination was performed of the anterior and posterior segments, along with visual acuity estimation and refraction, goldmann applanation tonometry, pachymetry and gonioscopy. the patients were assessed and monitored for glaucomatous progression by serial humphrey perimetry and optical coherence tomography (oct) of the optic nerve head and retinal nerve fiber layer. all surgeries were performed under local anesthesia by the author using a standardized technique with facial nerve and retrobulbar blocks. a fornix based approach for trabeculectomy was used with a limbal conjunctival peritomy performed, and then fashioning of a triangular superficial scleral flap measuring 4 x 4 mm with blade # 15, then 5-fu (50 mg/ml) was applied above and below the superficial flap with cotton pledgets for 5 minutes. after thorough washing of the 5-fu, a paracentesis was done, and a deep scleral window was made 1.5 x 2 mm in size with a blade # 11, and a peripheral iridectomy was performed with vannas scissors. then the superficial flap was approximated to the sclera with 10/0 nylon sutures one at the apex, and one on the right side with the left side being left unstitched. then the conjunctiva was sutured with 8-0 silk or 6-0 vicryl on the right side ensuring a water-tight closure. fluid was injected through the paracentesis to ensure bleb formation and patency of the procedure. in cases of subconjunctival bevacizumab injection (2.5 mg in 0.1 ml), the injection was performed from the left side with a bent needle of a 1 cc (30 g) syringe, horizontally into the bleb 8 mm from the limbus. a subconjunctival antibiotic and steroid injection was given at the end of the surgery. in case of phaco-trabeculectomy, after peritomy and fashioning of superficial flap, phacoemulsification with intraocular lens implantation was performed, after which the trabeculectomy was completed. the patients were examined by the operating surgeon on the post-operative visits at day 1, 1 week, 1 month, and then monthly for 3 months. visual acuity, goldmann tonometry, and slit lamp examination with fundus assessment was done as routine post operative examination. bleb assessment using a simple grading system6-8 was done after healing of the conjunctiva, according to which blebs were classified into four types; type 1: thin-walled, polycystic (well-functioning), type 2: diffuse, flatter and thicker (good functioning), type 3: flattened bleb with scarring and little or no function, and type 4: encapsulated (tenon’s cyst) with engorged blood vessels and poor function. the data was analyzed using spss version 20. frequencies and percentages were calculated for all the variables. unpaired and paired samples t-tests were used for the data analysis as the case may be. the wilcoxon signed-rank test was used to assess the types of bleb formation between the two groups, as well as complications between the two groups. a p-value of less than 0.05 was considered statistically significant. results a total of 30 eyes of 22 patients were included in this study, with 15 eyes in each group assigned randomly, one group undergoing ‘enhanced trabeculectomy with 5-fu’ alone, and the other group undergoing ‘enhanced trabeculectomy with 5-fu + subconjunctival bevacizumab’. these patients were consecutive patients presenting to the operating sana nadeem 274 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology surgeon, who fulfilled the inclusion criteria for trabeculectomy. the majority of patients were females accounting for 21 (95.4%) cases. primary open angle glaucoma was predominant with 18 (60%) eyes, primary angle closure in 9 (30%) eyes, and pseudoexfoliative glaucoma in the rest of 3 (10%) eyes (table 1). enhanced trabeculectomy with 5-fu alone or combined 5-fu with subconjunctival bevacizumab was performed in 22 (73.3%) eyes and phacotrab was performed in 8 (26.7%) eyes. the mean pre-operative iop in the 5-fu group was 30.6 ± 17.1 mm hg (range 15-68), while the mean pre-operative iop in the 5-fu + bevacizumab group was 28.9 ± 18.9 mm hg (range 14-78). however, the difference between the two was not statistically table 1: baseline patient characteristics. age, years (mean ± sd) range, years 62.8 ± 7.2 50-84 gender n (%) male female 22 1 (4.5) 21(95.4) eye n (%) right left 17 (56.7) 13 (43.3) glaucoma diagnosis n (%) poag pacg pxf 18 (60) 9 (30) 3 (10) pre-op anti-glaucoma medicines 5-fuø group mean ± sd range 5-fu + bevacizumab group mean ± sd range 2.87 ± 0.35 (2-3) 2.93 ± 0.25 (2-3) surgical procedure n (%) enhanced trabeculectomy phacotrab 22 (73.3) 8 (26.7) significant (p = 0.758). iop differences were analyzed at day 1, week 1, month 1, and month 3, and were compared with pre-operative iop as well as between the two groups (table 2). the mean iop of the 5-fu group at day 1 was 10.0 ± 5.8 mm hg, at week 1 was 8.9 ± 5.36 mm hg, at month 1 was 10.6 ± 5.4 mm hg, and at month 3 was 13.8 ± 4.25 mm hg. the differences between pre-operative and post-operative iop in the 5-fu group was significant at all occasions; day 1 (p = 0.001), week 1 (p = 0.001), month 1 (p = 0.001), and month 3 (p = 0.002), thus depicting surgical success in the short term period. in case of the 5-fu + bevacizumab group, the mean iop at day 1 was 11.2 ± 6.8 mm hg, at week 1 was 9.2 ± 4.25 mm hg, at month 1 was 16.2 ± 7.39 mm hg, and at month 3 was 12.5 ± 3.37 mm hg. . the differences between pre-operative and post-operative iop in the 5-fu + bevacizumab group was also significant at all occasions; day 1 (p = 0.005), week 1 (p = 0.003), month 1 (p = 0.042), and month 3 (p = 0.008). this too amounts to successful surgery in the short term. comparison of differences in the mean iop between the two groups revealed lower mean iop in the 5-fu group at day 1 (p = 0.556), week 1 (p = 0.872), and month 1 (p=0.042), but higher at month 3 (p = 0.339). however, only the iop differences at month 1 were statistically significant between the two groups (table 3). analysis of bleb formation and comparison between the two groups, revealed equal number of cystic bleb formation in the two groups with 5 (33.3%) in each group, with early bleb failure in 2 (13.4%) cases of the 5-fu group, 1 case of a flattened bleb and 1 case of an encapsulated bleb, which required needling (table 4). however, bleb comparison between the two groups did not reveal statistically significant differences (p = 0.405). table 2: iop§ at different time periods. iop§ mm hg (mean ±sd) pre-op day 1 week 1 month 1 month 3 trabeculectomy with 5fuø 30.6 ± 17.1 [maximum 68] [minimum 15] 10.0 ± 5.8 8.9 ± 5.36 10.6 ± 5.4 13.8± 4.25 trabeculectomy with 5fuø + s/c¤ bevacizumab 28.9±18.9 [maximum 78] [minimum 14] 11.2 ±6.8 9.2± 4.25 16.2± 7.39 12.5±3.37 ø 5-fluorouracil § intraocular pressure ¤ subconjunctival subconjunctival bevacizumab as an adjunct to 5-fluorouracil enhanced trabeculectomy: short term pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 275 table 3: paired samples t-test in the 5-fu group & 5-fu + bevacizumab group. paired samples test paired differences t df sig. (2tailed) mean std. deviation std. error mean 95% confidence interval of the difference lower upper pair 1 pre-op iop in 5fu group pre-op iop in bevacizumab + 5-fu group 1.66 20.51 5.29 -9.69 13.02 .315 14 .758 pair 2 iop day 1 5fu group iop day 1 bevacizumab + 5-fu group -1.13 7.26 1.87 -5.15 2.89 -.604 14 .556 pair 3 iop week 1 5-fu group iop week 1 bevacizumab + 5-fu group -.26 6.30 1.62 -3.75 3.22 -.164 14 .872 pair 4 iop at 1 month 5-fu groupiop at 1 month bevacizumab + 5-fu group -5.53 9.59 2.47 -10.84 -.21 -2.233 14 .042 pair 5 iop at 3 months 5-fu groupiop at 3 months bevacizumab + 5-fu group 1.33 5.21 1.34 -1.55 4.22 .989 14 .339 table 4: bleb analysis. type of bleb trabeculectomy with 5-fu n (%) trabeculectomy with 5-fu + s/c bevacizumab n (%) type 1 cystic 5 (33.3) 5 (33.3) type 2 diffuse 8 (53.3) 10 (66.7) type 3 flattened 1 (6.7) 0 type 4 encapsulated 1 (6.7) 0 z -.832b asymp. sig. (2-tailed) .405 a. wilcoxon signed ranks test b. based on positive ranks. the number of pre-operative anti-glaucoma medications in both groups ranged from 2-3 (table 1), and there was a significant reduction of medicines post-operatively in both groups, at 3 months. the comparison for the 5-fu group between the preoperative medicines (2.87 ± 0.35) and the postoperative medicines (0.20 ± 0.414), was statistically significant (p = 0.000), with only 3 eyes requiring 1 anti-glaucoma agent at 3 months. for the 5-fu + bevacizumab group, similarly the comparison between the pre-operative anti-glaucoma medicines (2.93 ± 0.25) and post-operative medicines (0.27 ± 0.458), were statistically significant (p = 0.000), with 4 eyes requiring 1 drop at 3 months. the difference in anti-glaucoma agents at 3 months between the two groups was not statistically significant (p = 0.334). a few early complications were encountered in both groups, summarized in table 5, with a slightly higher number in the 5-fu + bevacizumab group, but the differences between the two groups were not found to be statistically significant (p = 0.373). shallow sana nadeem 276 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology table 5: complications of trabeculectomy. complications trabeculectomy with 5-fu n (%) hyphema failure of filtration bleb leak 1 (6.7) 2 (13.3) 2 (13.3) trabeculectomy with 5-fu + s/c bevacizumab n (%) epithelial defect 1 (6.7) imperforate piα 1 (6.7) hyphema 1 (6.7) shallow acβ & choroidal detachment 1 (6.7) peaked pupil 1 (6.7) posterior synechiae 2 (13.3) z -.891b asymp. sig. (2-tailed) .373 a. wilcoxon signed ranks test b. based on negative ranks. α peripheral iridectomy β anterior chamber anterior chamber (ac) was considered only if iris cornea touch was present in the mid-peripheral iris and this was present in 1 (6.7%) case which led to choroidal detachment, in the 5-fu + bevacizumab group, which resolved with steroids and cycloplegics. also 1 case of imperforate peripheral iridectomy (pi) required nd: yag iridotomy post-operatively, also in the same group. bleb leaks were found in 2 (13.3%) cases of the 5-fu group, managed by bandage contact lenses (bcl). the complications encountered did not have a considerable long lasting effect in terms of success. discussion the results of our study indicate no added benefit of subconjunctival bevacizumab used as an adjunct to 5fu enhanced trabeculectomy, in terms of iop lowering, as the mean iop in the 5-fu group was lower at all occasions except at month 3. similarly, no significant differences in bleb formation or complication rate were seen on comparison of the two surgical groups. mean post-operative iop was significantly lower in both groups at all times, when compared to the pre-operative iop. a vascularized bleb is long known to cause trabeculectomy failure. failure of trabeculectomy is invariably caused by subconjunctival and episcleral fibrosis, which is the result of myofibroblast transformation9 triggered by vascular endothelial growth factor (vegf), by the induction of transforming growth factor (tgf)-β1. thus factors inhibiting vegf would result reduce this fibrosis. wound modulation by subconjunctival bevacizumab in rabbits undergoing trabeculectomy was demonstrated in 2014 by ozgonul10 and colleagues, who concluded it to be superior to subconjunctival 5fu. evidence in literature initially suggested adjunctive treatment of bevacizumab in trabeculectomy to be promising as indicated by frieberg et al1 in 2013, who used this agent and it reduced the number of post-operative injections of 5fu. however, similar to our study, no statistically significant reduction in iop, bleb morphology or complications was observed. sedhipour et al2 in 2011 assessed the short-term benefit of bevacizumab and found no significant difference when compared to placebo, similar to our results. jukowska-dudzińska11 et al found more patients with the bevacizumab group needing medical therapy at 1 year, compared to 5-fu, the rest of results were similar to ours. nilforushan12 et al in 2011, found benefit of bevacizumab alone on iop lowering, but less than that of mitomycin alone. bitelli5 et al found it to safe and effective adjuvant therapy with mmc. suh et al13, kiddie3 et al, saeed8 et al and elgin14 and coworkers, did not find additional additive effects. the effectiveness and safety of this drug was assessed by akkan15 et al in 2015, which appeared to be safe but not superior to mmc. mild central bleb avascularity was observed with subconjunctival bevacizumab by chua16 and coworkers, but not significantly so. a meta-analysis of randomized controlled trials carried out in 2016 by liu x et al17 found bevacizumab to be superior compared to placebo, but no difference was seen when used in conjunction with mmc versus mmc alone, and it was found to increase the rate of bleb associated complications like bleb leaks and encysted blebs, compared to mmc. in our study however, on the contrary, bleb leaks and encysted bleb was seen in the 5-fu group. wang18et al used subconjunctival bevacizumab as an adjunct to mmc and found no benefit as well. contrary to this, in 2017, adjuvant bevacizumab was found to be comparable to mmc in the long term, in primary open angle glaucoma, along with demonstrating significant bleb avascularity, as noted by kaushik19 et al in india. similarly, popescu20 has claimed its positive role in inflammatory glaucoma. cheng21 and coworkers did an extensive electronic database search on randomized controlled trials subconjunctival bevacizumab as an adjunct to 5-fluorouracil enhanced trabeculectomy: short term pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 277 comparing subconjunctival bevacizumab to other agents, and concluded in 2016, that there is insufficient and low quality evidence to support or refute its use for wound healing in glaucoma surgery. strengths of our study are that this is the first of its kind in pakistan. equal allotment of cases and good follow up has been ensured. a standard technique with a single surgeon and patient assessment has also been standardized. limitation of our study is small sample size. our department does not have a separate glaucoma facility and collecting patients has taken a lot of time. these patients will be continued to be followed up for long term results. future work required is larger scale studies with more study subjects and long term assessment. conclusion subconjunctival bevacizumab in conjunction with 5fluorouracil enhanced trabeculectomy offers no additional benefit in terms of iop lowering, bleb morphology or post-operative complications; when compared to 5-fu enhanced trabeculectomy alone, in the short term. author’s affiliation dr. sana nadeem assistant professor, department of ophthalmology, foundation university medical college/fauji foundation hospital, rawalpindi. role of authors dr. sana nadeem study design, manuscript writing, statistical analysis. references 1. freiberg fj, matlach j, grehn f, karl s, klink t. postoperative subconjunctival bevacizumab injection as an adjunct to 5-fluorouracil in the management of scarring after trabeculectomy. clin ophthalmol. 2013; 7: 1211-1217. 2. sedghipour m, mostafai a, taghavi y. low dose subconjunctival bevacizumab to augment trabeculectomy for glaucoma. clin ophthalmol. 2011; 5: 797-800. 3. kiddee w, orapiriyakul l, kittigoonpaisan k, tantisarasart t, wangsupadilok b. efficacy of adjunctive subconjunctival bevacizumab on the outcomes of primary trabeculectomy with mitomycin c: a prospective randomized placebo-controlled trial. j glaucoma. 2015; 24 (8): 600-606. 4. kaushik j, parihar jk, jain vk, gupta s, nath p, durgapal p, ram j. efficacy of bevacizumab compared to modulated trabeculectomy in primary open angle glaucoma: a one-year prospective randomized controlled study. curr eye research, 2017 feb; 42 (2): 217-224. 5. bitelli lg, prata ts. subconjunctival bevacizumab as an adjunct in first-time filtration surgery for patients with primary glaucomas. int ophthalmol. 2013 dec; 33 (6): 7. 6. leung ck, yick dw, kwong yy, li fc, leung dy, mohamed s, et al. analysis of bleb morphology after trabeculectomy with visante anterior segment optical coherence tomography. br j ophthalmol. 2007 mar; 91 (3): 340-344. 7. kanski jj, menon j. clinical ophthalmology. a systematic approach. fifth edition. elsevier: india, 2003; 264-265. 8. saeed am, aboul nasr tt. subconjunctival bevacizumab to augment trabeculectomy with mitomycin c in the management of failed glaucoma surgery. clin ophthalmol. 2014 sep 15; 8: 1745-55. 9. park hy, kim jh, park ck. vegf induces tgf-β1 expression and myofibroblast transformation after glaucoma surgery. am j pathol. 2013 jun; 182 (6): 214754. 10. ozgonul c, mumcuoglu t, gunal a. the effect of bevacizumab on wound healing in an experimental trabeculectomy model. curr eye res. 2014 may; 39 (5): 451-9. 11. jukowska-dudzińska j, kosior-jarecka e, zarnowski t. comparison of the use of 5-fluorouracil and bevacizumab in primary trabeculectomy: results at 1 year. clin exp ophthalmol. 2012 may-jun; 40 (4): 13542. 12. nilforushan n, yadgari m, kish sk, nassiri n. subconjunctival bevacizumab versus mitomycin c adjunctive to trabeculectomy. am j ophthalmol. 2012 feb; 153 (2): 352-357. 13. suh w, kee c. the effect of bevacizumab on the outcome of trabeculectomy with 5-fluorouracil. j ocul pharmacol ther. 2013 sep; 29 (7): 646-51. 14. elgin u, sen e, ḉolak s, yilmazbas p. initial trabeculectomy with 5-fluorouracil with or without subconjunctival bevacizumab in the management of pseudoexfoliation glaucoma. int ophthalmol. 2018 apr. 25. [epub ahead of print] 15. akkan ju, cilsim s. role of subconjunctival bevacizumab as an adjuvant to primary trabeculectomy: a prospective randomized comparative 1-year follow-up study. j glaucoma. 2015 jan; 24 (1): 1-8. 16. chua be, nguyen dq, qin q, ruddle jb, wells ap, niyadurupola n, et al. bleb vascularity following posttrabeculectomy subconjunctival bevacizumab: a pilot study. clin exp ophthalmol. 2012 nov; 40 (8): 773-9. sana nadeem 278 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology 17. liu x, du l, li n. the effects of bevacizumab in augmenting trabeculectomy for glaucoma: a systematic review and meta-analysis of randomized controlled trials. medicine (baltimore). 2016 apr; 95 (15): 1-13. 18. wang j, harasymowycz p. subconjunctival bevacizumab injection in glaucoma filtering surgery: a case control series. isrn ophthalmol. 2013 mar 14; 2013: 384134. 19. kauskik j, parihar jk, jain vk, gupta s, nath p, durgapal p, ram j. efficacy of bevacizumab compared to mitomycin c modulated trabeculectomy in primary open angle glaucoma: a one-year prospective randomized controlled study. curr eye res. 2017 feb; 42 (2): 217-224. 20. popescu v, leascu c, stana d, alexandrescu c, dumitrescu a. the efficacy of subconjunctival bevacizumab in refractory glaucoma-a case report. j med life, 2015 jan-mar; 8 (1): 103-5. 21. cheng jw, cheng sw, wei rl, lu gc. anti-vascular endothelial growth factor for control of wound healing in glaucoma surgery. cochrane database syst rev. 2016 jan. 15; (1): cd009782. microsoft word 5. omar rashid 132 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology original article role of subconjunctival bevacizumab in treatment of pterygium rashid omar, sarosh rimsha, raja waseem, rashid arshad, banday shahid shahzada, sayed iqbal assif pak j ophthalmol 2012, vol. 28 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: omar rashid 77, osman abad ashpeer sopore -193201 j & k india …..……………………….. purpose: to assess the efficacy and role of sub-conjunctival bevacizumab in treatment of primary and recurrent pterygium. material and methods: this off-label, single-dose, interventional case series was conducted at government medical college hospital in srinagar from january 2011 to march 2011 in patients with primary pterygium. twenty eyes of 20 patients with primary pterygium were selected and a single dose of subconjunctival injection of bevacizumab (0.05 ml, 1.25mg) was given. pterygium vascularity and thickness was graded. the size of the pterygium (measured by surface area in cm2) was recorded from baseline to 6 weeks, after injection. treatment-related complications and adverse events were reported. the main outcome measurements were the change in size, vascularity and thickness. results: there were 15 males (75%) and 5 females (25%) of 20 patients with a mean age of 45.5years (sd 11.68 years). there was a significant difference in the mean surface area of pterygium at different intervals (p < 0.05) and the size of pterygium were reduced. on comparison of the mean pterygium size, there was no significant difference between men and women (p >0.05). conclusion: sub-conjunctival bevacizumab injection is useful in management of patients with primary pterygium without local or systemic adverse effects. terygium is a triangular sheet of fibro vascular tissue that encroaches the cornea1,2. it occurs in the inter-palpebral fissure, more commonly on the nasal side of the eye and is often bilateral1,3. recent studies have provided evidence implicating genetic components, anti-apoptotic mechanisms, cytokines, growth factors, extra cellular matrix remodeling, immunological mechanisms, and viral infections in the pathogenesis of the disease4-8. vascular growth factors such as vascular endothelial growth factor (vegf) have been detected in pterygium9-12. jin and colleagues showed that pterygia contain decreased levels of pigment epithelium-derived factor, angiogenic inhibitor, and elevated vegf levels12. the treatment of pterygium is myriad, with various treatments being advocated in the scientific literature13. bevacizumab is a full-length, humanized, monoclonal antibody against all types of vegf. it binds to and neutralizes the biologic activity of all subtypes of human vegf14. bevacizumab is now an established modality in treatment of choroidal neovascularization due to age-related macular degeneration (armd), and diabetic macular edema. bevacizumab, when administered intra-vitreally, is well tolerated and associated with improvement in visual acuity, decreased central retinal thickness, and reduction in angiographic leakage15-17. we conducted this study to asses the effects of bevacizumab on ptregium, which has been shown to have vegf in its matrix. material and methods this off-label, single-dosing, interventional case series was conducted at government medical college hospital in srinagar from january 2011 to march 2011 in patients with primary and recurrent pterygium. pterygium measurement and grading was done according to tan and coworkers grading scheme proposed in 199718. grading is based on the visibility p role of subconjunctival bevacizumab in treatment of pterygium pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 133 of the underlying episcleral blood vessels. the pterygia were classified into grades i, ii, or iii based on slit lamp bio microscopy evaluation. grade i (atrophic) had clearly visible episcleral vessels under the body of the pterygium. grade ii (intermediate) had partially visible episcleral vessels under the body of the pterygium. in grade iii (fleshy) episcleral vessels were not visible under the body of the pterygium. on baseline examination, grade ii and grade iii pterygium patients were included in the study. exclusion criteria included grade i pterygium, any condition for which bevacizumab is contraindicated (hypertension, proteinuria, previous myocardial infarction or stroke). a complete eye evaluation was performed for each patient. this included visual acuity, applanation tonometry and slit lamp examination. the dimensions of the pterygium were determined by measuring its length in centimeters, from base (using the caruncle as landmark) to apex, and width in centimeters at the base and apical areas. 0.05 cc of bevacizumab (1.25 mg) was injected in sub-conjunctival area of pterygium body using an insulin syringe with 30gauge needle and lid retractor at place. patients were followed up after1, 3, and 8 weeks. a complete ophthalmologic evaluation was done for each followup. any complications and adverse events were noted. post injection complications such as ocular surface toxicity, corneal abrasion, persistent epithelial defect, sub-conjunctival hemorrhage, infection, were noted. results from jan 2011 to march 2011, 20 patients (15 males 75% and 5 females 25%) were involved in the study. patient age ranged from 24 to 62 years with mean of 43.5 years [standard deviation (sd) 10.58 years]. according to the results of table 1, average pterygium size reduction in the right eye (p=0.004), left eye (p=0.041) and both the eyes (p=0.002) during four stages of the study was significant. as seen from table 2 and 3, we had 12 cases of grade iii and 8 cases of grade ii pterygium selected for intervention. after a sub-conjunctival injection of bevacizumab, 4 cases of grade iii pterygium changed to grade ii, and 3 changed to grade i. also 4 cases of grade ii pterygium changed to grade i after bevacizumab injection. no ocular surface toxicity, persistent epithelial defects, corneal abrasion, infections, or uveitis were reported during the study. discussion pterygium is a chronic, degenerative disorder described histologically as elastotic degeneration of conjunctival tissue. it has a stromal overgrowth of fibroblasts and blood vessels accompanied by an inflammatory cell infiltrate and abnormal extra cellular matrix accumulation composed of elastin and collagen4. our study took into account the changes in the size and vascularity (grade) of pterygium after a sub– conjunctival injection of bevacizumab. comparing the size of pterygium, as seen in table 1 after an injection of bevacizumab, we found a statistically significant reduction in length of pterygium as measured from caruncle (significant p-value using annova test). these results can be compared to a study done by besharatiet al19. however, the dosage used by these workers was different. this encouraging result was supported by the changes seen in the vascularity or the grades of pterygium after our intervention. eleven cases changed from a higher grade to a lower one, highlighting the decrease in the vascular component of the pterygia (significant p-value, using chi-square test). over expression of vegf in pterygium tissue20 and ocular inflammation21 together with the rashid omar, et al 134 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology abundance of new vessels supported the role of angiogenesis in the formation of pterygias22-24. in a study done by asergadoo25, it was found that if pterygium is going to recur, it usually grows back or shows signs of recurrence during the first three months. our study observed effects maintenance of effects for at least 2 months. no local irritation, allergic reaction, or surface epitheliopathy was observed. this is in contrast with a 60% rate of spontaneous loss of epithelial integrity as recently reported by kim et al where topical bevacizumab was used twice daily for a much longer period (3 months), and adverse effects generally appeared during the second month of treatment26. this suggests that the duration of treatment may well determine the safety of topical bevacizumab. conclusion this study showed that sub-conjunctival injection of bevacizumab is useful in treatment of patients with primary pterygium without local or systemic adverse effects. author’s affiliation dr. rashid omar senior resident department of ophthalmolgy himsr, jamia hamdard university, hamdard nagar delhi-62 dr. sarosh rimsha resident department of ophthalmology government medical college srinagar-190010 dr. raja waseem resident department of ophthalmology government medical college srinagar-190010 dr. rashid arshad fellow, minimal access surgery loknayak hospital maulana azad medical college new delhi-110002 dr. banday shahid shahzada resident department of general surgery government medical college srinagar-190010 dr. sayed iqbal assif registrar department of general surgery sher-e-kashmir institute of medical sciences srinagar reference 1. kanski jj. clinical ophthalmology. 4thed. pterygium. butterworth-heinemann ltd publisher. 1994; 96. 2. duke-elders. systems of ophthalmology. diseases of the outer eye.conjunctivaldiseases: degenerative and pigmentary changes. london. henry kipton publisher. 1977; 7: 568. 3. pinkerton od, hokman y, shigemura la. immunologic basis for the pathogenesis of pterygium. am j ophthalmol. 1984; 98: 2256. 4. di girolamo n, chui j, coroneo mt, et al. pathogenesis of pterygia: role of cytokines, growth factors, and matrix metalloproteinases. prog retin eye res. 2004; 23: 195-228. 5. di girolamo n, coroneo mt, wakefield d. active matrilysin (mmp-7) in human pterygia: potential role in angiogenesis. invest ophthalmol vis sci. 2001; 42: 1963-8. 6. vansetten g, aspiotis m, blalock td, et al. connective tissue growth factor in pterygium: simultaneous presence with vascular endothelial growth factor-possible contributing factor to conjunctival scarring. graefes arch clin exp ophthalmol. 2003; 241: 135-9. 7. solomon a, grueterich m, li dq, et al. overexpression of insulin-like growth factor binding protein-2 in pterygium body fibroblasts. invest ophthalmol vis sci. 2003; 44: 573-80. 8. maini r, collison dj, maidment jm, et al. pterygiaderived fibroblasts express functionally active histamine and epidermal growth factor receptors. exp eye res. 2002; 74: 237-44. 9. marcovich al, morad y, sandbank j, et al. angiogenesis in pterygium: morphometric and immune histochemical study. curr eye res. 2002; 25: 17-22. 10. lee dh, cho hj, kim jt, et al. expression of vascular endothelial growth factor and inducible nitric oxide synthase in pterygia. cornea 2001; 20: 738-42. 11. gebhardt m, mentlein r, schaudig u, et al. differential expression of vascular endothelial growth factor implies limbal origin of pterygia. ophthalmology. 2005; 112: 1023-30. 12. jin j, guan m, sima j, et al. decreased pigment epithelium derived factor and increased vascular endothelial growth factor levels in pterygia. cornea 2003; 22: 473-7. 13. hirst lw. the treatment of pterygium. surv ophthalmol 2003; 48: 145–80. 14. hurwitz h, fehrenbacher l, novotny w, et al. bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. n engl j med. 2004; 350: 2335-42. 15. michels s, rosenfeld pj, puliafito ca, et al. systemic bevacizumab (avastin) therapy for neovascular age-related macular degeneration: twelve-week results of an uncontrolled open-label clinical study. ophthalmology. 2005; 112: 1035-47. 16. rosenfeld pj, moshfeghi aa, puliafito ca. optical coherence tomography findings after an intravitreal injection of bevacizumab (avastin) for neovascular age related macular degeneration. ophthalmic surg laser imaging. 2005; 36: 331-5. 17. avery rl, pieramici dj, rabena md. intravitreal bevacizumab (avastin) for neovascular age-related macular degeneration. ophthalmology. 2006; 113: 363-72. 18. tan dth, chee sp, dear kbg, et al. effect of pterygium role of subconjunctival bevacizumab in treatment of pterygium pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 135 morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. arch ophthalmol. 1997; 115: 1235-40. 19. besharati mr, manaviat mr, souzani a. subconjunctival bevacizumab injection in treatment of pterygium. acta medicairanica. 2011; 49: 179-83. 20. hosseini h, nejabat m, khalili mr. bevacizumab (avastin) as a potential novel adjunct in the management of pterygia. med hypotheses. 2007; 69: 925–7. 21. nagy ja, dvorak am, dvorak hf. vegf-a and the induction of pathological angiogenesis. annu rev pathol 2007; 2: 251-75. 22. hosseini h, nejabat m, mehryar m, et al. bevacizumab inhibits corneal neovascularization in an alkali burn induced model of corneal angiogenesis. clin experiment ophthalmol. 2007; 35: 745-8. 23. bock f, onderka j, dietrich t, et al. bevacizumab as a potent inhibitor of inflammatory corneal angiogenesis and lymphangiogenesis. invest ophthalmol vis sci. 2007; 48: 2545-52. 24. bahar i, kaiserman i, mcallum p, et al. sub-conjunctival bevacizumab injection for corneal neovascularization in recurrent pterygium. curr eye res 2008; 33: 23-8. 25. asregadoo er. surgery, thio-tepa and corticosteroid in the treatment of pterygium. am j ophthalmol. 1972; 74: 960. 26. kim sw, ha bj, kim ek, et al. the effect of topical bevacizumab on corneal neovascularization. ophthalmology 2008; 115: 33-8 61 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology author communication reduced fluence photodynamic treatment for a case of chronic central serous chorioretinopathy qasim lateef ch, tehmina jahangir pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tehmina jahangir associate professor of ophthalmology eye department jinnah hsopital lahore allama iqbal medical college email: tehminajahangir@gmail.com …..……………………….. to report a case of a 49 year old male with right sided recurrent chronic central serous chorioretinopathy (cscr). he was treated with half fluence photodynamic therapy resulting in resolution of cscr and significant improvement in best corrected visual acuity. keywords: central serous chorioretinopathy, photodynamic therapy, optical coherence tomography. chronic central serous chorioretinopathy (csc) is a well-recognized entity characterized by accumulation of serous sub retinal fluid (srf) which induces a localized detachment of the neurosensory retina. patients can present with various visual complaints including central scotoma, metamorphopsia and micropsia. it is most frequently unilateral and affects young adult males more commonly. there is often a history of recent stress and the subject usually has a type a personality. the visual deterioration in chronic cases results from damage to the underlying retinal pigment epithelium (rpe) and photoreceptors. the underlying pathogenesis involves multifocal areas of choroidal vascular hyper permeability1,2. it is speculated that the fundamental mode of action of photodynamic therapy (pdt) with verteporfin (visudyne; novartis pharma ag, switzerland) utilized for the treatment of csc is the shutdown of the vessels in the choriocapillaris resulting in hypo-perfusion and extended remodeling of choroidal vasculature. we approached this case of chronic symptomatic csc by treating him with half-fluence rate (25 j/cm2), without modifying the dose of verteporfin (6 mg/m2). the choice of a suitable fluence rate enables one to evade indirect damage to surrounding structures such as rpe atrophy, ischemia of the choroid, and development of secondary choroidal neovascularization (cnv) because of less choriocapillaris damage3. the intervention was done after seeking permission from the hospital’s ethical and research committee. the author has no financial interest in the products used. the authors declare no conflict of interest. reduced fluence photodynamic treatment for a case of chronic central serous chorioretinopathy pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 62 case report we report a case of 49 years old male, shopkeeper by profession, who was suffering from right sided recurrent chronic cscr. (figure 1,2) his condition dated back to 2002. he was treated with various treatment modalities including oral acetazolamide and also received multiple intravitreal injections of anti vegf. argon laser was also applied but the cscr never resolved. the earliest available oct (done in october 2012) shows right sided cscr involving the fovea with central macular thickness of 631 microns in the right eye (figure 3). fig. 1: color fundus photograph of right eye showing the dome shaped elevation of central serous chorioretinopathy. we decided to treat him with half-fluence pdt in june 2015. at that time, his vision was 6/36 in the right eye and central macular thickness of 483 microns (figure 4). the pdt was done on 10th of june 2015 to the right eye. it was decided to treat him with half-fluence pdt (25 j/cm2) instead of the regular 50 j/cm2). the halffluence rate was chosen as it is sufficiently effective while at the same time reducing the collateral choroidal hypo perfusion and thus being safer as demonstrated in the “visudyne in minimally classic choroidal neovascularization study group study”. after the treatment the patient was instructed to avoid strong light and wear protective glasses for 48 hours. we followed him with 2 monthly serial oct scans which showed gradual resolution over a period of 6 months. (figure. 5) his latest oct scan performed on 5th january 2016 showed complete resolution of the sub-retinal fluid in the right eye with central macular thickness of 190 microns. at this time his visual acuity was 6/9 od (figure 6). fig. 2: ffa of the same eye localizing the area of leakage. qasim lateef ch, et al 63 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology the patient did not experience any adverse systemic event neither during verteporfin infusion nor in the follow-up period. no collateral damage of the retina was observed for instance the growth of cnv or detachment of the pigment epithelium. fig. 3: oct macula od october 2012. fig. 4: oct macula od june 2015 (oct on the day of treatment). fig. 5: oct macula od october 2015 (3 months after treatment). fig. 6: oct macula od january 2016 showing complete resolution of the sub-retinal fluid 6 months after half-dose pdt. discussion in this case, we used half-fluence rate (25 j/cm2) and routine quantity of verteporfin (6mg/m2) to increase the effectiveness and at the same time decrease the associated damage caused by pdt in a patient with chronic cscr. we observed a steady decrease in the central macular thickness from the initial 483 microns to 190 microns and simultaneous gain in visual acuity from 6/60 to 6/9 at the last follow-up visit (fig. 4-6). currently there is no definitive therapy available for cases of either acute or chronic cscr. diverse efforts have been made at devising a therapy for this condition including argon laser to seal off the leakage points4,5. although treatment with laser may considerably reduce the span of the ailment, it has not been found to influence the final visual acuity or rate of recurrence of cscr6. smretschnig et al have reported very good outcomes in visual acuity and significant decrease in the central foveal thickness using half-fluence pdt in cases of both acute and chronic cscr7. the largest study conducted so far was by chan et al which included 48 eyes with a follow-up of one year and revealed the complete absorption of srf in 95%of eyes with betterment in visual acuity compared to a control group8. reduced fluence photodynamic treatment for a case of chronic central serous chorioretinopathy pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 64 reibaldi et al have assessed low-fluence pdt (25j/cm2) as opposed to standard fluence (50j/cm2) and found that the best-corrected visual acuity improved at 12 months in both the groups with resolution of srf in a considerable number of eyes. however, they also noted substantial choriocapillaris non-perfusion in 44% of cases which were treated with standard fluence pdt versus 0% in those which underwent treatment with half-fluence pdt9. shin et al have also stated identical findings10. conclusion central serous chorioretinopathy is a challenging clinical problem. the use of reduced fluence pdt appears to be a safe and potent treatment modality for chronic cscr. author’s affiliation dr. qasim lateef ch fcps, frcs, fcps (vr) associate professor of ophthalmology eye department jinnah hospital/ allama iqbal medical college, lahore. dr. tehmina jahangir fcps, fellowship in vitreoretina assistant professor of ophthalmology eye department jinnah hospital/ allama iqbal medical college, lahore. role of authors dr. qasim lateef ch case diagnosis, treatment and follow-up dr. tehmina jahangir case diagnosis, documentation, treatment, literature search and discussion writing. references 1. rosenthal jm and flaxel cj. half-dose and half-fluence photodynamic therapy for central serous chorioretinopathy. j eye ophthalmol. 2014; 1: 2. 2. rouvas a, stavrakas p, theodossiadis pg, stamatiou p, milia m, giannakaki e and datseris i. long-term results of half-fluence photodynamic therapy for chronic central serous chorioretinopathy. eur j ophthalmol. 2012; 22: 417-22. 3. shinojima a, kawamura a, mori r, fujita k and yuzawa m. detection of morphologic alterations by spectral-domain optical coherence tomography before and after half-dose verteporfin photodynamic therapy in chronic central serous chorioretinopathy. retina. 2011; 31: 1912-20. 4. silva rm, ruiz-moreno jm, gomez-ulla f, montero ja, gregorio t, cachulo ml, pires ia, cunha-vaz jg and murta jn. photodynamic therapy for chronic central serous chorioretinopathy: a 4-year follow-up study. retina, 2013; 33: 309-15. 5. ruiz-moreno jm, lugo fl, armada f, silva r, montero ja, arevalo jf, arias l and gomez-ulla f. photodynamic therapy for chronic central serous chorioretinopathy. acta ophthalmol. 2010; 88: 371-6. 6. nicolo m, zoli d, musolino m and traverso ce. association between the efficacy of half-dose photodynamic therapy with indocyanine green angiography and optical coherence tomography findings in the treatment of central serous chorioretinopathy. am j ophthalmol. 2012; 153: 474-480. 7. smretschnig e, ansari-shahrezaei s, hagen s, glittenberg c, krebs i and binder s. half-fluence photodynamic therapy in chronic central serous chorioretinopathy. retina, 2013; 33: 316-23. 8. chan wm, lai ty, lai ry, tang ew, liu dt and lam ds. safety enhanced photodynamic therapy for chronic central serous chorioretinopathy: one-year results of a prospective study. retina, 2008; 28: 85-93. 9. reibaldi m, boscia f, avitabile t, uva mg, russo a, zagari m, occhipinti f, russo v, reibaldi a and longo a. functional retinal changes measured by microperimetry in standard-fluence vs. low-fluence photodynamic therapy in chronic central serous chorioretinopathy. am j ophthalmol. 2011; 151: 953-960. 10. shin jy, woo sj, yu hg and park kh. comparison of efficacy and safety between half-chorioretinopathy. retina, 2011; 31: 119-26. microsoft word 7. oaqamar riaz 94 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology original article epidemiology of microbial keratitis in a tertiary care center in karachi qamar riaz, umar fawwad, nasir bhatti, aziz ur rehman, mazhar ul hasan pak j ophthalmol 2013, vol. 29 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: qamar riaz isra postgraduate institute of ophthalmology al-ibrahim eye hospital malir, karachi …..……………………….. purpose: to measure the frequency, etiology and outcome of management of microbial keratitis in a tertiary care center in karachi. material and methods: a prospective analysis of 133 cases clinically diagnosed as microbial keratitis at al ibrahim eye hospital in karachi over an 8 month period from 1st february to 31st september 2010, was performed. a standardised form was filled out for each patient, documenting sociodemographic features and information pertaining to ocular or systemic risk factors, management, microbiological tests and visual outcomes. corneal scrapes were collected and subjected to microscopy / staining, culture and sensitivity. viral ulcers, mooren’s ulcer and ulcer associated with systemic or autoimmune diseases were excluded from the study. results: males (63.2%) were affected more than the females. the most common predisposing cause of ulceration was corneal trauma (48%), usually with organic agricultural materials and most frequent diagnosis was fungal keratitis (63%). of the 68 (51.1%) patients who were followed up till the end of the treatment, visual outcome improved in 30 (44.1%), remained same in 15 (22.1%) while worsened in 23 (33.8%) patients. conclusion: microbial keratitis continues to be a frequent cause for concern among ophthalmologists and health managers. this study will serve as local epidemiological database regarding microbial ulcers as well as help us in formulating guidelines for prevention of suppurative keratitis in the population at risk. ince the discovery of antibiotics and the advancement of medical technology, the incidence of microbial keratitis has been drastically reduced especially in developed countries.1,2 however factors like lack of medical awareness and/or inaccessibility to medical treatment, corneal ulceration continues to be an important cause of mono ocular morbidity in most asian, african and the middle eastern countries.3-6 pakistan national survey for blindness and visual impairment also listed corneal scarring second only to cataract as the major etiology of blindness and visual disability.7 the knowledge regarding the predisposing risk factors to ulceration and etiological organisms within a given region is essential, firstly, to define the magnitude of the problem in terms of health care costs, human costs, and the economic burden of blindness; secondly, with regard to empirical management, as many eye clinics in the locality do not have microbiology facilities; and lastly to design an efficient and systematic public health programme for the rapid referral, diagnosis, treatment, and ultimately the prevention of this preventable but sight threatening condition in the population at risk. this approach has important public health implications for the treatment and prevention of corneal ulceration in the developing world. unfortunately a comprehensive data as regards to the demographical and etiological factors and responsible pathogenic organisms of suppurative corneal ulcerations from pakistan is s epidemiology of microbial keratitis in a tertiary care center in karachi pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 95 lacking and very few studies evaluating the etiological factors predisposing local population to corneal infection are available.8,9 the aim of the present study was to establish the frequency, etiologies (risk factors and causative organisms) and outcomes of microbial keratitis at ibrahim eye hospital. karachi. the aims of the management were reduction in the symptoms and signs of microbial keratitis and reduction in complications. material and methods it was a prospective case series. all patients above the age of 16 years, presenting in the outpatient department of al ibrahim eye hospital (aieh) from february 2010 till september 2010, and clinically diagnosed as microbial keratitis were included in the study. corneal ulcer was defined as a loss of the corneal epithelium with underlying stromal infiltration and suppuration associated with signs of inflammation with or without hypopyon. typical or suspected viral ulcers, healing ulcers, mooren’s ulcer, neurotrophic keratitis, and any ulcer associated with systemic or autoimmune diseases were excluded from the study. a standardised proforma was completed for each patient eligible for the study, documenting sociodemographic information as well as clinical findings including duration of symptoms, past treatment (if any), time and mode of presentation, predisposing ocular conditions and associated systemic risk factors amongst other clinical details. an informed verbal consent was taken from every patient who underwent a comprehensive ophthalmology examination, including slit lamp biomicroscopy, and clinical features of the ulcer by an ophthalmologist. the visual acuity was measured using snellen’s chart at 6 meters. the site and size of the ulcer and depth of infiltrate, as well as the severity of the ulcer, were documented. both peripheral and central ulcers were included. in case of any history of trauma, object and place of trauma were also recorded. corneal scrapings were done in all the patients and were sent for direct microscopy, gram staining, culture and sensitivity. it was performed, under aseptic technique, on all patients using a sterile bardparkar blade (no 15). material obtained from scraping of the leading edge and base of each ulcer was inoculated in the media and smeared onto two separate glass slides, one stained with gram stain and the other with 10% potassium hydroxide (koh) for direct microscopic evaluation. the specimens were inoculated onto blood agar, nutrient agar, chocolate agar and mcconkey agar for bacterial isolation and sabaroud’s dextrose agar for fungal culture. bacterial cultures were considered positive only if growth of the same organism was demonstrated on both media or there was semi confluent growth at the site of inoculation on one media with identification of morphological characteristics of similar organism in gram stain. the specific identification of bacterial pathogens was based on microscopic morphology, staining characteristics and biochemical properties using standard laboratory criteria. if by microscopy in koh mount preparation, hyphae were observed in corneal smear, but failed to grow in culture, the causative organism was reported as fungal. the cultures for the patients’ contact lenses and their cleaning solutions were also done when their usage was indicated. all laboratory methods followed standard protocols. specimens for detection and isolation of acanthamoeba were sent to aga khan laboratory. for all cases, treatment was commenced empirically with broad spectrum topical antibiotics immediately after the diagnosis was made. subsequent treatment was tailored according to the microbiological diagnosis and sensitivity results. the final visual acuity was defined as the visual acuity on the day of discharge from the ward. all the data was entered and analyzed using epi info 6.0. fig. 1: microbial keratitis qamar riaz, et al 96 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology results from 1st february to 30th september 2010 a total of 133 patients (0.5% of 25,502 patients’ opd) with the clinical diagnosis of central corneal defect with underlying stromal infiltration with or without hypopyon were examined at the opd of al ibrahim eye hospital. we determined the factors predisposing to bacterial, fungal, acanthamoeba and mixed corneal infections and analyzed the treatment outcome in them. of the total 133 patients 84 (63.2%) were males and 49 (36.8%) were females. in both groups, keratitis occurred most frequently in the middle decades of life (table 1). the predominance of corneal ulceration in the middle years was most pronounced in females (p = < 0.001). the youngest patient was 16 years old while the oldest was of 79 years of age. the duration of the patients’ symptoms before their evaluation at ibrahim eye hospital was also determined. most of the patients were examined within 7 days after the onset of their illness. the greatest number (37 patients, 27.8%) was seen in the second week, but 19 (14.3%) patients waited for more than a month before coming to the hospital for evaluation presumably because of the distance or earlier consultation at some other place. the occupations of the patients reflected a cross section of the work force in the surrounding area (table 2). a history of recent corneal trauma was obtained in 64 (48.1%) patients of which 31 patients presented with or gave a history of corneal foreign body. 26 (36.6% of the total trauma cases) patients had corneal injury with vegetative matter mostly tree branch or wheat stalk, followed by dust, stone etc (20; 28.9%). other agents were wooden stick, flying insect, metal and wood pieces impacted on the cornea during welding or wood cutting, chemicals like paint and spices etc. seven patients were soft contact lens users (table 3). majority of the patients suffered corneal trauma while at work (39, 60.9%) and while traveling on road (10, 15.6%). nine (14.1%) patients suffered corneal injury at home whereas 1 (1.6%) patient each had corneal trauma in school and playground respectively. ocular problems predisposing to corneal ulcer were present in 16 (22.5%) patients. among them severe blepharitis was present in 5 patients, ectropion in 2 patients, inflamed pterygia in 2 patients, pingeculitis in 1 patient, non-leprous lagophthalmos in 2 patients, bell’s palsy with exposure keratitis in 1 patient and spheroidal degeneration in 1 patient. one patient had suture in his eye one year and another had bullous keratopathy secondary to cataract surgery. two patients were diabetic and 1 patient had thyroid eye disease (table 4). in contrast with the patients who had a definite history of corneal trauma, the risks for corneal ulceration associated with these conditions were presumptive. clinically 64 cases were diagnosed as bacterial while 68 were diagnosed as fungal corneal ulcers. only one patient was suspected of having acanthamoeba infection. cultures were positive and fulfilled the criteria established for the presence of infection in 89 (68.4%) of the 133 corneal ulcers. 55 (62% of positive cultures) patients had pure fungal growth, 25 (28% of positive cultures) had pure bacterial growth, 02 (2% of positive cultures) cases had mixed bacterial and fungal growth, and 7 (8% of positive cultures) patients were positive for acanthamoeba. the remaining 45 (32.3%) patients epidemiology of microbial keratitis in a tertiary care center in karachi pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 97 were culture negative. all except one of the 07 patients with positive acanthamoeba cultures wore contact lenses and all except one were between 16 – 20 years of age. of the total 133 patients, only 68 (51.1%) patients were followed up till the end of the treatment. among them visual outcome improved in 30 (44.1%), remained same in 15 (22.1%) while worsened in 23 (33.8%) patients thus leaving 55 (80.9%) eyes with a visual acuity of < 6/12 (fig. 1). 7.4 19.1 14.7 8.8 7.4 10.3 22.1 13.2 44.1 41.2 4.4 7.4 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 6/6-6/12 6/186/24 6/366/60 <6/60hm pl + npl pre treatment visual acuity post treatment visual acuity hm= hand movement, pl = perception of light npl = no perception of light fig. 1: pre-treatment (baseline) and post treatment visual acuity distribution among patients with microbial keratitis n = 68, p value <0.05 discussion in our study majority of the patients with corneal ulcers, in both the genders, were in 41– 60 years of age (41.4%). this is in contrast to the study done in oman where patients between 30 – 60 years accounted for 23% of the cases10. the tendency to develop corneal ulcers in the middle decades of life may be due to the fact that they are predisposed to ocular conditions like chronic dacryocystitis, dryness, cataract surgery etc. also in our local setting people are presumably more active physically and at a higher risk for corneal injury especially men who are involved more in outdoor activities because of their responsibility as bread earners and thus at greater risk for eye injury in occupational and/or recreational settings. also their propensity for risk taking behavior renders them less likely to wear eye protection. this is also the reason for a higher incidence of corneal ulcers in males (84%) than females, a finding similar to the study done in malaysia,5 oman10 and india.11 another finding stressing the need for health education addressing manual workers in general and employers in particular is that the majority of corneal ulcer patients were agricultural workers, daily wage earners or laborers (78.8%), an occupation profile similar to south india12 and gangetic west bengal, eastern india study13 (79.3% and 70.7% respectively) and the majority of the patients suffered corneal trauma while at work (39%, 60.9%). the most common cause of corneal trauma was tree branch followed by wheat grains, leaves and thorns, soil and rocks, objects of % o f p at ie nt s qamar riaz, et al 98 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology animal origin like cow tail and horn, metal objects, and a number of other interesting materials. basak et al also identified corneal injury as the most common predisposing factor for microbial keratitis especially in developing countries.13 of the total 89 (67%) corneal cultures that yielded pathogens, 25 (28%) were bacterial as opposed to 55 (62%) fungal cultures. these figures are in contrast to those reported by srinivasan et al12 where bacterial keratitis was more (47.1%) and fungal keratitis were less (46.8%) than our study. however basak et al13 presented results similar to our study. the possible reason for reduced bacterial corneal ulcers might be more successful treatment of bacterial corneal ulcers in the peripheral centers and/or by general practitioners. chronic ocular surface diseases were identified as the main risk factor for fungal keratitis by tanure et al14 in their series but in our study only 12% patients had pre-existing ocular pathology which can predispose to development of corneal ulcers. on the other hand, dust or mud particles in the eye also resulted in development of fungal keratitis in addition to the vegetable matter thus increasing the overall number of fungal corneal ulcers in our study. of the 7 (8%) acanthamoeba keratitis patients, higher than that reported from madurai (1.0%)12 and west bengal (0.3%)13 six were contact lens wearers of which four were females and the remaining one patient gave a history of frequent visits to a swimming pool indicating that contact lens wear is becoming an important risk factor, mainly due to increasing urbanization as was the case in malaysia.5 only 25 (18.8%) patients presented for examination at the hospital during first three days of their illness while 14.3% took longer than 1 month to make the journey to the hospital. though this is better than the gangetic west bengal study13 where only 11% presented within first week but it still stresses strengthening of primary eye care services in pakistan. in our study distance, prior consultation with primary eye care worker or general practitioners, inadequate or wrong treatment, self-prescription with over-thecounter available non-prescription drugs including steroids, and use of traditional eye remedy with potential fungal or bacterial contamination were responsible for late presentation at aieh and also to their poor visual prognosis. interestingly, in our study, the results of microscopy were confirmed by culture findings in 90% of microbial keratitis cases suggesting the use of koh wet mount preparation or simple microscopy alone in identifying fungal infections especially in rural based settings where microbial keratitis is a problem and scientific expertise, and/or resources is an issue. current standard practice in managing microbial keratitis is empiric therapy with topical antibiotics followed by a modification of this therapy based on clinical response and on microbiological results of corneal scrapings.15 despite the severity, a majority of the eyes could be saved anatomically however a few eyes may require acute surgical intervention of some kind. conclusion in conclusion, suppurative microbial keratitis, a sightthreatening infection and it primarily affects lower socio/economic classes. in our environment fungal infections are common. considering the high magnitude of resulting visual loss, public education about the potential for loss of sight, need for regulating sales of drugs specially steroids, importance of use of safety measures at work and importance of timely and appropriate treatment are recommended. it is also essential to develop an efficient referral system at the community level, improve laboratory facilities and adopt effective methods of treatment and ensure follow up to decrease the burden of avoidable blindness. author’s affiliation dr. qamar riaz isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr. umar fawwad isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr. nasir bhatti isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr. aziz ur rehman isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr. mazhar ul hasan isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi references 1. bharathi mj, ramakrishnan r, vasu s, meenakshi r, palaniappan r. in-vitro efficacy of antibacterials against epidemiology of microbial keratitis in a tertiary care center in karachi pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 99 bacterial isolates from corneal ulcers. indian j ophthalmol. 2002;50:109-14 2. srinivasan m, upadhyay mp, priyadarsini b, mahalakshmi r, whitcher jp. corneal ulceration in sotugh est asia iii: prevention of fungal keratitis at the village level in south india using topical antibiotics. br j. ophthalmology. 2006; 90: 1472-5. 3. whitcher jp, srinivasan m, upadhayay mp. corneal blindness: a global perspective. bulletin of the world health organization. 2001; 79: 214–21. 4. whitcher jp, srinivasan m. corneal ulceration in the developing worlda silent epidemic. br j ophthalmol. 1997; 81: 622-3. 5. norina tj, raihan s, bakiah s, ezanee m, lizasharmini at, wan hazzabah wh. microbial keratitis: aetiological diagnosis and clinical features in patients admitted to hospital universiti sains malaysia. singapore med j. 2008; 49: 67-71. 6. kunimoto dy, sharma s, garg p, gopinathan u, miller d, rao gn. corneal ulceration in the elderly in hyderabad south india. br j ophthalmol. 2000; 84: 54-9. 7. dineen b, bourne rr, jadoon z, shah sp, khan ma, foster a, gilbert ce, khan md. pakistan national eye survey study group. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91: 1005-10. 8. baig sa, khan sa. corneal ulcers: a review of 152 cases at nawabshah. pakistan journal of surgery. 2000; 16: 25-9. 9. sethi s, sethi mj, iqbal r. causes of microbial keratitis in patients attending an eye clinic at peshawar. gomal journal of medical sciences. 2010; 8: 20-2. 10. keshav br, zacheria g, ideculla t, bhat v, joseph m. epidemiological characteristics of corneal ulcers in south sharqiya region. oman medical journal. 2008; 23: 34-9. 11. bashir g, shah a, thokar ma, rashid s, shakeel s. bacterial and fungal profile of corneal ulcers-a prospective study. indian jour. of pathology and microbiology. 2005; 48: 273-7. 12. srinivasan m, gonzales ca, george c, cevallos v, mascarenhas jm, asokan b, wilkins j, smolin g, whitcher jp. epidemiology and etiological diagnosis of corneal ulceration in madurai, south india. br j ophthalmol. 1997; 81: 965-71. 13. basak sk, basak s, mohanta a, bhowmick a. epidemiological and microbiological diagnosis of suppurative keratitis in gangetic west bengal, eastern india. indian j ophthalmol. 2005; 53: 17-22. 14. tanure ma, cohen ej, sudesh s, rapuano cj, laibson pr. spectrum of fungal keratitits at wills eye hospital, philadelphia, pennsylvania. cornea. 2000; 19: 307-12. 15. garg p, rao gn. corneal ulcer: diagnosis and management. j community eye health. 1999; 12: 21–3. 224 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology original article four cases of xeroderma pigmentosum in a pakistani family najia idrees, tanveer anjum chaudhry, arsalan pak j ophthalmol 2014, vol. 30 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tanveer anjum chaudhry section of ophthalmology department of surgery aga khan university, karachi tanveer.chaudhry@aku.edu …..……………………….. xeroderma pigmentosum (xp) is a rare autosomal recessive genetic disorder resulting from the defective repair of dna, damaged by exposure to ultraviolet radiation. this case series is focused on a pakistani family with 4 of its members suffering from xp. an 11 year old girl belonging to this family presented to us with substantial loss of vision in right eye, intolerance to light and mild pain for the past 4 years. her visual acuity was hand movement in the right eye and no perception of light in the left. on examination multiple hypoand hyper pigmented areas of skin around the eyes were visible. her signs and symptoms together with positive family history helped us reach the diagnosis of xp. eroderma pigmentosum (xp), first described by hebra and kaposi in 1874,1 is a rare autosomal recessive genetic disorder. it is characterized by faulty repair of dna damage induced by ultraviolet radiation. xp occurs worldwide, affecting all age groups, both sexes and all racial groups. the basic deficiency lies in the nucleotide excision repair (ner), a mechanism responsible for recognizing and repairing bulky dna damage caused by environmental and other exposures, thus resulting in the clinical manifestations. fibroblasts in normal human skin can repair damage caused by exposure to uv radiation. however, in patients with xp, this ability of fibroblasts is slower or completely absent.2 xp have many consequences including skin cancer, ocular abnormalities (e.g., conjunctivitis, ectropion and corneal opacities) and neurological anomalies resulting in decreased reflexes, progressive hearing loss and mental retardation.3 here, we describe four cases of this disease in a single pakistani family. our xp family an 11 year old girl, resident of karachi, pakistan presented to us with complaints of loss of vision in her right eye, intolerance to light and mild pain and ocular irritation for the past 4 years. the symptoms had increased in the last 4 months. her left vision was completely lost 3 years back. she had a strong family history of xp. four out of her 7 siblings suffered from it. two elder siblings, one elder brother and one elder sister, died because of xp – related complications at ages 18 and 9 respectively. their parents were first cousins. on examination multiple hypo and hyper pigmented areas of skin around the eyes were visible. similar lesions were observed on the scalp with loss of hair. there was no evidence of systemic malignancy. her visual acuity in the right eye was hand movement. her left eye was phthysical with no perception of light. examination showed right eye madarosis, completely opaque and dry cornea with peripheral corneal vascularization. based on her signs and symptoms and the associated family history, a clinical diagnosis of xeroderma pigmentosum was confirmed. discussion we reported a single pakistani family with 4 of 7 siblings affected by severe xeroderma pigmentosum. two of them died at the age of 9 and 18 years, respectively, while the two survived with unilateral blindness and extreme sensitivity of the skin. x four cases of xeroderma pigmentosum in a pakistani family pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 225 fig. 1: a picture of the family including the patient and her siblings affected by xp fig. 2: picture taken while examining the patients’ eye (left or right). visible pigmentation of skin near the eye there are multiple manifestations of xp including cutaneous, ocular and neurological some more prevalent and severe than others. for example, among 36 cases studied by bhutto and colleagues(18 males and 18 females, age range 2 30 years)4 in the dermatology unit of a tertiary care hospital in larkana or medical camps in remote areas over a period of seven years, two thirds had severe disease. they also found that 29 (81%) cases had ocular symptoms including photophobia, conjunctivitis, corneal keratitis and lid ulcer. one patient had complete bilateral loss of vision. both the family members we examined had unilateral loss of vision and severe ocular damage. it is well-established that ocular changes are more common in the tissues exposed to uv light, such as the eyelids, conjunctiva, cornea, and the lens.5 photophobia is often the first symptom to appear followed by pigmentation of eyelids, madarosis, ectropion and lower lid cancer. conjunctival damage results in xerosis, telangiectasia, chronic congestion, and pigmentry changes whereas involvement of the cornea results in dryness, exposure keratitis, hazyness, band-like nodular keratopathy and scarring and ulceration, resulting in severe visual impairment. other reasons for visual loss in xp patients could be pterygium, tumour invasion from the limbus, and corneal vascularization.6 the diagnosis of xp in this case series was based on clinical findings and positive family history. unfortunately, diagnostic tests were not available in our setting. although there is no cure for xp, an important measure of protection from sunlight is adopted to overcome skin damage. this is carried out by covering windows with uv resistant films and application of sun screen on exposed skin. since avoiding sunlight may result in vitamin d deficiency, it is advisable to prescribe vitamin d supplements. other protective actions like frequent eye examinations and removal of pre-cancerous lesions are also advised. more importantly the patient is offered psychological support to improve his quality of life. the common problems that need to be addressed here are feelings of isolation and career prospects. there are xp support groups in developed countries such as france, germany, uk and usa. they offer a wealth of advice and help. unfortunately, such groups do not exist in our part of the world and need to be established. moreover, genetic counseling and testing is also an important component of its prevention which is not readily available in pakistan. in conclusion, the four cases of xp we reported had devastating ocular consequences. author’s affiliation dr. najia idrees section of ophthalmology department of surgery aga khan university karachi najia idrees, et al 226 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology dr. tanveer anjum chaudhry section of ophthalmology department of surgery aga khan university karachi dr. arsalan rajput section of ophthalmology department of surgery aga khan university karachi references 1. grampurohit vu, dinesh us, rao r. multiple cutaneous malignancies in a patient of xeroderma pigmentosum. journal of cancer research and therapeutics. 2011; 7: 205-7. 2. cleaver je. defective repair replication of dna in xeroderma pigmentosum. nature. 1968; 218: 652-6. 3. kraemer kh, lee mm, scotto j. xeroderma pigmentosum. cutaneous, ocular, and neurologic abnormalities in 830 published cases. archives of dermatology. 1987; 123: 241-50. 4. bhutto am, shaikh a, nonaka s. incidence of xeroderma pigmentosum in larkana, pakistan: a 7-year study. the br. j of dermatology. 2005; 152: 545-51. 5. lehmann ar, mcgibbon d, stefanini m. xeroderma pigmentosum. orphanet journal of rare diseases. 2011; 6: 70. 6. goyal jl, rao va, srinivasan r, agrawal k. oculocutaneous manifestations in xeroderma pigmentosa. the br. j of ophthalmology. 1994; 78: 295-7. 132 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology editorial the basics of research in ophthalmology the knowledge explosion that we have witnessed in the 20th and 21st century and its mind boggling impact on human civilization through rapid technological developments, owe it all to advances in reasoning leading to innovative research. advances in medical knowledge including ophthalmic knowledge and practices are not an exception to this rule. in the early 20th century there were no strict ethical rules governing medical research. as a result of absence of such rules, during the second world war, some basic fundamental human rights were reportedly violated. the verdict delivered by the judges against the “the doctor trial” in 1947 lead to the development of the famous ten point nuremberg code.1 this code was later modified by the world medical association and eventually adopted as the famous declaration of helsinki (doh) in 1964.2 this set of global principles have been subjected to a number of revisions to ensure that it meets the current and future requirements of biomedical research.3 new and more detailed guidelines are now prepared by other interest groups like the nuffield council on bioethics, uk, the eu guidelines and the international ethical guidelines for biomedical research involving human subjects prepared by the council for international organizations of medical sciences in collaboration with the world health organization.4 apart from creating new knowledge, application of innovative research adds value to human health and also provides a mean for rapid social and economic growth and development of the country. while the basic scientists are focused on advances in the basic anatomical and physiological aspects of human body including the visual apparatus, clinicians are constantly engaged in enhancing our knowledge and understanding in disease causation, its pathological effects, its impact in terms of morbidity and mortality and its prevention and treatment. while the epidemiologists will tell us about the pattern of diseases, other medical scientists will be engaged in health system research who will answer our questions about the efficient and effective organization, funding and the mechanics of health delivery systems. still others would be engaged in research on the social and cultural aspects (medical sociology and anthropology), law (legal medicine), medical ethics and medical practices (clinical trials). currently there has been a lot of emphasis on impact measurement in terms of quality of life (qol) and patient satisfaction through qualitative research. more recently, there is a lot of research going on in the field of medical education, training, evaluation and lifelong commitment to learning. modern medical research is much cost and labor intensive. it needs tremendous personal commitment and generous funding. in order to attract necessary funding, the expected research outcomes must have the potential of a strong positive impact on human health and happiness. the paper based on the results of the project should be of such high quality that it should not only find a suitable place in an internationally respected medical science journal, but should make significant contributions to new knowledge with a strong possibility of opening up new avenues for scientific and technological development. before selecting the research question, it should be carefully examined in the light of its complexity, relevance, applicability, impact, the possible cost, the ethical dilemmas involved in the methodology and the simplicity of the model in terms of retesting the validity and reliability of the results. review of necessary literature is must, but plagiarism must be avoided at all costs. once you have prepared the abstract of your research project, it must be submitted to your concerned ethical board for approval. any conflict of interest must be declared at the outset. any financial support in the form grants etc. must be acknowledged. for a young scientists with a career in medicine, there are only two possible options, publish or perish. once your abstract is approved, you should chose a journal or few journals where you would like your article to be published. read the instructions to the author carefully and try to follow the instructions as closely as possible. the basics of research in ophthalmology pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 133 when it comes to writing your article, follow the general instructions for writing a scientific article. the write up should follow the basic structure of a scientific article. 5-7 title: it should be short, specific and comprehensive. avoid abbreviations. abstract: should cover, study goal/objective, study design, patient and methods/material and methods, results, conclusions and key words. introduction: should consist of brief review of the current knowledge, questions that need to be answered and state what you intend to do. method: should include the age and gender of the specimen, selection criteria, informed consent, experimental design and method of statistical analysis based on sound scientific principles of research. give enough details to enable the peers to check the validity of your results. results: communicate your results clearly. use table and graphs. avoid fabrication and falsification. discussion: summarize your results. explain whether your research findings have answered the research questions raised. compare your results to the findings of other investigators. give references. in the final concluding paragraph, firmly mention the point you are trying to make. if there are still some questions unanswered, express your interest in future research on the subject. acknowledgements: thank those who have helped but whose names could not be included as authors. references: put them in the style preferred by the journal selected. submission of manuscript: follow the instructions to the author. before you submit the manuscript, you must go through the uniform requirements for manuscripts submitted to biomedical journals 1997.8 references 1. hurren, elizabeth (may 2002)” patient’s rights: from adler hey to the nuremberg code” (http://www.history and policy.org/paper/ policy-paper-03.html). history and policy (in english). united kingdom: history and policy. retrieved 9 december 2010 2. u.s. national institutes of health. “nuremberg code”(http://history.nih.gov/researh/download s/nuremberg.pdf). retrieved on june 20, 2012. 3. holly fernandez lynch, human subjects research, international (http:/blog.law.havard.edu/bill of health/2013/04/18/revision-to-the-declaration of-helsinki/) 4. fundamentals of good medical writing by dr trish groves, deputy editor bmj, available at url:http://bmjopen.bmj.com/site/about/resour ces/fundamentals_of_good_medical_writing.ppt 5. medical writing by dr. sarwar j zuberi, available at url: http://www.pakmedinet.com/files/rm.ppt 6. roadmap to excelling in medical writing by dr trish groves, deputy editor bmj, available at url:http://bmjopen.bmj.com/site/about/resour ces/roadmap_for_medical_writing.ppt 7. writing up the research paper for medical journals by jeanne m. ferrante, m.d., m.p.h, available at url: http://rwjms.rutgers.edu/departments_institutes/fami ly_medicine/divisions/research/fellowship/document s/writingresearchpaper for medicaljournal.ppt 8. jama. 1997 march 19; 277(11):927-34 uniform requirements for manuscripts submitted to biomedical journals. international committee of medical journals editors. prof. m. daud khan http://www.history/ http://history.nih.gov/researh/downloads/nuremberg.pdf http://history.nih.gov/researh/downloads/nuremberg.pdf http://history.nih.gov/researh/downloads/nuremberg.pdf http://bmjopen.bmj.com/site/about/resources/fundamentals_of_good_medical_writing.ppt http://bmjopen.bmj.com/site/about/resources/fundamentals_of_good_medical_writing.ppt http://bmjopen.bmj.com/site/about/resources/fundamentals_of_good_medical_writing.ppt http://www.pakmedinet.com/files/rm.ppt http://bmjopen.bmj.com/site/about/resources/roadmap_for_medical_writing.ppt http://bmjopen.bmj.com/site/about/resources/roadmap_for_medical_writing.ppt http://bmjopen.bmj.com/site/about/resources/roadmap_for_medical_writing.ppt http://rwjms.rutgers.edu/departments_institutes/family_medicine/divisions/research/fellowship/documents/writingresearchpaper%20for%20medicaljournal.ppt http://rwjms.rutgers.edu/departments_institutes/family_medicine/divisions/research/fellowship/documents/writingresearchpaper%20for%20medicaljournal.ppt http://rwjms.rutgers.edu/departments_institutes/family_medicine/divisions/research/fellowship/documents/writingresearchpaper%20for%20medicaljournal.ppt pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 218 original article corneal endothelial cell loss after phacoemulsification with and without trypan blue assisted staining of anterior lens capsule arooj amjad, muhammad shaheer, ummarah rasheed pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. arooj amjad senior registrar, eye unit i, lahore general hospital/ post graduate medical institute, lahore. email: arooj.amjad@gmail.com …..……………………….. purpose: to study the mean loss of corneal endothelial cell in patients undergoing cataract surgery with phacoemulsification with and without trypan blue. study design: randomized controlled trial. place and duration of study: institute of ophthalmology, mayo hospital/ king edward medical university, lahore from 1-1-2016 to 30-5-2017. material and methods: all patients diagnosed with cataract were selected for surgery. the patients were divided into two groups a and b. group a patients underwent phacoemulsification with trypan blue aided central curvilinear capsulorhexis while group b patients underwent phacoemulsification without any aid of trypan blue. patients with any corneal opacity were excluded from study. specular microscopy was done on all patients before and three months after surgery. on specular microscopy, corneal endothelial count, hexagonality and coefficient of variation were noted. specular microscopy and recording of findings was done by researcher. results: a total of 152 patients presenting to the institute of ophthalmology were included in study. endothelial cell loss was observed in both the groups but it was more in the group a (74.3421 ± 0.6332) as compared to the group b (37.0658 ± 2.6891) (p 0.000). conclusion: phacoemulsification decreases corneal endothelial cell count both with and without trypan blue. the decrease in corneal endothelial cell count was more when phacoemulsification was done with trypan blue but it did not lead to corneal decompensation. key words: phacoemulsification, trypan blue, corneal endothelial cell count. ataract surgery is one of the most frequently executed surgeries around the globe. in this surgery the opaque cataractous lens is removed and is replaced by an artificial intraocular lens1. the history of cataract surgery goes back two centuries where it started as couching in this part of the world. later on intracapsular cataract extraction2 was introduced which was refined to extracapsular cataract extraction3 in which the lens capsule was preserved. phacoemulsification is the surgery of choice now a days as it gives early visual recovery and patient rehabilitation and minimal complications4,5,6. cornea is an important structure of the eye which imparts about two thirds of the dioptric power to the eye. due to this the health and status of cornea assumes an important role when deciding for the c arooj amjad, et al 219 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology prognosis after any ocular surgery7. the state of the cornea is mainly assessed by specular microscope8, 9, 10. it is well known that anterior segment surgery11,12 results in a decrease in corneal endothelial cell count and may lead to irreversible corneal compromise if the condition of cornea is not healthy before surgery. only very few studies are present in literature evaluating the effects of trypan blue during phacoemulsification on corneal endothelium. trypan blue is a vital dye which is used in both anterior and posterior segment surgery. in vitreo retinal surgery, trypan blue is used to stain the epiretinal membrane in cases of macular pucker and proliferative diabetic retinopathy. while in the anterior segment surgery trypan blue is mainly used to stain the anterior capsule in mature or white cataracts in which visualization of capsule is difficult. during staining of anterior lens capsule 0.2 ml of 0.18% trypan blue is injected into the anterior chamber13,14,15. we undertook this study to evaluate the effect of trypan blue on the corneal endothelium during phacoemulsification. materials and methods a total of 152 patients presenting to the institute of ophthalmology were included in study. patients diagnosed with cataract were selected for surgery. the patients were divided into two groups. group a patients underwent phacoemulsification with trypan blue 0.18% (rs blue by alchimia) staining of the anterior capsule for central curvilinear capsulorhexis while group b patients underwent phacoemulsification without any aid of trypan blue. patients diagnosed with any coexisting corneal disease or corneal opacity were excluded from the study. all the patients underwent phacoemulsification with intraocular lens implantation under local anesthesia. hpmc 2% (ocugel by farmigea) was used during surgery to maintain anterior chamber. after aseptic measures a corneal incision was made with keratome and 0.2 ml of 0.18% trypan blue was injected in anterior chamber of group a patients for 30 seconds while no dye was injected in group b patients. afterwards a central curvilinear capsulorhexis was done and phacoemulsification (optikon pulser 2) was done by divide and conquer technique followed by implantation of intraocular lens. the corneal incision was hydrated and antibiotic drops instilled into the eye. dressing was applied at the end of surgery. all the patients were prescribed a combination of steroid and antibiotic drops post operatively. on the first post-operative day the patients were discharged after slit lamp examination and called for follow up for corneal endothelial cell count measurement. all patients underwent pre-operative and three month post-operative bilateral specular microscopy for endothelial cell count, percentage of hexagonal cells and coefficient of variation. specular microscopy (sp-01 by cso) was done by researcher and findings were recorded. wilcoxon signed ranks test was applied for statistical analysis. results out of 152 patients 83 were male (54.6%) and 69 (45.4%) were female. in group a 42 (55.3%) patients were male and 34 (44.7%) patients were female while in group b 41 (53.9%) patients were male and 35 (46.1%) patients were female. the mean pre-operative bcva in the operated eye was 0.92 ± 0.97. the mean post-operative bcva in the operated eye was 0.096 ± 0.127. the mean preoperative corneal endothelial cell count in the operated eye was 2458.348 ± 72.382. the mean post-operative corneal endothelial cell count in the operated eye was 2402.644 ± 77.431 (p o.ooo). in group a, mean pre-operative bcva of the operated eye was 0.91 ± 0.098. the mean postoperative bcva in the operated eye was 0.090 ± 0.127. the mean pre-operative corneal endothelial cell count in the operated eye was 2443.315 ± 65.89. the mean post-operative corneal endothelial cell count in the table 1: overall visual acuity and endothelial count. sr. no. parameter operated eye pre-operative post-operative 1. visual acuity 0.92 ± 0.97 0.096 ± 0.127 2. corneal endothelial cell count 2458.348 ± 72.382 2402.644 ± 77.431 corneal endothelial cell loss after phacoemulsification with and without trypan blue assisted staining pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 220 table 2: visual acuity and endothelial count in group a. sr. no. parameter operated eye difference pre-operative post-operative post-pre operative 1. visual acuity 0.91 ± 0.098 0.090 ± 0.127 0.010 ± 0.8616 2. corneal endothelial cell count 2443.315 ± 65.89 2368.97 ± 66.52 74.3421 ± 0.6332 p 0.000 table 3: visual acuity and endothelial count in group b. sr. no. parameter operated eye difference pre-operative post-operative post-pre-operative 1. visual acuity 0.92 ± 0.096 0.10 ± 0.12 0.8263 ± 0.0322 2. corneal endothelial cell count 2473.381 ± 75.81 2436.315 ± 73.12 37.0658 ± 2.6891 p 0.000 operated eye was 2368.97 ± 66.52. the difference in visual acuity was 0.010 ± 0.8616 while the difference in endothelial cell count was 74.3421 ± 0.6332 (p 0.000). in group b, mean pre-operative visual acuity in the operated eye was 0.92 ± 0.096. the mean postoperative visual acuity in the operated eye was 0.10 ± 0.12. the mean pre-operative corneal endothelial cell count in the operated eye was 2473.381 ± 75.81. the mean post-operative corneal endothelial cell count in the operated eye was 2436.315 ± 73.12. the difference in visual acuity was 0.8263 ± 0.0322 while the difference in endothelial cell count was 37.0658 ± 2.6891 (p 0.000). discussion it is well known through literature that anterior and posterior segment surgery affects the corneal endothelium but no local data is available is present about the effects of trypan blue on corneal endothelium. our study shows that phacoemulsification with intraocular lens implantation decreases corneal endothelial cell count both with and without the use of adjunctive trypan blue. the authors compared the corneal endothelial cell loss with and without trypan blue during phacoemulsification and concluded that the corneal endothelial cell loss was more when phacoemulsification was done with adjunctive trypan blue. despite the corneal endothelial cell loss no patient presented with corneal decompensation on follow-up. dick hb et al16 studied corneal endothelial cell loss after phacoemulsification in terms of incision size, per operative phacoemulsification power used and surgery time. they found out that the corneal endothelial cell count decreased more with increasing surgery time and increasing ultrasound power. they concluded that 3.5 mm clear corneal incisions resulted in a meager decreased endothelial cell loss as compared to a 5 mm incision. jerome r et al17 compared loss of corneal endothelial cells after phacoemulsification using ultrasound or fluid based system. they reported a corneal endothelial cell loss of 498±415 in patients undergoing phacoemulsification with an ultrasound system, conversely, the patients undergoing phacoemulsification with fluid based system showed corneal endothelial cell loss of 302±302 cells. thus, they concluded that phacoemulsification with fluid based system results in a decreased corneal insult. price mo et al18 studied loss of corneal endothelial cell after two different techniques of descemet’s stripping endothelial keratoplasty. in their study, endothelial cell loss was less when the graft was inserted through a clear corneal incision while it was more when the graft was inserted through a scleral tunnel possibly due to more compression during insertion. arooj amjad, et al 221 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology hengerer ic et al19 compared corneal endothelial cell loss after femtosecond laser assisted phacoemulsification and conventional phacoemulsification. they reported a corneal endothelial cell loss of 7.9% after femtosecond laser assisted phacoemulsification and a loss of 13.7% with conventional phacoemulsification. they concluded that femtosecond laser assisted cataract surgery is a safer and more advantageous method in terms of visual rehabilitation and patient comfort. chung cf et al20 compared trypan blue and indocyanin green assisted anterior capsular staining during phacoemulsification for white cataract. they reported no major differences in phacoemulsification time and corneal endothelial cell loss in both the groups as they were comparable. jacob s et al21 assessed the postoperative outcomes of phacoemulsification assisted with trypan blue anterior capsule staining. they documented an endothelial cell loss of 8.5% in their study. absence of local data on this topic was the rationale to conduct this study. conclusion trypan blue assisted phacoemulsification results in more corneal endothelial cell loss as compared to conventional phacoemulsification but it does not result in corneal decompensation. the authors feel the need of a large randomized controlled study to have a bigger picture of the situation. author’s affiliation dr. arooj amjad fcps, senior registrar eye unit-ii, lahore general hospital dr. muhammad shaheer fcps, mrcsed, vitreoretina fellow senior registrar eye unit-iii, mayo hospital dr. ummarah rasheed m phill statistics statistician, coavs, kemu, lahore role of authors dr. arooj amjad conception of research idea, writing of paper, data collection dr. muhammad shaheer performing surgery, review of paper draft dr. ummarah rasheed statistical analysis references 1. mastropasqua l, toto l, mastropasqua a, vecchiarino l, mastropasqua r, pedrotti e, nicola md. femtosecond laser versus manual clear corneal incision in cataract surgery. journal of refractive surgery, 2014; 30 (1): 27-33. 2. lomi n, sharma r, khokhar s, dada t, vanathi m, agarwal t. risk factors for intra operative complications during phacoemulsification performed by residents. int ophthalmol. 2016; 36 (3): 401-6. 3. young al, jhangi v, liang y, congdon n, chow s, wang f, zhang x et al. a survey of perceived training differences between ophthalmology residents in hong kong and china. bmc med edu. 2015; 28 (15): 158. 4. the royal college of ophthalmologists. cataract surgery guidelines, 2010. 5. shah s, peris-martinez c, reinhard t, vinciguerra p. visual outcomes after cataract surgery: multifocal versus monofocal intraocular lens. j refract surg. 2015; 31 (10): 658-66. 6. venkatesh r, tan csh, sengupta s, ravindaran rd, krishnan kt, chang df. phacoemulsification versus small incision cataract surgery for white cataract. journal of cataract and refractive surgery, 2010; 36 (11): 1849-1854. 7. memon mn, siddiqui sn. changes in central corneal thickness and endothelial cell count following pediatric cataract surgery. j coll physicians surg pak. 2015; 25 (11): 807-10. 8. borego-sanz l, saenz-francis f, bermudez-vallicela m, morales-fernandez l, martinez-de-la-casa jm et al. agreement between central corneal thickness measured using pentacam, ultrasound pachymetry, specular microscopy and optic biometry lenstar ls 900 and the influence of intra ocular pressure. ophthalmologica. 2014; 231: 226-235. 9. monnereau c, quilendrino r, dapena i et al. multicentre study of descmets membrane endothelial keratoplasty, first case series of 18 surgeons. jama ophthalmol. 2014; 132 (10): 1192-1198. 10. lee jwy, chan jch, chang rt, singh k, liu ccl, gangwani r, wong mom, lai jsm. corneal changes after a single session of selective laser trabeculoplasty for open angle glaucoma. eye, 2014; 28: 47-52. 11. zoltan zn, agnes it, tamas f, kinga k, andrea g et al. complications of femtosecond laser assisted cataract surgery. journal of cataract and refractive surgery, 2014; 40 (1): 20-28. 12. robin ga, erica ds, jeffrey bk, penelope la, shawn ype, brenden jv. femtosecond laser assisted cataract corneal endothelial cell loss after phacoemulsification with and without trypan blue assisted staining pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 222 surgery versus standard phacoemulsification cataract surgery: outcomes and safety in more than 4000 cases at a single centre. journal of cataract and refractive surgery, 2015; 41 (1): 47-52. 13. hengerer fh, dick hb, kohnen t, conrad-hengerer i. assessment of intraoperative complications in intumescent cataract surgery using 2 ophthalmic visco surgical devices and trypan blue staining. journal of cataract and refractive surgery, 2015; 41 (4): 714-718. 14. hamzaoglu ec, straiko md, mayko zm, sales cs, terry ma. the first 100 eyes of standardized descmets stripping automated endothelial keratoplasty versus standard descmets membrane endothelial keratoplasty. ophthalmology. 2015; 122 (11): 2193-2199. 15. medsinge a, nischel kk. pediatric cataract: challenges and future directions. clin ophthalmol. 2015; 9: 77-90. 16. dick hb, kohnen t, jacobi fk, jacobi kw. long term corneal endothelial cell loss after phacoemulsification through a temporal clear corneal incision. journal of cataract and refractive surgery, 1996; 22 (1): 63-71. 17. jerome r, louis h, ridings f, john c. corneal endothelial cell loss after cataract extraction by using ultrasound phacoemulsification versus a fluid based system. cornea, 2008; 27 (1): 17-21. 18. price mo, price fw. endothelial cell loss after descemet’s stripping with endothelial keratoplasty. ophthalmology, 2008; 115 (5): 857-865. 19. hengerer ic, juburi ma, schultz t, hengerer fh, dick hb. corneal endothelial cell loss and corneal thickness in conventional compared with femtosecond laser assisted cataract surgery: three month follow-up. journal of cataract and refractive surgery, 2013; 39 (9): 1307-1313. 20. chung cf, liang cc, lai jsm, lo esf, lam dsc. safety of trypan blue 1% and indocyanin green 0.5% in assisting visualization of anterior capsule during phacoemulsification in mature cataract. journal of cataract and refractive surgery, 2005; 31 (5): 938-942. 21. jacob s, agarwal a, agarwal a, agarwal s, chowdhary c, chowdhary r, bagmar aa. trypan blue as an adjunt for safe phacoemulsification in eyes with white cataract. journal of cataract and refractive surgery, 2002; 28 (10): 1819-1825. microsoft word 13. ghulam mustafa pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 163 case report bilateral optic disc drusen in hypermetropic children of a family ghulam mustafa memon, shakir zafar, munira shakir, zeeshan kamil, syeda aisha bokhari pak j ophthalmol 2012, vol. 28 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ghulam mustafa memon lrbt, free base eye hospital korangi-2 1/2, karachi-74900 …..……………………….. optic disc drusen are calcified, round, yellow nodules, with various sizes tend to be located within any part of the optic nerve head. according to most theories they are caused by impaired ganglion cell axonal transport, probably related to a small sclera canal and mechanical obstruction. we report a case of 12 year old male child and his 13 year old sister, both presented with decrease vision in our outpatient department. fundus examination of both patients revealed bilateral optic disc swellings with no hyperemia. after investigations, it was proved that both patients suffered from bilateral buried optic disc drusen. decrease vision was because of hypermetropia in both children. ptic disc drusen, also known as hyaline or colloid bodies, are hyaline, calcified, microbodies situated in the prelaminar part of the optic nerve head1. the processes of development of drusen of the optic nerve head is proposed as abnormal axonal metabolism leading to intracellular mitochondrial calcification. small calcified microbodies are formed and calcium continues to deposit on the surface of these microbodies to form drusen2. axoplasmic transport variation is the anatomic substrate for creation of drusen of the optic disk3. optic disc drusen are associated with shorter and hypermetropic eyes, these anatomical situations and vascular factors may give rise to pathogenesis of drusen4,5. optic disc drusen is present in 3.4 to 24 per 1,000 populations and are bilateral in about 75%6. optic disc drusen have irregular autosomal dominant inheritance7. because of continuous calcium deposition, optic disc drusen will increase in size and will become more visible with age. a correct diagnosis of optic disc drusen is compulsory, though effective treatment is not yet present but it is most important to differentiate optic disc drusen from papilledema in order to evade unnecessary neurological examinations6,8. clinical interpretations prove that the optic nerve head drusen are widely asymptomatic and that visual acuity remains unaffected9 but discrete papillary calcifications or hyaline bodies commonly emerge and visual field deficits are commonly noticeable in the second decade of life in patients with pseudopapilledema due to optic disc drusen10. this case is presented to emphasize the importance of optic disc drusen and its association with hypermetropia and inheritance. case report 12 year old male child and his 13 year old sister presented in our eye outpatient department with decrease vision in both eyes since last 5 year. both were student and had no systemic illness. general physical examination and systemic examination were unremarkable. ophthalmologic examination of male child revealed best corrected visual acuity with correction of +19.5 ds in both eyes to be 6/60 (using snellen’s visual acuity chart) with no pin hole improvement. best corrected visual acuity of female patient with correction of +19.0ds in both eyes was 6/36 (using snellen’s visual acuity chart) with no pin hole improvement. there was no deviation in any eye and extra ocular muscle movements were full in both eyes of both patients. both pupils were round, regular and reacting to light and no relative afferent pupillary defect was noted. biomicroscopic examination of both the anterior segments was unremarkable. fundoscopic examination showed bilateral blurred and swollen optic discs margins with no hyperemia and with obliteration of the physiological optic disc cupping (fig 1a, 2a). venous pulsations were present in both eyes in both patients. visual field examination by confrontation showed grossly restricted peripheral o ghulam mustafa memon, et al 164 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology fig. 1a fig. 2a: fundus photographs of patient showing bilateral optic disc swelling and blurred margins and obliteration of the physiological optic disc cupping. fig. b: b-scan ultrasonograph showing focal high acoustic reflectivity because of calcific deposition. visual fields in both eyes but it was not possible to perform automatic humphery perimetry as the patients were young in age so were uncooperative and unable to understand commands for automatic humphery perimetry. a diagnosis of bilateral optic nerve head drusen was made, which was subsequently confirmed by b scan ocular ultrasonography (fig b) and optical coherence tomography (fig c) in our ophthalmic outpatient department. additionally ct scan brain and orbit was done to see the optic nerve head calcification and to exclude any central nervous system pathology. patients and their parents were informed about the condition and cause of decrease vision, which was hypermetropia and their parents were also informed that they and their other offspring should have an ophthalmic examination to exclude optic disc drusens. fig. c: optical coherence tomography showing typically elevated optic nerve head and optically empty cavity and perceptible reflection from posterior surface. disscusion optic disc drusen are congenital and developmental anomalies of the optic nerve head seen frequently in clinical practice, often as an incidental finding during routine ophthalmic examination. optic disc drusen can affect children as well as adults. it is important to consider optic nerve head drusen in the differential diagnosis of papilledema or optic nerve swelling in any age group11. the primary pathology of optic disc drusen is an inherited dysplasia of the optic disc and its blood supply, which influence the formation of optic disc drusen4,12. optic disc drusen has a greater tendency to form in eyes with a small scleral canal; therefore hypermetropic eyes would have a higher rate of optic disc drusen relative to myopic eyes5. the diagnosis of optic disc drusen can be made with bilateral optic disc drusen in hypermetropic children of a family pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 165 clinical findings combined with b scan ultrasound, fundus fluorescein angiography, ocular computed tomography and newer modalities using optical coherence tomography of optic nerve head,11 but ocular b-scan ultrasonography, a non-invasive and cost-effective technique is the most sensitive and method of choice in the recognition of optic disc drusen8,13,15. optic disc drusen shows autofluorescence (ability of substance to emit yellow-green light when stimulated by blue light in the absence of fluorescein dye) in fundus fluorescein angiography. incidental asymptomatic orbital calcifications are frequently encountered on modern high-resolution ct scan images of the brain and orbit14. optical coherence tomography can differentiate optic disc drusen from papilledema and small optic disc without disc drusen as optic nerve head drusen typically elevate the disc surface and appear as an optically empty cavity, sometimes with a perceptible reflection from the posterior surface. the disc surface is also elevated in cases of papilledema, but has a strong anterior reflection behind which, there is no visible structure. the surface of the small optic nerves was slightly elevated, but with less anterior reflectance,16 therefore oct of optic nerve head exposed unique and clinically helpful views of optic nerve drusen17. the aim of presenting this case is that we should consider optic disc drusen in any patient who presents with bilateral optic disc swelling, particularly when the patient is hypermetropic and asymptomatic. conclusion in our case the unique feature is presence of bilateral optic disc drusen in hypermetropic two children of the same family. optic disc drusen may be hereditary and have close association with small scleral canal. author’s affiliation dr. ghulam mustafa memon resident medical officer lrbt, free base eye hospital korangi-2 1/2, karachi-74900 dr. shakir zafar consultant ophthalmologist lrbt, free base eye hospital korangi-2 1/2, karachi-74900 dr. munira shakir consultant ophthalmologist & head of pediatric ophthalmology department lrbt, free base eye hospital korangi-2 1/2, karachi-74900 dr. zeeshan kamil ophthalmologist lrbt, free base eye hospital korangi-2 1/2, karachi-74900 dr. syeda aisha bokhari associate opthalmologist lrbt, free base eye hospital korangi-2 1/2, karachi-74900 reference 1. wilkins jm, pomeranz hd. visual manifestations of visible and buried optic disc drusen. j neuro-ophthalmol. 2004; 24: 125-9. 2. tso mo. pathology and pathogenesis of drusen of the optic nervehead. ophthalmology. 1981; 88: 1066-80. 3. spencer wh. drusen of the optic disk and aberrant axoplasmic transport. the xxxiv edward jackson memorial lecture. am j ophthalmol. 1978; 85: 1-12. 4. obuchowska i, mariak z. refraction and the axial length of the eyeball in patients with the optic disc drusen. klin oczna. 2009; 111: 33-6. 5. strassman i, silverston b, seelenfreund m. optic disc drusen and hypermetropia. metab pediatr syst ophthalmol. 1991; 14: 59-61. 6. auw-haedrich c, staubach f, witschel h. optic disk drusen. surv ophthalmol. 2002; 47: 515-32. 7. lorentzen se. drusen of the optic disk, an irregularly dominant hereditary affection. acta ophthalmol (copenh). 1961; 39: 626-43. 8. arbabi em, fearnley te, carrim zi. drusen and the misleading optic disc. pract neurol. feb; 10: 27-30. 9. giarelli l, ravalico g, saviano s, et al. optic nerve head drusen: histopathological considerations clinical features. metab pediatr syst ophthalmol. 1990; 13: 88-91. 10. hoover dl, robb rm, petersen ra. optic disc drusen in children. j pediatr ophthalmol strabismus. 1988; 25: 191-5. 11. davis pl, jay wm. optic nerve head drusen. semin ophthalmol. 2003; 18: 222-42. 12. antcliff rj, spalton dj. are optic disc drusen inherited? ophthalmology. 1999; 106: 1278-81. 13. kheterpal s, good pa, beale dj, et al. imaging of optic disc drusen: a comparative study. eye (lond). 1995; 9: 67-9. 14. murray jl, hayman la, tang ra, et al. incidental asymptomatic orbital calcifications. j neuroophthalmol. 1995; 15: 203-8. 15. kurz-levin mm, landau k. a comparison of imaging techniques for diagnosing drusen of the optic nerve head. arch ophthalmol. 1999 ; 117: 1045-9. 16. wester st, fantes fe, lam bl, et al. characteristics of optic nerve head drusen on optical coherence tomography images. ophthalmic surg lasers imaging. 41: 83-90. 17. patel nn, shulman jp, chin kj, et al. optical coherence tomography/scanning laser ophthalmoscopy imaging of optic nerve head drusen. ophthalmic surg lasers imaging. 41: 614-2. pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 89 original article topical diltiazem vs travoprost in reducing intraocular pressure in ocular hypertensive / glaucomatous rabbits saadat ullah khan, zulfiqar uddin syed, zulfiqar ali pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: saadat ullah khan department of pharmacology khyber medical college peshawar zulfiqaruddinsyed@gmail.com …..……………………….. purpose: to demonstrate the intraocular pressure (iop) lowering effect of topical diltiazem (calcium channel blocker) in comparison to travoprost (antiglaucoma drug). material and methods: the study was conducted on 50 healthy rabbits of local strain, weighing 1500 to 2000 grams. they were kept at the animal house of department of pharmacology, khyber medical college peshawar. effect of drugs was studied on both eyes of conscious rabbits. rabbits were divided into four groups i.e. a, b, c and d. rabbits of group a, b and c were made ocular hypertensive / glaucomatous by injecting weekly sub conjunctival betamethasone suspension. the iatrogenic glaucoma of group “a” animals were treated with topical diltiazem and group b with topical travoprost drops. group c served as ocular hypertensive control. it received only artificial tears during the research period. group d rabbits were used as normotensive control. they were neither induced for glaucoma nor did they receive any treatment during the research period. results: our study revealed that there was 19% (5.00 + 0.25 mm hg) drop in intra ocular pressure with topical diltiazem. its onset of action was quick and duration of action prolonged. whereas topical travoprost reduced iop by 15% (4.00 + 0.25 mm hg). topical diltiazem was found consistent in its intraocular pressure lowering effect as compared to travoprost. conclusion: topical diltiazem can be used as an alternative anti glaucoma drug in future if found safe in human trials. key words: glaucoma, ocular hypertension, betamethasone suspension, calcium channel blockers (ccb), intraocular pressure (iop). uman nature is curious and non-satisfying. a global research is always underway to find new and improved treatment of glaucoma. as per glaucoma continuum, clinical picture of glaucoma is quite horrible and unpredictable. extensive multicenter researches are in the pipe line to find out the exact mechanism of glaucoma and also to improve anti glaucoma therapy.9 allingham and m bruce shield have mentioned various groups of drugs that are under investigation having not only intraocular ocular pressure lowering properties but also vasodilating and neuroprotective effects.2 calcium channel blockers (ccb) are diverse group of drugs,16 whose therapeutic utilities are still to be explored to fully unleash its therapeutic effectiveness. the new millennium will hopefully explore their diversity in various medical specialties including ophthalmology and especially in glaucoma. since 1970‟s ccbs are being tested for their effects on iop. an ample literature is available on the h saadat ullah khan, et al 90 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology intraocular pressure affecting properties of ccb‟s. there are several conflicting reports available regarding the effects of ccb‟s on iop,18,20,23 but the general tendency is towards its intraocular pressure lowering effect.1,21,22 in glaucoma, the exact mechanism of calcium channel blockers (ccb‟s) on intraocular pressure regulation is not known however literature search has revealed following possible potential mechanisms: 1. ccb‟s act on vascular smooth muscles causing vasodilatation thereby improving optic nerve blood flow and on intracellular calcium metabolism causing neuroprotection.19 2. ccbs cause reduction in aqueous humor production by affecting the ultra-filtration of aqueous in ciliary processes. this is done by relaxing blood vessels in ciliary epithelium thus decreasing the hydrostatic pressure which is one of the factors that causes passage of fluid into ciliary processes.10 3. the (gap) junctions which are possibly regulated by calcium, exist between non pigmented and pigmented ciliary epithelial cells, ccbs may interfere with these (gap) junctions, altering cellular permeability of the ciliary epithelium and thus inhibiting normal aqueous humor formation.11 4. the potassium channel is important in formation of aqueous humor in ciliary epithelium, and this channel depends on the calcium ion. topical administration of the calcium ions has shown an increase in the iop.12 for the reason the ccbs tend to cause reduction in aqueous formation. 5. the trabecular meshwork cells have contractile properties which may be influenced by calcium ions influx through voltage-dependent l-type calcium channels, thus the relaxation of meshwork by ccbs can increase the trabecular outflow facility.13 the perfusion studies in dissected human eyes showed dose related increase in outflow facility after verapamil, diltiazem and nifedipine administration. however in addition, the outflow of aqueous humor influenced by episcleral venous pressure may be directly affected by calcium inhibition.14 in 1997 steroids in suspension form were used to raise intra ocular pressure.15 the present study has been designed to see the effectiveness of topically applied diltiazem on steroid induced raised intraocular pressure in an animal model. the result of the study will be an addition to the existing data and will help in the development of new drug for glaucoma therapy for human beings. ethical approval for this study was obtained from the college ethical committee. material and methods the study was done on both eyes of conscious and normal 50 rabbits. rabbits of either sex i.e. male / female and of both species i.e. colored and albino were used. ages of rabbits were between 1 – 2 years and weight in the range of 1500 – 2000 grams. they were observed for 02 weeks before experimentation. rabbits were kept in the animal house of department of pharmacology, khyber medical college peshawar. fresh and wholesome was provided ad libitum. animals were also provided fodder, wheat grains and grams ad libitum. rabbits were divided into four groups a, b, c and d. group „a‟ consisted of 10 steroid induced ocular hypertensive rabbits. these animals were treated with topical diltiazem 8.9 x 10¯² m, 1 drop daily for 04 weeks. group „b‟ consisted of 10 ocular hypertensive rabbits treated with topical travoprost 1 drop daily for 04 weeks. group „c‟ consisted of 20 ocular hypertensive rabbits that served as ocular hypertensive control. this group received artificial tears 1 drop daily for 04 weeks. group „d‟ consisted of 10 rabbits, used as normal control i.e. normotensive. it received no treatment during the entire period of study. the study was conducted in the department of pharmacology, khyber medical college peshawar in two phases i.e. phase i and phase ii. phase-i (ocular hypertensive phase): during this phase, rabbits of group a, b and c were made ocular hypertensive. rabbits of group d served as normal control. this phase lasted for 21 days i.e. 03 weeks (day 0 to day 21). phase-ii (treatment phase): there was a gap of 02 days (day 22 and day 23) to get a fully established raised intraocular pressure, prior to the start of phase-ii. during phase ii, animals of group a, b and c received topical treatment. topical diltiazem vs travoprost in reducing iop in ocular hypertensive / glaucomatous rabbits pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 91 animals of group „a‟ were instilled topical diltiazem 8.9 x 10¯²m solution, group „b‟, travoprost drops and group „c‟ artificial tears in their eyes. all the drugs were instilled in the frequency of 1 drop daily for 28 days i.e. 04 weeks (day 24 to day 51). reagents and drugs 1. diltiazem powder (i golani traders, chandi ghar, india). 2. travoprost solution; 0.004% (travatan; alconcouvereur, belgium). 3. proparacaine hcl 0.5% (alcaine; alcon – couvereur, belgium). 4. injection betamethasone suspension (celestone cronodose; schering – plough, spain). 5. artificial tears drops (alcon – couvereur, belgium). 6. fluorescein sodium 2% (alcon – couvereur, belgium). diltiazem is available only in tablet form in different strengths as diltiazem hcl. this drug is not available as ophthalmic preparation for therapeutic or experimental purposes. a solution of 8.9 x m strength was chosen. it is the strength which has been reported to induce iop lowering effectively15. its molecular weight is 450.98. 4.013 grams of diltiazem powder was dissolved in 100 ml of distilled water. it served as the stock solution. it was refrigerated and used during the study as a drug per instillation schedule induction of ocular hypertension/ glaucoma 1. group „a‟, „b‟ and „c‟ animals (n = 40) were made ocular hypertensive. 2. iop was raised by subconjunctival injection of steroids in the suspension form.24 to administer injection rabbits were held in especially designed wooden boxes. both the eyes of rabbits were anesthetized by instilling 1 drop of 5% proparacaine hcl every 15 seconds for one minutes. after two minutes betamethasone suspension was injected into the subconjunctival sac using insulin syringe. mild pressure was applied on the eyes for a short period to enhance absorption of drug. 3. in our study rabbits were given weekly subconjunctival injection of 0.7 ml solution of betamethasone sodium phosphate and betamethasone acetate 3 mg/ml each in both eyes for 3 weeks. total of three injections were administered. 4. this combination provided a slow released acetate fraction of betamethasone and readily available sodium phosphate. measurment of intra ocular pressure before starting the study, iop of all rabbits were measured for 2 weeks. 04 measurements were taken during this time. animals exhibiting fluctuations > 5 mm hg in their iop were excluded from the study (n = 5). the excluded animals were replaced with new set of rabbits. intraocular pressure was measured with perkins hand held applanation tonometer (clement clark int. ltd. essex england). throughout the study iop was measured twice a week only i.e. on thursday and monday to avoid corneal epithelial damage and at the same time i.e. 9:00 am, to avoid diurnal variation. during phase-i, the 1st reading of iop was taken immediately before injecting weekly betamethasone i.e. thursday and 2nd was recorded after 3 days i.e. monday. the values observed at “zero time” i.e. 1st injection of betamethasone were considered the base line pressure. animals were placed in especially designed containers to reduce movements. eyes of rabbits were anesthetized with topical local anesthesia and cornea stained with fluorescein. during phase-ii, steroid was stopped but measurement of iop continued. iop values observed at the start of phase-ii were considered to be the starting pressure. instillation of diltiazem, travoprost and artificial tears were started during phase-ii at the 24th day of study (02 days after 3rd betamethasone suspension injection). iop was recorded before instillation of drugs on monday and thursday at 9.00 am. results the iop measurements of 50 rabbits were recorded as shown in table 1 and 2. saadat ullah khan, et al 92 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology the overall normal iop (n = 50) before the start of injecting steroid was in the range of 19.50 ± 0.75 to 21.75 ± 0.25. mean pre-steroidal baseline pressure was 20.83 ± 0.75. injection of steroids led to a rapid rise in iop of group a, b and c. the rise in iop was found statistically significant after 2nd injection of betamethasone suspension and highly statistically significant after 3rd injection. the normotensive control (group d), did not show any statistically significant change in their iop throughout study (p > 0.05). their pressure was in the range of 20.62 ± 0.65 to 21.07 ± 0.37. table 1 represents mean iop ± sd of group a, b and c rabbits. topical diltiazem and travoprost reduced iop effectively. the change in iop of group a and b in comparison to group c, became highly statistically significant right from the 1st week of treatment and remained so throughout the observational period (p < 0.00). with reference to table 2, topical diltiazem proved to be efficacious in its iop lowering effect. it dropped the iop very briskly, particularly between week 1 and 2. amazingly, this iop lowering was so efficacious that, during week 4, it even dropped (20.50 ± 0.66) below base line iop‟s lowest observation of 20.62 ± 0.65 (p < 0.05). the iop, between week 3 and 4, was maintained at a constant level. interestingly iop drop became statistically non-significant in the last week of treatment (p > 0.05). travoprost efficaciously dropped iop (p < 0.05). onset of action was rather slower but gradual as compared to topical diltiazem. it was found consistent in its iop lowering effect during entire study with an average 1.90 ± 0.45 mm hg drops per week p < 0.00. topical diltiazem vs travoprost in reducing iop in ocular hypertensive / glaucomatous rabbits pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 93 iop lowering reached base line value during 4th week of treatment (table 1 and 2). this finding is not in parallel with diltiazem, in which, iop touched base line during 2nd week. topical diltiazem demonstrated an acute iop lowering potential, 5.10 ± 0.61, between week 0 and 2; with an average 1.38 ± 0.45 mm hg drop during week 3 and 4. it seemed that diltiazem took about 02 weeks to fully establish its iop lowering effect. topical diltiazem became statistically insignificant (p > 0.066) between week 2 and 3 and resumed its iop decremental activity between week 3 and 4. the duration of action of both drugs was found prolonged i.e. 24 hours and with an early onset of action. discussion ccb‟s are being investigated for more than three decades for their iop lowering effects. an ample data is available regarding iop lowering potential of calcium channel blockers. the ocular effects of ccb‟s have been reported since 1970‟s. it has been reported in humans, ocular normotensive and ocular hypertensive animals. results are conflicting and till date no consensus has been made.5,18,20,23 above all, ccb‟s are still in the main stray of researchers because of their greater positive potential to affect glaucoma patients by not only lowering iop but also providing vasodilatation and neuroprotection.3,4,7,17 american glaucoma society in its 22nd annual meeting has linked use of calcium and iron supplementation in glaucoma patients.6 this study revealed that diltiazem can lower iop effectively and briskly thus, leading to an addition in the existing data that favors ccb‟s role in the management of glaucoma / ocular hypertension. melena, et al, described the ocular hypotensive effect of ccbs in rabbit model for glaucoma.25 a single dose of verapamil, nifedipine and diltiazem produced a dose – dependent decrease in iop in ocular normotensive rabbits after topical application but not after intravenous administration.25 furthermore, the ocular hypotensive effect of diltiazem was remarkable due to its duration, thus permitting the appropriate administration frequency.26 in humans, topical verapamil, diltiazem and nifedipine have been found to significantly lower iop in normal and ocular hypertensive subjects.27 a single topical application of ccbs prompted iop decrease in ocular hypertensive patients. it was also found that verapamil and diltiazem significantly lowers the iop in normal human volunteers.28 conclusion diltiazem may be helpful in treatment of acute ocular hypertensive crises due to its brisk iop lowering effects and in the treatment of glaucoma and ocular hypertension. however further laboratory and animal studies are required to explore the exact iop lowering mechanism of action, vasodilation and neuroprotection properties of topical diltiazem and demonstrate its systemic or local untoward effect. detailed controlled clinical studies using diltiazem (0.25%) or (0.5%) eye drops for patients with glaucoma seemed to be recommended. author’s affiliation dr. saadat ullah khan department of pharmacology khyber medical college peshawar dr. zulfiqar uddin syed department of ophthalmology combined military hospital multan dr. zulfiqar ali department of ophthalmology ayub medical college abbottabad references 1. luksch a, rainer g, koyuncu d, ehrlich p, maca t, gschwandtner me, vass c, schmetterer l. effect of nimodipine on ocular blood flow and colour contrast sensitivity in patients with normal tension glaucoma. br j ophthalmology, 2005; 89: 21-25. 2. allingham, r rand, damji, shield mb. shield‟s text book of glaucoma. 6th ed. mc grawhill usa; 2010: 13446. 3. anastasios j, kanellopoulos aj, erickson ka, netland pa. systemic calcium channel blockers and glaucoma. laser vision, 2014. 4. araie m, mayama c. use of calcium channel blockers for glaucoma. prog retin eye res. 2011; 30: 57-71. 5. beatty jf, krupin t, nichols pf, becker b. elevation of intraocular pressure by calcium channel blockers. arch ophthalmol. 1984; 102: 1072-6. 6. calcium / iron supplementation and glaucoma linked. american glaucoma society 22nd annual meeting, 2012. saadat ullah khan, et al 94 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology 7. chihiro mayama. calcium channels and their blockers in iop and glaucoma. european journal of pharmacology, 2013. 8. ibrahim g, shaarawy t. the forgotten masses. in: john salman, jack j kanski. glaucoma. 3rd ed. edinburg. butterworth; 2004: 37-50. 9. kanellopoulos j, erickson ka, netland pa. calcium channel blockers and glaucoma. brilliantvision.comlaser vision.gr 2005. 10. caprioli j. the ciliary epithelia and aqueous humor. in: moses r.a. and hart w.m. alder‟s physiology of the eye clinical application. 9thed. mosby company. st. louis, 1997: pp. 204-22. 11. green k, kim k. papaverine and verapamil interaction with prostaglandin e2 and d9-tetrahydrocannabinol in the eye. exp. eye res. 2004; 23: 207-212. 12. podos sm. the effect of cationionophores on intra ocular pressure. invest ophthalmol. 1996; 17: 851-4. 13. soto d, comes n, ferrer e, morales m. modulation of aqueous humor outflow by ionic mechanism involved in trabecular meshwork cell volume regulation. ivest. ophthalmol. vis. sci. 2004; 45: 3650-61. 14. sears m, caprioli j, kazuyoshi k, bausher l. a mechanism for the control of aqueous humor formation. in: drance s.m., and neufeld a.h. glaucoma. applied pharmacology in medical treatment orlando. 2002: 303324. 15. santafe j, martinez de ibarreta mj, segarra j, melena j. a long lasting hypotensive effect of topical diltiazem on the iop in conscious rabbits. naunynschmiedebergs arch pharmacol 1997; 355: 64550. 16. kole p, bhusari ss, bhosale sm kundu s, gunasekaran j, kaushal s, negappa an. exploring therapeutic the utilities of calcium channel blockers. pharmabiz.com 2009. 17. koseki n, araie m, tomidokoro a, nagahara m, hasegawa t, tamaki y, yamamotos. a placebo – controlled 03 years study of calcium blockers on visual field and ocular circulation in glaucoma with low – normal pressure. ophthalmology, 2008; 115: 2049-57. 18. liu s, araujo sv, spaeth gl, katz lj, smith m. lack of effect of calcium channel blockers on open angle glaucoma. glaucoma, 1996; 5: 187-90. 19. abbasoglu oe, karanjitt s. kooner. future role of neuroprotective agents in glaucoma. in: thomas j zimmerman, karanjitt s kooner, mordechai shavir, robert d fechtner. text book of ocular pharmacology. 2nd ed philadelphia. lippincott-raven publisher usa; 1997: 329-47. 20. payne lj, slage tm, cheeks lt, green k. effect of calcium channel blockers on intraocular pressure. ophthalmic res. 1990; 22: 337-41. 21. netland pa, chaturvedi n, dreyer eb. calcium channel blockers in the management of low tension and open angle glaucoma. am j of ophthalmology. 1993; 115: 608-13. 22. segarra j, santafe j, garrido m, martinez de ibarreta mj. the topical application of verapamil and nifedipine lowers iop in conscious rabbits. gen pharmacol. 1993; 24: 1163-71. 23. sp kelly and tj wally. effect of calcium antagonist nifidipine on intraocular pressure in normal subjects. british journal of ophthalmology, 1998; 72: 216-8. 24. melena j., santafe j. and segarra j. the effect of topical diltiazem on the intraocular pressure in betamethasone induced ocular hypertensive rabbits. pharmacology and experimental theraprutics. 1998; 284: pp278-82. 25. santafe j, martínez mj, segarra j, melena j. a longlasting hypotensive effect of topical diltiazem on the intraocular pressure in conscious rabbits. naunynschmiedeberg's arch. pharmacol. 2001; 355: 645-50. 26. abelson mb, gilbert cm, smith lm. sustained reduction of intraocular pressure in humans with the calcium channel blocker verapamil. am. j. ophthalmol. 1998; 108: 155-9. 27. mooshian ml, leonardi lm, schooley gl, erickson k, greiner jv. one drop study to evaluate safety and efficacy of an ophthalmic calcium channel blocker, verapamil, in subjects with elevated intraocular pressure. invest. ophthalmol. vis. sci. 2002; 36: 924-9. 28. netland pa, grosskreutz cl, feke gt, hart lj. color doppler ultrasound analysis of ocular circulation after topical calcium channel blocker. am j ophthalmol. 1995; 119: 694-700. microsoft word 14. updated news and events vol 28_issue 4_ 2012 pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 229 news and events vol. 28, 4, 2012 35th annual national ophthalmic conference & karophth 2013 date: 08 – 10 march, 2013 venue: pearl continental hotel, karachi contact: dr. qazi m. wasiq phone: +92 333 2183272 email: ospkarachi@yahoo.com the 28th asia – pacific academy of ophthalmology (apao) congress date: 17 – 20 january, 2013 venue: hyderabad, india web: www.apaophth.org american society of cataract and refractive surgery (ascrs) / american society of ophthalmic administrators (asoa) symposium and congress date: 19 – 23 april, 2013 venue: san francisco web: www.ascrs.org the association for research in vision and ophthalmology (arvo) annual meeting 2013 seattle washington, united states date: 5 – 9 may, 2013 venue: seattle, washington web: www.arvo.org 26th asia – pacific association of cataract & refractive surgeon annual meeting 2013 (apacrs 2013) date: 11-14 july, 2013 venue: suntec singapore international convention centre, singapore web: www.apacrs.org 5th world glaucoma congress date: 17-20 july, 2013 venue: vancouver, canada web: www.worldglaucoma.org the 8th asia-pacific vitreo-retina society congress (apvr) date: 06-08 december, 2013 venue: nagoya, japan web: www.apvrs.org/2013/web 34th world ophthalmology congress (woc) & the 29th asia – pacific academy of ophthalmology (apao) congress date: 2 6 april, 2014 venue: tokyo, japan web: www.apaophth.org 11th european glaucoma society conference date: 7-11 june 2014 venue: nice, france web: www.eugs.org xxi biennial meeting of international society for eye research date: 20-24 jul, 2014 venue: san francisco, california web: www.iser.org institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091 – 9217376 – 80 fax: 92 – 42 – 36363326 email: pico@pes.comsats.net.pk college of ophthalmology and allied vision sciences lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics news and events 230 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042 – 37355998 fax: 042 – 37248006 email: pipo@brain.net.pk pakistan institute of ophthalmology, al – shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al – shifa trust eye hospital, jhelum road, rawalpindi – pakistan phone: 92 – 51 – 5487830, 5487820 – 25 fax: 92 – 51 – 5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt 4-a lda flats lawrence road, lahore phone: 92 – 42 – 36363326 email: pjoosp@gmail.com microsoft word 4. haroon tayyab 188 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology original article modified technique of four point scleral sutured posterior chamber intraocular lens without scleral flaps haroon tayyab, muhammad ali haider, tehmina jahangir sana jahangir, samina jahangir, akhwand abdul majeed pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: haroon tayyab house # suh-24, askari xi, cobbe lane, near qasim market, rawalpindi …..……………………….. purpose: to report the visual outcome, safety and complication profile of four point scleral sutured posterior chamber intraocular lens without sclera flaps. material and methods: this prospective interventional study comprised 21 eyes of 21 aphakic patients who were admitted in ophthalmology ward of jinnah hospital lahore from april 2010 to august 2011 for secondary intraocular lens implantation using four point scleral fixation technique. three follow up visits were scheduled starting at 1st post operative day, 1st and 5th post operative months. results: twenty one eyes of 21 patients, 12 male and 9 female, underwent four point scleral fixation of posterior chamber intraocular lens with custom modification in intraocular lens design. at 5th month follow up, 18 patients had best corrected visual acuity of 6/12 or better. two patients had cystoid macular edema and one had tilted intraocular lens. no patient had any sign of suture erosion, elevated intraocular pressure or intraoperative bleeding. conclusion: four point scleral fixation without scleral flaps is a safe technique of intraocular lens implantation in aphakic patients. osterior capsular (pc) rupture is one of the most frequent complications during phacoemulsification surgery1. visual rehabilitation of an aphakic eye becomes a challenging situation for the surgeon. common therapeutic options available for such a situation include aphakic spectacles, contact lenses, anterior chamber intraocular lens (ac iol), scleral fixated posterior chamber intraocular lens (pc iol) and refractive corneal surgery2. in patients with bilateral aphakia, aphakic spectacles remain safest and most cost effective solution but patients are optically intolerant to aphakic spectacles3. contact lens is a better optical solution for aphakia but intolerance, care and cost pose a significant problem to patients of middle and late age groups in our setup. ac iols provide a quick and readily available answer to aphakia, but they have been associated with a myriad of complications like glaucoma secondary to angle damage and pupil block, hyphaema, pigment dispersion and persistent anterior uveitis4. scleral fixation of pc iol is a suitable option for aphakic patients who are optically dissatisfied with aphakic spectacles and for those who cannot undergo expensive refractive surgery. scleral fixation of pc iol was first reported by girard5 in 1981 and then was later improved on by malbran6 and colleagues in 1986. american academy of ophthalmology sponsored report by wagoner and colleagues concluded that scleral fixation of pc iol is a safe and effective technique in adults with aphakia with minimal or no capsular support7. major problems with scleral fixation include tilting of intraocular lens (iol) and questionable long life of the suture material used. four point scleral fixation of p modified technique of four point scleral sutured posterior chamber intraocular lens pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 189 pc iol is a novel technique for correction of aphakia in children and adults8. recently almashad and colleagues conducted a case series of four point scleral fixation of pc iol without scleral flaps and concluded that this technique reduces the operation time, achieves good centration and stability of the iol, and minimizes postoperative suture – related complications8. we conducted a similar case series utilizing recommended surgical steps of four point scleral fixation with few modifications regarding the iol. material and methods this prospective interventional study was conducted in ophthalmology department of jinnah hospital lahore from april 2010 to august 2011. twenty one aphakic patients were enrolled for four point scleral fixation of pc iol after meeting the inclusion and exclusion criteria. inclusion criteria consisted of following: improvement of best corrected visual acuity to ≥ 6/36, age more than 50 years, patients unable to or intolerant to contact lens and aphakic spectacles, no significant anterior segment structural abnormality and no active uveitis. patients were excluded from the study based on the following criteria: patients with only eye, active or old vitreoretinal pathology threatening to compromise immediate and long term visual results of this surgery, patients with diabetic clinically significant macular edema, patients with cystoid macular edema and patients with active adnexal diseases like blephritis or nasolacrimal duct pathologies. an informed consent was obtained where all risks and benefits of this procedure were explained to patients. approval from hospital’s ethical committee was officially sought. patients were recruited from the outpatient patient department (opd) after undergoing complete ocular and systemic evaluation including best corrected visual acuity, intraocular pressure measurement, complete anterior and posterior segment evaluation using slit lamp and indirect ophthalmoscopy. a detailed medical history was taken to rule out uncontrolled diabetes, hypertension, asthma, orthopnea and history of seizures and tremors. broad spectrum topical antibiotic was started 1 day before surgery. biometry was performed using ocuscan by alcon (fort worth, texas). all surgeries were performed by a single surgeon under local anesthesia. local anesthesia consisted to equal proportion mixture of lignocaine 2% and bupivacaine 0.5%. surgical technique patients were prepared and draped following standard protocols for routine cataract surgery ensuring instillation of 5% povidone iodine on ocular surface and fornices for 3 minutes. limited anterior vitrectomy was performed for removal of vitreous from anterior chamber, pupillary plane and from the plane of posterior chamber (anticipated location of iol placement). limited conjunctival peritomy centered at 1:30 and 7:30 clock hours was performed. hemostasis on scleral bed was achieved through bipolar wet field cautry. 3mm long partial thickness (2/3 scleral depth) scleral grooves were made at 1:30 and 7:30 clock hours using 15° phaco knife. these scleral grooves were positioned exactly 0.75mm behind posterior surgical limbus to avoid damage to vascular portion of ciliary body (fig 1a). a 10° bent tip 27 gauge needle was passed vertically down from one edge of 7:30 clock hour scleral groove. a 10/0 prolene suture with straight needle was passed vertically into posterior chamber half way through its length 180° opposite to 27 gauge needle; using 1:30 clock hour scleral groove (fig 1b). 10/0 prolene needle was engaged in the lumen of 27 gauge needle and 27 gauge needle was carefully withdrawn (fig 1c). this resulted in a single strand of 10/0 prolene spanning from 1:30 to 7:30 clock hours in the posterior iris plane (fig 2a). the bent tip of 27 gauge needle ensured that 10/0 prolene needle does not slip out during its withdrawal from the globe. special attention was paid not to damage any intraocular structures during these maneuvers including iris, ciliary body and retina. an identical procedure was repeated from the other end of both scleral grooves (fig 2b). now we had 2 strands of 10/0 prolene spanning the posterior iris plane (fig. 2c). at this stage, 6.5 mm optic diameter pmma intraocular lens was prepared to be tied to 10/0 prolene. the haptics of iol were bent from their edges by a length of 1 mm using a squint hook heated on a spirit lamp (fig 3b). this modification (haroon’s technique) from standard technique was introduced to counter two issues. one, the lack of ready availability of standard scleral fixation iols in required powers. secondly, to ensure the prolene knot does not slip from the haptic during postoperative period. haroon tayyab, et al 190 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology one strand of 10/0 prolene was retrieved using standard iol dialer through a near clear corneal shelved incision (fig 3a). after dividing the exteriorized 10/0 prolene into two equal halves, its ends were tied to the haptics of iol (fig 3b). similar routine was repeated for the second strand of 10/0 prolene (fig 3c). this time around, special care was taken not to entangle the sutures and ensure careful placement of sutures at their appropriate places on iol haptics. corneal incision was enlarged to 7mm using phaco knife and iol was inserted in the eye while performing controlled tractions on the exposed edges of 10/0 prolene. knots were tied resulting in complete burial 10/0 prolene in the scleral grooves (fig 3d). corneal incision was secured using 10/0 ethilon and peritomies were closed using 6/0 vicryl. patients were started on routine post operative topical and systemic medications and were discharged on the same day. they were called back on 1st post operative day and then 1st and 5th post operative month. results 21 eyes of 21 patients underwent four point scleral fixation of pc iol without scleral flaps during the mentioned period of this interventional study. all patients fell in the age range of 50 to 75 years with mean age of 63 years. 12 (57%) patients were male and 9 (43%) were female. 10 (48%) patients had their right eye operated while 11 (52%) patients had surgery done on their left eye. all of these patients had a primary complicated extra-capsular cataract extraction (ecce) or phacoemulsification for age related cataracts resulting in minimal or no capsular support left, such that iol could not be implanted at the time of primary surgery. adequate time was given to all patients to recover from their primary complicated surgery before (a) (b) (c) fig 1: (a) shows 3 mm long partial thickness scleral grooves located 0.75mm away from surgical limbus. (b) shows entry of 10/0 prolene straight needle (green) from 1:30 clock hour and 27 gauge needle (blue) at 7:30 clock hour. (c) shows 10/0 prolene straight needle (green) engaged in the lumen of 27 gauge needle (blue) while the needle is being withdrawn from the globe. (a) (b) (c) fig 2: (a) shows a single strand of 10/0 prolene suture spanning the peripupillary plane. (b) shows the second needle pass from the other end of scleral groove. (c) shows 2 strands of 10/0 prolene suture spanning the peripupillary plane. (a) (b) (c) (d) fig 3: (a) shows one strand of 10/0 prolene being withdrawn from corneal incision with help of iol dialer. (b) shows cut ends of prolene being tied to the haptics of iol. it also shows that the edges of iol haptics are bent 1mm from the ends. (c) shows 2 strand of 10/0 prolene suture being tied to the haptics. (d) shows implanted iol in posterior chamber plane with 10/0 prolene knot securely buried in the scleral groove. modified technique of four point scleral sutured posterior chamber intraocular lens pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 191 secondary iol implantation was contemplated. descriptive statistics are shown in table 1. seven (33%) patients had pre operative best corrected visual acuity (bcva) of 6/12 or better (table 2). after 1st post operative month bcva was 6/12 or better in 16 (76%) patients (table 2). at the end of 5 month follow up, 18 (86%) patients had bcva of 6/12 or better (table 2). one patient (4.8%) had tilted iol at 5 month post operative follow up and cause was identified to be inadequate anterior vitrectomy done at the time of scleral fixation. two patients (9.5%) had cystoid macular edema (cmo) at 1 month follow up as shown in (fig. 4). standard treatment was started for both patients; one patient responded to the treatment with improvement of bcva at 5 month follow up to 6/18 partial. the other patient had bcva of 6/24 at the end of 5 month follow up. the mean bvca was statistically significant at the end of follow-up. there was no reported case of intraocular bleeding, suture related problems like suture erosion or exposed suture, persistent uveitis, pigment dispersion, raised intraocular pressure, pupil related complications or endophthalmitis. fig. 5 shows the cumulative improvement in bcva at the end of 5 months follow up. discussion four point scleral fixation is a very safe and effective technique for visual rehabilitation in aphakic eyes having minimal or no capsular support. recent studies have shown that four point scleral fixation significantly reduces the iol tilt related problems.8 tong and colleagues showed that four point scleral fixation is an effective method to counter aphakia secondary to complicated globe trauma10. almashad and his colleagues performed a case series of four point scleral fixation without scleral flaps. they utilized scleral grooves similar to that we described in our study and concluded that this technique significantly reduces surgical time, iol tilt related problems and suture related problems like knot exposure and erosion9. the results of these two studies are comparable. a deep scleral groove allows for easy concealment of 10/0 prolene knots and four point fixation permits ease and simplicity of knot tying. a comparison of 4 point versus 2 point scleral fixation was conducted by fass and colleagues. he concluded in his study that 4 point scleral fixation of pc iol has lower chances of cystoid macular edema and pigment dispersion glaucoma as compared to 2 point fixation.11 our results were comparable to this study. none 85.7% cystoid macular edema 9.5% titled iol 4.8% cystoid macular edema none titled iol fig. 4: shows complication profile as of four point sclera fixation. fig. 5: cumulative improvement in bcva at 5 months. most investigators prefer ciliary sulcus fixation but apple and associates12 have shown that posterior chamber iol haptics often miss the sulcus and that the sulcus diameter is only 11.0 to 11.5 mm, less than most surgeons think. duffey and associates13 used needles perpendicular to the sclera to demonstrate scleral relationships to the ciliary sulcus and found that the sulcus lies only 1.0 mm posterior to the posterior surgical limbus in the vertical meridian and 0.5 mm behind the limbus in the horizontal meridian. in view of this, we placed sutures 0.75 mm posterior to the limbus in oblique meridians. careful scleral location of needle entries maximized our chances for ciliary sulcus fixation and reducing the risk of bleeding from inadvertent perforation of the major arterial circle of the iris, which is located in the anterior ciliary body. berler proposed that the only negative feature of this haroon tayyab, et al 192 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology technique is the initial confusion the surgeon faces when he has to handle 4 very delicate 10/0 prolene sutures coming out of the main incision site at the same time. but this initial problem is adequately handled with an experience of 1 or 2 cases and suture handling keeps on getting better with every case. due to meager availability of special iols designed for the sole purpose of scleral fixation, we were compelled to modify the haptics of a regular (6.5 mm optic diameter) polymethylmethacrylate (pmma) iol in such a fashion to minimize every chance of knot slippage from haptics in post operative period. this novel approach resulted in very satisfactory results for all the patients in this study. four patients are in their second year of follow up with no complications like knot slippage, tilting of iol and suture erosion. our results of post operative bcva were comparable to almashad9 and fass11. follow up of our patients was brief (5 months) but modified technique of four point scleral sutured posterior chamber intraocular lens pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 193 initial 5 months of uneventful recovery and extensive review of four point scleral fixation of pc iol experienced by others in the literature suggested that no complications need be anticipated in the near or long term future. we encourage the appropriate use of four point scleral fixation of pc iol without scleral flaps and offer an alternate to custom made scleral fixation iols by proposing a very subtle modification of iol haptics in above described fashion to avoid knot slippage. we offer an implantation technique that may prove beneficial in certain situations. author’s affiliation dr. haroon tayyab senior registrar jinnah hospital lahore dr. muhammad ali haider medical officer lahore general hospital dr. tehmina jahangir senior registrar jinnah hospital lahore dr. sana jahangir medical officer jinnah hospital lahore prof. dr. samina jahangir professor and head of ophthalmology department jinnah hospital lahore dr. akhwand abdul majeed medical officer jinnah hospital lahore references 1. langwińska we, szulborski k, broniek kk. the complications during phacoemulsification in patients with posterior polar cataract. klin oczna 2011; 113: 16-8. 2. mutoh t, matsumoto y, chikuda m. scleral fixation of foldable acrylic intraocular lenses in aphakic postvitrectomy eyes. clin ophthalmol. 2011; 5: 17–21. 3. buckley e g. hanging by a thread: the long-term efficacy and safety of transscleral sutured intraocular lenses in children (an aamerican ophthalmological society thesis). trans am ophthalmol soc. 2007; 105: 294–311. 4. huang ys, xie lx, wu xm, han ds. long-term followup of flexible open-loop anterior chamber intraocular lenses implantation. zhonghua yan ke za zhi. 2006; 42: 391-5. 5. girard lj. pars plana phacoprosthesis (aphakic intraocular implant): a preliminary report. ophthalmic surg. 1981; 12: 19-22. 6. malbran es, malbran e jr, negri i. lens guide suture for transport and fixation in secondary iol implantation after intracapsular extraction. int ophthalmol. 1986; 9: 151-60. 7. wagoner md, cox ta, ariyasu rg. intraocular lens implantation in the absence of capsular support: a report by the american academy of ophthalmology. ophthalmology 2003; 110: 840-59. 8. sewelam a. four-point fixation of posterior chamber intraocular lenses in children with unilateral aphakia. j cataract refract surg. 2003; 29: 294-300. 9. almashad gy, abdelrahman am, khattab ha, et al. four-point scleral fixation of posterior chamber intraocular lenses without scleral flaps. br j ophthalmol. 2010; 94: 693-5. 10. tong jp, luo wl, yang cq, lu h: two techniques of posterior chamber intraocular lens (iol) implantation by a 4-point ciliary sulcus suture fixation technique combined with vitrectomy. zhejiang da xue xue bao yi xue ban. 2009; 38: 525-30. 11. fass on, herman wk. four-point suture scleral fixation of a hydrophilic acrylic iol in aphakic eyes with insufficient capsule support. j cataract refract surg. 2010; 36: 991-6. 12. apple dj, price fw, gwin t. sutured retropupillary posterior chamber intraocular lenses for exchange or secondary implantation. ophthalmology. 1989; 96: 12417. 13. duffey rj, holland ej, agapitos pj. anatomic study of transsclerally sutured intraocular lens implantation. am j ophthalmol. 1989; 108: 300-9. 40 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology original article spontaneous internal limiting membrane removal while peeling epiretinal membrane irfan qayyum malik, haroon tayyab, ali zain, junaid afzal pak j ophthalmol 2015, vol. 31 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irfan qayyum malik department of ophthalmology gujranwala medical college irfan790@yahoo.com …..……………………….. purpose: to determine the incidence of accidental internal limiting membrane removal in cases of epiretinal membrane peel. material and methods: it was a prospective observational study. the study was done at eye unit iii mayo hospital lahore from 1 st january 2014 to 30 th june 2014. twenty patients (11 males and 9 females) of epiretinal membrane peeling were included in the study. in all the cases epiretinal peeling was done by a single surgeon. after epiretinal membrane removal brilliant blue dye was used to stain the internal limiting membrane and the surgeon observed the characteristic of internal limiting membrane, that whether it was removed spontaneously during the peeling of epiretinal membrane or not. the main outcome measured was status of the ilm after erm peel. results: out of 20 patients 11(55%) patients had spontaneous internal limiting membrane peeling during the removal of epiretinal membrane, with only very minute remnants at some places. while 8 (40%) patients had intact ilm but it was damaged at various sites. while one patient had intact and undamaged ilm. conclusion: internal limiting membrane is frequently removed during erm peeling. staining with brilliant blue g facilitates its identification. key words: ilm peel, internal limiting membrane, epiretinal membrane. n epiretinal membrane (erm) is a relatively common retinal disorder with a prevalence of 3.5% to 6.9%.1 it mostly occurs in elderly patients. it can be caused secondarily in various ocular conditions, such as uveitis, trauma, retinal detachment, or retinal vascular diseases. however, causative abnormalities are not found and are considered to be idiopathic in many cases. it is believed that migration of glial cells through defects of internal limiting membrane (ilm) into the vitreous cavity causes erm development on the surface of ilm2. clinically significant erm ranges from dense opaque tissues to fine transparent membranes. epiretinal membranes can cause tangential traction with retinal changes like thickening of retinal layers, surface wrinkling, or nerve fiber layer (nfl) fibrillation. these changes lead to reduction of visual acuity and metamorphopsia. advanced forms of erm with decrease of visual acuity and progression of clinical symptoms can be treated with pars plana vitrectomy and erm peeling.3 staining of these transparent tissues with vital dyes during vitrectomy greatly simplifies the procedure. over the past decade, several substances, including indocyanine green (icg), trypan blue, and brilliant blue g (bbg), have been used during vitrectomy as staining agents. their staining capabilities have been confirmed, but concerns over retinal toxicity remain4. vitrectomy is usually performed to remove the erm in symptomatic cases. recurrence after successful surgery has been reported to occur in 10% to 16.3% of cases.5 ilm removal can be performed to a http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3730067/#b1 spontaneous internal limiting membrane removal while peeling epiretinal membrane pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 41 reduce the recurrence rate, because the ilm can act as a scaffold for glial proliferation after successful removal of the erm.6 latest studies have shown that there is less chance of erm formation if ilm peeling is done per operatively7. our rational was to find that what are the chances of spontaneous ilm removal in cases of erm peel surgery. material and methods it was a prospective observational study. the study was done at eye unit iii, mayo hospital lahore from 1st january 2014 to 30th june 2014. twenty patients of epiretinal membrane were included in the study. all patients had symptomatic visual loss. the patients were admitted from outpatient department of mayo hospital lahore. eyes with idiopathic epiretinal membrane were included in the study. eyes with epiretinal membranes following retinal detachment repair were excluded from the study. eyes with intrinsic macular diseases that may have decreased visual acuity such as diabetic retinopathy, branch retinal vein occlusion, or pars planitis were also excluded. a detailed pre-operative examination was carried out in all patients, with their visual acuity, pupil reaction, intraocular pressure, slit lamp examination of anterior segment, slit lamp and indirect ophthalmoscopy of posterior segment. informed consent was taken from all the patients. fig. 1: fundus photograph of epiretinal membrane. the surgical procedure consisted of 3-ports pars plana vitrectomy using 20 gauge instrumentations, which was followed by intravitreal triamcinolone acetonide to verify that the posterior hyaloid had been removed. the macular erm was removed according to the surgeon’s preferred technique. erm was grasped directly with an intraocular forceps and was removed from the macular surface. once the membrane was free from the retinal surface, it was removed from the eye. the surgeon then observed the characteristics of the underlying ilm by using brilliant blue g. the ilm was classified as a, absent; b, present and undamaged c, present and damaged. peeling of the remainder of the ilm was performed in all the cases. patients were examined preoperatively and at 1 day, 1 week, 2 weeks, 1 month, and 2 months after surgery, and at different times thereafter. the followup examinations included: bcva, slit-lamp examination of the anterior segment, intraocular pressure measurements, +90d lens – aided fundus biomicroscopy. results out of 20 patients 11 (55%) patients had spontaneous internal limiting membrane peeling during the removal of epiretinal membrane, with only very minute remnants at some places. while 8 (40%) patients had intact ilm but it was damaged at various sites. while one patient had intact and undamaged ilm. peeling of the remainder of the ilm was performed in all the cases. fig. 2: after the removal epiretinal membrane. discussion the ilm is a basement membrane, deriving from muller cells. it is made up of the footplates of the irfan qayyum malik, et al 42 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology müller cells and represents the interface between the retina and the vitreous. it is thinner in the periphery and thicker in the macula, with a mean width of 2.5 μm. epiretinal membranes are avascular, fibrocellular membranes that proliferate on the inner surface of the ilm and produce various degrees of visual impairment.8 some erms may be hardly visible clinically and may have little or no effect on vision, while extensive erms cause secondary complications and marked visual loss. vitrectomy has become a common procedure for the treatment of visual loss due to epiretinal membranes over the past 2 decades. ilm peeling is frequently performed to reduce erm recurrence9. removal of the ilm was expected to reduce the recurrence rates by limiting the myofibroblasts proliferation, consequently minimizing the development of a recurrent erm. researchers have also demonstrated that the surgical outcome is better and erm recurrence is significantly lower in erm patients undergoing ilm peeling compared with those without ilm peeling.10 a number of dyes are in use with different affinities for intraocular collagen and cellular elements. commonly used dyes in clinical practice include indocyanine green (icg), trypan blue (tb), and brilliant blue. we used brilliant blue g to stain the ilm. the importance of ilm peeling in erm surgery and its influence on visual acuity improvement was evaluated in previous studies11. studies suggest that the interpretation of the ilm may be helpful to predict functional outcome. they have suggested that simultaneous ilm peeling showed a slower restoration of the retinal anatomy compared with eyes that had erm peeling only. so there is less chance of erm recurrence. since the evolution of optical coherence tomography, there have been several publications on the morphology of erm and functional outcome after surgery. spectral domain oct (sd) is a recent, novel technique that provides dramatic increase of imaging speed; 50-times faster than standard resolution oct. so contour of posterior hyaloid, traction forces of erm and internal limiting membrane wrinkling are easier to identify. due to non availability of spectral domain oct (sd) in our centre, we checked the characteristic of ilm by using brilliant blue dye peroperatively, that whether ilm was spontaneously removed during the peeling of erm or not. researchers have shown that during the removal of the erm, the internal limiting membrane is spontaneously removed together with the erm in about 40% of cases.3 the rate of simultaneous removal of both the erm and the ilm was 55% in our study. the focus of our study was to find that what are the chances of spontaneous ilm removal in cases of erm peel surgery, and we found that in 55% of the cases it was removed along with the removal of erm. conclusion our study showed that internal limiting membrane is frequently removed during the peeling of epiretinal membrane. author’s affiliation dr. irfan qayyum malik assistant professor of ophthalmology gujranwala medical college, gujranwala dr. haroon tayyab department of ophthalmology mayo hospital, lahore dr. ali zain department of ophthalmology mayo hospital, lahore dr. junaid afzal department of ophthalmology mayo hospital, lahore references 1. kawasaki r, wang jj, sato h, mitchell p, kato t, kawata s, kayama t, yamashita h, wong ty. prevalence and associations of epiretinal membranes in an adult japanese population: the funagata study. eye (lond) 2009; 23:1045–51. 2. n. mandal, m. kofod, h. vorum, jorgen villumsen, jesper eriksen, steffen heegaard, jan u. prause, satpal ahuja, bent honore and morten la cour. “proteomic analysis of human vitreous associated with idiopathic epiretinal membrane,” acta ophthalmologica, vol. 91, no. 4, pp. e333–e334, 2013. 3. mcdonald hr, verre wp, aaberg tm. surgical management of idiopathic epiretinal membranes. ophthalmology. 1986; 93: 978–83. 4. querques g1, prascina f, iaculli c, noci nd retinal toxicity of indocyanine green. int ophthalmol. 2008 apr; 28 (2): 115-8. epub 2007 jun 21. 5. grewing r, mester u. results of surgery for epiretinal membranes and their recurrences. br j ophthalmol. 1996; 80: 323–6. http://www.ncbi.nlm.nih.gov/pubmed/?term=mitchell%20p%5bauthor%5d&cauthor=true&cauthor_uid=19440207 http://www.ncbi.nlm.nih.gov/pubmed/?term=kato%20t%5bauthor%5d&cauthor=true&cauthor_uid=19440207 http://www.ncbi.nlm.nih.gov/pubmed/?term=kawata%20s%5bauthor%5d&cauthor=true&cauthor_uid=19440207 http://www.ncbi.nlm.nih.gov/pubmed/?term=kayama%20t%5bauthor%5d&cauthor=true&cauthor_uid=19440207 http://www.ncbi.nlm.nih.gov/pubmed/?term=yamashita%20h%5bauthor%5d&cauthor=true&cauthor_uid=19440207 http://www.ncbi.nlm.nih.gov/pubmed/?term=wong%20ty%5bauthor%5d&cauthor=true&cauthor_uid=19440207 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epiretinal membranes affecting the macula and removed by vitreous surgery. trans am ophthalmol soc. 1982; 80: 580-656. 9. grimbert p, lebreton o, weber m. optical coherence tomography and micro-perimetry after internal limiting membrane peeling for epiretinal membrane. j fr ophtalmol. 2014; 37: 434-41. 10. park dw, dugel pu, garda j, sipperley jo, thach a, sneed sr, blaisdell j. macular pucker removal with and without internal limiting membrane peeling: pilot study. ophthalmology. 2003; 110: 62-4. 11. falkner-radler ci, glittenberg c, binder s. spectral domain high-definition optical coherence tomography in patients undergoing epiretinal membrane surgery. ophthalmic surg lasers imaging. 2009; 40: 270-6. http://www.ncbi.nlm.nih.gov/pubmed/?term=mori%20r%5bauthor%5d&cauthor=true&cauthor_uid=19427701 http://www.ncbi.nlm.nih.gov/pubmed/?term=mizutani%20y%5bauthor%5d&cauthor=true&cauthor_uid=19427701 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vol. 33, no. 2, apr – jun, 2017 240 original article effect of stress on visual functions syeda rushda zaidi, samia iqbal, hakim anjum nadeem, syed hamza ali, muhammad jamshed pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syeda rushda zaidi department of optometry and vision sciences, fahs, the university of lahore email: rushdazaidi15@live.com …..……………………….. purpose: to find out the effect of stress on visual function. study design: cross-sectional study. duration and place of study: department of psychology, fountain house, lahore and department of optometry and vision sciences, the university of lahore from february to may 2017. material and methods: visual acuity screening, glare sensitivity, contrast sensitivity, color vision and visual field were performed on a sample of 70 patients having stress using ishihara test, snellen chart, pelli-robson contrast sensitivity test, snellen chart for glare sensitivity and confrontation method respectively. screening tests were carried to measure visual functions in patients with diagnosed stress disorders. patients diagnosed with stress within the age range of 18 – 40 years were taken into consideration. data was analyzed using spss version 20. results: out of 70 patients having history of stress 47.1% patients showed defects in contrast sensitivity and 42.85% patients showed decrease in visual acuity. there were 35.7% subjects having decrease in glare sensitivity while 99% of patients exhibited no defect in visual field and color vision. the study conducted was unbiased to age, occupation and gender. conclusion: stress affects the visual functions. visual acuity, glare sensitivity and contrast sensitivity are affected by stress in majority cases. however, stress patients have normal color vision and visual field. key word: stress, visual acuity, visual field, contrast sensitivity, color vision. ost cases demonstrate that stress is a diagnosable and quite obvious sickness. feeling unhappy cannot be usually characterized as stress; there are certain symptoms which exhibit the effects physically. clinical depression has several names such as unipolar stress, major stress disorder and recurrent stress1. underlying cause of stress is mostly mood disorders. anxiety, extremes and phobia can be a part of an acute attack of stress, but during the stress episode each patient may present with several scenarios. stress, in general can be explained as low mood in the form of sadness, decreased self-esteem, guilt or reduced interest in things once found pleasurable. the basic symptoms in clinical terms for stress, is deviance in mental abilities, distressful mood, sadness, sense of de-personalization, reduction and aggravation of motor behavior. moreover it involves somatic fixation, suicidal thinking, insomnia, loss of weight and appetite loss1. anomalies are approximately 50% of psychopathology in stress but prevalence varies with the type of stress2. there are different types of stress including persistent stress disorder, major stress, postpartum stress, bipolar disorder and seasonal affective disorder3. stress has its several forms, whether it can be seasonal or non-seasonal. it can be due to psychosis or anxiety (neurotic). individual can have bipolar disorder or a mother can suffer from postpartum stress. symptoms of stress are intrusive in daily routine activities. such activities can be very simple as sleeping, eating etc but it just happens once in a m mailto:rushdazaidi15@live.com syeda rushda zaidi, et al 241 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology lifetime and an individual can possibly have many cycles4. persistent stress includes patients with symptoms longing for 2 years. individuals can have episodes of major stress with major symptoms of less severity5. symptoms of psychotic stress include hallucinations or psychosis of delusions5. postpartum stress happens because of the hormonal and physical changes in women, after giving birth to a new born5. with reduced sunlight, seasonal affective stress elevates in winters. one of the treatment is connected with light therapy5. bipolar disorder has two phases. first one is known as maniac phase, the other one is the low extreme, which is very depressive stage. it is less common than persistent depression5. in some scenarios, depression can also be related to stress but figuratively not being a type of stress. depression is known as burden, and in other terms, it would be the lack of ability to cope with the surrounding environment6. anxiety on other side is the distressing sense of being nervous, panic and fear being its component7. stress is characterized as diminution in gratifications, pessimistic feeling toward self, crying spells, failure of emotional attachments, disconsolate temper and loss of mirth response. we undertook this study to find which component of visual system is compromised due to stress level. materials and methods a cross sectional study was conducted on 70 patients having history of stress with age range of 18 – 40 years. all patients were diagnosed with stress by a psychiatrist. patients of all other ages or having any other systemic disorders were excluded from the study. the purpose of the study was to find the relationship of stress with visual functionality. therefore all patients underwent measurement of distance (6 m) and near (33 cm) visual acuity by using near visual acuity charts and snellen distance charts. contrast sensitivity was measured by using pellirobson chart. visual fields were measured by confrontation test and glare sensitivity was measured by photo stress test. results were obtained by asking the patient to fill a structured proforma. the results were analyzed using spss version 20. results results of table 1 show that there is an associated effect of stress on visual acuity. in forty subjects visual acuity in both eyes was 6/6 to 6/12 in range. remaining 30 subjects have visual acuity 6/12 to 6/60. table 2 clearly shows that there is relevant impact of stress on contrast sensitivity. thirty seven subjects were found with contrast sensitivity of 1.25% to 5%. other 33% had contrast sensitivity from 5% to 25%. table 1: visual acuity and stress cross tabulation. count stress frequency percentages yes visual acuity 6/6 – 6/12 40 40 57% 6/12 – 6/60 30 30 43% total 70 70 100% table 2: contrast sensitivity and stress cross tabulation. count stress frequency percentage yes contrast sensitivity 1.25% 5% 37 37 53% 5% 25% 33 33 47% total 70 70 100% effect of stress on visual functions pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 242 table 3: color vision and stress cross tabulation. count stress frequency percentage yes color vision of right eye 12/12 – 8/122 70 70 100% total 70 70 100% table 4: glare sensitivity a d stress cross tabulation. count stress frequency percentage yes glare sensitivity 6/6-6/12 45 45 64% 6/12-6/60 25 25 36% total 70 70 100% table 5: visual field of right eye and stress cross tabulation. count stress frequency percentage yes visual field good 70 70 100% total 70 70 100% table 3 shows that there is no relevant effect of stress on color vision. all the subjects are found with normal color vision. table 4 shows that there is relevant effect of depression on glare sensitivity. in photostress test 45 subjects gives visual acuity after 6/6 to 6/12 and remaining 25% have 6/12 to 6/60. table 5 shows that there is no relevant impact of stress on visual field. disscussion stress impacts the efficiency and performance of daily tasks, eating habits, sleep cycle, irritability, body aches, intestinal problems, even decision making process slows down. reasons of stress: is a vast topic with some really adverse debates. causes of such disease can be related with the age, occupation, gender, and environment. it can be hereditary or idiopathic. females tend to have more stress than males. stress may have various causes in adolescence including absence of autonomy, competitive environment in academia, inability to perform certain tasks which seems quite cool for other age fellows, relationship with sibling and family. they feel very different as compared to others8. relation among stress and vision is complex in a bi-directional way as it can be the root cause or it can be the consequence of the circumstances. it is observed that these patients, if encounter difficulty in vision, they feel reluctant for an eye checkup. according to a study, distress specifically related to vision is an indicator for the precursor of anxiety and stress9. stress impacts body and specifically the general health by altering the typical mind program. stress has an impact on contrast sensitivity. in both ways, it hinders ocular health. some facts made it clear that a stressed patient sees the world more in gray tones which is well illustrated with the phrase “feeling blue” as one of the indicators of sense of sadness9. science wonders has also established a statement that a stressed patient focuses on low tones or sad angle of a particular picture for longer than normal human being9. stress is syeda rushda zaidi, et al 243 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology a mental disease which is significantly related to brain and in some serious way it interferes with the ability of an individual with clear vision. eye is the intricate neurosensory organ with the basic tenacity to discriminate patterns and differences in light stimuli. one’s natural ability to perceive the surrounding is termed as vision but it is a very complex process. it involves optical nerves, tracts to transport these peculiar signals to the visual cortex and the translating brain centers. there are five visual functions which comprise of visual acuity, contrast sensitivity, color vision, visual field and glare sensitivity. visual acuity is how clearly we can resolve an object at a specific distance while it forms a particular angle at the eye10. visual acuity has established four major components including recognition acuity, detection acuity, hyper acuity and localization acuity. recognition acuity requires recognition or it can be referred to as discriminating or naming the object. detection acuity pacts with the consciousness of an object in space whether it is absent or present; it doesn’t cope with the discrimination. hyper acuity is the stereo acuity11. localization acuity deals with the localizing of targets by discerning the spatial positions of sections of the object. visual acuity can be measured by log mar chart, snellen chart and landolt c etc. a visual acuity of 6/60 means that visual acuity is poor and the lower values lead to the perception of defective visual acuity, having difficulty in reading print of smaller letters or otherwise visual impairment which requires a prescription12. color vision is described as: some delusion characterized by the connections of billions of neurons in the brain. it is crucial for remembering and specifying various areas15. to look, perceive and interpret depending upon saturation, brightness and hue is defined as color vision. it is probable that a person can suffer from imperfect color vision. with reference to a study males are more prone to color defects than females because it is recessive sex linked trait. in some persons one, two or three of the three cones can be absent or dysfunctional which may lead to monochromacy, dichromacy (protanopia, deutranopia) and trichromacy16. we have many procedures to check color vision like d-15 photo chromic plates etc. with reference to a study conducted in 2006 thresholds for contrast sensitivity for various types of stress (seasonal affective stress and major stress) were quantified in stress and control patients20. higher values of contrast sensitivity for definite type of spatial frequencies was noted in seasonally stressed patients compared to average people. stressed persons have values for recognition based on luminance at 6.0 cpd and 12.0 cpd. therefore, clinical stress is associated to contrast sensitivity21. administration of a 25 item visual function test by the national eye institute lead us to know that self-reported stress is a vital factor of consideration during assessment of visual functions in latinos. measuring the stress was done by a single item on the sf-12. self-reported visual irregularities were related to stress in latinos22. stressed people aged 40 had low values on the nei vfq-25. this study was done to see how stress affects vision of individuals of older age using specific set of questions. stress could be a reason in older individuals due to higher burden of vision related diseases which obstructs their visual functions23. research conducted in britain established the link between stress and ocular health considering parameters such as age, general health and gender. in older people high ratio of vision issues of unknown etiology were detected. it was a vague reason for stress, so it required further questions24. values of contrast sensitivity have recently been stated to be lower in stressed patients as compared to healthy controls. graphic illustration strongly supported the conclusion that stressed people have high curve readings of contrast sensitivity but it still needs further examination25. significant thrashing of visualization results in a reduced superiority of life. a study conducted in year 2008 reveals that depressed individuals have high values for detection acuity and contrast sensitivity on luminance at 6.0 cpd and 12.0 cpd. it has been determined that clinical stress is related to contrast sensitivity using erg (electroretinogram) our study also support the different values of visual acuity and contrast sensitivity along with stress as the collected data was mainly based on screening tests. thresholds for contrast sensitivity of several types of stress was quantified in normal individuals and stressed patients. it provided an evidence that stress is a major cause of higher values for contrast sensitivity. one of the earlier studies suggested that stress could be a reason in old individuals to perceive higher burden of vision diseases. data of our research support and provide evidence for the effects of age and anxiety, on vision. visual contrast sensitivity has recently been reported to be at low levels in stressed patients in contrast to healthy controls which lead to reduced visual contrast sensitivity but further investigations are still needed to get more details. research work can provide support data for the stress interference in right hemisphere. effect of stress on visual functions pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 244 the analysis of our study demonstrates that significance of the visual functions and their related functionality is affected by anxiety, stress, depression or panic attack. conclusion major part of evidence provided in our study shows that stress may be the cause of any ocular anomaly. however it has been made quite a valid fact that increased ocular anomalies lead to stress. this study provides a firm foundation to demonstrate this bidirectional relationship of ocular anomalies and stress. authors affiliation syeda rushda zaidi head of the department department of optometry & visual sciences (dovs) samia iqbal optometrist, dovs hakim anjum nadeem course coordinator, dovs. syed hamza ali ca finalist auditor (proof reader). dr. muhammad jamshed mbbs (medical officer). role of authors syeda rushda zaidi lead and corresponding author, presented the main idea, review of literature and data analysis. samia iqbal co-author, contributed to data collection. hakim anjum nadeem co-author, contributed to experimental design. syed hamza ali co-author, contributed in article review and manuscript preparation. muhammad jamshed co-author, contribution in technical support. refrences 1. lorr m, sonn tm, katz mm. toward a definition of depression. archives of general psychiatry, 1967; 17 (2): 183-6. 2. creed f, dickens c. depression in the medically ill, 2007. 3. baxter lr, schwartz jm, phelps me, mazziotta jc, guze bh, selin ce, et al. reduction of prefrontal cortex glucose metabolism common to three types of depression. archives of general psychiatry, 1989; 46 (3): 243-50. 4. insel tr, charney ds. research on major depression: strategies and priorities. jama. 2003; 289 (23): 3167-8. 5. care m. mental health. geneva: world health organization, 1951. 6. dobson h, smith r. what is stress, and how does it affect reproduction? animal reproduction science, 2000; 60: 743-52. 7. simon nm, pollack mh, labbate la, nicolaou dc, stern ta. definition of anxiety. 8. burns jm, andrews g, szabo m. depression in young people: what causes it and can we prevent it? medical journal of australia. 2002; 177 (7): s93. 9. rees g, tee hw, marella m, fenwick e, dirani m, lamoureux el. vision-specific distress and depressive symptoms in people with vision impairment. investigative ophthalmology & visual science, 2010; 51 (6): 2891-6. 10. gilbert m. definition of visual acuity. the british journal of ophthalmology, 1953; 37 (11): 661. 11. snowden r, snowden rj, thompson p, troscianko t. basic vision: an introduction to visual perception: oxford university press, 2012. 12. nakayama k, mackeben m. sustained and transient components of focal visual attention. vision research, 1989; 29 (11): 1631-47. 13. boynton rm. human color vision: holt rinehart and winston, 1979. 14. land eh. the retinex theory of color vision: scientific america, 1977. 15. gegenfurtner kr, kiper dc. color vision. neuroscience, 2003; 26 (1): 181. 16. nathans j, thomas d, hogness ds. molecular genetics of human color vision: the genes encoding blue, green, and red pigments. science, 1986; 232 (4747): 193-202. 17. barten pg. contrast sensitivity of the human eye and its effects on image quality: spie press, 1999. 18. gibson jj. the perception of the visual world, 1950. 19. abrahamsson m, sjöstrand j. impairment of contrast sensitivity function (csf) as a measure of disability glare. investigative ophthalmology & visual science, 1986; 27 (7): 1131-6. 20. rovner bw, casten r. stability of visual acuity measurement in depression. the american journal of geriatric psychiatry: official journal of the american association for geriatric psychiatry, 2005; 13 (3): 255-8. 21. wesner mf, tan j. contrast sensitivity in seasonal and non-seasonal depression. journal of affective disorders, 2006; 95 (1-3): 19-28. 22. paz sh, globe dr, wu j, azen sp, varma r, los angeles latino eye s. relationship between selfreported depression and self-reported visual function in syeda rushda zaidi, et al 245 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology latinos. archives of ophthalmology, 2003; 121 (7): 10217. 23. owsley c, mcgwin g, jr. depression and the 25-item national eye institute visual function questionnaire in older adults. ophthalmology, 2004; 111 (12): 2259-64. 24. iliffe s, kharicha k, harari d, swift c, gillmann g, stuck a. self-reported visual function in healthy older people in britain: an exploratory study of associations with age, sex, depression, education and income. family practice, 2005; 22 (6): 585-90. 25. fam j, rush j, haaland b, barbier s, luu c. p-479 visual contrast sensitivity in depression. european psychiatry, 2012; 27, supplement 1 (0): 1. microsoft word 14. abstracts 28-2-12 112 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology abstracts edited by dr. qasim lateef chaudhry ranibizumab and bevacizumab for treatment of neovascular age-related macular degeneration: two – year results comparison of age – related macular degeneration treatments trials (catt) research group martin df, maguire mg, fine sl, ying g, jaffe gj, grunwald je, toth c, redford m, ferris fl ophthalmology 2012; 119: 1388-98. the multicenter, randomized comparison of agerelated macular degeneration treatments trial (catt) has demonstrated that ranibizumab and bevacizumab have similar effects on visual acuity after a 2-year period. investigators with the catt research group reported that mean gains in visual acuity at 2 years were within 1.4 letters, and the difference in vision averaged over the 2-year period was 0.7 letters. in addition, at 2 years, as-needed dosing of either drug produced 2.4 letters less mean gain than monthly dosing, with the greatest difference – 3.8 letters – between ranibizumab monthly and bevacizumab as needed. both drugs also substantially and immediately reduced fluid in or under the retina. finally, the rates of death, myocardial infarction, and stroke did not differ between drugs during the 2-year study period, although the imbalance seen in adverse events favoringranibizumab at 1 year persisted at year 2. given these findings, the authors note the choice of drug and dosing regimen must be weighed against the effects on vision, potential for adverse events and the 40-fold difference in per-dose cost between ranibizumab and bevacizumab. a twenty-year follow-up study oftrabeculectomy: risk factors and outcomes landers j, martin k, sarkies n, bourne r, watson p, ophthalmology 2012; 119, 694-702. this retrospective cohort studystudy was undertaken to determine the performance of trabeculectomy surgery over a 20-year period and examine the associations between outcome and risk factors for trabeculectomy failure. a total of 234 patients (330 procedures) who had undergone trabeculectomy surgery at addenbrooke’s hospital, cambridge, united kingdom, between january 1988 and december 1990 were identified through surgical logbooks (521 procedures on 380 patients); after this, a case-note review was undertaken, which identified 234 patients (330 procedures) who had available case notes. surgical success was defined as “complete success” when intraocular pressure (iop) remained less than or equal to 21 mm hg with no additional medication and as “qualified success” if those requiring additional opical medication were included. functional success was defined if patients did not progress to legal blindness (visual acuity 3/60 or visual field 10 degrees).the results showed that after 20 years, 57% were classified as complete success, 88% were classified as qualified success, and 15% had become blind. those at risk of trabeculectomy failure were younger or had uveitic glaucoma. those with pseudoexfoliation or aphakia were more likely to progress to blindness. furthermore, those using 2 or more topical medications or with advanced visual field loss at the time of surgery were more atrisk of both trabeculectomy failure and blindness. this study concluded that trabeculectomy survival at 20 years may be approximately 60% with no topical medication and approximately 90% with additional topical medication. patient age, preoperative topical medication use, glaucoma type, and glaucoma severity will independently influence this outcome. trabeculectomy surgery is therefore a long-term solution to iop control. early experience with the femtosecond laser for cataract surgery bali sj, hodge c, lawless m, roberts tv, sutton g, ophthalmology 2012; 119: 891-9. this prospective, consecutive cohort study was done to report the intraoperative complications and to evaluate the learning curve with femtosecond laser cataract surgery (lensx laser system by alcon lensx lasers inc., aliso viejo, ca).the first 200 eyes undergoing femtosecond laser cataract surgery and refractive lens exchange at vision eye institute, usa qasim lateef chaudhry pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 113 between april 2011 and june 2011 by 6 surgeons were included in this study. these cases underwent anterior capsulotomy, lens fragmentation, and corneal incisions with the femtosecond laser. the procedure was completed by phacoemulsification and insertion of an intraocular lens. data were collected about patient demographics, preoperative investigations and intraoperative complications. the cases were divided into 4 groups-group 1 included the first 50 cases, group 2 included cases 51 through 100, group 3 included cases 101 through 150, and group 4 included cases 151 through 200-and were analyzed. main outcome measure was intraoperative complication rate. the mean age of patients included were 69.2 ± 9.8 years. of the 200 eyes, 74.5% underwent a complete procedure of laser capsulotomy, lens fragmentation, and corneal incisions. five eyes had suction breaks during the laser procedure that led to the remainder of the laser procedure being aborted. twenty – one (10.5%) eyes showed the presence of small anterior capsular tags. the number of eyes with free-floating capsulotomies was 35 (17.5%). the other complications during the study were anterior radial tears (n = 8; 4%), posterior capsular ruptures (n = 7; 3.5%), and dropped nucleus (n = 4; 2%). a significant difference was noted among the sequential groups with respect to the number of docking attempts (p < 0.001), miosis after the laser procedure (p < 0.001), and free – floating capsulotomies (p < 0.001), suggesting an improving learning curve. the surgeons with prior experience with femtosecond lasers had fewer complications in the first 100 cases (p < 0.001). no difference in complications was observed after the initial 100 cases. in this case series, there was a clear learning curve associated with the use of femtosecond lasers for cataract surgery. adjustment to surgical technique and prior experience with a femtosecond laser seemed to flatten the learning curve. 178 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology original article presentation and surgical management of epibulbar (limbal) dermoids khawaja khalid shoaib, tariq shakoor, muhammad shahbaz amin pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: khawaja khalid shoaib health bridge hospital ghazi road, near bhatta chowk, dha, lahore email: kkshoaib@hotmail.com …..……………………….. purpose: to report clinical characteristics and surgical outcomes of limbal dermoids excision in pakistani patients. study design: retrospective, descriptive. place and duration of study: mughal eye hospital lahore from 1 st june 2016 to 30 dec 2017. material and methods: records of 15 epibulbar dermoids were reviewed. site, colour, presence of pigmentation and presence of ocular and systemic associations of the lesions were studied. lesions were photographed and then surgically managed. excision was done with blade and scissors. postoperative follow up included management of complications and photograph on each visit. results: age ranged from 4 to 60 years (mean 18 ± 13.48). male to female ratio was 6:9. all the patients had unilateral epibulbar dermoids, which were present in inferotemporal quadrant of the limbus. most lesions (9 cases 60%) involved cornea and sclera equally while a few extended more on the scleral (3 cases 20%) or corneal side (3 cases 20%). most (12 cases 80%) were round and a few (3 cases20%) tapering. 5 (33%) had goldenhar syndrome. 4 (27%) patients had preauricular tags. one (7%) patient had maxillary hypoplasia and divergent squint. postoperatively one patient (7%) had corneal thinning and one patient (7%) had extensive formation of granulation tissue. there was pigmentation of the lesion in 12 cases (80%). three (20%) patients had microtia. conclusion: limbal dermoids in pakistani patients have characteristics resembling those described in other parts of the world. treatment with excision and superficial sclerokeratectomy without graft gives satisfactory results. keywords: epibulbar dermoids, limbal dermoids, goldenhar syndrome. pibulbar dermoid is a choristoma. it is composed of fibrous and fatty tissue, covered by keratinized epithelium. it is present from birth. a few produce a lipoid infiltration of the corneal or scleral stroma at their leading edge. in some instances there may also be subconjunctival dermolipomas (adipose tissue and dense connective tissue) which are present in the lateral quadrant of the eye. these can be up to 10 mm in diameter and usually straddle the limbus. most are on the inferior temporal limbus1,2. the pathogenesis of dermoids is multifactorial. very rarely more than one family members have been found to have similar lesions3. on histopathological examination, they contain many tissues including skin, hair, fat, sweat gland, connective tissue, lacrimal gland, muscle, bone, teeth, cartilage, vascular/neurologic tissue and may even contain brain tissue. lymphoid elements can also be present. dermoids are classified into three types on the basis of location of the lesion. the most common involves the limbus. limbal dermoids mostly present as superficial lesions but deeper ocular structures can also be involved. the second type is entirely in the e presentation and surgical management of epibulbar (limbal) dermoids pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 179 superficial cornea. the last variety of dermoid is rare and affects full thickness of cornea and deeper tissue are replaced with a fibrous and fatty tissue. epibulbar dermoid is often seen with goldenhar (oculoauriculovertebral) syndrome4. these patients may have a variety of other anomalies, including ear deformities (partially formed ear microtia or totally absent ear anotia), preauricular appendages, auricular fistulae, maxillary or mandibular hypoplasia, vertebral deformities, hemifacial microsomia and vertebral anomalies. dermoids can be associated with ocular abnormalities including colobomata of the eyelids, duane retraction syndrome and other ocular motility disorders, lacrimal anomalies, scleral and corneal staphylomata, aniridia, and microphthalmia. variant of the syndrome like a fibroepithelial polyp attached to limbal dermoid has also been described5. unilateral morning glory syndrome has been found in a patient with multiple limbal dermoids6. associations like scalp7,8 and nager syndrome9 are reported in the literature. a new grading system keeping in view area of cornea and conjunctiva involved as well as surface shape has been proposed10. reviewing pakistani literature on the subject found a few case reports and small studies11–15. this study was carried out to analyze our experience regarding the clinical presentation and results of simple excision of limbal dermoids type one in pakistani population. material and methods a total of 15 epibulbar dermoids presented in oculoplastic and pediatric ophthalmology division of mughal eye hospital lahore and were surgically managed from 1st june 2016 to 30 dec 2017. this study was approved by the ethics committee of mughal eye hospital and followed the tenets of the declaration of helsinki. written informed consent was taken from all patients. all the patients presenting with type one limbal dermoid (i.e. present at the limbus) who were concerned about cosmetic appearance and were willing for surgical removal were included in the study. one case of dermoid which was involving the entire cornea was excluded. informed consent was taken from all the participants. all the excisions were done by the first author. adults were operated under local anesthesia and children were operated under general anesthesia. after excision with blade and scissors, conjunctiva was stitched in 6 (40 %) cases when lesion was affecting significant part of conjunctiva. all the operated cases were reviewed in outpatient department on 1st post-operative day, every week for three weeks and then every month for 4 months. follow up ranged from 3 weeks to 4 months (mean= 6 ± 3.5 weeks). results age ranged from 4 years to 60 years (mean 18+ 13.48). 3 (20%) out of 15 patients presented in 1st decade of life, 8 (53%) were in second, 3 (20%) in third decade and one (6.7%) patient in 6th decade of life. all patients presented due to cosmetic concerns though 12 cases (80 %) had visual deterioration. male to female ratio was 6:9. all the patients had unilateral epibulbar dermoids. in our study all the patients presented with epibulbar dermoid in inferior temporal quadrant however in 3 patients (20%) lesion was more towards inferior aspect of limbus. most (9 cases 60%) were present at limbus equally involving cornea and sclera. however, 3 cases (20%) extended more on the scleral side while 3 cases (20%) were predominantly on the corneal side. most (12 cases 80%) were round and 3 cases (20%) tapering. 5 (33%) had goldenhar syndrome (table 1). 4 (27%) patients table 1: systemic associations of limbal dermoid (total no. of patients =15). ocular & systemic associations 5 (33%) preauricular skin tags 4 (27%) ear deformity 3 (20%) maxillary hypoplasia 1 (7%) divergent squint 1 (7%) had preauricular tags. pre auricular tags were on the same side as the lesion in 2 patients, on opposite side in 1 patient and bilateral in one patient. one (7%) patient had maxillary hypoplasia. she also had divergent squint. postoperatively (table 2) one patient (7%) had extensive formation of granulation tissue while one patient (7%) had corneal thinning and his post-operative steroids were stopped immediately. table 2: post operative complications. post operative complications 2 (14%) corneal thinning 1 (7%) extensive formation of granulation tissue 1 (7%) there was variable yellowish to brownish pigmentation of the lesion in 12 cases (80%). five khawaja khalid shoaib, et al 180 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology patients (33%) out of 15 had more marked superficial pigmentation of epibulbar dermoid. three (20%) patients had ear deformity (hypoplastic ear microtia). after excision cornea and conjunctiva healed within 57 days, generally with some scarring and imperfect corneal transparency; however, the appearance was considerably improved. discussion limbal dermoids belong to benign congenital tumors containing choristomatous tissue i.e. normal tissue derived from germ cells layers, which is foreign for that site. there is no racial predisposition and males and females are equally affected. in our study male to female ratio was 6:9. most common site of presentation of limbal dermoid is inferior temporal quadrant of the corneal limbus. most of limbal dermoids were equally involving corneal and scleral sides of limbus while in a few patients lesion was more on corneal side or scleral side. epibulbar dermoids are dome shaped, with or without keratinized surface. hair follicles and cilia are usually visible. they are fleshy and can have fine superficial vessels. they usually are not malignant. multifactorial pattern of inheritance is well-recognized in limbal dermoids associated with ocular and systemic findings such as goldenhar syndrome. in our study, patients presented at different age groups. the late presentation in our cases was probably due to socio economic reasons as poor patients could not afford early treatment. fourteen (93%) out of 15 patients presented with superficial epibulbar dermoids while one patient had deep corneal stromal involvement. management of limbal dermoids may be conservative with artificial lubricants and epilation of offending hair if there is foreign body sensation. surgical removal of the lesion can be done in case of cosmetic disfigurement or if it is causing visual disturbance. surgical treatment is indicated only when there is requirement for improving the patient's vision or cosmetic appearance. surgical removal of the mass which is above the surface of sclera or cornea is the preferred method. it is unnecessary to completely remove the deeper lesion as inadvertent entry inside eyeball is high in case of repeated attempts for complete excision of the lesion. the exposed sclera is covered with the help of undermining surrounding conjunctiva and suturing it over exposed surface. in case of removal of most thickness of cornea or sclera, a patch graft is done to restore thickness of the wall of eyeball. amniotic membrane may be stitched in a single or multiple layers at the site if there is risk of perforation. the amniotic membrane is sutured to underlying sclera or fibrin-glue adhesive is used to secure the grafted tissue16,17. placement of a processed pericardial graft to cover exposed surface after excision has also been tried18. in all of our study cases, superficial sclerokeratectomy was done with the help of blade and scissors for excision of epibulbar dermoid. in cases where the epibulbar dermoid was more on scleral side the defects was closed with simple suturing of the conjunctiva. one patient had more deep involvement of corneal stroma with postoperative thinning of the cornea. his postoperative steroids were stopped immediately. one should remain vigilant and should have a plan to apply patch if there is impending perforation. one younger patient operated at the age of 4 years had extensive formation of postoperative granulation tissue. such cases may be confused to have recurrent keloid19. limbal stem cell transplantation from the same patient has been found effective20. sutureless corneoscleral grafts fixed with fibrin glue are becoming more popular21. 0.02% mitomycin c applied for 2  min following the excision has been claimed to prevent occurrence of pseudopterygium following excision22. tattooing of the cornea and a conjunctival graft of the same patient after simple excision has been claimed to produce better postoperative appearance23,24. cosmetic concern remains the main indication for the decision to remove limbal dermoids25. our study has a few limitations which include relatively small number of cases, short follow up (as most patients were satisfied and did not report for follow up) and not using mitomycin or amniotic membrane so we cannot comment which is a relatively better procedure. strength of our study is that we have preoperative and postoperative photograph of each patient with all findings. we achieved satisfactory results by simple surgical removal. presentation and surgical management of epibulbar (limbal) dermoids pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 181 fig. 1: limbal dermoids. fig. 2: upper two rows: goldenhar syndrome in 5 cases. upper left 3 photo, maxillary hypoplasia & divergent squint lower row (post op): left 2 photo, appearance after excision: central photo, corneal thinning: 2nd photo from right, post conj congestion: right photo, post op marked granulation tissue formation. khawaja khalid shoaib, et al 182 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology conclusion in our study there was yellowish to brownish superficial pigmentation in epibulbar dermoid in most cases, which is not reported earlier to the best of our knowledge. treatment with excision and superficial sclerokeratectomy without graft gives satisfactory results. no significant visual threatening complication was encountered. author’s affiliation dr. khawaja khalid shoaib fcps, frcs, mcps hpe health bridge hospital, ghazi road, near bhatta chowk, dha, lahore. dr. tariq shakoor mcps, fcps rahbar medical & dental college, lahore dr. muhammad shahbaz amin mcps, fcps lahore medical & dental college, lahore. role of authors dr. khawaja khalid shoaib performed surgery, review of literature, collection of data, analysis of data, writing manuscript, critical proof reading dr. tariq shakoor review of literature, collection of data, analysis of data, writing manuscript, critical proof reading dr. muhammad shahbaz amin review of literature, collection of data, analysis of data, writing manuscript, critical proof reading references 1. fard am, pourafkari l. images in clinical medicine. the hairy eyeball—limbal dermoid. n engl j med. 2013; 368 (1): 64. 2. dey r, dey s. images in clinical medicine. limbal dermoid. n engl j med. 2011; 364 (6): e9. 3. zhu j, cheng hb, fan n, liu cm, yu wh, chen xm, liu xy. studies of a pedigree with limbal dermoid cyst. int j ophthalmol. 2012; 5 (5): 641-3. 4. hafidi z, daoudi r. limbal dermoid in goldenhar syndrome. pan afr med j. 2013; 15: 69. 5. seymenoğlu g, başer e, tansuğ n, demireli p. an unusual association of goldenhar syndrome. int ophthalmol. 2013; 33 (1): 91-4. 6. lowry ea, de alba campomanes ag. unilateral morning glory disc anomaly with ipsilateral limbal dermoids. j pediatr ophthalmol strabismus. 2014; 51 online: e37-9. 7. lam j, dohil ma, eichenfield lf, cunningham bb. scalp syndrome: 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https://www.ncbi.nlm.nih.gov/pubmed/?term=kim%20ej%5bauthor%5d&cauthor=true&cauthor_uid=20337313 https://www.ncbi.nlm.nih.gov/pubmed/?term=seong%20gj%5bauthor%5d&cauthor=true&cauthor_uid=20337313 https://www.ncbi.nlm.nih.gov/pubmed/?term=seo%20ky%5bauthor%5d&cauthor=true&cauthor_uid=20337313 https://www.ncbi.nlm.nih.gov/pubmed/20337313 https://www.ncbi.nlm.nih.gov/pubmed/20337313 presentation and surgical management of epibulbar (limbal) dermoids pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 183 lasers imaging, 2010; 9: 1-2. 21. zhou ax, ambati bk. sutureless lamellar corneoscleral patch graft with fibrin sealant for limbal dermoid removal. j pediatr ophthalmol strabismus. 2016 jun. 3; 53 online: e22-5. doi: 10.3928/0191391320160509-03. 22. lang sj, böhringer d, reinhard t. surgical management of corneal limbal dermoids: retrospective study of different techniques and use of mitomycin c. eye (lond). 2014; 28 (7): 857-62. 23. jeong j, song yj, jung si, kwon jw. new surgical approach for limbal dermoids in children: simple excision, corneal tattooing, and sutureless limboconjunctival autograft. cornea, 2015; 34 (6): 720-3. 24. cha dm, shin kh, kim kh, kwon jw. simple keratectomy and corneal tattooing for limbal dermoids: results of a 3-year study. int j ophthalmol. 2013; 6 (4): 463-6. 25. matsuo t. clinical decision upon resection or observation of ocular surface dermoid lesions with the visual axis unaffected in pediatric patients. springerplus, 2015; 4: 534. https://www.ncbi.nlm.nih.gov/pubmed/?term=zhou%20ax%5bauthor%5d&cauthor=true&cauthor_uid=27281829 https://www.ncbi.nlm.nih.gov/pubmed/?term=ambati%20bk%5bauthor%5d&cauthor=true&cauthor_uid=27281829 https://www.ncbi.nlm.nih.gov/pubmed/27281829 https://www.ncbi.nlm.nih.gov/pubmed/?term=lang%20sj%5bauthor%5d&cauthor=true&cauthor_uid=24858530 https://www.ncbi.nlm.nih.gov/pubmed/?term=b%c3%b6hringer%20d%5bauthor%5d&cauthor=true&cauthor_uid=24858530 https://www.ncbi.nlm.nih.gov/pubmed/?term=reinhard%20t%5bauthor%5d&cauthor=true&cauthor_uid=24858530 https://www.ncbi.nlm.nih.gov/pubmed/24858530 https://www.ncbi.nlm.nih.gov/pubmed/?term=jeong%20j%5bauthor%5d&cauthor=true&cauthor_uid=25881973 https://www.ncbi.nlm.nih.gov/pubmed/?term=song%20yj%5bauthor%5d&cauthor=true&cauthor_uid=25881973 https://www.ncbi.nlm.nih.gov/pubmed/?term=jung%20si%5bauthor%5d&cauthor=true&cauthor_uid=25881973 https://www.ncbi.nlm.nih.gov/pubmed/?term=kwon%20jw%5bauthor%5d&cauthor=true&cauthor_uid=25881973 https://www.ncbi.nlm.nih.gov/pubmed/25881973 https://www.ncbi.nlm.nih.gov/pubmed/?term=cha%20dm%5bauthor%5d&cauthor=true&cauthor_uid=23991379 https://www.ncbi.nlm.nih.gov/pubmed/?term=shin%20kh%5bauthor%5d&cauthor=true&cauthor_uid=23991379 https://www.ncbi.nlm.nih.gov/pubmed/?term=kim%20kh%5bauthor%5d&cauthor=true&cauthor_uid=23991379 https://www.ncbi.nlm.nih.gov/pubmed/?term=kwon%20jw%5bauthor%5d&cauthor=true&cauthor_uid=23991379 https://www.ncbi.nlm.nih.gov/pubmed/23991379 https://www.ncbi.nlm.nih.gov/pubmed/?term=matsuo%20t%5bauthor%5d&cauthor=true&cauthor_uid=26413440 https://www.ncbi.nlm.nih.gov/pubmed/26413440 microsoft word 14. erratum pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 127 erratum non-penetrating eye injuries in victims of bomb blasts and mine blasts mumtaz alam, mustafa iqbal pak j ophthalmol 2013, vol. 29 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . in pjo vol. 29; issue 1; 2013, on page 10, table 4 final visual acuity was missing. the complete table is as follows: author’s affiliation dr. mumtaz alam senior registrar ophthalmology department kuwait teaching hospital, peshawar dr. mustafa iqbal professor and in charge eye “b” unit khyber teaching hospital, peshawar pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 122 editorial new perspectives in the management of diabetic macular edema the prevalence of diabetes is increasing worldwide. with urbanization in the developing countries, and increasingly sedentary lifestyle, the incidence of diabetes is reaching an epidemic, particularly among the young. prevalence of diabetes is estimated to double by 2025 in pakistan to a staggering 11.6 million people. pakistan will become the 4th most populous country in terms of the number of diabetics.1 rising prevalence means the burden of visual loss is likely to increase many folds. to identify sight-threatening retinopathy, systematic screening is recommended. unfortunately, there is no effective screening programme for diabetic retinopathy in pakistan. the two most common causes of visual loss in diabetes are proliferative diabetic retinopathy and diabetic macular edema (dme). dme is the commonest cause of visual loss among the working age group. good control of systemic risk factors is vital in managing diabetic retinopathy. ophthalmologists, however, tend to focus mostly on local treatment modalities. it is worth remembering that a 10% decrease in hba1c, say from 8% to 7.2%, reduces diabetic retinopathy by 40%, progression to vision threatening retinopathy by 25%, need for laser therapy by 25% and blindness by 15%. in addition to hba1c, diabetics should have a regular evaluation of complete blood count, lipid profile, serum creatinine levels and random blood sugar. anemia contributes to the ischemic injury caused by retinal non-perfusion in diabetics. high lipid levels cause direct endothelial damage. microalbuminuria not only predicts nephropathy but also predicts myocardial infarction and stroke. smoking 20 cigarettes a day triples the risk of retinopathy. passive smoking may double the risk. similarly, sleep apnea, a treatable condition, contributes to dme and visual loss2. certain medications such as glitazones, used to control blood sugar, cause fluid retention and macular edema3. glitazones should be avoided in dme. therefore, when a diabetic patient presents to an ophthalmologist, with visual impairment, the interaction is an opportunity for counselling about systemic risk factor control. statins are recommended for diabetics 40 year and older, if tolerated well, regardless of the cholesterol level. a fibrate such as finofibrate 200mg once daily may be advisable in patients with exudative maculopathy. in recent years two large randomized controlled trials, field study4 and accord-eye study5, have reported efficacy of finofibrate in diabetic retinopathy. field study reported reduced frequency of laser treatment for dme by 31% and pdr by 30% (40% in accord – eye study). in accord-eye finofibrate was taken with simvastatin. this benefit was more marked in patients with pre-existing retinopathy. finofibrate is not recommended as a prophylactic treatment to prevent diabetic retinopathy in patients with no pre-existing retinopathy. once systemic factors are looked at, what local treatment options are available to us in 2014? only a decade ago, macular laser was the only proven treatment for dme. edtrs reported a 50% reduction in moderate visual loss with laser treatment. back then the choice was simple; either treat with laser or observe. in 2014 we are fortunate to have many treatment modalities at our disposal. however, this also makes it difficult to decide which treatment option is best for a particular patient. laser photocoagulation was the standard of care for dme for more than 25 years. focal macular laser still remains a viable treatment option for extra foveal dme, particularly to treat micro-aneurysms associated with circinate exudates. focal laser may also be used as an adjunctive therapy to reduce number of antivegf injections. scatter laser of peripheral areas of ffa proven capillary non-perfusion may reduce the vegf drive, important for vascular hyperpermeability and fluid accumulation at the macula. in recent years, trials of intravitreal anti-vegf agents in dme have shown their remarkable efficacy. industry funded studies such as rise, ride, vividdme, and vista-dme, which evaluated ranibizumab and aflibercept, have all shown significant gains in vision when compared to laser treatment alone. rise and ride are phase iii multicenter randomized m. a. rehman siddiqui 123 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology controlled trials with identical methodology6. they enrolled 759 patients to evaluate efficacy and safety of ranibizumab versus sham injections in dme. macular laser treatment was allowed as indicated. at 2 years mean gain in visual acuity was +12 letters and +2.5 letters in the ranibizumab and sham arms, respectively. similarly, vivid-dme and vista-dme are two parallel phase iii randomized controlled trials evaluating aflibercept versus laser treatment for dme.7 at 1 year patients treated with aflibercept had a mean gain of +11 letters while the laser treated group had only +1 letter gain. there were no safety signals associated with aflibercept use. ranibizumab and aflibercept are both approved by fda for dme. bevacizumab is the most common intravitreal anti-vegf used in pakistan, and worldwide. the use of intravitreal bevacizumab for dme is off-label. the randomized trial of intravitreal bevacizumab or laser treatment (bolt) for dme,8 reported +9 letters gain in the bevacizumab arm compared to +2.5 letters in the laser arm at 2 years. the median number of injections required was 9 and 4 in the first and second year of the study, respectively. is the efficacy of bevacizumab, ranibizumab and aflibercept equal in dme? to date there are no randomized clinical trials, comparing head-to-head efficacy of the three compounds in dme. drcr.net protocol t is designed to directly compare the efficacy and safety of these antivegf agents in dme. results are expected in 2016. because anti-vegfs are angiostatic, repeated monthly injections are often times necessary. unfortunately, patient compliance with a monthly treatment schedule is suboptimal. however, unlike macular degeneration, injections do not need to continue every month indefinitely. for example, the median number of injections in the drcr. net protocol i (ranibizumab and deferred laser arm) were 9 in the first year, 3 in second year and 2 injection in the third year. mean number of injections in this arm was 15 out of a possible maximum of 39 injections. intravitreal steroids are used off-label in dme when anti-vegf therapy is not effective. in drcr.net protocol i, when a subgroup analysis of pseudophakic eyes at baseline was performed, 4 mg triamcinolone and laser arm showed similar visual gains to ranibizumab and laser arm. steroid therapy is associated with raised iop, and cataract formation in phakic eyes. if patients are treated with intravitreal steroids, regular and long term follow up is warranted. the observation that dme prevalence is higher among patients with attached vitreous, and that a posterior vitreous detachment in patients with preexisting dme may result in resolution of dme has led many to believe that vitrectomy (with removal of any antero-posterior and tangential traction) is a useful option in the management of dme. there are abundant case reports and case series, however, only a few high quality randomized control trials evaluating efficacy of vitrectomy in dme. a large case series9 of vitrectomy outcomes in dme with co-existing vitreomacular traction (vmt) was reported by drcr.net they reported reduction in central macular thickness in most eyes. nearly half the patients had 10 or more letters gain. significantly, one third of the patients lost 10 or more letters following surgery. patel et al10 in their randomized controlled trial included dme patients with no vmt. they reported no benefit of vitrectomy over laser treatment. it is worth noting that the prevalence of vmt in dme is low at 4%. in summary, blindness caused by dme can be avoided by early detection, and timely treatment. in 2014 intravitreal anti-vegfs are the gold standard treatments for center involving dme. for edema away from fovea, focal laser may be given. intravitreal steroids may also be useful in pseudophakic eyes. additionally, vitrectomy may be offered in select cases of vmt. to offer the most effective, individualized, treatment to our patients, we must keep a brace with the rapidly expanding scientific evidence about the emerging treatment modalities in dme. references 1. wild s, roglic g, green a, sicree r, king h. estimates for the year 2000 and projections for 2030. diabetes care. 2004; 27: 1047-53. 2. mason rh, kiire ca, groves dc, lipinski hj, jaycock a, winter bc, smith l, bolton a, rahman nm, swaminathan r, chong vn, stradling jr.. visual improvement following continuous positive airway pressure therapy in diabetic subjects with clinically significant macular oedema and obstructive sleep apnoea: proof of principle study. respiration. 2012; 84: 275-82. 3. fong ds, contreras r. glitazone use associated with diabetic macular edema. am j ophthalmol. 2009; 147: 583-6. 4. keech ac, mitchell p, summanen pa, o'day j, davis tm, moffitt ms. et al. field study investigators. effect of fenofibrate on the need for laser treatment for diabetic retinopathy (field study): a randomized controlled trial. lancet. 2007; 370: 1687-97. 5. accord study group; accord eye study group. effects of medical therapies on retinopathy progression in type 2 diabetes. n engl j med. 2010; 363: 233-44. 6. nguyen qd, brown dm, marcus dm, boyer ds, patel s, feiner l, gibson a, sy j, rundle ac, hopkins jj, rubio rg, http://www.ncbi.nlm.nih.gov/pubmed?term=roglic%20g%5bauthor%5d&cauthor=true&cauthor_uid=15111519 http://www.ncbi.nlm.nih.gov/pubmed?term=green%20a%5bauthor%5d&cauthor=true&cauthor_uid=15111519 http://www.ncbi.nlm.nih.gov/pubmed?term=sicree%20r%5bauthor%5d&cauthor=true&cauthor_uid=15111519 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http://www.ncbi.nlm.nih.gov/pubmed?term=schmelter%20t%5bauthor%5d&cauthor=true&cauthor_uid=25012934 http://www.ncbi.nlm.nih.gov/pubmed?term=yancopoulos%20gd%5bauthor%5d&cauthor=true&cauthor_uid=25012934 http://www.ncbi.nlm.nih.gov/pubmed?term=stahl%20n%5bauthor%5d&cauthor=true&cauthor_uid=25012934 http://www.ncbi.nlm.nih.gov/pubmed?term=vitti%20r%5bauthor%5d&cauthor=true&cauthor_uid=25012934 http://www.ncbi.nlm.nih.gov/pubmed?term=berliner%20aj%5bauthor%5d&cauthor=true&cauthor_uid=25012934 http://www.ncbi.nlm.nih.gov/pubmed?term=zeitz%20o%5bauthor%5d&cauthor=true&cauthor_uid=25012934 http://www.ncbi.nlm.nih.gov/pubmed?term=metzig%20c%5bauthor%5d&cauthor=true&cauthor_uid=25012934 http://www.ncbi.nlm.nih.gov/pubmed?term=brown%20dm%5bauthor%5d&cauthor=true&cauthor_uid=25012934 http://www.ncbi.nlm.nih.gov/pubmed?term=fraser-bell%20s%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=kaines%20a%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=michaelides%20m%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=hamilton%20rd%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=esposti%20sd%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=peto%20t%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=egan%20c%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=bunce%20c%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=leslie%20rd%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=leslie%20rd%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=leslie%20rd%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=hykin%20pg%5bauthor%5d&cauthor=true&cauthor_uid=22491395 http://www.ncbi.nlm.nih.gov/pubmed?term=hykin%20pg%5bauthor%5d&cauthor=true&cauthor_uid=16052254 http://www.ncbi.nlm.nih.gov/pubmed?term=schadt%20m%5bauthor%5d&cauthor=true&cauthor_uid=16052254 http://www.ncbi.nlm.nih.gov/pubmed?term=luong%20v%5bauthor%5d&cauthor=true&cauthor_uid=16052254 http://www.ncbi.nlm.nih.gov/pubmed?term=bunce%20c%5bauthor%5d&cauthor=true&cauthor_uid=16052254 http://www.ncbi.nlm.nih.gov/pubmed?term=fitzke%20f%5bauthor%5d&cauthor=true&cauthor_uid=16052254 http://www.ncbi.nlm.nih.gov/pubmed?term=gregor%20zj%5bauthor%5d&cauthor=true&cauthor_uid=16052254 160 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology original article comparison of changes in intraocular pressure after subtenon triamcinolone acetonide and topical dexamethasone mumtaz alam, habibullah khan pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mumtaz alam house no 310, street no 5, sector e-4 phase 7 hayatabad peshawar. …..……………………….. purpose: to compare the changes in intraocular pressure after subtenon triamcinolone acetonide and topical dexamethasone in patients undergoing phacoemulsification and intraocular lens implantation. material and methods: it was a double blind randomized control trial, conducted in the department of ophthalmology khyber teaching hospital peshawar, from march 2009 to february 2012. the patients were divided into two groups. patients undergoing cataract surgery with an injection of subtenon triamcinolone acetonide were included in group “a” and those receiving topical dexamethasone post-operatively for a period of 4-6 weeks were included in group “b” (control group). intraocular pressure was noted pre-operatively and on 1 st day, 1 st week, and 1 st month post-operatively. results: there were 84 patients in each group. the difference in mean intraocular pressure in the two groups did not reach statistical significance preoperatively (p value = 0.583). on 30 th post-operative day the mean iop was 15.08 ± 2.66 mmhg in group “a” and 15.39 ± 2.98 mmhg in group “b” (p value = 0.479). at 30 th post-operative day, intraocular pressure elevation above the normal value of 21 mmhg was seen in 2 patients (02.38%) in group “a” and in 3 patients (03.57%) in group “b”. conclusion: there is no statistically significant difference in intraocular pressure between both groups in our study. ataract surgery is the most commonly performed ophthalmic surgery throughout the world.1 cataract surgery causes a certain degree of post-surgical ocular inflammation.2 corticosteroids, non-steroidal anti-inflammatory drugs (nsaids) and immune modulators effectively control ocular inflammation. corticosteroids interfere with the activity of phospholipase a2, thereby inhibiting the release of arachidonic acid and the production of all arachidonic acid metabolites. however, they are associated with a number of adverse events, including a rise in intraocular pressure (iop) and increased susceptibility to microbial infections.3 topical corticosteroids form the mainstay of the anti-inflammatory therapy after cataract extraction.4,5 topical medications can have adverse effects on the cornea and compliance may be an issue. triamcinolone acetonide is a potent corticosteroid that is safe and effective for controlling post-operative ocular inflammation when administered as a single sub-tenon injection after uneventful phacoemulsification surgery.6,7 the purpose of this study was to compare the changes in intraocular pressure after subtenon triamcinolone acetonide and topical dexamethasone in patients undergoing phacoemulsification and intraocular lens (iol) implantation. material and methods it was a prospective double blind randomized c comparison of changes in iop after subtenon triamcinolone acetonide and topical dexamethasone pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 161 controlled trial. the study was conducted in the department of ophthalmology, khyber teaching hospital peshawar from march 2009 to february 2012. before starting the study, approval was taken from the ethical review board of the institution. sampling technique was non-probability consecutive sampling. patients with pre-existing glaucoma, known steroid responders, children and young adults (< 18 years), patients with ocular infections, uveitis and traumatic cataract were excluded from the study. patients who had difficult or complicated cataract surgery were also excluded from the study. the patients were divided into two groups i.e. group “a” and group “b”. total of 168 eyes were included in the study, with 84 eyes in each group. written informed consent was taken from all the patients. pre-operatively detailed history was taken followed by complete ocular examination including assessment of best corrected visual acuity using snellen chart, anterior segment examination with slitlamp (takagi sm-70, japan), fundus examination with 90 diopter lens (volk, usa) and iop measurement with goldman applanation tonometer. systemic assessment and routine laboratory investigations were also carried out on all the patients. all the patients underwent phacoemulsification and foldable iol implantation in the capsular bag. all the surgeries were performed by the same surgeon. patients of group “a” received a single injection of subtenon triamcinolone acetonide 40mg/ 1ml just after the surgery. patients of group “b” received topical dexamethasone post-operatively for a period of 4-6 weeks depending upon the inflammatory response (i.e. 2 hourly in the first few post-operative days and then 4 times/ day, 3 times/ day, 2 times/ day and 1 time/ day for 1 week each). no subconjunctival or intracameral antibiotics were given at the end of surgery in either group. topical tobramycin was given to the patients of both groups for 2 weeks. follow up was done on 1st, 7th and 30th post-operative day. iop was recorded at each visit. in addition, post-operative inflammation was quantified at each visit. all the data analysis was carried out using statistical package for social sciences-11 (spss-11) software. quantitative variable included age and iop at each visit. qualitative variables included gender. for quantitative variables mean, standard deviation and range were calculated, and for qualitative variables percentage and proportion were calculated. p-value was generated using t-test for comparison of mean and chi-square test for comparison of proportions and percentages. p-value < 0.05 was considered significant. results out of the 168 patients 106 were male and 62 were female. there were 54 males and 30 females in group “a” and 52 males and 32 females in group “b”. age of the patients was ranging from 30 to 84 years with a mean of 58.23 ± 9.68 years. age of group “a” was ranging from 33 to 84 years and that of group “b” was ranging from 30 to 81 years. mean age of group “a” was 59.23 ± 10.29 years and that of group “b” was 57.23 ± 8.98 years. there was no significant difference in mean iop in the two groups pre-operatively and post-operatively (table 1). total of 5 patients were steroid responders i.e. at 30th post-operative day, intraocular pressure elevation above the normal value of 21 mmhg was seen in 2 patients (02.38%) in group “a” and in 3 patients (03.57%) in group “b”. the mean rise in iop from baseline was slightly greater in group “b” as compared to group “a” but it was not statistically significant (table 2). discussion cataract surgery can cause varying degree of postsurgical intraocular inflammation. post-operative intraocular inflammation produces the mediators required for tissue healing.2 recent advances in surgical techniques, surgical tools and intraocular lens (iol) have reduced the amount of intraocular inflammation after cataract extraction.8 post-operative intraocular inflammation is treated with topical or periocular corticosteroids4-7. intraocular pressure (iop) elevation is one of the adverse effects of corticosteroid therapy. if the iop elevation is of sufficient magnitude and for a long duration, damage to the optic nerve (steroid-induced glaucoma) may occur.9 topical application to eyelid skin,10 subconjunctival and subtenon injection,11 intravitreal injection12 and systemic steroids13 may all cause iop elevation, but it is most commonly identified as a complication of topical therapy with drugs such as dexamethasone or prednisolone. in responsive patients, the iop typically rises after several weeks of continual corticosteroid therapy or subtenon injection and returns to normal following cessation of such therapy. in this study we compared the changes in iop after subtenon injection of triamcinolone acetonide mumtaz alam, et al 162 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology and topical dexamethasone in patients undergoing phacoemulsification and intraocular lens implantation. our study included 84 patients in each group. both the groups were similar in terms of age and gender distribution (p value = 0.182 and 0.749 respectively). baseline iop was recorded in all patients. all the cases underwent uneventful phacoemulsification with iol implantation by the same surgeon. post-operatively iop was noted at the 1st, 7th and 30th post-operative day. in our study there was no significant difference in iop between the 2 groups preoperatively (p value = 0.583) and at 1st (p value = 0.287), 7th (p value = 0.577) and 30th post-operative day (p value = 0.479). in the study of paganelli f et al.7 and lacmanovic et al14. a significantly lower intraocular pressure was recorded in patients who received subtenon triamcinolone acetonide injection as compared to patients who received topical prednisolone and dexamethasone respectively. in our study, there was a mean increase in iop from baseline of 0.52 ± 2.83 mmhg. the rise in iop was slightly greater in group “b” as compared to group “a” but this difference was not statistically significant (p value = 0.243). in our study all the patients had uncomplicated cataract surgery and there was no significant difference in the iop in both groups at each visit. therefore subtenon injection of triamcinolone and topical dexamethsone are equally safe for the control of post-operative intraocular inflammation. however, subtenon injection of triamcinolone should be used with great caution in glaucomatous eyes, because of its prolonged action. conclusion in this study there was no statistically significant difference in intraocular pressure after subtenon triamcinolone acetonide and topical dexamethasone in patients undergoing uncomplicated phacoemulsification and intraocular lens implantation. therefore subtenon triamcinolone acetonide with a few days of topical antibiotics can be used in routine after uncomplicated phacoemulsification. author’s affiliation dr. mumtaz alam senior registrar department of ophthalmology kuwait teaching hospital peshawar comparison of changes in iop after subtenon triamcinolone acetonide and topical dexamethasone pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 163 dr. habibullah khan resident department of ophthalmology khyber teaching hospital peshawar references 1. iqbal m, mahmood t. prevalence of antihepatitis c virus (hcv) antibodies in cataract surgery patients. pak j ophthalmol. 2008; 24: 16-8. 2. vaudaux jd, simone e, christophe n, yan gc. inflammation in cataract surgery. expert rev ophthalmol. 2007; 2: 803-18. 3. mcghee cn, dean s, danesh-meyer h. locally administered ocular corticosteroids: benefits and risks. drug saf. 2002; 25: 33-55. 4. simone jn, whitacre mm. effects of anti-inflammatory drugs following cataract extraction. curr opin ophthalmol. 2001; 12: 63-7. 5. abel r, abel ad. perioperative antibiotic, steroid, and nonsteroidal anti-inflammatory agents in cataract intraocular lens surgery. curr opin ophthalmol. 1997; 8: 29-32. 6. negi ak, browning ac, vernon sa. single perioperative triamcinolone injection versus standard postoperative steroid drops after uneventful phacoemulsification surgery: randomized controlled trial. j cataract refract surg. 2006; 32: 468-74. 7. paganelli f, cardillo ja, melo la, oliveira ag, skaf m, costa ra. a single intraoperative sub-tenon’s capsule triamcinolone acetonide injection for the treatment of post-cataract surgery inflammation. ophthalmology. 2004; 111: 2102-8. 8. monnet d, tepenier l, brézin ap. objective assessment of inflammation after cataract surgery: comparison of 3 similar intraocular lens models. j cataract refract surg. 2009; 35: 677-81. 9. kersey jp, broadway dc. corticosteroid-induced glaucoma: a review of the literature. eye 2006; 20: 40716. 10. cubey rb. glaucoma following the application of corticosteroid to the skin of the eyelids. br j dermatol. 1976; 95: 207-8. 11. kalina re. increased intraocular pressure following subconjunctival corticosteroid administration. arch ophthalmol. 1969; 81: 78-90. 12. gillies mc, simpson jm, billson fa, luo w, penfold p, chua w, mitchell p, zhu m, hunyor ab. safety of an intravitreal injection of triamcinolone: results from a randomized clinical trial. arch ophthalmol. 2004; 122: 336-40. 13. bernstein hn, mills dw, becker b. steroid-induced elevation of intraocular pressure. arch ophthalmol. 1963; 70: 15-8. 14. lacmanović lv, petric i, vatavuk z, musulin t, novaklaus k, iveković r, mandic z. triamcinolone acetonide in the treatment of inflammation after cataract surgery. acta med croatica 2006; 60: 125-8. http://www.jcrsjournal.org/article/s0886-3350(09)00065-0/abstract## http://www.jcrsjournal.org/article/s0886-3350(09)00065-0/abstract## javascript:al_get(this,%20'jour',%20'j%20cataract%20refract%20surg.'); javascript:al_get(this,%20'jour',%20'j%20cataract%20refract%20surg.'); javascript:al_get(this,%20'jour',%20'j%20cataract%20refract%20surg.'); http://www.jcrsjournal.org/issues?vol=35 microsoft word 11-ra khawaja khalid pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 46 review article tuberculosis (tb) – an ophthalmic perspective khawaja khalid shoaib pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: khawaja khalid shoaib pns hafeez, islamabad …..……………………….. t is estimated by the world health organization (who) that one-third of the world’s population is infected by mycobacterium tuberculosis. ophthalmologists should be aware of the ocular features and management strategies so that they can not only gauge the burden of the diseases in their population but also control it effectively. following are the updates, which are important from ophthalmic point of view. pathogenesis tuberculosis (tb) is a chronic infection caused by mycobacteria, mycobacterium tuberculosis. after entry of the organisms in the body, most persons remain asymptomatic, but the infection persists permanently in a latent or dormant state. active disease occurs when microorganisms begin replicating and it is usually when the immune system fails. the epidemic of human immunodeficiency virus (hiv) infection may have contributed to the increase in tb in the western countries. ocular involvement different ocular tissues can be involved (table 1). lid, conjunctiva and lacrimal sac: lupus vulgaris may spread from the face to the skin of the lids as translucent nodule that ulcerates. lid tuberculosis (with negative tuberculin reaction) may present as basal cell carcinoma1 and tarsitis can be mistaken as chalazion. chronic unilateral conjunctivitis is in the form of a conjunctival mass or ulceration associated with regional lymphadenopathy. tuberculous dacryocystitis can lead to fistula formation. sclera, uveal tissue, optic nerve and retina: tb associated uveitis (tau) may present as anterior uveitis,2 either granulomatous or nongranulomatous, choroiditis, or choriodal tubercles / tuberculoma. tuberculoma of the choroid may be confused with a choroidal melanoma3 or metastatic tumor.4 hypopyon is a rare manifestation of tau5. tb is responsible for half of the cases of infectious uveitis in pakistan,6 6% of uveitis cases in spain7 and 5% of anterior uveitis cases in india2. in scleritis cases, 1% had tb8. infective causes should be suspected in cases of scleritis which progress despite treatment9. disseminated tb has been observed to present as irido-ciliary granuloma in an immune competent patient.10 central nervous system tb can lead to bilateral papilloedema causing the branch retinal vein occlusion (brvo),11 horizontal gaze palsy, and papill edema with unilateral sixth nerve paresis.12 for intra-retinal white infiltrates associated with hemorrhage and vitritis, initial diagnostic considerations include infectious causes (cytomegalovirus retinitis, syphilis, toxoplasmosis, tuberculosis), inflammatory (retinal vasculitis associated with autoimmune disease or hypercoagulable states) or malignant (intraocular lymphoma) diseases.13 presumed tubercular cases include a case of i khawaja khalid shoaib 47 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology retinal vasculitis with serpiginous-like choroiditis in the other eye14 and a case of combined optic neuropathy with central retinal artery occlusion without systemic infection.15 tuberculous optic neuropathy may manifest as papillitis, neuroretinitis, or optic nerve tubercle and visual recovery from tuberculous optic neuropathy is common, if the appropriate treatment is given (davis ej et al 2012).16 ocular tb (choroidal tuberculoma) may be associated with cerebral abscesses that respond to anti tb treatment17 or multiple pigment epithelial detachments progressing to a large serous detachment of the macula (patient had positive t-spot test).18 reactivation of latent mycobacterium tuberculosis may occur especially in patients on long term systemic immunosuppressive treatment.9 chronic immune suppression (due to corticosteroids and immunosuppressive agents) to reduce inflammation in patients with posterior or panuveitis is a risk factor for systemic infections. choroidal tuberculoma associated with tuberculosis has been reported in a patient with ocular behçet disease19. sarcoidosis is rare in children but should be included in differential diagnosis of tb.20 management the diagnosis of ocular tuberculosis can be confirmed by finding caseating granuloma, acid-fast bacilli which are detected by histopathologic staining methods of ocular tissues and on isolation of the organism on lowenstein – jensen (lj) medium or by polymerase chain reaction (pcr). in the histopathologic specimens, microscopy reveals a paucity of organisms and often there are only 1 or 2 organisms near a giant cell or near an area of necrosis.21 pcr is an excellent test for the detection of organisms that are difficult to culture or that take long time to grow, such as mycobacterium tuberculosis.22 pcr using different gene targets can help in the diagnosis of extrapulmonary tuberculosis (eptb) including the ocular tb.23 nested pcr has been found positive in tubercular ampiginous choroiditis24. subjects with uveitis associated with tb who respond to anti-tb therapy do not have an active ocular tuberculous infection, but rather an autoimmunerelated ocular inflammation that may be triggered by tb.25 mtb genome was demonstrated in more than 50% of vitreous fluid samples with significant bacillary load, indicating that half of patients with socalled eales' disease are indeed cases of tubercular vasculitis.26 a modified loop – mediated isothermal amplification (lamp) assay has been used for detection of the mycobacterium tuberculosis complex and claimed to have high specificity, high sensitivity, simplicity, and superiority in avoidance of aerosol contamination.27 two interferon gamma release (ifn-c) assays (igra) are commercially available: t spot-tb (oxford immunotec, oxford, uk) and quanti feron tb gold in-tube (qft – it; cellestis, valencia, california, usa. these assays are highly sensitive and specific. uveitis patients have higher m tuberculosis infection rate and grade of intensity response than healthy control subjects detected by elispot-ifngamma (elispot – mtp).28 quantiferon®-tb gold test has been found to be useful in diagnosis of ocular tb.29 a combination of clinical signs, igra and tuberculin skin test (tst) has been recommended to diagnose tau.30 others have proposed that a combination of schirmer test > 10 mm, retinal tuberculosis (tb) – an ophthalmic perspective pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 48 vasculitis with areas of multiple, pigmented chorioretinal atrophy along blood vessels, and positive mantoux test may be used clinically to differentiate tubercular from sarcoid uveitis in indian population.31 in presumed tb a therapeutic trial of anti tb drugs (isoniazid, rifampin, pyrazinamide and ethambutol) can be given for 2 – 4 weeks. if the response is good, full anti tb course should be given (ethambutol for 2 months to prevent optic neuropathy and the rest for 6 months). tau with latent tb responds to anti-tb therapy.32 some believe that antitubercular treatment is not required in latent tuberculosis33. antituberculosis drugs are known to cause decreased vision.34 anti-tuberculosis drug, rifabutin induced uveitis35 should be kept in mind and especially in aids patients36 to avoid useless and potentially invasive interventions in these fragile people. visual acuity, contrast sensitivity, and multifocal erg are sensitive tests to detect ethambutol toxicity in subclinical stages37. continued progression of choroiditis lesions after initiating antituberculosis treatment in tubercular serpiginous – like choroiditis is an indication for increased immunosuppression with continuation of antituberculosis treatment which results in good outcome.38 author’s affiliation dr. khawaja khalid shoaib pns hafeez, islamabad references 1. wyrwicka a, minias r, jurowski p. [cutaneous eyelid tuberculosis-a case report]. [article in polish] klin oczna. 2011; 113: 172-4. 2. mathur g, biswas j. systemic associations of anterior uveitis in a tertiary care ophthalmic centre in south india. int ophthalmol. 2012; 9. [epub ahead of print]. 3. papastefanou vp, cohen vm. tuberculoma of the choroid masquerading as a choroidal melanoma. eye (lond). 2011; 25: 1519-20. 4. zhang m, zhang j, liu y. clinical presentations and therapeutic effect of presumed choroidal tuberculosis. retina. 2012; 32: 805-13. 5. chatziralli ip, keryttopoulos p, papazisis l, moschos mm. hypopyon in the context of tuberculous uveitis. clin exp optom. 2012; 95: 241-3. 6. ishaq m, muhammad js, mahmood k. uveitis is not just an ophthalmologists' concern. j pak med assoc. 2012; 62: 92-7. 7. llorenç bellés v, adán civera a, espinosa garriga g, cervera segura r, gonzález martínez j, pelegrín colás l, keller j, rey torrente a, mesquida febrer m. [uveitis diagnosis characterization at a referral centre in the area of barcelona, spain]. [article in spanish] med clin (barc). 2012; 138: 277-82. 8. gonzalez – gonzalez la, molina – prat n, doctor p, tauber j, sainz de la maza mt, foster cs. clinical features and presentation of infectious scleritis from herpes viruses: a report of 35 cases. ophthalmology. 2012; 119: 1460-4. 9. biswas j, aparna ac, annamalai r, vaijayanthi k, bagyalakshmi r. tuberculous scleritis in a patient with rheumatoid arthritis. ocul immunol inflamm. 2012; 20: 49-52. 10. basu s, mittal r, rath s, balne pk, sharma s. disseminated tuberculosis presenting as irido-ciliary granuloma in an immunocompetent patient. j ophthalmic inflamm infect. 2012. 11. kopsachilis n, brar m, marinescu ai, andrews r. central nervous system tuberculosis presenting as branch retinal vein occlusion. clin exp optom. 2012. 12. lolly p, rachita s, satyasundar m. ophthalmic manifestations of central nervous system tuberculosis-two case reports. indian j tuberc. 2011; 58: 196-8. 13. say ea, knupp cl, gertsch kr, chavala sh. metastatic b-cell lymphoma masquerading as infectious retinitis and vasculitis. oncol lett. 2012; 3: 1245-8. 14. nayak s, basu s, singh mk. presumed tubercular retinal vasculitis with serpiginous-like choroiditis in the other eye. ocul immunol inflamm. 2011; 19: 361-2. 15. ooi yl, tai ly, subrayan v, tajunisah i. combined optic neuropathy and central retinal artery occlusion in presumed ocular tuberculosis without detectable systemic infection. ocul immunol inflamm. 2011; 19: 370-2. 16. davis ej, rathinam sr, okada aa, tow sl, petrushkin h, graham em, chee sp, guex – crosier y, jakob e, tugal-tutkun i, cunningham et jr, leavitt ja, mansour am, winthrop kl, hills wl, smith jr. clinical spectrum of tuberculous optic neuropathy. j ophthalmic inflamm infect. 2012. 17. nor-masniwati s, zunaina e, azhany y. ocular tuberculosis with multiple cerebral abscesses. case rep ophthalmol med. 2012. 18. vayalambrone d, ivanova t, misra a. atypical central serous retinopathy in a patient with latent tuberculosis. bmj case rep. 2012. 19. atmaca l, yalçindağ fn, ciledağ a. choroidal tuberculoma in a patient with ocular behçet disease. int ophthalmol. 2012; 32: 93-6. 20. el hansali z, oukabli m, laktaoui a, kriet m, oubaaz a, chana h. [childhood sarcoidosis: ophthalmological manifestations and diagnostic difficulties in two cases]. [article in french]. j fr ophtalmol. 2012; 35: 290. 21. wroblewski kj, hidayat aa, neafie rc, rao na, zapor m. ocular tuberculosis: a clinicopathologic and molecular study. ophthalmology. 2011; 118: 772-7. 22. sharma s. diagnosis of infectious diseases of the eye. eye 2012; 26: 177-84. khawaja khalid shoaib 49 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology 23. mehta pk, raj a, singh n, khuller gk. diagnosis of extrapulmonary tuberculosis by pcr. fems immunol med microbiol. 2012. 24. bhuibhar ss, biswas j. nested pcr-positive tubercular ampiginous choroiditis: a case report. ocul immunol inflamm. 2012. 25. ang m, cheung g, vania m, chen j, yang h, li j, chee sp. aqueous cytokine and chemokine analysis in uveitis associated with tuberculosis. mol vis. 2012; 18: 565-73. 26. singh r, toor p, parchand s, sharma k, gupta v, gupta a. quantitative polymerase chain reaction for mycobacterium tuberculosis in so-called eales' disease. ocul immunol inflamm. 2012; 20: 153-7. 27. hong m, zha l, fu w, zou m, li w, xu d. a modified visual loop-mediated isothermal amplification method for diagnosis and differentiation of main pathogens from mycobacterium tuberculosis complex. world j microbiol biotechnol. 2012; 28: 523-31. 28. modorati g, berchicci l, miserocchi e, scarpellini p, mantegani p, bandello f, ortis c. clinical application of an in-house elispot assay in patients with suspicious tuberculous uveitis and no signs of active tuberculosis. eur j ophthalmol. 2012. 29. sudharshan s, ganesh sk, balu g, mahalakshmi b, therese lk, madhavan hn, biswas j. utility of quantiferon®-tb gold test in diagnosis and management of suspected tubercular uveitis in india. int ophthalmol. 2012; 32: 217-23. 30. ang m, wong w, ngan ccl, chee s.p. interferongamma release assay as a diagnostic test for tuberculosis associated uveitis. eye 2012; 26: 658-65. 31. babu k, kini r, mehta r, philips m, subbakrishna dk, murthy kr. predictors for tubercular uveitis: a comparison between biopsy-proven cases of tubercular and sarcoid uveitis. retina. 2012; 32: 1017-20. 32. ang m, hedayatfar a, zhang r, chee sp. clinical signs of uveitis associated with latent tuberculosis. clin experiment ophthalmol. 2012. 33. nazari h, rao na. anti-tubercular treatment is not required in latent tuberculosis. br j ophthalmol. 2012; 96: 463. 34. ayanniyi aa, ayanniyi ro. a 37-year-old woman presenting with impaired visual function during antituberculosis drug therapy: a case report. j med case rep. 2011; 5: 317. 35. saito t, oban a, tsuchiya y, saito k, hotta y. [three cases of uveitis induced by mycobacteriosis therapy using rifabutin]. [article in japanese] nihon ganka gakkai zasshi. 2011; 115: 595-601. 36. bazewicz m, fikri j, martin ch, libois a, meunier a, frippiat f, caspers l, willermain f. drug-induced uveitis in aids patients: two case reports. bull soc belge ophtalmol. 2011; 318: 19-23. 37. kandel h, adhikari p, shrestha gs, ruokonen el, shah dn. visual function in patients on ethambutol therapy for tuberculosis. j ocul pharmacol ther. 2012; 28: 174-8. 38. gupta v, bansal r, gupta a. continuous progression of tubercular serpiginous-like choroiditis after initiating antituberculosis treatment. am j ophthalmol. 2011; 152: 857-63. pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 103 original article type of horizontal deviation in consanguinity samia iqbal, muhammad shafiq, muhammad zeeshan, hakim anjum nadeem, muhammad jamshed pak j ophthalmol 2018, vol. 34, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: samia iqbal department of ophthalmology, the university of lahore email: samiaiqbal988@gmail.com …..……………………….. purpose: to find out the association and types of horizontal deviation in consanguinity. study design: cross-sectional study. place and duration of study: department of ophthalmology, the university of lahore teaching hospital from september to december 2017. material and methods: in this study, 93 patients of 3 to 15 years, with diagnosis of horizontal deviation and positive history of consanguinity were included in the study. while the patients with vertical deviation and negative history of consanguinity were excluded from study. data was collected by selfdesigned proforma after taking consent from patients having history of consanguinity. the visual acuity screening and orthoptic assessment were performed on the sample of 93 patients using snellen chart for visual acuity and pen torch for hirschberg test, cover uncover test and alternate cover test and prisms for krimsky test. data was analyzed using spss version 20. results: out of 93 patients, 55 (59.1) had exotropia and 38 (40.8%) had esotropia. 17 (18.2%) had emmetropia, 22 (23.65%) had myopia, 7 (7.5%) had hyperopia, 25 (26.8%) had myopic astigmatism, 10 (10.7%) had hyperopic astigmatism and the remaining 12 (12.9%) had mixed astigmatism. conclusion: it is concluded that consanguinity is related with horizontal deviation and refractive errors. key word: consanguinity, horizontal deviation, myopia. isalignment of the eyes is called deviation. it is also called squint or strabismus. deviation is a state in which the eyes do not appropriately align with each other while focusing at an object. deviation can be constant or intermittent. horizontal deviation is misalignment of eyes. it may be one or both eyes. horizontal deviation is divided into two main types; the first one is esodeviation and second is exodeviation. in esodeviation the eyes misaligned inward i.e. crossed eyes. convergent deviation is the other name of esodeviation. in exodeviation, the eyes are misaligned outward. exodeviation is also known divergent deviation1. consanguinity is the belongings of being from the same kinship as another person. in that characteristic, parental cousin marriages is the quality of being descend from the similar antecedent as another individual2. the credential of relative consanguinity may be confirmed with a consanguinity table wherein every level of lineal consanguinity (meiosis) appears as a row3. the consanguinity causes other main disorder given below3. • premature ear shot damage. • premature visual system development and perceptive damage. • intelligent delay or learning disorder. • growing delay or failure. • hereditary blood disease. • mental disorder like epilepsy4. m samia iqbal, et al 104 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology several recent studies suggested that there is greater frequency of horizontal deviation amongst parental cousin marriages5. survey on 7200 patients of strabismus has shown that almost 30% patients had a positive history of consanguinity6. the genetics of common styles of horizontal deviation is not properly diagnosed. the mode of horizontal deviation may be recessive, dominant or having different factors. numerous chromosomal susceptibility loci had been cautioned.7 it appears that the dominant and recessive association and codominant heirloom type of transmission was associated with esotropia in early age. the horizontal deviation seen due to autosomal recessive genetics is mentioned in consanguinity8. regarding these records, it appears that evidently recessive shape of heirloom shows an essential position within the case of horizontal deviation. alteration in selection correspondences can be soughtafter pre revealing of horizontal deviation in children of parental cousin marriages9,10. materials and methods it was cross sectional study conducted on 93 patients. in this study 93 patients of 3 to 15 years, with diagnosis of horizontal deviation and positive history of consanguinity were included. while the patients with vertical deviation and negative history of consanguinity were excluded from study. sample size was estimated by probability convenient method. all patients were diagnosed with horizontal strabismus by orthoptic assessment. patients of all other ages or having no positive history of consanguinity were excluded from the study. the purpose of the study was to find the type of horizontal strabismus in consanguinity. therefore, all patients underwent measurement of distance (6 m) and near (33 cm) visual acuity by using near visual acuity charts and snellen distance charts. orthoptic assessment, hirschberg, cover uncover test and alternate cover test were done to rule out the horizontal deviation. data was collected by self-designed proforma after taking consent from patients having history of consanguinity. the results were analyzed by using spss version 20. results results of table 1 shows that 93 patients were involved in study. out of 93 patients 28 (30.1%) were males and 65 (56.9%) were females. table 2 shows the age distribution of 93 patients. below table 3 shows that out of 93 patients, 55 (59.1) had exotropia and 38 (40.8%) had esotropia. table 1: gender. frequency percent valid percent cumulative percent valid female 65 56.9 56.9 56.9 male 28 30.1 30.1 30.1 total 93 100.0 100.0 100 table 2: age distribution. frequency percent valid percent cumulative percent valid 3 – 6 19 20.5 20.5 20.5 7 – 11 38 40.8 40.8 79.5 12 – 15 36 38.7 38.7 100.0 total 93 100.0 100.0 table 3: type of deviation. frequency percent valid percent cumulative percent valid esotropia 38 40.8 40.8 40.8 exotropia 55 59.1 59.1 100 total 93 100.0 100.0 type of horizontal deviation in consanguinity pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 105 table4: distribution of patients according to refractive error. frequency percent valid percent cumulative percent valid emmetropes 17 18.2 18.2 18.2 myopia 22 23.65 23.65 41.8 hyperopia 7 7.5 7.5 49.3 myopic astigmatism 25 26.8 26.8 76.1 hyperopic astigmatism 10 10.7 10.7 88.8 mixed astigmatism 12 12.9 12.9 100.0 total 93 100.0 100.0 17 patients (18.2%) were emmetropes and 22 (23.65%) were myopes. out of 93, 7 (7.5%) were hyperopes, 25 (26.8%) showed myopic astigmatism and 10 (10.7%) had hyperopic astigmatism. the remaining 12 (12.9%) had with mixed astigmatic error. disscussion the consanguinity and types of horizontal deviation is not properly identified. the mode of horizontal deviation inheritance can be dominant, recessive, or multifactorial. oligogenic heirloom for childhood esotropia was seen in a huge parental cousin marriages population12. similar results were obtained from recent study. autosomal recessive inheritance in horizontal deviation has been seen in consanguinity and mostly infantile esotropia seen with hypermetropia13. it is concluded from another study that due to autosomal recessive linkage, higher myopia was associated with exotropia in many children. all these children of myopia with exotropia had positive history of consanguinity14. infantile esotropia with hypermetropia and exotropia with myopia cases were observed due to consanguinity. anisometropic amblyopia in many school-going children were examined and 65% had positive history of consanguinity15. the parental cousin marriages is an extremely rooted community approach between one fourth of the world populace3. consanguineous communities are trying to find counseling on consanguinity16. the number one health care agencies are faced with consanguineous couple stressful solutions to their questions on the predicted health dangers to their offspring17. in clinical inheritances, a parental cousin marriages is defined as a relation between two individuals who are associated as second cousins or closer, with the coefficient breeding equal or higher than 0.0157, where the coefficient characterizes extent of the ratio of loci at which the children of a parental cousin marriages is predictable to inherit identical copies of genes from both parents18. similar studies suggested that inheritance has an important role in the etiology of strabismus. previous studies indicated the occurrence rate of 70 to 85% among monozygotic twins and 35 to 50% among dizygotic twins and all these offspring have significant myopia with exotropia19. in another similar research, strong genetic element in hyperopic accommodative esotropia was observed20. schlossmann and priestley suggested that 47.8% of patients with horizontal deviation, 49.9% with esotropia and 36.9% with exotropia, had positive history of parental cousin marriages21. other similar research showed that incidence of horizontal deviation in consanguinity is 65% higher as compared to normal population22. conclusion consanguinity causes abnormality in the eyes and causes refractive errors. horizontal deviation is seen in the children having age 3 to 15 years and positive history of consanguinity. it is concluded that consanguinity causes deviation in the eyes i.e. horizontal deviation and refractive errors. authors affiliation dr. samia iqbal (od) doctor of optometry, pgr ms opto(uol). department of optometry & visual sciences (dovs) the university of lahore teaching hospital lahore. samia iqbal, et al 106 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology dr .muhammad shafiq mbbs (medical officer). bhu malik pura bahawalnager. dr. muhammad zeeshan mbbs (medical officer). bhu amar singh tehsile minchanabad district bahawalnager. dr. hakim anjum nadeem (od) doctor of optometry. pgr ms opto (uol). senior lecturer, dovs ,uol lahore. dr. muhammad jamshed mbbs (medical officer) role of authors dr. samia iqbal study design, review of literature and data analysis. dr. muhammad shafiq data collection. dr. muhammad zeeshan experimental design. dr. hakim anjum nadeem article review and manuscript preparation. dr. muhammad jamshed technical support. refrences 1. akrami sm, montazeri v, shomali sr, heshmat r, larijani b. is there a significant trend in prevalence of consanguineous marriage in tehran? 2009; 18 (1): 82–86. 2. aurell e, norrsell k. a longitudinal study of children with a family history of strabismus: factors determining the incidence of strabismus, 1990; 74: 589–594. 3. cotter s, varma r, tarczy-hornoch k, mckeancowdin r, lin j, wen g, wei j, borchert m, azen sp, torres m, tielsch jm, friedman ds, repka mx, katz j, ibironke j, giordano l. risk factors associated with childhood strabismus: the multi-ethnic pediatric eye disease and baltimore pediatric eye disease studies, 2011; 118: 2251–2261. 4. dufier jl, briard ml, bonaiti c, frezal j, saraux h. inheritance in the etiology of convergent squint, 1979; 179: 225–234. 5. fujiwara h, matsuo t, sato m, yamane t, kitada m, hasebe s, ohtsuki h. genome-wide search for strabismus susceptibility loci. 2003; 57 (3): 109–116. 6. hamamy h. consanguineous marriages, 2012; 3: 185– 192. 7. khan ao, shinwari j, abu dhaim n, khalil d, al sharif l, al tassan n. potential linkage of different phenotypic forms of childhood strabismus to a recessive susceptibility locus (16p13.12-p12.3), 2011a; 17: 971–976. 8. khan ao, shinwari j, al sharif l, khalil d, algehedan s, tassan na. infantile esotropia could be oligogenic and allelic with duane retraction syndrome, 2011; 17: 001–002. 9. li d, chen y. a consanguineous mating couple and their concomitant esotropia, 1991; 7 (3): 153–155. 10. matsuo t, hayashi m, fujiwara h, yamane t, ohtsuki h (2002). concordance of strabismic phenotypes in monozygotic versus multizygotic twins and other multiple births, 2007: 46 (1): 59–64. 11. oystreck dt, lyons cj. comitant strabismus: perspectives, present and future, 2012; 26: 265–270. 12. paul to, hardage lk. the heritability of strabismus, 151–158. 13. saadat m, ansari-lari m, farhud d. consanguineous marriage in iran, 2004; 31: 263–269. 14. schlossmann a, priestley bs. role of heredity in etiology and treatment of strabismus, 1952; 47: 1–20. 15. stoll p, alembik y, dott b, feingold j. parental consanguinity as a cause of increased incidence of birth defects in a study of 131,760 consecutive births, 2005; 49: 114–117. 16. tohishiko m, takashi y, hirishi o. heredity versus abnormalities in pregnancy and delivery as risk factors for different types of comitant strabismus, 2001; 38: 78– 82. 17. ziakas ng, woodruff g, smith lk, thompson jr. a study of heredity as a risk factor in strabismus, 2008. 18. simon d, hadjiathanasiou c, garel c, czernichow p, léger j. phenotypic variability in children with growth hormone deficiency associated with posterior pituitary ectopia. clinical endocrinology, 2006 apr. 1; 64 (4): 41622. 19. wang sm, zwaan j, mullaney pb, jabak mh, alawad a, beggs ah, engle ec. congenital fibrosis of the extraocular muscles type 2, an inherited exotropic strabismus fixus, maps to distal 11q13. the a alazami am, hijazi h, al-dosari ms, shaheen r, hashem a, aldahmesh ma, mohamed jy, kentab a, salih ma, awaji a, masoodi ta. mutation in adat3, encoding adenosine deaminase acting on transfer rna, causes intellectual disability and strabismus. journal of medical genetics, 2013 apr. 24: jmedgenet-2012. american journal of human genetics, 1998 aug. 31; 63 (2): 517-25. 20. carnevale f, krajewska g, fischetto r, greco mg, bonvino a. ptosis of eyelids, strabismus, diastasis recti, hip defect, cryptorchidism, and developmental delay in two sibs. american journal of medical genetics part a, 1989 jun. 1; 33 (2): 186-9. 21. kekunnaya r, gupta a, sachdeva v, krishnaiah s, rao bv, vashist u, ray d. duane retraction syndrome: series of 441 cases. journal of pediatric ophthalmology and strabismus, 2012 may 1; 49 (3): 164-9. 22. salgado lj, ali ca, castilla ee. acrocallosal syndrome in a girl born to consanguineous parents. american journal of medical genetics part a, 1989 mar. 1; 32 (3): 298-300. 78 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology original article physical and physiological changes with presbyopia atif babiker mohamed ali, khalil a. lakho, ahmed elsiddig abdelbagi pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: atif babiker mohamed ali faculty of optometry and visual sciences, university of alneelain p.o.box 12702, khartoum sudan …..……………………….. purpose: to estimate the possible physical and physiological changes in the optical system of the eye related to age over 40 years in normal presbyopic persons. material and methods: sample of 20 subjects with presbyopia ages (40 – 45 years) was used as cases and other sample of 20 subjects from university student’s ages (20 – 25 years) was used for comparison. typical measurement procedures for the two groups included: accommodation, pupil size, anterior corneal surface power, and refraction from both eyes in each subject. results: t-test showed significant difference between the measurements of the two groups. the estimated changes from young age to presbyopic age demonstrated the amplitude of accommodation tends to decrease 0.27 d per year, the pupil size tends to become smaller 0.033 mm per year, the refraction tends to shift toward hypermetropia 0.018 d per year, the corneal astigmatism tends to decrease 0.0083 d per year, and the cylinder of corneal astigmatism was found to change gradually from with-the-rule to against-the-rule. conclusion: all measurements in this study suggesting significant changes in the optical system of the eye were essentially related to age. s age advances it is found initially to affect the optical system of the eye in the process of accommodation, hence the presbyopia occurs. accommodation is reasonably effective by the age of about four months and remains more than adequate for most purposes until the onset of presbyopia at the age of about 40 years1. with increasing age, it is generally believed that the crystalline lens progressively loses elasticity, leading to a complete inability to change shape and to loss of accommodation by the mid fifties2. although there appears to be no general agreement on how to define the onset of presbyopia, it is often accepted that this term should be applied when the subjective amplitude of accommodation falls below three dioptres3. the changes with age vary very little between individuals and, unlike many aspects of human physiology, do not appear to have been affected by the changes in nutrition4. it is found that anterior chamber depth decreases with accommodation and age, and the lens thickness increases with accommodation and age5. the cornea as a whole changes its shape with age, becoming flatter, its curvature diminishing particularly in the vertical meridian and there is decrease in the percentage of eyes showing with-therule corneal astigmatism and significantly higher potential for against-the-rule astigmatism with age6,7. the healthy ageing lens is seen to decrease in power with age due to difference between the refractive indices of cortex and nucleus of the lens8. accommodative miosis varies widely between subjects of the same age and does not appear to change systematically between the ages of 20 and 40 years9. although sorsby (1958) stated that the pupil becomes smaller and dilates poorly with old age10. therefore, the amount of entrant light may be reduced but provides a pinhole effect and this has advantage if the error is only slight11. this study aimed to calculate the effect of age on accommodation, pupil size, corneal power, and refraction. a physical and physiological changes with presbyopia pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 79 material and methods a comparative cross-sectional method was employed, in which two groups of subjects were selected, young adults and presbyopes to achieve the objectives. a total sample of fourty (40) subjects were recruited for this study, group (a) included twenty (20) subjects with presbyopia ages between (40 – 45 years) and group (b) included twenty (20) subjects of young adults ages between (20 – 25 years). each group contains equal number of (10) males and (10) females. all subjects were selected according to criteria of admission after consent. the criteria of admission included; (a) each subject should have no history of corrected refractive error, strabismus, eye surgery, and systemic or chronic diseases, (b) each subject have no symptoms of eye discomfort, except the difficulty in reading from presbyopia, (c) distance vision should not be less than 6/6 by snellen test types in each eye, (d) normal appearance of outer eye (slit lamp examination) and normal appearance of inner eye (direct ophthalmoscopy) should be achieved, (e) each eye pupil appears regularly round and the two pupils should not be different in size. four measurements were applied typically in same conditions and parameters for each subject and the data recorded in a data form. measurement of accommodation was performed by raf rule and the mean of three readings (in dioptres) were recorded. measurement of pupil size was done by pd-ruler and horizontal diameters of pupil (in mm) were taken with aid of magnifier under normal room lighting conditions. the autoref – keratometer (shin – nippon srk 9000) instrument was used to measure the two principal corneal powers (in dioptres), the average of the two powers, and the cylinder of the corneal astigmatism with its axis (in degrees) was recorded. the autoref – keratometer (shin – nippon srk 9000) was also used to measure refraction of the eye. three readings of each eye were obtained and the mean was selected. all examinations and measurements were done in alwalidain eye hospital. for analysis the mean and standard deviation of accommodation and pupil size were calculated directly from data. the keratometry expressed in two sets of data, the average k-reading of principal powers and the cylinder of corneal astigmatism. the refractometry also expressed in two sets of data, the spherical component and the cylinder component of refraction, the minus cylinder axis in this study referred to as being with-the-rule or direct (axis 180° ± 20°); against-the-rule or inverse (axis 90° ± 20°); and oblique (axis 45 / or 135 ± 25°)12. t-test was used to determine significant difference among the two groups. confidence interval at 95% and probability (p) value 0.05 was taken to indicate statistical significance and all results were summarized in four tables. results the mean age of group (a) was 42.40 years and of group (b) was 22.15 years, the average length of time between the mean of the two groups was 20.25 years (42.40 minus 22.15) which was used for calculations to estimate the changes per year in measurements. no doubt change in accommodation is highly significant when a person becomes presbyopic. according to this study the difference in accommodation between group (a) and group (b) was calculated 5.66 d, when distributed over 20.25 years the result was 0.27 d decrease in accommodation per year between young age towards presbyopia. the difference in pupil size between group (a) and group (b) was 0.68 mm, when distributed over 20.25 years the result was 0.033 mm decrease in pupil size each year towards old age. the mean corneal astigmatism of group (b) was slightly greater than in group (a) of about 0.17 d. however, if this difference distributed over 20.25 years the result was 0.0083 d decrease or flattening in corneal curvature each year due to aging. the spherical component of refraction in this study demonstrated that group (a) have a mean +0.37d and group (b) have a mean -0.01d, the difference in mean is +0.36d, when distributed over 20.25 years, it turned out to be a change of 0.018d per year on hypermetropic side in presbyopic age. discussion the results of this study indicated that accommodation, pupil size, corneal astigmatism, and refraction all change with age. the present results are in conformity with extent previous studies. however, there were no clinically significant differences between males and females in each group for any of the measurements except the pupil size and the cylindrical component of refraction in group (b). the significant decrease of accommodation (estimated 0.27d) occurs gradually and is continuous throughout life without any sudden alteration. the statistical analysis presented gender difference (at 0.05) in pupil size for group (b). the data in table 2 demonstrated that atif babiker mohamed ali, et al 80 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology females have slightly larger pupil size than males of about 0.40 mm; this result was supported by emsly 13 who stated that the pupil is somewhat larger in myopes and women, smaller in hypermetropes, men, and very old people. although the average k-reading in this study showed no statistical significant difference between the two groups, but the result of corneal astigmatism has shown significant difference. however, any changes in corneal curvature or axial length are far too small to account for the observed physical and physiological changes with presbyopia pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 81 changes in accommodation although, surprisingly, there is still debate on whether some minor changes in corneal curvature do occur14-16. the spherical component of refraction in this study demonstrated that group (a) have a tendency to acquired hypermetropia. undoubtedly the effects of the changes in the surface curvatures of the lens and those in the index gradients both make important contributions to the overall power changes in the lens during accommodation17. the cylinder component of refraction showed no statistical difference between means of cylinder in the two groups. the current study showed a mean cylinder of 0.48 d in group (a) and 0.43 d in group (b), this result agree with helmholtz(18) who stated that the limit of normal astigmatism of the eye given as 0.50d; the direct form (with-the-rule) being more common in youth and the inverse form (against-the-rule) in more advanced life. although functional near vision can be achieved with simple methods such as spectacles or contact lenses, or more advanced methods such as intraocular lenses, these are not ideal. the ideal method of treating presbyopia would be to restore the dynamic change in power that a young lens can achieve, therefore restoring the full range of near and far vision19. therefore, any explanation of presbyopia that relies on simple changes in the amplitude of accommodation is not reliable. conclusion all measurements in this study suggesting significant changes in the optical system of the eye were essentially related to age. author’s affiliation dr. atif babiker mohamed ali assistant professor faculty of optometry and visual sciences university of alneelain po box 12702, khartoum, sudan dr. khalil a. lakho medical director makkah eye complex, khartoum po box 12368, khartoum, sudan dr. ahmed elsiddig abdelbagi assistant professor faculty of optometry and visual sciences university of alneelain, po box 12702, khartoum, sudan references 1. brookman ke. ocular accommodation in human infants. am j optom physiol opt 1983; 60: 91–9. 2. atchison da. accommodation and presbyopia. ophthalmic and physiological optics 1995; 15: 255-72. 3. weale ra. why we need glasses before a zimmer – frame. vision res. 2000; 40: 2233–40. 4. charman n. the eye in focus: accommodation and presbyopia clin exp optom. 2008; 91: 207–25 5. dubbelman m, van der heijde g l, weeber h a. change in shape of the aging human crystalline lens with accommodation. vision research. 2005; 45, 117-32. 6. goto t, et al. genderand age-related differences in corneal topography. cornea. 2001; 20: 270-6. 7. lyle wm. changes in corneal astigmatism with age. am. j. optom arch acad. optom 1971; 48: 467–78. 8. glasser a, campbell mcw. presbyopia and the optical changes in the human crystalline lens with age. vision res. 1998; 38: 209–29. 9. kasthurirangan s, glasser a. age related changes in the characteristics of the near pupil response. vision res. 2006; 46: 1393–1403. 10. sorsby a. systemic ophthalmology 2nd edn. butterworth and co. london. 1958; 655– 63. 11. trevor-roper pd. ophthalmology a text book for diploma students. lloyd luke. ltd. london, 1955, 207-14. 12. elawad ma. measurement of ocular component contributions to residual astigmatism in adult human eyes "phd thesis" aston. uk. 1995; p 27. 13. emsly hh. visual optics vol i 5th edn. butterworth. 1979; p. 73. 14. pierscionek bk, popiolek–masajada a, kasprzak h. corneal shape change during accommodation. eye 2001; 15: 766–9. 15. yasuda a, amaguchi t, ohkoshi k. changes in corneal curvature during accommodation. j cataract refract surg. 2003; 29: 1297–1301. 16. buehren t, collins mj, loughridge j,carney lg, iskander dr. corneal topography and accommodation. cornea. 2003; 22: 311–6. 17. garner lf, smith g. changes in equivalent and gradient refractive index of the crystalline lens with accommodation. optom vis sci. 1997; 74: 114–9. 18. hirsch mj. changes in astigmatism after age forty. am j optom. 1958; 30: 395–405. 19. glasser a. restoration of accommodation: surgical options for correction of presbyopia. clin and exp optom. 2008; 91: 279-95. pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 172 case report cryptophthalmos syndrome: a case report jawad bin yamin butt, tariq mehmood qureshi, muhammad tariq khan, anwar-ul-haq ahmad pak j ophthalmol 2014, vol. 30 no.3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: jawad bin yamin butt layton benevolent trust hospital (lrbt), 436 a/i township, lahore …..……………………….. a 20 days female baby presented to us in opd. she was the 4th child of normal parents with 3 normal siblings. she exhibited few features of cryptophthalmos which fit the criteria of fraser syndrome. key words: cryptophthalmos, fraser syndrome, eye lid defect. ryptophthalmos (co) is defined as a set of rare congenital eyelid defects in which the lid folds are unable to divide in the embryo and the skin extends continuously from the forehead onto the cheeks covering the eyes.1-3 co maybe bilateral or unilateral and fluctuates in severity from the presence of rudimentary, distorted eyelids to complete absence of eyelids2. autosomal recessive and autosomal dominant inheritance have been reported, but most cases are autosomal recessive.4-8 co is of three clinical types: complete incomplete abortive2,3 co is termed as cryptophthalmos syndrome or fraser syndrome because in most cases it is usually associated with other malformations or systemic findings. however, it can also be isolated.2-8 fraser syndrome (fs) is a rare congenital autosomal recessive disorder,4-8 the prevalence of which is estimated to be 0.43 per 100,000 live births and 11.06 per 100,000 stillbirths9. the first case of fs as described by zehender and coworkers (1872).2,5,8,12 we will be presenting a case of unilateral cryptophthalmos with fraser syndrome. case report the patient is a 20 days old female. she is the 4th child of healthy parents. her three older siblings are normal with no congenital malformation. the infant is full term and delivered by spontaneous vaginal delivery which was eventless. the baby weighed 2900 grams at birth and exhibits normal feeding manner. clinical evaluation exhibits complete absence of right side eyelid formation with absent eyelashes. the skin is continuous from the forehead to the cheek, covering the entire globe. the temporal hairline is abnormal growing down towards the cheek on the right side. a small palpable globe is felt beneath the skin and the orbit is shallow with a deficient orbital rim. there is complete cryptophthalmos of the right side but the left eye is normal, with properly formed lids, lashes and eyeball (fig. 1). pupillary reflex, iop and fundus examination are normal on the left side. the nose has a wide nasal bridge but is flat. hypertelorism is also present in the subject (fig. 1). distortion is present on the right of the face (fig. 1). other findings that are noted includes: mild brachydactyly of hands (fig. 2). cutaneous syndactyly of both feet (fig. 3). external genitalia and ears are normal and the patient does not exhibit any other systemic malformations. c jawad bin yamin butt, et al 173 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology fig. 1: cryptophthalmos with hypertelorism fig. 2: mild brachydactyly of hands fig. 3: cutaneous syndactyly of feet discussion the findings present in this case are consistent with the fraser syndrome (fs) according to the diagnostic criteria proposed by thomas (1986) (table 1).5, 7, 8, 10 for the diagnosis, following requirements must be met: 2 major and 1 minor criteria. 1 major and 4 minor criteria.5, 7-9 in this case study, diagnosis is made on the following basis: co and syndactyly as major criteria. malformations of the nose as minor criteria. co is the primary feature of fs and has been described in 84% to 93% of the patients. it should also be noted that co isn’t a regular finding in the syndrome.5,8 our case has unilateral complete co of the right eye. syndactyly is taken as a chief feature of fs that occurs in almost 77% of the patients. syndactyly is always cutaneous and, in most cases, involves fingers and toes.5,8 genital anomalies in males are: 1. micropenis. 2. hypospadias. cryptophthalmos syndrome: a case report pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 174 3. cryptorchidism. 4. phimosis. genital anomalies in females are: 1. clitoromegaly. 2. bicornuate uterus. 3. uterine hypoplasia. 4. vaginal agenesis. 5. synechiae or hypoplasia of the labia.5,8 in this case study, cutaneous syndactyly of the toes is present, but the genitalia are completely normal. kinship is reported in 15 – 24.8% of the cases and an autosomal recessive pattern of inheritance is evident5,8. the parents of the patient, on this case study, are not related. there is 25% recurrence risk of this syndrome, among siblings5. fs should be suspected in all cases of stillbirths with renal agenesis. 25% of affected fetuses are stillborn10. currently, prenatal diagnosis of fs by an expert is possible with recognition of some of its characteristics through ultrasonography (usg) examination of the eyes, digits, kidney, and lungs in utero.7,11 therefore; usg is recommended in following patients (babies) with higher chances of fraser syndrome: blood related parents families with a previously affected child cases of stillbirths with renal agenesis author’s affiliation dr. jawad bin yamin butt layton benevolent trust hospital (lrbt) 436 a/i township, lahore dr. tariq mehmood qureshi layton benevolent trust hospital (lrbt) 436 a/i township, lahore dr. muhammad tariq khan layton benevolent trust hospital (lrbt) 436 a/i township, lahore dr. anwar ul-haq ahmad layton benevolent trust hospital (lrbt) 436 a/i township, lahore references 1. coulon p, lan pt, adenis jp, verin p. bilateral complete cryptophthalmos. illustration with a case. review of the literature [in french]. j fr ophthalmol. 1994; 17: 505–12. 2. seal hm, traboulsi ei, gavaris p, samango-sprouse ca, parks m. dominant syndrome with isolated cryptophthalmos and ocular anomalies. am j med genet. 1992; 43: 785-8. 3. kanhere s, phadke v, mathew a, irani sf. cryptophthalmos. indian j pediatr. 1999; 66: 805-8. 4. stevens ga, mcclanahan c, steck a, shiel fo, carey jc. pulmonary hyperplasia in the fraser cryptophthalmos syndrome. am j med genet. 1994; 52: 427–31. 5. ramsing m, rehder h, holzgreve w, meinecke p, lenz w. fraser syndrome (cryptophthalmos with syndactyly)in the fetus and newborn. clin genet. 1990; 37: 84-96. 6. schauer gm, dunn lk, godmilow c, eagle rc jr, knisely as. prenatal diagnosis of fraser syndrome at 18.5 weeks gestation, with autopsy findings at 19 weeks. am j med genet. 1990; 37: 583-91. 7. berg c, geipel a, germer u. prenatal detection of fraser syndrome without cryptophthalmos: case report and review of the literature. ultrasound obstet gynecol. 2001; 18: 76-80. 8. slavotinek am, tifft cj. fraser syndrome and cryptophthalmos: review of the diagnostic criteria and evidence for phenotypic modules in complex malformation syndromes. j med genet. 2002; 39: 623-33. 9. martinez-frias ml, bermejo-sanchez e, felix v. fraser syndrome: frequency in our environment and clinicalepidemiological aspects of a consecutive series of cases [in spanish]. an esp pediatr. 1998; 48: 634-8. 10. mahadevan b, bhat bv, sastri at. fraser syndrome with unusual features. a case report. j anatsoc india. 2002; 51: 5960. 11. karba m, gulati s, ghosh m. fraser cryptophthalmos syndrome. indian j pediatr. 2000; 67: 775-8. 12. khoury e, golalipour mj, haidary k, adibi b. fraser or cryptophthalmos syndrome: a case report. iranian med 2004; 7: 307-9. pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 162 case report a unique case of optic disc pit in one eye with csc in other eye haroon tayyab, akhwand abdul majeed jawad pak j ophthalmol 2015, vol. 31 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: haroon tayyab sharif medical & dental college, lahore email: haroontayyab79@google mail.com …..……………………….. a 41 year old male patient presented in eye opd of sharif medical city hospital in january 2015 with complaints of recent onset subacute painless decrease in vision along with metamorphopsia in his right eye. on detailed ophthalmic examination, he was found to have central serous chorioretinopathy (csc) in his right eye and optic disc pit in the left eye. he was investigated with ffa and oct and treated with focal argon laser in his right eye and systemic rifampicin 300mg for 3 months. his symptoms recovered after one month of laser and systemic therapy. we report this unique case of csc in one eye and optic disc pit without maculopathy in other eye. despite successful treatment of csc, this patient stands at risk of developing more severe maculopathy in the left eye which may warrant surgical treatment in future. keywords: central serous chorioretinopathy, optic disc pit, optical coherence tomography. on graefe was the first ophthalmologist to originally describe central serous chorioretinopathy (csc) in 1866 and used the term “récurantcentral retinitis” for csc at that time.1 it was gass who later described csc in further detail through fundus fluoroscein angiography (ffa) and coined the term “central serous chorioretinopathy”.2 current evidence from research shows that primary culprit in the pathogenesis of csc is choroidal hyper-permeability, stasis and ischemia.3,4 this concept has been further strengthened by recent reports of choroidal thickening shown by enhanced depth imaging optical coherence tomography (edioct).5 the role played by retinal pigment epithelium (rpe) still remains elusive although older research pointed out that malfunctioning rpe is the prime responsible for csc.6,7 perhaps the most authentic theory about role of rpe in pathogenesis of csc includes compromised rpe function due to increased choroidal hydrostatic pressure; this may also be evidenced by the presence of pigment epithelial detachments (ped) that often accompanies csc. other possible mechanisms promoting csc (through which csc happens) include hormones like glucocorticoids and catecholamines, h. pylori infection and newly discovered role of genetics in csc.8-11 optic disc pit is another pathology that may result in morphologically similar elevation of neurosensory retina as see in csc.12 the origin of subreitnal fluid in cases of optic disc pit is still being debated. recent advances in imaging modalities like high resolution optical coherence tomography (oct) have hinted on the origin of the subreitnal fluid from cerebrospinal fluid. one such study showed a communication between gap in lamina cribrosa present in optic pit and macular schisis associated with optic disc pit13. other most plausible source of subreitnal fluid is vitreous. case report a 41 year old male, goldsmith by profession, presented in the out-patient's department (opd) of sharif medical city hospital on 10th january, 2015 v haroon tayyab, et al 163 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology with primary complaints of mildly decreased vision in his right eye for last 2 months. his other complaints included metamorphopsia and micropsia. his only other significant information in history was multiple pet cats in his house. this was his first visit to an ophthalmologist in his life and his apprehension was clearly visible and he was very much concerned about his declining vision. on detailed examination of his eyes, his best corrected visual acuity (bcva) in right eye was 20/30 and 20/20 unaided in left eye. he documented metamorphopsia on amsler chart testing. both eyes had unremarkable anterior segment and vitreal examination. on retinal examination, a dome shaped elevation of neurosensory retina at posterior pole was noted in right eye and a temporally placed optic disc pit was noted in left eye. rest of retinal examination was unremarkable. after a strong clinical suspicion of csc in right eye, patient was advised ffa and spectral domain oct of macula in both eyes. also, his h.pylorianti body titer was (carried out which returned to be) normal. his pre intervention oct and ffa pictures are shown in fig. 1, 2and 3, oct which showed neurosensory retinal in the right eye with serous fluid underneath retina; ffa showed an extrafoveal ink blot focal leaking point more than 1500 um away from the centre of fovea (fig. 4). oct and ffa of macula in left eye were within normal limits. based on these findings, a clinical diagnosis of csc in the right eye and optic disc pit (without pit maculopathy) was made in the left eye. since the nature of his job demanded a healthy binocular vision and also considering his apprehension, (we started exploring treatment options for this gentleman. after discussing various treatment options with the patients) we decided to opt for focal argon laser in the right eye along with tablet rifampicin 300 mg twice a day for 3 months. after one month of focal laser and systemic therapy, his bcva improved to 20/20 in the right eye with significant resolution of metamorphopsia. oct was repeated at one month and 2 months post treatment as shown in fig. 5. on further follow-up, he was maintaining the bcva and oct findings recorded at 2 months without any significant complaints. systemic rifampicin was discontinued after 3 months of its commencement. fig. 1: csc in posterior pole of right eye. fig. 2: optic disc pit in left eye fig. 3: sub retinal fluid seen on oct discussion csc is a well documented ophthalmological entity that presents more commonly in middle age males.14 over the years, diagnosis of csc has been simplified a unique case of optic disc pit in one eye with csc in other eye pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 164 fig. 4: focal hotspot temporal to fovea. fig. 5: resolved subretinal fluid with the help of ffa and oct15,16. there are various infective, inflammatory and neoplastic conditions that can lead to serous macular elevation (and thus) which may mimic the morphological appearance of csc. these entities include vogt kayonagi harada (vkh) disease, presumed ocular histoplasmosis syndrome (pohs), white dot syndromes and granulomas of posterior pole due to infective or neoplastic infiltration of choroid. all these entities can be differentiated from typical csc on the basis of history, examination and ophthalmic investigations. optic disc pit is another pathology that can lead to central macular elevation and may cause similar symptoms like that of csc. despite morphological resemblance, optic pit maculopathy can be readily differentiated from typical csc on clinical examination alone. when examining optic disc maculopathy on oct, (one finds) the presence of retinoschisis that may precede the development of serous macular elevation.17 we report this unique case with optic disc pit in one eye with typical csc in the contralateral eye of a young healthy man. although, we were able to successfully treat csc in this patient, he still remains at a risk of recurrence in that eye which is known to occur after successful focal argon laser treatment of csc. the patient shall remain on alert of developing any visual symptoms (decreased bvca, metamorphosis and change in refraction) in his eye with optic disc pit since the management may not be laser and rifampicin and he may have to succumb to surgery for definitive treatment of optic disc maculopathy. author’s affiliation dr. haroon tayyab assistant professor sharif medical and dental college lahore dr. akhwand abdul majeed jawad consultant ophthalmologist sharif medical and dental college lahore role of authors dr. haroon tayyab case diagnosis, documentation and treatment, literature search and discussion writing. 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http://www.ncbi.nlm.nih.gov/pubmed/?term=hussain%2520r%255bauthor%255d&cauthor=true&cauthor_uid=25675311 http://www.ncbi.nlm.nih.gov/pubmed/?term=thachil%2520t%255bauthor%255d&cauthor=true&cauthor_uid=25675311 http://www.ncbi.nlm.nih.gov/pubmed/?term=haimovici%2520r%255bauthor%255d&cauthor=true&cauthor_uid=15019370 http://www.ncbi.nlm.nih.gov/pubmed/?term=koh%2520s%255bauthor%255d&cauthor=true&cauthor_uid=15019370 http://www.ncbi.nlm.nih.gov/pubmed/?term=gagnon%2520dr%255bauthor%255d&cauthor=true&cauthor_uid=15019370 http://www.ncbi.nlm.nih.gov/pubmed/?term=lehrfeld%2520t%255bauthor%255d&cauthor=true&cauthor_uid=15019370 http://www.ncbi.nlm.nih.gov/pubmed/?term=wellik%2520s%255bauthor%255d&cauthor=true&cauthor_uid=15019370 http://www.ncbi.nlm.nih.gov/pubmed/?term=wellik%2520s%255bauthor%255d&cauthor=true&cauthor_uid=15019370 http://www.ncbi.nlm.nih.gov/pubmed/?term=central%2520serous%2520chorioretinopathy%2520case-control%2520study%2520group%255bcorporate%2520author%255d http://www.ncbi.nlm.nih.gov/pubmed/?term=central%2520serous%2520chorioretinopathy%2520case-control%2520study%2520group%255bcorporate%2520author%255d http://www.ncbi.nlm.nih.gov/pubmed/?term=li%2520l%255bauthor%255d&cauthor=true&cauthor_uid=23302240 http://www.ncbi.nlm.nih.gov/pubmed/?term=li%2520dh%255bauthor%255d&cauthor=true&cauthor_uid=23302240 http://www.ncbi.nlm.nih.gov/pubmed/?term=yang%2520zk%255bauthor%255d&cauthor=true&cauthor_uid=23302240 http://www.ncbi.nlm.nih.gov/pubmed/?term=bian%2520al%255bauthor%255d&cauthor=true&cauthor_uid=23302240 http://www.ncbi.nlm.nih.gov/pubmed/?term=chen%2520yx%255bauthor%255d&cauthor=true&cauthor_uid=23302240 http://www.ncbi.nlm.nih.gov/pubmed/?term=dong%2520ft%255bauthor%255d&cauthor=true&cauthor_uid=23302240 microsoft word 02-oa hasan raza 3 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology original article frontalis suspension for unilateral ptosis with poor levator function s. hassan raza jafri, abdul rauf, nazia qidwai, abdul rashid shaikh, fayaz ahmed soomro, ashraf dawood pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syed hassan raza jafri isra postgraduate institute of ophthalmology al-ibrahim eye hospital, old thana village gaddap town, malir karachi …..……………………….. purpose: to assess the outcome and complications after frontalis suspension for unilateral ptosis with poor levator function material and methods: interventional case series of 30 eyes of 30 patients. patients were selected on non-probability purposive basis from oculoplasty clinic, isra post graduate institute of ophthalmology. all the patients with unilateral ptosis with poor levator function were included excluding those having poor bell’s phenomenon and associated pathology like jaw winking, 3rd nerve misdirection, squint, impaired corneal sensitivity and neoplastic lesions. patients were diagnosed clinically on the basis of history, old photographs and clinical examination. preoperative assessment included complete history, ocular and general examination including detailed ptosis examination with proper measurements. informed consent was taken. local anesthesia was used in adult patients while general anesthesia was used in children. all patients underwent unilateral frontalis suspension using polypropylene (prolene) 2/0 suture as sling material in a fox pentagon manner. postoperatively measurements were taken at regular intervals and complications were noted and managed accordingly. results: 30 eyes of 30 patients were included in this study. all patients had unilateral ptosis. age of the patients ranged from 2 years to 41 years (mean of 18.73 years). nineteen (63.33%) patients were male while 11 (36.66%) were female. twenty four (80%) eyes had good outcome (within 1 mm of normal), 4 (13.33%) had fair outcome (within 2 mm of normal) and 2 (6.66%) had undercorrection but as the patients were satisfied cosmetically, no second procedure was attempted. six (20%) eyes had lagophthalmos, which subsided with time without any further sequel. one (3.33%) eyes had knot failure, which was corrected by revising the sling procedure. exposure keratitis was not noted in any patient as the lid lag was not serious or prolonged. patients were followed for 2 years and no significant delayed failure or sling material related complication was noted. conclusion: frontalis suspension is an effective procedure for the treatment of unilateral ptosis with poor levator function. cosmetically acceptable symmetry can be achieved by addressing only the affected eye rather than operating both eyes including the normal eye. it is not associated with any serious complication. it shows promising long term results without any significant cosmetic decline. tosis with poor levator function has always been challenging for an ophthalmologist or an oculoplastic surgeon. there are many options for its correction1. usually, frontalis brow suspension is used for correction of ptosis with poor levator function2. although other procedures like levator resection3 alone or combined with tarsectomy4 have also been successfully tried in this regard, however p frontalis suspension for unilateral ptosis with poor levator function pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 4 most ophthalmologist agree on the superiority of frontalis sling for correction of ptosis with poor levator function. unilateral ptosis with poor levator function usually creates a dilemma for the surgeon. for long it has been advocated that the fellow normal eye must also undergo brow suspension to avoid any asymmetry. the decision of operating a normal eye is not easily accepted by the patient. in this study we performed unilateral frontalis suspension in patients having ptosis with poor levator function to assess the asymmetry in primary position. material and methods thirty eyes of 30 patients were included in the study. the study was done at oculoplasty clinic, al-ibrahim eye hospital, isra postgraduate institute of ophthalmology. patients were included from january 2006 to december 2008. patients were followed up for two years at regular intervals to look for subsequent complications and delayed failure. all the patients reporting at the institute for correction of unilateral congenital ptosis with poor levator function (i.e. less than 5 mm)5 were included. among these, some patients were excluded on the basis of having poor bell’s phenomenon, marcus gunn jaw winking, 3rd nerve misdirection, squint, impaired corneal sensitivity and neoplastic lesions. patients with simple congenital ptosis were diagnosed clinically on the basis of history, old photographs and clinical signs i.e. ptosis, absence of lid crease and defective levator function. pre-operative assessment included a proper history including personal biodata, relevant information and an informed consent. a detailed ocular and general examination was performed with special emphasis on the lid measurements such as vertical fissure height (vfh), marginal reflex distance in primary gaze (mrd), levator function (lf) and marginal limbal distance (mld). associated features such as bell’s phenomena, jaw winking, corneal sensitivity status and evidence of any pre-existing inflammatory, infectious or neoplastic lesion of the eyelids was noted. pre operative photographs were taken. all the information was recorded on a proforma. patients in whom procedure was done in general anesthesia, a detailed physical examination was done and relevant investigations such as complete blood count, random blood sugar and x-ray chest were done in consultation with an anesthetist. general anesthesia was used in children under 15 years. in adults frontal block along with local infiltration along the track of the sling was sufficient. additional sedation or analgesics were not required in any case. sling was planned in a fox pentagon1 design. skin was marked at five points with gentian violet dye. two marks were made along the lid margin, 2-3 mm superiorly near the medial and lateral extremes of the upper lid. two brow marks were made in the upper margin of the brow, the lateral one just lateral to the lateral lid margin mark and the medial one just medial to the medial one on the lid margin. the final mark was made 10 mm superior to the brow line over the frontalis muscle in between the two brow marks. all marks were incised with 11 no. blade. 2/0 polypropylene (prolene) suture was used as sling material. wright’s spatula needle was introduced through the incisions to drag the suture along until the two ends meet at the final incision over the frontalis muscle. knot was tied by making sure that the lid margin stays at the level of superior limbus. 5-6 knots were tied to decrease the chances of knot unwinding. the knot was then buried deep under the frontalis muscle, by making a facial pocket, to avoid knot exposure. the upper three incisions were closed with 6/0 polypropylene suture. the lower two incisions near the lid margin were left unstitched as the close approximation of their lips by the sling rendered it unnecessary. the sling was not anchored separately to the tarsal plate. a frost suture was applied near the lower lid margin to close the lids and support the sling. eye was closed with sterile eye pad with antibiotic eye ointment. on the first post-operative day, frost suture was removed. photographs were taken to record the outcome which was usually masked by some degree of lid edema. complications were looked for, especially lagophthalmos which was relatively common but innocuous. patients were discharged on oral nsaid’s, topical lubricants and antibiotic drops for use on hourly or two hourly bases depending on the amount of lagophthalmos. topical antibiotic ointment was prescribed for use at bedtime regularly. patients were followed on 1st post-operative week on which the skin sutures on the upper three incisions were removed. after that they were called on the 3rd week, then monthly for six months and then three monthly for next one and a half years. on each visit complete examination was performed to record the s. hassan raza jafri, et al 5 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology mrd, amount of lid lag, any signs of exposure keratitis and delayed sling failure. photographs were taken and examination recorded on the proforma. results thirty eyes of 30 patients were included in this study. all patients had unilateral ptosis. age of the patients ranged from 2 years to 41 years (average-18.73 years). 19 (63.33%) patients were male while 11 (36.66%) were female. levator function ranged from 0-4 mm (average 2.7 mm) 24 (80%) eyes had good outcome (within 1 mm of normal), 4 (13.33%) had fair outcome (within 2 mm of normal) and 2 (6.66%) had under correction (table 1) but as the patients were satisfied cosmetically, no second procedure was attempted. 6 (20%) eyes had lagophthalmos, which subsided with time without any further sequel. exposure keratitis was not noted in any patient as the lagophthalmos was not serious or prolonged. frequent post-operative lubrication was also very important in avoiding exposure keratitis. it was usual for lagophthalmos to improve after one week as the lid edema would resolve significantly by then, but even then lubrication with ointment at bedtime was continued. 1 (3.33%) eye had knot failure (table 2), which showed up on the 1stpost-operative week and was corrected by revising the sling procedure. all patients were followed up for 2 years and no significant delayed failure or sling material related complication such as extrusion, infection or granuloma formation was noted. discussion unilateral ptosis with poor levator function has always been challenging for an oculoplastic surgeon. bilateral frontalis brow suspension has long been advocated for attaining symmetrical result. however it’s not easy to convince any patient to operate upon his normal eye. no surgical procedure is free of complications. frontalis suspension is definitely no exception. frontalis brow suspension in unilateral ptosis has not been frequently advocated6,7 as it was thought to create gross asymmetry between the both eyes. however, in our study we found that in most of the cases the results are cosmetically acceptable. the post-operative elevation with some amount of excess skin fold was invariably acceptable for the patients. also we noted a decrease in the amount of this excess skin fold with time as the post-operative edema settled down. few other studies have also shown promising results with unilateral slings; however most of them have studied caucasian8 and oriental9 eyes. our study comprised of south asian eyes which might reflect minor differences in anatomical details. use of fascia lata has long been advocated as sling material in frontalis suspension, as being superior in giving good results and fewer complications. however, in some circumstances the availability or harvesting of fascia lata is not possible or feasible, such as in extremes of age and cosmetic concerns. this opens the door to the option of using artificial materials for sling. various materials have been successfully tried in this regard. these include silicon tubes10, expanded polytetrafloroethylene (eptfe),11-13 braided polyester14, nylon15, mersilene and polypropylene16 suture and strips of etpfe and mersilene17 mash. all these studies have shown their relevant merits and complications. frontalis suspension for unilateral ptosis with poor levator function pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 6 fig. 1a. five years old patient having od severe ptosis with poor levator function fig. 1b. same patient on 2nd (3 weeks post-operatively) follow up. we have tried a very common and easily available suture i.e. polypropylene 2/0 for sling in frontalis brow suspension. this suture is a synthetic, monofilamantous, non-absorbable suture usually used in oculoplastic procedures in sizes of 5/0 or 6/0. the size of 2/0 is usually used in general surgical procedures. it gives good cosmetic results as it allows minimal fibrosis along suture tract. this suture has not been tried commonly so far. the reason for this was not evident from literature review. however we have successfully used it with excellent results. we found the success rate very promising in terms of the final upper lid level or final mrd. in our study 93.33% (28 eyes) have satisfactory results. among these 80% had good result i.e. their final mrd was within 1mm of normal and 13.33% had fair result i.e. mrd within 2 mm of normal. all these patients were cosmetically satisfied. these results are comparable to kkl chong et al9 (83.3%) and kersten rc et al8 (95%).this comparison sufficiently advocates the efficacy of procedure in south asian eyes. we experienced few complications in our patients. the commonest was lagophthalmos. we experienced lagophthalmos in 6 (20% eyes), but it was not severe enough to cause exposure keratitis in any patient. lagophthalmos tends to improve with time and frequent use of lubricant drops and ointments especially during sleep is mandatory to avoid exposure keratopathy as do in our study. postoperative lagophthalmos is usually attributed to overcorrection as by lee v and konrad h18 and kersten rc8, however in our study there were no cases of overcorrection, hence we found the cause to be related to severity of ptosis and poor levator function. we found lagophthalmos as more of a sequel rather than a complication when we operate on eyes with poor levator function. the sling’s syncytium with the frontalis muscle affords good lid closure with a little effort. however during sleep lubrication is vital in early post-operative period. we did not notice any prolong lid lag in any patients. it usually resolved significantly on 2nd follow up i.e. at the end of the 1stpost-operative week. we experienced under correction in 6.66% (2 eyes), but as the patients were cosmetically satisfied, review surgery was not performed. however one patient (3.33%) presented in early post operative period with recurrence of ptosis due to knot failure. sling had to be repeated in that patient to regain the symmetry successfully. apart from those above mentioned, we did not experience any complications. we followed up our patients for two years but did not experience delayed complications such as granuloma formation11,13,15, suture infection11,13,17, sling exposure8,11 or hypertrophied scar formation12. this is in contrast to other researchers who have experienced all such complications with different sling materials. an important aspect to look for is that all these above mentioned complications were somehow related to the sling materials and not the surgical technique or expertise. conclusion frontalis suspension is an effective procedure for the cure of unilateral ptosis with poor levator function. cosmetically acceptable symmetry in primary position can be achieved by addressing only the affected eye rather than operating both eyes including the normal eye. it is not associated with any serious complication. it shows promising long term results without any significant cosmetic decline. s. hassan raza jafri, et al 7 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology author’s affiliation dr. s. hassan raza jafri assistant professor isra postgraduate institute of ophthalmology al-ibrahim eye hospital, karachi dr. abdul rauf senior registrar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, karachi dr. nazia qidwai postgraduate resident isra postgraduate institute of ophthalmology al-ibrahim eye hospital, karachi dr. abdul rashid shaikh assistant professor isra postgraduate institute of ophthalmology al-ibrahim eye hospital, karachi dr. fayaz ahmed soomro senior registrar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, karachi dr. ashraf dawood senior registrar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, karachi references 1. collins jro. ptosis. in: a manual of systemic eyelid surgery. 2nd ed. edinburgh: churchill livingstone, 1989: 41-48. 2. kanski jj. eyelids. in: clinical ophthalmology. 6th ed. london: butterworth. 2007: 133-140. 3. mehmood h. levator resection in congenital ptosis with poor levator function. pak j ophthalmol 1997; 13:103-106. 4. holds jb, mcleish wm, anderson rl. whitnall’s sling with superior tarsectomy for the correction of severe unilateral blepharoptosis. arch ophthalmol 1993; 111: 1285-91. 5. kanski jj. eyelids. in: clinical ophthalmology. 6th ed. london: butterworth. 2007: 133-140. 6. agarwal s. lids, adenexa and orbit. in: textbook of ophthalmology. 1stedition. india: jaypee brothers. 2002: 572. 7. callahan a. correction of unilateral blepharoptosis with bilateral eye suspension. am j ophthalmol. 1972; 74, 321. 8. kersten rc, bernardini fp, khouri l, moin m, roumeliotis aa, kulwin dr. unilateral frontalis sling for the surgical correction of poor-function ptosis. ophthal. plast reconstr surg. 2005; 412-6. 9. chong kk, fan ds, lai ch, rao sk, lan pt, lam ds. unilateral ptosis correction with mersilene mesh frontalis sling in infants: thirteen year follow-up report. eye 2010, 44–9. 10. junceda-moreno j, saurez-saurez e, dos-santosbernardo v. treatment of palpebral ptosis with frontal suspension: a comparative study of different materials. arch soc esp oftalmol. 2005; 80: 457-61. 11. ben simon g, macedo aa, schwarcz rm, wang dy, mccann jp, goldberg ra. frontalis suspension for upper eyelid ptosis; evaluation of different surgical designs and suture material. am j ophthalmol. 2005; 140: 877-85. 12. steinkogler fj, kuchar a, huber e, arocker-mettinger e. goretex soft tissues patch frontalis suspension technique in congenital ptosis and in blepharophimosis ptosis syndrome. plast reconstr surg. 1993; 92: 1057-60. 13. mencia – gutierrez e, clariana-martin a, gutierrez – diaz e, monsalve-cordova j, isquiredo-rodriguez c. results and complications of expanded polytetrafluoroethylene in frontalis suspension ptosis surgery. study of 59 cases. arch soc esp oftalmol. 2005; 80: 443-8. 14. bajaj ms, sastry ss, ghose s, betharia sm, pushker n. evaluation of polytetrafluoroethylene suture for frontalis suspension as compared with polybutylatecoated braided polyester. clin experiment ophthalmol. 2004; 32: 415-9. 15. wasserman bn, sprunger dt, helveston em. comparison of materials used in frontalis suspension. arch ophthalmol 2001; 119: 687-91. 16. jafri hr, nazia q. use of polypropylene suture as sling material in frontalis brow suspension for congenital ptosis with poor levator function. ophthalmology update 2010; 8:15-18. 17. collins jro. ptosis. in: a manual of systemic eyelid surgery. 2nd ed. edinburgh: churchill livingstone, 1989: 62-65. 18. lee v, konrad h, bruce c, collin jro. etiology and surgical treatment of childhood blepharoptosis. br j ophthalmol 2002; 86: 1282-86. 131 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology original article prevention of exposure keratopathy with sahaf wet chamber muhammad sharjeel, irfan qayyum malik, ch javed iqbal, farhan ali, imran akram sahaf pak j ophthalmol 2015, vol. 31 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irfan qayyum malik department of ophthalmology gujranwala medical college email: irfan790@yahoo.com …..……………………….. purpose: to assess the efficacy of sahaf wet chamber in preventing exposure keratopathy in patients with lagophthalmos. material and methods: seventy patients of lagophthalmos were included in the study from outdoor in ophthalmology department mayo hospital, king edward medical university lahore from 1 st january 2013 to 31 st december 2013 awaiting definitive surgical intervention. sahaf wet chamber (transparent polyurethane dressing opsite with antibiotic ointment) were changed every 24 hours. the corneal flourescein stains were performed and exposure keratopathy assessed daily till the time of surgery. the criteria of efficacy was improvement or progression of exposure keratopathy. results: none of 70 patients (0%) had progression of exposure keratopathy. the time on eye care every day was 3 min ± 1 min. conclusion: sahaf wet chamber is more effective, time saving, easy to apply and cost effective technique in reducing the incidence of corneal damage in patients with lagophthalmos awaiting definitive treatment. it can easily be done as an opd procedure. key words: exposure keratopathy, wet chamber, lagophthalmos roper eyelid closure and a normal blink reflex are essential to maintain a stable tear film and a healthy corneal surface.1 patients affected with lagophthalmos are unable to fully close their eyelids and have symptoms of dry, irritated eyes. common and sight threatening morbidities of lagophthalmos are corneal exposure, dryness, desiccation and subsequent keratopathy which may progress to corneal ulceration and infectious keratitis. so timely diagnosis and prompt management can save this sight threatening condition. the reported incidence for exposure keratopathy ranges from 20 to 42%2 within a relatively short time, ranging from 2 to 7 days that signifies the importance of effective intermediate treatment method in lagophthalmos patients awaiting definitive treatment in wards or homes. since lubrication3, moist chambers and polyethylene covers4 are most common temporary methods for preventing exposure keratopathy in lagophthalmos patients, they have got limitations. only lubrication has higher chances of exposure keratopathy as nursing staff has to be alert all the time for frequent instillation and are time consuming, moist chamber goggles are difficult to apply during sleep and for adults only .polyethylene covers can be ripped off and torn by infants and uncooperative patients. in our study we have tried sahaf wet chamber (polyurethane cover opsite with antibiotic ointment) a new method to prevent exposure keratopathy that is applicable in all age groups and readily available, easy to apply, compliant and highly efficacious in preventing exposure keratopathy. materials and methods patients were recruited from outdoor ophthalmology department mayo hospital lahore from 1st january 2013 to 31st december 2013. inclusion criteria were patients with all age groups with lagophthalmos (lids not covering the entire cornea) that were prone to p prevention of exposure keratopathy with sahaf wet chamber pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 132 exposure keratopathy prior to definitive treatment or have some grade of exposure keratopathy as shown in table. exclusion criteria were surgery in less than 24 hours after hospital admission as patients in study were given trial of sahaf wet chamber for at least 48 hours to 5 days). the outdoor patients meeting the inclusion criteria were simply recruited in the study. all patients received a standard eye cleansing regime of washes to the external eye with normal saline and drying of surrounding area with sterile gauze before every treatment (fig 1). antibiotic ointment was instilled inside the eye (fig 2). patients had pieces of opsite (polyurethane) cut to cover the eye from eye brows to the cheek bone (fig 3). the opsite was changed every 24 hours. patients completed the study when their turn for definitive treatment (surgery, tarsorraphy, gold weight implant) arrived but minimum time in study was 48 hours (table 1). the cornea was assessed by instillation of flourescein and viewing with cobalt blue light using an indirect ophthalmoscope and 20 d lens daily. grading of exposure keratopathy was done and any improvement or progression was noted. mean age of the patients was 27.5 years. total patients were 70. out of which 45 were males while 25 were females. none of the patient had progression of disease after sahaf wet chamber. 43% of the patients of grade 113 were improved to normal corneal epithelium13 (table 2, 3, 4). discussion the cornea is made of stratified, non-keratinized epithelium that relies on tears for nutrients and water. tear film is constantly spread over the corneal table 2: severity of ocular surface disease grading13 grade i punctate epithelial erosions (pees) involving the inferior third of the cornea grade ii pees involving more than the inferior third of the corneal surface grade iii macroepithelial defect (med) grade iv stromal whitening in the presence of epithelial defect (swed) grade v stromal scar grade vi microbial keratitis13 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1772779/#r13 muhammad sharjeel, et al 133 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology epithelium by lids. tears lubricate the ocular surface, providing oxygen to the cornea and washing away noxious stimuli and potential pathogens. eyelid closure and blinking contribute to replenishing and spreading the tear film across the cornea and preventing tear film evaporation and keratopathy.9 the process of tear evaporation changes the temperature of the conjunctival sac, making it unfavorable for bacterial growth.10 while asleep, lid closure protects the cornea by keeping it moist. eyelid closure is an active process that requires contraction of orbicularis oculi and inhibition of levator palpebrae superioris. lagophthalmos is inability to close the lids that can be due to heavy sedation, trauma, eyelid burns6, developmental defects (congenital colobomas)7-8, nocturnal lagophthalmos11 paralysis or use of paralytics that inhibit these processes. when the lids are not completely closed, tear film is not uniformly spread over the corneal epithelium so epithelium gets desiccated and shed off leading to corneal ulcers. the resulting desiccation and corneal epithelial damage allows bacteria to adhere to damaged epithelial cells with exposed collagen before migration into the stroma12. without an intact epithelium, the patient is more susceptible to microbial keratitis. microbial keratitis can lead to complications including abscess formation, acute perforation, scleritis, and endophthalmitis, causing rapid visual loss. suggestions that have been made for protecting the ocular surface temporarily include taping the eyes closed with transparent tape, eyelid closure, moisture prevention of exposure keratopathy with sahaf wet chamber pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 134 fig 1: patient with exposure keratopathy fig 2: after putting antibiotic ointment fig 3: after applying dressing chamber, covering the eyes with gauze, lubricants, cyanoacrylate glue blepharorrhaphy5, and normal saline irrigation of the eye. a moisture chamber refers to using a substance such as polyethylene covers, swimming goggles or polyurethane covers to completely seal-off the eye from the environment. in extreme cases, closure by tarsorrhaphy has been suggested, but it makes examination of the eyes difficult, is cosmetically ugly and hampers active use of the eye. the urgency and extent of treatment for keratopathy depends on the degree of ocular surface exposure13 several studies have directly compared eye care practices. lenart et al.14 studied 50 patients who each had one eye that received artificial tear ointment every 4 hours while the fellow eye was passively closed by nurses when it was noted to be open. among the 50 patients, there were nine abrasions in the passively closed eyes, compared with two abrasions in the ointment eyes (p=0.004). similarly, ezra et al15. compared eye toilet with geliperm (hydrogel dressing, geistlich pharma, wolhusen, switzerland) and lacrilube (artificial tear ointment, allergan, inc., irvine, ca). of the 24 patients in the eye toilet group, 13 (53%) had some degree of exposure keratopathy; out of 10 patients in the geliperm group, nine (90%) had exposure keratopathy; and of the 13 patients in the lacrilube group, two (15%) had exposure keratopathy. they concluded that lacrilube is more effective at preventing keratopathy in this population than eye toilet (p = 0.04) or geliperm (p = 0.001). the other method for preventing exposure keratopathy is prosthetic replacement with ocular surface ecosystem device which provides a liquid bandage to protect the cornea from eyelid interaction and desiccation in addition to improving vision.16 the tegaderm17 (3m) and opsite (polyurethane) covering creates a moist chamber providing a barrier against tear film evaporation and exposure to air currents. it also keeps the eye clean and closed by providing a physical barrier to organisms. its transparency facilitates frequent observation and monitoring of cornea but as polyurethane covers are thinner than 3m they are more transparent, tightly adherent and also conforms itself to uneven surfaces around the eye unlike tegaderm which leaves spaces. additional considerations for wet chamber use for clinical practice include the ease of application, time saving, cost effectiveness, tightly adherent polyurethane material, easily applicable in all age groups, effective to cover large lid defects (colobomas, muhammad sharjeel, et al 135 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology trauma), transparent and very compliant technique as you have to apply it once daily compared to 2 hourly lubrication and 12 hour change of moist chambers and polyethylene covers2. polyethylene (3m) covers are non-elastic and thick transparent membrane that can be removed by uncooperative patients with little effort and not able to fill small gaps and curves of surrounding skin whereas opsite (polyurethane) is a thin transparent material that adapts its shape to the gaps and curves and is highly elastic so very effective in uncooperative patients by forming close chamber and limiting evaporation of water from cornea. conclusion polyurethane covers with ointment are effective in reducing the incidence of corneal damage in lagophthalmos patients and it deserves to be popularized in our community to prevent exposure keratopathy. author’s affiliation dr. muhammad sharjeel department of ophthalmology mayo hospital lahore. dr. irfan qayyum malik assistant professor department of ophthalmology gujranwala medical college dr. ch javed iqbal assistant professor eye department mayo hospital, kemu, lahore dr. farhan ali department of ophthalmology mayo hospital lahore. prof. imran akram sahaf head department of ophthalmology mayo hospital lahore, kemu, lahore role of authors dr. muhammad sharjeel main author. dr. irfan qayyum malik collecting data and writing paper. dr. ch javed iqbal review of manuscript. dr. farhan ali collecting data and writing paper. prof. imran akram sahaf design and review of manuscript. references 1. lawrence sd, morris cl. lagophthalmos evaluation and treatment. aao eye net magazine 2008. 2. shan h, min d. prevention of exposure keratopathy in intensive care unit. int j ophthalmol. 2010; 3: 346-8. 3. ezra dg, lewis g, healy m, coombes a. preventing exposure keratopathy in critically ill .a prospective study comparing eye care regimes.br j ophthalmol. aug 2005; 89: 1068–9. 4. kocaçal güler e1, eşer i, eğrilmez s. effectiveness of polyethylene covers versus carbomer drops (viscotears) to prevent dry eye syndrome in the critically ill. j clin nurs. 2011; 20: 1916-22. 5. sonmez b, ozarslan m, beden u, erkan d. bedside glue blepharorrhaphy for recalcitrant exposure keratopathy in immobolized patients. eur j ophthalmol. 2008; 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br j ophthalmol. 1997; 81: 1060-3. 13. verity dh, rose ge. acute thyroid eye disease (ted): principles of medical and surgical management. eye (lond). 2013; 27(3): 308-19. 14. lenart sb, garrity ja. eye care for patients receiving neuromuscular blocking agents or propofol during mechanical ventilation.am j crit care. 2000; 9: 188-91. 15. ezra dg, chan pmy, solebo l, malik anj, healy m, coombes a. control trial comparing the effectiveness of methylcellusose eye dressings (geliperm) and http://www.ncbi.nlm.nih.gov/pubmed/?term=ezra%20dg%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=lewis%20g%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=healy%20m%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=coombes%20a%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed?term=koca%c3%a7al%20g%c3%bcler%20e%5bauthor%5d&cauthor=true&cauthor_uid=21414053 http://www.ncbi.nlm.nih.gov/pubmed?term=e%c5%9fer%20i%5bauthor%5d&cauthor=true&cauthor_uid=21414053 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http://www.ncbi.nlm.nih.gov/pubmed/?term=dh+v%2c+rose+ge.+acute+thyroid+eye+disease+(ted)%3a+principles+of+medical+and+surgical+management http://www.ncbi.nlm.nih.gov/pubmed/?term=dh+v%2c+rose+ge.+acute+thyroid+eye+disease+(ted)%3a+principles+of+medical+and+surgical+management http://www.ncbi.nlm.nih.gov/pubmed?term=lenart%20sb%5bauthor%5d&cauthor=true&cauthor_uid=10800604 http://www.ncbi.nlm.nih.gov/pubmed?term=garrity%20ja%5bauthor%5d&cauthor=true&cauthor_uid=10800604 http://www.ncbi.nlm.nih.gov/pubmed/10800604 prevention of exposure keratopathy with sahaf wet chamber pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 136 ocular lubricants in the prevention of exposure keratopathy in the critically ill ophthalmol vis sci. 2005; 46. 16. gire a, kwok a, marx dp. prose treatment for lagophthalmos andexposure keratopathy. ophthal plast reconstr surg. 2013; 29: 38-40. 17. airiani s, braunstein re, kazim m, schrier a, auran jd, srinivasan bd. tegaderm transparent dressing (3m) for the treatment of chronic exposure keratopathy ophthal plast reconstr surg. 2003; 19: 75-6. http://www.ncbi.nlm.nih.gov/pubmed/23034688 http://www.ncbi.nlm.nih.gov/pubmed/23034688 http://www.ncbi.nlm.nih.gov/pubmed/23034688 http://www.ncbi.nlm.nih.gov/pubmed?term=airiani%20s%5bauthor%5d&cauthor=true&cauthor_uid=12544796 http://www.ncbi.nlm.nih.gov/pubmed?term=braunstein%20re%5bauthor%5d&cauthor=true&cauthor_uid=12544796 http://www.ncbi.nlm.nih.gov/pubmed?term=kazim%20m%5bauthor%5d&cauthor=true&cauthor_uid=12544796 http://www.ncbi.nlm.nih.gov/pubmed?term=schrier%20a%5bauthor%5d&cauthor=true&cauthor_uid=12544796 http://www.ncbi.nlm.nih.gov/pubmed?term=auran%20jd%5bauthor%5d&cauthor=true&cauthor_uid=12544796 http://www.ncbi.nlm.nih.gov/pubmed?term=auran%20jd%5bauthor%5d&cauthor=true&cauthor_uid=12544796 http://www.ncbi.nlm.nih.gov/pubmed?term=auran%20jd%5bauthor%5d&cauthor=true&cauthor_uid=12544796 http://www.ncbi.nlm.nih.gov/pubmed?term=srinivasan%20bd%5bauthor%5d&cauthor=true&cauthor_uid=12544796 http://www.ncbi.nlm.nih.gov/pubmed/12544796 25 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology original article types of ocular surface foreign bodies and their correlation with location in the eye muhammad luqman ali bahoo, ahmad zeeshan jamil pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. ahmad zeeshan jamil assistant professor of ophthalmology, sahiwal medical college, sahiwal. email: ahmadzeeshandr@yahoo.com …..……………………….. purpose: to find the aetiology of ocular surface foreign bodies and correlation with their location in the eye. study design: cross sectional study. place and duration of study: this study was conducted at shahida islam teaching hospital affiliated with shahida islam medical college, lodhran from november 2016 to october 2017. material and methods: age and gender were recorded for all patients. detailed slit lamp examination was performed. location of the foreign body was noted. superficial foreign bodies were removed with the help of forceps. in case of impaction in the ocular surface foreign bodies were removed with the help of sterile 27/26 gauge needle. results: there were 796 patients with ocular surface foreign bodies included in this study. corneal injuries were most common. most common location for different foreign bodies included metallic particle on cornea in 104 eyes (13.1%), insect wing in upper lid sub tarsal space in 75 eyes (9.3%), straw particles on cornea in 60 eyes (7.5%), piece of plastic on cornea in 24 eyes (3.0%), whole insect or fly in inferior fornix in 12 eyes (1.5%), thread/cloth particle in upper lid sub tarsal space in 17 eyes (2.1%), dust particles on cornea in 54 eyes (6.8%) and contact lens in the superior fornix in 2 eyes (0.3%). no statistically significant correlation was found between the aetiology of ocular surface foreign body and their location in the eye. conclusion: most common aetiology of ocular surface injury was metallic particle and most common location was cornea. key words: foreign bodies, ocular, metallic, corneal injuries. rauma to the eye is a preventable cause of ocular injury. it is one of the leading causes of ocular morbidity1,2,3. a large number of hospital visits are due to eye injury4. superficial ocular surface foreign body injury is the most common form of ocular trauma. it causes significant discomfort and if not properly managed can lead to permanent visual impairment. a patient may encounter this type of injury in a variety of settings for example at home, while playing, at work or as a result of accident or assault5. usually ocular surface foreign bodies are small in size6. they are particles of iron, dust, insect wings, straw of vegetable matter, animal or human hair and threads of cotton or plastic. in most of the cases ocular surface foreign bodies are found on cornea and palpebral conjunctival surfaces. they may also be found in fornices, sub tarsal space and caruncle. patients experience pain, foreign body sensation, t aetiology of ocular surface foreign bodies and correlation with their location in the eye pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 26 watering and redness. if left untreated and not properly managed they can lead to erosion of underlying surface, establishment of infection, spread of infection leading to infective keratitis, conjunctivitis and endophthalmitis7. thorough eye examination including upper lid eversion is necessary in patients with history of foreign body. insects recovered from the eyes need to be examined by entomologist to identify its nature, species and toxic effects if any. this may help in planning proper and targeted spray to seasonal crops to decrease the number of insects. this is useful in rural and semi-urban areas in term of economics, by reducing damage to the crops. identification of the type of foreign bodies and their location of impaction into the eye will help in creating awareness and use of appropriate eye protective devices. this study was done to find the causes of ocular surface foreign bodies in a rural setting. material and methods this prospective study was conducted in ophthalmology department of shahida islam medical college lodhran. duration of the study was from november 2016 to october 2017. the study was approved by the ethical committee of the institution. consent was obtained from all patients who were included in the study. all patients coming in eye outpatient department with foreign body in eye were included in the study. this was a cross sectional study and sampling technique was purposive sampling. age and gender were recorded for all patients. detailed slit lamp examination was performed. fluorescein dye was instilled in the eye to delineate the location of the foreign body. topical anaesthesia was given by instilling proparacaine 0.5%. superficial foreign bodies were removed with the help of forceps. in case of impaction, the ocular surface foreign bodies were removed with the help of sterile 27/26 gauge needle. after removal of the foreign body topical antibiotic drops was instilled into the eye. postoperatively topical antibiotic eye drops were prescribed for seven days. statistical analysis was performed using statistical programme for social sciences (spss version 21). nominal variables like gender, type and location of foreign body were presented as percentages. continuous variable like age was presented as mean and standard deviation. correlation of the type of foreign body with their location in the eye was calculated using pearson’s r correlation. results total of 796 patients with ocular foreign bodies were included in the study. on average 2.18 patients with ocular surface foreign bodies presented per day. there were 378 (47.5%) right eyes and 411 (51.6%) left eyes. there were 7 (0.9%) bilateral cases. there were 568 (71.4%) males and 228 (28.6%) females. male to female ratio was 2.5:1. frequency and percentages of the type of foreign body are shown in table 1. table 1: aetiology of ocular surface foreign bodies. type of foreign body frequency percent insect wing 204 25.6 metallic ring 216 27.1 straw particle 156 19.6 plastic 48 6.0 insect/fly 24 3.0 thread/cloth particle 34 4.3 dust particles 112 14.1 contact lens 2 0.3 total 796 100.0 frequency and percentage of location of foreign bodies is shown in table 2. frequencies of location of at different locations of foreign bodies in the eye are shown is table 2. mean age of patients was 38.58 ± 21.49 years and the mode age was 45 years. the correlation between the aetiology of foreign body and their location in the eye was found to be 0.088 (pearson’s r correlation; chi-square test). correlation line between aetiology of ocular surface foreign body and location in the eye is shown in figure 1. results showed there was no statistically significant correlation between the aetiology of ocular surface foreign body and its location in the eye. pictures of different foreign bodies seen in the study are shown in figures 2-4. muhammad luqman ali bahoo, et al 27 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology table 2: distribution of location of foreign bodies. location of foreign body frequency percent corneal 320 40.2 palpebral conjunctival 147 18.5 upper lid sub tarsal 222 27.9 inferior fornix 51 6.4 superior fornix 14 1.8 caruncle 42 5.3 total 796 100.0 figure 1: regression line for aetiology of ocular surface foreign body and their location in eye. key: x axis = type of foreign body. y axis = location in the eye. discussion on an average 2.18 patients with ocular surface foreign bodies presented per day. ocular injury with ocular surface foreign bodies was more common in males than females. male to female ratio was 2.5:1. this is in close approximation to that presented by reddy et al8. males are at greater risk to trauma due to their exposure in occupation, travelling and assaults9. mean age in our study was 38.58 ± 21.49 years. jahangir t and co-authors reported mean age of 28.6 ± 17.6 years10. in another study the mean figure 2: straw particle at cornea. figure 3: insect in inferior fornix. figure 4: metallic particle at cornea. aetiology of ocular surface foreign bodies and correlation with their location in the eye pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 28 age of the patients was reported to be 35 years. in 40.2% cases cornea was involved, in 18.5% cases palpebral conjunctiva, in 27.9% cases upper lid sub tarsal conjunctiva, in 6.4 % cases inferior fornix, in 1.8% cases superior fornix and in 5.3% cases caruncle was involved. this is in contrast to study conducted by reddy et al where cornea was involved in 71.9% cases and in 28.03% cases conjunctiva and fornices were involved. in another study11 conducted by ozlem et al cornea was involved in 72.6% cases. this difference may be due to occupational variations12,13. our study was conducted in a rural and semi urban area where most of the population is involved in agriculture and fields works. corneal injuries most commonly occur due to metallic foreign bodies14. this sort of injury is commonly seen in occupations associated with engineering and industry15,16. ocular surface foreign bodies are found in different locations in the eye. this emphasizes the importance of thorough eye examination in case with history of foreign body in the eye. in our study metallic particle was seen in 27.1% cases. this is less than the injury by metallic particles in other studies. while in other studies similar percentage of metallic particle injuries is reported17. in 25.6% cases part of insect body was recovered from the eye. it may be due to driving practices of people. most of the people riding a bike and cycle do not use helmets and eye wear to protect them from foreign bodies18. in 19.6% cases straw particles were found. this is due to agricultural background of the region19. in our study left eye was more commonly injured in contrast to the study done by reddy et al where right eye was more commonly involved. ocular surface foreign bodies are found in all parts of the ocular surface. more exposed parts like cornea and palpebral conjunctiva are more prone to get such sort of injuries. sub tarsal space gets foreign bodies due to its anatomical configuration20,21. in our study there was no statistically significant correlation of type of ocular surface foreign bodies with their location of placement in the eye. search of literature could not reveal such type of correlation study. so we could not compare our results with the work of others. we did not include the profession and occupation of the patients in our study. this is limitation of our study. moreover our study is limited to semi urban and rural area. our results may not be applicable for other settings. conclusion ocular surface foreign bodies are common form of ocular trauma. more exposed parts of the ocular surface receive majority of trauma due to superficial foreign bodies. most common aetiology of ocular surface injury was metallic particle and most common location was cornea. no statistically significant correlation has been found between the type of ocular surface foreign body with their location in the eye. author’s affiliation dr. muhammad luqman ali bahoo mbbs, fcps, fellowship refractive and cornea surgery assistant professor of ophthalmology, shahida islam medical college, lodhran. dr. ahmad zeeshan jamil mbbs, mcps, fcps, frcs, fcps (vro) assistant professor of ophthalmology, sahiwal medical college, sahiwal. role of authors dr. muhammad luqman ali bahoo concept and design of study and interpretation of data dr. ahmad zeeshan jamil drafting of the article and critical revision for important intellectual content references 1. jan s, khan s, khan mt, et al. ocular emergencies. j coll physicians surg pak. 2004; 14: 333-6. 2. guerra garcia ra, garcia d, martinez fe et al. the cuban ocular trauma registry. j clin exp ophthalmol. 2013; 4 (2): 276. 3. negral ad, thylefors b. the global impact of eye injuries. ophthalmic epidemiol. 1998; 5: 143-69. 4. babar tf, khan mn, jan s, et al. frequency and causes of bilateral ocular trauma.j coll physicians surg pak. 2007; 17: 679-82. 5. khatry sk, lewis ae, schein od, et al. the epidemiology of ocular trauma in rural nepal. br j ophthalmol. 2004; 88: 456-60. 6. injuries to the eye. sihota and tandon, editors. parson’s disease of the eye. 20 edition. new delhi: elsevier; 2007: 362-4. 7. abraham d, vitale s, west s, et al. epidemiology of eye injuries in rural tanzania. ophthamic epidemiol. 1999; 6: 85-94. muhammad luqman ali bahoo, et al 29 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology 8. subba reddy, p., nirmala, k., radhika, s., ravi, s., paul, c. incidence of ocular surface foreign body and its correlation with specific occupation and preventive measures. global journal for research analyses, 2016; 5 (12): 56-8. 9. babar, t. f., khan, m. t., marwat, m. z., shah, s. a., murad, y., khan, m. d. patterns of ocular trauma. j coll physicians surg pak. 2007; 17 (3): 148-153. 10. jahangir, t., butt, n. h., hamza, u., tayyab, h., jahangir, s. patterns of presentation and factors leading to ocular trauma. pak j ophthalmol. 2011; 27 (2): 96-102. 11. güzel m, erenler ak, niyaz l, baydın a. management of traumatic eye injuries in the emergency department. oa emergency medicine, 2014; 18 (1): 1-6. 12. fasih u, shaikh a, fehmi ms. occupational ocular trauma (causes management and prevention). pak j ophthalmol. 2004; 20: 65-73. 13. mieler wf. ocular injuries: is it possible to further limit the occurrence rate? arch ophthalmol. 2001; 119: 17123. 14. rama krishnan t, constantinous m, jhanjiv, et al. corneal metallic foreign body injuries due to suboptimal ocular protection. arch environ occup health, 2012; 67 (1): 48-50. 15. voon, l. w., see, j., & wong, t. y. the epidemiology of ocular trauma in singapore: perspective from the emergency service of a large tertiary hospital. eye (lond). 2001; 15 (pt 1): 75-81. 16. gumus k, karakucuk s, mirza e. corneal injury from a metallic foreign body: an occupational hazard. eye & contact lens, 2007; 33 (5): 259-60. 17. yigit o, yuruktumen a, arslan s. foreign body traumas of the eye managed in an emergency department of a single institution. turkish journal of trauma & emergency surgery, 2012; 18 (1): 75-9. 18. tahira mn, hawortha n, kinga m, washingtona s, editors. observations of road safety behaviours and practices of motorcycle rickshaw drivers in lahore, pakistan australasian road safety conference, 2015; 1416 october; australia. 19. dass ri, gohel dj. ocular surface foreign body: its incidence and correlation with specific occupation. gcsmc j med sci. 2013; 2 (2): 42-5. 20. alastair denniston, p. m. oxford handbook of ophthalmology, 2014; oxford: oup oxford. 21. bowling, b. kanski's clinical ophthalmology a systematic approach, 2015; sydnery: saunders. microsoft word 14. abstracts 28-3-12 166 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology abstracts edited by dr. qasim lateef chaudhry recurrence and complications after 1000 surgeries using pterygium extended removal followed by extended conjunctival transplant hirst lw ophthalmology 2012; 119:2205–10 lawrence w. hirst has reported findings from an open prospective study of 1000 consecutive patients undergoing the pterygium extended removal followed by extended conjunctival transplantation (p.e.r.f.e.c.t. for pterygium) technique which he himself has developed. this study involved 1000 patients from august 2001 to september 2009 and only one recurrence occurred (0.1%). there was follow-up of 1 year in 99% of participants. seven patients needed more surgery including 3 graft replacements, and 1 patient each had procedures to manage recurrence, strabismus, inclusion cyst, and granuloma. the author credits 2 basic components of p.e.r.f.e.c.t. for pterygium–extensive tenonectomy and the use of a much larger graft than usually used in conjunctival autografting for the extremely low recurrence rate. in addition, he points to the specific suturing technique involving excision of the semilunar fold for the good cosmetic result. he concludes that while this surgical approach requires a steep learning curve, the outcomes of nonrecurrence and low complications rates are worth the extra effort required for this surgical technique. intravitreal ranibizumab for diabetic macular edema with prompt versus deferred laser treatment: threeyear randomized trial results elman mj, qin h, aiello lp, beck rw, bressler nm, ferris iii fl, glassman ar, maturi rk, melia m ophthalmology 2012; 119: 2312–8 three-year study results from the diabetic retinopathy clinical research network indicate that focal/grid laser treatment at the introduction of intravitreal ranibizumab is no better, and possibly worse for vision outcomes, than deferring laser treatment for at least 24 weeks in diabetic macular edema (dme) involving the fovea and with vision impairment. the trial involved 361 participants with visual acuity of 20/32 to 20/320 and dme involving the fovea. the estimated mean change in visual acuity letter score from baseline through the 3-year visit was 2.9 letters greater in patients who deferred laser treatment compared with the prompt laser treatment patients. in the prompt laser treatment group and deferral group, respectively, the percentage of eyes with a10 letter gain was 42% and 56%, while the percentage of eyes with a 10 letter loss was 10% and 5%. some of the differences in visual acuity may be related to fewer cumulative ranibizumab injections in the prompt laser treatment group. the patients in the study will be followed through 5 years. benefit from bevacizumab for macular edema in central retinal vein occlusion: twelve-month results of a prospective, randomized study epstein dl, algvere pv, wendt gv , seregard s, kvanta a. ophthalmology 2012; 119: 2587–91 epstein et al have found that intraocular injections of bevacizumab every 6 weeks for 12 months signifycantly improve visual acuity and reduce macular edema (me) secondary to central retinal vein occlusion (crvo). this prospective study, which included a randomized 6-month, sham injectioncontrolled doublemasked clinical trial followed by a 6month open-label extension, involved 60 patients. at 12 months, 60% of patients in the bevacizumab/ bevacizumab group had gained 15 letters compared with 33.3% of patients in the sham/bevacizumab group. the best corrected visual acuity improved by 16.0 letters at 12 months in the bevacizumab/ bevacizumab group compared with 4.6 letters in the sham/bevacizumab group. mean decrease in central retinal thickness was 435 m in the bevacizumab/ bevacizumab group compared with 404 m in the sham/bevacizumab group. patients receiving delayed treatment experienced limited visual improvement. the authors hope that future studies will determine whether the need for reinjections of bevacizumab can be reduced over time. abstracts pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 167 brow ptosis after temporal artery biopsy: incidence and associations` murchisonap, bilyk jr ophthalmology 2012; 119: 2637–42 although temporal artery biopsy (tab) is generally considered a low-risk procedure, damage to the facial nerve may cause brow ptosis and/or orbicularis oculi weakness. the incidence of this complication is not well reported. in this prospective study analyzing tabs performed by 2 surgeons during a 17-month period (68 patients undergoing 75 tabs), murchison and bilyk found a 16.0% incidence of postoperative facial nerve damage with a full recovery in 58.3% of these patients. an additional 16.7% improved over 6 months. results showed that incisions close to the orbital rim and brow were more likely to have postoperative facial nerve dysfunction, whereas incisions greater than 35 mm from both the orbital rim and brow or above the brow were less likely to have postoperative brow ptosis. because as many as 4% of patients undergoing tab may experience permanent frontalis dysfunction, the authors recommend that patientsshould be warned of this risk during preoperative counseling. microsoft word 3. oasameera irfan 68 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology original article role of topical cyclosporin in scleritis: a case series sameera irfan, harris iqbal pak j ophthalmol 2013, vol. 29 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sameera irfan 312, k1,wapda town lahore …..……………………….. purpose: to report on a series of cases of anterior, non-necrotizing scleritis, that were effectively treated with topical 0.075% 1% cyclosporine a and to provide a literature review on other treatment modalities of this condition. material and methods: this study includes eleven consecutive patients of acute anterior, non-necrotizing scleritis reporting to mughal eye hospital, lahore, during january to december 2012. there were 7 females and 4 males between the age 18 and 65 years. they all had mild to moderate, anterior scleritis, nodular in 6 cases and diffuse in 5 cases. all patients were thoroughly investigated regarding auto-immune disorders. only 2 cases had associated rheumatoid arthritis. they were treated with topical cyclosporine and preservative-free artificial tears for 2-3 months and followed-up for 1 year regarding recurrence. results: all patients showed a favorable response to treatment. the scleritis score improved remarkably within 2 weeks of cyclosporin therapy. the symptoms flared up in only 2 out of 11 cases (18%) when they abruptly stopped therapy. all cases remained asymptomatic over the one year follow-up after stopping treatment. conclusion: topical 0.075% 1% cyclosporine a is a safe and effective longterm treatment of anterior scleritis of mild to moderate severity. it should be considered as a steroid-sparing agent, particularly in recurrent disease and in those patients who experience adverse effects of systemic medications. cleritis is a severe, potentially sight threatening, inflammatory disease involving the ocular surface. it has been be classified by pg watson et al,1 into anterior and posterior. anterior scleritis can be diffuse, nodular, necrotizing with inflammation (necrotizing), and necrotizing without inflammation (scleromalacia perforans). posterior scleritis2 is characterized by flattening of the posterior aspect of the globe, thickening of the posterior coats of the eye (choroid and sclera), and retrobulbar edema. the author states that the anatomical site and clinical appearance of the disease at presentation reflected its natural history; majority of patients remain in the same clinical category throughout the course of their disease. diffuse anterior scleritis had a lower incidence of visual loss (9%) than either nodular scleritis (26%) or necrotizing disease (74%), patients with necrotizing scleritis were older than patients in the other groups and more frequently had an associated systemic disease than patients with either diffuse or nodular disease, 57%.3 according to another study, necrotizing scleritis is associated with rheumatoid arthritis in most cases and less often with sle, crohn's disease, behcet's disease and gout.4 diffuse and nodular anterior scleritis is less often associated with any systemic disease. an underlying infectious etiology has been found to be relatively less common. according to a study by gonzalez et al5, out of 500 patients presenting with scleritis, only 9.4% had an underlying infection with herpes virus infection (74%), tuberculosis (10%) and other infections in the remaining 14%. s role of topical cyclosporin in scleritis: a case series pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 69 an autoimmune deregulation in a genetically predisposed host is presumed to cause scleritis. inciting factors may include infectious organisms, endogenous substances, or trauma. the inflammatory process may be caused by immune complex–related vascular damage (type iii hypersensitivity) and subsequent chronic granulomatous response (type iv hypersensitivity).6 ocular complications of scleritis, which cause visual loss and eye destruction, appear as a result of the extending scleral inflammation. these include peripheral ulcerative keratitis (13 – 14%), uveitis (about 42%), glaucoma (12 – 13%), cataract (6 – 17%), and fundus abnormalities (about 6.4%).7.they are most common in necrotizing scleritis, the most destructive type of scleritis. despite recent advances, its treatment remains a difficult problem. systemic immunosuppressive therapy with corticosteroids or immunosuppressive agents or both is usually required to control the disease. early therapeutic intervention is important to prevent ocular complications and to minimize the potential morbidity and mortality associated with underlying systemic disease. systemic corticosteroids in high dosage, either topical orally or in intravenous pulses, are widely accepted as an effective form of treatment in patients with severe scleritis.8 but this treatment is often associated with unacceptable side effects and does not always control scleral inflammation. side effects include adrenal suppression, vertigo, psychosis, pseudotumour cerebri, acne, osteoporosis, myopathy and delayed wound healing. the addition of immunosuppressive agents in patients with severe scleritis improves the ocular outcome and decreases the morbidity associated with systemically administered corticosteroids.9 azathioprine, cyclophosphamide, and cyclosporine have previously been reported to be effective and safe in the management of severe ocular inflammation.10 various studies have reported the successful use of topical cyclosporine in the treatment of patients with a variety of ocular inflammatory syndromes resistant to other immunosuppressive regimens.11,12 evidence obtained from these studies supports the efficacy of topical cyclosporine treatment through its immunomodulatory action, reversing inflammation of the ocular surface and lacrimal glands. in the present study we report the therapeutic effect of topical cyclosporine in the treatment of mild to moderate scleritis. material and methods this is a prospective case series of eleven consecutive patients with scleritis who attended the out patients department of mughal eye hospital, lahore, from january to december 2012. all cases were assessed by the same ophthalmologist. a detailed history was taken and physical examination performed; distinction was made between episcleritis and scleritis by the presence of eye pain, local tenderness over the area of nodule in 6 cases and diffuse purplish hue in 5 cases of scleritis; the conjunctiva could be freely moved over that area and no blanching of the lesion was achieved by a drop of 10% phenylephrine eye drops. the cases presenting with episcleritis were excluded from the study. all patients were graded to have an active anterior non-necrotizing scleritis of mild to moderate severity without associated anterior or posterior uveitis. appropriate investigations including cbc, esr, rh – factor, serum anca, ace, chest x-ray and mantoux test to exclude the presence of an associated auto-immune or infectious disease; hla autoantibodies and c reactive protein testing was not done due to economic constraints. the clinical features of the patients are summarized in (table 1). there were seven females between ages of 18 – 65 years and four males with the age of 45 years. a subjective grading system, analogous to that previously described for patients with uveitis and retinal vasculitis was used (table 2).13 a scleritis score was calculated when the patients first presented, then at each follow-up visit and at the end of the study (table 3). improvement was defined as a decrease in the total score of greater than 2 and resolution at a total score of less than or equal to 4. all patients were fully informed regarding the proper use and expected side-effects of topical cyclosporine which was then started as 1% twice /day (freshly prepared from cyclosporin capsules, 50 mg bioral; the water-miscible gel from 2 capsules mixed with 5cc distilled water) along with preservative – free artificial tears 4 x / day (biolan gel from stullin pharma, germany). treatment was started and patients were reviewed weekly to note their subjective and objective improvement. the therapy was continued for 2 months in mild cases (scleritis score 6 – 7) and 3 months in moderate cases (scleritis score = > 8). then it was gradually tapered by reducing the strength of cyclosporin drops to 0.075%, twice daily for 1 week, then once daily for one week, then on alternate day for a week and then it was finally stopped. sameera irfan, et al 70 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology results associated active rheumatoid arthritis was found in only 2 female cases who were 60 years old. no other systemic auto-immune or infectious disease was present in any other case. in all cases, the subjective improvement of eye pain was noted in the first week of therapy and objectively, reduction in scleral injection and tenderness improved within 2 weeks of therapy. the scleritis scoring system is detailed in table 2, and table 3 summarizes the scleritis score for each patient at presentation and at four weeks after the commencement of treatment. in all patients there was a significant decrease in the scleritis score at four weeks. this decrease in the scleritis score was maintained over the subsequent observation period. none of the cases developed scleral thinning, uveitis or a raised iop during or after the termination of therapy. the mean duration of treatment was 2 months in mild cases and 3 months in moderately severe cases. no recurrence of scleritis was noted in 9 cases after stopping the therapy. two cases (18%) stopped therapy abruptly after one month only; in role of topical cyclosporin in scleritis: a case series pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 71 them, scleritis re-appeared which was again successfully controlled by starting the same therapy and educating them regarding their proper use and weaning. no recurrence of symptoms was noted in any case over one year follow-up after stopping the therapy. cyclosporin eye drops were well tolerated by all patients. table 4 summarizes the side effects looked for in the study. the only problem noted was stinging and a burning sensation on instillation of drops which subsided after instilling preservative-free tear drops after 10 minutes of instillation of cyclosporin eye drops. no other side effect was noted. discussion all eleven patients included in the study responded to the use of cyclosporine (freshly prepared at our hospital pharmacy). a subjective improvement of eye pain was noted within one week following the start of therapy and improvement of scleral injection and tenderness was noted after two weeks of therapy. it has been increasingly recognized as an effective therapeutic agent in the management of a variety of autoimmune diseases. it has been effectively used topically in ocular surface disorders like vernal keratoconjunctivitis, dry eye syndrome. inflammatory eye disease, particularly uveitis, is often well controlled by the regular use of systemic cyclosporin14. cyclosporin represents the prototype of a new class of drug that appears to work, at least in part, by acting at the level of cytokine production by immune cells.15 the selective ability of cyclosporine to interfere with the action of interleukin-2 makes it an appropriate agent for the treatment of diseases mediated by t cells. although the immunepathogenesis of scleritis is not fully understood, it is believed to be due to immune complex mediated vascular damage to scleral vessels, with the subsequent generation of a granulomatous reaction. t cells have an essential role in the formation of such granulomas, and cyclosporine may act in part by decreasing this component of the inflammatory response. multiple studies on the efficacy of topical cyclosporine for treating inflammatory ocular surface disorders have consistently shown a beneficial effect of the drug.14,17 the immune-pathogenic mechanism is complex and involves an ige mediated immediate hypersensitivity response as well as a t cell mediated immune reaction. animal studies have shown that cyclosporin has no intraocular penetration; it concentrates on the ocular surface which enhances its anti-inflammatory effect after long term use. even after a year of regular topical therapy, none to minimal blood concentration and in aqueous taps was found in rabbits. a large study16 of 392 patients with non-infectious anterior scleritis highlighted various therapeutic options available included nsaids, particularly cox-2 inhibitors (but they result in cardiovascular side effects) in 144 (36.7%), oral or topical steroids in 29 (7.4%), immune modulatory drugs (systemic cyclophosphamide, azathioprine, methotrexate) in 149 (38.0%), biologic response modifiers (brm) in 56 (14.3%), and none (n = 14). patients with idiopathic diffuse or nodular scleritis with a low degree of scleral inflammation or without ocular complications may respond to nsaids. patients with idiopathic diffuse or nodular scleritis with a high degree of scleral inflammation may respond to steroids. patients with diffuse or nodular scleritis with associated systemic disease may respond to imt or brms. patients with necrotizing scleritis may respond to imt, mainly alkylating agents. all these systemic therapies are associated with many side effects. similarly, topical steroids potentiate sameera irfan, et al 72 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology corneo-scleral thinning, raised intra-ocular pressure and cataract. in comparison, topical cyclosporin has minimal side-effects. only precaution to be used is that the beneficial affect is achieved after two weeks of therapy but the immune process is still active and the therapy has to be continued for at least two months and then gradually tapered, otherwise the disease flares up if treatment is stopped abruptly and too early as seen in our two cases. conclusion this study highlights the fact that topical cyclosporine is a potentially useful drug in the treatment of mild to moderate anterior scleritis; subjective and objective clinical improvement is achieved within 2-3 weeks of regular usage. hence, it is an effective steroidsparing agent. unfortunately, its use is complicated by frequent, mild side effects, like burning and stinging for a short while after instillation of eye drops and may be associated with recurrence of disease on suddenly stopping the therapy.14 patients need to be informed and educated regarding its appropriate use. to avoid recurrence of the disease, therapy has to be continued for at least 2 – 3 months and then gradually tapered. another problem with cyclosporine eye drops is that they have to be made fresh, without preservatives and have a shelf life of one week only. despite these limitations we consider that topical cyclosporine is a useful drug in the management of mild to moderate scleritis, and has a high therapeutic value in the treatment of this disease. author’s affiliation dr. sameera irfan mughal eye hospital (trust) lahore dr. harris iqbal mughal eye hospital (trust) lahore references 1. tuft sj, watson pg. progression of scleral disease. ophthalmology. 1991; 98: 467-71. 2. machado dde o, curi al, fernandes rs, bessa tf, campos wr, oréfice f. scleritis: clinical characteristics, systemic associations, treatment and outcome in 100 patients. arq bras oftalmol. 2009; 72: 231-5. 3. riono wp, hidayat aa, rao na. scleritis: a clinicopathologic study of 55 cases. ophthalmology. 1999; 106: 1328-33. 4. sousa jm, trevisani vf, modolo rp, gabriel la, vieira la, freitas dd. comparative study of ophthalmological and serological manifestations and the therapeutic response of patients with isolated scleritis and scleritis associated with systemic diseases. arq bras oftalmol. 2011; 74: 405-9. 5. sainz de la maza m, jabbur ns; foster cs. severity of scleritis and episcleritis. ophthalmology. 1994; 101: 38996. 6. sainz de la maza m, foster cs, jabbur ns. scleritis associated with systemic vasculitic diseases. ophthalmology 1995; 102: 687-92. 7. durrani k, zakka fr, ahmed m, memon m, siddique ss, foster cs. systemic therapy with conventional and novel immunomodulatory agents for ocular inflammatory disease. ophthalmol. 2011; 56: 474-510. 8. raizman m. corticosteroid therapy of eye disease. fifty years later. arch ophthalmol. 1996; 114: 1000-1. 9. sainz de la maza m, molina n, gonzalez-gonzalez la, doctor pp, tauber j, foster cs. scleritis therapy. ophthalmology. 2012; 119: 51-8. 10. carrasco ma, cohen ej, rapuano cj, laibson pr. therapeutic decision in anterior scleritis: our experience at a tertiary care eye center. j fr ophtalmol. 2005; 28: 1065-9. 11. machado dde o, curi al, fernandes rs, bessa tf, campos wr, oréfice f. scleritis: clinical characteristics, systemic associations, treatment and outcome in 100 patients. arq bras oftalmol. 2009; 72: 231-5. 12. gumus k, mirza ge, cavanagh hd, karakucuk s. topical cyclosporine a as a steroid-sparing agent in steroid-dependent idiopathic ocular myositis with scleritis: a case report and review of the literature. eye contact lens. 2009; 35: 275-8. 13. foster cs, forstot sl, wilson la. mortality rate in rheumatoid arthritis patients developing necrotizing scleritis or peripheral ulcerative keratitis. ophthalmology. 1984; 91: 1253-63. 14. utine ca, stern m, akpek ek. topical ophthalmic use of cyclosporine a. immunology and inflammation. 2010; 18: 352-61. 15. mccluskey pj, wakefield d. current concepts in the management of scleritis. aust nz j ophthalmol. 1988; 16: 169-76. 16. hillenkamp j, kersten a, althaus c, sundmacher r. cyclosporin a therapy in severe anterior scleritis. 5 severe courses without verification of associated systemic disease treated with cyclosporine a. ophthalmology. 2000; 97: 863-9. 17. kaçmaz ro, kempen jh, newcomb c, daniel e, gangaputra s, nussenblatt rb, rosenbaum jt, suhler eb, thorne je, jabs da, clarke ga, foster cs. cyclosporine for ocular inflammatory diseases. ophthalmology. 2010; 117: 576-84. pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 225 original article role of topical human milk in the treatment of neurotrophic corneal opacity munawar ahmed, muhammad saeed, m. arshad mahmood pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: munawar ahmed department of ophthalmology liaquat university of medical & health sciences jamshoro munawar_404@yahoo.com …..……………………….. purpose: to study the effect of topical human milk on neurotrophic corneal opacity. material and methods: this observational clinical analysis was done at departments of ophthalmology, liaquat university of medical & health sciences jamshoro, azra naheed medical college lahore, and college of medicine and dentistry lahore from june 2005 to june 2011 to determine effects of human milk on forty three (28 male and 15 female) patients within 55 years of age, having neurotrophic corneal opacity. three patients were dropped due to incomplete follow up. forty patients with neurotrophic cornea, sixteen non insulin dependent diabetics, and twenty four with previous viral keratitis were included in the study after taking informed consent these patients were put on topical human milk and tobramycin 0.3% eye drops four times daily. before treatment every patient was seen on slit lamp to assess size, site, level and density of opacity. thickness and vascularization of cornea, condition of endothelium, and any reaction in the anterior chamber was also noted. corneal staining was done to rule out ulcer and tear strip along the inner border of lower lid was also noted to see the level of dryness associated with neurotrophic cornea. best corrected visual acuity was recorded and corneal sensitivity was tested with a cotton tip. sensitivity to chemical stimulation was also determined with diclofenac sodium eye drops by noting intensity of burning sensation. follow up was done for six months, on day 7, day 15 and monthly. the beneficial and adverse effects were noted and results were compiled. only forty patients who completed six months follow up were included in the final result analysis. results: treatment response began within 15 days of instillation of topical human milk, corneal sensitivity improved in 24 (60%) eyes and visual acuity improved in 28 (70%). transient conjunctival hyperemia was noted in most of the patients. out of forty patients (28 male 12 female) 32 patients (80%) achieved nearly complete recovery of corneal transparency by last follow up. 8 (20%) diabetic patients failed to respond completely. bacterial conjunctivitis occurred in 6 (15%) patients. conclusion: human milk helps in restoring corneal transparency in neurotophic corneal opacity, especially in patients with previous viral keratitis. orneal diseases are a major cause of blindness, second only to cataract in overall importance1. furthermore, persons with corneal blindness are of a younger age group compared with those suffering from cataract. therefore, in terms of total blind years, the impact of corneal blindness is greater. the cornea is a virtually avascular tissue, but it has very dense innervation (40 times more than the tooth pulp and 400 times more than skin)2. nerve growth factor plays a special role in growth and differentiation of peripheral sensory nerve cells and help in repairing the damaged nerve fibers3. thus, any inflammatory reaction and subsequent healing are controlled by this neuronal innervation4. corneal c munawar ahmed, et al 226 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology sensitivity threshold is significantly higher in male than female (females more sensitive). reduction in corneal threshold (increase in sensitivity) occurs with age in females but not males5. corneal nerves damage impairs epithelial healing and induces trophic keratopathy even in the absence of injury or infection6. according to mackie classification7,8, neurotrophic keratopathy is divided into three stages. stage 1: is dry eye, with resultant vascularization and scarring of cornea. stage 2: is non healing corneal epithelial defect. stage 3: is stromal melting leading to perforation. treatment of neurotrophic keratopathy at stage 1 is therefore necessary to prevent further complication, and to restore corneal function. unfortunately available treatments do not help the patient to the level of their satisfaction. several ocular and systemic diseases, including fifth-nerve palsy, viral infections, chemical burns, corneal surgery, abuse of topical anesthetics, diabetes mellitus, leprosy, and multiple sclerosis, can cause sensory-nerve impairment8. loss of corneal sensation leads to a decrease in the number of corneal stem cells9, decreased metabolic and mitotic rates in the corneal epithelium10. the result is progressive corneal damage with epithelial defects, vascularization, stromal scarring, ulceration, and ultimately perforation even in the absence of injury or infection. in viral keratitis interaction with host immunity results in corneal opacity11. the standard treatment of corneal opacity is expensive, often ineffective, and the outcome may be loss or severe impairment of vision. new drug modalities such as epidermal growth factor, nerve growth factor, fibroblast growth factor (fgf-2), vascular endothelial growth factor etc have been found effective in achieving normal corneal integrity. majority of these growth factors are present in the human milk including ngf12. growth factor activity is present throughout the lactation period in the human milk but in bovine milk only during the colostral phase13. human breast milk is still in use as traditional eye medicine (tem) for corneal ulcer in rural areas. however, no clinical research has been conducted so far to see its beneficial or adverse effects on the human eye. this study will therefore be the first of this nature. material and methods before treatment, informed consent was taken from all the patients. dignity, honor, and privacy of patient and the human milk provider were always maintained. observational clinical analysis was then carried out on patients of either sex having corneal opacity accompanied with decreased corneal sensitivity and negative conjunctival swab culture. patients having neurotrophic corneal opacity due to viral keratitis (mackie classification stage 1), long standing disciform keratitis, recurrent viral keratitis and long standing diabetes with neurotrophic cornea were registered for study. initial examination was performed in outpatient department. after getting informed consent, detailed history was taken which included; age, sex, residency, occupation, any previous history of trauma to eye, and socioeconomic condition. the data was also collected related to any surgery which can damage trigeminal nerve, topical medication, corneal surgery, associated systemic disease and family history. best – corrected visual acuity was noted using snellen’s chart. slit lamp examination of normal and affected eye was done, and where possible dilated indirect ophthalmoscopy with 90d was also performed. corneal staining of affected eye was done to rule out active ulcer, for which one drop of fluorescein 1% was used. the corneal opacity was examined for size, site, density, location and invasion of blood vessels. all layers of cornea and anterior chamber were examined carefully on slit lamp. corneal sensitivity was tested with cotton tip at the center of the cornea of affected eye. when the cornea was touched with cotton tip, the sensitivity was considered normal if a blink reflex was present. if the patient felt contact but had no blink reflex corneal hypoesthesia was diagnosed, and if no response was present corneal anesthesia was diagnosed. corneal/ conjunctival sensitivity to chemical stimulation was also determined by noting a burning sensation after conjunctival instillation of a pungent substance in the affected eye of patient14 for which naclof (diclofenac sodium) eye drops were used in the affected eye. short term use of non steroidal anti-inflammatory drugs (nsaid) are harmless to ocular surface and do not decrease corneal sensitivity and tear secretion15. intraocular pressure was checked with air puff tonometer in both eyes. conjunctival swab sampling, culture, and random blood glucose assessment was performed by the pathologist in the laboratory. the patients were then put on topical human milk four times daily. every patient requested the healthy nursing woman at his or her home or any other role of topical human milk in the treatment of neurotrophic corneal opacity pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 227 nursing woman for fresh milk four times daily. the milk was taken in a clean stainless steel spoon and used by the patient with the help of sterilized dropper immediately. topical tobramycin 0.3% ophthalmic drops were also used four times daily to prevent bacterial infection. follow up was done on day 7, day 15, and then every month up to 6 months. on every follow up visit complete assessment including visual acuity, size and thickness of corneal opacity, corneal sensitivity, and any complication was noted. same research protocol was used by all the authors and all patients were discussed online to maintain uniformity. data analysis spss 14.0 (statistical package for social sciences) was used for statistical analysis. paired t-test was used to assess visual acuity in numbers of eyes before and after treatment with human milk in patients with diabetic neurotrophic and viral neurotrophic corneal patients. for data analysis visual acuity was used in decimals. mean visual acuity before management was 0.2 and after management was 0.7, independent sample test was performed to see significant difference between two groups. there was significant difference in visual outcome between viral and diabetic neurotrophic corneal opacity patients, p value 0.004. results out of 43 recruited patients of neurotrophic corneal opacity, only 40 patient completed full follow up of six months. three patients with incomplete follow up were dropped from study. among these 40 patient 16 were diabetic and 24 with previous viral keratitis. majority of these patients were from rural areas and most of them were poor. most of these patients were previously treated with acyclovir due to decreased corneal sensitivity (table 1). these patients had either central or paracentral corneal opacity which was visible with naked eye (figure 1 and 2) and reduced corneal sensitivity. size of corneal opacity ranged between 2 to 5 mm. in diabetic patients skin sensitivity was also affected on the extremities along with corneal sensitivity but in viral patients peripheral skin sensation was normal. best corrected visual acuity ranged between hand movements to 6/24 before treatment (table 2). table 1: bio-data of patients total recruited patients 43 dropped from study (incomplete follow up) 03 patients completed follow up of 6 months 40 male 26 female 14 age 20 to 55 years diabetic more than 10 years 16 patients previous viral keratitis 24 patients socioeconomic condition middle and lower class residency 32 rural 8 urban past medical history acyclovir eye ointment response to treatment was observed within 15 days following topical use of human milk. viral induced neurotrophic corneal opacity responded much better than diabetic neurotrophic opacity. 32 patients (80%) achieved nearly complete transparency of cornea within 30 to 90 days of treatment (figure 3 and 4). corneal sensitivity improved in 24 (60%) eyes and reported a burning sensation after conjunctival instillation of naclof (diclofenac sodium) eye drops. eight patients in whom corneal clarity occurred munawar ahmed, et al 228 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology without significant improvement in sensitivity were diabetic. best corrected visual acuity improved in 28 (70%). visual acuity did not improve in two diabetic patients due to cataract although cornea became clear. transient conjunctival hyperemia was noted in nearly all cases during initial treatment. 8 (20%) patients did not respond completely. bacterial conjunctivitis occurred in 6 (15%) patients which recovered with frequent use of tobramycin eye drops. post-treatment findings are given in table 3. complications were mostly encountered in diabetic and malnourished patients. the mean duration of treatment was 55 days. the first sign of good response on slit lamp examination was reduction in scar size in subepithelial layers (bowman’s and stroma). feeling of burning to naclof eye drops was also noted. burning sensation indicates recovery of corneal sensation. these ocular findings gradually disappeared and cornea became completely clear. the improvements in corneal sensitivity and visual acuity were maintained throughout the followup period. none of the patients had systemic side effects during treatment with human milk. moreover, none had a relapse of their eye disease during followup. discussion persistent corneal epithelial defects due to decreased corneal sensitivity result in corneal scarring, neovascu fig. 1: central corneal opacity. fig. 2: clear cornea after treatment fig. 3: before treatment fig: 4: after treatment role of topical human milk in the treatment of neurotrophic corneal opacity pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 229 larisation, and decreased vision. threshold corneal sensitivity level is required which can maintain anatomical and functional integrity of cornea16. many ocular and systemic conditions provoke a loss in corneal sensitivity sufficient to alter anatomical and physiological integrity of cornea: surgical treatment of trigeminal neuralgia and acoustic neuroma, ocular viral infection, diabetes, corneal graft, lasik, chemical burns, multiple sclerosis, local anesthetics and anti-inflammatory medication, contact lenses, familia dysautonomia. it is not possible to reverse corneal sensory loss in all these conditions, however corneal sensitivity can be improved where the cause of sensory loss is viral, contact lens, or local anesthetic. topical use of growth factor, sensory neurotransmitter or human milk cannot restore corneal sensory loss in systemic disease with17 generalized neuropathy, however local neurotrophic corneal opacity do respond to topical treatment; with human milk, individual growth factor, or neurotransmitter which is deficient in neurotrophic cornea. the effect of ngf is mediated through trkangfr and p75ntr receptors18. several studies showed that loss of ngf receptor trkangfr (tropomyosin receptor kinases) develop corneal opacity and impairment of corneal sensitive nerves. human milk contains nerve growth factor in reasonable concentration which is maintained throughout the lactational period. lactoferrin plays an important role in the defense against infections, including herpes simplex virus (hsv) keratitis19. lactoerrin is an iron binding protein. it is very abundant in colostrum. lactoferrin can inhibit viral infection by binding tightly to the viral envelope protein. neurotrophic cornea is usually accompanied by a reduction of tears or a reduced blinking of the lids which further aggravates the condition. human milk contains not only growth factors and lactoferin but also tear components, like fat water and electrolytes, which helps in maintaining tear film. human milk therefore covers all aspects of the problem. we have found human milk very effective in eliminating corneal opacity associated with corneal hypoesthesia. these are the growth factors and lactoferrin in the human milk which play important role in the elimination of neurotrophic corneal scar. nutritional factors in the human milk may also have positive effect in this process. however extent of response to human milk varies from patient to patient depending on cause of neurotrophic corneal opacity, age and general health of the patient. human milk therefore, inhibits viral infection, clears corneal opacity, improves corneal sensitivity, and restores corneal integrity with minimal complications and little expense. human milk contains significantly more lactose, even more than cow's milk and this may also stimulate the growth of microorganisms20 but this can be prevented by topical use of antibiotic (tobramycin 0.3%). during treatment some patients had photophobia and burning of their eyes during slit-lamp examinations, which suggests functional recovery of corneal innervation. the maintenance of corneal sensitivity after treatment with human milk suggests that such treatment completely restores sensory innervation of the cornea mainly in viral patients. conjunctivitis was main side effect reported during the treatment. no relapse of the disease was observed during the follow-up period in the patients who responded to treatment, but relapse is possible in neurotrophic cornea due to systemic disease, as in diabetes. because no other study has been so far conducted directly on human milk therefore results cannot be compared with other studies, however individual growth factors like epidermal growth factor21, nerve growth factor22, and vascular endothelial growth factor23 are effective in neurotrophic keratopathy. our results are comparable with nerve growth factor which restores corneal integrity. conclusion human milk is effective in restoring corneal transparency in neurotophic corneal opacity, especially in viral neurotrophic cornea, if risk of bacterial infection is controlled with topical antibiotics. the treatment is easy to use, available everywhere, and cost effective especially in developing country. however we do not recommend its use until the facts are fully established by case and control study. the results can be improved further by using bensalkonium chloride free antibiotic and good nutrition for malnourished patients. author’s affiliation dr. munawar ahmed assistant professor department of ophthalmology liaquat university of medical and health sciences jamshoro munawar ahmed, et al 230 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology dr. muhammad saeed associate professor department of ophthalmology azra naheed medical college the superior university lahore dr. m. arshad mahmood associate professor department of ophthalmology university college of medicine & dentistry the university of lahore references 1. oliva ms, schottman t, gulati m. turning the tide of corneal blindness indian j ophthalmol. 2012; 60: 423-7. 2. bonini s, lambiase a, aloe l, mantelli f, sacchetti m, rocco ml. capsaicin-induced corneal sensory denervation and healing impairment are reversed by ngf treatment. invest. ophthalmol. vis. sci, 2012; 53: 8280-7. 3. levi-montalcini r. the nerve growth factor 35 years later. science. 1987; 237: 1154-62. 4. tervo k, latvala tm, tervo tm. recovery of corneal innervation following photorefractive keratoablation. arch ophthalmol. 1994; 112: 1466-70. 5. golebiowski, blanka boptom, papas, eric b, faao; stapleton, fiona mcoptom. faao factors affecting corneal and conjunctival sensitivity measurement optometry and vision science. 2008; 85: 241-6. 6. price fw jr, whitson we, marks rg. graft survival in four common groups of patients undergoing penetrating keratoplasty. ophthalmology. 1991; 98: 3228. 7. groos, e. cornea, 2004; 94: 1189–1196. 8. mackie ia. neuroparalytic keratitis. in: fraunfelder ft, roy fh, eds. current ocular therapy, philadelphia w.b. saunders; 1995: 506-8. 9. puangsricharern v, tseng scg. cytologic evidence of corneal diseases with limbal stem cell deficiency. ophthalmology. 1995; 102: 1476-85. 10. sigelman s, friedenwald js. mitotic and woundhealing activities of the corneal epithelium: effect of sensory denervation. arch ophthalmol. 1954; 52: 46-57. 11. shtein rm, elner vm. herpes simplex virus keratitis: histopathology and corneal allograft outcomes expert rev ophthalmol. 2010; 5: 129-34. 12. gaull ge, wright ce, isaacs. significance of growth modulators in human milk pediatrics. 1985; 75: 142-5. 13. yw shing, m klagsbrun human and bovine milk contain different sets of growth factors. endocrinology. 1984; 115:273-82. 14. faulkner wj, varley ga. corneal diagnostic technique. in: krachmer jh, mannis mj, holland ej. cornea: fundamentals of cornea and external disease. st. louis: mosby–year book, 1997: 275-81. 15. yanai k, huang j, kadonosono k, uchio e. corneal sensitivity after topical bromfenac sodium eye-drop instillation clinical ophthalmology. 2013; 7: 741-4. 16. dogru m, yildiz m, baykara m, ozçetin h, erturk h. corneal sensitivity and ocular surface changes following preserved amniotic membrane transplantation for non healing corneal ulcers eye. 2003; 17: 139-48. 17. nishida, teruo, yanai, ryoji. advances in treatment for neurotrophic keratopathy current opinion in ophthalmology. 2009; 20: 276-81. 18. you l, kruse fe, hans e. volcker neurotrophic factors in human cornea investigative ophthalmology and visual science. 2000; 41: 692-702. 19. keijser s, jagar mj, dogterom – ballering, schoonderwoerd, krose, jj. houwing – duistermaat. lactoferrin glu561asp polymorphism is associated with susceptibility to herpes simplex keratitis. experimental eye research. 2008; 86: 105-9. 20. prajna vn, pillai mr, manimegalai tk, srinivasan m. use of traditional eye medicines by corneal ulcer patients presenting to a hospital in south india indian journal of ophthalmology. 1999; 47: 15-8 21. g carpenter. science promoting agent in breast milk. science, 1980; 210: 198-9. 22. lambiase a, rama p, bonini s, caprioglio g, aloe l. topical treatment with nerve growth factor for corneal neurotrophic ulcers. the new england journal of medicine, 1998; 17: 1174-80. 23. yu cq, zhang m, matis ki, kim c, m. i. rosenblatt. investigative ophthalmology and visual science. 2008; 49: 3870-8. http://content.nejm.org/content/vol338/issue17/index.shtml pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 193 original article pattern of common eye diseases in children in a tertiary eye hospital, karachi bilqis khatri, ayesha kashif pak j ophthalmol 2014, vol. 30 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: bilqis khatri hashmanis hospital jm-75, jacob lines, off m.a jinnah road, karachi. bilqis_khatri@gmail.com …..……………………….. purpose: to assess the pattern of common eye diseases in the children visiting tertiary eye hospital karachi. material and methods: a random cross sectional survey was conducted during two weeks and data was recorded through a performa containing details of bio data, personal history, presenting complains, aided and un aided visual acuity, refractive error and signs of eye and adnexa and ocular alignment. data was analyzed using spss 16.0. results: a total of 250 patients were examined out of which male patients were 52.8% and females constitutes 47.2%. majority of patients 40.8% belonged to the age group 1 – 6 years. vkc 24.8% was the most common ocular morbidity found followed by squint 15.2%, refractive error 14.8%, nld blockage 14.0%, congenital cataract 6.0%, amblyopia 4.4%, infective conjunctivitis 4.4%, blephritis 4.0%, convergence insufficiency 4.0% ptosis 2.4%, traumatic cataract 2.0%, chalazion 1.6%, corneal opacity 1.6%, keratitis and stye each 0.4%. conclusion: vernal catarrh was the most common ocular morbidity encountered in the study with male preponderance. further studies are required to find out the etiology and risk factors associated with it. key words: common eyes, congenital cataract, keratitis resentation of eye diseases vary worldwide1,4. studies had shown that certain eye diseases are common in certain age, gender, and occupation.4-6 some eye morbidities and visual abnormalities of children could affect their learning abilities, personality and adjustment in school, to avoid such problems prompt and proper eye care is needed.2,3 while some eye diseases are just the cause of ocular morbidities and are easily treatable, others if cannot treated or prevented timely can invariably leads to blindness7 therefore it is important to find out the pattern of eye diseases. early diagnosis is required in some eye diseases to prevent vision loss and optimized visual outcome.8 the years of early development make the child particularly vulnerable to visual disorders, especially if the normal development of the eye is affected by the occurrence of disease. this has been documented by various authors as it may have a devastating impact on the child’s psychological and physical development and his ability to learn.9 children with poor vision may be considered by their teachers to be poor students and both teachers and parents may subsequently lower their expectations of the child’s performance.9 the aim of this study was to find out the pattern of eye diseases of anterior chamber and adnexa oculi in children of pediatric ophthalmology department of layton rehmatullah benevolent trust (lrbt), korangi – karachi. it is the pakistan`s largest nongovernmental organization which provide free eye care services and works to fight against blindness.10 material and methods this was a hospital-based cross sectional survey with descriptive methodological design. all children aged 0 – 15 years attending outpatient department in lrbt p mailto:bilqis_khatri@gmail.com bilqis khatri, et al 194 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology hospital karachi, having diseases of anterior segment of eye and adnexa oculi were included in the study while those presented with the diseases of posterior segment of eye were excluded. children were selected randomly in duration of 2 weeks in the month of may 2013. data of 250 children aged 0 – 15 years were recorded who have diseases related to anterior segment of eye and adnexa oculi after examining by consultant ophthalmologist. children were placed into three age groups i.e, less than 1 year, 1 to 6 years and 7 to 15 years of age a pre designed performa was filled for every patient consisting the examination details which includes bio data, personal history, presenting complains, aided and unaided visual acuity, refractive error and signs of eye and adnexa, ocular alignment was also been recorded. this information was retrieved by methods of examination such as visual acuity testing by using snellen test (for school going children),and by preferential looking system (for younger children), refraction (subjective, objective and cycloplegic), slit lamp examination, and fundoscopy. after examination patients were provided treatment accordingly and those who need further evaluation were called for follow up. the recorded data was analyzed on spss 16.0 and are presented as simple frequencies or crosstabulations. a chi-squared test was used to compare variables. results data of 250 patients was recorded where male proportion was found to be higher i.e, 52.8 % (n=132) and female constitute 47.2% (n=118) (table 1). the ratio of bilateral disease was found to be more than unilateral as 68.4% cases show bilateral involvement and 31.6% were presented with unilateral presentation. among three age groups 19.6% (n=49) patients were of age less than 1 year, 40.8% (n=102) were of age 1–6 years and 39.6% (n=99) children were belong to 7 – 15 years of age group (table 2). around 15 diseases were diagnosed such as refractive error, amblyopia, nld blockage, blephritis, ptosis, chalazion, stye, vkc / allergic conjunctivitis, infective conjunctivitis (viral and bacterial), corneal opacity, keratitis, congenital cataract, traumatic cataract, convergence insufficiency, and squint in the patients of lrbt hospital. the proportion of disease as shown in (table 3) was vkc – vernal keratoconjunctivitis i.e. 24.8% was the most common ocular morbidity found in children of lrbt hospital with male pre-dominance i.e., 16.0% and in female it was found to be 8.8% followed by squint both convergent and divergent 15.2%, refractive error 14.8% where astigmatism was common, mostly associated with diseases like squint, nld blockage 14.0% which was common among the children of age less than 1 year, congenital cataract 6%, amblyopia 4.4%, infective conjunctivitis including viral and bacterial conjunctivitis was 4.4%, blepharitis 4.0%, ptosis 2.4%, traumatic cataract 2.0%, causes involve injury by needle, chisel and edges of paper, followed by chalazion 1.6%, corneal opacity 1.6% and convergence insufficiency, keratitis and stye each constitute 0.4%. a total of 37 children (out of 250) were presented with refractive error, in which 15 (40.54%) patients were astigmatic, 7 (18.91%) were hypermetropic while 15 patients (40.54%) were presented with myopia (table 4). as 250 patients from age 0-15 are divided into three groups, the second age group i.e. 1 – 6 years was presented with highest proportion of diseases (40.8%), while 7 – 15 years group accounts for 39.6% patients followed by less than 1 year group which constitutes 19.6% (table 5). the most common disease found in 1 – 6 years was vkc (11.2%) followed by squint (9.6%) out of total 40.8% cases from this age group while children from 7 – 16 years were presented with refractive errors mostly (11.6%) out of 39.6% and 8.8% out of 19.6% in age group less than 1 year were presented with nld blockage. discussion the major ocular disorder encountered in our study was vkc – vernal keratoconjunctivitis which was similar to the study of a.i ajaiyeoba done in south – western nigeria4 vkc is a chronic, bilateral inflammation of the superior and limbal palpebral conjunctiva. the warmer the climate, the greater its prevalence. onset typically occurs between ages 3 and 25 years. males typically are affected more than females,11 although vernal or allergic conjunctivitis is not usually a cause of blindness except with complications, it has been found to be a leading cause of absenteeism from school and could compromise the quality of life, impairing daily activities and work.8,13 males were found to be more effected in our study and similar result was found in study conducted by zareen mahdi at sindh government hospital new pattern of common eye diseases in children in a tertiary eye hospital, karachi pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 195 fig. 1: proportion of diseases on gender basis 0 10 20 30 40 50 refractive error astigmatism hypermetropia myopia fig. 2: proportion of refractive errors karachi12and study done at khyber teaching hospital peshawar by sadia sethi.15 total cases of squint registered were 15.2% which was somehow similar with the study done in sindh government hospital new karachi12. the ability of the eyes and the brain to work together develops throughout childhood up to the age of about 8 years but particularly within the first two years of life. if a child 0 5 10 15 20 25 30 vkc/ allergic … squint refractive errors nld blockage cong. cataract amblyopia infective conjunctivitis … blepharitis convergence … ptosis traumatic cataract chalazion corneal opacity keratitis stye column1 female bilqis khatri, et al 196 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology develops a squint, the eyes stop working together and they stop developing the ability to work together correctly which may lead to amblyopia a lazy eye.14 refractive error accounts for 14.8% majority of those belongs third age group (7 – 15 years) with same result as the study of nigeria where refractive error account for 14.3%,17 while in the study in peshawar the frequency of refractive error was 12.8%.15 in this study 8.0% children were having cataract in which the ratio of congenital cataract was higher i.e. 6.0% whereas traumatic cataract accounts for only 2%. the similar result were found in the study of nigeria where 6.6% children came with cataract17 cataract is the most common cause of visual impairment in pakistan followed by refractive error, retinal diseases, glaucoma and conjunctivitis, if timely and appropriate treatment is not initiated at the first sign of emerging eye problem these diseases can cause blindness16. the ratio of nld blockage in this study was found quite high i.e. 14.0% as compared to the study at khyber teaching hospital where nld was found 5.4%15 and at sindh government hospital it was found 3.5%.12 the major affected group (8.8%) was less than one year of age. eye injuries remain a major cause of unilateral visual impairment worldwide18and a common cause of non-congenital unilateral blindness.19children are particularly at risk of ocular injury due to their decreased ability to detect and avoid potential hazards.18,21 most childhood eye injuries are sustained during unsupervised play and domestic activities.22-25 in the study at south– western nigeria ocular trauma was the most common ocular morbidity in children where 21.7% patients were presented with trauma17 and in another study at sindh govt. trauma accounts for 9.6% cases12while in this study very few cases i.e: 2.0% were reported, usually presented with traumatic cataract and corneal opacity (1.6%). pattern of common eye diseases in children in a tertiary eye hospital, karachi pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 197 amblyopia – lazy eye is the reason for permanent vision loss if not treated timely26 in this study amblyopia cases were found around 4.4% where as in the study at south karachi only 0.5% cases were reported27and in another study at south western nigeria 0.08% cases were found.28 convergence insufficiency is the leading cause of eye starin, blurred vision, double vision and headache29 in this study 10 (4.0%) children were presented with convergence insufficiency. they had complained of headache with normal visual acuity 6/6. around 6 patients were presented with ptosis, 4 with chalazion and 1 with stye, these external eye conditions are not threat to vision. ranking of these diseases were lowest in other studies30,31which is similar to this study. eye infections are preventable but challenging cause of blindness, in this study 11 patients were presented with infective conjunctivitis including bacterial and viral conjunctivitis and only 1 patient had keratitis. conclusion male preponderance was more than females. the most common eye disease found out in this study was vernal catarrh requires long term medical treatment. further studies are required to find out the risk factors which aggravate the symptoms and to find the etiology so that the incidence can be minimized. author’s affiliation bilqis khatri research assistant &ophthalmic technologist. hashmanis hospital jm-75, jacob lines, off m.a jinnah road, karachi. ayesha kashif ophthalmic technologist graduated from duhs jm-75, jacob lines, off m.a jinnah road, karachi references 1. topalovo av. incidence of eye diseases in different parts of the world. ophthalmol. 1984; 6: 374-7. 2. pratab vb, lai hb. pattern of pediatric ocular problem in north india. india j ophthalmol. 1989; 37: 171–2. 3. adegbehingbe bo, adeoye ao, onakpoya oh. refractive errors in childhood. nigerian journal of surgical sciences. 2005; 15: 19–25. 4. ajayeoba ai, scott sco. risk factors associated with eye disease in ibadan, nigeria. afr j biomed res. 2002; 5: 1-3. 5. canavan ym, o'flaherty mj, archer db. a ten -year survey of eye – injuries in northern ireland. br j ophthalmol. 1980; 64: 618-25. 6. alakija w. eye morbidity among welders in benin city, nigeria. public health. 1988; 102: 381-4. 7. onwasigwe en, umeh re, onwasigwe cn, et al. referral pattern of children to the eye department of the university of nigeria teaching hospital, enugu, nigeria. nigerian journal of ophthalmology. 1996; 1: 5-6. 8. simon jw, kaw p. albany medical college, albany, new york am fam physician, 2001; 64: 623-9. 9. newcomb, d. robert. public health and community optometry.2nd ed. missouri, u.s.a.: butterworth-heinemann,: saint louis, 1990. 10. lrbt[homepage on internet]:available at::www.lrbt.org.pk 11. sowka jw, gurwood as, kabat ag. “vernal kerato conjunctivitis.” the handbook of ocular disease management. n.p.: jobson, 2001. 12. mahdi z, munami s, sheikh za, awan h, wahab s. pattern of eye diseases in children at secondary level eye department in karachi, pak j ophthalmol. 2006; 22:146-51. 13. joss jd, craig tj. seasonal allergic conjunctivitis: overview and treatment update. j am osteopath assoc. 1999; 99:513–8. 14. squint in childhood." royal national institute of blind people [home page on inernet]. london n.p., n.d. available from: http://www.rnib.org.uk/eyehealth/eyeconditions/eyeconditi onsoz/pages/squint. aspx 15. sethi s, sethi mj, saeed n, nk kundi. pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital peshawar, pak j ophthalmol. 2008; 24: 166-70. 16. mursalin s.m, younus a, iqbal n, rehman b, malik im. an assessment of burden of eye diseases and surgeries in pakistan, college of ophthalmology and allied vision science. accessed on 01-01-2014. 17. onakpoya oh. childhood eye diseases in south-western nigeria, clinics. 2009; 64: 947. 18. niiranem m, ratvio i. eye injuries in children. br j ophthalmol. 1981; 65: 436–8. 19. causes of childhood blindness and current control measures. "prevention of childhood blindness. geneva: world health organization, 1992. pp. 21–22. 20. alhaski m, almaaita j. retrospective analysis of pediatric ocular trauma at prince ali hospital. middle east journal of family medicine, 2007; 5: 42–5. 21. olurin o. eye injuries in nigeria. a review of 433 cases. am j ophthalmol. 1971; 72: 159–66. 22. nwosu snn. domestic ocular and adnexa injuries in nigeria. w afr j med. 1995; 14: 137–40. 23. kwari f, alhassan mb, abiose a. pattern and outcome of peadiatric ocular trauma – a 3 – year review national eye centre kaduna. nigerian journal of ophthalmology, 2000; 8: 11–6. 24. nkanga dg, doln p. school vision screening in enugu, nigeria: assessment of referral criteria for refractive error. nigerian journal of ophthalmology, 1997; 5: 34–40. 25. adeoye ao. eye injuries in the young in ile ife, nigeria. nig j med. 2002; 11: 26–8. http://www.rnib.org.uk/eyehealth/eyeconditions/eyeconditionsoz/pages/squint.%20aspx http://www.rnib.org.uk/eyehealth/eyeconditions/eyeconditionsoz/pages/squint.%20aspx bilqis khatri, et al 198 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology 26. american association for pediatric ophthalmology and strabismus, [home page on the internet], accessed on 01-022014, available from: http://www.aapos.org/ 27. sheikh sp, aziz tm. pattern of eye diseases in children of 5-15 years at bazzertaline area (south karachi) pakistan, j coll physicians surg pak. 2005; 15: 291-4. 28. ayotunde i. ajaiyeoba, pattern of eye diseases and visual impairment among students in southwestern nigeria, int ophthalmol. 2007; 27: 287–92. 29. cooper j, cooper r. conditions associated with strabismus: convergence insufficiency. optometrists network, all about strabismus, 2001 – 2005. 30. abiose a, allanson db. ocular health status of post primary school children in kaduna, nigeria. report of a survey. j paediatr ophthalmol strab. 1980; 17: 337-40. 31. akinsola fb, ajaiyeoba ai. causes of low vision and blindness in a blind school in lagos, nigeria. w afr j med. 2002; 2: 63– 5. http://www.ncbi.nlm.nih.gov/pubmed?term=shaikh%20sp%5bauthor%5d&cauthor=true&cauthor_uid=15907241 http://www.ncbi.nlm.nih.gov/pubmed?term=aziz%20tm%5bauthor%5d&cauthor=true&cauthor_uid=15907241 http://www.ncbi.nlm.nih.gov/pubmed/15907241 http://www.ncbi.nlm.nih.gov/pubmed/15907241 http://www.ncbi.nlm.nih.gov/pubmed/15907241 http://www.strabismus.org/miscellaneous.html#convergence http://www.strabismus.org/miscellaneous.html#convergence http://www.strabismus.org/miscellaneous.html#convergence 134 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology original article prophylactic use of mitomycin – c on haze formation in photorefractive keratectomy abdul hamid awan pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: abdul hamid awan jhatla eye clinic, 89 e jail road lahore …..……………………….. purpose: to study the results of prophylactic use of mitomycin – c on corneal haze after photorefractive keratectomy (prk). material and methods: sixty – four eyes of 32 patients with myopia were enrolled in this prospective study. all patients were between the ages 20 years and 37 years with simple myopia range 6.0 d to 9.0 d. all eyes underwent prk with application of 0.02% mitomycin – c for 20 seconds and irrigation with 20 ml of normal saline. patients were examined 1, 3 and 6 months after surgery. a scale of 0 to 4+ was used to grade the haze. results: pre-operatively, mean spherical equivalent refraction (se) was -8.34 diopters (d) range (6.0 d to 9.50 d). all eyes were examined 1, 3 and 6 months after surgery. one month after prk, 2 patients (3.12%) having myopia 8.5 d and above developed grade 0.5 to 1.0 haze. however, at 3 months this haze disappeared completely in one patient, whereas, the second one continued to show corneal haze grade 0.5 till 6 months postoperatively. all eyes had uncorrected visual acuity of 6/9 or better, whereas 53 eyes (82.81%) achieved uncorrected visual acuity of 6/6 or better. conclusions: to prevent haze development in high myopia, mitomycin – c makes a useful adjunct to excimer laser prk. however, further studies with a longer follow-up are required. here is always the risk of corneal haze development in patients with myopia greater than 6.0 d following photorefractive keratectomy1,3 (prk). mitomycin-c 0.02% can prevent corneal haze in patients undergoing prk. mitomycinc is an antibiotic with anti-metabolite properties that can inhibit keratocyte proliferation without affecting normal corneal cells. mitomycin-c 0.02% has previously been used in the treatment of post-prk corneal haze5. the cause of developing corneal haze may be due to the process of wound healing due to overproduction of keratocytes. previous studies show the prophylactic use of mitomycin – c for inhibition of haze formation in high myopia.5,6,8 material and methods 64 eyes of 32 patients with a spherical equivalent of -6.0 d or above were enrolled in this non comparative, prospective interventional case series. patients with dry eye syndrome, anterior and posterior uveitis, lens opacities, history of severe eye injuries, ocular surgery, keratoconus, corneal dystrophies, glaucoma, retinal disorders and systemic diseases like collagen vascular disorders or diabetes were excluded from study. orbscan was done on every patient preoperatively to rule out ecstatic corneal conditions and predict corneal thickness after prk, which was over 350 microns. all eyes underwent photorefractive keratectomy using topical anesthesia by a single surgeon. after marking 7.0 mm to 8mm in diameter by a marker depending upon the pupil size, the corneal epithelium was removed by a mechanical scrape, using a spatula. in all cases the ablation zone was 7.0mm to 8.0mm including 5.5mm to 6.0mm central optical zone and a 1.5mm to 2.0mm transitional zone. laser ablation was performed with the technolas 217c laser. t prophylactic use of mitomycin c on haze formation in photorefractive keratectomy pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 135 mitomycin-c 0.02 % was applied to the ablated area immediately for 20 seconds using microsponge. then both cornea and conjunctiva were irrigated with 20 ml of normal saline. bandage contact lens was applied on the cornea and removed on day 4. patients were advised to take vigamox, nevanac and fluoromethalone (fml) 0.1 % eye drops 4 times a day for 4 days and all eye drops were to be discontinued after day4 except fml. all patients were advised to use fml eye drops 4 times a day for 1st month, 3 times a day for the 2nd month, twice a day for the 3rd month and once a day for the 4th month. the patients were advised to use artificial tears for irritation and discomfort as required. preoperative examination included best-corrected visual acuity (bcva), manifest refraction, slit lamp examination, applanation tonometry, and corneal topography and dilated pupil examination of fundi for every patient. bandage contact lenses were removed on day 4 after ensuring corneal healing. unva, bcva refraction, slit-lamp examination, applanation tonometry, orbscan were performed on every visit 1,3 and 6 months postoperatively. corneal haze was evaluated using hanna scale from zero (no haze) to +4 (dense corneal haze). results sixty-four eyes of 32 patients (9 males and 23 females) with mean age of 30 years (range 21 to 39) underwent prk. all eyes were examined 3 and 6 months after prk. pre-operatively, mean spherical equivalent refraction (se) was -8.34 diopters (d) range (6.0 d to 9.50 d). post-operatively 53 eyes (82.81%) achieved visual acuity of 6/6or better. mean central corneal thickness was 560 micronspreoperatively and 357 microns postoperatively. at month 3 postoperatively, 37 eyes (57.81%) were within 0.5 d of emmetropia and 56 (87.5%) were within 1.0 d, while at 6 months the corresponding figures were 42 (65.62%) and 61 (95.31%) respectively. after3 months, ucva was 6/9 or better in 58 (90.62%) eyes, and 6/6 or better in 47 eyes (73.43%). after 6 months post-operatively, all(100%) eyes had 6/9 or better, whereas 53 eyes (82.81%) had 6/6 or better. 2 patients (3.12%) with myopia (-8.50 d or more) lost one line due to persistent 0.5 grade haze. no other post-operative complication occurred in any case. discussion there is always a risk of developing corneal haze in 72 28 male female fig. 1: male – female ratio. 0 0.5 1 1 .0 d 2 .0 d 3 .0 d 4 .0 d 5 .0 d 6 .0 d 7 .0 d 8 .0 d 9 .0 d 9 .5 d haze at 1 m haze at 3 m fig. 2: pre-op refraction in diopters. patients with high myopia undergoing prk, which may be enhanced by darker skin color and exposure to sunlight. mitomycin-c with antimetabolite properties exerts cytotoxic effects through inhibiting dna synthesis and is used mainly as a systemic chemotherapeutic agent. it is already being used in conjunction with glaucoma, pterygium surgery and in conjunctival or corneal neoplasm. it prevents the stromal keratocyte proliferation and thus inhibits sub epithelial fibrosis. the effects of mitomycin – c has been studied in experimental models by talamo et al,9 xu et al.10 majmudar et al5 and carones et al6and they have reported that prophylactic use of mitomycin – c can eliminate the corneal haze after prk and radial keratotomy. nassaralla ba et al11 found mitomycin c to be effective in preventing sub epithelial corneal haze following radial keratotomy. fazel e, roshani l, rezae l12 also proved mitomycin c be useful in efficacy of the procedure abdul hamid awan 136 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology preventing frequency and severity of haze formation after prk. our results on a group of pakistani patients with high myopia are comparable with the previous studies. conclusions to prevent haze development in high myopia, mitomycin – c in addition to pharmacological modulation of wound healing using fluoromethalone, makes a useful adjunct to excimer laser prk however, further studies with a longer follow-up are required. author’s affiliation dr. abdul hamid awan jhatla eye clinic 89 e jail road, lahore references 1. teal p, breslin c, arshinoff s, edmison d: corneal subepithelial infiltrates following excimer laser photorefractive keratectomy. j cataract refract surg. 1995; 21: 516-8. 2. probst le, machat jj: corneal subepithelial infiltrates following photorefractive keratectomy. j cataract refract surg. 1996; 22: 281. 3. hardten dk, sher na, lindstrom rl. correction of high myopia with the excimerlaser. visx 20/15, visx 20/20, and summit experience. the visx 20/15 excimer laser. in: salz jj, mc donnell pj, mc donald mb. eds, corneal laser surgery. st. louis, mosby, 1995: 189-206. 4. maldonado mj, arnau v, navea a, et al: direct objective quantification of corneal haze after excimer laser photorefractive keratectomy for high myopia. ophthalmology. 1996; 103: 1970-8. 5. majmudar pa, forstot sl, dennis rf, re, et al: topical mitomycin-c for subepithelial fibrosis after refractive corneal surgery. ophthalmology 2000; 107: 8994. 6. carones f, vigo l, scandola e, vacchini l: evaluation of the prophylactic use of mitomycin – c to inhibit haze formation after photorefractive keratectomy. j cataract refract surg. 2002; 28: 2088-95. 7. xu h, liu s, xia x, et al: mitomycin – c reduces haze formation in rabbits after excimer laser photorefractive keratectomy. j cataract refract surg. 2001; 17: 342-9. 8. winker von mohrenfels c, reischl u, lohmann cp: corneal haze after photorefractive keratectomy for myopia: role of collagen iv mrna typing as a predictor of haze. j cataract refract surg. 2002; 28: 1446-51 9. talamo jh, gollamudi s, green wr, et al: modulation of corneal wound healing after excimer laser keratomileusis using topical mitomycin – c and steroids. arch ophthalmol. 1991; 109: 1141-6. 10. xu h, liu s, xia x, et al: mitomycin – c reduces haze formation in rabbits after excimer laser photorefractive keratectomy. j cataract refract surg. 2001; 17: 342-9. 11. nassaralla ba. prophylactic mitomycin c to inhibit corneal hazeafter photorefractive keratectomy for residual myopia following radial keratotomy. j refrac surg. 2007; 23: 226-32. 12. fazel e, roshani l, rezae l: two step versus single application of mitomycin c in photorefractive keratectomy for high myopia. j ophthalmic vis res. 2012; 7: 17-23. pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 197 original article association between hyperhomocysteinemia and diabetic retinopathy imran ghayoor, shabana siddiqui, ghazala tabssum pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: imran ghayoor liaquat national hospital karachi-74800 imranghayoor@hotmail.com …..……………………….. purpose: to study the association between hyperhomocysteinemia (hcy) and retinopathy among diabetics and non diabetics. material and methods: this case control study was carried out at the department of ophthalmology liaquat national hospital karachi from march 2008 to november 2008. a total of 154 subjects were selected from eye opd, out of them 77 were diabetics with early retinopathy (cases) and 77 were non diabetics and had no history of ocular diseases (controls). patients with advance proliferative dr were excluded. sample size was calculated with the help of openepi software. non probability purposive sampling was done. results: serum hcy levels measured higher than 12 µmol/l in 69 (85.2%) patients and lower than 12 µmol/l in 8 (10.9%) patients with diabetes. while serum hcy levels were lower than 12 µmol/l in 65 (89.1%) patients and higher than 12 µmol/l in 12 (14.8%) patients of control groups. serum hcy levels were significantly higher in dr patients than non diabetics. according to the findings, serum hcy levels more than 12 µmol/l were 47 times more frequent in diabetic patients with retinopathy than in non diabetics, with odds ratio of 46.71 (95% ci:17.95 to 121.6). conclusion: a significant association was observed between hyperhomocysteinemia and dr, with chi square value of 46.79 and p value 0.0005 at the end of the study. iabetes mellitus refers to the group of diseases that leads to high blood glucose levels due to defects in either insulin secretion or insulin action in the body1. pakistan has a population of 154 million and more than 10% of its adult population has diabetes2. according to world health organization (who) estimates, there are 177 million diabetics in the world3. diabetes mellitus is characterized by recurrent or persistent hyperglycemia as fasting plasma glucose level at or above 126 mg/dl, and plasma glucose at or above 200 mg/dl, two hours after a 75 gm oral glucose load as in a glucose tolerance test4. the current recommended goal for hba1c in patients with diabetes is < 7.0 %, which is considered good glycemic control. people with diabetes who have hba1c levels within this range have a significantly lower incidence of complications from diabetes including retinopathy and diabetic nephropathy5,6. individuals with diabetes are 25 times more likely to become blind than individuals without this disease. in many developed countries diabetic retinopathy (dr) is a leading cause of new cases of visual impairment and blindness among adults aged 20 – 74 years.8 among people with type 1 diabetes, about 25% develop dr during the first five year and about 100% within two decades8. among people who have type 2 diabetes, about 31% have retinopathy at diagnosis,8 and more then 60% develop dr during the first two decades of the disease9. dr seems to be essentially a retinal vascular disorder probably beginning in the capillary bed. epidemiological studies have shown that the risk and severity of dr are strongly related to the duration of diabetic mellitus, hyperglycemia and hypertension, and also but less consistently to hypercholesterolemia and smoking10. another study showed an association d mailto:imranghayoor@hotmail.com imran ghayoor, et al 198 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology between the presence of dr and c677t polymorphism of the methylenetetrahydrofolate reductase (mthfr) gene among patients with type 2 dm11. dr involves both morphologic and functional changes of retinal capillaries12,13. homocysteine (hcy) is a sulfhydryl amino acid that is considered to play an important role in vascular injury resulting in the development of peripheral and coronary arterial disease14. hyperhomocysteinemia may induce endothelial dysfunction and injury followed by platelet activation and thrombus formation, possibly by increasing oxidative stress;15 therefore, it is conceivable that hyperhomocysteinemia is causally related to retinal vasculopathy through changes of the retinal vasculature and formation of microthrombi16. hyperhomocysteinemia is a strong risk factor for overall mortality in diabetic patients than among diabetics and non-diabetics17. so, plasma hcy should be assessed in all diabetic patients and any existing hyperhomocysteinemia should be treated with the aim of reducing the toxic effect of hcy and preventing further capillary closure and hypoxia. this research was an attempt to study the association between hyperhomocysteinemia and retinopathy in our population of diabetics and non diabetics, which may help in early diagnosis, treatment and prevention of new cases of visual impairment. material and methods this case control study was carried out at the department of ophthalmology, liaquat national hospital karachi from march 2008 to nov 2008. a total of 154 subjects were selected. sample size was calculated with the help of openepi software. non probability purposive sampling was done. inclusion criteria for case: patients between 20-60 years of either gender, suffering from dr of duration between 5-15 years, which was diagnosed on fundus examination using slit lamp. the fasting blood glucose should be >126 mg/dl or random blood glucose of >200 mg/dl or hba1c should be between 6.0-9.0 mg%. inclusion criteria for controls: patients between 20-60 years of either gender who were non diabetic and had no history of ocular diseases. exclusion criteria for cases: diabetic patients without retinopathy and diabetic patient with retinopathy but duration of < 5 year. diabeties with advance diabetic retonopathy with serum creatinine of >1.5 mg/dl. exclusion criteria for controls: patients who refused to get serum homocysteine levels checked or who did not have serum creatinine level of >1.5 mg/dl as increased serum creatinine level means there is spurious increase level of serum homocysteine, so it would not represent the true status of hcy level. patients who fulfill exclusion and inclusion criteria were collected through ophthalmology department of liaquat national hospital. controls were matched on age and gender, were selected from the same opd, and were not suffering from diabetes as confirmed by investigations. from all patients serum hcy levels was analyzed for determination of association in both groups which were matched according to the gender and age. informed consent was taken from all patients and as there was no active intervention involved, ethical committee approval was not sought, the hospital approved to bear the cost of tests done for this study. history, ocular examination (via slit lamp biomicro-scopy through 90d) and hcy levels were recorded in a performa. patients with renal dysfunction associated with high hcy levels were excluded from the study. spss-10 was used to analyze data. frequency and percentage were computed for categorical values like gender, dr and hcy level (>12.0 µmol/l) {5.0 -12.0 µmol/l}. mean and standard deviation were computed for quantitative variables like age and duration of diabetes. odds ratio was computed to determine the relationship between dr and hyperhomocysteinemia using 2x2 table and significance was evaluated through the confidence interval (ci). p value <0.05 was considered as significant. results a total of 154 patients were included in this study, in which 77 patients with dr were taken as cases and 77 non diabetics with no history of the ocular disease were taken as control in the study. controls were matched by age and gender and were selected from the same opd. the average age of the patients was 42.21±11.95 years (95% ci: 40.31 to 44.11). similarly average hcy level was 16.35 ± 9.83 µmol/l (95%ci: 14.79 to 17.92) and average duration of diabetes was 8.99 ± 3.44 years (95% ci: 8.21 to 9.77) as shown in table 1. age and gender were similar in both groups because of matching. of the 77 diabetes patients, 34 (44.2%) patients were observed with duration of diabetes 8 to 10 years, association between hyperhomocysteinemia and diabetic retinopathy pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 199 28 (36.7%) patients were with the duration of 5 to 7 years and 15 (19.5%) were observed with the duration of diabetes 11 to 15 years. out of 154 patients, 80 (51.9%) were male and 74 (48.1%) were female with 1.08:1 male to female ratio. there were 34 (44.2%) patients with background diabetic retinopathy (mean age 36.18 ± 9.82 years) and 13 (16.9%) patients with proliferative diabetic retinopathy (mean age 57.77 ± 4.17 years) and 30 (39%) patients with ppdr (mean age 40.47 ± 10.74 years) as shown in (table 2). associations between hyperhomocysteinemia and dr in diabetics and non diabetics are presented in table 3. serum hcy levels measured higher than 12 µmol/l in 69 (85.2%) patients and lower than 12 µmol/l in 8 (10.9%) patients of cases. while serum homocysteine level lower than 12 µmol/l in 65 (89.1%) patients and higher than 12 µmol/l in 12 (14.8%) patients of control groups as presented in table 3. serum homocysteine level was significantly higher in diabetic retinopathy patients than no diabetics. according to the findings, serum homocysteine level more than 12 µmol/l. was 47 times more frequent in diabetic patients with retinopathy than non diabetics (odds ratio = 46.71, 95% ci: 17.95 to 121.6). discussion dr is a leading cause of blindness among patients with dm18. it involves both morphologic and functional changes of retinal capillaries19,20. pdr is augmented by retinal hypoxia21. hyperhomocysteinemia may induce endothelial dysfunction and injury following platelet activation and thrombus formation, possibly by increasing oxidative stress15. so it is thought that hyperhomocysteinemia is casually related to retinal vasculopathy through changes of the retinal vasculature and formation of microthrombi15,17. oxidative stress is thought to be increased in dm22; this may make them more susceptible to hyperhomocysteinemia induced oxidative damage. hoogeveen et al looked for an association between the hcy level and retinopathy among subjects diabetics and non diabetics. there were 625 numbers of patients. they defined hyperhomocysteinemia as serum total hcy level greater than 16 µmol/l. in their study the prevalence of retinopathy was 9.8% (28/285) in subjects with normal glucose tolerance, 11.8% (20/169) in those with impaired glucose tolerance, 9.4% (10/106) in those with newly diagnosed dm, and 32.3% (21/65) in those with known dm. it was 12.0% (64/534) in subjects with a serum total hcy level of 16 µmol/l or less and 16.5% (15/91) in those with a serum total hcy level of more than 16 µmol/l. after imran ghayoor, et al 200 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology stratification for dm and adjustment for age, sex, glycosylated hemoglobin, and hypertension, the odds ratio (95% confidence interval) for the relation between retinopathy and hyperhomocysteinemia was 0.97 (95% confidence interval, 0.42 2.82) in nondiabetic patients and 3.44 (95% confidence interval, 1.13 – 10.42) in diabetic patients with dm, p value was 0.0823. ambrosch et al examined 65 patients with diabetes; 43 were found to have diabetic neuropathy and this subgroup had elevated levels of hcy and a higher prevalence of hyperhomocysteinaemia24. vaccaro et al studied 66 patients with diabetes and found patients with pdr; hcy was significantly higher when compared to patients without retinopathy due to the genetic homozygote c677t mutation which was at least twice as frequent in the diabetic patients25. m goldstein et al, evaluate the prevalence of hyperhomocysteinemia in diabetic patients with no dr with non proliferative diabetic retinopathy (npdr) and with proliferative diabetic retinopathy (pdr) that study included 179 diabetic patients and 156 age matched controls with no diabetes and no history of the ocular disease, who were undergoing routine physical checkups. they were using high performance liquid chromatography (hplc) technique for plasma hcy level measurement. hyperhomocysteinemia was defined when hcy level were higher than 15 µmol/l. the mean plasma homocysteine level was 11.75 ± 0.24 in the control group, 13.46 ± 0.74 in the no dr group, 14.56 ± 0.64 in the n pdr group and 15.86 ± 1.34 in the pdr group. mean hcy levels were significantly elevated in the npdr and pdr groups compared to the control group (p=0.001 and <0.0001, respectively). the prevalence of hyperhomocysteinemia was also higher in the npdr and pdr groups compared to the control group (p=0.032 and 0.011, respectively). no statistically significant difference was found between the no dr and the control group26. a total of 154 patients were included in this study, 77 diabetic patients with dr including background, non proliferative and proliferative diabetic retinopathy and 77 age and gender matched controls with no diabetes and non history of ocular disease were selected from the same opd. plasma hcy levels of all study participants were measured using fluorescence polarization immunoassay technique (fpit)27. serum homocysteine level measured higher than 12 µmol/l in 69 (85.2%) patients and lower than 12 µmol/l in 8 (10.9%) patients of cases. while serum homocysteine level lower than 12 µmol/l in 65 (89.1%) patients and higher than 12 µmol/l in 12 (14.8%) patients of control groups as presented in table 3. serum homocysteine levels were significantly higher in dr patients than non diabetics. according to the findings, serum homocysteine level more than 12 µmol/l was 47 times more frequent in diabetic patients with retinopathy than non diabetics, an odds ratio of 46.71 with 95% ci: 17.95 to 121.6. it was concluded that significant association was observed between hyperhomocysteinemia and dr, chi square 46.79 and p value 0.0005 at the end of the study. it is considered that a higher plasma level of hcy in diabetic patients may play a role in accelerating the micro vascular retinal changes, and may therefore contribute to the severity of dr. the prevalence of hyperhomocysteinemia and mean plasma homocysteine level in dr patients were higher than in the control group, those patients who have ppdr and pdr have higher hcy level than bdr. therefore, a longer follow up period is needed to evaluate the long term effects of hcy levels on the progression of dr. hyperhomocysteinemia is one of the contributing factor to micro vascular angiopathy via thrombus formation in the capillaries and further impairment in blood supply to the affected tissue. it is necessary that plasma homocysteine should be assessed in all diabetic patients and that any existing hyperhomocysteinemia should be treated with the aim of reducing the toxic effect of hcy and preventing further capillary closure and hypoxia. conclusion hyperhomocysteinemia may be a risk factor for retinopathy in patients of diabetes, but probably not in patients without diabetes and it partially explains the increased risk of micro vascular angiopathy in diabetic patients and can be used as a marker for the development of dr. author’s affiliation dr. imran ghayoor liaquat national hospital karachi dr. shabana siddiqui liaquat national hospital stadium road, postal code74800 karachi association between hyperhomocysteinemia and diabetic retinopathy pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 201 dr. ghazala tabssum liaquat national hospital karachi references 1. rother ki. diabetes treatment bridging the divide. n engl j med. 2007; 356: 1499-501. 2. shera as, rafique g, khwaja ia, baqai s, khan ia, king h. pakistan national diabetes survey prevalence of glucose intolerance and associated factors in north west at frontier province 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http://www.ncbi.nlm.nih.gov/pubmed?term=%22shera%20as%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22rafique%20g%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22khwaja%20ia%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22baqai%20s%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22khan%20ia%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22king%20h%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract javascript:al_get(this,%20'jour',%20'j%20pak%20med%20assoc.'); javascript:al_get(this,%20'jour',%20'j%20pak%20med%20assoc.'); 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http://www.ncbi.nlm.nih.gov/pubmed?term=%22pe'er%20j%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22shweiki%20d%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22itin%20a%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22hemo%20i%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22gnessin%20h%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22keshet%20e%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22keshet%20e%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract 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http://www.ncbi.nlm.nih.gov/pubmed?term=%22jakobs%20c%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22dekker%20jm%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22nijpels%20g%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22heine%20rj%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract javascript:al_get(this,%20'jour',%20'circulation.'); http://www.ncbi.nlm.nih.gov/pubmed?term=%22ambrosch%20a%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22dierkes%20j%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22lobmann%20r%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22k%c3%bchne%20w%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22k%c3%b6nig%20w%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22k%c3%b6nig%20w%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22k%c3%b6nig%20w%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22luley%20c%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract javascript:al_get(this,%20'jour',%20'diabet%20med.'); 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javascript:al_get(this,%20'jour',%20'nutr%20metab%20cardiovasc%20dis.'); http://www.ncbi.nlm.nih.gov/pubmed?term=%22goldstein%20m%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22leibovitch%20i%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22yeffimov%20i%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22gavendo%20s%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22sela%20ba%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22loewenstein%20a%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract javascript:al_get(this,%20'jour',%20'eye%20(lond).'); http://www.ncbi.nlm.nih.gov/pubmed?term=%22leino%20a%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvabstract javascript:al_get(this,%20'jour',%20'clin%20chem.'); 151 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology original article to assess the efficacy of chemical corneal tattooing for unsightly corneal scars sameera irfan, faiza rashid, irfan shahzad pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sameera irfan consultant oculoplastic surgeon & strabismologist mughal eye trust hospital 301, h3 block, johar town lahore …..……………………….. purpose: to study the efficacy and safety of chemical corneal tattooing for unsightly corneal scars. material and methods: a prospective clinical study of 44 consecutive cases in the age range from 5 60 years was conducted at the oculoplastic department of mughal eye trust hospital, lahore from june 2012 dec 2013. all patients desired a cosmetic treatment for their disfigured, white blind eye. after a complete ophthalmic examination and b scan ultrasound, and photographs of the patients' eyes were taken. chemical corneal tattooing was performed using 2% gold chloride and 2% hydrazine hydrate. patients were followed up at the first, third and fifth post-operative day; then weekly for a month, at 3rd month, 6th month and 1st year post-operatively. results: all patients had a mild red eye and discomfort in first few days but not afterwards. no corneal erosion or corneal melting was not noted in any case. procedure had to be repeated in 5 cases (11.5%) after 3-6 months of the initial therapy. one year postoperatively, 42 cases (95.5%) were satisfied and asymptomatic; 2 cases (4.5%) were lost to follow-up. conclusion: chemical corneal tattooing is a simple, safe and an efficient technique yielding acceptable cosmetic results. key words: corneal tattoo, corneal scar, ocular trauma. orneal tattooing has been used not only as a cosmetic treatment for corneal opacities but for optical reasons as well for centuries. a whitish corneal scar following keratitis or trauma is cosmetically disfiguring as well as causes scattering of light and glare. tattooing such a cornea not only blends the opacity to the normal eye color which is cosmetically acceptable in a blind eye but removes the glare in a sighted eye. it has been recommended to improve the sight of an eye in cases of albinism, aniridia, coloboma, iridodialysis, keratoconus or diffused nebulae of the cornea.1,2 in these situations, it reduces the symptomatic glare associated with a dysfunctional pupil or scattering of light produced by corneal opacities. various methods have been introduced and modified over the years. galen (131-210 a.d.)3 is considered to be the first who dyed human cornea to mask a corneal opacity using reduced copper sulphate. then louis von wecker4, an oculoplastic surgeon in 1869, used black india ink to tattoo a leucoma of the eye. he anesthetized the eye with cocaine and covered the cornea with a thick solution of ink. the pigment was then inserted into the corneal tissue with a grooved needle obliquely. in 1901, nieden5 used an electric tattooing needle based upon the idea of a fountain pen. another physician, armaignac5, used a small funnel fixed to the cornea by three small points. china ink was filled into the instrument and injected into the stroma with a needle. nowadays, two methods are used predominantly for tattooing the cornea. (1) chemical method: this involves using metallic salts which react with each other chemically to produce a brown-black precipitate that is taken up by the keratocytes and stain the cornea. the chemicals c http://en.wikipedia.org/wiki/albinism http://en.wikipedia.org/wiki/aniridia http://en.wikipedia.org/wiki/coloboma http://en.wikipedia.org/wiki/iridodialysis http://en.wikipedia.org/wiki/keratoconus http://en.wikipedia.org/wiki/india_ink to assess the efficacy of chemical corneal tattooing for unsightly corneal scars pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 152 used are gold chloride, platinum chloride, silver nitrate reduced by hydrazine hydrate to a black pigment. the reacting chemicals are applied over the stroma directly after peeling the corneal epithelium. this technique was first introduced by arif o khan and david meyer6. (2) coloring method: this technique involves the direct introduction/impregnation of colored pigments into the corneal stroma. to obtain a uniform color, the dyeing agent is injected through multiple micropunctures7 by a needle inserted into the corneal stroma. various colored dyes and inks such as indian ink, organic colors, animal uveal pigment, chinese ink, soot have been used. to obtain different shades, surgeons experiment with different combinations of such chemical products. the new advances in technology include using excimer laser to prepare the corneal bed for tattooing8; lamellar keratectomy offers excellent results in terms of a homogeneous application of colour9 but for many scars, this is not possible because of irregularity, thinning, staphyloma or calcification of cornea. penetrating keratoplasty (pk) has the risks of infection and graft rejection and its use for cosmetic purposes is ethically unacceptable in many parts of the world due to the worldwide shortage of corneal donors. mechanized keratopigmentation10 is another costly option. alternative methods to improve the aesthetic appearance of disfigured eyes are cosmetic contact lenses, keratoplasty, wearing ocular prosthesis with or without an enucleation or evisceration11. with contact lenses, intolerance frequently develops after prolonged use12 while wearing an ocular prosthesis over a scarred cornea often causes inflammation, infection and corneal erosion. hence tattooing of corneal opacities still has a role for the cosmetic improvement of unsightly corneal scars. our study aimed to investigate the potential of corneal tattooing to improve the ocular cosmetic appearance, to demonstrate its safety, efficacy and to investigate its potential as an alternative to invasive reconstructive surgery for the cosmetic correction of disfigured corneas. material and methods this prospective, interventional, non-comparative clinical case study was conducted at the oculoplastic department of mughal eye trust hospital, lahore, a tertiary care referral centre, from june 2012-dec 2013. 44 consecutive, non randomized patients were included in the study between the age range of 5 – 60 years (median 21 years). there were 19 females (43.18%) and 25 males (56.82%). all of them were blind in one eye due to past trauma and desired a cosmetic treatment for their disfigured, white eye. ophthalmic examination was performed thoroughly including b scan ultrasound to exclude intraocular tumor. the depth of corneal opacity, corneal thickness, the presence and extent of band keratopathy and corneal vascularization was carefully assessed by biomicroscopy. study inclusion criteria was superficial or deep corneal opacities, band keratopathy, leukokoria (due to a dense cataract with no visual potential or a pupillary membrane). patients with phthisical eyes, thin corneas, corneal edema (bullous keratopathy), anterior staphyloma and glaucoma were excluded from the study. after fully explaining to the patients and their parents that this procedure was not meant to restore sight but only their cosmetic appearance and they may need a repeat procedure, an informed consent was obtained and preoperative photographs of the patients’ eyes were taken. corneal tattooing was performed under general anesthesia in children and local anesthesia (retrobulbar) in adults. accurate measurement of corneal area to be tattooed compared to the second eye was done intra-operatively with a caliper. corneal epithelium was debrided using a no.15 bard parker-knife. in eyes with band keratopathy (12 cases), first chelation was performed with edta solution applied with a cotton wick on the debrided cornea for 10 minutes. it was then washed off with normal saline. any bleeding corneal vessels were cauterized at the limbus. after drying the cornea with a sponge, 2% gold chloride solution was applied over the corneal stroma and left for two minutes; then 2% hydrazine hydrate solution was applied over the stroma painted with gold chloride. a black precipitate immediately formed (due to a chemical reaction between the two solutions) which deeply stained the stroma. it was left in place for 25 seconds and then washed off with normal saline. atropine eye drops (1%) and tobramycin eye ointment were instilled and a pressure dressing was done with a double eye-pad for 24 hour. postoperatively, all cases were given nsaids orally for two days. the dressing was removed the next morning and diclofenac sodium eye drops were prescribed four times / day, atropine 1% eye drops twice / day and antibiotic eye drops four times /day for a week. patients were followed up at the first, third and fifth post-operative day; then weekly for a period sameera irfan, et al 153 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology of 1 month and then at 3rd month, 6th month and 1st year post-operatively. results forty four eyes of 44 patients, 19 females (43.18%) and 25 males (56.82%), (table 1), with an age range of 5 to 60 years (table 2) underwent corneal tattooing for disfiguring corneal scars (table 3). 24 cases (54.53%) had superficial corneal opacities, 12 cases (27.27%) had deep corneal opacities with associated band keratopathy. a dense pupillary membrane with clear cornea was present in 4 cases (9.1%) while a cataract with no visual potential and an associated corneal opacity was present in 4 cases (9.1%). on the first postoperative day (table 4), 96% of the patients complained of a moderate foreign body sensation and exhibited a conjunctival injection which corresponded to the surgically induced corneal epithelial defect and chemical reaction. once the cornea was completely epitheliazed in 48 hours in 37 cases (84%) and after 5 days in 7 cases (16%), the discomfort and conjunctival injection resolved. corneal infection was not observed in any case. minimal pigment loss was observed in 5 cases (11.5%) from 3 month onwards and they underwent a repeat procedure. corneal melting and corneal erosions were not seen in any case. one year postoperatively, 42 cases (95.5%) were satisfied with the cosmetic appearance and were asymptomatic; 2 cases (4.5%) were lost to follow-up. discussion several methods for corneal tattooing are in practice today with varying opinions regarding their safety and success. chemical tattooing as described in this study involves a chemical reaction where gold chloride is reduced by hydrazine hydrate to a black precipitate7. this metallic precipitate is deposited in the keratocytes and between the stromal lamellae from which it slowly migrates into the regenerated epithelium and stays there for a variable time period. it is important that the bowman's membrane is not damaged during the procedure as its integrity is very essential for maintaining a strong and healthy epithelial lining of the cornea. injury to this membrane either mechanically while performing epithelial debridement or chemically results in recurrent corneal erosions which is an intractable and painful condition14. in our technique, the epithelium was carefully removed under the microscope without damaging the bowman's membrane. this gave 95% satisfactory results to our patients with no corneal erosion seen in any case during follow up. on the other hand, the method of direct impregnation of colored dyes either by a needle or a blade is not 100% safe12. it is very difficult to determine the exact depth the needle or the blade has traversed through an opaque cornea and accidental damage to the bowman's membrane can easily occur particularly when multiple needle punctures are made. the corneal epithelium fails to adhere and stabilize at the site where bowman's membrane is damaged. hence the problem of recurrent corneal erosions is frequently seen because of this technique. moreover, there is always a risk of accidently puncturing the cornea at the area of stromal thinning when corneal punctures are made blindly at multiple to assess the efficacy of chemical corneal tattooing for unsightly corneal scars pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 154 sites by a needle. this complication was easily avoided by our technique. according to walter sekundo et al.14, in the british journal of ophthalmology, chemical dyeing is easier and quicker than carbon impregnation, but it fades more rapidly than non-metallic tattooing. however, in our study, fading of the dye occurred only in 5 cases (16.67%) and they needed repeating of the corneal tattooing. in the remaining 25 cases (83.33%), corneal staining remained stable over the one year follow-up. commercially available sterilized drawing ink in different shades had been used over decades being first introduced by holth13 in 1926. sekundo14 and coworkers recently supported this assessment of ink as a well tolerated staining agent in their histological evaluation of specimens up to 61 years after corneal tattooing. these inks obviously are superior to the ancient china ink, which is well known to cause substantial inflammation14. nevertheless, the composition of the ink used is a crucial point and without a chemical analysis, the possibility of corneal or conjunctival toxicity cannot be excluded. generally, these inks contain 85% water and 10% pigments which are water insoluble. therefore, absorption and systemic toxicity may be excluded but there have been reports of keratitis and iridocyclitis seen as a result of toxicity caused by commercially prepared dyes and inks. a chemical reaction can potentially cause corneal toxicity; it was seen in two of our initial cases when we started this procedure (these cases are excluded from our study). in these, the hydrazine hydrate was not washed away for a minute and corneal epithelial healing was found to be delayed with a persistent red eye for a week. this was caused by epithelial toxicity and stromal melting by the chemicals. it was treated by applying a bandage contact lens and 1% cyclosporin eye drops twice a day. since then, we have revised the procedure and recommend washing away the black precipitate with plenty of distilled water after 25 seconds of application of hydrazine hydrate over gold chloride. once we adopted this method, no epithelial defects were seen in any case; the cornea was fully epitheliazed in 37 cases (84%) within 48 hours and in 9 cases (16%), in five days, conjunctival injection disappeared similarly in all cases. it was observed in our study that the normal cornea as well as superficial corneal scars stained well permanently than deep stromal fibrotic scars; the 5 cases (11.5%) in which fading of the color was noted was on areas of dense stromal fibrosis and they needed a repeat procedure. the 12 cases (27.27%) with calcified corneal plaques were easily managed by dissolving the calcium deposits in edta paste applied over the abraded corneal epithelium for 10 minutes. edta dissolves the calcium in the epithelium as well as the corneal stroma. however, it is a painful procedure and retrobulbar anesthesia in adults and general anesthesia in children is recommended. simple corneal tattooing can be done under topical anesthesia alone. conclusion chemical tattooing of unsightly corneal scars has proved to be an efficient and a simple technique. it is a safe surgical procedure that does not require sameera irfan, et al 155 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology expensive materials and offers a viable option to avoid more extensive and invasive reconstructive ocular surgery. chemical corneal tattooing by this technique gives a stable, satisfactory cosmetic result with high patient satisfaction in all cases and an improved quality of life. author’s affiliation dr. sameera irfan mughal eye trust hospital lahore dr. faiza rashid mughal eye trust hospital lahore dr. irfan shahzad mughal eye trust hospital lahore references 1. reed jw. corneal tattooing to reduce glare in cases of traumatic iris loss. cornea. 1994; 13: 401-5. 2. vassileva, snejina and evgeniya hristakieva. "medical applications of tattooing." clinics in dermatology. 2007; 25: 36774. 3. galen c. de compositionemedicamentorumsecundum locos. in: kühn cg, ed. claudiigaleni opera omnia. hildesheim: olms, 1965; 12: 696–803. 4. duke-elder and leigh ag. tattooing of the cornea. in dukeelder s ed. system of ophthalmology volume 8. part 2. london. herry kimpton. 1965: 645-8. 5. roper-hall mj. the conjunctiva, cornea and sclera. in: stellard,s eye surgery. 7th edn. kent: butterworths. 1989: 252-4. 6. khan, arif o, meyer d. "corneal tattooing for the treatment of debilitating glare in a child with traumatic iris loss." am j of ophthalmlogy. 2005; 920-1. 7. pitz s. et al. "corneal tattooing: an alternative treatment for disfiguring corneal scars." br j ophthalmology. 2003; 86: 397-9. 8. anastas cn, mcghee cnj, webber sk, et al. corneal tattooing revisited: excimer laser in the treatment of unsightly leucomata. aust nz j ophthalmol. 1995; 23: 227–30. 9. panda a, mohan m, chawdhary s. corneal tattooing— experiences with ―lamellar pocket procedure.‖ ind j ophthalmol. 1984; 32: 408–11. 10. alio jl, sirerol b, walewska-szafran a, miranda m. corneal tattooing (keratopigmentation) with new mineral micronised pigments to restore cosmetic appearance in severely impaired eyes. br j ophthalmol. 2010; 94: 245-9. 11. custer pl, kennedy rh, woog jj, et al. orbital implants in enucleation surgery. a report by the american academy of ophthalmology. ophthalmol. 2003; 110: 2054-61. 12. snejina v, hristakieva e. "medical applications of tattooing." clinics in dermatology. 2007; 25: 367-74. 13. holth s. die technik der hornhauttätowierung, speziell der mehrfarbigen. klin monatsbl augenheilkd. 1926; 77: 289–302. 14. sekundo w, seifert p, seitz b, et al. long term ultrastructural changes in human corneas after tattooing with non-metallic substances. br j ophthalmol. 1999; 83: 219–24. http://www.ncbi.nlm.nih.gov/pubmed?term=alio%20jl%5bauthor%5d&cauthor=true&cauthor_uid=19679571 http://www.ncbi.nlm.nih.gov/pubmed?term=sirerol%20b%5bauthor%5d&cauthor=true&cauthor_uid=19679571 http://www.ncbi.nlm.nih.gov/pubmed?term=walewska-szafran%20a%5bauthor%5d&cauthor=true&cauthor_uid=19679571 http://www.ncbi.nlm.nih.gov/pubmed?term=miranda%20m%5bauthor%5d&cauthor=true&cauthor_uid=19679571 http://www.ncbi.nlm.nih.gov/pubmed/19679571 microsoft word 13. invitation for letter to editor 126 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology   letter to editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   pakistan journal of ophthalmology aims to improve quality and standard of the journal to promote research in the field of ophthalmology and in this regard pjo invites our valuable readers to submit letter to editor with their ideas, suggestions and positive scientific criticism with reference not more than 300 words long for possible publication within one month. pakistan journal of ophthalmology reserves the right to edit letters and may publish them in upcoming issues in print and electronic media (website). submission of a letter implies consent for publication unless otherwise indicated in the letter. all letters must include the correspondent's name and address and are subject to editing to meet style, clarity, and space requirements. we shall highly appreciate if letters may be sent to pjoosp@gmail.com. please include “letter to editor" in the subject line and address your typed letter to: editor, osp house, 4-a lda flats lawrence road, lahorepakistan. please include your name and address. pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 227 original article comparison of brilliant blue g and trypan blue during vitrectomy for macular hole surgery chaudhary nasir ahmad, muhammad shaheer pak j ophthalmol 2014, vol. 30 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: chaudhary nasir ahmad college of ophthalmology and allied vision sciences (coavs), king edward medical university/mayo hospital lahore drnasirch1@gmail.com …..……………………….. purpose: to compare the ease in internal limiting membrane peeling with the use of trypan blue and brilliant blue g. material and methods: this comparative cross sectional study was conducted at eye unit iii, over duration of two years 1 st march 2012 to 28 th february 2014, institute of ophthalmology, mayo hospital, lahore. patients with stage three and four age related macular hole were included in study. they were divided into two groups of thirty patients each. group a patients underwent internal limiting membrane peeling with the use of brilliant blue g while group b patients underwent internal limiting membrane peeling with adjunctive trypan blue. results: the internal limiting membrane peeling was done in of patients in first bite in brilliant blue g group. while only patient underwent successful internal limiting membrane peeling in first bite in the trypan blue group. the internal limiting membrane peeling was done in less than three minutes in patients in brilliant blue g group as compared to in trypan blue group. collateral damage occurred in patients in trypan blue group as compared to patient only in brilliant blue group. conclusion: brilliant blue g is the a more useful dye than trypan blue in internal limiting membrane peeling in terms of staining, ease of peel and less side effects. key words: brilliant blue g, macular hole, vitrectomy, he human retina and vitreous are bound together by an intervening tissue called internal limiting membrane which acts as a junction for the proliferation of various cells. diseases of the macula i.e. epimacular membranes and macular holes commonly involve the internal limiting membrane. the constituents of internal limiting membrane include collagen, proteoglycans, basement membrane and plasma membranes of muller cells and myofibrocytes. it is believed that contraction of these myofibrocytes leads to an enlargement of macular hole thus preventing its closure. therefore removal of internal limiting membrane from the macula leads to closure of macular holes by inducing gliosis. as the internal limiting membrane is a transparent structure so its removal is a very delicate and difficult procedure as it may lead to inadvertent trauma to retina. difficult visualization of the internal limiting membrane and its firm attachment to the underlying retina can present technical challenges while trying to peel this membrane.1 the problem of visibility of internal limiting membrane has been greatly reduced with the introduction of vital dyes to stain the internal limiting membrane. trypan blue is one of the first dyes used to stain the internal limiting membrane. it is successfully being used to stain the anterior lens capsule in surgery of cataracts with absent red reflex.2 now a day's trypan t mailto:drnasirch1@gmail.com chaudhary nasir ahmad, et al 228 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology blue is widely being used in posterior segment surgeries as epiretinal or internal limiting membrane peel and cystoids macular oedema surgery. up till now trypan blue has not been shown to be associated with any per operative complications such as staining of retinal pigment epithelium cells leading to cell death as with indocyanin green. previously indocyanin green was being used in epiretinal membrane and macular hole surgery. it was superior to trypan blue in staining the internal limiting membrane but was toxic to retinal pigment epithelium where trypan blue is superior in having no such adverse effects and better visual and functional outcomes.3 brilliant blue g also known as coomasian blue has recently been reported as a tool in chromovitrectomy. it has been widely used for protein staining in biological fields as it non-specifically binds to most proteins. brilliant blue g stains internal limiting membrane more effectively than other dyes used for staining ilm, erm and lens capsule. it is easier to handle and is in granular form so that it is easily dissolved at a stable ph. histological analysis shows that it has no toxic changes on retinal layers and also successful peeling of ilm occurs without any remnant retinal cells.4 brilliant blue g is comparable to other dyes with regard to visual and functional outcomes but is superior to then as it only and selectively stains ilm. the purpose of this study is to compare ilm peel assisted with trypan blue and brilliant blue g. material and methods this study was conducted at mayo hospital, institute of ophthalmology, eye unit iii, over duration of two years (1-3-1 to 28-2-14). 0 patients with stage 3 and 4 macular hole were included which were divided into two groups each containing equal number of patients. all patients with idiopathic macular holes were included while patients with rehgmatogenous retinal detachment and myopic / traumatic macular hole and those with erm were excluded on slit lamp examination of the retina and oct. informed consent was taken from the patients followed by detailed history and complete examination of the anterior and posterior segments with the help of slit lamp bimicroscopy and indirect ophthalmoscope. pre operative oct was done to stage the macular hole. post operative oct was done at 1 week and 1 month to check for anatomical closure. pre and post operative visual acuity was recorded to check for visual outcome. in the group a patients internal limiting membrane peeling was done with the assistance of brilliant blue g while group b patients underwent internal limiting membrane peeling with adjunctive trypan blue. in group a patients, after induction of posterior vitreous detachment, air was injected, brilliant blue g (0.5 ml, 0.25 mg/ml) was sprayed over the macular area followed by an air fluid exchange and internal limiting membrane peeling after about one minute of spraying. similarly the group b patients underwent the same procedure but with the assistance of trypan blue (0.5 ml, 0.06%). in all the patients sf6 was used after internal limiting membrane peeling and patients were advised face down posture for one week. results 0 patients with ages between 40 to 60 years were included in study over a period of one year. in group a there were male and female patients while group b comprised of male and female patients. in group a internal limiting membrane peel was successfully done in patients in first bite while patients underwent the procedure in more than two bites. in group b only patients underwent internal limiting membrane peeling successfully in the first bite (p value 0.037) while patients required more than one bite. internal limiting membrane peeling was completed within three minutes in patients in group a as compared to patients in group b (p value 0.002). there was iatrogenic break and iatrogenic retinal hemorrhages in group b as compared to only iatrogenic hemorrhage in group a. discussion vitreo retinal surgeons are commonly performing peeling of internal limiting membrane now a days. various macular disorders such as macular hole, epiretinal membrane tractional macular oedema and vitreomacular traction syndrome are being treated by doing peeling of internal limiting membrane.5 indocyanin green was first introduced in ophthalmology for the study of choroidal circulation. later on it was used in the posterior segment surgery to stain the transparent internal limiting membrane during macular hole surgery.6 in macular hole surgery the concentration of indocyanin green injected into the air or fluid filled vitreous cavity ranges from 0.25 to 0.50 mg/ml.7 comparison of brilliant blue g and trypan blue during vitrectomy for macular hole surgery pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 229 application of indocyanin green changes the light absorption properties of the ilm and increases the stiffness of the membrane. the indocyanin green potentiated light toxicity can be prevented by using a filter that could block the wavelengths beyond 620 nm.8 trypan blue is a vital stain which has been widely used in ocular surgery. in ocular surgery a concentration of 0.06 to 0.15% is used. internal limiting membrane staining with trypan blue is subtler than with indocyanin green probably because trypan blue only stains a mild epiretinal membrane above the internal limiting membrane rather than itself.9 the latest application of trypan blue in chromovitrectomy is in the staining and localization of retinal breaks during vitrectomy for retinal detachment. 0.15% trypan blue is injected transretinally. gandorfer et al concluded in their research that trypanblue staining promoted no ultra structural retinal damage but there were fragments of muller cells adherent to retinal side of internal limiting membrane and muller cell end feet were avulsed and ruptured.10 naryanan et al also examined the effect of trypan blue exposure on human rpe cells using the dye exclusion method and concluded that trypan blue at all concentrations did not affect rpe cells with or without light exposure. brilliant blue g has emerged as a leading dye among all the vital dyes in staining the internal limiting membrane during vitrectomy. brilliant blue g shows no retinal toxicity or adverse effects such as ganglion cell death and retinal pigment cell atrophy which is seen with the use of other dyes. recently modifications have been made in brilliant blue g by mixing it with 10% dextrose and heavy water thereby making it dense than vitreous and intraocular fluids. this modification serves two purposes. first the dye accumulates on the posterior pole rather than spreading in the vitreous thus making the macular contact time prolonged. secondly less amount of dye is used both in terms of volume and concentration.11 atul kumar12 et al compared brilliant blue g and triamcinolone acetonide in internal limiting membrane peeling. it was concluded that there was a statistically significant difference in the visual acuity of both the groups making brilliant blue g with better visual outcome. machaida s13 et al compared the cone electroretinograms after icg, bbg and ta assisted macular chaudhary nasir ahmad, et al 230 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology hole surgery. the a and b wave potentials were generally decreased in all the patients but the photopic sensitivity response was significantly decreased in patients undergoing surgery with the assistance of icg as compared to normal responses in patients treated with adjunctive bbg. baba t14 et al compared vitrectomy with brilliant blue g and indocyanin green and its effect on functioning of the eye. the best corrected visual acuity was better in the brilliant blue g group. the mean retinal sensitivity significantly improved in the bbg group. they concluded that brilliant blue g was better in making the visibility of internal limiting membrane as well as having minimal side effects. doaa awaad15 et al studied the toxic effects of brilliant blue g and trypan blue. in their study the exposed the cultured human retinal pigment epithelial cells to the trypan blue and brilliant blue g at varying concentrations and time. they concluded in their study that trypan blue was more toxic to the cultured human retinal epithelial cells at all concentrations and times of exposure. also brilliant blue g was more safe in maintaining the integrity of muller cells after internal limiting membrane peeling for macular hole. shukla r16 et al compared trypan blue, brilliant blue g and indocyanin green in their ease in internal limiting membrane peeling. the brilliant blue g group had a better post operative visual acuity and less visual decline as compared to other groups. based on these observations it was concluded that bbg was comparable with trypan blue in optimizing visual function while it was similar to icg in ease of internal limiting membrane peeling. but it was associated with less side effects and toxicity as compared to other two groups. in our study we compared brilliant blue g and trypan blue in internal imiting membrane peeling with respect to staining, timing of membrane eeling, number of bites of internal limiting membrane during peeling and collateral damage (retinal break or hemorrhage). it was observed that patients underwent membrane peel within minutes while surgeries took more than five minutes in brilliant blue g group. similarly patients underwent membrane peel within minutes and the rest took more than minutes in the trypan blue group. surgeries were completed with first bite while required more than one bite in the brilliant blue g group. similarly only membrane peel were done with first bite while the rest required more than one bite. there was iatrogenic retinal break during surgery while 3 patients had iatrogenic retinal hemorrhage in the trypan blue group as compared to only one iatrogenic retinal hemorrhage in the brilliant blue g group during surgery. follow up oct was done to see the anatomical closure. 29 macular holes in brilliant blue g group and 28 macular holes in the trypan blue group were closed on oct after one month of surgery. post operatively visual acuity improved in 43 patents out of 60 while 17 patients showed no improvement or worsening in visual acuity. conclusion based on above observations in our studies we conclude that brilliant blue g is more efficacious in staining the internal limiting membrane leading to a statistically significant ease in visibility, peeling, shorter surgery time and less side effects and less collateral damage (though not statistically significant) but still significant clinically as compared to trypan blue. author’s affiliation dr. chaudhary nasir ahmad college of ophthalmology and allied vision sciences (coavs), king edward medical university / mayo hospital, lahore dr. muhammad shaheer college of ophthalmology and allied vision sciences (coavs), king edward medical university / mayo hospital, lahore references 1. kagimoto hts, hishatomi t, eneida h, ishibashi t. this potent stain is easy to handle with minimal side effects. retina today. 2001; 45-48. 2. gerrit rjm, peter wtd, jan hp, w houdijn b. trypan blue staining to visualize capsulorhexis during cataract surgery. journal of cataract and refractive surgery. 1999; 25: 7-9. 3. jeffery sg, alain ap, john rg, alexandar jm, cindy mlh. comparison of in vitro toxicity of indocyanin green to that of trypan blue in human retinal pigment epithelium cell cultures. american journal of ophthalmology. 2004; 138: 64-9. 4. nithani p, vashisht n, khunduja s, et al. brilliant blue g assisted peeling of internal limiting membrane in macular hole surgery. indian j ophthalmol. 2011; 59: 158-60. comparison of brilliant blue g and trypan blue during vitrectomy for macular hole surgery pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 231 5. abdelkader e, louis n. internal limiting membrane peeling in vitreoretinal surgery. surv ophthalmol. 2008; 53: 368-96. 6. kadonosono k, ito n, uchio e, nakamura s, ohno s. staining of internal limiting membrane in macular hole surgery. arch ophthalmol. 2000; 118; 1116-8. 7. ando f, sasano k, suzuki f. indocyanin green assisted ilm peeling in macular hole surgery revisited. am j ophthalmol. 2004; 11: 2246-53. 8. wollensak g. vital dyes in vitreoretinal surgery. dev ophthalmol. 2008; 42: 82-90. 9. farah m, maia m, furlani b, bottos j, meyer c, lima v, penha f, costa e, rodrigues e. current concepts of trypan blue in chromovitrectomy. dev ophthalmol. 2008; 42: 91-100. 10. gandorfer r, rohleder m, charteris dg, sethi c, kempik a, luthert p. staining and peeling of the internal limiting membrane in cat eye. curr eye res 2005; 30: 977-88. 11. shukla d, kelliath j, patwardhan a, kannan nb, thayyil sb. a preliminary study of heavy brilliant blue g for internal limiting membrane staining in vitreoretinal surgery. indian jr of ophthalmology. 2012; 60: 531-4. 12. kumar a, gogia v, shah vm, sinha s. brilliant blue g versus triamcinolone assisted ilm peeling: a comparitive evaluation in macular hole surgery. world journal of retina and vitreous. 2011; 1: 1-4. 13. machida s, toba y, nishimura t, ohzeki t, murai k, kurosaka d. comparisons of cone electrograms after indocyanin green, brilliant blue g, or triamcinolone assisted macular hole surgery. greafe arch clin exp ophthalmol. 2014; 252: 1423-33. 14. baba t, hagiwara a, sato e, arai m, oshitari t, yamamoto s. comparison of vitrectomy with indocyanin green or brilliant blue g on retinal microvasculature and function of eyes in macular pathology. ophthalmology. 2012; 119: 2609-15. 15. awaad d, schrader i, bartok m, mohr a, gabel d. comparitive toxicology of brilliant blue , trypan blue and their combination together with polyethylene glycol on human pigment epithelial cells. investigative science and visual ophthalmology. 2011; 52: 4085-90. 16. shukla d, kelliath j, neelakantan n, naresh k, ramasamey k. a comparison of brilliant blue g, trypan blue and indocyanin green dyes to assist internal limiting membrane peeling during macular hole surgery. retins. 2011; 31: 2021-5. microsoft word 5. kanwal z abbasi 194 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology original article evaluation of fresh human amniotic membrane transplantation for the treatment of corneal perforation and impending corneal perforation kanwal zareen abbasi pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: kanwal zareen abbasi department of ophthalmology rmc & allied hospitals (dhq hospitals) rawalpindi …..……………………….. purpose: to determine the outcome of amniotic membrane transplantation for the treatment of corneal perforation and impending corneal perforation. material and methods: this quasi experimental study was carried out in ophthalmology department, benazir bhutto hospital from 16th april 2007 to 15th april 2008. total of 30 patients with either corneal perforation or impending corneal perforation were selected. freshly prepared amniotic membrane was transplanted over these diseased corneas. results: mean age was 58.7 years with minimum 28 years, maximum 75 years and standard deviation of ± 12.04, post op hospital stay was 1 week in 28 (93.3%) patients and 2 weeks in 2 (6.7%) patients with mean of 1.07 and standard deviation of ± 0.25, duration for which graft remained intact was minimum 1 week to maximum 10 weeks with mean of 3.97 weeks and standard deviation of ± 2.40. patients were evaluated for relief of symptoms, reduction in conjunctival inflammation, epithelial healing and globe preservation. 28 patients (93.3%) showed improvement in symptoms, reduction in conjunctival inflammation, epithelial healing and globe preservation. conclusion: amniotic membrane is a useful material in treating patients with corneal perforation and impending corneal perforation, by relieving the symptoms, healing the lesion, control of infection and ensuring globe preservation. mniotic membrane, the innermost layer of placenta, was first used along with the chorion as a biologic membrane to promote healing of the skin burns in 19101. in ophthalmology, it was used in 1940, for the management of conjunctival defects1. its revival in 1990 was due to its ability to reduce ocular surface inflammation and scarring, promoting rapid epithelialization due to the presence of growth factors and antimicrobial properties1. in 1995, amniotic membrane transplantation was used for ocular surface reconstruction of severely damaged rabbit corneas2 and since that experimental study, amniotic membrane transplantation has been used for different ocular surface disorders. as far as cornea is concerned, amniotic membrane acts as a biological contact lens, when transplanted over thin or perforated corneas3. it may be considered as an alternative method for treating persistant epithelial defects and sterile ulceration that are refractory to conventional treatment and before considering treatment by conjunctival flaps or tarsorrhaphy4. amniotic membrane graft can be used as an effective biomaterial to improve wound healing in corneoscleral ulcerations5. it has also been found to be effective in promoting epithelialization and preventing corneal perforations in acute fungal keratitis and there a evaluation of fresh human amniotic membrane transplantation pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 195 is no risk of rejection as surface cells of amnion do not express hla a,b,c or beta 2-microglobulin and so make it an excellent grafting material6-8. material and methods it was a quasi experimental study, carried out in department of ophthalmology, benazir bhutto hospital during the period 16th april 2007 to 15th april 2008. non-probability convenience sampling was done and 30 patients with corneal perforation or impending corneal perforation, regardless of age and gender, were included in the study. on day of amniotic membrane transplantation, human placenta was harvested from elective cesarean section delivery with no history of rh incompatibility, hepatitis b, c and hiv, from gynae department benazir bhutto hospital. under aseptic measures, placenta was washed thoroughly with antibiotic solution containing inj. streptomycin 50 µg/ml, inj. genticin 100 µg/ml, inj. benzyl penicillin 50 µg/ml. while still attached to the placenta, amniotic membrane was separated from chorion and continuously irrigated with the antibiotic solution, till the debris was removed completely and membrane became almost transparent. the freshly prepared membrane was then transplanted over the diseased corneas. while applying membrane over the cornea, it was placed with the epithelial side up i.e. away from lesion and stromal side of the membrane facing the lesion and anchored with 10/0 nylon. either inlay (only the lesion is covered), overlay (whole cornea), or filler (multilayered) technique was used according to the extent and severity of lesion, followed by bandage contact lens application over the graft, which was kept for at least two weeks. post operatively, patients were to be kept in hospital for one week, so that daily assessment could be done. 28 patients who started showing improvement were kept for 1 week and 2 patients who didn’t show response, were kept for 2 weeks and ultimately were given other treatment modalities. post operative medication included topical antibacterials, antifungals and steroids. parameters assessed were reduction in pain, redness, watering, reduction in conjunctival inflammation and corneal epithelial healing. this assessment was made daily for 1st week, weekly for next 3 weeks and monthly for next 2 months. so the final conclusion used to be made at the end of 3 months or even earlier if infection control and complete healing had been achieved earlier, that whether the globe preservation has been achieved or not. it was noted that graft either disintegrates, or becomes part of ocular tissue or in some cases, we removed the graft ourselves when epithelial healing was achieved so duration for which it remained intact, was also noted. data was converted into variables and entered in spss version 10. descriptive statistics were used to calculate mean and standard deviation for age, post operative stay in hospital and the duration for which graft remained intact. frequencies were calculated for age, symptoms, inflammation, epithelial healing, globe preservation and duration for which graft remained intact. results this was a quasi experimental study carried out, on 30 subjects suffering from either corneal perforation or impending corneal perforation. minimum age was 28 years, maximum 75 years with mean 53.87 years and standard deviation of ±12.04. among these 30 patients, 17(56.7%) were males and 13 (43.3%) were females. in 12 patients (40%) inlay technique, in 17 patients (56.7%), overlay technique and multilayered (2 layers) in 1 patient (3.3%) was used. minimum duration for which graft remained intact was 1 week and maximum 10 weeks with the mean of 3.97 week and standard deviation of ± 2.40. details are shown in following table: minimum hospital stay was 1 week, which was in 28 patients (93.3 %) and maximum was 2 weeks in 2 complicated cases (6.7%) with mean of 1.07 weeks and standard deviation of ± 0.25. as far as improvement in symptoms is concerned, following results were obtained: globe preservation by either control or prevention of infection): in 28 patients (93.3%) globe was preserved due to amniotic membrane transplantation. in rest of two patients 1 underwent tarsorrhaphy in 2nd week and later on his keratoplasty was done. in 2nd patient, evisceration was done in 2nd week. kanwal zareen abbasi 196 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology evaluation of fresh human amniotic membrane transplantation pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 197 fig. 1: preparation of human amniotic membrane a: after (overlay technique) b: healed cornea fig. 2: right eye, central corneal perforation with amniotic membrane graft perforated cornea with intact am graft b” healed cornea fig. 3: left eye, corneal perforation was an effort to treat these cases with the use of amniotic membrane grafting in a setting where there was ample supply of fresh amniotic membrane but which lacked proper harvesting and storage facilities in an endeavor to introduce an old technique with relatively newer interests. the average duration for which the graft remained intact was 4 weeks varying between 1 and 10 weeks. this was the time, which actually was required for epithelialization to be completed. this duration was almost the same as found out by lee and tseng in a similar study4. a” ” perforation, cataract b” ” incorporating graft c” ” healed cornea with implanted iol. figure 4: right eye, an eye with eccentric corneal perforation. the two parameters, redness and conjunctival inflammation were directly related to each other and of course associated with the state of wound healing. at the end of the 2nd month 93.3% had marked improvement in both redness and inflammation. these findings of marked improvement in inflammation associated with healed corneal surface are consistent with what ma, david hui-kang et al5. the anti-inflammatory effect were established by chen-hung chi and associates when eyes with acute fungal keratitis and associated corneal perforations improved after amniotic membrane transplantation6. in this study, the freshly prepared amniotic membrane was used. most clinical experiences have been with properly preserved tissue at -80 degree celsius in glycerol solution and flattened onto nitrocellulose filter paper9. however, several authors have described the use of freshly prepared human amniotic membrane and found that amniotic membrane transplantation promoted epithelial healing, reduced inflammation, increased comfort, and decreased severity of vascularisation. they did not find any infectious, inflammatory, or toxic kanwal zareen abbasi 198 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology reactions.10,11 the cases were generally complication free, as was expected from our prior knowledge from studies on use of freshly prepared amniotic membrane to heal corneal lesions10,11. there have been reports of development of a sterile hypopyon and in some cases, infection12. no such problem was encountered in this study. although fresh tissue may be associated with a higher risk of blood borne diseases13, the authors felt that freshly prepared tissue may be important in ocular surface restoration in developing countries. one of the parameters that was selected to judge wound healing in this study was improvement in symptoms. there was improvement in pain in 93% cases at the end of the first week which was not only a result of a bandage like effect providing a cover to the exposed nerve endings, it actually also signified a good healing response. this benefit of relieving pain when using amniotic membrane in treating corneal diseases has been seen in study of parasad jk, et al14. there was also reduction in the amount of watering which again was a collateral advantage of wound healing and the bandage effect. at the end of the 4th week equal number of patients (93.3%) showed a marked reduction in pain and watering. the prime objective of treating all these eyes was to ensure an optimal epithelial healing of the initial defect and to secure the integrity of the globe. 30% of the eyes achieved epithelial healing by the end of 2nd week, 76.6% at the end of the 4th week and 90% after the 2nd month. 28 out of 30 eyes eventually had complete epithelial healing. one of the patients had a severe corneal melting disorder. in fact, the perforation that he developed exhibited initial recovery with amniotic membrane grafting, his iris got adherent to the posterior corneal surface, developed raised iop, worsening of the lesion for which a tarsorrhaphy was performed. the perforation got sealed but the cornea later became staphylomatous. a tectonic / cosmetic / therapeutic penetrating keratoplasty was eventually performed. the other case that failed to recover developed infection, continued corneal melting and endophthalmitis, ultimately requiring evisceration. if this was the lowest point in the duration of this study, the highest point came when an only eyed patient was able to see 6/12 after recovering from a corneal perforation through an amniotic membrane transplant and later extraction of a mature complicated cataract and iol implantation. what we ultimately achieved in 28 out of the 30 eyes that were selected for the amniotic membrane transplantation was globe preservation. taking into account 90% globe preservation by lee6, considering the presenting condition of the eyes, and where azuara – blanco failed to show improvement in any one of the 5 eyes with either corneal perforation or impending perforation when they used amniotic membrane transplantation as a treatment modality15, 93.3% success rate in our study was more than satisfactory. conclusion amniotic membrane transplantation is an important tool for the healing of corneal perforations and impending corneal perforations. healing of these corneas decreases the distressing symptoms associated with these corneal lesions and helps in globe preservation. author’s affiliation dr. kanwal zareen abbasi senior registrar ophthalmology rmc & allied hospitals (dhq hospitals) rawalpindi references 1. sridhar fm, sangwan ms, virender s, et al. amniotic membrane transplantation for ocular surface reconstruction. cornea. 2005; 24: 643-53. 2. kim jc, tseng sg. transplantation of presereved human amniotic membrane for surface reconstruction in severely damaged rabbit cornea. cornea 1995; 14: 47384. 3. letko e, stechschulte su, kenyou kr, et al. amniotic membrane inlay and overlay grafting for corneal epithelial epithelial defects and stromal ulcers. arch ophthalmol. 2001; 119: 659-63. 4. lee sh, tseng sc. amniotic membrane transplantation for persistent epithelial defects with ulceration. am j ophthalmol. 1997; 123: 303-12. 5. ma, hui-kang d, su-fang w, su, wan-ya, tsai, et al. amniotic membrane graft for the management of scleral melting and corneal perforation in recalcitrant infectious scleral and corneoscleral ulcers. cornea. 2002; 21: 27583. 6. chen, hung-chi, tan, hsin-yuan, et al. amniotic membrane transplantation for persistent corneal ulcers and perforations in acute fungal keratitis. cornea. 2006; 25: 564-72. 7. adinolfi m, akle ca, mccoll i, et al. expression of hla antigen, beta 2-microglobulin and enzymes by human amniotic epithelial cells. nature. 1982; 295: 32527. evaluation of fresh human amniotic membrane transplantation pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 199 8. akle ca, adinolfi m, welsh ki, et al. immunogenicity of human amniotic epithelial cells after transplantation into volunteers. lancet. 1981; 2: 1003-5. 9. tseng scg, prabhasawat p, barton k. amniotic membrane transplantation with or without limbal allografts for corneal surface reconstruction in patients with limbal stem cell deficiency. arch ophthalmol. 1998; 116: 431-41. 10. meija lf, acosta c. symptomatic management of postoperative bullous keratopathy with non-preserved human amniotic membrane. cornea. 2002; 21: 342-45. 11. ucakhan oo, koklu g, firat a. non preserved human amniotic membrane transplantation in acute and chronic chemical eye injuries. cornea. 2002: 21: 169-72. 12. gabler b, lohmann cp. hypopyon after repeated transplantation of human amniotic membrane onto the corneal surface. ophthalmology. 2000; 107: 1344-46. 13. dua hs, azuara – blanco a. amniotic membrane transplantation. br j ophthalmol. 1999; 83: 748-52. 14. prasad jk, feller i, thompson pd. use of amnion for the treatment of steven jhonson syndrome. j trauma. 1986; 26: 945-6. 15. azura-blanko a, pillai ct, dua hs. amniotic membrane transplantation for ocular surface reconstruction. br j ophthalmol. 1999; 83: 399-402. comparison of salbutamol delivered by a metered dose inhaler with spacer versus a nebulizer in children presenting with wheeze in pediatric emergency department pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 279 original article how cataract extraction helps in improving aqueous outflow? hafiza sadia imtiaz, irfan qayyum malik, farhan ali pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: correspondence to: hafiza sadia imtiaz, pgr ii, ophthalmology dhq, uth, gujranwala email: sadiaimtiaz69@gmail.com …..……………………….. purpose: to assess changes in anterior chamber angle depth and width induced by phacoemulsification and intraocular lens implantation in normal population using anterior segment optical coherence tomography (as-oct). study design: quasi experimental study. study place and duration: eye department of dhq-teaching hospital gujranwala, from january, 2018 to june 2018. material and methods: all patients of both genders with senile cataract, having uneventful cataract surgery were randomly included in this study. after routine ophthalmic examination, pre-operative intraocular pressure (iop) using goldmann applanation tonometer along with anterior segment oct for measuring angle parameters was done in the temporal quadrant of respected eye at the time of admission. post-operatively the same procedure was repeated at the time of discharge. a p-value ≤ 0.05 was considered to be statistically significant. results: out of 82 patients, 44 (53.7%) were male and 38 (46.3%) were female. mean axial length recorded was 23 ± 1.2 mm with mean iol power of 22.0 ± 3.2d. mean pre-op trabecular iris angle (tia) was 41.5 ± 8.7° that widened to 48.6 ± 8.3° post-operatively while mean pre-op angle opening distance (aod-500 µm) recorded was 447.5 ± 149.8 µm that increased to 609.5 ± 169.8 µm post-operatively. similarly, mean pre-op iop recorded was 16.8 ± 2.8 mm hg that reduced to 15.1 ± 2.9 mm hg post-operatively. p-value of all three parameters turned out significant (< 0.05). conclusions: cataract extraction and iol implantation causes an increase in anterior chamber angle depth and width along with a reduction in intra-ocular pressure which is a direct evidence of improved aqueous outflow. key words: anterior chamber, trabecular meshwork, angle, oiptical coherence tomography. n cataract surgery, cloudy crystalline lens is removed and replaced by clear artificial lens called intra-ocular lens. there are various methods for cataract extraction and most recent and efficient one is phacoemulsification and intra-ocular lens implantation1. in phacoemulsification, ultrasonic vibrations are used to break the crystalline opaque lens into pieces which are then removed by aspiration. cataract extraction and iol implantation causes change in anterior chamber configuration2 that includes an increase in anterior chamber depth (acd), increase in anterior chamber angle (aca) with increase in angle depth and width. these changes in anterior chamber configuration ultimately lead to fall in intra-ocular pressure3. there are various methods to determine anterior chamber details that include gonioscopy for anterior chamber angle details, ultrasound biomicroscopy i hafiza sadia imtiaz, et al 280 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology (ubm), that gives high resolution images of anterior chamber4,5,6 and anterior segment oct. the most recent one is anterior segment optical coherence tomography (as-oct) that uses light of longer wavelength and is superior being non-contact and non-invasive, having less inter-observer and intra observer variability, rapid and easy to perform, providing efficient storage capacity for images that can be visualized at any time7. the rationale of our study was to study how much angle is widened after cataract extraction with resultant decrease in intra-ocular pressure (iop) in our local population. the purpose of this study is the quantitative measurement of change in anterior chamber angle depth and width after uneventful phacoemulsification and intra-ocular lens implantation in normal population using anterior segment optical coherence tomography (as-oct). material and methods after approval from hospital ethical committee, a written informed consent with demographic information was collected from each patient before participating in this study. patients of both genders, between 50-70 years of age, with senile cataract, having uneventful cataract surgery were randomly included in this study. glaucoma patients, patients with previous intra-ocular surgery and with optic nerve or retinal dysfunction were excluded from this study. this study included 82 patients (sample size was calculated using formula and values taken from junejo, et al., 2016 study). it was conducted at eye department of dhq-teaching hospital gujranwala from january 2018 to june 2018. all patients underwent routine ophthalmic examination including unaided visual acuity (uva), visual acuity with pinhole (ph), best corrected visual acuity (bcva), slit lamp biomicroscopy and fundus evaluation. biometry of the respected eye was done to determine axial length and iol power. gonioscopy was done by experienced examiner in dark to exclude patients with angle closure glaucoma. goldmann applanation tonometry and anterior segment optical coherence tomography (optovue; model ivue 500) of respected eye was done pre-operatively and 2 days post-operatively in non-dilated eye under dark conditions. while performing as-oct the patient was asked to sit comfortably with forehead touching the forehead rest and fixate on the green indicator. focusing was done manually. one examiner, masked to the results of clinical findings performed as-oct in temporal quadrant of respected eye under standardized dark conditions. scans were manually centered on pupil and auto-adjusted to obtain best quality images. one best image was selected among all with no motion or artifact due to eyelid movements. these images were finally processed using customized software by the same experienced observer. the only input of examiner was to determine the location of the scleral spurs. the algorithm then automatically calculated the anterior segment parameters. among all parameters, trabecular iris angle (tia) and angle opening distance at 500 (aod-500) were included in this study. two surgeons performed all cataract surgeries using phacoemulsification under retro-bulbar anaesthesia with 1% lignocaine and 0.5% bupivacaine followed by 10 minutes of external ocular massage. temporal clear corneal incision was given that was not sutured at the end of surgery. uneventful phacoemulsification and foldable iol implantation was done. if accidently any case met a per-op or postop complication, then it was excluded from this study. patients were discharged on second post-op day after repeating iop and as-oct of respected eye. data was analyzed using spss version 23.0. results were expressed as mean ± sd and ranges. comparison between pre-operative and postoperative angle parameters was done using a paired ttest. a p-value ≤0.05 was considered to be statistically significant. results 82 patients were included in this study. out of which 38 (46.3%) were female and 44 were male (53.7%). right eye was involved in 42 cases (51.2%) and left one in 40 cases (48.8%). average age noted was 60.7 ± 6.5 (range 50-70) years. 50 patients (61%) were below 60 years of age and 32 patients (39%) were above 60 years of age. demographic variables study population(n=50) age: mean ± sd 60.7 ± 6.5 gender male/female 53.7% (44)/46.3%(38) laterality: right/left 51.2% (42)/48.8%(40) how cataract extraction helps in improving aqueous outflow? pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 281  mean iol power recorded was 22 ± 3.2 with range of 11-29.5 d and mean axial length recorded was 23 ± 1.2 with range of 16.6-27.3 mm. fig. 1a: axial length readings. x-axis showing no of pts. and y-axis showing axial length in mm. fig. 1b: iol power readings. x-axis showing no of pts. and y-axis showing iol power in diopters.  only foldable intra-ocular lenses were being used during phaco surgery. various types of foldable iol with their frequencies are given in following table; types ee of intraocular cataract lenses frequency percent alcon 7 8.5 bf 16 19.5 focus force 25 30.5 i-stream 24 29.3 phys iol 3 3.7 zeiss 7 8.5 total 82 100.0  mean pre-op tia recorded was 41.5 ± 8.7° that widened to 48.6 ± 8.3° post-operatively with significant p-value of 0.0001 (< 0.05). trabecular iris angle (tia) mean n std. deviation p-value pre-op tia 41.5 82 8.7 0.0001 post-op tia 48.6 82 8.3 fig. 2: pre and post op tia. x-axis showing no of pts. and y-axis showing tia in°  mean pre-op angle opening distance (aod500 μm) recorded was 447.5 ± 149.8 μm that increased to 609.5 ± 169.8 μm post-operatively with significant p-value of 0.0002 (< 0.05). anterior chamber (aod500 μm) mean n std. deviation p-value pre-op (aod500 μm) 447.5 82 149.8 0.0002 post-op (aod500 μm) 609.5 82 169.8 fig. 3: pre and post op aod. x-axis showing no of pts. and y-axis showing aod-500 in μm. hafiza sadia imtiaz, et al 282 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology  mean pre-op iop recorded using goldmann applanation tonometer was 16.8 ± 2.8 mm hg that declined to 15.1 ± 2.9 mmhg post-operatively with significant p-value of 0.00001 (< 0.05). intraocular pressure (iop) mean n std. deviation p-value pre-iop 16.8 82 2.8 0.00001 post-iop 15.1 82 2.9 fig. 4: pre and post op iop. x-axis showing no of pts. and y-axis showing iop in mmhg. discussion this study is based on a simple question,” does cataract extraction improve aqueous outflow or not?” to prove this, we conducted this study. for which, we included patients with senile cataract having uneventful cataract surgery while excluding glaucoma patients and patients with previous intra-ocular surgery to minimize confounding factor. anterior chamber angle parameters were being studied pre and post-operatively using as-oct. various studies have been done in glaucomatous as well as non-glaucomatous eyes to determine changes in anterior chamber configuration after cataract surgery. in glaucoma patients, it makes the basis for clear lens extraction and iol implantation to reduce intra-ocular pressure (iop)8. in a study published by kim et al 11 eyes of 11 patients with angle closure glaucoma (acg) and 12 eyes of 12 patients with open angle glaucoma (oag) were included. the results showed that central acd and angle parameters as measured by as-oct increased significantly in eyes with glaucoma (p < 0.05) after cataract extraction. before surgery, mean central acd in the acg group was approximately 1.0 mm smaller than that in the oag group (p < 0.001). after surgery, mean acd of the acg group was still significantly smaller than that of the oag group. in the acg group, postoperative iop at the final visit was significantly lower than preoperative iop (p = 0.018)9. another study compared the role of cataract surgery in normal population with only cataract and in patients with both cataract and normal tension glaucoma (ntg) using swept source-optical coherence tomography (ss-oct). and they concluded that angle parameters remarkably increased in both groups but iop changes were only statistically significant in patients with normal tension glaucoma10. a study published by junejo et al showed the effect of uneventful cataract surgery on anterior chamber depth (acd) using ultrasonography a-scan in 74 healthy eyes. results showed that the mean acd after 1 day of cataract surgery was 3.46 ± 0.44,mm after 1 week of surgery was 3.64 ± 0.46,mm and after 1 month of surgery was 3.81 ± 0.46. mm significant increase of 0.73 ± 0.58 mm (p < 0.0001) in the mean acd was seen after 1 month of uneventful cataract surgery11. there are various angle parameters which include fig. 1: anterior chamber angle (aca) is the angle between the iris anterior surface and that of the posterior corneal surface with its apex in the angle recess. trabecular iris angle (tia) is the angle that is measured with its apex in the scleral spur and the arms 500 µm from the scleral spur passing through a point on the trabecular meshwork and a perpendicular point on the iris. how cataract extraction helps in improving aqueous outflow? pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 283 aca, tia, aod-500, aod-750, tisa-500, tisa-750 which are being discussed in following paragraph along with diagrammatic illustrations. fig 2: angle opening distance at 500 μm (aod-500) and 750 μm (aod-750) is the distance from the corneal endothelium to the anterior surface of iris just perpendicular to a line drawn along the trabecular meshwork at 500 and 750 µm from scleral spur. trabecular-iris space areas (tisa) defined as the areas bounded by the corneal endothelium, trabecular meshwork, and anterior iris surface out to a distance of 500 µm or 750 µm from the scleral spur. in this study, we included trabecular iris angle (tia) and angle opening distance at 500μm (aod500). both of these actually specify aca depth and width and are standardized as well. reason not to include aca is that it was difficult to identify proper angle recess in many patients and thus it can lead to reduced study sensitivity. it is important to note that aca depth is different from anterior chamber depth (acd) and this study doesn’t include acd that is the distance from corneal endothelium at the center of cornea to the anterior surface of lens12. though previous studies included acd change that can be well explained on this fact that thick cataractous lens is replaced with a thin intra-ocular lens that will ultimately deepen the ac13. another limitation for this parameter is that it includes some portion of posterior chamber when measured in eyes with intra-ocular lens while we are only concerned about anterior chamber. it was very surprising to note that after cataract surgery, anterior chamber angle depth and width increased when examined via anterior segment oct(as-oct) giving quantitative proof by measuring tia and aod500 pre and post-operatively as documented in some previous studies as well. in this study, we included surgeries with only foldable intra-ocular lenses to eliminate confounding factor, single piece iol’s with an optic diameter of 6.0 fig 3: a) acd with thick cataractous lens. b) acd with thin iol. note that little part of post. chamber is also included in acd measurement when iol is present. hafiza sadia imtiaz, et al 284 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology fig 4: a) pre-op tia of 25.97° and pre-op aod-500 of 226μm in temporal quadrant of left eye. b) post-op tia being 40.00° and post-op aod-500 being 369 μm showing an increase in anterior chamber angle depth and width. mm, though of different manufacturing companies. no statistically significant difference was found in study parameters among different types of iol’s. this is exactly in accordance with previous studies. anterior segment oct (as-oct) being noncontact makes it very feasible for patient as well as for observer to use and gives instant best quality high resolution images14 which can be stored and reproduced afterwards. it uses infrared radiations which are absorbed by posterior pigment epithelium of ciliary body thus reliable view of ciliary body and of posterior structures can’t be obtained.15 initially oct machine was designed to see status of macula, retina and optic disc but now it’s been largely used for anterior segment configuration. many studies used as-oct to sub-classify angle closure glaucoma16,17,18, to differentiate phacomorphic angle closure from acute angle closure eyes19 and also from mature cataract not causing phacomorphic glaucoma.20 so recent studies are using as-oct in a very novel way even to see responses of treatment modalities such as to evaluate changes over time in anterior chamber angle anatomy following laser peripheral iridotomy (lpi)21 and many more. in our study, we proved that anterior chamber angle depth and width increases after cataract surgery thus increasing aqueous outflow and reducing intra-ocular pressure(iop) which makes basis for clear lens extraction in uncontrolled angle closure glaucoma22,23,24due to intumescent cataract. conclusions in the light of above mentioned results and discussion, it is concluded that cataract extraction and intra-ocular lens implantation causes widening of anterior chamber angle (aca) along with increasing anterior chamber angle depth (aca-d) thus lowering intraocular pressure which is a direct evidence of improved aqueous outflow .and also that anterior segment oct is an efficient method for determining anterior chamber angle changes. author’s affiliation hafiza sadia imtiaz, pgr ii, ophthalmology dhq, uth, gujranwala dr. irfan qayyum malik associate professor, ophthalmology dhq, uth, gujranwala farhan ali assistant professor, ophthalmology dhq, uth, gujranwala your text here how cataract extraction helps in improving aqueous outflow? pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 285 role of authors hafiza sadia imtiaz manuscript writing, data collection. dr. irfan qayyum malik supervisor, surgeon. dr. farhan ali data collection, surgeon. references 1. jaggernath j, gogate p, moodley v, naidoo k. comparison of cataract surgery techniques: safety, efficacy, and cost-effectiveness. european journal of ophthalmology, 2014; 24 (4): 520-526. 2. baxant a, hornová j. anterior chamber morphometry before and after cataract surgery. journal of clinical & experimental ophthalmology, 2016; 07 (02). 3. cetinkaya s, dadaci z, yener h, acir n, cetinkaya y, saglam f. the effect of phacoemulsification surgery on intraocular pressure and anterior segment anatomy of the patients with cataract and ocular hypertension. indian journal of ophthalmology, 2015; 63 (9): 743. 4. cui s, zou y, li q, li l, zhang n, liu x. gonioscopy and ultrasound biomicroscopy in the detection of angle closure in patients with shallow anterior chamber. chinese medical sciences journal, 2014; 29 (4): 204-207. 5. alfarhan h, al mutairi r. anterior segment biometry using ultrasound biomicroscopy and the artemis-2 very high frequency ultrasound scanner. clinical ophthalmology, 2013; 7: 141-147. 6. salcan i, aykan u, yildirim o, kanik a. quantitative ultrasound biomicroscopy study of biometry of the lens and anterior chamber. european journal of ophthalmology, 2011; 22 (3): 349-355. 7. kim m, park k, kim t, kim d. changes in anterior chamber configuration after cataract surgery as measured by anterior segment optical coherence tomography. korean journal of ophthalmology, 2011; 25 (2): 77. 8. hsia y, moghimi s, coh p, chen r, masis m, lin s. anterior segment parameters as predictors of intraocular pressure reduction after phacoemulsification in eyes with open-angle glaucoma. journal of cataract & refractive surgery, 2017; 43 (7): 879-885. 9. kim m, park k, kim t, kim d. anterior chamber configuration changes after cataract surgery in eyes with glaucoma. korean journal of ophthalmology, 2012; 26 (2): 97. 10. lee w, bae h, kim c, seong g. the change of anterior segment parameters after cataract surgery in normaltension glaucoma. international journal of ophthalmology, 2017; 10 (8): 1239-1245. 11. junejo m, chaudhry t. anterior chamber depth changes after uneventful phacoemulsification. pakistan journal of ophthalmology, 2016; 32 (1): 31-35. 12. lubis z, dewi m, delfi. change in anterior chamber depth and intraocular pressure after phacoemulsification surgery of senile cataract. international journal of scientific and research publications (ijsrp). 2018; 8 (8). 13. engren a, behndig a. anterior chamber depth, intraocular lens position, and refractive outcomes after cataract surgery. journal of cataract & refractive surgery, 2013; 39 (4): 572-577. 14. high resolution anterior segment oct and lamellar corneal surgery. acta ophthalmologica. 2017; 95. 15. guzman c, gong t, nongpiur m, perera s, how a, lee h et al. anterior segment optical coherence tomography parameters in subtypes of primary angle closure. investigative ophthalmology & visual science, 2013; 54 (8): 5281. 16. kwon j, sung k, han s, moon y, shin j. subclassification of primary angle closure using anterior segment optical coherence tomography and ultrasound biomicroscopic parameters. ophthalmology, 2017; 124 (7): 1039-1047. 17. li f, zhang x. re: kwon et al. subclassification of primary angle closure using anterior segment optical coherence tomography and ultrasound biomicroscopic parameters (ophthalmology, 2017; 124: 1039-1047). ophthalmology, 2017; 124 (10): e79. 18. nouri-mahdavi k. anterior segment optical coherence tomography in subtypes of angle closure glaucoma. journal of current ophthalmology, 2016; 28 (4): 159-160. 19. moghimi s, ramezani f, he m, coleman a, lin s. comparison of anterior segment-optical coherence tomography parameters in phacomorphic angle closure and acute angle closure eyes. investigative ophthalmology & visual science, 2015; 56 (13): 7611. 20. mansouri m, ramezani f, moghimi s, tabatabaie a, abdi f, he m et al. anterior segment optical coherence tomography parameters in phacomorphic angle closure and mature cataracts. investigative opthalmology& visual science, 2014; 55 (11): 7403. 21. zhekov i, pardhan s, bourne r. ocular coherence tomography-measured changes over time in anterior chamber angle and diurnal intraocular pressure after laser iridotomy: impact study. clinical & experimental ophthalmology, 2018. 22. rown r, zhong l, lynch m. clear lens extraction as treatment for uncontrolled primary angle-closure glaucoma. journal of cataract & refractive surgery, 2014; 40 (5): 840-841. 23. potop v, corbu c. the role of clear lens extraction in angle closure glaucoma. romanian journal of ophthalmology, 2017; 61 (4): 244-248. 24. sung k, lee j, kim j. clear lens extraction as the first line treatment of primary angle closure/primary angle closure glaucoma. annals of eye science, 2017; 2: 6-6. microsoft word 6. ps mahar 136 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology original article outcome of mitomycin-c augmented trabeculectomy in primary congenital glaucoma p.s mahar, a. sami memon, sadia bukhari, israr a. bhutto pak j ophthalmol 2012, vol. 28 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p.s mahar isra postgraduate institute of ophthalmology, al-ibrahim eye hospital malir, karachi, pakistan …..……………………….. purpose: to evaluate the efficacy of trabeculectomy with mitomycin-c (mmc) in controlling intraocular pressure (iop) in children with primary congenital glaucoma (pcg). material and methods: the medical records of 37children (50 eyes) with pcg were reviewed. all patients underwent trabeculectomy with mmc (0.2 mg/ml) from january 2008 to december 2010. the pre and post-operative intraocular pressure (iop) was the main outcome measure evaluated using analysis of variants (anova). a successful iop was defined as an iop under 15 mm hg without any antiglaucoma medication at the end of 1 year follow up. results: a total of 50 eyes of 37 children were evaluated. the mean ± sd age of children were 23.8 ± 14.2 months (range 1 month to 36 months). the gender distribution showed predominance of male at 25(67.7%) and 12 (32.4%) female. the mean ± sd preoperative iop was 30.4 ± 6.3 mm hg (range 22 – 52 mm hg). the postoperative iop at 1 month, 6 month and 12 months were 16.6 ± 8.9 mm hg, 18.4 ± 8.5 mm hg and 20.3 ± 8.2 mm hg respectively (range 4 – 48 mm hg). the mean postoperative iop was significantly decreased compared with preoperative value (p < 0.0001). out of 50 eyes, iop was controlled (≤ 15 mm hg) in 34 eyes (68%) at first month, while at 6 and 12 month, control was seen in 32 (64%) and 29 (58%) eyes respectively. conclusion: the success rate of mmc augmented trabeculectomyin terms of controlling iop of <15 mm hgoccurredin 58% eyes in children up to age of 3 years with pcg at the end of 1 year follow up. he true prevalence of primary congenital glaucoma (pcg) is not known in this country, but it occurs in about 1 of 10,000 live births in usa,1 with 80% of affected children developing glaucoma within the first year of life. the condition is usually managed surgically. the surgical techniques are designed to eliminate the resistance of aqueous outflow created by structural abnormalities in the anterior chamber angle. these congenital changes include presence of non-permeable barkan’s membrane covering the trabecular meshwork and insertion of anterior ciliary body and iris overlapping the trabecular meshwork2,3. the goniotomy is a procedure of choice in cases with clear cornea4. once cornea becomes opaque, trabeculotomy or trabeculectomy are preferred as an initial procedure5. trabculectomy has been reported to have low success rate in children compared to adults6, 7. this is mainly due to excessive scarring caused by increased fibroblast activity in young age8. over the decades, success rate of trabeculectomy has improved in children with the concomitant use of mitomycin-c (mmc), an antimotabolite and an antifibrotic agent. this retrospective study was aimed to evaluate the outcome of mmc-augmented trabeculectomy regarding control of intraocular pressure (iop) in children with pcg. t outcome of mitomycin-c augmented trabeculectomy in primary congenital glaucoma pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 137 material and methods the medical record of 37 children (50 eyes) were evaluated, who were diagnosed with pcg with increased iop and went under trabeculectomy as a primary procedure augmented with mmc. all surgeries were performed between january 2008 to december 2010 at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, karachi. the diagnosis of pcg was established after examining the children under anesthesia (eua), measuring iop, corneal diameters, axial length of the eye, anterior segment and fundus examination when possible. the iop was measured in the early stage of the anesthesia with hand held perkins applanation tonometer. in bilateral cases, both eyes were operated in the same sitting, but for the second eye all instruments were resterilized with fresh prep and draping. surgical technique after putting 7-0 vicryl traction suture in clear cornea at 12-0 clock position, a fornix based conjunctival flap was fashioned from 10 to 2-0 clock position. the hemostasis of episcleral blood vessels was achieved with wet field bipolar cautery. three sponges soaked in mmc with concentration of 0.2mg/ml (0.02%) were placed under tenon’s capsule over sclera for duration of 4 minutes. the mmc exposed area was irrigated with about 50ml of balance salt solution (bss). a triangular partial thickness scleral flap measuring 3x3mm was created. the internal sclerotomy was performed with kellys punch measuring about 1x1mm. the anterior chamber was filled and maintained with viscoelastic substance. after peripheral iridectomy, the scleral flap was closed with 3 interrupted 10-0 nylon sutures. the conjunctiva was sutured back at limbus with 10-0 nylon suture. at the end of procedure, subconjunctival injection of dexamethasone and gentamycin was given. the postoperative medical regimen included moxifloxacin 0.5% (vigamox-alcon, belgium) 4 times a day, dexamethasone 0.1% (maxidex-alcon, belgium) 4 times a day andtropicamide 1.0%(mydriacyl-alcon, belgium) twice a day. all children were examined at day 1, week 1, week 4, week 8 and then at 12 weeks subsequently. at week 4, eua was carried again with measurement of iop, corneal diameters, axial length, anterior segment and fundus examination. all 10-0 nylon conjunctival sutures were removed at this stage. the antibiotic and dilating drops were also discontinued at 4 week postoperatively. however topical steroids were maintained for another month. the successful outcome of trabeculectomy was defined as iop measuring under 15 mm hg without any topical anti-glaucoma medication. visual acuity was not taken as an outcome measure since the age of children in this study was too young to obtain reliable results. all data was analyzed by using spss version 17. mean ± sd was calculated for age and pre and postoperative iops and frequencies and percentages were calculated for gender, visual acuity and final outcome in terms of raised or control iop at month 1, month 6 and month 12 follow up. repeated measure anova (analysis of variants) was applied to compare the mean iop between pre and postoperative at different follow-ups while chi-square test for proportion was applied to compare the final outcome at 5% level of significance. results a total of 50 eyes of 37 patientswithpcg underwent mmc augmented trabeculectomy to control their iops. themean ± sd age of patients was 23.8 ± 14.2 months (min – max = 1 – 36 months). the majority of cases had age > 24 months. the gender distribution showed 25 (67.6%) male and 12 (32.4%) female patients (table i). the mean ± sd pre-operative iop was 30.4 ± 6.3 mmhg (min – max = 22 – 52 mmhg), while postoperative iop after 1 month, 6 months and 12 months was 16.6 ± 8.9 mmhg, 18.4 ± 8.5 mmhg and 20.3 ± 8.2 mmhg respectively (min – max = 4 – 48 mmhg). themean post-operative iops were significantly decreased as compared with pre-operative iops (p-value < 0.0001) (table 2). out of 50 eyes, iop was controlled (≤ 15 mmhg) in 34 (68%) eyes post operatively at first month, this proportion is significantly high (p-value = .011). while at 6 and 12 months iop were controlled in 32 (64%) and 29 (58%) eyes respectively (table 3). discussion the treatment of primary congenital glaucoma still remains challenging. the definitive treatment is surgical, with medical therapy being used transiently. the goniotomy is a procedure of choice in children with clear corneas9. in our country, because of the late presentation of the child and the delay in the proper diagnosis, most of the children with pcg present with cloudy corneas. once cornea becomes hazy and angle p. s. mahar, et al 138 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology structures are not visualized, goniotomy cannot be performed. the trabeculotomy can be recommended in such cases but because of the larger eye balls, the schlemm’s canal remains compressed and cannot be visualized, making it also a difficult procedure to perform10. although trabeculectomy is widely performed drainage surgery, it also remains technically difficult in children with congenital glaucoma due to distorted limbalanatomy and scleral thinning, leading to inadvertent scleral perforation.11it is also considered to be less successful in young children due to thick tenon’s fascia and an exaggerated response to the healing process with increased fibroblastic reaction. as a result, use of antimetabolites such as mmc has gained acceptance for improved outcome in childhood glaucomas. over the years, several studies have found the success of primary trabeculectomy in congenital glaucoma comparable to that of goniotomy and trabeculotomy12-14. pechuho and colleagues15 carried out trabeculectomy with mmc (0.4mg/ml for 3 minutes) in children with pcg. their cohort of patients consisted 40 eyes of 30 patients, age between 15 days to 10 years with duration of follow up between 1 to 36 months. in their series, complete success was observed in 55% eyes (iop <21mm hg) and qualified success (iop <18mmhg with addition of single anti-glaucoma medication) in 27.5% eyes. susana et al16 achieved an overall success rate of 67% with a mean follow up 17 months in a series of 56 patients (79 eyes) with primary congenial or developmental glaucoma. their success rate is higher than ours (at 58 %). this difference can be attributed to the higher age group included in their study. sidoti and colleagues17 showed a success rate of 59% in a case series of 29 eyes with a mean follow up of 25.1 ± 16 months. although they included children up to age of 18 years in their study and also a higher concentration of mmc was used (0.5mg/ml). beck18 reported success in 67% ± 13% of eyes (total 49 eyes) at 12 months under going trabeculectomy with mmc. however the age of patients in their series was 17 years or younger with mixed type of primary or secondary infantile glaucoma.al-hazmi et al19 reported a successful outcome of trabeculectomy with mmc in 39% of eyes in children with pediatric glaucoma up to age of 7 years with mean follow up of 1 year. some workers have found no difference in success rate with different surgical procedures in pcg.zhang and coworkers14, in a retrospective study of 81 eyes of 48 patients with pcg under 4 years of age, reported no significant difference in success rate of primary trabeculectomy, trabeculotomy or combined trabeculotomy / trabeculectomy, with mean follow up of 5.49 ± 3.09 years. however, they concluded that over 4 years of follow up, success rate of trabeculectomy and combined trabeculotomy / trabeculectomy declined outcome of mitomycin-c augmented trabeculectomy in primary congenital glaucoma pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 139 more slowly than that of trabeculotomy.dietlein20 and colleagues performed trabeculotomy in 17 eyes of 11 patients, trabeculec-tomy in 29 eyes of 17 patients and combined trabeculotomy / trabeculectomy in 15 eyes of 10 patients with pcg. their study revealed no significant difference in the surgical outcome between various procedures. it is extremely difficult to compare various studies and their outcome of success in children with pcg due to different racial background, ethnicity, variation in age group, concentration of mitomycin used and mean follow up time. the surgical outcome of trabeculectomy, regarding control of iop is definitely less in pediatric population compared to the adult patients21, 22. the principal limitation to our study is its retrospective nature with no control group. conclusion the success rate of mmc augmented trabeculectomy controlling iop of <15mm hg in children up to the age of 3 years with pcg was seen in 58% of eyes at the end of 1 year follow up in our institute. the remaining eyes required second surgical procedure or addition of anti-glaucoma medication to control the iop. author’s affiliation prof. p.s mahar isra postgraduate institute of ophthalmology karachi dr. a. sami memon isra postgraduate institute of ophthalmology karachi dr. sadia bukhari isra postgraduate institute of ophthalmology karachi dr. israr a. bhutto isra postgraduate institute of ophthalmology karachi reference 1. hoskins hd jr, shaffer rn, hetherington j. anatomical classification of developmental glaucomas. arch ophthalmol 1984; 102: 1331-7. 2. barkan o. pathogenesis of congenital glaucoma. am j ophthalmol. 1995; 40: 1-11. 3. anderson dr. the development of the trabecular meshwork and iris abnormality in primary infantile glaucoma. trans am ophthalmol soc. 1981; 79: 458-85. 4. worst ig. goniotomy: an improved method for chamber angle surgery and congenital glaucoma. am j ophthalmol. 1964; 57: 185-200. 5. hoskins hd, sheffer rn, hethrington j. goniotomy versus trabeculotomy. j paed ophthalmol & strabismus. 1984; 21: 1538. 6. beauchamp gr, parks mm. filtering surgery in children. barriers to success. ophthalmology. 1979; 86: 170-80. 7. cadera w, pachtman m et al. filtering surgery in childhood glaucoma. ophthalmic surg. 1984; 15: 319-22. 8. skuta gl, parish rk. wound healing in glaucoma filtering surgery. surv ophthalmol. 1987; 32: 149-70. 9. mcpherson sd jr, berry dp. goniotomy versus external trabeculotomy for developmental glaucoma. am j ophthalmol. 1983; 95: 427-31. 10. burke jp, bowell r. primary trabeculectomy in congenital glaucoma. br j ophthalmol. 1989; 73: 186-90. 11. khaw pt. what is the best primary surgical treatment for infantile glaucoma (editorial). br j ophthalmol. 1996; 80: 495-6. 12. debnath sc, teichman kd, salamah k. trabeculectomy versus trabeculotomy in congenital glaucoma. br j ophthalmol. 1989; 73: 608-11. 13. fulcher t, chan l et al. long term follow up of primary trabeculectomy for infantile glaucoma. br j ophthalmol. 1996; 80: 499-502. 14. zhang x, du s et al. long term surgical outcomes of primary congenital glaucoma in china. clinics 2009; 64: 543-51. 15. pechuho ma, siddiqui sj, shah sia, et al. trabeculectomy with mitomycin c as primary surgery in congenital glaucoma. medical channel. 2009; 15: 77-9. 16. susana r, oltrogge ew, carani jce, et al. mitomycin as adjunct chemotherapy in congenital and developmental glaucoma. j glaucoma. 1995; 4: 151-7. 17. sidoti pa, belmonte sj, liebmann jm, et al. trabeculectomy with mitomycin-c in the treatment of pediatric glaucoma. ophthalmology. 2000; 107: 422-9. 18. beck ad, wilson wr et al. trabeculectomy with adjunctive mitomycin-c in pediatric glaucoma. am j ophthalmol. 1998; 126: 648-57. 19. al-hazmi a, zwaan j et al. effectiveness and complications of mitomycin-c use during pediatric glaucoma surgery. ophthalmology. 1998; 105: 1915-20. 20. dietlein ts, jacobi pc, krieglstein gk. prognosis of primary abexterno surgery for primary congenital glaucoma. br j ophthalmol. 1999; 83: 317-22. 21. bindish r, condon gp et al. efficacy and safety of mitomycinc in primary trabeculectomy: five year follow up. ophthalmology. 2002; 109: 1336-42. 22. fontana h, nouri-madhavi k et al. trabeculectomy with mitomycin-c, outcomes and risk factors for failure in phakic open angle glaucoma. ophthalmology. 2006; 113: 930-6. pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 139 original article sf6 assisted pneumatic vitreolysis in cases of vitreomacular traction syndrome rana muhammad mohsin javed, asad aslam khan, haroon tayyab, nasir chaudhry pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: haroon tayyab eye unit-iii, institute of ophthalmology, king edward medical university, mayo hospital, lahore email: haroontayyab79@googlemail.com …..……………………….. purpose: to evaluate the efficacy of intravitreal expansile sulfur hexafluoride gas injection (sf6) for the treatment of symptomatic vitreomacular traction (vmt) syndrome. study design: prospective interventional study. place and duration of study: eye unit-iii, institute of ophthalmology, king edward medical university, mayo hospital lahore. study was conducted from september 2017 to february 2018. material and methods: a total of 21 eyes were included in the study who presented with vmt diagnosed on optical coherence tomography findings including patients whose vmt was associated with epiretinal membrane and vmt in patients of diabetic retinopathy. symptomatic patients with vmt were offered the option of intravitreal sf6 injection. patients were included in this study after meeting specific inclusion and exclusion criteria. results: total 21 patients were included in this study. mean age was 57.80 ± 10.77 years. mean value for pre injection mean foveal thickness was 506.33 ± 192.37 and post injection mean foveal thickness was 383.61 ± 270.37. significant decreases in post injection mean foveal thickness was seen in patients (p-value = 0.053). after 1 st week follow up vmt release was seen in only 3 (14.3%) patients and at 1 st month follow up vmt release was seen in 9 (42.9%) patients. conclusion: intravitreal sf6 gas injection is safe, cheaper and effective alternative for vmt treatment in terms of better results when compared with intravitreal ocriplasmin. although its efficacy is not comparable with vitrectomy. key words: vitreomacular traction, sulfur hexafluoride, macula, ocriplasmin, vitrectomy. n 1970, reese et al reported an uncommon condition of macula in which traction on macula was associated by an incomplete detachment of posterior vitreous and escorted by low visual acuity1. this condition was confirmed with the help of histological studies because at that time imaging studies were not possible due to unavailability of oct. later on this condition was termed as vitreomacular traction (vmt) syndrome. as primarily described in typical form of vmt syndrome, throughout the peripheral fundus the vitreous is separated from the retina but remains adherent to macular area posteriorly, causing anteroposterior traction on macula2. in general population, prevalence of isolated idiopathic vmt without macular hole has been estimated around 22.5 cases per 100,000 patients with an incidence rate of 0.6 per 100,000 persons years3. as per findings of epidemiological studies the age range i rana muhammad mohsin javed, et al 140 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology of vmt patients ranges in between 48-64 year with a mean age around 56-70 years with higher prevalence among females4. patients with vitreomacular traction (vmt) may possibly suffer from compromised sight-related issues, emotional impact and physical restrictions5. the impact of vitreomacular traction and macular hole can affect daily living activities, lifestyle, and quality of life5. patients can experience irreversible vision loss and progressive sight-threatening symptoms due to vitreomacular traction2,6,7. research has shown that in only around 10% of people, vmt resolves spontaneously8. in cases where vmt does not resolve spontaneously, patients may experience anatomical damage and further visual impairment2. more recently, based on reports of landmark clinical trials9,10 intravitreal ocriplasmin injection was approved in october 2012 for use in patients with vmt syndrome. pharmacologic vitreolysis with ocriplasmin injection is less invasive than vitrectomy but has been reported in premarketing and postmarketing experiences to cause transient visual loss, lens subluxation, electroretinogram changes, ellipsoid zone changes, retinal breaks and dyschromatopsias11-13. in (mivi-trust) trial, it was reported that ocriplasmin resulted in improved visual outcome as reported by patients as compared to placebo14. in addition, although a randomized controlled trial demonstrated that the rate of release of vmt after intravitreal ocriplasmin injection was significantly higher than placebo (26.5 vs. 10.1% at 28 days), this success rate is much lower than that seen with vitrectomy15. intravitreal sulfurhexaflouride (sf6) injection provides a less invasive and lower cost alternative to vitrectomy for symptomatic vmt syndrome. although vitrectomy is very successful in releasing vmt, there are risks of endophthalmitis, cataract, and retinal tear and detachment16. in contrast, intravitreal gas injection safety profile is well recognized over many decades of use in the repair of retinal detachments, and sf6 gas is readily available in most retina practices17. vmt was defined by oct findings of: vitreous attachment to within 3 mm diameter of fovea with peri-foveal detachment accompanied by foveal structural distortion; foveal detachment from rpe; and no full thickness foveal defect. rationale for this study was to determine the efficacy of intravitreal expansile sulfur hexafluoride gas injection (sf6) for the management of symptomatic vmt. although traditional management of vmt is with vitrectomy, this can be invasive and costly; however use of sf6 is injection provides a lower cost alternative to vitrectomy for symptomatic vmt syndrome. so far, no local study has been conducted that evaluates the role of sf6 in management of vmt. results of this study may provide support for the future clinical use of sf6 to treat vmt in our population. material and methods this prospective interventional study was performed from september 2017 to february 2018 for a duration of 6 months in eye unit-iii of mayo hospital lahore. approval from hospital ethical committee was sought before commencing this study. patients were selected from opd of eye unit-iii, mayo hospital lahore after informed consent non-randomized purposive sampling. all patients underwent baseline best corrected visual acuity (bcva), tonometry, complete slit lamp examination and spectral domain oct (sdoct). symptomatic patients with vmt were offered the option of intravitreal sf6 injection. the patients were included and excluded after meeting the following criteria: inclusion criteria was, patients with age >18 presenting with vmt as defined by clinical and sdoct findings. clinical findings included metamorphopsia or decreased bcva (<20/25). sd-oct findings included posterior vitreous adherent within a 1,500 µm radius of the foveal center leading to vitreofoveal traction plus microstructural retinal changes with history of more than one month. vmt associated with epiretinal membrane (erm) and vmt in patients of diabetic retinopathy were included in the study. following patients were excluded from the study; pseudophakia with posterior capsular rent, any macular hole, subluxated iol and crystalline lens, macular degeneration, retinal vascular occlusion, aphakia, high myopia (> -8 dioptres), uncontrolled glaucoma, vitreous opacification, retinal tear or retinal detachment, vitrectomy surgery and macular laser. intravitreal injections were performed in the operation theater of eye unit-iii with the use of topical anesthetic, lid speculum, and povidone–iodine sf6 assisted pneumatic vitreolysis in cases of vitreomacular traction syndrome pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 141 preparation. 0.3 ml of 100% sf6 gas was injected under visualization of microscope through the pars plana in a 30-gauge needle.no positioning was required after the injection except in phakic patients who were advised to avoid supine position to prevent gas induced cataract formation. patients were evaluated 01 week and 01 month after the injection with full examination and spectral domain optical coherence tomography. we used ibm spss 23 for data analysis. quantitative data (age, hvma, mft & va) was presented by using mean ± sd. qualitative data (gender, side of eye, lens status, release of vmt & side effects) was presented by using frequency table and percentages. pre and post injection va was compared with the help of paired sample test (if data fulfilled the assumption of normality)/wilcoxon signed rank test. p-value <0.05 was taken as significant. results a total of 21 eyes were included in this study. mean age of patients was 57.80 ± 10.77 years. age of the patients ranged between 40-70 years. among patients 3 (14.3%) were males and 18 (85.7%) were females. male to female ratio was 1:6. mean duration of symptoms of patients was 3.14 ± 1.27. there were 17 (80.95%) patients whose right eye was injected and the remaining 4 (19.05%) patients left eye was injected. 14 (66.67%) patients were phakic and 07 (66.67%) patients were pseudophakic. pre injection and post injection bcva is shown in table 1. mean value for pre-mft was 506.33 ± 192.37 and post-mft was 383.61 ± 270.37 (table 2). significant decrease in post injection mft was seen in patients (p-value = 0.053). after 1st week follow up vmt release was seen in only 3 (14.3%) patients and at 1st month follow up vmt release was seen in 9 (42.9%) patients (table 3). during follow up time period none of the patients presented with any side effects. the pre and post intervention oct results of 3 patients are shown in figure 1, 2 and 3. table 1: visual acuity of patients pre & post injection (1st week and 1st month). visual acuity preinjection post injection 1st week va (1st month) post injection 6/18 1 3/60 3 6/36 5 6/12 3 6/60 4 6/18 3 cf 1 feet 9 6 6/24 2 cf 1 meter 2 6/36 3 cf 2 meter 0 3 6/9 1 total 21 9 cf 1 meter 3 cf 2 1 meter 3 total 21 table 2: pre & post injection mft. pre-mft post –mft n 21 21 mean 506.33 383.61 sd 192.37 270.37 min 299 168 max 762 905 wilcoxon signed rank test= -1.932, p-value=0.053 table 3: vmt release & side effects. vmt release side effects n=21 n=21 1st week post-injection 3 (14.3%) 0 (0%) 1st month post-injection 9 (42.9%) 0 (0%) rana muhammad mohsin javed, et al 142 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology fig. 1: pre sf6 injection and post one month of injection – release of vmt. fig. 2: pre sf6 injection and post one month of injection – release of vmt but failure of full thickness macular closure. fig. 3: pre sf6 injection and post one month of injection – failure of release of vmt. sf6 assisted pneumatic vitreolysis in cases of vitreomacular traction syndrome pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 143 discussion results of this study report the efficacy of intravitreal expansile sulfur hexafluoride gas injection (sf6) for the treatment of symptomatic vmt syndrome. vmt was released in 14.3% patients within 1st week after the injection and at 1st month vmt was released in 42.9% patients. none of the patients suffered any side effects after the injection at 1st week and 1st month follow up. a significant difference was seen in mft after injection. i.e. pre-mft: 506.33 & post-mft: 383.61, pvalue = 0.053. no local study is published yet in which efficacy of intravitreal expansile sulfur hexafluoride gas injection (sf6) was determined for the treatment of symptomatic vmt syndrome. day et al in his retrospective study treated symptomatic vmt syndrome patients with pure 0.3ml intravitreal sf6. vmt was released in 55.6% of the patients on sd-oct at one month. significant reduction was seen in mean central subfield thickness and significant change was seen in va18. mori et al, in his case series achieved 95% complete pvd after a single intravitreal sf6 injection in eyes with a stage ii macular hole19. steinle n in his study reported the vmt release among 113 patients by using 3 treatment modalities. i.e. intravitreal ocriplasmin (54 patients), c3f8 gas injection (32 patients), and sf6 gas injections (27 patients). vmt release with c3f8 was achieved in 84% patients, with sf6 it was 56% and with intravitreal ocriplasmin it was 48% respectively20. results of this study are consistent with the findings of day et al, mori and steinle n in terms of vmt release. however in this study none of the patients suffered any kind of side effects. mg claus in his study reported the release of vmt after 19 days of intravitreal injection of sf6 gas21. the main advantage of using sf6 gas are its shorter duration as compared to the average duration of c3f8 which is 38 days22. the shorter duration of sf6 allows early resumption of normal activities and travel as well as it may reduce unwanted vitreoretinal traction that may result into retinal breaks. although success rate for inducing a pvd is higher with c3f8 gas as compared to sf6 gas. keeping this point in mind duration is much more important factor than the size of a gas bubble which promotes liquefaction of vitreous followed by vmt release23. there are different kinds of gases which can be used as an option for treating vmt. intravitreal air does not expand and lasts less than 1 week. size of sf6 gas doubles the original volume injected and it can last for 20 days. however c3f8 gas quadruples its initial volume and it lasts for >2 months in the eye. using shorter acting bubble of gas has its own advantages (inferior scotoma symptoms with shorter duration, short altitude restrictions duration, lower cataract chances in phakic patients, minor expansion and fewer iop concerns). but shorter acting gas bubble is not as much effective as c3f8 for the release of vmt24. if the use of pneumatic vitreolysis is proven safe and effective, it has protean advantages. injection of gas is cost effective, readily available, needs no detailed and special preparations unlike vitrectomy25. conclusion intravitreal sf6 gas injection is a safe, cheaper and effective alternative for the treatment of vmt in terms of better results when compared with intravitreal ocriplasmin. when compared to vitrectomy, it has lower success rates. conflict of interest none to disclose. author’s affiliation dr. rana muhammad mohsin javed mbbs, fcps, vr fellow eye unit iii, institute of ophthalmology, king edward medical university, mayo hospital lahore prof. asad aslam khan mbbs, ms, fcps, phd eye unit iii, institute of ophthalmology, king edward medical university, mayo hospital lahore dr. haroon tayyab mbbs, fcps, fcps (vro), fico eye unit iii, institute of ophthalmology, king edward medical university, mayo hospital lahore dr. nasir chaudhry mbbs, fcps, fellowship vr eye unit iii, institute of ophthalmology, king edward medical university, mayo hospital lahore role of authors dr. rana muhammad mohsin javed primary surgeon, literature search. prof. asad aslam khan study concept, design. rana muhammad mohsin javed, et al 144 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology dr. haroon tayyab, literature search, data analysis dr. nasir chaudhry manuscript write up references 1. reese ab, 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https://www.ncbi.nlm.nih.gov/pubmed/?term=daher%20n%5bauthor%5d&cauthor=true&cauthor_uid=28099316 https://www.ncbi.nlm.nih.gov/pubmed/28099316 https://www.ncbi.nlm.nih.gov/pubmed/28099316 http://retinatoday.com/2017/12/pointers-for-performing-pneumatic-vitreolysis http://retinatoday.com/2017/12/pointers-for-performing-pneumatic-vitreolysis https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5350360/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5350360/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5350360/ pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 231 original article eye diseases and refractive errors in hargeisa, somaliland and implications for human resource development for eye care muhammad aslam bhatti, ayesha sumera abdullah, intzar hussain, mohamud ahmed mohamed, ahmed nur ismail ege, hafeez-ur-rahman pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ayesha sumera abdullah associate professor, ophthalmology, peshawar medical college, pakistan e-mail: msqheartline@hotmail.com …..……………………….. purpose: to estimate the burden of eye diseases & refractive errors in hargeisa, somaliland and analyze the need for human resource development for eye care in this region. study design: cross-sectional descriptive study. place and duration of study: the study was conducted at manhal specialty hospital, hargeisa, somaliland from 2014-2015. material and methods: all those patients who presented to the ophthalmology out-patient department (opd) were included in the study. complete ocular assessment including clinical examination, refraction, visual field assessment and b scan ultrasonography was done to identify causes of the presenting eye problems. after completing the protocol the diagnosis was recorded. for the human resource development needs’ assessment the data were obtained from the somaliland’s national health professions commission database and the university of hargeisa (uoh). results: a total of 5327 patients participated in the study, 75% of whom were adults (n = 4003) and 54.53% (n = 2905) were women. cataract was the commonest eye disease accounting for 28.93% (n = 1541) of the cases followed by conjunctival diseases (n = 1212, 22.75%) and refractive errors n = 1089, 20.44%). the most frequent refractive error was myopia (n = 680 [12.77%]). needs assessment for eye care human resource showed that there was only one trained ophthalmologist in hargeisa at the time of the study. this study is the first to report burden of various eye diseases in hargeisa, somaliland. conclusion: the human resource needed to deal with this burden of ocular diseases is very scarce and needs to be strengthened to prevent visual impairment and to promote eye health in the region. key words: refractive errors, blindness, visual impairment, cataract, human resource isual impairment caused by various eye diseases is known to have grave socioeconomic consequences for the individual, the health care system and the community1. the current estimate for the global burden of blindness is 39 million people, 18% of which live in africa2. almost 50% of this burden is attributable to cataract. with less than 1 ophthalmologist per million population in the region it is estimated that less than 10% of those who need eye care actually receive it. africa is a continent with varied demographic, socio-economic and geopolitical characteristics but these estimates are v muhammad aslam bhatti, et al 232 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology based on surveys from only selected countries of the region like uganda, tanzania, rwanda, nigeria, mali, kenya, ghana, gambia, ethiopia, eritrea, cameroon and botswana3. the horn of africa (hoa) is a distinct geographic entity of east africa with special demographic, climatic and socio-economic features. africa is estimated to be the major growing region in 2050 accounting for over 25% of the world’s populationi. with the changing demographics and growing prevalence of chronic illnesses, eye diseases are expected to contribute to a growing burden of blindness and visual impairment in the region2. scant epidemiological data about various eye diseases are available for the countries of the hoa which is home to over 200 million people. somaliland is an autonomous region (since 1991) striving for international recognition. it is a relatively peaceful and politically stable territory of the region. this study was conducted at the largest tertiary eye care (tec) centre of somaliland to estimate the burden of various eye diseases that require consultation and to analyze the human resource development needs of the area in the field of ophthalmology required to deal with this burden of disease. it is expected to provide baseline information for health care policy makers to take measures for the treatment and prevention of these diseases in the area. material and methods the study was conducted at the manhal specialty hospital (msh), hargeisa from 2014-2015. the institutional ethics committee (iec) approved the study. all those patients who presented to the ophthalmology out-patient department (opd) were included in the study. distance visual acuity was measured by a trained ophthalmic technician using the snellen’s visual acuity chart. after this the subjects had refraction followed by detailed eye examination by an ophthalmologist. every patient had biomicroscopic examination on slit lamp. after assessment of pupils posterior segment examination was done with dilated pupils and intraocular pressure was measured. visual field assessment, fundus photography and b-scan (ultrasound scan) of the eye was done where indicated to diagnose the cause of impaired vision. after completing the protocol the diagnosis was recorded. i united nations, department of economic and social affairs, population division. world population prospects: the 2017 revision. 2017. new york: united nations. for the human resource development needs assessment (hrdna), gap analysis was done against the estimated burden of eye disease and the available human resource for the provision of eye care data, obtained from somaliland’s national health professions commission database and the university of hargeisa (uoh). results a total of 5327 patients who presented to the opd of msh and consented to participate were included in the study. seventy five percent of the subjects were adults (n = 4003, 75.15%). majority of the participants were females (n = 2905, 54.53%). cataract was the commonest eye disease accounting for 28.93% (n = 1541) of the cases followed by conjunctival diseases (n = 1212, 22.75%) and refractive errors (n = 1089, 20.44%). frequency of other eye diseases is given in table 1. table 1: types of eye disease and their distribution (bhatti, abdullah, hussain, mohamed, ege, rahman). disease frequency percentage (%) 1 cataract & other disorders of the lens 1541 28.93 2 conjunctival diseases 1212 22.75 3 refractive errors 1089 20.44 4 corneal diseases 517 9.71 5 ocular trauma 334 6.27 6 ocular adnexal diseases 263 4.94 7 glaucoma 191 3.58 8 vitreo-retinal diseases 74 1.39 9 strabismus 31 0.58 10 uveitis 18 0.34 11 others 57 1.07 total 5327 100 corneal and conjunctival diseases (n = 1729) emerged as a major cause of consultation for ocular problems. amongst this category the distribution of specific diseases is given in figure 1. eye diseases and refractive errors in hargeisa, somaliland and implications for human resource pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 233 fig. 1: distribution of corneal and conjunctival diseases. refractive errors accounted for 1089 cases (20.44%). patients with myopia, hyperopia, astigmatism, presbyopia and children with amblyopia were included in this category. the most frequent refractive error was myopia (n = 680 [12.77%]). out of a total of 1324 children 50 (3.77%) had amblyopia while the overall frequency of amblyopia was 0.94%. the details of the distribution of other types of refractive errors are shown in figure 2. fig. 2: frequency of refractive errors & amblyopia. needs assessment for eye care human resource showed that there was only one trained ophthalmologist (holding an mcps degree) in hargeisa at the time of the study. the population of hargeisa is estimated to be around 900,000ii. this ii republic of somalilandministry of national planning and development. national development plan (2012-2016). december 2011. translates into one ophthalmologist per 900,000 individuals whereas the minimum required for the region is 1 ophthalmologist per 400,000 individualsiii a target that only 14 of the 46 countries of african region could meetiii. in view of this situation in 2014 a collaborative programme for the training of ophthalmologist was started at msh in collaboration with uoh, peshawar medical college, riphah international university, pakistan, who (emr) and federation of islamic medical associationssave vision. as of 2018, the programme has produced 11 ophthalmologists with a diploma in ophthalmology (do). currently 7 trainees are enrolled in the do programme and 2 in the ms programme. uoh also initiated a graduate programme in optometry in which currently 42 students are enrolled. discussion this study is the first to report the frequency of various eye diseases and refractive errors at hargeisa, somaliland. since this area of hoa is relatively a peaceful area with comparatively stable socio-political status and moderate climate, it carries a lot of potential for further human resource development to meet the burden of eye diseases in the region. the sample of the study was large enough to establish reasonable estimates and conclusions. in our sample majority of the patients were females i.e. 54.53%. gender inequality in eye health is a complex issue and less utilization of eye care services by women is likely to be associated with their compromised socioeconomic and educational status4. contrary to the evidence from developing countries5 our study showed a preponderance of women seeking treatment for their eye problem. the fact that blindness is more likely to affect women6 and the greater socio-political and economic autonomy of women in hargeisa is likely to have contributed to more women seeking consultation for eye problems. moreover female literacy in the area http://somalilandgov.com/new/wpontent/uploads/2012/05/somaliland-5-year-nationalplan.pdf iiivision 2020human resource development working group (hrdwg). global human resource development assessment for comprehensive eye care. june 2006. https://www.iapb.org/wp-content/uploads/global-hrdevelopment-assessment-for-comprehensive-eyecare_2006.pdf http://somalilandgov.com/new/wp-ontent/uploads/2012/05/somaliland-5-year-national-plan.pdf http://somalilandgov.com/new/wp-ontent/uploads/2012/05/somaliland-5-year-national-plan.pdf http://somalilandgov.com/new/wp-ontent/uploads/2012/05/somaliland-5-year-national-plan.pdf https://www.iapb.org/wp-content/uploads/global-hr-development-assessment-for-comprehensive-eye-care_2006.pdf https://www.iapb.org/wp-content/uploads/global-hr-development-assessment-for-comprehensive-eye-care_2006.pdf https://www.iapb.org/wp-content/uploads/global-hr-development-assessment-for-comprehensive-eye-care_2006.pdf muhammad aslam bhatti, et al 234 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology (age 15-24 female literacy; 44.1%)iv is comparatively higher than the neighboring countries of the regionv and educational status of women is reported to be the strongest independent predictor of utilization of health care services. studies from nigeria also reported higher proportion of women presenting for treatment of their eye diseases7. nigeria has a higher overall literacy (66.8%) with a gender parity index (gpi) of 0.8, which is significantly higher than the other countries in the regionv. in our study cataract was the most frequent reason of eye consultation followed by conjunctival diseases and refractive errors. these findings are similar to previously reported studies. according to global estimates among all eye diseases, cataract is still the leading cause of blindness and visual impairment followed by uncorrected refractive errors, age-related macular degeneration (amd) and glaucoma8. the reported causes for blindness in the eastern part of sub-saharan africa were cataract ( 36.7%) followed by uncorrected refractive errors (13.1%), amd (5.8%) and glaucoma (4.0%). for moderate and severe visual impairment uncorrected refractive errors (44.8%), cataract (19.6%), amd (4.0%) and glaucoma (1.5%)8 were the main causes. in our study external diseases of the eye i.e. conjunctival and corneal problems together accounted for a significant number of eye consultations. amongst this category; conjunctivitis (especially allergic conjunctivitides like vernal keratoconjunctivitis vkc) was a major presenting problem followed by corneal diseases. this finding correlates with other studies from africa9. trachomaan infectious type of conjunctivitis is still endemic in 29 of the 47 countries of the region with the highest prevalence reported in ethiopia and southern sudan10. although better sanitation conditions and personal hygiene practices have been able to control active trachoma in somaliland, allergic conjunctivitis is still a problem iv unicefsomalia, somaliland ministry of planning & national development (pnd). somaliland multiple indicator cluster survey (mics) 2011, final report. 2014. nairobi, kenya. https://www.unicef.org/somalia/som_resources_mics4ke yfindings_somaliland_eng.pdf v unesco. efa global monitoring report, 2006literacy for all. regional overviewsub-saharan africa. unesco. 2006. http://www.unesco.org/education/gmr2006/full/africa_ eng.pdf largely due to the dry and windy environment of the area. further studies need to be done to establish the risk factors responsible for this prevalent eye disease with blinding complications. refractive errors were the 3rd leading cause of eye consultations (n = 1089, 22.44%) in our study. uncorrected refractive errors are a major contributor to the burden of low vision and the second leading cause of blindness worldwide3,8. other hospital-based studies from the african region have also reported refractive errors to be among the top three causes of ocular morbidity9. the overall frequency of amblyopia in this study was much lower than that reported by caucasian and asian populations11,12,13,14. however the finding is in conformity with the 0.1-2% frequency reported from the african populations15,16,17. in our study ocular trauma was a major cause of eye diseases (n = 627 [6.27%]). with an estimated global frequency of 55 million eye injuries a year, ocular trauma is a preventable cause of ocular morbidity that can result in monocular or even binocular blindness18. the frequency of eye injuries resulting in eye disease varies from region to region depending on the socio-economic, educational and occupational health awareness level of the population and engagement in conflicts19,20,21,22. regional studies from africa have reported a frequency of 3.0315.95%23,24,25. our results correspond to the studies from ethiopia which have reported 3.03-6.9% frequency of ocular trauma. ocular trauma predominantly affects males, children and young adults and the fact that it can largely be prevented makes it a high priority for public health interventions. further research to identify the environmental, social and occupational factors responsible for the magnitude of ocular trauma and its impact on vision and the quality of life needs to be conducted. this study has shown that almost all major anterior and posterior segment diseases of the eye are prevalent in this community. to deal with this burden of ocular diseases at the time of this study there was only one trained ophthalmologist per 9 million population and only one tertiary eye care facility at hargeisa. to address this enormous need the collaborative programmes for the training of ophthalmologists and allied eye care personnel introduced by the uoh are expected to meet the eye care hrd needs of somaliland and the neighboring countries. https://www.unicef.org/somalia/som_resources_mics4keyfindings_somaliland_eng.pdf https://www.unicef.org/somalia/som_resources_mics4keyfindings_somaliland_eng.pdf http://www.unesco.org/education/gmr2006/full/africa_eng.pdf http://www.unesco.org/education/gmr2006/full/africa_eng.pdf eye diseases and refractive errors in hargeisa, somaliland and implications for human resource pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 235 conclusion this study is the first to report burden of various eye diseases in hargeisa, somaliland. cataract, refractive errors, external diseases of the eye and trauma were among the common eye diseases that required consultation. human resource needed to deal with this burden of ocular diseases is very scarce and needs to be developed further on priority basis to prevent visual impairment and to promote eye health in the region. conflict of interest: none. author’s affiliation muhammad aslam bhatti assistant professor, manhal specialty hospital, hargeisa, somaliland dr. ayesha sumera abdullah associate professor, ophthalmology, peshawar medical college, pakistan dr. intzar hussain professor & head of the department of ophthalmology, khawaja muhammad safdar medical college, sialkot, pakistan dr. mohamud ahmed mohamed consultant ophthalmologist & director, manhal specialty hospital, hargeisa, somaliland dr. ahmed nur ismail ege consultant ophthalmologist, manhal specialty hospital, hargeisa, somaliland dr. hafeez-ur-rahman professor & head of the department of ophthalmology, peshawar medical college, pakistan role of authors dr. muhammad aslam bhatti study design, data collection & analysis, manuscript drafting. dr. ayesha sumera abdullah study design, data collection & analysis, literature review, manuscript drafting, critical review of the draft & finalization for submission. dr. intzar hussain study design, literature review and critical review of the manuscript. dr. mohamud ahmed mohamed study design, data collection, literature review and critical review of the manuscript. dr. ahmed nur ismail ege study design, data collection, literature review and critical review of the manuscript. dr. hafeez-ur-rahman study design, literature review and critical review of the manuscript. references 1. nutheti r, shamanna br, nirmalan pk, keeffe je, krishnaiah s, rao gn et al. impact of impaired vision and eye disease on quality of life in andhra pradesh. invest ophthalmol vis sci. 2006; 47: 4742–4748. accessed on 21/06/2017 from: http://iovs.arvojournals.org/pdfaccess.ashx?url=/data /journals/iovs/932936/ 2. lewallen s, courtright p. blindness in africa: present situation and future needs. br j ophthalmol. 2001; 85: 897–903. 3. pascolini d & mariotti sp. global estimates of visual impairment: 2010. br j ophthalmol. 2012; 96 (5): 614– 618. 4. geneau r, lewallen s, paul i, bronsard a, courtright p. the social and family dynamics behind the uptake of cataract surgery: findings from kilimanjaro region, tanzania. br j ophthalmol. 2005; 89: 1399-1402. 5. lewallen s & courtright p. gender and use of cataract surgical services in developing countries. bull world health organ. 2002; 80: 300-3. 6. abou-gareeb i, lewallen s, bassett k, courtright p. gender and blindness: a meta-analysis of populationbased prevalence surveys. ophthalmic epidemiol. 2001; 8: 39-56. 7. olukorde oa, oluymka js. pattern of eye diseases in air force hospital in nigeria. pak j ophthalmol. 2012; 28: 144-8. 8. bourne rra, stevens ga, white ra, smith jl, flaxman sr, price h et al. causes of vision loss worldwide, 1990–2010: a systematic analysis. lancet glob health, 2013; 1 (6): e339–49. downloaded on 1st july 2017 from http://thelancet.com/pdfs/journals/langlo/piis2214109x(13)70113-x.pdf 9. amadi an, nwankwo bo, ibe ai, chuwuocha um, nwoga ks, oguejior, iloh gup. common ocular problems in aba metropolis of abia state, eastern nigeria. pak j soc sci. 2009; 6 (1): 32-35. 10. who alliance for the global elimination of blinding trachoma by 2020. weekly epidemiological record. 2014; 89 (39): 421-428. downloaded on 21st june 2017 from http://www.who.int/wer/2013/wer8939.pdf?ua=1 11. solebo al, cumberland pm, rahi js. wholepopulation vision screening in children aged 4-5 years to detect amblyopia. lancet. 2015; 385: 2308-19. 12. fu j, li sm, liu lr, li jl, li sy, zhu bd, et al. anyang childhood eye study group. prevalence of http://iovs.arvojournals.org/pdfaccess.ashx?url=/data/journals/iovs/932936/ http://iovs.arvojournals.org/pdfaccess.ashx?url=/data/journals/iovs/932936/ http://thelancet.com/pdfs/journals/langlo/piis2214-109x(13)70113-x.pdf http://thelancet.com/pdfs/journals/langlo/piis2214-109x(13)70113-x.pdf http://www.who.int/wer/2013/wer8939.pdf?ua=1 muhammad aslam bhatti, et al 236 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology amblyopia and strabismus in a population of 7th -grade junior high school students in central china: the anyang childhood eye study (aces). ophthalmic epidemiol. 2014; 21: 197-203. 13. ganekal s, jhanji v, liang y, dorairaj s. prevalence and etiology of amblyopia in southern india: results from screening of school children aged 5-15 years. ophthalmic epidemiol. 2013; 20: 228-31. 14. abdullah as, jadoon mz, akram m, awan zh, azam m, safdar m, nigar m. prevalence of uncorrected refractive errors in adults aged 30 years and above in a rural population in pakistan. j ayub med coll. 2015; 27 (1): 8-12. 15. ajaiyeoba ai, isawumi ma, adeoye ao, oluleye ts. prevalence and causes of eye disease amongst students in south-western nigeria. ann afr med. 2006; 5: 197203. 16. akpe ba, abadom eg, omoti ea. prevalence of amblyopia in primary school pupils in benin city, edo state, nigeria. afr j med health sci. 2015; 14: 110-4. 17. ikuomenisan sj, musa ko, aribaba ot, onakoya ao. prevalence and pattern of amblyopia among primary school pupils in kosofe town, lagos state, nigeria. niger postgrad med j. 2016; 23: 196-201. 18. ad négrel, thylefors b. the global impact of eye injuries. ophthalmic epidemiol.1998; 5 (3): 143-69. 19. wong ty, klein be, klein r. the prevalence and 5year incidence of ocular trauma. the beaver dam eye study. ophthalmology, 2000; 107 (12): 2196-202. 20. wang w, zhou y, zeng j, shi m, chen b. epidemiology and clinical characteristics of patients hospitalized for ocular trauma in south-central china. acta ophthalmol. 2017; 95 (6): e503-10. doi: 10.1111/aos.13438 21. krishnaiah s, nirmalan pk, shamanna br, srinivas m, rao gn, thomas r. ocular trauma in a rural population of southern india-the andhra pradesh eye disease study. ophthalmology, 2006; 113: 1159–64. 22. sobaci g, akýn t, mutlu fm, karagül s, bayraktar mz. terror-related open-globe injuries: a 10-year review. am j ophthalmol. 2005; 139 (5): 937-9. 23. bekele s, gelaw y. pattern and prognostic factor of ocular injuries in southwest ethiopia: a hospital based prospective study. int eye sci. 2016; 16 (5): 811-7. 24. addisu z. pattern of ocular trauma seen in grarbet hospital, butajira, central ethiopia. ethiop j health dev. 2011; 25: 150-5. 25. okoye oi. eye injury requiring hospitalization in enugu nigeria: a one-year survey. niger j surg res. 2006; 8: 34-7. http://www.ncbi.nlm.nih.gov/pubmed/26182727 pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 197 original article comparison of intraocular pressure lowering effect of travoprost and timolol / dorzolamide combination in primary open angle glaucoma farooq khan, mubashir rehman, omar ilyas, mohammad zeeshan tahir, imran ahmad pak j ophthalmol 2015, vol. 31 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: farooq khan ophthalmology department khyber teaching hospital peshawar …..……………………….. purpose: to compare the efficacy of once daily travoprost 0.004% and twice daily timolol 0.5% plus dorzolamide 2% combination in primary open angle glaucoma. material and methods: this study was conducted at outpatient department, ophthalmology unit, khyber teaching hospital, peshawar. study design was randomized controlled trial and (group b receiving timolol 0.5% and dorzolamide 2% was considered as control group) the duration of the study was 6 months in which a total of 136 patients were included. all cases included in the study were diagnosed as cases of primary open angle glaucoma. patients were divided into two groups i.e. a and b with each group having 68 patients. patients in group a were given travoprost 0.004% eye drops daily and patients in group b were given eye drops having combination of timolol 0.5% and dorzolomide 2% twice daily. patients were advised to come at 6 weeks interval for follow up. at each follow up visit, iop was recorded. results: mean age in group a was 53 ± 13.26 years while in group b was 55 ± 14.31 years. in group a 56% patients were male and 44% patients were female where as in group b 59% patients were male and 41% patients were female. our results show that timolol + dorzolamide was more effective than travoprost as timolol + dorzolamide cause reduction in iop of at least 20% in 84% patients while travoprost cause reduction in iop of at least 20% in 80% patients. also pvalue calculated at six week is statistically significant). conclusion: our study concludes that dorzolamide with timolol is more efficacious than travoprost in open angle glaucoma. key words: primary open angle glaucoma, travoprost, timolol plus dorzolamide. laucoma is one of the most common causes of permanent visual loss all around the world,1 affecting about 60 million people worldwide2. in pakistan, it is the fourth commonest cause of visual loss3. glaucoma is characterized by optic nerve degeneration causing visual field defects and is usually associated with raised intraocular pressure (iop)4. the main aim of treatment is to lower the intraocular pressure to preserve the vision and prevent progressive optic nerve degeneration5. various treatment options include medical therapy, laser and surgical treatment. timolol a beta-blocker acts by decreasing aqueous secretion. it has been found to be effective for treatment in all types of glaucoma6. dorzolamide causes highly selective inhibition of carbonic anhydrase ii isoenzyme present g farooq khan, et al 198 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology on the ciliary processes in the eye which lowers the aqueous humor production and intraocular pressure7. dorzolamide and timolol are also used in combination with additive therapeutic effect. the efficacy of fixed combination of timolol and dorzolamide (fcdt) is well established. the clinical efficacy of (fcdt) defined as 20% or more reduction in mean intraocular pressure was found to be 82.9% in a study conducted by andrew et al8. travoprost, a prostaglandin analog is one of the newer anti-glaucoma drugs. it can strongly lower intraocular pressure9. the clinical efficacy of travoprost, (defined as 20% or more reduction in mean iop) was found to be 58.8% in a study conducted by yuya nomura et al10. another study showed that 64.2% of the patients treated with travoprost had marked reduction in intraocular pressure11. trovoprost offers better patient compliance as it is given in once daily dose as opposed to twice daily dose for fcdt and hence trovoprost is emerging as an alternative to the fcdt12 due to cost effectiveness and better compliance. studies comparing the clinical efficacy of trovoprost against the traditional fcdt combination are scarce. moreover the clinical efficacy of trovoprost is yet to be evaluated in our local population. our study aims to assess the clinical efficacy of the newer drug travoprost 0.004% against the established combination of timolol and dorzolamide in our local population. on the basis of this study, if travoprost is found to be effective, this can be prescribed in routine instead of timolol plus dorzolamide for patients with primary open angle glaucoma, with better compliance and safety profile. material and methods patients with open angle glaucoma were selected from outpatient department, department of ophthalmology, khyber teaching hospital, peshawar as per operational definition. the purpose and benefits of the study were explained to the patient and the patient was explained that this research study is being done purely for research and a written informed consent was obtained, if agreed upon. patient compliance was stressed upon by education of the patient, relatives and by checking of the used bottles by patient. patients with newly diagnosed primary open angle glaucoma with either gender between the ages of 15 to 60 years were included in the study. exclusion criteria were: patients with iop > 30, advanced visual field loss, cdr > 0.8 or best corrected visual acuity < 6/60 (these patients have advanced disease and require more aggressive treatment and this may act as confounder and affect the results of the study), patients in whom beta blockers are contraindicated e.g. patients with copd, asthma, sinus bradycardia, heart block, and patients using drugs which can affect the intraocular pressure e.g. patients already on antiglaucoma medications or on systemic beta blockers. after inclusion in the study, patients was divided into group a and group b by lottery method i,e first patient went either into group a or group b by simple lottery and the subsequent patients were consectively placed in the respective groups. group a received once daily travoprost 0.004% and b received twice daily timolol 0.5% plus dorzolamide 2% combination. in both groups, detailed history was taken followed by complete examination including assessment of best corrected visual acuity (bcva) using snellen chart; pupillary reaction, anterior segment examination with slit-lamp; baseline iop measurement with goldman applanation tonometer; anterior chamber angle assessment with goldman goniolens; fundus examination with direct ophthalmoscope and 90 d lens and perimetry (humphrey’s). the patient was advised to come at 6 weeks interval for follow up. at each follow up visit, iop was recorded. efficacy was defined as at least 20% reduction in the intraocular pressure from the baseline, at 6 weeks follow up, measured on tonometry. all the relevant data was recorded in a predesigned printed proforma. those patients who developed drug side effects and those who don’t come for follow up were omitted from the study. confounders and bias in the study was controlled by strictly following the inclusion and exclusion criteria. spss 10 was used for analysis of data. efficacy in terms of reduction of iop was compared between travoprost and fcdt. mean ± standard deviation was calculated for quantitative variables; percentage and proportion were calculated for qualitative variables. chi-square test was used to compare the efficacy in both groups. all the results were presented as tables and charts in a meaningful way. (p-value had generated using student t-test for comparison of mean and chi-square test for comparison of percentages. pvalue < 0.05 had considered significant.) comparison of intraocular pressure lowering effect of travoprost and timolol / dorzolamide pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 199 results a total of 136 (68 in each group) patients were included in the study. in group a mean age was 53 years with standard deviation ± 13.26 whereas in group b mean age was 55 years with standard deviation ± 14.31. gender distribution among two groups was analyzed as in group a 38 (56%) patients were male and 30 (44%) patients were female where as in group b 40 (59%) patients were male and 28 (41%) patients were female (table 1). baseline iop (mm hg) among two groups was analyzed (table 2). in group a mean iop was 27.05 mm hg with sd ± 1.8401. where as in group b mean iop was 26.67 mmhg with sd ± 2.0008 (table 2). status of iop after 6 weeks among two groups was analyzed (table 3). in group a mean iop was 18.37 mmhg with sd ±1.9344. where as in group b mean iop was 17.18 mmhg with sd ±1.8979 (table 3). comparison of mean baseline iop and mean iop at 6 weeks is shown in (table 4). efficacy of the two drugs was analyzed as travoprost (group a) was effective in 55 (80%) patients and was not effective in 13 (20%) patients. whereas timolol+ dorzolamide (group b) was effective in 57 (84%) patients and was not effective in 11 (16%) patients (table 5) (comparison of mean iop is shown in (table 4). farooq khan, et al 200 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology discussion open angle glaucoma can cause permanent loss of vision. it remains asymptomatic and progress slowly until it is very severe and irreversible damage has occurred in one or both eyes. it is the second most common cause of irreversible blindness throughout the world2. a number of risk factors are responsible for progression of glaucoma but intraocular pressure iop is currently the most important modifiable risk factor that can be used to prevent progression of glaucoma. according to early manifest glaucoma treatment study iop reduction by at least 25% reduced progression damage in the treated group from 62% to 45% compared to an untreated group13. mean intraocular pressure should be decreased to a patient dependent target pressure in order to prevent progressive glaucomatous damage and to preserve vision8. this target pressure depends on a number of factors, including baseline iop, age of patient, status of optic disc and nerve fiber layer and functional damage assessed on visual field assessment11. the main objective of management of glaucoma is to preserve the visual functions and hence improve the individual’s quality of life. the main treatment modality particularly of open angle glaucoma is medical treatment. number of drugs is available which lowers the iop either by enhancing the aqueous outflow or decreasing aqueous secretion. the main objective of medical treatment is to maintain iop at lower level according to patient’s target pressure with the minimum possible concentration, fewer numbers of drugs as well as using the safest drugs with limited local and systemic side effects11. most commonly used drugs to decrease intraocular pressure in glaucoma are topical beta blockers. they are useful in all types of glaucoma and act by decreasing aqueous secretion. this iop lowering effect however, decreases with time in approximately 10% of cases. this iop lowering effect may be lost within a few days (short time escape) or may take months (long term drift)5. beta blockers can cause local as well as systemic side effects including respiratory, cardiovascular, and metabolic side effects5. our study results are similar to the results of some international studies, in one of two small (n 50 and 56), single – blind, parallel-group, single center studies, parmaksiz et al13 had showed that the iop-lowering effect of dorzolamide 2%/timolol 0.5% used twice daily was greater than that of travoprost 0.004% used once daily. the reduction in mean diurnal iop (average of measurements noted at 08:00, 10:00 and 16:00 hours) from baseline with dorzolamide 2%/timolol 0.5% was superior to that with travoprost 0.004% (11.5 vs. 9.3 mm hg; p0.05) after 6 months of treatment. in another single dose blind, parallel group, single-center comparison dorzolamide 2%/timolol 0.5% was less effective than travoprost 0.004%. in the parallel-group comparison, the reductions in mean diurnal iop (average of measurements made at 08:00, 12:00, 16:00 and 20:00 hours) from baseline were significantly less with dorzolamide 2%/timolol 0.5% than with travoprost 0.004% after both 3 weeks of treatment (23.1% vs. 32.7%; p 0.01) and 6 weeks of treatment (21.7% vs. 30.7%; p 0.01). in a cross-over comparison, franklin et al14 had shown that the decrease in mean diurnal iop (average of measurements made at 8:00 am, 10:00 am and 4:00 pm) from baseline following 3 months of treatment with dorzolamide 2%/timolol 0.5% (14.3%; p 0.0001 vs. baseline) was significantly less than that with travoprost 0.004% (18.4%; p 0.0001 vs baseline) and dorzolamide 2%/timolol 0.5%) and latanoprost 0.005% (22.1%; p 0.0001 vs. baseline) and dorzolamide 2%/timolol 0.5%). the tolerability of a drug is the main barrier to compliance as shown by strohmaier k et al15. local burning, stinging, discomfort, and taste perversion are the most common adverse effects associated with dorzolamide16. kalzuny et al17 showed in their study that dorzolamide 2%/ timolol 0.5% fixed combination twice daily was generally well tolerated in large in large group of patients (n 177 – 492) given either as monotherapy or concomitantly, trials of 3 to 6 months duration which evaluated this fixed combination in relation to the individual components, or against other ocular hypotensive agents. in these studies 33% and comparison of intraocular pressure lowering effect of travoprost and timolol / dorzolamide pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 201 77% of patients receiving dorzolamide 2%/timolol 0.5% reported adverse effects. 10% to 68% reported drug-related adverse events. most commonly reported ocular adverse event in majority of the trials was transient mild to moderate burning and/or stinging of the eye (5% – 41%). while the most common systemic adverse effect was dysgeusia (2% – 38%)18. teus et al19 in their study compared timolol 0.5% and brinzolamide 1%. the most common side effects with brinzolamide 1% were blurred vision and taste perversion; while ocular discomfort was less common. manni et al20 in their study showed that of the 106 subjects, 79.2% preferred brinzolamide 1%/timolol 0.5% (p 0.0001). ocular discomfort was significantly higher with dorzolamide 2%/timolol 0.5% than brinzolamide 1%/timolol 0.5% (2.9 vs 1.4, respectively; p0.0001). with dorzolamide 2%/timolol 0.5% instillation most common side effect was ocular pain and discomfort while with brinzolamide 1%/timolol 0.5% instillation it was transient blurred vision. manni et al20 observed in his study that brinzolamide 1%/timolol 0.5% showed significantly less ocular irritation (2.7% vs. 10.6%; p 0.0009) than dorzolamide 2%/timolol 0.5%.a statistically significant difference in conjunctival hyperemia in travoprost 0.004%/ timolol 0.5% group compared to dorzolamide 2%/ timolol 0.5% was shown by teus et al in his study19. in a non-blind extension of one study, fixed combination was generally well tolerated for up to 1 year21. in 3 small, single-center studies, the iop-lowering effects of dorzolamide–timolol fixed combination therapy were shown to be both better and worse than the efficacy of travoprost 0.004% monotherapy22-24. fixed combination therapy with dorzolamide– timolol dosed twice daily was less efficacious than monotherapy with travoprost 0.004% dosed once daily in patients with oag or oh as shown by suzuki et al22. iop reduction and percentage of iop reduction were compared. mean average iop reductions from baseline at 3 and 6 weeks, were −7.5 mm hg and −7.1 mm hg respectively, for the travoprost monotherapy group and −4.8 mmhg and −4.5 mm hg at 3 and 6 weeks, respectively, for the dorzolamide–timolol fixed combination therapy group. the better mean diurnal iop reduction in the patients receiving travoprost 0.004% monotherapy compared with those receiving dorzolamide–timolol fixed combination therapy was statistically significant at both follow-up time points (p < 0.01). conclusion our study concludes that dorzolamide 2% with timolol 0.5% combination used twice daily is more efficacious than travoprost 0.004% used once daily in primary open angle glaucoma. our results show that timolol + dorzolamide cause reduction in iop of at least 20% in 84% patients while travoprost cause reduction in iop of at least 20% in 80% patients. also p-value calculated at six week is statistically significant. author’s affiliation dr. farooq khan trainee medical officer ophthalmology department khyber teaching hospital, peshawar dr. mubashir rehman medical officer ophthalmology department lady reading hospital, peshawar dr. omar ilyas trainee medical officer ophthalmology department khyber teaching hospital, peshawar dr. mohammad zeeshan tahir medical officer ophthalmology department lady reading hospital, peshawar dr. imran ahmad vitreoretina trainee ophthalmology department hayatabad medical complex, peshawar role of authors dr. farooq khan patients’ selection, data collection and data analysis dr. mubashir rehman patients’ selection, data collection and data analysis. dr. omar ilyas patients’ selection, data collection and data analysis. dr. mohammad zeeshan tahir literature search and references. dr. imran ahmad literature search and references. farooq khan, et al 202 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology references 1. kumarasamy na, lam fs, wang al, theoharides tc. glaucoma: current and developing concepts for inflammation, pathogenesis and treatment. eur j inflamm. 2006; 4: 129-37. 2. quiiqley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006; 90: 262-7. 3. dineen b, bourne rr, jadoon z. causes of blindness and visual impairment in pakistan. br j ophthalmol. 2007; 91: 1005-10. 4. hazin r, hendrick am, kahook my. primary openangle glaucoma: diagnostic approach and management. j nati med assoc. 2009; 101: 46-50. 5. kanski jj. glaucoma. in: kanski jj clinical ophthalmology. a systemic approach 6th ed. butterworth heinemann elsevier 2007; 371-440. 6. izzotti a, bagnis a, saccà sc. the role of oxidative stress in glaucoma. mutat res. 2006; 612: 105-14. 7. theelen t, meulendij cf, geurts de. impact factors on intraocular pressure measurement in healthy subjects. br j ophthalmol. 2004; 88: 1510-1. 8. lodhi aa, talpur ki, khanzada ma. latanoprost 0.005% v/s timolol maleate 0.5% pressure lowering effect in primary open angle glaucoma. pak j ophthalmol. 2008; 24 (2): 68-72. 9. macleod sm, clark r, forrest j, bain m, bateman n, azuara-blanco a. a review of glaucoma treatment in scotland 1994-2004. eye 2004; 22: 251-5. 10. the european glaucoma prevention study (egps) group. results of the european glaucoma prevention study. ophthalmology. 2005; 112: 366-75. 11. parikh rs, parikh sr, navin s, arun e, thomas r. practical approach to medical management of glaucoma. indian j ophthalmol. 2008; 56: 223-30. 12. sharma r, kohli k, kapoor b, mengi rk, sadotra p, verma u. comparative effect of timolol, levobunolol and betaxolol on iop in patients of chronic simple glaucoma. jk science. 2005; 7: 61-4. 13. parmaksiz s, yuksel n, karabas vl. a comparison of travoprost, latanoprost, and the fixed combination of dorzolamide and timolol in patients with pseudoexfoliation glaucoma. eur j ophthalmol. 2006; 16: 73–80. 14. franklin lm, da silva lj. comparison of the efficacy and safety of travoprost with a fixed – combination of dorzolamide and timolol in patients with open – angle glaucoma or ocular hypertension. curr med res opin. 2006; 22: 1799–805. 15. strohmaier k, snyder e, dubiner h. the efficacy and safety of the dorzolamide-timolol combination versus the concomitant administration of its components. dorzolamide-timolol study group. ophthalmology. 1998; 105: 1936–44. 16. sevda ak, semih a, ahmet a, nurver o, tomris s, osman o. the effects of topical antiglaucoma drugs as monotherapy on the ocular surface: a prospective study. j. ophthal. 2014: 112-120. 17. kalzuny j, szaflik j, czechowicz-janicka k. timolol 0.5%/ dorzolamide 2% fixed combination versus timolol 0.5%/pilocarpine 2% fixed combination in primary open angle glaucoma or ocular hypertensive patients. acta ophthalmol scand. 2003; 81: 349–54. 18. cvenkel b, stewart ja, nelson la, stewart wc. dorzolamide/timolol fixed combination versus latanoprost/timolol fixed combination in patients with primary open-angle glaucoma or ocular hypertension. curr eye res. 2008; 33: 163–8. 19. teus ma, miglior s, laganovska g. efficacy and safety of travoprost/timololvsdorzolamide/timolol in patients with open-angle glaucoma or ocular hypertension. clin ophthalmol. 2009; 3: 629–36. 20. manni g, denis p, chew p. the safety and efficacy of brinzolamide 1%/timolol 0.5% fixed combination versus dorzolamide 2%/timolol 0.5% in patients with open-angle glaucoma or ocular hypertension. j glaucoma. 2009; 18: 293–300. 21. mundorf tk, rauchman sh, williams rd, notivol r. brinzolamide/ timolol preference study group. a patient preference comparison of azarga (brinzolamide/timolol fixed combination) vscosopt (dorzolamide/timolol fixed combination) in patients with open-angle glaucoma or ocular hypertension. clin ophthalmol. 2008; 2: 623–8. 22. suzuki er. comparison of the efficacy and safety of travoprost with a fixed-combination of dorzolamide and timolol in patients with open-angle glaucoma or ocular hypertension. curr med res opin. 2006; 22: 1799-805. 23. nicholas pb, josé lr, robert mf. safety, tolerability, and efficacy of fixed combination therapy with dorzolamide hydrochloride 2% and timolol maleate 0.5% in glaucoma and ocular hypertension. clin ophthalmol. 2010; 4: 1331–46. 24. jin-wc, shi-wc, lian-dg, guo-cl, rui-lw. pressurelowering effects of commonly used fixedcombination drugs with timolol: a systematic review and meta-analysis. plos one. 2012; 7: e45079. microsoft word 7. mushtaq ahmad 206 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology original article visual outcome and complications of anterior chamber intraocular lens versus scleral fixated intraocular lens mushtaq ahmad, muhammad naeem, sofia iqbal, sanaullah khan pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mushtaq ahmad house no. 31b, street no 2, sector n4, phase 4, hayatabad, peshawar …..……………………….. purpose: to compare the visual outcome and complications associated with anterior chamber iol versus scleral fixated iol following cataract surgery with poor capsular support. material and methods: this interventional comparative study was conducted from april 2010 to december 2011 in the department of ophthalmology hayatabad medical complex peshawar. thirty two eyes were included in the study consisting of twenty eight patients. they were classified into 2 groups; group i: where 16 eyes underwent anterior chamber iols (aciols) implantation either primary or secondary and group ii: where 16 eyes underwent scleral fixated iols (sfiols) implantation either primary or secondary. patients were followed for one month, 3 months and 6 months. results: there was no statistically significant difference noted between the two groups after six months. bcva 6/6 – 6/9 in 25% preoperatively improved to 56.25% in group – i after six months postoperatively while in group-ii it improved from 31.25% to 56%. complications rate was analysed, corneal astigmatism > 1 diopter was noted 31.25% in group – i and 25% in group – ii. hyphaema / vitreous hemorrhage was 18.75%, iol decentration was 12.50% in group – ii, but no case recorded in group – i. conclusion: bcva improved in both groups with no significant differences in outcome in complicated cataract extraction with poor capsular support. however higher rate of complications were noted in aciols group as compared to sf iol. further large scale evaluation is need. he first intraocular lenses were introduced in cataract surgery by sir harold ridley in 19491. it became standard of care in the late 1980s. fixation of intraocular lenses in cases of insufficient or no capsular support is challenging and requires good surgical techniques to resolve different situations. in such a situation, the surgeon has four options, to leave the eye aphakic, to implant an anterior chamber intraocular lens (ac iol), to fixate a posterior chamber intraocular lens (pc iol) in the iris or to fixate a pc iol in the sclera. the potential issues of anisometropia, optical aberrations, and contact lens intolerance make aphakia a less-than-optimal solution in all but a few patients3. presently, there are five primary methods for dealing with iol requirements in the absence of capsular support, mainly depending on the preoperative status of the eye: flexible openloop aciols and iris claw aciols; iris-fixated retropupillary aciols; iris-sutured pciols and transscleral – sutured pciols. if both the iris and the capsule are absent or disrupted, sutured transscleral pciols are the only option2. it has been postulated that ac iol cause subclinical uveitis secondary to lens-tissue, which creates inflammatory products that could be directly toxic to the endothelium and angle and could also result in cystoid macular edema4. considerable controversy remains over the relative efficacy and safety of the different implantation t visual outcome and complications of aciol’s vs scleral fixated pc iol’s pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 207 approaches when capsular supportis absent. anterior chamber intra-ocular lens implantation is coming back into favor among some surgeons, thanks to improved, open loop aciol designs and re-emergence of the iris fixated claw iol. sizing is less critical with the flexible haptics of the open-loop aciols; as opposed to the more rigid or closed-loop aciol designs.5 several studies demonstrated improved results with these modern devices. nevertheless, concern remains that aciols are more damaging to the corneal endothelium than pciols. the modern aciol designs had decreased the complications which were associated with the closed-loop aciols but they have not been eliminated6. in 1986, malbran and colleagues were the first to describe scleral sulcus fixation of pc iols.7 in 2003, an american academy of ophthalmology sponsored report on iol implantation in the absence of capsular support after a thorough literature assessment, by wagoner and colleagues concluded that the scleral sutured posterior chamber iols were safe and effective in adults8. today, considerable controversy remains over the relative efficacy and safety of the different implantation approaches when capsular support is absent. material and methods this interventional comparative study was conducted from april 2010 to december 2011 in the department of ophthalmology hayatabad medical complex peshawar. thirty two eyes included of 28 patients and they were classified into 2 groups; group i: where 16 eyes underwent anterior chamber iols (aciols) implantation either primary or secondary and group ii: where 16 eyes underwent scleral fixated iols (sfiols) implantation either primary or secondary. indications for surgery included aphakia, subluxated lenses and cases with posterior capsular rents. exclusion criteria included iritis, uveitis, glaucoma, amblyopia, macular scar and patients with poor vision other than cataract. a structured proforma was used for each patient including demography, clinical history, investigations and complete ophthalmic examination. reason for failed pciol implantation, mean preoperative and postoperative snellen bcva recorded. surgery was carried out under local anaesthesia in adults and under general anaesthesia in children. surgical technique in group-i, large 6 to 9 mm incision was used, after the completion of surgery limited anterior vitrectomy and one superior pi done in each case and pupil was constricted with carbacol 0.01%. viscoelastic hydroxylpropylmethyl cellulose (hpmc) 2% injected to the anterior chamber. aciol with overall diameter 12.50 mm, optic diameter6.50 mm and with 115 a –constant implantation was performed either primary in complicated cataract surgeries or secondary in aphakic cases. corneal wound was stitched using interrupted 10/0 nylon sutures. in group-ii, limited conjunctival peritomy was carried out and 2 triangular scleral flaps 2/3rd of the scleral thickness and 180° apart were made at 3 and 9 o’clock with the base at the limbus. one side port was made for anterior chamber (ac) maintainer, viscoelastichydroxyl propyl methyl cellulose (hpmc) 2% was pushed into the anterior chamber. corneal incision was made from 6-9 mm and surgery was completed after limited anterior vitrectomy. viscoelastic pushed into the ac a 27-gauge needle was passed through a sclera at 0.7mm scleral bed from the limbus on one side and a 10/0 prolene suture on a straight needle through opposite scleral bed. the prolene suture needle was engaged into the 27 gauge needle in the peripupillary plan. the 27 gauge needle was withdrawn along with the prolene needle. the suture was drawn out through the dilated pupil and corneal incision. the suture was cut and each end tied to the haptics eyelets of the iol. sutures were pulled through the scleral bed and tied. scleral flaps were sutured with 10/0 nylon and conjunctiva with 7/0 vicryl. the corneal wound was stitched with 10/0 nylon interrupted sutures. postoperatively, topical antibiotics and steroid drops were used routinely for one month. patients were followed for one month, 3 months and 6 months. during each follow up visit bcva and complications recorded in both groups. results total 32 eyes of 28 patients were included in the study all of them had completed six months follow up. they were divided in to two groups group-i aciols group and group–ii sfiols group. the mean age of patients in aciol group was 57.30 ± 18.54 years and male: female ratio was 12:9 in the sfiol group, mean age was 57.35 ± 18.80 years; m: f ratio was 10:9. the pre and post-operative visual acuity was measured and there was no statistically significant difference noted between the two groups after six months. bcva 6/6-6/9 in 25% preoperatively improved to 56.25% in group-i after six months postoperatively while in group-ii it improved from 31.25% to 56% as shown in (table 1). mushtaq ahmad, et al 208 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology visual outcome and complications of aciol’s vs scleral fixated pc iol’s pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 209 complications rate was analysed as shown in table 2, corneal astigmatism, cystoid macular oedema and hyphaema / vitreous haemorrhage were more in group-i as compared to group-ii. intraocular pressure was recorded pre and postoperatively in both groups no significant change noted in pre and post-operative readings (table 3). discussion the surgical approach in this series was influenced by the specialty (vitreo-retina) and the preferences of the operating surgeon (as), but standardization was established regarding the scleral fixation itself, while the remainder of the procedure was determined by the case pathology and operative circumstances. the stability and centralization of the scleraly fixated iols in this study were excellent during the follow up period with no rotation or subluxation. the visual acuity significantly improved postoperatively. our results were comparable to ellakwa et al who showed no significant difference existed regarding the final visual outcome between anterior chamber (log mar=0.88) and scleral fixation iol (log mar=0.84) groups, also non significant difference existed regarding the final visual outcome between primary and secondary ac iol implantation, however higher postoperative visual acuities were detected in secondary sfiol. in group i, the most common complications were uveitis (35%), ocular hypertension (25%), cme (20%), retinal detachment in one case (5%) and endophthalmitis in one case (5%). in group ii, the most common complications were ocular hypertension (25%), retinal detachment (15%), cme (15%), suture erosion (15%), vitreous hemorrhage (10%), uveitis (5%) and endophthalmitis in one case (5%).9 our results were also comparable to the results of donaldson et al11, who showed that mean postoperative bcva 20/60 (0.5 log mar) in aciol group and 20/50 (0.4 log mar) in sfiol group with no statistically significant difference between both groups, donaldson et al10 study also recorded elevated iop in 39% of aciol group versus 42% of sfiol group with no statistically significant difference between the two groups which differs from our study in that percentage of ocular hypertension in aciol group was more than sfiol group. cme found at 12% of aciol group versus 10% of sfiol group with no statistically significant difference between the two groups that matches our results. a research done by sujata et al,11 showed that the mean post-operative log mar bcva was 0.75 in sfiol group and 0.52 in ac iol group with better bcva in aciol group. this difference was statistically significant (p = 0.0003). our study showed no statistically significant difference in the final bcva in both groups because at our study ac iol implantation was done by different surgeons not by a single surgeon besides sujata et al5 compared sf iol versus primary ac iol only. kwong et al,12 recorded better results from primary ac vs primary sclera – fixated iols in eyes with poor capsular support, log mar visual acuity averaged 0.322 in eyes that received an anterior chamber iol, significantly better than the sclera – fixated iol group, which had a mean visual acuity of 0.486 (p = 0.01). in the anterior chamber iol group, 71% of eyes achieved a snellen visual acuity of 20/40 or better compared with 47.2% of eyes in the scleral fixated iol group, in our study no statistically significant difference was found between primary ac vs. primary scleral – fixated iols. conclusion bcva improved in both groups with no significant differences in outcome in complicated cataract extraction with poor capsular support. however higher rate of complications were noted in aciols group as compared to sf iol. further large scale evaluation is needed. author’s affiliation dr. mushtaq ahmad registrar ophthalmology department hmc, peshawar dr. muhammad naeem postgraduate trainee ophthalmology department hmc, peshawar dr. sofia iqbal associate professor ophthalmology department, hayatabad medical complex, peshawar dr. sanaullah khan assistant professor bannu medical college bannu references 1. ridley h: intra-ocular acrylic lenses. trans ophthalmol soc uk. 1951, 71: 617–21. mushtaq ahmad, et al 210 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology 2. poor ym, lavin mj. techniques of intraocular lens suspension in the absence of capsular/zonular support. surv ophthalmol. 2005; 50: 429-62. 3. oh h, chu y, woong known o. surgical technique for suture fixation of a single piece hydrophilic acrylic intraocular lens in the absence of capsular support. j cataract refract surg. 2007; 33: 962-5. 4. dick hb, augustin aj. lens implant selection with absence of capsular support. curr opin ophthalmol. 2001; 12: 47-57. 5. apple dj, brems rn, park rb. anterior chamber lenses. part i: complications and pathology and a review of designs. j cataract refract surg. 1987; 13: 157-74 6. auffarth gu, wesendahl ta, brown sj. are there acceptable anterior chamber intra-ocular lenses for clinical use in the 1990s? an analysis of 4104 explanted anterior chamber intra-ocular lenses. ophthalmology. 1994, 101: 1913–22. 7. malbran es, malbran e jr, negri i. lens guide suture for transport and fixation in secondary iol implantation after intracapsular extraction. int ophthalmol. 1986; 9: 151-60. 8. wagoner md, cox ta, ariyasu rg, rt al. intraocular lens implantation in the absence of capsular support: a report by the american academy of ophthalmology. ophthalmology. 2003; 110: 840–59. 9. ellakwa af, hegazy ka, farahat hg, et al. anterior chamber intraocular lens versus scleral fixated intraocular lens in cases with insufficient capsular support. mmj july 2010; 23 :5– 12 10. donaldson ke, gorscak jj, budenzdl. anterior chamber and sutured posterior chamber intraocular lenses in eyes with poor capsular support. j cataract refract surg. 2005; 31: 03–9. 11. sujata s, rajamohan m, prabhakar. comparison of outcomes of scleral fixated versus anterior chamber iols in complicated cataract surgeries, aioc 2008 proceedings, cataract session ii. 2008; 2: 91-3. 12. kwong yy, yuen kl, lam rf. comparison of outcomes of primary scleral – fixated versus primary anterior chamber intraocular lens implantation in complicated cataract surgeries. ophthalmology. 2007; 114: 1: 80–5. microsoft word 6. nadeem 2 pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 77 original article outcome of macular hole surgery at mayo hospital, lahore nadeem ahmad, syed raza ali shah, qasim lateef ch, m. younis tahir, tehseen mehmood mahju, ch nasir ahmed, muhammad arif, sohail sarwar, anwar-ul-haq, asad aslam khan pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nadeem ahmad vitreo-retina fellow coavs, lahore …..……………………….. purpose. to evaluate the anatomic and visual out come in patients undergoing pars plana vitrectomy (ppv) with internal limiting membrane (ilm) peel for idiopathic macular hole. material and methods. fifteen cases of full thickness macular hole were selected and underwent ppv with ilm peeling and 20% sulphar hexafluoride gas (sf6) as internal tamponade. results. out of 15 cases 13 (86.7%) patients achieved anatomical success and in 2 cases the macular remained open. the visual acuity in 6 cases (40%) improved by 2 or more lines. conclusion. ppv with ilm peel is associated with significant anatomical and functional improvement. acular hole is an important cause of central visual loss and the overall prevalence is approximately 3.3 per 10001. macular hole can be associated with trauma or myopia but most common cause is idiopathic. idiopathic macular hole are commonly seen in women in the seventh decade of life without any apparent predisposing conditions2. kelly and wendel introduced a surgical procedure to close macular holes. they achieved an anatomical closure rate of 73% and visual improvement of two or more lines3. during the last decade closure rates have improved significantly due to improved surgical techniques4. brooks has shown significant improvement in anatomical and functional outcome after macular hole surgery5. gupta b and colleagues had the anatomical success rate of 86% and variable visual success rate.6 brooks reported 100% closure in holes of less than 6 months duration with ilm peeling7. the purpose of study was to see the anatomical and visual results in our circumstances. material and methods study design: non comparative interventional case series. the study was conducted at college of ophthalmology & allied vision sciences, mayo hospital lahore. one year study started from june 2010 to may 2011. fifteen cases of stage 2, 3 and 4 idiopathic macular hole were included. patients having pseudomacular hole, stage i macular hole, macular cyst and secondary macular hole were excluded from the study. all patients after enrollment from outpatient department of mayo hospital lahore were admitted for surgery. detailed history including the age, sex and duration of symptoms were noted. best-corrected visual acuity (bcva) was recorded. detailed anterior segment and fundus examination was performed. stage and size of the macular hole was noted with the help of optical coherent tomograph (oct) [optovue]. all patients underwent 20 gauge ppv with ilm peeling with or without staining and 20% sulphar hexafluoride (sf6) gas as internal temponade under local anesthesia. in two cases brilliant peel (0.025%) was used under air to stain ilm and in remaining cases triamcinolone was sprinkled over it. triamcinolone does not stain the ilm but gives a good contrast as the peeled area lacks the white particles. one to one half disc area of ilm was peeled in a circular fashion around the macular m nadeem ahmad, et al. 78 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology hole. non expansible concentration (20%) of sf6 was prepared by taking 4ml of pure gas mixed with 16ml of sterile air in 20ml syringe. all patients were instructed to position face down for one week. the patients were reviewed on post op day 1, week 1, 4 and 12. on follow up visits again history, bcva, intraocular pressure (iop), and dilated fundus examination were performed. at week 4 and 12 oct images were also taken to establish the closure of macular hole. outcome measures: the primary outcome measure was to achieve successful anatomically closure of macular hole which was defined as closure of the edges of the hole. the secondary outcome was to gain improvement in bcva. table 1. base line characteristics of macular hole patients age in yrs mean 57.8 range 50 – 70 sex male 06 (40%) female 09 (60%) eye right 09 (60%) left 04 (26.6%) both 02 (13.3%) duration of symptoms < 6 mo 08 (53.33%) > 6mo 07 (46.66%) pre op bcva • 6/60 • 6/36 • cf 10 (66.66%) 02 (13.3%) 03 (20%) stage of macular hole • stage 2 • stage 3 • stage 4 0 01 (6.66%) 14 (93.33%) lens status • phakic • pseudophakic 13 (86.66%) 02 (13.3%) results fifteen cases of full thickness macular holes underwent surgery at retina clinic of mayo hospital lahore from june 2010 to may 2011. baseline characteristics of these patients are presented in table 1. the mean age of patients was 57.8 + 5.8 years. both eyes were involved in 13.3% of cases and 53.3% of cases have 6 month or less duration of symptoms. pre op bcva in 66.7% cases were 6/60 and 93.3% cases had stage 4 macular hole on oct. 86.7% cases were phakic with grade ii nuclear sclerotic changes. outcome measures are presented in table 2. out of 15 cases 13 achieved closure of macular hole which were confirmed on oct. snellen visual acuity before surgery was 6/60 in 10 (66.7%), 6/36 in 02 (13.3%) and cf in 03cases (20%). improvement of 2 or more lines occurs in 40% of cases and one line improved in one case (6.66%). during surgical procedure no significant complication occurred. in the follow up period, iop rise was not found in any case which was defined as iop rise > 30mmhg. one case developed significant cataract due to improper posture. two holes remained open and one case developed hypotony on first post op day. table 2. out come measures of macular hole surgery hole status based on oct • closed • not closed 13 (86.66%) 02 (13.3%) post op bcva • 6/60 • 6/36 • 6/24 • 6/18 • cf 06 (40%) 01 (13.3%) 04 (26.6%) 02 (13.3%) 02 (13.3%) discussion the anatomical success rate for this study was 86.7%, which is equal to the similar studies from the other centers8,9. the two holes remained open despite of surgery. the redo surgery was planned but patients did not report back. some times more than one surgery is required to achieve the anatomical success10. one case developed hypotony on post op day 1, the most likely cause was wound leak. 0.3 ml of pure gas was injected into vitreous cavity under topical anesthesia. next day the iop was 18 mmhg and remained under control during follow up. these problems can be avoided by ensuring the proper closure of all the vitrectomy ports. rhegmatogenous retinal detachment occurred in one case after one month. this complication may occur in 1% to 2% of cases undergoing macular hole surgery11. this case was successfully managed with laser retinopexy and intravitreal gas temponade due to the presence of superior break. one patient develop significant out come of macular hole surgery at mayo hospital, lahore pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 79 cataract due to improper posture and underwent phacoemulsification with intraocular lens implanttation. we did not combine phacoemulsification with macular hole surgery because in a large randomised trial of posturing for macular hole, patients who had combined surgery did not have a higher success rate than those who had vitrectomy alone12. another reason is that biometry may be less accurate due to presence of macular disease and anterior displacement of the capsular bag caused by the gas bubble may cause slight myopic shift13. fig. 1: showing complications fig. 2: showing preoperative oct of macular hole fig. 3: 3 months postoperative oct of same patient in addition to determining the anatomical success, visual outcomes must be examined. visual success, defined as an acuity of 6/18 or better. in our study the visual success was 13.3% although 6 cases improved by 2 lines and one case by one line. the diameter of the macular hole provides a prognostic factor for postoperative visual outcome. freeman and coworkers found that a macular hole with a small diameter was associated with better functional outcome15. another study showed visual success of 2% in older patients with visual acuity of 6/60 or worse and hole diameter of more than 500 mm6. in our study minimum diameter was 516 mm and most cases were having visual acuity of 6/60. visual success can be improved by timely presentation and intervention. conclusion surgical intervention for macular hole (ppv with ilm peel) is associated with significant anatomical and functional improvement. results could be better if surgery is performed at an earlier time. author’s affiliation dr. nadeem ahmad vitreo-retina fellow coavs, lahore dr. syed raza ali shah department of ophthalmology mayo hospital, lahore dr. qasim lateef ch department of ophthalmology mayo hospital, lahore dr. m. younis tahir department of ophthalmology mayo hospital, lahore dr. tehseen mehmood mahju department of ophthalmology mayo hospital, lahore dr. ch nasir ahmed department of ophthalmology mayo hospital, lahore dr. muhammad arif department of ophthalmology mayo hospital, lahore dr. sohail sarwar department of ophthalmology mayo hospital, lahore nadeem ahmad, et al. 80 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology dr. anwar-ul-haq department of ophthalmology mayo hospital, lahore prof. asad aslam khan department of ophthalmology mayo hospital, lahore reference 1. fine s. discussion, macular holes. ophthalmology 1993; 100: 871. 2. margherio rr, schepens cl. macular breaks. i. diagnosis, etiology and observations. am j ophthalmol. 1972; 74: 233-40. 3. wendel rt, patel ac, kelly ne, et al. vitreous surgery for macular holes. ophthalmology 1993; 100: 1671-6. 4. scott ra, ezra e, west jf, et al. visual and anatomical results of surgery for long standing macular holes. br j ophthalmol. 2000; 84: 150-3. 5. brooks hl jr. macular hole surgery with and without internal limiting membrane peeling. ophthalmology. 2000; 107: 193948. 6. gupta b, laidlaw da, williamson th, et al. predicting visual success in macular hole surgery. br j ophthalmol. 2009; 93: 1488-91. 7. brooks hl jr. macular hole surgery with and without internal limiting membrane peeling. ophthalmology. 2000; 107: 193948. 8. gupta b, laidlaw dah, williamson th, et al. predicting visual success in macular hole surgery. br j ophthalmol. 2009; 3: 1488-91. 9. christensen uc, krøyer k, sander b, et al. value of internal limiting membrane peeling in surgery for idiopathic macular hole stage 2 and 3: a randomised clinical trial. br j ophthalmol. 2009; 93: 1005-15. 10. mark jjd’ chaudhary sv, devenyi r, et al. re-operation of idiopathic full-thickness macular holes after initial surgery with internal limiting membrane peel. br j ophthalmol. 2011; 95: 1564-7. 11. sjaarda rn, thompson jt, et al. distribution of iatrogenic retinal breaks in macular hole surgery. ophthalmology. 1995; 102: 1387-92. 12. guillaubey a, malvitte l, lafontaine po, et al. comparison of face-down and seated position after idiopathic macular hole surgery: a randomized clinical trial. am j ophthalmol. 2008; 146: 128-34. 13. patel d, rahman r, kumarasamy m. accuracy of intraocular lens power estimation in eyes having phacovitrectomy for macular holes. j cataract refract surg. 2007; 33: 1760-2. 14. freeman wr, azen sp, kim jw, et al. bailey i for the vitrectomy for treatment of macular hole study group. vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes. arch ophthalmol. 1997; 115: 11-21. pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 95 original article efficacy of intra-vitreal bevacizumab for resolution of macular edema secondary to central retinal vein occlusion muhammad younis tahir, afshan ali pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad younis tahir ophthalmology department bvh/qamc, bahawalpur …..……………………….. purpose: to determine the efficacy of intravitreal injection of bevacizumab in resolution of macular edema in patients of central retinal vein occlusion. material and methods: it was a descriptive case series, conducted at institute of ophthalmology unit iii, mayo hospital lahore and bahawal – victoria hospital bahawalpur simultaneously. a total of 60 cases were selected though purposive sampling for this study. diagnosis was ascertained on fundus fluorescein angiography. pre and post injection macular edema was measured on optical coherence tomography on the day of drug administration and thirty days after it. results: mean macular thickness before treatment was 663.10 ± 109.76 microns and after treatment mean thickness was 453.06 ± 106.09 microns which was a significant (p = 0.0000001) finding. majority (75%) of patients achieved a reduction of ≥ 200 microns in their retinal thickness after treatment. whereas in the remaining 15 (25%) patients reduction in retinal thickness was < 200 microns. these findings were independent of gender bias. conclusion: intravitreal injection of bevacizumab is effective in the resolution of macular edema in the patients of central retinal vein occlusion. key words: central retinal vein occlusion, macular edema, bevacizumab. entral retinal vein occlusion (crvo) is the second most common retinal vascular disorder1 with incidence of 0.5% and prevalence of 1.3%.1,2 it is thought to be caused by thrombus formation in at the level of lamina cribrosa.3 crvo is characterized by edema of the optic nerve, retinal hemorrhages and marked vascular dilatation and tortuosity.4 fluorescein angiography is used as a diagnostic tool for crvo and it also classifies it into ischemic and non-ischemic types on the basis of degree of retinal capillary non perfusion.5 ischemia induces a rise in intraocular levels of vascular endothelial growth factor (vegf)6 – a cytokine which not only increases vascular permeability which leads to macular edema but also stimulates endothelial cell hypertrophy, thus reducing the capillary lumen, causing more ischemia and perpetuating further edema.7 if left untreated, persistent macular edema, macular ischemia and neovascular glaucoma can lead to visual morbidity and blindness.2,8 to date, no effective and safe therapy has been found for macular edema secondary to central retinal vein occlusion. intravitreal injection of steroids such as triamcinolone acetonide initially showed some promising results but later it was found to be associated with unacceptable ocular complications.4 bevacizumab is a monoclonal antibody that inhibits vegf and has been advocated to facilitate resolution of macular edema by breaking vegf cycle which is critical for perpetuating macular edema in the setting of crvo as a famous study7 has shown a decrease of 200 microns in macular thickness from baseline in at least one third of patients, one month after the injection. in another study, in addition to all these changes, significant reduction in venous dilation, tortuosity, optic disc swelling was also found.9 c muhammad younis tahir, et al 96 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology current study was the first of its kind in local population of punjab, pakistan to explore the efficacy of this drug in resolving macular edema due to central retinal vein occlusion. it has also provided data for comparison with the results from studies being conducted across the globe. material and methods it was a descriptive case series, conducted at institute of ophthalmology unit iii, mayo hospital lahore and bahawal – victoria hospital simultaneously. a total of 60 cases central retinal vein occlusion were selected after informed written consent of patients and approval of institutional ethics committee. sample size was selected though purposive sampling technique through following criteria; inclusion criteria  both genders.  age more than or equal to 20 years.  central retinal vein occlusion in one eye of the patients diagnosed on fluorescein angiography as per operational definition.  macular edema of equal to or more than 300 microns at baseline confirmed by optical coherence tomography. exclusion criteria  previously treated according to history.  cases of increased intraocular pressure (more than 21mm hg) evidenced by applanation tonometry.  filtration surgery, corneal transplantation, cataract surgery three months prior to baseline assessed on slit lamp examination.  diabetic retinopathy in rapid progression confirmed by fluorescein angiography.  vitreous hemorrhage seen on ultrasonography.  pregnancy according to ultrasound findings. the diagnosis of central retinal vein occlusion was made if delayed arteriovenous transit time (more than 12 seconds), blockage by hemorrhages, good retinal capillary perfusion (non-ischemic type), capillary non perfusion (ischemic type) and leakage was observed on fluorescein angiography. macular edema was defined as retinal thickness of more than or equal to 300 microns confirmed by the presence of intra-retinal cysts in the central macular area on optical coherence tomography (oct). the main outcome measure was efficacy of bevacizumab which was defined in terms of resolution of macular edema on oct measured in microns. edema was considered resolved if the decrease in retinal thickness is equal to or more than 200 microns from the baseline measurement after one month of giving injection. demographic information like name, age and gender was recorded. pre and post treatment macular edema was measured by optical coherence tomography. all the information collected was noted on a special proforma attached. all patients received ciprofloaxacin antibiotic drops for three days pre and post treatment. intravitreal injection of 1.25 mg bevacizumab in 0.05 ml total volume was given via superior pars plana area, under aseptic condition after topical anesthesia of lidocaine. to avoid bias the whole procedure was done by a single skilled surgeon and all the observations were recorded by a single observer. follow up was done after one month and documenting the post treatment macular edema on optical coherence tomography. final reading was taken at the end of one month. complications if any, were dealt with accordingly. results males (n = 36, 60%) and females (n = 24, 40%) having mean age of 58.83 ± 9.33 and 58.75 ± 8.19 years respectively having macular edema due to crvo were treated with intravitreal injection of bevacizumab. mean macular thickness before and after treatment was 663.10 ± 109.76 and 453.06 ± 106.09 microns respectively as shown in table 1 and fig. 1. macular thickness before treatment among male and female patients was 667.27 ± 108.30 and 656.83 ± 113.96 microns. after treatment mean macular thickness among male and female patients was 463.30 ± 106.03 and 437.70 respectively. it was clear after treatment significant reduction in macular thickness was observed as shown in table 2 and fig. 2. efficacy criteria was set as decrease in retinal thickness ≥ 200 microns. keeping in mind this criteria there were 45 (75%) patients in which retinal thickness decrease from baseline was ≥ 200 microns after treatment. whereas the remaining 15 (25%) patients retinal thickness was < 200 microns showing no efficacy of treatment for these patients. among male patients efficacy of treatment (retinal thickness ≥ 200 microns) was observed among 25 (69.4%) whereas among female patients efficacy of treatment was observed in 20 (83.3%) patients as shown in table 3 efficacy of intra-vitreal bevacizumab for resolution of macular edema secondary to central retinal vein pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 97 and fig. 3. pre and post-operative out of 2 patients are shown in fig. 4 and 5. discussion a definite therapeutic target for central retinal vein muhammad younis tahir, et al 98 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology fig. 1: macular thickness on oct before and after treatment. fig. 2: macular thickness on oct (microns) before and after treatment; comparison of resolution between two genders. occlusion has yet to be proclaimed. much focus has been given to treat macular edema which arises secondarily in the setting of crvo and causes markedly diminished and visual acuity.10 among the various treatment modalities that have been tried, many discarded either due to therapeutic failure or due to systemic or local complications were associated with their use, these included vitrectomy, radical optic neurotomy etc.11,12 however, intra-vitreal injection of anti-angiogenic monoclonal antibody bevacizumab has shown promising results without any major adverse effects. current study was an effort to investigate the repeatability and reliability of this claim in local circumstances, to validate the findings of previous similar reports and to add more data into an emerging area of wider interest where previous publications have in fact demanded further studies. fig. 3: efficacy of treatment with respect to gender of patients. fig. 4: after and before treatment (oct). we observed that mean macular thickness before treatment was 663.10 ± 109.76 microns which was reduced to a mean macular thickness of 453.06 ± 106.09 microns after the treatment, which means almost 1/3rd reduction in simple arithmetic terms and highly significant in statistical terms thus proving the efficacy of the bevacizumab for the treatment of macular edema. current study also shows that after one month of giving intra-vitreal bevzcizumab, there is significant decrease in retinal thickness. this efficacy of intra-vitreal bevacizumab for resolution of macular edema secondary to central retinal vein pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 99 fig. 5: after and before treatment oct. decrease is more than or equal to 200 microns from the baseline value which fulfills our efficacy criteria for bevacizumab in cases of macular edema secondary to crvo. a total number of 60 patients were included in the study. out of those, 75% patients showed a reduction of more than 200 microns in their retinal thickness from its baseline value. while in 25% patients the decrease in retinal thickness was less than 200 microns. as for the gender distribution, macular thickness before treatment among male and female patients was 667.27 ± 108.30 and 656.83 ± 113.96 microns. after treatment mean macular thickness among male and female patients was 463.30 ± 106.03 and 437.70 respectively. similarly, 69.3% men and 83.3% women with macular edema were found to achieve a reduction of > 200 microns in the retinal thickness. these findings show that the results were apparently more favorable in women however it was statistically not significant and we can say that our results were independent of gender. manayath et al., included 15 patients of retinal vein occlusion developing macular edema who were serially evaluated with best corrected visual acuity (bcva), optical coherence tomography (oct), fluorescein angiography, and tonometry. mean followup was 12 ± 3.6 months (range, 6 18 months); mean number of injections was 2.2 (range, 1 4) per patient. they found statistically significant reduction of macular thickness (p < 0.001) at six weeks (mean, 346 μ); three months (mean, 353 μ); six months (mean, 348 μ); and final follow-up (mean, 342 μ) and thus concluded that intravitreal bevacizumab is effective for resolution of macular edema.13 another recent study by thapa et al., also found similar results.14 epstein et al. used different outcome measures for the trial of bevacizumab. their primary outcome measure was the proportion of patients gaining at least 15 letters at 12 months. secondary outcome measures included mean change from baseline bestcorrected visual acuity (bcva), change in foveal thickness, and development of neovascular glaucoma and they also found intra-vitreal injection of bevacizumab an effective therapy for the macular edema secondary to crvo.15 these studies mentioned above show comparable findings. however, current study has larger sample size which makes our results more reliable as most of the other studies done on intravitreal bevacizumab have a very small sample size. in south east asian region, not much research is done on role of bevacizumab in cases of central retinal vein occlusion. so this study provides valuable data for treatment and further research on patients of crvo. there are a few limitations of our study as well. we are studying the effect of intravitreal bevacizumab on macular thickness one month after its administration. although macular thickness shows a significant decrease in thickness i.e. 200 microns but in many cases residual thickness is still more than 300 microns, which means there might be need for further injections. further study needs to be done on effects of multiple injections of intravitreal bevacizumab in cases of crvo. many studies have reported results of three intravitreal injections of bevacizumab given on monthly basis in these patients. in our region research need to be carried out regarding this, and the possible adverse effects of long term administration of injection bevacizumab. conclusion our study demonstrates that intra-vitreal injection of anti vegf agent bevacizumab is effective in resolution of macular edema in patients of central retinal vein occlusion. muhammad younis tahir, et al 100 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology author’s affiliation dr. afshan ali ophthalmology department bvh / qamc, bahawalpur dr. muhammad younis tahir fellowship in vitreo-retina assistant professor ophthalmology department bvh / qamc, bahawalpur references 1. ehlers jp, fekrat s. retinal vein 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http://www.ncbi.nlm.nih.gov/pubmed/?term=berrocal%20mh%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=graue-wiechers%20f%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=robledo%20v%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=colina-luquez%20j%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=fromow-guerra%20j%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=jim%c3%a9nez-sierra%20jm%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=guerrero-naranjo%20jl%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=morales-cant%c3%b3n%20v%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=morales-cant%c3%b3n%20v%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=wali%20uk%5bauthor%5d&cauthor=true&cauthor_uid=20671833 microsoft word 12-cr ghulam h yaghoobi pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 50 case report bilateral symmetric retinal pigmentation versus heterochromia: a case of waardenburg syndrome gholamhossein yaghoobi, elahe heidari pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: gholamhossein yaghoobi birjand medical university, ophthalmology department, valiasr hospital, southern khorasan, birjand, iran …..……………………….. this report describes a 22 year intellectual female who presented with poor vision while working on a microscope. slit lamp biomicroscopic examination showed heterochromia iridis and retinal pigmentary changes that disclosed waardenburg syndrome (ws) type 2. except of white forelock, we could not find any other association or anomaly elsewhere. ophthalmological examination revealed ws type 2 with heterochromia iridis. she also had the specific pattern of bilateral posterior heavy retinal pigmentation versus peripherally albinotic pattern. this retinal finding in ws type 2 is the first report in literature to the best of our knowledge. aardenburg syndrome (ws) is an uncommon autosomally inherited and genetically heterogeneous disorder of neural crest cell development. it consist of six distinctive features: lateral displacement of the medial canthus and lacrimal punctae, broad and high nasal root, hypertrichosis of medial part of the eyebrows, partial or total heterochromia iridis, white forelock, and congenital deaf mutism1. the diagnosis of ws is made clinically. genetic testing is available for confirmation of diagnosis and prenatal diagnosis if the mutation in the family has been identified2. failure of neural crest-derived melanocyte differentiation results in a spectrum of phenotypic presentations that are subdivided into 4 clinical types. type 1 is the classic form of ws with dystopia canthorum (lateral displacement of the inner canthi), type 2 characterized by the presence of white forelock, unilateral or bilateral deafness, but without the dystopia canthorum. ws3 have hypoplasia of limb musculature and/or contractures of elbows and fingers, and ws4 have hirschprung disease in addition to the other common feature of ws3. the others report describe variable retinal pigmentary disturbances, the extensive albinoid areas nasally and in posterior pole, versus the temporal region which showed a homogeneous area of dense hyperpigmentation4, 5. we report here a case of ws, for its rarity, variability of systemic and clinical eye involvement in literature. the heterchoromia with symmetrically bilateral posterior retinal hyperpigmentation versus peripheral hypopigmentation was the unique finding that it is not reported till now. case report a 22 year old girl with white forelock complained of poor vision while working on a microscope. she had centrally placed white forelock in the frontal area without any associated depigmentation of scalp or elsewhere on the body. her nasal root was not broad without wide intercanthal distance. she had not any complain of hearing or any others anomaly elsewhere. on ophthalmological examination, pupils were mid dilated with sluggish reaction and full eye movements. the best corrected vision was 20/25 with 1 diopter of myopic correction in both eyes. anterior segment examination was within normal limit except w gholamhossein yaghoobi, et al 51 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology the presence of unilateral right blue iris. fundoscopic examination showed bilateral symmetrical posterior hyperpigmentation and peripheral hypopigmentation of the retina fig. 1 – 2. the abstinence of high illumination and spectacle prescription reduced her complaint. the white forelock could not be showed due to patient's non consent. fig. 1: right and left posterior pole retinal hyperpigmentation versus peripheral hypopigmentation. discussion we present a 22 year old female with heterochromia and unusual retinal pigmentary change with waardenburg syndrome type 2. she did not have any obvious classical systemic or family history but her ocular examination helped us discover another variable feature of ws2. the white forelock and right blue iris versus left brown iris, was accompanied by bilateral central retinal hyperpigmentation and peripheral hypopigmentation in our case that not observed till now. the peripheral retinal hypopigmentation had similarity to funduscopic change that may be albinotic pattern or may show pigment mottling in the periphery as described by tagra sunita et al6. tagra sunita et al also describe that except the deafness all features of waardenburg type 1 and 2 are essentially benign and cosmetic in nature and do not necessitate active intervention but the visual complaint in this case without causative finding may warrant more knowledge about funduscopic change and heterochromia. study of abah et al7 among deaf student demonstrated four (0.6%) students that had iris heterochromia, three bilateral and one unilateral involvement, they also had white forelock hair and together with the deafness were presumed to have waardenburg syndrome but none of the students had the funduscopic finding of typical salt and pepper retina of congenital rubella7. another case report by manish mahta et al8 also showed choroidal depigmentation with classical salt and pepper retina appearance in a two year deaf female with brilliant blue iris8. a case report of waardenburg by naeimeh tayebi described a 2 year old girl with waardenburg syndrome whose father was also affected. the ophthalmic examination revealed dystopia canthorum and telecanthus, accommodative isotropia in either eyes without heterochromia or any other eye anomaly2. this case did not have any misalignment. according to our knowledge the fundoscopic finding of ws2 in our case introduced another variable feature of waardenburg which was associated with bilateral similar retinal pigmentary change in spite of dissimilar iridis in a female. author’s affiliation dr. gholamhossein yaghoobi ophthalmologist, vitreoretinal fellowship, associate professor birjand university of medical science birjand medical university, ophthalmology department, valiasr hospital, southern khorasan, birjand, iran dr. elahe heidari resident of pediatric of mashad university of medical science, birjand medical university, ophthalmology department, valiasr hospital, southern khorasan, birjand, iran references 1. ghosh sk, bandyopadhyay d, ghosh a, biswas sk, mandal rk. waardenburg syndrome: a report of three cases. indian j dermatol venereol waardenburg syndrome: a report of three cases, ijdvl. 2010: 76; 5: 550-2. 2. tayebi n. waardenburg syndrome type i in an iranian female, iran j pediatr. 2008; 2: 193-6. bilateral symmetric retinal pigmentation vs heterochromia: a case of waardenburg syndrome pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 52 3. soni cr, kumar g. child neurology: a patient with dissimilar eye color and deafness neurology. 2010; 8: 25-6. 4. müllner-eidenböck a, moser e, frisch h, read ap. waardenburg syndrome type 2 in a turkish family: implications for the importance of the pattern of fundus pigmentation, br j ophthalmol. 2001; 11: 1384-6. 5. ohno n, kiyosawa m, mori h, wang wf, takase h, mochizuki m. clinical findings in japanese patients with waardenburg syndrome type 2, jpn j ophthalmol. 2003; 1: 77-7. 6. tagra s, talwar ak, walia rl, sidhu p. waardenburg syndrome, ijdvl. 2006; 4: 326. 7. abah er, oladigbolu kk, samaila e, merali h, ahmed ao, abubakar th. ophthalmologic abnormalities among deaf students in kaduna, northern nigeria,, annals of african medicine. 2011; 10: 29-33. 8. mehta m, kavadu p, chougule s. waardenburg syndrome, indian journal of otolaryngology head and neck surgery. 2004; 56: 300-2. 19 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology original article comparison of anti-inflammatory effect between intracameral triamcinolone acetonide and topical dexamethasone after phacoemulsification asif manzoor, muhammad moin pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: asif manzoor vr fellow department of ophthalmology, lahore general hospital, lahore. email: asifmanzoor259@gmail.com …..……………………….. purpose: to compare the role of single dose intracameral injection of triamcinolone acetonide versus topical dexamethasone to control postoperative inflammation after phacoemulsification. study design: randomized controlled trial. place and duration of study: ophthalmology department, lahore general hospital, lahore, from march 2015 to august 2015. material and methods: a total of 60 patients of 40 – 70 years of age of either gender undergoing phacoemulsification for cataract were included. selected patients were placed randomly into two groups by using lottery method. group a patients were given 1 mg/0.1 ml triamcinolone acetonide into anterior chamber at the end of surgery and no topical steroids were given post-operatively. group b were not given intracameral injection but topical dexamethasone eye drops were given 4 hourly for one week and then four times a day for 4 weeks. outcome variable was control of postoperative inflammation, which was noted at day 1, 7 and 28. results: mean age of patients in group a was 58.63 ± 7.30 years and in group b was 56.63 ± 5.87 years. out of 60 patients, 34 (56.67%) were males and 26 (43.33%) were females. the male to female ratio was 1.3:1. the difference in efficacy between the two groups was statistically nonsignificant. conclusion: single dose intracameral injection of triamcinolone acetonide controls post-operative inflammation after phacoemulsification without the use of any eye drops and is equally as effective as topical dexamethasone for post-operative inflammation keywords: cataract, inflammation, phacoemulsification, triamcinolone. ataract is the leading cause of treatable blindness in the world1. in pakistan, 51.5% blindness is due to cataract2. amongst all people with visual impairment due to cataract in the world, about 65% are above 50 years of age3. more than 50% of people over the age of 65 develop age-related cataract with significant decrease in vision4. globally, with increase in population, age and lifespan of people, cataract cases are expected to increase in number. cataract is the leading cause of vision loss in developed and developing countries5. cataract surgery is the most commonly performed procedure done by ophthalmologists worldwide6. approximately 18 million cataract surgeries are performed every year in the world and expected to c mailto:asifmanzoor259@gmail.com comparison of anti-inflammatory effect between intracameral triamcinolone acetonide and topical pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 20 increase as the population and lifespan increases7. small-incision cataract surgery using phacoemulsification has become the most popular modern technique and gold standard in cataract surgery8. inspite of improved surgical techniques and intraocular lenses postoperative inflammation is one of the most common postoperative complications. blood aqueous barrier is damaged due to surgical trauma which causes leakage of proteins and inflammatory cells into the anterior chamber. uncontrolled postoperative inflammation can increase recovery time, increased intraocular pressure (iop), synechiae formation and cystoid macular edema9, 10. routinely topical steroids are used in treatment of postoperative inflammation after cataract surgery. other routes of delivery of steroids in eye include intracameral, sub-tenon, sub-conjunctival and intravitreal injections11. a study by coronel mcg et al12 showed that intracameral triamcinolone use is safe and post-operative inflammation was resolved in 100% cases after four weeks of phacoemulsification. a study held in pakistan by waseem m13 showed that topical dexamethasone 0.1% resolved post-operative inflammation in 98% cases after five weeks of phacoemulsification. no study has been published in pakistan on use of intracameral triamcinolone after phacoemulsification. topical steroids are effective in controlling postoperative inflammation but they have few disadvantages like poor compliance due to multiple time dosage daily, tear film disruption and irritation. the purpose of this study was to see the comparison between efficacy of single dose intracameral triamcinolone injection and topical dexamethasone in controlling post-operative inflammation after phacoemulsification in our population. on the basis of these results, some practical recommendations can be made in our routine practice for reducing postoperative inflammation after phacoemulsification in order to reduce the morbidity and improving patient compliance. methodology study was conducted in ophthalmology department, lahore general hospital, lahore, from march 2015 to august 2015. study design was randomized controlled trial and non-probability, consecutive sampling technique was used. after approval from the ethical review committee a total of 60 patients between 40 70 years age of either gender were admitted to ophthalmology unit-ii, lahore general hospital, lahore to undergo phacoemulsification for cataract. patients with anterior uveitis, any ocular pathology, any complication during cataract surgery like posterior capsular rupture and vitreous loss, previous surgery and co-morbid conditions were excluded. all patients were operated by the same consultant ophthalmologist (at least 10 years of experience) by phacoemulsification procedure with foldable intraocular lens implantation under topical anaesthesia. after taking written, informed consent for participation in the study, a total of 60 cases were selected and were divided in two groups by lottery method.group a comprising of 30 patients were given single intracameral injection of triamcinolone acetonide 1mg at the end of surgery using a 27-guage cannula. post-operatively moxifloxacin 0.5% eye drops (one drop every six hours) given for 4 weeks. group b comprising of 30 patients were not given intracameral triamcinolone acetonide injection. post-operatively dexamethasone 0.1% eye drops (one drop every four hours) and moxifloxacin 0.5% eye drops (one drop every six hours) were given for 4 weeks with gradual tapering of dose of dexamethasone eye drops. all patients in both groups were evaluated by same consultant at 1st, 7thand 28thday after surgery for anterior chamber inflammation (cells and flare). anterior chamber cells were examined in 1x1mm slit beam field and grading was done as: grade 0 = <5 cells, grade 1 = 6 15 cells, grade 2 = 16 25, grade 3 = 26 50, grade 4 = > 50. grading of aqueous flare was done as following: 0 = none; 1 = mild (just detectable); 2 = moderate (iris details clear); 3 = marked (iris details hazy), and 4 = severe (heavy with fibrin deposits and clots). all the data was recorded on a predesigned proforma. the data was entered and analyzed by spss version 20.comparison between the groups with respect to efficacy was analyzed by chi square. p value ≤ 0.05 was considered significant. results range of age of patients in this study was from 40 70 years with mean age of 57.35 ± 6.57 years. mean age of patients in group a was 58.63 ± 7.30 years and in group b was 56.63 ± 5.87 years. majority of the patients 37 (61.67%) were between 56 to 70 years of age as shown in table 1. among 60 patients, 34 (56.67%) were males and 26 (43.33%) were females and male to female ratio was 1.3:1 as shown in figure 1. asif manzoor, et al 21 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology 34 (56.67%) 26 (43.33%) male female fig. 1: %age of patients according to gender. table 2 shows the mean post-operative inflammation (anterior chamber cells and flare) at day 1 and day 7 in both treatment groups. flare was resolved in majority of the cases at day 7 and at 28th day post-operative inflammation (cells and flare) was completely resolved in both groups. both drugs were equally effective in controlling post-operative inflammation with a p-value > 0.05 that was statistically non-significant. intraocular pressure was monitored in all patients pre-operatively and all post-operative visits. preoperative mean iop in group a and b was 15.67 and 15.83 mmhg respectively. post-operative mean iop in group a and b was 16.33 and 16.17 mmhg at post-op day 1 and 14.83 and 14.93 mmhg at post-op day 28.the change in iop was not significant in both groups as shown in table 3. there was no case of postoperative endophthalmitis or secondary glaucoma in both groups. table 1: age distribution for both groups (n = 60). age (years) group a (n = 30) group b (n = 30) total (n = 60) no. of patients %age no. of patients %age no. of patients %age 40 55 11 36.67 12 40.0 23 38.33 56 70 19 63.33 18 60.0 37 61.67 mean ± sd 58.63 ± 7.30 56.63 ± 5.87 57.35 ± 6.57 p-value 0.12  p-value is >0.05 which is statistically non-significant. table 2: efficacy of both groups. group a (n = 30) group b (n = 30) p-value mean range mean range cells day 1 1.7 0 2 1.8 0 2 0.41 day 7 0.2 0 1 0.23 0 1 0.14 day 28 0.0 0 0 0.0 0 0 1.0 flare day 1 0.23 0 1 0.27 0 1 0.42 day 7 0.07 0 1 0.10 0 1 0.64 day 28 0.0 0 0 0.0 0 0 1.0  p-value is > 0.05 which is statistically non-significant. comparison of anti-inflammatory effect between intracameral triamcinolone acetonide and topical pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 22 table 3: mean intraocular pressure of both groups. group a (n=30) group b (n=30) p-value mean mean intra-ocular pressure (iop) (mmhg) pre-op 15.67 15.83 0.98 day 1 16.33 16.17 0.61 day 7 15.36 15.40 0.18 day 28 14.83 14.93 0.26  p value is > 0.05 which is statistically not significant. discussion management of inflammation is thus a main focus in modern era cataract surgery14. steroids have strong anti-inflammatory effect that act on a number of intercellular inflammatory mediators. corticosteroids are being used by ophthalmologists since 1950s to reduce post-operative intraocular inflammation by controlling inflammatory cell leakage and inhibiting proliferation of fibroblasts and formation of granulation tissue15. there are different methods to use corticosteroids in eye like topical eye drops, subconjunctival, subtenon and retrobulbar injections or systemic steroid in the form of oral medication, intramuscular or intravenous injections. so, we have conducted this study to compare the efficacy of single dose intracameral injection of triamcinolone acetonide versus topical dexamethasone in preventing postoperative inflammation after phacoemulsification in patients with cataract. triamcinolone acetonide is being used to treat posterior segment inflammatory diseases in the form of intraocular injections. oh et al16 injected triamcinolone acetonide into anterior chamber of rabbit eyes to check its effect on corneal endothelium. they examined after 2 hours of injection and found there was decrease in microvilli but no statiscally significant difference noted on endothelial cell count and central corneal thickness. chang et al18 also found some toxic effects of triamcinolone acetonide on cultured endothelium. despite toxic effects of triamcinolone acetonide on corneal endothelium shown by some studies, triamcinolone acetonide is being used to control postoperative inflammation after cataract surgery. gills and gills18 injected different doses of triamcinolone acetonide in anterior chamber to control post cataract surgery inflammation. they started with 0.25 mg and gradually increased to 3.0 mg and 4.0 mg in patients with diabetes mellitus but they could not find appropriate dose. they suggested that increasing the dose of triamcinolone acetonide decreased the requirement of postoperative steroid use from 45% to 2% with 1.8 2.1 mg dose. in a prospective study19 60 patients were randomized into two groups. half of the patients had to receive single intracameral injections of triamcinolone acetonide and gentamicin at the end of phacoemulsification and then followed by topical tobramycin eye drops four times daily for one week (ic ta group, n = 30). other half of patients had to use topical dexamethasone-tobramycin combination eye drops after phacoemulsification for four times daily until no inflammation was seen (topical group, n = 30). they found no significant difference between the two groups in anterior chamber cells at one day and one week after surgery (p = 0.50 and 0.328, respectively). however they observed that the anterior chamber cells were significantly less in the ic ta group than in the topical group at one month postoperatively (p = 0.006). no significant difference was seen between two groups in terms of mean bcva or iop at any time point (p > 0.05). no significant complications like endophthalmitis were observed. intracameral and intravitreal triamcinolone injected after performing phacoemulsification, in combination with standard postoperative corticosteroid eye drops, has beneficial role in uveitic eyes20-21. gills jp et al18 successfully replaced postoperative steroid drops use with higher concentrations of intracameral steroid injection after cataract surgery. chang dtw et al17 in a study used intracameral dexamethasone at the end of cataract http://www.ncbi.nlm.nih.gov/pubmed/?term=chang%20dt%5bauth%5d asif manzoor, et al 23 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology surgery and found that it significantly decreases postoperative inflammation in eyes with and without glaucoma. postoperative inflammation after cataract surgery is treated with topical corticosteroids and they prove to be effective but they have some side effects like poor compliance due to frequent use of eye drops after cataract surgery, toxic effects of topical drops and preservatives on cornea, irritation in eyes due to tear film disruption, and substantial cost of topical drops. to minimized these side effects of topical eye drops alternate routes of corticosteroids use are under trials.22 karalezli a et al23 reported effective suppression of post-operative inflammation with intracameral triamcinolone acetonide injection after cataract surgery. he concluded that intracameral steroids and topical prednisolone are equally effective in controlling post cataract surgery inflammation. intracameral steroids improve patient compliance and help to avoid side effects of topical eye drops like corneal melting, dry eyes and conjunctival irritation. intracameral injection of triamcinolone can have advantage in complicated cases when chances of postoperative inflammation are higher. intracameral injection of triamcinolone can reduce cystoid macular edema after posterior-capsular rupture and chances of macular edema in diabetic patients by gaining access to posterior segment through zonules. so, on the whole it is concluded that intracameral triamcinolone injection is an effective way to reduce post-operative inflammation after phacoemulsification. it may be an alternate option to the topical dexamethasone and should be used routinely in our general practice. conclusion this study concluded that single dose intracameral injection of triamcinolone acetonide and postoperative topical dexamethasone are equally effective in controlling post-operative inflammation after phacoemulsification. so, we recommend that intracameral injection of triamcinolone acetonide can be used routinely per-operatively in these particular patients instead of topical dexamethasone in order to prevent multiple and frequent use of eye drops that are usually prescribed after phacoemulsification. author’s affiliation dr. asif manzoor (fcps ophthalmology) ophthalmology department. lahore general hospital, lahore. house # 570. gblock. gulshan-e-ravi, lahore. dr. muhammad moin (professor of ophthalmology) ophthalmology department. lahore general hospital, lahore. role of authors dr. asif manzoor data collection, manuscript writing, data analysis dr. muhammad moin manuscript review, study design references 1. murthy gvs, john n, shamanna br, pant hb. elimination of avoidable blindness due to cataract: where do we prioritize and how should we monitor this decade? ind j ophhthalmol. 2012; 60: 438-445. 2. jamil az, ahmed a, mirza ka. effect of intracameral use of dexamethasone on corneal endothelial cells. coll phys surg pak. 2014; 24: 245-248. 3. fact sheet n 282. updated october 2013. visual impairment and blindness. world health organization. 4. dua hs, attre r. treatment of post-operative inflammation following cataract surgery a review. eur ophthalmol rev. 2012; 6: 98-103. 5. khairallah m, kahloun r, bourne r, et al. number of people blind or visually impaired by cataract worldwide and in world regions, 1990 to 2010. invest ophthalmol vis sci. 2015 oct; 56 (11): 6762-9. 6. hashmi fk, khan qa, chaudhry ta, ahmad k. visual outcome of cataract surgery. coll phys surg pak. 2013; 23: 448-449. 7. pascolini d, mariotti sp. global estimates of visual impairment: 2010. br j ophthalmol, 2012; 96 (5): 614– 618. 8. zusman nb. the miracle of modern cataract surgery: no needle, no stitch, no patch. july 28, 2013; feeling fit, sun newspapers. 9. imdad t, tanweer fs, raza a. effect of dexamethasone versusdiclofenac sodium after phacoemulsification with intraocular lens implantation. jrmc; 2013; 17: 254-256. 10. amon m, busin m. loteprednoletabonate ophthalmic suspension 0.5%: efficacy and safety for postoperative anti-inflammatory use. intophthalmol. 2012; 32: 507-517. 11. patel a, cholkar k, agrahari v, mitra ak. ocular drug delivery systems: an overview. world j pharmacol. 2013; 2 (2): 47–64. comparison of anti-inflammatory effect between intracameral triamcinolone acetonide and topical pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 24 12. coronel m. c. g, co gn. safety and efficacy of intracameral triamcinolone in post cataract inflammation. philippine j ophthalmol. jan – jun 2008. 13. waseem m, humayun s. comparison of antiinflammatory activity of dexamethasone and diclofenac sodium eye drops in phacoemulsification. j coll physic surge pak. 2009; 19: 570-574. 14. chen p, han x, zhu y, xu j. comparison of antiinflammatory effects of flourometholone 0.1% combined with levofloxacin 0.5% and tobramycin/dexamethasone eye drops after cataract surgery. int j ophthalmol. 2016; 9 (11): 1619–1623. 15. ellis pp. pharmacological effects of corticosteroids. int ophthalmol clin. 1996; 6: 799–819. 16. oh jy, wee wr, lee jh, kim mk. short-term effect of intracameral triamcinolone acetonide on corneal endothelium using the rabbit model. eye (lond) 2007; 21: 812–8. 17. chang ys, tseng sy, teseng sh, wu cl, chen mf. triamcinolone acetonide suspension toxicity to corneal endothelial cells. j cataract refract surg. 2006; 32: 1549– 55. 18. gills jp, gills p. effect of intracameral triamcinolone to control inflammation following cataract surgery. j cataract refract surg. 2005; 31: 1670–1. 19. simaroj p1, sinsawad p, lekhanont k. effects of intracameral triamcinolone and gentamicin injections following cataract surgery. j med assoc thai. 2011 jul; 94: 819-25. 20. li j, heinz c, zurek-imhoff b, heiligenhaus a. intraoperative intraocular triamcinolone injection prophylaxis for post-cataract surgery fibrin formation in uveitis associated with juvenile idiopathic arthritis. j cataract refract surg. 2006; 32: 1535–39. 21. dada t, dhawan m, garg s, nair s. safety and efficacy of intraoperative intravitreal injection of triamcinolone acetonide injection after phacoemulsification in cases of uveitic cataract. j cataract refract surg. 2007; 33: 1613– 18. 22. sanders dr, kraff m. steroidal and non-steroidal antiinflammatory agents: effects on post-surgical inflammation and blood) aqueous humour barrier breakdown. arch ophthalmol. 1984; 102: 145–46. 23. karalezli a, borazan m, akova ya. intracameral triamcinolone acetonide to control postoperative inflammation following cataract surgery with phacoemulsification. acta ophthalmol. 2008; 86: 183–7. http://www.ncbi.nlm.nih.gov/pubmed/?term=simaroj%20p%5bauthor%5d&cauthor=true&cauthor_uid=21774289 http://www.ncbi.nlm.nih.gov/pubmed/?term=sinsawad%20p%5bauthor%5d&cauthor=true&cauthor_uid=21774289 http://www.ncbi.nlm.nih.gov/pubmed/?term=lekhanont%20k%5bauthor%5d&cauthor=true&cauthor_uid=21774289 http://www.ncbi.nlm.nih.gov/pubmed/21774289 175 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology case report a case series of waardenberg syndrome nausheen hayat, alyscia cheema pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nausheen hayat c-61, darakhshan villas phase-6, dha, karachi ph: 0321-2101888 …..……………………….. waardenburg syndrome (ws) is a rare autosomally inherited and genetically heterogeneous disorder of neural crest cell development with distinct cutaneous manifestations 1 . we report here a case series of patients of a single family, presented with assemblage of complete heterochromia, dystopia canthorum, synophrys and broad nasal root. other family members with presence of heterochromia and telecanthus have been delineated in pedigree. in our case series second generation of family also found to be affected, which is rarely reported till now. to our knowledge no local cases have been reported till date. key words: waardenberg syndrome, heterochromia, telecanthus. aardenburg syndrome is a rare disease characterized by deafness in association with pigmentary anomalies and defects of neural crest-derived tissues1. above mentioned case was first reported in 1951, by a geneticist p. j. wardenberg who potrayed it along with the 6 main features. those features are lateral displacement of the medial canthi combined with dystopia of the lacrimal puncta and blepharophimosis, prominent broad nasal root, hypertrichosis of the medial part of the eyebrows, white forelock, heterochromia iridis, deafmutism2. waardenberg syndrome is divided into four sub types; this division is based on the presence and absence of dystopia canthorum along with other certain clinical features. these subtypes are ws1, ws2, ws3 and ws4. it affects equally both sexes and all races3. it is estimated that 1 per 10,000 20,000 people are diagnosed with waardenberg syndrome, with a prevalence rate of approximately 1 in 10,000 or 0.01% in us4. among four types of syndrome, i and ii are the most common, whereas types iii and iv are rare. five major and five minor criteria exist for diagnosing ws. the major criteria are sensorineural hearing loss, iris pigmentary abnormality (two eyes different color or iris bicolor or characteristic brilliant blue iris), hair hypopigmentation (white forelock or white hairs at other sites on the body), dystopia canthorum (lateral displacement of inner canthi) and the presence of a first-degree relative previously diagnosed with ws. the minor criteria are skin hypopigmentation (congenital leukoderma/white skin patches), medial eyebrow flare (synophrys), broad nasal root, hypoplasia of alae nasi, and premature graying of hairs (before age 30)3. case report our first patient is a 22 year old male presented to the outpatient department of our tertiary eye care hospital with chief complaints of difference in color of his eyes with decreased vision in right eye (fig. 1). his best corrected visual acuity at presentation was 6/24 p od with -3.50 x -1.00 at 90 degree and 6/6 os. patient also has complain of decreased hearing in right ear. he was the last child of a non-consanguineous marriage among 7 siblings with one affected brother as well. (3 brothers and 3 sister). his birth and developmental history did not reveal anything significant. his detailed family history revealed that his mother has telecanthus along with 1 brother and 2 nephews and 2 nieces affected as well. on systemic examination, he was moderately built with an average height, weight and normal iq. he had premature graying of hair with absence of any associated depigmentation elsewhere on the body. his ent and abdominal examinations were normal. w a case series of waardenberg syndrome pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 176 on ocular examination, gross inspection shows broad nasal root and synophrys. the palpebral fissure height of right eye was 1.5 cm and 1.4 cm in left eye along with lateral displacement of canthi. he also had dystopia canthorum with interpupillary distance of 8cm and inner canthal distance of 5.7 cm. hirschberg corneal reflex was central but medially sclera was visible o a lesser extent. complete heterochromia due to hypoplastic iris, blue in color was noted in right eye (fig. 2). sectoral atrophy of iris seen in left eye. besides this anterior fig. 1: shows telecanthus. right eye left eye fig. 2: shows anterior segment right eye left eye fig. 3: shows right hypopigmented fundus fig. 4: shows telecanthus, synophrys and heterochromia left eye right eye left eye fig. 5: anterior segment 2 children of elder brother (our 3rd and 4th patient) showed only telecanthus and broad nasal root in examination with rest of the examinations normal. nephew niece fig. 6: shows telecanthus and broad nasal root. segment examination was otherwise normal in both the eyes. iop was in normal limits. pupillary reactions were normal. right fundus was albinotic showing hypopigmentation and temporal disc pallor and left fundus was normal (fig. 3). gonioscopy revealed nausheen hayat, et al 177 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology grade iv angle in both eyes, normal iris vessels seen in angle of right eye. our second patient is 46 years old male, elder brother of patient. his history revealed presence of white forelock of hairs at birth (due to hair dying at early age patient has no old picture) and premature graying of hairs, dystopia canthorum, synophrys and heterochromia irides. his visual acuity was 6/6 in both eyes. right eye shows sectoral iris atrophy and complete heterochromia found out in left eye. both fundii were normal. fig. 7: pedigree chart. dark blue box: first patient. light blue box: other affected males. red circles: affected females. discussion waardenburg consortium proposed diagnostic criteria for diagnosing ws types. according to it, for placing patient in category of ws i, patient should have 2 major or 1 major + 2 minor criteria present. ws ii is characterized by sensor neural hearing loss and heterochromia iridis but absence of dystopia canthorum. ws iii (klein–waardenburg syndrome) resembles type i with supplementary musculoskeletal abnormalities. these patients have hypoplastic muscles and contractures of the upper limbs. ws iv is associated with hirschsprung disease. liu et al. suggested method for diagnosis of wsii, which requires presence of at least two major criteria and the same study propounded the use of premature graying as one of the mature criteria instead of dystopia canthorum5. we present a case series of a single family with several members affected of first and second generation. according to the above mentioned criteria our first and second patient falls in category of ws 1. since all of these are only cosmetic problems therefore they do not require compulsory treatment. it is plausible that in certain cases ws may remain undiagnosed until other family members with similar features seek medical attention. one of the purposes to present this case series is to bring in light the significance of detailed examination of all the family members to recognize undiagnosed cases. clinical features of ws are mainly cosmetic problems for which no definitive treatment exist, except for few occuloplastic procedures which can be done for broad medial canthus. in some cases muted diseases, such as, sensorineural deafness, bony abnormalities or hirschsprung disease are found to be associated with ws which results in deterioration in quality of life. an ophthalmologist can help these patients by making an early diagnosis which may aid in the initiation of early treatment, social and vocational training, and rehabilitation of these patients. acknowledgement we would like to express our special thanks to prof. hassan niazi for his valuable guidance and advise during diagnosis and workup of this patient. author’s affiliation dr. nausheen hayat ophthalmology ward jinnah post graduate medical centre karachi dr. alyscia cheema head of department ophthalmology ward jinnah post graduate medical centre karachi references 1. eglabian f. waardenberg-shah syndrome; a case report and review of literature. iran j pediatr. 2008; 18: 71-4. 2. waardenberg pj. a new syndrome combining developmental anomalies of the eyelids, eyebrows and nose root with pigmentary defects of the iris and head hair and with congenital deafness. am j hum genet. 1951; 3: 195-253. 3. ghosh sk, bandyopadhyay d, ghosh a, biswas sk, mandal rk. waardenberg syndrome: a report of three cases. indian j dermatol venereol leprol. 2010; 76: 550-2. 4. right diagnosis.com. denver (co): health grades inc; 2011. statistics by country for waardenberg syndrome. 2013; 7. 5. bansai y, jain p, goyal g, singh m, mishra c. waardenberg syndrome-a case report. clae. 2012; 36: 49-51. pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 173 original article alcohol related toxic optic neuropathy case series sajjad ali surhio, shahzad memon, muhammad memon, noor bakht nizamani, khalid i. talpur pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: shahzad memon department of ophthalmology liaquat university eye hospital, jail road, hyderabad, 71000, sindh, …..……………………….. purpose: to report a case series of alcohol induced toxic optic neuropathy, discussing their visual status and optic disc changes in response to high dose steroid treatment. material and methods: this study was conducted at the department of ophthalmology, liaquat university of medical and health sciences, hyderabad, pakistan. ten cases (twenty eyes) of alcohol induced toxic optic neuropathy were received between november 2009 and january 2010, with chief complaint of sudden loss of vision following use of alcohol. patients were started with intravenous high dose steroids and vitamin b complex. they were followed up until 3 months for visual improvement and changes of optic disc with the help of fundus photographs. results: all the patients were males and habitual drinkers with definite history of consuming adulterated alcohol. seven of the patients were received in first week for acute visual loss while remaining three after 4 weeks. seventy percent patients responded well to high dose steroid therapy with visual acuity improving from perception of light to 6/6 within 3 months. conclusion: high dose steroids had a great therapeutic effect on the visual outcome in patients of alcohol induced toxic optic neuropathy. however the optic disc appearance was not proportionate to the visual status of the patients. oxic optic neuropathy is a complex multifactorial disease potentially affecting individuals of all ages and races worldwide. etiologically it includes nutritional factors like bcomplex vitamins deficiency and toxic factors, especially associated with alcohol abuse and tobacco use. the condition leads to morbid metabolic, neurologic effects and even death1. alcohol related toxic optic neuropathy cases have been on rise in the subcontinent although previously these were mainly seen in western population. methanol is an organic solvent, common constituent in many commercially available industrial solvents. being cheap and easily available it is used frequently in adulterated alcoholic beverages. the major factor responsible for the adverse effects is not methanol itself but its metabolite formic acid, which due to slow clearance produces toxic effect.2 patients with alcohol related toxic optic neuropathy present with a bilateral progressive painless loss of visual acuity, dyschromatopsia, subsequent disc changes including marked temporal disc pallor and retinal nerve fiber layer loss mainly in papillomacular bundle3. although there is no specific treatment; early detection and prompt management may decrease visual impairment. we report 10 cases of alcohol induced toxic optic neuropathy, discussing their visual status and optic disc changes in response to high dose steroid treatment. material and methods this is a prospective case series of 10 cases reported from november 2009 to january 2010, at department of ophthalmology, liaquat university of medical and t sajjad ali surhio, et al 174 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology health sciences, hyderabad. majority of patients were well educated and had habitual of alcohol consumption in groups. the source of beverage purchase was not known, suggestive of adulterated alcohol. there were no concomitant illnesses or systemic signs confirmed by the history and examination. results all the patients were males with a mean age of 39 years (± 13.5 years; sd = 13.96) including; old age (between 50 – 60 years), middle age (30 – 50 years) and even young age (16 – 30 years). all the patients were chronic alcoholics with mean duration of 12.37 years (sd = 9.97); two of the patients were consuming alcohol for 25 – 30 years (cases 4, 9). meanwhile case 3 who was youngest of all had the shortest duration of 3 months. one of the patients (case 10) refrained from giving duration as he was not comfortable with the questionnaire. all the cases except 4 patients (case 2, 3, 4 and 9) had chronic history of smoking, majority dating since they were 15 – 16 years old (table 1). before starting treatment, a written consent was taken and all the patients were immediately started with intravenous (i/v) steroids (injection decadron 1cc i/v twice a day) and i/v vitamin b complex (injection neurobion, merck private limited, on alternate days). after 1 week of i/v medication patients were switched to oral steroids (tablet deltacortil 1mg/kg/day) and oral vitamin b complex. finally, all patients were followed up for visual improvement and changes of optic disc with the help of fundus photographs for 3 months. majority of patients responded to the treatment. figure 1 summarizes the visual status before and after treatment. it was found that more than half of the patients had visual status ranging from perception of light (pl) and projection (pr) to mere counting finger at 1 meter (cf-1m) at the time of presentation (cases 1 – 3, 7, 9, 10). four cases at the time of recruitment had no perception of light (npl) (cases 4 – 6, 8). case 2 was the only patient with 6/9 vision in left eye. finally, after 3 months visual improvement was seen in all the cases except case 8, who after some improvement in vision (i.e. pl pr) started drinking again and finally ended up being npl. dramatic visual improvement was noted in case 9 from pl pr to 6/6. cases with npl improved to pl or cf-1m except for case 8 which remained npl. also significant improvement was observed in cases 1 and 3 from pl to 6/36 and 6/24 respectively. case 7 improved to cf2m from pl. over 50% eyes had mild improvement, 20% moderate and total improvement each, while 10% did not show any improvement (table 2). alcohol related toxic optic neuropathy case series pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 175 fig. 1: visual status at 1st and final visits, x-axis showing the best corrected visual acuity while y-axis showing the number of eyes. cfcounting finger, plperception of light, prprojection of light, nplno perception of light the optic disc photographs taken during 3 months follow up period have been shown in figure 2. comparing initial pictures of cases 7 and 9 variable amount of nerve fiber edema can be seen correlating well with the visual status, whereas case 8 there seemed to be no significant finding in correlation to the visual status of the patient. during the follow up period after 1 week in case 7 the nerve fiber edema was significantly decreased, with a proportional improvement in visual acuity. whereas, case 8 with a paler atrophic disc and mild nerve fiber edema had mild improvement to pl. comparing the findings of both cases 7, 8 there had been no significant change in the disc morphology with comparison of visual improvement which is quiet significant. above all the optic disc photographs had nerve fiber edema at superior and inferior poles rather than papillomacular bundle. the cases 7 and 8 had no remarkable change in visual status, pointing more towards a posterior ischemic optic neuropathy or suggesting a deeper pathology involving optic nerve. fig. 2: showing optic disc photographs taken during follow up with visual correlation. discussion patients diagnosed with toxic optic neuropathy tend to have a variable clinical course. in early stages most of the patients have relatively normal appearing optic disc, whereas, few may present with bilateral disc edema, hyperemia and flame-shaped hemorrhages after acute alcohol abuse. later stages, may present with variable optic atrophy.4,5 the anterior visual pathway is more susceptible to damage from toxins or nutritional deficiency. although the exact pathogenesis of the toxic optic neuropathy has not been established yet, it has also been postulated in few studies that toxic effect of the formic acid impairs the tissue vascular supply especially optic nerve predisposing to the accumulation of toxic agents.1 in routine we have almost no referral or direct encounter of patients with alcohol related toxic optic sajjad ali surhio, et al 176 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology neuropathy as alcohol consumption is banned and prohibited in our country since 1977. conversely illegal consumption of alcohol in the form of beer, wine and most commonly adulterated spirits have become a rising trend. a group of alcohol experts estimated unrecorded alcohol consumption in pakistan, after 1995; to be 0.3 liters pure alcohol per capita for over 15 years age population.6 our cases had same history suggesting unknown origin of alcohol source from their routine consumption, most probably adulterated spirits. a similar but larger outbreak of adulterated alcohol has been reported from different parts of india.7 in the aforementioned study 99% patients were middle age men, kept on corticosteroids and multivitamins, with varying degrees of optic atrophy and loss of vision. in our series 100% patients were males, mostly middle age only one minor with similar management and visual loss patterns. a collaborative study conducted by pan american health organization including 123 patients conducted in cuba suggested epidemic optic neuropathy in people using tobacco, particularly cigar smoking, at increased risk of optic neuropathy.8 this is consistent with our series in which majority of the patients were cigarette smokers. abrishami et al reported a significant improvement in visual acuity from 6/60 to 6/12 in all their cases suffering from methanol induced toxic optic neuropathy, following high dose intravenous predinisolone.9 this is comparable to our study results in which 70% patients had mild to moderate improvement in vision while 20% had 6/6 vision while 10% did not show any improvement. local literature review revealed no significant study on alcohol related toxic optic neuropathy, perhaps due to the under reporting of cases and social stigma. however ali et al have reported significant improvement in vision up to 6/6 following use of high dose predinisolone in an ethambutol induced optic nerve damage. 10 conclusion alcohol related toxic optic neuropathy has been on the rise despite the prohibition of alcohol consumption. chronic alcoholics and smokers had a worse visual outcome as compared to other patients. the optic disc morphology was not proportionate to the visual status of the patients. early detection and management with high dose corticosteroids and vitamin b complex aid in reversing the optic nerve damage and revival m visual status. author’s affiliation dr. sajjad ali surhio department of ophthalmology, liaquat university of medical and health sciences, jamshoro / hyderabad dr. shahzad memon department of ophthalmology, liaquat university of medical and health sciences, jamshoro / hyderabad dr. muhammad memon department of ophthalmology, liaquat university of medical and health sciences, jamshoro / hyderabad dr. noor bakht nizamani department of ophthalmology, liaquat university of medical and health sciences, jamshoro/hyderabad dr. khalid i. talpur department of ophthalmology, liaquat university of medical and health sciences, jamshoro/hyderabad references 1. sharma p, sharma r. toxic optic neuropathy. indian j ophthalmol. 2011; 59: 137–41. 2. rathi m, sakhuja v, jha v. visual blurring and metabolic acidosis after ingestion of bootlegged alcohol. hemodial int. 2006; 10: 8-14. 3. moura fc, monteiro ml. evaluation of retinal nerve fiber layer thickness measurements using optical coherence tomography in patients with tobacco-alcoholinduced toxic optic neuropathy. indian j ophthalmol. 2010; 58: 143-6. 4. macaluso dc, shults wt, fraunfelder ft. features of amiodarone-induced optic neuropathy. am j ophthalmol. 1999; 127: 610-2. 5. nagra pk, foroozan r, savino pj, castillo i, sergott rc. amiodarone induced optic neuropathy. br j ophthalmol. 2003; 87: 420-2. 6. alcohol per capita consumption, patterns of drinking and abstention worldwide after 1995. appendix 2. european addiction research. 2001, 7: 155–7. 7. ravichandran rr, dudani ra, almeida af, chawla kp, acharya vn. methyl alcohol poisoning. (experience of an outbreak in bombay). j postgrad med. 1984; 30: 69-74. 8. cuba neuropathy field investigation team. epidemic optic neuropathy in cuba: clinical characterization and risk factors. n eng j med. 1995; 333: 1176-82. 9. abrishami m, khalifeh m, shoayb m, abrishami m. therapeutic effects of high-dose intravenous prednisolone in methanol – induced toxic optic neuropathy. j ocular pharmacology and therapeutics. 2011, 27: 261-3. 10. ali s, usman u, wasay m. rapidly developing optic neuritis secondary to ethambutol: possible mechanism of injury. j pak med assoc. 2005, 55(7). 125 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology original article trabeculotomy in primary congenital glaucoma abdul qayyum, riaz ahmed baloch pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: abdul qayyum department of ophthalmology bolan medical college quetta e-mail: draqayyum2k3@outook.com …..……………………….. purpose: to evaluate outcome and frequency of complications involved in trabeculotomy in pediatric patients. material and methods: a total of 10 children were enrolled from pediatric ophthalmology clinic, bolan medical college, quetta during month of january and february 2013. only primary congenital glaucoma (pcg) patients were registered. every patient had complete ocular examination under general anesthesia including anterior segment examination, measurement of intraocular pressure, corneal diameter, gonioscopy, axial lengths, fundoscopy and retinoscopy where possible. the success criteria was defined as: intraocular pressure bellow < 15 mm hg (under general anesthesia), simultaneous absence of cup: disc ratio progression, disproportional enlargement of cornea and stoppage or reduction in enhancement of axial length. follow up period comprised of one, two, four & eight months respectively. results: ten patients under went trabeculotomy. their mean age at the time of surgery was 15 months (range 10-29 months). the iop was successfully controlled in 8 patients (80%). the pre-operative measurement was as follow: iop 30 mm hg (±5.7), horizontal corneal diameter 13.06 mm (±0.6), axial length 21.9 mm (±0.8), cdr was 0.52 (0.23). the final reading of various parameters was as under: iop measured under ga 12 mm hg, horizontal corneal diameter 13.0 mm (±0.5), axial length 20.9 mm (0.6) and cdr was 0.3 (±0.21). 8 patients (80%) had successful surgery while 2 patients (20%) had unsuccessful surgery. 4 (40%) patients had complications comprising of false passage, iris prolapse, stripes in descement‘s membrane and hyphaema. conclusion: trabeculotomy is highly successful procedure in primary congenital glaucoma. the complications observed were quite few in number. distorted limbal anatomy of buphthalmic eyes may affect prognosis of surgery. some of the steps of trabeculotomy are similar to trabeculectomy. key words: trabeculotomy, congenital glaucoma, buphthalmos. rimary congenital glaucoma is a worldwide diagnostic and therapeutic challenge. it is responsible for 0.01 – 0.04% of total blindness and 5% of childhood blindness.¹ it is an unusual, inherited anomaly of trabecular meshwork and anterior chamber angle which leads to obstruction of aquous outflow, increased iop, and optic nerve damage.² incidence varies worldwide, as low as 1:20000-30000 live births in western countries, as high as 1:1250 live births in roman slovakian.3 it is typically bilateral (70 80%) with male (60%) preponderance. the high incidence is related to parental consanguity.4 pathogenesis is still disputed; most observers have not been able to document ultrastructurally a continuous endothelial membrane, as initially advanced by barkan.5 it is an isolated trabeculodysgenesis. it is know thought to be due to thick, compacted trabecular sheets.6 it is typically autosomal recessive7. medical therapy is accorded a supportive role, definitive treatment is surgical. both p trabeculotomy in primary congenital glaucoma pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 126 goniotomy and trabeculectomy give similar good results. goniotomy clinically introduced by barkan in 1940s was undoubtedly a great step forward in the surgical management of congenital glaucoma. however, good visibility of chamber angle structures and considerable surgical experience is required for delicate kind of ab-interno surgery8. trabeculotomy was developed by smith in early 1960’s.in the 1970’s and 1980’s trabeculotomy became an established alternative ab-externo procedure in surgical treatment of congenital glaucoma9. the aim of the study was to evaluate outcome and frequency of complications involved in trabeculotomy. material and methods a total of 10 children were underwent trabeculotomy. all patients were registered from pediatric ophthalmology clinic, bolan medical college, quetta during month of january and february 2013. the written consent was taken on prescribed form. only primary congenital glaucoma patients were registered while secondary congenital glaucoma were excluded. every patient had complete ocular examination under general anesthesia including anterior segment examination, measurement of intraocular pressure, corneal diameter, gonioscopy, axial lengths, fundoscopy, retinoscopy where possible. indication for pressure reducing surgery was established if 4 of following criteria were fulfilled: (1) typical symptoms (epiphora, photophobia, blepharospasm) (2) cloudy cornea (3) increased iop (4) increased corneal diameter (5) increase in axial length (6) deep excavated cup (7) pcg in contralateral eye. success criteria was defined as iop below 15 mm hg under general anesthesia, stable axial lengths, disproportional enlargement of cornea, improvement or at least stability of optic disc excavation (absence of cdr progression). visual function was not taken as criteria since mean age of patients included in study was too young to obtain reliable result concerning visual acuity. a limbal based conjunctival flap was reflected above. following peritomy, wet cautry applied. subsequently, a 4 x 4 mm lamellar rectangular scleral flap was dissected crossing the grey white border line zone into clear cornea. then radial incision was given in the middle of underlying sclera, approximately 1 mm away of limbus. the schlemm’s canal was located by either scleral cut down via a deep scleral flap or direct unroofing via a deep scleral flap. to confirm about localization of schlemm’s canal and avoid false passage, 6/0 prolene or nylon suture was entered. the passive entry of suture or prolene in the passage confirms about proper location of schlemm’s canal. then the trabeculotome was gently passed on either side of incision along the canal for about 5-6 mm, with the other parallel arm of trabeculotome as a guide and the trabeculotome was rotated in the anterior chamber. the trabeculotome sweeped back and removed. the same procedure was performed on the other half. follow-up period comprised of one, two, four and eight months respectively. results ten primary operations (trabeculotomy) were performed. their mean age was 15 months (range 1029m). among 10 patients, 6 (60%) were male and 4 (40%) were female. 2 (20%) patients have family history of congenital glaucoma. bilateral glaucoma was found in 8 (80%) patients while unilateral glaucoma was found in 2 (20%). out of 10, 5 patients had opaque corneas (table 1). the trabeculotomy was successful in 8 (80%) patients, while 2 (20%) patients’ needs second surgery (table 2). their intraocular pressure was temporarily controlled with antiglaucoma medications. abdul qayyum, et al 127 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology the intraocular pressure was successfully controlled in 8 (80%) patients. the mean value of intraocular pressure was 30 ± 5.7 mm hg pre operatively and 12 ± 5.3 mm hg at the end of study (measured under general anesthesia). mean horizontal corneal diameter at detection of glaucoma was 13.06 ± 0.6. the horizontal corneal diameter was observed as stabilized. axial length was 21.9 ± 0.8 mm initially. the mean value of axial length was reduced to 20.9 ± 0.6 mm. the enhancement of cdr was also stopped. the refraction was possible in 5 patients only (5 patients had opaque corneas). the myopic shift seems to be stopped finally (table 3). 4 (40%) patients had complications comprising of false passage, hyphaema (moderate), iris prolapse and stripes in descemet’s membrane (table 4). discussion external trabeculotomy has proved to be valuable procedure in the surgical treatment of primary congenital glaucoma. our results are comparable to those reported by harms and dannheim, singer, dubois – poulsen in their publications.10, 11 one of the big advantages of trabeculotomy is that it may be done just as easily in eyes with cloudy cornea as those with clear ones.12 in settings like balochistan, where there is lack of awareness, illiteracy, lack of communications the patients of primary congenital glaucoma presents very late with hazy corneas and buphthalmos. so this procedure may be beneficial to treat primary congenital glaucoma in balochistan, keeping in view of the advantage of trabeculotomy. the numbers of patients of congenital glaucoma with opaque corneas are very high. accurate localization of schlemm’s canal is the key to successful trabeculotomy and this is made easier in several ways: if scleral flap is sufficiently deep and if sclera is dried, one can often see iris insertion with portable slit lamp and thus can localize the trabeculum. use of prolene (6/0) or nylon suture: after incising the trabecular meshwork, there is oozing of aqueous. later on 6/0 prolene or nylon suture is passed to locate the schlemm’s canal. passive entry of suture or prolene in the passage is indication of proper localization of schlemm’s canal. in this case series, tabeculotomy proved to be successful in 8 (80%) cases and failed in 2 (20%) cases. primary congenital glaucoma responds well to surgical treatment like goniotomy and trabeculotomy from 80 – 93% as noted by akimoto at al.13 the failures occur in eyes with enlarged corneas and in eyes with distorted limbal anatomy like buphthalmos. 4 patients had complications comprising of false passage, moderate hyphaema (resolved in one week), iris prolapse (relieved by peripheral iridectomy) and stripes in descemet’s membrane. trabeculotomy in primary congenital glaucoma pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 128 the trabeculotomy provides a significant reduction of iop i.e. mean iop was 12 mmhg (measured under general anesthesia) in most of the patients.14 lack of prognostic factor for the pre-operative iop should mainly be attributed to measurement in deep anesthesia. a massive reduction (decrease) of iop has been shown in animal’s models after application of halothene. consequently, it is important to consider that the normal iop in infants and children ranges between 9-12 mm hg under general anesthesia with halothane.15 in this short term study, we conclude that at least there is a decrease or stabilization in enhancement of axial lengths, stability in optic disc excavation. the refraction was possible in 5 patients (5 patients had opaque corneas) indicating low myopia. the progression of myopic shift was stopped during follow up visits. although primary congenital glaucoma is described as an entity with leading pathological feature of trabeculodysgenesis resulting in pathologically increased out flow obstruction. prognosis of surgery is thought to be influenced by the individual nature of dysgenesis. axial length of eye is also a critical factor. early manifestation and large ocular dimensions are key to limited prognosis of any pressure reducing surgery in pcg.16 as re-surgery is often inevitable in congenital glaucoma owing to lifelong expectancy, a step wise surgical strategy has to be devised, starting with ab interno surgery proceeding to conventional ab externo procedures before using anti-metabolites or cyclo destructive procedures. the present study has several limitations including relatively small number of patients, short follow-up period, difficulty of measuring visual acuity in too young, pre-verbal patients and poor patients compliance. conclusion the trabeculotomy may be performed easily both in cloudy as well as clear corneas. some of its phases are similar to trabeculectomy. the complications are not very frequent. distorted limbal anatomy buphthalmic eyes may affect prognosis of surgery. author’s affiliation dr. abdul qayyum associate professor and pediatric ophthalmologist department of ophthalmology bolan medical college, quetta prof. dr. riaz ahmed baloch head of department department of ophthalmology bolan medical college quetta references 1. chang ta c, cavuoto km. surgical management in primary congenital glaucoma: four debates. j ophthalmol. 2013; 612708. 2. morales j, shahwan sa, odhayb sa, jadaan ia, edward dp. current surgical options for the management of pediatric glaucoma. jr of ophthalmology. 2013; id763735: 16. 3. khan ao. genetics of primary glaucoma. current opinion in ophthalmolgoy. 2011; 22: 347-55. 4. mandal a, chakrabati d. updates on congenital glaucoma. indian j of ophthalmology. 2011; 59: 148-157. 5. kanski jj,. cong; glaucoma in: kanski jj. editor clinical ophthalmology 6th edition, oxford: butterworth heineman, 2009: 245-8. 6. taylor d, hoyt cs. childhood glaucoma in: david taylor & creig s hoyt-editor. pediatric ophthalmology and strabismus 3rd edition. oxford. elsevier saunders. 2005: 460-62. 7. mendicino me, lynch mg, drack a, beck, harbin t, pollard z, vela ma, lynn mj. long term surgical and visual outcomes in primary congenital glaucoma: 360 degree trabeculotomy versus goniotomy. journal of american association for pediatric ophthalmology & strabismus. 2000; 4: 205-10. 8. desilva dj, khaw pt, brooks jl. long term outcome of primary congenital glaucoma. j aapos. 2011; 15: 148-56. 9. moore db, oren tomkins o, ben-zion i. surgical results in management of advanced primary congenital glaucoma in rural population. ophthalmology. 2011; 118: 2-3. 10. harms h, dannheim r: ’’trabeculotomy-results and problems’’ in mackensen, g: microsurgery in glaucoma, basel, s. karger, 1970: pp.121-131. 11. brachet. a, singer b, dubios-poulsen a: complications de la trabeculotomy. ann oculist (paris), 1972; 205: 1203-1213. 12. neely de. false passage: a complication of 360 degree suture trabeculotomy. jaapos. 2005; 9: 396-7. 13. akimoto m. tanihara h, negi a, nagata m. surgical results of trabeculotomy ab externo for developmental glaucoma. arch ophthalmol 1994; 112: 1540-4. 14. ouy, caprioli j. surgical management of pediatric glaucoma. developments in ophthalmology. 2010; 50: 157-72. 15. rodrigues am, paranhos a, montezano ft, de arruda melo pa, prata j. comparison between results of trabeculotomy in primary congenital glaucoma with and without mitomycin c. journal of glaucoma. 2004; 13: 228-32. 16. filous a, brunova b. results of modified tabeculotomy in the treatment of primary congenital glaucoma. jaapos. 2002; 6: 182-6. http://www.ncbi.nlm.nih.gov/pubmed?term=chang%20tc%5bauthor%5d&cauthor=true&cauthor_uid=23762530 http://www.ncbi.nlm.nih.gov/pubmed?term=cavuoto%20km%5bauthor%5d&cauthor=true&cauthor_uid=23762530 pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 107 original article association between refractive errors and heterotropia: a counter check syeda rushda zaidi, mohammad ali a sadiq, asad aslam khan, hijaz ijaz pak j ophthalmol 2018, vol. 34, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. syeda rushda zaidi department of optometry & vision sciences, the university of lahore, lahore. e-mail: rushdazaidi15@live.com …..……………………….. purpose: to determine an association between refractive errors and heterotropia. study design: cross sectional study. place & duration of study: orthoptic clinic mayo hospital lahore from october 2015 to december 2015. material & methods: data was collected from college of ophthalmology and allied vision sciences, eye opd pediatrics clinic mayo hospital lahore using a non-probability convenient sampling technique. visual acuity of patients was recorded using vlc monitor at distance in decimal notation. refractive error and orthoptic assessment of the patients was later recorded for further analysis. results: a sample of 100 patients with heterotropia up to the age of 40 years was analyzed. the random composition of the male and female objects in the study was estimated to be 42% and 58% respectively. it was observed that hyperopia and hyperopic astigmatism were more prevalent in esotropia and emmetropia while myopia and myopic astigmatism were more common in exodeviations. the (p-value ≤ 0.000) confirmed an association between refractive error and heterotropia. conclusion: there is a strong association between refractive error and heterotropia. key words: refractive errors, heterotropia, hyperopic astigmatism. ncidence of strabismus is 5-8% in the general population1. typically, it encompasses a deficiency of harmonization between the two eyes, which prevents the gaze of each eye to the same point in space, thus inhibiting binocular vision and depth perception2. most common types of strabismus are ‘exotropia’ and ‘esotropia’. exotropia is an outward deviation of the eye and usually starts at the age of 2-4 years. exotropia may be constant or intermittent where inward deviation of one or both eyes occurs in esotropia. it can be constant or intermittent. ametropia indicates presence of refractive error.3,4 the patient can get different ametropic conditions such as hypermetropia, myopia or astigmatism. for instance, myopia is a type of refractive error where parallel rays of light coming from infinity are focused in front of retina when accommodation is at rest.5in addition, hypermetropia is also called long sightedness when parallel rays of light coming from infinity are focused behind the retina with accommodation at rest. astigmatism is a type of refractive error where eye has different refractive powers in different meridians6-9. a large numbers of heterotropic population have refractive errors, which can positively or negatively affect the deviation. the main cause of the refractive errors is heterotropia, which is the main interest of the study. we carried out a perspective study to evaluate the association between refractive errors and heterotropia. i syeda rushda zaidi, et al 108 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology material and methods an institutional based cross sectional data was collected from college of ophthalmology and allied vision sciences, eye opd pediatrics clinic mayo hospital lahore and a non-probability convenient sampling techniques was used to collect the data. a sample of 100 patients (october 2015 to december 2015) with heterotropia up to the age of 40 years was carried out in the analysis. in addition, data was collected by clinical examination and recording the readings in self-designed proforma consisting of patient profile, strabismus history, visual acuity, motor assessment and diagnosis. visual acuity of patients was observed using visual acuity chart (vlc) monitor at distance and visual acuity of either eye was recorded in decimal notation. refractive error and orthoptic assessment of the patients was also recorded for further analysis. patients with cataracts, subnormal best-corrected visual acuity, nystagmus and aphakics were excluded from the study. spss (version 16) was used for statistical analysis and results. results there were 43% patients with emmetropia, 2% patients had myopia while 9% had hyperopia. 28% of the patients were having hyperopic astigmatism and 15% of the patients were found with myopic astigmatism while 3% had mixed astigmatism (fig. 1). hyperopia and hyperopic astigmatism were more prevalent in esotropia whereas myopia, myopic astigmatism and emmetropia were more common in exodeviations (fig. 2). no significant association between hypertropia and refractive errors was present. subsequently the amount of deviation at distance in most of the patients lied in the range of 2645 prism diopter (pd), however 35% of patients showed deviation of 5-25 pd, 15% illustrated 46-65 pd fig. 1: distribution of patients according to refractive error. fig. 2: refractive error and type of deviation. while only 01% depicted 66-85 pd. moreover, the distribution of patients according to the amount of deviation at near in majority of the patients lied in the range of 5-25 pd while 37% had 26-45 pd, 15% showed 46-65 pd, 5% showed 66-85 pd and 3% had 86-105 pd. a significant association between refractive error and heterotropia was confirmed with (chisquare = 40.044, df = 10 and p = 0.000) as shown in table 1. table 1: refractive error with type of deviation cross tabulation. refractive error type of deviation total esodeviation exodeviation hypertropia emmetrope myopia hyperopia myopic astigmatism hyperopic astigmatism mixed astigmatism 11 27 5 43 0 2 0 2 6 3 0 9 2 13 0 15 23 5 0 28 1 1 1 3 total 43 51 6 100 chi-square (40.044) (p≤ 0.000) association between refractive errors and heterotropia: a counter check pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 109 discussion the basic purpose of this study was to counter check the association of refractive erorr with heterotropia. the study was carried out at the pediatric eye clinic mayo hospital lahore. world health organization has estimated that 153 million people worldwide live with visual impairment due to uncorrected refractive errors10. these anomalies of ocular alignment could have a strong association with visual acuity, which is the reciprocal of the minimal resolvable visual angle measured in minutes of arc for a standard test pattern11. in this study, association between refractive error and misaligned eye was counter checked. 100 heterotropic patients aged between 4-40 years were included in the study. females were more prevalent than males with a male and female percentage of 42% and 58%. exotropia commonly begins around age 2 to 4 years. it can appear at any age. exotropia may be constant or intermittent12-14. esotropia is a form of strabismus, in which one or both eyes turn inwards. the condition can also be constant or intermittent15. a study was conducted in population-based sample and the frequency of occurrence of ocular deviation and the carrier characteristics had been identified. despite other factors, the association of the ocular deviation and refractive error, esotropia and also exotropia can be present in individuals with varying degrees of myopia (up to -5.75 for xt and -2.50 for et) or hyperopia (up to +9.00 for xt and +8.00 for et)16. a study concluded that strabismus was found in 45 of 170 children (26.5%), and esodeviation was the most common type. 9 (20%) had exodeviation and 4 (8.9%) vertical deviation. in 27 of 32 esotropic patients, the strabismus was regarded as acquired esodeviations. the frequency of strabismus was lowest in the high-grade hyperopia group (5%). concerning esodeviations, fewer cases (3%) were in the high-grade hyperopia group. most of the cases with esodeviations were in correlation with low-grade hyperopia (31%), myopia (28%) and emmetropia (16%). hyperopia was the most common refractive error. astigmatism was present in 72.4% of patients. defocus in the peripheral retina associated with the misalignment of the eyes during near work might be the reason for the differences, considering the visual regulation mechanism of eyeshape17, 18. another, study revealed that in children with intermittent exotropia, myopia was calculated to occur in more than 90% of patients. observation versus surgical correction did not alter the refractive outcome19,20. in our study emmetropic population was 43% (43), myopes 2% (2), hypermetropes 9% (9) while myopic astigmatism was found in 15% (15), hypermetropic astigmatism in 28% (28) and mixed astigmatism was 3% (3). the amount of deviation at distance and the number of patients in the range of 5-25 pd were 35% (35), in 26-45 pd were 49% (49) and in 46-65 pd were 15% (15) and in 66-85 pd were 1% (1). a significant association between refractive error and heterotropia was found (chi-square 40.044) (p value 0.000). 62.8% emmetropes had exotropia while 25.6% had esotropia and 11.6% were hypertropic. all myopes in our study had exotropia. in hyperopic patients, 66.7% had exotropia and 33.3% had esotropia. 86.7% with myopic astigmatism had exotropia, 13% had esotropia. in hyperopic astigmatism, 17.9% had exotropia and 82.1% had esotropia. 33% of mixed astigmatic patient had exotropia, 33.3% had esotropia and 33.3% had hypertropia. conclusion our study confirmed that heterotropia is strongly associated with refractive errors. it is observed that hyperopia and hyperopic astigmatism was more prevalent in esotropia, emmetropia, myopia. myopic astigmatism was more common in exodeviations. author’s affiliation dr. syeda rushda zaidi m. phil, orthoptist department of optometry & allied vision sciences kemu dr. mohammad ali a sadiq fcps, assistant professor department of optometry & allied vision sciences kemu. dr. asad aslam khan fcps, professor department of optometry & allied vision sciences kemu. dr. hijaz ijaz hod, optometrist dhq hospital kasur role of authors dr. syeda rushda zaidi presented the main idea, review of literature and data analysis. http://en.wikipedia.org/wiki/strabismus http://en.wikipedia.org/wiki/human_eye syeda rushda zaidi, et al 110 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology dr. mohammad ali a sadiq data collection and analysis dr. asad aslam khan overal guidance and supervision. dr. hijab ijaz manuscript preparation. refrences 1. billson f. fundamentals of clinical ophthalmology. 1st ed. malaysia. elsevier, 2003: p.3. 2. louis s. optometric clinical practice guideline: care of the patient with strabismus: esotropia and exotropia. american optometric association, 1997. 3. bhattacharyya, b. text book of visual science and clinical optometry. 1st edition. new delhi: jaypee, 2009: p.118. 4. khurana ak. theory and practice of optics and refraction. 2nd edition. new delhi: elsevier, 2009: p. 62. 5. elkington frank jh, greaney jm. clinical optics. 3rd edition, 1999. (optics of ametropia; chap. 10): p.113115. 6. bhattacharyya, b. text book of visual science and clinical optometry. 1st edition. new delhi: jaypee, 2009: p. 120. 7. khurana ak. comprehensive ophthalmology. 4th edition. new delhi: new age international (p) ltd. 2007: p.28. 8. khurana ak. theory and practice of optics and refraction. 2nd edition. new delhi: elsevier, 2009: p. 79. 9. agarwal a. agarwal s, apple dj, burrato l, alio ji, pandy sk. ophthalmology, 1ed ed. 2002; vol. 1: p.18. 10. tanaka a, ohno-matsui k, shimada n, hayashi k, shibata y, yoshida t et al. prevalence of strabismus in patients with pathologic myopia. j med dent sci. 2010 mar; 57 (1): 75-82. 11. rowe f. clinical orthoptics. 2nd ed. india: blackwell publishing, 2004:p. 69-70. 12. rowe fj. clinical orthoptics. 3rd ed. uk. wiley black well, 2012: p. 161. 13. clarke mp. intermittent exotropia. j of pedriatr ophthalmol & strabismus, 2007 may/june; 44 (3): 153157. 14. kanski jj, bowlding b. clinical ophthalmology. 7th ed. usa. elsevier, 2011. ch. 18. strabismus: p. 771. 15. abrams. practice of refraction. 10 edi. 2005: new delhi: blackwell, p. 37. 16. hyperopia. how does the eye see? available at url http://www.laserlubbock.com/eye_basics.htm.cited on 22/10/2010. 17. abrams. practice of refraction. 10 edi. 2005. new delhi. the refraction of the eye_ physiological optics chap. 3. p.47. 18. datta h. strabismus. 1st ed. new delhi: jaypee, 2004: p. 31. 19. abrams. practice of refraction. 10 edi. 2005. new delhi. the refraction of the eye_ physiological optics chap. 3. p. 47. 20. datta h. strabismus.1sted. new delhi: jaypee, 2004: p. 31. http://www.laserlubbock.com/eye_basics.htm.cited%20on%2022/10/2010 http://www.laserlubbock.com/eye_basics.htm.cited%20on%2022/10/2010 microsoft word 15. index 28,12 pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 231 indexes (volume 28, 2012) no.1. jan – mar ................................................. page 01 – 55 no.2. apr – jun ................................................. page 56 – 114 no.3. jul – sep .................................................. page 116 – 169 no.4 oct – dec ................................................. page 170 – 237 subject index abstracts: 28: 53, 112-3, 166, 227-28. adnexa • comparison of dacryocystorhinostomy with mitomycin c against dacryocystorhinostomy with intubation in patients of nasolacrimal duct block 28: 214-8. • problems / complications, success rate – endoscopic dacryocystorhinostomy 28: 17: 21. • timing of probing for congenital nasolacrimal duct obstruction 28: 43-6. cataract • modified technique of four point scleral sutured posterior chamber intraocular lens without scleral flaps 28: 188-93. • pre-operative screening of patients for hepatitis b and c virus 28: 69: 71. • randomized clinical trial of topical versus retrobulbur anesthesia for phacoemulsification: comparison of patient satisfaction 28: 157-60 • visual outcome and complications of anterior chamber intraocular lens versus scleral fixated intraocular lens 28: 206-210. community • conservative management of congenital eversion of the upper lid in a nigerian child 28: 222-3. • factors influencing choice of specialty amongst nigerian ophthalmologists 28: 10-13. • pattern of ocular problems in school going children of district lasbela, balochistan 28: 20005. • prevalence of incidental amblyopia in buraidah city 28: 140-3. • prevalence of oculo-visual disorders amongst university students in varanasi district, north india 28: 86-90. • pattern of eye diseases in an air force hospital in nigeria 28: 144-8. conjunctiva • comparison of pterygium recurrence rate between consultants and residents using 5 fu as an adjuvant after excision of primary pterygium 28: 219-21. • role of subconjunctival bevacizumab in treatment of pterygium 28: 132-5. cornea • corneal graft in children 28: 72-6. • conductive keratoplasty for presbyopia 28: 184-7. • evaluation of fresh human amniotic membrane transplantation for the treatment of corneal perforation and impending corneal perforation 28: 194-9. • side effects and effectiveness of subconjunctival bevacizumab injection in patients with corneal neovascularization 28: 33-7. • visual and keratometric results after corneal collagen cross linking in keratoconus 28: 17983. editorial • femtosecond laser assisted cataract surgery 28: 116-7. • ophthalmic viscosurgical devices (ovds) past, present and future 28: 56-9 • restructuring of pakistan journal of ophthalmology 28: 1,2. • physical examination of patients from a glaucoma perspective 28: 170-1. glaucoma • idiosyncratic topiramate – induced high myopic shift with angle closure glaucoma 28: 224-6. • outcome of mitomycin-c augmented trabeculectomy in primary congenital glaucoma 28: 136-9. • transscleral diode laser cyclophotoco-aglation for refractory glaucoma 28: 22-6. news and events: 28: 54, 114, 167-8, 229-30. index 232 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology peads ophth • avoid euas; adequate examination possible under sedation with chloral hydrate28: 91-4. • bilateral optic disc drusen in a hypermetropic children of a family 28: 1635. • citicoline treatment of children with visual impairment; a pilot study 28: 172-8. retina • corneal topography pattern in healthy volunteers coming to the ophthalmology department hayatabad medical complex, peshawar as attendants 28: 81-5. • effect of bevacizumab and laser in the management of diabetic maculopathy 28: 2732. • intravitreal bevacizumab for treatment of diabetic macular edema 28: 3-9. • incidence of endophthalmitis after bevacizumab (avastin) 28: 66-8. • intravitreal bevacizumab for the treatment of subfoveal choroidal neovascularization secondary to age related macular degeneration 28: 211-3. • outcome of rhegmetogenous retinal detachment surgery in uncomplicated pseudophakic eyes 28: 38-42. • outcome of macular hole surgery at mayo hospital, lahore 28: 77-80. • prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicentre diabetic clinics in karachi 28: 99104. • retinal redetachment after silicone oil removal 28: 127-32. • total retinal detachment 28: 4953. • to compare the effect of intravitreal bevacizumab on the resolution of macularedema secondary to diabetic retinopathy and branch retinal vein occlusion 28: 60-5. • visual outcome after intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion 28: 154-6. • yag laser for macular subhyaloid hemorrhage 28: 105-8. sclera • congenital erythropoietin porphyria (cep) a case of necrotic scleritis 28: 47: 8. squint • graded recession for primary inferior oblique over action 28: 122-6. trauma • epidemiology of penetrating ocular trauma 28: 14-6. • management of intraocular foreign body in tertiary care hospital 28: 118-121. • presentation of ocular and orbital dermoid cysts at holy family hospital rawalpindi 28: 95-8. • sebaceous gland carcinoma of the lower eyelid 28: 109-111. uveitis • presentation of posner schlossman syndrome and viral uveitis 28: 161-2. uveitis • sulfadiazine plus clindamycin and trimethoprim / sulfamethoxazole plus clindamycin versus standard treatment for therapy of ocular toxoplasmosis 28: 14953. vitreous • cholesterosis bulbi in a painful blind eye with high intraocular pressure and long standing 28: author index ali z: epidemiology of penetrating ocular trauma 28: 14-6. aslam s: congenital erythropoietin porphyria (cep) a case of necrotic scleritis 28: 47: 8. ahmad s: problems / complications, success rate – endoscopic dacryocystorhinostomy 28: 17: 21. ahmed s: problems / complications, success rate – endoscopic dacryocystorhinostomy 28: 17: 21. aslam i: problems / complications, success rate – endoscopic dacryocystorhinostomy 28: 17: 21. ahmad n: effect of bevacizumab and laser in the management of diabetic maculopathy 28: 27-32. ahmed cn: effect of bevacizumab and laser in the management of diabetic maculopathy 28: 27-32. arif m: effect of bevacizumab and laser in the management of diabetic maculopathy 28: 27-32. ain q: effect of bevacizumab and laser in the management of diabetic maculopathy 28: 27-32. ahmad n: out come of macular hole surgery at mayo hospital, lahore 28: 77-80. ahmad m: corneal topography pattern in healthy volunteers coming to the ophthalmology department hayatabad medical complex, peshawar as attendants 28: 81-5 ahmed cn: out come of macular hole surgery at mayo hospital, lahore 28: 77-80. index pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 233 arif m: out come of macular hole surgery at mayo hospital, lahore 28: 77-80. ali ss: sebaceous gland carcinoma of the lower eyelid 28: 109-111. asim aa: graded recession for primary inferior oblique over action 28: 122-6. arshad r: role of subconjunctival bevacizumab in treatment of pterygium 28: 132-5. ahmed mi: prevalence of incidental amblyopia in buraidah city 28: 140-3. al-debasi yh: prevalence of incidental amblyopia in buraidah city 28: 140-3. adenuga oo: pattern of eye diseases in an air force hospital in nigeria 28: 144-8. asif si: role of subconjunctival bevacizumab in treatment of pterygium 28: 132-5. awan ah: conductive keratoplasty for presbyopia 28: 184-7. ahmad m: visual outcome and complications of anterior chamber intraocular lens versus scleral fixated intraocular lens 28: 206-10. ahmed a: intravitreal bevacizumab for the treatment of subfovealchoroidal neovascularization secondary to agerelated macular degeneration 28: 211-3. abbasi kz: evaluation of fresh human amniotic membrane transplantation for the treatment of corneal perforation and impending corneal perforation 28: 194-9. azhar mn: intravitreal bevacizumab for the treatment of subfovealchoroidal neovascularization secondary to age – related macular degeneration 28: 211-3. baig mirza ab: visual and keratometric results after corneal collagen cross linking in keratoconus 28: 179-83. bokhari sa: bilateral optic disc drusen in a hypermetropic children of a family 28: 1635. butt mh: news and events 28: 54, 114, 167-8, 229-30. bhutto ia: outcome of mitomycin-c augmented trabeculectomy in primary congenital glaucoma 28: 136-9. bukhari s: outcome of mitomycin-c augmented trabeculectomy in primary congenital glaucoma 28: 136-9. bokhari sa: management of intraocular foreign body in tertiary care hospital 28: 118-121. baig mirza ab: visual outcome after intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion 28: 154-6. behnaz f: sulfadiazine plus clindamycin and trimethoprim / sulfamethoxazole plus clindamycin versus standard treatment for therapy of ocular toxoplasmosis 28: 14953. burney ja: sebaceous gland carcinoma of the lower eyelid 28: 109-111. bokhari sa: to compare the effect of intravitreal bevacizumab on the resolution of macularedema secondary to diabetic retinopathy and branch retinal vein occlusion 28: 60-5 bhushan p: prevalence of oculo-visual disorders amongst university students in varanasi district, north india 28: 86-90. bokhari sa: corneal graft in children 28: 72-6. bhatti n: side effects and effectiveness of subconjunctival bevacizumab injection in patients with corneal neovascularization 28: 33-7. bokhari sa: transscleral diode laser cyclophotocoaglation for refractory glaucoma 28: 22-6. choudhry aa: intravitreal bevacizumab for treatment of diabetic macular edema 28: 3-9. chaudhry ql: effect of bevacizumab and laser in the management of diabetic maculopathy 28: 27-32. chaudhry ql: out come of macular hole surgery at mayo hospital, lahore 28: 77-80. chaudhry ql: abstract: 28: 53, 112-3, 166, 227-8. dawar s: prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicentre diabetic clinics in karachi 28: 99-104. fawad u: side effects and effectiveness of subconjunctival bevacizumab injection in patients with corneal neovascularization 28: 33-7. fehmi ms: randomized clinical trial of topical versus retrobulbur anesthesia for phacoemulsification: comparison of patient satisfaction 28: 157-60. fasih u: randomized clinical trial of topical versus retrobulbur anesthesia for phacoemulsification: comparison of patient satisfaction 28: 157-60. ghayoor i: yag laser for macular subhyaloid hemorrhage 28: 105-8. huda w: randomized clinical trial of topical versus retrobulbur anesthesia for phacoemulsification: comparison of patient satisfaction 28: 157-60. hashmani s: graded recession for primary inferior oblique over action 28: 122-6. haider si: yag laser for macular subhyaloid hemorrhage 28: 105-8. hashmani s: yag laser for macular subhyaloid hemorrhage 28: 105-8. hasan t: prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicentre diabetic clinics in karachi 28: 99-104. index 234 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology hussain m: side effects and effectiveness of subconjunctival bevacizumab injection in patients with corneal neovascularization 28: 33-7. hasan mu: side effects and effectiveness of subconjunctival bevacizumab injection in patients with corneal neovascularization 28: 33-7. hussain sa: congenital erythropoietin porphyria (cep) a case of necrotic scleritis 28: 47: 8. haq sn: problems / complications, success rateendoscopic dacryocystorhinostomy 28: 17: 21. hussain m: epidemiology of penetrating ocular trauma 28: 14-6. hussain m: intravitreal bevacizumab for treatment of diabetic macular edema 28: 3-9. haq a: effect of bevacizumab and laser in the management of diabetic maculopathy 28: 27-32. haider a: cholesterosis bulbi in a painful blind eye with high intraocular pressure and long standing total retinal detachment 28: 4953. haider sa: incidence of endophthalmitis after bevacizumab (avastin) 28: 66-8. haq a: out come of macular hole surgery at mayo hospital, lahore 28: 77-80. haq mi: visual and keratometric results after corneal collagen cross linking in keratoconus 28: 179-83. haider ma: visual results and safety profile of a modified technique of four point scleral sutured posterior chamber intraocular lens without scleral flaps 28: 188-93. haider ma: intravitreal bevacizumab for the treatment of subfovealchoroidal neovascularization secondary to agerelated macular degeneration 28: 211-3. iqbal s: visual outcome and complications of anterior chamber intraocular lens versus scleral fixated intraocular lens 28: 206-10. iqbal y: visual and keratometric results after corneal collagen cross linking in keratoconus 28: 179-83. iqbal s: corneal topography pattern in healthy volunteers coming to the ophthalmology department hayatabad medical complex, peshawar as attendants 28: 81-5 irfan s: avoid euas; adequate examination possible under sedation with chloral hydrate 28: 91-4. islam z: timing of probing for congenital nasolacrimal duct obstruction28: 43-6. imran m: congenital erythropoietin porphyria (cep) a case of necrotic scleritis 28: 47: 8. imran m: presentation of posner schlossman syndrome and viral uveitis 28: 161-2. iqbal y: visual outcome after intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion 28: 154-6. jamil ma: graded recession for primary inferior oblique over action 28: 122-6. jahangir k: retinal redetachment after silicone oil removal 28: 127-32. jahangir t: cholesterosis bulbi in a painful blind eye with high intraocular pressure and long standing total retinal detachment 28: 4953. jahangir s: cholesterosis bulbi in a painful blind eye with high intraocular pressure and long standing total retinal detachment 28: 4953. jadoon z: prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicentre diabetic clinics in karachi 28: 99-104. jahangir k: pre-operative screening of patients for hepatitis b and c virus 28: 69: 71. jehangir n: corneal topography pattern in healthy volunteers coming to the ophthalmology department hayatabad medical complex, peshawar as attendants 28: 81-5. jahangir t: modified technique of four point scleral sutured posterior chamber intraocular lens without scleral flaps 28: 188-93. jahangir s: modified technique of four point scleral sutured posterior chamber intraocular lens without scleral flaps 28: 188-93. jadoon mz: pattern of ocular problems in schoolgoing children of district labella, baluchistan 28: 20005. jafri hr: comparison of dacryocystorhinostomy with mitomycin c against dacryocystorhinostomy with intubation in patients of nasolacrimal duct block 28: 214-8. kamil z: to compare the effect of intravitreal bevacizumab on the resolution of macularedema secondary to diabetic retinopathy and branch retinal vein occlusion 28: 60-5 kamil z: corneal graft in children 28: 72-6. khan aa: out come of macular hole surgery at mayo hospital, lahore 28: 77-80. khaqan ha: incidence of endophthalmitis after bevacizumab (avastin) 28: 66-8. khan aa: effect of bevacizumab and laser in the management of diabetic maculopathy 28: 27-32. khan a: intravitreal bevacizumab for treatment of diabetic macular edema 28: 3-9. index pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 235 kamil z: transscleral diode laser cyclophotocoaglation for refractory glaucoma 28: 22-6. kamil z: management of intraocular foreign body in tertiary care hospital 28: 118-121. kamil z: bilateral optic disc drusen in a hypermetropic children of a family 28: 1635. lateef q: incidence of endophthalmitis after bevacizumab (avastin) 28: 66-8. lakho ka: pattern of ocular problems in school going children of district labella, baluchistan 28: 200-05. lennerstrand g: citicoline treatment of children with visual impairment; a pilot study 28: 172-8. mahar ps: pattern of ocular problems in school going children of district labella, baluchistan 28: 200-05. majeed aa: modified technique of four point scleral sutured posterior chamber intraocular lens without scleral flaps 28: 188-93. mahmood h: pre-operative screening of patients for hepatitis b and c virus 28: 69: 71. mahju tm: out come of macular hole surgery at mayo hospital, lahore 28: 77-80. memon wu: prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicentre diabetic clinics in karachi 28: 99-104. maurya rp: prevalence of oculo-visual disorders amongst university students in varanasi district, north india 28: 86-90. mubaruk b: intravitreal bevacizumab for treatment of diabetic macular edema 28: 3-9. mahar ps: ophthalmic viscosurgical devices (ovds) past, present and future 28: 56-9 moin m: restructuring of pakistan journal of ophthalmology 28: 1,2. malik iq: epidemiology of penetrating ocular trauma 28: 14-6. moin m: epidemiology of penetrating ocular trauma 28: 14-6. manzoor m: problems/complications, success rateendoscopic dacryocystorhinostomy 28: 17: 21. mahju tm: effect of bevacizumab and laser in the management of diabetic maculopathy 28: 27-32. memon f: outcome of rhegmetogenous retinal detachment surgery in uncomplicated pseudophakic eyes 28: 38-42. mahar ps: outcome of rhegmetogenous retinal detachment surgery in uncomplicated pseudophakic eyes 28: 38-42. muhammad z: timing of probing for congenital naso-lacrimal duct obstruction 28: 43-6. mahmood h: news and events 28: 54-5, 114, 167-8, 229-30. mahar ps: outcome of mitomycin-c augmented trabeculectomy in primary congenital glaucoma 28: 136-9. memon as: outcome of mitomycin-c augmented trabeculectomy in primary congenital glaucoma 28: 136-9. miratashi am: sulfadiazine plus clindamycin and trimethoprim / sulfamethoxazole plus clindamycin versus standard treatment for therapy of ocular toxoplasmosis 28: 14953. maanaviat mr: sulfadiazine plus clindamycin and trimethoprim / sulfamethoxazole plus clindamycin versus standard treatment for therapy of ocular toxoplasmosis 28: 14953. muhammad safdar iqbal: presentation of posner schlossman syndrome and viral uveitis 28: 161-2. memon gm: bilateral optic disc drusen in a hypermetropic children of a family 28: 1635. nair v: prevalence of incidental amblyopia in buraidah city 28: 140-3. naz s: prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicentre diabetic clinics in karachi 28: 99-104. nadeem s: presentation of ocular and orbital dermoid cysts at holy family hospital rawalpindi 28: 95-8. naeem m: visual outcome and complications of anterior chamber intraocular lens versus scleral fixated intraocular lens 28: 206-10. nizamani nb: idiosyncratic topiramate – induced high myopic shift with angle closure glaucoma 28: 224-26. oluwatosin g: comparison of pterygium recurrence rate between consultants and residents using 5 fu sas an adjuvant after excision of primary pterygium 28: 219-21. omolase co: conservative management of congenital eversion of the upper lid in a nigerian child 28: 222-3. ogunleye ot: conservative management of congenital eversion of the upper lid in a nigerian child 28: 222-3. omolase bo: conservative management of congenital eversion of the upper lid in a nigerian child 28: 222-3. ogedengbe a: conservative management of congenital eversion of the upper lid in a nigerian child 28: 222-3. oluwole oc: factors influencing choice of specialty amongst nigerian ophthalmologists 28: 10-3. qureshi ma: prevalence of incidental amblyopia in buraidah city 28: 140-3. omar r: role of subconjunctival bevacizumab in treatment of pterygium 28: 132-5. index 236 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology qidwai u: side effects and effectiveness of subconjunctival bevacizumab injection in patients with corneal neovascularization 28: 33-7. pansell t: citicoline treatment of children with visual impairment; a pilot study 28: 172-8. qidwai n: comparison of the surgical outcome of dacryocystorhinostomy with mitomycin c against dacryocystorhinostomy with intubation in patients of nasolacrimal duct block 28: 214-8. qazi za: intravitreal bevacizumab for the treatment of subfovealchoroidal neovascularization secondary to age – related macular degeneration 28: 211-3. qidwai u: prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicentre diabetic clinics in karachi 28: 99-104. rehman a: epidemiology of penetrating ocular trauma 28: 14-6. rizvi sf: transscleral diode laser cyclophotocoaglation for refractory glaucoma 28: 22-6. rehman au: side effects and effectiveness of subconjunctival bevacizumab injection in patients with corneal neovascularization 28: 33-7. raza a: presentation of ocular and orbital dermoid cysts at holy family hospital rawalpindi 28: 95-8. rizvi sf: corneal graft in children 28: 72-6. rizvi f: to compare the effect of intravitreal bevacizumab on the resolution of macularedema secondary to diabetic retinopathy and branch retinal vein occlusion 28: 60-5 rahman h: pre-operative screening of patients for hepatitis b and c virus 28: 69: 71. rimsha s: role of subconjunctival bevacizumab in treatment of pterygium 28: 132-5. rizvi sf: management of intraocular foreign body in tertiary care hospital 28: 118-121. rehman a: randomized clinical trial of topical versus retrobulbur anesthesia for phacoemulsification: comparison of patient satisfaction 28: 157-60. rydberg a: citicoline treatment of children with visual impairment; a pilot study 28: 177-8. sana j: modified technique of four point scleral sutured posterior chamber intraocular lens without scleral flaps 28: 188-93. sanaullah: visual outcome and complications of anterior chamber intraocular lens versus scleral fixated intraocular lens 28: 206-10. siddiqui ap: citicoline treatment of children with visual impairment; a pilot study 28: 172-8. sultan s: randomized clinical trial of topical versus retrobulbur anesthesia for phacoemulsification: comparison of patient satisfaction 28: 157-60. shaikh a: randomized clinical trial of topical versus retrobulbur anesthesia for phacoemulsification: comparison of patient satisfaction 28: 157-60. shakir m: bilateral optic disc drusen in a hypermetropic children of a family 28: 1635. shakir m: management of intraocular foreign body in tertiary care hospital 28: 118-121. shahzada bs: role of subconjunctival bevacizumab in treatment of pterygium 28: 132-5. samuel oj: pattern of eye diseases in an air force hospital in nigeria 28: 144-8. shakir m: corneal graft in children 28: 72-6. shah sra: out come of macular hole surgery at mayo hospital, lahore 28: 77-80. shah s: yag laser for macular subhyaloid hemorrhage 28: 105-8. sarwar s: out come of macular hole surgery at mayo hospital, lahore 28: 77-80. singh vp: prevalence of oculo-visual disorders amongst university students in varanasi district, north india 28: 86-90. singh mk: prevalence of oculo-visual disorders amongst university students in varanasi district, north india 28: 86-90. sen pr: prevalence of oculo-visual disorders amongst university students in varanasi district, north india 28: 86-90. siddiq z: intravitreal bevacizumab for treatment of diabetic macular edema 28: 3-9. shoaib kk: problems / complications, success rateendoscopic dacryocystorhinostomy 28: 17: 21. shakir m: transscleral diode laser cyclophotocoaglation for refractory glaucoma 28: 22-6. shah sra: effect of bevacizumab and laser in the management of diabetic maculopathy 28: 27-32. sarwar s: effect of bevacizumab and laser in the management of diabetic maculopathy 28: 27-32. soomro q: outcome of rhegmetogenous retinal detachment surgery in uncomplicated pseudophakic eyes 28: 38-42. shoaib kk: timing of probing for congenital nasolacrimal duct obstruction28: 43-6. tariq m: timing of probing for congenital nasolacrimal duct obstruction28: 43-6. tayyab aa: congenital erythropoietin porphyria (cep) a case of necrotic scleritis 28: 47: 8. tahir my: effect of bevacizumab and laser in the management of diabetic maculopathy 28: 27-32. tayyab h: cholesterosis bulbi in a painful blind eye with high intraocular pressure and long standing total retinal detachment 28: 4953. index pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 237 tahir my: outcome of macular hole surgery at mayo hospital, lahore 28: 77-80. tayyab aa: presentation of posner schlossman syndrome and viral uveitis 28: 161-2. talpur ki: femtosecond laser assisted cataract surgery 28: 116-7. tayyab h: visual results and safety profile of a modified technique of four point scleral sutured posterior chamber intraocular lens without scleral flaps 28: 206-10. tayyab h: intravitreal bevacizumab for the treatment of subfovealchoroidal neovascularization secondary to agerelated macular degeneration 28: 211-3. talpur ki: idiosyncratic topiramate – induced high myopic shift with angle closure glaucoma 28: 224-6. ubah josephine nu: a comparison of pterygium recurrence rate between consultants and residents using 5 fu sas an adjuvant after excision of primary pterygium 28: 219-21. upadhyay op: prevalence of oculo-visual disorders amongst university students in varanasi district, north india 28: 86-90. waseem r: role of subconjunctival bevacizumab in treatment of pterygium 28: 132-5. zafar s: transscleral diode laser cyclophotocoaglation for refractory glaucoma 28: 22-6. zafar s: corneal graft in children 28: 72-6. zaheer m: graded recession for primary inferior oblique over action 28: 122-6. zafar s: management of intraocular foreign body in tertiary care hospital 28: 118-121. zadeh m: sulfadiazine plus clindamycin and trimethoprim / sulfamethoxazole plus clindamycin versus standard treatment for therapy of ocular toxoplasmosis 28: 14953. zafar s: bilateral optic disc drusen in a hypermetropic children of a family 28: 1635. zia s: visual outcome after intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion 28: 154-6. abstracts index cataract • early experience with the femtosecond laser for cataract surgery 28: 112. • phacoemulsification versus trabeculectomy in medically uncontrolled chronic angle – closure glaucoma without cataract 28: 227-8. conjunctiva • recurrence and complications after 1000 surgeries using pterygium extended removal followed by extended conjunctival transplant 28: 166. cornea • efficacy and safety of long-term corticosteroid eye drops after penetrating keratoplasty: a prospective, randomized, clinical trial 28: 53. • visual outcomes and safety of a refractive corneal inlay for presbyopia using femtosecond laser 28: 228. glaucoma • a twenty – year follow-up study after abeculectomy: risk factors and outcomes 28: 112. ptosis • brow ptosis after temporal artery biopsy: incidence and associations 28:167. retina • benefit from bevacizumab for macular edema in central retinal vein occlusion: twelve-month results of a prospective, randomized study 28:166. • grid laser photocoagulation for macular edema due to branch retinal vein occlusion in the age of bevacizumab? results of a prospective study with crossover design 28:227. • intravitreal ranibizumab for diabetic macular edema with prompt versus deferred laser treatment: three-year randomized trial results 28:166. • long-term visual acuity and the duration of macular detachment: findings from a prospective population – based study 28:227. • outcomes of sulfur hexafluoride (sf6) versus perfluoroethane (c2f6) gas tamponade for non-posturing macular-hole surgery 28: 53. • ranibizumab and bevacizumab for treatment of neovascular age – related. macular degeneration: two – year results. comparison of age – related macular degeneration treatments trials (catt) research group 28: 112. tumor correlation between clinical features, magnetic resonance imaging, and histopathologic findings in retinoblastoma: a prospective study 28: 53. 184 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology original article scleral patch graft in spontaneous and traumatic corneoscleral perforations sharjeel sultan, nisar a. siyal, nargis nizam ashraf, a. rasheed khokhar pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sharjeel sultan department of ophthalmology civil hospital, karachi email: sharj35@outlook.com …..……………………….. purpose: to study the efficacy of scleral patch graft in spontaneous and traumatic corneoscleral perforations. study design: interventional case series. place and duration of study: civil hospital karachi, unit 2 of ophthalmology, from march 2017 till august 2017. material and methods: patients underwent scleral patch graft in spontaneous and traumatic corneoscleral perforations. convenience sampling was used for patient sampling. baseline demographic characteristics such as age, gender and clinical parameters were included. visual acuity (preand postoperative), details of surgery, final outcome and the complications were noted. statistical package for social sciences (spss) version 20 was used for data analysis. results: fifteen eyes of 15 patients were studied with scleral patch grafting in spontaneous and traumatic corneoscleral perforations. ten patients (66.7%) were male and five (33.3%) were females. age ranged from 10 to 80 years. surgery was done in seven (46.7%) right eyes and eight (53.3%) left eyes. in five eyes (33.3%), postoperative visual acuity remained unchanged. stable ocular surface was observed in nine patients (60.0%) and improvement was observed in one eye (case 3). in 3 patients (case 1, 10 and 12) keratoplasty was advised and one patient (case 13) was advised evisceration. conclusion: preserved scleral graft in spontaneous and traumatic corneoscleral perforations gives both functional and structural stability to eyes. keyword: scleral patch graft, corneoscleral perforations, visual acuity. ye is a very delicate organ of the body so nature has protected it in a very hard bony socket. injuries to eye are a common cause of emergency attendance and can vary from simple corneal laceration to the most devastating globe rupture1. small self-sealing wounds are easier to manage by patching and bandage contact lens whereas large defects may need primary repair. around the world, corneal and scleral perforations are a common cause of blindness2. trauma is considered the most important cause of unilateral vision loss and second major cause of corneal blindness in developed countries3,4. in patients with severe visual loss it also represents a profound psychological and economic trauma for patients and their families. for preserving both structural and functional integrity of the globe a simple and an effective method of scleral grafting with overlying conjunctival or amniotic membrane was used5. staphyloma formation, scleral perforation, and uveal exposure can result after this treatment. globe rupture is also a risk factor in patients with pre-existing scleral pathology during scleral buckling procedures6. as scleral graft is readily available from the cadaveric corneal button it can be used in cases of emergency where other materials are difficult to seek7. scleral graft obtained from donor eyes can be preserved for months and is strong with high tensile e scleral patch graft in spontaneous and traumatic corneoscleral perforations pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 185 strength. donor sclera was observed with rare rejections by the host8. it is avascular and is well tolerated with little inflammatory reaction9. it has long shelf life and because of its color it is cosmetically most acceptable. use of scleral grafting is not limited to globe rupture but can also be used in various conditions of impending globe rupture such as scleral thinning after pterygium excision, high myopia, scleral ectasia, necrotizing scleritis systemic vasculitis etc. to reinforce thin sclera and prevent uveal prolapse10. nowadays, for managing such dreadful conditions homograft and auto grafts are gaining success, to close the defect and make eye water-tight and restore the tectonic stability of eye and prevent the eye from endophthalmitis11. surgeons from different parts of world use different grafts for this purpose, but none are superior to the other5,12,5. other commonly used grafting materials are fascia lata, periosteum, skin, amniotic membrane, autologous and homologous sclera13. in this study, homologous sclera was used as the graft. the aim of our study was to study efficacy of scleral patch graft in spontaneous and traumatic corneoscleral perforations. material and methods the study was an interventional case series conducted between march 2017 and august 2017. patients admitted in the ophthalmology ward, civil hospital karachi, unit 2 from emergency or outpatient department (opd) with spontaneous or traumatic corneoscleral perforation and eligible for scleral patch graft were included in the study. convenience sampling was used for patient selection. baseline demographic characteristics such as age, gender and clinical parameters were recorded. the included visual acuity (preand postoperative), surgical detail, length to follow-up, outcomes and related complications. after complete history, examination and necessary investigations, patient were planned for surgery on the next day. remaining corneoscleral buttons after corneal transplantation procedures at our hospital were used. they were stored in tissue culture medium, at 2–6°c (hypothermic storage method) or 31–37°c (organ culture method)14. storage time can be extended after removing corneoscleral button from globe. the longer the storage time the greater is the flexibility. the first step was to do 360-degree peritomy to identify the extent of rupture, then all nonviable and sloughed off tissues and foreign body if any was removed15. size of the defect was measured by using a caliper. according to the size of defect the donor sclera was isolated from corneal button, washed and cleaned to remove any debris over the sclera. before surgery it was soaked in ringer lactate solution for 10 minutes, then in betadine for 10 minutes and in the end in gentamicin 20 mg/ml solution for 10 minutes. it was sutured over the defect with interrupted nylon sutures. conjunctiva was reposited. local or general anesthesia was used for operation throughout the study. after surgery, eyes were bandaged and opened the next day. post-operative treatment included topical steroids, antibiotics, and lubricant eye drops. surgical success was recorded as eligibility for keratoplasty, stable ocular surface and phthisis bulbi. complications and visual outcomes were noted. statistical package for social sciences (spss) version 20 was used for analyzing percentages, mean and standard deviation. results fifteen eyes of 15 patients were included who had scleral patch grafting in spontaneous and traumatic corneoscleral perforations. ten patients were male (66.7%) and five were females (33.3%). age range of patients was 10-80 years. mean age was 52.93 ± 20.69. surgery was done in seven (46.7%) right eyes and eight (53.3%) left eyes. table 1 describes the other details. pain, redness and irritation were most common symptoms. traumatic corneoscleral perforation was the common indication for surgical interventions in these patients. the most common findings observed in these patients were; descemetoceles (case 1 and case 4), post limbal scleral perforation (case 3), old scar leading to perforation of cornea (case 5), central corneal thinning with perforation (case 12), adherent leucoma with iris prolapse (case 13) and loss of corneal sensation causing perforation of cornea with thinning (case 14). complications were observed in three cases, who developed phthisis bulbi (case 9, 11) and evisceration was performed (case 13) due to late onset postoperative endophthalmitis. in five (33.3%) eyes postoperatively, visual acuity remained same as preoperative visual acuity. stable ocular surface was seen in nine patients (60.0%) and in one (case 3) eye, improvement was seen. in three (case 1, 10 and 12) eyes, keratoplasty was advised but patients declined surgery. other complications such as sharjeel sultan, et al 186 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology phthisis bulbi was observed in case 9 and case 11. one eye (case 13) was advised evisceration. evisceration was performed for postoperative endophthalmitis. scleral melt after pterygium in fig 1 shows pre operative scleral thinning after traumatic scleral perforation with a nail. in fig 2, medial rectus muscles were exposed which results in visualization of underlying uvea with scleral thinning by scleral patch graft. in figure 3 severe corneal thinning with descemetocele covered with scleral patch graft is shown. table 1: baseline characteristics, treatment and outcome of scleral patch graft. s. no. age sex eye pre-operative visual acuity findings surgery post-operative visual acuity outcome complications 1 55 m od cf at 4 ft descematocele cspg cf at 4 ft advised keratoplasty none 2 70 m os hm traumatic corneal perforation cspg cf at 3 ft stable ocular surface none 3 10 f os 6/60 post limbal scleral perforation spg 6/12 stable ocular surface none 4 60 m od cf at 3 ft descematocele cspg cf at 3 ft stable ocular surface none 5 75 f os hm olsd scar leading to perforation of cornea cspg cf at 1 ft stable ocular surface none 6 35 m od cf at 3 ft traumatic corneal perforation with sloughing of cornea cpg cf at 1 ft stable ocular surface none 7 48 f os cf at 4 ft traumatic corneoscleral perforation cspg 6/60 stable ocular surface none 8 62 m od hm traumatic scleral rupture spg cf at 1 ft stable ocular surface none 9 68 m os pl + ve traumatic corneoscleral perforation spg pl+ve shrunken eye ball phthisis bulbi 10 34 f od hm traumatic corneal perforation cpg cf at 2 ft advised keratoplasty none 11 38 m os pl+ve traumatic corneoscleral perforation with sloughing of sclera cspg pl+ ve shrunken eyeball phthisis bulbi 12 23 m od cf at 3 ft central corneal thinning with perforation cpg cf at 1ft advised keratoplasty none 13 69 f os pl +ve adherent leucoma with iris prolapse cpg pl+ve advised evisceration due to late postoperative endophthalmitis evisceration done 14 80 m od cf at 4 ft loss of corneal sensation spg cf at 1 ft stable ocular surface none scleral patch graft in spontaneous and traumatic corneoscleral perforations pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 187 causing perforation of cornea with thinning 15 67 m os cf at 2 ft traumatic scleral perforation spg cf at 5 ft stable ocular surface none right eye (od), left eye (os) corneoscleral patch graft (cspg) scleral patch graft (spg) counting fingers (cf at a certain number of feet) hand motion (hm at a certain number of feet) light perception (pl) no light perception (npl) visual acuity (va) fig. 1: preoperative scleral thinning after traumatic scleral perforation with a nail. discussion the main outcome in our study was a stable ocular surface in patients who received scleral patch grafting after spontaneous and traumatic corneoscleral perforations. previous report shows that corneal and corneoscleral injuries are well known major cause of decreased vision and ensuing decrease in quality of life for service members16. in our study, human homograft and autograft techniques were used as it is used to manage ocular diseases reported in earlier study17. in our study, patients were found with trauma at initial visit and were treated with scleral patch grafts in spontaneous and traumatic corneoscleral fig. 2: postoperative picture showing scleral thinning strengthened by a scleral patch graft. perforations similar to many other studies2,18. the biological quality of corneoscleral discs was reported comparable to that of tissue obtained from enucleated eye. sclera (corneoscleral button) has number of advantages but the strict criticism was necrotic process. similarly, peripheral corneal grafting is also the rare surgical treatments with tectonic sclera excluding in case of necrotizing sclera19. sclera was also used as a graft in most of the studies, in scleromalacia. similarly, there is a list of many tissues used as reconstructive materials but, still no such material is universally acceptable. sharjeel sultan, et al 188 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology fig. 3: severe corneal thinning with descemetocele covered with scleral patch graft. in our study, males are more commonly affected than females similar to shalini mohan et.al. study in which five times more affected peoples are males than females15. the risk of damage was commonly found in young age group – around half of patients in our study were under 50 years of age. detailed patient data which includes mode, duration and injury object are foremost step followed in any corneoscleral perforation repair. but, it was included in limitations of our study that no such related history was noted from patients. patients before surgery were properly evaluated to the injury with other associated injuries for possibility of concomitant microbial contamination etc. it is well known that surgical treatment alone does not solve the problem of the patient, therefore physician must control the immunoregulatory dysfunction which causes destruction of the graft and, subsequently, the patient's eye20. after scleral graft visual acuity was improved in our study similar to study done by hwan and coworkers21. previous studies show that visual improvement was made by removing sutures on corneal side of scleral graft and by decreasing inflammation22. ti et al, reported that after pterygium surgery in patients with scleral melting, corneal lamellar graft help to maintain integrity of the globe23. in this study, scleral patch grafting in spontaneous and traumatic corneoscleral perforations was achieved in most of the eyes for scleral defects of favorable structural outcome. only, three patients had complications; two patients developed phithisical eye and one eye was eviscerated due to late onset endophthalmitis. this study has numerous limitations, including the loss of patients to follow-up and incomplete records. despite the numerous limitations, the study demonstrates the limitations of our current surgical capabilities to combat ocular trauma. another limitation is the lack of details of re-epithelialization of the stable ocular surface. conclusion this study concludes that preserved scleral graft in spontaneous and traumatic corneoscleral perforations provides functional and structural stability to eyes with rare complications. conflict of interest there is no conflict of interest. author’s affiliation dr. sharjeel sultan mbbs, doms, mcps, fcps, frcs. assistant professor ophthalmology dow university of health sciences civil hospital, unit 2 eye department karachipakistan dr. nisar a siyal mbbs, mcps, fcps assistant professor ophthalmology dow university of health sciences civil hospital, unit 2 eye department karachipakistan dr. nargis nizam ashraf mbbs, fcps. assistant professor ophthalmology dow university of health sciences civil hospital, unit 2 eye department karachipakistan dr. a rasheed khokhar mbbs, fcps professor and head of department ophthalmology dow university of health sciences civil hospital, unit 2 eye department karachipakistan scleral patch graft in spontaneous and traumatic corneoscleral perforations pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 189 role of authors dr. sharjeel sultan concept and design, undertook the data analyses, wrote, edited and revised the manuscript. dr. nisar a siya interpretation of data, wrote and reviewed the manuscript dr. nargis nizam ashraf wrote, edited and reviewed the manuscript dr. a rasheed khokhar reviewed and approved the manuscript references 1. jennifer hs, marian s. m needles, sutures, and instruments. available from www.ophed.com 2. fong yy, yu m, young al, jhanji v. presentation and management outcomes of corneal and scleral perforations in geriatric nursing home residents. medicine, 2015; 94 (36). 3. shalini m, anand a, anita p, shibal b. repair of corneoscleral perforations. dos times– 2008; 14 (2). 4. dandona r, dandona l. corneal blindness in a southern indian population: need for health promotion strategies. br j ophthalmol. 2003; 87 (2): 133-141. 5. sangwan vs, jain v, gupta p. structural and functional outcome of scleral patch graft. eye, 2007; 21 (7): 930-5. 6. nguyen qd, foster cs. scleral patch graft in the management of necrotizing scleritis. international ophthalmology clinics, 1999; 39 (1): 109-31. 7. parekh m, ferrari s, di iorio e, barbaro v, camposampiero d, karali m, ponzin d, salvalaio g. a simplified technique for in situ excision of cornea and evisceration of retinal tissue from human ocular globe. journal of visualized experiments: jove. 2012; (64): 3765. 8. sangwan vs, jain v, gupta p. structural and functional outcome of scleral patch graft. eye, 2007; 21 (7): 930. 9. lee js, shin mk, park jh, park ym, song m. autologous advanced tenon grafting combined with conjunctival flap in scleromalacia after pterygium excision. journal of ophthalmology, 2015; 2015. 10. ramenaden er, raiji vr. clinical characteristics and visual outcomes in infectious scleritis: a review. clinical ophthalmology (auckland, nz). 2013; 7: 2113. 11. sahin i, alhan d, nışancı m, ozer f, eski m, işık s. auto-/homografting can work well even if both autograft and allograft are meshed in 4: 1 ratio. ulusal travma ve acil cerrahi dergisi = turkish journal of trauma & emergency surgery: tjtes. 2014; 20 (1): 33-8. 12. ti se, tan dt. tectonic corneal lamellar grafting for severe scleral melting after pterygium surgery. ophthalmology, 2003; 110 (6): 1126-36. 13. stunf, s., lumi, x., & drnovšek-olup, b. preserved scleral patch graft for unexpected extreme scleral thinning found at the scleral buckling procedure: a case report. indian journal of ophthalmology, 2011; 59 (3): 235–238. 14. elisabeth, p., hilde, b., & ilse, c. eye bank issues: ii. preservation techniques: warm versus cold storage. international ophthalmology, 2008; 28 (3), 155–163. 15. yonekawa y, chodosh j, eliott d. surgical techniques in the management of perforating injuries of the globe. international ophthalmology clinics, 2013; 53 (4): 127-37. 16. vlasov a, ryan ds, ludlow s, coggin a, weichel ed, stutzman rd, bower ks, colyer mh. corneal and corneoscleral injury in combat ocular trauma from operations iraqi freedom and enduring freedom. military medicine, 2017; 182 (1): 114-9. 17. hamdi m, hamdi i. scleral repair by biodegradable collagen implant in strabismus surgery. ophthalmol res an int j. 2015; 3 (4): 141-6. 18. repair of corneoscleral perforations (pdf download available). available from: https://www.researchgate.net/./234059015_repair_of_ corneoscleral_perforations. 19. nguyen qd, foster cs. scleral patch graft in the management of necrotizing scleritis. international ophthalmology clinics, 1999; 39 (1): 109-31. 20. parada-vasquez rh, benitez-castrillon pc, de leonortega je, leon-roldan cr. scleral patch graft in the management of necrotizing scleritis with inflammation. a case report. archivos de la sociedad espanola de oftalmologia. 2016; 91 (7): 353. 21. hwan j, kim jc. repair of scleromalacia using preserved scleral graft with amniotic membrane transplantation. cornea, 2003; 22: 288–293. 22. sangwan vs, jain v, gupta p. structural and functional outcome of scleral patch graft. eye, 2007; 21 (7): 930. 23. pai v, shetty j, amin h, thomas m. management of scleral thinning: an alternate approach. nitte university journal of health science, 2016; 6 (1): 88. https://www.researchgate.net/ 82 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology original article vitrectomy combined with scleral buckling in patients with inferior retinal breaks zubair saleem, nadeem riaz, muhammad aftab, muhammad moin, muhammad irfan karamat, adeel chaudhry pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zubair saleem dept. of ophthalmology lahore general hospital, lahore …..……………………….. purpose: to study the anatomical results and complications of vitrectomy with internal tamponade, combined with scleral buckling in patients having retinal detachment due to inferior break(s) material and methods: this descriptive case series study was conducted on 34 patients having retinal detachment due to inferior break(s). 22 patients were male and 12 patients were female. all patients underwent vitrectomy with silicone oil combined with buckling. patients were followed for six months and status of retina noted, along with any post-operative complications. results: successful attachment of the retina was achieved in 32 (94.12%) patients. four patients (11.76%) had post-operative glaucoma, 3 (8.82%) had transient diplopia, while 3 out of the 13 phakic patients (23.08) developed cataract within six months of the surgery. conclusion: vitrectomy combined with scleral buckling is a safe and effective procedure to treat retinal detachment in patients having inferior retinal breaks. etinal detachment is the separation of neurosensory retina from the retinal pigment epithelium. rhegmatogenous retinal detachment involves a full thickness retinal break and accumulation of liquefied vitreous under the neurosensory retina, separating it from the retinal pigment epithelium1. various procedures are employed to treat rhegmatogenous retinal detachment. all of them involve closing the break(s) by chorioretinal adhesion, either by internal or external tamponade. the choice of procedure is governed by many factors, primarily the location of the break, the amount of proliferative vitreoretinopathy (pvr) and the availability of instrumentation and expertise. eyes with minimal pvr and anteriorly located break(s) can be successfully managed by pneumatic retinopexy, scleral buckle or vitrectomy while eyes with posterior break(s) or significant pvr need vitrectomy along with tamponading gas or oil2. the specific gravities of most of the internal tamponading agents are less than balanced saline solution. that is why oil or gas bubble floats at the top most position, pressing the retina and providing a tamponade for superior retina. however, its effect on the inferior retina is not enough to press the retina down to pigment epithelium layer and it fails to provide a tamponade3. this poses a problem in managing patients having high grade pvr and inferior breaks, since neither scleral buckle nor vitrectomy alone can keep the retina attached. various studies have been conducted on which procedure should be carried out for such cases, with no general consensus. some authors suggest carrying out vitrectomy with internal tamponade alone4, followed by strict head posture, while others have suggested scleral buckle and vitrectomy with internal tamponade combined5. the protocol for such cases in our department is to carry out scleral buckle plus vitrectomy combined with internal tamponade, and we would like to share our experience of the results and complications of this procedure. material and methods the study was conducted in eye department of lahore general hospital, lahore. patients were operated r vitrectomy combined with scleral buckling in patients with inferior retinal breaks pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 83 between january 2012 to june 2013, while postoperative examination continued till december 2013. thirty four patients having primary rhegmatogenous retinal detachment, with inferior breaks between 4 o’clock to 8 o’clock positions were included in the study. all the patients were informed about their inclusion in the study and a written consent was obtained. the study was approved from the ethical committee of the hospital. a detailed pre-operative examination was carried out in all patients, with their visual acuity, pupil reaction, intraocular pressure, slit lamp examination of anterior segment, slit lamp and indirect ophthalmoscopy of posterior segment, status of the retina, grading of proliferative vitreoretinopathy (pvr), extent of detachment and location of breaks noted. the exclusion criteria were: 1) patients with a past history of surgery for retinal detachment. 2) patients with detachment due to retinal dialysis. 3) patients with grade a pvr. all surgeries were performed by two experienced vitreo-retinal consultants. 360o scleral encirclement was performed using a silicone band – 240, anchored at 12-14mm from the limbus. it was supplemented with an appropriate segmental buckle (silicone tyre277) to cover the retinal break(s). a 23-g, 3-port pars plana vitrectomy was performed on each patient using accurus vitrectomy system. silicone oil, 1000 centistokes (26 patients) or 5000 centistokes (8 patients), was used for internal tamponading. laser barrage around the break(s) was applied in all patients. postoperative examination was carried out on 1st and 7th post operative days; and then after 1, 3 and 6 months and status of retina noted on each visit. statistical analysis was done by using spss version 20. descriptive statistics was used to analyse the data. a quantitative variable like age was measured by mean and standard deviation. frequency and percentage was calculated for gender and surgical outcome in terms of retinal attachment or nonattachment. results thirty four patients fulfilling the inclusion and exclusion criteria were identified from january 2012 to june 2013. 22 (64.7%) patients were male, while 12 (35.2%) were female (fig. 1).the statistical analysis of gender is shown in table 1. the mean age of the patients was 32.88 with standard deviation of 13.42 (table 2). in 17 patients, the break was located inferotemporally, in 3 patients, it was located inferomedially, in 6 patients, it was located inferiorly at 6 o’clock, while 5 patients had multiple breaks inferiorly. no definite break could be identified in 3 patients due to poor peripheral visibility. however, their inferior retinas showed diffuse degeneration and atrophic areas. the configuration of the detached retina also corresponded to the presence of an inferior retinal pathology (lincoff rule), so they were supported with an inferior tyre and included in the study (table 3). fourteen patients had grade b pvr, while twenty patients had grade c pvr. four patients had myopia of greater than -6 diopters while lattice degeneration was noted in 4 patients. 9 patients had pseudophakia while 11 were aphakic and one patient presented with dropped iol. there was a history of trauma in 4 patients (fig. 2). successful attachment of the retina was achieved in 32 (94.12%) patients, while 2 had persistent detachment (fig. 3). out of the patients with grade b pvr (14), one developed grade c pvr but his retina zubair saleem, et al 84 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology remained attached. the statistical representation of surgical outcome in terms of retinal reattachment is shown in table 4. 64.70% 35.29% males females fig. 1: gender analysis 0 2 4 6 8 10 12 my op ia (> -6 d) la ttic e de ge ne ra tio n ps eu do ph ak ia ap ha kia dr op pe d i ol tr au ma fig. 2: number of patients with risk factors for retinal detachment the findings were further analyzed by the t-test and the paired samples statistics, correlations and samples test are shown in tables 5, 6 and 7 respectively. four patients (11.76%) had post-operative glaucoma while 3 patients (8.82%) complained of diplopia which resolved spontaneously. three out of the 13 phakic patients (23.08%) developed cataract within 6 months of the surgery (fig. 4). out of the two patients with persistent retinal detachment following first surgery, one patient had successful reattachment following a second surgery, while the retina of one patient remained detached even after a second surgery. discussion current surgical techniques can obtain high rates of anatomical and visual success in patients with retinal detachment6. however, the management of retinal detachment with inferior break(s) has been the focus of debate recently. the nature of the internal tamponading agents, due to low specific gravity than normal saline, does not serve to tamponade the inferior retina against the choroid. some authorities advocate pars plana vitrectomy with internal tamponade alone, along with strict post operative posturing in cases of inferior retinal breaks in which buckling alone is not sufficient (e.g. high grade pvr). they argue that combining scleral buckling does not add any additional advantage over vitrectomy alone and poses the patient to additional risks of scleral buckling like diplopia7, explant extrusion, infection8 and choroidal haemorrhage. one such argument has been given by wickham and associates4. they state gender analysis (percentage) patients with risk factors for rd vitrectomy combined with scleral buckling in patients with inferior retinal breaks pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 85 6% 94% attached detached fig. 3: postoperative results 0 1 2 3 4 glaucoma diplopia cataract persistent rd fig. 4: postoperative complications that the success rate of the group of patients who underwent vitrectomy combined with scleral buckle (73%) was lower than the group of patients undergoing vitrectomy with internal tamponade alone (89%). the most common cause of treatment failure in vitrectomy combined with scleral buckle was noted to be pvr (20%, as opposed to 5% in vitrectomy alone group). one reason of such a high rate of pvr in vitrectomy combined with scleral buckling group in his study can be the retrospective nature of the study and the lack of randomization. amount of preoperative pvr is a risk factor for severe postoperative pvr9. it is possible that relatively complicated cases with higher pre-operative pvr were treated with vitrectomy combined with scleral buckling, leading to high post operative pvr in this group. wickham and associates also state that the primary break and drainage sites were treated either with cryotherapy or endolaser. incidence of pvr after cryotherapy (25.8%) is much more than that of endolaser (2.2%)10. it hasn’t been mentioned what percentage of patients in each group received cryotherapy, and that can be one of the reasons for such a high percentage of pvr in vitrectomy combined with scleral buckling group. in our study, there were fourteen patients with grade b pvr preoperatively, out of which only one patient (10%) had developed grade c pvr after six months of follow up. the anatomical success rate of vitrectomy combined with scleral buckling was also higher (94%) in our study. a study by alexander p et al5 has shown 95% success rate with a combined procedure, without any sight-threatening complications. mehmet demir et al11 found a similar anatomical success rate in patients treated with either vitrectomy alone (96.0%) or vitrectomy combined with scleral buckling (95.8%). similar comparable results in two groups were reported in a retrospective comparative case series12, being 98.9% for vitrectomy alone and 98.8% for combined procedure. another study reported that the difference in the rate of secondary surgical procedure was similar in the two groups13. in a retrospective study of thirty pseudophakic or aphakic eyes who underwent a primary combined procedure, qin b et al14 found that all retina were anatomically reattached after the first operation. in their retrospective series of 512 patients who underwent primary vitrectomy for retinal detachment, heimann et al15 found a significantly higher rate of re-detachment in patients postoperative status of the retina zubair saleem, et al 86 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology with inferior detachment. they attribute this to their use of relatively short-acting tamponades which are probably not sufficient to support the inferior retina. sharma et al16 did not find any significant difference in outcome in two groups of patients treated with vitrectomy and gas alone, either with or without inferior break detachments. we did not find any significant sight – threatening complications of scleral buckling in our study. similar conclusions have been drawn in other studies too, in which vitrectomy combined with scleral buckling was done4,5. however, some studies, in which scleral buckling was done alone, report potentially sightthreatening complications of scleral buckling17,18. conclusion our study shows that supplementary scleral buckling has its role in cases with inferior retinal breaks, as it provides an external tamponade to inferior breaks, which would otherwise not be covered by internal tamponading agents like silicone oil or sf6 gas etc. it is an effective and safe procedure that improves the primary success rate in such cases author’s affiliation dr. zubair saleem mbbs ; fcps senior registrar ophthalmology, lahore general hospital, lahore prof. dr. nadeem riaz mbbs; do; frcs; frcophth. professor and head of ophthalmology dept, lahore general hospital, lahore dr. muhammad aftab mbbs; mrcs post graduate resident ophthalmology, lahore general hospital, lahore prof. dr. muhammad moin frcs, frcophth, mrcophth professor of ophthalmology, lahore general hospital, lahore dr. muhammad irfan karamat mbbs medical officer ophthalmology, lahore general hospital, lahore dr. adeel chaudhry mbbs; mcps medical officer ophthalmology, lahore general hospital, lahore references 1. ghazi ng, green wr. pathology and pathogenesis of retinal detachment. eye (lond). 2002; 16: 411-21. 2. minihan m, tanner v, williamson t. primary rhegmatogenous retinal detachment: 20 years of change. br j ophthalmol. 2001; 85: 546-8. 3. wetterqvist c, wong d, williams r, stappler t, herbert e, freeburn s. tamponade efficiency of perfluorohexyloctane and silicone oil solutions in a model eye chamber. br j ophthalmol. 2004; 88: 692–6. 4. wickham l, connor m, aylward g w. vitrectomy and gas for inferior break retinal detachments: are the results comparable to vitrectomy, gas, and scleral buckle? br j ophthalmol 2004; 88: 1376–9. 5. alexander p, ang a, poulson a, snead mp. scleral buckling combined with vitrectomy for the management of rhegmatogenous retinal detachment associated with inferior retinal breaks. eye 2008; 22: 200–3. 6. schwartz sg, flynn hw jr, mieler wf. update on retinal detachment surgery. curr opin ophthalmol. 2013; 24: 255-61. 7. fison p n, chignell a h. diplopia after retinal detachment surgery. br j ophthalmol. 1987; 71: 521-5. 8. flindall rj, norton ew, curtin v, gass jd. reduction of extrusion and infection following episcleral silicone implants and cryopexy in retinal detachment surgery. am j ophthalmol.1971 apr; 71 (4): 835-7. 9. girard p, mimoun g, karpouzas i, montefiore g. clinical risk factors for proliferative vitreoretinopathy after retinal detachment surgery. retina. 1994; 14: 417-24. 10. bonnet m, guenoun s. surgical risk factors for severe postoperative proliferative vitreoretinopathy (pvr) in retinal detachment with grade b pvr. graefes arch clin exp ophthalmol. 1995; 233: 789-91. 11. demir m, guven d, yıldız aa, kara o. comparison the results of pars plana vitrectomy (ppv) with and without an encircling scleral band (sb) for the repair of primary rhegmatogenous retinal detachment. sch. j. app. med. sci., 2013; 1: 215-8. 12. kinori m, moisseiev e, shoshany n, fabianid, skaat a, barak a, et al. comparison of pars plana vitrectomy with and without scleral buckle for the repair of primary rhegmatogenous retinal detachment. am j ophthalmol. 2011; 152: 291-7. 13. mansouri a, almony a, shah gk, blinder kj,sharma s. recurrent retinal detachment: does initial treatment matter? br j ophthalmol 2010; 94: 1344-7. 14. qin b, huang ln, zhao ty, cheng hb. combined scleral buckle and vitrectomy as a primary surgery for pseudophakic and aphakic retinal detachments. int j ophthalmol 2008; 1 (2): 117-8. 15. heimann h, zou x, jandeck c, kellner u, bechrakis ne, kreusel km et al. primary vitrectomy for rhegmatogenous retinal detachment: an analysis of 512 cases. graefe’s arch clin exp ophthalmol 2006; 244: 69–78. 16. sharma a, grigoropoulos v, williamson th. management of primary rhegmatogenous retinal detachment with inferior breaks. br j ophthalmol 2004; 88: 1372–5. 17. abdullah as, jan s, qureshi ms, khan mt, khan md. complications of conventional scleral buckling occuring during and after treatment of rhegmatogenous retinal detachment. j coll physicians surg pak 2010; 20 (5): 321-6. 18. ambati j, arroyo jg. postoperative complications of scleral buckling surgery. int ophthalmol clin. 2000; 40 (1): 175-85. 137 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology original article serum sodium and potassium levels in senile cataract patients and age matched normal individuals rayees ahmad sofi, waseem raja, junaid nabi, asmat ara mufti pak j ophthalmol 2015, vol. 31 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: rayees ahmad sofi department of ophthalmology mobile surgical eye unit,dhs srinagar-190012, jammu and kashmir, india email: rayees630@yahoo.co.in …..……………………….. purpose: the purpose of the study was to compare the mean sodium and potassium levels in patients with senile cataract and age-matched normal individuals in kashmir. material and methods: the study was designed as cross sectional observational study. 200 senile cataract patients scheduled for cataract surgery in the department of ophthalmology and 200 individuals of the same age group without cataract were selected. mean serum sodium and potassium levels in the senile cataract group were calculated and compared with the control group. serum sodium and potassium levels were measured by flame photometry technique. statistical software spss-16 was used and means were compared between two groups by t-test. since the study was a non interventional one, clearance was given by the department and study abides by the guidelines laid in the declaration of helsinksi. results: mean serum sodium level in senile cataract patients and normal individuals was 139.60 ± 5.23 meq/l and 137.15 ± 2.93 meq/l respectively and there was statistically significant difference (p < 0.0001). mean serum potassium level in senile cataract patients and normal individuals was 4.35 ± 0.574 meq/l and 4.31 ± 0.45 meq/l, and the difference was not statistically significant (p = 0.60). conclusion: serum sodium level in senile cataract patient was higher as compared to the control group. this outcome might suggest that increased dietary intake of the sodium leads to higher levels of serum sodium which in turn influences the cataractogenesis in senile patients. keywords: cataract, risk factors, sodium, dietary. everal studies have been carried out to elucidate the risk factors which are responsible for the development of cataract. cataract, being the most important cause of blindness worldwide1, has a heavy toll on public health. senile cataract usually develops in persons after 45 years of age. risk factors for cataract which are established include use of corticosteroids, diabetes and smoking1. approximately, 75 percent of population over the age of 75 years suffers from lens opacity or cataract2 and it is reported that worldwide 50 million people suffer from age-related cataracts3. in india, the number of new cataract cases reported annually is 4 million.3 every year, a substantial amount of financial resources are spent on cataract surgeries, mostly aimed at preventing blindness and improving quality of life, which makes it difficult for the health system to carry on4-5 since financial allocation for health services in developing countries is deficient. although, the exact etiology of senile cataract is not understood, multiple mechanisms have been proposed such as oxidative stress of highly reactive oxygen species,6-7 protein aggregates,7 osmotic imbibitions,8 post translational protein changes9 and phase separation9 have been s serum sodium and potassium levels in senile cataract patients and age matched normal individuals pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 138 suggested. several studies have evaluated the role of nutritional status in general and that of elevated serum sodium in particular, and the possibility to use biochemical parameters as markers for determining the risk for development of cataract, considering that nutritional status can be modified.9-11 although, kashmiri diet is very high in salt content,12 and we tried to figure out any association. material and methods the study was conducted in the department of ophthalmology, mobile surgical eye unit srinagar, kashmir. it was a cross sectional observational study. a total of 400 individuals who came for ophthalmic evaluation were included in the study. they were further grouped into study groups, defined as individuals with nuclear/cortical/posterior subcapsular cataracts. controls were ageand gendermatched individuals who had no cataract, and the ones who did not have any confounding factors. both groups were asked about and investigated for drug history, hypertension, diabetes or any other systemic diseases which formed the exclusion criteria and subsequently such individuals were not included in either of the groups. patients having secondary causes of cataract in the same age groups like postinflammation, steroid induced, were also excluded according to the study protocol. detailed ophthalmic evaluation, including slit-lamp examination and fundus evaluation was done. locs iii classification was used to grade the cataract. serum sodium and potassium were measured by flame photometry method. the normal serum sodium and potassium levels used for analysis were 130 – 143 meq/l and 3.5 – 5.5 meq/l respectively. data were analyzed on ssps-16 software and means were compared in both groups by t-test. the procedure was carried out with appropriate informed consent of the patients participating in the study and ethical committee clearance was obtained. the following assumptions on data have been made; 1. dependent variables showed to be normally distributed. 2. samples drawn from the population should be random. 3. cases of samples should be independent. the student t test has been used to find the significance of study parameters on a continuous scale within each group. results in our study, the case group consisted of 200 patients suffering from senile cataract, with 120 female and 80 male patients. control group, taken in the same number, consisted of 200 individuals who were healthy volunteers with 120 male and 80 female patients. the age range of the cases and controls was taken as 50-70 years. the mean age and standard deviation for cases’ group was 58.2 ± 12.7 years and that of controls’ group was 56.33 ± 11.9 years, and the difference was statistically insignificant (p = 0.35). comparison of mean sodium levels among cases and controls demonstrated mean serum sodium levels to be higher in cases (139.60 ± 5.23 meq/l) compared to controls (137.15 ± 2.93 meq/l) table 1. the difference was statistically significant (p < 0.0001), albeit the means of the two groups were within the normal range. comparison of mean serum potassium levels among the cases and controls revealed slightly increased levels of serum potassium in cases (4.35 ± 0.57 meq/l) compared to controls (4.31 ± 0.45 meq/l). the difference was statistically not significant (p = 0.60). discussion it is complex to identify the risk factors for cataract; however, attempting to do so provides valuable insights into the etio-pathology and helps in lowering the economical burden of the disease. in perspective of kashmir, high salt (sodium chloride) content diet has been implicated in esophageal carcinomas12, but the rayees ahmad sofi, et al 139 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology effect of this diet on development of cataract has not been explored. our study provides the first attempt at recognizing high sodium levels as a risk factor for cataract genesis in the kashmir valley. the aim of this study was to find whether a significant difference exists between serum sodium and serum potassium levels in individuals with cataract and age-matched normal individuals. certain previous studies have also found significantly higher levels of bilirubin, alkaline phosphatase, and glutamyl transpeptidase in senile cataract patients compared to normal individuals13. although, age is itself the most important risk for senile cataract, and thus its name but several other risk factors have also been cited7. there are studies9-11 which have demonstrated relationship between serum biochemical elements such as sodium and cataract development while there is some contradiction to the claim as well, by reports14 that could not find a veritable connection. one of the important findings of our study include the reaffirmation that serum sodium levels are elevated in persons suffering from senile cataract as has been found by various previous studies.9-11 therefore, alteration in concentrations of cations in aqueous humor, which is attributed to the alterations in serum cation concentration, can be known as a risk factor for development of cataract.15 it should be noted, however, that many studies15-17 have demonstrated significant and meaningful difference between serum sodium levels of individuals afflicted with senile cataract against those that do not have cataract, but the same does not hold true for serum potassium levels as is also the case in our study. in turn, it seems like high level of serum sodium contributes to formation of cataract18. levels of sodium was found high in cataract patients and it seemed lowering their dietary intake may retard the cataract progression.19-20 conclusion serum sodium levels in senile cataract patients were found to be higher as compared to the control group, while this did not hold true for potassium levels. these findings suggest that diets that are high in sodium content are a risk factor for the formation of senile cataract. as such, higher sodium intake may be a risk factor. author’s affiliation dr. rayees ahmad sofi department of ophthalmology mobile surgical eye unit srinagar-190012, jammu and kashmir india dr. waseem raja department of ophthalmology skims medical college and hospital srinagar-190012, jammu and kashmir india dr. junaid nabi shaheed suhrawardy medical college and hospital sher-e-bangla nagar, dhaka-1207 bangladesh dr. asmat ara mufti consultant ophthalmologist mobile surgical eye unit health department jammu and kashmir role of authors dr. rayees ahmad sofi substancial contribution to conception and design of work, acquisition of data, analysis, interpretation of data, revising it, final approval. dr. waseem raja substancial contribution to conception, acquisition of data, interpretation of data, final approval. dr. junaid nabi substancial contribution to conception, acquisition of data, interpretation of data, final approval. dr. asmat ara mufti substancial contribution to conception, acquisition of data, interpretation of data, final approval. references 1. hodge wg, whitcher jp, satariano w. risk factors for age related cataract. epidemiology rev. 1995; 17: 336-46. 2. west sk, valmadrid ct. epidemiology of risk factors for age related cataract. survey of ophthalmology. 1995; 39: 323-7. 3. minassian dc, mehra v. blinded by cataract: each year. projection from the first first epidemiological study of incidence of cataract blindness in india. br j ophthalmol. 1990; 74: 341-3. 4. sperducto rd. epidemiological aspects of age related cataract. in: (ed) tasman w, jaegar a. duane’s clinical ophthalmology. philadelphia lippincott – raven publishers 2000; 3-11. 5. kahn ha et al. the framingham eye study 1. outline and major prevalence findings. american journal of epidemiology 1977; 106: 17-32. serum sodium and potassium levels in senile cataract patients and age matched normal individuals pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 140 6. jacob ra, buri bj. oxidative damage and defense. american journal of clinical nutrition. 1996; 63: 985-90. 7. augustein rc. protein modification in cataract. in: duncan g ed. mechanism of cataract formation in the human lens. academic press; 1981; 72-115. 8. duncan g, bushell ar. ion analysis of human cataractous lens. experimental eye research. 1995; 20: 223-30. 9. mirsamadi m, nourmohammadi i, imamian m. comparative study of serum sodium and potassium levels in senile cataract patients and normal individuals. int j med sci. 2004; 1: 165-9. 10. cumming rg, mitchell p, smith w. dietary sodium intake and cataract: blue mountains eye study. am j epidemiology 2000; 15: 624-6. 11. tavani a, negri e, la vecchia c. food and nutrient intake and risk of cataract. ann epidemiol. 1996; 6: 41-6. 12. mir mm, dar na. esophageal cancer in kashmir (india): an enigma for researchers int j health sci 2009; 3(1): 71–85. 13. donnelly ca, seth j, clayton rm, phillips ci, cuthbert j, prescott rj. some blood plasma constituents correlate with human cataract. br j ophthalmol. 1995; 79: 1036-41. 14. the iranian – american cataract study group. risk factors for age – related cortical, nuclear and posterior subcapsular cataracts. am j of epidemiology. 1991; 133: 541-4. 15. clayton rm, cuthbert j, phillips ci, bartholomew rs, stokoe nl, fytch t. analysis of individual cataract patients and their lenses: a progress report. exp eye res. 1980; 31: 533-6. 16. clayton rm et al. some risk factors associated with cataract in scotland. a pilot study. trans ophthalmology society 1982; 102: 331-6. 17. philips ci, bartholomew rs, clayton r, duffey j et al. cataract: a search for association or causative factors. in: (ed). regnault f. symposium on the lens. princeton nj. excerpta medica. 1980; 19-25. 18. phillips ci. cataract: a search for associated or causative factors. excerpta med. 1980; 34: 19-25. 19. usha s adiga, adline harris et al. serum electrolytes in senile cataract patients. al ameen j med sci. 7: 164-8. 20. mathur g, pai v. comparison of serum sodium and potassium levels in patients with senile cataract and age – matched individuals without cataract. indian journal ophthalmol. 2013; 4. http://www.ncbi.nlm.nih.gov/pubmed?term=tavani%20a%5bauthor%5d&cauthor=true&cauthor_uid=8680624 http://www.ncbi.nlm.nih.gov/pubmed?term=negri%20e%5bauthor%5d&cauthor=true&cauthor_uid=8680624 http://www.ncbi.nlm.nih.gov/pubmed?term=la%20vecchia%20c%5bauthor%5d&cauthor=true&cauthor_uid=8680624 http://www.ncbi.nlm.nih.gov/pubmed/8680624 http://www.ncbi.nlm.nih.gov/pubmed/?term=mir%20mm%5bauth%5d 202 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology original article comparison between topical olopatadine hydrochloride 0.1% and ketotifen fumarate 0.025% for the relief of symptoms of vernal keratoconjunctivitis (vkc) muhammad rizwan khan, muhammad naeem azhar, muhammad sufyan aneeq ansari, tariq mahmood arain, zaheer uddin aqil qazi pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad rizwan khan bahawal victoria hospital bahawalpur …..……………………….. purpose: to compare the topical administration of olopatadine hcl 0.1 % and ketotifen fumarate 0.025% for the relief of symptoms of vkc. material and methods: from april 2010 to september 2010, this randomized controlled trial was conducted on 120 diagnosed patients of vkc from out-door patient department of bahawal victoria hospital bahawalpur, equally and randomly enrolled in two groups. in group a patients were given topical olopatadine hcl 0.1% qid and in group b topical ketotifen fumarate 0.025% qid. regular follow up of all the patients were done for relief of symptoms on day 0, 7 and 28. final outcome was determined at the end of 4 th week from start of the treatment. results: all 120 patients completed the study with regular follow up. patients presented with multiple symptoms and clinical types of vkc. all the patients felt early and significant relief in their symptoms, but the effectiveness and tolerability of olopatadine hcl 0.1% was significantly more (p<0.05) as compared to ketotifen fumarate 0.025%. conclusion: both topical olopatadine hcl 0.1% and ketotifen fumarate 0.025% are effective in treating the vkc. however, olopatadine hcl 0.1% provides greater symptomatic relief in patients of vkc as compared to ketotifen fumarate 0.025%. cular allergies are the most common conditions affecting the external ocular adnexa throughout the world1. these allergies are type 1 hypersensitivity reactions mediated by ig-e in response to various environmental allergens such as pollens, mites, molds, dust, grass, weeds and animals dander2,3. vernal keratoconjunctivitis (vkc) is a bilateral, recurrent allergic conjunctivitis affecting the children and young adults in 5-15 years age group usually2. vkc rarely persists till puberty2. vkc is associated with genetic predisposition, history of atopy and nonspecific hypersensitivity. vkc is an ig-e and cellmediated immune response in the conjunctival mucosa to exogenous allergens2. it usually occurs at the onset of hot weather (spring season) and subsides during winter2. seasonal recurrences with exacerbations and remissions are common2. symptoms of vkc consist of: intense itching, lacrimation, redness, foreign body sensation, photophobia, thick mucoid discharge2. the clinical signs of vkc on slit lamp examination are; conjunctival hyperemia, chemosis, papillary hypertrophy, macro papillae, gelatinous thickening of limbal conjunctiva and punctuate epithelial erorions2. conjunctival mast cells play the main role in the pathophysiology of vkc. when a specific allergen o comparison between topical olopatadine hydrochloride 0.1% and ketotifen fumarate 0.025% pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 203 binds to the sensitized mast cells in the conjunctiva, degranulation of the mast cells and release of inflammation mediators such as histamine, eosinophilic chemotactic factor, prostaglandins, leukotrienes, platelet activating factors occur1,2. these inflammatory mediators predominantly histamine are responsible for symptoms of vkc1,2. the main clinical types of vkc are: palpebral, limbal, mixed, corneal disease or keratopathy1,2,8. the rationale of the study is to compare the effectiveness of olopatadine hcl 0.1% and ketotifen fumarate 0.025% for the relief of symptoms of vkc. material and methods from april 2010 to september 2010, this randomized controlled trial was conducted on 120 diagnosed patients of vkc from out-door patient department of bahawal victoria hospital bahawalpur, equally and randomly enrolled in two groups. 120 patients included in the study, 62 were male and 58 patients were female. the age varied from 5-20 years in both groups. mean age of the patients was 9.10 ± 3.90 years. in group a patients were given topical olopatadine hcl 0.1% qid and in group b topical ketotifen fumarate 0.25% qid. regular follow up of all muhammad rizwan khan, et al 204 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology the patients were done for relief of symptoms on day 0, 7 and 28. final outcome was determined at the end of 4th week from start of the treatment. the efficacy of two drugs was determined by the relief of symptoms of vkc. symptoms included in this study were; itching, redness, watering, foreign body sensation, photophobia. relief of the symptoms was considered as resolution of disease. data analysis the collected data was entered and analyzed by using the spss version 10. the data was analyzed and presented in univariate and bivariate tables. for categorical variables like gender, frequencies & percentages were presented. effect modifiers like age & gender were controlled to observe the effect on outcome between two groups. the level of statistical significance was p <0.05. chi-square test was used as the test of significance to compare the proportion of relief of symptoms between the two groups. results all 120 patients were included in two study groups (each group consisting of 60 patients). group a was treated with topical olopatadine hcl 0.1% and the group b was treated with topical ketotifen fumarate 0.025%. among 120 patient included in the study, 62 were male and 58 patients were female. the age varied from 5-20 years in both groups. mean age of the patients was 9.10 ± 3.90 years. all patients completed the study and came for follow up. drug compliance was very good among the patients and they followed the directions very well. all the patients were followed up until the resolution of their complaints of allergy (table 1). patients presented with multiple symptoms and clinical types of vkc. all the patients felt early and significant relief in their symptoms, but the effectiveness and tolerability of olopatadine hcl 0.1% was significantly more (p<0.05) from ketotifen fumarate 0.025% (table 2). discussion ocular allergies affects more than 20% of the world’s population and impairs their daily activities. the number of ocular allergy symptoms is increasing day by day along with the environmental pollution. allergic conjunctivitis hampers the quality of life. the goal of treatment of vkc is to rapidly and effectively resolve the clinical signs and symptoms and improve the quality of life. as the mast cells degranulation and release of histamine and other inflammatory mediators is the main event in the ocular allergic cascade, so the aim of treatment of vkc is to antagonize the histamine activity and to maintain stability of mast cells. the pharmacotherapy of allergic conjunctivitis consists of several classes of drugs, antihistamines, mast cells stabilizers, dual acting agents, nsaids and steroids2,6,8. ketotifen is a mast cell stabilizer with inhibitory effects upon the release of inflammatory mediators and eosinophilic chemotaxis. it has been shown to offer great efficacy in controlling the symptoms of vkc. it is the only drug available in unit dose form without preservatives. olopatadine in turn possess dual action and better tolerability7,8. in this study olopatadine hcl 0.1% and ketotifen fumarate 0.025% ophthalmic solutions were instilled as a dose of 1 drop qid in two sets of 60 patients each and their effects in relieving the symptoms of vkc were studied and compared. this study showed that olopatadine was significantly more effective and well tolerated as compared to ketotifen. this study also revealed that olopatadine is significantly more effective (p<0.05) against symptoms of vkc as compared to ketotifen after four weeks. this is the first comparative study between 0.1% olopatadine and 0.025% ketotifen in treatment of vernal keratoconjunctivitis in pakistan. the results of our study favour the olopatadine for treatment of vkc. the use of olopatadine provides quick recovery to eyes suffering from vkc with no apparent risk of side effects. as this study was conducted on a limited number of patients and was a single centre trial, so further prospective interventional multicentered placebo controlled trials may be needed for better assessment of efficacy and safety of these new treatment modalities in management of vkc. conclusion both topical olopatadine hcl 0.1% and ketotifen fumarate 0.025% are effective in treating the vkc. however, olopatadine hcl 0.1% provides greater symptomatic relief in patients of vkc as compared to ketotifen fumarate 0.025%. comparison between topical olopatadine hydrochloride 0.1% and ketotifen fumarate 0.025% pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 205 author’s affiliation dr. muhammad rizwan khan medical officer bahawal victoria hospital bahawalpur dr. muhammad naeem azhar ophthalmologist lrbt free eye hospital lahore dr. muhammad sufyan aneeq ansari rmo lrbt free eye hospital lahore dr. tariq mahmood arain associate professor bahawal victoria hospital bahawalpur dr. zaheer uddin aqil qazi chief consultant ophthalmologist lrbt free eye hospital lahore references 1. katelaris ch. ocular allergy: implications for the clinical immunologist. ann allergy asthma – immunol. 2003; 90: 23-7. 2. kanski jj. clinical ophthalmology: a systematic approach, 7th edition butterworth heinemann elsevier; 2011; 200-1. 3. avunduk am, tekelioglu y, turk a, akyol n. comparison of the effects of ketotifen fumarate 0.025% and olopatadine hcl 0.1% ophthalmic solutions in seasonal allergic conjunctivities: a 30 – day, randomized, double-masked, artificial tear substitute – controlled trial. clin ther. 2005; 27: 1392-402. 4. greiner jv, mundorf t, dubiner h, lonsdale j, casey r, parver l, et al. efficacy and safety of ketotifen fumarate 0.025% in the conjunctival antigen challenge model of ocular allergic conjunctivitis. am j ophthalmol. 2003; 136: 1097-105. 5. kumar v, abbas ak, fausto n, mitchell rn. robbins basic pathology 8th edi elsevier saunders; 2007; 120-4. 6. leonardi a, abelson mb. double-masked, randomized, placebo – controlled clinical study of the mast cell – stabilizing effects of treatment with olopatadine in the conjunctival allergen challenge model in humans. clin ther. 2003; 25: 2539-52. 7. abelson mb, turner d. a randomized double-blind parallel-group comparison of olopatadine 0.1% ophthalmic solution versus placebo for controlling the signs and symptoms of seasonal allergic, clin ther. 2003; 25: 93-7. 8. hida wt, nogueira dc, schaefer a, dantas pe, dantas mc. comparative study between 0.025% ketotifen fumarate and 0.1% olopatadine hydrochloride in the treatment of vernal keratoconjunctivitis. arq bras oftalmol. 2006; 69 (6): 851-6. http://www.ncbi.nlm.nih.gov/pubmed?term=avunduk%20am%5bauthor%5d&cauthor=true&cauthor_uid=16291412 http://www.ncbi.nlm.nih.gov/pubmed?term=tekelioglu%20y%5bauthor%5d&cauthor=true&cauthor_uid=16291412 http://www.ncbi.nlm.nih.gov/pubmed?term=turk%20a%5bauthor%5d&cauthor=true&cauthor_uid=16291412 http://www.ncbi.nlm.nih.gov/pubmed?term=akyol%20n%5bauthor%5d&cauthor=true&cauthor_uid=16291412 http://www.ncbi.nlm.nih.gov/pubmed?term=hida%20wt%5bauthor%5d&cauthor=true&cauthor_uid=17273679 http://www.ncbi.nlm.nih.gov/pubmed?term=nogueira%20dc%5bauthor%5d&cauthor=true&cauthor_uid=17273679 http://www.ncbi.nlm.nih.gov/pubmed?term=schaefer%20a%5bauthor%5d&cauthor=true&cauthor_uid=17273679 http://www.ncbi.nlm.nih.gov/pubmed?term=dantas%20pe%5bauthor%5d&cauthor=true&cauthor_uid=17273679 http://www.ncbi.nlm.nih.gov/pubmed?term=dantas%20mc%5bauthor%5d&cauthor=true&cauthor_uid=17273679 http://www.ncbi.nlm.nih.gov/pubmed/17273679 http://www.ncbi.nlm.nih.gov/pubmed/17273679 http://www.ncbi.nlm.nih.gov/pubmed/17273679 pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 231 original article reconstruction of congenital lid defects muhammad khalid, muhammad moin, muhammad abid latif pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad khalid quaid-e-azam medical college, bahawalpur khalidvision@hotmail.com …..……………………….. purpose: to study the cosmetic results in congenital lid defect repairs. material and methods: retrospective case series review of ten patients operated during the last five years (2006 to 2011). all patients with congenital lid defects were included. these included patients with colobomas of upper or lower lid and abortive cryptophthalmos. reconstruction was done using rotation flaps or lid sharing procedures by a single surgeon. results: four patients underwent direct closure, four patients underwent tenzel flap, one underwent composite graft and one underwent cutler beard flap. there were three patients with abortive cryptophthalmos who also underwent mucous membrane graft or conjunctival advancement. three patients had good, four patients had satisfactory and three patients had poor results post-operatively. three patients had dehiscence of wound after surgery which required further reconstruction. exposure keratopathy due to delayed presentation was seen in three patients while cornea was scarred in three cases of abortive cryptophthalmos. mild upper lid notch was seen in three patients and mild upper lid symblephron was seen in one patient. conclusion: early surgery with adequate sized advancement flap for closure is the key to good cosmetic result. ongenital coloboma is partial or full thickness lid defect1 which is unilateral or bilateral.2,3 the upper lid colobomas are more common and are present at the junction of middle and medial third of lid. the lower lid coloboma is present at the lateral third of lid. in abortive crytophthalmos, the lids are replaced by a layer of skin which is fused with microphthalmos. these lid defects are associated with systemic conditions like goldenhar syndrome,4 treacher collins syndrome and fraser syndrome. the exact cause is not known but genetic and environmental factors are involved. any delay or interference in the union of mesodermal sheets with the frontonasal processes or maxillary processes leads to lid defects. the main complications resulting from lid defects are exposure keratitis, corneal opacity and visual deprivation leading to amblyopia.5 the ideal treatment of lid defect is early surgical reconstruction to restore the anatomical structure of eyelid. material and methods a retrospective review of a series of 10 patients with upper and lower lid defects was conducted at bahawal victoria hospital, bahawalpur and mayo hospital lahore from 2006 to 2011. the age of the patients ranged from 5 days to 2 years with a mean of 6 months. out of these 10 patients 6 were male and 4 were female (table 1). there were 8 (80 %) cases with defects of upper lid and 2 (20%) with defects of lower lid. in the series of upper lid defect patients, 3 cases had abortive cryptophthalmos. the extent of the defect varied from less than one third to more than half of the horizontal lid dimension. only patients with congenital lid defects were included. family history for any congenital lid defect was taken with details of pregnancy and delivery. thorough ocular and systemic examination was done. possible ocular associations like coloboma of iris and choroid, symblepharon, exposure keratopathy (fig. 1), corneal opacity, nystagmus, trichiasis, dermolipoma and lacrimal abnormality were noted. pre and post c muhammad khalid, et al 232 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology operative photographs were taken. reconstruction was done by using direct closure (fig. 2), lid sharing procedure, tenzel rotational flap and cutler beard technique (fig. 3) by a single surgeon (table 2). the patients were followed up at weekly interval for 1 month and then at every month for 6 months. the mean follow up was 6 months (2 months to 1 year). assessment of the eyelid stability and corneal status was noted. results reconstruction was done by using direct closure, lid sharing procedure, tenzel rotational flap and cutler beard technique by a single surgeon (table 2). the success of post operative results was defined as “good” if it was cosmetically acceptable with no complication, “satisfactory” if it was adequate cosmetically with minor complications and “poor” if it was inadequate cosmetically. 3 (30%) patients had good while 4 (40%) patients had satisfactory and 3 (30%) patients had poor post operative results. 3 (30%) patients had wound dehiscence after surgery which required further reconstruction. exposure keratopathy (fig. 1) was seen in 3 (30%) patients while corneal scarring occurred in 3 (30%) of cases of abortive crytophthalmos due to delayed presentation for surgery. these patients were referred to corneal surgeon for corneal graft. other complications included mild upper lid notch in 3 (30%) cases and mild upper lid symblepharon in 1 (10%) case (table 3). discussion anatomically eyelid is divided into two lamellae. the anterior lamella consists of skin and orbicularis oculi muscle while posterior lamella consists of tarsus and conjunctiva. both these lamellae should be replaced in the repair of lid defects. for lid reconstruction, the defects are classified into small, medium and large according to the size of defect6. small defects are less than one third of horizontal dimension of the lid margin, are closed directly7. medium defect are one third to half of the horizontal lid dimension. these are repaired as direct closure with lateral cantholysis, tenzel semicircular reconstruction of congenital lid defects pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 233 flap8 or mustarde cheek rotation flap.9 large defects are more than half of the horizontal dimension of the lid. these defects are repaired with lid sharing procedure like cutler beard technique,10 hughes procedure11,12 or composite graft.13 in composite graft, the full thickness pentagonal graft is taken either from a donor eye or from contralateral eyelid when the defect involves the only seeing eye of the patient. the aim of eyelid reconstructive surgery is to reconstruct anatomically and cosmetically better eyelid with protection of globe and restoration of good vision as early as possible. the main vision threatening complication resulting from the congenital lid defect is keratopathy. aggressive treatment of exposure keratopathy by the referring pediatrician is essential to prevent permanent corneal scarring. we found that poor lubrication of the cornea had led to permanent corneal scarring in 3 (30%) of our cases. early repair is fig. 1: exposure keratopathy due to coloboma. fig. 2: director closure for bilateral upper lid coloboma reconstruction with follow-up pictures for 5 years. fig. 3: cutler beard technique for large upper lid defect. required to combat this complication. these patients were referred to corneal surgeon. proper alignment of the anatomical structures is a key factor for good results. the data shows good / satisfactory results (70%) in our series. the lid is well vascularized and tissue survives reasonably well. if the lid margins are not precisely aligned, complications like distortion, trichiasis and notching of the lid occur. therefore adequate sized flap should be made to prevent these complications. lateral cantholysis of lower lid without reestablish-ment of lateral support may cause lower lid laxity and ectropion. in direct closure, wound is closed along the anatomical lines. this causes minimum tension on the wound. the lower lid is more lax so it can be pulled maximally to close the defect. but in upper lid excessive pull can lead to ptosis. after lid sharing procedures, if the flap is cut near the newly formed lid margin, the lid margin can roll inward14. lid sharing procedure is also a major cause of visual deprivation amblyopia because of prolong period of closure of lids especially in very young patients. the marginal artery is situated 3 4 mm from lid margin. during bridging flap, inadequate blood supply can lead to flap necrosis.15 this can be avoided if the horizontal incision to form flap is made about 3 4 mm from lid margin to avoid injury to vascular arcade. the vertical height of the pedicle of graft must be at least 4 6 mm. the upper lid defect repair can damage the lacrimal system leading to epiphora. the graft should be of proper size to cover the gap, otherwise the contraction will lead to scar formation. proper homeostasis of bed and cauterization of bleeding vessel prevents the flap necrosis and hematoma formation.16 oedema of lids is common due to interruption of lymphatic drainage. it resolves after several days. cold ice packs are indicated. the flaps should be broad. broad flaps retract less than narrow flaps. the retraction of narrow flap leads to distortion of constructed lid. sometimes altered pigmentation occurs in the scars. it usually improves with time. in tenzel semicircular flap, the line of incision from the lateral canthus should not be horizontal but a continuation of the lid to be constructed. a shallow depression will form in the lateral part of lid if the incision is horizontal. visual outcome after penetrating keratoplasty in children is significantly worse with congenital corneal opacity due to low scleral rigidity, forward displacement of lens iris diaphragm cataract formation and post surgical anterior segment inflammation leading to corneal graft rejection.17 muhammad khalid, et al 234 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology conclusion early surgery with adequate sized advancement flap for closure is the key to good cosmetic result. early surgical treatment prevents pre-operative complications and produces acceptable cosmetic results. there is a high rate of wound dehiscence in cases with tight closure. lid sharing procedure should be reserved for cases with wound dehiscence. author’s affiliation dr. muhammad khalid quaid-e-azam medical college bahawalpur professor dr. muhammad moin quaid-e-azam medical college bahawalpur dr. muhammad abid latif quaid-e-azam medical college bahawalpur references 1. kanski jj. clinical ophthalmology, six edition, edinburgh, elsevier science. 2007; 61-3. 2. ankola pa, azim ha. congenital bilateral upper eyelid coloboma. jr. of perinatology. 2003; 23: 166-7. 3. ad-el dd, moore ev, neman a, weinberg a. bilateral isolated upper eyelid coloboma, an infrequent entity with rare clinical presentation. eur j plast surg. 1994; 17: 264-5. 4. grover ak, chaudhari z, malik s. congenital eyelid colobomas in 51 patients. j pediatr ophthalmol strabismus. 2009; 46: 151-9. 5. seah ll, choo ct, fong ks. congenital eyelid coloboma. management and visual outcome. ophthal plast reconstr surg. 2002; 18: 190-5. 6. rafii aa, enepekides dj. upper and lower eyelid reconstruction: the year in review. cur opin otolaryngol head neck surg. 2006; 14: 227-33. 7. tyers a, collin jro. eyelid reconstruction, direct closure. colour atlas of ophthalmic plastic surgery. churchill livingstone. 1994; 14: 256. 8. tenzel rr, stwart wb. eyelid reconstruction by semicircular flap technique. ophthalmology. 1987; 85: 1164-9. 9. mustarde jc. major reconstruction of the eyelid: function and aesthetic consideration. clin plast surg. 1981; 8: 367-82. 10. cutler nl, beard c. a method for partial and total upper lid reconstruction. am j ophthalmic. 1995; 39: 17. 11. hugh nh. total lower lid reconstruction: technical details. trans am ophthalmol soc. 1976; 74: 321-9. 12. chang jh, o donnell ba. secondary transconjunctival flap after previous lower eyelid hughes repair. ophthal plast reconstr surg. 2006; 22: 2: 105-8. 13. cannon ps, mdge sn, kakizaki h, selva d. composite graft in eyelid reconstruction: the complications and outcomes. br j ophthalmol. 2009; 10: 1136. 14. mauriello ja, antonacci r. single transconjunctival flap (lower eyelid) for upper eyelid reconstruction (reverse modified hughes procedure). ophthalmic surg. 1994; 25: 6: 374-8. 15. betharia sm, kumar s. congenital coloboma of the eyelid. ijo. 1988; 36: 1: 29-31. 16. thaller v, then k, luhishi e. spontaneous eyelid expansion after full thickness eyelid resection and direct closure. br j ophthalmol. 2001; 85: 12: 1450-4. 17. mcclellan k, lai t. penetrating keratoplasty in children: visual and graft outcome. br j ophthalmol. 2003; 87: 1212-4 pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 246 original article pattern, causes, and management of ocular injuries at rural community setting of bangladesh mohammad shamsal islam, abul hasnat golam quddus pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mohammad shamsal islam, ms, mph senior research officer dr. ahmadur rahman research center university of chittagong, bangladesh email: msislam009@gmail.com …..……………………….. purpose: this study was undertaken to investigate the pattern, causes and management of ocular injuries in bangladesh. study design: cross sectional study. place and duration of study: at dr. ahmadur rahman research center, university of chittagong, bangladesh from august to december 2014. material and methods: ocular injured patients of community were invited through mass publicity to come to free clinic for check-up. they were interviewed by optometrist after the medical check-up. two sets of data were collected; one from the hospital files and another from the community. a proforma was developed for collecting data from the hospital files on the basis of information available in the files of the patients. similarly data was collected from the community patients. results: there were 425 patients from the hospital and 126 from the community. the vast majority of the injuries were open globe (91%) and the rest closed globe (9%). the most common type of injury was penetrating (81.4%), followed by lime burn (7%), ruptured globe (6.4%) and others (5%). the most common structural abnormalities were found in cornea (91%), conjunctiva (59%), iris and pupil (48%). open globe injuries were as high as 91% for hospital patients as against only 18% for the community patients. similarly closed globe injuries were 82% among community patients as against 9% of hospital patients. conclusion: the nature of injuries found in hospital and community setting is different. important ocular injury in community includes physical assault of married women by their husbands. key words: ocular trauma, visual acuity, blunt injury, community. cular trauma is the second most common cause of unilateral, partial or total loss of vision after cataract in all age groups. the global pattern of eye injuries and their consequences suggest that about 55 million eye injuries are restricting activities of people for more than one day every year and 750,000 cases will require hospitalization each year including some 200,000 open globe injuries1. ocular injuries occur at different places and by different agents. a significant percentage of ocular injuries occur at the residence of patients, which varies from 33% to 61% in different countries1-8. another common source of injury is automobile accidents. in some countries, the percentage of occurrence of automobile accidents was found to be 55% or more of the total ocular injuries9-17. significant percentage of ocular injuries occur among children during recreational activities10 and among farmers during farm activities18-22. many children receive injuries by kitchen knives, pen, pencil tips, stone, cable wires, scissors, thorn, crackers burst, gun pellet, stick and sharp objects23-24. one of the most frequently o mohammad shamsal islam, et al 247 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology occurring injuries in developing countries is blunt injury and intentional assault by husbands and familial feuds. chemical, bird-beak and agricultural trauma are also found in limited numbers in developing countries25. we undertook this study to investigate the pattern, causes and management of ocular injuries in bangladesh. materials and methods data was collected from two sources, one from the hospital records of patients with ocular injuries who received services from october 2012 to december 2013 at the hospital and the other from field survey along with eye examination in an ophthalmic clinic. the study was approved by the ethical review committee of dr. ahmadur rahman research center on august 7, 2014. a total of 425 patients with ocular injuries were selected from more than one thousand patient files in the hospital. patients with ocular injuries in the community were invited through mass publicity to come to the free clinic for check up. some of them came on their own while others were brought to the clinic at the cost of the researcher. they were also interviewed by optometrists after their initial medical check-up. two sets of data collection instruments were developed. a proforma was developed for collecting data from the hospital files on the basis of information available in the files of the patients. another proforma was developed for collecting data from the community patients, which included medical examinations and personal interviews. there were open and close ended questions in both data collection instruments. in addition to these data collection tools, some qualitative data was collected through informal group discussions and in-depth interviews. interview questions were prepared for conducting informal group discussions and in-depth interviews. discussions, however, were not limited to selected questions. analysis of quantitative data remained limited to frequency distribution, measures of central tendency, and descriptive and inferential statistics. results nearly two-thirds of the patients were 18 years or younger. it was observed that over 68% females patients were 10 years or below as against only 37% of males. the mean ages of male and female patients were 19 and 13 years, respectively but median ages were only 15 years for males and 6 years for females, which means a large number of patients were young and few were elderly. the most interesting fact was that only 35% of the total ocular injured patients were in active age group (table 1). table 1: percentage distribution of age of the injured patients by sex. age categories1 male n = 324 female n = 101 total n = 425 frequency percentage frequency percentage percentage 1 – 5 years 62 19.40 46 45.50 25.60 6 – 10 years 56 17.30 23 22.80 18.60 11 – 18 years 65 23.50 12 11.90 20.70 19 – 30 years 68 18.50 09 8.90 16.20 31 – 40 years 32 10.20 04 4.00 8.70 41 – 50 years 15 5.20 01 1.00 4.20 51 – 80 years 16 5.90 05 5.90 5.90 total 324 100.0 101 100.0 100.0 1 ideally class interval is supposed to be done by some standard formula. one of such formulas is k= 1+3.322log10 (n). according to this formula the class interval should have been 9.22, {1+3.322log10 (425) = 9.22} (sturges, 1926), but because we required more precise information about the status of injured eye of children of different age groups (ending at 18 years), of active population, and of elderly people we purposively classified age to meet our study goals. this classification does not violate the principal of class interval as this is widely practiced in studies. in fact vast majority of statistics books do not even discuss about the principal of making class interval rather it leaves to the researchers' needs. pattern, causes, and management of ocular injuries at rural community setting of bangladesh pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 248 mean 19.68 12.76 18.03 median 15.0 6.0 13.0 st. deviation 15.88 15.91 16.14 x2= 37.782; cramer‟s v= .30, df = 6; sig; p= < .001 the difference of age of injured patients by sex was found statistically significant at .001 level (x2 = 37.8, df = 6; cramer‟s v = .30) (table 1). the vast majority of the injuries were open globe (91%) and the rest closed globe (9%). the most common type of injury was penetrating (81.4%), followed by lime burn (7%), and ruptured globe (6.4%) and other (5%). other injuries were traumatic hyphaema and chemical injury (except lime burn) (table 2). the major instrument of injury was sharp objects (82%), which could be a knife, pencil, pen, stone throw, iron rod, etc. only 12% of the patients with ocular trauma had normal vision, 30% had poor vision and 58% had vision close to blindness or completely blind. the structures of some of the ocular components were found normal ranging from 86% to 97%. abnormalities in the above mentioned components varied from 3% to 14%. the most abnormalities in the structure were found in cornea (91%), conjunctiva (59%), iris and pupil (48%). there was one common factor in each of these components and that was corneal penetration (81%) in cornea, congestion of conjunctiva (58%) and prolapsed tissue of iris (45%) causing irregular pupil. as a matter of routine, all first reporting patients had to undergo injury assessment and visual acuity. surgery was the main means of management (95.5%) because most of them came to the hospital with grave injuries. pre-operative diagnosis at first reporting showed that about 87% were diagnosed with penetrating injury followed by ruptured globe injury (7%) and nearly 7% were diagnosed with the chemical injury and traumatic hyphaema. attendance to followup services progressively declined. the first follow-up service was attended by 78% of the first reported patients while it was only 21% in the fourth. one of the reasons of fall in attendance could be progressive improvement in conditions of injured eyes, but there could also be other reasons. among different followup attending patients, 50% to 65% had severe low vision or were blind. range of good vision of patients (6/6 to 6/18) varied from 12.2% to 18.1% at first report through subsequent follow-ups. the majority of the follow-up attending patients had experienced an improvement. about 13% of the patients reported having either infection or inflammation in the injured eye in the first follow-up and that went down to zero at the fourth follow-up. table 2: percentage distribution of types and causes of ocular injury, and preoperative diagnosis for surgeries of patients. injury types n = 425 causes of injury** n = 425 preoperative diagnosis n = 406* penetrating injury 81.40 foreign body 6.40 penetrating injury 86.5 ruptured globe injury 7.30 sharp object/instrument 81.60 ruptured globe injury 8.40 chemical injury 1.40 chemical materials 0.90 chemical injury 2.20 lime burn injury 7.10 acid 0.50 traumatic hyphaema 3.00 traumatic hyphaema 2.80 blow/punch 1.90 ------------- ----------lime 7.30 ------------- ----------blunt materials or object 1.40 ------------- total 100.0 total 100.0 total 100.0 mohammad shamsal islam, et al 249 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology table 3: percentage distribution of events contributing to ocular injury. activities at the time of occurring the injury male n = 65 x2 p value female n = 61 x2 p value total n = 126 playing 20.0 18.76 <.05 9.8 15.25 <.06 15.1 recreation 12.3 16.54 <.05 13.1 17.58 <.05 12.7 accident 3.1 18.78 <.001 6.5 17.88 <.001 4.0 assault by husband 19.7 19.90 <.001 10.3 assault by others 4.6 14.25 <.06 4.9 12.20 <.06 4.8 during farming activities 16.5 17,33 <.03 4.9 10.45 <.09 11.1 during non-farming activities 33.8 11.55 <.09 18.0 15.50 <.05 26.2 during household chores 6.2 10.23 <.08 21.3 15.35 <.05 13.5 other activities 3.1 11.44 <.09 1.6 10.60 <.06 2.4 total 100.0 100.0 100.0 data collected from the rural community showed that only 21% of male patients were farmers. among the non-farm occupational groups, most vulnerable one should have been wage laborers, but they were only 18% of the ocular injured patients, whereas service-holders and businessmen were 33% and 20%, respectively. this means at present it is difficult to identify a vulnerable group for ocular injury in the rural setting. we cannot compare background of patients of hospital and community patients because no data on occupation was recorded in hospital patients‟ files. in response to a question, “how did you get injured”, 25% of the patients reported that they got it while doing non-farm occupational activities followed by playing 2(15%), recreational activities (13%), household chores (14%), farming activities (11%), physical assault by husband (10%), assaulted by others (5%), accident (4%), and other reasons (2.4%) (table 3). when we look into these data from the gender perspective we get a picture like this. about 20% male patients received injuries at the time of playing as against only 10% of the females. this could be for women‟s limited involvement with outdoor games or activities. it is a matter of grave concern that nearly 2 this group of people was mostly young children. 20% of the female patients had ocular injuries due to physical assault by their husbands (p value <.001). ocular injuries during occupational activities skewed toward males compared to females3 both for farm (male = 17%, female = 5%) and non-farm activities (male = 34%, female = 18%). fewer women‟s occupational injuries could be for their smaller number and less hazardous occupational involvement. with regard to household chores the situation is just the reverse. the normal vision was found among 46% of injured eyes as against 82% of fellow eyes. unfortunately, 39% injured eyes had vision near blind or totally blind compared to none for fellow eyes. hence injury to eyes seemed to have contributed significantly to monocular blindness or near blindness. the most affected components of the eye were cornea as 52% of the injured eyes were not found normal and 39% of them had corneal opacity. except for cornea, all other components of eyes, such as orbit and periorbita, lid and lacrimal system, conjunctiva, iris and pupil, lens, retina and globe. contour was found to be normal for 81% or more cases. about 20% of all injured eyes were normal and the rest 80% had some kind of abnormalities. 3 women are primarily housewives but they are engaged in various non-agricultural and agricultural activities as a part of familial duties in addition to household chores. pattern, causes, and management of ocular injuries at rural community setting of bangladesh pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 250 table 4: percentage distribution of places from where first treatment was received. first treatment received male n =65 female n = 61 total n = 126 sought no treatment 12.3 27.9 19.9 traditional healer/quack 16.9 19.6 18.3 registered village physician 9.2 4.8 qualified physician 4.6 3.3 4.0 general hospital 18.5 18.0 18.3 eye specialist or eye hospital 33.8 26.3 30.2 others 4.6 4.9 4.8 total 100.0 100.0 100.0 x2= 7.90, df=1, cramer‟s v= 0.25 at p=<.01 level fig. 1: picture of an ocular injured woman assault by her husband. one-third of the community patients did not receive treatment within 24 hours. they assigned the cause to financial constraint, the absence of escort, considered the injury not serious and no physician or service center nearby. among the service recipient, women were fewer than men. patients treated only with medicine were given antibiotic, atropine eye drop, systemic drugs, anti-glaucomatous drugs and nsaids eye drops. about 78% of the victims encountered problems due to ocular injury. more women (81%) than men (68%) faced it. about 70% of the patients were satisfied with the treatment they had received. those who were dissatisfied with the management assigned the cause to non-improvement of vision and wrong treatment. discussion there were two sets of data for the study. one collected from the patients‟ files of the hospital and another from the community after thorough examinations and interviews. although both groups were ocular injured patients, they significantly differed in age structure. about 65% of hospital patients were children aged 18 or below while it was only 19% for the community patients. there is a gender disparity regarding incidences of ocular injury as 68% of girls of 10 years or below came to the hospital as against only 37% of boys of the same age. this means more girls at young age are involved with risky activities prone to ocular injury. the same result we have observed from desai et al., 2015 study. they found that gender differences persisted with females more likely to have an injury from falls, or in the home and less likely to have one in the workplace26. some differences were found between hospital and community data regarding types of injuries. in hospital most of the patients (81%) came with penetrating injury while only half of the hospital patients (41%) came to research clinic in the community. the reason behind this difference might be that the penetrating injuries are ocular emergency and most of the time patients have to go to the tertiary level hospital where the management of such ocular emergency is available all the time. therefore, more patients‟ with penetrating injuries were found in hospital then community. another noticeable difference between hospital and community data is the presence of ocular surface injury which was 9% among community patients as against none among hospital patients. the nonpresence of this type of injury among hospital patients could be that injuries of this kind are manageable by simple medicine or heals naturally and thus there was https://www.ncbi.nlm.nih.gov/pubmed/?term=desai%20p%5bauthor%5d&cauthor=true&cauthor_uid=25679414 mohammad shamsal islam, et al 251 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology no need to go to the hospital. blunt injuries which ruptured the globe were present in both types of data and it was 6% among community patients and 7.3% among hospital patients. findings also revealed that the hospital cases were mostly open globe (91.0%), while community cases were mostly close globe (81.7%). the reason behind more patients‟ presence with open globe injury in the hospital could be for children‟s predominance as patients who are hyperactive due to involvement with games and innovative activities. contrary to it, close globe injuries were found in community in greater numbers for which people do not go to the hospital as vision is less affected by close globe injuries. sometimes they adjust with some abnormalities and discomfort with local treatment. some studies support our findings and the range of open global injuries varies from 51% to 92%5,11,13. the sharp objects were the primary cause of ocular injuries among hospital patients (81%) and community patients (38%), which could be for their young age when the children are usually hyperactive. an opposite image was found for blunt materials as a cause of ocular injury because it was as high as 48% among community patients as against 1.4% among hospital ones. the largest numbers of people of different ages receive eye injuries by sharp objects like kitchen knife, pen, pencil, tips, stone missiles, wood, glasses4,5,9,10,13,20. it may be due to the fact that blunt materials like punch, assault, ball etc. are not always dangerous enough to need ocular emergency treatment like those of penetrating injuries by sharp objects. this study has identified assault as a growing cause of ocular injury for women. about 20% of ocular injured women in the community were assaulted by their husbands and 5% by others. this problem has to be solved through informal education and empowerment of women in addition to medical services. many women opined that they could not timely go to physicians due to the objection from their husbands and kin. registered village physicians receive ocular injured patients and they prescribe drops and tablets for immediate relief of pain and swelling. our ophthalmologist has found that they often prescribe tropical steroid eye drops which are extremely harmful for the ocular injured patients. however, the village physicians have requested for a one day workshop on how to deal with ocular injured patients. we believe this suggestion is worth consideration. some community people until this test clinic held was less concerned about ocular injury as 17% of the patients never went to a physician possibly because it was not life threatening like other diseases. people seem to go by wait and see technique and do not consider its devastating effects in future. this notion can be changed only through health education that may be more appropriately done through school sight testing and community mobilization programs. perceptions were measured through informal group discussion and few structured questions. however, despite some superstitious perceptions about eye sights all agree that modern treatment of ocular injuries are needed and service facilities should be made available. conclusion the nature of injuries found in hospital and community setting is different. the open globe injured patients are mostly children aged 18 years or below. surgery was the main mode of management of hospital patients (95.5%) but in the community the main mode of management was medicine (62%). the most serious concern for ocular injured patients is that about 58% of the hospital patients and 41% of the community patients had monocular blindness. hence, preventive measures along with high quality management should receive priority for reducing monocular blindness. a new fact about the ocular injury of community married women is husbands‟ physical assault. the assaulted women even can‟t seek treatment for the restriction of movement imposed by their husbands and kin. conflicts of interest no conflicts of interest. acknowledgements the authors are grateful to dr. ahmadur rahman research center, for providing logistic support during data collection and report completion. we are also grateful to respondents, for allocating their valuable time during data collection. author’s affiliation dr. mohammad shamsal islam ms, mph. dr. ahmadur rahman research center, university of chittagong, bangladesh. pattern, causes, and management of ocular injuries at rural community setting of bangladesh pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 252 prof. abul hasnat golam quddus mph, phd. director (research), dr. ahmadur rahman research center, university of chittagong, bangladesh. role of authors dr. mohammad shamsal islam, ms, mph conception 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„trends in serious ocular trauma in scotland‟ eye (lond). 2015 may; 29(5): 611–618. published online 2015 feb 13. doi: 10.1038/eye.2015.7; pmcid: pmc4429283 http://archtrauma.com/?page=search&article_author_fname=davood&article_author_mname=&article_author_lname=aghadoost%20&do_search=1&type=authors http://www.ncbi.nlm.nih.gov/pubmed?term=onyekonwu%20gc%5bauthor%5d&cauthor=true&cauthor_uid=19256319 http://www.ncbi.nlm.nih.gov/pubmed?term=chuka-okosat%20cm%5bauthor%5d&cauthor=true&cauthor_uid=19256319 http://www.ncbi.nlm.nih.gov/pubmed/19256319 http://www.ncbi.nlm.nih.gov/pubmed/?term=soliman%20am%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=el-sebaity%20dm%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=soliman%20w%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=fathalla%20am%5bauth%5d http://www.jpmi.org.pk/index.php/jpmi/issue/view/64 http://www.jpmi.org.pk/index.php/jpmi/issue/view/64 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https://www.ncbi.nlm.nih.gov/pubmed/?term=macewen%20cj%5bauthor%5d&cauthor=true&cauthor_uid=25679414 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4429283/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4429283/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4429283/ https://dx.doi.org/10.1038%2feye.2015.7 pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 169 editorial ilm: to peel or not to peel i was first introduced to internal limiting membrane (ilm) peeling in 1996 by prof. eckardt on his visit to moorfields eye hospital. his elegant videos of ilm peeling were carried out without the help of any dye and were inspiring. prof eckardt subsequently published his work in 19971. morris et al had performed ilm peeling in 1990 for haemorrhagic retinal cysts and published their 7 year followup in 19972. this report also demonstrated the long term safety of ilm peeling. ilm is only 6 micron thick and is the structural boundary between the retina and the vitreous. it is adherent to the collagenous cortex of the vitreous on its one side, and to the muller (glial) cell end feet on the retinal side3. ilm peeling is now an established procedure in vitreo retinal surgery mainly for the following indications: 1. macular hole surgery. 2. diabetic macular oedema. 3. vitreo macular traction. 4. epiretinal membrane peel. 5. vitrectomy for retinal detachment. however the literature on ultrastructural effects of ilm peeling on “human retina” are scant. ofparticular importance is the effect on muller cells and its end feet. wolf et al4 carried out ilm peel with icg on post mortem eyes (within 60 minutes of death) and subjected it to electron microscopy. they made the following observation: “in the peeled area proper, many end-feet remained apparently intact may be because the human muller cell endfoot membranes are not tightly fixed at the basal lamina (e.g., by hemidesmosomes); thus, some end-feet may be dissociated from the basal lamina without forces strong enough to disrupt the cells.“ “although direct evidence cannot be obtained from enucleated eyes, these observations suggest that only the endfeet and adjacent parts of some of the muller cells were destroyed, whereas their somata and some cell processes could have survived by sealing the disrupted cell membranes.” there were suggestions that the effects could have resulted from the use of icg during surgery which was refuted by the authors of the study. on the other hand this type of cellular injury in vivo stimulates regenerative mechanisms in the muller cells that then may contribute to the closure of the macular hole5. the effects of ilm peel on muller cells in porcine eyes has been adequately studied. there was excellent growth in culture6 of muller cells following ilm peel in porcine eyes. in addition the long term functional status of ilm peeled retina in human retina was also established by carrying out multifocal erg after 1 year of ilm peel7. the role of ilm peeling during vitrectomy for various indications can be established by carrying out meta analysis of randomised control trials and the results in the literature are reproduced below. 1. macular hole: the role of ilm peeling in macular hole surgery is now well established. a meta analysis of randomised control trials comparing ilm peel versus non ilm peel in vitrectomy in stage 2, 3 and 4 holes was carried out by cornish et al8. it was observed: • there was no evidence of difference in visual acuity at 6 months between the peel and non peel group. • ilm peel group had statistically superior closure of macular hole. this was present both for primary and final closure. • ilm peeling was found to be cost effective with no difference in the complications between the two groups and ilm peeling in macular holesurgery and is recommended as the treatment of choice. 2. diabetic macular oedema: the ilm of patients with diabetes has a higher expression of collagen, fibronectin, and laminin,9,10 is thicker than that of non diabetic eyes11. it would make sense to remove ilm in all cases of diabetic macular oedema however the superiority of ilm peeling versus non peeling combined with patients with diabetic macular oedema cannot be statistically proven. mustafa iqbal 170 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology in a review of 644 reports on the role of vitrectomy in dmo only 5 studies directly compared ilm peeling with non peelingin vitrectomy for dmo (4 of them were not rcts). nakajima12 et al carried out meta analysis of these studiesand concluded that: the mean postoperative bcva improved in patients who underwent vitrectomy regardless of ilm peeling in four of five studies. • postoperative bcva itself the superiority in bcva by additional ilm peeling was equivalent to 2 etdrs letters and not statistically significant. • change in bcva before and after surgery by additional ilm peeling was equivalent to 2 etdrs letter) and not statistically significant. the results of internal limiting membrane peeling on central macular thickness: • when evaluated by the change in cmt before and after surgery the further decrease in cmt by additional ilm peeling was not statistically significant. since 4 of these studies were not rcts hence the bias/influence of pvd, pdr, previous laser therapy and hba1c cannot be eliminated hence the need for a large rct! kumagai kazuyuki13 et al had reduced the bias of diabetic control (hba1c) and duration of diabetes by carrying out vitrectomy in each eye of the same patient with one eye having ilm peel and the fellow eye no peel. however their results were not different from those in the previous meta-analysis. they concluded that the differences in the best-corrected visual acuity between the two groups were not significant at any time point. 3. vitreomacular traction: once again the role of ilm peeling is not entirely clear with lack of statistically significant data (lack of randomised clinical trial). a meta analysis14 of the available data fails to establish any benefit of vitrectomy with ilm peel over the non-peel group. however the results of ilm peel in myopic traction maculopathyare encouraging with improved bcva in cases with foveal detachment and macular retinoschisis but not in the macular hole associated with high myopia15. 4. epiretinal membrane: the role of ilm peeling in epiretinal membrane is well established by the excellent histological study carried out by gandorferet al16. in 2 of 3 patients with idiopathic erm, the vitreous cortex splits when the erm is removed leaving cells on the ilm. as these cells are capable of proliferation and causing erm recurrence, staining of the ilm with subsequent removal seems beneficial in macular pucker surgery. this is further corroborated by a large but retrospective study of 440 patients17. it was found out that ilm peeling was the only factor preventing erm recurrence. 5. retinal detachment: apart from anatomical success the occurrence of macular pucker can affect visual acuity after repair of retinal detachment. the epiretinal membrane in retinal detachment differs from those idiopathic cases and stains for myofibroblasts and retinal pigment epithelial cells with a propensity to contract. in a retrospective study18 comparing ppv with no ilm peel and ilm peel the following observations were made: • post-operativemacular pucker: 34.4% of eyes in non-peel vs. 3.3% in ilm peel group. • re operation for macular pucker: 9.4% in non ilm group (almost 1 in 10 patients require re operation!!) and none in ilm peel group. • post-operative va: no difference between the 2 groups but only 1 in 4 patients were macula on before surgery. in a larger retrospective study it was observed19: no erm occurred in the ilm peeling group, whereas erm occurred 21.5% of nonpeelinggroup. this difference was significant (p< 0.001). in the macula on group, the overall mean bestcorrected visual acuity was better in the ilm peeling group and was significantly higher 12 months postoperatively (p = 0.03). ilm peeling in cases of retinal detachment prevents macular pucker formation. however there is no statistical difference in vision when ilm peel group is compared to non-peelgroup in macula off retinal detachments. safety of ilm peeling: ilm peeling can be associated with some side effects. the dyes used in ilm peeling especially icg can cause retinal dysfunction at least temporarily and it is recommended to use a lower concentration of icg20. a reduction of gcipl layer thickness was also observed when ilm peeling was combined with icg staining21. ilm: to peel or not to peel pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 171 the development of para central retinal holes is well documented22 and reported regularly. in conclusion ilm peeling is now an established and safe procedure procedure in vitreo retinal surgery. the indications for ilm peeling are gradually expanding however concrete and statistically proven efficacy of ilm peeling is lacking and requires large multicentrerandomised control trials. the surgeon should aware of the available data on the subject and evidence based treatment should be carried out. references 1. eckardt c, eckardt u, groos s, et al. entfernung der membrana limitansinterna bei makulalochem. klinische und morphologische befunde. ophthalmologe 1997; 94: 545–51. 2. morris r, witherspoon cd, kuhn f, priester b. internal limiting membrane maculorrhexis for traction maculopathy. vitreoretin surg technol 1997; 8: 1–5. 3. fine bs. limiting membranes of the sensory retina and pigment epithelium an electron microscopic study. arch ophthalmol 1961; 66: 847–60. 4. wolf s, schnurbusch u, wiedemann p, grosche j, reichenbach a, wolburg h. peeling of the basal membrane in the human retina: ultrastructural effects. ophthalmology 2004; 111: 238–43. 5. bringmann a, reichenbach a. role of muller cells in retinal degeneration. front biosci 2001; 6: e72–92. 6. guidry c. isolation and characterization of porcine muller cells myofibroblastic dedifferentiation in culture. invest ophthalmol vis sci 1996; 37: 740–52. 7. morris r, witherspoon cd, kuhn f, et al. traction maculopathy. in: kriegelstein g, ed., retinology today, munich: verlag fur. 8. cornish ks, lois n,scott nw, burr j, cook j, boachie c, tadayoni r, la cour m, christensen u, kwok ak. vitrectomy with internal limiting membrane peeling versus no peeling for idiopathic full – thickness macular hole. ophthalmology 2014; 121: 649-655. 9. kohno t, sorgente n, goodnight r, ryan sj. alterations in the distribution of fibronectin and laminin in the diabetic human eye. invest ophthalmol vis sci 1987; 28: 515–521. 10. ljubimov av, burgeson re, butkowski rj, couchman jr, zardi l, ninomiya y, sado y, huang zs, nesburn ab, kenney mc. basement membrane abnormalities in human eyes with diabetic retinopathy. j histochem cytochem 1996; 44: 1469–1479. 11. matsunaga n, ozeki h, hirabayashi y, shimada s, ogura y. histopathologic evaluation of the internal limiting membrane surgically excised from eyes with diabetic maculopathy. retina 2005; 25: 311–316. 12. nakajima t, roggia mf, noda y, ueta t. effect of internal limiting membrane peeling during vitrectomy for diabetic macular edema: systematic review and meta-analysis. retina 2015; 35: 1719-25. 13. kazuyuki k, masanori h, nobuchika o, et al. effect of internal limiting membrane peelingon long term visual outcomes for diabetic macular edema. retina. 2015; 35: 1422-1428. 14. jackson tl, nicod e; angelis a, grimaccia f, prevost at, simpson ar, kanavos p.pars plana vitrectomy for vitreomacular traction syndrome. a systematic review and meta analysis of safety and efficacy. retina; 33: 2012-2017. 15. taniuchi s, hirakata a, itoh, y, hirota k, inoue m. vitrectomy with or without internal limiting membrane peeling for each stage of myopic traction maculopathy. retina 2013; 33: 2018-2025. 16. gandorfer a, haritoglou c, scheler r, schumann r, zhao f, kampik a. residual cellular proliferation on the internal limiting membrane in macular pucker surgery. retina 2012; 32: 477-485. 17. sandali o, el sanharawi m, basli e, bonnel s, lecuen n, barale po, borderie v, laroche l, monin c. epiretinal membrane recurrence: incidence, characteristics, evolution, and preventive and risk factors. retina 2013; 33: 2001-2002. 18. rc rao, kj blinder, gk shah.triamcinolone–assisted internal limiting membrane peeling during primary rhegmatogenous retinal detachment repair reduces postoperative macular pucker. investigative ophthalmology and visual science 2012; 53: 5791. 19. ky nam, jy kim. effect of internal limiting peeling on development of epiretinal membrane after pars plana vitrectomy for rhegmatogenous retinal detachment. retina 2015; 35: 880-885. 20. t. y. y. lai, a. k. h. kwok, a. w. h. au, and d. s. c. lam, “assessment of macular function by multifocal electroretinography following epiretinal membrane surgery with indocyanine green – assisted internal limiting membrane peeling,” graefe’s archive for clinical and experimental ophthalmology 2007; 245: 148–154. 21. seo kh, yu sy, kwak hw. topographic changes in macular ganglion cell–inner plexiform layer thickness after vitrectomy with icg guided internal limiting membrane peel for idiopathic macular hole. retina 2015; 35: 1828-1835. 22. p. steven, h. laqua, d. wong, and h. hoerauf. “secondary paracentral retinal holes following internal limiting membrane removal. british journal of ophthalmology 2006; 90: 293–295. prof. mustafa iqbal frcs mrcophth. head department of ophthalmology khyber medical college peshawar http://www.ncbi.nlm.nih.gov/pubmed/?term=grosche%20j%5bauthor%5d&cauthor=true&cauthor_uid=15019369 http://www.ncbi.nlm.nih.gov/pubmed/?term=reichenbach%20a%5bauthor%5d&cauthor=true&cauthor_uid=15019369 http://www.ncbi.nlm.nih.gov/pubmed/?term=wolburg%20h%5bauthor%5d&cauthor=true&cauthor_uid=15019369 http://www.ncbi.nlm.nih.gov/pubmed/?term=burr%20j%5bauthor%5d&cauthor=true&cauthor_uid=24314837 http://www.ncbi.nlm.nih.gov/pubmed/?term=cook%20j%5bauthor%5d&cauthor=true&cauthor_uid=24314837 http://www.ncbi.nlm.nih.gov/pubmed/?term=boachie%20c%5bauthor%5d&cauthor=true&cauthor_uid=24314837 http://www.ncbi.nlm.nih.gov/pubmed/?term=boachie%20c%5bauthor%5d&cauthor=true&cauthor_uid=24314837 http://www.ncbi.nlm.nih.gov/pubmed/?term=tadayoni%20r%5bauthor%5d&cauthor=true&cauthor_uid=24314837 http://www.ncbi.nlm.nih.gov/pubmed/?term=la%20cour%20m%5bauthor%5d&cauthor=true&cauthor_uid=24314837 http://www.ncbi.nlm.nih.gov/pubmed/?term=christensen%20u%5bauthor%5d&cauthor=true&cauthor_uid=24314837 http://www.ncbi.nlm.nih.gov/pubmed/?term=kwok%20ak%5bauthor%5d&cauthor=true&cauthor_uid=24314837 http://www.ncbi.nlm.nih.gov/pubmed/?term=couchman%20jr%5bauthor%5d&cauthor=true&cauthor_uid=8985139 http://www.ncbi.nlm.nih.gov/pubmed/?term=zardi%20l%5bauthor%5d&cauthor=true&cauthor_uid=8985139 http://www.ncbi.nlm.nih.gov/pubmed/?term=ninomiya%20y%5bauthor%5d&cauthor=true&cauthor_uid=8985139 http://www.ncbi.nlm.nih.gov/pubmed/?term=sado%20y%5bauthor%5d&cauthor=true&cauthor_uid=8985139 http://www.ncbi.nlm.nih.gov/pubmed/?term=huang%20zs%5bauthor%5d&cauthor=true&cauthor_uid=8985139 http://www.ncbi.nlm.nih.gov/pubmed/?term=huang%20zs%5bauthor%5d&cauthor=true&cauthor_uid=8985139 http://www.ncbi.nlm.nih.gov/pubmed/?term=nesburn%20ab%5bauthor%5d&cauthor=true&cauthor_uid=8985139 http://www.ncbi.nlm.nih.gov/pubmed/?term=kenney%20mc%5bauthor%5d&cauthor=true&cauthor_uid=8985139 http://www.ncbi.nlm.nih.gov/pubmed/?term=shimada%20s%5bauthor%5d&cauthor=true&cauthor_uid=15805908 http://www.ncbi.nlm.nih.gov/pubmed/?term=ogura%20y%5bauthor%5d&cauthor=true&cauthor_uid=15805908 http://www.ncbi.nlm.nih.gov/pubmed/?term=nakajima%20t%5bauthor%5d&cauthor=true&cauthor_uid=26079478 http://www.ncbi.nlm.nih.gov/pubmed/?term=roggia%20mf%5bauthor%5d&cauthor=true&cauthor_uid=26079478 http://www.ncbi.nlm.nih.gov/pubmed/?term=noda%20y%5bauthor%5d&cauthor=true&cauthor_uid=26079478 http://www.ncbi.nlm.nih.gov/pubmed/?term=ueta%20t%5bauthor%5d&cauthor=true&cauthor_uid=26079478 http://www.ncbi.nlm.nih.gov/pubmed/?term=grimaccia%20f%5bauthor%5d&cauthor=true&cauthor_uid=24013261 http://www.ncbi.nlm.nih.gov/pubmed/?term=prevost%20at%5bauthor%5d&cauthor=true&cauthor_uid=24013261 http://www.ncbi.nlm.nih.gov/pubmed/?term=prevost%20at%5bauthor%5d&cauthor=true&cauthor_uid=24013261 http://www.ncbi.nlm.nih.gov/pubmed/?term=simpson%20ar%5bauthor%5d&cauthor=true&cauthor_uid=24013261 http://www.ncbi.nlm.nih.gov/pubmed/?term=kanavos%20p%5bauthor%5d&cauthor=true&cauthor_uid=24013261 http://www.ncbi.nlm.nih.gov/pubmed/?term=hirota%20k%5bauthor%5d&cauthor=true&cauthor_uid=23975004 http://www.ncbi.nlm.nih.gov/pubmed/?term=inoue%20m%5bauthor%5d&cauthor=true&cauthor_uid=23975004 http://www.ncbi.nlm.nih.gov/pubmed/?term=schumann%20r%5bauthor%5d&cauthor=true&cauthor_uid=22068175 http://www.ncbi.nlm.nih.gov/pubmed/?term=zhao%20f%5bauthor%5d&cauthor=true&cauthor_uid=22068175 http://www.ncbi.nlm.nih.gov/pubmed/?term=kampik%20a%5bauthor%5d&cauthor=true&cauthor_uid=22068175 http://www.ncbi.nlm.nih.gov/pubmed/?term=bonnel%20s%5bauthor%5d&cauthor=true&cauthor_uid=23612050 http://www.ncbi.nlm.nih.gov/pubmed/?term=lecuen%20n%5bauthor%5d&cauthor=true&cauthor_uid=23612050 http://www.ncbi.nlm.nih.gov/pubmed/?term=lecuen%20n%5bauthor%5d&cauthor=true&cauthor_uid=23612050 http://www.ncbi.nlm.nih.gov/pubmed/?term=barale%20po%5bauthor%5d&cauthor=true&cauthor_uid=23612050 http://www.ncbi.nlm.nih.gov/pubmed/?term=borderie%20v%5bauthor%5d&cauthor=true&cauthor_uid=23612050 http://www.ncbi.nlm.nih.gov/pubmed/?term=laroche%20l%5bauthor%5d&cauthor=true&cauthor_uid=23612050 http://www.ncbi.nlm.nih.gov/pubmed/?term=monin%20c%5bauthor%5d&cauthor=true&cauthor_uid=23612050 http://iovs.arvojournals.org/article.aspx?articleid=2359490 http://iovs.arvojournals.org/article.aspx?articleid=2359490 http://iovs.arvojournals.org/article.aspx?articleid=2359490 http://iovs.arvojournals.org/article.aspx?articleid=2359490 http://europepmc.org/search;jsessionid=kqzwgk51tmry2qpfwshe.0?page=1&query=auth:%22seo+kh%22 http://europepmc.org/search;jsessionid=kqzwgk51tmry2qpfwshe.0?page=1&query=auth:%22yu+sy%22 http://europepmc.org/search;jsessionid=kqzwgk51tmry2qpfwshe.0?page=1&query=auth:%22kwak+hw%22 microsoft word 06-oa zeynep ozbek 21 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology original article can subconjunctival bevacizumab injection regress corneal neovascularization? zeynep ozbek, rukiye aydin, ozlem barut selver, m. alper selver, ali osman saatci, ismet durak pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zeynep ozbek associate professor department of ophthalmology, dokuz eylul university school of medicine izmir, turkey …..……………………….. purpose: to determine the effect of subconjunctival bevacizumab injection on corneal neovascularization. material and methods: the study included 16 eyes of 8 new zelland albin rabbits. a 6/0 silk suture was placed intrastromally near the superior limbus in bot eyes of rabbits to induce corneal neovascularization. eyes were checked weekly fo neovascularization and adjacent conjunctival injection. subconjunctival injections o 1.25mg and 2.5mg bevacizumab were given in right and left eyes respectively eyes were examined under the operating microscope. digital photographs wer taken weekly for 6 weeks and then evaluated by using a computerized imag processing technique and a transparent grid technique to quantify the area o corneal neovascularization and adjacent conjunctival injection. results: corneal neovascularization and adjacent conjunctival injection wer observed by the end of first week. injections were performed at the second week only four rabbits could complete the study. conjunctival injection improve significantly at the first week following injection. most significant reduction o corneal neovascularization was observed in the second week in both eyes of all rabbits. no recurrence was noted although no repeat injection was given. conclusion: subconjunctival injection of bevacizumab may become an adjunct in the treatment of corneal neovascularization. eovascularization is the formation of new vascular structures in areas that were previously avascular1. although cornea is a transparent and a vascular tissue, it may be subject to neovascularization due to prolonged inflammation which eventually can lead to corneal opacification, impaired vision and induce corneal graft rejection after corneal transplantation.1-3 vascular endothelial growth factor (vegf) is a potent stimulator of endothelial cell growth in vitro and neovascularization in vivo.4 the role of vegf was well-established in different clinical conditions such as tumors, proliferative diabetic retinopathy, age-related macular degeneration5-7 and various anti-vegf agents have been utilized for neovascular eye diseases. vegf was an important endogenous factor for wound and inflammation-related corneal neovascularization in the rat model as well8. bevacizumab is a recombinant humanized monoclonal antibody developed against vegf which binds to soluble vegf and prevents receptor binding thus inhibits endothelial cell proliferation and vessel formation.9 this animal study was conducted in order to assess whether subconjunctival bevacizumab injection could regress corneal neovascularization. material and methods sixteen eyes of 8 new zelland albino rabbits (2 – 3 kilograms) were included. the study was approved by the institutional animal care and use ethics committee of dokuz eylul university, school of medicine. all procedures were performed in accordance with the arvo statement for the use of n can subconjunctival bevacizumab injection regress corneal neovascularization? pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 22 animals in ophthalmic and vision research. all animals were housed in individual cages and maintained under standard conditions. the cornea and anterior segment were examined in both eyes under the operating microscope to confirm normal anatomy and absence of previous neovascularization prior to the study. corneal neovascularization model rabbits were anesthetized with intramuscular ketamine hydrochloride (35mg/kg) and xylazine (5mg/kg) in the animal laboratory. for the topical anesthesia, one drop of proparacaine hydrochloride 0.5% (alcaine®, alcon) was instilled bilaterally. a double pass 6/0 silk suture was placed intrastromally near the superior limbus in order to induce neovascularization. all eyes were observed weekly for the development of corneal neovascularization. drug administration after the neovascularization was observed, bevacizumab (altuzan®, roche) was injected subconjunctivally by the help of a 27 g needle adjacent to the neovascularized area. right eyes received 1.25mg (0.05ml) and left eyes received 2.5mg (0.1ml) of bevacizumab. assessment of neovascularization digital photographs were taken weekly by nikon coolpix 4500, 4.0 megapixel camera, with 4x optic zoom under constant magnification and distance. all photographs were then evaluated by a computerized image processing technique to visualize the change in neovascularization and also by using a transparent grid pattern in order to quantify and compare the regression in neovascularization. computerized image processing at the beginning of the process, a region of interest (roi) was selected on the photographs taken before and after subconjunctival injection. this roi was converted to grayscale, the contrast was enhanced for better rendering of vascularization and two images were registered. (image registration is the process of aligning two or more images of the same scene. typically, one image is considered the reference to which the second image is compared). the object of image registration is to bring the reference image into alignment with the second image by applying a spatial transformation. this spatial transformation maps locations in reference image to new locations in the second one. the spatial transformation used for registration is the ‘local weighted mean’ method which is applied by selecting 12 control points from each image and processing this points by using matlab 7.04 image processing toolbox. after registering the two images, another roi was selected where the vascularization was dense (fig.1a and 1b). then an edge detection procedure was applied to detect the vasculature in both images (fig. 2a and 2b). this procedure looks for places in the image where the intensity changes rapidly, using one of these two criteria: 1) places where the first derivative of the intensity is larger in magnitude than a threshold. 2) places where the second derivative of the intensity has a zero crossing. finally, the resulting images were automatically thresholded by using the method described by otsu.10 we got the vasculature in two binary images. the subtraction of these two images resulted with a final image where the difference between two vasculature was visible (fig. 3). quantification of regression by point counting the technique described by howie et al11 was used. a transparent grid pattern composed of uniform, equidistant points (4mm apart) was placed over each photograph and the number of points coinciding with the area of neovascularization was counted. the numbers representing the area of neovascularization just before bevacizumab injection were considered as baseline and the baseline number of points was compared to the number obtained from the photos taken at each week. statistical analysis mann-whitney u test was used to compare the numbers obtained from transparent grid technique in order to assess the efficacy of 1.25mg and 2.5mg of bevacizumab injections on neovascularization. wilcox on analysis was performed in order to evaluate the regression in neovascularization at each week. results corneal neovascularization developed in all eyes by the end of first week after placing the stromal suture (fig. 4). circumferential and radial corneal neovascularization was observed originating from the area of adjacent limbal injection at the second week. after the zeynep ozbek, et al 23 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology fig. 1: 1a 2b fig. 2: a 2b fig. 3: injection of bevacizumab (fig. 5), some decrease in baseline corneal neovascularization was noted within the first week, this change was not significant. the regression of conjunctival injection was most significant at the first week when compared to the following weeks. the most significant reduction of corneal neovascularization, was observed between the baseline evaluation and the second week (fig. 6) in both eyes of all 4 rabbits whereas the difference between the second week and the following weeks was not significant. the graph in fig. 7 shows the fig. 4: fig. 5: fig. 6: regression in conjunctival injection and corneal neovascularization during the study period. no difference in regression of neovascularization was observed between right and left eyes, which received 1.25mg and 2.5mg of bevacizumab respectively. regression persisted and no complications were encountered during six weeks of follow-up. although can subconjunctival bevacizumab injection regress corneal neovascularization? pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 24 no repeat doses of subconjunctival bevacizumab were given, neovascularization did not recur fig. 8. fig. 7: fig. 8: discussion the pathogenesis of corneal angiogenesis has not yet been clearly defined.12 however, it is obvious that prevention of corneal neovascularization would help maintain the transparency and immune privilege of the cornea. the role of vegf in inflammatory corneal neovascularization has been investigated recently. vegf was up regulated in inflamed and vascularized corneas in human and in animal models.8, 12 amano and co-workers8 used a rat model in order to quantify corneal vegf mrna levels with ribonuclease protection assay. they removed corneal and limbal epithelium in order to induce circumferential corneal neovascularization and identified a positive correlation between corneal vegf mrna levels and neovascularization. constitutive vegf mrna was very low in normal cornea while it was expressed greater than 10-fold higher levels after wounding. the majority of vegf immunoreactivity was localized in the invading inflammatory cells. the specific inhibition of vegf bioactivity with implantation of pellets containing controlled – release polyclonal anti-vegf antibody into corneal stroma potently suppressed corneal neovascularization.8 another rat study of established corneal transplant model for rejection evaluated vegf production in the graft by immunohistochemistry.13 twenty-one rats underwent corneal transplantation. grafted rats were divided into three groups each receiving 0.9 m nacl, rabbit serum immunoglobin, or anti-vegf antibody topically. from the day of operation, the treatment was applied five times daily for 10 days on the left eyes. immunohistochemical analysis showed that immune deposits for vegf existed in infiltrative cells in grafts and corneal epithelial cells. histologic sections showed a moderate to marked mononuclear cell infiltration in saline and anti-rabbit igg-treated grafts. with anti-vegf antibody – treated grafts, mononuclear cell infiltration was mild compared with saline and anti-rabbit igg-treated grafts. neovascularization and edema were significantly suppressed from day 6 to day 19 in anti-vegf antibody-treated grafts compared with rabbit igg and saline-treated grafts. joussen et al14 showed that vegf had a regulatory effect in the conjunctivalization of the corneal surface. they reported that corneal neovascularization preceded the appearance of the goblet cells and demonstrated that vegf is required for both corneal neovascularization and appearence of goblet cells after extensive limbal injury. manzano et al15 administered bevacizumab topically on experimental corneal neovascularization in rats. after chemical cauterization of the rat corneas, daily instillation of bevacizumab 4mg/ml drops inhibited the corneal neovascularization significantly. in this study, we have investigated the effect of subconjunctival bevacizumab injection on corneal neovascularization. we have observed significant reducetion of corneal neovascularization with subconjunctival injections of 1.25mg and 2.5mg of bevacizumab without any significant difference between the two doses. the regression was most prominent at the second week after injection when compared to baseline or other weeks. interestingly, significant decrease in the adjacent conjunctival injection was observed earlier, in the first week. this might be related to the higher reported levels of vegf zeynep ozbek, et al 25 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology in the adjacent conjunctiva when compared to cornea.1,8 although we could achieve significant regression in corneal vascularization, we could not provide complete resolution. a possible reason for this situation could be that vegf was shown to lead to the regression of newly formed vessels while it did not cause regression in established neovascularization.14 besides, corneal neovascularization is a complex process, which involves other cytokines than vegf such as transforming growth factor and fibroblast growth factor and is still under investigation. on the other hand, the dosing and frequency of bevacizumab should also be evaluated in future studies with control groups and bigger study population to clarify the place of subconjunctival bevacizumab injection in the treatment armamentarium of corneal neovascuarization. the authors have no proprietary or commercial interest in any materials discussed in this article. author’s affiliation dr. zeynep ozbek associate professor department of ophthalmology, dokuz eylul university school of medicine izmir, turkey dr. rukiye aydin resident department of ophthalmology, dokuz eylul university school of medicine izmir, turkey dr. ozlem barut selver resident department of ophthalmology, dokuz eylul university school of medicine izmir, turkey dr. m. alper selver resident department of ophthalmology dokuz eylul, university school of medicine izmir, turkey dr. ali osman saatci research assistant, electrical and electronics engineering department dokuz eylul university, izmir, turkey dr. ismet durak professor, department of ophthalmology dokuz eylul university school of medicine izmir, turkey references 1. chang jh, gabison ee, kato t, azar dt. corneal neovascularization. curr opin ophthalmol. 2001; 12: 242-9. 2. epstein rj, stulting rd, hendricks rl, harris dm. corneal neovascularization:pathogenesis and inhibition. cornea 1987; 6: 250-57. 3. miller jw. vascular endothelial growth factor and ocular neovascularization. am j pathol. 1997; 151: 13-23. 4. leung dw, cachianes g, kuang wj, goeddel dv, ferrara n. vascular endothelial growth factor is a secreted angiogenic mitogen. science. 1989; 246:1306-9. 5. presta lg, chen h, o’connor sj, chisholm v, meng yg, krummen l, winkler m, ferrara n. humanization of an anti-vegf monoclonal antibody for the therapy of solid tumors and other disorders. cancer res. 1997; 57: 4593-9. 6. adamis ap, miller jw, bernal mt, d'amico dj, folkman j, yeo tk, yeo kt. increased vascular endothelial growth factor levels in the vitreous of eyes with proliferative diabetic retinopathy. am j ophthalmol. 1994; 118: 445. 7. avery rl, pieramici d, rabena md, castellarin aa, nasir ma, giust mj. intravitreal bevacizumab (avastin) for neovascular age-related macular degeneration. ophthalmology. 2006; 113: 363-72. 8. amano s, rohan r, kuroki m, tolentino m, adamis ap. requirement for vascular endothelial growth factor in woundand inflammation-related corneal neovascularization. invest ophthalmol vis sci. 1998; 39: 18-22. 9. wang y, fei d, vanderlaan m, song a. biological activity of bevacizumab, a humanized anti-vegf antibody in vitro. angiogenesis. 2004; 7: 335–45. 10. otsu n. a threshold selection method from gray-level histograms," ieee transactions on systems, man, and cybernetics. 1979; 9: 62-6. 11. howie aj, gunson bk, sparke j. morphometric correlates of renal excretory function. j pathol. 1990; 160: 245-53. 12. philipp w, speicher l, humpel c. expression of vascular endothelial growth factor and its receptors in inflamed and vascularized human corneas. invest ophthalmol vis sci. 2000; 41: 2514-22. 13. yatoh s, kawakami y, imai m, kozawa t, segawa t, suzuki h, yamashita k, okuda y. effect of a topically applied neutralizing antibody against vascular endothelial growth factor on corneal allograft rejection of rat. transplantation. 1998; 66: 1519-24. 14. joussen am, poulaki v, mitsiades n, stechschulte su, kirchhof b, dartt da, fong gh, rudge j, wiegand sj, yancopoulos gd, adamis ap. vegf-dependent conjunctivalization of the corneal surface. invest. ophthalmol. vis. sci. 2003; 44: 117-23. 15. manzano r, peyman g, khan p, carvounis pe, kivilcim m, ren m, lake jc, chevez-barrios p. inhibition of experimental corneal neovascularization by bevacizumab (avastin). br j ophthalmol. 2007; 91: 804-7. microsoft word 3. hamid awan 184 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology original article conductive keratoplasty for presbyopia abdul hamid awan pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: abdul hamid awan consultant ophthalmologist shalamar hospital lahore …..……………………….. purpose: to assess the safety and efficacy of conductive keratoplasty (ck) in the treatment of plano presbyopia. material and methods: twenty plano presbyopic patients (14 women and 6 men) underwent ck in non dominant eye. mean age was 48.5 year (range 45 to 52 years). the post-operative target refraction for these eyes were minus 1.250 d. results:pre-op near refraction was +1.85 d (range +1.50 d to +2.25 d and near vision was j8 to j12. one year after conductive keratoplasty on non-dominant eye, the mean uncorrected near vision was j1 (range j1 to j3). 90% (18) eyes achieved j1 and 100% (all 20 eyes) achieved j3 or better. conclusion: conductive keratoplasty for the treatment of presbyopia provided safe and effective results one year following the initial surgery. large segment of our population has presbyopic refractive error and refractive surgery procedure. cataract surgery also produces plano presbyopia when distance viewing monofocal iols are used. for more than 100 years different techniques to shrink peripheral corneal collagen and thereby steepens the central cornea have been developed. thermokeratoplasty was used in 1980s to produce thermal burns in hyperopic eyes and it showed a lack of predictability and stability, and further development was warrented1. current techniques include thermal holmium: yttrium-aluminum-garnet (ltk)6, and conductive keratoplasty (ck). non thermal, excimer laser-based techniques for correcting hyperopia include prk and lasik7. conductive keratoplasty is a laser less radiofrequency based collagen shrinkage procedure. the viewpointck system (refractec inc, irvine, calif) uses a probeto deliver low energy, high frequency (350 khz) current directlyinto the paracentral corneal stroma at 8 to 16treatments spots. striae form between the spots as the collagen contracts, producing a band of tightening that increases the mid central cornealcurvature, thereby treating presbyopia. as controlled-released energy flows through the stainless steel keratoplast tip (refracted inc), the surrounding corneal tissue creates resistance to the energy, resulting in heat production to a temperature of 65°c, causing collagen shrinkage. the keratoplast tip, with a diameter of 90 μm and length of 450 μm, penetrates the cornea, delivering the current equally from the corneal surface to the end of the tip. the collagen surrounding the entire length of the tip is exposed to the same temperature, creating a column or cylindrical footprint that extends deep into the stroma up to approximately 80% depth. conductive keratoplasty has us food and drug administration (fda) approval for the treatment of 0.75 to 3.00 diopters (d) of spherical hyperopia in patients aged 40 years and is approved for presbyopia for 1.0 to 3.0 d in non dominant eye in march 2004.2 this study presents the 1-year postoperative results from the first 20 eyes that the author treated with ck. these near plano presbyopic patients underwent unilateral ck in the non-dominant eye to improve near vision. material and methods 20 eyes of 20 patients (14 females and 6 males) underwent near vision conductive keratoplasty procedure on non dominant eyes in this prospective, a conductive keratoplasty for presbyopia pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 185 consecutive case series. view point ck system (refractec inc california) was used to perform this procedure. detailed informed consent was obtained from each patient before surgery. mean age was 48.5 years (range 45 to 52 years). eligibility criteria: uncorrected binocular visual acuity no worse than 6/9, manifest refraction spherical equivalent ranging from -0.75 d to +0.75 d and 0.75 d of cylinder. patients with ocular surface disorders, cataract, glaucoma and any other retinal disorders were excluded from study participation. patients in good general health with no prior history of ocular surgery were included in the study. dominant eye dominant eye was determined using card test. the patient was instructed to sight the 6/60 snellen e in the examination room. the patients were given 81/4 by 41/2 inch card with 11/4 inch hole in the center. keeping both eyes open and observing 6/60 e the patient holds the card horizontally at arm’s length and centers the card just below the target e. the patient then raises the card so that the distance target is perfectly centered in the middle of the hole in the card the patient then moves the card towards his/her face, all the time keeping the “e” in the center of the hole. the patient repeats these steps several times. the dominant eye is determined by asking the patient to close each eye one at a time keeping the card stationary, and observe which eye focuses the letter e 6/60 at snellen chart. the eye, which can see the letter e, is the dominant eye and the other eye, which cannot see the letter e by closing dominant eye, is non dominant eye. this is important in non dominant eye procedures for patients with plano presbyopia, since they will be using their dominant eye for distance vision and binocularly gets blended vision. the loose lens test determines binocular near and distance visual acuity, demonstrates monovision tolerance, clarifies expectations for informed consent, and helps determine the final surgical plan the loose lens test was performed using loose lens +0.75 d to +2.00 d held in front of non dominant eye while binocularly viewing first the near vision chart held at 14 inches and then snellen chart to determine patient satisfaction at both near and far distance. preoperatively, one drop of moxifloxacin (vigamox, alcon) and 0.5% proparacain (alcain, alcon) eye drops were administered two times at 5minute intervals. the patient was placed in a supine position. the eye was prepared with pyodine and a specific lid speculum was placed to obtain maximal exposure and provide the electrical return path. the operating microscope was centered over the eye and focused. while the patient fixated on the light from the surgical microscope, the cornea was marked with a gentian-violet-dampened, eight-intersection ck marker that marks the 7-mm treatment zone and makes radial marks that extend from the 7to 8-mm treatment zone. the keratoplast tip was placed on the cornea at the treatment markings, perpendicular to the corneal surface. light pressure was applied until the tip penetrated the stroma to its insulator stop (light touch technique). energy was applied by depressing the foot pedal. all eyes were treated at the default setting of 350 khz, 60% power, for 0.6 seconds. a target refraction of -1.25 d to in the non-dominant was selected. conductive keratoplasty procedure the mechanical effects of ck appear to optimize the prolate curvature of the cornea. the band of circumferential tightening about 3.5 mm from the center of the cornea creates four (1 – 4) distinct zones on the cornea. the apical zone is elevated and slightly steepened. the mid – central cornea is markedly steepened which is meant for near vision. the third zone shows a belt like tightening effect. the peripheral limbal zone is flattened as a result of being tethered to the limbus. after surgery, one drop of vigamox and one drop of nevanac (alcon) were advised for4 days. tear natural ii (alcon) were advised as required afterwards. postoperative examinations were performed at 1 and 7 days and 1, 3, and 12 months. patients were asked to subjectively evaluate the quality of their vision indicate whether spectacle correction was need for near or distance vision and report their level of satisfaction. results in our study, 20 eyes of 20 plano presbyopic patients treated with ck for near vision correction were followed for 12 months. all eyes were available for follow-up examination at 12 months. near vision measurements for the treated eyes before and 12 months after surgery are shown in fig. 2. before surgery, mean near vision was j10 (range: j12 to j8). at 12 months after surgery, mean near vision was j1 (range: j3 to j1), with 90% of eyes j1 and 100% of eyes j3. abdul hamid awan 186 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology pre-op near vision post-op near vision preoperatively mean distance visual acuity was 6/7.5 (range 6/9 to 6/6). at 12 months postoperatively, mean distance visual acuity was 6/9 (range 6/12 to 6/6) fig 3. treated eyes lost an average of 1.75 lines (range: 1 to 2.5 lines) of distance visual acuity but gained an average of 7.5 lines (range: 6 to 9 lines) of near vision. fig 1. preoperatively, 2 (10%) patient had binocular distance uncorrected visual acuity 6/9 and near vision j8. at 12 months after surgery, 90% (18/20) of patients had binocular distance visual acuity6/6 and near vision j1. fig. 2. the mean binocular distance visual acuity was 6/7.5 in all 20 patients before surgery and 6/9 one year after surgery. fig 3. no eye had lost lines of best corrected visual acuity. all 20 ck-treated eyes were evaluated for stability at1 month, an overcorrection was observed with a mean of -2.25 d for a final correction of -1.25 d. at 3 months, the mean manifest refraction was -1.50d, representing a decrease of the 0.70 d from 1 month. the 1 – year refraction was -1.25 d, target and a 44% regression from the 1-month overcorrection. the rate of regression was low between 3 and 12 months with the mean se changing 0.050 d per month. conductive keratoplasty spots (leukomas) that extend approximately 80% to 90% of the corneal thickness are produced during the treatment. striae are seen between two adjacent spots by collagen shrinkage, which develop band like effect by connecting all 8 spots results in steepening of para central prolate cornea meant for near vision without glasses. at one year spots and striae faded gradually conductive keratoplasty for presbyopia pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 187 and are not cosmetically visible, but faint ck spots can be seen on slit lamp examination. no complications occurred during the procedure or postoperatively in all 20 eyes. discussion clinical results 1 year after near vision ck indicate that this is a promising technology for presbyopia. all 20 patients in this study, ranging in age from 45 to 52 years, were reluctant to wear reading glasses. they belong to the category of plano presbyopes, defined as having 0.75 d of emetropia with no more than 0.75 d of cylinder, having significant presbyopic symptoms. binocular distance vision was 6/6 in all 20 patients but they were dependent on near vision glasses for all daily life activities. all patients achieved improved uncorrected near vision after ck treatment.100 % of patients achieved j3 or better near vision with 90% of patients reading j1, while maintaining binocular distant visual acuity of 6/6 in 100% of patients at one year after procedure. an overcorrection observed initially following ck treatment, was reduced by early hyperopic regression. the rate of regression decreased between 3 months and 1 year after surgery. pallikaris4 et al. reported that ck for low to moderate hyperopia had demonstrated more stable results than prk and similar stability as lasik for hyperopic correction. our results are comparable with previous study of jason e.stahl3 with similar results. mcdonald et al5 reported the mrse changed 0.05 d in 89% of eyes between 3 and 6 months postoperatively in the ck presbyopia fda clinical trials. the stability of ck for the correction of presbyopia should be similar to ck for the correction of hyperopia. conclusion conductive keratoplasty is a valuable addition to refractive surgery. for plano presbyopia it appears to be a safe, effective and predictable procedure, for patients who want to see without glasses at near but it has to be done after loose lens testing and detailed informed consent. author’s affiliation dr. abdul hamid awan consultant ophthalmologist shalamar hospital lahore references 1. newmann ac, sanders d, raanan m. hyperopic thermokeratoplasty: clinical evaluation. j cataract refract surg. 1991; 17: 830-8. 2. united states fda pma p010018: refractec viewpoint ck system. physician’s reference guide for treatment of presbyopic emmetropes and hyperopes to improve near vision utilizing conductive keratoplasty (ck). irvine, calif: refractecinc. 2004. 3. stahl je. j refract surg. 2006; 22: 137-144. 4. pallikaris ig, naoumidi tl, panagopoulou si, et al. conductive keratoplasty for low to moderate hyperopia: 1-year results. j refract surg. 2003; 19: 496-506. 5. mcdonald mb, durrie d, asbell p, et al. treatment of presbyopia with conductive keratoplasty: six month results of the 1 – year united states fda clinical trial. cornea. 2004; 23: 661-8. 6. alio jl, ismailmm, sanchez pego jl. correction of hyperopia with non contact ho: yag laser thermal keratoplasty. j refract surg. 1997; 13: 17-22. 7. davidorf jm, eghabli f, onclincx t, et al. effect of varying the optical zone diameter on the results of hyperopic laser in situ keratomileusis. ophthalomology. 2001; 108: 1261-5. pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 156 original article comparison of pre and postoperative astigmatism after cataract extraction by phacoemulsification through a 3.2 mm clear corneal superotemporal incision m. shakaib anwar pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: m. shakaib anwar ophthalmology. department rawal institute of health sciences khana dak lehtrar road. islamabad. e mail: shakaib_2001@yahoo.co.uk …..……………………….. purpose: to evaluate the difference between pre and postoperative astigmatism in patients undergoing cataract extraction by phacoemulsification with intraocular lens implantation through 3.2 mm superotemporal clear corneal incision. material and methods: a prospective study was performed on 144 eyes of 132 patients. they were operated upon for cataract between 12/01/2007 and 31/12/2012 by a single eye surgeon at a private set up. follow up period was from 6 month to five years (mean 33 months). the patients included in this study, underwent cataract surgery by phacoemulsification through 3.2 mm superotemporal clear corneal incision. their mean age at the time of surgery was 50.5 years (range: 25 to 76 years). they were divided into two groups depending upon, “with the rule” (group a) or “against the rule”(group b), pre operative astigmatism. results: before surgery, mean astigmatism in group a patients was -0.83 d (diopter) and in those of group b was -0.76 d. after the surgery, mean astigmatism in group a patients was -1.10 d and in those of group b was -1.10 d. the mean increase in astigmatism post operatively in the two groups was 0.27 d and 0.34 d respectively. conclusion: superotemporal clear corneal incision of 3.2 mm size is favourable in terms of wound stability and the final optical outcome. when followed up over a long time, the post operative astigmatism approaches almost the preoperative value although there may be a negligible increase in it. key words: astigmatism, phacoemulsification, intraocular lens. hacoemulsification, and foldable iols, have made cataract surgery through a small incision possible1-3. rapid and stable optical recovery is achieved by preventing significant changes in corneal curvature. the smaller incision size induces less postoperative astigmatism.1,4,5 the clear corneal incision technique was introduced by fine. this has lead to increased safety, decreased pain, inflammation and surgically induced astigmatism (sia).6 a positive sia (horizontal positive cylinder) means “against the rule” change while a negative sia (horizontal negative cylinder) signifies a “with the rule” change.14 visual outcome after cataract surgery is significantly affected by the preexisting astigmatism and the one induced by the surgery itself. usually, in young people cornea is steepest in its vertical meridian, i.e. awr (horizontal negative cylinder). with the advancing age there is a shift to atr astigmatism (horizontal positive cylinder). in cataract age group we mostly find atr astigmatism. p m. shakaib anwar 157 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology modern techniques in cataract surgery aim to achieve optimum uncorrected visual acuity (ucva). different sites and sizes of incisions have been tried to reduce pre-existing astigmatism which adds to the total post operative astigmatism. a small incision leads to less astigmatism postoperatively.2,7-11 mostly superior or temporal approaches are preferred by the surgeons. when the preoperative corneal astigmatism is significant, incision can be placed on the steeper corneal meridian (parallel to negative cylinder or on the positive cylinder axis) to reduce overall postoperative astigmatism. surgically induced astigmatism with small incision surgery is significantly lower if incision is placed posteriorly nearer to the limbus12. the size, shape, and place of the incision influence surgically induced astigmatism. it has an important bearing on the corneal stability13. a medium sized (3.2 mm) superotemporal clear corneal incision has the advantage of its size and site. this size does not allow the wound lips to undergo unnecessary stretching, while injecting the iol, avoiding increase and change in axis of the preoperative astigmatism14. the superotemporal site of the incision in the oblique meridian, in fact, has a positive effect on both types of astigmatisms as the steepest meridians are not usually exactly at 180 or 90 degrees15, rather these lie in between and have a relative vertical or relative horizontal positions as we have considered in our study. generally, a clear corneal incision placed superotemporally leads to smaller postoperative astigmatism by flattening the horizontal corneal axis. this has an advantage as atr astigmatism is common in older age group16. another factor, which can influence the expected out come is axis in which the iol haptics are placed. if the iol haptics are placed at 180°, pre-existing wtr astigmatism can be reduced and vice versa17. these days toric intraocular lenses can reduce preexisting astigmatism quite effectively18. femtosecond laser assisted cataract surgery further promises better incision morphology and stability thereby reducing chances of post operative astigmatism19. material and methods a retrospective study was performed on 144 eyes of 132 patients. they were operated upon for cataract with intraocular lens implantation from 12 jan 2007 to 31 dec 2012 with a follow up period of 6 month to five years (mean 33 months). the patients underwent cataract surgery by phacoemulsification through 3.2 mm superotemporal clear corneal incision (approx. 0.5mm central to the limbus). at the time of surgery their mean age was 50.5 years (range: 25 to 76 years). they were divided into two groups depending upon, “with the rule” (group a) or “against the rule” (group b). in group a, mean astigmatism before surgery was 0.83 d while it was -0.76 d in group b. wtr astigmatism (negative cylinder in the horizontal axis) was considered to be the one in the meridian between 60 and 120 degrees and atr (negative cylinder in the vertical axis) in the meridian between 1 and 30 degrees and 150 and 180 degrees. astigmatism other than these was classified as oblique. the patients with oblique or irregular astigmatism were not included in the study. similarly the patient who had undergone filtration, refractive or pterygium excision surgery or had corneal scaring and opacities, very high or irregular preoperative astigmatism, were also not included in this study. intraocular lens calculations were performed using a-scan ultrasonography (quantel medical 11 m hz) for axial length measurements and keratometry using topcon kr 8800 digital autokeratorefractometer. after administering peribulbar local anaesthesia with 2% lignocane with 1:200,000 adrenaline, in all the cases a clear corneal superotemporal (10-11 clock) incision (approx 0.50 mm central to the limbus) was made using a 3.2 mm true cut keratome. a continuous curvilinear capsulorhexis was performed with cystitome. phacoemulsifation was performed using system (ammerican optics inc.) machine with 19 ga 30 degree tip. all patients implanted with single piece, foldable acrylic iol with an optical diameter of 6.0 mm (total diameter of 13.0mm), placed in the capsular bag. all patients were treated postoperatively with a combination of dexamethasone 0.1 % and tobramycin 0.3%, three hourly for the first week and then six and eight hourly over the three subsequent weeks. topical ofloxacin was given 6 hourly for 1 week postoperatively. follow up for evaluation of astigmatism was performed on topcon kr 8800 autokerato-refractometer from three months onwards after surgery. results mean preoperative astigmatism in group a (45 patients) was 0.83 and in group b (99 patients) was comparison of pre and postoperative astigmatism after cataract extraction by phacoemulsification pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 158 0.76 (table 1). in group a and and b, the mean and median postoperative astigmatism were -1.10 and 0.75 diopters respectively. the mean increase in astigmatism post operatively in the two groups was 0.27 and 0.34 and the median increase was 0.50 and 0.25 diopters respectively over 6 months to 5 years follow up (table 1-3). this showed a slight shift toward wtr astigmatism post operatively. in group a, 15 (33.33%) cases showed an increase in astigmatism while 9 (20%) remained unchanged, 9 (20%) converted to atr astigmatism, 6 (13.33%) neutralized and 6 (13.33%) experienced a decrease in wtr astigmatism. in group b, 60 (62.50%) cases showed an increase in astigmatism while 9 (9.37%) remained unchanged, 12 (12.50%) converted to wtr astigmatism, 3 (3.12%) neutralized and 12 (12.50%) experienced a decrease in atr astigmatism (table 4). in group a 24 (53.33%) eyes showed a clockwise shift in the axis (median 11 degrees) and 9 (20%) eyes showed an anti-clockwise shift (median 20 degrees). in group b 27 (28.12%) eyes showed a clockwise shift in the axis (median 14 degrees) and 51(53.12%) eyes m. shakaib anwar 159 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology showed an anti-clockwise shift (median 7 degrees) (table 5). the rest did not show any shift. discussion in our study we have found that a superotemporal (10-11 o’ clock) 3.2 mm incision hardly causes any astigmatism or induces any significant change in the existing preoperative astigmatism, i.e. less than 0.50 diopters generally, when followed over a longer period of time. this correlates with a similar study carried out by s c moon et al14. however the median value showed a slightly more shift on the wtr side (table 2&3). regarding the toric shift, most of the cases in group a showed a clockwise shift (median 7 degrees) while in group a the trend was opposite (median shift 8 degrees) in most of the cases (table 5). this shift is not very significant during refraction and prescription of glasses. less number of cases in both the groups showed wider shift (14-20 degrees). this concluded a minor overall change in the keratometric readings although the incision was made through the clear cornea. our patients showed a slight shift towards higher median wtr astigmatism with the passage of time. different studies have demonstrated flattening of the cornea along the incisional meridian14. this leads to wtr astigmatic changes with a temporal incision20,21, comparable with the results of our study. in a similar study where keratometric analysis of corneal astigmatism was done after surgery and a comparison was done between two groups undergoing phacoemulsification through superotemporal corneal incision and superior scleral incision. the former did not increase keratometric corneal astigmatism more than the one by superior scleral incision after three months of operation22. the incision length and location have a bearing on the changes in the horizontal and vertical meridians of the cornea after cataract surgery. this study was also affected by these two factors. this fact is also supported by two other similar studies; small temporal incisions induced less change than superior incisions14,23. conclusion superotemporal, 3.2 mm clear corneal incision is quite stable and does not significantly increase post operative astigmatism when followed up over a long (several months to years) period of time. this size and site of the incision have also proved to be superior to smaller or larger and superior or scleral incisions respectively. one limitation of this study was that 27 patients did not return for follow up at their designated times. author’s affiliation dr. m. shakaib anwar associate professor of ophthalmology rawal institute of health sciences khana dak lehtrar road islamabad e mail: shakaib_2001@yahoo.co.uk references 1. leaming dv. practice styles and preferences of ascrs members-1997 survey. j cataract refract surg. 1998; 24: 552–61. 2. drews rc. five year study of astigmatic stability after cataract surgery with intraocular lens implantation: comparison of wound sizes. j cataract refract surg. 2000; 26: 250–3. 3. mamalis n. incision width after phacoemulsification with foldable intraocular lens implantation. j cataract refract surg. 2000; 26: 237–41. 4. phleger t, scholz u, skorpik c. postoperative astigmatism after no-stitch, small incision cataract surgery with 3.5 mm and 4.5 mm incision. j cataract refract surg. 1994; 20: 400–5. 5. kohnen t, lambert rj, koch dd. incision sizes for foldable intraocular lenses. ophthalmology. 1997; 104: 1277–86. 6. fine ih, fichman ra, grabow hb. clear corneal cataract surgery and topical anesthesia. thorofare, nj: slack; 1993. 7. muller-jensen k, barlinn b, zimmerman h. astigmatism reduction: no-stitch 4.0 mm versus sutured 12.0 mm clear corneal incisions. j cataract refract surg. 1996; 22: 1108–12. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2687929/#r14 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2687929/#r14 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2687929/#r15 comparison of pre and postoperative astigmatism after cataract extraction by phacoemulsification pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 160 8. oshika t, nagahara k, yaguchi s. three year prospective, randomized evaluation of intraocular lens implantation through 3.2 and 5.5 mm incisions. j cataract refract surg. 1998; 24: 509–14. 9. masket s, tennen dg. astigmatic stabilization of 3.0 mm temporal clear corneal cataract incisions. j cataract refract surg. 1996; 22: 1451–5. 10. kohnen t, dick b, jacobi kw. comparison of the induced astigmatism after temporal clear corneal tunnel incisions of different sizes. j cataract refract surg. 1995; 21: 417–24. 11. rainer g, menapace r, vass c. surgically induced astigmatism following a 4.0 mm sclerocorneal valve incision. j cataract refract surg. 1997; 23: 358–64. 12. ernest p, hill w, ptvom r. minimizing surgically induced astigmatism at the time of cataract surgery using a square posterior limbal incision. j ophthalmol. 2011; 2011: 243170. 13. koch ps. structural analysis of cataract construction. j cataract refract surg. 1991; 17: 672–6. 14. moon sc, mohamed t, fine ih. comparison of surgically induced astigmatisms after clear corneal incisions of different sizes. korean j ophthalmol. 2007; 21: 1–5. 15. lam hy, yen kg. change in astigmatism after temporal clear corneal cataract extraction in the pediatric population. open ophthalmol j. 2008; 2: 43–5. 16. tejedor j, murube j. choosing the location of corneal incision based on preexisting astigmatism in phacoemulsification. am j ophthalmol. 2005; 139: 767–76. 17. kim it, park hyl, kim hs. korean j ophthalmol. 2011; 25: 22–8. 18. miyake t, kamiya k, amano r, iida y, tsunehiro s, shimizu k. long-term clinical outcomes of toric intraocular lens implantation in cataract cases with preexisting astigmatism. j cataract refract surg. 2014 aug 20. pii: s0886-3350(14)00942-0. 19. mastropasqua l, toto l, mastropasqua a, vecchiarino l, mastropasqua r, pedrotti e, di nicola m. femtosecond laser versus manual clear corneal incision in cataract surgery. j refract surg.2014 jan; 30(1):27-33. 20. oshika t, sugita g, tanabe t, tomidokoro a, amano s. regular and irregular astigmatism after superior versus temporal scleral incision cataract surgery. ophthalmology. 2000; 107: 2049-53. 21. percival p, beare n. clear cornea sutureless phacoemulsification and astigmatic decay after two years. eye (lond). 1997; 11: 381-4. 22. he y, zhu s, chen m, li d..comparison of the keratometric corneal astigmatic power after phacoemulsification: clear temporal corneal incision versus superior scleral tunnel incision. j ophthalmol. 2009; 2009: 210621. 23. merriam jc, zheng l, urbanowicz j, zaider m. change on the horizontal and vertical meridians of the cornea after cataract surgery. trans am ophthalmol soc. 2001; 99: 187-97. http://www.ncbi.nlm.nih.gov/pubmed/?term=ernest%20p%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=hill%20w%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=moon%20sc%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=mohamed%20t%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=fine%20ih%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=lam%20hy%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=yen%20kg%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=kim%20it%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=park%20hy%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=kim%20hs%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed?term=miyake%20t%5bauthor%5d&cauthor=true&cauthor_uid=25149554 http://www.ncbi.nlm.nih.gov/pubmed?term=kamiya%20k%5bauthor%5d&cauthor=true&cauthor_uid=25149554 http://www.ncbi.nlm.nih.gov/pubmed?term=amano%20r%5bauthor%5d&cauthor=true&cauthor_uid=25149554 http://www.ncbi.nlm.nih.gov/pubmed?term=iida%20y%5bauthor%5d&cauthor=true&cauthor_uid=25149554 http://www.ncbi.nlm.nih.gov/pubmed?term=tsunehiro%20s%5bauthor%5d&cauthor=true&cauthor_uid=25149554 http://www.ncbi.nlm.nih.gov/pubmed?term=shimizu%20k%5bauthor%5d&cauthor=true&cauthor_uid=25149554 http://www.ncbi.nlm.nih.gov/pubmed?term=shimizu%20k%5bauthor%5d&cauthor=true&cauthor_uid=25149554 http://www.ncbi.nlm.nih.gov/pubmed?term=shimizu%20k%5bauthor%5d&cauthor=true&cauthor_uid=25149554 http://www.ncbi.nlm.nih.gov/pubmed?term=oshika%20t%5bauthor%5d&cauthor=true&cauthor_uid=11054330 http://www.ncbi.nlm.nih.gov/pubmed?term=sugita%20g%5bauthor%5d&cauthor=true&cauthor_uid=11054330 http://www.ncbi.nlm.nih.gov/pubmed?term=tanabe%20t%5bauthor%5d&cauthor=true&cauthor_uid=11054330 http://www.ncbi.nlm.nih.gov/pubmed?term=tomidokoro%20a%5bauthor%5d&cauthor=true&cauthor_uid=11054330 http://www.ncbi.nlm.nih.gov/pubmed?term=amano%20s%5bauthor%5d&cauthor=true&cauthor_uid=11054330 http://www.ncbi.nlm.nih.gov/pubmed/11054330/ http://www.ncbi.nlm.nih.gov/pubmed?term=percival%20p%5bauthor%5d&cauthor=true&cauthor_uid=9373481 http://www.ncbi.nlm.nih.gov/pubmed?term=beare%20n%5bauthor%5d&cauthor=true&cauthor_uid=9373481 http://www.ncbi.nlm.nih.gov/pubmed/9373481/ http://www.ncbi.nlm.nih.gov/pubmed/9373481/ http://www.ncbi.nlm.nih.gov/pubmed/9373481/ http://www.ncbi.nlm.nih.gov/pubmed/?term=he%20y%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=zhu%20s%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=chen%20m%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=li%20d%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=merriam%20jc%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=zheng%20l%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=urbanowicz%20j%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=zaider%20m%5bauth%5d pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 89 original article topical diltiazem vs travoprost in reducing intraocular pressure in ocular hypertensive / glaucomatous rabbits saadat ullah khan, zulfiqar uddin syed, zulfiqar ali pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: saadat ullah khan department of pharmacology khyber medical college peshawar zulfiqaruddinsyed@gmail.com …..……………………….. purpose: to demonstrate the intraocular pressure (iop) lowering effect of topical diltiazem (calcium channel blocker) in comparison to travoprost (antiglaucoma drug). material and methods: the study was conducted on 50 healthy rabbits of local strain, weighing 1500 to 2000 grams. they were kept at the animal house of department of pharmacology, khyber medical college peshawar. effect of drugs was studied on both eyes of conscious rabbits. rabbits were divided into four groups i.e. a, b, c and d. rabbits of group a, b and c were made ocular hypertensive / glaucomatous by injecting weekly sub conjunctival betamethasone suspension. the iatrogenic glaucoma of group “a” animals were treated with topical diltiazem and group b with topical travoprost drops. group c served as ocular hypertensive control. it received only artificial tears during the research period. group d rabbits were used as normotensive control. they were neither induced for glaucoma nor did they receive any treatment during the research period. results: our study revealed that there was 19% (5.00 + 0.25 mm hg) drop in intra ocular pressure with topical diltiazem. its onset of action was quick and duration of action prolonged. whereas topical travoprost reduced iop by 15% (4.00 + 0.25 mm hg). topical diltiazem was found consistent in its intraocular pressure lowering effect as compared to travoprost. conclusion: topical diltiazem can be used as an alternative anti glaucoma drug in future if found safe in human trials. key words: glaucoma, ocular hypertension, betamethasone suspension, calcium channel blockers (ccb), intraocular pressure (iop). uman nature is curious and non-satisfying. a global research is always underway to find new and improved treatment of glaucoma. as per glaucoma continuum, clinical picture of glaucoma is quite horrible and unpredictable. extensive multicenter researches are in the pipe line to find out the exact mechanism of glaucoma and also to improve anti glaucoma therapy.9 allingham and m bruce shield have mentioned various groups of drugs that are under investigation having not only intraocular ocular pressure lowering properties but also vasodilating and neuroprotective effects.2 calcium channel blockers (ccb) are diverse group of drugs,16 whose therapeutic utilities are still to be explored to fully unleash its therapeutic effectiveness. the new millennium will hopefully explore their diversity in various medical specialties including ophthalmology and especially in glaucoma. since 1970‟s ccbs are being tested for their effects on iop. an ample literature is available on the h saadat ullah khan, et al 90 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology intraocular pressure affecting properties of ccb‟s. there are several conflicting reports available regarding the effects of ccb‟s on iop,18,20,23 but the general tendency is towards its intraocular pressure lowering effect.1,21,22 in glaucoma, the exact mechanism of calcium channel blockers (ccb‟s) on intraocular pressure regulation is not known however literature search has revealed following possible potential mechanisms: 1. ccb‟s act on vascular smooth muscles causing vasodilatation thereby improving optic nerve blood flow and on intracellular calcium metabolism causing neuroprotection.19 2. ccbs cause reduction in aqueous humor production by affecting the ultra-filtration of aqueous in ciliary processes. this is done by relaxing blood vessels in ciliary epithelium thus decreasing the hydrostatic pressure which is one of the factors that causes passage of fluid into ciliary processes.10 3. the (gap) junctions which are possibly regulated by calcium, exist between non pigmented and pigmented ciliary epithelial cells, ccbs may interfere with these (gap) junctions, altering cellular permeability of the ciliary epithelium and thus inhibiting normal aqueous humor formation.11 4. the potassium channel is important in formation of aqueous humor in ciliary epithelium, and this channel depends on the calcium ion. topical administration of the calcium ions has shown an increase in the iop.12 for the reason the ccbs tend to cause reduction in aqueous formation. 5. the trabecular meshwork cells have contractile properties which may be influenced by calcium ions influx through voltage-dependent l-type calcium channels, thus the relaxation of meshwork by ccbs can increase the trabecular outflow facility.13 the perfusion studies in dissected human eyes showed dose related increase in outflow facility after verapamil, diltiazem and nifedipine administration. however in addition, the outflow of aqueous humor influenced by episcleral venous pressure may be directly affected by calcium inhibition.14 in 1997 steroids in suspension form were used to raise intra ocular pressure.15 the present study has been designed to see the effectiveness of topically applied diltiazem on steroid induced raised intraocular pressure in an animal model. the result of the study will be an addition to the existing data and will help in the development of new drug for glaucoma therapy for human beings. ethical approval for this study was obtained from the college ethical committee. material and methods the study was done on both eyes of conscious and normal 50 rabbits. rabbits of either sex i.e. male / female and of both species i.e. colored and albino were used. ages of rabbits were between 1 – 2 years and weight in the range of 1500 – 2000 grams. they were observed for 02 weeks before experimentation. rabbits were kept in the animal house of department of pharmacology, khyber medical college peshawar. fresh and wholesome was provided ad libitum. animals were also provided fodder, wheat grains and grams ad libitum. rabbits were divided into four groups a, b, c and d. group „a‟ consisted of 10 steroid induced ocular hypertensive rabbits. these animals were treated with topical diltiazem 8.9 x 10¯² m, 1 drop daily for 04 weeks. group „b‟ consisted of 10 ocular hypertensive rabbits treated with topical travoprost 1 drop daily for 04 weeks. group „c‟ consisted of 20 ocular hypertensive rabbits that served as ocular hypertensive control. this group received artificial tears 1 drop daily for 04 weeks. group „d‟ consisted of 10 rabbits, used as normal control i.e. normotensive. it received no treatment during the entire period of study. the study was conducted in the department of pharmacology, khyber medical college peshawar in two phases i.e. phase i and phase ii. phase-i (ocular hypertensive phase): during this phase, rabbits of group a, b and c were made ocular hypertensive. rabbits of group d served as normal control. this phase lasted for 21 days i.e. 03 weeks (day 0 to day 21). phase-ii (treatment phase): there was a gap of 02 days (day 22 and day 23) to get a fully established raised intraocular pressure, prior to the start of phase-ii. during phase ii, animals of group a, b and c received topical treatment. topical diltiazem vs travoprost in reducing iop in ocular hypertensive / glaucomatous rabbits pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 91 animals of group „a‟ were instilled topical diltiazem 8.9 x 10¯²m solution, group „b‟, travoprost drops and group „c‟ artificial tears in their eyes. all the drugs were instilled in the frequency of 1 drop daily for 28 days i.e. 04 weeks (day 24 to day 51). reagents and drugs 1. diltiazem powder (i golani traders, chandi ghar, india). 2. travoprost solution; 0.004% (travatan; alconcouvereur, belgium). 3. proparacaine hcl 0.5% (alcaine; alcon – couvereur, belgium). 4. injection betamethasone suspension (celestone cronodose; schering – plough, spain). 5. artificial tears drops (alcon – couvereur, belgium). 6. fluorescein sodium 2% (alcon – couvereur, belgium). diltiazem is available only in tablet form in different strengths as diltiazem hcl. this drug is not available as ophthalmic preparation for therapeutic or experimental purposes. a solution of 8.9 x m strength was chosen. it is the strength which has been reported to induce iop lowering effectively15. its molecular weight is 450.98. 4.013 grams of diltiazem powder was dissolved in 100 ml of distilled water. it served as the stock solution. it was refrigerated and used during the study as a drug per instillation schedule induction of ocular hypertension/ glaucoma 1. group „a‟, „b‟ and „c‟ animals (n = 40) were made ocular hypertensive. 2. iop was raised by subconjunctival injection of steroids in the suspension form.24 to administer injection rabbits were held in especially designed wooden boxes. both the eyes of rabbits were anesthetized by instilling 1 drop of 5% proparacaine hcl every 15 seconds for one minutes. after two minutes betamethasone suspension was injected into the subconjunctival sac using insulin syringe. mild pressure was applied on the eyes for a short period to enhance absorption of drug. 3. in our study rabbits were given weekly subconjunctival injection of 0.7 ml solution of betamethasone sodium phosphate and betamethasone acetate 3 mg/ml each in both eyes for 3 weeks. total of three injections were administered. 4. this combination provided a slow released acetate fraction of betamethasone and readily available sodium phosphate. measurment of intra ocular pressure before starting the study, iop of all rabbits were measured for 2 weeks. 04 measurements were taken during this time. animals exhibiting fluctuations > 5 mm hg in their iop were excluded from the study (n = 5). the excluded animals were replaced with new set of rabbits. intraocular pressure was measured with perkins hand held applanation tonometer (clement clark int. ltd. essex england). throughout the study iop was measured twice a week only i.e. on thursday and monday to avoid corneal epithelial damage and at the same time i.e. 9:00 am, to avoid diurnal variation. during phase-i, the 1st reading of iop was taken immediately before injecting weekly betamethasone i.e. thursday and 2nd was recorded after 3 days i.e. monday. the values observed at “zero time” i.e. 1st injection of betamethasone were considered the base line pressure. animals were placed in especially designed containers to reduce movements. eyes of rabbits were anesthetized with topical local anesthesia and cornea stained with fluorescein. during phase-ii, steroid was stopped but measurement of iop continued. iop values observed at the start of phase-ii were considered to be the starting pressure. instillation of diltiazem, travoprost and artificial tears were started during phase-ii at the 24th day of study (02 days after 3rd betamethasone suspension injection). iop was recorded before instillation of drugs on monday and thursday at 9.00 am. results the iop measurements of 50 rabbits were recorded as shown in table 1 and 2. saadat ullah khan, et al 92 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology the overall normal iop (n = 50) before the start of injecting steroid was in the range of 19.50 ± 0.75 to 21.75 ± 0.25. mean pre-steroidal baseline pressure was 20.83 ± 0.75. injection of steroids led to a rapid rise in iop of group a, b and c. the rise in iop was found statistically significant after 2nd injection of betamethasone suspension and highly statistically significant after 3rd injection. the normotensive control (group d), did not show any statistically significant change in their iop throughout study (p > 0.05). their pressure was in the range of 20.62 ± 0.65 to 21.07 ± 0.37. table 1 represents mean iop ± sd of group a, b and c rabbits. topical diltiazem and travoprost reduced iop effectively. the change in iop of group a and b in comparison to group c, became highly statistically significant right from the 1st week of treatment and remained so throughout the observational period (p < 0.00). with reference to table 2, topical diltiazem proved to be efficacious in its iop lowering effect. it dropped the iop very briskly, particularly between week 1 and 2. amazingly, this iop lowering was so efficacious that, during week 4, it even dropped (20.50 ± 0.66) below base line iop‟s lowest observation of 20.62 ± 0.65 (p < 0.05). the iop, between week 3 and 4, was maintained at a constant level. interestingly iop drop became statistically non-significant in the last week of treatment (p > 0.05). travoprost efficaciously dropped iop (p < 0.05). onset of action was rather slower but gradual as compared to topical diltiazem. it was found consistent in its iop lowering effect during entire study with an average 1.90 ± 0.45 mm hg drops per week p < 0.00. topical diltiazem vs travoprost in reducing iop in ocular hypertensive / glaucomatous rabbits pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 93 iop lowering reached base line value during 4th week of treatment (table 1 and 2). this finding is not in parallel with diltiazem, in which, iop touched base line during 2nd week. topical diltiazem demonstrated an acute iop lowering potential, 5.10 ± 0.61, between week 0 and 2; with an average 1.38 ± 0.45 mm hg drop during week 3 and 4. it seemed that diltiazem took about 02 weeks to fully establish its iop lowering effect. topical diltiazem became statistically insignificant (p > 0.066) between week 2 and 3 and resumed its iop decremental activity between week 3 and 4. the duration of action of both drugs was found prolonged i.e. 24 hours and with an early onset of action. discussion ccb‟s are being investigated for more than three decades for their iop lowering effects. an ample data is available regarding iop lowering potential of calcium channel blockers. the ocular effects of ccb‟s have been reported since 1970‟s. it has been reported in humans, ocular normotensive and ocular hypertensive animals. results are conflicting and till date no consensus has been made.5,18,20,23 above all, ccb‟s are still in the main stray of researchers because of their greater positive potential to affect glaucoma patients by not only lowering iop but also providing vasodilatation and neuroprotection.3,4,7,17 american glaucoma society in its 22nd annual meeting has linked use of calcium and iron supplementation in glaucoma patients.6 this study revealed that diltiazem can lower iop effectively and briskly thus, leading to an addition in the existing data that favors ccb‟s role in the management of glaucoma / ocular hypertension. melena, et al, described the ocular hypotensive effect of ccbs in rabbit model for glaucoma.25 a single dose of verapamil, nifedipine and diltiazem produced a dose – dependent decrease in iop in ocular normotensive rabbits after topical application but not after intravenous administration.25 furthermore, the ocular hypotensive effect of diltiazem was remarkable due to its duration, thus permitting the appropriate administration frequency.26 in humans, topical verapamil, diltiazem and nifedipine have been found to significantly lower iop in normal and ocular hypertensive subjects.27 a single topical application of ccbs prompted iop decrease in ocular hypertensive patients. it was also found that verapamil and diltiazem significantly lowers the iop in normal human volunteers.28 conclusion diltiazem may be helpful in treatment of acute ocular hypertensive crises due to its brisk iop lowering effects and in the treatment of glaucoma and ocular hypertension. however further laboratory and animal studies are required to explore the exact iop lowering mechanism of action, vasodilation and neuroprotection properties of topical diltiazem and demonstrate its systemic or local untoward effect. detailed controlled clinical studies using diltiazem (0.25%) or (0.5%) eye drops for patients with glaucoma seemed to be recommended. author’s affiliation dr. saadat ullah khan department of pharmacology khyber medical college peshawar dr. zulfiqar uddin syed department of ophthalmology combined military hospital multan dr. zulfiqar ali department of ophthalmology ayub medical college abbottabad references 1. luksch a, rainer g, koyuncu d, ehrlich p, maca t, gschwandtner me, vass c, schmetterer l. effect of nimodipine on ocular blood flow and colour contrast sensitivity in patients with normal tension glaucoma. br j ophthalmology, 2005; 89: 21-25. 2. allingham, r rand, damji, shield mb. shield‟s text book of glaucoma. 6th ed. mc grawhill usa; 2010: 13446. 3. anastasios j, kanellopoulos aj, erickson ka, netland pa. systemic calcium channel blockers and glaucoma. laser vision, 2014. 4. araie m, mayama c. use of calcium channel blockers for glaucoma. prog retin eye res. 2011; 30: 57-71. 5. beatty jf, krupin t, nichols pf, becker b. elevation of intraocular pressure by calcium channel blockers. arch ophthalmol. 1984; 102: 1072-6. 6. calcium / iron supplementation and glaucoma linked. american glaucoma society 22nd annual meeting, 2012. saadat ullah khan, et al 94 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology 7. chihiro mayama. calcium channels and their blockers in iop and glaucoma. european journal of pharmacology, 2013. 8. ibrahim g, shaarawy t. the forgotten masses. in: john salman, jack j kanski. glaucoma. 3rd ed. edinburg. butterworth; 2004: 37-50. 9. kanellopoulos j, erickson ka, netland pa. calcium channel blockers and glaucoma. brilliantvision.comlaser vision.gr 2005. 10. caprioli j. the ciliary epithelia and aqueous humor. in: moses r.a. and hart w.m. alder‟s physiology of the eye clinical application. 9thed. mosby company. st. louis, 1997: pp. 204-22. 11. green k, kim k. papaverine and verapamil interaction with prostaglandin e2 and d9-tetrahydrocannabinol in the eye. exp. eye res. 2004; 23: 207-212. 12. podos sm. the effect of cationionophores on intra ocular pressure. invest ophthalmol. 1996; 17: 851-4. 13. soto d, comes n, ferrer e, morales m. modulation of aqueous humor outflow by ionic mechanism involved in trabecular meshwork cell volume regulation. ivest. ophthalmol. vis. sci. 2004; 45: 3650-61. 14. sears m, caprioli j, kazuyoshi k, bausher l. a mechanism for the control of aqueous humor formation. in: drance s.m., and neufeld a.h. glaucoma. applied pharmacology in medical treatment orlando. 2002: 303324. 15. santafe j, martinez de ibarreta mj, segarra j, melena j. a long lasting hypotensive effect of topical diltiazem on the iop in conscious rabbits. naunynschmiedebergs arch pharmacol 1997; 355: 64550. 16. kole p, bhusari ss, bhosale sm kundu s, gunasekaran j, kaushal s, negappa an. exploring therapeutic the utilities of calcium channel blockers. pharmabiz.com 2009. 17. koseki n, araie m, tomidokoro a, nagahara m, hasegawa t, tamaki y, yamamotos. a placebo – controlled 03 years study of calcium blockers on visual field and ocular circulation in glaucoma with low – normal pressure. ophthalmology, 2008; 115: 2049-57. 18. liu s, araujo sv, spaeth gl, katz lj, smith m. lack of effect of calcium channel blockers on open angle glaucoma. glaucoma, 1996; 5: 187-90. 19. abbasoglu oe, karanjitt s. kooner. future role of neuroprotective agents in glaucoma. in: thomas j zimmerman, karanjitt s kooner, mordechai shavir, robert d fechtner. text book of ocular pharmacology. 2nd ed philadelphia. lippincott-raven publisher usa; 1997: 329-47. 20. payne lj, slage tm, cheeks lt, green k. effect of calcium channel blockers on intraocular pressure. ophthalmic res. 1990; 22: 337-41. 21. netland pa, chaturvedi n, dreyer eb. calcium channel blockers in the management of low tension and open angle glaucoma. am j of ophthalmology. 1993; 115: 608-13. 22. segarra j, santafe j, garrido m, martinez de ibarreta mj. the topical application of verapamil and nifedipine lowers iop in conscious rabbits. gen pharmacol. 1993; 24: 1163-71. 23. sp kelly and tj wally. effect of calcium antagonist nifidipine on intraocular pressure in normal subjects. british journal of ophthalmology, 1998; 72: 216-8. 24. melena j., santafe j. and segarra j. the effect of topical diltiazem on the intraocular pressure in betamethasone induced ocular hypertensive rabbits. pharmacology and experimental theraprutics. 1998; 284: pp278-82. 25. santafe j, martínez mj, segarra j, melena j. a longlasting hypotensive effect of topical diltiazem on the intraocular pressure in conscious rabbits. naunynschmiedeberg's arch. pharmacol. 2001; 355: 645-50. 26. abelson mb, gilbert cm, smith lm. sustained reduction of intraocular pressure in humans with the calcium channel blocker verapamil. am. j. ophthalmol. 1998; 108: 155-9. 27. mooshian ml, leonardi lm, schooley gl, erickson k, greiner jv. one drop study to evaluate safety and efficacy of an ophthalmic calcium channel blocker, verapamil, in subjects with elevated intraocular pressure. invest. ophthalmol. vis. sci. 2002; 36: 924-9. 28. netland pa, grosskreutz cl, feke gt, hart lj. color doppler ultrasound analysis of ocular circulation after topical calcium channel blocker. am j ophthalmol. 1995; 119: 694-700. microsoft word 2. aisha bokhari 60 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology original article to compare the effect of intravitreal bevacizumab on the resolution of macular edema secondary to diabetic retinopathy and branch retinal vein occlusion syeda aisha bokhari, zeeshan kamil, fawad rizvi pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syeda aisha bokhari 395-c, 1st floor p.e.c.h.s. block-2 karachi-75400 …..……………………….. purpose: to assess the efficacy of intravitreal bevacizumab in treating patients with macular edema secondary to diabetic retinopathy and retinal vein occlusion. material and methods: this comparative study was carried out in lrbt free base eye hospital, karachi from 1st march 2010 to 28th february 2011. total 60 patients were recruited for the study among which 32 (53.33%) were male and 28 (46.66%) were female, with age ranging from 40-65 years. out of the 60 patients, 35 (58.33%) were diagnosed with macular edema secondary to diabetic retinopathy, and 25 (41.66%) with macular edema secondary to branch retinal vein occlusion. they were classified into group a and group b respectively. informed written consent was obtained from all the patients before their participation in the study. detailed medical and ophthalmic history was recorded. baseline assessment of patients included best-corrected visual acuity (bcva) on snellen chart, slit lamp examination of anterior segment and posterior segment (using 78d/90d lens), indirect fundoscopy with 20d lens, intraocular pressure measurement, colour fundus photography, fundus fluoresein angiography and optical coherence tomography. all the patients were treated with 2 injections of intravitreal bevacizumab 1.25 mg/0.05 ml, at an interval of 6 weeks, and assessment was carried out at 6 weeks and 12 weeks. efficacy of intravitreal bevacizumab was assessed in terms of improvement in bcva and reduction of macular thickness. results: 60 patients were enrolled in this study and were followed for a period of 3 months. group a: at the end of three months, 27 (77.14%) out of 35 patients showed improvement in bcva of 2 snellen lines from baseline, and the mean central macular thickness (cmt) reduced from 502µm to 384µm. group b: at the end of three months, 17 (68%) out of 25 patients showed improvement of bcva of up to 2 snellen lines and mean cmt reduced from 510µm to 370µm. no serious adverse effects were observed in both the groups such as inflammation, increased intraocular pressure, endophthalmitis or thromboembolic event. conclusion: intravitreal bevacizumab injection for macular edema caused by branch retinal vein occlusion and diabetic macular edema was safe and effective for improving visual acuity and reducing central retinal thickness. syeda aisha bokhari et al. pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 61 acular edema associated with vascular diseases, such as diabetic retinopathy, vascular occlusions and choroidal neovascularization, can have different etiopathologies1. diabetic retinopathy is a significant public health problem2. diabetic retinopathy occurs due to abnormal retinal blood vessels either due to their proliferation (proliferative retinopathy) or due to the fact that the vessels are functionally incompetent and leak fluid and lipid in to the retina. visual impairment occurs when edema affects the central retina or macula (diabetic macular edema)3. retinal vein occlusion (rvo) is the most common retinal vascular disease after diabetic retinopathy4. the most common sequelae of branch retinal vein occlusion (brvo) is the development of macular edema (me) with a consecutive deterioration in vision. the major stimulus for the formation of macular edema and neovascularization in patients with rvo seems to be hypoxia-induced production of vascular endothelial growth factor (vegf), an angiogenic factor that promotes angiogenesis and increases vascular permeability5. vegf has been implicated as an important factor in the breakdown of the blood-retinal barrier, with increased vascular permeability resulting in retinal edema in diabetic patients by affecting the endothelial tight junction proteins6. vegf levels are significantly elevated in eyes with diabetic macular edema7. therefore, anti-vegf treatments have been proposed as an alternative adjunctive treatment for diabetic maculae edema (dme) 8. while several studies have been conducted assessing the role of bevacizumab in the management of diabetic macular edema and macular edema secondary to retinal vein occlusion, there are no studies available comparing the efficacy of bevacizumab in both diabetic retinopathy and macular edema secondary to retinal vein occlusion. material and methods this study was carried out in lrbt free base eye hospital, karachi from 1st march 2010 to 28th february 2011. study included 60 patients, 32 (53.33%) were males and 28 (46.66%) females with age ranging from 40 to 65 years. out of 60 patients, 35 (58.33%) were diagnosed with macular edema secondary to diabetic retinopathy, 25 (41.66%) were secondary to branch retinal vein occlusion, all were divided into two groups. group a included 35 patients with diabetic macular edema and group b included 25 patients with macular edema secondary to brvo. informed written consent was obtained from all patients before their participation in the study. detailed medical and ophthalmic history was noted. base line assessment of patients included best corrected visual acuity on snellen chart, amsler grid chart was used to detect any metamorphosis, slit lamp examination of anterior segment, intraocular pressure was recorded, posterior segment examination was carried out by slit lamp biomicroscopy with 78d/90d lens as well as indirect fundoscopy with 20 d lens. color fundus photograph was taken, fundus fluorescein angiography was performed to observe leakage and to ascertain the limits of macular edema. central macular thickness was assessed with optical coherence tomography (figure 1 and 2). systemic investigations include blood pressure recording, laboratory test for urea, creatinine and electrolytes and glycosylated hemoglobin (hba1c) was checked to determine diabetic control over the last three months. those patients having any evidence of other macula pathology like age related macular degeneration (amd), glaucoma, previous pan retinal photocoagulation or grid laser within the past six months, evidence of vitreomacular traction, any irregularity or widening of the foveal avascular zone (faz) on fundus fluorescein angiography, glycosylated hemoglobin >8 mg/dl, uncontrolled hypertension, chronic renal failure or recent history of cerebrovascular accident, were excluded from the study. the administration of intravitreal bevacizumab (avastin) was approved by the hospital ethics committee. the dose of intravitreal bevacizumab (avastin) delivered was 1.25 mg/0.05 ml. two injections were given at an interval of 6 weeks under strict aseptic conditions. prophylactic antibiotics were given for 4 days after the procedure. patients were followed on the 1stpost operative day to check for any elevation of intraocular pressure, subconjunctival hemorrhage or any signs of infection. the next followup was scheduled on the 6th week to assess any improvement in best corrected visual acuity, central macular thickness on optical coherence tomography and extent of edema on fundus flourescein angiography. after recording these findings, patients were administered the second injection of bevacizumab 1.25 mg/0.05 ml. the last follow up was done 6 weeks later (12 weeks after the first injection) and the results were tabulated. m to compare the effect of intravitreal bevacizumab on the resolution of macular edema secondary to diabetic retinopathy 62 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology data was analysed in spss (version 13). frequency and percentages were calculated for categorical variables like visual acuity and central macular thickness. mcnemar’s test was applied pre and post injection changes in visual acuity and central macular thickness within each group; and chi-square test was applied to compare these changes between the two groups. results 60 patients, 32 (53.33%) males and 28 (46.66%) females with age ranging between 40-65 years were enrolled in the study. among them group a consisted of 35 (58.33%) patients who were diagnosed with diabetic macular edema whereas, group b consisted of 25 (41.66%) patients diagnosed with macular edema secondary to brvo. patients in both the groups received two doses of intravitreal bevacizumab (avastin) 1.25 mg/0.05 ml. group a: on the first post-injection evaluation at 6 weeks, 12 (34.28%) out of 35 patients had visual improvement from 6/60 to 6/36, 6 (17.14%) out of 35 patients had visual improvement from 6/36 to 6/24, 2 (5.71%) out of 35 patients had visual improvement from 6/24 to 6/18, 2 (5.71%) out of 35 patients had visual improvement from 6/18 to 6/9 and2 (5.71%) out of 35 patients had visual improvement from 6/12 to 6/6. average decrease in macular thickness was 71µm. on final evaluation after 3 months, 12 (34.28%) out of 35 patients had visual improvement from 6/36 to 6/24, 6 (17.14%) out of 35 patients had visual improvement from 6/24 to 6/18, 2 (5.71%) out of 35 patients had visual improvement from 6/18 to 6/9, 2 (5.71%) out of 35 patients had visual improvement from6/9 to 6/6. thus, overall 24 (68.57%) patients showed an improvement of 2 lines of vision on the snellen chart, whereas, in 8 (22.85%) patients visual acuity remained unchanged. in 3 (8.57%) patients, vision deteriorated despite decrease in macular thickness. mean decrease in central macular thickness was 118µm at 12 weeks follow up and 10 (28.5%) out of 35 patients showed a decrease in focal and diffuse leakage. group b: six weeks after the first injection, 2 (8%) out of 25 patients had visual improvement from counting finger at 3 feet to 6/60, 10 (40%) out of 25 had visual improvement from 6/60 to 6/36, 4 (16%)out of 25 had visual improvement from 6/36 to 6/24, 2 (8%) out of 25 had visual improvement from 6/24 to 6/18 and 1 (4%) out of 25 had visual improvement from 6/18 to 6/12. mean reduction in macular thickness was 80 µm. on final assessment after 3 months (i.e. 6 weeks after the 2nd injection), 2 (8%)out of 25 had visual improvement from 6/60 to 6/24 partial, 10 (40%) out of 25 had visual improvement from 6/36 to 6/24, 4 (16%) out of 25 had visual improvement from 6/24 to 6/18, 2 (8%) out of 25 had visual improvement from6/18 to 6/12, 1(4%) out of 25 had visual improvement from 6/12 to 6/9. thus, overall 19 (76%) patients showed an improvement of up to 2 lines of vision on snellen chart, whereas in 4 (16%) patients, visual acuity remained unchanged. in 2 (8%) patients, vision deteriorated despite the decrease in macular edema. mean decrease in central macular thickness was 140 µm at 12 weeks follow up. on comparing the visual acuity at final assessment at 12months, no statistical difference was found between the two groups (p=0.794). similarly, on comparing the central macular thickness values at 12 months, no statistical difference was found (p=0.355). figure 3 and 4 indicate the post operative improvement in visual acuity and macular edema in both the groups. discussion macular edema can result from a variety of retinal diseases and can cause varying degrees of visual loss. the most common cause of macular edema is diabetic macular edema (dme), and me within one disc diameter of the fovea occurs in 9% of patients with diabetic retinopathy (dr)9. retinal vascular occlusion (rvo) is the second most common cause of macular edema and often has devastating visual consequences10. diabetic macular edema is a manifestation of diabetic retinopathy that produces loss of central vision. macular edema affects approximately 29% of diabetic patients with disease duration of 20 years or more and main reason for reduced vision in this population11. diabetic macular edema is now the principle cause of vision loss in people with diabetes12. diabetic macular edema has been characterized by inflammation, including intravenous induction of proinflammatory cytokines13 and intraretinal expression of proinflammatory responses14. retinal vein occlusion is a frequent vascular disease that often leads to visual impairment. one of the main reasons for visual loss is the development of macular edema15. an impaired microcirculation and syeda aisha bokhari et al. pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 63 fig. 1: illustrates the coloured photograph and redfree photograph of a patient with superior branch retinal vein occlusion with macular edema. the images at the bottom show the optical coherence tomographic pictures. the image on the left was taken before the injection bevacizumab (avastin) was administered and the image on the right was taken 3 months post-injection. fig. 2: illustrates the coloured photograph and redfree photograph of a patient with diabetic macular edema. the images at the bottom show the optical coherence tomographic pictures. the image on the left was taken before the injection bevacizumab (avastin) was administered and the image on the right was taken 3 months post-injection. fig. 3: indicates the post injection best corrected visual acuity at 3 months (on snellen chart) in the two groups. it also indicates the p-value which shows that statistically there is no difference between the two groups. p = 0.794 (insignificant difference) fig. 4: indicated the central macular thickness preinjection and at final follow up at 3 months in group a and group b. it also gives the mean difference of central macular thickness in the two groups. it also indicates the p-value which shows that statistically there is no difference between the two groups. p = 0.355 (statistically insignificant) reduced blood flow lead to a dysfunction of the endothelial blood-retinal barrier with increase permeability and plasma exudation into the central retina. efforts are required to reduce macular edema as soon as possible as irreversible damage of the photoreceptors occurs as early as 3 months after the development of macular edema16. bevacizumab was initially studied for the treatment of exudative age-related macular degeneration (amd) with intravenous delivery with promising results17. in this study we compared data of to compare the effect of intravitreal bevacizumab on the resolution of macular edema secondary to diabetic retinopathy 64 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology baseline values and after treatment with two injections of intravitreal bevacizumab (avastin) 1.25mg/0.05ml in patients with macular edema secondary to diabetic retinopathy and branch retinal vein occlusion. in group a, 68.57% (24/35) showed visual improvement up to two lines of snellen chart, and on average; macular thickness was reduced up to 118µ at the end of 12 weeks. whereas seo wj18 in 2009, showed improvement of best corrected visual acuity >2lines and macular thickness reduction was 139µ on three months follow up. nagasawa et al19 did not observe any change in best visual acuity and retinal thickness in the short term observation up to 4 weeks after the intravitreal injection of bevacizumab. shen et al20 in 2011, observed mean bcva improved from 41.76 ± 15.59 to 48.41 ± 17.90, and macular thickness up to 123µ on three months of follow up. in group b, 76% (19/25) showed visual improvement of up to two lines of snellen chart, and on average; macular thickness was reduced up to 140µ at the end of 12 weeks. whereas hoeh et al21 in 2009, showed visual acuity improved by 1.8 ± 2.6 lines on (etdrs), and mean central retinal thickness decreased 215µ on 25 weeks follow up. abegg et al22 in 2008, showed improvement of visual acuity from 0.7 ± 0.3 to 0.5 ± 0.3 (logmar), and decrease in central retinal thickness was 149µ on 6 weeks after intravitreal injection of bevacizumab. astem et al23 in 2009 observed that intravitreal bevacizumab seems to be more effective for macular edema due to retinal vein occlusion than diabetic macular edema. but in this study, no statistically significant difference was observed regarding the efficacy of avastin on the resolution of macular edema between the two groups in terms of visual acuity (p=0.794) and central macular thickness (p=0.355). conclusion for macular edema caused by retinal vein occlusion and diabetic macular edema, bevacizumab administration intravitreally improved visual acuity and central retinal thickness at each time point through to 12 weeks and although the follow up period was short with limited number of patients, it was observed that intravitreal bevacizumab was more effective in eyes with branch retinal vein occlusion than those with diabetic macular edema. further larger control trials as well as longer duration of follow up are required to establish the efficacy of intravitreal bevacizumab in resolving macular edema in these two vascular diseases. author’s affiliation dr. syeda aisha bokhari associate ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi postal code74900 dr. zeeshan kamil associate ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi postal code74900 dr. fawad rizvi chief consultant ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi postal code74900 reference 1. mittal n, desai th. comparison of single dose bevacizumab with single dose intravitreal triamcinolone in cases eith cystoids macular edema due to diabetic retinopathy and vascular occlusion [online] 2009 [cited 2009]; available from: url: http://www.aios.org/proceed09/paper2009/rv-iii/ rv-iii8.pdf. 2. centers for disease control and prevention. national diabetes fact sheet: general information and national estimates on diabetes in the united state, 2005 atlanta [online] 2005 [cited 2005]; available from: url: http://www.cdc.gov/diabetes/ pubs/pdf/ndfs-2005. pdf. 3. moss se, klein r, klein be. the 14-year incidence of visual loss in a diabetic population. ophthalmology. 1998; 105: 9981003. 4. cugati s, wang jj, rochtchine e, et al. ten year incidence of retinal vein occlusion in an older population: the blue mountain eye study. arch ophthalmol .2006; 124: 726-32. 5. cugati s, wang jj, rochtchine e, et al. ten year incidence of retinal vein occlusion in an older population: the blue mountain eye study. arch ophthalmol. 2006; 124: 726-32. 6. aiello lp, avery rl, arrig pg, et al. vascular endothelial growth factor in ocular fluid of patients with diabetic retinopathy and other retinal disorders. n engl j med 1994; 331: 1480-87. 7. qaum t, xu q, joussen am, et al. vegf-initiated bloodretinal barrier breakdown in early diabetics. invest ophthalmol vis sci. 2001; 42: 2408-13. 8. fanatsu h, yamashita h, ikeda, et al. angiotensin ii and vascular endothelial growth factor in the vitreous fluid of patients with diabetic macular edema and other retinal disorders. am j ophthalmol. 2002; 133: 537-43. 9. cunningham etjr, adamis ap, altaweel m, et al. a phase ii randomized double-masked trial of pegaptanib, an antivascular endothelial growth factor aptamer, for diabetic macular edema. ophthalmology. 2005; 112: 1747-57. 10. klein r, klein be, moss se, et al. the wisconsin epidemiological study of diabetic retinopathy. ophthalmology. 1984; 91: 1464-74. syeda aisha bokhari et al. pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 65 11. choi jy, ling ca, buzney sm, et al. cystoid macular edema: current mode of therapy. in: miller, j.w, and vavvas d, eds. controversies in ophthalmology. philedelphia: lipincott williams and wilkins, 2005: 143-51. 12. amin ss, mukhtar ma. diabetic macular edema -recent development and challenges. pak armed forces med j. 2006; 56: 182-8. 13. klein r, klein be, moss se, et al. the wisconsin epidemiological study of diabetics xvii: the 14-tear incidence and progression of diabetic retinopathy and associated risk factors in type 1 diabetes. ophthalmology. 1998; 105: 1801-15. 14. funatsu h, yamashita h, ikeda t, et al. vitreous levels of interleukin-6 and vascular endothelial growth factor are related to diabetic macular edema. ophthalmology. 2003; 110: 1690-6. 15. mehr s, tang j, kem ts. caspace activation in retinas of diabetic and galactosemic mice and diabetic patients. diabetes. 2002; 51: 1172-79. 16. nagpal k, nagpal m, narendra gv, et al. optical coherence tomograph. [online]. 2004 [cited 2004 jun]; available from: url: www.boamumbai.com/journalpdfs/apr-jun 2004/ octnagpal.pdf. 17. stahl a, agostini h, hansen ll, et al. bevacizumab in retinal vein occlusion-results of a prospective case series. graefes arch clin exp ophthalmol. 2007; 245: 1429-36. 18. photocoagulation for diabetic macular edema. early treatment diabetic retinopathy study report number 1. early treatment diabetic retinopathy study group. arch ophthalmol. 1985; 103: 1796-1806. 19. seo wj, park iw. intravitreal bevacizumab for treatment of diabetic macular edema. korean j ophthalmol. 2009; 23: 17-22. 20. nagasawa t, naito t, matsushita s et al. efficacy of intravitreal bevacizumab for short-term treatment of diabetic macular edema. j med invest 2009; 56: 111-5. 21. sheng wy, xiao li, yan wh et al. intravitreal bevacizumab combined with/without triamcinolone acetonide in single injection for treatment of diabetic macular edema. chin med j 2011; 124: 352-58. 22. hoeh ae, ach t, schaal kb, et al. long-term follow-up of oct-guided bevacizumab treatment of macular edema due to retinal vein occlusion. graefes arch clin exp ophthalmol. 2009; 247: 1635-41. 23. abegg m, tappeiner c, wolf-schnurrbusch u, et al. treatment of branch retinal vein occlusion induced macular edema with bevacizumab. bmc ophthalmol. 20088: 18. 24. astem n, batioglu f, ozmart e. short-term efficacy of intravitreal bevacizumab for the treatment of macular edema due to diabetic retinopathy and retinal vein occlusion. int ophthalmol. 2009; 29: 343-8. 286 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology original article proportion of dry eye in hepatitis c patients samia iqbal, iftikhar ahmed, aisha azam pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: iftikhar ahmed department of ophthalmology, alhaded trust hospital, lahore email: dr.iftikharsahito@yahoo.com …..……………………….. purpose: the main purpose of this study was to find out the proportion of dry eye in patients of hepatitis c. study design: descriptive cross sectional study. duration and place of study: department of ophthalmology, alhaded trust hospital, lahore. duration of study january 2017 to august 2017. material and method: the study was conducted on 61 patients having positive history of hepatitis c with age range of 25-65 years. the sample size was collected by non-probability convenient method. all patients were diagnosed with hepatitis c by department of medicine, alhaded trust hospital after pcr. patients of all other ages or having any other systemic disorders were excluded from the study. schirmer test was used for the measurement of tear film breakup time. data was collected by a self-designed proforma after written informed consent. data entry and statistical analysis was done by arithmetical software spss. results: total 61 patients were included in the study. out of 61 patients, 28 (45.9%) were females and 33 (54.1%) were males. there were 18 (29.5%) patients who were 25 to 35 years of age and 27 patients (44.3%) had age of 36 to 50 years. there were 16 patients (26.2%) who were 51 to 65 years of age. there were 17 (27.8%) patients who had normal tear breakup time, 14 (22.9%) had moderate tear breakup time and remaining 30 (49.1) had severely reduced tear breakup time. conclusion: in patients of hepatitis c, dry eye disorder is commonly present. therefore, all patients with dry eyes should be evaluated for hepatitis c. key words: dry eye disorder, hepatitis c. ear film is a layer that sustains and lubricates the surface of the eyeball. tears are constantly retained and dissipated from the visual surface to prevent the effects of dry eye. tear film is made up of following three layers, a mucin layer which is produced by conjunctival goblet cells and epithelial cells of the eye1. it provides hydrophilic surface to stabilize aqueous against hydrophobic epithelium. an aqueous layer consisting primarily of water produced by lacrimal gland and accessory lacrimal gland and an external layer consisting of polar and non-polar lipids, which are produced by meibomian glands. the lipid layer of tear film is essential for stability2, and prevents evaporation of aqueous layer. keratoconjunctivitis sicca (kcs), one of the main features of sjogren’s syndrome, is the lack of sufficient quality or quantity of lacrimal gland secretions to maintain the tear film and ocular surface3,4. around 3.6 million people in the united states are infected with hepatitis c infection (hcv), having both hepatic and extrahepatic sequelae5. chronic hcv contamination has been related with distinctive condition which may, or may not, be casually t proportion of dry eye in hepatitis c patients pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 287 connected to the hepatic infection.4the infection is typically associated with contamination and stimulates progressive liver disorder in a widespread range of patients over a time of a few decades6. a wide range of visual issues have been associated with hcv disease, around 10% of tear test detected hepatitis c rna, indicating the capability of disease transmission through tears7,8. the most well-known visual manifestation of hepatitis c infection includes keratoconjunctivitis sicca, mooren's ulcer and ischemic retinopathy9,10. as of now, the visual associations of hcv diseases include dry eye disorder like sjögren syndrome and ischemic retinopathy caused either by an hcv-incited vasculitis or treatment with interferon11. screening for hcv should be considered in patients with risk factors for hcv contamination who experience the ill effects of unexplained ischemic retinopathy or dry eyes12. one study showed hepatitis c infection (hcv) in tear tests of 71 patients with untreated hcv disease13,14. another study showed decreased tear production in hcv patients as estimated by the jones test.15 utilizing polymerase chain reaction test another study showed hcv rna in 10% of 52 tear tests16. material and methods a cross sectional study was conducted on 61 patients having positive history of hepatitis c with age range of 25 – 65 years. the sample size was collected by non probability convenient method. all patients were diagnosed with hepatitis c by medicine department of alhaded trust hospital after pcr. patients of all other ages or having any other systemic disorders were excluded from the study. schirmer’s test was used for the measurement of tear film breakup time. data was collected by a self-designed proforma after written informed consent. the data was entered and investigated by arithmetical software spss. results table 1 shows 61 patients were involved in study. out of 61 patients 28 (45.9%) were females and 33 (54.1%) were males. table 1: gender. frequency percent female 28 45.9 male 33 54.1 total 61 100.0 table 2 shows that out of 61 patients, 18 (29.5%) people had 25 to 35 years of age, 27 (44.3%) had 36 to 50 years of age and remaining 16 (26.2%) were 51 to 65 years old. table 2: age distribution. frequency percent 25-35 18 29.5 36-50 27 44.3 51-65 16 26.2 total 61 100.0 table 3: tear breakup time in right eye. frequency percent normal 17 27.8 moderate 14 22.9 severe 30 49.1 total 61 100.0 table 3 shows that out of 61 patients, 17 (27.8) patients had normal tear breakup time, 14 (22.9%) had moderate tear breakup time and remaining 30 (49.1) had severely decreased tear breakup time. table 4: tear breakup time in left eye. frequency percent normal 17 27.8 moderate 14 22.9 severe 30 49.1 total 61 100.0 table 4 shows that out of 61 patients 17 (27.8) had normal tear breakup time, 14 (22.9%) had moderate tear breakup time and remaining 30 (49.1) had severely reduced tear breakup time. discussion the study shows dry eye and ocular surface changes related to tear film by schirmer test in hepatitis c patients. so tear film components reduced in patients with diagnosed hepatitis c. to evaluate the ocular surface and systemic factors related to hepatitis c which shows tear film values related to age and sex. dry eye is most common in older patients as patients get older ocular surface become dry. corneal changes are also related with the interferons therapy which samia iqbal, et al 288 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology suggests that patients could have abnormalities in cornea. some studies showed reflex of tear film secretions which did not change2. in hepatitis c, microvasculature of lacrimal gland is associated with impaired function of gland. in hepatitis c patients increased rate of dry eye is associates with tear film osmolarity and decreased corneal sensitivity. most of the hepatitis c complain of itching and burning sensation. tbut values for hepatitis c and normal subjects are different due to the symptoms of dry eye in hepatitis c patients. hepatitis c individuals with dry eye have high frequency of dry eye symptoms as compared to normal subjects15. studies found that women reported dry eye symptoms than men and which has etiology of multifactorial condition, in most cases, is chronic. dry eye syndrome is a source of discomfort that affects the patient’s quality of life, especially in older population. there are many methods to assess the dry eye. however, there is no common combination of tests which conclusively diagnose the dry eye. a key aspect of dry eye that remains a major problem is the lack of association between the symptoms and signs of dry eye and the poor test reproducibility of objective tests making it difficult to assess disease progression or the impact of treatments on symptoms. currently, the major management for those patients with dry eye disease consists of palliative regimens such as lubricating drops, which target symptoms alone, with no treatment modality available that truly “treats” the underlying cause of the disease. the necessity for characterizing and understanding the underlying biomarkers in the ocular surface cells that are involved in the disease process may be beneficial in targeting towards treatment strategies13. in hepatitis c patients, microvasculature of lacrimal gland is associated with impaired function of gland. in hepatitis c patients increased rate of dry eye is associates with tear film osmolarity and decreased corneal sensitivity. most of the subjects complain of itching and burning sensation. our investigation was intended to decide if there was a high predominance of clinically significant visual injuries in patients with hcv disease17. the chance that hcv causes noteworthy dry eye disorder most probably keratoconjunctivitis18, will probably be distinguished in patients with the further developed types of hcv. in studies that are currently available there is a difference in dryness of eyes with the time span and severity of hepatitis c19. the females having positive history of hepatitis c have more chances of dry eye disorder as compared to males. the autoimmune disorder known as sjogren's disorder having feature of dry eye is observed in many subjects of hepatitis c20, the ocular manifestations of hcv also cause dry eye disorder mostly sjogren syndrome which is autoimmune disorder in which tear breakup time decrease as compare to normal. hcv also causes ischemic retinopathy and vasculitis due to injection interferons. another previous study suggested that hcv causes dry eye disorder keratoconjunctivitis sicca in which the function of lacrimal gland compromised and tear production decreased. due to decreasing tear production in keratoconjuntivitis the maintenance of tear film disturbed the ocular surface. this type of dry eye severity is due to interferons.20 conclusion it is concluded that most of the hepatitis c patients suffer from dry eye disorder. therefore, hepatitis c infection should be considered a risk factor for dry eye disease. author’s affiliation samia iqbal optometrist department of ophthalmology, university of lahore, teaching hospital lahore dr. iftikhar ahmed mbbs, fcps, ophthalmologist department of ophthalmology, university of lahore, teaching hospital lahore dr. aisha azam mbbs, fcps, ophthalmologist department of ophthalmology, university of lahore, teaching hospital lahore role of author samia iqbal presented the main idea and data analysis contribution dr. iftikhar ahmed contribution in review of literature, manuscript preparation aisha azam contributed to data collection and data review proportion of dry eye in hepatitis c patients pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 289 references 1. who. global surveillance and control of hepatitis c. j viral hepatitis, 1999; 6: 35-47. 2. poynard t, bedossa p, opolon p. natural history of liver fibrosis progression in patients with chronic hepatitis c. lancet, 1997; 349: 825-32. 3. scott ca, avellini c, desinan l, et al. chronic lymphocytic sialoadenitis in hcv-related chronic liver disease: comparison of sjogren's syndrome. histopathology, 1997; 30: 41-8. 3. hadziyannis s. non-hepatic manifestations of chronic hcv infection. j viral hepatitis, 1997; 4: 1-17. 4. daruich j, zas m, findor j, et al. lacrimal dysfunction in patients with chronic hcv infection. hepatology aasld abstract 1200, 1995; oct.: 406a. 5. wilson s, lee w, murkami c, et al. mooren-type hepatitis c virus-associated corneal ulceration. ophthalmology, 1994; 101: 736-45. 6. baratz kh, fulcher sf, bourne wm. hepatitis cassociated keratitis. arch ophthalmol. 1998; 116: 529-30. 7. disdier p, bolla g, veit v, et al. association of uveitis and hepatitis c: 5 cases [letter]. presse med. 1994; 23: 541. 8. pirisi m, scott c, fabris c, et al. mild sialoadenitis: a common finding in patients with hepatitis c virus infection. scand j gastroenterol. 1994; 29: 940-2. 9. scott ca, avellini c, desinan l, et al. chronic lymphocytic sialoadenitis in hcv-related chronic liver disease: comparison of sjogren's syndrome. histopathology 1997; 30: 41-8. 10. haddad j, deny p, munz-gotheil c, et al. lymphocytic sialoadenitis of sjogren's syndrome associated with chronic hepatitis c virus liver disease [see comments]. lancet, 1992; 339: 321-3. 11. king p, mcmurray r, becherer p. sjogren's syndrome without mixed cryoglobulinemia is not associated with hepatitis c virus infection. am j gastroenterol. 1994; 89: 1047-50. 12. pawlotsky jm, ben yahia m, andre c, et al. immunological disorders in c virus chronic active hepatitis: a prospective case-control study [see comments]. hepatology, 1994; 19: 841-8. 13. mcmonnies c. key questions in a dry eye history. j am optom assoc. 1986; 57: 513-7. 14. mcmonnies c, ho a. patient history in screening for dry eye conditions. j am optom assoc. 1987; 58: 297301. 15. lemp m, hamill j jr. factors affecting tear film breakup in normal eyes. arch ophthalmol. 1973; 89: 103-5. 16. van bijsterveld o. diagnostic tests in the sicca syndrome. arch ophthalmol. 1969; 82: 10-4. 17. wright j, meger g. a review of the schirmer test for tear production. arch ophthalmol. 1962; 67: 564-5. 18. sarah bauerle bass, amy jessop, laurie maurer, muhamed gashat, mohammed al hajji and mercedes gutierrez. mapping the barriers and facilitators of hcv treatment initiation in methadone maintenance therapy patients, 2018; 23, 1:117. 19. zegans me, anninger w, chapman c, gordon sr. ocular manifestations of hepatitis c virus infection. current opinion in ophthalmology, 2002 dec. 1; 13 (6): 423-7. 20. vitali cb, del papa n. classification criteria for sjögren’s syndrome. in sjögren's syndrome, 2016 (pp. 47-60). pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 203 original article pneumatic retinopexy for early rhegmatogenous retinal detachment irfan qayyum malik, ch. javed iqbal, yasir afzal, nasir ch., tehseen mehmood mahju pak j ophthalmol 2015, vol. 31 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irfan qayyum malik asst. professor of ophthalmology gujranwala medical college …..……………………….. purpose: the purpose of this study was to evaluate the success rate of pneumatic retinopexy in the patients of early rhegmatogenous retinal detachment. material & methods: the study was performed at ophthalmology department of gujranwala medical college/ teaching hospital. all the patients were admitted from outpatient department. retinal examination with confirmation of all retinal pathology was done by using indirect ophthalmoscope and three mirror indirect lens. topical anesthesia or a retrobulbar block was used for patient comfort. laser photocoagulation was applied in attached areas of retina. intraocular gas was injected. sf6 was drawn into tuberculin syringe to provide tamponade to the detached retina. intraocular pressure was assessed by checking the pulsations at optic disc and by checking the light perception. antibiotic steroid ointment was applied and eye was patched. postoperatively argon laser was reinforced close to the break in all the cases to seal the break. patients were followed up for six months. anatomical reattachment of the retina was our primary outcome. results: 15 patients of early rhegmatogenous detachment were included in this study, 9 were male and 6 were females. all the patients had single retinal break at superior quadrant. after pneumatic retinopexy 10 patients had attached retina till their last follow up of six months. the success rate of pneumatic retinopexy was 66%. rest of the five patient required further surgery. conclusion: in selected cases of early rhegmatogenous retinal detachment pneumatic retinopexy is an effective and less expensive procedure that avoids most of the complications that usually occur with other retinal reattachment procedures. key words: pancreatic retinopathy, retinal detachment, intraocular gas. hegmatogenous retinal detachment is a fullthickness defect in the sensory retina, caused by vitreous traction. the term rhegmatogenous is derived from the greek word rhegma, which means a discontinuity or a break. a rhegmatogenous retinal detachment occurs when a break in the retina leads to accumulation of fluid between neurosensory retina and the retinal pigment epithelium. it is the most common retinal emergency causing loss of vision, with an incidence of 1 in 10,000 person per year.1 pneumatic retinopexy, scleral buckling, and pars plana vitrectomy are the most accepted surgical interventions for eyes having rhegmatogenous retinal detachment1.2 pneumatic retinopexy was first introduced by hilton and grizzard in 1986 as an outpatient procedure to treat rhegmatogenous retinal detachment3. it is indicated in patients with single break having subclinical retinal detachment in the superior quadrant of eye. it supplemented the preexisting surgical techniques used to treat the rhegmatogenous detachments including scleral buckling and parsplana vitrectomy. it is an effective, less invasive treatment option for retinal detachment in selected cases4,5. pneumatic retinopexy is technically an easy r irfan qayyum malik, et al 204 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology procedure with very few complications like proliferative vitreo retinopathy, new break formation, glaucoma and cataract6. during pneumatic retinopexy a gas is injected into the vitreous cavity and head is positioned so that the gas bubble floats to the detached area and presses it against the detachment. then a freezing probe (cryopexy) or laser beam (photocoagulation) is used to seal the tear in the retina. the size and location of the tear in the retina will determine whether pneumatic retinopexy can be helpful or not. pneumatic retinopexy can be useful if there is a single break or small tear that caused the detachment and there is fresh retinal detachment and break is in the superior portion of the retina. pneumatic retinopexy reattaches the retina in most of the selected cases. there are more chances of good vision after the surgery if the macula was attached before surgery. if macula is affected, chances of good vision after the surgery is still possible but are less. generally patient experiences less pain, and there are chances of quicker recovery in most of the cases and he patient feels more comfortable in home environment. the purpose of this study was to assess the success rate of pneumatic retinopexy in some selected patients presenting with fresh rhegmatogenous retinal detachment with break in the superior part of the retina. material and methods an interventional case series was performed on 15 patients from june 2014 to september 2015 at gujranwala medical college / teaching hospital. all the patients were admitted from outpatient department. patients with early retinal detachment with superior retinal break between 10 2 ’o’ clock, patients having minimal or no media opacity, and the patients who were able to maintain positioning for 5-8 days after the procedure were included in the study. the exclusion criteria were proliferative vitreoretinopathy (pvr), extensive lattice degeneration or traction, severe glaucoma, and the patients who have to travel to altitude soon after the surgery. after taking informed consent and complete examination, patients were admitted in the ward. retinal examination with confirmation of all retinal pathology was done by using indirect ophthalmoscope and three mirror indirect lens. topical anesthesia or a retrobulabar block was used for patients comfort. laser photocoagulation was done on attached areas of retina. 0.35 to 0.60 ml intraocular gas was injected. sf6 was drawn into 1 cc syringe to provide tamponade to the retina. intraocular pressure was assessed by checking the pulsation at optic disc by checking the light perception. anterior chamber paracentesis was done if intraocular pressure was raised after injecting gas. antibiotic steroid ointment was applied and eye was patched. after injection of sulfur hexafluoride and 6 hours face down positioning, the head position was changed so that the gas bubble could efficiently tamponade the retinal break. postoperatively argon laser was reinforced close to the break to seal it7. patients were examined daily for one week postoperatively while they were in ward. follow up visits were done after one week, three weeks and then monthly up to six months. results a total of 15 pneumatic retinopexies were performed to treat rhegmatogenous retinal detachment between june 2014 and september 2015 were identified. the average patient age was 48 years (range 28 68). there were 9 right eyes and 6 left eyes. 9 (60%) of the http://www.webmd.com/eye-health/tc/laser-photocoagulation-and-cryopexy-for-retinal-tears-topic-overview http://www.webmd.com/eye-health/tc/laser-photocoagulation-and-cryopexy-for-retinal-tears-topic-overview http://www.webmd.com/hw-popup/retinal-tear http://www.webmd.com/hw-popup/macula pneumatic retinopexy for early rhegmatogenous retinal detachment pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 205 patients were male and 6 (40%) were female. twelve (80%) cases were phakic, 4 (26%) were pseudophakic. ten (66%) eyes had retinal detachment with subretinal fluid involving the fovea. out of 15 patients of rhegmatogenous retinal detachment 10 had attached retina till their last follow up of six months. the success rate of pneumatic retinopexy was 66%. rest of the patients required further surgery. discussion the rate of retinal reattachment with pneumatic retinopexy varies from 60% to 91% depending upon patient’s selection. it is less costly to perform pneumatic retinopexy than scleral buckling and pars plana vitrectomy and it avoids many of the complications associated with these procedures.8 single operation success rate is slightly lower than operating room procedure. one survey of the literature showed a initial success rate of 75.5%, with a final success rate of 97.4%, as opposed to the initial success rate of pars plana vitrectomy and scleral buckling which are in the range of 85-88%9. generally studies have reported higher success rate of pneumatic retinopexy in phakic eyes, likely due to missed or new tears in pseudophakics and aphakics. complications may include proliferative vitreoretinopathy (pvr), new break formation. aniseikonia may also occur after pneumatic retinopathy.10 a study was done from 2000 to 2012 which showed that the success rate of pneumatic retinopexy was 63%.11 a study was done in 2013 which showed that the success rate of pneumatic retinopexy was 69.6% and it showed that causes of failure include pseudophakia, a large retinal break, missed breaks or new breaks and proliferative vitreo retinopathy pvr.12 success rate in our study was 66% which is almost similar to the studies which were done previously. our study showed a 26% of new or missed retinal breaks. it is most likely that most of these breaks were new breaks because good preoperative examination of the retina with no additional break was a prerequisite for pneumatic retinopexy. may be the gas bubble caused movement of the vitreous and there was formation of additional retinal breaks, making this high complication rate worrying. our study showed that pneumatic retinopexy is technically an easy and useful minimally invasive technique for the treatment of subclinical rhegmatogenous retinal detachment with single break in the superior quadrant. in our study sample size was small so further multicentre studies are recommended. conclusion in selected cases of early rhegmatogenous retinal detachment pneumatic retinopexy is an effective and minimally invasive procedure that prevents most of the complications that are usually associated with other retinal detachment surgeries. author’s affiliation dr. irfan qayyum malik assistant professor of ophthalmology gujranwala medical college dr. ch. javed iqbal department of ophthalmology mayo hospital lahore dr. yasir afzal department of ophthalmology mayo hospital lahore dr. nasir ch. department of ophthalmology mayo hospital lahore dr. tehseen mehmood mahju department of ophthalmology mayo hospital lahore role of authors dr. irfan qayyum malik main author. dr. ch. javed iqbal suggested title dr. yasir afzal helped in collecting data. dr. nasir ch. helped in writing manuscript. dr. tehseen mehmood mahju acting supervisor. references 1. nicolas feltgen, prof. dr. med. and peter walter, prof. dr. med, rhegmatogenous retinal detachment—an ophthalmologic emergency, dtscharztebl int. 2014; 111: 12–22. http://www.ncbi.nlm.nih.gov/pubmed/?term=feltgen%20n%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=walter%20p%5bauth%5d irfan qayyum malik, et al 206 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology 2. hatef e, sena df, fallano ka, crews j, do dv. pneumatic retinopexy versus scleral buckle for repairing simple rhegmatogenous retinal detachments. cochrane database syst rev. 2015; 5: 8350. 3. hilton gf, grizzard ws. pneumatic retinopexy (a twostep outpatient operation without conjunctival incision). ophthalmology. 1986; 93: 626–41. 4. brinton da, hilton gf. pneumatic retinopexy and alternative retinal detachment techniques, in ryan sj, wilkinson cp (eds). retina. 2001; 5: 2047-62. 5. torna mbe pe, hilton gf, kelly nf, et al. expanded indications for pneumatic retinopexy. ophthalmology. 1988; 95: 597-600. 6. abecia e, pinilla i, olivan jm, et al. anatomic results and complications in a long-term follow-up of pneumatic retinopexy cases. retina. 2000; 20: 156–61. 7. rahat f1, nowroozzadeh mh, rahimi m, farvardin m, namati aj, sarvestani as, sharifi f. pneumatic retinopexy for primary repair of rhegmatogenous retinal detachments. retina. 2015; 35: 1247-55. 8. mandelcorn ed, mandelcorn ms, manusow js. update on pneumatic retinopexy curr opin ophthalmol. 2015; 26: 194-9. 9. holz er, mieler wf. view 3: the case for pneumatic retinopexy. br j ophthalmol. 2003; 87: 787-9. 10. lee hn, lin kh, tsai hy, shen yc, wang cy, wu r. aniseikonia following pneumatic retinopexy for rhegmatogenous retinal detachment, am j ophthalmol. 2014; 158: 1056-61. 11. modi ys, epstein a, flynn hw jr, shi w, smiddy we. outcomes and complications of pneumatic retinopexy over a 12-year period, ophthalmic surg lasers imaging retina. 2014; 45: 132-7. 12. rootman db1, luu s, m conti s, mandell m, devenyi r, lam wc, kertes pj. predictors of treatment failure for pneumatic retinopexy. can j ophthalmol. 2013; 48: 549-52. 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http://www.ncbi.nlm.nih.gov/pubmed/?term=namati%20aj%5bauthor%5d&cauthor=true&cauthor_uid=25763464 http://www.ncbi.nlm.nih.gov/pubmed/?term=sarvestani%20as%5bauthor%5d&cauthor=true&cauthor_uid=25763464 http://www.ncbi.nlm.nih.gov/pubmed/?term=sharifi%20f%5bauthor%5d&cauthor=true&cauthor_uid=25763464 http://www.ncbi.nlm.nih.gov/pubmed/25763464 http://www.ncbi.nlm.nih.gov/pubmed/?term=mandelcorn%20ed%5bauthor%5d&cauthor=true&cauthor_uid=25784106 http://www.ncbi.nlm.nih.gov/pubmed/?term=mandelcorn%20ms%5bauthor%5d&cauthor=true&cauthor_uid=25784106 http://www.ncbi.nlm.nih.gov/pubmed/?term=manusow%20js%5bauthor%5d&cauthor=true&cauthor_uid=25784106 http://www.ncbi.nlm.nih.gov/pubmed/25784106 http://www.ncbi.nlm.nih.gov/pubmed/25784106 http://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20hn%5bauthor%5d&cauthor=true&cauthor_uid=25127694 http://www.ncbi.nlm.nih.gov/pubmed/?term=lin%20kh%5bauthor%5d&cauthor=true&cauthor_uid=25127694 http://www.ncbi.nlm.nih.gov/pubmed/?term=tsai%20hy%5bauthor%5d&cauthor=true&cauthor_uid=25127694 http://www.ncbi.nlm.nih.gov/pubmed/?term=shen%20yc%5bauthor%5d&cauthor=true&cauthor_uid=25127694 http://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20cy%5bauthor%5d&cauthor=true&cauthor_uid=25127694 http://www.ncbi.nlm.nih.gov/pubmed/?term=wu%20r%5bauthor%5d&cauthor=true&cauthor_uid=25127694 http://www.ncbi.nlm.nih.gov/pubmed/25127694 http://www.ncbi.nlm.nih.gov/pubmed/?term=modi%20ys%5bauthor%5d&cauthor=true&cauthor_uid=24635154 http://www.ncbi.nlm.nih.gov/pubmed/?term=epstein%20a%5bauthor%5d&cauthor=true&cauthor_uid=24635154 http://www.ncbi.nlm.nih.gov/pubmed/?term=flynn%20hw%20jr%5bauthor%5d&cauthor=true&cauthor_uid=24635154 http://www.ncbi.nlm.nih.gov/pubmed/?term=shi%20w%5bauthor%5d&cauthor=true&cauthor_uid=24635154 http://www.ncbi.nlm.nih.gov/pubmed/?term=smiddy%20we%5bauthor%5d&cauthor=true&cauthor_uid=24635154 http://www.ncbi.nlm.nih.gov/pubmed/24635154 http://www.ncbi.nlm.nih.gov/pubmed/24635154 http://www.ncbi.nlm.nih.gov/pubmed/24635154 http://www.ncbi.nlm.nih.gov/pubmed/?term=rootman%20db%5bauthor%5d&cauthor=true&cauthor_uid=24314421 http://www.ncbi.nlm.nih.gov/pubmed/?term=luu%20s%5bauthor%5d&cauthor=true&cauthor_uid=24314421 http://www.ncbi.nlm.nih.gov/pubmed/?term=m%20conti%20s%5bauthor%5d&cauthor=true&cauthor_uid=24314421 http://www.ncbi.nlm.nih.gov/pubmed/?term=mandell%20m%5bauthor%5d&cauthor=true&cauthor_uid=24314421 http://www.ncbi.nlm.nih.gov/pubmed/?term=devenyi%20r%5bauthor%5d&cauthor=true&cauthor_uid=24314421 http://www.ncbi.nlm.nih.gov/pubmed/?term=devenyi%20r%5bauthor%5d&cauthor=true&cauthor_uid=24314421 http://www.ncbi.nlm.nih.gov/pubmed/?term=lam%20wc%5bauthor%5d&cauthor=true&cauthor_uid=24314421 http://www.ncbi.nlm.nih.gov/pubmed/?term=kertes%20pj%5bauthor%5d&cauthor=true&cauthor_uid=24314421 http://www.ncbi.nlm.nih.gov/pubmed/24314421 microsoft word 4. oaadnan afaq pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 73 original article effectiveness of intravitreal bevacizumab in various ocular diseases adnan afaq, erum shahid, khwaja sharif ul hasan pak j ophthalmol 2013, vol. 29 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: erum shahid department of ophthalmology abbassi shaeed hospital karachi …..……………………….. purpose: to evaluate the efficacy of monthly intravitreal bevacizumab injections (1.25 mg/.05 ml) in improving or stabilizing visual outcomes measured by snellen’s visual acuity charts for diverse ocular diseases. material and methods: this was a prospective hospital based study in which a total number of 108 eyes of 80 patients were included with various ocular diseases. maximum three intravitreal bevacizumab injections 1.25mg in 0.05ml each was given over a period of 3 months and follow up for 06 months after the first injection was carried out. the criteria for improvement was a gain of at least one line on snellen’s visual acuity chart, compared to the baseline while stabilization was considered if the visual acuity was unchanged relative to the baseline. results: a total number of 108 eyes of 80 patients were included in the study. males were 40 and females were also 40 with an age range of 32-70 years. they were subjected to intravitreal injection of bevacizumab. ten eyes (62.5%) with neovascular age related macular degeneration (armd) showed improvement while visual acuity was stabilized in 06 eyes (37.5%). in diabetic macular edema (dme) 30 eyes (68.1%) showed improvement, 10 eyes (22.7%) were stabilized and in 04 eyes (9%) visual loss continued. in patients with proliferative diabetic retinopathy (pdr) with vitreous hemorrhage 30 eyes (93.7%) showed improvement while stabilization of visual acuity was noted in 02 eyes (6.2%). in central retinal venous occlusion (crvo) 04 eyes (80%) showed improvement and stabilization occurred in 01 eye (20%). out of the 08 eyes of branch retinal venous occlusion (brvo) all eyes showed visual improvement (100%). all 03 eyes (100%) of myopic choroidal neovascular membrane (cnv) patients also showed improvement. no systemic side effects of the given treatment were observed. conclusion: the treatment with bevacizumab is beneficial in improving and stabilizing visual acuity not only in neovascular armd but also in other chorioretinal vascular disorders. nti-vegf therapy, has fast become a mainstay of managing diseases such as agerelated macular degeneration and the indications for its use have increased considerably ever since. the role of vascular endothelial growth factor in the growth of blood vessels was identified in the 1980s, and agents that could block the angiogenic cascade first came for cancer treatments in the early 1990s.1 after exhaustive research on the pathogenesis of abnormal blood vessels and exudation of fluid, investigators were convinced of the role of anti-vegf therapy to curb the effect of these abnormalities. first came macugen (pegaptanib sodium, eyetech/pfizer) and later avastin (bevacizumab, genentech) followed by lucentis (ranibizumab, genentech).2 the recent results of two studies; study of efficacy and safety of ranibizumab injections in patients with macular edema secondary to central retinal vein a adnan afaq, et al 74 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology occlusion (cruise) and study of efficacy and safety of ranibizumab injections in patients with macular edema secondary to branch retinal vein occlusion (bravo), indicated that anti-vegf therapy is effective in reducing macular edema secondary to branch retinal vein occlusion (brvo) and central retinal vein occlusion (crvo). in those studies, patients experienced rapid vision gain, some within the first 12 to 24 hours after injection. imaging with optical coherence tomography (oct), indicated a higher degree of anatomical resolution of edema compared with placebo. after the availability of the anti-vegf drugs and the encouraging results on the visual functions of the patient, some physicians are skeptic about the future role of photocoagulation treatment, as the gold standard therapy.1 bevacizumab prevents vegf from binding to its receptors and subsequently inhibits receptor signaling pathways.3 interestingly, studies using magnetic resonance imaging showed decreased microvascular permeability as early as 24 hours after anti-vegf treatment.4 bevacizumab was first used off-label in 2005 for neo-vascular age related macular degeneration.5 the purpose of the study is to evaluate the efficacy of monthly intravitreal bevacizumab injections (1.25 mg/.05 ml) in improving or stabilizing visual outcomes; best corrected visual acuity (bcva), as measured by snellen’s visual acuity charts, for diverse ocular diseases. material and methods it was a hospital based, quasi experimental and prospective study. it was conducted at baqai medical university and taj eye hospital, federal b area, karachi from 18th feb. 2010 to 27th feb. 2011. a total number of 108 eyes from 80 patients were selected on the basis of non-probability, purposive sampling. patients diagnosed with the following ocular diseases were included in the study. neovascular amd, classic / occult cnv confirmed on fundus fluorescein angiography (ffa) and without macular scarring, clinically significant diabetic macular edema, proliferative diabetic retinopathy with vitreous hemorrhage, brvo and crvo (nonischemic) with macular edema and myopic choroidal neovascular membrane (cnv) on ffa. all patients with the above mentioned entities, but who had received prior treatments with other modalities like laser photocoagulation, photodynamic therapy (pdt), intravitreal ranibizumab, intravitreal or posterior sub tenon triamcinolone, were excluded from the study. pre-operatively detailed history was taken, visual acuity was measured using snellen’s acuity chart, complete anterior segment and posterior segment examination was done using slit lamp, +90d lens, indirect ophthalmoscopy and intraocular pressure (iop) was measured using goldman applanation tonometer. fundus fluorescein angiography, optical coherence tomography and b-scan ultrasound examinations were ordered where necessary. patients were informed beforehand about the offlabel status of the drug, risks and benefits of treatment were discussed and informed consent was taken on avastin (bevacizumab) specific consent forms. all the patients included in the study received intravitreal bevacizumab 1.25mg in 0.05ml dispensed by a well reputed pharmacy of the city and given by the same surgeon. preoperative topical antibiotic moxifloxacin qid started 03 days before. tropicamide and topical anesthetic proparacaine were started ½ hour before injection and repeated as necessary. all the injections were given in the operating room (or), with strict sterile technique. patients were advised to continue pre-operative antibiotic drops for 07 days more after the intravitreal injection. follow up was scheduled after 1 week, 4 weeks and every month till the end of follow up at 6 months. follow up visits included checking visual acuity by snellen’s chart and complete ocular examination. the primary end point of the treatment was functional or symptomatic rather than anatomic i.e. a change in best corrected visual acuity from baseline over 06 months. the maximum number of injections given was three for each eye and they were given four weeks apart. the criteria for improvement was a gain of at least one line on snellen’s visual acuity chart , compared to the baseline while stabilization was considered if the visual acuity on the snellen’s chart was unchanged relative to the baseline. results a total number of 108 eyes of 80 patients 40 males and 40 females with an age range of 32-70 years were subjected to intravitreal injection of bevacizumab even in table 1. effectiveness of intravitreal bevacizumab in various ocular diseases pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 75 sixteen patients (20%) had neovascular amd, 26 patients (32%) had dme, pdr with vitreous hemorrhage was noticed in 24 patients (30%), 4 patients (05%) had crvo, 8 patients (10%) had brvo and 2 patients (2.5%) with myopic cnv were included in the study. out of the total 108 eyes, 16 eyes (14.8%) had neovascular age related macular degeneration, 44 eyes (40.7%) diabetic macular edema, 32 eyes (29.6%) proliferative diabetic retinopathy, 05 eyes (4.6%) with central retinal vein occlusion, 08 eyes (7.4%) branch retinal vein occlusion and 03 eyes (2.7%) had myopic cnv. ten eyes (62.5%) with neovascular amd showed improvement while visual acuity was stabilized in 06 eyes (37.5%). 30 eyes (68.1%) with dme showed improvement, 10 eyes (22.7%) were stabilized and in 04 eyes (9%) with dme visual loss continued. in patients with pdr with vitreous hemorrhage 30 eyes (93.7%) showed improvement while stabilization of visual acuity was noted in 02 eyes (6.2%). in crvo patients 04 eyes (80%) showed improvement and stabilization occurred in 01 eye (20%). out of the 08 eyes of brvo patients all showed visual improvement (100%). all 03 eyes (100%) of myopic cnv patients also showed improvement. all of the preinjection visual acuities are given in table 2. gradual improvement in visual acuities of all the diseases after one month, then 3rd month and at 6th month post injection are given in table 3, 4 and 5 respectively. no systemic side effects of the given treatment were observed. however amongst the local side effects subconjunctival hemorrhage was the most frequent; occurred in 05 eyes (4.5%), traumatic corneal abrasion in 01 eye (0.9%). complications like endophthalmitis, retinal detachment or traumatic cataracts were not seen in any case. discussion the discovery of anti-angiogenic agents and its clinical application has opened new avenues for the treatment of retinal vascular disorders. the first antiangiogenic agent to be approved by the us food and drug administration (fda), bevacizumab, was originally developed to inhibit tumorigenisis. bevacizumab is used off-label intravitreal to treat ocular diseases with high vegf levels, such as choroidal neovascularization (cnv), proliferative diabetic retinopathy, diabetic maculopathy and retinal vein occlusion. vegf, also known as vegf-a or vascular permeability factor (vpf), was first identified in 1989 by napoleon ferrara6. numerous effects on endothelial cells were found when vegf was inhibited and without it endothelial cells in immature vessels could not survive. endothelial cells were unable to grow and proliferate. increased vitreous vegf levels were found in diabetic retinopathy, diabetic maculopathy, and retinal vein occlusions. this led to the development of a therapeutic armamentarium targeted at selective inhibition of vegf with antibodies, fragments of antibodies and aptamers. the first designed for ocular use, pegaptanib and ranibizumab demonstrated success in clinical trials for neovascular age-related macular degeneration. despite a large full length antibody, bevacizumab demonstrated full retinal penetration7. no evidence of a toxic effect was observed in patients treated with 1.25mg of bevacizumab for exudative amd measured by full field and multifocal erg8. neovascular amd is the most common indication for intravitreal bevacizumab. publications regarding intravitreal bevacizumab for the treatment of exudative amd include six prospective studies,9-13 one uncontrolled randomized trial,14 nine retrospective studies, and uncontrolled case series. the majority of the papers showed mean improvement in visual acuity and a reduction in macular thickness after intravitreal bevacizumab. avery ri, et al,15 studied 79 patients with a diagnosis of exudative amd, affected eyes were injected monthly with 1.25mg of intravitreal bevacizumab until there was no sign of cnv. they adnan afaq, et al 76 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology effectiveness of intravitreal bevacizumab in various ocular diseases pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 77 were followed for eight weeks and showed an improvement in mean visual acuity from 20/200 to 20/80, however an average of 3.5 intravitreal injections were required. the results of our study are comparable except that out of the 108 eyes 16 eyes(15%), were diagnosed with neovascular amd, our follow up was however longer (24 wks), improvement in mean visual acuity from 6/60 to 6/12 was noted in 62.5% of the eyes. in central and branch retinal vein occlusions, macular edema is often treated with intravitreal bevacizumab. grid pattern laser photocoagulation was the first widely accepted treatment.16 this has been the standard treatment and has shown benefit in selected cases of branch retinal venous occlusion (brvo).17 intravitreal triamcinolone acetonide has also been used to treat brvo, with several studies showing an improvement in visual acuity and decreased macular thickness assessed by oct. as vegf levels are elevated in patients with retinal vein occlusions18 .however the side effects of triamcinolone including cataract formation and elevated intraocular pressure are much less common with anti vegf.18 in a study conducted by rabena m, et al, intravitreal bevacizumab in the treatment of macular edema secondary to branch retinal vein occlusion.19 27 patients with brvo who received intravitreal bevacizumab, visual acuity improved from 20/200 at baseline to 20/100 at three months. in our study of 08 eyes with macular edema secondary to brvo, 6/6 vision was noted in 4 eyes (50%), 6/12 in 02 eyes (25%) and 6/18 in 02 eyes (25%), at the end of six months follow up. in a study by iturralde d, et al, intravitreal bevacizumab treatment of macular edema in central retinal vein occlusion, a short term study, 16 eyes with crvo during a mean follow-up of three months, mean visual acuity improved from 20/600 to 20/138 at month three20. out of the 05 eyes with crvo in our study, visual acuity improved to 6/9 in 02 eyes(40%), 6/12 in 02 eyes (40%) and 6/18 in one eye (20%). intravitreal bevacizumab in diabetic retinopathy was first used in patients with advanced proliferative diabetic retinopathy with vitreous hemorrhage that obscured the view for panretinal photocoagulation.21 in a prospective study of patients with proliferative diabetic retinopathy treated with intravitreal injections of bevacizumab, jorge r costa ra, et al, found a rapid regression of actively leaking neovascularization, as well as significant improvement in mean visual acuity from 20/160 to 20/125 at three months follow up.22 in this study, out of the 32 eyes with advanced proliferative diabetic retinopathy with vitreous hemorrhage, 6/6 vision was achieved in 04 eyes (12.5%), 6/9 in 06 eyes (18.7%), 6/12 in 06 eyes (18.7%), 6/18 in 06 eyes (18.7%), 6/24 in 04 eyes (12.5%) and 6/60 in 06 eyes (18.7%), at the end of 06 months of follow up. the rationale for the use of a vegf inhibitor in the treatment of diabetic macular edema is strong, funatsu and colleagues23 found elevated levels of vegf in the aqueous humor in eyes of patients with diabetic macular edema. in a non-comparative case series, haritoglou c, et al24 51 patients with diffuse macular edema, refractory to other treatments were studied. oct measurements showed central retinal thickness decreased signifycantly from 501µm to 416µm at six weeks and 377µm adnan afaq, et al 78 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology at 12 weeks follow up. improvement in visual acuity of one line was reported at six weeks follow up. in this prospective study, out of 44 patients with diabetic macular edema, 30 patients showed significant improvement (68.1%), however, 4 patients (9.09%), continued to show deteriorating visual acuity, all these patients had extensive hard exudates at macula. it is comparable to a local study which also showed significant improvement in visual acuity in patients with diabetic macular edema after intravitreal avastin.25 in these cases oct of the macula was done to rule out vitreomacular traction (vmt) component to the macular edema, however no such traction was noted in any of the case. these refractory cases may represent tachyphylaxis; however lipid profile was also deranged in all these cases. these were scheduled for combination treatment with bevacizumab and laser photocoagulation. physician’s help was also needed to manage the lipid derangement. intravitreal bevacizumab has been used in cases of cnv secondary to high myopia. initially, the intravitreal bevacizumab dose was 1.25mg, and was reserved for cases of progression of cnv despite treatment with pdt, with or without intravitreal triamcinolone.26 initial results was positive, showing cnv regression as well as visual acuity improvement. in our study all the 03 patients (100%) with myopic cnv, showed an improvement in the visual acuity. the basic limitation of our study was the non availability of the etdrs (early treatment diabetic retinopathy study) vision screening charts. that’s why the visual acuity was measured on snellen’s acuity charts. other limitation was financial restraints which discouraged us to follow the progression of macular thickness by periodic oct scans. serial oct revealed decrease in central macular thickness to normal or near – normal levels in eyes with choroidal neovascularization (cnv) secondary to age – related macular degeneration (amd).27 conclusion the central role of vegf in chorio-retinal vascular disorders is now well established. results of our study conclude that the treatment with bevacizumab is beneficial in improving and stabilizing visual acuity not only in neovascular armd but also in other chorioretinal vascular disorders. it is less expensive as compared to ranibizumab. the findings of this important study will cut down the cost of treatment. standardized guidelines are needed for the commencement and conclusion of the treatment sessions, dosing regimens, frequency of treatment sessions and protocols of combination treatments for each ocular condition. author’s affiliation dr. adnan afaq associate professor of ophthalmology baqai medical university karachi dr. erum shahid senior registrar department of ophthalmology abbassi shaeed hospital karachi prof. khwaja sharif ul hasan prof. emeritus and chairman department of ophthalmology baqai medical university karachi references 1. rosenfeld pj, malik y kahook my. anti vegf finds expanding role in ophthalmology. retina/vitreous. ocular surgery news u.s. edition; november 10, 2010. 2. van wijngaarden p, coaster d, williams ka. inhibitors of ocular neovascularization: promises and potential problems. jama. 2005; 293: 1509-13. 3. ferrara n, hillan kj, gerber hp, novothy w. discovery and development of bevacizumab, an antivegf antibody for treating cancer. nat rev drug disc. 2004; 3: 391-400. 4. brasch r, pham c, shames d. assessing tumor angiogenesis using macromolecular mr imaging contrast media. j magn reson imaging. 1994; 7; 68-74. 5. rosenfeld pj, moshfegul aa, puliafito ca. optical coherence tomography findings after an intravitreal injection of bevacizumab (avastin) for neovascular age related macular degeneration. ophthalmic surg laser imaging. 2005; 36; 331-5. 6. senger dr, galli si, dvorak am. tumor cells secrete a vascular permeability factor that promotes accumulation of ascites fluid. science. 1983; 219; 983-5. 7. shahar j, avery rl, hellwell g. electrophysiologic and retinal penetration studies following intravitreal injection of bevacizumab (avastin). retina 2006; 26: 2629. 8. maturi rk, bleau ia, wilson dl. electro physiologic findings after intravitreal bevacizumab (avastin) treatment. retina 2006; 26: 270-4. 9. spaide rf, laud k, fine hf, klancnik jm jr, meyerle cb, yannuzzi la, sorenson j, slakter j, fisher yl, cooney mj. intravitreal bevacizumab treatment of choroidal neovascularization secondary to age related macular degeneration. retina 2006; 26: 383-90. effectiveness of intravitreal bevacizumab in various ocular diseases pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 79 10. rich rm, rosenfeild pf, pulaffto ca. short term safety and efficacy of intravitreal bevacizumab (avastin) for neovascular age related macular degeneration. retina 2006; 26: 495-511. 11. avery ri, pieramid dj, rabena md. intravitreal bevacizumab for age related macular degeneration. ophthalmology. 2006; 113: 363-72. 12. yoganathan p, deramo va, lai jc. visual impairment following intravitreal bevacizumab (avastin) in exudative age related macular degeneration. retina 2006; 26: 994-8. 13. jonas jb, libondi t, ihloff ak, harder b, kreissig i, schlichtenbrede f. visual acuity change after intravitreal bevacizumab for exudative age related macular degeneration in relation to subfoveal membrane type. acta ophthalmologica. 2007; 85: 563-5. 14. costa ra, jorge r, calucci d. intravitreal bevacizumab for choroidal neovascularization caused by amd (ibena study); results of a phase i dose escalation study, invest ophthalmol vis sci. 2006; 47; 4569-78. 15. avery ri, pieramid dj, rabena mc. intravitreal bevacizumab for neovascular age related macular degeneration, ophthalmology. 2006; 113; 363-72. 16. branch vein occlusion study group, argon laser photocoagulation for macular edema in branch vein occlusion. am j ophthalmol. 1984; 98; 271-82. 17. argon laser photocoagulation for macular edema in branch vein occlusion, the branch vein occlusion study group. am j ophthalmol. 1984; 98; 271-82. 18. noma h, minamoto a, funatsu h. intravitreal levels of vascular endothelial growth factor and interleukin-6 are correlated with macular edema in branch retinal vein occlusion, graefes arch clin exp ophthalmol. 2006; 244; 309-15. 19. rabena m, pieramici df, castellarin aa. intravitreal bevacizumab in the treatment of macular edema secondary to branch retinal vein occlusion. retina 2007; 27; 419-25. 20. iturralde d, spaide fr, meyerle cb. intravitreal bevacizumab treatment of macular edema in central retinal vein occlusion; s short term study. retina 2006; 26; 279-84. 21. bakri sj, donaldson mj, link tp. rapid regression of disc neovascularization in a patient with proliferative diabetic retinopathy following adjunctive intravitreal bevacizumab, eye. 2006; 20; 1474-5. 22. jorge r, costa ra, callucci d. intravitreal bevacizumab for persistent new vessels in diabetic retinopathy (ibeppe study). retina 2006; 26; 1006-13. 23. funatsu h, yamashita h, ikeda t, mimra t, hori s. vitreous levels of interleukin 6 and vascular endothelial growth factor are related to diabetic macular edema, ophthalmology. 2003; 110; 1690-6. 24. hanitoglou c, kookd, neubauer a. intravitreal bevacizumab therapy for persistent diabetic macular edema. retina 2006, 26; 999-1005. 25. jahangir t, jahangir s, tayyab h, hamza u. visual outcome after intravitreal avastin (bevacizumab) for persistent diabetic macular edema. pak j ophthalmol 2011; 27; 4;187-190 26. laud k, spaide rf, freund kb. treatment of choroidal neovascularization in pathologic myopia with intravitreal bevacizumab. retina 2006; 26; 960-3 27. azhar mn, haider ma, tayyab h, zaheer-ud-din aa, qazi z a. intravitreal bevacizumab for the treatment of subfoveal choroidal neovascularization secondary to age related macular degeneration, pak j ophthalmol 2012; 28; 4; 211-213. pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 46 original article mean retinal nerve fiber layer thickness in high myopes using optical coherence tomography in a tertiary care hospital in karachi, pakistan afeefa mubashir, mubashir alam khan, saira saeed, babar irfan, omar irfan, javed hassan niazi pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: saira saeed department of ophthalmology, jinnah sindh medical university email: sairasaeed40@gmail.com …..……………………….. purpose: to assess the mean retinal nerve fiber layer thickness in high myopic patients using optical coherence tomography in pakistan. study design: cross sectional with non-probability, purposive sampling. place and duration of study: the ophthalmology department, jinnah postgraduate medical centre, from 25 th january 2014 to 25 th july 2014. material and methods: this study was conducted at the ophthalmology department, jinnah postgraduate medical centre from 25 th january 2014 to 25 th july 2014. there were 161 patients between 12 to 40 years who were analyzed. patients with highly myopic eyes were selectively enrolled in the study while those with other eye diseases were excluded. data was analyzed in spss version 19. results: the average age of patients was 26.02 (sd ± 7.15) years. mean duration of myopia was 2.74 (sd ± 1.38) years. there were 78 (48.44%) males and 83 (51.56%) females. the mean rnfl thickness was 88.61 ± 7.41 and 87.88 ± 7.12 in right and left eyes respectively. a significant mean rnfl difference between right and left eyes in male patients (p = 0.016) was observed. conclusion: individuals with high myopia have a tendency to develop decreased thickness of retinal nerve fiber layer and are subjected to various sight threatening pathologies. key words: high myopia, optical coherence tomography, retinal nerve fiber layer thickness. yopia is reported to be 26% among adults1. with an axial length greater than 25.5 mm and/or a minimum refractive error of 6 diopters2 and globe elongation, the condition is termed high myopia3. current stats claim that as much as 30% of the world population is myopic. with chances of the disease affecting almost 5 billion people by 2050, this would make it 50% of the global population4. as per sydney myopia study conducted recently, it was found that 17-year old myopic adults around the world collectively constituted 31%, which is twice the number obtained in a similar study done almost a decade ago5. prevalence of myopia was found to be 6% among adults aged 30 and above at a local village in northern pakistan6. another study conveyed that in the 5-10 year age group, 0.45% patients presented with myopia whereas in 10 – 16 year olds7 it was about 1.44%. on the contrary, a study done in a district of northern m afeefa mubashir, et al 47 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology pakistan it was found that myopia was 52.6% among school children8. myopia was also found to be the most common refractive error in adults aged 25 to 80 years at a teaching hospital in bannu, pakistan where 44.06% patients were noted to have this visually debilitating disease2. time differences in reflected light from each part of the tissue are used to calculate the rnfl thickness using the optical coherence tomography (oct). individuals with high myopia have a tendency to develop decreased thickness of retinal nerve fiber layer along with various sight threatening pathologies that include peripheral retinal degenerations, retinal detachment and posterior pole chorioretinal lesions9. this study aims to encourage the practice of rnfl assessment in high myopes, thereby enabling the health care system to manage such cases satisfactorily. it further aims to investigate the link between myopia and rnfl thickness, particularly the high myopes, in such a manner that its diagnostic value in the assessment of myopia and other detrimental conditions of the eye is made transparent. the myopic patients studied in the research have also been subdivided into groups based on the gender, age and the level of disease for individual comparison of variables. material and methods this was a cross sectional study conducted at the department of ophthalmology, jinnah postgraduate medical centre (jpmc) from 25th january 2014 to 25th july 2014. non-probability purposive sampling was used. jpmc is a tertiary care public hospital in karachi, pakistan. approval from the institutional ethical review committee was taken, before commencement of the study. all patients diagnosed with high myopia between the ages of 12 to 40 years who presented during the study duration were included in the study. patients with glaucoma, history of underlying diabetes and hypertension or any other retinal abnormality, media opacities (cataract, corneal opacities) reported to have undergone any retinal surgery, were excluded from the study. informed consent for inclusion in the study was taken from all patients. the refractive error from the manifest refraction (mr) was adjusted to spherical equivalent. mild to moderate myopia group was between -3.00 diopters to -6.00 diopters whereas from -6.00 diopters to values greater were termed high myopia. patients having spherical equivalent ≥ -6 (high myopia) underwent optical coherence tomography evaluation of both eyes following pupillary dilatation with 1% tropicamide and 5% phenylephrine. measurements were conducted under direct supervision of consultant ophthalmologist having 5 years’ experience to control the bias in observation. statistical package for social sciences (spss version 19.0) was used to analyze and interpret data. the measurement of quantitative variables like retinal nerve fiber layer thickness, age, duration of myopia were presented by their mean ± sd values. the stratification of age, duration of disease and gender was made to control the effect modifiers and to see the effect of these on outcomes. results a total of 161 patients with highly myopic eyes were analyzed in this study. the average age of patients was 26.02 (sd ± 7.15) years and mean duration of myopia since diagnosis was observed to be 2.74 (sd ± 1.38) years. out of the total 161 patients, 78 were (48.44%) males while 83 (51.56%) were females. the mean rnfl thicknesses found in patients enrolled for the study was 88.61 ± 7.41 and 87.88 ± 7.12 in right and left eyes respectively as shown in table 1. stratification analysis was performed to observe and compare the rnfl thickness with respect to age groups, gender and duration of myopic disease. no significant difference in the mean rnfl was observed in the different age groups but among the 26 to 30 year olds, which included a total of table 1: mean retinal nerve fiber layer thickness in high myopic patients using optical coherence tomography. statistic retinal nerve fiber layer thickness (rnfl) right eye left eye mean 88.61 87.88 std. deviation 7.41 7.12 95% confidence interval for mean lower bound 87.46 86.79 upper bound 89.76 88.97 median 87 86 mean retinal nerve fiber layer thickness in high myopes using optical coherence tomography pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 48 table 2: comparison of mean retinal nerve fiber layer thickness in high myopic patients among age groups and both genders. age groups (years) n right eye rnfl right eye rnfl p-values mean ± sd mean ± sd 12 – 20 years 30 92.17 ± 5.28 92.20 ± 5.65 0.93 21 – 25 years 45 87.98 ± 7.47 87.42 ± 6.94 0.12 26 – 30 years 40 86.63 ± 8.02 84.83 ± 6.65 0.024 31 – 35 years 30 89.13 ± 7.66 88.97 ± 6.92 0.73 36 – 40 years 16 87.69 ± 7.05 86.81 ± 6.75 0.23 male 78 88.96 ± 8.06 88.10 ± 7.63 0.016 female 83 88.28 ± 6.77 87.66 ± 6.38 0.16 table 3: comparison of mean retinal nerve fiber layer thickness in high myopic patients between duration of myopia. duration of myopia n right eye rnfl right eye rnfl p-values mean ± sd mean ± sd 1 to 3 years 120 88.62 ± 7.31 88.21 ± 7.04 0.15 4 to 7 years 41 88.59 ± 7.78 86.90 ± 6.86 0.02 40 patients, mean rnfl slightly differed in left and right eyes. it was found to be 86.63 ± 8.02 and 84.83 ± 6.65 for the right and left eyes (p = 0.024) as denoted in table 2. the same age group presented with the most striking reduction of the rnfl thickness (p = 0.024) while no such discrepancy was noted for other groups. analysis of the rnfl thickness on the basis of gender revealed that the difference was significant between right and left eyes in male patients (p = 0.016) as compared to females (p = 0.16) (table 2). a significant thinning of the rnfl was also seen among male patients as compared to the females with values of 88.96 ± 8.06 and 88.10 ± 7.63 for the right and left eyes (p = 0.016) respectively (table 2). though majority patients presented with disease duration of 1 to 3 years (n = 120), cases with time interval between 4 to 7 years (n = 41) had considerably reduced mean rnfl thicknesses of 88.59 ± 7.78 (right eye) and 88.59 ± 7.78 (left eye) (p = 0.02) as shown in table 3. discussion myopia is a very common refractive error of the eye. the disease has managed to progress rapidly in the recent years; particularly in the asian countries10. current data reporting the influence of myopia on the retinal nerve fiber layer thickness is rather conflicting. some studies show no association11 whereas budenz et al12 and leung et al1 reported significant correlations. retinal nerve fiber layer (rnfl) is the innermost retinal layer closest to vitreous. it was found that the normal mean retinal nerve fiber layer thickness for various age groups analyzed by a research for various ethnic groups obtained in a study estimated to a mean of around 97.3 ± 9.6 µm.13 whereas in a multi linguistic and urban hub like karachi, it equalized to around 99.02 ± 9.08 µm14. our mean (± sd) rnfl thickness in myopic patients were 88.61 ± 7.41 in right eye and 87.88 ± 7.12 in left eyes. in view of this comparison, it can be deduced from our results that the rnfl afeefa mubashir, et al 49 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology thickness tends to decrease with degree of myopia. the retinal nerve fiber layer thickness diminishes owing to various medical conditions like myopia and diabetes. the mean rnfl thickness noted in high myopic groups was quoted to be 80.0 (18.6) µm.9 posterior staphyloma, scleral thinning, large irregular tilted optic discs, fuch’s spot, chorioretinal atrophy, large cup-to-disc ratios, peripheral retinal degenerations, lacquer cracks, myopic crescent, retinal detachment, thin lamina cribrosa and localized retinal nerve fiber layer (rnfl) defects are various defects associated with myopia1. in patients with pseudo-exfoliation syndrome, a reduction in the mean rnfl thickness has been deciphered15. a reduced rnfl thickness was also seen with unilateral retinal vein occlusion16 as well as optic neuritis17. rnfl thickness can be directly measured using oct by calculating the area between the internal limiting membrane (ilm) and rnfl border. the oct has emerged as one authentic technique that heralds the presence of glaucoma prior to visual fields anomalies, preventing loss of 30 – 50% of the retinal ganglion cells18. multiple studies have been directed at measuring the rnfl thickness via oct in high myopes but the data from our region stands limited. one of the few, conducted at the mayo hospital (lahore) elucidated the significance of oct in determining a link between the axial length and rnfl thickness in myopic patients19. this method of oct utilization was found to provide highly reproducible measurements of retinal thickness21. in our study, repeated scans were not performed but the scan quality can be considered a reliable representative of those encountered in clinical practice by experienced technicians under similar conditions with similar patients. with reference to a study conducted in china, it was ascertained that the mean rnfl thickness in high myopes (≥ − 6 d) was significantly reduced compared to those with myopia1. similar results were obtained in a korean study which confirmed links between the mean rnfl thickness and degree of myopia21. a thin rnfl has also been linked to thinning and elongation of the retina and sclera1 and could be representation of an actual decrease in nerve fiber number contradictory to histological analysis. another research inferred that an unevenness of the rnfl thickness is seen with varying degrees of myopia; the adverse the myopia, the more the elongation of the ap axis and greater the attenuation of the rnfl22. while such studies lay the basis for the mean rnfl and high myopia linkage, a study done in singapore by hoh et al concluded that there was no significant correlation between the two using a 4.5 mm scan diameter23. similar outcomes were identified in numerous prior studies24. such refutation can be explained by poor resolution of earlier octs and the low sensitivity, early confocal laser devices. the potency of this study lies in the utilization of high-quality, high-repetition scanning current generation oct instruments. moreover, the homogenous nature of our subjects provided increased sensitivity by controlling for confounders that could have affected rnfl measurements. a tertiary care centre, jinnah postgraduate medical centre was chosen for the study so that a variety of subjects representing diverse socioeconomic classes, ethnic groups and occupational backgrounds are enrolled; which helped make the result much more assorted and coherent. an almost equally sized sample from both genders ensures that conclusions regarding rnfl thickness, myopia and gender can be considered authentic. in opposition, the limited sample size stands as a drawback; though the magnitude and strength of the findings in the study indicate that only a small size is required to amply power. another limitation for the study would be unequal representations from each age group; 45 entries for patients aged 21 to 25 years while only 16 for the 36 to 40 years group. this prevents reliable comparisons of results age wise. myopia has proved to be a leading source of impaired vision and blindness round the globe. this study helps identifying the risks earlier in patients, thereby allowing them to be rescued with a guarantee of vision. in a third world country where people are burdened with various other expenses, a simple monitoring of the rnfl thickness via oct can help estimate the risk for hazardous conditions like glaucoma much earlier, saving huge sums that go into treatment. when the expenditure and loss related to a condition as passive as myopia are cut short, major health risks can be assessed in the country efficiently. conclusion in the present study it was perceived that the average rnfl thickness decreases with the degree of myopia. since individuals with high myopia overtime develop a decremented retinal nerve fiber layer, they are prone mean retinal nerve fiber layer thickness in high myopes using optical coherence tomography pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 50 to suffer from various pathologies that are a serious threat to vision. hence, adequate prophylactic measures aided with monitoring the mean rnfl thickness to determine the risk for vicious outcomes should be practiced so that long term vision is guaranteed to the patients. disclosures human subjects: consent was obtained by all participants in this study. animal subjects: this study did not involve animal subjects or tissue. no funds to disclose. no conflicts of interest. author’s affiliation dr. afeefa mubashir mbbs, fcps, consultant department of ophthalmology, jinnah post graduate medical center karachi, pakistan. dr. mubashir alam khan mbbs, fcps, consultant endocrinologist, almana general hospital, al-khobar saudi arabia. dr. saira saeed final year mbbs department of ophthalmology, jinnah sindh medical university. dr. babar irfan final year mbbs department of ophthalmology, jinnah sindh medical university. dr. omar irfan graduate department of ophthalmology, aga khan university. dr. javed hassan niazi frcs, fcps, professor and head of department jinnah post graduate medical center karachi, pakistan. role of authors dr. afeefa mubashir came up with the concept and design of the study, defined the intellectual content; participated in all the necessary clinical studies, data and statistical analysis. final approval and agreement. dr. mubashir alam khan, contributed further ideas to the study design and concept; also defined some of the intellectual content; participated in the clinical studies and data analysis. final approval and agreement. dr. saira saeed actively contributed to the literature review, manuscript preparation, modification and editing. also did a review of the finalized manuscript draft. dr. babar irfan actively contributed to the literature review, manuscript preparation, modification and editing. also did a review of the finalized manuscript draft. dr. omar irfan actively contributed to the literature review, manuscript preparation, modification and editing. also did a review of the finalized manuscript draft. dr. javed hassan niazi helped devise the concept and design of the study, define the intellectual content; participated in all the necessary clinical studies, data and statistical analysis. final approval and agreement. references 1. leung ck, mohamed s, leung ks, cheung cy, chan sl, cheng dk, et al. retinal nerve fiber layer measurements in myopia: an optical coherence tomography study. invest ophthalmol vis sci. 2006; 47: 5171–6. 2. mahsud h, wazir mi, saleem mw, ayaz m. refractive errors in adults studied at a teaching hospital. gomal j med sci. 2015; 13: 223-5. 3. ho t, shih y, lin s, lin ll, chen m. peculiar arcuatescotoma in pathologic myopia-optical coherence tomography to detect peripapillary neural tissue loss over the disc crescent. graefes arch clin exp ophthalmol. 2005; 243: 689–94. 4. holden ba, fricke tr, wilson da, jong m, naidoo ks, sankaridurg p, wong ty, naduvilath tj, resnikoff s. global prevalence of myopia and high myopia and temporal trends from 2000 through 2050, ophthalmology, may 2016; 123 (5):1036–1042. 5. french an, morgan ig, burlutsky g, mitchell p, rose ka. prevalence and 5to 6-year incidence and progression of myopia and hyperopia in australian schoolchildren. ophthalmology, 2013; 120: 1482-91. 6. abdullah as, jadoon mz, akram m. prevalence of uncorrected refractive errors in adults aged 30 years and above in a rural population in pakistan. j ayub med coll abbottabad, 2015; 27 (1): 8-12. 7. gull a, raza a. visual screening and refractive errors among school aged children. jrmc; 2014; 18 (1): 97100. https://www.ncbi.nlm.nih.gov/pubmed/?term=abdullah%20as%5bauthor%5d&cauthor=true&cauthor_uid=26182727 https://www.ncbi.nlm.nih.gov/pubmed/?term=jadoon%20mz%5bauthor%5d&cauthor=true&cauthor_uid=26182727 https://www.ncbi.nlm.nih.gov/pubmed/?term=akram%20m%5bauthor%5d&cauthor=true&cauthor_uid=26182727 https://www.ncbi.nlm.nih.gov/pubmed/26182727 https://www.ncbi.nlm.nih.gov/pubmed/26182727 https://www.ncbi.nlm.nih.gov/pubmed/26182727 afeefa mubashir, et al 51 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology 8. atta z, arif as, ahmed i. prevalence of refractive errors in madrassa students of haripur district. j ayub med coll abbottabad, 2015; 27 (4): 850-2. 9. schweitzer kd, ehmann d, garcía r. nerve fiber layer changes in highly myopic eyes by optical coherence tomography.can j ophthalmol. 2009; 44 (3): e13-6. 10. matsumura h, hirai h. prevalence of myopia and refractive changes in students from 3 to 17 years of age. surv ophthalmol. 1999; 44 (suppl): 109–15. 11. salchow dj, oleynikov ys, chiang mf. retinal nerve fiber layer thickness in normal children measured with optical coherence tomography. ophthalmology, 2006; 113: 786–91. 12. budenz dl, anderson dr, varma r. determinants of normal retinal nerve fiber layer thickness measured by stratus oct. ophthalmology, 2007; 114: 1046-52. 13. alasil t, wang k, keane pa, lee h. analysis of normal retinal nerve fiber layer thickness by age, sex, and race using spectral domain optical coherence tomography. j glaucoma, 2013 sep; 22 (7): 532-41. 14. mukhtar s, hassan n, dawood z. retinal nerve fiber layer thickness in a subset of karachi (pakistan) population. british journal of medicine & medical research, 2015; 10 (9): 1-7, 15. yasmeen n, fatima n, islam q. comparison of retinal nerve fiber layer thickness in patients having pseudo exfoliation syndrome with healthy adults. pak j med sci. 2016; 32 (6): 1533–1536. 16. kim mj, woo sj, park kh, kim tw. retinal nerve fiber layer thickness is decreased in the fellow eyes of patients with unilateral retinal vein occlusion. ophthalmology. 2011 apr; 118 (4): 706-10. 17. saxena r, bandyopadhyay g, singh d. evaluation of changes in retinal nerve fiber layer thickness and visual functions in cases of optic neuritis and multiple sclerosis. indian j ophthalmol. 2013; 61 (10): 562-6. 18. mansoori t, viswanath k, balakrishna n. ability of spectral domain optical coherence tomography peripapillary retinal nerve fiber layer thickness measurements to identify early glaucoma. indian j ophthalmol. 2011; 59: 455–459. 19. akram m, malik i, ahmad i. correlation between axial length and retinal nerve fiber layer thickness in myopic eyes. pak j ophthalmol. 2013, vol. 29 no. 3. 20. budenz dl, chang st, huang x. reproducibility of retinal nerve fibre layer measurements using the stratus oct in normal and glaucomatous eyes. invest ophthalmol vis sci. 2005; 46: 2440–6. 21. choi s, lee s. thickness changes in the fovea and peripapillary retinal nerve fiber layer depend on the degree of myopia. korean j ophthalmol. 2006; 20: 215–9. 22. éfendieva mé. comparison of the retinal nerve fiber layer thickness in patients with myopia of different degrees. vestn oftalmol. 2014; 130 (4): 18-21. 23. hoh st, lim sc, seah sk. peripapillary retinal nerve fibre layer thickness variations with myopia. ophthalmology, 2006; 113: 773–7. 24. kashiwagi k, tamura m, abe k. the influence of age, gender, refractive error, and optic disc size on the optic disc configuration in japanese normal eyes. acta ophthalmol scand. 2000; 78: 200-3. https://www.ncbi.nlm.nih.gov/pubmed/?term=atta%20z%5bauthor%5d&cauthor=true&cauthor_uid=27004337 https://www.ncbi.nlm.nih.gov/pubmed/?term=arif%20as%5bauthor%5d&cauthor=true&cauthor_uid=27004337 https://www.ncbi.nlm.nih.gov/pubmed/?term=ahmed%20i%5bauthor%5d&cauthor=true&cauthor_uid=27004337 https://www.ncbi.nlm.nih.gov/pubmed/27004337 https://www.ncbi.nlm.nih.gov/pubmed/27004337 https://www.ncbi.nlm.nih.gov/pubmed/27004337 microsoft word 7. naz jahangir pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 81 original article corneal topography pattern in healthy volunteers coming to the ophthalmology department hayatabad medical complex, peshawar as attendants naz jehangir, sofia iqbal, mushtaq ahmad pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: naz jehangir ophthalmology department hmc, peshawar …..……………………….. purpose: to determine the proportion of normal and abnormal topography patterns in attendants of patients coming to the ophthalmology department hayatabad medical complex, peshawar. material and methods: it was a descriptive cross sectional study conducted at ophthalmology department, hayatabad medical complex, peshawar from august 2009 to feb 2010. sample size was 91 individuals using epi info 6 (expected frequency of abnormal patterns is 39% with precision of 1and confidence interval 95%) while simple random sampling technique was used. all health volunteers coming to the institute, both males and females with age ranged from 18 to 60 years were included in this study while contact lens wearer, previous ocular surgery, previous ocular trauma, ocular surface disorders and refractive errors five diopter of hyperopia, myopia or astigmatism patients were excluded. spss version10 was used for analysis of the data. results: we analyzed 182 eyes of 91 patients, 47 subjects were males and 44 were females. abnormal patterns of corneal topography (asymmetric bow tie and irregular corneal topographic patterns) were seen in 77-79% of the people and normal patterns (oval, round and symmetric bow tie topographic patterns) were seen in 21-23% people. conclusion: due to the variability in corneal topographic patterns developing a meaningful classification system for our local people is a challenge. this study which is the 1st of its nature to be conducted in this area will help in providing a possible standard for corneal topography patterns for khyber pukhtoonkhwa local people. orneal topography allows qualitative and quantitative measurement of corneal curvature. databases of corneal topography patterns of normal human corneas are available in the united states and europe1,2. they serve as a reference for detecting early corneal curvature abnormalities. previous studies describe the variation in normal corneal topography patterns that exist in different populations1-3. the spectrum of topography present in the general population of our country has not been reported so far. the detection of early changes on the anterior corneal surface to classify it as a diseased state is difficult due to non availability of standardized data. keratorefractive surgeries are gaining more popularity4,5. a corneal topography database of the local population is useful for planning such surgeries. topography guided ablation for conditions such as keratoconus is based on this data6,7. patterns of corneal topography are classified into five subgroups based on objective criteria8. the reported frequency of normal corneal patterns range from 61% to 71% (abnormal c naz jehangir, et al. 82 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology patterns range from 29% to 39%) in studies conducted in atlanta and miami respectively1,8. these abnormal corneal topographic patterns could help in detection of early keratoconus2. the proportion of eyes in the local population that fall into each of these categories needs to be determined. as khyber institute of ophthalmic medical sciences is one of the centers of excellence and people from all cadres and socioeconomic strata and different districts come here so this will help establish normal variables for corneal topography in our people. the purpose of the study was to make a corneal topography database of our local people to differentiate normal from abnormal corneas which will help us in the future for early detection of subclinical keratoconus and also in planning of keratorefractive surgeries and the response of cornea to such surgeries. material and methods the study was conducted at the khyber institute of ophthalmic medical sciences, hayatabad medical complex, peshawar. this descriptive cross sectional study was carried out for six months august 2009 to february 2010. the sample size consisted of 91 patients using epi info 6 (expected frequency of abnormal patterns is 39% with precision of 1and confidence interval 95%). the sampling was simple random. health volunteers coming to the institute, both males and females with age range from 18 to 60 years were included in the study. contact lens wearer, previous ocular surgery, previous ocular trauma, ocular surface disorders and refractive errors five diopter of hyperopia, myopia or astigmatism were excluded from the study. results gender distribution among 91 patients were analyzed as n=47(51.6%) patients were males and n=44(48.4%) patients were females. location was analyzed most of the patients n=24 (26.7%) were from peshawar, n=11 (12.2%) patients were from kohat, n=11 (12.2%) patients were from mardan, n=9 (10%) patients were from charsadda n=35 (40%) patients were from other districts. both eyes were examined of all the 91 volunteers. the corneal topography of the right eye showed abnormal patterns in 72 eyes {56 (61.5%) patients had asymmetric bowtie, 16 (17.5%) patients had irregular topographic patterns}. normal patterns were observed in 19 eyes {9 (9.8%) patients had symmetric bowtie, 4 (4.3%) patients had oval shape and 6 (6.5%) patients had round shape} (table-2). the corneal topography of the left eye showed that 70 eyes had abnormal topographic patterns {45(49.4%) patients had asymmetric bowtie, 25(27.4%) patients had irregular patterns}. the left eye had normal topographic patterns in 21 eyes {15 (16.4%) patients had symmetric bowtie, 4 (4.4%) patient had round shape and 2 (2.2%) patients had oval shape} (table-3). table 1: age distribution (n=91) age frequency n (%) 18 30 years 59 (65.6) 31-40 years 19 (21.1) 41-50 years 13 (13.3) total 91 (100) table 2: right eye distributions (n=91) right eye topographic patterns frequency n (%) abnormal patterns asymm bowtie 56 (61.5) irregular 16 (17.5) normal patterns symm bowtie 9 (10.0) oval 4 (4.3) round 6 (6.5) total 91 (100) table 3: left eye location left eye topographic patterns frequency n (%) abnormal patterns asymm bowtie 45 (49.4) irregular 25 (27.4) normal patterns symm bowtie 15 (16.4) oval 2 (2.2) round 4 (4.4) total 91 (100) corneal topography pattern in healthy volunteers coming to the ophthalmology department h.m.c., peshawar pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 83 table 4: age verses right and left eye location age in groups right eye total p value asymm bowtie irregular symm bowtie oval round 18 30 years 44 5 6 2 2 59 0.107 31-40 years 5 8 3 2 3 19 41-50 years 7 3 1 13 total 56 16 9 4 6 91 left eye asymm bowtie irregular symm bowtie oval round 18 30 years 35 10 10 2 2 59 0.575 31-40 years 7 8 2 2 19 41-50 years 3 7 3 13 total 45 25 15 2 4 91 table 5: right eye verses left eye location (n=91) right eye topographic patterns left eye topographic patterns total asymm bowtie irregular symm bowtie oval asymm bowtie 22 20 9 0 51 irregular 12 14 2 0 28 symm bowtie 3 2 3 1 9 oval 0 1 0 1 2 total 37 37 14 2 90 gender distribution was compared with left eye and right eye and the difference was found to be statistically insignificant. most of the patients were between the ages of 18 to 30 years and there was no statistically significant difference between different age groups regarding the topography patterns as shown in (table-4). there was no statistically significant difference between right eye and left eye corneal topographic patterns shown in (table-5). discussion to our knowledge this is the 1st study to investigate the corneal topography patterns in our local people. the total number of volunteers in this study were 91.many authors have studied variable number of volunteers ranging from 110-232 subjects2, 9-12. our study included people aged from 18-60 years which were almost similar to a korean study10. a wide variety of age groups have been used in different studies ranging from 8 -79 yrs9,10 the refractive errors included in our study ranged from +5d to -5d, which were very different from the rest of the studies, bogan2 included +5.5d to -8.37d whereas both the korean studies included up to -16d of myopia. bogan and coworkers2 studied both ametropic and emmetropic eyes by videokeratography. they derived a qualitative system for classifying normal corneal topography. their study showed that asymmetric bow tie pattern was seen in 32% of normal corneas, round 22%, oval naz jehangir, et al. 84 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology 21%, symmetric bow tie 18% and irregular patterns in 7% of people. kim et al10 also reported asymmetric bow tie pattern to be the most frequent pattern 42.7%, irregular 19%, symmetric bow tie 18.1%, oval 13.4% and round pattern was the most infrequent 6.9% in korean adults. in our study asymmetric bow tie was found to be the most frequent pattern 56% followed by irregular 22.5%, symmetric bow tie 13.4%, round 5.5% and oval 3.2%. there were no statistically significant differences between males and females. no statistically significant difference was found between both eyes as like all other studies conducted elsewhere2,9-11. overall our study showed abnormal topographic patterns ranging from 77-79% and normal patterns ranging from 21-23%. these results are much different from the american studies (bogans2 61% normal patterns, zuguos9 study showing approximately 80% normal topography patterns). our study results are comparable to the two korean studies10,11 in which 38% normal, and about 61% abnormal patterns were seen. irregular patterns were seen to be 22.5% in our study which was much more than the american studies (bogans 7.1%, zingu 4.53%)2,9. korean10 study showed comparable results to our study with 19% irregular patterns. there were no statistically significant differences between males and females and no statistically significant difference was found between both eyes. overall our study showed abnormal topographic patterns ranging from 77-79% and normal patterns ranging from 21-23%. these results are much different from the american studies (bogans2, 61% normal patterns, zuguos9 study showing approximately 80% normal topography patterns). our results are comparable to the two korean studies 38% normal, and 61% abnormal topography patterns)10,11. possible explanations for high number of abnormal especially irregular patterns include tear film abnormalities (possibly dry eyes due to infrequent blinking during the topography). bogan had a large number of normal results because they instilled artificial tears into every patient’s eyes before the topography thus preventing drying of the corneas2. another study also proves that artificial tear instillation reduced the irregular patterns from 45.24% to %.30.95%12. other causes for abnormal patterns could be improper focusing of keratoscope, eccentric fixation or different location of corneal apex2. although all patients were examined for tear film abnormalities but eccentric fixation cannot be ruled out. another explanation could be the presence of high percentage of abnormal patterns due to unequal distribution of age and sex2. korean studies showed a tendency of more irregular topographic patterns than western adults10,11. their might be some role of genetic make up and dietary habits which needs to be investigated in the future as well as increasing age. different result scan also be attributed because of use of different topography machines. we used shin nippon2000. another study used another machine corneal modeling system2, zuguo used orbscan9 which is the most recent development and yields more information not only from the anterior corneal surface but also the posterior corneal surface. results differences can also be attributed to the different range of refractive errors included in different studies inclusion criteria2, 9-11. so a number of factors are involved in the variability of corneal topographic patterns. conclusion due to the variability in corneal topographic patterns developing a meaningful classification system for our local people is a challenge. this study which is the 1st of its nature to be conducted in this area will help in providing a possible standard of corneal topography patterns for khyber pukhtoonkhwas local people. author’s affiliation dr naz jehangir medical officer ophthalmology department hmc, peshawar dr. sofia iqbal associate prof. ophthalmology khyber girls medical college hmc peshawar dr. mushtaq ahmad registrar ophthalmology department hmc peshawar corneal topography pattern in healthy volunteers coming to the ophthalmology department h.m.c., peshawar pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 85 reference 1. rabinowitz ys, yang h, brickman y, et al. videokeratography database of normal human corneas. br j ophthalmol. 1996; 80: 610-6. 2. bogan sj, warring go, ibrahim o. classification of normal corneal topography based on computer assisted videokeratography. arch ophthalmol. 1990; 108: 945-9. 3. dingeldein sa, klyce sd. the topography of normal corneas. arch ophthalmol. 1989; 107: 512-8. 4. tahir m. visual outcome of photorefractive keratectomy for low to 5.moderate myopia. pak j ophthalmol. 2002; 18: 35-9. 5. erdelyi b, csakany b, nemeth j. spontaneous alterations of the corneal topographic pattern. j cataract refract surg. 2005; 31: 973-8. 6. koller t, iseli hp, donitzky c, et al. topography guided surface ablation for form fruste keratoconus. ophthalmology 2006; 113: 2198-02. 7. castellvi gls, simon s, simon jm, et al. special topographic patterns. dr agarwal’s textbook on corneal topography.1sted. new delhi: jaypee brothers medical publishers ltd. 2006; 34. 8. zuguo b, andrew j, stephen c. evaluation of corneal thickness and topography in normal eyes using the orbscan corneal topography system. br j ophthalmol. 1999; 83: 774-8. 9. kim sj, kim dm, lee jh, et al. normal corneal topographic patterns of korean adults. j korean ophthalmolo soc. 2000; 37: 1789-95. 10. kim hc, chang sd. relationship between topographic patterns and corneal astigmatism in korean adults. korean j ophthalmol. 2003; 17: 91-6. 11. liu z, pflugfeder sc. corneal surface regularities and effect of artificial tears in aqueous tear deficiency, ophthalmology. 1999, 106, 939-43. case report pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 177 case report conjunctival leiomyoma “a case report” imran ghayoor, asad jafri, ghazala tabassum, fariha zubair pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: imran ghayoor department of ophthalmology liaquat national hospital, …..……………………….. a 16 years old boy presented to the eye opd with a conjunctival growth of one year duration which was gradually increasing in size. on examination visual acuity was 6/6 in both eyes. it was a conjunctival growth originating from the inferior fornix and lateral end of medial canthus, it was like a pedunculated, congested, out pouching of the conjunctiva. we opted for excision biopsy and per-operatively it was found to be very vascular and tough tissue to cut. end to end conjunctival suturing was done to cover the defect. the histopathology done at liaquat national hospital, histopathology lab. showed it to a leiomyoma. onjunctival growths can have many etiologies and occasionally one is surprised with the histopathology that comes ones way. to find a leiomyoma in the histology of a conjunctival growth was a real surprise; it being a tumor of the female uterus1. leiomyoma is a benign tumor that usually arises from smooth muscle of vascular tissue, subcutaneous tissue, stomach, large and small intestine and the uterus. uterus being the most common site. orbital leiomyoma has been reported since 1896. case report a 16 years old boy presented to the eye opd with a conjunctival growth of one year duration which was gradually increasing in size. he only came for cosmetic reasons. there was no history of trauma, infection, surgery or bleeding from the lesion. on examination visual acuity was 6/6 in both eyes. it was a conjunctival growth originating from the inferior fornix and lateral end of medial canthus, it was like a pedunculated, congested, out pouching of the conjunctiva. the rest of the ocular examination was unremarkable and within normal limits. movements were full with no double vision and it looked benign, well pedunculated, conjunctival growth. no further investigation like b-scan or c.t scan were done as they would not have contributed to current management to the patient as the patient only wanted excision of the growth. we opted for excision biopsy and per-operatively it was found to be very vascular and tough tissue to cut. end to end conjunctival suturing was done to cover the defect. the biopsy showed it to be a leiomyoma. the cut section revealed conjunctival and skin tissue with intact surface lining. the underlying stroma was collagenous and the lesion was fairly circumscribed composed of spindle shapes cell showing a vaguely whorled arrangement. these cells were highlighted with trichome. immunohistochemistry was done to confirm the diagnosis (anti-smooth muscle actin antibody)2 (fig 2-4). no atypia or mitosis were seen. discussion leiomyoma of conjunctiva is one of the rarest tumors of the eye. the only report which we could find was by brannan so in 20035. as far as we know it has never been reported by anyone in pakistan. leiomyoma is a benign tumor that usually arises from the smooth muscle of blood vessels, subcutaneous tissues, stomach, large and small intestine and uterus, the last being the most common site1,2. histopathologically they may resemble any “spindle cell” tumor, and immunohisto chemical c imran ghayoor, et al 178 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology staining with smooth muscle actin is necessary to differentiate this tumor from other spindle cell tumors.2-5 fig. 1: conjunctival lesion fig. 2: interlacing bundles of spindle shaped cells fig. 3: tumor is positive for muscle on trichrome stain fig. 4: spindle shaped cells show strong positivity for anti smooth muscle actin antibody fig. 4: 6 weeks post operative picture after removal of conjunctival lesion. among the ocular leiomyomas orbit is the most common site. it has been reported from both anterior and posterior part of orbit and capsulo – palpebral muscle of hessor as well as smooth muscles of the blood vessels implicated.2 recurrence after incomplete excision has been observed.2 orbital leiomyoma is not radiosensitive2. there are reported cases of iris, ciliary body and choroidal leiomyomas.2-6 the most probable site of origin of this leiomyoma may be from the smooth muscle of the blood vessels or embryonic tissue present in the medial canthus. there are also reports of leiomyosarcomas3-4 as well, which tell us that these benign tumors can turn to malignancy, and that the patient will require follow-up for the rest of their life. conjunctival leiomyoma “a case report” pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 179 author’s affiliation dr. imran ghayoor department of ophthalmology liaquat national hospital dr. asad jafri department of ophthalmology liaquat national hospital dr. ghazala tabassum department of ophthalmology liaquat national hospital dr. fariha zubair department of ophthalmology liaquat national hospital references 1. nath k, shukla br. orbital leiomyoma and its origin. br j ophthalmol. 1963; 47: 369-71. 2. gündüz k, günalp i, erden e, erekul s. orbital leiomyoma: report of a case and review of the literature. surv ophthalmol. 2004; 49: 237-42. 3. guerriero s, sborgia a, giancipoli g, fiore mg, ross r, piscitelli d. a rare case of primitive epithelioid leiomyosarcoma of the conjunctiva. orbit. 2011; 30: 169-71. 4. shenoy r, bialasiewicz aa, nair nv, date a. concurrent leiomyosarcoma and basal cell carcinoma of the conjuctiva: a case report. asian j ophthalmol. 2008; 10: 401-3. 5. brannan so, cheung d, trotter s, tyler aj, reuser tq. conjunctival leiomyoma. am j ophthalmol. 2003; 136: 749-50. 6. van den broek pp, de faber jt, kliffen m, paridaens d. anterior orbital leiomyoma: possible pulley smooth muscle tumor. arch ophthalmol. 2005; 123: 1614. http://www.ncbi.nlm.nih.gov/pubmed?term=g%c3%bcnd%c3%bcz%20k%5bauthor%5d&cauthor=true&cauthor_uid=14998695 http://www.ncbi.nlm.nih.gov/pubmed?term=g%c3%bcnalp%20i%5bauthor%5d&cauthor=true&cauthor_uid=14998695 http://www.ncbi.nlm.nih.gov/pubmed?term=erden%20e%5bauthor%5d&cauthor=true&cauthor_uid=14998695 http://www.ncbi.nlm.nih.gov/pubmed?term=erekul%20s%5bauthor%5d&cauthor=true&cauthor_uid=14998695 http://www.ncbi.nlm.nih.gov/pubmed?term=guerriero%20s%5bauthor%5d&cauthor=true&cauthor_uid=21574810 http://www.ncbi.nlm.nih.gov/pubmed?term=sborgia%20a%5bauthor%5d&cauthor=true&cauthor_uid=21574810 http://www.ncbi.nlm.nih.gov/pubmed?term=giancipoli%20g%5bauthor%5d&cauthor=true&cauthor_uid=21574810 http://www.ncbi.nlm.nih.gov/pubmed?term=fiore%20mg%5bauthor%5d&cauthor=true&cauthor_uid=21574810 http://www.ncbi.nlm.nih.gov/pubmed?term=ross%20r%5bauthor%5d&cauthor=true&cauthor_uid=21574810 http://www.ncbi.nlm.nih.gov/pubmed?term=ross%20r%5bauthor%5d&cauthor=true&cauthor_uid=21574810 http://www.ncbi.nlm.nih.gov/pubmed?term=ross%20r%5bauthor%5d&cauthor=true&cauthor_uid=21574810 http://www.ncbi.nlm.nih.gov/pubmed?term=piscitelli%20d%5bauthor%5d&cauthor=true&cauthor_uid=21574810 http://www.ncbi.nlm.nih.gov/pubmed?term=brannan%20so%5bauthor%5d&cauthor=true&cauthor_uid=14516824 http://www.ncbi.nlm.nih.gov/pubmed?term=cheung%20d%5bauthor%5d&cauthor=true&cauthor_uid=14516824 http://www.ncbi.nlm.nih.gov/pubmed?term=trotter%20s%5bauthor%5d&cauthor=true&cauthor_uid=14516824 http://www.ncbi.nlm.nih.gov/pubmed?term=tyler%20aj%5bauthor%5d&cauthor=true&cauthor_uid=14516824 http://www.ncbi.nlm.nih.gov/pubmed?term=reuser%20tq%5bauthor%5d&cauthor=true&cauthor_uid=14516824 http://www.ncbi.nlm.nih.gov/pubmed?term=reuser%20tq%5bauthor%5d&cauthor=true&cauthor_uid=14516824 http://www.ncbi.nlm.nih.gov/pubmed?term=van%20den%20broek%20pp%5bauthor%5d&cauthor=true&cauthor_uid=16286632 http://www.ncbi.nlm.nih.gov/pubmed?term=de%20faber%20jt%5bauthor%5d&cauthor=true&cauthor_uid=16286632 http://www.ncbi.nlm.nih.gov/pubmed?term=kliffen%20m%5bauthor%5d&cauthor=true&cauthor_uid=16286632 http://www.ncbi.nlm.nih.gov/pubmed?term=paridaens%20d%5bauthor%5d&cauthor=true&cauthor_uid=16286632 http://www.ncbi.nlm.nih.gov/pubmed?term=paridaens%20d%5bauthor%5d&cauthor=true&cauthor_uid=16286632 http://www.ncbi.nlm.nih.gov/pubmed?term=paridaens%20d%5bauthor%5d&cauthor=true&cauthor_uid=16286632 microsoft word 7. mushtaq ahmad 206 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology original article visual outcome and complications of anterior chamber intraocular lens versus scleral fixated intraocular lens mushtaq ahmad, muhammad naeem, sofia iqbal, sanaullah khan pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mushtaq ahmad house no. 31b, street no 2, sector n4, phase 4, hayatabad, peshawar …..……………………….. purpose: to compare the visual outcome and complications associated with anterior chamber iol versus scleral fixated iol following cataract surgery with poor capsular support. material and methods: this interventional comparative study was conducted from april 2010 to december 2011 in the department of ophthalmology hayatabad medical complex peshawar. thirty two eyes were included in the study consisting of twenty eight patients. they were classified into 2 groups; group i: where 16 eyes underwent anterior chamber iols (aciols) implantation either primary or secondary and group ii: where 16 eyes underwent scleral fixated iols (sfiols) implantation either primary or secondary. patients were followed for one month, 3 months and 6 months. results: there was no statistically significant difference noted between the two groups after six months. bcva 6/6 – 6/9 in 25% preoperatively improved to 56.25% in group – i after six months postoperatively while in group-ii it improved from 31.25% to 56%. complications rate was analysed, corneal astigmatism > 1 diopter was noted 31.25% in group – i and 25% in group – ii. hyphaema / vitreous hemorrhage was 18.75%, iol decentration was 12.50% in group – ii, but no case recorded in group – i. conclusion: bcva improved in both groups with no significant differences in outcome in complicated cataract extraction with poor capsular support. however higher rate of complications were noted in aciols group as compared to sf iol. further large scale evaluation is need. he first intraocular lenses were introduced in cataract surgery by sir harold ridley in 19491. it became standard of care in the late 1980s. fixation of intraocular lenses in cases of insufficient or no capsular support is challenging and requires good surgical techniques to resolve different situations. in such a situation, the surgeon has four options, to leave the eye aphakic, to implant an anterior chamber intraocular lens (ac iol), to fixate a posterior chamber intraocular lens (pc iol) in the iris or to fixate a pc iol in the sclera. the potential issues of anisometropia, optical aberrations, and contact lens intolerance make aphakia a less-than-optimal solution in all but a few patients3. presently, there are five primary methods for dealing with iol requirements in the absence of capsular support, mainly depending on the preoperative status of the eye: flexible openloop aciols and iris claw aciols; iris-fixated retropupillary aciols; iris-sutured pciols and transscleral – sutured pciols. if both the iris and the capsule are absent or disrupted, sutured transscleral pciols are the only option2. it has been postulated that ac iol cause subclinical uveitis secondary to lens-tissue, which creates inflammatory products that could be directly toxic to the endothelium and angle and could also result in cystoid macular edema4. considerable controversy remains over the relative efficacy and safety of the different implantation t visual outcome and complications of aciol’s vs scleral fixated pc iol’s pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 207 approaches when capsular supportis absent. anterior chamber intra-ocular lens implantation is coming back into favor among some surgeons, thanks to improved, open loop aciol designs and re-emergence of the iris fixated claw iol. sizing is less critical with the flexible haptics of the open-loop aciols; as opposed to the more rigid or closed-loop aciol designs.5 several studies demonstrated improved results with these modern devices. nevertheless, concern remains that aciols are more damaging to the corneal endothelium than pciols. the modern aciol designs had decreased the complications which were associated with the closed-loop aciols but they have not been eliminated6. in 1986, malbran and colleagues were the first to describe scleral sulcus fixation of pc iols.7 in 2003, an american academy of ophthalmology sponsored report on iol implantation in the absence of capsular support after a thorough literature assessment, by wagoner and colleagues concluded that the scleral sutured posterior chamber iols were safe and effective in adults8. today, considerable controversy remains over the relative efficacy and safety of the different implantation approaches when capsular support is absent. material and methods this interventional comparative study was conducted from april 2010 to december 2011 in the department of ophthalmology hayatabad medical complex peshawar. thirty two eyes included of 28 patients and they were classified into 2 groups; group i: where 16 eyes underwent anterior chamber iols (aciols) implantation either primary or secondary and group ii: where 16 eyes underwent scleral fixated iols (sfiols) implantation either primary or secondary. indications for surgery included aphakia, subluxated lenses and cases with posterior capsular rents. exclusion criteria included iritis, uveitis, glaucoma, amblyopia, macular scar and patients with poor vision other than cataract. a structured proforma was used for each patient including demography, clinical history, investigations and complete ophthalmic examination. reason for failed pciol implantation, mean preoperative and postoperative snellen bcva recorded. surgery was carried out under local anaesthesia in adults and under general anaesthesia in children. surgical technique in group-i, large 6 to 9 mm incision was used, after the completion of surgery limited anterior vitrectomy and one superior pi done in each case and pupil was constricted with carbacol 0.01%. viscoelastic hydroxylpropylmethyl cellulose (hpmc) 2% injected to the anterior chamber. aciol with overall diameter 12.50 mm, optic diameter6.50 mm and with 115 a –constant implantation was performed either primary in complicated cataract surgeries or secondary in aphakic cases. corneal wound was stitched using interrupted 10/0 nylon sutures. in group-ii, limited conjunctival peritomy was carried out and 2 triangular scleral flaps 2/3rd of the scleral thickness and 180° apart were made at 3 and 9 o’clock with the base at the limbus. one side port was made for anterior chamber (ac) maintainer, viscoelastichydroxyl propyl methyl cellulose (hpmc) 2% was pushed into the anterior chamber. corneal incision was made from 6-9 mm and surgery was completed after limited anterior vitrectomy. viscoelastic pushed into the ac a 27-gauge needle was passed through a sclera at 0.7mm scleral bed from the limbus on one side and a 10/0 prolene suture on a straight needle through opposite scleral bed. the prolene suture needle was engaged into the 27 gauge needle in the peripupillary plan. the 27 gauge needle was withdrawn along with the prolene needle. the suture was drawn out through the dilated pupil and corneal incision. the suture was cut and each end tied to the haptics eyelets of the iol. sutures were pulled through the scleral bed and tied. scleral flaps were sutured with 10/0 nylon and conjunctiva with 7/0 vicryl. the corneal wound was stitched with 10/0 nylon interrupted sutures. postoperatively, topical antibiotics and steroid drops were used routinely for one month. patients were followed for one month, 3 months and 6 months. during each follow up visit bcva and complications recorded in both groups. results total 32 eyes of 28 patients were included in the study all of them had completed six months follow up. they were divided in to two groups group-i aciols group and group–ii sfiols group. the mean age of patients in aciol group was 57.30 ± 18.54 years and male: female ratio was 12:9 in the sfiol group, mean age was 57.35 ± 18.80 years; m: f ratio was 10:9. the pre and post-operative visual acuity was measured and there was no statistically significant difference noted between the two groups after six months. bcva 6/6-6/9 in 25% preoperatively improved to 56.25% in group-i after six months postoperatively while in group-ii it improved from 31.25% to 56% as shown in (table 1). mushtaq ahmad, et al 208 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology visual outcome and complications of aciol’s vs scleral fixated pc iol’s pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 209 complications rate was analysed as shown in table 2, corneal astigmatism, cystoid macular oedema and hyphaema / vitreous haemorrhage were more in group-i as compared to group-ii. intraocular pressure was recorded pre and postoperatively in both groups no significant change noted in pre and post-operative readings (table 3). discussion the surgical approach in this series was influenced by the specialty (vitreo-retina) and the preferences of the operating surgeon (as), but standardization was established regarding the scleral fixation itself, while the remainder of the procedure was determined by the case pathology and operative circumstances. the stability and centralization of the scleraly fixated iols in this study were excellent during the follow up period with no rotation or subluxation. the visual acuity significantly improved postoperatively. our results were comparable to ellakwa et al who showed no significant difference existed regarding the final visual outcome between anterior chamber (log mar=0.88) and scleral fixation iol (log mar=0.84) groups, also non significant difference existed regarding the final visual outcome between primary and secondary ac iol implantation, however higher postoperative visual acuities were detected in secondary sfiol. in group i, the most common complications were uveitis (35%), ocular hypertension (25%), cme (20%), retinal detachment in one case (5%) and endophthalmitis in one case (5%). in group ii, the most common complications were ocular hypertension (25%), retinal detachment (15%), cme (15%), suture erosion (15%), vitreous hemorrhage (10%), uveitis (5%) and endophthalmitis in one case (5%).9 our results were also comparable to the results of donaldson et al11, who showed that mean postoperative bcva 20/60 (0.5 log mar) in aciol group and 20/50 (0.4 log mar) in sfiol group with no statistically significant difference between both groups, donaldson et al10 study also recorded elevated iop in 39% of aciol group versus 42% of sfiol group with no statistically significant difference between the two groups which differs from our study in that percentage of ocular hypertension in aciol group was more than sfiol group. cme found at 12% of aciol group versus 10% of sfiol group with no statistically significant difference between the two groups that matches our results. a research done by sujata et al,11 showed that the mean post-operative log mar bcva was 0.75 in sfiol group and 0.52 in ac iol group with better bcva in aciol group. this difference was statistically significant (p = 0.0003). our study showed no statistically significant difference in the final bcva in both groups because at our study ac iol implantation was done by different surgeons not by a single surgeon besides sujata et al5 compared sf iol versus primary ac iol only. kwong et al,12 recorded better results from primary ac vs primary sclera – fixated iols in eyes with poor capsular support, log mar visual acuity averaged 0.322 in eyes that received an anterior chamber iol, significantly better than the sclera – fixated iol group, which had a mean visual acuity of 0.486 (p = 0.01). in the anterior chamber iol group, 71% of eyes achieved a snellen visual acuity of 20/40 or better compared with 47.2% of eyes in the scleral fixated iol group, in our study no statistically significant difference was found between primary ac vs. primary scleral – fixated iols. conclusion bcva improved in both groups with no significant differences in outcome in complicated cataract extraction with poor capsular support. however higher rate of complications were noted in aciols group as compared to sf iol. further large scale evaluation is needed. author’s affiliation dr. mushtaq ahmad registrar ophthalmology department hmc, peshawar dr. muhammad naeem postgraduate trainee ophthalmology department hmc, peshawar dr. sofia iqbal associate professor ophthalmology department, hayatabad medical complex, peshawar dr. sanaullah khan assistant professor bannu medical college bannu references 1. ridley h: intra-ocular acrylic lenses. trans ophthalmol soc uk. 1951, 71: 617–21. mushtaq ahmad, et al 210 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology 2. poor ym, lavin mj. techniques of intraocular lens suspension in the absence of capsular/zonular support. surv ophthalmol. 2005; 50: 429-62. 3. oh h, chu y, woong known o. surgical technique for suture fixation of a single piece hydrophilic acrylic intraocular lens in the absence of capsular support. j cataract refract surg. 2007; 33: 962-5. 4. dick hb, augustin aj. lens implant selection with absence of capsular support. curr opin ophthalmol. 2001; 12: 47-57. 5. apple dj, brems rn, park rb. anterior chamber lenses. part i: complications and pathology and a review of designs. j cataract refract surg. 1987; 13: 157-74 6. auffarth gu, wesendahl ta, brown sj. are there acceptable anterior chamber intra-ocular lenses for clinical use in the 1990s? an analysis of 4104 explanted anterior chamber intra-ocular lenses. ophthalmology. 1994, 101: 1913–22. 7. malbran es, malbran e jr, negri i. lens guide suture for transport and fixation in secondary iol implantation after intracapsular extraction. int ophthalmol. 1986; 9: 151-60. 8. wagoner md, cox ta, ariyasu rg, rt al. intraocular lens implantation in the absence of capsular support: a report by the american academy of ophthalmology. ophthalmology. 2003; 110: 840–59. 9. ellakwa af, hegazy ka, farahat hg, et al. anterior chamber intraocular lens versus scleral fixated intraocular lens in cases with insufficient capsular support. mmj july 2010; 23 :5– 12 10. donaldson ke, gorscak jj, budenzdl. anterior chamber and sutured posterior chamber intraocular lenses in eyes with poor capsular support. j cataract refract surg. 2005; 31: 03–9. 11. sujata s, rajamohan m, prabhakar. comparison of outcomes of scleral fixated versus anterior chamber iols in complicated cataract surgeries, aioc 2008 proceedings, cataract session ii. 2008; 2: 91-3. 12. kwong yy, yuen kl, lam rf. comparison of outcomes of primary scleral – fixated versus primary anterior chamber intraocular lens implantation in complicated cataract surgeries. ophthalmology. 2007; 114: 1: 80–5. pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 145 original article pterygium excision with adjunctive subconjunctival bevacizumab narain das, shakir zafar, asma shams pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: narain das mbbs, fcps (ophthalmology) assistant professor smbbmc lyari, karachi e-mail: narainpagarani@yahoo.com …..……………………….. purpose: to analyze the efficacy of bevacizumab in primary pterygium excision. study design: randomized controlled clinical trial. place and duration of study: study was done at shaheed mohtarma benazir bhutto medical college, lyari general hospital, karachi. duration of study was six months from 15 th october, 2016 to 15 th april, 2017. material and methods: 34 eyes of 34 patients (males 22, females 12) with age range from 35 to 60 years (mean age of 45 years sd ± 12.2 years) were included. all patients of primary pterygium were selected and divided into two groups, group i underwent bevacizumab therapy (0.2 ml which is equal to 5 mg) and group ii placebo (0.2 ml balanced salt solution) given by sub conjunctival injection. after completing all necessary stages of surgery, 0.2 ml (5 mg) bevacizumab was injected in the inferior fornix. all patients were followed for 6 months. postoperative complications and recurrence were noted. recurrence was defined as any fibrovascular extension that passed the corneal limbus by more than 1 mm. results: the average time for each procedure was 30 ± 10 minutes. during follow up period, the recurrence was noted in 5 patients. 2 eyes out of 17 (11.76%) in group i and 3 eyes out of 17 (17.64%) in group ii. postoperative conjunctival vascularization occurred in 1 patient in group i and 2 patients in group ii and subconjunctival hemorrhage occurred in 4 patients in group i and 2 patients in group ii while no other ocular complications were observed in any group. conclusion: bevacizumab injection subconjunctivaly showed statistically no significant effect on recurrence of pterygium and having no significant adverse effects. key words: subconjunctival injection, bevacizumab, pterygium excision. pterygium is a triangular fibro vascular sub epithelial ingrowth of degenerative bulbar conjunctival tissue over the limbus onto the cornea”. pterygium typically develops in patients who have been exposed to hot climates, chronic dryness and ultraviolet radiations1. the pathogenesis of pterygia is so far not known2,3. various factors such as genetic and many immunological factors play a vital role in the disease progression4,5. jin j et al expressed that pterygium contains increased levels of vegf and decreased levels of pigment epithelium-derived factor (pedf) and angiogenic inhibitor. this changed ratio leads to the development of pterygia6. the treatment of pterygium is controversial since pterygium is composed of proliferating fibro vascular tissue, its progression requires neovascularization.7 a mailto:narainpagarani@yahoo.com narain das, et al 146 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology mitomycin-c, 5-fluorouracil, corticosteroids and beta irradiations have been tried along with pterygium excision to prevent recurrence of pterygia8,9. in the past, many aseptic techniques were used for removal of pterygium such as horse hair and threads etc10. bevacizumab (avastin; roche, usa) is a recombinant humanized monoclonal antibody. it is an inhibitor of vegf, which interferes with the growth of endothelial cells. this drug has been tried off-label in neovascular ocular diseases with timely good results1113. bevacizumab pharmacokinetics are quite different i.e. the dose does not cause increase in efficacy but rather it increases its half-life 14. this was the main reason behind the usage of 5 mg (bevacizumab 3 times level of normal dose) subconjunctivaly after primary excision of pterygium, as there was altering data regarding its dose, the current study did not observe any local or systemic side effect15-16. after extensive literature search, the mechanism of action of bevacizumab in pterygium is not well understood. however, the longest reported duration of action is achieved via intravitreal route17. material and methods during the period of 15 october 2016 to 15 april 2017, this randomized placebo controlled clinical trial study was conducted at the shaheed mohtarma benazir bhutto medical college lyari (smbbmcl) and sindh government lyari general hospital. written informed consent was taken from all the patients. 34 eyes of 34 patients were selected and were randomly divided into two groups, group i (bevacizumab) and group ii, balanced salt solution (bss). pterygium more than 3 mm involving visual axis causing decreased visual acuity or cosmetic disfigurement were included in our study. patients with a history of myocardial infarction and vascular thrombosis in the last six months and allergic to bevacizumab were excluded. patients with diabetes, pregnancy, lactation, glaucoma, regurgitation from lacrimal puncta indicating nasolacrimal duct block, any ocular disease or inflammation, autoimmune disorders and previous eye surgery were not included. following criteria for bevacizumab allergy assessment was applied. 1. all patients were kept in ward for six hours after procedure for observing blood pressure, hypersensitivity reactions such as localized flushes, urticaria, dyspnoea and angioedema. 2. hypertension was managed with anti hypertensive e.g. calcium channel blockers after consultation with physician. 3. emergency trolley containing inj: solucortef, inj: chlorpheniramine maleate, inj: adrenaline, airway tube, ambo bag, i/v cannula /normal saline drip, disposable syringes and hand gloves were ready to deal with any emergency. we recorded all patients’ demographic data, bestcorrected visual acuity, manifest refraction, keratometry reading, and intra ocular pressure by goldmann applanation tonometer, detailed slit lamp examination including horizontal length and grading of pterygium in mm and fundus examination. all patients were examined before and after surgery on each visit on day 1, 7, 30, 90 and 180. post injection complications such as sub conjunctival hemorrhage, corneal abrasion infection etc were analyzed if observed. in both groups, excision of pterygium was done via conjunctival flap method. group i was injected with 5 mg / 0.2 ml (2.5 mg / 0.1 ml) of bevacizumab and group ii was injected with 0.2 ml of bss at the end of surgery. proparacaine hcl was used as a local anesthetic. sub conjunctival 2% lidocaine with 1:100000 adrenaline was used in area of pterygium. after completing all necessary stages of surgery, 0.2 ml, (5 mg) bevacizumab was injected in the inferior fornix. dexamethasone 1 mg and moxifloxacin 5 mg was given topically qid (quarter in die) with hydroxypropyl methyl cellulose qid for 4 weeks. results the study group comprised 34 eyes of 34 patients (males 22, females 12) with primary pterygium (there were 11 males and 6 females in each group). there was no statistically significant difference regarding the age or gender between the groups (p > 0.05). visual acuity of all the patients in the study after procedure was improved or maintained without further deterioration of vision even in a single patient (table 2). the difference between the groups relating to pre operative visual acuity, daily sun exposure, pterygium size and type, keratometric readings or intra ocular pressure was not significant (p > 0.05). during follow up period recurrence was noted in five patients, 2 eyes out of 17 (11.76%) in group 1 and 3 eyes out of 17 (17.64%) in group 2 (table 3). pterygium excision with adjunctive subconjunctival bevacizumab pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 147 postoperative conjunctival vascularization occurred in three patients (8.82%) out of 34 patients (1 in group i and 2 in groups ii), which was observed in the recurrent cases. apart from sub conjunctival hemorrhage which was seen in four patients in group i and two patients in group ii, which resolved within two weeks. table 1: demographic data of (34 patients). gender eye age no. & (%) of patients male female right left < 45 years 19 (55.8%) 22 (64.7%) 12 (35.3%) 12 (35.3%) 22 (64.7%) > 45 years 15 (44.4%) table 2: comparison of the pre-operative and the post-operative visual acuity of 34 eyes studied. visual acuity pre-operative patients post-operative patients 6/6 10 19 6/9 11 09 6/12 08 04 6/18 03 02 6/60 02 00 table 3: recurrence of pterygium between two groups. groups total patients recurrence group i (bevacizumab group) 17 2 eyes (11.76%) group ii (bss group) 17 3 eyes (17.64%) no corneal abrasion, infection, persistent epithelial defect and uveitis were noted after surgery (table 4). table 4: ocular complications. complications group i group ii total sub conjunctival hemorrhage 04 02 06 conjunctival vascularization 01 02 03 ocular surface toxicity 00 00 00 corneal abrasion 00 00 00 persistent epithelial defect 00 00 00 infection 00 00 00 uveitis 00 00 00 discussion fibrovascular proliferation and inflammation play a pivotal role in the pathogenesis of pterygium, which is a degenerative process. the extent and grade of pterygium seem to predict recurrences after surgery quite reliably18. many immunological and genetic factors have been found in the progression of the disease4,5. the development of pterygium depends upon the imbalance of angiogenic and anti-angiogenic factors6. the findings of abundant levels of vegf in pterygium may lead to the use of anti vegf therapy like bevacizumab, in regressing local blood vessels and size of pterygium at a statistically significant level. the therapeutic effects of bevacizumab are not well understood to date mainly due to decrease in sample size and lack of randomized control trials. the present aim of our study is to use anti vegf therapy in the treatment of primary pterygium in pakistani population. however the current study have shown statistically, no beneficial effect of sub conjunctival bevacizumab (2.5 mg / 0.1 ml) on preventing the narain das, et al 148 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology recurrence of pterygium in given sample size over six months duration like study done by razeghinejad mr et al19. in this study they used a total of 7.5 mg subconjunctival bevacizumab. 5 mg / 0.2 ml on the day of surgery and 2.5 mg / 0.1 ml on the fourth day after surgery. this is comparable to our study in which we used a total of 2.5 mg / 0.1 ml of bevacizumab for only one time. although studies by rashid omar et al and alhammami et al showed that sub-conjunctival bevacizumab reduces size and recurrence rate of pterygium20, 21. like our study, the researchers in their studies did not found statistically significant ocular complications and allergies. another researcher oguz et al in his study found decreased recurrence rate of pterygium22. mohammad-reza et al, in their study found clinically significant effect of sub conjunctival bevacizumab injection on pterygium recurrence but not statistically 23. the current study as seen in table 04 did not observe any local ocular complications and allergies statistically like ocular surface toxicity, corneal abrasion, persistent epithelial defect and infection. this was really an astonishing finding in contrast to finding of kim et al 24, who found spontaneous loss of epithelial integrity in excess percentage. in their study, they used high concentration (1.25%) of bevacizumab topically twice daily for two months. the findings are impactful as it is one time use and less in complications. this clearly indicates that the safety of topical bevacizumab is inversely proportional to the duration of the treatment. so, from our study it is seen that single per operative subconjunctival injection of bevacizumab can be safely used without significant ocular complications and allergies. it decreases recurrence rate of primary pterygium, but this decrease was not statistically significant. more over bevacizumab has been observed in six human trials to be safe during subconjunctival administration; it helps in halting fibrovascular proliferative process by stopping g1 and g0 phase and initiating apoptosis. our current study showed effect of bevacizumab on pterygium proliferation and recurrence is not significant statistically. a recent study demonstrated no recurrence of pterygium in the duration of six years of the subconjunctival bevacizumab injection while in the current we have not observed such finding maybe due to the lesser duration of study. in a study done by hirst lw et al, he defined the time interval required to follow the patients after pterygium excision to recurrence of the disease should be acceptably one year25. in the current study, follow up period was six months. it is suggested that in future for promising and clarification of results longer follow up and increased sample size is needed. conclusion bevacizumab injection given sub conjunctival, showed statistically no significant effect on recurrence of pterygium and no significant adverse effects. author’s affiliation dr. narain das (nd) mbbs, fcps (ophthalmology) assistant professor, smbbmc lyari, karachi. dr. shakir zafar (sz) mbbs, fcps (ophthalmology) associate professor united medical & dental college, karachi. dr. asma shams (as) mbbs, fcps (ophthalmology) senior registrar, smbbmc lyari, karachi. role of authors dr. narain das performed all surgeries. dr. shakir zafar manuscript writing and language correction. dr. asma shams data collection and statistical analysis. references 1. kanski jj. conjunctiva. in kanski jj clinical ophthalmology 5th edition new york butterworth heinemann, 2003: 62-94. 2. di girolamo n, chui j, coroneo mt, wakefield d. pathogenesis of pterygia: role of cytokines, growth factors, and matrix metalloproteinase’s. prog retin eye res. 2004; 23: 195-228. 3. van setten g, aspiotis m, blalock td, grotendorst g, schultz g. connective tissue growth factor in pterygium: simultaneous presence with vascular endothelial growth factor-possible contributing factor to conjunctival scarring. graefes arch clin exp ophthalmol. 2003; 241: 135-139. pterygium excision with adjunctive subconjunctival bevacizumab pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 149 4. solomon a, grueterich m, li dq, meller d, lee sb, et al. over expression of insulin-like growth factor – binding protein-2 in pterygium body fibroblasts. invest ophthalmol vis sci. 2003; 44: 573-580. 5. miani r, collision dj, maidment jm, davies pd, wormstone im. pterygial derived fibroblasts express functionally active histamine and epidermal growth factor receptors, exp eye res. 2002; 74: 237-244. 6. jin j, guan m, sima j, gao g, zhang m, et al. decreased pigment epithelium-derived factor and increased vascular endothelial growth factor levels in pterygia. cornea, 2003; 22: 473-477. 7. hurwitz h, fehrenbacher l, novotny w, cartwright t, hainsworth j, et al. bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. n engl j med. 2004; 350: 2335-2342. 8. ang lp, chua jl, tan dt. current concepts and techniques in pterygium treatment. curr opin ophthalmol. 2007; 18: 308-313. 9. frucht-prey j, raiskup f, ilsar m, landau d, orucov f, solomon a. conjunctival autografting combined with low-dose mitomycin c for prevention of primary pterygium recurrence. am j ophthalmol. 2006; 141: 1044-1050. 10. hirst lw. the treatment of pterygium. surv ophthalmol. 2003; 48: 145-148. 11. ferrara n, hillan kj, novotny w. bevacizumab (avastin), a humanized anti-vegf monoclonal antibody for cancer therapy. biochem biophys res commun. 2005; 333 (2): 328-335. 12. mutlu fm, sobaci g, tatar t, yildirim e. a comparative study of recurrent pterygium surgery: limbal conjunctival autograft transplantation versus mitomycin c with conjunctival flap. ophthalmology, 1999; 106: 817-821. 13. hosseini h, nejabat m, khalili mr. bevacizumab (avastin) as a potential novel adjunct in the management of pterygia. med hypotheses, 2007; 69: 925-927. 14. meyer ch, krohne tu, holz fg. intraocular pharmacokinetics after a single intravitreal injection of 1.5 mg versus 3.0 mg of bevacizumab in humans. retina, 2011; 31: 1877-1884. 15. lekhanont k, patarakittam t, thongphiew p, suwanapichon o, hanutsaha p. randomized controlled trial of subconjunctival bevacizumab injection in impending recurrent pterygium: a pilot study. cornea, 2012; 31: 155-161. 16. enkvetchakul o, thanathanee o, rangsin r, lekhanont k, suwan-apichon o. a randomized controlled trial of intralesional bevacizumab injection on primary pterygium: preliminary results. cornea, 2011; 30: 1213-1218. 17. krohne tu, eter n, holz fg. meyer ch. intraocular pharmacokinetics of bevacizumab after a single intravitreal injection in humans. am j ophthalmol. 2008; 146: 508-512. 18. tan dth, chee sp, dear kbg, lim as. effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. arch ophthalmol. 1997; 115 (10): 1235-1240. 19. razeghinejad mr, hosseini h, ahmadi f, rahat f, eghbal h. preliminary results of subconjunctival bevacizumab in primary pterygium excision. ophthalmic res. 2010; 43: 134-138. 20. omar r, rimsha s, waseem r, banday ra, shahzada bs, assif si. role of subconjunctival bevacizumab in treatment of pterygium, pak j ophthalmol. 2012; vol. 28 no. 3. 21. alhammami h, farhood q, shuber h. subconjunctival bevacizumab injection in treatment of recurrent pterygium, j clin exp ophthalmol. 2013; 4: 267. 22. oguz h, kilitc; oglu a, yasar m. limbal conjunctival using autografting for preventive recurrences after pterygium excision. ophthalmol res. 2010; 43: 134-8. 23. mohammad-reza razeghinejad, md and mohammad banifatemi, md. subconjunctival bevacizumab for primary pterygium excision; j ophthalmic vis res. 2014; 9 (1): 22-23. 24. kim sw, ha bj, kim ek, tchan h, km ti. the effect of topical bevacizumab on corneal neovascularization. ophthalmology, 2008; 115: e33-e38. 25. hirst lw, sebban a, chant d. pterygium recurrence time, ophthalmology, 1994; 101: 755-8. microsoft word 8. olukorede o.adenuga 144 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology original article pattern of eye diseases in an air force hospital in nigeria olukorede o. adenuga, oluyinka j. samuel pak j ophthalmol 2012, vol. 28 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: olukorede o. adenuga deptt. of ophthalmology, jos university teaching hospital, jos plateau state, nigeria. …..……………………….. purpose: the aim of the study was to determine the pattern of eye diseases among armed forces personnel and other patients attending the eye clinic of the 347 nigeria air force hospital, jos and to make recommendations to the hospital management for improvements in the clinic in respect of manpower and equipments. material and methods: a prospective study involving all new cases presenting to the eye clinic of the 347 nigeria air force hospital, jos over a 42 month period from october 2008 to march 2012. results: a total of 1865 patients were seen during the study period with a male to female ratio of 1:1.2. the mean age was 30.46 years (sd 18.3). majority of those seen were civilians (59%) with armed forces personnel accounting for 13%. the commonest eye diseases were allergic conjunctivitis (42%), refractive errors and presbyopia (33%) and degenerative conjuctival diseases (5%). among armed forces personnel, refractive error and presbyopia was the commonest disorder (43%). conclusion: the pattern of eye diseases observed in the armed forces personnel was similar to the civilian population. the eye clinic will require additional manpower and an optical laboratory is recommended to address the spectacle needs of patients with refractive errors. he causes of blindness and the pattern of eye diseases differ in developing and developed countries and often in communities1. a study of the pattern of ocular diseases is very important because while some eye conditions are just causes of ocular morbidity others invariably lead to blindness2. in nigeria, studies carried out in the southern part of the country on the pattern of ocular diseases in children3,4 and young adults5 have shown that refractive errors, allergic conjunctivitis are the commonest causes of ocular morbidity. the 347 nigeria air force (naf) hospital treats armed forces personnel and ex-servicemen and their families, students of the two air force secondary schools within the city as well as the general public. the hospital is located in the nigeria air force base, jos in north central nigeria. the eye clinic, which was established in 2006 is managed by a visiting consultant ophthalmologist who runs the clinic twice a week. the clinic is equipped with a slit lamp, an applanation tonometer and a trial lens set. the aim of this study was to determine the pattern of eye diseases among patients presenting to the air force hospital, jos and specifically among armed forces personnel and to make recommendations to the hospital management for improvements in the clinic in respect of equipments and manpower. to the best of the authors’ knowledge, no study has been conducted on the pattern of eye diseases among armed forces personnel in the country. the information from this study will therefore be of assistance in planning for eye health care delivery in armed forces hospitals across the country. material and methods this is a prospective study of all new patients seen at the eye clinic of the 347 naf hospital, jos in northcentral nigeria between october 2008 and march 2012. t pattern of eye diseases in an air force hospital in nigeria pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 145 the patients were first seen in the general outpatient department before being referred to the eye clinic on account of ocular symptoms. all patients were seen by one consultant ophthalmologist who runs the eye clinic alone twice a week. for each patient the distance and near visual acuity was recorded using the snellen or illiterate e chart and near chart except when this was not possible e.g. in infants and pre-school children. the anterior segment was examined with a torch and loupe or with the slit lamp. posterior segment examination was done using a direct ophthalmoscope with the pupils dilated, if found necessary. treatment was offered following a diagnosis. refractions were also done by the ophthalmologist when va was less than 6/9. patients who required spectacles were referred to optical laboratories outside the hospital as the hospital did not have one. a register was opened and the names of the patients seen, the hospital number, age, sex and diagnosis were recorded. the patients were classified as civilian, armed forces personnel (both serving and ex-service men), and family members of armed forces personnel and student of the air force schools. any person less than 18yrs of age was classified as a child. data analysis was done using epi info 2002 version 3.2.2. results mean age of the patients seen was 30.5 years (range 8 days to 95 years, sd 18.32). the mean age for females was 30.5 years while the mean age for males was 30.4 years. children seen were 618 (33%) in number while adults were 1247 (67%). this difference was statistically significant using the chi square test with a p value of less than 0.05. there were 857 males (46%) and 1008 (54%) females giving a male to female ratio of 1:1.2. the difference was not statistically significant with a p value of 0.25. in the paediatric age group, 297 (48%) of those seen were males while there were 321(52%) females. adults also had a preponderance of females accounting for 687 (55%) of adults seen. table 1, shows the age and sex distribution of the patients seen. majority of the patients were civilians (1108) accounting for 59.4% while armed forces personnel (249) accounted for 13.4%. family members of personnel were 351 (19%) while students from the air force schools were 157 (8%). the commonest eye disorder (table 2) encountered was allergic conjunctivitis (42%). this was followed by refractive errors and presbyopia (34%). eighty one percent of cases of cataract and 74% of cases of glaucoma occurred in those 40yrs and above. when compared with those below 40 years of age, the differences were statistically significant with p values of less than 0.05 using the chi square test. among armed forces personnel the leading eye diseases were refractive error and presbyopia 107 (43%) and allergic conjunctivitis 79 (32%). in children the commonest eye disorders were allergic conjunctivitis 392 (63%), refractive errors 127 (21%), infective conjunctivitis 39 (6%) and blunt trauma 17 (2.8%). there was no significant difference in the prevalence of allergic conjunctivitis and refractive errors between the sexes with p values of 0.15 and 0.08 respectively. however, ocular trauma and infective conjunctivitis were significantly higher in boys with p values of less than 0.05 using the chi square test. in adults the commonest ocular disorder was refractive errors and presbyopia 501 (40%). two hundred and fifty (50%) of these were cases of presbyopia only and 67 (13%) presbyopia with refractive error. women accounted for 55% of the cases of presbyopia and men 45%. this difference was not statistically significant with a p value of 0.15. other common eye disorders seen in adults were allergic conjunctivitis 396 (32%), degenerative conjunctival disorders 97 (8%), cataract 65 (5%), glaucoma 49 (4%). allergic conjunctivitis was significantly higher in women with a p value of less than 0.05. table 3 shows the age distribution of the major eye disorders seen. discussion this study reveals a slight female preponderance. this contrasts with the general observation that fewer females are seen in medical clinics than males in the developing countries1. this may be due to the close proximity of the hospital to the barracks and residences of the air force personnel and the location of the hospital close to the city centre making it easily accessible to women who do not have to depend on their spouses or relations to bring them to the hospital. a similar study in south west nigeria also reported a female preponderance6. more adults had ocular problems in this study than children. ajaiyeoba7 reported a similar trend though the difference observed in his study was not statistically significant. a likely explanation for this is that children may not be able to adequately articulate their problems and hence may not present to the hospital until the features are prominent enough to be noticed by their parents or guardians. olukorede o. adenuga, et al 146 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology allergic conjunctivitis was the commonest ocular morbidity in this study with an incidence of 42%. other studies reported it as the third leading cause of ocular morbidity with prevalence of less than 20%5,6,8. the dusty and windy nature of the weather in northern nigeria may be responsible for the high occurrence in this study. it was also the major cause of eye disease in the paediatric age group in this series. this agrees with other hospital based studies as well as school eye health surveys that have also reported it as either the commonest2,4,9 or the second most common3,10-12 cause of eye disease in children. uncorrected refractive errors constitute important ocular health problems across the globe13. it has impact on quality of life, and has educational and socioeconomic consequences14. in this present study it was the second commonest cause of ocular morbidity. this is in agreement with previous reports6,8. studies24,10-12 have also shown that a major cause of eye disorder in children and without school health services that regularly screen for refractive errors many children with refractive errors will not be detected. a study on the prevalence of refractive errors in children in iran revealed that many of the children were not aware of their refractive errors15. presbyopia was the commonest refractive condition among those 30 years and above in this study. this is similar to observations by other authors5,14. a female preponderance for presbyopia as observed in this study is also in agreement with studies by patel and west16 and ayanniyi et al14. the youngest age of presentation of 32 years in this study compares with 30 years reported by ayanniyi et al14 pattern of eye diseases in an air force hospital in nigeria pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 147 and 33 years reported by benice and emmanuel17. africans been reported to have a younger age of onset as well as more severe presbyopia16. degenerative conjunctival diseases (pterygium and pingueculum) were the third leading cause of ocular morbidity in this series. pterygium is particularly prevalent in tropical and subtropical areas of the world18 with chronic ultraviolet light exposure attributed as a major cause19. our finding compares with 2% reported by amadi et al8 in south east nigeria. cataract and glaucoma had prevalence of 3.75% and 2.65% respectively in this series. similarly amadi et al8 reported less than 5% for both disease conditions. adeoye and omotoye6 however reported higher figures of 26% for cataract and 10.9% for glaucoma in a similar study in south west nigeria. this difference may due to the fact that their study had a mean age of 52 years while the mean age for this study was 30.5 years. both disease conditions are commoner with increasing age and in this study the prevalence was statistically greater in those aged 40yrs and above. ocular trauma has recently been highlighted as an important cause of visual morbidity20. even though the overall prevalence in this study was less than 3%, it was the fourth leading cause of ocular morbidity in children. this compares favourably with other studies in the country conducted in children, which also reported ocular trauma as the third4,21 and fourth10 major cause of ocular morbidity. a male preponderance as seen in this study is consistent with previous observations by other authors20,22,23. majority of the cases of eye trauma were blunt injuries. this is also in agreement with findings in other studies11,20,24. our experience on the pattern of eye diseases among the armed forces compares favourably with a study conducted in an army hospital in nepal25 where conjunctival and sclera disorders, refractive errors and glaucoma were the most common ocular disorders among regular army personnel. similarly, nowak et al25 observed that the commonest ocular disorder in candidates and members of the polish military service was refractive error. however, the other major ocular disorders seen in the polish study were not observed among the armed forces personnel in this series. these are colour vision disturbances and strabismus. in washignton27, the most common ocular diseases and non-battle injuries seen in military personnel were uveitis, retinal detachment, infectious keratitis and choroidal neovascularization. this contrasts with our observation and environmental and racial factors may account for these differences. in conclusion, the leading causes of eye disease in this study were allergic conjunctivitis, refractive error and presbyopia and degenerative conjunctival disorders. the pattern of diseases observed among armed forces personnel was similar to the civilian patients. the high prevalence of refractive errors and presbyopia indicate that the hospital will require an optometrist as well as an optical laboratory to address the spectacle needs of patients with these conditions. this will not only improve service delivery in the eye clinic but it will also serve as a source of revenue generation for the hospital. author’s affiliation dr. olukorede o. adenuga consultant ophthalmologist department of ophthalmology jos university teaching hospital jos plateau state, nigeria. dr. oluyinka j. samuel medical officer 347 naf hospital jos, nigeria, reference 1. kawuma m. eye diseases and blindness in adjumani refugee settlement camps, uganda. east afr med j. 2000; 77: 580-2. 2. ajaiyeoba aa, isawumi ma, adeoye ao, et al. prevalence and causes of eye diseases amongst students in south-western nigeria. annals of african medicine. 2006; 5; 197-203. 3. adio ao, alikor a, awoyesuku e. survey of pediatric ophthalmic diagnoses in a teaching hospital in nigeria. niger j med. 2011; 20: 105-8. 4. bodunde ot, onabolu oo. childhood eye diseases in sagamu. nig journal of ophthalmol. 2004; 12: 6-9. 5. nwosu snn. ocular problems of young adults in rural nigeria. int ophthalmol. 1998; 22: 259-63. 6. adeoye ao, omotoye oj. eye disease in wesley guild hospital, ilesa, nigeria. afr j med med sci. 2007; 36: 377-80. 7. ajaiyeoba ai, scott sc. risk factors associated with eye diseases in ibadan, nigeria. african journal of biomedical research. 2002: 5: 1-3. 8. amadi an, nwankwo bo, ibe ai, et al. common ocular problems in aba metropolis of abia state, eastern nigeria. pak. j. soc. sci. 2009; 6: 32-5. 9. sethi s, sethi mj, saeed n, et al. pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital. pak j ophthalmol. 2008; 24: 166-70. 10. ajaiyeoba ai. childhood eye diseases in ibadan. afr j med med sci. 1994; 23: 227-31. 11. onakpoya oh, adeoye ao. childhood eye diseases in southwestern nigeria: a tertiary hospital study. clinics. 2009; 64: 947-52. olukorede o. adenuga, et al 148 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology 12. abah er, oladigbolu kk, samaila e, et al. ocular disorders in children in zaria children's school. niger j clin pract. 2011; 14: 473-6. 13. dandona l, dandona r, naduvilath tj, et al. burden of moderate visual impairment in an urban population in southern india. ophthalmol. 1999; 106: 497-504. 14. ayaniniyi aa, fadamiro co, adeyemi ja, et al. common refractive errors among the ekitis of southwestern nigeria. j. med. med. sci. 2010; 1: 401-6. 15. khalaj m, gasemi m, zeidi im. prevalence of refractive errors in primary school children (7-15 years) of qazvin city. european journal of scientific research. 2009; 28: 174-85. 16. patel i, west sk. presbyopia: prevalence, impact, and interventions. comm. eye health j. 2007; 20: 40-1. 17. bernice o, emmanuel os. risk factors for early presbyopia in nigerians. nigerian journal of surgical sciences. 2006; 16: 7-11. 18. varssano d, michaeli-cohen a, loewenstein a. excision of pterygium and conjunctival autograft. isr med assoc j. 2002; 4: 1097-1100. 19. bradley jc, yang w, bradley rh, et al. the science of pterygia. br j ophthalmol. 2010; 94: 815-20. 20. asaminew t, gelaw y, alemseged f. a 2-year review of ocular trauma in jimma university specialized hospital. ethiop j health. 2009; 19: 67-73. 21. ezegwui ir, onwasigwe en. pattern of eye disease in children at abakaliki, nigeria. int j ophthalmol. 2005; 5: 1128-30. 22. adeoye ao. eye injuries in the young in ile ife, nigeria. nig j med. 2002; 11: 26-8. 23. macewena cj, bainesa ps, desaib p. eye injuries in children: the current picture br j ophthalmol. 1999; 83: 933-6. 24. wade pd, adenuga oo. visual outcome following management of ocular injury; a ten year review of cases in jos university teaching hospital. jos journal of medicine. 2006; 1: 9-11. 25. rajkarnikar s, gurung a, bist rr, et al. pattern of ophthalmological diseases in the patients of shree birenda hospital. medical journal of shree birenda hospital. 2010; 9: 30-7. 26. nowak ms, goś r, smigielski j. epidemiology of ocular diseases-a review of medical examinations from the area of military medical commission in lodz. klin oczna. 2009; 111: 42-5. 27. psolka m, bower ks, brooks db, et al. ocular diseases and non-battle injuries seen at a tertiary care medical center during the global war on terrorism. mil med. 2007; 172: 491-7. pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 237 original article frequency of hypertensive retinopathy, on the basis of imtiaz's grading system, at larkana pakistan syed imtiaz ali shah, huda fatima, azizullah jalbani, shujaat ali shah, partab rai, darikta dargai shaikh pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syed imtiaz ali shah professor of ophthalmology chandka medical college/smbb medical university larkana. e-mail: syedimtiazalinaqvi@yahoo.com …..……………………….. purpose: to determine the frequency of hypertensive retinopathy on the basis of “imtiaz's grading system of hypertensive retinopathy”, at larkana pakistan. study design: case series study. place and duration of study: department of ophthalmology and medical unit 1 chandka medical college hospital larkana, pakistan from january 2016 to january 2018. material and methods: this study was conducted from january 2016 to january 2018 on 288 clinically diagnosed patients of hypertension by at least two senior consultants simultaneously and selected in accordance with inclusion and exclusion criteria. a standard proforma was filled in for every patient. complete clinical examination including fundoscopy and blood pressure level was recorded. spss version 20 was used for data entry and analysis. results: utilizing imtiaz's grading system of hypertensive retinopathy, out of the total 288 patients, 87 (30.21%) had hypertensive retinopathy. there were 39 (44.83%) male and 48 (55.17%) female patients. there were 51 (58.62%) patients who had grade i hypertensive retinopathy, 19 (21.84%) patients had grade ii hypertensive retinopathy and 17 (19.54%) patients had grade iii hypertensive retinopathy. there were 83.9% patients presenting with headache, 35.6% complained of blurred vision, 17.2% patients complained of floaters, 8% had diplopia, 5.7% patients complained of pain in the eyes and 10.3% patients presented with transient visual loss (amaurosis fugax). conclusion: early detection and management of hypertension and its systemic complications to prolong the life span of hypertensive patients, is possible if symptoms are given importance towards diagnosis of hypertension. keywords: hypertensive retinopathy, hypertension, headache, diplopia. ypertensive retinopathy not only causes damage to eyesight but its presence is strongly associated with cardiovascular disease1. the increasing incidence of hypertension in the global community i.e. at the start of twenty first century more than a quarter of the world‟s population is suffering from hypertension2. other vital organs of the body involved include kidneys and central nervous system, the most common part of the human body being involved in hypertension is retina3. h mailto:syedimtiazalinaqvi@yahoo.com syed imtiaz ali shah, et al 238 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology normal view of the retinal vessels visible on ophthalmoscopy is formed by the reflection from the interface between the blood column and vessel wall4.with persistently raised blood pressure leading to sclerosis and hyalinization of vessel walls, the appearance of retinal vessels changes first to redbrown (copper wiring) and then to complete sheathing (silver wiring) and focal areas of narrowing develop in them due to vascular spasm followed by fibrosis5. sclerosis upon sustained hypertension may shorten or elongate the retinal arterioles which may consequently lead to deflection of the veins at the common sheath changing the course of the veins (salus sign)6. the thickened wall of retinal arteriole in hypertension leads to compression of vein at the arteriovenous crossing resulting in dilated vein peripheral to crossing, arteriovenous nicking, known as the gunn sign4. the rationale of the study was to introduce a new grading system of hypertensive retinopathy which describes three grades of hypertensive retinopathy on the basis of retinal signs of hypertensive retinopathy and associated systemic symptoms7. this grading system was chosen for this study on the basis of the fact that it is based on both signs and symptoms contrary to other available grading systems of hypertensive retinopathy which are based on signs only8, 9,10,11,12. the purpose of this study was to determine the frequency of hypertensive retinopathy on the basis of “imtiaz's grading system of hypertensive retinopathy” in this part of pakistan for the first time. material and methods a total of 288 diagnosed patients of essential hypertension (with persistently raised blood pressure over 150/100 mmhg) presenting at the department of ophthalmology and department of medicine unit-1, chandka medical college hospital larkana pakistan from january 2016 to january 2018 were included in the study, after ethical approval from ethical review committee of smbb medical university larkana pakistan. on duty residents/consultants of department of ophthalmology and medicine unit-1, chandka medical college hospital larkana were provided with standard proforma and instructed to record the symptomatic hypertensive patients on the basis of inclusion/exclusion criteria and report to author no. 1 and 3 as a part of data collection procedure. patients below 20 years of age, with diabetes mellitus, with sickle-cell retinopathy, with retinal vasculitis and with hypertension due to secondary causes like renal hypertension and adrenal medulla tumors were excluded from the study. complete clinical examination was performed on each patient including blood pressure monitoring, fundoscopy with direct and indirect ophthalmoscopes and with 90 d lens on slitlamp biomicroscope. a standard proforma was filled in for every patient; it included family history of hypertension, fundoscopic evidence of signs of hypertensive retinopathy and associated symptoms. presence of hypertension in first degree relatives was considered as positive family history. sample size was calculated by using the formula n= z2 p (1-p) e2 where „n‟ is the sample size, „z‟ is the confidence level, „p‟ is the population proportion and „e‟ is the margin of error. sample size of 288 was calculated by keeping the confidence level of 95%, margin of error of 5.78 and assuming the population proportion to be 50%. data was entered and analyzed in spss version 20 to assert the correlation of symptoms and signs in the relevant grades of hypertensive retinopathy by calculating the percentages of gender, hypertensive retinopathy, its various grades and symptoms among the patients under study. results we evaluated 288 patients of hypertension out of which 87 (30.21%) patients were found to have hypertensive retinopathy, among these patients 39 (44.83%) were males and 48 (55.17%) were females. breakup of these patients in grades and presenting symptoms are shown in table-1 & 2 and figures 1. utilizing imtiaz's grading system of hypertensive retinopathy, out of the total 87 patients, 51 (58.62%) had grade i hypertensive retinopathy, 19 (21.84%) patients had grade ii hypertensive retinopathy and 17 (19.54%) patients had grade iii hypertensive retinopathy. the most common presenting complaint in patients was headache 73 patients (83.9%) followed by blurred vision in 31 patients (35.6%), floaters in 15 patients (17.2%), amaurosis fugax in 9 patients (10.3%), diplopia in 7 patients (8%) and eye pain in 5 patients (5.7%). frequency of hypertensive retinopathy, on the basis of imtiaz's grading system, at larkana pakistan pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 239 table 1: distribution of patients in various grades of retinopathy. symptoms grades of hypertensive retinopathy grade i (n=51) grade ii (n=19) grade iii (n=17) total (n=87) blurred vision 11 5 15 31 headache 45 15 13 73 diplopia 0 4 3 7 floaters 0 12 3 15 eye pain 0 0 5 5 amaurosis fugax 0 0 9 9 table 2: gender distribution. distribution of hypertensive retinopathy hypertensive patients without hr hypertensive patients with hr total gender male 137 39 176 female 64 48 112 total 201 87 288 hr = hypertensive retinopathy fig. 1: distribution of patients in various grades. discussion retina is the only part of the human body where vasculature can be visualized noninvasively. therefore state of vessels can be studied easily, adequately and at earliest in systemic disorders like hypertension and diabetes. based on imtiaz‟s grading system of hypertensive retinopathy, our study shows that most of the patients (71.46%) suffering from hypertension became symptomatic in the first two grades which is expected to coincide with less damage to the target organs in the body contrary to grade-3 which may reflect advanced target organ damage13,14. underestimation of the importance of classifying hypertensive retinopathy is not justifiable as it not only guides the management of retinal problems but stays as a marker of vital organ damage. international society of hypertension and british hypertension society consider that grade-3 and 4 of keith, wagener, barker grading coincides with presence of the target organ damage15,16. medical specialists have utilized hypertensive retinopathy to predict the morbidity and even the mortality related to hypertension17 therefore assessment of hypertensive retinopathy has a crucial place in management of patients with hypertension18, 19. researchers have shown favor for development of hypertensive retinopathy classification comprising of fewer grades like mild, moderate and malignant20to facilitate easier clinical use. to our knowledge presently only imtiaz‟s grading system of hypertensive retinopathy7 is based on both signs/ symptoms and fewer grades (three grades). imtiaz’s grading of hypertensive retinopathy describes three grades of hypertensive retinopathy, grade 1. silver wiring of arterioles with av nippings and headaches. grade 2. as grade 1 with flame shaped hemorrhages, soft exudates and floaters. grade 3. as grade 2 with papilledema and amaurosis fugax. according to our knowledge, there is one grading system “mitchellwong simplification of kwb system” that utilizes fewer grades (three grades) but is based only on signs. although this study is limited and a large study is required to better explore the prevalence of author, et al 240 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology hypertensive retinopathy in this part of pakistan, the present study has opened the gate of understanding regarding picking up hypertensive retinopathy at relatively early stage on the basis of symptoms and has pointed out (30.21%) prevalence of hypertensive retinopathy in hypertensive population in upper parts of sindh and adjacent baluchistan. conclusion the observations of our study reveals that most of the patients had mild to moderate degree of hypertensive retinopathy (in first two grades of imtiaz‟s grading system of hypertensive retinopathy, 71.46%) at the time of presentation and they attended the health facility due to symptoms like blurred vision, headache and floaters. therefore, relatively early detection and management of hypertension and its systemic complications to prolong the life span of hypertensive patients, is possible if symptoms are given importance towards early detection and diagnosis of hypertension. on the basis of our study, we recommend that all symptomatic patients with raised blood pressure must undergo fundoscopy as a routine in all departments, to detect and manage hypertensive retinopathy and its associated complications either at the same health facility or by referral to appropriate place. author’s affiliation prof. syed imtiaz ali shah fcps, professor, department of ophthalmology chandka medical college/smbb medical university larkana. dr. huda fatima trainee registrar, department of ophthalmology chandka medical college larkana. dr. azizullah jalbani professor, department of medicine chandka medical college/smbb medical university larkana. dr. shujaat ali shah trainee registrar, department of ophthalmology chandka medical college larkana. dr. partab rai fcps, professor, department of ophthalmology chandka medical college/smbb medical university larkana. dr. darikta dargai shaikh associate professor, department of ophthalmology chandka medical college/smbb medical university larkana. role of authors prof. syed imtiaz ali shah conceived and designed the research, assessed the cases, wrote the paper. dr. huda fatima collected the data, did the literature search, drafted the manuscript, assisted in writing the paper. dr. azizullah jalbani involved in data collection, analyzed the data, revised the manuscript. dr. shujaat ali shah revised the original manuscript, reviewed the cases, analyzed the data and assisted in writing the paper. dr. partab rai revised the original manuscript, reviewed the cases. dr. darikta dargai shaikh involved in data collection. disclaimer: none. conflict of interest: none. source of funding: none. references 1. wong ty, mcintosh r. hypertensive retinopathy signs as risk indicators of cardiovascular morbidity and mortality. br med bull. 2005 sept. 73-74: 57-70. 2. zampagalione b. pascale c. marchisio m, et al. hypertensive urgencies and emergencies; prevalence and clinical presentation. hypertension, 1996; 27: 44147. 3. shubhangi v dhadke, vithal n dhadke, dhruv s batra. clinical profile of hypertensive emergencies in an intensive care unit. j assoc physici ind. 2017; 65: 1822. 4. spencer wh. an atlas and textbook (cd-rom). systemic diseases with retinal involvement: vascular diseases. based on: ophthalmic pathology. wb saunders co; 1995. 5. wang s, xu l, jonas jb, wang ys, wang yx, you qs, et al. five-year incidence of retinal microvascular abnormalities and associations with arterial hypertension: the beijing eye study 2001/2006. ophthalmol. 2012; 119: 2592–9. 6. albert d, jakobiec f, christlieb ra. based on: principles and practice of ophthalmology (cd-rom). hypertension. wb saunders co; 1993. title pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 241 7. shah sia et al. concise ophthalmology text & atals. 5th ed. param b (pvt.) ltd. 2018: 85-95. 8. wong ty, mitchell p. hypertensive retinopathy. n engl j med 2004; 351: 2310– 2317. 9. scheie hg. evaluation of ophthalmoscopic changes of hypertension and arteriolar sclerosis. ama arch ophthalmol. 1953; 49: 1170– 1238. 10. keith nm, wagener hp, barker nw. some different types of essential hypertension: their course and prognosis. am j med sci. 1939; 197: 332–343. 11. chatterjee s, chattopadhyay s, hop e-ross m, lip pl. hypertension and the eye: changing perspectives. j hum hypertens. 2002; 16: 667–675. 12. ferdinand kc, saunders e. hypertension-related morbidity and mortality in african americans–why we need to do better. j clin hypertens. 2006; 8: 21–30. 13. noblat ac, lopes mb, lopes aa. race and hypertensive target-organ damage in patients from an university-affiliated outpatient care referral clinic in the city of salvador. arq bras cardiol. 2004;82: 116–20, 111– 5. 14. cheung cy, ikram mk, sabanayagam c, wong ty. retinal micro-vasculature as a model to study the manifestations of hypertension. hypertens. 2012;60: 1094–103. 15. whitworth ja; world health organization, international society of hypertension wrinting group. 2003 world health organization (who)/ international society of hypertension (ish) statement on management of hypertension. j hypertens. 2003; 21(1): 1983-92. 16. williams b, poulter nr, brown mj, davis m, mcinnes gt, potter jf, et al. british hypertension society guidelines for hypertension management 2004 (bhsiv): summary. bmj. 2004, 328 (1): 634-40. 17. tso mo, jampol lm. pathophysiology of hypertensive retinopathy. ophthalmology, 1982; 89: 1132-1145. 18. mancia g, fagard r, narkiewicz k, et al. esh/esc guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the european society of hypertension (esh) and of the european society of cardiology (esc). j hypertens. 2013; 31: 1281-357. 19. taylor j. 2013 esh/esc guidelines for the management of arterial hypertension. eur heart j. 2013; 34: 2108-2109. 20. downie le, hodgson lab, d’sylva c, et al. hypertensive retinopathy: comparing the keithwagener-barker to a simplified classification. j hypertens. 2013; 31: 960-65. microsoft word 11. crm amir yaqoob 116 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology case report cryo assisted minimally invasive surgery for the treatment of orbital cavernous haemangiomas muhammad amer yaqub, saadullah ahmad, muhammad khizar niazi, teyyeb azeem janjua, omer farooq pak j ophthalmol 2013, vol. 29 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad amer yaqub classified eye specialist oculoplastic surgeon afio rawalpindi, …..……………………….. purpose: to study cryo assisted minimally invasive surgery for the treatment of orbital cavernous hemangiomas. material and methods: we present a case series of six patients having orbital cavernous haemangiomas. all patients underwent minimally invasive cryosurgical extraction of the tumour at the armed forces institute of ophthalmology, rawalpindi. results: all the tumours were successfully removed en bloc with the help of cryo extraction. the vision was improved in all but one case. the recovery was uneventful and histopathological reports confirmed the diagnosis after more follow-ups of nine months, no recurrence was observed in any of the operated eye. conclusion: cryo-assisted minimally invasive surgery offers an exciting approach for management orbital cavernous hemangiomas, with good cosmetic results and early functional recovery. avernous haemangioma is the most common primary benign vascular orbital tumour.1 it presents with painless unilateral proptosis that is reducible and associated with hyperopia.2 most cavernous haemangiomas are intraconal and lateral in location. they result from new vessel formation, proliferation of tissue components of the vessel wall, and hyperplasia of cellular elements of vascular origin.3 computed tomography (ct) and magnetic resonance imaging (mri) are of particular importance in the diagnosis of orbital vascular lesions. surgical access to posterior orbit is difficult because of the presence of delicate structures including optic nerve, ophthalmic artery and veins, extra-ocular muscles and nerves. surgical approaches to treat orbital disease should provide a good exposure of intra-orbital anatomical structures, and provide good cosmetic results. different approaches to the intra-orbital space have been described in the literature.4 in an attempt to maintain this philosophy and to avoid large incisions still providing an increased operative exposure, we describe cryo-assisted minimally invasive approach which mostly avoids bone removal or intraconal muscle sectioning. it provides access to the superior, medial, lateral, and inferior quadrants of the orbit, depending on the extent of the conjunctival and eyebrow incisions. thus, complete exposure and resection of very large intraorbital lesions is feasible with reduced morbidity. material and methods we describe the outcome of 6 patients with cavernous haemangioma of the orbit treated in our department between april 2008 and feb 2010. study design was interventional case series. patients underwent minimally invasive surgery through different approaches, completely removing the angiomas. all patients with intraconal mass and a strong clinical suspicion of cavernous hemangiomas underwent c cryo assisted minimally invasive surgery for the treatment of orbital cavernous haemangiomas pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 117 minimally invasive cryosurgical extraction. patients having any surgical intervention in the past were excluded from the study. the presenting features of all six cases in given in table-1. pre-op marking of site of incision and tumor was carried out. the tumor was reached either by lateral orbitotomy, a lid crease incision, or via transconjunctival approach depending upon location of tumor (table 2). after securing the vascular connections, lesion was extracted en bloc with the help of cryo-probe and blunt dissection. wound was closed in layers. histopathology was carried out in the end to confirm the diagnosis. results the mean age of patients was 32 years with a range of 1655 years. all the tumours were successfully removed en bloc with the help cryo extraction. the vision improved in all but one cases, and table-3 shows the comparison of pre-op and post-op visual acuity of the selected cases. the recovery was uneventful and histopathological reports confirmed the diagnosis of cavernous hemangioma. after a mean follow-up of nine months, no recurrence was observed in any of the operated eyes. case 1 a 32 – year old female presented with a 07 years history of painless progressive proptosis and impaired visual acuity of her right eye. she denied history of trauma. in the past, she was given a course of systemic steroids and biopsy was attempted elsewhere. her systemic and medical history was not contributory. she was admitted in another institute where she was given a course of systemic steroids and biopsy was taken which was non diagnostic because the sample was inadequate. she was using only lubricants on admission to our hospital. on examination the best corrected visual acuity (bcva) was 6/36 in right eye and 6/6 in left eye. right eye showed proptosis, diplopia in primary gaze, chemosis and restriction of extraocular movements in all gaze positions. examination of right fundus showed choroidal folds. ct scan orbit and brain with coronal sections showed a well circumscribed intraconal lesion in right orbit. a plan for excisional biopsy was made. the mass in her right orbit was approached via a subciliary incision. extensive adhesions were encountered after opening the orbital septum, probably from her previous biopsy. these were lysed and the rest of the mass was extracted en masse using a cryoprobe and blunt dissection. the recovery was uneventful. histopathology revealed an encapsulated cavernous haemangioma. her vision improved to 6/9, the choroidal folds resolved and ocular movements recovered in all gaze positions (fig. 1 and 2). fig. 1: 7th post-op day in opd in primary position. fig. 2: subciliary incision sutured with 7/0 vicryl with mild lower lid post op. edema. case 2 a 37 years old man presented with gradual painless proptosis with gradual loss of vision in his left eye for the last 08 years. bcva in right eye was 6/6, while in the left eye was 6/60. left eye showed axial proptosis of 35 mm and supero-temporal dystopia of 5 mm (fig. 3). extra-ocular movements were restricted in all gaze positions. there was no retropulsion or bruit. fundus showed choroidal folds. examination of right eye was unremarkable. ct scan showed a large well circumscribed intraconal lesion in left orbit (fig. 4). the patient was planned for orbitotomy under muhammad amer yaqub, et al 118 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology fig. 3: proptosis and suprotemporal dystopia of left eye. fig. 4: ct scan axial view showing large well circumscribed intraconal lesion in left orbit. fig. 5: three weeks after the surgery showing resolved proptosis and dystopia. general anesthesia. after marking an extended lazy s incision till zygomatic arch, lateral orbital margin was removed and the lesion approached through blunt dissection. on opening the periorbita, a plump, nodular, encapsulated mass with vascular channels on its well defined surfaces was found. an apical vascular tag was identified and cauterized; to prevent the gush of blood. a cryoprobe assisted extraction was done. the lesion was completely excised. wound was closed in layers. visual acuity of patient was checked in the evening to exclude optic nerve compression. histopathology confirmed the diagnosis of multilobulated, well encapsulated left cavernous haemangioma. vision in the left eye improved to 6/24 six weeks after the surgery (fig. 5). fig. 6: right eye with inferior dystopia and proptosis. fig. 7: ct – scan revealed a large extraconal, well circumscribed lesion in supero-nasal region of right orbit. case 3 a 35 years old female presented to our hospital with inferior displacement of right eye for last 04 years associated with gradual deterioration of vision. there was no history of trauma or any systemic illness. on ocular examination bcva in right eye was 6/36 while that in left eye was 6/6. right eye showed 6 mm inferior dystopia, 2 mm of proptosis compared to left eye and restriction of ocular motility more marked in vertical than in horizontal gaze (fig. 6). there was no cryo assisted minimally invasive surgery for the treatment of orbital cavernous haemangiomas pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 119 retropulsion or bruit. fundus showed choroidal folds. examination of left eye was unremarkable. ct-scan revealed a large extraconal, well circumscribed lesion in supero-nasal region of orbit (fig. 7). patient was planned for orbitotomy under general anesthesia. pre op. marking was made (fig. 8). lid crease incision extending temporally 15 mm lateral to temporal orbital margin was made. after penetrating the septum, the lesion was approached through blunt dissection which revealed a well encapsulated nodular mass. vascular connections were secured and the lesion was removed en bloc with the help of cryoprobe (fig. 9). it measured 35 x 22 mm. wound was closed in layers. histopathology confirmed the diagnosis of multi-lobulated, well encapsulated cavernous hemangioma. vision in the left eye improved to 6/12 two weeks after surgery. fig. 8: right upper lid crease marking extending temporally. fig. 9: lesion being removed en bloc with the help of cryoprobe. case 4 a 16 years old male presented to our hospital with inferior displacement of right eye for last 3 years associated with gradual deterioration of vision (fig. 10) there was no history of trauma or any systemic illness. on ocular examination bcva in right eye was 5/60 while visual acuity in left eye was 6/6. right eye showed 07 mm inferior dystopia, 04 mm of proptosis compared to left eye and restriction of ocular motility more marked in vertical than in horizontal gaze. there was no retropulsion or bruit. fundus showed choroidal folds. examination of left eye was unremarkable. ct – scan revealed a large extraconal, well circumscribed and encapsulated lesion in superonasal region of orbit. patient was planned for orbitotomy under general anesthesia. lid crease incision extending temporally 13 mm lateral to temporal orbital margin was made. the lesion was reached through blunt dissection. the tumour was found to be plum coloured well encapsulated nodular mass. after securing the vascular connections, lesion was extracted en bloc with the help of cryoprobe. it measured 30 x 20 mm. wound was closed in layers. histopathology confirmed the diagnosis of multi-lobulated, well encapsulated left cavernous hemangioma. bcva in the right eye improved to 6/12 six weeks after the surgery (fig. 10). fig. 10: inferior dystopia and proptosis of right eye. case 5 a 65 years old man presented with gradually enlarging mass below right eye for last 3 years. on examination visual acuity in right eye was hand movement (hm) positive. he had relative afferent pupillary defect in the same eye. extraocular muhammad amer yaqub, et al 120 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology fig. 11: six weeks after the surgery. fig. 12: mass bulging through inferior fornix causing mechanical ectropion. fig. 13: well demarcated homogenous hyper dense mass involving inferonasal aspect of right orbit. fig. 14: lesion below right eye ball visible under conjunctiva and with bluish discoloration of lower lid. fig. 15: brownish well encapsulated mass measuring 3.0 x 2.8 cm was extracted en bloc. fig. 16: cosmetic improvement three weeks post operatively. cryo assisted minimally invasive surgery for the treatment of orbital cavernous haemangiomas pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 121 0.2 0.7 0.1 0.25 0.2 0.5 0.08 0.5 0.02 0.02 0.25 0.7 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 patient 1 patient 2 patient 3 patient 4 patient 5 patient 6 pre op va post op va table 3: decimal equivalent of pre-op ad post-op visual acuities of cases (n=6) movements were severely restricted. mass was visible bulging through inferior fornix causing mechanical ectropion. (fig. 12) ct scan showed a well demarcated homogenous hyper dense mass involving infero-nasal aspect of right orbit (fig. 13). cryo-assisted extraction through trans-conjunctival approach was done. patient made smooth post operative recovery but his vision did not improve. case 6 a 30 years old female presented with gradual deterioration of vision and swelling below right eye ball for last one and half year. (fig. 14) on examination her bcva was 6/24 in right eye and 6/6 in left eye. there was a mass involving inferior aspect of right orbit but not causing any dystopia. growth was visible under the conjunctiva in inferior fornix. lesion was excised through trans-conjunctival approach. a brownish well encapsulated mass measuring 3.0 x 2.8 cm was extracted en bloc. (fig. 15) post operative recovery was uneventful and patient’s visual acuity improved to 6/9 three weeks post operatively (fig. 16). discussion cavernous haemangiomas are the most common benign, non-infiltrative neoplasms of the orbit and represents 9.5 to 15% of the primary expansive lesions of the orbit.5 they usually grow slowly between the extrinsic muscles and present as a mass effect on the globe. it is a vascular malformation characterized by the presence of sinusoids with fine walls, which muhammad amer yaqub, et al 122 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology contain an accumulation of blood with no apparent arterial or venous inflow.7 its incidence peaks between the ages of 40 – 50 years and women are affected more.8 a slowly progressive painless proptosis is the typical presenting symptom. impaired extraocular movements and visual function are seen with large lesions and with lesions located at the orbital apex.9 most cavernous haemangiomas are located within the intraconal space. nearly all patients with cavernous haemangioma can be correctly diagnosed by preoperative radiological studies.10 orbital ct scan is the single most useful diagnostic test and shows a well circumscribed lesion with no osseous involvement.2 in our study, ct scan showed very well defined smooth mass, which enhanced with intravenous contrast. surgical treatment is recommended for optic nerve compression as evidenced by visual field defects, optic nerve swelling and pallor. other indications include diplopia and bothersome cosmesis.11 several therapeutic modalities and surgical approaches have been described, in order to preserve the normal orbital structures. most approaches used to remove orbital tumours typically include bone removal (orbitotomies) with or without craniotomies.12 complete excision is generally accomplished without recurrencesas the tumour is well encapsulated with relatively few feeding vessels.13,14 lateral orbitotomy has been widely employed for the removal of orbital tumors, being used in large sized hemangiomas, especially those located in the lateral compartment of the orbit and orbital apex.15 transconjunctival approach can be used successfully for anterior as well as retrobulbar intraconal cavernous hemangiomas.16 anterior orbitotomy is useful in many cases, without significant complications and warrants more favourable consideration if combined with the use of cryoprobe and surgical microscope.17 postero-inferior orbitotomy through the maxillary sinus18 can be used in small, well demarcated lesions in the posterior and inferior orbit near the apex. endoscopic trans-ethmoidal approach of the orbit is a minimally invasive surgery for retro-bulbar orbital neoplasm, leading to excellent cosmetic results with less bleeding. the medial wall of the orbit, the orbital apex, and the optic canal can be exposed through a middle meatal antrostomy, an anterior and posterior ethmoidectomy, and a sphenoidotomy.19 lateral suprabrow,20 trans-nasal21 and the combined pterional and orbitozygomatic approach22 are employed for removal of tumors affecting the optic canal. transcranial approaches offer an excellent surgical exposure and a good cosmetic outcome and should be considered for big lesions located superiorly or medially to the optic nerve, especially those involving the apex.23 complications of surgery include ptosis, impairment of ocular movements, diplopia due to mechanical or vascular trauma and visual disturbances.10 careful preoperative workup including plan for minimal invasive approach based on ct scan offered excellent exposure and a rewarding cosmetic result in our cases and that this technique might also be considered for larger lesions figure 1 – 4 show preand post-operative picture of one of cases with technique of en bloc removal of these tumours. avoiding large incisions and osteotomies resulted in early rehabilitation and decreased morbidity. additionally, there were no risks of cerebrospinal fluid leakage or significant blood loss during the procedure, no bone removal or reconstruction was required and no postoperative enophthalmos or temporal muscle atrophy was encountered. conclusion cryo-assisted minimally invasive surgical excision offers an exciting approach for management orbital cavernous hemangiomas. with improvement of neuroimaging techniques, it is possible to obtain a correct pre-operative diagnosis in almost every case of vascular orbital lesions. this can lead to excellent cosmetic results with complete functional recovery and minimal morbidity. author’s affiliation dr. muhammad amer yaqub classified eye specialist oculoplastic surgeon afio rawalpindi dr. saadullah ahmad graded eye specialist cmh malir dr. muhammad khizar niazi classified eye specialist vitreoretinal surgeon afio rawalpindi dr. teyyeb azeem janjua graded eye specialist cmh bannu cryo assisted minimally invasive surgery for the treatment of orbital cavernous haemangiomas pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 123 dr. omer farooq graded eye specialist pns shifa, rawalpindi references 1. wende s, kazner e, grumme t. the diagnostic value of computed tomography in orbital diseases. a cooperative study of 520 cases. neurosurg rev. 1980; 3: 43-9. 2. ruchman mc, flanagan j. cavernous hemangiomas of the orbit. ophthalmology. 1983; 90: 1328-36. 3. rosca ti, pop mi, curca m, vladescu tg, tihoan cs, serban at. vascular tumors in the orbit – capillary and cavernous hemangiomas. ann diagn pathol. 2006; 10: 13-9. 4. maroon jc, kennerdell js. surgical approaches to the orbit. indications and techniques. j neurosurg.1984; 60: 1226-35. 5. anand r, deria k, sharma p, narula m, garg r. extraconal cavernous hemangioma of orbit: a case report. indian j radiol imaging. 2008; 18: 310-2. 6. harris gj, jakobiec fa. cavernous hemangioma of the orbit. j neurosurg. 1979; 51: 219-28. 7. bouguila j, yacoub k, bouguila h, neji nb, sahtout s, besbes g. intraorbital cavernous hemangioma. rev stomatolchir maxillofac. 2008; 109: 312-5. 8. acciarri n, giulioni m, padovani r, gaist g, pozzati e, acciarri r. orbital cavernous angiomas: surgical experience on a series of 13 cases. j neurosurg sci. 1995; 39: 203-9. 9. bilaniuk lt. orbital vascular lesions. role of imaging. radiol clin north am. 1999; 37: 169-83. 10. wu zy, yan jh, han j, yang hs, lin z, chen zc. diagnosis and surgical management of 209 cases of orbital cavernous hemangioma. zhonghua yan kezazhi. 2006; 42: 323-5. 11. missori p, tarantino r, delfini r, lunardi p, cantore g. surgical management of orbital cavernous angiomas: prognosis for visual function after removal. neurosurgery. 1994; 35: 34-8. 12. cho kj, paik js, yang sw. surgical outcomes of transconjunctival anterior orbitotomy for intraconal orbital cavernous hemangioma. korean j ophthalmol. 2010; 24: 274-8. 13. arai h, sato k, katsuta t, rhoton al, jr. lateral approach to intraorbital lesions: anatomic and surgical considerations. neurosurgery. 1996; 39: 1157-62. 14. cheng jw, wei rl, cai jp, li y. transconjunctival orbitotomy for orbital cavernous hemangiomas. can j ophthalmol. 2008; 43: 234-8. 15. rosen n, priel a, simon gj, rosner m. cryo-assisted anterior approach for surgery of retroocular orbital tumours avoids the need for lateral or transcranial orbitotomy in most cases. acta ophthalmol. 2010; 88: 675-80. 16. kennerdell js, maroon jc, celin se. the posterior inferior orbitotomy. ophthal plast reconstr surg. 1998; 14: 277-80. 17. tsirbas a, kazim m, close l. endoscopic approach to orbital apex lesions. ophthal plast reconstr surg. 2005; 21: 271-5. 18. kosaka m, mizoguchi t, matsunaga k, fu r, nakao y. novel strategy for orbital tumor resection: surgical “displacement” into the maxillary cavity. j craniofac surg. 2006; 17: 1251-8. 19. maus m, goldman hw. removal of orbital apex hemangioma using new transorbital craniotomy through suprabrow approach. ophthal plast reconstr surg. 1999; 15: 166-70. 20. rohde v, schaller k, hassler w. the combined pterional and orbitozygomatic approach to extensive tumours of the lateral and latero-basal orbit and orbital apex. acta neurochir (wien). 1995; 132: 127-30. 21. castelnuovo p, dallan i, locatelli d, battaglia p, farneti p, tomazic pv, seccia v, karligkiotis a, pasquini e, stammberger h. endoscopic transnasal intraorbital surgery: our experience with 16 cases. eur arch otorhinolaryngol. 2012; 269: 1929-35. 22. scheuerle af, steiner hh, kolling g, kunze s, aschoff a. treatment and long-term outcome of patients with orbital cavernomas. am j ophthalmol. 2004; 138: 237-44. 23. santoro a, salvati m, vangelista t, delfini r, cantore gp. fronto-temporo-orbito-zygomatic approach and variants. surgical technique and indications. j neurosurg sci. 2003; 47: 141-7. pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 178 case report orbital fungal myositis; a case report sahar khalid, mohammad moin pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: saher khalid eye unit 2 lahore general hospital lahore …..……………………….. to report a case of 20 years old female presenting with proptosis of the left eye and restricted medial gaze due to medial rectus fungal involvement in an immune competent patient. she underwent removal of the medial rectus followed by muscle transposition surgery few months later with satisfactory outcome. key words: orbital myositis, proptosis, corneal mucormycosis. rbital masses can be inflammatory, infectious and neoplastic in origin. in orbital space, they present with overlapping clinical manifestations. the slow growth of a solitary, discrete mass is usually suggestive of tumor. fungal infections of the orbit are usually seen in immune compromised state1. but here, we report a case of orbital fungal granuloma in a young female who was immunecompetent and managed satisfactorily. case report a 20 years old unmarried female, presented to our tertiary care hospital with painless progressive nonaxial proptosis of the left eye for the last 1 year. she had outward deviation of the left eye with no double vision. she had no visual complaints, no complaints of redness, discharge and photophobia. there was no history of trauma, surgery, systemic illness, lymphadenopathy and nose or throat infection. she had no fever and reported no change in appetite or weight. past medical and surgical history was unremarkable. she reported no evidence of a disease causing immune suppression. family history was unremarkable. on examination, visual acuity was 6/6 unaided in both eyes. there was non-axial proptosis of 23 mm of the left eye on hertel’s exophthalmometer, which increased slightly on valsalva maneuver. she had an exotropia of 45 degrees on cover test. the dystopia was measured to be 5 mm outwards and 5 mm upwards in the left eye (fig 1). there was no complaint of diplopia. bruit and pulsation were absent. anterior segment examination was normal. fig. 1: proptosis and exotropia of left eye on initial presentation. fig. 2: ct scan coronal and axial view showing mass involving medial rectus. laboratory findings revealed normal blood count, blood glucose level, pt and aptt. ultrasound abdomen and x-ray chest were of no significance. computed tomography of orbits and pns revealed, diffuse thickening of medial rectus (fig. 2). rest of the left eye appeared normal. right eye, nasal cavity and sinuses were within normal limits. o sahar khalid, et al 179 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology mri orbit showed thickening of medial rectus muscle and involvement of retrobulbar fat with proptosis of left eye and compression of optic nerve fig. (3). brain appeared normal. fig. 3: mri axial view showing the mass invading the medial rectus. these findings gave the impression of a mass involving the medial rectus. surgical excision was performed under general anesthesia. lynch howarth approach was used. the excised mass which was yellowish in colour unlike the medial rectus on naked eye examination was excised and wound closed with 6/0 vicryl (fig 4). but the medial rectus tendon was forming the anterior end of the mass which suggested that the muscle had lost its characteristic appearance due to pathological changes. the tendon was identified and separated from the sclera with a muscle hook before excision. biopsy specimen was sent for histopathology (fig. 5). fig. 4: the tumour being removed. fig. 5: biopsy specimen. on a follow up examination, 2 weeks after surgery, proptosis was decreased to 20 mm. optic disc, anterior and posterior segments were within normal limits. intraocular pressure was 16 mm hg. inward eye movements were restricted (grade -4), but normal on superior, inferior and lateral gaze (fig. 6). there was no diplopia. fig. 6: left exotropia with absent abduction at 2 weeks post op. histopathology report showed fibro-connective tissue with granulomatous inflammation. granulomas were composed of aggregates of epitheloid cells, surrounded by collar of lymphocytes and histiocytes with multiple multinucleated giant cells within the granuloma. scattered eosinophills were also identified. few granulomas showed septate hyphae. histochemical stains were positive for fungal organisms. fig. 7: post op ct showing residual fungal granuloma. the proptosis decreased after 2 weeks, but there was no movement of left eye on medial gaze, due to absent medial rectus muscle and exotropia of 45 degrees was seen. post op ct and mri scans were carried out. they showed residual fungal granuloma (fig. 7). patient was prescribed tablet itraconazole( sporonox) 100 mg twice a day for 3 months. after 3 orbital fungal myositis; a case report pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 180 months, ct and mri were again carried out, which showed no recurrence of fungal granuloma. cosmetic squint correction was done for the large angle exotropia by performing hummulsheim procedure. in this procedure, there was full tendon transfer of superior and inferior recti to the medial rectus. a jenson procedure involving split tendon transfer could be done but we opted for full tendon transfer due to the very large angle exotropia. lateral rectus recession was not feasible due to the absence of medial rectus which would pull it medially after surgery. post-op examination after 4 weeks showed improvement of exotropia on primary position to 30 degrees (fig. 8). fig. 8: residual small angle exotropia of left eye at 4 weeks post op. discussion in adults, primary orbital tumors are lymphoid tumors, cavernous hemangioma, meningioma, neurofibroma and schwannoma. most common presentations are proptosis and exophthalmos. infectious and inflammatory process has acute onset as compared to tumors, which has slow onset. in the presented case fungal granuloma developed in an immune competent patient over a period of 1 year with no acute symptoms except proptosis. orbital infections occur due to spread of infections from paranasal sinuses or direct from trauma and surgery. most common organisms are bacteria, while viral and fungal infections are rare. organisms causing fungal infections include aspergillus. mucormycosis and cryptococcus species2. aspergillus granuloma is the most commonly reported intracranial granuloma among fungal granulomas3. it is the common causative fungal organism of intracranial fungal mass lesion accounting for approximately 56% to 69%3.the estimated annual incidences of systemic invasive fungal infections caused by aspergillus species are 1234%4. the estimated incidence of fungal infection is 46% of cns involvement5. fungal infections commonly occur in immune compromised state like diabetes mellitus (37%)6, aids or excessive steroid use. the common sites of involvement are nasal cavity (10%), brain with sinonasal (36.6%) and nose and orbital cavity (53.3%)7. some of the reports shows that the fungal infections can present as optic neuritis8. it can present in the form of sub periosteal abscess9. optic neuropathy8, orbital apex syndrome10 and orbital tuberculosis with coexisting fungal granulomas11. to assess the orbital disease, mri imaging is preferable because it gives full detail of the soft tissue structures. the mri findings are characteristics in fungal granuloma. these include a mass lesion producing hypo-intense or iso-intense lesion on t1 weighted and hypo intense lesion on t2 weighted images12. in our case, mri findings of fungal granuloma on t1 weighted images were iso-intense while they were hypointense on t2 weighted images, which in literature are characteristic of aspergillus fungal granuloma. its non-tender and non-inflammatory nature caused it to be misdiagnosed as tumor. so, fungal infections should always be kept in differentials of such solitary orbital masses. surgery is important both for initial diagnosis and for excision of granuloma, allowing for a better treatment efficacy of systemic antifungal agents like amphotericin b and itraconazole 100-400 mg twice a day for 3 months. conclusion orbital fungal granuloma may affect immune competent healthy patients as well as immune compromised patients. main stays of treatment are surgical debridement and systemic antifungal therapy. early diagnosis can prevent the extensive surgical intervention. author’s affiliation dr. saher khalid pgr eye unit 2 lahore general hospital lahore dr. mohammad moin professor ophthalmology eye unit 2 lahore general hospital lahore sahar khalid, et al 181 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology references 1. zafar ma, waheed ss, enam sa. orbital aspergillus infection mimicking a tumor: a case report. cases journal. 2009; 2: 7860. 2. hershay bl, roth tc. orbital infections. semin ultrasound ct mr 1997; 18: 448-59. 3. sundram c, umabala p. pathology of fungal infections of central nervous system: 17 years experience from southern india. histopathology. 2006; 49: 396-405. 4. pfaller ma. pappas pg. invasive fungal pathogens, current epidemiological trends. clinical infectious disease. 2006; 43: 314. 5. kethireddy s, andes d. cns pharmacokinetics of antifungal agents. expert opinion on drug metabolism and toxicology. 2007; 3: 573-81. 6. finn dg. mucormycosis of paranasel sinuses. ear nose throat j. 1998; 67: 813-16. 7. javadi m. fungal infection of the sinus and anterior skull base. med j islam repub iran. 2008; 22: 137-40. 8. mafee mf, goodim j. optic nerve sheath meningiomas. radiolclin north am. 1999; 37: 37-58. 9. spoor tc, hartel wc. aspergillosis presenting as a corticosteroid responsive optic neuropathy. j clin neuroophthalmol. 1982; 2: 103-7. 10. matsou t, notohara k. aspergillosis causing bilateral optic neuritis and later orbital apex syndrome. jpn j ophthalmol. 2005; 49: 430-1. 11. reddy ss, penmmaiah dc. orbital tuberculosis with coexisting fungal infection. surg neurolint. 2014; 5: 32. 12. siddiqui aa, bashir sh. diagnostic mr imaging features of craniocerebralaspergillosis of sino nasal origin in immune competent patients. acta neurochir. 2006; 148: 155-66. pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 101 original article clinical and neuro-imaging patterns of meningiomas of visual pathway tayyaba gul malik, khalid farooq, muhammad khalil pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. tayyaba gul malik ophthalmology department lahore medical and dental college lahore e.mail: tayyabam@yahoo.com …..……………………….. purpose: to highlight the clinical and neuro-imaging patterns of meningiomas of visual pathway. materials and methods: it was a descriptive retrospective study conducted during 2007 to 2013. 94 patients with intra cranial meningiomas affecting the visual pathway were selected for study. clinical data included history, ocular and systemic examinations and neuro-imaging reports. special attention was given to the neurological data, which was the only source available to us for diagnosing meningiomas. histological confirmation of meningioma was available in 9.6% cases (n = 9). results: ninety – four patients, 51 females and 43 males (female: male ratio, 1.19:1) were included in the study. mean age was 48.23 years. the commonest type of meningioma affecting visual pathway was meningioma of inner table of occipital bone causing mass effects on the occipital lobe (30.85%, n = 29). other meningiomas were parasellar (21.3%, n = 20) and supra sellar meningiomas (18.1%, n = 17) pressing upon optic chiasma. tumor size ranged from 0.7 cm to 8.5 cm in smallest and largest dimensions respectively. only one patient in our series had neurofibromatosis type 1 and one patient had neurofibromatosis type 2. conclusion: neuro-imaging including conventional radiology plays a pivotal role in non-interventional diagnosis of intracranial meningiomas. owing to the benign nature of meningioma, it should be differentiated from other aggressive tumors which need to be diagnosed and treated at the earliest. key words: parasellar meningiomas, supra sellar meningiomas, visual pathway, dural tail sign, neuro-imaging he term, “meningioma” was first coined by harvey cushing1. generally, meningiomas are tumors, which arise from arachnoidal cap cells, commonly occurring on the brain surface. rarely, they are seen in the brain ventricles. they are either solitary or multiple. many cases of meningiomas are diagnosed incidentally. tumors less than 2.5 cm are usually symptomless. whereas, larger tumors show symptoms which worsen with time.2 these tumors produce symptoms by different mechanisms. firstly, by irritating the brain substance (leading to epilepsy), by pressing the underlying brain tissue or cranial nerves (optic nerve meningioma), causing hyperostosis (meningioma of greater wing of sphenoid), by invading the soft tissues (rarely) and finally by vascular compression or invasion (invasion of cavernous sinus by meningioma).3,4 this article reappraises the neuro-imaging patterns of meningiomas of visual pathway. material and methods it was a descriptive retrospective study. we reviewed clinical and imaging charts of 506 patients of meningioma. 94 patients who had meningiomas affecting the visual pathway were selected for study. t tayyaba gul malik, et al 102 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology clinical data included history, visual acuity, color vision, pupillary reactions, extra ocular movements, intra ocular pressures, field of vision, slit lamp examination and fundoscopy. neuro-imaging with both plain and post contrast images were studied. gd dtpa was utilized for post contrast component. data was compiled, results deduced and descriptive statistical analysis was done. results ninety four patients, 51 females and 43 males (female: ratio, 1.19:1) were included in the study. age ranged from 12 years to 96 years (mean 48.23 years). 33 patients were ≤ 40 years and 61 patients were more than 40 years of age. the commonest type of meningioma affecting visual pathway was meningiomas of inner table of occipital bone causing mass effects on the occipital lobe (30.85%, n = 29). refer to table 1. second common were parasellar (21.3%, n = 20) and supra sellar meningiomas (18.1%, n = 17) pressing upon optic chiasma (fig. 1 and 2). tumor size ranged from 0.7 cm to 8.5 cm in smallest and largest dimensions respectively. there were 9 patients with multiple meningiomas (9.6%). among these, there was an interesting patient with two well-defined meningiomas. one in the middle cranial fossa and the other in left parietal region. middle cranial fossa mass was encasing the cavernous sinus and internal carotid artery and causing pressure effects on right optic nerve, optic tract, pons and midbrain. patient had right lateral rectus palsy and visual field defects in both eyes (fig. 3). only one patient in our series had neurofibro matosis type 1 and one patient had neurofibromatosis table 1: different types of meningiomas affecting visual pathway. fig. 1: solid enhancing planum sphenoidale meningioma. mass effect on pituitary stalk and optic nerve / optic chiasm. fig. 2: right para sellar meningioma t1, t2 and coronal / axial post contrast images showing significant mass effect on right cavernous sinus, pituitary stalk and optic chiasm. fig. 3: two well defined meningiomas in the middle cranial fossa and left parietal region. middle cranial fossa mass is encasing the cavernous sinus and internal carotid artery and causing pressure effects on right optic nerve, optic tract, pons and midbrain. type 2. the diagnosis of meningioma was purely based on radiological findings. histological confirmation of meningioma was available in 9.6% cases (n=9). cavernous sinus meningiomas are associated with multiple cranial nerve palsies including oculomotor, trochlear, trigeminal and abducent. we did not have any patient with purely cavernous sinus meningiomas but there were patients with large parasellar clinical and neuro-imaging patterns of meningiomas of visual pathway pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 103 meningiomas (21.27%, n = 20), which were causing mass effects on the cavernous sinus laterally and on optic chiasma medially. meningiomas which cause pressure effects on the occipital lobe result in contra lateral hemianopia (30.1%, n = 29 in our series). there were 14.9% patients with meningiomas of optic nerve causing ipsilateral vision loss, proptosis, optic atrophy and opticociliary shunt vessels. similarly 14.9% cases in our series had meningiomas of the greater wing of sphenoid with multiple cranial nerve palsies. ocular associations of these meningiomas were visual field defects, proptosis, optic disc edema, optic atrophy, ocular motor nerve palsies and pupillary defects. other neurological deficits were hearing defect, hemiplegia, trigeminal neuralgia and epilepsy. discussion meningiomas are slow growing tumors, which are sometimes, diagnosed incidentally (2 – 3%). it is the second most common intracranial tumor in adults (constituting 20% of all intracranial tumors).5 world health organization (who) has defined meningiomas as “meningothelial (arachnoid) cell neoplasms, typically attached to the inner surface of the dura mater.”6 it is more common in females and reach a peak incidence in seventh decade of life7. in this particular study, female to male ratio was 1.19:1. previous studies in caucasians had shown a ratio of 3:1. in africans, the gender ratio was same. another study depicted this ratio to be 24:1, which is very high.8 mean age in this study was 48.23. in a similar case series, mean age in adults was 50 years.9 tumors that arise from sphenoid bone and result in visual complaints usually present in 5th to 6th decade.7 another characteristic feature of this tumor is that it causes symptoms by compressing the underlying structures without invading brain tissue. symptoms depend on the site of tumor. meningiomas in the region of olfactory groove cause anosmia, ipsilateral optic atrophy and contra lateral papilledema. the triad is called foster kennedy syndrome. in this particular study, we did not encounter any patient with foster kennedy syndrome. cavernous sinus meningiomas are associated with multiple cranial nerve palsies including oculomotor, trochlear, trigeminal and abducent. we did not have any patient with purely cavernous sinus meningiomas but there were patients with large parasellar meningiomas (21.27%, n = 20), which were causing mass effects on the cavernous sinus laterally and on optic chiasma medially. meningiomas which cause pressure effects on the occipital lobe result in contra lateral hemianopia (30.1%, n = 29 in our series). meningiomas of optic nerve cause ipsilateral vision loss, proptosis, optic atrophy and opticociliary shunt vessels (14.9% in this study). meningiomas of the greater wing of sphenoid cause multiple cranial nerve palsies if superior orbital fissure is involved (14.9% in this study). many causative agents for meningiomas are being investigated. viruses, trauma, up-regulation of cox2 and high dose cranial irradiation are some agents.10 some investigators have proposed a relation of female hormones with meningiomas. similarly, estrogen, progesterone and androgen receptors were found on some meningiomas, which further strengthened the hypothesis but it is still not proved. increase in the tumor size in pregnancy also throws light on the role of hormones.11 meningiomas rarely occur in children 17 but when they do, they are more common in males12. in our study, there were only four patients of meningiomas less than 15 years of age and all of them were males. radiation induced meningiomas are multiple, aggressive and have a high proliferation rate.13 they appear 20 to 35 years after irradiation to brain tumors regardless of the dose of radiation14. none of our patients had history of radiation. excessive use of cellular phones is also blamed but available data do not confirm this.15 small meningiomas are usually incidental findings on neuro-imaging performed for some other disease. hence, surgical excision and biopsy is not required in all cases. diagnosis depends on the imaging studies. even the role of plain radiographs should not be overlooked. we can analyze hyperostosis, calcifications and increased vascular markings of the skull. on plain ct scans, meningiomas are isoattenuating to hyper-attenuating. injection of iodinated contrast material leads to homogenous and intense enhancement of the tumor. mr scans with contrast are very helpful in radiological diagnosis of meningiomas. after injecting gadolinium gadopentetate, these tumors enhance homogenously and intensely. another important radiologic diagnostic feature of meningiomas is dural tail sign. goldsher et al described dural tails as a “highly specific feature of meningiomas”.16 the dural tails are composed of hyper vascular, presumably reactive tissue, but not tayyaba gul malik, et al 104 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology meningioma tumor cells. peritumoral edema is also associated with meningiomas which is well demonstrated on flair images. research is being going on regarding the role of vegf-a in inducing this edema. jack hou et al have shown that vegf-a is secreted by meningioma cells.17 meningiomas of the optic nerve have a typical “bull’s eye” picture in coronal images of mri. there is surrounding mass of tumor tissue around an attenuated optic nerve. in axial images, the tumor takes an appearance of “tram track”.18 this is in contrast to optic nerve gliomas in which nerve itself is increased in diameter. optic nerve sheath meningiomas are either primary or secondary depending on whether they are primary arising from optic nerve sheath or invading the orbit from cranial cavity respectively. conclusion neuro-imaging including conventional radiology plays a pivotal role in non-interventional diagnosis of intracranial meningiomas. owing to the benign nature of meningiomas, it should be differentiated from other aggressive tumors which need to be diagnosed and treated at the earliest. author’s affiliation dr. tayyaba gul malik associate professor of ophthalmology lahore medical and dental college lahore dr. khalid farooq professor, department of radiology lahore medical and dental college lahore dr. muhammad khalil associate professor of ophthalmology lahore medical and dental college lahore references 1. cushing h, eisenhardt l, thomas c, ed. meningiomas: their classification, regional behaviour, life history, and surgical end results. springfield, ill: charles c thomas; 1938. 2. sughrue me, rutkowski mj, aranda d, barani ij, mcdermott mw, parsa at. treatment decision making based on the published natural history and growth rate of small meningiomas. j neurosurg. 2010; 113: 1036-42. 3. pieper dr, al-mefty o, hanada y, buechner d. hyperostosis associated with meningiomas of the cranial base: secondary changes or tumor invasion. neurosurgery. 1999; 44: 742-6. 4. pieper dr, al-mefty o, hanada y, buechner d. hyperostosis associated with meningiomas of the cranial base: secondary changes or tumor invasion. clin radiol. 2013; 68: 837-44. 5. claus eb, bondy ml, schildkraut jm, wiemels jl, wrensch m, black pm: epidemiology of intracranial meningioma. neurosurgery, 2005; 57: 1088–95. 6. perry a, louis dn, scheithauer bw, budka h, von deiming a. louis dn, ohgaki hiroko, wiestler od, and cavenee wk. meningioimas in who classification of tumours of the central nervous system. lyon, france: international agency for research on cancer, 2007: 164-72. 7. roy and fraunfelder’s meningioma. in: current ocular therapy. saunders elsevier. 6th edition, 2008. page 255. 8. yang j, ma sc, liu yh, wei l, zhang cy, qi jf, et al. large and giant medial sphenoid wing meningiomas involving vascular structures: clinical features and management experience in 53 patients. chin med j (engl). 2013; 126: 4470-6. 9. sheikh by, siqueira e, dayel f. meningioma in children: a report of nine cases and a review of the literature. surg neurol. 1996; 45: 328-35. 10. ragel bt, jensen rl, couldwell wt. inflammatory response and meningioma tumorigenesis and the effect of cyclooxygenase-2 inhibitors. neurosurg focus, 2007; 23: e7. 11. baxter ds, smith p, stewart k, murphy m. clear cell meningiomas presenting as rapidly deteriorating visual field and acuity during pregnancy. j clin neurosci. 2009; 16: 1502-4. 12. menon g, nair s, sudhir j, rao br, mathew a, bahuleyan b. childhood and adolescent meningiomas: a report of 38 cases and review of literature. acta neurochir (wien), 2009; 151: 239-44. 13. claus eb, calvocoressi l, bondy ml, et al. dental xrays and risk of meningiomas. cancer, 2012; 118: 4530– 7. 14. perry a, louis d, scheithauer b, et al. meningiomas. louis b, ohgaki h, wiestler o, cavenee w, editors., 4th ed. lyon, france: iarc press; 2007. 15. milham s. meningioma and mobile phone use. int j epidemiol. 2010; 39: 1117. 16. goldsher d, litt aw, pinto rs, bannon kr, kricheff ii. dural “tail” associated with meningiomas on gddtpa – enhanced mr images: characteristics, differential diagnostic value, and possible implications for treatment. radiology, 1990; 176: 447-50. 17. hou j, kshettry vr, selman wr, nicholas c. bamb akidis, m.d. neurosurg focus, 2013: 35. 18. zimmerman rd, seidenwurm dj, davis pc, brunberg ja, de la paz rl, dormont pd, et al. orbits, vision, and visual loss. [online publication]. reston (va): american college of radiology (acr); 2006. http://reference.medscape.com/viewpublication/6840 http://reference.medscape.com/viewpublication/4922 http://reference.medscape.com/viewpublication/4922 http://reference.medscape.com/viewpublication/4922 http://reference.medscape.com/viewpublication/6116 http://reference.medscape.com/viewpublication/6116 http://reference.medscape.com/viewpublication/6116 232 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology original article neonatal screening for leukocoria sana nadeem, b. a. naeem, parveen akhtar, mariam farooq pak j ophthalmol 2014, vol. 30 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sana nadeem department of ophthalmology, foundation university medical college/ fauji foundation hospital, jhelum road, rawalpindi doctorsana@hotmail.com …..……………………….. purpose: to incorporate distant direct ophthalmoscopy for red reflex analysis to screen neonates for leukocoria and establish its importance. material and methods: a prospective study was conducted at department of pediatrics, fauji foundation hospital, rawalpindi, from february 2013 to september 2013. a total of 500 random neonates (newborns less than 28 days of age) were screened for leukocoria by distant direct ophthalmoscopy at 50 cm by means of a direct ophthalmoscope in dark conditions. the red reflex was compared between the two eyes and was classified into five categories: red, orange, yellow, suspect / faint, and absent / leukocoria. the red reflex was compared to the gestational age, birth weight, oxygen therapy, phototherapy, and blood transfusion. results: the results were tabulated and analyzed using spss version 17. the red reflex was analyzed and compared with neonatal variables (weight, gestational age, use of oxygen therapy, phototherapy and blood transfusion). the red reflex was found to be normal shades of red or orange in 495 neonates (990 eyes), with orange being predominant in 786 (78.6%) eyes, red in 204 (20.4%), yellow in 4 (0.4%), suspect / faint in 4 (0.4%), and absent / leukocoria in 2 (0.2%) eyes. statistically significant association of the red reflex was found with oxygen therapy only (p = 0.000). conclusion: neonatal screening for red reflex assessment with distant direct ophthalmoscopy is essential for the early diagnosis and prompt management of ocular diseases causing leukocoria, which will subsequently prevent irreversible blindness, which is bound to occur if the diagnosis is delayed. hence the importance of routine neonatal screening cannot be overemphasized. key words: neonatal, red reflex analysis, leukocoria eukocoria is a term used for a white pupillary reflex or an altered red reflex on distant direct ophthalmoscopy,1 and is a grave cause of visual morbidity in children. the term derives its name from the greek8 words, ‘leukos’ meaning white, and ‘kore’ meaning pupil. leukocoria implies opacification of the structures lying within the visual axis and heralds danger. it is a rare and ominous finding which signifies serious ocular disease like congenital cataract, retinoblastoma, advanced retinopathy of prematurity (rop), persistent hyperplastic primary vitreous (phpv), coat’s disease, uveitis etc, which threaten vision permanently and some, like retinoblastoma are life threatening.2,3 the assessment of the red reflex or bruckner test by means of the direct ophthalmoscope is a very simple, useful, quick, non-invasive, and effective tool for detecting leukocoria in neonates.4 childhood blindness varies in etiology according to regional and socioeconomic differences. regarding the developing countries; 7 – 31% of childhood blindness and visual impairment can be avoided, 3 – 28% is preventable, and around 10-58% can be treated.5 this constitutes a tremendous public health issue in such countries6. hence, the need for screening for potentially blinding ocular diseases arises with enormous magnitude, to prevent blindness. according to estimates in 2000, 1.4 million children are blind7 l mailto:doctorsana@hotmail.com neonatal screening for leukocoria pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 233 globally, and the majority belongs to developing countries. in these countries, due to illiteracy, poverty, and unawareness, there is reluctance to seek medical advice, and often delayed presentation to the ophthalmologists, with resultant advanced disease or refractory amblyopia, often with no chance of salvation of vision. the importance of neonatal screening for leukocoria is often overlooked and is not a routine in most maternity or pediatric departments in our country. this results in delay in diagnosis and seeking of medical treatment, with subsequent disastrous consequences. thus we decided to undertake a study to routinely screen neonates by distant direct ophthalmoscopy in order to detect those potentially vision threatening conditions which present with leukocoria, and manage them promptly. we also embarked to observe the red reflex variations in different neonates, and whether there existed an association between the reflex and the various neonatal variables; gestational age, birth weight, oxygen therapy, phototherapy, and blood transfusion. by this study, we aim to establish the importance of screening neonates for leukocoria, which should become a routine practice in all the maternity and pediatric units of the country. this will result in early detection, prompt referral, treatment and consequently good visual development of the newborns afflicted with such disease. material and methods this descriptive, quantitative study was carried out by the department of ophthalmology with cooperation of the department of pediatrics, fauji foundation hospital, rawalpindi, from february to september, 2013. a total of 1000 eyes of 500 random newborns in the nursery or neonatal intensive care unit, which were either delivered or admitted after birth, were examined by a single observer, to assess the colour of the reflex, homogeneity, and any abnormality (figures 1 and 2). distant direct ophthalmoscopy of a neonate. the heine beta 200 direct ophthalmoscope was used at a distance of about 50 cm in dark conditions, to evaluate the red reflex, separately, and simultaneously of the two eyes. the reflex was classified into the following: red, orange, yellow, suspect / faint, or absent / leukocoria, according to the experience of the observer. the eyes were not routinely dilated except for very small pupils, in which case, dilating drops of phenylephrine 1% and cyclopentolate 0.2% were instilled thrice before the assessment. the gestational age, gender, birth weight, oxygen therapy, phototherapy, or blood transfusion (if needed) were noted for each neonate from the hospital files, as assessed by the peadiatricians and gynaecologists, to compare with the reflex, and to note any association. all these were recorded on a data sheet. exclusion criteria included very ill newborns and those with syndromes. fig. 1: distant direct ophthalmoscopy of a neonate fig. 2: red reflex assessment the data was tabulated and analyzed in the spss version 17 software. frequencies and percentages were calculated for the red reflex shades, gestational age, gender, birth weight, and the neonatal variables (oxygen therapy, phototherapy, and blood transfusion). the chi square test was used to analyze any association between the red reflex and the above sana nadeem, et al 234 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology variables. the significance level was set at 95% for each. results the neonates examined included 266 males, and 234 females. the red reflex was found to be normal shades of red or orange in 990 eyes, with orange being predominant in 786 (78.6%), red in 204 (20.4%), yellow in 4 (0.4%), suspect / faint in 4 (0.4%), and absent / leukocoria in 2 (0.2%) eyes (table 1). the yellow, suspect / faint and absent reflexes were examined in detail, in the eye out patient department. one of the yellow reflexes had a normal exam, the other was lost to follow up, one suspect / faint reflex was found to be bilateral anterior uveitis, with a normal fundus, the other died before examination, and the neonate with absent reflex had bilateral leukocoria due to congenital anterior polar and nuclear cataracts, with normal posterior segments. the child was subsequently operated within 3 weeks and fitted with aphakic spectacles promptly. the reflexes were symmetrical in hue in 312 (62.4%), and asymmetrical in 188 (37.6%) neonates. comparison of the reflex with neonatal variables resulted in a statistically significant association of the orange hue with oxygen therapy only (p = 0.000), and no association with gestational age (p = 0.559), birth weight (p = 0.204), phototherapy (p = 0.503), or blood transfusion (p = 0.476) (table 2). discussion leukocoria is generally classified1 into pre-lenticular, lenticular, retrolenticular, and mixed presentation leukocoria. causes of leukocoria are manifold: the most devastating being the retinoblastoma; most commonly presenting with a white pupillary reflex, with an estimated incidence of 1 in every 15000 – 20000 live births, and a worldwide mortality of 5 – 11%.9-12 retinopathy of prematurity (rop), previously termed ‘retrolental fibroplasia’ is one major preventable cause13. another major cause is congenital cataract, which represents 10% of the global preventable visual loss, with an incidence of 1 in every 2000 live births.14-15 other causes of leukocoria include persistent hyperplastic primary vitreous (phpv), coat’s disease, toxocariasis, retinal detachment, chorioretinal colobomas, other retinal tumors, corneal scarring, and uveitis to name a few.2,16 the red reflex seen by illuminating the fundus by means of a direct ophthalmoscope is caused by light passing through the pupil onto the retina, and resultant partial reflecting back of the light from the retina, through the pupil to give a reddish – brown homogenous reflex indicating the colour of retina and choroid. the test should be performed with the ophthalmoscope at 50 cm away, with the dial preferably set at ‘0’, in a dark room to allow mydriasis and for better contrast. in presence of normal transparent ocular media the reflex is reddish-orange. any abnormality or opacification of the cornea, aqueous humor, lens, vitreous, or retina can result in a suspect or absent red reflex. hence, this test is very useful and any absence of the red reflex, abnormal size, shape, position, non-homogeneity, presence of dark spots, significant asymmetry, or milky white spots, need immediate ophthalmologist referral. variations in colour exist with race due to difference in fundus pigmentation.17-22 in our study, we found the red reflex to be of varying shades of red and orange predominantly, with yellow, suspect or absent reflex in only 5 neonates. we found bilateral anterior uveitis and congenital cataract in one child each. studies carried out on red reflex screening on neonates and children are many fold. neonatal screening for leukocoria pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 235 a study18 carried out in brazil on 190 neonates found a suspect reflex in 3 newborns. five infants were identified with congenital cataract on routine testing, in a study carried out in israel in 2007-200819. the sensitivity of this test in detecting ocular pathology is 82.6%, as depicted by a study from nepal in 2012.22 in our study, a significant association of the red reflex was found, with oxygen therapy only. out of the 125 neonates who received oxygen therapy after birth, predominantly orange reflex was observed in 84 (67.2%) cases, followed by red in 39 (31.2%) cases. although, we consider red and orange reflexes to be normal, larger scale studies are needed to establish a definitive relation of oxygen therapy if any. we did not include duration of oxygen therapy in our study. a colour gradient instrument was used in a study carried out in brazil18 in 2011 to classify the red reflex and significant associations were found between the instrument and neonatal variables including weight, gestational age, and oxygen therapy. here too, orange reflex was predominant in 52.6% of neonates receiving oxygen; however, no relationship was seen with duration of exposure. the importance18-28 of red reflex screening of neonates and children has been established in various countries around the world like america, canada, britain, israel, and india, to name a few. studies carried out by abramson29 et al and canzano30 et al recommend pupillary dilatation for detection of retinoblastoma as a dilated pupil increases the sensitivity of the red reflex test. we avoided dilating all the patients, for fear of the known adverse effects of the topical agents, and only dilated those neonates with very small pupils in which the red reflex was difficult to discern. this could be a limitation of our study. the importance of red reflex testing needs to be realized by ophthalmologists, and measures to create awareness of this noninvasive and useful test need to be undertaken in the nurseries and pediatric units of all hospitals, to train their doctors; with appropriate urgent referral to the ophthalmologist if any abnormality is detected on routine testing. the early detection of such diseases which cause leukocoria would result in saving vision or lives of children, which would have immense long-term benefits for those unfortunately afflicted with the disease. prevention of visual loss is also our responsibility and we should play our role as much as we can for this cause. identification of risk factors such as low birth weight and a positive family history for certain diseases like retinoblastoma and congenital cataract would result in meticulous screening at birth and at frequent follow ups. childhood blindness and visual impairment is a considerable public health issue. prevention of visual impairment and blindness in children is an international concern of foremost priority. screening for ocular diseases by doctors will play a key role in early detection, intervention and subsequent management. conclusion screening of neonates for red reflex assessment with distant direct ophthalmoscopy, for diagnosing leukocoria is an extremely easy, noninvasive and useful test for early detection and management of, vision or life threatening diseases, and needs to become a routine in all hospitals of our country. this will have a long term effect on the lives of neonates affected by ocular disease. author’s affiliation dr. sana nadeem assistant professor department of ophthalmology foundation university medical college/ fauji foundation hospital jhelum road, rawalpindi prof. b. a. naeem professor and head, department of ophthalmology foundation university medical college/ fauji foundation hospital jhelum road, rawalpindi prof. parveen akhtar professor and head, department of paediatrics foundation university medical college/ fauji foundation hospital jhelum road, rawalpindi dr. mariam farooq post graduate trainee department of paediatrics foundation university medical college/ fauji foundation hospital jhelum road, rawalpindi sana nadeem, et al 236 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology references 1. tartarella mb, britez-colombi gf, fortes filho jb. proposal of a novel classification of leucocorias. clin ophthalmol. 2012; 6: 991-5. 2. patel n, salchow dj, materin m. differentials and approach to leukocoria. conn med. 2013; 77: 133-40. 3. balmer a, munier m. differential diagnosis of leukocoria and strabismus, first presenting signs of retinoblastoma. clin ophthalmol. 2007; 1: 431-9. 4. tuli sy, giordano bp, kelly m, fillipps d, tuli ss. newborn with an absent red reflex. j pediatr health care. 2013; 27: 51-5. 5. kong l, fry m, al-samarraie m, gilbert c, steinkuller pg. an update on progress and the changing epidemiology of causes of childhood blindness worldwide. j aapos. 2012; 16: 507-1. 6. maida jm, mathers k, alley cl. pediatric ophthalmology in the developing world. curr opin ophthalmol. 2008; 19: 403-8. 7. world health organization. preventing blindness in children: report of who / iapb scientific meeting. programme for the prevention of blindness and deafness, and international agency for prevention of blindness. geneva: who, 2000 (who/pbl/00.77) 8. buscombe c, headland s. infantile leukocoria: the white pupil. bujo. 2013; 1: 1-4. 9. bukhari s, aziz-ur-rehman, bhuttu ia, qidwai u. presentation pattern of retinoblastoma. pak j ophthalmol. 2011; 27: 142-5. 10. khurram d, zaheer n, hassan s. clinical presentation and staging of newly diagnosed intraocular retinoblastoma according to international classification of retinoblastoma. alshifa journal of ophthalmology. 2011; 7: 32-8. 11. arif m, iqbal z, zia-ul-islam. retinoblastoma in nwfp, pakistan. j ayub med coll abbottabad. 2009; 21: 60-2. 12. luo c, deng yp. retinoblastoma: concerning its initiation and treatment. int j ophthalmol. 2013; 6: 397-401. 13. sabzehei mk, afjeh sa, farahani ad, shamshiri ar, esmaili f. retinopathy of prematurity: incidence, risk factors, and outcome. arch iran med. 2013; 16:507-12. 14. rosenfeld si, blecher mh, bobrow jc, bradford ca, glasser d, berestka js. lens and cataract. section 11. basic and clinical science course. american academy of ophthalmology. san francisco. 2004-2005; p 33-9. 15. simon jw, buckley eg, drack av, hutchinson ak, plager da, rabb el, ruttum ms, aaby aa. paediatric ophthalmology and strabismus. section 6. basic and clinical science course. american academy of ophthalmology. san francisco. 2004-2005; p 277-89. 16. haider s, qureshi w, ali a. leukocoria in children. j pediatric ophthalmol strabismus. 2008; 45: 179-80. 17. tamura myy, teixeira lf. leukocoria and the red reflex test. einstein. 2009; 7: 376-82. 18. carvalho de aguiar as, ximenes lb, lúcio iml, pagliuca lmf, cardoso mvlml. association of the red reflex in newborns with neonatal variables. rev latino-am enfermagem. 2011; 19: 309-16. 19. eventov – friedman s, leiba h, flidel – rimon o, justerreicher a, shinwell es. the red reflex examination in neonates: an efficient tool for early diagnosis of congenital ocular disease. isr med assoc j. 2010; 12: 259-61. 20. buckley ej, ellis gs jr, glaser s, granet d, kivlin jd, lueder gt, et al. red reflex examination in neonates, infants, and children. pediatrics. 2008; 122: 1401-4. 21. mclaughlin c, levin av. the red reflex. pediatr emerg care. 2006; 22: 137-40. 22. saiju r, yun s, yoon pd, shresta mk, shresta ud. bruckner red light reflex test in a hospital setting. kathmandu univ med j. 2012; 10: 23-6. 23. bell al, rodes me, collier kellar l. childhood eye examination. am fam physician. 2013; 88: 241-8. 24. patel n, salchow dj, materin m. differentials and approach to leukocoria. conn med. 2013; 77: 133-40. 25. li lh, li n, zhao jy, fei p, zhang gm, mao jb, rychwalski pj. findings of perinatal ocular examination performed on 3573, health full-term newborns. br j ophthalmol. 2013; 97: 588-91. 26. muen w, hindocha m, reddy m. the role of education in the promotion of red reflex assessments. jrsm short rep. 2010; 1: 46. 27. li j, coats dk, fung d, smith eo, paysse e. the detection of simulated retinoblastoma by using red-reflex testing. pediatrics. 2010; 126: e202-7. 28. gogate p, gilbert c, zin a. severe visual impairment and blindness in infants: causes and opportunities for control. middle east afr j ophthalmol. 2011; 18: 109-14. 29. abramson dh, beaverson k, sangani p, vora ra, lee tc, hochberg hm, kirszrot j, ranjithan m. screening for retinoblastoma: presenting signs as prognosticators of patient and ocular survival. pediatrics. 2003; 112: 1248-55. 30. canzano jc, handa jt. utility for pupillary dilatation for detecting leukocoria in patients with retinoblastoma. pediatrics. 1999; 104: e44. microsoft word 1. editorial 28,3,12 116 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology editorial femtosecond laser assisted cataract surgery cataract surgery has passed through many phases. from couching to intracapsular cataract extraction to extracapsular cataract extraction and then to phacoemulsification. phacoemulsification, a revolutional invention of charles kelman, brought great refinement in surgical management of cataract. now ever increasing use of modern technology has lead to use of laser assisted cataract surgery. this is a new emerging use of a technology called as femtosecond laser. it is an ultrafast, infrared laser with the speed of 0.001 mm at one billionth of a second (10-15 sec) working at wave length of 1052 nm. uses of femtosecond laser in ophthalmology 1. flap preparation in lasik 2. laser assisted cataract surgery 3. astigmatic keratotomy 4. tunnel formation for implantation of icrs in progressive keratoconus. 5. corneal biopsy among all these indications, the use in cataract surgery is extremely important as cataract is the commonest eye surgery performed. image guided femtosecond laser brings a lot of automatation in many crucial steps of cataract surgery which ultimately makes some of the more difficult and unreliable parts of cataract surgery more precise and more dependable. the femtosecond is a more accurate, reproducible and gives surgeons the ability to be more consistent. this laser is precise down to micron level instead of millimeters. although enhanced performance in all of these areas is desirable for every cataract patient, however the individuals who elect premium iols perhaps desire improvement, the most. their high expectation have been fuelled by excellent safety and performance of refractive laser corneal surgery. most patients in general, however, now expect emmetropia after cataract surgery. the following steps of cataract surgery will be performed by femtosecond laser. the capsulorhexis femtosecond laser will be used to perform centered, round, custom – designed anterior capsulotomy in any size of surgeon’s choice. capsulorhexis is a key determinant of an emmetropic outcome in cataract surgery. many ophthalmologists have identified this step as single most important surgical contributor to the predictability of the refractive outcome. variations in the shape, size and position of capsulorhexis have a significant influence on the effective lens position and correspondingly patients refractive outcome. for example in case of too large sized rhexis, the edge of rehexis does not completely overlap iol’s optic and it can slide behind the optic, which will alter the position of iol, and with small sized capsular rhexis, phimosis can occur which can cause tilt and anterior displacement of iol. both these scenarios will have adverse refractive outcomes. the manual techniques of capsulorhexis formation have changed significantly over the years nevertheless great variation still exists in terms of outcomes. it has been found that only 10% of manually created capsulorhexes are with in 0.25 mm of their intended diameter versus 100% of those created by femtosecond laser1. femtosecond laser can allow surgeon to place a circular rhexis with a precise diameter at an exact location on the anterior capsule. in some machines real time oct is integrated into the femtosecond laser system to image anterior and posterior capsule intraoperatively in three dimensions. the true spheroid of the lens can then be defined. with this information a logical location of capsularhexis can be determined that would otherwise be impossible with current mechanical and subjective means, which are limited to the surgeon’s view of twodimensional surface of the anterior lens capsule and the pupil. conditioning of crystalline lens image guided femtosecond laser softens or emulsifies cataract into small fragments using shock waves that will cause bubble like implosions. this technology can condition the lens to reduce both the amount of ultrasonic energy and the number and amplitude of femtosecond laser assisted cataract surgery pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 117 manipulations needed for its removal. lensconditioning patterns include a ‘cubing’ guide laid down with in the central endonucleus. the resultant cubes represent a fractionation and disruption of the mechanical structure of the crystalline lens and the effectively decrease the nuclear density. a nuclear sclerotic cataract is typically softened by two grades (eg, from grade 4 to grade 2). this softening increases the patient’s safety, because less vigorous manipulations will be required than for a denser nucleus. this conditioned nucleus is removed by using traditional ultrasonic handpiece. in the future it may be possible to cube and soften lenses to the extent that their removal is possible with irrigation and aspiration alone. another option in lens conditioning is the creation of fracturing plane. this is like mechanical prechopping technique of takayuki akahoshi. femtosecond laser can create a channel in the nucleus. a chopping or quadranting maneuver can then be performed along these planes but with considerably less intraocular force. safety should increase due to less imposed zonular and capsular stress. incisions the image guided femtosecond technology has the potential to greatly augment the current cataract procedure by addressing the inherent variability of mechanical methods for making corneal incisions. the main cataract incision can induce astigmatism and contribute to wound leaks and subsequent endophthalmitis. with its high level of precision and consistency, femtosecond technology can allow surgeons greater control of corneal curvature and astigmatism induced by the corneal incision. more importantly, the laser has the potential to create more consistently watertight incisions, which should decrease the postoperative ingress of pathogens. femtosecond technology may also offer a means of improving the creation of peripheral corneal relaxing incisions. many techniques for relaxing incisions call for a set blade depth of 600 micron, which likely has an unpredictable effect because the depth of the peripheral cornea varies among patients and even with in the perimeter of a given patient’s cornea. such variation can lead, at best, to suboptimal refractive accuracy and, at worst, to microor macro-corneal perforations. nomograms such as that developed by louis nichamin are designed to deliver greater accuracy by measuring peripheral corneal pachymetry and adjusting the diamond blade accordingly. these efforts represent a step in the right direction. femtosecond technology can go farther by combining the flexibility of patterns with optical coherence tomography, not only to deliver more precise cuts, but also to permit completely different approaches to relaxing incisional architecture. advantages of femtosecond cataract surgery 1. less time than standard phaco surgery. 2. less corneal complications than standard phaco surgery due to reduction in power or u/s power. 3. femtosecond laser can be used to create a perfectly centered, shaped and sized refractive capsulotomy with no radial tears. 4. water tight main corneal incision and improved and consistant peripheral corneal relaxing incisions. 5. good iol centration and improve outcomes of premium iol implantation and accommodative iol insertion because these iols need a continuous central capsulotomy to hold them in place. based on the technology’s established results for lasik and the promising human cataract trials currently being conducted, the femtosecond cataract surgery may well be the first major paradigm shift since ultrasound disrupted the status quo. reference 1. nagy z. intraocular femtosecond laser applications in cataract surgery. cataract & refractive surgery today. 2009; 9: 79-82. prof. dr. khalid iqbal talpur abstract: 65 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology author communication intravitreal bevacizumab in non-arteritic anterior ischemic optic neuropathy with bilateral optic disc drusen muhammad khalil, tayyaba gul malik pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyaba gul malik professor of ophthalmology rashid latif medical college e-mail: tayyabam@yahoo.com …..……………………….. non-arteritic anterior ischemic optic neuropathy is a vascular disease of optic nerve head. it occurs around 60 years of age and usually associated with hypertension, diabetes, hyperlipidemia and smoking. we present a case of bilateral optic disc drusen with unilateral anterior ischemic optic neuropathy in a 50 years old asian male. he had history of transient obscuration of vision before he developed non-arteritic anterior ischemic optic neuropathy. intra vitreal bevacizumab was given and no improvement was seen in visual acuity after three months of follow-up. key words: optic disc drusen non-arteritic anterior ischemic optic neuropathy, optic disc edema, intravitreal bevacizumab. nterior ischemic optic neuropathy (aion) is a disease of micro-circulation of the optic nerve head. although arteritic aion is related with giant cell arteritis, non-arteritic aion (naion) is associated with small crowded discs, optic disc drusen, hypertension, diabetes, hyperlipidemia and smoking. naion with optic disc drusen occurs at an earlier age. vascular supply is compromised due to drusen in already small discs. presence of optic disc drusen is an incidental finding but there is evidence that patients report transient visual obscurations as a result of increased pressure in the optic nerve head. we present a case of bilateral optic disc drusen with unilateral naion. the effect of a single injection of intravitreal bevacizumab is discussed in this case report. case report a fifty years old asian male presented with sudden onset of decreased vision in left eye. he also complained of transient obscuration of vision in the last few months. he was known hypertensive and non-diabetic. there was history of familial hyperlipidemia and transient ischemic attacks. the patient suffered left hemiparesis in 2005 and he had undergone left cholesteotoma surgery three times in the past (latest in year 2000). the patient was an average stature, average built male and general physical examination showed no systemic abnormality. he was orthotropic with bestcorrected visual acuity of 6/9 in right eye and 6/60 in left eye. color vision was disturbed in left eye. extra ocular movements were normal with no pain on eye movements. there was left rapd and slit lamp examination for anterior segment showed +1 nuclear sclerosis in each eye. intra ocular pressures were 13 mm hg in each eye. fundus examination revealed bilateral macular drusen. optic disc drusen were also seen in both eyes and optic disc edema in left eye. optic disc drusen were confirmed on b-scan and red free fundus photographs. oct showed inferior rnfl defect in right eye while in left eye there was thickening of rnfl indicating disc edema. blood work up was unremarkable (cbc, esr, lfts, rfts). serum cholesterol was normal but triglycerides were high (524.2 mg/dl). ecg and echocardiography were normal. carotid doppler was normal. ct angio showed tiny calcific atheromatous plaques in distal a mailto:tayyabam@yahoo.com intravitreal bevacizumab in naion with bilateral optic disc drusen pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 66 portion of left common carotid artery and proximal left internal carotid artery with normal lumen. the patient was given an intravitreal injection of bevacizumab 1.25 mg in 0.05 ml. there was no improvement in visual status after three months of follow up. discussion naaion is associated with hypertension, diabetes and hyperlipidemia. other associations include, migraine, use of oral contraceptives, anemia and use of antihypertensive medicines at bed time. this particular patient had systemic as well as ocular risk factors for naion; hyperlipidemia, hypertension, small crowded discs and optic disc drusen. optic disc drusen with co-existing vascular risk factors in a patient of naaion was also reported by deborah and sharon1. although optic disc drusen are asymptomatic but they can lead to complications including naion. optic disc drusen can also cause fig. 1: fundus photographs showing optic disc drusen in both eyes and disc edema in left eye. fig. 2: red free fundus photographs showing auto-fluorescence of optic disc drusen in both eyes and disc edema in left eye. muhammad khalil, et al 67 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology fig. 3: b-scan showing optic disc drusen. fig. 4: inferior altitudnal visual field defect in naaion and optic disc drusen. crao and crvo due to small scleral canal and crowding of retinal nerve fibers in the optic disc. naaion with optic disc drusen occurs at a younger age as was seen in our patient whose age was 50 years. ayhan z has reported naion with bilateral optic disc drusen in a 46 years old patient2. the youngest patient reported to have naion with optic disc drusen was of 12 years3. other authors have also reported optic disc drusen with naion.4 purvin et al in a case series showed that patients with naion with optic disc drusen have transient visual obscurations5. this finding was consistent with our patient who had transient obscuration of vision and transient ischemic attacks before he developed optic neuropathy. although purvin reported better visual prognosis in such patients, our patient had poor visual outcome after three months of follow up. this particular patient had inferior altitudinal visual field loss which is seen in 55 to 80% cases of naion6. hypertension can have a direct effect on optic disc blood supply as well as indirect effect, caused by nocturnal hypotension due to antihypertensive drugs taken at bed time. use of anti vegf agents in retinal diseases has become wide spread all over the world. its use in the treatment of naion is also reported in literature but with variable results. it is hypothesized that antivegfs decrease disc edema thus resulting in decrease pressure on optic nerve fibers and better visual outcome. but the results are inconsistent. some authors showed visual improvement after injecting intravitreal anti-vegf for naion7. others showed no visual improvement in vision after intravitreal antivegf injection8. this was similar to our result. still there are other reports which found no difference between bevacizumab and natural history for change in visual field, visual acuity, or optic nerve oct thickness9. one case report showed definitive promising results where naion was related with macular edema10. this can be explained by the fact that the visual loss caused by macular edema was corrected with anti-vegf which has shown promising results in macular edema cases. intravitreal bevacizumab in naion with bilateral optic disc drusen pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 68 few case reports are not enough evidence for use of anti-vegf in naion. further clinical trials are needed to see the role of these agents in optic nerve diseases. conclusion optic disc drusen are important risk factor for development of naion in younger patients, even in the absence of vascular risk factors. however, these patients should be kept at close watch for earlier and timely management of vascular factors like hypertension, diabetes, migraine, hyperlipidemia and anaemia etc. role of anti-vegf in this condition is still a question mark. authors affiliation dr. muhammad khalil fcps, professor of ophthalmology lahore medical and dental college dr. tayyaba gul malik fcps, professor of ophthalmology, rashid latif medical college role of authors dr. muhammad khalil data acquisition, analysis, data compiling and manuscript drafting. dr. tayyaba gul malik data acquisition, analysis, data compiling and manuscript drafting. references 1. deborah kl, sharon lc. acute visual loss in a patient with optic disc drusen. clin ophthalmol. 2013; 7: 795– 799. 2. ayhan z, yaman a, bajin ms, saatci ao. unilateral acute anterior ischemic optic neuropathy in a patient with an already established diagnosis of bilateral optic disc drusen. case rep ophthalmol med. 2015; 4. 3. nanji aa, klein ks, pelak vs, repka mx. nonarteritic anterior ischemic optic neuropathy in a child with optic disk drusen. j aapos. 2012; 16: 207–9. 4. megur, d. megur, u. megur, and s. reddy. anterior ischemic optic neuropathy in association with optic nerve head drusen. indian j ophthalmol. 2014; 62 (7): 829–31. 5. purvin v, king r, kawasaki a, yee r. anterior ischemic optic neuropathy in eyes with optic disc drusen. arch ophthalmol. 2004; 122: 48–53. 6. traustason oi, feldon se, leemaster je, weiner jm. anterior ischemic optic neuropathy: classification of field defects by octopus automated static perimetry. graefes arch clin exp ophthalmol. 1988; 226: 206–12. 7. saatci ao, taskin o, selver ob, yaman a, bajin ms. efficacy of intravitreal ranibizumab injection in acute nonarteritic ischemic optic neuropathy: a long-term follow up. open ophthalmol j. 2013; 7: 58-62. 8. pece a, querques g, quinto a, isola v. intravitreal ranibizumab injection for nonarteritic ischemic optic neuropathy. j ocul pharmacol ther. 2010; 26: 523-7. 9. rootman db, gill hs, margolin ea. intravitreal bevacizumab for the treatment of nonarteritic anterior ischemic optic neuropathy: a prospective trial. eye, 2013; 27: 538-44. 10. dave vp, pappuru rr. an unusual presentation of nonarteritic ischemic optic neuropathy with subretinal fluid treated with intravitreal bevacizumab. indian j ophthalmol. 2016; 64 (1): 87-8. microsoft word 05-oa uzma feseeh pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 16 original article review of outpatient department spencer eye hospital (a study of 1900 patients) uzma fasih, arshad shaikh, atiya rahman, m. s. fehmi, m. rais pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: uzma fasih b-21 block 10 federal b area karachi …..……………………….. purpose: to determine the pattern of different diseases among the patients attending the opd. material and methods: the study was carried out at outpatient department spencer eye hospital from march 2011 to july 2011 and included 1,900 patients. patients were selected from outpatient department spencer eye hospital through non probability consecutive sampling technique. relevant history was taken. they were examined thoroughly including detailed slit lamp examination, direct and indirect fundoscopy and refraction. diagnosis was established and data of the patient was recorded and later on compiled. results: nineteen hundred patients were included in the study, 900 (47.3%) were male and 1000 (52.7%) were female. most commonly presenting age group among male patients was 60 – 69 years, while most common age group among female patients was 40 -49 years. we observed that the main bulk of the opd consisted of patients who presented with infectious conjunctivitis (mostly trachoma) (24%) and with cataract (23.1%), followed by those who presented with refractive error (17.4%). presentation of pterygium and corneal ulcer was 11.0% and 3.02% respectively. cases of glaucoma and strabismus, were 2.8% and 1.28% respectively. few patients with vitamin a deficiency and albinism also reported. conclusion: infectious diseases and cataract are more prevalent in this area as compared to other ocular disorders especially of posterior segment. so the available funds should be directed in these lines. utpatient departments forms the major component of health care systems in national health services. successful management of opd services is costly requiring funding for building itself employment of medical and clerical staff and use of paramedical services.1,2 even if an organized opd setup is available people usually do not present to get the eye care facilities until and unless a potentially blinding emergency is faced. a study conducted at aravind eye hospital, south india to evaluate the utilization of eye care services in rural south india. 5150 randomly selected subjects underwent ocular examinations and previous use of eye care services was collected via questionnaire in order to determine utilization of eye care services in a rural population of southern india. 3,476 (72.7%) of 5,150 subjects examined required eye care examinations. 1,827 (35.5%) people gave a history of previous eye examinations, primarily from a general hospital (n= 1,073, 58.7%).3 another study was done in andhra pardesh to understand the reasons why people in rural south india with visual impairment arising from various ocular diseases do not seek eye care. barriers to seeking treatment among those who had not sought treatment despite noticing a decrease in vision over the past five years were personal in 52% of the respondents, economic in 37% and social in 21%.4 in spite of the fact that modern technical facilities like phacoemulsification and microincision cataract surgery are available in most parts of the world but old traditional treatment methods like couching are still practiced in certain parts of the world like africa.6 o uzma fasih, et al 17 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology complications of couching like hypheama, glaucoma and panuveitis are prevalent in these parts of the world.5, 6 spencer eye hospital was built in 1940 and has such a location that it drains population not only from central parts of karachi and lyari and its associated areas (less privileged / low socioeconomic status) but also caters for the population from the coastal areas as makran and balochistan. we conducted an opd survey with the objective to determine the pattern of different diseases among the patients attending the opd. material and methods the study was carried out at outpatient department spencer eye hospital from march 2011 to july 2011 and included 1,900 patients. it was a hospital based descriptive study all patients who attended the opd during the allocated time period were included. patients were selected from outpatient department spencer eye hospital through non-probability consecutive sampling technique. relevant history was taken. patients evaluation consisted of slit lamp examination, direct and indirect fundoscopy and refraction. diagnosis was established and data of the patient was recorded and compiled later on. results nineteen hundred patients were included in the study. there were 900 (47.3%) male patients and 1000 (52.7%) female patients. most common presenting age group among male patients was 60-69 years, while most common age group among female patients was 40-49 years (table 1). we observed that the main bulk of the opd consisted of patients who presented with infectious conjunctivitis (mostly trachoma) 24% and cataract 23.1%, followed by those who presented with refractive error were 17.4%. presentation of pterygium and corneal ulcer was present in 11.0% and 3.02% of patients respectively. cases of glaucoma and strabismus were 2.8% and 1.28% respectively. few cases of vitamin a deficiency and albinism were also reported (table 2). discussion the status of eye health care has been evaluated from time to time in our country and steps have been taken to improve it further. in 1980 a who consultant dr. hugh taylor was invited to assess the eye health status of the country and according to his report estimated prevalence of blindness at that time was 2%. in addition cataract was the major cause of blindness and there was a gross mismatch of human recourses in the country7. following this national blindness surveys were done at five year intervals and various steps were taken for the development of eye health care system in the country in the light of these surveys. at present a vision 2020 program has been designed to address priority disease like cataract, trachoma and refractive errors8. according to 2nd national blindness survey all age prevalence of blindness was 0.9%9. spencer eye hospital was built in 1940. location of spencer eye hospital is such that it drains population not only from central areas of karachi and lyari but and its associated areas (less privileged/low socioeconomic status) but also from hub, baluchistan and coastal areas of makran. poverty, illiteracy and ignorance prevail in these areas. in addition transport facilities are insufficient. basic infrastructure is poorly developed and facilities for clean drinking water and sanitation are not up to the mark. this leads to the prevalence of infectious diseases in these areas. 54,150 patients present in opd of spencer eye hospital every year on an average. we conducted a survey to determine the pattern of different diseases among the patients attending the opd in this area. our aim was to develop a database of the disease pattern of our opd so that human resources could be redirected towards more common diseases. review of outpatient department spencer eye hospital (a study of 1900 patients) pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 18 in our study, the bulk of the opd (24.8%) consisted of patients who presented with infectious conjunctivitis (mostly trachoma 70% and acute bacterial conjunctivitis 30%). this could be the result of unhygienic living conditions in the locality. the area is lacking in proper sanitation and there is not only deficiency of clean drinking water but also unavailability of water for cleaning purposes. this may lead to high rate of infections. different studies have proven that people belonging to lower socioeconomic groups share greater burden of blindness than those belonging to higher socioeconomic groups. eye disease like trachoma is mostly prevalent in lower socioeconomic strata.10, 11 in late 1990 pakistan was recognized a one of those countries having endemic trachoma, one of the leading cause of blindness in country. it was included in the list of 47 countries that needed priority intervention. thus pakistan became the member of global elimination of trachoma program (get 2020) 2015 has been fixed as the last date for declaring the country free from blinding trachoma.8 second most common presenting disease in our study was cataract in 23.1% patients. most of the patients presented with mature and hypermature cataracts. quite a number of patients presented with their vision threatening complications as phacomorphic and phacolytic glaucoma. the cause for this late presentation could be lack of awareness, poverty and lack of transport facilities. according to the results of second national survey for blindness all age prevalence of blindness was 0.9%, and cataract was identified as leading cause of blindness. the burden of blindness due to cataract is high (51.5%) and avoidable blindness being 85.4%.9 anjum et al found the overall prevalence of bilateral cataract blindness 4.8% in a study of 1,549 patients12. most of them presented with mild complains of itching irritation and watering which just required symptomatic treatment, while others had posterior capsular opacification which was managed by yag laser capsultomy. according to pakistan national blindness and visual impairment survey avoidable blindness due to posterior capsular opacification was 3.6%.13 11% patients presented with pterygium. as most of the population in the surrounding areas is engaged in outdoor activities and most of the patients were labourers and field workers, this large presentation of pterygium could be due to excessive exposure to ultraviolet radiations of sun. ultraviolet radiation uvr-a and uvr-b play most important role in its pathogenesis14. studies have proven that ptreygium is fairly common in pakistan especially in hot regions of the country15. 4.1% patients presented with ocular trauma. major presentation was of industrial trauma as the hospital is surrounded by an industrial zone. most of the patients had uniocular injuries and potentially preventable injuries as they were caused by lack of or ignorance towards safety measures. ocular injuries are potentially preventable cause of ocular morbidity.16 more than half million blinding uzma fasih, et al 19 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology eye injuries occur every year. there are approximately 1.6 million people blind from eye injuries, 2.3 million with bilateral visual loss and 19 million with unilateral visual loss. ocular trauma is the commonest cause of unilateral blindness.17 khan et al study shows that negligent attitudes, lack of protective devices and severe aggression were the cause of most of the ocular trauma.18 3.58% patients presented with corneal ulcers. majority of these were acute bacterial ulcers and were the direct consequence of unattended corneal injuries and corneal foreign bodies. poverty and poor hygienic conditions were additional factors to aggravate the condition. 17.4% patients attended the opd for refractive errors. these were newly reported cases of refractive errors including myopia, hypermetropia astigmatism in addition to aphakia and pseudophakia. refraction was done and spectacles were prescribed accordingly. according to pakistan national blindness and visual impairment survey avoidable blindness due to uncorrected refractive errors was 2.7% in our country.13 presentation of various types of glaucoma was 2.8%. a portion of this group comprised of those patients who presented with phacomorphic or phacolytic glaucoma while a majority had open angle glaucoma. few cases of angle closure and pseudoexfoliative glaucoma were also reported. allergic conjunctivitis was reported in 2.56% patients vernal catarrh being the most common form. 2.05% patients presented with stye and 0.76% presented with chalazion. these were either the result of poor hygienic conditions or presented as complication of chronic blephritis. 1.53% patients presented with chronic dacryocystitis. majority of these patients belonged to such remote areas where they could not get treatment. 1.28% presented with various types of squints. most of these patients were children who required proper evaluation and refraction. 1.02 % patients presented with diabetic retinopathy. according to pakistan national blindness and visual impairment survey avoidable blindness due to diabetic retinopathy was 0.2%13. awareness about proper diabetic control and timely treatment of diabetic retinopathy should be emphasized. presentation of endophthalmitis was 0.56% and pthisis bulbi 0.51% respectively. pthisis bulbi formed 2.7% of unavoidable blindness in pakistan national blindness and visual impairment survey13. 0.3% patients presented with vitamin a deficiency a fact directly related to poverty and malnutrition. vitamin a deficiency was recognized as an important cause of blindness among children19. vitamin a distribution program was added to the national immunization program. patients presenting with retinal detachment were 0.2%. presentation of albinism was 0.1%. in the light of above statistics it is required that funds and resources should be directed towards more prevalent ocular conditions as infections and cataract and they should be given their due priority. conclusion our study shows that infectious disease and cataract are more prevalent in this area as compared to other ocular disorders especially those of posterior segment. this fact may be the direct result of poor hygienic and sanitary conditions prevalent in this area and poverty. illitracy and ignorance are additional factors. so the available funds and resources should be directed in these lines. although less common diseases cannot be ignored since this hospital is a referral center for lyari and baluchistan areas. author’s affiliation dr. uzma fasih associate professor eye department (unit 2) karachi medical and dental college spencer eye hospital, karachi dr. arshad shaikh professor and head of eye department eye department karachi medical and dental college abbasi shaheed hospital, karachi dr. atiya rahman assistant professor eye department (unit 2) karachi medical and dental college spencer eye hospital, karachi dr. m.s. fehmi professor and incharge eye department (unit 2) karachi medical and dental college spencer eye hospital, karachi dr. m. rais senior registrar eye department (unit 2) karachi medical and dental college spencer eye hospital, karachi review of outpatient department spencer eye hospital (a study of 1900 patients) pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 20 references 1. king a, david d, jones sh, brien oc. factors affecting non attendance in an outpatient department. journal of royal society of medicine. 1995; 88: 88-90. 2. department of health. health and personal social service statistics for england and wales for 1988 london doh 1989. 3. nirmalan pk, katz j, robin al, krishnadas r, ramakrishnan r, thulasiraj rd, tielsch j. utilization of eye care services in rural south india: the aravind comprehensive eye survey. br j ophthalmol. 2004; 88: 1237-41. 4. kovai v, krishnaiah s, shamanna br, thomas r, rao gn. barriers to accessing eye care services among visually impaired populations in rural andhra pradesh, south india. indian j ophthalmol. 2007; 55: 365-71. 5. omoti ae. complications of traditional couching in a nigerian local population. west afr j med. 2005; 24: 7-9. 6. ademola-popoola ds, owoeye jf. traditional couching for cataract treatment: a cause of visual impairment.
west afr j med. 2004; 23: 208-10. 7. the hugh taylor report who 1980. 8. natoinal programme for prevention of blindness 2nd five year plan 1999-2003 ministry of health special education and social welfare islamabad. 9. jadoon mz, dineen b, bourne rr, shah sp, khan ma, johnson gj, gilbert ce, khan md. prevalence of blindness in pakistani adults. the pakistan national blindness and visual impairment survey. invest ophthalmol vis sci. 2006; 47: 4749-55. 10. gilbert ce, shah sp, jadoon mz, bourne r, dineen b, khan ma, johnson gj, khan md. poverty and blindness in pakistan: results from pakistan national blindness and visual impairment survey. bmj. 2008; 336: 29-32. 11. smith af, smith jg. the economic burden of global blindness: a price too high. br j ophthamol. 1996; 80: 267-7. 12. anjum km, qureshi mb, khan ma, jan n, ali a, ahmad k, khan md. cataract blindness and visual outcome of cataract surgery in a tribal area in pakistan. br. j ophthalmol. 2006; 90: 135-8. 13. dineen b, bourne rr, jadoon z, shah sp, khan ma, foster a, gilbert ce, khan md. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 10: 1136. 14. detorakis et, zafiropoulosa, arvanitis da, spandidos da. detection of point mutations at codon 12 of ki –ras in ophthalmic ptreygia. eye (lond). 2005: 19; 210-4. 15. fahmi ms, sayed j, ali m. after removal of pterygium role of mitomycin c and conjunctival autograft. ann abbasi shaheed hosp karachi med dent coll. 2005: 10; 757-61. 16. gothwal vk, adolph s, jalali s, naduvilath tj. dermography and prognostic factor of ocular injuries in south india. aust nz j ophthalmol. 1999: 27; 318-25. 17. negrel ad, thylefors b. the global impact of eye injuries ophthalmic epidemiol. 1998; 5: 143-69. 18. khan md, kundi n, mohammed z, nazeer af. a six and a half year survey of intraocular and intraorbital foreign bodies in nwfp province, pakistan. br j ophthalmol. 1987; 71: 716-9. 19. khan ma, khan md. classification of 154 clinical cases of vitamin a deficiency in children (0-15 years) in a tertiatry hospital in north west frontier province pakistan j. pak med assoc. 2005; 55: 77-8. 44 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology original article role of post-injection antibiotics after intravitreal bevacizumab injection in preventing endophthalmitis muhammad afzal pachuo, amjad ali sahto, muhammad hashim quraishi, ali muhammad abbasi pak j ophthalmol 2015, vol. 31 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mohammad afzal pechuho department of ophthalmology ghulam mohammad mehar medical college & hospital sukkur sindh …..……………………….. purpose: to evaluate the role of using antibiotics after intravitreal injection of bevacizumab in patients to prevent postinjection endophthalmitis. material and methods: a multicentre prospective case control study was carried out at pumhsw hospital nawabshah and ghulam muhammad mehar medical college hospital sukkhur. the injection was given by different surgeons but with same technique. immediately after intravitreal bevacizumab injection the patient was started with topical moxifloxacin and oral ciprofloxacin 500 mg for three days. patients were followed at 1 st , 2 nd and 4 th week post-injection to look for any sign of endophthalmitis. result: out of 620 injections given in 480 eyes, 310 were control group without any post-injection medicine and 310 were cases who were given post-injection medicine. no case of proven or suspected endophthalmitis was identified, corresponding to a risk of 0% per injection. conclusion: in our study use of antibiotics after intravitreal bevacizumab injection does not make any difference for the prevention of postoperative endophthalmitis. keywords: endophthalmitis, bevacizumab,intravitreal antibiotics. ith the recent advancement of widespread indications for the use of antivascular growth factor for different retinal disorders like wet armd, diabetic maculopathy, and crvo, the frequency of intravitreal injection of these drugs is rising. in the year 2009 more than 1000,000 intravitreal anti vegf injections were performed in the united states alone. 1 the number of intravitreal injection of anti vegf given for different indications has increased so much so that it is now 2 nd most to cataract surgery in european countries. 2 the documented complications of the therapy are bacterial endophthalmitis, sterile uveitis, traumatic cataract and rhegmetogenous retinal detachment. 3 however none of the adverse events exceeded 0.21%. 4 endophthalmitis is a visual threatening inflammatory disorder resulting from infection of vitreous cavity. intravitreal injection, penetrating trauma and intraocular surgery are the routes through which exogenous endophthalmitis may occur. 5 multicentre clinical trials with anti vegf therapy showed an incidence rate of post injection endophthalmitis by 0.019% – 1.6%. 6-8 recent survey have suggested that 40% of retina specialists use topical antibiotics prior to intravitreal antivegf injection and 86% use topical antibiotics after intravitreal anti vegf injection. 9 one of the study 10 showed 3 cases of endophthalmitis postinjection to ranibizumab out of 1276 cases who were not given antibiotics before or after injection. because of reported cases of endophthalmitis we carried out a study to reveal the role of post injection antibiotics for it’s prevention, keeping the standard international protocol of preoperative and operative care during intravitreal bevacizumab injection. materials and methods this was a prospective case control study with 310 cases of intravitreal bevacizumab injection given postinjection antibiotics while 310 cases of intravitreal injection given no antibiotics as control group. the later suggests that this w role of post-injection antibiotics after intravitreal bevacizumab injection in preventing endophthalmitis pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 45 wasn’t a consecutive series study. the patients were sorted out from opd with the indications being exudative age related macular degeneration, macular edema due to crvo, brvo, diabetes, uveitis, proliferative retinopathies and choroidal neovascular membrane secondary to myopic degeneration. the study was carried out simultaneously at peoples university of medical and health sciences hospital nawabshah and ghulam muhammad medical college sukkhur between december 2013 and december 2014. the age of patients ranged between 30 to 70 years. all the injections were given in operation theatre with drape administered on the effected eye, washed with povidone iodine. the surgeon with aseptic measures after identifying the site of injection with caliper, 3.5mm in pseudophakic and 4 mm in aphakic eyes, either inferotemporal or superotemporal to limbus gave 0.05 cc of 1.25 mg bevacizumab. postinjection 310 patients were given tab ciprofloxacin 500 mg per oral bd for 3 days along with topical ofloxacin. on the other hand 310 were not given any medication. patients with uncontrolled diabetes and hypertension were excluded from study. those patients with any other intraocular surgical procedure performed at least 4 weeks before injection were also excluded. all the bevacizumab injections were brought from akuh hospital with cold storage and were injected within 24 hours of arrival. acute postoperative endophthalmitis was defined as the presence of progressive inflammation in the vitreous cavity and or anterior chamber within 4 weeks following intravitreal injection of bevacizumab. postinjection patients were followed at 1 st , 2 nd and 4 th week. immediate follow-up on 1st postinjection day was impractical as most patients of study belonged to remote areas and refused to follow back on 1st postinjection day. keeping in view the ground facts the patients were called on 1st postinjection day to ask about any complain. results a total of 620 intravitreal injections of bevicazumab were performed for 480 eyes with macular edema due to diabetic retinopathy, crvo and brvo, uveitis as well as cnv and armd. out of 620 injections 198 (31.93%) were reinjections. follow up after each injection was at least 4 weeks. case group with post injection oral ciprofloxacin 500mg and topical moxifloxacin were not different in any follow up than control group without any post injection antibiotic. no sign and symptom of acute postoperative endophthalmitis seen in any case. 5 (0.80%) patients showed fresh vitreous hemorrhage. no other complication seen. discussion endophthalmitis is a serious vision threatening ocular condition that can occur after intravitreal injections from exogenous approach. 5 bevacizumab is a recombinant humanized mono-clonal igg1 antibody that inhibits human vegf 4 . the intravitreal use of bevacizumab for vegf mediated disease such as choroidal neovascularization, 6 central retinal vein occlusion, proliferative diabetic retinopathy; pseudophakic cystoid macular edema 11 is well established. though there has still not being long term studies in human, limited human and animal studies show that intravitreal bevacizumab is safe. 12,13 the risk factors for endophthalmitis in intravitreal injections are diabetes, old age and blepharitis. insulin depandant diabetes and old age are risk factors for infection due to immunosuppression. 14,15 a general concept proved by studies is that most infections arouse from own flora 16 .this concept is further supported by the fact that blepharitis 17 is one of the major risk factor for postinjection endophthalmitis. jonaset et al, 18 reported that the rate of infectious endophthalmitis after intravitreal injection of 1.5 mg bevacizumab was 1:1000. other studies reporting incidence of endophthalmitis after intravitreal injections of anti vegf drugs include vision clinical trial for pegaptanib injection where infective endophthalmitis rate was 0.16%. 19 another study by macugen 20 used pegaptanib in the treatment of diabetic macular edema found the endophthalmitis occurrence rate to be 0.15%. ranibizumab a newer anti vegf drug, with target on all active isoforms of vegf a showed endophthalmitis rate of 0.25% per injection in a study. 21 in the marina study the incidence of endophthalmitis was 0.05% per injection 7 . in a recent internet based survey fung ae, et al, found the infectious endophthalmitis rate after intravitreal bevacizumab to be 0.01%. 4 fig. 1: number of patients according to indications. along with an established ot set up with all sterilization, disinfection of lid and conjunctiva with povidone iodine it is necessary to keep the needle of injection away from eyelashes which serve as nidus of infection. although definite evidence does not exist to show that pre-injection and post-injection topical antibiotics drops reduce the incidence of endophthalmitis, enhanced topical muhammad afzal pachuo, et al 46 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology antibiotic concentration can facilitate antibiotic bioavailability in ocular tissue (aqueous humour, vitreous humour) and improve antibacterial efficacy. in this regard a recent study showed that although bacterial colony counts can be reduced by the use of topical antibiotic drops administered several days prior to procedure, topical antibiotic drops did not appear to reduce colony counts significantly more than topical povidone as a part of preparation alone. 22 in our study also no difference was found among the two groups who received post injection antibiotics and who do not received any antibiotic. many studies involving intravitreal injections without topical antibiotics have demonstrated a low risk of endophthalmitis. 23-25 yet proved by meredith ta et al. 26 incidence of endophthalmitis was 0.15% among injections with no antibiotic use, 0.08% among injections with preinjection antibiotics only, 0.06% among injections with postinjection antibiotics only, and 0.04% among injections with preinjection and postinjection antibiotics. recent large series have estimated this risk to be about one in 3,000 injections or less. 27 another study with differing results showed that a low incidence of endophthalmitis can be achieved when topical antibiotics are omitted. 28 park y et al in his study concluded that the rate of endophthalmitis after intravitreal injection using aseptic techniques in the clinical practice setting is similar with or without the use of preinjection antibiotics. 29 however because of very low incidence of endophthalmitis no study can rule out the possibility that topical antibiotics might have some role in its incidence. conclusion the results of our study do not prove that topical antibiotics have no effect on reducing the risk of endophthalmitis following intravitreal injection. further if strict preparation protocols of intravitreal bevacizumab injection are followed including use of drape, topical povidone iodine and sterile speculum, the necessity of using postinjection antibiotics is minimal. author’s affiliation dr. mohammad afzal pechuho associate professor and hod department of ophthalmology, ghulam mohammad mehar medical college and hospital, sukkur sindh dr. amjad ali sahto assistant professor department of ophthalmology, peoples university of medical and health sciences, nawabshah sindh dr. muhammad hashim qureshi ophthalmologist department of ophthalmology, ghulam muhammad mehar medical college and hospital, sukkur sindh dr. ali muhammad abbasi ophthalmologist department of ophthalmology, peoples university of medical and health sciences, nawabshah sindh references 1. wykoffcc, flyn hw, rosenfield pj. prophylaxis of endophthalmitis following intravitreal injection, antisepsis and antibiotics. am j ophthalmol. 2011; 152: 717-9. 2. ta cn. topical antibiotic prophylaxis in intraocular injections. arch ophthalmol. 2007; 125: 972-4. 3. van der reis mi, la heij ec, dejong hasse y et al. a systematic review of the adverse events of intravitreal antivascular endothelial growth factor injections. retina 2011; 31: 1449-69. 4. fung ae, rosenfield pj, reichel e. the international intravitreal bevacizumab safety survey using the internet to assess drug safety worldwide. br. j ophthalmol. 2006; 90: 1344-9. 5. lamley ca, han dp. endophthalmitis. a review of current evaluation and management. retina. 2007; 27: 662-80. 6. scoh iu, flyn jr hw. reducing the risk of endophthalmitis following intravitreal injection. retina 2007; 27: 10-2. 7. rosenfield pj, bown dm, heir js, boyer ds, kaiser pk, chung cy et al. the marina study group. ranibizumab for neovascular age related macular degeneration, n engl. j med 2006; 355: 1419-31. 8. brown dm, kaiser pil, 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incidence of acute onset endophthalmitis following intravitreal bevacizumb injection. retina 2008; 28: 564-7. 18. jonas jb, spandau uh, rensh f, vonbeltz s, sch lichten brede f. infectious and noninfectious endophthalmitis after intravitreal bevacizumab. j ocul pharmacol ther. 2007; 23: 240-2. 19. gragoudas es, adamins ap, cunnigham et, femsod m, gayer dr. pegaptanib for neovascular age related macular degeneration. n engl med 2004; 351: 2805-16. 20. macugen diabetic retinopathy study group. a phase ii randomized double mask trial of pegaptanib, an antivascular endothelial growth factor optamen, for diabetic macular oedema. ophthalmology. 2005; 112: 1747-57. 21. heier js, antosyk an, pavan pr, leff sr, rosenfield pj, ciulla ta et al. ranibizumab for treatment for neovascular age related macular degeneration. a phase ii multicenter controlled multidose study. ophthalmology 2006; 113: 642. 22. heiman h. intravitreal injection technique and sequele. in holz fg sapide rf, eds. medical retina. springer berlin heidlberg; 2007: 67-87. 23. diabetic retinopathy clinical research network. a randomized trial comparing intravitreal triamcinolone acetonide and focal /grid photocoagulation for diabetic macular oedema. ophthalmology. 2008; 115: 1447-9. 24. bhavsar ar. a consecutive series of 1000 intravitreous injections without topical antibiotic prophylaxis. invest ophthalmol vis sci. 2008; 49: arvo e abstract 6047. 25. bhavsar ar, emerson gg, emerson mv. a consecutive series of 7450 intravitreous injections without topical antibiotic prophylaxis. invest ophthalmol vis sci. 2010; 51: arvo e abstract 6047. 26. meredith ta, mccannel ca, barr c, doft bh, peskin e, maguire mg, martin df, prenner jl. comparison of age – related macular degeneration treatments trials research group. postinjection endophthalmitis in the comparison of age-related macular degeneration treatments trials (catt). ophthalmology. 2015; 15: s0161-6420 (14)01044-6. 27. schwartz sg, flynn hw jr. endophthalmitis associated with intravitreal anti-vascular endothelial growth factor injections. curr ophthalmol rep. 2014; 2: 1-5. 28. bhavsar ar, sandler dr.eliminating antibiotic prophylaxis for intravitreal injections: a consecutive series of 18,839 injections by a single surgeon. retina. 2014. 29. park y, kim ks, park yh. acute endophthalmitis after intravitreal injection and preventive effect of preoperative topical antibiotics. j ocul pharmacol ther. 2013; 29: 900-5. 129 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology original article estimation of range of intraocular pressure in normal individuals by air puff tonometer sarfraz ahmad mukhtar, ahmad zeeshan jamil, zulfiqar ali pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ahmad zeeshan jamil h # 636/422, street no: 19 muslim town, bahawalpur email: ahmadzeeshandr@yahoo.com …..……………………….. purpose: to estimate the range of iop among normal individuals of different age groups. material and methods: this cross sectional descriptive study was conducted in department of ophthalmology, bahawal victoria hospital, bahawalpur for a period of six months from 1 st feb 2010 to 31 st july 2010. data was collected from 300 normal individuals. the iop was measured with air puff tonometer and results were recorded on specially designed structured proforma. as the variable was quantitative in nature simple descriptive analysis was performed to calculate mean and range of intraocular pressure. results: mean iop was found to be 15.368 ± 3.37 mm hg giving a range of 5 to 25 mm hg. no significant difference was found in the range of iop between individuals of both sexes of various age groups. it also revealed that iop in both eyes of the same individual was almost the same. conclusion: in different age groups iop was similar. similarly, mean iop was found to be same in two sexes. no difference was found in the iop of two eyes. key words: intraocular pressure, air puff tonometer, glaucoma. uman eye is a spherical structure with flexible and elastic walls. maintenance of spherical shape is essential for the optical properties of eye. tissue pressure of the intraocular contents is called intraocular pressure that is maintained by a balance between aqueous humor production and its outflow through the drainage pathways1. intraocular pressure is found to vary depending on the gender, the presence of diabetes mellitus and refractive error in different population of the world.. iop in children is much lower than the adults and it is noted to increase with age2. intraocular pressure is known to differ in various racial groups and even within various regions of the same country.3-5 iop varies with time of the day, changes in body posture, and changes in eye movements6. in population based studies the mean iop is 16 mm hg. two standard deviation of 2.5 on either side gives a range from 11 to 21 mm of hg. there is a significant number of population whose iop is found to exceed normal iop of 21 mm hg on several consecutive occasions but are without any visual damage. similarly in few people, glaucomatous damage is found despite very low iop7. so the rationale of our study is to estimate the range of iop in normal individuals of various age groups of either sex presenting in our settings as this can vary in various setups. consequently this range of iop will act as a tool to early detect and to refer all the cases outside this range to glaucoma clinic for more complex and time consuming tests like assessment of cup disc ratio, automated visual fields and optical coherence tomography to complete the diagnosis and management. material and methods in this cross sectional descriptive study 300 individuals (600 eyes) were included. study subjects were divided into three groups according to age. first group included individuals between 25 to 40 years of h mailto:ahmadzeeshandr@yahoo.com estimation of range of iop in normal individuals by air puff tonometer pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 130 age; second group included 41 to 60 years and third was comprised of individuals older than 60 years. convenient sampling technique was employed to carry out the study. individuals of either sex above 25 years of age with normal vitals including pulse rate, respiratory rate and blood pressure were included in the study while following individuals were excluded from the study. 1. individuals with systemic disease like diabetes mellitus, hypertension. 2. individuals using drugs affecting iop. 3. individuals with history of ocular trauma or surgery. 4. individuals with high astigmatism that could affect iop measurements. 5. individuals with conditions causing difficulty in taking iop like blepharospasm and lid abnormalities. 6. individuals with abnormal cup disc ratio on fundus examination. 7. individuals with visual field defects. the healthy relatives of the patients presenting to outpatient department and admitted in our ward were explained the purpose of study and requested to participate in the study. each individual underwent a thorough ophthalmic examination including visual acuity, visual field analysis by humphrey field analyzer, slit lamp examination and dilated fundus examination to rule out conditions affecting the iop. those who fulfilled our criteria were included in the study. study was approved by ethical and research committee of our hospital. informed consent was taken from study subjects and their demographics like name, age, sex were noted. intraocular pressure of both eyes was taken by air puff tonometer which was shin nippon non-contact tonometer nct-10. average of three iop readings with air puff tonomeret was recorded. iop measurement was performed during the morning hours from 8 am to 11 am. data was collected on specially designed structured proforma. mean outcome measures include 1. range of iop 2. iop according to various age groups. 3. iop in both sexes separately. data were analysed using spss version 10. mean and range of intraocular pressure was calculated in each group. results in our study, a total of 300 subjects (600 eyes) were studied. mean iop was found to be 15.368 ± 3.37 mm hg giving a range of 5 to 25 mm hg. table 1 shows iop in both sexes at different age groups. no significant difference was found in the range of iop between individuals of both sexes of various age groups. similarly table 2 shows mean iop and standard deviation of both right and left eye of the same individual under study. it also revealed that iop in both eyes of the same individual was almost same. in table 3 the range of iop in different age groups is shown which reveals that range of iop in middle age group is wider than younger and elder age groups. discussion in this study of healthy individuals, mean iop is found to be 15.368 ± 3.37 mm hg while range of iop is 5–25 mm hg. in another study conducted in pakistan8 previously mean iop was found to be 14.3 ± 0.17 mm hg. elevated iop is a major risk factor for open angle sarfraz ahmad mukhtar, et al 131 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology glaucoma. similarly there are several other factors that affect iop. one of these is relationship of increasing age with iop. so it is very difficult to accurately define a level of iop which is likely to cause glaucomatous damage. in our study, no age related increase in iop was found. this finding is similar to a study, conducted on a large number of individuals in united states9 that stated there was no evidence found of an independent age effect on iop. in our study effort was made to include only healthy subjects. all those using any kind of medicine were excluded from the study. this excluded a large number of older individuals from the study. accordingly this result may not be representative of general older population as this study was conducted on a limited scale. all the patients with ocular diseases or history of ocular trauma were also excluded from the study. mean value of iop was found to be 13.6 ± 2.6 mm hg in men and 13.3 ± 2.6 mm hg in women in japanese population10. the iop was found to be decreasing with age in japanese population. central corneal thickness is one of the most important factors affecting corneal rigidity which is a major source of error in applanation tonometry11. an extremely thick or thin cornea can respectively cause overestimation or underestimation of iop12. since cct and applanation tonometeric estimates of iop correlate positively, monitoring of the former parameter has served as the basis for adjusting readings pertaining to the latter, with the consequence that many patients have had to be reclassified13. study of this variable was beyond the scope of my study. furthermore in my study, all measurements were taken with puff tonometer. the variation in iop was also studied in two sexes and no significant difference was found as in other studies conducted in pakistan previously14. iop undergoes fluctuation with the time of the day15 and with seasonal variation16. in our study no diurnal variation and seasonal variation in iop was noted. there is ocular hypotensive effect of pregnancy17 and higher iop is found in postmenopausal women than in those who are still menstruating18. this factor should be considered while assessing for iop variations. in our study this factor was not considered and this is our limitation. iop is also altered by changing the subject’s gravity dependent body position19. so while taking iop values this factor should be kept in mind. since my study was conducted in opd and iop measurements was done in sitting position in all subjects, so bias due to this factor is eliminated. iop readings can be altered by many factors including instrumental, anatomical, physiological, examiner induced and patient induced sources of error20. all these factors should be considered while taking iop readings. so far the most accurate instrument to take iop is goldmann applanation tonometer whereas in my study, all measurements were made by puff tonometer. the readings taken with it are found to be higher than those measured with goldmann applanation tonometer21 so actual range of iop might be lower than that found in my study. this is another limitation of our study. sample size in our study was 300 normal individuals. sample size should be in thousands as it is reflective of big population. small sample size is a limitation of our work. our study estimated the range of iop in normal individuals of various age groups of either sex presenting in our settings. all cases having iop outside this range can be further examined and investigated to rule out glaucoma. conclusion the mean iop in normal individuals is found to be 15.368 ± 3.37 mmhg. no difference was found in two sexes. also insignificant relationship was found between age and iop. consequently this range of iop will act as a tool to early detect and to refer all the cases outside this range to glaucoma clinic for more complex and time consuming tests like assessment of cup disc ratio and automated visual fields to complete the diagnosis and start early management. author’s affiliation dr. sarfraz ahmad mukhtar department of ophthalmology bahawal victoria hospital bahawalpur dr. ahmad zeeshan jamil department of ophthalmology rashid latif medical college lahore dr. zulfiqar ali department of ophthalmology bahawal victoria hospital bahawalpur estimation of range of iop in normal individuals by air puff tonometer pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 132 references 1. shafiq i. influence of central corneal thickness (cct) on intraocular pressure (iop) measured with goldmann applanation tonometer (gat) in normal individuals. pak j ophthalmol. 2008; 24: 196-200. 2. sihota r, tuli d, data t, gupta v, sachdeva mm. distribution and determinants of intraocular pressure in a normal pediatric population. j pediatr ophthalmol strabismus. 2006; 43: 14-8. 3. yazici a, sen e, ozdal p, aksakal fn, altinok a, oncul h, et al. factors affecting intraocular pressure measured by noncontact tonometer. eur j ophthalmol. 2009; 19: 61-5. 4. vandeviere s, germononpre p, renier c, stalmans i, zeyen t. influences of atmospheric pressure and temperature on intra-ocular pressure. invest ophthalmol vis sci. 2008; 49: 5392-6. 5. liu j, roberts cj. influence of corneal biomechanical properties on intraocular pressure measurement: quantitative analysis. j cataract refract surg. 2005; 31: 146–55. 6. sawada a, yamamoto t. posture-induced intraocular pressure changes in eyes with open-angle glaucoma, primary angle closure with or without glaucoma medications, and control eyes. invest. ophthalmol. vis. sci. 2012; 53: 7631-5. 7. kanski jj, bowling b. clinical ophthalmology a systemic approach: glaucoma. 7th ed. china: butterworth heinemann elsevier; 2011: 390-504. 8. qureshi ia, xi xr, huang yb, lu hj, wu xd, shiarkar e. distribution of intraocular pressure among healthy pakistani. chin j physiol. 1996; 39: 183-8. 9. rochtchina e, mitchell p, wang ii. relationship between age and intraocular pressure: the blue mountain eye study. clin experiment ophthalmol. 2002; 30: 173-5. 10. nomura h, ando f, niino n, shimokata h, miyake y. the relationship between age and intraocular pressure in japanese population: the influence of central corneal thickness. curr eye res. 2002; 24: 81-5. 11. feltgen n, leifert d, funk j. correlation between central corneal thickness, applanation tonometry and direct intracameral intraocular pressure readings. br j ophthalmol. 2001; 85: 85-7. 12. dueker dk, singh k, lin sc, fechtner rd, minckler ds, samples jr, schuman js corneal thickness measurement in the management of primary open angle glaucoma: a report by the american academy of ophthalmology. 2007; 114: 1779-87. 13. weizer j s, stinnett ss, herndon l w. longitudinal changes in central corneal thickness and their relation to glaucoma status: and 8 year follow up study. br j ophthalmol. 2006; 90: 732-6. 14. hassan m, rehman a, munawar a, fawad u, bhatti n, daud a. relationship between central corneal thickness and intraocular pressure in selected pakistani population. pak j ophthalmol. 2010; 26: 79-82. 15. magacho l, toscano da, freire g, shetty rk, avila mp. comparing the measurement of diurnal fluctuations in intraocular pressure in the same day versus over different days in glaucoma. eur j ophthalmol. 2010; 20: 542-5. 16. gardiner sk, demirel s, gordon mo, kass ma. seasonal changes in visual field sensitivity and intraocular pressure in the ocular hypertension treatment study. ophthalmology 2013; 120: 724–730. 17. ebeigbe ja, ebeigbe pn, ighoroje ada. intraocular pressure in nigerian women. afr j reprod health. 2011; 15: 20-3. 18. qureshi ia. intraocular pressure: association with menstrual cycle, pregnancy and menopause in apparently healthy women. chin j physiol. 1995; 38: 229-34. 19. selvadurai d, hodge d, sit aj. aqueous humor outflow facility by tonography does not change with body position. invest ophthalmol vis sci. 2010; 51: 1453–7. 20. yazici a, sen e, ozdal p, aksakal fn, altinok a, oncul h, koklu g. factors affecting intraocular pressure measured by noncontact tonometer. eur j ophthalmol. 2009; 19: 61-5. 21. chou cy, jordan ca, mcghee cnj, patel dv. comparison of intraocular pressure measurement using 4 different instruments following penetrating keratoplasty. am j ophthalmol. 2012; 153: 412-8. http://www.ncbi.nlm.nih.gov/pubmed?term=dueker%20dk%5bauthor%5d&cauthor=true&cauthor_uid=17822980 http://www.ncbi.nlm.nih.gov/pubmed?term=singh%20k%5bauthor%5d&cauthor=true&cauthor_uid=17822980 http://www.ncbi.nlm.nih.gov/pubmed?term=lin%20sc%5bauthor%5d&cauthor=true&cauthor_uid=17822980 http://www.ncbi.nlm.nih.gov/pubmed?term=fechtner%20rd%5bauthor%5d&cauthor=true&cauthor_uid=17822980 http://www.ncbi.nlm.nih.gov/pubmed?term=minckler%20ds%5bauthor%5d&cauthor=true&cauthor_uid=17822980 http://www.ncbi.nlm.nih.gov/pubmed?term=samples%20jr%5bauthor%5d&cauthor=true&cauthor_uid=17822980 http://www.ncbi.nlm.nih.gov/pubmed?term=schuman%20js%5bauthor%5d&cauthor=true&cauthor_uid=17822980 pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 87 original article b-scan ultrasonography in blast related posterior segment eye injuries mumtaz alam, akbar khan pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mumtaz alam house no. 310, street no. 5, sector e-4, phase 7, hayatabad, peshawar …..……………………….. purpose: to study the role of b-scan ultrasonography in determining the extent of posterior segment pathology in blast related eye injuries. material and methods: it was a descriptive case series conducted at ophthalmology department of khyber teaching hospital peshawar, from march 2010 to february 2012. patients with blast related eye injuries and poor fundus view at presentation were included in the study. patients with shattered globe in which corneal / scleral repair was not possible were excluded from the study. b– scan ultrasonography was done to know about the extent of posterior segment pathology. in those with open globe injury, b-scan was done after restoring the globe integrity. results: ninety seven patients were included in the study. ocular injury was unilateral in 66 patients (68.04%) and bilateral in 31 patients (31.95%). of the 128 eyes involved, 83 eyes (64.84%) had open globe injury and 45 eyes (35.15%) had closed globe injury. b-scan was normal in 45 eyes (35.15%). vitreous hemorrhage was the most common pathology seen in 54 eyes (42.18%), followed by retinal detachment which was seen in 27 eyes (21.09%) and intraocular foreign body in 19 (14.84%) eyes. conclusion: bomb blast / mine blast can result in very severe eye injuries. in the presence of media opacities, b-scan ultrasonography is a very useful diagnostic tool for determining the extent of posterior segment pathologies in blast related eye injuries. undt and hughes were the first to use ultrasound in ophthalmology in 19561. they used an (amplitude) scan for evaluation of intraocular tumor. baum and greenwood introduced the use of b (brightness) scan in 19582. both a-scan and b-scan techniques are important for the diagnosis of ocular diseases3. diagnostic ultrasound uses sound waves at frequencies above the range of human hearing (more than 20,000 hz or 20 khz)4. b-scan ultrasonography is a safe, inexpensive, non-invasive, and accurate tool for evaluation of the posterior segment of eye when there is media opacity4,5. it requires the use of high frequency transducer i.e. a 10 mhz is commonly used for posterior segment assessment. nowadays very highfrequency systems (e.g. 50 mhz) can be used for the assessment of anterior segment of the eye6. ultrasonography has more than 90% sensitivity and specificity in the diagnosis of ocular trauma cases7. it can detect vitreous hemorrhage, posterior vitreous detachment (pvd), hemorrhagic choroidal detachment, serous choroidal detachment, posteriorly dislocated lens, retinal detachment (rd), ocult scleral rupture, vitreous incarceration and retained intraocular foreign body (iofb)7. bomb blast / mine blast can cause a variety of potentially blinding posterior segment injuries, which may be difficult to detect without the use of b-scan ultrasonography. the purpose of our study was to study the role of b-scan ultrasonography in determining the extent of posterior segment pathology in blast related eye injuries. m mumtaz alam, et al 88 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology material and methods it was a descriptive case study conducted at ophthalmology department of khyber teaching hospital peshawar, from march 2010 to february 2012. inclusion criteria were unilateral or bilateral eye injury due to bomb blast / mine blast, both gender & all age groups and poor fundus view at presentation (due to corneal edema / opacity, hyphema, cataract or vitreous opacities). exclusion criteria were shattered globe in which corneal / scleral repair was not possible; consecutive sampling technique was employed i.e. all the patients who met the inclusion criteria were included in the study. detailed history was taken and complete ocular examination was performed in all cases. b-scan ultrasonography was done with ab 5500+ a/b scan (sonomed, usa) to know about any posterior segment pathology. in eyes with open globe injury, b-scan was done after restoring the globe integrity. results total number of patients was 97, including 93 males (95.87%) and 4 female (04.12%). age of patients was ranging from 4 to 65 years with a mean of 23.70 years. ocular injury was unilateral in 66 patients (68.04%) and bilateral in 31 patients (31.95%). of the 128 eyes involved, 83 eyes (64.84%) had open globe injury and 45 eyes (35.15%) had closed globe injury (table 1). b scan was normal in 45 eyes (35.15%). in the remaining 83 eyes (64.84%) various abnormalities were detected on b-scan including vitreous hemorrhage, rd, pvd, choroidal detachment, iofb, endophthalmitis and phthisis bulbi (table 2). vitreous hemorrhage was the most common pathology seen in 54 eyes (42.18%), followed by rd which was seen in 27 eyes (21.09%) and iofb in 19 (14.84%) eyes. discussion eye injury is a very important cause of visual impairment. eye injuries make upto 10% of body injuries, despite the fact that eye makes only 0.27% of the body surface8. approximately 2 million eye injuries occur in the united states annually, more than 40 thousand of these results in permanent visual los9. ocular injuries predominantly occur in young males10 and can lead to blindness. approximately 5% of blindness in the developing countries is the result of trauma11. ocular injuries can be divided into 2 main groups i.e. open globe and closed globe. open globe eye injuries include rupture and laceration while closed globe eye injuries include contusion and lamellar laceration12. bomb blasts are a common cause of severe eye injury among adult males13. they are becoming increasingly common in our country. bomb blast/ mine blasts can cause a wide range of potentially blinding posterior segment injuries14,15. direct visualization of the fundus is not possible in eyes with media opacities such as opaque corneal, hyphema, lenticular or vitreous opacities16,17. b-scan can help us assess the posterior segment when the fundus cannot be visualized due to media opacities4. in this study, 128 eyes with poor view of fundus due to corneal edema / opacity, hyphema, cataract and/or vitreous opacities were included. one or more posterior segment pathologies were detected in 83 eyes. vitreous hemorrhage was the commonest pathology followed by rd and iofb. b-scan ultrasonography in blast related posterior segment eye injuries pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 89 in one study, ultrasonography detected one or the other pathology in 21% of ocular trauma cases. vitreous membrane was seen in 7 %, rd in 6%, vitreous hemorrhage in 4% & iofb in 4% cases18. in another study, ultrasonography revealed rd in 17 (13%), vitreous haemorrhage in 14 (10.7%), macular edema in 14 (10.7%), endophthalmitis in 12 (9.2%), pvd in 7 (5.4%) and panophthalmitis in 1 (0.7%) eyes19. djosevska ed, in his study, detected vitreous hemorrhage 20.9% eyes, rd in 4.4%, endophthalmitis in 3.3%, pvd in 3.8%, iofb in 6.6% and choroidal detachment in 1.1% eyes on ultrasonography20. in our study posterior segment pathology was more frequently detected than the other studies. the reason for this being more severe eye injuries in blast victims as compared to eye injuries due to other causes. b scan is a very important diagnostic tool in such patients. the energy used in b-scan ultrasonography, does not damage the ocular tissues and it can be repeated (if needed), without any harmful effects20. conclusion b – scan ultrasonography is a very useful diagnostic tool for determining the extent of posterior segment pathologies in blast related eye injuries. in eyes with open globe injury, b – scan ultrasonography can be safely performed after restoring the globe integrity. author’s affiliation dr. mumtaz alam assistant professor ophthalmology department, kuwait teaching hospital peshawar dr. akbar khan eye surgeon, khyber eye foundation peshawar references 1. mundt gh, hughes w. ultrasonics in ocular diagnosis. am j ophthalmol 1956; 41: 488-98. 2. baum g, greenwood i. the application of ultrasonic locating techniques to ophthalmology, part i: reflective properties. am j ophthalmol 1958; 46: 319-29. 3. kanski jj. imaging techniques. in: kanski jj clinical ophthalmology. a systemic approach 6th ed. butterworth heinemann elsevier. 2007; 33-58. 4. rai p, shah sia, cheema am, niazi jh, sidiqui sj. usefulness of b-scan ultrasonography in ocular trauma. pak j ophthalmol. 2007; 23: 136-43. 5. modrzejewska m. the use of ultrasonic techniques for the diagnosis of retinopathy of prematurity. ann acad med stetin 2006; 52: 83-8. 6. frederic l, lizzi d, coleman j. history of ophthalmic ultrasound. j ultrasound med. 2004; 23: 1255-66. 7. vyas j. mahesh g. ultrasonography in ocular trauma. kerala j ophthalmol. 2010; 22: 273-6. 8. belkin m. a historical prospective of ocular trauma. in: miller d, stegmman r, (edi). treatment of anterior segment ocular trauma. montreal medicopia. 1986. p. 7-21. 9. mcgwin g, xie a, owsley c. the rate of eye injury in the united states. arch ophthalmol. 2005; 123: 970-6. 10. tielsch jm, parver lm. determination of hospital charges and length of stay for ocular trauma. ophthalmology. 1990; 97: 2317. 11. thylefors b. epidemiological pattern of ocular trauma. aust nzj opthalmol. 1991; 7: 15-8. 12. kuhn f, morris r, witherspoon cd, mester v. the birmingham eye trauma terminology system (bett). j fr ophtalmol. 2004; 27: 206-10. 13. newmann tl, russo pa. ocular sequelae of bb injuries to eye and surrounding adnexa. j am optom assoc. 1998; 69: 583-90. 14. weichel ed, colyer mh, ludlow se, bower ks, eiseman as. combat ocular trauma visual outcomes during operations iraqi and enduring freedom. ophthalmology. 2008; 115: 223545. 15. rahman f, rashid h, naseem a. ocular sequlae of blast injuries: experience at a teaching hospital. pak j med res 2008; 47: 29-32. 16. blumenkanz ms, byrne sf. standardized echography (ultrasonography) for the detection and characterization of retinal detachment. ophthalmology. 1982; 89: 821-31. 17. rabinowitz r, yagev r, shoham a and lifshitz t. comparation between clinical and ultrasound findings in patients with vitreous haemorrhage. eye 2004; 18: 253-6. 18. bhatia im, panda a, dayal y. role of ultrasonography in ocular trauma. indian j ophthalmol. 1983; 31: 495-8. 19. harshadbhai ht, tyagi m, jani s, thakkar j, sudhalkar a. paediatric ocular trauma and role of echography in evaluation of these cases. aioc proceedings. trauma session. 2010; p. 694-6. 20. djosevska ed. ultrasonography in ocular trauma. contributions sec med sci. 2013; 34: 105-12. http://www.ijo.in/searchresult.asp?search=&author=im+bhatia&journal=y&but_search=search&entries=10&pg=1&s=0 http://www.ijo.in/searchresult.asp?search=&author=a+panda&journal=y&but_search=search&entries=10&pg=1&s=0 http://www.ijo.in/searchresult.asp?search=&author=y+dayal&journal=y&but_search=search&entries=10&pg=1&s=0 microsoft word 15. news and events vol 28 114 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology news and events vol. 28, 2, 2012 34th national congress of ophthalmological society of pakistan & 7th khyber eye symposium date: 28 – 30 september, 2012 venue: pearl continental hotel, peshawar contact: dr. sanaullah jan phone: 091-5825087/0313-8584819 email: sanaullahjan@hotmail.com 18th hyderabad ophthalmic conference date: 9-10-11 november 2012 venue: hotel indus hyderabad contact: prof. khalid iqbal talpur phone: 0222106801/0300-304-9951 email: osphydbranch@gmail.com khalid_talpur@hotmail.com 32nd lahore ophthalmo 2012 date: 07 – 09 december, 2012 venue: pearl continental hotel, lahore contact: prof. mian muhammad shafique phone: 042-36363325 email: osplhr@gmail.com the association for research in vision and ophthalmology (arvo) annual meeting 2013 seattle washington, united states date: 5-9 may, 2013 venue: seattle, washington web: www.arvo.org european glaucoma society 10th congress date: 17 – 22 june, 2012 venue: copenhagen, denmark web: www.eugs.org xx biennial meeting of international society for eye research date: 22 – 27 july, 2012 venue: berlin, germany 8th international symposium of ophthalmology – hong kong (iso-hk) & 7th asia-pacific vitreoretina society (apvrs) congress date: 14 – 16 december, 2012 venue: hong kong convention & exhibition centre the 28th asia-pacific academy of ophthalmology (apao) congress date: 17 20 january, 2013 venue: hyderabad, india web: www.apaophth.org american society of cataract and refractive surgery (ascrs) / american society of ophthalmic administrators (asoa) symposium and congress date: 19 23 april, 2013 venue: san francisco 34th world ophthalmology congress (woc) & the 29th asia-pacific academy of ophthalmology (apao) congress date: 2 6 april, 2014 venue: tokyo, japan institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091 – 9217376 – 80 fax: 92 – 42 – 36363326 email: pico@pes.comsats.net.pk college of ophthalmology and allied vision sciences lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics hamid mahmood pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 115 contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042 – 37355998 fax: 042 – 37248006 email: pipo@brain.net.pk pakistan institute of ophthalmology, al – shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al – shifa trust eye hospital, jhelum road, rawalpindi – pakistan phone: 92 – 51 – 5487830, 5487820 – 25 fax: 92 – 51 – 5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt 4-a lda flats lawrence road, lahore phone: 92 – 42 – 36363326 email: pjoosp@gmail.com pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 137 original article complications of contact lenses; a clinico-experimental study to evaluate the effects of bacterial contamination yousef homood aldebasi, salah mesalhy aly, muhammad ijaz ahmad pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: yousef homood aldebasi department of optometry college of applied medical sciences, qassim university saudi arabia. …..……………………….. purpose: to diagnose the complications and to study the effects of isolated bacteria from contact lens users on rabbit eyes. material and methods: a total of 100 contact lens wearers were subjected to clinical examinations. contact lenses/or corneal swabs from 100 patients were collected for bacteriological examinations. the isolated bacteria were tested for pathogenicity through experimental study that was conducted on rabbits with the aid of clinical, serum biochemistry and histopathological examinations. results: among the 100 contact lens users, 23 were men and 77 women. the mean age was 21 years. clinical examination revealed keratitis in 52% of contact lenses users, out of that 48% showed corneal infiltrates and 4% exhibited superficial corneal ulcer. corneal abrasions, giant papillary conjunctivitis (gpc) and increased limbal neovascularization were found in 8, 10 and 6% of cases; respectively. in addition to this, nonspecific complications were found in 24% of cases. lab investigations of the 100 collected contact lenses/corneal swabs revealed bacterial isolates from 28 samples. the isolated bacteria were identified as staphylococcus aureus, staphylococcus epidermidis, pseudomonas aeruginosa, escherichia coli and klebsiella pneumonia from 7, 3, 10, 2 and 2 cases respectively and their antimicrobial sensitivity was done whereas multiple bacteria were detected in 4 samples. in parallel to the above study, the induced experimental eye infection of rabbits was performed which showed corneal abscess and corneal ulcers in case of pseudomonas aeruginosa and staphylococcus aureus induced corneal ulcers and clinical picture of the patients who proved culture positive results for pseudomonas aeruginosa and staphylococcal aureus was worse as compared to other patients. e coli or klebsiella pneumonia developed macular and leucomatous types of corneal opacities. the infected rabbits showed varied biochemical changes regarding urea, creatinine and uric acid levels and the rabbits infected with pseudomonas aeruginosa showed almost double increase of serum uric acid level (p 0˂.05). conclusion: keratitis was the most predominant complication among contact lens users. contact lens over wear, overnight wear and poor hygiene are the common causes of contact lens complications. proper contact lens care and regular follow-up visit are essential for patient safety and wearing success. http://en.wikipedia.org/wiki/keratitis yousef homood aldebasi, et al 138 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology ontact lens wearing is associated with a significant risk of microbial keratitis leading to severe sight – threatening complications.1 acanthamoeba keratitis although not so common but is severe vision threatening condition in contact lens users and increased risk of microbial and sterile keratitis has been reported with both conventional hydrogel and highly oxygen permeable silicone hydrogel materials.2-4 patients using soft contact lenses are at greater risk of developing microbial keratitis than those using other lenses and there is increased risk of microbial keratitis in daily disposable lens users.7-8 different organisms have been associated with contact lens – related microbial keratitis. ulcerative keratitis is one of the most serious complications of contact lens wear, occurring in an estimated 1 out of 500 persons using contact lenses for extended wear.7-9 the gram-negative bacterium, pseudomonas aeruginosa, is the most commonly isolated bacteria from contact lens-related ulcerative keratitis.7-10 it causes a rapidly destructive ulcer, which often leads to scarring and vision loss in otherwise healthy persons. several investigators have suggested that contact lenses may provide the vehicle whereby organisms are transferred from the environment to the anterior eye.10-12 the ocular surface of healthy individuals inherently supports a small population of bacteria, typically coagulase negative staphylococci (cns) which are believed to exist as commensals on the mucosa and lid margins.13,14 under ideal conditions, there is little or no opportunistic bacterial colonization of the conjunctiva or cornea, because of the washing effect of the tears,14-16 in conjunction with the action of antibacterial proteins and enzymes within the tear film.17-19 dry eye, due to tear deficiency or excessive tear evaporation is often associated with ocular surface conditions such as anterior blepharitis20,21 and keratitis.22,23 different alterations in the concentration and type of bacteria have been reported, independent of the presence of conjunctivitis. such disorders have been associated with several gram – positive and negative bacteria, including staphylococcus aureus, streptococcus sp., bacillus subtilis, rhodococcus sp., pseudomonas aeruginosa, haemophilus influenza, haemophilus aegyptius, and klebsiella sp.24,25 the production of lipases and toxins by many of these bacteria may induce significant ocular irritation.26,27 the present study is aimed to diagnose the complications associated with the use of contact lenses together with identification of the bacterial contamination and to study its pathogenesis in rabbit cornea. material and methods patients and sampling: a cross sectional study was conducted during december 2010 to may 2011 in collaboration with king fahd specialist hospital, buraidah, saudi arabia. about 100 patients suffering from contact lens related problems were received in emergency department were interviewed and detailed ocular examination were performed. patients were received with painful red eyes either coming directly or referred by ophthalmologists or peripheral health units and detailed examinations were performed after the history about age, gender, the use of contact lenses, overnight use, duration, type of contact lenses, duration of symptoms, any use of antibiotic drugs before coming to hospital, change and type of solutions, instructions for use and personnel hygiene. the patients were examined for visual acuity, corneal epithelial defects, number and position of corneal infiltrates and anterior chamber reaction. regular overnight use of contact lenses and sleeping in lenses overnight once per week or more was considered as overnight wear also known as extended wear. occasional use of contact lenses in sleep was not considered as overnight use. hundred corneal scrapings/contact lenses (68/32) were collected under aseptic conditions, kept in ice box and transferred immediately to the laboratory for bacteriological examinations. patients with diabetes mellitus, associated infectious ocular disease, dry eyes, keratoconus using contact lenses and aphakic contact lenses, any traumatic / non-traumatic corneal disease and all other causes of keratitis were excluded from the study. bacteriological isolation and identification technique: this technique was done routinely in all collected samples including culturing, sub culturing and purification, isolation and identification. the collected swabs were inoculated in tryptic soya broth overnight at 37°c, consequently the broth was inoculated onto blood agar, macconkey’s agar, mannitol salt agar, and chocolate agar media and incubated aerobically at 37°c for maximum up to 48 hours. inoculated chocolate agar plates were left in anaerobic incubator at 5% co2. all the bacterial isolates were identified by c complications of contact lenses; a clinico-experimental study pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 139 their colony morphology, gram staining, pigment production, relevant biochemical tests and api strips. bacterial inoculum were prepared by cultivating each bacterial species onto nutrient agar for 24 hours at 37o c, then 5-7 colonies were transferred to a tube containing 5 ml sterile normal saline solution. the tubes were vortexed to make a bacterial suspension with turbidity equal to 0.5 mcfarland’s standard solution. then, 0.5 ml of bacterial suspension was dropped to the corneal ulcer of the experimental animal. antimicrobial sensitivity test: the isolated pathogenic bacteria were tested to various antibiotics using some selected antibiotics discs through agar-well diffusion method as recommended by the manufacturer. all bacterial isolates were tested for their antimicrobial susceptibility against cefoxitin (30μg), gentamicin (10μg), ciprofloxacin (5μg), cefuroxime (30μg), tobramycin (10μg), chloramphenicol (30ug) and tetracycline (30μg). all experiments were carried out in triplicate. each isolate was spread onto the surface of mullerhinton agar with a sterile swab. after 24 h of incubation, inhibition zones were measured. control wells were filled with 50 ml. of 0.1 m potassium phosphate buffer of ph 7. the results of susceptibility were recorded as sensitive(s), intermediate (i) or resistant(r). experimental study animals this experimental was study conducted on 50 healthy male albino rabbits. the rabbits were obtained from animal health unit at qassim university7 days before starting the experiment. the animals were free of any infection, weighing between 2 and 2.5 kg. they were housed in standard aluminum cages and fed with standard rabbit diet and normal tap water. the animal house temperature was maintained at 23oc and 12 h drak/light condition. the rabbits were handled as per the international rules implemented in the experimental laboratory animals, qassim university, ksa. experimental groups and protocol: the rabbits were divided randomly into five equal groups. first group was subdivided into two subgroups. the protocol was done as shown in (table 1). induction of corneal ulcer and bacterial inoculation: for the induction of corneal ulcer in rabbit eyes, circular filter papers (5 mm diameter) were produced by standard paper punch and immersed in 1 n naoh for 5 seconds. surface anesthesia of rabbit eyes was obtained by topical alcaine (proparacain) eye drops for 5 minutes, the eyelids were secured in the open position, then immersed filter paper disc was placed on the central corneal surface and was held gently in position with thumb forceps for 30 seconds. after few minutes, the rabbits eyes of groups 2-5 were contaminated with pseudomonas aeruginosa, staphylococcus aureus, e. coli and klebsiella pneumonia; respectively. ophthalmic examination: after 24 h of bacterial contamination of the induced corneal ulcer by selected bacteria, the cornea of the rabbits were stained with a fluorescein paper strips. the detailed eye examinations for corneal ulcer was performed by hand held portable slit-lamp biomicroscope. the rabbits eyes were followed every day for the signs and symptoms of ulcerative keratitis such as photophobia, blephrospasm, lid edema, conjunctival edema, conjunctiva injection, discharge, corneal abscess and hypopyon. the severity of corneal ulcer was labeled as mild, moderate or severe accordingly (table 2). the follow up was continued for two weeks. biochemical examinations: after 2 weeks of post ocular infection, rabbits were sacrificed and blood sample were collected directly into tubes and were allowed to clot at room temperature for 30 min and the serum was separated by centrifugation at 1000×g for 15 min at 4oc. the serum was separated and saved in aliquots and stored at -20oc before analyzing for liver and kidney function parameters. the infected corneal samples were also taken and preserved for microscopic examinations. among 100 contact lens users, eye complications were seen in 23 men and 77 women aged between 12 years to 55 years (mean age 21 years). most of them were living in urban areas. types of lenses: the spectrum of lenses used by the patients in this study was as follows, only 2% were using daily disposable lenses and the remaining 98% were using yousef homood aldebasi, et al 140 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology daily wear lenses. in the daily wear group 65 (66.33%) were using hydrogel and 33 (33.67%) were using silicone hydrogel lenses. complications associated with contact lenses: based on clinical examinations, keratitis of varying degree was found in 52% of cases in which 48% showed corneal infiltrates compatible with bacterial keratitis and 4% showed superficial corneal ulcer. corneal abrasions of varying degrees without clinical evidence of bacterial infection were found in 8% of cases. giant papillary conjunctivitis (gpc) was detected in 10% of cases and increased limbal neovascularization was found in 6% of cases, in addition to this non-significant/specific complications in 24% of cases (fig. 1). clinical characteristics of keratitis: the following criteria were used for bacterial keratitis. severe keratitis: vision loss of ≥ 2 lines of best – corrected visual acuity compared with pre-event data. moderate keratitis: no significant vision loss with one or more of: positive corneal culture, any part of lesion within or overlapping central 4 mm of corneal, hypopyon ≥ 2mm in diameter. mild keratitis: all other cases of microbial keratitis. complications of contact lenses; a clinico-experimental study pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 141 yousef homood aldebasi, et al 142 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology complications of contact lenses 4% 6% 8% 10%0 48% 24% corneal infiltrates gpc corneal abraions neovascularization corneal ulcer others fig.1: description of the percentage of different complications observed in contact lens users. 51.92% 23% 19.23% 5.7% 0.00 10.00 20.00 30.00 40.00 50.00 60.00 contact lens overwear over night wear poor hygiene improper solutions fig. 2: represents the frequency of various risk factors like contact lens over – wear, overnight wear, poor hygiene, and improper contact lens solution among contact lens users. among patients with a corneal infiltrates and corneal ulcers which were compatible with a diagnosis of keratitis, 35 cases were examined for the first time in the emergency department, 17 cases were referred by general practitioners or ophthalmologists. the clinical course of these patients was acute with lid and conjunctival edema, reduced vision, pain, redness, photophobia and discharge. keratitis involved the right eye in 57% (30) of cases, and the left eye in 43% (22) of cases. infection was bilateral in six cases. visual acuity at the time of examination ranged from 20/20 to 20/200. nasal infiltrates were most common and seen in 20 (41.66%) patients. corneal infiltrates were single in 40 eyes (83.34%) and multiple in 8 (16.66%). anterior chamber inflammation was absent in 21 (40.39%) cases. a 1+ to 2+ tyndall effect was present in 9(55.77%) of cases, whereas severe anterior chamber percentage f re q u e n c y complications of contact lenses; a clinico-experimental study pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 143 inflammation (3+ to 4+) and hypopyon were present in 1 (1.92%) each. the location of corneal infiltrate fig. 4: rabbit eye showing corneal abscess with hypopyon. fig. 5: rabbit eye showing macular type corneal opacity among patients is reported in (table 3). contact lens over wear was the most common risk factor followed by overnight wear, poor hygienic conditions (hand washing) and improper usage of solutions (fig. 2). microbiological characteristics: the cultures of corneal scrapings / contact lenses were positive in 28 cases, showing different kinds of bacterial contaminations as shown in (table 4). among the patients who were using daily disposable lenses no bacterial culture was revealed. the patients which were referred from peripheral health units, out of seventeen patients 4(23.52%) were received with use of antibiotics and out of these only 1(25%) reveled positive bacterial culture. no significant difference in risk was observed between lens materials. also overnight use of lenses was associated with more infection irrespective of material. as shown in (table 5), all isolated bacteria were sensitive to gentamicin (10μg) and cefuroxime (30μg). the highest culture positive results were detected in overnight contact lens users. figure 3 shows the association between the risk factors and positive bacterial cultures. as shown in (table 6), the rabbits of the control group subdivided into two subgroups, 1stsubgroup (negative control) were kept for the comparison without ulcer, 2nd subgroup (positive control) where the rabbits eyes with non-contaminated corneal ulcers which developed nebular type of corneal opacities and one rabbit developed macular type of corneal opacity. in 2-5 groups where corneal ulcers were induced in rabbit eyes then contaminated with different types of bacteria. among pseudomonas induced corneal ulcers, one developed corneal abscess with hypopyon and ultimate perforation within 8-9 days (figure 4) and others developed leucomatous corneal opacity within two weeks. staphylococcus aureus induced corneal ulcers developed macular corneal opacity within two weeks period (figure 5). the rabbits that contaminated with either e coli or klebsiella pneumonia revealed macular type of corneal opacities in two cases and leucomatous corneal opacity in eight cases within two weeks period. the biochemical analyses of rabbits with induced corneal ulcer inoculated with different bacteria revealed significant increase (p <0.05) in the level of urea to almost double level with pseudomonas as compared to the control and other bacterial inoculation groups. the level of uric acid and creatinine were higher in e coli and klebsiella pneumonia inoculated groups as compared to control and other groups (table 7) but the difference was nonstatistically significant (p > 0.05). discussion complications due to contact lens wear affect roughly 5% of contact lens wearers each year28. contact lens– related complications range from self – limiting to sight threatening, that require rapid diagnosis and treatment to prevent vision loss. http://en.wikipedia.org/wiki/complication_(medicine) yousef homood aldebasi, et al 144 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology microbial keratitis is a potentially serious corneal infection and a major cause of visual impairment worldwide. a conservative estimate of the number of corneal ulcers occurring annually in the developing world alone is 1.5-2 million29. permanent visual dysfunction has been reported in a significant proportion of patients in both developing30 and developed31 countries. the most common clinical complications compatible with keratitis observed in this study were corneal infiltrates (48%) and corneal ulcer (4%) with overall incidence of keratitis being 52%.the majority of these cases were related to those subjects who were having poor hand hygiene, over wear of contact lenses and in particular over-night wear. studies conducted throughout the world show that approximately 11% to 49% of patients always fail to wash their hands before handling their lenses. there is an increased risk of 1.5 times for developing microbial keratitis and two times greater risk for developing sterile keratitis11,12 in patients who fail to wash their hands32-38. sleeping without removing lenses is associated with a tenfold increased risk of microbial keratitis.37,39,40 a study conducted by bourcier et al, in paris showed that contact lenses wear caused bacterial keratitis in 50.3% of cases.41 among the collected corneal scrapings / contact lenses of 100 cases, 28% of cases revealed culture positive results for bacteria and the highest culture positive rate (39.13%) was found in samples which were collected from patients in which overnight wear was common as mentioned in fig.3. different studies conducted throughout the world have shown greatly variable percentage of culture positive results in microbial keratitis ranging from 48.40% to 100%.42-48 a study conducted by morgan et al, showed that the corneal scrape was performed in 23 of the 38 cases classified as severe keratitis and it yielded a positive culture result for bacteria in nine cases (39.13%) and pseudomonas was cultured in most severe keratitis.49 oral antibiotic therapy has been associated with improved dry eye symptoms, which may be related to a reduction in bacterial counts or bacterial enzymes. therefore, it is reasonable to propose that there may be an important relationship between ocular surface bacteria, tear film function, and ocular surface inflammation50. in the current study gentamicin (10μg) and cefuroxime (30μg) are the antibiotic of choice. nearly similar studies were reported by kim and toma.51 the production of lipases and toxins by many of these colonizing bacteria may induce ocular surface cellular damage and contributing to tear film instability, inflammation and symptoms of significant ocular irritation.26,27 these findings were reflected by biochemical parameters. contact lens wear can induce a distinctive sterile keratitis, which presents as a sudden onset of an anterior stromal or subepithelial polymorphonuclear leukocyte and mononuclear cell infiltrate typically in the periphery of the cornea. the infiltrates usually are small (0.1 – 2 mm) and may be single or in groups. the infiltrates may be round, oval or arcuate and may underlie either an intact epithelium or an epithelial defect. as shown in fig. 2, the major risk factors for contact lens-related microbial keratitis have been related to overwear, overnight use and improper hygiene. a parallel study referred to overnight use of contact lenses, in addition to smoking, male sex and lower socioeconomic status revealed similar results52. the findings in (table 1) where corneal infiltrates can be seen in different localities indicate that contact lensrelated corneal infections continues to be a major challenge to ophthalmologists and lens care practitioners. eighty percent of bacterial corneal ulcers are caused by staphylococcus aureus, streptococcus pneumoniae and pseudomonas species where pseudomonas aeruginosa is the most frequent and the most pathogenic ocular pathogen which can cause corneal perforation within 72 hours.53 the clinical course of rabbit eyes which were contaminated with pseudomonas aeruginosa and staphylococcal aureus was more prolonged and worse as compared to eyes contaminated with other bacteria possibly indicating the virulence and pathogenicity of these bacteria.the clinical course of majority of the patients which were proved culture positive for pseudomonas aeruginosa and staphylococcal aureus was also worse as compared to other patients. in addition to the microbial keratitis, other complications in our study were seen such as giant papillary conjunctivitis (gpc) corneal abrasions and increased neovascularization in 24% of cases. the study conducted by keech et al., reported clinduced complications in approximately two fifth of patients. the most recorded common complications were spk and neovacularization.54 complications of contact lenses; a clinico-experimental study pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 145 conclusion despite all the advances in the diagnosis and treatment of bacterial keratitis, it remains the most aggressive and destructive pathogen invading the cornea and is responsible for sight threatening complications. the expansion of contact lenses wear has increased the worldwide incidence of bacterial keratitis. microbial keratitis was the most predominant complication among contact lenses users and staphylococcus aureus, staphylococcus epidermidis, pseudomonas aeruginosa, escherichia coli and klebsiella pneumonia were common bacterial contaminants of contact lenses. contact lens overwear, overnight wear and poor hygiene are the common cause of contact lens complications. proper contact lens care and regular follow-up visit are essential for patient safety and wearing success. author’s affiliation yousef homood aldebasi depart of optometry, college of applied medical sciences, qassim university, saudi arabia. salah mesalhy aly depart of medical laboratories, college of applied medical sciences, qassim university, saudi arabia muhammad ijaz ahmad depart of 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http://www.ncbi.nlm.nih.gov/pubmed?term=edwards%20k%5bauthor%5d&cauthor=true&cauthor_uid=12772749 http://www.ncbi.nlm.nih.gov/pubmed?term=stretton%20s%5bauthor%5d&cauthor=true&cauthor_uid=12772749 http://www.ncbi.nlm.nih.gov/pubmed?term=stapleton%20f%5bauthor%5d&cauthor=true&cauthor_uid=12772749 yousef homood aldebasi, et al 146 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology 26. berry m, harris a, lumb r, powell k. commensal ocular bacteria degrade mucins. br j ophthalmol. 2002; 86: 1412-6. 27. aristoteli lp, bojarski b, willcox md. isolation of conjunctival mucin and differential interaction with pseudomonas aeruginosa strains of varied pathogenic potential. exp eye res. 2003; 77: 699-10. 28. john stamler. 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antimicrobial resistance and ophthalmic antibiotics. arch ophthalmol. 2011; 129: 1180-8. 52. liesegang tj. contact lens-related microbial keratitis, part:epidemiology. cornea. 1997; 16: 125-31. 53. synder rw, hyndiuk ra. mechanisms of bacterial invasion of the cornea. in: tasman w, jaeger ea, editors. duane‘s foundations of clinical ophthalmology. philadelphia: j b lippincott & co. 1990; 11-44. 54. keech p,ichikawa l, barlow w. a prospective study of contact lens complications in a managed care setting. optom vis sci. 1996; 73: 653-8. http://www.emedicine.com/oph/topic651.htm http://www.ncbi.nlm.nih.gov/pubmed?term=vajpayee%20rb%5bauthor%5d&cauthor=true&cauthor_uid=10632009 http://www.ncbi.nlm.nih.gov/pubmed?term=dada%20t%5bauthor%5d&cauthor=true&cauthor_uid=10632009 http://www.ncbi.nlm.nih.gov/pubmed?term=saxena%20r%5bauthor%5d&cauthor=true&cauthor_uid=10632009 http://www.ncbi.nlm.nih.gov/pubmed?term=vajpayee%20m%5bauthor%5d&cauthor=true&cauthor_uid=10632009 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http://www.thelancet.com/search/results?fieldname=authors&searchterm=siu%20l+leung http://www.thelancet.com/search/results?fieldname=authors&searchterm=hans%20w+hoekman http://www.thelancet.com/search/results?fieldname=authors&searchterm=w%20houdijn+beekhuis http://www.thelancet.com/search/results?fieldname=authors&searchterm=paul%20gh+mulder http://www.thelancet.com/search/results?fieldname=authors&searchterm=paul%20gh+mulder http://www.thelancet.com/search/results?fieldname=authors&searchterm=paul%20gh+mulder http://www.thelancet.com/search/results?fieldname=authors&searchterm=annette%20jm+geerards http://www.thelancet.com/search/results?fieldname=authors&searchterm=aize+kijlstra http://www.ncbi.nlm.nih.gov/pubmed?term=schein%20od%5bauthor%5d&cauthor=true&cauthor_uid=16325711 http://www.ncbi.nlm.nih.gov/pubmed?term=mcnally%20jj%5bauthor%5d&cauthor=true&cauthor_uid=16325711 http://www.ncbi.nlm.nih.gov/pubmed?term=katz%20j%5bauthor%5d&cauthor=true&cauthor_uid=16325711 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http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20borderie%20v%5bauth%5d http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20chaumeil%20c%5bauth%5d http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20laroche%20l%5bauth%5d http://www.sciencedirect.com/science/article/pii/s0161642005010316 http://www.sciencedirect.com/science/article/pii/s0161642005010316 http://www.sciencedirect.com/science/article/pii/s0161642005010316 http://www.sciencedirect.com/science/article/pii/s0161642005010316 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20morgan%20pb%5bauth%5d http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20efron%20n%5bauth%5d http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20hill%20ea%5bauth%5d http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20raynor%20mk%5bauth%5d http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20whiting%20ma%5bauth%5d http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20tullo%20ab%5bauth%5d pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 235 case report retinal detachment surgery in oculocutaneous albinos patient washoo mal, shakir zafar, shahab-ul-hasan siddiqi, syed fawad rizvi pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: washoo mal lrbt free base eye hospital korangi 2 ½, karachi dr.wash_72@yahoo.com …..……………………….. this is an interventional case report of a 30 years old male patient of oculocutaneous albinism with high myopia associated with retinal detachment in both eyes. he had best corrected visual acuity of hand movement in right eye due to fresh rhegmatogenous retinal detachment and perception of light in fellow eye because of long standing retinal detachment. micro incision vitrectomy surgery was done in right eye after flattening of retina with pfcl, endolaser photocoagulation attempted but failed to get adequate burns over tear and detached retina. then cryopexy was performed around the retinal tear and 360° of peripheral retina. lbinism is a genetically determined, heterogeneous group of melanin synthesis disorder which involves either hypopigmentation of eyes only (ocular albinism) usually inherited as x – linked or occasionally ar autosomal recessive (ar)1 or hypopigmentation involves eyes along with skin and hairs known as oculocutaneous albinism (oca) is inherited as autosomal recessive. oculocutaneous albinism may be: a) tyrosinasepositive albinos synthesize varying degree of melanin (pigment). the hairs may be white, yellow or red and darken with age; skin color is very pale at birth but usually darkens by age of 2 years, b) tyrosinase intermediate albinos has no melanin pigment at birth but varying degree of pigmentation with age, c) tyrosinase – negative albinos are incapable to synthesize melanin and have no pigments in skin, hairs and ocular structures throughout life. the albinos usually have impaired visual acuity (va) 20/40 to 20/200 or <20/200 due to foveal hypoplasia1-3, may have high refractive error, strabismus or nystagmus at 2 – 3 month age and hypopigmented fundus with iris transillumination and amblyopia secondary to strabismus or anisometropia. albinos are at increased risk of cutaneous basal and squmous cell carcinomas before 4th decade of life1. the failure of endolasers in reattachment of retina due to melanin deficiency therefore cryopexy is method of choice for attachment of sensory retina to retinal pigment epithelium and choroid by with freezing with cryo-probe to surface of sclera. case report a 30 years old male patient of oculocutaneous albinism (figure 1), with high myopia using 7.50 d and 8.00 d concave (minus) spherical lenses in right & left eyes respectively, visited our tertiary care eye hospital for sudden deterioration of vision in his right eye. his best corrected visual acuity (bcva) was hand movement (hm) due to rhegmatogenous retinal detachment with macula off associated with giant retinal tear superiorly. bcva in fellow eye was perception of light only, b-scan ultrasound showed total retinal detachment (figure 2). vitreoretinal surgery is planned with guarded prognosis in fellow eye. for retinal detachment in right eye micro incision vitrectomy surgery (mivs) was performed with 23-g system and pfcl was used per operatively to flatten the retina. argon endolaser photocoagulation was tried at edges of giant retinal tear but it failed to get adequate reaction due to insufficient amount of melanin pigment in retina; ultimately cryopexy around giant retinal tear and 360o to peripheral retina was carried out in order to reattach the retina and a washoo mal, et al 236 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology finally silicone oil was injected into vitreous cavity as internal tamponade. at succeeding follow ups and after 3 months of surgery, retina was found attached and bcva was improved from hm to 6/60 (decreased visual acuity was due to foveal hypoplasia). fig. 1: color photograph – right eye of albinos patient fig. b: scan of right eye showing total detachment of retina discussion albinism resulting from mutation from genes coding for tyrosinase, the enzyme used in synthesis of melanin; at least 14 genes are distinguished4. the melanin is synthesized from an amino acid tyrosine, which is first converted to dihydroxyphenylalanine through copper-containing enzyme tyrosinase5. the tyrosinase activity is assessed by using the hair bulb incubation test, which is reliable after five years of age. oculocutaneous albinism is most frequent type; whereas ocular albinism is caused by mutation in gpr 143 gene6. to diagnose the albinos patients the denaturing high performance liquid chromatography (dhplc) couple with direct sequencing is an effective and exact test7. rarely albinism is associated with inherited systemic disorders like chediak-higashi syndrome involving the leucocytes abnormality resulting in recurrent pyogenic infection and another is hermansky-pudlak syndrome which causes bleeding disorder due to platelet dysfunction that may be responsible for intra-operative bleeding in albinos patients, therefore pre-operative evaluation has significance. with extensive literature search it was found that only two cases of retinal detachment in the albinos have been reported. one case of rrd in oculocutaneous reported by yang jw et al in korea, shown the failure of endolasers in reattachment of retina due to melanin deficiency but successful result of cryopexy in case if albinism8. while the second case ocular albinism with rrd reported by m. hiroshi et al in japan shown reattachment of retinal hole & lattice degeneration with photo coagulation by krypton laser9. r.j hanson et al in their study on therapeutic challenge in proliferative diabetic retinopathy in oca also suggest that no visible endo laser burns were seen in cases of retinopathy and ultimately cryopexy was done10. we are reporting as first case of rrd in oculocutaneous albinism in our country and it observed that argon endo laser photocoagulation is not successful to reattach the retina but cryopexy is more useful and effective. in conclusion, the albinos patient should be rehabilitated promptly and timely; it is suggested that cryopexy should be attempted for retinal detachment in albinos patients and further work up to be needed. author’s affiliation dr. washoo mal associate ophthalmologist lrbt free base eye hospital korangi 2 ½, karachi, postal code: 74900 dr. shakir zafar consultant ophthalmologist lrbt free base eye hospital korangi 2½, karachi, postal code: 74900 retinal detachment surgery in oculocutaneous albinos patient pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 237 dr. shahab-ul-hasan siddiqi associate ophthalmologist lrbt free base eye hospital korangi 2 ½, karachi, postal code: 74900 dr. syed fawad rizvi chief consultant ophthalmologist lrbt free base eye hospital korangi 2 ½, karachi, postal code: 74900 references 1. hereditary fundus dystrophies. eye in: kanski jj, bowling b, editors. clinical ophthalmology a systemic approach. edenburgh: elsevier saunders; 2011: 647-85. 2. general ophthalmic problems. eye in: gerstenblith at, robinowitz mp, editors. the wills eye manual office and emergency room diagnosis and treatment of eye disease. philadelphia: lippincott williams and wilkins. 2012: 394-15. 3. retinitis pigmentosa and related disorders. (paul a. sieving). eye in: yanoff m, duker js, editors. ophthalmology. st. louis: mosby; 2004: 813-23. 4. molecular mechanisms of inherited disease. (wiggs jl). eye in: albert, jakobiec, editors. priciples and practice of ophthalmology. abelson: elsevier saunders; 2008: 19-25. 5. zuhlke c, kasman – knellnern b. genetics of oculocutaneous albinism. ophthalmology. 2007; 104: 674-80. 6. prising mn, forster h, gonser m, lorenz b. screening for tyr, oca2, gpr 143 and mcir in patients with congenital nystagmus, macular hypoplasia and fundus hypopigmentation indicating albinism. mol vis. 2011; 17: 939-48. 7. lin su, chien sc. rapid genetic analysis of oculocutaneous albibnism (oca1) using denaturing high performance liquid chromatography (dhplc). prenat diagn. 2006; 26: 466-70. 8. yang jw, lee sj, kang sb, park yh. j korean. a case of retinal detachment surgery in albinism patient. ophthalmol soc. 2008; 49: 840-4. 9. hiroshi m, hiroyuki m. a case of ocular albinism with rhegmatogenous retinal detachment. japanese review of clinical ophthalmology. 1999; 93: 861-4. 10. hanson rj, rubinstein a, batesh r .therapeutic challenges in management of pdr in oculocutaneous albinism. invest ophthalmol vis sci. 2005; 46: 346. microsoft word 15. news and events vol 28 168 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology news and events vol. 28, 3, 2012 32nd lahore ophthalmo 2012 date: 07 – 09 december 2012 venue: pearl continental hotel, lahore contact: prof. mian muhammad shafique phone: 042-36363325 email: osplhr@gmail.com the 28th asia – pacific academy of ophthalmology (apao) congress date: 17 20 january, 2013 venue: hyderabad, india web: www.apaophth.org 35th annual national ophthalmic conference & karophth 2013 date: 08-10 march, 2013 venue: pearl continental hotel, karachi contact: dr. qazi m. wasiq phone: +92 333 2183272 email: ospkarachi@yahoo.com 8th international symposium of ophthalmology – hong kong (iso-hk) & 7th asia-pacific vitreoretina society (apvrs) congress date: 14 – 16 december, 2012 venue: hong kong convention and exhibition centre web: www.apvrs.org american society of cataract and refractive surgery (ascrs) / american society of ophthalmic administrators (asoa) symposium and congress date: 19 23 april, 2013 venue: san francisco web: www.ascrs.org the association for research in vision and ophthalmology (arvo) annual meeting 2013 seattle – washington, united states date: 5-9 may, 2013 venue: seattle, washington web: www.arvo.org 34th world ophthalmology congress (woc) & the 29th asia – pacific academy of ophthalmology (apao) congress date: 2 – 6 april, 2014 venue: tokyo, japan 11th european glaucoma society conference date: 7 – 11 june, 2014 venue: nice, france web: www.eugs.org xxi biennial meeting of international society for eye research date: 20 – 24 jul, 2014 venue: san francisco, california web: www.iser.org institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091 – 9217376 – 80 fax: 92 – 42 – 36363326 email: pico@pes.comsats.net.pk news and events pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 169 college of ophthalmology and allied vision sciences lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042 – 37355998 fax: 042 – 37248006 email: pipo@brain.net.pk pakistan institute of ophthalmology, al – shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al – shifa trust eye hospital, jhelum road, rawalpindi – pakistan phone: 92 – 51 – 5487830, 5487820 – 25 fax: 92 – 51 – 5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt 4 – a lda flats lawrence road, lahore phone: 92 – 42 – 36363326 email: pjoosp@gmail.com microsoft word 08-oa -formattedmazhar soomroo _1_ 31 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology original article prevalence of hepatitis b and hepatitis c in elective ocular surgery (rural origin) at shifa eye hospital, khanpur mazhar zaman soomro, riaz mahmood pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mazhar zaman soomro al shifa eye hospital khanpur …..……………………….. purpose: to estimate the prevalence of hepatitis b and c infection in elective ocular surgery in patients of rural origin. material and methods: the study was conducted at al shifa eye hospital khanpur from july 2010 to june 2012. patients who were admitted for ocular surgery were included in this study. a proforma was designed for collection of data and consent was obtained from patients for the study. patients of rural origin of either sex between the ages of 40 to 90 years were included in the study. results: two thousand and fifty six (2,056) patients who had been admitted for elective ocular surgery were screened for hepatitis b and hepatitis c. among them one thousand and forty three (50.73%) patients were male and one thousand and thirteen (49.27%) were female. of these four hundred and twenty five (20.67%) patients were serologically positive for hepatitis. forty eight patients were serologically positive for hepatitis b positive (11.29%) and three hundred seventy seven (88.70%) were positive for hepatitis c. among hepatitis b seropositive patients twenty seven (56.25%) were male and twenty one (43.75 %) were female. among hepatitis c patients one hundred and ninety four (51.45%) were male and one hundred and eighty three (48.54%) patients were female. conclusion: the prevalence of hepatitis c antibodies is high in our rural population that is about to undergo ocular surgery. iral hepatitis is a major health problem. hepatitis b virus (hbv) has infected more than 2000 million persons and 350 million people are carrier of the virus. each year approximately one million people die from hepatitis b which makes it one of the major causes of morbidity and mortality1. hepatitis c virus (hcv) infection is increasing even more rapidly and has occurred in endemic situation in most parts of the world, with a prevalence of about 3% world wide2. hepatitis c virus infection progresses slowly and caries high risk of chronic liver disease (70 – 80%) and later liver malignancy3. in pakistan a large proportion of the population is already infected with hepatitis b and c with a prevalence of 10 % for hepatitis b and 4-7 % for hepatitis c4. in certain parts especially in the rural areas the percentage of infected individuals is significantly higher than the above quoted figures5,6. the transmission of virus is through the blood and secretions. most common source of spread of these infections is through the use of unsterilized syringes or instruments especially dental instruments or unchecked blood transfusion, other factors involved in the spread of hepatitis are contaminated instruments (e.g.: haemodialysis sets, reuse of contaminated medical devices, tattooing devices, acupuncture needles and razors) and occupational and nocosomialexposures7. v prevalence of hepatitis b and hepatitis c in elective ocular surgery (rural origin) at shifa eye hospital pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 32 the study was conducted at shifa eye hospital khanpur to see the prevalence of hepatitis b and hepatitis c in patients attending the hospital. material and methods this retrospective study was conducted at shifa eye hospital khanpur from july 2010 to june 2012. a total of 2,056 patients were included in this study that had undergone elective ocular surgery. patients from rural origin of either sex or occupation were included in the study and patients from urban origin were excluded. every patient was serologically screened by rapid chromatography immunoassay (ict) for qualitative detection of hepatitis c virus and hepatitis b antibodies in patients before surgery. this test is done by a cassette containing a membrane strip which is pre-coated with mouse monoclonal anti-hbs capture antibody on the test band region. the mouse monoclonal anti –hbscolloid gold conjugate and serum sample move along the membrane chromatographically to the test region (t) and form a visible line as the antibody – antigen-antibody gold particle complex forms. the cassette used for this is of standard diagnostics inc. (korea). results a total number of 2056 patients were operated during the study; one thousand and forty three (50.73%) patients were male and one thousand and thirteen (49.27%) were female table 1. of these four hundred and twenty five (20.67%) patients were serologically positive for hepatitis. forty eight patients were serologically positive for hepatitis b positive (11.29%) and three hundred seventy seven (88.70%) were positive for hepatitis c. among hepatitis b seropositive patients twenty seven (56.25%) were male and twenty one (43.75 %) were female. among hepatitis c patients one hundred and ninety four (51.45%) were male and one hundred and eighty three (48.54%) patients were female (table 2). discussion hepatitis b virus (hbv) is a member of the hepadnavirus family8. the virus particle, (virion) consists of an outer lipid envelope and an icosahedral nucleocapsid core composed of protein. the virus particle, (virion) consists of an outer lipid envelope and an icosahedral nucleocapsid core composed of protein. the hepatitis c virus is a small (50 nm in size), enveloped, single-stranded, positive sense rna virus. it is the only known member of the hepacivirus genus in the family flaviviridae. there are six major genotypes of the hepatitis c virus, which are indicated numerically (e.g., genotype 1, genotype 2, etc.). based on the ns5 gene there are three major and eleven minor genotypes. the major genotypes diverged about 300–400 years ago from the ancestor virus. the minor enotypes diverged about 200 years ago from their major genotypes. all of the extant genotypes appear to have evolved from genotype 1 subtype 1b genotypes diverged about 200 years ago from their major genotypes. the earliest record of an epidemic caused by hepatitis b virus was made by lurman in 18859. in the mid 1970s, harvey j. alter, chief of the infectious disease section in the department of transfusion medicine at the national institutes of health, and his research team demonstrated how most post transfusion hepatitis cases were not due to hepatitis a or b viruses. in 1988, the virus was confirmed by alter by verifying its presence in a panel of nanbh specimens. in april 1989, the discovery of the virus, renamed hepatitis c virus (hcv), was published in two articles in the journal sciences10,11. the incidence of hepatitis b and c has achieved alarming situation in many countries of the world, especially in underdeveloped countries. in pakistan the condition more grave in rural areas where patients are more exposed to infection due to protean constraints. according to cloud hay and his colleagues the prevalence of hepatitis c was 11.26%. ali and his associates12 reported 5.1% patients suffering from hepatitis c in their study and carrier state of hbs ag mazhar zaman soomro, et al 33 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology was found to be 2.8%. the carrier state of hbs ag is around 10% in different segments of pakistani people. surgeons and operation room personnel have the high risk of occupational exposure. in our study the prevalence of hepatitis was 20.67%. among these 425 patients prevalence of hepatitis b was 11.29% while hepatitis c was 88.70%. there is high prevalence of hepatitis c as compared to hepatitis b. also the prevalence of hepatitis was more as compared to previous studies. the reason for this might be people of rural origin get health facility from medical and dental quakes due to protean reasons. quakes are unaware of hazards of unsterilized syringes. dental quakes also use unsterilized dental instruments for dental diseases managements and exposed the community toward hepatitis. with such high rate of transmission in a highly developed country like usa little is known about the rate of risk in our part of the world. once inflicted this disease results in social, psychological and economic problems for the patient. conclusion the incidence of hepatitis c antibodies positive is higher in our population. invasive procedures represent an important mode of hbv and hcv transmission. since a large proportion of the adult general population is exposed to these procedures and an effective hcv vaccine is not yet available, nonimmunological means of controlling iatrogenic modes of transmission are extremely important. author’s affiliation dr. mazhar zaman soomro ophthalmic surgeon shifa eye hospital khanpur prof. dr. riaz mahmood clinical pathologist qasim lab. bahawalpur references 1. kane m. global program for control of hepatitis b infection, vaccine. 1995; 47-9. 2. khokhar n, gill ml, malik gl. general sero prevalence of hepatitis b and c infection in the population. j coll physician surg pak 2004; 14; 534. 3. supsa ve, hadjipashali e, hatzakisa. prevalence of risk factors and evaluation of a screening strategy for hepatitis band c viral infections in healthy company employees. euro j epidemiol. 2001; 17: 721. 4. nangrejo km, qureshi ma, sahto aa, siddiqui sj. prevalence of hepatitis b and c in the patients undergoing cataract surgery at eye camps. pak j ophthalmol. 2011; 27: 1. 5. malik ia, kaleem sa, tarique wuz. hepatitis c infection in prospective, where do we stand? j coll phy surg pak. 1999; 9: 234-7. 6. yousaf a, mohammad a, ishaque m, yousaf m. can we afford to operate on patients without hbs ag screening? j coll phy surg pak. 1996; 9: 98-100. 7. department of ophthalmology liaquat university of medical and health sciences jamshoro from july 2007 to june 2008. managing occupational risks for hepatitis c transmission in the health care setting. clin microbiol rev. 2003; 16: 546-68. 8. zuckerman aj. "hepatitis viruses". in baron s, et al. baron's medical microbiology (4th ed.). university of texas medical branch. isbn 1996; 0-9631172-1-1. 9. lurman a. "eine icterus epidemic". berl klin woschenschr. 1885; 22: 20–3. 10. choo ql, kuo g, weiner aj, overby lr, bradley dw, houghton m. "isolation of a cdna clone derived from a blood-borne non-a, non-b viral hepatitis genome". science. 1989; 244: 359–62. 11. kuo g, choo ql, alter hj, gitnick gl, redeker ag, purcell rh, miyamura t, dienstag jl, alter mj, stevens ce, et al. "an assay for circulating antibodies to a major etiologic virus of human non-a, non-b hepatitis". science 1989; 244: 362–4. 12. ali sa, sheikh fa, ahmed k. prevalence of hepatitis b and c virus in surgical patients. pak j surgery. 2007; 23: 109-12. pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 140 original article screening of diabetic retinopathy in a diabetic medical center saher khalid, mohammad moin, muhammad imran hasan khan pak j ophthalmol 2015, vol. 31 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: saher khalid pgr, eye unit ii lahore general hospital lahore email:viakhan123@gmail.com …..……………………….. purpose: to estimate the prevalence of diabetic retinopathy on the posterior pole of newly diagnosed diabetic patients using a non-mydriatic fundus camera. materials and methods: descriptive case series of 822 patients (male: female 29.4:70.6), screened during 10 months (august 2014-may 2015) was done in diabetes endocrine and metabolic centre (demc) using a single posterior pole photograph centered on the fovea using a non-mydriatic fundus camera. without pupil dilation, grading of diabetic retinopathy was done using airlie house classification which divides diabetic retinopathy (dr) into 5 grades i.e. background dr, pre-proliferative dr, proliferative dr, maculopathy and advanced disease. after grading, patients were referred to eye outpatient department for further management. newly diagnosed diabetics, including pregnant and hypertensive patients were studied. patients with hazy media, cataracts and evisceration were excluded. results: 170 (20.6%) out of 822 patients showed diabetic retinopathy in which 10 patients had type 1 (5.8%) while 160 patients (94.1%) had type 2 diabetes at presentation. highest distribution of diabetic retinopathy belonged to the age group 50 (21.7%) (mean 50.4, std. deviation 9.76). out of 170, 98 patients showed background diabetic retinopathy (57.6%), 31 patients showed preproliferative (18.25%), 20 patients showed proliferative diabetic retinopathy (pdr) (11.7%), 12 showed maculopathy (7.05%) and only 9 patients (5.2%) showed advanced disease. patients with vitreous hemorrhage, tractional retinal detachment and neovascular glaucoma were considered as having advanced disease. these results were totally based on posterior pole findings of diabetic patients. out of 170 patients, 8 had nephropathy (4.7%), 122 had neuropathy (71.7%) and 99 patients (58.2%) had preexisting hypertension. conclusion: fundus photograph with a non mydriatic camera in a diabetic medical center is a very useful tool to guide patients for early treatment, to prevent blindness. key words: diabetes mellitus, fundus camera, diabetic retinopathy screening. iabetes mellitus is now a leading cause of morbidity and mortality throughout the world. diabetes is associated with high rates of hospitalization, blindness, renal failure and nontraumatic amputation1. it is one of the most common non communicable disease globally. according to pakistan national diabetes survey, pakistan ranks 7th highest worldwide in the prevalence of diabetes and it will be 4th largest by the year 2030.2 world health organization (who) has estimated that global number of people with diabetes will be double over the next 25 years period3. a diabetic can have serious eye disease and not even know until complication has occured4. diabetic retinopathy is a leading cause of blindness in adults aged 20-74 years. the rationale of our study is to find the burden of d saher khalid, et al 141 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology diabetic retinopathy in newly diagnosed patients with diabetes mellitus in a tertiary care diabetic medical center using a non-mydriatic fundus camera. this can lead to early detection of complications to eye and help in prevention of visual loss. material and methods the study was descriptive case series conducted between august 2014 – may 2015. diabetic patients of both gender, aged 20 years and above, pregnant and hypertensives, were included in the study. critically ill, those with opaque media like corneal opacity, cataract and eviscerated eye patients were excluded from the study. as a first step, patients were screened in demc of lahore general hospital with a single posterior pole photograph centered on the fovea using a nonmydriatic fundus camera with undilated pupils. informed consent was taken before fundus photograph and full counselling about diabetes was done in diabetic eye clinic of lahore general hospital. fundus photograph was taken by an ophthalmic technician and photograph read by an ophthalmologist. grading of diabetic retinopathy was done using airlie house classification grading system which divides diabetic retinopathy into 5 grades i.e. background, pre-proliferative, proliferative, maculopathy and advanced disease and then patients with any above mentioned grade of diabetic retinopathy were referred to eye out patient department for further evaluation and treatment. patients with no retinopathy were called for followup photograph at 6 months intervals. results we screened a total of 822 patients in duration of 10 months from august 2014 to may 2015. the male (29.4%) to female (70.6%) distribution were 1:3.3 (table 1). out of them, 170 (20.6%) had diabetic retinopathy, 10 had type 1 diabetes (5.8%) and 160 had type 2 diabetes (94.1%) (table 2). highest distribution of diabetic retinopathy belonged to the age group 50 (mean 50.4, std. deviation 9.76) (table 3, fig. 1). the commonest presentation of diabetic retinopathy was background diabetic retinopathy that is 98 patients (57.6%) followed by pre-proliferative diabetic retinopathy 31 patients (18.2%), proliferative diabetic retinopathy 20 patients (11.7%), maculopathy 12 patients (7.05%) and only 9 patients showed advanced disease (5.2%) (table 4). patients with vitreous fig. 1: age distribution chart. hemorrhage, tractional retinal detachment and neovascular glaucoma are considered as having screening of diabetic retinopathy in a diabetic medical center pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 142 advanced disease. out if 170 patients, 8 had nephropathy (4.7%), 122 had neuropathy (71.7%) and 99 patients (58.2%) had preexisting hypertension (table 4). in our study, patients with hypertension and diabetes are more than diabetes without hypertension (table 5). discussion diabetes mellitus is a chronic metabolic disorder that has emerged as a great socioeconomic burden for the developing world. over the past two decades, there has been a significant rise in the prevalence of this devastating illness and is presenting as an alarming issue. currently diabetes affects 240 million people worldwide and this number is projected to increase to 380 million by 20255. pakistan belongs to high prevalence area, currently having 6.9 million affected people, expected to double by 2025 and affect 11.5 million people. this alarming situation can have serious repercussions and presents as a challenge for health care providers and health care policy makers in the country. a diabetic patient is 25 times more likely to become blind than non-diabetic.6 diabetes is the 4th leading cause of death in most developed countries with pakistan currently ranking at 7th position in the list of countries with major burden of diabetes and if the current situation continues, it will definitely come to 4th position by 2025.2 diabetic retinopathy is the most common cause of blindness in the working age group. it is one of the few ophthalmic diseases where there is a role of preventive measure to delay the progression of disease and visual loss.7 in a study done by hansen et al, 83 patients with type 1 and 2 diabetes were screened using non mydriatic fundus camera. they found its sensitivity of about 89.9% when used on patients without pupil dilation8. in another study 4318 diabetic patients were screened using non mydriatic fundus camera and the incidence of diabetic retinopathy was 15.8%9 (table 6) summarizes the results of various studies on diabetic retinopathy in developing countries. ghana10 and spain11 showed a significantly lower prevalence of 17.9% and 12.3% respectively (p < 0.01). the prevalence’s reported from saudi arabia,12 sri lanka13 and brazil14 reported a prevalence of 30%, 31.3% and 35.4% respectively, kashmir16 (27%) and south africa17 (40.3%) are significantly higher (p < 0.05) from our findings. this could be due to younger age of that population and the shorter duration of disease. egypt15 (20.5%) showed similar results to our study. the reported prevalence among 3000 diabetics from karachi18 (26.1%) is significantly higher while from india (18%),19 malaysia (14.9%) and victoria20 (18%) is significantly lower than our findings. a local study done in 2001 shows 33.3% prevalence of diabetic retinopathy.21 saher khalid, et al 143 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology in our setup, we have screened 822 diabetics patients in 10 months interval. type 1 and type 2 diabetics were both included. frequency of diabetic retinopathy among diabetics was 20.6% (170 patients) which is higher in most of the countries but lower in local study21 which was done in 2001. the most prevalent type of diabetic retinopathy in our study was background diabetic retinopathy 57.6%. non proliferative dr accounts for 18.2% which is consistent with those of kayani h in 2001 who observed npdr in 21.5% diabetics.21 we found a low frequency of proliferative diabetic retinopathy (11.8%) and local study also showed same prevalence21. prevalence of advanced diabetic retinopathy was (5.3%). in our study prevalence of nephropathy with dr is 4.7% which is lower than the prevalence in spain11 (8.6%). so nephropathy is well correlated with diabetic retinopathy. as far as neuropathy is concerned, our study shows a prevalence of 71.7% which is quiet high as compared to studies 29.2%,23 28%24 and 2.3%25 and slightly lower than another study 78.1%26. in present study, preexisting hypertension was present in 58.2% of patients while 38% prevalence is shown by study gillow jt et al27 and 53.5% prevalence by one local study done in peshawar by rahman s et al.28 hypertension is a well – known risk factor for several chronic conditions in which lowering blood pressure has proven to be beneficial. the available evidence supports a beneficial effect of intervention to reduce blood pressure with respect to preventing diabetic retinopathy for up to 4 to 5 years29. the appropriate blood pressure control in diabetes (abcd) trial is a prospective randomized blinded clinical trial that compares the effects of intensive versus moderate blood pressure control on the incidence and progression of type 2 diabetic complications like retinopathy, neuropathy and nephropathy.30 one limitation of our study is the use of old grading system of diabetic retinopathy that is not universally used in epidemiological studies now a days. we have chosen this classification because the patients included in our study were non-dilated and we took only the posterior pole images of these patients as we have already said. the modified airlie house classification needs 5-6 pictures of whole fundus involving the periphery so we could not use this new classification system. secondly, this study is limited to those who attended demc out patient clinic only, so it is likely that the rates may be an underestimation because our study is hospital based and not population based with low sample size, and actual prevalence may be different. main limitation of the study is that we have taken the fundus photograph of the posterior pole only, so the peripheral findings might have been missed. we are planning to rectify this in future by taking two photographs, centered on macula and disc with non mydriatic fundus camera. conclusion diabetic retinopathy screening using non mydriatic fundus camera improved the quality of care for our diabetic patients. this screening method identified patients requiring prompt referral to the ophthalmologist for further complete eye examination. extending this screening program to other areas of country should be considered. pakistan needs such screening programs for early identification of the condition with its associated complications, to provide appropriate timely treatment to reduce the burden of blindness due to diabetes. lastly, the development of an integrated health and social care pathway, including further education and better communication screening of diabetic retinopathy in a diabetic medical center pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 144 between all relevant parties, may be helpful in reducing the prevalence of diabetic retinopathy. author’s affiliation dr. saher khalid pgr, eye unit ii lahore general hospital, lahore prof. mohammad moin professor of ophthalmology eye unit ii, post graduate medical institute lahore general hospital, lahore dr. muhammad imran hasan khan associate professor of medicine medical unit 1, post graduate medical institute lahore general hospital, lahore role of authors dr. saher khalid main data collection and result compilation. prof. mohammad moin research design and research supervision. dr. muhammad imran hasan khan data collection and result analysis. references 1. cowic cc, eberhardt ms eds. alexandria, va. american diabetes association; diabetes 1996: vital statistics. american diabetes association 1996. 2. national society to prevent blindness: vision problem in the us: facts and figures. the american academy of ophthalmology preferred practice pattern series: diabetic retinopathy 1993; 18-20. 3. amos aj, mccarty dj, zimmet p. the rising global burden of diabetes and its complications; estimates and projections to the year 2010. diabetic medicine, 1997; 14 (suppl):s7 s84. 4. iqbal f, naz r. patterns of diabetes mellitus in pakistan: an overview of the problem. j pak med res. 2005; 44:123-50. 5. diabetes atlas 3rd ed. brussels, belgium. international diabetes federation: 2006. 6. carty mc a. use of eye care services by people with diabetes. br j med. 1998; 82: 410-4. 7. stuebiger n, smiddy w, wang j, jiang h, debuc dc. assesment of conjunctival microangiopathy in a patient with diabetes mellitus using the retinal function imager. j clin exp ophthalmol. 2015; 6: 400. 8. hensen ab, hartvig nv, jensen ms, borch-johnsen k, lund-andersen h, larsen m. diabetic retinopathy screening using digital non mydriatic fundus photography and automated image analysis. acta ophthalmol scand. 2004; 82: 666-72. 9. levy j, lifshitz t. screening of diabetic retinopathy with a mobile non mydriatic fundus camera in southern israel. isr med assoc j. 2011; 13:137-40. 10. rotimi c, daniel h. prevalence and determinants of diabetic retinopathy and cataracts in west african type 2 diabetes patients.ethn dis. 2003 summer;13(2 suppl 2):s110-7 11. rodriguez-poncelas a, miravet-jiménez s. prevalence of diabetic retinopathy in individuals with type 2 diabetes who had recorded diabetic retinopathy from retinal photographs in catalonia (spain).br j ophthalmol. 2015 jun 18. 12. khan ar. prevalence and determinants of diabetic retinopathy in al hasa region of saudi arabia: primary health care centre based cross-sectional survey, 2007–2009. middle east afr j ophthalmol. 2010; 17: 257–63. 13. fernando dj. prevalence of retinopathy in a sri lankan diabetes clinic. ceylon med j. 1993; 38: 120-3. 14. schellini sa, carvalho gm, rendeiro fs, padovani cr, hirai fe. prevalence of diabetes and diabetic retinopathy in a brazilian population. ophthalmic epidemiol. 2014; 21: 33-8. 15. macky ta, khater n, al-zamil ma, el fishawy h, soliman mm. epidemiology of diabetic retinopathy in egypt: a hospital-based study. ophthalmic res. 2011; 45: 73-8. 16. qureshi t, abdullah n. prevalence of diabetic retinopathy in kashmir india. a hospital based study. global journal of medicine and public health. 2013; 2: 1. 17. rotchford ap et al. diabetes in rural south africa-an assessment of care and complications. s afr med j. 2002; 92: 536-41. 18. khan aj. prevalence of diabetic retinopathy in pakistan subjects. a pilot study. j pak med assoc. 1991; 41: 49-50. 19. raman r, rani pk. prevalence of diabetic retinopathy in india: sankara nethralaya diabetic retinopathy epidemiology and molecular genetics study report 2. ophthalmology, 2009; 116: 311-8. 20. harper ca. screening for diabetic retinopathy using a non-mydriatic retinal camera in rural victoria. aust n z j ophthalmol. 1998; 26: 117-21. 21. kayani h, rehan n. frequency of retinopathy among diabetics in a teaching hospital of lahore. 22. pedro ra, ramon sa, marc bb, juan fb, isabel mm. prevalence and relationship between diabetic retinopathy and nephropathy, and its risk factors in the north – east of spain, a population – based study. ophthalmic epidemiol. 2010; 17: 251-65. 23. bansan d, gudala k. prevalence and risk factors of development of peripheral diabetic neuropathy in type 2 diabetes mellitus in a tertiary care setting. j diabetes investig. 2014; 5: 714–21. 24. tesfaye s, stevens lk, stephenson jm. prevalence of diabetic peripheral neuropathy and its relation to glycaemic control and potential risk factors: the eurodiab iddm complications study. diabetologia. 1996; 39: 1377-84. http://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20j%5bauthor%5d&cauthor=true&cauthor_uid=26301125 http://www.ncbi.nlm.nih.gov/pubmed/?term=jiang%20h%5bauthor%5d&cauthor=true&cauthor_uid=26301125 http://www.ncbi.nlm.nih.gov/pubmed/?term=debuc%20dc%5bauthor%5d&cauthor=true&cauthor_uid=26301125 http://www.ncbi.nlm.nih.gov/pubmed/?term=jensen%20ms%5bauthor%5d&cauthor=true&cauthor_uid=15606461 http://www.ncbi.nlm.nih.gov/pubmed/?term=borch-johnsen%20k%5bauthor%5d&cauthor=true&cauthor_uid=15606461 http://www.ncbi.nlm.nih.gov/pubmed/?term=lund-andersen%20h%5bauthor%5d&cauthor=true&cauthor_uid=15606461 http://www.ncbi.nlm.nih.gov/pubmed/?term=larsen%20m%5bauthor%5d&cauthor=true&cauthor_uid=15606461 saher khalid, et al 145 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology 25. fedele d, comi g, coscelli c. a multicentre study on the prevalence of diabetic neuropathy in italy. diabetes care. 1997; 20: 836-43. 26. abdollahi a, moghimi s, tabasi a, rajabi mt, sabet b. neuropathy and retinopathy in diabetes: is there any association. int j ophthalmol. 2009; 2: 1. 27. gillow jt, gibson jm, dodson pm. hypertension and diabetic retinopathy-what’s the story? br j ophthalmol 1999; 83: 1083-7. 28. rahman s, nawaz r, khan gj, aamir ah. frequency of diabetic retinopathy in hypertensive diabetic patients in a tertiary care hospital of peshawar, pakistan. j ayub med coll abbottabad. 2011; 23. 29. do dv, wang x, vedula ss, marrone m, sleilati g, hawkins bs, frank rn. blood pressure control for diabetic retinopathy. cochrane database syst rev. 2015; 1: cd006127. 30. estacio ro, jeffers bw, gifford n, schrier rw. effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. diabetes care, 2000; 2: b54-64. http://www.ncbi.nlm.nih.gov/pubmed/?term=khan%20gj%5bauthor%5d&cauthor=true&cauthor_uid=24800364 http://www.ncbi.nlm.nih.gov/pubmed/?term=aamir%20ah%5bauthor%5d&cauthor=true&cauthor_uid=24800364 pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 204 original article comparison of complications between forceps and injector delivery for acrylic multipiece iol muhammad moin, asif manzoor, lubna siddiq pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. asif manzoor yaqin vision eye center, lahore email: asifmanzoor259@gmail.com …..……………………….. purpose: to compare complications between forceps and injector delivery for acrylic multipiece intraocular lens (iol) in phacoemulsification. study design: non-randomized clinical trial. place & duration of study: yaqin vision eye center from october 2002 to june, 2017. material and methods: all patients undergoing routine phacoemulsification with implantation of foldable acrylic multipiece iol (acrys of ma60 ac, alcon, usa) were included in the study. the patients were divided into two groups according to the method of insertion of the iol. group a included patients undergoing foldable implantation with forceps while group b included patients in which injector was used to implant the iol. any complications arising during insertion of iol were recorded in the electronic records of the patients. results: there were 820 patients out of which group a included 408 patients while group b included 412 patients in group a there were 392 (96%) iols implanted in the bag and 16 (4%) in the sulcus. in group b there were 396 (96%) iols implanted in the bag and 16 (4%) in the sulcus. forceps delivery needed enlargement of incision to 3.5 – 4.0 mm for iol insertion with no insertion related complication. while injector delivery needed only 3.0 mm enlargement of wound with few injectors related complications. these included optic and haptic damage 2 (0.48%), flipping of iol back to front 4 (0.97%) and posterior capsular rent (pcr) with haptic 1 (0.24%) while injecting. conclusion: delivery of multipiece iol with injector has more complications compared to forceps delivery. keywords: phacoemulsification, acrylic intraocular lens, injector, forceps. ataract surgery is the most common procedure done across the world for the management of the number one cause of treatable blindness1. advancements in cataract surgery have evolved new procedures with small incision producing very little astigmatism postoperatively and thereby producing quick visual recovery for the patient2. these requirements are met by phacoemulsification and therefore it has become the most popular technique for cataract surgery during the past decades4. small incision size requires a foldable iol to be inserted after removal of the cataractous lens. two techniques have been used to achieve this goal. folding of the iol with a specially designed forceps has been a popular technique in the past. the technique is easy to learn with minimal instrumentation. the technique does require the incision to be enlarged. using an injector has come in vogue in the recent years and it causes less manipulation and minimal wound enlargement. moreover the risk of infection is reduced due to no contact of the iol with the lid or conjunctiva during c muhammad moin, et al 205 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology the insertion. the technique requires a disposable cartridge and injector system which has a learning curve in the beginning6. some studies suggest that forceps delivery of iol drags microorganisms into eye7. hydrophobic acrylic iol with square edge design produces the least posterior capsular opacifications8,9. the rationale of this study is to compare the complications of forceps versus injector delivery systems for hydrophobic acrylic multi piece foldable iol in phacoemulsification. material and methods this non-randomized clinical trial was conducted in yaqin vision center, lahore from october 2002 to june, 2017. approval was obtained from hospital ethical review board. all patients undergoing routine phacoemulsification with implantation of foldable acrylic multipiece iol (acrys of ma60 ac, alcon, usa) were included in the study. the patients were divided into two groups according to the method of insertion of the iol. group a included patients undergoing foldable implantation with forceps while group b included patients in which injector was used to implant the iol. total 820 patients were included in study. group a included 408 (49.76%) patients and 412 (50.24%) patients were included in group b. patients undergoing phaco trabeculectomy, phaco vitrectomy, lensectomy and implantation of all other types of iol, were excluded from the study. any complications arising during insertion of iol were recorded in the electronic records of the patients. surgery in both groups was performed by the same surgeon using a 2.75 mm incision at 12 o clock. the wound was enlarged to 3.5 4 mm for forceps delivery of iol insertion. while in the cases with injector delivery wound was only enlarged to 3.0 mm. complete evaluations of all patients was done before surgery including complete ocular and systemic history and eye examination including best corrected visual acuity assessment, extra ocular movements and dilated fundus examination on slit lamp. preoperative kerotometery using javal-shiotz keratometer or iol master and axial length using acoustic or optical biometer were recorded. majority of the patients were operated under subtenon anesthesia while some required retrobulbar or topical anesthesia. all patients underwent a standard surgical procedure and were examined on 1st post-operative day. slit lamp examination was performed to evaluate post-operative anterior uveitis. topical antibiotics and steroids ciprofloxacin or moxifloxacin, 0.1% dexamethasone and diclofenac sodium or nepafenac eye drops were prescribed in all cases. all the data was recorded and analyzed by spss20. qualitative variables like gender and complications were described in frequency and percentage. numerical variables like age were described by mean and standard deviation. complications due to the injecting technique in two groups were compared by applying student’s `t’ test with significance p value equal to or less than 0.05. results out of 820 patients group a included 408 patients with average age of 63 ± 12.2 yrs with 189 (46.32%) males and 219 (53.68%) females while group b included 412 patients with average age of 60 ± 16.4 years with 182 (44.17%) males and 230 (55.83%) females. in group a there were 392 (96%) iols implanted in the bag and 16 (4%) in the sulcus. in group b there were 396 (96%) iols implanted in the bag and 16 (4%) in the sulcus. forceps delivery needed enlargement of incision to 3.5 to 4.0 mm for iol insertion with no insertion related complication. while injector delivery needed only 3.0 mm enlargement of wound with few injectors related complications. these included optic and haptic damage 2 (0.48%), flipping of iol back to front 4 (0.97%) and posterior capsular rent (pcr) with haptic 1 (0.24%) while injecting. injector insertion allowed insertion of iol in bag in cases of small pcr due to deep and stable chamber table 1: results of forceps delivery of iol. in bag in sulcus intact ccc radial tear total small ccc radial tear / pc rent total 384 8 392 7 10 16 group a, n = 408 comparison of complications between forceps and injector delivery for acrylic multipiece iol pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 206 table 2: results of injector delivery of iol. in bag in sulcus intact ccc small pcr radial tear iol front to back damage to haptic off center iol crack total small ccc radial tear/pc rent radial tear due to haptic haptic damage total 378 6 8 2 1 1 396 5 9 1 1 16 group b, n = 412 during iol insertion compared to forceps delivery. these complications with injectors happened in early transition from forceps to injector technique. patients with haptic damage had to undergo iol removal with re-insertion of new iol. discussion cataract surgery has become a relatively safer procedure with highly predictable visual results due to advanced surgical technique and technology. now a days patients undergoing cataract surgery expect comparable results to the patients undergoing refractive surgery. but the most important factor limiting final visual outcome after modern cataract surgery is the amount of postoperative astigmatism and it remains unpredictable most of the time. surgically induced astigmatism (sia) depends on location, type and length of the incision and to the source of wound closure techniques8,9. self-sealed small-incision surgery with a foldable intraocular lens has become popular with a significantly lower complication rate10,11. foldable intraocular lenses and improved iol injectors and insertion forceps have made easier intraocular lens implantation through smaller incisions of phacoemulsification. in studies related to cataract surgery incision size emphasized that the incision should be measured after iol implantation12. in a study by kohnen and coauthors12, they concluded that with use of injectors for iol insertion cataract surgery incisions are enlarged by approximately 11.0%. another study done by mamalis13 reported that they needed a larger wound for iols insertion with forceps as compared to lens insertion with the help of an injector. as in our study wound size with forceps delivery system was slightly larger than the wound with injector delivery system. it is important to know the proper size of a wound to avoid uncontrolled wound enlargement during foldable iol implantation14. we used 2.7 5mm keratome in our study and wound was slightly enlarged in forceps delivery system to minimize risk of uncontrolled wound extension. radner and coauthors15 stated that injecting iol through a small incision maximizes the chances of corneal damage with tearing of stromal lamellae. takeshita et al16 reported single-action implantation of a 3-piece acrys of ma30ba acrylic foldable intraocular lens (iol) (alcon) with the help of monarch ii (alcon) injector. in 134 eyes iols were implanted using this technique. their incision widths were ranging from 3.00 to 3.75mm. all the intraocular lenses were implanted in the capsular bag successfully. complications observed during iol implantation were haptic damage in 3 eyes (3%), cracked iol optic in 3 eyes (3%) and inadequate selfsealing of the incision in 18 eyes (13%). results of our study also showed small off center optic crack in one patient, 2 patients had haptic damage and 2 patients had back to front delivery of the iol. nasrullah et al17 conducted a comparative study on intraocular lens implantation with injector and forceps and they concluded that both methods were safe and equal statistically and they did not found any statistically significant difference in surgically induced astigmatism. in their study a ceeflex single piece iol was used. they did not report any damage to the iol compared to our study in which injector caused damage to delicate prolene haptics of the iol. baráková et al18 studied the results of acrys of ma30ba multipiece iol using the monarch iol injector system. they explained the facility of this injector system including the iol position within the cartridge, iol folding, passage of the lens through the cartridge and unfolding of iol in the anterior chamber. the results showed that monarch iol delivery system is safe and easy to use for implantation of the acrys of ma30ba iol. the size of muhammad moin, et al 207 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology incision after implantation performs criterion of suture-less technique and corresponds contemporary requirements of the modern cataract surgery of small incision. unlike our study they did not report any complication with this multipiece iol. khokhar et al19 recently published a comparative study between effect of using new motorized injector versus manual injector for insertion of foldable iols on wound integrity through a 2.2 mm clear corneal incision using single piece acrys of sn60wf iol. parameters for comparison between two groups included intraocular lens safety, final incision width and wound integrity in terms of anterior and posterior wound gape, and detachment of descemet’s membrane. they found motorized iol insertion system gentle and much safer for the intraocular lenses with lesser incidence of iol nicks. in terms of wound safety, it caused significantly low chances of incision enlargement and better posterior wound integrity. similarly in this study no damage to the iol was shown with injector delivery as it was a single piece iol. singh et al20 showed cartridge cracks during foldable intraocular lens insertion. in 350 consecutive cases small incision cataract surgery was performed. in all cases foldable silicone iol (allergan medical optics si-40) was implanted using the un-folder cartridge and they used 3 viscoelastic agents: sodium hyaluronate (healon, vitrax) and sodium chondroitin sulfate-sodium hyaluronate (viscoat). they observed cartridge cracks in 52 eyes (14.86%). almost all cartridge cracks (98.1%) observed in cases in which healon was used to load the intraocular lens. it was noted that in every case of cracked cartridge, there was an evidence of the plunger overriding the optic edge. but we did not encounter such a problem as most of our cases used methylcellulose to inject the iols through the cartridge. the next development in multipiece iol will be development of a preload injector system which will reduce these complications due to manual loading of the iol. the superiority of preloaded iol injector systems has been shown in recent studies by nanvatny21 and wang22. although they have evaluated single intraocular lenses but these designs promise to reduce infection due to intraocular lens insertion further. conclusion delivery of multipiece iol with injector has more complications compared to forceps delivery. therefore practice of iol insertion with injector in wet lab is recommended before switching to this technique. author’s affiliations prof. muhammad moin department of ophthalmology, postgraduate medical institute, lahore. consultant ophthalmologist, yaqin vision center, lahore. dr. asif manzoor consultant ophthalmologist, yaqinvision eye center, lahore. vitreo-retinal fellow, lahore general hospital, lahore. dr. lubna siddiq senior registrar, lahore general hospital, lahore role of authors prof. muhammad moin study design, data collection, manuscript writing. dr. asif manzoor data analysis, manuscript writing. dr. lubnasiddiq, critical review. references 1. stenevi u, lundstrom m, thorburn w. an outcome study ofcataract surgery based on national register. acta ophthalmol. 1997; 75: 688-91. 2. rainer g, menapace r, vass c. corneal shape changes after temporal supero-lateral 3.0 mm clear corneal incisions. j cataract refract surg. 1999; 25: 1121-6. 3. data vk, sidhu n. management of cataract: revolutionary change that occurred during last two decades. j indian med assoc. 1999; 8: 313-7. 4. hussain m, durrani j, nisar a. phacoemulsification: a review of 210 cases. pak j ophthalmol. 1996; 12: 38-9. 5. takeshita t, yamada k, tanihara h. single-action implantation of a 3-piece acrylic intraocular lens with aninjector. j cataract refract surg. 2003; 29: 246-9. 6. asia ei, jubran rz, solberg y, et al. the role of intraocular lenses in anterior chamber contamination during cataract surgery. graefes arch clin exp ophthalmol. 1998; 236: 721-4. 7. kohnen t, koch dd. experimental and clinical evaluation of incision size and shape following forceps and injectorimplantation of a three – piece high – refractive – index siliconeintraocular lens. graefes arch clin exp ophthalmol. 1998; 236: 922-8. 8. simsek s, yasar t, demirok a. effect of superior and comparison of complications between forceps and injector delivery for acrylic multipiece iol pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 208 temporal clear corneal incisions on astigmatism after suture-less phacoemulsification. j cataract refract surg. 1998; 24: 515-8. 9. roman sj, auclin fx, chong-sit da, et al. surgically induced astigmatism with superior and temporal incisions in cases ofwithin the rule preoperative astigmatism. j cataract refract surg. 1998; 24: 1636-41. 10. john t, sims m, hoffmann c. intraocular bacterial contamination during suture-less, small incision, singleport phacoemulsification. j cataract refract surg. 2000; 26: 1786-91. 11. muller-jensen k, barlinn b. corneal refractive changes after acrys of lens versus pmma lens implantation. ophthalmologica. 2000; 214: 320-3. 12. kohnen t, dick b, jacobe kw. comparison of the induced astigmatism after temporal clear corneal tunnel incisions ofdifferent sizes. j cataract refract surg. 1995; 21: 417-24. 13. mamalis n. incision width after phacoemulsification with foldable intraocular lens implantation. j cataract refract surg. 2000; 26: 237-41. 14. tekeshita t, yamada k, tanihara h. single-action implantation of a 3 piece acrylic intraocular lens with aninjector. j cataract refract surg. 2003; 29: 246-9. 15. radner w, menapace r, zehetmayer m, et al. ultrastructure of clear corneal incision. part 1. effect of keratomes and incision width on corneal trauma after lens implantation. jcataract refract surg. 1998; 24: 48792. 16. takeshita t, yamada k, tanihara h. single-action implantation of a 3-piece acrylic intraocular lens with an injector. j cataract refract surg. 2003 feb; 29 (2): 246-9. 17. khan n, ahmed am, waheed k, mahmood t. surgically induced astigmatism comparison between forceps and injector delivery system for foldable iol in phacoemulsification. pak j of ophthal april. 2011; 27 (2): 63-67. 18. baráková d, kuchynka p, cihelková i. implantation of the acrys of ma30ba lens using the monarch system]. cesk slov oftalmol. 2002 may; 58 (3): 149-52. 19. khokhar s, sharma r, patil b, aron n, gupta s. comparison of new motorized injector vs. manual injector for implantation of foldable intraocular lenses onwound integrity: an asoct study. eye (lond). 2014 oct; 28 (10): 1174-8. 20. singh ad, fang t, rath r. cartridge cracks during foldable intraocular lensinsertion. j cataract refract surg. 1998 sep; 24 (9): 1220-2. 21. nanavaty ma, kubrak-kisza m. evaluation of preloaded intraocular lens injection systems: ex vivo study. j cataract refract surg. 2017 apr; 43 (4): 558-563. 22. wang l, wolfe p, chernosky a, paliwal s, tjia k, lane s. in vitro delivery performance assessment of a new preloaded intraocular lens delivery system. j cataract refract surg. 2016 dec; 42 (12): 1814-1820. http://www.pjo.com.pk/27/2/nasrullah.pdf http://www.pjo.com.pk/27/2/nasrullah.pdf http://www.pjo.com.pk/27/2/nasrullah.pdf 172 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology original article retinopathy in pregnancy induced hypertension muhammad imran janjua, saira bano, ali raza pak j ophthalmol 2015, vol. 31 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad imran janjua postgraduate trainee ophthalmology holy family hospital, rawalpindi janjua.doc@gmail.com …..……………………….. purpose: the purpose of this study was to observe the prevalence of hypertensive retinopathy in patients with pregnancy induced hypertension. materials and methods: this cross-sectional study was carried out at holy family hospital, rawalpindi from july 2013 to july 2015. 168 patients with pregnancy induced hypertension were examined for any fundus changes. patient’s age, number of pregnancies, gestation period, blood pressure and proteinuria were noted. pupils were dilated and fundus examination was done by direct ophthalmoscope. the data was analyzed by spss program. results: a total of 168 patients were examined, 42 (25%) were primi-gravida, 91 (54.2%) were multi-gravida and 35 (20.8%) were grand multi-gravida. the mean age was 27.66 (± 5.20) years. the average gestation period was 33.36 (±3.91) weeks. 126 (75%) patients had gestational hypertension, 37 (22%) had preeclampsia and 5 (3%) patients had eclampsia. hypertensive retinopathy was observed in 87 (51.78%) patients. central serous chorioretinopathy (cscr) was seen in 3 (1.8%) patients. a statistically significant positive correlation was seen between the severity of retinal hypertensive changes and blood pressure (p = 0.005), the grade of proteinurea (p = 0.000), severity of disease (p = 0.000) and no of pregnancies (p = 0.001). conclusion: the level of blood pressure, severity of disease and proteinuria are significantly related with severity of hypertensive retinopathy in cases of pih. retinal examination can greatly help in predicting the severity of pih and also in timely diagnosis and management of such cases. key words: retinopathy, hypertension, pregnancy. regnancy induced hypertension (pih) is defined as an elevated blood pressure of ≥ 140/90 mm hg recorded at rest on two different occasions and emerging after 20 weeks of gestation in a pregnant woman. it is classified into three types according to associated features: gestational hypertension: bp of > 140/90 mm hg without associated proteinurea. pre-eclampsia: bp of ≥ 140/90 mm hg with associated proteinurea of ≥ 300 mg / 24 hours. eclampsia: the onset of convulsions in a woman with pre-eclampsia that cannot be attributed to other causes.2 hypertensive disorders in pregnancy are a major cause of maternal and fetal morbidity and mortality. pih is the most common cause of maternal mortality in europe. it is also amongst the leading causes of maternal deaths in developing countries like india and pakistan.5 pih, in its different forms, is responsible for 10 – 15% maternal deaths worldwide.3 it is also associated with an increased risk of fetal and neonatal mortality.6 nearly 5 – 11% of pregnant women develop hypertensive disorders and fundus changes are seen in 40 – 100% of these patients.4,11 the most common finding in such patients is attenuation of small retinal p mailto:janjua.doc@gmail.com retinopathy in pregnancy induced hypertension pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 173 blood vessels especially arterioles. these vascular changes are reversible and the resultant signs and symptoms resolve after delivery.1 the potential complications of hypertensive retinopathy in pregnancy are development of central serous chorioretinopathy (cscr) and serous retinal detachment.8,9 retina is the only site in human body where blood vessels can be visualized directly with the help of an ophthalmoscope. as hypertension has its effects on all the vessels of human body, retinal examination and assessment of vascular changes in pregnant women can provide valuable information about the status of placental circulation and fetal well being 12. hypertensive retinopathy is a well known predictor of increased cardiovascular risk.10 women affected with pre-eclampsia or eclampsia are twice at risk of cardiovascular and cerebrovascular accidents as compared with unaffected women.3 this study was undertaken to determine the prevalence of retinal changes in pih and association between the retinal changes and blood pressure, proteinuria and severity of the disease. materials and methods this cross – sectional study was carried out at holy family hospital, rawalpindi from july 2013 to july 2015. a total of 168 patients diagnosed with pregnancy induced hypertension were included in this study. the patients with known diabetes or hypertension or any other ocular pathology which hindered posterior segment examination were excluded from the study. similarly patients who had any renal disease were also excluded. patient’s age, number of pregnancies, gestation period in weeks, blood pressure and proteinuria were noted from their clinical records. the pupils were dilated with tropicamide 1% eye drops and retina was examined with a direct ophthalmoscope. the examination was carried out by two senior residents of ophthalmology department to minimize the observer’s bias. any pathological findings were noted and the keith – wagener classification7 was used to grade the hypertensive retinopathy as shown below: grade 1: mild generalized arterial attenuation, particularly of small branches; grade 2: more severe grade 1 + focal arteriolar attenuation; grade 3: grade 2 + hemorrhages, hard exudates, cotton wool spots; grade 4: grade 3 + optic disc swelling the dipstick method was used to test proteinurea and it was graded as nil = not detectable, + = ≥ 0.3 gm/l, ++ = ≥ 1 gm/l and +++ = ≥ 3 gm/l. the severity of pih was classified as gestational hypertension, pre-eclampsia and eclampsia according to clinical and laboratory findings as described above. the data was analyzed by statistical package for social sciences (spss) version 20.0 and values were expressed in terms of frequencies, percentages and means. bi-variate correlation was used to determine the association between retinal changes and blood pressure, proteinuria, and severity of the disease. pvalue < 0.05 was considered statistically significant. results a total of 168 patients were examined, of which 42 (25%) were primi-gravida (first time pregnant), 91 (54.2%) were multi-gravida (2 to 4 pregnancies) and 35 (20.8%) were grand multi-gravida (5 or more pregnancies). the age ranged from 18 to 42 years with a mean of 27.66 (±5.20) years. the gestation period was between 25 and 41 weeks with an average of 33.36 (±3.91) weeks. 126 (75%) patients were diagnosed with gestational hypertension, 37 (22%) had pre-eclampsia and 5 (3%) patients had eclampsia. 94 (56%) patients had a bp < 150/100 mm hg while 74 (44%) patients had > 150/100 mm hg. 126 (75%) patients did not have any detectable proteinurea, 13 (7.7%) had a proteinurea of +, 24 (14.3%) had ++ and 5 (3%) patients had +++. 81 (48.2%) patients did not show any retinal changes. hypertensive retinopathy was observed in 87 (51.78%) patients. grade 1 changes were seen in 51 (30.4%) patients, grade 2 in 28 (16.7%), grade 3 in 5 (3%) and grade 4 in 3 (1.8%) patients. central serous chorioretinopathy (cscr) was seen in 3 (1.8%) patients (table 1). a statistically significant positive correlation was seen between the severity of retinal hypertensive changes and blood pressure (p=0.005). similarly, a highly positive correlation was observed between the severity of retinopathy and the grade of proteinurea (p = 0.000), severity of disease (p = 0.000) and no of pregnancies (p = 0.001) (table 1). muhammad imran janjua, et al 174 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology discussion hypertensive disorders are a common cause of morbidity and mortality in pregnant women. in pakistan 10 – 12% women suffer from pregnancy induced hypertension.3 in the developed countries like us the reported incidence is much less and only 4% of pregnant women suffer from pih6. this study included 168 women who were diagnosed with pregnancy induced hypertension. the mean age was about 27 years. it is similar to the average age of women as shown in previous studies from malaysia1 (30 years) and india12 (25 years). however, in the us, most of the women who suffered from pih were either younger than 20 years or older than 35 years of age.6 out of the 168 patients examined, 87 (51.78%) showed signs of hypertensive retinopathy. previous literature shows a prevalence of retinal changes from 13% to 59%1. most of the previous studies showed only grade 1 and grade 2 hypertensive changes in pregnant women1, 12, while this study showed grade 3 changes in 5 (3%) and grade 4 changes in 3 (1.8%) patients. 3 (1.8%) patients also showed cscr. this is very high as compared to a study by said – ahmed, et al9 which showed a rate of only 0.008%. this may be due to delayed presentation of patients for medical care in our setup. 42 (25%) out of 168 patients were primi-gravida, of which 18 (42.8%) showed retinal changes. 91 (54.2%) were multi-gravida and 41 (45%) had retinopathy. 35 (20.8%) patients were grand multi-gravida and retinal hypertensive changes were seen in 28 (80%). this shows that grand multi-gravida had almost twice the incidence of retinal hypertensive changes as compared to primi and multi-gravida. there was a significant correlation between number of pregnancies and severity of retinopathy (p = 0.001). this correlation was not seen in previous literature.1,12 126 (75%) patients had gestational hypertension, 37 (22%) had pre-eclampsia and 5 (3%) patients had eclampsia. a statistically significant positive correlation was seen between the severity of disease and the grade of retinopathy in this study (p = 0.000). this positive correlation was also observed in previous studies.1,12 94 (56%) patients had a blood pressure of < 150/100 mm hg and 74 (44%) had a bp of > 150/100 mm hg. of these, retinopathy was seen in 41 (43.6%) and 46 (62.1%) patients respectively. a positive correlation was seen between blood pressure and grade of retinopathy (p = 0.005) as described by previous literature.1,12 in this study, statistically significant positive correlation was observed between the grade of proteinurea and the grade of retinopathy (p=0.000). 126 (75%) patients had no proteinurea and out of these 58 (46%) showed retinopathy. 13 (7.7%) patients had a proteinurea of “+”, 24 (14.3%) had “++” and 5 (3%) had “+++”. out of these 6 (46.1%), 18 (75%) and 5 retinopathy in pregnancy induced hypertension pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 175 (100%) patients had hypertensive changes. previous studies also showed similar positive correlation between grade of proteinurea and grade of retinopathy in patients of pih.1,12 many physiological cardiovascular and hemodynamic changes occur in pregnant women to provide for the well being of the developing fetus.5 if a woman suffers from hypertension during pregnancy, it affects all the blood vessels in the body including placental vasculature1. if not properly managed, it results in significant maternal and fetal morbidity and can even lead to maternal or fetal mortality6. presence of hypertensive retinopathy in pregnant women is a strong indicator of similar vascular changes in placental circulation and can be used as a predictor of fetal well – being.11 conclusion in conclusion, the level of blood pressure, grade of proteinurea and severity of pih are all correlated with the severity of vascular changes in pregnant women. routine ophthalmoscopy should be performed in women suffering from pih so that the status of retinal vasculature in particular and placental vasculature in general can be assessed. with timely diagnosis and management of such patients significant loss in terms of maternal and fetal morbidity and mortality can be prevented. author’s affiliation dr. muhammad imran janjua postgraduate trainee ophthalmology holy family hospital, rawalpindi dr. saira bano postgraduate trainee ophthalmology holy family hospital, rawalpindi prof. dr. ali raza head of ophthalmology department rawalpindi medical college and allied hospitals role of authors dr. muhammad imran janjua study conception, data collection, analysis and drafting. muhammad imran janjua, et al 176 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology dr. saira bano study conception, data collection and analysis. prof. dr. ali raza critical review, analysis and overall supervision. references 1. reddy sc, sivalingam n, sheila rani kg, tham sw. fundus changes in pregnancy induced hypertension. int j ophthalmol. 2012; 5: 694-7. 2. watanabe k, naruse k, tanaka k, metoki h, suzuki y. outline of definition and classification of “pregnancy induced hypertension (pih)” hypertens res pregnancy 2013; 1: 3–4. 3. khan a, fahim a, qureshi a, nizamani gs, azmi ma. pregnancy induced hypertension; assessment of prognostic value of platelet count in women with varying degree. professional med j. 2014; 21: 436-440. 4. mackensen f, paulus we, max r, ness t. ocular changes during pregnancy. dtsch arztebl int. 2014; 111: 567–76. 5. kintiraki e, papakatsika s, kotronis g, dimitrios g. goulis,1 kotsis v. pregnancy – induced hypertension. hormones. 2015, 14: 211-23. 6. ananth cv, basso o. impact of pregnancy-induced hypertension on stillbirth and neonatal mortality in first and higher order births: a population-based study. epidemiology 2010; 21: 118–23. 7. kanski jj. clinical ophthalmology-a systematic approach, 2nd ed, oxford, butterworth heinmann, 1989; p 329. 8. omoti ae, erameh jmw, okeigbemen vw. a review of the changes in the ophthalmic and visual system in pregnancy. afr j reprod health. 2008; 12: 185-96. 9. said-ahmed k, moustafa g, fawzy m. incidence and natural course of symptomatic central serous chorioretinopathy in pregnant women in a maternity hospital in kuwait. middle east afr j ophthalmol 2012; 19: 273-6. 10. van den born bh, hulsman caa, hoekstra jbl, schlingemann ro, van montfrans ga. value of routine funduscopy in patients with hypertension: systematic review. bmj.com. 2005; 331: 73. 11. ranjan r, sinha s, seth s. fundus changes and fetal outcomes in pregnancy induced hypertension: an observational study. int j sci stud. 2014; 2: 6-9. 12. shah ap, lune aa, magdum rm, deshpande h, shah ap, bhavsar d. retinal changes in pregnancy induced hypertension. med j dy patil univ. 2015; 8: 304-7. blindness due to glaucoma ahmad i, khan bs 190 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology original article mean change in intra-ocular pressure following trabeculectomy with mitomycin c in congenital glaucoma wali ullah, omar illyas, mubashir rehman, hina khan pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mubashir rehman department of ophthalmology hayatabad medical complex, peshawar email: drmubashirrehman78@gmail.com …..……………………….. purpose: to determine the mean change in intraocular pressure after trabeculectomy with mitomycin c surgery in primary congenital glaucoma. study design: quasi experimental study. place and duration of study: outpatient department of ophthalmology hayatabad medical complex, peshawar. from jan 20, 2016 to june 20, 2016. material and methods:. patients of both genders between age of 0-6 years with pcg and iop of 21 mm hg or more with and without topical anti-glaucoma medication were included in the study. eyes with complicated or traumatic cataract and previous ocular surgeries were excluded from the study. sample size was calculated by who software for sample size calculation using 77.10 % proportion of decrease in iop and 95% confidence interval and a 7% margin of error. diagnosis was confirmed by examination under general anesthesia. all the surgeries were done by same ophthalmologist. 0.4 mg/ml of mmc was applied below the flap for two minutes followed by copious irrigation. follow up visit was done on 14th post-operative day. eua was performed 2 months after surgery where the eye was examined for bleb morphology, leakage, infection or any other complication. results: in this study 38 patients undergoing trabeculectomy with mitomycin c were followed. out of 38 patients 24 were male and 14 were female. average age was 1.49 ± 0.95sd years. average preoperative intraocular pressure (iop) was 29.81 ± 4.80 sd while postoperative iop was 17.21 ± 3.82 sd. conclusion: intraocular pressure was decreased significantly in patients after trabeculectomy with mitomycin c. key words: congenital glaucoma, trabeculectomy, mitomycin c. laucoma is the leading cause of irreversible blindness worldwide1. it is considered the second most common cause of blindness affecting 60 million people worldwide, with an estimated 8.4 million people blind due to glaucoma. this overwhelming figure is set to increase to 80 million diseased and 11.2 million blind by 20202. in pakistan, glaucoma is the fourth most important cause of irreversible blindness3. in infancy, primary congenital glaucoma (pcg) is the most common type of glaucoma with an incidence of 1 in 10,000 to 68,000 live births among different ethnic populations. worldwide pcg is responsible for g mean change in intra-ocular pressure following trabeculectomy with mitomycin c in congenital glaucoma pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 191 about 18% of children in institutions for the blind and 5% of overall pediatric blindness4. the incidence of pcg in the pakistani children is about nine times higher than that in caucasians3. the incidence of pcg varies when high rates of consanguinity are present5. medical therapy plays only an adjunctive role to the main treatment strategy, which is surgical management of congenital glaucoma. in order to maintain best visual function before permanent structural changes occur to the eye, surgery should be considered as early as possible4. successful control of iop through surgical treatment is crucial to provide a lifetime vision, in children with glaucoma6. in glaucoma surgery, the resistance to the aqueous outflow due to structural abnormalities in the anterior chamber angle are bypassed. insertion of anterior ciliary body and iris overlapping the trabecular meshwork and presence of non-permeable barkan’s membrane over the trabecular meshwork are the main structural abnormalities in the angle of congenital glaucoma patients7. regarding surgical options, trabeculectomy is an effective treatment option in primary congenital glaucoma. it is however challenging in children and because of a vigorous healing reaction, trabeculectomy is less successful when compared with outcomes in adults7. this reduced surgical success rate is due to postoperative proliferation of fibroblast and scarring of the filtering bleb. to prevent scarring of the filtration bleb numerous techniques have been applied including application of anti-metabolites, anti-vegf agents and beta radiation8. to improve the success rate, 5-fluorouracil and mitomycin c are most commonly used as a surgical adjunct to prevent bleb scarring9. mitomycin c (mmc) selectively inhibits dna replication, mitosis, and protein synthesis. the drug inhibits the proliferation of fibroblasts, suppresses vascular ingrowth. optimum concentration and exposure time are not known and vary between 0.2–0.5 mg/ml and 1–5 min10. no proper data is available regarding iop control after trabeculectomy with mmc in our community. there is limited local data available about the outcome of trabeculectomy surgery and its effectiveness in decreasing intraocular pressure. the international data available also shows a wide range of variance in decreasing intraocular pressure after trabeculectomy with mmc. this study is designed to find out the accurate mean decrease in intraocular pressure after trabeculectomy with mmc locally. the data and results will be shared with the local consultants. material and methods patients attending the outpatient department of ophthalmology hayatabad medical complex, peshawar, of both genders between age 0 6 years with pcg and iop of 21 mm hg or more with and without topical anti-glaucoma medication were included in the study. eyes with complicated or traumatic cataract, previous ocular surgeries like repair, squint surgery, retinal detachment surgery, cataract extraction etc., previous ocular trauma, intraoperative vitreous loss, post-operative endophthalmitis and eyes which received trauma postoperatively in the follow up period, were excluded from the study. provisional diagnosis of congenital glaucoma was made in opd after initial examination of all children. diagnosis was confirmed by examination under general anesthesia. both eyes were examined. the intraocular pressure was measured first, using perkins tonometer. horizontal corneal diameter was measured with calipers. gonioscopy was done with swan jacob goniolens. further evaluation including anterior segment examination, fundoscopy and retinoscopy (if the cornea was clear enough) was performed. the patient's condition was explained to parents and consent obtained for surgery which was performed under general anesthesia on the nearest available list. all the surgeries were done by single consultant ophthalmologist. a limbal-based conjunctival and tenon's capsule flap was made. a rectangular (4×3 mm) partial thickness scleral flap was fashioned superotemporally/supero-nasally with 15 size blade or crescent knife up-to clear cornea and 0.4 mg/ml of mmc was applied sub-conjunctively and below the flap for two minutes followed by copious irrigation with balanced salt solution. scleral flap was sutured using 10/0 nylon applied on corners of scleral flap. conjunctiva was closed with 10/0 nylon suture. topical combination of steroid and antibiotic medications was started on the first post-operative day for 8 to 12 weeks. every patient underwent follow up visit on 14th post-operative day. eua was performed 2 months after surgery where the eye was examined for bleb morphology, leakage, infection or any other wali ullah, et al 192 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology complication, which can be related to surgery along with afore-mentioned parameters. intraocular pressure was measured before surgery on the day of surgery and 2 months after the surgery by perkin’s tonometer to calculate the mean change. total sample size was 38 which was calculated using confidence interval (2 sided): 95%, power: 90%, mean group 1: 27.40, mean group 2: 19.40, mean difference: 08, standard deviation group 1: 6.3, standard deviation group 2: 8.5. data was analyzed utilizing spss format of windows 20. for quantitative variables like age, preoperative and postoperative intraocular pressure mean ± standard deviation was calculated. frequency and percentage were used for qualitative variables like gender and eye involved. comparison of pre and post-operative intraocular pressure was done using paired t test. to see the effect modification, pre and post-operative iop was stratified among gender and age. to see the effect modification, post stratification pair t-test was applied. p value < 0.05 was taken as significant. results 38 patients undergoing trabeculectomy with mitomycin c. were followed. in which 24 (63.15%) were male and 14 (36.84%) were female patients. male to female ratio was 1.71:1 (table 1). right eye was involved in 21 (55.26%) cases while the rest of 17 (44.73%) patients had left eye involvement (table 2). table 1: gender wise distribution of patients. gender frequency percentage (%) male 24 63.15 female 14 36.84 total 38 100 table 2: laterality (side) wise distribution of patients. eye involved frequency percentage (%) right 21 55.26 left 17 44.73 total 38 100 mean pre-operative intraocular pressure (iop) was 29.81 + 4.80 s.d while post-operative iop which decreased in patients after trabeculectomy with mitomycin c to 17.21 + 3.82 s.d and was found highly significant with p-value < 0.003 (table 3). table 3: comparison of mean pre-op and post-op iop in total patients. iop (mm hg) p value n mean std. dev pre op iop 38 29.81 4.80 < 0.003 post op iop 38 17.21 3.82 paired ttest applied stratification for pre-operative and post-operative iop with regards to age groups showed that there was statistically significant lowering of iop in both the age groups whether it was less than or more than 1 year of age (table 4). similar pattern was found when the preop and post-op iop was stratified with regard to gender, as p-value was less than 0.05 indicating significance. p-value for male and female was found to be less than 0.003 and 0.005 in both the age groups respectively (table 5). table 4: stratification for pre-op and post-operative iop with regard to age groups. age group n iop mean ±s.d p-value ≤ 1year 14 pre-op 30.07 ± 4.77 < 0.004 post -op 17.41 ± 4.11 > 1 year 24 pre-op 29.66 ± 4.73 < 0.005 post -op 17.08 ± 3.39 table 5: stratification for pre-op and post-operative iop with regard to gender. gender n iop mean ±s.d p-value male 24 pre-op 29.62 ± 4.94 < 0.003 post -op 17.41 ± 4.1 female 14 pre-op 30.14 ± 4.73 < 0.005 post -op 16.85 ± 3.39 when pre-operative and post-operative mean iop was stratified with regard to eye involved it was found significant statistically (p-value < 0.05) in both the right and left eye. p-value for right eye and left eye was less than 0.005 and 0.002 respectively (table 6). mean change in intra-ocular pressure following trabeculectomy with mitomycin c in congenital glaucoma pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 193 table 6: stratification for pre-op and post-operative iop with regards to eye involved. side n iop mean ±s.d p-value right 21 pre-op 30.61 ± 4.77 < 0.005 post –op 17.53 ± 4.1 left 17 pre-op 28.8 ±4.73 < 0.002 post –op 17.2 ± 4.3 discussion primary congenital glaucoma (pcg) is the leading cause of blindness in infancy with an incidence of 1 in 10,000 to 68,000 live births among different ethnic populations4. an imbalance of aqueous production and aqueous outflow via the trabecular meshwork and the uveoscleral pathway results in raised intraocular pressure. in congenital glaucoma, the pathology lies in the trabecular meshwork which exhibits a developmental defect leading to raised intraocular pressure11. the primary objective in the management of primary congenital glaucoma is to prevent loss of visual function and preserve the ocular integrityby normalizing and permanently controling the intraocular pressure12. primary treatment option for treating congenital glaucoma is surgical with medical therapy having only an adjunctive role. surgery should be considered as early as possible to prevent permanent visual loss4. male predominance was seen in this study accounting for 63.15% of cases. the literature showed a preponderance of males in 65-80% of the cases13. olusanva et al, in their study on outcome of trabeculectomy in congenital glaucoma had a male to female ratio of 3.5:1. in their study the male population accounted for 77.7% of the total sample14. however, in certain ethnicities the incidence of congenital glaucoma is more in female gender. in japan females are more affected, with a ratio of girls to boys of 3:215. average pre operative intraocular pressure (iop) in this study was 29.81 + 4.80 sd while post operative iop was 17.21 + 3.82 sd which was decreased in patients after trabeculectomy with mitomycin c and found highly significant. our results are comparable to other similar studies. essuman et al. reported the mean pre-operative and postoperative intra-ocular pressures of 30.3 ± 8.8 mmhg and 18.1 ± 6.8 mmhg respectively following trabeculectomy with mitomycin c. the difference between pre-operative and post-operative iop in their study was statistically significant16. postoperative fibrosis and scarring at the surgical wound site is a known complication and a risk factor for failure of surgery. postoperative scarring may hamper the drainage of aqueous fluid from anterior chamber through the artificial opening made during glaucoma drainage surgery17. mitomycin is an alkylating agent which reduces the fibroblast proliferation and reduces the amount of scarring18. susanna et al in their study showed that the use of mitomycin reduces post surgery fibrosis and attributed to the favourable results in casess with adjuvant use of mitomycin c19. in more than 80% of cases, the onset of the clinical profile of the disease appears during the first year of life, with 25% diagnosed in the neonatal period and 60% during the first 6 months of life20. in our study, the highest number of cases presented during the first year of life accounting for 36.84% of the study cohort. one of the many possible explanations to the problem is lack of patient education regarding the disease. advanced disease is a known risk factor for poor outcome in congenital glaucoma which is often associated with poor visual prognosis. nevertheless, late presentation is a problem commonly encountered in developing countries21. olusanva et al reportedly had 50% of cases presenting after first year of life14. we did not encounter any patient for bleb revision or repeat surgery due to raised iop in our series. moreover, for early postoperative bleb leaks we never had to use a bandage contact lens, as described by some authors. there was no incidence of choroidal effusion which is reported in 17-23% of cases in other studies22. conclusion trabeculectomy with mitomycin c is a safe and effective method in lowering intraocular pressure in cases of primary congenital glaucoma. it is helpful by reducing the intraocular pressure and in preventing further structural changes to the eye and thus forestalling permanent visual disability. it is a convenient and economical method to manage congenital glaucoma. author’s affiliation dr. wali ullah mbbs, fcps, fico (ophthalmology) wali ullah, et al 194 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology medical officer type d hospital, kakki bannu dr. omar illyas mbbs, fcps, fico (ophthalmology) medical officer thq, tangi hospital dr. mubashir rehman mbbs, fcps, (ophthalmology) medical officer department of ophthalmology, nowshera medical college, qazi hussain ahmad medical complex, nowshera dr. hina khan mbbs, fcps, (ophthalmology) trainee registrar department of ophthalmology, hayatabad medical complex peshawar role of authors dr. wali ullah patient’s selection, data collection, results and discussion. dr. omar illyas patient’s selection, data collection, results and discussion. dr. mubashir rehman patient’s selection, data collection, results and discussion. dr. hina khan literature search. refrences 1. olawoye oo, ashaye ao, baiyeroju am, teng cc, liebmann jm, ritch r. outcomes of trabeculectomy with 5-fluorouracil at a nigerian tertiary hospital. j ophthalmic vis res. 2013; 8 (2): 126-33. 2. cook c, foster p. epidemiology of glaucoma: whats new? .can j ophthalmol. 2012; 47: 223-6. 3. bashir r, sanai m, azeem a, altaf i, saleem f, naz s. contribution of glc3a locus to primary congenital glaucoma in pakistani population. pak j med sci. 2014; 30 (6): 1341-5. 4. moore db, tomkins o, ben-zion i. a review of primary congenital glaucoma in the developing world. surv ophthalmol. 2013; 58: 278-85. 5. chang tc, cavuoto km. surgical management in primary congenital glaucoma: four debates. j ophthalmol. 2013; 98: 134-9. 6. jayaram h, scawn r, pooley r, chiang m, bunce c, strouthidis ng, et al. long-term outcomes of trabeculectomy augmented with mitomycin c undertaken within the first 2 years of life. am. j. ophthalmol. 2015; 122: 2216-22. 7. mahar ps, memon as, bukhari s, bhutto ia. outcome of mitomycin-c augmented trabeculectomy in primary congenital glaucoma. pak j ophthalmol. 2012; 28 (3): 136-9. 8. cheng jw, cheng sw, wei rl, lu gc. anti-vascular endothelial growth factor for control of wound healing in glaucoma surgery. cochrane database syst rev. 2016; 15: 32-38. 9. ji qs, qi b, liu l, lao w, yang zh, wang gf, yu gc, zhong jx. comparison of trabeculectomy and trabeculectomy with amniotic membrane transplantation in the same patient with bilateral glaucoma. int j ophthalmol. 2013; 6 (4): 448-51. 10. hafez mi. trabeculectomy with collagen matrix implantation versus trabeculectomy with mitomycin c application for the treatment of primary congenital glaucoma. j egypt ophthalmol soc. 2015; 108: 26–31. 11. deluise vp, anderson dr. primary infantile glaucoma (congenital glaucoma). surv ophthalmol. 1983; 28: 1-19. 12. mandal ak, gothwal vk, bagga h, nutheti r, mansoori t. outcome of surgery on infants younger than 1 month with congenital glaucoma. ophthalmology, 2003; 110: 1909-15. 13. elder mj. congenital glaucoma in the west bank and gaza strip.br j ophthalmol. 1993; 77 (7): 413-6. 14. olusanya ba, ugalahi mo, malomo mo, baiyeroju a. trabeculectomy for congenital glaucoma in university college hospital, ibadan: a 7 year review of cases. niger j ophthalmol. 2015; 23: 44-7. 15. dickens cj, hoskins jr hd. epidemiology and pathophysiology of congenital glaucoma. in: ritch r, shields mb, krupin t. (editors). the glaucomas. 2a ed. st. louis: mosby; 1996. 16. essuman va, braimah iz, ndanu ta, ntimamponsah ct. trabeculectomy with mitomycin c: outcome for primary congenital glaucoma in a west african population. eye (lond) 2011; 25: 77-83. 17. ghate d, wang x. surgical interventions for primary congenital glaucoma. cochrane database syst rev. 2015; 30: 1. 18. hsu cr, chen yh, tai mc, lu dw. combined trabeculotomy-trabeculectomy using the modified safer surgery system augmented with mmc: its long-term outcomes of glaucoma treatment in asian children. graefes arch clin exp ophthalmol. 2018; 256: 11871194. 19. susanna r jr1, oltrogge ew, carani jc, nicolela mt. mitomycin as adjunct chemotherapy with trabeculectomy in congenital and developmental glaucomas. j glaucoma. 1995; 4 (3): 151-7. 20. shaarawy tm, sherwood mb, hitchings ra, crowston jg. glaucoma: medical diagnosis with therapy. united kingdom: elsevier; 2009: 112-114. https://www.ncbi.nlm.nih.gov/pubmed/?term=susanna%20r%20jr%5bauthor%5d&cauthor=true&cauthor_uid=19920661 https://www.ncbi.nlm.nih.gov/pubmed/?term=oltrogge%20ew%5bauthor%5d&cauthor=true&cauthor_uid=19920661 https://www.ncbi.nlm.nih.gov/pubmed/?term=carani%20jc%5bauthor%5d&cauthor=true&cauthor_uid=19920661 https://www.ncbi.nlm.nih.gov/pubmed/?term=nicolela%20mt%5bauthor%5d&cauthor=true&cauthor_uid=19920661 https://www.ncbi.nlm.nih.gov/pubmed/19920661 mean change in intra-ocular pressure following trabeculectomy with mitomycin c in congenital glaucoma pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 195 21. jayaram h, scawn r, pooley f, chiang m, bunce c, strouthidis ng, khaw pt, papadopoulos m. longterm outcomes of trabeculectomy augmented with mitomycin c undertaken within the first 2 years of life. ophthalmology, 2015; 122: 2216-22. 22. schrieber c, liu y. choroidal effusions after glaucoma surgery. curr opin ophthalmol. 2015; 26: 134-42. 1 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology editorial oct in glaucoma diagnosis nadeem hafeez butt pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cular coherence tomography (oct) has revolutionized the diagnosis of glaucoma since it was launched as a time domain machine. with advancements in technology fourier domain and swept source machines have been introduced with very high resolution. a higher scan speed of oct machines (80,000 to 100,000 scan/sec) has made it possible to get a uniform sensitivity over the entire scan window showing both rnfl and lamina cribrosa. world glaucoma association consensus on diagnosis of glaucoma states that clinical diagnosis of glaucoma is predicted on the detection of a thinned retinal nerve fiber layer and narrowed neuroretinal rim which can now be studied in detail with higher resolution machines. with swept source oct there is increased penetration to choroid and sclera. there is better visualization even in cataract therefore you can assess glaucoma damage before cataract surgery. glaucoma has always been diagnosed with visual field changes but with the advent of oct the term pre-perimetric glaucoma has been established which literally means glaucoma with normal perimetry. oct has also become a useful tool for high myopes who are at risk for developing glaucoma. there is a risk of false positives in myopic patients due to the presence of peripapillary atrophy. this can be verified by ganglion cell layer analysis which is the earliest form of glaucoma damage which can be picked up by oct. optic nerve can also be visualized using enface imaging or angio oct. moreover all the oct machines have the capability to do an oct analysis of the angle and the corneal thickness. pachymetry helps to give a corrected reading of intraocular pressure and angle analysis is crucial in patients with narrow angle and plateau iris. the hood glaucoma report1 has been recently developed and it aids in the understanding of glaucoma better using multiple parameters. this includes oct b scan of circumpapillary rnfl with reference database, correlation of oct rnfl data (structure) with visual field test locations (function), wide field oct enface image, wide field rnfl thickness map, circumpapillary rnfl thickness 4 sector and 12 clock charts with reference database, gcl + ipl thickness map, correlation of oct gcl + ipl data (structure) with visual field test locations (function). it is generally thought that local defects are most often seen in the superior and inferior quadrants. for example, oct studies typically find that circum papillary retinal fiber layer (cprnfl) thinning of the superior and inferior quadrants is a more sensitive measure of glaucomatous damage than is thinning of the temporal or nasal quadrants.2 however, according to hood et al3, it is the temporal half of the superior and inferior quadrants (i.e., 45° to 90° and −45° to −90° that are particularly vulnerable to early local damage. this is consistent with oct cprnfl thickness data suggesting that 6, 7, 11, and 12 are the clock hours of the disc that are most likely to be affected by glaucomatous damage. evaluation of deep optic nerve head and parapapillary microvasculature in glaucoma has been made possible with angio oct.4 it helps in diagnosis, predicting glaucoma development in glaucoma suspect and seeking pathogenesis. deep retinal layer microvasculature dropout has been detected by the oct-a in glaucoma. this has been verified by a comparative study using oct-a and icg angiography.5 posterior displacement of the lamina cribrosa happens in glaucoma leading to increased mean lamina cribrosa depth in patients with glaucoma6. in patients with glaucoma the central and mid peripheral lamina cribrosa is located more posteriorly than in normal eyes. similar observation is seen in eyes with defects in visual fields (vf) compared to fellow eyes with no vf defects. lamina cribrosa curvature index (lcci) has a better o oct in glaucoma diagnosis pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 2 discriminating capability than lamina cribrosa (lc) depth in diagnosis of patients with glaucoma7. it has been shown that eyes with greater lcci lose retinal nerve fiber layer (rnfl) more rapidly. progressive thinning of macular ganglion cell inner plexiform layer (gcipl) and thinning of parapapillary rnfl are correlated strongly with each other. progressive gcipl and rnfl thinning indicate progression of glaucoma visual fields. therefore macular gcip and parapapillary rnfl readings have been incorporated into the guided progression analysis (gpa)8 for picking up deterioration in patients with glaucoma early. thinning of rnfl on oct occurs more rapidly in patients having localized progressive rnfl defects than patients with rfnl defects which are localized and constant. this has been shown in trend based progression analysis (tpa).9 data suggests that we can get a useful analysis of glaucoma progression if rnfl thickness on oct is analyzed using a trend-based strategy. other diagnostic tests may be complemented with it as well. retinal nerve fiber layer optical texture analysis (rota) for detection of glaucoma in color fundus photographs compared with quantitative analysis of oct rnfl thickness on normal subjects has shown that local mean value, standard deviation, and shannon entropy extracted from the green and blue channel of fundus images are correlated with corresponding rnfl thickness10. in conclusion oct has made significant changes in our understanding of glaucoma and has nearly replaced the visual field test as an objective test with high reliability. author’s affiliation prof. nadeem hafeez butt department of ophthalmology allama iqbal medical college, lahore references 1. hood dc. improving our understanding, and detection, of glaucomatous damage: an approach based upon optical coherence tomography (oct). prog retin eye res. 2017 mar; 57: 46-75. 2. kanamori a, nakamura m, escano mf, seya r, maeda h, negi a. evaluation of the glaucomatous damage on retinal nerve fiber layer thickness measured by optical coherence tomography. am j ophthalmol. 2003; 135: 513–520. 3. hood dc, wang dl, raza as, de moraes cg, liebmann jm, ritch r. the locations of circum papillary glaucomatous defects seen on frequencydomain oct scans. invest ophthalmol vis sci. 2013b; 54: 7338–7343. 4. lee ej, kim tw, lee sh, kim ja. underlying microstructure of parapapillary deep-layer capillary dropout identified by optical coherence tomography angiography. invest ophthalmol vis sci. 2017 mar. 1; 58 (3): 1621-1627. 5. lee ej, lee km, lee sh, kim tw. parapillary choroidal microvasculature drop out in glaucoma; a comparison between optical coherence tomography angiography and indocyanine green angiography. ophthalmology, 2017 aug; 124 (8): 1209-1217. 6. furlanetto rl, park sc, damle uj, sieminski sf, kung y, siegal n, liebmann jm, ritch r. posterior displacement of the lamina cribrosa in glaucoma: in vivo inter individual and inter eye comparisons. invest ophthalmol vis sci. 2013 jul. 18; 54 (7): 4836-42. 7. lee sh, kim tw, lee ej, girard mj, mari jm. diagnostic power of lamina cribrosa depth and curvature in glaucoma. invest ophthalmol vis sci. 2017 feb. 1; 58 (2): 755-762. 8. hou hw, lin c, leung ck. integrating macular ganglion cell inner plexiform layer and parapapillary retinal nerve fiber layer measurements to detect glaucoma progression. ophthalmology, 2018 feb. 9. pii: s0161-6420(17)32732-x. doi:10.1016/j.ophtha.2017.12.027. 9. lin c, mak h, yu m, leung ck. trend-based progression analysis for examination of the topography of rates of retinal nerve fiber layer thinning in glaucoma. jama ophthalmol. 2017 mar. 1; 135 (3): 189-195. 10. odstrcilik j, kolar r, tornow rp, jan j, budai a, mayer m, vodakova m, laemmerr, lamos m, kuna z, gazarek j, kubena t, cernosek p, ronzhina m. thickness related textural properties of retinal nerve fiber layer in color fundus images. comput med imaging graph, 2014 sep; 38 (6): 508-16. 108 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology case report sympathetic ophthalmitis tanvir abbas, asadaslam khan,mohammad ali ayazsadiq pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mohammad ali a sadiq institute of ophthalmology mayo hospital lahore, king edward medical university, lahore email: sadiq.maa@gmail.com …..……………………….. sympathetic ophthalmitis is a rare bilateral granulomatous panuveitisoccurring after ocular penetrating trauma most frequently associated with uveal tissue prolapse. it can also occur following ocular surgery like cataract, vitrectomy, trabeculectomy, retinal detachment surgery and even after laser photocoagulation. incidence varies between 0.05% to 0.2% following penetrating trauma and 0.01% following ocular surgery. key words: sympathetic ophthalmitis, granulomatous panuveitis. sympatheticophthalmitis is a rare bilateral granulomatous panuveitisrarely occurring after ocular penetrating trauma most frequently associated with uveal tissue prolapse1. it can also occur following ocular surgery like cataract, vitrectomy, trabeculectomy, retinal detachment surgery and even after laser photocoagulation. incidence varies between 0.05% to 0.2% following penetrating trauma and 0.01% following ocular surgery2. with the improvement of microsurgical technique and early enucleation the incidence of the sympathetic ophthalmitis has decreased. it is very important to diagnose this blinding condition early to avoid visual threatening complication. case report forteen year old young boy presented in theout patient clinic with the complaint of right painful gradual and progressive decrease in vision for two weeks. past ocular history is significant for trauma in the left eye with a fire cracker 3 months back. he underwent open globe repair within 24 hours of injury. on examination patient had counting fingers at 3 feet in the right eye and no perception of light in the left. right eye showed sluggish pupillary response. the pupil of the left eye was not appreciable. the patient also had a positive reverse marcus gun. slit lamp examination showed mutton fat keratitic precipitates mainly involving the inferior part along with grade 3 cells and flare in the right eye (figure 1) and a repaired corneoscleral tear in the left (figure 2). right eye intraocular pressure was 14 mmhg and the left eye was phthiscal.the posterior segment in either eye was not visible. complete blood picture, erythrocyte sedimentation rate, chest x-ray, venereal disease research laboratory (vdrl), toxoplasmosis ig g and m, montoux test and serum angiotensin converting enzyme level, were ordered and found to be within normal limits. sympathetic ophthalmitis was diagnosed. the patient was started on oral prednisolone in divided doses (weight adjusted) under cover of antacid, predforte eye drops every 4 hourly and 1% atropine eye drops twice a day. on the 2nd week follow up the best corrected visual acuity improved to 6/18 with quite and maintained anterior chamber and no keratic precipitates. intra-ocular pressure was 16 mmhg. the posterior segment showed disc edema and a dull foveal reflex (figure 3). the treatment was continued. s mailto:sadiq.maa@gmail.com sympathetic ophthalmitis pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 109 fig. 1: right eye showing mutton fat keratitic precipitates more inferiorly. fig. 2: left eye shows a pthysical eye with a corneoscleral tear repair. at 1 month follow up visit, the best corrected visual acuity improved to 6/9 and anterior segment was quite with resolving disc and macular edema. topical steroids were reduced to four times a day and atropine was stopped. systemic steroids were, however kept on maintaining dose. at two months visit, the best corrected visual acuity was 6/6 and disc edema had resolved with a good foveal reflex. the intraocular pressure was 18mmhg. the patient complained of weight gain due to systemic steroid. discussion the condition was first recognized by hippocrates and described and named by mackenzie in the mid1800s.4fuch's provided the first histopathologic details in 19052. fig. 3: colour fundus photograph and fundus fluoroceine angiography showing disc edemaand abnormal foveal reflex. it is a rare condition with no gender or racial correlation. it can occur in any age group following penetrating trauma or surgical intervention. cases have been reported after cataract3 and vitreoretinal surgeries4 and even after ocular laser.5 the etiology of this is poorly understood with immunological reaction mediated by t cells against photoreceptor and uveal tissue antigen being the most important factor. while the particular antigen is yet to be determined, putative retinal antigens include retinal soluble antigen (s-antigen), rhodopsin, interphotoreceptor retinoid-binding protein, and recoverin6,7. the retinal s antigen has been the most extensively studied. the first symptom of sympathetic ophthalmia is photophobia and the decrease of near vision followed by far vision. signs such as mutton fat keratitic precipitates, anterior chamber reaction, disc edema with late leakage on fundus fluorescein angiography and exudative retinal detachment with dalenfuchs nodules are pathognomic.8it is important to rule out other causes of granulomatous inflammation before making a final diagnosis as the diagnosis is that of exclusion. sympathetic ophthalmitis can be prevented by doing enucleation of sympathizing blind eye within 10 days of trauma, especially in those cases having exposed cillary body. tanvir abbas, et al 110 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology treatment includes topical and systemic steroids. antimetabolites are used in case of steroid intolerance. systemic steroid should be continued for six months and then tapered off as sympathetic ophthalmitis has a relapsing and remitting course. author’s affliliation dr. tanvir abbas medical officer, institute of ophthalmology mayo hospital lahore prof. asadaslam khan professor, institute of ophthalmology mayo hospital lahore, king edward medical university lahore dr. mohammad ali ayaz sadiq assitant professor, institute of ophthalmology mayo hospital lahore, king edward medical university, lahore refrences 1. jack j kanski, brad bowling, etal. degenrative disorder of conjunctiva. 7th edition.china:elseveir; 2011: 162-65. 2. albert dm, diaz – rohena. a historical review of sympathetic ophthalmia and its epidemiology survophthalmol. 1989; 34 (1): 1-14. 3. el-asrar am1, al-obeidan sa. sympathetic ophthalmia after complicated cataract surgery and intraocular lens implantation.eur j ophthalmol. 2001 apr-jun; 11 (2): 193-6. 4. masatoshi haruta,1hirokazu mukuno,2 kazuaki nishijima, etal. sympathetic ophthalmia after 23 – gauge transconjunctival sutureless vitrectomy. clin ophthalmol. 2010; 4: 1347–1349. 5. albahlal a1, al dhibi h1, al shahwan s, et al. sympathetic ophthalmia following diode laser cyclophotocoagulation. br j ophthalmol. 2014 aug; 98 (8): 1101-6. 6. schalken jj, winkens hj, van vugt ah, de grip wj, broekhuyse rm. rhodopsin – induced experimental autoimmune uveoretinitis in the monkeys. br j ophthalmol.1989; 73 (3):168-172. 7. grey i, wiggert b, redmond tm, kuwabara t, crawford ma, vistica bp, chader gj. uveoretinitis and pinealitis induced by immunization with interphotoreceptor retinoid – binding protein. invest ophth vis sci. 1986; 27 (8): 1296-1300. 8. sharp dc, bell ra, patterson e, pinkerton rm. sympathetic ophthalmia. histopathologic and fluorescein angiographic correlation. arch ophthalmol. 1984 feb; 102 (2): 232-5. pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 182 abstracts edited by dr. qasim lateef chaudhry intravitreal aflibercept injection for macular edema due to central retinal vein occlusion (two-year results from the copernicus study) heier js, clark wl ophthalmology, 2014; 1414–20 jeffrey et al have published the 2 year results from the copernicus study which was done to evaluate the efficacy and safety of intravitreal aflibercept injection (iai) for the treatment of macular edema secondary to central retinal vein occlusion (crvo). in this randomized, double-masked, phase 3 trial 188 patients with macular edema secondary to crvo were enrolled. patients received iai 2 mg (iai 2q4) (n = 114) or sham injections (n = 74) every 4 weeks up to week 24. during weeks 24 to 52, patients from both arms were evaluated monthly and received iai as needed, or pro re nata (prn) (iai 2q4 + prn and sham + iai prn). during weeks 52 to 100, patients were evaluated at least quarterly and received iai prn. the primary efficacy end point was the proportion of patients who gained ≥15 letters in bestcorrected visual acuity (bcva) from baseline to week 24. this study reports week 100 results. the proportion of patients gaining ≥15 letters was 56.1% versus 12.3% (p < 0.001) at week 24, 55.3% versus 30.1% (p < 0.001) at week 52, and 49.1% versus 23.3% (p < 0.001) at week 100 in the iai 2q4 + prn and sham + iai prn groups, respectively. the mean change from baseline bcva was also significantly higher in the iai 2q4 + prn group compared with the sham + iai prn group at week 24 (+17.3 vs. −4.0 letters; p < 0.001), week 52 (+16.2 vs. +3.8 letters; p < 0.001), and week 100 (+13.0 vs. +1.5 letters; p < 0.0001). the mean reduction from baseline in central retinal thickness was 457.2 versus 144.8 μm (p < 0.001) at week 24, 413.0 versus 381.8 μm at week 52 (p = 0.546), and 390.0 versus 343.3 μm at week 100 (p = 0.366) in the iai 2q4 + prn and sham + iai prn groups, respectively. the mean number (standard deviation) of prn injections in the iai 2q4 + prn and sham + iai prn groups was 2.7 ± 1.7 versus 3.9 ± 2.0 during weeks 24 to 52 and 3.3 ± 2.1 versus 2.9 ± 2.0 during weeks 52 to 100, respectively. the most frequent ocular serious adverse event from baseline to week 100 was vitreous hemorrhage (0.9% vs. 6.8% in the iai 2q4 + prn and sham + iai prn groups, respectively). the authors concluded that the visual and anatomic improvements after fixed dosing through week 24 and prn dosing with monthly monitoring from weeks 24 to 52 were diminished after continued prn dosing, with a reduced monitoring frequency from weeks 52 to 100. collagen cross-linking with photoactivated riboflavin (pack-cxl) for the treatment of advanced infectious keratitis with corneal melting said dg, mohamed s. elalfy ms, gatzioufas z, elzakzouk es, dalia g. said ds ophthalmology, 2014; 121: 1377-82. dalia et al investigated the efficacy and safety of corneal collagen cross-linking (cxl) with photoactivated riboflavin (photoactivated chromophore for infectious keratitis [pack]–cxl) in the management of infectious keratitis with corneal melting in this prospective clinical trial of forty eyes from 40 patients with advanced infectious keratitis and coexisting corneal melting. twenty-one patients (21 eyes) underwent pack-cxl treatment in addition to antimicrobial therapy. the control group consisted of 19 patients (19 eyes) who received only antimicrobial therapy. the slit lamp characteristics of the corneal ulceration, corrected distance visual acuity, duration until healing, and complications were documented in each group. the mann–whitney u test was used for statistical analysis. p values less than 0.05 were considered statistically significant. the average time until healing was 39.76 ± 18.22 days in the pack-cxl group and 46.05 ± 27.44 days in the control group (p = 0.68). after treatment and healing, corrected distance visual acuity was 1.64 ± 0.62 in the pack-cxl group and 1.67 ± 0.48 in the control group (p = 0.68). the corneal ulceration's width and length was significantly bigger in the pack – cxl group (p = 0.004 and p = 0.007). three patients in the control group demonstrated corneal perforation; infection recurred in 1 of them. no serious complications occurred in the pack-cxl group. the authors concluded that corneal cxl with photoactivated riboflavin did not shorten javascript:void(0); javascript:void(0); javascript:void(0); javascript:void(0); javascript:void(0); javascript:void(0); javascript:void(0); qasim lateef chaudhry 183 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology the time to corneal healing; however, the complication rate was 21% in the control group, whereas there was no incidence of corneal perforation or recurrence of the infection in the pack-cxl group. these results indicate that pack-cxl may be an effective adjuvant therapy in the management of severe infectious keratitis associated with corneal melting. changes in postoperative refractive outcomes following combined phacoemulsification and pars plana vitrectomy for rhegmatogenous retinal detachment cho kh am j of ophthalmology. 2014; 158: 251-6. in this retrospective observational case-control study carried out at department of ophthalmology, hallym university college of medicine, hallym university sacred heart hospital, anyang-si, south korea, the authors evaluated changes in postoperative refractive outcomes following combined phacoemulsification and pars plana vitrectomy for rhegmatogenous retinal detachment (rrd) compared with other retinal diseases. a total of 55 patients who had combined surgery between january 2007 and december 2012 were enrolled. the 25 patients who underwent combined surgery for rrd were included in the rrd group, and 30 patients who underwent combined surgery for other vitreoretinal pathology were included in the control group. refractive axial length and intraocular pressure (iop) measurements were performed, and the factors influencing the postoperative refractive outcomes were analyzed. the mean differences between the postoperative and predicted refractive outcomes in the rrd group and the control group were -0.43 d ± 0.67 (p = .046) and -0.08d ± 0.53 (p = .767), respectively. the mean preoperative iops of the affected eye and the fellow eye in the rrd group were 11.44 mm hg ± 3.15 and 13.16 mm hg ± 2.73 (p = .045), but no differences were found in the affected eyes and fellow eyes of the control group. the differences were 14.20 mm hg ± 2.95 and 14.17 mm hg ± 3.50, respectively (p= .974). the mean postoperative iops in the affected eyes and the fellow eyes of the 2 groups were not significantly different. for all eyes, the refractive differences correlated with iop changes in the rrd group. (r = .659, r2 = .435, p < .001). the study concluded that postoperative refractive outcomes in the rrd group shifted toward myopia by a mean of 0.35 diopters compared with the control group. normalizing preoperative lowered iop after combined surgery in rrd may be the key factor in understanding this myopic shift. the utility of routine tuberculosis screening in county hospital patients with uveitis. bryan kun hong, hossein nazari khanamiri, simon r bababeygy, narsing a rao british journal of ophthalmology, 2014; 98: 1091-5. bryan et al evaluated the utility of tuberculosis (tb) screening in diagnosing ocular tb in uveitis patients in a government-funded hospital in this study. the charts of 142 consecutive patients seen during august 2011 – july 2012 at the los angeles county hospital uveitis clinic were reviewed for manifestation / laterality of uveitis, purified protein derivative (ppd) test results, interferon γ release assay, chest x-ray, birthplace, treatment history and diagnosis. ‘presumed tb – uveitis’ was diagnosed when patients had positive tb screening and favourable response to anti-tb therapy, and definite ocular tb when mycobacterium tuberculosis’ presence was demonstrated. post-test probabilities were determined. tb screening was positive in 21.1%. six patients were diagnosed with tb-related uveitis: one definite, four presumed and one systemic tb with uveitis. with regard to ppd positivity, being foreign-born was the only statistically significant factor with or of 2.26 (95% ci 1.01 to 5.13; p < 0.01) if born in mexico and 4.90 (95% ci 1.74 to 13.83; p < 0.01) if born in other foreign countries. the post-test probabilities of a positive ppd in a uveitis patient showed a 17.2% (overall) or 30.3% (foreign-born patients) chance of ocular tb. the authors concluded that ppd skin test plays an important role in the diagnosis of tbassociated uveitis in high – risk groups, such as immigrants from tb endemic regions. javascript:void(0); http://bjo.bmj.com/search?author1=bryan+kun+hong&sortspec=date&submit=submit http://bjo.bmj.com/search?author1=hossein+nazari+khanamiri&sortspec=date&submit=submit http://bjo.bmj.com/search?author1=simon+r+bababeygy&sortspec=date&submit=submit http://bjo.bmj.com/search?author1=simon+r+bababeygy&sortspec=date&submit=submit http://bjo.bmj.com/search?author1=simon+r+bababeygy&sortspec=date&submit=submit http://bjo.bmj.com/search?author1=narsing+a+rao&sortspec=date&submit=submit 70 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology editorial primary rhegmatogenous retinal detachment surgery in modern era amer awan pak j ophthalmol 2018, vol. 34 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . hegmatogenous retinal detachment (rrd) is a common clinical challenge that affects up to one of every 170 people1. rrd is one of the most common indications for vitreoretinal surgery. jules gonin treated the first case of idiopathic retinal detachment with a clear media on 16 october 1916 and the outcome was successful. gonin subsequently reported on his first 300 cases (1929– 1931) and quoted a success rate of 39%2. rrd surgery is somewhat different among ophthalmic surgeries because excellent outcomes may be achieved using three distinct approaches: scleral buckling (sb), first described in 1950s3,4, pars plana vitrectomy (ppv) first reported in 19715 and pneumatic retinopexy (pr) first reported in 19866. however, the main principles in rrd management include identification and treatment of all retinal breaks7. ppv is increasingly employed in the repair of primary rrd in most part of world due to advancement in vitrectomy machines and viewing systems. a 2012 us medicare claims database analysis reported 74%, 11% and 15% of primary rrd being repaired with ppv, sb and pr, respectively8, with substantial regional differences. despite this evolving trend in more surgical exposure to ppv during training, reasonable number of surgeons still preferably use sb depending on the region. the 2015 preferences and trends survey revealed 67% of surgeons place an sb in 11% or more of rrd surgeries, with 24% placing an sb in 41% or more of rrd surgeries9. while high surgical success rates can be achieved with each technique, all approaches to primary rrd repair have less than perfect success rates: 10–40% of eyes require more than one surgical procedure, and as many as 5% of eyes may sustain permanent anatomic and functional failure despite favorable surgical timing and technical expertise10. regardless of surgical approach, anatomic single operation success rate (sosr) is influenced by pre-existing rrd characteristics. for example, high-risk rrd with giant retinal tear or in the presence of proliferative vitreoretinopathy (pvr), choroidal detachment (cd) or hypotony has a well-documented lower sosr11. more common clinical findings such as inferior retinal breaks, increasing number of retinal breaks and extent of rrd appear to reduce sosr12. in comparison to medical retinal diseases, surgical retinal diseases have less commonly been subjected to the scrutiny of large, prospective randomized clinical trials (rcts). furthermore, few prospective analyses have compared different approaches to rrd repair13,14,15. for a surgical trial, standardization of techniques among surgeons is a major challenge. the current analysis aims to synthesize published data and incorporate recent observational reports into a clinical guide for optimal decision-making when considering primary rrd surgical options. prospective data retinal detachment study the retinal detachment study13 was a prospective multicentre rct comparing sb with pr in 198 patients with uncomplicated rrd involving the superior twothirds of the fundus with retinal breaks no greater than one clock hour in size. anatomic sosr (82% vs 73%) and final anatomic success rates (98% vs 99%) were not statistically different between the sb and pr groups, respectively. pr was associated with less ocular morbidity and significantly better postoperative visual acuity (p = 0.01). at 6 months postoperatively among macula-involving rrd patients, 56% of sb r primary rhegmatogenous retinal detachment surgery in modern era pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 71 cases compared with 80% of pr cases achieved 20/50 or better13. scleral buckling versus primary vitrectomy in rrd (spr) the spr study was a prospective multicenter rct comparing sb with ppv14,16. twenty-five european centers comprising 55 surgeons randomized 416 phakic and 265 pseudophakic eyes to sb or ppv. exclusion criteria included rrd that could be treated with a single episcleral radial sponge and pvr stage b or c. simultaneous sb placement to eyes randomized to ppv was allowed at surgeon discretion and was a significant limitation of the study. among phakic eyes, the sosr and final anatomic success rate for sb and ppv groups were nearly identical: 63.6%, 96.7% and 63.8%, 96.6%, respectively. however, sb resulted in significantly better visual outcomes than ppv (p = 0.0005), reduced risk of reoperation (p < 0.0001) and reduced cataract development (45.9% vs. 77.3%; p < 0.00005), with anatomic success correlating positively with subretinal fluid drainage, and correlating negatively with multiple breaks, breaks larger than 1 clock hour and the use of cryopexy14,17,18. among pseudophakic eyes, ppv resulted in a better sosr (p = 0.002) and similar final success rate compared with sb (72.0%, 95.5% and 53.4%, 93.2%) and also reduced the risk of reoperation (p = 0.0009)14,18. crucially, however, 66.7% of pseudophakic eyes randomized to ppv underwent simultaneous sb placement, a non-randomized event performed with surgeon preference; recurrent rrd occurred in 40.9% of eyes without an sb and 11.4% of eyes with an sb, a 3.5-fold greater rate of recurrent rrd without a sb. the authors concluded, “anatomic results were significantly better in pseudophakic/aphakic patients operated on with an additional buckle”14. possibly limiting current-day applicability of the spr, this trial recruited patients between 1998 and 2003 and excluded pvr stage b and c. since then, ppv techniques have experienced substantial refinement and miniaturization. scottish retinal detachment study it was a prospective, multicentre, population based epidemiology study15, in which each patient with primary rrd presenting to one of the six vitreoretinal surgical centers in scotland was approached for study inclusion. in total, 1202 cases were recruited to the study representing over 95% of all incident cases in scotland during this period15. in total, 64.4% (628) of cases had a ppv, 29% (283) had a scleral buckle, 5.6% (55) had a combined ppv and scleral buckle and 0.9% (9) had pneumatic retinopexy as their primary surgical procedure. the choice of surgical procedure was based on clinical evaluation and the surgeon's preference. the overall sosr was 80.8% (95% ci 78.1 to 83.3%) after one procedure15. no significant difference was noted in the success rate by types of surgery. the presence of preoperative proliferative vitreoretinopathy of any degree and each additional clock hour of detachment increased the risk of failure by an or of 2.4 and 1.13 respectively (p < 0.05)15. in this study, the patients with macula off rd were further analyzed about the visual outcome. in total, there were 291 patients with macula-off rrd without pre-existing retinal disease who had successful repair after one operation. 65.9% achieved a final visual acuity (va) of 0.48 log mar (6/18). this model identified two time points (day 8 (95% ci 3 to 15 days) and (day 21 (95% ci 6 to 26 days) after which there was a statistically significant worsening in final va19. macula-affected rrd of ≤ 8 days demonstrated a significant continuing improvement in va for each pairwise postoperative visit up to month 3, with an overall significant trend towards continuing visual gain up to 1 year. individuals with the macula detached for over 8 days demonstrated a significant improvement in va at the first postoperative visit (6 weeks) with no significant improvement thereafter19. retrospective data european vitreo-retinal society analysis the european vitreo-retinal society (evrs) retrospectively evaluated 7678 rrd repaired by 176 surgeons across 48 countries20. this subjective, informational survey collected data from 2010 until july 2011 from evrs members. cases were considered uncomplicated or complex. complex rrd were defined by the presence of pvr grade b or c, cd, hypotony, large or giant retinal tears and macular holes21. among uncomplicated rrds combining phakic, pseudophakic and aphakic eyes, ppv with or without sb was associated with a significantly greater final failure rate compared with sb alone (1.2% vs. 0.5% p = 0.04)20. the anatomic benefit of sb compared with ppv was driven by phakic patients, in whom final failure rates were 1.3% and 0.5% among ppv-treated and sbamer awan 72 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology treated patients, respectively (p = 0.028). among pseudophakic patients, no such difference in final failure rates was observed between ppv-treated and sb-treated eyes. among complex rrds, outcomes were superior with ppv compared with sb alone21. among patients with grade b pvr, ppv with or without sb resulted in significantly improved outcomes, with a final failure rate of 0.8% compared with 4.0% with sb alone (p = 0.0017). in eyes with choroidal detachment or hypotony, ppv performed better than sb alone, with 4.9% vs 14.7% final failure rates, respectively (p = 0.0015). finally, in eyes with large or giant retinal tears, ppv performed better than sb alone, with 2.2% vs 10.2% final failure rates, respectively (p = 0.00000007). wills pvr study group in this retrospective, single centre, based study 678 patients were identified as having rrd. patients were considered at high risk for pvr if they presented with retinal detachment in two or more quadrants, retinal tears > 1 clock hour, preoperative pvr, or vitreous hemorrhage. of the 678 patients with rrd, 65 were identified as high risk for pvr. 36 patients were treated with simultaneous ppv-scleral buckle and 29 patients were treated with ppv alone, with an overall success rate of 63.1%. the use of ppv-scleral buckle was associated with significantly higher sosr compared with patients treated with ppv alone (odds ratio, 3.24; 95% confidence interval, 1.12-9.17; p = 0.029). visual acuity at 3 months post-procedure or final follow-up was no different between the treatment groups. overall, 23.1% of patients developed postoperative pvr with no difference between surgical approaches. recommendations based on evidence and individualized approach it is very important to consider duration of rrd and status of macula as deciding factors in timing of surgery. rrd reattachment surgery should be considered as an emergency surgery. even in macula off rrd early surgery achieves better visual outcome. status of posterior vitreous detachment (pvd), clarity of media such as cataract and vitreous opacities, location of breaks (anterior versus posterior) are vital elements in selecting the choice of procedure. sb and ppv offer a number of well-accepted benefits and shortcomings to be considered for the individual patient. encircling sb can create a significant refractive shift and sb elements can interfere with extraocular muscle function and contribute to ocular misalignment and resultant diplopia. it can also lead to buckle extrusion with passage of time that can cause recurrent infection, eventually producing thinning of sclera. ppv allows simultaneous removal of vitreous opacities. however, ppv typically involves the use of gas tamponade, temporarily precluding air travel and often requiring short-term head positioning. in addition, ppv can lead to cataract progression eventually, often necessitating additional ocular surgery after rrd repair. in selected patients, pr is a good option, obviating the need for an operating room and carrying limited ocular risks. in phakic patients, ppv may make it difficult to remove the anterior peripheral vitreous, thus allowing the potential for residual traction that may have been relieved by sb and may lead to additional retinal breaks22. however, with introduction of smaller gauge valved vitrectomy systems (23 gauge, 25 gauge & 27 gauge) and modification of ppv techniques, anterior peripheral vitreous can be tackled in a better way. in summary, pr, sb and ppv all afford a high rate of surgical success and substantial visual benefit can be achieved in most rrd cases. however, specific approaches may be optimal in certain clinical scenarios, supporting a personalized approach to rrd reattachment surgery. many young, phakic patients with uncomplicated non pvd rrd may be ideally suited for sb rather than ppv. uncomplicated pseudophakic rrd or phakic rrd with pvd may be successfully repaired with ppv, sb, pr or combination technique, but current trends indicate a greater use of ppv with similar success rate. more complex rrd may be best approached with ppv with or without supplemental sb placement. in ppv cases gas tamponade works very well with better visual outcome in simple rrd and slight complex rrd with type a and b pvr. however posturing is a key to remove sub retinal fluid and keep the break closed while laser or cryotherapy produces adequate adhesion. rrd has an excellent reattachment rate and better visual outcome if timely intervention is done. referring ophthalmologists should stress the patients to immediately see the vitreo-retinal surgeon and have early surgery. primary rhegmatogenous retinal detachment surgery in modern era pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 73 authors affiliations amer awan consultant ophthalmologist and retinal surgeon shifa international hospital, islamabad. references 1. sodhi a, leung ls, do dv, et al. recent trends in the management of rhegmatogenous retinal detachment. surv ophthalmol. 2008; 53: 50–67. 2. gonin j. le decollement de la retine. lausanne: librairie payot, 1934. 3. custodis e. treatment of retinal detachment by circumscribed diathermal coagulation and by scleral depression in the area of tear caused by imbedding of a plastic implant. klin monbl augenheilkd augenarztl fortbild, 1956; 129: 476–95. 4. schepens cl, okamura id, brockhurst rj. the scleral buckling procedures. i. surgical techniques and management. ama arch ophthalmol. 1957; 58: 797– 811. 5. machemer r, parel jm, norton ew. vitrectomy: a pars plana approach. technical improvements and further results. trans am acad ophthalmol otolaryngol. 1972; 76: 462–6. 6. hilton gf, grizzard ws. pneumatic retinopexy. a twostep outpatient operation without conjunctival incision. ophthalmology, 1986; 93: 626–41. 7. schwartz sg, flynn hw jr., mieler wf. update on retinal detachment surgery. curr opin ophthalmol. 2013; 24: 255–61. 8. hwang jc. regional practice patterns for retinal detachment repair in the united states. am j ophthalmol. 2012; 153: 1125–8. 9. pat survey. asrs, 2014. 10. group sprs. view 2: the case for primary vitrectomy. br j ophthalmol. 2003; 87: 784–7. 11. tewari hk, kedar s, kumar a, et al. comparison of scleral buckling with combined scleral buckling and pars plana vitrectomy in the management of rhegmatogenous retinal detachment with unseen retinal breaks. clin experiment ophthalmol. 2003; 31: 403–7. 12. williamson th, lee ej, shunmugam m. characteristics of rhegmatogenous retinal detachment and their relationship to success rates of surgery. retina, 2014; 34: 1421–7. 13. tornambe pe, hilton gf. pneumatic retinopexy. a multicenter randomized controlled clinical trial comparing pneumatic retinopexy with scleral buckling. the retinal detachment study group. ophthalmology, 1989; 96: 772–88. 14. heimann h, bartz-schmidt ku, bornfeld n, et al. scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. ophthalmology, 2007; 114: 2142–54. 15. mitry d, awan ma, borooah s et al. surgical outcome and risk stratification for primary retinal detachment repair: results from the scottish retinal detachment study.br j ophthalmol. 2012; 96: 730-4. 16. heimann h, hellmich m, bornfeld n, et al. scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment (spr study): design issues and implications. spr study report no. 1. graefes arch clin exp ophthalmol. 2001; 239: 567–74. 17. feltgen n, heimann h, hoerauf h, et al. scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (spr study): risk assessment of anatomical outcome. spr study report no. 7. acta ophthalmologica. 2013; 91: 282–7. 18. heussen n, hilgers rd, heimann h, et al. scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study (spr study): multiple-event analysis of risk factors for reoperations. spr study report no. 4. acta ophthalmologica. 2011; 89: 622–8. 19. mitry d, awan ma, borooah s, et al. long-term visual acuity and the duration of macular detachment: findings from a prospective population-based study.br j ophthalmol. 2013; 97: 149-52. 20. adelman ra, parnes aj, ducournau d, et al. strategy for the management of uncomplicated retinal detachments: the european vitreo-retinal society retinal detachment study report 1. ophthalmology, 2013; 120: 1804–8. 21. adelman ra, parnes aj, sipperley jo, et al. strategy for the management of complex retinal detachments: the european vitreo-retinal society retinal detachment study report 2. ophthalmology, 2013; 120: 1809–13. 22. silva ra, flynn hw jr., ryan eh jr., et al. pars plana vitrectomy for primary retinal detachment: persistent anterior peripheral retinal detachment. jama ophthalmology, 2013; 131: 669–71. microsoft word 2. aneequllah pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 179 original article visual and keratometric results after corneal collagen cross linking in keratoconus aneeq ullah baig mirza, yasir iqbal, mirza inamul haq pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: aneeq ullah baig mirza islamic international medical college, riphah international university railway hospital westridge rawalpindi …..……………………….. purpose: to evaluate the safety and efficacy of riboflavin – ultraviolet type a light rays induced cross-linking of corneal collagen in keratoconus. material and methods: forty cases of collagen cross-linking were studied retrospectively. preoperative examination included uncorrected and bestcorrected visual acuity, refraction, slit-lamp, fundoscopy and orbscan. routine cross-linking procedure was performed. postoperatively, a bandage contact lens was applied which was removed on the 5th day. subsequent postoperative examinations were performed monthly for six months. results: forty cases completed six months of follow up. there were 21 males and 19 females in the study. the age range was 16-32 years. in the six months study, 13 out of 40 cases showed improvement of un-corrected visual acuity by one line and 15 out of 40 had improvement by 2 or more lines. only two eyes out of 40 (5%) lost 2 or more lines of uncorrected visual acuity. keratometric improvement was seen in 22.5%. 65% showed keratometric stability while progression was seen in 12.5%. conclusion: collagen cross – linking is a safe and effective procedure in halting the progression of keratoconus. eratoconus is a progressive, non-inflammatory, bilateral (usually asymmetrical) disease of the cornea, characterized by paraxial stromal thinning that leads to corneal surface distortion. the thinning and protrusion in keratoconus induces myopia, irregular astigmatism and scarring, resulting in visual loss and mild to marked impairment of vision. it starts around puberty. consanguineous marriages and genetic factors have been suggested in the etiology. asian population is more likely to present with keratoconus compared to whites1. it has been said that the transmission is autosomal dominant with incomplete penetrance. its incidence in the general population is about one in 20002. in keratoconus, central anterior stroma and bowman’s membrane undergo changes in collagen structure and extracellular matrix, apoptosis and necrosis of keratocytes3,4. in the early stages of the disease, spectacles and contact lenses are utilized for visual improvement. in cases with stromal opacification, penetrating keratoplasty (pkp) is done. eventually, 21% of patients require pkp to restore corneal anatomy and eyesight5. in cases of advanced disease in younger patients with transparent cornea, lamellar keratoplasty6,7 and use of intacs can be employed. a recent advancement in treating keratoconus is collagen cross-linking (cxl). it is a method which addresses the underlying pathophysiology of keratoconus8. cxl involves photopolymerization of stromal collagen fibres by utilizing riboflavin or vitamin b2 and uv (ultraviolet) type a radiation9,10. there is a dual function of riboflavin. not only does it act as a photosensitizer for the production of oxygen free radicals (which induce physical cross-linking of k aneeq ullah baig mirza, et al 180 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology collagen) but also gives a “shielding effect” by absorbing 90% of uv-a radiation thereby preventing damage to the deeper ocular structures. the net result of photopolymerization is increased rigidity of corneal collagen11, which increases the corneal strength by more than 300%12. the process of cross-linking stabilizes the stromal collagen which results in increased biomechanical stability of cornea13. a similar mechanism has been seen in corneal aging14 and young diabetics15. the present study was conducted to evaluate the safety and efficacy of cxl in visual improvement and halting the keratometric progression in keratoconus. material and methods forty cases that underwent cxl at amanat eye hospital rawalpindi were studied retrospectively. the time period of study was from feb. 2008 to nov. 2010. history of contact lens wear was taken. soft contact lens was removed for at least 2 weeks and hard contact lens 4 weeks prior to eye examination. routine eye examination was performed in all the cases. examination included uncorrected and best spectaclecorrected visual acuity, refraction and keratometry. orbscan (topography and pachymetry) was performed in all the cases preoperatively. keratoconus was confirmed by orbscan findings of increased posterior corneal map differential value of 50 µm or more (with respect to the best fitting sphere), anterior corneal map differential of 25 µm or more, irregular keratometric maps with inferior steepening and central corneal thinning to less than 500 µm. the inclusion criteria for cxl consisted of patients who fitted diagnostic criteria of keratoconus, evidence of progression on topography and pachymetry, no prior history of ocular surgery, treated eye to have a maximum corneal power of 47-60 d, corneal thickness greater than 450µm and absence of corneal scarring. the cases excluded from the procedure were those with history of prior ocular surgery, average corneal power greater than 60 d, corneal scarring, corneal thickness less than 450 µm, history of herpes simplex keratitis, history of uveitis and pre-existing glaucoma. after corneal epithelial debridement, riboflavin eye drops were instilled for 30 min. slitlamp examination was performed to confirm the presence of flare in the anterior chamber. the eye was exposed to uv-a light of 370 nm wavelength at 3mw/cm2 for a further 30 minutes utilizing the uv-x system. topical antibiotic was instilled and a bandage contact lens applied. the patient was advised a topical antibiotic/ steroid combination for two weeks. bandage contact lens was removed on the 5th day. subsequent postoperative examinations were performed monthly for six months. the data was analyzed on spss 17. results 40 cases completed six months of follow-up. there were 21 male and 19 female eyes in the study (fig 1). all had progressive keratoconus. 22 cases (55%) had mild, 13 cases (32.5%) moderate and 5 cases (12.5%) had severe keratoconus. seven patients underwent bilateral cxl. 12.5% of the cases had been using rigid gas permeable c ontact lenses prior to treatment. the age range was 16 – 32 years. majority of the cases were in the 16-20 years age group (table 1). 19 21 male female fig 1: male/female distribution (n=40) thirteen out of 40 cases (eyes) showed improvement of un-corrected visual acuity (ucva) by one line and 15 out of 40 had improvement by 2 or more lines (fig 2). a total of 28 out of 40 eyes (70%) showed visual improvement. spearman correlation visual and keratometric results after corneal collagen cross linking in keratoconus pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 181 showed the difference to be statistically significant with a p-value of <.05 (confidence limit 95%). only two eyes out of 40 (5%) lost 2 or more lines of preoperative ucva. a mean improvement of 1.2 lines of ucva was seen by the end of 6 months. the mean preoperative keratometric reading was 49.14d, which reduced to 49.02d by the end of six months. however, this difference was not statistically significant. according to keratometric changes, three categories were formed retrospectively; keratometric improvement, stability and progression of original disease groups. a difference of more than 0.50 d between the preoperative and postoperative mean keratometric reading was taken as significant. in the six months study, keratometric improvement was seen in 9 out of 40 cases (22.5%). 26 out of 40 (65%) showed keratometric stability while progression was seen in 12.5% i.e. 5 out of 40 eyes (fig 3). 0 5 10 15 20 25 30 35 40 1 line improvement 2 or more lines improvement achieved total fig 2: improvement in ucva (n=40) 0 10 20 30 40 50 60 70 keratometric improvement (>0.5d) keratometric stability (within 0.5 d) progression of original disease (> 0.5 d) percentage fig 3: six months keratometric study (n=4 no ocular complications related to cxl including keratitis or corneal scarring were seen in our cases. discussion corneal collagen cross linking is a new method for the treatment of keratoconus that acts by increasing the cross links between and within the collagen fibers utilizing uv-a light and riboflavin, both of which act as photomediators16. a growing body of recent research has found that not only did cxl stabilize progression of keratoconus, it also resulted in “significant” improvements in visual acuity and reductions in aberrations8. various studies have shown that uv-a light and riboflavin resulted in significant stiffening in the anterior 300µm of cornea which reduced the anterior elevation significantly17,18. a study of 117 eyes undergoing cxl published in the journal of cataract & refractive surgery by koppen c et al19 found that one year postoperatively, 2.9% lost two or more snellen’s lines. our results showed that two eyes (5%) lost 2 or more lines of ucva after 6 months. in their study, 7.6% of eyes had continued progression. four of the eyes in their study developed keratitis as compared to none in our study. they concluded that the inclusion criteria of cxl may significantly reduce the complications and failures by including a patient’s age of less than 35 years and a preoperative maximum k reading of less than 58.0d. in our study, the age range was 16-32 years. in study of 153 eyes conducted at dresden20, keractoectasia significantly decreased in the first year by 2.29 d, in the second year by 3.27 d and in the third year by 4.34 d. visual acuity improved in at least one line in 48.9% and remained stable in 23.8% in the first year. our study showed an improvement of ucva by one or more lines in 70% of cases in the first six months. like our study, no serious side effects were noted in their study, while three patients showed continued progression of keratoconus and received retreatment. visual results of agarwal21 in indian eyes showed improvement in best – corrected visual acuity (bcva) in at least one line in 54% and stability in 28% of eyes after 12 months. in one of the studies conducted in a military hospital in pakistan,22 mean preoperative bcva improved by at least one line in 61.29%, remained stable in 35.48% and deteriorated in 3.23% of eyes. preoperative mean of steepest k value was 50.60 ± 5.41 d, which reduced to 48.85 ± 6.11 d. the steepest k value reading improved in 67.74%, remained stable aneeq ullah baig mirza, et al 182 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology in 25.81% and deteriorated in 6.45% of cases. 2 eyes (6.45%) developed keratitis leading to scarring. dan reinstein has described that epithelium is thinner in patients with keratoconus, even before keratoconus is evident on corneal topograghy23. there are some differences in the results that likely stem from removal of epithelium during standard cxl that results in a thinner corneal pachymetry, at least in the short-term. the k values are said to be steeper when the cornea is measured after epithelium is debrided and supports the notion that epithelium acts as a “masking agent” in very early stage of keratoconus. in our cases, epithelium was routinely removed before the cxl procedure, which might have caused some keratometric steepening postoperatively. the difference between the preoperative and postoperative mean keratometric readings was not statistically significant. however, the ucva improved in 70% of cases, which might have been caused by increased tensile strength and a more regular curvature of the cornea. previous studies have shown that cxl results in stabilization of keratoconus in 90% of cases. however, the disease shows continued progression in about 10%. in our study, 12.5% of eyes had continued progression of keratometric readings. this progression of original disease pattern in our study resembles previous findings. the limitations of our study are short duration of follow up i.e. six months, lack of control group and postoperative topographic comparison. hersh, greenstein and fry evaluated 71 eyes of 58 patients who underwent cxl. they observed significant increase in keratometry after one month, which was followed by significant decrease between 1 to 3 months and 3 to 6 months. however, no significant change was observed between 6 months to one year.24 this adds value to our study of 6 months duration. we did not have a control group because it was a retrospective study. our study was concentrated around keratometric and topographic diagnosis of keratoconus and comparison of preoperative versus postoperative visual and keratometric changes. regarding keratoconus, maguire and lowry observed that refractive changes at the cone apex were a good indicator of progression25. we recommend that further studies be carried out with larger treated and control groups for a longer duration and curvature and elevation-guided topographic comparisons be carried out to further ascertain the beneficial effects of cxl. conclusion collagen cross-linking with uv-a light and riboflavin is a safe and effective procedure in improving the visual acuity and halting the progression of keratoconus. author’s affiliation dr. aneeq ullah baig mirza, prof. of ophthalmology islamic international medical college riphah international university railway hospital, westridge rawalpindi dr. yasir iqbal senior registrar ophthalmology islamic international medical college riphah international university rawalpindi dr. mirza inamul haq associate prof. of community medicine islamic international medical college riphah international university rawalpindi references 1. georgiou t, funnell cl, cassels – brown a, et al. influence of ethnic origin on the incidence of keratoconus and associated atopic disease in asians and white patients. eye 2004; 18: 379-83. 2. rabinowitz ys. keratoconus. surv ophthalmol 1998; 42: 297-319. 3. radner w, zehetmayer m, skorpik c, et al. altered organization of collagen in the apex of keratoconus corneas. ophthalmic res. 1998; 30: 327-32. 4. kaldawy rm, wagner j, ching s, et al. evidence of apoptotic cell death in keratoconus. cornea 2002; 21: 206-9. 5. waller sg, steinert rf, wagoner md. long-term results of epikeratoplasty for keratoconus. cornea 1995; 14: 84-8. 6. tan bu, purcell tl, torres lf, et al. new surgical approaches to the management of keratoconus and post-lasik ectasia. trans am ophthalmol soc. 2006; 104: 212-20. 7. bilgihan k, ozdek sc, sari a, et al. microkeratome assisted lameller keratoplasty for keratoconus: stromal sandwich. j cataract refract surg. 2003; 29: 1267-72. 8. arbelaez mc, sekito mb, vidal c,et al. collagen crosslinking with riboflavin and ultraviolet-a light in keratoconus: one – year results. oman journal of ophthalmology. 2009; 2: 33-8. visual and keratometric results after corneal collagen cross linking in keratoconus pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 183 9. wollensak g. crosslinking treatment of progressive kerato-conus: new hope. curr opin ophthalmol. 2006; 17: 357-60. 10. wollensak g, spoerl e, seiler t. riboflavin/ ultraviolet-a-induced collagen crosslinking for the treatment of keratoconus. am j ophthalmol. 2003; 135: 620-7. 11. wollensak g, spoerl e, seiler t. stress-strain measurements of human and porcine corneas after riboflavin-ultraviolet-a-induced cross-linking. j cataract refract surg. 2003; 29: 1780-5. 12. hafezi f, mrochen m, iseli hp, et al. collagen crosslinking with ultraviolet a and hypoosmolar riboflavin solution in thin corneas. j cataract refract surg. 2009; 35: 621-4. 13. wollensak g, spoerl e, wilsch m, et al. endothelial cell damage after riboflavin-ultraviolet-a treatment in the rabbit. j cataract refract surg. 2003; 29: 1786-90. 14. daxer a, misof k, grabner b, et al. collagen fibrils in the human corneal stroma: structure and aging. invest ophthalmol vis sci. 1998; 39: 644-8. 15. seiler t, huhle s, spoerl e, et al. manifest diabetes and keratoconus: a retrospective case-control study. graefe’s archive for clinical and experimental ophthalmology. 2000; 238: 822-5. 16. spoerl e, seiler t. techniques for stiffening the cornea. j refract surg. 1999; 15: 711-3. 17. mazzotta c, balestrazzi a, traversi c, et al. treatment of progressive keratoconus by riboflavin – uv – a induced cross – linking of corneal collagen: ultrastructural analysis by heidelberg retinal tomograph ii in vivo confocal microscopy in humans. cornea. 2007; 26: 390-7. 18. seiler t, hafezi f. corneal cross – linking – induced stromal demarcation line. cornea. 2006; 25: 1057-9. 19. koppen c, vryghem jc, gobin l, et al. keratitis and corneal scarring after uva / riboflavin cross – linking for keratoconus. j refract surg. 2009; 25: 819-23. 20. hoyer a, raiskup-wolf f, spörl e, et al. collagen cross-linking with riboflavin and uva light in keratoconus. results from dresden. ophthalmologe. 2009; 106: 133-40. 21. agarwal vb. corneal collagen cross-linking with riboflavin and ultraviolet-a light for keratoconus. results in indian eyes. ind j ophthalmol. 2009; 57: 1114. 22. khan md, ameen ss, ishtiaq o, et al. preliminary results of uv – a riboflavin cross – linking in progressive cases of keratoconus in pakistani population. pak j ophthalmol. 2011; 27: 21-6. 23. reinstein dz, archer tj, gobbe m. corneal epithelial thickness profile in the diagnosis of keratoconus. j refract surg. 2009; 25: 604-10. 24. hersh ps, greenstein sa, fry kl. corneal collagen cross – linking for keratoconus and corneal ectasia: one – year results. j cataract refract surg. 2011; 37: 14960. 25. maguire ij, lowry jc. identifying progression of subclinical keratoconus by serial topography analysis. am j ophthalmol. 1991; 112: 41-5. microsoft word 10. yasir iqbal 154 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology original article visual outcome after intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion yasir iqbal, sohail zia, aneeq ullah baig mirza pak j ophthalmol 2012, vol. 28 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: yasir iqbal department of ophthalmology iimc-t railways hospital rawalpindi …..……………………….. purpose: to determine the effect of intravitreal bevacizumab on visual acuity in patients with macular edema secondary to branch retinal vein occlusion material and methods: this prospective non-randomized clinical interventional study with convenience (non probability) sampling was conducted at redo eye hospital, rawalpindi; from june 2008 to july 2010. twenty eyes of twenty patients received a single injection of bevacizumab in a dose of 1.25 mg/0.05 ml .the visual acuity was measured pre injection and at 4, 8 and 12 weeks post injection using snellen’s visual acuity chart. results: at presentation 50% of the patients presented with best corrected visual acuity of 6/60 or worse, 35% were in between 6/60 and 6/24 where as 15 % were 6/18 or better. on the 3rd post injection follow up month 5% of the patients were with best corrected visual acuity of 6/60 or worse , 30 % were in between 6/60 and 6/24 where as 65% were 6/18 or better. the results are statistatically significant (p value less than 0.05). conclusions: intravitreal therapy using bevacizumab appears to be an effective treatment for improvement of vision in patients with macular oedema secondary to branch retinal vein occlusion. the positive results though based on short term basis, encourage studies to be conducted on a longer follow up period. ranch retinal vein occlusion (brvo) is a common retinal vascular disease seen most frequently in individuals who are older than 50 years1. the usual complaint of the patients is sudden loss of vision or visual field defect. the vision is decreased due to complications like macular edema, retinal capillary non-perfusion and vitreous haemorrhage from neovascularisation. macular edema is the major cause of visual disturbance in brvo, occurring in about 60% of cases2. only proven treatment modality for eyes with macular edema secondary to brvo is macular grid laser photocoagulation. but after grid laser photocoagulation the visual acuity improvement is often very limited (average improvement in vision of 1.33 snellen’s lines)3. it may also be associated with several complications including sub macular fibrosis, visualfield sensitivity deterioration, enlargement of laser scar and choroidal neovascularisation. this insufficient response to laser therapy has led researchers for other therapeutic options. several studies have demonstrated the usefulness of intravitreal injection of anti-vascular endothelial growth factor (anti-vegf) agents, such as bevacizumab and ranibizumab in dealing with macular edema due to brvo4,5. in smaller case series, bevacizumab has been shown to improve visual acuity (va) and decrease central retinal thickness (crt) in macular edema secondary due to central retinal vein occlusion6. the purpose of this study was to determine the effect of intravitreal bevacizumab on visual acuity in b visual outcome after intravitreal bevacizumab for macular edema secondary to branch retinal vein pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 155 patients with macular edema secondary to branch retinal vein occlusion. material and methods this prospective non-randomized clinical intervenetional study with convenience (non probability) sampling was conducted at redo eye hospital, rawalpindi; from june 2008 to july 2010. the patients were first allotted the hospital registration number before proceeding to the examination. systemic history was taken and general physical examination was done. complete eye examination was performed including snellen's best corrected visual acuity (bcva), intraocular pressure measurement by goldmann’s applanation tonometry, slit-lamp biomicroscopy and indirect ophthalmoscopy. twenty patients with acute attack of branch vein occlusion, with duration not more than a month, were selected for the study. we excluded those patients whom best corrected visual acuity was better than 6/12 on initial presentation, who had history of diabetes or nephropathy or previous treatment for brvo and had other retinal pathologies like glaucoma, diabetic retinopathy and hypertensive retinopathy. the study procedure and its aim were explained to all the patients before beginning the treatment and they had to sign an informed written consent form. all intravitreal injections of bevacizumab (1.25 mg/0.05ml) were performed under topical anesthesia in the operation theatre. patients used topical antibiotics (moxifloxacin 0.5%, vigamox alcon) 4 times per day for 1 week after the injection. the patients were examined after 4, 8 and 12 weeks. on each visit routine evaluation comprising of snellen's best corrected visual acuity (bcva), intraocular pressure measurement by goldmann’s applanation tonometry, slit-lamp biomicroscopy and indirect ophthalmoscopy, were done. all data were analyzed using spss 13.0 for windows. the paired t-test was used for comparison of preoperative and post operative bcva and p value of <0.05 was considered statistically significant. results the study was completed in period of 2 years and a total of 20 eyes of 20 patients (table 1). at presentation 50% of the patients presented with best corrected visual acuity of 6/60 or worse, 35% were in between 6/60 and 6/24 where as 15 % were 6/18 or better (table 2). after one month post injection 25% of the patients were with best corrected visual acuity of 6/60 or worse , 45% were in between 6/60 and 6/24 where as 30 % were 6/18 or better (table 2). follow up on second post injection month showed 5% of the patients were with best corrected visual acuity of 6/60 or worse ,35 % were in between 6/60 and 6/24 where as 60 % were 6/18 or better (table 2). on the 3rd post injection follow up month 5% of the patients were with best corrected visual acuity of 6/60 or worse , 30 % were in between 6/60 and 6/24 where as 65% were 6/18 or better (table 2). there was improvement of at least 2 snellen’s line in visual acuity of all the patients. after comparing the visual acuities at presentation and 3rd month post injection there was statistatically significant difference of p value less than 0.05. disscussion bevacizumab has been used on “off – label” basis since 2005. intravitreal bevacizumab was first used by pai et al7 as a treatment for macular edema related to brvo. the major stimulus for macular edema and neovascularisation seems to be hypoxia-induced production of vascular endothelial growth factor (vegf), an angiogenic factor that promotes angiogenesis and increases vascular permeability4. the yasir iqbal, et al 156 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology intravitreal bevacizumab has been met with great enthusiasm as an anti vegf. consequently, there have been other reports of short-term beneficial effect of intravitreal bevacizumab to treat macular edema secondary to retinal vascular disease, including central retinal vein occlusion6 and diabetic retinopathy8. gunduz9 reported a dramatic improvement in the visual acuity with significant macular thickness reduction after intravitreal bevacizumab injections (1.25 mg / 0.05 ml) for patients with brvo. jaissle et al10 demonstrated for the first time a significant long-term effect of intravitreal bevacizumab (1.25 mg / 0.05 ml) for the macular oedema due to brvo. their study showed a 39% reduction of the median central retinal thickness and increase of visual acuity to 6/12 at 48 weeks. the result of a prospective clinical trial carried out by prager et al11 showed that in the brvo group after intravitreal bevacizumab (1 mg / 0.04 ml) visual acuity increased from 55 etdrs letters at baseline to 73 etdrs letters and central retinal thickness decreased significantly after 1 year of follow-up. in our study, we observed significant improvement in visual acuity, 30% of the patients ended up with visual acuity between 6/60 and 6/24 where as 65% with 6/18 or better.all of the patients experienced a significant increase in visual acuity from preoperatively to a final best postoperative visual acuity with improvement of at least 2 snellen’s lines postoperatively. some limitations are inherent in our study, such as the small sample size, limited duration of follow-up, non-randomized trial and also as the nature of treatment was prophylactic. the effects of bevacizumab have been reported to be temporary by gündüz9 and jaissle et al10. other reports by rabena4 also disclosed similar results with periods ranging from 2 to 3 months from the last intravitreal bevacizumab to recurrence of macular oedema. large prospective, randomized clinical trials are necessary to compare the long-term efficacy of intravitreal bevacizumab for patients with macular oedema associated with brvo. conclusion the positive result of this short term study are very encouraging and suggests for a longer randomized study to find out long term efficacy of intravitreal bevacizumab in cases of branch vein occlusion with macular edema. author’s affiliation dr. yasir iqbal senior registrar department of ophthalmology iimc-t railways hospital rawalpindi dr. sohail zia senior registrar department of ophthalmology iimc-t railways hospital rawalpindi prof. aneeq ullah baig mirza professor of ophthalmology iimc-t railways hospital rawalpindi reference 1. martin w, wilfried r, iris s, et al. role of thrombophilic gene polymorphisms in branch retinal vein occlusion. ophthalmology 2005; 112: 1910-5. 2. maurizio bp, sonela s, pierluigi i, et al. subthreshold grid laser treatment of macular edema secondary to branch retinal vein occlusion with micropulse infrared (810 nanometer) diode laser. ophthalmology 2006; 113: 2237-42. 3. argon laser photocoagulation for macular edema in branch vein occlusion. the branch vein occlusion study group. am j ophthalmol. 1984; 98: 271-82. 4. rabena md, pieramici dj, castellarin aa, et al. intravitreal bevacizumab (avastin) in the treatment of macular edema secondary to branch retinal vein occlusion. retina 2007; 27: 419-25. 5. campochiaro pa, heier js, feiner l, et al. ranibizumab for macular edema following branch retinal vein occlusion: sixmonth primary end point results of a phase iii study. ophthalmology 2010; 117: 1102-12 6. iturralde d, spaide rf, meyerle cb, et al. intravitreal bevacizumab (avastin) treatment of macular edema in central retinal vein occlusion: a short-term study. retina 2006; 26: 279-84. 7. pai sa, shetty r, vijayan pb, et al. clinical, anatomic and electrophysiologic evaluation following intravitreal bevacizumab for macular edema in retinal vein occlusion. am j ophthalmol. 2007; 143: 601-6. 8. haritoglou c, kook d, neubauer a, et al. intravitreal bevacizumab (avastin) therapy for persistent diffuse diabetic macular edema. retina 2006; 26: 999-1005. 9. gunduz k, bakri sj. intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion. eye 2008; 22: 1168-71. 10. jaissle gb, leitritz m, gelisken f, et al. one-year results after intravitreal bevacizumab therapy for macular edema secondary to branch retinal vein occlusion. graefes arch clin exp ophthalmol. 2009; 247: 27-33. 11. prager f, michels s, kriechbaum k, et al. intravitreal bevacizumab (avastin) for macular oedema secondary to retinal vein occlusion: 12-month results of a prospective clinical trial. br j ophthalmol. 2009; 93: 452-6. pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 207 original article role of laser suture lysis in immediate trabeculectomy failure syed imtiaz ali shah, shujaat ali shah, partab rai, shahid jamal siddiqui, safdar ali abbasi, dure yakta shaikh pak j ophthalmol 2015, vol. 31 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syed imtiaz ali shah professor, department of ophthalmology, chandka medical college larkana syedimtiazalinaqvi@yahoo.com …..……………………….. purpose: to study the role of laser suture lysis in immediate trabeculectomy failure. material and methods: this was a prospective case series study conducted at department of ophthalmology, chandka medical college hospital larkana, pakistan from may 2007 to may 2015. 21 eyes of 20 patients who underwent trabeculectomy for primary open angle glaucoma and encountered immediate trabeculectomy failure were included in the study. immediate trabeculectomy failure was considered when iop during first 48 hours after trabeculectomy remained above 25 mm hg. laser suture lysis was carried out with nd: yag laser (1064 nm) or with frequency doubled nd: yag laser (532 nm). the preprocedure and post-procedure iop was noted and iop below 18 mm hg was considered as successful laser suture lysis. data entry and analysis was done on spss version 20. results: 12 (60 %) patients out of the total 20 patients were males and 8 (40 %) were females. the mean age ± standard deviation of patients was 61.45 ± 7.37 years and the age range was 47 to 71 years. iop came down to normal in all the cases after the laser suture lysis, without encountering any major complications. mean iop before laser suture lysis was 30.95 ± 2.20 mm hg and mean iop one hour after successful laser suture lysis was 13.38 ± 1.53 mm hg. conclusion: laser suture lysis is a safe, effective and day care procedure in the management of immediate trabeculectomy failure. keywords: glaucoma, trabeculectomy, failure, laser, suture. rabeculectomy, described firstly by cairns in 1968,1 is currently the most popular and widely performed surgery for the treatment of glaucoma.2 despite the advancements in techniques and instruments, trabeculectomy failure remains a significant problem. the rate of trabeculectomy or bleb failure has been reported to be around 10 – 20%.4-6 trabeculectomy failure may be early (within one month of surgery) or late (after one month of surgery), the latter being more common8. the importance of early trabeculectomy failure lies in immediate detection and management. these cases can only be detected when either a sign of raised iop is picked up within first 48 hours or a habit of assessment of iop during immediate postoperative period is developed. once this complication occurs and remains undetected, it eventually ends up in resorting to more invasive procedures to control iop, like another surgical procedure with enhancements, including use of cytotoxic medications (mmc14,15 and 5-fu16,17) and implants.18,19 topical steroids, 5-florouracil (5-fu), ocular massage.3 releasable sutures9, 10 and laser suture lysis11-13 all have been used for the management of early trabeculectomy failure. we took up this study to see the role of laser suture lysis in immediate trabeculectomy failure. t syed imtiaz ali shah, et al 208 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology material and methods this prospective case series study was conducted at department of ophthalmology, chandka medical college hospital larkana pakistan from may 2007 to may 2015. patients of immediate trabeculectomy failure who underwent trabeculectomy for primary open angle glaucoma were included in the study; immediate trabeculectomy failure was considered when iop during first 48 hours after trabeculectomy remained above 25 mm hg. we picked up 21 eyes of 20 patients with immediate trabeculectomy failure, out of 367 eyes of 321 patients undergoing trabeculectomy for primary open angle glaucoma; with the mean immediate failure rate of 5.72%. patients with primary angle closure glaucoma and secondary glaucoma were excluded from the study. all patients underwent trabeculectomy by the first author. limbal based conjunctival flaps were created and blunt dissection was done followed by wet field cautery to the sclera for acquiring a clear field and securing hemostasis. a 5 × 5 mm triangular scleral flap was formed, an internal window of 1 × 3 mm was created and a peripheral iridectomy was performed. the scleral flap was sutured with three 8/0 silk or 10/0 nylon sutures and the conjunctiva was stitched with buried 8/0 silk sutures. a subconjunctival injection of antibiotic and steroid combination was given at the end of the procedure. laser suture lysis was carried out with nd: yag laser (1064 nm) or with frequency doubled nd: yag laser (532 nm). 2 to 2.5 milijoules energy was used when nd: yag laser was utilized and 300 to 400 milivolt energy was used when frequency doubled nd: yag laser was utilized. laser suture lysis of one edge suture of the triangular scleral flap was done and iop was recorded after 5 minutes. if iop did not fall, ocular massage was carried out and if iop still remained high, another edge suture lysis was carried out followed by ocular massage till the iop came down to below 18 mm hg, which was considered as normal iop and the procedure was considered successful. the pre-procedure and post-procedure iop was noted and data entry and analysis was done on spss version 20. results 21 eyes of 20 patients undergoing trabeculectomy for primary open angle glaucoma with immediate trabeculectomy failure were included in the study. 12 (60%) patients were males and 8 (40%) were females (fig. 1). the mean age ± standard deviation of patients was 61.45 ± 7.37 years and the age range was 47 to 71 years. laser suture lysis was performed within the first week after the trabeculectomy surgery. iop came down to normal in all the cases, after laser lysis of one suture in 15 (71.43%) eyes and after laser lysis of two sutures in 6 (28.57%) eyes. mean iop before laser suture lysis was 30.95 ± 2.20 mm hg and mean iop one hour after successful laser suture lysis was 13.38 ± 1.53 mm hg (fig: 2). only two complications were fig. 1: age distribution of patients. fig. 2: mean iop before and after laser application. (± 1.53 mm hg) 990 (± standard deviation) role of laser suture lysis in immediate trabeculectomy failure pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 209 noted after the procedure, which were patient dissatisfaction in 2 cases and bleeding at the sight of laser application in 4 eyes (table 1), which settled with conservative measures. discussion the technique of laser suture lysis was initially reported in 1983 by lieberman13 with a goniolens and then in 1984 by hoskins and migliazzo7 with a special lens developed by them for the management of failing filtering blebs. a previous study by downes sm et al20 has observed that patients at risk of developing trabeculectomy failure can be identified in the early postoperative period on the basis of iop. this study noted that patients with initial postoperative iop of greater than 17 mm hg had increased chances of going into trabeculectomy failure and those patients having initial postoperative iop lesser than 17 mm hg had increased chances of a successful trabeculectomy and long term iop control. this fact shows the importance of adequate drainage immediately after trabeculectomy and the probable role of laser suture lysis in preventing not only the immediate trabeculectomy failure but late trabeculectomy failure as well. laser suture lysis is most successful in iop reduction when it is performed within two weeks of trabeculectomy. macken p et al21 have reported many complications in their study on laser suture lysis such as flat anterior chamber, external aqueous leak, iris incarceration, hyphaema, malignant glaucoma and excessive bleb elevation. similarly other studies have reported ocular hypotony with laser suture lysis after the use of antimetabolites in trabeculectomy,24,25 but in our study we came across minor complications. it seems that laser suture lysis results in more complications in eyes which have undergone trabeculectomy with antimetabolites. overall our study shows that laser suture lysis is an efficient method for the management of immediate trabeculectomy failure as is reported by other studies.7,13,22,23 conclusion laser suture lysis is a safe and effective procedure in the management of immediate trabeculectomy failure. it avoids the need of invasive methods and their resultant risks and complications. it is an outpatient procedure, does not require any special expertise and does not need anesthesia. author’s affiliation dr. syed imtiaz ali shah professor of ophthalmology chandka medical college, larkana dr. shujaat ali shah trainee registrar department of ophthalmology chandka medical college larkana dr. partab rai professor of ophthalmology chandka medical college larkana dr. shahid jamal siddiqui professor & chairman department of ophthalmology chandka medical college larkana dr. safdar ali abbasi registrar department of ophthalmology chandka medical college larkana dr. dure yakta shaikh assistant professor department of ophthalmology chandka medical college larkana role of authors dr. syed imtiaz ali shah substantial contribution to conception and design, acquisition of data, analysis and interpretation of data for intellectual content. dr. shujaat ali shah drafted and revised the manuscript, reviewed the figures, contributed to conception and design, acquisition of data, analysis and interpretation of data. dr. partab rai contributed to acquisition of data, analysis and interpretation of data and final approval of the study for publication. dr. shahid jamal siddiqui revised the study critically and contributed to acquisition of data. dr. safdar ali abbasi reviewed the manuscript and contributed to acquisition of data. dr. dure yakta shaikh contributed to acquisition of data. syed imtiaz ali shah, et al 210 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology references 1. cairns je. trabeculectomy, preliminary report of a new method. am j ophthalmol. 1968; 66: 673-9. 2. al habash a, aljasim la, owaidhah o, edward dp. a review of the efficacy of mitomycin c in glaucoma filtration surgery. clin ophthalmol. 2015; 9: 1945-51. 3. ali m, akhtar f. ocular digital massage for the management of post-trabeculectomy under filtering blebs. j coll physicians surg pak. 2011; 21: 676-9. 4. hitchings ra, grierson i. clinico pathological correlation in eyes with failed fistulizing surgery. trans ophthalmol soc uk. 1983; 103: 84-8. 5. addicks em, quigley ha, green wr, robin al. histologic characteristics of filtering blebs in glaucomatous eyes. arch ophthalmol. 1983; 101: 795-8. 6. migdal c, gregory w, hitchings r. long-term functional outcome after early surgery compared with laser and medicine in open-angle glaucoma. ophthalmology. 1994; 101: 1651-7. 7. hoskins hd jr, migliazzo c. management of failing filtering blebs with the argon laser. ophthalmic surg. 1984; 15: 731-3. 8. azuara-blanco a, katz lj. dysfunctional filtering blebs. surv ophthalmol. 1998; 43: 93-126. 9. zhou m, wang w, huang w, zhang x. trabeculectomy with versus without releasable sutures for glaucoma: a meta-analysis of randomized controlled trials. bmc ophthalmol. 2014; 14: 41. 10. matlach j, hoffmann n, freiberg fj, grehn f, klink t. comparative study of trabeculectomy using single sutures versus releasable sutures. clin ophthalmol. 2012; 6: 1019-27. 11. vijaya l, manish p, ronnie g, shantha b. management of complications in glaucoma surgery. ind j ophthalmol. 2011; 59: 131-40. 12. hiroshi k, kaori k. a comparison of the intraocular pressure lowering effect of adjustable suture versus laser suture lysis for trabeculectomy. j glaucoma. 2011; 20: 228-33. 13. lieberman mf. suture lysis by laser and goniolens. am j ophthalmol. 1983; 95: 257-8. 14. mostafaei a. augmenting trabeculectomy in glaucoma with subconjunctival mitomycin c versus subconjunctival 5-fluorouracil: a randomized clinical trial. clin ophthalmol. 2011; 5: 491-4. 15. lin z-j, li y, cheng j-w, lu x-h. intraoperative mitomycin c versus intraoperative 5-fluorouracil for trabeculectomy: a systematic review and metaanalysis. j ocular pharmacol ther. 2012; 28: 166-73. 16. chawla a, mercieca k, fenerty c, jones np. outcomes and complications of trabeculectomy enhanced with 5fluorouracil in adults with glaucoma secondary to uveitis. j glaucoma. 2013; 22: 663-6. 17. anand n, dawda vk. a comparative study of mitomycin c and 5-fluorouracil trabeculectomy in west africa. mid east afr j ophthalmol. 2012; 19: 14752. 18. shen cc, salim s, du h, netland pa. trabeculectomy versus ahmed glaucoma valve implantation in neovascular glaucoma. clin ophthalmol. 2011; 5: 281-6. 19. gessesse gw. the ahmed glaucoma valve in refractory glaucoma: experiences in southwest ethiopia. ethiop j health sci. 2015; 25: 267-72. 20. downes sm, mission gp, jones hs, o'neill ec. the predictive value of post-operative intraocular pressures following trabeculectomy. eye.1994; 8: 394-7. 21. macken p, buys y, trope ge. glaucoma laser suture lysis. br j ophthalmol. 1996; 80: 398-401. 22. sng cc, singh m, chew pt, ngo cs, zheng c, tun ta. quantitative assessment of changes in trabeculectomy blebs after laser suture lysis using anterior segment coherence tomography. j glaucoma. 2012; 21: 313-7. 23. haynes wl, alward wl, mckinney jk. low-energy argon laser suture lysis after trabeculec-tomy. am j ophthalmol. 1994; 117: 800-1. 24. bardak y, cuypers mh, tilanus ma, eggink ca. ocular hypotony after laser suture lysis following trabeculectomy with mitomycin c. int ophthalmol. 1997-98; 21: 325-30. 25. schwartz al, weiss hs. bleb leak with hypotony after laser suture lysis and trabeculectomy with mitomycin c. arch ophthalmol. 1992; 110: 1049. http://www.ncbi.nlm.nih.gov/pubmed/?term=azuara-blanco%20a%5bauthor%5d&cauthor=true&cauthor_uid=9763136 http://www.ncbi.nlm.nih.gov/pubmed/?term=katz%20lj%5bauthor%5d&cauthor=true&cauthor_uid=9763136 http://www.ncbi.nlm.nih.gov/pubmed/9763136 http://journals.lww.com/glaucomajournal/toc/2011/04000 http://www.ncbi.nlm.nih.gov/pubmed/?term=chawla%20a%5bauthor%5d&cauthor=true&cauthor_uid=22706335 http://www.ncbi.nlm.nih.gov/pubmed/?term=mercieca%20k%5bauthor%5d&cauthor=true&cauthor_uid=22706335 http://www.ncbi.nlm.nih.gov/pubmed/?term=fenerty%20c%5bauthor%5d&cauthor=true&cauthor_uid=22706335 http://www.ncbi.nlm.nih.gov/pubmed/?term=jones%20np%5bauthor%5d&cauthor=true&cauthor_uid=22706335 http://www.ncbi.nlm.nih.gov/pubmed/22706335 http://www.ncbi.nlm.nih.gov/pubmed/?term=gessesse%20gw%5bauthor%5d&cauthor=true&cauthor_uid=26633930 http://www.ncbi.nlm.nih.gov/pubmed/26633930 http://www.ncbi.nlm.nih.gov/pubmed/26633930 http://www.ncbi.nlm.nih.gov/pubmed/26633930 http://www.ncbi.nlm.nih.gov/pubmed/?term=sng%20cc%5bauthor%5d&cauthor=true&cauthor_uid=21562432 http://www.ncbi.nlm.nih.gov/pubmed/?term=singh%20m%5bauthor%5d&cauthor=true&cauthor_uid=21562432 http://www.ncbi.nlm.nih.gov/pubmed/?term=chew%20pt%5bauthor%5d&cauthor=true&cauthor_uid=21562432 http://www.ncbi.nlm.nih.gov/pubmed/?term=ngo%20cs%5bauthor%5d&cauthor=true&cauthor_uid=21562432 http://www.ncbi.nlm.nih.gov/pubmed/?term=zheng%20c%5bauthor%5d&cauthor=true&cauthor_uid=21562432 http://www.ncbi.nlm.nih.gov/pubmed/?term=tun%20ta%5bauthor%5d&cauthor=true&cauthor_uid=21562432 http://www.ncbi.nlm.nih.gov/pubmed/?term=tun%20ta%5bauthor%5d&cauthor=true&cauthor_uid=21562432 http://www.ncbi.nlm.nih.gov/pubmed/?term=tun%20ta%5bauthor%5d&cauthor=true&cauthor_uid=21562432 http://www.ncbi.nlm.nih.gov/pubmed/21562432 microsoft word 12. abstracts 29-2-13 124 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology abstracts edited by dr. qasim lateef chaudhry corneal cross-linking as a treatment for keratoconus four-year morphologic and clinical outcomes with respect to patient age vinciguerra r, romano mr, camesasca fi, azzolini c, orth st, morenghi e, vinciguerra p ophthalmology 2013; 120: 908–16 riccardo vinciguerra et al have reported the 4-year outcomes of corneal cross-linking (cxl) for progressive keratoconus in a population of different age groups in this retrospective, single – center, nonrandomized clinical study. four hundred consecutive eyes treated with corneal cxl for progressive keratoconus from april 2006 through april 2010 were included in this study. in cxl procedure after removal of the epithelium, the cornea was irrigated for 30 minutes with a solution of 0.1% riboflavin and 20% dextran, followed by irradiation with an ultraviolet a light of 3 mw/cm2 for 30 minutes. the main outcome measures noted were best-corrected visual acuity (bcva), sphere and cylinder refraction, corneal topography,sche impflug tomography, and aberrometry. these findings were assessed at baseline and at 1, 6, 12, 24, 36, and 48 months after corneal cxl treatment. the compiled data were stratified according to age (group a, younger than 18 years; group b, 18–29 years; group c, 30–39 years; and group d, older than 40 years). comparative analysis included 400 eyes of 301 patients. functional results showed a significant increase in bcva in group a by a mean reduction of – 0.11 logarithm of the minimum angle of resolution (logmar) after 12 months, in group b by a mean reduction of –0.31 logmar after 36 months, in group c by a mean reduction of –0.33 logmar after 36 months, and in group d by a mean reduction of –0.26 logmar after 36 months. morphologic results showed an analogous regularization of corneal shape with a significant reduction of opposite sector index by a mean value of –0.53 at 12 months in group a, –1.14 at 36 months in group b, –1.10 at 36 months in group c, and –0.55 at 12 months for group d. optical quality improvement was demonstrated by a mean significant reduction of coma –1.52 m after 12 months in group a, –1.58 m after 24 months in group b, –2.57 m after 36 months for group c, and –0.25 m after 36 months in group d. the authors concluded that these outcomes stratified by age indicate the efficacy of corneal cxl in stabilizing the progressionof ectatic disease in all age groups and improving the functional and morphologic parameters in select groups. these results also indicated better functional and morphologic results in the population between 18 and 39 yeavgf87-rs of age. effect of corneal collagen cross-linking on corneal innervation, corneal sensitivity, and tear function of patients with keratoconus kontadakis ga, kymionis gd, kankariya vp, pallikaris ai ophthalmology 2013; 120: 917–22 georgios et al studied the effect of corneal collagen cross – linking (cxl) on corneal innervation, corneal sensitivity, and tear function in patients with keratoconus. in this prospective, interventional case series twenty-four patients with bilateral keratoconus (30 eyes) who presented to the institute of vision and optics, university of crete, from may 2008 to october 2008 were enrolled and underwent cxl. confocal microscopic analysis of corneal sub-basal nerve plexus (total nerve length per image), corneal sensitivity (assessed with the cochet–bonnet esthesiometer), basic tear secretion (assessed with schirmer’s i test with anesthesia), and tear film stability (evaluated by means of tear film break-up time [tfbut]) were assessed preoperatively and at 1, 3, 6, 9, 12, 18, and 24 months postoperatively. the main outcome measures were comparisons between preoperative and each postoperative value of total nerve length per image, corneal sensitivity, schirmer’s i test results, and tfbut. the results showed that total nerve length per image and corneal sensitivity were significantly decreased until postoperative month 6 (for both parameters: p_0.05 paired-samples t test at 1, 3, and 6 months postoperatively). total nerve length per image tended to increase up to 2 years postoperatively, when it reached the preoperative level, but differences with abstracts pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 125 the preoperative values after the sixth post-cxl month were insignificant. the results of schirmer’s i test and tfbut had no statistically significant difference at any time point. the authors concluded that a transient decrease in corneal innervation and corneal sensitivity can be observed up to 6 months after cxl. no significant effect of cxl could be detected on basic tear secretion and tear film stability in these patients. displacement of the retina and its recovery after vitrectomy in idiopathic epiretinal membrane nitta e, shiraga f, shiragami c, fukuda k, yamashita a, fujiwara a am j ophthalmol. 2013; 155: 1014–20 eri nitta et al studied the the displacement of the retina and its change after vitrectomy in idiopathic epiretinal membrane (erm) in this prospective, interventional case series of fifty-six eyes of 53 consecutive patients with erm who underwent vitrectomy with erm removal and internal limiting membrane peeling. fundus autofluorescence (faf) imaging was examined before and at 1, 3, 6, and 12 months after vitrectomy. the main outcome measures were the proportion of eyes with retinal displacement for erm detected by faf imaging and the recovery rate of retinal displacement after vitrectomy. the results showed that before surgery, faf photography demonstrated hyperautofluorescent lines within the vascular arcade in 37 (66.1%) of the 56 eyes. the lines seemed to be consistent with the location of the retinal vessels before their displacement. these hyperautofluorescent lines appeared significantly more frequently among patients in whom the disease duration was 3 years or less. in 23 (62.2%) of these 37 eyes, within the first postoperative month, the hyperautofluorescent lines disappeared. the disappearance of the hyperautofluorescent line was thought to be the result of the return of the retinal vessel to its original position. greater visual improvements (logarithm of the minimal angle of resolution, ‡ 0.3) were statistically significantly obtained in patients in whom the hyperautofluorescent lines had become indistinct at 1 month after surgery (p<.05). so the authors concluded that hyperautofluorescent lines indicating retinal displacement were found by faf in 66.1% of patients before surgery for erm. in addition, retinal displacement was significantly more common among patients who had experienced subjective symptoms for 3 years or less. fundus autofluorescence is useful for predicting postoperative visual acuity improvement. excimer laser phototherapeutic keratectomy in eyes with corneal stromal dystrophies with and without a corneal graft reddy jc, rapuano cj, nagra pk, hammersmith km am j ophthalmol. 2013; 155: 1111–8. jagadesh et al evaluated and compared the visual out comes and recurrence patterns of corneal stromal dystrophies after excimer laser phototherapeutic keratectomy (ptk) in eyes with and without a corneal graft in this retrospective, comparative case series done at cornea service, wills eye institute, philadelphia pennsylvania. the patients were divided into 2 groups. group 1 comprised patients with no graft who underwent ptk (22 eyes of 15 patients), and group 2 comprised patients who underwent ptk over a previous full-thickness graft (18 eyes of 14 patients). all patients underwent ptk for decreased vision, symptoms of recurrent erosions, or both. visual outcomes and recurrence patterns of corneal stromal dystrophies were noted as main outcome measures. the results showed that preoperative and postoperative best-corrected visual acuities were 0.46 ± 0.25 and 0.51 ± 0.27 (p [.56), respectively, in group 1 and 0.16 ± 0.13 and 0.21 ± 0.18 (p[.25), respectively, in group 2. mean preoperative spherical equivalent was 1.54 ± 2.59 diopters (d) andl5.10 ± 5.81 d (p[.01) in groups 1 and 2, respectively, and mean postoperative spherical equivalent was 0.44 ± 1.8 d and l1.8 ± 4.25 d (p [ .19) in groups 1 and 2, respectively. there was no statistically significant difference in the efficacy (p[.73) and safety (p[.62) indices between the 2 groups. in group 1, mild recurrence was seen in 7 eyes (32%) and significant recurrence was seen in 4 eyes (18%) at a mean of 32 and 47 months after ptk respectively. in group 2, mild recurrence was seen in 5 eyes (28%) and significant recurrence was seen in 5 eyes (28%) at a mean of 36 and 50 months after ptk, respectively. the authors concluded that ptk improved central corneal clarity, alleviated symptoms resulting from recurrent erosions, and improved visual acuity in both groups. 180 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology case report use of silver nitrate in superior limbic keratoconjunctivitis muhammad khalil, tayyaba gul malik, sania munawar, mian muhammad shafique pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad khalil ophthalmology department lahore medical and dental college, lahore …..……………………….. a 38 years old pakistani female presented in outpatient department with a history of irritation and redness in both eyes for the last five months. it was associated with foreign body sensations and watering of both eyes. she had been using different eye drops but there was no recovery. there was no history of contact lens use. slit lamp examination revealed superior limbal congestion in the form of inverted trapezoid, centered at 12 o’clock. examination of the upper tarsal conjunctiva showed velvety congestion and papillae formation. patient was prescribed topical lubricants and fluorometholone eye drops. follow up after three weeks showed mild recovery. we applied 0.5% silver nitrate solution as a trial to the upper tarsal conjunctiva. the patient showed marked improvement in congestion after three weeks. during this period she used lubricant eye drops. uperior limbic keratoconjunctivitis (slk) is a chronic inflammatory condition of the superior bulbar conjunctiva in a corridor, tunnel or inverted trapezoid fashion, associated with the papillary hypertrophy of the upper tarsal conjunctiva. the first ever description of this condition dates back to the year 1963, when theodore and kimura presented it as a localized, chronic inflammation of the superior conjunctiva.1 most common associations of slk are thyroid abnormalities and dry eye disease. the exact etiology is still unknown but the final common pathway in this condition is the mechanical soft tissue micro trauma.2 since it is a multifactorial disease, there is no single consensus on the final treatment. one of the treatment options is topical application of 0.5% to 1% silver nitrate. in this particular case report, remarkable results of a single application of silver nitrate in slk, its historical use, application protocol in slk, possible mechanism of action, side effects and precautions are discussed. case report a 38 years old pakistani female presented in outpatient department with a history of irritation and redness in both eyes for the last five months. it was associated with foreign body sensation and watering of both eyes. she had been using different eye drops but there was no recovery. there was no history of contact lens use. she was hypertensive, which was not properly controlled. systemic history negated any heat intolerance, insomnia and weight loss. however, she underwent mastectomy two years back and had been using tamoxifen since then. family history was unremarkable. on examination, she was orthophoric and extra ocular movements were of full range. pupils were round, regular and normally reacting to light and accommodation. visual acuity was 6/6 and intra ocular pressures with applanation tonometry were 10 mm hg in each eye. slit lamp examination revealed superior limbal congestion in the form of inverted trapezoid, centered at 12 o’clock, (fig. 1). examination of the upper tarsal conjunctiva showed velvety congestion and papillae formation (fig. 2). tear meniscus and tear film was normal. tear film break up time was 17 seconds. cornea and lens were clear and fluorescein staining of cornea was negative. anterior chamber was quiet. fundoscopy showed normal retina. on general physical examination, all vitals were normal except blood pressure, which was 150/85 mm of hg. cbc and thyroid function tests were within the normal range. s use of silver nitrate in superior limbic keratoconjunctivitis pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 181 fig. 1: superior tunnel shaped congestion in both eyes. fig.2: velvety appearance of the upper tarsal conjunctiva due to papillary hypertrophy. fig.3: showing instillation of a drop of 0.5% silver nitrate on the upper tarsal conjunctiva. patient was prescribed topical lubricants and fluorometholone eye drops. follow up after three weeks showed mild recovery. we decided to apply 0.5% silver nitrate solution as a trial. topical proparacaine was used to anesthetize the conjunctiva. upper lid was everted. a drop of 0.5% silver nitrate solution was applied to the upper tarsal conjunctiva and the lid was closed for one minute (fig. 3). after one minute, the conjunctival sac and cornea were irrigated with normal saline solution. slit lamp examination was normal and fluorescein staining of the cornea was negative after the procedure. fig. 4: marked improvement in superior bulbar congestion. the patient was asked to use lubricant eye drops and called for follow up after three weeks. there was a marked improvement in congestion after three weeks as shown in (fig. 4). discussion superior limbic keratoconjunctivitis (slk) is a chronic inflammation of the superior bulbar conjunctiva, distributed in a corridor, tunnel or inverted trapezoid fashion. it is associated with the papillary hypertrophy of the upper tarsal conjunctiva. theodore coined the term superior limbic keratoconjunctivitis for this condition in 1963.1 the exact etiology of slk is still unknown but most of the patients may have abnormal thyroid function3. studies have also shown that almost 50% of patients with slk have keratoconjunctivitis sicca.4 in this particular patient, thyroid function tests and the tear film were normal. there are certain other risk factors associated with it. these include prolonged eyelid closure with associated hypoxia, conjunctivochalasis and tight conjunctival apposition to the globe following upper eyelid procedures.5 how do all these factors contribute to the superior bulbar congestion, still remains unsettled. one of the possible mechanisms could be the upper lid tightness caused by chronic inflammation of the upper bulbar conjunctiva. this can disturb the normal turnover of the bulbar conjunctival epithelial cells, which further increases the inflammation.2 furthermore, the chronic muhammad khalil, et al 182 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology inflammation can lead to blepharospasm, which presses upon the bulbar conjunctiva aggravating the existing inflammation.6 our patient did not have tight lids but conjunctiva was a bit lax. there are certain single case reports available in literature, which increase the confusion about the etiology of slk. one case of hyperthyroidism with slk is also reported which recovered after resection of the tumor.7 darrell described another case of slk in identical twins proposing a possible genetic basis7. but the family history of our patient was unremarkable. whatever be the cause, the final common pathway in all these conditions is soft tissue trauma.8 it is hypothesized that there are frictional forces between (i) tarsal and bulbar surfaces; and (ii) between conjunctival stroma and sclera which may be responsible for this trauma.2 due to a multifactorial pathogenesis of slk, there has been no consensus on a single best treatment. various treatment options including artificial tears and punctal occlusion in dry eyes, alternate patching of the eyes, topical mast cell stabilizers, vitamin a eye drops, cyclosporin a 0.5%, bandage contact lenses, cryotherapy and recession or resection of superior bulbar conjunctiva have all been described in literature with variable success. a case has been reported where unilateral bandage contact lens has improved the bilateral slk.9 thermal and chemical cautery with silver nitrate has also been used by many clinicians. in one study, a success rate of 73% was seen with thermal cautery. it was seen that the number of goblet cells improved following cautery.10 we decided to try silver nitrate solution in our patient after many different types of treatments failed in the previous five months. historically, silver had been mentioned in many literary and medical works since ancient times. in myths of vampire stories it was believed that only those bullets would kill a vampire which contained silver in it. while medical use of silver salts dates back to 1881 when it was discovered that instillation of a drop of 1% silver nitrate in the eyes of neonates would prevent ocular infections. it was named crede prophylaxis after the name of its discoverer.11,12 at that time it was also called lunar caustic because it was believed by ancient alchemists that, silver was associated with the moon. it was also used for water storage, as the water kept in silver containers did not get stale. some people used to put silver coins in water utensils as well. dramatic relief of signs and symptoms in our case suggests that the possible mechanism of action of silver nitrate in slk is its anti-inflammatory character. the earliest records of its anti inflammatory action was observed in early 1900 when it was found that if silver nitrate was applied to the indolent wounds, the inflammation was reduced. in 1920, united states fda approved silver for wound treatment.13 later it was found that ag ions were released in water which might have the anti inflammatory action. with the advent of antibiotics, the use of silver was abandoned and crede’s prophylaxis became a history due to corneal burns. in this new era of modern medical science there is more research going on silver nitrate and not very long ago, it was postulated that the nitrate ions in silver nitrate had pro inflammatory effect13. this could be the reason that application of silver nitrate causes irritation and burning as an early effect. later this is taken over by the anti-inflammatory effect of silver ions. slight burning and irritation noticed in our patient immediately after application of silver nitrate could be the result of this effect. another proposed mechanism of action of silver nitrate is its cauterizing effect. there is 75% silver nitrate with 25% potassium nitrate on a typical applicator of silver nitrate. as it is applied to a wet surface on the body, nitric acid is formed. this nitric acid has a chemical cauterizing effect, which is responsible for the resolution of superior bulbar congestion in slk. hence, silver nitrate, when applied, will achieve its hemostatic effect by creating chemical cauterization or sealing of the vessels. we could not find the results of large prospective studies on the use of silver nitrate in slk. however, there are two cases of corneal burns associated with the use of silver nitrate in slk where the practitioners had to settle the cases by large indemnity payments. in one case, silver nitrate stick was applied to the tarsal conjunctiva after dipping in dactriose. the cornea became hazy and final visual acuity was 20/200. in another case of a 35 yrs old patient, stick was directly applied to the limbus at 12 o’clock. a drop of solution dripped on to the cornea causing severe corneal burn at the spot. it is worth mentioning that in both cases silver nitrate stick was used.14 these sticks are impregnated with concentrated silver nitrate and should be avoided in eyes. we took special precautions to avoid these corneal burns. firstly, the concentration of silver nitrate was very low. only 0.5% solution was used. it must be emphasized that if the use of silver nitrate in superior limbic keratoconjunctivitis pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 183 required effect is attained after such a low concentration, there is no need to risk the cornea by using concentrated solutions or sticks. secondly, the eyelid was everted to apply the solution to the tarsal conjunctiva rather than directly applying to the bulbar conjunctiva. thirdly, the cornea and conjunctiva were irrigated one minute after the application, to remove excess of silver nitrate. so, we make following recommendations for the use of silver nitrate in slk. 1. the surgeon should be vigilant in using silver nitrate. solution should not be more concentrated than 1%. 2. contact with the skin should be avoided. 3. the eye should be irrigated after application of the solution for least 5 to 10 minutes. 4. direct contact of silver nitrate with the cornea should be avoided by everting the lid. 5. if one has to repeat the procedure, it should not be before 4 to 6 weeks after the first application. 6. it is also important that the solution must be kept in a dark and cool, dry location. if it is not, the medication will degrade and will be ineffective. it is always better to use a freshly prepared solution. author’s affiliation dr. muhammad khalil assistant professor of ophthalmolgy lahore medical and dental college, lahore. dr. tayyaba gul malik assistant professor of ophthalmolgy lahore medical and dental college, lahore. dr. sania munawar medical officer ghurki trust teaching hospital, lahore dr. mian muhammad shafique professor of ophthalmology lahore medical and dental college, lahore references 1. thygeson p, kimura sj. chronic conjunctivitis. trans am acad ophthalmol otolaryngol. 1963; 67: 494-517. 2. cher i. superior limbic keratoconjunctivitis: multifactorial mechanical pathogenesis. clin experiment ophthalmol. 2000; 28: 181-4. 3. wright p. superior limbic keratoconjunctivitis. trans ophthalmol soc uk. 1972; 92: 555–60. 4. udell ij, kenyon kr, sawa m, dohlman ch. treatment of superior limbic keratoconjunctivitis by thermocauterisation of the superior bulbar conjunctiva. ophthalmology 1986; 93: 162. 5. sheu mc, schoenfield l, jeng bh. development of superior limbic keratoconjunctivitis after upper eyelid blepharoplasty surgery: support for the mechanical theory of its pathogenesis. cornea. 2007; 26: 490-2. 6. mondino bj, zaidman gw, salamon sw. use of pressure patching and soft contact lens in superior limbic keratoconjunctivitis. arch ophthalmol. 1982; 100: 1932–4. 7. roy fw. fraunfelder fw. roy and fraunfelder's current ocular therapy. 6th edition. p. 393. 8. cher i. blink-related micro trauma: when the ocular surface harms itself. clin experiment ophthalmol. 2003; 31: 183-90. 9. watson s, tullo ab, carley f. treatment of superior limbic keratoconjunctivitis with a unilateral bandage contact lens. br j ophthalmol. 2002; 86: 485-6. 10. udell ij, kenyon kr, sawa m, dohlman ch. treatment of superior limbic keratoconjunctivitis by thermo cauterization of the superior bulbar conjunctiva. ophthalmology 1986; 93: 162-6. 11. grier n. silver and its compounds. in: block ss (ed). disinfection, sterilization and preservation, third edition. philadelphia, pa: lea febiger; 1983. 12. peter h. (2000). “dr carl credé (1819 – 1892) and the prevention of ophthalmia neonatorum”. arch dis child fetal neonatal. 2000; 83:158–9. 13. demling rh, desanti l. effects of silver on wound management. wounds. 2001; 13: 4. 14. bettman jw. medication error study. physician insurers association of america, washington, dc. june 1993. seven hundred medicolegal cases in ophthalmology. ophthalmology. 1990; 97: 1379-84. http://www.ncbi.nlm.nih.gov/pubmed?term=dohlman%20ch%5bauthor%5d&cauthor=true&cauthor_uid=3951822 http://bjo.bmj.com/search?author1=s+watson&sortspec=date&submit=submit http://bjo.bmj.com/search?author1=a+b+tullo&sortspec=date&submit=submit http://bjo.bmj.com/search?author1=f+carley&sortspec=date&submit=submit http://www.ncbi.nlm.nih.gov/pubmed?term=udell%20ij%5bauthor%5d&cauthor=true&cauthor_uid=3951822 http://www.ncbi.nlm.nih.gov/pubmed?term=kenyon%20kr%5bauthor%5d&cauthor=true&cauthor_uid=3951822 http://www.ncbi.nlm.nih.gov/pubmed?term=sawa%20m%5bauthor%5d&cauthor=true&cauthor_uid=3951822 http://www.ncbi.nlm.nih.gov/pubmed?term=dohlman%20ch%5bauthor%5d&cauthor=true&cauthor_uid=3951822 http://www.ncbi.nlm.nih.gov/pubmed/3951822?dopt=abstract http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1721147/ http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1721147/ 150 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology original article role of mitomycin c probing and syringing in failed dcr (dacrocystorhinostomy) patients bakht samar khan, abid nawaz, maqbol-ur-rehman pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: bakht samar khan mbbs, doms, fcps associate professor ophthalmology unit khyber teaching hospital, peshawar email: bsetbakht@yahoo.com …..……………………….. purpose: to evaluate the role of 0.01% (0.1 mg/ml) mitomycin c probing followed by syringing with 0.1% mmc in failed dcr patients. study design: prospective cohort study. place and duration of study: from jan 2014 to dec 2015 at department of ophthalmology, khyber teaching hospital peshawar. material and methods: thirty (30) patients, 19 females and 11 males of failed dcr were included in the study. patients with symptoms of epiphora and positive/doubtful regurgitation test were included in the study. exclusion criteria were traumatic chronic dacryocysitis, history of failed dcr for more than two weeks and nasal abnormality. probing with mitomycin c followed by syringing and irrigation were done at presentation, at 6 weeks interval, at 3 months interval and 6 months interval if needed. the procedure was declared successful if saline came into the nose or throat. the patient was prescribed topical antibiotic drops, saline nasal drops and saline gargles. each time ent consultation was done to see the side effects of mitomycin in throat and nose. results: all of the thirty patients included in the study showed improvement in nld patency after probing followed by syringing with mmc when failed dcr was detected within first fifteen days of dcr. conclusion: if failed dcr patients are detected within fifteen days after surgery, probing and syringing done with mitomycin c improves the patency of nld system. keywords: dacrocystorhinostomy, mitomycin c, probing and syringing of lacrimal sac. cr is done for epiphora due to nasolacrimal duct obstruction. if epiphora and conjunctivitis persists after dcr surgery it is a troublesome situation for patients. the reported failure rate after primary dcr procedure is from 11 to 28%1. various options are used to manage these patients. these include long-term medications to surgical intervention. after a successful patent dcr operation, the causes of later failure include fibrosis at canalicular or osteotomy site2,3. even intubation of lacrimal drainage system can have granulation tissue formation4,5. to prevent this complication some surgeons use anti fibrotic agent mitomycin c at these sites6,7. mitomycin c is a chemotherapeutic agent, which prevents fibrosis by inhibiting collagen synthesis. mitomycin was first used in ophthalmology in 1969 in recurrent pterygium. later, in filtration and dcr to prevent scarring8. various types of application and concentrations have been used with different routes. these include cotton tip soaked in mmc application to nasal and lacrimal mucosa followed by d role of mitomycin c probing and syringing in failed dcr (dacrocystorhinostomy) patients pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 151 irrigation with normal saline. kamal et al, used the technique of intramucosal injection of 0.1ml of 0.02% mmc along the ostium called cos mmc9. long-term medication is just symptomatic treatment with many side effects. similarly, re-surgery does not suit the surgeon or the patient. if failure of dcr is detected in first fifteen days of surgery, it is possible to treat by simple ways comparatively. in this study, we have used a new technique of mmc probing followed by mmc syringing. the role and effectiveness of mitomycin c probing and syringing is highlighted. material and methods this study was done in eye b unit of kth/kmc. exclusion criteria were traumatic chronic dacryocystitis, history of failed dcr more than two weeks and nasal abnormality. a total of 30 patients with symptoms of epiphora and positive/doubtful regurgitation test were included in the study. patients were taken into ot. patient’s consent was taken and procedure was explained. under topical anesthesia syringing with diluted 0.5% lignocaine ( one ml of 2% xylocaine with four ml saline) done to confirm the blockage or failure of dcr. probing was done with lacrimal probe soaked in 0.01% mmc. this was followed by syringing and irrigation with 0.1% mmc mixed saline for ten minutes. after ten minutes interval the naso-lacrimal duct drainage system was irrigated with normal saline. this process was repeated at 6 weeks, three months and six months interval. the procedure was declared successful if saline came into the nose or throat. the patient was prescribed topical antibiotic drops, saline nasal drops and saline gargles. each time ent consultation was done to see the side effects of mitomycin in throat and nose. as far as level of obstruction in different cases was concerned, our objective was failure at any site. results the results were classified in four phases (table 1). phase 1 a total thirty patients of recent dcr were identified and confirmed by syringing and irrigation method. in all these patients on presentation probing and syringing with 0.01% mmc solution were done. the result showed that 17 nld were fully patent and 13 were partially patent. phase 2 the technique was repeated at 6 weeks and it was found that 15 nld were fully patent, 10 nld had partial and 5 nld had complete block. the procedure or technique of probing and irrigation with mitomycin was repeated in all patients irrespective of patency. there were 20 nld fully patent and 10 partially patent. phase 3 after three months interval again the patency was checked. 18/30 patients had fully patent drainage system, 11/30 had partial and one completely blocked passage. probing and syringing with mitomycin was done. all were patent with 19/30 fully patent and 11/30 partial. phase 4 the procedure was repeated after six months and it was found that 20/30 patients had patent nld and 10/30 patients had partial blockage. (partial means some fluid into throat or nose and some fluid through upper or lower punctum). all cases were followed for six months from date of patency noted. table 1: summary of the procedure and results. syringing before probing syringing with mmc after probing with mmc patency partial patency total blocked patency partial patency total blocked at presentation 0 0 30 (100%) 13 (43%) 17 (57%) 0 at 6 weeks 10 (33%) 15 (50%) 5 (17%) 10 (33%) 20 (67%) 0 at 3 months 11 (37%) 18 (60%) 1 (03%) 11 (37%) 19 (63%) 0 at 6 months 10 (33%) 20 (67%) 0 10 (33%) 20 (67%) 0 bakht samar khan, et al 152 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology discussion dcr with or without intubation of drainage system is choice of primary surgical standard procedure for nld obstruction for age 7 years and above. in spite of all surgical available techniques there is an average failure rate of 9.4%10. the causes of failure may help the surgeon in planning to exclude causes of failure before or during operation. the major failure rate reported by wilham and wulc is 32.21%. they reported the cause of failure as malposition of window and scarring by anterior ethmoid air cells11. many authors have noted that the cause of failure is scarring or fibrosis at canalicular system, osteotomy site or nasal septum site12,13,14. performing second surgery pico found an occluding membrane at the site of drainage channel15. scarring is one of the key factors in failure of naso lacrimal drainage apparatus. various authors started to use mmc for prevention of failure in primary surgery. as far as usage is concerned, you and fang used different concentration of mitomycin as 0.02% (0.2 mg/ml) mmc in one group and 0.05% (0.5 mg/ml) mmc in other group16. there was no statistical significance of dose used. however, mmc increased the success rate over traditional dcr. deka et al used intraoperative mmc with 95% success rate17 and mukhtar et al reported 97.5% success rate6. postoperative mmc soaked cotton ball swab was used intranasally by henson et al with success rate of 92.8%18. feng ct al in their meta analysis stated that intra operative use of mmc is safe and increase the success rate after both primary dcr and revision endo laser dcr16. gupta et al did re surgical intervention in failed dcr patients with success rate of 92.4%19. in our study it was confirmed that mmc 0.01% (0.1mg/ml) helps in patency even after post operative failure. as far as dose and concentration is concerned, various authors have used different concentration of mmc in various procedure of dcr to enhance the success rate of surgery. the dose concentration used as, 0.02% mmc and 0.05% mmc by you and fang respectively.16 0.05% mmc and 0.4% mmc by deka et al,17 0.02%mmc by mukhter et al6. various concentration for different time period were used. the minimum effective concentration 0.2 mg/ml for 3 minutes is more effective while in our study 0.01% (0.1 mg/ml) was equally effective. in another study, the dose of 0.02 to 0.04% for 5-30 minutes was successfully used with no complication20. the route used was intra operative by you and feng16, intra operative by deka et al17, circum-ostial inj of mitomycian (cos-mmc) on nasal mucosa by ari et al21. in our study it was 0.01% (0.1 mg/ml). route was probing with mmc, syringing and irrigation with 0.01% mmc. in various studies the success rate in qadir m et al was 96% with mitomycin c vs 80% without mitomycin.22 in mukhter et al study, by using 0.02% (0.2 mg/ml) mmc success was 97.5%,6 in deka et al 0.04% (0.4 mg/ml) it was 95%17. in kamal et al all the success rate was 97.3%.8 otolaryngologist (ent surgeon) used intraoperative mitomycin c during endoscopic dcr surgery at 93.3% success rate vs 78.3% without mitomycin c23. they all used mmc as intra operative in primary procedure while in our study the concentration used was 0.01% (0.1 mg/ml) mmc after failure of surgery. the success rate was 100% if failed dcr was detected in first two weeks of surgery. conclusion if failed dcr patients are detected in first fifteen days after surgery, probing and syringing is done with mitomycin c. it improves the patency of nld system. author’s affiliation dr. bakht samar khan mbbs, doms, fcps, associate professor ophthalmology unit, khyber teaching hospital peshawar. professor abid nawaz mbbs, do, frcs, professor of ophthalmology kabir medical college, peshawar. maqbol-ur-rehman post graduate trainee ophthalmology department khyber teaching hospital, peshawar. roles of authors dr. bakht samar khan study design, data collection, analysis, result compilation and article writing. dr. abid nawaz analysis, critical review. role of mitomycin c probing and syringing in failed dcr (dacrocystorhinostomy) patients pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 153 dr. maqbol-ur-rehman literature review, data collection and reference collection. references 1. liao ls. kao scs. tseng jhs, chen ms, hou pk. results of intraoperative mitomycin c application in dacryocystorhinostomy. br j ophthalmol. 2000; 84: 9036. 2. karkos pd, leong sc, sastry a, assimakopoulos ad, swift ac. evidence-based application of mitomycin c in the nose. am j otolaryngol. 2011; 32: 422-5. 3. leong sc, macewen cj, white ps. a systematic review of outcomes after dacryocystorhinostomy in adults. am j rhinol allergy, 2010; 24: 81-90. 4. agarwal s. endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction. j laryngol otol. 2009; 123: 1226-8. 5. ozkiris m, ozkiris a. endoscopic dacryocystorhinostomy not using canalicular silicone intubation tube with and without mitomycin c: a comparative study. eur j ophthalmol. 2012; 22: 320-5. 6. mukhtar sa, jamil az, ali z. efficacy of external dacryocystorhinostomy (dcr) with and without mitomycin c in chronic dacryocystitis. j coll physicans surg. pak. 2014; 24: 732-5. 7. penttila e, smirnov g, seppa j, kaarniranta k, tuomilehto h. mitomycin cin revision endoscopic dacryocystorhinostomy: a prospective randomized study. am j rhinol allergy, 2011; 25: 425-8. 8. kunitomoro n, mori s. studies on pterygium: part 4, a treatment by mitomycin-c installation. acta soc ophthalmol jpn. 1969; 67: 601-7. 9. kamal s, ali mj, naik mn. circumostial injection of mitomycin c (cos –mmc) in external endoscopic dacryocystorhinostomy. efficacy, safty profile, and outcome. ophthalmic plas reconconst surg. 2014; 30: 187-90. 10. walland mj, rose ge. factors affecting the success rate of open lacrimal surgery. br j ophthalmol. 1994; 78: 88191. 11. welham ran, wulc ae. management of unsuccessful lacrimal surgery. br j ophtalmol. 1987; 71: 152-7. 12. hallum av. the dupuy-dutemps dacryocystorhinostomy. am j ophthalmol. 1949; 32: 1197-206. 13. mepherson tr, egleston db. dacryocystorhinostomy. am j ophthalmol. 1959; 47: 328-31. 14. cheng sm, feng yf, xu l, li y, haung jh. efficacy of mitomycin cin endoscopic dacryocystorhinostomy. a systemic review and meta-analysis. plos one 2013, 8: e62737. 15. pico ga. a modified technique of external dacryocystorhinostomy. am j ophthalmol. 1971; 72: 679-90. 16. you ya, feng ct. intra operative mmc in dcr, ophthal plastic reconst surf. 2001; 17: 115-9. 17. deka a, bhattacharjee k, bhuyan sk, barua ck, bhattacharjee h, khaund g. effect of mitomycin c on ostium in dacryocystorhinostomy, clin experiment ophthalmol. 2006; 34: 557-61. 18. henson rd, cruz hl, henson rg jr, ali mj, kakizaki h. postoperative application of mitomycin c in endocanalicular laser dacryocystorhinostomy. ophthal plast reconstr surg. 2012; 24: 732-5. 19. gufta r, gupta p, kushwaha rn. failed dcr dealing with care to succeed. sch j, app.med. sci. 2320-6691; 2013. 20. kao sc, liao cl, tseng jh, chen ms, hou pk. dacryocystorhinostomy with intraoperative mitomycin c. ophthalmology, 1997; 104: 86-91. 21. ari s, gun r, surmeli s, atay ae, caca i. use of adjunctive mitomycin c in external dacryocystorhinostomy surgery compared with gurgery alone in patients with nasolacrimal duct obstruction: a prospective, double-masked, randomzed controlled trail. curr ther res clin exp. 2009; 70: 267-73. 22. qadir m, ahangar a, dar ma, hamid s, keng mq. comparative study of dacryocystorhinostomy with and without intraoperative application of mitomycin c. saudi journal of ophthalmology, 2014; 28: 44-48. 23. farooq mu, ansari ma, khyani ia. role of mitomycin c in endoscopic management of nasolacrimal duct obstruction. j dow uni health sci. 2013; 7 (2): 63-67. pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 237 original article post operative anterior chamber reaction in adult cataract surgery after adding heparin in irrigating solution yasir iqbal, sohail zia, qaim ali khan pak j ophthalmol 2014, vol. 30 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: yasir iqbal assistant professor department of ophthalmology islamic international medical college-trust pakistan railways hospital rawalpindi yazeriqbal@yahoo.com …..……………………….. purpose: to document the post operative anterior chamber reaction in adult cataract surgery after adding heparin in irrigation solution. material and methods: it was a quasi experimental study in which 193 eyes of patients, with ages 50 years to 75 years, were selected by convenience (non probability) sampling technique for cataract surgery in redo eye hospital, rawalpindi from feb 2011 to dec 2011. all the cases under went operation by the single surgeon having expertise in the technique of manual sutureless cataract surgery (mscs). at the beginning of the surgery, 1 ml of heparin sodium (concentration 10 iu/ml) was added to the balanced salt solution to irrigate the anterior chamber during the surgery. all patients were followed on the first post operative day and after one week. at follow up visits, postoperative intraocular cellular reaction based upon modified hogan’s classification was noted. results: on the first post operative day, 5.2% of the cases had mild and 1% cases had moderate anterior chamber reaction. the patient were put on the standard topical treatment and on first week follow up the anterior chamber reaction was absent in all of the cases. conclusion: we found that after adding heparin in the irrigating solution there was mild anterior chamber reaction in 5.2% of our cases and it can play a role to reduce the post operative inflammation in adult cataract surgery. key words: cataract surgery, heparin, anterior chamber mong the world’s blind population, 4% lives in pakistan; 80% of which is avoidable.1 cataract is one of the leading causes of reversible blindness in the world and cataract surgery consists of major work load of every ophthalmic unit.2 every procedure whether phacoemulsification, extracapsular cataract extraction or manual suture less cataract extraction merits and demerits are being debated by the ophthalmology community but one consensus remains for every procedure that the postoperative inflammation after surgery should be minimal3. anterior chamber inflammation following cataract surgery has been reported up to 30% varying from mild to severe.4 post operative anterior chamber reaction is significant as it may lead increased intraocular pressure (iop), corneal edema, endothelial injury, fibrin formation on intraocular lens (iol) surface, posterior synechia (ps), posterior capsular opacity (pco), cystoid macular edema (cme), and chronic anterior uveitis. heparin having anti-inflammatory properties is being used in pediatric cataract surgery in the form of coatings on the intraocular lenses 5 and in irrigating solutions to reduce the post operative inflammation6. we conducted a quasi experimental study to document the severity of post operative anterior chamber reaction after adding heparin to the irrigating solution during cataract surgery in adults. a mailto:yazeriqbal@yahoo.com yasir iqbal, et al 238 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology material and methods this prospective study was conducted in the redo eye hospital, rawalpindi from feb 2011 to dec 2011. two hundred cases, with ages 50 years to 75 years, were selected by convenience (non probability) sampling technique for cataract surgery. they were allotted a hospital number and had to sign an informed consent for the procedure. preoperative examinations like slit lamp examination, intraocular pressure measurement by goldman's applanation tonometry, indirect ophthalmoscopy, a-scan and keratometry were carried out for all cases. criteria were patients diagnosed with senile uncomplicated cataract and pupil diameter equal or greater than 7 mm after mydriasis. exclusion criteria were history of ocular pathology, a relative afferent pupillary defect glaucoma, uveitis, high myopia, pseudoexfoliation, or corneal pathology, traumatic, subluxated and posterior polar cataract, previous ocular surgery, diabetic retinopathy and patients with fuchs dystrophy and any ocular surface disease. dark brown cataracts were also excluded because of prolonged surgical time. cases with intra operative complications like posterior capsular rent were also excluded from the study. all the cases under went operation by the single surgeon having expertise in the technique of manual sutureless cataract surgery (mscs). at the beginning of the surgery, 1 ml of heparin sodium (concentration 10 iu/ml) was added to the 500cc balanced salt solution to irrigate the anterior chamber during the surgery. procedure was started with a conjunctival flap made at superotemporal part of the limbus. scleral tunnel was constructed using a crescent knife and extended up to 1.0 mm into clear cornea. a 3.2 mm keratome was used to access the anterior chamber and the internal corneal incision was extended for about 0.5 mm more than the external scleral incision. the anterior chamber was deepened using a standard viscoelastic i.e. 2% hydrooxypropyl methylcellulose and continuous curvilinear capsulorrehexis of 5 6 mm was done using a bent 27 – gauge needle mounted on the irrigating infusion. the nucleus was delivered by visco expression and the cortex was washed using a simcoe cannula. a 6.5 mm optic pmma pc iol was implanted in the capsular bag inflated by viscoelastic. the viscoelastic material was replaced by bss solution .the integrity of the selfsealing scleral incision was ensured and the cut conjunctival flap was apposed using a forceps fitted to bipolar diathermy. in the event of any intraoperative complication the surgical technique was modified accordingly and the case was excluded from the study. standardized postoperative treatment comprised of prednisolone acetate 1% four hourly and moxifloxacin four times a day for one week. no oral steroids or topical mydriatic treatment was given. all patients were followed on the first post operative day and after one week. at follow up visits, postoperative intraocular cellular reaction based upon modified hogan’s classification7, was noted i.e. cell counting in the anterior chamber performed by slit-lamp biomicroscopy examination adjusting the lamp as 3 mm height, 1 mm width and x40 magnification defined as in table 1. results this study was completed in redo eye hospital, rawalpindi in a period of 10 months. a total of 193 cases were included in the study consisting of 54.45% females and 45.55% males with age ranging between 50 to 75 years table 2. all patients underwent the same procedure of mscs. on the first post operative day, 5.2% patients had mild and 1% cases had moderate anterior chamber reaction (table 3). the patient were put on the standard topical treatment and on first week follow up the anterior chamber reaction was absent in all of the cases. post operative anterior chamber reaction in adult cataract surgery after adding heparin in irrigation pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 239 discussion age – related cataract is the commonest cause of avoidable blindness all over the world. cataract surgery forms the major workload of eye units worldwide and is a major health care expense. it is one of the most cost effective of all public health interventions in terms of restored quality of life. initially cataract surgery was aimed to prevent blindness. now it has progressed to a refractive procedure that aims for post operative emmetropia. the quality of vision and early visual rehabilitation are the important parameters which determine the success of modern cataract surgery. these two parameters are in turn dependent upon complications associated with the surgical procedure and the post operative inflammation. addressing the post operative inflammation is always a challenge for the ophthalmologist. in the era of modern phacoemulsification the post operative inflammation is minimal and it is the procedure of choice in the developed countries. but due to high cost of phacoemulsification;8 manual sutureless cataract surgery (mscs) is preferred in the developing countries.9 during mscs the iris manipulation is universal during the some point of surgery10. this may lead to higher incidence of postoperative iritis. a series from south india had iritis in 6% and moderate iritis in 3% in the first postoperative week11. similarly a study conducted in pakistan mentioned patients having mild iritis in 16% and moderate iritis in 5.6% of their cases.12 we added heparin in the infusion solution and found that there was mild anterior chamber reaction in 5.2% of our cases. this finding is in accordance to other findings of the researchers. xia et al added heparin for cataract surgery and observed less fibrin and pigment deposits on the lens.13 similarly a study conducted in germany14 concluded that heparin – sodium added to the infusion solution during small incision cataract surgery reduced inflammation in the early postoperative period. a comparative study by kruger et al15 reported that heparin sodium group had lesser number of inflammatory cells postoperatively. they also reported a complication of hyphema in their study but we did not encounter any such complication in our study. heparin an anti coagulant has associated anti inflammatory actions16. it inhibits fibrinous reactions after intraocular surgery by inhibiting fibroblastic activity17. these unique properties of heparin lead researchers to use heparin in surface modified iols18 and in pediatric cataract surgery. similarly bayramlar and colleagues19 also concluded that the addition of heparin to the irrigating solution during surgery decreases postoperative fibrinoid reaction and late inflammatory complications. the same was concluded by ihsan ç and colleagues20 in their study. we are aware of the short comings of the study. the sample size was small and it was not a comparative study but to best of our knowledge we were the first to conduct such a study in pakistan. our results may prove a key role in decreasing the post operative inflammation. conclusion we found that by adding heparin in the irrigating solution there was mild anterior chamber reaction in 5.2% of our cases and it can reduce the post operative inflammation in adult cataract surgery. author’s affiliation dr. yasir iqbal assistant professor department of ophthalmology islamic international medical college-trust pakistan railways hospital, rawalpindi dr. sohail zia assistant professor department of ophthalmology islamic international medical college-trust pakistan railways hospital, rawalpindi dr. qaim ali khan assistant professor department of ophthalmology poonch medical college, rawalakot, ajk references 1. henning a, kumar j, yorston d, foster a. sutureless cataract surgery with nucleus extraction: outcome of a prospective study in nepal. br j ophthalmol. 2003; 87: 266–70. yasir iqbal, et al 240 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology 2. gogate pm. small incision cataract surgery: complications and mini-review. indian j ophthalmol. 2009; 57: 45–9 3. gogate pm, kulkarni sr, krishnaiah s, deshpande rd, joshi sa, palimkar a, deshpande md. safety and efficacy of phacoemulsification compared with manual small-incision cataract surgery by a randomized controlled clinical trial: sixweek results. ophthalmology. 2005; 112: 869-74. 4. mohammadpour m, jafarinasab mr, javadi ma. outcomes of acute postoperative inflammation after cataract surgery. eur j ophthalmol. 2007; 17(1):20-8. 5. çaça i, şahin a, cingü ak, ari s, alakuş f, çinar y. effect of low molecular weight heparin (enoxaparin) on congenital cataract surgery. int j ophthalmol. 2012; 5: 596-9. 6. kohnen t, dick b, hessemer v, jacobi kw. the antiinflammatory effect of heparin-containing infusion solutions during phacoemulsification. ophthalmology. 1995; 92: 297-302. 7. hogan mj, kimura sj, thygeson p. signs and symptoms of uveitis. 1 anterior uveitis. am j ophthalmol. 1959; 47: 155–70. 8. jongsareejit a, wiriyaluppa c, kongsap p, phumipan s. costeffectiveness analysis of manual small incision cataract surgery (msics) and phacoemulsification (pe). j med assoc thai. 2012; 95: 212-20. 9. haripriya a, chang df, reena m, shekhar m. complication rates of phacoemulsification and manual small-incision cataract surgery at aravind eye hospital. j cataract refract surg. 2012; 38: 1360-9. 10. parikshit mg. small incision cataract surgery: complications and mini-review. indian j ophthalmol. 2009; 57: 45–9. 11. srikant ks, sujata d, suryasnath r. blumenthal technique and its modification: the glory of anterior chamber maintainer. indian j ophthalmol. 2010; 58: 86. 12. zaman m, qadir a, maooz, shah i, rehman i, farooq t. cataract a nigra (black cataract): a challenging task made easy with sutureless manual extracapsular cataract extraction. j ayub med coll abbottabad. 2011; 23: 108-10. 13. xia xp, lu dy, wang lt. a clinical study of inhibition of secondary cataract with heparin. j chung hua yen ko tsa chih. 1994; 30: 405-7. 14. kohnen t, hessemer v, koch dd, jacobi kw. effect of heparin in irrigating solution on inflammation following small incision cataract surgery. j cataract refract surg. 1998; 24: 23743. 15. kruger a, amon m, formanek ca, schild g, kolodjaschna j, schauersberger j. effect of heparin in the irrigation solution on postoperative inflammation and cellular reaction on the intraocular lens surface. j cataract refract surg. 2002; 28: 87–92. 16. dada t. intracameral heparin in pediatric cataract surgery. j cataract refract surg. 2003; 29: 1056. 17. wilson me, trivedi rh. low molecular-weight heparin in the intraocular irrigating solution in pediatric cataract and intraocular lens surgery. am j opthalmol. 2006; 141: 537–8. 18. koraszewska-matuszewska b, samochowiec-donocik e, pieczara e, flilipek e. heparin-surface-modified pmma intraocular lenses in children in early and late follow up. klin oczna. 2003; 105: 273-6. 19. bayramlar h, totan y, borazan m. heparin in the intraocular irrigating solution in pediatric cataract surgery. j cataract refract surg. 2004; 30: 2163–9. 20. ihsan ç, alparslan ş, abdullah kc, şeyhmus a, fuat a, yasin ç. effect of low molecular weight heparin (enoxaparin) on congenital cataract surgery. int j ophthalmol. 2012; 5: 596–9. http://www.ncbi.nlm.nih.gov/pubmed/?term=gogate%20pm%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/15878068 http://www.ncbi.nlm.nih.gov/pubmed?term=kongsap%20p%5bauthor%5d&cauthor=true&cauthor_uid=22435252 microsoft word final ammended editorial 1 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology editorial restructuring of pakistan journal of ophthalmology the primary objective of the ophthalmic society of pakistan is promotion of education and science in the field of ophthalmology. the pakistan journal of ophthalmology is the principal tool through which the second objective is to be attained. to achieve this objective the pjo has to adapt and change. the cause of science in pakistan will be served if the pjo gets recognition in national and international databases and builds the impact factor of the journal. to meet these objectives pakistan journal of ophthalmology has been undergoing evolutionary changes for the last few years. to improve the impact factor and get accreditation the pjo needed to become an electronic journal, recruit competent peer review members and establish standard operating procedures (sop) for publishing. some of the objectives have been met and some will be accomplished in the next few years. pjo was started in nov 1968 in lahore and the first editor in chief was prof. raja mumtaz. later it was published by khalid j awan from 1985 – 1993 from usa. finally it was restarted in pakistan by prof. lateef chaudhry in 1993. the journal has always been a precious jewel of the society and all the members want it to progress rapidly over the next few years and to be recognized by the higher education commission of pakistan and medline. a lot of systematic steps need to be taken before this can be accomplished. this was apprehended by the prof. lateef, the ex chief editor of pjo, and the president of the osp, dr. mazhar qayyum. the first pre-requisite was establishment of a transparent process of selecting the next editor in chief. this procedure was established and by consensus of the central council of the ophthalmological selected prof. syed ali haider as editor in chief for a fixed term of 4 years. a new chief editor will be appointed by the central council after this period is over. the journal is published quarterly with 10 original articles, 1 case report and abstracts from other journals. this has been made electronic with the following features. current issue and archives for the last 10 years are available for preview as abstracts and full text articles in html and pdf formats. a very useful search engine has been included which will let anybody search the pjo for articles by giving the name of the author or title of the article. the peer review committee is helping us finalize more articles for printing so we have introduced a section showing these finalized articles as published ahead of print. in the future we plan to make this a bimonthly journal with the support of local and international authors. a section for online submission and subscription application has been included. the instructions for authors section, has been edited and now pjo accepts articles only in electronic format. the next big task was to recruit competent peer review members to improve and hasten the review process of articles submitted for publication. this has been accomplished in part by selection of peer review faculty from all teaching hospitals across pakistan. we are planning to hold sessions in all the national meetings to interact with the faculty so that the process of article review can be standardized. invitations have been sent to many international authors to become members of the peer review committee. a standard operating procedure for all submitted articles has been established over the last 2 years after hiring a dedicated desk manager for the journal. as soon as the article is submitted an acknowledgment letter is sent to the author. the paper goes through initial screening and in the next few months we will put it through anti-plagiarism software. at this stage the article can be rejected outright if does not meet the minimum acceptance criteria. later it undergoes peer review by 2 members who will certify it for acceptance or rejection with comments for improvement of the article. we plan to hire a statistician to check for all the calculations in the journal. once the article has been corrected by the author, the final go ahead for printing is given by the editor and editor in chief. the articles that are not accepted by reviewers are sent to a senior peer review committee for final assessment. their prof. muhammad moin pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 2 verdict on the fate of an article is considered final. the accepted articles are uploaded as published ahead of print and are also sent to the publisher for hard copy publication. hard copies are circulated to all the members through mail. at the same time all members of the osp are sent an e. mail alert by using a dedicated member database of all the members of the osp. the task of generation of funds, printing, posting, maintenance of a database of subscribers and management of the staff falls with the office of the managing editor, held by prof nadeem h. butt. constant improvement is being made to improve the quality of print of the journal. every life member of the osp is entitled to receive a copy of the journal, which is a huge drain on finances of the journal. it is expected of all members to notify the office of the journal of any change in address. pjo has now been approved by the pakistan medical and dental council and listed in doaj (open access database), index copernicus and open j gate. application for approval by the higher education commission of pakistan has been submitted. we are constantly trying to improve the impact factor of the journal by improving the quality of articles, selection of articles from all sub-specialties, improve citation of pjo articles in other journals and improve access of full articles. the next step would be to improve the quality of research being done in the field of ophthalmology. the editors of the pjo send extensive feedback to the authors to help them improve their articles and their writing skills. the osp has taken an important step in this regard by creating a research foundation, which offers financial help to conduct research proposals. in conclusion restructuring of the pjo is important for national and international recognition of the journal. moreover it will provide a forum for national research and develop a research culture. prof. muhammad moin 223 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology original article comparison of changes in intraocular pressure after subtenon and peribulbar local anaesthesia for phacoemulsification sher akbar khan, mir ali shah,ibrar hussain, faisal nawaz, mumtaz alam pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. mir ali shah department of ophthalmology, lady reading hospital peshawar, pakistan. e-mail:drmashahpsh@hotmail.com …..……………………….. purpose: to compare the changes in intraocular pressure after subtenon and peribulbar local anesthesia in patients undergoing phacoemulsification. study design: prospective interventional case series. place and duration of study: the study was conducted at the department of ophthalmology, khyber teaching hospital peshawar. the duration of study was one year i.e. from october 2009 to october 2010. materials and methods: the patients were divided into two groups. group “a” received subtenon anesthesia and group “b” received peribulbar anesthesia. intraocular pressure was measured just before, after 1 minute and 10 minutes after the administration of anesthesia. all the data were recorded on a proforma. spss-20 was used for data analysis. results: there were 152 patients in each group. the 2 groups were similar in terms of age (p value = 0.83) and gender (p value = 0.73). there was no difference in mean intraocular pressure between two groups just before injection (p value = 0.72). there was a greater rise in mean intraocular pressure just after injection in group “b” as compared to group “a” (p value < 0.0001); in both groups the mean intraocular pressure declined to its base level after 10 minutes of injection (p value = 0.52). conclusion: subtenon anesthesia leads to little rise in intraocular pressure as compared to peribulbar anesthesia immediately after the injection. however 10 minutes after injection the intraocular pressure declines to its base level in both groups. key words: subtenon anaesthesia, peribulbar anaesthesia, intraocular pressure. ataract is the leading cause of avoidable blindness in the world1, and accounts for over half of the causes of blindness in pakistan2.cataract surgery can be carried out under general or local anesthesia. due to unwanted effects of general anesthesia3 local anesthesia is preferred by most surgeons and patients for cataract surgery; the latter having good analgesia and quick recovery4. local anesthesia includes topical anesthesia and regional anesthesia. topical anesthesia affects only the nerve endings of the trigeminal nerve in the cornea and conjunctiva so akinesia of the globe will not be achieved. therefore, surgical training and good patient cooperation is required for safe use of topical anesthesia5. one type of regional anesthesia is peribulbar which is performed by injecting the anesthetic solution in the orbit around the equator of the eye ball (outside the muscle cone) using sharp needle6 and the other is subtenon anesthesia which involves the use of blunt canula7. serious complications such as sight threatening globe perforation and life threatening brainstem depression c comparison of changes in intraocular pressure after subtenon and peribulbar local anaesthesia pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 224 have a 2.5 fold greater risk in sharp needle techniques (peribulbar, retrobulbar) as compared with subtenon block8. subtenon block has 2.3 times more risks of minor complications like subconjuctival haemorrhages and conjunctival chemosis8. the goal of ideal local anesthesia is to obtain complete anesthesia and akinesia of the eye ball and low intraocular pressure in order to provide optimal surgical conditions9. this study was aimed at comparing the changes in intraocular pressure after subtenon and peribular local anaesthesia in patients undergoing cataract surgery. material and methods this prospective interventional study was conducted in the department of ophthalmology khyber teaching hospital peshawar. the duration of study was one year i.e. from october 2009 to october 2010. before starting the study, approval was taken from the ethical review board of the hospital. patients admitted to eye unit for cataract surgery in the age group between 50 – 70 years were included in the study.patients with uncontrolled diabetes mellitus, glaucoma or ocular hypertension, systemic hypertension, carotid stenosis, anterior chamber abnormalities, hypersensitivity to lignocaine, uncooperative patients like mentally retarded, history of convulsions or epilepsy and on topical systemic antihypertensive medicine were excluded from the study. written informed consent was taken from all the patients. the cases were randomly divided into two groups as group “a” and group “b”. patients in group “a” received subtenon anesthesia and in group “b” received peribulbar anesthesia. digital compression was started after anesthesia administration and continued for 10 minutes with interval for 10 seconds after every 2 minutes. all procedures were performed by a single and experienced surgeon. intraocular pressure (iop) was measured with perkins tonometer (clement clarke london) just before, one minute after and 10 minutes after the anesthesia administration in lying position. all the data were recorded on a predesigned proforma. spss 20.0 was used for data analysis. descriptive statistics like mean and standard deviation were calculated for age and iop while frequencies and percentages were calculated for gender. p-value was generated using student t-test for comparison of iop after both types of anesthesia procedures. p-value of <0.05 was considered significant. results there were 152 patients in each group. mean age for group “a” was 59.74 ± 5.58 years and for group “b” it was 59.88 ± 5.91 years (p value = 0.83). in group “a” there were 79 (52%) females and 73 (48 %) males and in group “b” there were 77 (50.7%) female and 75 (49.3%) male (p value = 0.73). there was no significant difference in mean iop in the two groups just before the administration of anesthesia (p value = 0.72). one minute after anesthesia the iop increased to 14.99 ± 1.25 mmhg in group “a” and 17.37 ± 1.28 mmhg in group “b” (p value < 0.0001). so the difference between the mean iop of both groups 1 minute after injection was statistically significant. however after 10 minutes of injection the mean iop returned to its base level in both groups and there was no significant difference in mean iop in both groups after 10 minutes (p value = 0.52), as shown in table 1. table 1: comparison of intraocular pressure between two groups. group “a” mean ± sd group “b” mean ± sd p value iop just before anesthesia 12.16 ± 1.23 mmhg 12.11 ± 1.22 mmhg 0.72 iop 1 minute after anesthesia 14.99 ± 1.25 mmhg 17.37 ± 1.28 mmhg <0.0001 iop 10 minute after anesthesia 11.97 ± 1.22 mmhg 11.88 ± 1.25 mmhg 0.52 iop: intraocular pressure. group “a” subtenon anesthesia. group “b” peribulbar anesthesia. discussion ophthalmic surgery is one of the most frequent surgical procedures requiring anesthesia in developed countries10. in the past most of the cataract surgeries used to be performed under general anesthesia.11 with the passage of time, new advances and developments in the cataract surgeries were made. the time of surgery was reduced and incision became smaller and now most of the surgeries are performed under safe and effective means of local anesthesia12 and hence the unwanted effects of general anesthesia are obviated with the use of local anesthesia3. there are different techniques of local anesthesia available for cataract surgeries. topical anesthesia10,13 sher akbar khan, et al 225 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology is free of serious and life threatening complications and can be used in selected cases14, however it lacks akinesia and a possible association between topical anesthesia and endophthalmitis has also been noted.15patients undergoing cataract surgery under topical anesthesia experience more postoperative pain and discomfort as compared to those receiving subtenon anaesthesia16. subconjunctival block is pain free17 provides anesthesia to the anterior segment and is not very popular18. needle blocks like peribulbar and retrobulbar anesthesia provides excellent analgesia and akinesia however serious and life threatening complications can occur with these procedures. therefore, these techniques require intravenous lines and presence of anesthetist and can be performed under the supervision of senior and experienced ophthalmic surgeon as suggested by joint report of royal college of anesthesia and royal college of ophthalmologists.19subtenon technique is safe, effective and painless and is perfect block20,21. there is a statistically significant increased risk of serious complications with sharp needle anesthesia compared with subtenon technique8. an ideal anesthetic technique must be safe from serious complications, effective in terms of providing good akinesia and analgesia and must not elevate intraocular pressure in order to provide optimal surgical conditions. in this study we compared the changes in iop after subtenon and peribulbar local anesthesia in patients undergoing cataract surgery. iop was measured with perkins tonometer just before, one minute after and 10 minutes after the anesthesia administration in lying position. iop measured just before and then 1 minute after administration of anesthesia revealed that there was a greater increase in mean iop just after anesthesia administration in group “b” as compared to group “a”. mean iop just before anesthesia in group “a” was 12.16 ± 1.23 mm hg which increased to 14.99 ± 1.25 mm hg 1 minute after injection. mean iop just before anesthesia in group “b” was 12.11 ± 1.22 mmhg which increased to 17.37 ± 1.28 mmhg 1 minute after injection. so comparing the difference between the mean iop before and 1 minute after administration of anesthesia there was a significant rise of mean iop in group “b” as compared to group “a” (p value < 0.0001). this is comparable with the results of other study in which there was a significant rise in iop following the peribulbar injections (median rise 0.5 mmhg sub-tenon’s method, 3.5 mmhg peribulbar method, p = 0.02) but for both methods, iop fell to a similar level at 5 min after use of the pressure lowering device22. another study showed that one minute after the injection, iop increased significantly in the peribulbar group (mean 7.97 mm hg ± 8.80 [sd]) (p< .05). there was no significant increase in the sub-tenon’s injection group (mean 0.12 ± 3.09 mm hg). in both groups, iop returned to pre-injection levels by 10 minutes postoperatively. the mechanism of this increase in iop may be attributed to the restricted orbital space in which a larger volume of anesthetic solution is injected.23 in both groups mean iop declined to the base level 10 minute after anesthesia administration i.e. in group “a” iop decreased to 11.97 ± 1.22 mmhg and in group “b” it decreased to 11.88 ± 1.25 mmhg. thus, 10 minute of anesthesia administration, there was no significant difference in the intraocular pressure in both groups (p value = 0.52), which is comparable with other studies.22,23 therefore both groups have equally optimal surgical conditions. with peribulbar anesthesia the iop may be elevated to the level, although for a short time, sufficient to cause reduction in pulsatile ocular blood flow which may cause potential problems for the patient with ocular vascular compromise24. conclusion peribulbar anesthesia leads to significant rise in intraocular pressure as compared to peribulbar anesthesia immediately after the injection. however, 10 minutes after injection the intraocular pressure declines to its base level in both groups. author’s affiliation dr. sher akbar khan principal author fcps district ophthalmologist saidu teaching hospital, swat. dr. mir ali shah (corresponding author) fcps, ico (retina) associate professor of ophthalmology, lady reading hospital peshawar. prof ibrar hussain fcps, frcs chairman department of ophthalmology, khyber teaching hospital peshawar comparison of changes in intraocular pressure after subtenon and peribulbar local anaesthesia pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 226 dr. faisal nawaz fcps, vr fellow lrh lady reading hospital peshawar. dr. mumtaz alam fcps, consultant ophthalmologist ksa. role of authors dr. sher akbar khan concept and design, data collection/assembly. dr. mir ali shah (corresponding author) concept and design, drafting, statistical expertise, critical revision. prof ibrar hussain concept and design, critical revision. dr. faisal nawaz drafting, statistical expertise dr. mumtaz alam data collection/assembly. references 1. hening a, kumar j, yonston d, foster a. sutreless cataract surgery with nucleus extraction: outcome of prospective study in nepal. br j ophthalmol. 2003; 87: 266-70. 2. dineen b, bourne rra, jadoon z, shah sp, khan ma, foster a,gilbert ce, khan md. causes of blindness and visual impairment in pakistan: the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91: 1005-10. 3. friedman ds, reeves sw, bass eb, lubomski lh, fleisher la, schein od. patient preferences for anesthesia management during cataract surgery. br j ophthalmol. 2004; 88: 333-5. 4. parker t, gogate p, deshpande m, adenwala a, maske a. comparison of subtenon anesthesia with peribulbar anesthesia for manual small incision cataract surgery. indian j ophthalmol. 2005; 53: 255-9. 5. ahmad s. cataract surgery: is it time to convert to topical anaesthesia? pak j ophthalmol. 2008; 24 (2): 627. 6. alhassan mb, kyari f, ejere ho. peribulbar versus retrobulbar anaesthesia for cataract surgery. the cochrane database of systematic reviews, 2008 (3): cd004083. 7. chandra mk, timothy cd. complications of ophthalmic regional blocks: their treatment and prevention. ophthalmologica. 2006; 220: 73-82. 8. el-hindy n, johnston rl, jaycock f, eke t, brage aj, tole dm et al. the cataract national database electronic multi-centre audit of 55567 operations: anaesthetic techniques and complications. eye, 2009 jan; 23 (1): 50-5. 9. olmez g, cakmar ss, caca i, unlu mk. iop and quality of blockade in peribulbar anesthesia using ropivacaine or lidocaine with adrenaline: tohokuj. exp med j. 2004; 204: 203-8. 10. leaming dv. practice styles and preferences of ascrs members-2003 survey. j cataract refract surg. 2004 apr; 30 (4): 892-900. 11. hodgkins pr, luff aj, morrell aj, botchway lt, featherston tj, fielder ar. current practice of cataract extraction and anaesthesia. br j ophthalmol. 1992; 76: 323-6. 12. navaleza js, pendse sj, blecher mh. choosing anesthesia for cataract surgery. ophthalmol clin north am. 2006 jun; 19 (2): 233-7. 13. rocha g, turner c. safety of cataract surgery under topical anesthesia with oral sedation without anesthetic monitoring. can j ophthalmol. 2007; 42: 288-94. 14. ahmad s, ahmad a. complications of ophthalmologic nerve blocks: a review. j clin anesth. 2003 nov; 15 (7): 564-9. 15. garcia-arumi j, fonollosa a, sararols l, fina f, martínez-castillo v, boixadera a, zapata ma, campins m. topical anesthesia: possible risk factor for endophthalmitis after cataract extraction, 2007 jun; 33 (6): 989-92. 16. srinivasan s, fern ai, selvaraj s, hasan s. randomized double-blind clinical trial comparing topical and sub-tenon's anaesthesia in routine cataract surgery. br j anaesth. 2004 nov; 93 (5): 683-6. 17. kaderali b, avei r. comparison of topical and subconjunctival anesthesia in intravitreal injection administration. eur j ophthalmol. 2006; 16 (5): 718-20. 18. saeed n, nasir n, khan md. subconjunctival anesthesia in trabeculectomy, an experience with 80 cases. jopgmi. 2005; 19 (2): 166-70. 19. local anaesthetic for intraocular surgery. joint report by the royal college of anaesthetists and the royal college of ophthalmologists. rcoa and rcopht london, 2001. 20. canavan ks, dark a, garrioch ma. sub-tenon’s administration of local anaesthetic: a review of the technique. br j anaesth. 2003; 90: 787-93. 21. guise pa. sub-tenon anesthesia: a prospective study of 6,000 blocks. anesthesiology, 2003; 98: 964-8. 22. budd m, brown jpr, thomas j, hardwick m, mcdonald p, barber k. a comparison of subtenon’s with peribular anaesthesia in patients undergoing sequential bilateral cataract surgery. anaesthesia, 2009; 64: 19-22. 23. azmon b, alster y, lazar m, geyer o. effectiveness of sub-tenon’s versus peribulbar anesthesia in extracapsular cataract surgery. j cataract refract surg. 1999; 25: 1646-50. 24. watkins r, yates m, chang b, linardos e. intraocular pressure and pulsatile ocular blood flow after retrobulbar and peribulbar anaesthesia. br j ophthalmol. 2001; 85: 796-8. https://www.ncbi.nlm.nih.gov/pubmed/?term=gilbert%20ce%5bauthor%5d&cauthor=true&cauthor_uid=17229806 https://www.ncbi.nlm.nih.gov/pubmed/?term=khan%20md%5bauthor%5d&cauthor=true&cauthor_uid=17229806 javascript:al_get(this,%20'jour',%20'j%20cataract%20refract%20surg.'); http://www.ncbi.nlm.nih.gov/pubmed?term=%22navaleza%20js%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22pendse%20sj%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22blecher%20mh%22%5bauthor%5d javascript:al_get(this,%20'jour',%20'ophthalmol%20clin%20north%20am.'); javascript:al_get(this,%20'jour',%20'ophthalmol%20clin%20north%20am.'); javascript:al_get(this,%20'jour',%20'ophthalmol%20clin%20north%20am.'); http://www.jcrsjournal.org/article/s0886-3350(07)00458-0/abstract## http://www.jcrsjournal.org/article/s0886-3350(07)00458-0/abstract## http://www.jcrsjournal.org/article/s0886-3350(07)00458-0/abstract## http://www.jcrsjournal.org/article/s0886-3350(07)00458-0/abstract## http://www.jcrsjournal.org/article/s0886-3350(07)00458-0/abstract## https://www.ncbi.nlm.nih.gov/pubmed/?term=zapata%20ma%5bauthor%5d&cauthor=true&cauthor_uid=17531691 https://www.ncbi.nlm.nih.gov/pubmed/?term=campins%20m%5bauthor%5d&cauthor=true&cauthor_uid=17531691 http://bja.oxfordjournals.org/search?author1=s.+srinivasan&sortspec=date&submit=submit http://bja.oxfordjournals.org/search?author1=s.+selvaraj&sortspec=date&submit=submit http://bjo.bmj.com/search?author1=russell+watkins&sortspec=date&submit=submit pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 95 original article efficacy of intra-vitreal bevacizumab for resolution of macular edema secondary to central retinal vein occlusion muhammad younis tahir, afshan ali pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad younis tahir ophthalmology department bvh/qamc, bahawalpur …..……………………….. purpose: to determine the efficacy of intravitreal injection of bevacizumab in resolution of macular edema in patients of central retinal vein occlusion. material and methods: it was a descriptive case series, conducted at institute of ophthalmology unit iii, mayo hospital lahore and bahawal – victoria hospital bahawalpur simultaneously. a total of 60 cases were selected though purposive sampling for this study. diagnosis was ascertained on fundus fluorescein angiography. pre and post injection macular edema was measured on optical coherence tomography on the day of drug administration and thirty days after it. results: mean macular thickness before treatment was 663.10 ± 109.76 microns and after treatment mean thickness was 453.06 ± 106.09 microns which was a significant (p = 0.0000001) finding. majority (75%) of patients achieved a reduction of ≥ 200 microns in their retinal thickness after treatment. whereas in the remaining 15 (25%) patients reduction in retinal thickness was < 200 microns. these findings were independent of gender bias. conclusion: intravitreal injection of bevacizumab is effective in the resolution of macular edema in the patients of central retinal vein occlusion. key words: central retinal vein occlusion, macular edema, bevacizumab. entral retinal vein occlusion (crvo) is the second most common retinal vascular disorder1 with incidence of 0.5% and prevalence of 1.3%.1,2 it is thought to be caused by thrombus formation in at the level of lamina cribrosa.3 crvo is characterized by edema of the optic nerve, retinal hemorrhages and marked vascular dilatation and tortuosity.4 fluorescein angiography is used as a diagnostic tool for crvo and it also classifies it into ischemic and non-ischemic types on the basis of degree of retinal capillary non perfusion.5 ischemia induces a rise in intraocular levels of vascular endothelial growth factor (vegf)6 – a cytokine which not only increases vascular permeability which leads to macular edema but also stimulates endothelial cell hypertrophy, thus reducing the capillary lumen, causing more ischemia and perpetuating further edema.7 if left untreated, persistent macular edema, macular ischemia and neovascular glaucoma can lead to visual morbidity and blindness.2,8 to date, no effective and safe therapy has been found for macular edema secondary to central retinal vein occlusion. intravitreal injection of steroids such as triamcinolone acetonide initially showed some promising results but later it was found to be associated with unacceptable ocular complications.4 bevacizumab is a monoclonal antibody that inhibits vegf and has been advocated to facilitate resolution of macular edema by breaking vegf cycle which is critical for perpetuating macular edema in the setting of crvo as a famous study7 has shown a decrease of 200 microns in macular thickness from baseline in at least one third of patients, one month after the injection. in another study, in addition to all these changes, significant reduction in venous dilation, tortuosity, optic disc swelling was also found.9 c muhammad younis tahir, et al 96 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology current study was the first of its kind in local population of punjab, pakistan to explore the efficacy of this drug in resolving macular edema due to central retinal vein occlusion. it has also provided data for comparison with the results from studies being conducted across the globe. material and methods it was a descriptive case series, conducted at institute of ophthalmology unit iii, mayo hospital lahore and bahawal – victoria hospital simultaneously. a total of 60 cases central retinal vein occlusion were selected after informed written consent of patients and approval of institutional ethics committee. sample size was selected though purposive sampling technique through following criteria; inclusion criteria  both genders.  age more than or equal to 20 years.  central retinal vein occlusion in one eye of the patients diagnosed on fluorescein angiography as per operational definition.  macular edema of equal to or more than 300 microns at baseline confirmed by optical coherence tomography. exclusion criteria  previously treated according to history.  cases of increased intraocular pressure (more than 21mm hg) evidenced by applanation tonometry.  filtration surgery, corneal transplantation, cataract surgery three months prior to baseline assessed on slit lamp examination.  diabetic retinopathy in rapid progression confirmed by fluorescein angiography.  vitreous hemorrhage seen on ultrasonography.  pregnancy according to ultrasound findings. the diagnosis of central retinal vein occlusion was made if delayed arteriovenous transit time (more than 12 seconds), blockage by hemorrhages, good retinal capillary perfusion (non-ischemic type), capillary non perfusion (ischemic type) and leakage was observed on fluorescein angiography. macular edema was defined as retinal thickness of more than or equal to 300 microns confirmed by the presence of intra-retinal cysts in the central macular area on optical coherence tomography (oct). the main outcome measure was efficacy of bevacizumab which was defined in terms of resolution of macular edema on oct measured in microns. edema was considered resolved if the decrease in retinal thickness is equal to or more than 200 microns from the baseline measurement after one month of giving injection. demographic information like name, age and gender was recorded. pre and post treatment macular edema was measured by optical coherence tomography. all the information collected was noted on a special proforma attached. all patients received ciprofloaxacin antibiotic drops for three days pre and post treatment. intravitreal injection of 1.25 mg bevacizumab in 0.05 ml total volume was given via superior pars plana area, under aseptic condition after topical anesthesia of lidocaine. to avoid bias the whole procedure was done by a single skilled surgeon and all the observations were recorded by a single observer. follow up was done after one month and documenting the post treatment macular edema on optical coherence tomography. final reading was taken at the end of one month. complications if any, were dealt with accordingly. results males (n = 36, 60%) and females (n = 24, 40%) having mean age of 58.83 ± 9.33 and 58.75 ± 8.19 years respectively having macular edema due to crvo were treated with intravitreal injection of bevacizumab. mean macular thickness before and after treatment was 663.10 ± 109.76 and 453.06 ± 106.09 microns respectively as shown in table 1 and fig. 1. macular thickness before treatment among male and female patients was 667.27 ± 108.30 and 656.83 ± 113.96 microns. after treatment mean macular thickness among male and female patients was 463.30 ± 106.03 and 437.70 respectively. it was clear after treatment significant reduction in macular thickness was observed as shown in table 2 and fig. 2. efficacy criteria was set as decrease in retinal thickness ≥ 200 microns. keeping in mind this criteria there were 45 (75%) patients in which retinal thickness decrease from baseline was ≥ 200 microns after treatment. whereas the remaining 15 (25%) patients retinal thickness was < 200 microns showing no efficacy of treatment for these patients. among male patients efficacy of treatment (retinal thickness ≥ 200 microns) was observed among 25 (69.4%) whereas among female patients efficacy of treatment was observed in 20 (83.3%) patients as shown in table 3 efficacy of intra-vitreal bevacizumab for resolution of macular edema secondary to central retinal vein pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 97 and fig. 3. pre and post-operative out of 2 patients are shown in fig. 4 and 5. discussion a definite therapeutic target for central retinal vein muhammad younis tahir, et al 98 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology fig. 1: macular thickness on oct before and after treatment. fig. 2: macular thickness on oct (microns) before and after treatment; comparison of resolution between two genders. occlusion has yet to be proclaimed. much focus has been given to treat macular edema which arises secondarily in the setting of crvo and causes markedly diminished and visual acuity.10 among the various treatment modalities that have been tried, many discarded either due to therapeutic failure or due to systemic or local complications were associated with their use, these included vitrectomy, radical optic neurotomy etc.11,12 however, intra-vitreal injection of anti-angiogenic monoclonal antibody bevacizumab has shown promising results without any major adverse effects. current study was an effort to investigate the repeatability and reliability of this claim in local circumstances, to validate the findings of previous similar reports and to add more data into an emerging area of wider interest where previous publications have in fact demanded further studies. fig. 3: efficacy of treatment with respect to gender of patients. fig. 4: after and before treatment (oct). we observed that mean macular thickness before treatment was 663.10 ± 109.76 microns which was reduced to a mean macular thickness of 453.06 ± 106.09 microns after the treatment, which means almost 1/3rd reduction in simple arithmetic terms and highly significant in statistical terms thus proving the efficacy of the bevacizumab for the treatment of macular edema. current study also shows that after one month of giving intra-vitreal bevzcizumab, there is significant decrease in retinal thickness. this efficacy of intra-vitreal bevacizumab for resolution of macular edema secondary to central retinal vein pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 99 fig. 5: after and before treatment oct. decrease is more than or equal to 200 microns from the baseline value which fulfills our efficacy criteria for bevacizumab in cases of macular edema secondary to crvo. a total number of 60 patients were included in the study. out of those, 75% patients showed a reduction of more than 200 microns in their retinal thickness from its baseline value. while in 25% patients the decrease in retinal thickness was less than 200 microns. as for the gender distribution, macular thickness before treatment among male and female patients was 667.27 ± 108.30 and 656.83 ± 113.96 microns. after treatment mean macular thickness among male and female patients was 463.30 ± 106.03 and 437.70 respectively. similarly, 69.3% men and 83.3% women with macular edema were found to achieve a reduction of > 200 microns in the retinal thickness. these findings show that the results were apparently more favorable in women however it was statistically not significant and we can say that our results were independent of gender. manayath et al., included 15 patients of retinal vein occlusion developing macular edema who were serially evaluated with best corrected visual acuity (bcva), optical coherence tomography (oct), fluorescein angiography, and tonometry. mean followup was 12 ± 3.6 months (range, 6 18 months); mean number of injections was 2.2 (range, 1 4) per patient. they found statistically significant reduction of macular thickness (p < 0.001) at six weeks (mean, 346 μ); three months (mean, 353 μ); six months (mean, 348 μ); and final follow-up (mean, 342 μ) and thus concluded that intravitreal bevacizumab is effective for resolution of macular edema.13 another recent study by thapa et al., also found similar results.14 epstein et al. used different outcome measures for the trial of bevacizumab. their primary outcome measure was the proportion of patients gaining at least 15 letters at 12 months. secondary outcome measures included mean change from baseline bestcorrected visual acuity (bcva), change in foveal thickness, and development of neovascular glaucoma and they also found intra-vitreal injection of bevacizumab an effective therapy for the macular edema secondary to crvo.15 these studies mentioned above show comparable findings. however, current study has larger sample size which makes our results more reliable as most of the other studies done on intravitreal bevacizumab have a very small sample size. in south east asian region, not much research is done on role of bevacizumab in cases of central retinal vein occlusion. so this study provides valuable data for treatment and further research on patients of crvo. there are a few limitations of our study as well. we are studying the effect of intravitreal bevacizumab on macular thickness one month after its administration. although macular thickness shows a significant decrease in thickness i.e. 200 microns but in many cases residual thickness is still more than 300 microns, which means there might be need for further injections. further study needs to be done on effects of multiple injections of intravitreal bevacizumab in cases of crvo. many studies have reported results of three intravitreal injections of bevacizumab given on monthly basis in these patients. in our region research need to be carried out regarding this, and the possible adverse effects of long term administration of injection bevacizumab. conclusion our study demonstrates that intra-vitreal injection of anti vegf agent bevacizumab is effective in resolution of macular edema in patients of central retinal vein occlusion. muhammad younis tahir, et al 100 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology author’s affiliation dr. afshan ali ophthalmology department bvh / qamc, bahawalpur dr. muhammad younis tahir fellowship in vitreo-retina assistant professor ophthalmology department bvh / qamc, bahawalpur references 1. ehlers jp, fekrat s. retinal vein occlusion: beyond the acute event. survey of ophthalmology. 2011; 56: 28199. 2. mohamed q, macintosh rl, saw sm wong ty. interventions for central retinal vein occlusion: an – evidence based systematic review. ophthalmology, 2007; 114: 507-19. 3. pieramici dj, rabena m, castellarin aa, nasir m, see r, norton t, sanchez a, risard s, avery rl. ranibizumab for the treatment of macular edema associated with perfused central retinal vein occlusions ophthalmology, 2008; 115: e47-54. 4. kinge b, stordhal pb, forsaa v, fossen k, haugstad m, helgesen oh, seland j, stene-johansen i. efficacy of ranibizumab in patients with macular edema secondary to central retinal vein occlusion: results from the sham – controlled rocc study. am j ophthalmol. 2010; 150: 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http://www.ncbi.nlm.nih.gov/pubmed/?term=cheung%20n%5bauthor%5d&cauthor=true&cauthor_uid=20430446 http://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20jj%5bauthor%5d&cauthor=true&cauthor_uid=20430446 http://www.ncbi.nlm.nih.gov/pubmed/?term=mitchell%20p%5bauthor%5d&cauthor=true&cauthor_uid=20430446 http://www.ncbi.nlm.nih.gov/pubmed/?term=kowalski%20jw%5bauthor%5d&cauthor=true&cauthor_uid=20430446 http://www.ncbi.nlm.nih.gov/pubmed/?term=nguyen%20hp%5bauthor%5d&cauthor=true&cauthor_uid=20430446 http://www.ncbi.nlm.nih.gov/pubmed/?term=wong%20ty%5bauthor%5d&cauthor=true&cauthor_uid=20430446 http://www.ncbi.nlm.nih.gov/pubmed/?term=nguyen%20qd%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=ying%20h%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=do%20dv%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=quinlan%20e%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=zimmer-galler%20i%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=haller%20ja%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=haller%20ja%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=haller%20ja%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=solomon%20sd%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=sung%20ju%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=hadi%20y%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=janjua%20ka%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=jawed%20n%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=jawed%20n%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=jawed%20n%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=choy%20df%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=arron%20jr%5bauthor%5d&cauthor=true&cauthor_uid=18362932 http://www.ncbi.nlm.nih.gov/pubmed/?term=arruabarrena%20c%5bauthor%5d&cauthor=true&cauthor_uid=20679089 http://www.ncbi.nlm.nih.gov/pubmed/?term=thorne%20je%5bauthor%5d&cauthor=true&cauthor_uid=25576994 http://www.ncbi.nlm.nih.gov/pubmed/?term=rodriguez%20fj%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=dalma-weiszhausz%20j%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=dalma-weiszhausz%20j%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=quiroz-mercado%20h%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=morales-canton%20v%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=roca%20ja%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=berrocal%20mh%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=graue-wiechers%20f%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=robledo%20v%5bauthor%5d&cauthor=true&cauthor_uid=18779709 http://www.ncbi.nlm.nih.gov/pubmed/?term=colina-luquez%20j%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=fromow-guerra%20j%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=jim%c3%a9nez-sierra%20jm%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=guerrero-naranjo%20jl%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=morales-cant%c3%b3n%20v%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=morales-cant%c3%b3n%20v%5bauthor%5d&cauthor=true&cauthor_uid=15943889 http://www.ncbi.nlm.nih.gov/pubmed/?term=wali%20uk%5bauthor%5d&cauthor=true&cauthor_uid=20671833 133 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology original article complications of nd: yag laser capsulotomy bilal khan, mumtaz alam, mir ali shah, bilal bashir, asif iqbal, adnan alam pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mumtaz alam house no 310, street 5, sector e-4, phase 7 hayatabad peshawar e-mail: drmumtazalam@gmail.com …..……………………….. purpose: to evaluate the complications of nd: yag laser capsulotomy. material and methods: it was a prospective study conducted from may 2012 to may 2013 at khyber eye foundation peshawar. 437 eyes of 406 patients were included in the study. before performing yag laser detailed history was taken and complete ocular examination was performed. a consultant ophthalmologist performed all yag laser capsulotomies. follow up was done at 1 day, 1, 2 and 4 weeks. detail eye examination was performed at each visit to look for any complications. results: out of the 406 patients 189 (46.55%) were male and 217 (53.44%) were female. mean age of the patients was 56.7 years. a variety of complications were noted after yag laser capsulotomy. intraocular lens pitting was the most common complication seen in 56 eyes (12.81%). transient rise of intraocular pressure was seen in 38 eyes (8.69%) and cystoid macular edema was seen in 17 eyes (3.89%). serious complications such as retinal detachment and endophthalmitis were seen in 2 eyes (0.45%) and 1 eye respectively (0.22%). conclusion: a number of complications can occur after nd: yag laser capsulotomy. the most common of these complications are intraocular lens pitting, transient intraocular pressure elevation and cystoid macular edema. key words: intraocular lens, capsulotomy, cystoids macular edema. ataract is responsible for over half of blindness worldwide.1 cataract surgery is the most commonly performed ocular surgery. posterior capsule opacification (pco) is one of the most common late complications of cataract surgery.2 in one study the frequency of pco after cataract surgery was 1.6%, 12.3% and 26.5% at 1, 2 and 3 years respectively.3 pco results from migration and proliferation of residual lens epithelial cells in the capsular bag after cataract surgery, to produce elschnig’s pearls or fibroblastic transformation causing capsular fibrosis.4 it causes gradual deterioration of visual function by obstructing or by scattering the light rays resulting in decreased visual acuity, decreased contrast sensitivity, glare or even monocular diplopia.5,6 it also decreases the field of view during therapeutic and diagnostic procedures.7 the current treatment of choice for pco is neodymium doped: yttrium-aluminum-garnet (nd: yag) laser capsulotomy. it is relatively safe, gives instantaneous results and can easily be administered in an out-patient setting.08 the nd: yag laser is solid type of laser, causes disruption of tissues by ionization mode of action. it has 1064nm wave length, with infrared radiation. it is a powerful continuous wave laser which is usually q switched when used to treat the eye. the 1064nm wavelength is invisible and requires a he-ne laser red aiming beam.09 a number of complications can occur after yag laser capsulotomy such as elevation of intraocular pressure, rupture of anterior vitreous face, damage to intra ocular lens, hyphema, acute iritis, and cystoid macular edema (cmo).10,11 unusual complications include corneal endothelial damage,12 macular hole,13 vitreous hemorrhage,10 retinal detachment,08 macular hemorrhage,14 and endophthalmitis.15 c complications of nd: yag laser capsulotomy pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 134 nd: yag laser posterior capsulotomy is a frequently performed procedure in any ophthalmology department. the purpose of this study was to find out the complications of nd: yag laser capsulotomy in our set up. material and methods it was a prospective study conducted over a period of 1 year (from may 2012 to may 2013) at khyber eye foundation peshawar. a total of 406 patients (437 eyes) were included in the study. inclusion criteria 1. patients who had decreased vision due to posterior capsular opacification 2. more than 6 months duration after cataract surgery with intraocular lens 3. age > 15 years 4. both genders exclusion criteria 1. uncooperative patients 2. previous history of retinal detachment or vitreoretinal surgery 3. glaucoma 4. uveitis 5. dislocated iol written informed consent was taken from all the patients. before performing yag laser detailed history was taken and complete ocular examination was performed including assessment of visual acuity using snellen’s vision chart, slit lamp examination, tonometry with goldmann applanation tonmeter and fundus examination with 90 d/ 78 d lens. topical anesthetic (0.5% proparacaine hydrochloride) drops were instilled in the conjunctival sac and abraham’s posterior capsulotomy lens was applied for proper focusing and stabilization of eyeball. a consultant ophthalmologist performed all nd: yag laser capsulotomies using single shot mode. the amount of energy and number of pulses were adjusted as required. post-laser topical diclofenac (4 times/ day for 1 week) was given to all patients. follow up was done at 1 day, 1, 2 and 4 weeks. detailed eye examination was performed at each visit including measurement of iop, anterior chamber examination, status of iol, vitreous and fundus examination. topical beta blocker therapy was started in eyes with raised iop. results a total of 406 patients were included in the study including 189 male (46.55%) and 217 female (53.44%). mean age of the patients was 56.7 years, with a range of 15-82 years. age distribution of patients is shown in (table 1). yag laser capsulotomy was performed in 1 eye in 375 patients and in both eyes in 31 patients. the number of eyes included in the study was 437. mean energy used was 4.1 mj/ pulse (range: 1.5 to 8.0 mj/ pulse). number of shots varied from 6 to 19 with a mean of 10.7. one or more complications were noted after yag laser capsulotomy in 82 eyes (table 2). intraocular lens pitting was the most common complication seen in 56 eyes (12.81%). transient elevation of intraocular pressure was seen in 38 eyes (8.69%) and cystoid macular edema was seen in 17 eyes (3.89%). serious complications such as retinal detachment (rd) and endophthalmitis were uncommon and were seen in 2 eyes (0.45%) and 1 eye (0.22%) respectively. bilal khan, et al 135 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology discussion yag laser capsulotomy is the treatment of choice for posterior capsular opacification. it is usually a safe procedure but it may sometime cause complications.08, 10-15 in our study, iol pitting was the most common complication seen in 56 eyes (12.81%). in one study iol damage was seen in 19.2% cases after yag laser capsulotomy.08 khan my et al found iol pitting in 22.4% cases,16 while in another study it was seen in 3.33% cases.17 although iol pitting is one of the common complications of yag laser capsulotomy, it is usually asymptomatic and doesn’t adversely affect the visual functions. in our study, posterior yag offset was used to reduce the risk of iol damage during the procedure, however the relation of iol pitting with the extent of posterior yag offset was not determined. the second most common complication of yag laser capsulotomy in our study was transient iop elevation, which was seen in 38 eyes (8.69%). the mean iop elevation was 7.4 mm hg above the baseline. the frequency of raised iop after yag laser capsulotomy is highly variable, ranging from 0.8%11 to 82%16 in different studies. however the iop elevation is usually transient. in our study, the iop was well controlled with topical beta blocker therapy (0.5% levobunolol twice daily) in all cases. in our study, cystoid macular edema was seen in 17 eyes (3.89%). in eyes with clinical suspicion, optical coherence tomography (oct) was performed to confirm the presence of cmo. in one study cmo was seen in 9.6%.08 in another study cmo was seen in 8.0% cases,20 while in another study it was seen in 0.2% cases.11 anterior uveitis was seen in 05 eyes (1.14%) in our study. in one study anterior uveitis was noted in 46.2% cases after yag laser.08 in one study conducted by muhammad l et al anterior uveitis was seen in 8.0% cases,18 while in another study it was seen in 0.6% cases after yag laser capsulotomy.11 in our study anterior uveitis was very mild in all cases and responded well to topical steroid therapy. hyphema, retinal detachment, lens dislocation / subluxation, and endophthalmitis were less common complications seen in our study. these complications were uncommon in other studies as well.08,11,16-18 other complications of yag laser such as corneal endothelial damage,12 vitreous hemorrhage,10 macular hole,13 and macular hemorrhage,14 were not seen in our study. most of these complications are associated with the use of high energy level and poor focusing, although individual susceptibility also plays an important role. nevertheless, minimum energy level combined with minimum number of precisely focused shots for achieving the desired effect can reduce the risk of complications.11 conclusion a number of complications can occur after nd: yag laser capsulotomy. the most common of these complications are intraocular lens pitting, transient intraocular pressure elevation and cystoid macular edema. author’s affiliation dr. bilal khan vitreo-retina trainee lady reading hospital peshawar dr. mumtaz alam assistant professor ophthalmology department peshawar medical college peshawar dr. mir ali shah associate professor ophthalmology department lady reading hospital peshawar dr. bilal bashir vitreo-retina trainee lady reading hospital peshawar dr. asif iqbal vitreo-retina trainee hayatabad medical complex peshawar dr. adnan alam trainee medical officer lady reading hospital peshawar references 1. polack s, kuper h, wadud z, fletcher a, foster a. quality of life and visual impairment from cataract in satkhira district, bangladesh. br j ophthalmol. 2008; 92: 1026-30. complications of nd: yag laser capsulotomy pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 136 2. awasthi n, guo s, wagner bj. posterior capsular opacification: a problem reduced but not yet eradicated. arch ophthalmol 2009; 127: 555-62. 3. erie jc, hardwig pw, hodge do. effect of intraocular lens design on neodymium:yag laser capsulotomy rates. j cataract refract surg. 1998; 24: 1239-42. 4. mcdonnell pj, stark w, green wr. posterior capsule opacification: a specular microscopic study. ophthalmology 1984; 91: 853-6. 5. claesson m, klaren l, beckman c, sjostrand j. glare and contrast sensitivity before and after nd:yag laser capsulotomy. acta ophthalmol. 1994; 72: 27-32. 6. sunderraj p, villada jr, joyce pw, watson a. glare testing in pseudophakes with posterior capsule opacification. eye 1992; 6: 411-3. 7. niazi mk, hanif mk, khan ha, yaqub ma. neodymium: yag; capsulotomy rates following implantation of pmma and arylic intraocular lenses. professional med j. 2006; 13(4): 53842. 8. burq ma, taqui am. frequency of retinal detachment and other complications after neodymium: yag laser capsulotomy. j pak med assoc 2008; 58 (10): 550-2. 9. elkington ar, frank hj, greaney mj. lasers. in: clinical optics 3rd ed. 1999; 216-29. 10. shaikh a, shaikh f, adwani jm, shaikh za. prevalence of different nd: yag laser induced complication in patients with significant posterior capsule opacification and their correlation with time duration after standard cataract surgery. int j med med sci. 2010; 2: 12-7. 11. khanzada ma, jatoi sm, narsani ak, dabir sa, gul s. experience of nd: yag laser posterior capsulotomy in 500 cases. j liaquat uni med health sci. 2007; 6: 109-15. 12. sherrard es, kerr muir mg. damage to corneal endothelium by q switched nd: yag laser posterior capsulotomy. trans ophthalmol soc uk. 1985; 104: 524-8. 13. wilkins m, mcpherson r, fergusson v. visual recovery under glare conditions following laser capsulotomy. eye 1996; 10: 117-20. 14. majeed a, bangash t, muzaffar w, durrani o. macular hemorrhage: an unusual complication of nd: yag laser capsulotomy. pak j ophthalmol. 1998; 14: 118-20. 15. chambless ws. neodymium: yag laser posterior capsulotomy results and complications. j am intraocul implant soc. 1985; 11: 31-2. 16. khan my, jan s, khan mn, khan s, kundi n. visual outcome after nd-yag capsulotomy in posterior capsule opacification. pak j ophthalmol. 2006; 22: 87-91. 17. javed ea, sultan m, ahmad z. nd: yag laser capsulotomy and complications. professional med j 2007; 14: 616-9. 18. muhammad l, jabeen m, wazir f, qadir a, salim m, ahmad i. efficacy of nd: yag laser posterior capsulotomy in visual improvement of patients having posterior capsular opacification. gomal j med sci. 2013; 11:97-100. http://www.pakmedinet.com/jlumhs microsoft word 8. p.r mayrya r. p. maurya, et al. 86 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology original article prevalence of oculo-visual disorders amongst university students in varanasi district, north india r.p. maurya, prashant bhushan, v.p. singh, m. k. singh, o.p. upadhyay, p.r. sen pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: r.p. maurya b-33/10 x 2 c-1 rohit nagar extn., naria b.h.u., varanasi -221 005 (u.p.), india …..……………………….. purpose : (a) to estimate the magnitude of various oculo-visual disorders amongst the university students (b) to find out the factors responsible for the cause of ocular disorders and (c) to suggest possible intervention and preventive strategies for the same. material and methods: this prospective study was conducted in student health care complex and department of ophthalmology, sir sundar lal hospital, institute of medical sciences of banaras hindu university, varanasi, india. 20,680 students between 15 – 45 years age group were included in this study, which was carried out from september 2009 to august 2010. a detailed clinical history and complete ophthalmic examination of all the students was conducted including best corrected visual acuity, refraction, slit lamp biomicroscopy, intra ocular pressure (iop) measurement, extra ocular movements and fundus evaluation with direct ophthalmoscope. clinical details were recorded in a predesigned and pre-tested proforma. after a thorough examination, a provisional ocular diagnosis was made and treatment started accordingly. result: out of the 20680 students who visited university students’ health care complex, 4054 had various ocular disorders. the commonest ocular morbidities observed were refractive errors (39.78%) followed by conjunctivitis (30.64%), blepharitis (16.85%), computer vision syndrome (10.73%), stye (8.68%), ocular injuries (8.16%) and others (1.92%). 18.92% students had more than one ocular disorders. conclusion: majority of these ocular morbidities need attention as they are preventable and treatable. hence health education, regular eye checkup and screening are advocated. cular problems are frequently noted in the student community can affect the student’s performance in university and restricts their chances in educational and occupational opportunities. studies on ocular morbidities amongst university students are few and largely confined to school children1-7. this study was therefore designed to estimate the prevalence of ocular disorders among students of a large residential university and also to determine the factors responsible for ocular disorders and to suggest possible intervention and preventive strategies. information obtained from the study will help university administration in planning primary eye care in university student’s health care complex. material and methods this prospective, non-randomized, selectively analyzed, single-centre pilot study was conducted amongst university students of a large residential university with more than 30,000 students enrolled. out of 20680 students who attended the university student’s health care complex for various health problems, 4054 students with various ocular disorders o prevalence of oculo-visual disorders amongst university students in varanasi district, north india pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 87 were included in this study from september 2009 to august 2010. all the students underwent a detailed clinical history including present and past complaints, their routine study hours, use of computers and spectacles history. ocular examination included visual acuity (unaided, pinhole and with glasses) assessed by using snellens chart from a distance of six meters, extra ocular movements, alignment, cover tests, convergence test using raf rule, retinoscopy under mydriasis and subjective refraction. colour vision test with the help of ishihara chart, anterior segment examination with torch, magnifying binocular loupe, fundus examination with direct ophthalmoscope and slit lamp biomicroscopy were also done. the particulars were recorded in a pre-designed and pretested proforma. the diagnostic criteria of refractive errors used in our study are as follows: myopia was diagnosed if refractive error was minus 1.0 diopter spherical or more, hypermetropia was diagnosed if it is plus 1.0 diopter spherical or more and astigmatism was recorded if it is more than 0.75 diopter cylinder and anisometropia with difference of one dioptre spherical equivalent in between two eyes. data was analyzed by using spss. the chi square test of significance was applied to analysis. a p value of less than 0.05 was considered as significant. results out of 20680 students who visited the university student’s health care complex in one year period, 4054 (19.6%) had ocular diseases. amongst them 2894 (71.39%) were males and rest 1160 (28.61%) were females. 1873 (46.20%) were those students who belonged to it, medical, management and research stream (technical students) and 2181 (53.80%) were from arts, science, social sciences and other allied subjects (general stream students). the prevalence of ocular diseases was highest (38.83%) amongst 20-24 years age group, followed by the 25-29 years (25.33%) and 15-19 years of (25.06%) (table 1). ocular disorders were more prevalent in male study subjects (2894, 71.39%). the major ocular disorders observed in the study were refractive errors, conjunctival disorders, lid disorders, computer vision syndrome and eye injuries (table 2). 3287 (81.08%) students had single ocular morbidity while 767 (18.92%) had more than one ocular morbidity (table 3). out of 767 study subjects who presented with more than one ocular morbidity, 263 (6.49%) belonged to age group 20 – 24 years. refractive error was the most prevalent ocular disorder occurring in 1613 (39.78%) students. the prevalence rate for myopia was 21.41% as compared to hypermetropia (14.89%) and astigmatism (3.48%), which was statistically significant (χ2 test of significance). the refractive error was more prevalent among males (967, 23.85%) as compared to females (646, 15.93%) (table 4). refractive error was more common among the technical students (22.20%) like students of it, medical, management and research stream as compared to students of general stream (17.58%). in this study myopia of less than -3 diopter spherical was found in 12.38% and relatively high myopia (more than -6 diopter spherical) was observed in 9.03% cases. higher grades of myopia was more prevalent in female students. the incidence of myopia gradually decreased with advancement of age. conjunctival diseases were the second most common ocular morbidity observed in 1242 (30.64%) students. allergic conjunctivitis was observed in 603 (14.87%) students. infective (bacterial/viral) conjunctivitis due to epidemics was seen in 618 (15.24%) students while 21 (0.52%) students had contact lens related conjunctival disorders. disorders of the lid were the third common cause of ocular morbidity. 683 (16.85%) students had blepharitis, 352 (8.68%) had stye while 435 (10.73%) students had computer vision syndrome. 331 (8.16%) study subjects had various eye injuries including insect crawling and foreign body (table-2). other less common ocular disorders observed in this study were squint (0.52%), ptosis (0.30%), posterior segment pathology (0.91%) and colour blindness (0.07%) (fig. 1). prevalence of ocular disorders weas higher during march to october, with peak in month of september (13.07%) and august (11.98%). discussion out of the 20680 study subjects, 4054 (19.6%) had ocular disorders. prevalence rate of ocular morbidity amongst school going children as reported in various studies were rajesh kumar et al. (24.6%)1, ajaiyeoba ai et al. (15.5%)8, rosek et al. (28.8%)9 and nepal bp et al. (11.0%)3. in our study prevalence of ocular morbidity decreased with age, with minimum of 152 (3.75%) in age group 35 years and above and maximum of 1574 (38.83%) in 20 – 24 years age group, which was clinically significant (p<0.05, χ2 test of significance). unlike this study rajesh kumar et al1 r. p. maurya, et al. 88 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology table 1: distribution of ocular morbidity according to age and sex age group (yrs) male n %) female n (%) no. of patients n (%) 15-19 706(17.41) 310(7.64) 1016(25.06) 20-24 1166(28.76) 408(10.06) 1574(38.83) 25-29 689(17.00) 338(8.34) 1027(25.33) 30-34 159(3.92) 79(1.95) 238(5.87) 35-39 104(2.57) 19(0.47) 123(3.04) >40 70(1.73) 6(0.15) 76(1.87) total 2894(71.39) 1160(28.61) 4054(100.0) table 3: distribution according to age and number of morbidity age group (yrs) one disease n (%) two disease n (%) no. of patients n (%) 15-19 844 (20.82) 172(4.24) 1016(25.06) 20-24 1311(32.34) 263(6.49) 1574(38.83) 25-29 817(20.15) 210(5.18) 1027(25.33) 30-34 140(3.45) 98(2.42) 238(5.87) 35-39 102(2.52) 21(0.52) 123(3.04) >40 73(1.80) 3(0.07) 76(1.87) total 3287(81.08) 767(18.92) 4054(100.0) table 4: distribution of refractive errors type of refractive error male n (%) female n (%) no. of patients n (%) myopia 476(11.74) 392(9.67) 668(21.41) hypermetropia 401(9.89) 203(5.00) 604(14.89) astigmatism 90(2.22) 51(1.26) 141(3.48) total 967(23.85) 646(15.93) 1613(39.78) table 2: distribution of ocular morbidity by type ocular morbidity no. of patients n (%) refractive errors 1613(39.78) conjunctivitis 1242(30.64) blepharitis 683(16.85) computer vision syndrome 435(10.73%) stye 352(8.68%) traumatic eye injury 331(8.16%) others 78(1.92%) total 4054(100.0) fig. 1 : month wise distribution of ocular morbidity prevalence of oculo-visual disorders amongst university students in varanasi district, north india pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 89 reported increased prevalence of ocular morbidity with age, being minimum (17.5%) in 5 – 6 years age group and maximum (37.5%) in 30 – 40 years age group. this is because both the study used population of non-comparable age. studies of ocular morbidity among university students could not be found in literature despite our best efforts. the distribution of ocular morbidities in this study were refractive errors (39.78%), conjunctivitis (30.64%), blepharitis (16.85%), computer vision syndrome (10.73%), stye (8.68%), eye injury (8.16%) and others (1.9%) quite in contrast to the study done in school children where refractive errors (5.4%) are followed by conjunctivitis (4.6%), trachoma (4.3%) and vitamin a deficiency (4.1%)1. the number of students with two or more ocular diseases was 767 (18.92%), which was higher as compared to studies on school children (4%)1. this is due to cumulative effect of diseases like refractive error and conjunctivitis, as there is possibility of greater exposure to pathogen/allergen in older students on account of more outdoor activities leading to higher incidence of conjunctivitis. the ocular morbidities were more in summer and rainy seasons with peak during month of august (11.98%) and september (13.07%), this is most likely due to outbreaks of epidemic conjunctivitis and entomological factors like insect crawling, insect bite etc. the prevalence was least in month of january (4.54%) due to cold climate, which limits outdoor activities, university examination and low attendance of students in university students in health care complex. in this study, refractive error was the most prevalent ocular disorder seen in 1613 (39.78%) students, which is greater than the who’s range of 210%.10 refractive errors were the most common ocular problems in the various studies conducted by ajaiyeoba ai et al (5.8%),8 rajesh kumar et al (5.4%),1 nepal bp et al (8.1%),3 adegbehingbe bo et al (13.5%)11 and ho c-sd et al (22.3%).12 in our study refractive error was slightly more common in technical students (22.2%) than non-technical ones (17.58%). similar pattern was observed in study conducted amongst the singapore teenagers (uncorrected refractive error among express students 19.6%, normal academic students 20.5% and technical students were 31.1%)12. among the refractive errors, myopia was most common, constituting 21.41% followed by hypermetropia (14.89%) and astigmatism (3.48%). however, findings of kleinstein rn et al. study (myopia 9.2%, hyperopia 12.8% and astigmatism 28.4%)9 and nepal bp et al. study (myopia 4.3%, hypermetropia 1.3% and astigmatism 2.5%)3 are contrary to our findings. amongst diseases of conjunctiva, infective (15.24%) and allergic conjuncttivitis (14.87%) were the most common, which may be due to increase in concentration of allergens in university campus, over crowding and poor ocular hygiene among students. contrary to our finding prevalence of allergic conjunctivitis was reported to be 49% by adegbehingbe bo et al11 and 7.4% by ajaiyeoba ai et al8. third common cause of ocular disorders was diseases of lids like blepharitis (16.85%) and stye (8.68%), which did not pose any threat to vision. the environmental factors including poor ocular hygiene, acne, seborrhic dermatitis or dandruff may contribute to the aetiology of above diseases of the eyelids in our study. computer vision syndrome was seen in 10.73% university students, majority of whom belonged to technical students having tendency of late night study and prolonged work on computer. conclusion majority of ocular problems observed in our study were either preventable or treatable. to reduce ocular morbidity amongst university students, health education towards eye care, regular eye examination, correction of refractive errors and use of protective eyewear are advocated. author’s affiliation dr. r.p. maurya medical officer sir sundarlal hospital institute of medical sciences banaras hindu university varanasi-221 05, (u.p.) india dr. prashant bhushan assistant professor sir sundarlal hospital institute of medical sciences banaras hindu university varanasi-221 05. (u.p.) india dr. v.p. singh professor sir sundarlal hospital institute of medical sciences banaras hindu university, varanasi-221 05, (u.p.) india r. p. maurya 90 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology dr. m. k. singh professor sir sundarlal hospital institute of medical sciences banaras hindu university, varanasi-221 05 (u.p.) india dr. o.p. upadhyay chief medical officer sir sundarlal hospital institute of medical sciences banaras hindu university, varanasi-221 05 (u.p.) india dr. p.r. sen senior medical officer sir sundarlal hospital institute of medical sciences banaras hindu university, varanasi-221 05 (u.p.) india reference 1. kumar r, dabas p, mehra m, et al. ocular morbidity amongst primary school children in delhi. health and population prospective and issues. 2007, 30; 222-9. 2. gupta m, gupta b.p., chauhan a. ocular morbidity prevalence among school children in shimala himanchal, north india. indian journal of ophthalmology, 2009; 57: 133-8. 3. nepal bp, koirala s, adhikary s., et al. ocular morbidity in school children in kathmandu. br j ophthalmol. 2003; 87: 5314. 4. fotouhi a, hashami h, khabazkhoob m, et al. the prevlanece of refractive errors among school children in dezful, iron. br. j. ophthalmol. 2007; 91: 287-92. 5. wedner sh, ross da, todd j et al. myopia in secondary school students in mwanza city, tanzania : the need for a national screening programme. br j ophthalmol. 2002; 36: 1200-6. 6. maul e, barroso s, munoz sr et al. refractive error study in children : results from la florida, chile. am j ophthalmol. 2000; 129: 445-54. 7. zhao j, pan x, sui r, et al. refractive error study in children results from shunji district china. am j ophthalmol. 2000; 129; 427-35. 8. ajaiyeoba ai, sawumi mai, adeoye ao, et al. ohileye. prevalence and causes of eye diseases amongst students in south western nigeria. annals of african medicine. 2006; 5:, 197-203. 9. rose k, younan c, morgan i et al. prevalence of undetected ocular conditions in a pilot sample of school children. cln. exp. ophthalmol. 2003; 31: 237-40. 10. wedner sh, foster a. prevalence of eye diseases in primary school children in a rural area of tanzania. br j ophthalmol. 2000; 84: 1291-7. 11. adegbehingbe bo, oladehinde mk, majemgbasan to, et al. screening of adolescents for eye diseases in nigerian high schools. ghana medical journal. 2005, 39, 138-42. 12. ho c-sd, ng c-bc, chan e, ngeon a et al. uncorrected refractive error in singapoore teenagers. br j ophthalmol. 2006; 90: 202-7. 13. kleinstein rn, jones la, hullett s, et al. refractive error and ethnicity in children. arch ophthalmol. 2003; 121: 1141-7. microsoft word 2. shakir zafar 118 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology original article management of intraocular foreign body in tertiary care hospital shakir zafar, zeeshan kamil, munira shakir, syeda aisha bokhari, syed fawad rizvi pak j ophthalmol 2012, vol. 28 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: shakir zafar consultant ophthalmologist l.r.b.t free base eye hospital karachi korangi 21/2, karachi. postal code74900 …..……………………….. purpose: to share the experience of managing fifty cases of intraocular foreign body in a tertiary care hospital. material and methods: the study was conducted in lrbt free base eye hospital eye karachi from january 2008 to december 2010. we retrospectively reviewed the record of fifty patients of intraocular foreign body who underwent pars plana vitrectomy for foreign body removal. in this study twenty eight (56%) patients had self sealing wound which did not need primary repair, rest of twenty two (44%) patients’ needed primary surgical intervention to restore ocular integrity. after initial management all patients underwent pars plana vitrectomy for foreign body removal. minimum follow up was 6 months while mean follow up was 15 months. results: there were fifty eyes of fifty patients, all males with age ranging between 20 and 50 years who had sustained ocular trauma, mostly involving anterior as well as posterior segments, and few involving only the posterior segment. preoperative visual acuity was pl to 6/60 in 68% patients and 6/60 to 6/12 in 32% patients, whereas; postoperative visual acuity at final follow up was 6/12 to 6/60 in 64% of patients and 6/60 to pl in 36% of patients. conclusion: intraocular foreign body is a common occupational injury of the eye. timely management of removal of intraocular foreign body and meticulous follow up improves visual acuity. rauma can result in a wide spectrum of tissue lesions of the globe, optic nerve and adenexa, ranging from the relatively superficial to vision threatening. the birmingham eye trauma terminology (bett) classifies each injury type in a comprehensive system (fig. 1)1. penetrating injuries are three times more common in males than in females, and typically occur in the younger age group. extent of damage caused by flying foreign bodies is determined by their kinetic energy2. intraocular foreign bodies account for almost 40% of penetrating ocular injuries3. most foreign bodies lodge in the posterior segment4. intraocular foreign body cause a significant and unique type of trauma that requires skillful investigation and an early intervention. the earliest cases of intraocular foreign body were removed through a corneal incision using an external magnet5. intraocular foreign body survival techniques progressed over time to removal through the pars plana using an external magnet6. metallic intraocular foreign body, removed by magnetic extraction was associated with a high incidence of intraocular damage7. with the development of pars plana vitrectomy (ppv), both magnetic and nonmagnetic intraocular foreign bodies could be removed from the vitreous cavity8. intraocular foreign body removal was originally localized using scout films of the orbit. this technique has long been replaced by improvements in ultrasonography and computed tomography (ct) technology9,10. material and methods the study was conducted in lrbt free base eye hospital eye karachi from january 2008 to december t management of intraocular foreign body in tertiary care hospital pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 119 2010. we retrospectively reviewed the record of fifty patients of intraocular foreign body who underwent pars plana vitrectomy for foreign body removal. patients with previous history of retinal detachment surgery, corneal disease, glaucoma, any other intraocular disease, diabetes mellitus, and hypertension are excluded from the study. a performa was used to record demographics, the etiology of injury; the type of material that may have entered the eye such as metallic (magnetic/ nonmagnetic), nonorganic (stone), organic (plant/ wood), or autologous (bone / cilia); time elapsed since injury, vaccination for tetanus, time elapsed since last meal, and allergy to any medicine. complete ophthalmic examination was carried out. b scan ultrasonography was deferred until the primary globe repair was completed to evaluate the retina and choroid. ct was used where necessary. in this study twenty eight (56%) patients had self sealing wound which did not need primary repair, and who underwent pars plana vitrectomy for foreign body removal within two weeks of injury. the remaining twenty two (44%) patients’ required primary surgical intervention to restore ocular integrity within a day or two. subsequently these patients underwent pars plana vitrectomy for foreign body removal within two weeks. minimum follow up was 6 months while mean follow up was 15 months. surgical technique the preoperative testing such as medical history and ct scan will usually suggest the composition and size of the intraocular foreign body. size is the most important factor in determining the instrumentation for iofb removal. magnetic metallic intraocular foreign bodies less than 1×1×1 mm in dimension were removed using the alcon grieshaber sutherland (ng712.0012) iofb magnet and larger foreign bodies were removed with alcon grieshaber sutherland (ng335.00) intraocular forcep. nonmagnetic intraocular foreign bodies were also removed with the above mentioned forcep. results the study included fifty eyes of fifty patients, all males with age ranging between 20 and 50 years who had sustained ocular trauma, mostly involving both the anterior as well as posterior segments and a few involving just the posterior segment and who were managed between january 2008 to december 2010. minimum follow up was 6 months while mean follow up was 15 months. type of injury and entry site are shown in table 1. cataract developed preoperatively in twenty nine (58%) patients. foreign body removal by enlarging an incision through the pars plana and vitrectomy with 23g was done in 38 (76%) patients, whereas; foreign body removal through a limbal incision and vitrectomy with 23g was done in 12 (24%) patients. foreign body was localized in mid vitreous in 9 (18%) patients, at retina beyond the equator in 31 (62%) patients, between equator and macula in 6 (12%) patients, on macula in 4 (8%) patients. cataract was removed in all 29 patients but intraocular lens was implanted in 22 (75.86%) patients and rest 7 (24.13%) patients left aphakic. preoperative and postoperative visual acuity is shown in table 2. postoperative complications were retinal detachment in 3 (6%) patients, vitritis in 4 (8%) patients, cystoid macular edema in 6 (12%) patients, and intraocular lens decentration in 2 (4%) patients and endophthalmitis in 1 (2%) patient. discussion ocular trauma associated with retained intraocular foreign bodies (iofb) constitutes a significant proportion (18-40%) of all ocular injuries requiring surgical management11. visual outcomes after intraocular foreign body injury can vary depending on other concomitant globe injuries. preoperative visual acuity is usually reduced by traumatic cataract or vitreous hemorrhage. these two media opacities are shakir zafar, et al 120 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology fig. 1: betts. the double framed boxes show the diagnoses that are used in clinical practice fig. 2: intraocular foreign body at the posterior pole being lifted by a magnet. fig 3: intraocular foreign body being removed through the enlarged sclerotomy incision removed during intraocular foreign body removal. the major contributing factors for long term poor visual acuity are traumatic optic neuropathy, corneal scarring, residual effects of post traumatic endophthalmitis, and suprachoroidal hemorrhage as well as proliferative vitreoretinopathy (pvr) causing irreparable chronic retinal detachment. the most common type of intraocular foreign body injury involves a small corneal laceration with traumatic cataract and vitreous hemorrhage in more than 50% of these cases. these intraocular foreign body injuries have excellent visual recovery with most obtaining best corrected visual acuity ≥ 20/4012,13. in this study 36% patients had post-operative final visual acuity ranging between 6/60 to pl, the contributing factors for poor visual acuity in decreasing order of frequency were corneal scarring, aphakia, retinal detachment, endophthalmitis and traumatic optic neuropathy. corneal scarring and astigmatism are significant factors for vision loss after an intraocular foreign body injury. a hard contact lens or penetrating keratoplasty may be needed for visual rehabilitation14. aniridia iol can be used to manage traumatic aniridia with symptomatic photophobia15. traumatic optic neuropathy can be followed using visual field or multifocal visual evoked potential testing16. in this study, 76% patients had foreign body removal by enlarging the sclerotomy incision, and 24% patients through a limbal incision. in this study most common type of injury was with hammer/chisel accounting for 64% of the cases, and most common site of entry was cornea 52%; 64% of the patients had visual acuity ranging between 6/12 to 6/60, where as warrasak s et al showed 72.22% patients had visual acuity ranging between 20/20 to 20/60.17 in another study 65.96% patients achieved visual acuity of 20/400 or better18. in this study post operative retinal detachment was seen in 6% of patients whereas; weissgold dj et al reported post operative retinal detachment in 15.38% of patients19. the rate of preoperative retinal detachment associated with an intraocular foreign body has been reported at 31%12. intraocular foreign body removal associated with a retinal detachment can be extremely complicated, especially with subretinal intraocular foreign bodies located away from the entry site of the iofb. postoperative intra ocular foreign body related retinal detachment can also contribute to poor visual outcome, with large intra ocular foreign body and endophthalmitis as the strongest predictive factors20. in this study postoperative endophthalmitis occurred in 2% of patient, where as zhao sh et al reported in 6.25% of patients with endophthalmitis18. post management of intraocular foreign body in tertiary care hospital pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 121 traumatic endophthalmitis has historically averaged 4% to 8% of all intra ocular foreign body injuries, with up to 30% in rural settings21. thus, timely management, absence of risk factors for post traumatic endophthalmitis (including delay in primary closure, delay in iofb removal, disruption of the crystalline lens, and sustaining ocular trauma in rural setting), and close follow up improves visual outcome after removal of intraocular foreign body. conclusion ocular trauma due to intraocular foreign body requires urgent surgical management. based on the findings of the current study, prompt removal of the intraocular foreign body results in favorable improvement in visual acuity. author’s affiliation dr. shakir zafar consultant ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi. dr. zeeshan kamil associate ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi. dr. munira shakir consultant ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi. dr. syeda aisha bokhari associate ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi. dr. syed fawad rizvi chief consultant ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi. reference 1. kuhn f, morris r, witherspoon cd, et al. the birmingham eye trauma terminology system (bett). j fr ophtalmol. 2004; 27: 206-10. 2. ocular trauma in: kanski jj. clinical ophthalmology a systemic approach london: butterworth heineman. 2011; 871-95. 3. cazabon s, dabbs tr. intralenticular metallic foreign body. j cataract refract surg. 2002; 28: 2233-4. 4. behrens-baumann w, praetorius g. intraocular foreign bodies. 297 consecutive cases. ophthalmologica. 1989; 198: 848. 5. trevor-roper pd. the late results of removal of intraocular foreign bodies with the magnet. br j ophthalmol 1944; 28: 3615. 6. cridland n. intraocular foreign bodies. magnet extraction. int ophthalmol clin. 1968; 8: 213-29. 7. percival sp. late complications from posterior segment intraocular foreign bodies with particular reference to retinal detachment. br j ophthalmol. 1972; 56: 462-8. 8. machemer r. a new concept for vitreous surgery. surgical technique and complications. am j ophthalmol. 1972; 74: 102233. 9. kwong js, munk pl, lin dt, et al. real-time sonography in ocular trauma. ajr am j roentgenol. 1992; 158: 179-82. 10. lakits a, prokesch r, scholda c, et al. multiplanar imaging in the preoperative assessment of metallic intraocular foreign bodies. helical computed tomography versus conventional computed tomography. ophthalmology. 1998; 105: 1679-85. 11. azad rv, kumar n, sharma yr, et al. role of prophylactic sclera buckling in the management of retained intraocular foreign bodies. clin exp ophthalmol. 2004; 32: 58-61. 12. colyer mh, weber ed, weichel, et al. delayed intraocular foreign body removal without endophthalmitis during operations. iraqi freedom and enduring freedom. ophthalmology. 2007; 114: 1439-47. 13. woodcock mg, scott ra, huntbach j, et al. mass and shape as factors in intraocular foreign body injuries. ophthalmology 2006; 113: 2262-9. 14. tanzer dj, smith re. black iris diaphragm intraocular lens for aniridia and aphakia. j cataract refract surg. 1999; 25: 1548-51. 15. klistorner a, fraser c, garrick r, et al. correlation between full-field and multifocal veps in optic neuritis. doc ophthalmol. 2008; 116: 19-27. 16. wiechel de, yeh s. techniques of intraocular foreign body removal. tech ophthalmology. 2009; 7: 45-52. 17. warrasak s, euswas a, hongsakorn s. posterior segment trauma: types of injuries result of vitreo-retinal surgery and prophylactic broad encircling sclera buckle. j med assoc thai. 2005; 88: 1916-30. 18. zhao sh, zhang y, wu jh, et al. combined lens and vitreoretinal surgery in patients with traumatic cataract and intraocular foreign body. int j ophthalmol. 2009; 2: 61-4. 19. weissgold dj, kaushal p. late onset of rhegmatogenous retinal detachments after successful posterior segment intraocular foreign body removal. br j ophthalmol. 2005; 89: 327-31. 20. mahaparta sk, rao gn. visual outcome of pars plana vitrectomy with intraocular foreign body removal through sclerocorneal tunnel and sulcus-fixated intraocular lens implantation as a single procedure, in cases of metallic intraocular foreign body with traumatic cataract. indian j ophthalmol. 2010; 58: 115-8. 21. al-omran am, abboud eb, abu el-asrar am. microbiologic spectrum and visual outcome of post traumatic endophthalmitis. retina. 2007; 27: 236-42. 48 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology case report management of aniridia with ectopia lentis sharif hashmani, syed irshad haider, bilqis khatri, ghulam kubra rind pak j ophthalmol 2015, vol. 31 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: bilqis khatri jm-75, jacob lines, off m.a jinnah road, karachi. bilqis_khatri@hotmail.com …..……………………….. we report a case of bilateral congenital aniridia with ectopia lentis and cataract in a female child of 14 years old in whom artificial iris and iol complex was transplanted to attain cosmetic results and somehow visual outcomes. the surgery was successful in achieving desired outcomes. key words: aniridia, artificial iris, artificial iris. niridia is characterized by complete or partial iris hypoplasia, usually involving both eyes, with neonatal onset. may be with systemic association or isolated which is not limited to a defect in iris development, but is a panocular condition with macular and optic nerve hypoplasia, cataract, and corneal changes (often later onset).1 aniridia may be familial or sporadic. mutation on the pax6 gene on chromosome 11 is responsible for causing aniridia.2 a more recent study from denmark reported the incidence as 1 per 96,000 live births with no gender and racial predilection.2 vision may be severely compromised due to associated ocular complications such as: nystagmus, amblyopia, buphthalmos, and cataract.1 very few lens opacities in infancy require lens extraction, but visually significant lens opacities eventually develop in 50 – 85% of affected individuals, often in the teens or early adulthood. lens subluxation or dislocation occurs but is uncommon (in 18 – 35%), nystagmus occurs in 85 – 92% of patients and glaucoma present in 70% cases.2 symptoms of aniridia are treated accordingly and surgical intervention is carried out for cosmetic results which include transplantation of iris. it is also available in combination with intraocular lens (iol) for the combine treatment of aphakia and aniridia. case report a 14 year old female child resident of quetta came to hashmanis hospital presented complaints of decreased vision and sensitivity to light (photophobia) with involuntary eye movements. on examination unaided visual acuity was found to be counting finger at 1m in both eyes. there was no improvement with pinhole. slit lamp examination revealed the absence of iris with opaque and subluxated lens in both eyes hence aniridia was diagnosed, associated with nystagmus, cataract and ectopia lentis. relevant systemic examinations were carried out but no systemic association was found. surgical plan including artificial iris implant with iol under general anesthesia was prepared with patient’s consent to maximize cosmetic appearance and improve visual outcome. prior to surgery iol power was calculated and color of iris was chosen. biometric calculations showed the resulting iol powers of +31d and +32d for right and left eye respectively and green color of iris was chosen as per patient’s choice. both eyes were operated with a gap of three days. single piece artificial iris +iol complex was used manufactured by reper – nn russia. the complex is made of the optic part with the diameter of 3.5 mm and painted peripheral part. the diameter of the block was 13 mm. a http://en.wikipedia.org/wiki/macular_hypoplasia http://en.wikipedia.org/wiki/optic_nerve_hypoplasia http://en.wikipedia.org/wiki/cataract http://en.wikipedia.org/wiki/cornea http://en.wikipedia.org/wiki/amblyopia http://en.wikipedia.org/wiki/buphthalmos http://en.wikipedia.org/wiki/cataract management of aniridia with ectopia lentis pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 49 post-operative cosmetically outcomes were remarkable along with improved visual status with decrease glare problem and photophobia. the best corrected visual acuity was improved to 6/60 in both eyes. the patient is happy and satisfies with the results. the patient is kept on follow up to monitor intra ocular pressure and other associated conditions. fig. 1: pre-op. iris + complex implanted in both eyes. fig. 2: post-op. iris + iol complex implanted in both eyes surgical procedure: the eye was fixed by using a superior rectus suture. it was planned to secure the artificial iris + iol complex with three sutures at 10, 2, and 6 o’ clock positions. the cornea was marked in clock wise fashion with a radial marker to ensure accurate suture placement for lens centeration. conjunctiva and tenon’s were disected at 6 o’ clock position and sclera was exposed. a partial thickness, lamellar scleral flap was created at 6 o’clock position. two incissions of 3.2 mm length were made at 2 o’clock and 10 o’clock positions. the lensectomy and anterior viterectomy were done. both the wounds were secured with sutures. the artificial iris + iol complex was then prepared for implantation. three sutures of, 10 0 polypropylene were tied in a fashion to be fixed in the eye at 10, 2 and 6 o’clock positions. a 5.2 mm limbal incission was placed superiorly and anterior chamber was reformed using a visco elastic. the long needle of suture was passed through superior incission and reterieved from 6 o’ clock position. the artificial iris + iol complex was folded and implanted in ciliary sulcus. the inferior 6 o’ clock suture was pulled and the lens was fixed at 6 o’ clock position. for the superior fixation of the complex the needles were bent and passed from inside out at 10 and 2 o’clock positions and were fixed there. superior incissions and scleral flap at 6 o’clock position were closed using 10-0 nylon sutures. the conjunctiva and tenon were closed using 8 0 virgin silk. the residual viscoelastic material was removed by irrigation. dexamethasone and tobramycin were injected subconjunctivaly and the eye was patched. post operatively the patient was seen after 24 hours, 3 days, 1 week, 2 weeks and after 1 month. the patient was asked for a follow up check up at three monthly interval for a year and then to be seen every year. post operatively she was given topical steroids and topical antibiotics 4 to 6 times a day , which gradualy tapered of over a period of 6 to 8 weeks. discussion iris implant surgery is a new modality treatment for people in whom iris could not develop normally or who lack natural iris (for e.g: in conditions of aniridia). though these patients who undergone such procedure are also at the risk of complications but the benefits of gaining an iris may outweigh their risks.3 the artificial iris is a thin prosthesis made of the silicone which is also used for intraocular lenses that is very flexible and can be folded and inserted into the eye by making a peripheral corneal surgical incision, about 2.8mm in length.4 the first artificial iris implant was introduced in the 1980s for patients with a cataract and an intact capsule while the first implantation under fda clinical trial was done in us in 2002.5 since then it has been used in many patients in whom there was cosmetic disfigurement due to absence of iris. a study in march 2000 evaluated the long term results of implantation of a black diaphragm intra ocular lens (iol) in eyes with congenital aniridia which carried out a 46 months follow up and reported sharif hashmani, et al 50 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology improvement of visual acuity in 73.68% (14 of 19 eyes) however, post-operative problems were glaucoma (2.73%), cystoid macular edema (18.18%) and chronic endothelial cell loss (27.27%).6 a study from pozedyeva na et al, also reported improvement in corrected visual acuities for 75% eyes. post-operative complications include 2 cases of hyphema, 1 case of ciliochoroidal detachment, 4 eyes with exaggerated immediate post-operative reaction and 1 eye with persistent low grade cyclitis out of 20 eyes under study.7 a study by i mavrikakis et al reported the efficacy of prosthetic iris devices along with iol in patients with iris deficiencies. the best corrected visual acuity found to be improved in 90% of patients while glare reduced in 80% of patients.8 a study in european journal of ophthalmology, 2011 describes the efficacy of elastic artificial ild (irislens diaphragm) from reper – nn for combination of aphakia and iris defects of various extent.9 iris implantation is not much common in pakistan because of very low incidence of aniridia and low socio economic conditions. conclusion artificial iris + iol transplantation provides good management option for aniridia patients either congenital or traumatic as it restores cosmetic appearance and resolve visual associated symptoms so it should be promoted by surgeons and made available to the patients. author’s affiliation dr. sharif hashmani hashmanis eye hospital, jm 75 off m. a, jinnah road, jacob lines karachi dr. syed irshad haider hashmanis eye hospital, jm 75 off m. a, jinnah road, jacob lines karachi dr. bilqis khatri hashmanis eye hospital, jm 75 off m. a, jinnah road, jacob lines karachi dr. ghulam kubra rind hashmanis eye hospital, jm 75 off m. a, jinnah road, jacob lines karachi references 1. hingorani m, moore a. aniridia. 2003 may 20 [updated 2013 nov 14]. in: pagon ra, adam mp, ardinger hh, et al., editors. gene reviews® [internet]. seattle (wa): university of washington, seattle; 19932014. available from: http://www.ncbi.nlm.nih.gov/books/nbk1360/. 2. bakri s, simon jw, cibis gw. aniridia in the newborn clinical presentation, medscape[internet] dec 3, 2013 [cited on 2nd july 2014] available from: http://emedicine. medscape.com/article/1200592clinical#a0217. 3. cosmetic iris implants: risks outweigh benefits, eye smart [internet], updated on nov-01-2013 [cited on 05july-14] 4. artificial iris implant surgery, vistar eye center [home page on the internet], virginia [cited on 05-july-2014] 5. jules stein eye institute, clinical update january 2011 vol. 20|no. 1 [cited on 06-july-2014]. 6. reinhard t, engelhardt s, sundmacher r. black diaphragm aniridia intraocular lens for congenital aniridia: long-term follow-up. j cataract refract surg. 2000; 26 (3): 375-81. 7. pozdeyeva na, pashtayev np, lukin vp, batkov yn. artificial iris – lens diaphragm in reconstructive surgery for aniridia and aphakia. j cataract refract surg. 2005; 31: 1750–9. 8. mavrikakis i, mavrikakis e, syam pp, bell j, casey jh, casswell ag, brittain gp, liu c. surgical management of iris defects with prosthetic iris devices. eye (lond.) 2005; 19: 205-9. 9. pozdeyeva na, pashtayev np, viktorova ea, treushnikov vm, starostina ov. artificial iris – lens diaphragm design modifications for surgical correction of iris defects combined with aphakia, eur j ophthalmol. 2011; 00(00). http://www.ncbi.nlm.nih.gov/pubmed?term=reinhard%20t%5bauthor%5d&cauthor=true&cauthor_uid=10713232 http://www.ncbi.nlm.nih.gov/pubmed?term=engelhardt%20s%5bauthor%5d&cauthor=true&cauthor_uid=10713232 http://www.ncbi.nlm.nih.gov/pubmed?term=sundmacher%20r%5bauthor%5d&cauthor=true&cauthor_uid=10713232 http://www.ncbi.nlm.nih.gov/pubmed/10713232 http://www.ncbi.nlm.nih.gov/pubmed/?term=mavrikakis%20i%5bauthor%5d&cauthor=true&cauthor_uid=15218523 http://www.ncbi.nlm.nih.gov/pubmed/?term=mavrikakis%20e%5bauthor%5d&cauthor=true&cauthor_uid=15218523 http://www.ncbi.nlm.nih.gov/pubmed/?term=syam%20pp%5bauthor%5d&cauthor=true&cauthor_uid=15218523 http://www.ncbi.nlm.nih.gov/pubmed/?term=bell%20j%5bauthor%5d&cauthor=true&cauthor_uid=15218523 http://www.ncbi.nlm.nih.gov/pubmed/?term=casey%20jh%5bauthor%5d&cauthor=true&cauthor_uid=15218523 http://www.ncbi.nlm.nih.gov/pubmed/?term=casswell%20ag%5bauthor%5d&cauthor=true&cauthor_uid=15218523 http://www.ncbi.nlm.nih.gov/pubmed/?term=brittain%20gp%5bauthor%5d&cauthor=true&cauthor_uid=15218523 http://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20c%5bauthor%5d&cauthor=true&cauthor_uid=15218523 242 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology original article biometric findings in patients undergoing cataract surgery; gender comparison khawaja khalid shoaib, tariq shakoor pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: khawaja khalid shoaib fcps, frcs, mcps hpe health bridge hospital, ghazi road, near bhatta chowk, dha, lahore e-mail: kkshoaib@hotmail.com …..……………………….. purpose: to report normal biometric findings in patients undergoing cataract surgery and make comparison of these values between males and females. study design: cross sectional, descriptive. place and duration of study: data collected in armed forces institute of ophthalmology (afio) rawalpindi during 2016 was analyzed. material and methods: a total of 752 biometeries were done in patients undergoing cataract operation. axial length (al), keratometry readings (k1 and k2), anterior chamber depth (acd) and posterior chamber intraocular lens power (pc iol) of the patients were assessed to find mean, standard deviation, minimum value and maximum value. statistical analysis was done in spss 20. comparison of these values for males and females was done by independent samples t test. results: age ranged from 16 years to 105 years (mean 63.05 ± 10.52). male were 412 (54.79%) and female were 340 (45.2%). mean al was 23.22 ± 1.08 mm. mean k1 was 42.87 ± 1.98 d. mean k2 was 43.96 ± 1.8 d. 4.55. mean acd was 3.2397 ± .40 and mean pc iol was 21.2 ± 2.35. significant differences were observed in all the parameters when the findings for males and females were compared. conclusion: pakistani female cataract patients have smaller axial length and anterior chamber depth but higher corneal curvature when compared to their male counterparts. keywords: axial length of eye, keratometry, intraocular lens. ataract surgery is one of the most commonly done operations in the world. posterior chamber intraocular lens implantation (pc iol) at the time of cataract surgery is routinely done nowadays and biometry is used to calculate the required power of the iol. biometry includes measurement of many parameters and the most important are axial length (al), corneal curvature (keartometry or k reading) and anterior chamber depth (acd). axial length is the anteroposterior diameter of the eye measured at center of the cornea. k readings are measured with keratometers and represent horizontal and vertical curvature of the cornea. presence of corneal astigmatism reflected by difference of k readings in different corneal meridian alerts eye surgeon to think of corrective methods before starting surgery. good biometry improves post cataract surgery refractive status and this is now the aim of cataract surgery. we can achieve in more than 90% cases within ± 1 d of target refraction1. thus measurement of axial length and corneal curvature are very important issues. axial length is measured with different techniques2,3,4,5,6. ultrasound biometers being most economical are still the predominant source of biometry in pakistan. cycloplegia7,8,9 and trabeculectomy10 have been associated with effect on acd, al and k readings. one should be cautious, not to take biometric findings after mydriasis/cycloplegia. similarly findings after trabeculectomy operations cannot be taken as of normal population. there is c biometric findings in patients undergoing cataract surgery; gender comparison pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 243 scarcity of good studies (involving large sample size) regarding age, axial length, corneal curvature and power of intraocular lens undergoing cataract surgery in pakistani males and females. keeping in mind all the above mentioned facts we conducted this study to find the normal biometric findings in pakistani population. material and methods a total of 752 biometeries were done in patients undergoing cataract operation in armed forces institute of ophthalmology (afio) rawalpindi from 1st january 2016 to 31st dec 2016. this study was approved by the ethics committee of afio and followed the tenets of the declaration of helsinki. all the cases for cataract operations were included in the study. patients who had history of any form of eye surgery were excluded from the study.all the data was collected by ts. keratometery was done with autorefrectometere rf 2 (canon japan). al was measured with axis iiultrasound a mode biometer (quantel medical -france). srk-t formula was used to calculate pc iol power. a constant was taken as 118.0. axial length (al), keratometry readings (k1 and k2), anterior chamber depth (acd) and pc iol power of the patients were assessed to find mean, standard deviation, minimum value and maximum value in males and females. findings were noted when the pupil was not dilated (without cycloplegia). statistical analysis was done in spss 20.p-value of < 0.05 was taken as significant.comparison of the values for males and females was done by independent samples t test. results age ranged from 16 years to 105 years (mean 63.05 ± 10.52). males were 412 (54.79%) and females were 340 (45.2%). mean al was 23.22 ± 1.08 mm (table 1). mean k1 was 42.87 + 1.98 d (table 1). mean k2 was 43.96 ± 1.8 d. 4.55. mean acd was 3.2397 ± .40 and mean pc iol was 21.2 ± 2.35 (table 1 and 2). significant differences were observed in all the parameters when the findings for males and females were compared (table 3). table 1: descriptive statistics. n minimum maximum mean std. deviation age 742 16 105 63.05 10.520 axial length (mm) 677 20.04 28.83 23.2160 1.08738 k1(d) 705 23.66 48.75 42.8680 1.97796 k2 (d) 705 37.75 51.75 43.9611 1.80413 ac depth (mm) 352 2.11 4.55 3.2397 .40445 pc iol power (d) 723 6.00 31.00 21.2055 2.35320 table 2: group statistics. gender n mean std. deviation std. error mean age male 407 65.13 11.129 .552 female 335 60.52 9.123 .498 gender n mean std. deviation std. error mean axial length (mm) male 368 23.4744 1.04453 .05445 female 309 22.9082 1.05841 .06021 gender n mean std. deviation std. error mean anterior chamber depth (mm) male 175 3.3122 .42181 .03189 female 177 3.1680 .37408 .02812 gender n mean std. deviation std. error mean k1 (d) male 384 42.3846 2.11665 .10802 female 321 43.4463 1.62140 .09050 gender n mean std. deviation std. error mean k2 (d) male 384 43.4987 1.74641 .08912 female 321 44.5142 1.71667 .09581 khawaja khalid shoaib, et al 244 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology gender n mean std. deviation std. error mean posterior chamber intra ocular lens power (d) male 393 20.8219 2.10595 .10623 female 330 21.6624 2.54616 .14016 table 3: comparison between mean values of male and female patients. male female p value (sig) age 65.13 60.52 .000 axial length 23.47 22.91 .000 ant chamber depth 3.3122 3.1680 .001 k1 42.3846 43.4463 .001 k2 43.4987 44.5142 .000 post chamber iol power 20.82 21.66 .000 discussion age at the time of cataract operation varies from country to country e.g. in southern chinese11mean age was 70.4 years ± 10.5 about 7 years older than our patients. similarly different readings of axial length and corneal curvature have been reported from different areas of the world. in west, norfolk island residents (descended from the english bounty mutineers and their polynesian wives) findings for al, acd and mean k (km) were 23.5mm, 3.32mm and 43.52 d respectively12. in this study al and acd are higher but k is lower than our values. their findings are comparable to another european study (portugal) where mean al, km, and acd have been 23.87 ± 1.55 mm (19.8–31.92 mm), 43.91 ± 1.71 d (40.61–51.14 d), and 3.25 ± 0.44 mm (2.04–5.28 mm), respectively13. coming to chinese studies, one study revealedal, acd, and mean k value of 24.07 ± 2.14 mm, 3.01 ± 0.57 mm and 44.13 ± 1.63 d respectively.11all of these findings are slightly higher (except acd) than our findings.in beijing study mean axial length was 23.25 ± 1.14 mm (range: 18.96-30.88 mm)14which is slightly less but close to our finding. taiwan, china findings were mean al of 24.75 ± 2.71 mm, and the mean k value of 43.48 ± 1.66 d15. al in this study is higher than ours but k is almost same. chinese in singapore had al and acd of 23.23 +/1.17 mm and 2.90 +/ 0.44 mm respectively16 and their al was slightly higher and acd was slightly less than our readings. al was 23.13 +/1.15 mm in mongolian adults aged 40 years or more which is slightly less than ours17. average corneal curvature in nigerians was found to be 42.98 ± 1.19 d18. it is very close to our finding. central rural india finding of mean axial length was 22.6+/-0.91 mm (range, 18.22-34.20 mm)19. it is less than our finding. findings from nepal for al, k1 and k2 are 22.96 + 0.95, 43.64 + 1.45, 44.29 + 1.47 respectively20. so their al is smaller while corneal curvature is comparable to ours. pakistani studies on this topic include following. in hyderabad al, k1 and k2 was found to be 22.96 ± 1.04, 44.00 ± 1.83, 44.78 ± 1.88 respectively21. these readings are less than our readings. in a study from gomal university the range of axial length was 19.50 to 28.0mm22. 581 (58.1%) patients were having axial length 22-23.50mm. ten (1.0%) had axial length > 26 mm and 6 (0.6%) 25 d. the minimum k1 and k2 readings noted were 37.0 d, while the maximum readings were 48.0d. the minimum power calculated as 10.0 d, while the maximum one was 33.0 d. this study divided all the parameters in different subsets but did not give mean and standard deviation. thus though the findings are close to our findings it is difficult to compare the two. our findings are in agreement with the trend observed21 that our eyes are shorter than european eyes and comparable to chinese eyes. however our study differed that indian eyes are shorter and not comparable. regarding differences between males and females,in older male chinese al was 23.38 mm (22.83, 24.00) and acd was 2.75 mm (2.53, 3.00) while for females al was 22.83 mm (22.32, 23.46) and acd was 2.61 mm (2.42, 2.84)23. al and acd findings in this study for both males and females is close to our findings (though slightly less) and confirm our finding that female findings are lower than male readings. los angeles study also found that females had significantly shorter al and shallower acd than males24. in rajasthan, india al in emmetrope males 40 to 60 year of age, was 22.33 mm and in females 22.99 mm25. these readings are less than readings in our biometric findings in patients undergoing cataract surgery; gender comparison pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 245 males and more than our female readings. this study is different because findings in both sexes have been subdivided according to refractive state and mean of total population studied is not available. limitation of our study is that a few readings were missing in the analyzed data while strength of the study is a relatively large sample size. conclusion axial length in pakistani patients is less than that of europeans but more than our asian neighbors like india and nepal. chinese findings are more or less the same as ours. pakistani female cataract patients have smaller axial length and anterior chamber depth but higher corneal curvature and they undergo operation at younger age as compared to their male counterparts. authors affiliation dr. khawaja khalid shoaib fcps, frcs, mcps hpe health bridge hospital, ghazi road, near bhatta chowk, dha, lahore. dr. tariq shakoor mcps, fcps rahbar medical & dental college, 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2013 oct 5. https://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20jk%5bauthor%5d&cauthor=true&cauthor_uid=23638414 https://www.ncbi.nlm.nih.gov/pubmed/?term=chang%20sw%5bauthor%5d&cauthor=true&cauthor_uid=23638414 https://www.ncbi.nlm.nih.gov/pubmed/?term=wang+jk%2c+chang+sw.+optical+biometry+intraocular+lens+power+calculation+using+different+formulas+in+patients+with+different+axial+lengths. https://www.ncbi.nlm.nih.gov/pubmed/?term=wong%20ty%5bauthor%5d&cauthor=true&cauthor_uid=11133850 https://www.ncbi.nlm.nih.gov/pubmed/?term=foster%20pj%5bauthor%5d&cauthor=true&cauthor_uid=11133850 https://www.ncbi.nlm.nih.gov/pubmed/?term=ng%20tp%5bauthor%5d&cauthor=true&cauthor_uid=11133850 https://www.ncbi.nlm.nih.gov/pubmed/?term=tielsch%20jm%5bauthor%5d&cauthor=true&cauthor_uid=11133850 https://www.ncbi.nlm.nih.gov/pubmed/?term=johnson%20gj%5bauthor%5d&cauthor=true&cauthor_uid=11133850 https://www.ncbi.nlm.nih.gov/pubmed/?term=seah%20sk%5bauthor%5d&cauthor=true&cauthor_uid=11133850 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https://www.ncbi.nlm.nih.gov/pubmed/?term=wickremasinghe+s%2c+foster+pj%2c+uranchimeg+d%2c+lee+ps%2c+devereux+jg%2c+alsbirk+ph%2c+et+al.+ocular+biometry+and+refraction+in+mongolian+adults.+invest+ophthalmol+vis+sci+2004%3b45%3a+776-83. https://www.ncbi.nlm.nih.gov/pubmed/?term=wareham%20nj%5bauthor%5d&cauthor=true&cauthor_uid=20606021 https://www.ncbi.nlm.nih.gov/pubmed/?term=khaw%20kt%5bauthor%5d&cauthor=true&cauthor_uid=20606021 https://www.ncbi.nlm.nih.gov/pubmed/?term=nangia%20v%5bauthor%5d&cauthor=true&cauthor_uid=20363029 https://www.ncbi.nlm.nih.gov/pubmed/?term=jonas%20jb%5bauthor%5d&cauthor=true&cauthor_uid=20363029 https://www.ncbi.nlm.nih.gov/pubmed/?term=sinha%20a%5bauthor%5d&cauthor=true&cauthor_uid=20363029 https://www.ncbi.nlm.nih.gov/pubmed/?term=matin%20a%5bauthor%5d&cauthor=true&cauthor_uid=20363029 https://www.ncbi.nlm.nih.gov/pubmed/?term=kulkarni%20m%5bauthor%5d&cauthor=true&cauthor_uid=20363029 https://www.ncbi.nlm.nih.gov/pubmed/?term=panda-jonas%20s%5bauthor%5d&cauthor=true&cauthor_uid=20363029 https://www.ncbi.nlm.nih.gov/pubmed/20363029 http://pubs.sciepub.com/ajphr/3/4a/6/index.html#table1 http://pubs.sciepub.com/ajphr/3/4a/6/index.html#table1 http://pubs.sciepub.com/ajphr/3/4a/6/index.html#table1 http://pubs.sciepub.com/ajphr/3/4a/6/index.html#table1 https://www.ncbi.nlm.nih.gov/pubmed/?term=nizamani%20nb%5bauthor%5d&cauthor=true&cauthor_uid=25523728 https://www.ncbi.nlm.nih.gov/pubmed/?term=surhio%20sa%5bauthor%5d&cauthor=true&cauthor_uid=25523728 https://www.ncbi.nlm.nih.gov/pubmed/?term=memon%20s%5bauthor%5d&cauthor=true&cauthor_uid=25523728 https://www.ncbi.nlm.nih.gov/pubmed/?term=talpur%20ki%5bauthor%5d&cauthor=true&cauthor_uid=25523728 https://www.ncbi.nlm.nih.gov/pubmed/25523728 https://www.ncbi.nlm.nih.gov/pubmed/25523728 https://www.ncbi.nlm.nih.gov/pubmed/25523728 https://www.ncbi.nlm.nih.gov/pubmed/?term=he%20m%5bauthor%5d&cauthor=true&cauthor_uid=19553618 https://www.ncbi.nlm.nih.gov/pubmed/?term=huang%20w%5bauthor%5d&cauthor=true&cauthor_uid=19553618 https://www.ncbi.nlm.nih.gov/pubmed/?term=li%20y%5bauthor%5d&cauthor=true&cauthor_uid=19553618 https://www.ncbi.nlm.nih.gov/pubmed/?term=zheng%20y%5bauthor%5d&cauthor=true&cauthor_uid=19553618 https://www.ncbi.nlm.nih.gov/pubmed/?term=yin%20q%5bauthor%5d&cauthor=true&cauthor_uid=19553618 https://www.ncbi.nlm.nih.gov/pubmed/?term=foster%20pj%5bauthor%5d&cauthor=true&cauthor_uid=19553618 https://www.ncbi.nlm.nih.gov/pubmed/?term=.+he+m%2c+huang+w%2c+li+y%2c+zheng+y%2c+yin+q%2c+foster+pj.+refractive+error+and+biometry+in+older+chinese+adults%3a+the+liwan+eye+study.+invest+ophthalmol+vis+sci+2009%3b+50%3a5130-6. https://www.ncbi.nlm.nih.gov/pubmed/?term=shufelt%20c%5bauthor%5d&cauthor=true&cauthor_uid=16303933 https://www.ncbi.nlm.nih.gov/pubmed/?term=fraser-bell%20s%5bauthor%5d&cauthor=true&cauthor_uid=16303933 https://www.ncbi.nlm.nih.gov/pubmed/?term=ying-lai%20m%5bauthor%5d&cauthor=true&cauthor_uid=16303933 https://www.ncbi.nlm.nih.gov/pubmed/?term=torres%20m%5bauthor%5d&cauthor=true&cauthor_uid=16303933 https://www.ncbi.nlm.nih.gov/pubmed/?term=varma%20r%5bauthor%5d&cauthor=true&cauthor_uid=16303933 https://www.ncbi.nlm.nih.gov/pubmed/?term=varma%20r%5bauthor%5d&cauthor=true&cauthor_uid=16303933 https://www.ncbi.nlm.nih.gov/pubmed/?term=varma%20r%5bauthor%5d&cauthor=true&cauthor_uid=16303933 https://www.ncbi.nlm.nih.gov/pubmed/?term=los%20angeles%20latino%20eye%20study%20group%5bcorporate%20author%5d https://www.ncbi.nlm.nih.gov/pubmed/?term=shufelt+c%2c+fraser-bell+s%2c+ying-lai+m%2c+torres+m%2c+varma+r.+refractive+error%2c+ocular+biometry%2c+and+lens+opalescence+in+an+adult+population%3a+the+los+angeles+latino+eye+study. https://www.ncbi.nlm.nih.gov/pubmed/?term=shufelt+c%2c+fraser-bell+s%2c+ying-lai+m%2c+torres+m%2c+varma+r.+refractive+error%2c+ocular+biometry%2c+and+lens+opalescence+in+an+adult+population%3a+the+los+angeles+latino+eye+study. https://www.ncbi.nlm.nih.gov/pubmed/?term=shufelt+c%2c+fraser-bell+s%2c+ying-lai+m%2c+torres+m%2c+varma+r.+refractive+error%2c+ocular+biometry%2c+and+lens+opalescence+in+an+adult+population%3a+the+los+angeles+latino+eye+study. https://www.ncbi.nlm.nih.gov/pubmed/?term=bhardwaj%20v%5bauthor%5d&cauthor=true&cauthor_uid=24298478 https://www.ncbi.nlm.nih.gov/pubmed/?term=rajeshbhai%20gp%5bauthor%5d&cauthor=true&cauthor_uid=24298478 https://www.ncbi.nlm.nih.gov/pubmed/?term=bhardwaj+v%2c+rajeshbhai+gp.+axial+length%2c+anterior+chamber+depth%3a+a+study+in+different+age+groups+and+refractive+errors.+j+clin+diagn+res+2013%3b+7%3a2211-2. pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 111 original article dropout of newly diagnosed glaucoma patient from follow-up schedule anis-ur-rehman, jamsed faridi, s.m enamul haque, mukti rani mitra, md abdus salam, mostak ahmed pak j ophthalmol 2018, vol. 34, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. anis-ur-rehman green eye hospital dhaka, bangladesh. email: anjumk38dmc@gmail.com …..……………………….. purpose: to evaluate the impact of verbal counseling alone and verbal with structured written counseling in prevention of drop out of glaucoma patients from follow-up schedule. study design: descriptive study. place and duration of study: green eye hospital dhaka, bangladesh for 18 months, from july 2015 to december 2016. material & methods: during the study period, 300 newly diagnosed glaucoma patients were enrolled. they were divided into two groups. group: a & b. each group comprised of 150 patients. group: a patients were verbally counseled and structured written counseling brochures were given and group: b patients were counseled only verbally. results: we compared the dropout during follow-up between the two groups. there was significant difference between the two groups (the chi-square statistics was 9.8182. the p value was 0.001728). moreover, the drop out of elderly patients (>50 years) was less than the patients with < 50 years of age. when there was positive family history of glaucoma dropout was significantly less. in group: a, (p-value was 0.029932, in group b, p value was 0.00011 using chi square test). conclusion: drop out during follow up in newly diagnosed glaucoma patients is less if they are given written brochures with verbal counselling. drop out of elderly glaucoma patients is lesser than the younger age group. key words: glaucoma, glaucoma counseling, intra ocular pressure laucoma is a form of disease in which there is a characteristic potentially progressive optic neuropathy that is associated with visual field loss and in which iop is a key modifiable factor1,2. because it often goes undetected in its early stages, glaucoma is called the “sneak thief of sight." it is estimated that nearly half of the americans who currently have glaucoma are unaware of their condition3. glaucoma prevalence is relatively high in bangladesh. prevalence of definite glaucoma was 2.1%. the prevalence of definite and probable glaucoma was 3.1% in subjects of the same age4. it is the second most common cause of blindness5,6. once nerve fibers die and visual function is lost, it cannot be recovered7. treatment can only help preserve remaining vision; hence it is imperative to detect the disease in its earliest stage8. often, glaucoma is asymptomatic. therefore, people suffering from glaucoma may lose vision without knowing it. regular eye examinations are an important way to detect glaucoma9. after the diagnosis of glaucoma, about half of the patients do not come for follow up visit. most prevalent barrier to being lost to follow up is the belief that there is no problem with one‟s eyes10. this sort of belief is irrespective of age, gender, economic status, level of education. if patient has, any idea about g http://www.geteyesmart.org/eyesmart/eye-health-news/sneak-thief-of-sight.cfm anis-ur-rehman, et al 112 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology glaucoma such as when there is positive family history of glaucoma, dropout of follow up is reduced. most probably it is due to the awareness about the disease. with this concept, we prepared a brochure, which contained some preliminary idea about glaucoma. the brochure contained general concept of glaucoma for the patients and their family and answers to the most frequently asked questions. if the family members have some knowledge about the disease and its ultimate fate, they can persuade the patient for regular follow-ups. the study was undertaken to evaluate the impact of verbal counselling alone and verbal with structured written counselling in prevention of drop out of glaucoma patients from follow-up schedule. material and methods it was a prospective descriptive study done in a private eye hospital in dhaka, bangladesh. study period was from january 2015 to june 2016. during this eighteen months 300 patients were enrolled who were newly diagnosed cases of glaucoma (except acute congestive glaucoma). the diagnosis was made by measurement of intra ocular pressure (iop) with applanation tonometer, cup-disc ratio by direct ophthalmoscopy, visual field analysis by humphrey visual field analyzer, assessment of angle structure by gonioscopy, measurement of corneal thickness by oct and sometimes analysis of optic nerve fiber layer thickness by oct14. when there was no visual field damage, we performed the measurement of retinal nerve fiber layer thickness. decreased rnfl reflectivity may be a predictor of future structural and functional glaucomatous damage15, 16. most of the patients were diagnosed incidentally. others had either positive family history of glaucoma or there was frequent change of presbyopic glasses. after diagnosis of glaucoma, some demographic data was recorded and the two groups were further classified according to: age of the patientabove 50 years and below 50 years, gender, economic status belowand above middle class, level of education below 12 classes or above, family history of glaucoma. we divided all 300 patients into two groups. group a (150 patients) included those who got the written counseling brochures after verbal counselling. the brochure was prepared in local bangla language. following questions were answered in the brochure: 1. what is glaucoma? glaucoma is a lifetime disease like diabetes and hypertension. there is mild increase of your intraocular pressure which causes permanent damage of optic nerve (optic nerve is a part of brain which carries your visual sensation to the brain. if there is damage to the optic nerve, this sensation will not reach to the brain). 2. is glaucoma a curable disease11? it is not a curable disease but if you control your iop with the help of medicines (usually eye drops) there will be no chance of damage of vision for glaucoma. 3. why people cannot realize that he/she is suffering from glaucoma? most glaucoma patients do not have symptoms. as visual loss usually starts from the far periphery, glaucoma sufferers may not notice any visual loss in the early to moderate stages of the disease. by the time, an individual realizes something is wrong; there is usually already quite considerable irreversible visual loss. there is nothing that can completely prevent glaucoma but you can slow down its development and progression with early effective treatment. 12 4. how long should i treat for glaucoma? you should treat it life long as diabetes and hypertension but you have to go to your eye doctor according to his advice and he will check your eye pressure and other investigation if needed. 5. is there any chance to be blind due to glaucoma? there is chance of irreversible blindness in glaucoma if you do not control your eye pressure13. 6. how can i get rid of vision loss due to glaucoma? if you contact your eye doctor regularly and use, eye drop in time according to his advice there is no chance of blindness14. 7. is there any other treatment of glaucoma? usually eye drops are sufficient for glaucoma but sometimes to reduce the number of eye drops, eye specialists like to use laser. surgery is other option but if drops and laser cannot stop progression of the disease your doctor may need to advice you for trabeculectomy surgery. group b included patients who were only counseled verbally. these two groups were advised to come after one month to three months for follow up. no reminder was sent to patients for follow up. we used purposive sampling technique. patients were enlisted in the groups according to the need of the study. after collecting the data, we compared it with the follow up group and with those who did not come for follow up. dropout of newly diagnosed glaucoma patient from follow-up schedule pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 113 association of each group was analyzed by 2x2 table (chi-square test). all statistical analysis was conducted using social science statistics for windows 10. results table 1 shows the demographic profile of both the groups. there is no significant difference between the two groups regarding age, gender, monthly income, education status and family history of glaucoma. in the two groups, the overall follow up was 165 (55%). in group: a it was 96 (64%) and group: b, it was 69 (46%). in two groups, the overall follow up was 165 (55%). in group a, it was 96 (64%) and group b, it was 69 (46%). the difference is significant it means those who were verbally counseled as well as got the brochure “glaucoma the silent killer of your vision” were more motivated regarding their follow-up (table 2). according to age group, those above 50 years were more aware of follow up if they were provided with written counseling brochure (table 3). the results according to gender and income of the patient are given in table 4 & 5. the level of education was also found to be positively related with follow-up (table 6). table 1: shows demographic profile of glaucoma patients during enlistment. group a group b total age below 50 54 51 105 ⁕ ns chi-squared test was done to find the difference between the two groups ⁕ns: non significance above 50 96 99 195 gender male 71 77 148 ⁕ ns female 79 73 152 income above average 83 81 168 ⁕ ns below average 67 69 132 education below 12 class 104 98 202 ⁕ ns above 12 class 46 52 98 + family history yes 47 45 92 ⁕ ns no 103 105 208 table 2: patient follow up between two groups. group a group b p value present 96 69 0.001728 absent 54 81 table 3: follow-up according to age group. group a: came for follow-up no follow-up total p value below 50 24 30 54 0.000182 above 50 72 24 96 total 96 54 150 group b: 0.231469. total below 50 20 31 51 above 50 49 49 99 total 69 81 150 anis-ur-rehman, et al 114 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology table 4: follow-up according to gender. group a: came for follow-up no follow-up total p value male 45 26 71 0.76338 female 51 28 79 total 96 54 150 group b: 0.88084 total male 38 39 77 female 31 42 73 total 69 81 150 table 5: according to income of patient. group a: came for follow-up no follow-up total p value >aver 54 29 83 0.763338 < aver 42 25 67 total 96 54 150 group b: 0.367777 total >aver 40 41 81 <aver 29 40 69 total 69 81 150 table 6: according to level of education of patient. group a: came for follow-up no follow-up total p value < 12 class 60 44 104 0.015521 > 12 class 36 10 46 total 96 54 150 group b: 0.090334 total > aver 40 41 81 < aver 29 40 69 total 69 81 150 table 7: according to family history of glaucoma. group a came for follow-up no follow-up total p value +family 36 11 47 0.029932 -family 60 43 103 total 96 54 150 dropout of newly diagnosed glaucoma patient from follow-up schedule pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 115 group b 0.00011 total +family 33 12 45 -family 36 69 105 total 69 81 150 discussion glaucoma is a disease of the optic nerve and some studies have reported glaucoma as a leading cause of permanent blindness worldwide7. although glaucoma is neither preventable nor curable, the progression of the disease can be halted with appropriate treatment. glaucoma cannot be cured, but it can be successfully controlled in most cases8. as visual loss usually starts from the far periphery, glaucoma sufferers may not notice any visual loss in the early to moderate stages of the disease. by the time an individual realizes something is wrong (needing more light and blurry vision) quite considerable irreversible visual loss has occurred15,16. the results of our study show that both the groups are demographically homogenous. the overall follow up was found to be 55%, which is more than the ashaye et al10 study. in their study, dropout from follow-up was 60.5%, which is higher than our study (in our study overall drop out was 45%) but closer to our group: b population (drop out 54%) where only verbal counseling was given. another study by gupta v1et al showed that even after trabeculectomy surgery only 30% of patients maintained a 5-year follow-up17. in our study drop out from follow-up in group a is significantly less than group: b (p value is 0.001728). gender related drop out in our study was not consistent with ashaye ao et al where males had a higher dropout rate than females (78.6% vs. 34.5%). this was found to be due to male patients coming from a distant locality. however, in our study we did not record the locality of the patient. the drop out of follow-up in relation to economic status was insignificant in our study, which does not correspond to some previous works. maybe this is because the study was done in a private eye hospital and equal accessibility of poor was not possible18. we found that educated patients were more aware of follow-up, which is consistent with bradford et al studies19. level of education is directly proportional with the follow-up rate. in multivariate analysis they showed level of education is directly proportional to follow-up. in adjusted or for poor follow-up (95% ci) is 1.34 (0.65-2.76) vs. 4.13 (1.44-11.90) educated vs. noneducated19. glaucoma is 2 to 4 fold more common with positive family history20,21. we found that drop out of follow-up is significantly reduced when there is positive family history of glaucoma irrespective of counseling which is consistent with green et al22. in their study, follow-up of glaucoma patient was 60% more than those with negative family history of glaucoma, irrespective of counseling. in our study both a (p-value is 0.029932) & b group (p-value is 0.00011) patients came for follow-up (76.6% and 73.3%) whereas the overall was 165 (55%) in a and b groups. in group a it was 96 (64%) and group b, it was 69 (46%)23. conclusion glaucoma is a slowly progressing, symptomless, sight threatening disease and one of the leading cause of preventable blindness worldwide because of missed or late diagnosis and large number of „follow-up dropouts‟ even after diagnosis. counseling is an effective method of creating awareness among the diagnosed patients as well as the risk groups. this study clearly shows the effectiveness of a combined verbal with structured written format of counseling over verbal counseling alone in reducing the dropout rate of the diagnosed glaucoma patients irrespective of age, gender, economic status, and level of education. author’s affiliation dr. md anisur rahman. fcps. head of dept of ophthalmology dhaka medical college dr. jamsed faridi. do registrar department of ophthalmology department of cornea. nio & h https://www.ncbi.nlm.nih.gov/pubmed/?term=ashaye%20ao%5bauthor%5d&cauthor=true&cauthor_uid=18414110 https://www.ncbi.nlm.nih.gov/pubmed/?term=gupta%20v%5bauthor%5d&cauthor=true&cauthor_uid=23350554 https://www.ncbi.nlm.nih.gov/pubmed/?term=ashaye%20ao%5bauthor%5d&cauthor=true&cauthor_uid=18414110 anis-ur-rehman, et al 116 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology dr. s. m. enam-ul-haque soumo ms, ophthalmology assistant professor dr.mukti rani mitra fcps assistant professor department of ophthalmology dhaka medical college dr. md abdus salam ms, fcps, consultant kuwait bangladesh friendship govt hospital. dhaka dr. md mostak ahmed ms ophthalmology, associate professor department of ophthalmology manikganj medical college role of authors dr. md anisur rahman. conception and planning of the work, analysis and interpretation of the data, drafting and/or critical revision of the manuscript for important intellectual content, approval of the final submitted version of the manuscript. dr. jamsed faridi. do conception and planning, analysis and interpretation of the data, drafting, approval of the final submitted version of the manuscript. dr. s.m enamul haque soumo conception and planning, analysis and interpretation of the data, drafting dr. mukti rani mitra conception and planning, analysis and interpretation of the data, drafting dr. md abdus salam conception and planning, analysis and interpretation of the data, drafting dr. md mostak ahmed conception and planning, analysis & drafting references 1. brad bowling. kanski‟s clinical ophthalmology a systemic approach. 8th edition. sydney. elsevier, 2016: 307 p. 2. open angle glaucoma: poag. by admin september 26, 2015. medic for you ‖ medical community. 3. patient's guide to living with glaucoma. stuart carduner. discovering the sneak thief: diagnosing glaucoma. 4. rahman mm, rahman n, foster pj, haque z, zaman au, dineen b, johnson gj. the prevalence of glaucoma in bangladesh: a population based survey in dhaka division. br j ophthalmol. 2004 dec; 88 (12): 1493-7. 5. newspaper: the daily star. glaucoma 3rd biggest cause of blindness. 1:04 am, march 14, 2015. 6. suman s thapa, kurt h kelley, ger v rens, indira paudyal lan chang. a novel approach to glaucoma screening and education in nepal. bmc ophthalmology, 20088: 2. 7. leading causes of blindness. nih medline plus, summer, 2008; 3(3): 14 – 15. 8. robin a, grover sd. compliance and adherence in glaucoma management. indian j ophthalmol. 2011;59 (suppl. 1): s93–s96. doi: 10.4103/0301-4738.73693. 9. cindy x huet al. what do patients with glaucoma see? visual symptoms reported by patients with glaucoma. ajms 2014; 348 (5):403-409. 10. ashaye ao, adeoye ao. characteristics of patients who dropout from a glaucoma clinic. j, glaucoma, 2008; 17 (3): 227-32. doi: 10.1097/ijg.0b013e31815768b3. 11. harry aq. glaucoma: what every patient should know: usa. create space independent publishing platform; 1 edition (may 7, 2011). 12. goldberg i, susanna r jr. how to save your sight. glaucoma 2015; 13: 978-9062992423. 13. jackson a. “glaucoma research foundation. san francisco. understanding and living with glaucoma. 14. boyd k. what is glaucoma? american academy of ophthalmology. uploaded on mar. 01, 2017, cited on 21 feb. 2018. 15. lucy ka, wollstein g. structural and functional evaluations for the early detection of glaucoma. expert rev ophthalmol. 2016; 11 (5): 367–376. 16. “glaucoma research foundation. san francisco. 5 common glaucoma tests. available on https://www.glaucoma.org/glaucoma/diagnostictests.php uploaded on last reviewed on october 29, 2017 cited on. 17. gupta v, chandra a, yogi r, sihota r, singh d. prevalence and causes of patient dropout after glaucoma surgery. ophthalmic epidemiol. 2013; 20 (1): 40-4. doi: 10.3109/09286586.2012.741278. 18. krishnaiah set al. awareness of glaucoma in the rural population of southern india. indian j ophthalmol. 2005; 53 (3): 205-208. 19. bradford w et al. predictors of and barriers associated with poor follow-up in patients with glaucoma in south india. arch ophthalmol. 2008; 126 (10). 20. budde mm, jost b. jonas. family history of glaucoma in the primary and secondary open-angle glaucoma. ophthalmology 1999; 237 (7): 554–557. http://www.tandfonline.com/doi/full/10.1080/17469899.2016.1229599?src=recsys http://www.tandfonline.com/doi/full/10.1080/17469899.2016.1229599?src=recsys http://www.tandfonline.com/doi/full/10.1080/17469899.2016.1229599?src=recsys dropout of newly diagnosed glaucoma patient from follow-up schedule pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 117 21. charles w, monnies j. glaucoma and risk factors. j optom. 2017; 10 (2): 71–78. 22. green cm et al. how significant is a family history of glaucoma? experience from the glaucoma inheritance study in tasmania. clin ex ophthalmol. 2007; 35 (9): 793-9. 23. jeffrey s. build your own medical optometry practice part 1. 2nd edition. 2017 virginia 2. publisher: the od/md consulting group. microsoft word 5. oa rajendra p[1]. maurya rajendra p. maurya, et al 80 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology original article a clinico-epidemiological study of ocular trauma in indian university students rajendra p. maurya, kundan sinha, prithvi r. sen, virendra p. singh, mahendra k. singh, prashant bhushan pak j ophthalmol 2013, vol. 29 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: rajendra p. maurya s.s.hospital, institute of medical sciences, banaras hindu university varanasi, u.p) india …..……………………….. purpose: to observe the pattern, severity and outcome of ocular injuries and to identify the etiological factors responsible for ocular trauma among university students. material and methods: this prospective interventional study was conducted in university students health care complex and department of ophthalmology, institute of medical sciences, banaras hindu university, varanasi from september 2009 to august 2011. one hundred and sixty six university students with eye injuries attending as outpatient or emergency patient were thoroughly examined as per standard clinical procedures to identify the cause, type, extent and severity of injuries and impact on vision. the follow up period was six months. results: out of the 166 patients, 117 (70.48%) were male while 49 (29.52%) were females. patients were aged between 16 and 45 years. 67.47% were delegacy students while 32.53% were hostellers. mechanical injuries accounted for 70.48%, while rest were chemical (11.44%), thermal (9.04%) and radiational injuries (9.04%). most of the injuries occurred at workplace (25.90%) or on the road (25.30%), hostel/residence (21.69%) and during play and sports (19.28%). 79.29% students suffered accidental injuries and rest 27.71% had assault related injuries. the assault related injuries were more common amongst male students (21.69%). 56.02% of mechanical injuries were caused by blunt objects and rest 14.46% were due to sharp objects. commonest type was periocular and lid injury (50%), followed by globe injury (44.58%) and orbital injury (5.42%). left eye was affected in 42.77%, right eye in 34.94% while in 22.29% cases both the eyes were involved. 23.49% student suffered from severe injury, 36.49% had moderate while 40.96% sustained minor injuries. there was bimodal seasonal distribution with first spike during spring and second during rainy season. 73.49% of the injured patients were managed by conservative treatment while rest underwent surgical procedures. the final visual acuity was 6/18 or better in 60.24% patients between 6/18 to 3/60 in 24.11% and 3/60 or less in 12.65%. assessment was not possible in 3.01% cases. conclusion: this study highlights epidemiology of ocular trauma in university students. health education and preventive strategies should be focussed specially during workshop, laboratory work, in play ground and while driving. cular injury remains an important cause of avoidable and predominantly, monocular visual impairment and blindness.1,2 management of ocular trauma has always been a challenge to ophthalmologist.3 eye injuries have significant impact on the individual and society in terms of morbidities, medical cost and loss of productivity, thereby affecting the quality of life. the o a clinico-epidemiological study of ocular trauma in indian university students pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 81 adverse consequences of ocular injuries like visual impairment and physical disfigurement can also isolate the patient socially by imposing a physical and psychological barrier.4 young adult males are more prone to ocular trauma as they indulge in high risk behaviours. a good proportion of work related, assault and sports related eye injuries were reported in young adult males.5 it has been estimated that 90% of all ocular injuries are preventable.6 the formulation of preventive strategies need detailed epidemiological study of ocular trauma which varies in different countries and populations depending on geographical location, socioeconomic status and literacy level etc. the aim of this prospective study was to determine incidence, etiology, severity and outcome of ocular injuries amongst the university students. ocular injuries are one of the common causes of absence of students from classes and it also adversely affects the students performance and educational opportunities. material and methods this prospective interventional study was carried out at the university student’s health care complex and department of ophthalmology, sir sundar lal hospital, institute of medical sciences, banaras hindu university, varanasi over a period of two years, from 5.9.2009 to 4.8.2011. one hundred sixty six students, who presented with acute eye injuries at the outpatient or emergency opd, were included as the study subjects. patients with old ocular trauma, surgically treated elsewhere or those having coexisting vision threatening ocular disease were excluded from the study. the study was approved by the research ethics committee of institute of medical sciences, banaras hindu university. a prior informed consent was obtained from the study subjects. the following demographic and clinical information was recorded for every study subject : age, sex, residence (hosteller / delegacy), educational status (faculty and subjects), date, time, season and place of injury, circumstances leading to eye injury, type and manner of injury, the object causing ocular injury, history of alcohol consumption at the time of injury and use of protective eyewear. the patients were examined by standard ophthalmological procedures to note the areas injured, type and related injury, severity of injury and initial visual acuity. radiological investigations, if indicated, for confirming foreign body and extent of injury, were performed. after confirming the diagnosis, patients were segregated in minor, moderate and severe group depending on threat to globe and potential for disfigurement (table 1). the study subjects were assessed for deciding the treatment modalities and prognosis. finally, the visual outcome at the end of the treatment and during follow up was noted. all this information was collected in a predesigned and pre-tested performa. the collected data was entered in the spss version 11.0. categorical and numerical variables were analyzed as frequency and percentages. chi – square test of significance was applied and p-value of less than 0.05 was taken as significant. results out of the one hundred and sixty six students who presented with ocular injury during the study period, 117 (70.48%) were males and 49 (29.52%) were females. the two commonest affected age groups were between 26 to 35 years (43.37%) and 16 to 25 yeas (33.74%). 54 (32.53%) students were hosteller and rest 112 (67.47%) were residing outside the university campus. 76 (45.78%) were professional (technical) students who belonged to engineering, medical, management and research stream, while 90 (54.22%) were non-professional (non-technical) students from arts, social science and other allied subjects. 43 (25.90%) students were under the influence of alcohol when they sustained ocular injury. only 13 (7.84%) patients had worn protective eyewear at the time of injury (table 2). the ocular injury occurred most often in males between the age of 26 – 35 years (29.52%) and 16 – 25 years (25.30%). majority of female (n = 23, 13.86%) patients belonged to 26 – 35 years age group. the left eye was involved in 71 (42.77%) and right eye in 58 (34.94%), while 37 (22.29%) patients sustained bilateral eye injuries (table 3). when place of injury was ascertained according to age distribution, it was found that commonest place of injury in all age group was place of work (25.90%) like department, laboratory, workshop etc., followed by road / street (25.30%), residence / hostel (21.69%) and place of sports or ground (19.28%) (table 4). a bimodal seasonal distribution was observed with first spike between february to april and second between july to september (fig. 1). most common causes of eye injury amongst the university students was assault (n = 46, rajendra p. maurya, et al 82 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology a clinico-epidemiological study of ocular trauma in indian university students pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 83 fig. 1: month wise distribution of ocular injury. 27.71%) followed by road traffic accident (n = 31, 18.67%), sports and recreational activities (n = 23, 13.85%) and accidental fall (n = 19, 11.45%). however, in 19 (11.45%) students, injury resulted from chemical exposure and in 15 (9.04%) cases it was radiational injury (table 5). the most common source of injury was mechanical (n = 117, 70.48%) followed by blunt trauma (n = 83, 50%) and 24 (14.46%) by sharp objects, the remaining 10 (6.02%) were indeterminate. commonest type of injury was periocular and lid (n = 83, 50%) (fig. 2 and 3) followed by globe (n = 74, 44.58%) and orbital injuries (n = 9, 5.42%) (fig. 4). amongst the periocular and lid injuries, 20 (12.05%) had contusion, 15 (9.04%) had lacerated wound while 22 (13.25%) cases sustained burn. amongst the open globe injuries (n = 30, 18.07%), 11 (6.63%) had corneal/ corneo-scleral laceration, 13 (7.84%) had penetrating injury with or without lens/uvea involvement while 6 5 16 23 22 7 5 12 21 0 5 10 15 20 25 30 jan feb mar apr may jun jul aug sep oct nov dec 3.01% 9.64% 13.86% 13.25% 4.22% 3.01% 7.23% 12.65% 27 16.27% 10 6.02% 9 5.42% 9 5.42% rajendra p. maurya, et al 84 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology (3.61%) cases had ruptured globe (fig. 5). closed globe injury accounted for 44 (26.51%) including lamellar laceration in 7 (4.22%) and contusion in 38 (22.89%) cases (table 6). the most commonly involved structure of eyeball was anterior segment (n = 50, 30.12%) while posterior segment abnormalities were present in 24 (14.4.6%) cases. 39 (23.49%) students suffered severe injury, 59 (35.54%) had moderate while 68 (40.96%) had minor injuries. most of the severe injuries among the a clinico-epidemiological study of ocular trauma in indian university students pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 85 (a) (b) fig. 2: (a) pre and (b) post operative photograph of a student having left eye lid and periocular injury (a) (b) fig. 3: (a) pre and (b) post operative photograph of student having right eye lid injury (a) (b) fig. 4: (a) photograph of student having left eye blow out fracture orbit due to assault with blunt object (b) ct scan coronal view showing fracture floor of left orbit with soft tissue protrusion in left maxillary sinus. students were caused by road traffic accidents (n = 12, 7.23%), assault injury (n = 9, 5.42%) (fig. 5 and 6) and sports related events (n = 6, 3.61%) (table 5). 133 (80.12%) study subjects were treated on outpatient basis and rest 33 (19.88%) cases required hospitalization. five of them required emergency intervention. 122 (73.45%) students were managed by conservative treatment while the rest 44 (26.51%) had to undergo surgery. 21 (12.65%) study subjects needed fig. 5: photograph of student having rupture globe (a) (b) fig. 6: (a) photograph of student having gunshot injury right eye (b) ct scan axial view of same patient showing penetrating injury right globe. only primary wound repair. (n = 23, 13.80%) required secondary procedures including skin grafting (n = 5, 3.01%), cataract extraction with lens implantation (n = 8, 4.82%), vitreoretinal surgery (n = 4, 2.41%), rajendra p. maurya, et al 86 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology orbital surgery (n = 4, 2.41%) and evisceration (n = 2, 1.20%). upon initial presentation, (n = 74, 44.58%) had visual impairment (va<6/18) out of which 25 (15.06%) were blind (va< 3/60). 86 (51.81%) had normal vision (va 6/6 to 6/18). assessment of visual acuity on initial visit was not possible in 6 (3.61%) serious patients. on final follow up, the number of visually impaired patients had fallen to 61 (36.76%) and blind cases to 21 (12.65%). discussion although ocular injury is an important cause of preventable unilateral loss of vision, particularly in developing countries7, relatively few epidemiological studies have been carried out in developing countries. young adult males carry the highest incidence of ocular injuries.8 in our studies 77.11% students were below 35 years of age out of which 43.3.7% were between 26 – 35 years of age and 33.74% between 16 – 25 years. our study showed male predominance with male / female ratio being 2.4/1. other studies revealed a male:female ratio of 4:1 (babar et al.)9, 3:1 (jahangir et al)10 and 5.25:1 (arfat my et al)11. some authors2,12-14 have also reported age and gender pattern comparable to our study. our observation indicates that male students were more exposed to outdoor activities. maximum (67.47%) students who sustained ocular injuries were residing outside the university campus. they usually traveled long distance and thus exposed to vehicular and projectile object related ocular injuries. the frequency of ocular trauma was higher in the left (71; 42.77%) as compared to right eye (58; 34.94%). it may be due to high (27.71%) assault related injuries in this study. groessl et al.15 and shephered et al16 reported high proportion of left eye involvement in assault related ocular and facial injury. this may be due to the fact that a right handed assailant can more easily strike the left side of the face of victim. however, arfat m.y. et al.11 reported high proportion of right eye injury (66%). the frequency of bilaterality was 22.29% in our study in contrast to findings of babar t.f. et al.17 (2.9%) and jahangir t. et al.(3%)10. this is probably because most of our injury cases were as a result of assault, road traffic accident, fall and chemical or thermal exposure. it was observed that most common place of injury was the place of work (25.90%) like laboratory, workshop and department etc. followed by road or street (25.30%), at home / hostel (21.69%) and place of sport or recreation (19.28%). other researchers reported home as the commonest place of injury [thompson et al.6 (58%), luff et al.18 (34%), kuhn et al.19 (43%) and macewen et al.20 (51%). work related injuries were reported to be the commonest cause of eye injury in adults.21-23 bimodal trend of seasonal distribution was observed with first spike between february to april (spring) and second between july to september (rainy). mackiewicz et al24 and keklikci u et al.25 reported peak ocular injures in summer months when schools have holidays and students indulge more in outdoor games. gyasi m.e. et al.21 from ghana reported bimodal pattern between march to may and september to november which is the actual farming and harvesting season in this country. canavana y.m. et al.26 from ireland reported high incidence of ocular injury due to sports and domestic or agricultural accidents in winter season in contrast to our study in which incidence of injury was least in winter due to cold weather and students examination time and in month of may & june when university was closed due to summer vacation. assault has been recognized as a frequent and serious cause of eye injury in young adults.15,22,27,28 groessl et al.15 reported incidence of assault related ocular injuries ranging from 1% to 53%. in our study also commonest cause of ocular injury was assault (n = 46, 27.71%), which reflects increasing trends of personal conflicts among the university students. similar incidence was reported in previous studies of dannenberg a et al.29 (22%), macewen et al.20 (18.6%), niiranene m. et al.30 (27%) and gilbert et al.31 (30%). however, higher incidence of assault related eye injuries were reported in us (41%) by liggett et al32 in war prone countries like israel (34%) by scherf and zonis33 and in lesotho (53%) by gordon and mokete.34 second common cause of ocular injury was road traffic accident (n = 31, 18.67%). out of this majority (n = 20, 12.85%) were delegacy students probably as a result of fast, uncontrolled two wheeler driving and poor road condition in our district. canavan y.m. et al.26 reported 32.5% and mackay et al35, 70% eye injuries as a result of road traffic accidents. sport or play related injuries were third most common cause of ocular injury (n = 23, 13.85%) in our study. similar observations were reported by luff et al18 (15%) and kuhn et al.19 (13%) sechein et al22 (34%) and blomdahl et al36 (23%) reported slightly higher incidence of sports related injuries. a clinico-epidemiological study of ocular trauma in indian university students pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 87 other important causes were chemical injury (11.45%) like acid or lime burn and radiation injury (9.04%) like infrared or ultraviolet keratitis. majority of these subjects were professional or technical students sustaining injury while working with chemicals and uv or infrared lamps in the laboratory. no eye protection was taken by 118 (71.08%) students at the time of injury. our study emphasized the need to wear appropriate protective devices like safety goggles, helmet, uv protective shield and protective face-masks during driving, working in laboratory or workshop and while playing hockey / football or other games. in our study, blunt injuries predominate (50%). in only 14.46%, injury was caused by sharp objects. this finding was consistent with those of macewen et al.20 and contrary to the study of jahangir et al10 and fasih et al.37 in which most common source of injury was sharp objects. most of our cases were of peri-ocular and lid injuries of minor severity. blunt objects cause contusional posterior segment injury (4.82%) and ruptured globe (3.61%) while penetrating injury caused by sharp object (7.48%) results in severe ocular injury. 77.10% of the students having mild to moderate injury were managed by conservative/medical treatment or by minor surgical procedures without hospitalization, rest underwent surgical intervention after hospitalization. final visual acuity was normal (6/6 to 6/18) in 60.24% visual impairment (<6/18 – 3/60) in 24.11% and blindness (<3/60 – npl) in 12.65%. visual outcome depends on the type and extent of injury and presence or absence of complications. in our study injury caused by blunt objects especially ruptured globe have worse prognosis than those caused by sharp objects. similar findings were reported by other authors.2,31,38 complications like hyphaema, vitreous hemorrhage, retinal detachment and uveal tissue prolapse or incarceration were associated with very poor prognosis.9,39 conclusion this study has unveiled pertinent information related to causes, incidence and severity of ocular injury in young adults. the study also emphasizes the need to wear appropriate protective devices during work, play and driving because most of the ocular injuries were preventable. though prevention of assault related eye injuries is more difficult than work and sport related eye injuries, government and university administration could play important role in prevention of ocular injury by imposing / implementing protective eye health policies and strict rules against conflict / assault. author’s affiliation dr. rajendra p. maurya m.s (ophthalmology) medical officer, casuality, s.s. hospital, institute of medical sciences, banaras hindu university varanasi, u.p) india -221005 dr. kundan sinha m.d.( medicin) chief medical officer incharge ,university student health care complex, b.h.u, varanasi, (u.p) india -221005 dr. prithvi r. sen m.d (psm) siniar medical officer, university health care complex b.h.u, varanasi, (u.p) india -221005 dr. virendra p. singh m.s (ophthalmology) head department of ophthalmology, i.m.s, b.h.u, varanasi, (u.p) india -221005 dr. mahendra k. singh m.s (ophthalmology) department of ophthalmology ims, b.h.u, varanasi, (u.p) india -221005 dr. prashant bhushan m s (ophthalmology) ssistant professor department of ophthalmology, institute of medical sciences , banaras hindu university, varanasi ,(u.p) india 221005 references 1. editorial progress in surgical management of ocular trauma. british j. ophthalmology, 1976; 60: 731. 2. desai p. macewen cj., baines p. minassain dc. incidence 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injury. am j ophthalmol. 1993; 116: 26-33. 16. shepherd jp, al-kotary my. subandanc and scully c. assault and facial soft tissue injuries. br j plast surg. 1987; 40: 614. 17. babar tf, khan mn, jan s, shah sa, zaman m, khan md. frequency and causes of bilateral ocular trauma. jcpsp. 2007; 17: 679-82. 18. luff aj, hodgkins pr, baxter rj, morrell aj, calder i. aetiology of perforating eye injury. arch. dis. child. 1993, 68: 682-3. 19. kuhn f, morris r, witherspoon cd, mann l. epidemiology of blinding trauma in united state eye injury registry. ophthalmic epidemiol. 2006; 13: 209-16. 20. macewen cj, baines ps, desai p. eye injuries in children: the current picture. br. j. ophthal. 1990; 83: 933-6. 21. gyasi me, amoaku wmk, adjuik ma. epidemiology of hospitalized ocular injuries in the upper east region of ghana. ghana medical journal. 2007; 4194: 171-5. 22. schein od, hibberd pl, shingleton bj, kunzweiler t, frambach da, seddon jm, fontan nl, vinger pf. the spectrum and burden of ocular injury. ophthalmology. 1988; 95: 300. 23. nirmalan pk, katz j, tielsch jm, robin al, thulasirj rd, krishnadas r, et al. ocular trauma in a rural south indian population: aravind comprehensive eye survey. ophthalmol. 2004; 111: 1778-81. 24. mackiewicz j, machowicz-matejko e, salaga-pylak m, piecyk-sidor m, zagórski z. work related penetrating eye injuries in rural environments. ann. agric. environ. med. 2005; 12: 27-9. 25. keklikci u, celik y, cakmak ss, sakalar yb, unlu mk. evaluation of perforating eye injuries by using cluster analysis. ann. ophthalmol. 2008; 40: 87-93. 26. canavan ym, o’flaherty mj, archer db and elwood jh. a 10 year survey of eye injuries in northern ireland, 1967-76. br j ophthalmol. 1980; 64: 618-25. 27. garrow a. a statistical enquiry into a thousand cases of eye injury. br j ophthalmol. 1990; 83: 933-6. 28. rapaport i, romem m, kinck m, et al. eye injuries in children in israel; a nationwide collaborative study. arch ophthalmol. 1990; 108: 376-9. 29. dannenberg al, parver lm, fowler cj. penetrating eye injuries related to assault. the national eye trauma system registry. arch. ophthalmol. 1992; 110; 849. 30. niiranen m. perforating eye injuries related at helsinkin university eye hospital 1970 to 1977. ann ophthalmol. 1981; 13: 957. 31. gilbert cm, soong hk and hirst lw. a two year prospective study of penetrating ocular trauma. ann ophthalmol. 1987; 19: 104. 32. liggett pe, pince kj, barlow w, ragen m, ryan sj. ocular trauma in an urban population. review of 1132 cases. ophthalmology. 1990; 97: 581. 33. scherf j and zonis s. perforating injuries of the eye. eye, ear, throat. mon. 1976, 55: 32. 34. gordon yj, mokete m. adult ocular injuries in lesotho. doc. ophthalmol. 1981; 51: 187. 35. mackay gm. incidence of trauma to the eyes of car occupants. trans. ophthalmol. soc. uk, 1975; 95: 311-4. 36. blomdahl s, norell s. perforating eye injury in the stockholm population. an epidemiological study. acta ophthalmol. 1984; 62: 378-90. 37. fasih u, shaikh a, fehmi ms. occupational ocular trauma (causes, management and prevention). pak j ophthalmol. 2004; 20: 65-73. 38. rahman i, maino a, devadson d, leatherbarrow b. open globe injuries: factors predictive of poor outcome. eye 2005: 1-5. 39. yeung l, chen tl, kuo yh, chao an, wu wc, chen kj, hwang ys, chen y, lai cc. severe vitreous haemorrhage associated with closed globe injury. graefes arch clin exp. ophthalmol. 2006; 244: 52-7. microsoft word 04-oa sohail zia pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 12 original article intraocular pressure after iol implantation with hydroxypropylmethylcellulose 2% vs hydro-implantation sohail zia, yasir iqbal, khalid masood ashraf, aneeq mirza pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sohail zia eye department islamic international medical college pakistan raiways hospital rawalpindi …..……………………….. purpose: to compare post-operative intraocular pressure between intraocular lens (iol) implantation using hydroxypropylmethylcellulose (hpmc) 2% and iol implantation by hydro-implantation technique after phacoemulsification. material and methods: this comparative, prospective study with convenience (non probability) sampling was conducted on 100 patients. we divided the patients into two groups. fifty patients (group a) had iol implantation with hpmc 2% and 50 patients (group b) had iol with hydro-implantation after phacoemulsification of the lens. post-operative iop changes were compared with the preoperative iop of the same group and between the two groups at 24 hours and 7th post-operative day. a p-value < 0.05 was used as significance cut off point. results: there was no significant difference in mean pre-operative iop of both groups (p-value = 0.480). group a, experienced statistically significant elevation in mean iop at 24 hours after surgery, over the pre-operative values (p-value: 0.021). elevation in mean iop in group b at 24 hours after surgery was found insignificant (p-value: 0.154). difference between mean post-operative iop of the two groups at 24 hours after surgery was also significant (p-value: 0.032). on 7th day after surgery, mean iop in both groups had returned to approximately pre-operative values. moreover, the mean iop values at 7th post-operative day were also comparable between the two groups (p-value: 0.420). conclusions: compared with the use of hpmc for iol implantation, hydroimplantation of iol resulted in insignificant rise in post-operative iop at 24 hours. phthalmic viscosurgical devices (ovds) are being used successfully in many ophthalmic surgeries, most commonly in cataract surgery1. ovds help in cataract surgery by maintaining the depth and shape of anterior chamber (ac) especially in the stages of capsulorhexis and iol implantation2. they also provide viscous protection to the delicate corneal endothelium from surgically induced trauma3. based on their rheological properties ovds have been classified as cohesive and dispersive4. the cohesive ovds have high viscosity, high molecular weight and contain long molecular chains, dispersive ovds like hydroxypropylmethylcellulose 2% (hpmc) have lower viscosity with shorter molecular chains that have less tendency to entangle5. use of ovds in cataract surgery can be associated with adverse effects; the most commonly and potentially dangerous is the rise, usually transient, in post-operative intra ocular pressure (iop)6. to prevent this complication, the ovd should be removed through aspiration after intraocular lens (iol) implantation; however, an ovd located in the ciliary sulcus or behind the iol may not be easily removed. o sohail zia, et al 13 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology hydro-implantation is a technique of implanting iol under continuous irrigation from either irrigation cannula of phacoemulsification machine or simco cannula without using ovds. we conducted a study to evaluate the effect on iop following phacoemulsification with iol implantation by either using ovd (hpmc 2%) or hydro-implantation of iol. material and methods this comparative, prospective study with convenience (non probability) sampling was conducted from september 2011 to march 2012 at lrbt eye hospital mandra, rawalpindi. patients with ages from 50 years to 75 years were selected for the study. the patients were first allotted the hospital registration number before proceeding to the examination. complete eye examination was performed. eyes with senile uncomplicated cataracts were selected. patients with pre-operatively raised iop, previous history of glaucoma or narrow/closed angle on gonioscopy were excluded. dark brown cataracts were also excluded because of a likelihood of converting to ecce or prolonged phacoemulsification time. cases that had any serious complication like posterior capsule rent with or without vitreous loss were also excluded from the study. one hundred patients meeting the inclusion and exclusion criteria were selected for the study and were divided into two groups, a and b of 50 patients each. the study procedure and its aims were explained to all the patients before beginning the treatment and they had to sign on informed written consent form. pre-operative iop (baseline iop) was again checked and recorded one day prior to surgery. a 3.25mm clear corneal incision and two side ports were constructed at 10 and 2 o’clock positions in all patients. anterior chamber (ac) was filled with hpmc and capsulorhexis was carried out. phacoemulsification was done with same technique in both groups. in group a after completion of phacoemulsification, incision was enlarged to 5.5mm after maintenance of ac and capsular bag with hpmc and 5.5mm rigid pmma iol was secured in capsular bag. hpmc was aspirated thoroughly from the ac, the angle, the capsule fornix and the retrolenticular space using simco cannula. side ports and main incision were sealed with stromal hydration. in group b after completion of phacoemulsification, incision was enlarged after maintaining the ac by the inflow of the fluid from the simco cannula held in non dominant side’s side port (left side in our case). pmma iol was held with mcpherson forceps in the right hand and advancing haptic of iol was inserted through the main incision, pushing it forward and downward, with an angle of 45-50 degrees, securing it in the capsular bag. through main incision, with the iol dialer, iol was engaged from the hapticoptic junction. with a forward, downward and clockwise movement trailing haptic was secured in the capsular bag. as no ovd was used for implantation of iol, no removal of ovd was required. side ports and main incision were sealed with stromal hydration. iop measurements were done at 24 hours and 1 week post-operatively in both groups and were compared with the baseline iop (preoperative). iop measurement was carried out by the same ophthalmologist on same instrument used for preoperative iop measurement. analysis of the data was carried out using statistical package for social sciences (spss) version 13.0. student ‘t’ test was used to compare the mean iop of each group at each time interval. ‘t’ test was also applied for comparison of results between the two groups. a p-value < 0.05 was used as significance cut off point. results data of 100 patients (47 males and 53 females) was analyzed. out of those, 50 (24 males and 26 females) were in group a (2% hpmc group) and 50 (23 males and 27 females) were in group b (hydro-implantation group). age spectrum was from 56 to 72 years in group a and from 54 to 74 years in group b. the age difference between the two groups was statistically insignificant (p-value: 0.275). there was no significant difference in mean pre-operative iop of both groups (p-value: 0.483), table 1. no patient in either group had a pre-operative iop greater than 19mm of hg. group a experienced statistically significant elevation in mean iop at first 24 hours after surgery, over the pre-operative values (p-value: 0.021), table-2. elevation in mean iop in group b at first 24 hours after surgery was found insignificant over the preoperative values (p-value: 0.154), table-2. difference between mean post-operative iop of the two groups at 24 hours after surgery was also compared and found significant (p-value: 0.032). on 7th day after surgery, iop after iol implantation with hydroxypropylmethylcellulose 2% vs hydro-implantation pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 14 mean change in iop from their respective baselines in both groups was found insignificant and iop in both groups had returned approximately to the preoperative values, table 3. moreover, the mean iop values at 7th postoperative day were also comparable between the two groups (p-value: 0.420). discussion elevated iop is common post-operative complication following phacoemulisification7. ovd remaining in the eye may cause mechanical obstruction of the trabecular meshwork and is a major cause for early post-operative rise in iop8. the particles of low-viscosity ovds like hpmc are considered dispersive, because they do not adhere to one another. dispersive ovds protect individual structures in the anterior chamber such as the corneal endothelium better than cohesive ovd9. however, low-viscosity ovds are generally more difficult to remove from the eye completely because of their dispersive nature10. arshinoff had published multiple studies comparing different ovds4,11-13. he concluded that, if not completely removed, all ovds cause postoperative increases in iop. according to arshin off et al, all high-viscosity ovds are associated with higher post-operative iops (although not necessarily above 21mm hg) compared with lower-viscosity ovds. he concluded that retained viscoelastic and predisposetions like trabecular insult or undiagnosed glaucoma are the main causes of post-operative rises in iop. a local study conducted by waseem et al14 compared the effect on iop between hpmc and sodium hyaluronate (cohesive ovd) and concluded that iop rises in both groups but more significantly in sodium hyaluronate group. in 1983, berson et al15 also reported that sodium hyaluronate when injected into the anterior chamber caused increase in iop ranging from 55 to 60mm of hg due to blockade of trabecular meshwork. thorough removal of ovd is vital for avoidance of a post-operative iop increase. however, complete removal of the ovd behind the iol is known to be difficult. several surgical techniques for removal of ovd, particularly from behind the iol, have been described16, however, complete avoidance of a postoperative iop increase has not been achieved with any technique. in our study, we used hydro-implantation technique for iol implantation in one group. no spike of raised iop was recorded at any time interval in this group. this indicates that hydro-implantation did reduce the risk for elevated post-operative iop. our results are augmented by a study conducted by tak17 for foldable iol implantation using hydroimplantation. the learning curve of the technique is short but the beginner might find some difficulties in implantation iol with this technique initially. in case of any difficulty, surgeon can always shift back to conventional method of iol implantation with ovd. conclusion we conclude that hydro-implantation technique can reduce the risk for post-operative high iop and related ocular co-morbidities. author’s affiliation dr. sohail zia senior registrar eye department islamic international medical college pakistan railways hospital, rawalpindi dr. yasir iqbal senior registrar eye department islamic international medical college pakistan railways hospital, rawalpindi sohail zia, et al 15 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology dr. khalid masood ashraf layton rahmatulla benevolent trust (lrbt) eye hospital, g. t. road, mandra rawalpindi dr. aneeq mirza professor and head of eye department islamic international medical college pakistan railways hospital rawalpindi references 1. larson rs, lindstrom rl, skelnik dl. viscoelastic agents. clao j. 1989; 15: 151-60. 2. bissen-miyajima h. ophthalmic viscosurgical devices. curr opin ophthalmol. 2008; 19: 50–4. 3. storr-paulsen a, nørregaard jc, farik g, tarnhoj j. the influence of viscoelastic substances on the corneal endothelial cell population during cataract surgery: a prospective study of cohesive and dispersive viscoelastics. acta ophthalmol scand. 2007; 85: 183–7. 4. arshinoff s. new terminology: ophthalmic viscosurgical devices. j cataract refract surg. 2000; 26: 627–8. 5. pandey s, thakur j, werner l, izak a, apple d. update on ophthalmic viscosurgical devices. agarwal s, agarwal a, agarwal a. phacoemulsification. 3rd ed. boca raton, fl: taylor and francis. 2004; 179-95. 6. vajpayee r, verma k, sinha r, titiyal j, pandey rm, sharma n. comparative evaluation of efficacy and safety of ophthalmic viscosurgical devices in phacoemulsification. bmc ophthalmol. 2005; 5: 17. 7. dooley i, beatty s. discussion of changes in intraocular pressure and anterior morphometry following phacoemulsification cataract surgery. arch ophthalmol. 2012; 130: 949-50. 8. bömer tg, lagrèze wd, funk j. intraocular pressure rise after phacoemulsification with posterior chamber lens implantation: effect of prophylactic medication, wound closure, and surgeon's experience. br j ophthalmol. 1995; 79: 809-13. 9. bollinger k, smith s. ophthalmic viscosurgical devices. henderson b. essentials of cataract surgery. thorofare, nj: slack inc. 2007; 63-8. 10. oshika t, okamoto f, kaji y, hiraoka t, kiuchi t, sato m, kawana k. retention and removal of a new viscous dispersive ophthalmic viscosurgical device during cataract surgery in animal eyes. br j ophthalmol. 2006; 90: 485-7. 11. arshinoff sa, jafari m. new classification of ophthalmic viscosurgical devices. j cataract refract surg. 2005; 31: 2167-71. 12. arshinoff sa, wong e. understanding, retaining and removing dispersive and pseudo dispersive ophthalmic viscosurgical devices. j cataract refract surg. 2003; 29: 2318-23. 13. arshinoff sa, albiani da, taylor-laporte j. intraocular pressure after bilateral cataract surgery using healon, healon5, and healon gv. j cataract refract surg. 2002; 28: 617-25. 14. waseem m, rustam n, qamar ul islam. intraocular pressure after phacoemulsification using hydroxypropylmethylcellulose and sodium hyaluronate as viscoelastics. j ayub med coll abbottabad. 2007; 19: 425. 15. berson fg, patterson mm, epstein dl. obstruction of aqueous outflow by sodium hyaluronate in enucleated human eyes. am j ophthalmol. 1983; 95: 668-72. 16. h y lee, y j choy, j s park. comparison of ovd and bss for maintaining the anterior chamber during iol implantation. korean j ophthalmol. 2011; 25: 15-21. 17. tak h. hydro-implantation: foldable intraocular lens implantation without an ophthalmic viscosurgical device. j cataract refract surg. 2010; 36: 377-9. pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 147 original article prevalence of hepatitis b and c in urban patients undergoing cataract surgery waqar ul huda, naz jameel, uzma fasih, attiya rehman, arshad shaikh pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: waqar ul huda r-104 sector 7 d, north karachi karachi …..……………………….. purpose: this study was carried out to measure the prevalence of hbv and hcv in cataract surgical patients. material and methods: this was a prospective observational study conducted at ophthalmology department abbasi shaheed hospital karachi from december 2010 to april 2011. a total of 150 patients above the age of 30 years undergoing elective cataract surgery were screened for hepatitis b and c. the patients were screened for hbs ag and anti-hcv using immunochromatography (ict method). those who were positive by ict were further tested by enzyme linked immunosorbent assay (elisa). results: hbv or hcv was present in 26 (17.33%) patients out of 150. prevalence among the male patients was 20% while among female was 13.33%. out of 26 positive patients, 7 patients (26.92%) were hepatitis b positive and 19 patients (73.07%) were hepatitis c positive. conclusion: it is mandatory to be screened for hepatitis b and c preoperatively for every patient undergoing cataract surgery. epatitis b and c virus infections affect the liver and results in a broad spectrum of disease outcomes. an infection with hbv can spontaneously resolve and lead to protective immunity, result in a chronic infection and, in rare cases, cause acute liver failure with a high risk of dying. in contrast to hbv, an infection with hcv becomes chronic in most cases.1 people with chronic hepatitis b and/or c virus infection remain infectious to others and are at risk of serious liver disease such as liver cirrhosis or hepatocellular cancer (hcc) later in life.2,3 estimated prevalence of chronic carrier state of hepatitis b amongst high-risk groups in pakistan ranges from 6 – 12% whereas prevalence of hepatitis c in the high-risk population is much higher ranging from 15 – 25%. in addition, it has also been estimated that 5% of the general population are chronic carriers of hepatitis c and 3% of general population are chronic carrier of hepatitis b.4 the prevalence of hepatitis varies from country to country, and at times it will also vary among different regions of the same country. the epidemiological estimates by who show that the prevalence of hepatitis c is low (<1%) in australia, canada and northern europe, and about 1% in countries of medium endemicity, such as the usa and most of europe. it is high (>2%) in many countries of africa, latin america, central and south-east asia. in these countries, prevalence figures between 5% and 10% are frequently reported.5 pakistan is a developing country of 180 million people with low health and educational standards. according to the human development index of the united nations, it was ranked 134th out of 174 countries.6 public health authorities are creating awareness about hepatitis through print and electronic media,7 but still tremendous efforts are required to increase the awareness regarding various risk factors involved in hepatitis transmission. in developing countries, due to non-implementation of international standards regarding surgical procedures like cataract surgery, blood transfusion, reuse of needles, reuse of syringes, injecting drug users, tattooing, shaving from h waqar ul huda, et al 148 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology barbers, unsterilized dental and surgical instruments are the main source of transmission of hbv and hcv.8 hepatitis b and c are not routinely tested before cataract surgery in majority of our ophthalmology setting. this study was carried out to find out the prevalence of hepatitis b and hepatitis c in our cataract surgical patients in order to get an idea about the requirement of routine preoperative testing for hepatitis b and c. material and methods this study was conducted in ophthalmology department of abbasi shaheed hospital, karachi from december 2010 to april 2011. institutional ethical approval was taken and informed consent was taken from every patient. we included all the patients who came to ophthalmology clinic and underwent elective cataract surgery. all patients who were known hepatitis b and c positive were excluded. the blood samples of all these patients were taken in the hospital laboratory and were screened for hbsag and anti hcv using immunochromatography (ict method). those who were positive by ict were further tested by enzyme linked immunosorbent assay (elisa). we entered all the data in spss version 16 and we measured the prevalence and percentage of all variables. results the total number of patients included in our study was 150. out of 150, 90 (60%) were male and 60 (40%) were female. most of patients were in the 5th (43.33%) and 6th (26.66%) decade of life as shown in (fig. 1). hbv or hcv was present in 26 (17.33%) patients. among male patients (90), 18 were positive for hepatitis b/c, so the prevalence among male patients was 20%. among 60 enrolled female patients, 8 were positive for hepatitis b/c, so the prevalence among female patients was 13.33%. out of 26 hbv or hcv positive patients, 7 patients (26.92%) were hepatitis b positive and 19 patients (73.07%) were hepatitis c positive. most of hepatitis b/c positive patients (70%) were in the age group of 5th and 6th decade of life as shown in (fig. 2). discussion viral hepatitis is the major health problem in the 3rd world countries today including pakistan. hbv and hcv prevalence is high in the general population1. screening of unknown asymptomatic people is not only important tool in disease detection, prompt diagnosis and treatment but also prevent disease transmission. 0 10 20 30 40 50 60 70 31 41 years 41 50 years 51 60 years above 70 years fig. 1: age distribution of patients in the study 0 2 4 6 8 10 12 31 40 years 41 50 years 51 60 years above 60 years hcv hbv fig. 2: age distribution of hbv and hcv positive patients in our study the higher prevalence of hepatitis b and c were in the age range of 51 – 60 years, which is comparable to the study of talpur et al in which 65% positive patients were above the age of 40 years.9 hepatitis b and c was present in 26 patients (17.33%) out of 150. we enrolled 90 male patient and 60 female patients. among male patients, 18 were positive for hepatitis b/c, so the prevalence among male patients was 20%. while among 60 enrolled female patients, 8 were positive for hepatitis b/c, made the prevalence 13.33% in female, which was consistent with the study done by ali et al.10 our study showed that prevalence of hepatitis c was more than hepatitis b. this was consistent with prevalence of hepatitis b and c in urban patients undergoing cataract surgery pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 149 zahid et al11 in which hepatitis b was present in (3.08%) and hepatitis c was present in (5.90%). ali et al10 also reported hepatitis b in (3.6%) as compared to hepatitis c in (5.1%) of all the positive patients. in another study prevalence of hepatitis b was (8.66%) and hepatitis c was (11.66%).12 soomro et al also reported that among the 20.67% positive patient of hepatitis b/c, prevalence of hepatitis b was 11.29% while hepatitis c was 88.70%.13 our results were also consistent with the study conducted by chaudhry et al which showed hcv was 9.09% and hbv was 1.73%.12 our study was also consistent with the study conducted by ashok et al which showed hcv was 334 (29.60%) out of 1128 patients and the male were predominant with the male to female ratio was 1.21:1.14 the prevalence of hepatitis b and c in our study was contradictory to other studies carried out at national15,16 and international level.17,18 this study shows that the prevalence of hepatitis b and c is quite high. doctors and paramedical staff in surgical practice are at high risk of acquiring blood borne diseases from the patients on whom they operate. considering these facts, routine screening for hepatitis b and c for all patients coming for cataract surgery should be done. the print and electronic media of the country should play their part regarding awareness about hcv and hbv. the doctors and paramedical staff should follow proper precautions regarding exposure and dissemination of these blood borne viral infections. it is also an utmost importance to get mass immunization against hbv especially for heath personnel in pakistan. conclusion we found high prevalence of hbv and hcv preoperatively in patient coming for cataract surgery. it is mandatory to do screening of hepatitis b and c preoperatively for every patient undergoing cataract surgery. author’s affiliation dr. waqar ul huda resident trainee department of ophthalmology abbasi shaheed hospital, kmc dr. naz jameel assistant professor department of pathology abbasi shaheed hospital, kmc dr. uzma fasih associate professor department of ophthalmology abbasi shaheed hospital, kmc dr. attiya rehman assistant professor department of ophthalmology abbasi shaheed hospital, kmc dr. arshad shaikh professor, department of ophthalmology abbasi shaheed hospital, kmc references 1. lauer gm, walker bd. hepatitis c virus infection. n engl j med. 2001; 345: 41-52. 2. sorrell mf, belongia ea, costa j, gareen if, grem jl, inadomi jm, kern er, mchugh ja, petersen gm, rein mf, strader db, trotter ht. national institutes of health consensus development conference statement: management of hepatitis b. ann intern med. 2009; 150: 104-10. 3. national institutes of health consensus development conference statement: management of hepatitis c: 2002--june 10-12, 2002. hepatology. 2002; 36: s3-20. 4. national hepatitis control programme, ministry of health, government of pakistan, islamabad, may 2006. 5. world health organization. world health statistics, 2008. geneva (switzerland): who press, geneva, switzerland, 2008. 6. united nations development program. human development report, 1996. new york (america): oxford university press, 1996. 7. hamid s, umar m, alam a, siddiqui a, qureshi h, butt. psg consensus statement on management of hepatitis c virus infection--2003. j pak med assoc. 2004; 54: 146-50. 8. akhtar s, rozi s. an autoregressive integrated moving average model for short-term prediction of hepatitis c virus seropositivity among male volunteer blood donors in karachi, pakistan. world j gastroenterol. 2009; 15: 1607-12. 9. talpur aa, ansari ag, awan ms, ghumro aa. prevalence of hepatitis b and c in surgical patients. pak j of surgery. 2006; 22: 150-3. 10. ali sa, shah fa, ahmed k. prevalence of hepatitis b and c virus in surgical patients. pak j of surgery. 2007; 23: 109-12. 11. askar z, khan nu, tariq m, durrani z, hakeem a, ullah f. prevelence of hepatits b and c and their risk factors in patients admitted in orthopaedic unit. j. med. sci. 2010; 18: 154-6. 12. choudhary ia, khan sa, samiullah. should we do hepatitis b & c screening on each patient before surgery? pak j med sci. 2005; 21: 278-80. waqar ul huda, et al 150 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology 13. soomro m, mahmood r. prevalence of hepatitis b and hepatitis c in elective ocular surgery (rural origin) at shifa eye hospital, khanpur . pak j ophthalmol. 2013; 29: 31-3. 14. jatoi s, narsani a, kumar m. frequency of anti hepatitis c virus in eye surgery patients at tertiary referral center, lumhs. pak j ophthalmol. 2009; 25: 86-8. 15. mujeeb a, jamal q, khanani r, iqbal n, kaher s. prevalence of hepatitis b surface antigen and hcv antibodies in hepatocellular carcinoma cases in karachi. pak j tropical doctor. 1997; 27: 45-6. 16. rehman k, khan aa, haider z, iqbal j, khan ru, ahmad s, siddiqui a, syed sh. prevalence of seromarkers of hbv and hcv in health care personnel and apparently healthy blood donors. j pak med assoc. 1997; 47: 100-1. 17. arora dr, sehgal r, gupta n, yadav a, mishra n, siwach sb. prevalence of parenterally transmitted hepatitis viruses in clinically diagnosed cases of hepatitis. indian j med microbiology. 2005; 23: 44-7. 18. ghavanini aa, sabri mr. hepatitis b surface antigen and antihepatitis c antibodies among blood donors in the islamic republic of iran. eastern mediterranean health journal. 2000; 6: 1114-6. http://www.ncbi.nlm.nih.gov/pubmed?term=iqbal%20j%5bauthor%5d&cauthor=true&cauthor_uid=8993043 http://www.ncbi.nlm.nih.gov/pubmed?term=khan%20ru%5bauthor%5d&cauthor=true&cauthor_uid=8993043 http://www.ncbi.nlm.nih.gov/pubmed?term=ahmad%20s%5bauthor%5d&cauthor=true&cauthor_uid=8993043 http://www.ncbi.nlm.nih.gov/pubmed?term=siddiqui%20a%5bauthor%5d&cauthor=true&cauthor_uid=8993043 http://www.ncbi.nlm.nih.gov/pubmed?term=syed%20sh%5bauthor%5d&cauthor=true&cauthor_uid=8993043 http://www.ijmm.org/searchresult.asp?search=&author=n+gupta&journal=y&but_search=search&entries=10&pg=1&s=0 http://www.ijmm.org/searchresult.asp?search=&author=a+yadav&journal=y&but_search=search&entries=10&pg=1&s=0 http://www.ijmm.org/searchresult.asp?search=&author=n+mishra&journal=y&but_search=search&entries=10&pg=1&s=0 http://www.ijmm.org/searchresult.asp?search=&author=sb+siwach&journal=y&but_search=search&entries=10&pg=1&s=0 pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 196 original article frequency and risk factors of dry eye disease in pakistani population, a hospital based study abdullah ayub, faryal muhammad akhtar, najeeha saleem, muhammad hassaan ali, muhammad hammad ayub, nadeem hafeez butt pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad hassaan ali department of ophthalmology, jinnah hospital, lahore email: mhassaanali@hotmail.com …..……………………….. purpose: to determine prevalence and risk factors of dry eye in hospital based pakistani population. study design: cross-sectional study. place and duration of study: department of ophthalmology, jinnah hospital, lahore. from april 2016 to june 2016. materials and methods: three hundred cases above 18 years of age who presented to out-patient department with various ophthalmic complaints were enrolled in the study. patients with acute inflammatory conditions, acute infections, gross corneal or conjunctival diseases, contact lens wearers and those who had undergone any form ocular surgery within the last 6 months were excluded from the study. after taking detailed history, a pre-designed questionnaire was administered to the patients that inquired about various symptoms of dry eyes followed by a detailed ophthalmic assessment and measurement of tear film breakup time (tbut) using fluorescein dye. patients exhibiting tbut < 10 seconds were labeled as dry eye sufferers. results: there were 300 participants enrolled in the study with mean age 46.8 ± 8.3 years. 54.3% were female patients in the study. the prevalence of dry eye was found to be 18.7%. patients aged more than 70 years showed significantly higher prevalence of dry eyes (p = 0.006). there were 18.9% hypermetropes, 16.2% myopes and 15.2% emmetropes suffering from dry eyes. multivariate regression analysis showed that outdoor workers, people working in air conditioners, housewives, diabetics, smokers, people exposed to excessive sunlight, wind, temperature, and patients suffering from meibomian gland dysfunction were at higher risk of developing dry eye. conclusion: dry eye is associated with increasing age, female gender, outdoor occupations, smoking, diabetes, meibomian gland dysfunction and refractive errors. key words: dry eye, frequency, diabetes, risk factors. ry eye is caused by abnormalities in the tear film which consists of lipid, aqueous and mucous layers from anterior to posteriorly1. the definition of dry eye disease has been under continuous revisions in the recent past. the current diagnosis and definition of dry eye disease is based on 3 criteria as given in international dry eye workshop (dews) guidelines 2007: 1) decreased tear production or increased tear evaporation, 2) damage to the ocular surface, and 3) associated ocular discomfort or visual disturbance2. various researchers have labeled dry eye as the most prevalent condition seen in ophthalmology clinics3. due to tear film instability, dry eye patients report varying degree of stinging, d abdullah ayub 197 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology burning, irritation, foreign body sensation, watering, fatigue, redness and photophobia etc. in the affected eye. the symptomatology of dry eye may even be seen in the absence of full triad of features mentioned above that define dry eye disease. various studies have reported prevalence of dry eyes from 10% to 70% depending on the type of patients/subjects, diagnostic criteria and objective tear film tests used in the study3. many factors have been reported in literature that are associated with dry eyes that include hot weather, windy air conditions, excessive sun exposure, pollution, smoking, advancing age in females, menopause etc4. recently, a large prevalence of dry eye disease has been reported in computer users due to decreased blink rate during performance of visual tasks with deep concentration5,6. we conducted a literature on google scholar, pubmed, embase and cochrane library to find out earlier researches on the subject from pakistan. only one study was found in which jehangir et al had shown presence of dry eye disease with various other ocular pathologies7. we believe that climatic and environmental conditions of pakistan mandate similar studies. we conducted this study with the objectives to determine prevalence and risk factors of dry eye in hospital based pakistani population. materials and methods the study was conducted in department of ophthalmology of jinnah hospital, lahore, a tertiary care hospital, from april 2016 to june 2016, after taking approval from ethical review board/ institutional review committee of allama iqbal medical college/jinnah hospital, lahore. the study was conducted following the principles of good clinical practice as laid down in declaration of helsinki. informed written consent was taken from all the study participants. we evaluated 300 cases above 18 years of age who presented to our out-patient department with various ophthalmic complaints. the patients were selected following consecutive purposive sampling. only those patients were selected who consented to take part in the study. patients with acute inflammatory conditions, acute infections, gross corneal or conjunctival diseases, contact lens wearers and those who had undergone any form of ocular surgery within the last 6 months were excluded from the study. three researchers (ab, fa, ns) recorded detailed ophthalmic and general history of the patients focusing on main causations associated with dry eyes. sun exposure raised outdoor temperatures, smoking, exposure to air pollutants and drugs were especially asked about. after detailed history, another researcher (mhna) administered a pre-designed questionnaire about symptoms of dry eye. the questionnaire was administered in language of the patients and asked for socio-demographic data including age, gender, occupation, residence; and symptoms of dry eyes including recurrent watering, foreign body sensation (grittiness), itching, burning, stinging, dryness, soreness, heaviness etc. subsequently, a consultant ophthalmologist (mhda) performed detailed ophthalmic examination of all the patients. during ocular examination, special attention was paid to ocular surface abnormalities, diseases of the eyelids, meibomian gland dysfunction, presence of any strands or filaments etc. lastly, status of the precorneal tear film was assessed using tear film break-up time (tbut). the test was performed at room temperature, keeping fans turned off after application of fluorescein dye in the inferior fornix. the patient was asked to blink 4 – 5 times to allow even distribution of fluorescein dye over the ocular surface. finally, the patient was asked not to blink any further and was examined on slit lamp biomicroscope with cobalt blue filter. time interval between last blink and appearance of first area of discontinuation in the precorneal tear film was tbut. patients exhibiting this interval to be less than ten seconds were labelled to be suffering from dry eyes. if any patient reported usage of ocular lubricants, his tbut was measured after discontinuation of that medicine for at least 24 hours. spss version 20.0 (spss inc., chicago, illinois, usa) was used to do data analyses using 95% confidence intervals (ci). the likelihood ratio was used to calculate the p-values using pearson chisquare tests with a p-value of less than 0.05 considered as statistically significant. associations of environmental risk factors with dry eye were assessed using regression analysis. the strength of association of environmental factors with dry eyes was found out by calculating odd ratio.the difference in the mean number of dry eye symptoms between dry eyed and normal individuals was assessed using analysis of variance test (anova). a p-value < 0.05 was considered statistically significant. results three hundred patients participated in the study with mean age 46.8 ± 8.3 years. there were 163 (54.3%) females and 137 (45.3%) males in the study. the frequency and risk factors of dry eye disease in pakistani population, a hospital based study pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 198 detailed socio-demographic characteristics of the patients are shown in table 1. the most common presenting complaint of the patients with dry eyes was blurring of vision in 29 (51.8%) of the cases followed by recurrent watering and itching in 39.3% and 19.6% of the cases respectively (table 2). the frequency of dry eye was found to be 18.7% (56 cases) in our study population. patients aged more than 70 years showed significantly higher prevalence as compared with rest of the groups in 40.0% of the cases (p = 0.006; 95% ci 1.346 – 5.780) (table 3). a relative peak of dry eye prevalence was noted in age group 31-40 years (20.3%). as compared to males (16.1%), females showed significantly higher prevalence of dry eyes (26.4%) (p = 0.021; 95% ci 1.080 – 2.631). menopausal women showed higher prevalence than nonmenopausal women 30.1% versus 21.5% respectively. though the prevalence of dry eye came out to be more in rural population (20.6%) as compared with urban population (17.6%) (p = 0.611; 95% ci 0.552 – 1.392), this result was not statistically significant. a detailed analysis of prevalence of dry eye according to age, gender and place of residence is presented in table 3. the most commonly affected people with dry eye were farmers and laborers 13 (27.1%) followed by high exposure individuals (4, 25.0%) that included professional computer users, professional drivers, field salesmen, field workers, outdoor painters, mechanics and cooks (table 4). odd’s ratios to show strength of associations of various occupations, environmental factors, systemic illnesses and drugs with dry eye as measured through multivariate regression analysis are shown in table 5. briefly, outdoor workers, people working in air conditioners, housewives, diabetics, smokers, people exposed to excessive sunlight, wind, temperature, and patients suffering from meibomian gland dysfunction were at higher risk of developing dry eye. as part of detailed ophthalmic examination, all patients underwent assessment of their refractive status as well. 15.2% of emmetropes suffered from dry eyes while 16.2% (16/105) myopes and 18.9% (22/116) hypermetropes were affected by this condition. the mean number of ocular symptoms in dry eye patients was significantly higher as compared to non-dry eye group: 6.8 ± 2.1 versus 3.4 ± 2.3 (p = 0.001; 95% ci 1.69 2.86). table 1: socio-demographic characteristics of participants in the study (n = 300). number of subjects percentage (%) age groups (years) 21 – 30 70 23.4 31 – 40 59 19.7 41 – 50 62 20.6 51 – 60 55 18.3 61 – 70 34 11.3 above 70 20 6.7 gender distribution male 137 45.7 female 163 54.3 residence urban 193 64.3 rural 107 35.7 occupation farmers / labourers 48 16.0 others with high exposurea 16 5.3 abdullah ayub 199 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology indoor office workers/shopkeepers 53 17.7 others with low exposureb 55 18.3 housewives/students 123 41.0 factory workers 5 1.7 a professional computer users, professional drivers, field salesmen, field workers, outdoor painters, mechanics, cooks etc. b doctors, teachers, scientists, priests etc. table 2: presenting symptoms of dry eye patients (n = 56). symptoms number of participants percentage (%) blurred vision 29 51.8 watering 22 39.3 itching 11 19.6 heaviness 8 14.3 burning 7 12.5 stickiness 6 10.7 dryness 5 8.9 grittiness 4 7.1 excessive mucoid discharge 3 1.7 table 3: prevalence of dry eyes according to age, gender and residence. number of subjects dry eye subjects prevalence (%) p-value 95% ci age groups (years) 21 – 30 70 10 14.3 0.110 0.381 – 1.118 31 – 40 59 12 20.3 0.502 0.671 – 1.898 41 – 50 62 10 16.1 0.182 0.471 – 1.394 51 – 60 55 9 16.4 0.990 0.485 – 1.620 61 – 70 34 7 20.5 0.054 0.551 – 2.121 above 70 20 8 40.0 0.006 1.346 – 5.780 gender distribution male 137 22 16.1 0.021 1.080 – 2.631 female 163 43 26.4 residence urban 193 34 17.6 0.611 0.552 – 1.392 rural 107 22 20.6 frequency and risk factors of dry eye disease in pakistani population, a hospital based study pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 200 table 4: prevalence of dry eye in various occupational groups. occupation number of subjects dry eye subjects prevalence (%) p-value 95% ci farmers/ labourers 48 13 27.1 0.059 0.980 – 2.863 others with high exposure 16 4 25.0 0.781 0.459 – 2.897 housewives / students 123 25 20.3 0.341 0.783 – 1.979 factory workers 5 1 20.0 0.714 0.088 – 6.183 indoor office workers/ shopkeepers 53 7 13.2 0.132 0.310 – 1.192 others with low exposure 55 7 12.7 0.079 0.287 – 1.098 table 5: multivariate logistic regression analysis showing strength of associations of various variables with dry eyes. variable p-value odd’s ratio 95% ci occupation a) farmers / labourers/ high exposure group 0.059 2.091 0.980 – 2.863 b) indoor office workers/ shopkeepers 0.132 1.868 0.310 – 1.192 c) other low exposure group 0.079 1.010 0.287 – 1.098 d) housewives/ students 0.015 1.942 1.139 – 3.229 meibomian gland dysfunction 0.000 21.173 4.897 – 84.854 diabetes 0.001 2.315 1.371 – 3.810 smoking 0.139 1.44 0.452 – 1.249 excessive wind 0.005 2.12 0.263 – 0.791 sunlight/high temperature 0.012 1.94 0.309 – 0.872 air pollution 0.291 1.34 0.389 – 1.340 discussion the main objectives of this study to determine the prevalence and risk factors of dry eyes were successfully met. various studies have shown prevalence of dry eyes to vary from around 10% to 70% depending on the diagnostic criteria used and cut-off values for various tear film assessment tests8. some studies performed tests only on those patients who had significant number of positive complaints about dry eyes resulting in higher prevalence of dry eyes9. besides, some studies were carried out solely on patients with rheumatoid arthritis or sjogren’s syndrome who reported a high prevalence of dry eyes10-13. our prevalence (18.7%) results fall within the aforementioned range and are in accordance with results from various other studies. our results showed that the prevalence of dry eye increased as the age of the patients increased showing a direct relationship between age and dry eyes. this result was also consistent with many other studies14-17. a relative peak of dry eye prevalence was found in the age group 31-40 years as had earlier been observed by hikichi et al18. we believe this age group suffers most from the occupational hazards due to maximum exposure to outdoor environmental risk factors leading to ocular dryness. countries like pakistan with plenty of sun exposure can exhibit this phenomenon to abdullah ayub 201 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology a greater extent. however, we recommend more studies in this regard to find exact cause of this spike of prevalence of dry eyes in age group 31 – 40 years. like many other studies19, our study also showed significantly higher prevalence of dry eyes in females as compared to males (26.4% versus 16.1%; p = 0.021). the higher prevalence of dry eyes in females implies that females seek medical attention earlier than males for their dry eye symptoms. besides, menopause causes decreased estrogen level in females that lead to decreased tear film production in them20. we found out higher prevalence of dry eyes in post-menopausal women as compared to pre-menopausal women (30.1% versus 21.5%) which might be explained by the aforementioned normal physiological mechanism. though our patients showed a higher prevalence of dry eyes in post-menopausal women, earlier studies have shown same prevalence of dry eyes in both preand post-menopausal women14. people residing in rural areas showed higher prevalence of dry eyes as compared to urban residents. but contrary to various other studies, the difference was not statistically significant. the higher prevalence in rural residents is thought to be the result of excessive exposure to sunlight and high outdoor temperatures21. people belonging to various occupations like farmers/labourers, housewives; people with meibomian gland dysfunction, diabetics, and people with excessive exposure to sunlight, wind, cigarette smoking and air pollution were significantly related to dry eye. khurana et al reported high prevalence of dry eyes in farmers and labourers (32% and 28% respectively) most likely due to increased exposure to hot temperatures and sunlight22,23. this necessitates urgent need to create awareness among farmers and labourers to take safety measures during their work. many earlier studies have shown smoking, diabetes and pollution to be risk factors for dry eyes24. smokers who suffer from dry eyes should be counseled about quitting or limiting smoking as a potential therapy for their dry eyes by reducing direct irritant effect of smoking on ocular surface. moss et al showed higher prevalence of dry eyes in patients with refractive errors as compared to emmetropes25. our study also showed this relationship with refractive errors. these patients suffered more than emmetropes from dry eyes. comparing emmetropes with refractive error group individuals, the prevalence of dry eyes was higher in both corrected and uncorrected refractive error group. however, subjects with their refractive errors corrected suffered less in this condition as compared to those with uncorrected refractive error (16.3% versus 25.6%). this difference in patients with corrected and uncorrected refractive error was not statistically significant (p > 0.05). it has been proposed that persons with refractive errors rub their eyes frequently leading to deposition of debris and infected particles in the fornices leading to instability of the tear film. our study also showed that prevalence of dry eye was most in hypermetropes (18.9%) followed by myopes (16.2%) and emmetropes (15.2%). incorporating refractive errors in dry eye researches has earlier been postulated in various studies25. the main limitation of our study was exclusion of patients with various corneal and conjunctival pathologies which led to a relative apparent underestimation of prevalence of dry eyes in our sample. besides, participants using contact lenses were also excluded who could have been a potential source of the condition. fluorescein dye was used to carry out tear film break up time which itself was irritating and could cause reflex tearing. so, newer studies may use non-invasive and non-contact techniques of measuring tear breakup time. further studies may be conducted to establish a uniform criterion for diagnosis and more etiologic associations of dry eyes. this raises the need to gather more data on the subject from our country. conclusion dry eye is quite prevalent in our cohort of patients who were suffering from ocular disease other than gross corneal and conjunctival pathologies. the study reflects a major but underdiagnosed burden of the condition in our out-patient departments. we conclude that dry eye is associated with increasing age, female gender, outdoor occupations, smoking, diabetes, meibomian gland dysfunction and refractive errors. the results should guide ophthalmic community in developing more targeted and focused approaches towards management of this issue since dry is not only an ocular disease but also a great burden on the economics of the patient. detailed history about symptoms of the condition and good clinical examination with tear film break up time can help us properly diagnose and manage this condition actively. author’s affiliation dr. abdullah ayub mbbs frequency and risk factors of dry eye disease in pakistani population, a hospital based study pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 202 house surgeon department of ophthalmology, jinnah hospital lahore. dr. faryal muhammad akhter mbbs house surgeon department of ophthalmology, jinnah hospital lahore. dr. najeeha saleem mbbs house surgeon department of ophthalmology, jinnah hospital lahore. dr. muhammad hassaan ali bsc, mbbs postgraduate resident department of ophthalmology, jinnah hospital, lahore dr. muhammad hammad ayub mbbs, fcps associate professor department of ophthalmology, jinnah hospital lahore. prof. nadeem hafeez butt mbbs, fcps, frsced, frcs (glas), mhpe department of ophthalmology, jinnah hospital lahore. role of authors dr. abdullah ayub conception, data collection, data entry, data analysis, article write up. dr. faryal muhammad akhter data collection, data entry, data analysis, article write up. dr. najeeha saleem data collection, data entry, data analysis, article write up. dr. muhammad hassaan ali conception, data collection, data analysis, article write up. dr. muhammad hammad ayub data collection, data analysis, final critical review. prof. nadeem hafeez butt senior author, conception, final critical review. references 1. lienert jp, tarko l, uchino m, christen wg, schaumberg da. long-term natural history of dry eye disease from the patient's perspective. ophthalmology, 2016 feb. 29; 123 (2): 425-33. 2. lemp ma, foulks gn. the definition and classification of dry eye disease. the ocular surface, 2007; 5 (2): 75-92. 3. ali mh, javaid m, jamal s, butt nh. femtosecond laser assisted cataract surgery, beginning of a new era in cataract surgery. oman j ophthalmol. 2015 sep; 8 (3): 141. 4. ranjan r, shukla sk, singh cv, mishra bn, sinha s, sharma bd. prevalence of dry eye and its association with various risk factors in rural setup of western uttar pradesh in a tertiary care hospital. open journal of preventive medicine, 2016 jan. 15; 6 (01): 57. 5. rosenfield m. computer vision syndrome (aka digital eye strain). optometry, 2016; 17 (1): 1-0. 6. courtin r, pereira b, naughton g, chamoux a, chiambaretta f, lanhers c, dutheil f. prevalence of dry eye disease in visual display terminal workers: a systematic review and meta-analysis. bmj open, 2016 jan. 1; 6 (1): e009675. 7. jehangir s. dry eye syndrome in pakistani community. j pak med assoc. 1990 mar; 40: 66-7. 8. bakkar mm, shihadeh wa, haddad mf, khader ys. epidemiology of symptoms of dry eye disease (ded) in jordan: a cross-sectional non-clinical population-based study. contact lens and anterior eye, 2016 jun. 30; 39 (3): 197-202. 9. nowak ms, smigielski j. the prevalence and risk factors for dry eye disease among older adults in the city of lodz, poland. open journal of ophthalmology, 2016 feb. 4; 6 (01): 1. 10. fostad ig, eidet jr, utheim tp, ræder s, lagali ns, messelt eb, dartt da. dry eye disease patients with xerostomia report higher symptom load and have poorer meibum expressibility. plos one, 2016 may 5; 11 (5): e0155214. 11. beckman ka, luchs j, milner ms. making the diagnosis of sjögren’s syndrome in patients with dry eye. clinical ophthalmology (auckland, nz), 2016; 10: 43. 12. ali mh, ullah s, javaid u, javaid m, jamal s, butt nh. comparison of characteristics of femtosecond laserassisted anterior capsulotomy versus manual continuous curvilinear capsulorrhexis: a meta-analysis of 5-year results. j pak med assoc. 2017; 67 (10): 1574–9. 13. atalay k, ustun i, cabuk ks, kirgiz a, karacan i, taskapili m. how does rheumatoid arthritis affect corneal biomechanical properties? int j clin exp med. 2016 jan. 1; 9 (2): 4665-9. 14. javaid u, ali mh, jamal s, butt nh. pathophysiology, diagnosis, and management of glaucoma associated with sturge–weber syndrome. int ophthalmol. springer; 2017; 1–8. abdullah ayub 203 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology 15. jamal s, ali mh, ayub mh, butt nh. frequency and grading of diabetic retinopathy in diabetic end stage renal disease patients. pak j ophthalmol. 2016; 32: 65. 16. butt nh, ayub mh, ali mh. challenges in the management of glaucoma in developing countries. taiwan j ophthalmol. elsevier; 2016; 6 (3): 119–22. 17. bashir zs, ali mh, anwar a, ayub mh, butt nh. femto-lasik: the recent innovation in laser assisted refractive surgery. j pak med assoc. 2017; 67 (4): 609. 18. hikichi t, yoshida a, fukui y, hamano t, ri m, araki k, horimoto k, takamura e, kitagawa k, oyama m, danjo y. prevalence of dry eye in japanese eye centers. graefe's archive for clinical and experimental ophthalmology, 1995 sep. 1; 233 (9): 555-8. 19. schaumberg da, uchino m, christen wg, semba rd, buring je, li jz. patient reported differences in dry eye disease between men and women: impact, management, and patient satisfaction. plos one, 2013 sep. 30; 8 (9): e76121. 20. agarwal r, singh p, rajpal t, kumar r, raghuwanshi s, ramnani v. hospital based study of prevalence of dry eye in post-menopausal women. indian journal of clinical and experimental ophthalmology, 2016; 2 (1): 56-61. 21. ranjan r, shukla sk, singh cv, mishra bn, sinha s, sharma bd. prevalence of dry eye and its association with various risk factors in rural setup of western uttar pradesh in a tertiary care hospital. open journal of preventive medicine, 2016 jan. 15; 6 (01): 57. 22. khurana ak, chaudhary r, ahluwalia bk, gupta s. tear film profile in dry eye. actaophthalmologica. 1991 feb. 1; 69 (1): 79-86. 23. lee jh, lee w, yoon jh, seok h, roh j, won ju. relationship between symptoms of dry eye syndrome and occupational characteristics: the korean national health and nutrition examination survey 2010–2012. bmc ophthalmology, 2015 oct. 29; 15 (1): 1. 24. sayin n, kara n, pekel g, altinkaynak h. effects of chronic smoking on central corneal thickness, endothelial cell, and dry eye parameters. cutaneous and ocular toxicology, 2014 sep. 1; 33 (3): 201-5. 25. moss se, klein r, klein be. long-term incidence of dry eye in an older population. optometry & vision science, 2008 aug. 1; 85 (8): 668-74. 238 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology case report endophthalmitis in an immunocompromised patient mirjana a. janicijevic – petrovic, tatjana sarenac – vulovic, katarina janicijevic, dejan vulovic, dragan vujic, predrag jovanovic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mirjana a. janicijevic-petrovic clinic of ophthalmology, clinical centre kragujevac, zmaj jovina 30, 34000 kragujevac, serbia mira.andreja@yahoo.com …..……………………….. purpose: the goal of manuscript was to report a case of mixed infection eye in an immunocompromised patient. case report: a case of bilateral cytomegalovirus (cmv) retinitis with endogenous endophthalmitis in the left eye in an immunocompromised drug user is reported. fundus examination showed retinitis of the right eye. slit lamp examinations revealed endogenous endophthalmitis of left eye. authors applied disposable therapeutic modules. conclusion: cytomegalovirus retinitis is an infection of the retina in an immunocompromised patients localised to the back of eye. untreated endogenous endophthalmitis leads to progressive destruction of almost all eye structures and poor visual outcome. the prognosis is dependent on adequate antiviral therapy and immune competence of the patient. ganciclovir treatment was effective in our case. mv belongs to the herpes group of viruses. it is a rare cause of eye infection. however in immunocompromised patients, patients with acquired immune deficiency syndrome (aids), intra venous drug abusers (ivda) or patients on any kind of immune-suppressive therapy, such as organ transplant patients, are at higher risk to develop cmv retinitis. 1. endophthalmitis is sight threatening condition defined as clinical infection all layers of eye. it might be endogenous or exogenous depending on the route of the infection. exogenous is the result of direct contacts, as corneal lesion (intraocular inoculation of microbe), post-surgery intraocular infection and postpenetrating ocular trauma with intraocular foreign bodies. endogenous endophthalmitis also termed metastatic endophthalmitis occurs when microbes disseminate through blood and cross ocular blood barrier and enter internal ocular spaces. case report a 35 – years old male, ivda, was seen in clinic of ophthalmology in kragujevac, serbia (july, 2012) with decreased visual acuity of both eyes; redness and pain of the left eye. history indicated that our patient was an ivda for many years. best corrected visual acuity of the right eye was 20/60 and of the left eye 1/60 (by snellen test). intraocular pressures of both eyes were normal. slit lamp examination of right eye was normal; slit lamp examination of left eye showed a fibrous exudation in the anterior chamber, (fig. 1a) slit lamp examination of left eye indicated inflammatory reaction in the anterior segment, (fig. 1. b) indirect ophthalmoscope of right eye indicated inflammatory lesion of the retina along infra-temporal vascular arcade; no vitreous exudation was detected and ultrasound of left eye showed thickening of chorioretinal with vitreous exudation, (fig. 1. c). complete blood and immunological examination were performed. hiv antibody and rna tests were negative, and cmv (igg and igm) positive; but his full blood count revealed lymphocytopenia, with the low cd4+ subset2. in consultation with microbiologist and infectious disease specialist. we started antiviral therapy for our patient: ganciclovir (5 mg/kg) twice daily intravenous for fourteen days, and ganciclovir (4 mg/dl) intravitreal; then corticosteroids intramuscular and antibiotic intravenous for c mailto:mira.andreja@yahoo.com endophthalmitis in immunocompromised patient pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 239 (a) (b) (c) fig. 1: (a) slit lamp examination of left eye. (b) photo fundus of right eye. (c) ultrasound of left eye controlling inflammation and secondary infection (august, 2012). corticosteroids may be implicated in disease reactivation. after this medical treatment visual acuity of the right eye was improved to 40/60 and of left eye was very poor. fundus examination of right eye showed amelioration of retinal lesion, but on left eye exudation of vitreous was persistent. because of the immunocompromised condition of our patient and clinical signs of left eye we performed antiviral intravitreal injection for the treatment of the endogenous endophthalmitis. anterior chamber tap of the aqueous was pcr positive for acinetobacter species. we performed antibacterial systemic therapy with amp. tolycar®, intravenous, for ten days. our patient was treated with these antibiotic based on results of anti-biogram test, as well as with anti-inflammatory local and systemic therapy (steroids). condition of left eye became better and visual acuity was improved to (60/60). discussion visual symptoms of peripheral lesions include floaters and loss of peripheral vision, but some ocular condition can be asymptomatic. retinal necrosis and secondary macular edema that occurs with the development of cmv retinitis, often results in loss of vision. in addition to cmv retinitis, endogenous endophthalmitis can be one of the causes of loss of the central and peripheral vision as well, by its pathological mechanism of action3, 4. endogenous endophthalmitis by viral / fungal etiology, acute retinal necrosis by herpetic etiology, and toxoplasmosis often presents a differential diagnostic problem in relation to cmv retinitis. paracentesis of the anterior chamber, or during a formal pars-plana vitrectomy, about 1 ml of aqueous humor or vitreous can be taken for microbiological analysis, usually in aseptic conditions and by the clinical protocols5, 6. cmv retinitis is the most common opportunistic infection which affects immunocompromised patients and those with aids, and it may lead to endogenous endophthalmitis. the most probable way of spreading cmv is through blood to eye. central type of cmv retinitis is clinically characterized with white and clearly limited, retinal necrotic foci, mainly localized along the vascular arcades. peripheral cmv retinitis shows less limited but specific necrotic lesions. ganciclovir administered intravenously and-or intravitreous in the induction phase. in acute exacerbation of disease oral acyclovir is used with ganciclovir by intravitreal administration as a depot preparation in vitreous7. intra vitreous ganciclovir implant is surgically applied following vitrectomy with silicone oil in the projection of the pars plane vitreous, the drug release for 7 to 8 months, which is the treatment of choice, but we have not been able to employ this therapeutic module7. endophthalmitis might be endogenous or exogenous depending on the way of the infection. endogenous endophthalmitis termed metastatic endophthalmitis occurs when microbes disseminate through blood ocular barrier. endogenous endophthalmitis reported to account by 8% of all cases of endophthalmitis. endogenous endophthalmitis is most often associated with the medical condition, including intravenous drug abuse adults, liver mirjana a. janicijevic – petrovic, et al 240 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology diseases, diabetes mellitus, cardiac disease, malignancy etc. endogenous endophthalmitis is the diagnostic and serious treatment problem for the ophthalmologists. polymerase chain reaction is emerging as the valid diagnostic test of choice for identifying causes of the infective endophthalmitis, whether bacterial, fungal or mixed infection7, 8. endophthalmitis is a frequent complication of fungal infections by candida albicans, klebsiella pneumoniae, and less commonly occurs in patient who has the systemic aspergillosis9, 10. implicit in the approach for treatment of endogenous endophthalmitis under the assumption that we achieve adequate concentrations of antifungal drug in the infected tissues represents the crucial piece to the puzzle of our success. the choroid and retina are highly vascular compared with the vitreous, and the vascular compartments are separated from intraocular structures by the blood ocular barrier. thus, infection localized to chorioretinal layers, which are not protected by this barrier, can be treated with systemic antifungal drugs, but treatment of other intraocular infections requires penetration of antifungal drugs through this relatively impermeable barrier. however, sight threatening lesions in the macula and chorioretinitis with vitritis usually necessitate intravitreal injection of antifungal drugs, with or without vitrectomy11, 12. the second assumption in treating endogenous endophthalmitis is that an examination has been performed by an ophthalmologist familiar with fungal endophthalmitis soon after the diagnosis of candida and the other infection. if endophthalmitis is found, follow up examinations should be routinely performed to evaluate the response to therapy and the development of complications. the greatest clinical experience has been acquired with amphotericin b. intravitreal – amphotericin b has been used as mono treatment for endogenous candida endophthalmitis to avoid systemic toxicity. intravitreal injection of amphotericin b is used as adjunctive therapy along with systemic antifungal drugs in patients who have sight threatening endophthalmitis caused by candida species and in most cases of aspergillums’ endophthalmitis. outcomes for early vitrectomy combined with systemic antifungal therapy with amphotericin b or fluconazol have been favorable for candida endophthalmitis11, 12. conclusion cmv retinitis with young adults who are drug users represents clinical entity of immune deficiency conditions. therapy effects of ganciclovir, most importantly intravitreal, in remission are most important, also in recovery of visual acuity. endogenous endophthalmitis with mixed etiology includes bacterial, viral or fungal infection represents a complication of eye infections, with the bed prognosis for visual acuity. vitrectomy is an option to debulk the infection and to provide any intra-ocular treatment required. author’s affiliation dr. mirjana a. janicijevic-petrovic clinic of ophthalmology clinical centre in kragujevac, serbia dr. tatjana sarenac-vulovic clinic of ophthalmology clinical centre in kragujevac, serbia dr. katarina janicijevic faculty of medical sciences university of kragujevac, serbia dr. dejan vulovic faculty of medical sciences university of kragujevac, serbia dr. dragan vujic state university of novi pazar, serbia dr. predrag jovanovic medical faculty university of nis, serbia references 1. taylor gh. cytomegalovirus. am fam physician. 2003; 67: 519-24. 2. au eong k, beatty s, charles sj. cytomegalovirus retinitis in patients with acquired immune deficiency syndrome. postgrad med j. 1999; 75: 585-90. 3. mota a, breda j, silva r, magalhãesa a, falcão – reisa f. cytomegalovirus retinitis in an immunocompromised infant: a case report and review of the literature. case rep ophthalmol. 2011; 2: 238-42. 4. connell pp, o’neill1 ec, fabinyi d, islam fma, buttery r, mc combe m essex rw, roufail e, clark b, chiu d, campbell w, allen p. endogenous endophthalmitis: 10-year experience at a tertiary referral centre. eye 2011; 25: 66-72. 5. schiedler v, scott iu, flynn jr hw, davis jl, benz ms, miller d. culture – proven endogenous endophthalmitis: clinical features and visual acuity outcomes. am j ophthalmol. 2004; 137: 725-31. 6. sowmya p, madhavan hn. diagnostic utility of polymerase chain reaction on intraocular specimens to establish the etiology of infectious endophthalmitis. eur j ophthalmol. 2009; 19: 812-7. endophthalmitis in immunocompromised patient pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 241 7. langer – wegscheider bj, ten dam – van loon n, mura m, faridpooya k, de smet md. intravitreal ganciclovir in the management of non-aids – related human cytomegalovirus retinitis. can j ophthalmol. 2010; 45: 157-60. 8. pappas pg, kauffman ca, andes d, benjamin dk jr, calandra tf, edwards je jr, filler sg, fisher jf, kullberg bj, ostrosky – zeichner l, reboli ac, rex jh, walsh tj, sobel jd. clinical practice guidelines for the management of candidiasis: 2009 update by the infectious diseases society of america. clin infect dis. 2009; 48: 503-35. 9. dehghani ar, masjedi a, fazel f, ghanbari h, akhlaghi m, karbasi n. endogenous klebsiella endophthalmitis associated with liver abscess: first case report from iran. case report ophthalmol. 2011; 2: 10-4. 10. karthaus m. treatment of aspergillosis. clin infect dis. 2008; 47: 427. 11. cannon jp, fiscella r, pattharachayakul s, garey kw, de alba f, piscitelli s, edward dp, danziger lh. comparative toxicity and concentrations of intravitreal amphotericin b formulations in a rabbit model. invest ophthalmol vis sci. 2003; 44: 2112-7. 12. shen x, xu g. vitrectomy for endogenous fungal endophthalmitis. ocul immunol inflamm. 2009; 17: 14852. http://www.ncbi.nlm.nih.gov/pubmed?term=pappas%20pg%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=kauffman%20ca%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=andes%20d%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=benjamin%20dk%20jr%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=calandra%20tf%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=edwards%20je%20jr%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=filler%20sg%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=fisher%20jf%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=kullberg%20bj%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=ostrosky-zeichner%20l%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=reboli%20ac%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=rex%20jh%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=rex%20jh%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=rex%20jh%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=walsh%20tj%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=sobel%20jd%5bauthor%5d&cauthor=true&cauthor_uid=19191635 http://www.ncbi.nlm.nih.gov/pubmed?term=cannon%20jp%5bauthor%5d&cauthor=true&cauthor_uid=12714650 http://www.ncbi.nlm.nih.gov/pubmed?term=fiscella%20r%5bauthor%5d&cauthor=true&cauthor_uid=12714650 http://www.ncbi.nlm.nih.gov/pubmed?term=pattharachayakul%20s%5bauthor%5d&cauthor=true&cauthor_uid=12714650 http://www.ncbi.nlm.nih.gov/pubmed?term=garey%20kw%5bauthor%5d&cauthor=true&cauthor_uid=12714650 http://www.ncbi.nlm.nih.gov/pubmed?term=de%20alba%20f%5bauthor%5d&cauthor=true&cauthor_uid=12714650 http://www.ncbi.nlm.nih.gov/pubmed?term=piscitelli%20s%5bauthor%5d&cauthor=true&cauthor_uid=12714650 http://www.ncbi.nlm.nih.gov/pubmed?term=edward%20dp%5bauthor%5d&cauthor=true&cauthor_uid=12714650 http://www.ncbi.nlm.nih.gov/pubmed?term=danziger%20lh%5bauthor%5d&cauthor=true&cauthor_uid=12714650 pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 187 news and events vol. 29, 3, 2013 xi biennial congress of saarc academy of ophthalmology and 16th islamabad conference of osp federal branch pakistan date: 03-06 october, 2013 venue: pearl continental bhurban contact: mr. muhammad mohsin phone: +92-323-5542666 email: ospfederaleye@gmail.com web: http://saarccongress2013.com 26th asia-pacific association of cataract & refractive surgeon annual meeting 2013 (apacrs 2013) date: 11-14 july, 2013 venue: suntec singapore international convention centre, singapore web: www.apacrs.org 34th world ophthalmology congress (woc) & the 29th asia – pacific academy of ophthalmology (apao) congress date: 2 6 april, 2014 venue: tokyo, japan web: www.apaophth.org american society of cataract and refractive surgery (ascrs) / american society of ophthalmic administrators (asoa) symposium and congress date: 25 29 april, 2014 venue: boston web: www.ascrs.org the association for research in vision and ophthalmology (arvo) annual meeting 2014 orlando, florida date: 4-8 may, 2014 venue: orlando, florida web: www.arvo.org 11th european glaucoma society conference date: 7-11 june 2014 venue: nice, france web: www.eugs.org xxi biennial meeting of international society for eye research date: 20-24 jul, 2014 venue: san francisco, california web: www.iser.org institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091 – 9217376 – 80 fax: 92 – 42 – 36363326 email: pico@pes.comsats.net.pk college of ophthalmology and allied vision sciences lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042 – 37355998 fax: 042 – 37248006 email: pipo@brain.net.pk tel:%2b92-323-5542666 mailto:ospfederaleye@gmail.com http://saarccongress2013.com/ http://www.apacrs.org/ http://www.apaophth.org/ http://www.arvo.org/ http://www.eugs.org/ mailto:pico@pes.comsats.net.pk mailto:pipo@brain.net.pk news and events 188 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology pakistan institute of ophthalmology, al – shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al – shifa trust eye hospital, jhelum road, rawalpindi – pakistan phone: 92 – 51 – 5487830, 5487820 – 25 fax: 92 – 51 – 5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt 4-a lda flats lawrence road, lahore phone: 92 – 42 – 36363326 email: pjoosp@gmail.com mailto:info@alshifa-eye.org.pk mailto:pjoosp@gmail.com pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 211 case report vitreous cyst: a case report hussain ahmad khaqan, usman imtiaz, farukh jameel pak j ophthalmol 2015, vol. 31 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hussain ahmad khaqan eye unit lll, lahore general hospital, lahore …..……………………….. vitreous cysts represent a very rare ocular malformation. these cysts can occur in an otherwise healthy eye or in a diseased eye or they can occur in association with the remnants of hyaloid system. we report here a case of a 14-year-old male presenting to us with complaint of painless transient blurring of vision in left eye. visual acuity was 6/6 in right eye and 6/24 in left eye, which improved to 6/6 once the transient blurring goes away. on examination of the left eye, there was a freely floating cyst in the vitreous. it was translucent, with a smooth, brownpigmented surface. rest of the examination was unremarkable. blood tests including serology were normal. periodic observation was recommended without any treatment. key words: vitreous cyst, visual acuity, hyaloid system itreous cysts represent a very rare ocular condition. tansley first described it in 1899, as an irregularly spherical cyst that showed lines of pigment on its surface1. these cysts can occur in an otherwise normal eye or they can occur in association with the remnants of hyaloid system2. several theories have been proposed for the origin of these cysts but no common agreement has been reached. we report here an unusual case of free floating pigmented cyst in the vitreous. case report a 14-year-old male presented to our opd with complaint of transient blurring of vision in left eye for the preceding 1 month. patient reported it as a shadow coming in front of him and then going away when he moved his head. his previous medical and surgical history was unremarkable. patient denied any history of trauma. there was no history of any ocular inflammation or infection. the clinical assessment comprised a physical examination, blood tests including serology for toxocara, toxoplasma gondi, cysticercosis, echinococcosis and a blood cell count for eosinophils. all of the blood tests were normal. visual acuity was 6/6 in the right eye and 6/24 in the left eye. when the shadow moved away the visual acuity improved to 6/6 in the left eye. slit lamp biomicroscopy revealed a normal anterior segment examination with no sign of infection or inflammation, transparent media and reactive pupil. his intraocular pressure was 15 mm hg in right eye and 14 mm hg in left eye. fundus examination of the right eye was unremarkable. in the left eye there was an ovoid cyst in the vitreous cavity. the cyst surface was smooth and brown in colour (fig. 2). it was translucent. when the patient was asked to move the eyeball, the cyst freely floated in the vitreous cavity showing that it was not attached to any other ocular structure. macula, peripheral retina and the optic disc were normal. no posterior vitreous detachment was seen. regular follow-up was recommended without any treatment. discussion vitreous cysts are classified by most authors as congenital or hereditary. congenital cysts are thought to be the remnants of hyaloid vascular system3. this theory is supported by the histopathological findings of nork and millecchia4, which shows cyst as a choristoma of primary hyaloid system. acquired cysts can occur due to ocular trauma or inflammatory conditions like toxoplasmosis5 and intermediate v hussain ahmad khaqan, et al 212 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology uveitis6. they are also associated with retinal detachment surgery7 and degenerative retinal and choroidal pathologies, like high myopia with uveal colobomas8. fig. 1: fig. 2: free-floating vitreous cysts are usually of little clinical importance but they should be differentiated from other serious conditions. pigmented cysts may mimic malignant melanoma. non-pigmented cysts often resemble parasitic cysts like in cysticercosis. careful examination and serological tests are essential to reach the correct diagnosis. our patient denied any history of trauma, ocular surgery or any inflammation in the past few years. furthermore the absence of signs of inflammation, like vitritis, retinitis, choroiditis or vasculitis taken in correlation with normal blood tests ruled out any acquired cause of the cyst. so the cyst was classified as congenital. regular follow up was recommended without any treatment as the patients symptoms were only mild and didn’t bother him much. in the literature however, argon laser9, neodymium: yag laser10, and pars plana vitrectomy with cyst excision has been described as possible treatment options for cysts causing moderate to severe symptoms. author’s affiliation dr. hussain ahmad khaqan assistant professor eye unit lll, lahore general hospital. dr. usman imtiaz post graduate resident eye unit lll, lahore general hospital. dr. farukh jameel post graduate resident eye unit lll, lahore general hospital. role of authors dr. hussain ahmad khaqan examination and finding. dr. usman imtiaz article writing, editing and diagnostic images. dr. farukh jameel history taking and collection of data. references 1. tansley jo. cyst of the vitreous. trans am ophthalmol soc. 1899; 8: 507-9. 2. cruciani f, santino g, salandri ag. monolateral idiopathic cyst of the vitreous. acta ophthalmologica scandinavica. 1999; 77: 601-3. 3. bullock jd. developmental vitreous cysts. arch ophthalmology. 1974; 91: 83-4. 4. nork tm, millecchia ll. treatment and histopathology of a congenital vitreous cyst. ophthalmology. 1998; 105: 825-30. 5. pannarale c. on a case of preretinal mobile cysts in a subject affected by congenital toxoplasmosis. g ital oftalmol. 1964; 17: 306-17. 6. tranos pg, ferrante p, pavesio c. posterior vitreous cyst and intermediate uveitis. eye (lond). 2010; 24: 1115-6. http://www.ncbi.nlm.nih.gov/pubmed/?term=santino%20g%5bauthor%5d&cauthor=true&cauthor_uid=10551312 http://www.ncbi.nlm.nih.gov/pubmed/?term=salandri%20ag%5bauthor%5d&cauthor=true&cauthor_uid=10551312 http://www.ncbi.nlm.nih.gov/pubmed/?term=millecchia%20ll%5bauthor%5d&cauthor=true&cauthor_uid=9593381 http://www.ncbi.nlm.nih.gov/pubmed/?term=pannarale%20c%5bauthor%5d&cauthor=true&cauthor_uid=5849862 http://www.ncbi.nlm.nih.gov/pubmed/?term=ferrante%20p%5bauthor%5d&cauthor=true&cauthor_uid=19911021 http://www.ncbi.nlm.nih.gov/pubmed/?term=pavesio%20c%5bauthor%5d&cauthor=true&cauthor_uid=19911021 vitreous cyst: a case report pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 213 7. asiyo-vogel mn, el-hifnawi el-s, laqua h. ultrastructural features of a solitary vitreous cyst. retina. 1996; 16: 250-4. 8. tuncer s, bayramoglu s. pigmented free-floating vitreous cyst in a patient with high myopia and uveal coloboma simulating choroidal melanoma. ophthalmic surg lasers imaging. 2011; 14: 49-52. 9. awan kj. biomicroscopy and argon laser photocystotomy of free floating vitreous cysts. ophthalmology. 1985; 92: 1710-1. 10. ruby aj jl. nd:yag treatment of a posterior vitreous cyst. am j ophthalmol. 1990; 110: 428-9. http://www.ncbi.nlm.nih.gov/pubmed/?term=el-hifnawi%20el-s%5bauthor%5d&cauthor=true&cauthor_uid=8789866 http://www.ncbi.nlm.nih.gov/pubmed/?term=laqua%20h%5bauthor%5d&cauthor=true&cauthor_uid=8789866 http://www.ncbi.nlm.nih.gov/pubmed/?term=bayramoglu%20s%5bauthor%5d&cauthor=true&cauthor_uid=21485975 http://www.ncbi.nlm.nih.gov/pubmed/?term=awan%20kj%5bauthor%5d&cauthor=true&cauthor_uid=4088623 microsoft word 1. editorial 56 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology editorial ophthalmic viscosurgical devices (ovds) past, present and future ophthalmic viscosurgical devices (ovds) are an integral part of the modern anterior segment surgery. although used initially as vitreous substitute, their role came in the forefront of ophthalmology with the success of extra capsular cataract extraction (ecce) and the use of intra ocular lens implants (iols). sodium hyaluronate (healon) was the first ovd launched by pharmacia in 1980. however, over the years, different ovds have been evolved with very tissue-specific role, based on their physical properties. the ovds are aqueous solution of naturally occurring long-chain polymers such as sodium hyaluronate, hydroxy propyl methyl cellulose and chondroitin sulphate. they are differentiated from each other by their physical properties of viscosity, elasticity, rigidity, pseudoplasticity and cohesion. all ovds are used to create space, to balance pressure in the anterior and posterior segment of the eye, to stabilize tissue and to protect the corneal endothelium1. the function of protection, cohesion, lubrication and retention of ovds is governed by their polymer structure, molecular weight, electrical charge, purity and inter-chain molecular interaction. ovds act as viscous liquids as well as elastic gels. the ideal viscoelastic substance should be viscous enough to prevent collapse of anterior chamber. it should be cohesive also to be removed easily from the anterior chamber but not so cohesive that it is aspirated during irrigation and aspiration, providing no protection to the corneal endothelial cells2. ovds are generally categorized into “cohesive” and “dispersive” groups on their rheological properties3. cohesion is the tendency of the constituent molecules to adhere to one another. this property is dependable on the molecule’s chain length and chemical structure. they all are pseudoplastic with high resting viscosity and high molecular weight. the pseudoplastic propertyrefers to the compounds which show greater viscosity in stationary form but exhibit decrease in viscosity when operative shear rate or force is applied. this differentiates it from true plastics (like many household objects) which always remain in solid state. cohesive ovds tend to stay together as a mass and come out as a single blob. they do not stay in the anterior chamber if aspirated, even when you want them to stay behind. dispersive ovds have short molecular length, stay where placed and are harder to remove. they are termed as pseudoplastic when their viscosity decrease with movement e.g. viscoat (alcon-usa), or nonpseudoplastic showing no decrease in viscosity with increasing movement, e.g. occu coat (storzgermany). the simple distinction between cohesive and dispersive ovds has been intrigued by the introduction of the new generation of viscoelastic products such as: healon 5 (amo – usa), which displays the either properties under different environment. at slow shear rate, it appears to be extremely viscous and cohesive but at increase flow rate, its molecule breaks up, manifesting dispersive behavior. this ability of healon 5 to change from super-viscous cohesive to pseudo-dispersive behavior is termed as viscoadaptivity4. viscoadoptive ovds have high viscosity but comfortably fractionate so are easily retained behind. ovds are classified in respect to their zero shear viscosity and cohesion. the zero shear viscosity is directly proportional to the molecular weight of the compound. they are broadly grouped as high viscosity cohesive, lower viscosity dispersive, viscoadoptive and visco-dispersive or combined cohesive / dispersive ovds. the high viscosity cohesive ovds are superviscous when these agents show extremely high zeroshear viscosity greater than 1 million mpas (milli pascal seconds) e.g. healon gv (amo-usa). healon gv has concentration of 1.4 % sodium hyaluronate and a molecular weight of 5 million daltons. its property of high cohesiveness of super viscous material results in its easy removal as a single mass at p. s. mahar pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 57 the end of the surgical procedure, thus preventing post-operative rise in intraocular pressure. they can be viscous cohesive with viscosity between 10,000 and 1 million mpas. the original healon (amo-usa) and provisc (alcon – usa) fall under this category. both of these agents contain 1% sodium hyaluronate. however healon has molecular weight of 4 million daltons compared to 2 million daltons of provisc. the lower viscosity dispersive ovd sareagents with low molecular weight and shorter molecular chains. they can be medium viscosity dispersive with zero-shear viscosity between 10,000 and 100,000 mpas, such as viscoat (alcon-usa) containing sodium hyaluronate 3% and chondroitin sulphate 4%, or very low viscosity dispersive agents including all unmodified hydroxy propyl methyl cellulose (hpmc) compounds. when injected in to the eye, these agents fragment in to small portions and disperse in to anterior chamber. they are useful in protecting corneal endothelium especially in hard cataracts when extra ultrasonic energy is used and in abnormal corneal endothelial conditions such as fuch’s endothelial dystrophy. these agents are also capable of surgical compartilization, dividing anterior chamber in to ovd-occupied space and surgical zone, in which irrigation and aspiration is taking place. the visco-adaptive ovd sare agents which change their behavior at different flow rate during phacoemulsification. healon 5 (amo-usa) containing 2.3% sodium hyaluronate, is specifically developed so that at lower flow rate, it behaves as very cohesive viscoelastic like healon gv and at higher flow rate during chopping, it begins to fracture and acts similarly to a dispersive viscoelastic such as viscoat. visco-dispersive or combined cohesive/ dispersive ovd sconsists of discovisc (alcon – usa) having 4% chondroitin sulphate and 1.7% sodium hyaluronate. it is a unique result of attempting to form an ovd in which zero – shear viscosity and cohesion have been dissociated and independently adjusted, combining the attributes of two ovd groups, so it has the desired viscosity of healon, and dispersive characteristics similar to viscoat. the chondroitin sulphate in discovisc and viscoat is very dispersive with a low viscosity and remains adhered to the corneal endothelium. the chondroitin sulphate also works better when it is mixed with sodium hyaluronate, achieving better viscosity profile. clinical applications of the ovds ovds are commonly used during modern phacoemulsification technique for removing cataract. during capsulorhexis high viscosity cohesive ovds or visco-dispersive agent are used for this maneuver. they provide excellent visibility due to high transparency. they not only maintain the depth of anterior chamber (ac) but keep the pressure of ac greater than or equal to that inside the capsular bag. this provides good capsular flap control with prevention of capsular flap dragging peripherally. a lot of surgeons use low viscosity dispersive such as hpmc to carryout capsulorhexis. the reason for this is relative less cost of the compound. to maintain ac with hpmc, the entry wound has to be smaller in width or hpmc has to be injected repeatedly. when emulsifying nucleus, cohesive ovds help to preserve the space in ac while dispersive compounds adhere to the corneal endothelium providing much needed protection against transmission of higher ultrasonic energy and mechanical trauma due to nuclear fragments. the higher viscous agents like healon 5 also enlarge small pupils (visco-mydraisis) and push back iris and vitreous to neutralize positive vitreous pressure. at the beginning of all phacoemulsification cases, an appropriate period of irrigation and aspiration without ultrasound should be carried out to produce a sizable fluid cavity inside the ovd-filled ac. the dispersive ovds take longer and their removal is enhanced by moving the phaco probe tip from side to side. the entry wound burns within seconds of starting surgery with ultrasonic energy in ovd filled ac are due to irrigation occlusion and heat generating potential of the ovds. floyd and co workers5 have elegantly shown that ovds are not only concern due to outflow occlusion but also they variably can add up to 6 times the heat creation of ultrasound in comparison to balance salt solution (bss). soft shell technique was developed and described by arshinoff6 to protect corneal endothelium, when hard cataracts are emulsified using ultrasonic energy. in this technique first the lower viscosity dispersive is injected into the anterior chamber, followed by high viscosity cohesive agent injected in the center to push dispersive viscoelastic layer against the corneal endothelium. role of viscoelastic during irrigation and aspiration is the protection of corneal endothelium. the low viscosity dispersive remains attached to the cornea while lens cortical matter is being removed. during iol implantation it is necessary to expand the capsular bag ophthalmic viscosurgical devices (ovds) past, present and future 58 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology with a viscoelastic. it allows easy iol rotation with correct positioning and centering. use of various dyes such as fluorescein sodium, indocyanine green (icg) and trypan blue has been reported for staining the anterior lens capsule in white cataracts7. akahoshi8 proposed soft shell stain technique for performing capsulorhexis in the white cataracts. this technique is identical to one described by arshin off with difference that, after injecting high molecular dispersive and high viscosity cohesive, icg is injected over the lens surface staining anterior capsule while cornea remains unstained. alternatively the dye solution can be mixed with viscoelastic agent as described by kayikicioglu and coworkers9. the purpose is to limit the contact of trypan blue to the corneal endothelium. the viscoelastic agents are also mixed with the topical anesthetic solution of lidocaine. in experimental and human studies, it has been suggested that viscoanesthetic solution with lidocaine concentration up to 1.65% are non-toxic to corneal endothelium, uveal and retinal tissue10, 11. ovds are also used to maintain ac throughout the trabeculectomy. the intracameral use of healon 5 has been found helpful to prevent early post-operative hypotony12. lopes and coworkers13 in a prospective randomized trial used injection of balanced salt solution (bss) or healon 5 subconjuctivally to modulate bleb formation. there was no difference in the overall success rate; however healon 5 was associated with more diffuse blebs. during viscocanalostomy, the schlemm’s canal is opened using high viscosity ovds preferably healon gv or healon 514. ovds are used in vitreo-retinal procedures such as macular hole repair and other vitreo retinal surgeries. ovds are used to maintain the ac during penetrating keratoplasty (pk) and also to expose the descement’s membrane in deep anterior lamellar keratoplasty (dalk)15. complications of ovds the use of ovds is not without any side effects also. they can cause an increase in the intraocular pressure (iop). the rise in iop occurs during first 24 hours after the phacoemulsification but resolves spontaneously within 72 hours in most of the cases16. the increase in iop is due to decrease in outflow facility caused by large molecules of viscoelastic material blocking the trabecular meshwork. to avoid this complication, the viscoelastic material should be thoroughly evacuated from ac at the end of the procedure. the capsular block or capsular distension syndromeis another complication which occurs when the opening of capsulorhexis is quite smaller than the optical diameter of the iol, with entrapment of viscoelastic material in the capsular bag17. this can induce pseudomyopia in the immediate postoperative period. this condition can be easily diagnosed with slit-lamp biomicroscopy, ultrasonic biomicroscopy (ubm) and optical coherence tomography (oct) of the anterior segment. the pseudo-anterior uveitishas also been reported with the use of ovds. this occurs because of viscous nature of ovds and electrostatic charge of their chemical compound. it usually resolves within few days requiring no specific treatment. ovdsarean integral part of the modern cataract surgery. ophthalmologist should be aware of all different properties of different viscoelastic substances. the field of ovds is constantly evolving and keeping abreast of all changes is in the benefit of both the patient and the physician. reference 1. arshinoff sa. dispersive and cohesive viscoelastic materials in phacoemulsification. oph pract 1995; 13: 98-104. 2. liesengang tj. viscoelastics. survey ophthalmol, 1990; 34: 268-293. 3. arshinoff sa, jafri m. new classification of ophthalmic viscosurgical devices. j cataract refract surg. 2005; 31: 2167-71. 4. tognetto d, cecchini p, ravalico g. survey of ophthalmic viscosurgical devices. curr opin ophthalmol. 2004; 15: 29-32. 5. floyd m, valentine j, coombs j, olson rj. effect of incisional friction and ophthalmic viscosurgical devices on the heat generation of ultrasound during cataract surgery. j cataract refract surg. 2006; 32: 1222-6. 6. arshinoff sa. dispersive–cohesive viscoelastic soft shell technique. j cataract refract surg. 1999; 25: 167-73. 7. pandey sk, werner l, apple dj. staining of the anterior capsule. j cataract refract surg. 2001; 27: 647-8. 8. akahoshi t. soft shell stain technique for the white cataracts: presented at the ascrs symposium on cataract, iol and refractive surgery, boston, ma. 2000. 9. kayikicioglu o, erakgun t, guler c. trypan blue mixed with sodium hyaluronate for capsulorhexis. j cataract refract surg. 2001; 27: 970-4. 10. macky ta, werner l, apple dj et al. visco anesthesia part ii. evaluation of the toxicity to ocular structures after phacoemulsification in a rabbit model. j cataract refract surg. 2002; 13: 436-9. 11. pandey sk, werner l, apple dj et al. viscoanesthesia part iii. evaluation of the removal time of viscoelastic/ viscoanesthetic p. s. mahar pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 59 solution from capsular bag of human eyes obtained postmortem. j cataract refract surg. 2003; 29: 563-7. 12. gutierrez-ortiz c, moreno-lopez m. healon 5 as a treatment option for recurrent flat anterior chamber after trabeculectomy. j cataract refract surg. 2003; 29: 635-8. 13. lopes jf, moster mr, wilson rp et al. subcojunctival sodium hyaluronate 2.3% in trabeculectomy: a prospective randomized clinical trial. ophthalmology. 2006; 113: 756-60. 14. stegmann r, pienaar a, miller d. visocanalostomy for open angle glaucoma in black african patients. j cataract refract surg. 1999; 25: 316-22. 15. bissen-miyajima h. ophthalmic viscosurgical devices. curr opin ophthalmol. 2008; 19: 50-4. 16. barron ba, busin m, page c et al. comparison of the effect of viscoat and healon on postoperative intraocular pressure. am j ophthalmol. 1985; 100: 377-84. 17. miyake k, ota i, ichihashi s, et al. new classification of capsular block syndrome. j cataract refract surg. 1998; 24: 1230-4. prof. p.s. mahar pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 199 original article pre-operative diclofenac sodium eye drops vs intra-operative adrenaline irrigation in maintaining mydriasis during extracapsular cataract extraction jehanzeb khan, imran ahmad, mubashir rehman, zeeshan tahir pak j ophthalmol 2014, vol. 30 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: jehanzeb khan medical officer lady reading hospital, peshawar …..……………………….. purpose: to compare the effectiveness of pre-operative diclofenac sodium eye drops with per-operative intraocular irrigation with adrenaline 1:1,000,000 (one in one million) solution in maintaining mydriasis during cataract surgery. material and methods: it was a randomized control trial and was conducted in the department of ophthalmology, khyber teaching hospital peshawar from september 2010 to march 2011. 210 patients with senile mature cataracts were divided into two groups “a” and “b” with 105 patients in each group. group “a” received pre-operative diclofenac eye drops for 24 hours and group “b” received per-operative irrigation with 1:1,000,000 of adrenaline solution. in all patients pupillary size was measured after cortical matter removal during extracapsular cataract extraction. results: the mean age of patients in group “a” was 59.87 ± 6.54 sd years and in group “b” was 61.38 ± 6.30 sd. the mean pupillary size after cortical matter removal in group “a” was 7.0667 mm ± 1.78 sd while that in group “b” was 8.3371mm ± 1.94sd. the difference between the two was statistically significant after applying independent sample„t‟ test with p value of <0.000. conclusion: per-operative irrigation of adrenaline 1:1,000,000 solution keeps better pupillary size as compared to pre-operative diclofenac sodium for patients undergoing extracapsular cataract extraction, key words: adrenaline, extra capsular cataract extraction, diclofenac sodium ataract surgery is one of the most common surgical procedures in patients over the age of 60 years.1 over the past decade operative technique in cataract surgery has improved and the operation has become less traumatic to the eye.2 pupillary constriction during cataract surgery is found to be the major cause of iris damage, incomplete cortex removal, posterior capsular rupture, vitreous loss, and even posterior lens matter dislocation.3,4 cataract surgery can be performed more easily and safely if mydriasis can be maintained until intraocular lens implantation.5 different drugs e.g. cyclopentolate, tropicamide and diclofenac sodium have been used pre-operatively to maintain per-operative pupillary dilatation.6,7 per-operative intraocular irrigation with adrenaline 1:1,000,000 solution has been found to be safe and effective in maintaining mydriasis during cataract surgery.6 pre-operative diclofenac sodium eye drops have also been used and have found effective in maintaining mydriasis during cataract surgery.8 purpose of the study was to determine the outcome of per-operative intraocular irrigation with adrenaline 1:1,000,000 solution is better than preoperative diclofenac sodium eye drops in maintaining c jehanzeb khan, et al 200 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology mydriasis during cataract surgery that help in prevention of complication. it is also cost effective and compliance is better than diclofenac sodium eye drops. no local study with such a sample size had been carried out on this topic and this will help in changing the protocol used for maintaining mydriasis during cataract surgery. material and methods this was a randomized control trial and was conducted at the department of ophthalmology of khyber teaching hospital, peshawar from september 2010 to march 2011. all patients with age related cataracts that undergone extracapsular cataract extractions by the same surgeon were enrolled in the study. patients with complicated cataracts including cataracts with uveitis, pigment dispersion syndrome, pseudoexfoliation, lens related glaucoma, traumatic cataracts and patients with cardiac diseases, diabetes and hypertension were excluded from the study to avoid biased in the study results. patients were diagnosed with slit – lamp examination and ophthalmoloscopy. written informed consent was taken from all patients. pupil in patients of both groups was dilated with topical tropicamide 1% eye drops (1 drop every 10 minutes for 45 minutes1 hour before surgery). these patients were randomly allocated into “a” (diclofenac group) and “b” (adrenaline group) by lottery method. adrenaline 1:1,000,000 solution was made by diluting one adrenaline ampule 1:1000 in 1 liter (1000 ml) of ringer lactate. patients in group “a” had mydriasis with preoperative diclofenac sodium for 24 hours before surgery and patients in group “b” were irrigated peroperatively with adrenaline 1:1,000,000 solution. intraoperatively pupil size was measured with a caliper after cortical lens matter removal during surgery. exclusion criteria were followed strictly to avoid any confounder and bias in study results. all the statistical analysis was carried out using spss version 11.0. student t-test was applied between the pupil sizes of both the drugs to see their effects. p-value of ≤ 0.05 was considered significant. results a total of 210 patients were enrolled in the study and were randomly distributed in two groups a and b with 105 patients in each group. in group a there were 71 (68.6%) male and 34 (32.4%) female patients, whereas in group b there were 74 (70.5%) male and 31 (29.5%) female patients. all patients enrolled have age range of 51 – 71 years with a mean of 59.87 ± 6.54 sd in group a and 61.38 ± 6.30 sd in group b. average pupillary size in group a was 7.0667 mm ± 1.78 sd and in group b was 8.3371 mm ± 1.94 sd which was highly significant with p-value = 0.000 (table 1). the efficacy of group a was 29 (27.6%) and group b was 63 (60%) (p-value = 0.000) (table 2). age wise distribution of efficacy shows that 25 (27.2%) of efficacy belongs to patients with age equal to or less than 55 years while 18 (19.6%) in age group of 56 – 60 years, 24 (26.1%) in 61 – 65 years while 25 (27.2%) efficacy was seen in above 66 years of age, which is significant with p-value = 0.254 (table 3). efficacy in male patients was 58 (63%) while in females it was observed in 34 (37%). majority of efficacy was shown in male as compared to female, although it was not significant statistically with p-value = 0.097 (table 4). discussion cataract extraction in majority of cases is a safe and effective procedure, but maintenance of mydriasis can contribute to the ease with which surgery can be performed.7 a small pupil during surgery may increase the risk of damage to the iris, incomplete removal of soft lens matter and more importantly, rupture of the posterior capsule with vitreous loss.8 to maintain mydriasis during surgery, various drugs have been used but it depends upon the surgeons choice and available authentic literature9. the persistence of good mydriasis is a prerequisite for cataract surgery.10 adequate use of preoperative mydriatics, subconjunctival mydricaine, preservativefree intracameral adrenaline, iris retractors and sphincterotomies are some of the methods to combat poor mydriasis.11 inspite of all these measures, the problem of poor mydriasis is still a problem for surgeons.12 hence we undertook this study, creating a new local data regarding the best mydriatic among diclofenac sodium and adrenaline regimen to enable us to achieve better mydriasis during cataract surgery. the present study demonstrates that adrenaline 1:1,000,000 in the intraocular infusion is of significant benefit in maintaining mydriasis during cataract surgery compared to diclofenac sodium. the mean age of patient in diclofenac sodium group was 59.87 ± 6.54 sd while that in the adrenaline group was 61.38 ± 6.30 sd. the mean pupillary size at the time of cortical matter removal in diclofenac sodium group was pre-operative diclofenac sodium eyed rops vs intra-operative adrenaline irrigation in maintaining mydriasis pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 201 7.0667 mm ± 1.78 sd while that in adrenaline group was 8.3371 mm ± 1.94 sd. the difference was statistically significant after applying independent sample t-test with p-value of < 0.000. the results of our study clearly verified that adrenaline 1:1000000 solution is quite effective in maintaining mydriasis during cataract extraction along with iol insertion for age related senile cataract. a study conducted by flach aj comparing the pupillary sizes at various stages of extracapsular cataract extraction. the average dilation in adrenaline group at 45minutes was 7.13 mm and that in diclofenac group was 5.88 mm.13 the difference achieved in both the dilating regimens was 1.25 mm which was statistically significant using the unpaired t-test (p < 0.001). the results of this study were quite comparable and in close approximation to what are achieved in our study. similar results were obtained in a study conducted by ong-ton l, he concluded his results showing better jehanzeb khan, et al 202 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology efficacy of adrenaline over diclofenac sodium as mean pupil diameter after cortical lens matter removal was 8.14 mm ± 0.85 for adrenaline and 7.87 mm ± 1.03 for diclofenac sodium and the difference was statistically significant (p < 0.002).6 these results were quite closer to what we found in ours study. 0 20 40 60 80 100 efficacy no efficacy male female fig. 1: ender wise comparison of efficacy fahimi ms et al also demonstrated similar results in his study for pupillary size during ecce with a p-value of < 0.04 proving that the difference between in pupillary size is statistically significant.13 and even a much stronger difference has been quoted by guadalupe cervantes-coste with the mean pupil size at the end of surgery, between diclofenac sodium (6.84 ± 0.93 mm) and adrenaline group (7.91 ± 0.74 mm) was statistically significant (p < 0.001).14 similarly in a study conducted by bäckström g, showed that there was a greater degree of contraction in the absence of adrenaline in the irrigation solution (2.3 ± 1.0 mm in the intracameral mydriatics (icm) group and 3.2 ± 0.7 mm in the placebo group (p = 0.015).15 our study has shown that per-operative intraocular irrigation with adrenaline 1:1000,000 has significant benefit in maintaining mydriasis during cataract surgery. conclusion per operative irrigation of adrenaline 1:1,000,000 solution keeps better pupillary size compared to pre operative diclofenac sodium for patient undergoing extracapsular cataract extraction. author’s affiliation dr. jehanzeb khan medical officer department of ophthalmology lady reading hospital, peshawar dr. imran ahmad medical officer pakistan institute of community ophthalmology hayatabad medical complex, peshawar dr. mubashir rehman medical officer lady reading hospital, peshawar dr. zeeshan tahir medical officer lady reading hospital, peshawar references 1. reeves sw. advances in cataract surgery and intraocular lenses. clinical and health affairs. ophthalmol. 2005; 103-19. 2. ocampo vvd, foster cs. cataract, senile: treatment and medication. e-medicine specialties >ophthalmology>lens may 2009. 3. liou sw, yang cy. the effect of intracameral adrenaline infusion on pupil size, pulse rate, and blood pressure during phacoemulsification. j ophthalmol and therapeutics. 2009; 14: 357-61. 4. ms, sheikh a, fasih u. comparative study of diclofenac sodium with adrenaline for prevention on intra operative miosis. ann abbasi shaheed hosp karachi med dent coll. 2005 10: 729-31. 5. hirowatari t, tojuda k, kamei y, miyazaki y, matsubara m. evaluation of a new preoperative ophthalmic solution. can j ophthalmol. 2005; 40: 58-62. 6. ong-tone l, bell aj. cataract refract surg. pupil size with and without adrenaline with diclofenac use before cataract surgery. 2009; 35:1396-400. 7. rafnsson v, olafsdottir e, hrafnkelsson j, sasaki h, arnarsson a, jonasson f. "cosmic radiation increases the risk of nuclear cataract in airline pilots: a population-based casecontrol study". arch ophthalmol. 2005; 123: 1102-5. 8. finger, stanley. origins of neuroscience: a history of explorations in to brain function. oxford university press. 1994; 70: 22-8. 9. zigler jr js. pathogenesis of cataracts. in: tasman w, jaeger ea, eds. duane's ophthalmology. 15th ed. philadelphia, pa: lippincott williams & wilkins; 2009. 10. howes fw. indications for lens surgery/indications for application of different lens surgery techniques. in: yanoff m, duker js, eds. ophthalmology. 3rd ed. st. louis, mo: mosby elsevier; 2008. 11. hargrave sl, jung jc, fini me, gelender h, cather c, guidera a, et al. possible role of vitamin e solubilizer in topical diclofenac on matrix metalloproteinase expression in corneal melting: an analysis of postoperative keratolysis. ophthalmology. 2002; 109: 343-50. 12. corbett mc, richards ab. intraocular adrenaline maintains mydriasis during cataract surgery. british journal of ophthalmology. 1994; 78: 95-8. 13. flach aj. corneal melts associated with topically applied nonsteroidal anti-inflammatory drugs. trans am ophthalmol soc. 14. cervantes-coste g, sánchez-castro yg, orozco-carroll m, mendoza-schuster e, velasco-barona c. inhibition of http://www.ncbi.nlm.nih.gov/pubmed?term=%22b%c3%a4ckstr%c3%b6m%20g%22%5bauthor%5d http://en.wikipedia.org/wiki/oxford_university_press pre-operative diclofenac sodium eyed rops vs intra-operative adrenaline irrigation in maintaining mydriasis pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 203 surgically induced miosis and prevention of postoperative macular edema with diclofenac. clin ophthalmol. 2009; 3: 21926. 15. bäckström g, behndig a. redilatation with intracameral mydriatics in phacoemulsification surgery. acta ophthalmol scand. 2006; 84: 100-4. http://www.ncbi.nlm.nih.gov/pubmed?term=%22b%c3%a4ckstr%c3%b6m%20g%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22behndig%20a%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed/16445447## http://www.ncbi.nlm.nih.gov/pubmed/16445447## http://www.ncbi.nlm.nih.gov/pubmed/16445447## 147 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology original article pattern of pediatric eye diseases soufia farrukh, muhammad abid latif, ahmad hussain klasra, munawer ali pak j ophthalmol 2015, vol. 31 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: soufia farrukh department of ophthalmology quaid e azam medical college bahawalpur email: soufiafarrukh@yahoo.com …..……………………….. purpose: to assess the pattern of common eye diseases in pediatric population of bahawalpur. material and methods: total 1000 children coming to outpatient department of ophthalmology, bahawal victoria hospital bahawalpur over a period of two months from 1 st june 2014 to 31 st july 2014, with age ≤ 16 years were included in this study. results: mean age of the patients was 9.51 ± 4.8 years. out of 1000 patients 483 (48.3%) patients were males and 517 (51.7%) patients were females. most of the patients 455 (45.5%) belonged to age group 9-12 years. most common disorder was refractive errors 322 (32.2%) followed by congenital cataract 231 (23.1%), vkc 219 (21.9%) and squint 124 (12.4%). conclusion: male and female children were almost equally affected with ocular disorder and refractive error was the most common disorder in this study. key words: ophthalmology, consanguineous marriages, congenital, childhood blindness, refractive errors. phthalmology is one of the important specialty in medical health services.1 ophthalmology unfortunately lags behind in this field of quality of life assessment even though our discipline and the organ with which we deal have a major impact on quality of life.2 this includes a sense of well-being and other considerations, including whether people feel a burden to their families, have trouble getting up in the morning or performing daily duties.1 it is a common problem in both rural and urban areas.3 also equally spread over developed and under developed countries.1 according to a concluded population census in 1998, pakistan has an estimated population of 142 million in 2003. it is estimated that 40% of the population is below 16 years of age. the prevalence of blindness in children in pakistan is estimated to be about 10 per 10,000 children, which means there are about 60,000 blind children. a further 100,000 to 80,000 children are estimated to have low vision.4 the high incidences of consanguineous marriages together with maternal infections and environmental factors are responsible for the significant proportion of congenital / developmental abnormalities in these children. other causes of childhood blindness include nutritional factors and trauma. in poor countries of the world, corneal scarring due to vitamin a deficiency, ophthalmia neonatrum trachoma and use of harmful traditional practices (tp) predominates.4,5 increasingly, refractive errors is being recognized as an important cause of visual impairment in both children and adults, the type and magnitude of refractive errors clearly changes with advancing age and also appears to be changing overtime , with recent cohort having higher prevalence than earlier one. visual acuity is the most appropriate screening test to identify individual with visual impairment due to uncorrected refractive errors.6 material and methods we have studied all children coming to outpatient department of ophthalmology, bahawal victoria hospital bahawalpur over a period of two months from 1st june 2014 to 31st july 2014. a standard performa was used. on anatomical basis the disorders were divided into disorders affecting conjunctiva, o mailto:soufiafarrukh@yahoo.com pattern of pediatric eye diseases pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 148 whole globe, cornea, lens, uvea, retina, optic nerve, ocular muscles, nasolacrimal system and refractive system. detailed ocular examination was done for decision making, teaching and training purposes. refraction was performed routinely under cycloplegia. anterior segment examination was done with slit lamp and torch. posterior segment examination was performed after dilating pupil using direct and indirect ophthalmoscope and fundus contact lenses. intraocular pressure was checked with perkins tonometer. squint assessment was done in detailed way using prisms and tests for steropsis. all the data was entered in spss version 16 and analyzed. mean and standard deviation was calculated for numerical data and frequencies were calculated for categorical data. results total 1000 children with ophthalmic disorder were included in this study. mean age of the patients was 9.51 ± 4.8 years. out of 1000 patients 483 (48.3%) patients were males and 517 (51.7%) patients were females (fig. 1). out of 1000 patients 273 (27.3%) patients belong to age group 1-4 years, 272 (27.2%) patients belongs to age group 5-8 years and 455 (45.5%) patients belongs to age group 9-12 years (table 1). as shown in table.2 refractive errors were present in 322 (32.2%) patients, vkc 219 (21.9%), squint 124 (12.4%), nld block in 58 (5.8%), retinitis pigmentosa was present in 29 (2.9%) patients, congenital abnormalities like congenital cataract 231 (23.1%) and congenital glaucoma in 17 (1.7%) patients. discussion in present study male was 48% and female was 52%. these findings are in agreement with the study of fasih u el al,7 where 59.50% patients were male and 40.5% were female. but our findings are in contrast with a study conducted at eye department khyber teaching hospital peshawar where male patients were 68.9% and female patients were only 31.1%.8 this is due to many scio-economic factors of our society. uncorrected refractive errors have a direct effect on learning capabilities of the children and their education.9 according to a study refractive errors are third largest cause of curable blindness in pakistan.7 most frequently reported disease in our study was refractive errors 32%. iqbal y et al reported 62.9% children with refractive errors in his study. this is almost double than our finding.10 in another study by fig. 1: gender distribution soufia farrukh, et al 149 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology fasih u et al refractive errors were found in 8.11% children. studies by sethi et al8 and khan et al11 were also in contrast with our study. refractive errors were the commonest in children and adolescents. they predominate but their number at opd clinics varies from day to day. second most common ophthalmic disorder in our study was congenital cataract disorder found in 23.1% children. the cataract found in other studies nationally and internationally was not greater than 10%. this high percentage found in our study is due to many factors one of them is that patient’s parents pay many visits to opd clinic before taking decision of surgery. moreover our society have high ratio of consoganity which is an important risk factor for it.12 vkc is a common, prevalent and clinically significant ige mediated hypersensitivity response. vkc is an immunopathological disease in which the number of mast cells in substantia propria increases. activation of mast cells by ige bound receptor crosslinking by allergen promotes the release of several mediators such as histamine, prostaglandins and cytokinase, all of which contribute to the symptoms of vkc. the mast cell is considered to play a pivotal role in producing symptoms and signs of vkc.13 vernal conjunctivitis which is an allergic form of conjunctivitis was very common 21.9% among the study population. similar 21.1% results were reported by hassan m et al.14 ajayeoba et al12 and iqbal y et al10 were in contrast with our study. this disease usually results from allergic materials such as dust. also chemical conjunctivitis could result from inappropriate instillation of eye drugs from self-medication. this is due to the fact that prescribed drugs are freely dispensed over the counter and the failure of government to control drug distribution. also traditional eye remedy which had been found to be dangerous is usually on display in open market.15 several publications had documented the role of traditional healers and their medications in most african communities and had observed that harmful traditional eye medication could lead to blindness.16 our study shows an alarmingly 12.4% number of patients who had strabismus. sethi et al17 found similar results 13.5% in north west frontier province. onakpoya et al18 found strabismus as 15.9% which is also comparable with our study. this actually means that a high number of patients are threatened not only by the development of amblyopia and the non development of binocular single vision but also by social condemnation which may have damaging effects on the psychological development of the children that could be more harmful than the visual problem itself. congenital glaucoma was found in 1.7% children. similar results 0.81% were found by fasih u et al7 in their study. sethi et al8 also found congenital glaucoma in 0.99% children. the incidence of congenital glaucoma varies among different geographic locations and ethnic groups, with the highest recorded incidence found in the gypsy population of slovakia (1:1250), and followed by the general populations of the middle east (1:2500) and the western nations (1:10,000).8 conclusion male and female children were almost equally affected with ocular disorder and refractive error was the most common disorder in this study. author’s affiliation dr. soufia farrukh associate professor department of ophthalmology quaid e azam medical college, bahawalpur dr. muhammad abid latif senior medical officer department of ophthalmology quaid e azam medical college, bahawalpur dr. ahmad hussain klasra medical officer department of ophthalmology quaid e azam medical college, bahawalpur dr. munawer ali medical officer department of ophthalmology quaid e azam medical college, bahawalpur role of authors dr. soufia farrukh research design, methodology and result analysis. dr. muhammad abid latif data collection and result analysis. pattern of pediatric eye diseases pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 150 dr. ahmad hussain klasra literature research and follow-up. dr. munawer ali script drafting and follow-up. references 1. murad mau, alam ms, miah akma, akter ms, kabir mh. pattern of eye diseases in a tertiary hospital in a suburban area: a retrospective study orion med j 2007; 28: 292-4. 2. lichter. quality of life as an indicator. highlights of ophthalmology. 1994; 22: 10. 3. shrestha mk, guo cw, maharjan n, gurung r, ruit s. health literacy of common ocular diseases in nepal. bmc ophthalmol. 2014; 14: 1–8. 4. mahdi z, munami s, shaikh za, awan h, wahab s. pattern of eye diseases in children at secondary level eye department in karachi. pak j ophthalmol. 2006; 22: 145-51. 5. pakistan national programme for the prevention of blindness. first five year plan 1994 – 1998, national committee for the prevention of blindness, ministry of health, special education and social welfare islamabad. 6. elimination of avoidable visual disability due to refractive errors; report of an informal meeting geneva 3-5 july 2000 who/pbl/0079; 6-10. 7. fasih u, rahman a, shaikh a, fahmi ms, rais m. pattern of common paediatric diseases at spencer eye hospital. pak j ophthalmol. 2014; 30: 10-4. 8. sethi s, sethi jm, saeed n, kundi kn. pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital. pak j ophthalmol. 2008; 24: 166-70. 9. negral ad, maul ep. pokheral, zhap refractive error study in children: sampling and measurement methods for a multicountry survey. am j ophthalmol. 2000; 129: 421-6. 10. iqbal y, niazi fk, niazi mak. frequency of eye diseases in school age children. pak j ophthalmol. 2009; 25: 185-90. 11. khan ma, gullab a, khan md. prevalence of blindness and low vision in north west frontier province of pakistan. pak j ophthalmol. 1999; 15: 1-2. 12. ajaiyeoba ai, isawumi ma, adeoye ao, oluleye ts. pattern of eye diseases and visual impairment among students in southwestern nigeria. int ophthalmol. 2007; 27: 287-92. 13. shoja mr, besharaty mr. comparison of efficacy and safety of topical ketotifen (ketotifenfumerate) with cromolyn sodium in the treatment of vernal keratoconjunctivitis. j res med sci. 2005; 10: 87-92. 14. hassan m, adeleke n, akinleye c, adepoju e, olowookere s. patterns of presentations at a free eye clinic in an urban state hospital. njcp. 2013; 16: 145. 15. ajaiyeoba ai, scott sco. risk factors associated with eye diseases in ibadan, nigeria. afr j. biomed. res. 2002; 5: 1-3. 16. tabbara kf, el-sheikh hf, shawaf ss. pattern of childhood blindness at a referral clinic in saudi arabia. ann saudi med. 2005; 25: 18-21. 17. sethi s, khan md. pediatric ophthalmic disorders. j postgrad med inst. 2001; 15: 144-50. 18. onakpoya oh, adeoye ao. childhood eye diseases in southwestern nigeria: a tertiary hospital study. clinics (sao paulo). 2009; 64: 947–52. microsoft word editorial 170 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology editorial physical examination of patients from a glaucoma perspective many years ago one of our teachers in ophthalmology said to us during a clinical tutorial:”it is very easy to forget that the eyes are attached to a structure called ’the body’, diseases of which can affect the eyes”. he was actually highlighting the fact that a very significant number of ophthalmologists develop ‘tubular vision’ concentrating only on the eyes of a patient and not considering patient as a whole. advantages in carrying out a systemic assessment of patients are many and include: (1) diagnosis, particularly with an atypical presentation (2) general management plan (3) surgical decisions clinical examples to highlight the above points 1. secondary glaucomas are a subgroup of glaucomas having varied and diverse causes. one of the causes being sturge weber syndrome which presents with a dramatic port wine stain on the face. in dark-skinned individuals the port wine stain may not be very obvious and can be missed. the importance of this diagnosis has implications if surgical intervention such as trabeculectomy is being planned since surgical complications such as suprachoroidal haemorrhage is more likely to take place in this type of glaucoma. 2. most of the glaucoma patients use eye drops for their disease and therefore it is very important that they should be able to use them. if patients have some form of physical disability such as arthritis or limb paresis, the disability is likely to affect compliance. these points have to be taken into account in the clinic as part of the glaucoma management plan. 3. people who have a tendency towards keloid scar formation on their skin are likely to have an aggressive healing response after trabeculectomy. this information is vital to plan treatment modalities such as introduction of antimetabolites during glaucoma filtration surgery. suggested plan for a quick general examination a systemic examination needs not to be comprehensive or time consuming and neither is it feasible while working in a busy eye clinic to carry out detailed general examination. however important clues can be gained if consciously looked for and can help to focus on a particular area when examining patients on the slit lamp. taking into the account the following, vital clinical information may be quickly obtained: (i) gait and general appearance: e.g. thick neck, tight collar, dementia, cushionoid appearance, arthroptahy. (ii) face: e.g. evidence of facial injury, ptosis, proptosis, thyroid eye disease, hetrerochromia iridis, skull malformations as part of anterior segment dysgenesis etc. (iii) skin: e.g. dementia, rosacea, oculodermal melaocytosis, sturge weber syndrome, neurofibromatosis (iv) hands: e.g. arthritis, tremors, raynaud’s phenomena, joint hypermobiltiy. clinical examples (i) pitutary tumours and glaucomas have been reported to coexist in the same individual. both may cause field defects leading to confusion in diagnosis. the clinical features of acromegaly such as supraorbital ridges, spade-like hands & feet, and thick skin will be noticeable if specially looked for, otherwise they might be missed. physical examination of patients from a glaucoma perspective pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 171 (ii) some patients may be having mild dementia which is very easy to be overlooked in the eye clinic. this has multiple implications; firstly they may perform poorly on automated visual field system. secondly they may show poor compliance towards ocular medication for glaucoma. in such individuals surgical intervention or laser trabeculoplasty may be a better option. (iii) patients from low socioeconomic class who are suffering from effects of poor nutrition may have poor healing which clinically is likely to manifest as wound leaks following trabeculectomy. early appreciation of this would be an indication for modifying surgical technique (avoiding antiproliferative agents, less post operative steroids, using non-absorbable sutures) (iv) patients who have thick neck and wearing a tight collar may show an artificially high intraocular pressure during applanation tonometry on the slit lamp. (v) patients who have some degree of ptosis may produce artifactual visual field defects on field testing giving rise to a wrong diagnosis of glaucoma. (vi) patients who are suffering from asthma or chronic obstructive airway disease may be using inhaled or systemic steroids. this steroid usage may be responsible for secondary glaucoma. (vii) obvious respiratory disease with element of bronchospasm would be a contraindication for the use of topical beta blockers for obvious reasons. (viii) in traumatic angle recession, secondary peripheral anterior synechiae may mask the angle recession. under such a situation evidence of facial injury may be a valuable sign that should prompt careful examination. in such cases if surgery is being considered the possibility of lens zonule trauma, retinal dialysis and the increased risk of failure of drainage surgery will affect management2. (ix) patients with eczema may develop secondary glaucoma3 owning to the fact that they may be using topical corticosteroids for the skin condition. the above are just a few examples of how clues obtained from general examination can assist in glaucoma management. this assessment of the patients as a whole and the advantage of fitting together small bits of information and clues cannot be overemphasized. references 1. howard g, english f. occurrence of glaucoma in acromeglics. archives of ophthalmology 1965; 73: 765. 2. mermound a, salmon jf, barron a, straker c, murray ad. surgical management of post traumatic angle recession glaucoma. ophthalmology 1993; 100 (5): 63442. 3. aggarwal r.k, potamitis t, chong nh,guaro m, shah p, kheterpaul s. extensive visual loss with topical facial steroids, eye 1993. amjad akram consultant ophthalmologist pakistan army masood alam shah assistant professor, aj&k medical college muzaffarabad (ajk) pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 61 original article effectiveness of supratarsal triamcinolone injection in patients with vernal keratoconjunctivitis sher akbar khan, tajbar khan, mubashir rahman, mir ali shah pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sher akbar khan vitreoretinal fellows, department of ophthalmology, lady reading hospital peshawar …..……………………….. purpose: to determine the efficacy of supratarsal injection of triamcinolone acetate amongst patients with vernal keratoconjunctivitis. material and methods: it was descriptive case series study conducted in the department of ophthalmology, lady reading hospital peshawar in 6 months from 6 th february to 6 th july, 2012. a total of 196 patients with vernal keratoconjunctivitis were subjected to supratarsal injection of triamcinolone acetate. to determine the effectiveness, all patients were followed after two weeks of supratarsal injection of triamcinolone acetate for the complete disappearance of papillae and those patients in whom there was complete disappearance of the papillae were followed for the next three months for recurrence of the papillae. data was analyzed by statistical package for social sciences (spss) version 10.0 and presented in the form of tables and graphs. results: there were total of 196 patients comprising of 130 (66.33%) males and 66 (33.67%) females with an overall mean age of 15.23 ± 5.79sd. maximum patients i.e. 130 (66.33%) were from the age group of 11 to 20 years. the supratarsal triamcinolone acetate injection was effective in 170 (86.73%) patients including 123 (61.18%) males and 47 (27.65%) females. no recurrence of the papillae was noted in any of the patients when followed for further three months time. conclusion: supratarsal injection of triamcinolone acetate is effective in vernal keratoconjunctivitis for complete disappearance of papillae. key words: vernal keratoconjunctivitis; supratarsal injection; triamcinolone acetate; papillae. ne of the most frequent and ideal location for allergic reactions is eye in the human body.1 vernal keratoconjunctivitis is a chronic and recurrent inflammation of the conjunctiva and cornea and affects both eyes. three quarters of vkc patients have atopy and among them two – third have family history. vkc usually starts after the age of 5 years and resolve around puberty but in very small number of patients it persists beyond the age of 25 years.3 it is more common in summer, dry, subtropical climates such as mediterranean, the middle east, central and west africa, south africa and asian countries such as japan, thailand and india.4 boys are usually affected twice more common than girls. the chief symptoms of this disease include severe itching, photophobia, redness and tenacious discharge. the clinical signs develop in conjunctiva and cornea; and include cobble stone papillae in the upper tarsal conjunctiva, limbal conjunctival thickening with gelatinatious nodule and tranta’s dots in the conjuctiva and superficial punctate keratopathy, shield ulcer and vascularization known as pannus formation in the cornea.5 the etiology of vkc is not simply a type 1 hypersensitivity reaction.6 previous studies have o sher akbar khan, et al 62 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology shown that t helper type 2 cells and their cytokines, corneal fibroblasts and epithelium along with various growth factors plays an important role in the pathogenesis of vkc,7 however the immunoglobulin e (ige) – mediated mechanism does not explain the severity and the clinical course of vernal (vkc) which are probably also related to t cell – mediated responses, massive eosinophils attraction and activation of non-specific hypersensitivity. recent studies suggest that a wide range of cytokines, chemokines, proteases and growth factors are involved by complex interactions rather than distinct and parallel pathways. there is also a role of several non-specific enzymatic systems activated during acute and chronic allergic inflammation, thus contributing to the complex pathogenesis of the disease.8 treatment options in vkc include mast cell stabilizers, antihistamines, corticosteroids, and immunosuppressive drugs. cyclosporine has also been shown to be effective in the treatment of vkc but further randomized control trials are required to establish the minimum effective concentration9. keeping in view the above pathogenesis of vkc, new and more specific treatment strategies such as antichemokine receptor antibodies, leukotriene receptor antagonists, and specific macrobiomolecules are under evaluation.10,11 in refractory vkc a number of new therapeutic agents have been tried which include topical nonsteroidal anti-inflammatory agents (suprofen), topical mast cell stabilizers (nedocromil, lodoxamide), topical immunomodulators (cyclosporine), topical antihistamines (levocabastine), and ganglioside derivatives (miprogoside). most of these treatment strategies have been found relatively less effective. high doses of steroids given systemically relieve some signs and symptoms, but tarsal cobblestone papillae and shield ulcers remain relatively unaffected. one of the effective corticosteroid used in vkc is triamcinolone which is given in the form of injection in the supratarsal area.12 it has good therapeutic results in vkc patients according to the study conducted by sahu n, et al,5 most of the patients experienced dramatic symptomatic relief from the disease. another study conducted by sadiq mn, et al, showed 50% reduction of symptoms12. triamcinolone acetonide has been effectively used in ocular therapeutics for over 50 years. recently its use has increased for periocular and intraocular treatment of allergic disorders of eye.13 according to burney et al, cobble stone papillae were completely disappeared in 14 out of 18 patients.14 vkc patients have to use topical medication for a longer period of time and many times a day so poor compliance and cost are the two main problems often experienced by vkc patients. therefore, this study was designed to determine the effectiveness of supratarsal injection of triamcinolone acetate (kanakot) in vkc patients. this study was also aimed to provide us local statistics regarding the effectiveness of triamcinolone in vkc as no such study has been conducted locally. the objective of the study was to determine the efficacy of supra tarsal injection of triamcinolone acetate among patients with vernal keratoconjunctivitis. material and methods it was a descriptive case series. this study was carried out at department of ophthalmology, lady reading hospital peshawar. the duration of the study was 6 months from 6th february to 6th july, 2012. it was non probability (consecutive) sampling. the sample size was calculated to be 196, using 50%12 efficacy of triamcinolone injection in the treatment of vkc, 95% confidence level and 7% margin of error according to who software for sample size determination. all those patients presented to our opd with vkc, patients of either gender and patients of age greater than 6 years were included in the study. patients who were having intra ocular pressure more than 21 mm of hg by goldman applanation tonometer, patients who were having active bacterial infection with mucopurulent discharge and patients who were receiving steroids for other eye diseases like uvietis, scleritis were excluded from the study. all patients fulfilling the inclusion criteria were included in the study through the opd. the diagnosis of vkc was based upon history of itching, photophobia and slit lamp examination showed papillae over palpebral conjunctiva. the purpose and benefits of the study was explained to the patients / attendants and a written informed consent was obtained. all patients were worked up with complete history, clinical examination including detailed ophthalmological examination followed by routine investigation to rule out confounder and bias in study result. the entire patients were subjected to injection triamcinolone acetate by an expert ophthalmologist in the dose of 0.5 ml (20 mg) of triamcinolone acetonide effectiveness of supratarsal triamcinolone injection in patients with vernal keratoconjunctivitis pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 63 in potential space between conjunctiva and muller muscle. the patients were followed-up for two weeks after the injection for relief of itching and photophobia and disappearance of papillae to determine the efficacy of the drug and all the above mentioned information including age, gender, address were recorded in a predesigned proforma. the potential complications like blephrpotosis, skin depigmentation, infections, motility disturbances, conjunctival scarring and increase in intraocular pressure were also observed in the patients in follow-up. all the data was analyzed in spss version 10. frequency and percentages were calculated for categorical variables like gender and drug efficacy. mean ± sd were calculated for continuous variables like age and duration of symptoms. drug efficacy was stratified among the age, gender and duration of symptoms to see the effect modifiers. all the results were presented as tables and graphs. results the total number of patients presenting with vernal keratoconjunctivitis was 196 comprising of 130 (66.33%) males and 66 (33.67%) females (fig. 1). 66.33% 33.67% 0.00% 20.00% 40.00% 60.00% 80.00% male female male female fig. 1: gender distribution of patients with vernal keratoconjunctivitis treated with supra tarsal injection of triamcinolone n = number of observed patients, % = percentage maximum number of patients presenting with vernal keratoconjunctivitis was 130 (66.33%) from the age group of 11 to 20 years followed by 34 (17.35%) and 26 (13.26%) patients from the age groups of 6 to 10 and 21 to 30 years respectively. minimum number of patients were 6 (3.06%) from the age group of 31 to 40 years (table 1). the mean age of male and female patients with vernal keratoconjunctivitis was 14.69 years ± 5.50 sd and 16.31years ± 6.23 sd respectively with an overall mean age of 15.23 ± 5.79sd (table 2). according to duration of symptoms, maximum number of patients with vernal keratoconjunctivitis sher akbar khan, et al 64 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology treated with supra tarsal injection of triamcinolone were those having symptoms of less than 30 days and were 98 (50.00%). minimum number of patients were 36 (18.37%) who were having symptoms of vernal keratoconjunctivitis for more than 90 days. full detail is shown in table 3. for patients with duration of symptoms less than 30 days, mean ± standard deviation was 25.95days ± 2.45 sd, for 30 to 90 days, it was 58.17 days ± 18.365 sd and for patients having symptoms more than 90 days, mean ± standard deviation was 108.75 days ± 21.87 sd. the overall mean duration of symptoms was 51.35 ± 33.78 sd (table 4). according to age wise stratification of supratarsal triamcinolone injection effectiveness in patients with vernal keratoconjunctivitis in terms of complete disappearance of papillae at 2 weeks follow up, effectiveness was most in the age group of 11 to 20 years, which was noted in 120 (70.59%) patients. minimum effectiveness was observed in the age group of 31 to 40 years in which only 2 (1.18%) patients showed effectiveness to supratarsal triamcinolone injection (fig. 4). 86.73% 13.27% 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% effective in-effective fig. 2: effectiveness of supratarsal triamcinolone injection in patients with vernal keratoconjunctivitis in terms of complete disappearance of papillae at 2 weeks follow-up. n= number of observed patients, % = percentage 72.35% 26.65% 0.00% 20.00% 40.00% 60.00% 80.00% male female male female fig. 3: effectiveness of supratarsal triamcinolone injection according to gender in patients with vernal keratoconjunctivitis in terms of complete disappearance of papillae at 2 weeks follow-up (n = 170) n = total number of patients, n = number of observed patients, % = percentage the supratarsal triamcinolone injection was effective in 170 (86.73%) patients with vernal keratoconjunctivitis in terms of complete disappearance of papillae at 2 weeks follow up while n=170 n=26 n=123 n=47 effectiveness of supratarsal triamcinolone injection in patients with vernal keratoconjunctivitis pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 65 26 (13.27%) patients showed no response (fig. 2). and those patients in which it was effective were followed for further three months for recurrence of the papillae but no recurrence noted in any of the patients. also the intraocular pressure measurement was taken at two weeks and three months follow up to note iop of above 21 mm hg in any patients but in none of the patients iop of above 21 mm hg noted. according to gender wise distribution of effectiveness to supratarsal triamcinolone injection for vernal keratoconjunctivitis, 123 (61.18%) males and 47 (27.65%) females showed response in terms of complete disappearance of papillae at 2 weeks follow up (fig. 3). according to duration of symptoms of vernal keratoconjunctivitis, supratarsal triamcinolone injection was most effective in patients having symptoms less than 30 days and this was observed in 90 (52.94%) patients. patients having duration of symptoms of 30 to 90 days and those having for more than 90 days showed effectiveness in 50 (29.65%) and 30 (17.65%) patients respectively (table 5). 16.47% 70.59% 11.76% 1.18% 0.00% 20.00% 40.00% 60.00% 80.00% 6-10 years 11-20 years 21-30 years 31-40 years fig. 4: effectiveness of supratarsal triamcinolone injection according to age in patients with vernal keratoconjunctivitis in terms of complete disappearance of papillae at 2 weeks follow up (n = 170). discussion almost 33% of the population of world is affected by some form of allergic disease15 of whom ocular allergic symptoms are estimated to be present in 40%–80%16 and this prevalence is even greater in western countries than in asia or africa.17 allergic vernal keratoconjunctivitis (vkc) which affects children and young adults is a chronic and recurrent inflammatory disease of conjunctiva18. of all ophthalmology visits in outpatient clinics about 1– 2.5% have vernal keratoconjunctivitis.19 vkc is more common in teenagers, especially boys. in majority of patients it presents with mild symptoms and does not draw much attention of either patient or the doctor. while in severe cases the symptoms are very disturbing to the patient as well as treatment of severe vkc is a challenge for the ophthalmologist and these patients develop disease related and / or iatrogenic complications. many treatment strategies are currently available for vkc. 20 patients need an effective treatment due to debilitating symptoms and signs of vkc. medical treatments with current topical medications such as artificial tears, topical antihistamines, mast cell stabilizers, nsaid, or topical steroids are not fully effective. topical cyclosporine was used recently, but after cessation of treatment, symptoms and signs recurred.21 in 1996 holsclaw22 reported his initial experience of managing twelve such patients with supratarsal injection of either short or intermediate acting corticosteroids. dramatic symptomatic and clinical response was noted in all patients irrespective of the type of corticosteroid used. however persistent increase in intra ocular pressure was also observed in one patient in their series after injection of intermediate acting corticosteroid. the initial symptomatic relief is provided by supratarsal injection of corticosteroids because it decreases inflammation locally. the depot steroid injections in the lesion do not raise significant blood cortisol levels, avoiding systemic anti-inflammatory activity and remission of inflammation at another site in the body.23 in our study, the supratarsal triamcinolone injection was effective in 86.73% patients with vernal keratoconjunctivitis in terms of complete disappearance of papillae at 2 weeks follow up while 13.27% patients showed no response. in our study the clinical resolution of cobblestone papillae was universal. it also resulted in the resolution of limbal edema and shield ulcer despite their closeness to the site of injection in all patients. each patient achieved impressive symptomatic improvement and marked decrease in cobblestone papillae. furthermore in 86.73% patients complete disappearance of cobblestone papillae occurred after supratarsal injection. according to aghadost d et al20 triamcinolone n=28 n=120 n=20 n=2 sher akbar khan, et al 66 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology acetonide injection in supratarsal area relieved signs and symptoms in 100% of patients and there was no recurrence of vkc in 87.5% of cases (p < 0.05). douglas et al24 in 1995 showed that they had no recurrence of vkc after short or intermediate acting steroids injection in supratarsal areas. this difference may be due to quality of medication and immunologic status of patients. in 2010 study conducted by qamar mr et al2 440 patients were treated, out of which 81.82% were males. mean age was 16 years (range: 2 42 years). mean duration of disease was 18 weeks (range: 4 weeks to 6 months). patients were followed up and multiple injections were given to control the disease. the most common side effect injection therapy was transient redness. study showed 100% effectiveness of supratarsal injection of triamcinolone acetonide. in a study by sadiq mn et al,12 in first few days of injection a dramatic relief of symptoms (burning, itching, lacrimation and photophobia, ropy discharge) was observed in all patients .the decrease in size of the cobble stone papillary hypertrophy in tarsal conjunctiva and gelatinous thickening of conjunctiva at limbus was significant in the first month but never disappeared completely. no complication was noticed and all patients tolerated the treatment well. in our study, the mean age of male and female patients with vernal keratoconjunctivitis was 14.69 years ± 5.50sd and 16.31years ± 6.23sd respectively with an overall mean age of 15.23 ± 5.79sd. the male to female ratio was 1.96:1. the mean age of patients reported by aghadost d et al,20 was 12.8 ± 3.9 years (range, 8 – 23) with male to female ratio of 2:1. in other studies the mean was 12 years.19 in other reports, males were more affected than females, with 3:1 frequency.24,25 in our study, maximum number of patients (66.33%) presenting with vernal keratoconjunctivitis were from the age group of 11 to 20 years and it was due to the fact that vkc effects the younger age group. our this observation is in accordance to kumar s and hall a.4,26 we noticed in our study that the effectiveness was maximally in those who were having symptoms of vkc for less duration. the reason for this might be the fact that this disease is usually seasonal, and such patients respond more to supra tarsal injection of triamcinolone. this has also been noted by pucci n, et al27 and leonardi a.28 we did not note any complication and there was no rise in intraocular pressure after steroid injection at two weeks follow-up and three months follow up. this was also noted by aghadost d, et al,20 and even they did not noted any rise in intraocular pressure after 54 months of follow-up. conclusion from the results of our study it has been concluded that that supratarsal injection of triamcinolone is effective in vernal keratoconjunctivitis for complete disappearance of papillae after two weeks of injection and there is no recurrence of the papillae for three months. as there is no intraocular pressure rise and any other complications noted so can be given to patients with poor compliance or poor response to other topical medication. author’s affiliation dr. sher akbar khan vitreoretinal trainee department of ophthalmology lady reading hospital, peshawar dr. tajbar khan junior registrar saidu group of teaching hospital, ophthalmology department swat. dr. mubashir rahman vitreoretinal trainee department of ophthalmology lady reading hospital peshawar dr. mir ali shah associate professor, department of ophthalmology, lady reading hospital peshawar references 1. benitez-del-castillo jm. how to promote and preserve eyelid health. clinical ophthalmology (auckland, n.z.) 2012; 61689-98. 2. qamar mr, latif e, arain tm, ullah e. supratarsal injection of triamcinolone for vernal keratoconjunctivitis. pak j ophthalmol. 2010: 26: 28-31. 3. shafiq i, shaikh za. clinical presentation of vernal keratoconjunctivitis: a hospital 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allergy asthma rep 2012; 12: 232-9. 12. sadiq mn, bhatia j, rahman n, varghese m. safety and efficacy of supra tarsal injection of triamcinolone in the management of refractory vernal keratoconjunctivitis. rmj. 2008; 33: 235-8. 13. jermak cm, dellacroce jt, heffez j, peyman ga. triamcinolone acetonide in ocular therapeutics. surv ophthalmol. 2007; 52: 503-22. 14. burney ja, ali ss, baig msa. efficacy of supratarsal injection of triamcinolone acetonide (corticosteroid) for treating severe vernal keratoconjunctivitis (vkc) refractory to all conventional therapy. pak j ophthalmol. 2010; 26: 201-4. 15. key b. allergy and allergic diseases. n engl j med. 2001; 344: 30-7. 16. ono sj, abelson mb. allergic conjunctivitis update on pathophysiology and prospects for future treatment. j allergy clin immunol. 2005; 115: 118-22. 17. hussain a, awan h, khan md. prevalence of nonvision impairing conditions in a village in chakwal district, punjab, pakistan. ophthalmic epidemiol. 2004; 11: 413-26. 18. javadi m. focal points in treatment of vernal keratoconjunctivitis. bina j ophthalmology (supplement) 1996; 4: 14-5. 19. bagheri a, khaksar m. epidemiology of vernal keratoconjunctivitis in kashan. feiz 1996; 2: 34-52. 20. aghadoost d, zare m. supratarsal injection of triamcinolone acetonide in the treatment of refractory vernal keratoconjunctivitis. arch of iranian med. 2004; 7: 41-3. 21. mantelli f, santos ms, petitti t, sgrulletta r, cortes m, lambiase a. systematic review and meta-analysis of randomised clinical trials on topical treatments for vernal keratoconjunctivitis. br j ophthalmol. 2007; 91: 1656-61. 22. holsclaw ds, witcher jp, wong ig, morgolis tp. supratarsal injection of corticosteroid in the treatment of refractory vernal keratoconjunctivitis. am j ophthalmol. 1996; 121: 243-9. 23. bielory l, katelaris ch, lightman s, naclerio rm. treating the ocular component of allergic rhinoconjunctivitis and related eye disorders. med gen med. 2007; 15: 35. 24. douglas h, whitcher jp, wong ig, margolis tp. supratarsal injection of corticosteroid in treatment of refractory vernal keratoconjunctivitis. am j ophthalmol. 1996; 121: 243-9. 25. choi sh, bielory l. late-phase reaction in ocular allergy. curr opin allergy clin immunol. 2008; 8: 43844. 26. hall a, shilio b. vernal keratoconjunctivitis. community eye health j. 2005; 18: 76-8. 27. pucci n, novembre e, lombardi e, cianferoni a, bernardini r, massai c, et al. atopy and serum eosinophil cationic protein in 110 white children with vernal keratoconjunctivitis: differences between tarsal and limbal forms. clin exp allergy. 2003; 33: 325-30. 28. leonardi a. vernal keratoconjunctivitis: pathogenesis and treatment. prog ret eye res. 2002; 21: 319–39. http://www.ncbi.nlm.nih.gov/pubmed?term=corthay%20a%5bauthor%5d&cauthor=true&cauthor_uid=19751267 http://www.ncbi.nlm.nih.gov/pubmed/19751267/ http://www.ncbi.nlm.nih.gov/pubmed/19751267/ http://www.ncbi.nlm.nih.gov/pubmed/19751267/ http://www.ncbi.nlm.nih.gov/pubmed?term=irani%20am%5bauthor%5d&cauthor=true&cauthor_uid=18282544 http://www.ncbi.nlm.nih.gov/pubmed/18282544/ http://www.ncbi.nlm.nih.gov/pubmed/18282544/ http://www.ncbi.nlm.nih.gov/pubmed/18282544/ http://www.ncbi.nlm.nih.gov/pubmed?term=kari%20o%5bauthor%5d&cauthor=true&cauthor_uid=22428383 http://www.ncbi.nlm.nih.gov/pubmed?term=saari%20km%5bauthor%5d&cauthor=true&cauthor_uid=22428383 http://www.ncbi.nlm.nih.gov/pubmed/22428383 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20kari%20o%5bauth%5d http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=%20saari%20km%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed?term=messmer%20em%5bauthor%5d&cauthor=true&cauthor_uid=19430798 http://www.ncbi.nlm.nih.gov/pubmed/19430798 http://www.ncbi.nlm.nih.gov/pubmed?term=kari%20o%5bauthor%5d&cauthor=true&cauthor_uid=22382607 http://www.ncbi.nlm.nih.gov/pubmed?term=saari%20km%5bauthor%5d&cauthor=true&cauthor_uid=22382607 http://www.ncbi.nlm.nih.gov/pubmed/22382607 http://www.ncbi.nlm.nih.gov/pubmed/22382607 http://www.ncbi.nlm.nih.gov/pubmed/22382607 http://www.scopemed.org/?jid=27 2008;%2033 http://www.ncbi.nlm.nih.gov/pubmed?term=jermak%20cm%5bauthor%5d&cauthor=true&cauthor_uid=17719372 http://www.ncbi.nlm.nih.gov/pubmed?term=dellacroce%20jt%5bauthor%5d&cauthor=true&cauthor_uid=17719372 http://www.ncbi.nlm.nih.gov/pubmed?term=heffez%20j%5bauthor%5d&cauthor=true&cauthor_uid=17719372 http://www.ncbi.nlm.nih.gov/pubmed?term=peyman%20ga%5bauthor%5d&cauthor=true&cauthor_uid=17719372 http://www.ncbi.nlm.nih.gov/pubmed/17719372 http://www.ncbi.nlm.nih.gov/pubmed/17719372 http://www.ncbi.nlm.nih.gov/pubmed/17719372 http://www.ncbi.nlm.nih.gov/pubmed?term=mantelli%20f%5bauthor%5d&cauthor=true&cauthor_uid=17588996 http://www.ncbi.nlm.nih.gov/pubmed?term=santos%20ms%5bauthor%5d&cauthor=true&cauthor_uid=17588996 http://www.ncbi.nlm.nih.gov/pubmed?term=petitti%20t%5bauthor%5d&cauthor=true&cauthor_uid=17588996 http://www.ncbi.nlm.nih.gov/pubmed?term=sgrulletta%20r%5bauthor%5d&cauthor=true&cauthor_uid=17588996 http://www.ncbi.nlm.nih.gov/pubmed?term=cortes%20m%5bauthor%5d&cauthor=true&cauthor_uid=17588996 http://www.ncbi.nlm.nih.gov/pubmed?term=cortes%20m%5bauthor%5d&cauthor=true&cauthor_uid=17588996 http://www.ncbi.nlm.nih.gov/pubmed?term=lambiase%20a%5bauthor%5d&cauthor=true&cauthor_uid=17588996 http://www.ncbi.nlm.nih.gov/pubmed/17588996 http://www.ncbi.nlm.nih.gov/pubmed?term=bielory%20l%5bauthor%5d&cauthor=true&cauthor_uid=18092041 http://www.ncbi.nlm.nih.gov/pubmed?term=katelaris%20ch%5bauthor%5d&cauthor=true&cauthor_uid=18092041 http://www.ncbi.nlm.nih.gov/pubmed?term=lightman%20s%5bauthor%5d&cauthor=true&cauthor_uid=18092041 http://www.ncbi.nlm.nih.gov/pubmed?term=naclerio%20rm%5bauthor%5d&cauthor=true&cauthor_uid=18092041 http://www.ncbi.nlm.nih.gov/pubmed/18092041 http://www.ncbi.nlm.nih.gov/pubmed/18092041 http://www.ncbi.nlm.nih.gov/pubmed?term=choi%20sh%5bauthor%5d&cauthor=true&cauthor_uid=18769198 http://www.ncbi.nlm.nih.gov/pubmed?term=bielory%20l%5bauthor%5d&cauthor=true&cauthor_uid=18769198 http://www.ncbi.nlm.nih.gov/pubmed/18769198 196 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmolog original article frequency of armd in the local pakistani population presenting at a tertiary care hospital hussain ahmad khaqan, usman imtiaz, hassan raza, umrah imran, ateeq-ur-rehman pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. hussain ahmad khaqan frcs associate professor department of ophthalmology lahore general hospital …..……………………….. purpose: to evaluate the frequency of armd in local pakistan population presenting at a tertiary care hospital. study design: cross sectional descriptive study. place and duration of study: lahore general hospital from 1 st october 2015 to30 th march 2018. material and methods: a total of 1002 participants with age above 65 years were included. participants with clear ocular media were selected randomly from outpatient department. informed consent was taken from all participants for taking retinal images. a non-mydriatic 8 megapixel (mp) topcon fundus camera was used to take 45 degree retinal images. fundus fluorescein angiography was done in patients having armd and they were treated accordingly. a proforma was designed to collect data including age, sex, smoking, far and near vision and status of retina (armd present or not and its type). blood pressure, serum cholesterol, weight, and height of persons having armd were recorded. results: a total of 1020 participants were included in study. there were 500 (49%) males and 520 (51%) females. mean age of participants was 70.3±5 years. frequency of armd was found to be 1.56% in local population. prevalence of dry armd (68.75%) was greater than wet armd (31.25%). there was no significant gender predisposition for armd. among all risk factors of armd smoking (41%) had strong association while hypertention (24%), diabetes (12%), hyperlipidemia (15%) and obesity (9%) had also some association with armd. conclusion: age related macular degeneration is most frequent in smokers and they should be educated about this risk. keywords: age-related macular degeneration, hypertension, diabetes, obesity. ge related macular degeneration (armd) is one of the leading causes of blindness worldwide1. it is a chronic disease that affects the part of retina, which is required for maximum fine details of vision. according to an analysis 15 million people are affected with armd in north america2. worldwide its documented prevalence is 5.6%3. age is one of the primary risk factors for armd, others include smoking, obesity, hypertension, hypercholesterolemia, excessive sun exposure and a diet deficient in fruits and vegetables4. there are two documented types of armd i.e. dry and wet armd (neovascular). dry form is more prevalent than wet armd but gross vision loss is associated with wet form of armd2. armd can also be classified on the a frequency of armd in the local pakistani population presenting at a tertiary care hospital pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 197 grounds of severity i.e. early, intermediate and advanced armd5. small to intermediate size drusens with no pigmentation are seen in early armd while intermediate armd includes several intermediate size drusen with at least one large size drusen (> 125 um)5. geographic atrophy and exudative armd are considered as advanced forms of armd5. symptoms of dry armd appear gradually and are usually associated with difficulty in adaptation to light or dark while wet armd is associated with profound loss of central vision and metamophopsia6. there are many treatment modalities for wet armd including intra-vitreal anti vegf, intra-vitreal steroid, laser photocoagulation and photodynamic therapy7. dry armd does not have specific treatment but includes prophylaxis and visual rehabilitation8. anti oxidants and zinc supplements have an important role in preventing armd in other eye9. these supplements are referred as "areds" supplements because their efficacy was established by the national eye institute's age-related eye disease study9. trials of other supplements i.e leutin, xiazanthine and omega-3 fatty acids are in progression of armd10. the purpose of our study was to find the frequency of armd in a tertiary hospital and also determine associations with other conditions. material and methods a total of 1020 participants with age above 65 years were included in the study. participants with clear ocular media were selected randomly from outpatient department. informed consent was taken from all participants for taking retinal images. distance visual acuity was recorded by using snellen’s acuity chart while near vision was recorded by using jaegar near vision chart. a non-mydriatic 8 mp topcon fundus camera was used to take 45 degree retinal images. fundus fluorescein angiography was done in patients having armd and treated accordingly. a proforma was designed to collect data including age, gender, status of retina (armd present or not) and smoking. all images and data were collected by the same person. associations of armd i.e. smoking, hyperlipidemia, hypertension, diabetes and obesity were also evaluated. patients with known history of hypertension and those with blood pressure of > 150/90 mm hg were labeled as hypertensive. patients with known history of diabetes and those with fasting blood sugar level of > 7 mmol were considered as diabetics. participants with fasting lipid profile more than 250 mg/dl were considered hyperlipidemic. height and weight were measured. body mass index was calculated using the formula: weight (in kgs)/(height × height) (in meters). armd was graded according to international classification. digital fundus photography was done including colored as well as red free images. dry armd included drusens and geographic atrophy with respect to severity of disease. wet armd included disorders of choriocapillary plexus including choroidal neovascular membranes (cnvm) and pigment epithelial detachment (ped). we assumed that the proportion of armd would be 5.6% according to a published study4. to achieve 95% confidence interval with acceptable error margin of 3%, we needed to examine 1020 persons of this age group. statistical analysis was done by spss version 20. results a total of 1020 participants were included in this study. there were 500 (49%) males and 520 (51%) females. mean age of participants was 70.3 ±5 years. frequency of armd came out to be 1.56% (16/1000) in local population. prevalence of dry armd (68.75%) was greater than wet armd (31.25%). there was no significant gender predisposition for armd. age wise statistical analysis is shown in table 1. table 1: age-wise distribution of armd in local population. age groups no. of persons (n) percentage % armd (x) percentage armd % 60 – 65 550 53.92 3 0.29 66 – 70 300 29.41 6 0.58 71 – 75 150 14.7 4 0.39 75 – 80 20 1.96 3 0.29 hussain ahmad khaqan, et al 198 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmolog 68.75 31.25 0 10 20 30 40 50 60 70 80 dry amd wet amd fig. 1: percentage of dry vs wet armd. associations of armd i.e. smoking, hyperlipidemia, hypertension and obesity were also evaluated. among all risk factors of armd smoking (41%) had the strongest association while hypertension (24%), hyperlipidemia (15%), diabetes (12%) and obesity (9%) had also some association with armd. (fig 02) 9% 24% 15% 41% 12% smoker hyperlipidemia hypertension obesity diabetes fig. 2: risk factors for armd. discussion age related macular degeneration (armd) is one of the leading causes of acquired blindness worldwide11. in our study its prevalence came out to be 1.56%, which is quite lower than usa, which is 5.6%3. another study was conducted in india showing prevalence near to our study12. novartis pharmaceuticals uk also suggested 26,000 new cases of wet amd in the uk per year, reported as being calculated from our earlier review of prevalence. this figure is commensurate with estimates that there are 13,000 to 37,000 incident cases of neovascular amd in england and wales per year13. a study was conducted to evaluate the difference in prevalence of armd among black and white races; they concluded no significant difference among these races with respect to prevalence rate. mediums size drusen were found equally in both races but in white race they transformed to large size drusen later more frequently14. equal proportion of male and female were included in the study but there was no gender predisposition for armd. there are many studies which showed the same pattern of gender predisposition15. another study showed that females are more prone to develop neovascular amd than males and associated with profound visual loss16. focal hyper-pigmentation was also evaluated in our study and found in only 5 patients (3 female and 2 male). a study conducted in baltimore suggested that focal hyper pigmentation was more prevalent among white race as compared with black race people17. a study was conducted in brazil among japanese immigrants and they showed that armd was more prevalent in men while in our study no such difference was noted. maximum age group prone to armd was 60-65 years of age group while in our study it came out to be 66-70 years of age group18. another study showed that 66-70 years of age group is most prone to develop armd, which is same as our study19. in our study we observed that dry armd was more prevalent (68.75%) than wet armd (31.25%). these results are consistent with published studies29,30. in contrast a study was published in uk showed that there is no significant difference of prevalence among dry and wet armd20. dry armd is associated with gradual loss of vision while wet armd is associated with sudden gross loss of vision12,13. in our study, patients with wet armd were associated with gross drop in vision as compared with dry armd. dry armd if not treated can lead to wet form of armd (cnv or ped). etiology of armd is not well known but there are few documented predisposing factors i.e. smoking, hypertension, hyperlipidemia, diabetes and obesity which my lead to armd4. in our study smoking was the most significant predisposing factor. according to a survey in usa smoking and hyperlipidemia were among the most significant predisposing factors for developing armd21. body mass index is also an important predisposing factor for developing armd but no association of high bmi was seen in our study. frequency of armd in the local pakistani population presenting at a tertiary care hospital pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 199 there are some psychological issues like depression that may predispose to armd as well22. studies show that greater attention from families, physicians, and society to the mental health needs and also alleviation of mobility challenges may help improve the condition22. our study showed hypertension as the second significant predisposing factor for armd. there are multiple studies showing relation of hypertension with armd17,22. a study was conducted that showed that antihypertensive drugs like systemic beta blockers reduce lysozyme levels. these drugs reduce the requirement for intravitreal anti-vegf injections in patients with wet amd23. as there are few treatment options for the management of armd so its prevention and retardation of growth plays an important role. areds study was conducted to evaluate the role of antioxidants in prevention and delaying the disease process. areds explained that antioxidants i.e. beta carotene (15 mg), vitamin c (500 mg), vitamin e (400 iu), zinc (80 mg) and copper (as cupric oxide) are associated with remarkable delay in progression of disease24. another clinical trial areds 2 was carried out to look for efficacy of omega 3 fatty acids and lutein/zeaxanthin in reducing the rate of progression of disease. areds 2 clinical trial explained that omega 3 fatty acids are of no importance when added with these supplements while lutein and zeaxanthin was associated with delay in progression of armd. beta carotene was found to be associated with increased risk of lung cancer25. in this study 50% of patients were smoker while in our study 40% of patients were smoker. according to different published studies smoking came out to be the most persistent risk factor in addition to all other risk factors. as there is no such geographic data published regarding the prevalence and incidence of age related macular degeneration in pakistan so this will help to compare it with other populations in east as well as in western countries. this evidence-based data can be used to provide health care and social awareness to population and its comparison with other parts of the world. this awareness can help to prevent further by following the international guidelines that will help in present as well as in future. conclusion age related macular degeneration is most frequent in smokers and they should be educated about this. author’s affiliation dr. hussain ahmad khaqan frcs associate professor department of ophthalmology lahore general hospital dr. usman imtiaz fcps, vitreo-retina fellow department of ophthalmology lahore general hospital dr. hassan raza mrcsed, final year pgr department of ophthalmology lahore general hospital dr. umrah imran mbbs, final year pgr department of ophthalmology lahore general hospital dr. ateeq-ur-rehman mbbs, 2nd year pgr department of ophthalmology lahore general hospital role of authors dr. hussain ahmad khaqan conception and design, literature search dr. usman imtiaz literature search, critical review, manuscript editing dr. hassan raza data collection, manuscript writing dr. umrah imran data collection, manuscript writing dr. ateeq-ur-rehman data analysis, data collection, literature search references 1. klein r, klein be, linton kl. prevalence of age-related maculopathy: the beaver dam eye study. ophthalmology, 1992; 99 (6): 933–943. 2. american academy of ophthalmology. retina and vitreous. american academy of ophthalmology basic and clinical science course, 2010-2011; 60-89. hussain ahmad khaqan, et al 200 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmolog 3. r. klein, c f chou. prevalence of age-related macular degeneration in the us population. arch ophthalmol. 2011; 129 (1): 75-80. 4. age-related eye 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132-35. 15. wong ty, loon s-c, saw sm. the epidemiology of age related eye diseases in asia. british j ophthalmol. 2006; 50-56. 16. thornton j, edwards r, mitchell p, et al. smoking and age-related macular degeneration: a review of association. eye (lond), 2005; 19: 935–44. 17. coleman hr, chan cc, ferris fl, 3rd, chew ey. agerelated macular degeneration. lancet. 2008; 372: 1835– 45. 18. arnarsson a, sverrisson t, stefánsson e, sigurdsson h, sasaki h, sasaki k, et al. risk factors for five-year incident age-related macular degeneration: the reykjavik eye study. am j ophthalmol. 2006; 142: 419– 28. 19. ferris fl davis md clemons te et al. the age-related eye disease study research group, a simplified severity scale for age-related macular degeneration: areds report no. 18. arch ophthalmol. 2005; 123 (11): 1570-1574. 20. zhou j, pham l, zhang n, he s, gamulescu ma, spee c, ryan sj, hinton dr. neutrophils promote experimental choroidal neovascularization. molecular vision, 2005; 11: 414–424. 21. popescu ml, boisjoly h, schmaltz h, kergoat mj, rousseau j, moghadaszadeh s, djafari f, freeman ee. explaining the relationship between three eye diseases and depressive symptoms in older adults. invest ophthalmol vis sci. 2012: 2308-13. 22. tatar o, yoeruek e, szurman p, bartz-schmidt ku, adam a, shinoda k, eckardt c, boeyden v, claes c, pertile g, et al. effect of bevacizumab on inflammation and proliferation in human choroidal neovascularization. archives of ophthalmology, 2008; 126: 782–790. 23. davis md gangnon re lee ly et al. the age-related eye disease study research group, the age-related eye disease study severity scale for age-related macular degeneration: areds report no. 17. arch ophthalmol. 2005; 123 (11) 1484-1498 [erratum published in arch ophthalmol. 2006; 124 (2): 289-290]. 24. chong ew, simpson ja, robman ld, hodge am, aung kz, english dr, et al. red meat and chicken consumption and its association with age-related macular degeneration. am j epidemiol. 2009; 169: 867– 76. 25. montero ja, ruiz – moreno jm, sanchis – merino e, perez– martin s: systemic beta-blockers may reduce the need for repeated intravitreal injections in patients with wet age – related macular degeneration treated by bevacizumab. retina. 2012; 24. 26. age-related eye disease study research group. a randomized, placebo-controlled, clinical trial of highdose supplementation with vitamins c and e, beta carotene, and zinc for age-related macular degeneration and vision loss: areds report no. 8. arch ophthalmol. 2001; 119 (10): 1417–1436. 27. age-related eye disease study 2 research group. lutein + zeaxanthin and omega-3 fatty acids for agerelated macular degeneration: the age-related eye disease study 2 (areds2) randomized clinical trial. jama. 2013; 309: 2005–2015. pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 241 case report subconjunctival loa loa worm: a case report mohammad mateen amir, afsar saeed shaikh, ameena ashraf pak j ophthalmol 2014, vol. 30 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mohammad mateen amir 320-a, pcsir – phase two lahore …..……………………….. a male patient 70 years old presented in outpatient department with a history of heaviness and irritation in his left eye for the last four months. he had been using different eye drops but there was no recovery. slit lamp examination revealed a black subconjunctival mass 2-3 mm on surface. removal under microscope revealed the mass was a worm about 3 cm and pathologist confirmed the worm was a dead loa loa. laboratory report revealed eosinophilia of 8%. the patient also gave history of pruritis and swelling on medial side of thigh a year back. the patient showed marked improvement after 3 weeks. key words: subconjunctival, loa loa worm. oa loa is a parasitic infection endemic in the tropical rain forests of africa. it is unique among the human filarial infestation and adult worms are occasionally visible during subconjunctival migration. this case report is the removal of a dead loa loa worm from subconjunctival space of a patient who came in the ophthalmology department of alkhidmat teaching hospital mansoora. medline search revealed this as the first case in pakistan. case report we report a case of removal of sub conjunctival loa loa of a patient aged 70, who belongs to phool nagar (bhai pheru), about 40 km from lahore on multan road (fig. 1). he underwent cataract surgery in both eyes a year back. he came with the complaint of heaviness and some uneasiness in his left eye. slit lamp examination revealed an indistinct sub conjunctival structure about 2-3 mm in size. we first tried to remove it on slit lamp but the mass slipped and seemed unusual in nature. so we decided to remove that under microscope in operation theatre. we found that the mass was a worm whose remaining part was deep and surrounded by fibrous tissue (fig. 2). one end of the worm was curled up. it was dissected out and measured about 2.8 cm in length (fig. 3). we suspected worm to be loa loa and sent it for parasitological examination. the patient did not give any history of travel to africa except a visit to saudi arabia for hajj seven years back. the patient also gave history of swelling and pruritis on medial side of thigh a year back. blood examination revealed eosinophilia. the pathological report confirmed the diagnosis. discussion loa loa belongs to super family filarioidea. adult worm is long thread like. they are parasites of subcutaneous tissues or serous cavities as sub conjunctival spaces. the worms are viviparous that they give birth to larvae and do not lay eggs. they commonly migrate rapidly in the body and may be seen in sub conjunctival space or thinned skin areas. adult worm measures 3 cm in length and 350 micron meter in width. female worm measures 6 cm in length and 450 micron meter in breadth. its vector, in which the parasite undergoes larval stages, is a blood sucking fly of the genus chrysops.1 there are some reports of worm located in the anterior chamber of the eye.2 the worm causes loais is characterized by the occurrence of swelling in various parts of the body known as calabar swellings. the swellings are transient and may be painful if situated over joints. they are caused by maturing larvae migrating away from the site of inoculation by vector fly. eosinophilia l mohammad mateen amir, et al 242 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology fig. 1: patient of subconjunctival loa loa fig. 2: during surgery fig. 3: loa loa worm after removal is common. most of the cases of sub conjunctival loa loa reported are live worms while one case report of dead worm recovered from eye in brazil 3-5. history of travel to africa is usual in most of the case reports.6-8 the disease was also found in some of the african students studying abroad9. the worm also recovered from periocular subcutaneous tissue in few reports.10,11 we report a case with subconjunctival loaiasis. in summary, this is a case of loaiasis encountered in non-endemic area. there is no history of travel to africa. the patient gave history of visit to saudia arabia to perform hajj seven years back. loa loa although endemic in africa, an increasing number of reports are coming from non-endemic areas. therefore, any patient with an unclassifiable eye affection should also be investigated for rare pathogens as well. it must not be considered anymore as being limited to certain geographical areas and must be known by ophthalmologists. author’s affiliation dr. mohammad mateen amir associate professor of ophthalmology university of lahore & head of department alkhidmat teaching hospital mansoora lahore dr. afsar saeed shaikh associate professor pathology gujranwala medical college gujranwala dr. ameena ashraf associate professor pathology gujranwala medical college gujranwala references 1. roberts ls, john janoy jr: foundation of parasitology. 8th ed; mcgraw hill international. 2010; 472. 2. barua p, barua n, hazarika nk, das s. loa loa in the anterior chamber of the eye: a case report. indian journal medical microbiology. 2005; 23: 59-60. 3. carme b, botaka e, lehenaff ym. dead loaloa filarial in a subconjunctival site. apropos of a case. journal french ophthalmol. 1988; 11: 865-7. 4. bowler gs, shah an, bye la, saldana m. ocular loiasis in london 2008-2009: a case series. eye (london) 2011; 25: 389-91. 5. carbonez g, oogziekten. lindendreef 1, 2020 antwerpen. subconjunctival loaloa worm: case report. bull soc ophthalmol, 2002; (283): 45-8. 6. aiello f, palma s, varesi c, cerulli a, valente r, ajello l. a rare case report of loa loa ocular filariasis. europeon journal ophthalmol. 2010; 20: 237-9. 7. eballe ao, epee e, koki g, owono d, myogo ce, bella al. intraocular live male filarial loa loa worm. clinical ophthalmol. 2008. dec; 2. 965-7. 8. wickremesinghe rs, goonesinghe sk, samarasinghe s. loa loa in a sri lankan expatriate from nigeria. ceylon medical journal. 1989; 34: 31-4. 9. ali s, fisher m, juckett g. the african eye worm: a case report and review. j travel med. 2008; 15: 50-2. 10. sbeity zh, jaksche a, martin s, loeffler ku. loa loa microfilariasis in the eyelid: case report of the first periocular subcutaneous manifestation in germany. graefes arch clin expophthalmol. 2006; 244: 883-4. 11. bhedasqaonkar s, baile rb, nadkarni s, jakkula g, gogri p. loa loa macrofilaiasis in the eyelid: case report of the first periocular subcutaneous manifestation in india. journal parasit dis. 2011; 35: 230-1. 60 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology editorial retinopathy of prematurity and pakistan; an epidemic coming retinopathy of prematurity (rop) is responsible for blindness in an estimated 50,000 children in the world each year. in middle income countries 15 – 35% of childhood blindness is due to rop1,2. in the usa between 1999 – 2012, 13 – 14% of childhood blindness was attributed to rop3. studies have shown that this can amount to a financial burden of $69-117 million a year. these estimates do not include loss of potential life long earnings, especially in the developing countries where services to train individuals with blindness are lacking. although gestational age is the most important risk factor in the development of rop, there are other factors that have been implicated, such as oxygen therapy. in developed countries, the 1940s-1950s saw the first epidemic of rop due to inadequately monitored oxygen therapy4-6. with changes in clinical practice, and controlled oxygen administration, this epidemic was brought under control. in usa, the proportion of blindness due to retrolental fibroplasia dropped from 50% in 1950 to 4% by 19657. however, the decrease in oxygen therapy resulted in an increase in neonatal deaths, due to respiratory compromise8. increased survival rates of extremely premature (gestational age < 29 weeks) and very low birth weight infants (750999g) gave rise to the second epidemic of rop in the late 1970s and 1980s9-11. data from the developing countries is very limited. gilbert et al, speculate that infant mortality rates (imr) may negatively correlate with the risk of rop related blindness. with improvement in neonatal care, more preterm infants are surviving worldwide; in high income countries, with imr of < 9 per 1000 live births, the risk of rop related blindness is low, due to good screening and treatment facilities. in countries with high imr (>60 per 1000 live births) not many preterm babies survive, due to lack of basic health care facilities and proper neonatal intensive care, so rop is not a significant problem. however, middle income countries in latin america, eastern europe, india, china and other countries in asia, with imr of 9 – 60 per 1000 live births, represent the population at the highest risk of rop blindness since 1990s. this has been described as the third epidemic of rop; although neonatal care has improved, good screening and treatment facilities are inadequate in these regions1,2. babies are being exposed to risk factors which, to a large extent, have been addressed in high income countries e.g., oxygen exposure. screening for the disease is a key component of the treatment of rop. specific ‘standard’ criteria, based on gestational age of less than 32 weeks and birth weight of less than 1500 gms, is being used in the united states. results show, that 66% of infants < 1,250g and 82% of infants < 1,000g developed rop, while 9% became eligible for treatment1-12. however, these screening criteria may not be applicable to middle and low income countries, where more mature and heavier babies have been shown to develop rop13-20. gilbert et al highlighted (table 1) that 13% of infants would have been missed if the ‘standard’ screening criteria had been applied in such countries2. multiple trials involving infants with rop have highlighted the importance of timely treatment to reduce the risk of blindness21-22. the latest trial etrop (early treatment for rop) has shown that laser retinopexy within 48 hours for type 1 rop (definition) was associated with a decrease (19.8% to 14.3%) in unfavorable visual outcomes23. therefore screening protocols are being followed in nicus to identify infants needing treatment. oxygen regulation trials, such as stop – rop, support and boost – ii, have been conducted to observe ophthalmic outcomes with retinopathy of prematurity and pakistan; an epidemic coming pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 61 supplemental oxygen13-15 and the results reveal that rop is best controlled by avoidance of fluctuations and by strict maintenance of spo2 between 85% 92% in theses babies24,25. rop in pakistan neonatal care services have expanded and more premature babies are now surviving. infant mortality rate (imr) in pakistan dropped to 61.3 per 1000 live births in 2012 from 82.5 per live births in 2000, thus pakistan is now at the threshold for an epidemic of blindness due to rop26. there are only 2 published studies on rop, both from aga khan university hospital, with a very well equipped tertiary care nicu. in 2008, a retrospective analysis of 68 premature infants with birth weight < 1500 gm and gestational age < 32 weeks, had reported an incidence of 32.4% of any stage of rop, with 20.6% with severe rop27. a later studied conducted prospectively at the same institute with a broader screening criterion i.e., birth weight ≤ 2000g and gestational age ≤ 35 weeks – any stage of rop, showed that no rop was seen in the 66/301 infants who weighed > 1500g at birth and/or were born at > 32 weeks of gestation. using the standard screening criteria, there was an improvement with only 11.5% developing rop, while stage 3 rop requiring treatment were 8.1% of the cases as compared 20.6%, in the earlier study28. these levels are now comparable to rop outcomes in high income countries. there is still a severe lack of awareness of the disease, appropriate screening criteria, consequences of delayed or no treatment as well as a lack of expertise for the management of such babies29. in 2010 a descriptive study conducted at 10 centers with highest delivery rates in karachi showed that only 2 centers had a screening protocol for rop in place, but which was not being followed. only 2 out of the 15 pediatricians who were interviewed were aware that rop can cause blindness30. future recommendations there is an urgent need for creation of appropriate screening and oxygen protocols, training of ophthalmologist to screen the infants, creation of close liaison between the nicu, ophthalmologist and parents, education for all care givers on the importance of rop, to protect premature infants in pakistan from permanent blindness. we propose the creation of a pakistan retinopathy of prematurity educational and research alliance (propera). initially, a few hospitals in 2 to 3 major cities should be involved. an rop coordinator and an ophthalmologist for screening should be designated. an initial screening criteria and an oxygen protocol should be followed at these sites. data should be collected and transmitted to a central collection center weekly. subsequently, the network should be expanded, by adding other centers, and additional cities. an annual rop conference should be organized to include all health care individuals involved with management of infants at risk of rop. collected rop data should be presented, deficiencies identified, creation of appropriate screening guidelines and formulation of a plan for the next year agreed upon. individuals with experience and interest in rop will be vital for the success of this endeavor to save the sight of our next generation. author’s affiliation dr. umar k. mian director retina service department of ophthalmology and visual sciences montefiore medical center / albert einstein college of medicine, new york, usa for propera network dr. farzeen hashmi, dr. tanveer chaudhry dr. khabir ahmad department of ophthalmology aga khan university hospital, karachi references 1. gilbert, c. retinopathy of prematurity: a global perspective of the epidemics, population of babies at risk and implications for control. early human development. 2008; 84: 77-82. 2. gilbert c, et al. characteristics of infants with severe retinopathy of prematurity in countries with low, moderate, and high levels of development: implications for screening programs. pediatrics. 2005;. 115: 518-25. 3. kong l, et al. an update on progress and the changing epidemiology of causes of childhood blindness worldwide. jr of am assoc. for pediatric ophthalmology and strabismus. 2012; 16: 501-7. 4. campbell k. intensive oxygen therapy as a possible cause of retrolental fibroplasia; a clinical approach. the medical j of australia. 1951; 2: 48. 5. patz a, hoeck le, cruz edl. studies on the effect of high oxygen administration in retrolental fibroplasia. i. nursery observations. am j ophthalmol. 1952;. 35: 1248. 6. ashton, n., b. ward, and g. serpell, effect of oxygen on developing retinal vessels with particular reference to the problem of retrolental fibroplasia. the br j ophthalmol. 1954; 38: 397. umar k. mian, et al 62 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology 7. hatfield em. blindness in infants and young children. sightsaving review. 1972. 8. avery me, eh. oppenheimer, recent increase in mortality from byaline membrane disease. the jr of pediatrics, 1960; 57: 553-9. 9. gibson, dl, et al. retinopathy of prematurity: a new epidemic? pediatrics. 1989; 83: 486-92. 10. valentine ph, et al. increased survival of low birth weight infants: impact on the incidence of retinopathy of prematurity. pediatrics. 1989; 84: 442-5. 11. todd da, et al. retinopathy of prematurity in infants less than 29 weeks' gestation at birth. australian and new zealand j of ophthalmol. 1994; 22: 19-23. 12. zin a,. gole ga. retinopathy of prematurity-incidence today. clin perinatol. 2013; 40; 185-200. 13. jalali s, et al. modification of screening criteria for retinopathy of prematurity in india and other middle-income countries. am j ophthalmol. 2006, 141: 966-8. 14. vinekar a, et al. retinopathy of prematurity in asian indian babies weighing greater than 1250 grams at birth: ten year data from a tertiary care center in a developing country. indian j ophthalmol. 2007; 55: 331-6. 15. chen y, li x. characteristics of severe retinopathy of prematurity patients in china: a repeat of the first epidemic? br j ophthalmol. 2006; 90: 268-71. 16. filho fjb, et al., results of a program for the prevention of blindness caused by retinopathy of prematurity in southern brazil. jr pediatr (rio j). 2007; 83: 209-16. 17. zin aa,, et al. retinopathy of prematurity in 7 neonatal units in rio de janeiro: screening criteria and workload implications. pediatrics. 2010, 126: 410-7. 18. araz-ersan b, et al. epidemiological analysis of retinopathy of prematurity in a referral centre in turkey. br j ophthalmol. 2012. 19. binkhathlan aa, et al. retinopathy of prematurity in saudi arabia: incidence, risk factors, and the applicability of current screening criteria. br j ophthalmol. 2008; 92: 167-9. 20. amer m, et al. retinopathy of prematurity: are we missing any infant with retinopathy of prematurity? br j ophthalmol. 2012; 96: 1052-5. 21. mintz-hittner ha, kennedy ka, chuang az. efficacy of intravitreal bevacizumab for stage 3+ retinopathy of prematurity. new england j of medicine. 2011; 364: 603-15. 22. cryotherapy for retinopathy of prematurity cooperative, g., multicenter trial of cryotherapy for retinopathy of prematurity: ophthalmological outcomes at 10 years. archives of ophthalmology. 2001. 119: 1110. 23. good wv. final results of the early treatment for retinopathy of prematurity (etrop) randomized trial. transactions of the american ophthalmological society. 2004; 102: 233. 24. saugstad od. oxygen and retinopathy of prematurity. jr of perinatology. 2006; 26: 46-50. 25. chow lc, wright kw, sola a. can changes in clinical practice decrease the incidence of severe retinopathy of prematurity in very low birth weight infants? pediatrics, 2003; 111: 339-45. 26. khan a, et al. newborn survival in pakistan: a decade of change and future implications. health policy and planning. 2012; 27: 72-87. 27. taqui am, et al. retinopathy of prematurity: frequency and risk factors in a tertiary care hospital in karachi, pakistan. jr pak med assoc. 2008; 58: 186-90. 28. chaudhry ta, et al. retinopathy of prematurity: an evaluation of existing screening criteria in pakistan. br j of ophthalmol. 2013; 30: 4018. 29. sethi s, awan h, khan nu. an audit of neonatal services in khyber pakhtunkhwa province (kpk), pakistan to identify implications for screening ‘retinopathy of prematurity’. ophthalmology. 2012; 10: 136-42. 30. hashmi fk, chaudhry ta, ahmad k. an evaluation of referral system for retinopathy of prematurity in leading health centers across karachi, pakistan. jr pak medical assoc. 2010; 60: 840. 206 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology original article efficacy of sub-conjunctival bevacizumab in high risk corneal transplantations nasir bhatti, umair qidwai, munawar hussain, asif kazi pak j ophthalmol 2013, vol. 29 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nasir bhatti ophthalmology department isra postgraduate institute of ophthalmology karachi nasirbhatti_dr@yahoo.com …..……………………….. purpose: to evaluate the efficacy of sub-conjunctival and topical bevacizumab in high risk corneal transplant survival. material and methods: eyes with high risk corneal transplantation with corneal neovascularization (nv) were included in this randomized clinical trial. patients were randomly allocated to 2 groups. group a and group b. after penetrating keratoplasty, group a patients received sub-conjunctival bevacizumab (2.5 mg/ 0.1 ml), group b, patients received sham injection. corneal neovascular invasion area i.e. the fraction of area on transplanted cornea in which vessels are present is measured using mathematical software program matlab. primary measurement variable was neovascular invasion area while secondary measurement variable was visual acuity. results: among the 2 groups mean corneal neovascular invasion area was minimum in the sub-conjunctival bevacizumab injection group (group a), with p value < 0.05. conclusion: sub-conjunctival bevacizumab can offer an adjunctive measure to traditional treatment methods of prevention of vascularization on grafted cornea. orneal graft rejection is the most important reason that causes corneal graft failure and thus a foremost indication for repeat penetrating keratoplasty1. presence of preexisting blood vessels is an important risk factor for corneal graft rejection2. high-risk corneal transplantations such as corneal grafting into the vascularized corneal beds, has greater than 50% immune rejection rate, even with a stringent regimen of topical and systemic immunosuppressive drugs3. many investigators has been using the angiogenesis as the main factor of modification by immune suppressors in order to increase the success of high risk corneal transplantation4,5. it is not fully understood what are the factors that disturb the immune privileged state in patients with corneal neovascularization (nv). on the other hand, experimental evidence suggests that certain molecular factors such as the local immunosuppressive cytokines such as transforming growth factor-β, α-melanocytestimulating hormone and anterior chamber-associated immune deviation, plays a critical role in maintaining the physiologic serenity in the anterior chanber6. therefore, management of corneal neovascularization after corneal transplantation can be controlled by bounding both sensitization arm as well as rejection arm of the autoimmunity and, consequently, reduce the susceptibility for immune-inflammatory reactions6. vascular endothelial growth factor (vegf) is the most important mediator of nv7. the major role of vegf in the development of corneal neovascularization was established in experimental models of corneal angiogenesis7. vegf inhibitors, such as pegaptanib sodium (mucagen), ranibizumab (lucentis), and bevacizumab (avastin), have been used in wet type of age related macular degeneration with successful reasults8. in recent times, there has been growing interest in using anti-vascular endothelial growth factor for the treatment of corneal neovascularization when used either topically or subconjunctivaly9-14. these studies put forward that anti-vascular endothelial growth factor can be used as c file:///c:\users\users\hp\desktop\keratoplasty%20avstin\neovesels%20keratopathy.htm%23ref-6 efficacy of sub-conjunctival bevacizumab in high risk corneal transplantations pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 207 an adjunctive measure to conventional therapies such as corticosteroids to restrain factors that provocate graft rejection in vascularized high-risk corneal transplantation. for that reason, we wanted to assess the effects of sub-conjunctival bevacizumab injection treatment on corneal graft survival in high-risk (vascularized) corneal transplantation. to make a methodical and complete evaluation of corneal neovascularisation, a quantitative method was used to measure neovessel invasion area. our results specify that subconjunctival bevacizumab therapy inhibit corneal neovascuarization (growth of new vessels on the transplanted cornea) after high-risk corneal transplantation. material and methods the study was carried out at isra postgraduate institute of ophthalmology and yasin eye hospital, karachi from december 2008 to february 2012 for 38 months. eyes with high risk corneal transplantation with corneal neovascularization were included in this randomized clinical trial. ethical approval was taken from the ethical review committee of al-ibrahim eye hospital / isra postgraduate institute of ophthalmology. informed written consent was taken from every patient included in the study. indications for corneal transplantation were: vascularized corneal opacity secondary to keratitis or mechanical or chemical trauma, bullous keratopathy, corneal dystrophy, and failed corneal grafts. patients were randomly allocated to 2 groups. group a, and group b. after penetrating keratoplasty, group a patients were given subconjunctival bevacizumab 2.5 mg/ 0.1 ml in all the quadrants in each patient at the end of corneal transplantation surgery and also on follow ups. in group b, patients were given sham injection in all the quadrants in each patient at the end of corneal transplantation surgery and also on follow ups. follow-up period was 2 to 8 months (mean 7.1 months). due to poor compliance in our community longer follow-ups were not possible. primary measurement variable was neovascular invasion area while secondary measurement variable was visual acuity. a method we have used was that the objective quantification of cornea. for objective quantification, we first captured a sequence of slitlamp images of transplanted corneas. graphics editing software (photoshop cs2) was used to outline the blood vessels in the transplanted corneal image. the corneal neovascular invasion area i.e. the fraction of area on transplanted cornea in which vessels were present was measured using mathematical software program matlab (fig. 1). (matlab is highly specialized analytical software, which has a feature in it that it calculates exact area on a specialized grid pattern giving percentages of the specified area as well, when the picture from photoshop is opened in it will calculate its percentage coverage using its analytical grids). percentage of corneal neovascular invasion area was calculated from the transplanted cornea. visual acuity was measured using snellens acuity chart. statistical analyses was done using spss version 20.0. student's t-tests were applied. p < 0.05 was considered significant. complications occurred were noted as well. results eighty two patients were included in the study, of them 41 were in the group a (subconjunctival bevacizumab injection), 41 in group b (subconjunctival sham injection). out of these 82 patients, males were 61 (74.4%) while females were 21 (25.6%). they were between 47 years of age to 59 years of age with mean age of 51.22 years. among the 2 groups mean corneal neovascular invasion area was minimum in the subconjunctival bevacizumab injection group (group a), with p value < 0.05. (fig. 2). maximum no of patients (36) attained visual acuity of 6/36 or better in the sub-conjunctival bevacizumab group compared to 17 in sham group. (p < 0.05) (fig. 3). discussion corneal neovascularization has been renowned as an important risk factor for transplant rejection after keratoplasty. the results of our study suggest that bevacizumab can lessen the sternness of corneal neovascularization when used subconjunctivally. it results in a noteworthy falling off of neovascular invasion area. in addition, bevacizumab when used subconjunctivaly promotes graft survival considerably in the increased peril corneal transplantations. even though our results were noteworthy but the regression of corneal neovascularization was not complete. the main reasons for this was that, the quantity and extent of treatment were insufficient to completely antagonize vascular endothelial growth factor. many apprehensions reported regarding the side effects of bevacizumab for the treatment of nasir bhatti, et al 208 vol. 29, no. 4, oct – dec, 2013 pakistan journal of ophthalmology fig. 1: method and softwares used for measurement of neovascular invasion area on transplanted cornea fig. 2: corneal neovascular invasion area among the two groups fig. 3: visual acuity among the groups n=82 corneal neovascularization,12 we limited our treatment of bevacizumab to the 8 weeks only after the keratoplasty. pre-existing corneal vessels in the recipient bed of may not be as susceptible as neovessels to anti-vascular endothelial growth factor treatment18. another important factor of incomplete regression of corneal neovascularization that other relevant proangiogenic factors like fibroblast growth factor, interleukin-1, tumour necrotic factor-α, and ifn-γ are also up regulated and involved in corneal neovascularization6. lastly, bevacizumab is a specific antibody for a subtype of vegf called vegf-a only; other types are not covered by it. corneal neovescularization is consistently related with increased corneal graft rejection rates, and level of vascularization at the time of corneal transplantation was considered, correlated with corneal graft endurance19. one study by frederick20 showed that corneal graft rejection occurred in 3.5% of cases with no neovascularization due to endothelial causes, 13.3% of mildly vascular cases, 28% of moderately vascular cases, and 65% of heavily vascular cases. in the present study, significant and marked regression of corneal neovascular invasion area occurred with sub-conjunctival treatments. the only possible complications observed were sub conjunctival hemorrhage which resolved spontaneously after few days. conclusion sub-conjunctival injection of bevacizumab (avastin) is very effective in treating corneal neovascularization. it not only reduces neovascularization growth chances but also increases the corneal graft survival. subconjunctival bevacizumab can offer an adjunctive measure to conservative therapies such as steroids in preventing corneal graft rejection caused by neovascularisation in vascularized (high risk) corneal transplantations. more work / research is needed to identify the exact amount and frequency of administration to achieve the best clinical results. author’s affiliation dr. nasir bhatti associate professor of ophthalmology isra postgraduate institute of ophthalmology, karachi dr. umair qidwai ophthalmologist isra postgraduate institute of ophthalmology, karachi week 4 week 8 week 12 week 24 group a 8.3 6.1 5.7 6.23 group b 14.2 18.3 19.8 26.7 0 10 20 30 co rn e a l n e o v a sc u la r in v a si o n a re a ( % ) corneal neovascular invasion area among the two groups 0 50 n o o f p a t ie n t s visual acuity visual acuity among the groups n=82 group a group b file:///c:\users\users\hp\desktop\keratoplasty%20avstin\neovesels%20keratopathy.htm%23ref-24 file:///c:\users\users\hp\desktop\keratoplasty%20avstin\neovesels%20keratopathy.htm%23ref-37 file:///c:\users\users\hp\desktop\keratoplasty%20avstin\neovesels%20keratopathy.htm%23ref-43 efficacy of sub-conjunctival bevacizumab in high risk corneal transplantations pakistan journal of ophthalmology vol. 29, no. 4, oct – dec, 2013 209 dr. munawar hussain ophthalmologist isra postgraduate institute of ophthalmology, karachi dr. asif kazi ophthalmologist isra postgraduate institute of ophthalmology, karachi references 1. coster dj, williams k. the impact of corneal allograft rejection on the long-term outcome of corneal transplantation. am j ophthalmol. 2005; 140: 1112-22. 2. sellami d, abid s, bouaouaja g, ben amor g, kammoun b, masmoudi m, dabbeche k, boumoud h, ben zina z, feki j. epidemiology and risk factors for corneal graft rejection. transplantation proceedings. 2009: 39, 2609-11. 3. williams ka. esterman aj. bartlett c. holland h, hornsby nb, coster dj. how effective is penetrating corneal transplantation? factors influencing long-term outcome in multivariate analysis. transplantation. 2006; 81: 896-901. 4. bachmann bo. bock f., wiegand sj., maruyama k. dana rm, kruse, fe, drecoll el, cursiefen c. promotion of graft survival by vascular endothelial growth 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report. adelaide, south australia: flinders university press; 2007. 20. frederick sb. the allograft rejection: the leading cause of late graft failure of clinical corneal grafts. in: porter r, knight j eds. corneal graft failure. amsterdam: elsevier; 1973. http://www.ncbi.nlm.nih.gov/pubmed?term=dabbeche%20k%5bauthor%5d&cauthor=true&cauthor_uid=17954190 http://www.ncbi.nlm.nih.gov/pubmed?term=boumoud%20h%5bauthor%5d&cauthor=true&cauthor_uid=17954190 http://www.ncbi.nlm.nih.gov/pubmed?term=ben%20zina%20z%5bauthor%5d&cauthor=true&cauthor_uid=17954190 http://www.ncbi.nlm.nih.gov/pubmed?term=feki%20j%5bauthor%5d&cauthor=true&cauthor_uid=17954190 http://www.ncbi.nlm.nih.gov/pubmed?term=holland%20h%5bauthor%5d&cauthor=true&cauthor_uid=16570014 http://www.ncbi.nlm.nih.gov/pubmed?term=hornsby%20nb%5bauthor%5d&cauthor=true&cauthor_uid=16570014 http://www.ncbi.nlm.nih.gov/pubmed?term=coster%20dj%5bauthor%5d&cauthor=true&cauthor_uid=16570014 http://www.ncbi.nlm.nih.gov/pubmed?term=wiegand%20sj%5bauthor%5d&cauthor=true&cauthor_uid=19224901 http://www.ncbi.nlm.nih.gov/pubmed?term=wiegand%20sj%5bauthor%5d&cauthor=true&cauthor_uid=19224901 http://www.ncbi.nlm.nih.gov/pubmed?term=wiegand%20sj%5bauthor%5d&cauthor=true&cauthor_uid=19224901 http://www.ncbi.nlm.nih.gov/pubmed?term=hos%20d%5bauthor%5d&cauthor=true&cauthor_uid=19224901 http://www.ncbi.nlm.nih.gov/pubmed?term=dana%20r%5bauthor%5d&cauthor=true&cauthor_uid=19224901 http://www.ncbi.nlm.nih.gov/pubmed?term=kruse%20fe%5bauthor%5d&cauthor=true&cauthor_uid=19224901 http://www.ncbi.nlm.nih.gov/pubmed?term=cursiefen%20c%5bauthor%5d&cauthor=true&cauthor_uid=19224901 http://www.ncbi.nlm.nih.gov/pubmed?term=luetjen-drecoll%20e%5bauthor%5d&cauthor=true&cauthor_uid=18195221 http://www.ncbi.nlm.nih.gov/pubmed?term=cursiefen%20c%5bauthor%5d&cauthor=true&cauthor_uid=18195221 http://www.ncbi.nlm.nih.gov/pubmed?term=kim%20s%5bauthor%5d&cauthor=true&cauthor_uid=18362666 http://www.ncbi.nlm.nih.gov/pubmed?term=kim%20t%5bauthor%5d&cauthor=true&cauthor_uid=18362666 http://www.ncbi.nlm.nih.gov/pubmed?term=kim%20ek%5bauthor%5d&cauthor=true&cauthor_uid=18362666 http://www.ncbi.nlm.nih.gov/pubmed/?term=carvounis%20pe%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=kivilcim%20m%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=kivilcim%20m%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=kivilcim%20m%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=ren%20m%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=lake%20jc%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=ch%26%23x000e9%3bvez%26%23x02010%3bbarrios%20p%5bauth%5d http://www.aaojournal.org/article/s0161-6420%2808%2900176-0/abstract http://www.aaojournal.org/article/s0161-6420%2808%2900176-0/abstract http://www.ncbi.nlm.nih.gov/pubmed?term=rootman%20d%5bauthor%5d&cauthor=true&cauthor_uid=18216566 http://www.ncbi.nlm.nih.gov/pubmed?term=slomovic%20a%5bauthor%5d&cauthor=true&cauthor_uid=18216566 http://www.ncbi.nlm.nih.gov/pubmed/?term=hamrah%20p%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=jurkunas%20uv%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=pineda%20r%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=pavan-langston%20d%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=dana%20r%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed?term=tatar%20o%5bauthor%5d&cauthor=true&cauthor_uid=17995975 http://www.ncbi.nlm.nih.gov/pubmed?term=tura%20a%5bauthor%5d&cauthor=true&cauthor_uid=17995975 http://www.ncbi.nlm.nih.gov/pubmed?term=tura%20a%5bauthor%5d&cauthor=true&cauthor_uid=17995975 http://www.ncbi.nlm.nih.gov/pubmed?term=tura%20a%5bauthor%5d&cauthor=true&cauthor_uid=17995975 http://www.ncbi.nlm.nih.gov/pubmed?term=grisanti%20s%5bauthor%5d&cauthor=true&cauthor_uid=17995975 http://www.ncbi.nlm.nih.gov/pubmed?term=bartz-schmidt%20ku%5bauthor%5d&cauthor=true&cauthor_uid=17995975 http://www.ncbi.nlm.nih.gov/pubmed?term=szurman%20p%5bauthor%5d&cauthor=true&cauthor_uid=17995975 http://www.ncbi.nlm.nih.gov/pubmed?term=t%c3%bcbingen%20bevacizumab%20study%20group%5bcorporate%20author%5d http://www.ncbi.nlm.nih.gov/pubmed?term=rouvas%20a%5bauthor%5d&cauthor=true&cauthor_uid=18207123 http://www.ncbi.nlm.nih.gov/pubmed?term=giamarellos-bourboulis%20ej%5bauthor%5d&cauthor=true&cauthor_uid=18207123 http://www.ncbi.nlm.nih.gov/pubmed?term=vergados%20ia%5bauthor%5d&cauthor=true&cauthor_uid=18207123 microsoft word 10-oa huma kayani pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 40 original article comparison between 23 – gauge and 25 – gauge pars plana vitrectomy for posterior segment disease huma kayani, aamir ahmed, kashif jahangir, hizb-ur-rehman, khurram chauhan pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: huma kayani 9-q gulberg ii lahore …..……………………….. purpose: to compare the safety, efficacy and complications (intra and post operative) of 25 and 23 – gauge transconjunctival suture less vitrectomy. material and methods: it was a single centre, prospective, interventional case series. fifty eight eyes underwent pars plana vitrectomy using one of the two surgical procedures in ophthalmology department of sir ganga ram hospital, lahore from july 2010 to january 2012. 24 eyes were operated using 25 – gauge and 34 eyes with 23-gauge surgical instruments and technique. in 25 – gauge series, majority of the patients (22 cases, 91.7%) had vitreous hemorrhage as complication of proliferative diabetic retinopathy and venous occlusion complicating into vitreous hemorrhage in remaining 2 cases (8.3%). vitreous hemorrhage with epiretinal membranes overlying macula (6 cases, 25%) and vitreous hemorrhage alone (18 cases, 75%). 23 gauge series included a greater variety of vitreo-retinal pathologies like vitreous hemorrhage (22 cases) due to proliferative diabetic retinopathy, with epiretinal membranes (10 cases, 29.4%) or without (12 cases, 35.3%) epiretinal membranes, rhegmatogenous retinal detachment (12 cases, 35.5%), out of which superior rd was seen in 10 cases and total rd in 2 cases. in 25 – gauge series, internal tamponade was not required while in 23gauge series, silicone oil (1000cst) for internal tamponade was used in 18 eyes (52.9%). results: in 25-gauge series, most of the procedure was possible. however, the 25 – gauge instruments are quite delicate, narrow gauge and fragile. bending of the fiber optic light frequently occurred during procedure. the thin epiretinal membranes were easily peeled off from macular area but the stiffer membranes could not be lifted or cut easily with delicate 25 – gauge curved scissors. instead, vitreous cutter was used to lift and peel the membranes. the fragility of instruments hindered ocular rotation making peripheral vitreous shaving difficult and so required indentation. in 23 – gauge series, the instruments are relatively stiffer making it possible to complete the procedure with ease with including silicone oil fill. most common complication seen in 25 – gauge series was transient vitreous hemorrhage (6 eyes, 25%) while in 23-gauge series, transient low iop (14 eyes, 41.2%), transient recurrent vitreous hemorrhage (4 eyes, 11.8%) and scanty leakage of silicone oil (6 eyes, 11.7%) was seen. no wound suturing was required in either series. visual acuity improved in both groups in postoperative follow-ups. conclusion: both 25-gauge and 23 – gauge vitrectomies are minimally invasive and safe surgical techniques. 23 – gauge offers benefits of stiffer instruments and suitable for larger number of vitreo-retinal pathologies while 25 – gauge instruments are delicate and need careful handling. however, simpler vitreoretinal pathologies are better suited to 25 – gauge procedure. huma kayani, et al 41 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology he recent evolution in pars plana vitrectomy is the minimal invasive surgery using small gauge instruments. compared to the traditional 20 – gauge vitrectomy system, both the 23 – gauge and 25 – gauge system makes small, self – sealing suture less transconjunctival pars plana sclerotomies which minimize surgical trauma to conjunctiva and sclera and allows faster recovery.1 several authors have reported the successful anatomic and visual outcomes with individual techniques in different vitreo-retinal disorders.2,3 the purpose of this study is to compare the operative and post-operative safety and efficacy of the 23 and 25 – gauge systems. material and methods we studied two consecutive case series that underwent suture less vitrectomy from july 2010 through january 2012 in department of ophthalmology, sir ganga ram hospital, lahore. all surgeries were carried out by a single surgeon in a single centre. a total of fifty eight cases were enrolled in the study. data collected included patients age, gender, pathology, examination and indication for surgery. twenty four eyes were prepared for 25 – gauge and thirty four eyes for 23 – gauge vitrectomy procedure. the indications for 25 – gauge vitrectomy predominantly included diabetic vitreous hemorrhage (18 cases, 75%) and vitreous hemorrhage with epiretinal membranes involving macula (6 cases, 25%), in total 22 eyes (91.7%) while venous occlusion complicating into vitreous hemorrhage was the causative factor in 2 cases (8.3%). the indications for 23-gauge vitrectomy included diabetic vitreous hemorrhage in 12 cases (35.3%), vitreous hemorrhage with erm in 10 cases (29.4%), rhegmatogenous retinal detachment in 12 cases (35.5%). out of these 12 cases, superior rd was diagnosed in 10 eyes and total rd in 2 eyes. in both series, vitreo-retinal disease requiring external and internal tamponade were excluded from this study. informed consent from the ethical committee was obtained. alcon accurus vitreo-retinal system was used for both procedures. in the 25 – gauge transconjunctival suture less vitrectomy series, 18 cases were operated under peribulbar local anesthesia while 6 cases under general anesthesia. 25 – gauge surgical technique consisted of angled transconjunctivo-scleral insertion of 25 – gauge trocar mounted polyamide cannula 3.5 – 4 mm from limbus in inferotemporal, superotemporal and superonasal quadrants, each measuring 0.5 mm. trocars were pulled out leaving self-retaining cannula in place. the infusion line was secured into inferotemporal port. 5 – gauge instruments used were 1500c.p.m pneumatic cutter, fiberoptic light, membrane pick, soft tip back flush needle, curved microscissors and endodiathermy probe. photocoagulation was done in all cases. ppv alone was done in 18 eyes (75%) while ppv plus erm peeling was done in 6 eyes (25%). triamcinalone was injected to visualize and assist in membrane peeling. on completion of surgery, the cannulas were pulled out one by one with inferotemporal being the last one out. the conjunctiva above the sclerotomy was slightly displaced to compensate for entry sites. wound was observed for any leakage and a mixture of antibiotic and steroid was injected in inferior sub-conjunctival space. in the 23 – gauge series, 22 cases (64.7%) were operated using peribulbar anesthesia while 12 cases (35.5%) under general anesthesia. surgical technique consisted of transconjunctival one step angled incision. 23-gauge cannula mounted trocar was used for creating three 0.75 mm (each) incisions in inferotemporal, superotemporal and superonasal quadrant. rest of the technique and instruments used was identical to 25 – gauge. of 34 cases, ppv alone was done in 12 cases, ppv plus erm peeling in 4 cases, ppv plus silicone oil tamponade in 14 cases and finally ppv, erm peeling and silicone oil tamponade in 4 cases. intravitreal triamcinalone was injected to assist in membrane peeling. silicone oil (1000 cst) tamponade was used in 18 eyes (52.9%). on completion of surgery, cannulas were pulled out and wound site massaged with cotton tip. wound site was observed for leakage and sub-conjunctival injection of antibiotic and steroid was given. patients in both series were examined on first day, first week, one month and finally three month post-op for wound leakage, visual acuity, intraocular pressure, anterior and posterior segment examination. results in 25 – gauge series, 24 cases were operated. out of these, 16 (66.7%) were males and 8 (33.3%) females. age ranged between 30-60 years. pre-operative visual acuity (using snellen’s chart) ranged between hand movements to 6/36. six eyes (25%) had hand movement, fourteen eyes (58.3%) had counting t comparison between 23 – gauge and 25 – gauge pars plana vitrectomy for posterior segment disease pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 42 fingers, two eyes (8.3%) had 6/60 and remaining two eyes (8.3%) recorded visual acuity of 6/36. slit-lamp examination revealed clear lens in 8 eyes (33.3%), early lens changes in 12 eyes (50%) and pseudophakia in 4 eyes (16.7%). intraocular pressure was within normal range in all cases. posterior segment examination revealed vitreous hemorrhage alone in 18 eyes and vitreous hemorrhage with epiretinal membranes in 6 eyes. diabetic retinopathy (22 eyes) and venous occlusion (2 eyes) were responsible for the vitreous hemorrhage (table 1). all three ports were easily made with little or no pressure on entry. the infusion cannula was long, flexible and had to be secured to avoid accidental lens touch. the 25-gauge instruments were easily used during procedure. due to narrow, delicate instruments, bending of fiberoptic light occurred during surgery (fig. 1). extra care was taken to avoid breakage of instruments. peripheral vitreous shaving was incomplete due to fragile instruments (cutter and fiberoptic light) which made rotation of eyeball difficult and external indentation was required to complete vitreous shaving. thin epiretinal membranes were easily cut while stiff membranes could not be cut with curved 25-gauge scissors. cutter was used to lift, peel and cut these membranes. in 23-gauge series, of 34 cases, 28 (82.4%) were males and 6 (17.6%) were females. age ranged between 18 to 76 years. pre-operative visual acuity ranged between hand movements to counting fingers. slit-lamp examination revealed clear lens in 21 eyes (61.8%), early lens changes in 6 eyes (17.6%) and pseudophakia in 7 eyes (20.6%). intraocular pressure was within normal range in all cases. posterior segment examination showed vitreous hemorrhage alone in 12 eyes, vitreous hemorrhage plus epiretinal membranes in 10 eyes, superior rhegmatogenous retinal detachment in 10 eyes and total rd in 2 eyes (table 1 or 2). the three transconjunctivo-scleral ports made with trocar mounted cannula were angled and required some pressure on insertion into the eyeball, unlike 25 – gauge entry which required little or no pressure on insertion. cannulas were self-retaining. the 23 – gauge instruments were rigid and handling these instruments during vitrectomy was much easier than 25-gauge instruments. no bending or breakage of instruments occurred. peeling/ cutting of epiretinal membranes were easily done with 23-gauge pick, endgripping forceps and scissors. the rotation of eye with 23-g cutter and fiberoptic light made peripheral vitreous shaving quite easy and no indentation was needed. silicone oil (1000 cst) was injected for internal tamponade in eighteen cases (41.2%). 6 eyes (17.6%) showed scanty leakage of silicone oil from one of the ports on completion of vitrectomy. no sutures were applied as leakage was minute and pressure was well controlled. fig. 1: bending of fiberoptic light day 1 follow-up in both series, minor sub-conjunctival hemorrhage was seen overlying one of the sclerotomy. in 25 – gauge, 4 eyes (16.7%) and in 23 – gauge series, 8 eyes (23.5%) showed hemorrhage. the bleeding came from huma kayani, et al 43 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology accidental puncture of conjunctival or episcleral vessels by sharp trocar during port formation. in 25 – gauge series, after cannula removal, the sclerotomy sites showed leakage. in 23 – gauge series, 6 eyes (17.6%) showed scanty leakage of silicone oil from one of the sclerotomy site. however, the eyes were quiet and intraocular pressure well maintained so no sutures were applied to seal that sclerotomy port. these six eyes were padded and examined daily. leakage stopped within 24 – 48 hours and no complications took place. in 25 – gauge series, intraocular pressure remained within normal range in all cases. highest iop of 16 mm hg in 2 eyes and lowest iop of 8 mm hg in 3 eyes, while in 23 – gauge, transient low iop was recorded in 14 eyes (41.2%) with iop of 4 mm hg in four eyes, 6 mm hg in four eyes and 8 mm hg in six eyes. eyes without silicone oil tamponade were the ones with lower iop. the intraocular pressure returned to normal range with 24 – 72 hours post-op. no pressure related ocular complications (e.g. choroidal detachment etc.) developed. transient vitreous hemorrhage was seen in greater number in 25 – gauge series (6 eyes, 25%) than in 23 – gauge series (4 eyes, 11.8%). this is probably due to greater number of diabetic patients with vitreous hemorrhage in 25 – gauge series with retinal neovessels. these vessels are fragile and bleed easily. visual acuity results were almost identical in both series. in 25-gauge series, 14 cases (58.3%) improved, 8 cases (33.3%) reduced and 2 cases visual acuity remained unchanged. in 23 – gauge series, 18 cases (52.9%) showed improvement, 12 cases (35.3%) reduced and 4 eyes (11.8%) remained unchanged (table 2). 1 week follow-up in both series, intraocular pressure returned to baseline values in all with no iop related complications. in both series, partial clearing of vitreous hemorrhage was seen in affected eyes (6 eyes in 25 – gauge, 4 eyes in 23 – gauge series). visual acuity further improved in both series from day 1 follow-up readings. in 25 – gauge series, 12 eyes and in 23 – gauge series, 16 eyes improved further (table 2). 1 month, 3 month follow-up in 25 – g and 23 – g series, eyes with transient vitreous hemorrhage showed complete clearing of vitreous cavity. comparison between 23 – gauge and 25 – gauge pars plana vitrectomy for posterior segment disease pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 44 in 23 – g series, minimal lens changes were seen in 9 cases at 1 month which worsened by 3 months follow-up. silicone oil fill resulted in early cataract formation in all these cases. visual acuity remained stable in all except those with cataract formation. discussion since the introduction of vitrectomy in the early 1970s, numerous retinal conditions like retinal detachment, macular hole and diabetic retinopathy are managed surgically. recently, the procedure has undergone a series of revisions, allowing for smaller angled incisions that do not require suture support and are self sealing, thus, potentially laying the groundwork for a more efficient and patient friendly procedure. besides 20 – gauge systems, today 23 – and 25 – gauge systems are marketed by ophthalmic device makers. simplicity of entry is desirable, and that’s why a one-step angled incision was made in both 23 and 25 – gauge series with self-retaining cannula. both techniques (25 – and 23 – gauge) required stabilizing the eye on entry into the globe. however, greater pressure was applied when forming ports with 23 – gauge trocar mounted cannula. this is probably due to smaller size of 25 – gauge (0.5 mm) wound as compared to 23 – gauge (0.7 mm) requiring greater pressure on trocar – cannula insertion. no entry site retinal tears were seen in either group. this compares well with published data. fine et al4 reported no intraoperative sclerotomy site tears in 77 patients undergoing 23 – gauge vitrectomy. however, their study was only on 23 – gauge technique and not 25 – gauge. in comparison to 23 – g, 25 – g ppv is much more tedious and requires careful handling. the instruments are thin, flexible and bend easily with threat of breakage. luckily, no instrument broke but bending of 25 – g fiberoptic light occurred during surgery in every case. also, peripheral vitreous shaving was incomplete in 25-g series as globe rotation was difficult due to flexible instruments and scleral indentation helped complete the work. inoue m et al5 in his case series reported intra-operative breakage of 25 – g cutter during vitrectomy, while tomic et al6 reported bending of 25 – g light pipe during surgical procedure. no such problems arose in 23 – g series. the instruments were rigid, allowing easy rotation of globe and complete peripheral vitreous shaving. on completion of pars plana vitrectomy, suture closure was not needed in any case in either series. though scanty leakage of silicone oil was observed in 6 eyes (17.6%) in 23 – gauge series, suture closure wasn’t required as iop was maintained within normal range. misra et al7 also reported similar findings with only one out of one hundred and fifty cases requiring suturing of a sclerotomy port while eckardt’s 8 series of forty four patients needed no port sutured. lakhanpal et al9 in his 25-gauge series reported 10 cases (7.1%) requiring suture placement at a single sclerotomy site. post-operative hypotony following both 23 – and 25 – gauge suture less vitrectomy has been raised as a concern in the literature.2,4,6 in our 25 – gauge group, iop readings were within normal range while in 23 – gauge series, fourteen eyes (41.2%) showed low iop readings of ≤ 8 mmhg on the first postoperative day. majority of non silicone oil filled eyes received fluid (internal) tamponade. none of these patients developed hypotony related complications like choroidal detachment. iop returned to normal range within first 48 – 72 hours with no adverse outcome on visual acuity. similar data was published by misra et al7, reporting transient hypotony (iop < 10 mm hg) in four (out of fifty) eyes in 23 – gauge series on first postoperative day which normalized within 2 weeks of surgery with no complications and stable vision. however their study was between 23 – g and 20 – g series and not 25 – g. tomic et al6 published their comparative study between 23 – g and 25 – g ppv and reported a higher rate (41%) of transient hypotony in their 25 – gauge series compared to 14% in 23 – gauge group. localized minor sub-conjunctival hemorrhage occurred in a few patients in either group [4 of 24 (16.7%) in 25 – g and 8 of 34 (23.5%) in 23 – g group]. this happened as a result of accidental puncture of conjunctival vessels by trocar during sclerotomy. another author7 has also reported similar finding. the hemorrhage cleared spontaneously within a few days. 25 – g group showed a greater percentage of transient vitreous hemorrhage (25%) on first follow-up than the 23 – g group (11.8%). this difference is probably due to patient selection in the respective group. majority of patients in 25 – g series were diabetics with pdr with vitreous hemorrhage as a complication of pdr. thus, the diabetic retinal new vessels are more vulnerable and prone to re-bleed with trivial trauma or even ocular movements. in 23 – huma kayani, et al 45 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology g group, there was greater variety of posterior segment disease and silicone oil for internal tamponade was used in many patients. tomic et al6 have published a 2% transient post-op vh in 25 – g and 1% in 23 – g series. they too had similar selection of patients in the respective groups. finally, visual acuity improved in all cases in both groups from their pre-op values. except for transient vitreous hemorrhage which resolved spontaneously, no case in either series required repeat vitrectomy till the last follow up (3 months). conclusion in summary, 25 and 23 – gauge suture less vitrectomies are safe and minimally invasive. they enhance post-operative recovery. in our experience, 23-gauge vitrectomy system offers advantages of suture less system, larger and stiffer instrumentation and is suitable for a wider variety of indications. for 25 – gauge vitrectomy, we need to select vitreo-retinal conditions requiring minimal tissue manipulations and dissection. overall, both procedures induce minimal ocular trauma, decrease inflammatory response and allows faster patient and visual recovery. further studies with longer follow-ups are warranted to determine if procedures involving more extensive fibrovascular proliferation should be performed especially with 25 – gauge instruments. author’s affiliation dr. huma kayani associate professor fjmc / sgrh, lahore dr. aamir ahmed assistant professor fjmc / sgrh, lahore dr. kashif jahangir senior registrar sgrh, lahore dr. hizb-urrehman pg trainee sgrh. lahore dr. khurram chauhan pg trainee sgrh, lahore references 1. fujii gy, de juan e jr, humayun ms, chang ts, pieramici dj, barnes a, kent d. initial experience using the transconjunctival sutureless vitrectomy for vitreoretinal surgery. ophthalmology. 2002; 109: 181420. 2. soni m, mchugh d. 23-gauge transconjunctival sutureless vitrectomy: a way forward. eye news. 2007; 14: 18-20. 3. chen e. 25 – gauge transconjunctival sutureless vitrectomy. curr opin ophthalmol. 2007; 18: 188-93. 4. fine hf, iranmanesh r, iturralde d, spaide rf. outcomes of 77 consecutive cases of 23 – gauge transconjunctival vitrectomy surgery for posterior segment disease. ophthalmology 2007; 114: 1197-1200. 5. inoue m, noda k, ishida s, nagai n, imamura y, oguchi y. intraoperative breakage of 25 – gauge vitreous cutter. am j ophthalmol. 2004; 138: 866-9. 6. tomic z, gili jn, theocharis i. comparison between 25-gauge and 23 – gauge sutureless vitrectomy techniques. retina today 2007; 4 (1): 7. http:// www.retinatoday. org/rt/rt.nsf/url? openform&id=19. 8. misra a, yen gh, burton rl. 23-gauge sutureless vitrectomy and 20-gauge vitrectomy: a case series comparison. eye 2009; 23: 1187-91. 9. eckardt c. transconjunctival sutureless 23-gauge vitrectomy surgery. retina. 2005; 25: 208-11. 10. lakhanpal rr, hamayun ms, juan jr ed, lim ji, chong lp, chang ts, javaheri m, fujii gy, barnes ac, alexandrou tj. outcomes of 140 consecutive cases of 25 – gauge transconjunctival surgery for posterior segment disease. ophthalmology. 2005; 112: 817-24. pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 51 case report electrical injury and ocular complications: a case report chandana chakraborti, swati mazumder pak j ophthalmol 2015, vol. 31 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: chandana chakraborti a/1/1, pearl apartment 50b, kailas bose street, kolkata 700006 cchakoptha@yahoo.com …..……………………….. high voltage electrical injury may result in various ocular complications. these are particularly more common if the injury occurs over scalp. electrical injury induced cataract is usually bilateral though cases of unilateral cataract have also been reported. we report a case of high voltage electrical injury in a 60 years old male resulting in anisocoria, iritis, bilateral cataract and optic atrophy. patient underwent manual small incision cataract surgery (msics) with posterior chamber intraocular lens implantation in both eyes with poor visual recovery. fundoscopy revealed bilateral optic atrophy. this case highlights that in spite of a good extracapsular cataract extraction with intraocular lens implantation, the final visual outcome will depend on other ocular damage due to electric current. key words: electrical injury, iritis, cataract, optic atrophy. lectrical injury may cause various ocular complications without major damage to other organs of the body. electrical voltage ranging from 220 to 50 000, can lead to cataract formation in 5% to 20% of cases.1 a detailed ocular examination should be performed at presentation or as soon as practical for documentation. the final visual outcome after cataract surgery depends on other ocular complications caused by electric current2. we report a case of electrical injury induced cataract with other ocular complications developing after exposure to electric current. case report a 60 years old male complained of painless progressive diminution of vision in both eyes for the preceding 1 month. there was history of unconsciousness with burn of scalp, face, back and legs following high voltage electrical injury (12000 volts) about two months back for which he was admitted in hospital and was treated conservatively. ocular examination revealed visual acuity of perception of light (pl + ve) with accurate projection of rays in both eyes. there was ciliary congestion and sluggishly reacting pupil in both eyes (be) with anisocoria. slit lamp examination revealed advanced immature cataract in be (fig. 1). left eye (le) pupil was irregular with posterior synechiae extending from 9-12 0’clock. the intraocular pressure was 21 mm hg in both eyes. the posterior segment was normal on b – scan ultrasonography in both eyes. general physical examination showed non-healing scalp wound which was about 10 cm × 4 cm in size (fig. 2). face, back and legs showed healed lesion of burn injury. on the basis of history and clinical examination a diagnosis of bilateral electric cataract with anisocoria and resolving iritis was made. patient underwent small incision cataract surgery with posterior chamber intraocular lens implantation in be at an interval of one week. postoperatively corrected visual acuity was 6/24 in right eye and 6/60 in left eye. fundus examination revealed marked pallor of the disc (le > re) with normal cup: disc ratio (fig. 3). macula showed dull reflex in be with retinal pigment epithelial defects. fundus flurescein angiography was within normal limit. discussion ocular complications from electrical burn injuries are not very common. anterior segment involvement in the form of corneal burn, anisocoria, acute bilateral iritis has been reported. posterior segment e mailto:cchakoptha@yahoo.com chandana chakraborti, et al 52 vol. 31, no. 1, jan – mar, 2015 pakistan journal of ophthalmology complications like vitreous hemorrhage or vascular occlusion, retinal detachment, macular cyst, macular hole, optic neuropathy, papillopathy, papilledema, optic atrophy has been reported.3 fig. 1: bilateral electric cataract with posterior synechiae in the left eye fig.2: electrical injury induced non-healing scalp wound. fig. 3: bilateral disc pallor. the anterior segment complications are considered to be due to secondary to heat, as well as electrical injury. posterior segment changes are thought to be caused by the passage of electrical current.4 lenticular opacities following electrical trauma usually occur with a latency period varying from immediately after injury to a few years.5 the closer the point of contact of the current to the eye, the greater the chance of cataract formation. the crystalline lens is a good conductor of electric current because of its high water content. electrical injury seems to change the capsular permeability directly or indirectly6. typical electric cataract starts as snowflake-like anterior subcapsular lens opacities which we missed, as our case presented with advanced stage of cataract. bouzalis dt et al reviewed one hundred fiftynine patients with high voltage electrical injuries, out of which two had recurrent iritis, eight had cataracts, two had macular holes, and one had central retinal artery occlusion.7 in our case, we presume that bilateral cataract, iritis, optic atrophy was all caused by high voltage electrical current (12,000 volt). poor visual recovery post operatively is related to optic neuropathy induced by electrical injury. most of the ocular changes occur immediately after injury, but some late changes may also occur days to years after a severe electrical injury. high voltage injury patients usually present with severe burns requiring prolonged hospitalization. referral to an ophthalmologist and careful follow-up is recommended in all cases of ocular / scalp electrical injuries. author’s affiliation dr. chandana chakraborti assistant professor a/1/1, pearl apartment 50b, kailas bose street, kolkata 700006 dr. swati mazumder assistant professor department of ophthalmology maldah medical college west bengal references 1. johnson ev, kline lb, skalka hw. electrical cataracts: a case report and review of literature. ophthalmic surg.1987; 18: 283-5. 2. biro z, pamer z. electrical cataract and optic neuropathy. int ophthalmol. 1994; 18: 43–7. 3. robert e, raymond m, paul f. electrical injuries: engineering, medical and legal aspects. 2nd ed. lawyers electrical injury and ocular complications: a case report pakistan journal of ophthalmology vol. 31, no. 1, jan – mar, 2015 53 judges publishing company, 2004: 401. 4. bienfang dc, zakov zn, albert dm. severe electrical burn of the eye. graefe’s archive for clinical and experimental ophthalmology. 1980; 214: 147-3. 5. hanna c, fraunfelder ft. electric cataracts. ii: ultrastructural lens changes. arch ophthalmol.1972; 87: 184-91. 6. grewal ds, jain r, brar gs, grewal sps. unilateral electric cataract: scheimpflug imaging and review of the literature. j cataract refract surg. 2007; 33: 116-9. 7. boozalis gt, purdue gf, mcculley jp. ocular changes from electrical burn injuries: a literature review and report of cases. j burn care rehabil. 1991; 12: 458-2. microsoft word 10. crg. h. asif 110 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology case report descemet’s membrane detachment repair with sodium hyaluronate after phacoemulsification ghulam hussain asif, wasif m. kadri pak j ophthalmol 2013, vol. 29 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ghulam hussain asif department of ophthalmology dhq hospital, vehari …..……………………….. purpose: to evaluate the use of sodium hyaluronate in reattachment of detached descemet’s membrane after phacoemulsification. material and methods: five eyes of five patients with non planar descemet’s membrane detachment (dmd) during phacoemulsification from 2006 till 2012 are included in this interventional case series. planar dmd cases were excluded from the study. this study was conducted at dhq hospital vehari. there were four females and one male with the age range of 65 to 75 years with mean age of 70 years. results: all eyes got reattachment of non planar dmd with intracameral injection of sodium hyaluronate. descemet’s membrane remained attached in all the subsequent visits till 12 months post-operatively. the average time for the corneal decompensation to resolve was 24 to 48 hours. all the patients had raised intra ocular pressure (average 31-35 mm hg) within the first 24 hours which was managed with a single mannitol injection and topical beta blockers for one week. in one of the patients intracameral sodium hyaluronate (provisc) had to be repeated after 21 days. post-operative bcva of 6/9 to 6/6 was achieved at 6 weeks postoperatively. conclusion: if non planar extensive descemet’s membrane detachment is noted during phacoemulsification then limited manipulation helps in preventing aggravation of the problem. after surgery identifying the degree of dmd and intracameral injection of sodium hyaluronate re-attaches the dmd. mall descemet’s membrane detachment is not an uncommon occurrence during cataract surgery,1 but large detachment is uncommon.2 it was diagnosed by weve in 1927. descemet’s membrane detachment (dmd) has been classified as planar descemet’s membrane detachment if separation is <1mm and non planar if separation is > 1mm from stroma. each one is further classified in to central and combined (central & peripheral). there are non-surgical factors which are traumatic, congenital glaucoma, corneal ectasia and surgical like cataract surgery, cyclodialysis, penetrating keratoplasty, trabeculectomy, irridectomy, lamellar keratoplasty,3 viscocanalostomy and inadvertently while excessively manipulating the incision, injecting viscoelastic / injections.4-7 dmd can be localized, extensive (fig 1) or total and can cause corneal edema and permanent corneal decompansation. the incidence is 2.6% in ecce and 0.5% in phacoemulsification8-10. time interval is important and it is one day to one year11. vastine et al suggest surgical intervention for large planar and scrolled detachments.12 in extensive dmd, early surgical treatment is recommended to achieve good results.13 treatment options include topical treatment with steroids and hyper osmotic agents. in spontaneous resolution although, rare,14-18 endothelial cells hypertrophy, migrate and redistribute to reverse the corneal edema. the other options are intracameral air injection,11,19-21 supra descemet fluid drainage with s descemet’s membrane detachment repair with sodium hyaluronate after phacoemulsification pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 111 intra-cameral air,22 viscoelastic injection,23,24 transcorneal suturing,9,11 intracameral expandable gases, 14% c3f818,25 or 20% sf6.13,26,27,28 if all the above management fails then keratoplasty is the treatment.3 in the last few years gas injection has gained increased acceptance however i report 5 cases of scrolled dmd managed with sodium hyaluronate (cohesive viscoelastic) with good results. material and methods it was an interventional case series of five patients, one male and four females of age range 65 – 75, with mean age 70 years. only the non planar dmd cases during phacoemulsification cataract surgery were included in this study and the planar were excluded. all the females were operated for cataract surgery at dhq hospital vehari while the male was referred from elsewhere. cases 1, 2 first patient who underwent cataract surgery with phacoemulsification had pre op visual acuity of cf in both eyes. torn sleeve of the tip caused ripping of the descemet’s membrane and cellophane reflex was noticed during chopping of the nucleus. the rest of the procedure was completed with repeated use of hpmc viscoelastic and foldable iol was implanted in the bag. careful irrigation and aspiration was performed to remove the viscoelastic and air was injected in the anterior chamber at the end. in the second case pre op visual acuity was 6/60 and 3/60 in right and left eye. during cracking nucleus the sleeve was torn which detached the descemet’s membrane. the case was managed same way. the next day vision was only hand movement in both cases. intensive topical prednisolone eye drops were used along with ofloxacin eye drops qid post operatively but there was no improvement till 5th post op. day. i applied transcorneal 10/0 nylon sutures at 4 places in case a. the case b was followed as such for spontaneous reattachment. slight improvement was noticed in the repaired cornea but no improvement in the case b. after examination of case on the slit lamp, dmd was identified. under local anesthesia sodium hyaluronate (healon) was injected in the ac under the descemet’s membrane and left there. with the tamponade effect of the viscoelastic, descemet’s membrane reattached to stroma. next day rise in iop was managed with inj. mannitol once and topical beta blockers for one week. examination showed vision in affected eye 6/9p, 1 – 2+ cells, clear cornea and 12 mm of hg iop. the patient a was called and the same procedure was done with her and the transcorneal sutures were removed at the same time. the next day she was examined with good vision and attached descemet’s’ membrane with two small wrinkles but clear cornea. ghulam hussain asif, et al 112 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology cases 3, 4 in july 2007, a 70 years lady was admitted, she had bullous keratopathy in the right eye due to trauma and var was cf at 6 inches. in the left eye she had moderately dense cataract with 3/60 vision. intraocular pressure was 10 mm hg in each eye. she was obese, hypertensive, apprehensive and nondiabetic. she was operated under peribulbar anesthesia. during her surgery she was very irritable, moved and did valsalva maneuvers. despite all the precautions, ac went shallow during phacoemulsification and non-planar combined separation of descemet’s membrane occurred. the procedure was completed with repeated use of viscoat. air was injected at the end of surgery. on first post op day vision was cf at 6 inches and stromal edema was noted. on 6th post op day sodium hyaluronate was injected under l/a under the detached descemet’s and the eye was made firm. the next morning patient had pain due to raised iop of 34 mm hg which was treated with 20% inj. mannitol and topical beta blocker. after 48 hours she was able to see 6/12p unaided. she had one wrinkle on the attached membrane and bcva 6/9 at 6th week. an old gentleman of 68 years was referred to us with non planar extensive dmd during phaco two weeks back was also treated the same way. case 5 an only eyed old lady of 74 years with loss of vision due to trauma following surgery of the right eye presented to us in may 2012. previous notes showed right ecce with iol with descemet’s membrane detachment in 2000. she had val 2/60 with cataract and cornea guttata. phacoemulsification was started under cover of viscoat (alcon, fortworth texas) but a small rhexis of the descemet’s was noted at the wound edge after entering the phaco probe in the eye. while dividing the nucleus and chopping it, cellophane like reflex (non planar descemet’s detachment) was noted. a second side port at 5 o'c was made and the surgery was completed with repeated use of viscoelastic and intracameral air at the end. the next day there was stromal edema with perception of light vision. she was treated with topical steroid, antibiotics and hyper osmotic agent. the edema was not settling and non-planar dmd was noted on slit lamp examination when i decided to inject provisc on 9th post op day. next morning the patient complained of pain due to raised iop 30 mm hg and inj. mannitol was made. the following day the pt had 6/24 bcva. cornea was clear with no wrinkles and it remained clear till 21st post-operative day when she complained of haziness of vision again. on examination she had again dmd in the nasal half of the cornea (fig. 3 and 4). sodium hyaluronate was reinjected from the 5 o’c side port and the eye was made firm. next morning the cornea was clear (fig. 5 & 6) and iop was 12 mm hg. patient was sent home on topical treatment. cornea remained clear with bcva 6/9+ on subsequent follow up (fig. 7 and 8). fig 1. schematic diagram of dmd fig 2. schematic diagram of mechanism of action of sodium hyaluronate. results four out of the five patients got reattachment of descemet’s membrane with first injection and one got second injection of sodium hyaluronate. all eyes had raised iop on first post-operative day. cornea became descemet’s membrane detachment repair with sodium hyaluronate after phacoemulsification pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 113 fig 3. showing only eyed patient fig 4. redetached dmd fig 5. after re injection of sodium hyaluronate fig 6. post inj. sodium hyaluronate fig 7. ten days after 2nd inj. of sodium hyaluronate. fig 8. slit lamp shows clear cornea clear and vision was restored (bcva 6/9 to 6/6) in all the cases. descemet’s membrane remained attached till last follow up. the corneal decompensation resolved in 24 to 48 hours. all cases were tried to be managed with air at the end of procedure. in one case 4 trans-corneal sutures were also applied but unsuccessful. all cases were managed within 10 post operative days. discussion air in the anterior chamber at the end of surgery helps to re-attach planar dmd near the wound edge. intra cameral air with exchange to viscoelastic which remains in the anterior chamber for a few days is not enough to achieve good reattachment of the descemet’s membrane in many cases,18-21 although one case is reported to have spontaneous resolution after 10 months.14-17 surgical descemet’s membrane detachment is a complication that has serious impact on sight, if not treated adequately and at proper time. during surgery use of blunt knife8, 28, shallow anterior chamber, small pupil, ragged large opening of the ghulam hussain asif, et al 114 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology wound, irritable, moving patient and excessive manipulation of the wound / side port leads to this complication. however in the presence of iatrogenic causes there may be underlying suspicion of anatomical predisposing factors, as in my last case both eyes had detachment of descemet’s membrane. its early detection and management of not further damaging / removal is a good achievement till the end of the procedure. the cataract can be emulsified in the posterior chamber with frequent use of viscoelastic and low vacuum. the degree of dmd should be identified on slit lamp and sodium hyaluronate should be injected in the anterior chamber. with the temponate effect of sodium hyaluronate dmd attaches to the stroma of the cornea (fig 2). i filled the viscoelastic after seeing the patient on slit lamp and evaluating the position of descemet’s membrane on 6th to 10th post op day in all of my cases of non-planar extensive dm. in transcorneal sutures combined with sodium hyaluronate, the dm reattached but with some wrinkles, however the cornea remained clear. repair of dmd by putting gas with two needles at slit lamp is a new technique27. gases have problems of availability, are expensive, in some cases toxic and also its need removal for preventing the raised iop. using sodium hyaluronate is beneficial. anterior segment optical coherent tomography can be helpful in identifying the location of detachment in the presence of corneal oedema29. (table 1) conclusion sharp and proper instrumentation with maintained anterior chamber during surgery are helpful in preventing the descemet’s membrane detachment. if detachment is non planar extensive then early detection and limited manipulation helps in preventing aggravation of the problem. after surgery identifying and injecting intra cameral sodium hyaluronate is very useful in reattachment of dmd and prevention of corneal decompensation. author’s affiliation dr. ghulam hussain asif department of ophthalmology dhq hospital vehari professor wasif m kadri 18-g, model town lahore references 1. aust w, wernhard u. defects of descemet's membrane as a complication in cataract extraction with lens implantation. dev ophthalmol. 1987; 13: 20–29. 2. macsai ms. total detachment of descemet's membrane after small incision cataract extraction. am j ophthalmol. 1992; 114: 365-6. 3. mulhern m, barry p, condon p. a case of descemet’s membrane detachment during phacoemulsification surgery. br j ophthalmol. 1996; 80: 185–6. 4. bhattacharjee h, bhattacharjee k, medhi j, altaf a. descemet's membrane detachment caused by inadvertent vancomycin injection. indian j ophthalmol. 2008; 56: 241-3. 5. ostberg a, tornqvist g. management of detachment of descemet's membrane caused by injection of hyaluronic acid. ophthalmic surg. 1989; 20: 885-6. 6. hoover dl, giangiacomo j, benson rl. descemet's membrane detachment by sodium hyaluronate. arch ophthalmol. 1985; 103: 805-8. 7. kim cy, seong gj, koh hj, kim ek, hong yj. descemet's membrane detachment associated with inadvertent viscoelastic injection in viscocanalostomy. yonsei med j. 2002; 43: 279. 8. anderson cj. gonioscopy in no-stitch cataract incisions. j cataract refract surg. 1993; 19: 620–1. 9. pahor d, gracner b. surgical repair of descemet’s membrane detachment. coll antropol. 2001; 25: 13-6. 10. khng cy, voon cw, yeo kt. causes and management of descemet’s detachment associated with cataract surgery not always a benign problem. ann acad med. singapore. 2001; 30: 532-5. 11. amaral ce, palay da. technique for repair of descemet's membrane detachment. am j ophthalmol. 1999; 127: 88-90. 12. vastine dw, weinberg rs, sugar j, binder ps. stripping of descemet’s membrane associated with intraocular lens implantation. arch ophthalmol. 1983; 101: 1042–5. 13. walland mj, stevens jd, steele ad. repair of descemet’s membrane detachment after intraocular surgery. j cataract refract surg. 1995; 21: 250–3. 14. assia ei, levkovich-verbin h, blumenthal m. management of descemet’s membrane detachment. j cataract refract surg. 1995; 21: 714–7. 15. iradier mt, moreno e, aranguez c, cuevas j, garcía feijoo j, garcia sanchez j. late spontaneous resolution of a massive detachment of descemet's membrane after phacoemulsification. j cataract refract surg. 2002; 28: 1071–3. 16. minkovitz jb, schrenk lc, pepose js. spontaneous resolution of an extensive detachment of descemet's descemet’s membrane detachment repair with sodium hyaluronate after phacoemulsification pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 115 membrane following phacoemulsification. arch ophthalmol. 1994; 112: 551–2. 17. watson sl, abiad g, coroneo mt. spontaneous resolution of corneal oedema following descemet's detachment. clin experiment ophthalmol. 2006; 34: 7979. 18. potter j, zalatimo n. descemet's membrane detachment after cataract extraction. optometry. 2005; 76: 720-4. 19. jeng bh, meiser dm. a combined technique for surgical repair of descemet's membrane detachments. ophthalmic surg lasers imaging. 2006; 37: 291-7. 20. palmiero pm, aktas z. lee o, tello c, sbeity z. bilateral descemet membrane detachment after canaloplasty. j cataract refract surg. 2010; 36: 508-11. 21. richard j. mackool, md; s. jerome holtz, md. descemet membrane detachmentarch ophthalmol. 1977; 95: 459-63. 22. ghaffariyeh a, honarpisheh n, chamacham t. supradescemet’s fluid drainage with simultaneous air injection: an alternative treatment for descemet's membrane detachment. middle east afr j ophthalmol. 2011; 18: 189-91. 23. sonmez k, ozcan py, actintas ag. surgical repair of scrolled descemet’ membrane detachment with intracameral injection of 1.8% sodium hyaluronate. int. ophthalmol. 2011; 31: 421-3. 24. donzis p b, akarcioglu z, insler m s. sodium hyaluronate (healon) in the surgical repair of descemet's membrane detachment. ophthalmic surgery. 1986; 17: 735-7. 25. macsai m s, gainer k m, chisholm l. repair of descemet's membrane detachment with perfluoropropane (c3f8) cornea. 1998; 17: 1242-4. 26. gault ja, raber im. repair of descemet's membrane detachment with intracameral injection of 20% sulfur hexafluoride gas. cornea. 1996; 15: 483-9. 27. tai mc, yieh fs chou pi. repair of near total descemet,s membrane detachment with intracameral injection of 20% sulfur hexafluoride gas: j med sci. 2002; 22: 231-4. 28. kim t, hasan sa. a new technique for repairing descemet membrane detachments using intracameral gas injection. arch ophthalmol. 2002; 120: 181–3. 29. winn bj, lin s; hee mr, chiu cs. repair of descemet’ membrane detachment with the assistance of anterior segment optical coherence tomography. arch ophthalmol. 2008; 126: 730-2. microsoft word 9. mohammadzadeh m pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 149 original article sulfadiazine plus clindamycin and trimethoprim / sulfamethoxazole plus clindamycin versus standard treatment for therapy of ocular toxoplasmosis mohammadzadeh m, miratashi a.m, behnaz f, maanaviat m.r pak j ophthalmol 2012, vol. 28 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mohammadzadeh m infectious disease department shahid sadoughi hospital,ebne-sina avenue shahid ghandi blvd yazd-iran telephone no: 0351-8242632 …..……………………….. purpose: to compare efficacy and side effects of clindamycin plus sulfadiazine and trimethoprim / sulfamethoxazole plus clindamycin, with pyrimethamine plus sulfadiazine for treatment of toxoplasma chorioretinitis. material and methods: descriptive case series study. results: of 79 toxoplasma retinochoroiditis patients, 41, 16 and 22 patients were treated with standard treatment, clindamycin plus sulfadiazine (group1) and trimethoprim / sulfamethoxazole plus clindamycin (group2) respectively. visual acuity of three groups improved similarly, with no significant difference between them (6/21 ± 6/32, 6/24 ± 6/70 and 6/21 ± 6/37 in standard group, groups 1and 2 respectively) (pv: 0.496). decrease in activity of lesions began 27.2 ± 7.62, 27.8 ± 12.6 and 28.6 ± 8 days after treatment in standard group, group 1 and 2 respectively (pv: 0.572). vitreal inflammation also began to decrease similarly in three groups (pv: 0.152). the frequency of adverse drug effects leading to treatment interruption was highest in group 2 (14%) with mild side effects observed in 31.7% of them. conclusion: the efficacy of 3 regimens was similar, but highest frequency of side effects was associated with trimethoprim / sulfamethoxazole plus clindamycin, if careful monitoring of adverse drug effects is impractical it is not recommended. urrently standard treatment for treatment of ocular toxoplasmosis consists of pyrimethamine and sulfadiazine supplementd by folinic acid. it is not readily available in some areas1. there are other possible therapies for toxoplasmosis. clindamycin acts synergistically with pyrimethamine and sulfonamides2 with good ocular penetration in the choroid3. trimethoprim / sulfamethoxazole has been used in the treatment of toxoplasmosis. although it is less active than the combination of pyrimethamine and sulfadiazine, but does not have hematologic toxicity as frequently as standard treatment, is inexpensive, is readily available and has been used alone or in combination with clindamycin1, 4. the purpose of our was to evaluate practical options for clinicians practicing in areas with limited choices and inconsistent supply of sulfadiazine, pyrimethamine and folinic acid, we reviewed medical records of 141 patients with clinically diagnosed toxoplasmic retinochoroiditis to compare efficacy and side effects of standard treatment, combination of clindamycin with sulfadiazine and clindamycin plus trimethoprim/sulfamethoxazole. material and methods medical records of patients referred by ophthalmologists with clinical diagnosis of toxoplasmic c mohammadzadeh m, et al 150 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology retinchoroiditis to an infectious disease clinic in yazd from july 2001 to june 2010 were reviewed. the need for an anti-parasitic drug was determined by an ophthalmologist and treatment was carried out by infectious disease specialist. indications for therapy were as follow: severe vitritis, posterior pole lesions, papilitis, large lesions and when lesions were near arcades and optic disk. exclusion criteria were: charts of patients with diabetes mellitus as comorbidity, pregnancy (because oral prednisolone was not given to them), visual acuity in snellen metric scale (va) less than 6/30 at initial evaluation so that visual acuity could be taken as a continuous variable for comparison. another reason for excluding patients with va<6/30 was that most of them had been treated by standard regimen because of ethical concern. data was collected by completing a checklist for each patient’s medical record. charts including information about visual acuity, trend of severity of vitreous inflammation ,va at the end of treatment, size of lesions in terms of optic disk diameter (dd), their location (by drawing), presence of vasculitis, optic disk edema, macular edema and report of antitoxoplasma igg & igm were entered into study. main outcome measures were decrease in severity of vitreous inflammation (graded as trace to ++++), interval between initiation of therapy and time of beginning of decrease in activity of chorioretinitis. response to treatment was defined as: flattening of lesion, reduction in vitreous inflammatory reaction, (at least1+ reduction), disappearance of edema of disk, macula and retina, sharpening of lesion borders, beginning of pigmentation and scar formation. standard treatment consisted of an initial dose of 100mg pyrimethamine, followed by 50mg daily, sulfadiazine 1000 mg q 6h with supplement of 5mg calcium folinate per day. patients treated with clindamycin (300 mg q6h), sulfadiazine (1000 mg q6h) were designated as group 1 and those who have been treated with clindamycin (300 mg q6h) plus trimethoprim/ sulfamethoxazole (960 mg every 12 hours) were designated as group 2. oral prednisolone was given similarly to all of them, 1.2 mg/kg per day at third and fourth days (for two days), then 0.8 mg/kg daily for 17 days before tapering. adverse drug reactions had been monitored in all patients in each visit, but cbc and platelet count had been done once in each patient receiving standard treatment at about the third week. mean of visual acuity before and after treatment, duration mean (in days) to achieve best visual acuity, mean of interval between initiation of treatment and beginning of decrease in activity of retinal lesions, and mean of duration of therapy were compared by kruskal wallis test, the chi square test was employed to compare: levels of visual acuity before and after treatment, period between initiation of therapy and beginning of reduction in vitreous inflammation in each group, distribution of gender and age, percentage of recurrent lesions, location of lesions in relation to fovea, severity of vitreous inflammation, size of lesions before treatment. analysis was performed by spss11.5 version and p value of 0.05was taken as significant. frequencies of side effects were calculated by dividing the events observed by the number of patients exposed to each treatment group (i.e. 43, 21 and 35 in standard treatment group, group1and 2 respectively). results medical records of patients who were treated as toxoplasma chorioretinitis in infectious disease clinic in yazd from july 2001 to june 2010 were reviewed. one hundred and forty one patients’ medical records were eligible for study. medical records of 34 patient were excluded due to visual acuity < 6/30 in either eye (because all of them had been treated with standard regimen due to ethical concern, so their visual acuity could not be compared between groups as a continuous variable), diabetes mellitus and pregnancy (because they had not received prednisolone and their rate of vitreous reaction resolution could not be compared between groups). of 107 patients, 51 patients had received standard treatment, 21 patients, sulfadiazine plus clindamycin and 35 patients, trimethoprim / sulfamethoxazole plus clindamycin. ten patients in standard treatment group were excluded from analysis due to lost to follow up (n=7), discontinuation of drugs because of skin allergy (n=2) and vomiting (n=1). five patients in group 1 were excluded from analysis due to lost to follow up because of depression (n=1), discontinuation of treatment because of skin allergy (n=1), diarrhea (n=1), epigastric pain (n=1) and inadequate initial evaluation (n=1). thirteen patients in group 2 were excluded from analysis due to: lost to follow up (n=6), inadequate initial evaluation (n=2), discontinuation of treatment due to diarrhea (n=3) and gastrointestinal upset (n=2). sulfadiazine plus clindamycin and trimethoprim / sulfamethoxazole plus clindamycin versus standard pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 151 seventy nine patients (35 males, 44 females) including 41 patients in standard treatment group, 16 patients in sulfadiazine plus clindamycin group and 22 patients in trimethoprim / sulfamethoxazole plus clindamycin group had completed at least 28 days of the course of therapy who were compared regarding efficacy and adverse effects. there was no statistically significant difference between 3 groups with regard to age, gender, initial visual acuity and after visual acuity after treatment, improvement in visual acuity, interval between initiation of therapy and beginning of decrease in activity of lesions, mean time to achieve best visual acuity, location of lesions in relation to fovea, initial severity of vitreous inflammation, size of lesions (table1). the treatment groups responded similarly to treatment with improved va. range of patient’s initial visual acuity was 6/30 – 6/6 in the standard therapy group, 6/21-6/6 in the sulfadiazine plus clindamycin group and 6/30-6/6 in the tmp/smx plus clindamycin group (p=0.803). range of patient’s visual acuity achieved after treatment was 6/9-6/6 in the standard group, 6/9-6/6 in group1 and 6/12-6/6 in group 2. within each group there was seen significant improvement in va after treatment: va increased by 6/21 in standard group (p=0.000), by 6/24 in group1 (p=0.002) and by 6/21 in group2 (p = 0.001). however there was no statistically significant difference in visual improvement between the 3 treatment groups (p=496). excluding those patients who had full va (6/6) before treatment, visual acuity improved in all cases after treatment, except for 2 patients in group 2, who’s initial va had not been determined. none of patients had posttreatment va less than 6/12 (table 2). effect of therapy on the beginning of reduction of vitreous inflammation is presented in table 3. in standard treatment group, frequency of adverse effects leading to discontinuation of treatment was 7.8% (4 out of 51 exposed patients), 3 due to skin hypersensitivity and 1 due to nausea, vomiting and burning sensation in the skin. other less severe adverse effects were 3.9% renal colic (2 patient), 7.8% nausea and vomiting (4 patients), 5.9% gastrointestinal upset (3 patients), 2 cases of diarrhea and 1 case of abdominal pain. total frequency of adverse effects was 31.3%. in group 1 frequency of adverse effects leading to discontinuation of treatment was 14.3% (3 of 21 patients), 1 due to diarrhea, 1 due to cutaneous hypersensitivity and 1 due to drowsiness). in group 2, 14.3% of patients (5 of 35 patients), 3 with diarrhea, 2 with gastrointestinal upset discontinued their treatment, frequency of other less sever adverse effects observed were 17.3% mild diarrhea (6 patients), 8.6% mild gastrointestinal upset (3 patients) and 5.7% cutaneous hypersensitivity (2 patients) totally constituting 46% of those initially exposed. suboptimal dose consumption of drugs was observed only in this group, which may has been due to drug intolerance, although not mentioned by patients specifically. all of the adverse effects were reversible in 3 regimens. discussion our study revealed no significant difference between standard treatment, sulfadiazine plus clindamycin and tmp/smx plus clindamycin for toxoplasma retinochoroiditis in terms of improvement in visual acuity. in other similar studies there has been observed no difference in improvement of visual acuity, which is consistent with our findings1, 5. however mean of improvement in va have been higher than our study (6/18 to 6/21 versus 6/24-6/21 in the present study) which can be explained by two factors i.e. we excluded all patients with va less than 6/30 from the study greater proportion of our patients had initial va 6/6 compared with other studies for example that by soheilian1. regarding mean time to achieve best visual acuity, which was 32, 32.7 and 33.3 days in the regimens mentioned above respectively, again no significant difference was observed. in the study done by soheilian et al this period was 35.4 days for standard treatment group and 32.8 days for tmp/smx treatment group1. the frequency of skin rash observed with standard therapy in this study (7 %) was slightly higher than the study done by bosch-driessen et al (5%), 6 and much higher (due to higher dose of sulfadiazine in the present study) than soheilian et al's study (2.8%),1 but obviously lower than a study by theaudin et al (2 out of 7 patients), whose patients had higher mean of age with more extensive disease.7 some of other side effects observed in this study were mentioned by bosch – drissen lh et al’s study6. mohammadzadeh m, et al 152 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology sulfadiazine plus clindamycin and trimethoprim / sulfamethoxazole plus clindamycin versus standard pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 153 total adverse drug side effects in the present study (18.1%) with standard therapy (except for bone marrow side effects of pyrimethamine which may be under reported due to monitoring cbc infrequently) are of much less than the frequency (64%) than observed by bosch-drissen lh et al in their study6. the frequency of serious adverse effects in clindamycin plus sulfadiazine group is less than the study by rothova a et al (17% versus 14.3% in this study) with similar dosage used in two studies although we treated patients longer than them (4 weeks versus 6 weeks in the present study)4. but the frequencies of adverse effects in tmp/smx plus clindamycin were higher than both studies (2.8% in soheilian m et al's study and 4% in rothova a et al's study). this is probably due to addition of clindamycin, higher dose and longer duration of treatment than rothova a et al’s study4. the reason we choose 6 weeks as the preferred duration of treatment was our previous observation that more relapse had occurred in patients whose duration of therapy was shorter (μ=38 days) than those with 42 days duration. (published in bina journal of ophthalmology, scientific journal of eye bank of iri, vol. 7, no. 3, spring 2002). in the present study none of 3 regimens was statistically different from others regarding influence on vision, inflammatory activity and beginning of decrease in activity of lesion. in a physician survey among uveitis specialists in usa no consensus regarding the choice of anti parasitic agents for treatment regimens was present as well8. so it can be concluded that: the frequency of adverse side effects especially those leading to discontinuation of drugs determines the preferable regimen. the least preferable regimen in this study was tmp / smx plus clindamycin with total 46% adverse effects and the standard regimen was best tolerated by our patients. limitation in the present study was that cbc platelet has been done only once during the treatment, which may have led to underestimation of bone marrow suppression because of pyrimethamine. author’s affiliation dr. mohammadzadeh m infectious disease department shahid sadoughi hospital, ebne – sina avenue, shahid ghandi blvd, yazd. iran telephone no: 0351-8242632. dr. miratashi. a.m associate professor shahid sadoughi university of medical sciences ophthalmologist, fellowship of retina contributed in design and data collection yazd. iran fax no: 0351-8224100 dr. behnaz. f assistant professor shahid sadoughi university of medical sciences infectious disease department reviewed the manuscript critically yazd. iran fax number: 0351-8224100 dr. maanaviat. m.r associate professor shahid sadoughi university of medical sciences yazd. iran, contributing in data collection ophthalmology department fellowship of retina 0351-8224100 reference 1soheilian m, sadoughi mm, ghajarnia m, et al. prospective randomized trial of trimethoprim/sulfamethazole versus pyrimethamine and sulfadiazine in the treatment of ocular toxoplasmosis ophthalmology. 2005; 112: 1876-82. 2tabbara kf, o'connor gr. treatment of ocular toxoplasmosis with clindamycin and sulfadiazine. ophthalmology. 1980; 87:129-34. 3hofflin jm, remington js. clindamycin in a murine model of toxoplasmic encephalitis. antimicrob agents chemotherapy 1987; 31: 492-6. 4rothova a, meenken c, buitenhuis hj, et al. therapy for ocular toxoplasmosis. am j ophthalmol. 1993; 115: 517-23 5bosch-driessen lh, berendschot tjm, onkosuwito jv, et al. ocular toxoplasmosis, ophthalmology 2002; 109:869-78. 6bosch-driessen lh, verbraak fd, suttorp-schulten msa, et al. a prospective, randomized trial of pyrimethamine and azithromycin vs pyrimethamine and sulfadiazine for the treatment of ocular toxoplasmosis. am. j. ophthalmol. 2002; 134: 34-40. 7theaudin m, bodaghi b, cassoux n, et al. extensive toxoplasmic retinochoroiditis: diagnostic and therapeutic management j. fr. ophtalmol. 2003; 269: 921-7. 8holland gn, lewis kg. an update on current practices in the management of ocular toxoplasmosis. am j ophtalmol. 2002; 134: 102-4. pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 101 original article clinical and neuro-imaging patterns of meningiomas of visual pathway tayyaba gul malik, khalid farooq, muhammad khalil pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. tayyaba gul malik ophthalmology department lahore medical and dental college lahore e.mail: tayyabam@yahoo.com …..……………………….. purpose: to highlight the clinical and neuro-imaging patterns of meningiomas of visual pathway. materials and methods: it was a descriptive retrospective study conducted during 2007 to 2013. 94 patients with intra cranial meningiomas affecting the visual pathway were selected for study. clinical data included history, ocular and systemic examinations and neuro-imaging reports. special attention was given to the neurological data, which was the only source available to us for diagnosing meningiomas. histological confirmation of meningioma was available in 9.6% cases (n = 9). results: ninety – four patients, 51 females and 43 males (female: male ratio, 1.19:1) were included in the study. mean age was 48.23 years. the commonest type of meningioma affecting visual pathway was meningioma of inner table of occipital bone causing mass effects on the occipital lobe (30.85%, n = 29). other meningiomas were parasellar (21.3%, n = 20) and supra sellar meningiomas (18.1%, n = 17) pressing upon optic chiasma. tumor size ranged from 0.7 cm to 8.5 cm in smallest and largest dimensions respectively. only one patient in our series had neurofibromatosis type 1 and one patient had neurofibromatosis type 2. conclusion: neuro-imaging including conventional radiology plays a pivotal role in non-interventional diagnosis of intracranial meningiomas. owing to the benign nature of meningioma, it should be differentiated from other aggressive tumors which need to be diagnosed and treated at the earliest. key words: parasellar meningiomas, supra sellar meningiomas, visual pathway, dural tail sign, neuro-imaging he term, “meningioma” was first coined by harvey cushing1. generally, meningiomas are tumors, which arise from arachnoidal cap cells, commonly occurring on the brain surface. rarely, they are seen in the brain ventricles. they are either solitary or multiple. many cases of meningiomas are diagnosed incidentally. tumors less than 2.5 cm are usually symptomless. whereas, larger tumors show symptoms which worsen with time.2 these tumors produce symptoms by different mechanisms. firstly, by irritating the brain substance (leading to epilepsy), by pressing the underlying brain tissue or cranial nerves (optic nerve meningioma), causing hyperostosis (meningioma of greater wing of sphenoid), by invading the soft tissues (rarely) and finally by vascular compression or invasion (invasion of cavernous sinus by meningioma).3,4 this article reappraises the neuro-imaging patterns of meningiomas of visual pathway. material and methods it was a descriptive retrospective study. we reviewed clinical and imaging charts of 506 patients of meningioma. 94 patients who had meningiomas affecting the visual pathway were selected for study. t tayyaba gul malik, et al 102 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology clinical data included history, visual acuity, color vision, pupillary reactions, extra ocular movements, intra ocular pressures, field of vision, slit lamp examination and fundoscopy. neuro-imaging with both plain and post contrast images were studied. gd dtpa was utilized for post contrast component. data was compiled, results deduced and descriptive statistical analysis was done. results ninety four patients, 51 females and 43 males (female: ratio, 1.19:1) were included in the study. age ranged from 12 years to 96 years (mean 48.23 years). 33 patients were ≤ 40 years and 61 patients were more than 40 years of age. the commonest type of meningioma affecting visual pathway was meningiomas of inner table of occipital bone causing mass effects on the occipital lobe (30.85%, n = 29). refer to table 1. second common were parasellar (21.3%, n = 20) and supra sellar meningiomas (18.1%, n = 17) pressing upon optic chiasma (fig. 1 and 2). tumor size ranged from 0.7 cm to 8.5 cm in smallest and largest dimensions respectively. there were 9 patients with multiple meningiomas (9.6%). among these, there was an interesting patient with two well-defined meningiomas. one in the middle cranial fossa and the other in left parietal region. middle cranial fossa mass was encasing the cavernous sinus and internal carotid artery and causing pressure effects on right optic nerve, optic tract, pons and midbrain. patient had right lateral rectus palsy and visual field defects in both eyes (fig. 3). only one patient in our series had neurofibro matosis type 1 and one patient had neurofibromatosis table 1: different types of meningiomas affecting visual pathway. fig. 1: solid enhancing planum sphenoidale meningioma. mass effect on pituitary stalk and optic nerve / optic chiasm. fig. 2: right para sellar meningioma t1, t2 and coronal / axial post contrast images showing significant mass effect on right cavernous sinus, pituitary stalk and optic chiasm. fig. 3: two well defined meningiomas in the middle cranial fossa and left parietal region. middle cranial fossa mass is encasing the cavernous sinus and internal carotid artery and causing pressure effects on right optic nerve, optic tract, pons and midbrain. type 2. the diagnosis of meningioma was purely based on radiological findings. histological confirmation of meningioma was available in 9.6% cases (n=9). cavernous sinus meningiomas are associated with multiple cranial nerve palsies including oculomotor, trochlear, trigeminal and abducent. we did not have any patient with purely cavernous sinus meningiomas but there were patients with large parasellar clinical and neuro-imaging patterns of meningiomas of visual pathway pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 103 meningiomas (21.27%, n = 20), which were causing mass effects on the cavernous sinus laterally and on optic chiasma medially. meningiomas which cause pressure effects on the occipital lobe result in contra lateral hemianopia (30.1%, n = 29 in our series). there were 14.9% patients with meningiomas of optic nerve causing ipsilateral vision loss, proptosis, optic atrophy and opticociliary shunt vessels. similarly 14.9% cases in our series had meningiomas of the greater wing of sphenoid with multiple cranial nerve palsies. ocular associations of these meningiomas were visual field defects, proptosis, optic disc edema, optic atrophy, ocular motor nerve palsies and pupillary defects. other neurological deficits were hearing defect, hemiplegia, trigeminal neuralgia and epilepsy. discussion meningiomas are slow growing tumors, which are sometimes, diagnosed incidentally (2 – 3%). it is the second most common intracranial tumor in adults (constituting 20% of all intracranial tumors).5 world health organization (who) has defined meningiomas as “meningothelial (arachnoid) cell neoplasms, typically attached to the inner surface of the dura mater.”6 it is more common in females and reach a peak incidence in seventh decade of life7. in this particular study, female to male ratio was 1.19:1. previous studies in caucasians had shown a ratio of 3:1. in africans, the gender ratio was same. another study depicted this ratio to be 24:1, which is very high.8 mean age in this study was 48.23. in a similar case series, mean age in adults was 50 years.9 tumors that arise from sphenoid bone and result in visual complaints usually present in 5th to 6th decade.7 another characteristic feature of this tumor is that it causes symptoms by compressing the underlying structures without invading brain tissue. symptoms depend on the site of tumor. meningiomas in the region of olfactory groove cause anosmia, ipsilateral optic atrophy and contra lateral papilledema. the triad is called foster kennedy syndrome. in this particular study, we did not encounter any patient with foster kennedy syndrome. cavernous sinus meningiomas are associated with multiple cranial nerve palsies including oculomotor, trochlear, trigeminal and abducent. we did not have any patient with purely cavernous sinus meningiomas but there were patients with large parasellar meningiomas (21.27%, n = 20), which were causing mass effects on the cavernous sinus laterally and on optic chiasma medially. meningiomas which cause pressure effects on the occipital lobe result in contra lateral hemianopia (30.1%, n = 29 in our series). meningiomas of optic nerve cause ipsilateral vision loss, proptosis, optic atrophy and opticociliary shunt vessels (14.9% in this study). meningiomas of the greater wing of sphenoid cause multiple cranial nerve palsies if superior orbital fissure is involved (14.9% in this study). many causative agents for meningiomas are being investigated. viruses, trauma, up-regulation of cox2 and high dose cranial irradiation are some agents.10 some investigators have proposed a relation of female hormones with meningiomas. similarly, estrogen, progesterone and androgen receptors were found on some meningiomas, which further strengthened the hypothesis but it is still not proved. increase in the tumor size in pregnancy also throws light on the role of hormones.11 meningiomas rarely occur in children 17 but when they do, they are more common in males12. in our study, there were only four patients of meningiomas less than 15 years of age and all of them were males. radiation induced meningiomas are multiple, aggressive and have a high proliferation rate.13 they appear 20 to 35 years after irradiation to brain tumors regardless of the dose of radiation14. none of our patients had history of radiation. excessive use of cellular phones is also blamed but available data do not confirm this.15 small meningiomas are usually incidental findings on neuro-imaging performed for some other disease. hence, surgical excision and biopsy is not required in all cases. diagnosis depends on the imaging studies. even the role of plain radiographs should not be overlooked. we can analyze hyperostosis, calcifications and increased vascular markings of the skull. on plain ct scans, meningiomas are isoattenuating to hyper-attenuating. injection of iodinated contrast material leads to homogenous and intense enhancement of the tumor. mr scans with contrast are very helpful in radiological diagnosis of meningiomas. after injecting gadolinium gadopentetate, these tumors enhance homogenously and intensely. another important radiologic diagnostic feature of meningiomas is dural tail sign. goldsher et al described dural tails as a “highly specific feature of meningiomas”.16 the dural tails are composed of hyper vascular, presumably reactive tissue, but not tayyaba gul malik, et al 104 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology meningioma tumor cells. peritumoral edema is also associated with meningiomas which is well demonstrated on flair images. research is being going on regarding the role of vegf-a in inducing this edema. jack hou et al have shown that vegf-a is secreted by meningioma cells.17 meningiomas of the optic nerve have a typical “bull’s eye” picture in coronal images of mri. there is surrounding mass of tumor tissue around an attenuated optic nerve. in axial images, the tumor takes an appearance of “tram track”.18 this is in contrast to optic nerve gliomas in which nerve itself is increased in diameter. optic nerve sheath meningiomas are either primary or secondary depending on whether they are primary arising from optic nerve sheath or invading the orbit from cranial cavity respectively. conclusion neuro-imaging including conventional radiology plays a pivotal role in non-interventional diagnosis of intracranial meningiomas. owing to the benign nature of meningiomas, it should be differentiated from other aggressive tumors which need to be diagnosed and treated at the earliest. author’s affiliation dr. tayyaba gul malik associate professor of ophthalmology lahore medical and dental college lahore dr. khalid farooq professor, department of radiology lahore medical and dental college lahore dr. muhammad khalil associate professor of ophthalmology lahore medical and dental college lahore references 1. cushing h, eisenhardt l, thomas c, ed. meningiomas: their classification, regional behaviour, life history, and surgical end results. springfield, ill: charles c thomas; 1938. 2. sughrue me, rutkowski mj, aranda d, barani ij, mcdermott mw, parsa at. treatment decision making based on the published natural history and growth rate of small meningiomas. j neurosurg. 2010; 113: 1036-42. 3. pieper dr, al-mefty o, hanada y, buechner d. hyperostosis associated with meningiomas of the cranial base: secondary changes or tumor invasion. neurosurgery. 1999; 44: 742-6. 4. pieper dr, al-mefty o, hanada y, buechner d. hyperostosis associated with meningiomas of the cranial base: secondary changes or tumor invasion. clin radiol. 2013; 68: 837-44. 5. claus eb, bondy ml, schildkraut jm, wiemels jl, wrensch m, black pm: epidemiology of intracranial meningioma. neurosurgery, 2005; 57: 1088–95. 6. perry a, louis dn, scheithauer bw, budka h, von deiming a. louis dn, ohgaki hiroko, wiestler od, and cavenee wk. meningioimas in who classification of tumours of the central nervous system. lyon, france: international agency for research on cancer, 2007: 164-72. 7. roy and fraunfelder’s meningioma. in: current ocular therapy. saunders elsevier. 6th edition, 2008. page 255. 8. yang j, ma sc, liu yh, wei l, zhang cy, qi jf, et al. large and giant medial sphenoid wing meningiomas involving vascular structures: clinical features and management experience in 53 patients. chin med j (engl). 2013; 126: 4470-6. 9. sheikh by, siqueira e, dayel f. meningioma in children: a report of nine cases and a review of the literature. surg neurol. 1996; 45: 328-35. 10. ragel bt, jensen rl, couldwell wt. inflammatory response and meningioma tumorigenesis and the effect of cyclooxygenase-2 inhibitors. neurosurg focus, 2007; 23: e7. 11. baxter ds, smith p, stewart k, murphy m. clear cell meningiomas presenting as rapidly deteriorating visual field and acuity during pregnancy. j clin neurosci. 2009; 16: 1502-4. 12. menon g, nair s, sudhir j, rao br, mathew a, bahuleyan b. childhood and adolescent meningiomas: a report of 38 cases and review of literature. acta neurochir (wien), 2009; 151: 239-44. 13. claus eb, calvocoressi l, bondy ml, et al. dental xrays and risk of meningiomas. cancer, 2012; 118: 4530– 7. 14. perry a, louis d, scheithauer b, et al. meningiomas. louis b, ohgaki h, wiestler o, cavenee w, editors., 4th ed. lyon, france: iarc press; 2007. 15. milham s. meningioma and mobile phone use. int j epidemiol. 2010; 39: 1117. 16. goldsher d, litt aw, pinto rs, bannon kr, kricheff ii. dural “tail” associated with meningiomas on gddtpa – enhanced mr images: characteristics, differential diagnostic value, and possible implications for treatment. radiology, 1990; 176: 447-50. 17. hou j, kshettry vr, selman wr, nicholas c. bamb akidis, m.d. neurosurg focus, 2013: 35. 18. zimmerman rd, seidenwurm dj, davis pc, brunberg ja, de la paz rl, dormont pd, et al. orbits, vision, and visual loss. [online publication]. reston (va): american college of radiology (acr); 2006. http://reference.medscape.com/viewpublication/6840 http://reference.medscape.com/viewpublication/4922 http://reference.medscape.com/viewpublication/4922 http://reference.medscape.com/viewpublication/4922 http://reference.medscape.com/viewpublication/6116 http://reference.medscape.com/viewpublication/6116 http://reference.medscape.com/viewpublication/6116 pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 177 original article effect of chronic smoking on choroidal thickness as measured by swept source oct when compared to non smokers haroon tayyab, sana jahangir, shoji kishi pak j ophthalmol 2015, vol. 31 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: haroon tayyab ico fellow in vitreoretinal surgery gunma school of medicine, japan …..……………………….. purpose: to compare choroidal thickness between smokers and nonsmokers by utilising swept source optical coherence tomography. material and methods: a total of 80 subjects were included this study. forty patients were nonsmokers and 40 patients were smokers with a minimum history of 10 years of smoking. swept source optical coherence tomography was used to calculate central choroidal thickness as well as choroidal thickness measurements at varying distances from centre of fovea temporally and nasally. all subjects were asked to refrain from smoking at least 8 hours before measurements. results: the choroidal thickness measurements did not vary between smokers and non smokers when measured on swept source optical coherence tomography. the duration of smoking also did not seem to influence choroidal thickness (p-value = 0.280). conclusion: chronic smoking does not seem to influence choroidal thickness when compared to healthy non smokers. keywords: swept source optical coherence tomography, choroidal thickness, smokers igarette smoking is a known risk factor for causing arteriosclerotic and atherosclerotic complications in human body.1 similarly, smoking has also been implicated in the occurrence of various vascular ocular disorders like age related macular degeneration, central and branch retinal artery occlusion, ophthalmoplegia externa, ocular ischemic syndrome and hypertensive retinopathy.2-4 in recent times, there has been a lot of emphasis on the role of choroid in pathogenesis of various retinal disorders; especially the thickness of choroid has been in focus since the advent of optical coherence tomography.5 cumulative evidence suggests that choroidal thickness is influenced by some physiological factors like age, gender and axial length.6 the main function of choroidal vasculature is to provide nutrients to outer retinal layers and enhanced depth imaging via optical coherence tomography can help delineate choroidal structure7. the progression of various chorioretinal diseases may depend on thickness of choroidal vasculature. choroidal vascular insufficiency and decreased choroidal thickness may lead to functional impairment in retinal pigment epithelium (rpe) and photoreceptor degeneration, which may effect vision.8,9 smoking has been associated with causing vascular endothelial damage. it induces this damage by invoking oxidative stress and decreasing the levels of anti oxidants in the microenvironment of endothelial cells.10 there are a number of studies that postulate that smoking can influence retinal and choroidal vascular haemodynamics including its influence on the blood flow of optic nerve head.11,12 experimental evidence has suggested that chronic smoking may be associated with altered choroidal blood flow and vascular auto regulation which may c haroon tayyab, et al 178 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology itself be a risk factor for development of choroidal neovessels.13,14 choroidal blood flow and changes in its auto regulation can alter choroidal thickness.4,15 in recent times, swept source optical coherence tomography (ss-oct) utilizing a wavelength of 1050 nm has enhanced out ability to visual ocular structures beyond the retina and rpe. this advancement in ocular imaging technology has given us significant insight about the normality and pathology of choroid and sclera.16 in this study, we have used ss-oct to compare the choroidal thickness in chronic smokers with non smokers with the aim to delineate the effects of smoking on choroidal thickness. material and methods this case control study was conducted at department of ophthalmology, gunma school of medicine, japan from 10th january 2015 – 15th february 2015. a total of 80 volunteer subjects walking into out door patient department (opd) were examined in this study. an informed consent was obtained from all subjects and hospital ethical committee was informed about the nature of this study. forty patients were smokers and rest of them was non-smokers. most of the patients were visiting the opd as attendants for their relatives with ocular pathologies. smokers with minimum 10 years of smoking were included in the study. in this study, we included only those patients with best corrected visual acuity (bcva) of 20/20, no ocular or systemic pathology, no history of ocular surgery or trauma, axial length of 25 mm or less and refractive error of +/2.50 diopters or less. it was mandatory to perform a complete ocular examination and if any pathology in structure or function of globe was noticed, the patients were excluded from the study. all patients had completely normal anterior and posterior segment examination. male and female patients between the age of 40 and 80 years were enrolled in this study. rest of the patients not meeting the above mentioned inclusion criteria were excluded from the study. all subjects were instructed not to consume cigarettes or other caffeinated drinks at least 8 hours before choroidal measurements. all oct measurements were recorded between 08:00 hrs to 12:00 hrs taking into account some recent reports of diurnal variation in choroidal thickness. auto refraction was performed using automated refractrometer (nidek ark-1, gamagori, japan) and axial length was calculated by using noncontact partial coherence interferometry (pci; iol master, ver, 3.01; carl zeiss meditec ag, jena, germany). for measurement of choroidal thickness we used ss-oct (deep range imaging oct, topcon, tokyo, japan). all patients were dilated with 0.5 % tropic amide before oct examination. for all the patients, two separate scanning protocols were followed by two experienced ophthalmic technicians. for manual calculation, a single line scan of a resolution of 3 um with a length of 12 mm was taken. the automated calculation was also taken with 3 um resolution. it followed a 3d scanning algorithm on an area of 12 x 9 mm (fig. 1a & 1b). for manual calculations, choroidal thickness was taken from the hyper reflective line of rpe to the outer hyper reflective line of lamina suprachoroidea. a built-in choroidal segmentation software was used to calculate choroidal thickness between the machine defined rpe and lamina suprachoroidea lines. the mean of manual and automated readings were used for result analysis. if there were more than 15 um difference between manual and automated readings then automated readings were considered for analysis. choroidal thickness was measured at fovea and at 500 um, 1000 um, 1500 um and 2000 um nasal and temporal to fovea. only one eye of each patient was measured. for data analysis, spss version 20.0 was used. student t-test and mann whitney u test was used to compare quantitative parameters with normal and without normal distribution respectively. a p-value of less than 0.05 was considered significant while interpreting results. results one eye of 80 healthy volunteers was subjected to examination in this study. forty were smokers and rest of them was non-smokers. thrity four (42.5%) were females and 46 (57.5 %) were males. age range was from 44 years to 78 years with mean +/ standard deviation (sd) of 58.6 +/9.37 years. duration of smoking was from 10 – 40 years and number of cigarettes smoked were from half pack to 4 packs per day (one pack contains 20 cigarettes). axial length effect of chronic smoking on choroidal thickness as measured by swept source oct pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 179 ranged from 21.1 mm to 24.8 mm with mean and sd of 22.68 +/0.80 mm. fig. 1a: choroidal thickness as measured by swept source oct fig. 1b: choroidal thickness as measured there was no statistically significant difference between smokers and non-smokers when we compared central macular thickness (cmt), central choroidal thickness (cct) and choroidal thickness measured at varying distances nasal and temporal to foveal centre (p-value > 0.05) (table 1). there was no statistically significant difference in choroidal thickness between male and female patients in this study. discussion choroidal thickness can vary among patients of different age groups, gender, axial length and refractive status. there have also been reports of diurnal variation in choroidal thickness17. in this study, we examined choroidal thickness among chronic smokers and compared it with that of non smokers. patients with a history of 10-40 years of smoking were included in this study. we found no statistically significant difference in the choroidal thickness between smokers and non smokers. our results are similar to dervişoğulları et al who also demonstrated no difference in choroidal thickness between smokers and non smokers; although he performed his study using spectral domain oct (sd-oct).18 although ulas et al showed statistically significant increase in choroidal thickness when measurements were taken 5 minutes after smoking, his study also did not show any significant choroidal thickness difference measured on sd-oct between smokers and non smokers.17 but their results were different from sizmaz et al who reported that choroidal thickness acutely decreased once readings were taken 1 hour after smoking.4 to minimize the diurnal effect on choroidal thickness, we examined all the patients in morning hours of the day (0800 1200 hrs). although there have been contrasting reports by toyokawa et al and tan et al about the effect of time of day on choroidal thickness, a report from turkey did not report the effect of diurnal variation on choroidal thickness.8,19,20 these differing results can be due to different algorithms and techniques used for the measurement of choroidal thickness although most the studies did not report any change in choroidal thickness in chronic smokers. although various reports have shown effects of chronic smoking on choroidal blood flow auto regulation and hemodynamics of retinal vein blood flow, most of the studies have failed to show any effects of chronic smoking on choroidal thickness11,12. the weakness of this study is its cross sectional design, lack of standardization of amount of smoking in terms of “pack years of smoking”, lack of evidence about different compounds in tobacco of different brands using varying concentrations of nicotine and tar (some brands may vary in the content of nicotine and tar by 500% as compared to other brands). also we did not rule out some other known confounders of haroon tayyab, et al 180 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology choroidal thickness like body mass index, lipid profile and systemic blood pressure that may affect choroidal thickness at the time of examination. the strength of this study lies in the fact that all readings were taken using ss-oct which has a proven value for analysis of choroidal structure and is considered superior to sd-oct for choroidal measurements, where as other studies mentioned above used sd-oct for the same purpose21. also, we used manuals and automatic algorithms and took the final average reading used in our study whereas many studies used manual method for choroidal thickness measurements. also we emphasize on obtaining data of smokers with age matched controls. further studies with a better design need to be conducted to further delineate the effect of smoking on choroidal thickness. also, better measurement algorithms may help us in the future to measure choroidal thickness with higher reproducibility. conclusion chronic smoking does not effect the choroidal thickness as measured on ss-oct. author’s affiliation dr. haroon tayyab ico fellow in vitreoretinal surgery gunma school of medicine, japan dr. sana jahangir assistant professor department of ophthalmology sharif medical & dental college, lahore pakistan prof. shoji kishi head department of ophthalmology gunma school of medicine, japan effect of chronic smoking on choroidal thickness as measured by swept source oct pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 181 role of authors dr. haroon tayyab data collection. dr. sana jahangir statistics and discussion. prof. shoji kishi oct interpretation. references 1. sotoda y, hirooka s, orita h, wakabayashi i. recent knowledge of smoking and peripheral arterial disease in lower extremities. nihon eiseigaku zasshi. 2015; 70: 211-9. 2. joachim n, mitchell p, burlutsky g, kifley a, wang jj. the incidence and progression of age-related macular degeneration over 15 years: the blue mountains eye study. ophthalmology. 2015; 122(12): 2482-9. 3. luo rj, liu sr, li xm, zhuo yh, tian z. fifty-eight cases of ocular ischemic diseases caused by carotid artery stenosis. chin med j (engl). 2010; 123: 2662-5. 4. sizmaz s, küçükerdönmez c, pinarci ey, karalezli a, canan h, yilmaz g. the effect of smoking on choroidal thickness measured by optical coherence tomography. br j ophthalmol. 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http://www.ncbi.nlm.nih.gov/pubmed/?term=nawrocka%2525252520z%252525255bauth%252525255d http://www.ncbi.nlm.nih.gov/pubmed/?term=bednarski%2525252520m%252525255bauth%252525255d http://www.ncbi.nlm.nih.gov/pubmed/?term=nawrocki%2525252520j%252525255bauth%252525255d http://www.ncbi.nlm.nih.gov/pubmed/?term=dervi%25252525c5%252525259fo%25252525c4%252525259fullar%25252525c4%25252525b1%2525252520ms%252525255bauthor%252525255d&cauthor=true&cauthor_uid=25198410 http://www.ncbi.nlm.nih.gov/pubmed/?term=totan%2525252520y%252525255bauthor%252525255d&cauthor=true&cauthor_uid=25198410 http://www.ncbi.nlm.nih.gov/pubmed/?term=tenlik%2525252520a%252525255bauthor%252525255d&cauthor=true&cauthor_uid=25198410 http://www.ncbi.nlm.nih.gov/pubmed/?term=yuce%2525252520a%252525255bauthor%252525255d&cauthor=true&cauthor_uid=25198410 http://www.ncbi.nlm.nih.gov/pubmed/?term=toyokawa%2525252520n%252525255bauthor%252525255d&cauthor=true&cauthor_uid=22320414 http://www.ncbi.nlm.nih.gov/pubmed/?term=kimura%2525252520h%252525255bauthor%252525255d&cauthor=true&cauthor_uid=22320414 http://www.ncbi.nlm.nih.gov/pubmed/?term=fukomoto%2525252520a%252525255bauthor%252525255d&cauthor=true&cauthor_uid=22320414 http://www.ncbi.nlm.nih.gov/pubmed/?term=kuroda%2525252520s%252525255bauthor%252525255d&cauthor=true&cauthor_uid=22320414 http://www.ncbi.nlm.nih.gov/pubmed/?term=tan%2525252520cs%252525255bauthor%252525255d&cauthor=true&cauthor_uid=22167095 http://www.ncbi.nlm.nih.gov/pubmed/?term=ouyang%2525252520y%252525255bauthor%252525255d&cauthor=true&cauthor_uid=22167095 http://www.ncbi.nlm.nih.gov/pubmed/?term=ruiz%2525252520h%252525255bauthor%252525255d&cauthor=true&cauthor_uid=22167095 http://www.ncbi.nlm.nih.gov/pubmed/?term=sadda%2525252520sr%252525255bauthor%252525255d&cauthor=true&cauthor_uid=22167095 http://www.ncbi.nlm.nih.gov/pubmed/?term=hamzah%2520f%255bauthor%255d&cauthor=true&cauthor_uid=25421855 http://www.ncbi.nlm.nih.gov/pubmed/?term=shinojima%2520a%255bauthor%255d&cauthor=true&cauthor_uid=25421855 http://www.ncbi.nlm.nih.gov/pubmed/?term=mori%2520r%255bauthor%255d&cauthor=true&cauthor_uid=25421855 http://www.ncbi.nlm.nih.gov/pubmed/?term=yuzawa%2520m%255bauthor%255d&cauthor=true&cauthor_uid=25421855 microsoft word 9. samira irfan pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 91 original article avoid euas; adequate examination possible under sedation with chloral hydrate sameera irfan pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sameera irfan mughal eye trust hospital lahore …..……………………….. purpose: to find the safety and efficacy of oral sedation with chloral hydrate for ophthalmological examination of pediatric patients. material & methods: in a prospective study from april 2010 till december 2011, 3500 children between the ages 4 months -6 years were examined under sedation with chloral hydrate syrup given in a dosage not exceeding 25mg/kg body weight. there were 1900 males and 1600 females. parents were informed to keep the neck of their child supported at all times while the child was in deep sleep. with the child fully sedated, retinoscopy, direct and indirect ophthalmoscopy, measurement of intraocular pressure was performed in all patients; b scan and axial length measurements were done in children with media opacity only. results: adequate sedation was achieved in 98% children (3,430) within 30-40 minutes. in all children, retinoscopy, indirect ophthalmoscopy and measurement of intraocular pressurewas performed easily. b-scan, measuring axial length and calculation of iol power was easily performed in children with pediatric cataract or media opacity. no side effects were noted in the 98% (3,430 cases). side effects were noted in 2% (70 children); 62 (1.77%) children had vomiting with the first dose; out of these, 52 (1.48%) were sedated after a repeat dose mixed with juice at the same visit; 10 (0.28%) were called after one week and were given chloral hydrate mixed with juice; no gastric irritation was noted at that visit. eight children (0.22%), who were mentally subnormal, needed eua. conclusion: examination under sedation with chloral hydrate syrup is safe and effective for complete ophthalmological examination and many un-necessary euas can be avoided. it saves not only the patient’s and clinician’s time but also reduces the workload in the operating theatres. hloral hydrate was introduced into medical use by liebreich in 1869 as the first nonbarbiturate, synthetic sedative-hypnotic. unlike opioids, it produces sedation without significant adverse effects on cardiovascular or respiratory function at therapeutic doses. as early as 1894, chloral hydrate was being used in children1 as a sedative. despite the availability of newer agents, chloral hydrate remains a common choice. in a 2003 survey of pediatric critical care fellowship training programs in the united states, chloral hydrate was the seventh most frequently used drug for sedation and analgesia2. it has been found to have minimal side effects hence safe to use in the pediatric population. chloral hydrate syrup and suppositories have been approved by the fda in usa and have been in use for chronic sleep disorders. in a study done by noske et al,3 ophthalmic examination in pediatric age group was compared for chloral hydrate given orally or as rectal suppositories; they concluded that orally, it is a more effective sedative and with fewer side effects. however, their study size was small comprising of only 20 children. in another study done by fox et al4 in 304 infants and children, chloral hydrate syrup was found to be a safe and effective sedative in this age group. c sameera irfan 92 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology infants and young children, who are uncooperative, and need a complete ophthalmological examination, have been examined under anesthesia for a very long time. this increases the work load not only in the operating theatres but of the surgeons as well. hence this large study was undertaken to assess the safety and efficacy of oral sedation with chloral hydrate syrup in the out patients department. material and methods a prospective study was done over a period of 18 months, from april 2010 till december 2011, at mughal eye hospital, lahore, a tertiary referral center. this study included 3500 children between the ages 4 months to 6 years. there were 1900 males (54.28%) and 1600 females (45.71%). all pediatric patients were given chloral hydrate syrup in the dosage not exceeding 25mg/kg body weight. a few children vomited with the first dose and were therefore given chloral hydrate syrup given mixed with orange juice. after the child was adequately sedated, retinoscopy, indirect fundoscopy, measurement of intraocular pressure was performed in all children; b-scan,axial length measurement and iol power calculation was done in children with pediatric cataract or media opacity. all parents were told to keep the children within the hospital premises and to adequately support the neck till the child was fully awake. a few children who vomited with the second dose as well were called after 1 week and were given the syrup mixed with juice after making sure they had their breakfast that morning. results 98% children (3,430) were adequately sedated within 30-40 minutes and no problem was experienced by the ophthalmologist in performing the clinical examination. out of the remaining 2% (70 children), 8 children (0.22%), who were a little older (>4 years age) and mentally subnormal were not fully sedated and woke up during the examination; they were highly uncooperative hence they were booked for examination under anesthesia (eua). sixty two children (1.77%) vomited after the initial oral dose of the syrup; out of these, 52(1.48%) were fine after the chloral hydrate syrup was given mixed with orange juice and complete ophthalmological examination was performed at the same hospital visit; the other 10 children (0.28%) vomited again so they were called after one week and chloral hydrate syrup mixed with orange juice was given which they tolerated well this time. table 1: no. of patients n (%) males 1900 (54.28) females 1600 (45.71) total 3500 (100) table 2: side effects of chloral hydrate syrup: 70 cases, (2.0%) no. of patients n (%) vomiting due to gastric irritation. 62 (1.77) repeat dosage, same visit 52 (1.48) repeat sedation, next visit 10 (0.28) needed eua 8 (0.22) total 70 (2) discussion chloral hydrate produces effective sedation in 80 to 90% of patients. it is often selected because of the availability of an oral dosage form and its relatively mild adverse effect profile. unfortunately, its unpredictable onset, long duration, and the lack of a reversal agent, make chloral hydrate less than an ideal sedative1-6. there are a large number of studies examining the utility of chloral hydrate for procedural sedation. in the past decade, most have focused on unique patient populations or have used chloral hydrate as a standard for comparison to other sedatives5-8. one of the largest studies was published in 1996 by napoli and colleagues7. the population consisted of 405 children (3 weeks to 14 years of age) undergoing echocardiography. the average dose of chloral hydrate was 77 mg/kg, with a range of 25 to 125 mg/kg. effective sedation was achieved in 98% (397) children, with 82% (332) patients achieving sedation within 30 minutes. two percent (8 cases) failed to achieve sedation. children 3 years of age or younger were more likely to be successfully sedated than older children. none of the children had a clinically avoid euas; adequate examination possible under sedation with chloral hydrate pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 93 significant change in heart rate or blood pressure; however, oxygen saturation decreased in 6% (24.3). this was more common in children with trisomy 21. vomiting occurred in 6% (24.3) patients. the authors concluded that chloral hydrate was a safe and effective agent for this patient population. as compared to this study, most of our pediatric population was from age 4 months to 6 years; 98% (3,430) were fully sedated while only 2% children (70) were not adequately sedated the first time, while only 8 (0.22%) mentally sub-normal children needed a eua. hence, chloral hydrate is a more effective sedative in the younger age group. the efficacy of chloral hydrate was compared to midazolam in a study by d'agostino and terndrup8. forty children (2 months to 8 years of age) were randomized to receive a single oral dose of either 75 mg/kg of chloral hydrate or 0.5 mg/kg midazolam prior to outpatient neuroimaging. efficacy was significantly better in the chloral hydrate group (100% of patients completed the scan versus 50% of the midazolam patients). the need for supplementary dosing was also lower in the chloral hydrate group (9% versus 55%). mean duration of sedation was not significantly different, and no adverse effects were noted. wheeler and colleagues conducted another randomized, blinded comparison of chloral hydrate and midazolam for procedural sedation9. a total of 40 children under 5 years of age undergoing echocardiography were given either 75 mg/kg chloral hydrate or 0.5 mg/kg midazolam. there was no difference in mean time for onset of sedation between chloral hydrate (25.0 ± 4.7 minutes) and midazolam (27.3 ± 2.9 minutes). mean time to recovery was significantly shorter with midazolam (37.4 ± 3.4 minutes compared to 80.6 ± 15.6 minutes for chloral hydrate). the level of sedation was significantly deeper with chloral hydrate. successful sedation, as determined by a standardized score, was achieved in 93% of the chloral hydrate patients compared to only 36% of the midazolam group. no adverse events were reported in either group. a retrospective study published by mason compared pentobarbital to chloral hydrate for sedation of infants undergoing magnetic resonance imaging or computed tomographic studies10. the authors reviewed the records of 1,393 cases (1,024 pentobarbital cases and 374 chloral hydrate cases). the median dose was 4 mg/kg pentobarbital and 50 mg/kg chloral hydrate. there were no significant differences between the groups in mean time to sedation (18 ± 11 minutes for pentobarbital and 17 ± 12 minutes for chloral hydrate) or time to discharge (102 ± 34 minutes versus 103 ± 36 minutes). average duration of sedation was approximately 85 minutes in both groups. there were significantly fewer adverse effects in the pentobarbital group (0.5 versus 2.7%). this resulted from patients in the chloral hydrate group experiencing more episodes of oxygen desaturation. for sedation prior to medical procedures in infants and children, the recommended dose of chloral hydrate is 50 to 75 mg/kg given orally or rectally. in more recent studies, higher single doses of up to 100 mg/kg have been used with increased success in children and infants over 1 month of age11,13. a larger single dose may minimize the development of paradoxical excitation. the onset of sedation is usually within 30-40 minutes. as the child remains in deep sleep for an hour, it is important to tell the parent holding the child to support the neck till the child is fully awake. it is contra-indicated in liver and kidney diseases as it is metabolized by the liver to its active form and excreted in urine; renal disease will enhance its duration of action. conclusion this study demonstrates that chloral hydrate is a safe and effective drug for complete ophthalmological examination in the out-patient’s department with minimal side-effects11-13. this reduces the need for euas (examination under anesthesia) tremendously. author’s affiliation dr. sameera irfan mughal eye trust hospital lahore reference 1. buck ml. chloral hydrate use during infancy. neonatal pharmacol quart. 1992; 1: 31-7. 2. twite md, rashid a, zuk j, et al. sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: survey of fellowship training program. pediatric crit care med. 2004; 5: 521-32. 3. noske w, papadopoulos g. chloral hydrate for pediatric ophthalmologic examinations. ger j ophthalmol. 1993; 2: 18993. 4. fox be, o'brien co, kangas kj, et al. use of high dose chloral hydrate for ophthalmic exams in children: a retrospective review of 302 cases. j pediatr ophthalmol strabismus. 1990; 27: 242-4. sameera irfan 94 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology 5. pershad j, palmisano p, nichols m. chloral hydrate: the good and the bad. pediatr emerg care. 1999; 15: 432-5. 6. kao sc, adamson sd, tatman lh, et al. a survey of postdischarge side effects of conscious sedation using chloral hydrate in pediatric ct and mr imaging. pediatr radiol. 1999; 29: 287-90. 7. napoli kl, ingall cg, martin gr. safety and efficacy of chloral hydrate sedation in children undergoing echocardiography. j pediatr. 1996; 129: 287-91. 8. d'agostino j, terndrup te. chloral hydrate versus midazolam for sedation of children for neuroimaging: a randomized clinical trial. pediatr emerg care. 2000; 16: 1-4. 9. wheeler ds, jensen ra, poss wb. a randomized, blinded comparison of chloral hydrate and midazolam sedation in children undergoing echocardiography. clin pediatr 2001; 40: 381-7. 10. mason kp, sanborn p, zurakowski d, et al. superiority of pentobarbital versus chloral hydrate for sedation in infants during imaging. radiology. 2004; 230: 537-42. 11. american academy of pediatrics. use of chloral hydrate for sedation in children. pediatrics. 1993; 92: 471-3. 12. chloral hydrate. drug facts and comparisons. efacts [online]. 2006. available from wolters kluwer health, inc. 13. reimche ld, sankaran k, hindmarsh kw, et al. chloral hydrate sedation in neonates and infants: clinical and pharmacologic considerations. dev pharmacol ther. 1989; 12: 57-64. microsoft word 3. asad ali asim 122 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology original article graded recession for primary inferior oblique over action asad ali asim, sharif hashmani, muhammad ather jamil, captain muhahmmad zaheer pak j ophthalmol 2012, vol. 28 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: asad ali asim senior consultant ophthalmologist lakson medical trust sahiwal …..……………………….. purpose: to evaluate the results of graded recession of inferior oblique for primary inferior oblique over action. material and methods: ten patients were selected from opd of lakson medical trust, sahiwal having primary inferior oblique over action with v pattern of more than 5 degrees. bilateral graded inferior oblique recession was carried out using a fink’s caliper. final follow-up was at one year. results: mean age of the patients was 15.7 years. mean pre operative v pattern was 7.5 degrees (15pd). mean post operative v pattern was 1.6 degrees (3.2 pd). mean pre-op extortion in primary position was 4.3 degrees. it was decreased to mean post operative value of 1.3 degrees. cyclo vertical diplopia was also corrected that was present in one patient. conclusions: graded inferior oblique recession by fink’s method is an effective procedure to correct cyclo vertical deviations due to primary inferior oblique over action. it also improved cyclovertical diplopia in few cases. rimary inferior oblique over action (piooa) is usually associated with horizontal strabismus such as congenital esotropia or intermittent exotropia. isolated piooa can occur without associated horizontal strabismus. although piooa is bilateral in most of the cases but it is usually asymmetrical. since the inferior oblique muscle is an elevator, abductor and extortor (the primary action of inferior oblique being extortion), these elements are exaggerated in direct proportion to over action. there is typical upshoot of adducting eye and shows v-y pattern. in case of y pattern there may be little or no change in deviation in down gaze. bagolini test may reveal fusion in down gaze and diplopia in upgaze1,7. asymmetry can cause vertical deviation (vd) and extorsion. indirect ophthalmoscopy may show significant fundus extortion in both primary and secondary inferior oblique over action. one of the main secondary cause of io over action is trochlear nerve palsy. piooa should be differentiated from trochlear palsy where vertical deviation (vd) is incomitant and exyclotropia is maximum in downgaze3. park 3 step test is also important to isolate paretic muscle in case of vertical deviation/diplopia. piooa should also be differentiated from pseudo v due to dvd (dissociated vertical deviation) and duane syndrome. pseudo v may be present in intermittent exotropia with poor control in upgaze1. it is necessary to treat v pattern when child is adapting abnormal head position and having some fusional potential. the v patterns associated with exotropia are more cosmetically disturbing particularly in up gaze8. inferior oblique surgery is indicated in v pattern larger than 5 degrees. many surgical procedures for weakening of inferior oblique have been described including graded recession, anteriorization, myectomy, disinsertion, denervation, extirpation and z-myotomy1,2,7,8. graded recession is very logical approach to treat piooa according to its severity. grades are 8 mm, 10 mm and maximum recession (fig. 1, 2). in maximal recession anterior portion of muscle is attached at lateral side of insertion of inferior rectus muscle. maximum amount is an average 14.6 mm recession2. graded io recession by fink’s method is designed to correct cyclovertical deviations due to inferior oblique over action2,3,14. the effectiveness of graded recession p graded recession for primary inferior oblique over action pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 123 of inferior oblique for pioa was evaluated in this study. materials and methods ten patients with primary inferior oblique over action with v pattern of more than 5 degrees were selected from opd of lakson medical trust hospital, sahiwal from february 2006 to june 2007. detailed orthoptic assessment was carried out which included examination for chin up/down, head tilt, nystagmus and a, v or x pattern. horizontal and vertical deviations were measured by using prism cover test (pct). pct was done with full correction in place at 6 meters in primary position, 300 chin up, 200 chin down, right, left and near fixation. finding of pct were described in prism diopters, which were converted into degrees by taking half of its value. cyclo-torsions were measured by using double maddox rod test in primary position. versions were also checked for over action of inferior oblique. pseudo v was excluded by relying on prism cover test (pct). it was also differentiated from trochlear palsy where vertical deviation (vd) is incomitant and exyclotropia is maximum in down gaze. park 3 step test was done in routine to isolate paretic muscle in case of vertical deviation/diplopia. all the patients who were clinically diagnosed as v pattern more than 5 degrees due to pioa associated with either exotropia (exo) or esotropia (eso) were included in the study. patients with poor fixation, coexisting dvd and associated congenital ptosis were excluded from the study. bilateral graded io recession was done by using fink’s caliper along with horizontal corrections. for 510 degrees v pattern, 8 mm recession was done. fink’s point defines 8 mm recession (fig.1, 2)2,14. for 10-15 degrees v pattern 10 mm recession was performed. for more than 15 degrees of v pattern, maximal recession was done. co-existing horizontal deviations (exo/eso) were also corrected according to measurements in primary position by performing surgery on horizontal muscles. the data, measurements of horizontal deviations and postoperative results were not included in the study. surgical procedure incision was made by grasping inferolateral conjuctival fold adjacent to lateral canthus. squint hook was passed under insertion of lateral rectus, tenon was dissected, io muscle was localized, grasped and cut from its distal end where it inserts by a short tendon onto posterolateral part of globe along the inferior border of lateral rectus muscle. vicryl 6/0 suture was passed through anterior portion of io muscle and reinserted onto sclera according to fink’s measurements. graded recession was done according to pre op evaluation of v pattern. one end of fink’s caliper was placed at lateral rectus insertion; other end marked the fink’s point. fink’s point defines 8mm recession. (fig 1, 2). in 10 mm recession the anterior part of io muscle was reattached 2 mm from fink’s point on a line connecting fink’s point and the lateral insertion of inferior rectus. in maximal recession, anterior portion of muscle was attached at lateral side of insertion of inferior rectus muscle. fig. 1: fink’s point14 scanned from fink wh: surgery of the oblique muscles of the eye. first edition, st. louis, c.v.mosby, 1951. fig 2. use of fink’s caliper in surgical procedure of graded inferior oblique recession. lateral rectus insertion fink’s point e xtortion asad ali asim, et al 124 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology follow up was at post op day 1, one week, 2 weeks, 6 months and one year. the post op measurements taken at six months and one year were found to be stable. while comparing preoperative and postoperative results, post op values at one year follow up were considered. results mean age of the patients was 15.7 years. mean pre-op v pattern was 7.5 degrees (15pd). although we found correction of v pattern and reduction of extortion on the 1st postop day and one week as shown in fig.5. mean post op v pattern is 1.6 degrees (3.2 pd), (fig 3). mean correction of v was 5.9 degrees (11.8 pd). mean pre-op extortion in primary position was 4.3 degrees. it was decreased to mean post-op value of 1.3 degrees (fig. 4). one patient was suffering from cyclo vertical diplopia. on bagolini testing this patient was fusing in downgaze and described diplopia in upgaze preoperatively. diplopia was corrected after surgery in addition to correction of v pattern. 6 6 5 6 7 5 12 1 1 0 2 2 0 3 10 12 7 4 2 10 2 4 6 8 10 12 14 a b c d e f g h i j v pre op v post op fig 3: comparing amount (in degrees) of pre op and post op v pattern. (names of patients are not acceptable ethically, label as pat a to j, label y axis of graph): done discussions in our study, grades of recession were designed according to severity of inferior oblique over action. amount of v pattern determined the grade of recession. it is more logical than doing myectomy for all cases of v pattern8. although different methods of grading io recession have been mentioned in the literature7 but we used fink’s method2,14. during recession, anterior portion of inferior oblique tendon was reinserted on sclera and posterior portion was left loose hanging on posterior check ligament. posterior portion would self adapt by sliding backwards. in our study 10 patients were treated. mean age was 15.7 years. mean correction of v pattern was 5.9 degrees. mean correction of extortion was 3 degrees. our results showed correction of cyclovertical deviation and improved cosmesis. it also eliminated diplopia in a case where fusion was present. kamlesh et al showed mean preoperative v pattern as 38.3 pd (19.15 degrees) and mean postop residual v pattern was 11.4 pd (5.70 degrees). mean correction of v was 26.9 pd (13.45 degrees)4. residual v in this study is 3.2 pd (1.06 degrees) which is quiet low. kamlesh et al selected very large amount of v patren and did 10 mm recession in all cases while in this study, io recession was done according to degree of v pattern. akar et al selected patients with mean v pattern of 27.7 pd. mean post-op v was 9.6pd (4.8 degrees). mean change in v pattern was 18.6 pd (9.3 degrees). they performed a variety of surgical procedures on inferior oblique like myotomy, myectomy, recession and anterior transposition5. cooper and sond all reported that io recession led to a correction of v pattern of 11.96 pd (5.98 degrees) with a residual over correction of 3.11 pd10. our study shows mean correction of v pattern of 11.8 pd (5.9 degrees) with no over correction. burian et al reported an average change of 15.4 pd (7.7 degrees) in v pattern esotropia and an average change of 11.47 pd (5.85 degrees) in v pattern exotropia with a residual v of 9.13 pd (4.56 degrees) and 14.07 pd (7.03 degrees) respectively. graded recession for primary inferior oblique over action pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 125 right fixation left fixation primary position upgaze downgaze fig 5: (preop).a 8 years old boy suffering from piooa primary position shows exotropia; right fixation: left eye in adduction shows io overaction. left fixation: right eye in adduction shows io over action. upgaze/downgaze: exotropia increases in upgaze and decreases in primary position and further in down gaze manifesting v pattern. right fixation left fixation primary position up gaze down gaze fig 6: post operative (1 week): orthotropic in primary position. right and left fixation shows almost no io over action and excessive extortion. upgaze and downgaze shows correction of v pattern in the series of costanbader and kertey, fink’s 8 mm recession lead to an average correction of 2.2 u of iooa (i u: 1-9 pd)6. in both burian et al and costanbadar and kertey studies postoperative v pattern is comparable to that in our studies. baker et al reported decrease in inferior oblique over action (iooa) and extortion after io weakening procedures. they graded both io over action and fundus extortion from 0 to 4. they used inferior oblique recession as a primary procedure. they performed extirpation and disinsertion as a second procedure for residual iooa13. we also found decrease in amount of v pattern that is proportional to io over action. we also found decrease in extorsion. in the sense our results are comparable with baker et al. some authors also reported recurrence, post-op hypotropia, adherence syndrome and internal ophthalmoplegia. however we did not get any of these complications11,12. conclusions graded io recession by fink’s method is an effective procedure to correct cyclo vertical deviations due to primary inferior oblique over action. it also improves cyclovertical diplopia in selective cases. author’s affiliation dr. asad ali asim senior consultant ophthalmologist lakson medical trust sahiwal dr. sharif hashmani medical director lakson medical trust sahiwal dr. muhammad ather jamil ophthalmologist lakson medical trust sahiwal dr. captain muhahmmad zaheer senior medical officer lakson medical trust sahiwal reference 1. wright kw. oblique dysfunction and a and v pattern; in: strabismus and pediatric ophthalmology; 2nd edition, baltimore; william and wilkins; 1997: 297-309. asad ali asim, et al 126 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology 2. boergan kp, ali al, shworm hd. effect of maximal inferior oblique recession in v pattern. trans 22nd esa meeting, cambridge, uk. 1995: 147-152. 3. boergen kp, arzt m, schworm hd. results of different surgical procedures in trochlear palsy. trans 23rd esa meeting, farance. 1996: 289-92. 4. kamlesh, dadeya s, kohli v, et al. primary inferior oblique over action management by inferior oblique recession. indian j ophthalmol. 2002; 50: 97-101. 5. akar s, gokyigit b, eren a, et al. effeciency of bilateral inferior oblique procedure in v pattern strabismus. trans 32 esa meeting, munich, germany. 2008; 253-6. 6. costonbadar fd, kertey e. relaxing procedure of inferior oblique. am j ophthalmol. 1964; 57; 276-80. 7. plager ad, buckley eg, repka mx, et al. oblique dusfunction; in: strabismus surgery basics and advanced strategies, first ed. new york: oxford press. 2004: 40-44. 8. pratt-jhonson ja, tilson g. a,v and x patern strabismus. in: management of strabismus and amblyopia,a practical guide, first ed. newyork; thieme medical publishers. 1994: 138-142. 9. masaya-anon p, subhangkasen i, hiriotappa j. the surgical outcome of inferior oblique recession on bilateral superior oblique palsy in children: j medical association thai. 2009; 92: 217-23. 10. cooper el, sondall gs. recession versus free myotomy at the insertion of io muscle. j pediatr ophthalmol. 1969; 6: 6-10. 11. burian h symposium. the a and v patterns in strabismus treatment. trans. am acad ophthalmol otolayng. 1964; 68: 375-80. 12. parkash p, menon v nath j. surgical management of a and v pattern. indian j ophthalmol. 1983; 31: 463-65. 13. baker jd, macfarlane wa. effectiveness of inferior oblique surgery. trans 30th esa meeting; ireland: 125-6. 14. fink wh. surgery of the oblique muscles of the eye. first edition, st. louis, c.v. mosby. 1951. pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 30 original article impaired colour vision and contrast sensitivity in patients with diabetes mellitus muhammad yasir malik, hira tariq, amna yasmeen, rida ahmed, anila naz, syed omair adil pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syed omair adil department of research, dow university of health sciences email: omair.adil@duhs.edu.pk …..……………………….. purpose: this study determines the major factors which lead to the complications in diabetic patients irrespective of diabetes status. study design: cross-sectional study. place and duration of the study: department of ophthalmology, dow university hospital from september 2015 to december 2016. material and methods: a total of two hundred patients were included. information regarding types of diabetes (type 1 diabetes mellitus (t1dm) / type ii diabetes mellitus (t2dm)), diabetic status (controlled / uncontrolled), snellen acuity, color vision and contrast sensitivity was collected from patients attending eye opd along with demographic data of patients. result: there were 51% males and 49% females with mean age of 50.23 ± 7.89 years. there were 87% married patients, 60.5% had controlled diabetes while 39.5% had uncontrolled diabetes. patients having t2dm were 76.5% and patients with t1dm were 23.5%. snellen visual acuity of 6/9 was seen in 27% patients in the right eye and 28% in the left eye. there was a significant association of status of diabetes with colour vision deficiency (p-value 0.031). diabetic patients, who were using glasses, were 2.2 folds more susceptible to have defects in contrast visual acuity than those who were not using glasses (oradj=2.2, 95% ci: 1.0 – 4.7). conclusion: colour vision deficiency was significantly associated with status of diabetes (controlled/uncontrolled) while contrast sensitivity was significantly associated with patients having refractive errors. keywords: diabetic retinopathy; colour vision; contrast sensitivity; diabetes mellitus. orldwide, diabetes mellitus (dm) distresses the physiology of the retinal neurons and in its pathogenesis, vascular and metabolic aspects are dominantly involved. according to the world health organization there are 285 million people with visual impairment & contrast sensitivity is one of the leading cause of visual impairment1. diabetic retinopathy with impaired vision, colour vision defect & contrast sensitivity is the common cause of legal irreversible blindness2, especially between 20 to 74 years of age3, even though it can be prevented by proper glycaemic control4,5. colour vision deficiency secondary to ocular disease is recognized as acquired colour vision deficiency. in entire world, 8% of males and 0.5% of females are affected from acquired colour vision deficiency6. in diabetic patients, increase in lens density, retinal changes, and hyperglycaemia are involved in the changes in contrast sensitivity, with or without the presence of diabetic retinopathy. w mailto:omair.adil@duhs.edu.pk muhammad yasir malik, et al 31 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology pakistan ranks eighth in the prevalence of diabetes among most populated countries in the world7,8. approximately 6.2 million are suffering from diabetes in pakistan8 and one in every third diabetic patient has diabetic eye disease9-11. in our region, most of the studies have been done on colour vision and contrast sensitivity of diabetic patients which were mostly related to diabetic retinopathy but we planned to see the defects of colour vision & contrast sensitivity in relation to the diabetic status (controlled / uncontrolled). methods and materials this cross-sectional study was conducted from september 2015 to december 2016 at eye department of tertiary care hospital. all diabetic patients in eye opd irrespective of age and gender were included. people with non-diabetic status, known cognitive impairment that were unable to comprehend and answer the interview questions were excluded. data was collected from participants with the help of structured questionnaire. the questionnaire was designed to collect information about demographic, exposure and outcome variables of patients in which risk factors such as diabetic status (controlled/uncontrolled), duration of diabetes, type of diabetes, snellen visual acuity with diabetic retinopathy and maculopathy, colour vision loss, reduced contrast sensitivity and blood glucose level were noted. a brief ocular history was also taken about the frequency of visits in eye hospital, status of glasses and history of eye surgery. patient’s random capillary blood glucose values were measured to determine their fasting and random blood glucose level. visual acuity of both eyes was measured by snellen visual acuity chart on six-meter notation. colour vision in each eye was assessed by using ishihara 14-plates test in which plates 1 to 11 only assessed the normality of colour vision. the colour vision was regarded as normal when ≥ ten plates were read normal and it was abnormal (deficient) when ≤ seven plates were read normal.12 contrast sensitivity was measured by using pelli-robson contrast sensitivity acuity chart. normal score of contrast sensitivity was 2.0, i.e. 100%. those who had score below 1.5 were abnormal, which was recorded as a decrease in the contrast sensitivity. testing was carried out at a distance of one meter (40 inches) with the patients wearing their distance correction13,14. a written informed consent was taken before collecting data. patient’s identity and their data were kept confidential and anonymous. only researchers had access to their data. no monetary burden was put on patients. participants had full right to withdraw at any time during the study. spss version 20 was used for statistical analysis. descriptive statistics was explored by using frequency and percentages for qualitative and median and interquartile range for quantitative variables. the correlation of diabetic status (controlled/ uncontrolled), colour vision and contrast visual acuity with other variables were explored by using chisquare test. mann-whitney test was also applied to see the difference of fasting blood sugar, random blood sugar with diabetic status, colour vision acuity and contrast visual acuity. p-value < 0.05 was taken as significant. further we used binary logistic regression analysis to check the association of contrast visual acuity with other variables. variables with p-values less than 0.25 in univariate (crude) analysis were included in the multiple logistic regression (adjusted) analysis to assess the association of contrast visual acuity with other significant variables. variables were added in the model one by one, starting with the most significant variable in the univariate analysis. only those variables were considered to report from multiple logistic models which had p value less than 0.05. the contrast visual acuity was expressed with the effect size and 95% confidence interval. results a total of 200 patients were included in the study. mean age of the patients was 50.23 ± 7.89 years and participants with > 50 years were 55.5% (n = 111) and < 50 years were 45.5% (n = 89). the frequency of males was slightly higher 51% (n = 102) as compared to females 49% (n = 98). majority of the patients were married 87% (174). defective contrast sensitivity was observed in 20% (n = 40) of the patients. however, 30% (n = 60) patients had reduced scotopic vision. colour vision deficiency was observed in three (1.5%) patients only. the median of fasting blood glucose was 130 with inter quartile range (iqr) (110 190) and random blood glucose was 220 with iqr (184 310). there were 66% (n = 132) diabetic patients with ≤ 15 years history of diabetes. t2dm was predominantly higher 76.5% (n = 153) as compared to t1dm 23.5% (n = 47). most of the patients had controlled diabetes 60.5% (n = 121) while uncontrolled diabetes was observed in 39.5% (n = 79) patients. refractive error was the most common complication noted in 66.5% (n = 133) patients, followed by cataract in 21.5% (n = 43), impaired colour vision and contrast sensitivity in patients with diabetes mellitus pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 32 0% 5% 10% 15% 20% 25% 30% 1/60 2/60 3/60 5/60 6/12 6/18 6/24 6/36 6/6 6/60 6/9 c.f h.m figure 1: snellen visual acuity of right eye. 0% 5% 10% 15% 20% 25% 30% 1/60 2/60 3/60 5/60 6/12 6/18 6/24 6/36 6/6 6/60 6/9 c.f h.m nlp npl fig. 2: snellen visual acuity of left eye. diabetic maculopathy/retinopathy in 1.5% (n = 3), history of eye surgery in 27% and use of glasses in 57% patients (table 1). by using univariate analysis, insignificant difference of controlled diabetes was observed with age (pchi-value 0.737), gender (pchi-value 0.098), marital status (pchi-value 0.085), duration of diabetes (pchivalue 0.513), types of diabetes (pchi-value 0.882), history of eye surgery (pchi-value 0.128), visual complications (pchi-value 0.196) and using glasses (pchivalue 0.195). colour vision deficiency was only found significantly associated with diabetes status (controlled/uncontrolled) (pchi-value 0.031) whereas contrast visual acuity (pchi-value 0.560) and problem in scotopic vision (pchi-value 0.298) was insignificantly associated with diabetic status. however, significant association of contrast visual acuity was observed with age (pchi-value 0.05), problem in scotopic vision (<0.001), duration of diabetes (pchi-value 0.03), type of diabetes (pchi-value 0.04), use of glasses (pchi-value 0.04) and complications (pchi-value <0.001) (table 2). by applying regression, participants with age group > 50 years had 2.0 folds more chances of having reduced contrast sensitivity than patients <50 years age (orcrude = 2.0, 95% ci: 1.0 4.3). patients having diabetes for more than 15 years, had 2.2 folds more chance of having reduced contrast visual acuity than those who had diabetes less than 15 years (orcrude = 2.2 ,95% ci:1.0 4.4). patients with t2dm were 60% less prone to have defective contrast visual acuity than those who muhammad yasir malik, et al 33 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology had t1dm (orcrude = 0.4, 95% ci: 0.2 1.0). diabetic patients who were using glasses had 2.2 folds more chance to have decreased contrast visual acuity than those who were not using glasses (orcrude = 2.2, 95% ci: 1.0 4.0) (table 3). by using multivariate analysis, only uses of glasses (padj value 0.05) remained significant after adjustment and types of diabetes was closed to significant (padj value 0.09). patients with t2dm were 50% less prone to have decreased contrast visual acuity than those who had t1dm (oradj = 0.5, 95% ci: 0.2 1.1) diabetic patients who were using glasses, were 2.2 folds more susceptible to have contrast visual acuity defects than those who were not using glasses (oradj = 2.2 , 95% ci:1.0 – 4.7) (table 3). table 1: baseline characteristics of the patients (n = 200). n (%) age (years) 50.23 ± 7.89 ≤ 50 89 (44.5%) > 50 111 (55.5%) gender male 102 (51%) female 98 (49%) marital status single 11 (5.5%) married 174 (87%) widow 11 (5.5%) divorced 4 (2%) reduced contrast sensitivity 40 (19.5%) reduced colour visual acuity 3 (1.5%) reduced scotopic vision 60 (30%) rcbg fbg 130 (110 190) * rbg 220 (184 310) * duration of diabetes (years) ≤ 15 132 (66) > 15 68 (34) type of diabetes type 1 47 (23.5) type 2 153 (76.5) status of diabetes controlled 121 (60.5) uncontrolled 79 (39.5) visits in eye hospital every 3 months 29 (14.5) every 6 months 44 (22) visual complications refractive error 133 (66.5%) diabetic mp/ rp 3 (1.5%) cataract 43 (21.5%) history of eye surgery 54 (27%) use glasses 115 (57.5%) note: random capillary blood glucose (rcbg), fasting blood glucose (fbg), random blood glucose (rbg), muculopathy (mp), retinopathy (rp), *median (iqr). impaired colour vision and contrast sensitivity in patients with diabetes mellitus pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 34 table 2: comparison of contrast visual acuity with general characteristics of the patients (n = 200). contrast vision p-value normal abnormal variables n (%) n (%) age (years) ≤ 50 77 (47.8) 12 (30.8) 0.054† > 50 84 (52.2) 27 (69.2) gender male 81 (50.3) 21 (53.8) 0.692† female 80 (49.7) 18 (46.2) marital status single 8 (5) 3 (7.7) 0.318† married 142 (88.2) 32 (82.1) widow 7 (4.3) 4 (10.3) divorced 4 (2.5) 0 (0) reduced scotopic vision yes 23 (14.3%) 37 (94.9%) < 0.001†* no 138 (85.7%) 2 (5.1%) rbcb fbg 130 (110 180) 148 (111 233) 0.084ǂ rbg 210 (180 285) 300 (200 330) 0.097ǂ duration of diabetes (years) ≤ 15 112 (69.6) 20 (51.3) 0.031†* > 15 49 (30.4) 19 (48.7) type of diabetes type 1 33 (20.5) 14 (35.9) 0.042†* type 2 128 (79.5) 25 (64.1) status of diabetes controlled 99 (61.5) 22 (56.4) 0.56† uncontrolled 62 (38.5) 17 (43.6) history of eye surgery yes 39 (24.2) 15 (38.5) 0.072† no 122 (75.8) 24 (61.5) use glasses yes 87 (54) 28 (71.8) 0.044†* no 74 (46) 11 (28.2) visual complications refractive error 131 (81.4) 2 (5.1) < 0.001†* diabetic mp/rp 0 (0) 3 (7.7) cataract 15 (9.3) 28 (71.8) others 15 (9.3) 6 (15.4) note: random capillary blood glucose (rcbg), fasting blood glucose (fbg), random blood glucose (rbg), muculopathy (mp), retinopathy (rp). †chi-square test applied, ǂ mann-whitney test applied, *p-value < 0.05. muhammad yasir malik, et al 35 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology table 3: regression analysis for variables associated with contrast visual acuity. univariate analysis multivariate analysis crude or (95% ci) p-value adjusted or (95%ci) p-value gender female 1.0 (0.4 1.8) 0.69 ns age > 50 years 2.0 (1.0 4.3) 0.05 2.0 (1.0 4.2) 0.12 marital status 0.49 ns married 0.6 (0.1 2.4) 0.47 widow 1.5 (0.3 9.3) 0.64 divorced 0 0.99 duration of diabetes > 15 years 2.2 (1.0 4.4) 0.03 1.5 (1.0 3.2) 0.32 types of diabetes type 2 0.4 (0.2 1.0) 0.04 0.5 (0.2 1.1) 0.09 status of diabetes uncontrolled 1.2 (0.6 -3.0) 0.56 ns history of eye surgery yes 2.0 (1.0 -4.0) 0.07 1.6 (0.7 3.5) 0.24 uses of glasses yes 2.2 (1.0-4.0) 0.04 2.2 (1.0 4.7) 0.05 note: or = odd ratio, ci = confidence interval, ns= not significant reference categories: male in gender, < 50 years in age, single in marital status, < 15 years in duration of diabetes, controlled in status of diabetes, no in history of eye surgery and no in uses of glasses. discussion the findings of our study showed increased rate of normal contrast sensitivity and short ratio of acquired colour vision deficiency in uncontrolled diabetic patients. moreover, it was observed in our study that acquired colour vision deficiency was significantly correlated with the uncontrolled high blood glucose level15. it has also been reported in another study that there was an association of acquired colour vision deficiency with macular edema16 and diabetic maculopathy was more likely to cause acquired colour vision deficiency. therefore, the severity of diabetic retinopathy can cause diabetic maculopathy which was associated with colour vision1,17,18. plausible reasons that macula was more affected in uncontrolled diabetic patients in which macula is responsible for central vision and it has large number of cones which support in colour vision. meanwhile uncontrolled blood glucose level fails macula to transmit light, this affects the short cone wavelength cones. furthermore, our study suggested that diabetic patients who were using glasses had two times more chances to have their contrast sensitivity reduced. our findings were concurrent with previous study conducted by alexandra anton that patients who were using lenses than glasses had decreased contrast visual sensitivity19. plausible reason of high prevalence of contrast sensitivity in diabetic patients with glasses that patients were using glasses only occasionally. our study found insignificant difference of controlled diabetes with age, gender, duration of diabetes and type of diabetes. the findings of our study were comparable with finding of previous study that controlled diabetic status was not dependend upon age, gender, and marital status, type of diabetes, duration of diabetes, history of eye surgery and use of glasses17,20. it was noted that age greater than 50 years, t2dm, greater than 15 years of diabetes, uses of glasses, vision problem in dim light and had some clinical signs of diabetic maculopathy predominantly showed contrast sensitivity defects. reason behind it was, the dysfunction of contrast sensitivity occurred because of ocular disease like maculopathy, cataract, and severity of retinopathy. our finding was concurrent with previous studies that diabetic retinopathy was the leading complication of diabetes in which colour vision defect, contrast sensitivity, absorptive loss of blue sensitivity vision and blindness were common1,21. contrast sensitivity is a function of the retina. even though, for early detection of maculopathy in the patients with diabetes mellitus, the measuring contrast sensitivity could be a beneficial tool and it could also impaired colour vision and contrast sensitivity in patients with diabetes mellitus pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 36 be beneficial in investigating the relationship between metabolic control and retinal function19. moreover, other studies suggested that diabetic patients were at higher risk of getting contrast sensitivity problems because patients who have diabetes for more than 15 years had usually high blood glucose level with greater than 50 years of age and they do not know the cautionary measures that reduces their eye complications. these findings are consistent with past studies7,8. although it has been revealed by different studies that central vision loss is caused by visual acuity and assessment of visual acuity with different tools is sufficient to measure visual impairment in diabetic retinopathy22,23. this study included both types of diabetes, i.e. type 1 and type 2 and we found predominately higher ratio of t2dm in patients. our result showed no statistical association of types of diabetes with colour vision acuity; but an association of types of diabetes was found with contrast sensitivity impairment. in contrary, in another study, significant association of colour vision impairment was found in type 2 diabetic patients.24nevertheless, in our study, t2dm had 60% less chance to have contrast visual acuity. the limitations are that controlled and uncontrolled diabetic patients were enrolled with small sample size that is why short result of colour vision acuity was found. moreover, we could not find significant results in association of colour vision and diabetes (controlled/uncontrolled) with other variables. it was a cross section and single centre study. moreover, in this study, we have short time to evaluate the diabetes, colour vision acuity and contrast sensitivity, and we used quick and easy procedures. therefore, we found diabetes by random capillary blood glucose, colour vision acuity by ishihara test and contrast sensitivity by pelli robbson20 and we did not use time consuming procedures which were more accurate. furthermore, certain important information regarding diabetes risk factor was also noted like diabetic cataract, retinopathy, and variation in refractive state of eye during refraction in uncontrolled diabetes. collection of this information along with above mentioned risk factors could help in better understanding the diabetic complications. however, the sub divisions of complications were found problematic in regression analysis and variable of complications has been excluded from multivariate analysis to stabilize the result. conclusion in this study, colour vision deficiency was found significantly associated with diabetes status (controlled/uncontrolled) while contrast vision was significantly associated with those who were using glasses. author’s affiliation muhammad yasir malik bs in clinical ophthalmology technology mba in health care management instructor ophthalmology dow institute of medical technology, dow university of health sciences. hira tariq ms biostatistics and epidemiology, research associate, agha khan university hospital. amna yasmeen bs in clinical ophthalmology technology dow institute of medical technology dow university of health sciences. rida ahmed bs in clinical ophthalmology technology dow institute of medical technology dow university of health sciences. anila naz bs in clinical ophthalmology technology dow institute of medical technology dow university of health sciences. syed omair adil ms biostatistics and epidemiology lecturer biostatistics & research associate department of research dow university of health sciences. role of authors muhammad yasir malik conception and designing of the study, write-up of the study, final approval of the article. hira tariq data analysis and write up of the study. amna yasmeen data collection and write up of the study. rida ahmed data collection and write up of the study. anila naz data collection and write up of the study. muhammad yasir malik, et al 37 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology syed omair adil conception and designing of the study, final approval of the article. references 1. alió jl, krueger rr, bidgoli s. the world burden of refractive blindness. journal of refractive surgery, 2016; 32 (9): 582-4. 2. daley ml, watzke rc, riddle mc. early loss of bluesensitive colour vision in patients with type i diabetes. diabetes care, 1987; 10 (6): 777-81. 3. zhang x, saaddine jb, chou cf, cotch mf, cheng yj, geiss ls, et al. prevalence of diabetic retinopathy in the united states, 2005-2008. jama. 2010; 304 (6): 649-56. 4. sayin n, kara n, pekel g. ocular complications of diabetes mellitus. world j diabetes, 2015; 6 (1): 92–108. 5. singh r, ramasamy k, abraham c. retinopathy: an update. indian j ophthalmol. 2008; 56 (3): 179–88. 6. simunovic mp. acquired colour vision deficiency. survey of ophthalmology, 2016; 61 (2): 132-55. 7. khan mm, mahmud s, karim ms, zaman m, prince m. case–control study of suicide in karachi, pakistan. the british journal of psychiatry, 2008; 193 (5): 402-5. 8. shaikh a, shaikh f, shaikh za, ahmed j. prevalence of diabetic retinopathy and influence factors among newly diagnosed diabetics in rural and urban areas of pakistan: data analysis from the pakistan national blindness & visual impairment survey 2003. pak j med sci. 2008; 24 (6): 774-9. 9. allen c, bates d. in vivo measurement of increased vascular permeability after stz induction of diabetes in rats by fluorescence angiography using the micron iv. acta ophthalmologica. 2016; 94 (s256). 10. draman n, mohamad wm, embong z, ali mh, yaakub a. predictors of proliferative diabetic retinopathy among patients with type 2 diabetes mellitus in malaysia as detected by fundus photography. journal of taibah university medical sciences, 2016: 1-6. 11. stitt aw, curtis tm, chen m, medina rj, mckay gj, jenkins a, et al. the progress in understanding and treatment of diabetic retinopathy. progress in retinal and eye research, 2016; 51: 156-86. 12. ishihara s. tests for colour blindness. tokyo, japan. 24 plates edition. available at: http://www.dfis.ubi.pt/~hgil/p.v.2/ishihara/ishihara .24.plate.test.book.pdf accessed: 10th october 2017 13. thayaparan k, crossland md, gary s. clinical assessment of two new contrast sensitivity charts. br j ophthalmol. 2007; 91 (6): 749–52. 14. owidzka m, wilczynski m, omulecki w. evaluation of contrast sensitivity measurements after retrobulbar optic neuritis in multiple sclerosis. graefe's archive for clinical and experimental ophthalmology, 2014; 252 (4): 673-7. 15. radwan tm, ghoneim em, ghobashy wa, orma aa. assessment of colour vision in diabetic patients. international journal of ophthalmic research, 2015; 1 (1): 19-23. 16. shin yj, park kh, hwang jm, wee wr, lee jh, lee ib, et.al. a novel colour vision test for detection of diabetic macular edema colour vision test to detect macular edema. invest ophthalmol vis sci. 2014; 55: 2532. 17. heravian j, shoeibi n, azimi a, yasini s, moghaddam o, yekta a, et al. evaluation of contrast sensitivity, colour vision and visual acuity in patients with and without diabetes. iranian j ophthalmol. 2010; 22: 33-40. 18. gella l, raman r, kulothungan v, pal ss, ganesan s, sharma t. impairment of colour vision in diabetes with no retinopathy: sankara nethralaya diabetic retinopathy epidemiology and molecular genetics study (sndreams-ii, report 3). plos one, 2015; 10: e0129391. 19. anton a, böhringer d, bach m, reinhard t, birnbaum f. contrast sensitivity with bifocal intraocular lenses is halved, as measured with the freiburg vision test (fract), yet patients are happy. graefes arch clin exp ophthalmol. 2014; 252 (3): 539–44. 20. rashmi s, varghese rc, anupama b, hegde v, jain r, kotian h. contrast sensitivity in diabetic patients without retinopathy and its correlation with the duration of diabetes and glycemic control. iosr journal of dental and medical sciences (iosr-jdms), 2016; 15 (8): 11-3. 21. wolff be, bearsejr ma, schneck me, dhamdhere k, harrison ww, barez s, et al. colour vision and neuroretinal function in diabetes, 2015; 130 (2): 131-9. 22. carpineto p, ciacagini m, di antonio l. fundus microperimetry patterns of fixation in type 2 diabetic patients with diffuse macular edema. retina, 2007; 27: 21–9. 23. muneeswar g. nittala, laxmigella, rajiv raman and tarun sharma. measuring retinal sensitivity with the micro-perimeter in patients with diabetes, retina (philadelphia, pa.), 2012; 32 (7): 1302-9. 24. feitosa-santana c, oiwa nn, paramei gv, bimler d, costa mf, lago m, et al. colour space distortions in patients with type 2 diabetes mellitus. visual neuroscience, 2006; 23: 663-8. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4317321/ http://www.dfis.ubi.pt/~hgil/p.v.2/ishihara/ishihara.24.plate.test.book.pdf http://www.dfis.ubi.pt/~hgil/p.v.2/ishihara/ishihara.24.plate.test.book.pdf microsoft word 9. nazia qidwai 214 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology original article comparison of dacryocystorhinostomy with mitomycin c against dacryocystorhinostomy with intubation nazia qidwai, hassan raza jafri pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nazia qidwai al-ibrahim eye hospital isra postgraduate institute of ophthalmology malir karachi75040 …..……………………….. purpose: to compare the surgical outcome of dacryocystorhinostomy (dcr) with mitomycin c (mmc) against dacryocystorhinostomy with intubation in patients of nasolacrimal duct block (nldb). material and methods: this randomized controlled trial was conducted on 130 patients with nldb, equally and randomly enrolled in two groups. in group a patients underwent dcr with intubation and in group b dcr with mmc from july 2009 to december 2009. patients were followed for 06 months. the main outcome measures were assessment of regurgitation and the patency of lacrimal drainage system (lds). results: 130 patients of nldb included in this study. out of 65 patients in group a, 62 (95.4%) patients remained symptom free whereas, 3 (4.6%) showed failed syringing at the end of 6 months. however, out of the 65 patients in group b, 59 (90.8%) patients remained symptom free and 6 (9.2%) showed failed syringing. the overall success rate was 93.1%. (statistics were and are mentioned in the results). conclusion: silicon tube and mmc, both yield equally successful results with dcr. however, use of mmc is more cost and time effective than silicon tube and also associated with lesser intra-operative and post-operative complications. bstructive epiphora due to blockage in the distal part of the nasolacrimal apparatus is the major indication of external dcr. first performed by adei toti, dcr is still the gold standard against which other methods are compared.1,2 its various modifications include, dupuy dutemps and bourguet’s idea of anastomosis of the flaps of the lacrimal sac and nasal mucosa3, ohm’s idea of suturing of nasal mucosa with the lacrimal sac,4 iliff’s suggestion of placing a rubber catheter into the sac5 and older’s suggestion of using a silicon tube6. success rate of dcr has been found to be 90%.7 10% of cases however, still fail with persistent excessive tearing and inability to irrigate7. the two commonest causes of dcr failure are obstruction of the common canaliculus and closure of the osteotomy site7. antiproliferative agents like mmc are used to prevent fibrous tissue growth and scarring. this overall decreases the failure rate of dcr7. success rates achieved with the adjunctive use of mmc in various studies are 95.5%, 95% and 97.7%7-9 and those with silicon tube are 83% and 97.5%.10,11 the aim of this study is to compare the surgical results of both these adjuncts of dcr. material and methods the study was carried out at the oculoplasty clinic, al-ibrahim eye hospital, malir karachi from july 2009 to december 2009. patients were followed postoperatively from january 2010 to june 2010. the ethical committee permission was taken before study. 130 patients of both gender and belonging to any age group presenting to the opd with complaints of o comparison of dcr with mmc against dcr with intubation pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 215 watering / epiphora and fulfilling the inclusion criteria were subjected to the planned ocular examination and investigation. inclusion criteria was complete nld obstruction and chronic dacryocystitis. the patients were randomly divided into 2 groups, each group consisting of 65 patients. exclusion criteria included acute on chronic dacyocystitis, punctal agenesis, common or individual canalicular obstruction, neoplasm of the lacrimal sac, tuberculosis of the lacrimal sac, osteomyelitis of the lacrimal bone, severe atrophic rhinitis, nasal polyp, granulomas, neoplasms of nasal cavity and patients who were unable to follow up for six months. a specific proforma was maintained for all the registered patients to assess the post-operative results. the patients were evaluated pre-operatively via history and examination. a detailed history regarding watering, swelling near the medial canthus, mucopurulent discharge was obtained. history of using eye drops such as adrenaline or phospholine iodide and anticoagulants, was also taken. ocular as well as nasal examination was done in all patients. ocular examination was done to assess for entropion, ectropion, trichiasis or blepharitis, punctal malposition, stenosis, agenesis or accessory puncta, canaliculitis, conjunctivitis, keratitis or any fistulae near medial canthus. regurgitation test was performed and reflux of mucus or mucopurulent material through the canaliculus and puncta was noted. schirmer test was perfomed in the elderly patients with suspected low tear secretion. nasal cavity was examined in all patients to exclude any nasal disease and patients with nasal problem were referred to otolaryngologist for treatment before performing dcr surgery. preoperatively patients were investigated for any bleeding diatheses via blood complete picture, erythrocyte sedimentation rate, blood sugar levels, bleeding and clotting time, hbsag and anti-hcv. other relevant investigations, wherever needed. surgical technique dcr was performed under general or local anesthesia as per patient need or request will. informed consent was taken after thorough explanation of the procedure, its risks and benefits to the patient. the nasal mucosa was anesthesized and vasoconstricted by packing the respective nasal cavity of all patients with ribbon gauze soaked in 4% xylocaine and adrenaline (1:100,000). after anesthesia and draping, the puncta were dilated with nettleship punctum dilator. the lacrimal sac was irrigated with normal saline. a vertical straight skin incision 6 mm away from the medial canthus was made to expose the anterior lacrimal crest. four traction sutures with 4/0 silk were made through the skin to expose the area of surgery. the periosteum over the anterior lacrimal crest was elevated towards the bridge of the nose for about 5 – 6 mm. the lacrimal fossa was exposed. the suture between the lacrimal bone and frontal process of maxilla lying in the posterior half of fossa was identified. an oval osteotomy, approximately 12 x 10 mm in size, with smooth edges and round corners, was created. small anterior and larger posterior flaps of sac were made. an h-shaped incision was made in the nasal mucosa forming a larger anterior and smaller posterior flap. in the dcr with mmc group, a piece of neurosurgical cottonoid / gauze piece was attached with a long thread and saturated with 0.2 mg/ml mmc. it was then placed over the anastomosed posterior flaps and osteotomy site for 5 minutes, with the long thread passing out through the nostril. meanwhile the anterior nasal and lacrimal sac flaps were anastomosed with 3 or 4 interrupted 6/0 prolene sutures on short ½ circle needles. at least 2 and upto 4 sutures were placed. traction sutures were then removed and the bridge of flaps sutured to the muscle layer with 2-3 suture of 6/0 vicryl to avoid collapse of bridge. the periosteum, orbicularis oculi and skin wounds were closed in separate layers with interrupted 6 / 0 sutures. the mmc saturated cottonoid / gauze piece was removed trans-nasally by pulling out the long thread from the nostril. steps for dcr with intubation were identical to the dcr with mmc upto the point of fashioning of the mucosal flaps. a fine silicon tube attached to malleable metal bodkins was then introduced through both upper and lower canaliculi and brought out through dcr skin incision. after suturing the posterior flaps, the tube ends were passed into the nose and out through the nostril by means of a curved artery forceps. the tube loops were then tied together with a 5/0 prolene suture and left in the nasal cavity near the external nostril without fixing it to the nasal wall. pressure bandage and nasal packing with ribbon nazia qidwai, et al 216 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology gauze soaked in antibiotic ointment was done in all patients to control bleeding post-operatively. post-operatively all patients were kept in ward for 24 hours. the nasal pack and bandage was removed the following day. skin sutures were removed after one week. all patients were kept on oral broadspectrum systemic antibiotics, non steroidal antiinflammatory medicines for one week to prevent postoperative soft tissue infection. they were also kept on topical moxifloxacin eye drops, qid for one month and polymyxin b, bacitracin eye ointment, od for local application over the wound. follow-up protocol: follow-up was maintained for 6 months for the evaluation of abnormal overflow of tears and the patency of the lds by syringing. the first follow-up was done on day one after surgery then after one week, and then at 1st, 3rd and 6th month postoperatively. skin sutures were removed on first postoperative week. outcome of the surgery was measured on the basis of these subjective and objective findings. the surgery was considered successful if the patient had no tearing or significant improvement in tearing in a patent with patent lds at the last follow-up. patients having persistent epiphora with non-patent lds were classified as failed dcr. at the end of follow-up period of 06 months results of dcr with mmc and dcr with intubation were compiled and compared with national and international results. results a total of 130 patients of nldb were included in this study. patients were equally and randomly allocated into two groups. in group a, patients were treated with mitomycin c and in group b, patients were treated with intubations. age distribution of the patients is presented in figure 1. the average age of the patients was 27.98 ± 5.6 years (95% ci: 25.89 to 29.87). similarly comparison of age between groups is presented in table 1. significant difference was not observed between groups in age at p = 0.72. (fisher exact test). out of 130 cases, 55 (42.3%) were male and 75 (57.7%) were female as presented in table 2. proportion of gender difference was also not significant between groups (p = 0.214). success rate of dcr with mmc and intubations was 93.1% while 6.9% of cases still fail with persistent excessive tearing and inability to irrigate. rate of surgical outcome was not statistically significant between the groups (fisher exact test; p = 0.49) as presented in table 3. similarly surgical outcome was also presented with respect to gender and this is also not significant as shown in table 4. 8 14 27 28 23 14 8 0 5 10 15 20 25 30 < 11 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 age groups (years) fig. 1: age distribution of the patients n=130 mean± sd= 27.98 ± 5.6 years (95%ci: 25.89 to 29.87) discussion external dcr is the gold standard procedure for relief of nld obstruction by which other methods are measured and compared.2 success rate of dcr has been found to be 90%.12-14 however, 10% of cases still fail with persistent excessive tearing and inability to irrigate the lds.7 the two commonest causes of dcr failure are obstruction of the common canaliculus and closure of the osteotomy site.15-17 fibrous tissue growth, scarring, and granulation tissue formation f re qu en cy comparison of dcr with mmc against dcr with intubation pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 217 during the healing process decrease the created surface area of the osteotomy site, leading to surgical failure7. thus, if we can reduce fibrous proliferation at the osteotomy site and at the anastomosed flaps, the success rate of dcrs may become much higher.7 in our study the overall success rate of dcr with mmc and intubations was 93.1% while 6.9% of cases still failed with persistent excessive tearing and inability to irrigate. the assessment criteria included symptomatic relief of epiphora and syringing at 1st day, 1st week and then at 1st, 3rd and 6th month. in our study we attained a success rate of 90.8% and a failure rate of 9.2% in the dcr with intubation group. 59 patients were labeled as successful on the basis of absence of epiphora confirmed by positive syringing. six patients however revealed persistent epiphora confirmed by failed syringing. various other studies have previously been conducted to assess the surgical outcome of dcr with silicon tube. zaman m et al showed a success rate of 97.5%10 whereas, ilff reported 90% 5 and tarbat and custer reported 95% success results12. in a comparative study hussain et al18 reported 94.7% success results in intubated series. similarly advani et al19 reported a success rate of 95% in intubated cases. a study by y m delaney and r khooshabeh showed that patent dcr system to irrigation and a positive dye test was achieved in 90% of procedures20. nawaz et al were successful by 93.33%11. the dcr with mmc group showed a success rate of 95.4% and failure rate of 4.6%. 62 patients remained symptom free. this was confirmed on syringing. three patients however revealed persistence of epiphora confirmed on failed syringing. from amongst the various studies previously conducted to assess the surgical outcome of dcr with mmc, shu l liao et al showed 95.5% success rate7, yildrim c et al gave a success rate of 95% and rahman a et al achieved a success rate of 97.77%8,9. kao et al showed 100% success with mmc in maintaining patency and a larger osteotomy site7. you in 2001, roozitalab in 2004 and akhund in 2005 applied mitomycin-c over the anastomosed flaps and achieved a success rate of 100%, 90.5% and 99%; respectively21, 22. mitomycin c, an anticancer agent isolated from streptomyces caespitosus, has the ability to significantly suppress fibrosis and vascular in growth. application of mmc over the osteotomy site and the flaps reduces the fibrous adhesion between the osteotomy site and the nasal septum as well as inhibits scarring around the opening of the common canaliculus7. in our study the most of the patients fell between 20-50 years of age. in the study by zaman et al the majority of patients were between 41 and 60 years10 whereas, that in the study by rahman a et al were between 41 and 50 years of age9. this shows that the commonest age group to suffer from nldb range between 30 and 60 years of age. in our study there were 75 (57.7%) females and 55 (42.3%) males. it is known that chronic dacryocystitis most commonly affects the women of post-menopausal age23. this female predominance is possibly due to the narrow lumens of bony lacrimal canal and nld in women, osteoporosis, hormonal changes and a heightened immune response24. in the study by zaman et al there were 62% females10, by rahman a et al there were 76% females9, by nawaz et al. there were 85% females11, by ali a et al. there were 79% females25. nazia qidwai, et al 218 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology we found from our study that both silicon tube and mmc are equal in yielding successful results with dcr. the difference in the results achieved is not statistically significant for surgical outcome as well as for gender and thereby, both the adjuncts namely mmc and silicon tube can be advised to patients undergoing dcr. however, the use of mmc is cost and time effective and the patient does not have to come for removal of the tube, neither does the patient have to suffer any irritation from the tube. this study is the first of its type, to compare the surgical outcome of the two adjuncts used in dcr, namely, mmc and silicon tube. we suggest that further studies be done to confirm these results. conclusion from our study we find that there is no significant difference between the success results achieved with these two adjuncts. thereby, both the adjuncts can be used with dcr. however, mmc is more cost and time effective. author’s affiliation dr. nazia qidwai al-ibrahim eye hospital isra postgraduate institute of ophthalmology malir karachi75040 dr. hassan raza jafri al-ibrahim eye hospital isra postgraduate institute of ophthalmology malir karachi75040 references 1. shun sin ga, thurairajan g. external dacryocystorhinostomy and end of an era? (commentary). br j ophthalmol. 1997; 81: 716-7. 2. seppa h, grenman r, hartikeinen j. endonasal co2–nd: yag laser dacryocystorhinostomy. acta ophthalmol copenh. 1994; 72: 703-6. 3. dupuy-dutemps l, bourguet j. method of plastic dacryocys-torhinostomy and results. ann ocul j. 1921; 158: 241-61. 4. ohm j. nerbesserungen an meinen nystagmo-graphen. klin monatsble augenheilk. 1926; 1: 791-4. 5. iliff ce. a simplified dacryocystorhinostomy 1954-1970. arch ophthalmol. 1971; 85: 586-91. 6. older jj. routine use of silicone stent in a dacryocystorhinostomy. ophthalmic surg. 1982; 13: 911-5. 7. liao sl, kao sc, tseng jh, et al. results of intraoperative mitomycin c application in dacryocystorhinostomy. br j ophthalmol. 2000; 84: 903-6. 8. yildrim c, yaylali v, esme a. long-term results of adjunctive use of mitomycin c in external dacryocystorhinostomy. international ophthalmology. 2007; 27: 31-5. 9. rahman a, channa s, niazi jh, et al.. dacryocystorhinostomy without intubation with intraoperative mitomycin-c. j coll physicians surg pak. 2006; 16: 476-8. 10. zaman m, babar tf, abdullah a. prospective randomized comparison of dacryocystorhinostomy (dcr) with and without intubation. pak j med. res. 2005; 44: 75-8. 11. nawaz m, sultan ms, hanif q, et al. dacryocystorhinostomy; a comparative study of the results with and without silicon intubation in pakistani patients of chronic dacryocystitis. professional med j mar. 2008; 15: 816. 12. tarbet kj, custer pl. external dacryocystorhinostomy: surgical success, patient satisfaction, and economic cost. ophthalmology. 4; 102: 1065–70. 13. walland mj, rose ge. factors affecting the success rate of open lacrimal surgery. br j ophthalmol. 1994; 78: 888–91. 14. becker bb. dacryocystorhinostomy without flaps. ophthalmic surg. 1988; 19: 419–27. 15. allen k, berlin aj. dacryocystorhinostomy failure: association with silicon intubation. ophthalmic surg. 1989; 20: 486-9. 16. rosen n, sharir m, moverman dc, et al. dacryocystorhinostomy with silicone tubes: evaluation of 253 cases. ophthalmic surg.1989; 20: 115–9. 17. mclachlan dl, shannon gm, flanagan jc. results of dacryocystorhinostomy: analysis of the reoperations. ophthalmic surg. 1980; 11: 427–30. 18. hussain m, akhtar s, awan s. dacryocystorhinostomy with or without intubations. ann king edward med uni.1998; 4: 34-6. 19. advani rk, halepota fm, shah sia, et al. comparative results of dacryocystorhinostomy with and without silicon intubation. pak j ophthalmol. 2004; 20: 29-34. 20. khooshabeh r. external dacrycystorhinostomy for the treatment of acquired partial nasolacrimal duct obstruction in adults. br j ophthalmol. 2002; 86: 533-5. 21. you ya, fang ct. intraoperative mitomycin c in dacryocystorhinostomy. ophthal plast recons surge. 2001; 17: 115-9. 22. roozitalab mh, amirahmedi m, namazi mr. results of the application of intraoperative mitomycin-c in dacryocystorhinostomy. eur j ophthalmol. 2004; 14: 461-3. 23. babar tf, masud mz, saeed n, et al. an analysis of patients with chronic dacryocystitis. pak j ophthalmol. 2003; 19: 77-83. 24. mortimore s, banhegyi gy, eancaster je et al. endoscopic dacryocytorhinostomy without silicon stenting. j r coll. surg edinb. 1999; 44: 371-3. 25. ali a, ahmed t. dacryocystorhinostomy (a review of 51 cases) pak j ophthalmol. 2001; 17: 122-8. microsoft word irfan qayyum pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 14 original article epidemiology of penetrating ocular trauma irfan qayyum malik, zeshan ali, a. rehman, muhammad moin, mumtaz hussain pak j ophthalmol 2012, vol. 28 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irfan qayyum malik eye unit-ii mayo hospital, lahore …..……………………….. purpose: to study the epidemiology of penetrating ocular trauma at the institute of ophthalmology, king edward medical university, mayo hospital, lahore material and methods: the study was conducted at the institute of ophthalmology, mayo hospital lahore which included 480 patients. most of the cases were admitted through emergency. detailed history was taken with special consideration to the duration of injury and the object causing injury. visual acuity was recorded using snellen chart and slit lamp examination included documentation of the size of the tear, its location, involvement of visual axis, iris prolapse, cataract formation, intraocular foreign body (iofb), and retinal detachment. all cases had pre and post operative b-scan ultrasound. regular follow up was done and final best corrected visual acuity (bcva) was recorded. results: mean age of patients was 18.24 year with almost 70% ocular trauma occurring in first two decades of life. in first decade male: female ratio was 1.6:1 but it increased to 10:1 after the first decade. intraocular foreign bodies (iofb) were found in 15% of cases and iris prolapse in 62.5% cases. visual axis was involved in 25% of cases.75% of the tears were corneal and 24 % were corneoscleral. incidence of cataract formation was 61.6%. 35% of trauma was related to sharp objects and 18% to blunt objects. retinal detachment occurred in 9.81%. post op visual acuity was related to the severity of trauma. conclusion: prevalence of trauma was much more common in first two decades of life with significantly higher ratio in males than female. majority of the trauma was caused by sharp objects. awareness of ocular trauma should be increased in the populations to reduce the incidence of childhood blindness. cular trauma is a major cause of visual loss in young population. annually, over 2.5 million americans suffer an eye injury1, and globally more than half a million blinding injuries occur every year. world-wide, there are approximately 1.6 million people blind from eye injuries, 2.3 million bilaterally visually impaired and 19 million with unilateral visual loss; however ocular trauma being the commonest cause of unilateral blindness today2. injuries cannot always be prevented but the methods of reducing the incidence of visually damaging trauma can be found by identifying the underlying factors in their etiology. the age distribution for the occurrence of serious ocular trauma is bi-modal, with the maximum incidence in young adults and a second peak in the elderly3. both hospital and population based studies indicate a large preponderance of injuries affecting males4. approximately half of all patients who present to an eye emergency department, present with ocular trauma5. the spectrum of injuries ranges from very mild, non-sight threatening to extremely serious with potentially blinding consequence6. the aim of this study was to study the epidemiology of penetrating ocular trauma at the institute of ophthalmology, king edward medical university, mayo hospital, lahore. material and method the retrospective study was conducted at the institute of ophthalmology, mayo hospital lahore from january 2005 to december 2010. a total of 480 patients with penetrating ocular trauma were included in the study. no discrimination of gender and age was made for admission. most of the cases were admitted through emergency. detailed history was taken with o irfan qayyum malik et al 15 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology special consideration to the duration of injury and the object causing injury. visual acuity was recorded using snellen chart where possible and slit lamp examination included documentation of the size of the tear, its location, involvement of visual axis, iris prolapse, cataract formation, iofb, and retinal detachment. all cases had pre and post op b-scan ultrasound. general physical examination of the patient and laboratory tests for various investigations especially general anaesthesia, total leukocyte count, differential leukocyte count, hemoglobin, complete urine analysis, x-ray chest and skull, electro cardiogram, electrolyte balance and kidney functions were done to avoid complications. regular follow ups were done for at least 3 months and final bcva was recorded on each visit. data was entered and analyzed using spss version 11. the age was analyzed by descriptive method with mean ± sd. the variables like sex, preoperative visual acuity, treatment, postoperative visual acuity and complications were analyzed as frequency and percentages. result total numbers of patients was 480. mean age of patient’s was 18.24 year with almost 70% ocular trauma occurring in first two decades of life. in first decade male: female ratio was 1.6:1 but it drastically increased to 10:1 after the first decade. intraocular foreign bodies (iofb) were found in 75 cases (15%) and iris prolapse in 300 cases (62.5%). visual axis was involved in120 cases (25%), 360 (75%) were corneal tears and 24% were corneo-scleral. incidence of cataract formation was 61.6%. 35% of trauma was related to sharp objects and 18% to blunt objects. retinal detachment occurred in 47 (9.81%). post op visual acuity was related to the severity of trauma. improvement in best corrected visual acuity was 30.24% cases, bcva lower than pre op visual acuity was in 57 cases (11.76% ), pre op and bcva was same in 280 cases (58 %). 48(10 %) eyes became npl (no projection of light), 21(4%) became phythisical eyes, 2(0.04%) were enucleated, 3(0.06%) were eviscerated . eleven eyes were lost to follow up. presentation after 24 hours was very common 80% which was associated with poor prognosis. different treatment options were used in the management of trauma. corneal tear repair was done in 317 (66%) patients, scleral tear repair was done in 73 (15%) patients, and corneoscleral tear repair was done in 90 (18%) patients. 75 patients had intraocular foreign body, 47 patients had retinal detachment, 14 patients had retinal hemorrhage, 3 patients had retinal tear. objects causing ocular trauma objects causing trauma frequency n (%) metal piece / rod 92(19) wooden piece/stick 82(17) glass 60 (12) stone 49 (10.2) firecracker 22(4.5) knife 26(5.4) finger nails 20 (4.1) needle 18 (3.7) fire arm 15(3.1) animal 11(2.2) scissors 17(3.5) pen/pencil 12(2.5) misc 56 (11.6) corneal vs scleral tear site of tear frequency n (%) corneal tear 317 (66) scleral tear 73 (15) corneoscleral tear 90 (18) discusson ocular trauma is the cause of blindness in approximately half a million people worldwide, and many more have suffered partial loss of sight. trauma is often the most important cause of unilateral loss of vision, particularly in developing countries7. males tend to have more eye trauma than females. young adults have the highest incidence of ocular injury8. lower socioeconomic classes are also more associated with ocular trauma. due to severity of ocular trauma, majority had poor visual outcome9. the setting for the occurrence of trauma is most commonly the workplace and, increasingly, road accidents. on the other hand, domestic accidents are probably underreported. of particular importance in some developing epidemiology of penetrating ocular trauma pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 16 countries is the occurrence of superficial corneal trauma in agricultural work, often leading to rapidly progressing corneal ulceration and visual loss. open globe injuries, especially ruptured globes, had the worst visual outcomes10. vitreous hemorrhage followed by open globe injury is usually associated with very poor prognosis11. delayed presentation is very common, which is associated with very poor prognosis12, but early referral to eye causality can improve outcome. ocular trauma in children is associated with visual loss. many of the cases were preventable. public education, general awareness and aggressive primary management may be indicated to optimize visual outcome13. there is a need for systematic periodic awareness to reduce these accidents and blindness14. ocular trauma in childhood is more frequent in the male schoolchildren and is mostly due to injury with agents like stone, wood and iron pieces, domestic utensils and leisure objects. the injuries occurred most frequently at home. programs of education and prevention for ocular trauma in childhood are necessary. awareness of ocular trauma should be increased in the populations to reduce the incidence of childhood blindness. conclusion prevalence of trauma is much more in first two decades of life with significantly higher ratio in males than females. majority of the trauma was caused by sharp objects. awareness of ocular trauma should be increased in the populations to reduce the incidence of childhood blindness. health education and awareness about the morbidity caused by delayed presentation is needed, especially in peripheral areas to save vision. basic health units should provide initial treatment as early as possible and refer serious cases to nearest tertiary care centre. author’s affiliation dr. irfan qayyum malik eye unit-ii mayo hospital, lahore dr. zeshan ali eye unit-ii mayo hospital, lahore dr. a. rehman mayo hospital, lahore eye unit-ii dr. muhammad moin prof. of ophthalmology qamc/bvh, bahawalpur dr. mumtaz hussain prof. of ophthalmology eye unit-ii mayo hospital, lahore reference 1. eye injury snapshot data summary, 2004-2008, american academy of ophthalmology and american society of ocular trauma 2. negrel ad, thylefors b. the global impact of eye injuries. ophthalmic epidemiol. 1998; 5: 143-69. 3. glynn rj, seddon jm, berlin bm. the incidence of eye injuries in new england. arch ophthalmol. 1988; 106: 785-9. 4. macewen cj. eye injuries: a prospective survey of 5671 cases. br j ophthalmol. 1989; 73: 888-94. 5. chiapella ap, rosenthal ar. 1 year in an eye casualty clinic. br j ophthalmol. 1985; 69: 865-70. 6. arfat my, butt hm. visual outcome after anterior segment trauma of the eye. pak j ophthalmol. 2010, 26: 74-78. 7. cillino s, casuccio a, di pace f, et al. a five-year retrospective study of the epidemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in a mediterranean area. bmc ophthalmol. 2008; 22: 6. 8. guly cm, guly hr, bouamra o, et al. ocular injuries in patients with major trauma. emerg med j. 2006; 23: 915-7. 9. jbabar tf, khan mn, jan su, et al. frequency and causes of bilateral occulartrauma. coll physicians surg pak. 2007; 17: 679-82. 10. yeung l, chen tl, kuo yh, et al. severe vitreous hemorrhage associated with closed-globe injury. graefes arch clin exp ophthalmol. 2006; 244: 52-7. 11. babar tf, khan mt, marwat mz, et al. patterns of ocular trauma. j coll physicians surg pak. 2007; 1: 148-53. 12. soliman mm, macky ta. pattern of ocular trauma in egypt. graefes arch clin exp ophthalmol. 2008; 246: 205-12. 13. lee ch, su wy, lee l, et al. pediatric ocular trauma in taiwan. chang gung med j. 2008; 31: 59-65. 14. zghal – mokni i, nacef l, kaoueche m, et al. epidemiology of work – related eye injuries. tunis med. 2007; 85: 576-9. microsoft word aurangzeb khan 3 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology original article intravitreal bevacizumab for treatment of diabetic macular edema aurangzeb khan, aamir ali choudhry, zahid siddiq, mahmood hussain, basum mubaruk pak j ophthalmol 2012, vol. 28 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: aurangzeb khan ophthalmology department. madina teaching hospital, faisalabad …..……………………….. purpose: to evaluate the effects of intra-vitreal bevacizumab on visual function and macular edema in diabetic patients material and methods: this study was conducted in the department of ophthalmology, madina teaching hospital, university medical and dental college, faisalabad. three months from 1st june 2010 to 31st august 2010. a total of 26 eyes of 26 diabetic patients (mean age 48.92 years) with diabetic macular edema were included in this study. best – corrected visual acuity, slitlamp biomicroscopic examination of anterior segment, fundus examination and fundus flourescein angiography, were done at baseline and at each follow up visits. all patients were treated with 0.05 ml intravitreal injection containing 1.25 mg of bevacizumab (ivb). results: all patients completed 3 months follow up. the mean bcva at baseline was 0.726 + log mar. it improved to 0.515, 0.461, and 0.452 + log mar at 1st week, 1st month, and 3rd months respectively. final bcva analysis demonstrated that 17 (65.38%) patients improved ≥ 2 lines of senellen’s visual acuity chart, 7 (26.38%) improved by one line, one (3.84%) remained stable, and one (3.84%) showed deterioration of one line. macular edema at 1st week resolved completely in 18 (69.23%) and moderately in 7 (26.92%) patients at 1st month and 3rd month follow up resolved moderately in 24 (92.30%). flourecein leakage stopped in 25 (96.15%) patients. no ocular toxicity or adverse effects to drug were observed. conclusions: ivb injection resulted in improvement of visual acuity, resolution of macular edema and stoppage of flourescein leakage as early as 1st week after injection in patients with dme. the slight reduction in visual improvement at 3rd months suggests wearing of effect of drug. further clinical trials will be needed to evaluate the long term safety and efficacy of this drug. iabetic macular edema (dme) is a manifestation of diabetic retinopathy, which causes visual impairment in working age diabetic population of developed and developing world. exact pathogenesis of dme is not clearly known, a disruption of inner blood retinal barrier is a reasonable explanation. it causes excessive vascular permeability and leakage of fluid and plasma constituents, such as lipoproteins, in retinal tissues and results in retinal edema. untreated dme often leads to irreversible visual impairment1. focal laser photocoagulation effectively treats dme and reduces visual loss by 50%2. however, some eyes may be refractory to laser treatment. therefore, failure of laser prompted interest in other treatment modalities, such as intravitreal corticosteroid,3 pars plana vitrectomy,4 and oral proteinkinase c inhibitor5. intravitreal corticosteroid is effective in improving vision and reducing edema, both as an initial or as a second line therapy after unsuccessful laser6. hypoxia is primary cause of diabetic retinopathy, which increases expression of vascular endothelial growth factor (vegf)7,8. it contributes to dme9. funastu, proved that vegf levels and its concentration in ocular fluids has strong correlation with severity of diabetic retinopathy. it is one of the d aurangzeb khan et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 4 glycoprotein molecules and is a potent inducer of vascular permeability10-13. introduction of vegf in normal primate eyes induces the same pathological processes, as is seen in diabetic retinopathy namely microaneurysm formation and increased vascular permeability14. thus a rational approach to treat dme with antibodies targeted vegf generated considerable interest15,16. bevacizumab, (avastin, genentech inc., south san francisco, ca, usa) is a full length, humanized monoclonal antibody against vegf, binds and inhibits all the biologically active isoforms of vegf-a and is approved by food drug administration as a systemic drug for tumor therapy17. recent studies proved usefulness of bevacizumab injection in the reduction of macular edema secondary to crvo, proliferative diabetic retinopathy (pdr) and choroidal neovascularization secondary to age related macular degeneration.18 although intravitreal use of bevacizumab is off-label option, its use has risen exponentially in last few years, mainly due to its efficacy and economic consideration. based on these observations this study was designed to evaluate visual acuity response, stoppage of flourescein leak and resolution of macular edema after ivb injection in patients with diabetic macular edema. study plan a study was conducted during june to 1st june to 31st august 2010, 26 eyes of 26 diabetic patients were selected for ivb injection as treatment for dme. there were 14 (53.84%) males and 12 (46.15%) females. the mean age of patients was 48.9 years (range 38 – 60 years). twenty three (88.5%) of type 2 and three (11.5%) of type-1 diabetes were patients. fifteen (58.6%) patients had active proliferative diabetic retinopathy (pdr), and eleven (42%) had severe non proliferative diabetic retinopathy (npdr) (table 1). all patients had diagnosed dme clinically and on fundus flourescein angiography (ffa). all the eyes had received at least one prior alternate therapy for diabetic retinopathy at least six months before ivb injection. eyes with following features were excluded from study, (i) focal macular edema attributed to focal leakages from micro aneurysm (ii) presence of any other macular pathology like vitreo-macular traction and armd (iii) optic disc pathology due to chronic glaucoma (iv) and history of treatment of dme with scatter prp and grid laser within the prior 6 months. patients with uncontrolled diabetes, hypertension and chronic renal dysfunction were also excluded. material and methods each patient underwent a complete ophthalmic assessment including best corrected visual acuity, anterior segment evaluation by slit lamp biomicroscopy, evaluation of fundus by non contact +90d lens, intraocular pressure (iop) measurement and fundus fluorescien angiography at the base line and at each follow up visits. patients were examined at 1st week, 1st month, and then 3rd month. vision of each patient was ascertained by using snellen chart of visual acuity situated at 20 feet (approximately 6 meters) away from the patients, and then all eyes were tested with the same correction throughout follow up period. each patient’s va was then converted to a logarithm of minimum angle of resolution (log mar) scale equivalent for analysis. written informed consents were taken from all patients and were fully informed about the off label use of the drug and its potential risks and benefits as well as the likelihood that additional treatment might be required. injection procedure all intravitreal injections were performed under topical anesthesia with proparacain hydrochloride 0.5% eye drops. the conjunctiva and the fornices were rinsed with povidone-iodine, which was also applied to the eyelid margins and lashes to avoid expression of the meibomian glands. after application of sterile drape an eyelid speculum was used to stabilize the eye lids. a 30 gauge needle on a 1 cm3 syringe was used to inject ivb through the supra temporal or supra nasal pars plana 3.5 4.00 mm posterior to the limbus with a dose of 1.25 mg in 0.05 ml. the needle was carefully removed using a sterile cotton applicator to prevent reflex. after injection, antibiotic eye drops were applied four times per day for 5 days. the study parameters were evaluated at 1st week, 1st month and 3rd month after ivb injection the study parameters included, (1) bcva improvement, (2) resolution of macular edema and stoppage of flourescein leakage (3) incidence of ocular sides effects like inflammation, iop rise (4) systemically monitoring for blood pressure rise, chest pain and thromboembolic events. intravitreal bevacizumab for treatment of diabetic macular edema 5 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology table 1. degree of diabetic retinopathy in different diabetic patients gender ratio type of diabetes degree of diabetic retinopathy male n (%) female n (%) type 2 dm n(%) type 1 n (%) npdr (severe) n (%) pdr n (%) 14(53.8) 12(46.2) 23 (88.5) 3 (11.5) 11 (42.30) 15(58.7) table 2. pre-injection alternative therapy pre treatment type no. of patients n (%) focal laser 02 (07.69) grid +focal laser 06(38.07) prp (scatter) 16(61.53) ivta 02(07.69) table 3. showing baseline evaluation baseline evaluations mean follow up period (months) mean follow up period (months) mean base line bcva (logmar) mean base line bcva (logmar) base line flourescein angiography leakage base line flourescein angiography leakage baseline macular edema clinically diagnosed baseline macular edema clinically diagnosed table 4. final visual activity analysis 1st week 1st month 3rd month no. of eyes n (%) no. of eyes n (%) no. of eyes n (%) improvement by > 2 lines of bcva 18 (69.23) 18 (69.23) 17 (65.35) improvement by 1 line of bcva 07 (26.92) 07 (26.92) 07 (24.92) remained unchanged bcva 01 (0.384) 01 (0.384) 01 ((0.384) deterioration of bcva 00 (00) 00 (00) 01 (3.84) chi-square p value 17.15** 0.000 17.15** 0.000 26.31** 0.000 fig. 1. fundus flourescein angiography revealed diabetic macular edema with late phase of flourescein leakage from retinal vessels before treatment with ivb injection. fig. 2. same patient after ivb injection showed the stoppage of flourescein leak and resolution of macular edema. results baseline characteristic the baseline characteristics included (1) mean bcva 0.726 +log mar. (2) clinically diagnosed dme present in all patients (3) flourescein leakage on ffa present in all patients (4) mean iop 13.59 mmhg. (table 3). 1st week outcome mean bcva was 0.515 +log mar. eighteen (69.23%) showed improvement of 2 lines of snellen chart. seven (26.92%) showed improvement of one line, one (3.84%) showed no improvement of visual acuity. dme resolved completely in 18 (69.23%), moderately in 7 (26.92%) and no resolution of edema in one aurangzeb khan et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 6 (3.84%) patient. flourescein leakage stopped in 25 (96.15%) patients. leakage was present in one (3.84%) patient. the mean iop was 13.39 mmhg. only one (3.84%) eye had developed anterior segment inflammation with +1 cells in anterior chamber. no other ocular and systemic complications were observed. 1st month outcome mean bcva was 0.461 +log mar. eighteen (69.23%) showed improvement of 2 lines of snellen chart. seven (26.92%) showed improvement of one line. one (3.84%) showed no improvement of visual acuity. macular edema resolved in 25 patients. one showed no resolution of edema. flouroscein dye leakage has stopped in 25 (fig. 1 and 2) and mean iop was 13.25 mmhg. no ocular, or systemic complications were observed. 3rd month outcome the mean bcva was 0.452 +log mar. seventeen (65.38%) showed improvement of 2 lines of snellen chart. seven (26.92%) showed improvement of one line. one (3.84%) showed no improvement, and one (3.84%) showed deterioration of va. macular edema resolved in 24 patients. floureoscein leakage stopped in 24 and mean iop was 13.25 mmhg. no ocular and systemic complications were seen. final bcva analysis demonstrated seventeen (65.38%) of 26 patients improved ≥2 lines on bcva, seven (26.92%) improved by one line, one (3.84%) remained stable, and one (3.84%) showed deterioration of bcva by one line of bcva (table 4). discussion dme is the most important cause of visual impairment. although the exact pathogenesis responsible for dme remain uncertain, the disruption of inner blood – retinal barrier is known to be associated with metabolic alteration affecting the retinal pigment epithelium or retinal vascular endothelium. several treatment modalities are under investigation like intensive glycemic control,19 blood pressure control,20 pharmacologic therapy with oral protein kinase c inhibitors21. intravitreal corticosteroids injection is a promising treatment but it’s efficacy is transient and repeated injections may be required22. the treatment is not without risks and complications. complications include intraocular pressure (iop) elevation, cataract progression, endophthalmitis, vitreous haemorrhage, and retinal detachment23, 24. according to etdrs, 25 dme treated with laser does not exhibit satisfactory visual improvement thus antibodies targeted to vegf generated considerable interest and are being investigated. vegf is proved as endothelial cell specific mitogen and angiogenic inducer in a variety of in vitro and in vivo models26. hypoxia upregulates vegf, which plays a vital role in pathogenesis of dme in diabetic patients. therefore anti-vegf therapy may be promising treatment for dme. cunningham et al reported that intravitreal pegaptanib sodium injection for treatment of dme has encouraging results27. more recently, ivb injection has been shown to have a beneficial effect in prevention and treatment of dme. it decreases vegf secretion and vascular extravasations thus improves integrity of inner retinal barrier28,29. the safety profile of ivb injection has been established by previous animal studies and human trials30. although preclinical experimental data from primates suggested that full length antibody might not penetrate the internal limiting membrane of the retina, but recent studies have shown full thickness penetration of the retina within 24 hours31. recently ivb injection has been reported to be effective in reducing retinal edema and improving visual acuity, in macular edema of various etiologies like crvo, armd and pdr32-34. ivb injection (125 mg/0.05 ml) offers, advantages of using a much lower dosage (1/300th to 1/400th) of systemic dose thus avoiding the rare but significant risk of thromboebmolic events35. recently haritoglou et al36. published a report about patients with persistent dme due to photocoagulation and ivta treatment, when treated with 1.25 mg ivb injection. the vision improved significantly from base line of 0.86 +log mar to a value of 0.75 +log mar at 6 weeks although this effect was not sustained at 12 week. similarly another study by gulkilik g,37 presented, results in which mean vision acuity was significantly better than at baseline at 2 week, diabetic macular edema decreased significantly at week 1, 2 and 4 but at third month macular edema increased, flourescein leak was moderately decreased in all patients at week 1 and 2, there was complete resolution of flourescein dye in 24 (70.5%) and moderately in 10 (29.5%) patients and at third month the flourescein leakage was fully resolved in five (14.7%), moderately in 24 (70.5%) and similar to baseline in 5 (14.7%) patients. in another study by sohelian, et al38. concluded that ivb injections yield better visual outcome in intravitreal bevacizumab for treatment of diabetic macular edema 7 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology dme at three months the results of these studies were confirmed in our study, where 25 (96.15%) out of 26 patients showed improvement in mean va with a decrease in retinal edema and stoppage of flourescein leak. mean va improved from 0.721 +log mar at baseline to 0.515, 0.461 and 0.452 +log mar at 1st week, 1st month and last 3rd month respectively. eighteen (69.23%) of 26 patients showed an improvement of 2 or more snellen lines, seven (26.92%) showed improvement of one line and one patient (3.84%) showed no improvement. the reduction of macular edema and stoppage of fluorescein leak was seen in all eyes at 1st week and 1st month. flourescein was completely resolved in 18 (69.23%) and moderately resolved in 7 (26.92%) patients and leak was continued similar to baseline in one (3.84%) patient. at 3rd month fluorescent leakage was increased in only one (3.84%) and remained similar to baseline in one (3.84%) patient. another report of pan-american collaborative retina study group, showed reduction of dme was achieved after one month of ivb injection and lasted for 6 months39. in our study, we found that improvement in both visual acuity, reduction of macular edema and stoppage of flourescein leak was achieved within one week after ivb injection and effect lasted for three months. twenty five (96.15%) patients have shown an improvement of va and macular edema resolved completely in 18 (69.23%) and moderately in seven (26.92%) patients. this confirms the findings of previous studies. the duration of action of ivb injection is unknown, recent electrophysiological and retinal penetration studies, have reported that full thickness retinal penetration is present at 24 hours40. this may explain the early clinical effect of ivb injection in our study. in our study the slight deterioration of vision, appearance of dme and flourescein leak at 3rd month follow up suggests wearing off effect of ivb injection thus repeat injection might be necessary at third month to maintain its beneficial effect. it is possible that a different dosing schedule, such as a series of ivb injections every 3 month may be superior to the method used in this study. however we chose to retreat the recurrent case only because of drug toxicity concerns. the results of ivb injection on visual acuity and dme was independent of both pdr, npdr and previous treatments like focal, grid, scatter prp and ivta injection. all these did not influence our results. our study had some differences from previous studies. first dme was diagnosed clinically and on ffa before and after ivb injection instead of by optical coherence tomography (oct). second reduction of edema and stoppage of flourescein leakage indicated as effectiveness of ivb injection. this study has several limitations. first, the follow-up time was relatively short, but visual improvement and resolution of dme was apparent during this follow-up period. secondly there is no control group in this study, but it can be argued that the enrolled eyes serve as their own controls because the pre and post treatment va and macular edema of the same patient were compared. thirdly va was measured on a snellen visual acuity chart, as opposed to the more standardized and accepted etdrs chart. conclusion this study demonstrated that ivb injection appeared to be an effective treatment for dme as it result in significant improvement of visual acuity and resolution of macular edema as early as 1st week after ivb injection and this beneficial effect was shown to persist through out fallow up period of 3 months. however, the slight reduction in improvement in visual acuity and macular edema at 3rd months suggests that repeated ivb injection might be necessary within three months to maintain its effect, the drug is well tolerated and there are no safety concerns. however, to evaluate the long term safety and efficacy of this new treatment, further studies are needed. author’s affiliation dr. aurangzeb khan assistant professor university medical and dental college, faisalabad dr. aamir ali choudhry professor of ophthalmology university medical and dental college, faisalabad dr. zahid siddiq assistant professor university medical and dental college, faisalabad dr. mahmood hussain assistant professor university medical and dental college, faisalabad aurangzeb khan et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 8 dr. basum mubaruk senior registrar university medical and dental college faisalabad reference 1. wild s, roglic g, green a, et al. global prevalence of diabetes, estimates for the year 2000 and projections for 2030. diabetes care. 2004; 27: 1047-53. 2. bresnick gh. diabetic macula edema: a review. a 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ophthalmol vis sci. 2004; 45: 617-24. 9. bresnick gh. diabetic macular edema. a review. ophthalmology. 1986; 93: 989-97. 10. funatsu h, yamashita h, noma h, et al. aqueous humor levels of cytokines are related to vitreous levels and progression of diabetic retinopathy in diabetic patients. graefes arch clin exp ophthalmol. 2005; 243: 3-8. 11. selim km, sahan d, muhittin t, et al. increased levels of vascular endothelial growth factor in the aqueous humor of patients with diabetic retinopathy. indian j ophthalmol. 2010; 58: 375-79. 12. arevalo jf, sanchez jg, lasaveve af, et al. intravitreal bevacizumab for dibetic retinopathy at 24-months. curr diabetes rev. 2010; 6: 313-22. 13. otani t, kishi s. a controlled study of vitrectomy for diabetic macularedema. am j ophthalmol. 2002; 134: 214-229. 14. tolentino mj, miller jw, gragoudas es, et al. intravitreous injections of vascular endothelial growth factor produce retinal ischemia and microangiopathy in an adult primate. ophthalmology. 1996; 103: 1820-8. 15. arevalo jf, garcia-amaris ra. intravitreal bevacizumab for diabetic retinopathy curr diabetes rev. 2009; 5: 39-46. 16. cunningham et, jr, adamis ap, altaweel m, et al. a phase ii randomized double-masked trial of pegaptanib, an antivascular endothelial growth factor aptamer, for diabetic macular edema. ophthalmology. 2005; 112: 1747–57. 17. presta lg, chen h, o'connor sj, et al. humanization of an anti-vascular endothelial growth factor monoclonal antibody for the therapy of solid tumors and other disorders. cancer res. 1997; 57: 4593–9. 18. schouten js, la heij ec, webers ca, et al. a systematic review on the effect of bevacizumab in exudative age related macular degeneration. graefes arch clin exp ophthalmol. 2009; 247: 1-11. 19. diabetes control and complications trial research group. the effect of intensiv treatment of diabetes on development and progression of long-term complications in insulin dependent diabetes mellitus. n engl j med. 1993; 329: 977-86. 20. uk prospective diabetes study group. tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: ukpds 38. bmj. 1998; 317: 703-13. 21. campochiaro pa; c99-pkc412-003 study group. reduction of diabetic macular edema by oral administration of the kinase inhibitor pkc412. invest ophthalmol vis sci. 2004; 45: 922-31. 22. konstantopoulos a, williams cp, newsom rs, et al. ocular morbidity associated with intravitreal triamcinolone acetonide. eye. 2007; 21: 317-20. 23. ozkiris a, erkilic k. complications of intravitreal injection of triamcinolone acetonide. can j ophthalmol. 2005; 40: 63–8. 24. jonas jb, kreissig i, degenring rf. retinal complications of intravitreal injections of triamcinolone acetonide. graefes arch clin exp ophthalmol. 2004; 242: 184–5. 25. early treatment diabetic retinopathy study research group.treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. early treatment diabetic 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intravitreal injection of bevacizumab. retina. 2006; 26: 262–9. 32. avery rl, pieramici dj, rabena md, et al. intravitreal bevacizumab (avastin) for neovascular age-related macular degeneration. ophthalmology. 2006; 113: 363–72. 33. costa ra, jorge r, calucci d, et al. intravitreal bevacizumab (avastin) for central and hemicentral retinal vein occlusions: ibevo study. retina. 2007; 27: 141-9. 34. mason iii jo, albert jr ma, vail r. intravitreal bevacizumab (avastin) for refractory pseudophakic cystoid macular edema. retina. 2006; 26: 356–7. 35. michels s, rosenfeld pj, puliafito ca, et al. systemic bevacizumab therapy for neovascular age related macular degeneration twelveweek results of an uncontrolled openlabel clinical study. ophthalmology. 2005; 112: 1035-47. 36. haritoglou c, kook d, neubauer a, et al. intravitreal bevacizumab (avastin) therapy for persistent diffuse diabetic macular edema. retina. 2006; 26: 999–1005. 37. gulkilik g, taskapili m, kocabora s, et al. intravitreal bevacizumab for persistant macular edema with proliferative diabetic retinopathy. int ophthalmol. 2010 dec;30(6):697-702. 38. soheilian, masoud md, ramezani, alireza md, et al. intravitreal bevacizumab (avastin) injection alone or combined with triamcinolone versus macular photocoagulation as intravitreal bevacizumab for treatment of diabetic macular edema 9 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology primary treatment of diabetic macular edema. retina. 2007; 27: 1187-95. 39. arevalo jf, fromow-guerra j, quiroz-mercado h, et al. primary intravitreal bevacizumab (avastin) for diabetic macular edema. ophthalmology. 2007; 114: 743–50. 40. shahar js, avry rl, heilweil g, et al. electrophysiologic and retinal penetration studies following intravitreal injection of bevacizumab. retina. 2006; 26: 262–9 microsoft word 07-oa ghazala tabssum pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 26 original article the effectiveness of conventional trabeculectomy in controlling intraocular pressure in our population ghazala tabassum, imran ghayoor, riaz ahmed pak j ophthalmol 2013, vol. 29 no.1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ghazala tabassum house # 106 block-h, phase – ii defence view karachi …..……………………….. purpose: to evaluate the effectiveness of conventional trabeculectomy in controlling intraocular pressure in patients with poag in our population. material and methods: this case control study was carried out in department of ophthalmology, liaquat national hospital karachi from 21st march 2005 to 20th march 2006. 50 patients included in this study were diagnosed case of poag, who underwent conventional trabeculectomy. mean follow up was one year. outcome measures were intraocular pressure and visual acuity. results: the study included 50 patients with poag who undergone conventional trabeculectomy. age range of patients was 41 – 74 with the mean 56.8 years. visual acuity showed no statistically significant difference between pre and post-operative periods. pre-op intra ocular pressure was 20 – 55 mmhg and it was reduced to a mean of 5-22 mmhg post operatively. the mean decline in iop after surgery was 15.78 mmhg. perimetry and c/d ratio showed no significant change after surgery. conclusion: results show that in most of the cases visual acuity is maintained and iop is controlled in the short term period of one year. so conventional trabeculectomy can be effective in controlling iop in our population. laucoma is the second leading cause of blindness worldwide1. three quarters of people with glaucoma have the open-angle variant, of whom 10% are bilaterally blind2. although it is generally a bilateral disease, its severity may be asymmetrical in two eyes. it has an adult onset, open and normal appearing angles on gonioscopy with the evidence of glaucomatous optic nerve damage. this optic nerve damage may take the form of changes in the appearance of the optic disc or nerve fiber layer or the presence of abnormality in visual fields.3 several factors have been implicated as risk factors in the development of glaucomatous optic nerve damage such as elevated intraocular pressure (iop), myopia and changes in the appearance of the optic nerve, family history of glaucoma, age, black race, diabetes mellitus and cardiovascular diseases.4 treatment modalities of glaucoma consist of topical and systemic medication, laser treatment5 and conventional surgical procedures6. traditionally maximum tolerated medical therapy has been used before laser trabeculoplasty or conventional surgery. trabeculectomy lowers iop by the creation of a new channel (guarded fistula) for aqueous outflow between the anterior chamber and subtenon space. performed early this filtering surgery gives excellent iop control with minimal complications7. we conducted this study to document the effectiveness of conventional trabeculectomy in controlling iop in our population. material and methods this study was carried out in the department of ophthalmology of liaquat national hospital from 21st march 05 to 20th march 06. after informed consent, 50 g ghazala tabassum, et al 27 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology patients (28 male and 22 female) were selected in the study. the age range of patients was 41 – 74 with the mean 56.86. inclusion criteria were patients with poag undergoing conventional trabeculectomy. exclusion criteria were patients having secondary glaucoma, primary / secondary angle closure glaucoma and history of prior surgery. complete biodata and detailed history were taken from all subjects about his / her eye illness as well as systemic illnesses. detailed ophthalmic examination including visual acuity with and without pinhole, objective and subjective refraction, papillary examination, color vision; adnexa, anterior and posterior segment examination by slitlamp, anterior chamber angle was assessed with goniolens. intraocular pressure was measured with goldmann application tonometer. 30–2 visual field analysis was performed with computerized (humphry) perimeter. after confirming as a case of poag, patients were kept on list for trabeculectomy. patients who had iop more then 40 mmhg were given pre op 20% mannitol 200 ml i/v in 20 minutes. patients were kept on regular follow up for one year. follow up consists of six visits postoperatively, done at 1st day, on 1st week 1st, 3rd, 6th and 12th months at each visit, refraction, visual acuity best corrected visual activity, iop, anterior chamber depth and pupil reaction and bleb appearance. c/d ratio with +90d lens was analyzed. massage was done to reform the bleb where needed. visual fields analysis was performed with computerized perimetry (humphery) in 6th and 12th post operative months. statistical package for social science (spss) 10.0 version was used to analyze data. relevant descriptive frequency and percentage was computed for qualitative variables like sex, visual acuity, iop. mean and standard deviation was computed for qualitative variables like age and iop. chi square test was used to see the association of pre and postoperative visual acuity and t-test was used to see mean ± standard deviation of pre and postoperative iop. results total 50 patients (28 male and 22 female) were included in the study. the age range of patients was 41 – 74 with the mean 56.86 and standard deviation of 10.40. table 1 shows the preoperative visual acuity and post operative best corrected visual acuity after 1 year. these results indicate that there is no statistically significant difference between pre and postoperative visual acuity. in most of the patient’s visual acuity is maintained after 1 year of surgery. the chi square is1.174 and p value is 0.978. preoperative iop was in the range of 20 – 55 mmhg, with the mean ± standard deviation of 32.70 ± 12.43. out of 50 patients, 10 (20%) had iop in the range of 10 – 21 mmhg; 16 (32%) had iop in the range of 22-30 mmhg; 10 (20%) had iop in the range of 31-40 mmhg; 10 (20%) had iop in the range of 41 – 50 mmhg and 04 (08%) had iop in the range of 51 – 55 mmhg. postoperative iop on 1st postoperative day was in the range of 3-22 mmhg with mean ± standard deviation of 11.20 ± 5.13. out of 50 patients, 06 (12%) patients had iop < 05 mmhg; 25 (50%) patients had iop in the range of 8 – 10 mmhg; 10 (20%) had had iop in the range of 11 – 16 mmhg; 09 (18%) patients had iop in the range of 17 – 22 mmhg. postoperatively in 4 (8%) patients bleb was flat and digital massage was done. these 4 patients were reviewed after 1 week. in 2 of these patients, iop came to below 21 mmhg, while other 2 needed beta blockers to bring the iop below 21mmhg. these results indicate that iop is controlled in most of the patients that is statically significant. p value is < .0001. effectiveness of conventional trabeculectomy in controlling iop in our population pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 28 range of iop at the 1st postoperative month was 320 mmhg. out of 50 patients, 2 (4%) patients had iop < 5 mmhg; 18 (36%) patients had iop in the range of 5 – 10 mm hg; 20 (40%) patients had iop in the range of 11 – 16 mmhg; 10 (20%) patients had iop in the range of 16 – 20 mmhg. range of iop in the 3rd postoperative month was 5-18 mmhg. out of 50 patients, 5 (10%) patients had iop in the range of 5 – 10 mmhg; 15 (30%) patients had iop in the range of 11 – 12 mmhg; 25 (50%) patients had iop in the range of 13 – 16 mmhg; 5 (10%) patients had iop in the range of 16 – 18 mmhg. range of iop in the 6th postoperative month was 5-20 mmhg. out of 50 patients, 5 (10%) patients had iop in the range of 5 – 10 mmhg; 15 (30%) patients had iop in the range of 11 – 14 mmhg; 25 (50%) patients had iop in the range of 15 – 18 mmhg; 5 (10%) patients had iop > 18 mmhg. the range of iop in 12th postoperative month was 5-22 mmhg as shown in table 2 with mean and standard deviation of 15.78 ± 3.71. out of 50 patients, 5 (10%) patients had iop in the range of 5 – 10 mmhg; 25 (50%) patients had iop in the range of 11 – 17 mmhg; 15 (30%) patients had iop in the range of 18 – 20 mmhg and 5 (10%) patients had iop in the range of 21 – 22 mmhg; out of last 5 patients, 2 stopped using beta blockers and 3 had cystic bleb. these results indicate that iop is controlled in 45 patients out of 50, that is statically significant. p value is < 0.0001. visual fields and c/d ratio showed no significant change after 1 year of surgery. postoperative complications were hypotony in 5 (10%) patients flat anterior chamber in 6 (12%) patients due to bleb leak in 2 (4%) patients and excessive drainage in 4 (8%) patients. all of them were managed with topical cycloplegics, double patching and aggressive anti inflammation hyphema occurred in 10 (20%) patients, lasted for 1 – 4 days and settled with conservative management. in our study the mean iop was 15.78 after 1 year of surgery. iop controlled and visual acuity maintained in 45 out of 50 patients. so in our study 90% cases achieved target pressure after conventional trabeculectomy. discussion glaucoma affects between 60 and 70 million people worldwide and is the leading cause of irreversible blindness.8 the aim of glaucoma therapy is to preserve the visual function by achieving a “target pressure” in each patient. the so called target pressure goal should actually be a range with an upper iop limit that is likely to reduce further damage to the optic nerve in a given patient. the target pressure range needs to be reassessed or changed as comparison of iop fluctuations, optic nerve changes and / or visual field progression dictate. in points with advanced glaucoma or normal tension glaucoma, the need for especially low pressures should be recognized.9 we feel that the aim of trabeculectomy is a constant maintenance of reduced iop in order to prevent further damage to visual function with the main goal to improve or at least preserve the patient’s quality of life10. studies of trabeculectomy as initial therapy for glaucoma, however suggest that there may be some advantages such as reduction of patient visits to the doctor and possibly better visual field preservation.11 surgery once had a bad reputation because of high complication rates both at the time of operation and later. the introduction of improved surgical instruments and suture material has led to various refinements of original operation12. since the late 1960’s the operation of choice in poag has been trabeculctomy” in which controlled fistula is created between the anterior chamber and the subconjunctival space utilizing a partial thickness scleral trap door guarding an internal sclerostomy.13 in britain and much of europe, filtration surgery is performed early in the course of the disease, without extensive use of medication.14 advocates of early surgery points to its high rate of success when performed early in the course of the disease.15 a long term multi center, prospective follow up study in scotland, which compared early trabeculectomy and conventional medical therapy, showed better iop control in the early surgery group, with less visual fields decay.15 ghazala tabassum, et al 29 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology in this study we have tried to find out whether the conventional trabeculectomy will work in our population or not. all the cases in our study were diagnosed case of poag. we included the patients with the age ranging from 41 – 74 years. all the patients were pakistani belonging to different localities and different postoperative behaviors. it was ensured that all patients were undergoing trabeculectomy by the same skilled surgery. in the moorfields primary treatment study16 the group of patients successfully treated by trabeculectomy achieved a mean iop of 14.5 mmhg, compared with 18.5mmhg for the patients successfully treated with laser or medication. the significantly lower iops in the surgical patients were maintained throughout the initial 5 years follow up period. there was a markedly high success rate of 98% (in terms of iop control) in the surgical group at 5 years, compared with 80% in the medical group and only 60% in the laser patients. so our results are comparable to moorefield’s primary treatment study.7,16 the difference is that they also observed the result of laser and medication treatment. our results are also comparable to that baber et al.17 in their study, out of 46 eyes, the iop was maintained at below 21 mmhg without medication in 42 eyes (91.3%). the difference is that his study includes all types of primary glaucoma. in our study the mean iop is around 15 mmhg after one year of surgery. iop is controlled and visual acuity maintained in 45 out of 50 patients. so in our study 90% cases achieved success. in a nutshell although convention a trabeculectomy is affective in controlling iop in our population, the obvious down side of any short term, small study is its limitation, but it does present a trend, obviously in order to really prove whether conventional trabeculectomy will be working long term, it requires longer set of patient and a longer duration of study. conclusion in our study the mean iop is 15.78 after 1 year of surgery. iop is controlled and visual acuity is maintained in 45 out of 50 patients. so in our study 90% cases achieved success after conventional trabeculectomy. conventional trabeculectomy can be effective in controlling intraocular pressure in patients with primary open angle glaucoma in our population in the short term. author’s affiliation dr. ghazala tabassum liaquat national hospital stadium road, postal code74800 karachi dr. imran ghayoor liaquat national hospital stadium road, postal code74800 karachi dr. riaz ahmed liaquat national hospital stadium road, postal code74800 karachi references 1. yanoff and ducker ophthalmology. glaucoma: epidemiology of glaucoma. 3rd edition. 2009; 10: 10951101. 2. quigley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006; 90: 262-7. 3. gupta n, weinreb rn. new definition of glaucoma. curr opin ophthalmol. 1997; 8: 38-41. 4. dielemans i, vingerling jr, algra d, hofman a, grobbee de, de jong pt. primary open angle glaucoma, intraocular pressure, & systemic blood pressure in general elderly population: the rotterdam study. ophthalmology. 1995; 102: 54-60. 5. higginbotham ej. medication in the treatment of choice for chronic open angle glaucoma. arch ophtalmol. 1999; 116: 239-40. 6. jampel hd. laser trabeculoplasty is the treatment of choice of chronic open angle glaucoma. arch ophthalmol. 1998; 116: 240-1. 7. migdel c, gregory w, hitchings ra. long term functional outcome after early sugery compared with laser and medicine in open angle glaucoma. ophthalmology. 1994; 101: 1651-7. 8. thylefors b, negral ad, pararajasegaram r, dadzie ky. global date on blindness. bull world health org. 1995; 73: 115-21. 9. jampel hd. target pressure in glaucoma therapy. j glaucoma. 1997; 6: 133-8. 10. jagdish bhatia outcome of trabeculectomy surgery in primary open angle glaucoma oman med j. 2008; 23: 86-9. 11. american academy of ophthalmology. glaucoma: surgical therapy of glaucoma. american academy of ophthalmology 2001-2002. 12. vernon sa, spencer af. intraocular pressure control following microtrabeculectomy. eye 1995; 9: 299-303. 13. waston pg, grierson i. the place of trabeculectomy in the treatment of glaucoma. ophthalmology. 1981; 88: 175-96. effectiveness of conventional trabeculectomy in controlling iop in our population pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 30 14. jay jl. rational choice of therapy in primary open angle glaucoma. eye 1992; 6: 243-7. 15. jay jl, allen d. the benefit of early trabeculectomy versus conventional management in primary open angle glaucoma relative to severity of the disease. eye 1989; 3: 528-35. 16. migdal c, hitchings r. control of chronic simple glaucoma with primary medical, surgical and laser treatment. trans ophthalmol soc uk. 1986; 105: 653-6. 17. baber tf. an audit of 81 cases of trabeculectomies in primary glaucoma in nwfp. journal of medical sciences. 2000; 10: 37. 137 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology original article epidemiological survey of traumatic eye injury in a southwestern nigeria tertiary hospital iyiade a ajayi, kayode o ajite, olusola j omotoye pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: iyiade adeseye ajayi department of ophthalmology ekiti state university teaching hospital, pmb 5355 ado-ekiti, nigeria …..……………………….. purpose: to evaluate the prevalence, pattern and causes of ocular trauma in nigerians. material and methods: this is a prospective hospital based study over a 15 month period. eighty five patients of all ages presenting with acute eye injuries to one or both eyes were included. patients who had healed ocular trauma or had been given surgical treatment for trauma elsewhere were excluded from this study. all patients with eye trauma seen within this period were included in the study, relevant data was recorded with a structured questionnaire and analysed with spss version 13. results: there were 91 eyes of 85 patients which constituted about 4% of all new patients seen over the study period. male to female ratio was 2:1 with age ranged between 4 years and 78 years (mean = 31.7 ± 19.7 years). more than half of the patients (53.1%) were in the working age group of 20–60 years. twothird presented to the clinic after 24 hours of injury with about 43.5% presenting with blindness in the affected eye. of the patients, 69.4% had applied various forms of medication before presentation. closed globe injuries accounted for 87% of all injuries with occupational and leisure activities constituting a greater proportion of the activity at the time of injury. majority (98.8%) of the patients were not wearing any protective device at the time of injury. conclusion: ocular injuries affected mostly the economically active age group. most injuries were either occupational related or related to play or assaults. many patients engaged in some form of self-care before presentation. key words: ocular trauma, open globe injury, blindness. cular trauma is an important cause of visual impairment1 and a leading cause of preventable uni-ocular blindness world wide.2 it is an important cause of utilization of ophthalmic service resources.3 it has been rated as the third most common ophthalmic indication for hospitalization in the united states.4 even the most minor injuries can cause pain and discomfort, lost wages and health care expenses.5 in nigeria, ocular injuries are still rampant6. there are varying pattern and causes of ocular injuries from one country to another and even within regions in the same country. many studies however report higher prevalence of eye injuries among males when compared with their female counterparts.7,8 most cases of trauma are avoidable.9 visual outcomes following eye injuries vary from full recovery to complete blindness with physical and psychological loss and enormous costs to society.10 blindness from trauma could be as a result of the direct impact of the trauma as well as the appropriateness and timeliness of the treatment technique utilized. knowledge of the pattern and causes of eye trauma in this environment will help to know the common causes as well as get the facts necessary for health education materials for planning of preventive actions as well as need to seek o epidemiological survey of traumatic eye injury in a southwestern nigeria tertiary hospital pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 138 early and appropriate intervention for eye injuries when they occur. material and methods a prospective observational study of all consecutive cases of trauma was seen at an eye care centre over a 15 month period from january 2012 to march 2013. eighty five patients presenting with eye injuries were included. this included patients of all ages with acute injury to one or both eyes. patients who had healed ocular trauma or had been given surgical treatment for trauma elsewhere were excluded from this study. a questionnaire was administered to each respondent by face to face interview. the interview was conducted in english language, with language translation into yoruba when necessary. the interview elicited information on the following: demographic data, affected eye, agent of injury, activity at time of injury, duration before presentation, associated injury, medication used, source of referral and protective spectacle wear at the time of injury. all the patients had their visual acuity checked with the snellens chart (or illiterate e chart) placed at 6 metres. visual acuity in the better eye of 6/6 – 6/18 was considered to be normal; < 6/18 6/60 was classified as visual impairment and < 6/60 – 3/60 as severe visual impairment while visual acuity less than 3/60 was classified as blindness. eye examination was carried out with the aid of a pentorch, a slit lamp biomicroscope and a direct ophthalmoscope. dilated examination with indirect ophthalmoscopy was carried out on those with poor view from hazy media. ocular ultrasound was done for those with closed globe injuries when the view of the fundi was precluded by hazy media. intraocular pressure check was conducted with the aid of goldman applanation tonometer for cooperative patients with closed globe injuries. data was recorded and all statistical analyses were performed with commercially available computer program, statistical package for social science (spss) version 13.0. data are expressed as mean ± standard deviation (sd) and frequency expressed as a percentage. the relationships between categorical data were analyzed using chisquare (x2) test. at the adopted confidence level of 95%, p value of 0.05 (i.e. 5%) or less was considered to be significant. yates’s corrected chisquare and the appropriate fisher’s exact p value were used where the value of any cell was less than 5. results ninety one eyes of eighty five patients were seen during this study period with their ages ranging from 4 years to 78 years and a mean age of 31.7 ± 19.7 years. this constituted 3.8% of all the outpatients seen in the clinic during the study period. eighteen (21.2%) were children while 67 (78.8%) were adults with 45 (53.1%) of these aged between 20 – 60 years. there were more males than females across the age groups with a male to female ratio of 2:1. the affectation was unilateral in 79 patients (93%) (39 on the left and 40 on the right) and bilateral in 6 (7%). there was associated injury involving the head in 1 patient (1.2%), and face in 8 (9.4%). there were no associated injuries in 76(89.4%). the activities at the time of injury are as shown in table 1 below. injuries were work-related in 34 (40.0%). open globe injuries occurred in 11 (12.9%) of the subjects while a larger percentage 74 (87%) had closed globe injuries. there were no cases of retained intraocular foreign bodies. majority 84 (98.8%) of the patients were not wearing protective eye spectacle at the time of injury. the commonest agent of injury was non-organic matter in 49 (57.6%) of the subjects, another 32 (37.6%) was due to injury from organic matter as shown in table 2. table 3 shows that only 20 (23.5%) of the patients presented within 24 hrs of injury. visual acuity at presentation was less than 6/60 in 37 (43.5%) of the affected eyes of the patients. other details are as shown in table 4. majority of the patients 60 (70.6%) self presented to the hospital without any referral letter. the significant eye findings at presentation are as shown in table 5. the types of medications applied to the eyes before presentation are as shown in figure 2. 58 (68.2%) of the patients had medical intervention while 27 (31.8%) had surgical intervention. discussion traumatic eye injuries have been found to be a common phenomenon in developing countries like ours11. they are an important cause of utilization of ophthalmic service resources.4,12 in this study, there were 2 times more males than females. this finding is in line with previous reports stating that there is a higher involvement in trauma among the male gender because the males are more active and engage in a lot more outdoor and risk – ladened activities than their female counterparts.5,13,14 more than half of the study population were aged between 20 – 60 years. these are mostly people in the active and economically productive age similar to the findings by some other iyiade a ajayi, et al 139 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology authors.5,15-17 the greater percentage of unilateral cases than bilateral suggests a reason why trauma has been found to be the commonest cause of unilateral blindness. there was no left-right preponderance in table 5: examination findings at presentation lid laceration 5 (5.9) subconjunctival hemorrhage 13 (15.3) cornea foreign body 9 (10.6) cornea/corneoscleral laceration 11 (12.9) cornea infiltrates 5 (5.9) cornea ulcer 17 (20) hyphema 8 (9.4) mydriasis 7 (8.2) cataract 12 (14.1) ruptured lens 4 (4.7) subluxated lens 1 (1.2) commotio retina 1 (1.2) retinal detachment 1 (1.2) disc edema 1 (1.2) the eye affected contrary to studies where the left eye has been found to be more commonly affected compared with the right.14.18 there were many more cases of closed globe injuries (87%) in this study with the impact of trauma extending from the surrounding eyelid to the retina. a similar finding has been reported by other authors in other regions of the country.15,16,19 in a study in pakistan closed globe injuries were also reported to be commoner accounting for 50.6% of cases.20 a possible explanation to this is the fact that most of the agents of injuries are possibly blunt objects like fist / finger and other non organic and organic matters. near half (43.5%) of the patients were blind in the affected eye at presentation while another (9.4%) had low vision. all these patients claimed to have normal vision in the affected eye before the injury. this reinforces the possibility of variable effects of injuries to the globe. the effect of trauma on the eye may vary with the agent of injury, impact site and force as well as timeliness and appropriateness of interventional measures. it may also vary with the type and appropriateness of protective eye device worn at the time of injury. only one (1.2%) of our patients was wearing a protective eye device at the time of injury. there could also be concomitant injuries to other surrounding structures epidemiological survey of traumatic eye injury in a southwestern nigeria tertiary hospital pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 140 like the face and head as shown in our study and also in a study on maxillofacial injuries in abuja21 many injuries were occupationally related (44.7%) occurring either in a workshop (24.7%) or during farmwork (20.0%). work related eye injuries have been found to constitute a substantial proportion of eye injuries.22,23 they are found to be largely preventable especially if adequate eye protections are worn and appropriate guards are positioned over obvious hazards.24 some injuries were related to leisure activities like playing (14.1%) or fighting (17.6%) similar to the finding by desai et al25 where they observed that domestic and leisure activities were common causes of ocular trauma especially in women and children. domestic related eye injuries were however very few (3.5%) in this study just like it constituted 4.85% (100 out of 2061) of all ocular emergencies seen in a study in iran.26 contrary to a study in another region of the country where it was reported as the commonest cause of eye injury accounting for 55 eyes out of 230 0 10 20 30 40 50 60 self friends/ relations medical doctors nurse fig. 1: source of referral 0 5 10 15 20 25 30 35 antibiotics none not sure traditional eye medication steroid fig. 2: medications utilized before presentation eyes. a study in south nigeria reported assault as the commonest source of injury accounting for 62.2% of cases of eye injuries.27 more than half of the patients presented after 24 hours of injury. this shows a late pattern of presentation among our patients. the reasons for late presentation were not determined in this study however we discovered that many of our patients 59 (69.4%) had utilized one form of selfcare or the other before presentation to our centre. top on the list of this self care materials was antibiotics in 32 (37.6%) of the patients. other things utilized are as shown in figure 2. this may contribute to delayed presentation by the patients. other factors that may contribute to delayed presentation include awareness of existing eye care facilities, proximity to eye care facility and cost of care. the modality of management could vary depending on the extent and impact of trauma to the eye as shown in our study. as shown in table 5 the impact of trauma to the globe were of varying extent from lid laceration (5.9%), subconjunctival hemorrhage (15.3%) cornea affectation in 49.4%, lens affectation in 18.8% and retina affectation (2.4%). about 32% had surgical intervention while the other larger group were managed medically as shown above. the determinants of modality of intervention include presence of foreign body as well as the violation of the structural and functional integrity of the wall of the globe. conclusion ocular injuries are still common in our community. the age group that are most predisposed are the working and economically active group. most injuries were either occupational related or related to leisure activities like play or assault. many of the patients engaged in some form of self care before presentation. many of them presented to the clinic after 24 hours of injury with about 43.5% presenting with blindness in the affected eye. author’s affiliation dr. iyiade a ajayi department of ophthalmology university teaching hospital, ado-ekiti nigeria dr. kayode o ajite department of ophthalmology university teaching hospital, ado-ekiti nigeria iyiade a ajayi, et al 141 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology dr. olusola j omotoye department of ophthalmology university teaching hospital, ado-ekiti nigeria references 1. mac ewen c. j eye injuries: a prospective survey of 5671 cases. br. j ophthalmol. 1989; 73: 888-94. 2. nwosu sn. blindness and visual impairment in anambra state nigeria. trop. geogr. med. 1994; 46: 346-9. 3. schein od, hibberd pl, shingleton bj, et al. spectrum and burden of ocular injury. ophthalmology. 1986; 95: 300-5. 4. mieler wf. ocular injuries: is it possible to further limit the occurrence rate? arch ophthalmol. 2001; 119: 1712-3. 5. jahangir t, butt nh, hamza u, et al. pattern of presentation and factors leading to ocular trauma. pak j ophthalmol. 2011; 27: 96-102. 6. ajaiyeoba ai. ocular injuries in ibadan. nig.j. ophthalmol. 1995; 3: 23-25. 7. qureshi mb. ocular injury pattern in turbat, baluchistan, pakistan. comm eye health. 1197; 10: 57-8. 8. mukherjee ak, saini js, dabrai sm. a profile of penetrating eye injuries. indian j ophthalmol. 1984; 32: 269-71. 9. nordber e. ocular injuries as a public health problem in subsaharan africa: epidemiology and prospect for control east africa med j 2000; 77: 1-43. 10. castellarin aa. pieramici d.j open globe management. compr ophthalmol update. 2007; 8: 111-24. 11. negrel ad. magnitude of eye injuries worldwide. j comm. eye health. 1997; 10: 49-64. 12. schein od, hibberd pl, shingleton bj, et al. spectrum and burden of ocular injury. ophthalmology. 1986; 95: 300-5. 13. otoibhi sc, osahon ai. perforating eye injuries in children in benin city, nigeria. journal of medicine and biomedical research. 2003; 2: 18-24. 14. omoti ae. ocular trauma in benin city. africa journal of trauma. 2004; 2: 67-71. 15. okeigbemen vw, osaguona vb. seasonal variation in ocular injury in a tertiary health center in benin city sahel med j 2013; 16: 10-4. 16. omolase co, omolade eo, ogunleye ot, omolase bo, ihemedu co, adeosun oas. pattern of ocular injury in owo, nigeria. journal of ophthalmic and vision research. 2011; 6: 114-8. 17. okoye oi. eye injury requiring hospitalization in enugu nigeria: a one year survey. nigerian journal of surgical research. 2006; 8: 34-7. 18. ukponwan cu, akpe ab. aetiology and complications of ocular trauma nig j surgsci. 2008; 18: 92-100. 19. bankole oo. ocular injuries in a semiurban region nig j ophthalmol. 2003; 11: 86-9. 20. bukhari s, mahar ps, qidwai u, et al. ocular trauma in children pak j ophthalmol. 2011; 27: 208-13. 21. osunde od, omole io, ver-or n, akhiwu bi, adebola ra, iyogun ca, efunkoya aa. paediatric maxillofacial injuries at a nigerain teaching hospital: a 3 year review nigerian journal of clinical practice. 2013; 16: 149-54. 22. lipscomb hj, dement jm, mcdougal v, et al. work related eye injuries among union carpenters. appl occup environ hyg. 1999; 14: 665-76. 23. khan md, kunndi n. mohammed z, nazeer a. a 61/2 years survey of intraocular and intraorbital foreign bodies in the north west frontier province, pakistan. br j ophthalmol. 1987; 71: 716-9. 24. lipinscomb hj. effectiveness of intervention to prevent work related eye injuries. am j prev med. 2000; 18: 27-32. 25. desai p, macewen cj, baines p, minnaissian dc. epidemiology and implications of ocular trauma admitted to hospital in scotland. j epidemiol comm. health health. 1996; 50: 436-41. 26. mansouri mr, mirshahi a, hosseini m. domestic ocular injuries: a case series. eur j ophthalmol. 2007; 17: 654-9. 27. emem a, uwemedimbuk e prevalence of traumatic ocular injuries in a teaching hospital in south-south nigeriaa two year review. adv trop med pub health int. 2012; 2: 102-8. 290 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology original article dry eye disease following cataract surgery munir amjad baig, rabeeya munir, shakeel faiz pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: munir amjad baig mbbs, doms, mcps, fcps associate professor eye ajkmc, muzaffarabad e-mail: drmuniramjad@gmail.com …..……………………….. purpose: to know the changes in tear film and the presence or absence of dry eye disease (ded) after cataract surgery. study design: prospective descriptive study. place and duration of study: federal government services hospital islamabad, jan. 3-dec 2013. material and methods: the baseline characteristics of 192 patients were recorded and dry eye (de) questionnaire was administered by a trained interviewer. dry eye tests were performed on day 0 (baseline), day 7, 30 and day 90 after phacoemulsification under the same physical conditions by a single surgeon. spss version 17 was used and data analyzed for frequencies/percentages. diagnosis was made on three of five parameters. results: of the 192 patients, 121 (63%) patients had dry eyes and 71 (37%) patients did not have any dry eyes. after surgery, symptoms of de increased but all dry eye tests declined. maximum change in both sexes was on 7 th postoperative day and in those above 60 years of age. among all patients the height of marginal tear strip was nearly 1 mm and was discarded for grading. on 30 th day the tests improved gradually but interestingly preoperative values were not achieved even after sixty days. conclusion: de symptoms and signs appeared within seven days which improved later on slowly. key words; dry eye, cataract surgery, corneal nerves, dry eye tests. ecently, emphasis has been given to dry eye disease following cataract surgery. before surgery most cases had normal lacrimal secretions. a grooved incision can raise these symptoms during early postoperative period. damage to any part of the lacrimal functional unit results in tear film instability and ocular surface damage so dry eyes influence patient’s ocular, general health and quality of life1. various studies have shown the de prevalence to be 13.3% and 21.6% respectively between the ages of 43 and 86 years after 5-10 years of follow-up2. in us population, it is 5% to 17% and the incidence of dry eye after phacoemulsification was 9.8%3. in the united states alone, about 7-10 million americans require artificial tear preparation spending over 100 million dollars/year4. dry eyes can develop after different ocular surgeries like photorefractive keratectomy and laserassisted in situ keratomileusis. cataract surgeryaffects the neurogenic response and decreases tear secretions5. cornea has rich innervations having 44 nerve bundles entering around the limbus. larger nerve fibers enter from 9 to 3 o’clock position6. during surgery, temporal corneal incisions reduce the corneal sensitivity7. moreover longer the surgical time the more damage to the corneal nerves. neurogenic inflammation and inflammatory mediators can reduce corneal sensitivity8. r mailto:drmuniramjad@gmail.com dry eye disease following cataract surgery pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 291 after 4 weeks, neural growth factors regenerate the subepithelial corneal neurite cells during healing process of the corneal nerves9. this explains the occurrence of de early after surgery which then improves slowly. the aim of our study was to know tear film changes and the presence or absence of ded after cataract surgery. material and methods a prospective descriptive study was conducted at ophthalmology department, federal government services hospital islamabad from jan.2013-dec2013 after taking their consent and permission from ethical committee. first operated eyes of one hundred and ninetytwo (52% males, 48% females) uncomplicated cataract patients undergoing phacoemulsification with no dry eye symptoms were included. the mean age was 60.07 years with 40-78 years range. patients with autoimmune diseases, previous ocular surgery/injury, ocular allergies and using topical eye drops were excluded. patients who developed complications during surgery were also excluded. under subtenon anesthesia a standard surgical technique with 2.80 mm superior/temporal corneal incision was used on all patients. after surgery, all patients used tobramycin with dexamethasone eye drops four times daily for four weeks. clinical examinations included de questionnaire (deq 5), tear film breakup time (tbut), shirmer’s test (st), corneal fluorescein staining (cfs) with oxford schema, tear meniscus height (tmh) and slit-lamp examination of lid margin changes based on ‘the international dry eye workshop’ (dews) 2007 guidelines by a single surgeon under same physical conditions. follow-up was on 7th day, 1 month and 3 months postoperatively. diagnosis was based on deq scores, tbut values < 10 sec, st values < 10 mm/5s and cfs staining > 1 and presence of lid plugging and telengiectasias. data was entered into spss version 17 and analyzed for percentages/frequencies. results of 192 subjects there were 48% females and 52% males. majority of patients 110 (57.2%) were from urban areas and most of them, 98 (51%), belonged to age group of 53-65 years. there were 138 (72%) patients who were operated for right eye. of the 192 patients, 121 (63%) {71 (58.6%) male and 50 (41.4%) females} patients had dry eyes and 71 (37%) patients did not have any dry eyes. the observations about the dryness of the eyes, if present, were graded according to the dews 2007 report. table 1 shows the baseline characteristics of all the patients. dry eye symptoms and severity on 7th, 30th and 90th days are shown in table 2. at the end of the 30th post-operative day, out of 192 patients, 42 (15.4%) had improved tbut and st values. table 1: baseline characteristics. characters number (n = 192) percentage age group 40-52 years 55 28.7% 53-65 98 51% 66-78 39 20.3% sex male 100 52% female 92 48% residential urban 123 64% rural 69 36% operated eye right eye 138 72% left eye 54 28% incision site superior incision 101 52.6% temporal incision 91 4 7.4% table 2: de scoring on 7th, 30th, 90th day. ocular history visit-1 (7 days) visit-2 (30 days) visit-3 (90 days) n % n % n % f.b sensation 99 51.5% 82 42.7% 77 40% burning 98 51.4% 90 46.8% 72 37.5% dryness 81 42.6% 80 41.6% 67 34.9% watering 80 41.6% 78 41.2% 77 40% itching 42 21.8% 41 21.6% 35 18.2% munir amjad baig, et al 292 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology after cataract surgery all dry eye tests values were low with increased symptoms of patients. there were 12.2% eyes which had grade 4, 21.4% eyes had grade 3, 33.6% had grade 2 and 60 eyes (30.6%) had grade 1 oxford schema staining. there were 88 eyes (44.8%) which showed tbut values below 10 seconds and 45 (23%) eyes showed values < 5s. st values were below 10 mm/5 seconds in 22 eyes (11.2%) and below 5 mm/5 sec in 17 eyes (8.6%) (table 3). table 3: de positive signs on 7th day. tests incidence tbut 69% st 19.8% oxford schema 51% lid margin 53% deq 5 62% the tbut test was more reliable than the schirmer test. maximum change in value in both genders was on 7th day after operation and in subjects over 60 years (table 4). the height of marginal tear strip in all subjects varied from 0.5 mm to 1 mm so it was discarded for grading. interestingly 30 days after operation the values gradually improved but even after 60 days of surgery the baseline levels were not achieved. table 4: tear film break-up time and schirmer’s result analysis on 7th day. tbut n= % > 15s 59 30.7% < 10s 45 23.4% < 5 sec 88 45.8% schirmer’s test values 15 mm 153 80% < 10 mm 17 8.9% < 5 mm 22 11.1% discussion the de disease after cataract surgery has multiple factors. corneal nerves sections and decreased sensitivity, phototoxic microscopic light, irrigations of the corneal epithelium during operation, increased tear’s inflammatory cytokines, use of eye drops preservatives during or after surgery influence dry eye disease after cataract surgery10. cho and kim mentioned rise of dry eye symptoms after cataract surgery11. in liu's study, symptoms aggravated in both diabetics and non-diabetics which reached preoperative levels in non-diabetic group between 30 and 180 days while they remained high in diabetics even on day 18012. in the present study, all were non-diabetics and 62% of them showed enhancement of de symptoms postoperatively which showed reduction after 60th day. hawaian eye 2011 meeting13 highlighted the incidence of de in 272 eyes after cataract surgery showing low tbut in 60%, low st values in 21.3% while 50% of eyes had central corneal staining similar to present study showing low tbut in 69%, st values in 20% and 51% had cfs, all of which are diagnostic signs of dry eye disease. many studies have compared pre and postoperative tear film functions and all have reported change in tear film after surgery. moon et al.14 compared 25 eyes before and after surgery and noticed low tbut and st values up to 2 months postoperatively. other study15 mentioned a similar decrease of both tbut and st levels in eyes up to 3 months. cho and kim13 conducted a study in 70 eyes of 35 patients after phacoemulsification showing decline in all three tests upto 3 months. khanal et al.16 studied 18 patients and found changed tear physiology and decreased sensitivity immediately after surgery where the tear functions recovered within 1-month. we also found a similar trend where tbut andst values started recovering after 1-month but srinivasan et al.17 and gharaee et al. denied any effect of modern surgery on tear film and ocular surface. oh et al.18 compared diabetic cataract patients with equal age-matched non-diabetic cataract patients. diabetic cataract patients showed reduced tear secretions after phacoemulsification. the postoperative decrease in tbut was seen in nondiabetics as well, similar to our study which showed the same results after one month. the possible explanation for reduced tbut and st values may be the severing nerves by corneal incision which deteriorates the corneal-lacrimal gland loop producing tear secretions19. in our study the tbut reduction indicated unstable tear film resulting from irregular surface at incision site or from a decreased mucin secretion by the conjunctiva as proposed by han et al20. dry eye disease following cataract surgery pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 293 operating microscope related phototoxicity was observed in other study21. the light exposure caused rise of de symptoms and signs in cho's and kim's11 study. in our study we did not any find relationship between microscopic light exposure time and de tests. movahedan et al.22 mentioned that a healthy ocular surface has best visual results in cataract patients. mild to moderate de disease may not disturb vision but severe de disturbs the vision in patients. so a proper preoperative assessment should be done10. the present study showed abnormal interpalpebral staining of ocular surface characteristic of de in contrast to inferior staining which occurs in drug toxicity. the abnormal oxford schema grading after cataract surgery may be the result of neurogenic inflammation23. in the present study, 101 (52.6%) cases had superior incision while 91 (47.4%) had temporal incision which showed more de symptoms postoperatively explaining severing of corneal nerve twigs8. benzalkonium chloride containing topical eye drops reduce the number of mucin-expressing cells resulting in tear film instability24. over use of drops affect corneal toxicity and dry eye after surgery. in the present study we did not find the same observations. author’s affiliation dr. munir amjad baig mbbs, doms, mcps, fcps associate professor eye, ajk medical college, muzaffarabad dr. rabeeya munir b.d.s demonstrator anatomy rawal institute of healh sciences dr. shakeel faiz mbbs, frcog, professor ajk medical college, muzaffarabad role of authors dr. munir amjad baig conception, synthesis and planning of research. dr. rabeeya munir active participation in active methodology. dr. shakeel faiz interpretation, analysis and proof reading. conclusion our results revealed that cataract surgery negatively affects the tear film parameters and ocular surface in early postoperative period thus leading to de. recommendations cataract surgeons can improve their results by treating the ocular surface before and after operation. references 1. international dry eye workshop (dews) the definition and classification of dry eye disease: report of the definition and classification subcommittee of the international dry eye workshop. ocul surface, 2007; 5: 75–92. 2. han sb, hyon jy, woo sj, lee jj, kim th, et al. prevalence of dry eye disease in an elderly korean population. arch ophthalmol. 2011; 129: 633–8. 3. luthe r. dry eye screening and the cataract patient. ophthalmology management, may 2012; vol. 16: 48-51. 4. galor a, feuer w, lee dj. prevalence and risk factors of dry eye syndrome in a united states veterans affairs population. am j ophthalmol. 2011; 152: 377–384. 5. shankar s. ganvit h.d. ahir , sadhu j, pandya nn. study of the dry eye changes after cataract surgery int j res med. 2014; 3 (2): 142-145. 6. al-aqaba ma, fares u, suleman h, lowe j, dua hs. architecture and distribution of human corneal nerves. br j ophthalmol. 2010; 94: 784–9. 7. han ke, yoon sc, ahn jm, nam sm, stulting rd, kim ek, et al. evaluation of dry eye and meibomian gland dysfunction after cataract surgery. am j ophthalmol. 2014; 157: 1144–50. 8. jiang y.1., ye h., xu j., lu y. non-invasive keratograph assessment of tear film break-up time and location in patients with age-related cataracts and dry eye syndrome. j int med res. 2014; 42 (2): 494–502. 9. morano m, wrobel s, fregnan f, ziv-polat o, shahar a, ratzka a, grothe c, geuna s, haastert-talini k. nanotechnology versus stem cell engineering: in vitro comparison of neurite inductive potentials. int j nanomed. 2014; 9: 5289–5306. 10. sahu pk, das gk, malik a, biakthangi l. dry eye following phacoemulsification surgery and its relation to associated intraoperative risk factors middle east afr j ophthalmol. 2015 oct-dec; 22 (4): 472–4. 11. cho yk, kim ms. dry eye after cataract surgery and associated intraoperative risk factors. korean j ophthalmol. 2009; 23: 65–73. 12. liu zg, li w. dry eye relevant to ocular surgery. zhonghua yan ke za zhi. 2009; 45: 483–5. 13. hawaiian eye 2011 meeting; monday, february 14, 2011. available from: http://www.cataract-surgeryinformation.blogspot.com/2011/02/cataract-surgeryhttp://www.cataract-surgery-information.blogspot.com/2011/02/cataract-surgery-dry-eyes-what-you-need.html http://www.cataract-surgery-information.blogspot.com/2011/02/cataract-surgery-dry-eyes-what-you-need.html munir amjad baig, et al 294 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology dry-eyes-what-you-need.html. [last accessed on 2013 mar 02 14. moon h, yoon j, hyun s, kim kh. short-term influence of aspirating speculum use on dry eye after cataract surgery, 2014; 33: 373–375. 15. kasetsuwan n, satitpitakul v, changul t, jariyakosol s. incidence and pattern of dry eye after cataract surgery. plos one, 2013; 8: 1–6. 16. khanal s, tomlinson a, esakowitz l, bhatt p, jones d, et al. changes in corneal sensitivity and tear physiology after phacoemulsification. ophthalmic physiol opt. 2008; 28: 127–34. 17. srinivasan r, agarwal v, suchismitha t, kavitha. dry eye after phacoemulsification. aioc. 2008: 116-8. 18. oh t, jung y, chang d, chang d, kim j, kim h. changes in tear film and ocular surface after cataract surgery. jpn j ophthalmol. 2012; 56: 113–8. 19. cetinkaya s, mestan e, l acir no, cetinkaya yf, dadac zi, yener hi. the course of dry eye after phacoemulsification surgery. bmc ophthalmol. 2015; 15: 68. 20. han ke, yoon sc, ahn jm, nam sm, stulting rd, kim ek, et al. evaluation of dry eye and meibomian gland dysfunction after cataract surgery. am j ophthalmol. 2014; 157 (6): 1144–1150. 21. hwang hb, kim hs. phototoxic effects of an operating microscope on the ocular surface and tear film. cornea, 2014; 33 (1): 82–90. 22. movahedan a., djalilian a.r. cataract surgery in the face of ocular surface disease. curr opin ophthalmol. 2012 jan; 23 (1): 68–72. 23. lee h, chung b, kim ks, seo ky, choi bj, kim ti. effects of topical loteprednol etabonate on tear cytokines and clinical outcomes in moderate and severe meibomian gland dysfunction: randomized clinical trial. am j ophthalmol. 2014; 158 (6): 1172–1183. 24. chung yw, oh th, chung sk. the effect of topical cyclosporine 0.05% on dry eye after cataract surgery. korean j ophthalmol. 2013; 27: 167–7. https://www.ncbi.nlm.nih.gov/pubmed/?term=cetinkaya%20s%5bauthor%5d&cauthor=true&cauthor_uid=26122323 https://www.ncbi.nlm.nih.gov/pubmed/?term=mestan%20e%5bauthor%5d&cauthor=true&cauthor_uid=26122323 https://www.ncbi.nlm.nih.gov/pubmed/?term=acir%20no%5bauthor%5d&cauthor=true&cauthor_uid=26122323 https://www.ncbi.nlm.nih.gov/pubmed/?term=cetinkaya%20yf%5bauthor%5d&cauthor=true&cauthor_uid=26122323 https://www.ncbi.nlm.nih.gov/pubmed/?term=dadaci%20z%5bauthor%5d&cauthor=true&cauthor_uid=26122323 https://www.ncbi.nlm.nih.gov/pubmed/?term=yener%20hi%5bauthor%5d&cauthor=true&cauthor_uid=26122323 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4485332/ 74 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology original article consensus guidelines for management of congenital cataract in pakistan mian muhammad shafique, muhammad moin pak j ophthalmol 2018, vol. 34, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mian muhammad shafique pediatric ophthalmologists of the ophthalmological society of pakistan email: mianmshafiq@hotmail.com …..……………………….. purpose: to formulate guidelines for management of congenital cataract in pakistan through consensus of pediatric ophthalmologists. study design: mixed methods study using delphi technique. place and duration of study: study was conducted among pediatric ophthalmologists of the ophthalmological society of pakistan from june 2016 to february 2017. material and methods: a survey questionnaire was constructed containing 40 questions after literature review, which covered almost all aspects of the management of congenital cataract. this survey was answered by 56 renowned pediatric ophthalmologists of pakistan using the survey monkey online program. the analyzed data was presented in a planned face-to-face meeting of top 15 members of the association of pediatric ophthalmology, pakistan. the data was discussed point by point and consensus was built with some additions and modifications. results: 41 out of 56 pediatric ophthalmologists answered the survey. the most common presentation of a child with congenital cataract in our study was white pupil (72%) and 97.5% participants said that repeat eye examination should be done after dilation of pupil to confirm the diagnosis. 77% participants felt that the child should not be operated if cataract opacity is smaller than 3 mm. in our country, only one-third of the pediatric ophthalmologists were in favor of implanting intraocular lens (iol) by the age of one year but there was 80% consensus to do so by the age of 2 years. children with dense cataract should be operated by 2 months of age according to 80% participants. it is preferred to perform primary posterior capsulotomy with or without anterior vitrectomy in all children who undergo congenital cataract surgery in any age until 5years (87%). conclusion: management of congenital cataract by pediatric ophthalmologists in pakistan is consistent with internationally available guidelines. key words: congenital cataract, consensus, guidelines, management. ongenital cataract is considered to be one of the most important treatable causes of childhood blindness worldwide1. pediatric cataracts can have a profound impact on health and vision-related quality of life, and on functional visual ability2. its prevalence varies from country to country3,4, in usa 3-4 per 10,000 live births5, and in uk 3.18 per 10,000 live births6. in developing countries like india, 7.4 – 15.3% of childhood blindness is due to cataract7. the pakistan national blindness and visual impairment survey, published in 2007 indicates crude adult cataract prevalence as 1.75% but there is no mention of congenital cataract in this document8. according to our study survey, about 1% of children c consensus guidelines for management of congenital cataract in pakistan pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 75 having eye diseases are found to have the congenital cataract. in a population of 200 million in our country, the number and the percentage of children is rising day by day and so is the constant rise in the number of children having eye diseases. congenital and developmental cataract is a very common presentation in our outpatients and if not treated properly and in time may lead to lifelong disability. unfortunately, there is a lot of confusion among our colleagues for its treatment plans and its execution. there is an urgent need to develop consensus guidelines for treatment of this disease of our children on priority basis so that we can save the vision of our future generations. the main purpose of this effort is to establish consensus for treatment of childhood cataract in pakistan and develop guidelines which could be followed by all pediatric ophthalmologists and also provide enough help to general ophthalmologists of our country. as there is no such document available in our country we took the responsibility to get a consensus among the renowned pediatric ophthalmologists of our country in the light of evidence of their experience of managing this diseases in the previous 25 years. material and methods to start this project we did a literature search to see internationally available guidelines for treatment of congenital cataract. based on this, a plan was made which comprised the following steps. a survey questionnaire was constructed on the basis of the knowledge acquired about the treatment of childhood cataract in excellent centers of the world. it contained 40 questions, which covered almost all aspects of management of congenital cataract. a survey was conducted with the help of ‗survey monkey‘ and online opinion was sought from 56 renowned pediatric ophthalmologists of our country in all provinces and all big cities of pakistan. received data was compiled, analyzed and later presented in a faceto-face meeting of top fifteen pediatric ophthalmologists of our country on the platform of association of pediatric ophthalmology pakistan during osp national conference in peshawar in february 2017. the data was rigorously discussed in this meeting point by point and consensus was built with some additions and modifications. after the consensus, final guidelines for the management of congenital cataract in pakistan were drafted. results forty-one out of 56 pediatric ophthalmologists responded and gave their opinion. more than 90% of them had been regularly managing congenital cataract for last 11 – 25 years. the results of the key questions in the survey are shown in figures 1 – 19. fig. 1: factors in making a diangosis. fig. 2: pupil dilation to make a diangosis. mian muhammad shafique, et al 76 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology fig. 3: minimal age for cataract surgery. fig. 4: preferred pocedure for cataract surgery. fig. 5: preferred incision for cataract surgery. fig. 6: preferred technique for anterior capsulotomy. fig. 7: is hydrodissection needed in all cases. fig. 8: hydrodissection in posterior polar cataract. consensus guidelines for management of congenital cataract in pakistan pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 77 fig. 9: preferred method of nucleus removal. fig. 10: age for primary posterior capsulotomy. fig. 11: age for iol implantation. fig. 12: preferred type of iol for implantation. fig. 13: compensation of iol in child < 2 years. fig. 14: preferred position for iol placement. mian muhammad shafique, et al 78 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology fig. 15: preferred wound sealing measures. fig. 16: duration of topical antibiotics after surgery. fig. 17: duration of topical steroids after surgery. fig. 18: timing of yag posterior capsulotomy. fig. 19: follow up after congenital cataract surgery. discussion the most common presentation of a child with congenital cataract in our study was white pupil (72%) followed by ‗abnormal visual behavior‘ (23%). only these two symptoms helped the ophthalmologist to think of congenital cataract in 95% of cases. the presentation of congenital cataract with a white pupil in our study was far more common as compared to findings in a neighboring country (72% vs. 24%)9. among the uncommon presentations of the condition were strabismus and nystagmus. these two are considered as important risk factors for poor visual outcomes10. consensus guidelines for management of congenital cataract in pakistan pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 79 although the torch examination is a very common practice, the use of the slit lamp for anterior segment examination followed by distant direct ophthalmoscopy are the two pivotal tests for making the diagnosis of congenital cataract (82%). if possible, indirect ophthalmoscopy and retinoscopy may also be performed to rule out other causes of abnormal visual behavior. for uncooperative children, a special method of slit lamp–adapted anterior segment photography with assistance technique and sleep aid administration has been used in china successfully for monitoring and classifying pediatric cataracts11. there is a strong consensus (97.5%) among ophthalmologists of our study on repeat examination of the child's eye after dilatation of the pupil before confirming the diagnosis of congenital cataract. the dilating drops if having the character of cycloplegia will also help to perform cycloplegic retinoscopy at the same time. if the intention is to perform the later test also then use atropine eye ointment for children younger than 2 years and cyclopentolate eye drops for children older than this age. in our study, 77% pediatric ophthalmologists felt that one should not be in hurry to operate if the opacity in congenital cataract is small (< 3 mm) and the vision improves with dilatation of the pupil. tropicamide dilating eye drops were generally preferred (60%) as these are short-acting mydriatic and weak cycloplegic. these drops should be used twice a day. through the dilated pupil the child will be able to focus both for distance and near as still, we have saved the accommodation in this crystalline natural lens. other drugs like cyclopentolate and atropine are strong cycloplegic and are less commonly used for this therapeutic purpose. such children who are under treatment with dilating drops should be kept under monthly follow up to observe the progress of this small opacity and save the child from the risk of sensory deprivation amblyopia. once decision on surgery for dense cataract has been made and conveyed to the parents, they may ask about the visual prognosis. always be ready to answer rightly, which can only be done if macular function tests have been performed. the easiest and reliable test for younger children is brisk pupillary light reflex (70%). other tests like visual acuity, color vision, and if possible, the two-point discrimination test should be performed. motivation and education of the family members especially the parents before and after the surgery of a child of congenital cataract is of utmost importance (100%) and should not be ignored. if surgery is not yet indicated then the parents must be made to realize the importance of regular and frequent follow-ups. on the other hand, if the child has undergone surgery then the reasons for regular follow up and meticulous application of post-operative measures is even more important. all this can be achieved only if good rapport with parents is developed by giving them the knowledge of the disease and motivating them for cooperation to achieve the targeted outcome. in our survey, 100% of the participants were in favor to address the following three major aims of treatment of congenital cataract. the first one was to remove the cataract by the procedure, which suits the type of cataract. second was to correct the high hypermetropia related with lens removal either by intraocular lens implantation per-operatively or by glasses postoperatively. the third aim was to treat any associated amblyopia, which should never be forgotten. all the following conditions related with congenital cataract should be considered an indication of surgery: lens opacity 3 mm or larger, posterior subcapsular lenticular opacity, lens opacity with no fundal view, lens opacity with nystagmus and lens opacity with strabismus. the participants felt that if the child was having dense congenital cataract then his surgery should not be delayed much. operating before the age of one month was not considered safe, as there are more chances to develop aphakic glaucoma.12 85% of pediatric ophthalmologists of our country were of the opinion that the child should be operated by the age of two months, which is consistent with international standards13. if there was any reason for avoiding general anesthesia like some serious cardiac congenital abnormalities, cataract surgery can be undertaken with necessary precautions like intensive monitoring, keeping a standby cardiac setup14. in these circumstances, the operation can be delayed until 6 months. general anesthesia was the main choice for surgery of congenital cataract (100%). endotracheal intubation was preferred over laryngeal mask (lma) for maintenance (69% vs 39%). for some reasons, if these two were not possible to use, then anesthesia with ketamine injection may be a safe and potent option15. everybody felt that there was no place for relying solely on local anesthesia in this surgery. mian muhammad shafique, et al 80 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology the most favored surgical technique for congenital cataract was a combination of several procedures. irrigation and aspiration of lens matter alone was not liked as almost 100% of these operations were complicated by posterior capsular thickening. the participants felt that if the child was younger than 2 years of age it was preferable to combine irrigation, aspiration and iol implantation with primary posterior capsulotomy with or without anterior vitrectomy (67%). primary iol implantation should also be done in the same session if the age of the child is more than one year. tunnel incision was more popular (92.3%) for reason of more stable anterior chamber during surgery and sealing of wound without any stitch in the majority of cases. a keratome was preferred to make the tunnel incision of 2.7 mm or 3.2 mm. both corneoscleral tunnel and clear corneal tunnel were equally liked as compared to the scleral tunnel. straight limbal or straight corneal incisions are now less used as these need stitching to close the wound and the post-op astigmatism is quite high. continuous curvilinear capsulorhexis (ccc) was the most popular technique (82%) as it was easy to master with cystotome or capsular forceps. due to the higher elasticity of capsule in this age group, there are more chances of extending the rhexis out as compared to adults. in case of failure to make a complete ccc the anterior capsulotomy can be safely converted to can opening capsulotomy. other innovative techniques like two incisions push-pull technique, radiofrequency diathermy and plasma blade (fugo blade) although applied uncommonly in our country are becoming popular in some places around the world16. in white congenital cataract during anterior capsulotomy, the capsular edge is seen with great difficulty. in such cases, use of trypan blue dye is a good adjunct for handling a smooth anterior capsulotomy and was liked by most of the pediatric ophthalmic surgeons (90%). there was split opinion among the pediatric ophthalmologists regarding the need to go for hydrodissection routinely in every case of congenital cataract to separate the nucleus from the cortex (59% vs. 41%) however, it is very important not to be aggressive to perform hydrodisection in posterior polar and posterior subcapsular cataract where it is rather contraindicated. in such type of cataracts, it was preferred (77%) to avoid the hydrodissection but if performed the pressure of injecting fluid should be very low and gentle otherwise there can be a risk of posterior capsular rupture even before irrigation and aspiration. the nucleus in congenital cataract is very soft and hardly needs removal by expression through an open wound. this has given place to small tunnel incision in surgery for congenital cataract. the majority of surgeons (62%) removed the nucleus of congenital cataract easily by i/a cannula, which normally is used to aspirate cortex. if it fails then phaco-probe or vitrector can be applied to aspirate the nucleus. i/a cannula was the preferred instrument to aspirate cortical matter in congenital cataract surgery (82%). hardly ever, there was any need to use phacoprobe or vitrector for this purpose. almost all children operated for congenital cataract before the age of 4-5 years develop posterior capsular (pc) thickening postoperatively if the posterior capsule is left intact17. it is preferred to perform primary posterior capsulotomy with or without anterior vitrectomy in all children who undergo congenital cataract surgery in any age until 5years (87%). the chances of development of pc thickening are reduced after this age and if it occurs, can be treated with yag laser in children older than this age under topical anesthesia, so the primary posterior capsulotomy and the anterior vitrectomy should be avoided after this age. 77% pediatric ophthalmic surgeons liked to use preservative-free triamcinolone acetonide during congenital cataract surgery after posterior capsulotomy for better visualization of prolapsed vitreous and as a safe adjunct to post-op steroid drops. there has been great controversy and debate among the pediatric ophthalmologists regarding the minimum age to implant an iol in a child of congenital cataract. in a survey, approximately 70% of the american association of pediatric ophthalmology and strabismus members worldwide preferred to implant an iol in children18,19. in our country, only one-third of the pediatric ophthalmologists were in favor of implanting iol by the age of one year but there was 80% consensus to do so by the age of 2 years. there is no evidence in favor of delaying it beyond the age of 4 years. the best choice is the foldable iols (95%) among which multi-piece foldable lens was preferred over single piece foldable lens. both these can easily be injected through the same 2.75 mm/3.2 mm sized tunnel incision. the rigid iol 5.5mm may be used if the foldable is not available or if the given incision is consensus guidelines for management of congenital cataract in pakistan pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 81 straight, otherwise the tunnel will have to be extended to more than 5.5 mm with larger keratome. the eye of an infant at birth has high hypermetropia, which continuously decreases until the age of 10 – 13 years18. this decrease is rapid in first five years. as the implanted iol power remains static, the choice of iol power should be adjusted according to the expected adult power of lens for this child. the majority of participants of our survey were in the favor to reduce the biometric power of iol by 30% until the age of one year, 20% up to the age of 2 years, 10% between 2 – 5 years and no reduction at the age of 10 years. there was no controversy regarding the choice to place the iol during congenital cataract surgery. the best choice was ‗in the bag' (95%). if for some reason bag is not intact and there is a risk of iol sinking to vitreous then the second choice is ‗in the sulcus, and the placement in the anterior chamber or posterior fixation are only done if above two choices are not available. some studies have advocated the use of capsular tension ring (ctr) in children with subluxated lenses20. when a primary iol is not implanted, residual aphakia should be treated using either aphakic glasses or contact lenses (cl). aphakic glasses can be used for the correction of bilateral aphakia but these are not suitable for eyes with unilateral aphakia. many physicians insert a silicone cl immediately at the end of cataract surgery under general anesthesia but others delay it until 1 to 2 weeks after surgery. to calculate the power of cl preoperatively, use the formula for iol power calculation with an a constant of 112.176, which provides a good cl estimation21. although the opinion was divided for use of intracameral steroids (46% vs. 54%) at the end of surgery of congenital cataract, the majority was against the use of intracameral antibiotics (60.5%). however, these two can be injected intracamerally when manipulation has been done for a longer period or there is any doubt about the strict application of sterilization rules. the wound sealing measures at the end of congenital cataract surgery depend on the type of given incision. the tunnel incision whether clear corneal or corneoscleral may close itself or may require just corneal hydration of the wound. however, majority liked to apply one stitch (71%) to secure the wound and sleep with comfort as the tensile strength of the wound lips in this age group is less as compared to adults. nylon 10/0 was the most used suture (60.5%) for closing wound for congenital cataract. its disadvantage of being non-absorbable mounts an additional session of general anesthesia for removal of stitches after 8 weeks. this problem can be overcome by use of absorbable suture 8/0 vicryl or 10/0 vicryl out of which the latter is becoming more popular9. if available, fibrin glue is another good option to seal the wound without a stitch. during the wound healing phase after congenital cataract surgery, it is advised to continue the use of topical antibiotics and steroids for some time. the majority of pediatric ophthalmologists liked to use postoperative topical antibiotics for 2 – 4 weeks. however, the topical steroids were used for a relatively long period ranging from 4 – 8 weeks depending upon the condition of the operated eye. the frequency of post-surgery refractions in an operated child of congenital cataract may vary with advancing age. in first 5 years of life, the six monthly visits were ideal and liked by the majority of pediatric ophthalmologists (82%). after 5 years of age, annual refractions may be sufficient to cater for expected changes in glasses. if primary posterior capsulotomy has not been done during the congenital cataract surgery, the chances of posterior capsular thickening are quite high. younger the child more are the chances. if the capsule becomes thick then it cannot be left as it is. we must perform yag laser capsulotomy or surgical capsulotomy to avoid development of sensory deprivation amblyopia. it should not be performed until 3 months after the operation but should not be delayed more than six months after surgery. to perform nd-yag laser capsulotomy under topical anesthesia in children less than 5 yrs of age is not an easy task. however, a very good percentage of pediatric ophthalmologists (49%) feel confident in successfully performing this procedure after the age of 5 years while the high majority (92%) can do so at the age of 9 years. this needs to prepare the child and the parents in several frequent visits before embarking upon this procedure. congenital cataract and amblyopia go side by side for the array of reasons i.e. cataract develops in amblyogenic age, under correction by reducing the biometric power of implanted iol during surgery, posterior capsular thickening, wrong refractions and ignorance about the importance of the regular use of mian muhammad shafique, et al 82 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology glasses. the amblyopia should be diagnosed vigilantly and treatment started immediately. the cheapest and most popular method (97%) is occlusion therapy. the normal eye is patched and the amblyopic eye is kept open and is forced to focus the colorful objects. the prescribed glasses must be worn during the session of patching. there are different patching regimens but ‗one hour daily for every year of age' is the simplest and the successful rule for treatment of amblyopia related to congenital cataract. other methods like the use of atropine eye drops to blur the normal eye can be applied in highly uncooperative children in place of patching. although the healing process after cataract surgery takes only a few months to complete, the child cannot be discharged from care so early due to continuous growth and changes occurring in refraction of the eye. the post-operative management and follow up is the cornerstone of successful pediatric cataract surgery.22 in our study, there was a strong opinion (69%) to keep the child under constant follow up during the whole time of growth or at least until the age of 10 years. however, the literature review shows evidence of poor follow-up in these children. all efforts should be made to improve this important part of management.23 the loss to follow up is much more commonly seen in free eye camps of rural areas as compared to surgery done in tertiary care centers.24 the limitation of the study is that it includes only the members of osp (ophthalmological society of pakistan) and apop (association of pediatric ophthalmology of pakistan). there are other pediatric ophthalmologists who are working quite successfully all around the country but they were not included in the study. in future, the study can be expanded to a broader base by increasing the number of its participants as well as adding up the individual interviews to collect additional data from pediatric ophthalmologists. conclusion data received by a national survey on "evidencebased management of congenital cataract‖ from renowned pediatric ophthalmologists of our country has helped us formulate ―consensus guidelines for management of congenital cataract in pakistan‖. these are very much consistent with internationally available guidelines for management of this disease. all aspects of management right from symptoms, signs, diagnosis, surgery and postoperative follow-up has been covered. an attempt has been made to address all controversial issues related with management of congenital cataract in light of survey results and international practices. acknowledgment this study was done as a project of the osp leadership program. financial support and sponsorship nil. conflicts of interest there are no conflicts of interest. author’s affiliation prof. mian muhammad shafique head of the ophthalmology department lahore medical and dental college, lahore. prof. muhammad moin head of the department of ophthalmology, postgraduate medical institute, ameer-ud-din medical college, lahore. role of authors prof. mian muhammad shafique study design, manuscript drafting, data collection. prof. muhammad moin study design, critical review. data analysis. references 1. lenhart pd, courtright p, wilson me, et al. global challenges in the management of congenital cataract: proceedings of the international congenital cataract symposium held on march 7, 2014, in new york city, new york. journal of aapos : the official publication of the american association for pediatric ophthalmology and strabismus/american association for pediatric ophthalmology and strabismus. 2015; 19 (2): e1e8. doi:10.1016/j.jaapos.2015.01.013. 2. tailor vk, abou-rayyah y, brookes j, et al. quality of life and functional vision in children treated for cataract—a cross-sectional study. eye, 2017; 31 (6): consensus guidelines for management of congenital cataract in pakistan pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 83 856864. doi:10.1038/eye.2016.323.) 3. sheeladevi s, lawrenson jg, fielder ar, suttle cm. global prevalence of childhood cataract: a systematic review. eye, 2016; 30 (9): 1160-1169. doi:10.1038/eye.2016.156. 4. wu x, long e, lin h, liu y. prevalence and epidemiological characteristics of congenital cataract: a systematic review and meta-analysis. scientific reports, 2016; 6: 28564. doi:10.1038/srep28564. 5. holmes jm, leske da, burke jp and hodge do. birth prevalence of visually significant infantile cataract in a defined u.s. population. ophthalmic epidemiol. 2003 apr: 10: 67-74. 6. rahi js, dezateux c: british congenital cataract interest group. measuring and interpreting the incidence of congenital ocular anomalies: lessons from a national study of congenital cataract in the uk. invest ophthalmol vis sci. 2001 june; 42: 1444-8. 7. jun yi, jun yun, zhi-kui li, chang-tai xu, and borong pan. ―epidemiology and molecular genetics of congenital cataracts‖ int j ophthalmol. 2011; 4 (4): 422– 432. 8. dineen, bourne rr, jadoon z, shah sp, khan ma, foster a, gilbert ce, khan md. ―causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey‖ br j ophthalmol. 2007 aug; 91 (8): 1005–1010. 9. khokhar sk, pillay g, dhull c, agarwal e, mahabir m, aggarwal p. pediatric cataract. indian j ophthalmol. 2017; 65: 1340-9. 10. ma f, ren m, wang l, wang q, guo j. visual outcomes of dense pediatric cataract surgery in eastern china. bhattacharya s, ed. plos one, 2017; 12 (7): e0180166. doi:10.1371/journal.pone.0180166. 11. long e, lin z, chen j, et al. monitoring and morphologic classification of pediatric cataract using slit-lamp-adapted photography. translational vision science & technology, 2017; 6 (6): 2. doi:10.1167/tvst.6.6.2. 12. vishwanath m, cheong-leen r, taylor d, et al. is early surgery for congenital cataract a risk factor for glaucoma? br j ophthalmol. 2004; 88: 905-910. 13. pandey sk, wilson me, trivedi rh, et al. pediatric cataract surgery and intraocular lens implantation: current techniques, complications and management. int. ophthalmol clin. 2001 summer; 41 (3): 175-96. 14. goswami d, seetharamaiah s, kedia sk, nayak bk, akshat s. anesthetic dilemma in planning bilateral cataract surgery for an infant associated with congenital cardiac anomaly. indian journal of ophthalmology, 2015; 63 (6): 548-549. doi:10.4103/0301-4738.162630.). 15. wilson me, pandey sk, thakur j. paediatric cataract blindness in the developing world: surgical techniques and intraocular lenses in the new millennium. the british journal of ophthalmology, 2003; 87 (1): 14-19. 16. khokhar sk, pillay g, agarwal e, mahabir m. innovations in pediatric cataract surgery. indian journal of ophthalmology, 2017; 65 (3): 210-216. doi:10.4103/ijo.ijo_860_16. 17. medsinge a, nischal kk. pediatric cataract: challenges and future directions. clinical ophthalmology (auckland, nz). 2015; 9: 77-90. doi:10.2147/opth.s59009. 18. wood ic, hodi s, morgan l. longitudinal change of refractive error in infants during the first year of life. eye (lond). 1995; 9 (pt 5): 551–557. 19. wilson me, trivedi rh. choice of intraocular lens for pediatric cataract surgery: survey of aapos members. j cataract refract surg. 2007; 33 (9): 1666–1668. 20. kim ej, berg jp, weikert mp, kong l, hamill mb, koch dd, et al. scleral-fixated capsular tension rings and segments for ectopia lentis in children. am j ophthalmol. 2014; 158: 899–904. [pubmed: 25127699] 21. trivedi rh, wilson me. selection of an initial contact lens power for infantile cataract surgery without primary intraocular lens implantation. ophthalmology, 2013; 120 (10): 1973-1976. doi:10.1016/j.ophtha.2013.03.013. 22. ram j, agarwal a. the challenge of childhood cataract blindness. he indian journal of medical research, 2014; 140 (4): 472-474. 23. kishiki e, van dijk k, courtright p. strategies to improve follow-up of children after surgery for cataract: findings from child eye health tertiary facilities in sub-saharan africa and south asia. eye, 2016; 30 (9): 1234-1241. doi:10.1038/eye.2016.169. 24. ram j, sukhija j, thapa br, arya vk. comparison of hospital versus rural eye camp based pediatric cataract surgery. middle east african journal of ophthalmology, 2012; 19 (1): 141-146. doi:10.4103/09749233.92131. https://www.ncbi.nlm.nih.gov/pubmed/?term=yi%20j%5bauthor%5d&cauthor=true&cauthor_uid=22553694 https://www.ncbi.nlm.nih.gov/pubmed/?term=yun%20j%5bauthor%5d&cauthor=true&cauthor_uid=22553694 https://www.ncbi.nlm.nih.gov/pubmed/?term=li%20zk%5bauthor%5d&cauthor=true&cauthor_uid=22553694 https://www.ncbi.nlm.nih.gov/pubmed/?term=xu%20ct%5bauthor%5d&cauthor=true&cauthor_uid=22553694 https://www.ncbi.nlm.nih.gov/pubmed/?term=pan%20br%5bauthor%5d&cauthor=true&cauthor_uid=22553694 https://www.ncbi.nlm.nih.gov/pubmed/?term=pan%20br%5bauthor%5d&cauthor=true&cauthor_uid=22553694 microsoft word 3. hussain ahmad khaqan 66 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology original article incidence of endophthalmitis after bevacizumab (avastin) hussain ahmad khaqan, qasim lateef, syed ali haider pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hussain ahmad khaqan eye department lgh/pgmi, lahore …..……………………….. purpose: to assess the rate of infectious endophthalmitis after an intravitreal injection of bevacizumab (avastin). material and methods: the patients undergoing intravitreal injections of antivascular endothelial growth factor bevacizumab (avastin) from june 1st, 2006, through to june 30, 2011 were followed up for one month after injection at unit 3, department of ophthalmology, lahore general hospital, lahore to determine rate of infectious endophthalmitis after an intravitreal injections of antivascular endothelial growth factor bevacizumab (avastin). results: 7 (0.134%) cases of clinically suspected endophthalmitis were identified after a total of 5189 intravitreal injections of antivascular endothelial growth factor (avastin). the mean interval between intravitreal anti vegf injections and onset of symptoms was 2.55 days. the interval between onset of symptoms and examination was average 4 days. conclusion: endophthalmitis remains an infrequent but severe complication of intravitreal injections of bevacizumab (avastin). using a strict injection protocol may help in reducing the incidence of infection. he use of intravitreal antivascular endothelial growth factor (anti vegf) agents such as bevacizumab and ranibizumab has increased dramatically during the past few years following reports of successful treatment of neo-vascular age related macular degeneration1-6 diabetic macular oedema,7-9 macular oedema secondary to retinal vein occlusion10-11 and others. a serious complication associated with treatment is infectious endophthalmitis with a reported incidence ranging between 0.03% and 0.16% per injection,1,12-15 which may cause permanent loss of vision despite prompt and appropriate antibiotic therapy. various protocols have been proposed to minimize the infection rate16,17. we wished to enquire into the infection rate within our own environment. material and methods this prospective study was conducted at unit 3, department of ophthalmology, lahore general hospital, lahore from june 1, 2006, through june 30, 2011. all patients who received intravitreal injections of bevacizumab (avastin) were included in the study. patients receiving other intravitreal injections (including corticosteroids, antibiotics, antivirals and other medications were excluded. all intravitreal injections in the current study were performed with nursing assistance and procedure was recorded in doctor and nursing logbook. the protocol of intravitreal injections at our department does not include pre injection antibiotics. the lgh (lahore general hospital) protocol of sterilization was as follow: a registered pharmacist formulated the injection preparation at shokat khanum memorial hospital. the injection protocol included insertion of pledget soaked in 5% povidone iodine and proparacaine 0.5% in conjunctival sac five minutes before injection. after five minutes lashes, eyelid skin were swabbed and conjunctival sac was irrigated with 5% povidone iodine and after another t hussain ahmad khaqan, et al. pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 67 five minutes lashes and lids were cleaned with alcohol swab and pledget was removed. the eyelids were draped with sterile drape and a sterile speculum was used to open the lids. the injection was performed in the infero-temporal quadrant with the injecting physician wearing sterile gloves, followed by one drop of a topical antibiotic (moxifloxacin). all the patients were instructed to use antibiotic drops four times a day for one week. sterilization protocol was same for all the patients of our study. clinical diagnosis of endophthalmitis was made on the basis of the presence of anterior chamber reaction, keratic precipitates, hypopyon, fibrin and /or posterior synaechie. data analysis: the data were entered into computer and analyzed using spss 16 (statistical package for social sciences). the data were described in terms of mean ± sd (standard deviation) for quantitative variables. frequencies and percentages were given for qualitative variables. independent sample t-test was used to observe groups mean differences. one-way anova (analysis of variance) was applied to observe mean differences among groups. pearson chisquare was used to observe associations between qualitative variables. a p-value of <0.05 was considered statistically significant. results a total of 5189 intravitreal injections of bevacizumab (avastin) were performed at our department over a period of five years (june 1st, 2006, through to june 30th, 2011). there were 7 (0.134%) cases of clinically suspected endophthalmitis. patients presented with symptoms of pain, red eye and decreased vision. the mean interval between intravitreal injection and onset of symptoms was 2.55 days. the interval between onset of symptoms and examination was average 4 days. discussion we report 7 cases of clinically suspected endophthalmitis after intravitreal antivascular endothelial growth factor avastin (incidence 0.134%). a clinical diagnosis of endophthalmitis of anterior chamber reaction with keratic precipitates, hypopyon, fibrin and / or posterior synaechie. the institutional injection protocol remained unchanged during the duration of study. this protocol is different from published suggested protocols14,18. the current study is one of the largest series reported to date in case of endophthalmitis after intravitreal injections of antivascular endothelial growth factor avastin. the strength of this study is that the study was conducted at one unit of ophthalmology department of a hospital rather than at different hospitals and protocol of dis-infection and injection remained the same. table 1: incidence of endophthalmitis after intravitreal injection: selected prospective clinical trials. study medication number/ incidence (per eye), n (%) number/ incidence (per injection), n (%) marina19 ranibizumab 5/477(1.0) 5/10,443(0.05) anchor20 ranibizumab 2/227(0.7) table 2: incidence of endophthalmitis after intravitreal injection: selected large retrospective case series. study medication rate of infection (per injection),n(%) mason et al21 bevacizumab 1/5,233(0.02) fung et al22 bevacizumab 1/7,113(0.014) wu et al23 bevacizumab 7/4,303(0.16) artunay et al24 bevacizumab 2/3,022(0.066) the low incidence of endophthalmitis after intravitreal injection of avastin in probably due to strict adherence to this protocol. most prospective clinical trials involving intravitreal antivegf injections reported rates of endophthalmitis per study and per injection on the order of 1% and 0.1% respectively19,20. most retrospective case series reported cases of endophthalmitis in populations of patients receiving variable number on injections and were typically reported as rates per injection, rather than rates per eye21-24. our case series found the rate of endophthalmitis after intravitreal injection of anti vascular endothelial growth factor avastin to be 0.134%. the diagnostic clues of endophthalmitis were the main outcome measure. there was anterior chamber reaction in all patients with keratic precipitates, hypopyon. incidence of endophthalmitis after bevacizumab (avastin) 68 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology conclusion endophthalmitis remains an infrequent but severe complication of bevacizumab (avastin). using a strict injection protocol may help in reducing the incidence of infection. author’s affiliation dr. hussain ahmad khaqan vitreo retinal fellow eye department lgh/pgmi, lahore dr. qasim lateef assist. professor mayo hospital, lahore dr. syed ali haider professor of ophthalmology eye department lg h/pgmi, lahore reference 1. rosenfeld pj, brown dm, heier js, et al. marina study group. ranibizumab for neovascular age related macular degeneration. n eng j med. 2006; 355: 1419-31. 2. heier js, boyer ds, ciulla ta, et al. focus study group. ranibizumab combined with vetiporfin photodynamic threrapy in neovascular age-related macular degeneration: year 1 result of the focus study. arch ophthalmol. 2006; 124: 1532-42. 3. brown dm, kaiser pk, michels m, et al. anchor study group. ranibizumab versus vetiporfin for neovascular age related macular degeneration. n eng j med. 2006; 355: 1432-44. 4. regillo cd, brown dm abraham p, et al. randomized, double-masked, sham-cotrolled trial of ranibizumab for neovascular age-related macular degeneration: pier study year1. am j ophthalmol. 2008; 145: 239-48. 5. rosenfeld pj, moshfegi aa, puliafito ca. optical coherence tomography findings after an intravitreal injection of bevacizumab (avastin) for neovascular age related macular degeneration. ophthalmic surg lasers imaging. 2005; 36: 331-5. 6. avery rl, pieramicic dj, rabena md, et al. intravitreal bevacizumab (avastin) for neovascular age-related macular degeneration. ophthalmology 2006; 113: 363-72. 7. arevalo jf, fromow-guerra j, quiroz-mercado h, et al. panamerican collaborative retina study group. primary intravitreal bevacizumab (avastin) for diabetic macular edema: result from the pan-american collaborative retina study group at 6-month follow up. ophthalmology 2007; 114: 743-50. 8. chun dw, heier js, topping tm, et al. a pilot study of multiple intravitreal injections of ranibizumab in patients with center-involving clinically significant diabetic macular edema. ophthalmology. 2006; 113; 1706-12. 9. nguyen qd, tatlipinar s, shah sm, et al. vascular endothelial growth factor is a csitical stimulus for diabetic macular edema. am j ophthalmol. 2006; 142: 961-9. 10. kriechbaum k, michels s, prager f, et al. inteavitreal avastin for macular edema secondary to retinal vein occlusion: a prospective study. br j ophthalmol. 2008; 92: 518-22. 11. ferrara dc, koizumi h, spaide rf, et al. early bevacizumab treatment of central retinal vein occlusion. am j ophthalmol. 2007; 144: 864-71. 12. pilli s, kotsolis a, spaide rf, et al. endophthalmitis associated with intravitreal anti-vascular endothelial growth factor therapy injections in an office sitting, am j ophthalmol. 2008; 145: 879-82. 13. the eyetech study group. anti-vascular endothelial growth factor therapy for subfoveal choriodal neovascularization secondary toage-related macular degeneration: phase ii study results. ophthalmol. 2003; 110: 979-86. 14. heier js, antozyk an, pavan pr, et al. ranibizumab for treatment of neovascular age-related macular degeneration: a phase i/ii multcenter, cotrolled, multidose study. ophthalmology 2006; 113: 633. 15. wu l, marinez-castellanos ma, quiroz-mercado h, et al. pan american collaborative retina group (pacores). twelve-month safety of intravitreal injections of bevacizumab (avastin [r]): results of the pan-american collaborative retina study group (pacores). greafes arch clin exp ophthalmol 2008; 246: 81-7. 16. schwartz sg, flynn hw jr, scott iu. endophthalmitis after intravitreal injections. expert opin pharmacother. 2009; 10; 1-8. 17. el-ashray mi, dhillon b. the article by fintak et al on the incidence of endophthalmitis related to intravitreal injections of bevacizumab and ranibizumab. retina. 2009; 29: 720-1. 18. aiello lp, brucker aj, chang s, et al. evolving guidelines for intravitreous injections. retina. 2004; 24; s3-s19. 19. rosenfeld pr, brown dm, heier js, et al. ranibizumab for neovascular age-related macular degeneration. n eng j med. 2006; 355: 1419-31. 20. brown dm, michels m, kaiser pk, et al. anchor study group. ranibizumab versus veteporfin for neovascular agerelated macular degeneration. n eng j med. 2006; 355: 1432-44. 21. mason jo iii, white mf, feist rm, et al. incidence of acute onset endophthalmitis following intravitreal bevacizumab (avastin) injection. retina. 2008; 28: 564-7. 22. fung ae, rosenfeld pj, reichel e. the international intravitreal bevacizumab safety survey: using the internet to assess drug safety worldwide. br j ophthalmol. 2006; 90: 1344-9. 23. wu l, marinez-casellanos ma, quiroz-mercado h, et al. twelve-month safety of intravitreal injections of bevacizumab (avastin): results of the pan-american collaborative retina group study (pacores). greafes arch clin exp ophthalmol. 2008; 246: 81-7. 24. artunay o, yuzbasioglu e, rasier r, et al. incidence and managament of acute endophthalmitis after intravitreal bevacizumab (avastin) injection. eye 2009; 3: 2187-93. 184 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology abstracts edited by dr. qasim lateef chaudhry surgical management of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled trials soni c, hainsworth dp, almony a ophthalmology 2013; 120: 1440-7. chetan et al did this meta-analysis study to examine possible differences in clinical outcomes between pars plana vitrectomy (ppv) and scleral buckling (sb) for uncomplicated rhegmatogenous retinal detachment (rrd). adult patients with uncomplicated rrd from previously reported randomized controlled trials of ppv and sb were included in this meta analysis using a comprehensive literature search using the cochrane collaboration methodology to identify randomized controlled trials comparing ppv with sb for uncomplicated rrd. analysis was divided into phakic and pseudophakic/aphakic patients. primary outcome parameters included proportion of primary reattachment and difference of means of best-corrected visual acuity (bcva) at 6 months or more between the ppv and sb groups. secondary outcome parameters included the proportion of secondary reattachment and complications between the ppv and sb groups. seven studies were identified and analyzed for comparing ppv (636 eyes) with sb (670 eyes) for uncomplicated rrd. in the phakic group, there were no significant differences in the proportion of primary reattachments (odds ratio [or], 1.00; 95% confidence interval [ci], 0.69–1.46) or secondary reattachments (or, 0.99; 95% ci, 0.34–2.87) between the ppv and sb groups. meta-analysis showed a statistically significant difference in the logarithm of the minimum angle of resolution (logmar) bcva at 6 months between the ppv-treated and sb-treated phakic eyes (mean deviation, 0.14; 95% ci, 0.06–0.21; p-0.0004). in the pseudophakic/aphakic group, there were no significant differences in the proportion of primary reattachments (or, 1.46; 95% ci, 0.79–2.71) or logmar bcva at 6 months between the ppv and sb groups (mean deviation, -0.03; 95% ci, -0.10 to 0.04). a statistically significant difference was noted in the proportion of secondary reattachments (or, 2.08; 95% ci, 1.08-4.03; p 0.03) between the ppv and sb groups in pseudophakic/aphakic eyes. metaanalysis showed a statistically significant rate of cataract progression in the ppv group (or, 4.11; 95% ci, 2.70–6.25; p-0.00001). the authors concluded that there were no significant differences in the proportions of primary reattachment in the ppv and sb groups in phakic eyes. the sb-treated phakic eyes had better postoperative bcva at 6 months or more. this was most likely related to higher rates of cataract progression in ppv-treated phakic eyes. there were no significant differences in proportions of primary reattachment and postoperative bcva at 6 months or more in pseudophakic/aphakic eyes. corneal collagen cross-linking with riboflavin and ultraviolet a irradiation for keratoconus hashemi h, mohammad amin seyedian ma, miraftab m, fotouhi a, asgari s ophthalmology 2013;-120:-1515–20. hassan et al evaluated the long-term results of corneal collagen cross-linking (cxl) in patients with progressive keratoconus in this prospective case series. this study was conducted on 40 eyes of 32 patient with progressive keratoconus between 2006 and 2012. patients underwent cxl no later than 1 month after baseline examinations. for cxl, ultraviolet irradiation was applied for 30 minutes, during which riboflavin instillation was repeated every 3 minutes. patients were tested for best-corrected visual acuity (bcva), uncorrected visual acuity (ucva), manifest refraction spherical equivalent (mrse), and scheimpflug imaging from which they extracted maximum keratometry reading (max-k), average of minimum and maximum keratometry readings (mean-k), central corneal thickness (cct), and anterior and posterior elevation at the apex at baseline, at 1, 3, 6 months after cxl, and 1, 2, 4, and 5 years later. they studied results at 5 years after cxl as well as the trend of changes over the 5-year period. the results showed that mean ucva was 0.67-0.52 logarithm of the minimum angle of resolution (logmar) at baseline and 0.65-0.51 logmar at 5 years after the procedure. for mean bcva, these values were 0.31-0.28 and 0.19-0.20 logmar, respectively (p 0.016). the mean mrse changed from -3.18 -2.23 diopters (d) to -2.77 -2.18 d, and mean refractive cylinder error changed from -3.14 -2.22 to -2.49 -1.71 d abstracts pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 185 (p -0.089). mean max-k and mean-k decreased by 0.16-2.20 and 0.10-1.69 d, respectively. the cct increased from 483.87 -29.07 to 485.95 -28.43 -m. mean anterior elevation at the apex changed from 13.9 2 8.28 to 11.45 -8.18 -m (p -0.030) and posterior elevation at this point changed from 29.54 -18.39 to 26.34 -19.59 m. the mean-k, max-k, ucva, and astigmatism showed no change over time during these 5 years. after the first year, bcva, mrse, and cct showed no change and stabilized, whereas elevation readings continued to decrease up to 5 years after cxl. the authors concluded based on 5-year results that treatment of progressive keratoconus with cxl can stop disease progression, without raising any concern for safety, and can eliminate the need for keratoplasty. incidence of canalicular closure with endonasal dacryocystorhinostomy without intubation in primary nasolacrimal duct obstruction cannon ps, chan wo, selva d ophthalmology 2013; 120: 1688-92. paul et al describe the incidence of canalicular closure with powered endonasal dacryocystorhinostomy (dcr) without canalicular intubation in primary acquired nasolacrimal duct obstruction (pando) in this single-surgeon, prospective, nonrandomized, noncomparative, interventional case series. the participants were consecutive patients attending a specialist clinic of an oculoplastic surgeon (ds) with radiologically confirmed diagnosis of pando. cases of canalicular disease were excluded. all patients with radiologically confirmed pando without canalicular involvement underwent endonasal dcr without intubation. the operation was performed by 1 surgeon (ds) and follow-up was at 4 weeks and 12 months. outcomes were recorded as subjective symptomatic relief at 12 months and endoscopic evidence of ostium patency and canalicular patency. there were 132 cases that fulfilled the inclusion criteria. three cases were lost to follow-up. preoperatively, 96.3% of cases had munk scores of >2. of the 129 cases, 127 (98.5%) had endoscopic evidence of a patent ostium with a positive endoscopic dye test at the 12-month follow-up. all cases had a patent canalicular system as demonstrated by syringing and probing. of the 129 cases, 117 (90.7%) had subjective improvement of epiphora at 12 months with 88.4% of cases reporting munk scores of 1. the authors concluded in this prospective series of non intubation for pando, there were no cases of canalicular closure or stenosis at 12 months. anatomic and functional success was similar to reported outcomes for dcr with intubation for pando. the also advocated that routine intubation for the purpose of maintaining canalicular patency is not necessary when performing endonasal dcr in pando. detection of glaucomatous progression by spectraldomain optical coherence tomography na jh, sung kr, lee jr, lee ks, baek s, kim hk, sohn yh ophthalmology 2013; 120: 1388-95. the authors compared the rate of change of circumpapillary retinal nerve fiber layer (crnfl) thickness, macular volume and thickness, and optic nerve head (onh) parameters assessed using spectraldomain optical coherence tomography (sd-oct) between eyes with progressing and nonprogressing glaucoma in this longitudinal, observational study. two hundred seventy-nine eyes from 162 glaucoma patients followed for an average of 2.2 years. eyes were classified as progressors and nonprogressors according to assessment of optic disc and rnfl photographs and visual field progression analysis. linear mixed effects models were used to evaluate the overall rate of change of crnfl thickness, macular volume and thickness, and onh parameters after adjustment for age, spherical equivalent, signal strength, and baseline sd-oct measurements. the main outcome measures were the rate of change of crnfl thickness, macular volume, and thickness and onh parameters. sixty-three eyes (22.6%) from 52 subjects were identified as progressors. average, inferior quadrant, and 6and 7-o’clock sector crnfl thickness decreased faster in progressors than in nonprogressors (-1.26 vs -0.94, -2.47 vs -1.75, -3.60 vs 2.52, and -2.77 vs -1.51 -m/year, respectively; all p0.05). the onh rim area decreased faster, and average and vertical cup-to-disc ratio increased faster in progressors than in nonprogressors (-0.016 vs -0.006 mm2/year, and 0.004 vs 0.002 and 0.006 vs 0.004 per year, respectively; all p-0.05). macular cube volume and the thickness of temporal outer and inferior inner macular sectors decreased faster in progressors than in nonprogressors (-0.068 vs -0.048 mm3/year, and -2.27 vs -1.67 and -2.51 vs -1.73 -m/year, respectively; all p0.05). the authors concluded that serial measurement of parameters in all 3 areas (crnfl, macula, and onh) by sd-oct may permit identification of progression in glaucomatous eyes. pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 151 original article congenital cataract: morphology and management sana nadeem, muhammad ayub, humaira fawad pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sana nadeem senior registrar ophthalmology department fauji foundation hospital, rawalpindi …..……………………….. purpose: to evaluate the morphology of congenital cataracts presenting to us and their subsequent surgical management and visual rehabilitation. material and methods: a total of 46 eyes of 28 patients in the age range from 3 months to 25 years with unilateral or bilateral congenital cataract (diagnosed at any age), with no other associated ocular pathology of the anterior or posterior segment, no history or features of trauma, and without systemic or syndromic associations, presenting to the department of ophthalmology, holy family hospital, rawalpindi between 1 st january, 2012 to 30 th september, 2012 were included in this prospective, interventional study. results: the most common morphological type of isolated congenital cataract found in our study was lamellar cataract in 12 eyes (26.1%), and total white cataract also in 12 eyes (26.1%), followed by isolated blue dot cataract in 3 eyes (6.5%). mixed morphologies were found in 13 (28.2%) eyes. pre-operative visual acuity was better than 6/18 in 13 (28.3%) eyes, less than 6/18 in 15 (32.6%) eyes, and unrecordable in 18 (39.1%) eyes. best corrected visual outcome was significantly improved, with a visual acuity achieved better than 6/18 in 25 (54.3%) eyes, less than 6/18 in 5 (10.9%) eyes and unrecordable in 16 (34.8%) eyes. (p= 0.000) the minimum follow up was 3 months and maximum follow up was 15 months. conclusions: isolated lamellar and total white cataracts are the common morphologies of congenital cataract found in our study. good visual outcome can be achieved with early surgical intervention and appropriate visual rehabilitation. ongenital cataracts account for 1 out of every 2000 live births,1 and are quite common, causing 10% of all preventable visual loss in children globally.2 pediatric cataracts are responsible for more than 1 million childhood blindness in asia.3 visual loss is mainly due to stimulus deprivation amblyopia, strabismus and nystagmus which are proportionately related to the size, location and density of the opacity, especially if bilateral.4,5 several different classification systems exist including morphology, etiology, presence of specific metabolic disorders, associated ocular anomalies or systemic findings.1 compared to adults, decision for surgery is more difficult as subjective visual assessment in children cannot be obtained, and surgeons rely largely on the morphology and location of the cataract and behavior of the child. surgery needs to be undertaken within the first three months of life as indicated by experimental and clinical research,5 as early detection and management is directly related to the visual outcome. controversy6 still remains as regards to the age at which an iol can be safely implanted inside the eye. aphakia management poses a significant problem and needs spectacles or contact lenses. success; however is directly related to parental compliance and child cooperation. results of pediatric cataract surgery are based not only on the anatomic success but the postoperative maintenance of a clear visual axis, and aggressive management of pre-existing amblyopia and its prevention. c sana nadeem, et al 152 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology we embarked on this study, to observe different morphologies of the congenital cataracts which presented to us, and to manage them surgically, with appropriate visual rehabilitation, and to assess the visual outcome after management. material and methods a total of 46 eyes of 28 patients presenting to ophthalmology department, holy family hospital, rawalpindi from to 1st january, 2012 till 30th september, 2012 who were diagnosed as congenital cataracts on the basis of morphology (any age), and were operated during this period, were included in this study. exclusion criteria included trauma, uveitis, glaucoma, anterior segment abnormalities, fundus abnormalities and systemic or syndromic associations. a detailed history and physical examination was done, along with visual acuity assessment, tonometry, slit lamp examination, retinoscopy, ophthalmoscopy, b-scan ultrasonography, keratometry and intraocular lens (iol) power assessment by srk-ii formula where necessary. the pupils were dilated with cyclopentolate 1% or phenylephrine 10%. all patients were treated with lens aspiration with anterior capsulorhexis via the limbal approach. primary posterior capsulotomy with anterior vitrectomy was done only in selected cases due to absence of an ac maintainer in our hospital. primary iol implantation was done in children above two years of age. all cases were treated with topical steroid-antibiotics for at least 6 weeks. cycloplegics or systemic steroids were needed in severe postoperative inflammation. the patients were followed up at 1st postoperative day, then 1st postoperative week, then monthly for at least 3 months. thereafter, follow up was variable, with the range between 3 months to 15 months. visual acuity was done with snellen chart in adults, the picture snellen chart in co-operative children, and fixation was noted in smaller children. data was analyzed using spss version 16. frequencies and percentages of age, gender, cataract morphology, and complications were noted. pre and post-operative visual outcome was assessed and chi square test was applied, with a p value less than 0.05 being considered significant. results a total of 46 eyes of 28 patients ranging from 3 months to 25 years, with a mean age of 9.6 ± 8.1 years, were included in this study. there were 16 (57.1%) females and 12 (42.8%) males. unilateral cataracts were seen in 3 (10.7%) patients only with bilateral involvement in 25 (89.2%) patients. consanguinity was present in 16 (57.1%) patients. morphologically, isolated lamellar cataract with riders was the most common type found in 12 eyes (26.1%), along with total white cataract, also in 12 eyes (26.1%), followed by isolated blue dot cataract in 3 eyes (6.5%), isolated nuclear, sutural and psco (posterior subcapsular cataract) in 2 (4.3%) eyes each. a combination of different morphologies were found in 13 (28.2%) eyes, with combined blue dot and sutural in 4 (8.7%) eyes, blue dot and psco in 3 (6.5%) eyes, nuclear and psco in 3 (6.5%) eyes, coronary and psco in 2 (4.3%) eyes and combined lamellar and sutural cataract in 1 (2.2%) eye (table 1) (fig. 1). lamellar nuclear + psco lamellar + sutural nuclear total blue dot sutural psco coronary + psch blue dot + sutural blue dot + psco fig. 1: pie chart of congenital cataract morphology congenital cataract: morphology and management pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 153 lens aspiration with intraocular lens (iol) implantation was done in 31 (67.4%) eyes, lens aspiration with anterior capsulotomy alone, was performed in 13 (28.3%) eyes, and lensectomy with posterior capsulotomy and anterior vitrectomy was done in only 2 (4.3%) eyes due to lack of an ac maintainer. iol implantation was done in children above 2 years of age. aphakic and uncooperative children required a secondary procedure for posterior capsular opacification with surgical capsulotomy alone or surgical capsulotomy with a secondary iol later. cooperative children and adults were treated with nd-yag laser capsulotomies. visual rehabilitation was done in all patients, either with aphakic spectacles in children less than 2 years and residual refractive error was corrected with appropriate spectacles. patching was advised to the parents in case of children. at presentation, visual acuity ranged from light perception to 6/12, with only 13 (28.3%) eyes with visual acuity of 6/18 or better, 15 (32.6%) eyes had vision less than 6/18, and 18 (39.1%) eyes had unrecordable vision. the postoperative best corrected visual outcome was significantly improved (p= 0.000) ranging from unrecordable to 6/6, with 24 (52.2%) eyes having visual acuity of 6/18 or better (table 2). 3 patients were lost to follow up at 3 months. early complications included severe inflammation in 22 (47.8%) eyes, mild inflammation in 13 (28.3%) eyes and striate keratitis in 10 (21.7%) eyes. these were managed appropriately with topical antibiotic-steroid combinations, cycloplegics and systemic steroids. late complications included posterior capsular opacification (pco) in 40 (86.9%) eyes, retinal detachment in 2 (4.3%) cases, pseudophakic glaucoma in 1 (2.2%) case, and persistent uveitis leading to phthisis bulbi in 1 (2.2%) case. pco was managed by surgical capsulotomies in children less than 4 years and older patients were treated with nd-yag laser capsulotomy. the patients are still on follow up and are part of a larger study. discussion congenital cataract is a term used to define lenticular opacities at birth. infantile cataract encompasses all lens opacities that develop within the first year of birth. the terms are used interchangeably due to some of these opacities being missed at birth only to be discovered later in life by ophthalmologists. they vary in severity from being non-progressive and visually insignificant to causing profound visual impairment.1 bilateral congenital cataract accounts for 15%7 of blindness in children worldwide. idiopathic2,7 cataracts are the most common. underlying and associated causes of congenital cataract vary worldwide. isolated hereditary cataracts account for 25% of cases, the most common being autosomal dominant, then autosomal recessive or x-linked.2,8 down, patau, edward, turner and cri du chat syndromes along with systemic diseases like galactosemia, lowe, fabry, alport, dystrophia myotonica, hypoglycemia, hypoparathyroidism and marfan syndrome are frequent associations. maternal infections like rubella, toxoplasma, cytomegalovirus, herpes simplex and varicella (torch) may be causative.1,2,4,8,9 morphologically cataracts may be classified into fibre-based and non-fibre based. these include anterior or posterior polar cataracts, lamellar (round, grey shell surrounding a clear nucleus), nuclear or cataracta centralis pulverulenta, sutural or stellate, floriform (flower – shaped), coralliform (coral-shaped), blue dot (punctate cerulean cataract), coronary (supranuclear), subcapsular, total white, disciform, oildroplet, spear and membranous cataracts. lamellar cataract is the commonest.1,2,4,8,9,10 in our study, isolated lamellar and isolated total white cataract were the most common, but combined patterns accounted for the largest number of eyes. other studies have shown lamellar,10 nuclear11 and total white12 cataracts to be the commonest. visual loss in congenital cataract is predominantly caused by amblyopia, which arises in a number of ways7: stimulus – deprivation; competitive inhibition between the two eyes due to unilateral or asymmetrical bilateral cataract; improper aphakia management; or stimulus deprivation secondary to sana nadeem, et al 154 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology posterior capsular opacification. thus amblyopia reversal, treatment and prevention have profound long term implications on the patient. in unilateral cataract, clinical observational studies have revealed that surgery by six to eight weeks7 has a better visual outcome as compared to later intervention. this may also be the “critical period” for bilateral disease. optimal timing for surgery is difficult to establish due to the association of aphakic glaucoma with very early surgery. some have suggested that early iol implantation may protect against this complication.7,13 despite significant improvements in surgical, optical and visual rehabilitation techniques, an optimal surgical approach is yet to be established. several techniques are available like lensectomy, anterior vitrectomy and/or combined with primary posterior capsulotomy. two main approaches exist for pediatric cataract removal: the limbal approach and the pars plana approach, the latter being considered the most versatile4. the anterior chamber maintainer (acm) is considered vital for pediatric cataract surgery. anterior capsulorhexis, either manually or with a vitrectomy probe, along with elective posterior capsulectomy and deep anterior vitrectomy has been considered for infants under 2 years of age; above 2 years, this is considered optional.1,2,4,7,9,13 the pars plana approach is indicated mainly for infants less than 2 years of age, particularly with bilateral cataracts. simultaneous surgery reduces the risk of relative amblyopia which may occur even when few days apart.4 iol implantation has been advocated in children two years2 and above, due to problems arising due to iol power, size, availability, material, refraction change and long term iol safety.6 however, many ophthalmologists now implant iols in younger age groups like one year with successful outcomes.14-16 iol power should be under corrected by 20% in children less than 2 years, and in children between 2 and 8 years, under corrected by 10%.4,9 the postoperative residual refractive error is corrected with spectacles. pediatric iols should be in the range of 10.5-12mm ideally17. techniques of iol placement include in-thebag, ciliary sulcus or iol optic placement behind the capsular bag.18 hydrophilic acrylic iols have fewer postoperative complications15 as compared to rigid pmma lenses. heparin coated7 pmma iols reduce postoperative uveitis. in our study, we implanted either hydrophilic acrylic or rigid pmma iols, with comparable results. pediatric eyes are especially prone to complications like fibrinous anterior uveitis, posterior capsular opacification, lens reproliferation (soemmerring ring), secondary pupillary membranes, aphakic or pseudophakic glaucoma in 25% (often years later), endophthalmitis, retinal detachment (also late) and unpredictable final refraction.1,2,4,6,7,8,9,13,19 the visual outcome depends on cataract type, timing of intervention, quality of surgery, and above all, amblyopia management. poor visual outcome with refractory amblyopia is associated with dense cataracts, unilateral cataracts, late presentation to the ophthalmologist, and poor compliance to occlusion therapy20. bilateral cataracts have been associated with a lesser risk of refractory amblyopia. dense, central, large and posterior cataracts lead to early amblyopia, and a subsequent poor visual outcome. partial, less dense, anterior, and smaller cataracts even if detected late, can be managed effectively with a good visual outcome21. in our study, most lamellar cataracts although detected late, resulted in very good postoperative vision. limitations of our study were many. this is not a study on pediatric patients alone and to evaluate morphology, we included older patients as well. lack of an acm prevented us from managing children less than 2 years of age appropriately with a primary posterior capsulotomy and anterior vitrectomy and only irrigation and aspiration was done, which resulted in early pco formation, necessitating surgical capsulotomies and increasing the number of surgical procedures for every patient. final visual outcome in children was poorer as compared to older patients, due to poor parental compliance with spectacles, patching and follow up. appropriate management of congenital cataract in a developing country poses a lot of problems both for the doctors and the patients. lack of essential equipment, together with illiteracy, poverty and irregular follow up affect tremendously the management of such cases. late presentation of children to hospitals results in refractory amblyopia. unaffordability of contact lenses, poor compliance with aphakic glasses and reluctance to patching all contribute to poor postoperative visual outcomes in aphakic children. similarly in children who present later and are implanted iols, refractory amblyopia is difficult to reverse and owes mostly due to poor compliance of patching. however, partial cataracts even when detected later, when treated, yield good results with much patient and doctor satisfaction. congenital cataract: morphology and management pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 155 early diagnosis and management along with parental advice and support is the key to successful visual rehabilitation. strategies to screen and detect congenital cataract within the first three months of life are needed for early diagnosis and routine ocular examination5 of neonates and young infants should be done routinely by ophthalmologists to prevent late detection and subsequent poor visual outcome. conclusion congenital cataract varies considerably in morphological appearance with the major types being lamellar, total white, combined pattern and blue dot. early surgical management with aggressive postoperative rehabilitation and amblyopia therapy is essential for effective visual outcome. visual outcome is better for partial, bilateral cataracts as compared to total white or unilateral cataracts. author’s affiliation dr. sana nadeem senior registrar ophthalmology department fauji foundation hospital, rawalpindi dr. muhammad ayub senior registrar ophthalmology department holy family hospital, rawalpindi dr. humaira fawad consultant ophthalmologist ophthalmology department district headquarters hospital, rawalpindi references 1. rosenfeld si, blecher mh, bobrow jc, bradford ca, glasser d, berestka js. lens and cataract. section 11. basic and clinical science course. american academy of ophthalmology. san francisco. 2005; 33-9. 2. simon jw, buckley eg, drack av, hutchinson ak, plager da, rabb el, ruttum ms, aaby aa. paediatric ophthalmology and strabismus. section 6. basic and clinical science course. american academy of ophthalmology. san francisco. 2005; 277-89. 3. world health organisation. prevention of childhood blindness. geneva: who; 1992. 4. yanoff m, duker js. ophthalmology. second edition. mosby: st louis. 2004; 279-379. 5. rahi js, dezateux c. national cross sectional study of detection of congenital and infantile cataract in the united kingdom: role of childhood screening and surveillance. the british congenital cataract interest group. bmj. 1999; 318: 362-5. 6. javadi ma. pediatric cataract surgery. editorial. j ophthalmic vis res. 2009; 4: 199–200. 7. wormald r, henshaw k, smeeth l. evidence-based ophthalmology. london: bmj publishing group; 2008. www.books.google.com. 2012; 47-51. 8. kanski jj, bowling b. clinical ophthalmology. a systematic approach. seventh edition. elsevier: london. 2011; 298-304. 9. denniston ako, murray pi. oxford handbook of ophthalmology. oxford university press: karachi. 2007; 235-627. 10. jain is, pillay p, gangwar dn, dhir sp, kaul vk. congenital cataract: etiology and morphology. j pediatr ophthalmol strabismus. 1983; 20: 238-42. 11. wilson me, trivedi rh, morrison dg, lambert sr, buckley eg, plager da et al. the infant aphakia treatment study: evaluation of cataract morphology in eyes with monocular cataracts. j aapos. 2011; 15: 4216. 12. kaid johar sr, savalia nk, vasavada ar, gupta pd. epidemiology based etiological study of pediatric cataracts in western india. indian j med sci. 2004; 58: 115-21. 13. mazhar-ul-hasan, qidwai ua, aziz-ur-rehman, bhatti n, alvi rh. complication and visual outcome after pediatric cataract surgery with or without intraocular lens implantation. pak j ophthalmol. 2011; 27: 30-4. 14. yorston d. intraocular lens implants in children. j comm eye health. 2001; 14: 57-8. 15. rowe na, biswas s, lloyd ic. primary iol implantation in children: a risk analysis of foldable acrylic v pmma lenses. br j ophthalmol. 2004; 88: 481-5. 16. flicroft di, knight-nanan d, bowell r, lanigan b, o’keefe m. intraocular lenses in children: changes in axial length, corneal curvature, and refraction. br j ophthalmol. 1999; 83: 265–9. 17. bluestein ec, wilson me, wang xh, rust pf, apple dj. dimensions of the pediatric crystalline lens: implications for intraocular lenses in children. j pediatr ophthalmol strabismus. 1996; 33: 18-20. 18. gimbel hv, debroff bm. posterior capsulorhexis with optic capture: maintaining a clear visual axis after pediatric cataract surgery. j cataract refract surg. 1994; 20: 658-64. 19. speeg-schatz c. results and complications of surgery of congenital cataract. [article in french] j fr ophthalmol. 2011; 34: 203-7. 20. harrad r. modulation of amblyopia therapy following early surgery for congenital cataracts. br j ophthalmol. 1995; 79: 793. 21. ondráček o, lokaj m. visual outcome of congenital cataract surgery. long term clinical results. scripta medica. 2003; 76: 95-102. http://www.ncbi.nlm.nih.gov/pubmed/9933197 http://www.ncbi.nlm.nih.gov/pubmed/9933197 http://www.ncbi.nlm.nih.gov/pubmed/9933197 http://www.ncbi.nlm.nih.gov/pubmed/9933197 http://www.ncbi.nlm.nih.gov/pubmed/9933197 http://www.ncbi.nlm.nih.gov/pubmed/9933197 http://www.books.google.com/ http://www.ncbi.nlm.nih.gov/pubmed?term=jain%20is%5bauthor%5d&cauthor=true&cauthor_uid=6417311 http://www.ncbi.nlm.nih.gov/pubmed?term=pillay%20p%5bauthor%5d&cauthor=true&cauthor_uid=6417311 http://www.ncbi.nlm.nih.gov/pubmed?term=gangwar%20dn%5bauthor%5d&cauthor=true&cauthor_uid=6417311 http://www.ncbi.nlm.nih.gov/pubmed?term=dhir%20sp%5bauthor%5d&cauthor=true&cauthor_uid=6417311 http://www.ncbi.nlm.nih.gov/pubmed?term=kaul%20vk%5bauthor%5d&cauthor=true&cauthor_uid=6417311 http://www.ncbi.nlm.nih.gov/pubmed/6417311 http://www.ncbi.nlm.nih.gov/pubmed/6417311 http://www.ncbi.nlm.nih.gov/pubmed/6417311 http://www.ncbi.nlm.nih.gov/pubmed?term=bluestein%20ec%5bauthor%5d&cauthor=true&cauthor_uid=8965219 http://www.ncbi.nlm.nih.gov/pubmed?term=wilson%20me%5bauthor%5d&cauthor=true&cauthor_uid=8965219 http://www.ncbi.nlm.nih.gov/pubmed?term=wang%20xh%5bauthor%5d&cauthor=true&cauthor_uid=8965219 http://www.ncbi.nlm.nih.gov/pubmed?term=rust%20pf%5bauthor%5d&cauthor=true&cauthor_uid=8965219 http://www.ncbi.nlm.nih.gov/pubmed?term=apple%20dj%5bauthor%5d&cauthor=true&cauthor_uid=8965219 http://www.ncbi.nlm.nih.gov/pubmed?term=apple%20dj%5bauthor%5d&cauthor=true&cauthor_uid=8965219 http://www.ncbi.nlm.nih.gov/pubmed?term=apple%20dj%5bauthor%5d&cauthor=true&cauthor_uid=8965219 http://www.ncbi.nlm.nih.gov/pubmed/8965219 http://www.ncbi.nlm.nih.gov/pubmed/8965219 http://www.ncbi.nlm.nih.gov/pubmed/8965219 http://www.ncbi.nlm.nih.gov/pubmed?term=gimbel%20hv%5bauthor%5d&cauthor=true&cauthor_uid=7837081 http://www.ncbi.nlm.nih.gov/pubmed?term=debroff%20bm%5bauthor%5d&cauthor=true&cauthor_uid=7837081 http://www.ncbi.nlm.nih.gov/pubmed/7837081 214 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology case report posterior microphthalmia, a challenging diagnosis nazia qidwai, kalimullah shaikh pak j ophthalmol 2015, vol. 31 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nazia qidwai department of ophthalmology) alibrahim eye hospital malir, karachi nazia_qidwai@hotmail.com …..……………………….. microphthalmia involves eyes with total axial length of at least 2 standard deviations below age-similar controls. this case report presents an unusual form of microphthalmia, the posterior microphthalmia which has never been reported in pakistan before. it also emphasises on the importance of use of optical coherence tomography (oct) for the diagnosis of posterior micropohthalmia. a 7 year old boy presented to us with bilaterally decreased vision and was found to have bilateral high hypermetropia. his fundal examination showed blurred optic disc margins and dolphin shaped elevated pappillomacular fold extending from the fovea to the optic disc in both the eyes. oct showed elevated neurosensory retina with normally attached retinal pigment epithelium. this confirmed the diagnosis of posterior microphthalmia. the use of oct thus aids in not just establishing the diagnosis of posterior microphthalmia but also prevents us from developing the wrong diagnosis of papilledema and carrying out any unnecessary investigations. key words: posterior microphthalmia, high hypermetropia, optical coherence tomography, pseudopapilledema. icrophthalmia is defined as total axial length of eyeball at least 2 standard deviations below age – similar controls. posterior microphthalmia is a rare subset of microphthalmia in which the total axial length of the eye ball is reduced resulting in high hypermetropia. whilst the anterior segment dimensions including corneal diameter, anterior chamber depth and anteroposterior length of the lens are normal, the posterior segment is foreshortened and is associated with a papillomacular retinal fold. the optic discs are crowded with blurred margins.1,2 this case report highlights the significance of optical coherence tomography in diagnosing this rare entity. to our knowledge no case of posterior microphthalmia has been reported in pakistan before. case report a 7 year old boy presented to us in june 2014 with the complaint of gradually progressive loss of distant vision in both eyes for the last 2 years. he had been using spectacles for the last 2 years. his medical, surgical, drug and birth history were un-eventful. his parents had had consanguineous marriage. on examination visual acuity was 1/60 unaided ou (both eyes) and it improved to 6/12 with +10.00 ds (diopter spherical) od (right eye) and 6/18 os (left eye) with +11.00 ds, respectively. his anterior segment examination was unremarkable with the corneal diameter within normal range, keratometryreadings od: k1: 47.25 × 90° and k2: 47.25 × 180° os: k1: 47.00 × 90° and k2: 47.25 × 180°, central corneal thickness od 0.591 microns and os 0.589 microns. the anterior chamber depth was 3.06 mm od and 3.07 mm os. lens thickness was 3.50 mm ou. axial length od was 16.5 mm and os 17.00 mm which were smaller for his age. on fundus examination we found small clustered optic disc with blurred margin ou and a dolphin shaped elevated papillomacular retinal fold extending m posterior microphthalmia, a challenging diagnosis pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 215 from the fovea to the optic disc ou (fig. 1). intraocular pressure was 12 mm hg ou. optic nerve function tests were normal in both the eyes as were the macular function tests. extra-ocular muscle movements were full in all gazes. systemically the patient was normal and did not complain of headache or vomiting as might be expected with bilateral optic disc swelling when suspecting for papilledema. to study this unusual finding of the elevated papillomacular retinal fold, ultrasound b-scan and optical coherence tomography (oct) were perfomed. the ultrasound b-scan revealed small eye balls with foreshortened posterior segment. oct was done to further study the elevated retinal fold closely and it showed that the neurosensory retina was folded as a unit leaving the rpe and the choroid normally intact. there were cystic lesions present within this fold ou. (fig. 1) there was no other associated pathology in the retina. the patient’s siblings did not reveal similar ocular findings. discussion posterior microphthalmia is a rare subset of microphthalmia in which the anterior segment of the eye is within normal dimensions but the posterior segment is foreshortened.1,2 the total axial length is thereby reduced. this results in severe hypermetropia with significant associated clinical findings. the most prominent finding is bilaterally small optic discs with blurred margins and an elevated papillomacular retinal fold of the neurosensory retina whereas the rpe and choroid remain intact. this is attributed to the fact that the sclera is abnormally thickened; limiting the growth of rpe and the choroid, while allowing normal growth of the neurosensory retina.3 the blurred margins of the optic discs might give the false impression of papilledema but since intracranial pressure is normal in these patients thereby this is labeled under pseudopapilledema. autosomal recessive and sporadic patterns have been reported for this syndrome.1 many other clinical associations have been reported by various authors, along with these hallmark findings. these include; retinoschisis, dialysis,4 esotropia, optic nerve hypoplasia5, chorioretinal folds, uveal effusion syndrome, pigmentary retinopathy, retinitis punctata albescens, absent or marked reduction of the capillary free zone1, duane retraction syndrome7 and iridocorneal anomaly.4-7 fig. 1: top; right: fundus photo od, left: fundus photo os. both showing blurred optic disc margins and dolphin shaped pappillomacular retinal fold between the optic disc and the fovea. bottom right: oct od, left: oct os. both showing elevated neurosensory retina with contained cystoids spaces. high hyperopia and elevated papillomacular retinal fold are the main causes of visual impairment in such children. newer investigations like ultrasound biomicroscopy (ubm) and optical coherence tomography (oct) have not only helped in studying the nature of posterior microphthalmia but also the various anterior and posterior segment clinical findings found associated with it. in our case we used oct to study the papillomacular folds. it is an advancement of the recent past. it gives cross section of the retina and thereby clearly elicits each of its layers. any retinal pathology can hence be extensively studied on oct in aspects of its level, nature and type. posterior microphthalmia is a challenging diagnosis. its timely diagnosis is critical to prevent the patient from the misdiagnosis of papilledema and thus unnecessary radiological investigations. oct is a very helpful advancement which aids in seeing the crossnazia qidwai, et al 216 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology sections of retina. in our case it clearly showed the elevated neurosensory retina and the flat retinal pigment epithelium thus helping us in reaching the diagnosis of posterior microphthalmia. its use is strongly advocated in cases suspected for posterior microphthalmia. author’s affiliation dr. nazia qidwai department of ophthalmology) alibrahim eye hospital malir, karachi dr. kalimullah shaikh department of ophthalmology) alibrahim eye hospital malir, karachi role of authors dr. nazia qidwai data collection and research design. dr. kalimullah shaikh data collection and research design. references 1. khairallah m, messaoud r, zaouali s, ben yahia s, ladjimi a, jenzri s. posterior segment changes associated with posterior microphthalmos. ophthalmology. 2002; 109: 569-74. 2. spitznas m, gerke e, bateman jb. hereditary posterior microphthalmos with papillomacular fold and high hyperopia. arch ophthalmol. 1983; 101: 413-7. 3. meire f, leys m, boghaert s, et al. posterior microphthalmos. bull soc belge ophtalmol. 1989; 231: 101-6. 4. kim jw, boes da, kinyoun jl. optical coherence tomography of bilateral posterior microphthalmos with papillomacular fold and novel features of retinoschisis and dialysis. am. jr. ophthalmol. 2004; 480-1. 5. slotnick s, fitzgerald de, sherman j, krumholz dm. pervasive ocular anomalies in posterior microphthalmos. optometry. 2007; 78: 6. mittal v, gupta a, sachdeva v, kekunnaya r. duane retraction syndrome with posterior microphthalmos: a rare association. j pediatr ophthalmol strabismus. 2012; 49: e48-51. 7. erdol h, kola m, turk a, akyol n. ultrasound biomicroscopy and oct findings in posterior microphthalmos. eur j ophthalmol. 2008; 18: 479-82. http://www.ncbi.nlm.nih.gov/pubmed?term=%22khairallah%20m%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22messaoud%20r%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22zaouali%20s%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22ben%20yahia%20s%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22ladjimi%20a%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22jenzri%20s%22%5bauthor%5d javascript:al_get(this,%20'jour',%20'ophthalmology.'); http://www.ncbi.nlm.nih.gov/pubmed?term=spitznas%20m%5bauthor%5d&cauthor=true&cauthor_uid=6830494 http://www.ncbi.nlm.nih.gov/pubmed?term=gerke%20e%5bauthor%5d&cauthor=true&cauthor_uid=6830494 http://www.ncbi.nlm.nih.gov/pubmed?term=bateman%20jb%5bauthor%5d&cauthor=true&cauthor_uid=6830494 http://www.ncbi.nlm.nih.gov/pubmed/6830494 http://www.ncbi.nlm.nih.gov/pubmed/?term=kim%20jw%5bauthor%5d&cauthor=true&cauthor_uid=15364236 http://www.ncbi.nlm.nih.gov/pubmed/?term=boes%20da%5bauthor%5d&cauthor=true&cauthor_uid=15364236 http://www.ncbi.nlm.nih.gov/pubmed/?term=kinyoun%20jl%5bauthor%5d&cauthor=true&cauthor_uid=15364236 http://www.ncbi.nlm.nih.gov/pubmed?term=mittal%20v%5bauthor%5d&cauthor=true&cauthor_uid=22881831 http://www.ncbi.nlm.nih.gov/pubmed?term=gupta%20a%5bauthor%5d&cauthor=true&cauthor_uid=22881831 http://www.ncbi.nlm.nih.gov/pubmed?term=sachdeva%20v%5bauthor%5d&cauthor=true&cauthor_uid=22881831 http://www.ncbi.nlm.nih.gov/pubmed?term=kekunnaya%20r%5bauthor%5d&cauthor=true&cauthor_uid=22881831 http://www.ncbi.nlm.nih.gov/pubmed/22881831 http://www.ncbi.nlm.nih.gov/pubmed?term=%22erdol%20h%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22kola%20m%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22turk%20a%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22akyol%20n%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed/18465740 comparison of salbutamol delivered by a metered dose inhaler with spacer versus a nebulizer in children presenting with wheeze in pediatric emergency department 118 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology original article pars-plana vitreous tap for phacoemulsification in the eyes with crowded anterior segment irfan qayyum malik, hafiza sadia imtiaz, fazeela qazi pak j ophthalmol 2018, vol. 34, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irfan qayyum malik eye department of dhqteaching hospital gujranwala email: irfan790@yahoo.com …..……………………….. purpose: to determine the efficacy of pars plana vitreous tap for safe accomplishment of phacoemulsification in eyes with severely crowded anterior segment. study design: quasi-experimental study. place and duration of study: eye department of dhq-teaching hospital gujranwala, from january 2014 to december 2017. material and methods: patients of both genders, above 40 years of age who had crowded anterior segments and in whom viscoelastic substance could not deepen the anterior chamber sufficiently during cataract surgery (phacoemulsification) were included in this study. all patients underwent phacoemulsification and pars-plana vitreous aspirate of 0.1 ml taken 4 mm from the limbus in supero-temporal quadrant using 27-gauge needle. results: 50 eyes of 40 patients with crowded anterior segment were included in this study. sixteen (40%) were male and 24 (60%) were female. average age noted was 54.3 ± 7.4 (range 48 – 65) years. mean pre-op iop recorded was 17.6 ± 2.3 (range 12 – 24.2) mm hg, mean pre-op anterior chamber depth (acd) of 2.1 ± 0.34 (range 1.6 – 2.6) mm and mean pre-op axial length (al) of 20.6 ± 0.45 (range 19.5 – 22.2) mm. vitreous tap was successful in 42 eyes (84%) on first attempt and in remaining 8 eyes (16%), second attempt was required. average volume of aspirated vitreous was 0.116 ± 0.03 (0.1 – 0.2) ml. the overall success rate was 100% with no per-op or post-op complications noted during follow up period of 6 months. conclusions: vitreous tap using needle is simple, safe, efficient and costeffective technique for management of shallow anterior chambers during phacoemulsification. key words: crowded anterior segment, axial length, anterior chamber depth, capsulorhexis, pars plana vitreous tap. yes with crowded anterior segments give a difficult time to the operating surgeon due to less working field and close proximity between lens and cornea, making capsulorhexis, phacoemulsification and iol implantation quite tricky to perform. these eyes present with narrow angles and shallow anterior chambers1. shallow anterior chamber can be with short axial length or with normal axial length. short axial length occurs in patients with microphthalmos (simple or complex) and nanophthalmos. shallow anterior chamber with normal axial length (al) can be with relative anterior microphthalmos, intumescent cataract, subluxated lens and in the presence of angle closure glaucoma2. positive vitreous pressure can also lead to anterior e pars-plana vitreous tap for phacoemulsification in the eyes with crowded anterior segment pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 119 chamber shallowness during phacoemulsification.this positive vitreous pressure is precipitated by chronic obstructed pulmonary disease (copd), constipation, obesity, systemic or ocular hypertension and senility. risks encountered in such eyes during phacoemulsification include corneal endothelial damage due to close proximity of corneal endothelium with phaco tip, descemet’s membrane detachment, iris prolapse, capsulorhexis extension, posterior capsular rent, vitreous haemorrhage and supra-choroidal haemorrhage3. to encounter these challenging situations and to prevent associated risks, different methods were opted by ophthalmologists, which include pre-op use of dehydrating agents4, intra-operative use of ophthalmic viscoelastic device (ovd)5, parsplana vitrectomy6,7,8 and pars-plana vitreous tap among all of these, parsplana vitreous tap during phacoemulsification, in case of crowded anterior segment when viscoelastic substance fails to maintain anterior chamber, is found to be safe, easy and efficacious, as supported by various studies. the rationale of our study was to determine the efficacy of pars-plana vitreous tap in making the anterior chamber deep thus allowing every step of cataract surgery to be carried out safely and effectively in these high risky eyes while keeping the advantages of a small incision. material and methods a quasi-experimental study was conducted after approval from ethical and research committee of gujranwala medical college. informed consent was taken from all those patients. patients of both genders, above 40 years of age who had crowded anterior segments and in whom viscoelastic substance could not deepen the anterior chamber sufficiently during cataract surgery (phacoemulsification), were included in this study. whereas patients younger than 40 years of age, patients with posterior segment pathologies such as vitreous haemorrhage, retinal detachment, malignant tumors and endophthalmitis were excluded from this study. it was carried out in 50 eyes of 40 patients at eye department of dhq-teaching hospital gujranwala from january 2014 to dec. 2017. best corrected visual acuity (bcva) using snellen chart, iop recording using goldmann applanation tonometer, complete ophthalmic examination using slit lamp biomicroscopy, anterior chamber angle assessment using gonioscopy, anterior chamber depth (acd) estimation using ultrasound a-scan and axial length (al) measurement with the help of biometry was done pre-operatively. eyes with crowded anterior segment were selected for pars-plana vitreous tap. the final decision to include patients in this study was made per-operatively when anterior chamber failed to deepen with viscoelastic substance. pupil was dilated with mydriatic eye drops. surgery was carried out under retro-bulbar anaesthesia with 1% lignocaine and 0.5% bupivacaine followed by 10 minutes of external ocular massage. supero-temporal or super-nasal corneal incision was given and anterior chamber was maintained with viscoelastic substance. where there was failure to deepen the anterior chamber with viscoelastic gel, pars-plana vitreous tap was done using 27-gauge needle attached to 1 cc syringe, inserted 4 mm from limbus in supero-temporal quadrant and 0.1 ml of vitreous was removed. if the first attempt failed to aspirate vitreous fluid or if it was insufficient to adequately deepen the anterior chamber in spite of successful vitreous removal, a second vitreous tap was tried at the same site. failure of the technique was defined as failure of two attempts to deepen the anterior chamber. when the anterior chamber was adequately deepened, continuous curvilinear capsulorhexis followed by hydro-dissection, phacoemulsification via chop technique, irrigation and aspiration of remaining cortical matter, iol implantation in capsular bag was successfully done in all cases without any intra-operative complication. patients were followed up for 6 months to determine any post-op complication. data was collected from all these patients, statistical analysis was done and results expressed as mean values with standard deviations, ranges and percentages. p-value < 0.05 was considered significant. results 50 eyes of 40 patients were included in this study. out of which, 16 (40%) were male and 24 (60%) were female. right eye was involved in 30 cases (60%) and left one in 20 cases (40%). average age was 54.3 ± 7.4 (range 48 – 65) years (table 1). mean pre-op iop was 17.6 ± 2.3 (range 12 – 24.2) mm hg with mean pre-op anterior chamber depth (acd) of 2.1 ± 0.34 (range 1.6 – 2.6) mm and mean preop axial length (al) of 20.6 ± 0.45 (range 19.5 – 22.2) mm (table 2). irfan qayyum malik, et al 120 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology table 1: demographic variables. demographic variables study population (n = 50) age: mean ± sd 54.3 ± 7.4 (range 48–65) gender: male/female 40% (16)/60% (24) laterality: right/left 60% (30)/40% (20) table 2: results. variables findings (n = 50) pre-op iop mean ± sd 17.6 ± 2.3 (range 12 – 24.2) mmhg pre-op acd mean ± sd 2.1 ± 0.34 (range 1.6 – 2.6) mm pre-op al mean ± sd 20.6 ± 0.45 (range 19.5 – 22.2) mm figure 1: types of patients. there were 8 cases (16%) with angle closure glaucoma, 13 cases (26%) with intumescent cataract resulting in phacomorphic glaucoma, 3 cases (6%) of subluxated lens, 4 cases (8%) with simple microphthalmos, 2 cases (4%) with nanophthalmos, 6 cases (12%) with relative anterior microphthalmos and 14 cases (28%) with positive vitreous pressure (that was determined per-operatively when anterior chamber failed to deepen with viscoelastic substance) (figure 1). vitreous tap was successful in 42 eyes (84%) on first attempt and in remaining eight eyes (16%), second attempt was required which made anterior chamber deep enough to allow phaco process to continue safely. average volume of aspirated vitreous was 0.116 ± 0.03 (0.1 – 0.2) ml. the overall success rate was 100% with no intra-operative or post-operative complications during 6 months follow up period (figure 2, 3). 84% 16% 1st attempt successful second attempt rrequired figure 2: success rate of vitreous tap. discussion crowded anterior segment is a descriptive term, not a measureable entity. it is used to describe eyes with shallow anterior chambers due to short axial lengths, with intumescent cataract causing shallow chambers with normal axial length, narrow ac angle eyes or positive vitreous pressure where one would say, “i had difficulty in doing phaco in this patient because he had crowded anterior chamber”. fig. 3: a. normal anterior segment, b. crowded anterior segment. pars-plana vitreous tap for phacoemulsification in the eyes with crowded anterior segment pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 121 crowded anterior segment can be seen in many ophthalmic diseases. microphthalmos10,11 is an eye with a short axial length. microphthalmic eyes are divided into simple and complex ones. simple microphthalmos has short axial length with no other ocular malformation. complex microphthalmos is an eye with a short al and ocular anatomic malformations such as iris coloboma, chorioretinal coloboma, persistent fetal vasculature, and retinal dysplasia with normal scleral thickness. nanophthalmos12,13,14 is a rare condition in which the eye has a short axial length along with a small anterior segment and thickened choroid and sclera. relative anterior microphthalmos is an eye with a normal al but a small anterior segment. these eyes have an axial length longer than 20.5 mm, but the anterior chamber depth (acd) is equal to or less than 2.2 mm and the corneal diameter being shorter than 11.0 mm. it is more common than microphthalmos and nanophthalmos15,16. phacomorphic glaucoma is the secondary angleclosure glaucoma due to intumescent cataract resulting in increased lens thickness, which can lead to pupillary block and angle closure17. positive vitreous pressure also occurs during cataract surgery and is associated with acute hypotony that causes forward displacement of the lens-iris diaphragm with shallowing of the anterior chamber resistant to reformation, repeated iris prolapse, that can lead to a cascade of intraoperative complications18. extreme care is required in all these patients. proper preoperative evaluation allows better planning of the surgery to avoid complications. to reduce positive vitreous pressure, i/v infusion of mannitol 30-60 min prior to surgery was also recommended, but its use is limited due to its serious side effects. pars plana vitrectomy also remained a choice for many surgeons to deepen the anterior chamber but it has some disadvantages. the fashioned sclerotomy may leak or require suturing. that is why using the small 23 or 25 gauge19 vitrectomy probe is preferred than using the conventional 20-gauge vitrectomy probe for this purpose, in addition to the advantage of higher cutting rates resulting in minimal retinal traction, but unfortunately most of the phacoemulsification systems incorporate low-cutting speed 20-gauge vitreous cutters20. the idea of using vitreous needle aspiration to manage positive vitreous pressure during surgery was investigated previously in penetrating keratoplasty (pkp) 21 and in triple procedure involving pkp, cataract extraction, and intraocular lens implantation22. the main fear of vitreous needle aspiration is inducing retinal traction with subsequent retinal tears, vitreous haemorrhage, or retinal detachment16. however, this technique was found to be safe without any complications. earlier it was suggested that using a 23to 26-gauge needle attached to an insulin syringe without the plunger allow passive removal of vitreous and avoids vitreous aspiration which may induce traction on the retina. ashraf et al23 carried out a retrospective study including 26 eyes of 17 patients who underwent phacoemulsification in which vitreous tap was done using 27 gauge needle attached to 5 ml syringe in crowded eyes where viscoelastic substance failed to deepen the anterior chamber and results showed no complication related to vitreous tap, successful removal of vitreous with subsequent deepening of anterior chamber on first attempt in 26 eyes (100%). in this study, we used 27-gauge needle, attached to 1 cc syringe and aspiration of 0.1 cc vitreous was done 4 mm from supero-temporal quadrant during cataract surgery in crowded anterior segment eyes that adequately deepened the anterior chamber. thus, preventing damage to corneal endothelium, descemet’s membrane detachment, iris prolapse, capsulorhexis extension, posterior capsular rent, vitreous haemorrhage and supra-choroidal haemorrhage without increasing the risk of retinal traction as aspirated fluid was minimal. vitreous tap using needle aspiration is machine independent. it uses simple needles and syringes which are easily available in operation theatres. it is quite easy to perform, cost-effective and saves time without creating an extra wound while allowing a precise amount of vitreous to be removed for safe accomplishment of phacoemulsification in crowded anterior segment eyes. conclusion a pars-plana vitreous tap makes the anterior chamber deep thus allowing every step of cataract surgery (capsulorhexis, phacoemulsification and iol implantation) to be carried out safely and effectively in these high risky eyes without causing any corneal decompensation, capsulorhexis extension, pc rupture or supra-choroidal haemorrhage while keeping the advantages of a small incision. irfan qayyum malik, et al 122 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology vitreous tap using 27-gauge needle is simple, safe, efficient and cost-effective technique for management of shallow anterior chambers. author’s affiliation dr. irfan qayyum malik associate professor ophthalmology gujranwala medical college dr. hafiza sadia imtiaz pgr gujranwala medical college dr. fazeela qazi associate professor gynecology gujranwala medical college role of authors dr. irfan qayyum malik study design, manuscript writing, critical review. dr. hafiza sadia imtiaz helped in data collection dr. fazeela qazi helped in writing manuscript references 1. chang d. pars plana vitreous tap for phacoemulsification in the crowded eye. j cataract refract surg, 2001; 27 (12): 1911-1914. 2. hoffman r, vasavada a, allen q, snyder m, devgan u, braga-mele r. cataract surgery in the small eye. j cataract refract surg, 2015; 41 (11): 2565-2575. 3. masket s. cataract surgical problem. j cataract refract surg, 2006; 32 (6): 908. 4. see j. phacoemulsification in angle closure glaucoma. j curr glaucoma pract, 2009; 3 (1): 28–35. 5. khng c, osher r.h. surgical options in the face of positive pressure. j cataract refract surg, 2006; 32 (9): 1423–1425. 6. chalam k.v, gupta s.k, agarwal s, shah v.a. sutureless limited vitrectomy for positive vitreous pressure in cataract surgery. ophthalmic surg lasers and imaging retina, 2005; 36 (6): 518–522. 7. dada t, kumar s, gadia r, aggarwal a, gupta v, sihota r. sutureless single-port transconjunctival pars plana limited vitrectomy combined with phacoemulsification for management of phacomorphic glaucoma. j cataract refract surg, 2007; 33 (6): 951-954. 8. miura s, ieki y, ogino k, tanaka y. primary phacoemulsification and aspiration combined with 25gauge single-port vitrectomy for management of acute angle closure. eur j ophthalmol, 2008; 18 (3): 450–452. 9. wladis e.j, gewirt m.b, guo s. cataract surgery in the small adult eye. survey of ophthalmology, 2006; 51 (2): 153–161. 10. carifi g, safa f, aiello f, baumann c, maurino v. cataract surgery in small adult eyes. br j ophthalmol 2014; 98 (9): 1261–1265. 11. tailor r, ng a, murthy s. cataract surgery in patients with nanophthalmos. ophthalmology, 2014; 121 (2): e11. 12. day a, maclaren r, bunce c, stevens j, foster p. outcomes of phacoemulsification and intraocular lens implantation in microphthalmos and nanophthalmos. j cataract refract surg, 2013; 39 (1): 87-96. 13. lemos j, rodrigues p, resende r, menezes c, gonçalves r, coelho p. cataract surgery in patients with nanophthalmos: results and complications. eur j ophthalmol, 2015; 26 (2): 103-106. 14. steijns d, bijlsma w, van der lelij a. cataract surgery in patients with nanophthalmos. ophthalmology, 2013; 120 (2): 266-270. 15. yuzbasioglu e, artunay o, agachan a, bilen h. phacoemulsification in patients with nanophthalmos. can j ophthalmol, 2009; 44 (5): 534-539. 16. b. kaplowitz k. an evidence-based approach to phacomorphic glaucoma. jceo, 2013; 04 (02). 17. chronopoulos a, thumann g, schutz j. positive vitreous pressure: pathophysiology, complications, prevention, and management. surv ophthalmol, 2017; 62 (2): 127-133. 18. leng t, moshfeghi d. valved 25-gauge cannula for vitreous tap and injection. ophthalmic surg, lasers and imaging retina, 2017; 48 (11): 916-917. 19. spirn m. comparison of 25, 23 and 20-gauge vitrectomy. curr opin ophthalmol, 2009; 20 (3): 195199. 20. gross r, shaw e. management of increased vitreous pressure during penetrating keratoplasty using pars plana anterior vitreous aspiration. cornea, 2002; 21 (4): 435-436. 21. vongthongsri a, jakpaiwong w, preechanon a, lekhanont k, chuck r. anterior vitreous tapping to manage positive vitreous pressure during triple procedures. ophthalmology, 2005; 112 (5): 875-878. 22. sethi h, dada t. pars plana vitreous tap in crowded eyes. j cataract refract surg, 2002; 28 (11): 1897. 23. nossair a, ewais w, ali l. retrospective study of vitreous tap technique using needle aspiration for management of shallow anterior chamber during phacoemulsification. j ophthalmol, 2017; 2017: 1-6. microsoft word m imran 47 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology case report congenital erythropoietin porphyria (cep) – a case of necrotic scleritis muhammad imran, syed ahmer hussain, ashraf ali tayyab, sehbaz aslam pak j ophthalmol 2012, vol. 28 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad imran post graduation trainee nishtar hospital multan …..……………………….. purpose: to discuss a case of bilateral temporal sclera necrosis leading to scleral perforation. material and methods: this is an observational case report in an institutional setting, reporting an unusual case. a 26 years old young man, farmer by occupation presented to nishtar hospital multan with pain and photophobia in his left eye. examination showed bilateral involvement of temporal sclera leading to sclera perforation. the visual acuity was 20/20 on log mar in both eyes. the pupils were reactive to light and intra-ocular pressure was 14mmhg and 12 mmhg in right and left eye respectively. dilated fundus examination was found to be normal with cup – disc ratio of 0.3 both eyes. investigation (cbc, peripheral blood film, crp, rh factor, x-ray chest, biochemical analysis of specimen) led to unusual case of gunther’s disease also known as congenital erythropoietin porphyria 3. ongenital erythropoietic porphyria (cep) is very rare metabolic disorder affecting the synthesis of haem, the iron-containing pigment that binds oxygen onto red blood cells. cutaneous signs of gunther's disease (congenital erythropoietic porphyria) may develop 5 years after the onset of symptomatic thrombocytopenia1. other symptoms include alopecia, hypertrichosis, and cutaneous blistering disease involving face, neck, and dorsum of hands, deformities of cartilages of ear and nose etc2. occular signs of this disease may develop from as first decade to 3rd decade of life3. ocular symptoms include pain, photophobia and lacrimation while signs include congestion, scleritis, sclera necrosis and ulceration sometimes leading to uveal prolapsed as well. material and methods this is an observational case report carried out at nishtar hospital multan. a young male of 26 years age presented to out patient department with pain and photophobia in left eye and grittiness in his right eye. his symptoms had existed for 15 days back. he had a history of blistering skin disease affecting his face, neck, dorsum of hands and causing disfigurement of his nose, ear and proximal digits of upper limbs. he was farmer by occupation. one of his cousins had similar complaints in childhood but had now recovered except few cutaneous lesions. on examination it revealed acute scleritis with scleral perforation almost 1cm in diameter just 2 mm away from the limbus. in the base of ulcer ciliary body some yellowish deposits was visible at the margins of the ulcer. two telengiectatic vessels were present in juxta ulcer area with corneal haze in juxta limbal area. the visual acuity was 20/20 on log mar in both eyes. the pupils were reactive to light and intra-ocular pressure was 14mmhg and 12 mmhg in right and left eye respectively. dilated fundus examination was found to be normal with cup-disc ratio of 0.3 both eyes. systemic evaluation revealed no abnormality and complete blood cell count was within normal range with low hemoglobin level was low while esr and crp was normal. no lesion was seen on x-ray chest pav. rheumatoid factor was found to be negative. he was admitted in the ward and mild topical steroids (florometholone e/d qid) along with oral steroids (tab. prednisolone 5 mg, 3 / po / qid) and c muhammad imran et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 48 topical lubricants (tears plus e/d qid) were started. after 3 days of treatment symptoms were improved but photophobia was still severe. the fascia lata was grafted on sclera on both sides to fill the gap and strengthen the sclera. during surgery hard crystals were removed from the wound margin4, which after laboratory examination showed calcium and porphyrin. on right side wound margins were quite healthy but on left side melting of sclera was present. after grafting, conjunctival flap was transposed. after 48 hours the right eye was quite normal and left eye showed congestion. patient was discharged on topical and oral steroids and topical lubricants. on follow up after 7 days, his wounds were quite normal and asymptomatic. discussion cep is an inherited disorder in which there is a mutation in a gene on chromosome 10 that encodes uroporphyrinogen iii synthase. it is transmitted in autosomal recessive pattern. carriers of a single abnormal gene do not usually exhibit any sign or symptom of the disorder. due to deficiency of uroporphyrinogen iii synthase, hydroxymethylbilale is not converted into uroporphyrinogen iii instead it is converted into uroporphyrinogen i and caproporphyrinogen i which accumulates in the body as uroporphyrin i and caproporphyrin i respectively5. this disease affects primarily the red blood cells leading to increased number of immature rbcs in the blood. very rarely it affects the sclera causing necrotic scleritis, but can cause loss vision6,7. treatment involves oral steroids, rapid blood transfusion for anemia and splenectomy for thrombocytopenia. cep if associated only with scleritis is treated with topical and oral steroids and intensive prevention of exposure to sunlight by wearing dark goggles containing uv filters and topical lubricants. advanced cases with scleral perforations require surgical interventions like facia lata graft. conclusion in cases of spontaneous scleral necrosis especially when bilateral rare disease like porphyria should not be missed. in this case as serological investigation did not show any significant evidence, localized toxic response causing local inflammation was probably the culprit. author’s affiliation dr. muhammad imran post graduation trainee nishtar hospital multan dr. syed ahmer hussain assistant professor of ophthalmology nishtar hospital multan dr. ashraf ali tayyab professor of ophthalmology nishtar hospital multan dr. sehbaz aslam assistant professor of ophthalmology nishtar hospital multan reference 1. a murphy mb, g gibson mb et al. adult onset congenital erythropoietic porphyria presenting with thrombocytopenia; journal of the royal society of medicine. 1995; 88: 357-8. 2. desnick rj. congenital erythropoietic porphyria; advances in pathogenesis and treatment; br j heamotology. 2002; 117: 77995. 3. venkatesh p, garg sp, kumaran e et al. congenital porphyria with necrotizing scleritis in 9 years old child; clinical experimental ophthalmology. 2000; 28: 314-8. 4. kurihara n, takamura n, slmaizumi, et al. ocular complications of porphyria; br j ophthalmology. 2001; 85: 1260. 5. debach jc, de verneuil h, boulechfar s et al. point mutations in the uroporphyrinogen iii synthase gene in congenital erythropoitic porphyria; blood. 1990; 75: 1763-5. 6. altiparmak ue, oflu y, kocaoglu fa et al. ocular complications in 2 cases with porphyria; cornea. 2008; 27: 1093-6. 7. arne jl, depyre c, lesueur l. corneoscleral involvement in congenital erythropoietic porphyria. j fr ophthalmol. 2003; 26 : 498-502. 68 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology original article central corneal thickness changes after phacoemulsification tanveer anjum chaudhry, muhammad hamza, wajiha koomal, khabir ahmad pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tanveer anjum chaudhry section of ophthalmology, department of surgery, aga khan university hospital, stadium road, karachi tanveer.chaudhry@aku.edu …..……………………….. purpose: to determine when the mean central corneal thickness (cct) returns to normal values after uneventful phacoemulsification. material and methods: this was a prospective case series. the study was carried out at the section of ophthalmology, department of surgery, aga khan university hospital, karachi. eyes scheduled to undergo phacoemulsification during december 2011 – march 2012 were eligible to be included. eyes with corneal degenerations, dystrophies or high pre-op astigmatism were excluded. a structured proforma was used to collect data on sociodemographics, comorbids, visual acuity, and cct before surgery and 1 day, 1 week and 1 month after surgery. changes in the mean cct over time were measured using repeated measures analysis of variance (anova) was done. results: eighty one eyes were included in the study. the mean (±sd) age of the participants was 58.30 (± 10.04) years. the majority of them (58.0%) were women. sixty two (76.5%) eyes completed the last follow-up and were included in the final analysis. the mean cct was 542.81 ± 34.85 mm before surgery which markedly increased to 595.27 ± 43.78 mm 24 hours after surgery, but decreased to 565.82 ± 38.30 at one week, and returned to normal baseline values (544.42 ± 28.95) in almost all operated eyes in 1 month time. there was no statistically significant difference in the mean cct before surgery and at 1 month (p=0.685). conclusion: the mean cct substantially increasing after post-operative uneventful cataract surgery but returns to normal baseline values in almost all operated eyes in 1 month time. iop measured during this period may be falsely higher than the true values due to increased cct. key words: central corneal thickness, phacoemulsification, cataract surgery. ataract surgery is the commonest surgical procedure performed worldwide.1 central corneal thickness (cct) increases significantly immediately after cataract surgery and gradually returns to normal values over the next few weeks.2,3 cautions should be taken while interpreting the results of intraocular pressure measurements during this period as increased cct may lead to false higher readings and unnecessary treatment and anxiety.4,5 cct is an important predictor of iop.6,7 generally, thicker the cornea, greater is the false iop readings. changes in cct after cataract surgery have been described by several investigators.2,4 we aimed to determine when the mean cct returns to normal values after uneventful phacoemulsification in our population. material and methods this was a prospective case series. consecutive eyes scheduled to undergo phacoemulsification cataract surgery by a single surgeon at the section of ophthalmology, aga khan university hospital, karachi, during december 2011 – march 2012 were enrolled. those who had corneal degenerations, corneal dystrophies or high pre-op astigmatism of 2.5 c central corneal thickness changes after phacoemulsification pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 69 d or greater were excluded. after informed consent, patients underwent a thorough eye assessment and specific questions were asked regarding refractive errors, glaucoma and refractive surgery. iop was measured using goldman applanation tonometer. cct was measured using ultrasonic pachymetry (tomey sp-3000, tomey ltd, japan). five cct reading were taken and their mean reading was recorded. all measurements were taken by a single senior ophthalmic technician. using a structured proforma, data were collected on age, sex, ethnicity, co-morbids (diabetes, hypertension and glaucoma), visual acuity as well as cct before surgery and 1 day, 1 week and 1 month after surgery. the data were entered and analysed using ibm spss version 19. repeated measures analysis of variance (anova) was used to compare changes in the mean cct over time. a pvalue < 0.05 was considered statistically significant. graphpad prism version 5.0 software (graphpad, san diego, ca, usa) was used for graph production. fig. 1: changes in the mean central corneal thickness after phacoemulsification. results a total of 81 eyes were included in the study. the mean (± sd) age of the participants was 58.30 (± 10.04) years where as the median age was 60 years (range 29– 77). 42% of the participants were men (table 1). complete follow-up data were available for 62 (76.5%) of the eyes and were included in the final analysis. the mean cct was 542.81 ± 34.85 μm before surgery which markedly increased to 595.27 ± 43.78 μm 24 hours after surgery (table 2 and figure 1). it decreased to 565.82 ± 38.30 one week after surgery, and to 544.42 ± 28.95 four weeks after surgery, which was not significantly different from the baseline cct values (p = 0.685). discussion corneal thickness influences iop readings. if it is greater than the normal values, it will require greater force to indent the cornea and significantly high iop readings will be obtained. for a thin cornea, it is otherwise. knowledge of how changes in cct can influence iop readings is critical.6,7 previous research has shown that central corneal thickness returns to normal levels in most operated eyes following an initial increase 1 week after cataract surgery.2 our study shows that the mean cct markedly increases tanveer anjum chaudhry, et al 70 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology after uneventful clear corneal cataract surgery, returns to normal baseline values in majority of the operated eyes at 1 week, touching near normal baseline values at 1 month. the increase in cct after cataract surgery appears to be due to corneal edema, which generally settles over the next 1 – 4 weeks. compared with the baseline, there was a mean increase in cct of 52.46 μm at 1 day, and 23.01 μm at 1 week, and 1.61 μm at 4 weeks. the mean increase at day 1 in our study is higher than that reported by other authors2,3,8 as is the mean increase at 1 week. for example, salvi et al2 reported a mean increase of 3.15 μm at week 1. possible explanations could be the difference in the population studied, duration of surgery, and density of cataract that were operated. our study provides a key message regarding postoperative measurement. iop measured postoperatively in the first week and even up to 1 month may be falsely elevated because of the increased corneal thickness after cataract surgery; thus, not all iop rise have to be treated in this period in otherwise healthy eyes. a limitation of our study was the loss to follow up. 23.5% of the eyes were lost to follow up at 4 week. while there was no difference in the mean preoperative cct values between those who were lost to follow-up (n = 19) and those who completed the last follow-up (n = 62), there were significant differences between the two groups at 24 hours and 1 week. early visual recovery may have led them to skip the final routine visit. conclusion our study shows that the mean cct substantially increases after uneventful clear corneal cataract surgery but returns to normal baseline values in almost all operated eyes in 1 month time. cautions should be taken while interpreting the results of intraocular pressure measurements during this period as increased cct may lead to false higher readings and unnecessary treatment and anxiety. author’s affiliation dr. tanveer anjum chaudhry section of ophthalmology, department of surgery, aga khan university hospital, stadium road, karachi dr. muhammad hamza section of ophthalmology, department of surgery, aga khan university hospital, stadium road, karachi central corneal thickness changes after phacoemulsification pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 71 dr. wajiha koomal section of ophthalmology, department of surgery, aga khan university hospital, stadium road, karachi dr. khabir ahmad section of ophthalmology, department of surgery, aga khan university hospital, stadium road, karachi references 1. taylor hr. cataract: how much surgery do we have to do? the br j ophthalmology. 200; 84: 1-2. 2. salvi sm, soong tk, kumar bv, hawksworth nr. central corneal thickness changes after phacoemulsification cataract surgery. journal of cataract and refractive surgery. 2007; 33: 1426-8. 3. falkenberg b, kutschan a, wiegand w. analysis of optical parameters after cataract surgery and implantation of foldable lens. der ophthalmology: zeitschrift der deutschen ophthalmologischen gesellschaft 2005; 102: 587-91. 4. bolz m, sacu s, drexler w, findl o. local corneal thickness changes after small-incision cataract surgery. journal of cataract and refractive surgery. 2006; 32: 166771. 5. recep of, hasiripi h, cagil n, sarikatipog h. relation bwtween corneal thickness and intraocular pressure measurement by noncontact and applanation tonometery. journal of cataract and refractive surgery. 2001; 27: 1787-91. 6. brandt jd. the influence of corneal thickness on the diagnosis and management of glaucoma. journal of glaucoma 2001; 10: s65-s7. 7. chu j, tham yc, liao j, zheng y, aung t, wong ty, cheng cy. ethnic differences of intraocular pressure and central corneal thickness; the singapore epidemiology of eye diseases study. ophthalmology 2014; 121: 2013-22. 8. hager a loge k, fullhas mo, schroeder b, grossherr m, wiegand w. changes in corneal hysteresis after clear corneal cataract surgery. am j ophthalmology 2007; 144: 341-6. http://www.ncbi.nlm.nih.gov/pubmed/?term=zheng%20y%5bauthor%5d&cauthor=true&cauthor_uid=24950592 http://www.ncbi.nlm.nih.gov/pubmed/?term=aung%20t%5bauthor%5d&cauthor=true&cauthor_uid=24950592 http://www.ncbi.nlm.nih.gov/pubmed/?term=wong%20ty%5bauthor%5d&cauthor=true&cauthor_uid=24950592 http://www.ncbi.nlm.nih.gov/pubmed/?term=cheng%20cy%5bauthor%5d&cauthor=true&cauthor_uid=24950592 pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 247 original article bacteriology of chronic dacryocystitis in patients coming to a tertiary care hospital erum shahid, uzma fasih, mohammad sabir, arshad shaikh pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: erum shahid assistant professor, department of ophthalmology karachi medical and dental college & abassi shaheed hospital email: drerum007@yahoo.com …..……………………….. purpose: to determine microbiology of dacryocystitis in patients coming to a tertiary care hospital of pakistan and to find out bacterial sensitivity of different antibiotics towards causative organisms. study design: cross sectional observational study. place and duration of study: ophthalmology department, abbassi shaheed hospital, karachi from january to december 2017. material and methods: total 100 patients were enrolled by non-probability consecutive sampling technique. patients with chronic dacryocystitis, primary or acquired nasolacrimal duct blockage were included. acute dacryocystitis, canaliculitis, mucoceles and who had used topical or systemic antibiotics within 48 hours were excluded from the study. detail history, ocular adnexal examination and regurgitation test was performed. specimen was collected with a soft cotton tip applicator under sterile aseptic conditions. gram staining and culture was done. data was collected and analyzed on statistical package for social sciences (spss) version 16. results: mean age of the patients was 29.8 years ± 19.6 sd with 75% females. mean duration of symptoms was 5.9 years ± 10.5. right eye was affected in 58% of patients. culture was positive in 83% and gram positive organisms were seen in 52% of cases. the most common pathogen was staphylococcus aureus 21%, than pseudomonas 18% of cases. gram positive and negative both were most sensitive to moxifloxacin 66% and 57% respectively. conclusion: the most common pathogen in chronic dacryocystitis is gram positive organism staphylococcus aureus followed by gram negative pseudomonas. both gram positive and gram negative organisms are most sensitive to moxifloxacin. keywords: antibiotic, bacteriology, chronic dacryocystitis, gram negative bacteria, gram positive bacteria. nflammation of the lacrimal sac due to nasolacrimal duct obstruction or secondary to trauma or neoplasm is called dacryocystitis. this obstruction of the canal leads to stagnation of tears and creates a pathological environment. this accumulates material within lacrimal sac thereby exacerbating infection, more stasis and beginning of a vicious circle. normal flora of the eye acts as an opportunistic pathogen there by producing infection of lacrimal sac 1. dacryocystitis is the most common disease of the lacrimal drainage system1. chronic dacryocystitis is chronic inflammation of the lacrimal sac due to obstruction of lacrimal sac and most common cause of epiphora 2,3. pathologically within the sac there is inflammation, hyperemia, edema, and hypertrophy of mucosal epithelium. accumulation of mucoid and mucopurulent exudates cause the sac to dilate, i mailto:drerum007@yahoo.com erum shahid, et al 248 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology ultimately leading to pyocele4. this acts as a potential nidus for the organisms to proliferate within the sac. the infection in dacryocystitis can spread to the anterior orbit causing marked edema of the eyelids or can develop into a pre-septal or orbital cellulitis1. it can also give rise to vision threatening complications like corneal ulcer and endophthalmitis following any intra ocular surgery5. therefore, a delay in management may lead not only to secondary infection in the remaining years of life but also eventually to blindness1. retrograde spread of infection from the conjunctiva to nasal cavity, paranasal sinuses, allergic rhinitis and deviated nasal septum have also been reported6. dacryocystitis can develop at any age but it is much more frequent in infants, young adults and elderly. incomplete canalization of the nasolacrimal duct, nasolacrimal atresia, facial cleft, and dacryocystocele may lead to infantile dacryocystitis7. some studies suggest it is significantly more frequent in the age above 30 years and globally much more common in females with female to male ratio of 3.99:13. this disease is more prevalent in persons belonging to low socioeconomic background and poor personal hygiene3. microbiology may vary in acute and chronic infections. single infection predominates in severe acute dacryocystitis often involving gram-negative rods. multiple other species of bacteria could be involved in the pathogenesis of chronic dacryocystitis8. these patients usually harbor multiple microorganisms8. since various studies on microbial analysis of dacryocystitis and their sensitivity pattern towards different antibiotics are published internationally but the data is scarce at local level. the objective of the study is to determine the frequency of bacterial organisms responsible for causing dacryocystitis in patients coming to a tertiary care hospital and to determine different antibiotic sensitivity pattern toward gram negative and positive organisms. this hospital caters to patients belonging to lower middle class so our study will help to identify bacterial pathogens representing that class. it will also help us in treating the disease with sensitive drug and to avoid unnecessary medications. material and methods this study was conducted in the department of ophthalmology, abbasi shaheed hospital, karachi, a tertiary care hospital. the study was carried out in accordance with guidelines of declaration of helsinki. it was a cross sectional observational study started in january 2017 till december 2017. total of 100 patients presented in eye out patient department (opd) were enrolled in the study. sample was collected by nonprobability consecutive sampling technique. patients presenting with epiphora due to chronic dacryocystitis, primary or acquired nasolacrimal duct blockage were included. patients with acute dacryocystitis, canaliculitis, mucoceles and who had used topical or systemic antibiotics within 48 hours of presenting were excluded from the study. patients with complaints of epiphora, based on inclusion and exclusion criteria were selected from an eye opd. verbal informed consent was obtained from all the enrolled patients after explaining the procedure to them. detail history of the patients regarding their bio data, symptoms and duration of the symptoms were taken. ocular adnexal examination was carried out with help of slit lamp to rule out other causes of epiphora. diagnosis of chronic dacryocystitis was established based on history and examination. regurgitation test was performed in every patient. specimen was collected from the puncta after applying pressure on lacrimal sac by an ophthalmologist. it was collected with a soft cotton tip applicator under sterile aseptic conditions taking care not to touch surrounding skin, lashes and lid. the specimen was sent to the standard microbiology lab of the same tertiary care hospital. gram staining was done to identify gram negative and gram-positive bacteria. specimen was cultured in blood agar, chocolate agar specifically for gram-negative organisms, macconkey's agar for further identification of bacteria and for antibiotic sensitivity pattern. the specimen was incubated for 24 hours at 37 degree centigrade and in case of no growth; it was further incubated for 48 hours. biochemical tests were performed to identify bacteria in case of colonies formation on the media. after 48 hours if there was no growth the sample was declared culture negative. final report was issued after 3 days. data was collected and analyzed on statistical package for social sciences (spss) version 16. the continuous data like age and duration of disease are presented by means and range. the categorical data like gender, symptoms, diagnosis, organisms, culture positive and negative, sensitivity of various antibiotics are represented as the frequencies and percentages. bacteriology of chronic dacryocystitis in patients coming to a tertiary care hospital pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 249 results the mean age of the patients was 29.8 years ± 19.6 sd, median was 32 and mode was 50 years of age. minimum age was 11 months and maximum was 62 years of age. mean duration of the symptom was 5.9 years ± 10.5 sd. females were 75% out of 100 patients and 57% of them were housewives. all (100%) patients presented with watering and 20% with discharge. right eye was involved in 58% of patients and 73% had chronic dacryocystitis. culture was positive in 83% of patients. gram positive organisms including both rods and coccis were seen in 52% of cases. other demographic features of the patients are given in table one (1). table 2 demonstrates frequencies of various organisms. the most common pathogen identified is staphylococcus aureus in 21%, followed by pseudomonas in 18% of cases. the least common is enterobacter seen in 1% of patient. table 3 shows sensitivity of commonly used antibiotics against gram negative and positive organisms. table 1: demographic characters of patients. variables frequencies (%) males females pre-school children student house wives employed retired watering discharge chronic conjunctivitis right eye left eye chronic dacryocystitis congenital nld block culture +ve gram + organisims gram – organisims 25 (25%) 75 (75%) 20 (20%) 10 (10%) 57 (57%) 13 (13%) 20 (20%) 100 (100%) 20 (20%) 24 (24%) 58 (58%) 42 (42%) 73 (73%) 27 (73%) 83 (83%) 52 (52%) 31 (31%) table 2: frequency of organisms. variables frequency (%) none 17 (17%) staphylococcus aureus pseudomonas streptoccocuspneumo 21 (21%) 18 (18%) 16 (16%) streptococcus virdans 16 (16%) e coli 5 (5%) moraxella 2 (2%) mixed 2 (2%) klebsella 2 (2%) enterobacter 1 (1%) total 100 table 3: common antibiotic sensitivity pattern. sensitivity of medicines gram positive organisms (%) gram negative organisms (%) amoxicillin 1st generation cephalosporin 2nd generation cephalosporin 3rd generation cephalosporin tobramycin gentamycin vancomycin flouroquinolones moxifloxacin chloramphenicol 34% 45% 25% 52 % 21% 19% 57% 19% 66% 37% 22% 18% 33% 43% 31% 25% 35% 34% 57% 45% discussion microorganisms responsible for causing acute or chronic dacryocystitis differ from place to place or with geographical location. culture was positive in 83% of patients in our study and 9 different species of bacteria have been isolated. gram positive organisms predominate (52%) in our study. if we compare our results with other studies they have also reported more frequent gram positive pathogens, 61% by aseefa et al9, 94.2% by ahuja et al10, 78.6% by sarkar i erum shahid, et al 250 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology study place organism bacteria assefa y et al 9 ahuja et al. 10 pornpanich k et al 20 chang hoon lee et al eshraghi et al 12 briscoe d et al 16 ali mj et al13 sharat et al. 20 sun x et al 14 dm mills et al 15 chaudhry et al 17 north west ethiopia northern india thailand korea tehran, iran kfar saba, israel india south india china usa saudi arabia gram + gram +ve gram +ve gram+ve gram +ve gram -ve gram +ve gram +ve gram +ve gram +ve gram +ve staph epidermidis (17.6%) staph aureus (54.6%) coagulase-negative staph (27.8%) staph epidermidis (33.8%) s. aureus in 26%. pseudomonas (22%) staph aureus (25%) strep pneumone (40%) staphy aureus (34.5%) staph aureus (78.3%) coagulase negative staphylococci (33.9%) et al11. most common gram positive organism isolated in this study was staphylococcus aureus (21%) followed by gram negative organism pseudomonas (18%). studies conducted at various hospitals in different countries9-17 have also reported staphylococcus particularly aureus species to be more frequent. one of them collected pus from acute cases of dacryocystitis15. these countries have different geographical location including usa and mostly asian countries summarized in table 4. briscoe et al, reported the only study among asian countries, conducted in israel, in which gram negative organisms mostly pseudomonas (22%) were more frequently seen than gram positive organisms in cases of dacryocystitis16. in this study, swabs were taken from both dacryo abscess and chronic dacryocystitis. it can be deduced that these organism do not follow any particular pattern of geographical location. rare pathogens were enterobacter (1%), moraxella (2%) and klebsiella (2%). these pathogens do not specifically target any age group or gender. staphylococcus epidermidis is a dominant normal flora of lacrimal sac18. healthy individuals also possess microbial flora on their ocular surfaces and it includes small amount of coagulase-negative staphylococci. under normal circumstances, this bacterial flora helps to eliminate harmful pathogens, starts an immune response to injury and maintains a peaceful eco system on ocular surfaces19. once this equilibrium is disturbed by lacrimal duct obstruction this starts a cascade of reactions. it destroys tear film dynamics, delays microbial clearance, changes the normal microbial flora on ocular surfaces14. there might be a change in ph which leads to proliferation of other pathogens. the source of infection could be from conjunctival cul de sac or nasal cavity if duct is partially open. these pathogens are then involved not only in causing dacryocystitis but to preseptal cellulitis, orbital abscess, corneal ulcer, endophthalmitis, panophthalmitis and eventually blindness. classically it is staphylococcus aureus which is associated with chronic dacryocystitis but fungus have also been reported14. changes in the spectrum of causative microbiological agents over time have been reported in published indexed english literature13. male to the female ratio in our study was 1:3 which is comparable with other studies3,13. narrow nasolacrimal duct, smaller nasolacrimal fossa, hormonal factors, unhygienic or dusty working conditions and use of cosmetics including surma and kajal are known multiple factors responsible for causing dacryocystitis in females15,16. in our study, 57% of these female patients were house wives and 20% were retired personnel. mean age for presentation in our patients was 29.8 years. other studies had reported mean age of 50 years20-23. possible reason for early presentation and more common in females is their involvement in cooking and the use of cosmetics, not only kajal or surma on eyes but also use of poor quality face powder and talcum powder on face. all of these fine particles reach conjunctival sac, then mix in tears and settle in lacrimal sac or duct finally blocking it. right eye was more commonly involved i.e. 58% of cases as compared to left eye. laterality has no association with age or gender of patients. every patient had complained of watering in which 24% had developed chronic conjunctivitis and 20% with discharge on compressing. primary surgical treatment option for patients with chronic dacryocystitis is dacryocystorhinostomy (dcr) with intubation once an acute episode has https://www.ncbi.nlm.nih.gov/pubmed/?term=eshraghi%20b%5bauthor%5d&cauthor=true&cauthor_uid=25349808 bacteriology of chronic dacryocystitis in patients coming to a tertiary care hospital pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 251 settled with a course of antibiotics, anti-inflammatory and warm compresses. therefore, it is very essential to know about the sensitivity and resistance pattern of a drug. we have shown various commonly prescribed antibiotics with their sensitivity pattern in table 3. gram positive organisms are most sensitive to moxifloxacin (66%) and vancomycin (57%). cephalosporin and amoxicillin also have better sensitivity pattern. gram negative cocci and bacilli are most sensitive to moxifloxacin (57%) and chloramphenicol (45%). sensitivity pattern are low if compared with other studies3,9. patients presenting in our clinic had mean duration of symptoms of 5.9 years. these patients already had multiple visits to general practitioners, quacks and over the counter prescriptions before coming to an ophthalmologist. on top of that they keep delaying surgery by injudiciously using multiple antibiotics for treatment of dacryocystitis and its prophylaxis. such ignorant practices in our part of the world are alarmingly increasing the already existing natural antibiotic resistance mechanisms of bacteria and might be responsible for the relatively higher prevalence rate of their resistance9. this study is a small, single center study but it has contributed significantly in representing local data and validating the most common pathogen isolated for causing chronic dacryocystitis. there are few limitations of our study. there is lack of local data regarding prevalence, incidence and comparison of bacteriology in chronic dacryocystitis. culture negative specimens could have been fungus or anaerobes as they were not stained and cultured. conclusion we conclude that chronic dacryocystitis is more frequent in females, among 3rd to 4th decade; the most common isolated pathogen was a gram positive organism staphylococcus aureus. second most common pathogen was gram negative pseudomonas. both gram positive organisms and gram negative organisms are most susceptible to moxifloxacin. author’s affiliation dr. erum shahid mcps, fcps assistant professor, department of ophthalmology karachi medical and dental college & abassi shaheed hospital. dr. uzma fasih fcps associate professor, department of ophthalmology karachi medical and dental college & abassi shaheed hospital. dr. mohammad sabir m phil, microbiology professor, pathology department karachi medical and dental college & abassi shaheed hospital. dr. arshad shaikh mcps, fcps professor, hod ophthalmology department karachi medical and dental college & abassi shaheed hospital. role of authors dr. erum shahid concept, design, data collection, manuscript writing, data analysis, critical review. dr. uzma fasih concept, design, critical review. dr. mohammad sabir concept, design, critical review. dr. arshad shaikh concept, design, data collection, critical review. refrences 1. stephen. j.h. miller. diseases of the lacrimal apparatus. parson’s diseases of the eye, eighteenth edition. isbn 0 443 04263 2. 2. ghose s, nayak n, satpathy g. current microbial correlates of the eye and nose in dacryocystitis their clinical significance. aioc proc. 2005; 437-9. 3. bharathi mj, ramakrishnan r, maneksha v, shivakumar c, nithya v, mittal s comparative bacteriology of acute and chronic dacryocystitis. kerala j ophthalmol. 2008 ;(8): 20-28. 4. nayak n. fungal infections of eye and their laboratory diagnosis and treatment. nepal medical college j. 2008; 60 (1): 48-63. 5. kanski jj, editor. clinical ophthalmology, 7th ed. new york: butterworth-heinemann; diseases of the lacrimal apparatus, 2007: p. 163-4. 5.. 6. thomas r, thomas s, braganza a, muliyil j. evaluation of the role of say ringing prior to cataract surgery. indian j ophthalmol. 1997; 45: 211-4. 7. tower rn. dacryocystitis and dacryolith. in: tindal r, jensvold b (eds) roy and fraunfelder’s current ocular therapy. saunders, philadelphia, 2008; 6th edn: pp 538– erum shahid, et al 252 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology 540. 8. imtiaz ca, farouchesa, al-rashed w. bacteriology of chronic dacryocystitis in a tertiary eye care center. ophthalmic plast reconstr surg. 2005; 21 (3): 207–10. 9. assefa y, moges f, endris m, zereay b, amare b, bekele d, tesfaye s, mulu a, belyhun y. bacteriological profile and drug susceptibility patterns in dacryocystitis patients attending gondar university teaching hospital, northwest ethiopia. bmc ophthalmology, 2015 dec; 15 (1): 34. 10. ahuja s, chhabra ak, agarwal j. study of bacterial spectrum in patients of chronic dacryocystitis, at a tertiary care centre in northern india. j community med health educ. 2017; 7: 536. 11. sarkar i, choudhury sk, bandyopadhyay m, sarkar k, biswas j. a clinicobacteriological profile of chronic dacryocystitis in rural india. surgery, 2015; 4: 5. 12. eshraghi b, abdi p, akbari m, fard ma. microbiologic spectrum of acute and chronic dacryocystitis. intl j ophth 2014; 7 (5): 864. 13. ali mj, motukupally sr, joshi sd, naik mn. the microbiological profile of lacrimal abscess: two decades of experience from a tertiary eye care center. j ophthalmic inflamm infect. 2013; 3 (1): 57. 14. sun x, liang q, luo s, wang z, li r, jin x. microbiological analysis of chronic dacryocystitis. ophthalmic physiol opt. 2005; 25 (3): 261–263. 15. mills dm, bodman mg, meyer dr, morton iii ad. asoprs dacryocystitis study group. the microbiologic spectrum of dacryocystitis: a national study of acute versus chronic infection. ophthalmic plastic & reconst surg, 2007 jul. 1; 23 (4): 302-6. 16. briscoe d, rubowitz a, assia e. changing bacterial isolates and antibiotic sensitivities of purulent dacryocystitis. orbit, 2005; 24 (1): 29–32. 17. chaudhary m, bhattarai a, adhikari s. bacteriology and antimicrobial susceptibility of adult chronic dacryocystitis. nepalese journal of ophthalmology, 2010; 2 (2): 105–13. 18. coden d, hornblass a, haas bd. clinical bacteriology of dacryocystitis in adults. ophthal plast reconstr surg. 1993; 9: 125-131. 19. miller d, iovieno a. the role of microbial flora on the ocular surface. curr. opin. allergy clin. immunol. 2009; 9: 466–70. [pubmed] 20. sharat s, nagaraja ks. a study on the epidemiology of chronic dacryocystitis in an economically-deprived population in south india. j. evolution med. dent. sci. 2016; 5 (70): 5116-5117. 21. pornpanich k, luemsamran p, leelaporn a, santisuk j, tesavibul n, lertsuwanroj b, vangveeravong s. microbiology of primary acquired nasolacrimal duct obstruction: simple epiphora, acute dacryocystitis, and chronic dacryocystitis. clinical ophthalmology (auckland, nz), 2016; 10: 337. 22. deangelis d, hurwitz j, mazzulli t. the role of bacteriologic infection in the etiology of nasolacrimal duct obstruction. can j ophthalmol. 2001; 36 (3): 134– 139. 23. hartikainen j, lehtonen op, saari km. bacteriology of lacrimal duct obstruction in adults. br j ophthalmol. 1997; 81 (1): 37–40. type of article: original 154 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology original article arc light as an alternative approach to diagnose diabetic retinopathy (dr) at grass root level of health care system muhammad moin, asif manzoor, farah riaz pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad moin professor department of ophthalmology, lahore general hospital, lahore email: mmoin7@gmail.com …..……………………….. purpose: to compare arc light and direct ophthalmoscope in diagnosing patients with normal eyes, patients having signs of diabetic retinopathy and patients with other eye diseases. study design: quasi experimental study. place and duration of study: basic health units in nishtar town, lahore in collaboration with eye department lahore general hospital, lahore from sep 2017 to nov 2017. material and methods: a total of 552 examinations (276 examinations with ophthalmoscope and 276 examinations by using arclight) were performed on 46 patients. all patients were selected using purposive sampling. the patients were examined by the optometrist, medical officers (mo) and ophthalmologists in sequence and findings of the selected patients were noted using arc light and ophthalmoscope on the prescribed format. results: we found that findings of medical officers for right eye and left eye using arc light had 50% and 54.9% agreement respectively with findings of consultant who was gold standard in this study and more technical person in eye care. when optometrist findings were compared with consultant, they were excellent in terms of accuracy and level of agreement in findings of both users. when consultant findings using arc light were compared with ophthalmoscope findings only one case was misdiagnosed through arc light. sensitivity and specificity of arc light was 100% in right eye but it was reduced to 94.4% in left eye. conclusions: arc light is nearly as efficient tool as an ophthalmoscope and provides comparable results during diabetic retinopathy examination. key-words: arc light, direct ophthalmoscope, diabetic retinopathy. ision 2020 is the global initiative, launched in 1999 by the international agency for the prevention of blindness (iapb) and world health organization (who), with the aim of eliminating avoidable blindness. in pakistan, the national survey done in 2006 showed prevalence of blindness to be 3.4% and severe visual impairment as 4.9% in patients who were 30 years or older1. significant development has been noted in treatment and prevention options of anterior segment eye diseases like cataract and trachoma but a large proportion of avoidable blindness in developing countries of asia is due to posterior segment diseases such as glaucoma and diabetic retinopathy2. pakistan has 6th largest population in the world. diabetic association of pakistan (dap) and who showed an overall prevalence of diabetes as 11.47% (ranged from 6.39–16.5%)3. according to internal diabetic federation v arc light as an alternative approach to diagnose diabetic retinopathy (dr) at grass root level of health pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 155 (idf), there were 6.9 million cases of diabetes in pakistan in 2014 and prevalence of diabetes in adults of 20-79 years of age was 6.8%. however, the projected estimates of international diabetic foundation (idf) for 2035 shows an alarming situation and pakistan with an estimated number of 12.8 million diabetics, will be ranked 8th among the world‟s top 10 countries having increased prevalence of diabetes4. diabetic retinopathy is the most common micro-vascular complication of diabetes mellitus5 and, globally, is the leading cause of avoidable blindness in working age group adults6,7. a 2014 review of worldwide poag prevalence among people aged 40-80 years showed estimates of 2.31% in asia, 3.65% in latin america and the caribbean, and 4.20% in africa8. although, no cure has been found yet for glaucoma or diabetic retinopathy, early diagnosis and management is the key to slow down progression of disease and improve visual prognosis9,10. in many asian countries the per capita number of ophthalmologists and the prevalence of blindness are inversely related; majority of ophthalmologists are practising in urban areas and most of the patients are living in poorer rural regions11,12. in addition to this, the total numbers of eye health providers are less than the required. there is a great variation in the ratio of ophthalmologists and the populations in different south asian countries. on an average this ratio between ophthalmologist and population is 1:22,000. most of ophthalmologists are located in urban areas, on the contrary around 70% of the population lives in rural areas, 50% of the ophthalmologists are surgically inactive and clinical ophthalmology is more in practice than community ophthalmology13. in pakistan there are ten consultant ophthalmologists per million14. therefore, most of the time patients with eye diseases are reviewed by general practitioners, opticians, and allied eye care personnel. these groups need access to equipment and sufficient training to enable them to examine and detect abnormality in the posterior segment of the eye. standard direct ophthalmoscopes are expensive that ranges from usd $200 to 600 per instrument. the arclight ophthalmoscope (figure 1) is a low-cost alternate to standard direct ophthalmoscopes. it costs usd $7.50 when purchased in bulk. at one end it has a small direct ophthalmoscope while on the other end has an illuminating magnifying loupe (allowing examination of the anterior segment) and a detachable otoscope. its weight is 18 grams, uses three led light sources, and has an inbuilt battery which is rechargeable by either an integrated solar panel (useful for mobile clinics in pakistan) or a usb port. three different lenses are integrated on an adjustable lens slider which allows a rough correction of the patient‟s or examiner‟s refractive error. the device also consists of a small colour vision test, a near visual acuity chart, a ruler, and a pupil size gauge. the rationale of this study was to find an alternative and cheaper approach to diagnose diabetic retinopathy (dr) at gross root level of health care system. the arc light has been shown to provide effective results and findings which are similar to an ophthalmoscope; an available gold standard in the market. so this study is focused on the comparison of arc light versus ophthalmoscope in diagnosing patients with normal eyes (dr negative), patients having symptoms of diabetic retinopathy (dr positive) and patients with other eye diseases. material and methods a total of 552 examinations (276 examinations with ophthalmoscope and 276 examinations by using arclight) were performed on 46 patients at basic health units in nishtar town, lahore from sep 2017 to nov 2017. sample size was calculated by following formula: n= (zα/2 + zβ) 2 x (p1(1 − p1) + p2 (1 − p2)) / (p1-p2)2 the study was planned such that training was given to medical officers (mo‟s) at bhu level so that they could identify major eye diseases early at bhu level which could then be referred for treatment to tertiary care referral centre. mo‟s findings were compared with consultant; gold standard in this study and arc light findings were compared with ophthalmoscope: another gold standard tool of the study. this quasi experimental study was planned to evaluate the effectiveness of training given to medical officers (mo) on arc light and ophthalmoscope to diagnose dr positive and others eye diseases. further efficiency of arc light was compared with ophthalmoscope so that in future it would be used as replacement instrument of eye disease diagnosis. this study was an evidence based study including medical officers, optometrist and consultant ophthalmologist. the study was started after approval from the ethical committee of the lahore general hospital (lgh) which was the tertiary care centre attached with the basic health unit. training was given to medical officers of nishtar town district lahore at lgh before the start of the study. the study included subjects having dr positive, muhammad moin, et al 156 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology dr negative and others diseases. the patients were examined by these three persons systematically. they noted findings in right and left eyes of these subjects using arc light and ophthalmoscope. all patients who were un-cooperative or had media opacities were excluded from the study. fig. 1: arc light. all patients were selected using mr number from health information management system (hims) olive track through purposive sampling. first of all, patients were examined by the optometrist of the project team and the finding of the selected patients were noted using arc light and ophthalmoscope on the prescribed format and also entered in the hims. then all selected patients were referred to medical officers (mo‟s) on the same day for diagnosis by using arc light and ophthalmoscope. findings of both were kept separate and they did not know about each other‟s findings. these selected patients were later examined by the visiting consultant ophthalmologist from lgh by using arc light and ophthalmoscope for final evaluation and comparison of findings of the optometrist and medical officer. consultant ophthalmologist findings and ophthalmoscope assessments were labeled as the gold standards in this study. all these findings were added in hims by each person separately; mo‟s, optometrist and consultants. this data was also added in spss version 20 by data manger. after that it was further analyzed by consultant researcher according to guidelines to produce an evidence based study. sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) and level of agreement were performed on this collected data. this analysis was used to make a decision about the efficiency of arc light in comparison with ophthalmoscope and also to evaluate the mo‟s training impact. results results showed that the short term training of medical officers had only some impact on their skills for making a correct diagnosis using an arc light or an ophthalmoscope. but optometrist produced exceptionally good results and matched with consultant findings; gold standard in this study. afterwards the validity of arc light was assessed using sensitivity and specificity analysis. findings showed that arc light produced excellent results or almost in parallel to ophthalmoscope, another gold standard tool, if it was used by optometrist or consultant ophthalmologist. results of the right eye when observed through arc light and ophthalmoscope by medical officers and consultant showed that there were 23 patients who were classified by consultant as dr positive cases by using arc light while only 11 patients out of 23 were rightly classified by medical officers, table 1. remaining 12 subjects were misclassified into dr negative and others. similarly, 19 subjects were dr negative or diagnosed as normal by consultant. here only 2 cases out of 19 were wrongly classified into other categories. in the category of people having other diseases were rightly classified by mo. chisquare test of association showed a strong relationship between these two types of observations. further kappa test had a value of 0.506 which showed that there was 50% level of agreement between consultant and mo findings about right eye through arc light. similarly, optometrist findings were also compared with consultant; gold standard in this study. their findings 100% matched with the consultant findings in case of re diagnosis through arc light, table 2. after observing right eye, arc light was used to assess the problems of le by both; mo and consultant. almost similar findings were recorded for left eye. here association results were also significant. kappa test value shows that there was 54.9% agreement in both observers. medical officers (mo) were not good at diagnosing dr positive cases of left eye as 10 out of 17 were wrongly classified, table 3. arc light as an alternative approach to diagnose diabetic retinopathy (dr) at grass root level of health pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 157 table 1: mo findings for re with arc light compared with consultant's findings of re. consultant's findings for re with arc light total chi-square with p-value kappa dr positive dr negative others mo findings for re with arc light dr positive 11 0 0 11 37.586 (.000) .506 dr negative 11 17 0 28 others 1 2 4 7 total 23 19 4 46 table 2: optometrist findings for re with arc light compared with consultant's findings. consultant's findings for re with arc light total chi-square with p-value kappa dr positive dr negative others optometrist findings for re with arc light dr positive 23 0 0 23 92.000 (.000) 1.000 dr negative 0 19 0 19 others 0 0 4 4 total 23 19 4 46 table 3: mo findings for le with arc light compared with consultant's findings of le. consultant's findings for le with arc light total chi-square with p-value kappa dr positive dr negative others mo findings for le with arc light dr positive 7 0 0 7 41.776 (.000) .549 dr negative 10 18 1 29 others 0 2 8 10 total 17 20 9 46 table 4: optometrist findings for le with arc light compared with consultant's findings. consultant's findings for le with arc light total chi-square with p-value kappa dr positive dr negative others optometrist findings for le with arc light dr positive 17 0 1 18 84.617 (.000) .966 dr negative 0 20 0 20 others 0 0 8 8 total 17 20 9 46 findings of left eye diagnosed through arc light by optometrists were also analyzed. here there was a small discrepancy as only 1 case out of 46 was misclassified by optometrist. their findings matched 96.6% with the consultant findings, table 4. table 5 depicts comparison of findings with ophthalmoscope by mo and consultant. medical officers classified the re findings as dr positive cases identified by consultant into three categories; positive, negative and others. here level of agreement was 61.3% with strong association between these two users. table 6 shows findings of optometrist diagnosed through ophthalmoscope compared with consultant‟s findings. here, there was again 100% performance by optometrist. their findings 100% matched with the consultant findings. table 7 shows le diagnosis by using ophthalmoscope. medical officers classified the dr positive cases identified by consultant again into three categories; positive, negative and others. they misclassified 8 dr positive cases into dr negative and others. all other cases having dr negative and other diseases were reasonably correctly classified. here level of agreement was 62.1% with strong association between these two users. now, left eye was diagnosed through ophthalmoscope by optometrists. here, there was muhammad moin, et al 158 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology table 5: mo findings for re with ophthalmoscope compared with consultant's findings. consultant's findings for re with ophthalmoscope total chi-square with p-value kappa dr positive dr negative others mo findings for re with ophthalmoscope dr positive 14 0 0 14 40.447 (.000) .613 dr negative 7 17 0 24 others 2 2 4 8 total 23 19 4 46 table 6: optometrist findings for re with ophthalmoscope compared with consultant. consultant's findings for re with ophthalmoscope total chi-square with p-value kappa dr positive dr negative others optometrist findings for e with ophthalmoscope dr positive 23 0 0 23 92.000 (.000) 1.000 dr negative 0 19 0 19 others 0 0 4 4 total 23 19 4 46 table 7: mo findings for le with ophthalmoscope compared with consultant's findings. consultant's findings for le with ophthalmoscope total chi-square with p-value kappa dr positive dr negative others mo findings for le with ophthalmoscope dr positive 10 0 0 10 42.605 (.000) .621 dr negative 7 18 1 26 others 1 2 7 10 total 18 20 8 46 table 8: optometrist findings for le with ophthalmoscope compared with consultant. consultant's findings for le with ophthalmoscope total chi-square with p-value kappa dr positive dr negative others optometrist findings for le with ophthalmoscope dr positive 18 0 0 18 92.000 (.000) 1.000 dr negative 0 20 0 20 others 0 0 8 8 total 18 20 8 46 table 9: consultant's findings for re with arc light and ophthalmoscope. consultant's findings for re with ophthalmoscope total chi-square with p-value kappa dr positive dr negative others consultant's findings for re with arc light dr positive 23 0 0 23 92.000 (.000) 1.000 dr negative 0 19 0 19 others 0 0 4 4 total 23 19 4 46 table 10: consultant's findings for le with arc light and ophthalmoscope. consultant's findings for le with ophthalmoscope total chi-square with p-value kappa dr positive dr negative others consultant's findings for le with arc light dr positive 17 0 0 17 84.617 (.000) .966 dr negative 0 20 0 20 others 1 0 8 9 total 18 20 8 46 arc light as an alternative approach to diagnose diabetic retinopathy (dr) at grass root level of health pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 159 again 100% performance by optometrist. their findings matched 100% with the consultant findings, table 8. the most important part of the study was to validate the arc light as an efficient tool for diagnosis of dr cases and others. for this purpose, consultant findings on both, arc light and ophthalmoscope were compared and matched. cross table and bar chart analysis highlighted that both results matched 100%. it shows that arc light can be an effective tool for diagnosis, table 8. now, same procedure was performed for left eye by consultant. in this case only one case out of 46 subjects was misclassified through arc light. performance analysis shows that there was 96.6% level of matching in the consultant findings through two different tools, table 9. validity analysis of the arc light was done and compared its findings with ophthalmoscope. in this case only dr positive and dr negative cases of re were compared through both diagnosing tools. arc light produced 100% sensitivity, specificity, ppv, npv and accuracy. in addition to these values, confidence intervals were also given to see the range of accuracy and measurements, table 10. table 11: validation parameters of re. statistic formula value 95% ci sensitivity 100.00% 85.18% to 100.00% specificity 100.00 % 82.35% to 100.00% disease prevalence 54.76% (*) 38.67% to 70.15% positive predictive value 100.00% (*) negative predictive value 100.00% (*) accuracy 100.00% (*) 91.59% to 100.00% these two tools were also applied on le diagnosis by consultant. but when we validated the arc light findings with ophthalmoscope for dr positive and dr negative cases, one case was misdiagnosed by arc light. so, here sensitivity, npv and accuracy reduced to 94.4%, 95.24% and 97.37% from 100% respectively, table 12 and 13. table 12: validation parameters of le. statistic formula value 95% ci sensitivity 94.44% 72.71% to 99.86% specificity 100.00 % 83.16% to 100.00% disease prevalence 47.37% (*) 30.98% to 64.18% positive predictive value 100.00% (*) negative predictive value 95.24% (*) 74.86% to 99.26% accuracy 97.37% (*) 86.19% to 99.93% discussion the arc light ophthalmoscope is emerging as a reliable, low-cost alternative to the standard direct ophthalmoscope. the cost of an arclight ophthalmoscope is significantly lower than a direct ophthalmoscope or comparable instruments. comparing the current price of heine direct ophthalmoscope (usd $365), one can buy 48 arclight ophthalmoscopes at their marketed bulk order price (usd $7.5). arclight is the only direct ophthalmoscope that is specifically designed for low-income settings15. however, it would be useful in medical training and education across the globe by providing an affordable direct ophthalmoscope for medical students. in comparison to other low-cost direct ophthalmoscopes16,17 the arclight has an adjustable lens power with three power settings (+4, −3, and −6 diopters). these lenses will be sufficient for most of the patient and examiner refractive error. arc light also has an additional attachable otoscope which is helpful to examine ear problems (figure 1). muhammad moin, et al 160 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology we found that findings of medical officers for right eye and left eye using arc light had 50% and 54.9% agreement respectively with findings of consultant who was gold standard in this study and more technical person in eye care. when the medical officer used the ophthalmoscope for the assessment of same case‟s re and le, they got 61% and 62% agreement with consultant findings. in this study, more than one medical officer was involved and got training on both tools. so it was planned to see the individual findings and their agreement with consultant findings. when split analysis was performed it was observed that there was huge element of heterogeneity among mo‟s in the performance and accuracy. this detailed analysis showed that they were not at same level and kappa test also reported 23.4% to 75% level of agreement for re through arc light. for le it was 39.4% to 76.5%. in both cases; re and le through arc light, mo‟s accuracy was 31.8% to 100% in different doctors when they used ophthalmoscope for re and similarly 45.5% to 100% for le. overall it can be seen that, mo‟s mostly got confused and gave wrong assessment when they diagnosed those patients who have dr positive status. in the case of dr negative and others diseases their accuracy was comparatively good. lowe et al18 in a similar study, in which examination was performed by final-year medical students, found no clinically significant difference between the arclight ophthalmoscope and the heine k180 direct ophthalmoscope in terms of accuracy of the vertical cup to disc ration (vcdr) measurement and with a similar proportion of examinations yielding a ≥ 0.2 difference in the vcdr compared to the reference standard for both the arclight and heine ophthalmoscopes. importantly, 85% of arclight examinations yielded vcdr estimation, compared to 61% with the heine ophthalmoscope. medicalstudents found that the arclight was much easier to use than heine ophthalmoscope. moreover the study also found that the led bulb used in the arclight ophthalmoscope was better tolerated by the subjects during ocular examination, with considerably lower scores for both “glare” and “length of examination”. arc light ophthalmoscope has a solar powered battery which makes it useful even in remote, rural areas with interrupted power supply and also cuts the cost of buying new batteries regularly. our study assessed the accuracy of the arc light ophthalmoscope in detecting pathologies in the retina and it could be used to detect diabetic retinopathy. with such a low cost, arc light has the capacity to be much more widely available and will improve training opportunities and examination of the diabetic retinopathy by medical specialists in rural areas. earlier detection and management of retinopathy will improve the prognosis of the patients with a less likelihood of progression to blindness. blundell r et al19 compared arclight with traditional direct ophthalmoscope to examine retinal diseases and found that arclight was equally effective in terms of identification of clinical signs and making correct diagnosis and observers found more ease in using arclight. arc light could be helpful in better training of fundoscopy and easy access to direct ophthalmoscopes in low budget settings. in another study by mccomiskie et al20 panoptic versus conventional direct ophthalmoscope was compared in a group of „naïve‟ first year medical students to determine which would be more suitable for non-ophthalmoligists. their results showed that the medical students found the panoptic (po) much easier to use, with accuracy of rating the vcdr similar to the conventional direct ophthalmoscope. we also compared the findings of optometrist with gold standard; consultant. they had excellent accuracy and level of agreement with the findings of the consultant. only one case was misdiagnosed by optometrist out of 184 cases. comparison was also made between findings of the consultant with arc light and ophthalmoscope. as a whole, only one case was misdiagnosed through arc light. validity of arc light versus ophthalmoscope was evaluated using sensitivity and specificity analysis. overall the arc light showed good results in its validity test. sensitivity and specificity of arc light were 100% in re. but in le its sensitivity reduced was to 94.4%. overall arc light produced excellent results. the ophthalmoscope was used as a gold standard versus the arc light in this analysis. the limitation of the study was that it was done at two centres. we have planned to extend this study to other centers to increase the number of patients examined. moreover medical students will also be included in the study to get another perspective. conclusion we found that medical officers had some difficulty in diagnosing dr positive cases with arc light. while arc light as an alternative approach to diagnose diabetic retinopathy (dr) at grass root level of health pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 161 optometrists were better at diagnosis and using these two tools. furthermore arc light is nearly as efficient tool as an ophthalmoscope when used by the consultants. arc light is easy to use and provides comparable results when examining diabetic retinopathy. it is capable of improving easy access to equipment in low-budget setups around the world and improvingfundoscopy skills in eye care workers and diagnosis of retinal diseases. on the basis of these findings we recommend that it is important to train the mo‟s before asking them to use the arc light. as mo‟s are not proficient in eye care, therefore it is better to introduce optometrists along with medical officers at bhu level on permanent basis where they can work in outpatients department. arc light can be used as a replacement of ophthalmoscope for diagnosing dr or other diseases as shown by the sensitivity and specificity analysis in this study. author’s affiliation prof. muhammad moin head of department of ophthalmology pgmi/lgh/amc, lahore dr. asif manzoor vitreoretinal fellow, lahore general hospital, lahore. dr. farah riaz project manager fred hollows foundation islamabad role of authors prof. muhammad moin study design, manuscript writing and critical review dr. asif manzoor study design, data collection and critical review dr. farah riaz manuscript writing, data analysis, study design conflict of interests none. acknowledgements the study was supported by 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furahini g, gilbert ce, burton mj, philippin h. the arclight ophthalmoscope: a reliable low-cost alternative to the standard direct ophthalmoscope; journal of ophthalmology volume 2015: 1-6. 19. blundell r, roberts d, fioratou e et al. comparative evaluation of a novel solar powered low-cost ophthalmoscope (arclight) by eye healthcare workers in malawi. bmj innov. 2018 apr; 4 (2): 98–102. 20. mccomiskie je, greer rm, gole ga. “panoptic versus conventional ophthalmoscope,” clinical & experimental ophthalmology, 2004; vol. 32, no. 3, pp. 238–242. https://www.ncbi.nlm.nih.gov/pubmed/?term=the+number+of+ophthalmologists+in+practice+and+training+worldwide%3a+a+growing+gap+despite+more+than+200000+practitioners pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 150 original article role of tetracycline in corneal neovascularization arshad ali lodhi, murtaza, munawar ahmed, noman ahmed, ghulam haider, sameen afzal junejo, mustafa kamal pak j ophthalmol 2015, vol. 31 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sameen afzal junejo department of ophthalmology. liaquat university of medical and health sciences/jamshoro, sindh pakistan email: sameenafzal1@gmail.com …..……………………….. purpose: to find the efficacy of topical tetracycline in corneal neovascularization. material and methods: in this prospective observational clinical analysis, patients more than fifteen year’s age of either sex were enrolled. anterior segment slit lamp examination was performed. fluorescein 1% dye and rose bengal were used to stain cornea at the bed and margins simultaneously. the area of corneal vascularization was measured in mm using 0.5% fluorescein dye. the percentage of neovascularized corneal areas to the entire cornea was calculated. result: out of twenty eight patients twenty one completed follow up period of four months. among 21 patients males were 10 (47.6%), and females 11 (52.38%) with unilateral and bilateral corneal neo-vascularization. 15 (71.42%) responded well and showed reduction in corneal new vessels from 7 mm pretreatment to 2 mm (overall) post treatment at the end of fourth month. six patient showed poor or no response due to extended fibrosis. conclusion: topical tetracycline has remained quite instrumental in reducing superficial epithelial and sub-epithelial corneal new vessels. key words: cornea; neovascularization; tetracycline; therapeutic effect. cular neovascularization is the abnormal growth of blood vessels in the retina, choroid and cornea. they can lead to many complications like fibrosis, scarring and blindness. common causes of corneal neovascularization are blepharitis, keratitis, corneal graft rejection, chemical injuries and improper or prolonged use of contact lenses.1 the main source of superficial corneal neovascularization arises from conjunctiva. the superficial vessels adopt the pattern of diffuse tree branches and are usually observed passing through the corneo-scleral junction invading anterior layers of cornea up to substantia propria. while deep corneal vessels are having straight course originate from deep scleral vessels and penetrate the deeper corneal layers including corneal stroma and beyond. antibiotics, lasers and other treatment have limited approach. steroids are used to combat with this problem but extended use can result in to unavoidable side effects and complications.1,2 tetracycline is a second generation long acting non selective antibiotic.2,3 topical application inhibits corneal lysis, treats corneal ulcers and encourages corneal epithelium healing.4,5 apart from this, tetracycline has also been proved to be quite effective in inhibiting corneal new vessels by inhibiting matrix metalloproteinase (mmp) activity.6,7 topically induced drugs have become more successful and better effective in the treatment of ocular surface disorders.8 tetracycline or its derivative preparations (doxycycline, minocycline) accelerate corneal wound healing and promote reduction in corneal new vessels by inhibiting mmp activity.9, 10 the objective of this study was to document the o mailto:sameenafzal1@gmail.com arshad ali lodhi, et al 151 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology therapeutic effect of topical tetracycline on superficial corneal neovascularization. material and methods this prospective observational clinical analysis was performed at liaquat university eye hospital hyderabad, sindh of liaquat university of medical and health sciences / jamshoro pakistan from june 2011 to may, 2015. inclusion criteria: the subjects of more than fifteen years of age from both genders with unilateral or bilateral superficial (epithelial and sub-epithelial bowman membrane) corneal vascularization associated with ocular surface disorders without any history of ocular surgery were included. all the enrolled cases were examined at outpatient department of the tertiary eye care center. detailed history and verbal consent of the patients was obtained. anterior segment was examined using slit lamp bio-microscope. corneal staining was done with fluorescein 1% dye. rose bengal stains were used to stain devitalized cornea. the area of corneal vascularization was measured in mm by using 0.5% fluorescein under cobalt blue filter on slit lamp biomicroscope by the same ophthalmologist. the percentage of neovascularized corneal areas to the entire cornea was calculated. the primary treatment of different antibiotics and steroids was stopped. the secondary treatment was started with tetracycline (hcl-usp 5 mg) ophthalmic gel thrice a day. tetracycline thus used during this study was arranged through a renowned pharmaceutical company. the area of corneal epithelial defect with new vessels was measured on 15th day, one month and every two months for four months. all the subjects were requested to complete the treatment follow up criteria of this study. statistical package of social science (spss) version 14 was used for statistical data analysis on corneal vascularization. results out of 28, seven patients did not complete the 4 months follow up and will not be discussed in the results. in twenty one patients who completed follow up, male were 10 (47.6%), female 11 (52.38%) with unilateral and bilateral corneal neo-vascularization were registered for this study (fig. 1-3). most of the subjects belonged to rural areas. the characteristics of enrolled patients is mentioned in table 1. seven (25.0%) subjects were lost to follow up. out of remaining twenty one, there was significant reduction in corneal neo-vascularization in 15 (71.42%) patients. the student – t test was used to evaluate the data. the mean age of the patients was 39.38 years. the results of treatment were quite significant (2-tailed), with the p value 0.002. standard deviation was 1.21253; confidence interval of the difference was role of tetracycline in corneal neovascularization pakistan journal of ophthalmology vol. 31, no. 3, jul – sep, 2015 152 95%.the documented overall reduction in new vessels was from 7 mm to 2 mm after four months of treatment (fig. 4 6). one (4.47%) lady recovered moderately and remaining five (23.81%) did not respond to the treatment due to extended fibrosis although the symptoms were relieved. discussion corneal neovascularization (cnv) is a sightthreatening condition. most often it develops secondary to inflammatory conditions and ocular surface disorders. corneal trauma due to chemical burns causes severe corneal neovascularization.11 in this study two patients developed corneal neovascularization after alkali burn, which could not improve inspite of abrupt treatment with tetracycline and associated medications. various sources promote neovascularization i.e. growth factors, prostaglandins and interleukins. the process of corneal new vessels formation consists of two steps. first is the vascular endothelial growth factor (vegf) related to proliferation of vascular endothelium. second step reformation of extracellular matrix followed by activation of cytokines. corneal neovascularization due to alkali burns is related to inflammation. in response to a chemical burn the inflammatory cells release cytokines and mmps. there is also a variety of compounds supposed to inhibit corneal new vessels. such anti angiogenic factors are non-steroidal anti-inflammatory agents, steroids and immuno suppressives.12, 13 the treatment of choice in corneal neovascularization is topical use of corticosteroids. but due to their disastrous side effects and complications now a days have got restricted application. 14 in our study steroids use was not documented in any registered subject. the efficacy of tetracycline depends upon its concentration, route of application, and patient’s acceptance. the recommended dosage of tetracycline is absolutely non-toxic to the corneal surface and adnexa. in our study tetracycline with the dosage of 5 mg was used topically three times a day. its effect on cornea is biological oriented rather than antimicrobial. according to the recent global research, tetracycline also acts to suppress tumor growth, angiogenesis, resorption of bone.15, 16 limitations to this study in our area not much work has yet been done on this issue. we could not compare the results of our study with other national studies. there is no doubt a need for advanced study and research on the efficacy of tetracycline in different ocular diseases particularly corneal neovascularization. conclusion tetracycline has proved itself to be more promising in preventing and reducing superficial corneal neovascularization thus enhancing the inhibitory effects of angiogenesis. author’s affiliation dr. arshad ali lodhi department of ophthalmology liaquat university of medical and health sciences/jamshoro, sindh/pakistan dr. murtaza department of ophthalmology liaquat university of medical and health sciences/jamshoro, sindh/pakistan dr. munawar ahmed department of ophthalmology liaquat university of medical and health sciences/jamshoro, sindh/pakistan dr. noman ahmed department of ophthalmology liaquat university of medical and health sciences/jamshoro, sindh/pakistan dr. ghulam haider department of ophthalmology liaquat university of medical and health sciences/jamshoro, sindh/pakistan dr. sameen afzal junejo department of ophthalmology liaquat university of medical and health sciences/jamshoro, sindh/pakistan dr. mustafa kamal department of ophthalmology liaquat university of medical and health sciences/jamshoro, sindh/pakistan role of authors dr. arshad ali lodhi drafting, methodology, patient’s selection, and literature search. arshad ali lodhi, et al 153 vol. 31, no. 3, jul – sep, 2015 pakistan journal of ophthalmology dr. murtaza maintained the post treatment follow up record of all the subjects who full filed regular follow up criteria of this study. dr. munawar ahmed drafting, methodology, patient’s selection, and literature search. dr. noman ahmed performing ocular examinations and data collection. dr. ghulam haider performing ocular examinations and data collection. dr. sameen afzal junejo selection of patients, examination treatment and follow-up. dr. mustafa kamal maintained the post treatment follow up record of all the subjects who full filed regular follow up criteria of this study. references 1. lim p, fuchsluger ta, jurkunas uv. “limbal stem cell deficiency and corneal neovascularization”, semin ophthalmol. 2000; 24: 139-48. 2. moses ma, harper j, folkman j. “doxycycline treatment for lymphangioleiomyomatosis with urinary monitoring for mmps,” n engl j med. 2006; 354: 2621–2. 3. lindeman jh, abdul-hussien h, van bockel jh, et al. clinical trial of doxycycline for matrix metalloproteinase-9 inhibition in patients with an abdominal aneurysm: doxycycline selectively depletes aortic wall neutrophils and cytotoxic t cells, “circulation. 2009; 119: 2209–16. 4. villarreal fj, griffin m, omens j, dillmann w, nguyen j, covell j. early short-term treatment with doxycycline modulates postinfarction left ventricular remodeling, circulation. 2003; 108: 1487–92. 5. ralph ra. tetracyclines and the treatment of corneal stromal ulceration: a review, cornea. 2000; 19: 274–7. 6. dan l, shi-long y, miao-li l, yong-ping l, hong-jie m, ying z, xiang-gui w. “inhibitory effect of oral doxycycline on neovascularization in a rat corneal alkali burn model of angiogenesis, “curr eye res. 2008; 33: 653–60. 7. cox ca, amaral j, salloum r, guedez l, reid tw, jaworski c, john-aryankalayil m, freedman ka, campos mm, martinez a, becerra sp, carper da. doxycycline's effect on ocular angiogenesis: an in vivo analysis. ophthalmology. 2010; 117: 1782–91. 8. samtani s, amaral j, campos mm, fariss rn, becerra sp. doxycycline-mediated inhibition of choroidal neovascularization, invest ophthalmol vis sci. 2009; 50: 5098–5106. 9. anumolu ss, desantis as, menjoge ar, hahn ra, beloni ja, gordon mk, sinko pj. doxycycline loaded poly (ethylene glycol) hydrogels for healing vesicantinduced ocular wounds. biomaterials. 2010; 31: 964–74. 10. su w, li z, lin m, et al. the effect of doxycycline temperature-sensitive hydrogel on inhibiting the corneal neovascularization induced by bfgf in rats. graefes arch clin exp ophthalmol. 2011; 249: 421–7. 11. wagoner md. chemical injuries of the eye: current concepts in pathophysiology and therapy, surv ophthalmol. 1997; 41: 275–313. 12. li t, hu a, li s, luo y, huang j, yu h, ma w, pan j, zhong q, yang j, wu j, tang s. kh906, a recombinant human vegf receptor fusion protein, is a new effective topical treatment for corneal neovascularization,” mol vis. 2011; 17: 797–803. 13. ma dh, chen jk, kim ws, hao yx, wu hc, et al. “expression of matrix metalloproteinases 2 and 9 and tissue inhibitors of metalloproteinase 1 and 2 in inflammation-induced corneal neovascularization, ophthalmic res. 2001; 33: 353–62. 14. de paiva cs, corrales rm, villarreal al, farley wj, li dq, et al. corticosteroid and doxycycline suppress mmp-9 and inflammatory cytokine expression, mapk activation in the corneal epithelium in experimental dry eye,“ exp eye res. 2006; 83: 526–35. 15. federici tj. the non-antibiotic properties of tetracyclines: clinical potential in ophthalmic disease. pharmacol res. 2011; 64: 614–23. 16. liang d, yan sl, lin ml, li yp, ma hj, et al. inhibitory effect of oral doxycycline on neovascularization in a rat corneal alkali burn model of angiogenesis. curr eye res. 2008; 33: 653–60. http://www.ncbi.nlm.nih.gov/pubmed/?term=dillmann%20w%5bauthor%5d&cauthor=true&cauthor_uid=12952845 http://www.ncbi.nlm.nih.gov/pubmed/?term=dillmann%20w%5bauthor%5d&cauthor=true&cauthor_uid=12952845 http://www.ncbi.nlm.nih.gov/pubmed/?term=dillmann%20w%5bauthor%5d&cauthor=true&cauthor_uid=12952845 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http://www.ncbi.nlm.nih.gov/pubmed/?term=tang%20s%5bauthor%5d&cauthor=true&cauthor_uid=21528000 microsoft word 6. michael chuka okosa pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 89 original article non-surgical management of hyphaema from non penetrating trauma among nigerian ophthalmologists okosa michael chuka, onyekwe lawrence obizoba, anajekwu cosmas chinedu mbakigwe chidi fidelis pak j ophthalmol 2013, vol. 29 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: okosa michael chuka ophthalmologist and former head, guinness eye centre nnamdi azikiwe university teaching hospital; onitsha, nigeria …..……………………….. purpose: to explore non-surgical treatment preferences and practices of ophthalmologists in nigeria. material and methods: the study was a survey done by means of selfadministered semi-structured questionnaire to nigerian ophthalmologists. literature search was done using google, and hinari results: in-patient treatment is favored by 72%; bed rest is practiced by 97.2%; while 54.8% routinely pad traumatized eye. commonest medications used are glucocorticoids by 87.1%; cycloplegics by 80.6%, and oral carbonic anhydrase inhibitors 59.1%. the commonest combinations of drugs used are these three medications, being deployed by 50.5% of surveyed ophthalmologists routinely in all patients with closed globe traumatic hyphaema. except for cai no oral medications enjoys significant favor conclusion: no aspect of treatment enjoys universal agreement. majority advocates routine use of topical glucocorticoid and cycloplegic agents. bed rest, hospitalization and padding should not be routine but based on need. these are suggested as approach for management of this condition pending availability of a better guideline. rauma to the eye may result in various injuries including presence of blood in the anterior chamber without perforation of the eye. closed-globe traumatic hyphaema may cause diverse complications including associated traumatic uveitis which generally accompanies the initiating trauma, secondary haemorrhage, corneal blood staining, synechia formation, and ocular hypertension / secondary glaucoma.1,2 aim of management is primarily to prevent these sight-threatening complications from occurring, or if that fails, treat them if they arise. treatment of complications when they arise is fairly straightforward, but preventing them from occurring is a challenge, arising from difficulty in predicting who among patients will develop any of these complications. the result is differences of approach among ophthalmologists and thus to different management practices. these practices and associated controversies include advantage of ancillary measures like hospitalization, bed rest with restriction of activities versus ambulation and at-home treatment;3,4 utility of padding the affected eye or both eyes;5.6 and the place and usefulness of various medications – topical, oral and systemic – in preventing complications. numerous studies disclose conflicting results as to benefit derivable from various medications commonly used in traumatic hyphaema1,6-8 resulting in many ophthalmologists in parts of the world either commonly using and recommending them, while others do not.3,5,6,9,10 surveys of ophthalmologists in texas11, usa disclosed absence of agreement in virtually all aspects of management; and in the uk,12 divergent views on appropriate medications were expressed by ophthalmologists. this study is designed t okosa michael chuka, et al 90 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology to disclose views and practices of nigerian ophthalmologists concerning the various medications they use routinely in uncomplicated closed-globe traumatic hyphaema so as to determine the dominant views among them in this regard. in the absence of a multi-center case-control study it is hoped the results obtained from a broad base of practitioners would act as a guide in the nigerian and similar environment. material and methods a convenience sampling of nigerian ophthalmologists who attended the afternoon scientific session on the 16th september 2008 of the annual general congress of the ophthalmological society of nigeria (osn) at ile ife in by means of a semi-structured pre-tested questionnaire. responses were analyzed with spss 11 software. results one hundred and seven questionnaires were distributed; 101 were retrieved, but 8 were discarded because filling was substantially incomplete, resulting in 93 used for this analysis. respondents were from 42 eye care centers. of these 93 practitioners, 9 ophthalmologists practice in 4 private eye care facilities and 84 represented 38 public hospitals-tertiary and secondary. public eye care centers captured in the study is estimated to constitute about 75% of such institutions in nigeria. among the practitioners, 92.5% declared that resort to surgery was infrequent in traumatic closed globe hyphaema, and they found non-surgical means usually adequate for preventing and treating of most complications. results are presented in tables 1-3, and in fig. 1. discussion ancillary management complications of traumatic hyphaema as depicted in figure 1 can result in loss of vision, and treatment is aimed at preventing this complication occurring or reducing their potential for causing loss of vision. the specific causes of traumatic hyphaema in nigeria as depicted in table 1 do not tend to be more amenable to non-surgical treatment as far as we know. part of traditional management of hyphaema patients involved hospital admission and restriction of activities in the form of bed rest. the patient was required to lie in bed with the head and shoulder raised to 30 – 45 degrees and both eyes were covered with a rigid shield. medications used included topical cycloplegics and glucocorticoids, oral sedatives and sometimes prednisone tablets 2. these measures were thought to be useful in preventing secondary haemorrhage: activity restriction to reduce stress – induced raised venous pressure, binocular patching to prevent accommodative and pupillary activity that might induce dislodgement of clot blocking the torn vessel and result in secondary haemorrhage. it is apparent from table 2 that nigerian ophthalmologists in large measure still practice these methods. this is because of its claimed benefits and the pressure of tradition. the value of head up position is to better estimate level of blood and thus classify the hyphaema, determine if it is decreasing or increasing, facilitate drainage from wider lower trabecular meshwork, and to have a hyphaema level below pupillary level for ease of ophthalmoscopy and faster recovery of vision for visual acuity assessment.13 this appears more of an empirical treatment since the head-up position is utilized in all grades of hyphaema-those with fluid level below the pupil, and even in the presence of clots. unfortunately if the inferior angle is the part damaged, the head-up position is valueless, and could in fact be deleterious as the rate of decrease of hyphaema may be compromised. 0 10 20 30 40 50 60 ocular htn/ glaucoma anterior uveitis re-bleeding corneal blood staining fig. 1: (okosa and onyekwe) complications observed by nigerian ophthalmologists on patients with traumatic hyphaema although studies with regards to hospitalization, padding and bed rest were found by investigators not to influence complication rate, duration of hyphaema and final visual acuity3,4,5,6 many ophthalmologists in many institutions still practice and recommend them non-surgical management of traumatic closed – globe hyphaema among nigerian ophthalmologists pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 91 to varying degrees. these different approaches are reflected among nigerian ophthalmologists: 97.8% insist on bed rest with head-up position, although 72% routinely admit all patients with closed-globe hyphaema on initial contact. reason for seeming preference for hospitalization is that all patients with hyphaema require daily examination and monitoring of intra-ocular pressure and other complications; and it is not possible to monitor for these with patient at home. compliance with bed rest and medication in a patient at home cannot be monitored. patients may find it inconvenient, or sometimes impossible, to come from far distances daily, and at the time required for necessary follow-op, making it seem prudent to admit them. padding of affected eye is not as widespread as bed rest or hospital admission as uniocular patching is deployed by 54.8%; as against 45.2% who do not pad at all, while 2.5% pad both eyes. explanation of the seeming preference for eye padding is to shield the injured eye and prevent further trauma and secondary haemorrhage although studies have not demonstrated any differences in complication rate or requirement for surgery between patients who had eye pad and others who do not5,6. topical medications a preponderant majority (91.4%) of nigerian ophthalmologists, as displayed in table 3, routinely use single or combination of medications as only 8 of the 93 sampled do not use any medication in uncomplicated hyphaema. cycloplegic and glucocorticoid eye drops the most commonly used combination, are deployed with the expectations that by stabilizing the iris blood vessels, they will control table 3: drugs routinely used by nigerian ophthalmologists, and their frequency for management of traumatic non-penetrating hyphaema glucocorticoid eye drops/ ointment 81 (87.1) atropine and other cycloplegics 75 (80.6) carbonic anhydrase inhibitors (cai) tablets 55 (59.1) gluco-corticoid eye drops + cycloplegic agent + cai 47 (50.5) vitamin c tablets 100 mg tid 10 (10.8) nsaid eye drops + tablet 3 (3.2) sedatives: diazepam 5 mg bid for adults 3 (3.2) acetaminophen tablets 500mg -1000mg tid for adults 2 (2.2) antibiotic eye drops 2 (2.2) pilocarpine eye drop 1% 1 (1.1) nsaid eye drop 1 (1.1) amino-caproic acid 1 (1.1) no routine medication 8 (8.8) okosa michael chuka, et al 92 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology anterior uveitis resulting from the trauma or presence of blood in the anterior chamber, which inflammation was both a source of discomfort to the patient, and thought to predispose to secondary haemorrhage14. additionally these medications prevented synaechia formation in hyphaema of long duration; and pupillary dilatation caused by mydriatics allowed an earlier visual acuity assessment in clearing hyphaema. the plethora of practices no doubt reflects effect of diverse and conflicting reports by investigators in this matter. for example oksala found topical steroid and cycloplegics reduced re-bleed rate in addition to treating associated anterior uveitis,14 but a study in kuwait city did not find any difference in resolution of traumatic hyphaema, the complication rate or requirement for surgery among three groups of patients: those treated with combination of topical cycloplegic agent with corticosteroid; those treated with corticosteroid eye drops only; and those treated with placebo in the form of artificial tears.6 it is not known what factors are responsible for differing effects of these drugs in these different population groups. could it be related to diet, habit, blood group, tissue types, and mechanism of injury? until these questions are answered, it appears the practice among nigerian ophthalmologists is to err on the side of safety by administering these drugs. it might be argued that cycloplegics by bunching the iris towards the anterior chamber angle may impede rate of drainage and raise the iop, and by its weakening effect on the iris muscle result in more frequent incidences of re-bleeding; or that miotics would have the opposite effect. however rakusin found no difference in complication rate and resolution of hyphaema among patients treated with miotics, mydriatics, both or none.7 conclusion from these studies is that ancillary and medical treatments have not been conclusively proved to influence the spontaneous resolution of hyphaema, reduce its complication rate or decrease need for surgery. this not withstanding routine use of topical cycloplegic and glucocorticoid drugs in this condition by a vast majority of nigerian ophthalmologists is a practice shared by many, but by no means all, of their contemporaries in other places.1,3,5,8 reasons for persistence in use of these medications prophylactically include that old practices die hard especially if they are not demonstrably harmful, and could cause some good. besides it is probably more satisfying for the patient and the doctor to be seen as doing something instead of not ‘treating’ the patient. very few ophthalmologists would be able to send a patient with uncomplicated closed – globe hyphaema home, without padding, no bed rest, and no drug despite reports that these measures are probably not helpful. perhaps legal and ethical consideration in the present situation of uncertain knowledge concerning possible benefits compel practitioners to offer probably unnecessary treatment in this condition corresponding to the assertions of romano and phillips.10 why do the few (8.6%) found in current study not give any medications routinely in uncomplicated hyphaema? the reason is probably because it would appear as ‘bad science’, pointless, and not evidence-based to subject patients to expenses and inconvenience of treatment without demonstrable good as the outcome. oral medications ophthalmologists in the uk were unanimous in agreeing on absence of any place for use of systemic medications in uncomplicated hyphaema12 except for carbonic anhydrase inhibitors (cai) which were used by 54% of them for adult patients with an iop of above 25 mm hg. this contrasts with situation among nigerian ophthalmologists in which 73% use at least one oral medication routinely (table 3). carbonic anhydrase inhibitors, is commonest oral medication, and are used routinely by 59.1% of nigerian ophthalmologists as a pro-active measure in all patients with hyphaema, to prevent secondary glaucoma, especially in large volume hyphaema. it is not clear why topical pressure lowering agents are not preferably used rather than oral cai as some of them are quite affordable, available and have less adverse reactions. use of nsaids however is not popular, being employed by only four ophthalmologistsas tablets by three (3.2%) and as tablet and topically by one (1.1%). the rationale for its use appears to be to prevent clot formation and quicken resolution time of hyphaema. however its efficacy in these has not been demonstrated in any study, to our knowledge, but rather its use in hyphaema has been associated with rebleeding.2 in present survey three of the four practitioners (75%) who routinely used nsaids as oral medication in uncomplicated hyphaema reported secondary haemorrhage as a frequent complication, one reported a frequent need for surgical evacuation of hyphaema; only 36.7% of those who do not use nsaids reported re-bleeding as a frequent complication. oral fibrinolytic agents -amino-caproic acid (aca) and tranexamic acid are in the main not used, probably because of lack of availability, cost and non-surgical management of traumatic closed – globe hyphaema among nigerian ophthalmologists pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 93 perhaps contradictory, and adverse effects reported by some investigators, and bias of practitioners against them.2,5,15,10 topical aca is currently not available in nigeria to the authors’ knowledge. use of oral sedatives, acetaminophen tablets and topical antibiotics are also not as popular as use of oral carbonic anhydras inhibitors or topical glucocorticoids and atropine as displayed in table 2. conclusion differences in both ancillary and medical treatment, found among nigerian ophthalmologists in management of closed – globe traumatic hyphaema reflect situation among practitioners in other parts of the world because of absence of clear cut protocol for management derived from controlled trials. difficulty in devising a controlled trial in this condition include problem of adequately matching patients and ethical considerations of study protocols in which no treatment controls are utilized10. many outcome studies of traumatic hyphaema management were noted as flawed due to inadequate protocol and bias10,16 limiting their utility and validity as guide. the best that can be done is to get data from a wide base of trained observers and practitioners who manage this condition for a closer approximation to a valid guideline. this we have attempted to do in this study resulting in some suggestions and recommendations to act as a guide, although the application in some situations may need modification as is usually advised in management of probably all medical conditions. author’s affiliation dr. okosa michael chuka senior lecturer, and former head, department of ophthalmology nnamdi azikiwe university and consultant ophthalmologist and former head, guinness eye centre nnamdi azikiwe university teaching hospital; onitsha, nigeria dr. onyekwe lawrence obizoba consultant ophthalmologist department of ophthalmology, nnamdi azikiwe university teaching hospital and guinness eye centre onitsha, and professor of ophthalmology, college of health sciences, nnamdi azikiwe university, nnewi campus, nigeria dr. anajekwu cosmas chinedu resident doctors nnamdi azikiwe university, nnewi campus, nigeria dr. mbakigwe chidi fidelis resident doctors nnamdi azikiwe university, nnewi campus, nigeria references 1. walton w, van hagen s, grigorian r, zarbin m. management of traumatic hyphaema. surv ophthalmol. 2002; 47: 297-334. 2. sheppard jd, crouch er, williams pb, crouch er, rastogi s, garcia-valenzuela e. hyphaema. http:// emedicine.medscape.com/article/1190165-overview. 3. luksza l, homziuk m, nowakowska – klimek m, glasner l, iwaszkiewicz – bilikiewicz. traumatic hyphaema caused by eye injuries. b. klin oczna. 2005; 107: 250-1. 4. shiuey y, lucarelli mj. traumatic hyphema: outcome of outpatient management. ophthalmol. 1998; 105: 8515. 5. fareed a, warid m, al mansouri f. management of non-penetrating traumatic hyphema in ophthalmology department of hmc review of 83 cases. middle east j of emergency. 2004; 4: 1. 6. behbehani ah, abdelmoaty sma, aljazaf a. traumatic hyphema – comparison between different treatment modalities. saudi j ophthalmol. 2006; 20: 1646. 7. rakusin w: traumatic hyphema. am j ophthalmol 1972; 74: 284-92. 8. papaconstantinou d, georgalas i, kourtis n, karmiris e, koutsandrea c, ioannis ladas i, georgopoulos g. contemporary aspects in the prognosis of hyphaema. clin ophthalmol. 2009; 3: 287–90. 9. yasuna e. management of traumatic hyphaema. arch ophthalmol. 1974; l 91: 190-91. 10. romano pe, phillips pj. traumatic hyphaema: a critical review of scientifically catastrophic history of steroid treatment therefore; and a report of 24 additional cases with no re-bleeding after treatment with the yasuna systemic steroid, no touch protocol. bin vis strab. 2000; 15: 187-96. 11. kelly jl, blanquist ph. management of traumatic hyphema in texas. tex med. 2002; 98: 56-61. 12. little bc, aylward bw. the medical management of traumatic hypheama: a survey of opinion among ophthalmologists in the uk. j roy soc med. 1993; 86: 458-9. 13. earl r, crouch er jnr. management of traumatic hyphaema: therapeutic options. j paedtr ophthlmol strab. 1999; 36: 238-50. 14. oksala a. treatment of traumatic hyphaema. br j ophthalmol. 1967; 51: 315. 15. fong lp. secondary hemorrhage in traumatic hyphema. predictive factors for selective prophylaxis. ophthalmol. 1994; 101: 1583-8. 16. hopewell s, loudon k, clarke mj, oxman ad, dickersin k. publication bias in clinical trials due to statistical significance or direction of trial results. cochrane database of systematic reviews 2009, issue 1. microsoft word 9. crsharmeen akram 106 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology case report lasik in hyperopic eyes with congenital nystagmus: a case report sharmeen akram, zarksis h. anklesaria, khabir ahmad pak j ophthalmol 2013, vol. 29 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sharmeen akram section of ophthalmology aga khan university department of surgery karachi …..……………………….. patients with nystagmus are considered to be poor candidates for laser in situ keratomileusis (lasik), because they are unable to fixate. this case report presents the first reported use of lasik surgery with a solid-state laser in hypermetropia and congenital nystagmus. a 23 year old woman with congenital nystagmus had lasik surgery to correct a refractive error of +2.25/+1.75 90º in the right eye and + 2.00 / +1.75 90º in the left one. baseline uncorrected visual acuity (ucva) was 20/200 in both eyes, and best spectacle corrected visual acuity was 20/40 in both the eyes. the procedure was performed using the nidek mk-2000 microkeratome and a customvis solid state laser system. twenty four hours postoperatively, the patient had a ucva of 20/50 in each eye which remained unchanged at 1 week and 8 weeks. conclusion: lasik surgery using solid state laser was effective in this case of congenital nystagmus. however, more cases should be examined before conclusions can be drawn. aser in situ keratomileusis (lasik) is an accepted surgical method for the correction of myopia, hyperopia and astigmatism.1,2 in this surgery, stabilization of the globe is essential both for flap formation and fixating the globe during laser ablation because movements during this procedure can result in complications, such as free caps, irregular flaps, or eccentric ablations which can result in glare and halos, especially at night.3-5 in 1998, siganos and colleagues6 described two myopic eyes with congenital nystagmus that had photorefractive keratectomy with good long term visual outcome. in a subsequent case report, soloway et al7 reported using the lasik procedure in a patient with nystagmus and myopia with no loss of best spectacle corrected visual acuity (bscva ) over 1 year in both the eyes. mahler et al8 described the use of lasik procedure using excimer laser in 16 eyes with myopia and congenital nystagmus, with no loss of greater than 1 line in bscva postoperatively. all these studies were done in myopic patients using excimer laser. this report aims to present a case of lasik surgery in a 23 – year – old hypermetropic female with congenital nystagmus. to the best of our knowledge, this is the first reported use of lasik surgery with solid-state laser in hypermetropia and congenital nystagmus internationally. case presentation a 23-year-old lady with congenital nystagmus underwent lasik surgery for hypermetropic correction after informed consent. she had a refractive error of +2.25/+1.75 90º in the right eye and a + 2.00 / +1.75 90º in the left one. baseline uncorrected visual acuity was 20/200 in both eyes, and best spectaclecorrected visual acuity was 20/40 in each eye. the central corneal thickness in both the eyes was 610 microns, using sonomed pachymeter. the patient demonstrated horizontal jerky nystagmus; the mean number of oscillations per second were approximately three, and the frequency of nystagmus increased with attempted fixation. there was no well-defined null zone or anomalous head movement or position. both eyes were operated by a single surgeon in a single setting. patient was given oral diclofenac l lasik in hyperopic eyes with congenital nystagmus: a case report pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 107 fig. 1: pre-op corneal topographies right and left eyes sodium 50 mg and alprazolam 1 mg half an hour before surgery. both eyes were anesthetized 20 minutes prior to surgery, using topical anaesthesia: 1 drop of 0.5% proparacaine hydrochloride instilled in each eye 3 times every 5 minutes. after the laser system was calibrated, the patient was placed in the supine position and draped. a drop of povidoneiodine 10% ophthalmic solution was instilled in the conjunctival sac and irrigated with saline solution. the eyeball was held with conjunctival forceps. corneal marker was applied. a corneal flap of 8.5 mm diameter and thickness of 160 microns, with a nasal hinge was prepared with the nidek mk-2000 microkeratome. after the flap was lifted, the eye was refocused while the surgeon stabilized the eye with conjunctival forceps. a scanning laser system fig. 2: corneal topographies right and left eyes one week post-lasik (customvis, australia) was used with a frequency of 300 hz and wavelength of 213 nm; the optical zone was 6 mm. the time for exposure was 42 seconds for the right eye and 39 seconds for the left one. oscillations of the globe during surgery were controlled by holding the globe with the conjunctival forceps. a peripheral ablation was performed. repeat refocusing during the procedure was done. postoperatively, eye lubricants (artificial tears), corticosteroid eye drops (fluorometholone 0.1%) and topical antibiotic (moxifloxacin 0.5%) were advised as per protocol. 24 hours post-operatively, ucva was 20/50 in each eye; there was no improvement with sharmeen akram, et al 108 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology spectacle correction and the binocular visual acuity was 20/50 without glare or halos. the vision remained unchanged when assessed at 1 week and 8 weeks. the pre and post-operative corneal topographies are shown in figures 1 and 2 discussion congenital nystagmus appears in the first 6 months of life as repetitive, involuntary, side-to-side oscillations which can persist throughout life. these movements are usually jerky and horizontal in nature which can dampen with convergence. this condition is commonly associated with visual impairment and abnormal head movements.9 in the case of congenital nystagmus we operated, no well-defined null zone, abnormal head movement or position were noticed. nystagmus patients are poor candidates for lasik surgery as these patients are unable to fixate, resultingin difficulty in obtaining reliable topography and centration of the ablation zone4,5. therefore, there is a high risk of decentered ablation. there has been very limited published literature on the use of lasik in nystagmus patients. most of published cases have focused on the use of lasik in myopic patients with nystagmus, using excimer laser6, 7. our case is unique in that the patient was hyperopic and a solid state laser was used10,11. currently, several devices are used to stabilize the globe, including forceps, and circular and semi-circular suction rings12. we used conjunctival forceps to stabilize the eyeball during corneal ablation. this did result in a small subconjunctival haemorrhage, which resolved over 2 weeks. although individuals with nystagmus are unable to fixate during lasik surgery, the procedure may still be performed in nystagmus with hyperopia after stabilization of the globe. iris tracking should be utilised to prevent eccentric ablation. the use of solidstate laser has been shown to be safe in routine lasik procedures13. we also used a solid-state laser with iris tracking and had good postoperative result. conclusion this case report illustrates that lasik surgery was effectively performed to correct hypermetropia in our patient with congenital nystagmus using a solid – state laser. however, more cases and long-term follow-up are necessary before conclusions can be drawn. however, our day 1, week 1 and week 8 results are satisfactory having lost only 1 line of bcva at this very early juncture. author’s affiliation dr. sharmeen akram section of ophthalmology aga khan university, department of surgery karachi dr. zarksis h. anklesaria laser vision centre eye clinic and hospital karachi dr. khabir ahmad section of ophthalmology aga khan university, department of surgery karachi references 1. sutton gl, kim p. laser in situ keratomileusis in 2010 – a review. clinical & experimental ophthalmology. 2010; 38: 192-210. 2. pallikaris ig, papatzanaki me, stathi ez, frenschock o, georgiadis a. laser in situ keratomileusis. lasers in surgery and medicine 1990; 10: 463-8. 3. alkara n, genth u, seiler t. diametral ablation--a technique to manage decentered photorefractive keratectomy for myopia. journal of refractive surgery 1999; 15: 436-40. 4. mulhern mg, foley-nolan a, o'keefe m, condon pi. topographical analysis of ablation centration after excimer laser photorefractive keratectomy and laser in situ keratomileusis for high myopia. journal of cataract and refractive surgery. 1997; 23: 488-94. 5. verdon w, bullimore m, maloney rk. visual performance after photorefractive keratectomy. a prospective study. archives of ophthalmology. 1996; 114: 1465-72. 6. siganos ds, evangelatou ka, papadaki tg, katsanevaki vj, dagos ai, pallikaris ig. photorefractive keratectomy in eyes with congenital nystagmus. journal of refractive surgery. 1998; 14: 64952. 7. soloway bd, roth re. laser in situ keratomileusis in a patient with congenital nystagmus. journal of cataract and refractive surgery. 2002; 28: 544-6. 8. mahler o, hirsh a, kremer i, barequet is, marcovich al, nemet p, levinger s. laser in situ keratomileusis in myopic patients with congenital nystagmus. journal of cataract and refractive surgery. 2006; 32: 464-7. 9. kanski jj, bowling b. clinical ophthalmology: a systematic approach 7th ed: w.b. saunders company; 2011. lasik in hyperopic eyes with congenital nystagmus: a case report pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 109 10. varley ga, huang d, rapuano cj, schallhorn s, boxer wachler bs, sugar a. ophthalmic technology assessment committee refractive surgery panel aaoo. lasik for hyperopia, hyperopic astigmatism, and mixed astigmatism: a report by the american academy of ophthalmology. ophthalmology. 2004; 111: 1604-17. 11. cobo – soriano r, llovet f, gonzalez – lopez f, domingo b, gomez – sanz f, baviera j. factors that influence outcomes of hyperopic laser in situ keratomileusis. journal of cataract and refractive surgery. 2002; 28: 1530-8. 12. konuk o, bilgihan k, hasanreisoglu b. laser in situ keratomileusis in an eye with congenital nystagmus. journal of cataract and refractive surgery. 2001; 27: 6368. 13. tsiklis ns, kymionis gd, kounis ga, pallikaris ai, diakonis vf, charisis s, markomanolakis mm, pallikaris ig. one-year results of photorefractive keratectomy and laser in situ keratomileusis for myopia using a 213 nm wavelength solid – state laser. journal of cataract and refractive surgery. 2007; 33: 971-7. pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 105 case report limbal relaxing incision for treatment of thermal corneal burns irfan qayyum malik, syed ali haider, qasim lateef pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irfan qayyum malik department of ophthalmology gujranwala medical college gujranwala irfan790@yahoo.com …..……………………….. a 60 years old lady, who underwent phaco with lens implantation, received corneal burn from a hot phacoemulsification tip. after two months of surgery her orbscan showed the corneal burn induced astigmatism of 5.0 d. her vision was cf unaided and 6/24 with correction. full thickness limbal relaxing incision was made and after 2 weeks her orbscan showed very less astigmatism. after 6 weeks her orbscan corneal topography showed astigmatism of just -0.3 d which was stable until her last follow up at 6 months and her visual acuity which was cf initially improved to 6/12 unaided. she was followed up for a period of six months with orbscan, uncorrected and best corrected visual acuity. so we concluded that limbal relaxing incision is a useful technique to reduce the high astigmatism induced by thermal corneal burns and to improve the visual outcome. key words: limbal relaxing incision, corneal burn, astigmatism hacoemulsification, introduced by charles david kelman in 1967, refers to cataract surgery in which the crystalline lens of the eye’s is emulsified and aspirated from the eye with an ultrasonic hand piece. the phaco probe has a tip made of titanium or steel and it vibrates at ultrasonic speed. the tip of the needle vibrates at an ultrasonic frequency to sculpt and emulsify the lens. the vibrating tip is hot. because it vibrates at speed more than 40,000 per second. it is covered by a silicone sleeve. it is kept cool by the irrigating fluid flowing around it through the silicone sleeve. complications of phacoemulsification include rupture of the posterior capsule, posterior loss of lens fragments, posterior dislocation of iol, suprachoroidal haemorrahge, corneal burn etc. among all of these complications, preoperative corneal burn is relatively a common condition. this is caused by hot phaco tip. material and mathods a 60 years old lady, who underwent phaco with lens implantation, received corneal burn from a hot phaco tip (fig. 1 and 2). after two months of surgery her orbscan showed the corneal burn induced astigmatism of -5.0 d at 60. her vision was cf unaided and 6/24 with correction due to high astigmatism of -5.0 d (fig. 3). full thickness limbal relaxing incision was made with 11 no blade at the site of contracture which was from 8 o’clock to almost 9:30 o’clock to reduce the contracture. then two loose sutures were applied to just close the lips of the incision. as a result of that incision after 2 weeks her orbscan corneal topography showed very negligible amount of astigmatism (fig. 4). regular follow ups were done with orbscan and best corrected visual acuity recorded on every visit. results after 6 weeks her orbscan corneal topography showed astigmatism of just 0.3 d which was initially 5.0 d (fig. 4). it remained stable until the end of her follow up period of six months and her visual acuity which was cf initially improved to 6/12 unaided. discussion corneal burn is relatively a common complication of phacoemulsification. it may occur due to hot phaco tip p http://en.wikipedia.org/wiki/cataract_surgery http://en.wikipedia.org/wiki/cataract_surgery http://en.wikipedia.org/wiki/cataract_surgery http://en.wikipedia.org/wiki/eye http://en.wikipedia.org/wiki/titanium http://en.wikipedia.org/wiki/steel irfan qayyum malik, et al 106 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology fig. 1: after 2 months of phaco surgery showing corneal burn at the site of phaco incision. fig. 3: after 2 months of phaco orbscan corneal topography showed astigmatism of -5.0d when accidently infusion is occluded or aspiration from the phaco prob is stopped during the surgery. some of the burns occur during sculpting and some occur during fragment removal1. fig. 2: 1st post-op orbscan showing astigmatism of -4.3 d. fig. 4: 2nd post-op orbscan showing astigmatism of -0.5 d. full thickness relaxing incision may be useful to reduce astigmatism in some selected cases. it is given at the limbus with the help of 11 no blade or 15o knife to penetrate into the anterior chamber. its role is very important in the cases where there is fibrosis and contracture of all the layers of cornea. because astigmatism cannot be corrected without relieving the contracture. other surgical options are radial keratotomy, prk, lasik, arcuate keratotomy, astigmatic keratotomy, and toric iols2. we decided to go for full thickness relaxing incision because there was fibrosis and contracture of all layers of cornea at the incision site along with thinning due to the thermal burn. the incision was 5-6 mm almost at the same area where there was steepening shown on orbscan. it is slightly different than the limbal limbal relaxing incision for treatment of thermal corneal burns pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 107 relaxing incision (lri), which consists of paired partial thickness incisions at opposite sites given at the time of cataract surgery or as an independent separate procedure.3 they usually correct astigmatism up to 8 diopters but generally are reserved for 0.5 to 4 diopters of astigmatism. they are made using a dsp gills pop-up micrometer knife (lri knife). the degree of arc was determined and assessed using the modified gills nomogram4. a 6 mm incision is required for each diopter of astigmatism up to 2 diopters. to correct between 2 3 diopters, lri’s of 8 mm in length are used. limbal relaxing incisions have gained much acceptance among the cataract surgeons where it is often combined with the cataract operation to minimize pre-existing astigmatism5. the incisions can be done as a part of cataract surgery or at any time after that. this result in better post-operative vision without spectacles.6 the procedure can also be used in individuals in which primary refractive error is astigmatism. incisions are made at the opposite sites of the cornea, following the curve of the iris, causing a slight flattening in that direction7. as the incisions are outside of the field of view, they usually do not cause glare and other visual effects that result from other corneal surgeries like keratotomy. they are simpler and less expensive than laser surgery such as femtolasik, lasik or prk. good results usually do not require the location and length of the incisions to be highly precise, and the incisions can easily be extended later if the visual acuity is not improved and the original procedure did not correct all of the astigmatism.8 in our case full thickness limbal relaxing incision was made with 11 no blade at the site of contracture. as a result of that incision after 2 weeks orbscan corneal topography showed very negligible amount of astigmatism. regular follow ups were done and on every orbscan and best corrected visual acuity was recorded. it remained stable until the end of her follow up period of six months and her visual acuity which was cf initially improved to 6/12 unaided. author’s affiliation dr. irfan qayyum malik asst prof of ophthalmology gujranwala medical college gujranwala prof. syed ali haider department of ophthalmology lahore general hospital lahore dr. qasim lateef associate professor of ophthalmology allama iqbal medical college lahore references 1. bradley mj, olson rja. survey about phacoemulsification incision thermal contraction incidence and causal relationships. am j ophthalmol. 2006; 141: 222-4. 2. naeser k, behrens jk, naeser ev. quantitative assessment of corneal astigmatic surgery: expanding the polar values concept. j cataract refract surg. 1994; 20: 162–8. 3. kaufmann c, peter j, ooi k, phipps s, cooper p, goggin m. limbal relaxing incisions versus on-axis incisions to reduce corneal astigmatism at the time of cataract surgery. j cataract refract surg. 2005; 31: 22615. 4. roman s, auclin f. baudouin c limbal relaxing incisions to correct preexisting astigmatism during cataract surgery j fr ophtalmol. 2009; 2: 390-5. 5. ouchi m, kinoshita s. prospective randomized trial of limbal relaxing incisions combined with microincision cataract surgery j refract surg. 2009; 26: 1-6. 6. kohnen t, klaproth ok. correction of astigmatism during cataract surgery klin monbl augenheilkd. 2009; 226: 596-604. 7. budak k, friedman nj, koch dd. limbal relaxing incisions with cataract surgery. j cataract refract surg. 1998; 24: 503-8. 8. müller – jensen k, fischer p, siepe u. limbal relaxing incisions to correct astigmatism in clear corneal cataract surgery. j refract surg. 1999; 15: 586-9. http://en.wikipedia.org/wiki/cornea http://en.wikipedia.org/wiki/iris_%28anatomy%29 http://en.wikipedia.org/wiki/lasik http://en.wikipedia.org/wiki/prk http://www.ncbi.nlm.nih.gov/pubmed?term=bradley%20mj%5bauthor%5d&cauthor=true&cauthor_uid=16387014 http://www.ncbi.nlm.nih.gov/pubmed?term=olson%20rj%5bauthor%5d&cauthor=true&cauthor_uid=16387014 http://www.ncbi.nlm.nih.gov/pubmed/16387014 http://www.ncbi.nlm.nih.gov/pubmed/?term=phipps%20s%5bauthor%5d&cauthor=true&cauthor_uid=16473215 http://www.ncbi.nlm.nih.gov/pubmed/?term=cooper%20p%5bauthor%5d&cauthor=true&cauthor_uid=16473215 http://www.ncbi.nlm.nih.gov/pubmed/?term=goggin%20m%5bauthor%5d&cauthor=true&cauthor_uid=16473215 http://www.ncbi.nlm.nih.gov/pubmed?term=%22roman%20s%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22auclin%20f%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22baudouin%20c%22%5bauthor%5d javascript:al_get(this,%20'jour',%20'j%20fr%20ophtalmol.'); http://www.ncbi.nlm.nih.gov/pubmed?term=%22ouchi%20m%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22kinoshita%20s%22%5bauthor%5d javascript:al_get(this,%20'jour',%20'j%20refract%20surg.'); http://www.ncbi.nlm.nih.gov/pubmed?term=%22kohnen%20t%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22klaproth%20ok%22%5bauthor%5d javascript:al_get(this,%20'jour',%20'klin%20monbl%20augenheilkd.'); microsoft word 13-cr ps mahr 53 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology case report negative dysphotopsia after uncomplicated phacoemulsification p.s. mahar pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p.s. mahar section of ophthalmology department of surgery aga khan university hospital stadium road, karachi – 74000 …..……………………….. purpose: to describe the complaint of images of darkness or crescent like shadow in the temporal field of patients after undergoing cataract surgery, termed as negative dysphotopsia (nd). material and methods: three patients of either gender are described, who underwent uncomplicated phacoemulsification with in-the-bag implantation of acrysof acrylic intraocular lens (iol), model sa60at (alcon – usa), under topical anesthesia at surgical day care of aga khan university hospital, karachi. all procedures were performed from march 2008 to october 2012. first two patients were 65 and 67 years old ladies, while the third patient was a gentleman, age 56 years. results: all three patients complained of nd symptoms. the first patient’s symptoms lasted for one year at her last visit. the second patient’s symptoms disappeared within three months without any specific treatment. the third patient still had the complaint, one month post-operatively. conclusion: nd is a relatively common post-operative complication after uncomplicated in-the-bag iol implantation. in majority of the patients, symptoms are transient but some patients can complaint about seeing these temporal shadows for long time. egative dysphotopsia (nd) is described as a crescent of shadow on the temporal side of vision after uncomplicated phacoemulsification with posterior chamber intraocular lens (iol) implantation. it is characterized by patient reporting a dark line in the temporal field of vision after going under cataract surgery. the prevalence is described, ranging between 0.16 to 15%.1 nd was first described by davison2, who associated it with the use of squareedge acrylic lenses. however it has also been reported with the use of round-edge silicon lenses3. there are two types of nd described: incisional1 and iol related3. the incisional type occurs in the immediate post-operative period after a clear cornea temporal approach, during cataract surgery. it is believed that incisional corneal edema can initiate these symptoms and once edema subsides, patient’s complaint also disappears. the iol related phenomenon last longer for several months. the exact mechanism of these symptoms is not known. it is hypothesized that square-edge lenses reflect incoming temporal light rays, thus casting a shadow on the nasal retina. some analysts believe that, this is probably due to combination of multiple factors, such as, incisional site, iol design and ocular anatomy4. various workers have described certain preventing measures to avoid this annoying symptom by placing the iol with its haptic at 3 and 9 o’ clock position4. it is presumed that placing the haptic in such a manner reduce the effect of the square – edge. we describe 3 patients with nd symptoms who were operated upon by the author. material and methods patient 1: a 65 year old woman had uncomplicated phacoemulsification under topical anesthesia in her right eye in march 2008, through clear corneal approach temporally. she had implantation of 21 diopter, 1 piece injectable iol, model sa60at acrysof n negative dysphotopsia after uncomplicated phacoemulsification pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 54 (alcon – usa), implanted in – the – bag. one week post-operatively she can see 6/7.5 unaided, but complained of seeing a dark shadow in the temporal visual field. two weeks later, she went under same procedure on her left eye with the implantation of same model of iol in power of 20.5 diopters. this time, incision was made in clear cornea at 9 o’clock position. although, she read 6/7.5 unaided in this eye, but complained again of seeing a dark crescent in her left temporal field. one year after her surgery, she still has these temporal shadows but has learned to live with them. patient 2: a 67 years old woman had uneventful cataract surgery on her right eye in may 2009, through clear cornea temporally with in-the-bag implantation of one piece acrysof sa60at (alcon – usa) iol of 19 diopter power. postoperatively she improved to 6/7.5 with -0.5 ds / -0.5 dc x 70°. she complained of seeing temporal shadow in the immediate postoperative period. but her symptoms disappeared within 3 months without any specific treatment. patient 3: this 56 years old gentleman had cataract surgery on his left eye in october 2012, through clear corneal incision at 135o. he had a single piece acrysof sa60at (alcon – usa) of 23 diopters implanted inthe-bag, with iol haptic positioned at 3 and 9 o’ clock. postoperatively, though he improved with – 0.5 dc x 170° to 6/9, he bitterly complaint of dark shadow in his temporal field. one month postsurgery, his symptoms are still persisting. discussion dysphotopsia involves seeing images or dark spots in front of the eye after cataract surgery. there are two types of dysphotopsia described. a positive dysphotopsia refers to images of light and negative dysphotopsia referring to images of darkness and crescent like shadow in the temporal field of patient after undergoing uncomplicated in-the-bag iol implantation. osher1 has categorized nd symptoms as short term or long term. he believed that short term symptoms were incision related, mostly on the temporal side in clear cornea not covered by the eyelid while long term symptoms were more prominent in patients with shallow orbit and brown eyes. holladay and coworkers5 using zemax optical design program simulator, hypothesized that primary optical factors required for nd symptoms are small pupil, a distance behind the pupil of 0.06mm or more and 1.23mm or less for acrylic iol, a sharp-edge design of iol and a functional retina that extends anterior to the shadow. he cited high index of refraction optic material, angle alpha and the nasal location of the pupil as secondary factors. using non-sequential component zemax raytracing technology, hong and co-researchers6 hypothesized that; anterior capsulorhexis interacting with iol could induce nd symptoms. masket and co-workers3 believe that, anterior circular round capsulorhexis edge overlapping the iol creates the negative shadow confirmed by ray tracing analysis. these authors suggested that, nd does not develop when iol is on the top of the capsule. in their study of 12 eyes of 11 patients with nd symptoms, piggy back iol implantation was performed in 7 cases, reverse optic capture (roc) in 3 cases, in-the-bag iol exchange in 3 cases and iris fixation of the capsular bag – iol complex in 1 case. the primary outcome measure was resolution of nd symptoms and secondary outcome measure was evaluation of posterior chamber anatomy with ultrasonic biomicroscopy (ubm). in their cohort of patients, symptoms of nd were partially or completely resolved in 10 patients having roc or piggy back iol implantation. according to these authors roc may be employed as a secondary surgery for symptomatic patient or as a primary prophylactic procedure. the procedure involves, freeing the anterior capsule from the underline optic by visco-dissection and retraction of nasal and temporal anterior capsule edge to slip it under the optic. secondary piggy – back iol is another surgical method described by ernest7 that has proven successful for patients with symptomatic nd. in this method, a second iol is implanted in the ciliary sulcus above the primary iol-capsular-bag complex. trattler8 in his study of 142 eyes reported 11 patients complaining about nd. he performed piggy back implantation, roc, in-the-bag iol exchange and iris suture fixation of capsular bag-iol complex. the symptoms of nd were partially or completely restored in 10 of his patients who underwent piggy back iol implantation or roc. no improvement was observed in patients who had in – the – bag iol exchange or iris suture fixation of the capsular bag – iol complex. cooke9 has described a patient with nd, having uncomplicated in – the – bag iol implantation with p.s. mahar 55 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology scleral tunnel incision at 10.30 o’ clock position, entirely covered by upper lid. patient’s complaint lasted for 6 months, eventually having iol exchange with clear cornea, temporal incision resulting in disappearance of symptoms. the case reported here shows that, not all cases of nd are due to temporal corneal incision because patient’s symptoms occurred with scleral tunnel incision and resolved after iol exchange with temporal incision. narvaez and coworkers10 described symptoms of nd in 2 patients, age 70 and 62 respectively, which had uneventful small incision cataract surgery with technis z9000 iol (pharmacia – usa). these symptoms persisted in both patients for more than 1 year. osher1 studied the incidence, course and common factors of patients with nd with possible role of corneal incision in cohort of 250 patients going under uncomplicated phacoemulsification with single-piece acrylic iol. his study revealed incidence of nd at 15.2% in the first post-operative day, decreasing to 3.2% after one year and 2.4% after 2 years. he related shallow orbit, prominent globe and space greater than 0.45 mm between the iris and iol by ultrasonic biomicroscopy in patients with nd symptoms. he also hypothesized that corneal edema associated with beveled temporal incision was related to the patient’s transient symptoms. varmosi et al4 reported six eyes out of 3,806 cataract procedures performed, reporting severe nd symptoms. an iol exchange was performed in three cases. in one case, the secondary iol was implanted in the reopened capsular bag. in two cases, secondary iol was placed in the cilliary sulcus. the nd symptoms disappeared in all cases except one having secondary iol placed in the capsular bag. in his patients, the distance between the iris and iol optic was not statistically different between the eyes with or without symptoms. however, the symptoms of severe nd improved when iol exchange reduced the iris – iol distance. masket11 believes that, in patients whose temporal shadows disappear in the first eight weeks after cataract surgery, corneal edema may be the cause at the site of incision. in patients with prolonged symptoms, shadows may result from interaction between iol optics and unique anatomical features. in his study of 250 eyes who had implantation of single piece acrylic iol (sn60wf or sn60at), threeplane 2.75 mm corneal incision was given superiotemporally in the right eye and temporally in the left eye. on 1st post-operative day, nd was reported in 38 eyes (15.2%), decreasing to only in 7 eyes (3.2%) at 1 year. the common anatomic features among this group with persistent nd symptoms were shallow orbit, prominent glow, a space greater than 0.45mm between iris and anterior surface of iol and transparent peripheral capsule. trattler and coworkers12 have described three patients, who had different types of iols in both eyes, but developed nd symptoms. their first patient had sa60at acrysof (alcon – usa) in one eye and a tecnis z9001 silicon aspheric iol (pfizer – usa) in another eye. the second patient received acrysof ma60ac iol (alcon – usa) and a phaco-flex s140nb silicon iol (amo – usa) in two eyes. the third patient had sa60at iol (alcon – usa) in right eye and a sensor hydrophobic acrylic iol ar40e (amo – usa) put in the left eye. bournas et al13 assessed the risk of nd after phacoemulsification with the use of four different iol models. in their series of 600 patients, they used 3 piece hydrogel meridian hp60m iol (bausch and lomb – germany), acrysof ma60bm iol (alcon – usa), acrysof ma30ba iol (alcon – usa) and silicon clariflex (amo – usa) lenses. at the first follow up visit, 117 (19.5%) of their patients reported nd symptoms. they concluded that amo clariflex with round anterior and square posterior edge was associated with least symptoms. all three patients described by the author had uncomplicated surgery with anterior capsule overlapping the iol optic. unfortunately we could not measure the distance between iris and iol optic in our patients. however the common finding among all three patients was clear peripheral anterior capsule which we think may be reflecting the light. all these patients had clear corneal incision at different angles and even iol haptic were left in 3 & 9o’ clock position but still these patients complained of seeing temporal dark lines. conclusion negative dysphotopsia is a relatively common postoperative complication after uncomplicated in-the-bag iol implantation. the condition occurs with almost all iols and with clear corneal incision located in any quadrant. the patients having these symptoms should be reassured as the symptoms will disappear in majority of them over short period of time. negative dysphotopsia after uncomplicated phacoemulsification pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 56 author’s affiliation prof. p.s. mahar aga khan university hospital karachi references 1. osher rh. negative dysphotopsia: long term study, possible explanation for transient symptoms. j cataract refract surg. 2008; 34: 1699-1707. 2. davison ja. positive and negatve dysphotopsia in patients with acrylic intraocular lenses. j cataract refract surg. 2000; 26 : 1346-55. 3. masket s, fram nr. pseudophakic negative dysphotopsia: surgical management and new theory of etiology. j cataract refract surg. 2011; 37: 1199-1207. 4. vámosi p, csákány b, németh j. intraocular lens exchange in patients with negative dysphotopsia symptoms. j cataract refract surg. 2010; 36: 418-24. 5. holladay jt, zhao h, reisin cr. negative dysphotopsia: the enigmatic penumbra. j cataract refract surg. 2012; 38: 1251-65. 6. hong x, liu y, karakelle m, masket s, fram nr. raytracing optical modeling of negative dysphotopsia. j biomed opt. 2011; 16: 125001. 7. ernest ph. severe photic phenomenon. j cataract refract surg. 2006; 32: 685-6. 8. trattler wb. iol exchange, iris suture fixation failed to restore post-op negative dysphotopsia. j cataract refract surg. 2011; 37: 1199-1207. 9. cooke dl. negative dysphotopsia after temporal corneal incision. j cataract refract surg. 2010; 36: 671-2. 10. narvaez j, banning cs, stulting d. negative dysphotopsia associated with implantation of the z9000 intraocular lens. j cataract refract surg. 2005; 31: 846-7. 11. masket s. negative dysphotopsia may result from several factors. j cataract refract surg. 2008; 34: 16991707. 12. trattler wb, whitsett jc, simone pa. negative dyspohotpsia after intraocular lens implantation irrespective of design and material. j cataract refract surg. 2005; 31: 841-5. 13. bournas p, drazinos s, kanellas d, arvanitis m, vaikoussis e. dysphotopsia after cataract surgery: comparison of four different intraocular lenses. ophthalmologica. 2007; 221: 378-83. microsoft word 11. waqar-ul-huda pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 157 original article randomized clinical trial of topical versus retrobulbur anesthesia for phacoemulsification: comparison of patient satisfaction waqar-ul-huda, m.s. fehmi, sharjeel sultan, uzma fasih, attiya rehman, arshad shaikh pak j ophthalmol 2012, vol. 28 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: waqar ul huda r-104 block 7-d 1 north karachi …..……………………….. purpose: current anesthetic options for phacoemulsification typically include injection techniques, such as retro bulbar block, peribulbar block, sub-tenon injection and topical anesthesia. consensus does not yet exist on whether regional or topical anesthesia is the superior option, although topical anesthesia is being more commonly used.1 material and methods: this was a randomized clinical trail done at eye operation theatre at abbasi shaheed hospital karachi. in group a topical anesthesia (ta), patients received a minimum total of 5 doses of 2% topical proparacaine. for performing retrobulbar (rba) block in group b, patients received 2 % lidocaine anesthetic solution 1-2 ml into the retrobulbar space. phacoemulsification was performed using clear corneal phacoemulsification and implantation of iol. we used a scoring system, the lowa satisfaction with anesthesia scale (isas) a self administered written questionnaire for assessment of patient satisfaction. results: mean lowa score in topical group was 2.71 while it was 2.3 in retrobulbar group. median lowa score in topical group was 3 while it was 2.54 in retrobulbar group. the difference in mean lowa score was found to be statistically significant between two groups (p value < 0.05). conclusions: topical anesthesia (ta) is a safe, satisfactory alternative to retrobulbar (rba) anesthesia without causing discomfort to the patients. ach year, cataract surgery enables millions of people to improve their vision. it is one of the most frequently performed and successful operations in the world today. although cataract surgery has been performed since ancient times, the last half-century has seen remarkable refinements of the procedure. despite various modifications that have been devised over the decades to reduce the potential risks of injuring intra orbital structures, the "blind" insertion of a needle into the retrobulbar space has never been completely free of several sight and life-threatening complications which includes8-12. hemorrhage, ptosis, conjunctival or eyelid bruising, globe penetration, optic nerve damage, central vein and artery occlusion, and brain stem anesthesia and death. the advantages of topical anesthesia include its ease of application, minimal to absent discomfort on administration, rapid onset of anesthesia and, most important, elimination of the potential risks associated with retrobulbar injections13-17. in addition to all of these advantages, the technique is economical, avoids undesirable cosmetic adverse effects, and allows instant visual rehabilitation. e waqar-ul-huda, et al 158 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology material and methods this was a randomized clinical trial done at eye operation theatre of abbasi shaheed hospital karachi. the trial was done for a period of six months having 32 patients in each group (group a topical and group b retrobulbar). the inclusion criteria were patients with cataract presenting to the outpatient department, aged 45-65 years, patients of either gender, first eye operation. mentally handicapped patients, patients with history of raised intraocular pressure (>21mm of hg), known case of lidocaine hypersensitivity and patient who had requested sedation for the operation were excluded. approval from institutional ethical committee was taken. written informed consent was taken from each patient after giving an information leaflet describing the study. the patients were randomly allocated to either of two groups a (topical ta) and b (retrobulbar rba) by the principal investigator through non probability purposive technique. in group a (ta), patients received 2 drop (approximately 40 microlites per dose) of 2% lidocaine 3-5 times. for performing retrobulbar block in group b (rba), 22-27 gauges, 3cm long needle was inserted at the infero lateral border of the bony orbit. following a negative aspiration for blood, 2.5 ml of local anesthetic solution was injected and the needle was withdrawn. phaco was performed by a single experienced phaco surgeon who has experience of more than 10 years in phacoemulsification. he had used standardized clear corneal incision with phacoemulsification and implantation of iol. we used a scoring system, the lowa satisfaction with anesthesia scale (isas) a written questionnaire for patient satisfaction. for each item, patient marked the answer that best showed how well the statement described his/her feeling. each question had a marking from -3 to +3. a totally satisfied patient had a score of + 3; a totally dissatisfied patient had score -3. the mean of their responses to the 11 statements gave a single number between -3 and +3, which was a quantitative measure of a patient’s satisfaction with their anesthesia care. results iowa satisfaction score data distribution for lowa score was not found to be normal. mean lowa score in ta group a was 2.71 while it was 2.3 in rba group b. median lowa score in topical group was 3 while it was 2.54 in retrobulbar group. the difference in mean lowa score was found to be statistically significant between two groups (p value < 0.05). this showed ta group patients were more satisfied than rba group. 0.00 1.00 2.00 3.00 topical retrobulbar topical retrobulbar fig. i: mean lowa score of topical and retrobulbar groups of patients discussion in recent years, there has been considerable discussion in the literature about ta and rba techniques for phacoemulsification anesthesia18. choice of local anesthesia technique depends largely on the preferences of anesthesiologists and surgeons, but increasing attention is being paid to patient preferences, their perceptions of intraoperative pain and satisfaction19-20. this is perhaps the first study to investigate levels of patient satisfaction after cataract surgery using a validated reliable and internally consistent assessment tool in pakistan. m ea n lo w a sc or e group of patient randomized clinical trial of topical versus retrobulbur anesthesia for phacoemulsification pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 159 in the present study 87 % of ta group and 69 % of rba were relaxed during the surgery. in other comparative study done in iran21, two hundred thirty five patients (83%) in the retrobulbar group and 238 (84%) in the topical group reported minimal discomfort (0 – 2) during phacoemulsification. the mean ± sd pain score in the topical was 1.13 ± 1.36, while in the retrobulbar is 1.14 ± 1.47 (p = 0.92). this showed that patients undergoing cataract surgery with topical and retrobulbar did not vary in pain score, efficacy of anesthesia and feasibility of surgery. this suggests that cataract surgery can be performed with topical anesthesia without compromising the safety of the procedure. there were some limitations of our study. although we did use iowa for patient satisfaction scoring but we did not measure any pain scale like vas for assessment of pain intra and postoperatively. we did not follow the patient for any surgery or procedure related complications. conclusions the topical anesthesia is an effective method in providing a painless surgical procedure in patients undergoing phacoemulsification. it is also safer and non invasive as compared to retrobulbar anesthesia. also by using topical anesthesia, we can eliminate pain and fear of needle insertion for retrobulbar anaesthesia. so considering all these, topical anaesthesia for phacoemulsification is worthy of clinical use. author’s affiliation dr. waqar ul huda trainee registrar abbasi shaheed hospital kmc, karachi dr. m.s. fehmi professor abbasi shaheed hospital and kmdc kmc, karachi dr. sharjeel sultan associate consultant abbasi shaheed hospital kmc, karachi dr. uzma fasih associate professor abbasi shaheed hospital and kmdc kmc, karachi dr. attiya rehman assistant professor abbasi shaheed hospital and kmdc kmc, karachi dr. arshad shaikh professor abbasi shaheed hospital and kmdc kmc, karachi reference 1. bellucci r. topical anaesthesia for small incision cataract surgery. dev ophthalmol. 2002; 34: 1-12. 2. ezra dg, allan bd. topical anaesthesia alone versus topical anaesthesia with intracameral lidocaine for phacoemulsification. cochrane database syst rev. 2007: cd005276. 3. feibel rm. current concepts in retrobulbar anesthesia. surv ophthalmol. 1985; 30: 102-10. 4. sullivan kl, brown gc, forman ar, et al. retrobulbar anesthesia and retinal vascular obstruction. ophthalmology. 1983; 90: 373-7. 5. morgan cm, schatz h, vine ak, et al. ocular complications associated with retrobulbar injections. ophthalmology. 1988; 95: 660-5. 6. nicoll jm, acharya pa, ahlen k, et al. central nervous system complications after 6000 retrobulbar blocks. anesth analg. 1987; 66: 1298-302. 7. maclean h, burton t, murray a. patient comfort during cataract surgery with modified topical and peribulbar anesthesia. j cataract refract surg. 1997; 23: 277-83. 8. feibel rm. current concepts in retrobulbar anesthesia. surv ophthalmol. 1985; 30: 102-10. 9. sullivan kl, brown gc, forman ar, et al. retrobulbar anesthesia and retinal vascular obstruction. ophthalmology. 1983; 90: 373-7. 10. morgan cm, schatz h, vine ak, et al. ocular complications associated with retrobulbar injections. ophthalmology. 1991; 95: 660-5. 11. nicoll jmv, acharya pa, ahlen k, et al. central nervous system complications after 6000 retrobulbar blocks. anesth analg. 1987; 66:1298-1302. 12. maclean h, burton t, murray a. patient discomfort during cataract surgery with modified topical and peribulbar anesthesia. j cataract refract surg. 1997; 23: 277-83. 13. fichman ra. use of topical anesthesia alone in cataract surgery. j cataract refract surg. 1996; 22: 612-4. 14. patel ea, carlson ta, crandall a, et al. a comparison of topical versus retrobulbar anesthesia for cataract surgery. ophthalmology. 1996; 103: 1196-1203. 15. zehetmayer m, radax u, skorpik c, et al. topical versus retrobulbar anesthesia in clear corneal cataract surgery. j cataract refract surg.1996; 22: 480-4. 16. koch ps. efficacy of lidocaine 2% jelly as a topical agent in cataract surgery. j cataract refract surg. 1999; 25: 632-4. 17. tseng sh, chen fk. a randomized clinical trial of combined topical-intracameral anesthesia in cataract surgery. ophthalmology. 1998; 105: 2007-11. 18. gombos ke. jakubovits a. kolos g, et al. cataract surgery anaesthesia: is topical anaesthesia really better than retrobulbar? acta ophthalmol. scand. 2007; 85: 309-16. 19. katz jma, feldman eb, bass lh, et al. injectable versus waqar-ul-huda, et al 160 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology topical anesthesia for cataract surgery: patient perceptions of pain and side effects. ophthalmology. 2000; 107: 2054-60. 20. boezaart ar, berry, nell m. topical anesthesia versus retrobulbar block for cataract surgery: the patient’s perspective. j. clin. anesth. 2000; 12: 58-60. 21. fazel mrz, forghani d, aghadoost, et al. retrobulbar versus topical anesthesia for phacoemulsification. pak j biol. sci. 2008; 11: 2314-9. 22. saunder g, jonas jb. topical versus peribulbar anaesthesia for cataract surgery. acta ophthalmol. scand. 2003; 81: 596-9. 23. a comparative study of topical versus peribulbar anesthesia in phacoemulsification and implantation of foldable intraocular lens in cataract surgery k. said m. microsoft word 6. khalil lakho 200 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology original article pattern of ocular problems in school going children of district lasbela, balochistan khalil a. lakho, m. zahid jadoon, p.s. mahar pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: khalil a. lakho community ophthalmologist isra postgraduate institute of ophthalmology al-ibrahim eye hospital karachi …..……………………….. purpose: to find out the pattern of eye problems in children of age 6 to 15 years, attending schools and madaris (religious schools) and also to determine the difference in prevalence of ocular disease in students attending these different types of institutions. material and methods: the study was conducted in madaris of district lasbela were screened from february 2008 to september 2009. all students of schools / madaris of district lasbela were included in the study. the visual acuity (va) was measured using standard snellen’s chart; external examination was carried out with the help of magnifying loop and direct ophthalmoscope. the children with va < 6/12 were refracted to the best correction. the study team included a community ophthalmologist, an ophthalmologist, an ophthalmic technician and a community social worker. a structured questionnaire was prepared and operational methods were field tested and refined by piloting at the outpatient of isra postgraduate institute of ophthalmology, al-ibrahim eye hospital (aieh), karachi. an ophthalmic technician with community social worker checked vision of all the students and an ophthalmologist examined the children for any abnormality and referred them to the base hospital (aieh). all children with va < 6/12 were refracted. every school and madarsa of the target area was visited. results: out of 25,437 examined school going children, 19,629 (77.16%) were found to be normal while 5,808 (22.84%) had ocular problems. the ocular conditions in order of frequency were conjunctivitis in 2,826 (11.10%) children, vitamin a deficiency disorders in 839 (3.29%) children, refractive error in 740 (2.90%) children, vernal conjunctivitis in 484 (1.90%) children, blepheritis in 373 (1.46%) children, strabismus in 119 (0.46%) children, cataract in 45 (0.17%) children, ptosis in 33 (0.12) children, nystagmus in 26 (0.10%) children, glaucoma in 2 (0.007%) children and non-specific ocular changes were found in 259 (1.01%) children. the prevalence of ocular problems occurred in 20.68% of children in main stream schools compared to 34.33% in children studying in madaris. the main difference in prevalence was of conjunctivitis noticed in 10.03% of school children, compared to 17% of madaris students and of refractive error present in 2.14% of school children, compared to 7% of students in madaris. conclusion: almost 23% of school going children in lasbela district needed treatment for their ocular problems. the prevalence of conjunctivitis and refractive error was more in madaris compared to schools. school screening could play an important role in the promotion of eye health and the prevention of childhood blindness. pattern of ocular problems in school going children of district lasbela, balochistan pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 201 cular problems, mainly leading to visual disability are important not because of the gross number but because of the number of blind years and its impact on the socio-economic condition of the community and country. the childhood blindness affects the entire family and many of them are left as street beggars in the poor countries. this has drawn the attention of world health organization’s vision 2020 program, which has included “childhood blindness” as one of its targets. there are an estimated 1.4 million blind children in the world1. one million of them reside in asia. every year, approximately half a million children add to this total (about one blind child every minute). the common causes of blindness in children are vitamin a deficiency disorders (vadd), refractive error, trachoma and hereditary / congenital diseases. baluchistan, the largest province of pakistan, is in the southeastern region of the country. it is mountainous and dry, with population of about 6.5 million people2. it is an under privileged province with poor health care, especially the eye care delivery. there are not many optical shops in most districts of baluchistan and services for refraction are almost non-existing. the school going children have to suffer from this lack of eye care and this may be one of the important constrains towards achieving good literacy rate. there are no reliable data available on the problems of school going children in pakistan except a study by afghani3 showing 4.24% of school going children having refractive error. there is a remarkable difference between mainstream schools and religious schools regarding socio-economic status, learning environment and “reading hours”. in religious schools students are expected to have long recitation hours (about 10 hours a day) in contrast to schools (1-2 hours a day). this difference may have some effect on the growth of the eye resulting in the higher prevalence of refractive error.4-6 the purpose of our study was to determine the pattern of eye problems in government sponsored schools and madaris and to find out the difference of prevalence of eye conditions existent in these two different settings. material and methods all student age 6-15 years studying in government sponsored schools and madaris in lasbela district of balochistan were screened for the presence of any ocular problem from february 2008 to september 2009. a team consisting of community ophthalmologist clinical ophthalmologist, ophthalmic technician and community social worker was formed and briefed about the structured questionnaire to collect the data and different aspects of the study. the team visited all the schools and madaris according to the schedule. the children examined belonged to the rural and urban areas, studying in primary, middle and high schools and madaris for girls and boys from the entire district labella. about 100 students were examined per day. a total number of 25,437 school going children were examined. the visual acuity of each child was assessed using snellen’s chart; the external ocular examination was carried out with magnifying loop and fundus was examined with direct ophthalmoscope after dilatation. a cyclyplegic refraction was carried out in children with va < 6/12. all children requiring glasses were provided spectacles and treatment was given for common ocular conditions like conjunctivitis and vernal conjunctivitisetc. the children with xerophthalmia were provided vitamin a capsules and health education reading material. the children needing surgical intervention were referred to the tertiary eye care center at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, karachi. the permission for this study was sought from the education department of lasbela district and the school headmasters/heads of madaris were requested to allow the screening. efforts were made to educate at least one teacher in each school / madrasa who could in the future check vision of the children. snellen’s charts were provided to each school without cost. the screening was conducted in the teaching institutions mainstream or religious, of the district lasbela consisting of hub, winder, dureji, uthal, liari, lakhra and belatahseels. the data analysis was conducted with the statistical package for social sciences (spss) version (14.0) the values were presented in the form of frequencies and percentages and the proportion test was used to observe the significance. the difference between two groups (children of schools and madaris) was analyzed through z-proportion test and p-value of < 0.05 was considered statistically significant. results we examined 21,432 school going children (6-15 years) in government sponsored schools and 4,005 students attending various madaris (total 25,437) with 2,487 students found absent. o khalil a. lakho, et al 202 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology out of 4,005 students of religious schools, 1,375 (34.33%) and out of 21,432 students of state run schools, 4,433 (20.68%) had ocular problems. the ocular conditions in order of frequency were conjunctivitis in 2,826 (11.10%) children, vitamin a deficiency disorder (bitot’s spots and xerophthalmia) in 839 (3.29%) children, refractive error in 740 (2.90%) children, vernal conjunctivitis in 484 (1.90%) children, blepheritis in 373 (1.46%) children, strabismus in 119 (0.46%) children, cataract in 45 (0.17%) children, ptosis in 33 (0.12) children, nystagmus in 26 (0.10%) children, glaucoma in 2 (0.007%) children and non-specific ocular features were seen in 259 (1.01%) children. the non-specific ocular changes included mild conjunctival redness and watering for which no specific reason was found. there was a considerable difference in the prevalence of eye problems between two institutions. the prevalence of ocular problems occurred in 20.68% of children in mainstream schools compared to 34.33% in children studying in madaris. the detailed examination (table 1) showed that conjunctivitis, refractive error and vernal conjunctivitis were responsible for the main difference. the common eye ailment found was conjunctivitis (11.12%), more common in religious schools (17.07%) than in government schools (10.03%). refractive error was found in 2.9% children. when considered separately, 2.14% children in government schools were found to be in need for correction with glasses, whereas 17.0% children in religious schools needed refractive correction. the overall prevalence of vernal conjunctivitis was 1.90%, with 1.62% children having it in schools compared to 3.33% pupils in madaris. the pattern of other eye disease was almost same in the two institutions. the p-value of all ocular problems in schools and madaris is mentioned in table 1. the number of children referred to the base hospital was 261 (4.49%) from schools and 48 (3.4%) from madaris. discussion the prevention and control of blindness in children is considered a high priority by world health organization’s vision 2020; the right to sight program. there are 1.4 million blind children in the world and approximately 500,000 children become blind every year i.e. one every minute – and about half of them die within one or two years of becoming blind. the children who are born blind or who become blind and survive have a lifetime of blindness ahead of them, with all the associated emotional, social and economic costs to the child, the family, and the society8. indeed, the number of ‘‘blind years’’ due to all causes of blindness in children is almost equal to the number of ‘‘blind years’’ due to cataract in adults, which is around 70 million years.9 unfortunately all these children remain uneducated and unskilled. in terms of economic loss, approximately one third of the total economic cost of blindness is thought to be due to childhood blindness. the control of childhood blindness is therefore also linked to the education and the poverty. many of the causes of blindness in children are either preventable or treatable. the conditions associated with the blindness in children are also causes of child mortality such as premature birth, measles, congenital rubella syndrome, vitamin a deficiency and meningitis. the control of blindness in children is therefore, closely linked to the child survival. reducing visual loss in children poses particular challenges, which are different from the challenges of controlling adult blindness. the children are born with an immature visual system and for normal visual development to occur, they need clear, focused images to be transmitted to the higher visual center. the failure of normal visual maturation (amblyopia) cannot be corrected in the adult life, so there is a level of urgency about treating childhood eye disease. the major causes of blindness in children vary widely from region to region, being largely determined by the socio-economic development and the availability of primary health care and eye care service. the corneal scarring from measles, vitamin a deficiency disease, the use of harmful traditional eye remedies and ophthalmianeonatorum are the major causes in low-income societies. the retinopathy of prematurity is an important emerging cause. other significant but less common causes are cataract, congenital abnormalities, and hereditary retinal dystrophies.10 various studies have been done on childhood eye problems in pakistan. afghani and colleagues3 screened one million children; with main focus on prevalence of refractive error. their study showed about 4.24% of children having various refractive errors required spectacle correction. masood11 looked at the various “institutions for the blind children” and found chorioretinal hereditary ocular disease involving 50.7% of children. there is paucity of literature in finding the prevalence of ocular disorders in children studying in pattern of ocular problems in school going children of district lasbela, balochistan pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 203 madaris and comparing the ocular morbidity with children in government sponsored schools. the present study was conducted in all schools, managed both by the government and the religious bodies to cover all the children of school going age between 6-15 years in district of balochistan (lasbela). a total of 27,924 students were registered in the area schools. during screening, 2,487 students were found absent with 25,437 students available for ocular examination. it may be of some interest that 84.25% of the students were registered in state run school. considering only the school going children, out of 25,437 children 5,808 students (22.23%) were found to have eye problems. a considerable difference was noted in the disease pattern between madaris students and state run schools. in former 34.3% students (1,375 out of 4,005) had eye problems whereas in later only 20.35% (4,433 out of 21,432) needed medical attention. this difference was mainly due to conjunctivitis and refractive error. in schools, 10% of the children suffered from conjunctivitis as compared to 17.0% of the students of madaris. the apparent cause was not the difference between hygienic environments but the fact that all the students in madaris were residents causing easy spread of the disease. the second important cause was refractive error with 2.14% of school students and 7.00% students from madaris having various refractive problems. prevalence of refractive errors in school going children varies from 0.5% in nepal12 to 5.1% in india.13 the second national blindness and impairment survey of 2002-314 had shown refractive error as 2.7% of the blindness in all ages. the variation of various studies on childhood eye problems can be due to racial factors; but lack of standardization of the screening procedures cannot be over looked. the high prevalence of refractive error in children in madaris certainly needs some consideration. a similar study conducted by zylbermann in jewish religious students has also shown the increased prevalence of myopia. abdullah and abdullah15 examined 3,153 students, age 5 – 15 years studying in madaris of district peshawar, to determine the prevalence of blindness and low vision. refractive error was the main cause of low vision (va between 6/18 and 3/60 in better eye) in this study. out of 142 children (4.5%) with low vision, 130 (4.1%) children had uncorrected refractive error and 10 (0.4%) had causes such as: hereditary maculopathies, optic nerve atrophy, amblyopia and cataract. our study found refractive error in 7% of children in madaris compared to only 2.1% of students enrolled in schools. continuous accommodation has been proposed to play some role in the axial development of the eye resulting in myopia.16 the uncorrected refractive error may have a dramatic impact on the learning capacity of children and their education potential.17 fortunately, refractive error is easily treatable, with the provision of a pair of spectacles, which is extremely cost-effective and provides immediate solution to the problem. the provision of affordable spectacles is another component of who’s vision 2020 program.18 a cross sectional study by deshpande and malathi19 in 622 children of age 10 – 15 years, found prevalence of ocular morbidity at 27.65%. refractive khalil a. lakho, et al 204 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology error was the leading cause of ocular disorder (10.12%) followed by vitamin a deficiency (7%) and conjunctivitis (2.57%). the higher prevalence of conjunctivitis in our study at 11.10% can be due to seasonal variation and the short duration of the disease. in another study alam and coworkers20 examined 1000 children from 20 schools in karachi and found 8.9% students with refractive error. this figure is higher than our study where we found overall 2.90% children with refractive error, 2.14% in schools and 7% in madaris. the prevalence of conjunctivitis was also found higher at 8% in a study carried out among students in south western nigeria.21 our study showed that 5,808 (22.8%) of the school going children had ocular problem. the important causes of impaired vision and possible blindness among them were refractive error (2.9%), vadd (3.29%), cataract (0.17%), nystagmus (0.1%), ptosis (0.1%), squint (0.46%), glaucoma (0.007%) and possibly vernal conjunctivitis (1.9%) in advanced stage involving cornea. from the management point of view, the eye problems can be grouped under three categories: manageable at primary health care level, secondary level and tertiary referral center level. the ocular problems such as conjunctivitis, blephritis, and vadd can be easily prevented by the health education of the community and can be treated by mid-level eye care providers. in this way, 69.5% (4,038) of the eye problems according to this study can be prevented or treated at primary level. amongst these diseases, vadd is a potentially blinding disease and an important cause of nutritional blindness. conjunctivitis though a harmless disease, can result in sight threatening corneal involvement. the refractive error was responsible for 2.90% (no = 740) of the ocular problem present in this study and can be managed by a refractionist. as there is a lack of this resource, the nearest place to refer the children would be to tahseel headquarter (thq) hospital. the training of this cadre can provide such service at the primary level making it more accessible and affordable. a well-trained refractionist can manage amblyopia, adding another 21.07% (no = 1224) to the cases to be managed at the primary level. according to this study 90.57% of the ocular problems of school going children can be managed at primary level provided by well-trained mid – level eye care personnel. the remaining 484 children (9.3%) having cataract, nystagmus, ptosis, squint, glaucoma and undiagnosed ocular problems needed referral to a tertiary center for further management. most of these congenital diseases cannot be prevented, but if diagnosed at the right time and treated, can save vision. though, we only screened school going children between 6 – 15 years of age, there are surely children under 6 years of age, having various ocular problems. in this respect, government and various non-governmental organizations (ngos) have to formulate a strategy to screen these children at preschool level. also 2487 students were found missing / absent from the schools, but even on repeated visits these students could not be found attending schools, making their enrollment in schools questionable. conclusion almost 23% of school going children in labella district needed treatment for their ocular problems (34.33% children in madaris and 20.68% in schools). though 90% were managed at the primary eye care level, 9.3% children needed referral to the tertiary care hospital with 3.87% of them having potentially blinding eye disease. the screening of school going children is important as early recognition and prompt treatment would reduce the ocular morbidity in that particular age group. author’s affiliation dr. khalil a. lakho isra postgraduate institute of ophthalmology karachi dr. m. zahid jadoon isra postgraduate institute of ophthalmology karachi prof. p.s. mahar isra postgraduate institute of ophthalmology karachi references 1. rahi js. measuring the burden of childhood blindness. br j ophthalmol. 1999; 83: 387-8. 2. census bulletin. population and housing census of pakistan, govt. of pakistan 1998. 3. afghani t, vine ha, bhatti ma et al. al-shifa al-noor (asan) refractive error study of one million school children, pak j ophthalmol. 2003; 19: 101-07. 4. chew sj, chia sc, lee lkh. the pattern of myopia in young singaporean men. singapore med j. 1988; 29: 201-11. 5. chow yc, dhillon b, chew ptk, et al. refractive errors in singapore medical students. singapore med j. 1990; 30: 472-73. pattern of ocular problems in school going children of district lasbela, balochistan pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 205 6. zylbermann r, london d, berson d. the influence of study habit on myopia in jewish teenagers. j pediatr ophthalmol & strabismus. 1993; 30: 319-22. 7. district census report of lasbella 199. population census organization statistics division government of pakistan islamabad. 1999; 16-17. 8. gilbert c, foster a. childhood blindness in the context of vision. 2020: the rightto sight. bull world health organ. 2001; 79: 227 -32. 9. shamannabr, muralikirshnan r. childhood cataract: magnitude, management, economics and impact. j comm eye health. 2004; 17: 17-8. 10. clare g. new issue in childhood blindness. jcomm eye health 2001; 40: 53-6. 11. masood ss. childhood blindness in sindh pakistan, unpublished document m sc (dissertation) iceh london 1995. 12. pokharel gp, negrel ad, munoz sr, et al. refractive error study in children: results from mechi zone, nepal. am j ophthalmol. 2000; 129: 436-44. 13. dandona r, dandona l, srinivas m, et al. refractive error study in children in a rural population in india. invest ophthalmol vis sci 2002; 43: 623-31. 14. dineen b, bourne rra, jadoon mz, et al. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91: 1005-10. 15. abdullah kn, abdullah mt. reaching out: a strategy to provide primary eye care through the indigenous educational system in pakistan. j comm eye health. 2006; 19: 52-54. 16. wallman j. retinal control of eye growth and refraction. prog retinal res. 1992; 12: 24349. 17. negrel ad, maul ep, pokharel, zhap j, et al. refractive error study in children: sampling and measurement methods for a multy-country survey. am j ophthalmol. 2000; 129: 421-6. 18. gilbert c, awan h. blindness in children, br med j. 2003; 327: 760-1. 19. deshpande jd, malathi k. prevalence of ocular morbidities among school children in rural area of north maharashatra in india. nat j comm med. 2011; 2: 24954. 20. alam h, siddiqui mi, jafri sia et al. prevalence of refractive error in school children of karachi. jpma. 2008; 58: 322-5. 21. ajaiyeoba ai, isawumi a, adeoye o, et al. prevalence and causes of eye diseases amongst students in southwestern nigeria. ann afr med 2006; 5: 197-203. microsoft word tehmina jahangir 3 187 original article visual outcome after intravitreal avastin (bevacizumab) for persistent diabetic macular edema tehmina jahangir, samina jahangir, haroon tayyab, uzma hamza pak j ophthalmol 2011, vol. 27 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tehmina jahangir 154-b, tech society canal bank lahore submission of paper march’ 2011 acceptance for publication november’ 2011 …..……………………….. purpose: to determine the effect of intravitreal bevacizumab (avastin) on visual acuity in patients with persistent diabetic macular edema. material and methods: a prospective, hospital based study conducted at department of ophthalmology, jinnah hospital lahore from may 2010 to october 2010. twenty eyes of 20 patients received a single intravitreal injection of bevacizumab in a dose of 1.25mg / 0.05ml. the visual acuity was measured pre-injection and at 1, 4 and 12 weeks post-injection using snellen’s visual acuity chart. results: prior to injection, there was 1 (5%) eye with best-corrected visual acuity (bcva) better than or equal to 6/18, 10 eyes (50%) with va between 6/24 and 6/60 and 9 (45%) with va below 6/60. at 12 weeks post-injection, 2 (10%) eyes had bcva better than or equal to 6/18; the number of eyes with bcva between 6/24 and 6/60 were 12(60%), while 6(30%) eyes had bcva below 6/60. the results are statistically significant (for each, p value is less than 0.05). conclusion: this study revealed that intravitreal bevacizumab (1.25mg/0.05ml) resulted in improvement of visual acuity in patients with persistent diffuse diabetic macular edema unresponsive to previous grid laser photocoagulation. the follow-up period was however too short to provide specific treatment recommendations, the short term results encourage further prospective studies with different treatment groups and longer follow-up. etinal edema threatening or involving the macula is an important visual consequence of abnormal retinal vascular permeability in diabetic retinopathy1. focal/grid photocoagulation has been the mainstay of treatment since its benefit was demonstrated in the early treatment diabetic retinopathy study (etdrs) in 19852. however, especially in macular edema laser treatment is not always beneficial3. most of the retinal damage that characterizes the disease is believed to result from breakdown of the inner blood retinal barrier mediated by numerous growth factors such as vascular endothelial growth factor (vegf)4,5. based on these facts anti-vegf agents like pegaptanib sodium and ranibzumab have been evaluated for diabetic macular edema in phase ii randomized trials6,7. one such vegf inhibitor is bevacizumab (avastin; genentech, inc., south san francisco, ca), a us food and drug administration approved full-length humanized monoclonal antibody that until recently was used for the treatment of metastatic colorectal cancer8. as compared to pegaptanib, which is a selective inhibitor of vegf 165, bevacizumab inhibits all active isoforms of vegf. intravitreal bevacizumab is currently being evaluated for use in macular edema following central retinal vein occlusion (crvo), wet age-related macular degeneration (armd), rubeosis iridis and proliferative diabetic retinopathy (pdr)9-12. it seems reasonable to assume that vegf inhibitors will also be beneficial in diabetic macular edema. although r 188 intravitreal use of bevacizumab is an off-label option, its use has risen exponentially in the recent past due to its efficacy and economic feasibility. however, there are very few studies to-date showing the beneficial effect of intravitreal bevacizumab for persistent diffuse diabetic macular edema13-15. the purpose of this study was to evaluate the beneficial effect of intravitreal injection of bevacizumab on visual acuity in diabetic macular edema. material and methods this was a prospective, interventional, noncomparitive case series carried out at the department of ophthalmology, jinnah hospital lahore. the study was carried out over a period of six months from may 2010 to october 2010. twenty eyes of twenty patients were included. the sampling technique was nonprobability convenience sampling. we included diabetic patients of all ages and both sexes having non-proliferative diabetic retinopathy with diffuse, clinically significant diabetic macular edema, which was previously treated with grid laser (more than six months ago). however, the following patients were excluded: those having only focal macular edema attributable to focal leaks from microaneurysm; patients with any other macular pathology like armd or any vascular occlusive disease affecting the macula; those previously treated with pan retinal photocoagulation (prp) and grid laser within last six months; those with angiographic evidence of widening or irregularity of the foveal avascular zone suggestive of ischemic maculopathy; and patients with uncontrolled diabetes, hypertension and/or chronic renal failure. at each visit, complete eye examination was performed, including best-corrected visual acuity using snellen’s testing, slit-lamp examination, intraocular pressure measurement, stereoscopic biomicroscopy of the retina using a 78-diopter lens, fluorescien angiography (only on the first and last visit) and fundus photography of the macular area. patients were informed regarding the experimental nature of the study and written informed consent was obtained from all patients and official permission was taken from the hospital’s ethics committee. injection technique: all intravitreal injections were performed under topical anesthesia. intravitreal bevacizumab injection was prepared and dispensed by the pharmacy at shaukat khanum memorial cancer hospital, lahore at the concentration of 1.25mg/0.05ml. the lid was prepared with 5% povidone-iodine applied directly to the eye, and bevacizumab was injected into the mid-vitreous 3.5mm posterior to the limbus in pseudophakic eyes and 4.0 mm posterior to the limbus in phakic eyes with a tuberculin syringe and 27-gauge needle. topical ciprofloxacin eye drops were applied four times daily for one week. follow-up visits were at 1 week after injection, and then at 1 month and 3 months. only one eye per subject was treated. all data were analyzed using spss 13.0 for windows. the paired t-test was used for comparison of preoperative and postoperative bcva. for all statistical tests a p value of <0.05 was considered statistically significant. results in this study, 20 eyes of 20 patients with diabetic macular edema were studied. of these 12 (60%) were males and 8 (40%) females. the age range was from 45 to 67 years with a mean of 59.2 ± 6.0 years. (table 1) all patients had diffuse, clinically significant macular edema at baseline for which they had received grid laser photocoagulation at least 6 months before injection. all patients completed 12 weeks of follow-up. the glycosylated hemoglobin (hba1c) averaged 6.0 ± 1.3 before starting the study. pre-injection, there was 1 (5%) eye with bestcorrected visual acuity(bcva) better than or equal to 6/18, 10 eyes (50%) with va between 6/24 and 6/60 and 9 (45%) with va below 6/60. at the first post-injection week, no changes were observed in the bcva. at first post-injection month, 2(10%) eyes had bcva better than or equal to 6/18; 15(75%) between 6/24 and 6/60 and in 3(15%) eyes the vision was worse than 6/60. three months after the injection, again 2 (10%) eyes had bcva better than or equal to 6/18. however, the number of eyes with bcva between 6/24 and 6/60 were 12(60%), while 6(30%) eyes had bcva worse than 6/60. thus twelve weeks after the injection, some regression of the increase in visual acuity was noted (fig. 1). 189 table 1: clinical characteristics patients with diabetic macular edema at baseline n = 20 gender male 12 female 8 age (years), mean ± sd 59.2 ± 6 glycosylated hemoglobin (hba1c, %) 6.2 ± 1.3 table 2: mean intraocular pressures of patients before and after intravitreal bevacizumab injection n = 20 mean iop (mmhg) pre-injection 16.2 ± 2.6 one week 15.8 ± 2.2 one month 16 ± 2.3 three months 16.1 ± 2.2 0 2 4 6 8 10 12 14 16 pre -inj ect ion 1 w eek po st-i nje ctio n 4 w eek s p ost -inj ect ion 12 we eks po st i nje ctio n > 6/18 6/24-6/60 < 6/60 fig. 1: graphical representation of pre and postinjection visual acuities there was statistically significant difference in the pre and post injection visual acuity of the patients. thus, in comparing the visual acuities at one month and 3 months the p value is less than 0.05. no significant increase of iop was observed throughout the study (table 2). mild anterior chamber cellular reaction was observed in 3 eyes (10%), however the inflammation resolved within a week with topical corticosteroid. other injection related adverse events such as endophthalmitis, vitreous hemorrhage and retinal detachment were not observed. discussion diabetic retinopathy is the leading cause of blindness in patients aged more than 50 years in our country. 16 the intravitreal injection of bevacizumab has been met with great enthusiasm especially for patients with neovascular age-related macular degeneration. a significant improvement has also been reported in macular edema secondary to other conditions such as crvo. it was also found that the concentration of vegf increased and correlated with the severity of macular edema in patients with dme17. in light of this information we decided to conduct a prospective, hospital-based study to investigate the visual outcome after intravitreal bevacizumab injection in patients with chronic diffuse diabetic macular edema unresponsive to previous grid laser photocoagulation. bevacizumab has attracted interest because of its low cost; however systemic safety is of concern18,19. the results of our study showed that intravitreal bevacizumab is useful in increasing visual acuity in patients with diffuse diabetic macular edema. there was a statistically significant increase in the va at 4 and 12 weeks after the injection. our results are comparable with those of hartitoglou et al13. the observed slight reduction of the increase in visual acuity at the limited 12-week follow-up is also consistent with the findings of haritoglou. this decrease also hints that repeated bevacizumab injections may be necessary. many clinical investigators have found that an intravitreal injection of triamcinolone (ta) may reduce macular edema. however, the intravitreal use of ta may lead to complications such as increased iop, progression of cataract and endophthalmitis. 16, 20 however unlike the eyes treated with triamcinolone, there was no significant rise in the iop. these results are comparable to those of toshihiko and associates14. a limitation of the present investigation is the short follow-up, due to which the long-term safety and efficacy of the treatment could not be assessed. other limitations are the lack of a control group, but it can be argued that the enrolled eyes served as their own controls because the pre and post-injection visual acuities of patients were compared. thirdly, the visual acuity was measured on a snellen’s chart as opposed to the more standardized and accepted etdrs chart. however, all eyes were tested with the same correction throughout the follow-up period. the strengths are prospective design and careful follow 190 up. most of the studies on the intravitreal injection of bevacizumab were designed as retrospective analysis14. many clinical investigators have found that an intravitreal injection of ta may reduce macular edema. however, the intravitreal use of ta may lead to complications such as increased iop, progression of cataract and endophthalmitis16,20. recent studies have shown that the combination of laser photocoagulation with intravitreal bevacizumab may improve bcva and retinal thickness more than laser photocoagulation alone or intravitreal bevacizumab alone for dme21, 22. conclusion the positive results of this prospective, nonrandomized study are quite promising and suggest the need for a longer, prospective randomized studies to evaluate the long-term safety and efficacy of intravitreal bevacizumab. author’s affiliation dr. tehmina jahangir senior registrar eye unit i, imc/jhl, lahore professor samina jahangir professor and head department of ophthalmology aimc/jhl, lahore. dr. haroon tayyab registrar eye unit 1, aimc/jhl, lahore. dr. uzma hamza assistant professor eye unit i, aimc/jhl, lahore reference 1. american academy of ophthalmology. diabetic macular edema. in: basic and clinical science course: section. 2009; 12: 113-4. 2. early treatment diabetic retinopathy study research group. photocoagulation for diabetic macular edema: early treatment diabetic retinopathy study report number 1. arch ophthalmol. 1985; 103: 1796-806. 3. diabetic retinopathy clinical research network. a randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. ophthalmology. 2008; 115: 1447-59. 4. adamis ap, miller jw, bernal mt, et al. increased vascular endothelial growth factor levels in the vitreous of eyes with proliferative diabetic retinopathy. am j ophthalmol. 1994; 118: 445-50. 5. ishidas, usui t, yamashiro k. vegf 164 is proinflammatory in the diabetic retina. invest ophthalmol vis sci. 2003; 44: 215562. 6. cunningham et, adamis ap, altaweel m, et al. a phase ii randomized double-masked trial of pegaptanib, an antivascular endothelial growth factor aptamer, for diabetic macular edema. ophthalmology. 2005; 112: 1747-57. 7. chun dw, heier js, topping tm, et al. a pilot study of multiple intravitreal injections of ranibzumab in patients with center-involving clinically significant diabetic macular edema. ophthalmology. 2006; 113: 1706-12. 8. marshall j. the role of bevacizumab as first-line therapy for colon cancer. semin oncol. 2005; 32: s43-s47. 9. spaide rf, laud k, fine hf, et al. intravitreal bevacizumab treatment of choroidal neovascularisation secondary to agerelated macular degeneration. retina. 2006; 26: 383-90. 10. avery rl, pieramici dj, rabena md, et al. intravitreal bevacizumab (avastin) for neovascular age-related macular degeneration. ophthalmology. 2006; 113: 363-72. 11. spaede rf, fisher yl. intravitreal bevacizumab (avastin) treatment of proliferative diabetic retinopathy complicated by vitreous hemorrhage. retina. 2006; 26: 275-8. 12. oshima y, sakaguchi h, gomi f, et al. regression of iris neovascularization after intravitreal injection of bevacizumab in patients with proliferative diabetic retinopathy. am j ophthalmol. 2006; 142: 155-8. 13. haritoglou c, kook d, neubauera, et al. intravitreal bevacizumab (avastin) therapy for persistent diffuse diabetic macular edema. retina. 2006; 26: 999-1005. 14. nagasawa t, naito t, matsushita, et al. efficacy of intravitreal bevacizumab (avastin) for short-term treatment of diabetic macular edema. the journal of medical investigation. 2009; 56: 111-5. 15. ozkiris a. intravitreal bevacizumab (avastin) for primary treatment of diabetic macular edema. eye. 2009; 23: 616-20. 16. mehmood k, malik ba, khan mt et al. visual effects of intravitreal triamcinolone acetonide injection in patients with refractory diabetic macular edema. pak j ophthalmol. 2010; 26: 193-6. 17. funatsu n, yamashita h, sakata k, et al. vitreous levels of vascular endothelial growth factor and intracellular adhesion molecule 1 are related to diabetic macular edema. ophthalmology. 2005; 112: 806-16. 18. rosenfeld pj. intravitreal avastin: the low cost alternative to lucentis? am j ophthalmol. 2006; 142: 141-3. 19. gillies mc: what we don’t know about avastin might hurt us. arch ophthalmol. 2006; 124: 1478-9. 20. bhavsar ar, glassman ar. drcrnet group, score study group: the risk of endophthalmitis following intravitreal triamcinolone injection in the drcrnet and score clinical trials. am j ophthalmol. 2007; 144: 454-6. 21. maia jr oo, takahashi bs, costa ra, et al. combined laser and intravitreal triamcinolone for proliferative diabetic retinopathy and macular edema: one year results of a randomized clinical trial. am j ophthalmol. 2008; 146: 930-41. 22. elman mj, aiello lp, beck rw et al. drcr network. randomized trial evaluating ranibzumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. ophthalmology. 2010; 117: 1059-60. pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 63 original article peribulbar versus topical anesthesia for cataract surgery; patient’s satisfaction zulfiqar-ud-din syed, tariq m malik, aamir m malik, dilshad alam khan, umar ejaz, arsalan farooq pak j ophthalmol 2014, vol. 30 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zulfiqar-ud-din syed classified ophthalmologist combined military hospital multan …..……………………….. purpose: to compare the level of satisfaction in patients undergoing phacoemulsification and implantation of foldable intraocular lens under topical anesthesia in one eye and peribulbar block in the other eye. material and methods: fifty patients (100 eyes) planned for bilateral phacoemulcification with foldable intraocular lens implantation in the eye department combined military hospital multan were included in this cohort study. all patients underwent clear corneal incision. one eye of each patient was operated under topical anesthesia and the other eye with peribulbar block. parameters like pain, discomfort and feeling of pressure during administration of anesthesia, during surgery and 4 hours after the procedure were assessed using visual analogue scale. results: level of pain (p = 0.003), discomfort (p = 0.001) and feeling of pressure (p = 0.00) was very low during instillation of topical anesthesia as compared to administration of peribulbar block. whereas intra-operatively feeling of pain (p = 0.020), discomfort (p = 0.010) and feeling of pressure (p = 0.005) was significantly high with topical anesthesia as compared to peribulbar block. however 4 hours post operatively pain (p = 0.000), discomfort (p = 0.000) and pressure (p = 0.000) was significantly lower in peribulbar group than topical group. conclusion: in patient’s undergoing phacoemulcification with foldable intraocular lens implantation, peribulbar block gives better patient comfort and satisfaction than topical anesthesia. n recent years, advances in cataract surgery have led to greater levels of refractive precision, faster visual rehabilitation, improved comfort and safety. refinements in phacoemulsification techniques and intraocular lens (iol) technology deserve much of the credit for these advances, but innovations in anesthesia, especially topical anesthesia, have also played an important role in improving outcomes and visual recovery1. peribulbar injection of anesthetic agent has been used for cataract surgery for more than a century, but it was associated with a high risk of injury to the orbital contents. for the last two decades a number of modifications have been devised to reduce the risks of injury to intra-orbital structures during administration of peribulbar injection2. in 1884 koller for the first time used cocaine for topical anesthesia3. after about a century fichman successfully introduced a new method of injecting a local anesthetic agent for cataract surgery which resulted in high patient satisfaction and faster visual recovery4. topical anesthesia increased from 8% in 1995 to 63% in 1998 for high volume cataract surgeries5. a number of studies have been conducted to assess patient’s satisfaction with topical versus peribulbar anesthesia but these studies have conflicting results6,7. our study assesses level of patient satisfaction in individuals who had bilateral phacoemulcification with topical anesthesia in one eye and peribulbar block in the other eye. i zulfiqar-ud-din syed, et al 64 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology material and methods the study was conducted in combined military hospital multan from november 2012 to july 2013. 50 patients, 17 (34%) females, 33 (66%) males with the ages between 59 to 74 years (mean age 66.5 years) having bilateral cataract was included in this study. one eye was operated under topical anesthesia and the other eye of the same patient with peribulbar block (50 eyes operated under topical anesthesia and 50 eyes under peribulbar block). eyes were randomly selected for topical or peribulbar anesthesia. uncooperative patients, patients with allergy to lidocaine, poor pupillary dilatation (less than 3 mm), anterior segment pathology, anxiety, dementia, deafness, nuclear sclerosis grade 4 and ocular movement disorders were excluded from the study. during their visit to the ophthalmology department, patients were informed about the details of study well before the procedure. consent was obtained from patients and relatives for possible topical or peribulbar anesthesia, according to the policy of our ethical committee. patient’s level of pain and discomfort was judged by the same anesthesiologist in all cases to reduce bias. all our patients were day care cases. all surgical procedures were performed by the same surgeon. since all patients had to undergo bilateral surgery the gap between bilateral surgeries was 30 days. stabilization of the globe was achieved by reducing the operating microscope light to the minimum and asking the patient to look to the operating microscope light8. surgeon had continuous verbal communication with the patient and patient was informed before performing certain steps like instillation of drops, making incision, inserting phaco probe and implantation of intraocular lens. standardized 3 steps clear corneal incision was made using 2.8mm keratome, supero-temporal for right eye and superonasal for left eye. one side port paracentesis, was performed on left side of the main port. viscoelastic injection, continuous curvilinear capsulorhexis, hydrodissection, hydro delineation, phacoemulsification, aspiration of the residual cortical lens matter, and implantation of foldable intra ocular lens in the bag was performed9. at the end of surgery viscoelastic substance was removed, pupil was constricted with intra-cameral 0.01% carbachol (miochol)10, intra cameral 0.1 ml 0.5% moxifloxacin eye drops was given in all cases. wound margins were hydrated, the selfsealing wound was checked for leakage by gentle compression with a sponge. postoperative treatments were similar in both groups; antibiotics and steroids combination eye drops were used at 6 hourly interval slowly tapered off. anesthesia (topical and peribulbar) was administered by the same anesthesiologist who also recorded temperature, heart rate, blood pressure, chest auscultation, and blood sugar level on anesthesia sheet. no patients received any oral sedation before injection or operation. patients used their routine drugs for treatment if any. on the table, patients were connected to monitors for recording blood pressure, ecg, respiratory rate and nasal / oral catheter for continuous supply of oxygen at a rate of 3 – 5 liter per minute. in addition, 22 gauge intra venous cannula was also inserted for any emergency. patients in the peribulbar anesthesia group received one injection each, 4 ml mixed solution of 0.5% bupivacaine hydrochloride (1.5 ml) and 2% lidocaine (2.5 ml) into the lower peribulbar space of the eye9. manual ocular compression for 10 minutes was given to facilitate drug absorption. for all patients the quality of peribulbar block was assessed after 10 minutes which is the maximum fixation time for the local anesthetic solution10. block was considered acceptable if there was no movement or slight flicker. prior to the surgery, the surgeon also assessed the effectiveness of block by eye movements in four directions of gaze. eleven doses (approximately 40 μl per dose) of proparacaine hydrochloride 0.5% were used in total (two drops on the cornea, and one each in the superior and inferior conjunctival cul de sac) 15 and 10 min before surgery. five minutes before surgery 2 more drops were instilled on the cornea. one drop was instilled on the cornea before eye was padded. the pain during surgery was controlled with additional 2 doses of 0.5% proparacaine drops if required. pain was scored using visual analogue scale. each patient was shown a visual analogue scale with numerical and descriptive ratings from 0 (no pain), 1 – 2 (slight stinging), 3 – 4 (mild pain), 5 – 8 (moderate pain) and 9 – 10 (severe pain). patients were briefed about the use of this pain scale to rate the level of pain felt pre-operatively (during administration of anesthesia topical / peribulbar), intra-operatively i.e. phacoemulcification with intra ocular lens implantation (immediately after surgery) and 4 hours post operatively. discomfort and feeling of pressure in the eye during administration of injection, during surgery and 4 hours post operatively were assessed as no = 0 or yes = 1. patients who were unable to read the printed scale were helped by the same colleague peribulbar versus topical anesthesia for cataract surgery; patient’s satisfaction pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 65 anesthesiologist who also performed the pain score recording in all the patients. the difficulties encountered by the surgeon during the surgeries were also graded as not difficult (grade 0), slightly difficult (patient uneasy = grade 1), moderately difficult (patient repeatedly squeeze eyes = grade 2) and extremely difficult requiring additional analgesia (unbearable pain = grade 3). operating surgeon also completed the form immediately after surgery. chi‑square test was used for categorical data. numerical data was analyzed using unpaired two tailed t‑test. nominal data and proportions were compared with chi-squared analysis. a p < 0.05 was considered statistically significant. results fifty patients with bilateral cataract (100 eyes) were included in the study. 50 eyes were operated with peribulbar block and 50 eyes with topical anesthesia. during administration of anesthesia feeling of pain (p= 0.003), discomfort (p = 0.001) and feeling of pressure (p = 0.00) were significantly lower with topical anesthesia as compared to peribulbar block (fig 1 – 3). intraoperative pain (p = 0.020), discomfort (p = 0.010) and feeling of pressure (p = 0.005) were higher in the topical anesthesia group as compared to peribulbar block. fig 1-3. four hours post operatively pain (p = 0.000), discomfort (p = 0.000) and feeling of pressure (p = 0.000) was significantly lower in peribulbar group than topical group. fig 1-3. pain with topical anesthesia y-axis no of patients x-axis pain scale 44 5 2 39 32 9 11 7 0 20 40 60 0 1 2 3 4 5 6 7 8 9 10 anesthesia application intraoperative 4 hrs post op fig. 1a: pain score during topical anesthesia: pain with peribulbar block y-axis no of patients x-axis pain scale 39 47 8 43 3 3 5 2 0 10 20 30 40 50 0 1 2 3 4 5 6 7 8 9 10 anesthesia application intraoperative 4 hrs postop fig. 1b: pain score with peribulbar block: feeling of discomfort 50 12 5 50 3 46 0 10 20 30 40 50 60 anesthesia application intraoperative 4 hrs post op peribulbar topical fig. 2: feeling of discomfort: feeling of pressure 50 2 6 50 4 42 0 10 20 30 40 50 60 anesthesia application intraoperative 4 hrs post op peribulbar topical fig. 3: feeling of pressure: zulfiqar-ud-din syed, et al 66 vol. 30, no. 2, apr – jun, 2014 pakistan journal of ophthalmology discussion our study reveals that patients were more anxious, felt more pain and discomfort in the eye that was operated under topical anesthesia, however patients were more satisfied and calm during surgery with the other eye that had phacoemulcification under peribulbar block. our results were similar to that of boezaart et al11 who reported that patient who have never experienced needle block may be satisfied with topical anesthesia while those who have experienced both techniques preferred the peribulbar injection. roman et al22 also reported that the level of satisfaction of patient undergoing cataract surgery with peribulbar block is much higher than topical anesthesia. in our study feeling of pain, discomfort and pressure were higher with topical anesthesia. in contrast, surgery under peribulbar anesthesia was painless despite the fact that patients felt comparatively more pain, discomfort and pressure during the administration of injection. others have found no difference in pain perception when comparing topical with peribulbar or retro-bulbar anesthesia12. fukasaku and marror13, comparing topical and peribulbar anesthesia, also reported more intraoperative pain in patients receiving topical anesthesia for cataract surgery. in recent years, topical anesthesia for cataract surgery has gained popularity as safe and atraumatic technique14,15. however, conflicting results have been presented regarding pain, anxiety, patient discomfort and patient satisfaction postoperatively with topical anesthesia16. the benefits of topical anesthesia over peribulbar or retro-bulbar anesthesia are: no risks of the needle techniques, the analgesia is immediate, no rise in intraocular pressure16, no need for globe compression and no preoperative sedation. different methods have been tried to improve the pain scores i.e. reduce pain in topical anesthesia. lignocaine gel, instead of drops gives low pain score due to prolonged contact time and better penetration17. although many surgeons used intracameral anesthetic along with topical anesthesia, however no significant benefit is documented18. the lack of akinesia is another drawback of the topical anesthesia. some surgeons find it difficult to work without akinesia; however, as reported by many authors19 lack of akinesia does not cause intraoperative difficulties to experienced surgeons. a study conducted by maclean h, burton t in 1997 revealed that most patients who received topical anesthesia do not feel major pain, similar to patients who underwent surgery with peribulbar or retrobulbar anesthesia,21 however, other studies have documented that patients under topical anesthesia alone were more likely to experience discomfort during manipulation of iris and zonular stretching21. roman et al have reported that there is increased surgical difficulty with and a distinct learning curve for topical anesthesia22. jenkins et al revealed that once the patient is cured there could be a bias from satisfaction score23, however in our study this bias was minimized by the fact that anesthesia (topical and peribulbar) was administered by and response of all patients was recorded by the same anesthesiologist. patient satisfaction is one of the important healthcare outcome measures. results from several studies have shown that there is higher patient satisfaction if postoperative pain is well controlled24. despite of pain and discomfort during administration of injection, both patients and surgeons are more satisfied with the peribulbar block for cataract surgery due to overall comfort. conclusion peribulbar anesthesia provides significantly better patient satisfaction as compared to topical anesthesia during cataract surgery. from surgeon’s perspective operating conditions with the peribulbar block is also superior then topical anesthesia. topical anesthesia is a safe and an effective alternative to peribulbar anesthesia in cataract peribulbar versus topical anesthesia for cataract surgery; patient’s satisfaction pakistan journal of ophthalmology vol. 30, no. 2, apr – jun, 2014 67 surgery. however for effective and patient friendly topical anesthesia surgical training, selection of cases, good preparation and education of patient, measures to further minimize pain and discomfort are required. author’s affiliation lt. col. dr. zulfiqar-ud-din syed classified ophthalmologist combined military hospital multan lt. col. dr. tariq mehmood malik classified anesthesiologist combined military hospital multan col. dr. aamir mehmood malak classified anesthesiologist combined military hospital multan col. dr. dilshad alam khan classified ophthalmologist combined military hospital multan maj. dr. umar ejaz classified ophthalmologist combined military hospital multan maj. dr. arsalan farooq trainee ophthalmology combined military hospital multan references 1. colvard dm, kandavel r. achieving excellence in cataract surgery; a step by step approach; springer; 2009. 2. hamilton rc. brain stem anesthesia as a complication of regional anesthesia for ophthalmic surgery. can j ophthalmol. 1993; 27; 323-5. 3. fichman ra. topical eye drops replace injection for anesthesia. ocular surgery news. 1992; 1; 20-21. 4. konstantos a. anticoagulation and cataract surgery: a review of current literature. anaesth intensive care, 2001; 29; 11-8. 5. leaming dv. practice styles and preferences of ascrs members: 1998 survey. j cataract refract surg. 1999; 25: 851-9. 6. said k, hassan m, qahtani fa. a comparative study of topical versus peribulbar anesthesia in phacoemulsification and implantation of foldable intraocular lens in cataract surgery. ijovs. 2003; 2: available online only. 7. gangolf g, jost bj. topical versus peribulbar anesthesia for cataract surgery. acta ophthalmol scand. 2003; 81: 596‑9. 8. salahuddin a. cataract surgery: is it time to convert to topical anesthesia. pak j ophthalmol. 2008; 24; 2; 62-7. 9. crandall as. zabriskie inj of lidocaine intraocular increase patient cooperative ophthalmology. 1999, 106: 60. 10. gills jp, williams dl. advantage of marcain for topical anesthesia. journal of cataract and ref. surg. 1993; 819. 11. boezaart a, berry r, nell m. topical anesthesia versus retro bulbar block for cataract surgery: the patients’ perspective. j clinanesth. 2000; 12: 58‑60. 12. nauman a, zahoor a, saeed a m, saba j, waleed r. satisfaction level with topical vs peribulbar anesthesia experienced by same patient for phacoemulcification: saudi j anesthesia. 2012; 6, 363-6. 13. fukasaku h, marror ja. pinpoint anesthesia: a new approach to local ocular anaesthesia. j cataract refract surg. 1994; 20: 468-71. 14. jolliffe dm, abdel-khalek mn, norton ac. a comparison of topical anesthesia and retrobulbar block for cataract surgery. eye. 1997; 11, 858–62. 15. kershner rm. topical anesthesia for small incision self-sealing cataract surgery. a prospective evaluation of the first 100 patients. j cataract refract surg. 1993; 19: 290-2. 16. jacobi pc, dietlein ts, jacobi fk. a comparative study of topical vs retrobulbar anesthesia in complicated cataract surgery. arch ophthalmology. 2000; 118: 1037-43. 17. grabow hb. topical anesthesia for cataract surgery. eur j implant refract surg. 1993; 5: 20-4. 18. bardocci a, lofoco g, perdicaro s. lidocaine 2% gel versus lidocaine 4% unpreserved drops for topical anesthesia in cataract surgery. ophthalmology. 2003; 110: 144-9. 19. gillow t, scotcher sm, deutsch j. efficacy of supplementary intra-cameral lidocaine in routine phacoemulsification under topical anesthesia. ophthalmology. 1999; 106: 2173-7. 20. tsuneoka h, ohki k, taniuchi o. tenon's capsule anesthesia for cataract surgery with iol implantation. eur j implant ref surg. 1993; 5: 29-34. 21. maclean h, burton t, murray a. patient comfort during cataract surgery with modified topical and peribulbar anesthesia. j cataract refract surg. 1997; 23: 277-83. 22. roman sj, auclin fx, ullern mm. topical versus peribulbar anesthesia in cataract surgery. j cataract refract surg. 1996; 22: 1121‑4. 23. jenkins k, grady d, wong j, correa r, armanious s, chung f. post‑operative recovery: day surgery patients’ preferences. br j anesthesia. 2001; 86: 272‑4. 24. seng th, chen fk. a randomized clinical trial of combined topicalintra-cameral anesthesia in cataract surgery. ophthalmology 1998; 105: 2007‑11. microsoft word 10. sana nadeem pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 95 original article presentation of ocular and orbital dermoid cysts at holy family hospital rawalpindi sana nadeem, ali raza pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sana nadeem department of ophthalmology rawalpindi medical college/holy family hospital rawalpindi …..……………………….. purpose: to evaluate the presentation of dermoid cysts related to the eye and orbit, appropriate management and results. material & methods: this prospective study was conducted in department of ophthalmology, holy family hospital, rawalpindi. a total of twenty eight (28) cases of dermoids presented to us from 1st january, 2007 to 1st december, 2011. ct scanning/mri were done where deemed necessary and all lesions were confirmed on histopathology. limbal dermoids were shaved off with conjunctival autografting or flap. superficial dermoids were removed via appropriate skin incisions and for deep dermoids, we performed orbitotomies. results: out of 28 cases of dermoids, 12 were limbal dermoids, 5 were superficial superonasal dermoids and 2 were superficial superotemporal, and 9 were deep orbital dermoid cysts. one superficial dermoid presented as a recurrence. post-operative hematoma developed in one patient only. follow up ranged from one month to four years. conclusion: dermoid cyst en bloc excision is a relatively safe procedure with minimal complications. recurrence can be effectively prevented by a careful evaluation and complete surgical removal. ermoid cysts are the most common congenital lesions of the orbit. they are developmental choristomatous tumors which are defined as normal tissue in an abnormal location. they are composed of derivatives of epithelial or connective tissue elements that are entrapped within facial clefts during embryogenesis, or from failure of separation of surface ectoderm from the neural tube. the solid or cystic masses are formed by proliferation of these cells1. they represent 24% of all orbital and eyelid masses, 6 – 8 of deep orbital tumors and 80% of cystic orbital masses2. conjunctival dermoid cysts are solid choristomas2, typically unilateral and located at the infertemporal limbus. they are well – defined slow growing painless lesions and have local mass effect on the bone with erosion and remodeling. growth may be outward into the eyelid, noted typically in childhood, or inward into the orbital cavity, and hence presents later. although congenital, only one fourth lesions are clinically obvious at birth, the remaining presenting within the first year. occasionally they present acutely after rupture simulating an acute inflammation with erythema, tenderness and swelling due to leakage of keratin3. mostly, dermoid cysts arise from keratinized squamous epithelium, but they may occasionally originate from the nonkeratinized conjunctival epithelium4. treatment is complete surgical excision, following which recurrences are rare. the purpose of our study is to segregate dermoids according to their site and to manage them diagnostically and surgically using different surgical approaches and to evaluate the results. material and methods all patients with dermoid cysts presented to the ophthalmology department at holy family hospital from 1st january, 2007 to 1st december, 2011 were included in this study. ct scan or mri were d sana nadeem, et al. 96 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology performed on all patients with orbital dermoids and all the lesions were confirmed on histopathology. all limbal dermoids were superficial and removed by shave excision and conjunctival autografting or a sliding flap. the superficial medial orbital dermoids were excised via medial skin incision or frontoethmoidal (lynch) incision. the superficial lateral dermoids were removed by sub-brow incisions. deep orbital dermoids were removed with a lateral orbitotomy in six (6) cases and lynch medial orbitotomy in one (1) case. in ten (10) cases, drainage was considered necessary before total removal. follow-up ranged from one month to four years and there was no recurrence seen. results a total of 28 cases were diagnosed and treated, out of which 12 (42.9%) were limbal dermoids. seven (25%) were superficial orbital, out of which 5 were medial (supero-nasal) orbital related to the frontoethmoidal suture and 2 were lateral (supero-temporal) orbital related to the zygomaticofrontal suture. nine (32%) were deep orbital, out of which 5 were related to the zygomatico-frontal suture, one superior orbital fissure, one posterior ethmoido-sphenoidal suture and 2 were related to the trochlear fossa (table 1) (fig. 1). table 1. location of dermoid location frequency n ( %) inferotemporal 12 (42.9) superotemporal 8 (28.6) superonasal 6 (21.4) temporal 2 (7.1) total 28 (100) limbal dermoids were all superficial and located on the inferotemporal limbus. removal resulted in mild corneal thinning and scarring, but no lesion required keratoplasty. one case was diagnosed as goldenhar syndrome. superficial medial and lateral dermoid cysts were present below the brow. rupture occurred in four (4) cases and the area was irrigated with saline and a dilute steroid solution. there was one case of recurrent superficial lateral dermoid which was treated successfully. deep orbital cysts were difficult to excise with drainage being considered necessary to facilitate posterior wall removal. no significant postoperative inflammation was observed in any case. all cysts were completely removed and sent for histopathology. they were found to be lined with stratified squamous epithelium, filled with keratin, sebaceous material and hair. patients were followed up for one month to four years to check for recurrences. one (1) patient developed a peri-ocular hematoma which spontaneously resolved. discussion solid limbal dermoids are usually unilateral pale lesions2 located most commonly at the inferotemporal limbus. mostly they are superficial and deep extension into cornea, sclera and conjunctiva is a rarity. treatment is shave excision, while lamellar or penetrating keratoplasty may be needed for deeper extension. bilateral limbal dermoids are found in patients with goldenhar’s syndrome. orbital dermoids can present at any age from infancy to old age. a slow growing, painless, subcutaneous mass presents in 90% of cases. they are non-tender, fluctuant or firm, and enlarge slowly as they become filled with keratin and sebum. deeper lesions usually symptomless initially, present later in life, in early adolescence or adulthood. deep dermoids if enlarge sufficiently may result in proptosis, diplopia due to globe compression or motility restriction due to cranial nerve palsies (iii, iv or vi)3. decreased vision due to optic nerve compression is rare. rarer still is its location within a rectus muscle5. they are usually unilateral with no predilection for laterality, gender or race. in our study, limbal dermoids were greatest in frequency, followed by deep orbital dermoids and lastly, superficial dermoids. we found superficial orbital demoids predominantly superonasally, however cavazza et al6 in their study, found predominantly superotemporal dermoids and sherman7 et al found equal number of medial and lateral dermoids in their study. deep dermoids were mostly lateral in our study. dermoids occur along the superotemporal orbital margin at the zygomaticofrontal suture in 75% of cases, although the frontoethmoidal suture, superonasally is the next most common site5. other sites are frontonasal and frontolacrimal sutures. presentation of ocular and orbital dermoid cysts at holy family hospital rawalpindi pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 97 fig. 1: pie chart depicting percentages of types of dermoid fig. 2. a large left recurrent superficial orbital dermoid cyst fig. 3: ct scan depicting the same cyst fig. 4: postoperative appearance at 3 weeks after excision dermoids are classified clinically into superficial or deep dermoids or exophyic and endophytic, according to their site of attachment in relation to the orbital rims8. superficial dermoids lie subcutaneously anterior to the orbital septum and their posterior margins can be palpated easily. deep lesions are located posterior to the orbital septum within the orbital cavity, discovered later in life when they produce bone damage, with or without invasion of the adjacent structures. deep dermoids are often complicated and may be misdiagnosed due to extent and complexity. in order to distinguish between deep and superficial dermoids, a thorough investigation is necessary, since deep dermoids may extend beyond the orbit into the temporalis fossa or intracranially9. also significant is the recognition of size, character, extension, and bony defects. histopathologically, dermoids are lined with keratinized, stratified, squamous epithelium with dermal appendages like hair follicles, sebaceous and eccrine glands and filled with keratin and sebaceous secretions. rupture leads to intense inflammation mimicking orbital cellulitis. histological evidence of leakage with inflammation has been found in more than half of these lesions10. ultrasonography reveals irregular internal structure on a-scan, with low to medium internal reflectivity, with the cyst wall being highly reflective. b-scan shows these lesions as round, smooth and welldefined with variable internal appearance11 and occasional fluid levels. excavation of adjacent bone or defects are frequent. management of dermoid cysts is complete surgical excision of the cyst wall and contents. most lesions show leakage and associated inflammation on sana nadeem, et al. 98 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology histopathology. the risk of rupture increases with patient age and size of the cyst12, due to thinning of the wall with increased size and also increased risk of trauma with age. therefore, these should be removed early to prevent tissue fibrosis. the superficial lesions are managed by a direct approach over them with. an upper-eyelid incision provides adequate exposure of most orbital lesions13. recognition of clinical features and imaging findings of dermoids is essential and with the help of imaging examinations and the combination of various surgical skills, the recurrence of dermoid cysts can be effectively prevented. conclusion to conclude, we clinically evaluated dermoid cysts which presented to us, calculated their frequency and investigated them with ct scanning/ mri and managed them surgically and confirmed via histopathology. enbloc dissection is the best method to remove these cysts with minimal complications. author’s affiliation dr. sana nadeem senior registrar department of ophthalmology rawalpindi medical college/ holy family hospital, rawalpindi dr. ali raza associate professor head of ophthalmology department rawalpindi medical college/ holy family hospital, rawalpindi reference 1. apple dj, rabb mf. ocular pathology. fifth edition. mosby: st louis. 1998; 568. 2. yanoff m, duker js. ophthalmology. second edition. mosby: st louis. 2004; 397-740. 3. karcioğlu za. orbital tumors: diagnosis and treatment. springerlink: new york. 2005; 293-6. 4. dutton jj, fowler am, proia ad. dermoid cyst of conjunctival origin. ophthal plast reconstr surg. 2006; 22: 137-9. 5. howard gr, nerad ja, bonavolonta g, et al. orbital dermoid cysts located within the lateral rectus muscle. opthalmology. 1994; 101: 767-71. 6. cavazza s, laffi gl, lodi l, et al. orbital dermoid cyst of childhood: clinical pathologic findings, classification and management. int ophthalmol. 2011; 31: 93-7. 7. sherman rp, rootman j, lapointe js. orbital dermoids: clinical presentation and management. br j ophthalmol. 1984; 68: 642-52. 8. bonavolontà g, tranfa f, de conciliis c, et al. dermoid cysts: 16-year survey. ophthal plast reconstr surg. 1995; 11: 187-92. 9. pfeiffer rl, nicholl rj. dermoid and epidermoid tumours of the orbit. arch ophthalmol. 1948; 40: 639. 10. shields ja, kaden ih, eagle rc jr, et al. orbital dermoid cysts: clinicopathologic correlations, classification, and management. the 1997 josephine e. 11. schuleler lecture. ophthal plast reconstr surg. 1997; 13: 265-76. 12. traboulsi ei, azar dt, khattar j, et al. a-scan ultrasonography in the diagnosis of orbital dermoid cysts. ann ophthalmol. 1988; 20: 229-32. 13. colombo f, holbach lm, naumann go. chronic inflammation in dermoid cysts: a clinicopathologic study of 115 patients. orbit. 2000; 19: 97-107. 14. bartlett sp, lin ky, grossman r, et al. the surgical management of orbitofacial dermoids in the pediatric patient. plast reconstr surg. 1993; 91: 1208-15. pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 201 original article association of asthenopia, pre-presbyopia and refractive errors in workers involved in hand crafting kiran shakeel, saba akram, saleem ullah, mahar safdar ali qasim, ayesha arshad pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: kiran shakeel demonstrator at department of optometry & vision sciences university of lahore email: safdarkemu@gmail.com …..……………………….. purpose: to determine the impact of hand crafting on different types of refractive errors and to check if is there any relationship of asthenopia and prepresbyopia with this work. study design: case series study (stratified sampling study). place & duration of study: kot qaisrani ,tehsil taunsa district dera ghazi khan and a local bazaar, hussaina gahi, in multan from jan 2017 to jun 2017. material and methods: 100 individuals were selected for this study having age 16-35 years. visual acuity, retinoscopy, torch light examination, ophthalmoscopy and pencil push-up test was done of every person. a questionnaire was also filled with the information given by the person after an informed consent. results: total 100 patients, 50 males and 50 females were selected in this study aging 16-35 years to check if is there any eye strain, headache, decrease in near vision before 35-40 years and if any type of refractive error is present in sample or not. there were 70% patients having near visual acuity of n6, 17% had n8 and 13% had between n10-n12. there were 74% emmetropes, 17% myopes and 9% hyperopes in this study. out of n6 group, 40 (57.1%) had eye strain and 44 (62.8%) had headache. out of n8 group, 15 (88.2%) had eye strain and 16 (94.1%) had headache. out of n10-n12 group 9 (69.2%) had eye strain and 12 (92.3%) had headache. conclusion: there is a weak relationship of refractive errors and pre presbyopia but strong association of asthenopia in workers of hand crafting. key words: asthenopia, pre presbyopia, refractive errors. ye is the most important human body organ which is responsible for the sense of vision. we see the world with the help of our eyes1. accommodation is a naturally occurring phenomenon in the human eye. an increase in the dioptric power of the crystalline lens occurs when we see from distance to some near object. this increase in power occurs because lens becomes more convex during accommodation. when ciliary muscles constrict, they release the tension on the zonular fibers of the crystalline lens and shape of the lens becomes more curved. this accommodative ability of the eye decreases with age. it is called presbyopia2,3. when a person is young the lens of his eye is more elastic. ciliary muscles around the crystalline lens stretch and relax for the phenomenon of accommodation. with increasing age lens progressively loses its ability to accommodate. with increasing age blurring of vision at near is a very common problem internationally. it almost happens to everyone. it is called presbyopia4. asthenopia is actually a combination of headache, eye strain and sometimes nausea. it is commonly associated with near work. a person who does excessive near work will face asthenopia. it is also e kiran shakeel, et al 202 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology defined as stress on the eyes associated with headache due to extra use of eyes5. convergence insufficiency is a main cause of visual fatigue, eye strain and headache. in this problem our eye converges less than it is required to see a near object. as a result after sometime of near work the person feels strain on the eyes and visual fatigue6. according to a study which is done by amitabha and his group on jewelry workers who do near work and related it to vdt operators and to graduate students. it was stated that excessive near work and extra usage of convergence can result in different type of visual disturbance which causes stress on the eyes. this study was done on 215 young males. the results showed that jewelry workers had more problems because they use their vision more than remaining two departments4,7. rafael did his research on 87 people aging from 18 to 31 years. he performed his research either on students or office workers. the purpose of that study was to check the relationship between asthenopia and accommodation due to near work. visual status of the sample was 6/9 to 6/6. results of this study suggested that we should take separate relations. near work time had negative relation with accommodative facility but had positive relation with asthenopic symptoms8-10. but many people suffered with condition of blurred vision and double vision due to near work and their accommodation reduced too11,12. rationale of this study is find the role of refractive error in different type of near work. the objective of study is to determine the impact of hand crafting on different types of refractive errors and to check is there any relationship of asthenopia and pre-presbyopia with this work. material and methods this study was carried out in a village named kot qaisrani tehsil taunsa district dera ghazi khan and a local bazaar in multan named hussaina gahi bazaar from jan 2017 to jun 2017. patients of 16 – 35 years of age having any kind of refractive errors with asthenopic symptoms were included in this study. presbyopic patients were also included in this study. both male and female were included in this study. all those patients who had cataract, amblyopia, low vision, nervous disorder, glaucoma, allergies and infections, any other disease which cause hazy media and less than 15 years of age were excluded from this study5. males and females who were involved in hand crafting were studied. we wanted to study the association of asthenopia, refractive errors, convergence insufficiency and pre-presbyopia with near work. people involved in hand crafting do more near work and they have more chances to develop such problems. our study design was case series with stratified sampling. stratified sampling is a type of sampling in which the researcher divides the objects to be examined in groups. after selection of these groups which are called strata, the researcher draws the probability sample from every single group. for example the group we studied were men in hand crafting and females of a village who were doing hand crafting in their homes. we selected 100 subjects. 50 of them were males and 50 were females. first of all informed consent from the patients was taken. examination was started by taking personal history of patients in which they were asked about diabetes, hypertension, smoking or any other disease which may be affecting vision. after that drug history was taken, history of trauma, past medical surgeries was also taken and then their visual acuity was measured with the help of logmar chart at distance and near respectively at 4 m and 25 cm to check if the patients had any refractive error or they had developed pre presbyopia after doing near work. after that torch light examination was done to see the anterior structures of eye to exclude the patients who were in the exclusion criteria of our study. retinoscopy was performed to find the type of refractive error. ophthalmoscopy was done to see the bruckner’s reflex. patients were checked digitally for glaucoma to exclude them from our study. a proforma was filled with the information given by the patient. a questionnaire was filled at the end to see if the patients had any headache, eye strain or nausea. patients with pre-presbyopia were prescribed the glasses. patients with asthenopia were asked to take short breaks during their work, convergence insufficiency was dealt with pencil push up exercises. results total 100 patients were included in this study with age range of 16-35 years. out of 100 people, 70% had near visual acuity of n6. 17% had n8 and 13% had n10n12. statistical studies showed that the mean was 0.433, standard deviation was 0.71428 and variance was 0.5.100. people who were selected in this study were mostly were emmetropes 74%, 17% were myopic association of asthenopia, pre-presbyopia and refractive errors in workers involved in hand crafting pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 203 and 9% were hyperopic. eye strain was the main variable of this study. out of 100 people the percentage of people having eye strain was 64%. there were 40% with visual acuity n6, 15% with visual acuity n8 and 9% having visual acuity 9%. and 34% didn’t have any eye strain. the percentage was 30%, 2% and 4% respectively with visual acuity n6, n8 and n10-12. so eye strain is associated with near work. pearson chi-square showed (p = 0.052) significant results. headache was also associated with asthenopia. there were 44% patients who experienced headache during near work having visual acuity n6 and 26% didn’t have any complain of headache. there were 16% patients with visual acuity of n8 sufferring from headache and only 12% having visual acuity from n10-n12 suffered from headache. pearson chi-square showed (0.008) significant results. table 1: refractive status. frequency percent valid percent cumulative percent valid emmetropia 74 74.0 74.0 74.0 myopia 17 17.0 17.0 91.0 hyperopia 9 9.0 9.0 100.0 total 100 100.0 100.0 table 2: eye strain. do you have any kind of eye strain during your work? total yes no near visual acuity n6 40 30 70 n8 15 2 17 n10-n12 9 4 13 total 64 36 100 discussion excessive near work leads to some problems in our eyes for example refractive errors, pre-presbyopia, asthenopia, convergence insufficiency. sometimes iop is also raised when a person does excessive near work. purpose of our study was to evaluate the association kiran shakeel, et al 204 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology of near work with these problems. according to this study near work has a strong association with asthenopia which includes eye strain, headache etc. more than 60% patients had eye strain due to near work and almost 70% people had headache due to near work. refractive status showed that 20% people were myopic and 10% people were hyperopic. we considered the patients above the age of 30 years prepresbyopic. almost 26 people were above 30 and 13 of them were pre-presbyopic which means that 50% of the people were pre-presbyopic who were involved in near work. more than 48% people were having convergence insufficiency. more than 45% people were working in improper light illumination. in the study by amitabha et al, he discussed asthenopia due to near work in jewelry workers. he described that the workers were working for long hours and they had low light illumination. subjects of our study were people who were involved in hand crafting and were doing near work for 12-14 hours consecutively. we also checked the environment in which they were working and almost 45% were working in low illumination. amitabha recommended his patients on follow up to increase the light illumination in which they were working. on follow-up when he studied them. they had improved their asthenopic symptoms when illumination was increased. we also recommendeded out patients to work in increased illumination4,7. study by unimanon et al describes that illumination, distance at which the worker is working and continuous near work causes eye strain. our results are also similar regarding the effects of near work. we also recommended the patients to work at more than 25 cm to 40 cm, illuminate the work environment and not to work continuously for 12-14 hour. we also prescribed them the 20-20 exercises (after every 20 minutes of near work look away for 20 seconds to relive the eye strain)5,13,14. unimanon in his study suggested a break for 10 minutes after every two hours of near work. his research had positive outcomes on follow-up. improving the work environment illumination, decreasing the working time and taking short breaks improved the situation1517. wholffsohn in his study discussed that eyes which work more are more prone to develop eye strain and visual problems. main purpose of our study was to address the problems that developed due to excessive near work18-20. the subjects of our study who were working for 12-14 hours had greater chances to develop eye problems due to near work and they had positive symptoms of asthenopia, refractive errors, pre-presbyopia and convergence insufficiency13,21. it was stated by shrewin that near work increases the chances to develop immature presbyopia and people in developing countries like pakistan face cost issues. in our study we also looked at this element but people who were doing near work of hand crafting were earning. they were independent of the cost issue. almost all of them could afford. if someone cannot afford glasses it increases the risk to develop more eye problems4,6,20. lee did his study on the effect of near work on the progression or development of myopia. he took some risk factors in general for example age, near work, work status and educational activity. he stated that people spending more time on near work were having more myopic shifts or myopia and in our study 20% people had developed myopia which means that there is a correlation between myopia and near work2,22. in karachi, uzma studied 246 patients in the opd to evaluate which factors are involved in the development of myopia. she studied patients below the age of 40 and we took the patients of 30-35 years for the criteria of pre-presbyopia. we considered this age to make sure that the patients are definitely presbyopic. she concluded that risk factors for prepresbyopia were financial crisis, social stress and sometimes profession is also a cause. in our study we explain that near work is the risk factor to develop pre-presbyopia1,3. jaffery cooper studied convergence insufficiency due to excessive near work. in convergence insufficiency one cannot converge his/her eyes properly and as a result patient feels visual discomfort. he said that convergence insufficiency can be related to accommodation. in our study 54% people had convergence insufficiency. in his study 72% people had asthenopia and convergence insufficiency. our results were also positive but the percentage is less than his results because the working timing of some of our study groups were less and people who were working less had less problems23. we recommended that the patients get treatment for their problems of refractive errors with prescribing glasses, pre-presbyopia with prescribing near add. we also asked them to improve the illumination. we dealt with convergence insufficiency with pencil push-up exercises. some of the people were using prednisolone because they had a concept that it cleanses the eye. we association of asthenopia, pre-presbyopia and refractive errors in workers involved in hand crafting pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 205 asked them to avoid using self-medication. we recommended them to have regular check-ups. conclusion near work has a strong association with asthenopia because in our results many patients had headache and eye strain. refractive errors were also present but not in a huge range. convergence insufficiency is also seen in these patients. author’s affiliation kiran shakeel bs (hons) optometry& orthoptics demonstrator at university of lahore saba akram m. phil optometry head of department university of lahore dr. saleem ullah mbbs quaid e azam medical college, bahawalpur mahar safdar ali qasim m. phil investigation ophthalmology head of department king edward medical university lahore ayesha arshad m. phil optometry university of faisalabad role of authors kiran shakeel principal investigator saba akram co investigator and research supervisor dr. saleem ullah co investigator/ author mahar safdar ali qasim co investigator and help in data editing and data analysis. all work on spss and endnote and research supervisor ayesha arshad co investigator and help in data collection refrences 1. hoffman rs, vasavada ar, allen qb, snyder me, devgan u, braga-mele r, et al. cataract surgery in the small eye. journal of cataract and refractive surgery, 2015; 41 (11): 2565-75. 2. kook d, kampik a, dexl ak, zimmermann n, glasser a, baumeister m, et al. advances in lens implant technology. f1000 med rep. 2013; 5: 3. 3. richdale k, sinnott lt, bullimore ma, wassenaar pa, schmalbrock p, kao cy, et al. quantification of agerelated and per diopter accommodative changes of the lens and ciliary muscle in the emmetropic human eye. investigative ophthalmology & visual science, 2013; 54 (2): 1095-105. 4. read sa, collins mj, carney lg. a review of astigmatism and its possible genesis. clinical & experimental optometry, 2007; 90 (1): 5-19. 5. vilela ma, castagno vd, meucci rd, fassa ag. asthenopia in schoolchildren. clinical ophthalmology, 2015; 9: 1595-603. 6. sherwin jc, keeffe je, kuper h, islam fm, muller a, mathenge w. functional presbyopia in a rural kenyan population: the unmet presbyopic need. clinical & experimental ophthalmology, 2008; 36 (3): 245-51. 7. patel i, west sk. presbyopia: prevalence, impact, and interventions. community eye health, 2007; 20 (63): 401. 8. heus p, verbeek jh, tikka c. optical correction of refractive error for preventing and treating eye symptoms in computer users. the cochrane database of systematic reviews, 2018; 4: cd009877. 9. ma mm, long w, she z, li w, chen x, xie l, et al. convergence insufficiency in chinese high school students. clinical & experimental optometry, 2018. 10. reindel w, zhang l, chinn j, rah m. evaluation of binocular function among preand early-presbyopes with asthenopia. clinical optometry, 2018; 10: 1-8. 11. cross fr. asthenopia and ocular headache. bristol med chir j (1883). 1893; 11 (40): 73-84. 12. neugebauer a, fricke j, russmann w. asthenopia: frequency and objective findings. ger j ophthalmol. 1992; 1 (2): 122-4. 13. borsting e, tosha c, chase c, ridder wh, 3rd. measuring near-induced transient myopia in college students with visual discomfort. optometry and vision science : official publication of the american academy of optometry, 2010; 87 (10): 760-6. 14. de a, dhar u, virkar t, altekar c, mishra w, parmar v, et al. a study of subjective visual disturbances in jewellery manufacturing. work. 2012; 41 suppl. 1: 340411. 15. vera-diaz fa, strang nc, winn b. nearwork induced transient myopia during myopia progression. current eye research, 2002; 24 (4): 289-95. 16. ostrin la, glasser a. accommodation measurements in a prepresbyopic and presbyopic population. journal of cataract and refractive surgery, 2004; 30 (7): 1435-44. kiran shakeel, et al 206 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology 17. vertinsky t, forster b. prevalence of eye strain among radiologists: influence of viewing variables on symptoms. ajr am j roentgenol. 2005; 184 (2): 681-6. 18. croft ma, glasser a, kaufman pl. accommodation and presbyopia. international ophthalmology clinics, 2001; 41 (2): 33-46. 19. glasser a, croft ma, kaufman pl. aging of the human crystalline lens and presbyopia. international ophthalmology clinics, 2001; 41 (2): 1-15. 20. hornbeak dm, young tl. myopia genetics: a review of current research and emerging trends. current opinion in ophthalmology, 2009; 20 (5): 356-62. 21. wolffsohn js, sheppard al, vakani s, davies ln. accommodative amplitude required for sustained near work. ophthalmic physiol opt. 2011; 31 (5): 480-6. 22. lee yy, lo ct, sheu sj, lin jl. what factors are associated with myopia in young adults? a survey study in taiwan military conscripts. investigative ophthalmology & visual science, 2013; 54 (2): 1026-33. 23. cooper j, jamal n. convergence insufficiency-a major review. optometry, 2012; 83 (4): 137-58. microsoft word 10. ubah josephine pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 219 original article comparison of pterygium recurrence rate between consultants and residents using 5 fu as an adjuvant after excision of primary pterygium ubah josephine n, gbadegesin oluwatosin g pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ubah josephine n department of ophthalmology ladoke akintola university of technology teaching hospital osogbo, osun state, nigeria …..……………………….. purpose: to compare the recurrence rates of pterygium between consultants and residents after primary pterygium excision. material and methods: a retrospective study of the primary pterygium excision cases with intraoperative 5-fu as an adjuvant therapy, done in a tertiary institution was carried out. all 36 case notes retrieved were reviewed. results: residents operated on 16 patients while consultants operated on 20 cases. of the 16 operations done by residents, 6(37.5%) had recurrence while it was seen in4 (20%) of the cases performed by consultants. the difference in recurrence not statistically significant. p=0.244. conclusion: although there was no statistical difference between the two groups considered in this study, the recurrence rate is still higher among the residents. terygium is a fibrovascular growth, a degenerative condition of the conjunctiva. it is usually seen in the interpalpebral feature. the exact cause of pterygium is not known but it has been found to be high in people who do outdoor work.1 the definitive treatment for the condition is surgical excision. the indications for pterygium excision include cosmesis, visual improvement and treatment of ocular discomfort.2 the recurrence rate of pterygium after surgical excision is high with the conventional bare sclera technique.3-7 this was found by young et al8 to rise steeply with the size of the pterygium as at the time of excision. to prevent recurrence, several techniques have been used. these include application of antimetabolites, mitomycin c and 5 fluorouracil, application of conjunctival autograft, amniotic membrane transplantation (amt), fibrin glue, beta irradiation ablation etc. in the part of the world where the present study was conducted, surgical training is incorporated in the residency training program. pterygium excision is one of the surgeries a well trained ophthalmologist in this part of the world should be comfortable with on completion of his training. those who have been trained sufficiently are usually allowed to perform this procedure under the supervision of the consultants during the training. the purpose of the current study is to compare the recurrence rate of pterygium after excision among resident doctors and consultants using 5 fu as an adjuvant. material and methods a retrospective study of cases of primary pterygium excision by resident doctors and consultants using 5 fluorouracil as an adjunctive therapy was carried out. out of 106 pterygium excision recorded done in the tertiary institution, only 62 case notes could be p ubah josephine n, et al 220 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology retrieved for the period 2005 to 2007. thirty six of these were excision with 5 fluorouracil. twenty of the surgeries were performed by consultants and 16 by resident doctors under very close supervision. the residents carried out the surgeries with the consultants in assistance. the surgical technique used was basically excision of the apex of the pterygium first, dissection of the body of pterygium from the sclera, and excision of the body and overlying conjunctiva. 5 fu (50 mg/ml) was then applied to the bare sclera using a sponge for duration of 3 minutes. this was followed by copious irrigation with normal saline solution. chloramphenicol eye ointment was applied to the eye and patched dressing left for 24 hours. topical dexamethasone three times daily was added from the first day post operatively. post operative follow up ranged from one to forty months, with a mean follow up period of 10.7 months. the results obtained were analysed using epi info 2002. results post operative recurrence was observed in a total 10 (27.8%) of the 36 cases. six (37.5%) of the 16 done by residents had recurrence, while 4 (20%) of the 20 done by consultants also reoccurred (table 1). the earliest time recorded for recurrence was at four weeks, in a case that was done by a consultant and the latest was at 4 months. there were no major intra or post operative complications recorded in both groups. the difference in the recurrence rate was not statistically significant, p = 0.244. discussion several studies have been conducted the on reduction of pterygium recurrence rate with 5 fu as an adjuvant. in this study, the resident had a higher recurrence rate compared to the consultants. the recurrence rates of 37.5% and 20% recorded by resident doctors and consultants respectively are comparable to what other authors have reported. bekibele et al,9 reported recurrence of 11.4% of 35 patients in their study on pterygium treatment using 5 fu as an adjuvant treatment compared to conjuctival autograft. akarsuet al10 recorded in their preliminary report, recurrence rate of 25%, in 25 patients. rahmanet al11 reported 33% recurrence rate. the difference in recurrence rate between the residents and consultants was not statistically significant. this is an encouragement for both the teachers and the residents. the reason for the higher incidence among residents however may be attributed to different reasons. the consultants must have performed this procedure several times and have some degree of mastery from experience. the residents on the other hand, not only are they just being introduced to the surgery, the number that each may have performed may not yet be sufficient. volume is required for efficiency and this will be acquired over time. conclusion in this study, the recurrence rate of pterygium was found to be higher among resident doctors compared to the consultant but not statistically significant. author’s affiliation dr. ubah josephine n department of ophthalmology ladoke akintola university of technology teaching hospital, osogbo, osun state, nigeria dr. gbadegesin oluwatosin g department of ophthalmology ladoke akintola university of technology teaching hospital, osogbo, osun state, nigeria references 1. durkin sr, abhary s, newland hs, et al. the prevalence, severity and risk factors for pterygium in central myanmar: the meiktila eye study. br j ophthalmol. 2008; 92: 25-9. 2. mohammed i. pterygium treatment. ann afr med. 2011; 10: 197-203. 3. ashaye ao. pterygium in ibadan. west afr j m. 1991; 10: 232-43. 4. sanchez-thorin jc, rocha g, yelin jb. meta-analysis on recurrence rates after bare sclera resection with and without mitomycin c use and conjunctival autograft placement in surgey for primary pterygium. br j ophthalmol. 1998; 82: 661-5. comparison of pterygium recurrence rate between consultants and residents using 5 fu pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 221 5. nazullah khan, mushtaq ahmed, abdul baseer, et al. to compare the recurrence rate of pterygium excision with bare sclera, free conjunctival auto graft and amniotic membrane grafts. pak j ophthalmol. 2010; 26: 138-42. 6. alpay a, ugurbas sh, erdogan b. comparing techniques for pterygium surgery. clin ophthalmol. 2009; 3: 69-74. 7. youngson rm. recurrence of pterygium after excision. br j ophthalmol. 1972; 36: 120-5. 8. young al, leung gys, wong ak, et al. a randomised trial comparing mytomycin c and limbal autograft after excision of primary pterygium. br j ophthalmol. 2004; 88: 995-7. 9. bekibele co, baiyeroju am, olusanya ba, et al. pterygium treatment using 5 fu as an adjuvant treatment compared to conjunctival autograft. eye 2008; 22: 31-4. 10. akarsu c, taver p, ergin a. 5 fu as chemoadjuvant for primary pterygium surgery: preliminary report. cornea. 2003; 22: 522-6. 11. rahmanur l, baig m a, islam q. prevention of pterygium recurrence by using intra-operative 5fluorouracil. pakistan armed forces medical journal. 1999; 49: 7-10. pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 111 case report ewing sarcoma of orbit with intracranial extension sabeen abbasi, alyscia cheema pak j ophthalmol 2015, vol. 31 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: b79, abbasi house defence officers housing society, opp. country cambridge school, hyderabad, pakistan email: sabeenabbasi@hotmail.com …..……………………….. ewing sarcoma causing unilateral proptosis in a child is unusual presentation. a young girl presented with painless proptosis of left eye with restricted eye movements. her radiology revealed a large soft tissue mass causing destruction of lateral orbital wall and zygomatic arch measuring 2.0 × 3.0 cm. total excision of intracranial and intra orbital part of the tumor brought about substantial relief. the clinical and radiological presentation and management of this entity are discussed. key words: sphenoid bone, ewing sarcoma, orbital proptosis, primitive neuroepithelial tumor (pnet), radiology, small round cell tumor, surgery. wing's sarcoma is a malignant small round-cell tumor classically involving the long bones of the limbs, the ribs, or the pelvis.' primary ewing's sarcoma of the head and neck region is unusual and generally involves the mandible or maxilla.1 the mean age of occurrence is between the first and the second decades in 80% of cases.2 the extra osseous ewing sarcoma and pnets share a unique and consistent genetic translocation t(11;22) (q24;q12).3 we report a young girl who presented with features of proptosis in left eye without visual deterioration. her radilogy revealed intraobital tumor with intracranial extension involving the greater wing of sphenoid bone. total excission of intraorbital and intracranial part of tumor brought about relief of proptosis. case report a 13 year old girl was presented with features of painful, progressively increasing proptosis of left eye for the last 6 months in 2010. there was no associated loss of vision, headache and vomiting. there was no history of trauma. family history was unremarkable. examination revealed a left sided proptosis downwards and laterally measuring 23 mm on hertel’s exophthalmometer, with restriction of extra ocular movements of all muscles. the dystopia was measured to be 5 mm laterally and 5 mm downwards (fig. 1). her visual acuity was 6/6 in both eyes. her fundoscopy was normal. she underwent full systemic evaluation with only two abnormal results: markedly raised leucocyte count and mcv, mchc, pcv slightly deranged. fig. 1: proptosis of left eye. her mri scan revealed abnormal high intensity signal within greater wing of sphenoid with e sabeen abbasi, et al 112 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology destructive permeative leision. a heterogeneous soft tissue mass was seen involving zygoma and greater wing of sphenoid, measuring 3.0 x 3.0 cm (fig. 2). fig. 2: mri axial view taken in 2010. when she came to us in 2010 we proved ewing sarcoma after an incisional biopsy. she was referred to oncology for consultation and was given 6 months course of vac regime (vincristine, actinomycin, and cyclophosphamide). at a follow-up of 3 months her proptosis had substantially subsided and extraocular movements had recovered. we repeated mri of brain in 2011, which showed reduction in size of mass as comparison with previous one. fig. 3: ct scan axial view at the level of orbit. in 2012, she again came to us with same complaints but with more aggressive in nature. her mri scan was repeated which showed cortical irregularity and thinning remodeling of greater wing of sphenoid associated with adjacent soft tissue swelling of lateral rectus and temporalis muscle (fig. 3). with the help of maxilo-facial department we performed panoramic orbitotomy on her. during surgery tumor was found to be firm, partly suckable and slightly vascularized. complete intraorbital and intracranial mass was excised (fig. 4), which was reddish brown in color (fig. 5). part of greater wing of the sphenoid bone was also removed (fig. 6). fig. 4: tumor is being removed. fig. 5: biopsy specimen. fig. 6: some of the bone also removed. ewing sarcoma of orbit with intracranial extension pakistan journal of ophthalmology vol. 31, no. 2, apr – jun, 2015 113 there was no damage done to vision or muscle. vision remained 6/6 in both eyes with no cosmetic disfigurement (fig. 7). on follow up 3 weeks after surgery proptosis decreased to 20 mm and postoperatively her mri was repeated which showed no evidence of mass (fig. 8). fig. 7: post-op picture after 2nd surgery. fig. 8: post-operative: mri axial view shows no growth. discussion ewing sarcoma is a malignant tumor that was first described as an endothelioma of the bone by james ewing in 1921.4 separate cases of involvement of either the cranial cavity or orbit have been reported, but a combination of the two has been ae rarity. ewing sarcoma is a highly malignant, small round cell tumor that primarily involves the pelvis and long bones. it accounts for 10% of all bony tumors and 4% of tumors in the head and neck region, typically involving the skull, mandible, and maxilla. however the orbital involvement is rare.5 metastases in the orbit from distant primary sites presenting as proptosis is rare, and unilateral, usually situated on the same side as the primary tumor. primary orbital ewing sarcoma/ pnet are extremely rare with only 17 reported cases as per literature.6 it is composed of sheets of small cells with high nuclear to cytoplasmic ratio. the cytoplasm is scanty, eosinophilic, and usually contains glycogen, which is detected by periodic acid schiff stain and is diastase degradable. the nuclei are round, with finely dispersed chromatin, and one or more tiny nucleoli.7 the histopathological examination revealed a characteristic round cell malignancy with a highly cellular tumor arranged in sheets with formation of nodules. together with this increased mitotic activity was identified. on immunohistochemistry, there was positivity for cd99 and neuron specific enolase (nse). the lesion was negative for synaptophysin and leukocyte common antigen (lca). spread of this tumor into the orbits is most likely through blood. metastases to orbits are extremely rare in ewing's sarcoma.8 computed tomographic scanning show mottled destruction of bone but typically no soft tissue enhancement with contrast. the characteristic periosteal “onion ring” reaction seen in long bones is not usually present in orbital cases.5 although ewing sarcoma was previously a tumor with high mortality, but with combined treatment of chemotherapy and surgery the prognosis has been improved greatly. in 2011, a case of ewing’s sacoma of orbit with intracranial extension has been reported. they gave treatment with combined regimen of surgery with chemo-radiotherapy. their patient responded well with this therapy.9 local treatment relying on surgical excision and radiotherapy alone has proven inadequate, with 5 – year survival rates of < 10%. the addition of chemotherapy has improved survival rates significantly to approximately 50%.10 treatment of ewing's sarcoma with a combination of surgery, chemotherapy and radiation therapy results in a 5 – year survival rate of approximately 65%. according to esiashvili and colleagues, the 5-year survival of localized disease increased from 44 to 68% in the period after 1993, whereas 5 – year survival of sabeen abbasi, et al 114 vol. 31, no. 2, apr – jun, 2015 pakistan journal of ophthalmology metastatic disease increased from 16 to 39%. the corresponding 10 – year survival increased from 39 to 63% for localized disease and from 16 to 32% for metastatic ewing's sarcoma.11 conclusion ewing sarcoma presenting as proptosis with intracranial extension is rare manifestation in pediatric age group. primary ewing sarcoma of the orbit should be considered in the differential diagnosis of children or young adults with proptosis, diplopia, and periorbital swelling. immunohistochemistry is essential to distinguish ewing sarcoma from other small round cell tumors. however if diagnosed early and with appropriate management complete cure is likely. author’s affiliation dr. sabeen abbasi post graduate, fcps ii trainee jinnah post graduate medical centre, karachi dr. alyscia cheema associate professor, fcps jinnah post graduate medical centre, karachi references 1. g woodruff, p thorner, b skarf. primary ewing’s sarcoma of the orbit presenting with visual loss. british journal of ophthalmology, 1988, 72, 786-792. 2. anup p. nair, guruprasad bettaswamy, awdhesh k. jaiswal, pallav garg, sushila jaiswal, and sanjay behari. ewing's sarcoma of the orbit with intracranial extension: a rare cause of unilateral proptosis. j pediatr neurosci. 2011; 6(1): 36–39. 3. hemalatha. a. l., asha u. primary extraosseous ewing sarcoma / pnet at an extraordinary site the orbit. national journal of basic medical sciences, volume iii, issue-1. 4. tomoaki kano, atsushi sasaki, shinichiro tomizawa, takashi shibasaki, masaru tamura, chihiro ohye. primary ewing’s sarcoma of the orbit: case report. brain tumor pathology 2009; 26(2): 95-100. 5. rosan y. choi, mark j. lucarelli, pascal d. imesch, g. reza hafez, daniel m. albert, richard k. dortzbach. primary orbital ewing sarcoma in a middle – aged woman arch ophthalmol. 1999; 117(4): 535-537. 6. hemalatha. a. l., asha u. primary extraosseous ewing sarcoma / pnet at an extraordinary site – the orbit. national journal of basic medical sciences, vol. iii, issue-1. 7. saral s desai and nirmala a jambhekar. pathology of ewing’s sarcoma / pnet: current opinion and emerging concepts. indian j orthop. 2010 oct-dec; 44 (4): 363–368. 8. woodruff g, thorner p. skarf b. primary ewing’s sarcoma of the orbit presenting with visual loss br. j. ophthalmol. 1988. 72: 786-79. 9. anup p. nair, guruprasad bettaswamy, awdhesh k. jaiswal, pallav garg, sushila jaiswal, and sanjay behari. ewing’s sarcoma of the orbit with intracranial extension: a rare cause of unilateral proptosis j pediatr neurosci. 2011; 6 (1): 36–39. 10. dutton jj, rose jg jr, debacker cm, gayre g. orbital ewing's sarcoma of the orbit. ophthal plast reconstr surg. 2000; 16 (4): 292-300. 11. anup p. nair, guruprasad bettaswamy, awdhesh k. jaiswal, pallav garg, sushila jaiswal, and sanjay behari. ewing’s sarcoma of the orbit with intracranial extension: a rare cause of unilateral proptosis. j pediatr neurosci. 2011; 6 (1): 36–39. microsoft word mazhar zaman soomro case report 11 226 case report latanoprost and herpetic keratitis mazhar zaman soomro, muhammad moin, imran attaulla pak j ophthalmol 2011, vol. 27 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mazhar zaman soomro ophthalmologist, shifa eye hospital, khanpur submission of paper march’ 2011 acceptance for publication october’ 2011 …..……………………….. herpetic simplex is a common cause of infection of the cornea. primary open angle glaucoma (poag) is the most common cause of irreversible blindness in the world. prostaglandin analogues are commonly prescribed as the first line therapy for poag. this is a report of a patient with recurrence of herpetic keratitis, who was on latanoprost for two months. clinicians should be alert to latanoprost as a cause of recurrence of herpetic keratitis. erpes simplex virus is a dna virus, which causes infection in humans only. there are two sub types; hsv-1which causes infection above the waist while hsv-2 causes infection below the waist (genital). case report a 70 years old lady presented to the outpatient clinic with left painful red eye. her visual acuity in the left eye was count fingers. left eye slit lamp examination revealed injected conjunctiva with hazy cornea. on fluorescein staining, there was a linear branching ulcer mimicking dendritic ulcer. the ends of branches characteristically had swollen appearance as terminal bulbs. corneal sensitivity was reduced. she had been operated on for cataract with posterior chamber intraocular lens implantation one year back. her post operative visual acuity was 6/18 and 6/24 in the right and left eye. after a year her visual acuity dropped to 6/24 in the right and 6/36 in the left eye.intra ocular pressure (iop) was 22 and 28mm of hg. visual fields showedcharacteristic features of glaucoma. her cup disc ratio was 0.5 and 0.8 in the right and left eye. a diagnosis of primary open angle glaucoma was madeand she was advised latanoprosteye drops in the evening in both eyes. while using latanoprost for a couple of months, she developed herpetickeratitis. she had no previous history of herpetic keratitis.she was neither hypertensive nor diabetic. latanoprost was stopped with initiation of brimonidine and a combination of timolol maleate and dorozolamideeye drops in order to control intraocular pressure in both eyes. acyclovirointment five times a day with tropicamideeye drops two times a day, were also started in the left eye. after three days tropicamide drops were stopped and acyclovir eye ointment was continued.dendrtic ulcer resolved after two weeks of treatment. discussion latanoprost is a prostaglandin with alpha analogue and it is used to reduce intraocular pressur. it increases uveoscleral outflow and reduces intraocular pressure by upto 25%. antiglaucoma prostaglandin analogues (latanoprost) because of their ability to induce the release of endogenous prostaglandins in the iris and the ciliary muscles may induce reactivation of hsv keratitis. viral infection is spread by direct contact of the skin or the mucous membranes to infected secretions. the initial attack is generally self-limiting and is often subclinical. however herpetic disease is recurrent and a wide range of clinical manifestations can result from an infection with this h 227 agent. the most common site of primary infection in humans is the skin and the mucous membrane innervated by the trigeminal nerve. the virus is transported via the nerve axon to its cell body in the sensory ganglion where it persists in a latent state until reactivation. some evidence exists that the human cornea also may harbor latent virus. recurrent disease is the result of reactivation of this latent virus. of adults in the united states, 50-90% have antibodies to hsv type 1, indicating previous exposure to the virus. incidence of ocular hsv infection is approximately 0.15%.the mean age of presentation is in the late fifth to early sixth decade of life. it is known that prostaglandin have effect on multiplication of herpes virus. harbour, blyth and hill1have observed prostanglandins enhance spread of herpes simplex virus in cell cultures. ultra violet light and trauma may induce herpes activation by releasing pharmacologically active agents in skin, including prostaglandins (pgs) such as pge2. these agents, and other compounds, which alter levels of adenosine cyclic monophosphate (cyclic amp), were tested for their effect on the replication of herpes simplex virus (hsv) in vero cells. prostanglandin e2 (pge2) and prostaglandin f2 alpha both increase the size of hsv plaques. analysis of the results suggests that prostaglandins can enhance cell-to-cell spread of hsv, but that cyclic amp is probably not involved in this effect. in one study by wand and associates2, recurrence of herpetic keratitis was reported in three patients using topical latanoprost. in one patient with latanoprost-associated herpes simplex keratitis cleared with the discontinuation of latanoprost and start of antiviral therapy; reinstitution of latanoprost with prophylactic antiviral medication kept the cornea clear, but as soon as the antiviral suppression was discontinued, herpes simplex keratitis reappeared.in a study conducted in rabbits by herbit e. kaufman and associates3, it was found that latanoprost increase the recurrence of herpetic keratitis in rabbits3. deai, fukuda and hibino4,quantitated herpes simplex virus (hsv) dna in tear film obtained from 2 patients who developed herpetic epithelial keratitis (hek) during treatment with latanoprost and a beta-blocker.in both cases, a real-time pcr assay was used to quantify hsv-dna in the tear film. dendrtic ulcer stained visual fields with fluorescein conclusion latanoprost which is an anti-glaucoma prostaglandin analogue may predispose to herpes simplex reactivation resulting in herpetic keratitis. it can cause inflammation and may have a common pathway for reactivation. therefore before prescribing anti glaucoma prostaglandin analogue one should take careful history of any previous herpetic infection. author’s affiliation dr. mazhar zaman soomro ophthalmologist shifa eye hospital khanpur professor muhammad moin head of department of ophthalmology bahawal victoria hospital bahawalpur dr. imran attaullah ophthalmologist thq hospital haroon abad reference 1. harbour da, blyth wa, hill tj. prostaglandin enhance spread of herpes simples virus in cell culture. j gen virol. 1978; 41: 87-95. 2. wand m, gilbert cm, liesegang tj. am j ophthalmol. 1999; 127: 602-4. 3. kaufman he, varnell ed, thompson hw. am j ophthalmol. 1999; 127: 531-6. 4. deai t, fukuda m, hibino t, et al. cornea. 2004; 23: 125-8. 182 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology original article comparison of pterygium resection with conjunctival auto graft versus amniotic membrane graft adnan alam, mubashir rehman, bilal khan, khurshid alam, adnan ahmad pak j ophthalmol 2015, vol. 31 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: adnan alam trainee medical officer, department of ophthalmology, lady reading hospital peshawar …..……………………….. purpose: to compare the effectiveness of pterygium resection with conjunctival auto graft versus amniotic membrane graft in terms of recurrence rate. material and methods: all patients were selected from eye opd lady reading hospital, peshawar. complete slit lamp examination was performed for pterygium. patients were divided into two groupsi. e group a who underwent pterygium excision with conjunctival autograft and group b who underwent pterygium excision with amniotic membrane graft. follow up was on 3 rd month postoperatively at which patient was examined on slit lamp for recurrence of pterygium. results: the recurrence rate in conjunctival autograft was 10% while the recurrence rate in amniotic membrane graft was 18%. conjunctival autograft was effective in 90% patients and was not effective in 10% patients, whereas amniotic membrane graft was effective in 82% patients and was not effective in 18% patients. conclusion: our study concludes that performing pterygium surgery with amniotic membrane graft compared to conjunctival autograft had a higher recurrence rate. key words: primary pterygium, conjunctiva autograft, amniotic membrane graft. terygium is an abnormal fibrovascular conjunctival tissue which encroaches the cornea.1 it is triangular in shape and is more frequently located nasally then temporally.2 ocular irritation, hyperemia and vision loss are the most common clinical symptoms of pterygium.3 early complaints e.g. foreign body sensation and inflammation are treated conservatively with artificial tears and anti-inflammatory drops to give symptomatic relief.4 however surgical excision remains the main treatment for pterygium causing visual impairment, cosmetic deformity, restriction of ocular motility or marked irritation or discomfort unrelieved by medical management.5 recurrence is the most common postoperative complication after pterygium excision.5 in the past pterygium was treated surgically with bare scleral technique.2 however this technique had a very high recurrence rate of about 24 – 89%.2 various techniques have been applied in the recent years to reduce the recurrence rate which include pterygium resection combined with conjunctival auto-graft, conjunctival resection with ammotic membrane graft and conjunctival resection with stem cell transplantation.6 surgical excision with conjunctival auto graft is not only safe and effective but it also reduces the recurrence rate.7 amniotic membrane transplantation after surgical excision of pterygium also appeared to be safe and effective with reduced rate of recurrence.8 purpose of our study is to compare the efficacy of pterygium resection combined with cojunctival auto p comparison of pterygium resection with conjunctival auto graft versus amniotic membrane graft pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 183 graft versus pterygium resection combined with amniotic membrane graft in our population. pterygium is a very common ocular disease presenting to eye department. main treatment modality in our set up is surgical excision but majority of these patients presents again with complaints of recurrence which is the most common post-operative complication. it not only disturbs daily life of patient but also put economic restrain on them. also these patients put extra burden on opd and ot. so in this study we wanted to find out the surgical procedure which reduces the recurrence rate to reduce burden on both patients and hospital. material and methods all patients were selected from eye opd, lady reading hospital, peshawar. patients between the age of 20 to 50 years both males and females, with primary pterygium of size between 2 to 4 millimeter presenting within 6 months of onset were included in the study. (in our set up pterigium between 2 mm to 4 mm usually presents within 6 months of onset, long duration pterigium were excluded to avoid pterium larger in size than 4 mm) patients with recurrent pterygium, pterygium associated with other chronic ocular surface disease, patients on long term topical steriods or topical nsaids, patients with previous history of any surgery on conjunctiva and patients with pterygium of size less than 2 mm and greater than 4 mm were excluded from the study. (pterigium of size 2 mm to 4 mm are more common so included in the inclusion criteria so as to make sample collection easier). complete slit lamp examination was performed for pterygium. the purpose and benefits of the study was explained to all patients and if agreed upon a written informed consent was obtained. the amniotic membrane was only taken from those patients who have undergone cesarean section and properly screened out pre operatively. patients were divided into two groupsi.e group a who underwent pterygium excision with conjunctival autograft and group b who were underwent pterygium excision with amniotic membrane graft. follow up was on 3rd month postoperatively.(we have followed the patients every three monthly, so follow up of first visit mentioned. on postoperative visit patient was examined on slit lamp for recurrence of pterygium. surgery was considered effective with no recurrence of pterygium and not effective with recurrence of at least 2 mm. the data was analyzed using spss version 16.frequencies and percentages were calculated for categorical variables like gender, side of the eye and effectiveness. mean and standard deviation were calculated for numerical variables like age and duration. chi square test was used to compare the effectiveness of both groups. p value of less than or equal to 0.05 was considered significant. effectiveness in both groups was stratified among age, side of the eye and gender to see the effect of modifiers. all the results were presented as tables and charts. post stratification chi square test was applied. discussion pterygium is one of the most common disorders in tropical and subtropical region including pakistan9. the most important risk factors are exposure to sunlight, hot, windy dry weather and old age10. short body height is also cited in literature as a risk factor for pterygiumdevelopment.11 (it has been mentioned in the literature for which reference no 11 is given) it causes irritation, redness and affects the visual acuity either by directly affecting the visual axis or by producing changes in the corneal curvature.12 prabhasawatetal9 conducted study on a total of 120 eyes in which 106 eyes had primary and 14 eyes had recurrent pterygia and showed that at 6 month after surgery conjunctival auto grafts had a recurrence rate of 13.3%. in our study the recurrence rates in both groups were higher than those reported previously, possibly because of amount of subconjunctival tissue removal, race of our population, type of suture used and drug given after surgery. tananuvat n et al10 in their study showed the recurrence rate of 12% in conjunctival auto graft group and 22% in amniotic membrane graft group which is in accordance to our study. soloman a et al11 conducted study on 167 eyes, which included 148 primary and 19 recurrent pterygia. they showed that after 6 months the recurrence rate in the amniotic membrane graft group was 28.1%. with the longer follow-up, the recurrence rates were 25.0% and 12.3% for amniotic membrane graft and conjunctival graft respectively. rahman l et al13 had shown that conjunctival auto grafts and amniotic membrane grafts differ in final appearance not only with respect to the rate of recurrence but also in the percentage of normal adnan alam, et a; 184 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology appearance. they suggested that covering the defect area with normal conjunctival tissue also has a higher likelihood of promoting the restoration of a normal appearance. in a study conducted by saleemm et al14 it was shown that amniotic membrane contain a thick basement membrane and a vascular matrix. the basement membrane reinforces adhesion of basal epithelial cells, facilitates migration of epithelial cells, promotes epithelial differentiation and prevents epithelial apoptosis. all these features promote rapid epithelialisation. narsani ak et al15 in their study showed that after pterygium excision, amniotic membrane grafts are less effective than conjunctival auto grafts in reducing recurrences. even if there is a recurrence conjunctival auto graft should be considered as the first choice for pterygium excision. however amniotic membrane graft can also be considered as first choice in certain situations e.g. those with advanced and diffuse conjunctival involvement or when it is needed to preserve the bulbar conjunctiva for glaucoma surgery. in similar study katbaab a et al16 first compared amniotic membrane graft (54) to a retrospective study using conjunctival auto graft (122) in both primary and recurrent pterygium. they noted that the recurrence rate is 10.9% using amniotic membrane graft, which is still higher than 2.6% of conjunctival graft. nevertheless, both results of amniotic membrane grafts and conjunctival auto grafts are significantly better than the primary closer, which resulted in 45% high recurrence rate for primary pterygium which is comparable to our study. fallah mr et al17 showed in their study that by removing larger amount of subconjunctival fibrosis tissue and injecting long acting steroids, amniotic membrane grafts achieved a recurrence rate of 3.0%, as compare to conjunctival auto grafts with a recurrence rate of 2.6%. similarly lateefur-rehman et al13 during follow up period, showed that recurrence of pterygia was high 41.33% in the patients with bare sclera method as compared to recurrence 33.33% while using 5-fluorouracil antimetbolite. ashok kumar narsani et al15 showed that there was 7.69% recurrences in conjunctival auto graft as compared to 16.13% recurrences with amniotic membrane graft. results age distribution among two groups is shown in table 1. in group a mean age was 38 years ±3.19, where as in group b mean age was 38 years ±3.77. gender distribution among two groups was analyzed as in group a 64(63%) patients were male and 38(37%) patients were female. where as in group b66(65%) patients were male and 36(35%) patients were female in table 2. duration of pterygium between two groups was analysed as in group a 44 (43%) patients had pterygium form < 3 months while 58 (57%) patients had pterygium form > 3 months. mean age was 3 months ± 2.16. where as in group b 48 (47%) patients had pterygium form < 3 months while 54 (53%) patients had pterygium form > 3 months. mean age was 4 months ± 2.99 table 3. laterality of pterygium among two groups was analyzed as in group a 57 (56%) patients had pterygium in left eye and 45 (44%) patients had pterygium in right eye. where as in group b 54 (53%) patients had pterygium in left eye and 48 (47%) patients had pterygium in right eye table 4. comparison of pterygium resection with conjunctival auto graft versus amniotic membrane graft pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 185 efficacy among two groups was analyzed as conjunctival autograft was effective in 91 (90%) patients and was not effective in 11 (10%) patients. whereas amniotic membrane graft was effective in 83 (82%) patients and was not effective in 19 (18%) patients table 5. stratification of efficacy with age, gender and side of the eye is given in table 6-8. adnan alam, et a; 186 vol. 31, no. 4, oct – dec, 2015 pakistan journal of ophthalmology conclusion our study concludes that performing pterygium surgery with amniotic membrane graft compare to conjunctival auto graft had a higher recurrence rate. author’s affiliation dr. adnan alam trainee medical officer department of ophthalmology lady reading hospital, peshawar. dr. mubashir rehman department of ophthalmology lady reading hospital, peshawar. dr. bilal khan vitreoretina trainee department of ophthalmology lady reading hospital peshawar. dr. khurshid alam trainee medical officer department of ophthalmology hayatabad medical complex, peshawar. dr. adnan ahmad junior registrar, department of ophthalmology, hayatabad medical complex, peshawar. role of authors dr. adnan alam patient selection, data collection, results and discussion. dr. mubashir rehman patient selection, data collection, results and discussion. dr. bilal khan patient selection, data collection, results and discussion. dr. khurshid alam literature search. dr. adnan ahmad literature search. comparison of pterygium resection with conjunctival auto graft versus amniotic membrane graft pakistan journal of ophthalmology vol. 31, no. 4, oct – dec, 2015 187 references 1. american academy of ophthalmology. basic and clinical science course. section 8, external disease and cornea. san francisco: american academy of ophthalmology 2004: 344. 2. khamar b, khamar m, trivedi n. degenerative conditions of the conjunctiva. in: dutta lc, dutta nk, eds. modern ophthalmology, 3rd ed. new delhi: jaypee. 2005: 127-30. 3. gupta v, tandon r, vajpayee rb. disorders of conjunctiva. in: agarwal s, agarwal a, apple dj, burato l, alio jl, panday sk, eds. textbook of ophthalmology, vol-2. lids, adnexa and orbit external eye diseases, cornea and refractive surgery. 1sted. new delhi: jaypee brothers. 2002: 862-9. 4. cameron me. histology of pterygium: an electron microscopic study. br j ophthalmol. 1983; 67: 604-8. 5. sekelj s, dekaris i, kondza – krstonijevic e, gabric n, predovic j, mitrovic s. ultraviolet light –b (uv-b) and pterygium. collantropol. 2007; 3: 45-7. 6. lu p, chen x, kang y, ke l, wei x, zhang w. pterygium in tibetans: a populationbased study in china. clin experiment ophthalmol. 2007; 35: 828-33. 7. durkin sr, abhary s, newland hs, selva d, aung t, casson rj. the prevalence, severity and risk factors for pterygium in central myanmar: the meiktila eye study. br j ophthalmol. 2008; 92: 25-9. 8. maheshwari p. pterygium-induced corneal refractive changes. indian j ophthalmol. 2007; 55: 383-6. 9. prabhasawat p, barton k, burkett g. comparison of conjuctival auto graft, amniotic membrane grafts and primary closure for pterygium excision ophthalmology. 1997; 104: 974-85. 10. tananuvat n, martin t. the results of amniotic membrane transplantation for primary pterygium compared with conjunctival autograft. cornea. 2004: 458–63. 11. soloman a, pires rtf, tseng scg. amniotic membrane transplantation after extensive removal of primary and recurrent pterygia. ophthalmology. 2001; 108: 449-60. 12. abraham lm, selva d, casson r, leibovitch i. the clinical applications of fluorouracil in ophthalmic practice. drugs 2007; 67: 237-55. 13. rahman l, baig ma, islam q. prevention of pterygium recurrence by using intra-operative 5-fluorouracil, pakistan armed forces medical j. 2008; 1: 23. 14. saleem m, khan sb, shah z. managing pterygium by excision and amniotic membrane grafts. gomal journal of medical sciences (gjms). 2008: 6. 15. narsani ak, jatoi sm, gul s. treatment of primary pterygium with conjunctival auto graft and amniotic membrane grafts. a comparative study. journal of liaquat university of medical & health sciences (jlumhs) hyderabad. 2008: 184-87. 16. katbaab a, ardekani ha, khoshniyat h. amniotic membrane transplantation for primary pterygium surgery. j opth vis res. 2008; 3: 23-7. 17. fallah mr, golabdar mr, amozadeh j. transplantation of conjunctival limbal auto graft and amniotic membrane vs. mitomycin c and amniotic membrane in the treatment of recurrent pterygium. eye. 2008; 22: 420-4. microsoft word abstracts 171 abstracts edited by dr. qasim lateef chaudhry the restore study ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema mitchell p, bandello f, schmidt-erfurth u, lang ge, massin p, schlingemann ro, sutter f, simader c, burian g, gerstner o, weichselberger a ophthalmology 2011; 118: 615-25. mitchell et al have shown that treatment with ranibizumab as monotherapy and combined with laser treatment is superior to laser treatment alone in rapidly improving and sustaining visual acuity in patients with visual impairment due to diabetic macular edema (dme). the 12 month restore study involved 345 patients with diabetes mellitus and visual impairment due to dme. one hundred and sixteen patients were randomized to ranibizumab + sham laser, 118 to ranibizumab+laser, and 111 to sham injections+laser. ranibizumab alone and combined with laser proved superior to laser monotherapy in improving the mean average change in best corrected visual acuity (bcva) from baseline through month 12 (+6.1 and +5.9 vs. +0.8). by month 12, a significantly larger proportion of patients had a bcva letter score ≥15 and bcva letter score level >73 with ranibizumab and ranibizumab+laser vs. laser alone. in addition, these patients quality of life improved significantly during the study period. in conclusion ranibizumab consistently improved bcva across all patient subgroups, including patients with focal or diffuse dme. intravitreal triamcinolone prior to laser treatment of diabetic macular edema; 24 – month results of a randomized controlled trial gillies mc, mcallister il, zhu m, wong w, louis d, arnold jj, wong ty mark et al conducted this study to report the 24 months outcome from a clinical trial of intravitreal triamcinolone acetonide (ivta) plus laser versus laser treatment only in eyes with diabetic macular edema (dme). it was a prospective, double-masked, randomized, placebo-controlled study. eighty-four eyes of 54 participants were entered into the study, with 42 eyes randomly assigned to receive ivta plus laser and 42 randomly assigned to receive laser treatment alone. primary end point data were available for 71 (84.5%) eyes at 24 months, with last visual acuity observation carried forward for the remaining eyes. best-corrected logarithm of minimum angle of resolution (logmar) visual acuity and central macular thickness (cmt) by optical coherence tomography were measured after laser treatment preceded by either ivta or sham. the primary outcome was the proportion of eyes with improvement in visual acuity of 10 letters or more at 24 months. the secondary outcomes were mean visual acuity, requirement for further treatment, change in cmt, and adverse events. at 24 months, improvement of 10 logmar letters or more was seen in 15 (36%) of 42 eyes treated with ivta plus laser compared with 7 (17%) of 42 eyes treated with laser only (p-0.047; odds ratio, 2.79; 95% confidence interval, 1.01–7.67). there was no difference in the mean cmt or mean logmar visual acuity between 2 groups. at least 1 retreatment was required in the second year of the study in 29 (69%) of 42 ivta plus laser-treated eyes compared with 19 (45%) of 42 laser only eyes (p-0.187). cataracts were removed from 17 (61%) of 28 phakic ivta plus laser-treated eyes versus 0 (0%) of 27 laser only eyes (p-0.001). treatment for elevated intraocular pressure was required in 27 (64%) of 42 ivta plus laser eyes compared with 10 (24%) of 42 laser only eyes (p-0.001). the study concluded that treatment with ivta plus laser resulted in a doubling of improvement in vision by 10 letters or more compared with laser only over 2 years in eyes with dme, but is associated with cataract and raised intraocular pressure. preoperative intravitreal bevacizumab use as an adjuvant to diabetic vitrectomy: histopathologic findings and clinical implications el-sabagh ha, abdelghaffar w, labib am, mateo c, hashem tm, al-tamimi dm, selim aa. hazem et al conducted this study to evaluate the effects of intervals between preoperative intravitreal 172 injection of bevacizumab (ivb) and surgery on the components of removed diabetic fibrovascular proliferative membranes. it was a interventional, consecutive, prospective, comparative case series. a total of 52 eyes of 49 patients with active diabetic fibrovascular proliferation with complications necessitating vitrectomy were enrolled. participant eyes that had ivb were divided into 8 groups in which vitreoretinal surgery was performed at days 1,3,5,7,10, 15,20, and 30 post injection. a group of eyes with the same diagnosis and surgical intervention without ivb injection was used for comparison. in all eyes, proliferative membrane specimens obtained during vitrectomy were sent for histopathologic examination using hematoxylin–eosin stain, immunohistochemistry (cd34 and smooth muscle actin) and masson’s trichrome stain and comparative analysis of different components of the fibrovascular proliferation (cd34, smooth muscle actin, and collagen) among the study groups was done. the results showed that pan-endothelial marker cd34 expression levels starting from day 5 post injection were significantly less than in the control group (p0.001) with minimum expression in all specimens removed at or after day 30 post injection. positive staining for smooth muscle actin was barely detected in the control eyes at day 1, and consistently intense at day 15 and beyond (p 0.001). the expression level of trichrome staining was significantly high at day 10, compared with control eyes (p 0.001), and continued to increase at subsequent surgical time points. so this study concluded that a profibrotic switch was observed in diabetic fibrovascular proliferation after ivb and suggested that at approximately 10 days postivb the vascular component of proliferation is markedly reduced, whereas the contractile components (smooth muscle actin and collagen) are not yet abundant at the same time. therefore after ivb, one should wait for atleast 10 days for the maximum effect before surgical intervention. pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 295 case report tuberous sclerosis complex: a case report rabia chaudary, areej riaz pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: rabia chaudary department of ophthalmology, liaquat university of medical & health sciences, hyderabad, pakistan email: rabiachaudhry19@gmail.com …..……………………….. tuberous sclerosis complex is an uncommon neurocutaneous syndrome characterized by development of benign tumors affecting multiple body systems including skin, brain, retina and viscera. the management of these patients is multidisciplinary, involving specialists from different fields. since it can present with a wide range of manifestations, the quality of life and prognosis depends on the particular abnormalities seen in a patient. here, we report a case of an 11 year old boy with typical clinical and radiological features of tuberous sclerosis. key words: adenoma sebaceum, subependymal giant cell astrocytoma, nonrenal hamartoma. uberous sclerosis also known as bourneville disease is a rare phacomatosis characterized by development of benign tumours1 affecting multiple organ systems including skin, brain, retina, kidney, heart and lungs. it may present in sporadic (60%) or autosomal dominant (40%) manner with a prevalence of 1 in 60001 live births affecting both sexes and all ethnicities. we report a case of an 11-year-old boy with distinctive clinical and radiological features of tuberous sclerosis. case report an 11-year-old boy presented to our opd with complaints of blurring of vision in both eyes for past few months and headache and vomiting for 15 days. headache and vomiting were more noticeable in early morning after waking from sleep. he also had abdominal pain for 15 days. on general physical examination, multiple welldefined brownish papules were seen on nose and cheeks in a typical butterfly pattern. a fibrous patch of around 2cm was present on forehead and right cheek. a skin tag was present in left preauricular area. a nodular growth involving nail bed of left fourth digit was seen. on ocular examination his best-corrected visual acuity was 6/18 od with -1.00 ds/-0.50 dc x30 and 6/9 os with -1.00 ds. anterior segment of both eyes was normal. on dilated fundus examination, established papilledema was seen. he was advised to get an mri brain done. mri brain revealed noncommunicating hydrocephalus secondary to intraventricular mass most likely a sub-ependymal giant cell astrocytoma. it also showed multiple subependymal nodules. for abdominal pain, he was referred to pediatrician who advised him abdominal ultrasound followed by a ct scan abdomen, which revealed the presence of a large extra-renal hamartoma. parents also gave history of seizures since childhood for which the child had taken sodium valproate for some time. currently, eeg revealed nonfocal seizure pattern. heart and lung imaging was normal. the child was result of a non-consanguineous marriage and no family member had similar manifestations. on the basis of above findings diagnosis of tuberous sclerosis was made. for the hydrocephalus, ventriculo-peritoneal shunt surgery was planned by neurosurgery department. for the extra-renal hamartoma, observation with yearly ct abdomen was advised by the pediatric oncologist. for early detection of retinal hamartomas, yearly fundoscopy was advised. t rabia chaudary, et al 296 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology table 1: diagnostic criteria for tuberous sclerosis1. major features minor features hypo-melanotic macules (>3 at least 5mm diameter) “confetti” skin lesions angiofibromas (>3) or fibrous cephalic plaque dental enamel pits (>3) ungual fibromas > 2 intraoral fibromas (>2) shagreen patch retinal achromic patch multiple retinal hamartomas multiple renal cysts cortical dysplasias non-renal hamartomas sub-ependymal nodules sub-ependymal giant cell astrocytoma cardiac rhabdomyoma lymphangioleiomyomatosis (lam) angiomyolipomas>2 discussion tsc is characterized by hamartomas of multiple organs from all primary germ layers2. it is an autosomal dominant disorder with nearly complete penetrance with variable expressivity. the mutation3,10 in genes tsc1 encoding hamartin and tsc2 encoding tuberin result in formation of hamartomas in various organs. the classic triad4,8 of epilepsy, mental retardation and adenoma sebaceum is seen in only a minority of patients. tsc has dermatological manifestations1,6 like hypomelanotic macules (ash leaf spots; 90%), facial angifibromas (adenoma sebaceum; 75%), ungula hamartomas (20%), skin tags, shagreen patch (50%) fig. 1: clinical photograph of the patient showing adenoma sebaceum, right cheek fibrous plaque, left preauricular skin tag and ungual fibroma. fig. 2: fundus photographs showing papilledema. and café-au-lait macules. hypo-melanotic macules are at least 5mm in size and typically appear at birth or in infancy on limbs, trunk or scalp. adenoma sebaceum appear between two and five years as fibroangiomatous red papules in a butter fly distribution around nose and cheeks. shagreen patch is an area of diffuse thickening over lumbar region having an orange peel appearance that usually appears in first decade of life. fibrous cephalic plaques can be seen on forehead as well as face in about 25%. subungual and fig. 3: ct brain showing subependymal nodules and giant cell astrocytoma. ct abdomen showing nonrenal abdominal hamartoma. periungual fibromas1 appear in second decade or later. confetti skin lesions are hypo-pigmented macules of 1 to 3 mm in size5. in oral cavity, dental enamel pits and fibromas may be seen. among ocular findings1, retinal tuberous sclerosis complex: a case report pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 297 astrocytoma, retinal achromic patch, patchy iris hypopigmentation and atypical iris coloboma may be seen. sub-ependymal nodules1 (sen; 80%) are benign growths that may be detected prenatally or at birth. sub-ependymal giant cell astrocytomas1 (sega; 515%) arise from sen mostly during childhood or adolescence. they are benign and slow growing but can cause obstructive hydrocephalus. seizures, learning difficulties, mental retardation and psychiatric disturbances can be present8,9. cardiac rhabdomyomas1 are frequently seen during prenatal life but regress later on and may cause arrhythmias. pulmonary lymphangioleio-myomatosis1 may be seen. angiomyolipomas1 usually affect kidneys but can affect other organs too. multiple renal cortical cysts can be present too. updated diagnostic criteria1 according to the recommendations of 2012 international tsc consensus conference is given in table 1. two major or one major with two minor features make a definite diagnosis. our patient had three major features including facial angiofibromas/fibrous cephalic plaque, subependymal nodules, subependymal giant cell astrocytoma and one minor feature i.e., non-renal abdominal hamartoma which led us to the clinical diagnosis of definite tsc. ungual fibroma and renal cortical cyst were also present but they did not meet the criterion. it is quite evident from our case report that an array of findings can be seen in tuberous sclerosis. the approach to management is therefore multidisciplinary and symptomatic to a large extent. likewise, the quality of life depends on the particular manifestations in a patient. author’s affiliation dr. rabia chaudhry consultant ophthalmologist jinnah postgraduate medical centre, karachi. dr. areej riaz postgraduate resident jinnah postgraduate medical centre, karachi. role of authors dr. rabia chaudhry diagnosis and management dr. areej riaz data collection and manuscript writing references 1. northrup h, krueger da. tuberous sclerosis complex diagnostic criteria update: recommendations of the 2012 international tuberous sclerosis complex consensus conference. pediatr neurol. 2013 oct; 49 (4): 243-54. 2. leung akc, robson lm. tuberous sclerosis complex: a review. j pediatr health care, 2007; 21: 108-114. 3. illahi y, tanveer s, khurshid pka, naeem a, ali n. tuberous sclerosis. classical presentation in a male patient. nmj. 2010; 2: 29-32. 4. jankar an, palange pb, purandare vc. tuberous sclerosisa case report. int j biomed res. 2014; 5: 64950. 5. cheng ts. tuberous sclerosis complex: an update. hong kong j dermatol venereol. 2012; 20: 61-7. 6. sarkar s, khaitan t, sinha r, kabiraj a. tuberous sclerosis complex: a case report. contemp clin dent. 2016 apr-jun; 7 (2): 236-34. 7. syed kn. tuberous sclerosis. j pak med assoc. 2010 aug; 60 (8): 683-85. 8. zeebaish s, hemalatha p, anusha y, surendra rn, durga prasad ts. case report on tuberous sclerosis. int j basic clin pharmacol. 2017 apr; 6 (4): 997-1000. 9. roach e, sparagana s. diagnosis of tuberous sclerosis complex. j child neurol. 2004; 19: 643-9. 10. li c, liao s, yu j. tuberous sclerosis complex confirmed by genetic analysis: a case report. j neurol neurosci. 2016; 6: 4. microsoft word 03-oa mumtaz alam pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 8 original article non-penetrating eye injuries in victims of bomb blasts and mine blasts mumtaz alam, mustafa iqbal pak j ophthalmol 2013, vol. 29 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mumtaz alam house no 310, street no 5, sector e-4, phase 7 hayatabad, peshawar. …..……………………….. purpose: to study the type of non-penetrating eye injuries in victims of bomb blasts and mine blasts and to assess their visual outcome. material and methods: the study was conducted at the department of ophthalmology, khyber teaching hospital and iqbal eye clinic peshawar, from march 2010 to february 2012. detailed history was taken from all patients and complete ocular examination was done. in eyes with poor or no view of fundus a b-scan ultrasonography was done. management and follow up varied according to the type and extent of eye injury. all the relevant data was recorded on a proforma. results: total number of patients was 52, including 50 males (96.15%) and 02 female (03.84%). mean age of patients was 24.12 years. ocular injury was unilateral in 36 patients (69.23%) and bilateral in 16 eyes (30.76%). vitreous hemorrhage was the most common ocular finding, seen in 21 eyes (30.88%). conservative management was done in 57 eyes (83.82%), while 11 eyes (16.17%) required surgical intervention. visual acuity improved in 49 eyes (72.05%) and remained unchanged in 19 eyes (27.94%). final best corrected visual acuity was 6/12 or better in 40 eyes (58.82%). conclusion: visual prognosis of non-penetrating eye injuries in blast victims is usually good. most cases do not require surgical intervention and can be managed conservatively. cular injury is an important cause of monocular visual impairment and blindness in younger age group1,2. approximately 2 million eye injuries occur in the united states every year; and more than forty thousand result in permanent visual impairment3. ocular injuries can be broadly divided into 2 groups i.e. closed globe (without full-thickness wound of eye wall) and open globe (with full-thickness wound of eye wall). open globe injuries are divided into rupture and laceration. closed globe injuries are divided into contusion and lamellar laceration4. bomb blast injuries are one of the most common causes of severe ocular injury among adult males5. in our part of the world, blast related eye injuries are becoming increasingly common. bomb blast causes peppering of the eye with multiple minute particles, which may be a combination of plastic or metallic particles, gunpowder, sand, dust and organic debris6. closed globe eye injuries are common in blast victims and are caused by the primary blast effect shock waves. the blast wave displaces a dense medium across a less dense interface, and inertial forces may cause displacement of optical structures causing non-penetrating eye injuries7. the spectrum of eye injuries in blast victims ranges from very mild non-sight threatening to extremely serious with potentially blinding conesquences. our aim was to study the type of nonpenetrating eye injuries in victims of bomb blasts and mine blasts and to assess their visual outcome. o mumtaz alam, et al 9 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology material and methods this was a prospective study conducted at ophthalmology department of khyber teaching hospital and iqbal eye clinic peshawar, from march 2010 to february 2012. the study was done in collaboration with an organization, which was working for people suffering war injuries. all the patients had bomb blast or mine blast injuries. the patients were assessed by a trauma surgeon and any serious injuries were properly managed. patients were then referred to us for the management of ocular injuries. all patients with closed globe injuries were included in this study (68 eyes of 52 patients). patients who had intraocular foreign bodies (detected on clinical examination or ct scan) were excluded from the study. informed consent was taken from all the patients. detailed history was taken and complete ocular examination was done including assessment of best corrected visual acuity (bcva) using snellen visual acuity chart, pupillary reaction, measurement of intraocular pressure with perkin’s tonometer mk2 (clement clarke, london), anterior segment examination with slit-lamp (takagi sm-70, japan) and dilated fundus examination with indirect ophthalmoscope (neitz, japan) and/or with slit-lamp using 90d lens (volk, usa). in eyes with poor or no view of fundus a b-scan ultrasonography was done with ab 5500+ a/b scan (sonomed, usa). management and follow up varied according to the type and extent of eye injury. all the relevant data was recorded on a performa. results the study included 68 eyes of 52 patients. out of 52 patients, 50 were male (96.15%) and 02 female (03.84%). mean age was 24.12 years (range 04 to 65 years). ocular injury was unilateral in 36 patients (69.23%) and bilateral in 16 patients (30.76%). vitreous hemorrhage was the most common ocular finding, seen in 21 eyes (30.88%). cataract was present in 11 eyes (16.17%) and retinal detachment in 05 eyes (07.35%). the types of eye injuries noted in our patients are given in table 1. the treatment varied according to the type and severity of eye injury. conservative management was done in 57 eyes (83.82%), while 11 eyes (16.17%) required surgical intervention table 2. cataract extraction with intraocular lens implantation and pars plana vitrectomy were the most commonly performed surgical procedures i.e. in 07 eyes (10.29%) each. vitrectomy was required in patients who had nonresolving vitreous hemorrhage, or retinal detachment. the type and number of surgeries are given in table 3. in addition, 360 argon laser was done in 06 eyes (08.82%) and yag laser capsulotomy was done in 2 eyes (02.94%). visual acuity improved in 49 eyes (72.05%) and remained unchanged in 19 eyes (27.94%). 40 eyes (58.82%) achieved best corrected visual acuity 6/12 or better. the initial and final visual acuities are given in table 4. discussion trauma is a common cause of ocular morbidity. the effect of trauma may be apparent immediately or may non-penetrating eye injuries in victims of bomb blasts and mine blasts pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 10 develop later as a secondary complication. ocular trauma can cause permanent visual or cosmetic defect in the affected individuals and is one of the major cause of monocular blindness and impaired vision throughout the world8. in addition to the impact on affected individuals, blindness and severe visual impairment resulting from the injuries have important socioeconomic implications. the cost of treatment including hospital stay is tremendously high, whereas, the indirect cost resulting from loss of productivity by young men is equally important9. developing countries carry the largest burden of such accidents, but are the least able to afford the costs10,11. bomb blast and mine blast are becoming increasingly common causes of ocular injuries, especially in this part of the world. in a study of 387 randomly selected soldiers injured by blasts in iraq, 329 (89%) sustained ocular injuries12-14. in the study of mader th et al,15 36.3% of all ocular injuries were closed globe, while in the study of weichel ed et al16 54.16% of all eye injuries were closed globe injuries. vitreous hemorrhage was the most common ocular finding, seen in 21 eyes (30.88%), followed by corneal edema, seen in 18 eyes (26.47%), corneal foreign bodies in 15 eyes (22.05%), retinal hemorrhages in 13 eyes (19.11%) and subconjunctival hemorrhage in 12 eyes (17.64%). cataract was present in 11 eyes (16.17%) and retinal detachment in 05 eyes (07.35%). most of the eyes (83.16%) were managed conservatively, only 11 eyes (16.17%) required surgical intervention. cataract, vitreous hemorrhage and retinal detachment were the most common indications for surgical intervention. visual outcome and prognosis in patients with ocular trauma due to blasts, depends upon the type of injury sustained. majority of the patients with perforating injuries have poor visual outcome. closed globe injuries usually have better visual outcome as compared to open globe injuries16. in our study, the best corrected visual acuity (bcva) improved in 49 eyes (72.05%) and remained unchanged in 19 eyes (27.94%). 40 eyes (58.82%) had final bcva > 6/12 or better, in 10 eyes (14.70%) the bcva was ranging from 6/60 to 6/18 and in 18 eyes (26.47%) it was < 6/60. in the study of weichel ed et al,16 42 % of all eyes (including both open globe and closed globe injuries) achieved a bcva of 6/12 or better, closed – globe injuries accounted for 65% of bcva of 6/12 or better. mumtaz alam, et al 11 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology conclusion bomb blast is becoming increasingly common cause of ocular injuries. visual prognosis of non-penetrating eye injuries in blast victims is usually good. most cases do not require surgical intervention and can be managed conservatively. author’s affiliation dr. mumtaz alam senior registrar ophthalmology department kuwait teaching hospital, peshawar dr. mustafa iqbal professor & in charge eye “b” unit khyber teaching hospital, peshawar references 1. hasnain sq, kirmani m. a 5 year retrospective case study of penetrating ocular trauma at the agha khan university hospital, karachi. j pak med assoc. 1991; 41: 189-91. 2. khattak mn, khan md, muhammad s, mulk ra. untreatable monocular blindness in pakistani eye patients. pak j ophthalmol 1992; 8: 3-5. 3. mcgwin g, xie a, owsley c. the rate of eye injury in the united states. arch ophthalmol. 2005; 123: 970-6. 4. kuhn f, morris r, witherspoon cd, mester v. the birmingham eye trauma terminology system (bett). j fr ophtalmol. 2004; 27: 206-10. 5. newmann tl, russo pa. ocular sequelae of bb injuries to eye and surrounding adnexa. j am optom assoc. 1998; 69: 583-90. 6. jackson h. severe ocular trauma due to landmines and other weapons in cambodia. j comm eye health. 1997; 10: 37-9. 7. harlan jb, pieramici dj. evaluation of patients with ocular trauma. ophthalmol clin north am. 2002; 15: 153-61. 8. jackson h. bilateral blindness due to trauma in cambodia. eye 1996; 10: 517-20. 9. baig msa, zafar mu, anwar m, rab m, khokar ar. major ocular trauma. (an analysis of 98 admitted cases). pak j ophthalmol. 2004; 20: 148-52. 10. umeh re, umeh oc. causes and visual outcome of childhood eye injuries in nigeria. eye 1997; 11: 489-95. 11. ilsar m, chirambo m, belkin m. ocular injuries in malawi. br j ophthalmol. 1982; 66: 145-8. 12. ramasamy a, harrisson se, clasper jc, stewart mp. injuries from roadside improvised explosive devices. j trauma. 2008; 65: 910-4. 13. weichel ed, coyler mh. combat ocular trauma and systemic injury. curr opin ophthalmol. 2008; 19: 51925. 14. wolf sj, bebarta mv, bonnet cj. blast injuries. lancet 2009; 374: 405-15. 15. mader th, carroll rd, slade cs, george rk, ritchey jp, and neville sp. ocular war injuries of the iraqi insurgency, jan–sept 2004. ophthalmology. 2006; 113: 97-104. 16. weichel ed, colyer mh, ludlow se, bower ks, and eiseman as. combat ocular trauma visual outcomes during operations iraqi and enduring freedom. ophthalmology. 2008; 115: 2235-45. pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 123 case report transient non-inflammatory vascular sheathing in combined crvo and cilioretinal artery imran akram pak j ophthalmol 2018, vol. 34, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: imran akram consultant ophthalmic & vitreoretinal surgeon st helens hospital, uk email:imranakram2020@gmail.com …..……………………….. to describe a case of evanescent sheathing of retinal vessels in a case of combined occlusion of the central retinal vein and cilioretinal artery. the sheathing was non-inflammatory and resolved spontaneously after a few days. this was accompanied by significant visual improvement. no active treatment was offered to this patient. even though transient vessel sheathing has been previously reported in retinal vein occlusion this is the first published report of transient vessel sheathing in association with combined central retinal vein and cilioretinal artery occlusion. key words: transient sheathing, central retinal vein occlusion, cilioretinal artery. entral retinal vein occlusion associated with cilioretinal artery occlusion is well documented1,2. it can occur even in the absence of reported systemic pathology3 although most patients do have associated comorbidity4,5. case report a 54-year-old caucasian man presented to our unit with a 24-hour history of painless visual loss in his right eye. he was a non-smoker, had no medical history of note .visual acuity was count fingers in the right eye, and 6/6 unaided left eye. right eye showed a significant relative pupillary defect (rapd++). anterior segment was quiet. fundus examination (fig. 1) showed a hyperaemic swollen disc, dilated tortuous veins accompanied by blot haemorrhages in all quadrants. the veins in all quadrants demonstrated segmental sheathing. some medium sized arterioles also demonstrated focal sheathing. there was no vitreous activity. there was a creamy pallor all over the posterior pole extending from temporal to the disc and involving the macula. oct scan (fig. 1) showed macular srf and hyper-reflectivity of the inner retina consistent with cloudy swelling. the left eye was entirely normal on examination. fluorescein angiography showed delayed filling and late venous leakage. there was no significant capillary closure. no macular edema was seen on ffa. the choroid showed poor filling throughout the angiogram. these findings supported a diagnosis of nonischaemic crvo combined with cilioretinal artery occlusion. however, the presence of venous sheathing was at the time considered by us to represent inflammatory activity. we therefore organised several tests including fbc, esr, urine complete, glucose, crp, angiotensin converting enzyme levels, serology for toxoplasmosis, syphilis, varicella, cmv and mantoux test. he also underwent x-ray chest. all these tests were reported as normal. he had no systemic features suggestive of bechet’s disease. carotid doppler scanning showed no narrowing. his blood pressure in clinic was noted to be 188/95 and his general practitioner was informed about this. c mailto:imranakram2020@gmail.com imran akram 124 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology fig. 1: colour fundus photo of right eye at presentation. note the vascular sheathing. oct scan shows inner retinal hyper-reflectivity. fig. 2: colour fundus photo of right eye at 4 weeks. spontaneous resolution of vascular sheathing and tortuosity is seen. oct scan appears almost normal. the patient was commenced on aspirin 75 mg daily and no other treatment was given. he was reviewed in clinic 2 weeks later. by then the va had spontaneously improved to 6/24 and there was considerable reduction in the retinal haemorrhages and vascular tortuosity. furthermore, the previously observed vascular sheathing had completely resolved. two weeks later va had improved to 6/18 and oct scan showed no retinal swelling (fig. 2). we continued to monitor him in clinic. ffa was repeated which showed normal retinal and choroidal filling. 6 months later va had improved to 6/12. discussion the interesting aspects of this case are the transient nature of the non-inflammatory vascular sheathing, and the spontaneous visual improvement without any active treatment. transient non-inflammatory venous sheathing has been reported before. one report describes this phenomena following trauma6. in the context of retinal vein occlusions, there is a report of four cases. lightman, foss et al7 described cases of retinal vein occlusion that demonstrated transient vessel wall sheathing which then resolved spontaneously. however, this is the first published report of this phenomenon seen in the setting of combined nonischaemic crvo and cilioretinal artery occlusion. the reason for the sheathing is unknown. the occlusion of the cilioretinal artery in this situation is considered a secondary occurrence following the initial crvo. it is thought to be due to increased hydrostatic pressure within the lamina cribrosa, which then leads to a hemodynamic stagnation within the cilioretinal artery8. spontaneous visual improvement following combined crvo and cilioretinal artery occlusion has been well described by hayreh in his extensive paper9. it is thought to be due to the mostly extradural course adopted by the cilioretinal artery, which protects it to some extent from the increased hemodynamic pressure in the lamina cribrosa. financial support nil. conflict of interest there is no conflict of interest. author’s affiliation dr. imran akram, mbbs, frcs, frcophth consultant ophthalmic & vitreoretinal surgeon transient non-inflammatory vascular sheathing in combined crvo and cilioretinal artery pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 125 role of authors dr. imran akram sole author. treating physician. preparing of manuscript. literature search. corresponding author. references 1. kim it, lee wy, choi yj. central retinal vein occlusion combined with cilioretinal artery occlusion. korean j ophthalmol. 1999 dec; 13 (2): 110-4. 2. murray dc, christopoulou d, hero m. combined central retinal vein occlusion and cilioretinal artery occlusion in a patient on hormone replacement therapy. br j ophthalmol. 2000 may; 84 (5): 546. 3. theoulakis pe, livieratou a, petropoulos ik et al. cilioretinal artery occlusion combined with central retinal vein occlusion a report of two cases and review of the literature. klin monbl augenheilkd. 2010; 227 (4): 302-5. 4. berkani z, kitouni y, belhadj a et al. cilioretinal artery occlusion and central retinal vein occlusioncomplicating hyperhomocysteinemia: a case report. j fr ophtalmol. 2013 sep; 36 (7): 119-27. 5. schmidt d. comorbidities in combined retinal artery and vein occlusions. eur j med res. 2013 aug; 18 (1): 27. 6. kahloun r, abroug n, ammari w et al .acute retinal periphlebitis mimicking frosted branch angiitis associated with exudative retinal detachment after blunt eye trauma. int ophthalmol. 2014 oct; 34 (5): 1149-51. 7. foss aj, headon mp, hamilton am, lightman s. transient vessel wall sheathing in acute retinal vein occlusions. eye, 1992; 6 (pt 3):313-6. 8. hayreh ss, fraterrigo l, jonas j. central retinal vein occlusion associated with cilioretinal artery occlusion. retina, 2008; 28: 581–594. 9. hayreh ss. acute retinal arterial occlusive disorders. prog retin eye res. 2011 sep; 30 (5): 359-394. microsoft word c.o. omolase pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 10 original article factors influencing choice of specialty amongst nigerian ophthalmologists omolase charles oluwole pak j ophthalmol 2012, vol. 28 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: omolase charles oluwole department of ophthalmology federal medical centre p.m.b 1053, owo. ondo state, nigeria …..……………………….. purpose: to determine the factors that influenced the choice of specialty amongst nigerian ophthalmologists. material and methods: this study was conducted during the annual congress and scientific conference of the ophthalmological society of nigeria which took place at the obafemi awolowo university, ile-ife, osun state, nigeria between 14th and 18th september, 2008 the respondents were interviewed with the aid of structured questionnaire by the author and three assistants. the data obtained with the study instrument (questionnaire) included the time the respondents opted for ophthalmology and the factors that influenced their choice. the data obtained was analyzed with spss 12.0.1 statistical soft ware. results: there were eighty respondents comprising of 33 (41.25%) consulants, 2 (2.5%) diplomats and 45 (56.25%) resident doctors. about a third of the respondents, 26 (32.5%) opted for ophthalmology after their one year youth service. the factors that influenced their choice of specialty were mainly interest in the specialty, 68 (85%), opportunity to combine medicine and surgery, 27 (33.8%) as well as life style, 34 (42.5%). conclusion: interest in the specialty was the leading factor that influenced choice of ophthalmology. areer is an individual’s course or progress through life. it is considered to pertain to remunerative work (and sometimes formal education). a career is traditionally seen as a course of successive situation that make up a person’s work life. medical profession is one of the most highly rated professions in nigeria. the profession is regarded as a noble profession, thus medical doctors tend to command a lot of respect in the society. the desire to help people and the intellectual challenge of the profession have been reported to be important motivating factors underlying the wish to study medicine1-3. medical training in nigeria lasts a period of six years and an additional one year for internship. there is an increasing trend towards specialization in nigeria as more doctors now enroll in the residency programme due to the relative improvement in the working condition in the teaching hospitals in recent time. ophthalmology is a unique field that combines intellectual aspect of diagnosis and the opportunity to perform surgical procedures4. the practice of ophthalmology is one of the most satisfying in medical profession due mainly to the broad scope of ophthalmic practice. training in the field of ophthalmology in nigeria is coordinated by west african post graduate medical college and national post graduate medical college. the training lasts a period of five to six years. a number of teaching hospitals have either provisional or full accreditation to train ophthalmologists. the specialty of ophthalmology has undergone significant changes due to series of technological and therapeutic advances5. medical practitioners have a range of choices to make among the different specialties. a number of factors tend to influence the choice of area of specialization. role model influence, internship and elective experiences affect the choice of specialty6-8. studies c omolase charles oluwole et al 11 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology have also shown that financial reward influence the choice of specialty9-11. the personal circumstances of the individual and the gender also play a role in specialty choice12. it has also been reported that academic and clinical factors play an important role in career choice among medical doctors13. the career choices and views of medical doctors about their jobs and training provide insight which can assist in workforce planning14. in view of the increase in the number of medical doctors opting for ophthalmology as a career, this study was designed to determine the factors that influenced specialty choice amongst nigerian ophthalmologists. it is hoped that the findings of this study will guide policy formulators in attracting more nigerian doctors to the field of ophthalmology. the author is not aware of similar studies among ophthalmologists in nigeria in recent time. material and methods this study was conducted during the ophthalmological society of nigeria’s annual congress, between 14th and 18th september, 2008. ile-ife is a yoruba community located in south-west nigeria. a total number of eighty ophthalmologists and resident doctors were selected by simple random sampling out of the two hundred and eight that attended the conference. the respondents were interviewed with the aid of structured questionnaire by the author and three research assistants. informed consent was obtained from each of the respondents. the information obtained with the study instrument (questionnaire) included their bio-data, the time the respondents chose ophthalmology and the factors that influenced the choice of ophthalmology as a career. the data obtained with the study instrument (questionnaire) was analyzed with spss 12.0.1 statistical soft ware package. relevant policy implications were drawn from the ensuing findings. results eighty respondents participated in this study. the ages of the respondents ranged between 26 years and 58 years, with a mean age of 37.5 years and median age of 36 years. the respondents comprised of 51 males (63.75%) and 29 females (36.25%). most respondents were married, 65 (81.25%) and the remaining 15 (18.75%) were single. majority of the respondents were christains, 60 (75%) and the rest were muslims, 20 (25%). ethnicity of the respondents revealed that most of them were yorubas, 50 (62.5%), 17 (21.25%) were ibos, 3 (3.75%) were hausas and the remaining 10 (12.5%) belonged to the other ethnic groups. professional status of respondents: 33 (41.25%) were consultant ophthalmologists, 2 (2.5%) were diplomats while 45 (56.25%) were residents doctors. the time the respondents decided on the choice of ophthalmology as a specialty is detailed in table 1. it shows that about a third of the respondents 26 (32.5%) took the decision after their youth service. the factors that influenced the choice of ophthalmology are shown in table 2. it reveals that interest in the specialty was the commonest factor, 68(85%). the other factors included opportunity to combine medicine and surgery, 35 (43.8%) as well as lifestyle, 34 (42.5%). discussion the age range of the respondents is in tandem with an active workforce that they belong to and this will come in handy in the quest for actualization of vision 2020. the involvement of consultant ophthalmologists and resident doctors in this study will help in reducing cadre related bias to the barest minimum. it is interesting to note that most of the respondents opted for ophthalmology after their qualification as medical practitioners. this finding is however expected as one is likely to make an informed decision about specialty choice after the person must have passed through all the areas of specialization. this finding is however at variance with that of odusanya et al in lagos,nigeria in which 82.9% of the house officers interviewed had taken a decision on their area of specilalization.15 the finding of this study also differs from that of noble in canada in which about 55% of the study population stated that they made the decision to pursue their career in ophthalmology during their training in the medical school16. medical doctors in nigeria are usually exposed to two to four weeks posting in ophthalmology during their medical training. however not all the training centers for house officers, mandate doctors to rotate through ophthalmology during their training. in order to actualize the efforts at encouraging more doctors to become ophthalmologists there is need for all training centers to introduce compulsory rotation in ophthalmology for a period of two weeks for house officers during their training. this measure will also factors influencing choice of specialty amongst nigerian ophthalmologists pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 12 expose the young doctors to more intense training in the field of ophthalmology and this will empower them to provide qualitative primary eye care to a reasonable extent in their practice. such group of doctors will also be an asset in actualization of vision 2020. table 1: time respondents opted for career in ophthalmology time frequency n (%) pre-medical training 2 (2.5) during medical training 22 (27.5) internship 14 (17.5) youth service 16 (20) post youth service 26 (32.5) total 80 (100) table 2: factors that influenced choice of ophthalmology factor frequency n (%) interest 68 (85) opportunity combine medicine and surgery 35 (43.8) life style 34 (42.5) domestic circumstances 27 (33.8) prospect of promotion 23 (28.8) self appraisal of own abilities 23 (28.8) employment opportunity 22 (27.5) role model 22 (27.5) private practice opportunity 19.23.8) structure of training 14 (17.5) family influence 12 (15) prestige 11 (13.8) rotation in ophthalmology 10 (12.5) financial reward 10 (12.5) interest in the specialty was the leading factor that influenced the respondents’ decision to study ophthalmology in this study. this is an important factor, as it will sustain their desire to keep up the practice. this finding is consistent with that of two other nigerian studies by odusanya et al15 and bojuwoye et al17 though not amongst ophthalmologists in which interest in specialty was the leading factor that influenced the career choice of their respondents. the finding of this study is also in keeping with that of studies done in pakistan18 and taiwan19 in which personal interest was the most important factor influencing choice of specialty. however a similar study done in canada by noble revealed that intellectual stimulation was the most cited factor that influenced specialty choice among ophthalmologists (81%)16. another canadian study by noble et al among ophthalmology residents revealed that having the opportunity to combine medicine and surgery was the most important factor that influenced the decision to pursue ophthalmology (98%)5. this factor was however cited by 43.8% of the respondents of this study. it is understandable that life style consideration played a significant role in opting to pursue career in ophthalmology as the specialty is less physically demanding than the core clinical specialties like general surgery. the relatively few females among the respondents may contribute to domestic responsibilities not been a leading factor that influenced the choice of ophthalmology. conclusion the factors that influenced the choice of ophthalmology amongst the respondents were mainly interest in the specialty, opportunity to combine medicine and surgery as well as lifestyle consideration. most respondents opted to pursue their career in ophthalmology after their qualification as medical doctors. author’s affiliation omolase charles oluwole department of ophthalmology federal medical centre p.m.b 1053, owo ondo state, nigeria omolase charles oluwole et al 13 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology reference 1. hyppola h, kumusalo e, neittaanmaki l, et al. becoming doctorwas it the wrong career choice? soc sci med 1998; 47: 1383-7. 2. todisco j, hayes s, farnill d. career motivation of male and female medical students. psychological reports. 1995; 77: 11992002. 3. vaglum p, wiers – jenssens j, ekeberg o. motivation for medical school: the relationship to gender and specialty preferences in a nation wide sample. med educ. 1999; 33: 236-42. 4. american academy of ophthalmology. about ophthalmology and eye mds. available: http:// www.aao.org/about/ mds.cfm (accessed on 28th october, 2008). 5. noble j, schendel s, daniel s, et al. motivations and future trends: a survey of canadian ophthalmology residents. can j ophthalmol. 2007; 42: 821-5. 6. erzurum vz, obermeyer rj, fecher a, et al. what influences medical students’ choice of surgical careers. surgery 2000; 128: 253-6. 7. grifftith 3rd ch, georgesen jc, wilson jf. specialty choices of students who actually have choices: the influence of excellent clinical teachers. acad med. 2000; 75: 278-82. 8. xug hojat m, brigham tp,veloski jj. factors associated with changing levels of interest in primary care during medical school. acad med. 1999; 33: 489-92. 9. thomton j, epsoto f. how important are economic factors in choice of medical specialty? health econ. 2003; 12: 67-73. 10. gagne r, leger pt. determinants of physicians decisions to specialize. health econ. 2005; 14: 721-35. 11. baerlocher mo. how do we choose our specialty? cmaj 2006; 174: 757. 12. batenburg v, smal ja, lodder a, et al. are professional attitudes related to gender and medical specialty. med educ. 1999; 33: 489-92. 13. dale a, newton md. trends in career choice by us medical school graduates. jama. 2003; 290: 1179-82. 14. trevor wl, michael jg, anthony jb. career choices for ophthalmology made by newly qualified doctors in united kingdom, 1974-2005. bmc ophthalmol. 2008; 8:3. 15. odusanya oo, nwawolo cc. career aspiration of house officers in lagos, nigeria. med educ. 2001; 35: 482-7. 16. noble j. factors influencing career choice in ophthalmology. can j ophthalmol. 2006; 41: 596-9. 17. bojuwoye bj, araoye mo, katibi ia. factors influencing career specialty choice among medical practitioners in kwara state, nigeria. the nigerian post graduate medical journal. 1998; 5: 118-21. 18. huda n, yousuf s. career preferences of final year medical students of ziauddin medical university. educ health (abingdon). 2006; 19: 345-53. 19. chang py, hung cy, wang ki, et al. factors influencing medical students’ choice of specialty. j formos med assoc. 2006; 105: 489-96. microsoft word 4. kashif jahangir pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 69 original article pre-operative screening of patients for hepatitis b and c virus kashif jahangir, hizb-ur-rahman, hamid mahmood pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: kashif jahangir department of ophthalmology fatima jinnah medical college sir ganga ram hospital lahore …..……………………….. purpose: to screen hepatitis b and c among patients and to establish policies to avoid hepatitis spread in an almost fully preventable setting. material and methods: this was a prospective observational study. a total of 543 patients admitted in eye ward were screened for hepatitis b and c, by immunochromatographic (ict) method. the study was conducted from august 2010 to october 2011. results: out of the total of 543 patients admitted in eye ward 255 of them were male and 288 were female. a total of 145 (27%) patients were found to be hepatitis c (hcv) positive and 11 (2.02%) were hepatitis b virus (hbs) positive. conclusion: such a high percentage of hepatitis c positive patients is alarming not only for patients but for health workers dealing with such patients. proper sterilization protocols should be implemented, and followed that would help in prevention of spread of the disease. iral hepatitis (hbv & hcv) is one of the single most important cause of chronic liver disease in pakistan and world wide1-2. it is estimated that it hcv causes infection in about 170 to 200 million people worldwide3,4. the hepatitis b virus (hbv) was first isolated in 19635. it has infected over two billion individuals worldwide. more than 520,000 die each year from hbv related acute and chronic liver disease6. the hepatitis b surface antigen (hbs ag), a serological marker for hbv was first demonstrated by blumberg in 19637. screening for hepatitis b and c is not routinely carried out in majority of hospitals in pakistan. precautions against hepatitis b and c are taken only when a known positive case is being treated or operated. surgeons, anesthetics, theater staff, nurses and other health care workers have significantly increased risks of infectivity along with further transmission of the disease, if preoperative screening and standard precautions are not followed strictly, this makes the preoperative screening for hepatitis b & c one of the most important investigations, so that standard precautions are taken to avoid further hazards of disease. material and methods the aim of this study was to screen for hepatitis b and c among patients admitted in department of ophthalmology, sir ganga ram hospital, lahore. this was a prospective observational study. 543 patients admitted in eye ward were randomly screened for hepatitis b and c, by ict method. the study was conducted from august 2010 to october 2011. hepatitis bs ag and hcv screening were carried out in all patients to see the carrier status of the patients before surgery. all findings were recorded and analyzed at the end of the study. results out of the total of 543 patients admitted in eye ward 255 of them were male and 288 were female. a total of 145 (27%) patients were found to be hcv positive and 11 (2.02%) were hbs positive. out of them, 255 were males and 288 females. the frequency of hbv was 2.8% (7/255) in males and 1.4% (4/288) in females. the frequency of hcv was 26% (67/255) in males and 27% (78/288) in females, as shown in (table 1). v kashif jahangir, et al. 70 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology the frequency of hepatitis b and c (combined) was more in age group ranging between 40 – 70 years, in both sexes as shown in (table 2). table 1: total hcv +ve n(%) hbs +ve n(%) infected n(%) male 255 67 (26) 7 (2.8) 29.01 female 288 78 (27) 4 (1.4) 26.47 table 2: age no. of patients hcv +ve hbs +ve <20 15 0 0 1-30 38 8 1 31-40 57 9 1 41-50 95 28 3 51-60 142 36 4 61-70 127 38 1 >70 69 26 1 total 543 145 11 discussion in our study the incidence of hcv infection amongst patients admitted was 27% as compared to hepatitis b (2.02%). hepatitis c is more common than hepatitis b among surgical patients. there is no significant difference between male and female infection. both hepatitis b and c are highly prevalent in the age group between 40-70 years, while prevalence of hbv and hcv infections is least in the age group <30 years. there are a number of factors contributing to transmission of hepatitis b & c but contaminated needles and unscreened blood products are the major factors8. contaminated needles and surgical instruments can transmit infection even after a month of being soiled by virus9. an average risk of hcv transmission after needle stick injury is estimated to be about 1.8%10. in a study from usa parenteral drug use was reported to be the major risk factor in majority of hcv positive cases11. hepatitis b & c virus infection is transmitted mainly by blood products. surgeons, anesthetics, theater staff, nurses and other health care workers are at greater risk of acquiring this infection12. screening for hepatitis b & c is not routinely performed in most of government and public sector hospitals because of number of factors. lack of awareness, poor health education, poor test facilities and high cost of the tests are some of the major contributing factors. due to tremendous increase in surgical workload, operation theaters can be one of source of transmission of hepatitis b & c. this can be easily avoided by making the operation theater staff alert, by preoperative screening of hepatitis b& c, so that proper standard precautions can be taken13. the isolation of hepatitis b virus14 and c virus15 from tear fluid and aqueous humor raises the possibility of transfer of hepatitis c virus during the course of an ophthalmologic examination, that is, goldmann tonometry and trial contact lens fitting. certain studies have discovered that the concentration of hepatitis c virus in human tear fluid is independent of the severity of hepatitis infection. other studies have reported that hepatitis c virus rna is found in higher concentrations in tear fluid compared with plasma16. blood or other body fluids from patients who are hcv positive splashing into the face and eyes is a risk for spread of hepatitis c virus17. conclusion hepatitis c should be a concern to public health authorities, and primary, secondary and tertiary prevention activities should be implemented and monitored, with precise targets set to be reached. it is a significant occupational hazard to all health care professionals especially surgeons, anesthetics and operation room assistant. author’s affiliation dr. kashif jahangir senior registrar department of ophthalmology fatima jinnah medical college sir ganga ram hospital lahore dr. hizb-ur-rahman trainee registrar department of ophthalmology fatima jinnah medical college sir ganga ram hospital lahore pre-operative screening of patients for hepatitis b and c virus pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 71 prof. dr. hamid mahmood head department of ophthalmology fatima jinnah medical college sir ganga ram hospital lahore reference 1. lavanchy d. the global burden of hepatitis c. liver international 2009; 29: 74-81. 2. ali sa,donahue rm,qureshi h, et al. hepatitis b and hepatitis c in pakistan: prevalence and risk factors. int j infect dis. 2009; 13: 9-19. 3. keck zy, li sh, xia j, et al. mutations in hepatitis c virus e2 located outside the cd81 binding sites lead to escape from broadly neutralizing antibodies but compromise virus infectivity. j virol.2009; 83: 6149-60. 4. yu my, bartosch b, zhang p, et al. neutralizing antibodies to hepatitis c virus (hcv) in immune globulins derived from anti-hcv-positive plasma. proc natlacadsci. 2004; 101: 770510. 5. cusheri a. acute and chronic hepatitis. in: cusheri a, steele jc, moosa ar. eds. essential’s surgical practice. 5th edition. oxford university press. 2002; 334-5. 6. easl easl jury. easl international consensus conference on hepatitis b. 13-14 september, 2002: geneva, switzerland. consensus statement (short version). j hepatol. 2003; 38: 53340. 7. blumberg bs. australia antigen and the biology of hepatitis b. science. 1977; 197: 17-25. 8. padilla fjb, elizondo gv, todd av, et al. gonzalez e g, gonzelez j a g, garza h j m. hepatitis c virus infection in health-care settings: medical and ethical implications. annals of hepatology. 2010; 9: 132-40. 9. yousaf a, mahmood a, ishaq. m. can we afford to operate on patients without hbs ag screening? j coll physicians surg pak. 1996; 9: 98-100. 10. satyanarayana r, melman ml. liver diseases, viral hepatitis. the washington manual of medical therapeutics 30th ed. lippincott williams and wilkins, usa. 2001; 380-1. 11. alter mj, kruszon md, nainan ov, et al. the prevalence of hepatitis c virus infection in the united states, 1988 through 1994. n engl j med. 1999; 341: 556-62. 12. puro v, lo presti e, d ascanio i, et al. the sero-prevalence of hiv, hbv and hcv infections in patients coming to the departments of general surgery of a public hospital. minerva chir. 1993; 15: 349-54. 13. haider mz, ahmed n, yasrab m, et al. screening for hepatitis b and c: a pre-requisite for all invasive procedures. professional med j. 2006; 13: 460-3. 14. su cs, bowden s, fong lp, et al. detection of hepatitis b virus in tears by polymerase chain reaction. arch ophthalmol. 1994; 112: 621–5. 15. feucht hh, polywka s, kollner b, et al. greater amount of hcv-rna in tears compared to blood. microbiolimmuno. 1994; 38: 157–8. 16. segal wa, pirnazar jr, arens m, et al. disinfection of goldmann tonometer after contamination with hepatitis c virus. am j ophthalmol. 2001; 131: 184-7. 17. hosoglu s, celen mk, akalin s, et al. transmission of hepatitis c by blood splash into conjunctiva in a nurse. am j infect control. 2003; 31: 502-4 227 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology original article screening of common eye problems in children by school teachers and community health workers ghulam hussain asif, ahla fatima, tahir mehmood sabir pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ghulam hussain asif consultant ophthalmologist head of eye department, dhq hospital, vehari email: drasif9@hotmail.com …..……………………….. purpose: to detect the refractive error, amblyopia, trachoma and squint in the school and non-school going children between the age of 3 to 16 years. design: cross sectional study. place and duration of study: dhq hospital vehari and duration of study was one year, march 2015 till feb 2016. material and methods: there were 33 villages of district vehari selected for this study. in the pilot phase, three villages were recruited. two primary schools (one female and one male) from each village were included. one teacher from each school, one community health worker and one community-based organization members were trained to detect visual deficit, squint, and red eye. eye examination kit consisting of vision chart, three-meter rope, first aid material for eye, was provided. the screening was carried out at the community and the affected children were referred for further examination to dhq hospital vehari. results: a total of 11086 (88.3%) children with age range from 3 years to 16 years (mean 9.5 years) were screened by the teachers and the community health workers. out of these screened children brought to our hospital 90% had positive findings like, refractive error, squint, amblyopia, trachoma and other ocular abnormalities. conclusion: primary school teachers and the community-based organizations are very helpful in recognizing and solving the eye problems in younger age groups in remote areas. key words: ccehp (community children eye health program), refractive error, school eye health. ision plays an important role in development of physiological and intellectual development in the life of a child. visual impairment in children is a worldwide problem and one of the major causes of significant morbidity. many of the causes are either preventable or treatable. it is estimated that globally there are 1.5 million children who are blind, and among these one million live in asia, 0.3 million live in africa, 0.1 million in latin america and 0.1 million live in the rest of the world. avoidable blindness amongst these is 39 – 72% while 9 – 58% is preventable and 14 – 31% is treatable. children with visual impairment need urgent attention as a delay can cause amblyopia1. prevalence of childhood blindness varies from 1.2/1000 in poor countries to 0.3/1000 in effluent countries of the world. it is also estimated that 8 new children are added per 100,000 children each year in developed countries and this number might be higher in underdeveloped countries2. the available data suggest that there may be a tenfold difference in prevalence between the wealthiest countries of the world and the poorest, v mailto:drasif9@hotmail.com screening of common eye problems in children by school teachers and community health workers pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 228 ranging from as low as 0.1/1000 children aged 0 – 15 years in the wealthiest countries to 1.1/1000 children in the poorest3. actual number of blind children are much smaller than the number of adults blind, e.g., from cataract but the number of years lived with blindness by blind children is almost the same as the total number of “blind years” due to age-related cataract. this high number of blind years due to childhood blindness is one of the reasons why the control of childhood blindness is a priority of the who/iapb vision 2020, the right to sight programme.4 often the children don’t complain of their poor vision and adjust themselves according to the circumstances, sit on front desk, squeeze eyes to see black board, bring printed matter close to eyes to read. sometimes they avoid work which needs concentration and are detained from school due to poor performance. effective methods of vision screening in school children are useful in detecting correctable causes of decreased vision, like refractive errors and in minimizing long-term visual disability5. eye screening in children is an initial examination which when positive, needs referral to ophthalmologist for examination and treatment6. this will lead to early detection and prompt treatment to prevent morbidity/disability. this will change behavior of child, improve learning capability, adjustment at school and have quality of life benefits7. visual impairment in children is a worldwide problem and refractive error is the major contributor which causes significant morbidity. dandona et al estimated that 12.3% total blindness was due to uncorrected refractive errors, which is also responsible for a large number of blind years lived by a person than most other causes if left uncorrected8. in one study it was estimated that blindness due to refractive errors resulted on an average of 30 years of blindness for each person as compared with 5 years of blindness due to untreated cataract for each person9. material and methods there were 12554 children of 33 communities of district vehari, between the ages of 3 to 16 years. out of these children school going were 7978 (63.54%) and non-school going were 4576 (36.45%) of both gender. all these children using or not using glasses were included in the study. patients of age 17 years and above and all those who did not want to participate were excluded from the study. there were 62 teachers, 26 community health workers (chws), 13 community-based organizers (cbos), 10 care givers of 33 communities trained by the consultant ophthalmologist, one focal person from the partners, 2 technicians, one wmo, one refractionist and one consultant ophthalmologist of secondary care hospital who took part in this study. the duration of this study was one year. mou was signed between the partners (that is plan pakistan sponsoring partner, rasti the implementing partner, the education department and the eye department dhq hospital vehari, the working partners), after signing the mou, education department provided the list of the teachers of primary schools. one teacher each from boys and girls schools was selected for training. working plan of these 33 communities was made in four clusters and the teachers, community health workers and the community-based organization member in groups of 25 to 30 were trained at the hospital by the consultant. they were provided with technical knowledge about primary eye care (pec), with the help of charts and audio visual aids, vision testing, disease detection and referral of affected children on performa. pec material kits were given to them which contained examination tools: 1 torch, with 2 batteries, 1 vision screening card (snellen’s test type), 1 instruction card, 1 measurement rope of 3 meters. first aid material like eye pads & sticking tape, tetracycline eye ointment, primary eye care educational material (1 booklet) containing written material, a bag for keeping all this and a register for record keeping. this study was divided in two phases, a pilot and the phase ii. pilot phase was instituted in three villages. after successful completion of this phase the study was expanded to the phase ii. the master trainers examined the children and the technicians helped and supervised them. the affected children with vision less than 6/12 or having squint, ptosis, amblyopia or red eye etc. were referred to the hospital. those affected children were examined at hospital and found either affected (refractive error or diseased) or normal. the focal person provided medicines to the children and delivered glasses at the community. after the provision of glasses and medicines the consultant visited the community on prescribed date and randomly checked the children and checked the performance of the students with the glasses and found them very satisfactory. results a total of 11086 (88.3%) children with age range of 3 years to 16 years with mean age of 9.5 years were screened by the teachers and the community health ghulam hussain asif, et al 229 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology workers. there were 1468 (11.7%) children who did not participate due to some reason or the other. table 1 and fig. 1 shows number of patients according to age distribution. in the 35 years age group there were 2700 (24.36%) patients, from 6 to 10 years there were 6515 (58.77%) patients, and from 11 to 16 years there were 1854 (16.87%) patients. table 2 and fig. 2 shows the gender distribution of the total screened and affected children. among these there were 5611 males (51%) and 5475 females (49%). total of 943 (8.5%) were selected as affected. of these 457 boys (48%) and 486 girls (52%), were referred to eye department dhq hospital vehari as affected children. table 1: age distribution of patients. age in years no. of children percentage 3 – 5 2700 24.36 6 – 10 6515 58.77 11 – 16 1871 16.87 total 11086 100 fig. 1: age distribution of patients. the affected children were examined by the consultant ophthalmologist at eye department and found 97 (10%) normal. the rest of the 846 (90%) were found affected and were given either glasses or medicines for the disease. total of 439 (3.95%) were given glasses and 488 (4.40%) were diagnosed as having any disease. in this study we found amblyopia 19 (0.17%), trachoma 124 (1.11%), conjunctivitis 89 (0.80%), squint 19 (0.17%), vernal catarrah 88 (0.79%), blepharitis 13 (0.11%) and other like congenital glaucoma 2 (0.01%), cataract 6 (0.05%), ptosis 4 (0.03%), bitot spots 6 (0.05%) etc. and other cases were 122 (1.22%) as shown in table 3. table 2: gender distribution of patients. gender distribution boys girls total screened 5611 5475 11086 affected 457 486 943 true positive 416 430 846 fig. 2: gender distribution. table 4 shows the affected children in different clusters. it is seen that the percentage of affected children in each is almost same except satluj cluster where there are 17.60% affected children. fig 4 is the bar chart showing the comparison different clusters children screened by the teachers. the consultant revisited the communities on prescribed date when the children were randomly checked and 94 of the children were found having diseases which either were missed or were using medicines. the screened children referred to dhq hospital were examined by the consultant and it was found that 97 (10%) were normal, which were false negative and those found affected were 846 (90%), true positive. the sensitivity of this screening was calculated to be 90%, and specificity was 99%. screening of common eye problems in children by school teachers and community health workers pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 230 table 3: disease distribution of patients. diseases affected children percentage of referred percentage of screened refractive error 439 49.10 3.9 vernal catarrh 88 9.33 0.79 conjunctivitis 89 9.4 0.8 squint 19 2.12 0.17 trachoma 124 13.14 1.11 amblyopia 19 2.12 0.17 blepharitis 13 1.3 0.11 others 122 12.9 1.1 normal 97 10.85 0.87 table 4: distribution of patients in different clusters. boys girls total percentage sacnjhi cluster 147 123 270 28.63 caravan cluster 92 179 271 28.74 satlug cluster 111 55 166 17.60 chanan cluster 107 129 236 25.03 table 5: table 5 shows the overall picture of the study. total screened males females referred males females normal actual affected glasses diseased revisit 12554 11086 5611 5475 943 457 486 97 846 439 488 94 fig. 3: disease distribution. fig. 4: distribution according to clusters. ghulam hussain asif, et al 231 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology fig. 5: sensitivity and specificity of screening. table 6: total percentage true positive 846 90 false positive 97 10 discussion we selected the communities of remote areas for screening the common eye problems by the teachers, community health workers, community-based organization members and care givers as they were of same locality who could approach the children and educate the parents about the refractive error, squint, trachoma, red eye etc. also, they were much influential and helpful in communication and transportation of children to and from the hospital for checkup and follow-up. the basic knowledge provided to them could be applied for the longer period so that such program could have been made sustainable. our study was both community and hospital oriented. the screened children labeled as affected were brought to hospital. that is why our results are comparable to any study. we found ocular morbidity of 7.6% which is quite comparable to the reports by arif and qamar 8.99%10 and haq nawaz during health screening in primary school children 4.38%11. khalil reported high prevalence 22.23% in school going children of distt. lasbella12. haseeb from karachi reported 10.9% morbidity in school going children ever checked during ophthalmic examination13. shoba misra noted 14.8% in urban primary school of south india14, and wedner sh et al 15.6% in rural area tanzania15. we found that amblyopia was 0.17% which is very close to the study by wedner sh et al: from tanzania which was 0.2% and strabismus was 0.2%15. a female preponderance was noted and we found 52% to be females and 48% males which is contrary to khyber teaching hospital and spenser eye hospital16. our study showed that 96% children had normal vision. it might be possible that some children having visual acuity of 6/6, having astigmatism may have been missed. a study by ugochuchcukwu on vision survey in primary school in south eastern nigeria showed 96.5% vision of 6/9 or better17. refractive error is a significant cause of visual morbidity worldwide.18 similarly the most prevalent condition we noted in our study was refractive error 3.9% while who studies show its prevalence to be 2 – 10%15 (which is quite in the range). the study by sethi et al “pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital” shows higher value of 12.8%16 of refractive errors and uzma fasih et al found a frequency of 8.11%19 and 8.9% was found in school children in a study by haseeb alam at hamdard university karachi20. the second most common condition was vernal catarrh 63 cases (0.63%) which is a condition quite common in our climate. sethi et al noted it as 35.6% which is higher as it may be in the patient presenting with the disease to a clinic at the hospital16 and uzma fasih repoted it to be 9.72%19. however study by kehinde et al is 4.5% which does not match with our study21 and is quite according to weather in nigeria. this is one of the most common surface disorders in agrarian labor communities and rural living is more prone to chronicity. the symptoms can be controlled/ alleviated from potentially blinding complications and absenteeism can be prevented. trachoma is the disease of poor countries but now endemic in australia which is a high income country. our study revealed a frequency of 1.11% which is quite less in number than a study by uzma fasih which is 20% and qureshi et al which is 48.98%. this may be due to different area of study with poor sanitation. trachoma is endemic in different parts of pakistan and it is 96.6% more prevalent in female children22. however, a study noted that less than half the ophthalmologists serving the affected areas were aware of the who grading system or the primary health care measures for trachoma23. conclusion primary school teachers, community health workers and community-based members are very helpful in screening of common eye problems in children by school teachers and community health workers pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 232 screening common eye problems in children at community level. acknowledgement we are grateful to plan and rasti pakistan for helping in conducting this study. authors affiliation dr. ghulam hussain asif mbbs, doms, fcps, consultant ophthalmologist head of eye department, dhq hospital, vehari dr. ahla fatima mbbs, wmo, eye department, dhq hospital, vehari dr. tahir mehmood sabir b.sc. optometry and ophthalmic technology refractionist, eye department, dhq hospital, vehari role of authors dr. ghulam hussain asif making strategy, planning, implementing, training of teachers, checking the work being done, examining the referred children and visiting the communities. checking and compiling the data. dr ahla fatima helped in vision testing, disease detection and delivering short lecture to class about “safe” for trachoma. dr. tahir mehmood sabir helped in doing refractions. references 1. steinkuller pg, du l, gilbert c, foster a, collins ml, coats dk. childhood blindness. j aapos. 1999 feb; 3 (1): 26-32. 2. gilbert c. new issues in childhood blindness. j comm eye health, 2001; 14 (40): 53-56. 3. gilbert ce, anderton l, dandona l, foster a. prevalence of visual impairment in children: a review of available data. ophthalmic epidemiol. 1999; 6: 73–8. 4. gilbert c, foster a. childhood blindness in the context of vision 2020 the right to sight. bulletin of who. 2001; 79: 227–232. 5 gupta m, gupta bp, chauhan a, bhardwaj a. ocular morbidity prevalence among school children in shimla, himachal, north india. indian j ophthalmol. 2009 marapr; 57 (2): 133–138. 6. perks k. screening for disease. in: perks k, editor. textbook of preventive and social medicine. 19th ed. barnasides: bhuanot co. 2007: pp. 115–116. 7. american association of pediatric ophthalmology and strabismus, and the american academy of ophthalmology 2003. author policy statement: eye examination in infants, children and young adults by pediatricians. pediatrics, 2003; 111: 902–907. 8. dandona l, dandona r. what is the global burden of visual impairment? bmc medicine, 2006; 4: 6, available at http:/www.biomedcentral.com/1741-7015/4/6 9. adegbehingbe bo, adeoye ao, onakpoya oh. refractive errors in children. nigerian journal of surgical science, 2005; 15: 19–25. 10. arif m, mehboob q. visual screening; government, private and community school going children in faisalabad. professional med j. 2014; 21 (6): 112-116. 11. haq nawaz anwar, muhammad iqbal zafar, shafqat hussain. health screening of primary school childrena case study of district sargodha-pakistan pak. j. life soc. sci. 2006;, 4 (1-2): 40-47. 12. khalil a. lakho, m. zahid jadoon, p.s. mahar. pattern of ocular problems in school going children of district lasbela, balochistan, pak j ophthalmol. 28 (4), oct – dec. 2012. 13. haseeb a, irfanullah s, imtiaz a j, abdul s, ishtiaq a, jafar. prevalence of refractive error in school children of karachi, jpma. june 2008; 58: 322325. 14. shobha misra, r. k. baxi, j. r. damor, nirav b prajapati, ravija patel; prevalence of visual morbidity in urban primary school children in western india, innovative journal of medical and health science. 3 july – august, 2013; 4: 193–196. 15. wedner sh, ross da, balire r, kaji l, foster a. prevalence of eye diseases in primary school children in a rural area of tanzania. br j ophthalmol. 2000; 84: 1291-7. 16. sethi s, sethi jm, saeed n, kundi kn. pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital. pak j ophthalmol. 2008; 24: 166-70. 17. ugochukwu co. survey of eye health status of primary school children in nkanu west local government area of enugu state of nigeria. dissertation for the award of a fellowship of the national postgraduate medical college in ophthalmology. 2002: 39–42. 18. opubiri i, pedro-egbe c n. screen in of primary school children for refractive error in south-south nigeria. ethiop j health sci. 2012 jul. 22 (2): 129-134. 19. fasih u, rahman a, shaikh a , fahmi m s, rais m. pattern of common paediatric diseases at spencer eye hospital, pak j ophthalmol 2014, vol. 30 no. 1 20. alam h et al. prevalence of refractive error in school children of karachi. j pak med assoc. june 2008; vol. 58, no. 6: 322-5. 21 kehinde av, ogwurike sc, enuchalu uv, pam v, samaila e. school eye health screening in kaduna http://www.ncbi.nlm.nih.gov/pubmed?term=steinkuller%20pg%5bauthor%5d&cauthor=true&cauthor_uid=10071898 http://www.ncbi.nlm.nih.gov/pubmed?term=du%20l%5bauthor%5d&cauthor=true&cauthor_uid=10071898 http://www.ncbi.nlm.nih.gov/pubmed?term=gilbert%20c%5bauthor%5d&cauthor=true&cauthor_uid=10071898 http://www.ncbi.nlm.nih.gov/pubmed?term=foster%20a%5bauthor%5d&cauthor=true&cauthor_uid=10071898 http://www.ncbi.nlm.nih.gov/pubmed?term=collins%20ml%5bauthor%5d&cauthor=true&cauthor_uid=10071898 http://www.ncbi.nlm.nih.gov/pubmed?term=coats%20dk%5bauthor%5d&cauthor=true&cauthor_uid=10071898 http://www.ncbi.nlm.nih.gov/pubmed/10071898 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2684438/ ghulam hussain asif, et al 233 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology northern nigeria. nigerian journal of surgical research, 2005; vol. 7, no .1-2: 191-94. 22. qureshi mh, siddiqui js, pechuho am, shaikh d, shaikh aq. prevalence of trachoma in upper sindh. pak j ophthalmol. 2010; 26: 118-21. 23. qureshi mb, khan md, khan ma. current status of trachoma in pakistan. pakistan j ophthalmol. 1998; 14: 165-171. pubmed http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=pakistan%20j%20ophthalmol%5bjour%5d+and+14%5bvolume%5d+and+165%5bpage%5d 204 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology original article prevalence of diabetic retinopathy among type – 2 diabetes patients in pakistan – vision registry mehreen sohail pak j ophthalmol 2014, vol. 30 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mehreen sohail 367, k, phase v dha, lahore email: mehreen61@gmail.com …..……………………….. purpose: to estimate the prevalence of diabetic retinopathy (dr) among patients with type 2 diabetes mellitus (t2dm) in pakistan. material and methods: this is a cross-sectional study carried out in 25 centers across pakistan between july 2009 to may 2010. each centre recruited 9 consecutive patients meeting the eligibility criteria of age ≥ 18 years with known t2dm for ≥ 3 years and willing to provide written consent. direct ophthalamoscopy to determine dr and blood tests for random blood sugar (rbs) and hba1c levels, were conducted. descriptive statistics (frequency, proportion, and mean) were used to analyze the data. results: of the 223 patients recruited, analysis was based on data gathered from 202 patients. the mean age of the patients was 52.9 ± 10.5 years, and their average rbs and hba1c levels were 219.2 ± 82.4 mg/dl and 8.9 ± 2.5%, respectively. mean duration of diabetes was 8.8 ± 5.1 years. over three-fourths (77.2%) of the patients had never been assessed for dr. the prevalence of dr was calculated at 56.9% (confidence interval: 50.1 – 63.3%). factors associated with dr were systolic blood pressure (p = 0.009), diastolic blood pressure (p = 0.001) and duration of diabetes (p = 0.04). conclusions: the prevalence of dr in pakistan is substantially high. regular screening needs to be implemented for early diagnosis of dr. key words: diabetic retinopathy, prevalence, type 2 diabetes mellitus. iabetes mellitus is a non-communicable medical disorder characterized by hyperglycaemia due to defective insulin secretion and is currently amongst the top ten causes of worldwide mortality.1 the incidence of diabetes is on the rise, especially in developing nations like india and china,2,3 and the estimated global burden for the year 2030 is 439 million people.2 pakistan currently ranks sixth amongst countries with the highest number of diabetes patients, and more than 11% of pakistani adults have diabetes.4 it is predicted that by 2030, pakistan will rise to the 5th position with 13.9 million diabetic patients.5 chronic hyperglycaemia in diabetes leads to various macrovascular (coronary heart disease, peripheral vascular disease, and stroke) and microvascular (retinopathy, neuropathy, and nephropathy) complications.6 given the observation that diabetes in most patients is diagnosed late, these microand macrovascular complications are already present in the patients at the time of diagnosis, and the frequency of their coexistence increases with the duration of diabetes.7 diabetic retinopathy (dr) is the leading cause of visual impairment in adults worldwide8. in dr, the blood vessels in the eye become swollen and leaky and new abnormal vessels form on the retina. eventually, dr causes irreversible blindness9. according to the american diabetes association (ada), 21% of patients with diabetes have dr at diagnosis10 and d prevalence of diabetic retinopathy among type-2 diabetes patients in pakistan-vision registry pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 205 more than 60% of patients with diabetes will have dr within two decades of diagnosis.11 a recent metaanalysis of 35 population-based prevalence studies carried out in the us, europe, australia and asia over a period of 28 years with data from 22,896 diabetes patients, revealed that the overall prevalence of dr is as high as 34.6% and more than 10% of the diabetes patients have vision – threatening dr.12 the findings of the two major diabetes trials, the diabetes control and complications trial 13 and the united kingdom prospective diabetes study,14 have established the importance of tight glycaemic control (target hba1c levels under 7%) in reducing the risk of microvascular complications. this is especially beneficial in the early stages of dr and nephropathy. however, a vast majority of patients who develop dr do not display any symptoms till late stage. since, early detection can prove beneficial in symptomatic amelioration and slowing the progression of dr, it is important to screen patients with diabetes for retinal disease on a regular basis15. according to ada guidelines, ophthalmic examination should be conducted at the time of diabetes diagnosis16, and repeated annually unless it is the ophthalmologist’s clinical judgment to have the exam every 2 – 3 years.17 in pakistan, there is insufficient data on the national prevalence and management of dr. a few community or hospital or region-based studies have been conducted, but the reported dr prevalence rates vary widely (15% – 33.3%).18-22 it is also estimated that only about 33% to 44% of the patients with diabetes in pakistan have accurate knowledge of their disease and its complications.4,23 cross-sectional studies play a vital role in determining the extent of the disease prevalence and can aid in implementation of effective strategies for early diagnosis, management, and patient education / awareness. accordingly, we present the findings of the prevalence of diabetic retinopathy amongst type – 2 diabetic population in pakistan (vision) registry that was designed to assess the prevalence of dr among diabetes patients in pakistan and the association between dr and glycaemic control. material and methods the vision registry was a national, multicentre, noninterventional, cross-sectional registry. it was designed to primarily estimate the prevalence of dr amongst patients with type 2 diabetes in pakistan. the secondary objectives of this study were to 1) determine the distribution of dr across hba1c levels; 2) document patient profile of all patients willing to participate; and 3) document other diabetic complications based on clinical signs and symptoms and / or historical evidence. the study was conducted in 25 randomly selected centres from 9 cities across 4 provinces in pakistan. the study was conducted in accordance with the principles laid by the 18th world medical assembly, the guidelines of good epidemiology practice and all local laws and regulations. written informed consent was obtained by the investigator from each patient enrolled in the study. study investigators were selected from a list of qualified general practitioners. each centre was supported by services of qualified ophthalmologists. each investigator recruited 9 consecutive patients who met the inclusion / exclusion criteria. patients enrolled were of either gender, aged ≥ 18 years with type 2 diabetes for ≥ 3 years, provided an informed consent, and were willing to undergo ophthalmoscopic examination. patients with known ophthalmic disorders other than dr were excluded. on a scheduled day in the general practitioner’s clinic, study patients were examined for evidence of dr by nine ophthalmologists. fundoscopic examinations were conducted on dilated pupils using a direct ophthalmoscope (welch allyn inc, skaneateles falls, ny, usa). random blood sugar (rbs) levels were measured using onetouch® blood glucose meter (life scan inc., a johnson & johnson company, milpitas, ca). diabetic neuropathy was determined by 10-g semmes-weinstein monofilament examination. additionally, 2 consecutive seated blood pressure readings were recorded at 3 minutes interval. patients also underwent the hba1c test by ngsp certified hba1c machine at a central laboratory (the aga khan university hospital, karachi). patient data was recorded on case report forms and included details on general and lifestyle information, diabetic history, rbs and hba1c levels, blood pressure, anthropometric measurements, ophthalmoscopic and microfilament findings and history of nephropathy, if present. patients with dr findings were referred to specialized eye care centres for further consultation. given a reported prevalence of 26% of dr amongst a dm prevalence of 11% in pakistan24, 225 patients were planned to be recruited to give the study a precision of ± 6% at 95% confidence interval (ci) mehreen sohail 206 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology after accounting for incomplete forms, withdrawal after consent, etc. being a descriptive cross-sectional study, categorical variables are reported as proportions and percentages while continuous variables are reported as mean with standard deviation (sd). results of the 223 patients recruited, analysis was based on data gathered from 202 patients. the average age of patients evaluated was 52.9 ± 10.5 years (table 1). there were more men (53.5%) than women (46.0%) enrolled. average body mass index (bmi) was 28.6 ± 8.9 and the mean duration of diabetes in the patients was 8.8 ± 5.1 years. the average blood pressure was 133.5 ± 17.4 mm hg systolic and 86.1 ± 9.6 mm hg diastolic. mean rbs was 219.2 ± 82.4 mg/dl while average hba1c was 8.9 ± 2.5%. the most commonly observed risk factor was hypertension, reported in 125 (61.9%) patients, followed by sedentary lifestyle, reported in 90 (44.6%) patients (table 1). other risk factors reported in more than 20% of the patients included metabolic syndrome, past smoking, and family history of cardiovascular disorders. over three-fourths of the patients (n=163, 80.7%) were on oral antidiabetic (oad) therapy (table 1). the drug classes of choice were biguanide (76.7%) and sulphonylurea (74.8%). only about one-third of the patients (35.6%) were on a single oad agent while half the number of patients (50.0%) were on 2 oads. insulin monotherapy was reported in 4 (1.9%) patients while insulin in combination with oad had been prescribed to 29 (14.4%) patients. a total of 115 patients out of 202 (56.9%, ci: 50.1%63.3%) had dr. as shown in figure 1, the most common dr findings were haemorrhages (70/202, 34.7%), hard exudates (67/202, 33.2%), cotton wool spots (21/202, 10.4%) and neovascularization (15/202, 7.4%). a substantial number of patients (n = 157, 77.7%) had never been assessed for dr prior to enrolment in the reported study. on 10-g monofilament examination, neuropathy was detected in 59.9% (121/201) patients and nephropathy was reported by 6.4% (13/202) patients. a comparison of various parameters in patients with and without dr is presented in table 2. patients with dr had a higher systolic blood pressure than patients without dr (136.4 ± 17.9 mmhg versus 129.7 ± 16.0 mmhg; p = 0.009). similarly, diastolic blood pressure in patients with dr was higher than patients without dr (88.1 ± 9.8 mmhg versus 83.5 ± 8.7 mm hg; p = 0.001). moreover, patients with dr had had dm for a longer period than those without dr (average duration 9.4 ± 5.6 versus 7.9 ± 4.2 years, p = 0.04). there was no statistically significant difference in the association of dr with other risk factors. in addition, more percentage of patients without than with dr were on oad monotherapy (34.9% versus 17.4%; p = 0.005). diabetic retinopathy was prevalent across all levels of hba1c values (figure 2). the highest prevalence of dr was in patients with hba1c levels > 10% (41/115, 35.6%). interestingly, the group with the next – highest prevalence was the one with hba1c levels < 7% where 45 (22.3%) patients had dr. discussion with a burgeoning epidemic of diabetes in south asia and the significant impact of diabetic complications on patients and the healthcare system, the vision registry aimed at estimating the prevalence of dr in pakistan. the findings of this first attempt at understanding the pervasiveness of dr nationally did reveal some very significant results. in comparison to the previously reported dr prevalence of 26% in patients with diabetes by khan et al in 1991,24 the current prevalence has doubled to 56.9%, which is substantially higher than any previously reported value worldwide12. while our study was not designed to identify the reasons for this dramatic increase, one can only speculate on subjective factors like lack of patient and physician education, glycaemic control, treatment adherence, and regular screening for dr. the latter holds especially true since we discovered that despite fig. 2: distribution of patients with diabetic retinopathy by their hba1c levels, n = 115 having diagnosed diabetes for an average duration of 8.8 ± 5.1 years, over threefourths of the patients had never been assessed for presence of dr prior to enrolment in the vision registry. since dr progression can be slowed with early detection, this finding provides impetus to include retinal screening as a routine part of diabetes management, and general practitioners need to have a baseline assessment of their diabetic patients upon diagnosis. moreover, comprehensive patient education programs on dr should be provided by the prevalence of diabetic retinopathy among type-2 diabetes patients in pakistan-vision registry pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 207 mehreen sohail 208 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology prevalence of diabetic retinopathy among type-2 diabetes patients in pakistan-vision registry pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 209 hba1c levels a/ % of patients % p a ti e n ts fig. 1: the most common diabetic retinopathy findings noted in analysed patients (n=115) 0 5 10 15 20 25 30 35 40 45 50 < 7 7.1-8.0 8.1-9.0 9.1-10.0 > 10.0 data was missing for 9 patients data was missing for 5 patients physician/ophthalmologist at the time of diagnosis of diabetes. the other major finding of the vision registry is that it revealed the association of elevated blood pressure with dr. the systolic blood pressure in patients with dr was higher than that in patients without dr (136.4 ± 17.9 mm hg versus 129.7 ± 16.0 mm hg; p=0.009). also, the diastolic blood pressure in patients with dr was higher than that in patients without dr (88.1 ± 9.8 mm hg versus 83.5 ± 8.7 mm hg; p = 0.001). we also discovered that average duration of diabetes was longer in patients with dr (9.4 ± 5.6 versus 7.9 ± 4.2 years; p=0.04) than that in patients without dr. the correlation between blood pressure and duration of diabetes with dr has been demonstrated in recent studies and our findings reiterate these.25-27 hypertension and diabetes are usually co-morbid. patients with diabetes are 1.5 – 2 times more susceptible to hypertension than patients without diabetes28 and the co-existence of diabetes and hypertension is shown to accelerate microvascular complications29. a recent study to estimate the global prevalence of dr indicated hypertension as one of the major risk factors for dr.12 in the vision registry, we observed that the most common risk factor was hypertension, reported in 61.9% patients. the proportion of patients with hypertension was almost the same in patients with or without dr (64.3% vs. 60.7%, p = 0.8) however, patients with dr were relatively inadequately controlled for blood pressure compared to those without dr as described above. better control of blood pressure in diabetic patients is likely to help impede the progression of dr. acetylated haemoglobin (hba1c) level is another major indicator of risk for dr. diabetic patients with a tight glycaemic control of hba1c < 7% have slower progress of microvascular complications while those with poor glycaemic control tend to rapidly deteriorate.12 the other major observation from the landmark diabetes control and complication trial is that even after regaining appropriate glycaemic control, a prolonged preceding hyperglycaemia does not halt the progression of dr.30 this imprinted effect of high blood glucose even after normal levels have been attained is termed as “metabolic memory” and plays an important part in the development and progression of diabetic complications, especially dr.3133 the vision registry revealed that patients with dr were present across the range of hba1c levels. mehreen sohail 210 vol. 30, no. 4, oct – dec, 2014 pakistan journal of ophthalmology expectedly, the rate of prevalence of dr (35.6%) was highest in patients whose hba1c levels were above 10%. however, the group with the next highest dr prevalence rate was the one in which the mean hba1c levels were < 7%. while this does not conform to the observations from other studies34-35 could probably be attributed to the presence of other contributing risk factors – hypertension, peripheral artery disease, etc. it may also be postulated that these patients to begin with had an elevated hba1c and also developed dr but eventually managed to have a better glycaemic control without reversal of dr changes. this suggests that early diagnosis and good glycaemic control at initial stage of diabetes sets in a good metabolic memory and hence are critical in preventing or delaying onset of dr. considering the limitation of cross sectional study it is suggested to follow the temporality of observations in such cohort of patients. nonetheless, one can advocate early detection through regular blood check-ups and achievement of tight glycaemic control for delaying the progression of dr. the other clinically significant complications of diabetes are neuropathy and nephropathy. diabetic neuropathy usually results in foot ulceration, charcot neuroarthropathy, and limb amputation;36 while diabetic nephropathy leads to chronic renal failure.37 though there is a dearth of information on the global prevalence of these complications, certain regional studies indicate that the prevalence of neuropathy is between 22% and 29% amongst the diabetics in europe,38-40 and the prevalence of nephropathy is 5.5% in india and 22.3% in asian indians in the united kingdom.41 given the seriousness of these diabetic complications it is equally necessary to monitor the prevalence of these in patients with diabetes.42 in the vision registry, a total of 6.4% of the diabetics had comorbid nephropathy. however, the prevalence of neuropathy was at a staggering 59.9%. this finding raises some critical questions on whether we are doing enough to increase awareness amongst patients and physicians, to ensure our physicians are compliant with international guidelines, to understand the gap between real-world practices and international recommendations, and to estimate the prevailing load of diabetic complications in our country. once understood, we can implement effective strategies to positively influence public health and decrease the economic burden of diabetes in pakistan. another observation from our study was the pharmacotherapy of type 2 diabetes in pakistan. more than 80% of the patients were prescribed oad, a substantial number (n = 101; 50.0%) of these being prescribed a dual therapy, usually biguanide and sulphonylurea. insulin usage was reported in a bit over 15% of the study patients. this is not entirely surprising given the ease of administration of oads. besides, most physicians and patients are hesitant to initiate insulin treatment due to the fear of injectable drug delivery, hypoglycaemia, weight gain and a “psychological insulin resistance”.43-44 traditionally, management of diabetes progresses from lifestyle management to oad to insulin.45 however, keystone studies have demonstrated that insulin therapy reduces microand macrovascular complications in diabetics.46,47 currently, a new school of thought is emerging with its premise being early insulinization to elicit long-lasting glycaemic control.45 in support, recent clinical trials have demonstrated the benefits of insulin therapy in new type 2 diabetics in terms of glycaemic control, treatment satisfaction and quality of life.48,49 the observation that over half of the patients in our study had dr but were still managed with oads warrants the need for a well-monitored, better pharmacologic management of type 2 diabetes. vision registry provides seminal insights on the burden dr in pakistan despite few limitations. being a cross-sectional study, it does not reveal the reasons for the surge in the prevalence of dr in pakistan within a span of > 20 years. this apparent surge may yet be an underestimate of the disease burden as this study was conducted in the offices of the general practitioner, who is the primary contact for majority of the population. it is also known that for every patient seeking care at the grass root level there is at least an equal number who for different reason may not seek care.50 moreover, the patients in this study were only examined for the presence of dr and not classified for a particular kind or a particular stage of dr. current statistical analysis was simple descriptive addressing study objectives. rigorous data mining may generate more hypotheses for future perusal. conclusion in conclusion, this first nationwide dr registry does indicate the gravity of the situation in pakistan and serves as a stimulus to overhaul the current diabetes management practices and implement more appropriate and contemporary initiatives. acknowledgements we duly thank all the participating physicians from: 1) lahore dr atif bashir, dr khalid mehmood, dr prevalence of diabetic retinopathy among type-2 diabetes patients in pakistan-vision registry pakistan journal of ophthalmology vol. 30, no. 4, oct – dec, 2014 211 iftikhar hussain, and dr bakhtawar ali; 2) sukkur – dr maqsood gul awan and dr rasheed kumbho; 3) hyderabad – dr muhammad irshad ahmad, dr idrees bawani, and dr aziz ur rehman; 4) gujranwala dr haji maqsood mahmood; 5) faisalabad dr khalid javed and dr wasim ahmad tariq; 6) multan dr faiz athar khan and dr muhammad safdar; 7) rawalpindi dr shehzad tahir, dr ehsan ul haque, dr tahir mehmood mirza, and dr m farooq sheikh; 8) peshawar – dr muhammad asif iqbal and dr muhammad irfan; 9) karachi – dr aslam pervaiz, dr m. shafqat mirza, dr shaukat ali, dr jabbir hussain, and dr faizullah lokhandwala. dr. amman ullah khan and dr. nabeea junaid, for conducting study design iqbal mujtaba from sanofi (pakistan) for conducting statistical analysis. satyendra shenoy and anahita gouri from sanofi (india) for providing assistance in writing this manuscript. the study was funded by sanofi pakistan limited. author’s affiliation dr. mehreen sohail consultant ophthalmologist, cavalry hospital, lahore references 1. world health organization. the top 10 causes of death.): world health organization, 2011. 2. shaw je, 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the management of type 2 diabetes: the canadian insight study. diabetes res clin pract. 2007; 78: 254-8. 50. hart jt. rule of halves: implications of increasing diagnosis and reducing dropout for future workload and prescribing costs in primary care. br j gen pract. 1992; 42: 116-9. pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 52 original article profile of pediatric cataract seen at lagos university teaching hospital, nigeria musa kareem olatunbosun, aribaba olufisayo temitayo, rotimi-samuel adekunle, ikuomenisan segan joseph, oluwoyeye abimbola olayinka, onakoya adeola olukorede pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. kareem moosa pediatric ophthalmology clinic, department of ophthalmology (guinness eye centre), lagos university teaching hospital, lagos, nigeria email: musa_kareem@yahoo.com …..……………………….. purpose: to describe the characteristics of pediatric cataracts seen at lagos university teaching hospital, lagos, nigeria. study design: retrospective descriptive study. place and duration of study: pediatric ophthalmology clinic, department of ophthalmology (guinness eye centre), lagos university teaching hospital, lagos, nigeria between january, 2012 and december, 2015. materials and methods: a retrospective review of the case files of all children below the age of 16 years, who had diagnosis of cataract was done. information retrieved from the case files included demographics, laterality, duration before presentation, family history of childhood cataract, pregnancy and delivery history, preceding history of trauma, type of cataract, ocular and systemic co-morbidities as well as serological test result for intrauterine infections (in congenital cataract). results: three hundred and thirteen eyes of 210 children with cataract were analyzed. there were 153 (72.9%) non-traumatic cataract and 57 (27.1%) traumatic cataract. the 153 non-traumatic cataract were made up of 78 (37.2%) congenital cataract, 62 (29.5%) developmental cataract as well as 13 (6.2%) complicated cataract. there were 132 (62.9%) males and 107 (50.9%) children had unilateral cataract. only 79 (37.6%) children presented within three months of the onset of symptoms. one and two children were positive for cytomegalovirus and rubella igm antibodies respectively. forty-five (78.9%) out of the 57 children with traumatic cataract sustained ocular injury while playing or being flogged either at home or school. conclusion: trauma and rubella were the main preventable causes of pediatric cataract identified in this study. late presentation was the case in the majority of the patients. keywords: pediatric cataract, lagos, nigeria, rubella. ataract is the opacification of the crystalline lens and remains one of the main causes of treatable blindness in children1. cataracts are estimated to be present in approximately 1 to 15/ 10,000 children worldwide, accounting for 5 – 20% of childhood blindness.2 recent african population based surveys (mostly using key informants) suggest that 15 – 35% of childhood blindness is due to congenital or developmental cataract3. cataract is the main cause of blindness among children in africa, replacing vitamin a deficiency and measles4. childhood cataract causes more visual disability than any other form of treatable blindness in children5. children with untreated, visually significant cataracts face challenging lifetime blindness at enormous c musa kareem olatunbosun, et al 53 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology quality of life and socioeconomic costs to the child, the family, and the society.5 unilateral cataracts associated with strabismus and bilateral cataracts associated with nystagmus are usually a reflection of the visual significance of the cataract, especially when intervention is delayed6,7. pediatric cataracts are of immense importance because they have the potential to inhibit maximal visual development, resulting in severe visual impairment and permanent blindness. hence, early diagnosis and prompt treatment of pediatric cataracts are very important to prevent the development of irreversible stimulus-deprivation amblyopia7. pediatric cataracts are both preventable and treatable. potentially preventable causes include congenital rubella syndrome, autosomal dominant disease and trauma. hence, this study was aimed at describing the characteristics of pediatric cataracts seen at the pediatric ophthalmology clinic of lagos university teaching hospital, lagos, nigeria with a view to identifying preventable causes for which awareness programs and control strategies could be recommended. materials and methods the case files of all children below the age of 16 years who had diagnosis of cataract at the pediatric ophthalmology clinic of lagos university teaching hospital, lagos, nigeria between january, 2012 and december, 2015 were retrieved and retrospectively reviewed. the information extracted from the case files included age at presentation, gender, laterality, main presenting complaint, duration before presentation, family history of childhood cataract, pregnancy and delivery history as well as preceding history of trauma. other information retrieved included, visual acuity at presentation, type of cataract (chronological, etiological and morphological), ocular co-morbidities, systemic co-morbidities and serological test result for rubella, toxoplasmosis, cytomegalovirus, herpes simplex virus, syphilis and varicella (in congenital cataract). for traumatic cataracts, type of injury, agent of injury, injury environment and injury circumstance were also extracted. chronologically, cataracts noticed within the first year of life were classified as congenital cataract while those noticed after one year of life were classified as developmental cataract. cataracts with underlying intraocular disease such as retinal detachment and uveitis were classified as complicated cataract. etiologically, pediatric cataracts were broadly classified as traumatic (preceding history of trauma) and non-traumatic. ethical approval was obtained from the health research and ethical committee of our institution. data obtained was analyzed using the statistical package for social sciences (spss) version 20 (ibm corp. armonk, ny). the associations between categorical variables were analyzed using crosstabulation and chi-square test and a p-value of less than 0.05 was considered statistically significant. fisher’s exact was used where applicable. results two hundred and ten cases of pediatric cataract were seen during the period under review.table 1 shows the demographic characteristics and laterality of the pediatric cataract seen in this study. there were 153 (72.9%) non-traumatic cataract and 57 (27.1%) traumatic cataract. the 153 non-traumatic cataract included, 78 (37.2%) congenital cataract, 62 (29.5%) developmental cataract as well as 13 (6.2%) complicated cataract. there were 132 (62.9%) males with a male: female ratio of 1.7:1 while 107 (50.9%) children had unilateral cataract. there were no statistically significant association (p = 0.92) between gender and types of cataract (table 1). altogether, 313 eyes of 210 patients were studied. the mean age at presentation was 5.6 ± 4.5 years and the median age was 5.0 years. the most common presenting complaint was whitish dot in the eye documented in 115 (54.8%). this was followed by poor vision and ocular deviation in 90 (42.9%) and 3 (1.4%) children respectively. the most common morphological type of cataract was total cataract documented in 178 (56.9%) out of 313 eyes. this was followed by lamellar, nuclear, cortical and posterior sub-capsular cataract observed in 70 (22.4%), 23 (7.3%), 14 (4.5%) and 10 (3.2%) eyes respectively. other types of morphological cataract documented were seven (2.2%) eyes each of anterior polar and membranous cataract as well as two (0.6%) each of posterior polar and anterior capsular cataract. overall, only 79 (37.6%) children presented within three months of the onset of symptoms while 131 (62.4%) children presented after three months (table 2). although, presentations were largely late, a large proportion of children with unilateral cataract presented relatively earlier than those with bilateral cataract (p = 0.00). however, gender did not have any profile of pediatric cataract seen at lagos university teaching hospital, nigeria pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 54 statistically significant influence on the duration before presentation (p = 0.47) as shown in table 3. table 1: demographics and laterality of pediatric cataract. demographics/ laterality types of pediatric cataract total n (%) pvalue traumatic n (%) congenital n (%) developmental n (%) complicated n (%) age group 0 – 3 2 (3.5) 63 (80.8) 17 (27.4) 3 (23.0) 85 (40.5) 0.00* 4 – 6 11 (19.3) 9 (11.5) 17 (27.4) 2 (15.4) 39 (18.6) 0.97 7 – 9 19 (33.3) 4 (5.1) 13 (21.0) 4 (30.8) 40 (19.0) 0.002* 10 – 12 16 (28.1) 2 (2.6) 7 (11.3) 4 (30.8) 29 (13.8) 0.001* 13 – 15 9 (15.8) 0 (0.0) 8 (12.9) 0 (0.0) 17 (8.1) 0.03* total 57 (100.0) 78 (100.0) 62 (100.0) 13 (100.0) 210 (100.0) gender female 21 (36.8) 32 (41.0) 18 (29.0) 7 (53.8) 78 (37.1) 0.92 male 36 (63.2) 46 (59.0) 44 (71.0) 6 (45.2) 132 (62.9) total 57 (100.0) 78 (100.0) 62 (100.0) 13 (100.0) 210 (100.0) laterality bilateral 0 (0.0) 54 (69.2) 45 (72.6) 4 (30.8) 103 (49.1) 0.00* unilateral left eye 26 (45.6) 9 (11.6) 11 (17.7) 3 (23.1) 49 (23.3) unilateral right eye 31 (54.4) 15 (19.2) 6 (9.7) 6 (46.1) 58 (27.6) total 57 (100.0) 78 (100.0) 62 (100.0) 13 (100.0) 210 (100.0) *statistically significant table 2: duration before presentation of pediatric cataract. duration before presentation types of pediatric cataract total n (%) p-value traumatic n (%) congenital n (%) developmental n (%) complicated n (%) within a month 15 (26.3) 17 (21.8) 5 (8.1) 1 (7.7) 38 (18.1) 0.09 > 1 month -3 months 14 (24.5) 16 (20.5) 7 (11.3) 4 (30.8) 41 (19.5) 0.35 > 3 months 6 months 9 (15.8) 9 (11.5) 4 (6.4) 1 (7.7) 23 (11.0) 0.26 > 6 months 9 months 3 (5.3) 3 (3.9) 1 (1.6) 0 (0.0) 7 (3.3) 0.39† > 9 months 1 year 7 (12.3) 7 (9.0) 13 (21.0) 2 (15.4) 29 (13.8) 0.87 > 1 year 9 (15.8) 26 (33.3) 32 (51.6) 5 (38.4) 72 (34.3) 0.001* musa kareem olatunbosun, et al 55 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology total 57 (100.0) 78 (100.0) 62 (100.0) 13 (100.0) 210 (100.0) * statistically significant, † = fisher’s exact table 3: association between gender, laterality and duration before presentation. duration before presentation total (210) p value within six months (n = 101) after six months (n = 109) gender female 35 (44.9%) 43 (55.1%) 78 (100%) 0.47 male 66 (50.0%) 66 (50.0%) 132 (100%) laterality bilateral 36 (35.0%) 67 (65.0%) 103 (100%) unilateral 65 (60.7%) 42 (39.3%) 107 (100%) 0.00 out of the 313 eyes with pediatric cataract, 222 (70.9%) eyes had visual acuity worse than 6/60 while another 30 (9.6%) eyes and 15 (4.8%) eyes had their visual acuity documented as less than 6/24 and at least 6/24 respectively (using hundreds and thousands). 15 (4.8%) eyes had a visual acuity of 6/6 to 6/18 while the remaining 31 (9.9%) eyes had a visual acuity of 6/24 to 6/60. twelve (7.8%) out of the 153 children with non-traumatic cataract had a positive family history of childhood cataract. five (41.7%) out of these 12 had congenital cataract while the remaining seven (58.3%) had developmental cataract. still on non-traumatic cataracts, 33 (21.6%) affected children had a positive history of maternal febrile illness in pregnancy. twenty-five (75.8%) out of these were congenital cataract while the remaining eight (24.2%) were developmental cataracts. similarly, 9 (5.9%) and one (0.7%) children with non-traumatic cataracts had a positive history of maternal rashes and use of abortifacients respectively in pregnancy. all of them had congenital cataracts. seven (77.8%) out of the nine children with maternal rashes in pregnancy equally had a positive history of maternal febrile illness in pregnancy. furthermore, eight (5.2%) children with non-traumatic cataracts had a positive history of maternal ingestion of herbal concoctions in pregnancy. seven (87.5%) out of these had congenital cataracts while the remaining one (12.5%) had developmental cataract. ninety-two (35.9%) out of the 256 eyes with non-traumatic cataracts had ocular comorbidities with nystagmus, strabismus and microphthalmos/nanophthalmos observed in 34 (40.0%), 22 (23.1%) and 18 (19.6%) children respectively (some eyes had multiple ocular comorbidities) as shown in table 4. twenty-six (17.0%) out of the 153 children with non-traumatic cataracts had systemic co-morbidities. the most common systemic co-morbidity was cardiac diseases documented in 10 (38.5%) children, followed by delayed developmental milestones and deafness in 7 (26.9%) and 5 (19.2%) children respectively as shown in table 4. out of the 10 children with cardiac diseases, patent ductus arteriosus (pda) was documented in 6 (60.0%) children being the most common, followed by ventricular septal defect (vsd) and atrial septal defect (asd) in 3 (30.0%) and 2 (20.0%) children respectively (some children had multiple cardiac diseases). seventy-five (49.0%) out of the 153 non-traumatic cataracts neither had family history, ocular nor systemic co-morbidities. the mean age at presentation for congenital cataract was 2.0 ± 2.5 years with a median age of 1.0 year. the youngest was a week old baby while the oldest was 11 years at presentation. fifty-four (69.2%) out of the 78 congenital cataracts were bilateral. forty (51.3%) children presented at age one and below. only 17 (21.8%) out of the 78 congenital cataract presented within a month of noticing the main presenting complaint while 36 (46.2%) presented after six months profile of pediatric cataract seen at lagos university teaching hospital, nigeria pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 56 (table 2). out of the 132 eyes of 78 children with congenital cataract, 83 (62.9%) eyes had total cataract being the most common. this is followed by nuclear, lamellar, anterior polar and membranous cataracts observed in 23 (17.4%), 9 (6.8%), 7 (5.3%) and 5 (3.8%) children respectively. out of the 40 children with congenital cataract who presented at age one and below, 12 did the torch screening test. out of these 12, 7 (58.3%) were positive for rubella igg antibodies but only 2 (16.7%) were positive for rubella igm antibodies. similarly, 4 (33.3%) children were positive for cytomegalovirus igg but only one (8.3%) child was positive for the igm antibodies. furthermore, five (41.7%) and one (8.3%) children had a positive igg for herpes and toxoplasmosis respectively but none of them had positive igm. there were 107 eyes of 62 patients with developmental cataract. the mean age was 6.6 ± 4.1 years and 45 (72.6%) had bilateral cataract. the most common morphological type of cataract was lamellar observed in 61 (57.0%) eyes followed by total and cortical cataract documented in 39 (36.4%) and three (2.8%) eyes respectively. two (1.9%) eyes each with developmental cataract had membranous and posterior sub-capsular cataract respectively. seventeen eyes of 13 children had complicated cataract with a mean age of 7.4 ± 3.7 years. nine (69.2%) out of the 13 children had unilateral cataract. total, posterior subcapsular and cortical cataracts were seen in 14 (82.4%), two (11.7%) and one (5.9%) eyes respectively. seven (41.2%) eyes with complicated cataract had co-existing retinal detachment while the remaining 10 (58.8%) were post-uveitic with seclusion pupillae. only three (23.1%) children out of the 13 with complicated cataract had systemic comorbidities. the systemic comorbidities were deafness, delayed developmental milestone and human immunodeficiency virus (hiv) infection. there were 57 children with traumatic cataract. all (100.0%) of them had unilateral cataract (p < 0.01) as shown in table 1 and the mean age at presentation was 9.1 ± 3.8 years. the youngest was a year old child who was inadvertently hit by a belt in the eye while the parents had a fight. the most common morphological type of cataract was total documented in 42 (72.4%) eyes. this was followed by cortical, posterior sub-capsular and anterior capsular cataract in seven (12.1%), six (10.3%) and two (3.4%) eyes respectively. forty-five (78.9%) cases were associated with closed globe injuries while 52 (91.2%) children sustained ocular injury at home or school as shown in table 5. the trauma circumstances were during playing or flogging in 45 (78.9%) children while wood, stick, broom, cane or belt were the most common agents of injury documented in 29 (50.9%) children. overall, forty-five (78.9%) out of the 57 children with traumatic cataract sustained ocular injury while playing or being flogged either at home or school. table 4: ocular and systemic co-morbidities in nontraumatic cataract patients. ocular and systemic co-morbidities frequency percentage ocular co-morbidities in 92 eyes nystagmus 34 40.0 strabismus 22 23.9 microphthalmos/ nanophthalmos 18 19.6 seclusiopupillae 15 16.3 retinal detachment 7 7.6 corneal opacity 5 5.4 high myopia 5 5.4 persistent fetal vasculature 2 2.2 aniridia 2 2.2 others 2 2.2 systemic co-morbidities in 26 children cardiac diseases 10 38.5 delayed developmental milestone 7 26.9 deafness 5 19.2 seizure disorders 2 7.7 hiv infection 2 7.7 musa kareem olatunbosun, et al 57 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology down syndrome 1 3.8 others 2 5.0 *some eyes and children had multiple ocular and systemic co-morbidities respectively. table 5: characteristics of traumatic cataract. ocular co-morbidities frequency percentage trauma type closed globe injury 45 78.9 open globe injury 12 21.1 total 57 100.0 trauma environment home 33 57.9 school 19 33.3 farm 1 1.8 not recorded 4 7.0 total 57 100.0 trauma circumstances playing 34 59.6 flogging 11 19.3 others 7 12.3 not recorded 5 8.8 total 57 100.0 discussion this study recorded a mean age of 5.6 years for pediatric cataract. this was within the range of 5.1 years and 7.1 years documented in previous studies from nigeria, ethiopia and india8-11. however, a higher mean age at presentation of 11.1 years was reported in bosnia and herzegovina12. this has been attributed to unavailability of cataract surgical services during the war period, lack of information and poor socio-economic background. the preponderance of non-traumatic cataracts (ntc) over traumatic cataracts compares favorably with the observations of halilbasic et al12, johar et al13 and randrianotahina et al14. late presentation was rampant in this study with over 60% presenting after three months of the onset of symptoms, more so that over 90% of the cataracts were visually significant. in fact, this study recorded a child with bilateral congenital cataract with nystagmus presenting at the age of 11. similar experiences of late presentation were documented in previous studies from nigeria9,15, bosniaherzegovina12 and tanzania16. late presentation could lead to the development of stimulus deprivation amblyopia with attendant effect on visual outcome after surgical intervention. furthermore, late presentation suggests barriers to early presentation. mwendeet al16 attributed the late presentation in their study to awareness of the problem (and surgical intervention), access to surgical services or acceptance of surgical services. unfortunately, barriers to early presentation could not be analyzed in this study because they were not documented in most patients’ record. to this end, there is a need for a prospective study to unravel these barriers to early presentation with a view to plan a result-oriented awareness and health education campaign. in spite of the rampant late presentation, children with unilateral cataract significantly presented earlier than those with bilateral cataract. this was contrary to the observation of mwende et al16 who found no association between laterality of cataract and duration before presentation. this is surprising as one would have expected the bilateral cataract to present earlier. however, this could be explained by the difference in study design because mwende et al16 only analyzed ntc and the cut-off for late presentation was 12 months compared to six months in this study. furthermore, the unilateral nature of all the traumatic cataracts in this study could have influenced a relatively early presentation as trauma could be associated with inflammatory eye symptoms like redness, photophobia and pain which could be scary for the parents and caregivers. however, gender did not influence the duration before presentation as reported by mwendeet al16. overall, there were more males with pediatric cataracts compared to females similar to observations in previous studies8-19. this study recorded more unilateral cataracts in children. this compares favorably with the observations of randrianotahina et al14, lim et al18 and khandehar et al19. haargaard et al17 and wirth et al20 however, documented more profile of pediatric cataract seen at lagos university teaching hospital, nigeria pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 58 bilateral cases. this disparity could be explained by the inclusion/exclusion criteria as the studies which included traumatic cataracts while those with more bilateral cataracts excluded traumatic cataract. trauma has been known to be a significant cause of monocular cataracts. in fact, if traumatic cataracts were excluded from this study, there would have been more bilateral cataracts as nearly 70% of congenital cataracts and over 70% of developmental cataracts in this study were bilateral. the preponderance of bilateral involvement in congenital cataract in this study was similar to the findings of rana et a21, naz et al22 and nadeem et al23. in this study, 7.8% of the ntc had a positive family history of childhood cataract. however, the pattern of inheritance could not be ascertained because of the lack of pedigree charts in the files of the patients. there were one and two cases of laboratory confirmed (igm positive) cytomegalovirus and rubella respectively although more chilren tested positive for their corresponding igg including herpes simplex and toxoplasmosis. intuitively, these proportions could have been more if all the 40 children with congenital cataracts seen at age one and below had done the torch screening. rubella is particularly relevant for being a preventable cause of congenital cataract since the vaccine is available in nigeria but not part of the national immunization coverage for school aged girls and women of child bearing age. to this end, the determination of the seroprevalence of rubella in children with congenital cataracts could be an important advocacy tool for the clamour for inclusion of rubella vaccination in the nigerian national vaccination program. the most common systemic co-morbidity in this study was cardiac diseases while the most common cardiac disease was patent ductus arteriosus. this finding compares favorably with the findings of duke et al8. congenital heart diseases as well as mental retardation, deafness and seizure disorders are common features of the disease entities that form the acronym “torch” infection. traumatic cataract was more common in boys compared to girls. this agrees with findings in previous studies by tomkins et al10, johar et al13 and gogate et al24. this is not surprising because boys are known to engage in rough play and activities that could attract punishment from parents or other caregivers. all the 57 cases of traumatic cataracts in this study were unilateral. this was similar to the observation of xu et al25. however, gogate et al24 reported a case of bilateral traumatic cataract in a tenyear old girl following a fall from a height. furthermore, closed globe injury was more associated with traumatic cataract in this study similar to the observations of johar et al13 and gogate et al24 although xu et al25 documented more open globe injury related pediatric traumatic cataracts. nearly 80% of the children with traumatic cataract sustained the ocular injuries while playing or being flogged either at home or in the school. these were inadvertent ocular injuries sustained while engaging in rough and unsupervised rough play as well as while being punished for perceived misbehaviour by the parents, teachers and other care givers. this calls for a better supervision of children while playing as well as the need to devise other punitive measures apart from corporal punishment when a child is deemed to have misbehaved. johar13 et al also reported that 80% and 20% of the pediatric traumatic cataracts in their study were play and work-related respectively. conclusion in conclusion, trauma and rubella were the main preventable causes of pediatric cataract identified in this study. late presentation was the case in the majority of the patients. this preventable attitude could affect the visual outcome after intervention. conflicts of interest: there are no conflicts of interest. author’s affiliation dr. musa kareem olatunbosun m.b.b.s, fwacs, fmcophth, fico, ico fellow in pediatric ophthalmology cunsultant ophthalmic surgeon and pediatric ophthalmologist/lecturer 1 department of ophthalmology (guinness eye centre), lagos university teaching hospital/college of medicine, university of lagos, lagos, nigeria. dr. aribaba olufisayo temitayo m.b.b.s, msc (london), fwacs, fmcophth, fics. cunsultant ophthalmologist/senior lecturer. department of ophthalmology (guinness eye centre), lagos university teaching hospital/college of medicine, university of lagos, lagos, nigeria. dr. rotimi-samuel adekunle m.b.b.s, fwacs, fmcophth cunsultant ophthalmologist/lecturer 1 musa kareem olatunbosun, et al 59 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology department of ophthalmology (guinness eye centre), lagos university teaching hospital/college of medicine, university of lagos, lagos, nigeria. dr. ikuomenisan segan joseph m.b.ch.b, fmcophth, fico cunsultant ophthalmologist ancilla catholic hospital eye centre, agege, lagos. dr. oluwoyeye abimbola olayinka m.b.b.s., senior registrar department of ophthalmology (guinness eye centre), lagos university teaching hospital, lagos, nigeria. prof. onakoya adeola olukorede m.b.b.s, fwacs, fmcophth professor of ophthalmology/consultant ophthalmologist department of ophthalmology (guinness eye centre), lagos university teaching hospital/college of medicine, university of lagos, lagos, nigeria. role of authors dr. musa kareem olatunbosun concept and design of study; acquisition of data; analysis and interpretation of data; drafting the article; revising the manuscript critically for important intellectual content and final approval of the version to be published. dr. aribaba olufisayo temitayo concept and design of study; interpretation of data; revising the manuscript critically for important intellectual content and final approval of the version to be published. dr. rotimi-samuel adekunle concept and design of study; revising it critically for important intellectual content and final approval of the version to be published. dr. ikuomenisan segan joseph concept and design of study; revising it critically for important intellectual content and final approval of the version to be published. dr. oluwoyeye abimbola olayinka concept and design of study; revising it critically for important intellectual content and final approval of the version to be published. prof. onakoya adeola olukorede concept and design of study; revising it critically for important intellectual content and final approval of the version to be published. references 1. wilson e, trivedi r. cataract in children. in: johnson gj, minassian dc, weale ra, west sk (eds). epidemiology of eye diseases, 3rd edition. london, imperial college press; 2012: 331-340. 2. foster a, gilbert c, rahi j. epidemiology of cataract in childhood: a global perspective. j cataract refract surg. 1997; 23: 601–604. 3. courtright p. childhood cataract in sub-saharan africa. saudi j ophthalmol. 2012; 26 (1): 3–6. 4. pediatric cataract middle east/africa american academy of ophthalmology. november 2015. available at www.aao.org/topic-detail/pediatriccataract-middle-east-africa. 5. wilson me. pediatric cataracts: overview. november, 2015. available at www.aao.org/pediatric-centerdetail/pediatric-cataracts-overview. 6. zetterström c, lundvall a, kugelberg m. cataracts in children. j cataract refract surg. 2005; 31 (4): 824–840. 7. medsinge a, nischal kk. pediatric cataract: challenges and future directions. clin ophthalmol. 2015 ; 9: 77–90. 8. duke r, oparah s, adio a, eyo o, odey f. systemic comorbidity in children with cataracts in nigeria: advocacy for rubella immunization. j ophthalmol. 2015; 2015: 927840. 9. umar mm, abubakar a, achi i, alhassan mb, hassan a. pediatric cataract surgery in national eye centre kaduna, nigeria: outcome and challenges. middle east afr j ophthalmol. 2015; 22 (1): 92–6. 10. tomkins o, ben-zion i, moore db, helveston ee. outcomes of pediatric cataract surgery at a tertiary care center in rural southern ethiopia. arch ophthalmol. 2011; 129 (10): 1293–7. 11. khokhar s, agarwal t, kumar g, kushmesh r, tejwani lk. lenticular abnormalities in children. j pediatr ophthalmol strabismus, 2012 ; 49 (1): 32–7. 12. halilbasic m, zvornicanin j, jusufovic v, mededovic a. pediatric cataract in tuzla canton, bosnia and herzegovina. med glas (zenica), 2014; 11 (1): 127-131. 13. johar srk, savalia nk, vasavada ar, gupta pd. epidemiology based etiological study of pediatric cataract in western india. indian j med sci. 2004; 58 (3): 115–21. 14. randrianotahina hcl, nkumbe he. pediatric cataract surgery in madagascar. niger j clin pract. 2014; 17 (1): 14–7. 15. ezegwui ir, aghaji ae, uche nj, onwasigwe en. challenges in the management of pediatric cataract in a developing country. int j ophthalmol. 2011; 4 (1): 66-68. 16. mwende j, bronsard a, mosha m, bowman r, geneau r, courtright p. delay in presentation to hospital for surgery for congenital and developmental cataract in tanzania. br j ophthalmol. 2005; 89 (11): 1478-1482. 17. haargaard b, wohlfahrt j, fledelius hc, rosenberg t, melbye m. a nationwide danish study of 1027 cases of congenital/infantile cataracts: etiological and clinical classifications. ophthalmology, 2004; 11 (12): 2292–8. http://www.aao.org/topic-detail/pediatric-cataract-middle-east-africa http://www.aao.org/topic-detail/pediatric-cataract-middle-east-africa http://www.aao.org/pediatric-center-detail/pediatric-cataracts-overview http://www.aao.org/pediatric-center-detail/pediatric-cataracts-overview profile of pediatric cataract seen at lagos university teaching hospital, nigeria pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 60 18. lim z, rubab s, chan yh, levin a v. pediatric cataract: the toronto experience-etiology. am j ophthalmol. 2010; 149 (6): 887–92. 19. khandekar r, sudhan a, jain bk, shrivastav k, sachan r. pediatric cataract and surgery outcomes in central india: a hospital based study. indian j med sci. 2007; 61 (1): 15-22. 20. wirth mg, russel-eggitt im, craig je, elder je, mackey da. aetiology of congenital and paediatric cataracts in an australian population. br j ophthalmol. 2002; 86 (7): 782-786. 21. rana am, raza a, akhter w. congenital cataracts; its laterality and association with consanguinity. pak j ophthalmol. 2014; 30 (4): 187-192. 22. naz s, sharif s, badar h, rashid f, kaleem a, iqtedar m. incidence of environmental and genetic factors causing congenital cataract in children in lahore. j pak med assoc. 2016; 66 (7): 819-822. 23. nadeem s, ayub m, fawad h. congenital cataract: morphology and management. pak j ophthalmol. 2013; 29 (3): 151-155. 24. gogate p, sahasrabudhe m, shah m, patil s, kulkarni a. causes, epidemiology, and long-term outcome of traumatic cataracts in children in rural india. indian j ophthalmol; 2012; 60 (5): 481–486. 25. xu yn, huang ys, xie lx. pediatric traumatic cataract and surgery outcomes in eastern china: a hospitalbased study. int j ophthalmol. 2013; 6 (2): 160-164. microsoft word khawaja khalid 17 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology original article problems / complications, success rate – endoscopic dacryocystorhinostomy khawaja khalid shoaib, salahuddin ahmad, muhammad manzoor, sabihuddin ahmed, iftikhar aslam syed nadeem ul haq pak j ophthalmol 2012, vol. 28 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: col. khawaja khalid shoaib eye department cmh mardan …..……………………….. purpose: to analyze endoscopic / endonasal dacryocystorhinostomy (endo dcr) cases regarding the problems encountered during the procedure, post operative complications, their management and success rate. material and methods: endo dcr, done from jan 2008 to sep 2011 in eye departments of cmh kharian and mardan, were analyzed in this retrospective study. in the initial ten cases, only nasal packing with 5 cc of 2 % xylocaine with adrenaline 1:100000 mixed with 0.5 cc of adrenaline 1: 1000 was done and kept for fifteen minutes. in the next ten cases, after packing, injection of the same solution (2 cc of 2 % xylocaine with adrenaline mixed with 0.5 cc of adrenaline 1: 1000) was given at the operation site (sac area and middle turbinate) and packing was done again for ten minutes. in the rest of the cases, after packing, cautery was done instead of injection. in all the procedures, silastic intubation and application of mitomycin c, 0.5 mg/ml for ten minutes was done. results: a total of 32 endo dcr operations were done in 31 patients (a three year boy had bilateral endo dcr) under general anesthesia. 3 were males and 28 were females. age ranged from three years to sixty years (mean 42 ± 15). follow up ranged from 6 to 10 months (7.5 ± 1.5). problems arising during the operation included moderate bleeding in the nose obscuring view through the nasal endoscope during six operations (19%), difficulty in localization of sac area inside the nose in five operations (16 %), mild bleeding on first post operative day after two operations (6%) and persistent watering after five operations (16 %) which required revision. revised cases were done with endonasal endoscopy and all improved except two. conclusion: problems / complications encountered during endo dcr can be managed and the procedure has good success rate. uring the last century, external dacryocystorhinostomy (dcr) remained a gold standard for the management of obstruction of lacrimal passages beyond the common canaliculus. now the internal approach is also gaining popularity. endoscopic / endonasal (endo) dcr can be done either mechanically or with different types of lasers. its advantages are decreased morbidity, no bleeding from skin and orbicularis, decreased post operative pain, reduced recovery time, magnified view, bright focal illumination, projection on closed circuit tv (fig. 1) and option of recording. the different designs of nasal endoscopes include 0 degreefor looking straight, 30 degree-for angled view and 70 degree – extreme angle view. to find out the problems encountered during endo dcr operation, post operative complications, their management and the overall success rate, the following study was carried out. material and methods endo dcr cases done from jan 2008 to sep 2011 in eye departments of cmh kharian and mardan were analyzed in this study. probing and sac syringing was done in all the cases. only cases having nasolacrimal duct obstruction underwent endo dcr. a total of 32 d khawaja khalid shoaib et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 18 endo dcr were done in 31 patients (a three year boy underwent bilateral endo dcr). table 1. problems encountered during the procedure and post operative complications s. no. problems / complications operations n (%) 1 bleeding in the nose obscuring view through endoscope 6 (19) 2 difficulty in localization of sac area inside the nose 5 (16) 3 mild bleeding on first post operative day 2 (6) 4 persistent watering after operations 5 (16) fig. 1. endoscope with camera and projection on monitor fig. 2. endonasal dcr endo dcr procedure had following general steps: packing with ribbon gauze soaked in 2% xylocaine with adrenaline 1: 100000 for ten minutes, which was followed by identification of sac area inside the nose. in the initial ten cases, localization of target site on the nasal mucosa was done by vitrectomy light pipe (20/23 g) which was passed through the punctum and canaliculi into the sac (fig 2). the light was then visualized inside the nasal cavity where a mucosal incision was made. in 5 revision cases a probe was passed from the canaliculi to nose to identify the area. in the initial ten cases, only nasal packing with 5 cc of 2% xylocaine with adrenaline mixed with 0.5 cc of adrenaline 1: 1000 was done and kept for fifteen minutes. in the next ten cases, after packing, injection of the same solution (2 cc of 2% xylocaine with adrenaline1:100000 mixed with 0.5 cc of adrenaline 1: 1000) was given at the operation site (sac area and middle turbinate) and packing was done again for ten minutes. in the rest of the cases, after packing, cautery was done instead of the injection to achieve haemostasis. under direct visualization, bone was removed with the ronguers / punch. an attempt was made to make a large osteotomy of more than 1.5 x 1.5 cm. bleeding at this point required packing of ribbon gauze soaked in 2% xylocaine with adrenaline 1:100000 for brief periods. in all the cases, silastic intubation was done. the dcr tube used (eagle, usa) had fine, long and malleable probes which were easily passed through the canalicular system. in all cases, ribbon gauze was soaked in 1 ml of mitomycin c (0.5 mg/ml) and placed at the osteotomy site for ten minutes. dcr tube was removed after six months in all the cases. success was based on subjective improvement reported by the patients. results a total of 32 endo dcr were done in 31 patients (a three year boy underwent bilateral endo dcr), under general anesthesia (ga). 3 were males and 28 were females. age ranged from three years to sixty years (mean 42 ± 15). follow up ranged from 6 to 10 months (7.5 ± 1.5). problems arising during the operation (table 1) included moderate bleeding in the nose obscuring view through the nasal endoscope during six operations (19%), difficulty in localization of sac area inside the nose in five operations (16%), mild bleeding on first post operative day after two operations (6%). nasal packing for 1 day in one case and for 2 days in another case controlled post operative bleeding nose. persistent watering after five operations (16%) required revisional operation. this gives a success rate of 84% after the first operation. problems / complications, success rate – endoscopic dacryocystorhinostomy 19 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology revised cases were done with endonasal endoscopy. all improved except two and thus a success rate of 94% after the second operation was achieved. discussion a three year boy had bilateral nasolacrimal duct obstruction for which bilateral surgery was done, the rest of the cases were unilateral. majority of the patients were females (90%). though the dcr is more frequently required in females, the selection also increased this ratio in the present series. these were initial cases of endo dcr and a few males were switched to external approach. the bones in males are thick and hard. it was thought that it would be difficult to break them through the narrow nasal cavity. all of the patients completed six months follow up as all reported for dcr tube removal. after that, only those patients reported back who had persistent problem. with the patient lying in supine position, as endoscope enters the external nares, the first thing which is visualized due to its large size is the inferior turbinate. as the tip is advanced, next structure encountered is middle turbinate. to identify the sac area in the initial ten cases, fiberoptic (vitrectomy) light pipe was passed through the canaliculi. when the tip was in the sac, transillumination could be appreciated in the nose. later on, with more experience in identifying the landmarks of nasal anatomy, the area corresponding to the sac (anterior to middle turbinate) could be located without the help of light pipe. in revised cases, a probe was passed through the canaliculi into the nose to recognize the osteotomy site because bone had already been removed. haemostasis control was important as even slight bleed in the nose resulted in blood on the tip of endoscope and blurring of the view. one had to remove the endoscope and clean its tip, thus increasing the operation time. in the initial ten cases, only nasal packing with 10cc of 2% xylocaine with adrenaline mixed with 0.5 cc of adrenaline 1: 10000 was done and kept for fifteen minutes but the bleeding was troublesome throughout the procedure. in the next ten cases, injection of the same solution (2cc of 2% xylocaine with adrenaline mixed with 0.5 cc of adrenaline 1: 10000) after packing, at the operation site (sac area and middle turbinate) was done and packing again for ten minutes. it resulted in increased heart rate as the absorption from nasal mucosa was very rapid. later on, only cautery could achieve an excellent haemostasis. chitosan – based haemostatic dressing (cbhd) has been found to decrease postoperative bleeding significantly as compared to collagen absorbable hemostat (cah) and is safe1. when a camera and monitor are attached, it has a number of advantages. first the surgeon is looking at the monitor while doing surgery and can keep the posture upright. secondly assistant knows what is being done inside the nose. doing surgery with the endoscope only, reduces the cost but forces surgeon to keep the eye in contact with the eye piece. ronguers / punch used in endo dcr are similar to the one used in external dcr, the only difference is that shaft and jaws are slender for passage through the narrow nasal cavity. to prevent formation of granulation / fibrous tissue occluding rhinostomy site, mitomycin c placed at the osteotomy site has been used in different concentrations for different durations for example 0.5 mg/ml for 10 minutes2, 0.5 mg/ml for 5 min3, 0.2 mg/ml for 2 min4, 0.05% nasal pack for 48 hours5, 0.03% with silicone intubation6 and 0.2 mg/ml for 30 minutes7. endo dcr has been done for dacryocystocoele in a 4 month old infant8 and in adults9,10. it has been found to be a safe and effective procedure for the management of persistent epiphora in children (as it avoids the need for overnight admission)11 and for adults12. the technique has been claimed to be appropriate for initial treatment of patients with common canalicular or even canalicular obstruction13. the common insertion of the upper and lower canaliculus of the lacrimal sac has been repaired with endoscopic dcr, silicone stenting and securing of stents intranasally14. formation of mucosal flaps at the end of the operation has been claimed to improve success rate15,16 and has been termed powered endonasal dcr by some while many use the term mechanical endonasal dacryocystorhinostomy (mendcr)17 when there is a large rhinostomy and mucosal flaps18. success rates of mendcr 92%16, 95%18 and 93.5%19 were found to compare favorably with that of standard external dcr 95.8%19. in a few studies, success was inferior (86% endo 94% ext)20 with endo dcr21 while in other studies, success rates after endo dcr have been found to be comparative (endo = ext)13,22-25. best endo dcr results have been claimed by stenting or removal of the medial wall of the lacrimal sac26. on the other hand some are of the opinion that endo dcr should be done without intubation. they argue that surgical success rates are same whether intubation is done or not. the reported disadvantages khawaja khalid shoaib et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 20 of intubation are granulation formation, patient discomfort, and extra cost of the silicon tube27. a persistent or recurrent epiphora after an external dcr can be treated by endoscopic procedure28. nasal endoscopy is such a useful tool that it has been recommended essential before and even after external dcr29. ophthalmologists frequently deal with the upper lacrimal system including puncta and canaliculi while otorhinolaryngologists are more familiar with the intranasal anatomy / pathology. either of these specialists can deal with the cases after a little bit of learning but the best results are achieved when endo dcr is performed by a combined team30. an injection of betamethasone has been administered intraoperatively in revision endoscopic dcr, under assisted local anaesthetic, claiming high success rate (89%)31. to sum up, disadvantages include steep learning curve, difficulty in manipulations in the narrow nasal cavity, preferred use of general anaesthesia by many surgeons, costly equipment, difficult to form large rhinostomy ( >10mm), not possible to suture mucosal flaps, synaechiae formation in case of inadvertent extensive nasal mucosal damage and (according to a few) a lower success rate. conclusion problems / complications encountered during endo dcr can be managed and the procedure has good success rate. author’s affiliation dr. khawaja khalid shoaib cmh, mardan dr. salahuddin ahmad cmh, gugranwala dr. muhammad manzoor pns hafeez, islamabad dr. sabihuddin ahmed cmh, rawalpindi dr. iftikhar aslam rmi, peshawar dr. syed nadeem ul haq cmh, muzaffarabad reference 1. dailey ra, chavez mr, choi d. use of a chitosan – based hemostatic dressing in dacryocystorhinostomy. ophthal plast reconstr surg. 2009; 25: 350-3. 2. dolmetsch am. nonlaser endoscopic endonasal dacryocystorhinostomy with adjunctive mitomycin c in nasolacrimal duct obstruction in adults. ophthalmology. 2010;117: 1037-40. 3. dolmetsch am, gallon ma, holds jb. nonlaser endoscopic endonasal dacryocystorhinostomy with adjunctive mitomycin c in children. ophthal plast reconstr surg. 2008; 24: 390-3. 4. tabatabaie sz, heirati a, rajabi mt, et al. silicone intubation with intraoperative mitomycin c for nasolacrimal duct obstruction in adults: a prospective, randomized, doublemasked study. ophthal plast reconstr surg. 2007; 23: 455-8. 5. rathore pk, kumari sodhi p, pandey rm. topical mitomycin c as a postoperative adjunct to endonasal dacryocystorhinostomy in patients with anatomical endonasal variants. orbit. 2009; 28: 297-302. 6. nemet ay, wilcsek g, francis ic. endoscopic dacryocystorhinostomy with adjunctive mitomycin c for canalicular obstruction. orbit. 2007; 26: 97-100. 7. liao s, kao s, tseng j, et al. results of intraoperative mitomycin c application in dacryocystorhinostomy. br j ophthalmol. 2000; 84: 903–6. 8. mladina r, stiglmayer n, dawidowsky k, et al. endonasal endoscopic dacryocystorhinostomy for dacryocystocoele in a 4 month old infant. br j ophthalmol. 2001; 85: 110. 9. eloy p, martinez a, leruth e, et al. endonasal endoscopic dacryocystorhinostomy for a primary dacryocystocele in an adult. b-ent. 2009; 5: 179-82. 10. plaza g, nogueira a, gonzález r, et al. surgical treatment of familial dacryocystocele and lacrimal puncta agenesis. ophthal plast reconstr surg. 2009; 25: 52-3. 11. marr j e, drake-lee a, willshaw h e. management of childhood epiphora. br j ophthalmol. 2005; 89: 1123-6. 12. aslam s, awan ah, tayyab m. endoscopic dacrocystorhinostomy: a pakistani experience. pak j ophthalmol. 2010; 26: 2-6. 13. yung m w, hardman-lea s. analysis of the results of surgical endoscopic dacryocystorhinostomy: effect of the level of obstruction. br j ophthalmol. 2002; 86: 792-4. 14. khan ha, bayat a, de carpentier jp. endoscopic dacrocystorhinostomy in lacrimal canalicular trauma. ann r coll surg engl. 2007; 89: 43. 15. trimarchi m, giordano resti a, bellini c, et al. anastomosis of nasal mucosal and lacrimal sac flaps in endoscopic dacryocystorhinostomy. eur arch otorhinolaryngol. 2009; 266: 1747-52. 16. sonkhya n, mishra p. endoscopic transnasal dacryocystorhinostomy with nasal mucosal and posterior lacrimal sac flap. j laryngol otol. 2009; 123: 320-6. 17. tan nc, rajapaksa sp, gaynor j, et al. mechanical endonasal dacryocystorhinostomy-a reproducible technique. rhinology. 2009; 47: 310-5. 18. tsirbas a, wormald pj. mechanical endonasal dacryocystorhinostomy with mucosal flaps. br j ophthalmol. 2003 january; 87: 43-7. 19. tsirbas a, davis g, wormald pj. mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. ophthal plast reconstr surg. 2004; 20: 50-6. 20. leong sc, karkos pd, burgess p, et al. a comparison of outcomes between nonlaser endoscopic endonasal and external dacryocystorhinostomy: single-center experience and a review of british trends. am j otolaryngol. 2010; 31: 32-7. 21. zílelíog˘lu g, tekeli o, ug˘urbas sh, et al. results of endoscopic endonasal non-laser dacryocystorhinostomy. documenta ophthalmologica. 2002; 105: 57–62. 22. poublon rm, hertoge kde r. endoscopic – assisted reconstructive surgery of the lacrimal duct. clin plast surg. 2009; 36: 399-405. problems / complications, success rate – endoscopic dacryocystorhinostomy 21 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology 23. sonkhya n, mishra p. endoscopic transnasal dacryocystorhinostomy with nasal mucosal and posterior lacrimal sac flap. j laryngol otol. 2009; 123: 320-6. 24. korkut ay, teker am, ozsutcu m, et al. a comparison of endonasal with external dacryocystorhinostomy in revision cases. eur arch otorhinolaryngol. 2010; 21. 25. leong sc, macewen cj, white ps. a systematic review of outcomes after dacryocystorhinostomy in adults. am j rhinol allergy. 2010; 24: 81-90. 26. de souza c, nissar j. experience with endoscopic dacryocystorhinostomy using four methods.otolaryngol head neck surg. 2010; 142: 389-93. 27. unlu hh, gunhan k, baser ef, et al. long-term results in endoscopic dacryocystorhinostomy: is intubation really required? otolaryngology – head and neck surgery. 2009; 140: 589-95. 28. choussy o, retout a, marie jp, et al. endoscopic revision of external dacryocystorhinostomy failure. rhinology. 2010; 48: 104-7. 29. elmorsy sm, fayk hm. nasal endoscopic assessment of failure after external dacryocystorhinostomy. orbit. 2010; 29: 197-201. 30. milojević m, avramović s, kostić b, et al. endoscopic dacryocystorhinostomy. vojnosanit pregl. 2010; 67: 463-7. 31. zeldovich a, ghabrial r. revision endoscopic dacryocystorhinostomy with betamethasone injection under assisted local anaesthetic. orbit. 2009; 28: 328-31. pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 169 original article correlation between axial length and retinal nerve fiber layer thickness in myopic eyes muhammad abdul rehman akram, irfan qayyum malik, idress ahmad, suhail sarwar, mumtaz hussain pak j ophthalmol 2013, vol. 29 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: abdul rehman akram ophthalmology department mayo hospital lahore …..……………………….. purpose: to determine the correlation between axial length and retinal nerve fiber layer thickness in myopic eyes. material and method: one hundred patients of myopia with best corrected visual acuity of at least 6/12 in the best eye were included in this study. optical coherence tomography was done with dilated pupils. axial length was measured with a-scan. after pupillary dilation, retinal nerve fiber layer thickness was measured with optical coherence tomography (oct) around the center of optic disc. mean retinal nerve fiber layer thickness was generated by automated computerized program in the analysis report and compared with the built in agematched normative database in 3d oct. results: the mean age was 27.08 + 7.85 years. there were 50 males (50%) and 50 (50%) females. the mean spherical equivalent (myopia) was -2.95 d + 1.36. the mean axial length 23.92 + 0.614. the mean retinal nerve fiber layer (rnfl) thickness was 111.49 µm + 4.04. pearson coefficient of correlation was .328. conclusion; in myopic patients the rnfl thickness decreases with increasing axial length. yopia is the most common ocular abnormality worldwide. its exact prevalence in pakistan is not known but different studies showed different results1,2 in the different areas of pakistan. retinal changes in persons with high myopia include peripapillary atrophy, peripheral lattice degeneration, tilting of the optic disc, posterior staphyloma and breaks in bruch’s membrane. although retinal nerve fiber layer thinning is indicative of glaucomatous damage, it remains uncertain whether retinal nerve fiber layer thickness would vary with the refractive status of the eye). it is therefore important to investigate whether any correlation exists between retinal nerve fiber layer thickness and axial length in myopia. for every 1 mm greater axial length, mean retinal nerve fiber layer thickness decreases by approximately 2.2 µm.3 the aim of this study is very important because it measures retinal nerve fiber layer thickness changes with the increase in axial length as in myopia. the decreasing retinal nerve fiber layer thickness is a major risk factor to develop glaucoma which is a second most common cause of blindness worldwide.4 material and methods 100 patients fulfilling the inclusion criteria were taken from the outdoor clinic of institute of ophthalmology mayo hospital, lahore. informed consent, sociodemographic data (name, age, gender, address and contact number), past medical and surgical history were recorded. the study was conducted in accordance with ethical standards approved by the hospital committee. examination included visual acuity with snellen’s chart, refractive error with autom muhammad abdul rehman akram, et al 170 vol. 29, no. 3, jul – sep, 2013 pakistan journal of ophthalmology refractometer, slit lamp examination for anterior segment evaluation, indirect ophthalmoscopy using 20 d lens for fundus examination with dilated pupils. axial length was measured with a-scan. after pupillary dilation, retinal nerve fiber layer thickness was measured with oct around the center of optic disc. mean retinal nerve fiber layer thickness was generated by automated computerized program in the analysis report and compared with the built in agematched normative database in 3d oct (topcon 3d oct-1000). to control the biases, only one expert person recorded the axial length and retinal nerve fiber layer thickness. the side of the eye was selected randomly. all the required information was collected on an especially designed proforma (attached herewith). results one hundred eyes of 100 patients were included in the study among which 60 (60%) were right eyes and 40 (40%) were left eyes (table 3). the mean age was 27.08 ± 7.85 years (table 2). there were 50 males (50%) and 50 (50%) females (table i). we studied the effect of axial myopia according to the axial length of the patient on the thickness of retinal nerve fiber layer. the mean spherical equivalent of the myopic patients was -2.95 d ± 1.36 (table 4). the mean axial length was 23.92 ± 0.614. the mean retinal nerve fiber layer (rnfl) thickness was 111.49µm ± 4.04 axial myopia is related with increased axial length and it affects the thickness of rnfl. in our study we calculated the pearson’s coefficient correlation between axial length and rnfl thickness by using spss and it was -.328 which is significant at the level of 0.01 the p value was 0.001 which is highly significant. pearson coefficient of correlation (r) between axial length and retinal nerve fiber layer thickness was calculated 0.314 in myopic eyes in my reference study. for every 1 mm greater axial length, mean retinal nerve fiber layer thickness decreases by approximately 2.2µm. table 1: distribution of cases by spherical equivalent (myopia) (n = 100) total no. of patients 100 mean -2.96 standard deviation ± 1.36 the results of our study show that given parameters in different population groups regarding axial length and rnfl thickness are also valid for our population which we are dealing in mayo hospital. so rnfl thickness values can be used in our population for early glaucoma detection and monitoring. table 2: distribution of cases by axial length (n = 100) total no. of patients 100 mean 23.92 standard deviation ± 0.61 table 3: distribution of cases by rnfl thickness (n =100) total no. of patients 100 mean 111.49 standard deviation ± 4.04 discussion retinal nerve fiber layer damage invariably occurs in glaucoma.5 various investigational modalities like, retinal nerve fiber layer analyzer (nfa), scanning laser ophthalmoscope (gdx, and gdx with variable corneal compensation), and oct are used to measure the rnfl changes. oct is a non-invasive, noncontact modality that can be used for measurement of peripapillary rnfl thickness. it is found to correlate with rnfl as measured with scanning laser ophthalmoscope (slo) and the heidelberg retinal tomography (hrt).6 oct measured rnfl thickness is not affected by the corneal and lenticular birefringence, as is the case with confocal scanning laser polarimetry. no additional reference plane is required to calculate the rnfl thickness because oct provides an absolute cross-sectional measurement of retina, from which rnfl thickness is calculated. a high level of correlation between oct generated rnfl thickness and visual function has been reported in previous studies. the rnfl may show a racial variation and the various values may be specific to the population under study. the detection of rnfl loss also varies in accordance with the imaging technology used, and the normative rnfl data of the concerned population. rnfl thickness parameters are already studied in the western population7. correlation between axial length and retinal nerve fiber layer thickness in myopic eyes pakistan journal of ophthalmology vol. 29, no. 3, jul – sep, 2013 171 this study is important as no study is available for pakistani population which gives a normal data of rnfl thickness which can be used as reference in different diseases especially glaucoma in which there is loss of rnfl which can be compared with the age match control of normal population.8 the mean rnfl thickness in our sample population was 113.91 microns, and it is comparable to the rnfl thickness reported in the chinese population9. a summary of some of the previous reports on normal rnfl thickness parameters is presented in reference studies. it shows a higher value of rnfl thickness in most of the studies in caucasians (except those 1 reported by bowd and mistelberger when compared to chinese eyes. such a discrepancy has not been addressed earlier but might be related to the ethnicity of study group, or to the oct model, and the analysis protocol used. although retinal nerve fiber layer thinning is indicative of glaucomatous damage, it remains uncertain whether retinal nerve fiber layer thickness would vary with the refractive status of the eye. in a study held at hong kong eye hospital, pearson coefficient of correlation (r) between axial length and retinal nerve fiber layer thickness was calculated 0.314 in myopic eyes10. for every 1 mm greater axial length, mean retinal nerve fiber layer thickness decreases by approximately 2.2 µm.11 the thinning of rnfl is a very good indicator of glaucoma but it also occurs in myopic eyes, it means measuring rnfl thickness without knowing refractive status can lead to misdiagnosis of glaucoma. we have found the relation between increased axial length and rnfl in our population, which is almost the same as concluded in others studies in the world. this fact has enabled us to use rnfl parameter for glaucoma detection in myopic eyes effectively.12 there was no effect of gender on the rnfl parameters measured in our study. a similar finding has been reported previously.13 schuman et al showed nerve fiber layer of men were usually thinner than the females, but not statistically significant.14 conclusion in conclusion, our study provides a reliable correlation values between axial length and retinal nerve fiber layer thickness in myopic pakistani eyes by optical coherence tomography. this can serve as a useful guideline in diagnosis, management and research in glaucoma in myopic eyes. author’s affiliation dr. abdul rehman akram eye unit-ii mayo hospital, lahore dr. irfan qayyum eye unit-ii mayo hospital, lahore dr idrees ahmad assistant professor sharif medical college lahore dr. suhail sarwar assistant professor of ophthalmology eye unit-iii mayo hospital, lahore dr. mumtaz hussain professor of ophthalmology eye unit-ii mayo hospital, lahore muhammad abdul rehman akram, et al 172 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http://www.ncbi.nlm.nih.gov/pubmed/21051712 http://www.ncbi.nlm.nih.gov/pubmed?term=lederer%20d%5bauthor%5d&cauthor=true&cauthor_uid=12511364 http://www.ncbi.nlm.nih.gov/pubmed?term=voskanian%20s%5bauthor%5d&cauthor=true&cauthor_uid=12511364 http://www.ncbi.nlm.nih.gov/pubmed?term=velazquez%20l%5bauthor%5d&cauthor=true&cauthor_uid=12511364 http://www.ncbi.nlm.nih.gov/pubmed?term=pakter%20hm%5bauthor%5d&cauthor=true&cauthor_uid=12511364 http://www.ncbi.nlm.nih.gov/pubmed?term=pedut-kloizman%20t%5bauthor%5d&cauthor=true&cauthor_uid=12511364 http://www.ncbi.nlm.nih.gov/pubmed?term=fujimoto%20jg%5bauthor%5d&cauthor=true&cauthor_uid=12511364 http://www.ncbi.nlm.nih.gov/pubmed?term=fujimoto%20jg%5bauthor%5d&cauthor=true&cauthor_uid=12511364 http://www.ncbi.nlm.nih.gov/pubmed?term=fujimoto%20jg%5bauthor%5d&cauthor=true&cauthor_uid=12511364 http://www.ncbi.nlm.nih.gov/pubmed?term=mattox%20c%5bauthor%5d&cauthor=true&cauthor_uid=12511364 http://www.ncbi.nlm.nih.gov/pubmed?term=hertzmark%20e%5bauthor%5d&cauthor=true&cauthor_uid=7748128 http://www.ncbi.nlm.nih.gov/pubmed?term=izatt%20ja%5bauthor%5d&cauthor=true&cauthor_uid=7748128 http://www.ncbi.nlm.nih.gov/pubmed?term=swanson%20ea%5bauthor%5d&cauthor=true&cauthor_uid=7748128 http://www.ncbi.nlm.nih.gov/pubmed?term=swanson%20ea%5bauthor%5d&cauthor=true&cauthor_uid=7748128 http://www.ncbi.nlm.nih.gov/pubmed?term=swanson%20ea%5bauthor%5d&cauthor=true&cauthor_uid=7748128 http://www.ncbi.nlm.nih.gov/pubmed?term=fujimoto%20jg%5bauthor%5d&cauthor=true&cauthor_uid=7748128 microsoft word haroon tayyab 49 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology case report cholesterosis bulbi in a painful blind eye with high intraocular pressure and long standing total retinal detachment haroon tayyab, muhammad ali haider, tehmina jahangir, sana jahangir, samina jahangir pak j ophthalmol 2012, vol. 28 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: haroon tayyab house # suh 24, askari xi cobbe lane, near qasim market rawalpindi cantt …..……………………….. this is case report of a 19 year old male who presented to the ophthalmology department of jinnah hospital lahore in july 2011 with a painful blind left eye for the last two years. examination of left eye showed no perception of light, circumcorneal injection, band keratopathy, pseudohypopyon of polychromatic crystals, polychromatic crystals embedded in iris stroma and aphakia. intraocular pressure was 32 millimeters of mercury. b scan ultrasound showed old retinal detachment. right eye examination was normal. there were no associated systemic examination findings. he had a history of cataract surgery for left congenital cataract at the age of four years followed by sudden painless loss of vision three years after cataract surgery. in our eye department, he was started on topical cycloplegics, corticosteroids and topical and systemic anti-glaucoma medication and was made symptomatically comfortable. retinal surgery was not contemplated taking into consideration his chronic retinal detachment and poor visual status. holesterosisbulbi is a condition involving presence of polychromatic, white or golden crystal in the vitreous cavity and / or anterior chamber. this condition is also known as hemophthalmos or synchysis scintillans1. this condition typically occurs as a sequel of chronic vitreous hemorrhage2 but may occur in cases of long standing retinal detachment, ocular trauma and advanced coats disease3,4. cholesterol crystals in anterior chamber is a rare manifestation of this condition, which may be found in advanced cases of cholesterosis bulbi3,5. these crystals are composed of cholesterol which is derived from degradation products of red blood cells or plasma cells. they can be found freely or engulfed within foreign body giant cells2. in addition these crystals can also form from breakdown of vitreous and from subretinal fluid of a long standing retinal detachment6. in anterior chamber, these crystals can be found in anterior chamber angle, embedded on iris or may form a hypopyon. in vitreous cavity, these crystals are found suspended in vitreous which tend to settle inferiorly when the eye is immobile. a considerable number of cases with cholesterosisbulbi have been treated with enucleation due to intractable pain associated with it and the risk of sympathetic ophthalmitis in the other eye.7 we are here to report the first case of cholesterosisbulbi in jinnah hospital lahore, associated with profound involvement of anterior chamber with cholesterol crystals, concurrent increased intraocular pressure and long standing total retinal detachment. case history a 19 year old male was brought to outdoor patient department of ophthalmology unit 1 in jinnah hospital lahore in july 2011 with the primary complaints of painful and blind left eye for last 2 years. his past ocular history revealed surgery on his left eye for congenital cataract at the age of 4 years (15 years ago) from an eye clinic at chakwal, punjab. patient was left aphakic after primary surgery. he was prescribed aphakic spectacles for visual correction. after 3 uneventful years, the patient suffered from sudden painless and severe decline in visual acuity which converted to no perception of light after few c haroon tayyab et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 50 months of no intervention. he had no history of trauma and was not using any ocular or systemic medication at the time of his presentation to us. family history was also insignificant. the patient did not have any medical record available for his previous ocular treatment. fig 1: anterior chamber photograph showing pseudohypopyon of polychromatic crystals and shallow anterior chamber. fig 2: anterior chamber photograph showing cholesterol crystals embedded on iris surface. fig 3: anterior chamber photograph showing cholesterol crystals embedded on iris surface. fig 4: b-scan showing total retinal detachment. examination of the eyes showed normal right eye and no perception of light in his left eye. anterior segment examination of the left eye showed circumcorneal injection, band keratopathy, shallow anterior chamber, pseudohypopyon of polychromatic crystals measuring 3 – 4 mm (fig 1), polychromatic crystals deposited on iris stroma (fig 2, 3), grade 1 flare and +2 cellular anterior chamber activity, interrupted posterior synechie with non reactive 3mm roughly round pupil and strongly positive reverse marcus gunn reaction, aphakia with intact but thickened and opacified posterior capsule. gonioscopy revealed cholesterol crystals in anterior chamber angle. goldmann’s tonometry displayed intraocular pressure of 14 and 32 millimeters of mercury in right and left eye respectively. there was no view available for examination of vitreous and retina. b scan ultrasonography showed left sided total retinal detachment (fig 4). his rest of general and systemic examination was unremarkable. no retinal surgery was advised to the patient, he was started on topical atropine 1% three times a day, topical dexamethasone 0.1% four times a days, topical timolol maleate 0.5% two times a day and oral acetazolamide 250 mg four times a day. he was also advised protective polycarbonate glasses for his right eye and to avoid contact sports. he was asked to follow up after 3 days of initial visit. at his first follow up, he was found to have intraocular pressure of 27 millimeters of mercury with mild reduction in his ocular symptoms. after a month of regular treatment and follow up and with addition of topical brimonidine tartrate 0.2% three times a day, his intraocular pressure was successfully controlled to 18 millimeters of mercury with occasional cells in cholesterosis bulbi in a painful blind eye with high intraocular pressure and long standing 51 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology anterior chamber. the patient was also noted to have significant improvement in his ocular symptom. currently he is on 15 day follow up with our department. discussion cholesterol crystals have been demonstrated in most tissues of eye but the commonest sites include lens, vitreous and retina. they usually occur as a long term consequence of ocular trauma, inflammation of uveal tract, degeneration, particularly of vitreous; and rarely neoplasia7. in a number of cases, the eye has been blind for a number of years and these crystals have been found accidently in anterior chamber. suresh7 conducted microscopic examination on these crystals and found them to be composed of cholesterol in the form of thin colorless transparent plates of square or rectangular shape. stevens calculated the normal concentration of cholesterol in normal aqueous and found it to be considerably lower than plasma cholesterol levels. he also demonstrated the chemical nature of these crystals through chromatography to be cholesterol8. the major source of these cholesterol crystals has been identified to be degenerating red blood cells either from hyphaema or vitreous hemorrhage9. long standing intraocular inflammation resulting in defective blood retinal barrier can also result in extravasation of cholesterol in the eye and thereafter, its deposition in different ocular tissues; aphakia is also a recognized cause of deposition of cholesterol crystals in anterior chamber6. kennedy6 also reported cases of cholesterosisbulbi involving anterior chamber resulting after long standing retinal detachments with no evidence of intraocular hemorrhage as reported in our case. forsius4 believed that the process the deposition of cholesterol accelerates when there is clinically demonstrable evidence of intraocular inflammation because proteins and fats enter the chamber with the flow of fluid in the eye, and as we know that cholesterol is insoluble in water, it crystallizes. an important factor in the deposition of crystals seems to the time for which the eye has remained blind7. all the seven cases reported by forsius4 had been blind for more than 5 years and in gruber’s series, atleast 6 cases had no sight for more than 5 years. awan10 reported a case of cholesterol crystals in anterior chamber of a 15 year old white girl with a structurally and functionally normal eye. the cause for high intraocular pressure can be secondary to deposition of cholesterol crystals in anterior chamber angle or direct damage of trabecular meshwork by the crystals3. this was the suspected reason for raised intraocular pressure in our case, since gonioscopy did not reveal any other angle pathology apart from cholesterol crystals in angle. under these circumstances the eye can be made comfortable by conservative measures as shown by kumar7. this was the mainstay of treatment in our patient. in the case reported by park3, the causative factor for high intraocular pressure was neovascularization in anterior chamber angle, which was successfully treated by intravitreal injection of bevacizumab along with pars planavitrectomy. in the past, the mainstay of treatment in patients with painful blind eyes along with cholesterosisbulbi has been enucleation, mainly due to ineffective treatment available and potential risk of sympathetic ophthalmitis9,11. with advances in therapeutic ophthalmology in the form of better anti-glaucoma therapy, potentially more effective anti inflammatory medications, lasers and anti-vascular endothelial growth factor agents, a more conservative and cosmetically acceptable approach has been adopted for such cases. such cases need to be in a close follow up so that additional and alternative treatment can be offered in the event of recurrent or persistently uncomfortable eye. author’s affiliation dr. haroon tayyab medical officer department of ophthalmology jinnah hospital lahore dr. muhammad ali haider medical officer layton rehmatullah benevolent trust township, lahore dr. tehmina jahangir medical officer department of ophthalmology jinnah hospital lahore dr. sana jahangir medical officer department of ophthalmology jinnah hospital lahore professor dr. samina jahangir head department of ophthalmology jinnah hospital lahore haroon tayyab et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 52 reference 1. spencer wh. ophthalmic pathology: an atlas and textbook. 4th ed., philadelphia. saunders, 1996. 2. kanski jj, bowling b. clinical ophthalmology: a systemic approach. 7th ed., london. saunders. 2011; 730. 3. park j, lee h, kim yk, et al. a case of cholesterosis bulbi with secondary glaucoma treated by vitrectomy and intravitreal bevacizumab. korean j ophthalmol. 2011; 25: 362-5. 4. forsius h. cholesterol crystals in the anterior chamber. a clinical and chemical study of 7 cases. actaophthalmol (copenh). 1961; 39: 284-301. 5. mielke j, freudenthaler n, schlote t, et al. pseudohypopyon of cholesterol crystals occurring 16 years after retinal detachment in x-linked retinoschisis. klinmonblaugenheilkd. 2001; 218: 741-3. 6. kennedy cj. the pathogenesis of polychromatic cholesterol crystals in the anterior chamber. aust n z j ophthalmol. 1996; 24: 267-73. 7. kumar s. cholesterol crystals in the anterior chamber. br j ophthalmol. 1963; 47: 295-9. 8. andrews js, lynn c, scobey jw, et al. cholesterosisbulbi. case report with modern chemical identification of the ubiquitous crystals. br j ophthalmol. 1973; 57: 838-44. 9. eagle rc jr, yanoff m. cholesterolosis of the anterior chamber. albrecht von graefes arch klin exp ophthalmol. 1975; 193: 121-34. 10. awan kj. crystals in aqueous humor of normal eye. ann ophthalmol. 1978; 10: 37-9. 11. yu ys, kwak hw, youn dh. cholesterol crystals in the anterior chamber. j korean ophthalmol soc. 1980; 21: 117-9. 84 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology original article initial experience of corneal collagen cross linking in progressive keratoconus munira shakir, faiza rameez, shakir zafar, muhammad ahsan sulaiman pak j ophthalmol 2018, vol. 34, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: munira shakir liaquat national hospital, stadium road, karachi, pakistan email: dr_munirasz@yahoo.com …..……………………….. purpose: to assess the outcome of corneal collagen cross-linking (ccxl) in patients with progressive keratoconus in terms of satisfaction. study design: descriptive case series. place and duration of study: this study was conducted at liaquat national hospital, karachi, pakistan. it documents a process that is spread on one year. material and methods: this prospective study is comprised of 34 patients who had bilateral corneal cross linking (cxl) treatment for progressive keratoconus. analysis was performed in terms of amount of corneal flattening (observed through topography), effect on vision (observed through snellen’s chart) and satisfaction of patient (assessed by filling of proforma 6 months postoperatively). results:. findings of 31 cases were analyzed as 3 cases missed the follow-up. mean age was 23.2 ± 5.5 years. 61.3% of the cases were males while 38.7% were females with respective frequency of 19 and 12. mean post-operative bcva on snellen’s chart improved on average by more than one line. postoperative mean of change in steepest k reading was 1.29 ± 0.52d. 16.13% of the cases were happy after treatment, while 64.52% were satisfied. however, 19.35% of the cases were unhappy. conclusion: this study shows that cxl retards progression and generally brings satisfaction among the participants. keywords: corneal collagen cross linking, keratoconus, corneal topography. eratoconus is a condition characterized by corneal steepening typically inferior to central cornea with corneal thinning, induced myopia and both regular and irregular stigmatism. it is usually a bilateral condition and is noninflammatory1. the onset is around puberty with slow progression until third and fourth decades of life. many treatment options are available including conservative options such as spectacles and rigid contact lenses. surgical options for the treatment include: intra-corneal ring segments; phakic intra ocular lens (iol); refractive lens exchange (rle); anterior lamellar keratoplasty (alk); and penetrating keratoplasty (pk)1-3. a disturbed cross-linking within or among the collagen molecule has been observed in keratoconus. by photo-oxidative collagen cross-linking with riboflavin and ultra violet light, additional covalent bindings between the collagen molecules is achieved which stabilizes the collagen scaffold1. eberhard spoesi and theo sieler developed corneal cross linking (cxl) procedure in late 1990s4. wollensak et al5 believed that collagen cross-linking was becoming a standard treatment for keratoconus. the aim of this case series is to evaluate the results of cxl in the patients with progressive keratoconus and the index of patient satisfaction is being used as a main gauge for proving its effectiveness. k initial experience of corneal collagen cross linking in progressive keratoconus pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 85 material and methods this study documents an ongoing case series, which was conducted in liaquat national hospital, karachi, pakistan. 34 cases of more than 10 years with central corneal ectasia and having commitment to follow up of six months were included in the study. each patient was first time assessed at day one, then after a week, then monthly for 6 months and corneal topography was repeated at 3 and 6 months. patients filled a proforma after topography. exclusion criteria for this study was; any patient having corneal thickness less than 400μm6; corneal scarring in the eye to be treated; loss to follow-up; prior history of corneal surgery. this study was conducted after getting an informed written consent of all the participants. it was carried out under the supervision of an advisory committee. pre-operative complete ocular checkup was done including: visual acuity; best corrected visual acuity (bcva) through snellen’s chart; iop through goldman applanation tonometer; corneal topography by pentacam; and pachymetry (ultrasonic and pentacam). further relevant information was collected, using a proforma, on follow ups. the cxl was done as a day-care procedure under sterilized environment. table-1 shows the inclusion criteria for this study, which is similar to o’bart et al7. table 1: inclusion criteria. 1. age between 16 – 35 2. no prior history of ocular surgery 3. steepest k value between 48d and 60d 5. corneal thickness > 400μm 6. patient must meet the diagnostic criteria for keratoconus8 7. progression verified by corneal topography i.e.: change of max. k by 1d9 cbm vega x-linker – device that emits uv radiation at 365-370nm after proper calibration to direct 5.4 j/cm2 to the cornea – was used on all the participant of this study. pre-operative antibiotics were given after the instillation of anesthetic drops. seiler or epi-off technique was used. a lid speculum was applied. after removing the epithelium, drops of riboflavin 0.1% (vitamin b2) were given at 1-5 minutes for 30 minutes or until it is visible in the anterior chamber. after riboflavin absorption, the participant was exposed to the uv light which was placed closer i.e. 1-5 cm from the corneal apex. a small digital video camera was included in the ultra-violet a (uva) array in order to monitor the aiming beam. following irradiation, cornea was rinsed with chilled saline, drops of antibiotic were applied and bandage contact lens (bcl) was placed. post-operatively, topical antibiotics, topical steroids (4 times a day), artificial tears, painkiller and oral vitamin-c were given. bcl was removed after 3-4 days. this post-operative regimen was in line with sherif et al10. data were analyzed using minitab. mean and standard deviation (sd) were used to define the variables. frequency and percentage were used to define variables such as satisfaction index (ordinal variable) and gender. descriptive statistics were developed and presented in the section of results. pvalue < 0.05 was considered as significant for normality testing of data. correlation of the two interval variables (vision improvement and flattening) was further determined using pearson coefficient. results 34 cases were studied for this research; however, three cases were lost for follow-up. analysis of the remaining 31 cases, who completed the follow-up, was carried out. all cases had progressive keratoconus, and other ectasias were excluded from this study. for corneal stabilization, preand post-operative topographic readings were taken as criteria. in addition, bcva was carried out through snellen’s chart and was taken as another criterion. 61.3% of the cases were males while 38.7% were females with respective frequency of 19 and 12. mean age was 23.2 ± 5.5 years. mean post-operative bcva on snellen’s chart improved by more than one line. specifically, the mean of change in vision improvement on snellen’s chart was additional 1.5 ± 0.62 lines. post-operative mean of change in steepest k reading was 1.29 ± 0.52d as shown in table 2. this shows improvement as the topographic findings showed lesser steepening postoperative. normality test was applied on each variable’s distribution, which were found to be nonnormal (p < 0.1); therefore, parametric statistical methods cannot be used and the scope was limited to descriptive statistics. at 6 months post-operative, a proforma (placed as munira shakir, et al 86 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology table 2: post-operative description of variables. variables mean* sd p-value for normality** flattening 1.2903 0.5211 < 0.006 vision improvement 1.5145 0.6151 < 0.005 *mean: for flattening read’ mean decrease in steepening’, and; for vision improvement read’ mean additional lines on snellen’s chart’ **anderson-darling normality test was used. as the pvalues are lower than 0.1 significance level, the data do not follow the normal distribution fig. 1: satisfaction response (n = 31). appendix) was filled for each case to gage the satisfaction. it had three options: happy, satisfied and unhappy; thus making it an ordinal variable. 16.13% of the cases were happy after treatment, while 64.52% were satisfied. however, 19.35% of the cases were unhappy, as shown in figure-1. none of the cases developed any complications. discussion we have found a significant flattening in the steepest k value in all the patients similar to the results of wollensak et al5 in whose study the decrease of mean keratometer value was by 2.01 d. as compared to other therapeutic measures used for the treatment of keratoconus such as: intra-corneal ring1,11; and epi-keratoplasty1; hovkimyan et al12, showed that cxl can be regarded as a useful approach to reduce number of keratoplasties. wollensak et al13, in their study showed that mechanical rigidity increases in porcine corneas, while they reported greater increase in human corneas. figure-2 visually describes the mean flattening and mean vision improvements in our cases. both distributions were found to be uni-modal and negatively skewed (as shown by the box plots as well). furthermore, figure-3 presents the scatter plot developed between these two interval variables. it manifests a marginal positive correlation, which can be testified by the value of 0.779 of pearson’s correlation coefficient. the findings of our study are in agreement with several earlier studies4,5,14-16 that proved the significant improvement in visual acuity and maximum keratometry as well as retarding progression after cxl. however, our study further takes into account the satisfaction of the patients who went through the (a) (b) fig. 2(a): description of flattening (mean line). fig. 2(b): description of vision improvement (mean d) initial experience of corneal collagen cross linking in progressive keratoconus pakistan journal of ophthalmology vol. 34, no. 2, apr – jun, 2018 87 procedure. this was carried out using a designed proforma. fig. 3: scatter plot of vision (mean d) versus flattening (mean line). wolensak et al.17 in their study showed that riboflavin/uva treatment is safe for endothelium only when the dose is below 0.65 j/cm2 and cornea should not be less than 400 μm thick. adverse outcomes have also been reported in different studies. wolensak et al.18 reported dose dependent keratocyte damage after riboflavin/uva treatment, which can be expected in human corneas down to a depth of 300 μm using a surface uva dose of 5.4 j/cm2. wolensak et al19, indicated that combined riboflavin/uva treatment leads to 10 fold lower threshold for keratocyte cytotoxicity at 0.5 mw/cm2 compared to 5 mw/cm2 after uva irradiation alone. conclusion cxl has proved to be a safer and an effective procedure in the treatment of progressive keratoconus and it usually results in satisfaction of the patient in terms of improvement of vision and retardation of the progression. other studies have similar conclusions20. author’s affiliation dr. munira shakir fcps, frcs ophthalmology associate professor liaquat national hospital, karachi. dr. faiza rameez mbbs, r5 ophthalmology liaquat national hospital, karachi. dr. shakir zafar fcps ophthalmology united medical & dental college, karachi. muhammad ahsan sulaiman final year medical student liaquat national hospital, karachi. role of authors dr. munira shakir surgeon who provided all the cases and who did all the surgeries. she is also a major contributor in writing this paper. dr. faiza rameez she assisted the surgeon in the surgeries. majorly wrote the paper along with data collection and carrying out all descriptive statistics. dr. shakir zafar surgeon whose experience was highly beneficial in analysis and conclusions of the findings. dr. muhammad ahsan sulaiman data collection and all data entry. references 1. pinelli r, leccisotti a. keratoconus surgery and crosslinking: jaypee brothers medical publishers; 2009. 2. kanski jj. clinical ophthalmology: a systematic approach: elsevier; 2007. 3. sandvik gf, thorsrud a, råen m, østern ae, sæthre m, drolsum l. does corneal collagen cross-linking reduce the need for keratoplasties in patients with keratoconus? cornea, 2015; 34 (9): 991-5. 4. khan md, ameen ss, ishtiaq o, niazi mk, araeen ma, naz ma, et al. preliminary results of uv-a riboflavin cross linking in progressive cases of keratoconus, in pakistan population. pak j ophthalmol. 2011; 27 (1): 21-6. 5. wollensak g, spoerl e, seiler t. riboflavin/ ultraviolet-a-induced collagen cross linking for the treatment of keratoconus. am j ophthalmol. 2003; 135: 620-7. 6. theuring a, spoerl e, pillunat l, raiskup f. corneal collagen cross-linking with riboflavin and ultraviolet-a light in progressive keratoconus. results after 10-year follow-up. ophthalmologe, 2015; 112 (2): 140-7. 7. o'brart dp, kwong tq, patel p, mcdonald rj, o'brart na. long-term follow-up of riboflavin/ultraviolet a (370 nm) corneal collagen cross-linking to halt the progression of keratoconus. br j ophthalmol. 2013; 97 (4): 433-7. 8. spoerl e, wollensak g, dittert d-d, seiler t. thermomechanical behavior of collagen-cross-linked munira shakir, et al 88 vol. 34, no. 2, apr – jun, 2018 pakistan journal of ophthalmology porcine cornea. ophthalmologica, 2004; 218 (2): 136-40. 9. bikbova g, bikbov m. transepithelial corneal collagen cross‐linking by iontophoresis of riboflavin. acta ophthalmol. 2014; 92 (1). 10. sherif am, ammar m, mostafa y, gamal eldin s, osman a. one-year results of simultaneous topography-guided photorefractive keratectomy and corneal collagen cross-linking in keratoconus utilizing a modern ablation software. j ophthalmol. 2015; 2015. 11. chan cc, sharma m, wachler bsb. effect of inferiorsegment intacs with and without c3-r on keratoconus. j cataract refract surg. 2007; 33 (1): 75-80. 12. hovakimyan m, guthoff rf, stachs o. collagen cross-linking: current status and future directions j ophthalmol. 2012: 1-12. 13. wollensak g, spoerl e, seiler t. stress-strain measurements of human and porcine corneas after riboflavin-ultraviolet-a-induced cross-linking. j cataract refract surg. 2003; 29: 1780-5. 14. toprak i, yaylali v, yildirim c. factors affecting outcomes of corneal collagen corsslinking treatment. eye, 2014; 28: 41-6. 15. kymionis gd, grentzelos ma, liakopoulos da, paraskevopoulos ta, klados ne, tsoulnaras ki, et al. long-term follow-up of corneal collagen cross-linking for keratoconus—the cretan study. cornea, 2014; 33 (10): 1071-9. 16. sykakis e, karim r, evans jr, bunce c, amissah‐arthur kn, patwary s, et al. corneal collagen cross‐linking for treating keratoconus. cochrane libr.2015. 17. wollensak g, spoerl e, wilsch m, seiler t. endothelial cell damage after riboflavin-ultraviolet-a treatment in rabbit. j cataract refract surg. 2003; 29: 1786-90. 18. wollensak g, spoerl e, wilsch m, seiler t. keratocyte apoptosis after corneal collagen cross-linking using riboflavin/uva treatment. cornea, 2004; 23 (1): 43-9. 19. wollensak g, spoerl e, reber f, seiler t. keratocyte cytotoxicity of riboflavin/uva-treatment in vitro. eye, 2004: 1-5. 20. meiri z, keren s, rosenblatt a, sarig t, shenhav l, varssano d. efficacy of corneal collagen cross-linking for the treatment of keratoconus: a systematic review and meta-analysis. cornea, 2016; 35 (3): 417-28. microsoft word sulaman himza 138 original article amniotic membrane transplantation in ocular surface disorders muhammad salman hamza, m. rizwan ullah, anwaar ul haq hashmi, imran akram sahaf pak j ophthalmol 2011, vol. 27 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad salman hamza institute of ophthalmology kemu/mayo hospital lahore submission of paper april’ 2011 acceptance for publication august’ 2011 …..……………………….. purpose: to evaluate the usefulness of amniotic membrane in the patients with ocular surface diseases. material and methods: this case series study of one year duration was conducted in institute of ophthalmology, mayo hospital lahore. 30 patients having ocular surface disorders were treated with amniotic membrane transplant (amt) and improvement in the signs and symptoms of ocular irritation like pain, photophobia was evaluated. results: out of 30 patients 18 (60%) were male and 12 (40 %) female. ocular surface disorders include 8 (26.7%) cases of bullous keratopathy, 5 (16.7%) mooren’s ulcer, 5 (16.7%) shabbir syndrome, 4(13.3%) impending perforations, 3 (10.0%) chemical injury, 3 (10%) steven johnson syndrome and 2 (6.7%) cases of neurotrophic ulcer. more than 90% of the cases after amt showed remarkable improvement in the symptoms of ocular irritation. conclusion: amniotic membrane is a useful material for the treatment of ocular surface disorders. he normal ocular surface is covered by epithelial cells which can be1 damaged by certain systemic inflammatory diseases,1 primary ocular diseases, and trauma resulting in the breakdown of ocular surface.2 if the normal epithelialization process fails ocular defect becomes chronic. chronic inflammation leads to neovascularization, corneal scarring, opacification, corneal thinning, and possible corneal perforation. traditional treatments for ocular surface disorders include correcting underlying pathology, suppressing inflammation and promoting healing process. currently, artificial tears, lubricants, fibronectins,3,4 growth factors,5 and substance p6 are used. however, if defect persists and stromal thinning develops, more invasive surgical options like tissue adhesive7, bandage contact lens,8 conjunctival flap9, and tarsorrhaphy can be performed10. but these treatments have their own complications. in this background amniotic membrane can be considered as an option for treating the ocular surface defects3,4. in 1910, davis reported the use of fetal membrane in skin transplantation for the first time11. amniotic membrane transplantation in ophthalmology was reported by de roth in 1914 who achieved partial success in treatment of conjunctival epithelial defects12. there was very little information available in ophthalmic literature until the study by kim and tseng in 1995 who used amniotic membrane transplantation for ocular surface reconstruction of severely damaged cornea in rabbit model. since that experimental study, amniotic membrane transplanttation has been used for persistent corneal epithelial defects, neurotrophic corneal ulcers, conjunctival surface reconstruction, bullous keratopathy, chemical or thermal burns and in patients of steven-johnson syndrome13-15. ocular surface disorders are a common problem and current management is not satisfactory. amniotic membrane transplantation has shown better results in treating these disorders. in pakistan, a very little work has been done so far in this regard. so, i scientifically studied this new technique in local setup. t 139 material and methods this case series was conducted at institute of ophthalmology, mayo hospital lahore for one year starting from 13 january 2008 with non-probability purposive sampling. thirty cases with ocular surface diseases were included. age of patients was 18 70 years. patients with any active ocular infection or with perforated globes were excluded from surgery. preparation of amniotic membrane: amniotic membrane was obtained from prospective donors undergoing caesarean section, who were negative for communicable diseases including hiv, hepatitis and syphilis. different protocols exist for the processing and storage. we used protocol described by kim et al16. according to which placenta is cleaned and stored with balanced salt solution containing a cocktail of antibiotics (table 1) under sterile conditions. surgical techniques i. inlay or graft technique: when amniotic membrane is tailored to the size of the defect, is meant to act as a scaffold for the epithelial cells and which then merges with the host tissue, it is referred to as a graft.17 amniotic membrane was secured with its basement membrane or epithelial side up to allow migration of the surrounding epithelial cells on the membrane (fig. 1). ii. overlay or patch technique: when the amniotic membrane is used akin to a biological contact lens in order to protect the healing surface defect beneath; it is referred to as a patch18. a patch also reduces inflammation by its barrier effect against the chemical mediators from the tear film. when used as patch the membrane is secured with its epithelial side up and it either falls off or is removed. iii. filling-in or layered technique: in this technique the entire depth of an ulcer crater is filled with small pieces of am trimmed to the size of the defect. a larger graft is sutured to the edges of the defect in an inlay fashion and an additional patch may help in preserving the deeper layers for a longer duration19. preoperative evaluation was applied to all patients with special attention given to patient’s symptoms with respect to pain and photophobia, best corrected visual acuity. follow up was done at first post operative day, 1st week, 2nd week and 1 month for best corrected visual acuity, ocular symptoms (pain and photophobia) and complications. the data was analyzed by spss version 10.00, the variables of outcome measures (pain, photophobia, best corrected visual acuity, graft uptake) was presented as proportions and ratios. the variables of outcome were compared with some of variables of demography. since this study was a quasi experimental, no test of significance was necessary. results of the 30 patients of different ocular surface disorders 18 were males (60%) and 12 were females (40 %). ocular surface disorders of various types were included in this study, most was the bullous keratopathy 8 (26.7%) followed by mooren’s ulcer 5 (16.7%), shabbir syndrome 5 (16.7%), impending perforations 4(13.3%), chemical injury 3 (10.0%), steven johnson syndrome 3 (10%) and 2 (6.7%) cases of neurotrophic ulcer. the ocular surface defects was present in both eyes of 9 (30.0%) cases. 13 (43.3%) cases had these defects in right eye, while 8 (26.7%) cases left eye was involved out of total 30 cases. ocular pain was one of the most important variable of study. it was recorded on the pain scale from grade 0 – 4 as described by the patient. three (10.0%) patients did not complain any pain (grade 0). six (20.0%) cases had mild pain (grade 1).seven (23.3%) cases were having moderate pain (grade 2). thirteen (43.3%) patients described severe pain. one (3.3%) case was having maximum pain imaginable (fig.2). after one month of amniotic membrane transplantation, most of the patients 25 (83.3%) were having no pain (grade 0). only 2 (6.7%) and 3 (10.0%) patients described mild (grade 1) and moderate (grade 2) pain. no patient described grade 3 and 4 level of pain (fig. 3). twenty seven (90%) of the patients were photophobic, only 3 (10.0%) out of 30 did not complain of photophobia. a remarkable improvement was noted in this regard. at one month after surgery, 26 (86.7%) patients did not complain of photophobia and only 4 (13.3%) cases were still complaining of it. there was a little improvement of best corrected visual acuity noted, after 1month of surgery 4 (13.3%) had best corrected visual acuity 6/12, while 1 (3.3%) case had 6/18 and 2 (6.7%) patients were having 6/24. majority of the cases 23 (67%) were still having best corrected visual acuity 6/60 or less. 140 table 1: contents and concentrations of antibiotics solution antimicrobial agent dose penicillin 50 mg/ml streptomycin 50 µg/ml neomycin 100 mg/ml amphotericin b 2.5 mg/ml a b fig.1: inlay technique used on mooren’s ulcer a. pre operative b. post operative 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 0 1 2 3 4 0 1 2 3 4 fig. 2: pre operative pain grade 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 0 1 2 3 4 0 1 2 3 4 fig. 3: post operative pain grade discussion ocular surface disorders are a common problem that presents not only with decrease of vision but also pain and photophobia. unfortunately, its currently medical or surgical treatment has not shown satisfactory results so far. amniotic membrane that had been used for other purposes like biological dressing to cover the open wounds and skin transplantation, have also shown good results in ocular surface defects healing and thus relieving the symptoms of ocular irritation. human amniotic membrane is derived from the fetal membranes and is loosely attached to the chorion. 20 it is composed of three layers: a single epithelial layer, thick basement membrane, and a vascular stroma. human amniotic membrane has been shown to contain collagen types iii and v. it also contains collagen types iv and vii similar to corneal epithelial basement membrane as well as fibronectin and laminin21. additionally, it contains fibroblast and other growth factors. amnion prevents inflammatory cell infiltration and reduces apoptosis in keratocytes after transplantation onto the corneal surface22. due to all these properties amniotic membrane transplantation is found to be an important tool for reconstruction of ocular surface disorders. reduction in symptoms of ocular irritation that includes pain and photophobia was 90 % in our study which is comparable to the other studies23. increased comfort level, improved the quality of life of the patients. there was no remarkable improvement in best corrected visual acuity observed in our study. the final visual acuity less than 6/60 was recorded in 67 % of cases in our study which was quite similar to study by prabhasawat p, tesavibul n who also observed the similar ratio in their study23. however increased comfort level improved the quality of life of these patients and visual acuity was not the issue in these patients. failure was noted in 3 (10%) cases in our study. this was due to graft necrosis, active infection and intractable corneal perforation. this failure points out the limitations of amt in treating ocular surface disorders. the possible causes of failure could be, continuous tissue destruction compounded with active infection underneath the graft had retarded healing and secondly there might have been inadequate limbal stem cells and intact sensory innervations which is mandatory for repairing and maintaining ocular surface integrity24. thirdly normal 141 keratocytes from adjacent area might be important in restoring stromal integrity after amt. the results of study showed that amniotic membrane transplantation is effective in ocular surface disorders when all other existing methods of management fail. conclusion amniotic membrane transplantation appears to be a useful method to alleviate symptoms of ocular surface irritation like pain, photophobia and lacrimation caused by the ocular surface disorders. it does not only heal the corneal surface defect but also helps in preserving the globe. the future studies are required for further elaboration of usefulness of this tissue. author’s affiliation dr. muhammad salman hamza institute of ophthalmology kemu/mayo hospital lahore dr. m. rizwan ullah institute of ophthalmology lahore general hospital (lgh) lahore dr. anwaar hashmi institute of ophthalmology kemu/mayo hospital lahore dr. imran akram sahaf institute of ophthalmology lahore general hospital (lgh) lahore reference 1. mejia lf, acosta c, santamaria p. use of nonpreserved human amniotic membrane for the reconstruction of ocular surface. cornea. 2000; 19: 288-91 2. sangwan vs, tseng scg. new perspectives in ocular surface disorders. an integrated approach for diagnosis and management. indian j ophthalmol. 2001; 49:153-68. 3. spigelman av, deutsch ta, sugar j. application of homologous fibronectin to persistent human corneal epithelial defects. cornea. 1987; 104: 494-501. 4. nishida t, nakagawa s, manabe r. clinical evaluation of ibronection eye drops on epithelial disorders after herpetic keratitis. ophthalmology. 1985; 92: 213-16. 5. feldman st. the effect of epidermal growth factor on corneal wound healing: practical consideration of therapeutic use. refract corneal surg. 1991; 7: 232-9. 6. brown sm, lamberts dw, reid tw, et al. neurotrophic and anhidrotic keratopathy treated with substance p and insulinlike growth factor i. arch ophthalmol. 1997; 115: 926-7. 7. globovic s, paronovic a. cyanoacrylate glue in the treatment of corneal ulcerations. fortschr ophthalmol. 1990; 87: 378-81. 8. pfiser rr. clinical measures to promote corneal epithelial healing. acta ophthalmol. 1992; 70: 78-83. 9. lugo m, arentsen jj. treatment of neurotrophic ulcers with conjunctival flaps. am j ophthalmol. 1987; 103: 711-2. 10. welch c, baum j. tarsorrhaphy for corneal disease in patients with rheumatoid arthritis. ophthalmol surg. 1988;19:31-32 11. davis jw. skin transplantation with a review of 550 cases at the johns hopkins hospital. johns hopkins med j. 1910; 15: 307-96. 12. de rotth a. plastic repair of conjunctival defects with fetal membranes. arch ophthalmol. 1940; 23: 522-5. 13. shimazaki j, yang hy, tsubota k. amniotic membrane transplantation for ocular surface reconstruction in patients with chemical and thermal burns. ophthalmology. 1997; 104: 2068-76. 14. meller d, pires rt, mack rjs. amniotic membrane transplantation for acute chemical and thermal burns. ophthalmology. 2000; 107: 980-90. 15. ucakhan oo, koklu g, firat e. nonpreserved human amniotic membrane transplantation in acute and chronic chemical eye injuries. cornea. 2002; 21: 169-72. 16. kim jc, tseng sc. transplantation of preserved human amniotic membrane for surface reconstruction in severely damaged rabbit corneas. cornea. 1995; 14: 473-84. 17. sippel kc, ma jj, foster cs. amniotic membrane surgery. curr opin ophthalmol. 2001; 12: 269-81 18. azuara-blanco a, pillai ct, dua hs. amniotic membrane transplantation for ocular surface reconstruction. br j ophthalmol. 1999; 83: 300-402. 19. hanada k, shimazaki j, shimmura s, et al. multilayered amniotic membrane transplantation for severe ulceration of the cornea and sclera. am j ophthalmol. 2001;131:324-31 20. trelford jd, trelford-sauder m. the amnion in surgery, past and present. am j obstet and gynecol. 1979; 134: 833-45. 21. fukada k, chikama t, nakamura m, et al. differential distribution of subchains of the basement membrane components type iv collagen and laminin among the amniotic membrane, cornea, and conjunctiva. cornea. 1999; 18: 73-9. 22. wang m, gray t, prabhasawat p, et al. corneal haze is reduced by amniotic membrane matrix in excimer laser photoablation in rabbits. invest ophthalmol vis sci. 1997; 38: 405. 23. prabhasawat p, tesavibul n, omolsuradej w. single and multilayer amniotic membrane transplantation for persistent corneal epithelial defect with and without stromal thinning and perforation. br j ophthalmol. 2001; 85: 1455-63. 24. van herendael bj, oberti c, brosens i. microanatomy of the human amniotic membranes. am j obstet gynecol. 1978; 131: 872-8. microsoft word 12. m imran pakistan journal of ophthalmology vol. 28, no. 3, jul – sep, 2012 161 case report presentation of posner schlossman syndrome and viral uveitis muhammad imran, ashraf ali tayyab, muhammad safdar iqbal pak j ophthalmol 2012, vol. 28 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad imran post graduation trainee nishtar hospital multan …..……………………….. purpose: to discuss an interesting case in which treatment of posner schlossman syndrome lead to unmasking signs of viral uveitis. clinical management: a patients was brought to nishtar hospital multan for management of unilateral raised intra ocular pressure (iop) being caused by anterior uveitis. first examination revealed posner schlossman syndrome as a diagnosis of exclusion. after 48 hours of treatment features of viral uveitis appeared that lead to change the diagnosis. osner schlossman syndrome is an infla mmatory condition that leads to raised intra ocular pressure (iop)due to trabeculitis1. it affects patients between the ages of 2050 years2. it has no clear etiology. it is also known as glaucoma to cyclitic crsis. it usually presents as unilateral, episodic, recurrent attacks of elevated intra-ocular-pressure along with mild anterior uveitis, usually with no posterior synechae. multiple mechanisms may be responsible for most cases of uveitic glaucoma. herpes uveitis may directly cause trabeculitis and thus increase iop. in addition inflammatory cells can cause trabecular obstruction. case report this is an observational case report carried out at nishtar hospital multan. a patient was examined in out patient department and was admitted in ward for the management. a male 38 years old presented with moderate pain in right eye for two days, it was associated with vomiting and severe right sided headache. examination revealed ciliary congestion, cornea clear, anterior chamber reactivity +3, no kp’s, no flare, anterior chamber angle was widely open (grade iv in 360 degree). iop was 44mmhg in right side and 18mmhg on left side. pupil was reactive, round. lens was clear, posterior segment showed no reactivity and retina was flat. cup disc ratio was 0.5-0.6 on right side and 0.4 on left side. other eye was quite normal. no history of ihd, tb, dm, joint pain and allergy. no family history of such ailment was found. provisional diagnosis was made of possner schlosman syndrome. topical acetazolamide + timolol +apraclonidine along with oral acetazolamide were started to lower the iop. intensive topical steroids were started to minimize anterior chamber activity. on the second post treatment day the patient had corneal haze with few punctate epithelial types of erosion. detailed slit lamp examination shows presence of weiss ring in deep stroma. diagnosis was reconsidered and changed to viral keratouveitis4. therapy was modified to oral valacyclovir 1 g 3 times / day along with topical antiviral and anti-glaucoma therapy4. mild steroids were also added in regimen under the cover of anti-viral and topical antibiotics. patient was observed for 3 days and it was found that reactivity responded well, corneal haze was also responding. patient was discharged on medicine after making sure for close follow-up. on first follow-up after 7 days his corneal haze was markedly reduced and there was no reactivity, iop was controlled. discussion in 1948, posner and schlossman first recognized glaucomatocyclitic crisis and described the features of this syndrome6. posner and schlossman identified the following features as recurrent episodes of mild p muhammad imran, et al 162 vol. 28, no. 3, jul – sep, 2012 pakistan journal of ophthalmology fig. central keratitis after steroid therapy cyclitis, uniocular involvement, duration of attack varying from a few hours to several weeks, signs of a slight decrease in vision, elevated iop in the range of 40 – 60 mmhg with open angles, corneal oedema with a few keratic precipitates, heterochromia with anisocoria, and a large pupil in the affected eye. normal visual fields, normal optic disc, normal iop, outflow facility and all provocative tests between episodes5. between attacks there are generally no signs or symptoms of inflammation or glaucoma and contra lateral eye is usually normal. episodic changes in the trabecular meshwork lead to impairment of outflow facility and result in an elevation of iop. these changes are accompanied by mild intraocular inflammation. in the acute phase of pss, optic nerve head parameters and retinal flow rates were altered; however, all returned to normal without any permanent damage after control of the elevated iop. electroretinogram studies in the acute phase demonstrate a selective reduction in the s-cone b-wave7. it is usually of unknown etiology but cytomegalovirus8 and herpetic9 infections have been reported. a significant number of patients with pss develop glaucoma over time and they need to have their optic disc appearance and visual field carefully monitored. conclusion it has been found in this study that viral uveitis and posner schlossman syndrome, both, may present with same signs as reactivity, raised intra ocular pressure etc until confirmation of diagnosis. author’s affiliation dr. muhammad imran post graduation trainee nishtar hospital multan dr. ashraf ali tayyab professor of ophthalmology nishtar hospital multan dr. muhammad safdar iqbal senior consultant ophthalmologist nishtar hospital multan reference 1. scott ks, wade nk. posner-schlossman syndrome (a patient education monograph) american uveitis society; february 2003. 2. harrington jr. (pss a case report) journal of american optometric association. 1999: 70: 715-23. 3. dinakaran s, kayarkar v. trabeculectomy in the management of posner-schlossman syndrome. ophthalmic surg lasers. 2002; 33: 321-2. 4. posner a, schlossman a. syndrome of unilateral recurrent attacks of glaucoma with cyclitic symptoms. arch ophthalmol. 1948; 39: 517. 5. posner a, schlossman a. further observations on the syndrome of glaucomatocyclitic crisis. trans am acad ophthalmol otolaryngol. 1953; 57: 531. 6. maeda h, nakamura m, negi a. selective reduction of the scone component of the electroretinogram in posnerschlossman syndrome. eye. 2001; 15: 163-7. 7. bloch-michel e, dussaix e, cerqueti p, et al. possible role of cytomegalovirus infection in the etiology of the posnerschlossman syndrome. int ophthalmol. 1987; 11: 95-6. microsoft word 14-abstracts 57 vol. 29, no. 1, jan – mar, 2013 pakistan journal of ophthalmology abstracts edited by dr. qasim lateef chaudhry treatment of coats’ disease with intravitreal bevacizumab ray r, david e barañano, g baker hubbard br j ophthalmo. 2013; 97: 272–7. robin et al compared the efficacy of intravitreal bevacizumab plus ablative therapy with ablative therapy alone for coats’ disease in this retrospective review of all paediatric patients who received treatment for coats’ disease from a single surgeon (gbh) from 1st january 2001 to 31st march 2010. ten consecutive patients who received intravitreal bevacizumab as part of their treatment were matched to 10 patients treated with ablative therapy alone by macular appearance, quadrants of subretinal fluid, and quadrants of telangiectasias. outcomes evaluated were number of treatment sessions, time to full treatment, and resolution of disease. the results showed that there was no statistical difference between baseline characteristics when comparing the bevacizumab and control groups. eyes treated with bevacizumab required more treatments over a longer time period compared to the control group. all patients in the bevacizumab group were successfully treated while two of the patients in the control group failed ablative techniques. so the authors concluded that intravitreal bevacizumab may play a role as adjuvant therapy in selected cases of coats’ disease, but its use does not reduce the time to full treatment. resolution of disease was seen in the most severe cases treated with bevacizumab plus thermal ablation whereas their matched controls failed therapy with laser and cryotherapy alone. lesions simulating retinoblastoma (pseudoretinoblastoma) in 604 cases results based on age at presentation shields cl, schoenberg e, kocher k, shukla sy, kaliki s, shields ja ophthalmology. 2013; 120: 311-6. this retrospective case series study was conducted by carol et al to determine the types and frequency of ocular conditions which simulate as retinoblastoma (pseudoretinoblastoma) based on age at presentation. the chart of two thousand seven hundred seventy-five patients referred for the management of retinoblastoma were reviewed by the authors and conditions simulating retinoblastoma were noted. of 2775 patients referred, 2171 patients (78%) had confirmed retinoblastoma and 604 patients (22%) had simulating lesions (pseudoretinoblastomas). in the pseudoretinoblastoma cohort, the mean patient age at presentation was 4 years (median, 2 years). there were 27 different pseudoretinoblastoma conditions and the 10 most common included coats’ disease (n _ 244; 40%), persistent fetal vasculature (pfv; n _ 158; 28%), vitreous haemorrhage (n _ 27; 5%), ocular toxocariasis (n _ 22; 4%), familial exudative vitreoretinopathy (fevr; n _ 18; 3%), rhegmatogenous retinal detachment (n _ 18; 3%), coloboma (n _ 17; 3%), astrocytic hamartoma (n _ 15; 2%), combined hamartoma of retina and retinal pigment epithelium (n _ 15; 2%), and endogenous endophthalmitis (n _ 10; 2%). simulating lesions differed based on age at presentation, and children younger than 1 year were most likely to have pfv (49%), coats’ disease (20%), or vitreous hemorrhage (7%); those 2 to 5 years of age were most likely to have coats’ disease (61%), toxocariasis (8%), or pfv (7%); and those older than 5 years were most likely to have coats’ disease (57%), toxocariasis (8%), or fevr (6%). in conclusion the most common pseudoretinoblastomas included coats’ disease, pfv, and vitreous hemorrhage, but the spectrum varies depending on patient age. long-term rejection incidence and reversibility after penetrating and lamellar keratoplasty guilbert e, bullet j, sandali o, basli e, laroche l, borderie vm am j ophthalmol. 2013; 155: 560–569 this institutional retrospective cohort study by emmanuel et al was done to identify risk factors for corneal graft rejection and rejection irreversibility. a total of 1438 consecutive eyes of 1438 patients who underwent corneal transplantation for optical indication at the centre hospitalier national abstracts pakistan journal of ophthalmology vol. 29, no. 1, jan – mar, 2013 58 d’ophtalmologie des xv-xx, paris, france, between december 1992 and december 2010 were studied. surgical technique was penetrating keratoplasty (pk) in 1209 cases, anterior lamellar keratoplasty (alk) in 165 cases, and descemet stripping with endothelial keratoplasty in 64 cases. cumulative incidence of rejection episodes and rejection irreversibility rate of 299 cases were noted of which 145 (48.5%) were irreversible after treatment. in multivariate analysis, the cumulative incidence of rejection episodes were influenced by recipient age (p [.00002), recipient rejection risk (p [.0003), lens status (p [.00003), and surgical group (p [.035). a higher incidence of rejection episodes were observed in young patients (< 20 years) and patients aged from 41 to 50, high-risk recipients, aphakic eyes and eyes with anterior chamber intraocular lens, and eyes with pk (compared with eyes with alk). rejection episodes were more likely to be irreversible for high risk recipients (p [.02), for eyes with preoperative hypertony (p [.009), and for eyes with poor visual acuity at presentation (p [.002). they concluded that recipient rejection risk and surgical group are the main risk factors for rejection as they both influence the incidence of rejection and the reversibility rate. recipient age and lens status are predictive factors for the occurrence of rejection. preoperative hypertony is a predictive factor for rejection irreversibility. the effect of an ahmed glaucoma valve implant on corneal endothelial cell density in children with glaucoma secondary to uveitis ayuso vk, scheerlinck lm, boer jd am j ophthalmol. 2013; 155: 530–5. this institutional cross-sectional study was done to assess the effect of ahmed glaucoma valve implants on corneal endothelial cell density (ecd) in children with uveitic glaucoma. eighty eyes from 42 patients diagnosed with uveitis before the age of 16 were included in this study. twenty-eight eyes had an ahmed glaucoma valve implant because of secondary glaucoma while fifty-two eyes without an implant served as controls. corneal ecd was examined cross – sectionally using a noncontact specular microscope. univariate and multivariate generalized estimating equations analyses with correction for paired eyes were performed. the main outcome measure was correlation of ecd with the presence of an ahmed glaucoma valve implant and with the time following implantation. the study results revealed that ecd was significantly lower in the ahmed glaucoma valve group than in controls (2359 and 3088 cells / mm2, respectively; p < .001) following an average of 3.5 years after ahmed glaucoma valve implantation. presence of an ahmed glaucoma valve implant, previous intraocular surgery, age, duration of uveitis, and history of corneal touch by the implant tube were all significantly associated with decreased ecd. following a multivariate analysis, presence of an ahmed glaucoma valve implant (b[l340; adjusted p < .011) and older age (b[l58; adjusted p [.005) remained independently associated with decreased ecd. within the implant group, the age – adjusted time interval following ahmed glaucoma valve implantation was highly correlated with decreased ecd (b [l558, p < .001). in conclusion the ahmed glaucoma valve implants in children with uveitic glaucoma are independently associated with decreased ecd, and this effect is associated with the time interval following ahmed glaucoma valve implantation. pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 163 original article frequency of dry eyes in patients of hyperthyroidism muhammad zubair, muhammad jamshed pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad zubair department of ophthalmology, the university of lahore teaching hospital, lahore email: starzubair94@gmail.com …..……………………….. purpose: to determine the frequency of dry eye disorder in patients of hyperthyroidism. study design: cross sectional study. place and duration of study: department of ophthalmology, the university of lahore teaching hospital lahore, from february to may 2017. material and methods: there were 44 patients included in the study. tear film breakup time was measured by schirmer test on slit lamp. patients involved in the study were between 20 years to 65 years of age. data was analyzed using spss version 20. results: out of 44 patients, 26 (59.0%) were females and 18 (40.9%) were males. 8 (18.1%) patients had age 20 to 35 years and 19 (43.1%) had age 36 to 50 years and remaining 17 (38.6%) had age 51 to 65 years. on studying the right eyes, 6 (13.6%) eyes had normal tear breakup time, 9 (20.4%) had moderate tear breakup time and remaining 29 (65.9) had severely reduced tear breakup time. analysis of left eye showed that 6 eyes (13.6%) had normal tear breakup time, 9 (20.4%) had moderate tear breakup time and remaining 29 (65.9) had severely reduced tear breakup time. result of chi square test showed that there is risk of dry eye in hyperthyroidism patients in this study. p-value of 0.0002 shows significant result which is less than 0.005. conclusion: there is a direct relationship of dry eyes in patients with hyperthyroidism. keywords: dry eye, hyperthyroidism, schirmer test ear film is a layer that nourishes, lubricates and protects the interior surface of the eye. tears are continuously absorbed and evaporated from the ocular surface. normal function of the tear film is to avoid dry eye symptoms. the structure of ocular tear film is complex. while its detailed structure is not completely clear some properties are well known. as the tear film is composed of following three layers, a mucin layer which is produced by specialized conjunctival cells and epithelial cells of the eye.1. it is immediately attached to the corneal epithelium. secondly, an aqueous layer which is produced by the main lacrimal gland and its accessories; and an outer layer that is composed of polar and non-polar lipids which are derived mainly from the meibomian glands. the intact outer lipid layer is held to stabilize the tear film and prevents the aqueous layer from evaporation. the most interior layer of the tear film is lipid layer and is important for stability2. time in which tear film returns to its stable position is measured by its tear film breakup time before and after blink. it was observed there is strong relation between tear spread times, which has a direct relation with hyperthyroidism. it was concluded that thickness and timing of tear film depends upon the hyperthyroidism.3 the fully developed range of t muhammad zubair, et al 164 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology thyroid gland is 10 to 20 g in weight and receive blood from thyroid arteries and a minute artery called the thyroid ima. there are two hormones secreted from thyroid gland. first one is thyroxine, t4 is the major portion of secretion of thyroid. it makes ninety percent hormone secretions. the second one is triiodothyronine t3, forms the remaining ten percent. tangential tissues renovate thyroxine to triiodothyronine, and most of triiodothyronine is derivative from thyroxine. the thyroid gland oozing is synchronized by the thyroid axis of hypothalamus pituitary gland throughout stimulatory proceedings of tsh and trh4. the thyroid hormones are elated in serum bound to carrier proteins (0.03%-0.04%0 of t4) and (0.3%-0.4% of t3) are gratis hormone. the (tbg) thyroid hormone binding globulin is the major hauler, secretarial intended for seventy-five percent of bound t4 and approximately remaining are bound to t35. the pre-albumin and albumin are bound with thyroxine. hyperthyroidism mostly occurs in females, it increases with age and it runs in families. the incidence of clinical hyperthyroidism is 0.5-1.9% in women and less than 1% in men and of subclinical 3 -13.6% in women and 7-5.7% in men. the normal t3 values 75-200 ng/di, tsh 3-5.0 u/ml and t4 normal values 92.8ng/di6. hyperthyroidism is a disorder in which thyroid gland yields too much of the hormone thyroxine. hyperthyroidism can speed up body's metabolism meaningfully, producing rapid weight loss, increase the heartbeat, sweating, and anxiety or petulance7. dry eye is very common in those patients having different systemic diseases. ocular changes and related symptoms like irritation, pain and burning sensation are common8. these symptoms are not generally related with the specific components but these are important in relation to it. the dysfunction of thyroid gland also affect the normal mechanism of the eye. due to the increasing level of thyroid hormone , the condition is known as hyperthyroidism14. in recent study it was concluded that hyperthyroidism initially affects the eyes and causes severe dryness due to decrease of normal tear breakup time. thyroxine production is linked with (tao) i.e. thyroid associated orbitopathy which is normally observed in disease known as graves’ thyrotoxicosis. the sign and symptoms of graves’ disease are mostly seen in the early detection of hyperthyroidism9. autoimmune disorders most likely myasthenia gravis have connection with autoimmune thyroid disorders. the clinical features of orbitopathy i.e. tao and eye disorder of myasthenia gravis have noteworthy extend beyond and in the unusual illustration of their coexistence.10 the purpose of the study was to determine the frequency of dry eye disorder in patients of hyperthyroidism. material and methods a cross sectional study was conducted on 44 patients having history of hyperthyroidism with age range of 20 – 65 years. all patients were diagnosed with hyperthyroidism by medicine ward university of lahore teaching hospital. patients of all other ages or having any other systemic disorders were excluded from the study. the purpose of the study was to find the relationship of hyperthyroidism with dry eye. therefore, all patients underwent measurement of tear production by schimer test using slit lamp. the instruments used in testing were fluorescein strips, slit lamp and pen torch. convenient sampling techniques were used from the prevalence of hyperthyroidism in pakistan to find out the sample size of study. results table 1: gender distribution of patients. frequency percent valid female 26 59.1 male 18 40.9 total 44 100.0 table 2: age distribution of patients. frequency percent valid 20-35 8 18.1 36-50 19 43.1 51-65 17 38.6 total 44 100.0 out of 44 patients 26 (59.1%) were females and 18 (40.9%) were males (table 1). moreover there were 8 (18.1%) people having age between 20 to 35 years, 19 (43.1%) having age between 36 to 50 years and 17 (38.6%) having age between 51 to 65 years (table 2). out of 44 patients in right eye 6 (13.6%) patients had normal tear film breakup time in right eye and 9 (20.4%) had moderate tear breakup time and frequency of dry eyes in patients of hyperthyroidism pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 165 remaining 29 (65.9%) had severely decreased tear breakup time (table 3). table 3: frequency of dry eyes in rt. eye. frequency percent valid normal 6 13.6 moderate 9 20.4 severe 29 65.9 total 44 100.0 table 4: frequency of dry eyes in lt eye. frequency percent valid normal 6 13.6 moderate 9 20.4 severe 29 65.9 total 44 100.0 out of 44 patients in left eye 6 (13.6) patients had normal tear breakup time in left eye and 9 (20.4%) had moderate tear breakup time and remaining 29 (65.9) had severely reduced tear breakup time (table 4). discussion recent researches have evaluated the compromised functions of the tear film in hyperthyroidism patients. hyperthyroidism patients tends to have less tear breakup time and results in severe deficiency. schirmer value of less than 6 mm and dry eyes disorder is present in hyperthyrodisiom11. bulging of the eyes is an additional hazardous feature with enlarged width of palpebral fissure resulting in evaporation of the tear film and increase the osmolarity of tear film12. therefore, it may be concluded that the decrease of tear break up time is due to hyperosmolarity caused by bulging of eyes13. in patient having lesser tear breakup time and severe dry eye disorder, thyroxine hormone is proved better for the normalization of tear break up time in hyperthyroidism patients.14 additionally artificial tears and modifications of environment is recommended to these patients.15 another similar study proved that in hyperthyroidism the tbut decrease and due to this the dryness of the eyes increased. after the biopsy of conjunctival tissues of the patients of hyperthyroidism, it was seen that most of the hyperthyroidism patients had orbitopathy.16,17. another similar study indicated that the incidence of decreased tear breakup time is observed in ptosis patients with myasthenia graves’ and this is autoimmune condition. therefore, the dry eye in hyperthyroidism is not only the effect of bulging of eyes.18. another study showed that thyroid eye disorder affects 400,000 people in the united kingdom.19. the graves’ disease is of about 2% (estimate value from 1% to 2.8%), and incidence of thyroid eye disorder in graves' disorder with reduced tear breakup time and dry eye disorder is about of 37.5%20. thyroid eye disorder is an extremely obnoxious, excruciating, cosmetically stressful, dryness with lower tear breakup time and sporadically vision menacing state. medicinal management has progressed in the precedent 20 years. new advances designate that a discriminatory dealing for thyroid eye disorder should be a practical purpose21,22. conclusion it is determined that hyperthyroidism is the factor which promote dry eye disorder. the results shows significant relationship of dry eye with hyperthyroidism and this value is 0.002. therefore it is concluded that hyperthyroidism causes severe dry eye disorder mostly seen as keratoconjunctivitis (kcs) and sjogren syndrome. author’s affiliation muhammad zubair optometrist department of ophthalmology, the university of lahore teaching hospital, lahore. dr. muhammad jamshed mbbs, medical officer bhu, bahawalnagar role of author muhammad zubair study design, manuscript writing and data collection. dr. muhammad jamshed contributed the data references 1. gürdal c, saraç o, genç i, kırımlıoğlu h, takmaz t, can i. ocular surface and dry eye in graves’ disease, current eye research, 2011; 36 (1): 8–13. https://www.ncbi.nlm.nih.gov/pubmed/21174592 muhammad zubair, et al 166 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology 2. bothun ed, scheurer ra, harrison ar, lee ms. update on thyroid eye disease and management, clinical ophthalmology, 2009; 3: 543–551. 3. burch hb, wartofsky l. current concepts regarding pathogenesis and management, endocrine review, 1993 dec; 14 (6): 747-93. 4. maheshwari r, weis e. thyroid associated orbitopathy, indian journal of ophthalmology, 2012; 60 (2): 87–93. 5. villani e, viola f, sala r, et al. corneal involvement in graves’ orbitopathy: an in vivo confocal study, investigative ophthalmology & visual science september, 2010; vol. 51: 4574-4578. 6. mizen tr. thyroid eye disease, seminars in ophthalmology, 2003; 18 (4): 243–247. 7. smith tj, hoa n. immunoglobulins from patients with graves’ disease induce hyaluronan synthesis in their orbital fibroblasts through the self-antigen, insulin-like growth factor-i receptor, the journal of clinical endocrinology and metabolism, 2004 oct; 89 (10): 507680. 8. yeatts rp. quality of life in patients with graves’s ophthalmopathy, transactions of the american ophthalmological society, 2005; 103: 368-411. 9. moss se, klein r, klein bek. prevalence of and risk factors for dry eye syndrome, archieves of ophthalmology, 2000 sep; 118 (9): 1264-8. 10. buchholz p, steeds cs, stern ls, et al. utility assessment to measure the impact of dry eye disease, the ocular surface, 2006 jul; 4 (3): 155-61. 11. galor a, feuer w, lee dj, et al. prevalence and risk factors of dry eye syndrome in a united states veterans affairs population, american journal of ophthalmology, 2011 sep; 152 (3): 377-384. 12. kim kw, han sb, han er, et al. association between depression and dry eye disease in an elderly population, investigative ophthalmology and vision sciences, 2011 oct. 10; 52 (11): 7954-8. 13. lee s-y, petznick a, tong l. associations of systemic diseases, smoking and contact lens wear with severity of dry eye, ophthalmic and physiologic optics (the journal of the british college of optician and optometris), 2012 nov; 32 (6): 518-26. 14. tong l, saw sm, lamoureux el, et al. a questionnaire-based assessment of symptoms associated with tear film dysfunction and lid margin disease in an asian population, ophthalmic epidemiology, 2009 janfeb; 16 (1): 31-7. 15. nowak m, marek b, kos-kudła b, kajdaniuk d, siemińska l. tear film profile in patients with active thyroid orbithopathy, europe pmc. 2005; 107 (7–9): 479–482. 16. achtsidis v, tentolouris n, theodoropoulou s, et al. dry eye in graves’s ophthalmopathy: correlation with corneal hypoesthesia, european journal of ophthalmology, 2013 jul-aug; 23 (4): 473-9. 17. ismailova ds, fedorov a, grusha yo. ocular surface changes in thyroid eye disease, orbit, 2013 apr; 32 (2): 87-90. 18. tomlinson a, khanal s. assessment of tear film dynamics: a quantitative approach, the ocular surface, 2005 apr; 3 (2): 81-95. 19. emrah k, killickan g. presence of dry eye in patients with hashimotos thyroiditis, journal of ophthalmology, 2014; 10: 1115-1158. 20. david mc, mcdermottleonard wl. adipose tissue as an endocrine organ.the journal of clinical endocrinology and metabolism, 2004; 89: 1-11. 21. david j, stott mb, nicolas r and patricia m. thyroid hormone therapy or older adults with subclinical hypothyroidism, the new england journal of medicine, 2017; 376: 2534-2544. 22. mc cully jp, aronowicz jd, uchiyama e, shine we and butowich ia. correlation in changes in aqueous tear evaporation with a change in relative humidity and the impact, american journal of ophthalmology, 2006 apr; 141 (4): 758-60. https://www.ncbi.nlm.nih.gov/pubmed/19898626 https://www.ncbi.nlm.nih.gov/pubmed/8119236 https://www.ncbi.nlm.nih.gov/pubmed/15472208 https://www.ncbi.nlm.nih.gov/pubmed/15472208 https://www.ncbi.nlm.nih.gov/pubmed/15472208 https://www.ncbi.nlm.nih.gov/pubmed/17057811 https://www.ncbi.nlm.nih.gov/pubmed/17057811 https://www.ncbi.nlm.nih.gov/pubmed/17057811 https://www.ncbi.nlm.nih.gov/pubmed/10980773 https://www.ncbi.nlm.nih.gov/pubmed/10980773 https://www.ncbi.nlm.nih.gov/pubmed/10980773 https://www.ncbi.nlm.nih.gov/pubmed/16900272 https://www.ncbi.nlm.nih.gov/pubmed/21684522 https://www.ncbi.nlm.nih.gov/pubmed/21896858 https://www.ncbi.nlm.nih.gov/pubmed/21896858 https://www.ncbi.nlm.nih.gov/pubmed/21896858 https://www.ncbi.nlm.nih.gov/pubmed/22958181 https://www.ncbi.nlm.nih.gov/pubmed/22958181 https://www.ncbi.nlm.nih.gov/pubmed/22958181 https://www.ncbi.nlm.nih.gov/pubmed/19191179 https://www.ncbi.nlm.nih.gov/pubmed/23483512 https://www.ncbi.nlm.nih.gov/pubmed/23483512 https://www.ncbi.nlm.nih.gov/pubmed/23483512 https://www.ncbi.nlm.nih.gov/pubmed/23565763 https://www.ncbi.nlm.nih.gov/pubmed/17131012 https://www.ncbi.nlm.nih.gov/pubmed/28976862 https://www.ncbi.nlm.nih.gov/pubmed/16564822 132 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology original article micro-incision vitreoretinal surgery in cases of idiopathic macular hole at a tertiary care hospital syed fawad rizwi, muhanmmad abdullah khan, zeeshan kamil, syeda a. bokhari, faisal murtaza, lubna feroze pak j ophthalmol 2017, vol. 33, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zeeshan kamil department of ophthalmology, l.r.b.t free base eye hospital, korangi 21/2, karachi email: dr.zeeshankamil@yahoo.com …..……………………….. purpose: to assess the anatomical and visual results of micro incision vitreoretinal surgery (mivs) in patients with idiopathic macular hole. study design: quasi experimental study. place and duration of study: lrbt free base eye hospital, karachi from january 2014 to december 2014. material and methods: the study included 18 eyes of 18 patients with idiopathic macular hole, who underwent mivs with dye assisted internal limiting membrane (ilm) peeling and 14% perfluoropropane (c3 f8) as internal tamponade. outcome measures were post-operative visual acuity and anatomical closure. post-operative follow-up was conducted up to 6 months after the surgery. results: eighteen patients were recruited for the study, out of which 11 (61%) were male and 07 (39%) were female. age ranged from 45 – 70 years (mean age 60.8 ± 5.2 years). visual improvement of up to 2 lines was seen in 11 (61%) of the patients, whereas, anatomical closure was achieved in 16 (88%) of the patients. conclusion: micro incision vitreoretinal surgery (mivs) in patients with idiopathic macular hole resulted in high anatomical success and significant visual improvement. keywords: microincision vitreoretinal surgery, idiopathic macular hole, perfluoropropane. diopathic macular hole is one of the major vitreoretinal disorders which causes metamorphopsia and poor central vision in the elderly1. the overall prevalence is approximately 3.3% per 10002. numerous causes of macular hole include myopia and trauma but most common cause is idiopathic with a female preponderence in the 7th decade3. it has been reported that 4-6% of full thickness macular holes close spontaneously4. the pathogenesis of idiopathic macular hole has been attributed to the presence of tangential and anteroposterior traction on the fovea by pre-foveal cortical vitreous5. it has been postulated, that the leading factors for spontaneous closure of macular hole are release of vitreo-foveal traction or glial proliferation6. kelly and wendell were the first surgeons, who report successful closure of idiopathic macular hole7. since then various modifications have vastly improved the surgical outcomes, especially with the introduction of ilm peeling8 and triamcinolone acetonide use for better visualization of the vitreous gel9. factors which may influence surgical outcomes include the size and duration of macular hole, internal limiting membrane and epiretinal membrane (erm) peeling, type of gas tamponade used and duration of face down posturing10. the type i micro-incision vitreoretinal surgery in cases of idiopathic macular hole at a tertiary care hospital pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 133 of internal tamponade used and the duration of facedown positioning has been under much debate. earlier clinical trials suggested use of long-acting tamponade with c3f8 gas and prolonged posturing for about 2 weeks, for improvement in visual acuity and higher rates of macular hole closure11. however, other studies recommended short-acting tamponade with a shorter duration of face-down positioning as an effective means to better anatomical and visual outcomes, comparable to those suggested by previous studies12. contrary to these beliefs, two recent studies have suggested that for macular holes < 400 µm in size, no face-down posturing was required13. success rates of up to 70% have been reported after macular hole surgery with erm peeling and use of sf6for internal tamponade.14whereas, anatomical closure of up to 90% have also been reported with vitrectomy, ilm peeling and c3f8 gas tamponade.15 in the current study, we assessed successful anatomical and visual outcomes of macular hole surgery in our set up. material and methods this prospective quasi experimental study was conducted on 18 eyes of 18 patients out of which 11 (61%) were male and 7 (39%) were female patients at lrbt free base eye hospital karachi from january 2014 to december 2014. all surgeries were carried out by senior vitreo-retinal surgeon (sfr) along with assistant surgeon (fm). the study was approved by institutional ethical review committee. after informed consent, patients with stage 2, 3 or 4 idiopathic macular holes were enrolled in the study. patients with stage 1 macular hole, macular cysts or secondary macular holes were excluded from the study. prior to surgical intervention, a detailed history was taken from all the patients, followed by ophthalmic examination on biomicroscopic slit lamp using 90 diopter (d) lens, indirect ophthalmoscopic fundoscopy with 20 d lens and visual acuity measurement on snellen’s chart by (mak). spectral domain optical coherence tomography (oct) was used to assess the stage of macular hole (figure 1) by (lf). all surgeries were performed under local peri-bulbar anesthesia with a mixture of lidocaine (2%) and bupivacain (0.7%). a total of 2 – 3 ml was injected. under strict aseptic measures, micro-incision vitrectomy using 25+ guage vitrectomy system (constellation vision system, alcon® surgicals) was done. surgical induction of posterior vitreous detachment (pvd) was done followed by ilm peeling assisted by brilliant blue (bbg) staining. after air-fluid exchange, 14% c3f8 was injected for internal tamponade. post-procedure, patients were advised strict face-down posturing for 2 weeks. the patients were reviewed on post-operative day 1, week 1, 6, 12 and 24. on each visit, bestcorrected visual acuity (bcva), intra-ocular pressure and dilated fundus examination were performed. at week 6 and 24, oct images were also taken to establish the closure of macular hole (figure 2). data collection and recording was done using spss statistics 21 by two of the authors (sab and zk).the outcome of the surgery was assessed by the extent of the anatomical closure of the macular hole achieved and improvement in the bcva. figure 1: pre-operative oct (ocular coherence tomography). figure 2: post-operative oct (ocular coherence tomography). syed fawad rizwi, et al 134 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology results eighteen cases of idiopathic macular hole underwent surgery at lrbt free base eye hospital, karachi from jan 2014 to dec 2014. the mean age of patients was 60.08 ± 5.2 years. among them 11 patients (61%) were male and 07 patients (39%) were female. pre-operative bcva ranged from 6/18 to 6/60 or below, whereas, postoperative bcva at the end of 24 weeks showed improvement of 2 snellen’s lines or more in 61% of cases. anatomical closure was achieved in 16 patients (88%) of the eyes (table 1). paired t-test was used to analyse the data. p-value of < 0.05 was considered to be significant. table 1: indicates pre-operative visual acuity and post-operative visual acuity at the end of 24 weeks follow up. visual acuity pre-operative post-operative (at 24 weeks) 6/9-6/12 0 02 (11%) 6/18-6/24 02 (11%) 02 (11%) 6/36-6/60 05 (28%) 10 (56%) 6/60 or below 11 (61%) 04 (22%) discussion the aim of macular hole surgery is to improve the patient’s vision and to prevent further visual deterioration. macular hole closure rates and visual outcomes have improved considerably over the last decade. important prognostic factors include the time it takes between the onset of hole formation to the development of an anatomical hole, and also the stage of macular hole16. the anatomical success rate for this study was 88%, which is comparable to local and international studies17-19. there were 2 patients in whom anatomical success was not obtained despite surgery. these two patients were excluded from the final result of anatomical success, and were planned for a repeat surgery. nadeem et al also reported the need for repeat surgery in patients in whom anatomical closure was not achieved after the first surgery19. in recent times there has been an increasing trend towards ilm peeling in macular hole surgery. ilm is the basement membrane which supports the muller cells. its contraction leads to tangential tractional forces on the macula which contributes in the pathogenesis of macular hole.10 therefore, ilm peeling results in relieving these forces, leading to increased surgical success rates as demonstrated by various studies. 20some studies have also suggested that by relieving these tractional forces may reduce the need for prolonged prone positioning21. significantly higher macular hole closure rates have also been found in cases where dye-assisted ilm peeling was performed for both stage 2 and stage 3 macular holes18. initially, indocyanine green, was being used for this purpose, but it was associated with toxic effects on vitreomacular interface22, but now several other dyes have been introduced. in this study brilliant blue was used to dye the ilm, for which no toxic effects on retina have been reported23. different agents for intraocular tamponade have been used including silicon oil and different concentrations of c3f8 gas24. in our study we used c3f8 gas which has shown to result in good anatomical and functional outcomes. significant improvement in bcva has been reported in many comparable studies.25,26in current study 61% of patients showed best corrected visual improvement of more than 2 snellen’s line at the end of 24 weeks of follow up. other studies have reported visual improvement in 70% of the cases, 24, 27 whereas, nadeem et al demonstrated an improvement of 2or more lines in 40% of the cases and one or more line in 6.66% of the cases19. conclusion micro-incision vitreo-retinal surgery with dye-assisted ilm peeling and the use of c3f8 as internal tamponade showed satisfactory visual and anatomical outcomes. however a larger group of operated eyes and a longer follow-up will be required to assess the longterm effects of this procedure. author’s affiliation dr. syed fawad rizvi m.b.b.s, m.c.p.s, f.c.p.s prof/ chief consultant ophthalmologist l.r.b.t free base eye hospital, korangi 21/2, karachi dr. mohammad abdullah khan m.b;b.s, m.c.p.s, f.c.p.s asst. prof/ consultant ophthalmologist l.r.b.t free base eye hospital, korangi 21/2, karachi dr. zeeshan kamil m.b;b.s, m.c.p.s, f.c.p.s, f.r.c.s asst. prof/ consultant ophthalmologist micro-incision vitreoretinal surgery in cases of idiopathic macular hole at a tertiary care hospital pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 135 l.r.b.t free base eye hospital, korangi 21/2, karachi dr. syeda aisha bokhari m.b;b.s, f.c.p.s, f.r.c.s asst. prof/ ophthalmologist l.r.b.t free base eye hospital, korangi 21/2, karachi dr. faisal murtaza m.b;b.s, m.c.p.s, f.c.p.s, f.r.c.s, f.c.p.s (vr) asst. prof/ consultant ophthalmologist l.r.b.t free base eye hospital, korangi 21/2, karachi dr. lubnaferoz m.b;b.s, medical officer l.r.b.t free base eye hospital, korangi 21/2, karachi role of authors dr. syed fawad rizvi senior vitreo-retinal surgeon dr. mohammad abdullah khan patient clinical assessment dr. zeeshan kamil data collection and recording dr. syeda aisha bokhari data collection and recording dr. faisal murtaza data collection and recording dr. lubna feroz oct conductor references 1. jackson tl, donochie ph, sparrow jm et al. united kingdom national ophthalmology database study of vitreoretinal surgery: report 2, macular hole. ophthalmology, 2013; 120: 629-634. 2. fine s. discussion, macular holes. ophthalmology, 1993; 100: 871. 3. margherio rr, schepens cl. macular breaks. i. diagnosis, etiology and observations. am j ophthalmol. 1972; 74: 233-40. 4. inoue m, arakawa a, yamane s et al. long-term outcome of macular microstructure assessed by ocular coherence tomography in eyes with spontaneous resolution of macular hole. am j ophthalmol. 2012; 153: 687-91. 5. khaqan ha, jameel f et al. visual outcomes of macular hole surgery, j coll physicians surg pak. 2016; 26 (10): 839-42. 6. lo wr, hubbard jb. macular hole formation, spontaneous closure, and recurrence in a previously vitrectomized eye. a j ophthalmol. 2006; 141: 962-4. 7. kelly ne, wendel rt: vitreous surgery for idiopathic macular holes. results of a pilot study. arch ophthalmol. 1991; 109: 654-659. 8. park dw, sipperly jo, sneed sr et al. macular hole surgery with internal limiting membrane peeling and intravitreous air. ophthalmology, 1999; 106: 1392-1397. 9. sakamoto t, ishibashi t: visualizing vitreous in vitrectomy by triamcinolone. graefes arch clin exp ophthalmol. 2009; 247: 1153-1163. 10. kumar a, gogia v, kumar p et al. evaluation of predictors for anatomical success in macular hole surgery in indian population. indian j ophthalmol. 2014 dec; 62 (12): 1141-1145. 11. thompson jt, smiddy we, glaser bm et al. intraocular tamponade duration and success of macular hole surgery. retina, 1996; 16: 373-382. 12. tadayoni r, vicaut e, devin f et al. a randomized controlled trial of alleviated positioning after small macular hole surgery. ophthalmology, 2011; 118: 150155. 13. guillaubey a, malvitte l, lafontaine po et al. comparison of face down and seated position after idiopathic macular hole surgery: a randomized clinical trial. am j ophthalmol. 2008; 146: 128-134. 14. wendel rt, patel ac, kelly ne et al. vitreous surgery for macular holes. ophthalmology, 1993; 100: 1671-6. 15. kumar a. gogia v, shah vm et al. comparative evaluation of anatomical and functional outcomes using brilliant blue g versus triamcinolone assisted ilm peeling in macular hole surgery in indian population. graefes arch clin exp ophthalmol. 2011; 249: 987-995. 16. kang hk, chang aa and beaument pe. the macular hole: report of an australian surgical series and metaanalysis of the literature. clin exp ophthalmol. 2008; 28: 298-308. 17. gupta b, laidlaw dah, williamson th et al. predicting visual success in macular hole surgery. br j ophthalmol. 2009; 3: 1488-91. 18. christenson us, kroyer k, sander b et al. value of internal limiting membrane peeling for surgery for idiopathic macular hole stage 2 and 3: a randomized clinical trial. br j ophthalmol. 2009; 93: 1005-15. 19. ahmed n, shah sra, choudry ql et al. outcomes of macular hole surgery at mayo hospital, lahore. pak j ophthalmol. 2012; 28 (2): 77-80. 20. lois n, burr j, norrie j, et al. full-thickness macular hole and internal limiting membrane peeling study (films) group. internal-limiting membrane peeling versus no peeling for idiopathic full-thickness macular hole: a pragmatic randomized controlled trial. invest ophthalmol vis sci. 2011; 52 (3): 1586-1592. 21. wickens jc, shah gk. outcomes of macular hole surgery and shortened face-down positioning. retina, 2006; 26: 902-4. 22. gandorfer a, haritoglou c, kampik a. retinal damage from indocyanine green in experimental macular surgery. invest ophthalmol vis sci. 2003; 44 (1): 316-323. syed fawad rizwi, et al 136 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology 23. enaida h, hisatomi t, goto y et al. pre-clinical investigation of internal limiting membrane peeling and staining using intravitreal brilliant blue g. retina, 2006; 26 (6): 623-630. 24. ivanoska-aadjievska b, boskurt s, semiz f, et al. treatment of idiopathic macular hole with silicone oil tamponade. clinical ophthalmology, 2012; 6: 1449-1454. 25. chang lk, koizumi h, spaide rf. disruption of the photoreceptor inner segment-outer segment junction in eyes with macular holes. retina, 2008; 28: 969-75. 26. oh j, smiddy we, flynn hw jr, et al. photoreceptor inner/outer segment defect imaging by spectral domain oct and visual prognosis after macular hole surgery. invest ophthalmol vis sci. 2010; 51: 1651-1658. 27. khokhar ar, faziur rabb k, akhtar hu. outcomes of macular hole surgery. j coll physicians surg pak. 2003; 13: 569-72. pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 137 original article corneal endothelial cell loss after vitrectomy with silicone oil tamponade in phakic versus pseudophakic patients with rhegmatogenous retinal detachment muhammad shaheer, asad aslam khan, nasir ahmed, tehseen m. mahju, ummara rasheed pak j ophthalmol 2017, vol. 33, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corresponding to: muhammad shaheer department of ophthalmology, lahore general hospital post graduate medical institute, lahore email: mshaheer212@gmail.com …..……………………….. purpose: to evaluate the corneal endothelial cell loss in patients of rhegmatogenous retinal detachment after vitrectomy with silicone oil tamponade. study design: randomized control study. place and duration of study: eye unit-iii, institute of ophthalmology, mayo hospital, lahore. 1 st may 2016 to 30 april 2017. material and methods: 50 patients were selected from the outpatient department of institute of ophthalmology, mayo hospital who were diagnosed with rhegmatogenous retinal detachment. they were divided into two groups a and b. group a included 25 patients who were phakic in the involved eye while group b contained 25 patients who were pseudophakic in the involved eye. the fellow eyes of all the patients were phakic. patients diagnosed with tractional retinal detachment, combined tractional & rhegmatogenous retinal detachment, any coexisting corneal or retinal disease and those having history of ocular surgery other than cataract surgery were excluded from study. all the patients underwent 23 gauge pars plana vitrectomy with silicone oil tamponade. all patients underwent pre-operative and three months post-operative bilateral specular microscopy for endothelial cell count, percentage of hexagonal cells and coefficient of variation. specular microscopy was done by researcher and findings were recorded. results: the endothelial cell count was decreased in both the groups showing a cell loss of 30.48 ± 25.78 in phakic patients group and 77.52 ± 40.03 in pseudophakic patients group. the decrease in the endothelial cell count was statistically insignificant. conclusion: vitreo retinal surgery with silicone oil tamponade decreases endothelial cell count and it may affect the corneal anatomy in the long run and affect visual prognosis. key words: rhegmatogenous retinal detachment, specular microscope, corneal endothelial cell count, phakic, pseudophakic. wenty three gauge pars plana vitrectomy has emerged as a popular vitreo ratinal surgical technique over the past few years. main reasons of success of this surgical modality are easier pars plana access with less conjunctival scarring, shorter surgical time, increased patients comfort and decreased postoperative inflammation. as a result of less post-operative inflammation and minimal corneal astigmatism by avoiding scleral sutures leads to early visual recovery with minimal post-operative t muhammad shaheer, et al 138 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology complaints1. cornea is a vital ocular structure which is responsible mainly for the dioptric power of the eye so in any ocular surgery the condition of the cornea pre and post operatively assumes major importance2. the condition of the cornea is assessed by specular microscope which measures the corneal endothelial cell count, mean cell density, percentage of hexagonal cell, coefficient of variation and corneal thickness3,4,5. it is widely accepted that anterior segment surgery6,7,8 decreases corneal endothelial cell count and may lead to corneal decompensation if the cornea is not healthy. but a very few number of studies are present on the effects of posterior segment surgeries9,10,11 on cornea especially when the surgery is aided by endotamponades. silicone oil is a widely used tamponade after surgery for retinal detachment. it is kept in eye for a period of at least three months after which it is removed depending upon state of posterior segment of eye. intra ocular silicone oil is associated with many complication which are raised intra ocular pressure, cataract, uveitis and band keratopathy on cornea12. studies have shown that vitreoretinal surgery with silicone oil affects corneal endothelium in aphakic and pseudophakic patients but its effects in phakic patients are unknown. silicone oil is commercially available in 5000 and 1000 centistoke formulations. 5000 centistoke silicone oil is widely used now a days due to its less side effects13. materials and methods 50 patients presenting to the outpatient department of institute of ophthalmology, mayo hospital were selected. patients diagnosed with rhegmatogenous retinal detachment were included in study. they were divided into two groups a and b. group a included 25 patients who were phakic in the involved eye while group b contained 25 patients who were pseudophakic in the involved eye. the fellow eyes of all the patients were phakic. patients diagnosed with tractional retinal detachment, combined tractional & rhegmatogenous retinal detachment, any coexisting corneal or retinal disease and those having history of ocular surgery other than cataract surgery were excluded from study. all the patients underwent 23 gauge pars plana vitrectomy with 5000-centistoke silicone oil tamponade. all patients underwent preoperative and three months post-operative bilateral specular microscopy for endothelial cell count, percentage of hexagonal cells and coefficient of variation. specular microscopy was done and findings were recorded. all the surgeries were performed under local anesthesia. after aseptic measure three ports were made into the posterior segment through pars plana with the help of 23 gauge trocars. core vitrectomy was done and posterior vitreous detachment was induced then. after that complete vitreous shave was performed. after that localization of the primary break was done and then fluid air exchange was performed. the sub retinal fluid was aspirated with the help of extrusion needle under air tamponade through the primary break but in some pseudophakic patients drainage retinotomy had to be made as the primary break could not be localized. once retinal reattachment was achieved, air oil exchange was done so that the cavity was filled with silicone oil bubble at the end of surgery. post operatively steroid and antibiotic eye drops were prescribed. post operatively the patients were discharged after confirming retinal reattachment on slit lamp funds examination. after three months of surgery patients were followed up for secular microscopy and recording of findings. results 50 patients were included in study out of whom 25 were male and 25 were female. the mean age of the patients was 52.44 ± 6.51. the age range in group a was 35 – 62 years and in group b it was 38-61 years. in group a mean pre-operative count in operated eye was 2469.06 ± 39.62 while in group b mean preoperative count in operated eye was 2342.56 ± 62.48. in group a mean post-operative endothelial count in the operated eye was 2439.08±38.31 while in group b mean post-operative count in operated eye was 2265.04 ± 75.72 (table 1). the mean change in hexagonality in the operated eye was 3.54 ± 1.79 (p 0.0001). in group a mean change in hexagonality in operated eyes was 2.52 ± 1.19 (p 0.0001). in group b mean change in hexagonality was 4.50 ± 1.73 in the operated eyes (p 0.0001) (table 2). in group a the mean change in coefficient of variation was 5.84 ± 0.85 in the operated eyes and 0.88 ± 0.72 in the non-operated eyes while in group b. mean change in coefficient of variation in operated eye was 5.24 ± 3.00 and in non-operated eyes it was 0.68±0.69 (p 0.0001) (table 3). corneal endothelial cell loss after ppv with silicone oil tamponade in phakic vs pseudophakic rrd pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 139 table 1: changes in the corneal endothelial cell count. sr. no. corneal endothelial cell count group a group b operated eye non operated eye operated eye non operated eye 1 pre-operative 2469.06 ± 39.62 2476.28 ± 34.66 2342.56 ± 62.48 2439.24 ± 50.55 2 post-operative 2439.08 ± 38.31 2472.80 ± 34.19 2265.04 ± 75.72 2433.36 ± 51.28 3 change 30.48 ± 25.78 3.48 ± 3.47 77.52 ± 40.03 5.88 ± 3.64 p 0.0001 table 2: changes in coefficient of variation. sr. no. co efficient of variation group a group b operated eye non operated eye operated eye non operated eye 1 pre-operative 41.60 ± 1.95 41.36 ± 1.70 40.00 ± 1.73 41.84 ± 1.57 2 post-operative 35.76 ± 1.80 40.48 ± 1.68 34.76 ± 2.50 41.16 ± 1.46 3 change 5.84 ± 0.85 0.88 ± 0.72 5.24 ± 3.00 0.68 ± 0.69 p 0.0001 table 3: changes in hexagonality. sr. no. percentage of hexagonal cells group a group b operated eye non operated eye operated eye non operated eye 1 pre-operative 63.00 ± 2.59 64.88 ± 2.43 55.52 ± 3.01 63.52 ± 2.36 2 post-operative 60.48 ± 2.93 64.28 ± 2.38 50.96 ± 3.56 62.92 ± 2.32 3 change 2.52 ± 1.19 0.60 ± 0.70 4.50 ± 1.73 0.60 ± 0.64 p 0.0001 discussion in this study the authors present the corneal changes after primary vitrectomy with silicone oil tamponade in pakistani population. it is well known that the anterior segment surgery decreases corneal endothelial cell count but a few studies have been conducted to observe the effects of pars plana vitrectomy with internal tamponade on human cornea. the authors believe that this is the first time such data was gathered from local population. our study shows that three port pars plana vitrectomy with silicone oil tamponade decreases the corneal endothelial counts in both phakic and pseudophakic patients. the authors also compared the changes in the endothelial count in the fellow non-operated eye of the patients. the study shows that corneal endothelial cell count was decreased more in the pseudophakic patients as compared to phakic patients suggesting that presence of crystalline lens has some protective effect. more over the pre-operative endothelial cell count in the pseudophakic patients was less as compared to the pre-operative endothelial cell counts in phakic patients which is explained by the history of previous anterior segment (cataract) surgery. despite this endothelial cell count, no patient presented with corneal decompensation on follow up suggesting that the muhammad shaheer, et al 140 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology endothelial count was not significant clinically. during the follow up period no patient presented with early complication of silicone oil tamponade such as raised intra ocular pressure or silicone oil bubble in anterior chamber. now a days 23 gauge system of pars plana vitrectomy has become the system of choice for retinal detachment surgery owing to less surgical time, more patient comfort, less postoperative complications and negligible corneal astigmatism owing to the avoidance of scleral sutures14,15,16,17. goyal ji et al18 studied corneal endothelial cell changes in pediatric population after pars plana lensectomy without any intra ocular tamponade. they concluded that the pars plana lensectomy resulted in 8.02 ± 76% corneal endothelial cell loss which was 2% less as compared to when the same procedure was done through the anterior chamber. setala k et al19 studied changes in corneal endothelium after vitrectomy with silicone oil tamponade. their study showed a lower mean corneal endothelial cell density (2076 ± 196 cell/mm2) as compared to the control fellow eyes (2738 ± 86cells/mm2) suggesting that intraocular tamponade with silicone oil definitely affects the corneal endothelium. goezinne et al20studied corneal endothelial cell density after vitrectomy with silicone oil in complex retinal detachments. their prospective control study showed an endothelial cell loss of 19% in patients who underwent additional phacoemulsification procedure in addition to vitrectomy with silicone oil tamponade while in the second group mean endothelial cell loss was 39% in eyes which underwent lens/iol removal in addition to vitrectomy with silicone oil tamponade. their results also suggest that the presence of an intact crystalline lens or artificial lens/ iris diaphragm may act as a protective barrier against corneal endothelial cell damage from long term silicone oil tamponade. friberg tr et al21 studied corneal endothelial cell loss after multiple vitreoretinal procedures with the use of silicone oil. their results showed 68.8% endothelial cell loss after three vitreoretinal procedures with the use of silicone oil. the average cell loss was higher in aphakic eyes (66.63%) as compared to pseudophakic eyes (51.66%). their results also suggest that the presence of artificial lens/ iris diaphragm may have protective effect on corneal endothelium from silicone oil tamponade. in another study friberg tr et al22 studied the effects of vitreous surgery on corneal endothelium. they concluded that phakic eyes suffered an endothelial cell loss of 1.3% after vitrectomy and aphakic eyes had an average cell loss of 12.6 ± 2.3% after combined vitrectomy and scleral buckling. the cell loss was 8.5 ± 1.8% when the vitrectomy and sclera buckling was combined with lensectomy. cinar e et al23 compared different endotamponades during vitreoretinal surgery in relation to their effect on corneal endothelium. the patients who underwent vitrectomy with silicone oil tamponade showed endothelial cell loss of 4.6 ± 5.4% in the operated eye and a cell loss of 0.14 ± 0.52% in the fellow eye. conclusion based on the results of our study we conclude that vitreo retinal surgery with silicone oil tamponade does effect the corneal endothelium irrespective of the lens status. but the presence of crystalline lens has the maximum protective effect on corneal endothelium from the long term tamponade of silicone oil. the authors feel the need of a large randomized control trial on local population to get a better understanding of the long term effects of silicone oil on corneal endothelium. author’s affiliation dr. muhammad shaheer fcps, mrcsed senior registrar, department of ophthalmology, lahore general hospital, lahore & vitreo retina fellow, mayo hospital, lahore prof. asad aslam khan mbbs, ms, fcps, (bd), professor of ophthalmology. eye unit 3, king edward medical university dr. nasir ahmed mbbs, fcps assistant professor. eye unit 3, mayo hospital/king edward medical university dr. tehseen mahmood mahju mbbs, ms, ms (vitreoretina) senior registrar. eye unit 3, mayo hospital lahore dr. ummara rasheed m phil statistics statistician. coavs/ mayo hospital/ king edward medical university, lahore corneal endothelial cell loss after ppv with silicone oil tamponade in phakic vs pseudophakic rrd pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 141 role of authors dr. muhammad shaheer research idea conception, data collection, paper writing prof. asad aslam khan research supervision and critical review dr. nasir ahmed diagnosing patients and performing surgeries. dr. tehseen mahmood mahju diagnosing patients and performing surgeries. dr. ummara rasheed statistical analysis. references 1. mentes r, stellmans p. comparison of post-operative comfort in 20 gauge versus 23 gauge pars plana vitrectomy. bull soc belge ophthalmol. 2009; 311: 5-10. 2. kim mj, park kh, hwang jm, yu hg, yu ys, chung h. the safety and efficacy of transconjunctival sutureless 23 gauge vitrectomy. korean j ophthalmol. 2007; 21 (4): 201-207. 3. suzuki s, oshika t, oki k, sakabe i, iwase a, amano s, araie m. corneal thickness measurements: scanningslit corneal topography and non contact specular microscopy versus ultrasonic pachymetry. journal of cataract and refractive surgery, 2003; 29 (7): 1313-1318. 4. mccarey bc, edelhauser hf, lynn mj. review of corneal endothelial specular microscopy for fda clinical trials of refractive procedures, surgical devices and new intra ocular drugs and solutions. cornea, 2008; 27 (1): 1-16. 5. islam qu, saeed mk, mehboob ma. age related changes in corneal morphological characteristics of healthy pakistani eyes. saudi j ophthalmol. 2017; 31 (2): 86-90. 6. ang m, mehta js, lim f, bose s, htoon hm, tan d. endothelial cell loss and graft survival after descemet’s stripping automated endothelial keratoplasty and penetrating keratoplasty. ophthalmology, 2012; 119 (11): 2239-2244. 7. hasegava y, najima r, mori y, sakisaka t, minami k, miyata k, oshika t. risk factors for corneal endothelial cell loss by cataract surgery in eyes with pseudoexfoliation syndrome. clin ophthalmol. 2016; 10: 1685-1689. 8. mamalis n, edelhauser hf, dawson dg, chew j, leboyer rm, werner l. toxic anterior segment syndrome. journal of cataract and refractive surgery, 2006; 32 (2): 324-333. 9. watanabe a, shibata t, takashina h, ogawa s, tsuneoka h. changes in corneal thickness after vitreous surgery. clin ophthalmol. 2012; 6: 1293-1296. 10. marco tg, stefano b, angelo b, gianluca m, davide m, giovanni n, tomaso c. corneal complications during and after vitrectomy for retinal detachment in photorefractive keratectomy treated eyes. medicine, 2015; 94 (50): 2215. 11. yanyelli a, celik g, dincyildiz a, horozoglu f, nohutcu hf. primary 23 gauge vitreoretinal surgery for rhegmatogenous retinal detachment. inj j ophthalmol. 2012; 5 (2): 226-230. 12. baillif s, gastaud p. complications of silicon oil tamponade. journal fransis d’ophthalmol. 2014; 37 (3): 259-265. 13. zafar s, shakir m, mahmood sa, amin s, iqbal z. comparison of 1000-centistoke versus 5000-centistoke silicone oil in complex retinal detachment surgery. j coll physicians surg pak. 2016; 26 (1): 36-40. 14. ellen lh, fred h, alfons k. results and complications of temporary silicone oil tamponade in patients with complicated retinal detachments. retina, 2001; 21 (2): 107-114. 15. gupta op, kaiser pk, regillo cd, chen s, dyer ds, dugel pu, gupta s, pollack js. short-term outcomes of 23-gauge pars plana vitrectomy. american journal of ophthalmology, 2008; 146 (2): 193-197. 16. wimpissinger b, kellner l, brannath w, krepler k, stolba u, mihalics c, binder s. 23-gauge versus 20gauge system for pars plana vitrectomy: a prospective randomized controlled trial. british journal of ophthalmology, 2008; 92 (11): 1483-1487. 17. recchia fm, scott iu, brown gc, brown mm, ho ac, ip ms. small-gauge pars plana vitrectomy. ophthalmology, 2010; 117 (9): 1851-1857. 18. goyal ji, panda a, angra sk. corneal endothelial changes following pars plana lensectomy. indian j ophthalmol. 1991; 39: 25-7. 19. setala k, ruusuvaara p, punnonen e, laatikainen l. changes in corneal endothelium after treatment of retinal detachment with intraocular silicone oil. acta ophthalmol. 1989; 67 (1): 37-43. 20. goezinne f, nuijts rm, liem at, lundgvist ij, berendschot tj, cals dw, hendrikse f, la heij ec. corneal endothelial cell density after vitrectomy with silicone oil for complex retinal detachments. retina. 2014; 34 (2): 228-36. 21. friberg tr, guibord nm. corneal endothelial cell loss after multiple vitreoretinal procedures and the use of silicone oil. ophthalmic surg lasers, 1999; 30 (7): 528-34. 22. friberg tr, doran dl, lazenby fl. the effect of vitreous and retinal surgery on corneal endothelial cell density. ophthalmology, 1984; 91 (10): 1166-9. 23. cinar e, zengin mo, kucukerdonmez c. evaluation of corneal endothelial cell damage after vitreo retinal surgery: comparison of different endotamponades. eye, 2015; 29 (5): 670-674. pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 247 original article bacteriology of chronic dacryocystitis in patients coming to a tertiary care hospital erum shahid, uzma fasih, mohammad sabir, arshad shaikh pak j ophthalmol 2018, vol. 34, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: erum shahid assistant professor, department of ophthalmology karachi medical and dental college & abassi shaheed hospital email: drerum007@yahoo.com …..……………………….. purpose: to determine microbiology of dacryocystitis in patients coming to a tertiary care hospital of pakistan and to find out bacterial sensitivity of different antibiotics towards causative organisms. study design: cross sectional observational study. place and duration of study: ophthalmology department, abbassi shaheed hospital, karachi from january to december 2017. material and methods: total 100 patients were enrolled by non-probability consecutive sampling technique. patients with chronic dacryocystitis, primary or acquired nasolacrimal duct blockage were included. acute dacryocystitis, canaliculitis, mucoceles and who had used topical or systemic antibiotics within 48 hours were excluded from the study. detail history, ocular adnexal examination and regurgitation test was performed. specimen was collected with a soft cotton tip applicator under sterile aseptic conditions. gram staining and culture was done. data was collected and analyzed on statistical package for social sciences (spss) version 16. results: mean age of the patients was 29.8 years ± 19.6 sd with 75% females. mean duration of symptoms was 5.9 years ± 10.5. right eye was affected in 58% of patients. culture was positive in 83% and gram positive organisms were seen in 52% of cases. the most common pathogen was staphylococcus aureus 21%, than pseudomonas 18% of cases. gram positive and negative both were most sensitive to moxifloxacin 66% and 57% respectively. conclusion: the most common pathogen in chronic dacryocystitis is gram positive organism staphylococcus aureus followed by gram negative pseudomonas. both gram positive and gram negative organisms are most sensitive to moxifloxacin. keywords: antibiotic, bacteriology, chronic dacryocystitis, gram negative bacteria, gram positive bacteria. nflammation of the lacrimal sac due to nasolacrimal duct obstruction or secondary to trauma or neoplasm is called dacryocystitis. this obstruction of the canal leads to stagnation of tears and creates a pathological environment. this accumulates material within lacrimal sac thereby exacerbating infection, more stasis and beginning of a vicious circle. normal flora of the eye acts as an opportunistic pathogen there by producing infection of lacrimal sac 1. dacryocystitis is the most common disease of the lacrimal drainage system1. chronic dacryocystitis is chronic inflammation of the lacrimal sac due to obstruction of lacrimal sac and most common cause of epiphora 2,3. pathologically within the sac there is inflammation, hyperemia, edema, and hypertrophy of mucosal epithelium. accumulation of mucoid and mucopurulent exudates cause the sac to dilate, i mailto:drerum007@yahoo.com erum shahid, et al 248 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology ultimately leading to pyocele4. this acts as a potential nidus for the organisms to proliferate within the sac. the infection in dacryocystitis can spread to the anterior orbit causing marked edema of the eyelids or can develop into a pre-septal or orbital cellulitis1. it can also give rise to vision threatening complications like corneal ulcer and endophthalmitis following any intra ocular surgery5. therefore, a delay in management may lead not only to secondary infection in the remaining years of life but also eventually to blindness1. retrograde spread of infection from the conjunctiva to nasal cavity, paranasal sinuses, allergic rhinitis and deviated nasal septum have also been reported6. dacryocystitis can develop at any age but it is much more frequent in infants, young adults and elderly. incomplete canalization of the nasolacrimal duct, nasolacrimal atresia, facial cleft, and dacryocystocele may lead to infantile dacryocystitis7. some studies suggest it is significantly more frequent in the age above 30 years and globally much more common in females with female to male ratio of 3.99:13. this disease is more prevalent in persons belonging to low socioeconomic background and poor personal hygiene3. microbiology may vary in acute and chronic infections. single infection predominates in severe acute dacryocystitis often involving gram-negative rods. multiple other species of bacteria could be involved in the pathogenesis of chronic dacryocystitis8. these patients usually harbor multiple microorganisms8. since various studies on microbial analysis of dacryocystitis and their sensitivity pattern towards different antibiotics are published internationally but the data is scarce at local level. the objective of the study is to determine the frequency of bacterial organisms responsible for causing dacryocystitis in patients coming to a tertiary care hospital and to determine different antibiotic sensitivity pattern toward gram negative and positive organisms. this hospital caters to patients belonging to lower middle class so our study will help to identify bacterial pathogens representing that class. it will also help us in treating the disease with sensitive drug and to avoid unnecessary medications. material and methods this study was conducted in the department of ophthalmology, abbasi shaheed hospital, karachi, a tertiary care hospital. the study was carried out in accordance with guidelines of declaration of helsinki. it was a cross sectional observational study started in january 2017 till december 2017. total of 100 patients presented in eye out patient department (opd) were enrolled in the study. sample was collected by nonprobability consecutive sampling technique. patients presenting with epiphora due to chronic dacryocystitis, primary or acquired nasolacrimal duct blockage were included. patients with acute dacryocystitis, canaliculitis, mucoceles and who had used topical or systemic antibiotics within 48 hours of presenting were excluded from the study. patients with complaints of epiphora, based on inclusion and exclusion criteria were selected from an eye opd. verbal informed consent was obtained from all the enrolled patients after explaining the procedure to them. detail history of the patients regarding their bio data, symptoms and duration of the symptoms were taken. ocular adnexal examination was carried out with help of slit lamp to rule out other causes of epiphora. diagnosis of chronic dacryocystitis was established based on history and examination. regurgitation test was performed in every patient. specimen was collected from the puncta after applying pressure on lacrimal sac by an ophthalmologist. it was collected with a soft cotton tip applicator under sterile aseptic conditions taking care not to touch surrounding skin, lashes and lid. the specimen was sent to the standard microbiology lab of the same tertiary care hospital. gram staining was done to identify gram negative and gram-positive bacteria. specimen was cultured in blood agar, chocolate agar specifically for gram-negative organisms, macconkey's agar for further identification of bacteria and for antibiotic sensitivity pattern. the specimen was incubated for 24 hours at 37 degree centigrade and in case of no growth; it was further incubated for 48 hours. biochemical tests were performed to identify bacteria in case of colonies formation on the media. after 48 hours if there was no growth the sample was declared culture negative. final report was issued after 3 days. data was collected and analyzed on statistical package for social sciences (spss) version 16. the continuous data like age and duration of disease are presented by means and range. the categorical data like gender, symptoms, diagnosis, organisms, culture positive and negative, sensitivity of various antibiotics are represented as the frequencies and percentages. bacteriology of chronic dacryocystitis in patients coming to a tertiary care hospital pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 249 results the mean age of the patients was 29.8 years ± 19.6 sd, median was 32 and mode was 50 years of age. minimum age was 11 months and maximum was 62 years of age. mean duration of the symptom was 5.9 years ± 10.5 sd. females were 75% out of 100 patients and 57% of them were housewives. all (100%) patients presented with watering and 20% with discharge. right eye was involved in 58% of patients and 73% had chronic dacryocystitis. culture was positive in 83% of patients. gram positive organisms including both rods and coccis were seen in 52% of cases. other demographic features of the patients are given in table one (1). table 2 demonstrates frequencies of various organisms. the most common pathogen identified is staphylococcus aureus in 21%, followed by pseudomonas in 18% of cases. the least common is enterobacter seen in 1% of patient. table 3 shows sensitivity of commonly used antibiotics against gram negative and positive organisms. table 1: demographic characters of patients. variables frequencies (%) males females pre-school children student house wives employed retired watering discharge chronic conjunctivitis right eye left eye chronic dacryocystitis congenital nld block culture +ve gram + organisims gram – organisims 25 (25%) 75 (75%) 20 (20%) 10 (10%) 57 (57%) 13 (13%) 20 (20%) 100 (100%) 20 (20%) 24 (24%) 58 (58%) 42 (42%) 73 (73%) 27 (73%) 83 (83%) 52 (52%) 31 (31%) table 2: frequency of organisms. variables frequency (%) none 17 (17%) staphylococcus aureus pseudomonas streptoccocuspneumo 21 (21%) 18 (18%) 16 (16%) streptococcus virdans 16 (16%) e coli 5 (5%) moraxella 2 (2%) mixed 2 (2%) klebsella 2 (2%) enterobacter 1 (1%) total 100 table 3: common antibiotic sensitivity pattern. sensitivity of medicines gram positive organisms (%) gram negative organisms (%) amoxicillin 1st generation cephalosporin 2nd generation cephalosporin 3rd generation cephalosporin tobramycin gentamycin vancomycin flouroquinolones moxifloxacin chloramphenicol 34% 45% 25% 52 % 21% 19% 57% 19% 66% 37% 22% 18% 33% 43% 31% 25% 35% 34% 57% 45% discussion microorganisms responsible for causing acute or chronic dacryocystitis differ from place to place or with geographical location. culture was positive in 83% of patients in our study and 9 different species of bacteria have been isolated. gram positive organisms predominate (52%) in our study. if we compare our results with other studies they have also reported more frequent gram positive pathogens, 61% by aseefa et al9, 94.2% by ahuja et al10, 78.6% by sarkar i erum shahid, et al 250 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology study place organism bacteria assefa y et al 9 ahuja et al. 10 pornpanich k et al 20 chang hoon lee et al eshraghi et al 12 briscoe d et al 16 ali mj et al13 sharat et al. 20 sun x et al 14 dm mills et al 15 chaudhry et al 17 north west ethiopia northern india thailand korea tehran, iran kfar saba, israel india south india china usa saudi arabia gram + gram +ve gram +ve gram+ve gram +ve gram -ve gram +ve gram +ve gram +ve gram +ve gram +ve staph epidermidis (17.6%) staph aureus (54.6%) coagulase-negative staph (27.8%) staph epidermidis (33.8%) s. aureus in 26%. pseudomonas (22%) staph aureus (25%) strep pneumone (40%) staphy aureus (34.5%) staph aureus (78.3%) coagulase negative staphylococci (33.9%) et al11. most common gram positive organism isolated in this study was staphylococcus aureus (21%) followed by gram negative organism pseudomonas (18%). studies conducted at various hospitals in different countries9-17 have also reported staphylococcus particularly aureus species to be more frequent. one of them collected pus from acute cases of dacryocystitis15. these countries have different geographical location including usa and mostly asian countries summarized in table 4. briscoe et al, reported the only study among asian countries, conducted in israel, in which gram negative organisms mostly pseudomonas (22%) were more frequently seen than gram positive organisms in cases of dacryocystitis16. in this study, swabs were taken from both dacryo abscess and chronic dacryocystitis. it can be deduced that these organism do not follow any particular pattern of geographical location. rare pathogens were enterobacter (1%), moraxella (2%) and klebsiella (2%). these pathogens do not specifically target any age group or gender. staphylococcus epidermidis is a dominant normal flora of lacrimal sac18. healthy individuals also possess microbial flora on their ocular surfaces and it includes small amount of coagulase-negative staphylococci. under normal circumstances, this bacterial flora helps to eliminate harmful pathogens, starts an immune response to injury and maintains a peaceful eco system on ocular surfaces19. once this equilibrium is disturbed by lacrimal duct obstruction this starts a cascade of reactions. it destroys tear film dynamics, delays microbial clearance, changes the normal microbial flora on ocular surfaces14. there might be a change in ph which leads to proliferation of other pathogens. the source of infection could be from conjunctival cul de sac or nasal cavity if duct is partially open. these pathogens are then involved not only in causing dacryocystitis but to preseptal cellulitis, orbital abscess, corneal ulcer, endophthalmitis, panophthalmitis and eventually blindness. classically it is staphylococcus aureus which is associated with chronic dacryocystitis but fungus have also been reported14. changes in the spectrum of causative microbiological agents over time have been reported in published indexed english literature13. male to the female ratio in our study was 1:3 which is comparable with other studies3,13. narrow nasolacrimal duct, smaller nasolacrimal fossa, hormonal factors, unhygienic or dusty working conditions and use of cosmetics including surma and kajal are known multiple factors responsible for causing dacryocystitis in females15,16. in our study, 57% of these female patients were house wives and 20% were retired personnel. mean age for presentation in our patients was 29.8 years. other studies had reported mean age of 50 years20-23. possible reason for early presentation and more common in females is their involvement in cooking and the use of cosmetics, not only kajal or surma on eyes but also use of poor quality face powder and talcum powder on face. all of these fine particles reach conjunctival sac, then mix in tears and settle in lacrimal sac or duct finally blocking it. right eye was more commonly involved i.e. 58% of cases as compared to left eye. laterality has no association with age or gender of patients. every patient had complained of watering in which 24% had developed chronic conjunctivitis and 20% with discharge on compressing. primary surgical treatment option for patients with chronic dacryocystitis is dacryocystorhinostomy (dcr) with intubation once an acute episode has https://www.ncbi.nlm.nih.gov/pubmed/?term=eshraghi%20b%5bauthor%5d&cauthor=true&cauthor_uid=25349808 bacteriology of chronic dacryocystitis in patients coming to a tertiary care hospital pakistan journal of ophthalmology vol. 34, no. 4, oct – dec, 2018 251 settled with a course of antibiotics, anti-inflammatory and warm compresses. therefore, it is very essential to know about the sensitivity and resistance pattern of a drug. we have shown various commonly prescribed antibiotics with their sensitivity pattern in table 3. gram positive organisms are most sensitive to moxifloxacin (66%) and vancomycin (57%). cephalosporin and amoxicillin also have better sensitivity pattern. gram negative cocci and bacilli are most sensitive to moxifloxacin (57%) and chloramphenicol (45%). sensitivity pattern are low if compared with other studies3,9. patients presenting in our clinic had mean duration of symptoms of 5.9 years. these patients already had multiple visits to general practitioners, quacks and over the counter prescriptions before coming to an ophthalmologist. on top of that they keep delaying surgery by injudiciously using multiple antibiotics for treatment of dacryocystitis and its prophylaxis. such ignorant practices in our part of the world are alarmingly increasing the already existing natural antibiotic resistance mechanisms of bacteria and might be responsible for the relatively higher prevalence rate of their resistance9. this study is a small, single center study but it has contributed significantly in representing local data and validating the most common pathogen isolated for causing chronic dacryocystitis. there are few limitations of our study. there is lack of local data regarding prevalence, incidence and comparison of bacteriology in chronic dacryocystitis. culture negative specimens could have been fungus or anaerobes as they were not stained and cultured. conclusion we conclude that chronic dacryocystitis is more frequent in females, among 3rd to 4th decade; the most common isolated pathogen was a gram positive organism staphylococcus aureus. second most common pathogen was gram negative pseudomonas. both gram positive organisms and gram negative organisms are most susceptible to moxifloxacin. author’s affiliation dr. erum shahid mcps, fcps assistant professor, department of ophthalmology karachi medical and dental college & abassi shaheed hospital. dr. uzma fasih fcps associate professor, department of ophthalmology karachi medical and dental college & abassi shaheed hospital. dr. mohammad sabir m phil, microbiology professor, pathology department karachi medical and dental college & abassi shaheed hospital. dr. arshad shaikh mcps, fcps professor, hod ophthalmology department karachi medical and dental college & abassi shaheed hospital. role of authors dr. erum shahid concept, design, data collection, manuscript writing, data analysis, critical review. dr. uzma fasih concept, design, critical review. dr. mohammad sabir concept, design, critical review. dr. arshad shaikh concept, design, data collection, critical review. refrences 1. stephen. j.h. miller. diseases of the lacrimal apparatus. parson’s diseases of the eye, eighteenth edition. isbn 0 443 04263 2. 2. ghose s, nayak n, satpathy g. current microbial correlates of the eye and nose in dacryocystitis their clinical significance. aioc proc. 2005; 437-9. 3. bharathi mj, ramakrishnan r, maneksha v, shivakumar c, nithya v, mittal s comparative bacteriology of acute and chronic dacryocystitis. kerala j ophthalmol. 2008 ;(8): 20-28. 4. nayak n. fungal infections of eye and their laboratory diagnosis and treatment. nepal medical college j. 2008; 60 (1): 48-63. 5. kanski jj, editor. clinical ophthalmology, 7th ed. new york: butterworth-heinemann; diseases of the lacrimal apparatus, 2007: p. 163-4. 5.. 6. thomas r, thomas s, braganza a, muliyil j. evaluation of the role of say ringing prior to cataract surgery. indian j ophthalmol. 1997; 45: 211-4. 7. tower rn. dacryocystitis and dacryolith. in: tindal r, jensvold b (eds) roy and fraunfelder’s current ocular therapy. saunders, philadelphia, 2008; 6th edn: pp 538– erum shahid, et al 252 vol. 34, no. 4, oct – dec, 2018 pakistan journal of ophthalmology 540. 8. imtiaz ca, farouchesa, al-rashed w. bacteriology of chronic dacryocystitis in a tertiary eye care center. ophthalmic plast reconstr surg. 2005; 21 (3): 207–10. 9. assefa y, moges f, endris m, zereay b, amare b, bekele d, tesfaye s, mulu a, belyhun y. bacteriological profile and drug susceptibility patterns in dacryocystitis patients attending gondar university teaching hospital, northwest ethiopia. bmc ophthalmology, 2015 dec; 15 (1): 34. 10. ahuja s, chhabra ak, agarwal j. study of bacterial spectrum in patients of chronic dacryocystitis, at a tertiary care centre in northern india. j community med health educ. 2017; 7: 536. 11. sarkar i, choudhury sk, bandyopadhyay m, sarkar k, biswas j. a clinicobacteriological profile of chronic dacryocystitis in rural india. surgery, 2015; 4: 5. 12. eshraghi b, abdi p, akbari m, fard ma. microbiologic spectrum of acute and chronic dacryocystitis. intl j ophth 2014; 7 (5): 864. 13. ali mj, motukupally sr, joshi sd, naik mn. the microbiological profile of lacrimal abscess: two decades of experience from a tertiary eye care center. j ophthalmic inflamm infect. 2013; 3 (1): 57. 14. sun x, liang q, luo s, wang z, li r, jin x. microbiological analysis of chronic dacryocystitis. ophthalmic physiol opt. 2005; 25 (3): 261–263. 15. mills dm, bodman mg, meyer dr, morton iii ad. asoprs dacryocystitis study group. the microbiologic spectrum of dacryocystitis: a national study of acute versus chronic infection. ophthalmic plastic & reconst surg, 2007 jul. 1; 23 (4): 302-6. 16. briscoe d, rubowitz a, assia e. changing bacterial isolates and antibiotic sensitivities of purulent dacryocystitis. orbit, 2005; 24 (1): 29–32. 17. chaudhary m, bhattarai a, adhikari s. bacteriology and antimicrobial susceptibility of adult chronic dacryocystitis. nepalese journal of ophthalmology, 2010; 2 (2): 105–13. 18. coden d, hornblass a, haas bd. clinical bacteriology of dacryocystitis in adults. ophthal plast reconstr surg. 1993; 9: 125-131. 19. miller d, iovieno a. the role of microbial flora on the ocular surface. curr. opin. allergy clin. immunol. 2009; 9: 466–70. [pubmed] 20. sharat s, nagaraja ks. a study on the epidemiology of chronic dacryocystitis in an economically-deprived population in south india. j. evolution med. dent. sci. 2016; 5 (70): 5116-5117. 21. pornpanich k, luemsamran p, leelaporn a, santisuk j, tesavibul n, lertsuwanroj b, vangveeravong s. microbiology of primary acquired nasolacrimal duct obstruction: simple epiphora, acute dacryocystitis, and chronic dacryocystitis. clinical ophthalmology (auckland, nz), 2016; 10: 337. 22. deangelis d, hurwitz j, mazzulli t. the role of bacteriologic infection in the etiology of nasolacrimal duct obstruction. can j ophthalmol. 2001; 36 (3): 134– 139. 23. hartikainen j, lehtonen op, saari km. bacteriology of lacrimal duct obstruction in adults. br j ophthalmol. 1997; 81 (1): 37–40. microsoft word nasir bhatti 4 191 original article three years clinical audit of patients presenting in cornea clinic at a tertiary care nasir bhatti, muhammad umar fawad, munawar hussain, umair qidwai, mazhar ul hasan, aziz ur rehman pak j ophthalmol 2011, vol. 27 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nasir bhatti isra postgraduate institute of ophthalmology / al-ibrahim eye hospital malir karachi submission of paper june’ 2011 acceptance for publication november’ 2011 …..……………………….. purpose: to determine the mode of presentation and aetiology of patients presenting in cornea clinic at a tertiary care teaching hospital in karachi. material and methods: this hospital based retrospective case study was conducted in al-ibrahim eye hospital karachi from 1st january 2008 to 1st january 2011. results: a total of 2213 new patients (1347 males and 866 females) presented in cornea clinic. the average age at presentation was 59.5 years. the most common disease was microbial keratitis followed by spheroidal degeneration in 230 (10.39%) and keratoconusin 178 (8.01%) patients. conclusion: corneal diseases are common in the population studied with microbial keratitis as the most common condition. health-promotion strategies have to be developed and implemented to raise awareness about the causes and prevention of corneal blindness. he transparent cornea is exposed to the external environment so it is more prone to injury, inflammation or infection. any insult which disrupts the natural anatomy and physiology of the cornea results in corneal scarring or opacity. as cornea is a highly specialized structure, any inflammation or injury is likely to cause some permanent damage. according to the who global data on the causes of blindness, corneal blindness is the 4thmajor cause of blindness worldwide. it affects 1.9 million people (5.1%) globally1. the prevalence and causes of corneal blindness vary from one region of the world to another. in the low income countries, corneal scarring due to vitamin a deficiency, measles infection, ophthalmianeonatorum, and the effects of harmful traditional eye remedies are the major causes of corneal scarring2. pakistan is a developing country. the national blindness and visual impairment survey reports the prevalence of blindness as 0.9%. corneal scarring (11.8%) is the leading cause of blindness in pakistan after cataract3. this clinical audit was performed to determine the mode of presentation and aetiology of patients presenting in cornea clinic at a tertiary care hospital in karachi. no community-based studies have been done to determine the prevalence and causes of corneal diseases in pakistan. as a preliminary to community based study to identify the relative importance of known causes of corneal blindness as seen in karachi pakistan, the aetiology of cases seen in hospital was determined. material and methods a retrospective review of patients attending the cornea clinic of al-ibrahim eye hospital / isra postgraduate institute of ophthalmology, karachi, t 192 pakistan between january 2008 and january 2011was carried out. information sought included age at presentation, sex and diagnosis of corneal disease. statistical analyses was done, using proportions and percentages to summarize the data. results there were 2213 new patients (1347 males and 866 females) registered in the cornea clinic of al-ibrahim eye hospital (aieh) during january 2008 till january 2011. the mean age at presentation was 59.5 years. the most common disease seen was microbial keratitis, followed by spheroidal degeneration in 230 (10.4%) and keratoconusin 178 (8%) patients. two hundred and seventy eight patients were offered corneal grafting however only 69 keratoplasties were performed during these 3 years. for the purpose of description, the diseases are classified into various categories as shown in (table 1). discussion corneal blindness is a common cause of blindness. according to who, it is the fourth major cause of blindness in the world. its epidemiology is complicated and diverse, and covers a wide range of infectious, inflammatory and degenerative eye diseases. the prevalence of corneal blindness also varies from country to country and even from one population to another, depending upon the availability and general standards of eye care4. the prevalence of blindness in pakistan is 0.9%. corneal blindness is the leading cause of blindness nationally after cataract and is responsible for 11.8%of the total blindness in pakistan. our study showed a male preponderance, 60.86% as compared to 39.13% females. this trend is found in various developing countries where men have more chances of accident or trauma due to greater outdoor activity and they have comparatively easier access to health care due to various economic and social factors5, 6. in our study, microbial keratitis was found to be the most common presentation at cornea clinic. it is one of the most common causes of ocular morbidity in the developing world. gonzales et al found that the annual incidence of corneal ulceration in madurai district in south india was 113 per 100,000 people.7 over the counter sale and indiscriminate use of steroids and antibiotics is an important risk factor for microbial keratitis. it also leads to corneal superinfection, which is an important factor for the high prevalence of corneal blindness in developing countries8. corneal opacities were another major cause of blindness in our study. most corneal opacities were secondary to microbial keratitis in our hospital, which serve a predominantly rural and agricultural population. gara and rao in india found that corneal infections are responsible for a large proportion of corneal scar and that corneal scar was the most common indication (28.1%) for corneal transplanttation, of which keratitis accounted for 50.5%9. management of corneal abrasions at primary care levels within 48 hours has been demonstrated to be the best way to prevent corneal ulcers in lowand middleincome countries10. communities need to be made aware about the principles of prevention of ocular infections. the ophthalmic technicians and lady health workers can help in the primary prevention of the disease. educational strategies can reduce avoidable risk such as trauma, but treatment protocols are required to manage established disease11. fuch’s endothelial dystrophy (1.3%) was the most prevalent corneal dystrophy in our study. another study that looked at the prevalence of corneal dystrophies in various races in usa indicated that endothelial dystrophies in asian subjects account for 2% of the total dystrophies12. geographical differences are present in the prevalence of corneal dystrophies worldwide. a report from iceland indicated that macular corneal dystrophy accounts for one third of corneal transplants13. another report from the czech republic posited that posterior polymorphous corneal dystrophy was one of the most prevalent corneal dystrophies14. the prevalence of keratoconus in our clinic was 8.1%. another hospital based study in singapore found out bilateral keratoconus in 56%15. a similar trend is found in usa where 59% patient had keratoconus where as in india, the prevalence was 2.3%16,17. among the corneal degenerations, spheroidal degeneration was the most prevalent with 10.39%. it is higher when compared to a south african population18. this may be due to the fact that our hospitals serve a predominately rural population, which mostly stay outdoors. 193 table 1: classification of diseases and their frequency in cornea clinic at aieh, jan 2008-jan 2011. diseases patients n (%) infectious viral keratitis 310 (14.01) bacterial keratitis 275 (12.43) fungal keratitis 94 (4.25) acanthamoeba keratitis 20 (0.90) trachoma 8 (0.36) nutritional xerophthalmia 6 (0.27) auto immune mooren’s ulcer 8 (0.36) peripheral ulcerative keratitis 4 (0.18) steven johnson’s syndrome 7 (0.32) degeration crocodile shagreen 141 (6.37) spheroidal degeneration 230 (10.39) band keratopathy 74 (3.34) salzman nodular 7 (0.32) dystrophy fuch’s endothelial dystrophy 29 (1.31) lattice 7 (0.32) ched 4 (0.18) macular 14 (0.63) granular 7 (0.32) gelatinous 1 (0.05) cogan’s microcystic 8 (0.36) infectious crystalline 2 (0.09) reis buckler 2 (0.09) ectasia keratoconus 178 (8.04) keratoglobus 1 (0.05) pellucid marginal degeneration 1 (0.05) opacity post traumatic 86 (3.89) post microbial keratitis 157 (7.09) vascularised 44 (1.99) exposure keratitis 7 (0.32) failed pkp 18 (0.81) bullous keratopathy acute hydrops 32 (1.45) postoperative 95 (4.29) aphakic 23 (1.04) trauma 79 (3.57) descematocoele 44 (1.99) miscellaneous vkc 58 (2.62) phylectunosis 24 (1.08) dry eyes 46 (2.08) chemical burns 43 (1.94) total 2213 (100) the most common cause of bullous keratopathy was post surgical. this finding is similar to the study in japan where pseudophakia or aphakia were the leading causes of bullous keratopathy19. five cases of bilateral blindness were found in our study. sixty nine penetrating keratoplasties were performed at our hospital although we offered this treatment to 278 patients. the indication and outcome of penetrating keratoplasty at our hospital has been published elsewhere20. the reason why most patients refused surgical option was high cost and persistent follow ups required post operatively. our study has the following limitations. it was a retrospective one, with relatively small number of patients. the patients belonged to a heterogeneous group and were not standardized. the findings of our study cannot be extrapolated to the general population of pakistan. due to the difficulty of treating corneal blindness once it has occurred, public health prevention programmes are the most cost-effective means of decreasing the global burden of corneal blindness21. there is a need for community based study on the aetiology of corneal blindness and programme for prevention of the major causes. conclusion corneal blindness can result from a wide variety of causes, depending upon the community and strata of the population. corneal diseases are common in the population studied with microbial keratitis as the most common condition. health-promotion strategies have to be developed and implemented to raise awareness about the causes and prevention of corneal blindness in developing countries like pakistan. author’s affiliation dr. nasir bhatti assistant professor isra postgraduate institute of ophthalmology / al-ibrahim eye hospital malir karachi dr. muhammad umar fawad postgraduate trainee isra postgraduate institute of ophthalmology / al-ibrahim eye hospital malir karachi dr. munawar hussain postgraduate trainee isra postgraduate institute of ophthalmology / al-ibrahim eye hospital malir karachi 194 dr. umair qidwai postgraduate trainee isra postgraduate institute of ophthalmology / al-ibrahim eye hospital malir karachi dr. mazhar ul hasan assistant professor isra postgraduate institute of ophthalmology / al-ibrahim eye hospital malir karachi dr. aziz ur rehman associate professor isra postgraduate institute of ophthalmology / al-ibrahim eye hospital malir karachi reference 1. resnikoff s, pascolini d, etya'ale d, et al. global data on visual impairment in the year 2002. bull world health organ. 2004; 82: 844-51. 2. gilbert c, foster a. childhood blindness in the context of vision 2020-the right to sight. bull world health organ. 2001; 79: 227-32. 3. dineen b, bourne rra, jadoon z, et al. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. british journal of ophthalmology. 2007; 91: 1005-10. 4. smith gt, taylor hr. epidemiology of corneal blindness in developing countries. refract corneal surg. 1991; 7: 436-9. 5. gopinathan u, sharma s, gn. r. review of epidemiological features, microbial diagnosis and treatment outcome of microbial keratitis. experience over a decade. indian j ophthalmol. 2009; 57: 273-9. 6. keshav br, zacheria g, ideculla t, et al. epidemiological characteristics of corneal ulcers in south sharqiya region. oman medical j. 2008; 23: 1-6. 7. gonzales ca, srinivasan m, whitcher jp, et al. incidence of corneal ulceration in madurai district, south india. ophthalmic epidemiol. 1996; 3: 159-66. 8. vajpayee rb, sharma n, chand m, et al. corneal superinfection in acute hemorrhagic conjunctivitis. cornea. 1998; 17: 614-7. 9. garg p, rao gn. corneal ulcer: diagnosis and management. community eye health. 1999; 12: 21-3. 10. upadhyay mp, karmacharya pc, koirala s, et al. the bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in nepal. br j ophthalmol. 2001; 85: 388-92. 11. tuft sj. suppurative keratitis. br j ophthalmol. 2003; 87:127. 12. musch dc, niziol lm, stein jd, et al. prevalence of corneal dystrophies in the united states: estimates from claims data. investigative ophthalmology & visual science. 2011; 52: 695963. 13. jonasson f, oshima e, thonar ej, et al. macular corneal dystrophy in ireland: a clinical, genealogic, and immunohistochemical study of 28 patients. ophthalmology. 1996; 103: 1111-7. 14. gwilliam r, liskova p, filipec m et al. posterior polymorphous corneal dystrophy in czech families maps to chromosome 20 and excludes the vsx1 gene. invest ophthalmol vis sci. 2005; 46: 4480–4. 15. khor wb, wei rh, lim l, et al. keratoconus in asians: demographics, clinical characteristics and visual function in a hospital-based population. clin experiment ophthalmol. 39: 299-307. 16. kennedy rh, bourne wm. a 48-year clinical and epidemiologic study of keratoconus. am j ophthalmol. 1986; 101: 267-73. 17. jonas jb, nangia v, matin a, et al. prevalence and associations of keratoconus in rural maharashtra in central india: the central india eye and medical study. am j ophthalmol. 2009; 148: 760-5. 18. bartholomew rs. spheroidal degeneration of the cornea. prevalence and association with other eye diseases. doc ophthalmol. 1977; 43: 325-40. 19. shimazaki j, amano s, uno t, et al. national survey on bullous keratopathy in japan. cornea. 2007; 26: 274-8. 20. bhatti mn, zaman y, mahar ps. outcome of penetrating keratoplasty from a corneal unit in pakistan. pak j ophthalmol. 2009; 25. 21. gilbert c. childhood blindness: major causes and strategies for prevention. community eye health. 1993; 11: 3-6. microsoft word 8. oa khawaja khalid 100 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology original article features, causes and prevention of toxic anterior segment syndrome (tass) an outbreak investigation khawaja khalid shoaib pak j ophthalmol 2013, vol. 29 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: khawaja khalid shoaib eye department pns hafeez, e 8 islamabad …..……………………….. purpose: to analyze features, causes and preventive measures for toxic anterior segment syndrome (tass) cases, occurring after coaxial phacoemulsification (phaco). material and methods: tass occurring after uneventful coaxial phaco during may/june 2008 in eye department, combined military hospital kharian, were analyzed retrospectively in this case series. clinical features, response to treatment and possible causes were checked during the outbreak (including intracamerally given drugs, irrigating solutions, intraocular lenses and washing/ sterilization techniques for instruments) and measures taken to prevent further cases. follow up continued till feb 2009. results: nineteen (14.8%) out of 128 phaco cases developed tass. out of these nineteen cases, nine (47%) were males and ten (53%) were females. age ranged from twenty eight years to seventy one years (mean 57 ± 9.7). follow up ranged from one month to seven months (mean 2.2 ± 2.1). post operatively, one patient had nausea and vomiting six hours after the operation. on first post operative day, there was corneal edema, anterior chamber inflammation, pupil dilatation, and pigment dusting on the corneal endothelium / anterior surface of intraocular lens in all (100%) cases. at last visit, eight cases (42 %) had corneal haze, seven (37%) had iris atrophy and two (11%) had dilated pupil. corrected visual acuity became 6/6 in nine cases (47%), rest ranged from 6/6p to hand movement. different steps were taken to stop tass and no case occurred in next seven months from july 2008 onwards. conclusion: tass can result in corneal haze or iris depigmentation / atrophy. even prompt and energetic treatment may leave significant visual morbidity. the exact cause could not be established in this series of cases however more vigilance resulted in cessation of such cases. oxic anterior segment syndrome (tass) is a general term used to describe acute, sterile postoperative inflammation due to a noninfectious substance that accidentally enters the anterior segment at the time of surgery. it has been reported after different types of intraocular surgery e.g. cataract surgery,1 (including the paediatric),2 iris – supported phakic iol implantation,3,4 intravitreal injection of bevacizumab,5 post cornea penetrating injury6, penetrating keratoplasty (pk)7 and vitrectomy with silicone oil injection.8 it resembles infectious endophthalmitis9 but improves with steroids. onset of inflammation in tass is earlier as compared to infectious uvietis, vitreous cultures are negative and visual recovery is usually better. the present study was carried out to analyze multiple cases of tass encountered after phacoemulsification (phaco). material and methods tass cases were encountered in eye department combined military hospital kharian during may / t features, causes and prevention of toxic anterior segment syndrome (tass) an outbreak investigation pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 101 june 2008 and follow up of these cases continued till feb 2009 (table 1). clinical features, response to treatment and possible causes were checked during the outbreak. data was then retrospectively studied. single surgeon was performing coaxial phaco and following the same technique for two and a half years prior to development of these cases. in each case, pre operatively, infection of adnexa was ruled out and anterior segment / optic disc assessment was done. next, 5% povidone iodine solution was instilled in conjunctival sac, kept for 3 minutes and was then washed with approximately 100 cc of intravenous drip solution of normal saline or ringer lactate. then finally, the surgeon flushed the conjunctival sac with 10 cc of balanced electrolyte / salt solution (bes / bss) after applying adhesive tape (opsite) and eye speculum. the routine included a clear corneal incision of 2.65 mm or 3.2 mm incision enlarged to 5.5 mm, use of sodium hyaluronate (visco supremeusa) and phaco tip of 0.9 mm or 1.0 mm (19 g / 20 g) depending upon whether a rigid or foldable intraocular lens (iol) had to be implanted. bes/bss was used in all the cases. intraocular lenses (iols) were implanted in all the cases. these included foldable acrylic (c flex, rayner – uk and idea – switzerland) and rigid pmma (dgr – usa). a single suture was applied in a few cases in which rigid iol was implanted and where wound leakage was suspected. though phaco hand piece and sleeve were not autoclaved for every new case, after each operation it was a routine to change the phaco tip and sleeve. at the end of surgery, every case was given 0.1 ml of 0.5% intracameral moxifloxacin (vigamoxalcon). phaco machine used during this period and afterwards was pulsar ii (optikon-italy). in all tass cases, extensive (1 – 2 hourly) topical steroid eye drops were used. initially prednisolone / dexamethasone (predforte / tobradex) and later flourometholone (fml forte) eye drops were used to avoid rise in intraocular pressure. visual acuity, state of cornea, intraocular inflammation, condition of iris / pupil and intraocular pressure were recorded on each visit. severe cases had follow up visit after every 1 – 2 weeks while mild / moderate cases were reviewed on monthly basis. results there were nine (47%) male and ten (53%) female patients (table 1). age ranged from twenty eight years to seventy one years (mean 57 ± 9.7). follow up ranged from one month to seven months (mean 2.2 ± 2.1). post operatively, one patient (case no. 8) had nausea and vomiting six / seven hours after the operation. he reported the incidence next day because he went home after surgery. on first post operative day, there was corneal edema, anterior chamber inflammation (average ++, 10 – 20 cells per field), pupil dilatation, and pigment dusting on the corneal endothelium and anterior surface of intraocular lens in all (100%) cases. despite treatment, the damage was severe in one case (case no.3). in this case, corneal edema was gradually replaced with broad white lines / tracks of fibrosis. pupil was widely dilated, there was severe diffuse iris atrophy (especially at mid peripheral iris, where a whitish band of atrophy replaced the normal iris architecture) and ectropion uveae (posterior pigmented epithelium pulled to anterior iris surface around the papillary margin). in another case, damage was slightly less severe (case no.8). in this case corneal edema was generalized and vision after eight months was counting fingers at 2 meters. in this case intraocular pressure remained high even after eight months of treatment with dorzolamide timolol combination (cosopt) and latanoprost. he was probably a steroid responder as steroids were continued for this duration. in five other cases, iris had slightly washed out appearance with loss of fine crypts on the surface. thus the total number of patients, who had iris atrophy, was seven (37%). there was pigment dispersion from anterior surface of iris resulting in pigment dusting on the corneal endothelium and anterior surface of intraocular lens in all these cases having iris atrophy. it gradually decreased in intensity with time. faint generalized corneal haze caused deterioration of corrected vision in six cases (32%). in two other cases (11%) corneal haze involved half / two thirds of cornea with the center at the limbal incision wound and sparing the part farthest from the entry wound. thus the total number of cases having corneal haze at the last visit, was eight (42%). pupil dilatation persisted in two cases (11%). corrected visual acuity became 6/6 in nine cases (47%). one case had decreased corrected vision due to unrelated diabetic retinopathy while rest of the cases had decreased corrected vision ranging from 6/6p to hand movement. apart from the two cases in which detailed retinal examination was not possible due to corneal haze and one having diabetic retinopathy, no macular problems were encountered in any case. different steps were taken to stop tass (table 2) and no case occurred in next seven months from july 2008 onwards. khawaja khalid shoaib 102 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology features, causes and prevention of toxic anterior segment syndrome (tass) an outbreak investigation pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 103 [ discussion presenting clinical features in an outbreak of tass involving 112 cases included blurred vision (60%), anterior segment inflammation (49%), and cell deposition (56%).10 main features reported in another series were, severe iridocyclitis, atrophic iris changes, cystoid macular edema, anterior capsule phimosis, and posterior capsule opacification.11 tass following cataract surgery with intraocular lens implantation is associated with a low corneal endothelial cell density.12 different causes of tass have been considered. in one series, increased levels of endotoxins were found in the bss which was withdrawn, resulting in termination of the outbreak10. in another cluster, no specific cause of the outbreak could be identified, however no additional cases were reported after changes were made to the materials and equipment used for surgery.13 tass encountered after penetrating keratoplasty was most likely due to accumulation of cleaning substances or heat – stable endotoxins on the surface of the routinely used guided trephine system.7 another outbreak investigation suspected washing process performed previous to the sterilization of the instrumentation used in the surgery, was to be blamed. tap water had been used instead of the recommended distilled and sterile water.14 review of a series concluded sterilization responsible for the syndrome, because after ethylene oxide gas sterilization was replaced with autoclaving, no such incidents occurred.2,15 similarly impurities in autoclave steam moisture have also been associated with tass.16 another series suspected residual povidone iodine on instruments among other causes of the syndrome.6 different other substances presumed to cause tass include antiseptic solution used to soak surgical instruments before subsequent surgery,17,18 trypan blue19 that was administered intracamerally to improve visualization of the capsule, preservatives in ophthalmic solutions, ophthalmic viscosurgical devices (e.g. multivisc bd),3 intraocular lenses,20 ointment in the anterior chamber following cataract surgery,21 preservatives22 (benzylchonium chloride), iris-supported phakic intraocular lens,23 intracameral cefuroxime (axetin), enzymatic detergents used in cleaning surgical instruments,24 talc from surgical gloves and silicone oil8 etc. other factors thought to cause tass are inadequate flushing of phaco and irrigation / aspiration handpieces, detergents at the wrong concentration, ultrasonic bath, antibiotic agents in balanced salt solution, preserved epinephrine, inappropriate agents for skin prep.25 recently a good trend of adequate handpiece flushing, deionized/distilled final rinse, reduction in the use of preserved epinephrine and reduction in the use of enzymatic detergents has been observed. however, increase in a few unfavourable practices e.g. handling of intraocular lenses or instrument tips with gloved hands, poor instrument maintenance, and ultrasound bath use without adequate routine cleaning, needs attention.26 penetrating keratoplasty may be required if corneal transparency is not restored. descemet-stripping automated endothelial keratoplasty has also been found effective in eyes with tass – associated corneal edema.27 in the present study all the cases were done by the same surgical team who had been doing high volume phaco in the preceeding two and a half years in the same hospital without any case of tass. out of four operation theater assistants, one was replaced during this period however the rest were supposed to continue the routine for washing and sterilization. these tass cases were randomly encountered during two months. there were twenty cataract instrument sets and ten sets of phaco tips / sleeves. tass was a clinical diagnosis. differential diagnosis considered was infectious endophthalmitis and corneal edema due to mechanical endothelial damage produced by instrumentation (excessive phaco etc). there was no pain in tass cases. corneal edema involved all the layers and extended from limbus to limbus, though it varied in intensity from case to case. vitreous visualization was not possible in severe cases but the rest of the cases had no involvement. corneal edema of tass and that of striate keratopathy (resulting from use of excessive phaco especially of hard nuclei) was similar in appearance but iris / pupillary involvement in tass, made the difference. moreover, resolution took many weeks in many cases of tass while it was faster in other cases. in the most affected patient seven months after the operation, cornea was almost opaque and milky white, causing marked deterioration of vision (hand movement). different causes were considered and measures were taken accordingly (table 2). 5 % povidone iodine solution is useful because when instilled in the conjunctival sac a few minutes before cataract surgery reduces the number of bacteria from 10 to 100 fold28,29 but causes problems if it gets into the anterior chamber.30 first possibility considered was that khawaja khalid shoaib 104 vol. 29, no. 2, apr – jun, 2013 pakistan journal of ophthalmology assistant might not have diluted 10% povidone iodine solution to 5% and rather used the 10% concentration which was being used for the skin. it was ensured that 5% solution was used. second possibility was that povidone iodine scrub was used instead of the solution because bottles and labels of the two, manufactured by many companies were found to be similar in appearance. to counter this factor, scrub was removed from operation theater and only solution was used. even for scrub purposes, surgical team used solution with soap. even povidone iodine solution of different companies was used to eliminate the possibility of one particular brand causing the problem. third potential cause was use of antiseptic solution / povidone iodine solution for disinfection of instruments like two way cannulas before autoclaving and possibility of improper washing resulting in some residual solution. it was addressed with discontinuation of use of any such solution. fourth factor suspected was detergent powder (surf) for cleaning of instruments and possibility of partial rinsing in water resulting in some residual material. it was ensured that proper rinsing with water was carried out. fifth aspect examined was the clear corneal incisions (cci). though simple to perform, it increases the likelihood of endophthalmitis by approximately 6 times as concluded by european society of cataract and refractive surgery (escrs) study.31 probably because of the fact that it is difficult to make this type of incision water tight, there are more chances that substances can gain entry inside the eye in the immediate post operative period. povidine iodine solution may be one of these especially in phaco of hard cataracts where excessive manipulations might distort the incision wound. it was especially probable in cases where corneal involvement was centered on limbal wound. however tass also occurred in a young male (case no. 3) where hardly any phaco power was required. probably more than one mechanism was involved in the causation of tass. finally practice of intracameral moxifloxacin was evaluated. 0.1 ml of preservative free moxifloxacin (vigamox – alcon) delivered intracamerally at the end of phaco was a routine for the last two years. it was thought that assistant might have used drug of any other brand. for a few weeks we stopped instilling povidone iodine solution in the eye and intracameral moxifloxacin. though the exact cause of tass could not be identified in this study, different steps were taken to stop tass. no case occurred in next seven months from july 2008 onwards. patients having good visual recovery were lost to follow up earlier while those having marked deterioration of vision reported for maximum duration of follow up. conclusion tass can result in prolonged decrease in corneal transparency or iris depigmentation / atrophy. the exact cause could not be established in this series of cases however more vigilance resulted in cessation of such cases. author’s affiliation dr. khawaja khalid shoaib eye department pns hafeez, e – 8 islamabad references 1. ozcelik nd, eltutar k, bilgin b. toxic anterior segment syndrome after uncomplicated cataract surgery. eur j ophthalmol. 2010; 20: 106-14. 2. ari s, caca i, sahin a, cingü ak. toxic anterior segment syndrome subsequent to pediatric cataract surgery. cutan ocul toxicol. 2012; 31: 53-7. 3. kremer i, levinger e, levinger s. toxic anterior segment syndrome following iris-supported phakic iol implantation with viscoelastic multivisc bd. eur j ophthalmol. 2010; 20: 451-3. 4. van philips la. toxic anterior segment syndrome after foldable artiflex iris – fixated phakic intraocular lens implantation. j ophthalmol. 2011; 98: 2410. 5. sato t, emi k, ikeda t, bando h, sato s, morita s, oyagi t, sawada k. severe intraocular inflammation after intravitreal injection of bevacizumab. ophthalmology. 2010; 117: 512-6. 6. yang sl, yan xm. retrospective analysis of clinical characteristics of toxic anterior segment syndrome. zhonghua yan ke za zhi. 2009; 45: 225-8. 7. maier p, birnbaum f, böhringer d, reinhard t. toxic anterior segment syndrome following penetrating keratoplasty. arch ophthalmol. 2008; 126: 1677-81. 8. moisseiev e, barak a. toxic anterior segment syndrome outbreak after vitrectomy and silicone oil injection. eur j ophthalmol. 2012; 22: 803-7. 9. rishi e, rishi p, sengupta s, jambulingam m, madhavan hn, gopal l, therese kl. acute postoperative bacillus cereus endophthalmitis mimicking toxic anterior segment syndrome. ophthalmology. 2013; 120: 181-5. features, causes and prevention of toxic anterior segment syndrome (tass) an outbreak investigation pakistan journal of ophthalmology vol. 29, no. 2, apr – jun, 2013 105 10. kutty pk, forster ts, wood-koob c, thayer n, nelson rb, berke sj, pontacolone l, beardsley tl, edelhauser hf, arduino mj, mamalis n, srinivasan a. multistate outbreak of toxic anterior segment syndrome, 2005. j cataract refract surg. 2008; 34: 58590. 11. sengupta s, chang df, gandhi r, kenia h, venkatesh r. incidence and long-term outcomes of toxic anterior segment syndrome at aravind eye hospital. j cataract refract surg. 2011; 37: 1673-8. 12. avisar r, weinberger d. corneal endothelial morphologic features in toxic anterior segment syndrome. cornea. 2010; 29: 251-3. 13. centers for disease control and prevention (cdc). toxic anterior segment syndrome after cataract surgerymaine, 2006. mmwr morb mortal wkly rep. 2007; 56: 629-30. 14. carricas ms, bellmunt gs, lasanta lj, sanz ai. toxic anterior segment syndrome (tass): studying an outbreak. farm hosp. 2008; 32: 339-43. 15. choi js, shyn kh. development of toxic anterior segment syndrome immediately after uneventful phaco surgery. korean j ophthalmol. 2008; 22: 220-7. 16. hellinger wc, hasan sa, bacalis lp, thornblom dm, beckmann sc, blackmore c, forster ts, tirey jf, ross mj, nilson cd, mamalis n, crook je, bendel re, shetty r, stewart mw, bolling jp, edelhauser hf. outbreak of toxic anterior segment syndrome following cataract surgery associated with impurities in autoclave steam moisture. infect control hosp epidemiol. 2006; 27: 294-8. 17. jun ej, chung sk. toxic anterior segment syndrome after cataract surgery. j cataract refract surg. 2010; 36: 344-6. 18. unal m, yücel i, akar y, oner a, altin m. outbreak of toxic anterior segment syndrome associated with glutaraldehyde after cataract surgery. j cataract refract surg. 2006; 32: 1696-701. 19. buzard k, zhang jr, thumann g, stripecke r, sunalp m. two cases of toxic anterior segment syndrome from generic trypan blue. j cataract refract surg. 2010; 36: 2195-9. 20. jehan fs, mamalis n, spencer ts, fry ll, kerstine rs, olson rj. postoperative sterile endophthalmitis (tass) associated with the memorylens. j cataract refract surg. 2000; 26: 1773-7. 21. werner l, sher jh, taylor jr, mamalis n, nash wa, csordas je, green g, maziarz ep, liu xm. toxic anterior segment syndrome and possible association with ointment in the anterior chamber following cataract surgery. j cataract refract surg. 2006; 32: 22735. 22. mamalis n, edelhauser hf, dawson dg, chew j, leboyer rm, werner l. toxic anterior segment syndrome. j cataract refract surg. 2006; 32: 324-33. 23. moshirfar m, whitehead g, beutler bc, mamalis n. toxic anterior segment syndrome after verisyse irissupported phakic intraocular lens implantation. j cataract refract surg. 2006; 32: 1233-7. 24. leder ha, goodkin m, buchen sy, calogero d, hilmantel g, hitchins vm, eydelman mb. an investigation of enzymatic detergents as a potential cause of toxic anterior segment syndrome. ophthalmology. 2012; 119: 30-5. 25. cutler peck cm, brubaker j, clouser s, danford c, edelhauser he, mamalis n. toxic anterior segment syndrome: common causes. j cataract refract surg. 2010; 36: 1073-80. 26. bodnar z, clouser s, mamalis n. toxic anterior segment syndrome: update on the most common causes. j cataract refract surg. 2012; 38: 1902-10. 27. arslan os, unal m, arici c, görgün e, yenerel m, cicik e. descemet – stripping automated endothelial keratoplasty in eyes with toxic anterior segment syndrome after cataract surgery. j cataract refract surg. 2010; 36: 965-9. 28. isenberg sj, apt l, yoshimuri r. chemical preparation of the eye in ophthalmic surgery. i. effect of conjunctival irrigation. arch ophthalmol. 1983; 101: 761-3. 29. isenberg sj, apt l, yoshimori r, khwarg s. chemical preparation of the eye in ophthalmic surgery. iv. comparison of povidone – iodine on the conjunctiva with a prophylactic antibiotic. arch ophthalmol. 1985; 103: 1340-2. 30. alp bn, elibol o, sargon mf, aslan os, yanyali a, karabas l, talu h, caglar y. the effect of povidone iodine on the corneal endothelium. cornea. 2000; 19: 546-50 31. escrs endophthalmitis study group: prophylaxis of post-operative endophthalmitis following cataract surgery: results of the escrs multi-centre study and identification of risk factors. j cataract refract surg. 2007; 33: 978-88. 142 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology original article visual outcome and complications of boston keratoprosthesis: an experience from north west pakistan ibrar hussain pak j ophthalmol 2017, vol. 33, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ibrar hussain department of ophthalmology, khyber teaching hospital, peshawar, pakistan email:dribrar@hotmail.com …..……………………….. purpose: the purpose of this study is to document the visual outcome and complications of boston keratoprosthesis implant in corneal blindness. study design: descriptive case series. place & duration of study: this study was performed at khyber teaching hospital peshawar from april 2009 to april 2016. material & method: nine eyes of 8 patients were included in the study. in all eyes preoperative visual acuity recorded and slit lamp examination performed. in each case status of anterior segment and diagnosis documented, b-scan performed and boston keratoprosthesis implanted under general anesthesia. postoperative visual acuity and complications documented during the course of follow up and data analyzed. results: preoperative diagnoses of these patients include steven johnson syndrome in 3 (33.3%) eyes, bomb blast injury in 3 (33.3%) eyes, healed corneal ulcers with failed corneal graft in 2 (22.2%) eyes and peter anomaly in 1 (11.1%) eye. all the corneas were opaque and vascularized and preoperative visual acuity was perception of light only. in final fallow up visual acuity was 20/200 in 2 (22.2%), 10/200 in 2 (22.2%), 3/200 in 1 (11.1%), perception of light in 3 (33.3%) and no perception of light in 1 (11.1%). postoperative complications were retro-prosthetic membrane in 6(66.6%) eyes, glaucoma in 1 (11.1%) eye, device extrusion in 3 (33.3%), sterile keratolysis in 3 (33.3%), phthisis bulbi in 3 (33.3%), retinal detachment in 1 (11.1%) and endophthalmitis in 1 (11.1%) eye. conclusion: type 1 boston keratoprosthesis implant still has poor prognosis in patients with sjs and severely traumatized eye e.g., bomb blast injuries and this is related mainly to preexisting bad eye condition. key words: artificial cornea, boston keratoprosthesis, corneal blindness. orneal blindness is the 2nd most common cause of blindness in the world1. standard way to treat corneal blindness is keratoplasty but there are several factors like severe dry eyes, corneal vascularization, etc which can lead to graft failure. in cases where there is repeated graft failure or primary graft is likely to fail, use of keratoprosthesis (kpro) is considered. the concept of using a keratoprosthesis in corneal blindness has been known for more than 200 years2. several groups have worked for many years to develop a keratoprosthesis that could treat patients with corneal blindness having poor prognosis for penetrating keratoplasty3, 4. recently it is gaining popularity due to its improved design with better visual outcome and relatively lesser complications. one of the most commonly used designs in recent year is “boston keratoprosthesis”. it consists of a mushroom shaped optical part and a fenestrated back plate. it is fitted in c mailto:dribrar@hotmail.com visual outcome and complications of boston keratoprosthesis: an experience from north west pakistan pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 143 the center of an 8.5mm donor corneal graft like a collar button. a titanium locking ring holds the back plate in place. then this kpro laden graft is implanted in the recipient eye like traditional penetrating keratoplasty. in 1974, dohlman et al first reported results from implantation of a pmma collar-button keratoprosthesis (kpro) in 36 patients5. present study is designed to evaluate indications, visual outcome and complication of boston kpro type l in north west pakistan and to compare its results with other international reports. material and methods nine eyes of eight patients were selected for boston kpro implantation. each patient underwent detailed slit lamp examination to assess the status of anterior segment. intraocular pressure was taken on each eye and also b-scan ultrasound performed to assess the status of posterior segment. all of the nine boston kpro type-l were obtained from massachusetts eye and ear infirmary, boston, usa, and were implanted by the author (ih) at department of ophthalmology, khyber teaching hospital peshawar, pakistan. the power of kpro was calculated by the provider, using axial length of the eye, which we provided in “order form” of each case. surgical technique involved the following steps. an 8.5mm donor button was prepared from donor corneal graft. in patients whose own cornea was used to hold the kpro, there central 8.5mm cornea was excised using a trephine. the 8.5mm button of cornea was trephined in the centre using 3mm dermatological punch. the stem of the mushroom shaped optical part of the kpro passed through the central 3mm hole of the corneal button in such a way that upper flat part of the kpro optic remained in convex (epithelial) and the stem protruded towards concave (endothelial) side of the corneal button. the fenestrated plate was applied to the back of this button. a titanium ring was passed into the stem behind the plate to stabilize the whole complex. later, under general anaesthesia, the patient’s cornea was trephined with 8.5 mm trephine and corneal button removed. in three patients crystalline lens was removed to make the patients aphakic, while rest of the patients were already aphakic. anterior vitrectomy was performed in all cases. finally the kpro laden corneal button was implanted into patient’s cornea like an ordinary penetrating keratoplasty, using 16 interrupted sutures with 10/0 nylon. this is a prospective study, in which preoperative diagnosis, surface wetting and intraocular pressure were noted. intraoperative complications and postoperative visual outcome and complications were also recorded. patients were followed up from 6 to18 months and visual acuity and complications were recorded on final visit. results obtained by analyzing data through spss (version 14). results nine eyes of eight patients were included in the study. seven (87.5%) patients were males and one (12.5%) was female. average age of patients was 34.11 ± 15.47 years ranging between 12 & 60 years. mean postoperative follow up duration of all patients was 13.85 months (range 6 – 18 months), while one patient missed initial follow up and reappeared after 8 months. data of all nine patients included in this study is given in table l. table l: complete data of all 9 patients included in the study. patients age in years diagnosis preop. va va at last follow up complications 1 35 sjs pl pl rpm sterile keratolysis implant extrusion phthisis bulbi 2 22 bbi pl pl rpm endophthalmitis implant extrusion phthisis ibrar hussain 144 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology 3 35 sjs pl pl sterile keratolysis phthisis bulbi 4 54 healed corneal ulcer with failed corneal graft pl 20/200 rpm 5 62 healed corneal ulcer with failed corneal graft pl 20/200 glaucoma rpm 6 25 bbi pl 10/200 rpm 7 32 bbi pl 10/200 rpm localized rd 8 12 peter anomaly pl 3/200 9 30 sjs pl no pl sterile keratolysis implant extrusion phthisis bulbi mean age 34.11 (bbi=bomb blast injury, pl=perception of light, rd=retinal detachment, rpm= retroprosthetic membrane, sjs= steven johnson syndrome) primary corneal pathologies include sjs 3 (33.3%) eyes bbi 3 (33.3%) eyes, healed corneal ulcer with failed corneal graft 2 (22.2%) eyes and peter anomaly one (11.1%) eye. six (66.6%) eyes had undergone one or more ocular surgeries before implantation of the kpro. these include corneal repair in 3 (33.3%) eyes and keratoplasty in 6 (66.6) eyes. three eyes with bbi underwent corneo-scleral repair followed by keratoplasty later on. in 3 (33.3) eyes the boston kpro was implanted with no prior keratoplasty (one eye of peter anomaly and two eyes of sjs). out of the nine kpro, 4 (44.4%) were implanted in their own corneas and 5 (55.5%) in donor corneas. intraoperative complication included spill over of blood from cut edge of patient’s vascularised cornea in anterior chamber and the vitreous in all (100%) cases. in 5 (55.5%) eyes anterior segment was found deformed due to adhesions of iris and pupil to back of cornea. six patients (66.6%) were already aphakic while in 3 (33.3%) cases lens extraction was also performed during surgery. preoperative visual acuity was only perception of light (pl) with good projection in all eyes. postoperative improvement in visual acuity at last follow up is shown in a table 2. table 2: preoperative and postoperative visual acuity in all patients. visual acuity number of eyes ( % ) all cases (preop) sjs (last follow up) bbi (last follow up) corneal ulcer (last follow up) peter anomaly (last follow up) all cases (last follow up) nopl 0 1 0 0 0 1 pl 9 2 1 0 0 3 3/200 0 0 0 0 1 1 10/200 0 0 2 0 0 2 20/200 0 0 0 2 0 2 total 9 (100%) 3 (33.3%) 3 (33.3%) 2 (22.2%) 1 (11.1%) 9 (100%) (no pl=no perception of light, pl= perception of light) visual outcome and complications of boston keratoprosthesis: an experience from north west pakistan pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 145 table 3: postoperative complications. retro prosthetic membrane sterile keratolysis implant extrusion phthsis bulbi endopthalmitis glaucoma retinal detachment bomb blast injury 3 0 1 1 1 0 1 healed corneal ulcer 2 0 0 0 0 1 0 peter anomaly 0 0 0 0 0 0 0 steven johnson syndrome 1 3 2 3 0 0 0 total 6 3 3 4 1 1 1 note: total number of eyes in this table is more than 9, because most of the eyes had more than one complication. the most common complication was retroprosthetic membrane (rpm) formation which occurred in 6 eyes. one eye developed endophthalmitis and became nopl (no perception of light). sterile keratolysis occurred in all 3 eyes with sjs, which led to extrusion of the implant in 2 eyes and ultimately the eyes became phthisic. the third eye with sjs also became phthisic. one eye with bbi developed localized retinal detachment. all complications with their relation to primary ocular disease are shown in table 3. discussion all the nine cases included in our study were hopeless cases with preoperative visual acuity of pl (perception of light) only. three eyes had bomb blast injuries (bbi) and had undergone corneo-scleral repairs. three other cases were of steven johnson syndrome (sjs), with severe dry eyes (fig. 1). all the nine eyes had severely vascularized and totally opaque corneae. out of the three cases of bbi, only two retained navigational vision (finger counting close to eye) till last follow up visit. one of these two had posterior pole preretinal fibrosis and other one had localized retinal detachment. third patient developed corneal melting followed by endophthalmitis and extrusion of the implant. we could not find any study in literature pertaining to the use of boston kpro in eyes with bbi. however, harissicdagher and dohlman in their paper “the boston keratoprosthesis in severe ocular trauma” mentioned 6 cases of mechanical trauma out of their total 30 studied cases. in their research anatomic success was achieved in 5 out of 6 mechanically traumatized eyes6. fig. 1: severe dry ocular surface in steven johnson syndrome. three eyes with sjs also had poor outcome (fig. 2). ibrar hussain 146 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology one eye retained 20/200 vision in first year but after that the cornea started melting and the kpro extruded. other eye of the same patient became phthisic within two months of the kpro implantation and vision did not improve from pl. third patient fig. 2: boston kpro in steven johnson syndrome. initially obtained 20/60 vision after one week of surgery but after that it started deteriorating and cornea started melting. within a month the kpro extruded and eye became phthisic. these three eyes had severe dry ocular surface and it is this dryness that determines the retention rate of the device. according to a study from massachusetts eye and ear infirmary by yaghouti f and colleagues, the outcome of kpro surgery is worse in patients with sjs7. in this condition chronic inflammation around the kpro makes the tissue vulnerable to necrosis, melting, leakage and infection. in this study7it is demonstrated that 33% of eyes with sjs maintained 6/60 (20/200) vision for 2 years. this figure was minimal as compared to chemical burns (64%), ocular cicatricial pemphegoid (72%) and non cicatricial causes (83%). another study from same institute mentions the use of corticosteroids (even in low doses) in sjs causes tissue melt and perforation8. in contrast, in a study by sayegle rr et al on fifteen patients with sjs, there was no kpro extrusion or endophthalmitis9. in this study only six eyes underwent type-1 kpro while the rest underwent type-2 kpro implantation. two of our cases were of healed corneal ulcer with corneal vascularization. both of these had undergone penetrating keratoplasty once, but failed. both of them retained the kpro till last follow up. visual acuity improved to 10/200 and 20/200 after 3 months but reduced again at last follow up. one patient developed retro-prosthetic membrane and other developed glaucomatous optic atrophy. both these complications are known complications in eyes with type 1kpro. one of the patient in this series was a 12 years old girl with peter anomaly. she had nystagmus since early childhood. in initial postoperative period, there was no improvement in vision but after 4 months she had developed navigational vision and the kpro was retained. use of boston kpro is gaining popularity in pediatric population. according to a study by aquavella jv and colleagues the boston kpro establishes and maintains a clear pathway and does not prejudice the management of glaucoma or retinopathy in children10. complications most common complication in our cases was retroprosthetic membrane (rpm) formation in 6(66.6%) cases. these membranes were thick and vascularized. only in two cases membranectomy was possible with nd-yag laser, while in other four cases the membrane was too thick to respond to nd-yag laser. in a study by shihadeh and mohidat on 20 eyes, the frequency of rmp formation was 45% and all of them treated successfully with nd-yag laser11. its frequency is 43% in a study by bradley et al12, 25% in a multicentre study by zerbe et al13 while 27% 35% in prior published data7. according to one hypothesis rpm formation may be caused by inflammatory cells reacting to polymethyl methacrylate material of kpro14. another theory about rpm formation is mentioned by colby, [15] according to which the histopathological fibrous structure of rpm originates from host stromal cells that migrate through gaps in the graft host tissue junction. in our study highest rate of rpm could be due to excessive inflammation in cases with sjs and bbi. glaucoma is another common and the most important vision threatening complication after boston kpro implant16. one patient (11.1%) of our series developed glaucoma after surgery. this patient disappeared and reappeared after about 8 months with glaucomatous optic atrophy and high iop detected digitally. in many studies glaucoma has been mentioned as a postoperative complication with different frequencies. zerbe et al mentioned 15 % of their cases had high iop after surgery13. shihadeh et al mentioned it in 25% eyes11, and chew et al indicated in 35% eyes14. in addition many patients have preexisting glaucoma. previous studies from multiple institutes have mentioned prevalence between 36 and visual outcome and complications of boston keratoprosthesis: an experience from north west pakistan pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 147 76%13,14,17-19. this is because eyes that need boston kpro have undergone multiple anterior segment surgeries or have diseases that cause intraocular inflammation and need to use steroid20. “steroids response ocular hypertension” is prevalent among these patients which can contribute to development of glaucoma21. glaucoma drainage devices are the mainstay for long term control of glaucoma but these have their own complications which can cause significant visual loss22. endophthalmitis is another damaging complication following boston kpro implantation. one case of our series developed severe endophthalmitis two months after kpro implantation and that led to extrusion of the implant and loss of vision to nopl (no perception of light). this was an eye with bbi and did not respond to intravitreal vancomycin. robert and colleagues reviewed endophthalmitis following boston kpro in literature from 2001 to 2011 and found that its prevalence was 5.4% and gram positive bacteria are the most common agents responsible23. rarely fungal endothalmitis can also occur and its rate is higher in patients using vancomycin prophylaxis and patients wearing therapeutic contact lens24. fig. 3: sterile keratolysis in eye with boston kpro. three (33%) implants of our case series were extruded. causes of extrusion were endothalmitis in one case and sterile keratolysis (fig.3) in 2 cases of sj syndrome. in a study by ciolino and colleagues on 300 eyes where boston kpro type 1 was implanted, 21(7%) eyes failed to retain the device25. in this study causes of extrusion include sterile keratolysis, infection and dense rpm. a high figure of 33% extrusion in our series is due to selection of high risk cases for kpro implant i.e., sj syndrome and bbi. conclusion type 1 boston keratoprosthesis implant still has poor prognosis in patients with sjs and severely traumatized eye like bomb blast injuries and this is mainly due to the preexisting bad eye condition. author’s affiliation prof. dr. ibrar hussain department of ophthalmology, khyber teaching hospital, peshawar, pakistan. role of author prof. ibrar hussain study design, data collection, result compilation, references collection and article writing. references 1. john pw, srinivasan m, madan pu. corneal blindness: a global perspective. bull world health organ, 2001; 79: 214-221. 2. pellier de quengsy g. precis au cours d’ operations sur la chirurgie des yeux. paris: didot, 1789. 3. barber jc. keratoprosthesis: past and present. int ophthalmol clin. 1988; 28: 103-9. 4. hicks cr, fitton jh, chirila tv, crawford gj, constable ij. keratoprosthesis: advancing toward a true artificial cornea. surv ophthalmol. 1997; 42: 175-89. 5. dohlman ch, schneider h, doane mg. prosthokeratoplasty. am j ophthalmol. 1974; 77: 694700. 6. harissi – daghaer m, dohlman ch. the boston keratoprosthesis in severe ocular trauma. can j ophthalmol. 2008, 43: 165-169. 7. yaghouti f, nouri m, abad jc, power wj, doane mg, dohlman ch. keratoprosthesis: preoperative prognostic categories. cornea, 2001; 20: 19-23. 8. dohlman jg, foster cs and dohlman ch. boston keratoprosthesis in steven-johnson syndrome: a case of using infliximab to prevent tissue necrosis. digital journal of ophthalmology, 2009: 15. 9. sayegh rr, ang lpk, foster cs, dohlman ch. the boston keratoprosthesis in steven – johnson syndrome. invest ophthalmol vis sci. 2010; 51: 857-863. 10. aquavella jv, gearinger md, akpek ek, mccormick gj. pediatic keratoprosthesis. ophthalmology, 2007; 114: 989-94. 11. shihadeh wa, mohidat hm. outcomes of the boston keratoprosthesis in jordan. middle east afr j ophthalmol. 2012; 19: 97-100. 12. bradley jc, hernandez eg, schwab ir, mannis mj. boston type 1 keratoprosthesis: the university of california davis experience. cornea, 2009; 28: 321-7. ibrar hussain 148 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology 13. zerbe bl, belin mw, ciolino jb. result from the multicenter boston type 1 keratoprosthesis study. ophthalmology, 2006; 113: 1779-85. 14. chew hf, ayres bd, hammersmith km, rapuano cj, laibson pr, myers js et al. boston keratoprosthesis outcomes and complications. cornea, 2009; 28: 989-96. 15. k colby. boston keratoprosthesis in 2012: preventing complication and optimizing outcomes. acta ophthalmologica 2012; 90: 0. 16. vora gk, colby ka. management of glaucoma following boston keratoprosthesis. european ophthalmic review, 2012; 6: 214-7. 17. ma jj, graney jm, dohlman ch. repeat penetrating keratoplasty versus the boston keratoprosthesis in graft failure. int ophthalmol clin. 2005; 45: 49-59. 18. netland pa, terada h, dohlman ch. glaucoma associated with keratoprosthesis. ophthalmology, 1998; 105: 751-7. 19. greiner ma, li jy and mannis mj. longer-term vision outcomes and complications with the boston type 1 keratoprosthesis and the university of california, davis, ophthalmology, 2011; 118: 1543-50. 20. khan bf, harissi dm, khan dm, dohlman ch. advances in boston keratoprosthesis: enhancing retention and prevention of infection and inflammation, int ophthalmol clin. 2007; 47: 61-71. 21. banitt m. evaluation and management of glaucoma after keratoprosthesis, curr opin ophthalmol. 2011; 22: 133-6. 22. li jy, greiner ma, james d, brandt, lim mc, mannis mj. long-term complications associated with glaucoma drainage devices and boston keratoprosthesis. am j ophthalmol. 2011; 152: 204-218. 23. robert mc, moussally k, harissi dagher m. review of endothalmitis following boston keratoprosthesis type 1. br j ophthalmol. 2012; 96: 776-780. 24. barnes sd; dohlman ch and durand ml. fungal colonization and infection in boston keratoprosthesis. cornea, 2007; 26: 9-15. 25. ciolino jb, belin mw, todani a, al-arfaj k, rudnisky cj. retention of the boston keratoprosthesis type 1: multicenter study results. ophthalmology, 2013; 20: 1195-1200. microsoft word khizr niazi corrected 182 original article duration of diabetes as a significant factor for retinopathy muhammad khizar niazi, arshad akram, muhammad afzal naz, salahuddin awan pak j ophthalmol 2010, vol. 26 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad khizar niazi house no: 80, st -14 falcon complex rawalpindi received for publication april 2010 …..……………………….. purpose: to determine the frequency and risk factors for severity of retinopathy in diabetic patients referred to a tertiary level military hospital. material and methods: diabetic patients referred for suspected diabetic retinopathy on fundoscopy from medical outpatient clinic of military hospital rawalpindi were randomly included in the study. retinopathy was assessed with slit lamp biomicroscope using fundus lens or indirect ophthalmoscope, and graded into absent, non-proliferative or proliferative retinopathy. anova test was used to perform univariate analysis, and to evaluate the simultaneous effect of significant risk factors on the different stages of retinopathy, multivariate regression analysis was done. results: out of four hundred and eighty patients, retinopathy was confirmed in 38% cases with advanced retinopathy in 16%. in univariate analysis, duration of diabetes, fasting blood glucose and glyscosylated haemoglobin test were significantly associated with retinopathy (p<0.005). on multivariate analysis, however, only duration of diabetes proved to be an independent risk factor for both type and progression of retinopathy (odds ratio 5.7 for 5 to 10 years and 32.3 for more than 10 years in cases of non-proliferative retinopathy). conclusion. the frequency of retinopathy observed was high with strong association to duration of diabetes. this emphasizes the need for regular screening of diabetic individuals to detect retinopathy in the early stages and increasing public awareness. iabetes mellitus is one of the most common non communicable diseases with an increasing incidence worldwide. while most individuals affected with diabetes in developed countries are elderly, it occurs at a much younger age in asian countries1. according to the latest world health organization report, pakistan has 5.2 million diabetic subjects, and the number is expected to increase to a staggering 13.9 million making it the 5th highest in the world by 20302. retinopathy is the most frequent microvascular complication of diabetes mellitus, causing blindness in over 10,000 people every year and is the leading cause of legal blindness3. according to pakistan national blindness survey the prevalence of blindness in adults older than 30 years of age is 2.7%, out of these, 15.3% have diabetic retinopathy4. the role of various risk factors for development and progression of diabetes has been demonstrated by several epidemiologic studies of western countries. these factors include type and duration of diabetes, age, gender, glycemic control, hypertension, body mass index, smoking, serum lipids and presence of microalbuminuria5,6. however, there is a paucity of data on the prevalence of diabetes-related eye diseases and the role of various risk factors in developing countries such as pakistan7. the aim of this study was to determine the frequency of diabetic retinopathy and associated risk factors in a tertiary care setup receiving referrals of military personnel and their dependents with clinical suspicion of diabetic retinopathy. d 183 materials and methods this was a cross sectional study conducted on diabetic patients with clinical suspicion of diabetic retinopathy based on direct ophthalmoscopy carried out in diabetic outdoor clinic of military hospital rawalpindi and referred to our institute for confirmation or otherwise, from march 2008 to february 2010. only those cases were randomly included in the study who had not received any previous intervention for diabetic retinopathy. any patient with corneal opacity or lenticular opacities which precluded proper fundus examination was excluded from the study. the cases were given a questionnaire that included information on patient's age, gender, weight, height, type and duration of diabetes. laboratory evaluations consisted of measuring blood hba1c test, and fasting blood glucose. hba1c test was measured by high performance liquid chromatography system (reference range 4.7-6.0%; merck-hitachi 9100, merck, darmstadt, germany). fasting plasma glucose was measured by the glucose-peroxidase colorimetric enzymatic method (biodiagnostics). serum total cholesterol was measured by enzymatic-colorimetric methods (merck diagnostics, germany). the hospital ethics committees approved the study protocol and an informed consent was obtained from all patients. ophthalmoscopy was done after pupillary dilatation by 1% tropicamide and 10% phenylephrine eye drops. classification of retinopathy was based on the findings in the worst eye. the binocular indirect ophthalmoscope (keeler instruments inc. pa, usa) and slit lamp biomicroscope (magnon sl-450, japan) with fundus lens were used to examine the fundus. diabetic retinopathy was clinically graded by an experienced retinal specialist as per the norms of the international clinical diabetic retinopathy guidelines10. the cases were divided then as having no retinopathy, non-proliferative retinopathy, and proliferative retinopathy15. the presence of clinically significant macular oedema was also noted for future study. a pre-tested form was used to collect the information for this study. the data was entered in spss version 15 (spss inc, chicago, usa). it was checked for inconsistencies and duplications. for descriptive purposes, quantitative variables were presented as mean and standard deviation. univariate analysis was carried out using analysis of variance (anova) for the comparison of quantitative variables between different stages of retinopathy. these variables were gender, type of diabetes, duration, fasting blood glucose, serum total cholesterol, and hba1c. p-value of less than 0.05 was considered significant. to evaluate the simultaneous effect of significant risk factors on univariate analysis on the different stages of retinopathy (the response variable), multivariate regression model was used. results a total of four hundred and seventy patients were evaluated (65.7% males, 92.4% type ii diabetics). mean age was 56.23 + 8.73 years (95% ci 55.47 to 57.78). age distribution according to type of retinopathy is given in table 1. diabetic retinopathy was confirmed in 38% cases (n = 180). 104 patients (22%) had non proliferative retinopathy and 76 patients (16%) were diagnosed with proliferative retinopathy. the demographic and clinical characteristics of patients are shown in table 2. overall, retinopathy was more prevalent in patients with type-2 diabetes compared with those with type-1 (12.6% vs. 9.4% for nonproliferative, and 8.6 % vs. 6.2% for proliferative respectively). during univariate analysis, patients with retinopathy showed statistically significant difference in duration of diabetes, fasting blood glucose, hba1c, compared to patients with no retinopathy (p<0.001). insignificant differences were found in hyperliipidemia (p=0.337). a multiple logistic regression model was then developed to identify which of the latter were related to each level of retinopathy. the results listed in table 3 show that hba1c and high fasting blood glucose were no longer significant when adjusted for in the logistic model. on the other hand, longer duration of diabetes was still at risk of developing any grade of diabetic retinopathy (table-3). during calculating the odds ratio the reference category was taken as no retinopathy. similarly for duration of diabetes and its effect on retinopathy, the first category (duration less than five years) was taken as reference. discussion recent studies indicate that prevalence of diabetes in our country is around 9-10%. this increase has been attributed to the rapid economic, demographic, and nutritional transition experienced that has led to lifestyle changes resulting in increased prevalence of diabetes. paralleling this high prevalence of diabetes is a concern that complications of diabetes, mainly diabetic retinopathy, in such subjects might also be high. however, few studies have attempted to assess 184 the prevalence of diabetic complications in pakistan4,7,12,13. in this study, we report the prevalence of dr in subjects attending the diabetic clinic of a tertiary care military hospital. in the present study diabetic retinopathy was present in 38% of the 470 patients considered for evaluation. various studies give different figures for the prevalence of diabetic retinopathy. high prevalence rates of 50-60% were found in uk, australia14 and other european nations15. our figures for non-prolifeartive retinopathy coincide with those of other studies16,17, with a slightly higher rate for proliferative retinopathy. this higher rate could be explained by the fact that the microvascular complications of dr are higher in the subcontinent due to poorer diabetic control. in this study, a number of medical risk factors were assessed (table-2), and the risk factors independently associated with any diabetic retinopathy, in order of importance, were, longer duration of diabetes, fbg, and hba1c levels. logistic regression analysis revealed longer duration of diabetes to be an independent risk factor associated with both the presence and severity of diabetic retinopathy. similar to regional studies18,19, the type of diabetes mellitus did not seem to be associated with the occurrence of diabetic retinopathy. this may be because diabetic patients on insulin were treated with the aim of tight glycaemic control so that they were now at a lower risk for such an occurrence. table 1: age characteristics of study patients with retinopathy type of dr no of cases mean age + sd 95% confidence interval no dr 290 55.69± 9.40 53.97 to 57.06 non proliferative dr 104 57.26± 8.74 56.19 to 59.07 proliferative dr 76 56.53± 8.90 55.27 to 57.89 total 470 56.23 ± 8.73 55.47 to 57.78 p value of 0.684 using anova test, dr= diabetic retinopathy association of total cholesterol levels with retinopathy has been clearly demonstrated, especially in type 2 diabetes patients12. however, this was not observed in the present study for any type of retinopathy. this could be explained by low mean levels of total cholesterol (<200 mg/ dl) of our patients studied, and could reflect the major role of genetic factors in various stages of diabetic eye disease. however, the cross-sectional design adopted precludes confirmation of this hypothesis. table 2: patients’ characteristics according to different stages of diabetic retinopathy (n=470) risk factors no dr (n=290) n(%) npdr (n=104) n(%) pdr (n=76) n(%) p values type of diabetes 0.368 type –i 36 (12.5) 47 (45.2) 31 (40.8) type –ii 254 (87.5) 57 (54.8) 45 (59.2) duration of diabetes <0.001 less than 5yrs 186 (64.2) 19 (18.3) 12 (15.8) 510 years 82 (28.3) 32 (30.7) 25 (32.9) more than 10yr 22 (7.5) 53 (51.0) 39 (51.3) fasting blood glucose <0.001 less than 100 mg/dl 146 (50.3) 22 (21.1) 16 (21.0) from 100-150 mg/dl 98 (33.8) 31 (29.8) 18 (23.6) more than 150 mg/dl 46 (15.9) 51 (49.1) 43 (56.4) hyperlipidemia 0.431 total cholesterol more than 6.2 mmol/l 22 (7.5) 11 (10.5) 7(9.2) total cholesterol of less than 6.2 mmol/l 268 (92.5) 93 (89.5) 69 (90.8) glycosylated haemoglobin (hba1c) <0.001 less than 7% 135 (46.5) 38 (36.5) 19 (25.0) from 7 to 9% 112 (38.6) 29 (27.8) 30 (39.5) more than 9% 43 (14.9) 37 (35.7) 27 (35.5) data expressed as number of cases (percentage), dr= diabetic retinopathy. 185 table 3: multivariate analysis of risk factors for mild to moderate and advanced diabetic retinopathy (n = 470) risk factor non proliferative retinopathy proliferative retinopathy odds ratio p value odds ratio p value duration of diabetes 05 to 10 years 5.780 <0.001 2×106 <0.001 duration of diabetes more than 10 years 32.364 <0.001 2×108 <0.001 the duration of diabetes, however, remained the strongest predictor for any diabetic retinopathy as well as its severity. patients with duration 5-10 years had 5 times more chances to have non proliferative retinopathy and 2×106 times more chances for advance retinopathy than patients with duration less than 5 years and no retinopathy. similarly patients with duration more than 10 years had 32 times more chances to have non proliferative retinopathy and 2×108 times more chance to have proliferative retinopathy than patients with duration less than 5 years and no retinopathy (table 3). moreover, such an association has been observed by several other investigators as well20, and it was probably related to the magnitude or prolonged exposure, or both, to hyperglycaemia coupled with other risk factors. reports in asian developing countries have also observed an association of high levels of fasting plasma glucose and hba1c with retinopathy8,13,21. our study also showed these factors to be significant in univariate analysis. poor diabetic control could reflect a dearth of clinical, evidence-based-knowledge regarding diabetic medication amongst our physicians. in view of the global increase in diabetes, this is a major concern for healthcare and underscores the importance of routine retinal examination in all diabetic patients. in contrast with developed countries22,23 most of the patients in our study had no regular follow up program for management of diabetes and the prevalence of retinopathy was found to be higher in these patients. the limitation of the present study was the target population and so the possibility of a selection bias. another limitation was that retinopathy grading was based on indirect ophthalmoscopy and not on fundus photography grading. this could have resulted in the underestimation of the prevalence of retinopathy. conclusion in conclusion, the present study suggests that although the frequency of retinopathy is similar to that reported earlier, given the large number of diabetic subjects in the country, even with the lower prevalence rates, diabetic retinopathy still poses an enormous public health and economic burden for pakistan. those with a longer duration of diabetes, elevated fasting blood glucose and hba1c levels, are at highest risk of complications. this emphasizes the need for regular screening of diabetic individuals to detect retinopathy in the early stages and increasing public awareness. this would minimize the occurrence of avoidable blindness in developing nations such as pakistan. author’s affiliation muhammad khizar niazi armed forces institute of ophthalmology (formerly department of ophthalmology military hospital rawalpindi-46000 arshad akram armed forces institute of ophthalmology (formerly department of ophthalmology military hospital rawalpindi-46000 muhammad afzal naz armed forces institute of ophthalmology (formerly department of ophthalmology military hospital rawalpindi-46000 salahuddin awan armed forces institute of ophthalmology (formerly department of ophthalmology military hospital rawalpindi-46000 reference 1. 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ann acad med singapore. 2008; 37: 753-9. 17. the eurodiab iddm complications study. retinopathy and vision loss on insulin-dependent diabetes in europe. ophthalmology. 1997; 104: 252–60. 18. el-haddad oa, saad mk. prevalence and risk factors for diabetic retinopathy among omani diabetics. br j ophthalmol. 1998; 82: 901-6. 19. asfour mg, lambourne a, soliman a. high prevalence of diabetes mellitus and impaired glucose tolerance in the sultanate of oman:results of the 1991 national survey. diabetes med. 1995; 12: 1122–5. 20. pradeepa r, anitha b, mohan v, et al. risk factors for diabetic retinopathy in a south indian type 2 diabetic population--the chennai urban rural epidemiology study (cures) eye study 4. diabetes med. 2008; 25: 536-42. 21. abdollahi a, malekmadani mh, mansoori mr, et al. prevalence of diabetic retinopathy in patients with newly diagnosed type ii diabetes mellitus. acta medica iranica. 2006; 44: 415-9. 22. sundling v, gulbrandsen p, jervell j, et al. care of vision and ocular health in diabetic members of a national diabetes organization: a cross-sectional study. bmc health serv res 2008, 8: 159. 23. wong ty, cheung n, tay wt, et al. prevalence and risk factors for diabetic retinopathy the singapore malay eye study. ophthalmology. 2008, 115: 1869-75. r n f l analysis quantitative retinal nerve fiber layer analysis at present is still a research tool but is likely to become a useful clinical tool in future. prof. m. lateef chaudhry editor in chief pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 149 original article awareness of diabetic retinopathy among diabetic patients lubna siddiq mian, muhammad moin, imran hassan khan, asif manzoor, javeria asif bajwa pak j ophthalmol 2017, vol. 33, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: correspondence to: muhammad moin, department of ophthalmology, lgh. lahore email: mmoin7@gmail.com …..……………………….. objective: to find the impact of disease duration and education on the awareness of diabetic retinopathy among diabetic patients visiting a tertiary care hospital in a in a developing country. study design: cross-sectional study. place and duration of study: lahore general hospital from 1st january, 2016 to 28th february, 2016. materials and methods: an interviewer administered questionnaire was used to assess patients’ awareness about ocular complications of diabetes on a 9-point questionnaire before their fundus examination using non-mydriatic fundus camera in the eye clinic. the questions were designed to observe the knowledge and awareness about systemic and ocular complications of diabetes, diabetic retinopathy, the availability of its treatment, treatment modalities, disease consequences and its preventive measures. the patients were divided into 2 groups a and b according to their educational levels and 2 groups c and d according to the duration of disease. results: among the enrolled 200 patients, 69 (34.5%) were male and 131 (65.5%) patients were female. the mean age of the participants was 48 + sd 10.57 years. patient’s education affected their knowledge about the normal random blood sugar levels (p = 0.001), the vascular complications of diabetes involving the retina (p = 0.008) and the absence of the role of glasses in treatment (p = 0.014). duration of diabetes improved patients knowledge about normal random blood sugar levels (p < 0.001), the vascular nature of disease (p < 0.001), its blinding potential (p < 0.001) and its role in early cataract formation (p < 0.001). it also contributed in patients’ motivation to seek annual fundus examination (p = 0.004). conclusion: the knowledge about diabetic retinopathy and its treatment was poor along with poor compliance with annual fundus examination. this is directly related to the educational level of the patient and the duration of diabetes. key words: diabetic retinopathy, awareness, annual fundus examination, screening, laser, intraocular injections. he alarming rise in the prevalence of diabetes mellitus is a global public health and economic problem. there are 280 million diabetic patients worldwide which is estimated to double by 2025. it has been predicted that more than 30% of the global number of people with diabetes in 2025 will be in the asia pacific region1. in pakistan the prevalence of diabetes mellitus is 12% according to the diabetes national survey 20102,3, which is high compared to the national diabetes report, 2014, which stated that the prevalence of diabetes mellitus was 7.6% among nonhispanic whites in america. diabetic retinopathy retinopathy is a major cause of blindness in the age group of 20 – 60 years4. prompt screening of diabetic patients for diabetic retinopathy is the key to address this huge amount of preventable t mailto:mmoin7@gmail.com lubna siddiq, et al 150 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology blindness in the working population, however it is unfortunately, not a top up priority in many parts of the world including pakistan5. the prevalence of diabetic retinopathy in pakistan is estimated to be 26% in a pilot study, and it increased alarmingly in the age group 51 years and above to 66.1%6. a high level of awareness is needed to educate diabetic patients in the context of this debilitating complication. a previous study assessing the awareness of diabetes complications in australia found that only 37% of the diabetic population was aware of the association between diabetes and eye disease7, whereas a study from the u.s. found that 65% of people with diabetes were aware of the association between diabetes and eye disease8. in a study of an urban general population in india where the prevalence of diabetic retinopathy was high, dandona et al9 observed a low level (27.0%) of awareness about this dreaded complication. little has been reported on awareness of eye complications and the retinopathy changes among diabetic patients in pakistan despite the high prevalence of diabetic retinopathy among pakistani diabetics10. the purpose of this article is to assess the awareness of diabetic retinopathy in this developing country. materials and methods we included 200 patients presenting to the diabetic clinic of lahore general hospital. the duration of the study was from 1st january, 2016 to 28th february, 2016. sample size was calculated using a confidence interval of 95%, margin of error 7% and diabetic population size visiting lahore general hospital of 10000 per year. the study was started after approval from the hospital ethical board. an informed consent was obtained from all the participants. an interviewer administered questionnaire was used to assess patients’ awareness about diabetic retinopathy. basic demographic data regarding age, gender, occupation and educational level of the patients was recorded. the patients were then asked to respond to a 9-point questionnaire before their eye examination in the eye clinic. the questions were designed to observe the knowledge and awareness about systemic and ocular complications of diabetes, diabetic retinopathy, the availability of its treatment, treatment modalities, disease consequences and its preventive measures. some of the questions were in the format of ‘yes’, ‘no’ and ‘do not know while others had options whereby the patients were asked to choose their best response. a sample of the questions related to diabetes knowledge and its complications is shown in annexure-1. this was followed by fundus examination using non-mydriatic fundus camera. the patients were divided into 2 groups a and b according to their educational levels and 2 groups c and d according to the duration of disease. patients’ response to questions along with their demographic data was entered into spss 20, and chi square test was applied to study the significance of patients’ education and the duration of diabetes in improving their knowledge. significance was expressed in the form of p values. results we interviewed 200 patients visiting the diabetic clinic of lahore general hospital to assess their awareness about diabetic retinopathy and other eye complications. patients’ age ranged from 21 to 75 years with the mean age of 48.57 ± sd 10.09 years. 69 (34.5%) participants were male and 131 (65.5%) were females. 113 (56.5%) patients were illiterate, 39 (19.5%) patients were literate but did not achieve matriculation and 42 (21%) patients have qualified matriculation or above educational levels. 120 (60%) patients had diagnosed diabetes mellitus for more than 5 years, 54 (27%) patients had diagnosed diabetes mellitus for a duration of less than 5 years and 26 (13%) patients were freshly diagnosed to have the disease. the patients were divided into 2 groups according to their educational levels, group a included the illiterate patients and those were 119 in number, group b included patients with some education under or above matriculation and those were 81 in number, the number and percentage of patients coming up with the correct answer in each group is displayed in table3 and p value is determined by applying chi square test. the patients were also grouped according to the duration of diabetes mellitus to study the effect of duration upon patients’ knowledge about diabetic retinopathy and diabetic eye disease. group c included patients freshly diagnosed to have diabetes and patients who have diabetes for less than 5 years, group d included patients having diabetes for five years and longer duration. the number and percentage of patients coming up with the correct answer is determined in each group and displayed in table 4. p value was obtained by applying chi square test. effects of educational level of the patient and the awareness of diabetic retinopathy among diabetic patients pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 151 table 1: demographic data. characteristic groups frequency and percentage age 21-40 years 41-60 >60 42 (21%) 124 (62%) 34 (17%) gender male female 69 (34.5%) 131 (65.5%) duration of diabetes newly diagnosed < 5 years >5 years 26 (13%) 54 (27%) 120 (60%) educational level illiterate under matriculation matriculation and above 119 (59.5%) 39 (19.5%) 42 (21%) total 200 (100%) table 2: effect of patients’ education on knowledge about diabetic retinopathy. question response p value group a (illiterate) n= 119 group b (educated) n=81 q1what is the normal range of random bsl? correct range (100-140 mg) correct range 68 (57%) incorrect range 51 (43%) correct range 69 (85%) incorrect range 12 (15%) p = 0.001 q2do you know that diabetes can affect the retina? yes 78 (65.5%) no 41 (34.5%) yes 69 (85%) no 12 (15%) p = 0.004 q3when did you come to know that diabetic retinopathy can lead to blindness? today 60 (50.4%) before today 59 (49.6%) today 29 (35.8%) before today 52 (64.2%) p = 0.008 q4do you go for a yearly complete eye examination? yes 32 (26.9%) no 87 (73.1%) yes 25 (30.9%) no 56 (69.1%) p = 0.520 q5is diabetic retinopathy correctable with glasses? yes 93 (78.2%) no 26 (21.8%) yes 48 (59.3%) no 33 (40.7%) p = 0.014 q6do you know that diabetes can lead to early cataract formation? yes 73 (61.3%) no 46 (38.7%) yes 57 (70.4%) no 24 (29.6%) p = 0.032 q7do you know that diabetic retinopathy may need treatment with eye laser or eye injections? yes 0 (0%) no 119 (100%) yes 1 (1.2%) no 80 (98.8%) p = 0.151 q8do you think that good control of blood sugar, blood pressure and healthy life style is sufficient to protect you from diabetic retinopathy? yes 113 (95%) no 6 (5%) yes 81 (100%) no 0 (0%) p = 0.122 q9enlist measures that can help you prevent permanent damage by diabetic retinopathy included regular fundus examination 32 (26.9%) did not include regular fundus examination 87 (73.1%) included regular fundus examination 25 (30.9%) did not include regular fundus examination 56 (69.1%) p = 0.520 lubna siddiq, et al 152 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology table 3: effect of duration of diabetes on knowledge about diabetic retinopathy. question response p value group c (diabetes of short duration < 5 years) n=80 group d (diabetes of long duration > 5 years) n=120 q1what is the normal range of random bsl? correct range (100-140mg) correct range 47 (58.8%) incorrect range 33 (41.2%) correct range 90 (75%) incorrect range 30 (25%) p < 0.001 q2do you know that diabetes can affect the retina? yes 43 (53.75%) no 37 (46.25%) yes 104 (86.7%) no 16 (13.3%) p < 0.001 q3when did you come to know that diabetic retinopathy can lead to blindness? today 56 (70%) before today 24 (30%) today 33 (27.5%) before today 87 (72.5%) p < 0.001 q4do you go for a yearly complete eye examination? yes 13 (16.25%) no 67 (83.75%) yes 44 (36.7) no 76 (63.3%) p 0.004 q5is diabetic retinopathy correctable with glasses? yes 65 (81.26%) no 15 (18.75%) yes 76 (63.7%) no 44 (36.7%) p = 0.041 q6do you know that diabetes can lead to early cataract formation? yes 37 (46.25%) no 43 (53.75%) yes 92 (76.7%) no 28 (23.3%) p < 0.001 q7do you know that diabetic retinopathy may need treatment with eye laser or eye injections? yes 1 (1.25%) no 79 (98.75%) yes 0 (0%) no 120 (100%) p = 257 q8do you think that good control of blood sugar, blood pressure and healthy life style is sufficient to protect you from diabetic retinopathy? yes 76 (95%) no 4 (5%) yes 118 (98.3%) no 2 (1.7%) p = 0.248 q9enlist measures that can help you prevent permanent damage by diabetic retinopathy included regular fundus examination 13 (16.25%) did not include regular fundus examination 67 (83.75%) included regular fundus examination 44 (36.7%) did not include regular fundus examination 76 (63.7%) 0.004 duration of diabetes of the patient on knowledge about diabetic retinopathy are given in table 2 and 3. discussion diabetes mellitus is a matter of global concern, as 415 million people have diabetes in the world, and more than 35.4 million people live in the mena region (middle east and north africa); pakistan is one of the 19 countries and territories of mena region. however further studies are required to estimate the difference between the prevalence of diabetes mellitus in the developed and the developing world11. there were over 7 million cases of diabetes in pakistan in 2015. therefore there is an urgent need to increase the awareness of diabetic retinopathy among diabetic patients pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 153 awareness and the knowledge about diabetes mellitus, because knowledge about the detrimental effects of a disease is the main incentive to make an effort to prevent that disease12,13. diabetic retinopathy is increasing with an equivalent pace with diabetes mellitus and it is giving rise to a worldwide diabetic retinopathy epidemic14. our study included diabetic patients visiting a tertiary care hospital located at an urban area in the capital of punjab, 73.5% of the diabetic patients knew that diabetes affects the vasculature of eye. ram pk et al15 studied the awareness of diabetic retinopathy in the rural population of india and it was as low as 37.1%. among the patients attending diabetic retinopathy screening for the first time in australia in 1998, only 37% of the patients knew that diabetes affects vision7. sixty five percent of the patients were aware about the vascular complications of diabetes in a study conducted in the united states in 20028. the awareness of ocular complications of diabetes was high (86.1%) in a study conducted in malaysia in 201116. in another study, 37% of diabetic patients presenting to avitreoretina clinic at a tertiary care hospital at nepal in 2012 were unaware of diabetic retinopathy17. thapa et al18 evaluated the awareness among diabetic patients who needed tertiary care hospital admission due to nonophthalmic diseases and an ophthalmic examination was requested by the respective department, nearly half of these patients were unaware of diabetic retinopathy and 44% of them had fundus examination for the first time. looking into the factors associated with patients’ awareness of diabetic eye complications; their educational levels were significantly affecting their knowledge about 5 questions. the duration of diagnosed diabetes mellitus was significantly related in the answers of 7 questions. however, their awareness was not related to their age or gender. both educational levels and the duration of diabetes could not improve patients’ knowledge about the treatment modalities used in the treatment of diabetic retinopathy, including retinal lasers and intra-vitreal injections, p = 0.151 for education and p = 0.257 for duration. these factors could not make them know that diabetic retinopathy can occur in the eyes of patients having good glycolic control as one of the consequences of long standing disease, thus those patients with good control cannot be exempted from mandatory annual funds examination and screening for diabetic retinopathy, p = 0.122 for education and p = 0.248 for duration. in our study only 55.5% of the patients knew that diabetic retinopathy is a blinding eye disease, the rest thought that they can’t at least go blind of diabetes. 99.6% of patients had no knowledge about the treatment modalities being used in treating this disease, 97% answered yes when they were asked if good glycolic control is sufficient to protect them from diabetic eye disease. so 97% of the patients were of the opinion that individuals with good blood sugar control will not have diabetic retinopathy which can be responsible for non-compliance with screening funds examination, delayed diagnosis and poor visual outcome on the long term. another study conducted in a turkish tertiary care hospital showed better knowledge in this aspect as 33% of the patients knew that diabetic retinopathy can affect diabetics with good glycolic control19. this question was followed with an open ended question asking how to prevent from permanent vision loss caused by diabetic retinopathy and only 28.5% included regular annual funds examination in their answer list. lack of understanding on diabetic retinopathy was found to be the most common barrier in vision preservation in patients with diabetes mellitus and diabetic retinopathy in a previous study conducted in malaysia15. another study was conducted to suggest an effective way to enhance patients’ knowledge about diabetic eye complications and it was found that medical personnel can better convey the information compared to mass media20. our study supports this, as the duration of diagnosed disease significantly improved patients’ knowledge regarding 7 out 9 questions included in the questionnaire, because patients with longer disease have more frequent contact with medical personnel. limitation of our study was that included patients from a tertiary care hospital in one city. a multicenter study is required to find the consistency of the results among the population of pakistan. conclusion the diabetic patients in pakistan, although aware of the fact that diabetes affects the eye, have poor knowledge about diabetic retinopathy. the diabetic patients in pakistan need more education regarding diabetic retinopathy. the following measures can play an effective role; prompt counseling by the health professionals, mass media and illustrated posters in the diabetic clinics of public and private hospitals. lubna siddiq, et al 154 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology author’s affiliation dr. lubna siddiq mian fcps, senior registrar lahore general hospital, lahore prof. m. moin frcs, frcophth professor of ophthalmology postgraduate medical institute, lahore dr. imran hassan khan associate professor of 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yıldırım c. assessment of awareness of diabetic retinopathy and utilization of eye care services among turkish diabetic patients. prim care diabet. 2013; 7 (4): 297-302. 20. robertson jl, akhtar s, petrie jr, brown fj, jones gc, perry cg, paterson kr. how do people with diabetes access information? pract diabetes int. 2005; 22 (6): 207– 210. javascript:void(0); javascript:void(0); javascript:void(0); javascript:void(0); microsoft word news and events 27,3,2011 _final_ news and events vol. 27, 3, 2011 11th biennial saarc ophthalmo & 34th karophth 2012 date: 20 23 september, 2012 venue: pearl-continental hotel karachi, pakistan secretary: dr. qazi m wasiq phone# 0333 2183272 email: ospkarachi@yahoo.com web: www.ospkarachi.com 33rd national congress of ophthalmological society of pakistan & 31st lahore ophthalmo date: 16-18 december, 2011 venue: lahore international expo centre secretary: dr. zahid kamal siddiqui secretariat: osp house 4 – a lda flats, lawrence road, lahore. phone: 92 – 42 – 36363325 fax: 92 – 42 – 36363326 email: osplhr@gmail.com 33rd world ophthalmology congress (woc) date: 16 – 20 february, 2012 venue: abu dhabi, united arab emirates the 27th apao congress busan, korea. date: 13 17 april, 2012 web: www.apaophth.org american society of cataract and refractive surgery (ascrs) / american society of ophthalmic administrators (asoa) symposium and congress date: 20-24 april, 2012 venue: chicago, il the association for research in vision and ophthalmology (arvo) annual meeting 2012 florida, usa date: 610 may, 2012 venue: fort lauderdale, florida, usa web: www.arvo.org institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091 – 9217376 – 80 fax: 92 – 42 – 6363326 email: pico@pes.comsats.net.pk college of ophthalmology and allied vision sciences lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042 – 37355998 fax: 042 – 37248006 email: pipo@brain.net.pk pakistan institute of ophthalmology, al – shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al – shifa trust eye hospital, jhelum road, rawalpindi – pakistan phone: 92 – 51 – 5487830, 5487820 – 25 fax: 92 – 51 – 5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt department of ophthalmology fatima jinnah medical college sir ganga ram hospital, lahore fax: 92 – 42 – 6363326 email: hamidbut@gmail.com mobile: 0300 – 4158962 microsoft word abstracts 28-1-12 53 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology abstracts edited by dr. qasim lateef chaudhry efficacy and safety of long-term corticosteroid eye drops after penetrating keratoplasty: a prospective, randomized, clinical trial shimazaki j, iseda a, satake y, shimazaki-den s ophthalmology 2012; 119: 668-73. in a prospective, randomized clinical trial, shimazaki et al (p. 668) have found that prolonged use of 0.1% fluorometholone helps to prevent rejection following penetrating keratoplasty (pkp). of the initial 42 patients in this 12 – month trial randomly assigned to either the steroid group (treated with 0.1% fluorometholone 3 times a day) or the non-steroid group (discontinuation of steroid eye drops), 4 in the steroid group and 6 in the no-steroid group did not complete the trial. of the remaining patients, 1 patient in the steroid group and 6 in the non-steroid group developed endothelial rejection at an average of 5.2±4.5 (mean ± standard deviation) months after they entered the study – a significant difference. in contrast, the researchers did not detect a significant difference between the groups in visual acuity, intraocular pressure, epithelial damage, tear – film break-up time, cataract progression, infection, or incidence of systemic side effects. the authors conclude lose – dose corticosteroids should be considered in pkp patients, even in those at low risk of rejection. correlation between clinical features, magnetic resonance imaging, and histopathologic findings in retinoblastoma: a prospective study chawla b, sharma s, sen s, azad r, bajaj ms, kashyap s, pushker n, ghose s ophthalmology 2012; 119: 850-6. chawla et al (p. 850) present findings from what they maintain is the first prospective study on the relationship among clinical features, magnetic resonance imaging (mri) and histopathologic findings in eyes primarily enucleated for retinoblastoma. the study involved 75 patients with group e retinoblastoma. the investigators found neovascularization of the iris, raised intraocular pressure, shallow anterior chamber, and tumor volume correlated well with high-risk histopathology. they note the accuracy of mri in detecting choroidal invasion was 68% – a figure found in earlier, similar reports. this shows that microscopic invasion of the choroid may be missed on mri. detection of ciliary body invasion was more accurate (93.3%) compared with previous studies, and mri correctly detected scleral invasion in all affected eyes, with no false positive findings. given the limitations of mri in reliably predicting microscopic infiltration of the choroid and optic nerve, the authors conclude any decision to treat with neoadjuvant chemotherapy based on suspected post-laminar invasion on mri is not justified without histopathologic evidence of disease. outcomes of sulfur hexafluoride (sf6) versus perfluoroethane (c2f6) gas tamponade for nonposturing macular – hole surgery rahman r, madgula i, khan k br j ophthalmol 2012; 96: 185-8. rahman et al compared the outcomes of non-posturing macular hole surgery (39 eyes) using sulfur hexafluoride (sf6) gas versus perfluoroethane (c2f6) gas tamponade. all patients underwent 23g transconjunctival phakovitrectomy without prone posturing in the postoperative period. primary hole closure was achieved in 89.75% in the c2f6 group and 87.2% in the sf6 group. two weeks after surgery, sf6 was completely absorbed in all cases, and the mean va improved to 0.5 log mar; however, it remained at 1.9 log mar in the c2f6 group. overall, macular-hole surgery with sf6 gas achieved similar results to c2f6 but absorbed faster, allowing quicker visual rehabilitation. microsoft word sharmeen akram case report 219 case report central serous retinopathy in a male patient with takayasu disease – a rare presentation sharmeen akram, azam ali, khabir ahmad pak j ophthalmol 2010, vol. 26 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: section of ophthalmology department of surgery aga khan university, karachi received for publication june’ 2010 …..……………………….. akayasu disease is a rare large and medium vessel arteritis. it was reported by dr mikito takayasu in 1908. it is more common in asia especially in japan where about 150 cases are reported per year1. the disease is reported all over the world with an incidence of 2.6 per million / year. the disease is more common among females. the ophthalmic vascular changes of takayasu arteritis are described in the literature2-8 , and are related to hypoxic changes with involvement of the carotids and retinal artery stenosis. we report a rare atypical presentation of ocular takayasu disease in a male patient which was successfully managed. case report a 28-year-old male with known takayasu disease presented to our eye clinic with a 6-month history of progressively worsening blurred vision in the left eye. on eye examination, his distant vision was 20/40 od and 20/50 os (uncorrected), corrected vision was 20/20 od (-1 ds) and 20/25 0s (-1 ds). anterior segments of both eyes were normal. the right eye posterior segment was normal while the left eye posterior segment showed macular edema. fundus fluorescence angiography revealed central serous retinopathy (fig 1 and 2). he responded well to intravitreal ranibizumab and argon laser (fig 3 and 4) with a vision returning to 20/25 unaided over a 9 month period. discussion takayasu disease rarely affects males as it is more common in young females. in addition, takayasu retinopathy has various modes of presentation which are mainly caused by hypoxia resulting in microanuersyms, ischemia, optic neuropathy or secondary to hypertensive changes. our case showed none of these changes instead the patient presented with a normal retinal vasculature with macular edema resulting from central serous retinopathy (csr) which responded to the standard treatment. causes of csr are not well-established yet. however it is thought to be due to retinal pigment epithelial insult, or leakage from choriocapillaries. also neurosensory detachment are known to occur in patients on long term corticosteroids following organ transplants. the relationship t 220 between takayasu disease and csr is not established in the literature and in our case, this presentation could be related to long term corticosteroids or may be associated or unassociated to the takayasu disease. author’s affiliation sharmeen akram section of ophthalmology department of surgery aga khan university, karachi azam ali section of ophthalmology department of surgery aga khan university karachi khabir ahmad section of ophthalmology department of surgery aga khan university karachi reference 1. koide k. takayasu arteritis in japan. heart and vessels. 1992; 7: 48-54. 2. demir mn, hazirolan d, altiparmak ue, et al. takayasu's disease and secondary ocular ischemic syndrome. j pediatr ophthalmol strabismus. 2010; 47: 54-7. 3. koz og, ates a, numan alp m, et al. bilateral ocular ischemic syndrome as an initial manifestation of takayasu's arteritis associated with carotid steal syndrome. rheumatol int. 2007; 27: 299-302. 4. kaliaperumal s, gupta a, sengupta s, et al. unilateral hemorrhagic keratouveitis as the initial presentation of takayasu's arteritis. indian j ophthalmol. 2007; 55: 397-8. 5. vedantham v, ratnagiri pk, ramasamy k. hypotensive retinopathy in takayasu's arteritis. ophthalmic surg lasers imaging. 2005; 36: 240-4. 6. kaushik s, gupta a, gupta v, et al. retinal arterial occlusion in takayasu's arteritis. indian j ophthalmol. 2005; 53: 194-6. 7. rodriguez-hurtado fj, sabio jm, et al. ocular involvement in takayasu’s arteritis: response to cyclophosphamide therapy. eur j med res. 2002; 7: 128-30. 8. karam ez, muci-mendoza r, hedges tr. 3rd. retinal findings in takayasu's arteritis. acta ophthalmol scand. 1999; 77: 209-13. microsoft word 11. co omolas case report 222 vol. 28, no. 4, oct – dec, 2012 pakistan journal of ophthalmology case report conservative management of congenital eversion of the upper lid in a nigerian child c.o. omolase, o.t. ogunleye, b.o. omolase, a. ogedengbe pak j ophthalmol 2012, vol. 28 no. 4 . . . . . . . . . . . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: omolase charles oluwole department of ophthalmology federal medical centre, owo. ondo state, nigeria …..……………………….. this is a case report of a male nigerian child who was brought to the eye centre of federal medical cente, owo, ondo state, nigeria by his mother and concerned relatives three hours after delivery at a maternity centre in a nearby town in may, 2011. the child was noticed to have eversion of both the upper eyelids, most prominent on the left immediately after an uncomplicated spontaneous vaginal delivery following a full term uneventful pregnancy. conservative management instituted led to resolution of the lid eversion within four days of presentation. case history we report the case of a male nigerian child who was brought to the eye centre of federal medical cente, owo, ondo state, nigeria by his mother and concerned relatives three hours after delivery at a maternity centre in a nearby town in may, 2011. the child was noticed to have eversion of both upper eyelids (more prominent on the left) immediately after an uncomplicated spontaneous vaginal delivery following a full term uneventful pregnancy. examination revealed both upper eyelids were everted most especially on the left. the right upper eye lid was easily repositioned with gentle digital pressure but there was spontaneous eversion of the right upper lid whenever the baby cried. eye balls could not be visualized because of swelling and chemosis. there was no systemic abnormality noted. there was no similar occurrence in his family. conservative treatment was commenced immediately. we applied chloramphenicol ointment to both eyes and the left eye was patched. the eversion of the upper lids resolved fully by the fourth day after conservative treatment. follow up two weeks later showed a sustained resolution of the eversion and normal ocular findings. discussion congenital eye lid eversion is a rare condition which was first described by adams in 1896.1 he described it as double congenital ectropion. the aetiology of the condition is not clear. however the aetiology of the condition had been attributed commonly to birth trauma or congenital lid hypotonia.2 the other implicated patho-physiological factors include vertical shortening of the anterior lamellar or vertical elongation of the posterior lamella of the eye lid and failure of the orbital septum to fuse with levator aponeurosis, absence of effective lateral canthal ligament as well as lateral elongation of the eye lid.3 the condition is associated with black race4, trisomy 215 and infants born with collodion disease.6 sella in a literature review carried out in 1992, found fifty one reported cases in the literature.5 there was a previous report of congenital eversion of the lids in our centre which was conservatively managed7. the condition is typically bilateral, however unilateral cases have also been reported.8 congenital eversion of the lids can be managed conservatively or surgically. surgical treatment options include tarsorrhaphy, subconjunctiva injection of hyaluronic acid, fornix sutures and full thickness skin graft of the upper lid.3 conservative management of congenital eversion of the upper lid in a nigerian child pakistan journal of ophthalmology vol. 28, no. 4, oct – dec, 2012 223 fig. 1: congenital upper eye lid eversion before commencement of management fig. 2: normal eyelids 4 days after treatment this case was successfully managed conservatively. the early presentation most likely contributed to the resolution of the lid eversion with conservative management. we need to create awareness among the populace about this ocular condition with emphasis on desirability of early presentation. author’s affiliation dr. c. o. omolase department of ophthalmology federal medical centre, owo ondo state, nigeria dr. o. t. ogunleye department of ophthalmology federal medical centre, owo ondo state, nigeria dr. b. o. omolase department of ophthalmology federal medical centre, owo ondo state, nigeria dr. a. ogedengbe department of family medicine federal medical centre, owo ondo state, nigeria references 1. adams al. congenital eversion of the upper eye lid. med forthnightly 1896; 9: 137-8. 2. raab e, saphir rl. congenital eye lid eversion with orbicularis spasm. j pediatr ophthalmol strabismus. 1985; 22: 125-8. 3. al-hassain h, al-rajhi aa, al-qahtani s, et al. congenital upper eye lid eversion complicated by corneal perforation. br j ophthalmol. 2005; 89: 771. 4. lu lw, bansal rk, katzman b. primary congenital eversion of the upper lids. j pediatr ophthalmol strabismus. 1979; 16: 149-51. 5. sellar pw, bryars jh, acher db. late presentation of congenital ectropion of the eye lids in a child with down’s syndrome: a case report and review of the literature. j pediatr ophthalmol strabismus. 1992; 29: 64-7. 6. shapiro rd, soentgen ml. collodion skin disease and everted eye lids. post grad med. 1969; 45: 216-9. 7. omolase co, aina as, omolase bo, et al. congenital eversion of the upper eye lids. asian journal of ophthalmology. 2008; 10: 236-7. 8. maheshwari r, macheshwari s. congenital eversion of the upper eye lids: case report and management .indian journal of ophthalmology. 2006; 54: 203-4. microsoft word tanveer a. chaudhry 48 case report a boy with bilateral complete cryptophthalmos in pakistan with subsequent blaming and shaming for his mother tanveer a chaudhry, bilal salman, khabir ahmad pak j ophthalmol 2010, vol. 26 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tanveer a chaudhry section of ophthalmology department of surgery aga khan university stadium road, karachi received for publication february’ 2009 …..……………………….. ryptophthalmos is a very rare congenital anomaly, in which there is developmental defect in the surface ectoderm part of the eye, with partial or complete failure of eyelid formation and is characterized by skin passing continually from the forehead to the cheek over a malformed eye, or failure of separation of lids. as in fraser syndrome1 it is mostly accompanied by urogenital anomalies, syndactyly, and cognitive disorders.1 we report a unique case of bilateral complete cryptophthalmos in pakistan where the mother was blamed for being responsible for the birth of malformed child. case report a seven-day old full-term male infant presented to the eye outpatient department of aga khan university hospital, karachi with bilateral complete unformed lids, with continuous skin covering both the eyes. he is the first child of his parents who come from the low socio-economic class and was delivered by lower segment cesarean section in a local hospital in karachi. according to his mother he had spontaneous breathing after delivery. she had no complication during delivery. his birth weight was 2.2 kg. his parents were non-consanguineous with was no family history of such condition. his appetite was good, bowel habits were normal and sleep was also normal. on ocular examination, there was complete closure of both eyelids by skin from the forehead (figure 1). no eyelashes or eyebrows were seen. on putting very bright light on the closed eyes, there were sudden head movements. there were also movements behind the closed lids. on digital ocular examination, soft globes were palpable. on b-scan ultrasonography, both eyes showed a malformed anterior segment, but formed vitreous cavity. on general examination, the body weight was 2.9 kg. head circumference was normal for age. both ears were small and malformed. his nasal bridge was broad and depressed. there was a swelling in the right inguinal region, suggestive of inguinal hernia (fig.1). c 49 fig. 1: showing broad & depressed nasal bridge, small malformed ears and swelling at right inguinal area. fig. 2: the children 24 hours after the surgery the child underwent reconstructive surgery with the aim to form the lids (fig.2). the surgery was performed under general anesthesia and was done jointly by an ophthalmologist (tac) and a plastic surgeon. during surgery, it was noted that the cornea were adherent to the skin and the eyes were small with completely malformed anterior segments. lids were created and conjunctiva was stitched to its inner surface in both eyes. the child was sent for conformers to be fitted in both sockets with the hope to prevent future adhesions. it was very difficult for them to find conformer of that small size and the smallest size found was fitted in with difficulty. few days later, the conformer fell off the sockets and lids started to adhere again. parents were advised further surgery in future but they got lost to follow up citing financial and social reasons. the mother was only 18 years old and she reported that her in laws were holding her responsible for her malformed child. they went on to seek advice from alternate therapists. discussion this is one of only few reported cases of bilateral complete cryptophthalmos. in 2005, egier and colleagues2 reported the 6th case of bilateral complete cryptophthalmos3. to the best of our knowledge this is the 7th reported case of this condition in the world and the first where bilateral complete cryptophthalmos is associated with inguinal hernia beside other reported malformations such as anomaly of ears and genitalia and depressed nasal bridge. the parents of the infant were young and belonged to low socioeconomic class with little education. they had a non-consanguious marriage and this was their first child. there was no family history of similar condition from both sides of the family. sadly, the mother was blamed for the malformation. such social implications have not been highlighted in other reported cases. the infant had not been screened for other possible systemic anomalies such as cardiac, pulmonary and renal. an attempted lid construction revealed eyes with malformed anterior segment. there was micro-cornea with opacities and disorganized and poorly visible anterior chamber. the aim of the surgery was to visualize the eyes and assess their anatomical and functional status because ultrasonography revealed normal looking vitreous cavity with no retinal detachment. 50 author’s affiliation dr. tanveer a chaudhry section of ophthalmology, department of surgery aga khan university, karachi dr. bilal salman section of ophthalmology, department of surgery aga khan university, karachi dr. khabir ahmad section of ophthalmology, department of surgery aga khan university karachi reference 1. slavotinek am, tofft cj. fraser sumdrp,e amd crutp[jtja;,ps: revoew pf the doagmpstoc croteroa amd evodemce fpr [jemptu[oc ,pdi;es om cp,[;ex ,a;fpr,atopm sumdrp,es/ j med gemet 2002; 39: 623-33. 2. egier d, orton r, a;;em, et al. bilateral complete isolated cryptophthalmos: a case report. ophthalmic genet 2005; 26: 185-9. 3. patrick-ferife ge, omoti ae. cryptophthalmox: report of a very reare case in nigeria. case rep clin pract rev. 2007; 8: 247-9. microsoft word abstracts vol. 27, 2,11 116 abstracts edited by dr. qasim lateef chaudhry antagonism of vascular endothelial growth factor for macular edema caused by retinal vein occlusions: two-year outcomes hafiz g, channa r, shah sm, nguyen qd, ying h, do dv, zimmer – galler i, solomon sd, sung ju, syed b. ophthalmology 2010; 117: 2387-94. a study by campochiaro et al suggests that antivascular endothelial growth factor (vegf) treatment provides long-term benefit in patients with macular edema due to branch retinal vein occlusion (brvo) or central retinal vein occlusion (crvo). in this small prospective, randomized clinical trial, 20 patients with macular edema due to brvo and 20 patients with crvo received injections of anti-vegf agents at 4 weekly intervals for 3 months. after month 3, the patients were seen every 2 months and received injections as needed for recurrent edema. at 2 years, the brvo patients experienced a mean improvement of 18.8 letters, while the crvo patients experienced a mean improvement of 8.5 letters. however, frequent injections were required in some of the patients with brvo and most patients with crvo. according to the authors, this latter finding suggests that excessive vegf production represents a long-term problem in many patients with crvo. they calls for additional studies to determine the long-term effects of frequentpossibly monthly-injections and/or the use of higher doses of anti-vegf agents randomized evaluation of the trabecular microbypass stent with phacoemulsification in patients with glaucoma and cataract samuelson tw, katz lj, wells jm, pharm d, duh yj, giamporcaro je. ophthalmology 2011; 118: 459-67. samuelson et al conducted a large-scale randomized, controlled, multicenter study comparing cataract surgery with a glaucoma drainage device versus cataract surgery alone in patients with mild to moderate open angle glaucoma. the investigators found the cataract surgery patients who received the stent demonstrated clinically and statistical improvement in terms of iop reduction with less medication use compared with those undergoing cataract surgery alone. the investigators enrolled 240 eyes in the study, randomizing them into 2 groups: the treatment group, who underwent cataract surgery with trabecular micro-bypass stent (istent) implanttation, and the control group who underwent cataract surgery only. at 1 year, 66% of treatment eyes versus 48% of control eyes achieved ≥20% iop reduction without medication. incidence of adverse events was similar between the groups. the researchers assert the istent demonstrates a positive benefit-risk intervention in patients with mild to moderate glaucoma undergoing cataract surgery, and may represent a novel therapeutic approach that may avoid the lifelong risk of complications, which can be associated with filtering blebs. central serous chorioretinopathy: an update on phathogenesis and treatment gemenetzi m, salvo gd, lotery aj. eye 2010; 24: 1743–56. central serous chorioretinopathy (csc) is a chorioretinal disease, incompletely understood with systemic associations, a multifactorial aetiology, and a complex pathogenesis. increased permeability from the choriocapillaris leads to focal or diffuse dysfunction of the retinal pigment epithelium causing a detachment of the neurosensory retina. csc has been described in patients with endogenously high levels of corticosteroids as well as in patients with hypercortisolism due to the treatment of ocular or systemic diseases. it is therefore the only‘ inflammatory’ choroiditis, not proven to be associated with infection that is precipitated or worsened by glucocorticoids. foveal attenuation, chronic macular oedema, and 117 damage of the foveal photoreceptor layer have been reported as causes of visual loss in csc. photoreceptor atrophy in the fovea, despite successful retinal reattachment, typically occurs after a duration of symptoms of approximately 4 months. treatment should therefore be considered after 3 months if there is angiographic evidence of ongoing foveal leakage in recurrent chronic csc or in a single csc episode accompanied by signs of chronic csc alterations. based on results of trials conducted so far, it appears that photodynamic therapy with verteporfin is effective and safer than argon laser treatment and should be considered as the treatment of choice, whereas micropulse diode laser photocoagulation seems to be an effective alternative. glucocorticoid inhibitors are an interesting alternative treatment. clinical trials are ongoing to test their efficacy. in addition, it is important, where possible, to discontinue any corticosteroid treatment. the possible association of csc with stress should also be discussed with patients. microsoft word akhtar jamal case report 1 case report infection of upper punctum and canaliculi caused by actinomyces akhtar jamal khan, jamal mughal pak j ophthalmol 2009, vol. 25 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: akhtar jamal khan chief consultant and medical director akhtar eye head & neck hospital gulshan-eiqbal karachi received for publication june’ 2008 … ……………………… purpose: the clinical and microbiological findings in a chronic case of lacrimal canaliculitis due to actinomyces are described. material and methods: a 55-year-old woman presented with a one year history of intermittent conjunctivitis associated with medial canthal swelling, pain and discharge from her right eye. topical and oral treatment failed to respond, gram staining was carried out and surgical exploration was done. results: canaliculitis due to actinomyces was diagnosed on the bases of clinical and laboratory findings. canaliculotomy was carried out with fine needle of high frequency radio wave cautery of that area to minimize the chance of recurrence. patient was completely asymptomatic after three moth follow up. conclusion: gram staining is a simple cheap and affordable method. it should be performed to identify the causative organism. once diagnoses confirmed surgical exploration is the treatment of choice. ctinomyces species is a gram-positive, non– acid-fast, non–spore-forming anaerobic bacillus that is difficult to isolate and identify1. its filamentous growth and mycelia like colonies have a striking resemblance to fungi2. primary canaliculitis is an uncommon problem caused by actinomyces. although culture play a vital role and give us improved results in diagnosis but fixation of smeared concretions on a slide in alcohol is simple and diagnostic of the disease3. we are reporting a case of old woman with one year history of intermittent conjunctivitis associated with medial canthal swelling, pain and discharge from her right eye. topical and oral treatment failed to respond so surgical exploration was done. case report a 55 year old woman presented with 1 year history of discharge, swelling and pain of medial canthal area and medial part of the right uper eye lid. she had been treated medically for the past one year elsewhere, a 2 without any improvement. her general health was good on her initial visit. she lives in an urban area, she was neither an agriculture worker nor had any close association with animals. initial examination revealed, both eye pseudophakic with corrected visual acuity of 6/6 in both eyes.there was swelling of the medial 1/3 of the right uper eye lid and the neighbouring part of the conjunctiva was inflammed. the right uper punctum was prominent (fig.1). on pressure over the sac, unusual yellowish white chessy granuler matereal came out from right upper punctum which was taken from the eye carefully for microscopic examination. material obtained for gram staining contained a large granule. a portion of the granule crushed under the cover-slip in koh revealed compact masses composed of delicate branching and intertwined filaments under high power lens. the ends of these filaments seen around the periphery of granules had club-shaped appearance characteristic of actinomycotic granule. the smears taken from this ground material were gramstained and examined under microscope, which showed gram positive short and long delicate and branched filaments (fig. 2) on the bases of appearance and morphology it was identified as actinomyces. fig. 1: canaliculitis of the right upper lid fig.2: actinomyces israelii (non-spore forming grampositive bacilli) courtesy of microbiology section we plan for canaliculotomy by radio frequency cautery and canaliculus was explored under local anesthesia. yellowish white cheesy material was removed from the canaliculus followed by application of a high frequency radio wave on that area leaving a cavity 2x 2 mm wide. the patient was continued on topical antibiotics for one month, by which time the infection had completely subsided. abnormal discharge and swelling around the right upper canaliculus had resolved. topical antibiotic was tapered and than discontinued. after a further one month the patient was considered to be free of infection and was discharged from the clinic. discussion canaliculitis is a relatively rare dacryocanal infection which occurs mostly unilateral4. it can easily be misinterpreted and due to this, condition does not improve until a correct diagnosis is established5. canaliculitis due actinomyces is characterised by granulation and suppurative infection of the hollow spaces with formation of concretion. only a microbiologic examination including cultivation of concretion and secretion enabled us to a reliable proof of actinomyces leading to appropriate therapy for canaliculitis6. it has been reported that actinomyces mostly occur endogeneously7 and this infection is rare in male is approximately twice as great as in female8. actinomyces can affect canaliculi, lacrimal gland, lidmargins, lids, cornea, conjunctva, posterior segment and orbit9,10,. recovery of concretions from an infected 3 canaliculus has been taken for diagnosis of actinomyces. in the majority of cases the so called sulfur granules, composed of aggregates of filamentous branching micro-organisms, classically associated with actinomyces. even though actinomycotic infections are sensitive to antibiotics11 and adjunctive hyperboric oxygen therapy for actinomycotic lacrimal canaliculitis has also been reported12 but cure of the canaliculitis does not occur until all the concretions and granulations that were present in the canaliculus were meticulously removed. along with canaliculotomy we used ellman dual frequency surgitron. a high frequency radio wave which causes minimal or no bleeding and give better appreciation and restoration of eye lid anatomy. principles of radiofrequency is based on method of cutting and coagulating soft tissue, directing ultrahigh frequency radiowaves through the tissue cells13. this technique is now getting popular in oculoplastic procedures and we thought that high frequency radio wave should be applied so any remaining intracellular organisms may be destroyed and minimize the chance of recurrences. conclusion a primary infection of the lacrimal canaliculus due to actinomyces is relatively uncommon. in our hospital this is 2nd case, 1st was reported in optic world in 1986. canaliculitis due to actinomyces should be considered in any patient who presents with chronic or recurrent conjunctivitis and the eyelid should be inspected for a discharging and 'pouting' punctum. despite the characteristic clinical symptoms, gram staining and culture if possible should be carried out to establish the diagnosis. medical treatment often dose not helps to cure, it requires surgical exploration of the canalicular system and removal of any casts. author’s affiliation dr. akhtar jamal khan chief consultant and medical director akhtar eye head and neck hospital gulshan-e-iqbal karachi dr. jamal mughal consultant ophthalmologist akhtar eye head and neck hospital gulshan-e-iqbal karachi reference 1. varma d, chang b, musaad s. a case series on chronic canaliculitis: orbit. 2005; 24: 11-4. 2. figdor d, davies j. cell surface structures of actinomyces israelii. aust dent j. 1997; 42: 125-8. 3. briscoe d, edelstein e, zacharopoulos i: actinomyces canaliculitis: diagnosis of a masquerading disease. graefes arch clin exp ophthalmol. 2004; 242: 682-6. 4. hussain i, bonshek r.e, loudon k, et al. canalicular infection caused by actinomyces. eye 1993; 7: 542-4. 5. vecsei vp, huber-spitzy v, arocker-mettinger e, et al. canaliculitis: difficulties in diagnosis, differential diagnosis and comparison between conservative and surgical treatment. ophthalmologica. 1994; 208: 314-7. 6. hass c, pittasch k, handrick w, et al. actinomycetes canaliculitis. immun infekt. 1995; 23: 222-3. 7. kathleen pt, arthus t. foundation in microbiology. 4th ed. mc graw hill company ohio usa. 2002; 597-8. 8. joklik wk, willett hp, amos db, et al. zinsser microbiology. 19th ed. prentice hall international usa. 1988: 524-36. 9. scarano fj, ruddat ms, robinson a. actinomyces viscosus postoperative endophthalmitis. diagn microbiol infect dis. 1999; 34: 115-7. 10. sullivan tj, aylward gw, wright je. actinomycosis of the orbit. br j ophthalmol. 1992; 76: 505-6. 11. barnard d, davies j, figdor d: susceptibility of actinomyces israelii to antibiotics, sodium hypochlorite and calcium hydroxide. int endod j. 1996; 29: 320-6. 12. shauly y, nachum z, gdal-on m, et al. adjunctive hyperbaric oxygen therapy for actinomycotic lacrimal canaliculitis. graefes arch clin exp ophthalmol. 1993; 231: 429-31. 13. aimino g, davi g, santella m. oculoplastic surgery with radiofrequency. new ed. via rosmini, 13 monza italy. 1999; 13-4. guess who? 4 see next issue for answer. microsoft word bakhat samar khan 2 65 original article measurement and expression of exact intraocular pressure of patient’s eye(s) and to determine normal or pathological iop bakht samar khan, mustafa iqbal, zubeda irshad, abid nawaz pak j ophthalmol 2010, vol. 26 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: bakht samar khan assistant professor department of ophthalmology khyber medical college peshawar pakistan received for publication april’ 2009 … ……………………… purpose: to determine the exact and uniform iop of patients eye(s) and need to redefine normal and pathological iop leading to glaucoma. material and methods: a prospective descriptive study of 10000 eyes of 5000 patients out of which 450 eyes were selected .the patients were examined in the department of ophthalmology of khyber teaching hospital peshawar pakistan from june 2003 to may 2008. all patients underwent iop measurement with different tonometers that is goldman, perkins and air puff at the same time. the iop was measured with distant looking eye position and near looking eye position to ascertain the difference in iop. results: the distant looking iop was higher as compared to near looking. thus three readings were obtained as distant looking iop, near looking iop and mean iop. conclusion: the present way of expressing iop as single reading (e.g.20 mm hg) need to be replaced by two readings i.e. distant looking/ near looking (dl/nl) e.g. 21/16 mm hg or as mean of distant looking and near looking iop (e.g. 18.5 mm hg). o diagnose glaucoma and to determine the prognosis; the parameters usually used are visual acuity, tonometry, gonioscopy, fundoscopy, perimetry and family history. the added investigations include hrt (hiedlberg retinal tomography), oct (optical coherence tomography), gdx and vcc (glaucoma diagnosis and variable corneal compensation), pachymetry, fdt (frequency doubling illusion), ultrasound bimicroscopy and arden screening test. among these raised iop is the best known risk factor for glaucomatous optic neuropathy1. the iop is the only risk factor that is modifiable. it is taken as diagnostic and prognostic factor. iop cannot in itself explain quite a number of glaucomatous optic neuropathies particularly ocular hypertension and low tension glaucoma2. so its reliability is questionable?3. but iop is still relied on. this conflict needs to be resolved and is addressed in this study. material and methods in this prospective descriptive study all patients older than ten years coming to opd or admitted in ophthalmology department of kth peshawar were studied (i.e. 10 000) eyes between june 2003 and may 2008. the iop measurement was taken at distant looking and near looking eye positions at the same time. (fig. 1-2) the results were placed in different groups. a total of 450 patients were selected who had iop in the range where glaucoma was suspected. the iop was labeled as distant iop while the patient was looking at a distance of six meters or more. and near iop while the patient was looking at his finger placed at half an arm distance. the average of these two was labeled mean iop. results out of 10,000 eyes examined 450 eyes were selected for study. these were placed in different groups. in t 66 one group of 100 eyes having distant looking iop of 25 mmhg near looking iop was also measured. the near looking iop was 20 mmhg in 15 eyes, 19mmhg in 25 eyes, 18mmhg in 25eyes, 18mmhg in 20 eyes, 17 mmhg in 20 eyes and 16 mmhg in 15 eyes (table 1). in another group 100 eyes having distant looking iop of 24mmhg the near looking iop was measured. the near looking iop was 20 mmhg in 15 eyes, 19mmhg in 25 eyes, 18mmhg in 25eyes, 18mmhg in 20 eyes, 17 mmhg in 20 eyes and 16 mmhg in 15 eyes (table 2). in third group of 100 eyes having distant looking iop of 23 mmhg, the near looking iop was 18 mmhg in 20 eyes, 17 mmhg in 20 eyes, 16 mmhg in 10 eyes, 15 mmhg in 30 eyes and 14 mmhg in 20 eyes (table 3). table 1: difference between dl and nl iop no. of eyes distant lookin iop mm hg near looking iop mm hg mean iop mm hg 100 25 20 (15) 19 (25) 18 (25) 17 (20) 16 (15) 22.5 (15) 22.0 (25) 21.5 (25) 21.0 (20) 20.5 (15) table 2: difference between dl and nl iop no. of eyes distant lookin iop mm hg near looking iop mm hg mean iop mm hg 100 24 20 (10) 19 (15) 18 (30) 16 (20) 15 (25) 22.0 (10) 21.5 (15) 21.0 (30) 20.0 (20) 19.5 (25) in fourth group 100 distant looking iop of 22 mmhg near looking iop was 18 mmhg in 20 eyes, 17 mmhg in 20 eyes, 16 mmhg in 10 eyes, 15 mmhg in 20 eyes, 14 mmhg in 15 eyes and 13 mmhg in 15 eyes (table 4). in another group 50 eyes having distant looking iop of 28 mmhg near looking iop was 24 mmhg in 05 eyes, 21 mmhg in 19 eyes, 20 mmhg in 11 eyes, 19 mmhg in 14 eyes and 16 mmhg in 01 eye (table 5). table 3: difference between dl and nl iop no. of eyes distant looking iop mm hg near looking iop mm hg difference in iop mm hg mean iop mm hg 100 23 18 (20) 17 (20) 16 (10) 15 (30) 14 (20) 5 (20) 6 (20) 7 (10) 8 (30) 9 (20) 21.5 (20) 20.0 (20) 19.5 (10) 19.0 (30) 18.5 (20) table 4: difference between dl and nl iop no. of eyes distant looking iop mm hg near looking iop mm hg mean iop mm hg 100 22 18 (20) 17 (20) 16 (10) 15 (20) 14 (15) 13 (15) 20.0 (20) 19.5 (20) 19.0 (10) 18.5 (20) 18.0 (15) 17.5 (15) table 5: if near looking iop taken then no. of eyes near looking iop mm hg distant looking iop mm hg 55 16 25 (15) 24 (20) 23 (10) 22 (10) table 6: difference between dl and nl iop no. of eyes distant looking iop mm hg near looking iop mm hg mean iop mm hg 25 28 24 (03) 21 (10) 20 (05) 19 (02) 27.0 (03) 24.5 (10) 24.0 (05) 23.5 (02) on the other hand when we select 55 eyes having near looking iop as 16 mmhg and observed their 67 distant iop, the results were as follows. the distant looking iop was 25 mmhg in 15 eyes, 24 mmhg in 20 eyes, 23 mmhg in 10 eyes and 22 mmhg in 20 eyes (table 6). fig.i: distant looking iop was 24 mm hg fig. 2: near looking iop 16 mm hg discussion the iop variation has been reported with various physiological and pathological situations4. for example with sitting and lying position and circadian variation. we are reporting for the first time iop variation while the eye is looking at distance and then at near. on various occasion this discrepancy was noted. with present diagnostic criteria when air puff or even goldmen tonometers were used in small rooms cases of iop of 1720 mmhg with cupping of the disc were labeled as normal tension glaucoma. while working in comparatively larger rooms and using the perkin tonometer the same eyes had iop more than 21mmhg. the observation of this discrepancy leads to the idea of discovering some better method for measurement of iop with lesser or no discrepancy like other studies5. with the technique presented in this study glaucoma can be diagnosed more accurately and particularly it will be helpful in monitoring the effect of medication. at present after glaucoma medication if iop is measured with air puff or goldman tonometer and the reading comes 17 mmhg the situation will appear satisfactory but when at the same time same instrument is used in a distant looking eye position the iop could be actually more i.e. up to 22 mmhg. this shows relying on a single reading could be erroneous and might mislead the management plan. in majority of studies the normal intra ocular pressure is mentioned as up to 21 mmhg. if this value is applied to this study, the number of glaucoma or ocular hypertensive cases will be as follows. 1. 450 if only distant looking iop is considered 2. 33 if only near looking iop is considered. 3. 145 if mean iop is taken after above described observations all 450 cases were investigated for glaucoma. only 100 cases were finally labeled as glaucoma. suggestion is that if distant looking iop is more than 21 and near looking iop comes more than 16 the eye should be further investigated for presence of glaucoma. explanation and mechanism in 1976 kaufman6 and his colleague mentioned that disinsertion of the ciliary muscle from trabecular meshwork abolishes aqueous outflow7. bill et al in 1983 stated that contraction of ciliary muscle is responsible for increased outflow facility as contraction of ciliary muscle causes widening of inter trabecular space in juxtacanalicular region and this contraction cause’s compression of interstitial spaces which stops uveoscleral outflow. normally 90% aqueous flows through trabecular meshwork pathway and 10% through uveoscleral pathway but when the later is closed due to near looking eye position the aqueous outflow through former increases to compensate for it and even more. the net result is increased aqueous outflow and low iop comparatively. contraction of sphincter pupillae has no effect on aqueous outflow8. 68 conclusion the value of iop comes different in same eye when measured while looking at a distance and then near. so instead of taking a single value of iop as final result , taking two measurements, one while eye is looking at distance and another while eye is looking at near or by taking mean of these two values is more realistic and correct indicator of iop in an eye. author’s affiliation dr. bakht samar khan assistant professor department of ophthalmology khyber medical college peshawar prof. mustafa iqbal department of ophthalmology khyber medical college peshawar dr. zubeda irshad lecturer girls medical college peshawar dr. abid nawaz associate professor ghandahara medical university peshawar reference 1. hart wm jr, ritch r, shields mb, et al. the glaucomas. mosby, st. louis. 1989; 789. 2. sommer a, tielsch jm, katz j, et al. baltimore eye survey research group. relationship between intraocular pressure and primary open angle glaucoma among white and black americans. the baltimore eye survey. arch ophthalmol. 1991; 109: 1090-5. 3. erik lg, h.ferdinand ad, h.caroline g. nitric oxide and endothelin in the pathogenesis of glaucoma, edited by i.o. haefliger and j. flammer. lippincott-raven publishers. philadelphia. 1998; 1-2. 4. kitazawa y, horie t. diurnal variation of iop in primary open angle glaucoma. am j ophthalmol. 1975; 79: 557-66. 5. rossitti l, marchetti i, orzalesi n, et al. randomized clinical trials on medical treatment of glaucoma. are they appropriate to guide clinical practice? arch ophthalmol. 1993; 111: 96-103. 6. kaufman pl, baranyeh. experiment in monkeys. invest ophthalmol. 1976; 15: 558. 7. bill et al. glaucoma updates 1983. 8. almegard and andersson. exp. eye. 1990; 51: 685. microsoft word tariq khan case report 100 case report choroidal melanoma in ocular melanocytosis muhammad tariq khan, sanaullah jan, zakir hussain, samina karim, muhammad kamran khalid, lal mohammad pak j ophthalmol 2010, vol. 26 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: muhammad tariq khan 2-lakhkar khan road university town peshawar received for publication may’ 2009 … ……………………… ocular melanocytosis is the melanocytic hyperplasia of the deeper layers of cojunctiva or the episclera. this should be differentiated from the other clinical entity, i.e. ocular melanosis, which is defined as melanocytic hyperplasia of the epithelial layers of conjunctiva. ocular melanocytosis, although rare in white races, is associated with somehow increased risk of uveal malignant melanoma. in darkskinned races, the disease entity is comparatively more common but its association for developing uveal melanomas is extremely rare. we report a case of congenital ocular melanocytosis, later on complicated by choroidal malignant melanoma, in a dark-skinned pakistani citizen. a 35 years old male with congenital conjunctival melanocytosis of the right eye (left eye being un-affected) presented to us. his visual functions remained unaffected till the age of 33 years, when he noticed slight dimness of vision in his right eye. at the time of presentation, his vision had dropped to light perception in the affected eye. after detailed clinical work up and after performing some necessary investigations, a diagnosis of choroidal malignant melanoma was made. the eye was enucleated and histopathological examination confirmed the diagnosis. cular melanocytosis is one of the three clinical variants of “congenital melanocytosis”; the other two being the dermal and the oculo-dermal melanocytosis. “ocular melanocytosis” is the least common of these three clinical settings. this is a congenital melanocytic hyperplasia involving only the eye and is typically unilateral1. ocular melanocytosis of the deep conjunctiva or superficial sclera occurs in about 1 in every 2500 individuals and is more common in the black, hispanic and asian populations. in caucasians, it affects approximately 0.04% of population. pathologically, ocular melanocytosis consists of focal proliferation of sub-epithelial melanocytes. patches of episcleral pigmentation appear slate gray through the normal conjunctiva. about one half of patients with ocular melanocytosis have ipsilateral dermal melanocytosis (nevus of ota), a proliferation of dermal melanocytes in the periocular skin of the first and second dermatomes of cranial nerve v2. ocular melanocytosis has been associated with an increased incidence of malignant melanomas in white patients. malignant melanoma can develop in conjunctiva, uvea or orbit. in whites, the lifetime risk of uveal melanoma in a patient with ocular melanocytosis is about 1 in 400; much greater than the risk of 1 in 13,000 of the general white population3. incidence of ocular melanocytosis is comparatively more common in asians and blacks, while the other entity, i.e. the benign acquired ocular melanosis, predominantly affects darkskinned and black population. the incidence of developing uveal malignant melanoma in patients with ocular melanocytosis in darkskinned population, although reported before, is extremely rare. we are hereby presenting a case report, where a 35 years old dark-skinned pakistani developed malignant melanoma of the choroid in an o 101 eye, previously diagnosed as a case of congenital conjunctival melanocytosis. case report a 35 years old male, taxi driver by profession, presented with congenital ocular melanocytosis of the right eye (left eye being un-affected). on slit-lamp examination, the melanotic hyper-pigmentation had clinically involved the conjunctiva and the episclera of the right eye. there was no periocular dermal involvement. the visual functions of the patient remained unaffected till the age of 33 years, when he for the first time, noticed slight dimness of vision in his right eye. at the time of presentation, his vision had dropped to perception of light in the affected eye. after clinical evaluation, a&b-scan ultrasonography was performed. a-scan typically showed initial high spike followed by low to medium internal reflectivity in the tumor. b-scan findings were consistent with mushroom-shaped melanoma showing choroidal mass with the typical internal acoustic hollowing and excavation (fig. 1). fig: b-scan ultrasound of the right eye of the patient after ruling out any metastatic spread by doing chest x-ray, abdominal ultrasound and blood profiles, a diagnosis of non-metastatic choroidal malignant melanoma was made. enucleation of the eye was done and the histopathology confirmed the diagnosis (mixed variety of the choroidal malignant melanoma). 102 discussion choroidal melanoma is the most common primary intraocular malignant tumor in adults, with an annual incidence of six per million populations. it is typically unilateral and uni-focal tumor, although bilateral and bi-focal cases have been reported4. melanocytosis oculi is often under-estimated as a risk factor for uveal and conjunctival melanoma in dark-skinned population. sabates fn and yamashita t, in 1967, reported a case of congenital melanocytosis oculi complicated by two independent malignant melanomas of the choroids5. hubel k, hanselmayer h. in 1979 reported a case with melanosis bulbi observed in a relatively young patient of 33 years, in which a malignant melanoma of the choroid developed. as reported earlier, the incidence of malignant melanoma in cases of melanosis bulbi in white races is much higher than in normal eyes. the authors recommended strongly routine biomicroscopic examinations in cases of melanosis bulbi every 1-2 years to recognize the development of a melanoma at an early stage6. straatsma br, duffin rm, foos ry, and kreiger ae in 1981 reported that in a white patient with melanosis oculi, a small choroidal melanoma in the hyperpigmented eye was observed for 8 years before enucleation. an important factor in the decision to enucleate was echographic evidence of extra-ocular tumor extension. histopathologic examination confirmed the presence of a small choroidal melanoma (with an intraocular tumor volume of about 60 mm3), scleral tumor infiltration, and extra-scleral tumor extension. discussion considered the extremely important role of echography in the management of even small choroidal melanomas, and its significance in extra-ocular tumor extension7. wilkes td, uthman eo, thornton cn and cole re, in 1984, reported a case of a choroidal melanoma in a black patient with oculo-dermal melanocytosis8. brini a. in 1985 reported a case of melanocytosis oculi with malignant melanoma of the choroid. microscopical examination confirmed the clinical diagnosis in this case9. roldan m, llanes f, negrete o and valverde f. of the department of ophthalmology, university hospital of madrid spain, in 1987, reported malignant melanoma of the choroid associated with melanocytosis oculi in a child10. gonder jr, shields ja, shakin jl, and albert dm. reported a woman with bilateral ocular melanocytosis, who later on developed a malignant melanoma of the choroid in one eye11. gunduz k, shields ja, shields cl, and eagle rc jr. in 1998, presented a 14-years old male adolescent with ocular melanocytosis and secondary glaucoma in the left eye, in whom ophthalmoscopy disclosed diffuse choroidal pigmentation and a pigmented mass that occupied the macular area and surrounded the optic nerve. ultrasonography showed an acoustically hollow lesion with scleral bowing and choroidal excavation. based on clinical and ultrasonographic findings, a diagnosis of choroidal melanoma was made. the eye was enucleated and histopathology confirmed the diagnosis12. lopez-caballero c, saornil-alvarez ma, blancomateos g, frutos-baraja jm, lopez-lara f, and gonzalez-sansegundo c. in 2003, presented four cases of ocular melanosis. choroidal melanoma was detected in all of them. three eyes had decreased visual acuity and were enucleated because they contained large active tumors. in the fourth case, the melanoma was detected on routine examination and the authors were able to apply a conservative treatment with i125 brachytherapy. the authors recommended that ophthalmic surveillance, every 6 or 12 months is important in patients with ocular melanosis, for early detection of high-risk diseases13. velazquez n, and jones is found fifteen patients with ocular or oculo-dermal melanocytosis, after reviewing 1210 cases of histologically proved uveal melanomas. the melanoma in each of these patients developed in the eye affected with ocular or oculodermal melanocytosis and not in the unaffected eye. in one case with bilateral oculo-dermal melanocytosis, the patient developed melanoma in the eye with more pronounced signs of melanocytosis. in case of partial ocular melanocytosis, melanoma developed in the sector of the eye affected by melanocytosis14. conclusion previous statistical data shows that the risk of uveal melanoma in white races is greater in patients with ocular melanocytosis than the normal white population. but this increased risk in case of darkskinned (like south-asians) or black population has hardly being supported by the literature in the past. 103 with this case report, we strongly recommend a yearly eye examination and b-scan ultrasound assessment in cases of ocular melanocytosis, so as to recognize the development of a choroidal melanoma at an early stage. author’s affiliation dr. muhammad tariq khan trainee medical officer (vitreo-retinal ophthalmology) khyber institute of ophthalmic medical sciences pgmi, hayatabad medical complex peshawar dr. sanaullah jan senior registrar khyber institute of ophthalmic medical sciences pgmi, hayatabad medical complex peshawar dr. zakir hussain trainee medical officer khyber institute of ophthalmic medical sciences pgmi, hayatabad medical complex peshawar dr. samina karim trainee medical officer khyber institute of ophthalmic medical sciences pgmi, hayatabad medical complex peshawar dr. muhammad kamran khalid district eye specialist lakki marwat, nwfp dr. lal mohammad assistant professor kohat medical college kohat university of science and technology kohat, nwfp reference 1. kanski jj. clinical ophthalmology. 5th ed; butterworthheinemann. 2003; 84-6. 2. kirk rw, andrew jw, david gh, et al. clinical approach to neoplastic disorders of the conjunctiva and corneaexternal diseases and cornea: aao, bcsc sec. 8, san fransisco. 1999; 244. 3. sakel ja, meyer lh, marcus dm, et al. nevus and melanocytoma. in: albert dm, jakobiec pa. principles and practice of ophthalmology. philadelphia wb saunders. 2002; 6: 5006-12. 4. honavar sg, shields cl, singh ad, et al. two discrete choroidal melanomas in an eye with ocular melanocytosis. surv ophthalmol. 2002; 47: 36-41. 5. sabates fn, yamashita t. congenital melanosis oculi complicated by two independent malignant melanomas of the choroid. arch ophthalmol. 1967; 77: 801-3. 6. hubel k, hanselmayer h. malignant melanoma of the choroid in melanosis bulbi. klin monatsbl augenheilkd. 1979; 174: 4047. 7. straatsma br, duffin rm, foos ry, et al. melanosis oculi, small choroidal melanoma, and extraocular extension. dev ophthalmol. 1981; 2: 92-104. 8. wilkes td, uthman eo, thornton cn, et al. malignant melanoma of the orbit in a black patient with ocular melanocytosis. arch ophthalmol. 1984; 102: 904-6. 9. brini a. a case of melanosis oculi with malignant melanoma of the choroid. int ophthalmol. 1985; 7: 169-74. 10. roldan m, llanes f, negrete o, et al. malignant melanoma of the choroid associated with melanosis oculi in a child. am j ophthalmol. 1987; 104: 662-3. 11. gonder jr, shields ja, shakin jl, et al. bilateral ocular melanocytosis with malignant melanoma of the choroid. br j ophthalmol. 198; 65: 843-5. 12. gunduz k, shields ja, shields cl, et al. choroidal melanoma in a 14-year-old patient with ocular melanocytosis. arch ophthalmol. 1998; 116: 1112-4. 13. lopez-caballero c, saornil-alvarez ma, blanco-mateos g, et al. choroidal melanoma in ocular melanosis. arch soc esp oftalmol. 2003; 78: 99-102. 14. velazquez n, jones is. ocular and oculodermal melanocytosis associated with uveal melanoma. ophthalmology. 1983; 90: 1472-6. microsoft word hamid awan 161 original article subjective assessment of pain level during phacoemulsification and extra capsular cataract extraction with intraocular lens implantation under topical anesthesia abdul hamid awan pak j ophthalmol 2009, vol. 25 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: abdul hamid awan department of ophthalmology shalamar teaching hospital shalimar link road lahore received for publication december’ 2008 ….………………………….. purpose: to investigate the level of pain in both phacoemulsicification and extra capsular cataract extraction using topical anesthesia with proparacain hydrochloride 0.5% as an alternate to peribulbar and retro bulbar anesthesia. materials and methods: sixty patients undergoing cataract surgery (thirty eyes using phacoemulsicification and thirty eyes with extra capsular cataract extraction technique) were included in the study. all patients received topical anesthesia with proparacain (alcain) eye drops combined with sponge socked in alcain eye drops in superior conjuctival sac, which remained there till the end of surgery. in all phacoemulsification cases incision site was supro-temporal clear corneal for right eyes and supro-nasal clear corneal for left eye with foldable intraocular lenses without sutures. in all cases of extra capsular cataract extraction, clear corneal superior limbal incision was given with implantation of 6.5 mm pmma intraocular lens and stitched with shoe-lace continuous 10/0 nylon sutures. all patients were evaluated for intra-operative pain. subjected pain was assessed by using 4-point scale. results: 3 patients (10 %) of patients in both groups experienced mild pain during both phacoemulsification and extra capsular cataract extraction.6 patients (20 %) had moderate pain during passing first suture in extra capsular cataract extraction cases only, for which subconjuctival xylocain was infiltrated just behind incision before suturing. no patient had severe pain during extra capsular cataract extraction in all 30 cases. conclusion: topical anesthesia can be safely used not only in phacoemulsification but also in extra capsular cataract extraction procedure, which is safe and effective alternative to peribulbar and retro bulbar anesthesia, thus, avoiding pain and other complications of regional blocks. ataract extraction is the most commonly performed operation in patients over 65 years of age1. topical anesthesia was first used in 1884 by koller who used cocaine2. after one century, fichman used an attractive alternative method of injecting local anesthetic agents resulting in faster visual recovery and high patient satisfaction 19953. the advantages of topical anesthesia include its ease of application, minimal to absent pain/ discomfort on administration, rapid onset of anesthesia and more important lack of devastating complications such as globe perforation and retro bulbar hemorrhage, injury to the nerves, muscles, raised vitreous pressure, which may occur following c 162 local injection4,5. the technique is also economical, avoids undesirable cosmetic adverse effects, and allows instant visual rehabilitation. topical anesthesia blocks the trigeminal nerve ending, provides at least analgesia of the eye. the optic nerve and motor neurons are not affected, and the ocular motility is maintained6. this is most likely due to the fact that, unlike retro bulbar or peribulbar anesthesia, topical anesthetic agents have no effect on the optic nerve. revolution in cataract surgery has brought about by phacoemulsification technique and the consequent reduced surgical time, led to further interest in topical anesthesia. however, in dense cataracts, extra capsular cataract extraction can also be performed under topical anesthesia (eye drops and xylocain soaked sponge in superior fornix) safely. some patients may require augmentation with subconjuctival infiltration of xylocain just behind the incision in extra capsular cataract extraction to prevent pain before suturing. the goal of study was to investigate the level of pain during both phacoemulsification and extra capsular cataract extraction procedures. materials and methods sixty eyes of 60 patients with cataract were included in this study, 30 eyes undergoing phacoemulsification and foldable iol implantation and 30 eyes undergoing extra capsular cataract extraction with rigid 6.5 mm iol operated under topical anesthesia. none of the patients had a history and/or ocular findings of glaucoma, uveitis or corneal opacity. the study protocol was explained to the patients and informed consent was obtained from all of them. the patients were told that they would be asked about their pain level, if any, during every stage of the surgery. as for the degree of pain, a 4-grade scale was used. 0=no pain, 1= mild (tolerated pain), 2= moderate (need interference like more anesthetic), 3= severe (not tolerated and need to stop the procedure). the surgery was divided into 9 stages, i.e., clear corneal incision, continuous curvilinear capsulorhexis, side-port incisions at 3 and 9 o'clock positions, hydro dissection, nuclear rotation, phacoemulsification, bimanual irrigation and aspiration, iol implantation, apposition of corneal incisions with stromal hydration and suturing in ecce. after each stage, patients were asked to grade their pain according to the pain scale described above. the surgical time was also recorded for each case. the pupillary dilatation was obtained by mydriacyl 1% and phenylephrine 2.5% given 30 min preoperatively (3 times at 10-min intervals). topical anesthesia was achieved by proparacain hydrochloride 0.5% (alcaine, alcon pharmaceuticals), given 3 times with 2-min intervals before the surgery along with sponge soaked in proparacain0.5% placed in superior fornix till the end of surgery. all operations were performed by a single surgeon (aha). in 30 eyes following a 2.75-mm superior clear corneal incision, phacoemulsification technique was used. by enlarging the corneal incision using 3.2mm keratome, a acrylic foldable posterior chamber iol with 6.0-mm optic diameter (kontour) was implanted into the capsular bag. 30 eyes undergoing ecce, partial thickness clear corneal incision given, capsulorhexis done, ripped at 10 and 2 o clock. after hydro dissection wound enlarged and nucleus delivered, pmma rigid posterior chamber iol (kontour) with 6.5 mm optic diameter was implanted into the capsular bag. wound stitched with continuous 10/0 nylon. the results of pain level were given as percentages and means with range, respectively. statistical analysis was performed with t test and p value less than 0.05 was accepted as statistically significant. results there were 39 male (65%) and 21 female (35%) patients. the average age was 60.5 years (range: 42-79 years). the preoperative best-corrected visual acuity was between counting fingers and 6/18 (snellen). the mean operation duration was 13.0 min (range: 8-18 min) in phacoemulsification and 31.5 min (range: 2340) in extra capsular cataract extraction. for the pain level during surgery, the overall pain score was found to be 0.66 (range: 0-3) in phacoemulsification, the highest mean pain score was during iol implantation (1.0) followed by phacoemulsification (0.7) and bimanual irrigation and aspiration 0.61, (table 1), which is comparable to previous study7 and in ecce, highest mean pain score was during suturing (2.0) followed by iol implanttation (1.25). a previous paper8 reported a mean pain score of 1.46 over a scale ranging from 0 to 10, which is fairly similar to our result. in that study, the most painful stage was phacoemulsification, followed by iol insertion and irrigation-aspiration. similarly, the highest mean pain scores were encountered during iol implantation, phacoemulsification, and bimanual irrigation-aspiration stages in our study. 163 table 1. mean pain scores during different stages of phacoemulsification and extra capsular cataract extraction under topical anesthesia stage pain score mean range corneal incision 0.0 0-1 capsulorhexis 0.0 0-1 hydrodisection 0.25 0.2 phacoemulsification 0.5 0.2 irrigation aspiration 0.7 0.2 iol implantation 1.25 0-3 wound enlargement in ecce 1.5 0-3 corneal opposition with stromal hydration 0.2 0-1 suturing wound in ecce 2.0 0-3 when the mean pain scores were compared across phaco and extra capsular cataract extraction the difference between phacoemulsification/nucleus delivery versus irrigation-aspiration, and iol implantation was not found to be statistically significant (p = 0.66 and p = 0.103, respectively). however, the difference between wound closure in ecce and stromal hydration in phacoemulsification was statistically significant (p = 0.007). all surgeries were completed with topical anesthesia alone in phacoemulsification but subconjuctival infiltration of xylocain was required before suturing in ecce with iol in 9 eyes (30 %), and no other complication was observed during any operation. discussion the popularity of topical anesthesia has increased progressively in recent years. in 1995 only 5% of eye surgeons in usa were doing cataract surgery using topical anesthesia, but this ratio has increased to 45% (1). however, there is hesitation to perform ecce using topical anesthesia. patients may experience pain during cataract surgery (phacoemulsification & extra capsular cataract extraction) under topical anesthesia. no such study is available to compare the results of pain level in both procedures simultaneously. the level of pain was compared between two groups and found to be similar to other local anesthesia methods (5,6). in our study, overall pain score was found to be 0.66 using a scale between 0 and 4. a previous paper8 reported a mean pain score of 1.46 over a scale ranging from 0 to 10, which is fairly similar to our result. in that study, the most painful stage was phacoemulsification, followed by iol insertion and irrigation-aspiration. similarly, the highest mean pain scores were encountered during iol implantation, phacoemulsification, and bimanual irrigation-aspiration stages in our study. however, the difference between wound closure in ecce and stromal hydration in phacoemulsification was statistically significant. therefore, in all those who felt mild to moderate pain during passing first suture were given subconjuctival xylocain, which make them pain free till the end of surgery, which is comparable with previous study9. the surgeon's experience with reduced intraocular manipulations, avoiding unnecessary conjunctival handling and short operation time also favored the low pain scores in our study. the reason for overall less pain score during phaco with foldable iol implantation is possibly due to insertion of the single piece acrylic foldable lens as compared to pain score in patients undergoing ecce, in which rigid silicon iol was implanted. topical anesthesia avoids the risk of globe perforation, retro bulbar hemorrhage, and damage to optic nerve, dural perforation and significant conjunctival chemosis. possible disadvantages of topical anesthesia is adverse eye movement but it appear to provide acceptable analgesia during surgery, wears off rapidly after surgery, and does not interfere with the patient’s ability to blink, see or move the eye. patients are able to follow commands, which are sometimes needed during surgery. in our study, movement of eyeball was rarely a problem. conclusion topical anesthesia is safe and effective method for not only small incision clear corneal phacoemulsification cataract surgery but also for quick and minimal manipulative extra capsular cataract extraction with iol with subconjuctival augmentation anesthesia if required before suturing wound. patients may experience visual sensations, and preoperatively they should be informed about the possibility of these experiences. additionally, patients can be told that the pain felt during the operation is low and tolerable. topical anesthesia with proparacain (soaked sponge in superior conjunctival sac and eye drops) provide 164 effective analgesic effect in both phacoemulsification as well as extra capsular cataract extraction. finally, topical anesthesia is rather comfortable and prevent long list of complications associated with local blocks. however, surgical training and good patient preparation is required for safe use of topical anesthesia. author’s affiliation abdul hamid awan consultant & head of department of ophthalmology shalimar teaching hospital shalimar link road, lahore reference 1. jaffe ns, jaffe ms, jaffe gf: cataract surgery and its complications. st louis, mosby. 1997; 2-3. 2. fichman. topical eye drops replace injection for anesthesia. ocular surgery news. 1992; 1; 20 and fichman topical technique appear safer in patient with anticoagulant anesthesia intensive care. 2001; 29: 8-11. 3. konstantos a. topical anesthesia in cataract does not carry the risk of injection. pubmid. 11261903. 4. zehetmayer m, radax u, skorpik c, et al: topical versus peribulbar anesthesia in clear corneal cataract surgery. j cataract refract surg. 1996; 22: 480-4. 5. leaming dv: practice styles and preferences of ascrs members: 1999 survey. j cataract refract surg. 2000; 26: 913-21. 6. b. cataract clinical ophthalmology 4th. ed. 7. yaylal v, yldrm c, tatlpnar s et al. subjective visual experience and pain level during phacoemulsification and intraocular lens implantation under topical anesthesia ophthalmologica. 2003; 217: 413-6. 8. o'brien pd, fulcher t, wallace d, et al. patient pain during different stages of phacoemulsification using topical anesthesia. j cataract refract surg. 2001; 27: 880-3. 9. junejo sa, halepota fm. phacoemulsification under topical anaesthesia and superior rectus infiltration. pak j ophthalmol. 2000; 16: 157-9. microsoft word ahmet satici 125 original article tear tnf-α, il-1α, and il-6 levels in patients with active trachoma ahmet satici, mustafa guzey pak j ophthalmol 2009, vol. 25 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: ahmet satici department of ophthalmology harran university, school of medicine, sanliurfa turkey received for publication january’ 2009 … ……………………… purpose: tear tnf-α, il-1α, and il-6 levels were investigated in patients with active trachoma. material and methods: fifteen eyes of 15 patients with active trachoma were included in this study. active trachoma was diagnosed using fluorescent monoclonal antibody test kit. fifteen eyes of 15 age-matched, healthy subjects were used as controls. tear fluid samples were obtained from the conjunctival cul-de-sac by means of blunted-tip glass capillary tubes. reflex tears from patients with active trachoma and normal subjects were collected by stimulating the nasolacrimal reflex with by a cotton-tipped applicator. the levels of cytokine in tears were measured elisa. results: the tear levels of tnf-α, il-1α, and il-6 were determined to be higher in the patients with active trachoma than in the control subjects (p=0.049), (p=0.000), (p=0.003), respectively. conclusion: the data suggest that tnf-α and il-1α with its regulatory cytokine il-6 may play a role in trachoma. in conclusion, levels of the certain cytokine in tears to reflect inflammation in active trachoma. rachoma is a chronic ocular disease caused by chlamydia trachomatis. in most patients with mild trachoma, it may heal without permanent visual loss, but in patients with severe chronic trachoma it may progress and cause serious damage of the ocular surface. severe inflammatory trachoma is felt to be a marker for subsequent severe scarring1,2. the pathogenic mechanisms in trachoma are not well understood. various immunologic mechanisms may give rise to trachomatous inflammation. certain cytokines such as il-6 could trigger or maintain the inflammatory immune response seen in trachomatous conjunctivitis2. understanding the exact mechanisms involved in the pathogenesis of trachoma is important for future therapeutic approaches3. in patients with active trachoma, both the epithelial and subepithelial layers of the conjunctiva are seen to be infiltrated with mononuclear and polymorphonuclear leukocytes, macrophages, and b and t lymphocytes. the pathogenesis of trachoma involves the recruitment of inflammatory cells to the conjunctiva where they participate in a local inflammatory response producing severe tissue damage. immunohistochemical studies have demonstrated that b and t cells that are stimulated by chlamydial antigens lead to the induction of reaction to tissue damage2. still endemic in many developing countries, trachoma is a common clinical problem in the southeastern region of turkey4. long regarded as a standard in the laboratory confirmed diagnosis of trachoma, direct immunofluorescence assay staining is a simple, quick, and extremely trustworthy technique for detecting chlamydial infections. previous studies have found direct immunofluorescence assay staining results to be more sensitive than those of culture5,6. therefore, we decided to use this method in the determination of active trachoma. in this study, we chose to investigate tear tnf-α, il-1α, and il-6 levels in patients with active trachoma because tnf-α and il-1 are considered primary t 126 cytokines and they initiate a cascade of events integral to the inflammatory process. they also induce the production of secondary cytokines such as il-67. this is the first study in which tear cytokine levels have been detected in patients with active trachoma. material and methods fifteen eyes of 15 patients with active trachoma were included in this study. patients complicated by infections or inflammations in addition to trachoma were excluded from the study. active trachoma was diagnosed with a fluorescent monoclonal antibody test kit for the direct staining of c. trachomatis (cellabs, australia). ocular specimens for chlamydial tests were taken from the upper tarsal conjunctiva after instillation of local anaesthetic. specimens were processed according to the manufacturer's instructions. slides were read on a fluorescence microscope (e 800 nikon, japan). a specimen was considered positive for c. trachomatis if three or more typical elementary bodies were identified8. in addition laboratory examination was performed on bacterial cultures (blood agar, thioglycolate broth, chocolate agar by gram's stain and giemsa stain. the control group consisted of fifteen eyes of 15 age-matched healthy subjects with no evidence of inflammatory eye disease no symptoms of ocular irritation and no history of eye disease or surgery, or use of contact lenses or ocular medication. all control subjects had negative results in the direct staining of chlamydia trachomatis. informed consent was obtained after the nature and possible consequences of the study were explained. tear fluid samples were collected atraumatically from the conjunctival cul-de-sac by means of bluntedtip glass capillary tubes. care was taken to avoid touching the ocular surface. reflex tears from patients with active trachoma and normal subjects were collected by stimulating the nasolacrimal reflex with a cotton-tipped applicator. the amount of tears collected was about 150 µl from each eye. the obtained samples were immediately stored at –700 c within plastic tubes until assay. immunoassays the tear fluid cytokine levels were determined by elisa. measurements of tnf-α, il-1α, and il-6 in tear samples were carried out with a commercially available kit (pelikine, amsterdam, the netherlands). all tests were performed according to the manufacturers’ recommended protocol. if the tear fluid samples were not of adequate volume, they were diluted. the samples were analyzed in duplicate. the minimum detectable concentrations for the assay kits were 1 pg/ml, 2 pg/ml and 1 pg/ml for tnf-α, il-1α and il-6, respectively. statistical analysis statistical analysis of data was performed by the paired t test. results the patients with active trachoma had a mean age of 9.4±5.7 years and comprised both sexes (8 females and 7 males). the normal subjects had a mean age of 10.8±4.9 years and also comprised both sexes (8 females and 7 males). in this study, tear tnf-α levels were found to be significantly higher in patients with active trachoma than in control subjects (t=-2.160, p=0.049). while detectable tear tnf-α levels were found in 80.0% of patients with active trachoma, they were found in only 13.3% of control subjects. there appeared to be a wider range of tear tnf-α levels than in controls (fig. 1). the tear il-1α concentrations were found to be higher in patients with active trachoma than control subjects (t=-5.466, p=0.000). tear il-1α levels were five times higher in the patients with active trachoma group than the control group (table 1). while il-1α levels were 9.6±3.5 pg/ml in control subjects, there were 48.5±27.8 pg/ml in patients with active trachoma (fig. 2). table 1: tear tnf-α, il-1α and il-6 levels in patients with active trachoma and control subjects (mean ± sd). tnf-α (pg/ml) il-1α (pg/ml) il-6 (pg/ml) control subjects 1.1±2.9 9.6±3.5 11.4±2.2 patients with active trachoma 53.2±96.4 48.5±27.8 109.6±104.8 higher il-6 levels were detected in the tears of patients with active trachoma than the controls (t=-3.628, p=0.003). tear il-6 levels were ten times higher in patients with active trachoma than in controls (table 1) (fig. 3). 127 0 50 100 150 200 250 300 350 controls patients t n fal p ha (p g /m l) fig. 1. tear tnf-α levels in patients with active trachoma and control subjects. 0 20 40 60 80 100 120 controls patients il -1 al ph a (p g/ m l) fig. 2. tear il-1α levels in patients with active trachoma and control subjects. 0 50 100 150 200 250 300 350 controls patients il -6 (p g /m l) fig. 3: tear il-6 levels in patients with active trachoma and control subjects discussion cytokines produced by the immune system cells as a result of an immune response induced by viral or bacterial infection may play an important role in the inflammatory process9. the inflammatory response is caused by microorganisms, accompanied by the infiltration of polymorphonuclear leukocytes, macrophages and lymphocytes. tnf-α is known to play an important role as primary mediator in the pathogenesis of inflammation. it is secreted mainly by activated monocytes/macrophages. our results showed that the levels of tnf-α were higher in the tears of patients with active trachoma than in controls. the source of the high levels of tnf-α determined in the tears of active trachoma patients may be inflammatory cells to collect on the ocular surface. tnf-α also triggers the in vivo and in vitro production of cytokines such as il-1 and il-69. il-1 is produced mainly by activated macrophages and neutrophils, but other cells such as conjunctival epithelial cells and b and t cells are capable of il-1 synthesis as well il -1 plays a variety of roles in the pathogenesis of many diseases. il-1 cannot on its own cause tissue damage, but it can potentialize the damage caused by tnf-α il-1 and tnf-α induce the release of secondary cytokines such as il-610. in this study we determined that tear levels of il1α were higher in patients with active trachoma than in healthy subjects. although il-1α is secreted by a number of cells, the increased levels determined in trachoma patients may have been caused by macrophages, neutrophils or lymphocytes infiltrating the conjunctiva, and or increased tear tnf-α levels. il-6 is synthesized and released mainly by monocytes and macrophages in response to inflammatory stimuli. it is secondary to tnf-α and il-1 production, but other cells for example, t and b lymphocytes may also produce it. il-6, like il-1 and tnf-α serves as an important immune mediator in inflammatory and immunologic processes. il-6 acts as a signal in t cell activation, induces antibody secretion by b cells, and induces differentiation of cytotoxic t cells. tnf-α, il1, and il-6 can exert synergistic effects in acute pathologic changes, including cellular infiltration10. increased tear il-6 levels are reported in many ocular inflammatory conditions. il-6 levels in the tears of patients with active trachoma were found to be significantly higher than in controls. the high il-6 levels determined in patients 128 tears may have been caused by inflammatory cells infiltrating the area of inflammation and/or by increased tear tnf-α and il-1 levels. tnf-α, il-1 and il-6 are inflammatory cytokines playing a role in inflammatory process. in this study elevated tear tnf-α, il-1α and il-6 levels were demonstrated in patients with active trachoma. these data suggest that tnf-α and il-1 along with its regulatory cytokine il-6, may play a role in the inflammatory processes of trachoma. immunologic events occurring on the ocular surface due to chronic chlamydial infection may lead to blindness11,12. increased knowledge about trachoma will contribute to eradication blindness caused by this disease. these finding suggest that tnf-α and il-1 may play important roles in the pathogenesis of trachoma, that it is worthwhile to investigate the role of cytokines in the pathogenesis of trachoma, and that further studies are necessary in order to better understand the inflammatory process in trachoma and identify the cellular sources of the cytokines found in high levels in the tears of trachoma patients. author’s affiliation ahmet satici department of ophthalmology harran university school of medicine sanliurfa turkey mustafa guzey department of ophthalmology harran university school of medicine sanliurfa turkey reference 1. west sk, munoz b, lynch m, et al. risk factors for constant, severe trachoma among preschool children in kongwa, tanzania. am j epidemiol. 1996; 143: 73-8. 2. tabbara kf. chlamydia: trachoma and inclusion conjunctivitis. in: tabbara kf, hyndiuk ra, editors. infections of the eye. 2nd ed. little, brown co: new york. 1996; 433-51. 3. conway dj, holland mj, bailey rl, et al. scarring trachoma is associated with polymorphism in the tumor necrosis factor alpha (tnf-α) gene promoter and with elevated tnf-α levels in tear fluid. infect immun. 1997; 65: 1003-6. 4. negrel ad, minassian dc, sayek f. blindness and low vision in southeast turkey. ophthalmic epidemiol. 1996; 3: 127-34. 5. schachter j, sweet rl, grossman m, et al. experience with the routine use of erythromycin for chlamydial infections in pregnancy. n eng j med. 1986; 314: 276-9. 6. preece pm, anderson jm, thompson rg. chlamydia trachomatis infection in infants: a prospective study. arch dis child. 1989; 64: 525-9. 7. leonardi a, borghesan f, depaoli m, et al. procollagens and inflammatory cytokine concentrations in tarsal and limbal vernal keratoconjunctivitis. exp eye res. 1998; 67: 105-12. 8. carta f, zanetti s, pinna a, et al. the treatment and follow up of adult chlamydial ophthalmia. br j ophthalmol. 1994;78: 06-8. 9. de vos af, klaren vna, kijlstra a. expression of multiple cytokines and il-1ra in the uvea and retina during endotoxininduced uveitis in the rat. invest ophthalmol vis sci. 1994; 35: 3873-83. 10. boisjoly h, laplante c, bernatchez sf, et al. effects of egf, il-1 and their combination on in vitro corneal epithelial wound closure and cell chemotaxis. exp eye res. 1993; 57: 293-300. 11. young e, taylor hr. immune mechanisms in chlamydial eye infection. invest ophthalmol vis sci. 1986; 27: 615-9. 12. taylor hr, rapoza pa, west s, et al. the epidemiology of infection in trachoma. invest ophthalmol vis sci. 1989; 30: 1823-31 . microsoft word col. zulfiqar uddin syed 77 original article pain associated with peribulbar injection for cataract surgery zulfiqar uddin syed, haroon javed, amjad akram, amir mustaqeem qureshi, tariq shakoor, muhammad saqib pak j ophthalmol 2009, vol. 25 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: zulfiqar uddin syed classified eye specialist combined military hospital sialkot purpose: patients planned/admitted for cataract surgery have a fear of worst pain due to peribulbar injection for anaesthesia rather than surgery itself. the principal objective and aim of this evidence based study is to find out the degree of pain associated with the anaesthetic peribulbar injection for cataract surgery. materials and method: this prospective randomised study was carried out at ophthalmology department cmh sialkot from 12th feb2008 to 22nd april 2008. 300 patients undergoing elective cataract surgery were administered a peribulbar block. before injection all patients were briefed about the procedure and counselled regarding the degree of pain that they may experience. patients were asked to grade the pain of peribulbar anaesthetic injection, using a visual analogue scale (vas). result: focus of the study was on the degree of pain associated with anaesthetic peribulbar injection for cataract surgery. 300 patients (180 males and 120 females) were included in the study. 200 patients were having their first surgery, they were more apprehensive especially about the injection associated pain. 100 patients with history of previous cataract surgery (61 right eye and 39 left eye operated) were calm, confident and had low anxiety level.28 (9.2%) patients claimed that they felt no pain at all. 252 (84%) patients had just needle prick to feeling of heaviness/ mild pain. only small percentage of patients i.e. 20 (6.66%) had injection associated moderate to severe pain. conclusion: the study revealed that the peribulbar anaesthesia for cataract surgery is safe and highly effective. the degree of pain associated with 78 received for publication august’ 2008 … ……………………… peribulbar injection is much less than what the patients actually have in their mind and fear of. the study also shows ‘pain threshold’ and anxiety level as major factors for pain perception. ge related cataract surgery is done under different forms of anaesthesia i.e. local anaesthesia with or without sedation, topical anaesthesia and general anaesthesia, local anaesthesia being the commonest. different techniques have been used to administer the local anaesthesia like retrobulbar injection, peribulbar injection and sub tenon blockade1. the pain often experienced during peribulbar injection for local anaesthesia is partly related to the needle prick and partly to the solution injected and it’s ph (true for solutions with adrenaline). however there is evidence that adding preservative free sodium bicarbonate to the local anaesthetic solution reduces the discomfort on injection2. the visual analogue scale (vas) was used to grade the intensity of pain or how much pain the patient was feeling. vas is a straight line marked from 0 to 10, with the left end of the line ‘0’ representing no pain and the right end of the line ‘10’ representing the worst pain. patients are asked to mark on the line where they think their pain is3. material and methods the study included 300 patients (180 male and 120 female), between the ages 24 to 95 years undergoing elective cataract surgery. all patients were premedicated with tablet valium 5mg 12 hours and tablet acetazolamide 500mg 3 hours before surgery. pre operatively pupil were dilated with 1% tropicamide and 10% phenylephrine eye drops (2.5% in hypertensive patients) at 60, 45, 30 and 15 minutes before surgery. topically local anaesthetic 0.5% proxymethacain drops were instilled into conjunctival sac of all patients before administration of peribulbar injection and the patients were properly positioned. all peribulbar injections were given by an experienced ophthalmologist, at the junction of middle and lateral third of lower lid using 5ml syringe having 23g lure slip 0.60,30 mm needle with a standard acidic local anaesthetic solution of 2.5ml 2% lignocain with adrenaline 1:1000 and 2.5ml 0.5% bupivacain, filled beforehand. before administration of injection patients were asked to grade the pain of peribulbar injection after administering the blockade on a standard visual analogue scale (provided to all the patients) which was enlarged to facilitate these visually impaired patients. identical questions were phrased for all patients. to adjust for cofounding effects of possible prognostic factors i.e. ‘pain threshold’ and ‘injector’ spss statistical software was consulted using the ‘drop pain’ scores as a covariate for ‘injection pain’. results patients were assessed on the basis of sex, age, associated illnesses with medications including analgesics, history of cataract surgery, anxiety level and pain threshold using a visual analogue scale (vas). 300 patients were included in the study, 180 (60%) male and 120 (40%) female. 100 patients (33.3%) had previous cataract surgery. they were more confident, calm and composed before their surgery. 200 (66.7%) patients undergoing surgery for the first time were more worried and anxious about the peribulbar injection and its associated pain rather than the surgery itself. 36 (12%) patients were relaxed, calm and claimed that they had no pain at all not even a needle prick. 224 (74.7%) patients were anxious and had just feeling of needle prick and slight heaviness. 28 (9.3%) patients were very anxious and complained of mild pain during injection. 12(4.0%) patients created a panic were extremely worried, and it was difficult to administer peribulbar injection had very low pain threshold complained of moderate to very severe pain. there is strong association between anxiety level, pain threshold ‘drop pain’ and injection pain. greater is the anxiety level, lower is the pain threshold and more is the pain perception. counselling regarding injection and pain however relaxed/calmed down the anxious patients and made the administration of injection easy. 225 (75%) patients included in the study were otherwise healthy, 39 (13%) hypertensive and 25 (8.3%) diabetics. associated diseases and their medication had no effect on the degree of pain. frequency distribution of injection pain reveals that 28 patients (9.3%) claimed that they had no pain at all and marked ‘0’ on vas. 156 patients (52%) graded their pain ‘1’ on vas, when they were asked to a 79 explain, had just needle prick sensation. 66 patients (22%) felt heaviness and graded their pain ‘2’. 30 patients (10%) had mild pain so marked ’3’ on vas.. only 20 patients (6.66%) had moderate to very severe pain and graded their pain from ‘4’ to ‘9’ on vas. hence most of our patients i.e. 252 patients (84%) claimed no to mild pain i.e. ‘0’-‘3’ on vas. discussion surgery for age related cataract is the highest volume surgical procedure carried out throughout the world. cataract surgery is almost exclusively performed as an out-patient in local anaesthesia. there are considerable national and international variations in anaesthesia management strategies for cataract surgery4. regional anaesthesia for eye surgery has traditionally consisted of retro bulbar block, peribulbar block, a facial nerve block and intravenous sedation. the use of local anaesthesia has risen from around 20% in 1991 to over 75% in 1996 and 86% in 1997 and the use of sedation with local anaesthesia has fallen from 45% in 1991 to 6% in 19965. although less invasive than general anaesthesia with endotracheal intubation and less likely to be associated with postoperative nausea, local anaesthesia is not without complications like retro bulbar haemorrhage, glob perforation especially with an axial length greater than (26mm), optic nerve atrophy, oculocardiac reflex, etc1. the peribulbar block is performed with the patient supine and looking directly ahead. after topical anaesthesia of conjunctiva an inferotemporal injection is given half way between the lateral canthus and the lateral limbus. the needle is advanced under the globe parallel to the orbital floor and when it passes the equator of the eye it is directed slightly medial (20 degree) and cephalad (10 degree), injecting 5ml local anaesthetic solution1. in peribulbar block the needle does not penetrate the cone formed by extra-ocular muscles, as in retro bulbar block. both the techniques achieve akinesia of the eye quite well. the effectiveness of regional block for cataract surgery has traditionally been assessed by describing the completeness and adequacy of globe akinesia (prevention of eye movement) and pain control4. advantages of the peribulbar technique include minimum risk of globe, optic nerve and artery penetration, and less pain on injection. disadvantages include a slower onset and an increased likelihood of ecchymosis6. local anaesthetic used for nerve block must cross perineural sheath and nerve membrane. these structures are permeable to these agents only in non ionized form. alkalinisation of anaesthetic agent also contributes to the reduction of pain in peribulbar injection due to many reasons. firstly adjustment of ph towards 7.0-7.4 reduces direct tissue irritation caused by injection of acidic solution. secondly, the increased relative concentration of non ionised form allows for a more rapid diffusion through tissues and results in immediate nerve blockade. thirdly nocioceptor receptors may be less sensitive to non ionised form. therefore the greater diffusebility of non ionised form may result in greater inhibition of pain transmission, thereby preventing nocioceptive impulses from being fully appreciated7. most anaesthetic agents are weak bases, although they are supplied as acidic solution to improve stability. in this form anaesthetic agents are ionised and therefore achieve nerve blockade more slowly than alkaline and lipid soluble solution/agents. alkalinisation of local anaesthetic agent with bicarbonate increases the amount of non ionised form, lipid solubility and despite ionised form being active in solution, penetrate the membrane and tissues faster8. regarding pain associated with administration of block, there was obvious evidence that peribulbar block was slightly less painful than retro-bulbar block and weak evidence that sedation or analgesia improves anxiety level, pain relief and patient satisfaction during cataract surgery and that one sedative or analgesic agent was superior to the other9. the pain experienced during injection is also related to the temperature of injectate and speed of delivery of the solution. pain is much reduced if solution is at body temperature and delivered slowely10. table 1: sex wise distribution of patients frequency n (%) valid % cumulative % valid male 180 (60) 60 60 valid female 120 (40) 40 100 total 300 (100) 100 table 2: patients with history of cataract surgery frequency valid % cumulative 80 n (%) % valid no 200 66.7 66.7 right eye 61 20.3 87 left eye 39 13.0 100 total 300 (100) 100 table 3: anxiety level frequency n (%) valid % cumulative % valid calm 36 (12) 12 12.0 anxious 224 (74.7) 74.7 86.7 v. anxious 28 (9.3) 9.3 96.0 panic 12 (4) 4.0 100 total 300 (100) 100 table 4: co. morbid frequency n (%) valid % cumulative % valid no 225 (75) 75 75 dm 25(8.3) 8.3 73 htn 39(0.3) 13 96.3 arthritis 1(03) 0.3 96.7 asthma 7(2.3) 2.3 99 uveitis 1(0.3) 0.3 99.3 glaucoma 2 (0.7) 0.7 100 total 300 (100) 100 in our study, table 5 revealed that majority of the patients 156 (52%) had just needle prick sensation, i.e. ‘1’ on vas and only few patients experienced severe pain ‘8’ and’9’on vas. table 5: frequency distribution of peribulbar injection pain frequency n (%) valid % cumulative % valid 0.00 28 (9.3) 9.3 9.3 1.00 156 (52.0) 52.0 61.0 2.00 66 (22.0) 22.0 83.3 3.00 30 (10.0) 10.0 93.3 4.00 5 (1.7) 1.7 95.0 5.00 6 (2.0) 2.0 97.0 6.00 6 (2.0) 2.0 99.0 7.00 1 (0.3) 0.3 99.3 8.00 1 (0.3) 0.3 99.7 9.00 1 (0.3) 0.3 100 total 300 (100) 100 conclusion a variety of commonly employed anaesthesia management strategies for cataract surgery appears to be safe and effective. there is obvious evidence that peribulbar block is less painful than retro bulbar block4. our study also revealed that the degree of pain associated with peribulbar injection for cataract surgery is much less than what the patients actually have in their mind and fear of. counselling improves patient satisfaction, lowers anxiety and hence pain perception. brief patients about the peribulbar injection, its administration and the way it will help them as well as the surgeon during cataract surgery (analgesia and akinasia). reassurance, that the degree of pain they will have with peribulbar injection and cataract surgery is much less than what they actually have in their mind and fear of. author’s affiliation dr. zulfiqar uddin syed classified eye specialist combined military hospital attockt haroon javed classified eye specialist cmh, sialkot lt. col. dr. amjad akram classified eye specialist cmh, multan amir mustaqeem qureshi classified eye specialist 81 cmh, okara tariq shakoor classified eye specialist cmh, lahore dr. muhammad saqib classified anaesthetist department of anaesthesia cmh, sialkot reference 1. morgan jr ge, mikhail ms, murray mj. clinical anaesthesiology, 4th ed. anaesthesia for ophthalmic surgery, company. 2006; p 831-3. 2. minasian mc, ionides ac, fernando r, et al. pain perception with ph buffered peribulbar anaesthesia. br j ophthalmol. 2000; 84: 1041-4. 3. wewers me, lowe nk. a critical review of visual analogue scales in the measurement of clinical phenomenon. research in nursing and health. 1990; 13: 227-36. 4. schein od, friedman ds, fleisher la, et al. anaesthesia management during cataract surgery volume 1: evidence report /technology assessment no.16; ahrq publication. #1e017, dec 0. 5. hodgkin pr, luff aj, morvell aj. current practice of cataract extraction and anaesthesia. br j ophthalmol. 1992; 76: 323-6. 6. khurana ak, sachdeva rk, gombar kk et al. evalution of subconjunctival versus peribulbar anaesthesia in cataract surgery. aao ophthalmol copenh. 1994; 72: 727-30. 7. christoph r, buchanan i, schwartz s. pain reduction in local anaesthetic administration through ph buffering. ann emerg med. 1998; 17: 117-20. 8. robert j, macleod b, hollands r. improved peribulbar anaesthesia with alkalinisation and hyaloronidase, can j ophthalmol. 1993; 40: 835-8. 9. murdoch ie. peribulbar versus retro-bulbar anaesthesia. eye 1990; 4: 445-9. 10. gillart t, bazin je, montetagaud m, et al. the effects of volume and speed of injection in peribulbar anaesthesia. anaesthesia. 1998; 53: 486-91. microsoft word sadia bukhari 142 original article presentation pattern of retinoblastoma sadia bukhari, aziz-ur-rehman, israr ahmed bhutto, umair qidwai pak j ophthalmol 2011, vol. 27 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sadia bukhari isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, old thana village memon goth road malir, karachi submission of paper may’ 2011 acceptance for publication august’ 2011 …..……………………….. purpose: to determine the pattern of presentation of retinoblastoma. materials and methods: this is a retrospective case series based on clinical records of patients less than 15 years identified with retinoblastoma from january 2006 to december 2009. demographic characteristics including; presenting symptoms and signs, family history, age, gender, laterality and provided treatment were analyzed. results: sixty two patients with retinoblastoma were identified, out of which 79% had unilateral involvement while 21% had bilateral involvement. the most common sign of presentation was leukocoria 56.5% followed by proptosis 24.2%. other presenting signs include fungating mass in orbit, red and watery eyes with raised intraocular pressure and diffuse vitreous haze. conclusion: the most common presenting sign is leukocoria but proptosis also accounts for significant number of cases. because of delay in presentation and diagnosis of retinoblastoma preservation rate of globe is very low. raising awareness and education of primary health care providers and parents is strongly recommended. etinoblastoma is the most common intraocular malignancy of childhood with an incidence of 1: 14,000 1: 20,000 live births1. it accounts for about 3%of all childhood malignancies under 15 years of age2. untreated retinoblastoma is almost fatal but with availability of resources for early detection and treatment the survival rate has increased to more than 90% in developed countries3,4. however in developing countries majority of patients present with advanced disease with resultant 5 year survival rate ranging from 40-79%5-7. most common presentation of retinoblastoma in children is with leukocoria8. other presentations are strabismus, glaucoma, hyphema. proptosis although rare in developed countries is still a frequent mode of presentation in developing countries9,10. the aim of this study is to determine the clinical presentation of children presented with retinoblastoma’s limited amount of work has been carried out on this subject within our community. material and methods this hospital based retrospective study was carried out at pediatric ophthalmology department of alibrahem eye hospital. the medical records of patients under 15 years between january 2006 to december 2009, were reviewed and analyzed. data was compiled on demographic characteristics, clinical examination, histopathology findings, treatment given and their outcomes. the initial evaluation of children included complete ocular history including presenting complaints, duration of symptoms, family history, birth history, prior treatment and any associated systemic problems. complete ophthalmological examination was carried out including visual acuity, slit lamp examination and dilated fundus examination with scleral indentation under ga. the diagnosis was made on basis of clinical signs as leukocoria associated with retinal mass. chalky areas of calcification were also visible majority of times and /or proptosis preceded by a history of abnormal glow in eye. sometimes leukocoria associated with corneal edema r 143 and raised iop with or without hyphema was the presenting feature or advanced proptosis with huge fungating mass in orbit. confirmation was made on imaging studies i.e. ct scan or b-scan ultrasonography looking for presence of calcification in intraocular mass arising from retina. mri was advised in those patients who presented with proptosis to see extra ocular extension (orbit, optic nerve and brain). treatment given includes enucleation with long piece of optic nerve in unilateral cases and at least one eye in bilateral cases along with chemotherapy including vincristine, etoposide, carboplatin or cyclophosphomide. after primary enucleation the diagnosis was confirmed on histopathological examination and patients were further evaluated for any signs of metastasis. systemic evaluation includes full blood count, lumber puncture for csf cytology. bone marrow aspirates for tumor cells and mri. data was analyzed for mode of presentation, age and gender, laterality, involvement of cut section of optic nerve by tumor, scleral and extra scleral infiltration. results sixty two patients were seen with retinoblastoma between january 2006 to december 2009 out of which, 33 (53.2%) were males while 29 (46.7%) were females. mean age of the patient at the time of presentation was 33.31 months with standard deviation of 22.8. minimum and maximum age of presentation was 5 months and 144 months respectively. only 2 (3.2%) patients had positive family history while rest of the 60(96.8%) patients had no family history of retinoblastoma. most of the patients i.e. 49 (79%) had unilateral involvement at the time of presentation while, 13 (21%) patients had bi-lateral involvement. different modes of primary presenting signs were noted of which leukocoria was the most commonly seen primary presentation. thirty five (56.5%) patient presented with leukocoria while proptosis also accounts for significant number of cases i.e. 24.2%.frequency of other different modes of primary presentations is shown in (fig. 1). none of the patients presented with squint. accidental diagnosis in a 6 months old girl having bilateral retinoblastoma who presented with stye in lower lid of left eye and parents were unaware of white pupillary reflex. the different treatment options applied on the patients are shown in (table 1). twenty four (38.7%) patients refused treatment and didn’t follow-up therefore their extent of extension is not known while extension of tumor in rest of the patients is shown in table 2. primary enucleation was performed in 31 patients (one patient had bilateral enucleation) while exentration was performed in 7 patients. after enucleation it was found that in 21 eyes (33.9%) the tumor had not extended beyond the cut section of optic nerve. the level of extension and sites of metastasis is shown in (table 2). the patients were followed from one day to 48 months. the survival rate of patients, who underwent any form of treatment for retinoblastoma, is shown in (fig. 2). table 1: treatment for retinoblastoma frequency n (%) enucleation 14 (22.6) exentration 2 (3.2) enucleation+chemotherapy 16 (25.8) exentration+chemotherapy 5 (8.1) eneucleation b/e 1 (1.6) refused for intervention 24 (38.7) table 2: extension of the retinoblastoma frequency n (%) extension not known (due to refusal of treatment) 29 (46.8) optic nerve free 21 (33.9) optic nerve involved 2 (3.2) orbit involved 3 (4.8) brain involved 2 (3.2) second eye involved 3 (4.8) brain and bone involved 2 (3.2) total 62 (100) discussion the different modes of presentations reported in this study are almost similar to what have been reported in 144 many other studies conducted in developing countries. the common clinical presentation of leukocoria and proptosis in this study are also comparable to those in other developing countries including study from former nwfp of pakistan11. these features together with other signs such as secondary glaucoma, fungating mass and hyphema are known signs of advance disease or high risk of metastasis12-14. a study was performed in congo on 29 patients revealed the common presenting signs to be leukocoria that is 49% followed by proptosis 28%. other signs were strabismus, red eye, anterior scleral staphyloma, hyphema and buphthalmos15. although in our patients no case presents with squint. in nepal an analysis of 43 patients demonstrated proptosis to be the commonest manifestation. 4.3 2.5 3.5 4.5 0 1 2 3 4 5 cate cate cate cate fig. 1: primary modes of presentation in retinoblastoma 13% 43% 44% did not follow-up alive dead fig. 2: survival rate this study showed that the majority of the patients presented with unilateral retinoblastoma. this confirms with studies from both developed and developing countries15,17. the mean age of diagnosis was high. this finding confirms observation from other developing countries of africa and asia15,18. a high mean age of diagnosis has been found to be associated with advance or metastatic retinoblastoma. this is in sharp contrast with findings from developed countries where the mean age of diagnosis is less than 24 months15,17. another problem observed in our patients is the denial of disease by the parents. those who presents while the tumor is still intraocular the parents don’t generally accept the fact that their child can have cancer, which can necessitate removal of the eye and there is therefore delay in disease management. some of them straight away refused for removal of the eye ball and they prefer to let their child die. enucleation is still the most common treatment option as documented in most studies. 19 this was also the commonest option in our study due to late presentation. at the early 20th century the survival rate of retinoblastoma patients was 25-30%, which was now improved to more than 90% in developed countries. in europe it is reported as (95%)4 and in us (more than 93%)20. however in developing countries the five years survival rate is still very low5-7. in our small series the survival rate could not be properly elicited because out of 62 patients 24 (38.7%) patients initially refused for any intervention and they left away. surgical intervention was done in 38 patients of, which five patients did not come back once enucleation / exentration was done and the tissue was handed over to them for biopsy, so we followed 32 patients (at least for one year with maximum followup of five years).the main limitation of our study was that it was conducted in only one centre, and not much of ethnic variation was possible. conclusion majority of patients that presented with advanced disease found it difficult to accept the treatment options. counseling is necessary to achieve complete understanding of the condition by care providers so as to avail the patients of the benefit of complete treatment and let them know the implications of defaulting. the most common presenting sign is leukocoria but proptosis also accounts for significant number of cases. due to the delay in presentation and diagnosis of retinoblastoma preservation rate of globe was very low. raising awareness and education of primary p e r c e n ta g e (% ) o f p a ti e n ts primary modes of presentation percentage (%) 145 health care providers and parents is strongly recommended. author’s affiliation dr. sadia bukhari assistant professor, isra postgraduate institute of ophthalmology al-ibraheem eye hospital, malir, karachi dr. aziz-u-rehman associate professor isra postgraduate institute of ophthalmology al-ibraheem eye hospital, malir, karachi dr. israr ahmed bhutto senior registrar isra postgraduate institute of ophthalmology al-ibraheem eye hospital, malir, karachi dr. umair qidwai postgraduate student isra postgraduate institute of ophthalmology al-ibraheem eye hospital, malir, karachi reference 1. american academy of ophthalmology basic and clinical science course. ocular and periocular tumors in childhood. in: pediatric ophthalmology and strabismus section 6 (2008-2009). leo; singapore. 2008. 390. 2. lennox el, draper gj, sanders bm. retinoblastoma: a study of natural history and progress of 268 cases. br. medical journal. 1975; 3: 731-4. 3. shields ja, shields cl. current management of retinoblastoma. mayo clin proc. 1994; 69: 50-6. 4. mac carthy a, draper gj. retinoblastoma incidence and survival in european children (1978-1997). report from automated childhood cancer information system project. eur j cancer. 2006; 42: 2092-102. 5. naseirpour m, falavarjani kg. retinoblastoma survival in iran: 10 years experience of a referral centre. iranian journal of ophthalmol. 2009; 21: 17-24. 6. andia lr, cordero hr. epidemiological features and survival of retinoblastoma patients in peru. 7th internet world congress for biomedical sciences. inabis. 2002; 14-20. 7. canturk s, quddoumil. survival of retinoblastoma in less developed countries impact of socio-economic and health related indicators. b j ophthalmol. 2010; 94: 1415-6. 8. taylor d, hoyt cs. retinoblastoma. in: pediatric ophthalmology and strabismus 3rd ed. elsevier saunders; london. 2005. 491. 9. kayembe-lubeji d. retinoblastoma in zaire. tropical doctor 1990; 20: 38. 10. kingston je, hungerford jl. retinoblastoma. in: paediatric oncology, 2nd ed. pinkerton cr and plowman pn (eds). chapman and hall, london. 1997; 357. 11. arif m, iqbal z, islam z. retinoblastoma in nwfp, pakistan. j ayub med coll abbottabad. 2009; 21: 60-2. 12. akang ee. retinoblastoma in ibadan nigeria iiclinico pathological features. west afri j med. 2000; 19: 6-11. 13. klauss v, chana hs. ocular tumors in africa. soc sci med. 1983; 17: 1743-50. 14. balasubramanya r, pushker n. atypical presentations of retinoblastoma. j pediatr ophthalmol strabismus. 2004; 41: 1824. 15. akimbo wa. presenting signs of retinoblastoma in congolese patients. bull soc belge ophthalmol. 2002; 283: 37-41. 16. badhu b, sah sp, thakur sk. clinical presentation of retinoblastoma in eastern nepal. clinical and experimental ophthal. 2005; 33: 386-9. 17. ozkan a, pazarli h. retinoblstoma in turkey survival and clinical characteristics 1981-2004. pediatr int. 2006; 48: 369-73. 18. sahu s, banavali sd. retinoblastoma problems and perspectives from india. pediatr hematol oncol. 1998; 15: 5018. 19. owoeye jf, afolayan ta. retinoblastoma – a clinical pathological study in llorin nigeria. afr j health sci. 2006; 13: 117-23. 20. abramson dh, beaverson k. screening for retinoblastoma; presenting signs as prognosticators of patients and ocular survival. pediatrics. 2003; 112: 1248-55. microsoft word nadeem ahmad 1 27 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology original article effect of bevacizumab and laser in the management of diabetic maculopathy nadeem ahmad, tehseen mehmood mahju, qasim lateef ch, m. younis tahir, syed raza ali shah, ch nasir ahmed, muhammad arif, sohail sarwar, qurat-ul-ain, anwar-ul-haq, asad aslam khan pak j ophthalmol 2012, vol. 28 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nadeem ahmad coavs, lahore …..……………………….. purpose. to compare the best corrected visual acuity response after repeated intravitreal bevacizumab and argon laser alone or in combination in patients with diabetic macular edema. material and methods. one hundred and twenty cases of diabetic macular edema involving the fovea were enrolled for the study. they were randomly divided in 3 groups. group a received intravitreal bevacizumab (ivb), group b argon laser alone and group c received both. the follow up was up to 9 months. main outcome measures were mean average change in best corrected visual acuity (bcva) and central macular thickness (cmt) from base line until final assessment at 9 months. results. the baseline mean etdrs bcva was 58.72 ± 10.68 (range 38 – 73) in the ivb group, 55.55 ± 10.75 (range 38 – 69) in laser group and60.12 ± 10.48 (range 38 – 73) in ivb + laser group. the mean etdrs bcva at month 9 was68.51 ± 8.59 (range 49 – 74) in the ivb group, 56.08 ± 12.63 (range 38 – 74) in laser group and 70.2 ± 8.74 (range 49 – 78) in ivb + laser group (p =0.000). at 9 months, central macular thickness decreased from 411.7 ± 96.38 (range 296 – 626) at baseline to 249.65 ± 65.37 (range 193 – 454) in ivb group, 413.03 ± 96.38 (range 302 – 615) to 364.92 ± 107.11 (range 206 – 588) in laser group and 415.9 ± 97.50 (range 299 – 649) to 244.8 ± 60.83 (range 193 – 488) in ivb + laser group (p= 0.000). conclusion. bevacizumab alone or in combination with argon laser provide better gain in bcva as compared to laser alone in patients with diabetic macular edema. iabetic maculopathy is responsible for the visual loss in patients with diabetic retinopathy1. it can be prevented by good metabolic and blood pressure (bp) control2. according to the early treatment of diabetic retinopathy study (etdrs), moderate visual loss can be reduced up to 50% in patients with clinically significant macular edema (csme) with laser photocoagulation but visual improvement was noted in less than 3% of cases3. despite of other therapeutic option, macular laser therapy (mlt) remains the standard treatment for diabetic macular edema (dme) for long time4. the increased levels of vascular endothelial growth factor (vegf) were found in the vitreous cavity of patients with diabetic retinopathy making anti-vegf treatment an attractive therapeutic modality in dme5. monthly injections of ranibizumab (0.5 mg in 0.05 ml) in the resolve study revealed improvement in visual acuity (mean gain of 10 letters in etdrs va)6. another study (read2) revealed improvement of a 7.2 – letter at 6 months in patients receiving ranibizumab alone, compared with 3.8 letters in patients receiving combined mlt and 3 monthly ranibizumab injections, and a 0.4 – letter loss in subjects receiving only mlt7. several studies have also reported favorable effect of intravitreal bevacizumab (ivb) in the management d nadeem ahmad et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 28 of nonischemic diabetic maculopathy8-9. we conducted this study to see the effect of ivb, laser alone and in combination of ivb and laser in the management of diabetic maculopathy. material and methods study design: prospective comparative intervenetional 3 arm case study. settings: the study was conducted at college of ophthalmology and allied visual sciences, mayo hospital lahore. duration of study. nine months sample size: 120 cases with diabetic maculopathy were included inclusion criteria: the following enrollment criteria were used: 1. diabetic patients of either sex of more than 18 years of age. 2. no previous treatment. 3. best corrected visual acuity (bcva) between 6/60 or 6/12. 4. media clarity, pupillary dilation sufficient for adequate fundus imaging. 5. csme involving the fovea and central macular thickness (cmt) of more than 270 micron on optical coherence tomography (oct). exclusion criteria: ischemic maculopathy 1. macular edema due to other causes 2. any cause which will not allow the visual improvement(e.g. dense subfoveal hard exudates, macular cyst, amblyopia) 3. proliferative diabetic retinopathy baseline evaluation. after detailed history bcva was measured using snellen chart. anterior segment and dilated posterior segment slit – lamp biomicroscopic examination was performed. intraocular pressure was also noted. all subjects had colour fundus photographs, fundus fluorescein angiography (ffa), and optical coherence tomography (oct) imaging (optovue).retinal thickness was measured on a point centered at fixation. (defined as central macular area 1000 micron in diameter from the center of fixation). randomization. eligible patients were randomized into 3 groups. group a received ivb, group b received laser and group c received ivb + laser within 7 days of recruitment. all patients were reviewed after every 6 weeks. group a. all patients received ivb injection (1.25 mg in 0.05 ml) in the supero or infero temporal quadrant using standard aseptic intravitreal injection technique within 7 days of randomization. two more injections were given at 6 and 12 weeks. all these patients were followed after every 6 week up to 36 weeks (6, 12, 18, 24, 30 and 36 weeks). retreatment decision was based on achievement of stable bcva and macular thickness. stable bcva was defined as no change in bcva during the last 2 consecutive visits or having 6/6 vision. stable macular thickness was defined as “on 3 consecutive visits with the cmt within 20 micron meter of the patient’s thinnest recorded cmt”. at each visit, the patients were asked about the side effects, a complete ocular examination (including bcva, anterior chamber reaction, iop, and dilated fundoscopy) and oct were performed. color fundus photography and ffa were performed at 18 and 36 weeks. group b. all patients received focal or grid laser treatment within 7 days of randomization. patients were followed up every 6 weeks. retreatments were given according to etdrs guidelines not earlier than 12 weeks from the last treatment (12, 24, and 36weeks). 50 – 100 micron argon laser spot size was used to mild blanching of retinal pigment epithelium and microaneurysms. similarly grid pattern was applied to the area of diffuse leakage. at each visit history and bcva was recorded. a complete ocular examination (iop, and dilated fundoscopy) and oct were performed. color fundus photography and ffa were performed at 18 and 36 weeks. group c. all patients received ivb and focal or grid laser treatment within 7 days of injection. these patients also received 2 more injection at 6 and 12 weeks times. patients were followed up every 6 week time. at each visit, a full history and bcva was recorded. a complete ocular examination (including anterior chamber reaction, iop, and dilated fundoscopy) and oct were performed. color fundus photography and ffa were performed at 18 and 36 weeks. the data was entered and analyzed in statistical package for social sciences version 16 (spss16). outcome measures. the primary outcome measure was a comparison of bcva at base line and 09 months effect of bevacizumab and laser in the management of diabetic maculopathy 29 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology table 1. base line demographic and disease characteristics group a group b group c no. of patients 43 36 41 male : female 27:16 22:14 24:17 mean age + sd men women 50.9 + 6.09 53 48 50.6 + 7.39 55 43.5 51.3 + 4.95 53 48.5 type of diabetes type i type ii 3 40 2 34 4 37 mean duration ( inyrs) 15 14 13.5 dme type focal diffuse 32 11 25 11 27 14 table 2. visual acuity letter score (approximate snellen equivalent) etdrs letter score approximate snellen equivalent more than79 (more than 20/25) 78-69 (20/32 to 20/40) 68-59 (20/50 to 20/63) 58-49 (20/80 to 20/100 48-39 (20/125 to 20/160) less than 38 (less than 20/200) table 3. out come measures among three groups group a group b group c base line mean etdrs bcva 58.72 ±10.68 range (3873) 55.55+ 10.75 range (38-69) 60.12+ 10.48 range (38-73) 9 months mean etdrs bcva 68.5 ± 8.59 range (49-74) 56.08 ±12.63 range (3874) 70.29 ± 8.74 range (4978) mean change in bcva from base line 9.7 ± 4.3 0.5 ± 3.9 10.1 ± 4.9 base line mean cmt (micron meter) 411.74±96.38 range (296626) 413.03± 96.38 range (302615) 415.97±97.50 range(299-649) 9 months mean cmt (micron meter) 249.65 ± 65.37 range (193 – 454) 364.92±107.11 range (206588) 244.85 ± 60.83 range (193-488) mean change in cmt -162±48.04 48±33.40 171± 56.37 nadeem ahmad et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 30 table 4. adverse effects group a group b group c angina pectoris 1 0 0 crebro vascular accident 0 0 0 myocardial infarction 0 0 0 hypertension 2 0 2 eye pain during &after inj or lasers 20 4 15 subconjunctival haemorrhage 5 0 3 floaters 4 0 2 nausea and vomiting during ffa. 1 2 1 endophthalmitis 0 0 0 intravitreal heamorrhage 0 0 0 56.08 60.1258.72 55.55 70.2968.51 0 10 20 30 40 50 60 70 80 group a group b group c base line mean values of va 6th follow up mean values of va fig. 1: mean change in best corrected visual acuity from base line to 9 months 411.74 413.03 415.85 364.92 249.65 244.85 0 50 100 150 200 250 300 350 400 450 group a group b group c base line mean values of cmt changes in cmt mean values in 6th follow up fig. 2: mean change in central macular thickness from base line to 9 months between three groups. the secondary outcome measures were a comparison between three groups at 12 months with regard to: 1. mean cmt 2. ocular and systemic side effects results one hundred and twenty eyes of 120 patients were enrolled for study starting from september 2010 to may 2011. the mean age of the patients was 50.66 ± 7.66 years (range 40 – 67 years), with 47 female (39.16%) and 73 male (60.83%). forty three patients were randomized to group a for ivb and 36 in group b for laser treatment. forty one patients received both iv b and laser in group c. the snellen visual acuity data was converted to etdrs study equivalent for calculation and comparison (table 2). baseline demographics and diabetes characteristics were compared among three groups (table 1). the mean change ± sd in bcva letter score from baseline to 9 months was 9.7 ± 4.3in the iv b group,0.5 ±3.9 in laser group and 10.1 ± 4.9 in iv b + laser group. the mean decrease in cmt from baseline to 9 month was -162 ± 48.04 in bevacizumab group, -48 ± 33.40 in laser group and -171 ± 56.37 in laser + iv b group. the mean average change in the bcva letter score from base line to 9 month was significant (p = 0.000) and cmt from baseline to end point (09 months) was also significantly better (p = 0.000) with bevacizumab and bevacizumab + laser than with laser treatment alone. m ea n mean comparison of va base line and 6th follow up mean comparison of cmt baseline and 6th follow up effect of bevacizumab and laser in the management of diabetic maculopathy 31 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology group a and c has little difference as improvement in bcva (p = 0.000) and reduction in cmt (p = 0.000). in the group a and c rapid improvement was noted on first post treatment follow up (at 6 week) which was continued up to month 3. these values were maintained until the last follow up at nine months except in 2 cases of group a. they were again given two more injection of iv b due to decrease in bcva and increase on cmt. in group b mean bcva remain stabilized around baseline level and reached a 0.5 letter gain at 09 months. safety: no serious ocular side effects were noted except pain at the time of injection followed by subconjunctival hemorrhage. few patients also noted floaters for a day or so after intravitreal injection. no case of endophthalmitis reported in any of the treatment group. hypertension was reported after injection in 4 patients, which was controlled with medications. it was due to systemic vegf inhibition. there was no case of myocardial infarction and stroke after iv b. discussion the results of the study revealed that bevacizumab alone or combined with laser treatment is superior to laser treatment in rapidly improving and maintaining va in patients of dme. there were no efficacy differences detected between group a and c. a greater proportion of patients treated with bevacizumab gained bcva letter scores from baseline as compared with the patients treated with laser. the bevacizumab also showed significant improvement in cmt on oct and resolution of leakage on fluorescein angiography. the results of restore and drcr.net study are consistent with our study. results from the drcr.net study showed that ranibizumab combined with laser (prompt or deferred) was more effective in improving va in dme than laser treatment alone after 1 year. the resolve study also revealed rapid and continuous improvements in bcva over a period of 12 months as compared to sham and laser treatment. the limitations of the study are small number of patients and relatively short follow-up. large multicenter studies are required with longer follow-up of at least 3 years which should compare laser with ivb + laser. in conclusion bevacizumab alone or in combination with laser is superior to standard laser in improving and maintaining bcva and cmt. author’s affiliation dr. nadeem ahmad senior medical officer nishtar hospital, multan dr. tehseen mehmood mahju consultant vr, kemu, lahore dr. qasim lateef ch assistant professor vitreo-retina coavs, kemu, lahore dr. m. younis tahir senior registrar ophthalmology bvh, bahawalpur dr. syed raza ali shah associate professor ophthalmology kemu, lahore dr. ch nasir ahmed senior registrar ophthalmology mayo hospital, lahore dr. muhammad arif senior registrar ophthalmology allied hospital, faisalabad dr. sohail sarwar assistant professor diagnostic, coavs, kemu lahore dr. qurat-ul-ain senior registrar ophthalmology mayo hospital, lahore dr. anwar-ul-haq senior registrar ophthalmology mayo hospital, lahore prof. asad aslam khan prof of ophthalmology director of coavs acting vc kemu, lahore reference 1. klein r, knudtson md, lee ke. the wisconsin epidemiologic study of diabetic retinopathy xxiii: the twenty fiveyear incidence of macular edema in persons with type 1 diabetes. ophthalmology. 2009; 116: 497–503. 2. uk prospective diabetes study group. tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: ukpds 38. bmj. 1998; 317: 703–13. 3. early treatment diabetic retinopathy study research group. photocoagulation for diabetic macular edema: early treatment nadeem ahmad et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 32 diabetic retinopathy study report number 1. arch ophthalmol. 1985; 103: 1796–806. 4. diabetic retinopathy clinical research network. a randomized trial comparing intravitreal triamcinolone acetonide and focal / grid photocoagulation for diabetic macular edema. ophthalmology. 2008; 115: 1447–9. 5. aiello lp, avery rl, arrigg pg, et al. vascular endothelial growth factor in ocular fluid of patients with diabetic retinopathy and other retinal disorders. n engl j med. 1994; 331: 1480–7. 6. safety and efficacy of ranibizumab treatment in patients with diabetic macular edema: 12 – month results of the resolve study. invest ophthalmol vis sci. 2009; 50: e-abstract 4331). 7. nguyen qd, shah sm, heier js. read-2 study group. primary end point (six months) results of the ranibizumab for edema of the acula in diabetes (read-2) study. ophthalmology. 2009; 116: 2175-81. 8. arevalo jf, sanchez jg, wu l. pan-american collaborative retina study group (pacores). primary intravitreal bevacizumab for diffuse diabetic macular edema: the pan – american collaborative retina study group at 24 months. ophthalmology. 2009; 116: 1488-97. 9. haritoglou c, kook d, neubauer al. intravitreal bevacizumab (avastin) therapy for persistent diffuse diabetic macular edema. retina. 2006; 26: 999-1005. 10. diabetic retinopathy clinical research network, elman mj, aiello lp, beck rwl. randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. ophthalmology. 2010; 117: 1064-77. 11. massin p, bandello f, garweg j. safety and efficacy of ranibizumab in diabetic macular edema (resolve study): a 12-month, randomized, controlled, double masked, multicenter phase ii study. diabetes care. 2010; 33: 2399-405. microsoft word ps mahar 154 original article role of laser peripheral iridoplasty in acute attack of primary angle closure glaucoma p.s mahar, dilshad laghari, israr a. bhutto pak j ophthalmol 2010, vol. 26 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p.s. mahar, isra postgraduate institute of ophthalmology al-ibrahim eye hospital malir, karachi received for publication december 2009 …..……………………….. purpose: to study the effect of laser peripheral iridoplasty (lpip) on the intra ocular pressure (iop) and the anterior chamber angle in the patients with an acute attack of primary angle closure glaucoma (pacg), non-responsive to the medical therapy. materials and methods: the study was carried out at isra postgraduate institute of ophthalmology, karachi, from april, 2005 to june, 2009. sixteen patients with the mean age of 61.36 year sd + 3.38 year, (10 female & 6 males) were treated with lpip, when their iop remained elevated with closed angle despite maximum medical treatment, comprising of intravenous mannitol 20%, topical beta blocker and pilocarpine. results: the pre-laser iop of the patients ranged between 36 mmhg to 48 mmhg with mean iop of 41.64mmhg sd + 4.03mmhg. the post laser iop measured at 1 hour ranged between 9 mmhg to 22 mmhg with the mean iop of 14.36 sd + 4.70 mmhg. pre-laser gonioscopy revealed total appositional closure of the angle in all 4 quadrants. after laser, 11 patients had grade ii angle (shaffer’s classification), revealing posterior part of the trabecular meshwork in 2 quadrants, while 5 patients had grade ii angle in all the quadrants. conclusion: lpip is a safe and effective procedure in controlling the iop in patients, with an acute attack of pacg, unresponsive to the medical therapy with opening of the anterior chamber angle n acute attack of primary angle closure glaucoma (pacg) constitutes a true ocular emergency. it is important to abort the attack with the reduction of the intra ocular pressure (iop) and opening of the anterior chamber angle, before permanent damage to the angle structure and optic nerve occurs. the management of an acute attack of pacg is achieved into two stages. first is to reduce the iop and second is to relieve the angle closure. the reduction of the iop is carried out by the intravenous use of hyper-osmotic agents such as mannitol or carbonic anhydrase inhibitor (cai) such as acetazolamide. the topical medication to reduce iop includes beta blockers and cai. once iop is brought under control, miotic therapy with pilocarpine is initiated to constrict the pupil with opening of the angle. miotic therapy is usually ineffective in the earlier phase of the attack, when the iop is very high resulting in the ischemia of the iris1. it is mostly started once iop is reduced. pilocarpine instilled three hours after the topical use of beta blocker breaks the angle closure attack2. the eventual treatment is relieving the pupillary block by the laser peripheral iridectomy (lpi)3. there is a group of patients presenting with an acute attack of pacg in which conventional medical treatment fails to reduce the iop, with the anterior chamber angle remaining occluded. laser peripheral a 155 iridoplasty (lpip) has been used in this group of patients to mechanically open the close angle with the settling of the iop4,5. lpip involves the placement of contraction laser burns in the peripheral iris, resulting in its tightening, pulling it posteriorly away from the trabecular meshwork, and thus opening the anterior chamber angle with the decrease in iop. we performed lpip on the patients with acute attack of pacg, where medical therapy failed to reduce the iop and the anterior chamber angle remained closed. in this prospective study, lpip was performed to demonstrate the effect of this procedure on the anterior chamber angle contour and on the level of iop. the study approval was granted by the ethical and educational committee of the institute. material and methods a total of 55 patients were treated with the clinical diagnosis of an acute attack of pacg at the isra postgraduate institute of ophthalmology/al–ibrahim eye hospital, karachi, between april, 2005 to june, 2008. sixteen of these patients failed to show any decrease in the iop with the standard medical treatment. the patient’s age ranged between 55 to 68 years with the mean age of 61.36 years sd ± 3.38 years. the gender distribution showed 6 male and 10 females. none of these patients had any previous history of glaucoma. the duration of the attack was between 2 to 5 days, determined by the onset of the patient’s symptoms. the patient’s snellen’s vision was charted between 6/36 to counting fingers. thirteen patients had initial treatment with topical timolol maleate 0.5% (betalol-sante, pakistan) and pilocarpine 2% (medicarpine-medipak, pakistan) along with intravenous mannitol 20% in the dose of 1g/1kg body weight. the remaining three patients had topical instillations of topical cai and pilocarpine but intravenous mannitol could not be given due to the medical history of congestive cardiac failure (ccf) in 2 patients and history of renal failure in 1 patient. the iop of all these patients remained above the normal level, measuring between 36 to 48 mmhg, despite the initiation of medical treatment. due to the high iop with fine corneal edema and mid dilated pupils, lpi could not be performed because of the bunched up thick iris in the peripheral part. after the informed consent, all patients received lpip under topical anaesthesia with one drop of proparacaine hcl 0.5% (alcaine-alcon, belgium) instilled in the affected eye. a double frequency yag laser emitting green light in the wave-length of 532nm was used (ophthalas 532 eyelite alcon usa). the laser setting comprised of spot size of 250-500 microns and duration between 0.2 to 0.5 seconds with the power use of 250-450 micro watts. the principle applied in the laser treatment is large area, long duration and low power to make the peripheral iris contract to pull away from the angle and not to burn6. the laser power is increased if no contraction of the iris is noticed, and power is reduced in the case of formation of gas bubble, liberation of iris pigment, charring of iris and pop noise causing burning of the iris. a double mirror goldmann gonio lens or ritch trabeculoplasty lens was used to focus the beam on the peripheral convex part of the iris away from the angle structures, striking tangentially. all quadrants of the iris were treated with 10-15 applications in the each quadrant. the end point of the laser treatment was the contraction of the iris at the area of the treatment. patient’s iop was checked using goldmann applanation tonometer (gat) before the treatment and one hour after the laser application, followed at every day. after the laser, medical treatment continued with timolol maleate 0.5% (betalol-sante, pakistan) twice a day, and pilocarpine 2% (medicarpine-medipak, pakistan) three times a day and brinzolamide 2% (trusopt-msd, france) three times a day (in patients with history of ccf) with the addition of dexamethasone 0.1% (maxidex-alcon, pakistan) four times a day, till the definitive treatment of lpi was undertaken. results our functional success was defined when the iop was brought under 22mmhg and the treated angle was opened to the posterior part of the trabecular meshwork, at least in 50% of the angle. sixteen patients with the mean age of 61.36 years sd ± 3.38 years with an acute attack of pacg, failed to show drop in their iops with the standard medical treatment. lpip was performed to open the angle in these patients. the results were analyzed on microsoft excel 2007 with data analysis pack. the pre-laser iop measured between 36 mmhg to 48 mmhg with the mean iop of 41.64 mmhg sd ± 4.03 mmhg. the post laser iop at 1 hour ranged between 9 mmhg to 22 mmhg with the mean iop of 14.36 mmhg sd ± 4.70 mmhg (table 1). there was an overall drop of 26.28 mmhg sd ± 4.70 mmhg. all corneal edema cleared with the lowering of the iop. the iop remained controlled within the normal limits throughout the follow up period. 156 pre-laser gonioscopy revealed total appositional closure of the angle in all the 4 quadrants of the patients. after laser, 11 patients had grade ii angle (shaffer’s classification)7, revealing posterior part of the trabecular meshwork in at least 2 quadrants while 5 patients had grade ii angle in all the quadrants. there was mild iritis, present in all the patients after the laser procedure. table i: patient’s characteristics with profile of the iop before and after lpip iop = intra ocular pressure, lpip= laser peripheral iridoplasty, m=male, f=female discussion the routine treatment to abort an attack of pacg involves starting patients on intravenous mannitol or acetazolamide to decrease the iop substantially8, with the concomitant use of topical beta-blockers and pilocarpine on the later stage. in this country, acetazolamide is not available for the intravenous use, so along with mannitol, oral cai is used. the use of mannitol is contraindicated in the patients with medical history of ccf (also beta-blockers) or compromised renal function9,10. oral cai can cause paraesthesia and confusion along with the serious side effects of metabolic acidosis,11,12 stevens johnson syndrome 13 and blood dyscrasias14 once the iop is reduced, opening of the anterior chamber angle with pilocarpine therapy and eventual treatment of lpi is carried out to relieve the pupillary block permanently. the opening of the anterior chamber angle is important with normalization of the iop, otherwise permanent damage to the angle structure occurs with the formation of the peripheral anterior synechiae (pas), resulting in the damage to the optic nerve head, leading to the permanent loss of vision. in this situation, even lpi performed, does not relieve the angle blockage and patient may require drainage surgery to control the iop. lpip is therefore a simple procedure, carried out when medical therapy fails to reduce the iop. the laser application makes the iris to contract away from the angle structures, with the opening of the angle, with due result of lowering of the iop. the patient eventually receives lpi to prevent any further attack of the pupillary block. the role of the lpip was established way back in 1982 when ritch5 showed its usefulness in patients where medical treatment failed to reduce the iop after an acute attack of pacg. this procedure is not a replacement of lpi, which is still a definitive treatment to prevent any further pupillary block. lpip is rather an adjunct to the medical treatment, to bring the iop down by opening the anterior chamber angle. lam and coworkers15 examined the iop lowering effect of an immediate lpip as a first line treatment for an acute attack of pacg. in their preliminary study of 10 patients, mean iop was reduced from 59.5 ± 10.4 mmhg to 28.7 ± 14.9 mmhg at 15 minutes, 21.7 ± 13.1 mmhg at 30 minutes and 16 ± 9.4 mmhg at 60 minutes. no complications from the laser procedure were noted and all patient’s corneal edema cleared with lowering of the iop. these authors16 carried out a further prospective trial, where 33 eyes with an acute attack of pacg received immediate lpip, whereas 40 eyes with similar attack had conventional systemic medical treatment. they concluded that, the lpip treated eyes had lower iop level then the medically treated group at 15 minutes, 30 minutes and 60 minutes, after the start of the treatment. tham et al17 studied the safety and efficacy of lpip in patients with secondary angle closure glaucoma due to intumescent cataract. after lpip, the mean iop was reduced from 56.1 ± 12.5 mmhg to 34.2 ± 9.7 mmhg at 60 minutes. although we did not study if the duration of the attack had any bearing on the effectiveness of the medical or laser therapy but this has been shown by lam et al16 that there were no statistically significant differences in the iop at each time point between the patients with shortage duration of attack and the patients with the longest. our patients only showed mild iritis after the procedure, treated successfully with the topical steroids. other complications reported in the literature include, transient elevation of the iop, corneal 157 endothelial burns, distortion of the pupil and focal iris atrophy18. the advantage of lpip is that, its early use can prevent formation of pas, preventing conversion of acute to chronic angle closure glaucoma. also some of the cases with an acute attack may have plateau iris configuration, for which this laser would be the treatment of the choice19. the only contraindications for this procedure, is totally flat anterior chamber when laser application can cause corneal endothelial burn and presence of significant corneal edema which dissipates the effect of the laser20. the usefulness of lpip has been established in the western and in the far-eastern people of the chinese origin. although our series of patients is small but with the positive outcome of the laser treatment, we feel, this procedure should be employed in an acute attack of pacg, especially when routine medical treatment fails, to bring down the iop or when medical treatment is contraindicated on certain medical grounds. conclusion lpip can be carried out in the patients with an acute attack of pacg, when medical treatment fails to bring down the iop or it can be used as a first line therapy in the acute attack, and lens related angle closure glaucoma. lpi however remains the definitive treatment for an acute attack of the pacg. author’s affiliation prof. p.s mahar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi dr. dilshad laghari isra postgraduate institute of ophthalmology karachi dr. israr a. bhutto isra postgraduate institute of ophthalmology karachi reference 1. charles st, hamasaki di. the effect of iop on the pupil size. arch ophthalmol. 1970; 83: 729-31. 2. ganias f, mapstine r. miotic in closed angle glaucoma. br j ophthalmol. 1979; 63: 822-6. 3. robin al, pollack ip. argon laser peripheral iridoctomies in the treatment of primary angle closure glaucoma. arch ophthalmol. 1982; 100: 919-23. 4. wies hs, shingleton bj, et al. argon laser gonioplasty in the treatment of angle closure glaucoma. am j ophththalmol. 1991; 114: 14–8. 5. ritch r. argon laser treatment for medically unresponsive attacks of angle-closure glaucoma. am j ophthalmol. 1982; 94: 197–204. 6. ritch r. argon laser peripheral iridoplasty: an overview. j glaucoma. 1992; 1: 206–18. 7. kanski jj. clinical ophthalmology. butterworth, 5th edition 2003; 202. 8. smith ew, drance sm. reduction of human intraocular pressure with intravenous mannitol. arch ophthalmol 1962; 68: 734-41. 9. spaeth gl, spaeth eb, spaeth pg, et al. anaphylactie reaction to mannitol. arch ophthalmol. 1967; 78: 583–7. 10. weaver a, sica da. mannitol-induced acute renal failure. nephron. 1987; 45: 233-8. 11. chaparon dj, gomolin ih, sweeney kr. acetazolamide blood concentrations are excessive in the elderly: propensity for acidosis and relationship to renal function. clin pharmacol. 1989; 29: 348–53. 12. cowan ra, hartnell gg, lowdell cp, et al. metabolic acidosis induced by carbonic anhydrase inhibitors and salicylates in patients with normal renal functions. br med j (clin res ed). 1984; 289: 347–8. 13. shirato s, kagaya f, suzuki y, et al. stevens-johnson syndrome induced by methazolamide treatment. arch ophthalmol. 1997; 115: 550–3. 14. mogk lg, cyrlin mn. blood dyscrasias and carbonic anhydrase inhibitors. ophthalmology. 1988; 95: 768–71. 15. lam ds, lai js, tham cc. immediate argon laser peripheral iridoplasty as treatment for acute attack of primary angle closure glaucoma: a preliminary study. ophthalmology. 1998; 105: 2231–6. 16. lam ds, lai js, tham cc, et al. argon laser peripheral iridoplasty versus conventional systemic medical therapy in treatment of acute primary angle closure glaucoma: a prospective, randomized, controlled trial. ophthalmology. 2002; 109: 1591–6. 17. tham ccy, lai jsm et al. immediate argon laser peripheral iridoplasty (alpi) initial treatment for acute phacomorphic angle closure (phacomorphic glaucoma) before cataract extraction, a preliminary study. eye 2005; 19: 778–83. 18. lai jsm, tham ccy, lam dsc. immediate argon laser peripheral iridoplasty as immediate treatment for an acute attack of primary angle closure glaucoma: a preliminary study. eye 1999; 13: 26–30. 19. chew p, chee c, lim a. laser treatment of severe acute angle closure glaucoma indark asian irides: the role of iridoplasty. lasers light ophthalmol. 1991; 4: 129-32. 20. lim asm, tan a, chew p, et al. laser iridoplasty in the treatment of severe acute angle closure glaucoma. int ophthalmol. 1993; 17: 33–6. microsoft word azizur rehman 12 original article management of secondary glaucoma after pars plana vitrectomy (ppv) and silicone oil injection in rhegmatogenous retinal detachment azizur rahman, asfandyar asghar, muhammad nasir bhatti, tayab shahzad, muhammad saleh memon pak j ophthalmol 2010, vol. 26 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . ... . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: aziz-ur-rahman isra postgraduate institute of ophthalmology, al-ibrahim eye hospital old thaana, malir karachi received for publication may’ 2009 … ……………………… purpose: to determine the outcome of secondary glaucoma after pars plana vitrectomy (ppv) and silicone oil injection in rhegmatogenous retinal detachment materials and methods: this interventional quasi experimental study was conducted at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi; from january 2006 to december 2007.study included total 50 eyes of 50 patients fulfilling the inclusion criteria. after examination, patients were divided into three groups. group -1 if iop (intraocular pressure) from 22 mmhg up to 28 mmhg managed medically by anti-glaucoma drug like timolol 0.5% alone, group ii if iop was raised over 28 mmhg than timolol 0.5% with dorzolamide 2% were prescribed and group – iii if the patient’s iop was not controlled medically, additional surgical intervention like silicone oil removal, diode cycloablation, cyclocryopexy and glaucoma valve surgery was performed. success was defined as iop ≤ 21 mmhg and ≥ 05 mmhg with or without medication. patients were followed for 6 months. results: over follow up period of 6 months, successful iop control was achieved in all 50 (100%) eyes. conclusions: glaucoma after ppv with silicone oil injection in rhegmatogenous retinal detachment can be effectively managed by anti-glaucoma medicines or with additional surgical measures. ntraocular silicone oil is used for the repair of complicated cases of retinal detachment,1,2 previous reports have described secondary glaucoma as a relatively common complication after pars plana vitrectomy (ppv) with silicone oil injection. gray, leaver et al3 have ranked glaucoma second to cataract as a late complication of silicone oil injection. highly purified silicone oils (5000cst) have been introduced for prolonged retinal tamponade in patients with complex retinal detachment. this silicone oil is chemically stable in the human eye, does not undergo chemical modification, and is less toxic to eye structures compared to other silicone oils, thus potentially reducing the incidence of secondary glaucoma4. other risk factors associated with an elevation of intraocular pressure after ppv with silicone oil injection include aphakia, pre-existing glaucoma, scleral buckling and other surgical procedures commonly used in conjunction with ppv, neovascular glaucoma, uveitis, peripheral anterior synechiae, pupillary block, steroid response, and mechanical obstruction of the trabecular meshwork by lens remnants and pigments5-7. most of the eyes are effectively managed with anti-glaucoma medications. eyes that did not respond to medical therapy may be effectively managed with surgical measures. this study was undertaken to determine the outcome of secondary glaucoma after pars plana vitrectomy (ppv) and silicone oil injection in rhegmatogenous retinal detachment. i 13 materials and methods this study was conducted at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi, from january 2006 to december 2007. there were 50 consecutive patients of age 8 to 92 years with iop ≥ 22 mmhg after pars plana vitrectomy with silicone oil injection in rhegmatogenous retinal detachment. the patients with corneal decompensation, cataract, uveitis, significant complications of surgery, previous history of glaucoma and retinal detachment surgery in same eye were excluded. patients who failed to follow up were also excluded from the study. success was defined as iop ≤ 21 mmhg and ≥ 05 mmhg with or without medication. the relevant information was entered on performa. an informed consent was taken from all patients for inclusion in the study as well as for treatment. after examination, patients were divided into three groups. group -1 if iop was raised over 22 mmhg up to 28 mmhg, then topical timolol 0.5% twice daily was prescribed, and group-ii if iop was raised over 28 mmhg, then additional drugs like topical carbonic anhydraze inhibiter (cais) were prescribed in combination with topical beta-blockers like (timolol 0.5% with dorzolamide 2%). in those circumstances, group-iii where iop couldn’t be managed medically, then after one month additional surgical measures were undertaken. some form of treatment designed to reduce aqueous production, such as cyclocryotherapy and diode cycloablation, or removal of silicone oil. patients were followed up in the surgical retina clinic at 1st week, 2nd week, 1st month, 2nd month and at 6th month. the final outcome was measured at 6th month. on each follow up visit, patients were evaluated in terms of iop, anterior segment examination, fundus examination and gonioscopy. the data was statistically analyzed using spss version 10.0. all categorical response variables including gender and age groups, medical and surgical management were given in frequencies and percentages. quantitative variables including age and intraocular pressures were computed and presented by mean and standard deviation. mean and standard deviation of iop were computed for pre treatment ist day, 1st week, 2nd week, 1st month, 2nd month and 6th month after medical and surgical management. student “t” test was applied for pre and post treatment iop. statistical significance was considered if p < 0.05. results there were 50 eyes of 50 patients with raised intraocular pressure after ppv with silicone oil injection included in this study ranged from 8-92 years of age; mean age was 42.68 ± 21.41 years. there were 36 (72%) male and 14 (28%) female patients. in this study, 5000 cst silicone oil was used in all the eyes; cup-disc ratio in our patients ranged from 0.3 -0.6, with 70% patients having cup-disc ratio below 0.4. the mean ± sd preoperative iop was 7.5 ± 3.6 mmhg. the mean ± sd postoperative iop at first postoperative (pretreatment) day was 26.5 ± 2.8 mmhg, which was an increase of 19.16 ± 5.4 mmhg, as compared to preoperative iop (95% c.i of 17.62 20.70, p< 0.001). the mean ± sd iop after one week of treatment was 19.62 ± 3.39 mmhg, after two weeks of treatment was 17.20 ± 3.17 mmhg, after 1 month of treatment was 16.96 ± 3.03 mmhg, after 2 months of treatment was 15.72 ± 2.80 mmhg and after 6 months of treatment was 15.0 ± 1.63 mmhg, which was a decrease of 11.60 ± 2.65 mmhg, as compared to pre-treatment iop (95% c.i of 10.85-12.35, p<0.001) (table 1). table i: outcome of medical and surgical treatment (n = 50) factors intraocular pressure mean ± s.d (in mmhg) p-value i pre treatment 26.68 ± 3.25 <0.001 ii after 1 week 19.62± 3.39 iii after 2 weeks 17.2± 3.17 iv after 1 month 16.96± 3.03 v after 2 months 15.72± 2.80 vi after 6 months 15.08± 2.80 significant mean reduction in intraocular pressure at 6 months was observed as compared to pre treatment iop (95% c.i. 10.85-12.35) as shown in fig. 1. average reduction in iop after 2 weeks was insignificant as compared to latest follow up after 6 months (95% c.i. = 8.69 9.97, p<0.05). use of anti-glaucoma drugs as a sole treatment controlled iop in 45 (90%) eyes, by reducing the iop from a mean ± sd of 25.96 ± 2.35 mmhg (18-32) before 14 treatment to 16 ± 1.6 mmhg after 6 months of treatment. in these patients, group –i the drug most commonly used was solely beta-blocker topical timolol 0.5% in 38 (74.5%) patients, and in group – ii combination of beta-blockers and cais in 7 (15.5%) patients. complications of medical treatment included irritation, lethargy and bitter taste in 2 (4%) patients. in group – iii diode cycloablation for uncontrolled iop was performed in 3 (6%) eyes with failed medical treatment to control iop for 1 month. the mean ± sd iop prior to diode cycloablation was 26.67 ± 1.15 mmhg. the post-laser mean ± sd iop was 17.33 ± 1.15 mmhg after 1 month, and 17.33 ± 1.15 mmhg after 5 months. after diode cycloablation, medical treatment in the form of combined therapy was continued. silicone oil removal for uncontrolled iop group– iii was performed in 2 (4%) eyes with failed medical treatment and emulsification of silicone oil. the mean ± sd iop prior to silicone oil removal was 27 ± 1.41 mmhg. postoperative mean ± sd iop was 17 ± 1.41 mmhg after 4 months. discussion silicone oils are widely used as a surgical tamponade and vitreous substitute in complicated retinal detachment repair and can be valuable in the surgical management of difficult vireo-retinal diseases. postoperative anterior segment complications have been reported after silicone oil injection, such as glaucoma, cataract, and keratopathy even after successful reattachment of the retina. in this study, 5000 cst silicone oil was used in all patients undergoing ppv in rhegmatogenous retinal detachment. the incidence of iop elevation after silicone oil injection has been described in case series using 1000 cst silicone oil. honavar et al8 reported the overall incidence of glaucoma after ppv and silicone oil injection was 40% (60 of 150 eyes). nguyen et al5 reported a 48% (24 of 50 eyes) incidence of glaucoma after ppv and silicone oil injection. valone and mccarthy9 reported a 23% (11 of 48 eyes) incidence of glaucoma after ppv and silicone oil injection. belington et al10 reported a 29% (16 of 55 eyes) incidence of glaucoma after ppv and silicone oil injection. in a case series that included patients treated with 5000 cst silicone oil, henderer et al6 found elevated iop in 12.9% at 6 months, 21% at 1 year and 29.5% at 2 years. the underlying mechanism of glaucoma associated after ppv with silicone oil injection is often multifactorial. for example, aphakia could contribute to the development of glaucoma after ppv with silicone oil injection by allowing direct entry of silicone oil into the anterior chamber, in addition to increasing the risk of pupillary block by the silicone oil bubble. in the silicone oil study, barr et al 11 noted that all of the eyes with elevated iop were aphakic. in our study, most of the patients were either phakic (58%), or pseudophakic (36%), with only 6% of the patients having aphakia. none of the patients in our study experienced pupillary block, which might have been avoided by peripheral iridectomy done at the time of ppv. ando12 introduced the concept of inferior peripheral iridectomy in aphakic and pseudophakic eyes to prevent forward migration of silicone oil and to reduce the incidence of pupillary block glaucoma. in this study, those patients were included who developed early postoperative rise in iop. early postoperative rise in the iop is common after ppv with silicone oil injection in both phakic and aphakic eyes. this rise in the iop is possibly related to anterior chamber inflammatory activity, obstruction to aqueous flow by choroidal effusion, a buckle or a combination13,14. al-jazzaf et al15 reported that over a period of 2 years, 78% of patients can be successfully managed medically. honavar et al8 reported that over a period of 5 years, 72% of patients can be successfully managed medically. in this study, it was observed that over a period of 6 months, 90% of patients were successfully managed medically. the iop was controlled in most eyes (90%) with topical betablockers and cais. the small proportion of patients requiring surgical therapy may be due to the availability of highly effective topical anti-glaucoma medications, or reduced severity of glaucoma due to improved silicone oil and surgical techniques. in this study, diode cycloablation was performed in 3 patients (6%) with failed medical therapy. this procedure was successful in controlling iop in all 3 (100%) patients. han sk et al16 reported a drop of iop before diode cycloablation of 43 ± 14.4 mmhg to 14.5 ± 4.3 mmhg after laser over a period of about 1 year. ghazi-nouri sm et al17 reported a drop of iop before diode cycloablation of 31.4 ± 10.9 mmhg to 18.8 mmhg after laser over a period of about 1 year. in our study, a drop of iop before diode cycloablation of 26.67 ± 1.15 mmhg to 17.33 ± 1.15 mmhg after laser over a period of about 5 months was observed. the most common complication of this procedure was transient uveitis, which was well controlled by topical steroids. 15 in this study, 2 patients developed resistant glaucoma to medical treatment along with emulsifycation of silicone oil. for these 2 (4%) patients, silicone oil removal was done. honavar sr et al8 reported that over a follow up period of 5 years, 25% of the patients needed silicone oil removal for controlling iop. in our study, over a follow up period of 6 months, 2% of the patients needed silicone oil removal for controlling iop. budenz di et al18 noted a 60% (20 of 32 patients) success in controlling iop in patients with refractory glaucoma by silicone oil removal. nguyen qh et al5 noted a 60% (8 of 14 patients) success in controlling iop in patients with refractory glaucoma by silicone oil removal. jonaz jb et al19 noted a 90% (188 of 198 patients) success in controlling iop in patients with refractory glaucoma by silicone oil removal. overall, the results of our study are comparable to the studies published in the international literature. the main drawback of our study is the short follow up period. conclusion the results of this study indicate that glaucoma after ppv with silicone oil injection can be effectively managed by anti-glaucoma medicines. in cases where glaucoma can’t be controlled by medication alone, additional surgical measures can effectively manage it. author’s affiliation dr azizur rahman associate professor isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, old thaana malir, karachi dr asfandyar asghar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, old thaana malir, karachi dr muhammad nasir bhatti isra postgraduate institute of ophthalmology al-ibrahim eye hospital, old thaana malir, karachi dr tayab shahzad isra postgraduate institute of ophthalmology al-ibrahim eye hospital, old thaana malir, karachi dr muhammad saleh memon isra postgraduate institute of ophthalmology al-ibrahim eye hospital, old thaana malir, karachi reference 1. wolf s, schon v, meher p, et al. silicone oil rmn3 mixture (“heavy silicone oil”) as internal tamponade for complex retinal detachment. the journal of retina and vitreous diseases. 2003; 23: 340-1. 2. schocket ls, witkin aj, et al. ultra high resolution optical coherence tomography in patients with decreased visual acuity after retinal detachment repair. am j ophthalmol. 2006; 113: 666-72. 3. leaver pk, grey hb, ganer a. silicone injection in the treatment of massive preretinal retraction. ii. late complications in 93 eyes. br j ophthalmol. 1979; 63: 361-7. 4. lakits a, nannadal t, scholda c, et al. chemical stability of silicone oil in the human eye after prolonged clinical use. ophthalmology. 1999; 106: 1091-100. 5. nguyen qh, lloyd ma, heuer dk, et al. incidence and management of glaucoma after silicone oil injection for complicated retinal detachment. ophthalmology. 1992; 99: 1520-6. 6. henderer jd, budenz dl, flynn hw jr, et al. elevated intraocular pressure and hypotony after silicone oil retinal tamponade for complex retinal detachments: incidence and risk factors. arch ophthalmol. 1999; 117: 189-95. 7. gedde sj. management of glaucoma after retinal detachment surgery. curr opin ophthalmol. 2002; 13: 103-9. 8. honavar sg, goyal m, majji ab, et al. glaucoma after pars plana vitrectomy and silicone oil injection for complicated retinal detachment. ophthalmology. 1999; 106: 169-76. 9. valone j jr, mccarthy m. emulsified anterior chamber silicone oil and glaucoma. ophthalmology. 1994; 101: 1908-12. 10. belington bm, leaver pk. vitrectomy and fluid/silicone oil exchange for giant retinal tears: results at 18 months. graefes arch clin exp ophthalmol. 1986; 224: 7-10. 11. barr cc, lai my, lean js, et al. ii. postoperative intraocular pressure abnormalities in the silicone study. silicone study report 4. ophthalmology. 1993; 100: 1629-35. 12. ando f. intraocular hypertension resulting from pupillary block by silicone oil. am j ophthalmol. 1985; 99: 87-8. 13. gallemore rp, mccuen bw. silicone oil in vitreoretinal surgery. in: ryan sj, editor. retina. 3rd ed. st: louis: mosby. 2001; 2195-220. 14. allingham rr. shield’s text book of glaucoma. 5th ed. philadelphia: lippincott, williams and wilkins; 2005: 410-33. 15. al-jazzaf am, netland pa, charles s. incidence and management of elevated intraocular pressure after silicone oil injection. j glaucoma 2005; 14: 40-6. 16. han sk, park kh, kim dm, et al. effect of diode laser transscleral cyclophotocoagulation in the management of glaucoma after intravitreal silicone oil injection for complicated retinal detachments. br j ophthalmol. 1999; 83: 713-7. 17. ghazi-nouri sm, vakalis an, bloom pa, et al. long term results of the management of silicone oil induced raised intraocular pressure by diode laser cycloablation. eye 2005; 19: 765-9. 18. budenz dl, toba ke, feuer wj, et al. surgical management of secondary glaucoma after ppv and silicone oil injection for complex retinal detachments. ophthalmology 2001; 108: 162832. 19. jonas jb, knorr hl, rank rm, et al. intraocular pressure and silicone oil endotamponade. j glaucoma 2001; 10: 102-8. microsoft word 11. waseemullah pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 99 original article prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicentre diabetic clinics in karachi waseem ullah memon, zahid jadoon, umair qidwai, samina naz, sanaullah dawar, tanveer hasan pak j ophthalmol 2012, vol. 28 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: waseem ullah memon al ibrahim eye hospital old thana, malir karachi …..……………………….. purpose: to estimate the frequency of diabetic retinopathy by age, sex and type of diabetes (type i & type ii) and to identify possible risk factors for diabetic retinopathy. material and method: it’s a descriptive cross – sectional study. during the study 525 diabetic subjects of age 30 years and above were screened at al-ibrahim eye hospital (aieh), diabetic association of pakistan (dap), and two primary eye care centres community based diabetic clinics(gadaap town and jamshed town). results: overall mean age of the subjects was 55.3 ( ± 8.9) years with male: female 1: 1.3. the diabetic retinopathy of any grade was detected 28.8% (151 subjects out of 525). out of them non-proliferative diabetic retinopathy (mild to severe) was 33.1%, proliferative diabetic retinopathy was 2.65%, clinically significant macular oedema + non proliferative diabetic retinopathy was 50.33%, clinically significant macular oedema + proliferative diabetic retinopathy was 4.64% and advanced diabetic retinopathy was 9.28%. 85 (56.29%) diabetic patients had uncontrolled diabetes among all retinopathies. conclusion: diabetes mellitus and diabetic retinopathy is becoming a major threat to eye health in our community. people with diabetes mellitus should be encouraged to maintain good glycemic control and undergo regular fundus screening (examination) to delay or prevent the development of diabetic retinopathy. iabetes is a major public health problem in the world. there is no available curative treatment for this costly disease. it is costly in terms of loss of quality of life1, loss of life2, economic burden on the community and on the family of the diabetic patient and on the health sector3. according to pakistan national diabetes survey4, pakistan ranks 8th highest worldwide in the prevalence of diabetes. a diabetic can have a serious eye disease and not even know about it until irreversible vision loss has occurred5,6. it has been estimated that 6.2 million people in pakistan have diabetes, representing 8.5% of the total adult population. this is expected to rise to 11.6 million by 20257. in pakistan, only 33% to 44% of known diabetic patients have correct knowledge of diabetes and its complications8. the main aim of the study is to find out the frequency of the diabetic retinopathy among patients with diabetes along with the identification of possible risk factors. material and methods the study was a descriptive cross-sectional study, conducted between february to april 2010. d waseem ullah memon, et al. 100 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology diabetic patients of both gender, aged 30 years and above were included in the study. critically ill patients, those with opaque media or subjects having bilateral phthysical eye or an empty socket were excluded from the study. as a first step patients were screened at the diabetic clinics of primary eye care centres located at gadaap town and jamshed town, then at the hospital based diabetic clinics for assessment of diabetic subjects for diabetic retinopathy. written permissions were taken from the head of ai-ibrahim eye hospital and diabetic association of pakistan for conducting the study and informed individual consent was taken from all diabetic patients at the examination site. snellen visual acuity, as recorded by an ophthalmic technician and demographic data and blood sugar, information about occupation, duration of diabetes, pregnancy, smoking and hypertension were also recorded. patients were examined on slit lamp for anterior and posterior segment examination by an ophthalmologist. all the patients (except diabetic association of pakistan) were dilated with tropicamide1% eye drops and examined with indirect ophthalmoscope. at diabetic association of pakistan, fundus photographs were taken with non-mydriatic fundus camera. during this stage the questionnaire file was created in computer by using epi-info 6 version program. data was entered and analysed by using same version in the computer. descriptive statistics of the diabetes was analyzed, age was recorded as mean and standard deviation, male to female gender ratio was recorded. frequency of diabetic retinopathy was calculated and relative frequency of different presentation of diabetic retinopathy was calculated. results we screened a total of 525 consecutive diabetic patients in four diabetic clinics from february to april 2010. the male to female distribution were 229(43.62%) and 296(56.38%) respectively (m: f = 1: 1.3) (table 1). of them, 151 (28.76%) had diabetic retinopathy, 2 (1.32%) had type i diabetes and 149 (98.68%) had type ii diabetes (table 2). out of 151 diabetic patients sex distribution of diabetic retinopathy was approximately same among male 76 (50%) as compared with female 75 (49.66%). highest distribution 56/151 (37%) of diabetic retinopathy belonged to the age group 50-59 years, 28.48% in age group 60-69 years, 21.85% in age group 40-49 years, 6.62% in age group ≥ 70 years and in the age group 30-39 years was 5.96% and this whole percentage belonged to type ii diabetes. (table 3) proportion of known diabetic (type ii diabetes mellitus) was 149/ 151 (98.68%). table 1: type of diabetes mellitus and sex distribution among total subjects n= 525 type of diabetes mellitus no. of patients n (%) type i 04 (0.76) type ii 521 (99.24) sex male 229 (43.62) female 296 (56.38) total 525 (100) table 2: diabetic retinopathy by sex and by type of diabetes mellitus n=151 male female total n (%) type i 02 00 02 (1.32) type ii 74 75 149 (98.68) dr 76 75 151 (100) table 4: clinical presentation of diabetic retinopathy n=151 types of diabetic retinopathy no. of patients n (%) mild npdr 21 (13.90) moderatenpdr 28 (18.54) severe npdr 01 (0.66) pdr 04 (2.65) csme+npdr 76 ()50.33 csme+pdr 07 (4.64) advanced diabetic retinopathy 14 (9.28) total 151 (100) prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicentre diabetic clinics in karachi pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 101 the commonest presentation of diabetic retinopathy was clinically significant macular oedema + non proliferative diabetic retinopathy 50.33%, non proliferative diabetic retinopathy (33.1% [mild: 13.90%, moderate: 18.54%, and sever non proliferative diabetic retinopathy: 0.66%]), followed by, advanced diabetic retinopathy (9.28%) clinically significant macular oedema + proliferative diabetic retinopathy (4.64%), and proliferative diabetic retinopathy (2.65%). (table 4). among 151 subjects with diabetic retinopathy 47% were house wives, 14.6% were self employed, 9.3% were government employees, 3.3% were labourers and 0.6% were farmers. discussion diabetes is a major public health problem in the world. it has emerged as one of the major health problems in pakistan9. there is no available curative table 3: diabetic retinopathy by age group and type of diabetes mellitus n=525 age group total diabetic patients type i diabetes type ii diabetes diabetic retinopathy percentage 30-39 41 02 39 09 (5.96) 40-49 130 02 128 33 (21.85) 50-59 195 00 195 56 (37.09) 60-69 134 00 134 43 (28.48) ≥ 70 years 25 00 25 10 (6.62) total 525 04 521 151 (100) table 5: diabetic retinopathy by duration of diabetes mellitus n=525 duration of diabetes mellitus total diabetic patients total with diabetic retinopathy n (%) < 5 years 232 32 (21.2) 5-10 years 141 41 (27.15) 11-15 years 83 41 (27.15) 16 years & on wards 69 37 (24.50) total 525 151(100) table 6: the distribution of diabetic retinopathy in female & male diabetic patients. no dr npdr csme+npdr csme+pdr pdr adv.dr female 3.6 2.5 3.4 0.6 0.5 0.4 male 2.5 2.6 2.9 0.7 0.5 2 csme=clinically significant macular oedema npdr=non proliferative diabetic retinopathy pdr=proliferative diabetic retinopathy adv. dr= advanced diabetic retinopathy waseem ullah memon, et al. 102 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology treatment for this costly disease. with the advent of anti-diabetic drugs, the average life of diabetic patients has increased, but at the same time the incidence of diabetic retinopathy has unfortunately increased many folds10. diabetes is the principal culprit for development of diabetic retinopathy. diabetes mellitus affects nearly all tissues of the eye. although some effects are mild or temporary with little visual disability, a significant loss of vision can occur when patients develop more serious ocular complications such as diabetic retinopathy and macular oedema11. king12 estimates a high prevalence of diabetes by 2025. this is a matter of great concern considering the potential for blindness due to diabetic retinopathy. table 7: the distribution of dr in diabetic patients types of diabetic retinopathy no. of patients n (%) adv.dr 14 (2.67) pdr 4 (0.76) csme+pdr 7 (1.34) csme+npdr 76 (14.47) npdr 50 (9.52) no dr 374 (71.24) csme=clinically significant macular oedema npdr=non proliferative diabetic retinopathy pdr=proliferative diabetic retinopathy adv. dr= advanced diabetic retinopathy according to a who survey the prevalence of diabetes in 1995 pakistan was at number 8 in the world and if interventional strategies are not adopted and implemented pakistan will be ranked at number 4 in the year 2025 having 14.5 million people with diabetes13. when compared to other population and center based studies conducted in different parts of the world, including tunisian, omanis, migrant indian, chinese mauritians, italian,14 asian indian,15 and south asian16 the prevalence ranges between 10%50%. the non insulin dependent diabetes mellitus in pakistan occurs at a relatively younger age, as compared to the western world where it occurs above the age of 4017. in current study this high frequency of diabetes mellitus might have resulted due to the fact that focus was given to younger age group (30 years and above). results of present study show that 27.81% of diabetic retinopathy belongs to working age group (between the age group 30-49 years).results show that most of them had uncontrolled diabetes. if they live longer (as life expectancy has increased up to 64 years for males and 63 years for females), we can well imagine how much proportion of diabetic subjects will have a chance to develop dr in future. during this study 525 diabetic patients were screened for diabetic retinopathy followed by estimating the frequency of dr in screened diabetic patients. out of total 525 diabetic patients 151 had diabetic retinopathy. it was estimated that total prevalence of dr was (28.76%). 1.32% were iddm, 98.68% were niddm. in present study the frequency of iddm was low, similarly it was reported that iddm (type i) diabetes continues to be a rare disorder in pakistan17. findings of a survey by the diabetic association of pakistan (dap) said that insulindependent diabetes mellitus (iddm) type i, constitutes less than two percent of total diabetic population while the other 98 per cent are non insulin-dependent diabetes (niddm) or type ii. a diabetic patient is 25 times more likely to become blind than non-diabetic18. and indeed diabetic retinopathy is the most common cause of blindness in the working age group19. diabetic retinopathy is one of the few ophthalmic diseases where there is a well developed role of preventive measure to delay progression of the disease and consequent visual loss20. population based assessment of a disease assists in assessing its magnitude in the population and in estimating the need for services for that disease. in our study, the frequency of dr among diabetics was 28.76% which is lower than that (51-60 %) reported in other studies conducted in karachi and other cities in pakistan21. the reason behind these differences could be that all the other studies were purely hospital based and were not conducted under similar circumstances. because of the small sample size and nonrepresentative nature of the sample, the observed frequency of our study cannot be generalized to the general population. the people who were screened for diabetic retinopathy were those who had diabetes and/or diabetic retinopathy thus causing an over representation of diabetic retinopathy. when compared with other clinical and population based studies of the world including united kingdom,22 united state of america,23 spain,24 senegal,25 china,26 prevalence of diabetic retinopathy in patients of age group 30 years and above attending multicentre diabetic clinics in karachi pakistan journal of ophthalmology vol. 28, no. 2, apr – jun, 2012 103 shows the great fluctuations in the prevalence of diabetic retinopathy, and the results vary between 1.78% 64.5%. the reason for such a large variation in the prevalence of diabetic retinopathy may be due to the fact that these studies were not performed under the similar condition and result varies in different ethnic groups27. lack of uniformity in study designs, protocols for examination and documentation may explain some of these differences. the most prevalent type of dr in our study was clinically significant macular edema +non proliferative diabetic retinopathy which accounted for 50.33% of the cases. non proliferative diabetic retinopathy accounted for 79.1% of the cases compared with 92%, 89.3 to 94.1% and 69.8% in studies conducted in australia, india and oman, respectively27. we found a low frequency of proliferative diabetic retinopathy out of all retinopathies (2.65%). similarly lower results of proliferative diabetic retinopathy also reported in hospital and community based studies in pakistan and elsewhere28. conclusion frequency of clinically significant macular edema in combination with non proliferative diabetic retinopathy is much higher followed by non proliferative diabetic retinopathy and advanced diabetic eye disease in the community. most patients of diabetic retinopathy belonged to middle age group (40 – 60 years). there was a lack of tendency among the patients to acquire treatment of diabetes mellitus. author’s affiliation dr. waseem ullah memon al ibrahim eye hospital old thana, malir karachi dr. zahid jadoon pakistan institute of community ophthalmology (pico), hayatabad peshawar dr. umair qidwai al ibrahim eye hospital old thana, malir karachi dr. samina naz pakistan institute of community ophthalmology (pico), hayatabad peshawar dr. sanaullah dawar pakistan institute of community ophthalmology (pico), hayatabad peshawar dr. tanveer hasan al ibrahim eye hospital old thana, malir karachi reference 1. jadoon mz, dineen b, bourne rra, et al. prevalence of blindness and visual impairment in pakistan: the pakistan national blindness and visual impairment survey, invest ophthalmol vis sci. 2006; 47: 4749-55. 2. ali m, khalid g, pirkani g. level of health education in patients with type 2 diabetes in quetta. j pak med assoc. 1998; 48: 334-6. 3. uk prospective diabetic study group. tight blood pressure control and risk of macrovascular and microvascular complication in type 2 diabetes. bmj 1998; 317: 313-20. 4. national society to prevent blindness: vision problems in the us: facts and figures. the american academy of ophthalmology preferred practice patterns series: diabetic retinopathy. 1993; 19-20. 5. iqbal f, naz r. patterns of diabetes mellitus in pakistan: an overview of the problem. j pak med res 2005; 44(1):123-50. 6. jawad f. diabetes in pakistan: diabetic voice. 2003; 48: 12-4. 7. diabetes atlas second edition, international diabetes federeation. 2003; 1: 9-11. 8. jabbar a, contractor z, ebrahim ma, et al. standard of knowledge about their disease among patients with diabetes in karachi, pakistan. j pak med assoc. 2001; 51: 216-8. 9. aziz tm. incidence of ophthalmic problems in diabetic patients in pakistan: a preliminary report. ophthalmic practice: asian edition. 1996; 2: 6-8. 10. khan aj. age sex and duration relationship and prevalence of diabetic retinopathy in pakistani population. pak j ophthalmol. 1990; 6: 6-8. 11. grey, rhb, malcolm, n, reily od. ophthalmic survey of a diabetic clinic. br j ophthalmol. 1986; 70: 797-803. 12. klein r, klein be, moss se, et al. the wisconsin epidemiologic study of diabetic retinopathy: the long term incidence of macular oedema. ophthalmology 1995; 102: 7-16. 13. diabetes cases on the rise –dawnnational; 04 march, 2002. 14. king h, maria r. diabetes in adults is now a third world problem. community eye health. 1996; 9: 51-3. 15. hawthorne k, mello m, tomlinson s. cultural and religious influences in diabetes care in great britain. diabet med. 1993; 10: 8-12. 16. unwin n, alberti kgmm, bhopal r, et al. comparison of the current world health organisation and new american diabetic association criteria for the diagnosis of the diabetic mellitus in three ethnic groups in the uk. diabet med. 1998; 15: 554-7. 17. diabetes cases on the rise. the dawnnational. 2000 march 04; sec. liv no. 62 (p-5). 18. carty mc a. catherine. use of eye care services by people with diabetes. br j med. 1998; 82: 410-4. 19. ulbig mrw, hamilton amp. factor influencing the natural history of diabetic retinopathy. eye 1993; 7: 242-9. 20. kanski jj. clinical ophthalmology. a systematic approach.5th ed. london: elsevier science limited. butterworth heinemann, 2003: 439-455. 21. haider z, obaidullah s. clinical diabetes mellitus in pakistan.j trop med hyg. 1981; 84: 155-8. 22. kohner m, eva. united kingdom prospective study. diabetic retinopathy at diagnosis of non-insulin dependent diabetes mellitus and associated risk factor. arch ophthalmol. 1998; 116: 297-303. waseem ullah memon, et al. 104 vol. 28, no. 2, apr – jun, 2012 pakistan journal of ophthalmology 23. klein r, sharrett ar, klein be, et al. aric group. the association of atherosclerosis, vascular risk factors, and retinopathy in adults with diabetes: am j ophthalmol. 2002; 109: 1225-34. 24. lopez im, diez a, velilla s, et al. prevalence of diabetic retinopathy and eye care in a rural area of spain. ophthalmic epidemiol. 2002; 9: 205-14. 25. ndiaye mr, cisse a, wane a, et al. prevalence of diabetic retinopathy at the dakar university hospital center. dakar med. 1999; 44: 158-61. 26. liu dp, molyneaux l, chua e, et al. retinopathy in a chinese population with type 2 diabetes. diabetes res clin pract 2002; 56: 125-31. 27. klien r, klein be, moss se. visual impairment in diabetes. ophthalmology. 1984; 91:1-9. 28. ossama aw, kamal sm. prevalence and risk factors for diabetic retinopathy among omani diabetics. oman j ophthalmol. 1998; 82: 901-6. 98 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology original article prevalence of hepatitis b & c at tehsil headquarter hospital in cataract surgery patients muhammad yasser nisar, taseer salahuddin pak j ophthalmol 2017, vol. 33, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. taseer salahuddin doms eye specialist consultant ophthalmologist at thq khanpur e.mail: salahuddin.taseer@gmail.com purpose: to investigate the prevalence of hepatitis b & c in the patients admitted for cataract surgery at thq khanpur. study design: cross sectional study. place and duration of study: tehsil headquarter hospital, khanpur from december 2015 till december 2016. material and methods: patients were informed and tested for hepatitis b and c via diagnostic tests for surface antigen hbsag (hepatitis b) and anti hcv (c). based on the positive results determination of prevalence of hepatitis b, c or both was done. patient information was recorded on performa and analyzed. results: 50 patients were operated for extracapsular cataract extraction (ecce) at thq khanpur during the period of last one year. mean age of the patients was 57 years. out of 50 patients 27 were females (54%) and 23 were males (46%). out of 50 patients, 7 (14%) suffered from hepatitis b, 8 (16%) from hepatitis c and 3 (6%) from both hepatitis b & c simultaneously. thus, 18 out of 50 (36%) patients were positive for either disease. conclusions: incidence of hepatitis b and c was higher than the average prevailing rates in pakistan both in males and females. percentage in males was higher than females in the sample. keywords: hepatitis b, hepatitis c, extra-capsular cataract surgery. prevelance of hepatitis b & c at thq hospital in cataract surgery patients pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 99 …..……………………….. here are multiple variants of hepatitis resulting from different stands of viruses namely a, b, c, d and e. they result in liver cirrhosis and hepatocellular carcinoma1. hepatitis caused due to virus strand b (a dna virus) is a virus that is life threatening. incidence of this type of hepatitis is very high with 3 million people being carriers, 2 billion being affected at some stage of their lives and one million dying due to it2. although this disease prevails at global level, however, its occurrence is highest in asia, africa and middle east3. high prevalence of hepatitis c has been recorded by world health organization who to be around 3% of global population or 120-170 million in numbers4. incidence of both hepatitis b and c is increasing5, which is an alarming situation. both these types of hepatitis have same modes of transmission, including prenatal transmission, blood transmission, sexual contacts, drug abuse and use of infected surgical instruments6. hospitals, both private and public ones where b & c screening is not being done especially before surgeries are potential threat in spreading these types of hepatitis7. awareness and knowledge for causes and limiting factors of hepatitis b and c are limited in rural areas and primary health care centers8. prevalence of hepatitis b is 10%9 and c is 4-7%10,11 in pakistan. realization of the fact that lack of facilities, screening practice and knowledge leads to spread of these diseases in patients also risking surgeons and operating room staff, has led to increased focus of research towards recording the incidence of hepatitis b and c in urban areas13. however, in primary care centers in pakistan there still is a need for research and focus to the screening and recording the occurrence of these types of hepatitis needs to be done. current research helps to fill this gap both from literature as well as quantitative point of view. material and methods this was an cross sectional study carried at thq hospital khanpur, district rahimyar khan, which is a secondary care hospital. here for the very first time since the beginning of the hospital cataract surgery started last year due to the provision of surgical equipment by the punjab government. all the patients admitted for cataract surgery were included in the study. patients who were admitted for other surgical procedures like pterygium or extraction of foreign body etc. were not included. screening of hepatitis b and c was kept as a necessary step before surgery. each patient was informed and record was kept on the surgery record register of the surgeon. during one year 50 surgeries were done. all infected patients were referred to medical specialist for treatment and all those who had not been vaccinated were advised for vaccination. furthermore, separate surgical sets were marked for both types of hepatitis and for each infected patient same type of labeled surgical sets were used. this was done to prevent further spread of these diseases during surgeries. surgeon and o.t staff took proper precautions for self-safety as well. results as mentioned earlier a total of 50 patients were operated out of which 27 were females and 23 were males. during analysis following gender distribution of hbsag and anti-hcv were observed. there was a clearly high incidence of b (17.3%) and c (21.73%) separately in males as compared to females (11.11%) respectively. when simultaneous incidence of both the types of hepatitis was seen, a comparatively high percentage (7.04%) of females suffered as compared to males (4.34%). along with the incidence of disease non-infected cases observed were higher in females as compared to males. 70.37% of females were not infected whereas only 56.52% were not infected. this showed an alarmingly high concentration of males (almost 45%) who were infected by hbsag and anti-hcv. t muhammad yasser nisar, et al 100 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology gender distribution of hepatitis b & c gender total not infected b+ c+ both b & c females 27 19 (70.37%) 3 (11.11%) 3 (11.11%) 2 (7.04%) males 23 13 (56.52%) 4 (17.39%) 5 (21.73%) 1 (4.34%) same situation is evident when a comparative bar chart for genders was drawn for both hepatitis b and c. furthermore, a detailed position chart also showed the concentration of more colored columns of hepatitis b and c in male region as compared to females. same was tested for association by running two slightly different versions of the chi-square procedure in minitab version 14, which gave results for the gender and over all hepatitis b and c prevalence. results reported by minitab showed a p-value of 0.000, which begin below 0.05 is pearson chi-square = 54,367, df = 1, p-value = 0.000 prevelance of hepatitis b & c at thq hospital in cataract surgery patients pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 101 likelihood ratio chi-square = 51.298, df = 1, p-value = 0.000 statistically significant. this means that gender and hepatitis b & c prevalence are related in a larger population. discussion hepatitis b and c increasing incidence is an emerging problem for developing countries like pakistan. this issue further aggravates in primary and secondary health care centers due to lack of proper protocols and awareness, which is a result of unsafe medical practice13. in our study a cross gender comparison has been done to investigate the difference between incidence of hepatitis b & c. within pakistan incidence of hbsag is around 10%14. our study has shown this incidence higher in both females (11.11%) and males (17.39%). this higher incidence in males as compared to females was also observed in another study by riaz et al13. however, for their study b+ prevailed in 7.4% cases as compared to 7% of females. similarly, for c positive their results were showing same trends with much less percentages. as for their results c positive females were 11.2% of the sample and males were 12.6%, whereas according to our results 11.1% of females were c+ whereas as high as 21.73% males were c positive. overall 18 out of 50 (36%) of the sample was b and c positive. this is more than three times higher than previously recorded results9,10,11,12,13. it is therefore, of utmost importance that government pays special attention to this medical issue at khanpur. this study also highlights the importance of further investigation of causes of such high incidence of hepatitis b and c at khanpur. there is also room of exploration of similar studies in other primary and secondary health care hospitals to see if same trend exists there. in another study by abbas z et al10 a crosssectional survey having 873 subjects belonging to 174 families residing in jarwar, a small town of upper sindh was done. hbsag was reactive in 44 (5%), hbcab in 494 (56.6%) and anti-hcv in 294 (33.7%). in the case control study, independent risk factors for exposure to hepatitis b were male sex, age greater than 16 years, absence of vaccination, previous history of jaundice, and family history of liver disease. independent risk factors for hepatitis c were age greater than 16 years, previous dental procedures, history of liver disease, lack of vaccination, and 10 or muhammad yasser nisar, et al 102 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology more injections in a year. there was indication of intrafamilial and household clustering: for hepatitis c, parent to child p = 0.001, sibling-to-sibling p = 0.046; for hepatitis b, spouse-to-spouse p = 0.052 and parent to child p = 0.001. proper screening and protocols for limiting the spread of these diseases at least via surgical procedures was followed at our hospital . this sets an example for other primary and secondary health hospitals in pakistan where safe medical procedures and screening are not being followed. as transmission of hbsag and anti-hcv is common via injections, needle pricks and surgical malpractices15-20. conclusion hepatitis b and c have multiple transmission modes, out of which lack of screening before surgical processes and unsafe surgical procedures are important ones. if proper protocols of screening and separating surgical instruments are followed there will be vast reduction in spread of these diseases. furthermore, practical application of screening tests and patient counseling by the surgeons and medical staffs can be the best awareness scheme for the prevention of both hepatitis b and c spread. authors affiliation dr. muhammad yasser nisar doms eye specialist consultant ophthalmologist thq khanpur taseer salahuddin mphil, phd scholar national college of business administration & economics independent researcher role of authors dr. muhammad yasser nisar data collection and literature review taseer salahuddin manuscript writing and data analysis references 1. mahale p, torres ha, kramer jr, hwang ly, li r, brown el, engels ea. hepatitis c virus infection and the risk of cancer among elderly us adults: a registrybased case-control study. cancer 2017; 123(7):1202-1211. 2. fu-sheng wang, jian-gao fan, zheng zhang, bin gao, and hong-yang wang. the global burden of liver disease: the major impact of china. 2014, hepatology volume 60, issue 6. 3. ali a mokdad, alan d lopez, saied shahraz, rafael lozano, ali h mokdad, jeff stanaway, christopher jl murray and mohsen naghavi. liver cirrhosis mortality in 187 countries between 1980 and 2010: a systematic analysis bmc medicine 2014 12: 145. 4. mohamed aa, elbedewy ta, el-serafy m, el-toukhy n, ahmed w, din el din z. hepatitis c virus: a global view. world j hepatol. 2015; 7 (26): 2676–80. 5. caccamo g, saffioti f, raimondo g. hepatitis b virus and hepatitis c virus dual infection. world journal of gastroenterolog  : wjg. 2014; 20 (40): 14559-14567. 6. tseng tc, kao jh. elimination of hepatitis b: is it a mission impossible? bmc med 2017;15(1):53. 7. pozzetto b, memmi m, garraud o, roblin x, berthelot p. health care-associated hepatitis c virus infection. world journal of gastroenterology: wjg. 2014; 20 (46): 17265-17278. 8. chaudry ia, khan sa, samiullah. should we do hepatitis b and c screening on each patient before surgery. pak j med sci. 2005; 21 (3): 278–280. 9. wallace j, pitt,s m, liu cg, lin v, wei l, richmond j, locarnini s. needs assessment of people with viral hepatitis – china. (arcshs monograph series no. 105), melbourne: australian research centre in sex, health and society, la trobe university. isbn: 9781921915734 the summary report and full report are available at http://www.latrobe.edu.au/arcshs/publications 10. abbas z, jeswani nl, kakepoto gn, islam m, mehdi k, jafri w. prevalence and mode of spread of hepatitis b and c in rural sindh, pakistan. trop gastroenterol. 2008; 29: 210-6. 11. sarwar j, gul n, idris m, rehman a, farid j, adeel my. seroprevalence of hepatitis b and hepatitis c in health care workers in abbottabad. j ayub med coll abbottabad, 2008; 20: 27-9. 12. khan aj, luby sp, firkee f, karim a, obaid s, dellawala s, et al. unsafe injections and the transmission of hepatitis b and c in a periurban community in pakistan. bull world health organ, 2000; 78: 956-63. 13. riaz s, khan mt, mehmood k, akhtar s. frequency of hepatitis b & c in previously unscreened patients admitted for elective cataract surgery. international ophthalmology with opthalmic & general sciences, 2016; 14 (4): 128-130. 14. chaudry ia, khan ss, majrooh ma, alvi aa. sero prevalence of hepatitis b and c among the patients reporting at surgical opd at fauji foundation hospital rawalpindi. pak j med sci. 2007; 23: 514-17. 15. talpur aa, ansari ag, awan ms, ghumro aa. prevalence of hepatitis b and c in surgical patients. pak j surg. 2006; 22 (3): 150-153. http://onlinelibrary.wiley.com/journal/10.1002/(issn)1527-3350 http://onlinelibrary.wiley.com/doi/10.1002/hep.v60.6/issuetoc http://www.latrobe.edu.au/arcshs/publications prevelance of hepatitis b & c at thq hospital in cataract surgery patients pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 103 16. daudpota aq, soomro aw. sero prevalence of hepatitis b and c in surgical patients. pak med sci. 2008; 24: 483-4. 17. bialek sr, bower wa, mottram k, purchase d, nakano t, nainan o, williams it, bell bp. risk factors for hepatitis b in an outbreak of b and d among injection drug users. j urban health, 2005; 82: 468-78. 18. yazdanpanah y, de carli g, migueres b, lot f, campins m, colombo c, et al. risk factors for hepatitis c virus transmission to healthcare workers after occupation exposure: a european case control study. clin infect dis. 2005; 41: 4123-30. 19. cholongitas e, sezolo m, patch d, kwong k, nikolopoulou v, leandro g, et al. risk factors, sequential organ failure assessment and model for endstage liver disease scores for predicting short term mortality in cirrhotic patients admitted to intensive care unit. aliment pharmacol ther. 2006; 23: 883-93. 20. wait s, kell e, hamid s, muljono dh, sollano j, mohamed r, shah s, mamun-al-mahtab, abbas z, johnson j, tanwandee t, wallace j. hepatitis b and hepatitis c in southeast and southern asia: challenges for governments. lancet gastroenterol hepatol. 2016; 1(3):248-255. https://www.ncbi.nlm.nih.gov/pubmed/?term=williams%20it%5bauthor%5d&cauthor=true&cauthor_uid=16049202 https://www.ncbi.nlm.nih.gov/pubmed/?term=bell%20bp%5bauthor%5d&cauthor=true&cauthor_uid=16049202 microsoft word m moin 104 original article role of cyclosporine eye drops in allergic conjunctivitis ather jameel, muhammad moin, mumtaz hussain. pak j ophthalmol 2009, vol. 25 no. 2 . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: ather jameel department of ophthalmology mayo hospital lahore received for publication september’ 2008 … ……………………… purpose: to evaluate the effects of topical 2% cyclosporin eye drops in patients with active vernal keratoconjunctivitis. material and methods: thirty seven patients with active vernal keratoconjunctivitis diagnosed at least one year before and treated with a variety of topical medications except cyclosporin were included in the study. all patients were treated with 2% cyclosporin eye drops four times daily in both eyes for 6 weeks. symptoms (itching, watering, photophobia, mucous discharge and foreign body sensation) and signs (conjunctival hyperemia, trantas’ dots, limbal oedema, epithelial punctate keratitis and palpebral conjunctival papillae) of vernal keratoconjunctivitis were recorded before treatment and at the end of treatment period. results: there was a statistically significant improvement in itching, photophobia, mucous discharge, conjunctival hyperemia, punctate keratitis and trantas’ dots after 6 weeks treatment period. no significant adverse effect of treatment with topical cyclosporin was observed except for mild to moderate stinging and burning upon administration. conclusion: topical cyclosporin is an effective and safe agent in the treatment of vernal keratoconjunctivitis. ernal keratoconjunctivitis (vkc) is an ocular allergic disease predominantly observed in children and young adults1. the disease is usually bilateral and is seen more commonly among males2. patients with vernal keratoconjunctivitis may suffer from symptoms throughout the year, but the intensity of the disease may increase in spring and summer. the precise immunopathogenic mechanism v 105 is unknown but it is thought to be more complex than a simple type i hypersensitivity reaction3. therapy of vernal keratoconjunctivitis includes the use of topical vasoconstrictors, antihistamines, mast cell stabilizers and corticosteroids4. the most effective treatment for vernal keratoconjunctivitis is stopical and supratarsal injection of corticosteroids, but this treatment carries considerable risk of complications5. although the disease is self limiting, signs and symptoms are often severe and difficult to control. corneal complications in untreated cases and prolonged steroid treatment in treated cases may lead to permanent impairment of vision. therefore the search for new, effective and safe treatments of this potentially blinding disease continues. cyclosporin is an immunosuppressive agent that specifically inhibits helper t-lymphocyte proliferation and production of interleukin-26. it is therefore inhibitory to many t-cell-dependent inflammatory mechanisms. it has direct inhibitory effects on eosinophil activation, release of granule proteins and cytokines. it also has direct and indirect inhibitory effects on mast cell activation, cytokine and mediator release, which are likely to be important in its role in the treatment of allergic inflammation7. to avoid the complications of current treatment of severe vkc (especially steroid), the efficacy of cyclosporin regarding the control of symptomatology of vkc was studied. materials and methods the study was conducted at the institute of ophthalmology, mayo hospital lahore from march to may 2002. a total of 37 patients were included in this quasi experimental study. patients included in the study were known cases of active palpebral or limbal vernal keratoconjunctivitis diagnosed at least one year before and treated with a variety of topical medications, except cyclosporin with poor response. patients excluded from the study were patients with associated ocular or systemic disease, patients who had history of periocular injections of steroids within a period of six months, patients taking systemic corticosteroids, anti-inflammatory agents or antihistamines and patients with shield ulcer. patients with vkc were selected according to inclusion and exclusion criteria. vkc was defined as recurrent bilateral conjunctivitis with giant papillae in the upper palpebral conjunctiva or by gelatinous hypertrophy of the limbus, associated with typical vernal epithelial keratitis. after taking informed consent patients were enrolled in the study. all patients were placed on a one week washout period. during that period patients were requested not to instill any eye drops in their eyes and parents were instructed to apply cold compresses whenever their children complained of symptoms related to the disease. after this washout period detailed ophthalmic and systemic history for associated disorders was recorded and a complete ophthalmological examination was performed. specific evaluation of the following symptoms and signs was carried out. symptoms include itching, watering, photophobia, mucous discharge and foreign body sensation. signs include conjunctival hyperemia, punctate keratitis, trantas’ dots, limbal oedema and palpebral conjunctival papillae. all patients were given 2% cyclosporin eye drops four times daily in both eyes. symptoms and signs were recorded before treatment and after 1st, 3rd and 6th week of treatment. grading of symptoms symptoms were graded as follows: 0= indicating no symptoms 1+= mild symptoms of discomfort which were just noticeable. 2 + = moderate discomfort noticed most of the day but did not interfere with daily routine activities. 3+ = severe symptoms interfering with daily routine activities. grading of signs conjunctival hyperemia was graded as follows: 0= no evidence of bulbar hyperemia. 1+ = mild bulbar hyperemia. 2+ = moderate bulbar hyperemia. 3+ = severe bulbar hyperemia. palpebral conjunctival papillae were graded as follows: 0= no papillary hypertrophy of the palpebral conjunctiva. 1+ = mild papillary hypertrophy. 2+ = moderate papillary hypertrophy (hazy view of the deep tarsal vessels). 3+ = severe papillary hypertrophy (deep tarsal vessels not visible in more than 50% of the surface). 106 punctate keratitis was graded as follows: 0= no evidence of punctate keratitis. 1+ = one quadrant of punctate keratitis. 2+ = two quadrants of punctate keratitis. 3+ = three or more quadrants of punctate keratitis. trantas’dots were graded as follows: 0 = no evidence of dots. 1 + = 1 to 2 dots. 2 + = 3 to 4 dots. 3 + = more than 4 dots. limbal oedema was graded as follows: 0 = no evidence of limbal oedema. 1 + = less than 90o of limbal oedema. 2 + = less than 180o of limbal oedema but more than 90o. 3 + = more than 180o of limbal oedema. blood was collected by antecubital venipuncture before and 6 weeks after the initiation of treatment. complete blood count, blood urea nitrogen, creatinine, serum glutamic oxaloacetic transaminase (sgot), serum glutamic pyruvic transaminase (sgpt) levels were determined to monitor the systemic side effects of cyclosporin. because 2% cyclosporin eye drops were not commercially available in the market they were prepared by us. these drops were prepared from the commercially available injection of cyclosporin (sandimmun) 250 mg /5ml. two millilitre solution (100mg) was withdrawn from this vial and diluted 5 times with 8 ml of artificial tears (tears naturale ii eye /drops) to get 2% cyclosporine eye drops. data was collected in terms of scores for different variables. wilcoxon signed rank test (non-parametric test) was used for before and after treatment comparison. results there were 32 males and 5 females enrolled in the study. patients had mean age of 9.8 years (ranged 5 to 18 years). twenty four (64.9%) of 37 patients were 10 years of age or younger (table 1) table 1: distribution age and sex (n =37) age 05-10 years 24 (64.9) 11-15 years 10 (27.0) 16-18 years 3 (8.1) sex male 32 (86.5) female 5 (13.5) in general, patients after using topical cyclosporin remained comfortable. no significant side effect occurred, except for mild to moderate stinging and burning upon administration. there was statistically significant improvement in itching, photophobia and mucous discharge. there was also improvement in watering and foreign body sensation, although not statistically significant. thirty six (97.3%) patients had decrease in itching after treatment with topical cyclosporin (p<0.01). tearing improved in 23(62.2%) patients after treatment with topical cyclosporin (p>0.05). photophobia improved in 32(86.5%) patients (p<0.02), mucous discharge improved in 33(89.2%) patients (p<0.05), foreign body sensation improved in 30(81.1%) patients (p>0.05) (table 2). conjunctival and corneal signs: there was a statistically significant improvement in the conjunctival and corneal signs after using topical cyclosporin. bulbar conjunctival hyperemia improved in 36(97.3%) patients (p<0.01). punctate keratitis improved in 34(91.9%) patients (p<0.02). trantas’ dots showed decrease in number in 31(83.8%) patients (p<0.01). limbal oedema improved in 33(89.2%) patients (p>0.05). palpebral conjunctival papillae showed improvement in 19(51.4%) patients (p>0.05) (table 3). the intraocular pressure was measured in patients who were co-operative, before, during and six weeks after treatment with topical cyclosporin. there was no significant change in the intraocular pressure after treatment. complete blood count showed normal white blood cells counts with differential count showing slight increase in the number of eosinophils. the number of eosinophils in patients of vkc entered in this study ranged between 3% and 13%. no significant difference was found after treatment with topical cyclosporin (table 4). kidney and liver function tests showed no significant change before and after treatment. discussion 107 vernal keratoconjunctivitis (vkc) is recurrent bilateral interstitial inflammation of the conjunctiva, afflicting children and young adults and usually of periodic seasonal incidence5. the immunopathogenic mechanism is complex and may be mediated by both ige and igg. a cell mediated immune process has also been postulated. untreated corneal complications as well as prolonged treatment with steroids may lead to impairment of vision. because the condition eventually resolves, usually after adolescence, the treatment should be conservative and aimed at preventing potential complications. the management of vkc often is difficult and is determined by availability of medications, safety and cost effectiveness8. milder cases can often be treated with tear substitutes, topical vasoconstrictors or topical antihistamines. more advanced cases may be treated with combinations of topical mast cell stabilizers and topical corticosteroids4 but unsupervised treatment may lead to glaucoma and cataract. therefore a drug which is effective in advanced cases of vkc with no or little side effects is highly desirable. our clinical trial demonstrated that topical cyclosporin was effective is controlling the symptoms and signs of patients with vkc. statistically significant improvement was observed for symptoms (itching, photophobia, mucous discharge) and signs (conjunctival hyperemia, punctate keratitis, trantas’ dots) of vkc. there was also improvement for other symptoms (watering, foreign body sensation) and signs (limbal oedema, palpebral conjunctival papillae) of vkc, although statistically not significant. these results are comparable with the studies carried out by table 2: symptom (before and after) n=37 symptom 0 1+ 2+ 3+ before n (%) after n (%) before n (%) after n (%) before n (%) after n (%) before n (%) after n (%) itching 7 (18.9) 1 (27) 27 (73.0) 29 (78.4) 3 (8.2) 7 (18.9) watering 1 (2.7) 9 (24.3) 17 (46) 22 (59.5) 15 (40.5) 6 (16.2) 4 (10.8) photophobia (%) 10 (27) 10 (27) 24 (64.9) 21 (65.8) 3 (8.1) 6 (16.2) (%) mucous discharge (%) 10 (27) 10 (27) 25 (67.6) 24 (64.9) 2 (5.4) 3 (8.1) (%) foreign body 1.(2.7) 5 (13.5) 5 (13.5) 25 (67.6) 25 (67.6) 7 (18.9) 6 (16.2) (%) table 3: signs (before and after) n=37 sings 0 1+ 2+ 3+ before n (%) after n (%) before n (%) after n (%) before n (%) after n (%) before n (%) after n (%) conjunctival hyperemia (%) 10 (27.0) 2 (5.4) 24 (64.9) 31 (83.8) 3 (8.1) 4 (10.8) (%) punctate keratitis (%) 24 (64.9) 19 (51.4) 11 (29.7) 15 (40.5) 2 (5.4) 3 (8.1) (%) trantas’ dots 3 (8.1) 18 (48.65) 9 (24.3) 18 (48.65) 23 (62.2) 1 (2.7) 2 (5.4) (%) limbal oedema 1 (2.7) 15 (40.5) 12 (32.4) 20 (54.1) 21 (56.8) 2 (5.4) 3 (8.1) (%) palpebral conjunctival papillae 6 (16.2) 20 (54.1) 23 (62.2) 13 (35.1) 5 (13.5) 3 (8.1) 3 (8.1) 1 (2.7) eosinophils in blood table 4: eosinophils in blood (before and after) (n-37) no of eosinophils no. of patients n (%) 108 3-5 9 (24.3) 6-10 22 (59.5) 11-13 6 (16.2) gupta et al9 and secchi et al10. however in studies carried out by mendicute et al11 and bleik et al6 there was statistically significant improvement in palpebral conjunctival papillae which is not observed in our study. mendicute et al’s study was carried out on only two patients, while in bleik et al’s study, the authors did not record the effect of topical cyclosporin on palpebral conjunctival papillae, but misinterpreted the result in abstract. topical cyclosporin was well tolerated by all of our patients. no significant side effects occurred, except for mild stinging and burning upon administration, which was also noted in studies carried out by hingorani et al7 and secchi et al10. however in study carried out by bleik et al6, no adverse effects and no detectable levels of cyclosporin were noted in the blood in the cyclosporin treated groups. literature shows that topical cyclosporin is not going to be absorbed into the systemic circulation in sufficient concentration to reach therapeutic or toxic dosages and therefore is not associated with any systematic side effects. prolonged use of topical 2% cyclosporin has been reported, and the only serious side effects reported are lid maceration and corneal epitheliopathy, both of which resolve on cessation of treatment and which do not necessarily preclude further use of cyclosporin. topical cyclosporin appears to carry none of the serious, sight threatening complications of topical steroids, such as glaucoma, cataract and exacerbation of corneal infection12. cyclosporin an immunosuppressive agent, most commonly used in organ transplantation has a selective inhibitory effect on helper t-lymphocytes proliferation and production of interleukin-2. it is therefore inhibitory to many t-celldependent inflammatory mechanisms. cyclosporin also has direct inhibitory effects on eosinophil activation and release of granule proteins and cytokines and both direct and indirect inhibitory effects on mast cell activation, cytokine, and mediator release, which are likely to be important to its role in the treatment of allergic inflammation7. two types of mast cells have been recognized in humans based on neutral protease composition and tlymphocyte dependency. the t-lymphocytedependent mast cells contain tryptase but not chymase whereas the t-lymphocyte independent mast cells contain both tryptase and chymase. patients with active vkc have a significant increase in the tlymphocyte-dependent mast cells in the epithelial cells of conjunctival biopsy specimens. the exact mechanism of action of cyclosporin on the mast cell is unknown but it may be postulated that cyclosporin modulates the local ige production by the b cell via its effects on the t-helper cells and possibly by influencing the t-lymphocyte-dependent mast cells6. topical cyclosporin has been used to treat a number of anterior segment conditions including sjogren’s syndrome, ligneous conjunctivitis, ocular cicatricial pemphigoid, mooren’s ulcer and autoimmune corneal melting. it also has been used in high risk penetrating keratoplasty and is also under trial for the treatment of steroid dependent atopic keratoconjunctivitis7. cyclosporin 0.05% is now available commercially (restasis, allergan, usa) in some countries and has been reported to be effective for allergic conjunctivitis13. we would suggest that topical cyclosporin 2% is also safe and effective therapy in patients with vkc who are resistant to conventional treatment or when there is danger of developing complications with conventional treatment. further studies are needed to compare the difference in results and complications of the two concentrations. conclusion topical cyclosporin is effective in controlling the symptoms and signs of patients with vernal keratoconjunctivitis who are refractory to conventional treatment and can be used safely without any significant side effect. author’s affiliation dr. ather jameel department of ophthalmology mayo hospital lahore dr. muhammad moin associate professor department of ophthalmology mayo hospital lahore prof. mumtaz hussain 109 department of ophthalmology mayo hospital lahore reference 1. avunduk am, avunduk mc, kapicioglu z, et al. mechanisms and comparison of anti allergic efficacy of topical lodoxamide and cromolyn sodium treatment in vernal keratoconjunctivitis. ophthalmology 2000; 107: 1333-37. 2. kanski jj. clinical ophthalmology 4th ed. oxford: butterworth heinemann; 1999: 55-93. 3. akpek ek, hasiripi h, christen wg, et al. a randomized trial of low dose, topical mitomycin-c in the treatment of severe vernal keratoconjunctivitis. ophthalmology. 2000; 107: 263-69. 4. holsclaw ds, whitcher jp, wong ig, et al. supratarsal injection of corticosteroid in the treatment of refractory vernal keratoconjunctivitis. am j ophthalmol. 1996; 121: 243-49. 5. khan md, kundi n, saeed n, et al. a study of 530 cases of vernal conjunctivitis from the north west frontier province of pakistan. pak j ophthalmol. 1986; 2: 111-4. 6. bleik jh, tabbara kf. topical cyclosporine in vernal keratoconjunctivitis. ophthalmology. 1991; 98: 1679-84. 7. hingorani m, moodaley l, calder vl, et al. a randomized, placebo-controlled trial of topical cyclosporin a in steroiddependent atopic keratoconjunctivitis. ophthalmology 1998; 105: 1715-20. 8. ovais sm, shaikh a. the morbidity of vernal keratoconjunctvitis. pak j ophthalmol. 2001; 17: 86-9. 9. gupta v, sahu pk. topical cyclosporin a in the treatment of vernal keratoconjunctivitis. eye 2001; 15: 39-41. 10. secchi ag, tognon ms, leonardi a. topical use of cyclosporin in the treatment of vernal keratoconjunctivtis. am j ophthalmol. 1998; 110: 641-5. 11. mendicute j, aranzasti c, eder f, et al. topical cyclosporin a 2% in the treatment of vernal keratoconjunctivitis. eye 1999; 11: 75-8. 12. hoang-xuan t, prisant o, hannouche d, et al. systemic cyclosporin a in severe atopic keratoconjunctivitis. ophthalmology. 1997; 104: 1300-5. 13. ozcan aa, ersoz tr, dulger e. management of severe allergic conjunctivitis with topical cyclosporin a 0.05% eye drops. cornea. 2007; 26: 1035-8. microsoft word index-6.doc original article evaluation of vitreo-retinal pathologies using b-scan ultrasound jamil ahmed, fahad feroz shaikh, abdullah rizwan, mohammad feroz memon pak j ophthalmol 2009, vol. 25 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: jamil ahmad department of ophthalmology isra university hospital, hyderabad received for publication february’ 2009 …..…………………..… purpose:: to determine the diagnostic use of b-scan in the detection of vitreoretinal pathologies in patients with vitreous opacities. material and methods: the study was conducted in the department of ophthalmology, isra university & hospital, hyderabad, sindh, from jan 2008 to dec 2008. in this study evaluation of over a period of 1 year, 73 eyes of 68 patients with vitreous opacities and poor retinal visualization were investigated with b-scan ultrasound. patients were selected from the retina clinic of the department of ophthalmology. the b-scan machine used was us scan3300 (nidek). results: out of 73 scans performed, 48 eyes had vitreous hemorrhage, 22 eyes showed inflammation in vitreous and 3 eyes had asteroid hyalosis. posterior segment pathologies detected in eyes with vitreous hemorrhage were rhegmatogenous retinal detachment, tractional retinal detachment, peripheral retinal tear, posterior vitreous detachment, intra-ocular tumor, intra-ocular foreign body, disciform macular lesion & traumatic scleral rupture. in patients with intraocular inflammation, the diagnoses made were endophthalmitis, dropped nucleus and expulsive choroidal hemorrhage. conclusion: b-scan ultrasound is very useful diagnostic tool in detection and evaluation of vitreo-retinal pathologies in patients with opacities in the vitreous cavity. ltrasound is an acoustic wave that consists of an oscillation of particles within a medium. ultrasound was first used in ophthalmology in 1956 by american ophthalmologists mundt and hughes1. they used a-scan mode to evaluate an intraocular tumor. b-scan was introduced in ophthalmic practice by baum and greenwood in 19582. both ascan and b-scan techniques are important for the diagnosis of intraocular disease. b (brightness) mode is useful for a better demonstration of the shape and topographic relationship of lesions in the posterior segment3. b-scan provides cross sectional display of diseased tissues and is valuable in detecting unsuspected posterior segment diseases4. the frequency used in the diagnostic ophthalmic ultrasound for posterior segment is 8-10 mhz. over the last 30 years ultrasonography has greatly advanced and this has enabled us to study posterior segment of the eye in the presence of opaque media5. the purpose of this study is to evaluate the nature of intraocular pathologies detected by ultrasound examination in patients with vitreous opacity. material and methods over a period of 1 year (jan 2008 to dec 2008), 73 eyes of 68 patients were selected from the retina clinic of the department of ophthalmology at the isra university hospital. there was poor visualization of fundus using slit lamp and indirect ophthalmoscope in all the patients due to vitreous opacities. b-scan ultrasound was advised for the evaluation of vitreous opacities and to detect any underlying posterior segment pathology. patients were explained about the procedure. topical anaesthetic eye drop was used to achieve ocular surface anesthesia. the b-scan machine used was us scan3300 (nidek). hydroxypropyl methyl cellulose was used as the coupling material u patient was seated in comfortable reclining chair; position of chair and the patient was so adjusted that the examiner could see the eye under evaluation and the monitor at the same time. systematic ultrasound examination was performed. basic screening was performed initially at high gain (i.e. 80 db) setting followed by examination under lower sensitivity. kinetic echography was done by keeping the probe still and asking the patient to move the eyes in different gazes to determine the after movements of membranous structures. any solid lesion detected was evaluated topographically. quantitative echography was performed to determine the internal reflectivity of a solid lesion. the clinical and ultrasound findings were recorded in proforma. results in this study 68 patients (73 eyes) with vitreous opacities and poor retinal visualization were investigated with b-scan ultrasound. there were 45 male (66%) and 23 female (34%) patients. age range was 569 (mean = 39) years. vitreous opacification was due to vitreous hemorrhage in 48 (65%) eyes, intraocular inflammation in 22 (30%) eyes and dense asteroid hyalosis in 3 (5%) eyes (table i). among 48 eyes with vitreous hemorrhage (fig. 1), concomitant posterior segment pathology was detected in 34 (71%) eyes while 14 (29%) eyes did not demonstrate any other pathology on b-scan; there was tractional retinal detachment (trd) in 12 (25%) eyes (fig. 2), rhegmatogenous retinal detachment (rrd) in 6 (12.5%) eyes (fig. 4), posterior vitreous detachment (pvd) in 8 (17%) eyes (fig. 3), peripheral retinal tear in 2 (4%) eyes, intra ocular tumor in 2 (4%) eyes, intra ocular foreign body in 2 (4%) eyes, disciform macular lesion due to age related macular degeneration (armd) in 1 (2%) and traumatic scleral rupture in 1 (2%) eye (table 2). in patients with intraocular inflammation (fig. 5), the diagnoses made were endophthalmitis in 11 (50%) eyes, drop nucleus in 3 (32%) eyes and expulsive choroidal hemorrhage in 1 (13.5%) eye and vitritis in 7 (4.5%) eyes (table 3). discussion ophthalmic ultrasound has become an indispensable diagnostic tool that has increased our ability to detect and differentiate many ocular and orbital diseases. echography is indicated whenever opacification of ocular media does not allow the examiner to peep into the posterior segment the latter is kept in the dark about the possibility of various pathologies. if the surgeon knows about these pathologies preoperatively, he can modify his plan of surgery and can also take measures to combat various predictable complications7. table 1: vitreous opacities vitreous opacities no. of eyes n(%) vitreous hemorrhage 48 (65) intraocular inflammation 22 (30) asteroid hyalosis 3 (5) total 73 table 2: diagnosis in cases with vitreous hemorrhage (n = 48) diagnosis no. of eyes n (%) vitreous hemorrhage only 14 (29) tractional retinal detachment 12 (25) rhegmatogenous retinal detachment 6 (12.5) posterior vitreous detachment 8 (17) peripheral retinal tear 2 (4) intra ocular foreign body 2 (4) intra ocular tumor 2 (4) disciform macular lesion due to armd 1 (2) traumatic scleral rupture 1 (2) total 48 table 3: diagnosis in cases with intraocular inflammation (n = 22) diagnosis no. of eyes n (%) endophthalmitis 11 (50) vitritis 07 (32) drop nucleus 03 (13.5) expulsive choroidal hemorrhage 01 (4.5) total 22 fig. 1: b-scan showing vitreous hemorrhage fig. 2: b-scan showing tractional retinal detachment fig. 3: b-scan showing vitreous hemorrhage with poterior vitreous detachment fig. 4: b-scan showing rhegmatogenous retinal detachment fig. 5: b-scan showing intraocular inflammation in this study, 73 eyes of 68 patients with vitreous opacities were examined. in all the cases, vitreous opacities were dense enough to preclude adequate assessment of retina and any underlying pathology. vitreous opacification was because of vitreous hemorrhage in 48 eyes, intraocular inflammation in 22 eyes and asteroid hyalosis in 3 eyes. the distinction between the opacities was clinical as well as echographic. fresh vitreous hemorrhage appears as dots & short lines on b-scan. the more dense the hemorrhage, the more opacities are seen on b-scan. organized blood produces larger membranous surfaces on bscan. inflammatory cells in vitreous give similar echogenic appearance as fresh vitreous hemorrhage; however, certain feature on b-scan can help differentiate posterior vitreous detachment (pvd) is more extensive in vitreous hemorrhage; inflammatory cells are evenly distributed while vitreous hemorrhage settles inferiorly due to gravity6. in asteroid hyalosis, calcium soaps produce bright echos on b-scan with clear vitreous gel located between asteroid opacities and retina6. out of 48 eyes with vitreous hemorrhage, 34 eyes showed associated posterior segment pathologies rhegmatogenous rd was detected in 6 eyes; it produces a bright continuous folded membrane that inserts into optic disc and/or ora serrata8. in contrast pvd produces a smooth membrane that shows low reflectivity as compared to rd. kinetic echography is helpful in differentiating these 2 conditions; in pvd there is very fluid undulating after movement on bscan, whereas rd exhibits a more tethered and restricted after movement. however there are situations in which the acoustic behavior of pvd is similar to rrd and the distinction may be quite challenging. peripheral retinal tear was detected with b-scan in 2 eyes; this appears on b-scan as a retinal flap; with a pvd or vitreous strand attached to it. twelve eyes with tractional rd and vitreous hemorrhage were examined. the causes of trd in our patients were advanced diabetic eye disease in 10 eyes and penetrating ocular trauma in 2 eyes. both tent like and table top configurations were observed on b-scan. whereas tent like trd is produced by a point like adherence, the table top detachment is the result of a broader vitreoretinal adherence. a thorough echographic examination is very helpful before vitrectomy in eyes with trd; it demonstrates the safest region to break the posterior hyaloid, allows the surgeon to anticipate areas of vitreoretinal traction and provide reasonable assessment of expected visual prognosis9. in our study, 2 patients had penetrating ocular trauma with vitreous hemorrhage and retained intraocular foreign body. standardized echography is invaluable in precise localization of iofb and to determine the extent of intraocular damage, even when a foreign body (fb) has been previously localized with ct scan. typical metallic fb produces a very bright signal on b-scan that persists at low sensitivity; also there is marked shadowing of ocular and orbital structures just posterior to it10. one patient had severe blunt trauma and presented with hemorrhagic chemosis and dense vitreous hemorrhage. b -scan showed rd and features suggestive of posterior scleral rupture i.e. irregular scleral contour and low reflectivity in the area of rupture along with vitreous incarceration and episcleral hemorrhage6. two patients with vitreous hemorrhage and intraocular tumor were scanned; the features were consistent with choroidal melanoma in one patient i.e. mushroom shape growth showing acoustic hollowness, choroidal excavation and orbital shadowing11. the other patient was an elderly lady with carcinoma of breast and metastatic spread. her bscan showed an irregular lesion with lobulated appearance and high internal reflectivity consistent with metastatic choroidal carcinoma. disciform macular lesion secondary to exudative armd was the cause of vitreous hemorrhage in one patient. the lesion appears as a small dome shaped subretinal elevation in the macular area12. endophthalmitis was diagnosed in 11 patients; 6 of these were postoperative eyes, 3 had traumatic endophthalmitis, while 1 patient had bilateral endogenous endophthalmitis secondary to meningococcal septicemia. ultrasound is useful to determine the severity and extent of inflammation in clinically suspected cases of endophthalmitis. when the presence of infection is questionable from clinical appearance, b-scan may help to differentiate whether the vitreous opacities are secondary to inflammation or to vitreous hemorrhage, as already discussed6. 3 postoperative patients showed vitreous opacities and membranes along with a dropped nucleus that appeared as an oval spherical mass adhered to the retina or floating in the vitreous cavity. one postoperative patient with history of expulsive hemorrhage during surgery large dome shaped membranes, extending from the periphery to the posterior pole along with echogenic shadows of fresh and clotted blood in the supra-choroidal space. echography is useful in following the course of hemorrhagy choroidal detachment and in determining the appropriate time for drainage6. b-scan ultrasound is very important for demonstrating the nature and extent of abnormalities in eyes with vitreous opacification13. it is also useful for monitoring progression of retinal diseases. in eyes with vitreous haze that are being considered for vitrectomy, ultrasonic evaluation helps to diagnose the underlying pathology, to determine the timing of surgery, in optimal placement of vitrectomy instruments and to predict the visual outcome. author’s affiliation dr. jamil ahmed h. no 127/c, block d, unit no 7, latifabad hyderabad dr. fahad feroz shaikh assistant professor ophthalmology isra university hospital hyderabad dr. abdullah rizwan professor of ophthalmology isra university hospital hyderabad dr. mohammad feroz memon assistant professor ophthalmology isra university hospital hyderabad reference 1. mundt gh, hughes wf. ultrasonics in ocular diagnosis. am j ophthalmol. 1956; 41: 488-98. 2. baum g, greenwood i. the application of ultrasonic locating technique to ophthalmology. arch ophthalmol. 1958; 60: 26379. 3. till p, osoining kc. ten year study on clinical echography in intraocular disease. bibl ophthalmol. 1975; 83: 49-62. 4. hodes bl. eye disorders: using ultrasound in ophthalmic diagnosis. post grad med. 1976; 59: 197-203. 5. zafar d, sajad am, qadeer a. role of bscan ultrasonography for posterior segmet lesions. jlumhs. 2008; 07: 7-12. 6. freeman hm. diagnostic ophthalmic ultrasound. in: ryan sj, editor. retina. vol. 3, 3rd ed. st: louis: mosby, 1989: 280-306. 7. imtiaz sa, rehman hu. role of b-scan in preoperative detection of posterior segment pathologies in cataract patients. pak j ophthalmol. 1997; 13: 108-12. 8. kerman bm, coleman dj: bscan ultrasonography of retinal detachments. ann ophthalmol. 1978; 10: 903-11. 9. bigar f, bosshard c, kolti r. combined aand bscan echography: preoperative evaluation of vitrectomy patients. mod probl ophthalmol. 1977; 18: 2-11. 10. awaschalom l, meyers sm: ultrasonography of vitreal foreign bodies in eyes obtained at autopsy. arch ophthalmol. 1982; 100: 979-80. 11. ossoining kc. standardized echography: basic principles, clinical applications and results. int ophthalmol clin. 1979; 19: 127-210. 12. valencia m, green rl, lopez pf. echographic findings in hemorrhagic disciform lesions. ophthalmology. 1994; 101: 1379-83. 13. mcleod d, restori m. ultrasonic examination in severe diabetic eye disease. br j ophthalmol. 1979; 63: 533-8. pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 103 original article awareness of contact lens care among medical students hijab ijaz, rida ijaz, naeem rustam pak j ophthalmol 2017, vol. 33, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hijab ijaz department: department of optometry and orthoptics, fatima memorial hospital college of medicine & dentistry, lahore. e-mail: hijabijaz@hotmail.com purpose: to determine the awareness of contact lens care among medical students. study design: cross sectional study. place and duration of study: fatima memorial hospital college of medicine and dentistry, lahore over a period of four months since 1st august 2012 to 30th november 2012. materials and method: data was collected through a self-design questionnaire from 100 medical students of fatima memorial hospital college of medicine and dentistry, lahore. questionnaires were distributed among those who used contact lenses presently or in the past. questions were asked about contact lens hygiene and complications related contact lens usage. gender, visual acuity and contact lens fitting etc. were independent variables. students related to other professions and those who had eye problems but did not use contact lenses were excluded. results: in this study there were total 100 medical students whose ages ranging between 18-23 years and majority of them were females 96% (96); most of the students occasionally 57% (57) used contact lenses; awareness about contact lens solution was found in 96% (96) of students. however students have little awareness regarding contact lens case cleaning and use of enzymatic cleaner 68% (68) did never used enzymatic cleaner. the complications occurred in 69% (69) students with the use of contact lens. conclusion: majority of the medical students were aware about the most of the mailto:hijabijaz@hotmail.com hijab ijaz, et al 104 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology …..……………………….. cleaning and hygienic steps of contact lens care but majority of them were unaware about contact lens case cleaning and use of enzymatic cleaner therefore they faced eye problems. keywords: awareness, contact lens, care, medical students. ontact lenses are thin optical corrective lenses worn on the eye, resting on the surface of the cornea. contact lenses are becoming popular in young generation specially students of school and colleges1. care and maintenance of contact lens is one of the most important aspects. it can influence the outcomes of contact lens wearers and contentment with their lenses2. non-compliance is a major issue in contact lens wearers and it is seen in various aspects of contact lens wear and care3,4. it has been estimated that approximately 140 million people were using contact lenses worldwide in 20055. use of contact lenses is increasing day by day yet people are not fully aware about various merits and demerits of contact lenses1. ignorance of contact lens care leads to a serious ocular health problems for example dry eyes, giant papillary conjunctivitis, corneal edema, corneal ulcer, keratitis, corneal warpage and neovascularization.1 ocular health education especially knowledge in the correct and careful practice regarding contact lens wear can prevent complication resulting from wearer’s inappropriate behavior6. the wearer’s attitude and knowledge relating to contact lens care including cleaning, disinfection, protein removal, keeping of solutions for a longer period, hygiene of hands and lens cases, a period of wear exceeding the recommended one, and the lack of regular eye assessment, have been proposed as the main causes of complications7. medical students having studied the basic physiology and anatomy of the eye are expected to have better knowledge about contact lens care compared to students studying other subjects. this study was undertaken to determine the awareness of contact lens care among medical students. materials and methods this was a cross sectional descriptive study. the study was conducted in 4 months since 1st august 2012 to 30th november 2012. helsinki (2008) principles were followed to conduct the study. after taking ethical approval from the institution data was collected and it was only for research purpose. after taking consent data was collected through a self-design questionnaire at fatima memorial hospital college of medicine and dentistry, lahore from 100 medical students of those who used contact lenses currently or ever had tried in the past. questions were asked about contact lens duration, type, hygiene and complication related contact lens usage. gender, visual acuity and contact lens fitting etc. are independent variables. students related to other professions and those who had eye problems but did not use contact lenses were excluded. after collection of data it was entered and analyzed by using spss 19. results in this study data was collected from 100 patients in which 96 (96%) were females and 4 (4%) were males. currently 69 (69%) were using contact lens and 31 c awareness of contact lens care among medical students pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 105 (31%) had tried them in the past. eight students (25.8%) stopped using contact lens because it was difficult to wear, 9 (29%) discontinued as they were fed up to wear contact lens because it needs proper care and they cannot maintain appropriate care, and 14 (45.2%) terminated their use due to its complications they faced. the patients who wore rigid gas permeable lens (rgp) or soft contact lenses presently or in the past were 2 (2%) and 98 (98%) respectively. according to the mode of wear 2 (2%) were using disposable lenses, 67(67%) wore their lenses daily and 31 (31%) were extended wearers. six (8.7%) were using contact lens for less than 6 months, 20 (29%) for 6 months to 1 year, 17 (24.6%) were using from 1 to 5 years and 26 (37.7%) were for more than 5 years. 43 (43%) daily wore their contact lenses and 57 (57%) used them occasionally. on average 56 (56%) were wearing less than 8 hours per day while 44 (44%) used them for more than 8 hours per day. 42 (42%) students were using contact lens for their refractive error, 31 (31%) for cosmetic problems, 22 (22%) for convenience while 5 (5%) were using lenses for other reasons. 91 (91%) removed contact lens before going to sleep, 4 (4%) removed after overnight, 3 (3%) after one week, 2 (2%) were removing after fortnight. frequency of hand washing (p-value=0.668) was 89% before handling contact lens. only a small number of students 2 (2%) never cleaned their lenses others cleaned them either before or after wear, weekly or monthly (p-value=0.305). mostly students 96 (96%) were using contact lens solution as cleaning material (p-value=0.207). when question was asked about contact lens case cleaning only 7 (7%) student never cleaned them while only few 4 (4%) students knew about enzymatic cleaning once a week (pvalue=0.223) as shown in table. table: contact lens use. male female gender 4 (4%) 96 (96%) current user past user contact lens wear 69 (69%) 31 (31%) <6 months 6 months to 1 year 1 to 5 year >5 year duration of contact lens wear of current user 6 (8.7%) 20 (29%) 17 (24.6%) 26 (37.7%) rigid gas permeable soft contact lenses type of contact lenses use 2 (2%) 98 (98%) daily wear extended wear disposable mode of wear 67 (67%) 31 (31%) 2 (2%) daily occasionally use contact lenses 43 (43%) 57 (57%) <8hours 8-12hours >12 hours hours per day wearing contact lenses 56 (56%) 33 (33%) 11 (11%) refractive cosmetic convenience others hijab ijaz, et al 106 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology reason of using contact lens 42 (42%) 31 (31%) 22 (22%) 5 (5%) table: knowledge about contact lens hygiene. yes no hand washing before using contact lens 89 (89%) 11 (11%) before going to sleep after overnight after one week after fortnight remove contact lenses 91 (91%) 4 (4%) 3 (3%) 2 (2%) before or after wear weekly once a month never contact lens cleaning 69 (69%) 20 (20%) 9 (9%) 2 (2%) once a week once a month off & on never contact lens case cleaning 37 (37%) 19 (19%) 37 (37%) 7 (7%) lens solution tap water cleaning material 96 (96%) 4 (4%) yes no knowledge about renewal of contact lens every 3 months 52 (52%) 48 (48%) once a week once a month off & on never enzyme cleaner use 4 (4%) 13 (13%) 15 (15%) 68 (68%) the patients who were using contact lenses 69% of them may had problems with its use while 31 (31%) students had no problem with contact lens usage. discussion it is very important that the medical students have knowledge about contact lens wear, hygiene, care and complications. many people prefer contact lenses over glasses for cosmetic reasons. broadly contact lens are classified in hard and soft lenses.8 soft contact lenses are usually more comfortable to wear, but they also tear more easily than hard contact lenses. in the present study 96% of the students used contact lenses were females. among them 69.8% (67) females were using contact lenses currently whilst 30.2% (29) had tried them in the past. 97.9% (94) females were soft contact lens users. the study conducted in malaya, karachi and brazil, females were most frequent users of contact lens respectively (87.6%, 92.6%, 69.2%). they were using them for refractive error or cosmetically4,7,9. most of the medical students in our study using contact lens for more than 5 years were 37.7%. among these 18 students (41.9%) were having more problems with contact lenses which are consistent with results that found in both previous researches4,7. in our study 56 medical students (56%) wore contact lenses for less than 8 hours and among them 56.7%experienced problems with contact lenses. however the study conducted in india found that 88.6% students had problems related to contact lens with p value 0.043 and concluded that hours per daily wear related to use of contact lens10. contact lenses are used to treat refractive error, keratoconus, anisometropia, nystagmus, unilateral aphakia and also use for cosmetic and therapeutic purposes11. in our study most of the students 42% were using contact lens for refractive purpose and 31% for cosmetic purposes while in study held in karachi awareness of contact lens care among medical students pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 107 contact lenses were used for refractive errors in 67.23% patients and for cosmetic purposes in 43.8% patients in the study of malaya4,7. the purpose of lens care system is to maintain comfort, provide good vision, maintain eye health, and maintain lens hydration and parameter stability.12 care for contact lenses is dependent on the type of contact lenses and solution recommended by your eye care professional13. in particular, including a "rub and rinse" step in the lens cleaning process, minimizing contact with water while wearing contact lenses and replacing the lens case frequently can help reduce the risk of infection14. contact lenses must also be safely stored in solution until they are next worn15. nine percent (9) students did not remove their lenses before going to sleep and among them 10.5% (7) faced problems. however 13.20% and 13.50% students did not remove their lenses before going to sleep in the studies of malaya and karachi respectively4,7. in our study hand washing is not related with contact lens problems. 89% (89) of medical students wash their hands before handling of contact lenses while students who did not wash their hands was slightly higher 11% (11) from another study in karachi in which 7.7% did not wash their hands4. 98% (98) of students claimed that they cleaned their lenses amongst them before/ after wear 69% (69), weekly 20% (20) and monthly 9% (9). however remaining 2% (2) did not clean them ever. among 98% who cleaned their lenses 70.4% (69) experienced an eye problems related to contact lens. on the other hand muneer et al reported that 94.2% of students cleaned their lenses while 5.8% did not and 84.3% of students cleaned their lenses reported by tajunisah et al4,7. contact lens solution are used to clean, disinfect and rinse the lens. multipurpose solution most commonly use now a days.16 in this study 96% (96) students claimed that they were using contact lens solution as cleaning material and 4% (4) using tap water. whereas in the study of giri, p.a., chavan, w.m., phalke et al. 79.31% used lens solution and 20.69% did not1. contact lenses can adversely affect most of the anterior ocular structures.17 patient using contact lenses often suffer from red eye, itching, and scratchiness. 18 69% (69) of medical students in our study reported that they were suffered from an eye problems associated with contact lens wear in which red eyes 18% (18) and discomfort 15% (15) with contact lenses were most prevalent; while in previous studies redness and irritation were found to be the most frequent complaint4,7. adverse effects due to contact lens wear can be acute or chronic in nature and can span the range from a mere annoyance to a disabling condition that results in permanent ocular damage or loss of the eye19. in our study 45% of student’s claimed that contact lens is not harmful which is slightly different from study by muneer et al in which 58.1% patients said that it is not dangerous for use4. patient education is of paramount importance and has been the gold standard for decades. recent findings however, suggest that recommendations amongst eye care practitioners are highly variable necessitating more effective practitioner educational programs to eliminate this ambiguity20. hijab ijaz, et al 108 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology conclusion this study shows that medical students have significant knowledge about how to use contact lens but majority of them lack proper awareness regarding enzymatic cleaning and contact lens case cleaning which can led to serious eye problems. therefore, the knowledge and practice about contact lens care should be increased by appropriate counseling. author’s affiliation dr. hijab ijaz department: department of optometry and orthoptics, fatima memorial hospital college of medicine and dentistry, lahore. dr. rida ijaz department: department of optometry and orthoptics, fatima memorial hospital college of medicine and dentistry, lahore. dr. naeem rustam department: department of optometry and orthoptics, fatima memorial hospital college of medicine and dentistry, lahore. role of authors dr. hijab ijaz study design, data collection, data analysis, manuscript drafting. dr. rida ijaz data collection, manuscript drafting dr. naeem rustam manuscript drafting, revision data analysis references 1. giri pa, chavan wm, phalke db, bangal sv. knowledge and practice of contact lens wear and care among contact lens users medical students of rural medical college, loni, maharashtra, india.int j biol med res. 2012; 3 (1): 1385-1387. 2. claydon be, efron n. non-compliance in contact lens wear. ophthal physiol optics, dec 2007; 14 (4): 356-364. 3. tellakula p. care and maintenance of contact lens an overview. kerala journal of ophthalmology, 2009; 21 (3): 294-303. 4. quraishy mm, khan b. awareness of contact lens care among medical students. medical channel, dec. 2009; 15 (4): 85-88. 5. stapleton et al. epidemiology of contact lens related 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selection of contact lenses, lima c.a., contact lenses in ophthalmic practice, new york, springer, 2004: 7-9. 12. chaudhry m, contact lens care system, contact lens primer, new dehli, jaypee, 2007; 185. 1st edition 13. engle jp. caring for contact lenses. am pharm. 1994 mar; ns34 (3): 73-82. 14. boyd, k, (2013, jan). proper care of contact lenses. retrieved from american academy of ophthalmology: https://www.aao.org/eye-health/glassescontacts/contact-lens-care 15. efron n. soft lens care systems, philip b morgan, contact lens practice, china, elsevier, 2010, 128, 2nd edition. 16. bennett we, weissman ba. hydrogel lens solution chemistry, clinical contact lens practice, new york, lippincott williams & wilkins, cop. 2005, 425. 17. efron n. soft lens care systems, philip b morgan, contact lens practice, china, elsevier, 2010, 388, 2nd edition. 18. gonzález-méijome jm, parafita ma, yebra-pimentel e, almeida jb. symptoms in a population of contact lens and noncontact lens wearers under different environmental conditions. optom vis sci., april 2007; 84 (4): 296-302. 19. national research council (us) working group on contact lens use under adverse conditions. contact lens use under adverse conditions: applications in military aviation. washington (dc): national academies press (us); 1990. available from: https://www.ncbi.nlm.nih.gov/books/nbk234039/ do i: 10.17226/1706. 20. danielle m. robertson, and h. dwight cavanagh. non-compliance with contact lens wear and care practices: a comparative analysis. optom vis sci. 2011 dec; 88 (12): 1402–1408. https://www.ncbi.nlm.nih.gov/pubmed/?term=chung%20my%5bauthor%5d&cauthor=true&cauthor_uid=19474751 https://www.ncbi.nlm.nih.gov/pubmed/?term=tsui%20a%5bauthor%5d&cauthor=true&cauthor_uid=19474751 https://www.ncbi.nlm.nih.gov/pubmed/?term=weissman%20ba%5bauthor%5d&cauthor=true&cauthor_uid=19474751 https://www.ncbi.nlm.nih.gov/pubmed/8192099 https://www.aao.org/eye-health/glasses-contacts/contact-lens-care https://www.aao.org/eye-health/glasses-contacts/contact-lens-care microsoft word ammended news and events vol 28; janmar;2012 pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 54 news and events vol. 28, 1, 2012 15th congress of ophthalmology osp federal branch islamabad date: 04 – 06 may, 2012 venue: pc bhurban, murree contact: dr. waheed afzal email: ospislamabad@gmail.com 34th national congress of ophthalmological society of pakistan & 7th khyber eye symposium date: 28 – 30 september, 2012 venue: pearl continental hotel peshawar contact: dr. sanaullah jan phone: 091-5825087/0313-8584819 email: sanaullahjan@hotmail.com 32nd lahore ophthalmo 2012 date: 07 – 09 december, 2012 venue: pearl continental hotel, lahore contact: prof. mian muhammad shafique phone: 042-36363325 email: osplhr@gmail.com the association for research in vision and ophthalmology (arvo) annual meeting 2012 florida, usa date: 6 10 may, 2012 venue: fort lauderdale, florida, usa web: www.arvo.org european glaucoma society 10th congress date: 17 – 22 june, 2012 venue: copenhagen, denmark web: www.eugs.org xx biennial meeting of international society for eye research date: 22 – 27 july, 2012 venue: berlin, germany 8th international symposium of ophthalmology – hong kong (iso-hk) & 7th asia-pacific vitreoretina society (apvrs) congress date: 14 – 16 december, 2012 venue: hong kong convention & exhibition centre the 28th asia-pacific academy of ophthalmology (apao) congress date: 17 20 january, 2013 venue: hyderabad, india web: www.apaophth.org american society of cataract and refractive surgery (ascrs) / american society of ophthalmic administrators (asoa) symposium and congress date: 19 23 april, 2013 venue: san francisco 34th world ophthalmology congress (woc) & the 29th asia-pacific academy of ophthalmology (apao) congress date: 2 6 april, 2014 venue: tokyo, japan institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091 – 9217376 – 80 fax: 92 – 42 – 36363326 email: pico@pes.comsats.net.pk news and events 55 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology college of ophthalmology and allied vision sciences lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042 – 37355998 fax: 042 – 37248006 email: pipo@brain.net.pk pakistan institute of ophthalmology, al – shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al – shifa trust eye hospital, jhelum road, rawalpindi – pakistan phone: 92 – 51 – 5487830, 5487820 – 25 fax: 92 – 51 – 5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt 4-a lda flats lawrence road, lahore phone: 92 – 42 – 36363326 email: pjoosp@gmail.com microsoft word abstracts 49 abstracts edited by prof. tahir mahmood rapid detection of acanthamoeba cysts in frozen sections of corneal scrapings with fungiflora y shiraishi a; kobayashi t, hara y, yamaguchi m, uno t, ohashi y br j ophthalmol. 2009; 93: 1563-7. acanthamoeba keratitis (ak) is an intractable, sight – threatening infection of the cornea and is frequently seen in contact lens wearers. the incidence of ak has increased with increasing numbers of contact lens wearers. the problems with ak include the difficulty in making a correct diagnosis at an early stage, and the lack of specific drugs to treat ak. the early clinical signs of ak are subepithelial infiltrates, pseudodendritic keratitis and radial neurokeratitis and these lesions often lead to ak being misdiagnosed as herpetic keratitis and or fungal keratitis, resulting in delays in initiating proper treatment. in addition, the ability to grow and identify acandoamoeba in culture is between 30% and 60%, and it requires a relatively long time to obtain the results from cultures. acanthamoeba cysts can be detected in corneal scraping, impression cytology or biopsies by a variety of staining methods including special stains such as calcofluor white and acridine orange, and also by immunohistochemistry. routine stains such as haematoxylin and eosin (h&e), giemsa, gram, periodic acid schiff (fas), and lactophenol cotton blue can also provide a positive identification. however, some of the special stains are time – consuming and more complicated, and the routine stains require skilled and experienced examiners to identify the acanthamoeba cysts or trophozoites. fungiflora y (ffy) was originally developed to detect fungi; and it has a specific affinity for chitin and cellulose, which are components of the cell wall of fungi. however, it has been shown that ffy also stains acanthamoeba cysts because cysts also contain cellulose. we present a simple and quick method to detect acanthamoeba cysts in ffy stained frozen sections of corneal scrapings. the purpose of this study was to evaluate the usefulness of serial frozen sections of corneal scrapings stained with fungiflora y (ffy to diagnose acanthamoeba keratitis (ak). eight patients with suspected ak were studied. serial frozen sections were made from part of the corneal epithelial scrapings and stained with ffy. the remaining corneal epithelial scrapings were submitted for laboratory culture. the ffy stained frozen sections were completed within an hour and acanthamoeba cysts were detected under a fluorescence microscope in all eight patients. the same sections were examined with a light microscope, and acanthamoeba cysts were confirmed to be present from their morphological characteristics. five of the eight patients had positive laboratory cultures for acanthamoeba. authors concluded with the remarks that ffy staining of frozen sections of corneal scrapings is a rapid and reliable technique which can be used to make an early diagnosis of ak. one – year outcomes of a bilateral randomised prospective clinical trial comparing prk with mitomycin c and lasik wallau ad, campos m br j ophthalmol. 2009; 93: 1634-8. eximer laser photorefractive keratectomy (prk) with adjunctive mitomycin c (mmc; mmc – prk) has recently been used as an alternative to laser in situ keratomileusis (lasik) for surgical correction of refractive errors. although surface ablation usually has a slower visual recovery and more early postoperative discomfort, it avoids lasik flaps complications and possibly results in less corneal biomechanical instability. mitomycin c is an alkylating, agent that inhibits dma and rna replication and protein synthesis. it regulates fibroblast proliferation and differentiation. and subsequently blocks myofibroblast formation, 50 which is responsible for corneal haze after prk in high myopic corrections. recent studies have shown that low – dose mmc (0.002%) has a similar efficacy to standard mmc concentration (0.02%) in preventing postoperative myopia corrections, and also minimise potential side effects. there are not many papers in the literature comparing mmc – prk and lasik. randleman ae tl compared wave front – optimised prk with standard dose mmc and wave front – optoin lasik in 272 preoperative refraction matched eyes for moderate myopia corrections. they found a better uncorrected visual acuity (ucva) and spherical equivalent (se) in mmc – prk eyes 3 months after surgeries. the purpose of this study is to compane visual acuity (va) outcomes (including satisfaction questionnaire, aberrometry, contrast sensitivity) and corneal biomechanical properties 1 year after wave front – guided prk with 0.002% mmc and lasik for myopic corrections. as a continum of our early postoperative outcomes study, we are unaware of any randomised prospective study the literature comparing 1 – year results of prk with mmc and lasik consecutively performed in both eyes of the same patients at the same treatment sitting. the purpose of this study was to compare 1 – year follow-up results of photorefractive keratectomy (prk) with mitomycin c (mmc) and laser in situ keratomileusis (lasik) for custom correction of myopia. eighty – eight eyes of 44 patients with moderate myopia were randomised to prk with 0.002% mmc for 1 min to one eye and lasik in the fellow eye. the 1 – year follow-up was evaluated. there were no differences between lasik and mmc – prk eyes preoperatively. forty – two patients completed the 1 – year follow-up. mmc – prk eyes achieved better uncorrected visual acuity (p = 0.03) and better best – spectacle – corrected visual acuity (p<0.001) 1 year after surgery. se did not differ. in the two grpups during follow-up (p = 0.12). clinically significant haze was not found in surface ablation eyes. lasik eyes showed a greater higher – order aberration (p = 0.01) and lower contrast sensitivity (p<0.05) than mmc – prk eyes postoperatively. excellent vision was reported in 64% of lasik and 74% of mmc – prk eyes 1 year after surgery. the corneal resistance factor and corneal hysteresis) ora, reichert) were higher in lasik than in mmc – prk eyes (p<0.01) at the last follow-up. authors concluded with the remarks that wave front – guided prk with 0.002% mmc was more effective than wavefront – guided lasik for correction of moderate myopia. further research is necessary to determine the optimal concentration, exposure time and long – term corneal side effect of mmc. effect of nd : yag capsulotomy on the morphology of surviving elschnig pearls hirnschall n, neumayer t, georgopoulos m br j ophthalmol 2009; 93: 1643-7. improvements in intraocular lens (iol) design and surgical technique diminished pco (posterior capsule opacification, secondary cataract, after – cataract) rates, but pco is still the most frequent long – term side effect and the main reason for a decrease in visual acuity and loss of contrast sensitivity after cataract surgery. in recent studies highly dynamic morphological changes of elschnig pearls were observed over short periods of time. georgopoulos and co-authors observed a spontaneous regression of elschnig pearls after yac capsulotomy with disappearance of pearls on the remaining capsule in 45% of the cases in a long– term follow-up study. however, it remains unclear when and why the pearls outside the capsulotomy opening undergo these changes. capsulotomy could be used as a model of mechanical destruction by the shock wave on surrounding pearls. the aim of this study was to assess the morphological changes of elschnig pearls immediately after capsulotomy. this knowledge may lead to a better understanding of the pathogenesis of pco and so may help to develop new strategies for controlling pco. this is of special interest, since pco remains the main problem in lens refilling (phakoersatz) for restoration of accommodation. the purpose of this study was to observe the short – term changes in morphology of elschnig pearls induced by nd : yag capsulotmy. setting department of ophthalmology, medical university of vienna, austria. twenty eyes of 19 pseudophakic patients with regeneratory posterior capsule opacification (pco) that were scheduled for yag capsulotomy were included in this prospective study. high – resolution 51 digital retroillumination images were taken 2 weeks. 1 week and shortly before and immediately, 1 week and 2 weeks after nd : yag capsulotomy. the series of images were analysed using a dedicated image analysing software (pearl tracer). in total, 2431 elschnig pearls were observed over the time – course of 4 weeks in this study. of these, 535 pearls (30.6%) disappeared, and 503 pearls (27.6%) survived on the remaining capsule peripheral to the capsulotomy opening. the surviving pearls showed a significant decrease in size (20%) from immediately before to 10 min after capsulotomy. within the first weeks after capsulotomy, there was a high number of newly appearance pearls, with 26% of all pearls being new between 1 and 2 weeks indicating high pearl turnover. authors concluded with the remarsk that capsulotomy had an immediate impact on the morphology of pco outside the capsulotomy opening probably due to the direct mechanical impact of the laser shock wave. robotic microsurgery : corneal transplantation bourges jl, hubschman jp, burt b, culjat m, schwartz sd br j ophthalmol. 2009; 93: 1672-5. the d vinci system (intuitive surgical, sunnyvale, california) is a commercially available teleoperative surgical system currently used for minimally invasive surgery in numerous surgical fields such as urology, cardiology, gynaecology, and thoracic and abdominal surgery. in ocular surgery, robotic assistance or complete robotic surgical systems have several interesting potential advantages such as improved instrument dexterity, reduced tremor and decreased tissue damage. in other words, the potential for increased precision and efficiency exists. further, the ability to perform remote teleoperative procedures exists. dedicated experimental robots capable of delicate ocular micromanipulations such as the cannulation of retinal blood vessels have been reported. we have previously demonstrated that the da vinci system possesses the necessary dexterity for intraocular procedures. in our laboratory, tsirbas et al also successfully repaired corneal lacerations using the da vinci surgical system, taking a first step toward robotic anterior segment surgery. we aimed to further test the da vinci surgical system’s ability to perform a more delicate, time – consuming corneal surgical procedure. we therefore performed a penetrating keratoplasty (pk) procedure, which is a complex anterior segment surgery where delicate tissue manipulation and 360 suturing are required under excellent visualisation. we used porcine eyes first to test the feasibility of the procedure. we then tested the ability of da vinci surgical instruments to move freely in real human anatomical environment during the pk procedure. robotic ocular microsurgery including corneal suturing has been proven to be “feasible in porcine eyes”. the purpose of this study was to determine whether or not bimanual teleoperated robotic penetrating keratoplasty (pk) can be performed in porcine and human eyes. three arms of the da vinci surgical robot were loaded with a dual – channel video and two, 360 – rotating, 8 mm, wrested – end effector instruments and placed over porcine eyes or over a human cadaver head. the surgeon remotely performed mechanical trephination, cardinal sutures, continuous 10.0 nylon sutures and suture adjustments on both eyes. the procedures were documented with still and video photography. using the da vinci robot, penetrating keratoplasty procedures were successfully performed on both porcine eyes and human eyes in natural anatomical conditions. the precise placement of continuous sutures was facilitated by the wrested – end forceps. orbital rims and nose did not limit surgical motions. teleoperated robotic penetrating keratoplasty is technically feasible in humans. further studies are pending to implement the procedure with femtosecond laser and other automated steps. frequency of computer vision syndrome in compute users 108 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology original article frequency of computer vision syndrome in computer users erum shahid, tasneem burhany, waseem ahmed siddique, uzma fasih, arshad shaikh pak j ophthalmol 2017, vol. 33, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: erum shahid senior registrar, ophthalmology, abbasi shaheed hospital & kmdc emial: drerum007@yahoomail.com …..……………………….. purpose: to determinethe frequency of computer vision syndrome in computer users. study design: cross sectional descriptive study place and duration of study: departmentof ophthalmology, abbasishaheed hospital and department of community medicine, karachi medical and dental college from may 2015 to october 2015. material and methods: computer users who work on computers for 3 hours continuously per day or more, working for last 1 year or more, ages between 18 to 50 years were included by simple random sampling technique.nonconsented subjects, diagnosed with neurological problems, diagnosed eye diseases and using any topical eye drops were excluded. results: total of 150 subjects were recruited in which 120 (80%) were males and 30 (20%) females. their age range was between 18 to 50 years with mean age of 32.9 ± 10.3. computer vision syndrome was present in 75% of them. headache was the most common symptom. conclusion: computer vision syndrome is common in computer users of our community. thesesymptoms can be avoided and relieved by simple modifications during computer use. key words: computer vision syndrome, computer users, headache, eye strain. 109 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology n this age of modern technology, the influence of computers on human lives cannot be denied. we are in twenty-first century and computers are used globally as the humble pen and paper in many people’s everyday life. the number of computers is increasing all the time. it has been assessed that there are nearly six computers per thousand populations with an installation of 18 million personal computers (pcs)1. computer is a vital tool in every aspect of life. although these advances are good task performers but they also affect health in terms of stress, postures, health performance and productivity2. an american optometric association has definedcomputer vision syndrome (cvs) as a complex of eye and vision problems associated with the activities thatstrain the near vision. it is experienced in relation to or while using the computers for longer durations3.digital electronic screens have become portable and can be used in any location. it is no longer limited to desktop computers in the workstations. currently visual necessities include not only viewing laptops and tablet computers but also other electronic gadgets like electronic book readers, note books and smartphones.furthermoreits use is not restricted to adults only4. visual symptoms like eye strain, headaches, ocular discomfort, diplopia, burning sensation and blurred vision are experienced by 90% of computer workers either when looking at near or into the distance after continued and extended computer use5.this happens even if duration of use is more than 3 hours6. symptoms of computer vision syndrome occur in approximately 75% to 90% of computer usersbutonly 22% of computer workers report musculoskeletal disorders7. it has been referred by some optometrist as a possible occupational epidemic of the 211st century8. in our country little work has been done on this subject and most of the work is published in nonmedical journals with their focus on ergonomics of work places. this study will be an initiative to create awareness among doctors and support future prevention of computer vision syndrome to help computer workers. materials and methods this study was conducted in the department of ophthalmology, abbasishaheed hospital, karachiand department of community medicine, karachi medical and dentalcollege (kmdc). it was aprospectiveand a cross sectional descriptive study which was started in may 2015 and completed in october 2015. it was started after approval from the ethics research committee of kmdc. sample size calculatedwere 1329 with help of who software with 5% margin of error, 95% confidence interval. we recruited 150 cases to avoid type 2 error. sampling technique was simple random sampling. we included computer users who work on computers for a minimum of 3 hours continuously per day or more, working on computers for last 1 year or more, ages between 18 to 50 years. we excluded those who werenon consented, diagnosed with neurological problems, diagnosed eye diseases and using any topical eye drops. data was collected by the data collectors on a selfadministered questionnaire in english language. these subjects were college students and employees of multinational companies, banks based on inclusion and exclusion criteria with their consent.incompletequestionnaires were not entertained. they were assured about the confidentiality and anonymity of the information attained in the proforma. it included their demographic details along with history of any visual problems related to prolong use of computers. data was analyzed on statistical package for social sciences [spss] version 21. descriptive statistics was used to calculate mean and standard deviation. frequencies were calculated of various symptoms along with the percentages. results in this study we had 120 (80%) males and 30 (20%) femalesout of a total of 150 computer users. their age ranged between 18 to 50 years with mean age of 32.9 ± 10.3. frequencies of their demographics are shown in table 1 like occupation, level of education, marital status, addiction, spectacles, contact lens, duration of table 1: demographics of subjects. variables no. % mean age min max 32.9± 10.3 18 50 gender males females 120 30 80 % 20 % occupation student service/employee 32 118 21% 79% i erum shahid, et al 110 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology marital status married unmarried 89 61 59.3 % 40.7 % level of education secondary graduates postgraduates 23 72 55 15 % 48 % 37 % addiction smokers nonsmokers 25 125 17% 83% spectacles yes no 82 67 55% 45% contact lenses yes no 10 140 7% 93% exercise yes no 40 110 27 % 73% working stress yes no 98 52 65% 35% duration of sleep less than 8 hrs more than 8 hrs 112 38 75% 25% hypertension yes no 28 121 19% 81% duration of computer use 3-4 hrs 4-6 hrs >6 hrs 28 34 88 19% 22% 59% cvs 113 75% sleep and duration of computer use etc. with their percentages. frequency of computer vision syndrome (cvs) calculated was 75%. table 2 shows frequencies of various symptoms like headache, tired eyes, watering of eyes, redness of eyes, blurred vision, and neck pain in subjects suffering from computer vision syndrome. most common symptom was headache i.e. in 69 (46%) of subjects, it was followed by tired eyes in 67 (45%) of the subjects. least common symptom was watering of eyes (23%). table 2: frequencies of cvs symptoms. symptoms no. % headache 69 46% tired eyes 67 45% neck pain 62 41% burning eyes 43 29% blurring vision 36 24% watering eyes 35 23% discussion in our study we had total of 150 respondents who filled the questionnaire. majority of the respondents were males (80%), since the data was randomly collected from different offices and colleges. in offices of thismetropolitancitymost of the workers are still males due to cultural trends of our society. toama et al., in their study stated that the percentage of females with cvs was more as compared to males10.since we have few females our data does not support positive association of cvs with female gender. in our study office workers were 79% and remaining 21% were students. mean ages of the subjects was 32.9 ±10.3 due to less number of students. our study reported computer vision syndrome to be 75%. another study conducted in islamabad reported cvs in only 25% of office workers and students 9. increase in frequency of cvs in our study could be due to more office workers than students and with increase in mean age of subjects.one of the study conducted in malaysia revealed cvs to be 63%11but another study12from nepal revealed cvs in 89.9%. the former one included office workers but the latter one included children less than 10 years of age with large sample size.prevalence of cvs was 69.3% in university students of chennai13 and 75% reported by madhan14. the incidence of cvs vary from place to place but the point on which every study agrees isthat longer a person works with the computer, the more visual discomfort complaints he experiences9-14. asthenopic symptoms noted by sheedy et al5comprised of eye strain,tiredness of eyes, discomfort, burning, irritation, pain, aching, soreness of eyes, diplopia, photophobia, blurring, itching, watering, drynessand foreign body sensation.however they can be broadly divided into two groups15. first group called external symptoms are related to dry eyes and they consist of irritation, burning, watering and dryness of eyes. the second group termed internal symptoms are due to refractive, frequency of computer vision syndrome in computer users pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 111 vergence and accommodative anomalies. it comprised of eye strain, eye ache, headache, diplopia and blurring of vision. asthenopic symptoms were common in our subjects which were tired eyes (45%), burning (29%) and watering (23%) sen et al16 documented 87% with eye fatigue, 55% of subjects with burning sensation and 46% with redness in their eyes11. talwar et al reported redness 40% cases17. causative factors responsible are decrease rate of blinking, environmental causes like use of air conditioners, heating, low humidity, exposure of cornea due to high degree of gaze while viewing desktop monitor, advancing age and in females8. there is a progressive decrease in mean blink rate from 22 per min in relaxed state to 10 per min when reading a book and 7 per min on the video display terminal18. a person experiencing blurred visionat near or looking far away afterextendedwork at computer is most frequent symptom related to cvs. this is due to an impreciseaccommodative response while working at computers or an inability to relax accommodation entirely following the near-vision strain. symptoms of the patients are commonly related to near vision activities and inappropriate accommodative responses. under or over accommodation in relation to the viewing objectarebasis of asthenopia19. our 24% of the subjects complained of blurred vision, 46% had headache and 41% had neck pain.talwar et al reported blurred vision in 13.2% and headache in 46% usersin his study. additional factors responsible are dimly illuminated surroundings, glare on the computer display, inappropriate viewing distances from the screen, bad postures, uncorrected or over corrected refractive errorsand a combinationof these reasons20. cvs can be managed adequately with help of anophthalmologist and modifications in work place environment21,22. correction of refractive error and dry eye can be easily managed by a visit to an ophthalmologist. frequently blinking is advised. proper lightening at work place and proper positioning of monitor,seating posture should be taken care of.there should be breaks for rest which is20/20/20 rule.it states that after every 20 minutes of viewing at computer screen, one should redirect gaze far away at a distance of 20 feet and keep directed for 20 seconds for eyes to refocus. another recommendation by the american optometric association is interruption of 15 minutes after every 2 hours of continues computer work. fortunately computer use doesn’t cause any permanent damage but temporary discomfort reduces the efficiency of work and thereby productivity23. limitation of the study is its sample size. additional information could have been retrieved if equal number of males, females and students, office workers were considered. other studies should be carried out regarding ocular examinations of people suffering from computer vision syndrome. conclusion we concluded from our studythat computer vision syndrome is quite common in computer users of our community. we need to create awareness among doctors and computer users about it. these symptoms can be avoided and relieved by simple modifications during computer use. author’s affiliation dr. erum shahid senior registrar, ophthalmology abbasi shaheed hospital & kmdc dr. tasneem burhany assistant professor, community medicine karachi medical and dental college dr. waseem ahmed siddique assistant professor, community medicine karachi medical and dental college dr. uzma fasih associate professor, ophthalmology abbasi shaheed hospital & kmdc dr. arshad shaikh head of the department, ophthalmology abbasi shaheed hospital & kmdc role of authors dr erum shahid concept, data collection, data analysis, interpretation, manuscript writing, critical review dr tasneem burhany concept, data collection, drafting, critical review dr waseem ahmed siddique concept, data collection, critical review dr uzma fasih concept, critical review dr arshad shaikh concept, critical review erum shahid, et al 112 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology refrences 1. sharma 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vision syndrome: a review. surv ophthalmol. 2005; 50 (3): 253-62. 9. ellahia a, khalilb ms, akram f. computer users at risk: health disorders associated with prolonged computer use. e. j. bus. manage. econ. 2011; 2 (4): 171182. 10. toama z, mohamed aa, hussein na.impact of a guideline application on the prevention of occupational overuse syndrome for computer users. j am sc. 2012; 8: 265–82. 11. huda z, mohdissa m.effect of human and technology interaction: computer vision syndrome among administrative staff in a public university.international journal of business, humanities and technology, 2014: 4 (3). 12. reddy sc, low ck, lim yp, low ll,mardina f, nursaleha mp. computer vision syndrome: a study of knowledge and practices in university students. nepal j ophthalmol. 2013; 5 (10): 161-168. 13. arumugam s, kumar k, subramani r, kumar s. prevalence of computer vision syndrome among information technology professionals working in chennai. world journal of medical sciences, 2014; 11 (3): 312-314. 14. madhan mr. computer vision syndrome. the nursing journal of india, 2009; 10: 236–237. 15. stella ci, allen ea, olajire ba. evaluation of visionrelated problems amongst computer users: a case study of university of benin, nigeria. proceedings of the world congress on engineering, 2007; 1: 2–4. 16. sen a, richardson s. a study of computer-related upper limb discomfort and computer vision syndrome. j hum ergol. 2007; 36: 45–50. 17. talwar r, kapoor r, puri k, bansal k, singh s. a study of visual and musculoskeletal health disorders among computer professionals in ncr delhi. indian j community med. 2009; 34: 326–8. 18. tsubota k, nakamori k. dry eyes and vdts. n engl j med. 1993; 328: 584-5. 19. birnbaum mh.optometric management of nearpoint vision disorders. butterworth-heinemann: boston, 1993; 121–160. 20. khalajm,ebrahimi m, shojai s, bagherzadeh r, sadeghi t , ghalenoei m. computer vision syndrome in eleven to eighteen-year-old students in qazvin. biotech health sci. 2015; 2 (3). 21. wimalasundera s. computer vision syndrome.galle medical journal, 2006: 11 (1). 22. barthakur r. computer vision syndrome.internet journal of medical update, 2013; 8 (2): 1-2. 23. logaraj m, madhupriya v, hegde sk. computer vision syndrome and associated factors among medical and engineering students in chennai. ann med health sci res. 2014; 4 (2): 179–185. https://www.ncbi.nlm.nih.gov/pubmed/?term=mitra%20s%5bauthor%5d&cauthor=true&cauthor_uid=15850814 https://www.ncbi.nlm.nih.gov/pubmed/?term=yee%20rw%5bauthor%5d&cauthor=true&cauthor_uid=15850814 microsoft word news and evants 27,2,2011 118 news and events vol. 27, 2, 2011 31st lahore ophthalmo date: 16 – 18 december, 2011 venue: lahore international expo centre secretary: dr. zahid kamal siddiqui secretariat: osp house 4 – a lda flats, lawrence road, lahore. phone: 92 – 42 – 36363325 fax: 92 – 42 – 36363326 email: osplhr@gmail.com xvix congress of the european society of cataract and refractive surgeons (escrs) date: 17 – 20 september, 2011 venue: vienna, australia annual meeting of american academy of ophthalmology (aao) date: 22 – 25 october, 2011 venue: orlando, usa 33rd world ophthalmology congress (woc) date: 16 – 20 february, 2012 venue: abu dhabi, united arab emirates the 27th apao congress busan, korea. date: 13 17 april, 2012 american society of cataract and refractive surgery (ascrs) / american society of ophthalmic administrators (asoa) symposium and congress date: 20-24 april, 2012 venue: chicago, il the association for research in vision and ophthalmology (arvo) annual meeting 2012 florida, usa date: 610 may, 2012 venue: fort lauderdale, fla institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091 – 9217376 – 80 fax: 92 – 42 – 6363326 email: pico@pes.comsats.net.pk punjab institute of preventive ophthalmology, lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042 – 37355998 fax: 042 – 37248006 email: pipo@brain.net.pk pakistan institute of ophthalmology, al – shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al – shifa trust eye hospital, jhelum road, rawalpindi – pakistan phone: 92 – 51 – 5487830, 5487820 – 25 fax: 92 – 51 – 5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt department of ophthalmology fatima jinnah medical college sir ganga ram hospital, lahore fax: 92 – 42 – 6363326 email: hamidbut@gmail.com mobile: 0300 – 4158962 161 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology original article early presbyopia a psychosomatic disorder uzma fasih, m. rais, atiya rahman, arshad shaikh, m. s. fahmi pak j ophthalmol 2014, vol. 30 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: uzma fasih b 21 block 10 federal b area karachi …..……………………….. purpose: to evaluate the frequency of factors associated with early presbyopia among patients presenting in the outpatient department. material and methods: the study was carried out in outpatient department of spencer eye hospital unit 2 karachi medical & dental college from january 2012 to august 2013. patients were selected from the opd through non probability consecutive sampling technique and included 246 patients. sample size was calculated by who formula given by l lamesho and sk lawanga. patients below 40 years were included in the study who presented with complaint of decreased near vision. majority of them were those who complained of inability to see the font of cell phone. patients having ocular pathologies that could affect the clarity of medias like corneal opacities, cataract, uveitis, vitritis and retinal detachment were excluded from the study. a detailed history of the patients was taken regarding any disorder, tobacco use, any refractive error, glaucoma and occupation, base line investigations as blood complete picture, urine detailed reporting, random and fasting blood suger were also done as and when required. patients were examined thoroughly in the opd and were refracted and appropriate glasses prescribed. data analysis was done on spss version 14. results: there were 40% male patients and 60% female patients with mean age of patients 35.6 ± 4.01 years. tobacco chewers who presented with early presbyopia were 88 (35.7%). fifty two (21.1%) patients had gastritis and 18 (7.31%) had hypertention. sixteen (6.50%) patients were diabetic. ten (4.06%) had both diabetes and hypertention. computer operators with early presbyopia were 5 (6.09%). presentation of patients with refractive errors was 14 (5.69%). less prevalent factors associated with early presbyopia were smoking 7 (2.85%) patients, glaucoma 5 (2.03%), anaemia 5 (2.03%), thyroid disease 4 (1.6%), history of use of hair dyes 4 (1.6%), osteoarthritis 2 (0.81%) and allergic disorders 2 (0.81%). patients who presented with no specific cause were 4 (1.62%). conclusion: early presbyopia is not uncommon in a society with associated psychosomatic disorders due to stressful social, environmental and financial conditions. people are anxious and they have habit of nicotine and tobacco abuse. associated gastritis, hypertension and headache are further indicators of early presbyopia being a psychosomatic disorder. key words: presbyopia, psychosomatic disorder, refractive errors. he amplitude of accommodation decreases steadily with the age. this occurs mainly due to sclerosis of the lens fibres and changes in the lens capsule which reduces the spontaneous steepening of lens surface when cilliary muscle contract. also the cilliary muscle itself may become t early presbyopia a psychosomatic disorder pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 162 less efficient with advancing age i.e. after 40 years. the eye is capable of 14 d (dioptres) accommodation in infancy which declines to 4 d by the age of 45 years and 1 d by the age of 60 years1. to focus at a reading object at 25 cm eye must accommodate by 4 d keeping one third of the available accommodation in reserve. a person will begin to experience difficulty for near vision at 25 cm when his accommodation decays to 6 d which usually occurs between the age of 40 and 45 years. this discomfort for near vision is experienced due to reduced amplitude of accommodation and the person is said to be presbyopic and is prescribed convex lenses to aid the near vision which is called presbyopic correction and this age related inadequacy of accommodation is called presbyopia1. presbyopia literally means old eye. it is most common ocular affliction in the world and no individual appears exempt, although high myopes who remove their spectacles may have their far point close enough to the eye to function satisfactorily2. in premature presbyopia, accommodative ability becomes insufficient for the patient's usual near vision tasks at an earlier age than expected, due to environmental, nutritional, disease related, or drug-induced causes.3,4 although age is the major risk factor for development of presbyopia, but the condition may occur prematurely as the result of factors such as trauma, systemic disease, cardiovascular disease, or a drug side effect5. there is earlier onset of presbyopia in females due to short stature, or menopause6. persons involved in occupations with near vision demands may also develop premature presbyopia7. hypermetropia where there is additional accommodative demand (if uncorrected) also leads to early presbyopia8. ocular disease or trauma, removal or damage to lens, zonules, or ciliary muscle, laser photocoagulation of retina systemic disease like diabetes mellitus where changes in lens leads to change in refractive state of the eye, multiple sclerosis associated with impaired innervations, cardio vascular accidents leading to impaired accommodative innervations, vascular insufficiency, myasthenia may all lead to early onset of presbyopia7. decreased accommodation is a side effect of both non prescription of appropriate spectacles and drugs such as chlorpromazine, hydrochlorothiazide, anti anxiety agents, anti depressants, antipsychotics, antispasmodics, anti histamines and diuretics. alcohol intake is also reported to be associated with early presbyopia7. geographic factors as proximity to the equator (higher average ambient temperatures, greater exposure to ultraviolet radiation) have also been reported to be a cause of early presbyopia9. material and methods patients were selected from outpatient department through non probability consecutive sampling technique and included 246 patients. it was a hospital based descriptive cross sectional study. sample size was calculated by who formula given by l lemesho and sk lawanga10 keeping confidence interval 95%, absolute precision 0.03%, population size 1000 and prevalence p 35.1% (tobbacco users with early presbyopia).11 patients with complains of decreased near vision (n/12-n10 on near vision chart) were included in the study. majority of them were those who complained of inability to see the font of cell phone and cell phone cards. majority of the patients were emmetrope. patients having ocular pathologies that could affect the clarity of medias like corneal opacities cataract, uveitis, vitritis and retinal detachment were excluded from the study. a detailed history of the patients was taken regarding their occupation tobacco use, any refractive error and glaucoma. in addition to ocular history, history regarding hypertension, diabetes mellitus gastritis and heart burn was also taken. blood cp, urine d/r, random and fasting blood sugar were also done as and when required. patients were examined thoroughly in the opd slit lamp examination applanation tonometery and direct and indirect fundoscopy and tonometery was done as and when required. patients were refracted and appropriate glasses prescribed. data was recorded and analyzed on spss programme version 14. 0 50 100 150 31-33 34-36 37-39 age in years no: of patients between 31 – 33 years = 45 (18.29%) no: of patients between 34 – 36 years = 126 (51.21% no: of patients between 37 – 39 years = 75 (30.48%) fig. 1: age distribution n o . o f p a ti e n ts uzma fasih, et al 163 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology results our study included 246 patients over a period of 1.8 years. female patients were 60% (148 and male patients were 40% (98). mean age of the patients was 35.6 ± 4.01 years. tobacco users who presented with early presbyopia were 88 (35.7%). 18 (7.31%). 16 (6.50%) patients were diabetic among the early presbyops. 10 (4.06%) had both diabetes and hypertention. computer operators with early presbyopia were 15 (6.09%). presentation of patients with refractive errors as 14 (5.69%). here 12 patients had hypermetropia and 2 patients had hypermetropic astigmatism. less prevalent factors associated with early presbyopia were smoking 7 (2.85%) patients, glaucoma 5 (2.03%), anaemia 5 (2.03%), thyroid disease 4 (1.6%), history of use of hair dyes 4 (1.6%), osteoarthritis 2 (0.81%) and allergic disorders 2 (0.81%). patients who presented with no specific cause were 4 (1.62%) (table 1). discussion although age is the major risk factor for development of presbyopia, but the condition may occur prematurely i.e. before 40 years of age the prevalence of presbyopia is higher in societies in which large proportions of the population survive into old age. because presbyopia is age related, its prevalence is directly related to theproportion of older persons in the population. although it is difficult to estimate the incidence of aged 42 to 44 years1. early diagnosis and intervention in systemic diseases identified in the process of caring for the presbyopic patient has public health ramifications. unmanaged presbyopia can result in significant visual disability, depending on factors such as the individual patient's amplitude of accommodation, refractive error, and nature of the near vision tasks. given the variety of spectacle and contact lens management options available, most patients do not experience significant disability due to presbyopia. our study reported a female preponderance as there were 60% female patients and 40% male patients but o bernice and et al reported that males had higher degrees of early presbyopic errors than females which is contrary to our study.14 our study had a female preponderance perhaps due to the fact that females bear more stresses in our society as compared to males including multiparity which was commonly reported in our study, child raising, anaemia and other household stresses. weale ra has also reported a female preponderance in his study16. our study reported that major factorassociated with early presbyopia was tobacco use 88 (35.7%) patients more common among male patients, followed by gastritis 52 (21.1%) patients more common among female patients. a population – based assessment of presbyopia was conducted in the state of andhra pradesh, south india known as ‘the andhra pradesh eye disease study'. according to this study 35.1% of subjects aged 35 years had presbyopia and they were tobacco users. these findings are quite close to our study12. tobacco use and gastritis are usually associated with stressful living conditions so early presbyopia could be a psychosomatic disorder. it should be kept in mind that spencer eye hospital is located in an old town lyariand illiteracy, ignorance and poverty prevails here. people usually live a stressful life style; they are addicted and habituated to different forms of tobacco. however no association between early presbyopia and gastritis has been reported in literature previously. among the early presbyopes 18 (7.31%) patients had associated hypertension and 16 (6.50%) patients had diabetes. those who presented with diabetes and hypertension both were 10 (4.06%). the medical history is important early presbyopia a psychosomatic disorder pakistan journal of ophthalmology vol. 30, no. 3, jul – sep, 2014 164 in the diagnosis of premature presbyopia, particularly diabetes mellitus (lens, refractive effects); multi plesclerosis (impaired innervation); cardiovascular accidents (impaired accommodative innervation) vascular insufficiency; myasthenia gravis anemia; influenza; measles5,7. in our study commonly found medical problems were diabetes mellitus, hypertension and anaemia. early presbyopes who presented with associated headache and refractive errors were 14 (5.69%) and with glaucoma were 5 (2.03%). jain and et al and pointer have reported that in hypermetropia where there is additional accommodative demand (if uncorrected) also leads to early presbyopia. here latent hypermetropia should be considered as important feature. in addition ocular disease as glaucoma or trauma, removal or damage to lens, zonules, or ciliary muscle, laser photocoagulation of retina may also lead to early presbyopia.7,8,13,16 in our study 4 (1.62%) patients has early presbyopia associated with the use of hair dye. jain and et al reported in their study that 35.75% patients entered presbyopia at or before the age of 38 years. environmental conditions including high average temperature, much ultraviolet radiation, chronic deficiency of essential amino acids, and exposure to toxic factors, particularly hair dye, may play a significant role in precipitating the early onset of presbyopia7. our study reported 15 (6.09%) computer operators had early prebyopia. computer operators are usually engaged in prolong near work. a hospital based prospective study conducted in nigeria revealed that 15.5% of the patients had presbyopia before age 40 years and majority of them were engaged in prolong near work. thus increased visual tasks are a major contributory factor towards onset of presbyopia before 35 years of age14-16; although age is a major risk factor for the development of presbyopia. several studies have reported that presbyopia occurs earlier among people who are exposed to high ambient temperature and ultraviolet radiation9. this phenomenon could have been implicated in our study as quite a number of patients presented from coastal areas of makran and balochistan where temperatures are at extremes during summers and exposure to ultraviolet radiations is more near coastal areas. our study reported 5 (2.03%) patients with anaemia. anaemia and poor nutritional status are also associated with early onset of presbyopia. gary l has also reported an association between poor nutrition and early onset of prebyopia15. less prevalent factors associated with early presbyopia were smoking 7 (2.84%) patients. glaucoma 5 (2.03%), anaemia 5 (2.03%), thyroid disease 4 (1.6%), hair dyes 4 (1.6%), osteoarthritis 2 (0.81%) and allergic disorders 2 (0.81%). patients who presented with no specific cause were 4(1.62%). conclusion early presbyopia is not uncommon in a society with associated psychosomatic disorder. people have habit of nicotine and tobacco abuse. associated gastritis, hypertension and headache are further indicators of early presbyopia being a psychosomatic disorder. although other factors like systemic diseases, nutritional deficiencies and environmental factors also cause early onset of presbyopia to some extent. n.b this study was conducted in a hospital located in an area with low socioeconomic strata perhaps the findings may differ depending on the locality. author’s affiliation dr. uzma fasih associate professor eye dept. (unit 2) karachi medical and dental college abbasi shaheed hospital, karachi spencer eye hospital, karachi dr. m. rais senior registrar eye dept. (unit 2) karachi medical and dental college abbasi shaheed hospital, karachi spencer eye hospital, karachi dr. atiya rahman assistant professor eye dept. (unit 2) karachi medical and dental college abbasi shaheed hospital, karachi spencer eye hospital, karachi dr. arshad shaikh professor and head of eye department eye dept. karachi medical and dental college spencer eye hospital, (unit 2) karachi medical and dental college, abbasi shaheed hospital, karachi dr. m. s. fahmi professor and incharge spencer eye hospital (unit 2) karachi medical and dental college, karachi uzma fasih, et al 165 vol. 30, no. 3, jul – sep, 2014 pakistan journal of ophthalmology references 1. helena j frank, michael j. greaney presbyopia in clinical optics andrew r. elkington, 3rd ed 141. 2. glasser a, kaufman pl. accommodation and presbyopia. in: kaufman pl, albert a. adler's physiology of the eye, clinical application, 10th ed. st. louis: cv mosby, 2003: 214-5. 3. patorgis cj. presbyopia. in: amos jf, ed. diagnosis and management in vision care. boston: butterworths, 1987: 203-38. 4. kleinstein rn. epidemiology of presbyopia. in: stark l, obrecht g, eds. presbyopia: recent research and reviews from the third international symposium. new york: professional press books, 1987: 12-8. 5. sardi b. nutrition and the eyes, vol. 1. montclair, ca: health spectrum, 1994: 59-65. 6. pointer js. the presbyopic add. ii. age-related trend and gender difference. ophthalmic physiol opt. 1995; 15: 241-8. 7. jain is, ram j, buptaa. early onset of presbyopia. am j optom physiol opt. 1982; 59: 1002-4. 8. pointer js. the presbyopic add. iii. influence of the distance refractive type. ophthalmic physiol opt. 1995; 15: 249-53. 9. miranda mn. the geographical factor in the onset of presbyopia. trans am ophthalmol soc.1979; 77: 603-21. 10. lwanga sk, lemeshow s. sample size determination in health studies: a practical manual. geneva: world health 1991. 11. nirmalank p, krishnaiah s, shamanna rb, rao n g, thomas r. a population-based assessment of presbyopia in the state of andhra pradesh, south india: the andhra pradesh eye disease study invest. ophthalmol. vis. sci. 2006; 47: 623242328. 12. susan as. lawrence ms. progress in retinal and eye research. elsvier. 2005; 24: 379-9 13. werner dl, press jl. clinical pearls in refractive are boston: butter worth heinemann. 2002: 140. 14. bernice o, soetan o. emmanuel risk factors for early presbyopia in nigerians nigerian journal of surgical sciences. 2006; 16: 7-11. 15. gary l. care of the patient with presbyopia. optometric clinical practice guidelines. 2006; 1:3-5. 16. wealera. epidemiology of refractive errors and presbyopia. surv ophthalmol. 2003; 48: 515-43. http://www.iovs.org/search?author1=sannapaneni+krishnaiah&sortspec=date&submit=submit http://www.iovs.org/search?author1=bindiganavale+r.+shamanna&sortspec=date&submit=submit http://www.iovs.org/search?author1=gullapalli+n.+rao&sortspec=date&submit=submit http://www.iovs.org/search?author1=ravi+thomas&sortspec=date&submit=submit http://www.ncbi.nlm.nih.gov/pubmed/?term=weale+ra.+epidemiology+of+refractive+errors+and+presbyopia.+surv+ophthalm%3a+515-543. http://www.ncbi.nlm.nih.gov/pubmed/?term=weale+ra.+epidemiology+of+refractive+errors+and+presbyopia.+surv+ophthalm%3a+515-543. microsoft word mazarul hassan 122 original article randomised controlled trial to evaluate the effects of intravitreal bevacizumab administration on visual outcome in diabetic patients with diabetic macular edema who underwent cataract surgery mazhar ul hassan, p.s mahar, aziz ur rehman, nasir bhattt, asfandyar asgahr, ashraf daud pak j ophthalmol 2010, vol. 26 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mazhar ul hasan isra postgraduate institute of ophthalmology al-ibrahim eye hospital malir, karachi received for publication september 2009 …..……………………….. purpose: to evaluate the efficacy of a single intravitreal bevacizumab injection either immediately after cataract surgery or during cataract surgery for the management of postoperative decrease of vision in patients with dme. material and methods: randomized, controlled, open-label, parallel group study of 60 eyes of 60 patients, having diabetic macular edema and lens opacity (of more than grade 3). the primary end-point was change in bcva at 6 weeks compared with that at baseline using the snellens acuity testing charts. results: the mean changes in bcva at 6 weeks compared with that at baseline were a worsening of visual acuity in the control group (no injection) and an improvement of visual acuity in the bevacizumab group (p = 0.01). conclusions: intravitreal bevacizumab after cataract surgery appears to be beneficial in preventing postsurgical visual loss in eyes with diabetic retinopathy by reducing the chance of macular thickening. any studies have revealed that visual outcome following cataract surgery in diabetic patients depends primarily on the status of macular edema1,2 or macular ischemia due to diabetes). previous reports have described many diabetic patients who developed severe maculopathy, following cataract surgery3. since it is important to be able to predict long-term visual effects before cataract surgery is performed, surgeons need to have a better understanding of the natural course of diabetic macular edema in addition to diabetic retinopathy (dr) after cataract surgery. diabetic macular edema has been shown to worsen after cataract surgery,4-6 although controversy remains as to the incidence of this worsening7,8. it has also been suggested that macular edema tends to show actual worsening in eyes afflicted with dr at the time of cataract surgery9. distinguishing transient edema from substantial progression of maculopathy is important to the timing of treatment for the macular edema, including laser photocoagulation,10 vitrectomy,11 and triamcinolone injection12-14. h owever, until recently, there had been no quantitative study to examine the progression of diabetic macular edema after cataract surgery. a recent study described by kim et al15 showed a short-term increase of macular thickness after cataract surgery. it has been suggested that 22% of diabetic patients develop increases in central retinal thickness after uncomplicated phaco-emulsification. the presence of csme is a strong risk factor for subsequent macular thickening after surgery15. even if the visual prognosis is improved by cataract surgery, macula edema remains a major risk factor for postoperative visual disturbance in diabetic patients. m 123 treatment to lessen the risk of postoperative macular thickening in individuals with diabetes, laser photocoagulation remains the standard approach16. however, it is sometimes difficult to obtain the sufficient efficacy of laser treatment in the cases with dense cataract. several other trials using intravitreal or sub-tenon’s triamcinolone acetonide17 and pars plana vitrectomy11 have been conducted, but no widely accepted technique has yet been established. vascular endothelial growth factor (vegf), is considered a key player in the progress of abnormal angiogenesis including dme18. hypoxia induces vegf gene transcription, and elevated levels of vegf have been found in ocular fluid of patients with dme19. bevacizumab is a humanized monoclonal antibody that inhibits all isoforms of vegf20. it has been reported that intravitreal injection of bevacizumab yields promising results in various neovascular eye diseases, including age-related macular degeneration,21 central retinal vein occlusion,22 and dme23. similar study was carried out by lanzagorta et al24 who have shown improvement in the vision and decrease in the retinal thickening in the bevacizumab group compared to control group. material and methods study design this trial was a randomized, controlled, open-label, parallel group study. patients were recruited from the al ibraheem eye hospital between july 2008 and july 2009. the trial was conducted in conformance with the tenets of the declaration of helsinki. approval was obtained from the ethics committee at the al ibraheem eye hospital, karachi and each patient provided signed informed consent before study entry. subject selection patients 20 years or older of either gender with type 1 or type 2 diabetes were eligible. all patients in the study underwent a complete ophthalmic examination, including best-corrected visual acuity (bcva), slitlamp biomicroscopy, funduscopy, applanation tonometry and fluorescein angiography (not more than a week old, other wise it was repeated) before recruitment, (because of the unavailability of optical coherence tomography in our institute we were unable to perform this test on all patients, only on few patients who were able to go to other centers for this test were performed); 60 patients with dme, who had significant lens opacity (more than grade 3 for any type of cataract: cortical, nuclear, or posterior sub capsular) by the lens opacities classification system iii were recruited for the study25. other inclusion criteria were that dme had occurred 3 to 18 months earlier, macular edema involved the fovea, and best corrected visual acuity (bcva) was 20/40 or worse. exclusion criteria were a history of ocular surgery, inflammation and poor diabetic control, the presence of other ocular diseases, and intra-operative complications such as posterior capsule rupture and severe iris damage. eyes with proliferative diabetic retinopathy, mixed maculopathy (ischemic and exudative) and also patients having dme due to epiretinal membrane or taut posterior hyaloid were also excluded. no patients had undergone photocoagulation of the treated eye within the previous 12 months, and none did so during follow-up. there was no previous intravitreal injection, including any vegf inhibitors or steroid. randomization and masking eyes were allocated to one of two groups (bevacizumab or control). neither subjects nor investigators were masked, but those who tested visual acuity, optometrists and statistical analyzers were masked as to treatment assignment of the eyes. study treatment the operative techniques included complete continuous curvilinear capsulorhexis and phacoemulsification through a 3.5-mm corneoscleral incision with intracapsular implantation of a foldable acrylic intraocular lens followed by a single intravitreal injection of bevacizumab. bevacizumab was prepared by the institutional pharmacy as sterile filled and packed tuberculin syringes containing 0.05 ml (1.25 mg) bevacizumab, which was injected intra-vitrealy using a 30-gauge needle. postoperatively, all patients received similar routine medication, including topical application of diclofenac sodium, an antibacterial agent, and 0.1% prednisolone 3 times daily for 3 months after surgery. eyes in the control group received no injections. outcome measurements and follow-up the primary end-point of the trial was a change in bcva at 6 weeks follow-up, compared with that at baseline. bcva was assessed by snellen visual acuity chart. similarly, resolution in macular edema in fluorescein angiography compared to baseline. 124 patients were evaluated at baseline and at 1, 3 and 6 weeks. bcva, intraocular pressure (iop), slit-lamp assessment and indirect ophthalmoscopic examination performed at each visit; fluorescein angiography was performed at baseline and 6 weeks follow-up. sample size 30 eyes (assuming a few dropouts) in each group were required to achieve a power of 80% based on an unpaired student t test with a two-sided significance level of 0.05. statistical analysis values are expressed as mean (sd). the significance of the differences between the intervention group and the control group data was assessed by the unpaired student t test, and that between the pretreatment and post-treatment data within the same group was assessed by the paired student t test. all statistical analyses were performed spss 17.0. a p value of less than 0.05 was considered to be statistically significant. results the study was performed at al ibrahim eye hospital, karachi. during the study period, total 60 eyes of 60 patients were examined. all the patients fulfilled the inclusion and exclusion criteria. out of 60 patients 32 (53.3%) were males and 28 (46.7%) were females (table 1). age range of patients was 45-83 years. mean age of the patients was 58.3 years with standard deviation=7.35. table 2 shows the distribution of bevacizumab and control group. there were no significant differences between the groups (bevacizumab and control) in age, gender and duration of dm, indicating that the baseline characteristics were well balanced. also, there were no statistically significant differences in bcva at the baseline. to evaluate postoperative changes we measured it at 1 day before and 1 and 6 weeks after cataract surgery. preoperative visual acuity is shown in (table 3). postoperative visual acuity shows that there has been statistically significant difference between the bevacizumab and control group (p<0.005). most of the patients in bevacizumab group had postoperative visual acuities above 6/18 with 27 out of 30 having either 6/12 or better compared to only 6 out of 30 in control group having 6/12 or better visual acuity. on the other hand none of the patients in bevacizumab group had visual acuity lesser than 6/18 while control group has 11 patients having visual acuity lesser than 6/18 (table 4, 5). changes in dme between the two groups (on the basis of fluorescein angiography) is shown in figure 1. table 1: gender distribution frequency n (%) male 32 (53.3) female 28 (46.7) total 60 (100) table 2: control or bevacizumab group frequency n (%) bevacizumab group 30 (50) control group 30 (50) total 60 (100) table 3: preoperative vision frequency n (%) 6/24 2 (3.3) 6/36 21 (35) 6/60 28 (46.7) fc 8 (13.3) hm 1 (1.7) total 60 (100) table 4: post operative vision frequency n (%) 6/6 20 (33.3) 6/9 13 (21.7) 6/12 8 (13.3) 6/18 8 (13.3) 6/24 5 (8.3) 6/36 2 (3.3) 6/60 4 (6.7) total 60 (100) 125 table 5: post operative vision in control group vs bevacizumab group visual acuity bevacizumab group (no. of patients) control group (no of patients) total 6/6 18 2 20 6/9 9 4 13 6/12 2 6 8 6/18 1 7 8 6/24 -5 5 6/36 -2 2 6/60 -4 4 total 30 30 60 0 5 10 15 20 25 contr… bevac… decrease in dme increase in eme no changes fig. 1: (changes in dme in both groups) discussion many studies have revealed that intravitreal injection of bevacizumab is useful in the management of dme23,26. similarly studies have shown that cataract surgery leads to noticeable thickening of retina, implying that operative invasion enhances retinal vascular permeability, because localized retinal edema is caused by focal leakage from microaneurysms and dilated capillary segments27. many inflammatory mediators such as vegf cause breakdown of the blood– retinal barrier28,29. patel et al30 reported that vegf levels in aqueous sample obtained from dm patients 1 day after surgery were approximately 10fold higher than those of controls. bevacizumab inhibits vegf, which is a potent permeability factor implicated in cystoid macular edema (cme)29. thus, we hypothesized that anti-vegf therapy would help to prevent the development of macular edema after cataract surgery in dm patients. similar work was carried out by lanzagorta et al,24 who have shown improvement in the vision and decrease in the retinal thickening in the bevacizumab group compared to control group. recently, many studies have shown the clinical effect of intravitreal bevacizumab for pseudophakic cme31–33. mason et al31 reported on 2 patients with persistent cme who had been effectively treated with bevacizumab, and both eyes showed noticeable improvement of va. similarly, another study, 25 cases of pseudophakic cme after cataract surgery were investigated, and found a significant improvement in vision and a decrease in macular thickness32. however, unlike these studies, spitzer et al33 reported that although 81% of patients showed significant improvement in central retinal thickening, visual outcome was not evidently improved. therefore, the clinical effectiveness of intravitreal bevacizumab for pseudophakic cme remains controversial. these case series excluded diabetic patients, and there were several weeks (approximately 13 weeks) between the day of cataract surgery and intravitreal bevacizumab therapy. in contrast, we injected bevacizumab into the vitreous cavity on the same day as the cataract surgery, immediately after intraocular lens implantation. our data suggested that the intravitreal injection of bevacizumab was effective in improving vision after cataract surgery in patients having diabetic macular edema. based on our results, intravitreal injection of bevacizumab improved bcva more effectively. the natural course of macular edema after cataract surgery can be self-limiting in some diabetic patients34. in fact, the increased retinal thickening at first month tended to show a decrease at third month. this incidence was consistent with the results of intravitreal triamcinolone for dme35,36. among the new treatments, such as corticosteroid and anti-vegf, drugs, laser photocoagulation remains the standard and the only treatment with proven efficacy in a large clinical trial10, 16. even though we report the effectiveness of bevacizumab, the application of photocoagulation should be considered for the treatment of dme in most of cases with the exception of the dense cataract. the dose of bevacizumab evaluated in this study was 1.25 mg, which is that used most commonly in clinical practice21–26. however, because no doseranging studies were done, the ideal intravitreal concentration remains to be determined. recurrence of 126 cme is a possibility and may require additional multiple injections of bevacizumab. although there was no case of recurrent cme in our series, the longterm efficacy is also currently unknown. in the present study, the change in bcva at 6 weeks compared with that at baseline (primary endpoint) in the bevacizumab group was statistically significantly less than that in the control group. one of the limitations of the study described herein is the use of an observation arm as control, rather than a sham injection, thereby making it impossible to ensure that the patient and investigators were masked with regard to treatment. however, this limitation was mitigated by ensuring that the technicians who performed the visual-acuity were masked. other limitations of this study are that it was performed at a single centre, and that it involved individuals of only one race, factors that limit its generalizability. although further investigation with a longer follow-up and a larger series of patients may be needed, anti-vegf therapy may be a potent tool for the treatment of dme after cataract surgery. bevacizumab contributed to the significant improvement of va after cataract surgery at 6 weeks. although a longer follow-up is needed, it is possible that intravitreal bevacizumab has the potential not only to prevent the progression of dme after cataract surgery, but also to improve its severity. several reports have indicated that intravitreal or posterior sub-tenon triamcinolone acetonide, or corticosteroid treatment, is also effective for reducing macula thickness in dme37–40. shimura et al41 compared the effect of an intravitreal injection of bevacizumab with triamcinolone acetonide for dme, and found that the triamcinolone treatment yielded better results in terms of macular thickness reduction and improvement of va41. however, they also found a significant postoperative increase of iop in the triamcinolone injected eyes, whereas the bevacizumab-treated eyes showed no significant change. because one of the most important side effects of triamcinolone treatment is elevation of the iop, bevacizumab may be beneficial for patients who are known steroid responders and who are unresponsive to non-steroidal antiinflammatory drugs. in our small case series, there was not significant increase of iop postoperatively, and no eyes showed infection and other severe ocular complications. however, a larger number of cases are needed to verify the safety of bevacizumab treatment. in summary intravitreal bevacizumab immediately after phacoemulsification or during the cataract surgery prevents exacerbation of the macular edema seen in many diabetic patients undergoing cataract surgery. results of our study show that patients who have diabetic macular edema before undergoing the cataract surgery, should receive an intravitreal injection of bevacizumab either during the cataract surgery or immediately after it, to improve visual outcome after cataract surgery and to prevent decrease in vision due to increase in macular edema after cataract surgery. author’s affiliation dr. mazhar ul hassan assistant professor isra postgraduate institute of ophthalmology al – ibrahim eye hospital, malir, karachi prof. p.s mahar isra postgraduate institute of ophthalmology al – ibrahim eye hospital, malir, karachi dr. aziz ur rehman isra postgraduate institute of ophthalmology al – ibrahim eye hospital, malir, karachi dr.nasir bhattt isra postgraduate institute of ophthalmology al – ibrahim eye hospital, malir, karachi dr. asfandyar asgahr isra postgraduate institute of ophthalmology al – ibrahim eye hospital, malir, karachi dr. ashraf daud isra postgraduate institute of ophthalmology al – ibrahim eye hospital, malir, karachi reference 1. joussen am, smyth n, niessen c. pathophysiology of diabetic macular edema. dev ophthalmol. 2007; 39: 1–12. 2. zaczek a, olivestedt g, zetterstrom c. visual outcome after phacoemulsification and iol implantation in diabetic patients. br j ophthalmol. 1999; 83: 1036–41. 3. benson we, brown gc, tasman w, et al. extracapsular cataract extraction with placement of a posterior chamber lens in patients with diabetic retinopathy. ophthalmology. 1993; 100: 730–8. 4. dowler jgf, sehmi ks, hykin pg, et al. the natural history of macular edema cataract surgery in diabetes. ophthalmology. 1999; 106: 663–8. 5. dowler jgf, hykin pg, hamilton amp. phacoemulsification versus extracapsular cataract extraction in patients with diabetes. ophthalmology. 2000; 107: 457–62. 6. funatsu h, yamashita h, noma h, et al. prediction of macular edema exacerbation after phacoemulsification in patients with nonproliferative diabetic retinopathy. j cataract refract surg. 2002; 28: 1355–63. 7. early treatment diabetic retinopathy study research group. results after lens extraction in patients with diabetic 127 retinopathy: early treatment diabetic retinopathy study report number 25. arch ophthalmol. 1999; 117: 1600–6. 8. squirrell d, bhola r, bush j, et al. a prospective, case controlled study of the natural history of diabetic retinopathy and maculopathy after uncomplicated phacoemulsification cataract surgery in patients with type 2 diabetes. br j ophthalmol. 2002; 86: 565–571. 9. henricsson m, heijl a, janzon l. diabetic retinopathy before and after cataract surgery. br j ophthalmol. 1996; 80: 789–93. 10. early treatment diabetic retinopathy study research group. photocoagulation for diabetic macular edema: early treatment diabetic retinopathy study report number 1. arch ophthalmol. 1985; 103: 1796–1806. 11. tachi n, ogino n. vitrectomy for diffuse macular edema in cases of diabetic retinopathy. am j ophthalmol. 1996; 122: 25860. 12. jonas jb, sofker a. intraocular injection of crystalline cortisone as adjunctive treatment of diabetic macular edema. am j ophthalmol. 2001; 132: 425–7. 13. martidis a, duker js, greenberg pb, et al. intravitreal triamcinolone for refractory diabetic macular edema. ophthalmology. 2002; 109: 920–7. 14. jonas jb, kreissig i, sofker a, et al. intravitreal injection of triamcinolone for diffuse diabetic macular edema. arch ophthalmol. 2003; 121: 57–61. 15. kim sj, equi r, bressler nm. analysis of macular edema after cataract surgery in patients with diabetes using optical coherence tomography. ophthalmology. 2007; 114: 881–9. 16. writing committee for the diabetic retinopathy clinical research network. comparison of the modified early treatment diabetic retinopathy study and mild macular grid laser photocoagulation strategies for diabetic macular edema. arch ophthalmol. 2007; 125: 469–80. 17. conway md, canakis c, livir-rallatos c, et al. intravitreal triamcinolone acetonide for refractory chronic pseudophakic cystoid macular edema. j cataract refract surg. 2003; 29: 27–33. 18. ferrara n. vascular endothelial growth factor: basic science and clinical progress. endocr rev. 2004; 25: 581–611. 19. funatsu h, yamashita h, nakamura s, et al. vitreous levels of pigment epithelium-derived factor and vascular endothelial growth factor are related to diabetic macula edema. ophthalmology. 2006; 113: 294–301. 20. ferrara n, hillan kj, gerber hp, et al. discovery and development of bevacizumab, an anti-vegf antibody for treating cancer. nat rev drug discov. 2004; 3: 391–400. 21. avery rl, pieramici dj, rabena md, et al. intravitreal bevacizumab (avastin) for neovascular age-related macular degeneration. ophthalmology. 2006; 113: 363–72. 22. iturralde d, spaide rf, meyerle cb, et al. intravitreal bevacizumab (avastin) treatment of macular edema in central retinal vein occlusion: a short-term study. retina. 2006; 26: 279– 84. 23. arevalo jf, fromow-guerra j, quiroz-mercado h, et al. panamerican collaborative retina study group. primary intravitreal bevacizumab (avastin) for diabetic macular edema: results from the pan-american collaborative retina study group at 6-month follow-up. ophthalmology. 2007; 114: 743– 50. 24. lanzagorta-aresti a, palacios-pozo e, menezo rozalen jl, et al. prevention of vision loss after cataract surgery in diabetic macular edema with intravitreal bevacizumab: a pilot study. retina. 2009. 29: 530-5. 25. chylack lt jr, wolfe jk, singer dm, et al. longitudinal study of cataract study group. the lens opacities classification system iii. arch ophthalmol. 1993; 111: 831-6. 26. diabetic retinopathy clinical research network. a phase ii randomized clinical trial of intravitreal bevacizumab for diabetic macular edema. ophthalmology. 2007; 114: 1860-7. 27. cunha-vaz jg. studies on the pathophysiology of diabetic retinopathy: the blood-retinal barrier in diabetes. diabetes. 1983; 32: 20-7. 28. stern al, taylor dm, dalburg la, et al. pseudophakic cystoid maculopathy: a study of 50 cases. ophthalmology. 1981; 88: 942– 6. 29. qaum t, xu q, joussen am, et al. vegf-initiated bloodretinal barrier breakdown in early diabetes. invest ophthalmol vis sci. 2001; 42: 2408–13. 30. patel ji, hykin pg, cree ia. diabetic cataract removal: postoperative progression of maculopathy-growth factor and clinical analysis. br j ophthalmol. 2006; 90: 697–701. 31. mason jo iii, albert ma jr, vail r. intravitreal bevacizumab (avastin) for refractory pseudophakic cystoid macular edema. retina. 2006; 26: 356–7. 32. arevalo jf, garcia-amaris ra, roca ja, et al. pan-american collaborative retina study group. primary intravitreal bevacizumab for the management of pseudophakic cystoid macular edema: pilot study of the pan-american collaborative retina study group. j cataract refract surg. 2007; 33: 2098-105. 33. spitzer ms, ziemssen f, yoeruek e, et al. efficacy of intravitreal bevacizumab in treating postoperative pseudophakic cystoid macular edema. j cataract refract surg. 2008; 34: 70–5. 34. kim sj, equi r, bressler nm. analysis of macular edema after cataract surgery in patients with diabetes using optical coherence tomography. ophthalmology. 2007; 114: 881-9. 35. diabetic retinopathy clinical research network. a randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. ophthalmology. 2008; 115: 1447–59. 36. diabetic retinopathy clinical research network. randomized trial of peribulbar triamcinolone acetonide with and without focal photocoagulation for mild diabetic macular edema: a pilot study. ophthalmology. 2007; 114: 1190–6. 37. jonas jb, kreissig i, söfker a, et al. intravitreal injection of triamcinolone for diffuse diabetic macular edema.arch ophthalmol. 2003; 121: 57–61. 38. sutter fk, simpson jm, gillies mc. intravitreal triamcinolone for diabetic macular edema that persists after laser treatment:three-month efficacy and safety results of a prospective, randomized, double-masked, placebo-controlled clinical trial. ophthalmology. 2004; 111: 2044–9. 39. massin p, audren f, haouchine b, et al. intravitreal triamcinolone acetonide for diabetic diffuse macular edema: preliminary results of a prospective controlled trial. ophthalmology. 2004; 111: 218–24. 40. martidis a, duker js, greenberg pb, et al. intravitreal triamcinolone for refractory diabetic macular edema. ophthalmology. 2002; 109: 920–7. 41. shimura m, nakazawa t, yasuda k, et al. comparative therapy evaluation of intravitreal bevacizumab and triamcinolone acetonide on persistent diffuse diabetic macular edema. am j ophthalmol. 2008; 145: 854–61. microsoft word mazharul hasan 2 84 original article visual outcome after intravitreal bevacizumab injection in macular edema secondary to central retinal vein occlusion mazhar-ul-hassan, umair qidwai, aziz-ur-rehman, niamatullah sial, nasir bhatti pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mazhar ul hassan isra postgraduate institute of ophthalmology karachi submission of paper september’ 2010 acceptance for publication may’ 2011 …..……………………….. objective: to evaluate visual outcome after intra-vitreal bevacizumab in macular edema secondary to central retinal vein occlusion. materials and methods: this prospective study was performed at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi. patients with macular edema secondary to central retinal vein occlusion, ischemic and non-ischemic were selected from 1st february 2009 to 31st july 2009, by using non-probability purposive sampling technique. informed written consent was taken from the patients. best-corrected visual acuity was checked before giving the intra-vitreal bevacizumab injection and after 1st, 4th and 12th week. results: out of 41 patients included in the study 32 patients (78 %) showed visual improvement of at least one line on snellen visual acuity chart (p value of <0.05), while rest of the 9 patients (22 %) did not show visual improvement. conclusion: intra-vitreal bevacizumab injection results in modest visual improvement in patients with macular edema due to central retinal vein occlusion. entral retinal vein occlusion (crvo) is a relatively common cause of visual loss and after diabetic retinopathy; it is the most frequent vascular accident. the prevalence and five year incidence of crvo were estimated to be 0.1–0.4% and 0.2%1. histopathologic studies have implicated thrombosis in the central retinal vein at the level of the lamina cribrosa or the retrolaminal optic nerve as the cause of crvo. there are two types of crvo – ischemic and non-ischemic. the main cause of visual loss in patients with crvo is macular edema1. vascular endothelial growth factor (vegf) has been implicated in the pathophysiology of crvo3. vegf causes conformational changes of tight junctions of retinal vascular endothelial cells leading to increased vascular permeability. there is still no safe treatment that promotes the return of lost vision. treatments that target the secondary effects of venous occlusion, such as grid laser photocoagulation for macular edema and prophylactic pan retinal laser photocoagulation for nonperfused crvo, were shown to be ineffective in improving visual acuity in the central vein occlusion study (cvos)4. at present there is considerable interest in intravitreal bevacizumab (avastin, genentech), which is a humanized monoclonal antibody that inhibits all active isoforms of vegf. intra-vitreal bevacizumab is a new treatment modality which is currently being tried out for use in macular edema following central retinal vein occlusion (crvo).in one study use of intra vitreal bevacizumab resulted in visual improvement from 20/600 to 20/138 at 3 months5. c 85 this study was conducted to evaluate the role of intra vitreal bevacizumab in treatment of macular oedema secondary to crvo issue in our local environment. materials and methods the study is an experimental study conducted at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi, from 1st february 2009 to 30th july 2009. 41(n=41, p=88%, d=10%, c-i=95%) patients were included in the study by non-probability purposive sampling. patients with macular edema secondary to central retinal vein occlusion that had persisted for more than three months were included in the study6. macular edema was identified clinically on the basis of slit lamp bio-microscopy. central retinal vein occlusion was clinically identified by multiple flame shaped hemorrhages all over the fundus and dilated retinal veins seen with a 90 d lens. patients with other visually significant ocular complications of central retinal vein occlusion, tractional retinal detachment, vitreous hemorrhage and glaucoma (primary open angle and neo-vascular glaucoma) were excluded from the study. patients were selected from general outdoor patient department of al-ibrahim eye hospital, according to inclusion criteria. informed written consent was taken. best corrected visual acuity (bcva) was checked using snellen acuity chart by the refractionist. this was taken as baseline bcva for the study. injection of 1.25 mg / 0.05 ml of bevacizumab was given by an ophthalmologist under topical anaesthesia in asceptic conditions in the operating theatre. patients were followed at 1, 4 and 12 weeks after the injection. visual findings of last follow-up (12 weeks) were considered as final outcome. at each follow-up, best corrected visual acuity (bcva) was checked by the refractionist using snellen acuity chart. difference between the best corrected visual acuity at baseline (before injection) and at final follow up visit (12 weeks) was evaluated and if at least single line improvement was seen at the final follow up (12 weeks), visual improvement was considered to be significant by the researcher. statistical analysis was done by spss version 13.0.frequencies and percentages were calculated for gender, age groups (which were divided into age groups of less than 20 years, 21 to 40 years, 41 to 60 and more than 61 years of age) and visual acuity. marginal homogenecity test was used to compare the proportions of visual acuity before injection and after 12 weeks at 5% level of significance. mean ± standard deviation was calculated for qualitative variables like age visual acuity and duration of crvo. results forty one eyes of 41 patients that fulfilled the inclusion and exclusion criteria were recruited in the study. out of 41 patients 24 (58.5%) were males and 17 (41.5%) were females. all patients were between 43-76 years of age. mean ages of the patients were 55.6 years with standard deviation of 7.51. most of the patients 25 (61%) belonged to the age group of 50-59 years, 7 patients (17%) belonged to the age group between 6069 years, while 6 (15%) patients belonged to the age group of less than 50 years. only 3 (7%) patients were older than 69 years. age distribution according to genders is as follows, mean± sd = 7.58 with age range of 43-76 (mean=55.96) years for males and mean ±sd 7.58 with age range of 44 74 (mean=55.12) years for females. the mean duration of central retinal vein occlusion before the intra-vitreal injection of bevacizumab was 5 months with standard deviation of2.25 the duration with the range of 4 months to 12 months. visual acuities before giving intra-vitreal injection of bevacizumab are shown in table 1. visual acuities on final follow up that are 12th week after intra-vitreal bevacizumab injection are shown in table 2. out of 41 patients included in the study 32 patients (78%) showed visual improvement of at least one line on snellen visual acuity chart (p value of <0.05), while rest of the 9 patients (22 %) did not show visual improvement, (fig. 1). discussion the principal cause of decrease in vision, in patients with non-ischemic crvo, is macular oedema. the central retinal vein occlusion study showed negative results of laser treatment (showed no benefit over the control group), which lead to its abandonment4. this provoked. 86 table 1: visual acuity before intravitreal bevacizumab injection (baseline) frequency n (%) 6/18 2 (4.9) 6/24 12 (29.3) 6/36 8 (19.5) 6/60 8 (19.5) counting fingers 3 (7.3) hand movement 6 (14.6) perception of light 2 (4.9) total 41 (100) table 2: visual acuity after intravitreal injection of bevacizumab (12th postoperative week) frequency n (%) 6/6 8 (19.5) 6/9 14 (34.1) 6/12 4 (9.8) 6/18 3 (7.3) 6/24 1 (2.1) 6/36 1 (2.1) 6/60 2 (4.9) counting finger 2 (4.9) hand movement 3 (7.3) perception of light 3(7.3) total 41 (100) researchers and clinicians to evaluate other medical and surgical interventions in crvo. currently, there is interest in a new drug called bevacizumab (avastin, genentech), an antibody against vascular endothelial growth factor (vegf). bevacizumab can lead to rapid reduction of macular edema which leads to improvement of vision as early as at the end of 1st week7. many other reports have found visual improvement from 20/600 to 20/138 at 3 months (average 2.8 injections), however it has few short-term safety issues5. these results suggest that bevacizumab can be used in the treatment of macular edema, especially, because of lack of intraocular pressure (iop) rise and absence of cataract formation. however, the effect does not appear to be persistent, and multiple intra-vitreal injections may be needed. it stabilizes the blood–retinal barrier in patients with crvo and inhibits vegf expression, thus reducing the retinal capillary permeability. 9 32 visual improvement no visual improvement fig. 1: visual improvement n = 41 0 2 4 6 8 10 12 14 6/6 6/9 6/12 6/18 6/24 6/36 6/60 fc hm pi pre-treatment va post-treatment va on week 12 fig. 2: pre-treatment (baseline) and post-treatment (on week 12) visual acuity distribution n = 41 va = visual acuity, hm = hand movement fc = finger counting, pi = perception of light many treatments for crvo have been developed but most have not stood the test of time. intra-vitreal steroids may be beneficial in selected cases of macular edema but have many adverse side effects. similarly, best corrected visual acuity 87 anti-vegf agents such as bevacizumab appear to be promising, but their role still needs to be tested. among interventions aimed at the underlying pathophysiology of crvo, haemodilution seems to be useful but it also requires careful patient selection and more trials. the exact therapeutic advantage of treatments such as ron, fibrinolytic therapy, and crva is not known fully. our study demonstrated the early and clinically relevant benefits of bevacizumab injection for macular edema due to central retinal vein occlusion. in our study, we found that intra-vitreal injections of bevacizumab resulted in a significant improvement of visual acuity in patients with central retinal vein occlusion along with reduction in macular edema, which was noted on clinical examination. the useful effects of intra-vitreal bevacizumab were observed as early as the first week and over a 3-month follow-up period. results of our study after 3 months showed that intra-vitreal bevacizumab treatment in patients with macular edema secondary to crvo was associated with a significant improvement in visual acuity (p<0.05). during this study, no severe ocular adverse events, such as endophthalmitis, retinal detachment, traumatic cataract or uveitis, were detected, for as long as 6 months (including follow up time of 3 months). none of the patients showed any evidence of severe drug-related systemic adverse events (e.g. thromboembolic events, hypertensive crisis or kidney failure). our study was too small to present solid data on safety, but several studies have showed comparable results regarding lack of severe adverse events8, 9. the results in our study are comparable to the preliminary results of several recently published papers5. the most comprehensive data on the natural history of crvo was provided by the central vein occlusion study group10. it is widely thought that clinical outcomes of every new treatment option for crvo must match with these data. according to the cvosg, in the natural course of crvo, only 19% of patients with initial visual acuity of less than 20/200 had a chance of visual acuity of better than 20/200.10 it reported that patients who presented with initial visual acuity between 20/200 and 20/50 had improved to better than 20/50 in 19% of cases, while in 44% of cases visual acuity remained between 20/200 and 20/50 and showed no improvement. on the other hand visual acuity of only 37% of patients became worse than 20/200. compared with this data, patients treated with intra-vitreal bevacizumab have shown much better improvement in visual acuity. one study reported improvement in visual acuity from 20/250 at baseline to 20/80 at the 6-month follow-up (p < 0.001) in a group of 46 crvo patients11. similarly, along with improvement in vision the mean central retinal thickness also decreased from 535 ± 48 microns at baseline to 323 ± 116 microns at the 6-month followup11. in another series of 30 eyes of crvo patients reported improvement in visual acuity from 20/394 at baseline to 20/313 at the 3-month follow-up, (p < 0.05) 12. results of these studies indicate that bevacizumab can be considered as an effective treatment option for crvo and it may improve the long-term prognosis of crvo. our study does have some limitations that must be recognized. there was no control group in our study and there was only a limited follow-up so we were unable to study the need of reinjection. another very important limitation in our study was that we failed to compare the anatomical changes in macular edema due to the absence of optical coherence tomography testing facility in our setup, so we had to depend on clinical assessment to evaluate improvement in the macular edema. conclusion bevacizumab is an emerging treatment modality; the promising results reported here in our study indicate that intra-vitreal bevacizumab injection can help treat macular edema secondary to central retinal vein occlusion with modest improvement in vision. author’s affiliation dr. mazhar ul hassan assistant professor and consultant eye surgeon isra postgraduate institute of ophthalmology karachi dr. umair qidwai resident medical officer isra postgraduate institute of ophthalmology karachi dr. aziz ur rehman associate professor and consultant eye surgeon isra postgraduate institute of ophthalmology karachi dr. niamatullah sial associate professor and consultant eye surgeon isra postgraduate institute of ophthalmology karachi 88 dr. nasir bhatti assistant professor and consultant eye surgeon isra postgraduate institute of ophthalmology karachi reference 1. klein rk, bmoss se. the epidemiology of retinal vein occlusion: the beaver dam eye study. trans am ophthalmol soc. 2000; 98: 133–43. 2. michael gm. jeffrey`s heller venous obstruction disease of retina. myron yanof md, jay sd ucker md. 5th ed. st. lion`s: mosby ophthalmology. 2004. 3. boyd sr, zachary i, chakravarthy u, et al. correlation of increased vascular endothelial growth factor with neovascularization and permeability in ischemic central vein occlusion. arch ophthalmol. 2002; 120: 1644-50. 4. group tcvos. evaluation of grid pattern photocoagulation for macular edema in central vein occlusion. the central vein occlusion study group m report. ophthalmology. 1995; 102: 1425-33. 5. iturralde d, spaide rf, meyerle cb, et al. intravitreal bevacizumab (avastin) treatment of macular edema in central retinal veinocclusion:a short-term study. retina. 2006; 26: 27984. 6. kriechbaum fk, michels s, prager f, et al. intravitreal bevacizumab (avastin) for macular oedema secondary to retinal vein occlusion: 12-month results of a prospective clinical trial. br j ophthalmol. 2009; 93: 452-56. 7. rosenfeld pj, fung ae, puliafito ca. optical coherence tomography findings after an intravitreal injection of bevacizumab 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27,2011 230 indexes (volume 27, 2011) no.1. january…………………………………………….. page 1-54 no.2. april………………………………………………. . page 55-118 no.3. july………………………………………………… page 119-173 no.4 october…………………………………………… page 174-239 subject index abstracts 27: 49-50, 116-7, 171-2, 229-30. adnexa • outcome of delayed lacrimal probing in congenital obstruction of nasolacrimal duct 27: 176-80. anterior segment • safety and efficacy of subtenon anesthesia in anterior segment surgeries 27: 133-7. cataract surgery • complication and visual outcome after peadiatric cataract surgery with or without intra ocular lens implantation 27: 30-4. • complications of hypermature cataract and its visual outcome 27: 58-62. • comparison between acrylic hydrophilic and acrylic hydrophobic intraocular lens after phacoemulsification 27: 222-6. • prevalence of hepatitis b and c in the patients undergoing cataract surgery at eye camps 27: 27-9. • safety and visual outcome of scleral sutured posterior chamber intraocular lenses (ss-pc iol) 27: 160-4. • surgically induced astigmatism comparison between forceps and injector delivery system for foldable iol in phacoemulsification 27: 637. • visual outcome and complications in abexterno scleral fixation iol in aphakia 27: 737. community • blindness and poverty 27: 165-70. conjunctiva • topical use of cyclosporine in the treatment of vernal keratoconjunctivitis 27: 121-7. cornea • amniotic membrane transplantation in ocular surface disorders 27: 138-42. • latanoprost and herpetic keratitis 27: 227-8. • preliminary results of uv – a riboflavin crosslinking in progressive cases of keratoconus, in pakistani population 27: 21-6. • three years clinical audit of patients presenting in cornea clinic at a tertiary care 27: 196-200. consensus document • consensus document on the use of avastin (bevacizumab) in retinal pathologies 27: 103-5. diagnostics • ultrasound and computerized tomography 27: 146-51. editorial • complications and management of glaucoma surgery 27: 55. • eales’ disease-a distressing mystery 27: 11920. • femtosecond laser assisted cataract surgry 27; 174-5. • reminders and regrets 27: 1-2. eye lids • basal cell carcinoma presentation, histopathological features and correlation with clinical behaviour 27: 3-7. glaucoma • 5-fluorouracil as an adjunct in glaucoma filtration surgery in younger age group 27: 12-6. • intraocular pressure control and post operative complications with mitomycin – c augmented trabeculectomy in primary open angle and primary angle-closure glaucoma 27: 35-9. • post-keratoplasty glaucoma in secondary trans-scleral fixation of posterior chamber intra-ocular lens implant 27: 181-7. infections • manifestations of pulmonary tuberculosis in the eye 27: 201-3. news and events 27: 54, 118, 173, 239. obituary • prof. dr. tahir mahmood (1962-2010) 27: 52. 231 paediatric ophthalmology • congenital heterochromia iridis in a nigerian girl child 27: 106-8. ptosis • outcome of levator resection in congenital ptosis with poor levator function 27: 128-32. retina • assessment of complications secondary to silicone oil injection after pars plana vitrectomy in rhegma-togenous retinal detachment in early post operative phase 27: 68-72. • comparison of raised iop after pars plana vitrectomy (ppv) using 1000 cst and 5000 cst silicone oil in rhegmatogenous retinal detachment 27: 40-3. • frequency and patterns of eye diseases in retina clinic of a tertiary care hospital in karachi 27: 155-9. • outcome of silicone oil removal in eyes undergoing 3-port parsplana vitrectomy 27: 17-20. • ocular trauma in children 27: 210-4. • retinal pigment epithelium rip following serial intravitreal injections of avastin 27: 44-5. • unilateral microphthalmos with associated retina detachment in a nigerian child 27: 46-8. • visual outcome after intravitreal bevacizumab injection in macular edema secondary to central retinal vein occlusion 27: 84-8. • visual outcome following intra-vitreal bevacizumab injection in neovascular age-related macular degenera-tion 27: 89-95. • visual outcome after intravitreal avastin (bevacizumab) for persistent diabetic macular edema 27: 188-91. social worker • lt. gen (retd) jahan dad khan (a social worker par excellence) 27: 53. trauma • pattern of presentation and factors leading to ocular trauma 27: 96-102. • visual outcome and pattern of industrial ocular injuries 27: 8-11. • visual outcome after primary iol implantation for traumatic cataract 27: 152-4. tumors • effects of primary chemotherapy, radiotherapy plus local treatments on regression patterns of posterior pole retinoblastoma 27: 215-21. • imaging in ocular trauma: optimizing the use of ultrasound and computerised tomography 27: 146-51. • presentation pattern of retinoblastoma 27: 1425. uveitis • role of initial preoperative medical management in controlling post-operative anterior uveitis in patients of phacomorphic glaucoma 27: 78-83. • sympathetic ophthalmitis: a case presentation and review of the literature 27: 109-12. author index ahmed am: surgically induced astigmatism comparison between forceps and injector delivery system for foldable iol in phacoemulsification 27: 63-7. ahmed f: comparison between acrylic hydrophilic and acrylic hydrophobic intraocular lens after phacoemulsification 27: 192-5. ahmad m: safety and visual outcome of scleral sutured posterior chamber intraocular lenses (ss-pc iol) 27: 160-4. ahmed n: visual outcome after primary iol implantation for traumatic cataract 27: 152-4. ahmed r: comparison between acrylic hydrophilic and acrylic hydrophobic intraocular lens after phacoemulsification 27: 192-5. adeosun oa: congenital heterochromia iridis in a nigerian girl child 27: 106-8. akinwalere ak: congenital heterochromia iridis in a nigerian girl child 27: 106-8. akinwalere ak: unilateral microphthalmos with associated retina detachment in a nigerian child 27: 46-8. akram s: visual outcome after primary iol implanttation for traumatic cataract 27: 152-4. alvi rh: complication and visual outcome after peadiatric cataract surgery with or without intra ocular lens implantation 27: 30-4. alvi rh: visual outcome and pattern of industrial ocular injuries 27: 8-11. ambreen s: sympathetic ophthalmitis: a case presentation and review of the literature 27: 109-12. 232 ameen ss: preliminary results of uv – a riboflavin crosslinking in progressive cases of keratoconus, in pakistani population 27: 21-6. amin s: imaging in ocular trauma: optimizing the use of ultrasound and computerised tomography 27: 146-51. ansari hm: 5-fluorouracil as an adjunct in glaucoma filtration surgery in younger age group 27: 126. anwar m: frequency and morphological patterns of malignant intra orbital tumors in various age groups 27: 204-9. araeen ma: preliminary results of uv – a riboflavin crosslinking in progressive cases of keratoconus, in pakistani population 27: 21-6. arbab tm: topical use of cyclosporine in the treatment of vernal keratoconjunctivitis 27: 121-7. attaulla i: latanoprost and herpetic keratitis 27: 227-8. aurangzeb zg: visual outcome and pattern of industrial ocular injuries 27: 8-11. awan ah: obituary prof. dr. tahir mahmood (19622010) 27: 52. awan zh: blindness and poverty 27: 165 aziz t: visual outcome after primary iol implantation for traumatic cataract 27: 152-4. bano ni: 5-fluorouracil as an adjunct in glaucoma filtration surgery in younger age group 27: 126. bhatti aa: post-keratoplasty glaucoma in secondary trans-scleral fixation of posterior chamber intra-ocular lens implant 27: 181-7. bhatti mn: visual outcome and complications in abexterno scleral fixation iol in aphakia 27: 737. bhatti n: assessment of complications secondary to silicone oil injection after pars plana vitrectomy in rhegmatogenous retinal detachment in early post operative phase 27: 68-72. bhatti n: complication and visual outcome after peadiatric cataract surgery with or without intra ocular lens implantation 27: 30-4. bhatti n: comparison of raised iop after pars plana vitrectomy (ppv) using 1000 cst and 5000 cst silicone oil in rhegmatogenous retinal detachment 27: 40-3. bhatti n: three years clinical audit of patients presenting in cornea clinic at a tertiary care 27: 196-200. bhatti n: visual outcome after intravitreal bevacizumab injection in macular edema secondary to central retinal vein occlusion 27: 84-8. bhutto ia: ocular trauma in children 27: 210-4. bhutto ia: presentation pattern of retinoblastoma 27: 142-5. bhutto ia: visual outcome and complications in abexterno scleral fixation iol in aphakia 27: 737. bukhari s: ocular trauma in children 27: 210-4. bukhari s: presentation pattern of retinoblastoma 27: 142-5. bukhari s: visual outcome and complications in abexterno scleral fixation iol in aphakia 27: 737. bokhari sa: comparision of conjunctival autograft and intra-operative application of mitomycinc in treatment of primary pterygium 27: 222-6. butt nh: pattern of presentation and factors leading to ocular trauma 27: 96-102. butt jy: retinal pigment epithelium rip following serial intravitreal injections of avastin 27: 44-5. chaudhry ml: reminders and regrets 27: 1-2. chaudhry ql: abstracts 27: 49-50, 116-7, 171-2, 22930. daula mih: imaging in ocular trauma: optimizing the use of ultrasound and computerised tomography 27: 146-51. fasih u: complications of hypermature cataract and its visual outcome 27: 58-62. fasih u: safety and efficacy of subtenon anesthesia in anterior segment surgeries 27: 133-7. fayaz m: comparison of raised iop after pars plana vitrectomy (ppv) using 1000 cst and 5000 cst silicone oil in rhegmatogenous retinal detachment 27: 40-3. fayaz m: preliminary results of uv – a riboflavin crosslinking in progressive cases of keratoconus, in pakistani population 27: 21-6. fehmi ms: safety and efficacy of subtenon anesthesia in anterior segment surgeries 27: 133-7. fawad mu: three years clinical audit of patients presenting in cornea clinic at a tertiary care 27: 196-200. ghayoor i: comparison between acrylic hydrophilic and acrylic hydrophobic intraocular lens after phaco-emulsification 27: 192-5. 233 ghayoor i: outcome of silicone oil removal in eyes undergoing 3-port parsplana vitrectomy 27: 17-20. hamza ms: amniotic membrane transplantation in ocular surface disorders 27: 138-42. hamza u: pattern of presentation and factors leading to ocular trauma 27: 96-102. hamza u: visual outcome after intravitreal avastin (bevacizumab) for persistent diabetic macular edema 27: 188-91. hanfi an: visual outcome following intra-vitreal bevacizumab injection in neovascular agerelated macular degeneration 27: 89-95. hashmi ah: amniotic membrane transplantation in ocular surface disorders 27: 138-42. hassan m: assessment of complications secondary to silicone oil injection after pars plana vitrectomy in rhegmatogenous retinal detachment in early post operative phase 27: 68-72. hassan m: comparison of raised iop after pars plana vitrectomy (ppv) using 1000 cst and 5000 cst silicone oil in rhegmatogenous retinal detachment 27: 40-3. hassan m: complication and visual outcome after peadiatric cataract surgery with or without intra ocular lens implantation 27: 30-4. hassan m: three years clinical audit of patients presenting in cornea clinic at a tertiary care 27: 196-200. hassan m: visual outcome and pattern of industrial ocular injuries 27: 8-11. hassan m: visual outcome and complications in abexterno scleral fixation iol in aphakia 27: 737. hassan m: visual outcome after intravitreal bevacizumab injection in macular edema secondary to central retinal vein occlusion 27: 84-8. hayder sa: manifestations of pulmonary tuberculosis in the eye 27: 201-3. huda w: safety and efficacy of subtenon anesthesia in anterior segment surgeries 27: 133-7. hussain i: basal cell carcinoma presentation, histopathological features and correlation with clinical behaviour 27: 3-7. hussain m: comparison of raised iop after pars plana vitrectomy (ppv) using 1000 cst and 5000 cst silicone oil in rhegmatogenous retinal detachment 27: 40-3. hussain m: role of initial preoperative medical management in controlling post-operative anterior uveitis in patients of phacomorphic glaucoma 27: 78-83. hussain m: three years clinical audit of patients presenting in cornea clinic at a tertiary care 27: 196-200. hye a: post-keratoplasty glaucoma in secondary trans-scleral fixation of posterior chamber intra-ocular lens implant 27: 181-7. imran s: imaging in ocular trauma: optimizing the use of ultrasound and computerised tomography 27: 146-51. iqbal s: safety and visual outcome of scleral sutured posterior chamber intraocular lenses (ss-pc iol) 27: 160-4. ishaq bm: eales’ disease – a distressing mystery 27: 119-20. ishtiaq o: preliminary results of uv – a riboflavin cross linking in progressive cases of keratoconus, in pakistani population 27: 21-6. jafri ar: safety and efficacy of subtenon anesthesia in anterior segment surgeries 27: 133-7. jahangir n: safety and visual outcome of scleral sutured posterior chamber intraocular lenses (ss-pc iol) 27: 160-4. jahangir s: pattern of presentation and factors leading to ocular trauma 27: 96-102. jahangir s: visual outcome after intravitreal avastin (bevacizumab) for persistent diabetic macular edema 27: 188-91. jahangir t: pattern of presentation and factors leading to ocular trauma 27: 96-102. jahangir t: visual outcome after intravitreal avastin (bevacizumab) for persistent diabetic macular edema 27: 188-91. kamil z: comparision of conjunctival autograft and intra-operative application of mitomycin-c in treatment of primary pterygium 27: 222-6. kazi a: assessment of complications secondary to silicone oil injection after pars plana vitrectomy in rhegmatogenous retinal detachment in early post operative phase 27: 68-72. kehar si: frequency and morphological patterns of malignant intra orbital tumors in various age groups 27: 204-9. 234 khan a: frequency and patterns of eye diseases in retina clinic of a tertiary care hospital in karachi 27: 155-9. khan a: sympathetic ophthalmitis: a case presentation and review of the literature 27: 109-12. khan bs: basal cell carcinoma presentation, histopathological features and correlation with clinical behaviour 27: 3-7. khan md: basal cell carcinoma presentation, histopathological features and correlation with clinical behaviour 27: 3-7. khan mt: retinal pigment epithelium rip following serial intravitreal injections of avastin 27: 44-5. khan md: preliminary results of uv – a riboflavin crosslinking in progressive cases of keratoconus, in pakistani population 27: 21-6. khan m: 5-fluorouracil as an adjunct in glaucoma filtration surgery in younger age group 27: 126. khan n: safety and visual outcome of scleral sutured posterior chamber intraocular lenses (ss-pc iol) 27: 160-4. khan n: surgically induced astigmatism comparison between forceps and injector delivery system for foldable iol in phacoemulsification 27: 637. khan wa: lt. gen (retd) jahan dad khan (a social worker par excellence) 27: 53. khaqan ha: manifestations of pulmonary tuberculosis in the eye 27: 201-3. khurram d: effects of primary chemotherapy, radiotherapy plus local treatments on regression patterns of posterior pole retinoblastoma 27: 215-21. khurram d: outcome of silicone oil removal in eyes undergoing 3-port parsplana vitrectomy 27: 17-20. latif a: outcome of levator resection in congenital ptosis with poor levator function 27: 128-32. latif e: outcome of levator resection in congenital ptosis with poor levator function 27: 128-32. latif e: outcome of delayed lacrimal probing in congenital obstruction of nasolacrimal duct 27: 176-80. laghari d: sympathetic ophthalmitis: a case presentation and review of the literature 27: 109-12. laghari da: intraocular pressure control and post operative complications with mitomycin-c augmented trabeculectomy in primary open angle and primary angle-closure glaucoma 27: 35-9. mahar ps: blindness and poverty 27: 165-70. mahar ps: complications and management of glaucoma surgery 27: 55-7. mahar ps: intraocular pressure control and post operative complications with mitomycin-c augmented trabeculectomy in primary open angle and primary angle-closure glaucoma 27: 35-9. mahar ps: ocular trauma in children 27: 210-4. mahar ps: sympathetic ophthalmitis: a case presentation and review of the literature 27: 109-12. mahar ps: visual outcome following intra-vitreal bevacizumab injection in neovascular agerelated macular degeneration 27: 89-95. mahmood h: news and events 27: 54, 118, 173. mahmood k: retinal pigment epithelium rip following serial intravitreal injections of avastin 27: 44-5. mahmood t: surgically induced astigmatism comparison between forceps and injector delivery system for foldable iol in phacoemulsification 27: 63-7. mahmood t: abstracts 27: 49-51. majekodunmi m y: congenital heterochromia iridis in a nigerian girl child 27: 106-8. majekodunmi my: unilateral microphthalmos with associated retina detachment in a nigerian child 27: 46-8. malik iq: role of initial preoperative medical management in controlling post-operative anterior uveitis in patients of phacomorphic glaucoma 27: 78-83. malik mm: comparison between acrylic hydrophilic and acrylic hydrophobic intraocular lens after phacoemulsification 27: 192-5. memon as: ocular trauma in children 27: 210-4. memon ms: blindness and poverty 27: 165-70. mirza ma: topical use of cyclosporine in the treatment of vernal keratoconjunctivitis 27: 121-7. moin m: latanoprost and herpetic keratitis 27: 227-8. moin m: outcome of delayed lacrimal probing in congenital obstruction of nasolacrimal duct 27: 176-80. moin m: role of initial preoperative medical management in controlling post-operative anterior uveitis in patients of phacomorphic glaucoma 27: 78-83. 235 najmi km: manifestations of pulmonary tuberculosis in the eye 27: 201-3. naz ma: preliminary results of uv – a riboflavin crosslinking in progressive cases of keratoconus, in pakistani population 27: 21-6. niazi mk: preliminary results of uv – a riboflavin crosslinking in progressive cases of keratoconus, in pakistani population 27: 21-6. omolase bo: congenital heterochromia iridis in a nigerian girl child 27: 106-8. omolase bo: unilateral microphthalmos with associated retina detachment in a nigerian child 27: 46-8. omolase co: unilateral microphthalmos with associated retina detachment in a nigerian child 27: 46-8. oluwole oc: congenital heterochromia iridis in a nigerian girl child. 27: 106-8. qamar rmr: outcome of levator resection in congenital ptosis with poor levator function 27: 128-32. qamar rmr: outcome of delayed lacrimal probing in congenital obstruction of nasolacrimal duct 27: 176-80. qazi am: comparison of raised iop after pars plana vitrectomy (ppv) using 1000 cst and 5000 cst silicone oil in rhegmatogenous retinal detachment 27: 40-3. qazi u: frequency and patterns of eye diseases in retina clinic of a tertiary care hospital in karachi 27: 155-9. qidwai u: visual outcome and pattern of industrial ocular injuries 27: 8-11. qidwai u: visual outcome after intravitreal bevacizumab injection in macular edema secondary to central retinal vein occlusion 27: 84-8. qidwal u: assessment of complications secondary to silicone oil injection after pars plana vitrectomy in rhegmatogenous retinal detachment in early post operative phase 27: 68-72. qidwai u: frequency and patterns of eye diseases in retina clinic of a tertiary care hospital in karachi 27: 155-9. qidwai u: presentation pattern of retinoblastoma 27: 142-5. qidwai u: three years clinical audit of patients presenting in cornea clinic at a tertiary care 27: 196-200. qidwai u: ocular trauma in children 27: 210-4. qidwai ua: complication and visual outcome after peadiatric cataract surgery with or without intra ocular lens implantation 27: 30-4. qureshi ma: prevalence of hepatitis b and c in the patients undergoing cataract surgery at eye camps 27: 27-9. qureshi tm: 5-fluorouracil as an adjunct in glaucoma filtration surgery in younger age group 27: 126. qureshi tm: retinal pigment epithelium rip following serial intravitreal injections of avastin 27: 44-5. rehman a: assessment of complications secondary to silicone oil injection after pars plana vitrectomy in rhegmatogenous retinal detachment in early post operative phase 27: 68-72. rehman a: complication and visual outcome after peadiatric cataract surgery with or without intra ocular lens implantation 27: 30-4. rehman a: comparison of raised iop after pars plana vitrectomy (ppv) using 1000 cst and 5000 cst silicone oil in rhegmatogenous retinal detachment 27: 40-3. rehman a: presentation pattern of retinoblastoma 27: 142-5. rehman a: role of initial preoperative medical management in controlling post-operative anterior uveitis in patients of phacomorphic glaucoma 27: 78-83. rahman a: safety and efficacy of subtenon anesthesia in anterior segment surgeries 27: 133-7. rehman a: three years clinical audit of patients presenting in cornea clinic at a tertiary care 27: 196-200. rahman a: visual outcome and complications in abexterno scleral fixation iol in aphakia 27: 737. rehman a: visual outcome after intravitreal bevacizumab injection in macular edema secondary to central retinal vein occlusion 27: 84-8. rehman a: visual outcome and pattern of industrial ocular injuries 27: 8-11. riaz q: frequency and patterns of eye diseases in retina clinic of a tertiary care hospital in karachi 27: 155-9. rizvi f: comparison of conjunctival autograft and intra-operative application of mitomycin-c in treatment of primary pterygium 27: 222-6. 236 sahaf ia: amniotic membrane transplantation in ocular surface disorders 27: 138-42. sahaf ia: post-keratoplasty glaucoma in secondary trans-scleral fixation of posterior chamber intra-ocular lens implant 27: 181-7. sahto aa: prevalence of hepatitis b and c in the patients undergoing cataract surgery at eye camps 27: 27-9. shahid e: complications of hypermature cataract and its visual outcome 27: 58-62. shaikh a: complications of hypermature cataract and its visual outcome 27: 58-62. shaikh a: safety and efficacy of subtenon anesthesia in anterior segment surgeries 27: 133-7. shaikh n: safety and efficacy of subtenon anesthesia in anterior segment surgeries 27: 133-7. sharif n: effects of primary chemotherapy, radiotherapy plus local treatments on regression patterns of posterior pole retinoblastoma 27: 215-21. sial n: visual outcome and pattern of industrial ocular injuries 27: 8-11. sial n: visual outcome after intravitreal bevacizumab injection in macular edema secondary to central retinal vein occlusion 27: 84-8. siddiqui r: cat (t) is out of the bag 27: 113-5. siddiqui sj: prevalence of hepatitis b and c in the patients undergoing cataract surgery at eye camps 27: 27-9. siddiqui zk: post-keratoplasty glaucoma in secondary trans-scleral fixation of posterior chamber intra-ocular lens implant 27: 181-7. siddiqui zk: obituary prof. dr. tahir mahmood (19622010) 27: 52. soni m: basal cell carcinoma presentation, histopathological features and correlation with clinical behaviour 27: 3-7. soomro f: frequency and patterns of eye diseases in retina clinic of a tertiary care hospital in karachi 27: 155-9. soomro mz: latanoprost and herpetic keratitis 27: 227-8. soomro t: frequency and morphological patterns of malignant intra orbital tumors in various age groups 27: 204-9. tabssum g: comparison between acrylic hydrophilic and acrylic hydrophobic intraocular lens after phacoemulsification 27: 192-5. tahir my: outcome of delayed lacrimal probing in congenital obstruction of nasolacrimal duct 27: 176-80. tahir my: outcome of levator resection in congenital ptosis with poor levator function 27: 128-32. talpur ki: femtosecond laser assisted cataract surgry 27; 174-5. tayyab h: pattern of presentation and factors leading to ocular trauma 27: 96-102. tayyab h: visual outcome after intravitreal avastin (bevacizumab) for persistent diabetic macular edema 27: 188-91. ullah mr: amniotic membrane transplantation in ocular surface disorders 27: 138-42. waheed k: surgically induced astigmatism comparison between forceps and injector delivery system for foldable iol in phacoemulsification 27: 63-7. zaheer n: effects of primary chemotherapy, radiotherapy plus local treatments on regression patterns of posterior pole retinoblastoma 27: 215-21. abstract index cornea • oral mucosal graft with amniotic membrane transplantation for total limbal stem cell deficiency 27: 230. • rapid detection of acanthamoeba cysts in frozen sections of corneal scrapings with fungiflora y 27: 49. • robotic microsurgery: corneal transplantation 27: 51. glaucoma • randomized evaluation of the trabecular micro-bypass stent with phacoemulsification in patients with glaucoma and cataract 27: 116. investigations • comparison of macular thickness measured by optical coherence tomography after deep anterior lamellar keratoplasty and penetrating keratoplasty 27: 230. lasers • effect of nd: yag capsulotomy on the morphology of surviving elschnig pearls 27: 50. 237 • one – year outcomes of a bilateral randomised prospective clinical trial comparing prk with mitomycin c and lasik 27: 49. retina • antagonism of vascular endothelial growth factor for macular edema caused by retinal vein occlusions: two-year outcomes 27: 116. • central serous chorioretinopathy: an update on phathogenesis and treatment 27: 116. • intravitreal triamcinolone prior to laser treatment of diabetic macular edema; 24month results of a randomized controlled trial 27: 171. • management of rhegmatogenous retinal detachment with coexistent macular hole in the era of internal limiting membrane peeling 27: 230. • preoperative intravitreal bevacizumab use as an adjuvant to diabetic vitrectomy: histopathologic findings and clinical implications 27: 171. • ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema 27: 171. microsoft word kabeer ahmed 1 original article use of home remedies and traditional medicines for the treatment of common eye ailments in pakistan: a qualitative study khabir ahmad, mohammad aman khan, mohammad babar qureshi, mohammad daud khan, azam ali, clare gilbert pak j ophthalmol 2009 vol. 25 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: khabir ahmad senior instructor, section ophthalmology department of surgery aga khan university karachi, stadium road, karachi 74800 purpose: qualitative studies focusing on the use of home remedies and traditional medicines for eye health are lacking. we explored the use of eye remedies and traditional eye medicines (referred to hereafter as “eye remedies/tem”) in pakistan’s abbottabad district. material and methods: we conducted face-to-face key informant interviews with 16 teachers (8 men, 8 women). participants were asked to list eye remedies/tem used in their home or in areas where they lived. they were also asked to specify conditions for which each one of them is used. their responses were noted manually and the interview scripts were translated from urdu into english. a content analysis of the transcripts was carried out to identify the main themes arising from the interviews. results: eye remedies/tem were popular with the participants and in areas where they lived. 18 eye remedies/tem were identified, the majority of them being used to treat irritable, red eye. the most frequently mentioned symptom necessitating eye remedies/tem was burning or itching, followed by redness, watering and pain, and swelling. one participant noted his family uses goat’s milk diluted with water to treat red, dirty and discharging eyes in newborn babies. other main themes were the use of remedies/tem particularly surma (kohl) to “sharpen the vision” and to “enhance the appearance of the eyes”. 2 received for publication may’ 2008 … ……………………… conclusions: our study provides evidence of the use of eye remedies/tem in pakistan. future studies should look at the safety and efficacy of these therapies, the frequency of use in a large population and explore if these therapies are used together with, or in place of, conventional medicine. the practice of putting goat’s milk in eyes of newborn babies with red, dirty and discharging eyes must be discouraged. ome remedies include using foods or other household items to prevent and treat illness or maintain well-being whereas traditional medicines are defined as “health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being.”1 they are used worldwide, particularly in developing countries where one-third of the population still lack access to even essential medicines. while it is important to ensure the safety of all home remedies, particular attention needs to be paid to the ones used for eye health because eyes are delicate and a great care is needed to avoid visual loss, blindness and other eye morbidities. there have been increasing concerns that some traditional therapies may be harmful to the eye.26 for example, in africa, it is a significant cause of corneal blindness, particularly among children.7 in many cases even if home remedies and traditional eye medicines are benign, using them may result in delay in seeking appropriate care. a few small studies8-11have shown that home remedies are popular in pakistan, a country with a population of 156 million and where a sizeable population lack access to allopathic medicines. however, there are no studies specifically focusing on the use of home remedies and traditional medicines for eye health in the country. we report the findings of a qualitative study that explored the use of remedies and traditional medicines for eye health (referred to hereafter as “eye remedies/tem”) in pakistan’s abbottabad district. material and methods this qualitative study was part of a wider study in which we were exploring the knowledge and perceptions of eye conditions and their treatment among school children and their teachers. we interviewed 16 teachers (8 men, 8 women) one-on-one to identify eye remedies/tem used in their homes or in areas where they lived. their mean age was 31.8(range: 21-59) years and they had an average of 8 years teaching experience (range: 6 months-22 years). they taught grade 4-5 children in primary schools in the abbottabad district in northern pakistan and the majority of them (10 of 16) were graduates (table 1). table 1 characteristics of interviewees s. no age sex qualification work experience (years) 1 27 m bachelor of arts 3 2 40 m bachelor of arts 22 3 23 m bachelor of arts 3 4 25 m bachelor of arts 4 5 32 f bachelor of science 10 6 59 f bachelor of science 18 7 27 f bachelor of science 3 8 26 f master of science 3 9 35 f matric 19 10 32 f matric 9 11 28 f matric 9 12 33 f faculty of arts 16 13 24 m bachelor of science 1 14 26 m master of science 1 15 21 m bachelor of science < 1 h 3 16 51 m bachelor of arts 8 there are four main types of schools in pakistan: government school for boys, government school for girls, private school for boys, and private school for girls. one school each was selected from these categories based on easy accessibility. in each school, 4 teachers were selected also based on convenience. one of us (ka) conducted all the interviews. interviewees were asked in urdu the following questions: what home remedies and traditional medicines do you know of that can treat eye diseases or improve eye health? please specify eye conditions in which each one of them is used in your home and the area where you live. participant’s responses were noted manually during the interviews. the scripts were translated from urdu into english and analyzed. a content analysis was performed to identify the main themes arising from the interviews. important quotations were selected from the narrations to exemplify the major categories. results eye remedies/tem were popular with nearly all the participants and in areas where they lived. interviewees listed a total of 16 eye remedies/tem, their method of application, and the conditions for which these are used. surma (kohl) was mentioned most frequently and used for the greatest number of conditions, ranging from sharpening of vision to treating redness, watering, burning and itching. other common eye remedies/tem mentioned included rose water, honey, cold water splashes, alum and ice. surprisingly, one participant stated she had never seen them being used: “i do not know anything about them.” we identified the following main themes (table 2) arising from the interviews: irritable, red eye the main theme that emerged from the interviews was that the majority of the eye remedies/tem are used to treat irritable, red eye, with burning or itching being the commonest symptoms. this was followed by redness, watering and pain, and swelling: “for minor eye diseases such as burning, itching, watering, redness, and when the colour of the eyes is not normal, i mean when it is red, surma (kohl) is useful. if there is any injury to eyes, you put salt in water and the eyes are washed with it. if there is minor injury to the eyes, ice is placed on them (eyes). ice is also useful when eyes become red after exposure to heat.” several participants reported they also use rose water, hot fomentation, and honey. as one participant stated, “we also use rose water to treat watering, and for pain control. for adults with burning and painful eyes, a piece of cloth is heated to apply hot fomentation. in case of chronic pain or burning that is temporary in nature, drops of honey are placed into the eyes.” some used alum to treat these symptoms. five participants mentioned “splashing water into the eyes” as a good way to remove minor irritants or relive burning. red, dirty and discharging eyes in new born babies and children most participants believed that eye remedies/tem for adults can also be used by children. one male participant put it, “if children’s eyes are burning, small cubes of ice are put in a piece of cloth and cold compresses are applied intermittently. a cold wash cloth over the eye relieves pain. if the eyes are discharging, they are cleaned frequently with a handkerchief.” a female interviewee noted that if a mosquito flies into the eye, or a long fingernail damages the eye accidentally, one should avoid rubbing them. “we apply hot compresses to the closed eyelid. if we can not treat it, we take the child to the doctor because if it [an eye] goes, it goes”. one interviewee noted that his family uses goat’s milk diluted with water to treat red, dirty and discharging eyes in new born babies. better vision another common theme was the use of eye remedies/tem such as sumra and peppers “to sharpen vision”. nearly half interviewees reported using surma for this purpose. a participant revealed that he and his family “use surma to keep vision sound and see clearly” a third of them said that vegetables, especially carrots were necessary for good vision. better appearance of eyes a very common theme was the use of eye remedies/tem for enhancing the appearance of the eyes, making them look more prominent. nearly all interviewees reported the use of surma in their homes as well as in their respective areas: “black surma beautifies eyes”. one female participant said children 4 should avoid using surma because it causes infection. a few of them noted that honey and olive oil stimulates eyelash growth. discussion to our knowledge, this is the first qualitative study that specifically focuses on eye remedies/tem in a developing country. a total of 16 eye remedies/tem were reported being used to treat irritable red eye, improve vision and enhance the appearance of the eyes. red eyes are very common in developing countries (including pakistan) and can be due to a variety of causes. our study shows that it is the commonest eye condition treated with eye remedies/tem. while an evidence base on the safety and efficacy of these therapies is lacking, individuals with red eyes that are not improving after three days of onset of symptoms must be referred to an eye physician. individuals with red eye(s) presenting with decreased vision and/or severe eye pain need immediate referral because the condition may be due to potentially sight threatening causes (e.g. raised table 2: themes related to home remedies and traditional medicines for eye health theme remedy/tem examples red, irritable eye redness burning itching watering pain swelling soothing foreign body/foreign body sensation white surma black surma rose water honey ice chilled water alum saline hot fomentation paste of turmeric and black tea boric acid desi ghee (butter oil) tripla’s extracts “white surma offers a cooling sensation to eyes. black surma is used to treat burning eyes. a foreign body in the eye is removed by washing the eye with water slowly. putting ice on eyes gives relief to burning eyes.” “we use black surma to treat redness. white kohl is used to treat swollen and burning eyes” alum is dissolved in water and then eyes are bathed with it. this relives pain.” “black peppers are good for the treatment of burning eyes. ice is used to treat burning, and surma to treat watering, and swelling. turmeric and black tea are mixed, liquefied. this paste should be put in a piece of cloth which is applied as a bandage to the eyes. we apply it at night and is used to treat swelling and burning. eyes should not be open when placing the bandage.” “eyes are splashed with cold water if red chilles goes into them or if they are burning.” “if something hits the eyes, hot fomentation is done.” white surma relives burning. it also stops watering. if the eye is painful and reddish, we use rose water.” “rose water is used [to treat] burning eyes, kohl is used to treat dirty, watery eyes, and the sensation, like sand being in the eye. cold water splashes into the eyes give them cooling sensation. pure honey put into eyes daily keeps eyes clean. extracts of medicinal plant tripla is mixed with water and then used to treat red and swollen eyes. desi ghee is applied to the eyelids when the eyes itch. in the morning when the eyes are sticky, we wash them thoroughly with boric acid. .” “we use surma because it relives pain completely. rose water cures red eyes. for tired eyes, we wash them with chilled water.” “the remedy for burning eyes is honey. we put it in eyes. for burning, painful or itchy eyes, surma is used. when eyes are painful, people also use rose water.” “for burning rose water or surma is used.” “if there is a minor injury, we use surma.” “alum is dissolved in water and if eyes are painful or have white discharge, they are washed with it.” 5 red, dirty and discharging eyes in new born babies goat’s milk diluted with water. “we add water to goat’s milk and then red, dirty and discharging eyes of newborn babies and others less than one year of age are washed out with it.” vision black surma black peppers “black peppers taken with water….ensures good vision.” “surma is used to sharpen the vision of children.” “surma keeps vision clear and sharp.” “black surma is said to keep vision sharp.” “we use surma because it sharpens the vision.” better appearance black surma honey olive oil surma is used to make eyes look prominent.” “honey and olive oil are used for better growth of eyelashes. black sumra makes eyes look beautiful.” intraocular pressure or inflammation) and any delay in treatment due to the use of eye remedies/tem can lead to visual loss. in africa, harmful tem (e.g. the use of urine infected with gonococcus) can result in the destruction of the cornea and thus irreversible blindness2-6,12. red eyes without photophobia, pain, or visual disturbance is most commonly a result of infection or allergy13. a related symptom is itching which is the distinguishing feature of allergic eye disease. in general, a red eye in the absence of itching is not caused by allergic eye disease14. it is important to mention that in most situations, lay people cannot distinguish between different eye diseases that result in a red eye and examination by a trained eye worker or ophthalmologist would be useful. a burning sensation in the eyes was the commonest eye symptom for which eye remedies/tem were used. while there is no harm in applying a cool compress, splashing water into the eyes is a potentially harmful practice because it may introduce infection. attention should also be paid to make sure that any solution put into the eye is sterile. burning can result from a variety of reasons such dry eyes, some drugs, and exposure to bright sunlight, smoke, cosmetics, chemical fumes, and pollen. it is always important to identify the source of burning, and then avoid it if possible. one respondent said that goat’s milk diluted with water was put into the eyes of newborn and infants to treat redness and discharge. this practice should be discouraged. red, discharging eyes during the first 28 days of life is called ophthalmia neonatorum and, if due to gonococcus infection, can lead to blindness15. there are several options for preventing this condition including instilling antiseptic or antibiotic eye drops or ointment at birth. another common theme was the use of eye remedies/tem “to sharpen vision”. it is encouraging to note that a third of participants deemed the use of vegetables, especially carrots to be necessary for good vision. carrots and dark green leafy vegetables are good sources of vitamin a, which plays a critical role in light transduction in the retina, and which is needed to prevent the potentially sight threatening changes of xerophthalmia16. the main limitation of our study was the relatively small sample size, with all participants working in a single profession. ideally, similar studies in future should include a wider variety of groups such as traditional healers, eye care workers, patients with eye diseases, and individuals without eye diseases. another limitation of our study was that several aspects of eye remedies/tem including the frequency and reasons for the use were not explored17 nor were perceptions of their safety and efficacy. we conclude that there is evidence of the use of eye remedies/tem in pakistan. research is needed to assess the safety and efficacy of these therapies, to explore the frequency and determinants of their use in a large and diverse population, and explore if these therapies are used together with, or in place of, conventional medicines. the practice of putting goat’s milk in eyes of new born babies with red, dirty and discharging eyes should be discouraged. author’s affiliation khabir ahmad section ophthalmology, department of surgery aga khan university karachi stadium road, karachi 74800, mohammad aman khan pakistan institute of community ophthalmology, hayatabad medical complex hayatabad, peshawar mohammad babar qureshi 6 pakistan institute of community ophthalmology, hayatabad medical complex hayatabad, peshawar mohammad daud khan pakistan institute of community ophthalmology, hayatabad medical complex hayatabad, peshawar azam ali section ophthalmology, department of surgery aga khan university karachi stadium road, karachi 74800 clare gilbert international centre for eye health clinical research unit london school of hygiene and tropical medicine, london reference 1. stone e, gomez e, hotzoglou d, et al. transnationalism as a motif in family stories. fam process. 2005; 44: 381-98. 2. courtright p, lewallen s, kanjaloti s, et al. traditional eye medicine use among patients with corneal disease in rural malawi. br j ophthalmol. 1994; 78: 810-2. 3. klauss v, adala hs. traditional herbal eye medicine in kenya. world health forum. 1994; 15:138-43. 4. lewallen s, courtright p. role for traditional healers in eye care. lancet. 1995; 345: 456. 5. lewallen s, courtright p. peripheral corneal ulcers associated with use of african traditional eye medicines. br j ophthalmol. 1995; 79: 343-6. 6. yorston d, foster a. traditional eye medicines and corneal ulceration in tanzania. j trop med hyg. 1994; 97: 211-4. 7. whitcher jp, srinivasan m, upadhyay mp. corneal blindness: a global perspective. bull world health organ. 2001; 79: 214-21. 8. qidwai w, alim sr, dhanani rh, et al. use of folk remedies among patients in karachi pakistan. j ayub med coll abbottabad. 2003; 15: 31-3. 9. qidwai w, alim sr, dhanani rh, et al. use of home remedies among patients presenting to family physicians. j coll physicians surg pak. 2003; 13: 62-3. 10. shinwari mi, khan ma. folk use of medicinal herbs of margalla hills national park, islamabad. j ethnopharmacol. 2000; 69: 45-56. 11. tovey pa, broom af, chatwin j, et al. use of traditional, complementary and allopathic medicines in pakistan by cancer patients. rural remote health. 2005; 5: 447. 12. courtright p, lewallen s, chirambo m, et al. collaboration with african traditional healers for the prevention of blindness 13. singapore world scientific pub co inc. 2000. 14. wirbelauer c. management of the red eye for the primary care physician. am j med. 2006; 119: 302-6. 15. morrow gl, abbott rl. conjunctivitis. am fam physician. 1998; 57: 735-46. 16. foster a, klauss v. ophthalmia neonatorum in developing countries. n engl j med. 1995; 332: 600-1. 17. ahmad k, khan ma, khan md, et al. perceptions of eye health in schools in pakistan. bmc ophthalmol. 2006; 8. guess who answer marc amsler swiss ophthalmologist, born 1891, died 1968. 7 marc amsler was a student of jules gonin at the university of lausanne and an exponent of gonin's ideas about retinal detachment repair. he succeeded gonin in 1935 as chair of ophthalmology at lausanne, and in 1944 became professor at the university of zurich. he pioneered in the study of aqueous humor in uveitis and developed an interest in how to monitor macular symptoms in retinal disease. it seems likely that amsler got the idea for his patterns from a small card with a grid pattern that landolt designed to place in the center of his perimeter to test the macula. several devices had been invented and manufactured by the first half of the 20th century for the testing of small macular scotomas, but these required an examiner to move tiny test objects across the grid, sometimes within a stereoscope for greater precision. these instruments were not so easy to use, and of course did not document metamorphopsia. landolt may have intended to describe his test card in print, but he never did, and his plans for the card are not known. it appears to have been amsler's idea to take the grid out of the perimeter and use it as an independent test and in doing so amsler experimented extensively with different patterns and different colors of grid design. the authors of one article have stated without references that amsler was working on grids as far back as the 1920s, but alfred huber, a renowned swiss ophthalmologist who was a resident with amsler in zurich, has written that he was actively designing the grids in the period between 1944 and 1952. huber states that amsler was "the first to draw attention to the possibility of this test which still today fortunately has kept its value in a wonderful way." amsler grid = chart used to detect or document macular diseases amsler's sign = haemorrhage caused by applanation tonometry and cataract surgery in fuch's heterochromic iridocyclitis (fhi). it was once thought to be pathognomonic for fhi, was previously used as a diagnostic and confirmatory test in patients with suspected fhi reference: 1. amsler m, verrey f: heterochromie de fuchs et fragilite vasculaire.ophthalmologica. 1946; 111: 177. microsoft word riaz ahmad 5 195 original article comparison between acrylic hydrophilic and acrylic hydrophobic intraocular lens after phacoemulsification riaz ahmed, imran ghayoor, m mubassher malik, ghazala tabssum, furrukh ahmed pak j ophthalmol 2011, vol. 27 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: riaz ahmed memon house # 123 c, pechs block 2, tariq road karachi submission of paper may’2011 acceptance for publication november’ 2011 …..……………………….. purpose: to compare the results of acrylic hydrophilic and acrylic hydrophobic intraocular lenses in terms of visual acuity (va), behavior of eye (uveitis) and posterior capsular opacification (pco). material and method: the study was carried out from september 2004 to october 2005 in the department of ophthalmology liaquat national hospital karachi. one hundred patients were included in the study and were equally divided in two groups. all patients underwent phacoemulsification with iol implantation (50 patients hydrophilic iol and 50 hydrophobic iol). results: 96% had va of 6/12 or better unaided or with refraction, 2% developed posterior capsule thickening, whereas, none of the patients developed uveitis after one year. conclusion: there was no significant difference between two iols regarding va, uveitis and pco after one year follow up. there was no effect of biomaterial on pco. ataract is opacity of the lens that impairs vision, which is the leading cause of blindness worldwide1. in pakistan it contributes to 66.8% blindness2. the commonest ophthalmic surgical procedure being performed in the world is cataract surgery with insertion of intra-ocular lens3. an ideal prosthetic lens would reproduce the original function of the crystalline lens at near and distant vision and should be biocompatible. it should also prevent posterior capsular opacification (pco). posterior capsular opacification can be prevented by using biocompatible iol materials, square optic geometry and maximal optic capsule contact4-6. we wished to compare the biocompatibility of two different materials, hydrophobic acrylic and acrylic hydrophilic, as well as their ability to prevent pco. both iol material are good but we wanted to compare these two materials in our population to see whether they produce comparable outcome. material and method a quasi-experimental study of 100 patients was carried out from september 2004 to october 2005 at department of ophthalmology liaquat national hospital, karachi. in group a fifty patients had acrylic hydrophilic iol(c-flex) and in group b fifty patients had acrylic hydrophobic iol (acrysof) implanted in their eyes. to ensure the complete follow up, informed written consent was taken from all subjects. we included patients with senile cataract, consisting of nuclear sclerosis grades 2 & 3, cortical and posterior sub capsular cataract. eyes with clear posterior capsule immediately after surgery were included in the study. all operations were performed by a single surgeon. we excluded patients with nuclear sclerosis grade 4, post traumatic cataract, eye with pre operative uveitis, axial length more than c 196 25mm and less then 19mm, diabetic retinopathy and corneal dystrophy. patients enrolled in the study had visual acuity assessment with the help of snellen’s chart, slit lamp biomicroscopy examination of anterior segment, detailed fundus examination posterior segment and intraocular pressure measurement before and after the surgery. the position of iol, state of posterior capsular opacification (pco) and any other complication were also noted. topical medication was prescribed postoperatively to all patients, which included dexamethasone plus neomycin, diclofenac sodium four times daily and betamethasone plus neomycin ointment at bedtime. the follow-up schedule includes first post operative visit on 1st day after surgery, second on 1st week, 3rd on 1st month, 4th visit on 4th month, 5th on seventh month and 6th on 12th month of post operatively. at each visit best-corrected visual acuity was checked, uveitis and posterior capsular opacification were assessed according to the criteria on slit lamp biomicroscopy. uvietis was graded as shown in table 3. pco was graded according to the sellemen and lindstrom system11,12 as shown in table 4. clinically significant pco was defined as that having grades 3 or 4 and patients were advised for nd: yag laser capsulotomy. statistical packages for social science (spss.10) were used to analyze data. relevant descriptive frequency and percentage was computed for qualitative variables like sex, visual acuity, pco, uveitis for both groups. mean and standard deviation was computed for quantitative variables age for both groups. chi square test was used to see association for visual acuity, pco, uveitis for group a and group b with level of significance 0.05. results this study of one hundred patients was conducted at department of ophthalmology liaquat national hospital karachi. the patients were divided into two groups of fifty patients each. group a had acrylic hydrophilic iol implanted and group b had acrylic hydrophobic iol implanted. the age range of patients in both groups was 51-73 year. in-group a the mean of age was 61 years, with standard deviation of 6.62 and in group b the mean of age 60.78 years with standard deviation was 5.89. in group a there were twenty-nine were male and twenty-one were female. in-group b there were twenty were male and thirty were female. table no 1 show the pre operative visual acuity most of the patients ranging between 6/60 to 6/18. table 1 shows range of pre operative visual acuity from 6/60 to 6/18. table 2 shows post operative bestcorrected visual acuity (bcva) after one year indicating no statistically significant difference between the two groups. the chi-square 2.56 and p value is 0.464. table no 3 shows 1st postoperative week uveitis. the results indicate that there is no statistically significant difference between the two groups in postoperative 1st week uveitis. table 3 shows incidence of uveitis on 1st postoperative week. the results indicate that there is no statistically significant difference between the two groups in respect of uveitis on 1st postoperative week. the chi square 1.342 and p value is 0.511. table 4 shows posterior capsule opacification. the results indicate that there is no statistically significant difference between the two groups in terms of development of pco. the chi-square 1.695 and p value is 0.792. discussion posterior capsular opacification has been reported since the beginning of extra capsular cataract extraction. sir harold ridley documented this complication in his first cases11. it was particularly common and severe in the early days of pc-iol surgery (late 1970s and early 1980s) when the importance of cell and cortex removal was much less well understood than it is today. the rate of pco and subsequent nd: yag laser capsulotomy is on decreasing order owing to modern surgical techniques and improved iol materials. reduction of this complication is important as nd: yag laser capsulotomy is sometimes dangerous procedure with potential damage to iol, vitreous, retina and other structures12 and treatment of pco imposes significant cost burden on poor patients in a country like pakistan. in our study we used hydrophobic acrylic (acrysof) uv foldable multipiece posterior chamber iol in 50 eyes and acrylic hydrophilic (c-flex iol) in 50 eyes. the physical properties of the hydrophobic iol include overall length of 13mm with an optic of 6mm diameter. it has modified c-flexible blue core pmma haptic, whereas, the optical portion consist of high refractive index of 1.55 soft hydrophobic acrylic material, which is capable of being folded prior to 197 insertion, allowing through an incision of approximately 3.5mm. acrylic hydrophilic (c-flex), has biconvex optic with supporting haptics made of acrylic. the optic is made from rayacryl, which is a copolymer of hydrophilic and hydrophobic methacrylates namely hydroxy ethyl methyacrylate (hema) and methyl methacrylate (mma) and has water content of 26%. acrylic hydrophilic was chosen because of the specially patented haptic which prevents decenration, antero-posterior movement and buckling in response to capsular contraction7. it has relatively low index of refraction (1.46) and reflection coupled with equi-convex design reduces the chance of optical aberration after surgery8. we used widely accepted surgical technique for preventing pco in this study. continuous curvilinear capsulorrhexis12 with diameter slightly smaller than iol optics13, routine capsule polishing and implantation of foldable iol14 all of which has been shown to reduce the pco rates, best post operative visual acuity and biocompatibility. in this study we compare the two iols (acrylic hydrophobic) and (acrylic hydrophilic) regarding va, pco and biocompatibility. as far as the visual acuity is concerned, 96% of the patients see 6/12 or better in both groups a and b, whereas, 2% develop pco in eyes having both types of iol. it was concluded that no statistical significant difference between two groups in terms of post-op visual acuity and pco. the biocompatibility of iol materials and ac reaction in the post-op period ranging from end of first week till one year in both groups shows no statistical significant difference. antony et al15, reported incidence of pco after three year in 3.5% of cases, whereas, spratt16 et al described it 1.8% at 30 months using hydrophilic iols. so the incidence of 2% of pco in both groups in our study is equally comparable with other international studies. our study is also comparable with ashok vyas17, which shows visual acuity 6/12 or better in 97% of the eyes and no pco and uveitis at two years with both hydrophilic (c-flex) and hydrophobic (acrysof) iols. this low rate of pco is because of design of iols. both iols have square edge shape optic which provide a secondary barrier to lens epithelial cell migration. this may provide a mechanical barrier to cell migration “no space no cells” phenomenon11. it has been also proposed that the mechanism by which the hydrophobic iol’s lowers the pco rate is a combination of two things: first is the sharp, rectangular optic edge and the second is its sticky surface18, which adheres to lens capsule. this second third factor is the basis for the "sandwich theory"19. this theory suggests that the anterior capsule over the iol's bioactive surface bonds to the iol directly or as a result of the remaining lens epithelial cells (lec) preventing lec proliferation. thus the anterior capsule over the iol remains clear. inside the bag, the remaining lecs proliferate and migrate behind the iol. the 90-degree edge of the iol optic against the posterior capsule directs the proliferating lecs to form a monolayer between the iol and posterior capsule. another bioactive bond is formed when a single lec has the posterior capsule on one side and the bioactive iol surface on the other. the sandwich is formed and the cell-posterior capsule and cellbioactive iol surface junction prevents more cells from migrating behind the iol. although this study consisted of patients who were all pakistanis, but they belonged to different localities and had different postoperative behaviors. the criteria were also the same for the two groups. some studies shows surgeon’s factor on pco. it was ensured that all the patients had phacoemulsification performed by same surgeons of fully acquainted with the advances in surgical skills needed to tackle the factors involved in pco. moreover the behavior of the pakistani population regarding development of pco is also similar to that observed in different parts of the world. the use of modern flexible acrylic lenses and surgical techniques has tremendously reduced the incidence of pco thereby, benefiting the patients a lot. we have worked on null hypothesis that these two types of intraocular lenses though different in their material, both of them provide equal benefit to patients as regard va and reduction in pco and our study of short duration to some extend confirm our impression that acrylic hydrophilic iol and acrylic hydrophobic iols available in market can provide equal amount of benefit to patients, a cheaper option can be available with no hesitation. the difference between two iol with respect to outcome regarding va, behavior of eye and pco at one year was not clinically significant. so we suggest that further studies be conducted using contrast sensitivity and with duration of two years or more to asses the significant difference between two iols in our population. 198 table 1: pre operative visual acuity va 6/12 n (%) 6/18 n (%) 6/24 n (%) 6/36 n (%) 6/60 n (%) cf n (%) total group a 5 (10) 12 (24) 11 (22) 9 (18) 10 (20) 3 (6) 50 group b 3 (6) 13 (26) 13 (26) 11 (22) 8 (16) 2 (4) 50 total 8 25 24 20 18 5 100 group a: acrylic hydrophilic iol implanted patients. group b: acrylic hydrophobic iol implanted patients va: visual acuity, cf: counging finger, iol: intraocular lens table 2: post operative visual acuity (12th month) va 6/6 6/9 6/12 6/18 total group a 38 8 2 2 50 group b 33 11 4 2 50 total 71 19 6 4 100 chi square 25b, df 3, p value 0.464 group a: acrylic hydrophilic iol implanted patients. group b: acrylic hydrophobic iol implanted patients va: visual acuity, iol: intraocular lens table 3: first week post operative uveitis uveitis grade 0 grade 1 grade 2 grade 3 grade 4 group a 39 10 1 0 0 group b 34 15 1 0 0 total 73 25 2 0 0 chi square 1,342, df 2, p 0.511 group a: acrylic hydrophilic iol implanted patients. group b: acrylic hydrophobic iol implanted patients cell in anterior chamber: grade 0: no or less than 5 cells, grade 1: 5 – 10 cells +, grade 2: 11-20 cells ++, grade 3: 21-50 cells +++, grade 4: > 50 cells ++++, iol: intraocular lens table 4: posterior capsule opacification (12th month) pco grade 1 grade 2 grade 3 grade 4 total group a 43 4 2 1 50 group b 41 6 2 1 50 total 84 10 4 2 100 chi square 1,695, df 4, p 0.792 group a: acrylic hydrophilic iol implanted patients. group b: acrylic hydrophobic iol implanted patients pco: posterior capsule opacification, iol: intraocular lens, grade 1: no or slight pco without reduced red reflex, also no pearls at all or pearl not on the iol edge. grade 2: mild pco reducing the red reflex, eschnig pearls to the iol edge. grade 3: moderate fibrosis or elschnig pearls inside iol edge but with a clearer visual axis. grade 4: severe fibrosis or elschnig pearls cover the visual axis and severely reducing the red reflex. 199 conclusion there was no significant difference in visual acuity, uveitis and pco in hydrophilic and hydrophobic iol after one year. these two iols show same characteristics. the optic of both lenses have square truncated edges that functionally blocks ingrowths of lens epithelium cell migration towards visual axis, leaving clear posterior capsules. author’s affiliation dr. riaz ahmed liaquat national hospital stadium road, postal code 74800 karachi dr. imran ghayoor liaquat national hospital stadium road, postal code 74800 karachi dr. muhammad mubassher malik liaquat national hospital stadium road, postal code 74800 karachi dr. ghazala tabssum liaquat national hospital karachi stadium road, postal code 74800 karachi dr. furrukh ahmed liaquat national hospital stadium road, postal code 74800 karachi reference 1. thylefors b, negral ad, pararaj sr, et al. global data on blindness. bull world health organ. 1995; 73: 115-21. 2. khan aq, qureshi mb, khan md. rapid assessment of cataract blindness in age 40 year and above in district skardu, baltistan, northern areas, pakistan. pak j ophthalmol. 2003; 19: 84-9. 3. nadeem hb, riaz ma. medical pre assessment clinic for cataract patient. pak j ophthalmol. 1999; 15: 105-7. 4. apple dj, peng q, visessook n, et al. surgical prevention of posterior capsule opacification. part 1: progress in eliminating this complication of cataract surgery. j cataract refract surg. 2000; 26: 180-7. 5. apple dj, peng q, visessook n, et al. surgical prevention of posterior capsule opacification. part 2: enhancement of cortical clean up by focusing on hydrodissection. j cataract refract surg. 2000; 26: 188-97. 6. peng q, visessook n, apple dj, et al. surgical prevention of posterior capsule opacification. part 3: intraocular lens optic barrier effect as second line of defense. j cataract refract surg. 2000; 26: 198-213. 7. erie jc, bandhauer mh, mclaren jw. analysis of postoperative glare and intraocular lens design. j cataract refract surg. 2001; 27: 700-12. 8. farbowitz ma, zabriskie na, carandall as, et al. visual complaint associated with the acrysof acrylic intraocular lens. j cataract refract surge. 2000; 26: 1339-45. 9. sellman tr, lindstrom rlk. effect of a planoconvex posterior chamber lens on capsule opacification from elschnig pearl formation .j cataract refract surg. 1998; 24: 68-72. 10. aslam tm, dhillon b, werghi n, et al. system of analysis of posterior capsule opacification. br j ophthalmol. 2002; 86: 1181-6. 11. apple dj, peng q, ram j. the 50th anniversary of the intraocular lens and a quiet revolution. ophthalmology. 1999; 106: 1861-2. 12. apple dj, solomon kd, tetz mr. posterior capsule opacification. surv ophthalmol. 1992; 37: 73-116. 13. .ravalico g, tognetto d, palmba. capsulorhexis size and posterior capsule opacification. j cataract refract surg. 1996; 22: 98-103. 14. yamda k, nagamoto t, yozawa. effect of intraocular lens design on posterior capsule opacification after continuous curvilinear capsulorhexis. j cataract refract surg. 1995; 21: 697-700. 15. antony s, glen t, fernado, basil b, crayford. posterior capsule opacification and lens epithelial cell layer formation: hydroview hydrogel versus acrysof acrylic intraocular lenses. cataract refract surg. 2001; 27: 1047-54. 16. spratt hac, khan y, claoue’c. pco and nd: yag rates after centerflex iol implantation: 30 month result. presented in ascrs congress, san diego, california, usa 2004. 17. ana hs. two-year results with center flex look promising. euro time. 2002; 75: 14. 18. nishi o, nishi k, wickstrom k. preventing lens epithelial cell migration using intraocular lenses with sharp rectangular edges. j cataract refract surg. 2000; 26: 1543-9. 19. linnola rj. sandwich theory: bioactivity-based explanation for posterior capsule opacification. j cataract refract surg. 1997; 23: 1539-42. microsoft word dawood khan 21 original article preliminary results of uv-a riboflavin crosslinking in progressive cases of keratoconus, in pakistani population muhammad dawood khan, sameer shahid ameen, omar ishtiaq, muhammad khizar niazi, muhammad aamir araeen, muhammad afzal naz, muhammad fayyaz pak j ophthalmol 2011, vol. 27 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad dawood khan armed forces institute of ophthalmology rawalpindi received for publication august’ 2010 …..……………………….. purpose: keratoconus is a progressive non-inflammatory thinning disorder of the cornea which being a disease of young, has a significant psychosocial value. corneal crosslinking with riboflavin stops progression by increasing the strength of the cornea and has revolutionized the treatment of corneal ectasias at an early stage. materials and methods: this is an ongoing prospective interventional single site study conducted in armed forces institute of ophthalmology, rawalpindi, pakistan.35 cases of more than 12 years with progressive keratoconus or any other corneal ectasia were included in the study after march 2006. results: the mean age was 17.71+4.6 years. 41.9% of the cases were males while 58.1% of them were females with a frequency of 13 and 18 respectively. right eye was treated in 54.8% of the cases whereas left eye was treated in 45.2% of the cases with a frequency of 17 and 14 respectively. mean preoperative bcva was 0.53+/-0.36 which improved by at least one line in 61.29% of the cases, remained stable in 35.48% cases and deteriorated in 3.23% cases. mean post-operative bcva was 0.39+/-0.24.pre-operative mean of steepest k reading (k steep) was 50.60+/-5.41d,which reduced to 48.85+/-6.11d (p< 0.001). the steepest k reading improved in 67.74% cases, remained stable in 25.81% cases and deteriorated in 6.45% cases. two cases (6.45%) developed keratitis leading to corneal scarring. conclusion: our study shows that cxl is a safe and effective procedure in stopping progression of corneal ectasias. eratoconus is a progressive noninflammatory thinning disorder of the cornea which leads to mixed myopic and irregular astigmatism1. it is derived from the greek words keratosmeaning “cornea” and konos meaning “cone”. eberhard spoesi and theo seiler developed corneal cross-linkage (cxl) procedure in late 1990’s2,.3. wollensak et al introduced the procedure as an alternative to penetrating keratoplasty in treating progressive keratoconus in 20034. owing to the latest diagnostic modalities the incidence of keratoconus is reported to be about 1 in 600 to 1 in 4205. moreover, being a disease of young, keratoconus has a significant psychosocial value causing loss of productivity and disproportionate impact on quality of life6. cxl strengthens the cornea by increasing the numbers of covalent bonds between collagen fibers. once the riboflavin is activated by ultraviolet-a light, it promotes a free radical pathway that causes crosslinkage of corneal collagen and increases its strength by more than 300%7. cxl was approved in europe for clinical use in january 2007 and is still undergoing fda trials in united states. apart from treating corneal ectasias, cxl with riboflavin is being studied in treatment of corneal k 22 infections where in vitro trials have shown elimination of methicillin resistant staph aureus and pseudomonas8. cxl is also being tried for the treatment of pseudophakic corneal edema where the corneal tissue was thinned by9. materials and methods this ongoing prospective interventional single site study was conducted in armed forces institute of ophthalmology, rawalpindi, pakistan. 35 cases of more than 12 years with progressive keratoconus or any other corneal ectasia and who could complete follow up of 6 months were included in the study after march 2006. any patient having corneal scarring, uncontrolled vkc or glaucoma, corneal thickness less than 400µm or prior history of corneal surgery were excluded from the study. informed written consent was obtained from the participants and the study was reviewed and approved by ethics committee. pre-operative complete ocular examination was performed including logmar bcva, keratometery (canon rk-f1), videokeratography (haag-streitctk 922) and pachymetry (reichert iopac advanced). relevant information was documented on a follow-up proforma. the cxl was performed under sterile conditions as a day-care procedure. after anaesthetizing with proparacaine hydrochloride 0.5% (alcain) eye drops, central 8 mm of corneal epithelium was removed. a drop of 0.1% riboflavin solution was applied to the cornea every 2 minutes for thirty minutes before the irradiation. aqueous flare in anterior chamber was checked on a slit-lamp. the ultraviolet lamp (iroc ag, zurich, switzerland) was checked on meter to confirm that uv-a light with a wavelength of 365+/-10 nm and an irradiance of 3+/ 0.3mw/cm2 was being emitted. then central cornea was irradiated with this source for 30 minutes during which riboflavin instillation was continued every 2 minutes. post-operative care included application of bandage contact lens, topical moxifloxacin (vigamox) and prednisolone (predforte) eye drops till complete re-epithelialization of the cornea. follow-up examination was performed at 6 months for record of bcva and k-readings. data had been analyzed using spss version 15. mean and standard deviation (sd) were used to describe the variables. frequency and percentage was used to describe variables such as gender and eye involved. paired sample t-test was applied to check the significance of change in numeric variables. pvalue <0.05 was considered as significant. results out of 35 cases enrolled for this study 4 cases were lost for follow-up. results of 31 cases who completed the follow-up were analyzed. all cases were having progressive keratoconus, other ectasias being very rare. pre and post operative keratometry readings were taken as criteria for corneal stabilization. however pre and post operative bcva was taken as additional criterion. the mean age was 17.71+4.6 years. 41.9% of the cases were males while 58.1% of them were females with a frequency of 13 and 18 respectively. right eye was treated in 54.8% of the cases whereas left eye was treated in 45.2% of the cases with a frequency of 17 and 14 respectively. mean pre-operative bcva on logmar was 0.53+/-0.36.bcvaimproved by at least one line in 61.29% of the cases, remained stable in 35.48% cases and deteriorated in 3.23% cases. mean post-operative bcva on logmar was 0.39+/-0.24. this was a statistically significant improvement (p<0.001). pre-operative mean of steepest k reading (k steep) was 50.60+/-5.41d. after treatment with cxl, mean k steep reduced to 48.85+/-6.11d (p< 0.001). the steepest k reading improved in 67.74% cases, remained stable in 25.81% cases and deteriorated in 6.45% cases. two cases (6.45%) developed keratitis leading to corneal scarring. discussion raiskup-wolf f et al in their study concluded that the improvement in vision after cxl is due to decrease in astigmatism and corneal curvature as well as topographical homogenization secondary to increase corneal rigidity. they followed up patients for up to six years. at 1 year post op 53% (127/241) of eyes had gained one line bcva from baseline and decreased astigmatism by a mean of 0.93d in 50% (120/241). keratometry and astigmatism remained unchanged in 17% (41/241) and 36% (86/241) eyes respectively10. mean improvement in our study is comparable to this study in which there is improvement in bcva by one line though after one year. grewel et al also concluded in his study halt of progression in keratoconus11. by 1 year post op he did 23 table-1: demogarphic description of patients (n = 31) variables frequency n (%) gender male female 13 (41.9) 18 (58 eye involved left right 14 17 table 2: pre & post-operative description of different variables (n = 31) variables pre operative post operative p-value mean sd mean sd bcva(log mar) 0.53 0.36 0.319 0.24 < 0.001 k steep 50.60 5.41 48.85 6.11 < 0.001 k flat 46.83 4.42 46.40 5.27 0.393 age sex eye pre-op bcva (logmar) post-op bcva (logmar) pre-op k steep (ds) pre-op k flat (ds) post-op k steep (ds) post-op k flat (ds) difference k steep result k steep result bcva lines 15 f r 1.00 0.60 65.25 60.00 64.00 60.25 -1.25 better -2 15 f l 1.00 0.60 63.00 57.50 61.25 56.25 -1.75 better -2 13 f r 0.18 0.18 42.00 40.25 41.25 43.25 -0.75 better 0 13 f l 0.18 0.18 52.50 50.50 51.75 50.25 -0.75 better 0 13 m r 0.78 1.00 55.25 50.25 61.50 54.75 6.25 worse +1 13 m l 0.78 0.48 49.50 47.50 49.25 47.25 -0.25 same -2 18 m r 0.60 0.60 52.75 48.75 49.75 48.75 -3.00 better 0 18 m l 0.48 0.48 51.25 48.75 50.25 47.25 -1.00 better 0 14 f r 0.78 0.48 45.25 44.00 46.00 43.00 0.75 worse -2 14 f l 1.00 0.60 47.50 45.00 46.25 43.25 -1.25 better -2 16 m r 1.00 0.60 56.25 48.50 55.75 48.00 -0.50 same -2 16 m l 1.00 0.48 57.00 48.25 56.00 47.50 -1.00 better -3 19 m r 0.78 0.18 53.25 49.00 51.25 47.50 -2.00 better -4 16 m r 0.30 0.18 47.75 46.75 45.75 46.25 -2.00 better -1 12 f r 0.18 0.18 49.75 44.75 44.25 51.50 -5.50 better 0 16 f r 0.00 0.00 42.00 40.25 41.50 43.50 -0.50 same 0 12 f l 0.30 0.18 51.50 46.50 45.50 51.75 -6.00 better -1 16 f l 0.00 0.00 52.50 50.50 53.00 51.75 0.50 same 0 16 f r 0.18 0.00 47.75 46.00 47.25 45.75 -0.50 same -1 19 m r 0.18 0.18 52.75 48.75 49.75 48.75 -3.00 better 0 19 m l 0.18 0.18 51.25 48.75 50.25 47.25 -1.00 better 0 21 f l 0.60 0.18 53.50 45.50 50.25 45.25 -3.25 better -3 23 m l 1.00 0.30 51.00 45.25 50.75 44.75 -0.25 same -4 20 f r 0.30 0.30 44.50 42.00 45.00 42.00 0.50 same 0 30 f r 0.18 0.18 48.00 44.75 47.50 43.25 -0.50 same 0 24 f r 0.48 0.18 45.00 43.25 40.75 39.25 -4.25 better -2 24 f l 0.30 0.00 44.75 43.50 40.50 39.25 -4.25 better -1 16 f r 0.78 0.30 47.75 42.25 43.25 38.00 -4.50 better -3 16 f l 1.00 0.30 47.50 41.75 43.50 38.50 -4.00 better -4 26 m r 0.78 0.60 55.25 50.25 49.75 45.00 -5.50 better -1 26 m l 0.30 0.18 45.25 42.75 41.75 39.50 -3.50 better -1 24 age 3025201510 fr eq ue nc y 10 8 6 4 2 0 mean =17.71� std. dev. =4.606� n =31 fig. 1: age description of patients (n = 31) 41.94% 58.06% male female fig. 2: gender description of patients (n = 31) 45.16% 54.84% left right fig. 3: eye involved or damage (n = 31) fig. 4: change in variables before and after the operation (n = 31) pre-operative picture post-operative picture 25 not observe any statistically significant changes from baseline mean bcva (p=0.89) whereas our study showed statistically significant improvement after only 6 months of follow up. in a study conducted by agarwal in india, bcva improved at least one line in 54% of eyes and remained stable in 28% of eyes after follow up of 12 months5.this study carries high significance being conducted in south asia. research cases were comparable with each other considering similar social and environmental factors. our study showed slightly better visual results which are comparable with this study. hoyer and colleagues found that visual acuity improved significantly in at least one line or remained stable in the first year in 48.9% and 23.8% respectively; in the second year in 50.7% and 29.6% respectively, and in the third year in 60.6% and 36.4%respectively. keratectasia significantly decreased in the 1st year by 2.29 d, in the 2nd year by 3.27 d, and in the 3rd year by 4.34 d12.conforming with this study we also found improvement of about 2 d within 6 months only. improvement in keratectasia is directly related to post op duration which is encouraging for our ongoing study because we may expect progressive improvement in bcva as well as k readings in our cases with longer follow-up. bcva improves by virtue of decreased astigmatism resulting from increased corneal rigidity13-15. carina and colleagues conducted study on 117 cases and found to have keratitis and corneal scarring in 4 cases. amount of visual loss was determined by the location of scarring. in our study we had only two cases who developed the complication which gives us the confidence to say that cxl is a safe procedure16,17. conclusion our study shows that cxl is a safe and effective procedure in stopping progression of corneal ectasias. it is recommended that more studies with longer follow up and larger sample size be conducted to see long term effects of this procedure. author’s affiliation brig dr muhammad dawood khan armed forces institute of ophthalmology rawalpindi col dr sameer shahid ameen armed forces institute of ophthalmology rawalpindi maj dr omar ishtiaq armed forces institute of ophthalmology rawalpindi maj dr muhammad khizar niazi armed forces institute of ophthalmology rawalpindi maj dr muhammad aamir araeen armed forces institute of ophthalmology rawalpindi brig dr muhammad afzal naz armed forces institute of ophthalmology rawalpindi brig dr muhammad fayyaz cmh rawalpindi reference 1. al-hamdan g, al-mutairi s, al-adwani e, et al. bilateral coexistence of keratoconus and macular corneal dystrophy. oman j ophthalmol. 2009; 2: 79-81. 2. sparl e, huhle m, kasper m, et al. increased rigidity of the cornea caused by intrastromal cross-linking. ophthalmologe. 1997; 94: 902-6. 3. spoerl e, huhle m, seiler t. induction of cross-links in corneal tissue. exp eye res. 1998; 66: 97-103. 4. wollensak g, spoerl e, seiler t. riboflavin/ultraviolet-ainduced collagen crosslinking for the treatment of keratoconus. am j ophthalmol. 2003; 135: 620-7. 5. agrawal vb. corneal collagen cross-linking with riboflavin and ultraviolet a light for keratoconus: results in indian eyes. ind j ophthalmol. 2009; 57: 111-4. 6. kymes sm, wallinejj, zadnik k, et al. quality of life in keratoconus. am j ophthalmol. 2004; 138: 527-35. 7. hafezi f, mrochen m, iseli hp, et al. collagen crosslinking with ultraviolet a and hypoosmolar riboflavin solution in thin corneas. j cataract refract surg. 2009; 35: 621-4. 8. greebelg, schrier a, attia h, et al. in vitro antimicrobial efficacy of riboflavin and ultraviolet light on staph aureus, methicillin resistant staph aureus (mrsa) and pseudomonas aeruginosa. invest ophthalmol vis sci. 2009; 25:799-802. 9. stulting rd. update on riboflavin-uv crosslinking. paper presented at: the ascrs symposium on cataract, iol and refractive surgery. april 6, 2009; san francisco, ca. 10. raiskup-wolf f, hoyer a, spoerl e, et al. collagen crosslinking with riboflavin and ultraviolet-a light in keratoconus: long term results. j cataract refract surg. 2008; 34: 796-801. 11. grewal ds, brar gs, jain r, et al. corneal collagen crosslinking using riboflavin and ultraviolet-a for keratoconus. j cataract refract surg. 2009: 35: 425-32. 12. hoyer a, raiskup-wolf f, spörl e, et al. collagen crosslinking with riboflavin and uva light in keratoconus. results from dresden. ophthalmologe. 2009; 106: 133-40. 13. kohlhaas m, spoerl e, schilde t, et al. biomechanical evidence of the distribution of cross-links in corneas treated with riboflavin and ultraviolet a light. j cataract refract surg. 2006; 32: 279-83. 26 14. hafezi f, kanellopoulos j, wiltfang r, et al. corneal collagen crosslinking with riboflavin and ultraviolet-a to treat induced keratectasia after laser in situ keratomileusis. j cataract refract surg. 2007; 33: 2035-40. 15. romppainen t, bachmann lm, kaufmann c, et al. effect of riboflavin-uva-induced collagen crosslinking on intraocular pressure measurement. invest ophthalmol vis sci. 2007; 48: 5494-8. 16. koppen c, vryghem jc, gobin l, et al. keratitis and corneal scarring after uva/riboflavin cross-linking for keratoconus. j refract surg. 2009; 25: 819-23. 17. angunawela ri, amalich-montiel f, allan bds. peripheral sterile corneal infiltrates and melting after collagen crosslinking for keratoconus. j cataract refract surg. 2009; 35: 606-7. 18. bateman j. microphthalmos. in development abnormalities of the eye. int ophthalmol clin. 1984; 24: 87-107. 19. conskunseven e, jankov mr, hfezi f. contralateral eye study of corneal collagen cross-linking with riboflavin and uva irradiation in patients with keratoconus. j refract surg. 2009; 25: 371-6. microsoft word editorial 24,2,08 53 editorial management of retinal detachment according to risk factors retinal detachment is a sight threatening and potentially blindening condition which if treated promptly can save and salvage good vision. on the other hand, in spite of prompt and timely surgery sometimes the visual outcome is not up to our expectations. these things pose a problem especially in our society where economics play a major role. there is very limited medical insurance for private sector and public sector is inundated with huge numbers. the number of vr surgeons is certainly insufficient to cope with the amount of patients and there is an obvious and dire need for more facilities to perform these surgeries. in this scenario we need to have some basis upon which we can build our decisions and expectations so that our system becomes more efficient with best possible results. there have been two good efforts recently in the form of studies done in pakistan, the first one to find out about the risk factors for developing pvr which eventually will predict the surgical outcome and the second about different presentations, their management and results. these efforts are extremely useful and give the idea of what kind of patients we are dealing with and at the same time some insight into our surgical management. they have shown for example that a retinal detachment of 1 month duration is a very significant landmark as a prognostic factor for pvr. on the other hand there are some concepts which require special attention. i would like to try and clarify some points from one of the studies which otherwise may create some confusion for others. some concepts of the study: a. the study gives an impression that there could have been some confusion between the diagnosis of a dialysis and a grt (giant retinal tear). the basis of my presumption is the fact that in their study all the dialysis had pvr which had developed within two weeks, they were dealt in by vitrectomy and they all had bad visual outcome. why? this compels us to look more carefully into the situation. b. second is a concept of leaving the oil in permanently. some believe that as silicone oil has not shown any problem for 6 months (period of their follow-up) therefore it will never do so in the future and can be left safely in the eye indefinitely. c. it was also stated that patients develop cataract in a grt. d. there were genuine concerns about anterior pvr which became a major factor resulting in failure of surgery, without any possible solution. e. one very interesting comment about their technique was that cryo was applied in 2 rows only posterior to the breaks. f. it has been quoted that silicone oil has better retinal attachment rate than sf6. the visual results in our local study are not up to the mark, so we will have to look into it in detail to see whether the results were as expected or not. the dialysis which were treated; were either not dialysis but grts or if they were dialysis then the surgical management should have been different. dialysis is usually (not always) a result of blunt ocular trauma where by the peripheral retina is torn or avulsed at the edge. there is a roof of vitreous base over the defect therefore, much less rpe cells will trickle over into the vitreous cavity resulting in much less pvr. that is why the procedure of choice for a dialysis is cryo / buckle and/or drain. best form of external temponade is a sponge for a dialysis but then personal preferences are justified. we know that if we do a vitrectomy on a dialysis then there is a danger of it being converted to a grt along with all the sequelae. as for the duration of silicone oil (so), the reality is that oil seldom causes any problem before 6 months. 54 1000 to 1300 cst so is supposed to last about 6 to 8 months after which it is usually removed; whereas, the 5000 cst is usually good for over 5 years. variations are always there. we are aware of the controversy about silicone oil being toxic to the retina at times, therefore where ever possible it should be removed. however, there will be cases where we have to leave it for as long as possible. cataract which is seen after a grt is usually because of the surgery and silicone oil. one belief is that oil will provide better temponade than the gas but the basis of this has been doubtful as gas was not tried at all in their study. it is the opinion of many authorities that gas can provide better temponade; it’s the reduction of size rate versus longevity of oil which makes the difference. the relative advantages of the oil include clear media in the post operative period which can help an only eye patient to cope and the surgeon to perform laser in some situations. it can also provide long term temponade. where as gas does not require a separate procedure for removal and cause less cataracts. indeed, we see a predominant trend here towards not using the intravitreal gases with vitrectomy as compared to the developed world. superior breaks can easily be covered with gas (sf6 or c2f6) even without any external support. in case of inferior break also; gases like c3f8 can be sufficient but usually with external temponade and proper post-op posturing. one very important message that i would like to pass here is about cryo. it should cover all the edges, as fluid can go around from anterior side. as rightly stressed by the author we should not freeze the exposed base in the middle of the hole as it can release rpe cells and cause pvr. we also have to be careful not to apply cryo twice at one spot as it can later cause necrosis and breaks. the freeze ball should only come to the edge of the break. books have taught us how far back to place our encircling bands and we may modify it according to our needs. we know that the purpose of a 360 degree band is not to cover the holes but to support the vitreous base and can also be used to counteract the pvr forces. when placed posteriorly these bands produce a barrage between the anterior and posterior retina so that the posterior retina stays relaxed and flat. but, when we encounter anterior pvr our placement of band should be anteriorly to counter act that force. inferior pvr and later tractional redetachments have haunted our surgeons for quite some time. once developed, it has to be countered by inferior relaxing retinotomies or even retinectomy, but liquids like heavy silicone can also help avoid these problems. however, the cost of this is higher and it has to be removed within 3 months. second option is 360 degree band or inferior high external temponade along with silicone oil and proper post-operative posturing. trauma and penetrating injury causes high level of pvr therefore, it is useful to consider anti proliferative agents like intravitreal triamcinolone and infusions containing heparin and 5fu to flush the vitreous cavity, just like in a macular translocation surgery. the responsibility lies with us ophthalmologists who are doing or are interested in doing retinal surgery to get as much training as possible in this field and to keep up to date with the newer developments to perform safe surgery. we should also try to follow basic rules laid down by the pioneers to deal with cases according to their risk factors. one such basic rule in the treatment of retinal detachment is, “do it from the outside as far as possible”. the common exceptions are: most aphakic and pseudophakic detachments, pvr with tightening, too far posterior multiple breaks etc. one of the most important factors in deciding whether to do an external procedure or a vitrectomy is presence or absence of a pvd (posterior vitreous detachment). and remember one thing, “pvr is often a result of failed surgery rather than a cause for it“. khurram a. mirza microsoft word abdul qayyum corrected 187 original article prevalence of diabetic retinopathy in quetta balochistan abdul qayyum, amir muhammad babar, gurmak das, abdullah jan badini pak j ophthalmol 2010, vol. 26 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: abdul qayyum department of ophthalmology bolan medical college quetta received for publication may’ 2010 …..……………………….. purpose: early detection, to study the frequency, appropriate photocoagulation therapy and to educate masses at broader level. material and methods: this study was carried out at department of ophthalmology, bolan medical college / helpers’ teaching eye hospital, quetta from june 2006 to june 2008. all patients were known diabetic. about 2580 patients were selected for the study. all the patients, screened for diabetic retinopathy, had complete detailed history including family history. the investigations included urine and blood sugar analysis both in fasting and random states. every patient had complete ocular examination. it included visual acuity, refraction, slit lamp biomicroscopy, tonometry, ophthalmoscopy with both, direct, indirect ophthalmoscope and +90d lens. ffa and fundus photography were done where it was necessary. the patients of proliferative diabetic retinopathy (pdr) and diabetic maculopathy were subjected to photocoagulation therapy. the patients with vitreous haemorrhage and tractional retinal detachment (trd) were dealt by vitrectomy. results: approximately 2580 patients were registered for study. age group ranged between 22-75 years. average age was 51 years. among them 1497 (58%) were male and 1083 (42%) were females. about 582 patients were having iddm while 1998 were niddm variety. out of 2580 patients, 1410 patients were suffering from diabetic retinopathy. the male patients were about 59% (832) and female were 41% (578). 92% of patients presented with bilateral retinopathy and 8% with unilateral retinopathy. the relationship of retinopathy with duration was as under. it was 19% in 1-5 years duration, 27% in 6-10 years, 70% in 11-15 years, 82% in 16-20 years and 90% in more than 20 years duration period. 1652 eyes (61%) presented as non-proliferative diabetic retinopathy (npdr) and 1056 (39%) as proliferative diabetic retinopathy (pdr). clinically significant macular edema (csme) was seen in 677 eyes with npdr and 216 eyes with pdr i.e. 893 eyes (33%). vitreous haemorrhage was seen in 189 eyes (7%) and tractional retinal detachment in 54 eyes (2%), neovascular glaucoma in 27 eyes (1%). laser photocoagulation was done in 1056 eyes. visual acuity improved in 327 eyes (3%). it remained same in 507 eyes (48%) while it got worse in 222 eyes (21%). conclusion: in this hospital based descriptive study, diabetic retinopathy was more frequently seen in male individual. (a) the presentation of diabetic retinopathy was bilateral in majority of patients. (b) the prevalence of diabetic retinopathy was related with duration of diabetes. non-proliferative diabetic retinopathy (npdr) was more frequent as compared to proliferative diabetic retinopathy (pdr). laser photocoagulation improved vision in patients of diabetic retinopathy who had no vitreous haemorrhage and tractional retinal detachment. 188 iabetes mellitus is undoubtedly of an ancient origin1. the history of diabetes mellitus is as old as medicine itself. in the pre-christian era, “the honey urine” was described by su’srute in hindu medicine and the flesh and the limbs to urine by aretaeus of cappadocia2. the diabetes mellitus is one of major cause of blindness in the world. in united states from 1980 through 1987, the annual prevalence of diabetes mellitus increased 9% from 24.4 to 27.6 / 1000 united states residents3. according to who estimates in 1995, 4.3 million people in pakistan had diabetes mellitus. it will swell up to 11.6 million by the year 20254. according to pakistan national survey, overall prevalence of diabetes mellitus is 11.47%. the advanced age, inheritance, excessive caloric intake, obesity, less physical activity and various forms of stress are associated risk factors5. of all systemic diseases that affect eye, diabetes mellitus is the most common condition that leads to visual loss and blindness6. the diabetic retinopathy now ranks with glaucoma and senile macular degeneration as the leading cause of blindness in developing countries7. the prevalence of diabetic retinopathy is related to the duration of diabetes mellitus. it occurs particularly in 5th to 7th decade of life, 50% of cases appear between ages of 40 & 50 years, only 51% (this percentage needs correction) in first decade and 3% in eighth. the incidence of diabetic retinopathy is influenced by several factors like, age of onset of diabetes, the length of its duration, the control of glycosuria, and above all, on the diligence of observer in searching early lesion. vageners et al pointed out that prior to introduction of insulin; the incidence of diabetic retinopathy was 8.3%. although after introduction of insulin, the life span of diabetic becomes long, but unfortunately the incidence of diabetic retinopathy has increased8. the incidence is 27% during first 5-10 years 71% if the duration is more than 10 years and 90-95% after 30 years9. the diabetic retinopathy is classified as nonproliferative diabetic retinopathy (npdr), proliferative diabetic retinopathy (pdr) and clinically significant macular edema (csme). non-proliferative diabetic retinopathy is described as mild moderate, severe and very severe. proliferative diabetic retinopathy (pdr) is described as early, high risk and advanced. macular edema is more common cause of visual blindness in diabetic patients10. material and methods this hospital based descriptive study was carried out at department of ophthalmology, bolan medical college / helpers teaching eye hospital, quetta from june 2006 to june 2008. all the patients were selected from diabetic clinic which is held twice a week at department of ophthalmology bolan medical college quetta. all the patients had detailed history and ocular examination. the history includes chief complaints, both systemic and ocular, were registered. type and duration of diabetes were thoroughly noted. the associated risk factors like hypertension, obesity, family history, social history includes smoking and alcohol use were noted. the method and frequency of blood sugar monitoring were assessed. every patient had complete ocular examination. it included distance and near visual acuity assessment, refraction, slit lamp biomicroscopy, tonometry, fundoscopy – with direct and indirect ophthalmoscopy with 90d. fundus fluorescein angiography and fundus photography was done where it was necessary. the treatment modalities comprised of conservative treatment in non-proliferative diabetic retinopathy. the laser photocoagulation was done in – severe cases of pdr (prp). clinically significant macular grid pattern edema (csme). results the age group ranged from 21-72 years of age and the average age was 51 years (table 1). total 2850 diabetic patients were studied. all were known diabetics. among them 1998 had niddm and 582 patients had iddm variety (table 2). the male patients were 58% (1497) while female patients were 42% (1083) (table 3). the number of diabetic retinopathy patients was 1410 (table 4). among them 59% (832) were male and 41% (578) were females (table 5). the presentation of retinopathy was bilateral in 1298 (92%) patients including 792 male (61%), 506 female (39%) and unilateral in 112 patients (8%), 75 male (58%), 47 female (42%) (table 6). the relationship of duration of diabetes with diabetic retinopathy was as follows. it was 19% during first 1-5 years, 27% in 6-10 years duration, 70% in 11-15 years, 82% in 16-20 years while it was 90% in patients above 20 year of duration of diabetes. (table 7). d 189 table 1. age distribution of patients studied (n = 2580) age group 21-72 years average age 51 years table 2. total number of patients studied with distri bution of types of diabetes mellitus (n = 2580) type of diabetes no. of patients n (%) iddm 582 (33) niddm 1998 (77) table 3: sex distribution (n = 2580) sex no. of patients n (%) male 1497 (58) female 1083 (42) table 4. number of diabetic retinopathy patients (n =1410) number of patients studied 2580 number of diabetic retinopathy patients 1410 (55%) table 5. sex distribution of diabetic retinopathy patients (n = 1410) male patients 832 (59%) female patients 578 (41%) table 6. mode of presentation (n = 1410) mode no. of patients n (%) bilateral 1298 (92) unilateral 112 (8) among 2708 eyes of 1410 patients, the nonproliferative diabetic retinopathy (npdr) (fig. 1) was seen in 1652 eyes (61%), proliferative diabetic retinopathy (pdr) (fig. 2) in 1056 (39%) eyes, clinically significant macular edema in 892 eyes (33%) including 677 eyes with npdr and 216 with pdr (table 8) (fig. 3). advanced diabetic eye disease was seen with proliferative retinopathy, vitreous haemorrhage in 189 years (7%), tractional retinal detachment in 54 eyes (2%) and neovascular glaucoma in 27 eyes (1%) (table 9). laser photocoagulation was done in 1056 eyes. prp was carried out in severe cases of pdr (figure-4) while in clinically significant macular edema, grid pattern done. the visual acuity improved in 327 eyes (31%), it remained same in 507 eyes (48%) while it got worse in 222 eyes (21%) (table 10). table 7. relationship of duration with diabetes retinopathy (n = 1410) duration dm (patients) dr (patients) age n (%) 1-5 years 572 108 19 6-10 years 655 177 27 11-15 years 449 349 70 16-20 years 436 356 82 20 and above 468 420 90 table 8: clinical presentation (n = 2708) status no. of eyes n (%) total number of eyes 2708 non-proliferative diabetic retinopathy (npdr) 1652 (61) proliferative diabetic retinopathy (pdr) 1056 (39) csme 893 (33) csme & npdr 677 (25) csme & pdr 216 (08) table 9. advanced diabetic eye disease disease no. of patients n (%) viterous haemorrhage 189 (7) tractional retinal detachment 54 (2) neo vascular glaucoma 27 (1) 190 table 10. visual outcome after laser photocoagulation (n = 1056) no. of patients n (%) same 507 (48) improved 327 (31) detoriated 222 (21) fig.1: fundus photograph showing npdr fig. 2: fundus photograph showing nvd (pdr) discussion in this hospital based descriptive study, total 2850 patients were registered to assess the prevalence of diabetic retinopathy. diabetic retinopathy is one of a major complication of diabetes mellitus which affects the retinal blood vessels and leads to blindness. about 4-8 million diabetics exist in pakistan and very little work has done on complication of diabetes mellitus. the age group included in this study was 21-72 years; it shows that diabetic retinopathy is commonest cause of legal blindness in this age group. it is also reported by the italian diabetologist grassi11. in our study, the prevalence of diabetic retinopathy was about 55% (i.e. 1410 patients out of 2850 patients). it was higher among males (59%) as compared to females (41%); the male preponderance has also been reported by kayani and her colleagues in their study at lahore12. fig. 3. fundus photograph showing severe pdr with diabetic maculopathy fig. 4. fundus photograph showing prp fig. 5. angiogram showing csme 191 the diabetic retinopathy is bilateral disease. in our study, 1298 (92%) individual out of 1410 presented with bilateral disease and 112 (8%) with unilateral disease. the incidence of diabetic retinopathy is influenced by duration of diabetes. at our centre, it was 19% (i.e. 108 out of 572 patients) in 1-5 years duration, 27% (177 out of 655) in 6-10 years duration, 70% (349 out of 449) in 11-15 years duration, 82% (356 out of 436) in 16-20 years duration, and 90% (420 out of 468) in above 20 years duration. this relationship is also studied and reported by akhter jamal khan in 1986 at akhter eye hospital karachi13. the report shows prevalence and duration of diabetic retinopathy in 1000 patients. the incidence and relationship of diabetic retinopathy with duration of diabetes is also mentioned in their report by klein r, klein bek, moss at al (needs reference number). the non-proliferative diabetic retinopathy (npdr) was present in (61%) of eyes, proliferative diabetic retinopathy (pdr) in 39% eyes. this shows npdr is more common as compared to pdr. this also has been reported by kayani and her colleagues in their study12. clinically significant macular edema (csme) was seen in 893 eyes (33%). csme was seen in 677 eyes with npdr and 216 eyes with pdr. leske and his colleagues have reported the incidence of csme 8.7% in their study at stony books university new york14. laser photocoagulation was performed in 1056 eyes. it was performed in eyes with severe bilateral npdr showing extensive capillary non-perfusion on fundus fluorescien angiography (ffa), proliferative diabetic retinopathy (pdr) and clinically significant macular edema (csme). the photocoagulation maintains/stabilizes va but not improve it15. according to visual outcome, the visual acuity remained same in 48% (507 eyes), improved in 31% (327 eyes) and deteriorated in 21% (222 eyes)16. it shows that timely laser photocoagulation obviates visual loss in diabetic retinopathy17. prevention of blindness in patients with diabetic retinopathy, by appropriate laser therapy has been acknowledged as one of the most significant advances in medical history. the credit of these retinal disease trials goes to drs18. we in ophthalmology think that information is widespread but we are misleading ourselves. it is our duty to see the facts about diabetic eye disease and its treatment are conveyed to the public on large scale for their maximum benefit19. it is important to identify retinopathy in early stages, before there is irreversible damage. screening of diabetic retinopathy is best undertaken by ophthalmologist because of complex diagnostic techniques involved and subtlety of the many of the physical signs. indeed both retinal edema and ischaemia require special technique for their identification. this result is posing to training and staffing considerable problems in relationship majority of the population is not even aware of the ophthalmic care. the physicians also ignore this aspect and have poor information regarding the laser treatment of diabetic retinopathy19. conclusion in this hospital based descriptive study, we conclude that the prevalence of: 1. diabetic retinopathy is related with duration of diabetes. 2. the diabetic retinopathy was more frequently seen in male individuals. 3. non-proliferative diabetic retinopathy (npdr) was more frequent as compared to proliferative diabetic retinopathy (pdr). 4. laser photocoagulation improves the vision in those patients: a. those who were treated in early stages of disease. b. those who had no vitreous haemorrhage. c. those who have tractional retinal detachment. 5. the presentation of diabetic retinopathy was bilateral in most of patients. 6. the incidence of diabetic retinopathy is increased as the duration of diabetes in enhanced. author’s affiliation dr. abdul qayyum assistant professor ophthalmology bolan medical college quetta dr. amir muhammad babar associate professor department of microbiology bolan medical college quetta dr. gurmak das registrar department of ophthalmology bolan medical college quetta 192 prof. abdullah jan badini professor of ophthalmology bolan medical college quetta reference 1. assal jph, frocsch fr. the pancreas, in: lablast a (ed). clinical endocrinology. theory and practice, 2nd ed. berlin, springer verlag. 1986; 749. 2. elder sd, dobree jn. diseases of retina. in: systems of ophthalmology steward duke elder (ed). vol.10 – cv mosby, st lovis. 1958; 422-3. 3. mmwr. prevalence, incidence of diabetes mellitus, united states, 1980-1987. jama. 1990; 264-3126. 4. ahmed mm: diabetes mellitus. editorial: pak j ophthalmol. 2002; 18: 90. 5. kahn ha, hiller, r. blindness caused by diabetic retinopathy. am j ophthalmol. 1974; 78: 58. 6. g.o.h naumann dj. diabetes mellitus. in; apple pathology of the eye. 1st ed. springer verlag. new york. 198; 875. 7. xiii congress of the asia – pacific academy of ophthalmology may 12-7-1991 [abstract]. international congress series 972. (mendius av, colombo, srilanka) session 1921. 8. elder sd dobree jh. diseases of retina. in: systems of ophthalmology edited by sir stewart duke-elder. vol 9. cv. mosby co, st lovis. 1958; 408-40. 9. klien r, klein bek, moses se et al. the winconsin epidemiological study of diabetic retinopathy. iii prevalence and risk of diabetic retinopathy when age is 30 or more years. arch ophthalmol. 1984; 102: 527-32. 10. kanski jj. retinal vascular disorders. in: clinical ophthalmology: a systemic approach 5th ed. butter worth and co; hong kong. 572. 11. grass g. diabetic retinopathy. in minerva med. 2003; 94: 41935. 12. kayani h, rehan n, ullah n. frequency of retinopathy among diabetes admitted in a teaching hospital of lahore in: ayub medical college abottabad. 2003; 15: 53-6. 13. khan aj. diabetic blindness; a preventable disease. pak j ophthalmol. 1988; 4: 7. 14. leske mc, wu yy, henni sa et al. barbados eye study group. in nine year study of diabetic retinopathy in the barbados eye studies. arch opthalmol. 2006; 124: 250-5. 15. sinclair sh, del vecchoic. the internet’s role in managing diabetic retinopathy: screening for early detection. cleve clin i med. 2004; 71: 151-9. 16. fennis fl. how are effective treatment for diabetic retinopathy?. jama. 1993; 269: 1290-7. 17. nwosu sn. diabetic retinopathy management update. niger postgra. med i. 2003; 10: 115-20. 18. early treatment diabetic retinopathy study research group. etdrs report no.9. ophthalmology. 1991; 98: 766-85. 19. witkin sr, klein r. ophthalmological care for persons with diabetes. jama .1984; 251: 25-34. a change in the appearance of optic disc may be the first detectable sign of glaucoma damage. characteristic configuration of neuroretinal rim is known as the = isnt rule = broadest in the inferior region, followed by the superior, nasal and temporal regions. document the appearance of disc changes by making a sketch or taking a photograph. prof. m. lateef chaudhry editor in chief pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 207 review article role of oct in diagnosis and progression of glaucoma p. s. mahar, nadeem h. butt, s. imtiaz ali pak j ophthalmol 2018, vol. 34, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: prof. p.s mahar isra postgraduate institute of ophthalmology karachi, pakistan e-mail: salim.mahar@aku.edu …..……………………….. optical coherence tomography (oct) has become a common tool in ophthalmic community for imaging of optic nerve head and macula. in glaucoma, it is of utmost importance in early diagnosis and monitoring the progression of the disease. measurement of peri-papillary rnfl thickness is a common method of diagnosing and monitoring glaucoma. recently ganglion cell complex (gcc) analysis of macula has also shown to be helpful in identification of early glaucoma and coincides with rnfl damage. oct can identify the structural damage in eyes before visual field defects occurs. high myopia with large discs, tilting and peri-papillary crescents and occasional hypoplasia of optic disc makes diagnosis of glaucoma difficult. it may be helpful in these patients to map ganglion cell complex (gcc) rather than relying on rnfl thickness. in advanced glaucoma when rnfl thickness level decreases to below 40 – 50 µm, the oct will be of not much value to record any progression. this is termed as floor effect. oct has now become commonly available in all parts of the country and is frequently used to determine rnfl and macular thickness in suspected or established cases of glaucoma. it not only helps in diagnosis and progression of the disease but helps us to make the patient being aware of the disease. however, we clinicians should also be aware of various artifacts related to acquisition of scans by our technicians, disease itself and related to the scanner. we must realize the limitation of comparative normative database incorporated in various scanners and that not every rnfl thinning is due to glaucoma. key words: optical coherence tomography, optic nerve head, macula. laucoma is the leading cause of blindness worldwide1,2. in pakistan, it is third cause of blindness accounting for 7.1% cases3. according to quigly, 58 million people will have primary open angle glaucoma (poag) by the year 2020, out of which 10% will be bilaterally blind4.as glaucoma causes irreversible damage to the vision, it is important to detect it at an early stage before significant visual loss occurs. the measurement of intraocular pressure (iop) is a poor screening tool in the diagnosis of glaucoma as mean iop in early manifest glaucoma trial5 (emgt) and united kingdom glaucoma treatment study group6 (ukgts) was found around 20 mm hg. the one off measurement of iop of < 21 mm hg in our office or clinic does not exclude possibility of glaucoma. in ocular hypertension treatment study7 (ohts), most patients who developed glaucoma from ocular hypertension showed changes in the optic disc. in general, structural changes appear earlier than any change in the visual field. the visual field loss occurs after at least 30% 40% retinal ganglion cells are damaged8. optical coherence tomography (oct) is an optical imaging technique providing high-resolution cross-sectional imaging of retina using near infrared light (840 nm). it uses the principles of low coherence interferometry using light echoes from the scanned structures to determine the thickness of the tissue9. oct detects optic nerve head changes with retinal nerve fiber layer (rnfl) thinning due to the g mailto:salim.mahar@aku.edu p. s. mahar, et al 208 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology loss of ganglion cells at macula. it compares thickness of rnfl between hemispheres of the same eye and between two eyes to determine any asymmetry, which is the hallmark of glaucoma. it measures the thickness of neuro-retinal rim, the inner retinal layer and ganglion cells complex at macula. the thickness of various parameters is then compared to a normative database to determine if the patient falls into abnormal or borderline category. as segmentation algorithms in different scanners are mutually exclusive and are not comparable, so long-term assessment of patients, need to be with the same oct scanner. oct and its use in the measurement of peripapillary rnfl thickness is a common method of diagnosing and monitoring glaucoma. recently ganglion cell complex (gcc) analysis of macula has also shown to be helpful in identification of early glaucoma and coincides with rnfl damage10. some studies have evaluated a combined structural index based on peri-papillary rnfl, the macular ganglion cell complex and the optic disc and found it superior and more sensitive in detecting glaucoma, when compared to the individual parameters11. oct can identify the structural damage in eyes before visual field defects occurs. wollstein and co-workers determined the rnfl thickness associated with structural changes corresponding with visual field defects. their study revealed that substantial structural loss of approximately 17% appeared necessary for functional loss to be detectable using the current testing methods on humphrey visual field analyzer12. the recent advent of spectral-domain oct (sdoct) with 40,000 scans per second has reduced scan acquisition time, enhanced resolution and improved layer segmentation. leung et al13 found rnfl measurement using sd-oct with sensitivity of 91.6% and specificity of 87.6% in pre-perimetric glaucoma, while leite et al14 found rnfl measurement using sd-oct in early disease with sensitivity of 82% and specificity of 85%. high myopia with large discs, tilting and peripapillary crescents and occasional hypoplasia of optic disc makes diagnosis of glaucoma difficult. it may be helpful in these patients to map ganglion cell complex (gcc) rather than relying on rnfl thickness. shoji and colleagues15 analyzed 51 patients with high myopia and associated perimetric glaucoma. they performed ganglion cell complex (gcc) and circumpapillary rnfl analysis using sd – oct machine. their conclusion was that gcc measurement offered best parameters for the clinical diagnosis of glaucoma in these patients. cvenkel & kontestabile16 measured rnfl thickness with sd-oct in patients with glaucoma to evaluate the correlation between visual field parameters and rnfl thickness & found decreased mean rnfl thickness in eyes with pre-perimetric glaucoma & perimetric glaucoma when compared to healthy control group suggesting the usefulness of the technology. koh and co-workers17assessed the repeatability of measuring optic nerve head parameters in relation to the head tilt using cirrus sd-oct and found that the optic nerve head parameters maintaining good repeatability despite head tilt to 30 degrees on the either side. the sd-oct machine has inbuilt software to control for head tilt and eye tracking. in the absence of this software to control head tilt, significant artifacts can occur with even 8 degrees of head tilt18. the effect of improper scan alignment on rnfl thickness measurement has been studied and it has been found that the average rnfl thickness is greater when scans are displaced temporally. the parapapillary scan misalignment is characterized by an increase in rnfl thickness in the quadrants in which scan is closer to the disc and significant decrease in rnfl thickness in the quadrant in which scan is displaced further from the disc19 (figure a). role of oct in diagnosis and progression of glaucoma pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 209 fig. a: effect of improper scan alignment on rnfl thickness. the presence of lens opacities and posterior vitreous detachment (pvd) can cause significant underestimation of rnfl measurement and in some machines, it is important to dilate the pupil20. axial length of the eyeball has shown to influence the oct measurement of rnfl thickness and optic nerve parameter. the longer the eye the thinner the rnfl measurement21. the signal strength should always be noted when assessing the quality of the scan. this is variable in different oct scanners. for cirrus scan (carl zeiss – meditec ca), it is reported on scale of 0 – 10 and is defined as the average intensity value of signal pixels in the oct image. the best quality scan should have signal strength of ≥ 7. for rtvue (fremont – ca) scanner and topcon (3d oct – 100 – japan), the signal strength range is 0 – 100 and a good quality scan strength should be at least > 40. for heidelberg (germany) scanner, the range of signal strength is 0 – 40 with good quality scan at signal strength of > 20. the lower signal strength can occur due to presence of corneal opacity, lens opacity and pvd resulting in artificial thinning of rnfl. in a series of 277 patients with glaucoma, asrani found 37 patients (28.2%) had imaging artifacts having macular thickness scan and with rnfl scans, 55 patients (19.9%) had artifacts. the most common cause of artifacts in both types of scans was presence of epiretinal membrane22. the scanner in these cases recognizes the epi-retinal membrane as rnfl and calculates its thickness erroneously. it is important therefore to look at the raw data and recognize the presence of epi-retinal membrane. in new generation of sd-oct, scanner can deduct the thickness of epiretinal membrane and can calculate the true rnfl thickness. by looking only at one sheet of rnfl analysis, the observer can misdiagnose the rnfl thickness. for this reason, it is also important to look at macular scan when performing rnfl analysis to exclude disease such as epi-retinal membrane (erm), vitreo-macular traction (vmt) and presence of any other macular pathology resulting in scar formation as this will influence the thickness of rnfl (figure b). p. s. mahar, et al 210 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology fig. b1: rnfl left eye with epiretinal membrane. b2: rnfl left eye with epiretinal membrane adjusted. ghazi and much studied a series of 13 eyes in whom repeated attempts at oct imaging failed to yield a good quality scan despite the absence of significant media opacity and inadequate pupil dilatation. corneal lubricants achieved a significant improvement in oct image quality from 4.35 to 6.2 on cirrus machine23. in advanced glaucoma when rnfl thickness level decreases to below 40 – 50 µm, the oct will be of not much value to record any progression. this is termed as floor effect. the normative database in most scanners is based on 300 – 400 patients with average age of 15 – 78 years and they do not necessarily have patients with extreme refractive errors, young children and people from different races. due to relatively small normative database, rnfl measurement may be flagged in patients who are not represented in the database. one common example is the patient of glaucoma with high myopic error as high myopes are not included in the normative database. as myopic eyes have already thin rnfl, this can be interpreted as having rnfl thinning due to the disease process. the limitation of normative database can affect the utility of oct scanner in diagnosing glaucoma in certain cases. it is therefore advised to take serial oct scans in these cases to judge glaucomatous progression by setting a role of oct in diagnosis and progression of glaucoma pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 211 fig. 1: optic disc showing cup disc ratio of 0.5 – 0.6 in both eyes. rnfl analysis is within normal limits. baseline scan against which subsequent scans can be compared for rnfl thinning. thus, each patient can act as his or her own normative database to diagnosis glaucoma and its progression. in this situation the clinician should be aware that rnfl thickness decreases with age which is estimated to be about 0.52 – 1.35 µm per year24. clinical interpretation errors also include failure to recognize compressive optic neuropathies (pituitary tumors) ischemic optic neuropathies, retinal vein occlusions & toxic optic neuropathies (methanol poisoning)25 which can damage the optic nerve and show changes in rnfl analysis and macular scan. chen and kardon have advised a systematic approach for acquisition and interpretation of oct26. some tips for better acquisition are, reducing room light in case of undilated pupil, the forehead of the patient has to be in constant touch with the headband and reminding patients to blink before scan is taken. confirm the name and age of the patient, check the signal strength, check refractive error and if available axial eye length. compare the fundus image and p. s. mahar, et al 212 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology fig. 2: optic disc on left side shows couple of splinter hemorrhages superiorly with corresponding rnfl thinning. thickness map to check that the border and cup identification by oct corresponds to clinical estimation. examine tsnit rnfl plot to ensure its peak corresponds to the peak from the normative database. clinical cases patient 1: ( figure 1) a 39 year old male was referred for evaluation of his glaucoma. he had been using topical latanoprost with the diagnosis of poag. his best-corrected vision was 6/6 in both eyes. his central corneal thickness was 537 and 536 µm in either eye with iop of 14 mmhg in both eyes. his fundi showed cup to disc ratio of 0.5 – 0.6 with good neuro retinal rim thickness. his oct (figure 1) showed normal rnfl thickness chart and full visual fields. patient’s latanoprost was discontinued and his iops were checked after 4 weeks (washout period of latanoprost) and were still found at 13 mmhg in both eyes (mean at 9 am & 4 pm). he has been followed up for last couple of years with no further change in his iops and rnfl thickness. patient 2: (figure 2) a 40 years old female was referred for painless decrease in vision in her left eye. she did not have any co-morbids. her best-corrected visual acuity was 6/6 in right eye (unaided) and 6/9 (0.75/-1.50 × 140) in role of oct in diagnosis and progression of glaucoma pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 213 his left eye. her anterior segments were unremarkable. the iop was 12 mm hg in right eye and 14 mm hg in left eye (at 10:00 am). her cct were on thin side measuring 486 µm in right eye and 492 µm in the left eye. the angles were open on gonioscopy. the fundus showed cup to disc ratio of 0.6 – 0.7 in both eyes but there was some splinter hemorrhages seen near the disc margin superiorly in the left eye. her iops were phased and they increased to 25 mm hg in her either eye at 5:00 pm. the rnfl on oct in right eye was normal but left eye showed thinning in superiortemporal quadrants. her visual fields were full on humphrey’s field analyzer. due to her thin corneas, her adjusted iop would have been + 4 mmhg and as her iop were recorded at 25 mmhg in afternoon, she was diagnosed has having pre-perimetirc glaucoma. fig. 3: neuroretinal rim thinning in both eyes with corresponding changes on rnfl analysis. patient 3: (figure 3) a 26 years old female with family history of glaucoma was reviewed for glaucoma evaluation. her best corrected visual acuity was 6/6 (unaided) in both eyes. the iops were recorded 10 mm hg in morning and remained same throughout the day on phasing. her cct were 519 µm in both both eyes. the anterior chamber angles were wide open and fundus examination showed optic disc cupping in both eyes with thin neuro-rims. the rnfl analysis on oct showed thinning in her both eyes though her fields of vision were normal. she was diagnosed with normal tension glaucoma. she had carotid doppler and mri scan of brain, which were within the normal limits. patient 4: (figure 4 a & b) a 44 years old woman with positive family history of glaucoma came for regular eye examination. her visual acuity was 6/7.5 in either eye. her iops were 25 mm hg in right eye and 26 mm hg in left eye. she was already on full anti-glaucoma medical treatment comprising of latanoprost at night, dorzolamide/ timolol combination and brimonidine eye drops, both twice a day in her each eye. her fundi showed 0.6 – 0.7 cup-disc ratio. oct revealed rnfl thinning throughout her follow-up with her fields of vision staying within normal limits. this case elegantly illustrates the role of oct in progression of early glaucoma. p. s. mahar, et al 214 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology fig. 4a: progression of rnfl thinning in right eye. role of oct in diagnosis and progression of glaucoma pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 215 fig. 4b: progression of rnfl thinning in left eye. next two cases demonstrate that not every rnfl thinning on oct examination is because of glaucoma patient 5:( figure 5 a & b) a 27 years old physician complained of inability to appreciate the inferior part of his visual field in his left eye for last couple of years. he had mri brain to rule out any space occupying lesion and was found within normal limits. he did not have any other significant medical and surgical history. he was diagnosed somewhere else as having glaucoma and was using combined dorzolamide/timolol drops in his left eye. his visual acuity was 6/6 with – 2.00 ds in his both eyes. iops measured 16 mm hg in either eye with anterior chamber angles open and cct of 550 µm in both eyes. the fundus examination showed his right optic disc with cup disc ratio of 0.1 while the left optic disc had no visible cup with blurred margins. the rnfl analysis was normal in right eye while showed severe thinning in the left eye. his visual field was normal/full on right side but showed arcuate type of scotoma inferiorly on the left side. his clinical diagnosis was apparent to us that he had optic nerve drusen on left side responsible for rnfl thinning and changes in the visual field. the treating physician only looked at patient’s oct and visual field and made the diagnosis of glaucoma without considering the appearance of his left optic disc. p. s. mahar, et al 216 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology fig. 5a: left optic disc drusen with thinning of rnfl in left eye. role of oct in diagnosis and progression of glaucoma pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 217 fig. 5b: left visual field demonstrating inferior arcuate scotoma. patient 6: (figure 6) a 43 years old female was referred for assessment of her glaucoma. she had been using timolol/ dorzolamide eye drops and latanoprost in her both eyes for last 1 year. her best corrected vision was 6/6 in her both eyes with small correction. her iops were 13 mm hg in her both eyes with angles open and central corneal thickness of 500 µm in right eye and 495 µm in the left eye. her cup to disc ratio were 0.4 in either eyes with healthy looking neuroretinal rim. her oct showed rnfl thinning in both eyes temporally with visual fields demonstrating temporal defects. mri revealed presence of pituitary macroadenoma. her glaucoma drops were discontinued and she was referred for neuro-surgical opinion. p. s. mahar, et al 218 vol. 34, no. 3, jul – sep, 2018 pakistan journal of ophthalmology fig. 6: patient with bitemporal hemianopia with corresponding changes on rnfl analysis. mri confirmed presence of pituitary macroadenoma role of oct in diagnosis and progression of glaucoma pakistan journal of ophthalmology vol. 34, no. 3, jul – sep, 2018 219 conclusion oct has now become commonly available in all parts of the country and is frequently used to determine rnfl and macular thickness in suspected or established cases of glaucoma. it not only helps in diagnosis and progression of the disease but helps us to make the patient being aware of the disease. however, we clinicians should also be aware of various artifacts related to acquisition of scans by our technicians, disease itself and related to the scanner. we must realize the limitation of comparative normative database incorporated in various scanners and that not every rnfl thinning is due to glaucoma. author’s affiliation p.s. mahar, frcs, frcophth professor of ophthalmology & dean isra postgraduate institute of ophthalmology consultant eye surgeon aga khan university hospital, karachi nadeem h. butt, fcps, frcs professor of ophthalmology & head allama iqbal medical college, lahore syed imtiaz ali, frcs, frcophth professor of ophthalmology & head al-nafees medical college, islamabad role of authors p.s. mahar manuscript writing. nadeem h. butt critical review. syed imtiaz ali manuscript writing financial interest: none. conflict of interest: none. references 1. weinreb rn, khaw pt. primary open-angle 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thickness and optic disc size measurement by spectral domain oct. br. j ophthalmol. 2012; 96: 57-61. 22. asrani s, essaid l, alder bd, santiago-turla c. artifacts in spectral-domain optical coherence tomography measurements in glaucoma. jama ophthalmol. 2014; 132 (4): 396-402. 23. ghazi ng, much jw. the effect of lubricating eye drops on oct imaging of the retina. digital j ophthalmol. 2009; 15 (2): 1-3. 24. leung ck, yu m, weinreb rn et al. retinal nerve fiber layer imaging with spectral domain optical coherence tomography: a prospective analysis of age-related loss. ophthalmology, 2012; 119: 731-737. 25. rosdahl ja, asrani s. glaucoma masqueraders: diagnosis by spectral domain optical coherence tomography. saudi j ophthalmol. 2012; 26 (4): 433-440. 26. chen jj, kardon rh. avoiding clinical misinterpretation and artifacts of optical coherence tomography analysis of the optic nerve, retinal nerve fiber layer, and ganglion cell layer. j neuro ophthalmol. 2016; 36 (4): 417-438. microsoft word abstract 26,4,10 221 abstracts edited by dr. tahir mahmood acanthamoeba keratitis: diagnosis and treatment update 2009 dart jkg, saw vpj, kilvington s am j ophthalmol. 2009, 148: 487-99. most ophthalmologists will know that acanthamoeha keratitis (ak) is a recently recognized infectious disease entity that is difficult to treat. there are good recent reviews of this subject. this perspective focuses on the diagnosis and treatment of this complex corneal infectious disease. in particular, we consider the management of diagnostic dilemmas, evidence for choice of initial therapy, and treatment of the challenging clinical problems of persistent ulceration, severe inflammation, and persistent infection, and provide guidelines for surgery. the purpose of this study was to describe the current management of acanthamoeba keratltis (ak). early diagnosis and appropriate therapy are key to a good prognosis. a provisional diagnosis of ak can be made using the clinical features and confocal microscopy, although a definitive diagnosis requires culture, histology, or identification of acanthamoeba deoxyribonucleic acid by polymerase chain reaction. routine use of tissue diagnosis is recommended, particularly for patients unresponsive to treatment for ak. topical biguanides are the only effective therapy for the resistant encysted form of the, organism in vitro, if not always in vivo. none of the other drugs that have been used meet the requirements of consistent cysticidal activity and may have no therapeutic role. the use of topical steroids is controversial, but probably beneficial, for the management of severe corneal inflammatory complications that have not responded to topical biguanides alone. the scleritis associated with ak is rarely associated with extracorneal invasion and usually responds to systemic anti-inflammatory treatment combined with topical biguanides. therapeutic keratoplasty retains a role for therapy of some severe complications of ak but not for initial treatment. with modern management, 90% of patients can expect to retain visual acuity of 6/12 or better and fewer than 2% become blind, although treatment may take 6 months or more. authors concluded with the remarks that better understanding of the pathogenesis of the extra corneal complications, the availability of polymerase chain reaction for tissue diagnosis, and effective licensed topical anti-amoebics would substantially benefit patients with ak. azathioprine for ocular inflammatory diseases pasadhika s, kempen oh, newcomb cw, llesegang tl, siddharth s. pujari ss, rosenbaum j, thorne jt, foster cs, jabs da, levy-clarke ga, nussenblatt rb, suhler eb am j ophthalmol. 2009: 148: 500-509. immunosuppressive drugs have been used widely to control severe cases of ocular inflammation, azathioprine a purine nuleoside analog that acts as an antimetabolite by interfering with deoxyribonucleic acid and ribonucleic acid synthesis is one of the immunosuppressive drugs recommended for this purpose. azathioprine is approved by the united states food and drug administration for the treatment of rheumatoid arthritis and also has been used widely for organ transplantation and various dermatologic, gastro intestinal and rheumatologic diseases, including psoriatic arthritis and systemic lupus erythematosus. for ophthalmic disease azathioprine has been used for treatment of corneal graft rejection and noninfectious ocular inflammatory conditions, such as chronic active iridocycliris, retinal vasculitis, behcet disease, and sympathetic ophthalmia. it also has been used in combination with other immunosuppressive agents for serpiginous retinochoroidiris. randomized clinical trials data are limited to use of azathioprine for behcet disease and a small trial evaluating its use for anterior uveitis. the systemic immunosuppressive therapy for eye diseases (site) cohort study! includes 222 information regarding the outcomes of a large number of ocular inflammation patients managed at tertiary ocular inflammation centers in the united states using a variety of agents, including azathioprine. in this report, we evaluate the incidence of successful control of inflammation, of corticosteroid-sparing benefits, and of treatment related complications leading to discontinuation of therapy in patients from the cohort treated with azathioprine as a sole (noncorticoste-roid) immunosuppressive agent who were followed up from the initiation of azathioprine therapy. the purpose of this study was to evaluate treatment outcomes of azathioprine for noninfectious ocular inflammatory diseases. medical records of 145 patients starting azathioprine as a sole noncorticosteroid immunosuppressant at 4 tertiarv uveitis services were reviewed. main outcome measures included control of ocular inflammation, sustained control after tapering prednisone to ≤ 10 mg/day, and discontinuation of treatment because of side effects. among 145 patients (255 eyes) treated with arathioprine, 63% had uveitis, 23% had mucous membrane pemphigoid, 11% had scleritis, and 3% had other inflammatory diseases. by kaplan-meier analysis, 62% (95% confidence interval [ci], 50% to 74%) of patients with active disease initially gained complete inactivity of inflammation sustained over at least 28 days within 1 year of therapy, and 47% (95% ci, 37% to 58%) tapered systemic corticosteroids to ≤ 10 mg daily while maintaining control of inflammation within 1 year of therapy. treatment success was most common for intermediate uveitis (90% with sustained inactivity within 1 year; 95% ci, 64% to 99%). over the median follow-up of 230 days (interquartile range, 62 to 679 days), azathioprme was discontinued at a rate of 0.45 per person years (/py): 0.16/py because of side effects, 0.10/py because of ineffectiveness, 0.09/py because of disease remission, and 0.10/py because of unspecified causes. authors concluded with the remarks that azathioprine was moderately effective as a single corticosteroid-sparing immunosuppressive agent in terms of control of inflammation and corticosteroidsparing benefits, but required several months to achieve treatment goals; it seems especially useful for patients with intermediate uveitis. treatment-limiting side effects occurred in approximately one-fourth of patients within 1 year, but typically were reversible. 223 the effect of biomicroscope illumination system on grading anterior chamber inflammation wong ig, nugent ak, varcas-marttn f am j ophthalmol 2009; 148: 516-20. inflammatory cells in the aqueous easier to detect with certain biomicroscopes than others of identical make and model. detecting inflammatory cells in the aqueous is critical in deciding whether to continue or discontinue a patient's treatment. a small number of cells in the aqueous beam can be difficult to see, and if presumed absent, treatment may be discontinued prematurely. the ability to see cells in the aqueous depends on the characteristics of the cells, the biomicroscope optics, the illumination system, and the observer's skillscharacteristics of the cells include the type and size of cells. the smallest inflammatory cell, the lymphocyte, measures approximately 5 µm in diameter and the largest, the macrophage, measures from 15 to 30 µm in diameter. the inflammatory cell’s cytoplasmic granules and inclusions such as pigment affect its ability to absorb, reflect, refract, and scatter light. the contrast between the cell and aqueous fluid, particularly when the 'aqueous is turbid, affects the visibility of cells. inflammatory cells are detected more easily when the slit-beam is brighter. however, seeing cells in the aqueous may be more related to the contrast ratio between the reflected light and the background, which would remain fairly constant even with reduced light. the ratio is assumed to be constant because the amount of light hitting the cells and the background are dependent on the same light source. thus, both would increase and decrease proportionately as the slit-beam light is adjusted up or down. the purpose of this study was to determine how the biomicroscope illumination system affects the grading of anterior chamber (ac) inflammation. does a brighter light allow for more inflammatory cells to be counted? does the width of the light beam affect the cell count? is there variation in illumination among biomicroscopes and does this variation influence the counting of inflammatory cells? if the illumination settings are critical for grading cells, clinical practice and clinical trials should require uniform standards to have comparable and reproducible grading data. an artificial ac was designed to replicate optically a human ac and was filled with 5-µm polystyrene beads suspended in ethanol. a highdefinition video eyepiece camera recorded the moving beads. using image processing software, the main outcomes measures determined were the average number of beads in a 1 x 1-mm field at varying widths of the slit-beam. the volume of light and number of beads observed increased significantly as the slit-beam widened. additionally, 3 separate biomicroscopes of identical make and model were found to produce different levels of luminance at the same aperture dial settings, influencing the number of beads observed, with the brighter biomicroscope yielding higher bead counts. authors concluded with the remarks that ability to count beads and perhaps the ability to count inflammatory cells in an inflamed eye depend on a number of factors, including the level of illumination and width of the slit-beam. this study demonstrated that the brighter the illumination and the wider the beam, the more beads were observed. this illustrates the importance of standardizing biomicroscope, particularly where consecutive observations are used to make clinical decisions and in cases of multi-center clinical trials where clinical data are evaluated across different facilities. rapid detection of acanthamoeba cysts in frozen sections of corneal scrapings with fungiflora y shiraishi a, kobayashi t, hara y, yamaguchi m, uno t, ohashi y br j ophthalmol. 2009, 93: 1563-5. acanthamoeba keratitis (ak) is an intractable, sightthreatening infection of the cornea and is frequently seen in contact lens wearers. the incidence of ak has increased with increasing numbers of contact lens wearers. the problems with ak include the difficulty in making a correct diagnosis at an early stage, and the lack of specific drugs to treat ak. the early clinical signs of ak are subepithelial infiltrates, pseudodendritic keratitis and radial neurokeratitis and these lesions often lead to ak being misdiagnosed as herpetic keratitis and or fungal keratitis, resulting in delays in initiating proper treatment. in addition, the ability to grow and identify acantoamoeba in culture is between 30% and 60%, and it requires a relatively long time to obtain the results from cultures. 224 acanthamoeba cysts can be detected in corneal scraping, impression cytology or biopsies by a variety of staining methods including special stains such as calcofluor white and acridme orange, and also by immunohistochemisfcry. routine stains such as haematoxylin and eosin (h&e), giemsa, cram, periodic acid schiff (fas), and lactophenol cotton blue can also provide a positive identification. however, some of the special stains are timeconsuming and more complicated, and the routine stains require skilled and experienced examiners to identify the acanthamoeba cysts or trophozoites. fungiflora y (ffy) was originally developed to detect fungi, and it has a specific affinity for chitin and cellulose, which are components of the cell wall of fungi. however, it has been shown that ffy also stains acanthamoeba cysts because cysts also contain cellulose. the purpose of this study was to evaluate the usefulness of serial frozen sections of corneal scrapings stained with fungiflora y (ffy) to diagnose acanthamoeba keratltis (ak). eight patients with suspected ak were studied. serial frozen sections were made from part of the corneal epithelial scrapings and stained with ffy. the remaining corneal epithelial scrapings were submitted for laboratory culture. the ffy stained frozen sections were completed within an hour, and acanthamoeba cysts were detected under a fluorescence microscope in all eight patients. the same sections were examined with a light microscope, and acanthamoeba cysts were confirmed to be present from their morphological characteristics. five of the eight patients had positive laboratory cultures for acanthamoeba. authors concluded with the remarks that ffy staining of frozen sections of corneal scrapings is a rapid and reliable technique which can be used to make an early diagnosis of ak. one-year outcomes of a bilateral randomised prospective clinical trial comparing prk with mitomycin c and lasik wallau ad, campos m br j ophthatmol. 2009; 93: 1634-8. excimer laser photorefractive keratectomy (prk) with adjunctive mitomycin c (mmc; mmc-prk) has recently been used as an alternative to laser in situ keratomileusis (lasik) for surgical correction of refractive errors. although surface ablation usually has a slower visual recovery and more early postoperative discomfort, it avoids lasik flaps complications and possibly results in less corneal biomechanical instability. mitomycin c is an alkylating agent that inhibits dna and rna replication and protein synthesis. it regulates ribroblast proliferation and differentiation. and subsequently blocks myofibroblast formation, which is responsible for corneal haze after prk in high myopic corrections. recent studies have shown that low-dose mmc (0.002%) has a similar efficacy to standard mmc concentration (0.02%) in preventing postoperative haze following surface ablation for moderate myopia corrections, and also minimise potential side effects. the purpose of this study was to compare 1-year follow-up results of photorefractive keratectomy (prk) with mitomycin c (mmc) and laser in situ keratomileusis (lasik) for custom correction of myopia. eighty-eight eyes of 44 patients with moderate myopia were randomised to prk with 0.002% mmc for 1 min in one eye and lasik in the fellow eye. the 1-year follow-up was evaluated. there were no differences between lasik and mmc-prk eyes preoperatively. forty-two patients completed the 1-year follow-up. mmc-prk eyes achieved better uncorrected visual acuity (p = 0.03) and better best-spectacle-corrected visual acuity (p<0.001) 1 year after surgery. se did not differ in the two groups during follow-up (p = 0.12). clinically significant haze was not found in surface ablation eyes. lasik eyes showed a greater higher-order aberration (p = 0.01) and lower contrast sensitivity (p<0.05) than mmc-prk eyes postoperatively. excellent vision was reported in 64% of lasik and 74% of mmc-prk eyes 1 year after surgery. the corneal resistance factor and corneal hysteresis (ora, reichert) were higher in lasik than in mmc-prk eyes (p<0.01) at the last follow-up. authors concluded with the remarks that wavefront-guided prk with 0.002% mmc was more effective than wavefront-guided lasik for correction of moderate myopia. further research is necessary to determine the optimal concentration, exposure time and long-term corneal side effect of mmc. 225 microsoft word erum shahid 58 original article complications of hypermature cataract and its visual outcome erum shahid, arshad sheikh, uzma fasih pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: erum shahid c-88, block a north nazimabad karachi submission of paper june’ 2010 acceptance for publication may’ 2011 …..……………………….. purpose: to evaluate the additional complications of hyper mature cataract and their low visual outcome after extra capsular cataract extraction. materials and method: this study was conducted in the department of ophthalmology abbasi shaheed hospital, karachi from june 2006-2007. in this study evaluation of fifty patients with senile hyper mature cataract after preoperative assessment and investigations underwent extra capsular cataract extraction. their surgical complications and postoperative complications were recorded. their visual outcome was studied at each stage of follow up, conducted at 1st week, 3rd week, 6th week, 3rd month and 6th month. best corrected visual acuity was obtained at 6 months. result: total of fifty patients 27 male and 23 female had extra capsular cataract extraction. 8 of the eyes had surgery complicated by posterior capsule rupture, vitreous loss, phacodonesis and drop nucleus. on first post operative day most common complication noted was striate keratitis (60%). best corrected visual acuity at 6 months was 6/18 or more in 38(76%) patients. conclusion: the operative and postoperative complication rate is higher in hyper mature cataracts. these complications can be reduced by early removal of cataract before it reaches the stage of hyper-maturity. extra capsular surgery of hyper-mature cataract has good results after thorough preoperative assessment and if performed with expertise. akistan is among the ones with highest number of blind people .the most prevalent cause of blindness and low vision being an un-operated cataract. a survey conducted in one region of pakistan yielded all age blindness prevalence rates at 1.78% and thus cataract is a major cause of treatable blindness contributing of 66.7%of total blindness1. by the year 2020, the elderly population of 60 years and above is expected to double from today’s number, thereby increasing the number of blind even more2-3. mature and hyper mature cataracts constitute a significant volume of the cataract surgical load in ophthalmic practice in developing countries. continuous curvilinear capsulorhexis (ccc) and emulsification of hard nucleus are the two steps that make phacoemulsification difficult in these cases4-6. after removal of a cataractous lens an intraocular (iol) lens can be implanted or aphakic spectacles can be used for refractive outcome7. a survey conducted in uk regarding complications of cataract surgeries, posterior capsular rupture was 5%8 and vitreous loss was 6.1% in a study in harpreet kapoor’s9. the vitreous loss rate was 11% vitreous loss in a large study series of ecce in malaysia10. postoperatively, the most frequent complication was striate keratopathy 8.4% in harpreet kapoor’s9 and endophthalmitis in 1.0% cases and residual lens matter in 10% of cases in study by jehangir,s and qadri11. the study was conducted in the department of ophthalmology, abbasi shaheed hospital, karachi, to evaluate the frequencies of complications that can occur with hyper mature cataract undergoing cataract extraction and assess their visual outcome. p 59 materials and methods a descriptive study was conducted in the department of ophthalmology at abbasi shaheed hospital and it was completed in almost a year. 50 patients were selected from an eye opd with senile hyper mature cataracts. their complete history was taken, thorough ocular examinations including b scan and systemic investigations where required. all the surgeries were planned day care extra capsular cataract extraction and were performed under local anaesthesia by a single experienced surgeon. dispersive ophthalmic viscoadaptives were used during surgery. complications encountered during and after surgeries were noted down. sutures were removed after three months. patients were followed regularly up to six months. data was entered and analyzed by spss computer software version 11.5. frequencies and percentages were computed for age, gender, preoperative, intra operative, postoperative complications and visual acuity. results the study was conducted on total of 50 patients with hyper mature cataract and they were evaluated according to the designed performa. they consisted of 27 (54%) males and 23 (46%) females. 28 (56%) of them had right eye and 22 (44%) had left eye operated (table 1). the age range was 50 to 80 years with a mean age 63.78 years. s9 (18%) of these patients had other systemic illness like diabetes and hypertension. pre-operative va was recorded which ranged from light perception (lp) to counting finger (cf) (table 2). majority of them had cf and hm i.e. 16 (32%) each. 3 (6%) of the patients presented with subluxated lenses preoperatively and 6 (12%) had posterior synechiae resulting in poor pupillary dilatation (table 3). forty two (84%) of these patients had uneventful surgery while 8 (16%) of them developed some complications intraoperatively. nine (18%) had poor pupillary dilation, 6 (12%) had posterior capsular rupture and vitreous loss, 2 (4%) had phacodonesis due to weak zonules and 1 (2%) developed dropped nucleus in vitreous (table 4). most of the patients 42 (84%) had posterior chamber intra ocular lenses implanted. 4 (8%) of them were managed with anterior chamber intra ocular lenses and 4 (8%) were left aphakic. table 1: gender distribution sex no. of patients n (%) male 27 (54) female 23 (46) total 50 (100) table 2: visual acuity before surgical procedure va no. of patients n (%) cf 16 (32) hm 16 (32) plpr 14 (28) pl 04 (8) total 50 (100) table 3: pre operative complications complications no. of patients n (%) posterior synechiae 6 (12) subluxated lens 3 (6) total 9 (18) table 4: complications encountered during surgery complications no. of patients n (%) poor pupillary dilatation 9 (18) pc rupture 6 (12) vitreous loss 6 (12) phacodonesis 2 (4) drop nucleus 1 (2) on the first post operative day their visual acuity ranged from hand movement to 6/12, 25 (50%) had visual acuity 6/60 and 6/36 (table 6).this was 60 improved with pinhole. post operative follow up was done at 1st week, 3rd week, 6th week, 3rd month and 6th month. visual acuity had improved by the last followup and only 12 (24%) had vision between 6/60 and 6/24 (table 6). early post operative complications were seen in 31 (62%) eyes (table 5), the most common being striate keratopathy 30 (60%), iritis 5 (10%), irregular pupil 3 (6%), sub conjunctival hemorrhage 2 (4%), cystoid macular edema 2 (4%), hyphaema, lens matter in ac and primary capsular thickening in 1 (2%) respectively. the results are illustrated in the given tables. table 5: early post operative complications complications no. of patients n (%) striate keratopathy 30 (60) iritis 4 (8) irregular pupil 3 (6) sub conjunctival hemorrhage 2(4) cme 2 (4) lens matter 1 (2) hyphaema 1 (2) pco 1 (2) table 6: va on 1st post operative day and 6 months va 1st postoperative day n (%) six months n (%) hm-cf 13(26) 0 6/60-6/24 29(58) 12(24) 6/18-6/12 08(16) 16(32) 6/9-6/6 0(0) 22(44) total 50(100) 50(100) discussion mature and hyper mature cataracts constitute a significant volume of the cataract surgical load in ophthalmic practice in the developing world5,6 and 12. the prevalence of visual impairment and blindness is 1,140,000 (962,000–1,330,000) in pakistan (2003 statistics). blindness prevalence varies throughout the country. rural areas had a higher prevalence of blindness than did urban areas (3.8% vs. 2.5%)13. in our neighboring country, there are 12.5 million blind and it is estimated that 50% to 80%14,15 are blind due to cataract. most patients have advanced stages of cataract with intumescent, mature or hyper mature cataracts. majority of these patients are socioeconomically disadvantaged and cannot afford procedures such as phaco-emulsification. conventionally an extra capsular cataract extraction with posterior chamber intraocular lens implantation (ecce-pc iol) is considered to be an effective means of restoring visual function in developing countries. however, it has its own problems related to wound suturing and its associated complications and late visual rehabilitation16. one of the commonest complications encountered during an ecce of hyper-mature cataract in this study was posterior capsule rupture with vitreous loss (12%), which is also the commonest in other studies17, 18. their frequencies are far less as compared to ours i.e. 5.7% and 0%. all of the cataracts with which we are dealing are hyper mature, these are associated with capsular fibrosis and loss of elasticity. one of the study conducted in a local hospital at rawalpindi19 had similar complications like pupillary miosis, posterior capsular rupture, and vitreous loss (6.6%) and lens subluxation. 2% had dropped nucleus, which is not common in case of extra capsular cataract extraction. the frequency of capsular rupture and vitreous loss can be reduced by staining the anterior capsule with trypan blue, to identify the capsular tear at an early stage17. the most common early post-operative complication was striate keratitis (60%). this complication was higher than other studies20 since all the cataracts are hyper mature and had large incision cataract extraction. they are associated with high rate of vitreous loss requiring vitrectomy and prolonged surgical time and more endothelial cell loss. ideally specular microscopy should be used preoperatively and post operatively21. these complications can be reduced by irrigation and aspiration in a closed chamber after insertion of an intra ocular lens and suturing. 61 hemorrhagic complications (4.02) and inflammatory complications (8.72) are comparable to a study conducted in russia22. pupil distortion (6%) is comparable to one in nigeria (5.6%)23 but the rate of posterior capsular opacity is (2%) as compared to (7%). as ecce with an iol is associated with long-term complications and our follow up was up to 6 months. the long-term effect of posterior capsular opacification (pco) needs to be assessed in larger populations24. our sample size was only 50. preoperatively, the study population presented with poor vision i.e. less than 6/60 in all of the cases. the first post operative day visual acuity was poor (i.e. 6/60 or less) in 26%, border line (6/36 to6/24) in 58% and good visual acuity (i.e. 6/18 or above according to who) in 16% of cases. at 3 months and 6 months 76% had good best corrected va i.e. 6/18 or better. it is comparable to the study related to visual outcome after vitreous loss25 in which 91% of eyes had vitreous loss and they had best corrected visual acuity of 6/9 or better. similarly the results of another study26 also showed that most of the patients after vitreous loss do reasonably well however their final visual out come was affected by cystoid macular edema, which was 4% in this study. two of our study population (4%) had va less than 6/36 due to age related macular degeneration. in cases of coexistent ocular diseases, macular degeneration was the main cause of reduced vision, accounting for 50% of those eyes with less than 6/18 and 46% of those with less than 6/60 best corrected visual acuity27. 57% and 77% cases had uncorrected va at 3 months more than 6/18 in watson and minassiana studies28,16. the results are comparable to a local study where final visual acuity reached 6/12 or better in 77% of eyes after ecce19 and 80% achieved a final va of 6/18 or better in review of 400 cases29 with similar complications. the good visual outcome signifies the importance of thorough preoperative assessment including macular function test, pupillary reflex and b-scan in cases where the fundus was not visible. the outcomes of ecce are good with fewer complications if performed with professional skills. ecce also favors economic factors for the population of this region19. the incidence of blindness in pakistan suggests that eye care facilities in general are inadequate. vision screening programs should be implemented on larger scales30. a large number of population in developing countries are still presenting with hyper mature cataracts. they should be advised for early removal of cataract before its progression to hyper maturity. early removal reduces the rate of complications and fastens the rate of rehabilitation. white cataracts require more professional skills. conclusion we conclude from our study that the chances of complications are higher in advanced cataracts. these complications can be reduced by irrigation and aspiration in a closed chamber after insertion of intraocular lens and suturing. patients should be advised to seek medical advise early for defective vision. author’s affiliation dr. erum shahid c-88, block a north nazimabad karachi dr. arshad sheikh prof. and head of department ophthalmology abbasi shaheed hospital karachi dr. uzma fasih assistant professor ophthalmology abbasi shaheed hospital karachi reference 1. khan aq, qureshi b, khan d. rapid assessment of cataract blindness, in age 40 years and above in district skardu, baltistan, northern areas, pakistan. pak j ophthalmol. 2003; 19: 84-9. 2. minassian dc, mehra v. 3.8 million blinded by cataract each year: projection from the first epidemiological study of incidence of cataract blindness in india. br j ophthalmol. 1990; 74: 341-3. 3. shaikh mr, janju mz., morphological and morphometrical study of hu more professional expertise man lens in senile cataract. j pak med. 1997; 47: 141-4. 4. hausmann n, richard g. investigations on diathermy for anterior capsulotomy.invest ophthalmol vis sci 1991; 32:215559. 5. chakarabati a, singh s, krishna as r. phacoemulsification in eyes with white cataract. j cataract refract surg. 2000; 26: 104147. 6. vajpayee rb, angra sk, honavar sg, et al. capsulotomy for phacoemulsification in hypermature cataracts. j cataract refract surg. 1995; 21: 612-5. 7. american academy of ophthalmology. surgery for cataract.in: american academy of ophthalmology. lens and cataract, 199962 2000. sanfrancisco: american academy of ophthalmology. 1999: 77-139. 8. parcel d., the national cataract surgery survey 2clinical out come j the eye. 1993; 7: 489-94. 9. kapoor h, chattergee a, daniel foster a. evaluation of visual outcome of cataract surgery in an indian eye camp. br j ophthalmol. 1999; 83: 343-6. 10. lewallan s, le mesurier rt. extracapsular cataract extraction in developing countries. arch ophthalmol. 1993; 111-18. 11. jehangir s, kadri wm. extracapsular cataract extraction with intraocular lens implantation in pakistan. pak j ophthalmol. 1988; 3: 80-2. 12. vasavada a, singh r, desai j. phacoemulsification of white mature cataracts. j cataract refract surg. 1998; 24: 270-7. 13. jadoon mz, dineeen b, bourne ra, et al. prevalence of blindness and visual impairment in pakistan:the pakistan national blindness and visual impairment survey. invest ophthalmol. 2006; 11: 4749-55. 14. dandona l, dandona r, naduvilath t, et al. is the current eye-care policy focus almost exclusively on cataract adequate to deal with blindness in india? the lancet. 1998; 74: 341-3. 15. jose r. national programme for control of blindness. indian j community health. 1997; 3: 5-9. 16. minassiana dc, rosenc p, dartb jkb, et al. extracapsular cataract extraction compared with small incision surgery by phacoemulsification: a randomized trial. br j ophthalmol. 2001; 85: 822-9. 17. kothari k, jain ss, shah nj. anterior capsular staining with trypan blue for capsulorhexis in mature and hypermature cataracts. a preliminary study. indian j ophthalmol. 2001; 49: 177-80. 18. tilahum y, sisay a. audit of extracapsular cataract extraction with posterior chamber intraocular lens implantation in a tertiary eye care centre in ethiopia. ethiop med j. 2006; 44: 61-6. 19. raja n, niazi mk. phacoemulsification versus extracapsular cataract extraction: the visual outcome. pak j surg. 2003; 19: 77-81. 20. dulayajinda d, nukhaw w, kampanartsanyakorn s, et al. outcomes of cataract surgery in senile cataract patients at siriraj hospital: a prospective observational study. j med assoc thai. 2005; 9: 82-8. 21. leatherbarrow b, trevett a, tullo ab. secondary lens implantation: incidence, indications and complications. eye 1988; 2: 370-5. 22. koos mj, muntean a, lehachi c. post operative complications in cataract surgery. oftalmologia. 2003; 56: 36-9. 23. alhassan mb, rabiu mm, ologunsua yo. long-term complications of extracapsular cataract extraction with posterior chamber intraocular lens implantation, in nigeria ophthalmol. 2004; 25: 27-31. 24. riaz y, mehta js, wormald r, et al. surgical interventions for age-related cataract. cochrane database syst rev. 2006: cd001323. 25. blomquist ph, rugwani rm. visual outcomes after vitreous loss during cataract surgery performed by residents. j cataract refract surg. 2002; 28: 847-52. 26. collins jf, krol wf, kirk gf, et al. va cooperative cataract study group. the effect of vitreous presentation during extracapsular cataract surgery on the postoperative visual acuity at one year. am j ophthalmol. 2004; 138: 536-42. 27. bourne rra, dineen bp, ali sm, et al. outcomes of cataract surgery in bangladesh: results from a population based nationwide survey. br j ophthalmol. 2003; 87: 813–9. 28. watson a, sunderraj p. comparison of small incision phacoemulsification with standard extracapsular cataract surgery: post operative astigmatism and visual recovery. eye 1992; 6: 626-9. 29. halepota fm, dahri gr, anjum n. complications of intraocular lens implantation: review of 400 cases. pak j ophthalmol. 1995; 11: 109-12. 30. afghani t, vine ha, bhatti ma, et al. al-shifa-al-noor refractive error study of one million school children. pak j ophthalmol. 2003; 19: 101-7. glaucoma standard automated perimetry is still the gold standard for visual field testing. to assess any progression of disease in glaucoma visual field testing should be performed much more frequently during the first few years after diagnosis. m lateef chaudhry editor-in-chief microsoft word nisar ahmad 152 original article visual outcome after primary iol implantation for traumatic cataract nisar ahmed, tariq aziz, sharmeen akram pak j ophthalmol 2011, vol. 27 no.3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nisar ahmed department of ophthalmology jinnah postgraduate medical centre, karachi submission of paper july’ 2011 acceptance for publication august’ 2011 …..……………………….. purpose: to assess the visual outcome of early cataract extraction with primary iol implantation for traumatic cataract caused by penetrating injury. material and methods: a prospective study was carried out on all patients with traumatic cataract caused by penetrating injury who underwent early cataract extraction (as surgery carried out within 2 weeks of the injury) with primary iol implantation at the jinnah post graduate medical center, karachi between october 1998 and march 2000. data was collected on age, gender, preoperative vision, post-operative vision at 3-6 months, and postoperative complications responsible for decreased visual acuity. results: sixty eyes in 60 patients were studied. there were 52 males and 8 females. the preoperative visual acuity was poor (≤ 6/60) in all 60 eyes. the postoperative visual acuity in 30 eyes was good (6-6/-6/12), whereas 26 eyes had borderline (6/18-6/36) and 4 eyes had poor (≤ 6/60) visual acuity. the cause of poor visual acuity was mainly corneal opacity and posterior capsular opacity. conclusion: our study shows that good visual results can be achieved in traumatic cataract surgery if the posterior segment is not involved and corneal scar does not block the optical axis. ye trauma can result in cataract formation along with other ocular problems. traumatic cataract may be caused by blunt trauma or penetrating trauma. children and young adults, especially boys are more predisposed to trauma and have a higher incidence of traumatic cataract1. the timing of surgery is important for visual rehabilitation especially in children as the risk of amblyopia is high due to media opacity. several studies have revealed that that early cataract extraction with iol implantation in traumatic cataract results in good vision2-9. this study was carried out to assess the visual rehabilitation that can be achieved following early cataract extraction and iol implantation in traumatic cataract due to penetrating injury in a tertiary hospital in karachi, pakistan. material and methods this was a prospective study. our main outcome measure was visual acuity at 3 to 6 months, assessed using snellen’s chart. all patients with traumatic cataract caused by penetrating injury who underwent early cataract extraction with primary iol implantation at jinnah post graduate medical center, karachi between october 1998 and march 2000. early surgery was defined as surgery carried out within 2 weeks of the trauma. data were collected on age, gender, preoperative visual acuity, postoperative visual acuity at 3 to 6 months and causes of poor surgical outcome. results a total of 60 eyes of 60 patients were included in the study. the majority of cases were males and aged ≤ 35 years. all eyes had a poor vision at presentation. (table 1) preoperative findings included peripheral corneal perforation in 54 eyes, central corneal perforation in 6 eyes, irregular pupil in 15 eyes and posterior synaechiae in 20 eyes. (table 1) following surgery, the visual acuity was good (6-6/6/12) in 30 e 153 table 1: key characteristics of the cataract cases at presentation (n=60) variable no. of patients n (%) age group 5-15 9 (15) 16-35 41 (68.3) 36-45 6 (10) ≥ 46 4 (6.7) sex male 52 (83.3) female 8 (13.3) visual acuity at presentation light perception 12 (20) hand movement 30 (50) counting fingers 13 (21.7) 6/60 5 (8.3) ocular conditions associated with traumatic cataract central corneal perforation 6 (10) peripheral corneal perforation 56 (93.3) irregular pupil 15 (25) eyes, borderline in 26 eyes and poor (≤ 6/60) in 4 eyes (table 2). the cause of poor visual acuity was mainly corneal opacity and post capsular opacity. late postoperative complications of iol implantation are shown in table 2. six cases developed lens decentration. lens decentrations were inconsequential for vision so no intervention was warranted. fifteen cases had high astigmatism due to corneal scar in penetrating ocular trauma and tight stitches. it decreased to acceptable limits by cutting approximately stitches three month postoperatively. ten cases developed posterior synechiae in early postoperative period. by keeping the pupil mobile with mydriacyl and increasing the topical corticosteroid eye drops the synechiae broke. seven cases developed posterior synechiae and did not responded to pupil dilation or corticosteroid eye drops. however, these syenchiae did not affect the vision so no intervention was carried out. three cases developed clinical cystoid macular edema. in these cases the visual acuity improved to 6/12 after subsidence of macular edema. thirty nine cases had corneal opacity as a late complication. table 2: visual outcome and long-term complications after surgery variable no. of patients n (%) visual acuity at 3-6 months 6/6-6/12 30 (50) 6/18-6/36 26 (43.3) ≤ 6/60 4 (6.7) long term complications corneal opacity 39 (65) posterior synaechie 7 (11.7) irregular pupil 15 (25) stitch granuloma 3 (5) iol decentration 6 (10) discussion most of the ocular trauma occurs in children and in adults in the productive age categories, a finding which was also seen in the present study. eye trauma remains a neglected public health problem and can be prevented by appropriate interventions. 52 (83.3%) of the cases were males. males are more likely to sustain an eye trauma than females because they are more likely to be involved in hazardous sports and occupations10. surgical interventions for traumatic cataract has variable outcome. 11 in our study half of the eyes (30/60) were within the good (6/66/12) visual range. such a high percentage of good out come was achieved as none of these cases had iofb or retinal detachment. our study adds to the growing body of work showing the importance of early iol implantation, which provides an everlasting solution to aphakia and results in a good visual prognosis5. the important reasons for decreased vision in our study included corneal scarring and posterior capsular opacification. our study demonstrates that good postoperative visual acuity can be achieved in traumatic cataract 154 surgery resulting from penetrating injury if the posterior segment is not involved and corneal scar does not block the vision. author’s affiliation dr. nisar ahmed department of ophthalmology, jinnah post graduate medical center1, and section of ophthalmology karachi dr. tariq aziz department of ophthalmology, jinnah post graduate medical center, and section of ophthalmology karachi dr. sharmeen akram department of surgery, aga khan university, karachi reference 1. coody d, banks j, yetman r, et al. eye trauma in children: epidemiology, management, and prevention. journal of pediatric health care. 1997;11:182-8. 2. bekibele co, fasina o. visual outcome of traumatic cataract surgery in ibadan, nigeria. niger j clin pract. 2008; 11: 372-5. 3. bienfait mf, pameijer jh, wildervanck de, et al. intraocular lens implantation in children with unilateral traumatic cataract. int ophthalmol. 1990; 14: 271-6. 4. blum m, tetz mr, greiner c, et al. treatment of traumatic cataracts. j cataract refract surg. 1996; 22: 342-6. 5. bowman rj, yorston d, wood m, et al. primary intraocular lens implantation for penetrating lens trauma in africa. ophthalmology. 1998; 105: 1770-4. 6. cheema ra, lukaris ad. visual recovery in unilateral traumatic pediatric cataracts treated with posterior chamber intraocular lens and anterior vitrectomy in pakistan. int ophthalmol. 1999; 23: 85-9. 7. gupta ak, grover ak, gurha n. traumatic cataract surgery with intraocular lens implantation in children. j pediatr ophthalmol strabismus. 1992; 29: 73-8. 8. reddy ak, ray r, yen kg. surgical intervention for traumatic cataracts in children: epidemiology, complications, and outcomes. j aapos. 2009; 13: 170-4. 9. cheema r, lukaris a. visual recovery in unilateral traumatic pediatric cataracts treated with posterior chamber intraocular lens and anterior vitrectomy in pakistan. international ophthalmology. 1999; 23: 85-9. 10. cillino s, cassiccio a, di pace f, et al. a five-year retrospective study of the epdemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in a meditteranean area. bmc ophthalmol. 2008; 22: 8:6. 11. reddy a, ray r, yen k. surgical intervention for traumatic cataracts in children: epidemiology, complications, and outcomes. journal of american association for pediatric ophthalmology and strabismus. 2009; 13: 170-4. microsoft word abstract vol.26,1,2010 51 abstracts edited by dr. tahir mahmood major shifts in corneal transplantation procedures in north china: 5316 eyes over 12 year xie l, qi f, gao h, wang t, shi w, zhao j br j ophthalmol 2009:93:1291-5. corneal transplantations are the main procedures performed to treat corneal blindness. traditionally, penetrating keratoplasty (pkp) has been the procedure selected for corneal diseases such as suppurative keratitis, keratoconus and corneal stromal dystrophy. however, immune rejection, which can lead to graft opacity, remains a major problem after pkp. even "normal" graft may have chronic corneal allograft dysfunction. with the accumulation of knowledge on corneal diseases, corneal endothelia and corneal surgery procedures, as well as the development of microsurgical technology, lamellar keratoplasty (lkp) has become more valued. although today it is well accepted that lkp should be preferred over pkp in as many cases without major problems with the corneal endothelia as it is possible to prevent endotheliumrelated problems such as immune rejection and chronic corneal allograft dysfunction. the purpose of this study was to investigate the major shifts in the ratio of lamellar keratoplasty (lkp) to penetrating keratoplasty (pkp) and in the preoperative indications for each procedure. medical records of patients who received lkp and/or pkp at shandong eye institute between 1996 and 2007 were categorised and reviewed. the time period was divided into intervals of 1996-8, 1999-2001, 2002-4 and 2005-7. a total of 4346 patients (5316 eyes) with integrated clinical records were included in the study. lkps and pkps were performed on 1558 eyes (29.3%) and 3758 eyes (70.7%), respectively. within the first 3-year interval, the top three indications for lkp were chemical burns, keratoconus and corneal dermoid; the top reasons for pkp were viral keratitis, suppurative keratitis and corneal scarring. within the last interval, suppurative keratitis, keratoconus and viral keratitis became most common indications for lkp and suppurative keratitis, viral keratitis and bullous keratopathy for pkp. the ratio of lkp to pkp operations tended to increase. authors concluded with the remarks that following proper indications, the use of lkp has increased in number in north china and has become particularly frequent in the management of corneal infections, keratoconus, corneal degeneration, and stromal dystrophy. spectacle use after routine cataract surgery wilkins mr, allan b, rubin g br j ophthalmol 2009: 93: 1307-12. the standard treatment for patients undergoing routine cataract surgery is to insert a monofocal or fixed focus intraocular lens (iol). when inserting such an iol we frequently select an iol power that will leave the patient with an emmetropic or low myopic prescription. following bilateral phacoemulsification surgery where emmetropia has been targeted, spectacle dependence for distance is at least 40%. what is not clear is what factors in the postoperative refraction predict whether a patient will be spectacle-dependent for near or distance. knowledge of such factors would allow the surgeon, by changing the iol power selected, or by managing preoperative astigmatism, to reduce spectacle dependence. the purpose of this study was to measure spectacle dependence following bilateral monofocal intraocular lens (iol) implantation and assess how it is predicted by post-operative refraction. 300 cataract patients had bilateral phacoemulsification surgery with monofocal iol implantation. a spherical equivalent of 0 to -0.5 d was targeted. three months after surgery, patients answered a questionnaire and had a spectacle refraction. refractions were converted into vector notation. logistic regression was used to evaluate whether spectacle dependence for near and distance was related to overall refractive error, spherical error, signed spherical error and astigmatic error. 52 169 patients attended for assessment. 38 wore distance glasses, and 160 wore reading glasses either some or all of the time. the mean right spherical equivalent was -0.03 d, and the mean right cylinder was -0.64 d. left outcomes were similar. patients were 34 times more likely to always use distance glasses per dioptre of astigmatic error in the better eye (p<0.003), but there was no significant increase in the likelihood of wearing distance glasses with spherical error (odds ratio = 3,85, p>0.15). similar effects were seen for both the better and worse eyes. near-spectacle use was not dependent on astigmatic error (odds ratio = 0.22, p> 0.12). it was only related to the signed spherical error in the worse eye with hypermetropic patients 6.74 times more likely to always wear spectacles per dioptre of positive spherical error (p<0.005). authors concluded with the remarks that following bilateral monofocal intraocular lens implantation, small levels of overall refractive error, in either eye, particularly astigmatism, predict distancespectacle dependence, whereas spherical ammetropia in the range of +1.0 d does not. hypemnetropia in the worse eye, but not astigmatism, predicts readingspectacle dependence. ten years after photorefractive keratectomy (prk) and laser in situ keratomileusis (lasik) for moderate to high myopia (control-matched study) alio jl, ortiz d, muftuoglu o, garcia mj br j ophthalmol 2009: 93: 1313-8. photorefractive keratectomy (prk) to correct myopia was introduced in the late 1980s. because of severe postoperative pain and relatively slow recovery after prk, laser in situ keratomilesis (lasik) was introduced in the early 1990s and became the most performed refractive surgery modality in the 2000s with claimed advantages over prk such as quick visual rehabilitation, higher predictability, minimal postoperative discomfort and absence of corneal haze. although, studies with short-term follow-up reported that the risks associated with lasik were considered to be low, postoperative flap-related complications and corneal ectasia can be sight-threatening. consequently, excimer laser superficial keratectomy techniques such as photorefractive keratectomy (frk), laser subepithelial keratectomy (lasek) and epithelial laser in situ keratomileusis (epi-lasik) have gained popularity in recent years to correct myopia to refrain from possible complications of lasik such as corneal ectasia. given that refractive surgery is mostly performed on young and healthy eyes of patients with high expectations, long-term safety and efficacy are the greatest concerns. despite millions of procedures having been preformed, there is a great lack of data about the long-term comparison of prk and lasik." previous studies comparing prk and lasik outcomes, up to 1 year after surgery, found similar or slightly better safety and efficacy outcomes for lasik. the aim of the present study is to perform a comparative analysis of the evolution of the corneal curvature and the refractive stability 10 years after myopic prk and lasik for moderate myopia by means of a control-matched retrospective study. the purpose of this study was to evaluate to compare the long-term outcomes of photorefractive keratectomy (prk) and laser in situ keratomilesis (lasik) for myopia between -6 and -10 d. a retrospective, control-matched study including 68 eyes, 34 which underwent prk and 34 lasik, with myopia between -6 and -10 d, operated using the visx 20/20 excimer laser, was performed. optical zones of 5.5 to 6 mm were used. all prk-treated eyes were matched with lasik-treated eyes of the same age, spherical equivalent within ± 1.25 d, sphere within ±.5 d and cylinder within ±. 5 d. all patients were evaluated 3 months, 1 year, 2 years, 5 years and 10 years after surgery. the main outcomes measures were refractive predictability and stability, safety, efficacy and re-treatment rate. at 10 years, 20 (71%) and 23 (88%) were within ± 1.00 d after prk and lasik respectively. the retreatment rate was 35% and 18% respectively. no eye lost more than two lines of bscva in both groups. the efficacy was 0.90 for prk and 0.95 for lasik. authors concluded with the remarks that both prk and lasik were safe for moderate myopia. lasik demonstrated slightly better efficacy, predictability, and less rate of re-treatment after 10 years. the technical improvements should be taken into account when comparing these results with those obtained more recently. comparison of outcomes of lamellar keratoplasty and penetrating keratoplasty in keratoconus han dcy, mehta js, por ym, htoon hm, tan dth 53 am j ophthalmol 2009; 148: 744-51. penetrating keratoplasty (pk), the full-thickness replacement of a diseased cornea with an allograft donor cornea, has been a well-accept-surgical treatment for keratoconus over the past few decades. however, it can be complicated by allograft endothelial rejection, which will lead to concomitant endothelial cell loss with subsequent risk of graft failure deep anterior lamellar keratoplasty (dalk), which involves replacing the anterior part of a diseased corner while retaining the healthy deeper tissue, has the advantage of reducing the risks of graft rejection and intraocular complications. it is, however, more technically demanding and may result in suboptimal visual outcomes because of interface and refractive irregularities. over the past few decades, several techniques of anterior lamellar keratoplasty (alk) have been described. these include the earlier predescemetic procedures in which some stromal tissue and descemet membrane (dm) are left behind, such as in the manual forms of dalk in which manual lamellar surgical dissections were performed. a recent innovation of predescemetic dalk is automated lamellar therapeutic keratoplasty, which uses microkeratome instrumentation to perform lamellar dissection. most recently, descemetic lamellar keratoplasty procedures have been described in which total stromal removal is attempted, leaving only the dm and endothelium behind, which includes the anwar big-bubble technique. this study aimed to compare the optical results of pk and two subgroups of alk in patients with keratoconus, that is, predescemetic and descemetic techniques. in our population, keratoconus is the fourth most common indication for corneal grafting after pseudophakic and aphakic bullous keratopathy, postinfectious scarring, and regrafts. because keratoconus represents low-risk keratoplasty and patients usually are young and free of other ocular pathologic features, they provide an ideal cohort to study success and visual outcomes between lamellar keratoplasty and pk. the purpose of this study was to evaluate to compare outcomes after penetrating keratoplasty (pk) and two techniques of deep anterior lamellar keratoplasty (dalk) in patients with keratoconus. one hundred and twenty-five corneal transplantations comprising 100 pk and 25 dalk procedures for keratoconus at the singapore national eye centre from. april 1992 through december 2006 were included. dalk was performed with the modified anwar technique (descemetic or dalka group) in 14 eyes and manual lamellar keratoplasty (predescemetic or dalkm group) was performed in 11 eyes. at 12 months, the dalka and pk groups achieved a logarithm of the minimum angle of resolution mean best spectacle-corrected visual acuity (bscva) of 0.15 and 0.27, respectively (p = .26), whereas the mean bscva of the dalkm group was 0.41 compared with the pk group (p = .12). significance level was achieved between the dalka and dalkm groups (p = .013). there was no significant difference in the mean spherical equivalent (p = .72) and astigmatism (p = .88) between the pk and dalk groups. the dalk group had a significantly lower incidence of complications compared with pk cases, including allograft rejection and glaucoma. graft survival rate of both the pk and dalka groups was 100%, whereas that of the dalkm group was 73% at 3 years after surgery (p = .000 between pk and dalkm groups). authors concluded with the remarks that visual acuity outcomes of the dalka technique are comparable with those of pk for keratoconus, whereas dalk surgery results in fewer postoperative complications than pk. dalka is emerging as a preferred choice among the lamellar techniques for better optical outcome. further studies are required to provide long-term analysis of these results. microsoft word obituary prof. tahir mahmood 52 obituary prof. dr. tahir mahmood (1962-2010) tahir mahmood had a sudden and fatal heart attack on 20th december 2010 (13th moharram-ul-haram). it was news which hundreds of his friends, students, colleagues and family members heard with a great degree of surprise and grief. prof. mahmood was born in 20th of july 1962 (48 years old at time of death). he graduated from the prestigious allama iqbal medical college, lahore in 1986. he had his basic training in ophthalmology from services and shaikh zayed hospital, lahore and then moved on to united kingdom, where he did frcs. he had further training at rotherham and kent in england. he came back to pakistan with great enthusiasm in 1995 and held various faculty positions at shaikh zayed hospital & federal postgraduate medical institute lahore till became professor in 2008. he was the first ophthalmologist to have served as the administrator of shaikh zayed hospital, lahore. in his carrier there were several highlights like; performed first lasik procedure in pakistan, performed more than 10,000 photo-refractive surgeries and performed more than 19,000 phacoemulsifications. he was a great teacher and produced several students who have achieved high positions in their own carriers. his academic commitment was remarkable. he took over responsibilities of pakistan journal of ophthalmology overnight from prof. j. durrani and assisted prof. m. latif chaudhry as editor to bring it to current status. he was a very active life member of ophthalmological society of pakistan and served lahore branch as joint secretary and member of executive committee. despite his high profile career his personality did not have a glimpse of attitude towards junior colleagues and sub-ordinates. he used all his positions to serve not to surpass. despite lot of work he did for the ophthalmic community, he preferred to avoid any moment of glorification. his soft voice and humble attitude became his trademark. the legacy he left behind for us is; adherence to professional ethics, seeking technical perfection and the ultimate humanism in all spheres of life. may allah (swt) bless his soul in peace and honour him with the companionship of prophet mohammad (saw) in jannat. zahid kamal siddiqui abdul hamid awan pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 187 author communication ocular complications of measles; a case series erum shahid, uzma fasih, arshad shaikh pak j ophthalmol 2017, vol. 33, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: erum shahid department of ophthalmology, kmdc abbasi shaheed hospital email: drerum007@yahoo.com …..……………………….. purpose: to report case series of ocular complication in patients with measles and how to manage them. study design: case series place and duration of study: abbasi shaheed hospital, karachi. winter spring outbreak (january – april) 2016. material and method: this is a case series of 9 patients who presented in an eye opd with ocular complications of measles over a period of 2 months during spring break 2016. their ages range between 7 months to 21-year-old. 7 patients presented with kerato conjunctivitis, 1 with keratomalacia and 1 with preseptal abscess. result: all the patients with keratoconjunctivitis responded to treatment and were 6/6. a seven-month old infant had keratomalacia and ended with leucoma in one eye. another 1-year-old girl with preseptal cellulitis was treated with incision and drainage. conclusion: keratitis is a common complication of measles which may lead to a serious complication like keratomalacia. preseptal abscess is another rare complication to look out for. key words: measles, ocular complications, keratoconjunctivitis, keratomalacia orldwide measles is an important health problem which may affect almost all nonimmune individuals in presence of an effective vaccine1. it is an acute and contagious disease characterized by fever and exanthematous infection. it follows a course of winter spring outbreak lasting 3 to 4 months every 2 to 5 years2. it is a disease with good prognosis in uncomplicated cases but with a high mortality rate in case of complications. life threatening complications are otitis media (7 – 9%), pneumonia (1 – 6%), diarrhea (0.6%), post-infectious encephalitis (0.1%), sub-acute sclerosing panencephalitis (sspe) (0.001%) and even death (0.1 – 0.3%)3. in third world countries its mortality rate is 3 to 5%4 or may be 4 to 10%5. conjunctivitis accompanied with lacrimation and photophobia is experienced in its prodromal stage following fever, malaise, anorexia, cough and coryzia. measles induced keratitis, corneal ulceration and perforation have been described6. one of the study carried on 628 hospital admitted cases during measles outbreak noted ocular complication like keratitis, ulceration, perforation, and blindness in 7.3% of patients7. measles complicated by meningitis and optic neuritis have also been reported8. we are reporting a case series of patients presenting with ocular complication of measles during winter spring outbreak (january – april) of 2016 in abbasi shaheed hospital, a tertiary care hospital of karachi. it will help us in understanding and managing its ocular complications. all the patients were diagnosed with measles based on clinical grounds and laboratory investigations. case 1 – 7: these 7 patients presented in eye opd with complain of redness, watering, and photophobia. age w erum shahid, et al 188 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology of youngest patient was 3 years and oldest was 21 years. these complain started after 1 to 2 week of an acute stage of measles. five patients had bilateral complains with one eye affected more than other. two had unilateral disease and less severe. their vision ranges between 6/18 to 6/9. they were examined on slit lamp. there was superficial punctate keratopathy with surrounding diffuse subepithelial infiltration. they had positive fluorescein staining but with normal corneal sensitivity. anterior chamber, pupillary reactions, intraocular pressure, and fundus were normal in these patients. diagnosis was made on history and clinical examination. they were treated with combination of topical mild steroid (loteprenolol) and antibiotic (tobramycin) along with artificial tears four times a day. they were followed up every week. all the patients except one were recovered in 2 weeks. one patient who was 21-year-old was completely recovered in 1 month. complete recovery was labelled when cornea became transparent and visual acuity was regained to 6/6. case 8: a seven-month old male infant was admitted in peadiatrics department with pneumonia secondary to measles. the baby was malnourished. he was referred due to watering, lid edema and whitening of cornea. on examination right eye showed central corneal sloughing and left eye with lusterless cornea. diagnosis of keratomalacia was made. he was prescribed topical antibiotics, cycloplegics and preservative free artificial tears in both eyes. he was also given oral vitamin a (200 000 iu) for 2 days along with systemic treatment of pneumonia (iv ceftriaxone). the baby was closely followed up. but after 1-month right eye had developed leucoma and left eye was normal. case 9: another 1-year-old female infant was also referred from pediatrics. she was admitted there due to measles but with normal weight. she had left lower lid abscess. it was around 3x4 cm, warm, tender and with pointing. globe was normal. she was already on systemic antibiotics (ceftazidime) for 2 days. lower lid abscess was drained next day under local anesthesia and packed with dressing. specimen was sent for culture and sensitivity. it was negative perhaps due to previous use of antibiotics. the dressing was changed every day for 2 days. the baby responded well to systemic antibiotics and was discharged after 1 week on oral treatment. discussion the complication of measles may affect and have been reported to affect every organ system. these complications are due to disruption of epithelial surfaces and immunosuppression9. conjunctivitis is most commonly seen in persons suffering from measles followed by inflammation of cornea (keratitis)10. since most of the viral conjunctivitis presents intensely with injected conjunctiva, watery discharge, lid swelling, burning, itching or foreign body table 1. distribution of different cases of measles. no age gender diagnosis outcome eye 1. 3 years m punctate keratitis 6/6 r&l 2. 13 year m punctate keratitis 6/6 l 3. 8 year m punctate keratitis 6/6 r 4. 10 year f r punctate keratitis 6/6 r&l 5. 21 year m punctate keratitis 6/6 l>r 6. 15 year m punctate keratitis 6/6 r>l 7. 7 year f punctate keratitis 6/6 r>l 8. 1 year f lower lid abscess 6/6 l 9. 7 months m r corneal sloughing l luster less cornea r leucoma adherent, phthisis r&l ocular complications of measles; a case series pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 189 sensation. papillary and follicular hyperplasia of palpebral conjunctiva may be seen. in severe form of infections, keratitis, sub conjunctival hemorrhages, preauricular lymphadenopathy with sore throat, headache, fever, and upper respiratory tract infections may be seen11. patients in our study presented with watery discharge and decreased vision when the acute symptoms have been resolved. duration of developing keratitis was from 10 days to 2 weeks of acute symptoms. on examination all features of other viral conjunctivitis were absent. clinical history and absence of other features makes clinical diagnosis easy. in one of the study 57% of the turkish military personnel developed keratitis10. in a well-nourished individual keratitis heals without residual damage. if complicated by secondary bacterial or viral infections can lead to scarring and blindness12. since most of the patients with keratitis were healthy, immune competent and in young ages so they did not develop any serious complication. measles along with vitamin a deficiency predisposes to severe form of keratitis followed by corneal dryness, ulceration, perforation, leucoma adherent and finally pthisis bulbi13,14. one of the infant in our case series had develop leucoma and blindness since the baby was malnourished with severe vitamin a deficiency. measles with vitamin a deficiency is a lethal combination and is responsible for the most common cause of acquired blindness in children in developing countries15. one of our patient presented with lower lid preseptal abscess. this complication is not documented in literature. it may be a coincidence that the child is suffering with measles and secondarily infected causing an abscess or may be due to immunosuppression. but on the other hand measles can affect any organ system9. one of the rare ocular complication is measles associated optic neuritis. this demyelination is due to an autoimmune response rather than direct viral invasion. its delayed onset after infection and relatively good visual prognosis favors an autoimmune mechanism16 17. diagnosis of measles is primarily based on clinical grounds and more accurately during an epidemic18. however, it can be confirmed by demonstrating measles igm antibodies up to a month after infection19. igg antibodies level peaks within four weeks than persists for many years after infection. doubtful cases can undergo further confirmatory testing using respiratory swabs or urine sample tested for measles real-time pcr, cell culture, conventional pcr, and genotyping 20. conclusion keratitis is a common complication of measles. it responds well to treatment without scarring in young, healthy, and immune competent individual. however, it may lead to a serious complication like keratomalacia especially in malnourished babies that may make them blind which needs longterm and expensive treatments. preseptal abscess is one of a rare complication not mentioned in literature. author’s affiliation dr. erum shahid fcps, mcps, senior registrar department of ophthalmology, kmdc abbasi shaheed hospital. dr. uzma fasih fcps, associate professor department of ophthalmology, kmdc abbasi shaheed hospital. dr. arshad shaikh fcps, mcps, professor + h.o.d department of ophthalmology, kmdc abbasi shaheed hospital. role of authors dr. erum shahid concept, data collection, manuscript review, critical review. dr. uzma fasih concept, data collection, critical review. dr. arshad shaikh concept, critical review. refrences 1. plotkin sl, plotkin sa. measles vaccine. in: plotkin s, orenstein w, offit p, editors. vaccines. 4th ed. philadelphia: w.b. saunders, 2004: pp 389-440. 2. asaria p, macmahon e. measles in the united kingdom: can we eradicate it by 2010. bmj. 2006; 333: 890-5. 3. gershon aa. measles virus. in: mandell gl. bennett je. dolin r, editors. principles and practice of infectious diseases. 5th ed. new york: churchill livingstone, 2000: pp 1801-9. erum shahid, et al 190 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology 4. t.a. willke, g. söyletir, m. doganay (eds.), infectious diseases and microbiology. 3th ed. istanbul: nobel tip publication, 2008: 1218-9. 5. nandy r, handzel t, zaneidou m, et al. case-fatality rate during a measles outbreak in eastern niger in 2003 clin infect dis. 2006; 42: 322 6. cherry jd. measles virus. in: textbook of pediatric infectious diseases, 6th ed, feigin rd, cherry jd, demmler harrison gj, et al (eds), saunders, philadelphia, 2009: p.2427. 7. tahir javed, ayesha bibi, akmallaeeq chishti, kashif siddique. morbidity and mortality pattern of hospitalized children with measles at mayo hospital, lahore (epidemic 2013). annals of kemc, 2014; vol. 20. 8. nobuhito nakajima, masayuki ueda, mineo yamazaki, toshiyuki takahashi, and yasuo katayama. optic neuritis following aseptic meningitis associated with modified measles: a case report jpn. j. infect. dis., 2013; 66: 320-322. 9. ludlow m, mcquaid s, milner d, de swart rl, duprex wp. pathological consequences of systemic measles virus infection. the journal of pathology, 2015 jan 1; 235 (2): 253-65. 10. kayikcioglu o, kir e, soyler m, guler c, irkec m. ocular findings in a measles epidemic among young adults. ocul immuno linflamm. 2000; 8: 59-62. 11. syed na, hyndiuk ra. infectious conjunctivitis. infect dis clin north am. 1992; 6: 789805. 12. foster a, sommer a. childhood blindness from corneal ulceration in africa: causes, prevention, and treatment. bull world health organ, 1986; 64: 619–23. 13. foster a, sommer a. corneal ulceration, measles, and childhood blindness in tanzania. br j ophthalmol. 1987; 71: 331–43. 14. sugerman de, barskey ae, delea mg, et al. measles outbreak in a highly vaccinated population san diego, 2009: role of the intentionally undervaccinated. pediatrics, 2010; 125: 747. 15. wairagkar ns, gandhi bv, katrak sm, shaikh nj, parikh pr, wadia nh, et al. acute renal failure with neurological involvement in adults associated with measles virus isolation. lancet, 1999; 354: 992–5. 16. selbst, r.g., selhorst, j.b., harbison, j.w., et al. parainfectious optic neuritis. report and review following varicella. arch. neurol., 1983; 40: 347–350. 17. johnson, r.t., griffin, d.e., hirsch, r.l., et al. measles encephalomyelitis—clinical and immunologic studies. n. engl. j. med., 1984; 310: 137–141. 18. lamabadusuriya sp, senanayake m, re-emergence of measles. ceylon medical journal, 1999; 44: 185-6. 19. collier l, oxford j. human virology: a text for students of medicine, dentistry, and microbiology. oxford: oxford university press, 1993: 115-16. 20. ono n, tatsuo h, hidaka y, aoki t, minagawa h, yanagi y. measles viruses on throat swabs from measles patients use signaling lymphocytic activation molecule (cdw150) but not cd46 as a cellular receptor. j virol. 2001 may; 75 (9): 4399-4401. microsoft word tayyaba gul case report 162 case report best vitelliform macular dystrophy with central retinal artery occlusion tayyaba gul malik, aamir ahmad, muhammad khalil, sania khan, mian mohammad shafique pak j ophthalmol 2010, vol. 26 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyaba gul malik department of ophthalmology lahore medical and dental college, lahore. received for publication december’ 2009 …..……………………….. best vitelliform macular dystrophy is a rare condition characterized by deposition of lipofuscin within the retinal pigment epithelium. we present a case of best vitelliform dystrophy with central retinal artery occlusion. est’s disease or best macular dystrophy is an autosomal dominant disorder. first pedigree was described by a german ophthalmologist dr. franz best in 19051. during its course the disease evolves gradually through five stages. this case presents the two different stages of the disease in the same patient along with the central retinal artery occlusion. case report in october 2008, a 45years old (pakistani) male presented in out patient department with sudden loss of vision in right eye two weeks earlier. while probing into the history, it was revealed that he had dimness of vision in both eyes for the last fifteen years. two weeks back he developed sudden loss of vision in his right eye which was not associated with pain and redness of eyes. he was an average built man, nonsmoker, non-diabetic, non-hypertensive and did not have any other systemic disease. ocular examination showed orthophoria with full extra ocular movements. his best corrected visual acuity was perception of light in right eye and 6/60 in the left eye. intra ocular pressures were 12mm of mercury in both eyes. there was right relative afferent pupillary defect. on slit lamp examination anterior segment was unremarkable. pupils were dilated and fundoscopy was performed. there was a large round egg-yolk like lesion involving the whole macula in right eye. branches of central retinal artery were thread-like and disc was pale. left fundus showed multifocal yellowish lesion with a large central lesion of 2.5 to 3 disc diameters at the fovea. the disc and the retinal vasculature was normal in this eye. on the basis of history and examination, he was diagnosed a case of best macular dystrophy (vitelliform stage) with central retinal artery occlusion in right eye and best macular dystrophy (vitelliruptive stage) in left eye. eog was not performed because of lack of electrophysiological test facilities. keeping in view the central retinal artery occlusion, cardio vascular system was evaluated. complete blood count, esr, lipid profile, ecg, echocardiography and carotid doppler were all normal (fig.1). as there is no treatment available for best’s disease and the central retinal artery occlusion was few weeks old, the patient was reassured and called after six months for follow up. b 163 after six months, patient’s best corrected visual acuity was 6/18 in the right eye and it was only on the temporal side. vision in the left eye was unchanged. on fundoscopy pseudohypopyon stage was seen in the right eye. foveal area was clear of the lipofuscin pigment and cilio-retinal artery could be seen supplying the macular area (fig. 2). this finding was consistent with the improvement in visual acuity. in the left eye it was vitelliruptive stage as before (fig. 3). discussion best vitelliform macular dystrophy is one of the rare fundus dystrophies. inheritance is autosomal dominant with variable penetrance. five stages of the disease has been recognized2. stage 0: pre-vitelliform stage 1: pigment mottling at macula stage 2: vitelliform with egg yolk macular lesion stage 3: peudohypopyon when part of lesion gets absorbed stage 4: vitelliruptive with a scrambled egg appearance. eog is sub normal in all these stages. adult onset foveomacular vitelliform dystrophy in contrast have smaller lesions, present late in life and do not demonstrate similar stages. morphologically both these diseases have similarities but they are generally considered different entities3. this patient was an unusual case in two aspects; visual acuity and association of this disease with central retinal artery occlusion. visual acuity in best vitelliform degeneration is generally good in the vitelliform stage. it is only with the onset of vitelliruptive stage when the vision starts to deteriorate. this occurs due to retinal pigment epithelial atrophy. according to fishman ga4 and colleagues, fall in visual acuity is more in patients above 50 years of age. our patient had only perception of light in right eye (even with the vitelliform stage) at the time of presentation. disc pallor with thread like arterioles indicated old central retinal artery occlusion. once the lipofuscin started to absorb from the foveal area the visual acuity improved because of the presence of cilioretinal artery. vision in the left eye with vitelliruptive stage remained 6/60. data available so far suggests that best vitelliform degeneration is an isolated disease with no systemic associations. however, there is a case report5 in which fig. 1: carotid doppler right common carotid artery, showing normal flow. fig. 2: pseudohypopyon stage with white pale disc six months after the initial presentation. fig. 3: vitelliruptive stage in left eye. 164 adult onset foveomacular vitelliform dystrophy was associated with neurofibromatosis type 1. similarly, there are few case reports of retinal folds, central serous chorioretinopathy and choroidal neovascularization being associated with adult onset vitelliform degeneration but not with the juvenile type. this disease has a wide range of expressivity and electro-oculography is the diagnostic test in doubtful cases. nobel kg6 presents a study in which two cases of choroidal neovascularization and central choroidal dystrophy later turned out to be vitelliform macular dystrophy on eog. similarly, lesions in best’s disease are usually single and central but there are few reports which describe multiple peripheral lesions7 outside the macula and posterior pole. due to the diverse clinical presentations of this disease, there are many single case reports found in literature. our case is another unique addition. conclusion our patient had an unusual presentation of best vitelliform degeneration with central retinal artery occlusion. to the best of our knowledge this is the first report. on cardio vascular investigations no cause of artery occlusion was found. how is it related to the central retinal artery occlusion needs to be established by further studies. author’s affiliation dr. tayyaba gul malik assistant professor department of ophthalmology lahore medical and dental college lahore. dr. aamir ahmad assistant professor of ophthalmology lahore medical and dental college lahore dr. muhammad khalil assistant professor of ophthalmology lahore medical and dental college lahore dr. sania khan medical officer ghurki trust teaching hospital lahore professor mian mohammad shafique department of ophthalmology lahore medical and dental college lahore reference 1. best f. ubereine hereditary maculaaffektion. beitrage zur vererbungslehre. augenheikd. 1905; 13: 199. 2. kanski jj. fundus dystrophies. in: clinical ophthalmology: a systematic approach. 6th ed. elsevier butterworth heinemann. 2007; 672. 3. kramer f, white k, pauleikhoff d, et al. mutations in the vmd2 gene are associated with juvenile-onset vitelliform macular dystrophy (best disease) and adult vitelliform macular dystrophy but not age-related macular degeneration. europ. j. hum. genet. 2000; 8: 286-92. 4. fishman ga, baca w, alexander kr, et al. visual acuity in patients with best vitelliform macular dystrophy. ophthalmology. 1993; 100: 1665-70. 5. mcloone em, buchanan ta. unusual macular lesions in a patient with neurofibromatosis type 1. int ophthalmol. 2005; 26: 115-7. 6. nobel kg, scher bm, carr re. polymorphous presentations in vitelliform macular dystrophy: subretinal neovascularisation and central choroidal atrophy. br j ophthalmol. 1978; 62: 56170. 7. laloum je, deutman af. peripheral vitelliform lesions in vitelliform macular dystrophy. j fr ophthalmol. 1991; 14: 74-8. every case of acute glaucoma is not angle closure every case of raised iop with a clear cornea and deep ac is not primary open angle glaucoma .determine the under lying cause of glaucoma and give appropriate treatment. prof. m lateef chaudhry editor in chief microsoft word news and events to be edited 238 news and events vol. 27, 4, 2011 18th hyderabad ophthalmo 2011 date: 21 – 23 january, 2012 venue: indus hotel, hyderabad contact: dr. khan muhammad nangrejo general secretary osp hyderabad phone: 0300-3218551 email: khannangrejo@hotmail.com 34th karophth 2012 date: 16 – 18 march 2012 venue: pearl continental hotel, karachi contact: dr. qazi wasiq general secretary cell: 92 333 2183272 email: ospkarachi@yahoo.com 34th annual congress of ophthalmological society of pakistan and 7th khyber symposium date: 28 – 30 september 2012 venue: pearl continental hotel peshawar contact: dr. sanaullah jan phone: 091-5825087/0313-8584819 email: sanaullahjan@hotmail.com 32nd lahore ophthalmo 2012 date: 21 – 23rd december 2012 venue: lahore international expo centre contact: dr. qamar ul islam lodhi president osp lahore phone: 042-36363325-6 email: osplhr@gmail.com the 27th apao congress busan, korea. date: 13 – 17 april, 2012 web: www.apaophth.org the 28th apao congress new delhi, india date: 06 – 09 february, 2013 33rd world ophthalmology congress (woc) date: 16 – 20 february, 2012 venue: abu dhabi, united arab emirates american society of cataract and refractive surgery (ascrs) / american society of ophthalmic administrators (asoa) symposium and congress date: 20 – 24 april, 2012 venue: chicago, il the association for research in vision and ophthalmology (arvo) annual meeting 2012 florida, usa date: 6 – 10 may, 2012 venue: fort lauderdale, florida, usa web: www.arvo.org european glaucoma society 10th congress date: 17 – 22 june, 2012 venue: copenhagen, denmark web: www.eugs.org xx biennial meeting of international society for eye research date: 22 – 27 july, 2012 venue: berlin, germany institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091 – 9217376 – 80 fax: 92 – 42 – 6363326 email: pico@pes.comsats.net.pk 239 college of ophthalmology and allied vision sciences lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042 – 37355998 fax: 042 – 37248006 email: pipo@brain.net.pk pakistan institute of ophthalmology, al – shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al – shifa trust eye hospital, jhelum road, rawalpindi – pakistan phone: 92 – 51 – 5487830, 5487820 – 25 fax: 92 – 51 – 5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt department of ophthalmology fatima jinnah medical college sir ganga ram hospital, lahore fax: 92 – 42 – 6363326 email: hamidbut@gmail.com mobile: 0300 – 4158962 microsoft word faisal aziz khan 69 original article the importance of excising or suturing the posterior mucosal flaps in external dacryocystorhinostomy faisal aziz khan, muhammad amer yaqub, muhammad fayyaz pak j ophthalmol 2010, vol. 26 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . … . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: faisal aziz khan eye specialist cmh, abbottabad received for publication june’ 2009 … ……………………… purpose: to compare the success rate of external dacryocystorhinostomy (with intubation) with suturing of the posterior flaps and without suturing of the posterior flaps. material and methods: a prospective comparative study of 70 patients attending the ophthalmology department military hospital rawalpindi between dec 2005 and march 2007 who underwent external dcr after dividing them into two groups of 35 each. in one group posterior flaps were sutured and in the other group posterior flaps were excised. all external dcrs were performed under general anesthesia. the posterior flaps were sutured with 5/0 vicryl or excised with spring scissors. all dcrs were intubated. the tube was removed after 03 months. at 04 months, the success was judged if there was relief of epiphora and potency confirmed by probing syringing. results: the success rate was 97.1% in dcr with suturing of the posterior flaps and 94.3% in dcr with excision of posterior flaps. statistically the difference in results were insignificant. (p-value > 0.05). conclusion: the surgical success of dcr with suturing of the posterior flaps is statistically insignificant to dcr without suturing of the posterior flaps. acryocystorhinostomy(dcr) creates a fistula between the lacrimal sac and nasal cavity1. in 1904 addeo toti was the first to propose the technique of external dcr, his steps were to expose the lacrimal sac by an external incision, remove the medial wall, punch out a piece of bone with hammer and chisell, resect a corresponding area of nasal mucous membrane and sew up the external wound2. the modern method was described by dupuy– dutemps and bourget (1921), who incised the posterior wall without removal of tissue and approximated flaps of lacrimal sac and nasal mucosa2. silicone tubing was introduced by gibbs (1967) and used by quickert and dryden (1970) to intubate the nasolacrimal duct2. older advocated that silicone tube is a useful adjunct to external dcr and should be used routinely3. external dcr has a success rate of 80 to 99% depending upon the surgeon’s experience4. with silicone intubation the success rate of external dcr in selected cases is 95 %5. external dcr in which only the anterior flaps are sutured with a slight modification of the bridge with the muscle layer has a success rate of 98.33%,3. the dcr procedure may fail due to a number of causes which include fibrous tissue growth, inappropriate size or location of bony ostium, common canalicular obstruction, scarring within the rhinostomy, intervening ethmoid air cells, interference of middle turbinate, sump syndrome and active systemic disease3. other than conventional external dcr, other techniques are being employed to relieve the obstructtion of nasolacrimal duct, these include endoscopic dcr6, endoscopic nasal dcr7, dacryocystoplasty8, endoscopic radiofrequency assisted dcr9. inspite of all new technological advancements external dcr still continues to be the cheapest and very effective surgical procedure for majority of patients with epiphora in our country9. d 70 the purpose of this study was to statistically compare the efficacy of external dcr with a slight modification in which the posterior flaps were sutured in one group and not sutured but excised in the other group; thus helping us in further polishing and refining our operative techniques of conventional dcr. materials and methods this study was carried out in department of ophthalmology military hospital rawalpindi. the duration of study extended over fifteen months from december 2005 to march 2007 which included 70 patients. they were randomly divided into two groups of 35 each and labeled group a and b respectively. in group a external dcr was done with suturing of the posterior flaps while in group b posterior flaps were excised. the inclusion criteria were adults having epiphora, chronic dacryocystitis, acute on chronic dacryocystitis and complete nasolacrimal duct obstruction confirmed with regurgitation test and probing and syringing .patients younger than 15 years and those who had common canalicular and individual canalicular occlusion or post traumatic lid and bony deformities were excluded from the study. all patients underwent complete ophthalmic and nasal examination, puncta were particularly examined for malposition, and agenesis. regurgitation test was performed and probing and sac syringing done. none of the patients was subjected to schirmer`s test, jones dye test or dacryocystography. history of diabetes, hypertension, ischaemic heart disease, bleeding disorder, aspirin use and antiplatelet therapy was taken. fitness to undergo general anesthesia was obtained after relevant investigations and written informed consent was taken. all patients were admitted and were operated upon by the same surgeon. skin incision was made which was slightly curved, slightly above the medial canthal tendon and carried downward for 20-25mm along the nose. after careful dissection the medial canthal tendon was incised exposing the lacrimal sac. the periosteum was incised and reflected posteriorly. anterior lacrimal crest and lacrimal fossa were exposed. osteotomy was initiated at the thin bone at the junction of the lacrimal and maxillary bone. the osteotomy extended anteriorly up to 5mm anterior to the anterior lacrimal crest, posteriorly up to the posterior lacrimal crest, superiorly up to the insertion of medial canthal tendon and inferiorly to the inferior orbital margin. a probe was passed into the lacrimal sac and incised down to the nasolacrimal duct. the lacrimal sac flaps were prepared by making a horizontal h shaped incision in both patient groups whether posterior flaps were to be sutured or excised. similarly the nasal mucosa was incised in h shaped manner. the patient group where posterior flaps were to be sutured equal size of both anterior and posterior lacrimal as well as nasal flaps were prepared whereas large anterior flaps were prepared in that group where posterior flaps were to be excised. two stitches with 5/0 vicryl were applied to suture the posterior flaps’ while whereas they were excised in group b patients. intubation was done with siiicone tube (0.6-0.8mm). anterior flaps were sutured with 5/0 vicryl with two stitches. the medial canthal tendon was reattached to its insertion. muscle and soft tissues were closed. the skin was closed with 7/0 vicryl mattress sutures. the silicone tube was tied with multiple square knots, and was not sutured to the nasal mucosa. patients were discharged on the second postoperative day. first follow up was at one week and then at monthly intervals till 03 months. in all the patients the tube was removed at 03 months. at 04 months the success of dcr was evaluated if there was symptomatic relief of epiphora and a patent lacrimal passage on probing and irrigation. results 70 patients were operated, 20 were male and 50 were female. male to female ratio was approximately 1:2.5 (table 1). the presenting complaints among the patients included epiphora alone in 55(78.6%) cases, 10(14.3%) cases had epiphora with mucocoele and 5(7.1%) cases had acute on chronic dacryocystitis (table 2). intraoperatively the surgery was uneventful in 67(95.7%) out of 70 cases. 01 (1.4%) case required middle turbinectomy, 02(2.9%) cases had bleeding from nasal mucosa. during the follow-up period no complications were encountered in the 68 (97.1%) cases and the tube was tolerated well except in 02(2.8%) cases the silicone tube migrated laterally which was repositioned surgically. at 04 months in group a, 34 (97.1%) cases out of 35 had symptomatic relief of epiphora and patency of lacrimal passage was confirmed with probing and irrigation. in 01(2.9%) case with persistent epiphora probing and irrigation showed obstruction at the level of anastomosis. 71 at 04 months in group b, 33 cases out of 35 (94.3%) were relieved of epiphora and patency of lacrimal passage was confirmed with probing and irrigation. in 02(5.7%) cases probing and irrigation revealed obstruction at the level of common canaliculus. the success rate of dcr in group a was 97.1% and in group b 94.3%. (table-3) chi square test was used to compare the frequency of success of group a with group b at a confidence limit of 95%. p-value was 0.555 which was greater than 0.05.therefore the success rates between group a and group b were statistically insignificant (table-3). table 1: gender wise distribution of patients (n=70) gender cases n=70 (%) male 20 (28.5) female 50 (71.4) table 2: presenting complaints presenting complaints no. of patients n=70 (%) epiphora 55(78.6) epiphora with mucocoele 10(14.3) acute on chronic dacryocystitis 5(7.1) table 3: comparison of the frequency of success between group a* and group b** group category successful dcr*** failed dcr*** total frequency frequency n (%) n (%) group a* (n=35) 34 (97.1) 1 (2.9) 35 group b** (n=35) 33 (94.3) 2 (5.7) 35 discussion this study was conducted with an aim to compare the two different techniques of external dcr with suturing of the posterior flaps and excision of the posterior flaps and its effect on the success of dcr. preoperatively canalicular obstruction may have an affect on the success. burns and cahill reported a success rate of 81% in patients with concomitant canalicular disease and 98% without preoperative canalicular disease10. in our study, patients with punctal and canalicular disease were excluded. the review of literature shows that external dcr may fail due to a number of factors including fibrous tissue growth, inappropriate size or location of bony ostium, common canalicular obstruction, scarring within the rhinostomy, intervening ethmoid sinus air cells, interference of middle turbinate, sump syndrome and active systemic disease11,12. in our study the exact cause of failure could not be detected as patients did not agree to be reoperated but with probing the level of obstruction was noted at the site of anastomosis in one and at the common canaliculus in two cases. various modifications in the surgical steps of external dcr have been introduced over the years for a better surgical outcome. studies in which both anterior and posterior flaps were anastomosed and without intubation report success rates of 94%13. in pakistan; ashraf reported a success rate of 100%14 serin et al reported that with posterior flap anastomosis success rates was 93.75% and with resection it was 96.67%. there was no statistically significant difference in success rate (p = 0.593). he suggested that dcr with double-flap anastomosis has no advantage over dcr with only anterior flaps15. elwan reported a success rate of 90% with excision of posterior flaps and 85% with suturing. he concludes that excision of the posterior sac mucosa may improve the success rate16. baldeschi et al anastomosed large and mobile anterior flaps of the lacrimal sac and nasal mucosa and passed sutures through orbicularis oculi to elevate the flaps forward and did not suture posterior flaps with a success rate of 100%. he believes that his modified technique can be used to simplify and speed up traditional external dcr without decreasing its well known reliability17. zaman et al gave a success rate of 98.33% he also sutured only the anterior flaps and engaged them in the muscle layer3. intubation of the reconstructed lacrimal passage is a useful modified procedure. in international studies with intubations iliff reported 90%18, tarbat and custer reported 95%19 and dolman reported 90.2%20 success rates. in comparative studies, hussein et al mentioned 94.7% success results in intubated and 77.8% success results in nonintubated cases21. similarly advani et al reported success rates of 95% in intubated and 88% in nonintubated cases, these are significant differences5. but zaman et al reported statistically insignificant results in intubated and in non intubated cases. but they concluded that better 72 results in nonintubated dcrs were because they did not include complicated cases and had stitched the mucosal bridge with the muscle layer22. evaluating the outcome of dcr with intubation and suturing or excising the posterior mucosal flaps has also been the focus of many studies. in our study the success rate in the group with intubation and suturing of the posterior flaps was 97.1% and 94.3% with intubation and excision of the posterior flaps. in non comparative studies with intubation and suturing of the posterior flaps ali and ahmed reported a success of 84.6%9. their lower success compared with our study was due to the presence of preoperative canalicular obstruction and dislodgment of tube. similarly baig et al reported a success rate of 87% and attributed failure to common canalicular obstruction, fibrous closure of ostium and bony ostium problem4. in studies with intubation and not anastomosing the posterior flaps, zaman et al22 reported a success rate of 97.5% and talpur et al23 reported 98.14% success, both of which are comparable to our result. in a prospective study on 94 patients dareshani et al compared the success rate in which they sutured anterior and posterior flaps in one group and left the posterior flaps unsutured in the second group. a stent was placed in all the 94 patients. the success rate in sutured group was 97.6% and 94.2% in the unsutured group24. the results of their study are identical to our study. to make an ultimate decision, studies have evaluated the final size of the ostium after external dcr. ezra et al assessed the soft tissue anastomosis using b mode usg. their final conclusion was that, to improve surgical success, it is important to create as large a rhinostomy as possible and also extensively suture both the anterior and posterior flaps25. yazici and yazici used digital subtraction macrodacryocystography for assessing the ostium. their conclusion was contrary to ezra et al. they reported that the final ostium height did not correlate with osteotomy site. moreover they concluded that suturing the posterior lacrimal and nasal flaps does not affect the ultimate ostium size26. conclusion the results of our study were statistically insignificant which are in agreement with the results reported in national and international data including the use of latest techniques such as digital subtraction macrodacryocystography. we therefore suggest that the decision to suture or excise the posterior flaps should be decided intraoperatively depending upon anatomy of the nasolacrimal area, condition of the posterior flaps and surgeon’s experience. with intubation the outcome can be further improved. though the future of lacrimal surgery is changing, external dacryocystorhinostomy is still the most economical, effective surgical procedure for relieving epiphora in pakistan and is still the gold standard by which other modern methods are measured. author’s affiliation dr faisal aziz khan eye specialist combined military hospital abbottabad dr muhammad amer yaqub associate professor in ophthalmology army medical college classified eye specialist military hospital rawalpindi dr muhammad fayyaz classified eye specialist head of eye department combined military hospital rawalpindi reference 1. fernandes sv. dacryocystorhinostomy [online] 2005 [cited 2008 mar20]. available from: url:http:// ww.emedicine.com/ ent/topic452.htm 2. mahmood s, sadiq a. a short history of lacrimal surgery. cme journal ophthalmology 2001; 5:76-8. 3. zaman m, babar tf, saeed n. a review of 120 cases of dacryocystorhinostomy (dupuy dutemps and bourget technique) [on line] 2005 [cited2008mar22]. availablefrom: url;http://www.ayubmed.edu.pk/jamc/past/15-4/ mirzaman. htm 4. baig msa, shaikh z.a, misbahul a. external dacryocystorhinostomy with silicone tube intubation. pak j ophthalmol 2000; 16:90-3. 5. advani rk, halepota fm, shah sia, et al. indications and results of dcr with silicone tube intubations. pak j ophthalmol. 2001; 17:60-2. 6. unlu hh, toprak b, aslan a, et al. comparison of surgical outcomes in primary endoscopic dacryocystorhinostomy with and without intubation. ann otol rhinol laryngol. 2002; 111: 704-9. 7. moore wm, bentley cr, olver jm. functional & anatomic results after two types of endoscopic endonasal dacryocystorhinostomy:surgical and holmium laser. ophthalmology 2002; 109: 1575-82. 73 8. yazici z, yazici b, parlak m, et al. treatment of obstructive epiphora in adult by balloon dacryocystorhinostomy. br j ophthalmol. 1999; 83:692-6. 9. ali a, ahmad t. dacryocystorhinostomy – a review of 51 cases. pak j ophthalmol. 2001; 17: 122-8. 10. burns ja, cahill kv. modified kinosian dacryocystorhinostomy: a review of 122 cases. ophthalmic surg 1985; 16: 710-6. 11. mc lachlan dl, shannon gm, flanagan jc. results of dacryocystorhinostomy: analysis of re-operations. ophthalmic surg 1980; 11: 427-30. 12. jordan dr, mcdonald h. failed dacryocystorhinostomy: the sump syndrome. ophthalmic surg. 1993; 24: 692-3. 13. leone cr, van gemert jv, underwood l. dacryocystorhinostomy: a modification of the dupuy-dutemps operation. ophthalmic surg. 1979; 10: 35-8. 14. ashraf m. a study of dacryocystorhinostomy using conescutive laminar bone resection for performing osteotomy. pak j ophthalmol. 1996; 12: 61-3. 15. serin d, alagoz g, karsloglu s, et al. external dacryocystorhinostomy: double-flap anastomosis or excision of the posterior flaps? ophthal plast reconstr surg. 2007; 23: 28-1. 16. elwan s. a randomized study comparing dcr with and without excision of the posterior mucosal flap. orbit. 2003; 22: 7-13. 17. baldeschi l, nardi m, hintschich cr, et al. anterior suspendded flaps: a modified approach for external dacryocystorhinostomy. br j ophthalmol. 1998; 82: 790-2. 18. iliff ce. a simplified dacryocystorhinostomy. 19541970. arch ophthalmol. 1971; 85: 586-91. 19. tarbat kj, custer pl. external dacryocystorhinostomy. surgical success, patient satisfaction, and economic cost. ophthalmology. 1995; 102: 1065-70. 20. dolman pj. comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. ophthalmology. 2003; 110:78-4. 21. hussain m, akhter s, awan s. dcr (dacryocystorhinostomy) with or without intubation. ann king edward med coll 1998; 4:34-6. 22. zaman m, babar tf, abdullah a. prospective randomized comparison of dacryocystorhinostomy (dcr) with and without intubation. pak j med res 2005; 44:75-8. 23. talpur ki, jatoi sm, khan sa. dacryocystorhinostomy – a clinical report of 54 cases. pak j ophthalmol 1998; 14:169-71. 24. dareshani s, niazi jh, saeed m, et al. dacryocystorhinostomy: importance of anastomosis between anterior and posterior flaps. pak j ophthalmol. 1996; 12: 129-31. 25. ezra e, restori m, mannor ge, et al. ultrasonic assessment of rhinostomy size following external dacryocystorhinostomy. br j ophthalmol. 1998; 82: 786-9. 26. yazici b, yazici z. final nasolacrimal ostium after external dacryocystorhinostomy. arch ophthalmol. 2003; 121: 76-80. microsoft word khalid iqbal 165 original article role of operative subconjunctival antibiotic in preventing postoperative endophthalmitis khalid iqbal talpur, mohammed muneer quraishy, arshad ali lodhi, sajjad ali surhio, mohammad memon, shahzad memon, arslan hassan rajper pak j ophthalmol 2009, vol. 25 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: khalid iqbal talpur liaquat university eye hospital hyderabad-71000 received for publication december’ 2008 … ……………………… purpose: to determine whether operative subconjunctival antibiotic is an effective method to prevent postoperative endophthalmitis after cataract and glaucoma surgeries. material and methods: the study was conducted in the department of ophthalmology at liaquat university of medical and health sciences, jamshoro, from 1st july 2006 to 31st december 2007. in this study evaluation of 1200 eyes listed for senile cataract surgery or trabeculectomy for primary glaucoma were randomized into two groups, one received subconjunctival gentamicin at the end of the surgical procedure and the other group did not receive any subconjunctival antibiotic. all other methods of sterilization and prophylaxis were standardized for both the groups. all patients received antibiotic-steroid combination eye drops postoperatively and were followed up for six weeks. patients with any major intraoperative complication or who were lost to follow-up were excluded. results: a total of 1140 eyes were included in the study. females were 50.6% of cases, and the mean age of patients was 59.44 years. conventional extracapsular cataract extraction with iol was performed in 52.2% of cases, phacoemulsification with iol in 40.7% of cases and trabeculectomy in 7.1% of cases. subconjunctival gentamicin injection was given in 53.6% of eyes at the end of the procedure, while 46.4% of eyes were not injected. only 01 case developed postoperative endophthalmitis, and this case was given subconjunctival antibiotic injection during phacoemulsification with iol. conclusion: operative subconjunctival gentamicin does not always protect against endophthalmitis. endophthalmitis did not occur even when operative gentamicin was not administered. ndophthalmitis is an infection of the interior of the eye that frequently results in visual loss despite prompt and often aggressive therapeutic and surgical intervention1. the infectious agent generally enters the eye during intraocular surgery (postoperative), following a penetrating injury of the globe (posttraumatic) or from hematogenous spread of bacteria to the eye from a distant anatomical site (endogenous). although uncommon, endophthalmitis can also result from infective keratitis if left untreated2. postoperative endophthalmitis is a rare but devastating complication following intraocular surgery. the incidence of postoperative endophthalmitis varies from 0.05 to 0.2% (1/2000 to 1/500 cataract operations) 3-7. at present there is no clear robust evidence with regards to, which prophylactic methods to use to prevent postoperative endophthalmitis after cataract surgery. most surgeons empirically use a variety of prophylactic techniques including preoperative topical antibiotics, povidonee 166 iodine preparation for periocular skin and conjunctival instillation, intraoperative antibiotics both intracameral and subconjunctival and postoperative antibiotics topical or systemic8,9. we in the department of ophthalmology, liaquat university of medical and health sciences have been routinely using injection gentamicin 20 mg / 0.5 ml subconjunctivally during cataract and glaucoma surgeries since last so many years. our aim of this study was to determine whether subconjunctival antibiotic injection is an effective method of preventing endophthalmitis presuming that not using this method will increase the occurrence of endophthalmitis. material and methods patients listed for senile cataract surgery or trabeculectomy for primary glaucoma were randomized into two groups. one received subconjunctival gentamicin injection 20 mg / 0.5 ml at the end of the surgical procedure and the other group did not receive any subconjunctival injection. all the methods of sterilization were standardized for both the groups. these methods included: 1. pre-operative moxifloxacin eye drops single drop every half an hour starting two hours before surgery. 2. povidone–iodine 10% over and around the eyelids. 3. povidone – iodine 5% eye drops for conjunctival instillation. 4. proper draping, covering the eye lashes and lid margins. 5. standard sterilization of surgical instruments. 6. standard scrubbing of the surgeon and assistant. 7. single drop of moxifloxacin eye drops at the end of surgery. all patients received antibiotic-steroid combination eye drops postoperatively, and were followed up for six weeks to assess for onset of postoperative endophthalmitis. patients were seen on 1st day, one week and then six weeks postoperatively. patients were asked to contact urgently if they develop any redness, pain or blurring of vision. the software spss version 11 was used for analysis of descriptive statistics and for graphical presentation. results a total of 1200 eyes of 1027 patients were initially included in the study. we excluded 60 eyes due to either an intraoperative complication or due to loss of follow-up. the mean age of our patients was 59.44 years. females constituted 50.6% of cases. graph 1 shows that, the conventional extracapsular cataract extraction with iol was performed in 52.2% of cases. subconjunctival gentamicin injection was given in 53.6% of eyes at the end of the procedure, and this group included different types of surgeries as shown in graph 2. only one case developed postoperative endophthalmitis, and this case was given subconjunctival antibiotic injection during phacoemulsification with iol. the endophthalmitis was diagnosed clinically; culture was negative on vitreous tap. it was treated with intravitral ceftazidime and the vision recovered to 6/18. the incidence of postoperative endophthalmitis in our study was 0.088% (1/1140). fig. 1: type of surgery fig. 2: subconjunctival antibiotics in different type of surgery 167 discussion postoperative endophthalmitis is one of the most feared complications following intraocular surgery and it is the second common cause of endophthalmitis after trauma in pakistan with poor visual outcome.10, 11 however, due to the low incidence of postoperative endophthalmitis, it has been difficult to assess the efficacy of various prophylactic measures. there are two approaches for prophylaxis; the first is to reduce ocular surface flora by using topical antiseptic preparation or antibiotics and the second is, to eradicate bacteria that enter the eye during surgery, by the use of antibiotics through intracameral, subconjunctival, topical or systemic route12. the most common source of organisms in postoperative endophthalmitis is the patient's own ocular surface flora, so it is recommended to instill preoperative 5% povidone – iodine in the conjunctival sac13,14. a review by ciulla et al15 has found that povidone – iodine antisepsis of skin, lids and conjunctiva to be the only recommended practice on the basis of the current evidence. ciulla ta et al had also reported that, all other prophylaxis interventions (including preoperative lash trimming, preoperative saline irrigation, preoperative topical antibiotics, antibiotic-containing irrigating solutions and postoperative subconjunctival antibiotic injection) are possibly relevant but not definitely related to clinical outcome. the european society of cataract and refractive surgeons (escrs) guideline on prevention of postoperative endophthalmitis recommend intracameral cefuroxime and does not encourage subconjunctival antibiotics16,17 for three reasons; 1. intracameral cefuroxime achieves higher aqueous concentration after surgery than subconjunctival cefuroxime. 2. the use of subconjunctival antibiotics has been questionable in their affectivity in preventing postoperative endophthalmitis. 3. the potential complications caused by subconjunctival injections like subconjunctival haemorrhage and penetration of sclera & the extraocular muscles. however subconjunctival antibiotics have been a standard method used to prevent postoperative endophthalmitis all over the world, including pakistan and the great majority of united kingdom surgeons routinely gives subconjunctival antibiotics at the end of cataract surgery, and that is due to the concerns regarding ocular toxicity from intracameral antibiotics18,19. lehmann oj et al20 and ng jq et al21 in their studies had favoured the use of subconjunctival antibiotics as prophylaxis against endophthalmitis and reported that it reduces the risk by 50%. to change our routine practice we did this study, which showed no case of endophthalmitis in 529 cases that were not given subconjunctival injections. this group included not only cataract surgeries but also 33 trabeculectomies. though the number of trabeculectomies was low, nevertheless it had proved that not using subconjunctival antibiotics did not put patients on extra risk of getting endophthalmitis. incidentally endophthalmitis occurred in one case out of 611 eyes which were given subconjunctival gentamicin injection. this patient underwent phacoemulsification with iol surgery. despite this, the incidence of endophthalmitis in our study remained low which is 1/1140 cases (0.088%), and this is similar to what was reported from canada by hammoudi et al22. in his study regarding the patterns of endophthalmitis prophylaxis in canada it was reported that only 26% of surgeons give intraoperative antibiotics intacamerally or subconjunctivally, while the majority of surgeons (74%) are using similar methods of prophylaxis as were used in our study like perfect draping technique and instillation of povidone – iodine 5% into the conjunctival sac prior to surgery. the limitation of this study may be that we included only senile cataract and primary glaucoma surgeries. we excluded all other surgeries along with any eventful surgery such as posterior capsular tear or vitreous loss which carries a significant risk for the development of postoperative endophthalmitis. this was done to avoid any extra risk to be put on patients with high risk. conclusion operative subconjunctival gentamicin does not always protect against endophthalmitis. endophthalmitis did not occur even when operative gentamicin was not administered. author’s affiliation prof. khalid iqbal talpur department of ophthalmology lumhs, jamshoro 168 dr. mohammed muneer quraishy department of ophthalmology duhs, karachi dr. arshad ali lodhi department of ophthalmology lumhs, jamshoro dr. sajjad ali surhio department of ophthalmology lumhs, jamshoro dr. mohammad memon department of ophthalmology lumhs, jamshoro dr. shahzad memon department of ophthalmology lumhs, jamshoro dr. arslan hassan rajper department of ophthalmology lumhs, jamshoro reference 1. zia-ul-mazhry, chaudhri ss, amir m, et al. treatment of endothalmitis with intravitreal injection of antimicrobials. pak j ophthalmol. 2000; 16: 33-7. 2. callegan mc, engelbert m, parke dw, et al. bacterial endophthalmitis: epidemiology, therapeutics, and bacteriumhost interactions. clin microbiol rev. 2002; 15: 111-24. 3. west es, behrens a, mcdonnell pj, et al. the incidence of endophthalmitis after cataract surgery among the us medicare population increased between 1994 and 2001. ophthalmology 2005; 112: 1388-94. 4. kamalarajah s, silvestri g, sharma n, et al. surveillance of endophthalmitis following cataract surgery in the uk. eye 2004; 18: 580-7. 5. schmitz s, dick hb, krummenauer f, et al. endophthalmitis in cataract surgery: results of a german survey. ophthalmology. 1999; 106: 1869-77. 6. wong ty, chee sp. the epidemiology of acute endophthalmitis after cataract surgery in an asian population. ophthalmology. 2004; 111: 699-705. 7. lalitha p, rajagopalan j, prakash k, et al. postcataract endophthalmitis in south india incidence and outcome. ophthalmology. 2005; 112: 1884-9. 8. gupta ms, mckee hd, stewart og. perioperative prophylaxis for cataract surgery: survey of ophthalmologists in the north of england. j cataract refract surg. 2004; 30: 2021-2. 9. rosha ds, ng jq, morlet n, et al. cataract surgery practice and endophthalmitis prevention by australian and new zealand ophthalmologists. clin experiment ophthalmol 2006; 34: 535-44. 10. babar tf, masud z, saeed n, et al. a two years audit of admitted patients with the diagnosis of endophthalmitis. pak j med res 2003; 42: 105-11. 11. hussain i, kundi nk. visual outcome in infective endophthalmitis. j med sci 2005; 13: 151-3. 12. ou ji, ta cn. endophthalmitis prophylaxis. ophthalmol clin n am. 2006; 19: 449-56. 13. speaker mg, milch fa, shah mk, et al. role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. ophthalmology 1991; 98: 639-49. 14. speaker mg, menikoff ja. prophylaxis of endophthalmitis with topical povidone-iodine. ophthalmology 1991; 98: 176975. 15. ciulla ta, starr mb, masket s. bacterial endophthalmitis prophylaxis for cataract surgery: an evidence – based update. ophthalmology 2002; 109: 13-24. 16. barry p, seal dv, gettinby g, et al. escrs endophthalmitis study group. escrs study of prophylaxis of postoperative endophthalmitis after cataract surgery: preliminary report of principal results from a european multicenter study. j cataract refract surg. 2006; 32: 407-10. 17. yu-wai-man p, morgan sj, hildreth aj, et al. efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery. j cataract refract surg 2008; 34: 447-51. 18. dinakaran s, crome da. prophylactic measures prevalent in the united kingdom. j cataract refract surg. 2002; 28: 387-8. 19. ang gs, barras cw. prophylaxis against infection in cataract surgery: a survey of routine practice. eur j ophthalmol. 2006; 16: 394-400. 20. lehmann oj, roberts cj, ikram k, et al. association between nonadministration of subconjunctival cefuroxime and postoperative endophthalmitis. j cataract refract surg. 1997; 23: 889-93. 21. ng jq, morlet n, bulsara mk, et al. reducing the risk for endophthalmitis after cataract surgery: population-based nested case-control study: endophthalmitis population study of western australia: sixth report. j cataract refract surg. 2007; 33: 269-80. 22. hammoudi ds, abdolell m, wong dt. patterns of perioperative prophylaxis for cataract surgery in canada. can j ophthalmol 2007; 42: 681-8. 169 graph 1 types of surgery trabeculectomy ecce+iol phaco+iol f re qu en cy 600 500 400 300 200 100 0 81 595 464 graph 2 subconjunctival antibiotics in different types of surgery not injectedinjected c ou nt 400 350 300 250 200 150 100 50 0 phaco + iol ecce + iol trabeculectomy33 48 205 390 291 173 microsoft word index-7.doc original article use of mitomycin-c in failed trabeculectomy and high risk glaucoma muhammad afzal pechuho, syed imtiaz ali shah, shahid jamal siddiqui, abdul waheed memon, abdul qadir shaikh pak j ophthalmol 2009, vol. 25 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: muhammad afzal pechuho banglow # 1 type ii, cmc staff colony larkana. received for publication october’ 2008 … ……………………… purpose: to compare the results of simple trabeculectomy with trabeculectomy using mitomycin–c (mmc) intraoperatively. material and methods: this is hospital based descriptive study conducted at the department of ophthalmology chandka medical college & hospital larkana. 50 eyes of 37 patients were selected from glaucoma clinic conducted once a week. after history and complete ocular examination the clinical diagnosis of failed trabeculectomy and high risk glaucoma was established. during the surgical procedure patients were divided into two groups (test group and control group). the twenty five eyes underwent trabeculectomy with mitomycin-c (mmc) 0.04% for duration of 3 minutes (test group), 25 eyes underwent primary trabeculectomy (control group). followup period of 6 months was observed in both the groups. the span of study was from january 2006 to december 2007. results: in this hospital based descriptive study 23 (62.16%) patients were male and 14 (37.83%) patients were female in both groups and mean age of patients in the test group 33.4 years and in control group were 24.4 years. mean preoperative iop in the test group was 34.6mmhg (range 20-62mmhg) while in the control group was 30.7mmhg (range 20-45mmhg) and mean postoperative iop was 17.4 mmhg (range 10-36mmhg) in test group while in control group it was 21.3mmhg (range 11-46 mmhg). mean iop lowering was significantly greater in test group than that of control group. also the number of patients taking adjunctive anti glaucoma medication to control iop was greater in the control group than in the test group. conclusion: mean iop lowering effect was statistically (p < .05) significantly greater in the test group with the use of mmc intraoperatively. laucoma is one of the main blinding diseases in our country. according to a who report, glaucoma is the third most common cause of blindness in the world1. in pakistan, glaucoma is the fourth most common cause of blindness while cataract, corneal opacities and refractive errors are the other three. about 3.9% (0.23 million) of the total blindness is due to glaucoma2. trabeculectomy is a standard filtration procedure by which iop is controlled adequately in many cases of glaucoma. it has been observed in certain groups for example in buphthalmos, aphakic glaucoma, glaucoma seconddary to trauma, neovascular glaucoma and developmental glaucoma, trabeculectomy that failure rate is very high. the main cause of failure of operation is scarring of the filtering bleb3. mmc is an antimetabolite drug, it inhibits the proliferation of tenon’s capsule and episcleral fibroblasts at surgical site when applied during surgery. material and methods patients were selected from glaucoma clinic conducted once a week in the department of ophthalmology chandka medical college & hospital larkana. all the patients underwent g detailed assessment including history, examination and investigations. during the surgical procedure patients were randomly divided into two groups (test group and control group). the inclusion criteria for both groups included previously failed trabeculectomy and high risk glaucoma cases. the latter included congenital glaucoma, aphakic or pseudophakic glaucoma, uveitic glaucoma and neovascular glaucoma. informed consent was obtained from all the patients and permission for use of intraoperative mmc during trabeculectomy. all the patients underwent complete preoperative ophthalmic examination including visual acuity (v.a), slit lamp examination, tonometery, direct and indirect ophthalmoscopy. surgical techniques the operations were largely carried out under local anesthesia (peribulbar) all the steps of operation were performed under the microscope. mostly limbus based conjuctival flap was fashioned and in few cases the fornix based conjuctival flap was made. all eyes underwent a guarded filtering procedure using a rectangular scleral flap. most of the procedure were performed in the superior conjuctival area, except in 4 cases (superiotemporal quadrant). 0.4 mg/ml of mmc was prepared by adding 5ml of water for injection in to the vial containing 2mg mmc. surgical sponge (4x4mm) soaked in with 0.4 mg/ml mmc solution was kept over dissected bed between conjuctivotenon layer and sclera in the area of scleral flap for duration of 3 minutes. surgical sponge was removed and entire area was thoroughly irrigated with ringer’s lactate solution and dried with surgical sponge. the anterior chamber (a/c) was not entered before administering mmc. thereafter 4x4 mm2 superficial scleral flap was dissected 1mm into the clear cornea. a 2 x 1mm2 deep trabecular block in front of scleral spur excised and peripheral iridectomy (p.i) was performed. superficial flap was closed with 2 interrupted 10-0 nylon suture. tenon capsule and conjuctival layers were closed in two separate layers with continuous 8.0 virgin silk suture. ringer’s solution was injected to reform the a/c and to look for leaks. postoperative management all the patients of both groups were examined on 1st postoperative day. topical dexamethasone 0.1% eye drops 4 hourly, topical chloromphenicol 0.3% eye drops 4 hourly were started and continued for 1-1/2 months. all patients were fully examined on 1st and 2nd postoperative days with slit-lamp, the anterior chamber depth, corneal appearance, iop, bleb appearance and fundus picture were documented. subsequently all patients were asked for follow up visit after 1st week, 2nd week, 1st month, 3rd and 6th months postoperatively. topical glaucoma control medications were used to control iop whenever necessary. results total number of patients in the test group 18 with 25 eyes, control group were 19 with 25 eyes. thirteen patients in the test group were male and 5 were female, while in the control group 10 patients were male and 9 were female. overall 23 patients were male and 14 patients were female giving a male to female ratio of 2:1. mean age of patients with the test group was 33.4 years with a range of 6 months–90 years. the mean age of patients in the control group were 24.4 years with a range of 1 month to 65 years. mean age of patients with test group was significantly lower 24.4 years than that of control group 33.9 years. family history was positive in 4 patients in the text group and 3 with control group and four in the test group. out of the 25 eyes in the test group, 10 cases were of failed trabeculectomy, 8 eyes were buphthalmos, 2 eyes were aphakic glaucoma, 4 of uveitic glaucoma, while one case was of primary open angle glaucoma (poag). in the control group, out of 25 cases, 11 cases were of poag, 2 belonged to pseudophakic glaucoma, 5 cases were of buphthalmos, 6 were aphakic glaucoma and one case was of uveitic glaucoma. all the patients were followed up for period of 6 months. both pre and postoperative mean iop in the two groups is shown in table-1. mean preoperative iop in the test group was 34.6 mmhg (range 20-62 mmhg) while in the control was 30.7mmhg (range 20-45mmhg). mean postoperative iop at 6 months control was 17.4 mmhg (range 10-36mmhg) in the test group while in the control group it was 21.3 mmhg (1146mmhg). mean iop lowering was significantly greater in the test group than that of control group. moreover, the pressure was completely successful in 20 eyes (80%), in the mmc test group, qualified successful in another 2 eyes (08%), while it was complete failure in 3 eyes (12%). in the control group, complete success was achieved in 13 eyes (52%), a qualified successful in 2 eyes (18%), complete failure in 10 eyes (40%) is shown in table 2. also the number of patients taking adjunctive antiglaucoma medication to control the iop was greater in the control group than in the test group. the following data were analyzed with paired t-test in computer program spss 8.0 and the result highly significant is attached for reference table-3. table 1. comparison of preoperative and postoperative intraocular pressure test group (25 eyes) control group (25 eyes) preoperative mean-34.6 mmhg range 20-62 mmhg mean-30 mmhg range 20-45 mmhg postoperative mean-17 .4 mmhg range 10-36 mmhg mean-21.3 mmhg range 11-46 mmhg table 2: surgical outcome result test group (25 eyes) n (%) control group 25 eyes) n (%) complete success 20 (80) 13 (52) qualified success 2 (8) 2 (8) failure 3 (12) 10 (40) discussion trabeculectomy is a standard filtering procedure for the control of high iop when medical therapy fails. it’s success is dependent mainly upon good function of filtering bleb. the most common cause of bleb failure is scarring of the bleb due to fibroblastic proliferation at the surgical site4. the degree of fibroblastic response varies greatly and is influenced by many factors like age, race etc5. the use of antimetabolite therapy has considerably improved the success rate of glaucoma following surgery by interfering with fibroblastic proliferations at the site of the filtration bleb. many investigators have studied the effects of intraoperative mmc application during trabeculectomy using different concentrations and exposure times to determine the minimum effective dose and application time of mmc6,7. the effect of mmc on the tissue is dose and time dependent. jamel showed that invitro exposure to mmc for periods as short as 1 minute inhibited fibroblast proliferation of human tenon’s capsule and that a 1-minute exposure may be as effective as 5-minutes exposure7. chen and co-cookers conducted that safest and most effective dose of mmc was between 0.2-0.4 mg/ml8. many studies have amply demonstrated that a low concentration and short exposure time of mmc to the tissue may still result in successful filtration surgery. it has become the procedure of choice for high risk glaucoma and failed trabeculectomy cases9. to assess the efficacy and safety of mmc use in our setting we undertook this short term study. beaty10 and misaki ishika11 reported 72% and 68.4% success rate respectively, both using 0.2mg/ml concentration of mmc. casser12 reported 81% success rate using 0.02% mmc for only two minutes. brat14 using 0.2mg/ml to 0.4mg/ml concentration of mmc for two minutes, reported 91% a relatively higher success rate. the present study by hye et al15 support the previous studies that mmc is highly effective drug when used in association with trabeculectomy. our study supports the conclusions of previous studies, because it clearly shows a high success rate of 88% and no significant complication over 6 months followup period. it also clearly shows that 0.4 mg/ml concentration of mmc applied for three minutes is also quite effective in our population. conclusion our study revealed that both in test group and in control group, preoperative iop and postoperative iop show a high significant (p<.05) difference. mean iop lowering effect was significantly greater in the test group with the use of mmc intraoperatively. author’s affiliation dr: muhammad afzal pechuho assistant professor department of ophthalmology chandka medical college & hospital larkana table 3: test group, paired samples test, t. test paired differences t df sig (2.tailed) mean std. deviation st. error mean 95% confidence interval of the difference lower upper pair 1 pre.op., post. op. 9.1842 13.3315 3.0584 2.7586 15.61 3.003 18 .008 control group, paired samples test, t. test paired differences t df sig (2.tailed) mean std. deviation st. error mean 95% confidence interval of the difference lower upper pair 1 pre. op., post. op. 16.6389 11.3679 2.6794 10.9858 22.2920 6.210 17 .000 professor syed imtiaz ali shah professor & head department of ophthalmology department of ophthalmology chandka medical college & hospital, larkana dr. shahid jamal siddiqui associate professor department of ophthalmology chandka medical college & hospital, larkana dr. abdul waheed memon assistant professor department of ophthalmology chandka medical college & hospital, larkana dr. abdul qadir shaikh ophthalmologist department of ophthalmology chandka medical college & hospital, larkana reference 1. foster a. world distribution of blindness. community eye health. 1988; 74: 280-4. 2. memon ms. prevalence and causes of blindness in pakistan. jpma august. 1992: 196-8. 3. louis e, jose ml: effectiveness of intraoperative versus sub conjunctival mitomycin – c on glaucoma filtering surgery in the rabbit. annals of ophthalmol. 1996; 28: 35-9. 4. katz gj, higginbotham ej, lichter pr, et al. intraoperative mitomycin versus postoperative 5-fu in high risk glaucoma filtering surgery. ophthalmology. 1992; 99: 438-44. 5. megevand gs, salman jf, sholtz rp, et al. the effect of reducing the exposure time of mmc in glaucoma filtering surgery. ophthalmology. 1995, 102. 6. smith sd, amore pa, dreyer eb. comparative toxicity of mmc and 5-fu in vitro am j, ophthalmology. 1994; 118: 332-7. 7. kitazawa y, kawase k, matsushita h, et al. trabeculectomy with 5-fluorouracial. arch ophthalmology. 1991, 109: 1693-8. 8. zacharia pt, deppermann sr, schuman js. ocular hypotony after trabeculectomy with mitomycin c. am j ophthalmol. 1993; 116: 314-26. 9. shutta gl, beeson lc, higginbotham ej, et al. mitomycin c verus 5-fu in high risk glaucoma filtering surgery. the journal of the american academy of ophthalmology. 1995; 10. 10. mills kb. trabeculectomy: a retrospective long-term follow up of 444 cases. br j ophthalmol. 1998; 65: 790-5. 11. beaty s, potamitis t, kheterpal s, et al. trabeculectomy augumented with mitomycin c application under the scleral flap. br j ophthalmol. 1998; 82: 397-403. 12. ishoka m, shimazaki j, yamagami j, et al. trabeculectomy with mitomycin c for post-keratoplasty glaucoma. br j ophthalmol. 2000; 84: 714-7. 13. casson r, rahman r, salmon jf. long term results of trabeculectomy augmented with low dose mitomycin c in patients at risk for filtration failure. br j ophthalmol. 2001; 85: 686-8. 14. brat dpso, shiew m, edmunds s. a randomized prospective study, comparing trabeculectomy with viscocanalostomy with adjunctive antimetabolite usage for the management of open angle glaucoma uncontrolled by medical therapy. br j ophthalmol. 2004; 88: 1012-7. 15. hye a, nadeem h, hammad m, et al. trabeculectomy with topical application of mitomycin c in high risk glaucoma patients. pak j ophthalmol. 2006; 22: 23-7. microsoft word editorial 1 editorial reminders and regrets despite repeated editorials, communications, highlights, tips, pearls, lectures, seminars in the past i regret to say that still a considerable lot of ophthalmologists ignore the valuable recommendations of their learned colleagues in their clinical practice resulting in unsatisfactory at times catastrophic outcomes for their patients both in public and private setups. in my farewell editorial i would like to remind once again these golden rules of the game. 1. the most important investigation in glaucoma is gonioscopy to determine the type of glaucoma for appropriate management. in angle closure glaucoma miotics (like pilocarpine) are the only logical treatment while iridotomy (laser) or iridectomy (surgical) are the ultimo. extensively advertised, glamorous and costly drugs like beta blockers, alpha adrenergic agonists, topical cai and prostaglandin analogues are meant for management of open angle type of glaucomas and have insignificant role in angle closure glaucomas. when filtration is indicated use mitomycin like drugs with great caution due to post operative hypotony and later thin blebs getting infected. try alternative measures like releasable sutures, suture lysis and various other bleb management techniques. 2. prevention is better than cure. in addition to ensuring the cleanliness and sterility of the operative field, lid margins and eye lashes, instil a few drops of povidine–iodine solution in the conjunctival sac for a few minutes before surgery. despite controversies preop prophylactic antibiotic drops; intra cameral antibiotics preop or at the end of surgery sub conjuctival injection of antibiotic-steroid are still recommended. your surgical maneuvers should be gentle, least traumatic and purposeful. 3. diabetic blindness is assuming empidemic proportions especially in our country. patients need proper advice regarding tight glycemic, hypertension and lipidemic control, dietary regulation and exercise. laser treatment is still the mainstay for proliferative and maculopathy cases. in certain situations intra vitreal steroids or antivegf injections like avastin are indicated but injudicious use is causing serious complications. 4. uniocular congenital cataract surgery should be done with a lot of reservations. prevention of amblyopia is not a convincing outcome in our set ups and the rate of complication are significant. avoid insertion of iol after cataract surgery in juvenile uveitis. 5. treatment of accommodative esotropia is not surgery because the parents dislike glasses. surgery in such cases will have adverse effects in passing years. 6. despite continuous better and safer techniques of cataract extraction, the dilemmas of post operative complications are still no less grave at times. hence the basic indication of cataract surgery still remains when it interferes with normal routines of the patient. drugs claiming to stop cataract formation and progression are not substantiated by any authentic study and are an economic strain in a poor country. in dropped nucleus during cataract surgery do not fish for it in the vitreous cavity if you are not a trained vitreo retinal surgeon. to avoid serious complications refer to proper facility. 7. in bacterial infective keratitis, the instillation of appropriate antibiotic drops should be intensive and to be continued even during sleep by attendants. 8. refractive surgery should never be done without proper topographic evaluation (like orbscan & 2 pupillometery). post operative ectasia is a serious complication if excessive tissue is removed. 9. pars plana uveitis like cases should be treated with steroids only if the vision is effected. to avoid systemic steroid side effects, try deep sub tenon steroid injection or consider anti metabolites as such or in combination with steroids. 10. imaging investigations are expensive and not without risks. these should be ordered to facilitate clinical localization and expectations of particular findings to reach proper diagnosis, plan appropriate management and provide more accurate prognosis of the history of the disease and these should be ordered only if the information is not available by simpler safer and less expensive means. 11. if a patient comes to you for second opinion after an unsatisfactory outcome of previous procedure else where be very kind, courteous, helpful and reassuring in a positive way to relieve the patients anxiety, grief, agony, anger and disappointment. 12. write comprehensive, legible, detailed account of treatment given to patients especially the surgical procedures. note down any complication or untoward happenings and their management. such information in future will guide for understanding the status of the structures, tissues and their response to further manipulations for providing better care to patient by you or someone else. 13. use of antioxidants is a fab without any significant proof of real benefit in degenerative conditions of the eye. a carrot, radish, cucumber, orange , apple or guava etc are a lot more cheaper, affordable, palatable and nourishing compared to costly anti oxidant pills for poor populations in particular. 14. be and always remain with it by acquiring the latest through all possible means. with best wishes prof. m lateef chaudhry editor in chief microsoft word editorial 24,3,08 110 editorial management of dry eye syndrome dry eye syndrome (des) is a common disorder where there is a qualitative or quantitative deficiency in the tear film. it is largely undiagnosed and mistreated in pakistan1. the diagnosis can be improved by identification of the symptoms namely; dry sensation, burning sensation, foreign body sensation (rarrak), photophobia, and blurred vision are common in patients with dry eye. these symptoms are often exacerbated in smoky and/or dry environments like kitchen, busy city streets and at out door work. the symptoms can also be precipitated by acts of visual concentrations like watching tv, reading and excessive computer use. sometimes a patient with des presents with paradoxical watering which is named as ‘wet dry eye’1. it has been shown that these symptoms can be quantified objectively in the ocular surface disease index (osdi) questionnaire2, which has 12 symptoms (grade 1-4). typically the symptoms are worse in the morning (due to increased tear osmolarity) or near the end of the day (due to constant exposure to environment). one should try to identify problems like; chemical burns, trachoma and cicatricial pemphigoid or lagophthalmos. recently new categories have been introduced like dry eye following cataract extraction, laser refractive surgery and contact lens induced dry eye (clide). in both these conditions des is precipitated by the reduced blink rate caused by corneal hypoesthesia. the systemic disorders like; connective tissue diseases, steven-johnson syndrome, vitamin a deficiency, aids, hepatitis c and polycystic ovarian syndrome (pco) have been reported to be associated with des. even if no systemic ct disease is found, yet there is xerophthalmia and xerostomia and the condition is labeled as primary sjogren syndrome (pss). people with diabetes; especially those with poor glycemic control have higher incidence of des. during orbital radiotherapy there is risk of damage to the lacrimal gland. patients who are unconscious and managed in intensive care units (icu) are at high risk of lagophthalmos related ocular surface dryness. on the other hand history of drug use can be important to identify the preventable des like antihistamine, β-blocker, interferon and oral contraceptives and ophthalmic drug preservatives. there are clinical signs which can be picked up by slit lamp biomicroscopy like; tear meniscus height less than 1mm, increased debris, foamy secretions, meibomian gland dysfunction, irregular corneal surface, punctate epitheliopathy, and mucous discharge. the severe cases may show filamentary keratopathy, infective keratitis, corneal neovascularization or keratinization of the ocular surface. as no single test has high specificity, more than one test should be employed to improve diagnosis. special tests currently available in pakistan are tear film break up time (but), schirmer test and rose bengal dye staining. there are certain tests which though are more specific, yet being expensive or invasive have more of a research value like; tear film biometry, tear turnover rate (ttr), central corneal thickness(cct) measurement, tear film osmolarity measurement, impression cytology(to measure goblet cell population) and lacrimal gland biopsy (to confirm sjogren syndrome). the patient education plays a fundamental role in the management of des in our society, where it is a common practice to switch to another practitioner if there is no response to the therapy within couple of days. first of all the patients should be convinced to accept the life long nature of treatment in cases where des is irreversible. they should be educated to conserve the remaining tear secretion. they should avoid dry hot atmosphere like kitchen, hair dryer and outdoor work. they should use desert coolers in summer and avoid dry heaters and smoke. those working on computers should be asked to consciously blink frequently. they should be encouraged to use glasses with wide side panels and wraparound style to increase humidity around eyes. some severe cases even need swimmer’s goggles in out doors. tear supplementation is the mainstay of therapy, however no single ophthalmic preparation can replace all ingredients given by allah (subhana hu wa taala) in the natural tears. more than a dozen lubricant 111 ocular preparations containing cellulose derivatives (e.g. hpmc), polyvinyl alcohol (pva), povidone, carbomers, sodium chloride, sodium hayluronate and liquid paraffin are available in pakistan. some authorities recommend rotating the brands, as patient may become intolerant to one preparation in 2-3 months. in mild cases preserved drops can be used 6 hourly; however in moderate to severe cases as the frequency of instillation increases, the preservatives in the drops can itself start damaging the already compromised ocular surface. some manufacturers have come up with the preservative, which are claimed to change into water and oxygen on instillation on to ocular surface. recently preservative free single dose unit (sdu) preparation has been marketed. there are however problems in self instillation by the arthritic patients, temptation of use as multi-dose (hence risk of microbial infection) and issue of increased cost. vitamin a ointment can be helpful in reversing keratinization. mucolytics like ilube are not yet available in pakistan. anti-inflammatory treatment in the form of topical and systemic steroid is helpful in acute phase of the autoimmune diseases like ss, cop and chemical burns. systemic tetracyclines are helpful in the management of blepharitis (mgd). topical cyclosporine 0.05% (restasis) has shown improvement in cases of des unresponsive to artificial tear therapy3. it works by reducing t-cell mediated inflammation of the lacrimal gland. autologous serum eye drops have shown good response in the severe cases of des 4. this is supposed to be due to the presence of essential tear components like vitamin a and growth factors in serum. however, it has got inherent problem of repeated phlebotomies of the patient. recently oral omega-6-fatty acid supplements have showed a significant improvement in the specific symptom of dryness' at 3 and 6 months. low water content or silicone rubber contact lens should be used and wearing time strictly limited. in acute stage of chemical burn and stevenjohnson syndrome amniotic membrane graft is pretty helpful in avoiding long term complications. punctual occlusion is a good mean of preserving natural tears and prolonging the effect of artificial tears. initially temporary plugging is done with commercially available plugs or 1/0 or 2/0 vicryl. if there is good response and no epiphora, one can proceed for thermal cauterization. those with severe des need constant care of an oculoplastic surgeon, who would do procedures to conserve tears. in the cases of lagophthalmos a lateral tarsorrhaphy can be helpful in reducing tear evaporation. similarly repair of congenital and acquired colobomas should be promptly done to reduce evaporative des. submandibular gland transplantation and parotid duct transposition require extensive surgery, but yield poor functional results. references 1. kamal z. dry eye in connective tissue diseases. pak j ophthalmol. 1991; 2: 63-8. 2. ozcura f, avdin s, helvaci mr. ocular surface disease index for the diagnosis of dry eye syndrome. ocul immunol inflamm. 2007; 15: 389-93. 3. perry hd, solomon r, donnenfeld ed,, et al. evaluation of topical cyclosporine for the treatment of dry eye disease. arch ophthalmol. 2008; 126: 1046-50. 4. lee ga, chen sx. autologous serum in the management of recalcitrant dry eye syndrome. clin experimnt ophthalmol. 2008; 36: 119-22. zahid kamal siddiqui microsoft word aamna jabran 81 original article role of moxifloxacin in bacterial keratitis aamna jabran, aurengzeb sheikh, syed ali haider, zia-ud-din shaikh pak j ophthalmol 2009, vol. 25 no. 2 . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: aamna jabran 465, a-1, township lahore received for publication august’ 2008 … ……………………… purpose: to study the safety and efficacy of moxifloxacin in bacterial keratitis. material and methods: the study was conducted in the department of ophthalmology, lahore general hospital and civil hospital, karachi from february 2007 to june 2007. the study consisted of two arms. the first arm had 13 diagnosed cases of bacterial keratitis were enrolled in this quasi-experimental study. they were diagnosed by microscopy, culture and sensitivity of corneal scrapings. the second arm consisted of 10 cases of keratitis that were culture and microscopy negative and had been resistant to all treatment. results: out of the 13 diagnosed cases of bacterial keratitis, 7 cases had treatment success while 6 cases had treatment failure. the second arm of the study consisted of 10 cases of bacterial keratitis, which were culture and sensitivity negative. all these 10 cases showed treatment success. collectively, 17 out of 23 patients of keratitis had treatment success. they showed improvement in signs and symptoms with corneal re-epithelization within 1 to 4 weeks of initiation of the treatment. 6 out of 23 patients showed treatment failure. out of these 6, 2 had corneal perforation and 1 had endophthalmitis within 3 to 7 days of initiation of therapy. conclusion: 74% of the patients had treatment success with monotherapy with moxifloxacin eye drops. moxifloxacin has been shown to be safe and effective in treatment of bacterial keratitis. acterial keratitis is a serious ocular disease that can lead to severe visual disability and even loss of the globe. the severity of the corneal infection usually depends on the underlying condition of the cornea and the pathogenecity of the infecting bacteria and presence or absence of the external eye disease. many patients have a poor clinical outcome if b 82 aggressive and appropriate therapy is not promptly initiated1. in the past the mainstay of treatment of microbial keratitis had been combination therapy with two antibiotics (first generation cephalosporin and an aminoglycoside)2, one each with potent gram positive and gram negative coverage. to achieve this broad cover both antibiotics had to be used initially at half hourly intervals. in addition the suprathreshold concentrations caused osmotic damage to the corneal epithelial cells. the ph was always indifferent and the method of preparation meant that the sterility could not be ensured. fourth generation fluroquinolone (moxifloxacin and gatifloxacin) with their wide spectrum covering both gram positive and gram negative bacteria have opened new possibilities in treatment of microbial keratitis3. they have broad spectrum, are bactericidal, have a rapid rate of bacterial kill, achieve therapeutic levels in target tissues and have minimal toxicity.4 moxifloxacin is a self preserved antibiotic, therefore in theory should be less toxic to the corneal epithelium. moxifloxacin is formulated at a physiological ph of 6.8, has acceptable osmolality, and does not precipitate. we conducted this study to ascertain the role of moxifloxacin in treatment of bacterial keratitis. material and methods a quasi-experimental study was conducted at two centers, namely department of ophthalmology, lahore general hospital affiliated with post graduate medical institute, lahore and department of ophthalmology, civil hospital, karachi. a total of 23 patients were enrolled in this study from february 2007 to june 2007. patients were diagnosed as suffering from bacterial keratitis either by microscopy and gram staining or by culture and sensitivity of corneal scrape. there were 13 diagnosed cases of bacterial keratitis, which showed the causative organism either on gram staining or on culture and sensitivity. apart from these 13 cases, there were 10 cases which were culture and sensitivity negative and did not show any causative organism. informed consent was taken from all patients. personal profile of the patients, duration of disease and the eye involved were recorded. a detailed examination of the eye was carried out. the condition of the eye before administering moxifloxacin and after its administration was recorded. all patients were treated with moxifloxacin eye drops at 1 to 2 hourly intervals along with a cycloplegic agent. all patients above 2 years of age with clinical diagnosis of bacterial keratitis were included in the study. patients with known history of hypersensitivity to flouroquinolones and patients with history of ocular allergy or ocular surgery within the last 6 months were excluded from the study. any improvement or worsening in the verbal pain response, redness, photophobia, size of ulcer, size of abscess, density of abscess, size of infiltrate and size of hypopyon was monitored during the course of treatment. complications like corneal perforations and endophthalmitis were also taken into account. statistical software “spss-13.0” was used for statistical analysis. age was presented by mean ± sd. the qualitative response variables like sign and symptoms, clinical outcome, patients’ overall response and side effects were presented by frequencies and percentages. non-parametric sign test (chi-square statistic) was applied to compare significance of outcome. for comparison of outcome and response of patients’ feeling to well being was compared between genders and age groups by using chi-square test. statistical significance was taken at p ≤ 0.05. results total 23 patients were recruited in this prospective open ended quasi-experimental study through nonprobability purposive sampling, 16 (69.6%) males and 7 (30.4%) females (m: f = 2.3: 1). fifteen patients were treated in lahore and 8 patients in karachi. mean age of the patients was 45.3±19.1 (range=5-80) years. majority of the patients (88.2%) were older than 30 years of age as detailed in (table-1). out of the 13 diagnosed cases of bacterial keratitis, 7 patients had treatment success with moxifloxacin eye drops while 6 had treatment failure. all of the 10 cases of bacterial keratitis which were culture and sensitivity negative showed treatment success with moxifloxacin eyedrops. collectively, complete resolution of sign and symptoms was observed in 12 (52.2%) patients and 5 (21.7%) showed improvement while deterioration was found in 3 (13%) patients and three (13%) patients showed no change; similar figures were recorded in response of overall feeling of patients well being. 83 therefore, 17 patients had treatment success and 6 had treatment failure. data (74% vs. 26%, p=0.001, sign test) reveals that moxifloxacin (megamox) had dramatic effect for relief in symptoms and patients response (fig.1 & 2). there was no difference in outcome gender-wise and age-wise (table-3). transient ocular burning and ocular pain was observed in 2 (13.3%) patients while one patient had fever (fig. 3). pattern of sign and symptoms from baseline to follow up visits is presented in (table-3). discussion we enrolled 23 patients in our quasi-experimental study through non probability purposive sampling. sixteen patients (69.6%) were males and 7 patients (30.4%) were females. fifteen patients were treated in lahore and 8 patients in karachi. mean age of the patients was 45.3 ±19.1 (range=580) years. no gender wise or age wise difference of clinical outcome was observed. eight cases out of the 23 patients showed growth of staphylococcus coagulase positive. four of them responded well to moxifloxacin, 3 of them worsened while 1 showed no change. this is in accordance with the study, which compared in vitro susceptibility patterns and mic values of both gatifloxacin and moxifloxacin with older generation flouroquinolones against bacterial keratitis isolates. staphylococcus aureus isolates that were resistant to ciprofloxacin, levofloxacin and ofloxacin showed susceptibility to fourth generation flouroquinolones7. table 1: demographic features (n=23): demographic variables frequency n (%) gender (m/ f) 16/ 7 (69.6/ 30.4) age (years) ≤ 15 2 (8.7) 16 – 30 3 (13.1) 31 – 45 7 (30.4) > 45 11 (47.8) occupation laborer 5 (21.7) guard 1 (4.35) sweeper 1 (4.35) non-working 16 (69.6) table 2: clinical outcome according to demographic variables (n=23) demographic variables relief of symptoms yes no p-value gender male 12 (75) 4 (25) female 5 (71.4) 2 (28.6) 0.845 age (years) ≤ 15 2 (100) 0 (0) 16 – 30 2 (66.7) 1 (33.3) 31 – 45 5 (71.4) 2(28.6) > 45 8 (72.7) 3 (27.3) 0.845 0 5 10 15 20 25 resolved improved no change worse resolved improved no change worse *significantly high proportion of improvement (p<0.001). 12 (62%) 5 (22%) 3 (13%) 3 (13%) clinical outcome n um be r of p at ie nt s 84 fig. 1 (a): clinical outcome and ocular sign and symptoms *significantly high proportion of improvement (74% vs. 26%, p<0.001). fig.-1 (b): clinical outcome and ocular sign and symptoms *significantly high proportion of improvement (74% vs 26%), (p<0.001). fig. 2: overall feeling of patient well being: table 3: pattern of sign and symptoms from baseline to follow up visits signs/ symptoms base n (%) day 2 n (%) day 3 n (%) day 4 n (%) day 5 n (%) day 6 n (%) day 7 n (%) verbal pain 0% 1 (4) 3 (13) 6 (26) 7 (30) 7 (30) 9 (39) 11 (47) 25% 4 (17) 2 (9) 1 (4) 1 (4) 6 (26) 5 (22) 4 (17) 50% 4 (17) 5 (22) 4 (17) 9 (39) 3 (13) 5 (22) 6 (26) 75% 0 (0) 2 (9) 8 (35) 4 (17) 6 (26) 2 (9) 0 (0) 100% 14 (61) 11 (47) 4 (17) 2 (9) 1 (4) 2 (9) 2 (9) redness none 0 (0) 4 (17) 3 (13) 8 (35) 8 (35) 9 (39) 9 (39) mild 2 (9) 2 (9) 2 (9) 6 (26) 1 (4) 1 (4) 4 (17) moderate 6 (26) 2 (9) 7 (30) 3 (13) 9 (39) 10 (43) 8 (35) severe 15 (65) 15 (65) 11 (48) 6 (26) 5 (22) 3 (13) 2 (9) photophobia none 1 (4) 2 (9) 11 (48) 5 (22) 8 (35) 9 (39) 10 (43) mild 3 (13) 4 (17) 2 (9) 6 (26) 2 (9) 5 (22) 8 (35) moderate 6 (26) 3 (13) 6 (26) 4 (17) 10 (43) 7 (30) 3 (13) severe 13 (57) 14 (61) 4 (17) 8 (35) 3 (13) 2 (9) 2 (9) edema of eyelids present 13 (57) 12 (52) 10 (43) 10 (43) 8 (35) 4 (17) 4 (17) clinical outcome improved, 5, 22% resolved, 12, 52% relief of symptoms, 17, 74% no change, 3, 13% worse, 3, 13% no change worse resolved improved overall feeling of patient well being worse, 3, 13% no change, 3, 13% better, 5, 22% complete recovery, 12, 52% complete recovery better no change worse 85 absent 10 (43) 11 (48) 13 (57) 13 (57) 15 (65) 19 (83) 19 (83) discharge present 17 (74) 14 (61) 15 (65) 10 (43) 8 (35) 7 (30) 6 (26) absent 6 (26) 9 (39) 8 (35) 13 (57) 15 (65) 16 (70) 17 (74) four patients showed gram positive rods on corneal scrapings, 3 of these patients improved while 1 patient showed no change. one patient showed gram negative rods on corneal scrapings. this patient had treatment failure and progressed to corneal perforation and was therefore subjected to surgical application of conjuctival flap8. complete resolution of sign and symptoms was observed in 12 (52.2%) patients and 5 (21.7%) showed improvement while deterioration was found in 3 (13%) patients and three (13%) patients showed no change. similar figures were recorded in the response of overall feeling of patients well being. many prospective randomized controlled trials have examined the efficacy of 2nd generation flouroquinolones such as ofloxacin and ciprofloxacin compared with the traditional combined fortified antibiotics in the treatment of bacterial keratitis9. ofloxacin, fortified tobramycin and moxifloxacin have shown to be equally effective against a wide range of ocular isolates in the treatment of severe bacterial keratitis. all are safe and well tolerated, no serious events directly attributable to therapy was observed during the study. there was no difference of healing rate or incidence of serious complications such as perforations or enucleation10. *significantly high proportion of patients satisfaction response (p<0.001). fig. 3: frequency of side effects of megamox: conclusion seventy four percent of the patients had treatment success with monotherapy with moxifloxacin eye drops. moxifloxacin has shown to be safe and effective in treating bacterial keratitis. large scale and multicenter trials are required to achieve precise results in order to establish recommendations and guidelines for its routine practices. author’s affiliation dr. aamna jabran 465, a-1, township lahore dr. aurengzeb sheikh department of ophthalmology civil hospital karachi dr. syed ali haider lahore general hospital lahore prof. zia-ud-din sheikh department of ophthalmology civil hospital karachi references 1. bourcier t, thomas f, borderie v, et al. bacterial kerititis: predisposing factors, clinical and microbiological review of 300 cases. br j ophthalmol. 2003; 87: 834-8. 2. kanski jj. bacterial keratitis. clinical ophthalmology a systematic approach; 102-3. 3. chaudhry ml. tackling microbial kerititis. pak. j ophthalmol. 2005; 21: 1. 4. katz hr. new advances in fluoroquinolones. eur j clin microbiol infect dis. 2003; 11: 106-9. 5. schlech ba, alfonso e. overview of the potency of moxifloxacin ophthalmic solution 0.5% (vigamox). surv ophthalmol. 2005; 50: 7-15. 6. mather r, karenchak lm, romanowsky eg, et al. fourth generation fluoroquinolones: new weapons in the arsenal of ophthalmic antibiotics. am j ophthalmol. 2002; 13: 46-9. 2 (13.3%) 2 (13.3%) 1 (6.7%) 0 0 0 0 0 1 2 number of patients transient ocular burning ocular pain/ discomfort fever transient decrease vision foreign body sensation photophobia headache frequency of side effects 86 7. kowalski rp, dhaliwal dk, karenchak lm, et al. gatifloxacin and moxifloxacin: an in vitro susceptibility comparison to levofloxacin, ciprofloxacin and ofloxacin using bacterial keratitis isolates. am j ophthalmol. 2003; 136: 500-5. 8. jhanji v, sharma n, satpathy g, et al. fourth generation flouroquinolones resistant bacterial keratitis. cataract and refract surgery. 2007; 33: 1488-9. 9. o’brien tp, maguire mg, fink ne, et al. efficacy of ofloxacin vs. cephazolin and tobramycin in the therapy of bacterial keratitis. arch opthalmol. 1995; 113: 1257-65. 10. constantinos m, daniell m, snibson gr, et al. efficacy of moxifloxacin vs. ofloxacin and fortified tobramycin. ophthalmology 2007; 114: 1622-9. microsoft word sumaira 193 original article comparison of intraocular pressure lowering effect of 0.5% levobunolol and 0.5% timolol maleate after nd: yag laser capsulotomy sumera nisar, tahir mahmood, durraiz rehman pak j ophthalmol 2008, vol. 24 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations ……………………… correspondence to: sumaera nisar department of ophthalmology shaikh zayed federal postgraduate medical institute lahore received for publication jan’ 2008 ………………………… purpose: to evaluate the efficiency of timolol maleate compared to levobunolol, in the prevention of the intra-ocular pressure (iop) after nd: yag laser posterior capsulotomy. material and method: this study was conducted on 50 patients in the department of ophthalmology, shaikh zayed hospital lahore. the patients were randomly assigned to receive either 0.5% timolol maleate, 1 drop 12 hourly for 5 days after nd: yag laser capsulotomy or 0.5% levobunolol, 1 drop 12 hourly after the procedure. results: there were no statistically significant differences between the two groups regarding the iop pre-yag and 2 hours, first day and 7 days after the laser treatment (p values, respectively: 0.077, 0.085, 0.36, and 0.60). conclusion: the results of this study suggest that 0.5% timolol maleate is as safe and effective as levobunolol in the prevention of the iop elevation after nd: yag laser posterior capsulotomy. osterior capsular opacification is one of the major complication after the extracapsular cataract extraction or phacoemulsification1. posterior capsular opacification is caused by proliferation and migration of residual lens epithelial cells which can produce visual loss through two mechanisms2. they can form swollen, abnormal shaped lens cell called elschnig's pearls, which migrate over the posterior capsule into the visual axis3. standard treatment of posterior capsular opacification p 194 consists of opening the posterior capsule using a neodymium: yatrium – aluminium garnet laser (nd: yag laser) 4,5. yag laser works on the principle of photodisruption. the laser shots produce plasma around the target spot which bursts producing a shock wave resulting in a hole in the posterior capsule6. the nd-yag laser in pulse mode was adopted for use in ophthalmology, and the first posterior capsulotomy in the human eye was performed7. the nd-yag laser capsulotomy is a very simple procedure which can be performed on outdoor basis, so it saves a lot of inconvenience and time both on the part of surgeon as well as patient9. the rise in intraocular pressure can be controlled by using topical ß-blockers8. topical 0.5% timolol maleate and 0.5% levobunolol are ß-blockers, which effectively known to control the rise of intraocular pressure9. 0.5% timolol maleate and 0.5% levobunolol are both commonly used topical ß-blockers with very good results in lowering iop and used twice daily. all the ß-blockers are the preferred medication in lowering iop after yag laser capsulotomy because of their easy dosage and reliable results. this study was conducted to evaluate the efficiency of timolol maleate compared to levobunolol in the prevention of the intra-ocular pressure (iop) after nd: yag laser posterior capsulotomy. material and methods the study was conducted in post cataract surgery patients reporting with posterior capsule thickening at the ophthalmology outpatient department of shaikh zayed hospital, lahore from 2004 to 2005. a total of 50 patients undergoing nd-yag laser capsulotomy were divided into two groups of 25 patients each by simple randomization. twenty five patients in group a was given 0.5% levobunolol after laser treatment, 1 drop 12 hourly for 5 days. the other 25 patients in group b was given 0.5% timolol maleate after laser treatment, 1 drop 12 hourly for 5 days. the patients were subjected to intraocular pressure measurements in mm of hg on goldman's applanation tonometer every time by same person and on the same apparatus. in this study, the patient underwent ndyag laser capsulotomy by visu yag ii plus (zeiss) laser with capsulotomy corneal contact lens. the statistical analysis was performed using a student’s t test for non correlate populations and a paired student’s t test to compare the mean iop between the two groups. a p value <0.05 was considered as statistically significant. results the mean iop before any medication or treatment (pre-yag) was 13.11 ± 2.72 mmhg in the timolol maleate group and 13.06 ± 2.49 mmhg in the levobunolol group showing no statistical difference between the groups (p value 0.90). mean values of iop in each interval are listed in table 1. there were no statistically significant differences between the two groups regarding the pre yag mean iop, two hours, 1st day and seven days after treatment (p=0.077, 0.085, 0.036, and 0.60, respectively). the levobunolol group had a significant decrease in iop, two hours after the laser treatment (p=0.0006 and 0.0009), as compared to baseline. no statistically significant decrease was observed 1st day after treatment (p=0.28) but there was a significant decrease in seven days after the laser treatment (p=0.0095). in the timolol maleate group there was no significant decrease in the iop measures two hours and 1st day after the laser application (p=0.063 and 0.77) as compared to the baseline. no statistically significant increase in iop was observed seven days after the procedure (p=0.065). there was no significant differences in the iop of the two groups at the various intervals (p=0.074, two hours after, 0.40, 1st day after and 0.54, seven days after the treatment). in the levobunolol group, 8% of the patients had an iop increase higher than 5mmhg two hour after the laser and 10% after 1st day. after seven days of treatment 16% of the patients had an increase in iop compared to the baseline. in the timolol maleate group, 6% of the patients had an iop higher than 5 mmhg two hour after the laser, 8% after 1st day. seven days after the laser treatment, 8% had iop values 5 mmhg above baseline. discussion in ophthalmology, nd: yag laser posterior capsulotomy is a routine procedure, since up to 40% of the patients submitted to cataract surgery with iol implantation develop posterior capsule opacification despite the progress made in surgical techniques1,3. 195 although nd: yag laser is considered to be a safe procedure, it can cause several complications, namely retinal detachment, iritis, macular edema, iol cracks and pits and iop spike1,2. in the present study we compare the preventive effect of 0.5% timolol maleate to 0.5% levobunolol in patients undergoing nd: yag laser for posterior capsule opacification after extracapsular cataract extraction and posterior chamber intraocular lens implantation. the groups were comparable regarding gender, age and mean baseline iop. there were no statistical differences between the two groups in iop measurement before treatment, showing that the study population was homogeneous. in addition, there were no statistically significant differences between the groups as concerns the iop increase or decrease at the various intervals. the results obtained suggest that the effect of 0.5% timolol maleate is similar to 0.5% levobunolol in the prevention of the iop spike after nd: yag laser posterior capsulotomy. table 1: iop mean values comparison between 0.5% timolol maleate and 0.5% levobunolol groups before and after yag laser capsulotomy pre-yag (baseline) 2 hour post yag 1st day 1st week timolol maleate 13.06±2.49 12.21±3.65 12.68±3.81 14.11±4. levobunolol 13.11±2.72 13.02±3.18 13.12±3.27 13.82±4.15 p value 0.90 0.07 0.08 0.03 iop intraocular pressure table 2: iop changes, comparison between 0.5% timolol maleate and 0.5% levobunolol groups before and after yag laser capsulotomy pre-yag (baseline 2 hour post yag 1st day 1st week timolol maleate iop change range (9-22) 0.85±3.14 (7-24) -0.38±3.49 (6-28) 0.90±3.99 (6-30) levobunolol iop change range (6-20) 0.08±3.15 (6-22) 0.02±3.46 (6-23) 0.71±4.19 (7-28) in this study, the incidence of iop increase above 10 mmhg, observed in both groups (1.04% in the levobunolol group and 0.82% in the timolol maleate group), is lower than the incidence described in the literature with other drugs. these findings support the hypothesis that either 0.5% timolol maleate or 0.5% levobunolol can be safely chosen as prophylactic medications for nd: yag laser procedures. the proven efficacy of different intraocular pressure lowering agents in preventing iop spikes after laser procedures provides alternative treatments that allow the physician to indicate the best prophylactic medication for each patient, according to their ocular and medical history. author’s affiliation dr. sumera nisar department of ophthalmology shaikh zayed federal postgraduate medical institute lahore dr. tahir mehmood department of ophthalmology shaikh zayed federal postgraduate medical institute lahore dr.. durraiz rehman assistant professor university college of medical and dintistery lahore reference 1. karezewicz d, pinikowska-machoy e, modrzeyewska m, et al. posterior capsular opacification as a complication of the 196 posterior chamber intraocular lens implantation. klin oczna. 2004; 106:19-22. 2. hayashi k, hayashi h, nakao f, et al. correlation between posterior capsular opacification and visual functions before and after nd-yag laser posterior capsulotomy. am j ophthalmol. 2003; 136: 720-6. 3. kurosaka d, kato k, kurosaka h, et al. elschnig pearl formation along nd-yag laser posterior capsulotomy margin, long term follow up. j cataract refract surg. 2002; 28: 1809-13. 4. aslam tm, denlin h, dhilon b. use of nd-yag laser capsulotomy. surv ophthalmol. 2003; 48: 594-612. 5. baratz kh, cook be, hodge do. probability of nd-yag laser capsulotomy after cataract surgery in olmsted country minnesota. am j ophthalmol. 2001; 131: 161-6. 6. polak m, zasnowaski t, zargorski z. results of nd-yag laser capsulotomy in posterior capsule opacification. ann univ mariac curie sklodowska. 2002; 57: 357-63. 7. daniele ar. performing the posterior capsulotomy. highlights of ophthalmology (letter). 1989; 17: 7-11. 8. seong gj, lee yg, lee jh, et al. effect of 0.2% bromonidine in preventing intraocular pressure elevation after nd-yag laser posterior capsulotomy. ophthalmic surg laser. 2000; 31: 30814. 9. rakafsky s, koch dd, faulkner jd, et al. levobunolol 0.5% and timolol maleate 0.5% to prevent intraocular pressure elevations after nd-yag laser posterior capsulotomy. j cataract refract surg. 1997; 23: 1075-80. microsoft word abstract vol. 25, 1,09 1 abstracts edited by dr. tahir mahmood effect of phacoemulsification on intraocular pressure in eyes with pseudoexfoliation single-surgeon series shingleton bj, laul a, nagao k, wolff b, donoghue mo, eagan e, flattem n, desai-bartoli s, j cataract refract surg 2008; 34: 1834-41 pseudoexfoliation (pfx) is characterized by the abnormàl production and accumulation of a fibrillar extracellular material with a gray appearance in the anterior segment of the eye and other tissues of the body. it is the most common identifiable cause of open-angle glaucoma, and there is an etio1oical association between pfx and cataract formation. complication rates for cataract surgery in eyes with pfx are higher than in eyes without pfx. because of the association of pfx with glaucoma and cataract, there is a need to assess the effect of cataract surgery on intraocular pressure (lop) in such eyes. several small series of pfx eyes having phacoemulsification show a small, but significant decrease in lop after relatively short follow-up. the purpose of this study was to assess the short-term and long-term effects of uneventful phacoemulsification with posterior chamber intraocular lens (pc iol) implantation for visually significant cataract in a large series of pfx eyes with and without glaucoma using the following parameters: best corrected visual acuity (bcva), iop, and glaucoma medication requirements. this retrospective analysis comprised 1122 eyes with pfx having uneventful phacoemulsification with iol implantation. of the eyes, 882 did not have glaucoma (pfx group) and 240 had glaucoma (pxg group). a comparative outcomes analysis was performed; the analysis focused on lop and change in glaucoma medication requirements between the groups. the mean was statistically significantly reduced through 7 years postoperatively compared with preoperatively in the pfx group. the pxg group had reduced mean lop for 1 year and reduced glaucoma medication requirements at almost all postoperative time intervals. higher mean preoperative was associated with a greater reduction in mean lop postoperatively in both groups. intraocular pressure spikes (>30mm hg) 1 day postoperatively occurred in 4% in the pfx group and 17% in the pxg group. postoperatively, 2.7% of pfx eyes progressed to a need for glaucoma medication and 3.7% of pxg eyes progressed to a need for laser and/or glaucoma surgery. author concluded with the remarks that a longterm reduction in mean iop occurred in pfx eyes with and without glaucoma. the iop reduction was proportional to the preoperative lop; higher preoperative iop was associated with a greater reduction in iop. glaucoma progression in both groups was low, suggesting a protective effect of phacoemulsification on iop in these eyes. polypropylene suture-guided valve tube for posterior chamber implantation in patients with pseudophakic glaucoma moreno-montafles j, fantes f, garcia-gomez p j cataract refract surg 2008; 34: 1828-31. authors described a new surgical procedure for implanting a glaucoma drainage tube in the posterior chamber. a needle with a 10-0 polypropylene suture is introduced into the posterior chamber, and a 23-gauge needle is also introduced as the barrel on the polypropylene needle tip. after the 23-gauge needle is withdrawn from the posterior chamber, the polypropylene needle tip is pulled and the suture crosses the anterior and posterior chambers. a sliding knot is made around the drainage tube. the tube is pushed into the scleral tunnel and posterior chamber as the suture is pulled to position the tube. the knot is loosened and the suture removed from the eye by pulling from either side. this procedure is easy and effective for implanting a tube in the posterior chamber in pseudophakic eyes and is indicated after penetrating keratoplasty or in eyes with compromised endothelial function. implantation of a glaucoma drainage device (gdd)) successfully controls surgical intraocular 2 pressure (iop) and optic nerve damage. a study comparing gdd) implantation in the anterior chamber and trabeculectomy showed similar iop reductions with both procedures alter 1 year. the incidence of postoperative complications was higher after trabeculectomy with mitomycin-c than with a gdd during the first year of follow-up. however, in some eyes, implanting a gdd in the anterior chamber may result in endothelial decompensation and corneal edema. these eyes include those with low endothelial cell density, fuchs endothelial dystrophy, a shallow anterior chamber, extensive synechial angle closure, or need for posterior keratoplasty. some reports have suggested that in these high-risk cases, it is advisable to insert the gdd into the posterior chamber if the patient is pseudophakic. however, in some eyes, it is difficult to implant a flexible silicone tube in the posterior chamber because the tube is pushed into the posterior chamber in restricted space under the iris without a clear microscopic view. in some cases, the iris or an intraocular lens (iol) may complicate adequate implantation of the tube. we describe an easy and effective technique to facilitate implantation of the tube in the posterior chamber using a 10-0 polypropylene (prolene) suture. topographically guided laser in situ keratomileusis for myopia using a customized aspherical treatment zone dougherty pj, waring iii g, chayet a, fischer j, fant b, bains bs j cataract refract surg 2008; 34: 1862-71. customized corneal ablations to treat refractive errors using laser in situ keratomileusis (lasik) or photorefractive keratectomy (prk) can be based on corneal topography, whole-eye wave front, or corneal wavefront. topography-based ablations treat irregularrities in corneal elevation in addition to the spherocylindrical refractive error. alternatively, wavefrontbased treatments address the wavefront aberrations of the cornea or of the entire eye in addition to the refractive error. several studies show that topographybased ablations are safe and effective for the treatment of primary myopia and astigmatism. custom ablation, whether topography based or ocular-wavefront based, was developed to address disadvantages of conventional spherocylindrical ablation. the unoperated, normal cornea is prolate, with an average positive asphericity of approximately + 0.24. conventional excimer laser ablations for myopia create an oblate cornea and induce positive spherical aberration, which can cause bothersome mesopic and scotopic symptoms such as glare, halos, and difficulty driving at night. the advantages of topography-guided treatments over wavefront-guided treatments are that topography-guided treatments deliver the treatment based on the shape of the cornea! surface, which (with the tear film) is the major refractive surface of the eye; topographers can measure and the excimer laser can treat a wider area because topographers measure a much wider diameter on the cornea (out to 11.50 mm) than aberrometers, which are limited by a 5.0 or 6.0mm pupil aperture; the treatments are not confounded by the presence of a cataract, an intraocular lens, or significant refractive gradients, as are whole-eye aberrometry measurements; topographers have a higher number of data points than aberrometers; the cornea is generally stable throughout life so a topography guided treatment is also more likely to be more stable than aberrometry measurements that take into account lenticular aberrations, which change throughout life. the purpose of this study was to assess the efficacy, predictability, safety, and quality-of-life effects of topographyguided laser in situ keratomileusis (lasik) for the correction of myopia with astigmatism using the ec-5000 cxii excimer laser equipped with a customized aspheric treatment zone algorithm. in a multicenter united states food and drug administration study of topographyguided lasik, 4 centers enrolled 135 eyes with a spherical manifest refraction error ranging from -0.50 to -1.00 diopters (d) and astigmatism ranging from 0.50 to 4.00 d. all eyes were targeted for emmetropia. refractive outcomes, higher-order aberrations (hoas), and contrast sensitivity were analyzed preoperatively and postoperatively. patient satisfaction was assessed using 2 questionnaires. six months postoperatively, the mean manifest refraction spherical equivalent in all eyes was -0.09 d ± 0.31 (sd); of the 131 eyes, 116 (88.55%) had an uncorrected visual acuity of 20/20 or better and 122 (93.13%) had an mrse within ± 0.50 d. the best spectacle-corrected visual acuity (bscva) increased by 2 or more lines in 21(16.03%) of 131 eyes; no eye lost 2 lines or more of bsgva. the total ocular hoa increased by 0.04 µm. patients reported significantly 3 fewer night driving and glare/halo symptoms postoperatively than preoperatively. author concluded with the remarks that use of a customized aspherical treatment zone in eyes with myopia and astigmatism was safe, effective, and predictable and reduced symptoms associated with night driving, glare, and halos. corneal elevation and thickness in relation to the refractive status measured with the pentacam scheimpflug system uçakhan ö ö, gesoglu p, ozkan m, kanpolat a j cataract retract surg 2008; 34: 1900-5. corneal topography is invaluable in the diagnosis of corneal disorders and in the screening and treatment of patients with refractive errors. with the increasing popularity and application of several types of refractive surgical procedures, cornea topography has become of utmost importance in determining patient suitability for refractive surgery and in monitoring corneal changes postoperatively. diligent analysis of preoperative topography is required to avoid postoperative complications, in particular cornea! ectasia. although the etiopathogenesis of cornea! ectasia is not completely understood, preoperative central corneal thickness less than 500 µm, patient age 25 years or younger, attempted correction greater than -8.00 diopters (d), refractive astigmatism that is not with the rule and is greater than 2.00 d, residual stromal bed thickness less than 250 µm, mean keratometry greater than 47.00 d, and preexisting forme fruste keratoconus (ffk) are proposed to be the main risk factors. although it may be difficult to differentiate ffk from normal keratoconus with reflection-based topography systems, numerous studies with relatively new systems that can measure anterior and posterior corneal elevation have linked high corneal elevation with ffk.on the other hand, although evidence on what is a truly safe preoperative central corneal thickness is lacking, most surgeons have generally accepted a pachymetry value thinner than 500 µm as a cutoff value for safe refractive surgery. despite this, several studies report good results in thin cornea, while others report corneal ectasia in patients with a preoperative corneal thickness greater than 500 µm. unfortunately, little is known about the anterior or posterior elevation or corneal thickness distribution in the normal population. the aim of this study was to determine the range and distribution of elevation and thickness data in patients without keratoconus and with different types of refractive errors applying for refractive correction. this information may help better define normal from abnormal in refractive surgery screenings. after the refractive errors in 215 consecutive patients were determined, corneal topography measurements with the pentacam scheimpflug system were taken in the right eye of all patients and the right eye of 31 healthy emmetropic volunteers. the eyes with refractive errors were assigned to 1 of the following 4 groups: myopia, myopic astigmatism, high myopia, and hyperopia. the means of the parameters of 3 pentacam measurements were evaluated and compared. eyes with high myopia had significantly lower mean corneal thickness and volume measurements and higher mean anterior chamber depth (acd) and anterior chamber volume (acv) measurements than eyes in the other groups. the mean acd, acv, and anterior chamber angle were significantly lower in hyperopic eyes than in the other groups. the mean keratometry readings were statistically significantly flatter in the hyperopia group than in the other 4 groups. authors concluded with the remarks that eyes with high myopia had thinner corneas and deeper anterior chambers than emmetropic eyes and eyes in the other ametropic groups. excluding eyes with hyperopia, which had significantly flat anterior and posterior elevation measurements, the elevation measurements in eyes with myopic refractive errors did not differ from each other or from those in emmetropic eyes. these findings may help clinicians and refractive surgeons using the pentacam to better define normal from abnormal in the clinical setting. anti-vascular endothelial growth factor and retinopathy of prematurity jonathan e sears je br j ophthalmol. 2008; 92: 1437-8. retinopathy of prematurity (rop) has been at the nexus of a progressive understanding of neovascularisation, in large part because of the mouse model of oxygen-induced retinopathy (oir) developed by lois smith. this model has been very 4 instructive, because it has crystallised the hypothesis that rop in general is caused by a two-step or twophase process, namely oxygen-induced vascular obliteration (phase i) followed by a hypoxia-induced over-production of vasoactive cytokines (phase ii), such as vascular endothelial growth factor (vegf), that is fuelled by increased metabolic demand, decreased oxygen supplementation and widespread local retinal ischaemia created by phase i hyperoxia. the crucial experiments that truly shaped the concept of phase i and phase ii were performed separately in eli keshet’s and lois smith’s laboratories in 1996, in which they showed that timely injection of vegf during phase i could prevent retinopathy. this observation confirms the causative role of hyperoxia in downregulating the tonic production of growth factors critical to retinal development. hyperoxia creates larger areas of unvascularised retina that are carried into phase ii, providing a larger substrate for pathological angiogenesis, as it is the unvascularised retina that secretes excessive vecf. additional studies have shown the effect of other growth factors, such as erythropoietin (epo), in the oir model. each has a uniform finding it is the timing of the application of these factors that decides whether they are harmful or helpful. proangiogenic molecules, such as vegf, epo or other factors in the angiogenic cascade, prevent rop when administered in phase i and exacerbate rop when administered in phase ii. this naturally suggests that anti-vece therapy should be administered in phase ii of the human disease. these experiments also demonstrate that the levels of growth factors can be fine-tuned by adjusting the one drug that stimulates or inhibits their production: oxygen. these studies report that lower oxygen saturation targets at age less than 32 weeks corrected gestational age, with higher targets at age greater than 32 weeks, reduces the incidence of threshold roe. flynn et al. suggested that keeping children at 100% oxygen saturation after premature birth was nonphysiological and therefore an irrational target saturation, because in utero, infants average 80% oxygen saturation. the safety and efficacy of ranibizumab in the treatment of exudative age related macular degeneration has led to the speculation that vegf therapies will also become a valid therapy for rop. vecf protein concentration is elevated in the vitreous of rop patients. rop is unique in that there is a window of opportunity, which suggests that a single injection may lessen the need for destructive thermal treatments. corneal biomechanics, thickness and optic disc morphology in children with optic disc tilt lim l, gazzard g, chan y-h, fong a, kotecha a, sim e-l, tan d, tong l, saw s-m br j ophthalmol 2008; 92: 1461-6 central cortical thickness (cct) may be a surrogate marker for glaucoma susceptibility. structural changes in the optic nerve head have been shown to precede or even predict functional deficits in glaucoma, while correlations between cct and various optic nerve head morphological parameters have been demonstrated. cct is significantly correlated with retinal nerve fibre layer (rnfl) thickness in both normal subjects and ocular hypertensives, and a thin rnfl may predispose to glaucoma. larger optic discs are also more susceptible to glaucomatous damage, and, in a study on 212 eyes of 137 adult primary open angle glaucoma (poac) patients, pakravan it at described an inverse relationship between cct and disc size. similarly, cankaya et al have described negative correlations between cct and disc area, rim area, rim volume and rnfl area in 208 normal adult patients. viestenz et al however, found that large discs were instead associated with thicker cct in a population of 180 normal adult subjects. the reichert ocular response analyser (ora; reichert ophthalmic instruments, depew, new york) is a recently introduced device that measures the biomechanical properties of the cornea in vivo. the principal biomechanical parameter measured by the ora is corneal hysteresis (ch). low values of ch are often generally described to indicate a “soft” or “floppy” cornea-it is perhaps more accurate to say that a lower ch suggests that the viscous properties of the “visco-elastic” character are more prominent. cr is correlated with cct, such that a thicker cornea has a larger ch, or greater dampening properties, and it has also been proposed that ch may likewise be a surrogate marker of glaucoma susceptibility through a relationship with the resistance of the optic nerve head to intraocular pressure (iop) related deformation. in the only study of 230 adults examining the relationship between corneal hysteresis and glaucoma damage to date, congdon et al reported that a lower cr but not cct was associated with visual-field progression in glaucomatous eyes. 5 the aim of this study is to determine the associations between the corneal biomechanical parameters (cr, crf; as measured by ora), cct and optic disc morphological measures and retinal nerve fibre layer thickness in normal singaporean children. the purpose of this study was to determine the associations between corneal biomechanical parameters as measured by the reichert ocular response analyser (ora) and disc morphology and retinal nerve fibre layer thickness (rnfl) measured by the heidelberg retinal tomograph (hat) ii in singaporean children. this is a cross-sectional study conducted on a subset of children enrolled in the singapore cohort study of the risk factors of myopia (scorm). corneal hysteresis (ch), corneal resistance factor (cre) and central corneal thickness (cct) were measured with the ora. optic disc morphology and anfl thickness were assessed by the hrt ii, cycloplegic refraction and ultrasound a-scans were also performed, and disc tilt was assayed from stereo photographs. 102 subjects (mean age 12.01 (sd 0.57) years; range 11-14 years) were included in the study. the mean ch was 12.00 (1.40) mm hg, the mean crf was 11.99 (1.65) mm hg, and the mean cct was 581.12 (33.53) rim. eyes with tilted discs had significantly longer axial lengths and more myopic refraction than eyes without tilted discs. there were no significant correlations between ch, crf or cct and the hat ii parameters, after the application of the bonferroni correction. when stratified for disc tilt, however, the global disc area was significantly correlated with cct (r = -.49, p = 0.001). authors concluded with the remarks that the corneal biomechanical properties as measured with the ora do not vary with optic disc parameters or rnfl central corneal thickness is correlated with disc area in singaporean schoolchildren with tilled discs. this relationship may influence glaucoma risk in myopic subjects. microsoft word khan muhammad corrected 27 original article prevalence of hepatitis b and c in the patients undergoing cataract surgery at eye camps khan mohammad nangrejo, manzoor ahmed qureshi, amjad ali sahto, shahid jamal siddiqui pak j ophthalmol 2011, vol. 27 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: khan mohammad nangrejo department of ophthalmology. peoples medical college nawabshah received for publication october’ 2010 …..……………………….. purpose: to assess the prevalence of hepatitis b and hepatitis c viral infection in the patients undergoing elective eye surgery. material and method: all patients who were selected for cataract surgery were included in the study. after history, examination and investigations patients were screened for hepatitis b and c virus antibody with chromatography (kit) method. all the details were recorded on preformed proforma and data was compiled and analyzed for age and sex mean values. pearson’s correlation coefficients were calculated to assess the prevalence of hepatitis b and c in general population undergoing cataract surgery. results: four hundred and thirty seven patients were operated on for cataract surgery at eye camps. mean age of patients was 60 years, 191 (43.70%) were male and 246 (56.29%) female. out of them 108 patients were found to be positive for hepatitis b and c (24.7%,) antibody. hepatitis b accounted for 19 cases (4.34%) and hepatitis c for 89 cases (20.36%). conclusion: the prevalence rate of hepatitis b and c antibody in our population is alarming, not only for the general population but also for the general health care personals. steps need to be taken to abort this preventable disease. iral hepatitis is a major health problem effecting approximately two billion people worldwide. the hepatitis b virus (hbv) has infected more than two billion people and 350 million people are carrier of the virus, each year approximately one million people die from hepatitis b, makes it one of the major causes of morbidity and mortality1. hepatitis c virus (hcv) infection is increasing even more rapidly and has occurred in endemic situation in most parts of the world, with a prevalence of about 3% world wide2. hepatitis c virus infection progresses slowly and carries high risk of chronic liver disease (70-80%) and later liver malignancy3. the prevalence of hepatitis b and c is also increasing in our country4. doctors, especially surgeons, and the paramedical staff have a high occupational risk of acquiring hbv and hcv infection from the infected patients. approximately 500,000 percutaneous blood exposures occur among hospital based health care workers in the united states each year. surgeons and operation room personnel have the high risk of occupational exposure5. with such a high figure, rate of transmission in the highly developed country like usa little is known about the rate of risk in our part of the world. due to this concern, this study was carried out to evaluate the presence of hepatitis b and c infection in patients admitted for surgery at eye camps. materials and methods the observational study was carried out at the eye camps of baloo-ja-kuba and kumb nawabshah in the v 28 district shaheed benazeerabad and khairpur organized by the department of ophthalmology pmc nawabshah from december 2008 to feb 2010. during this period 437 patients undergoing eye surgery were evaluated for hepatitis b and c antibody. after history, examination and investigations patients were screened for hbv and hcv with chromatography (kit) method. the details were recorded on proforma and data was compiled and analyzed for age and sex mean values. special emphasis was put on age, sex, occupation. all patients of either sex who were operated as elective cases were included in the study. results in this study 437 patients who underwent eye surgery at eye camps were screened for hbv and hcv. there `were 191 (43.70%) male and 246 (56.29%) female patients. mean age of these patients was 60 years. the range of age was 40 to 80 years (table 1). all the patients belonged to rural areas. total 108 patients were found positive for hepatitis b and c. amongst them 19 were positive for hepatitis b (4.34%) and 89 for hepatitis c (20.36%) (table 2). hepatitis b was found in 11 (57.89%) male and 08 (42.10%) female patients. hepatitis c was predominant in females 57 (64.04%) while it was found in 32 (35.94%) male patients. both hepatitis b and c were found in 108 (24.7.%) patients. amongst them 43 (39.81%) were male and 65 (60.18%) were females (table 2). discussion the incidence of hepatitis b and c has achieved endemic situation in many countries of the world, especially in underdeveloped countries. pakistan is no exception as the disease has been recorded to an alarming level in most parts of the country especially in the rural areas, as can be seen from tables 1 and 2. in pakistan a large proportion of the population is already infected with hepatitis b and c with the prevalence of 10% for hepatitis b and 4-7% for hepatitis c. in certain parts especially in the rural areas the percentage of infected individuals is significantly higher than the above quoted figures6,7. the transmission of virus is through the blood and secretions. most common source of spread of these infections is through the use of unsterilized syringes or instruments especially dental instruments or unchecked blood transfusion. other factors involved in the spread of infection are persons who have their armpits or face shaved by street barber or those involved in sexual abuse8,9,10. in this study 4.34% patients had hepatitis b and 20.36% patients had hepatitis c. according to cloud hay and his colleagues11 the prevalence of hepatitis c was 11.26% which is lower to our study. ali and his associates12 reported 5.1% patients suffering from hepatitis c in their study at gadap area. the carrier state of hbs ag is around 10% in different segments of pakistani people7 which is higher than our study. in a study by sheikh and his colleagues13 carrier state of hbs ag was found to be 2.8 %. weis and his coworkers14 reported 35% cases of hcv and 4% cases of hbv in their study of patients operated at john hopkins. table 1: patients data number of patients 437 age group 4080 years mean age 60 years. male 191 (43.70%) female 246 (56.29%) table 2: hbv and hcv positive total patients screened 437 patients positive for both hepatitis b and c. 108(24.7) hbv positive 19 (4.34%) hcv positive 89 (20.36%) male 43 (39.81%) female 65 (60.19%) conclusion with such a rate of hbv and hcv as reported in our study suggests screening of all the patients who are selected for surgery. at the same time the print and electronic media is required to making the public aware about the methods of the spread of disease to prevent further transmission. it is the prime duty of doctors and paramedical staff to counsel the patients and use ethical practice. 29 author’s affiliation dr. khan mohammad nangrejo department of ophthalmology peoples medical college nawabshah dr manzoor ahmed qureshi department of ophthalmology peoples medical college nawabshah dr. amjad ali sahto department of ophthalmology peoples medical college nawabshah dr. shahid jamal siddiqui department of ophthalmology peoples medical college nawabshah reference 1. kane m. global program for control of hepatitis b infection, vaccine. 1995; 47-9. 2. dubois f, desenclos jc, merriote n. gondean a, and the collaboration study group. hepatitis c in a french population – based surgery, 1994. sero prevalence surgery of viremia, genotype distribution and prognostic risk factors. hepatol. 1997; 25; 1490-6. 3. supsa ve, hadjipashali e, hatzakis a. prevalence of risk factors and evaluation of a screening strategy for hepatitis b and c viral infections in healthy company employees. euro j epidemiol. 2001; 17: 721. 4. khokhar n, gill ml, malik gl. general seroprevance of hepatitis b and c infection in the population. j college of physicians and surgeons pak. 2004; 14: 534. 5. bell dm. occupational risk of hbv, hcv and hiv infection in health care workers. an overview. j med. 1997; 102: 9-15. 6. malik ia, kaleem sa, tarique wuz. hepatitis c infection in prospective, where do we stand? j college of physicians and surgeons pak. 1999; 9: 234-7. 7. yousaf a, mohammad a, ishaque m, et al. can we afford to operate on patients without hbs ag screening? j college of physicians and surgeons pak. 1996; 9: 98-100. 8. luby s. the relationship between therapeutic injections and high prevalence of hepatitis c infection in hafizabad. pakistan. epidemiol infection. 1997; 119: 349-56. 9. khuwaja ak, qureshi r, fatimi z. knowledge and attitude about hepatitis b and c among patients attending family medicine clinics in karachi. eastern mediterranean health j. 2002; 8: 1-6. 10. thornburn d, roy k, camerson so. risk of hepatitis c virus transmission from patient to surgeons. gut 2003; 52; 1333-8. 11. chaudhary ia, khan sa, samiullah. should we do the hepatitis b and c screening on each patient before surgery. pak j med sci. 2005; 21; 278-80. 12. ali sa, sheikh fa, ahmed k. prevalence of hepatitis b and c virus in surgical patients. pak j surgery. 2007; 23: 109-12. 13. shaikh mh, shams k. prevalence of hbv in health care personnel and methods of control. j college of physicians and surgeons pak. 1995; 5: 19-21. 14. makary esw, weis ma. prevalence of blood borne pathogens in an urban university based general surgical practice. ann surg. 2005; 24: 803-9. microsoft word hussain ahmad khaqan 6 200 original article manifestations of pulmonary tuberculosis in the eye hussain ahmad khaqan, khalid mehmood najmi, syed ali haider pak j ophthalmol 2011, vol. 27 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hussain ahmad khaqan eye department lgh/pgmi, lahore submission of paper june’ 2011 acceptance for publication november’ 2011 …..……………………….. purpose: to study the manifestations of pulmonary tuberculosis in the eye. material and methods: a prospective study was conducted at department of ophthalmology pgmi / lgh lahore from april 2006 to july 2007. patients with established diagnosis of pulmonary tuberculosis were recruited from the tb dots programme. complete ocular examination including best corrected visual acuity (bcva) anterior segment and dilated posterior segment examination was carried out on all patients. results: bcva was 6/24 or better in 59% patients and 6/36 or worse in 41% patients. color vision was defective in 24 patients (12 %). interstitial keratitis was found in 2 (1%) patients, anterior uveitis in 9 (4.8%), periphlebitis in 17 (9%), choroiditis in 26 (14%), vitritis in 16 (8.6%), vitreous hemorrhage in 8 (4%), nve in 14 (7.4%), and optic atrophy in 7 (3.7%) patients. conclusion: significant proportion of patients on treatment for pulmonary tuberculosis showed signs of present or past ocular inflammation. uberculosis (tb) is a chronic infection caused by mycobacterium tuberculosis and is a leading cause of death worldwide. about 2 billion people are affected by tuberculosis of which 95% of tuberculosis cases and 98% of tuberculosis deaths occur in asia1. tb may affect the eye by direct invasion of the tubercle bacillus following haematogenous dissemination with local destruction and inflammation, or via a hypersensitivity reaction to the bacillus located elsewhere in the body. ocular tb has several potential manifestations3. it can appear on the external eye as a lid abscess or manifest as chronic blephritis or atypical chalazia. it can present as a mucopurulent conjunctivitis with regional lymphdenopathy. it can also present as a phylectenular conjunctivitis, infectious keratitis, interstitial keratitis, or as an infectious scleritis. all of these presentations are rare and are easy to diagnose as material can be obtained for culture and biopsy. rarely, orbital disease can also occur. the greater challenge is in the more common but difficult to diagnose tb uveitis. uveitis from tb involves delicate structures that are difficult or impossible to biopsy or culture. it may present as an iritis, which may be granulomatous (mutton fat keratic precipitates, or koeppe or busacca nodules) or as intermediate uveitis is distinguished by the presence of cells in the anterior and mid-vitreous with sometimes `snowball’ opacities and deposits over the inferior junction of the retina and cillary body. more commonly, intraocular tb presents with choroidal lesions including granulomas3,4. it can also present as an optic neuritis or papillitis. this study was undertaken with the primary intention of evaluating frequency of various ocular signs associated with the pulmonary tuberculosis. material and methods a prospective study was conducted at department of ophthalmology pgmi/ lahore general hospital, lahore. a total of 187 patients were included in the study. all the patients with confirmed diagnosis (sputum afb+ve and positive signs in chest x-ray) of pulmonary tuberculosis referred to eye opd of lahore general hospital, by pulmonologist at lahore general t 201 hospital and gulab devi chest hospital, lahore. ocular examination including bcva, anterior segment slit lamp examination and dilated fundus examination were carried out. evidence of both active or healed uveitis were included in the study. while every patient had his visual acuity recorded, we were not looking for a casual link between tb and reduced vision. the method of sampling was purposive, non probability. results total 187 patients were included in the study. 118 (63%) patients were male and 69 (37%) patients were female. bcva vision was 6/24 or better in 59% of patients and 6/36 or worse in 41% of patients. color vision was defective in 24 patients (12 %). discussion tuberculosis can affect practically any structure of the eye and its adnexae. ocular manifestations in tb may be attributed to either infection or non-infections immunologic reactions. hematolgenous dissemination may result in involvement of the uvea due to its great vascularity, while immunological reactions to tuberculo-protein may cause interstitial keratitis and retinal vasculites. the ministry of health of pakistan began implementing dots (the internationally recommended strategy for tb control) in 1995, with balochistan selected as a pilot province. much progress has been made over the past five years. the case detection rate for pakistan rose from 13 percent in 2002 to 67 percent in 2007, close to who’s target of 70 percent. pakistan ranks eighth on the list of 22 highburden tuberculosis (tb) countries in the world, according to the world health organization’s (who’s) global tuberculosis control 2009. in 2007, an estimated 297,108 people in pakistan (primarily adults in their productive years) developed tb. the emergence of multidrug-resistant (mdr) tb and tbhiv co-infection is a growing concern in the country. in this study we have found significant evidence of involvement of the retinal vasculature or the uveal tract in patients with overt pulmonary tuberculosis. all the cases in our study had established diagnosis of pulmonary tb according to the criteria set by the who tb dots program. most of the patients were already on anti tuberculous therapy. we were looking for signs of active as well as healed granulomata, to remove the bias that may develop from initiation of therapy. donahue reviewed the ophthalmic records of over 10,000 patients with primary pulmonary tb and found 1.4% incidence of ocular tb5. as a fraction of uveitis cases, the prevalence of ocular tb varies by area. in isolated descriptive studies, it has been estimated to be under 1% in the usa6, 4% in china7, 6% in italy8, 7% in japan9, and 16% in saudi arabia10. kontas ka (1958) found abnormalities of fundus in 43 (13%) out of 318 patients with pulmonary tb11. in our study 99 (52.9%) of the 187 patients had ocular findings that could be attributed to tuberculosis (tables 1-2). this is a much higher incidence and maybe linked to a high prevalence of systemic disseminated tuberculosis in our population, 11 patients had anterior segment findings and in 88 patients posterior segment was affected. table 1: external eye and anterior segment findings external and anterior segment findings no. of patients n (%) interstitial keratitis 2 (1.06) anterior uveitis 9 (9.81) table 2: posterior segment findings posterior segment findings no. of patients n (%) periphlebitis 17 (9.09) choroiditis 26 (13.9) vitritis 16 (8.55) vitreous hemorrhage 8 (4.27) nve 14 (7.4) optic atrophy 7 (3.7) a study of 158 patients with intraocular tb in india over 10 year period revealed that 42% showed posterior uveitis 36% had anterior uveitis, and 11% had intermediate uveitis12. bouza e et al found choroiditis in almost all (17 of 18) patients; with other lesions being papillitis, retinitis, vitritis, vasculitis, dacryoadenitis and scleritis13. salit mehta reported 202 83% incidence of choroidal tuberculosis and 16% retinal vasculites in her study, which evaluated ocular involvement in patients with mycobacterium sepsis. 14 in our study 13.9% patients had choroiditis. much higher incidences than our study have also been reported. in malawi africa 92.8% incidence of choroidal granuloma was reported in 109 patients with fever and tuberculosis, in a prospective study in 200215. 0 5 10 15 20 25 30 p er ip hl eb iti s c ho ro id iti s v itr iti s v itr eo us h ae m or rh ag e n v e o ph th ic a tr op hy o ph th ic a tr op hy fig. 1: relative frequency of various ocular findings our study is in agreement with the above mentioned studies in that posterior segment involvement is more common. 13.9% cases showed choroiditis at multiple sites followed by periphlebtitis (9.09%) and vitritis (8.5%). other significant findings included neovascularization (nve) in 7.4% cases. neovascularization may have the cause of vitreous haemorrhage seen in 4.27% patients. patients with neovascularization did not have any other systemic disease that could account for initiation of the neovascular process. optic atrophy occurred in 3.7% of cases. optic atrophy may occur due to anti tuberculosis drugs, or other causes. in tb optic nerve may be affected directly, as part of tuberculous posterior uveitis or through direct infiltration as part of tuberculous meningitis. conclusions a high frequency of patients with pulmonary tb had ocular signs that could be attributed to tuberculous infection. patients with proven pulmonary tb should have ocular examination including a dilated fundus examination. author’s affiliation dr. hussain ahmad khaqan vitreo retinal fellow eye department lgh/pgmi, lahore dr. khalid mehmood najmi assistant professor eye department shalamar hospital lahore dr. syed ali haider professor of ophthalmology eye department lg h/pgmi, lahore reference 1. akhter s, while f, i-hasan r, et al. hyperendemic pulmonary tuberculosis in periurban areas of karachi, pakistan bmc public health. 2007; 7: 70. 2. jawaertz microbiology 2nd edition: 279 285. 3. sheu sj, shyu js, chen lm, et al. ocular manifestations of tuberculosis. ophthalmology. 2001; 108: 1580-5. 4. bouza l, merino p, munoz p, et al. sanchez-carrillo c, yanez j, codes c. ocular tuberculosis, a prospective study in a general hospital, medicine (baltimore). 1997; 76: 53-61. 5. donahue hc. ophthalmologic experience in a tuberculosis sanatorium, am j ophthalmol. 1967; 64: 742-8. 6. henderly de, genstler aj, smith re, et al. changing patterns of uveitis, am j ophthalmol. 1987; 103; 131-6. 7. abrahams iw, jiang yq. ophthalmology in china. endogenous uveitis in chinese ophthalmological clinic, arch ophthalmol. 1986; 104: 444-6. 8. mercanti a, parolini b, bonora a, et al. epidemiology of endogenous uveitis in north-eastern italy, analysis of 655 new cases. acta ophthalmol scand. 2001; 79; 64-8. 9. wakabayashi t, morimura y, miyamoto y, et al. changing patterns of intraocular inflammatory disease in japan ocut immunnl inflamm. 2003; 11: 277-86. 10. islam sm, tabbara kf. causes of uveitis at the eye center in saudi arabia: a retrospective review, ophthalmic epulemiol. 2002; 9: 239-49. 11. konas ka (1958) ophthalmologia. 135-187. 12. gupta v. gupta a. rao na intraocular tb an update. sovnior ophthalmo. 2007; 52; 561-87. 13. bouza e, merino p, munaz p. sandez carilloc, yarlz .j, ortes ocular tb. a prospective study in a general hospital medicine (baltimore). 1993; 76; 53-1. 14. salit mehta. risk factors for the development of ocular tb in patients with disseminated tb ocular immunology inflammation. 2009; 17; 5: 319-21. 15. beara na, kublin jg, lewis dk et al. ocular disease in patients with tb & hw presenting with fever in africa, br. j ophthalmol. 2002, 86; 1076-79. microsoft word azonobi 129 original article risk factors of strabismus in southwestern nigeria azonobi ir, adido j, olatunji fo, bello a, mahmoud ao pak j ophthalmol 2009, vol. 25 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: azonobi ir department of ophhtalmology niger delta university teaching hospital yenagoa bayelsa state received for publication september’ 2008 … ……………………… purpose: the risk factors for strabismus among nigerian children have not been adequately determined despite the fact that strabismus is a significant cause of visual impairment among them. this study aims to evaluate such risk factors among some nigerian children. material and methods: school pupils aged between 2 and 17 years with manifest strabismus in some randomly selected elementary schools in ilorin, nigeria were screened. they were matched with controls comprising of children without ocular misalignment. the studied risk factors included prematurity, low birth weight, family history of strabismus and significant hypermetropia. a full ocular examination of each child included a noncycloplegic refraction using a topcon 8000r autorefractomter. results: 7,288 school children were screened. there were 32 cases of strabismus (22 esotropia and 10 exotropia). of the 32 cases of strabismus, 19 were males and 13 were females. there were 2 cases of significant hypermetropic astigmatism in strabismus group and 1 in controls (p > 0.05, odd ratio 1.0). significant myopia occurred in 3 cases and in 1 controls (p >0.05, odd ratio 1.5). there were 6 cases of significant hypermetropia in cases and 1 in controls (p <0.05, odd ratio 8.0). there were 12 cases of positive family history in cases and 1 in controls (odd ratio 19.8 and p<0.05).prematurity was observed in 18.8% of the cases and 15.6% of controls (p > 0.05,odd ratio of 1.2). conclusion: there is an association between heredity and strabismus. significant hypermetropia was found to be a risk factor for strabismus. trabismus is a common ocular problem among children1,2. although its pathogenesis and precise mode of inheritance is still obscure, several risk factors have been identified3. these include maternal cigarette smoking during pregnancy, increasing maternal age and maternal and paternal occupational lead exposures4’5. recently, it has been suggested that mutation in the albinism genes tyrosinase, p gene and tyrp1 may be responsible for congenital esotropia6. several studies have consistently shown that high hypermetropia is a risk factor for strabismus7-10. the relationship between strabismus and heredity is not in doubt. studies in monozygotic, dizygotic and other forms of multiple births along with family studies of patients with strabismus have consistently established the hereditary basis of strabismus11-15. prematurity and low birth weight are recognized risk factor for strabismus16-19 infants with gestational age <32weeks have a significantly higher risk of developing strabismus compared with children with gestational age > 32 the risk of strabismus increases with low birth weight. for infants weighing 1.5kg at birth compared to those weighing 4.0kg at birth, the odd ratios were 3.26 for esotropia and 4.01 for exotropia4. strabismus is a common cause of visual impairment among children and also has a tendency of causing amblyopia20.the risk factor for strabismus among nigerian children have not been adequately s 130 determined despite the fact that strabismus is a significant cause of visual impairment among them. this study was therefore carried out to evaluate the risk factors for strabismus among a group of nigerian children. matertals and methods this study took place among elementary school children in ilorin south local government area of kwara state, nigeria from october 2005 to september 2006. case definition these were school age children (2-17 years of age) of both sexes with manifest strabismus who were members of the participating schools and satisfied the inclusion criteria. controls definition these were children without ocular misalignment or any other ocular pathology in the same school as the cases matched for age and sex with the cases. included in the study were primary school pupils of any of the participating schools excluded were children with manifest strabismus in the selected schools whose squint was associated with any systemic or ocular pathology e.g. cataract, macular scar, cranial nerve palsies etc. the studied risk factors were prematurity, low birth weight, family history of strabismus and significant hypermetropia. prematurity was defined as birth of a child before 37 weeks from the last menstrual period of the mother (approximately 8 months gestational period) while low birth weight was taken as birth weight less than 2.5kg. a positive family history of strabismus was said to occur when at least one member of a first or second degree relative is affected. significant hypermetropia was defined as hypermetropia equal to or greater than +3.5ds (diopter shere) in one or both eyes while significant myopia refers to myopia greater than or equal to 3.0ds in one or both eyes. significant astigmatism refers to astigmatism equal to or greater than +2.0dcyl (dioptre cylinder) in any meridian in one or both eyes. informed consent was obtained from the education authority of the ilorin south local government area and from the parents of the children before commencement of the study. ethical clearance was also obtained from the ethical committee of the university of ilonn teaching hospital. a pilot study was earlier carried out to compare cycloplegic refraction using l% tropicamide with a non cycloplegic refraction using a topcon 8000r autorefractometer. results showed that the difference between the two was not statistically significant. a cluster random sampling technique was employed to select the cases and controls of the study. each of the 33 public primary schools in the local government area numbered 001 to 033 represented a cluster. the clusters were arranged serially in a sampling frame from which clusters were selected randomly for screening using a simple random sampling technique. any selected cluster was crossed to prevent its further selection. every eligible member of a cluster was screened to select the cases and controls of the study. in any selected school, screening proceeded from the most elementary class to the highest class. each of the children was screened for ocular misalignment at distance and near using the hirschberg’s and the cover-uncover test. in any class where a case of ocular misalignment was found a control matched for age and sex was also selected. at the end of the screening exercise, the number of cases and controls were compiled and their biological parents were later invited to the school to meet with the researchers. at the meeting with the parents the questionnaires were completed and consent was obtained to examine the children further in a hospital (ayo bello memorial eye centre). in the hospital, in the company of a school teacher assigned to follow the children, visual acuity was assessed using the snellen acuity chart (letter and e’ optotype) and picture chart for children too young to comprehend the above charts. a full ocular examination including extraocular motility assessment, anterior segment examination and fundscopy was done. a non-cycloplegic refraction was then done for each child using a topcon 8000r autorefractomter followed by a dilated fundoscopy using 1% tropicamide. each examination was carried out by an ophthalmologist (i.r) with the assistance of a school teacher who only helped to organize the children. 131 for each child, a questionnaire was completed by an ophthalmologist to obtain the child’s initials, age, sex, school and class. information obtained from the parents includes the child’s birth weight, duration of gestation, and family history of strabismus. all collected data were cross checked and analyzed using epi info 6.04, spss 12.01 and a pocket sized scientific calculator. statement of ethics we certify that all applicable institutional and governmental regulations concerning the use of human volunteers were followed during this research. results during the one year period, a total of 7,288 school children were screened (3.766 boys and 3522 grils). this yielded 32 cases of strabismus (22 esotropia and 10 exotropia). of the 32 cases of strabismus, 19 wee males and 13 were females. there were 6 cases of significant hypermetropia in cases and 1 in controls (p<0.05, odd ration 8.0), (table 1). table 1: relationship between significant refractive error and strabismus type of error number pvalue cases control hypermetropia significant (≥+3.5 ds) not significant (≥+0.5+ <+3.5ds) 6 14 1 18 >0.05 x2=2.540, df= 1.0, odd ratio = 8.0 astigmatism significant (≥+2.0dcyl) any meridian not significant (≥+0.5+ <+2.0dcyl) any meridian 2 10 1 5 >0.05 x2=0.450, df= 1.0, odd ratio = 1.5 myopia significant (≥+3.0ds) not significant (≥+0.5 + <-3.0ds) 3 5 2 5 0.05 x2=0.030, df= 1.0, odd ratio = 1.5 emmetropia (0-<±0.50 ds/cyl) any meridan 4 6 >0.05 total 44 38 there were 2 cases of significant astigmatism in cases and 1 in controls (p> 0.05, odd ratio 1.0). significant myopia occurred in 3 cases and in 1 controls (p>0.05, odd ration 1.5). there were 12 cases of positive family history in cases and 1 in controls (table 2) with and odd ration of 19.8 and p<0.05. table 2: heredity and strabismus factor no. of patients n (%) pvalue cases n (%) control n (%) total n (%) family history 12 (37.5) 1 (3.1) 13 (20.3) <0.05 no family history 18 (56.3) 28 (87.5) 46 (71.9) <0.05 no response 2 (6.25) 3 (9.4) 5 (7.8) >0.05 total 32 (100) 32 (100) 64 (100) x2= 11.680, df =2.0 odd ratio this familial tendency has no significant inclination towards either esotropia or exotropia (table 3). there were 8 cases of positive family history in esotropia and 4 in exotropia. the difference is not statistically significant (p>0.05). prematurity was observed in 18.8% of the cases and 15.6% of controls (p>0.05) with an odd ration of 1.2 (table 4). table 5 shows that 25.0% of the cases had low birth weight while 20.3% of controls had low birth weight (p>0.05) with an odd ration of 2.0. table 3: family history in relation to type of strabismus factor type of strabismus n (%) p-value esotropia n (%) exotropian n (%) family history 8 (36.4) 4 (40) <0.05 no family history 12 (54.6) 6 (60) <0.05 no response 2 (9.) 0 (0) <0.05 total 32 (100) 10 (100) x2 = 0.972, df=2.0 132 table 4: prematurity and strabismus factor no. of patients n (%) p-value cases n (%) control n (%) total n (%) permaturity 6 (18.8) 5 (15.6) 11 (17.2) <0.05 term gestation 24 (75) 24 (75) 48 (75) non-response 2 (6.3) 3 (9.4) 5 (7.8) >0.05 total 32 (100) 32 (100) 64 (100) x2 = 0.290, df = 2.0odd ratio = 1.2 table 5: low birth weight and strabismus factor no. of patients n (%) p-value cases n (%) control n (%) total n (%) low birth weight 8 (25) 5 (15.6) 13 (20.3) <0.05 normal birth weight 12 (37.5) 15 (46.9) 27 (42.2) <0.05 non-response 2 (6.3) 3 (9.4) 5 (7.8) >0.05 don’t know 10 (31.3) 9 (28.1) 19 (29.7) <0.05 total 32 (100) 32 (100) 64 (100) x2 = 1.280, df = 3.0 odd ratio = 2.0 discussion a family history of strabismus was established in 37.5% of cases in this study and 3.1% of controls (p < 0.05). cases with family history were 20 times more likely to develop strabismus compared with controls. this is similar to the findings of abeba and abebe21 in ethiopia and mvogo et al13 in cameroun. abeba and abebe found that 34.5% of cases of strabismus studied showed a positive family history while mvogo et al reported positive family history in 28.7% cases studied. however, these findings are lower than those reported by ferreria et al1 and dufier et al22 who reported a positive family history in 65.4% and 73.0% of cases respectively. in this study, there was no statistically significant difference in the percentage of familial cases with regard to the type of strabismus. 36.4%, and 40% of esotropia and exotropia respectively report a positive family history (p> 0.05). this is consistent with the findings of mvogo et al13 in cameroun. with significant hypermetropia occurring in 6 cases and in 1 control, the relationship between significant hypermetropia and strabismus is statistically significant (p <0.05). cases with significant hypermetropia are 8 times more likely to develop strabismus compared with controls. this is similar to the findings of previous authors8,23,24 significant hypermetropic astigmatism occurred in 2 cases and in 1 control and significant myopia occurred in 3 cases and 2 controls. the relationship between significant hypermetropic astigmatism and strabismus and between significant myopia and strabismus was not found to be statistically significant (p > 0.05, odd ratio 1.0 and 1.5) respectively. this is contrary to the findings of previous authors8,23,24. ingram and walker 8 found that bilateral spherical hypermetropia ≥ + 2.0 ds and or hypermetropic astigmatism ≥ + 1.0dcyl was significantly associated with strabismus (p = 0.0779%). atkinson et al23 found that children with abnormal hyperopia (≥ + 3.5 ds) are 13 times more likely to develop strabismus compared with controls. also irlgram et al24, showed that + 2.5ds of hypermetropia in any meridian in either eye is significantly associated with strabismus (p=0.00000005%). abnormal hypermetropia is a risk factor for accommodative esotropia24. the criteria for abnormal refraction (significant refractive error) used in this study is slightly different from that used by previous authors. similarly the age range of children in previous studies differs from the age range of children in this study. these may explain why the findings of this study is slightly different from those of previous authors. with 18.8% of cases and 15.6% of controls born before 37 weeks of gestation, the relationship between prematurity and strabismus is not statistically significant in this study (p > 0.05). this is contrary to the findings of previous authors16,17 schalij delfos et al16, found that prematurity is a risk factor for strabismus (p < 0.05). infants with gestational age <= 32 weeks have a significantly higher risk than infants with gestational age> 32 weeks. infants with gestational age> 32 weeks develop incidence of strabismus comparable to the normal population. galo and lennerstrand17, also observed a significant association between prematurity and strabismus. they found an incidence of strabismus of 9.9% in premature children and 2.1% in full term children. in our environment, children born before 32 weeks of gestation hardly survive because of complications associated with prematurity and the paucity of good neonatal care. it is very probable that most 133 prematurity observed in this study have gestational age > 32 weeks. since children with ga > 32 weeks develop an incidence of strabismus comparable with normal populations16, this may partly explain the findings of this study. low birth weight occurred in 25% of cases and 15.6% of controls in this study. thus the relationship between low birth weight and strabismus is not statistically significant (p > 0.05). this is contrary to the findings of previous authors4,25. chew et al found that the risk of strabismus increases with low birth weight (p < 0.0001). for children weighing 1.5kg at birth compared to those weighing 4.0kg at birth, the odd ratios were 3.26 for esotropia and 4.10 for exotropia. mc ginnity and bryas25, found the prevalence of strabismus in low birth children to be 19% and 2.5% in normal birth weight children. it was not possible to obtain birth weight of children in 3 1.3% of cases and 28.1% of controls in this study. this is due to poor record keeping by the parents and the probability that most of these children may not have been delivered in the hospital. this may partly account for the disparity between the findings of this study and the findings of previous authors. in conclusion there is an association between heredity and strabismus. however, there is no statistically significant difference in the occurrence of positive family history in esotropia and exotropia. significant hypermetropia was found to be a risk factor for strabismus. the relationship between prematurity, low birth weight and strabismus respectively could not be satisfactorily determined in this study because of poor obstetric records. author’s affiliation dr azonobi i.r dept of ophhtalmology niger delta university teaching hospital, yenagoa bayelsa state dr adido j dept of ophhtalmology university of ilorin teaching hospital ilorin, kwara state dr olatunji fo dept of ophhtalmology university of ilorin teaching hospital ilonn, kwara state dr bello a ayo bello memorial eye centre no 1 ayo bello way ilonn, kwara state dr mahmoud ao dept of ophhtalmology university of ilorin teaching hospital ilorin, kwara state reference 1. ferreira rf, faye 0, bronwyn, b. genetic aspects of strabismus. arq bras oftalmol. 2002; 65: 171-5. 2. deutsch ja, nelson lb. diagnosis and management of childhood strabismus. peadiatrician. 1990: 17: 152-62. 3. paul to, hardage lk. the heritability of strabismus. ophthalmic genet. 1994; 15: 1-18. 4. chew f, remaley n a, tamboli a, et al. risk factors for esotropia. archives of ophthalmol. 1994; 112: 1349-55. 5. hakim rb, stewart wf, canner jk, et al. occupational lead exposure and strabismus in offpsprings: a case control study. am j epidemiol. 1991; 133: 351-6. 6. kathryn pb, robin mw, julie mb, et al. investigation of albinism genes in congenital esotropia. molecular vision. 2003; 9: 710-14. 7. eileen fb, sherry lf, sarah em, et al. risk factors for accommodative esotropia among hypermetropia children. investig ophthalmol and visual science. 2005; 46: 526-9. 8. ingram rm, walker c. refraction as a means of predicting squint or amblyopia in preschool siblings of children known to have these defects. br j ophthalmol. 1979; 63: 238-42. 9. haase w. refraction in childhood as a risk factor for the development of amblyopia and/or strabismus. kim monatsbl augenheilkd. 1994; 204: 48-54. 10. abrahamsson m, fabian g, sjostrand j. refraction changes in children developing convergent or divergent strabismus. br j ophthalmol. 1992; 76: 723-7. 11. lang j. genetic aspects of esotropia in homozygous twins. kim monatsbl augenheilkd. 1990; 196: 275-8. 12. matsuo t, hayashi m, fujiwara h, et al. concordance of strabismic phenotypes in monozygotic versus multizygotic twins and other multiple births. jpn j ophthalmal. 2002; 46: 5964. 13. mvogo cb, ellong a, bella-hiag al, et al. hereditary factors in strabismus. sante, 2001; 11: 237-9. 14. zikas ng, woodruff g, smith lk, et al. a study of heredity as a risk factor in strabismus. eye 2002; 16: 519-21. 15. podgor mj, remaley na, chew e. associations between siblings of esotropia and exotropia. arch ophthlmol. 1996; 6: 737-44. 16. schalij delfos ne, de graaf me, treffers wf, et al. long term follow up of premature infants: detection of strabismus, amblyopia and refractive error. br j ophthalmol. 2000; 84: 9637. 17. gallo je, lennerstrand g. a population based study of ocular abnormalities in premature children aged 5 to 10 years am j ophthalmol. 1991; 111: 539-47. 18. keith cg, kitchen wh. ocular morbidity in infants of very low birth weight. br j ophthalomol. 1983; 67: 302-5. 19. holmstrom g, el azazi m, kugelberg u. ophthalmological follow up of preterm infants: a population based prospective 134 study of visual acuity and strabismus. br j ophthtalmol. 1997; 81: 935-40. 20. freeman aw, nguyen va, jolly n. component of visual acuity loss in strabismus. vision res. 1996; 36: 765-74. 21. abeba tg, abebe b. prevalence of strabismus among preschool children community in butajira town. ethiop i health dev. 2001; 15: 125-30. 22. dufier jl, briard ml, bonaiti c, et al. inheritance in the etiology of convergent squint. ophthalmologica, 1979; 179: 22534. 23. atkinson j, braddick 0, robier b, et al. two infants vision screening programmes: prediction and prevalence of strabismus and amblyopia from photo and video refractive screening. eye. 1996; 10: 189-98. 24. ingram rm, traynar mj, walker c, et al. screening for refractory error at age 1 year: a pilot study. br j ophthalmol. 1979, 63: 243-50. 25. mc ginnity fg, bryas jh. controlled study of ocular morbidity in school children born preterm. br j ophthalmol. 1992, 76: 520-4. guess who see next issue for answer 135 microsoft word news and events 54 news and events vol. 26, 1, 2010 the royal college of ophthalmologists annual congress date: 25-27 may 2010 venue: liverpool, uk phone. +44 (0) 20 7935 0702 +44 (0) 20 7935 9838 web. www.rcophth.ac.uk/scientific world ophthalmology congress 2010 xxxii international congress of ophthalmology 108th german society of ophthalmology date: 5-9 june 2010 venue: berlin, germany web. www.woc2010.org european society of cataract and refractive surgeons meeting (escrs) date: 4-8 september 2010 venue: paris, france 25th asia pacific academy of ophthalmology (apao) 15th national congress of the chinese ophthalmological society (cos) date: 16-19 september 2010 venue: beijing, china joint meeting: american academy of ophthalmology and middle east africa council of ophthalmology (meaco) date: 16-19 october 2010 venue: mc cormick place, chicago, usa web. www.aao.org/meeting lahore ophthalmo date: 24-26 december 2010 venue: pearl continental hotel lahore, pakistan secretary: dr. zahid kamal siddiqui secretariat: osp house 4-a lda flats, lawrence road, lahore. phone: 92-42-6363325 fax: 92-42-6363326 email: osplahore@hotmail.com american society of cataract and refractive surgery (ascrs) date: 27-31 january 2011 venue: mc cormick place, chicago, usa institute / courses pakistan institute of community ophthalmology, peshawar pakistan contact: professor shad mahmood rector pico, hayat abad medical complex peshawar college of ophthalmology and allied vision sciences (coavs) contact: prof. asad aslam khan principal/director general coavs, kemu / mayo hospital, lahore phone: 042-7355998 fax: 042-7248006 email: pipo@brain.net.pk pakistan institute of ophthalmology, al-shifa trust eye hospital, rawalpindi pakistan contact: secretary, pio, al-shifa trust eye hospital, jhelum road, rawalpindi pakistan phone: 92-51-5487830, 5487820-25 fax: 92-51-548827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt department of ophthalmology fatima jinnah medical college sir ganga ram hospital, lahore fax: 92-42-6363326 email: hamidbut@gmail.com mobile: 0300 – 4158962 microsoft word amjad akram 37 management corner management tips for glaucoma amjad akram, muhammad shahid, asad jamal dar, ghulam rasool mekan pak j ophthalmol 2008, vol. 24 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: amjad akram consultant eye surgeon cmh rawalakot ajk received for publication april’ 2007 …..……………………….. this article highlighted practical tips for glaucoma management. these tips include dealing with the glaucoma suspect, history taking, general medical history, gonioscopy, visual fields, optic disc cupping, secondary glaucomas, normal tension glaucoma and of course raised intraocular pressure. emphasis being on practical tips rather than being comprehensive on glaucoma. “most ophthalmologists on planet earth are confused regarding diagnosis and management of glaucoma” this is a sentence which caught our attention when reading an article on glaucoma in “highlights of ophthalmology” some years ago. we were quite amused by this remark but over the years while working in glaucoma units abroad as well as within pakistan we realized that there is plenty of truth in it. it has been our experience that most of the “confusion” is found in ophthalmologists of junior grade especially those in training but by no means are the seniors exempted. we tried to analyze reasons for “confusion” and found the following to be some of the reasons for “confusion” and found the following to be some of the reasons responsible for this. 1 most ophthalmologists regard an intraocular pressure of more than 21 mmhg synonymous with glaucoma and would start treatment. 2 inability to appreciate other lesions or diseases which may on occasions mimic glaucoma. 3 inability to appreciate pitfalls in intraocular pressure measurement. 4 negligence of various diagnostic protocols for different types of glaucomas. so we decided to write this article based on our personnel experience, teachings and experience of our mentors while working in various glaucoma units. aim being to give practical tips rather than being comprehensive on glaucoma. the glaucoma suspect whenever a patient is suspected to have glaucoma do not start treatment if doubt exists regarding diagnosis1. when dealing with suspected glaucoma it is better to investigate the patient further until things become clear rather than putting him on unnecessary lifelong treatment, since it is a common observation that once treatment is started in a particular patient, it is continued forever and subsequent ophthalmologists who manage the patient will probably continue the same management. history taking history taking is the most neglected aspect of glaucoma and ophthalmology in general since the physical findings are so apparent. however sometimes a carefully taken history will make the difference between successfully managing the disease and failure. 38 1. most cases of chronic open angle are asymptomatic while acute glaucoma by contrast will present with dramatic symptoms of pain, redness and blurred vision. 2. subacute attacks of angle closure glaucoma may present with migraine like symptoms with intermittent attacks of pain and visual disturbance. 3. a disease identical to chronic open angle glaucoma can be produced by previous trauma or steroid eye drops use so a history of eye injury, often many years previously or of eye drops use, should be sought. 4. patients with significant myopia and glaucoma should prompt an examination for pigment dispersion as a cause of glaucoma. 5. anisometropia and amblyopia are often associated with asymmetrical optic disc appearance, if the congenital disc asymmetry is not recognized a false suspicion of glaucoma may be raised 6. history of refractive corneal surgery has implications since eyes with corneal thinning may have erroneously low iop readings with goldman applanation tonometry. general medical history 1. bilateral adrenal hyperplasia is the only known medical condition to cause chronic glaucoma and is a very rare condition, whereas exogenous steroids are a much more frequent and unfortunately overlooked cause. 2. if patient is a hypertensive, topical beta antagonists should not be used in those taking systemic beta antagonists2. 3. if patients has a history of asthma or chronic obstructive airway disease, beta blockers should be avoided. dealing with raised intraocular pressure intraocular pressure should never be considered in isolation. if iop is found to be “raised “in a particular patient, the individual either has glaucoma or patient is ocular hypertensive. however pitfalls, in intraocular pressure measurement should be excluded in suspected glaucoma patients’ .e.g. check central corneal thickness3. 1. before labeling a patient as ocular hypertensive, secondary glaucoma must always, be excluded. this is because disc cupping and visual field loss are not absolutely essential to diagnose secondary glaucoma. 2. ocular hypertensive should have yearly fields done to check for development of glaucoma. 3. iop is genetically determined. therefore a difference of more than 5mmhg between the two eyes should be viewed with suspicion even if iop is within ‘normal’ range. gonioscopy one of the most common causes of an incorrect diagnosis is the omission of gonioscopy. the reasons offered is that if slit lamp examination does not suggest a narrow angle, ocular inflammation, new vessel formation or signs of previous trauma, the patient must be having open angle glaucoma. chronic angle closure glaucoma and many other forms of glaucoma can therefore be overlooked. visual fields 1. before interpreting fields one must always refer to the reliability indices. 2. fields with significant errors in reliability indices should be repeated if possible. 3. the most important scotomas in glaucoma appear in the para central areas or the bjerum’s area. therefore a visual field with only “edge effects” type of scotomas should be considered artifactual and fields should be repeated. 4. visual field which is normal (in the presence of reliable reliability indices) should be taken as correct and need not be repeated. 5. a scotoma which obeys the vertical meridian almost always points to a neurological pathology rather than glaucoma. 6. always remember that no field defect is pathognomonic of glaucoma. the field defects which are typical of glaucoma can also be produced by lesions such as anterior ischemic optic neuropathy, branch retinal vein occlusion etc 7. purely central scotomas with preservation of peripheral fields are suggestive of neurological pathology rather than glaucoma e.g. optic neuritis. 8. rapidly progressive field loss and markedly asymmetric field loss also raise the possibility of neurological disease rather than glaucoma. 39 9. as part of learning curve or fatigue patient may have non specific field defects. if such is the case repeat fields and artifactual scotomas will disappear. optic disc cupping 1. cup disc ratio (c/d) is genetically determined; therefore an asymmetry of greater than 0.2 between the two eyes should be regarded with suspicion4. 2. optic disc cupping is not unique to glaucoma only and can also occur in conditions such as compressive optic neuropathies, anterior ischemic optic neuropathies etc 5. 3. cupping can also be seen in elderly individuals with atherosclerosis even if there is no definitive field loss 6. 4. optic disc colobomas are very frequently confused with pathological cupping especially because they also produce significant field defects. 5 pallor involving cup as well as the neuroretinal rim suggests a neurological cause of cupping rather than glaucoma7. in glaucoma, the remaining neuroretinal rim retains its normal pink colour. secondary glaucomas 1. generally speaking there are two glaucomas where the diagnosis is not essentially based on visual fields a. angle closure glaucoma. b. secondary glaucomas 2. for the diagnosis of secondary glaucomas intraocular pressure almost always has to be raised. 3. raised iop in presence of other ocular evidence of secondary glaucoma is enough to make a diagnosis even in the presence of healthy discs and fields. of course fields will be indicated for follow up of disease progression or to judge efficacy of treatment. 4. the above points will be highlighted by the following example. a 45 years old lady came to our out patient clinic. she was being observed for glaucoma as we noticed from her file notes. her vision was 6/6 with -2.50 ds each eye. her iop was 22mmhg and 24mmhg in the right and left eye respectively as we observed from her notes. when we took the iop, almost similar readings appeared. she was presently not on any medication. her optic discs were healthy looking and her visual fields were completely within normal limits. however, the decision of starting the antiglaucoma treatment remained controversial. when we examined the patient on slit lamp we noticed that the patient had classic krukenberg spindles on the posterior aspects of both corneas and anterior chambers were deep in both eyes. gonioscopy revealed open angles with marked pigmentation in the trabecular meshwork. water drinking test was performed and within an hour the iop shot from 22 mmhg and 23 mmhg in the right and left eye respectfully to 37 mmhg and 39 mmhg in the right and left eye respectively. this rise in iop was dramatic and could not be ignored. it showed compromised facility of outflow. a diagnosis of pigment dispersion glaucoma was made and we put her on treatment in spite of the fact that fields were normal. however we did advise her to get fields done on yearly basis in order to judge effectiveness of the treatment. 5. whenever you diagnose “uniocular” poag, beware, you probably are dealing with a secondary glaucoma in which signs are subtle and have been missed. i.e. exclude secondary glaucoma before diagnosing uniocular poag. 6. patient who has traumatic angle recession should be followed up for the rest of their lives even if iops are normal since pressure may rise later on. 7. any eye with intraocular inflammation should be presumed to be having raised iop until proved otherwise. normal tension glaucoma (ntg) 1. the biggest mimicker of ntg is primary open angle glaucoma itself. 2. if you diagnose ntg on the very first visit of a patient the chances of the diagnosis being correct are minimum. 3. if ntg is considered a diagnosis of exclusion, chances of making mistakes in diagnosis are minimized. 4. common conditions which are likely to cause errors in diagnosis are: a. pitfalls in iop measurement. b. optic disc anomalies e.g. colobomas c. neurological lesions producing optic disc cupping. d. misinterpretation or wrongly performed visual fields. 5. if patient has typical glaucomatous cupping with field defects and “normal” iop, perform water 40 drinking test to see how much iop rises. in true ntg rise in iop should not be significant. 6. in case water drinking test is negative it is prudent to perform neuroimaging of brain and visual pathways before finally labeling patient as having ntg. aphakic glaucoma and glaucoma in aphakia aphakic glaucoma is a definite disease entity while glaucoma in an aphakic eye may have many reasons and mechanisms. author’s affiliation lt col. amjad akram eye surgeon cmh, rawalakot, ajk major muhammad shahid military hospital, rawalpindi col asad jamal dar cmh, multan cantt. major ghulam rasool mekan cmh rawalakot, ajk references 1. sommer a. doyne lecture. glaucoma facts and fancies. eye 1996 10 295-301 2. diggory p. franks wa. medical treatment of glaucoma. a reappraisal of the risks.br j ophthalmol. 1996; 80: 85-9. 3. whitacre mm, stein ra, hassanein k. the effect of corneal thickness on applanation tonometry. am j ophthalmol 1993; 115: 592-6. 4. garway. heath df, ruben st, viswanathan a, et al. vertical cup/ disc ratio in relation to optic disc size: its value in the assessment of the glaucoma suspect. br j ophthalmol. 1988; 82. 5. sebag j, thomas jv, epstein el, et al. optic disc cupping in arteritic aion resembles glaucomatous cupping. ophthalmol 1986 93: 357-61. 6. brownstein s, font rl, zimmerman le, et al. nonglaucomatous cavernous degeneration of optic nerve. report of two cases. arch ophthalmol. 1980; 98: 354. 7. kupersmith mj, krohn d. cupping of optic disc with compressive lesions of the anterior visual pathways. ann ophthalmol. 1984; 16: 948. microsoft word khalid mahmood 1 corrected 193 original article visual effects of intravitreal triamcinolone acetonide injection in patients with refractory diabetic macular edema khalid mehmood, baber attique malik, muhammad tariq khan, mirza jamil ud din baig, zaheer ud din aqil qazi pak j ophthalmol 2010, vol. 26 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: khalid mehmood department of ophthalmology avicenna medical college dha phase ix lahore received for publication june’ 2010 …..……………………….. purpose: the visual outcome in patients with refractory diabetic macular edema receiving intravitreal triamcinolone acetonide injection. materials and methods: this was an interventional, prospective hospital based study conducted at lrbt eye hospital lahore from jan 2007 to aug 2007. fifty eyes of 50 patients received lntravitreal injection of triamcinolone in a single dose of 4mg/0.1 ml. visual acuity was measured preoperatively and at postoperative visit of 1 week, 1 month and 3 months using snellen’s visual acuity chart. results: pre operatively there was 1 (2%) eye with va > 6/18, 28 (56%) eyes with va 6/24-6/60 and 21 (42%) eyes had va <6/60. on third post operative month follow up visit day there were 6 (12%) eyes with va > 6/18, 31 (62%) eyes with va 6/24-6/60 and 13 (26%) eyes had va <6/60. there is statistically significant difference between the preoperative and postoperative visual acuity, p=0.005. conclusion: this study suggests that lntravitreal injection of triamcinolone acetonide in a dose of 4mg/0.1ml considerably improved vision in patients with diffuse diabetic macular edema refractory to previous macular grid photocoagulation at three months after the injection. lindness is one of the most feared complications of diabetes but also one of the most preventable1. proliferative diabetic retinopathy and diabetic macular edema are the most common causes of blindness not only in pakistan but also all over the world2. visual impairment in diabetic patients is usually due to involvement of the fovea3. laser photocoagulation reduces the risk of moderate visual acuity loss for all eyes with diabetic macular edema by about 50% as demonstrated by early treatment diabetic retinopathy study [etdrs]. results show that for some patients, laser photocoagulation is effective but treated eyes often develop moderate visual loss inspite of the treatment4. the frequency of an unsatisfactory outcome following laser photocoagulation in eyes in diabetic macular edema has prompted interest in other treatment modalities. intravitreal injection of triamcinolone acetonide has emerged as a promising therapy for diabetic macular edema refractory to conventional laser photocoagulation5’6. this modality was first proposed in 1999 as a treatment for refractory diabetic macular edema due to its effect of attenuating the vascular endothelial growth factor (vegf) mediated retinal capillary permeability that is presumed to be a contributing factor in its pathogenesis. intravitreal triamcinolone acetonide is effective in improving vision, reducing macular thickness and inducing reabsorption of hard exudates. jonas jb and coworkers on the use of intravitreal triamcinolone acetonide suggest that this treatment resulted in reducing the macular edema and improvement of visual acuity in diabetic patients7. the aim of this study was to evaluate the visual b 194 outcome with intravitreal triamcinolone acetonide injection in patients with refractory diabetic macular edema. matrerials and methods this was an interventional prospective hospital based study. patients were selected from the outpatient department of lrbt eye hospital, lahore. fifty eyes of 50 patients were included in this study ranging between 44 – 64 years of age. all patients had nonproliferative diabetic retinopathy with unresolved diffuse exudative diabetic maculopathy with previous macular grid photocoagulation. preoperatively visual acuity with snellen’s visual acuity chart and intraocular pressure with goldman’s tonometer were recorded. slit lamp examination of anterior segment and detailed dilated fundus examination with volk superfield non-contact lens was performed in all patients. digital fundus fluorescein angiography was done in all patients but this was not taken as a reference point. all patients underwent an intravitreal injection of triamcinolone acetonide 4mg/0.1ml under topical anesthesia through pars plana 3.5 mm from limbus with a small-bore needle (27 gauge).the procedure was done in operation theatre under strict aseptic conditions.topical anaesthesia was given in the form of a cotton vick soaked in 2% lignocaine solution kept in lower fornix for 2 minutes with a single drop of proparacaine hydrochloride 0.5% just before inserting the needle.eye was padded for 4 hours. a combination of ofloxacin and dexamethasone topical eye drops was given 4 times a day for 1 week. postoperative visual acuity, intraocular pressure, slit lamp examination of anterior segment and dilated fundus examination were performed in all patients on 1week, 1 month and 3 months interval. results there were 27 (54%) males and 23 (46%) females. the age range was from 44-64 years with a mean age of 53.2 years with standard deviation of 4.76 years. pre operatively there was 1 (2%) eye with va >6/18, 28 (56%) eyes with va 6/24-6/60 and 21 (42%) eyes had va <6/60. pre-operatively intraocular pressure range was from 10-16 mmhg. mean iop was 13.12 mmhg with standard deviation of 8.51 mmhg. on first post operative week there was 1 (2%) eye with va > 6/18, 28 (56%) eyes with va 6/24-6/60 and 21 (42%) eyes had va <6/60. on first post operative month, there were 8 (16%) eyes with va > 6/18, 38 (76%) eyes with va 6/246/60 and 4 (8%) eyes had va <6/60. on third post operative month, there were 6 (12%) eyes with va > 6/18, 31 (62%) eyes with va 6/246/60 and 13 (26%) eyes had va <6/60. there was a statistically significant difference between the preoperative and postoperative visual acuity, p=0.005. postoperative intraocular pressure range was from 10-40 mmhg. mean iop was 19.86 mmhg with standard deviation of 8.51 mmhg. secondary glaucoma developed in 18 (36%) eyes which was successfully treated with topical medication in all patients. cataract developed in 2 (4%) eyes. one (2%) eye developed postoperative endophthalmitis while 29 (58%) eyes developed no postoperative complications. discussion diabetic retinopathy is the leading cause of blindness in patients aged more than 50 years in our country .among them macular edema is the main reason of reduced vision in this population. diffuse macular edema is one of the most intractable complications of diabetic retinopathy8. this was a hospital based prospective study to evaluate the visual outcome in patients with diabetic macular edema refractory to previous macular grid photocoagulation after administrating intravitreal triamcinolone acetonide injection. intravitreal triamcinolone acetonide has increasingly been used in previous studies as treatment for intraocular proliferative, edematous, and neovascular diseases9-11. table 1: post operative complications complications no. of eyes n (%) secondary glaucoma 18 (36) cataract 2 (4) endophthalmitis 1 (1) the results of our study showed that intravitreal triamcinolone acetonide may be useful in increasing va in patients with diffuse diabetic macular edema. postoperative va showed a significant increase in va as compared to the preoperative va, expressed on snellen’s visual acuity chart. our results are 195 comparable to the results of j b jonas and coauthors12 who also reported the similar results. male 27, 54% female 23, 46% fig. 1: gender distribution 18 15 5 12 43 45 years 46 50 years 51 55 years 56 60 years fig. 2: number of patients with age distribution 0 5 10 15 20 25 30 35 40 pre-op 1 weak postop 1 month post-op 3 months post-op > 6/18 6/24 6/60 < 6/60 fig. 3: comparison of pre and post-operative visual acuity based on the results of present study and in agreement with other studies13 it may be inferred that patients with persisting diffuse macular edema may undergo intravitreal injection of triamcinolone acetonide in a controlled manner. this study supported that the use of intravitreal injection of triamcinolone acetonide improved visual acuity in patients with refractory diabetic macular edema. another study conducted by j b jonas and coauthors showed that intravitreal injection of triamcinolone acetonide can increase visual acuity in patients with diffuse macular oedema14. another study conducted by nadeem ishaq showed that intravitreal injection of triamcinolone acetonide was a promising therapy for patients with diabetic macular edema refractory to laser treatment. it was effective in improving vision, reducing macular thickness and inducing re absorption of hard exudates15. our study is comparable to the above mentioned studies in that intravitreal injection of triamcinolone acetonide resulted in improvement in visual acuity in patients with refractory diabetic macular edema. one limitation of this study might be that, although intravitreal injection of triamcinolone acetonide will have increased the degree of cataract, cataract surgery was not performed in combination with, or after, the intravitreal injections of triamcinolone acetonide during follow up. the vision reducing effect of progressive cataract, however, might have hidden parts of a vision improving effect of triamcinolone so that this limitation of the study might serve to support the conclusion. the main side effect of intravitreal injection of triamcinolone acetonide observed in the present study was an increase in iop. eighteen (36%) eyes developed maximal iop measurements higher than 21 mmhg. as is described in other studies,16 the secondary glaucoma could usually be treated by topical beta blockers and carbonic anhydrase inhibitor anti glaucoma medications without the development of glaucomatous optic nerve damage. conclusion macular edema in diabetic patients is a major factor of visual impairment. intravitreal triamcinolone acetonide is effective alternative treatment for eye with diabetic macular edema refractory to medical and laser treatments. this study suggests that intravitreal injection of triamcinolone acetonide in a dose of 4mg/ 0.1ml improve visual outcome in patients with diffuse n o. o f e ye s 196 diabetic macular edema during the first three months after the injection. author’s affiliation dr. khalid mehmood associate professor of ophthalmology avicenna medical college lahore dr. baber attique malik consultant laser vision eye center lahore dr. muhammad tariq khan consultant ophthalmologist lrbt eye hospital lahore dr. mirza jamil ud din baig senior ophthalmologist lrbt eye hospital lahore dr. zaheer ud din aqil qazi chief consultant ophthalmologist lrbt eye hospital lahore reference 1. haider sa. blindness and diabetic retinopathy. pak j ophthalmol. 2001; 17: 42. 2. kanski jj. clinical ophthalmology. a systematic approach 5th ed. butter worth i leinemann; oxford. 2003: 445. 3. early treatment diabetic retinopathy study research group. retina and vitreous sec 12. american academy of ophthalmology. usa. 2003-04: 99. 4. jonas jb, sofker a. intraocular injection of crystalline triamcinolone as adjunctive treatment for diabetic macular edema. am j ophthalmol. 2001; 132: 425-7. 5. .jonas jb, kreissig i, sofker a, et al. intravitreal triamcinolone injection for diffuse diabetic macular edema. arch ophthalmol. 2003; 121: 57-61. 6. david nz, mark wj. combined intravitreal injection of triamcinolone acetonide and pan retinal photocoagulation for concomitant diabetic macular edema and proliferative diabetic retinopathy. retina. 2005; 25: 135-40. 7. jonas jb, kreisig i, sofker a, et al. intravitreal injection of triamcinolone for diffuse diabetic macular edema. arch ophthalmol. 2003; 121: 57-61. 8. early treatment diabetic retinopathy study group. etdrs report no. 11. classification of diabetic retinopathy from fluorescein angiograms. ophthalmology. 1991; 98: 807–22. 9. greenbewrg pb, martidis a, rogers ah, et al. intravitreal triamcinolone acetonide for macular edema due to central retinal vein occlusion. br j ophthalmol. 2002; 86: 247-8. 10. jonas jb, sofker a. intravitreal triamcinolone acetonide for cataract surgery with iris neovascularization. j cataract refract surg. 2002; 28: 2040-1. 11. martidis a, duker js, puliafito ca. intravitreal triamcinolone for refractory cystoid macular edema secondary to birdshot retinochoroidopathy. arch opohthalmol. 2001; 119: 1380-3. 12. jonas jb, akkoyun i, kreissig i, et al. diffuse diabetic macular oedema treated by intravitreal triamcinolone acetonide: a comparative, non-randomized study. br j ophthalmol. 2005; 89: 321-6. 13. massin p, audren f, haouchine b, et al. intravitreal triamcinolone acetonide for diabetic diffese macular oedema: preliminary results of a prospective controlled trial. ophthalmology. 2004; 111: 218-24. 14. nadeem ishaq. al-shifa journal of ophthalmology. 2005; 1: 303. 15. wingate rj, beaumount pe. intravitreal triamcinolone and elevated intraocular pressure. aust n z j ophthalmol. 1999; 27: 431-2. 16. jonas jb, kreissig i, degenring rf. secondary chronic open angle glaucoma after intravitreal injection of triamcinolone acetonide. br j ophthalmol. 2003; 87: 24-7 phacoemulsification in hard nuclear cataract. mostly stay within the bag away from posterior capsule and corneal endothelium. use good quality viscoelastic very frequently. prof. m. lateef chaudhry editor in chief microsoft word obituary lt. gen jahan dad 53 lt. gen (retd) jahan dad khan (a social worker par excellence) it is with great sadness that we learnt about the sad demise of lt. gen (retd) jahan dad khan on 13th february 2011. he was born in 1929 in village called malloo in attock district. he got commission in pakistan army in 1951 in artillery regiment. during his military career he served on various important assignments like commander4 of an infantry division, and corps commander x corps. he retired from active service in 1984. he then served as governor sindh from 1984 to 1987. for his outstanding services he was awarded hilal-eimtiaz (military) and sitara-e-basalat. it is after his retirement that his extraordinary capabilities as social worker started to make a mark in the society. in 1985 he established al shifa trust for prevention and cure of blindness. he used very skillfully all his contacts to raise funds for the trust. he was able to establish a state of the art eye care hospital in rawalpindi in 1991. from those days onwards he devoted every minute of his life to the cause of service to the ailing humanity. in the coming years we saw him completing two more eye hospitals, one at sukkur and other in kohat. fourth hospital has been completed but he could not live to see it functioning. through his efforts millions of patients suffering from eye diseases have been cured and hundreds of ophthalmologists and paramedics have been trained at these hospitals. his other social work projects include attock education trust and margallah study group. he wrote several books as well. he was also awarded hilal-e-imtiaz by the government of pakistan. gen jahan dad khan was among those rare people who believed in hard work, selfless dedication, unmatchable commitment, honesty and human values. he was visionary, a planner and an implementer at the same time. he had great leadership qualities and always believed in leading by personal example. he was admired and loved and general public for his philanthropic work spanning over two decades. his role in prevention and care of blindness is unparalleled in pakistan. public in general and ophthalmic community in particular are very saddened by his death. may allah bless his soul and given solace to the bereaved family and friends. prof. wajid ali khan chief consultant al shifa trust eye hospital, rawalpindi microsoft word nasir bhatti 2 23 original article regression of corneal vascularization by laser treatment muhammad nasir bhatti, yawar zaman, azizur rahman, p.s. mahar, muhammad fazal kamal, mazhar-ul-hassan, partab rai pak j ophthalmol 2010, vol. 26 no.1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: muhammad nasir bhatti d-232, block-4 near sultani darbar f.b area karachi. received for publication may’ 2009 … ……………………… purpose: to see the regression of corneal vascularization after ablation with frequency doubled nd: yag (532 nm) laser photocoagulation. material and methods: the study was conducted in the department of ophthalmology, isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, karachi; from june 2006 to may 2007. in this study evaluation of 50 eyes of 50 patients fulfilling the inclusion criteria. prelaser assessmentcomprised of detailed history, general and ocular examination including anterior segment examination with corneal vascularization measurements. after informed consent, all patients underwent frequency doubled nd: yag laser photocoagulation for corneal vascularization. patients were followed after one week and monthly for three months. patency of vessels and complications were noted. final result at the end of three months was recorded (as per proforma). result: total 194 vessels were seen in 50 eyes of 50 patients. out of 194 vessels, 80 (41.2%) vessels were completely occluded and 114 (58.8%) vessels were recanalized (p-value < 0.05). hence, there was 41.2% reduction in corneal vascularization. conclusion: frequency doubled nd: yag (532 nm) laser is an effective tool for the reduction of vascularization in quiescent eyes with vascularised corneal opacities. ornea provides the outermost layer of eyeball along with sclera1. it is transparent and avascular, being devoid of both blood and lymphatic vessels2. preservation of transparency is mandatory for corneal functioning3. corneal vascularization may interfere with corneal transparency, resulting in reduction in visual acuity. it also increases the risk of graft rejection4. due to its grave effects on cornea, various methods have been investigated for controlling or limiting the corneal vascularization. these include medical treatments; such as, topical steroids5, nonsteroidal anti-inflammatory drugs6 and cyclosporin a7. radiation, diathermy8 and conjuncttival resection are some of invasive treatments that have also been investigated. laser photocoagulation of corneal vascularization in humans was first reported in early 1970s9. since then laser photocoagulation of the corneal vessels has been found to be an effective alternate to above methods with lack of serious complications. this study was undertaken to see the regression of corneal vascularization after ablation with frequency doubled nd: yag (532 nm) laser photocoagulation and formulating recommendations for its application in clinical practice as well as future research. material and methods this study was conducted at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi, from june 2006 to may 2007. there were 50 consecutive patients of age 10 to 70 years with quiescent corneal vascularization having feeder vessels of 2 mm or more in length from limbus. patients with active inflammation of the ocular surface, and history of herpes simplex keratitis of less than three months duration in same eye were c 24 excluded. we also excluded the patients with history of diabetes mellitus, hypertension and any other comorbid conditions. detailed medical and ocular history was taken. history regarding previous treatment of corneal vascularization with laser, systemic steroids, and immunosuppression was also noted. slit lamp biomicroscopy was done. number of feeder corneal vessels was recorded by counting the number of red lines of 2 mm or more in length from limbus. informed consent regarding the procedure and its complications was taken. all data were recorded in a predesigned proforma. proparacine 1% eye drop was used to induce topical anesthesia. frequency doubled nd: yag laser (532 nm) was used at laser settings of 50 micron spot size, 0.1 second exposure time and power varying between 250 and 550 mw. after positioning of the patient in the slit lamp and the laser beam focused on the feeder vessel, laser shots were applied until blanching of the vessel occured. each feeder vessel was treated individually. the patients were prescribed topical lubricants four times daily as a placebo for one week following laser treatment. patients were followed after one week and monthly for three months. at each follow up, complete ocular examination was performed with special emphasis on the number of occluded and recanalized vessels. patency of the vessels was assessed by observing the flow of blood through corneal vessels. no intervention was done and no additional treatment was given. data analysis was done by spss 10.0 version. frequencies and percentages were calculated for all qualitative variables, i.e. gender, age groups, causes of corneal vascularization, complications of laser photocoagulation and number of feeder vessels. mean±sd was computed for age. sign test was applied to the feeder blood vessels before and after frequency nd: yag laser at 5% level of significance. results out of 50 corneal vascularization patients, 33 (66%) were males and 17 (34%) were females (m: f = 1.94: 1). age range of patients was 10–70 years, mean ± sd 38.58 ± 17.5 years. most of the patients 16 (32%) belonged to the age group 25–39 years, 11 (22%) patients belonged to the age group 10–24 years, 10 (20%) were between 40–54 years and 13 (26%) were between 55–70 years. out of 50 patients, 25 (50%) patients were presented with infective keratitis, 16 (32%) were presented with trauma and in 3 (6%) patients aphakic bullous keratopathy was the cause of corneal vascularization. other causes accounted for 18% cases including aphakic bullous keratopathy, dry eye, keratoconus and vernal keratoconjunctivitis (table 1). table 1: distribution according to the causes of corneal vascularization n=50 causes no. of patients n (%) infective keratitis 25 (50) trauma 16 (32) aphakic bullous keratopathy 3 (6) dry eye 2 (4) keratoconus 2 (4) vernal keratoconjunctivitis 2 (4) corneal vessels were treated in all 50 patients and total 194 vessels were seen in all patients. out of 194 vessels, 80 (41.2%) vessels were occluded and 114 (58.8%) vessels were recanalized (p-value < 0.05). hence, there was 41.2% reduction in corneal vascularization (fig. 1). 0 50 100 150 200 250 feeder ves sels ocduded ves sels recanalized fig. 1: sequential changes in lasered vessels n = 50 post laser results at the end of three months (pvalue < 0.05) out of 50 cases, laser photocoagulation was performed in right affected eye in 30 (60%) patients and in left affected eye in 20 (40%) patients. 88 (41.2%) 194 n um be r of v es se ls 114 (58.8%) 25 out of 50 patients, post laser complications were seen in 20 (40%) patients; corneal haemorrhage occurred in 12 (24%) patients and iris damage in 8 (16%) patients (fig. 2). 0 2 4 6 8 10 12 corneal iris damage fig. 2: complication of laser photocoagulation n=50 discussion corneal neovascularization is a sight-threatening condition that is associated with corneal graft rejection 10, infections11-13 contact lens wear14, metabolic disorders and nutritional deficiency states. persistent corneal vascularization is undesirable for various reasons. it is a major risk factor for corneal graft survival15. apart from graft rejection, vascularization can cause edema, scarring, and lipid keratopathy leading to decrease in visual acuity. the advantages and disadvantages of corneal vascularization have long been recognized. the need to treat corneal opacification, recurrent immune–mediated inflamma-tion and reduced vision has always been felt, and various methods to occlude corneal vessels have been developed and used over years. in our study, 50 patients were included. the gender distribution (66 % males against 34% females) shows a male preponderance. most of our patients 16 (32%) belonged to age group of 25-39 years. in our study, there was 41.2% reduction in corneal vascularization. it is comparable to sharma and samal16 who reported a reduction of 54.15% in corneal vascularization at three months follow-up. their study included 30 eyes (30 cases). the reason for higher success rate in their study is that sharma a and samal a used topical betamethasone 0.1% drops twice daily for one week after laser therapy. this had an additional vasoablative effect17. sheppard jd jr and epstein rj18 reported 7 patients for corneal neovascularization treated with argon laser (514 nm) using dihematoporphyrin ether (dhe). they reported 52.5% reduction in corneal neovascularization at 6 months follow-up. in comparison to our study sheppard used dhe as photosensitizer in addition to laser therapy. dhe helps in better visualization and photocoagulation of corneal neovascularization. nirankari vs19 has reported a reduction of 45.3% in corneal vascularization at 4 months follow-up. his study included 13 eyes (13 cases). regarding complications, the most obvious complication of laser therapy is iris damage. in our study 8 (16%) patients had iris damage. iris damage in our study is comparable to epstein rj and hendricks rl20 who reported iris damage in 18% cases. marsh rj21 reported iris damage as minor complication. in our study iris damage was associated with slight peaking of pupil in the direction of damaged iris patch. iris excavation and peaking of pupil were almost imperceptible after six to eight weeks. corneal hemorrhage was seen in 12 (24%) of our patients. sharma16 reported corneal haemorrhage in his 26% patients. marsh rj21 also documented corneal haemorrhage. corneal haemorrhage was resolved in 2 weeks in all our patients. this resolution of haemorrhage occurred without any consequence and no treatment was required. corneal thinning, descemetocele, corneal perforation and crystalline deposits on iris are other complications documented in literature22. in our patients no such complications were observed following laser treatment. an important and encouraging finding which we observed during our study was improvement in visual acuity. although, visual acuity notation was not included in our study, but it was performed as a part of routine follow-up. two of our patients with best corrected visual acuity of less than 4/60 improved to the best corrected visual acuity of 6/24 at the end of three months. in these cases, secondary lipid keratopathy was the cause of decreased vision. after ablation of corneal vessels, lipid exudation partially resolved resulting in increase in corneal transparency and visual acuity improvement subsequently. there are few reports of visual acuity improvement documented in literature23. three of our lasered patients underwent penetrating keratoplasty. all of them had clear grafts and no recurrence of corneal vascularization was observed till now. one complication which occurred in all three patients was the epithelial defect. it is usually present in most cases of penetrating 12 (24%) 8 (16%) n um be r of p at ie nt s (% ) complications 26 keratoplasty that have been done at our hospital and it takes about a week to heal. but in our patients, it took 2-3 weeks to heal. this may be related to extensive laser which probably damaged limbal stem cells at the site of corneal blood vessel ablation. in the light of current research, following recommendations about laser photocoagulation of corneal blood vessels will help in future research as well as in clinical practice. laser treatment of corneal vascularization is not indicated in presence of active or recurrent inflammation. therefore, the corneal lesion which is stimulating the vascularization, should be suppressed first with appropriate treatment. anterior segment angiography should be done before or at the time of laser as it will increase the efficiency of laser photocoagulation by delineating the efferent vessels (arteries). the power of laser should be adequate enough to blanch the respective corneal vessel as the use of excess laser power causes increased post laser inflammation providing stimulus for revascularization. conclusion laser photocoagulation is an effective treatment for corneal vascularization. it is a safe outpatient procedure and well tolerated by the patient. lack of serious complications makes it an effective alternate to other methods for reducing corneal vascularization in quiescent eyes with vascularised corneal opacities. author’s affiliation dr. muhammad nasir bhatti isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi dr. yawar zaman isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi dr azizur rahman fcps isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi prof: p.s. mahar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi dr muhammad fazal kamal isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi dr. mazhar-ul-hassan isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi dr. partab rai isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi reference 1. snell rs. the eyeball. in: clinical anatomy of the eye. 2nd ed. london: blackwell, 1998: 13-213. 2. regina m, zimmerman r, malik g, et al. lymphangiogenesis concurrent with haemangiogenesis in the human cornea. clin experiment ophthalmol. 2007; 35: 541-4. 3. johnson ac, li x, pearlman e. myd88 functions as a negative regulator of tlr3/trif-induced corneal inflammation by inhibiting activation of c-jun n-terminal kinase. j biol chem. 2008; 283: 3988-96. 4. williams ka, lowe m, bartlett c, et al. all contributors. risk factors for human corneal graft failure within the australian corneal graft registry. transplantation. 2008; 86: 1720-4. 5. aydin e, kivilcim m, peyman ga, et al. inhibition of experimental angiogenesis of cornea by various doses of doxycycline and combination of triamcinolone acetonide with low-molecular-weight heparin and doxycycline. cornea. 2008; 27: 446-53. 6. pakneshan p, birsner ae, adini i, et al. differential suppression of vascular permeability and corneal angiogenesis by nonsteroidal anti-inflammatory drugs. invest ophthalmol vis sci. 2008; 49: 3909-13. 7. sonmez b, beden u, erkan d. regression of severe corneal stromal neovascularization with topical cyclosporine 0.05% after penetrating keratoplasty for fungal corneal ulcer. int ophthalmol. 2009; 29: 123-5. 8. pillai ct, dua hs, hossain p. fine needle diathermy occlusion of corneal vessels. invest ophthalmol vis sci. 2000; 41: 2148-53. 9. cherry pm, faulkner jd, shaver rp, et al. argon laser treatment of corneal neovascularization. ann ophthalmol. 1973; 5: 911-20. 10. chong em, dana mr. graft failure iv. immunologic mechanisms of corneal transplant rejection. int ophthalmol. 2008; 28: 209-22. 11. siatiri h, moghimi s, malihi m, et al. use of sealant (hfg) in corneal perforations. cornea. 2008; 27: 988-91. 12. robert py, liekfeld a, metzner s, et al. specific antibody production in herpes keratitis: intraocular inflammation and corneal neovascularisation as predicting factors. graefes arch clin exp ophthalmol. 2006; 244: 210-5. 13. saita n, fujiwara n, yano i, et al. trehalose 6,6'-dimycolate (cord factor) of mycobacterium tuberculosis induces corneal angiogenesis in rats. infect immun. 2000; 68: 5991-7. 14. bergenske p, long b, dillehay s, et al. long-term clinical results: 3 years of up to 30-night continuous wear of lotrafilcon a silicone hydrogel and daily wear of low-dk/t hydrogel lenses. eye contact lens. 2007; 33: 74-80. 15. thompson rw jr, price mo, bowers pj, et al. long term graft survival after penetrating keratoplasty. ophthalmology. 2003; 110: 1396-402. 27 16. sharma a, samal a, narang s, et al. frequency doubled nd:yag (532 nm) laser photocoagulation in corneal vascularisation: efficacy and time sequenced changes. indian j ophthalmol. 2001; 49: 235-40. 17. banciu m, metselaar jm, schiffelers rm, et al. antitumor activity of liposomal prednisolone phosphate depends on the presence of functional tumor-associated macrophages in tumor tissue. neoplasia. 2008; 10: 108-17. 18. sheppard jd jr, epstein rj, lattanzio fa jr, et al. argon laser photodynamic therapy of human corneal neovascularization after intravenous administration of dihematoporphyrin ether. am j ophthalmol. 2006; 141: 524-9. 19. nirankari vs. laser photocoagulation for corneal stromal vascularization. trans am ophthalmol soc. 1992; 90: 595-669. 20. epstein rj, hendricks rl, harris dm. photodynamic therapy for corneal neovascularization. cornea. 1991; 10: 424-32. 21. marsh rj. argon laser treatment of lipid keratopathy. br j ophthalmol. 1988; 72: 900-4. 22. marsh rj, marshall j. treatment of lipid keratopathy with the argon laser. br j ophthalmol. 1982; 66: 127-35. 23. baer jc, foster cs. corneal laser photocoagulation for treatment of neovascularization. efficacy of 577 nm yellow dye laser. ophthalmology. 1992; 99: 173-9. microsoft word rao rashed qamar 1 175 original article outcome of delayed lacrimal probing in congenital obstruction of nasolacrimal duct rao muhammad rashad qamar, ejaz latif, muhammad younis tahir, muhammad moin pak j ophthalmol 2011, vol. 27 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . .. . . . . . . . . . . .. . . see end of article for authors affiliations …..……………………….. correspondence to: rao m. rashad qamar 29-b, medical colony, bahawalpur submission of paper october’ 2010 acceptance for publication august, 2011 …..……………………….. purpose: this study was conducted to evaluate the success of probing in congenital nasolacrimal duct obstruction in children age 13 months and older and to establish factors predictive of the outcome material and methods: it was a single center, prospective, interventional case series. the study was carried out from april 2007 to october 2009. the study was conducted at the department of ophthalmology, bahawal victoria hospital, bahawalpur. we treated 110 eyes of 100 patients selected by universal sampling technique. diagnosed cases of nasolacrimal duct blockade of any age and either sex were included. no patient with epiphora due to congenital nasolacrimal duct blockade was excluded. after securing complete aseptic measures each punctum was dilated one after the other, using bowman’s probes under general anesthesia. data was collected on special proforma and analyzed with the help of spss. results: the study population comprised of 110 blocked nasolacrimal ducts of one hundred (100) patients. male to female ratio was 2:3. all the bilateral cases were females. age ranged between 13-32 months (mean = 17 months). about 2/3rd patients were between 13 and 24 months. all patients had epiphora since birth. one attempt at probing resulted in resolution in 84.54 % (93 of 110) eyes. 17 eyes (15.45%) needed a repeat procedure. the overall success rate was 92.72% (102 of 110) and 08 cases resulted in failures. 04 were bilateral (all were females) and 04 were unilateral (02 males and 2 females). there was no significant difference in the cure rate with increasing age (p = 0.60). complications were noted in none of the patients. conclusions: results indicate that probing is a viable primary surgical option for congenital nasolacrimal duct obstruction in older age group. ongenital nasolacrimal duct obstruction (cnldo) is one of the most common congenital abnormalities which is reported to occur in 1.75 to 20% of infants1. obstruction of the nasolacrimal duct (nldo) results in epiphora. epiphora remains one of the most bothersome complications of lacrimal system obstruction and has social implications besides physical and psychological. epiphora in the first year of life has been reported to occur in as many as 20% of children2. dacryostenosis, or atresia, of the nasolacrimal duct is believed to result from failure of canalization of the column of epithelial cells that form the nasolacrimal duct. adhesions between the ductile epithelium and nasal mucosa may also be responsible for this condition. areas of obstruction can occur anywhere along the duct where valves are formed. the most common site of obstruction, however, is at the mucosal entrance into the nose (valve of hasner), under the inferior turbinate3. c 176 majority of the cases of cnldo improve spontaneously4 by delayed canalization and do not require surgical intervention. difference of opinion exists between surgeons regarding the optimal time of intervention in persistent cases. some authors advocate earlier nasolacrimal duct probing which may be performed under local anesthesia for reduced morbidity5,6. the optimal timing of probing remains controversial7. despite the natural history of the condition, in which, more than 90% of children with cnldo will resolve by 1 year of age, some ophthalmologists continue to advocate early surgical probing8-10. these early probers suggest that prolonged epiphora is annoying to both the parents and the child. they also voice concern that a delay in probing may increase the risk of infections and associated scarring of the system, and may decrease the success rate of initial probing8-10. fooks warned that abscess formation in the lacrimal sac may be a consequence of postponing surgical treatment half a century ago11. severe infections such as dacryocystitis are uncommon in children with cnldo and are usually managed successfully with systemic antibiotics. however, probing may be necessary for definitive management. we conducted this study to evaluate the success of probing in cnldo in children age 13 months and older and to establish factors predictive of the outcome. material and methods study design: it was a single center, prospective, interventional case series. the study was carried out from april 2007 to october 2009. setting: the study was conducted at the department of ophthalmology, a tertiary eye care and teaching facility, at bahawal victoria hospital, bahawalpur. sample: we treated 110 eyes of 100 patients selected by universal sampling technique. diagnosed cases of cnldo of any age and either sex were included. no patient with epiphora due to cnldo was excluded. but the patients, whose parents did not give consent, could not be intervened. technique of surgical intervention: parents were explained about the advantages, disadvantages, risks and alternatives of the intervention being offered to their children. fully informed/written consent was taken. fitness for the general anesthesia was taken before hand. after securing complete aseptic measures, each punctum was dilated one after the other with nettle ship punctum dilator and probing done using bowman’s probes as shown in figures 1-5. to minimize the chances of surgically induced infections, metal to metal touch technique was carried out without performing syringing. probes were twisted and kept for 2 minutes in the nld’s before removing. as post-operative care, topical tobramycin/ dexamethasone combination drops were prescribed qid for 1 week and sac massage was advised to continue for 3 weeks. definitions success: success was predefined as complete resolution of symptoms and signs (tearing, crusting, discharge, regurgitation on pressure over the lacrimal sac, negative dye disappearance test (ddt) of cnldo within 3 weeks of the procedure and continued remission at 6 months. failure: two attempts at probing were necessary before the procedure was declared a failure. follow-ups: all patients were followed-up at 1 day, 1 week, 1 month and six months post-operatively. repeat probing: probing was repeated after 2-3 weeks, if the initial attempt remained unsuccessful. data collection and analysis all the data was collected with the help of a specially designed proforma. the demographic features were inquired and clinical findings were recorded in the respective columns. the operative notes and post operative care was mentioned on the same proforma. follow-up data was collected on annexure-i. results the study population comprised of 110 (blocked nasolacrimal ducts) of 100 patients. male to female ratio was 2:3. all the bilateral cases were females. age ranged between 13-32 months (mean = 17 months). about 2/3rd patients 65.0% patients were between 13 and 24 months and 35% were between 25-32 months. all patients had epiphora since birth. one attempt at probing resulted in resolution in 84.54% (93 of 110) eyes. seventeen eyes (15.46%) needed a repeat procedure. the overall success rate was 92.72% (102 of 110). out of 08 failures, 04 were bilateral (02 females) and the rest were unilateral (2 males and 2 females). five (62.50%) failures were below 24 months. there was no significant difference in the cure rate with increasing age (p = 0.60). false passages, bleeding and piercing through palate were noted in none of the patients included in this study. 177 fig. i: fig. 2: fig. 3: fig. 4: fig. 5: 92.72% 84.54% 8.18% 0 10 20 30 40 50 60 70 80 90 100 success total initial repeat fig. 6: success rates of probing 178 discussion in a recent retrospective interventional case series casady and colleagues12 reported 76.9% success rate of lacrimal probing. in another retrospective study of 427 patients with cnldo involving 572 eyes, katowitz and welsh13 reported success in 97% of cases when probing was performed prior to 13 months of age. after 13 months, however, the success rate was found to decrease with age, 76.4% between 13 and 18 months and 33.3% for patients probed after 24 months. in contrast, when el-mansoury and associates13 reviewed the results of 138 initial probing performed between the ages of 13 months and 7 years of age, they found that more than 90% were curative regardless of age. robb reported similar data, reflecting a uniform cure rate of nearly 90% with the first – time probing in children ranging in age from 1 to 9 years old14. recently, kushner has reported that simple probing has an excellent success rate in children up to 4 years of age, if an uncomplicated obstruction is found at the valve of hasner15. there are many recent studies16-21 advocating probing as viable primary mode of surgical intervention in cases of cnldo. in our study, the initial success rate was 84.54% which escalated to 92.72% with repeat probing. these results are consistent with the findings by most of the other investigators11-21. we studied the age group ranging from 13 months to 32 months which is similar to the age distributions of most of the study populations took part in the studies mentioned above. the male to female ratio of our study group was also consistent with other studies. in our study, none of the patients experienced complications of probing like bleeding, false passage and piercing through palate. it is also in accordance with most of other studies12, 14-17, 19-21. there is an emerging trend of endoscopic assisted lacrimal probing where the results are almost the same as unassisted probing22. its being advocated that if probing is endoscopically assisted, where better visualization is there, management of probe failures may be possible23. moreover, today the availability of sophisticated investigations like b-scan echography of the lacrimal sac has made possible to measure the functional prognosis after probing treatment24. in conclusion, initial probing seems to be effective in cnldo in older patients and should not be withheld in children who are referred late. increasing age does not affect the success rate of probing. conclusions results indicate that probing is a viable primary surgical option for cnldo in older age group and hence should not be withheld in children who are referred late. increasing age does not affect the success rate of probing. author’s affiliation dr. rao muhammad rashad qamar associate professor of ophthalmology qamc/bvh, bahawalpur dr. ejaz latif professor of ophthalmology qamc/bvh, bahawalpur dr. muhammad younis tahir senior registrar of ophthalmology qamc/bvh, bahawalpur dr. muhammad moin professor of ophthalmology qamc/bvh, bahawalpur reference 1. abrishami m, bagheri a, salour sh, et al. late probing for congenital nasolacrimal duct obstruction. j ophthalmic vis res. 2009; 4: 102-4. 2. macewan cj. congenital nasolacrimal duct obstruction. compr ophthalmol update. 2006; 7: 79-87. 3. cassady jv. developmental anatomy of the nasolacrimal duct. arch ophthalmol. 1952; 47: 141. 4. kakizaki h, takahashi y, kinoshita s, et al. the rate of symptomatic improvement in congenital nasolacrimal duct obstruction in japanese infants treated with conservative management during 1st year of life. clin ophthalmol. 2008; 2: 291-4. 5. baggio e, ruban jm, sandon k. analysis of the efficacy of early probing in the treatment of symptomatic congenital lacrimal duct obstruction in infants. j fr ophthalmol. 2000; 23: 655-62. 6. paul to, shepherd r. congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention. j pediatric ophthalmol strabismus. 1994; 31: 362-7. 7. takahashi y, kakizaki h, chan wo, et al. management of congenital nasolacrimal duct obstruction. acta ophthalmologica. 2009. 8. baker jd. treatment of congenital nasolacrimal duct obstruction. j pediat ophthalmol strabismus. 1985; 22: 34. 9. koke mp. treatment of occluded nasolacrimal ducts in infants. arch ophthalmol. 1950; 43: 750. 10. kushner b. congenital lacrimal system obstruction. arch ophthalmol. 1982; 100: 597. 11. fooks oo. dacryocystitis in infancy. br j ophthalmol. 1962; 46: 422. 12. casady dr, meyer dr, simon jw, et al. stepwise treatment paradigm for congenital nasolacrimal duct obstruction. ophthalmic plastic and reconstructive surgery. 2006; 22: 243-7. 179 13. katowitz ja, welsh mg. timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. ophthalmology. 1987; 94: 698. 14. el-mansoury j, calhoun jh, nelson lb, et al. results of late probing for congenital nasolacrimal duct obstruction. ophthalmology. 1986; 93: 10524. 15. robb rm. success rates of nasolacrimal duct probing at time intervals after 1 year of age. ophthalmology. 1998; 105: 1307-9. 16. kushner bj. the management of nasolacrimal duct obstruction in children between eighteen months and 4 years old. j aapos. 1998; 2: 57. 17. pediatric eye disease investigator group. repeat probing for treatment of persistent nasolacrimal duct obstruction. jaapos. 2009; 13: 306-7. 18. suh sc, ha ms. clinical characteristics and treatment of congenital nasolacrimal duct obstruction. j korean ophthalmol soc. 2009; 50: 816-20. 19. warmar re, bullock jd. primary treatment of nasolacrimal duct obstruction with probing in children younger than 4 years. evidence-based ophthalmology. 2008; 9: 254-5. 20. nelson b. late probing success for congenital nasolacrimal duct obstruction. j pediatr ophthalmol strabismus. 2008;45:138. 21. maheshwari r. success rate and cause of failure for late probing for congenital nasolacrimal duct obstruction. j pediatr ophthalmol strabismus. 2008; 45: 168-71. 22. zilelioglu hosal bm. the results of late probing in congenital nasolacrimal duct obstruction. orbit. 2007; 26: 1-3. 23. kauri as, tsakanikos m, lenardos e, et al. results of endoscopic assisted probing for congenital nasolacrimal duct obstruction in older children. ijpo. 2008; 72: 891-6. 24. reh dd, metson rb, sindwani r. management of nasolacrimal duct obstruction. in: stucker fj, de souza c, kenyon gs, et al. rhinology and facial plastic surgery. springer berlin hiedelberg, boston. 2009: 357-366. microsoft word zahid kamal 128 original article reconstruction of empty sockets with sahaf’s orbital implant zahid kamal, m rizwan ullah, girdhari lal, abdula hye, imran akram sahaf pak j ophthalmol 2010, vol. 26 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zahid kamal siddiqui associate professor eye unit ii lahore general hospital lahore received for publication october 2009 …..……………………….. purpose: to measure the out come of sahaf’s orbital implant in empty sockets with little or no recognizable extraocular muscles. material and methods: a quasi interventional study was done in the department of ophthalmology of lahore general hospital lahore from august 2006 to april 2009. thirty eyes of 30 patients were included in this study. sahaf orbital implant is a polymethyl methacrylate orbital implant. it has pear shaped base, truncated edge. it is inert, cost effective, has no cutting edges and easily available in pakistan. three sizes are available to restore volume and enhance support of the prosthesis after implantation. after explaining the procedure a special written consent for surgery and anesthesia was taken by patient. the surgical technique included opening the conjuvtiva, tenon and fibrous tissue with a horizontal incision made with blade no 15. deepening of the incision to the orbital apex with a blunt tipped pair of scissors. widening of the wound to the orbital wall by opening the scissors. result: sahaf orbital implant inserted deep to the apex of the orbit with its flat base resting on the orbital floor. tenon and conjunctiva sutured over implant in two layers separately. wrapping of donar sclera or autogenous fascia lata used in most cases. the patients followed at 4, 8, 12 weeks and 6 months after the operation. the patients received a prosthetic eye after 6 weeks by the ocularist. conclusion: all patients had excellent cosmetic results, without any serious side effects. sahaf orbital implant has a special design to adjust to different sized orbits. it gives excellent fill to the orbit by using various sizes. it is economical and cost effective. it is readily available to the ophthalmologists in pakistan. it also gives better adjustment initially to conformer and later to the prosthesis. the technique of implantation is very easy. any general ophthalmologist can do it very easily. mpty socket is the term given to anophthalmos where no intra-orbital implant has been placed. the three most common causes for acquired (post-surgical) anophthalmos are intraocular malignancy, trauma and painful blind eye1. evisceration, enucleation and exenteration are indeed mutilating procedures; however, they are still resorted to in order to save the other eye, to relieve the patient from agonizing pain or to save the life of the patient2. orbital implants commonly being used are; allen type implants, silicone implants and porous implants3. spherical plastic, non-porous and non-pegged porous enucleation implants provide similar motility to implant and prosthetic eye4. the reasons for implant choice are cost, outcome and expertise of the surgeon5. primary orbital implantation with adequate sized allen type acrylic implant, after tension-free closure of tenon and conjunctiva gives fairly acceptable cosmetic results6. recently good results have been reported with use of sahaf orbital implant i for primary insertion at the time of enucleation7. e 129 fig. 1: implant view from above fig. 2: implant view from bottom fig. 3: implant view from side fig. 4: socket opened ???? fig. 5: implant inserted (wound closure in next step) fig. 6: diagrammatic representation from side fig. 7: diagrammatic representation from top fig. 8: immediate postoperative view showing orbital fill 130 in the past it was a practice in pakistan not to implant the orbit after enucleation of the eye for intraocular malignancy or eviscerating the eye for edophthalmitis8. the result was, quite a few empty eye socket patients near the adult age seeking cosmetic improvement. to provide volume to a socket where a traditional muscular supported implant insertion was not possible, prof. imran a sahaf (postgraduate medical institute, lahore) developed this pmma implant with an ingenious design. sahaf orbital implant ii is a pear shaped implant which rests on the orbital floor and projects up to fill the orbit. it has also been used in the cases of exenterated socket, along with temporalis muscle rotation and with 3600 fornix reconstruction using mucous membrane graft. aims and objectives the objective of study was to record the outcome of sahaf orbital implant ii, in terms of volume replacement, cosmesis and complications in empty sockets with little or no recognizable extraocular muscles. methodology study type: prospective, quasi interventional duration: three year (august 2006 –april 2009). setting: pgmi/lahore general hospital lahore, 1200 bedded teaching hospital in the densely populated area of amr sadhu chungi, lahore. population this hospital receives patients from all over lahore and the neighboring cities in the central punjab area. however referral cases come from all other provinces. inclusion criteria: all the patients who needed to restore volume of empty anophthalmic sockets or phthisical eyes were included in the study. the patients who needed exchange of implant for various reasons like exposure/excursion, infection or low volume were included in this study. exclusion criteria: surgical technique: all the procedures were done by one of the authors (ias or zks). the steps of surgery were as follows: • opening the conjunctiva, tenor’s fascia and fibrous tissue with a horizontal incision made with blade no 15. • deepening of the incision to the orbital apex with a blunt tipped pair of scissors. widening of the wound to the orbital wall by opening the scissors. • sahaf orbital implant inserted deep to the apex of the orbit with its flat base resting on the orbital floor. • tenon and conjunctiva sutured over implant in two layers separately. • wrapping of donor sclera or autogenous fascia lata used in most cases. • a temporary tarsorrhaphy was done for 2 weeks. a pressure dressing was kept on the socket for 1 week. the steps of surgery are shown in (fig 4-7). data collection and processing: hospital patient entry registers and prof i.a. sahaf’s data base were used to collect the data. all the information was then entered into the computer using the spss programme. entries were double checked and data cleaning was carried out by the investigators. analysis method: statistical analysis was done using spss. the data was analyzed according to age, gender, diagnosis, and management. the cosmetic results were defined as good if the patient was able to wear an appropriate sized prosthesis giving palpebral aperture height within 1-2 mm of the other eye. the results were fair if the difference was 2-4mm but still acceptable to patient. poor result was defined as inability to wear the prosthesis or difference >4mm. follow up: the patients were followed at 4, 8 and 12 weeks after the operation. the patients received a prosthetic eye after 6 weeks by the ocularist. the patient had a final follow up at 3 months after the procedure. results total number of the patients was 30 (30 eyes). twenty five patients (83%) were male and 5 (17%) female. the age range was 6-60 years. table 1 shows the age range of the patients. post-operative results are shown in (fig. 8,9). the good cosmetic results (fig 11,12) were noted in 20 cases (67%). five cases (16.5%) had fair results, while 5 (16.5%) needed further procedures to improve cosmesis. two initial cases (6%) had necrosis of the conjunctiva leading to exposure of implant, which needed reinforcement by autogenous fascia lata. later all those cases who had thin tenon’s fascia had a reinforcement by donor sclera or autologus fscia lata. 131 fig. 9: post-operative appearance after six weeks fig. 10: pre-operative appearance of case 1 fig. 11: post-operative appearance of case 1 discussion reconstruction of the empty socket is a challenging job. unfortunately due to lack of awareness both among patients and ophthalmologists the socket is left empty for many years and sometimes decades8. the patients when reached to the young adult age of marriage or job search look around to improve appearance. this was obvious from the fact that 80% patients belonged to the age group 16-35 years. according to our literature search no implant which fulfills specific requirements of this group of patients and can be available at an affordable cost has been designed. fig. 11: pre-operative appearance of case 2 fig. 12: post-operative appearance of case 1 table 1: age range of the patients age group no. of cases=30 n (%) 6-15 2 (7) 16-25 20 (76) 26-35 4 (13) 36-45 3 (10) 46-55 1 (3) 56-65 none 132 there have been anecdotal reports of use of acrylic sphere with or without wrapping. authors have seen follow up of few of these cases, where the implant had migrated into the lower lid thereby obliterating the inferior fornix after a few months. sahaf orbital implant ii (pear shaped) having flat lower surface resting on the floor of the orbit does very little migration in the orbit as it was obvious from only 2 cases of exposure and none of extrusion. moreover, because of the unique design its front surface presents in centre of the palpeberal aperture, which is ideal for the prosthetic eye. as the implant is used in the patient with little or no muscle there is no movement in the prosthetic eye. however, it is obvious that in these sockets being without an implant for many years the muscles have scarred and would be very difficult to identify. two third of our patients had good results. out of 1/3rd half had satisfactory results. out of the five patients who needed further surgery; two needed fornix deepening procedures, two needed mucous membrane graft to cover exposure and one needed exchange of implant with a smaller implant. hence all of these patients should be warned about possibility of further procedures after implant insertion. a series9 of 22 cases has been published reporting good results with reconstruction of the anophthalmic contracted sockets with radial forearm flaps. some of their patients received spherical or conical hydroxiapatite implants. this procedure is more complicated, extensive and expensive, whereas our procedure is more simple and cost effective. we also had good cosmetic results in most of our cases. however, we excluded complicated cases needing skin and/or muscle flaps from our series. further studies and long term follow up is needed to establish role of sahaf orbital implant ii in socket reconstruction. author’s affiliation dr zahid kamal associate professor lahore general hospital lahore dr m rizwan ullah assistant professor lahore genral hospital lahore dr girdhari lal post graduate trainee lahore genral hospital lahore dr abdul hye associate professor lahore genral hospital lahore prof. imran akram sahaf head of eye dept lahore general hospital lahore references 1. moshfeghi dm, moshfeghi aa, finger pt. enucleation. surv ophthalmol. 2000; 44: 277-301. 2. babr tf, masud z, iqbal a. should ophthalmologist ever opt for mutilating operations like evisceration, enucleation and exenteration? pak j ophthalmol. 2003; 19: 113-7. 3. ducasse a, segal a, gotzamanis a, et al. tolerance of orbital implants. retrospective study on 14 years. j fr ophtalmol. 2001; 24: 277-81. 4. custer pl, kennedy rh, woog jj, et al. meyer orbital implants in enucleation surgery: a report by the american academy of ophthalmology. ophthalmology. 2003; 110: 205461. 5. su gw, yen mt. current trends in managing the anophthalmic socket after primary enucleation and evisceration. ophthal plast reconstr surg. 2004; 20: 274-80. 6. saeed m, monis m, cheema am, et al. surgical treatment of anophthalmic socket -an experience with 42 intra orbital implants. j coll physicians surg pak. 2000; 10: 175-8. 7. siddiqui zk, lal g and hye a. outcome of sahaf enucleation implant in 60 patients. pak j ophthalmol. 2008; 24: 34-6. 8. sahaf ia. current status of orbital implants in pakistan (editorial). pak j ophthalmol. 2008; 24: 1. 9. li d, jie y, lie j, et al. reconstruction of anophthalmic orbits and contracted eye socket with microvascular radial forearm flaps. ophthal plast reconstr surg. 2008; 24: 94-7. microsoft word kamran khalid 55 original article clinical risk factors for proliferative vitreoretinopathy-ii muhammad kamran khalid, muhammad tariq khan, hidayatullah mahsud, m saleem khan gandapur, muhammad daud khan pak j ophthalmol 2008, vol. 24 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad kamran khalid h #1592/c, hayatullah streed dera ismail khan received for publication september ’ 2006 …..……………………….. purpose: to evaluate clinical variables as risk factors for proliferative vitreoretinopathy (pvr). material and methods: this cross sectional comparative study was conducted at khyber institute of ophthalmic medical sciences, hayatabad medical complex, peshawar from 1st august 2002 to 31st dec. 2002. fifty patients of rhegmatogenous retinal detachment (rrd) were included randomly in this study. they were evaluated for the presence of both risk factors and pvr grading. chisquare test was used to measure the difference in exposure rates and odds ration was calculated to estimate the strength of association between risk factors and outcome. results: large retinal breaks (p<0.05) was found to be statistically significant risk factor for pvr grade c or more. the exposure rates in myopia >5d, signs of anterior uveitis, vitreous hemorrhage and number of retinal breaks were statistically not significant (p>0.05). conclusion: large retinal breaks are associated with high risk of high grade pvr, so this factor should be considered as important prognostic factor in the management of rrd. hegmatogenous retinal detachment (rrd) is an ophthalmic emergency that may cause severe visual loss if not detected early and treated in time. one of the most challenging hurdles on achieving good outcome is development of proliferative vitreoretinopathy (pvr), which is an important cause of failure of retinal reattachment surgery. the exact pathogenesis of pvr is still under active research. workers have compared it to normal wound healing or tissue repair process but at an abnormal site1. damage to the blood ocular barrier is considered critical to the formation of pvr because serum derived chemoattractants and mitogens have been found in these membranes. retinal pigment epithelium (rpe) cells are essential in the formation of pvr because they are always found in preretinal membranes of rrd2,3. this may explain the greater frequency of pvr in rrd of long duration, giant retinal tears and multiple retinal tears. rpe cells undergo metaplastic changes into macrophages or fibrolast like cells4. the tobacco dust seen in vitreous is formed of pigment clumps and in part represents migrating rpe cells. retinal glial cells are also found in pvr membranes. they are thought to be derived from muller cells or astrocytes and form more rigid membranes than rpe cells5,6. r 56 fibroblasts or fibrocytes are also found in pvr membranes. in case of penetrating injuries they are thought to arise from different sources like optic nerve head, perivascular fibrocytes, glia or hyalocytes. other inflammatory cells like monocytes and lymphocytes are also found7-9. research workers are also trying to determine risk factors for both preoperative and postoperative pvr1011. these include clinical, surgical and biochemical risk factors. it is interesting to note that many of these variables are known risk factors for retinal detachment itself. this study was conducted to evaluate various clinical variables including high myopia, signs of anterior uveitis, vitreous hemorrhage, number of retinal breaks and size of retinal breaks as risk factors of preoperative pvr. material and methods a total of 50 patients of rrd, admitted at khyber institute of ophthalmic medical science (kioms), hmc, peshawar were included in the study. a comprehensive performa was designed and completed for every patient. initially a detailed history about the nature and duration of visual complaints, previous ocular surgery, trauma and family history of rd was taken. it was followed by a thorough ocular examination of the eye including checking of pupillary reactions, refracttive errors and anterior segment examination with the help of a slit lamp. phakic status of the eye and signs of anterior uveitis were also evaluated. it was followed by a detailed posterior segment examination with fully dilated pupils with the help of an indirect ophthalmoscope, slit lamp examination using 78d or 90d lens and goldman 3-mirror contact lens. it was a cross sectional comparative study. after describing the data obtained, cross tabulations were made between dependent variable (pvr) and independent variables (risk factor under study). chisquare test was applied for statistical significance. odds ration was calculated to estimate the strength of association between risk factor and outcome (pvr). results a total of 50 cases of rrd were included in our study. 34 (68%) were male and 16 (32%) were female patients. mean age was 47.5 years and age range was 12-82 years. patients presented as early as with in 2 week of onset of symptoms to as late as > 1 year of onset of symptoms. mean duration between onset of symptoms and presentation was 10.8 weeks (min=2 week and max=85 weeks). 39 (78%) patients were emetropic, 3(6%) having myopia <5d and 8 (16%) having myopia >5d. 41 (82%) had no signs of anterior uveitis and 9 (18%) had signs of anterior uveitis. 46 (92%) had no vitreous hemorrhage and 4 (8%) had vitreous hemorrhage. frequency distributions of number and size of retinal breaks and pvr are shown in tables 1,3 respectively. table 1: retinal breaks (frequency distribution) no of retinal breaks patients n (%) 0 1 (2) 1 34 (68) 2 9 (18) 3 4 (8) 4 2 (4) total 50 (100) table 2: size of retinal breaks (frequency distribution) size of retinal breaks patients n (%) dialysis 9 (18) gaint tears 1 (2) large tears 9 (18) small tears 31 (62) total 50 (100) table 3: pvr (frequency distribution) grade frequency n (%) a 3 (6) b 28 (56) c 18 (36) d 1 (2) total 50 (100) 57 for the sake of understanding of statistical analysis, the grades of pvr were divided into two groups i.e. (a+b) and (c+d). it is also logically acceptable when the management of pvr is taken into consideration. similarly, patients having either no refractive error or myopia <5d were taken as “no” myopia and those having myopia >5d as myopia “yes”. patients were divided into two groups on the basis of number of retinal breaks found i.e. with 1 and more than 1 breaks. they were also divided into two groups depending upon the size of retinal breaks i.e. small and large, giant tears and dialysis were included in the later group. relationship between pvr and the risk factors under study are shown in cross tabulation tables 4-8. tests for statistical significance i.e. chi-square value and degree of freedom (df), p-value and odds ration (or) are shown along with each table. it is evident from the preceding tables that there is a statistically significant (p<0.05) difference between the grades of pvr of those with small retinal breaks and those with large retinal breaks. the cases were four times (or=3.9) more exposed to the risk factor (large retinal breaks) than the controls. in case of rest of the risk factors i.e. high myopia, signs of anterior uveitis, vitreous hemorrhage and number of retinal breaks, the exposure rates were not statistically significant (p>0.05) between cases and controls. discussion our study has shown that large retinal break is a significant risk factor for pvr grade c or more. this is in accordance with the results of other international studies12-15. the rest of the variables studied are apparently not significant risk factors for grade c & d but it is in contrast to the findings of certain other studies e.g. uveitis, vitreous hemorrhage and multiple retinal breaks have been reported significant by la heij et al12 and girard et al13 as risk factors of high grade pvr. these differences may be because of small sample size of our study. if studied carefully it can be seen that all these significant risk factors are associated with dispersion of rpe cells in the vitreous and breakdown of blood retinal barrier which are the main factors involved in the pathogenesis of pvr. myopia was not significant risk factors for pvr grade c or more which is also supported to some externt by cardillo et al16. there is a possibility that these patients are often concerned about their vision or might have lost vision in one eye due to rd, so they present very early. it should be recalled that these variables are known risk factors for retinal breaks leading to rrd. we would like to recommend that special attention should be given to the management of rrd having high risk features to prevent postoperative pvr and ultimate surgical failure. therefore, the trend towards primary vitrectomy with internal tamponade even for cases of pvr grade b, in some of the cases may be justified. table 4: myopia: pvr cross tabulation myopia pvr total n(%) a+b n(%) c+d n(%) no 25 (50) 17 (34) 42 (84) yes 6 (12) 2 (4) 8 (16) total 31 (62) 19 (38) 50 (100) chi-square value=0.68, df= 1, p>0.05 table 5: anterior uveitis: pvr cross tabulation anterior uveitis pvr total n(%) a+b n(%) c+d n(%) no 25 (50) 16 (32) 41 (82) yes 6 (12) 3 (6) 9 (18) total 31 (62) 19 (38) 50 (100) chi-square value=0.01, df= 1, p>0.05 table 6: vitreous hemorrhage: pvr cross tabulation vitreous hemorrhage pvr total n(%) a+b n(%) c+d n(%) no 30 (60) 16 (32) 46 (92) yes 1 (2) 3 (6) 4 (8) total 31 (62) 19 (38) 50 (100) chi-square value=2.526, df= 1, p>0.05 58 table 7: no. of retinal breaks: pvr cross tabulation no of breaks pvr total n(%) a+b n(%) c+d n(%) 1 22 (44) 13 (26) 35 (70) >1 9 (18) 6 (12) 15 (30) total 31 (62) 19 (38) 50 (100) chi-square value=0.036, df= 1, p>0.05 identification of such risk factors and their prognostic values will assist vitreoretinal surgeons in better planning and better predicting the results of their surgical techniques. it will also help patients better understanding the value of going through the agony of surgical interventions. carefully designed case control studies or cohort studies will augment the role of various risk factors in the development of pvr. table 8: size of retinal breaks: pvr cross tabulation size of breaks pvr total n(%) a+b n(%) c+d n(%) small 23 (46) 8 (16) 31 (62) large 8 (16) 11 (22) 19 (38) total 31 (62) 19 (38) 50 (100) chi-square value=5.148, df= 1, p<0.05, or=3.9 conclusions in our study patients of rrd with large retinal breaks were at increased risk of developing high grade pvr. patients with high myopia, signs of anterior uveitis, vitreous hemorrhage and number of retinal breaks were not at increased risk of developing high grade pvr. author’s affiliation dr. muhammad kamran khalid medical officer department of ophthalmology dhqr teaching hospital d.i. khan dr. muhammad tariq khan medical officer, kioms hayatabad medical compex peshawar dr. hidayatullah mahsud junior registrar department of ophthalmology dhqr teaching hospital d.i. khan dr. m saleem khan gandapur assistant professor department of ophthalmology dhqr teaching hospital d.i. khan professor muhammad daud khan rector, kioms hayatabad medical complex peshawar reference 1. weller m, wiedemann p, heimann k. proliferative vitreoretinopathy is it anything more than wound healing at wrong place? int ophthalmol 1990; 14: 105-17. 2. kampik a, kenyon kr, michels rh. epiretinal and viteous membranes. a comparative study of 56 cases. arch ophthalmol 1981; 99: 1445-54. 3. kirchhof b, sorgente n. pathogenesis of vitreoretinopathy. modulation of retinal pigment epithelial cell functions by vitreous macrophages. dev ophthalmol. 1989; 16: 1-53. 4. clarkson jg, green wr, massof d. a histopathologic review of 168 cases of preretinal membrane. am j ophthalmol 1977; 84: 1-17. 5. jerdan ja, pepose js, michels rg. proliferative vitreoretinopathy membranes. an immunohistochemical study. ophthalmology 1989; 96: 801-10. 6. charteris dg, hiscott p, robey hl. inflammatory cells in proliferative vitreoretinopathy subretinal membranes ophthalmology. 1993; 100: 43-6. 7. baudouin c, fredj-reygrobellet d, gordon wc. immunohistologic study of epiretinal membranes in proliferative vitreoretinopathy. am j ophthalmol. 1990; 110: 593-8. 8. hiscott ps, grieson i, mcleod d. retinal pigment epithelial cells in epiretinal membranes: an immunohistochemical study. br j ophthalmol 1984; 68: 708-15. 9. newsome da, rodrigues mm, machemer r. human massive periretinal proliferation. in vitro characteristics of cellular components. arch ophthalmol 1981; 99: 873-80. 10. asaria rh, kon ch, bunce c, et al. how to predict proliferative vitreoretinopathy: a prospective study. ophthalmology. 2001; 108: 1184-6. 11. nagasaki h, shinagawa k, mochizuki m. risk factors for proliferative vitreoretinopathy. prog retin eye res 1998; 17: 7798. 12. la heij ec, derhaag pf, hendrikse f. results of scleral buckling operations on primary rhegmatogenous retinal detachment. doc ophthalmol. 2000; 100: 17-25. 13. garard p, mimoun g, karpouzas i, et al. clinical risk factors for proliferative vitreoretinopathy after retinal detachment surgery. retina 1994; 14: 417-24. 59 14. nagasaki h, ideta h, uemura a, et al. comparative study of clinical factors that predispose patients to proliferative vitereoretinopathy in aphakia. retina 1991; 11: 204-7. 15. hooymans jm, de lavalette vw, oey ag. formation of proliferative vitreoretinopathy in primary rhegmatogenous retinal detachment. doc ophthalmol 2000; 100: 39-42. 16. cardillo ja, stout jt, labree l, et al. post-traumatic proliferative vitreoretinopathy. the epidemiologic profile, onset, risk factors and visual outcome. ophthalmology. 1997; 104: 1166-73. 253 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology original article retinal re-detachment after silicone oil removal ata-ur-rasool, nasir chaudhry, asad aslam khan, tahseen mahjoo, kashif manan pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr .ata-ur-rasool vr fellow room no. 240 new hostel kemu, lahore email: …..……………………….. purpose: the objectives of this study were to see the recurrence rate and the time interval of retinal re-detachment after (roso) removal of silicone oil. study design: quasi experimental study design was used place and duration of study: this study was conducted at ophthalmology department unit-3 mayo hospital lahore and duration was 6 months from 1 st october 2016 to 31 march 2017. material and methods: total fifty (50) patients that underwent 3-ports ppv± scleral buckle with so (silicone oil) used as an internal tamponade of either sex were included in this study. all the subjects were selected by a convenience type of non-probability purposive sampling. results: out of a total of 50 patients, 15 (30%) developed retinal re-detachment, which was within the first 3 months after roso. out of 35 patients with attached retina after silicone oil removal 13 (37%) had improvement in snellen visual acuity of one line or more whereas 22 (63%) had no improvement in their vision. we observed that the silicone oil duration as an endotamponade had no major differences on the recurrence rate of retinal detachment after its removal. conclusion: recurrence of retinal detachment after (roso) removal of silicone oil is common which in this study more than half of re-detachments occurred in the first month of silicone oil removal. the visual acuity improved in only 13 (37%) patients after silicone oil removal with attached retina. keys words: (ppv) pars plana vitrectomy, (roso) removal of silicone oil. aul cibis first described use of silicone oil for the management of retinal detachment1. ever since, the silicone oil has been used as an internal tamponade in cases of complex retinal detachments during pars plana vitrectomy. retinal detachment is a separation of the neurosensory retina from the retinal pigment epithelium by sub retinal fluid, which may be either rhegmatogenous or non rhegmatogenous2. management of complex retinal detachment needs a long acting internal tamponades, such as silicone oil to decrease the recurrence of retinal detachment. surgery for the retina has progressed from external tamponade to the concept of removing human vitreous and replacing it with an inert substance which act as an internal tamponade to keep two layers of the retina apposed, thus attempting to close tears and relieving traction. injection of silicone oil after vitrectomy was tried first by haut in 1976, though cibis introduced silicone oil in retinal surgery and j. scott refined its use3. latest vitrectomy techniques and the use of silicone oil as an internal tamponade to treat complex retinal detachments have led to improvements in the anatomical success rates of retinal detachment surgery. in cases of complex retinal detachment that is in trauma, proliferative vitreoretinopathy (pvr) p retinal re-detachment after silicone oil removal pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 254 diabetic tractional detachment and giant retinal tears silicone oil can be an effective tamponade. the oil gives a clear view of the fundus and retina in these cases, than an airor gas-filled eyes. intravitreal (so) silicone oil use as an internal tamponade can lead to complications such as cataract, glaucoma4, band keratopathy and oil emulsification4. these complications are partly related to the duration of intraocular tissue exposure to silicone oil. these complications may or may not be reversible once the oil has been removed from the eye. therefore it has been recommended that the oil should be extracted when a stabilized retinal status has been achieved i.e. a period of 3 – 6 months5. as suggested by some vitreoretinal surgeons, 360 – degree laser photocoagulation prior to silicone oil removal may help to decrease the retinal redetachment rates12. removal of silicone oil is a surgical procedure that carries a definite risk of retinal redetachment between 6% and 40%.cases due to re-proliferation of epiretinal membranes and increasing traction on the retina6,7. retinal re-detachment is not dependent on the silicone oil duration in an eye and similarly the technique used for its removal. objectives the objectives of this study were to see the recurrence rate and the time interval of retinal re-detachment after removal of silicone oil combined with a 360 degrees endolaser treatment. material and methods this was done at the ophthalmology department, king edward medical university / mayo hospital, lahore. the study was conducted from 1st october 2016 to 31 march 2017 with a follow up period of six months. the approval was taken from the ethical review board of kemu. informed written consent was taken from the patients. the study enrolled fifty eyes of fifty patients of both genders in which ppv (pars plana vitrectomy) ± scleral buckle with silicone oil used as an endotamponade. the patients were enlisted for silicone oil removal either because of completely attached retina for a minimum of at least 12 weeks with or without a buckling procedure for the treatment of rrd or because of the development of silicone oil emulsification. the patients who fulfilled the inclusion criteria were included in this study. post traumatic and tractional retinal detachment patients were excluded from the study. a detailed proforma was filled containing both their medical and ocular examination preoperatively including age, gender, eye involved, first surgery details i.e. pars plana vitrectomy, encircling band or tyre, membrane peeling, use of heavy liquid and silicone oil injection were recorded. best corrected visual acuity, status of the lens, previous endolaser photocoagulation was reviewed. all surgeries were performed by the same surgeon. patients clinical details were reviewed retrospectively. silicone oil (so) was removed through the 2-ports pars plana with or without limbal approach in case of silicone oil in the anterior chamber. silicone oil was removed by lavage method, oil-fluid exchange and then fluid air exchange at least three times. ports were closed and conjunctiva sutured afterwards. postoperatively each patient was examined on the day one, then at 1st week, 1 month, 3 months and then 6 months. on each visit every patient was examined for visual acuity, slit lamp examination, iop and anatomical attachment of the retina. completely flat retina was defined as the anatomical success that remained attached till the last follow-up visit. retinal re-detachment due to ongoing (pvr) proliferative vitreoretinopathy or the internal contractions of the retina within six months after removal of silicone oil was considered as a failure. all the data was compiled and evaluated statistically at the end of the study. results out of 50 patients 35 (70%) were men and 15 (30%) were women. the mean age of the patients was 43.90 ± 15.80 years (range 18 – 70) years. silicone oil was successfully removed from the eyes of the patients. the mean intraocular silicone oil tamponade duration was ranged between 3 months to 24 months. according to pvr classification, 4% (2/50) patients were grade a, 12% (6/50) grade b; 84% (42/50) were grade c pvr. out of the total 50 patients, 31 (62%) underwent ppv with silicone oil as an initial attachment surgical procedure, and 19 (38%) patients had combined scleral buckling with ppv and silicone oil. attached retina was found in thirty five (70%) patients at the end of follow-up visit (table 3). no significant association between intraocular silicone oil duration and the risk of re-detachment of the retina (p = 0.6997). in 14 (28%) patients phacoemulsification combined with iol implantation plus silicone oil removal was done .retinal redetachment rate was 20% ata-ur-rasool, et al 255 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology in patients subjected to combined procedure phaco. plus silicone oil removal. phacoemulsification combined with iol implantation and silicone oil removal did not influence the bcva when compared with silicone oil removal alone (p = 0.426). in addition, bcva deterioration did not directly associate with removal of so (p = 0.6598). these results showed that the different initial surgical procedures used for attachment surgery did not have statistically significant results in terms of preferential procedure in prevention of retinal redetachment, after removal of silicon oil (p ≥ 0.05) (table 1). chi-square test was used to analyze the statistical results. table 1: surgical procedure used for retinal attachment. surgical procedure post op. status of retina attached detached ppv with silicon oil (n = 31) 20 (64.51) 11 (35.49) buckling with ppv with silicone oil (n = 19) 14 (73.68%) 5 (26.31%) chi-square = 0.455 p-value = 0.5 ( > 0.05) key: ppv= pars plana vitrectomy table 2: surgical procedure for removal of silicone oil. attached retina detached retina pars plana (n = 40) 28 (70%) 12 (30%) parsplana + limbus 7 (70%) 3 (30%) chi-square = 0 p-value = 1 (> 0.05) out of a total of 50 patients, in 40 patients removal of silicone oil was done through pars plana and out of which 12 (30%) eyes had recurrent detachment after oil removal and in 28 (70%) eyes the retina remained attached. in remaining 10 patients silicone oil was removed through the pars plana and limbus amongst which 3 (30%) had re-detachment where as in 7 (70%) after silicone oil removal retina remained attached. the results were found statistically insignificant in relevance to the technique used for silicone oil removal (p ≥ 0.05) (table 2). a total of 15 eyes (30%) developed recurrent rd whereas in 35 eyes (70%), the retina remained completely flat till the end of last follow up that is at the 6 months after removal of silicone oil (table 3). table 3: rate of retinal re-detachment. rate no. of patients (%) retina re-detached 15 (30%) retina attached 35 (70%) total 50 (100%) the duration of recurrent detachment after silicone oil removal was found to be within the first 3 months of the follow up period in our study. four patients (26.65%) had redetachment on the first day, 8 patients (53.35%) at one month and 3 patients (20%) at three months follow up visit (table 4). table 4: distribution of re-detachment according to duration of time after silicone oil removal. duration of time redetected no. of patients n (%) first post op day 4 (26.65%) one month 8 (53.35%) 3 months 3 (20%) 6 months 15 (100%) out of 50, 28 (56%) patients had intraocular silicone oil tamponade for less than 9 months period, in which 8 (28.57%) had recurrent detachment after oil removal where as in the 22 (44%) patients with oil tampondae more than 9 months 7 (31%) had recurrent detachment after removal of silicone oil. the best corrected visual acuity was measured which was found to be dependent on the preoperative visual status of the patients. out of 35 cases after oil removal with completely attached retina, 17 patients who had a visual acuity of 6/60 or better before silicone oil removal 7 (41.18%) patients had an improvement of vision of two lines or more after oil retinal re-detachment after silicone oil removal pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 256 removal, where as in the remaining 10 (58.82%) the visual acuity remained the same. in 18 patients with vision worse than 6/60 before oil removal, only 5 patients (28%) had postoperative improvement in their final best corrected visual acuity whereas 13 patients (72%) had no improvement in vision. discussion vitreoretinal surgery combined with internal tamponade of silicone oil is a recommended surgical procedure and it increases the prognosis of complicated retinal detachments associated with (pvr) proliferative vitreoretinopathy. unfortunately the silicone oil use is not without significant ocular complications including cataract, glaucoma, perisilicone epiretinal membrane proliferation, emulsification, and keratopathy. due to re-proliferation of epiretinal membranes and increasing traction on the retina, removal of silicone oil is a surgical procedure that has a definite risk of redetachment of the retina, especially in the presence of peripheral recurrent detachment before oil removal, requiring further surgery involving complex re-buckling procedures repeated membrane dissection and retinectomies. some vr surgeons did not consider the silicone oil removal timing as a risk factor for anatomical attachment of the retina as a success factor8,9,22. while others considered that shorter duration of tamponade had lower rate of retinal attachment rate than longer duration of tamponade10,11. since retinal re-detachment rate is not influenced by the duration of intraocular silicone oil, it seems reasonable to remove the oil as early as possible to avoid the initiation or worsening of oil associated complications. in this study we prefer to remove the oil in all patients after three months. we observed that the silicone oil duration as an endotamponade had no major effect on the retinal redetachment rate. in intraocular silicone oil tamponade the time interval ranged from 3 months to even 24 months in this study. these results showed that in the patients with silicone oil tamponade for a period more than one year had the same outcome as in the patients with as early removal as three months in terms of retinal attachment p ≥ 0.05. previously use of encircling buckle and peripheral laser before silicone oil removal has been reported to be a safe and beneficial procedure12,13. a 360 – degrees laser performed before roso may enhance chorioretinal adhesions in the periphery and decreases the chances of retinal redetachment in spite of residual tractions in the vitreous base14. in the light of the following results we came to a conclusion that longer time duration of silicone oil within the eye had no extra benefit, rather it had the disadvantage of having more chance of silicone oil induced complications. similar results were achieved by falkner and colleagues who conducted a study to evaluate the outcome of silicone oil extraction5. the silicone study reports conducted by hutton and colleagues in 1994 also gave the results that the length of silicone oil retained in the eye and incidence of recurrence of retinal detachment after oil removal had no association. heij and ellenin concluded in their study that in spite of the acceptable risk of retinal redetachment, early silicone oil removal may yield a lower anterior segment complications rates and an increase in best corrected visual acuity in approximately ½ of the eyes4. this study was conducted to assess the time interval of re-detachment of the retina after silicone oil extraction, which was not more than three months. this led us to a conclusion that any retina, which has a tendency to re-detach will do so in the early post operative period of oil removal. hence it is necessary to have a careful follow up of all the patients undergoing such surgery especially in the first three post operative months. unlu et al found that retina re-detached in the first 10 days in 81.3% of patients after silicone oil removal. the remaining vitreo retinal tractions especially at the vitreous base is the most likely reason for the redetachment of the retina after the removal of silicone oil, which is most commonly seen during the first 10 days15,21. suic in his study revealed that elevation of intraocular pressure following vitrectomy with silicone oil tamponade had a temporary effect, as it did not lead to permanent intraocular pressure elevation but regressed after silicone oil removal from the eye16,20. after removal of silicone oil the visual acuity of the patients with attached retina in this study had the final outcome in relevance to their preoperative visual status. there was no significant change in visual improvement noted in patients who had a visual acuity of counting finger or hand motion before the roso. some patients with 6/60 or better vision had an increase in their best-corrected va after silicone oil removal. the eleventh silicone study reports published in 1997 stated that the eyes in which silicone ata-ur-rasool, et al 257 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology oil retained in comparison with oil-removed eyes had a visual acuity of 5/200 or better (p < .001)17,18,19. in conclusion recurrent retinal detachment is the most important complication that may occur after removal of silicone oil with a 30% rate in this study. silicone oil tamponade duration had insignificant role on the re-detachment rate of the retina postoperatively (p ≥ 0.05). it was observed that retinal re-detachment rate after removal of silicone oil was not dependent on the techniques of silicone oil extraction (p ≥ 0.05). this study had good sample size and done by single surgeon but the duration is less and done in single centre. advantages of silicone oil removal must be outweighed against its long term duration in the eye and the possibility of complications. improvement in vision was dependent on the preoperative visual status of the patient. authors affiliation dr. ata-ur-rasool consultant ophthalmologist, vr fellow ophthalmology department mayo hospital, lahore. prof. asad aslam khan professor/head of ophthalmology department mayo hospital, lahore. dr. nasir chaudary assistant professor ophthalmology department mayo hospital, lahore. dr. tahseen mahjoo assistant professor ophthalmology department mayo hospital, lahore dr. kashif manan smo mayo hospital, lahore. role of authors dr. ata-ur-rasool conception of research idea, writing of paper, data collection. prof. asad aslam khan supervision of research, review of paper draft. dr. nasir chaudary diagnosing patients and performing surgery, statistical analysis. dr. tahseen mahjoo diagnosing patients and performing surgery. dr. kashif manan contributed in data collection. references 1. prazeres j, magalhães o jr, lucatto lf, et al. heavy silicone oil as a long-term endotamponade agent for complicated retinal detachments. bio med res int. 2014; 2014: 136031. 2. sharma a, grigoropoulos v, williamson th. management of primary rhegmatogenous retinal detachment with inferior breaks. br j ophthalmol. 2004; 88: 1372-5. 3. khurram d, ghayoor i. outcome of silicone oil removal in eyes undergoing 3-port parsplana vitrectomy: pak j ophthalmol. 2011; 27: 1. 4. heij l, ellen c, fred mdh, et al. results and complications of temporary silicone oil tamponade in patients with complicated retinal detachments. retina. 2001; 21: 107-14. 5. falkner ci, binder s, kruge a. outcome after silicone oil removal. br j ophthalmol. 2001; 85: 1324-7. 6. abu el-asrar am, al-bishi sm, kangave d. outcome of temporary silicone oil tamponade in complex rhegmatogenous retinal detachment. eur j ophthalmol. 2003; 13 (5): 474-481. 7. jonas jb, knorr hl, rank rm, budde wm. retinal redetachment after removal of intraocular silicone oil tamponade. br j ophthalmol. 2001; 85 (10): 1203-1207. 8. lam rf, cheung bto, yuen cyf, wong d, lam dsc, lai ww. retinal redetachment after silicone oil removal in proliferative vitreoretinopathy: a prognostic factor analysis. am j ophthalmol. 2008; 145 (3): 527–33. 9. nagpal mp, videkar rp, nagpal km. factors having implications on reretinal detachments after silicone oil removal. indian j ophthalmol. 2012; 60 (6): 517–20. 10. tan hs, dell’omo r, mura m. silicone oil removal after rhegmatogenous retinal detachment: comparing techniques. eye (lond), 2012; 26 (3): 444–7. 11. scholda c, egger s, lakits a, walch k, von eckardstein e, biowski r. retinal detachment after silicone oil tamponade. acta ophtalmol scand. 2000; 78 (2): 182–6. 12. laidlaw da, karina n, bunce c, aylward gw, gregor zj. is prophylactic 360-degree laser retinopexy protective? risk factors for retinal re-detachment after removal of silicone oil. ophthalmology. 2002; 109 (1): 53–8. 13. jain n, mccuen 2nd bw, mruthyunjaya p. unanticipated vision loss after pars plana vitrectomy. surv ophthalmol. 2012; 57 (2): 91–104. 14. avitabile t, longo a, lentini g, reibaldi a. retinal detachment after silicone oil removal is prevented by 360 degrees laser treatment. br j ophthalmol. 2008; 92: 1479–82. 15. ünlü n, kocaolan h, acar ma, et al. outcome of complex retinal detachment surgery after silicone oil removal. inter ophthalmol. 2004; 25: 33-6. 16. suic ps, sikic j, pokupec r. intraocular pressure values following vitrectomy with silicone oil tamponade. acta med croatica. 2005; 59: 193-6. retinal re-detachment after silicone oil removal pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 258 17. abrams gw, azen sp, mccuen bw, et al. vitrectomy with silicone oil or long-acting gas in eyes with severe proliferative vitreoretinopathy: results of additional and long-term follow-up. silicone study report 11. arch ophthalmol. 1997; 115: 335-44. 18. crisp a, de juan e, tiedeman j. effect of silicone oil viscosity on emulsification. arch ophthalmol. 1987; 105 (4): 546-550. 19. williams rl, kearns vr, lo ac, et al. novel heavy tamponade for vitreoretinal surgery. invest ophthalmol vis sci. 2013; 54 (12): 7284-7292. 20. caramoy a, kearns vr, chan yk, et al. development of emulsification resistant heavier-than-water tamponades using high molecular weight silicone oil polymers. j biomater appl. 2015; 30 (2): 212-220. 21. toklu y, cakmak hb, ergun sb, et al. time course of silicone oil emulsification. retina. 2012; 32 (10): 20392044. 22. nicholson bp, bakri sj. silicone oil emulsification at the fovea as a reversible cause of vision loss. jama ophthalmol. 2015; 133 (4): 484-486. 23. errera m-h, liyanage se, elgohary m, et al. using spectral-domain optical coherence tomography imaging to identify the presence of retinal silicone oil emulsification after silicone oil tamponade. retina. 2013; 33 (8): 1567-1573. microsoft word uzma fasih 86 original article secondary glaucoma causes and management uzma fasih, ms fehmi, nisar shaikh, arshad shaikh pak j ophthalmol 2008, vol. 24 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr.uzma fasih b 21 block 10 federal b area karachi received for publication october’ 2007 …..……………………….. purpose: to determine the causes of various types of secondary glaucoma and analyze the efficacy of various management plans for these glaucomas. material and methods: this analytical observational study was conducted at eye department abbasi shaheed hospital karachi, from june 2005 to june 2007. all patients attended glaucoma clinic were included in the study and their glaucoma was classified and appropriate treatment initiated to achieve the target pressure of 15 mmhg. results: in total 106 patient were studied .the number of male patients (66%)was more than the female patients(34%).most common presenting age group was between 51-60 years forming 28.3%, among secondary glaucomas inflammatory glaucomas were most common (29.2 %). conservative medical treatment including topical b blockers, prostaglandin analogues, sympathomimetics, miotics, steroids, oral and intravenous hyperosmotic drugs were used. trabeculectomy was the main surgical option used to control intraocular pressure. yag laser iridotomies were also done where required. control of intraocular pressure and visual outcome were quite satisfactory after management. conclusion: causes of secondary glaucomas are diverse, inflammatory glaucoma being most common. they could be well managed if present in time. medical antiglaucoma therapy plays important role in treatment as well as steroids. trabeculectomy is quite effective in resistant cases. laucoma is a potentially blinding disease of global importance. it is second leading cause of blindness after cataract1. glaucoma is 4th common cause of blindness in pakistan2. the number of people with primary glaucoma in the world by the year 2000 was estimated nearly 66.8 million with 6.7 million suffering from bilateral blindness1. information on secondary glaucoma is generally limited but the causes leading to glaucoma are seldom identified. few studies have described secondary glaucoma as a separate entity but it has been estimated that 6 million people in the world have secondary glaucoma as compared to 67 million who suffer from primary glaucoma. in india secondary glaucoma represents 6% of total new cases seen annually3. the causes of secondary glaucoma are diverse but commonly seen entities are inflammatory, lens induced, neovascular and traumatic. it is observed that trauma, cataract and infective uveitis represent special risk factors for development of secondary glaucoma. these are frequent causes of blindness in third world countries4. g 87 in pakistan late presentation of cataract patients, poor management of diabetes, and other diseases leading to neovascular glaucomas, poor management of chronic uveitis and indiscriminate use of topical steroids especially in ocular surface allergies are possible causes of high prevalence of secondary glaucoma3. although recent advances in sutureless small incision cataract surgery, phacoemulsification and improved iol designs have resulted in superior outcome with reduced complications related to wound repair and secondary glaucomas. special measures and training is required to deal with glaucoma and inflammation secondary to retained lens fragments. these measures will also reduce complications such as pseudophakic glaucoma, another significant cause of secondary glaucoma3. lack of facilities in remote peripheries, poverty, illiteracy, ignorance and poor management play an important role leading to complications like uncontrolled iop, reduced vision, constricted visual fields and glaucomatous optic atrophy. commonly available current treatment strategies include topical anti glaucoma drugs like topical b blockers, cholinergic agonists, carbonic anhydrase inhibitors topical as well as systemic, oral and intravenous hyperosmotic agents, and prostaglandin analogues. inflammatory glaucomas respond well to steroids and topical nsaids. yag laser iridotomies do play an important role in angle closure types of secondary glaucoma. failure of medical treatment leaves no option except to go for surgery as trabeculectomy. the objective of our study was to determine the causes of various types of secondary glaucoma presenting at our glaucoma clinic and to analyze the efficacy of various management plans for these glaucomas. material and methods this study was conducted at eye department abbasi shaheed hospital north nazimabad karachi, from june 2005 to june 2007. the patients included in the study were registered at our glaucoma clinic. complete history regarding ocular complaints and history of any other acute or chronic systemic illness was taken. information regarding visual aquity, intraocular pressure, slit lamp examination, perimetry, goniocopic and fundoscopy findings was noted on a predesigned performa. findings like corneal clarity, corneal oedema, anterior and posterior synechia, iris neovascularization and iris atrophy, fundoscopic details regarding condition of optic disc, cup disc ratio, retinal heamorrhages and neovascularization were clearly noted. treatment regime of each particular patient was noted on the performa keeping the target intraocular pressure 15 mmhg. any change in the treatment and details of surgical treatment if any was done were noted down at follow-up visits. iop was checked with applanation method at every visit. gonioscopies and perimetries were reevaluated from time to time. results a total of 106 patients of glaucoma were studied who presented at glaucoma clinic eye department abbasi shaheed hospital north nazimabad karachi. male patients were 66% while female patients were 34%. (table 1). the most common presenting age group was between 51-60 years (28.3%) followed by 61-70 years (18.9%) (table 2). table 1. gender distribution no of patient male n (%) female n (%) 106 70 (66) 36 (34) table 2. age distribution age group(years) patients n (%) 1-10 1 ( 0.9) 11-20 2 (1.9) 21-30 10 ( 9.4) 31-40 15 (14.2) 41-50 17 (16.0) 51-60 30 (28.3) 61-70 20 (18.9) 71-80 11 (10.4) the common type of secondary glaucoma was inflammatory glaucoma comprising of 45 patients. 31 patients were pseudophakic (29.4%) among them 21 were with posterior chamber implants and 10 were with anterior chamber implants. 2(1.88%) patients presented with aphakic glaucoma with pupillary 88 block. 12(11.3%) patients presented with glaucoma associated with chronic anterior uveitis. 12(11.3%) patients presented with traumatic glaucoma. this was either associated with hyphema and traumatic cataract or angle recession glaucoma. glaucoma associated with diabetic eye disease was seen in 9 patients (8.4%) patients. 7(6.6%) patients presented with glaucoma secondarily as a complication of hypertension. among the lens induced group 7(6.6%) presented with phacomorphic glaucoma and 5(4.7%) presented with phacolytic glaucoma. 6(5.6%) patients presented with glaucoma associated with pseudoexfoliation. among neovascular glaucoma group 3(2.8%) patients were diabetic and 2(1.8%) had central retinal vein occlusion (crvo) (table 3). table 3. types of secondary glaucoma and their management type of secondary glaucoma no. of patients n (%) management 1.inflammatory a.pseudophakia pc iol ac iol b.aphakia with papillary block c.chronic anterior uveitis 31 (29.2) 21 10 2 (1.9) 12 (11.3) pc iol=trabeculectomy 13,conservative 6, yag laser iridotomies 2 ac iol=trabeculectomy 7, conservative 3, pupilloplasty, synechioplasty, peripheral iridectomy 2 trabeculectomy 5, conservative 7 2.traumatic 12 (11.3) trabeculectomy 5, conservative 5, yag laser iridotomies 2 3.patients with diabetic eye disease 9 ( 8.4) conservative in all patients 4.hypertensive patients 7 (6.6) conservative in all patients 5.neovscular glaucoma diabetic crvo 3 (2.8) 2 (1.8) diabetic=prp in 2 diabetic patients, cryopexy in 1 diabetic patient crvo = conservative 6.lens induced phacomorphic phacolytic 7 ( 6.6) 7 ( 4.7) trabeculectomy + ecce +iol 3, *ecce+iol 4 trabeculectomy + ecce + iol 1, ecce +iol after conservative treatment 4 7.pseudoexfoliation 6 (5.6) trabeculectomy 2, trabeculectomy +ecce+iol 4 8.habitual tobacco user 5 (4.70) trabeculectomy 3, conservative 2 9.retinal detachment surgery with silicon oil 3 (2.8) trabeculectomy followed by silicon oil removal 3 10.steroid induced 2 (1.8) trabeculectomy 2 habitual tobacco users formed 4.7% (5 patients) of total secondary glaucoma. 3 (2.8%) patients presented with secondary glaucoma as a complication of retinal detachment surgery with silicon oil. another group 89 was steroid induced glaucoma comprising of 2(1.8%) patient both of them had history of vernal catarrh and indiscriminate use of topical steroids. all of the patients were managed conservatively at the initial stages. the conservative treatment included topical anti glaucoma drugs like topical b blockers, cholinergic agonists, carbonic anhydrase inhibitors topical as well as systemic, oral intravenous hyperosmotic agents, and prostaglandin analogues. inflammatory glaucomas responded well to steroids and topical nsaids. yag laser iridotomies were tried where secondary angle closures were suspected in pseuduphakic and traumatic glaucoma group. pupilloplasty, synechioysis and peripheral iridectomy were done in aphakic patients with pupillary block. cyclocryopexy was tried in neovascular glaucoma. trabeculectomy was indicated where conservative treatment failed or there was poor patient compliance. cataract surgery with intraocular implants was done in lens induced glaucomas along with trabeculectomy where required. those patients who presented with glaucoma as a complication of detachment surgery with silicon oil underwent trabeculectomies and silicon oil removal later on. unfortunately removal of silicon oil resulted in hypotony in 2 patients. table 4 shows the iop control with conservative treatment. it could be clearly seen that habitual tobacco users, hypertensive patients, diabetic patients and pseudophakic patients responded well to conservative treatment and where it failed surgical treatment was planned. table 4. iop control after conservative management type of glaucoma conservative treatment (total patients) patients with controlled iop n (%) 1.inflammatory a.pseudophakic • pc iol • ac iol b.chronic uveitis 6 3 7 5 (83.3) 2 (66.6) 5 (71.4) 2.traumatic glaucoma 5 4 (80.0) 3.glaucoma with diabetic eye disease 9 7 (77.7) 4.hypertensive patients 7 6 (85.7) 5.glaucoma in habitual tobacco users 2 2 (100) table 5 shows iop control of patients who underwent trabeculectomies either due to failure of conservative treatment or poor patient compliance. the table shows an overall success rate of almost 80% for trabeculectomy. table 6 shows the visual outcome of these patients. it is well depicted that most of the patients have a visual acuity ranging between 6/60 to 6/12 which is quite satisfactory. reasons where visual out come was poor were late presentation, corneal pathologies like corneal oedema, endothelial decompensation, corneal opacities etc. and glaucomatous optic atrophy due to persistently raised iop for a long time. table 5. iop control following trabeculectomy type of glaucoma trabeculec tomies no. of patients with controlled iop following trabeculectomy n (%) 1.inflammatory a.pseudophakia • pc iol • ac iol b.chronic anterior uveitis 13 7 5 11(84.6) 5(71.4) 3(60) 2.traumatic 5 4(80) 3.lens induced phcomorphic phacolytic 3 1 3(100) 1(100) 4.pseudoexfoliation 6 5(83.3) 5.habitual tobacco users 3 3(100) 6.retial detachment surgery with silicon oil 3 1(33.3) 7.steroid induced glaucoma 2 2(100) 90 pc=posterior chamber, ac=anterior chamber, iol=intraocular lens discussion while the prevalence of morbidity and visual impairment due to primary open angle and angleclosure glaucomas have been fairly well established by population surveys in the west and, recently, in the developing world, the issue of blindness from secondary glaucomas has received little attention from most investigators. individuals with secondary glaucoma tend to report promptly to the ophthalmologist since there is often marked reduction in visual acuity, apart from pain and ocular discomfort. as a consequence, these are largely selfreported2. table 6. visual outcome after the treatment type of glaucoma visual acuity pl/pr-fc 6/60-6/18 6/12-6/6 1.inflammatory a.pseudophakia • pc iol • ac iol b.aphakia c.chronic uveitis 4 6 2 4 11 5 8` 7 2.traumatic glaucoma 9 3 3.glaucoma with diabetic eye disease 4 4 1 4.hypertensive patients 7 5.neovascular glaucoma • diabetic • crvo 5 6.lens induced • phacomorphic • phacolytic 2 1 3 4 7.pseudoexfoliati on 6 8.habitual 3 2 tobacco user 9.r.d surgery with silicon oil 3 10.steroid induced 1 1 pl=perception of light, pr=projection of light, fc=finger counting based on the who blindness data bank, thylefors and negrel, in their world estimate of glaucoma blindness, found it was not possible to determine the number of blind from secondary glaucoma, although they estimated the world prevalence to be 2.7 million5. secondary open and closed angle glaucomas are an important cause of ocular morbidity and vision loss in our community. secondary glaucoma occurs with acquired ocular diseases (pigment dispersion, pseudoexfoliation, intraocular infection, intraocular inflammation and retinal vascular disease), blunt anterior segment injury, intraocular surgery (especially corneal grafting and congenital cataract surgery) and topical corticosteroid use. the medical treatment of secondary glaucoma is different from that of primary open angle glaucoma and must be tailored for the individual patient. awareness of patients at high risk should enable early detection and referral for appropriate management6. different studies carried out to determine the causes of secondary glaucoma depict different percentages of different causes depending upon the environments in which these studies are carried out and vary with different groups of patients. in a study conducted at hayatabad medical complex peshawar in 2003 secondary glaucoma was found to be 36.14% of the total glaucomas. in the study mentioned secondary glaucoma associated with chronic uveitis was 0.48%, aphakia with pupillary block 2.16%, traumatic glaucoma 7.95%, neovascular glaucoma with diabetes 2.4%, and central retinal vein occlusion 2.89%, phacolytic glaucoma 4.1%, phacomorphic 3.6%, pseudoexfoliation 6.02%, and steroid induced glaucoma was 6.03%. patients were treated conservatively on topical antiglaucoma treatment, yag laser iridotomies, cryopexy and trabeculectomy where other treatments failed with an overall success rate of 83.7 %. while in our study secondary glaucoma associated with chronic uveitis was 11.3%, aphakia with pupillary block 1.9%, traumatic glaucoma 11.3%, 91 neovascular glaucoma with diabetes 2.4% and central retinal vein occlusion 1.8%, phacolytic glaucoma 4.7%, phacomorphic 6.6%, pseudoexfoliation 5.6%, and steroid induced glaucoma was 1.8%. these results are somewhat similar to the results of above mentioned study. patients were treated conservatively as well surgically like trabeculectomy, the over all success rate of trabeculectomy being 80%7. another study was conducted in new delhi india from 1970-80 to describe various causative factors responsible for secondary glaucoma. this study shows that aphakic glaucoma and glaucoma associated with complications of mature cataract were responsible for nearly 50% of total secondary glaucoma. this percentage is very high as compared to our study (aphakic glaucoma 1.8% and lens induced 11.3%), perhaps the cataract surgery techniques have now been improved a lot and surgeons are more skilled. neovascular glaucoma was 9.6%, traumatic glaucoma 8.4%, glaucoma due to chronic uveitis 8.2% and steroid induced glaucoma 6.8% in the same study which is quite similar to our study8. another nationwide study conducted at islamabad included 13 tertiary care hospitals reports that secondary glaucoma was 35% of the total glaucoma burden9. in our study secondary glaucoma due to uveitis encountered 11.3% patients, while study conducted in boston usa 9.6% patients had secondary glaucoma due to uveitis and chronic anterior uveitis being the most common entity10. surgical management of secondary glaucoma after silicone oil injection for complex retinal detachment may achieve good iop control. patients who undergo silicone oil removal alone to control iop are more likely to have persistent elevation of iop and silicone oil removal and glaucoma surgery are more likely to have hypotony11. another interesting group in our study was of habitual tobacco users forming 4.7% of the total secondary glaucoma patients. in a study conducted in the same department for tobacco related eye disease it was found that 16.9% male and 20.5% female patients had secondary glaucoma who were habitual tobacco users12. tobacco has been found to be one of the agents having ill effects on ocular circulation and intraocular pressure13. in another study it was found that smokers have raised mean intraocular pressure14. tobacco may affect outflow channels of schelmm’s canal which are to some extent dependent on autonomic nervous control for outflow of aqueous. the trabecular meshwork is innervated by plexus of delicate axons that terminate without specialized endings within endothelium of of canal of schlemm. nerves originate from trigeminal and sympathetic nervous system15. another mechanism may be the toxic and ischemic effect causing vascular insufficiency at optic nerve head supplied by short posterior arterioles of haller zinn16. conclusions it was concluded that causes of secondary glaucoma are diverse but mainly intraocular inflammation is responsible for these types of glaucomas. they can be well managed with conservative medical treatment but where it fails surgery is the only option left. it is suggested: • easily accessible and affordable cataract surgery services of high quality should be provided to prevent lens induced glaucoma and pseudophakic glaucoma. • early detection and good management of conditions associated with the potential for retinal ischaemia and neovascularisation such as good management of hypertension to reduce retinal vein occlusions good control of diabetes to prevent neovascular glaucoma • increased awareness among eye care professionals, the public and pharmacists of the dangers of indiscriminate use of topical (and systemic) steroids • awareness should be created to prevent ocular trauma and timely presentation for its treatment if one gets such injury. author’s affiliation dr. uzma fasih assistant professor eye department karachi medical & dental college abbasi shaheed hospital karachi. dr. m.s fehmi associate professor eye department 92 karachi medical & dental college abbasi shaheed hospital karachi dr. nisar shaikh assistant professor eye department karachi medical & dental college abbasi shaheed hospital karachi dr. arshad shaikh proessor & head of eye department karachi medical & dental college abbasi shaheed hospital karachi reference 1. quigley ha. the number of people with glaucoma world wide. br j ophthalmol. 1996; 80: 389-93. 2. khan md, quraish nd, khan ma. facts about status of blindness in pakistan pak j ophthalmol. 1999; 15: 15-9. 3. krishnadas r, ramakrishnan r. secondary glaucomas. the tasks ahead. community eye health. 2001; 14: 40-2. 4. pozzi sap, wahieg r, roasen b, et al. secondary glaucoma in paraguay. etiology and medicine ophthalology. 1999; 96: 35963. 5. jafers bl, et al. world health organization pbc/94.40 global data on blindness an update. 6. anthony jh. secondary glaucoma clinical and experimental optometry. 2000; 83: 190-4. 7. baber ft, saeed n, zubairm, et al. two year audit of glaucoma admitted patients in hayatabad medical complex peshawar. pak j ophthalmol. 2003: 19: 32-40. 8. agarwal hc, sood nn, kalra br, et al. secondary glaucoma. indian j ophthalmol. 1982; 30: 121-4. 9. qureshi bm, khan dm, shah nm, et al. glaucoma admissions and surgery in public sector tertiary care hospitals of pakistan. results of a national study. ophthalmic epidemiology. 2006: 13: 115-9. 10. lloves mj, power jw, rodriguez a, et al. secondary glaucoma in patients with uveitis. ophthalmologica. 1999; 213: 300-4. 11. donal l, bundez md, katia e, et al. surgical management of secondary glaucoma after pars plana vitrectomy and silicon oil injection for complex retinal detachment. ophthalmology. 2001; 108; 1028-32. 12. shaikh a, alam p, sami ms. tobacco related eye diseases. pak j ophthalmol. 1999; 15: 113-6. 13. krishna k. tobacco and intraocular pressure. online j health and allied sciences. 2002; 0922-5997. 14. lee aj, rchtchina e, wang jj, et al. smoking effects intraocular pressure, findings of blue mountain study. 2003; 12: 212. 15. newell fw. anatomy and embryology. in ophthalmology principles and concepts 7th ed. mosby year book st. louis. 1992; 3-70. 16. khaw pt. the glaucomas. in aids to ophthalmology1st ed. churchill livingstone, london. 1989: 90-104. microsoft word editorial 27,2,2011 55 editorial complications and management of glaucoma surgery despite major advances in the development of novel drugs and laser techniques for intraocular pressure (iop) reduction in eyes with glaucoma, a significant proportion of glaucoma patients ultimately require surgery to achieve target pressure. trabeculectomy (trab) still remains the gold standard in management of uncontrolled glaucoma. many studies have compared initial trab versus medical treatment and confirmed trab providing consistently low iop1,2. other potential advantages of this surgical procedure include stabilization of iop without any diurnal fluctuation, less reliance on patient’s compliance and cost effectiveness, which is of great significance in our present socio-economic environment. since its first description by cairns3 in 1968, trab has also gone through various additions and modifications with adjunctive use of antimetabolites such as mitomycin-c (mmc) and 5-fluorouracil (5fu), use of releasable and adjustable sutures and maintenance of anterior chamber with balanced salt solution (bss) and viscoelastic substance such as hydroxy propyl methyl cellulose (hpmc) and sodium hyaluronate (healon). the use of 5-fu and mmc with glaucoma filtration surgery has become routine over last couple of decades. the benefit of postoperative subconjunctival 5-fu injections in eyes at high risk for filtration failure undergoing trab was demonstrated in the fluorouracil filtering surgery study4. subsequently, two randomized clinical trials showed intraoperative mmc application to be more beneficial than postoperative 5-fu injections in patients at high risk for filtration failure5,6. the complicated nature of postoperative 5-fu injections and associated corneal side effects led to the use of 5-fu, intra-operatively in similar fashion to mmc application7. mmc is currently in widespread use in primary trab to improve the success rate of iop control. controversy and variation exists with regard to optimum mmc concentration, exposure time and delivery method. however use of mmc is not without its own complications. the short term risks such as wound leak, corneal epithelial defects, shallow anterior chamber, choroidal detachment and late complications including pale atrophic blebs, bleb leaks,hypotony and late endophthalmitis are well known and described in literature8,9. the technique to improve the function of filtering blebs and to treat postoperative complications has progressed over last several years. the appearance of filtering bleb is an important factor in evaluating the outcome of glaucoma filtration surgery. functioning bleb contain small cystic spaces and show changes in appearance and size over time. there are still some issues related to trab and management of these complications are important for a successful outcome. hypotony (iop < 6mm hg) although less common but is serious complication of drainage surgery. it occurs due to decreased aqueous production caused by inflammation and cilio-choroidal detachment or excessive aqueous outflow caused by bleb leak or cyclodialysis cleft. fortunately most cases resolve in early postoperative period. chronic hypotony persisting for at least 3 months can be associated with hypotonymaculopathy and decrease in visual acuity. to prevent hypotony occurring, one must use tight sutures over scleral flap, prevent any buttonhole formation of conjunctiva and maintain anterior chamber depth with bss or viscoelastic substances. patients with persistent hypotony caused by excessive filtration require several therapeutic options such as pressure patching, large bandage contact lens, injection of autologous blood, use of argon laser to shrink symptomatic bleb and thermal cautery using continuous-wave nd-yag laser. as last resort, resuturing of scleral flap can be tried. bleb leaks can occur in the early postoperative period or later after filtration surgery. a buttonhole in the conjunctiva during surgery or a wound leak through the conjunctival incision especially in fornix based conjunctival flaps can be responsible for an 56 early leaking bleb. late bleb leaks are more frequent in avascular thin blebs, which occur more frequently with the use of antimetabolites. bleb leaks are detected with seidel sign. leakage of bleb can be associated with hypotony, shallow anterior chamber and choroidal detachment. several options are at hand to treat leaking bleb including use of pressure patching, bandage contact lens, tissue adhesives and lastly surgical revision. an elevated iop shortly after trabeculectomy occurs due to variety of causes such as tight closure of scleral flap, aqueous misdirection or suprachoroidal hemorrhage. in first week after surgery, a high iop with deep anterior chamber usually suggest tight closure of scleral flap. with gonioscopy, one should, however ensure patency of internal sclerostomy site, so that there is no obstruction to aqueous flow by iris, blood or viscoelastic substance. with tight closure of scleral flap, lower iop can be achieved by point pressure with cotton applicator adjacent to sclerostomy site or closed lid massage through upper or lower lid. permanent decrease in iop is possible by argon suture lysis using hoskins lens, usually after one week after the surgery. high iop with shallow anterior chamber usually suggest pupillary block, aqueous misdirection or suprachoroidal hemorrhage. pupillary block can occur with non-patent iridectomy. once this is confirmed with gonioscopy, nd-yag laser can be used to penetrate through intact epithelium or separate laser iridectomy can be fashioned. aqueous misdirection (cilliary block glaucoma) can be suspected with patent iridectomy and is usually treated with aggressive mydriaticcycloplegic therapy. in pseudophakic eyes, the anterior vitreous can be disrupted with nd-yag laser or anterior vitrectomy is performed. hemorrhage into suprachoroidal space appears dark brown dome shaped choroidal elevation confirmed on b-mode ultrasonography. treatment modality includes sclerotomy and drainage of blood. the failing filtering bleb is typically low or flat with vascularized conjunctiva, occurring due to inadequate aqueous outflow at the site of scleral flap. this occurs many weeks or months after surgery. application of regular digital pressure and laser suture lysis can work in limited cases. some of these patients can benefit with needle revision of the bleb with mmc. in the past years, search for a low risk and effective glaucoma surgery has prompted renewed interest in techniques other than trab and particulary in non-penetrating glaucoma surgery (npgs). in the early 1980s, zimmerman et al10 described deep sclerectomy (ds), later on modified by koslv11 using collagen implant placed under scleral flap. in 1999, stegmann12 introduced viscocanalostomy (vc) in patients with open angle glaucoma using high molecular weight visoelastic substance opening the schlemm’s canal. in modification to this procedure called canaloplasty, a microcatheter is inserted 360 degrees in schlemm’s canal. in npgs, as entry into anterior chamber is avoided, over filtration and hypotony are less troublesome. to facilitate iop lowering efficacy, numerous modifications of both ds and vc have been introduced. there are various types of implants inserted into scleral space or into schlemm’s canal and even antimetabolites are used along. hondur13 carried out meta-analysis of npgs studies published in literature over last 5 years and concluded that npgs seems to provide, iop reduction in high teens. the potential to achieve low target iops seems to be less. in the traditional stepped treatment, patient requiring surgery typically undergoes trab as a primary procedure. if trab fails then many surgeons will opt for various seton implantation. the tubeshunt insertion is also reserved for complicated cases such as inflammatory or neovascular glaucoma. recently conducted tube versus trab study14 (tvt) showed, equal iop reduction in both groups of patients at the end of three year follow up. however there are certain reservations about this study. the tvt study enrolled patients who already had failed trab or were pseudophakics, which could have favored the success of the tube. secondly, patients with iop of ≤ 5 mm hg in trab group were termed as failure. one has also to understand that, this study was not designed to answer the selection of primary surgery with the inclusion of a mix of nonhomogenous subjects. the best primary surgery for glaucoma could be quite different for each individual patient. considering the various options, trabeculectomy is still preferred mode of surgical procedure. references 1. lichter pr et al. interin clinical outcomes in the collaborative initial glaucoma treatment study comparing initial treatment randomized to medications or surgery. ophthalmology 2001; 108: 1943-53. 2. migdal c, gregory w, hitching r. long term functional outcome after early surgery compared with laser and medicine in open angle glaucoma. ophthalmology 1994; 104: 1654-6. 57 3. cairns je. trabeculectomy-preliminary report of a new method. am j ophthalmol. 1968; 115: 673-7. 4. fluorouracil filtering study group. fluorouracil filtering surgery study, one year follow up. am j ophthalmol. 1991; 108: 625-35. 5. kitazawa y, kawase k et al. trabeculectomy with mitomycin: a comparative study with fluorouracil. arch ophthalmol. 1991; 109: 1693-8. 6. skuta gl, beeson cc et al. intraoperative mitomycinvs postoperative 5-fluorouracil in high risk glaucoma filtering surgery. ophthalmology 1992; 99: 438-44. 7. smith mf, sherwood mb et al. results of intraoperative 5fluorouracil supplementation on trabeculectomy for open angle glaucoma. am j ophthalmol. 1992; 114: 737-41. 8. bidlish r, condon gp et al. efficacy and safety of mitomycinc in primary trabeculectomy. ophthalmology. 2002; 109:133642. 9. suner ij, greenfield ds et al. hypotonymaculopathy after filtering surgery with mitomucin-c. ophthalmology. 1997; 104: 207-15. 10. zimmerman tj, kooner ks et al. trabeculectomyvs nonpenetrating trabeculectomy: a retrospective study of two procedures in phakic patients with glaucoma. ophthalmic surg 1984; 15: 734-40. 11. koslov vi, bagrov sn, et al. non-penetrating deep sclerectomy with collagen. eye microsurg. 1990; 1: 44-6. 12. stegmann r, pienaar a, miller d. viscocanalostomy for open– angle glaucoma in black african patients. j cataract refract surg. 1999; 25: 316-22. 13. hondur a, onol m, hasanreisoglu b. nonpenetrating glaucoma surgery: meta-analysis of recent results. j glaucoma. 2008; 17: 139-46. 14. gedde sj, schiffman jc, feuer wj et al. three-year follow-up of the tube versus trabeculectomy study. am j ophthalmol. 2009; 20: 1-15. prof. p.s mahar glaucoma combining the cataract and glaucoma surgery (phaco trabeculectomy) might work but the results are not predictable always. m lateef chaudhry editor-in-chief microsoft word kh. khalid shoaib 1 109 review article update on risk factors and prophylaxis of endophthalmitis after cataract operation khawaja khalid shoaib pak j ophthalmol 2008, vol. 25 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: khawaja khalid shoaib, head of eye department cmh kharian cantt. received for publication may 2008 … ……………………… endophthalmitis is a devastating complication occurring in a few cases after cataract surgery but resulting in profound morbidity. thus every eye surgeon should remain vigilant to avoid it. the options of povidone iodine application to skin and conjunctiva, suturing the wound to make it leak proof, use of iol injectors, intracameral cefuroxime or moxifloxacin, post operative levofloxacin/ gatifloxacin / moxifloxacin has profoundly reduced the incidence of endophthalmitis. ndophthalmitis is an inflammatory reaction occurring as a result of intraocular colonization by bacteria, fungi or rarely parasites. commonly it is exogenous i.e. microbial entry from ocular surface through open wound/foreign bodies (e.g. post–traumatic) or through contaminated instruments/ intraocular lenses (iols) (e.g. post–operative). rarely endophthalmitis may be endogenous (septicemic) in origin. pathophysiology: in approximately 30-45% of cataract operations, intraocular contamination occurs with facultative pathogenic bacteria from the ocular surface without the development of endophthalmitis1-3. however, immune mechanisms of eye are effective in limiting the inflammatory process in most of the cases. whether the endophthalmitis will occur or not and its final picture depends on various factors: firstly the characteristics and quantitiy of pathogens. secondly patient’s body resistance. last but not least is the delay in initiation and the quality of treatment. in microbial endophthalmitis, the first phase is the incubation period, which lasts 16-18 hours and is mainly determined by generation time of the pathogen e.g. staphylococcus(staph) aureus up to 10 min, propionibacterium (p) >5 hours and specific characteristics of the pathogens (e.g. toxin production). next is the invasion by macrophages and lymphocytes (acceleration phase) which is followed by the destructtion phase in which the inflammatory mediators e 110 especially cytokines not only recruit further leukocytes but directly result in retinal injury4,5. microbial spectrum: pathogens causing post-phacoemulsification (phaco) endophthalmitis are5: in approximately 50% of cases coagulase– negative staphylococci (cns). in approximately 15% staphylococcus (staph) aureus. in approximately 15% streptococci (s) including β and α haemolytic, s. pneumoniae. in approximately 15% gram negative e.g. pseudossmonas (ps) aeruginosa, haemophilus influenzae etc. in approximately 5% fungi (candida, aspergillus) the most important pathogens causing acute post cataract endophthalmitis are streptococci, staph aureus, cns, and gram negative rods. in chronic postoperative endophthalmitis pathogens are5. propionibacterium acnes, diphtheroids, cns and fungi. in an indian study, nocardia species6 and in a pakistani study staph aureus was the commonest pathogen isolated in endophthalmitis cases7. ochrobactrum anthropi has also been found to cause chronic pseudophakic endophthalmitis8. incidence: after introduction of phaco and clear corneal incision (cci), with only povidone iodine prophylaxis, incidence of endophthalmitis is 0.3-0.5% in europe9,10 and 0.015% in usa. the european society of cataract and refractive surgery (escrs) study has found the lowest observed incidence rates were for the group which received both intracameral cefuroxime and perioperative topical levofloxacin11. these rates were 0.049 percent for presumed endophthalmitis and 0.025 per cent for proven endophthalmitis. incidence of acute endophthalmitis after cataract surgery has been found to be 0.05% in an indian study6 and following intraocular surgeries 0.60% in a pakistani study12. risk factors escrs study10 findings: endophthalmitis incidence was approximately 6 times greater with clear corneal incision (cci) than with scleral tunnel incision (csi). wound leak on first post op day13 has been implicated as important factor. thus suturing of the wound to produce leak proof incision after cci was found preferable14. the endophthalmitis risk was reduced by 5 fold in superior csi compared to temporal cci15. patients receiving silicone iols were 3.13 times more likely than any other material iol and those experiencing intraoperative capsular or zonular complications were 4.95 times more liable to develop infection. rate of complications is higher if operated by junior staff. use of injectors for iol: use of injectors for iol has been found to reduce the risk of developing infection16. diabetes mellitus: about 15 -20 % of all patients who develop post operative endophthalmitis after cataract operations are diabetic17,18. if glycemic control is poor or diabetic retinopathy is present17, prognosis is usually worse. immune suppression: patients on topically or systemically administered immuno suppressants (corticosteroids, antimetabolites) at the time of operation have a significantly higher risk of endophthalmitis19. altered bacterial flora: atopic and those having rosacea have preponderance of staph aureus20. preferably they should be given anti staph prophylaxis prior to and after surgery21. prophylaxis 1. operating theatre: all instruments for surgery should be thoroughly washed and sterilized with autoclaving. single use of tubing and other disposables is ideal if cost allows. tubing is preferably sterilized with ethylene oxide gas sterilizer. bottles of solutions containing bss (balanced salt solution) etc. should never be kept or used for more than one operating session. any air vent applied to these bottles should be protected by a bacterial filter. 2. antisepsis: after extracapsular cataract extraction, 85% of endophthalmitis cases have been traced to the patient by comparing dna profiles of vitreous isolates of bacteria with those collected from the lid and skin flora of the patient.22 the goal of pre-operative antisepsis is to reduce the total bacterial count in the wound area. for peri-orbital skin antisepsis, a 5-10 % povidone –iodine solution applied for a minimum of 3 min is recommended. in case of allergy to it, an aqueous solution of chlorhexidine (0.05%) can be used 23, 24. for antisepsis of conjunctiva and cornea, 5 % solution of povidone –iodine (a 10% solution of povidone – iodine can be diluted 1:1 with bss or isotonic saline) applied 111 for 3 min reduces the number of bacteria from 10 to 100 fold25-29. it can, however, cause problems if it gets into the anterior chamber30. large bottles of diluted povidone –iodine or chlorhexidine should be avoided and single-use sachets or vials be used as both antiseptics can become contaminated with ps. aeruginosa. covering the eye lashes with adhesive tape31 (opsite etc), prevents them from coming in the surgical field. 3. antibiotics • pre operative topical: lower endophthalmitis rate has been observed following use of topical ofloxacin compared to topical ciprofloxacin32. levofloxacin reaches higher concentrations in the anterior chamber than ofloxacin and ciprofloxacin33-35. in escrs study10 patients were administered one drop of 0.5% levofloxacin one hour and one drop 30 min before surgery and three drops at five – minute intervals immediately following surgery. moxifloxacin (vigamox, megamox etc) has been found to penetrate the eye significantly better than ofloxacin36. quinolones are more effective against methicillin-sensitive coagulase-negative staphylococci than methicillin-resistant coagulase-negative staphylococci and the fourth generation fluoroquinolones appear to be more potent, affecting even coagulasenegative staphylococcal strains resistant to second generation fluoroquinolones37. a few recommend that reserve/latest antibiotics should not be used for routine preoperative prophylaxis while others routinely use moxifloxacin. in an online survey of ophthalmologists practicing in canada, it was found that topical antibiotics, of which moxifloxacin was the most common (32%), were used preoperatively by 78%38. corneal precipitation of fluoroquinolones may provide an advantageous drug depot but delay healing and result in corneal perforation in approximately 10% of cases39. no significant difference in antibiotic effects between moxifloxacin and levofloxacin on most bacterial strains(except for serratia marcescens) has been found however levofloxacin seemed to be safer than moxifloxacin in human corneal epithelial cells40. systemic: in our set up many people use systemic antibiotic prophylaxis to cover mild/undiagnosed systemic infections however others recommend that routine cataract surgery does not require oral systemic antibiotic prophylaxis unless the patient has severe atopic disease. • intra-operative addition to irrigating solution: though a large number of surgeons have been using antibiotics like gentamicin and vancomycin, added to the irrigating solution, it has not been found to decrease incidence of endophthalmitis41-43. onset of action of vancomycin, in vitro is observed only after three to four hours while the half–life of the drug in anterior chamber is three hours. in addition there is risk of aminoglycoside retinal toxicity and development of resistance. as an intracameral injection in 0.1 ml at the end of surgery: all swedish cataract surgeons routinely give an intracameral injection of 1 mg cefuroxime in 0.1 ml at the end of phaco surgery and over 400000 patients had been given cefuroxime intracamerally till august 2007. escrs study found that risk of endophthalmitis following phaco was reduced by five fold by an injection of cefuroxime at the end of surgery10, 11. there is a small risk of allergic reaction to cefuroxime in patients with known allergy to penicillin44. in these patients an antihistamine tablet 15 minates before surgery may be considered. in patients with known allergy to cephalosporins, cefuroxime should not be used and vancomycin may be used instead. for intracameral use at the end of the operation moxifloxacin has been found to be safe in an animal model45 and humans46 as far as anterior chamber reaction, pachymetry, and corneal endothelial cell density is considered and also effective (68% of staph. epidermidis endophthalmitis were sensitive)47. espiritu presented his experience of intracameral injection at the end of operation, in asia pacific acadamy of ophthalmology, lahore in jan 2007. 0.1 ml of solution can be taken directly from the eye drop bottle as it is preservative free and isotonic with the aqueous. author has injected moxifloxacin in more than 1500 cataract (90 % phaco) operations in the last one and a half years and is satisfied with its safety and efficacy. subconjunctival injection: subconjunctival antibiotic injection prophylaxis has been used over the last 30 years but has not been found effective5,48. 125 mg of cefuroxime given by subconjunctival route gave levels of 20 µg /ml in the anterior chamber, which is far lower than that (3000 µg /ml) which occurs when injected by the intracameral route. gentamicin, used by many, has no activity against streptococci and propionibacterium acnes. • post operative 112 escrs study recommended that to maintain an adequate level of levofloxacin in the anterior chamber, it may be considered continuing to dose every one to two hours topically post operatively on the day of surgery and from the next day on four times daily49. use of the preoperatively applied topical antibiotic is recommended four times a day for upto two weeks. 1.25 per cent povidone iodine has been recommended post operatively as it significantly reduced conjunctival bacterial count28. in canada online survey revealed that postoperative topical antibiotics, of which moxifloxacin was the most common (30%), were used by 97% of ophthalmologists38. author’s affiliation lt. col. khawaja khalid shoaib head of eye department cmh, kharian cantt reference 1. sherwood dr, jacobs rwj, hart js, et al. bacterial contamination of intraocular and extraocular fluids during extracapsular cataract extraction. eye. 1989; 3: 308-12. 2. dickey jb, thompson kd, jay wm. anterior chamber aspirate cultures after uncomplicated cataract surgery. am j ophthalmol. 1991; 112: 278-82. 3. streile jw. ocular immune privilege and the faustian dilemma. lnvest ophthalmol vis sci. 1996, 1940 -1950; 37. 4. kon ch, occleston nl, aylward gw, et al. expression of vitreous cytokines in proliferative vitreoretinopathy: a prospective study. invest ophthalmol vis sci. 1999; 40: 705-12. 5. peyman g, lee p, seal dv. endophthalmitis-diagnosis and management. taylor and francis, london: 2004; 1-270. 6. lalitha p, rajagopalan j, prakash k, et al. postcataract endophthalmitis in south india incidence and outcome. ophthalmology. 2005; 112: 1884-9. 7. chaudhri ss, amir m, kadri wm. treatment of endophthalmitis with intravitreal injection of antimicrobials. pak j ophthalmol. 2000; 16: 33-7. 8. song s, ahn jk, lee gh, et al. an epidemic of chronic pseudophakic endophthalmitis due to ochrobactrum anthropi: clinical findings and managements of nine consecutive cases. ocul immunol inflamm. 2007; 15: 429-34. 9. patwardhan a, rao gp, saha k, craig ea. incidence and outcomes evaluation of endophthalmitis management after phacoemulsification and 3-piece silicone intraocular lens implantation over 6 years in a single eye unit. j cataract refract surg. 2006; 32: 1018-21. 10. escrs endophthalmitis study group: prophylaxis of postoperative endophthalmitis following cataract surgery: results of the escrs multi-centre study and identification of risk factors. j cataract refract surg. 2007; 33: 978-88. 11. seal dv, barry p, gettinby g, et al. escrs study of prophylaxis of post-operative endophthalmitis after cataract surgery: case for a european multi-centre study. j cataract refract surg. 2006; 32: 396-406. 12. babar tf, masud z, saeed nasir, et al. a two years audit of admitted patients with the diagnosis of endophthalmitis. pak j med res sep. 2003; 42: 105-11. 13. wallin t, parker j, jin y, et al. cohort study of 27 cases of endophthalmitis at a single institution. j cataract refract surg. 2005; 31: 735-41. 14. msaket s. is there a relationship between clear corneal cataract incisions and endophthalmitis. j cataract refract surg. 2005; 31: 643-5. 15. nagaki y, hayasaka s, kadoi c, et al. bacterial endophthalmitis after small-incision cataract surgery. effect of incision placement and intraocular lens type. j cataract refract surg. 2003; 29: 20-6. 16. mayer e, cadman d, ewings p. a 10 year retrospective study of cataract surgery and endophthalmitis in a single eye unit: injectable lenses lower the incidence of endophthalmitis. br j ophthalmol. 2003; 87: 867-9. 17. dey s, pulido js, tessler hh, et al. progression of diabetic retinopathy after endophthalmitis. ophthalmology. 1999; 106: 774-81. 18. philipps wb, tasman ws. postoperative endophthalmitis in association with diabetes mellitus. ophthalmology. 1994; 101: 508-18. 19. montan pg, koranyi g, setterquist he, et al. endophthalmitis after cataract surgery; risk factors relating to technique and events of the operation and patient history. a retrospective case-control study. ophthalmology. 1998; 105: 2171-7. 20. seal d, wright p, ficker l, et al. placebo-controlled trial of fusidic acid gel and oxytetracycline for recurrent blepharitis and rosacea. br j ophthalmol. 1995; 79: 42-5. 21. seal dv, bron aj, hay j. ocular infection-investigation and treatment in practice. martin dunitz, london. 1998; 1: 275. 22. speaker mg, milch fa, shah m k. role of external bacterial flora in the pathogenesis of acute post-operative endophthalmitis. ophthalmology. 1991; 98: 639-49. 22. kramer a, rudolph p. efficacy and tolerance of selected antiseptic substances in respect of suitability for use on the eye. in: kramer, a. and behrens-baumann, w. (eds.): antiseptic prophylaxis and therapy in ocular infections. s. karger ag, basel. 2002; 117-44. 23. montan pg, setterquist h, marcusson e, et al. pre-operative gentamicin eye drops and chlorhexidine solution in cataract surgery. experimental and clinical results. eur j ophthalmol. 10, 2000, 286-292. 24. binder ca, mino de kaspar h, engelbert m, et al. bakterielle keimbesiedelung der konjunktiva mit propionibacterium acnes vor und nach polyvidon-jod-applikation vor intraokularen eingriffen. ophthalmology. 1998; 95: 438-41. 25. binder ca, mino de kaspar h., kalu bv, et al. praoperative infektionsprophylaxe mit 1%-iger polyvidonjodlosung am beispiel von konjunktivalen staphylokokken. ophthalmology. 1999; 96: 663-7. 26. isenberg sj, apt l, yoshimori r, et al. chemical preparation of the eye in ophthalmic surgery. iv. comparison of povidoneiodine on the conjunctiva with a prophylactic antibiotic. arch ophthalmol. 1985; 103: 1340-2. 27. isenberg sj, apt l, yoshimori r, et al. efficacy of topical povidone-iodine during the first week after ophthalmic surgery. am j ophthalmol. 1997; 124: 31-5. 28. isenberg sj, apt l, yoshimuri r. chemical preparation of the eye in ophthalmic surgery. i. effect of conjunctival irrigation. arch ophthalmol. 1983; 101: 761-3. 29. alp bn, elibol o, sargon mf, et al. the effect of povidone iodine on the corneal endothelium. cornea. 2000; 19: 546-50. 113 30. behrens-baumann w, dobrinski b, zimmermann o. bakterienflora der lider nach praoperativer desinfektion. klin. mbl. augenheilkd. 1988; 192: 40-3. 31. jensen mk, fiscella rg, crandall as, et al. a retrospective study of endophthalmitis rates comparing qulnolone antibiotics. am j ophthalmol. 2005; 139: 141-8. 32. bucci fa. an in vivo study comparing the ocular absorption of levofloxacin and ciprofloxacin prior to phacoemulsification. am j ophthalmol. 2004; 137: 308-12. 33. colin j, simonpoli s, geldsetzer k, et al. corneal penetration of levofloxacin into the human aqueous humour: a comparison with ciprofloxacin. acta ophthalmol scand. 2003; 81: 611-3. 34. koch hr, kulus sc, roessler m, et al. corneal penetration of fluoroquinolones: aqueous humour concentrations after topical application of levofloxacin 0.5% and ofloxacin 0.3%eyedrops. j cataract refract surg. 2005; 31: 1377-85. 35. lai ww, chu ko, chan kp, et al. differential aqueous and vitreous concentrations of moxifloxacin and ofloxacin after topical administration one hour before vitrectomy. am j ophthalmol. 2007; 144: 315-8. 36. oliveira ad, höfling-lima al, belfort r jr, et al. fluoroquinolone susceptibilities to methicillin-resistant and susceptible coagulase-negative staphylococcus isolated from eye infection. arq bras oftalmol. 2007; 70: 286-9. 37. hammoudi ds, abdolell m, wong dt. patterns of perioperative prophylaxis for cataract surgery in canada. can j ophthalmol. 2007; 42: 681-8. 38. thompson am. ocular toxicity of fluoroquinolones. clin experiment ophthalmol. 2007; 35: 566-77. 39. kim sy, lim ja, choi js, et al. comparison of antibiotic effect and corneal epithelial toxicity of levofloxacin and moxifloxacin in vitro. cornea. 2007; 26: 720-5. 40. center for disease control: recommendations for preventing the spread of vancomycin resistance. morb mort wkly rep 44 (rr-12), 1995; 1-13. 41. aao-cdc task force: the prophylactic use of vancomycin for intraocular surgery. quality of care publications, number 515, american academy of ophthalmology. san francisco, ca, 1999. 42. may l, navarro vb, gottsch jd. first do no harm; routine use of aminoglycosides in the operating room. insight 2.5. 2000; 7780. 43. pichichero me. cephalosporins can be prescribed safely for penicillin-allergic patients. j fam pract. 2006; 55: 106-12. 44. o'brien tp, arshinoff sa, mah fs. perspectives on antibiotics for postoperative endophthalmitis prophylaxis: potential role of moxifloxacin. j cataract refract surg. 2007; 33: 1790-800. 45. espiritu cr, caparas vl, bolinao jg. safety of prophylactic intracameral moxifloxacin 0.5% ophthalmic solution in cataract surgery patients. j cataract refract surg. 2007; 33: 63-8. 46. miller dm, vedula as, flynn hw jr, et al. endophthalmitis caused by staphylococcus epidermidis: in vitro antibiotic susceptibilities and clinical outcomes. ophthalmic surg lasers imaging. 2007; 38: 446-51. 47. ciulla ta, starr mb, masket s. bacterial endophthalmitis prophylaxis for cataract surgery. ophthalmology. 2002; 109: 1324. 48. sundelin k, stenevi u, seal d, et al. corneal penetration of topical levofloxacin 0.5% pharmacokinetic profile with aqueous humour concentrations after intensive preand post-operative dosing and implications for prophylactic use. 2007, manuscript submitted to acta ophthalmol scand. microsoft word sorath noorani 7 original article role of fundus fluorescein angiography in preproliferative diabetic retinopathy sorath noorani, alyscia cheema pak j ophthalmol 2008, vol. 24 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sorath noorani pediatric ophthalmologist pcb cell, eye opd civil hospital karachi received for publication july’ 2007 …..……………………….. purpose: to identify subtle areas of ischemia and extent of capillary nonperfusion, not visible clinically and to differentiate intra-retinal microvascular abnormalities from neovascularization. material and methods: fundus fluorescein angiography of 25 patients having ppdr unilaterally or bilaterally was performed in eye department of jpmc from october 2001 to december 2002. fundus fluorescein angiography was used as an important diagnostic tool to show exact location and extent of vascular changes of ppdr. diabetic patients who had ppdr in one or both eye, clear media, no history of allergic reactions and normal renal profile were selected for fundus fluorescein angiography. argon panretinal photocoagulation was planned in patients who already had complications of diabetic retinopathy in other eye and in patients who were unable to attend follow up visits, which is a major problem in our society. results: out of 25 patients 9 patients (36%) showed areas of capillary dropout on angiogram, which were not visible on clinical examination. intraretinal microvascular abnormalities were confirmed in 13 patients (52%) along with areas of capillary nonperfusion. two patients (8%) were proved to have neovessels on angiogram. one patient (4%) showed no additional finding on angiogram but only confirmed the clinical findings. argon laser panretinal photocoagulation was performed on 24 eyes of 15 patients (60%). one patient (4%) had green laser photocoagulation around irma only. nine patients (36%) were advised strict diabetic control and follow up visits to monitor progression of disease and need of treatment conclusion: fundus fluorescein angiography was of the greatest assistance in showing the exact location of retinal vascular abnormalities and extent of capillary dropout, which were asymptomatic lesions, but a major threat to the sight of patient. or over 30 years, fundus photography and fluorescein angiography have been extremely valuable for expanding our knowledge to visualize the chorioretinal circulation1 and in evaluating retinal vascular disorders2. maumence and maclean3 had used fluorescein in human fundus to help distinguish melanomas from hemangiomas during ophthalmoscopy. fundus fluorescein angiography (ffa) is a well-established technique in ophthalmic practice. the common uses of fluorescein f 8 angiography are in retinal and choroidal vascular diseases such as diabetic retinopathy, macular degeneration, hypertensive retinopathy and vascular occlusions. the angiogram is used to determine the extent of damage, to develop treatment plan and to monitor the results of treatment4. in diabetic retinopathy the angiogram is useful in identifying the extent of ischemia, the location of micro aneurysms, the presence of intraretinal microvascular abnormalities (irma) that can only be confirmed on angiogram; neovascularization and the extent of macular edema5. fluorescein angiography is an excellent method to display the retinal capillaries in detail to show the pathologic changes because the retinal pigment epithelium provides a good background. ffa is not only useful for diagnosis but also to gauge the progression and management of diabetic retinopathy4 (dr). ffa is a therapeutic guide to laser photocoagulation treatment for several retinal vascular diseases. clinical investigations of dr are necessary using fundus photographs and fluorescein angiograms6,7. the objectives of this study were to identify subtle areas of ischemia and extent of capillary nonperfusion, which is not visible clinically and differentiate collaterals and irma from new vessels so that laser can be applied on required areas only. materials and methods fundus fluorescein angiography of 25 patients included in this study was performed in the eye department of jinnah postgraduate medical center, from october 2001 to december 2002. patients older than 12 years of age suffering from diabetes mellitus with clear media, with or without visual symptoms and clinical fundal findings of cotton wool spots and venous changes and patients having marked visual loss but no significant findings clinically were included in this study. clinical data of each patient fulfilling inclusion criteria was recorded on prescribed proforma. visual acuity and pinhole test of every patient were recoded using snellen’s chart for literate and e chart for illiterate patient. near vision was recorded using n chart uniocularly and binocularly. retinoscopy was done and best-corrected vision was noted. anterior segment examination on slit lamp biomicroscope was done for corneal abnormalities, anterior chamber assessment, rubeosis iridis, pupillary reaction, lenticular changes (media clarity) and anterior vitreous pathology. intra ocular pressure was recorded with goldman applanation tonometer. pupil dilation was done with 1 % tropicamide eye drops instilled in both eyes. in non hypertensive patients phenylephrine 10% eye drops were used for pupillary dilation and fundi were examined with direct ophthalmoscope, indirect ophthalmoscope, 90 diopter hand held non contact lens and three mirror contact lens on slit lamp biomicroscope. random, fasting blood sugar and renal profile to assess kidney function were carried out. procedure and possible side effects were also explained to the patient. kowa-rc-xv3 45084-fundus camera was used for color photographs and fluorescein angiography. standard method of ffa was followed. a resuscitation tray was kept ready to manage any serious complications of ffa. out of 25 patients 1 (4%) patient had dry throat and coughing and 1 (4%) patient had pain and discoloration at the site of injection due to extravasation of dye. no serious side effect of intravenous fluorescein was encountered. in this study, panretinal photocoagulation (prp) was done in patients who had severe subtype of preproliferative diabetic retinopathy (ppdr), proliferative diabetic retinopathy (pdr) in fellow eye, only eyed patients who have already lost sight in their fellow eyes due to complications of pdr and in patients who were unable to revisit for follow-up. this is the major problem in our part of society that leads the patients towards blindness. results fundus fluorescein angiography was performed on 50 eyes of 25 patients having ppdr. mean age of the patients was 53.2 ± 5.4 years (ranging from 43 to 61 years). there were 9 (36%) males and 16 (64%) females. family history of diabetes was positive in 16 (64%) patients while 9 (36%) patients had no family history of diabetes. diabetes mellitus was insulin dependent in 15 (60%) patients and non-insulin dependent in 10 (40%) patients. associated risk factor like hypertension was present in 14 (56%) patients and 11 (44%) patients had no history of hypertension. all three stages of diabetic retinopathy were seen in the 50 eyes of 25 patients. six (24%) patients were found to have pdr in one eye while ppdr in the other eye. fourteen (56%) patients had ppdr in both eyes. three (12%) patients had ppdr in one and background 9 diabetic retinopathy in the other eye. two (8%) patients had pdr bilaterally. in the eyes of 25 patients having ppdr in one or both eyes the most common angiographic finding was areas of capillary dropout seen in eyes of 9 (36%) patients (fig. 1). irma and areas of capillary nonperfusion together (fig. 2) were seen in eyes of 13 (52%) patients. two (8%) cases were clinically diagnosed as irma were found to have profuse and progressive leakage (hyper-fluorescence) proving them to have pdr. clinically 1 (4%) patient had microaneurysms, dot and blot hemorrhages scattered in all quadrants of fundus, multiple cotton wool spots, dilated and tortuous veins in both eyes. when ffa was done it only confirmed these clinical findings. areas of capillary nonperfusion were only present at the sites where cotton wool spots were clinically seen. no specific angiographic findings for ppdr like irma or capillary dropout other than cotton wool spots seen on clinical examination were observed. panretinal photocoagulation (prp) was performed in 24 eyes of 15 (60%) patients as shown in table 1. out of these 15 patients, 8 eyes of 4 patients had bilateral prp because on angiography 4 eyes of 2 patients were proved to have pdr in both eyes .two patients had pdr in 1 eye, which had to be treated by prp. their fellow eyes had severe type of ppdr which were treated by prp to prevent complications because they refused to come for follow up visits. four patients were treated by prp unilaterally because of the proliferative stage of the disease while their fellow eyes had ppdr clinically and angiographically so they were advised strict diabetic control and to keep follow up visits as they lived in the city. on angiography, 14 eyes of 7 patients were found to have ppdr bilaterally; prp was performed on 12 eyes of 7 patients as they belonged to remote areas. seven patients (14 eyes) having ppdr were advised to keep follow up visits as they belonged to the city. one patient was found to have irma and capillary dropout in his left eye along the superonasal arcade. his right eye had background diabetic retinopathy. green laser around irma was done in his left eye while grid treatment was performed bilaterally as he had diffuse exudative diabetic maculopathy in both eyes. he was also advised follow up visits. two patients having preproliferative in one and background diabetic retinopathy in other eye were also advised strict diabetic control and follow up visits to monitor progression of disease. discussion the early detection of diabetic retinopathy leads to a marked reduction of morbidity due to visual loss. major international studies indicate that therapy is best instituted before serious complications develop. a study made by harding et al8 suggested that screening of diabetic retinopathy prevents blindness but because of inadequacies of current screening programs, many diabetic patients never receive treatment before developing severe visual loss. after appropriate screening, early laser photocoagulation prevents severe visual loss. several alternative screening methods exist like direct ophthalmoscopy, various methods of fundus photography, slit lamp biomicroscopy and ffa8. in a study by adhi and associates9 diabetic retinopathy was identified in large number of patients, either focal or scatter laser photocoagulation was done after identifying leaking spots or capillary non-perfusion on fluorescein angiography. in our study ffa had been used as an important tool to evaluate the lesions of ppdr, which were not detectable on ophthalmoscopy and slit lamp biomicroscopy, such as areas of capillary nonperfusion. irma were also best picked up and differentiated from neovascularisation by means of ffa. by observing the change of fluorescence to detect and quantify areas of leakage and capillary nonperfusion. philips and coworkers10 believed this technique is sufficiently sensitive and robust for clinical use. ffa confirms a presumed diagnosis, determines the course of treatment and documents the finding that may change over time11. in 1993, sato, kamata, matsui12 classified 155 eyes (106 patients) affected by ppdr into three sub-groups on the basis of ffa. mild type with soft exudates and without apparent non perfused areas on fluorescein angiography (39 eyes), moderate type with demonstrable non perfused areas on angiography (103 eyes) and severe type with soft exudates, venous beading and non perfused areas on angiogram (13 eyes). the courses of these three sub-groups were analyzed after one year of follow up. after one year table 1: mode of treatment in 50 eyes of 25 patients 10 treatment preproliferative diabetic retinopathy n = 37 proliferative diabetic retinopathy n = 10 back ground diabetic retinopathy n = 3 follow up 22 0 3 prp 14 10 0 laser around irma 1 0 0 • irma = intraretinal microvascular abnormalities • cnp = capillary non-perfusion • none =(no irma or cnp seen) • nve = neovascularization elsewhere fig. 1: angiographic findings in 25 patients fig. 2: angiogram showing areas of capillary drop out and intra retinal microvascular abnormalities the population developing pdr was 0% in mild type, 18% in moderate type and 46% in severe type. sato and lee13 conducted another study in 2002 based on their sub-classification of ppdr proposed earlier12. they followed up 54 patients (95 eyes) with ppdr for at least 2 years and found out that proportion developing pdr was 24% in mild type and 60% in moderate type. in mild type eyes, the rate of progression to moderate type was 56% and further progression from moderate to pdr occurred in 43%. based on the above results they concluded that their sub-classification of ppdr on ffa could be applied to the early management of the patients with ppdr to prevent vision threatening complications. in etdrs14, ppdr had 15% chances and very severe ppdr had 45% chances of developing pdr within one year. in our study ffa in eyes having ppdr evaluated areas of capillary nonperfusion in 36%, irma and capillary dropout in 52% of patients. all of them had scattered intraretinal hemorrhages and micro-aneurysms in all four quadrants. by comparing this study with etdrs we found that 52% of patients had severe type of ppdr and they had 45% of chances to develop pdr within one year. a retrospective study on reperfusion of occluded capillary bed in diabetic retinopathy done by takahashi et al15 reviewed 292 fluorescein angiograms of 94 eyes of 74 patients with diabetic retinopathy. reperfusion of occluded capillary beds was observed in 65 (69%) of 94 eyes. reperfusion was characterized by re-canalization in 22 (34%) of 65 eyes or by intraretinal revascularization in 54 (83%) of 65 eyes. in angiographic findings n = 25 0 2 4 6 8 10 12 14 irma + cnp cnp none nve 11 our study intraretinal micro vascular abnormalities were observed in 52% of patients. several studies had been done on early laser treatment for diabetic retinopathy insisting to consider scattered prp in severe and very severe pdr before the development of high risk spdr16-18. treatment by prp in ppdr is indicated when patient is unable to attend follow up visits or when vision in one fellow eye has already been lost from complications of dr5. in our study 12 eyes of 7 patients having ppdr were treated by prp because they refused to attend follow up visits and 2 eyes of 2 other patients having ppdr were treated by prp as they had lost vision in their fellow eyes from complications of diabetic retinopathy. zhang c f19 made a study on laser treatment for ppdr and pdr. 105 patients with preproliferative dr and pdr were treated with argon laser prp. among 80 patients (138 eyes) followed up for over 1 year, 50.7% had visual acuity improved by 2 lines on snellen’s chart, 39.7% had visual acuity up or down by 1 line and 10.1% had visual acuity dropped over 2 lines due to complications. researcher had insisted on early treatment of diabetic retinopathy. in our study, 25 (50%) out of 50 eyes having pre pdr and pdr were treated by argon laser pan retinal photocoagulation to prevent vision threatening complications. in a study by carstocea b20 1050 eyes with diabetic retinopathy (70 eyes ppdr and 380 eyes pdr), were treated by argon laser photocoagulation after angiographic diagnosis. twenty percent of treated cases had repeated photocoagulation, 70% required no repeated treatment, and 10% presented with complication of dr. author had signified and stressed the early detection and treatment for diabetic retinopathy. while our results are well below these studies but considering the factors of late presentation and lack of awareness of the disease in our people, these figures are fairly acceptable. conclusion fundus fluorescein angiograpy was of the greatest assistance in showing the exact location of retinal vascular abnormalities and extent of capillary dropout, which was asymptomatic clinically, but a major threat to the sight of patient. it picks up the asymptomatic but progressive stage of diabetic retinopathy. severity of the disease process, which is not seen or assessed clinically, can be judged by means of ffa. screening of diabetic population and our elderly population to detect undiagnosed diabetic retinopathy should therefore be undertaken. laser treatment can be performed before the development of sight threatening complications of diabetic retinopathy and vision of the patients can be saved. acknowledgements i thank professor ziauddin shaikh, head of department ophthalmology civil hospital karachi, for his help and support in writing this paper. i also thank intisaar siddiqui, statistician at cpsp karachi for his help in statistical analysis of this study. author’s affiliation dr. sorath noorani pediatric ophthalmology pcb cell, eye opd civil hospital, karachi dr. alyscia cheema assistant professor of ophthalmology jinnah postgraduate medical center karachi 12 reference 1. sargento l, zabala l, saelanha c, et al. sodium fluorescein influence on the hemorheological profile of non-insulin dependent diabetes mellitus patients. clin hemerheol microcirc. 1999; 20: 77-84. 2. terasaki h, miyake y, awaya s. fluorescein angiography of peripheral retina and pars during vitrectomy for proliferative diabetic retinopathy, am j ophthalmol. 1997; 123: 370-6. 3. maclean al, maumence ae. haemangiomas of the choroids, am j ophthalmol. 1960; 50: 3. 4. durani j. fluorescein angiography: the concept that flourished, pak j ophthalmol. 1997; 13: 1–2. 5. kanski jj. retinal vascular diseases, kanski jj, (ed) clinical ophthalmology, oxford, buttersworth-heinemann. 1999; 464513. 6. funatsu h, yamashita h, shimada m, et al. reliability of evaluating grade of diabetic retinopathy, nippon ganka gakkai zasshi. 1993; 97: 396–402. 7. jeddi a, osman b, daghfous f, et al. methods for screening and surveillance of diabetic retinopathy, j fr ophthalmol. 1994; 17: 769–73. 8. harding sp, broadbent dm, neoh c, et al. sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the liverpool diabetic eye study, bmj 1995; 311: 1131-5. 9. adhi mi, ansari, aa, aziz mu, et al. clinical audit of fundus fluorescein angiograms, pak j ophthalmol. 1997; 13: 3–7. 10. phillips rp, rose pg, sharp pf, et al. use of temporal information to quantify vascular leakage in fluorescein angiography of retina, clin phys physiol meas. 1990; 11: 81–5. 11. muhammad s. fundus fluorescein angiography, j postgrad med inst pesh. 1998; 12: 8-16. 12. sato y, kamata a, matsui m. sub-classification of pre-proliferative diabetic retinopathy, jpn j ophthalmol. 1993; 37: 490-8. 13. sato y, lee z., the sub-classification and long-term prognosis of pre-proliferative diabetic retinopathy, jpn j ophthalmol. 2002; 46: 323-9. 14. early treatment diabetic retinopathy study research group. early photocoagulation for diabetic retinopathy. etdrs report 9, ophthalmology. 1991; 98: 766-85. 15. takahashi k, kishi s, muraoka k et al. reperfusion of occluded capillary beds in diabetic retinopathy, am j ophthalmol. 1998; 126: 791-7. 16. lloyd m., diabetic management and treatment of non proliferative diabetic retinopathy and macular edema, jakobiec a. k,ed. principles and practice of ophthalmology, philadelphia , pennsylvania ,w.b saunders. 1994; 747-60. 17. emily cy, frederick lf. non proliferative diabetic retinopathy, ryan sj,ed. retina, 3rd edition st. louis, cv mosby co. 2001; 1295-1308. 18. aiello lp, gardener tw, king gl, et al. diabetic retinopathy, diabetic care. 1998; 21: 143-56. 19. zhang cf. laser treatment for pre-proliferative and proliferative diabetic retinopathy chung hua yen ko tsa chin. 1989; 25: 329-32. 20. carstocea b, anitescu m, dumitrache m. laser treatment in diabetic retinopathy, ophthalmology. 1995; 39: 159-69. 3 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology original article role of oral rifampicin in chronic central serous chorioretinopathy p.s. mahar, nasir memon, a. sami memon, m. faisal faheem pak j ophthalmol 2018, vol. 34, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: prof. p.s mahar isra postgraduate institute of ophthalmology karachi, pakistan e-mail: salim.mahar@aku.edu …..……………………….. purpose: to determine the improvement in visual acuity and central macular thickness in patients with chronic central serous chorioretinopathy (cscr) with oral rifampicin. study design: quasi experimental study. place and duration of study: isra postgraduate institute of ophthalmology, alibrahim eye hospital, karachi. from september 2015 to december 2016. material & methods: ten eyes of 10 patients having chronic cscr of more than 6 months duration were prospectively treated with oral rifampicin 450 mg in single oral dose for 3 months duration. all patients were followed-up for 12 months. results: ten eyes of 10 patients were included in the study. the gender distribution showed 8 male (80%) and 2 female (20%) patients. there were five right and five left eyes. mean age of our patients was 40.10 ± 5.1 years (range 34 – 46 years). mean duration of patient’s ocular symptoms was 9.4 ± 2.9 months with range of 6 – 14 months. patient’s visual acuity improved at 3 months follow-up. mean pre-treatment central macular thickness was 350 ± 82.3 µm improving to 232 ± 54.3 µm at 3 months treatment. conclusion: all patients with chronic cscr of more than 6 months duration showed improvement in their vision and central macular thickness with oral rifampicin taken for 3 months. key words: rifampicin, central serous chorioretinopathy, visual acuity, central macular thickness. entral serous chorioretinopathy (cscr) is characterized by elevation of neuro sensory retina at the posterior pole. in majority of the cases, the cause remains unknown so the condition is termed as idiopathic. cscr is a self-limiting disease with spontaneous resolution occurring within 3 – 4 months of initial episode resulting in good visual outcome1. observation alone is therefore advised as the first line approach in the newly diagnosed cases. however, risks factors such as increase stress score, raised homocysteine and serum cortisol level and elevated systolic blood pressure should be addressed2. unfortunately, recurrences are seen in up to 50% of patients within the first year. in 10 – 20% of cases, patients can have persistent serous retinal detachment with progressive decreased vision3. the exact mechanism of the disease is not known. gass suggested that an increase in the choriocapillaris permeability was the primary cause of damage to the overlying retinal pigment epithelium (rpe), resulting in accumulation of fluid under the neuro sensory retina4. this theory has been recently supported by choroidal vessel staining on indo-cyanine green (icg) angiography and appearance of thickened choroid on swept source optical coherence tomography (oct)5. cscr has been associated with intake of steroids and also described in patients with cushing disease, pregnancy and stress with endogenous high level of cortisol secretion6. as glucocorticoids are implicated in c mailto:salim.mahar@aku.edu role of oral rifampicin in chronic central serous chorioretinopathy pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 4 the pathogenesis of cscr, their inhibition has been suggested as a potential treatment modality. there are several options of treatment described in patients when sub-retinal fluid persists beyond 3 months and condition takes a chronic course with progressive decrease in vision. the icg – guided photodynamic therapy with verteporfen was described by yannuzi in patients with chronic cscr with favorable results7. intravitreal anti – vascular endothelial growth factor (vegf) such as bevacizumab8 and systemic pharmacologic therapy affecting glucocorticoid metabolism has also been described in chronic cscr9. rifampicin is an anti-tuberculous drug and is known to induce cytochrome p450 3a4 to alter the metabolism of endogenous steroids with an improvement in clinical features of cscr10. although the first report of use of rifampicin in chronic cscr is attributed to ravage and packo11 for their presentation during american society of retinal specialist meeting in 2010, the first reported case in literature is described by steinle and colleagues published in british journal of ophthalmology (bjo) in 201112. we carried out a prospective study to evaluate the efficacy of oral rifampicin (rimactal sandoz pakistan) in patients with chronic cscr who had persistent sub-retinal fluid (srf) for more than 6 months of initial presentation with diminished vision. the primary outcome measure in our study was decrease in srf documented on oct and secondary outcome was an increase in the snellen’s visual acuity after the treatment with rifampicin for 3 months. materials & methods we prospectively treated 10 eyes of 10 patients having chronic cscr of more than 6 months duration with oral rifampicin 450 mg in a single oral dose for 3 months. all patients were followed up for 12 months duration. this was quasi experimental study with nonprobability convenience sampling. the study was conducted at isra postgraduate institute of ophthalmology, karachi from september, 2015 till december 2016. the study was approved by the research ethical committee of the institute (protocol no. a-00044). all patients gave consent for taking rifampicin orally. the study patients had detailed history of visual symptoms with any other significant medical or surgical history with intake of any oral medication. the ocular examination included best corrected visual acuity (bcva) on snellen’s chart, bio-microscopic examination of anterior segments with intraocular pressure (iop) measurement. every patient underwent dilated fundus examination with + 90 diopter lens and subsequently oct scan of macula (topcon – japan). in some cases fundus fluorescein angiography (ffa) was also obtained. once patient was initiated on oral rifampicin therapy, ocular examination was repeated at each monthly visit with recording of bcva. at monthly follow up, oct scan was also repeated to demonstrate any change in the presence of srf with decrease in central macular thickness (cmt). all patients with confirmed diagnosis of cscr on clinical examination confirmed with oct scan with age limit of 20 – 50 years were included in the study. any patient having oral acetazolamide, methotrexate or history of intravitreal injection of bevacizumab in last 3 months was excluded. patients taking topical non-steroidal anti-inflammatory drugs and topical carbonic anhydrase inhibitors were also excluded from the study. before the start of the treatment liver function tests (lfts) and complete blood count (cbc)of all patients was worked up. these tests were repeated every month while patient was taking oral rifampicin. rifampicin was discontinued after 3 months of treatment. statistical analysis data analysis was done through the software spss version 20.0. all the continuous variables were presented in mean and standard deviation. the entire categorical variables were shown in frequency and percentages. paired sample t test was used to find the significance between pre and post cmt and chi square test was used for categorical variable like visual acuity. p value≤0.05 was considered to be statistically significant. results ten eyes of 10 patients were included in the study. the gender distribution showed 8 males (80%) and 2 females (20%). there were five left and five right eyes. mean age was 40.10 ± 5.1 years (range 34 – 46 years). mean duration of patient’s ocular symptoms was 9.4 ± 2.9 months with range of 6 – 14 months (table 1). p.s. mahar, et al 5 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology oct= optical coherence tomography cmt= central macular thickness (microns) table 1: demographic characteristics of patients. role of oral rifampicin in chronic central serous chorioretinopathy pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 6 the enrolled patients were commenced on oral rifampicin (450 mg) half an hour before the breakfast. patient’s visual acuity improved at 3 months followup (figure 1). mean pre-treatment central macular thickness (cmt) was 350 ± 82.3 µm improving to 232 ± 54.3 µm at 3 months treatment (figure 2). all patients’ oct scans showing cmt are given in figure a. these patients were followed upto 12 months and showed stable vision. the drug was very well tolerated by all the patients for 3 months duration and improvements in visual acuity and cmt were sustained till 12 months follow-up. age, years 40.10 ± 5.1 age range, years` 32 – 46 gender male 8 (80%) female 2 (20%) affected eye right 5 (50%) left 5 (50%) duration of symptoms (months) 9.4 ± 2.9 *data presented in mean± sd & frequency (%) *chi-square test was applied to see the significance *p-value ≤ 0.05 considered to be statistically significant fig. 1: comparison of visual acuity. fig. 2: comparison of mean central macular thickness (cmt). discussion chronic cscr can be a debilitating disease with decrease in visual acuity due to persistent presence of fluid in the sub-retinal space and wide spread rpe atrophy. it is associated with higher recurrence rate and potentially poor visual prognosis. there are multiple options described in the literature to treat chronic cscr. this includes reduced fluence pdt with verteporfin13, transpupillary thermotherapy14, intravitreal ranibizumab15 and micro-pulse diode laser photocoagulation16. jampol and colleagues first suggested that glaucocorticosteroids antagonist may be of value in treating repeated episodes of cscr. this was based on the association of endogenous hypercortisolism with the development of cscr17. the exact role of glucocorticoids in pathogenesis of cscr is not known but possible mechanism include increased capillary fragility and hyper permeability leading to choroidal circulation decompensation with leakage of fluid in the sub-retinal space18. rifampicin is an anti-tuberculous drug with primary action of inducing cytochrome p450 3a4 which catalyzes the drug metabolism and synthesis of cholesterol, steroids and lipids19. it is therefore suggested that induction of cytochrome p450 3a4 increases the metabolism of endogenous steroids resulting in improvement of cscr features with resolution of sub-retinal fluid. we prospectively treated 10 eyes of 10 patients p-value = 0.028 p-value = 0.007 p.s. mahar, et al 7 vol. 34, no. 1, jan – mar, 2018 pakistan journal of ophthalmology with the diagnosis of chronic cscr showing subretinal fluid on oct scan of more than 6 months duration. all these patients had oral rifampicin 450 mg in single dosage taken for 3 months. as the drug can be hepatotoxic so all our patients had lfts done at baseline and repeated every month till cessation of drug. as all patients had visual complaints of long duration with presence of srf we feel that the resolution of patient’s symptoms with decrease in srf and cmt were induced by rifampicin. it is important to take previous drug intake history of patients before commencing them on rifampicin as it can cause multiple drug interactions with anticoagulants, anti-convulsants, anti-arrythmics, antifungal, beta blockers, calcium channel blockers, steroids and certain antibiotics20. nattis and josephberg has described 3 cases of chronic cscr with patients having blurred vision over past couple of years. all cases showed improvement in their visual acuity and amount of srf present on oct21. biggest series of rifampicin treated patients has come from israel by shulman and colleagues where 14 eyes of 12 patients had been treated with oral rifampicin in dose of 600 mg/day for 4 months22. choudhury and co-workers23 treated 13 patients with chronic cscr, though the duration of patient’s symptoms was merely 6 weeks old. ten of their patients showed improvement in vision with decrease in cmt after getting treatment with rifampicin 600 mg in single dose for 4 weeks. it is not clear from their work that for how long these patients were followed. khan et al24 found that central macular thickness was reduced from 494±96 um to 306±50 um after 4 weeks of treatment with 300 mg rifampicin daily. the optimal dosage and duration of rifampicin in treating chronic cscr is not known. our patients received 450 mg/day for 3 months with remarkable improvement in their clinical features. our work differ from other studies that we only treated those patients who has cscr with visual symptoms of more than 6 months duration and were followed-up for 12 months. as the drug is hepatotoxic and can cause interaction with other drug, proper medical history and lfts at baseline and follow up are mandatory. although cscr is self-limiting disease but persistence of symptoms with presence of srf beyond 3 – 4 months warrants treatment. photodynamic therapy (pdt) with verteporfin with reduced fluence and half exposure time is suggested as the first line treatment. however, this can be associated with pigmentary changes, rpe atrophy, rpe tear, choroidal ischemia and secondary choroidal neovascularization25. focal argon laser therapy is another option when leakage occurs outside foveal avascular zone. but these cases can also be complicated by secondary choroidal neovascularization. rifampicin appears promising, cost-effective and efficacious mode of treatment in chronic cscr. it will be interesting also to explore its value in acute cases where prompt visual recovery is required in patients such as in pilots and doctors. conclusion in this study all patients with chronic cscr of more than 6 months duration showed improvement in their visual acuity and corresponding decrease in central macular thickness on oct, when treated with oral rifampicin 450 mg in single dose for 3 months period. author’s affiliation dr. ps mahar frcs, do, frcophth professor & dean, isra postgraduate institute of ophthalmology, karachi. dr. nasir memon fcps, senior registrar isra postgraduate institute of ophthalmology, karachi. dr. a. sami memon md, fcps, assistant professor isra postgraduate institute of ophthalmology, karachi. mr. m. faisal faheem msc (statistics), statistician isra postgraduate institute of ophthalmology karachi. role of authors dr. ps mahar writing the manuscript. nasir memon collection of data. a. sami memon collection of data. role of oral rifampicin in chronic central serous chorioretinopathy pakistan journal of ophthalmology vol. 34, no. 1, jan – mar, 2018 8 m. faisal faheem statistical analysis. references 1. marmor mf. new hypotheses on the pathogenesis and treatment of serous retinal detachment. graefes arch clin exp ophthalmol. 1988; 226: 548-52. 2. agarwal a, garg m, dixit n, godara r. evaluation and correlation of stress scores with blood pressure, endogenous cortisol levels, and homocysteine levels in patients with central serous chorioretinopathy and comparison with age-matched controls. indian j ophthalmol. 2016; 64: 803-5. 3. spaide rf, goldbaum m, wong dwk, et al. serous detachment of the retina. retina. 2003; 23: 820-46. 4. gass jdm. pathogenesis of disciform detachment of the neuroepithelium: v. disciform macular detachment secondary to focal choroiditis. am j ophthalmol. 1967; 63: 661-87. 5. spaide rf, koizumi h, pozzoni mc. enhanced depth imaging spectral-domain optical coherence tomography. am j ophthalmol. 2008; 146: 496-500. 6. sharma t, shah n, rao m, et al. visual outcome after discontinuation of corticosteroids in atypical severe central serous choriorretinopathy. ophthalmology, 2004; 111: 1708-14. 7. yannuzzi la. chronic central serous and fundus autofluorescence. retinal cases and brief reports, 2008; 2: 1-5. 8. huang wc, chen wl, tsai yy, chiang cc, lin jm. intravitreal bevacizumab for treatment of chronic central serous chorioretinopathy. eye, 2009; 23 (2): 4889. 9. meyerle cb, freund kb, bhatnagar p, shah v, yannuzzi la et al. ketoconazole in the treatment of chronic idiopathic central serous chorioretinopathy. retina, 2007; 27: 943-6. 10. wang m, munch ic, hasler pw et al. central serous chorioretinopathy. acta ophthalmol. 2008; 86: 126-45. 11. ravage z, packo k. rifampicin for treatment of central serous chorioretinopathy. invest ophthalmol vis sci. 2011; 52: 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pathogenesis of central serous chorioretinopathy: a rationale for new treatment strategies. ophthalmology, 2002; 109: 1765-6. 18. garg sp, dada t, talwar d, et al. endogenous cortisol profile in patients with central serous chorioretinopathy. br j ophthalmol. 1997; 81: 962-4. 19. guengerich fp. cytochrome p-450 3a4: regulation and role in drug metabolism. annu rev pharmacol toxicol. 1999; 39: 1-17. 20. finch ck, chrisman cr, baciewicz am, self th. rifampicin and rifabutin drug interactions: an update. arch intern med. 2002; 162 (9): 985-92. 21. nattis a, josephberg r. rifampin as an efficacious therapy for chronic csc. retinal physician, 2015; 12: 527. 22. shulman s, goldenberg d, schwartz r, habot-wilner z, barak a, ehrlich n, loewenstein a, goldstein m. oral rifampin treatment for longstanding chronic central serous chorioretinopathy. graefe's archive for clinical and experimental ophthalmology. 2016; 254(1):15-22. 23. choudhury d, sharma p, dora j. role of rifampicin and ketoconazole in chronic central serous chorioretinopathy & 58; a comparative study. journal of evidence based medicine and healthcare, 2016; 3 (72): 3940-4. 24. khan ms, sameen m, lodhi aa, ahmed m, ahmed n, kamal m, junejo sa. effect of half adult dose of oral rifampicin (300mg) in patients with idiopathic central serous chorioretinopathy. pakistan journal of medical sciences. 2016 sep;32(5):1158. 25. kim sw, oh j, oh ik, huh k. retinal pigment epithelial tear after half fluence pdt for serous pigment epithelial detachment in central serous chorioretinopathy. ophthalmic surg lasers imaging, 2009; 40: 300-303. microsoft word ps mahr 2 89 original article visual outcome following intra-vitreal bevacizumab injection in neovascular agerelated macular degeneration p. s. mahar, azfar n. hanfi pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p.s. mahar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi received for publication march’ 2011 acceptance for publication may’ 2011 …..……………………….. purpose: to assess the visual outcome after intravitreal bevacizumab (avastin) injection in eyes with choroidal neovascularization due to age–related macular degeneration (armd). material and methods: this study was conducted in isra post-graduate institute of ophthalmology / al-ibrahim eye hospital, karachi from february 2007 to january 2008. forty – two eyes of 30 patients with neovascular armd received 3 intravitreal injections of bevacizumab (1.25 mg / 0.05 ml) at 4-weeks interval and were followed up for 12 weeks after the initial treatment. best – corrected visual acuity (bcva), complete ophthalmic examination, and fluorescein angiography were done at baseline and on follow up visits. main outcome measures were changes in snellen’s acuity, and change in angiographic characteristics of the lesions. results: the mean age ± sd of patients was 65.33 ± 8.32 years. the mean bcva ± sd at baseline was 20/178 ± 4.6 lines on snellen’s quotations which improved to 20/142 ± 4.9 lines and 20/138 ± 4.9 lines at 4 and 12 weeks, respectively (p<0.001). visual acuity (va) improved or remained stable in thirtyseven (88%) eyes. improvement of 1 or more lines was seen in 17 (40%) eyes. in majority of the patients, fluorescein angiography showed decreased leakage and regression of choroidal neovascularization (cnv). no patient had severe vision loss or significant ocular or systemic side effects. conclusion: intravitreal bevacizumab injection is effective in improving and stabilizing the visual acuity in patients with neovascular armd. ge – related macular degeneration (armd) is the leading cause of irreversible blindness in patients over the age of 60 years in developed nations1 and from a worldwide prospective, it has been estimated to cause 8.7% of total blindness2. the vast majority of severe vision loss occurs in patients with the exudative (‘wet’) form of the disease, which is caused by the growth of abnormal blood vessels under the central part of the retina3. several angiogenic factors have been identified as likely stimuli for choroidal neovascularization (cnv). among them, vascular endothelial growth factor (vegf) has proven to be a major stimulus for the development of neovascularization. not only does it promote the growth and survival of vascular endothelial cells, but also causes conformational changes of tight junctions of retinal vascular endothelial cells leading to increased vascular permeability4. a full – length monoclonal antibody that binds all isoforms of vegf, bevacizumab (avastin, genentech) was developed for the treatment of colorectal cancer. it has been used systemically as well as intravitreally for the treatment of choroidal neovascularization secondary to armd. significant improvements in visual acuity and decreased retinal thickness on a 90 optical coherence tomography (oct) were seen. however, systemic administration of bevacizumab has a small but significant risk of thromboembolism in patients with cancer6. contrary, short-term effects of intravitreal bevacizumab has shown to be well tolerated7. the purpose of this study is to investigate the short-term effect of intravitreal bevacizumab on the visual acuity of patients with neovascular armd. material and methods this study was conducted in isra post-graduate institute of ophthalmology/al-ibrahim eye hospital, karachi from february 2007 to january 2008. the design of the study was quasi experimental with purposive sampling. forty two eyes of 30 patients with neovascular armd with clinical and angiographic evidence of cnv, age 50 years or older, ability to comply with the study protocol, and without any previous treatment for neovascular armd were enrolled for the study. patients with a history of thromboembolic events within the past 3 months, presence of ocular conditions other than armd in the study eye that can affect the vision and/or safety, previous intraocular surgery within last 3 months and a history of fluorescein allergy were excluded from the study. patients were selected from retina clinic at alibrahim eye hospital according to the inclusion and exclusion criteria. the off-label use of the drug and its potential risks and benefits were discussed extensively with all patients. all patients signed a comprehensive consent form before administration of bevacizumab. baseline assessment included: best corrected visual acuity (bcva) using snellen’s chart; biomicroscopic examination of anterior segment; intraocular pressure measurement with goldman applanation tonometer; dilated fundus examination with +90 diopters lens and indirect ophthalmoscope; and colored photograph of the retina with the help of digital fundus camera. fluorescein angiography was performed to identify the location and subtype of the lesions and to verify the presence of active choroidal neovascular leakage. the aga khan university hospital pharmacy prepared 1.25mg (0.05 ml) injections in a 30-guage insulin syringe for each patient from commercially available 4 ml vial of bevacizumab (25mg/ml) under aseptic techniques. the eyes to be treated were prepared with 5% povidone-iodine solution. topical anesthesia was administered using proparacaine hydrochloride 1% ophthalmic drops (alcaine, alconbelgium). the site of the injection was measured with the help of a caliper. using a 30 –gauge needle, 0.05ml of bevacizumab (avastin; roche basel, ch; genentech, inc, south san francisco, california, usa) was injected intravitreally through the pars plana 3.5 mm from the limbus. intravitreal injection of bevacizumab was repeated in all eyes at four and eight weeks of follow-up. after the injection, intraocular pressure was measured along with the slit lamp examination of anterior segment. patients were instructed to use topical ciprofloxacin 0.3% (ciloxan, alcon-belgium) four times a day for three days. patients were examined at one week and four weeks after each injection. at each visit, bcva was measured along with the slit lamp examination of the anterior segment, intraocular pressure measurement and dilated fundus examination. fluorescein fundus angiography was repeated at 12th week follow-up. the main outcome measures were changes in snellen’s acuity, and change in angiographic characteristics of the lesions. snellen’s acuities were converted to the logarithm of the minimum angle of resolution (log mar) to facilitate statistical analysis. the paired student t-test was used to compare the mean visual acuity at week’s four to 12 after treatment with mean baseline measurements. the level of statistical significance was set at p< 0.05 with a 95% confidence interval. statistical analysis was done through statistical package for social sciences (spss) 10.0. results forty-two eyes of 30 patients with choroidal neovascularization due to armd were treated with an intravitreal injection of bevacizumab. there were 19 men and 11 women. the average age was 65.3 years, ranging between 54 to 83 years. out of 30 patients, 12 (40%) patients of neovascular armd had active cnv component in both eyes while the rest of the patients had unilateral lesion. baseline characteristics of cnv lesions on fluorescein angiography showed predominantly classic lesion in 8(19%) eyes, minimally classic in 18(43%) eyes and occult in 16(38%) eyes (fig. 1). thirty-one (74%) eyes had subfoveal location of cnv while the rest were juxtafoveal except for 2 (5%), which were extrafoveal (fig. 2). 91 the mean bcva ± sd at baseline was 20/178 ± 4.6 lines (logmar values= 0.95±0.46). most significant improvement was seen at 4th and 8th week with mean bcva ± sd of 20/142 ± 4.9 lines (logmar values = 0.85±0.49) and 20/138 ± 4.9 lines (logmar values= 0.84±0.49) [p < 0.0001], respectively (tables 1, 2). overall, 20 eyes (47.6%) had stabilization of visual acuity at the final follow-up. this was defined as no gain or loss in visual acuity. seventeen eyes (40.5%) had improvement in visual acuity (fig. 3). mean iop ± sd at baseline was 13.7± 3.3. insignificant increase was seen in iop after injecting bevacizumab (p-value = 0.096) (table 3). after 12 weeks, 26 eyes (62%) showed regression of cnv along with reduced leakage on fluorescein angiogram while the rest had stabilization of cnv after three injections of bevacizumab (fig. 4). discussion there is increasing evidence that medications targeting vascular endothelial growth factor (vegf) are effective in the treatment of choroidal neovascularization (cnv) associated with age-related macular degeneration (armd). pegaptanib (macugen), and more recently, ranibizumab (lucentis), have been subjected to large randomized clinical trials and have been proven safe and effective810. bevacizumab (avastin) is also an anti-vegf drug which is food and drug administration (fda) approved for intravenous use in patients with colorectal cancer. in patients with armd, systemic administration of the drug has been shown to improve vision and decrease retinal thickness11. preliminary laboratory studies have demonstrated the drug to be well tolerated as an intravitreal injection12. avery et al 13reported a retrospective case series of 81 eyes that had intravitreal bevacizumab for cnv associated with armd, showed promising results and supports the continued exploration of bevacizumab as a treatment option. in this study, 30 patients were included. the gender distribution (63% males against 37% females) shows a male preponderance. this was in contrast with studies done in developed countries, where either female preponderance13 or similar 14 distributions were seen. the difference in gender distribution in our study could be attributed to our rural social system where problems of female members of the family are usually overlooked. additionally, they have less access to any kind of treatment and the least is spent on their health as compared to males however it could not be stated with certainty as the collection of socioeconomic status and locality data of these patients was not carried out. the study found the baseline characteristics of cnv lesions on fluorescein angiography as predominantly classic lesion in 19%, minimally classic in 43% and occult in 38% of the eyes which was similar to a case series reported by yoganathanet al15. laic r et al16 reported 74.8 years as mean age of patients in his study. however, in our study the average age of the patients was 65.4 years. the discrepancy could be due to the fact that most of the (74%) eyes had subfoveal location of cnv in the current study and subfoveal cnv causes more severe and more rapid loss of vision than juxtafoveal or extrafoveal lesions, as fovea has the highest concentration of photoreceptors which could get damaged early due to the sub-retinal cnv. therefore, these patients presented at an earlier stage of the disease. results of this study support the hypothesis that there is significant improvement of visual acuity in eyes with choroidal neovascularization due to agerelated macular degeneration after giving intravitreal bevacizumab injection. mean snellen’s acuity improved from 20/178 to 20/145 at 3 months after administrating 3 intravitreal bevacizumab injections 1 month apart. most significant improvement in mean visual acuity, 20/142 and 20/ 138, was seen at 4 and 8 weeks respectively with a slight but significant decline at 12th week follow-up. these results are less impressive than those of rich et al14 and spade et al17 that described ≥ 3 lines of vision improvement in 38.3% to 44% of treated patients, respectively. this may represent short-term variability of visual acuity measurements or differences in baseline features of the respective patient populations. more over bari et al18 reported the vitreous half-life of 1.25 mg of intravitreal bevacizumab in a rabbit eye as 4.32 days. this also explains the necessity for frequent intravitreal injections of bevacizumab in exudative armd to persistently neutralize the vegf in these patients. smith and his collegues19 combined the photodynamic therapy with intravitreal injection of bevacizumab for the treatment of neovascular armd. 92 table 1. best corrected visual acuity pre and post bevacizumab injection, (n=42) best corrected visual acuity (bcva) mean ± sd p-value baseline 20/178± 4.6 lines < 0.0001 first week 20/158± 4.6 lines fourth week 20/142± 4.9 lines eighth week 20/138± 4.9 lines twelfth week 20/145± 4.9 lines table 2. comparison of baseline best corrected visual acuity (bcva) with each post-injection follow-up, (n=42) factors bcva mean ± s.d comparisons p-value i baseline 20/178± 4.6 lines ii after 1 week 20/158± 4.6 lines i vs. ii 0.058 iii after 4 weeks 20/142± 4.9 lines i vs. iii 0.001 iv after 8 weeks 20/138± 4.9 lines i vs. iv 0.003 v after 12 weeks 20/145± 4.9 lines i vs. v 0.029 table 3. comparison of intra ocular pressure pre and post bevacizumab injection, (n=42) best corrected visual acuity (bcva) mean ± sd p-value baseline 13.7± 3.3 0.096 first week 14.1± 2.6 fourth week 14.9± 1.9 eighth week 14.1± 2 twelfth week 14.45± 2.3 seventy-three percent of patients showed improvement in visual acuity. mean improvement in visual acuity of 1.73 lines in this study is similar to findings of other studies13,20 in, which patients received bevacizumab injection as monotherapy. however, they witnessed complete resolution of cnv in 65% of eyes after a single combination treatment while in this study 62% showed regression of cnv along with reduced leakage on fluorescein angiogram while the rest had stabilization of cnv after three injections of bevacizumab. only one case showed complete resolution of cnv component at 3 month. it was a small, (< ½ disc diameter) subfoveal and occult type of cnv in a 54 year old male. in the current study, overall post treatment visual acuity improved in 40.5% of cases while it remained stable in 47.6% of cases that was comparable with other studies. rich et al14 reported visual acuity improvement in 44% of eyes at 3 month and cleary et al21 found improvement or stabilization of vision in 76.5% of cases at 6 months. 93 16 (38%) 18 (43%) 8 (19%) predominantly classic minimally classic occult fig. 1: types of choroidal neovascular membrane on fundus fluorescein angiography ( n = 42) 0% 2 (5%) 9 (21%) 31 (74%) subfoveal juxtafoveal extrafoveal fig. 2: location of choriodal neovascular membrane on fundus fluorescein angiography ( n = 42) 17 (40.5) 5 (11.9) 20 (47.6) 0 5 10 15 20 25 30 35 40 improved decreased stable visual acuity fig. 3: overall post-treatment visual acuity, ( n = 42) theoretically, injecting any extra volume in the closed vitreous cavity can cause an increase in intraocular pressure. however, in this study we did not find any significant change in iop pre and post injection. similar results were also reported by yoganathan and coworkers15. this could be due to the short half-life of intravitreal bevacizumab as shown by bari et al18, who obtained data from 40 eyes of 20 rabbits showing a peak concentration of 400 µg/ml in the vitreous humor 1 day after the intravitreal injection of bevacizumab. vitreous concentrations of bevacizumab declined steadily with a half-life of 4.32 days maintaining the concentrations of ≥ 10 µg/ ml for 30 days. moreover, humans have a larger vitreous cavity then rabbits (4.5 ml and 1.5 ml respectively). in this study, after injecting intravitreal bevacizumab, we recorded the iop at 1st week and then at 4, 8 and 12 weeks. there might have been a transient rise in iop during the first few days as shown by fleckenstein et al 22 and hollands et al23 who reported a predictable volume related rise in iop after injecting intravitreal bevacizumab, which never occluded the central retinal artery and which spontaneously fell below 30 mmhg in all eyes within 15 minutes of injection. fig. 4. fluorescein angiographic changes in an eye with subfoveal occult choroidal neovascularization (cnv) due to age – related macular degeneration (armd) after three intravitreal injections of bevacizumab. late – phase angiograms at baseline (left) and at 12 weeks of follow-up (right), showing considerable decrease in the leakage and size of the cnv. the bevacizumab preparation is unpreserved and contains no ingredients that are known to be toxic to the eye. bevacizumab has been tested in rabbit eyes and no evidence of toxicity was seen by electroretinogram (erg) or visual evoked potential (vep) testing24. these findings were consistent with those by matura and associates25, who demonstrated that no evidence of retinotoxocity noted in the short term use n um be r of p at ie nt s (% ) 94 of intravitreal bevacizumab in patients with neovascular armd. adverse events observed during intravenous use of bevacizumab (5mg/kg) for treating colorectal cancer include hypertension, impaired wound healing, hemorrhage, thromboembolic events, myocardial infarction, stroke and proteinuria26. since, the intravitreal dose of bevacizumab is approximately 1/400th that of the intravenous dose therefore the safety profile of intravitreal bevacizumab appeared to be more favorable. in a study of avery and associates89 involving 79 patients, no significant systemic or ocular complications were noted. this finding was consistent with that of other investigators17,14,15,19. similarly, in the present study intravitreal bevacizumab at a dose of 1.25 mg (0.05 ml) appeared to be well tolerated by all patients. systemic adverse events like hypertension, stroke, or myocardial infarction and ocular adverse events, like uveitis, raised iop, endophthalmitis, vitreous hemorrhage or retinal detachment were not recorded. few patients experienced a reduction in visual acuity which could be due to the disease progression rather than the drug toxicity. the weaknesses of this study include absence of randomized controls, limited number of patients, nonstandard visual evaluation and short term followup. lesion size and chronicity were not evaluated. optical coherence tomography of these patients would have provided us with a better visualization of the retinal anatomy than fluorescein angiography. however, the oct was unavailable in our set up and we could not subject our patients to an extra financial burden of going to a private setup. nevertheless oct is recognized as a superior tool to ffa in documenting anatomical outcome. furthermore, randomized trials should also compare intravitreal bevacizumab with other available anti-vegf agents, such as pegaptanib sodium and ranibizumab because the much lower cost per dose of intravitreal bevacizumab compared with that of pegaptanib and ranibizumab, make it promising and cost effective treatment option for those who may not be able to afford the more expensive alternatives. conclusion intravitreal bevacizumab injection is effective in improving and stabilizing the visual acuity in patients with neovascular armd. large, randomized, controlled trial is warranted to evaluate the long term efficacy and safety of this treatment. author’s affiliation p.s mahar isra postgraduate institute of ophthalmology karachi azfar n. hanfi isra postgraduate institute of ophthalmology karachi reference 1. the eye diseases prevalence research group. prevalence of age-related macular degeneration in the united states. arch ophthalmol. 2004; 122: 564-72. 2. resnikoff s, pascolini d, etya’ale d, et al. global data on visual impairment in the year 2002. bull world health organ. 2004; 82: 844-51. 3. ambati j, ambati bk, yoo sh, et al. age-related macular degeneration: etiology, pathogenesis, and therapeutic strategies. surv ophthalmol. 2003; 48: 257–93. 4. otani a, takagi h, oh h, et al. vascular endothelial growth factor family and receptor expression in human choroidal neovascular membranes. microvasc res. 2002; 64: 162-9. 5. treatment of age-related macular degeneration with photodynamic therapy (tap) study group. photodynamic therapy of subfoveal choroidal neovascularization in agerelated macular degeneration with verteporfin: two-year results of 2 randomized clinical trials tap report 2. arch ophthalmol. 2001; 119: 198-207. 6. salesi n, bossone g, veltri e, et al. clinical experience with bevacizumab in colorectal cancer. anticancer res. 2005; 25: 3619-23. 7. lihteh wu, maria a, martinez-castellanos, et al. 12 month safety of intravitreal injection of bevacizumab: results of the panamerican collaborative retina study group (pacores). graefes arch clin exp ophthalmol. 2008; 246: 81-7. 8. gragoudas es, adamis ap, cunningham et jr, et al. vegf inhibition study in ocular neovascularization clinical trial group. pegaptanib for neovascular age-related macular degeneration. n engl j med. 2004; 351: 2805–16. 9. rosenfeld pj, brown dm, heier js, et al. marina study group. ranibizumab for neovascular age related macular degeneration. n engl j med. 2006; 355: 1419–31. 10. brown dm, kaiser pk, michels m, et al. anchor study group.ranibizumab versus verteporfin for neovascular agerelated macular degeneration. n engl j med. 2006; 355: 1432-44. 11. michels s, rosenfeld jr, puliafito ca, et al. systemic bevacizumab (avastin) therapy for neovascular age-related macular degeneration: twelve-week results of an uncontrolled open-label clinical study. ophthalmology. 2005; 112: 1035–47. 12. manzano rp, peyman ga, khan p, et al. testing intravitreal toxicity of bevacizumab (avastin). retina. 2006; 26: 257–61. 13. avery rl, pieramici dj, rabena md, et al. intravitrealbevacizumab (avastin) for neovascular age-related macular degeneration. ophthalmology. 2006; 113: 363–72. 14. rich rm, rosenfeld pj, puliafito ca, et al. short-term safety and efficacy of intravitrealbevacizumab (avastin) for neovascular age-related macular degeneration. retina 2006; 26: 495-511. 15. yoganathan p, deramo va, lai jc, et al. visual improvement following intravitrealbevacizumab (avastin) in exudative agerelated macular degeneration. retina. 2006; 26: 994-8. 95 16. lazic r, gabric n.intravitreally administered bevacizumab (avastin) in minimally classic and occult choroidal neovasculrization secondary to age – related macular degeneration. graefes arch clin exp ophthalmol. 2007; 245: 68-73. 17. spaide rf, laud k, fine hf, et al.intravitrealbevacizumab treatment of choroidal neovascularization secondary to agerelated macular degeneration. retina. 2006; 26: 383–90. 18. bakri sj, synder mr, reid jm, et al. pharmacokinetics of intravitrealbevacizumab (avastin). ophthalmology. 2007; 114: 855-9. 19. smith bt, dhalla ms, shah gk, et al. intravitreal injection of bevacizumab combined with verteporfin photodynamic therapy for choroidal neovascularization in age-related macular degeneration. retina. 2008; 28: 675-81. 20. chen cy, wong ty, heriot wj. intravitrealbevacizumab (avastin) for neovascular age – related macular degeneration: a short-term study. am j ophthalmol. 2007; 143: 510-2. 21. cleary ca, jungkim s, ravikumar k, et al. intravitrealbevacizumab in the treatment of neovascular age-related macular degeneration, 6and 9-month results. eye 2008; 22: 82-6. 22. falkenstein ia, cheng l, freeman wr. changes of intraocular pressure after intravitreal injection of bevacizumab (avastin). retina. 2007; 27: 1044-7. 23. hollands h, wong j, bruen r, et al. short term intraocular pressure changes after intravitreal injection of bevacizumab. can j ophthalmol. 2007; 42: 807-11. 24. bakri sj, cameron jd, mccannel ca, et al. absence of histologic retinal toxicity of intravitrealbevacizumab in a rabbit model. am j ophthalmol. 2006; 142: 162–4. 25. maturi rk, bleau la, wilson dl. electrophysiologic findings after intravitrealbevacizumab (avastin) treatment. retina. 2006; 26: 270-4. 26. hurwitz h, fehrenbacher l, novotny w, et al. bevacizumab plus irinotecan, fluorouracil and leucovorin for metastatic colorectal cancer. n engl j med 2004; 350: 2335-42. glaucoma considering the recent developments in imaging techniques and their applications to glaucoma, despite most of these still being research tools, the oct is somewhat better than hrt and gdx as diagnostic help and has the most potential for long term detection of structural changes in glaucoma. m lateef chaudhry editor-in-chief microsoft word editorial 119 editorial eales’ disease – a distressing mystery eales’ disease is an idiopathic; occlusive periphlebitis affecting the peripheral retina of young healthy males. retinal changes are characterized by perivasculitis, peripheral ischemia and neovascularization leading to recurrent vitreous hemorrhage and other sequelae. in 1880, henry eales – a british ophthalmologist first observed the disease entity characterized by idiopathic vitreous hemorrhage in young males. he observed seven males of ages 14 – 29 years, all of them having history of headache, epistaxis and constipation1. the disease was considered to be vasomotor neuritis till five years later wardsworth explained its association with retinal inflammation2. though cases of eales’ disease have been reported in europe and north america but for unknown reasons it is rare in the developed world and more commonly reported in the indian subcontinent. its incidence in india is 1 in every 200 – 250 ophthalmic patients. eales’ disease targets healthy young adults, mostly males (male predominance is up to 97.6%3,4) with an age group ranging from 20 – 30 years. the disease is bilateral 50–90% of the time5,6 and thus causes significant socioeconomic burden. the etiology is still obscure. eales’ disease is considered to be an immunological response to some exogenous exposure. favourable response to systemic steroids, histopathological evidence of inflammatory cells in vitreous and epiretinal membrane (erm) and altered levels of immune markers point towards immunological mechanism behind it. serum electrophoresis of patients with eales disease was conducted at armed forces institute of ophthalmology (afio), rawalpindi and 30% of them were found to have raised serum proteins and gamma globulins, 85% had raised esr pointing towards possible role of immune process7. hypoxia induces increased expression of vascular endothelial growth factor (vegf), which provides vasoproliferative stimulus. oxidative stress with oxygen and lipid free radicals are also said to cause retinal inflammation. mycobacterium tuberculosis dna has been isolated from pathological samples of patients of eales’ disease8. however, it was observed in india that only 1.3% of tb patients (active or healed) had eales’ disease. hypersensitivity to tuberculoprotein has long been associated with the etiology of eales’ disease. positive mantoux was observed in as high as 90% of eales’ patients in some case series. on the contrary, it has also been reported in mantoux negative patients. hla phenotyping was also studied at afio, which has suggested genetic basis of its etiology since hla dr – 3, ai, b8. b5 and dr – 15 (2) were found to be raised in eales’ patients9. eales’ disease is also known to have associations with haematological and neurological diseases10,11. retinal changes in eales’ disease patients may show retinal periphlebitis, later arteries may also be involved. obliteration of inflamed vessel may lead to ischemia and neovascularization, which is observed in 80% of eales’ patients. neovascularization elsewhere (nve) is commoner than neovascularization disc (nvd). capillary drop out of 20 area and 60 disc area cause nve and nvd respectively12. new vessels may bleed to cause recurrent vitreous hemorrhage. fibrovascular prolife-ration, retinal detachment (rd), uveitis, cmo, secondary brvo, optic atrophy, nvi and rubeotic glaucoma are other sequelae. macula is generally involved in later stages except in central eales’ disease9. treatment is purely symptomatic and is stage dependent. recurrent vitreous hemorrhage is the hall mark of this disease. stage of inflammation is amenable to oral corticosteroid therapy. ischemia and neovascularization are treated by photocoagulation and observation. vitreous hemorrhage requires observation and then photocoagulation with vitrectomy. complications require sophisticated procedures. empirical anti tuberculosis treatment has been tried for severe phlebitis and massive infiltration with nodule formation. systemic steroids, posterior subtenon and intravitreal triamcinolone acetonide (ivta) have been advocated. in one study ivta was given in 12 patients of eale’s disease. at eight weeks, 10 of them showed reduction in leakage13. photocoagulation is the mainstay of treatment for stage of ischemia and neovascularization. sectoral scatter for nve and prp for nvd is recommended. in a study at afio, 99 eales’ patients were recruited over 120 three years to ascertain the usefulness of laser photocoagulation in managing asymptomatic eyes. 90% (39) of the patients receiving photocoagulation (n = 43) showed visual improvement while 21% (9) of the control group (n = 43) showed improvement14. vitrectomy is performed for non clearing vitreous hemorrhage, tractional rd threatening macula, vitreous membranes with or without rd and combined tractional and rhegmatogenous rd. patients who had photocoagulation prior to surgery show better prognosis. vitrectomy is also found useful in managing asymptomatic fellow eyes of treated eales’ patients15. anterior retinal cryoabla-tion is applied for clearance of vitreous hemorrhage and ablation of ischemic peripheral retina or areas of nve and is usually reserved as an adjunct to photocoagulation in eales’ disease. anti vegf therapy is a promising new option as an adjunct to other therapies. a large prospective study has been planned at afio in a bid to explore the role of intravitreal bevacizumab in eales’ disease study its demographics, establish a treatment protocol and open new vistas for research. it is the 21st century with a bitter reality that eales’ is still an agonizing dilemma – an unrevealed mystery that awaits our joint endeavours to allay the distress of affected young males of this region. reference 1. eales h. retinal haemorrhage associated with epistaxis and constipation. brim med rev. 1880; 9: 262. 2. wardsworth. recurrent retinal haemorrhage followed by the development of blood vessels in the vitreous. ophthalmic rev 1887; 6: 289. 3. das t. eales disease. indian journal ophthalmol. 1994; 42: 1. 4. abraham c, baig sm, badrinath ss: eales disease. proc all india ophthalmol soc 1977; 33: 223-9. 5. duke – elder s, dobree jh. system of ophthalmology. vol x. london: henry kimpton. 6. murthy kr, abraham c, baig sm, et al. eales’ disease. proc all ind ophthalmol soc. 1977; 33: 323. 7. ishaq m, karamat s, niazi mr. serum electrophoresis in eales’ disease. pak armed forces medical journal 2005; 55: 198201. 8. niazi mk, ishaq m, ikram a. mycobacterium tuberculosis as a causative agent in eales’ disease; pcr based analysis of vitreous samples. idj of pak. 2010; 19: 164-6. 9. m ishaq, s karamat, mk niazi. hla typing in eales’ disease. j coll physicians surg pak. 2005; 15: 288-90. 10. das t, biswas j, kumar a, et al. namperumalsamy p, patnaik b, tewari hk. eales’ disease. indian j ophthalmol. 1964; 42: 318. 11. das t, pathengay a, hussain n, et al. eales’ disease: diagnosis and management. eye. 2010; 24: 472-82. 12. saxena s, kumar d, maitreya a, et al. ann 2005; 37: 273-5. 13. ishaq m, feroz ah, shahid m, et al. intravitreal steroids may facilitate treatment of eales’ disease; an interventional case series eye. 2006; 00: 1-3. 14. ishaq m, niazi mk. usefulness of laser photocoagulation in managing asymptomatic eyes of eales’ disease. j ayub medical coll abottabad. 2002; 14: 22-5. 15. ishaq m, niazi mk. usefulness of pars plana vitrectomy in managing asymptomatic eyes of eales’ disease. j ayub medical coll abbottabad. 2003; 15: 50-3. brigadier mazhar ishaq armed forces institute of ophthalmology (afio), rawalpindi microsoft word kh shariful hasan 1 original article relative distribution and amount of different types of astigmatism in mixed ethnic population of karachi khwaja sharif-ul-hasan, muhammad zia-ul-haque ansari, abrar ali, adnan afaq, tabassum ahmad pak j ophthalmol 2009, vol. 25 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: khwaja sharif-ul-hasan professor & chairman department of ophthalmology baqai medical university gadap road, super highway near toll plaza karachi, pakistan received for publication june’ 2008 purpose: astigmatism is a common refractive problem and is especially significant in children because of its effect on visual development. in this article we have analysed relative distribution of different types and amount of astigmatism in the mixed ethnic population of karachi. material and methods: records of 914 eyes with astigmatic error in a clinic based set up were analysed retrospectively. streak retinoscope was used for refraction and sphero cylindrical method was used to minutely neutralize the reflex. half diopter cross cylinder was used to verify and refine the power and axis of cylindrical lens. any error, stigmatic (spherical) or astigmatic (cylindrical) of ¼ diopter or more was considered an error and included in the analysis. result: astigmatic error was present in 914 of the 1898 eyes with ametropia (48.16%). of the 914 eyes with astigmatism, myopic astigmatism was present in 700 eyes (76.60%), hypermetropic astigmatism in 175 eyes (19.14%), and mixed astigmatism in 39 eyes (4.26%). of the 914 eyes with astigmatism, mild astigmatism (1/4 to 1 d) was present in 616 eyes (67.40%), moderate astigmatism (>1-2 d) in 247 eyes (27.02%), and high astigmatism (>3 d) in 51eyes (5.58%). conclusion: myopic astigmatism was the major type of astigmatic error found in the mixed ethnic population of karachi city in the age group from 1 to 40 years. astigmatism >1 d was found in 32.60% of eyes with astigmatic error. 2 … ……………………… n our previous audit of retinoscopic findings1 we retrospectively analysed the relative distribution of different types of refractive errors in ametropic mixed ethnic population of the metropolitan city of karachi. astigmatism is that form of refractive error wherein parallel rays of light from infinity passing through the optical media form two or more far lines rather than a point focus due to unequal refraction of light in different meridians. it results when one principal meridian of the corneal and/or lenticular surface is flatter than the other or the radii of curvature of the two principal meridians are unequal. in regular astigmatism two principal meridians are perpendicular to each other2,3. depending on the position of the two images (far lines) in relation to the retina, regular astigmatism has been classified as simple, compound and mixed. in ‘simple’ astigmatism, one meridian is emmetropic; therefore, only one far line is either in front (simple myopic) or behind (simple hypermetropic) the retina. in ‘compound’ astigmatism, both the far lines are either in front (compound myopic) or behind (compound hypermetropic) the retina. when one far line falls short of the retina and the other falls behind the resulting astigmatic error is called ‘mixed’2,3. astigmatism is a common refractive problem. the reported prevalence of this refractive error in children is quite varied, and is influenced by age4. in infants, studies have reported prevalence rates as high as 70% for astigmatism of more than 1 dioptre5. other studies have indicated that the prevalence of astigmatism of 1.00 d or more was 25% in children aged 1–48 months and decreased in older children to about 12–13% by the age of 10 years6. mayer also showed that 25% of children with same age group had astigmatism ( 1.00 d)7. a study in 570 chinese children aged 36–65 months reported that 38.6% of the children had an astigmatic error of 0.50 d or more8. the prevalence of astigmatism among chinese (aged 6 to 7 years) in singapore was 17.1%9. fan et al found astigmatism ( 1.00 d) in 21.1% of preschool children (mean age 55.7 months)10. unlike myopia and hypermetropia, astigmatism imposes considerable optical defocus at all viewing distances. the continuous strain imposed on ciliary muscles in a constant struggle to get a sharp focus is a source of considerable asthenopia and eye-strain in astigmatic individuals11. because of immature and developing visual system, astigmatism is especially significant in children. astigmatism has been implicated in the development of amblyopia and progression of myopia in children. abrahamsson et al pointed out a relation between astigmatism and the development of meridional amblyopia in children. they analyzed the refraction changes in 310 children with astigmatism greater than or equal to 1.0 d in at least one eye at one year of age; amblyopia was found in 23 of the children (7%) at the age 4 years. they also found that an increasing astigmatism was associated with an increased risk of developing amblyopia12. fulton et al described the relation between increasing myopia and an increase in astigmatism in their study of 298 children aged 0–10 years13. in children of all age groups, they found greater myopia in eyes with astigmatism more than 1.00 d. they indicated that astigmatism in children, particularly of higher degrees ( 3 d), might lead to visual perturbations that could trigger development of myopia, similar to that seen in animal models13,14. gwiaza et al also described a relation between astigmatism and the development of myopia in children and proposed the possible mechanism15. they regularly followed 245 subjects for a period of 6 to 23 years from infancy and showed that infantile astigmatism was associated with increased astigmatism and myopia during the school years. they proposed two possible mechanisms underlying this association: (a) infantile astigmatism disrupts focusing mechanisms; and (b) ocular growth induces astigmatism and myopia. cezipita et al also observed a positive correlation between astigmatism and myopia in 167 subjects with an average age of 24 months (p < 0.000001) and concluded that astigmatism predisposes to the progress of myopia16. they further analyzed the role of type of astigmatism on myopic progression in same subjects and found a positive correlation between with-the-rule (wtr) astigmatism and myopia; their conclusions were: (a) with-the-rule astigmatism (wtr) predisposes the creation of myopia. (b) against-therule (atr) as well as oblique astigmatism (ola) has no influence on the creation of myopia17. i 3 in a more recent article published in british journal of ophthalmology, fan et al not only substantiated this relationship between myopic progression and astigmatism but also suggested that astigmatism was related to longer axial length and axial length growth. however, they found no relationship between myopic progression and the axis of astigmatism10. another problem associated with astigmatism is its relative difficulty in refractive correction leading to poor vision and spectacle intolerance. garber substantiated this difficulty in school children and provided the evidence of difficulty of correcting high astigmatism in clinical practice, leading to rejection of eye wear in children, with a decrease in classroom performance as a result of unsatisfactory vision18. the purpose of this article is to analyse relative distribution of different types and amount of astigmatism in the same population of karachi. materials and methods we retrospectively analyzed the retinoscopic findings of 1898 ametropic eyes of 962 patients presenting with refractive problems to determine their refractive status. records of 914 eyes with astigmatic error were further analysed to determine the type and amount of astigmatism. all patients were examined at a private clinic located in a medical complex in the central part of the city where majority of patients belonging to multiple ethnic origins reported from different districts of karachi. records of patients seen from january 1984 to december 1991 were included in the analysis. refraction was performed objectively on all patients by one of us (ksh) using streak retinoscope of hamblin or welch allyn. sphero-cylindrical method of refraction was used to minutely neutralize the movements (one meridian was neutralized by spherical lens and the perpendicular meridian was neutralized by an appropriate cylindrical lens when required). subsequently, retinoscopic findings were subjectively verified. half-diopter cross cylinder was used to verify and refine the axis and power of any cylindrical lens. a complete adnexal and biomicroscopic anterior segment examination on haag-street slit-lamp was performed on all patients. fundus examination was also performed using keeler or welch allyn direct ophthalmoscope. cycloplegic refraction, after instillation of atropine eye drops for three days, was performed on all children less than 5 years of age. older children were refracted 40-50 minutes following topical instillation of 1% cyclopentolate eye drops twice at 5 to 10 minute interval. records of patients with any adnexal, anterior segment and posterior segment pathology were not included in the analysis. records of patients less than one year and more than forty years were also excluded. any astigmatic error of ¼ diopter or more was considered an error and included in the analysis. for the purpose of this article amount of astigmatism was considered in three grades of ¼ to 1 diopter, >1 to 3 diopter, and >3 diopter. compound myopic astigmatism was defined as that needing correction with negative powers in both the meridians, and simple myopic astigmatism was defined as that needing correction with minus cylinder in only one meridian. compound hypermetropic astigmatism was defined as that needing correction with plus cylinder in both the meridians, and simple hypermetropic astigmatism was defined as that needing correction with plus cylinder in only one meridian. mixed astigmatism was referred to as refraction needing correction with plus cylinder in one meridian and minus cylinder in the other. results table 1 summarizes the relative prevalence of stigmatic and astigmatic refractive error in this audit of retinoscopic findings of 1898 eyes with ametropia (fig. 1). stigmatic error (myopia and hypermetropia) was present in 984 of the 1898 eyes with ametropia (52.84%) while astigmatic error (myopic, hypermetropic, and mixed astigmatism) was present in 914 of the 1898 eyes with ametropia (48.16%). table 2 summarizes the relative distribution of myopic, hypermetropic, and mixed astigmatism (fig. 2). myopic astigmatism (simple and compound) was the most common type of astigmatic error present in our analysis. of the 914 eyes with astigmatism, myopic astigmatism was present in 700 eyes (76.60%). hypermetropic (simple and compound) astigmatism was found in 175 of the 914 eyes with astigmatism (19.14%), while mixed astigmatism was found in only 39 of the 914 eyes with astigmatism (4.26%). table 3 summarizes the amount of astigmatism in 914 astigmatic eyes (fig. 3). mild astigmatism (1/4 to 1 diopter) was present in 616 of the 914 eyes with astigmatism. two hundred and forty-seven of the 914 4 eyes with astigmatism (27.02%) had moderate astigmatism of 1 to 3 diopters. astigmatism of >3 diopters was present in only 51 of the 914 eyes with astigmatism (05.58%). table 4 summarizes the amount of astigmatism in 700 eyes with myopic astigmatism (fig. 4). mild astigmatism (1/4 to 1 diopter) was present in 496 of the 700 eyes with myopic astigmatism (70.86%). one hundred and sixty-three of the 700 eyes with myopic astigmatism (23.28%) had moderate astigmatism of 1 to 3 diopters. astigmatism of >3 diopters was present in only 41 of the 700 eyes with myopic astigmatism (05.86%). table 5 summarizes the amount of astigmatism in 175 eyes with hypermetropic astigmatic (fig. 5). mild astigmatism (1/4 to 1 diopter) was present in 110 of the 175 eyes with hypermetropic astigmatism (62.86). sixty-four of the 175 eyes with hypermetropic astigmatism (36.57%) had moderate astigmatism of 1 to 3 diopters. astigmatism of >3 diopters was present in only one of the 175 eyes with hypermetropic astigmatism (0.57%). table 6 summarizes the amount of astigmatism in 39 eyes with mixed astigmatism (fig. 6). mild astigmatism (1/4 to 1 diopter) was present in 10 of the 39 eyes with mixed astigmatism (25.64%). twenty of 0 500 1000 1500 2000 right eye lef t eye total stigmatism astigmatism total fig. 1: relative distribution of stigmatism and astigmatism 0 200 400 600 800 1000 right eye left eye total myopic hypermetropic mixed total fig. 2: relative distribution of myopic, hypermetropic and mixed astigmatism 0 200 400 600 800 1000 right eye left eye total 0.25 to 1 d >1 to 3 d >3 d total fig. 3: amount of astigmatism in 914 astigmatic eyes 0 200 400 600 800 right eye left eye total 0.25 to 1 d >1 to 3 d >3 d total fig. 4: amount of astigmatism in 700 eyes with myopic astigmatism 0 50 100 150 200 right eye lef t eye total 0.25 to 1 d >1 to 3 d >3 d total fig. 5: amount of astigmatism in 175 eyes with hypermetropic astigmatism 5 0 10 20 30 40 right eye lef t eye total 0.25 to 1 d >1 to 3 d >3 d total fig. 6: amount of astigmatism in 39 eyes with mixed astigmatism the 39 eyes with mixed astigmatism (51.28%) had moderate astigmatism of 1 to 3 diopters. astigmatism of >3 diopters was present in 9 of the 175 eyes with mixed astigmatism (23.08%). discussion the world health organization has grouped uncorrected refractive error with cataract, macular degeneration, infectious diseases, and vitamin a deficiency among the leading causes of blindness and vision impairment in the world. ‘vision 2020’, a global initiative for the elimination of avoidable blindness by the world health organization (who), also included refractive errors among the five conditions of immediate priority19. astigmatic error becomes more significant due to its high prevalence, its implications on visual development in early years of life, and the relative difficulty in its refractive correction leading to spectacle intolerance and its implications. before comparing our results with other surveys, it is important to note differences in the definitions of astigmatism, varying age compositions of the study table 1: relative prevalence of stigmatism and astigmatism refractive status right eye n (%) left eye n (%) total n (%) stigmatism 487 (51.32) 497 (52.37) 984 (52.84) astigmatism 462 (48.68) 452 (47.63) 914 (48.16) total 949 (100) 949 (100) 1898 (100) table 2: relative distribution of myopic, hypermetropic, and mixed astigmatism type of astigmatism right eye n (%) left eye n (%) total n (%) myopic 357 (77.27) 343 (75.88) 700 (76.60) hypermetropic 82 (17.75) 93 (20.58) 175 (19.14) mixed 23 (04.98) 16 (03.54) 39 (04.26) total 462 (100) 452 (100) 914 (100) table 3: amount of astigmatism in 914 astigmatic eyes amount of astigmatism right eye n (%) left eye n (%) total n (%) 0.25 to1 diopter 303 (65.59) 313 (69.25) 616 (67.40) >1 to 3 diopter 132 (28.57) 115 (25.44) 247 (27.02) >3 diopter 27 (5.84) 24 (5.31) 51 (05.58) total 462 (100) 452 (100) 914 (100) 6 table 4: amount of astigmatism in 700 eyes with myopic astigmatism amount of astigmatism right eye n (%) left eye n (%) total n (%) 0.25 to1 diopter 250 (70.03) 246 (71.72) 496 (70.86) >1 to 3 diopter 85 (23.81) 78 (22.74) 163 (23.28) >3 diopter 22 (06.16) 19 (05.54) 41 (05.86) total 357 (100) 343 (100) 700 (100) table 5: amount of astigmatism in 175 eyes with hypermetropic astigmatism amount of astigmatism right eye n (%) left eye n (%) total n (%) 0.25 to1 diopter 47 (57.32) 63 (67.74) 110 (62.86) >1 to 3 diopter 35 (42.86) 29 (31.18) 64 (36.57) >3 diopter 0 (0.00) 1 (1.08) 1 (0.57) total 82 (100) 93 (100) 175 (100) table 6: amount of astigmatism in 39 eyes with mixed astigmatism amount of astigmatism right eye n (%) left eye n (%) total n (%) 0.25 to1 diopter 6 (26.09) 4 (25.00) 10 (25.64) >1 to 2 diopter 12 (52.17) 8 (50.00) 20 (51.28) >3 diopter 5 (21.74) 4 (25.00) 9 (23.08) total (%) 23 (100) 16 (100) 39 (100) population, refractive error measurement techniques and study methodology. our audit is a clinic-based, retrospective analysis of the record of the retinoscopic findings on patients 1 to 40 years of age who were free from any organic ocular problem. we used more stringent criteria in defining astigmatism and any cylindrical error of 0.25 diopter or more was considered an error. most other studies defined astigmatism as cylinder power of 0.5 or 1.0 diopter20-25 except the brazilian study conducted by garcia al26. age composition of our studied patients also differed from other surveys which were conducted either on population of limited age group 20-21,24-26 or in a general population comprising all age groups22. our methodology was simple: retionoscopy by sphero-cylinderical method followed by subjective verification and minute refining of cylindrical axis and power by cross-cylinder by a single experienced consultant (ksh) in a clinical set-up. cycloplegia was used only in children. most of the recent studies rely on autorefractors with or without cycloplegia. with these limitations we would proceed to compare our results with some interesting studies recently conducted in neighbouring and other countries. in prevalence survey of 1327 first through eighth grade school children who were members of a native american tribe in arizona, usa, the overall prevalence of astigmatism of 1.00 diopter or more was 42%20. in this study noncycloplegic autorefraction was performed with handheld autorefractors. in prevalence study of 1,024 randomly selected students in the city of natal, brazil, 348 students (34.8%) had astigmatism 0.1 diopter or greater on refractometry. of 897 participants with ametropia of 0.1 diopter or more, 348 (38.8%) had astigmatism26. in this study, although a more stringent criteria was selected (at least 0.1 diopter), the overall prevalence and relative proportion of astigmatic error was not as 7 high as in our study (48.16%) as well as other neighboring and south-east asian countries. in a population-based cross-sectional study involving 11,189 adults 30 years of age and older in bangladesh, astigmatism 0.5 d or more was found in 3625 subjects (32.4%). of 6370 participants with ametropia, 3625 (56.90%) had astigmatism21. higher overall prevalence and higher relative distribution of astigmatism in this study as compared to ours (56.9% vs 48.16%) may be due to exclusion of all secondary and pathological causes of astigmatic error in our analysis and the entirely different age composition of the populations studied (>30 years vs 1 to 40 years). in a population-based study involving 4565 individuals 5 years of age and older representing a cross-section of the population of tehran, iran, prevalence of astigmatism 0.5 diopter or more was 50.2% on manifest refraction. of 2532 participants with ametropia, 1509 (59.6%) had 0.5 diopter or more astigmatism22. high astigmatism defined as manifest cylinder 1.5 diopter or more was found in 490 (11.1%) of right eyes. higher overall prevalence and higher relative distribution of astigmatism in this study as compared to ours (56.6% vs 48.16%) may be due to exclusion of all secondary and pathological causes of astigmatic error in our analysis and the entirely different age composition of the population studied (>5 years vs 1 to 40 years). in a population-based prevalence survey of 1043 adults 21 or more years of age conducted in five rural villages and one provincial town of the riau province, sumatra, indonesia, astigmatism of 1.00 diopter or more was found in 193 of 561 (34.40%) ametropic eyes23. in this study refraction was performed with handheld autorefractor. we found astigmatism in 48.16% of ametropic eyes but our cut off cylinder power was comparatively low (0.25 diopter) and our age composition was relatively younger (1-40 years). in a population-based cross-sectional study involving 1232 chinese people aged 40 to 79 years in singapore, astigmatism 0.5 diopter or more was found in 466 (37.8%) subjects. of 827 participants with ametropia, 466 (56.35%) had astigmatism24. relative distribution of astigmatic error in this older chinese population is higher than our younger individuals in spite of our quite low cut off cylinder power of 0.25 diopter. in a prevalence survey of 946 students aged 15-19 years from two secondary schools in singapore, astigmatism >0.5 d was found in 555 subjects (58.7%). of 841 participants with ametropia, 555 (65.99%) had astigmatism25. in this study non-cycloplegic autorefraction was performed with handheld autorefractors. compared to our results the overall prevalence and relative proportion of astigmatic error is quite high in these singaporean teenagers in spite of the fact that our cut off cylinder power was quite low (0.25 diopter). in spite of our best efforts we failed to find any national study addressing the issue of prevalence of astigmatism or relative distribution of different types and amount of astigmatism in pakistani population. this would probably be the first analysis of this type on a pakistani population to be published in ophthalmic literature. we hope this effort will inspire our colleagues to analyze their record of refraction or organize prevalence survey and present their results. author’s affiliation professor khwaja sharif-ul-hasan professor and chairman department of ophthalmology baqai medical university karachi dr. muhammad zia-ul-haque ansari. associate professor of ophthalmology baqai medical university karachi dr. abrar ali. professor of ophthalmology, hamdard medical university karachi dr. adnan afaq associate professor of ophthalmology baqai medical university karachi dr. tabassum ahmad associate professor of ophthalmology hamdard medical university karachi pakistan reference 1. ansari mz, ali a, afaq a, et al. relative distribution of refractive errors: an audit of retinoscopic findings. pak j ophthalmol. 2007; 23: 144-50. 2. duke-elder s: duke-elder’s practice of refraction, 9th edition, churchill livingstone inc. 1978; 52-5. 8 3. mittelman d: geometric optics and clinical refraction. in principles and practice of ophthalmology, w b saunders company. 1980; 1: 199. 4. gwiazda j, scheiman m, mohindra i, et al. astigmatism in children: changes in axis and amount from birth to six years. invest ophthalmol vis sci. 1984; 25: 88–92. 5. howland hc, sayles n. photorefractive measurements of astigmatism in infants and young children. invest ophthalmol vis sci. 1984; 25: 93–102. 6. dobson v, fulton ab, sebris sl. cycloplegic refractions of infants and young children: the axis of astigmatism. invest ophthalmol vis sci. 1984; 25: 83–7. 7. mayer dl, hansen rm, moore bd, et al. cycloplegic refractions in healthy children aged 1 through 48 months. arch ophthalmol. 2001; 119: 1625-8. 8. abrahamsson m, fabian g, sjostrand j. a longitudinal study of a population based sample of astigmatic children. ii. the changeability of anisometropia. acta ophthalmol (copenh). 1990; 68: 435–40. 9. zhan mz, saw sm, hong rz, et al. refractive errors in singapore and xiamen, china-a comparative study in school children aged 6 to 7 years. optom vis sci. 2000; 77: 302–8. 10. fan dsp, rao sk, cheung eyy, et al. astigmatism in chinese preschool children: prevalence, change, and effect on refractive development. br j ophthalmol. 2004; 88: 938-41. 11. duke-elder s. duke-elder’s practice of refraction, 9th edition, churchill livingstone inc, 1978; 52. 12. abrahamsson m, fabian g, andersson ak, et al. a longitudinal study of a population based sample of astigmatic children. i. refraction and amblyopia. acta ophthalmol (copenh). 1990; 68: 428-34. 13. fulton ab, hansen rm, petersen ra. the relation of myopia and astigmatism in developing eyes. ophthalmology. 1982; 89: 298–302. 14. howland hc. infant eyes: optics and accommodation. curr eye res. 1982; 2: 217–24. 15. gwiazda j, grice k, held r, et al. astigmatism and the development of myopia in children. vision res. 2000; 40: 1019– 26. 16. czepita d, filipiak d. role of astigmatism in the creation of myopia. klin oczna. 2003; 105: 385-6. 17. czepita d, filipiak d. the effect of type of astigmatism on the incidence of myopia. klin oczna. 2005; 107: 73-4. 18. garber jm. high corneal astigmatism in navajo school children and its effect on classroom performance. j am optom assoc. 1981; 52: 583-586. 19. pararajasegaram r. vision 2020-the right to sight: from strategies to action. am j ophthalmol. 1999; 182: 359-60. 20. harvey em, dobson v, miller jm. prevalence of high astigmatism, eyeglass wear, and poor visual acuity among native american grade school children. optom vis sci. 200; 83: 206-12. 21. bourne rr, dineen bp, ali sm, et al. prevalence of refractive error in bangladeshi adults: results of the national blindness and low vision survey of bangladesh. ophthalmology. 2004; 111: 1150-60. 22. hashemi h, hatef e, fotouhi a, et el. astigmatism and its determinants in the tehran population: the tehran eye study. ophthalmic epidemiol. 2005; 12: 373-81. 23. saw sm, gazzard g, koh d, et al. prevalence rates of refractive errors in sumatra, indonesia. invest ophthalmol vis sci. 2002; 43: 3174-80. 24. wong ty, foster pj, hee j, et al. prevalence and risk factors for refractive errors in adult chinese in singapore. invest ophthalmol vis sci. 2000; 41: 2486-94. 25. quek tp, chua cg, chong cs, et al. prevalence of refractive error in teenage high school students in singapore. ophthalmic physiol opt. 2004; 24: 47-55. 26. garcia ca, orefice f, nobre gf, et al. prevalence of astigmatism in noortheastern brazil. arg bras oftalmol. 2005; 68: 321-5 pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 163 original article efficacy and tolerability of latanoprost 0.005% in treatment of primary open angle glaucoma (poag) muhammad imran janjua, saira bano, ali raza pak j ophthalmol 2017, vol. 33, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad imran janjua holy family hospital rawalpindi email: janjua.doc@gmail.com …..……………………….. purpose: glaucoma is considered as a type of optic neuropathy for which intraocular pressure (iop) is accepted as an important causative factor. previous research has emphasized the value of iop reduction in treatment of glaucoma. there are many treatment modalities available including medical and surgical options. this study was undertaken to show the effectiveness and safety profile of latanoprost 0.005% in reducing the intraocular pressure to acceptable levels. materials and methods: this study was carried out at department of ophthalmology, holy family hospital, rawalpindi, from july to december 2015. fifty patients diagnosed with primary open-angle glaucoma (poag) were included in the study. following baseline measurements of iop, topical latanoprost 0.005% was administered once daily in the evening for 12 weeks. patients were followed up with visits at two, six and twelve weeks. mean iop reduction was taken as the primary parameter. the ocular side effects of the drug were also assessed by patient’s history and slit lamp examination. results: fifty patients, 22 (44%) males and 28 (56%) females, were enrolled for the study. the age ranged from 28 to 70 years with a mean of 59.56 (± 9.24) years. the mean iop at baseline was 22.48 mmhg (± 6.4). the iop at 2 weeks was 17.72 mmhg (± 4.70), at 6 weeks 14.88 mmhg (± 4.19) and at 12 weeks 13.20 mmhg (± 3.03) showing a mean reduction of 9.28 mmhg (± 5.36) from baseline. there was marked difference (± 41.28%) between the baseline and final iop readings (p < 0.001). 12 (24%) patients had ocular side effects of medication. the side effects reported were ocular irritation in 8 (16%), conjunctival hyperemia in 2 (4%) and watering of eyes in 2 (4%) patients. none of them required discontinuation of medication. 38 (76%) patients did not develop any side effects. conclusion: latanoprost can be regarded as an effective ocular hypotensive drug, having good compliance profile and no serious side effects. key words: latanoprost, primary open angle glaucoma (poag). rimary open-angle glaucoma (poag) is a type of optic neuropathy which damages the optic nerve head, causing cupping of the optic disc and thinning of the neuroretinal rim. these changes result in characteristic peripheral visual field defects1. high intraocular pressure (iop) is regarded as an important risk factor for development and progression of poag. progression of ocular damage can be prevented by lowering the iop. different treatment modalities are available including both surgical and medical options2-4. the most commonly used drugs for the treatment of poag are beta-blockers, carbonic p mailto:janjua.doc@gmail.com muhammad imran janjua, et al 164 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology anhydrase inhibitors, alpha-agonists and prostaglandin analogs2,5,6. aqueous humor production and iop levels follow a circadian rhythm, being high in morning and decreasing by night. similarly the systemic blood pressure also decreases during sleep hence affecting the ocular perfusion pressure. this gives more importance to the nocturnal control of iop in management of glaucoma2. previous research has demonstrated variability in the effectiveness of topical medications used for iop control during different times of the day. this includes decreased effect of beta-blockers during sleep. also, acetazolamide and apraclonidine decrease the rate of aqueous flow at night7-9. prostaglandin analogs have been in clinical use in the management of glaucoma since 19955. latanoprost reduces the iop by increasing the aqueous drainage through the uveoscleral route5,6,10. topical prostaglandin analogs generally have no significant systemic side effects. the adverse effects associated with the use of topical latanoprost are blurred vision, burning, itching or redness of the eye, changes in eyelash color and length and pigmentary changes in the iris and periocular skin11-14. this study was undertaken to show the effectiveness and safety profile of latanoprost 0.005% in reducing the intraocular pressure to acceptable levels. materials and methods this prospective non-randomized open-label study was carried out at the department of ophthalmology, holy family hospital, rawalpindi from july to december 2015. fifty patients with primary openangle glaucoma (poag) were enrolled. following baseline measurements of iop, topical latanoprost 0.005% was administered once daily in the evening for 12 weeks. patients were followed up with visits at two, six and twelve weeks. mean iop reduction was taken as the primary parameter. the ocular side effects of the drug were assessed by patient’s history and slit lamp examination. patients of both genders, ≥18 years of age, either newly diagnosed with poag or those previously diagnosed but showed progression of disease with topical poag treatment other than prostaglandin analogs were enrolled. for new patients, the diagnosis of poag was based on iop value of more than 21 mmhg with optic disc examination demonstrating glaucomatous damage and/or corresponding visual field defects on automated perimetry11. patients having closed or barely open anterior chamber angle or those with a history of acute angle closure in the past were excluded from the study. also, patients having ocular inflammation or infection, those who had previously used topical prostaglandin analogues, had surgical or laser treatment for glaucoma, those using contact lenses or having any condition preventing applanation tonometry, known hypersensitivity to any component of the study medication were excluded. the baseline visit comprised of complete medical history including treatment history, complete slit lamp examination, goldman applanation tonometry, gonioscopy and dilated fundus examination with special emphasis on the optic disc and peri-papillary area for typical glaucomatous changes. iop was measured at 10 am (± 1 hour) and the mean of three readings was noted. status of the eyelashes, periocular skin and iris color was also noted. no anterior segment photographs were taken. patients were instructed to instill the medication in the evening, preferably at 8 pm (± 1 hr). if the patients were already using some other topical medication for poag they were instructed to continue it along with latanoprost. the total duration of treatment was three months (twelve weeks) with follow up visits at two, six and twelve weeks. a deviation of ± 2 days for first follow up visit (i.e. at 2 weeks) and ± 5 days for second and third visits at six and twelve weeks was allowed. patients with adverse events at the end of study period were followed up for further 2 to 4 weeks. at each follow-up visit a complete ophthalmic examination including slit lamp examination, iop measurement and dilated fundus examination was performed. the adverse effects were diagnosed on the basis of patient’s history and clinical examination. severity was graded by the examiner as mild, moderate or severe. for patients treated for both eyes, only one randomly selected eye was included for analysis. the data was analyzed by statistical package for social sciences (spss) version 20.0 and values were expressed in terms of frequencies, percentages and means. the mean iop reduction was analyzed by comparing mean iop at follow up visits to the mean iop at baseline using student’s t-test. a p-value of < 0.05 was taken as significant. the occurrence of side efficacy and tolerability of latanoprost 0.005% in treatment of primary open angle glaucoma (poag) pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 165 effects was also analyzed and was expressed in terms of frequencies and percentages. results fifty patients were enrolled for the study, 22 (44%) were male and 28 (56%) were female. the age ranged from 28 to 70 years with a mean of 59.56 (± 9.24) years. left eye was selected for analysis in 31 (62%) and right eye in 19 (38%) patients. 40 (80%) patients were newly diagnosed and 10 (20%) were already using topical iop reducing medications other than latanoprost (table 1, fig. 1). table 2 shows the topical medications used by patients. the mean baseline iop was 22.48 mmhg (± 6.4). the iop at first follow up visit i.e. 2 weeks was 17.72 table 1: demographic distribution of patients (n=50). parameters n (%) gender male 22 (44) female 28 (56) eyes left 31 (62) right 19 (38) diagnosis new cases 40 (80) old cases 10 (20) fig. 1: age distribution of patients (n = 50). table 2: topical medications already being used other than latanoprost 0.005% (n = 50). medication n (%) none 40 (80) beta blocker 2 (4) beta blocker + cah* inhibitor combination 8 (16) * cahcarbonic anhydrase mmhg (± 4.70). this showed a mean reduction of 4.76 mmhg (± 3.26). the second follow up visit at 6 weeks showed a mean iop of 14.88 mmhg (± 4.19). there was a reduction of 7.60 mmhg (± 4.80) as compared to the baseline iop. the mean iop at final follow up visit at 12 weeks was 13.20 mmhg (± 3.03), showing a mean reduction of 9.28 mmhg (± 5.36) from baseline. a statistically significant reduction of iop was seen at 2 weeks as compared to the baseline values (p < 0.001). this effect continued to increase and at the end of study period there was marked difference between the baseline and final iop readings (p < 0.001) (table 3, fig. 2). the results showed a 21.17% reduction of iop from baseline at 2 weeks of treatment with. at 6 weeks there was 33.80% reduction. at 12 weeks, a mean reduction of 41.28% in iop was noted (fig. 3). 0 5 10 15 20 25 baseline 2 weeks 6 weeks 12 weeks mean iop mean iop reduction fig. 2: iop values (n = 50). a total of 12 (24%) patients had ocular side effects of medication. 8 (16%) patients reported ocular irritation. of these, 4 (8%) had mild symptoms and 4 (8%) had symptoms of moderate degree. none of them required discontinuation of medication. 2 (4%) io p m m h g visits muhammad imran janjua, et al 166 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology table 3: iop values (n = 50). mean iop mmhg (± sd) mean iop reduction mmhg (± sd) p-value baseline 22.48 (± 6.4) ------------------ 2 weeks 17.72 (± 4.70) 4.76 ( ± 3.26 ) < 0.001 6 weeks 14.88 (± 4.19) 7.60 (± 4.80 ) < 0.001 12 weeks 13.20 (± 3.03) 9.28 (± 5.36) < 0.001 table 4: adverse effects and their severity (n = 50). intensity of side effects total n (%) nil n (%) mild n (%) moderate n (%) side effects nil 38 (76) 0 (0) 0 (0) 38 (76) irritation 0 (0) 4 (8) 4 (8) 8 (16) conj. hyperemia 0 (0) 2 (4) 0 (0) 2 (4) watering 0 (0) 2 (4) 0 (0) 2 (4) total 38 (76) 8 (16) 4 (8) 50 (100) 41.28 0 21.17 33.8 0 10 20 30 40 50 baseline 2 weeks 6 weeks 12 weeks percent iop reduction fig. 3: percent iop reduction. patients developed conjunctival hyperemia and another 2 (4%) had watering of eyes after using the drops. both conjunctival hyperemia and watering were of mild degree. none of the patients developed any serious adverse effects. 38 (76%) patients tolerated the medication well and did not develop any side effects (table 4, fig. 4 and 5). discussion as new treatment modalities are being introduced for glaucoma management, research on the iop lowering efficacy and safety is important in clinical decisionmaking. numerous topical medications can be used in glaucoma patients. the six classes of drugs (miotics, beta-blockers, alpha-agonists, adrenalin derivatives, carbonic anhydrase inhibitors and prostaglandin analogs) are commonly being used either as a single drug therapy or in different combinations offering multiple medication options5,15. 0 5 10 15 20 25 n il ir ri ta ti o n c o n j. h y p e re m ia w a te ri n g male female fig. 4: adverse effects according to gender (n = 50). this short term study was designed to evaluate the effect and safety profile of latanoprost 0.005% in p e rc e n ta g e visits n o . o f p a ti e n ts adverse effects efficacy and tolerability of latanoprost 0.005% in treatment of primary open angle glaucoma (poag) pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 167 controlling the iop. latanoprost was given to patients with inadequate iop control, and the drugs already being used by previously diagnosed patients of poag were not washed out before adding latanoprost. the results showed a significant decrease in iop at two, six and twelve weeks of therapy. the mean iop reduction at 12 weeks was 9.28 mmhg. previous literature also showed a similar iop reduction pattern. this was achieved in patients who were newly diagnosed with poag, and were given only latanoprost for treatment, as well as in patients previously diagnosed and already using other topical iop lowering agents16,17. 0 1 2 3 4 5 6 7 8 9 28 45 50 55 60 63 65 68 70 nil irritation conj. hyperemia watering fig. 5: adverse effects according to age (n = 50). this study did not compare the iop lowering effect of latanoprost with other topical drugs or iop reducing modalities. several previous studies showed that latanoprost had a similar, and in some cases better iop lowering profile as compared to beta blockers and topical carbonic anhydrase inhibitors2,6,18,19. nagar et al. showed that latanoprost had a better effect in controlling iop as compared to selective laser trabeculoplasty (slt)20. a major concern in glaucoma management is poor compliance with topical therapy. most of the drugs usually require twice or thrice daily administrations. hence, another advantage of using latanoprost is better compliance of treatment since it has to be administered once daily in the evening. the safety profile of topical latanoprost is excellent. the reported side effects were only of mild to moderate degree and none of the patients needed to discontinue the treatment. previous literature also demonstrated a similar side effect profile with no serious local or systemic adverse effects with the use of topical latanoprost1,13,17. in patients with systemic diseases e.g. heart disease and asthma, bradycardia and bronchospasm have been reported by the use of topical beta blockers. therefore, caution is necessary in treating such patients. latanoprost has no effect on the circulatory and respiratory systems and can safely be used in cardiac or asthmatic patients 18. eyelash thickening and lengthening, iris and periocular hyperpigmentation are other reported side effects of long term use of topical prostaglandin analogs11,17. since this was a short term study, so no such adverse effects were seen in any of the patients. conclusion it can be concluded that topical latanoprost 0.005% is very effective in reducing the iop in glaucomatous patients. it also demonstrates good pharmacological effects when used along with other drugs that have not been able to keep the iop at desired level. it has excellent safety profile with no significant side effects and offers more convenience to the patients as a result of once daily administration. author’s affiliation dr. muhammad imran janjua mbbs, postgraduate trainee ophthalmology dept of ophthalmology.holy family hospital, rawalpindi dr. saira bano mbbs, postgraduate trainee ophthalmology dept of ophthalmology, holy family hospital, rawalpindi dr. ali raza mbbs. mcps. fcps, head of ophthalmology department dept of ophthalmology, holy family hospital, rawalpindi role of authors dr. muhammad imran janjua study conception, data collection, analysis drafting. dr. saira bano study conception, data collection, analysis. dr. ali raza, critical review, analysis, overall supervision. n o . o f p a ti e n ts age muhammad imran janjua, et al 168 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology references 1. eveleth d, starita c, tressler c. a 4-week, doseranging study comparing the efficacy, safety and tolerability of latanoprost 75, 100 and 125  μg/ml to latanoprost 50  μg/ml (xalatan) in the treatment of primary open-angle glaucoma and ocular hypertension. bmc ophthalmology. 2012; 12: 9. doi:10.1186/14712415-12-9. 2. orzalesi n, rossetti l, invernizzi t, bottoli a, autelitano a. effect of timolol, latanoprost, and dorzolamide on circadian iop in glaucoma or ocular hypertension. invest ophthalmol vis sci. 2000; 41: 256673. 3. heijl a, leske mc, bengtsson b, hyman l, bengtsson b, hussein m. early manifest glaucoma trial group. reduction of intraocular pressure and glaucoma progression: results from the early manifest glaucoma trial. arch ophthalmol. 2002; 120: 1268-79. 4. the advanced gglaucoma intervention study (agis). 7. the relationship between control of intraocular pressure and visual field deterioration. the agis investigators. am j ophthalmol. 2000; 130 (4): 429-440. 5. pacella f, turchetti p, santamaria v, impallara d, smaldone g, brillante c, et al. different differential activity and clinical utility of latanoprost in glaucoma and ocular hypertension. clinical ophthalmol. 2012; 6: 811–815. 6. bucci mg. the italian latanoprost study group. intraocular pressure lowering effects of latanoprost monotherapy versus latanoprost or pilocarpine in combination with timolol: a randomized, observer masked multicenter study in patients with open angle glaucoma. j glaucoma, 1999; 8 (1): 24-30. 7. brubaker rf. flow of aqueous humor in humans. invest ophthalmol vis sci. 1991; 32: 3145–3165. 8. reiss gr, lee da, topper je, brubaker rf. aqueous humor flow during sleep. invest ophthalmol. vis sci. 1984; 25: 776–778. 9. topper je, brubaker rf. effects of timolol, epinephrine, and acetazolamide on aqueous flow during sleep. invest ophthalmol vis sci. 1985; 26: 1315– 1319. 10. bill a, phillips ci. uveoscleral drainage of aqueous humuor in human eyes. exp eye res. 1971; 12: 275–281. 11. kanski jj, bowling b. clinical ophthalmology. 7th edi. london; elsevier saunders, 2011: 384-385. 12. rowe ja, hattenhauer mg, herman dc. adverse side effects associated with latanoprost. am j ophth. 1997; 124 (5): 683–685. 13. alm a, grierson i, shields mb. side effects associated with prostaglandin analog therapy. survey of ophth. 2008; 53 (6): s93–s105. 14. nakakura s, yamamoto m, terao e, nagatomi n, matsuo n, fujisawa y, et al. prostaglandin-associated periorbitopathy in latanoprost users. clinical ophthalmology, 2015; 9: 51–56. 15. alm a, widengard i, kjellgren d, soderstrom m, fristrom b, heijl a, et al. latanoprost administered once daily caused a maintained reduction of intraocular pressure in glaucoma patients treated concomitantly with timolol. br j ophthalmol. 1995; 79: 12-16. 16. mckibbin m, menage mj. the effect of once-daily latanoprost on intraocular pressure and pulsatile ocular blood flow in normal tension glaucoma. eye, 1999; 13: 31-34. 17. thomas r, parikh r, sood d, vijaya l, sekhar gc, sood nn, et al. efficacy and safety of latanoprost for glaucoma treatment: a three-month multicentric study in india. indian j ophthalmol. 2005; 53: 23-30. 18. zhang wy, po alw, dua hs, blanco aa. metaanalysis of randomised controlled trials comparing latanoprost with timolol in the treatment of patients with open angle glaucoma or ocular hypertension. br j ophthalmol. 2001; 85: 983–990. 19. peeters a, schouten jsag, severens jl, hendrikse f, prins mh, webers cab. latanoprost versus timolol as first choice therapy in patients with ocular hypertension. a cost-effectiveness analysis. acta ophthalmol. 2012; 90: 146–154. 20. nagar m, ogunyomade a, o’brart dps, howes f, marshall j. a randomised, prospective study comparing selective laser trabeculoplasty with latanoprost for the control of intraocular pressure in ocular hypertension and open angle glaucoma. br j ophthalmol. 2005; 89: 1413–1417. javascript:void(0); javascript:void(0); javascript:void(0); microsoft word editorial vol. 24, 4, 2008 163 editorial secondary iol implantation in this issue of pjo there is excellent coverage of cataract surgery related options like secondary iol implantation and particularly scleral fixation of iol. cataract treatment now is synonymous with cataract extraction with iol implantation, be it primary or secondary. the choicest procedure is iol in the bag. in certain situations in the bag insertion is not possible and one has to resort to anterior chamber (ac) insertion or scleral fixation of iol. we all know the complications of ac iol’s especially ugh syndrome etc. and also we are aware of demanding techniques and complications of scleral iol fixations in the past. we have come a long way with safer ac iol’s and evolution of easier and safer scleral fixation techniques. in certain situations where there is no contraindication to ac or scleral fixation iol one has to decide which one to choose for our patient. i have sought opinion of some learned colleagues in this regard and i am quoting the views of some of them for our guidance in decision making. i myself always preferred ac iol insertion in such a situation. dr. aqil qazi, senior consultant at lrbt lahore with enormous experience in cataract surgery has following views. when a patient presents to a doctor for a secondary iol without posterior capsule remnant puts a doctor into dilemma. anterior chamber iol doctor has a much simpler, quicker and shorter almost achievable option, that is ease of placing an anterior chamber iol. after the procedure the discomfort and photo sensitivity comes immediately. macular edema incidence becomes much higher and diabetic patient develops retinopathy out of proportion to other eye. this is due to low grade uveitis. due to turbulence the eye continuously sheds endothelial cells. when the endothelial count falls below the critical level bullous keratopathy sends patient to blind alley. scleral fixated iol on the other hand the option of placing lens behind iris contrary to anterior chamber iol, requires skilled surgeon with expertise, takes longer time and requires properly anesthetized eye. even with all expertise, hemorrhage, the iol power calculation error, iol tilting and low grade uveitis may be expected. but the threat of the corneal damage due to turbulence endotheliopathy is avoided. the task becomes easier with availability of eyelets on haptics of intra ocular lens, prolene suture with straight long needles and good operation environment i.e. assistant, instruments and microscope. dr. tariq saeed, an eminent u.s trained vitreo-retinal surgeon with background of pediatric care experience has following recommendations. i implanted my first intraocular lens implant in usa in 1980. it was an anterior chamber implant. all my colleagues did the same procedure till 1985. corneal decomposition and “ugh” syndrome (uveitis, glaucoma, hyphema) became known. chronic cme was a long term problem. in 1985 i explanted my first anterior chamber implant in order to get rid of these ongoing problems. we switched over to posterior chamber implants (initially over the shelf, and later on in the bag) in 1983. all those patients who were rendered aphakic prior to 1979, were implanted with posterior chamber (pc) lenses, placed over the dissected shelf, and combined with anterior vitrectomy only if a rent existed in pc. quite a large number of patients had no posterior capsul. this is where the need for scleral fixation arose. i implanted my first sclerelly fixated iol by using a 27 gauge needle, in 1986. 164 the technique needs good anterior vitrectomy, a prolene suture (preferably 9-0) with double needle, and a single piece pmma (or equivalent) large optic iol, with haptic-to haptic diameter of 13.00mm or larger. unless the cornea has gutttata caused by previous surgical damage, proper visco elastic coating of endothelium will prevent corneal endothelial damage secondary to vitrectomy-fluid & other maneuvers. mild (minimal) hemorrhage form the wound, that mixes up with vitreous, clears up in few weeks. intra ocular pressure increases to low 20’s in about 1/3 of patients. it is caused by erythroclasts, macrophages and in some patients by steriod drops that we use along with ansaid drops (for cme). iop is reversible in almost all cases. retinal detachment is avoided by keeping cutter speed high, (750 cuts / minute or more) suction at the lowest level, and choosing a reliably good cutter. we examine retina intra operatively (after vitrectomy) to assure structural integrity and treat with cryo or endolaser if needed. dr p. s. maher, professor of ophthalmology from aga khan university and isra postgraduate institute of ophthalmology has given his valuable opinion. intraocular lens implants have proven to be one of the most significant advancements in ophthalmology over past few decades. over the years, design of lenses has evolved greatly with also changes in the surgical technique. posterior chamber lenses are the preferred way of implanting lenses as they are associated with less intraocular inflammation, hyphema and glaucoma. they also lead to less endothelial cell loss after cataract surgery. the posterior chamber lens is closer to the nodal point and center of rotation of the eye leading to better optical properties. as the lens is posterior to the iris, the potential of pupillary block is decreased. because the lens is away from the corneal endothelium, there is less chance of corneal decompensation. more over the angle structures remain undisturbed, minimizing the peripheral anterior synechial formation. it is clear that the best lens implant during uncomplicated phacoemulsification or extra capsular cataract extraction is a pciol. how ever the problem arises when the capsular support is lost. alternate modalities include implanting an anterior chamber iol (ac-iol), the posterior chamber iol (pc-iol) sutured to the sclera or a pc-iol suture to the iris. ac-iols are used when there is an eventful cataract surgery resulting in insufficient capsular support or they are also implanted secondarily in the aphakic patients. these lenses are easy to implant. it is advisable to perform an anterior vitrectomy in the case of vitreous presenting after the capsular rupture. this will clear the vitreous strands presenting in the wound and allow pupil to constrict easily with the help of intracameral acetylcholine. most of ac-iols, available in the market have four fixation points to be supported by the angle structures. a peripheral iridectomy is helpful to prevent postoperative pupillary block. inserting of iol can be helped with the use of silicone glide. the common complications associated with the use of these lenses are pupillary block glaucoma, corneal decompensation due to endothelial cell loss resulting in psudophakic bullous keratopathy, uveitis – glaucoma – hyphema (ugh) syndrome and cystoid macular edema. scleral – sutured pc-iols were first described by spigelman and coworkers. these lenses are shown to be preferable to the ac-iols, because of less endothelial cell loss following penetrating kerato-plasty and cataract surgery. the possibility of late polypropylene suture break has been a concern with scleral sutured lenses resulting in lens dislocation. to minimize the incidence of dislocation, it is recommended to place the iol haptics in the ciliary body/ ciliary sulcus rather than posterior to the ciliary sulcus to promote scarring that can help fixate the iol. to provide a greater margin of safety when the haptics do not scar, it is advised to use 9 – 0 polypropylene suture available on cif –4 ethicon needle, because of its larger cross –sectional diameter and 60% greater tensile strength than 10-0 polypropylene. other possible complications of scleral sutured lenses are vitreous hemorrhage and cystoid macular edema. to avoid macular edema it is recommended to commence these patients routinely on non-steroidal anti-inflammatory drops along with steroids and antibiotics in immediate postoperative period. sinsky style angulated pc-iols with four centering holes in a 6mm diameter optic are described by many workers in association with penetrating keratoplasty. these lenses are sutured to the iris with prolene 10-0 double armed sutures, about 2mm peripheral to pupillary border to permit adequate mydriasis and to prevent irritation and chafing of the pupil. this technique is recently described in detail. pc lenses sutured with iris have certain drawbacks. pupillary dilatation can be a problem as pupil diameter dose not move beyond 1-2 mm, making it difficult for proper fundus examination. persistent 165 hyphema is another complication witnessed in these patients. the intraocular lenses have considerable optical and practical advantages over glasses or contact lens aphakic correction in the elderly population. the posterior chamber scleral sutured iols, although technically difficult, are less eventful than the iris sutured or ac-iols in the long term. while dr. ali haider, a budding vitreo retinal surgeon categorically recommended the preference of inserting a.c iol. prof. dr. syed imtiaz ali, head of eye department rmc & allied hospitals rawalpindi had communicated that following are my views about a scleral sutured iol as compared to ac iol. “i think that scleral sutured iol after the loss of posterior capsule is always preferable because the ac iol is ultimately going to produce corneal problems. it is not always easy to place an ac iol because of papillary abnormalities after the loss of vitreous. now that we have pc iols available which can be fixed to sclera without sutures, i think there is no place for ac iol in future. i would value the opinion if all the learned and experienced ophthalmic surgeons in this regard in the letters to the editor column for the guidance of our upcoming colleagues. m. lateef chaudhry microsoft word news and evants 27,1,2011 54 news and events vol. 27, 1, 2011 lahore ophthalmo date: 16 18 december, 2011 venue: to be announced secretary: dr. zahid kamal siddiqui secretariat: osp house 4 – a lda flats, lawrence road, lahore. phone: 92 – 42 – 36363325 fax: 92 – 42 – 36363326 email: osplhr@gmail.com american society of cataract and refractive surgery (ascrs) / american society of ophthalmic administrators (asoa) symposium and congress date: 26 – 30 march, 2011 venue: san diego, usa the association for research in vision and ophthalmology (arvo) annual meeting 2011 florida, usa date: 1 5 may, 2011 xvix congress of the european society of cataract and refractive surgeons (escrs) date: 17 – 20 september, 2011 venue: vienna, australia annual meeting of american academy of ophthalmology (aao) date: 22 – 25 october, 2011 venue: orlando, usa 33rd world ophthalmology congress (woc) date: 16 – 20 february, 2012 venue: abu dhabi, united arab emirates the 27th apao congress busan, korea. date: 13 17 april, 2012 institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091 – 9217376 – 80 fax: 92 – 42 – 6363326 email: pico@pes.comsats.net.pk punjab institute of preventive ophthalmology, lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042 – 37355998 fax: 042 – 37248006 email: pipo@brain.net.pk pakistan institute of ophthalmology, al – shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al – shifa trust eye hospital, jhelum road, rawalpindi – pakistan phone: 92 – 51 – 5487830, 5487820 – 25 fax: 92 – 51 – 5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt department of ophthalmology fatima jinnah medical college sir ganga ram hospital, lahore fax: 92 – 42 – 6363326 email: hamidbut@gmail.com mobile: 0300 – 4158962 microsoft word shafi m jatoi 86 original article frequency of anti hepatitis c virus in eye surgery patients at tertiary referral center lumhs shafi muhammad jatoi, ashok kumar narsani, mahesh kumar pak j ophthalmol 2009, vol. 25 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: dr. ashok kumar narsani assistant professor department of ophthalmology liaquat university eye hospital hyderabad. received for publication august’ 2008 … ……………………… purpose: to determine the incidence of anti-hepatitis c virus in patients undergoing eye surgery. material and method: the study was conducted in the department of ophthalmology liaquat university of medical and health sciences jamshoro from july 2007 to june 2008. in this study evaluation of 1128 patients of various ages under going eye surgeries and were unaware of hepatitis c infection were included in this study. each patients was serologically screened by rapid chromatography immunoassay for qualitative detection of antibodies for hepatitis c before surgery. result: five hundred forty four (48.22%) patients were male and 584 (51.77%) were female. large number of patients were in 4th and 5th decade of life in both sexes. of these 1128 patients, 334 (29.60%) were serologically positive for hepatitis c antibodies. majority of them were male (54.80%) with male to female ratio of 1.21:1. conclusion: the incidence of hepatitis c antibodies positive is higher in our population. there fore it is mendatory to screen every patient for hepatitis c and b before any surgical procedure. the surgeon and health care professional should protect themselves. the used infected material should be destroyed properly. 87 epatitis c virus is a small rna virus. the average incubation period is 7-8 weeks with a range of 2-26 weeks1. it is primarily a blood borne or parenterally transmitted infection. vehicles and routes of parenteral transmission include contaminated blood and blood products, needle sharing, contaminated instruments (eg:in haemodialysis, reuse of contaminate medical devices, tattooing devices, acupuncture needles, razors) and occupational and nocosomial exposures2. only a relatively small fraction of hcv infections are symptomatic. most infected individuals remain asymptomatic and presumably undiagnosed and leads to chronic carrier state. these are about 60% affected individuals3. it stands to reason that an occupational risk for transmission of hcv in the health care setting might exist, including transmission from infected patients to staff, from patient to patient, and from infected providers to patients4. presence of anti hcv antibodies in blood indicate that the person is infected with hepatitis c virus and may transmit the virus to others. without meticulous attention to infection control and disinfection and sterilization procedures, the risk for transmission of blood borne pathogens in the health care setting is magnified. the study was conducted to find out the incidence of hcv antibodies in patients undergoing surgery at department of ophthalmology liaquat university of medical and health sciences jamshoro at hyderabad. which is one of the largest tertiary care center in sindh. this institution is a great referral centre for whole interior sindh province. material and methods this prospective observational study was conducted at department of ophthalmology, liaquat university of medical and health sciences jamshoro/hyderabad from july 2007 to june 2008. a total of 1128 patients under going eye surgery, who were unaware of hepatitis c infection were included in this study. each patients was serologically screened by rapid chromatography immunoassay for qualitative detection of hepatitis c virus antibodies to find the carrier status of patients before surgery. results a total number of 1128 patients were operated during the study, five hundred forty four (48.22%) patients were male and 584 (51.77%) were female. of these 1128 patients, 334 (29.60%) were serologically positive for hepatitis c antibodies. male patients were more in number (54.80%) with male to female ratio of 1.21:1. (table 1). large number of patients 280 (83.82%) were in 4th and 5th decade of life in both sexes. table 1: incidence of anti hepatitis c in different age group age male n (%) female n (%) total n (%) 21-30 11 (3.29) 7 (2.10) 18 (5.59) 31-40 23 (6.89) 13 (3.90) 36 (10.78) 41-50 45 (13.47) 40 (11.98) 85 (25.44) >50 104 (31.14) 91 (27.25) 195 (58.38) total 183 (54.80) 151 (42.20) 334 (100) discussion hepatitis c virus was initially isolated from the serum of a person with nona, non b hepatitis in 1989 by choo et al.5 shortly after the cloning of hcv, this new isolated virus was discovered to be the cause of approximately 90% of non a, non b hepatitis in the united states. the world wide prevalence of hepatitis c virus infection is estimated by the world health organization (who) to be approximately 3% corresponding to170 million infected persons6,7. it appears to be endemic in most parts of world8. regional variation exists in the prevalence of hcv infection9 from high endemic area to non endemic area. figures have even widely varied within the same country. in pakistan hcv is highly endemic and its incidence is increasing since last few years. the incidence of anti hcv positive in our study is 29.60%. the incidence reported in other local studies were 4%in blood donors10 from normal healthy population, 4.6% in general population in bunner nwfp9 and 7% in surgical patients.11 chaudhary ia et al12 reported 11.26% incidence of hcv infection among their operated patients where as study conducted by khurrum13 et al repoted 6% incidence of anti hcv antibodies in health care workers in a local hospital. while the incidence ranges from 0.4% in the adult general population of fakuoka, japan to 14.4% in the healthy individuals from southern italy14. in brazil, who estimates suggest h 88 that between 2.5% and 4.9% of the general population is positive for anti-hcv antibodies5. concerning demographic variables, the increase in the risk for hcv seropositivity between 30 and 60 years age was different to that reported for blood donors in australia15 or the united states16. incidence increases with increasing age i-e 5.39% at the age of 20 to 30 years where 25.44% at the age of 40 to 50 years. increasing incidence with increasing age is also reported by mahmood t. et al1. in contrast brandaoa bm et al17 and patino-sarcinelli f et al18 reported decline of infection rate in person greater than 50 years. in this study the incidence of anti-hepatitis c in male is higher (54.80%) than the female (45.20%) which contrast to chaudhary ia et al11 who reported higher incidence in female patients. conclusion the incidence of hepatitis c antibodies positive is higher in our population. therefore it is mandatory to screen every patient for hepatitis c and b before any surgical procedure. the surgeon and health care professional should protect themselves by using protective mask, eye protection glasses, double gloves before handling infected cases. the used infected material, needles and other waste material should be destroyed properly. author’s affiliation prof. shafi muhammad jatoi chairman & head department of ophthalmology liaquat university eye hospital hyderabad dr. ashok kumar narsani assistant professor department of ophthalmology liaquat university eye hospital hyderabad dr. mahesh kumar clinical pathologist department of ophthalmology liaquat university eye hospital hyderabad reference 1. mahmood t, iqbal m. prevalence of anti hepatitis c virus (hcv) antibodies in cataract surgery patients. pak j ophthalmol. 2008; 24: 16-18. 2. department of ophthalmology liaquat university of medical and health sciences jamshoro from july 2007 to june 2008. managing occupational risks for hepatitis c transmission in the health care setting. clin microbiol rev. 2003; 16: 546-68. 3. lone ds, aman s, aslam m. prevalence of hepatitis c virus antibody in blood donors of lahore. biomedica 1999; 15: 103-7. 4. alain sv, loustaud-ratti f, dubois md, et al. seroreversion from hepatitis c after needle stick injury. clin. infect. dis. 2002. 34: 717-9. 5. world health organization. hepatitis c–global prevalence (update). wkly epidemiol rec. 2000; 75: 17–28. 6. world health organization. hepatitis c: global prevalence. wkly epidemiol rec. 1997; 72: 341–4. 7. world health organization. global surveillance and control of hepatitis c. report of a who consultation organized in collaboration with the viral hepatitis prevention board, antwerp, belgium. j viral hep. 1999; 6: 35–47. 8. khokhar n, gill ml, malik gj. general seroprevalence of hepatitis b and hepatitis c virus infection in population. j coll phys surg pak. 2004; 14: 534-6. 9. muhammad n, jan a. frequency of hepatitis c in bunner, nwfp. j coll physician surg pak. 2005; 15: 11-4. 10. ahmed j, taj as, rahim a, et al. frequency of hepatitis b and hepatitis c, in healthy blood donors of nwfp: a single center experience. j postgard med inst. 2004; 18: 343-5. 11. fayyaz h, gill lm, sohail r, et al. screening for hepatitis c in gynecological patients. ann king edward med coll. 2004; 10: 287-8. 12. chaudhary ia, khan sa. should we do hepatitis b and c screening on each patient before surgery: analysis of 142 cases. pak j medi sci. 2005; 21: 278-80. 13. khurrum m, hassan z, but aua et al. prevalence of anti hcv antibodies among health care workers of rawalpindi and islamabad. rawal med j.2003; 28: 7. 14. chowdhury a, santra a, chaudhuri s, et al. hepatitis c virus infection in general population: a community based study in west bengal india. hepatology. 2003; 37: 802-9. 15. kaldor jm, archer gt, buring ml, et al. risk factors for hepatitis c virus infection in blood donors: a case-control study. med j. 1992; 157: 227–30. 16. murphy el, bryzman s, williams ae, for the reds investigators et al. demographics determinants of hepatitis c virus seroprevalence among blood donors. jama. 1996; 275: 995-1000. 17. ajacio bm. brandao and sandra costa fuchs risk factors for hepatitis c virus infection among blood donors in southern brazil: a case-control study bmc gastroenterol. 2002; 2: 18. 18. patino-sarcinelli f, hyman j, camacho lab, et al. prevalence and risk factors for hepatitis c antibodies in volunteer blood donors in brazil. transfusion. 1994; 34: 138-41. 89 microsoft word abstract 26, 2,2010 104 abstracts edited by dr. tahir mahmood use of anterior segment optical coherence tomography to study corneal changes after collagen cross-linking doors m, tahzib ng, eggink fa, berendschot ttjm, webers cab, nuijts rmma am j ophthalmolol. 2009; 148: 744-51 keratoconus is a bilateral, progressive corneal disease with a multifactorial cause and a classical onset at puberty. it is characterized by corneal collagen structure changes, decreased corneal rigidity, and corneal thinning, leading to a progressive corneal deformation (conical protrusion) and decreased vision. early treatment options are correction of the refractive error by spectacles or contact lenses (such as soft, rigid, or scleral lenses). in contact lens-intolerant patients with mild to moderate keratoconus, the implantation of intracorneal ring segments can be considered because they lead to a flattening effect of the cornea and can increase contact lens tolerance. however, these treatment options do not interfere with the progression of the disease and therefore are insufficient in cases of progressive keratoconus. in advanced cases of keratoconus (eg, with corneal scars, thin, bulging corneas, or both), penetrating or lamellar keratoplasty procedures are the only solution. until now, keratoconus remains one of the leading indications for keratoplasty. for progressive, nonadvanced cases, corneal collagen cross-linking has become available, leading to a mechanical strengthening of the cornea and thereby achieving a stabilization of the disease. this may delay the need for keratoplasty in this young, nonadvanced patient group. corneal cross-linking, which combines riboflavin eye drops and ultraviolet a (uva) radiation, was first described by spoerl and associates in 1998. uva radiation in combination with riboflavin generates reactive oxygen species, leading to the formation of cross-links between the corneal collagen fibers. the primary goal of corneal cross-linking is to increase corneal rigidity by increasing the mechanical stability of the corneal stroma. wollensak and associates reported a 4.5 times increase in biomechanical rigidity in human corneas after corneal cross-linking, with a primary treatment effect in the anterior 300 µm of the corneal stroma. in current practice, patients with progressive keratoconus or post-laser in situ keratomileusis (lasik) ectasia may be eligible for corneal cross-linking, provided that their corneas are clear and not too thin. the purpose of this study was to investigate the stromal demarcation line after corneal cross-linking using anterior segment optical coherence tomography (as-oct) and its influence on the short-term results of cross-linking in patients with progressive keratoconus. twenty-nine eyes of 29 patients with progressive keratoconus (n=28) or after laser in situ keratomileusis ectasia (n=1) were included and treated with corneal cross-linking at our institution. measurements at 1, 3, 6, and 12 months after corneal cross-linking were refraction, best-corrected visual acuity (bcva), tonometry, corneal topography, as-oct, specular microscopy, and aberrometry. demarcation line depth was measured centrally, 2 mm temporally, and 2 mm nasally by two independent observers using as-oct and was correlated with clinical parameters. the stromal demarcation line was visible with asoct at 1 month after surgery in 28 of 29 eyes. pairwise comparisons between the two observers of the as-oct measurements did not show a statistically significant difference. after an initial steepening of maximal keratometry values and a decrease in bcva at 1 month after surgery (both with p < .012), no significant changes were found at 3, 6, and 12 months after surgery compared with before surgery. refractive cylinder, topographic astigmatism, aberration values, endothelial cell density, and intraocular pressure remained stable during all postoperative visits. a deeper demarcation line depth was associated with a larger decrease in corneal thickness (r = -0.506; p = .012). authors concluded with the remarks that as-oct is a useful device to detect the stromal demarcation line after corneal cross-linking. at 3 to 12 months follow-up, all clinical parameters remained stable, 105 indicating stabilization of the keratoconic disease. a simple and evolutional approach proven to recanalise the nasolacrimal duct obstruction chen d, ge j, wang l, gao q, ma p, li n, li dq, wang z br j ophthalmolol. 2009; 93: 1438-43 nasolacrimal duct obstruction (nldo) and chronic dacryocystitis are common ophthalmic diseases. the external dacryocystorhinostomy (ex-dcr) has been the most effective and standard surgery in treating these conditions since 1904 when it was reported by toti. however, ex-dcr is an invasive, relatively complex and time-consuming procedure that causes a facial cutaneous scar. many patients prefer to suffer tearing rather than undergo this surgery. the improvement on dcr has been made recently, such as the endonasal dcr and endocanalicular laser dcr. these approaches were promising but still necessitate bone removal and require costly equipment. these surgical procedures were reported to have less effective results than ex-dcr and involve a marked learning curve. the approach of the ex-dcr and these new procedures is to create a bypass draining system, rather than to restore the obstructed nasolacrimal duct. recanalisation of nasolacrimal duct obstruction (rc-nldo) was an evolutionally developed surgical approach for treating these conditions to restore the native nasolacrimal duct, using a simple instrument, the lacrimal canaliser, which we created in 1994. since then, this approach has been widely adopted by many ophthalmologists in china for its simplicity, safety, efficacy and minimal invasion. in the present study, we report the long-term follow-up results of rcnldo in the clinical treatment for 506 cases of nldo and chronic dacryocystitis, as well as the histopathological evidence from animal experiments. the relative indication, contraindication, surgical technique, postoperative care, complications, advantages and disadvantages of the rc-nldo are discussed. the purpose of this study was to evaluate a new approach of recanalisation of nasolacrimal duct obstruction (rc-nldo) in the treatment of the nasolacrimal duct obstruction (nldo) and chronic dacryocystitis. 583 patients with 641 eyes suffering from nldo and chronic dacryocystitis were enrolled in this study. the rc-nldo was performed in 506 eyes, with 135 eyes undergoing external dacryocystorhinostomy (ex-dcr) as controls. patient follow-up for 54 months was evaluated by symptoms, dye disappearance test, lacrimal irrigation and digital subtraction dacryocystogram. the rc-nldo was also performed in 12 rhesus monkeys for histopathological examination. the clinical success rates were 93.1% in 506 cases of rc-nldo and 91.11% in 135 cases of ex-dcr, the success rates for second surgery were achieved in 85.19% on rc-nldo and 40.0% on ex-dcr. no major intraor postoperative complications were observed in the rc-nldo group. the mean operative duration was 12.5 min for rc-nldo and 40,3 min for ex-dcr (p<0.001). a pathological study in rhesus monkeys demonstrated that the rc-nldo wounded epithetlium in nasolacrimal duct healed completely within 1 month without granulation tissue formation. authors concluded with the remarks that the findings demonstrate that the rc-nldo is a simple and effective approach proven to recanalise the obstructed nasolacrimal duct with a comparable success rate to ex-dcr. macular thickness decreases with age in normal eyes: a study on the macular thickness map protocol in the stratus oct eriksson u, aim a br j ophthalmol. 2009; 93: 1448-52. histological studies of the human retina and optic nerve have shown a decreased density of photoreceptors, ganglion cells, retinal pigmentepi-thelium and optic nerve fibres with age. these findings, however, do not necessarily have to result in retinal thinning, but one would expect some shrinkage of the total retina over time. non-invasive techniques have made it possible to measure the thickness of retinal structures in vivo. with optical coherence tomography (oct), both qualitative and quantitative measurements of the retina can be made. a macular mapping technique that has shown a good reproduce-bility is implemented into the oct 2000 and oct3 scanners, which are in clinical use today. observations based on single scan measurements have shown a decrease in retinal and rnfl thickness with age. in a pilot study, schuman et al reported that the peripapillary retinal nerve fibre layer (rnfl) decreases with age using 106 oct i. poinoosawmy and coworkers also demonstrated a progressive reduction in the nerve fibre layer thickness with age using scanning laser polarimetry (gdx). in an oct study by alamouti and funk, both retinal and rnfl thickness decreased slightly with age. finally, kanai and coworkers also found that retinal thickness decreases with age. none of these investigators, however, used the oct mapping technique. based on the findings in postmortem and in vivo studies, one would expect a slight thinning of the total retina. surprisingly, studies on normal retinal thickness with the mapping protocol have so far not shown any significant correlation between retinal thickness and age. therefore, we wanted to examine the relation between retinal thickness and age with the macular map technique. retinal and retinal nerve fibre layer (rnfl) thinning with age have been described in histological studies. in vivo techniques like optical coherence tomography (oct) have shown thinning of optic nerve rnfl and the retina in specific areas. one would expect thinning of the total macula, but so far, no correlation with the quantitative oct macular map tool and age has been found. sixty-seven healthy individuals underwent three repeated scans in both eyes with the macular thickness map protocol in the stratus oct. that protocol divides the macula area into nine etdrs fields. the rnfl was measured in one specific location close to the optic disc. correlations between retinal, rnfl thickness, macular volume and age were determined. authors found a statistically significant negative relationship between retinal thickness and age for all etdrs areas, total macular volume and rnfl thickness. retinal thickness decreased by 0.26-0.46 µm macula volume 0.01 mm and rnfl 0.09 µm per year. authors concluded with the remarks that retinal thickness within the area covered by the macular map significantly decreases with age. in the area examined in the papillomacular bundle, 20% of the retinal thinning is due to the rnfl, and 80% is due to thinning of other layers of the retina. intravitreal injection of pegaptanib sodium for proliferative diabetic retinopathy gonzalez v h, giuliari g p, banda r m, guel d a br j ophthalmol. 2009; 93: 1474-8. diabetic retinopathy (dr) is a major cause of blindness in the western world. research into the aetiology of ocular neovascular diseases such as dr has identified a pivotal role for vascular endothelial growth factor (vece) in promoting both angiogenesis and increased vascular permeability. intravitreal injection of vecp induces many of the pathological changes characteristic of dr, including intraretinal and preretinal neovascularisation, microaneurysm formation, intraretinal haemorrhage, macular oedema and areas of capillary non-perfusion with endothelial cell hyperplasia. elevated intraocular levels of vegf have been reported in patients with dr. moreover, this elevation is more pronounced in pdr than in non-proliferative diabetic retinopathy (npdr). the isoform165 of vecf-a (vecf165) is particularly potent in promoting ocular neovascularisation and breakdown of the blood-retinal barrier (brb) through a leucocyte-dependent mechanism. pegaptanib sodium is a selective anti-vecf aptamer that binds to vece. preclinical studies demonstrated that intravi-treal injections of pegaptanib (ivp) can inhibit pathological ocular neovascularisation while leaving physiological vascularisation unimpaired. in a recent phase ii study of pegaptanib for the treatment of diabetic macular oedema (dme), findings suggested that ivp may be capable of halting and even reversing pathological retinal neovascularisation (nv). authors hypothesised that in patients with active pdr, ivp would cause marked reduction in vitreous levels of vecf165 with regression or pathological nv, thereby hindering the progression of pdr. the purpose of this study was to compare the efficacy of intravitreal pegaptanib (ivp) with panretinal laser photocoagulation (prp) in the treatment of active proliferative diabetic retinopathy (pdr). a prospective, randomised, controlled, open-label, exploratory study. twenty subjects with active pdr were randomly assigned at a 1:1 ratio to receive treatment in one eye either with ivp (0.3 mg) every 6 weeks for 30 weeks or with prp laser. efficacy endpoints included regression of retinal neovascularisation (iw), changes from baseline in best-corrected visual acuity (bcva) and foveal thickness. safety outcomes included observed and reported adverse events. in 90% of randomised eyes to ivp, retinal nv showed regression by week 3. by week 12, all ivp eyes were completely regressed and maintained through 107 week 36. in the prp-treated group, at week 36, two eyes demonstrated complete regression, two showed partial regression, and four showed persistent active pdr. the mean change in bcva at 36 weeks was +5.8 letters in pegaptanib-treated eyes and -6.0 letters in prp-treated eyes. only mild to moderate transient ocular adverse events were reported with pegaptanib. authors concluded with the remarks that ivp produces short-term marked and rapid regression of diabetic retinal nv. regression of nv was maintained throughout the study and at the final visit. microsoft word sadaf imran 146 original article imaging in ocular trauma optimizing the use of ultrasound and computerised tomography sadaf imran, saima amin, m imran hameed daula pak j ophthalmol 2011, vol. 27 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sadaf imran resident radiology department of radiology national institute of child health, karachi submission of paper may’ 2011 acceptance for publication september’ 2011 …..……………………….. purpose: this study was conducted to identify the role of ultrasound (us) and computerized tomography (ct) scan in diagnosis of common ocular traumatic lesion. material and methods: a cross sectional observational study was conducted over one year period simultaneously at the jinnah postgraduate medical center (jpmc), karachi and the pns shifa hospital, karachi. fifty patients with traumatic ocular injuries who were referred by the ophthalmologist for radiological evaluation were included in the study. data regarding five common traumatic lesions namely intraocular foreign body, vitreous hemorrhage, lens dislocation, retinal detachment and choroidal detachment was analyzed. results: the age of subjects included in this study ranged from 08 years to 60 years (mean age was 28 ± 1 year). ultrasound was able to detect the pathologies in 93% of the patients when compared with ct scan. ct scan showed higher accuracy compared to ultrasound in detecting intraocular foreign body (25 patients out of which 24 cases were diagnosed by ultrasound) vitreous hemorrhage (26 patients out of which 22 cases were diagnosed on ultrasound) and lens dislocation (04 patients out of which 02 cases were diagnosed on ultrasound). however ultrasound showed higher accuracy compared to ct scan in detecting retinal detachment (20 patients out of which only 06 cases were diagnosed on ct scan) and choroidal detachment (08 patients while ct was unable to detect any case of choroidal detachment). conclusion: in the setting of acute ocular trauma ct scan is more accurate in detecting intraocular foreign body, vitreous hemorrhage and lens dislocation whereas ultrasound is superior in diagnosing retinal detachment and choroidal detachment. combined use of these imaging modalities is recommended in diagnosis and management of post traumatic patients with ocular injuries. cular trauma is common and may lead to vision threatening pathologies. it has been estimated that world-wide ocular injuries are responsible for blindness in approximately 1.6 million people, bilateral visual impairment in 2.3 million and unilateral visual loss in about 19 million people annually1. approximately half of all patients who present to an eye casualty department are suffering from ocular trauma2. ocular injuries are usually associated with injuries to head and neck or limb structures and definitive diagnosis of ocular trauma in the acute setting may be challenging. missed ocular injuries in polytrauma patients may lead to serious morbidity later on, necessitating the need of high index of suspicion and employment of appropriate imaging techniques to accurately define the extent and type of ocular injury. various imaging modalities exist to aid in the initial and subsequent evaluation of trauma involving the eye and orbit. however, the best modality for the initial evaluation of eye trauma remains indirect ophthalmoscopy. in the first few hours after a severe o 147 injury, the first examiner can obtain information with a level of detail that no other imaging method can provide. although the early view may not always be the best one, often the first look into a traumatized eye is the only look. direct visualization of intraocular structures however may become difficult or impossible when the eye lids are swollen after injury. the use of imaging modalities like ultrasonography and ct scanning can be useful adjuncts in the management of such patients. standard roentgenography, computed tomography (ct), magnetic resonance imaging (mri), and ultrasonography have been employed in managing ocular trauma patients and all have their strengths and weaknesses3-5. this study explores the role of ultrasound and ct scanning in the management of ocular trauma. material and methods after appropriate technical and ethical approval from the relevant review boards this cross sectional observational study was conducted simultaneously at the jinnah postgraduate medical center (jpmc), karachi and the pns shifa hospital, karachi. sampling technique was non-probability convenience. the sample comprised fifty patients with traumatic ocular injuries who were referred by the ophthalmologist for radiological evaluation. data regarding five common traumatic lesions namely intraocular foreign body, vitreous hemorrhage, lens dislocation, retinal detachment and choroidal detachment were analyzed. period of study was 01 year from 31st january 2009 to 30th january 2010. all the patients were examined by ultrasound in supine position with linear high frequency transducer of 7.5 mhz on single ultrasound machine (gevoluson 730), using closed eye technique with water soluble gel followed by orbital ct scan. spiral ct of patients was performed on toshiba asteion 16 slices ct scanner. axial slices were obtained with 120 kv and 250ma. the ct protocol included pitch of 1.0 slices thickness 1.0mm and reconstruction interval 5.0 mm. reformatted coronal and sagital images were also obtained. in all selected patients the findings seen on ultrasound and ct scan were collected and proforma were filled for each patient. results in this study there were 34 (68%) male patients and 16 (32%) were female patients. the mean age of patients in our study was 28± 1 year (sd 14.5). after ultrasound all patients underwent ct scanning. overall ultrasound was able to detect the pathologies in 93% of the patients when compared with ct scan results. data analysis for five individual pathologies as shown in tables 1 and 2 was carried out and it revealed that ct scan diagnosed foreign body in 25 patients out of which 24 cases were correctly diagnosed on ultrasound. ct scan diagnosed vitreous hemorrhage in 26 patients out of which 22cases were correctly diagnosed on ultrasound. ct scan diagnosed lens dislocation in 04 patients out of which 02 cases were correctly diagnosed on ultrasound. ultrasound diagnosed retinal detachment in 20 patients out of which 06 cases were correctly diagnosed on ct scan. ultrasound diagnosed choroidal detachment in 08 patients, none of these were picked up by ct scan. the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of ultrasound and ct scan for different ocular pathologies included in this study are shown in table 3. disease distribution include frequency of foreign body 25 (30%), vitreous hemorrhage 26 (31%), retinal detachment 20 (24%), choroidal detachment 8(10%) and lens dislocation 4 (5%).chi square test was applied to check association between categorical variables (p<0.00). discussion traumatic ocular emergencies can present in isolation or as part of poly trauma. it is difficult to perform a physical examination on a severely injured patient. the eye may be swollen shut or there may be intraocular bleeding rendering fundoscopic examination impossible. the patient may be unable to cooperate or respond, making it difficult to evaluate for visual acuity or ocular movement. since these lesions can lead to exceptional morbidity in the form of vision loss they warrant a high index of suspicion and prompt and judicious use of imaging modalities to obtain an accurate diagnosis and initiate appropriate management at an early stage. studies have shown that ultrasound and ct scan are highly accurate in detection of ocular pathologies.6 computed tomography is considered as having advantage due to its ability of performing multiplanar reformation, evaluating intraorbital structures with simultaneous imaging the bony orbit for fractures and any herniations of orbital contents7. 148 our study includes both children and adults with history of ocular trauma. mean age of patients was 28 ±1 year in our study while in study done by deramo et al it was 36 years7. in this study ocular sonography was done using a single machine (ge voluson 730)and a standardized technique similar to that used by other researchers (e.g. by hoffman) using close eye technique with linear 7.5 – 10 mhz probe in sagittal and transverse plane8. ultrasound was followed by ct scanning done by similar protocol as described by kazuhiro et al.9 axial slices were obtained from above the orbit to below the orbit, the field of view included the cavernous sinus and anterior brain stem with 120 kv and 100-160 ma, pitch of 1.5, slices thickness 1.0mm and reconstruction interval 1.0 mm. all ct scans done were on toshiba asteion 16 slice ct scanner. blaivas et al4 evaluated the accuracy of ultrasound for the diagnosis of ocular pathology in patients with ocular trauma and findings were confirmed by thin slices ct scanning. the results showed 100% sensitivity and 97.2 % specificity. while in our study the sensitivity is 97.3% and specificity is 94.4%. table 1: patient gender distribution based on pathology pathology female male total patients intraocular foreign body 09 16 25 vitreoushae morrhage 04 18 26 ectopialentis 02 02 4 retinal detachment 04 16 20 choroidal detachment 04 04 8 table 2: ultrasound vs ct scan diagnostic breakdown based on different pathologies pathology correctly diagnosed on ultrasound correctly diagnosed on ct scan incorrectly diagnosed on ultrasound incorrectly diagnosed on ct scan total intraocular foreign body 24 25 01 0 25 vitreous haemorrhage 22 26 4 0 26 ectopialentis 2 4 2 0 4 retinal detachment 20 6 0 14 20 choroidal detachment 8 0 0 8 8 table 3: sensitivity, specificity, ppv (positive predictive value), npv (negative predictive value) of ultrasound and ct scan for different ocular pathologies pathology ultrasound ct scan sensitivity % specificity % ppv % npv % sensitivity % specificity % ppv % npv % intraocular foreign body 96 92.8 92.3 96.2 100 96.15 96.15 100 vitreous haemorrhage 84.6 96.5 95.6 87.5 96.29 92.3 92.85 96 ectopialentis 75 97.9 66.6 96 80 95.8 66.6 96 retinal detachment 95.2 90.9 86.9 96.7 30 95.6 75 75.8 choroidal detachment 80 97.7 88.8 91.6 0 98 0 86.2 149 fig. 1: oculr ultrasound with linear probe fig. 2: 22-year male patient with vitreous hemorrhage, retinal detachment and foreign body. fig. 3: 30-year female presented with history of blunt trauma. ultrasound image reveals retinal detachment. fig. 4: 60-year-old male patient presented with oculartrauma during iron working,ultrasound and ct images show largeforeign body, vitreous hemorrhage and retinal detachment. 150 fig. 5: 21 year old female patient presenting with trauma. imaging reveals lens dislocation shiver et al3 stated the sensitivity of ultrasound for detecting foreign body to be 87.5% and specificity to be 95.8 %. in our study the sensitivity for foreign body detection was 96 % and specificity was 92.8%. ct is considered the most sensitive method for detection of intraocular foreign body reaching more than 95% detection rate10 while in our study the ct sensitivity for diagnosis of intraocular foreign body reached 100%. ultrasonography is an excellent method to detect all kinds of intraocular foreign bodies with an overall detection rate for metallic and non metallic foreign body reaching 93% stated by khan & khan et al11. in our study the sensitivity of ultrasound for the diagnosis of retinal detachment is 95.2% & specificity is 90.9% in comparison with dhakshina et al the sensitivity is 92.3 % and specificity is 100%12 hence retinal detachment is well demonstrated by ultrasound as well as sometimes by ct as a 'v' or a 'sunset sign13. in our study the sensitivity of ultrasound for the diagnosis of vitreous hemorrhage is 84.6% and specificity is 96.5 % in comparison with s. kim s. lee et al sensitivity is 73% and specificity 90%14. gilbert et al stated that sensitivity of ct for the diagnosis of lens dislocation is 100% and specificity is 96% 15while in our study the sensitivity of ct is 80 % and specificity is 95.8%. dislocation of lens into opaque media is a perfect indication for ultrasound. the abnormally placed lens is easily detected because of its shape and strong reflectivity. munk et al (1991) demonstrated lens fragmentation with individual fragments distinctly discernible on ultrasound16. the slight difference of results in my study in comparison with other studies was possibly due to incorporation of patients and operator dependency of ultrasound and ct scan done with 3-5 mm slice thickness due to patient load and time limitation rather than 1.0mm, which is used in other studies9. ultrasound provides good visualization of ocular anatomy that allows evaluation of intraocular foreign body and related lesions such as vitreous hemorrhage and retinal detachment17.ultrasound is inexpensive and readily available in most radiology departments. on the other hand it is operator dependent technique. the examination of the globe is exhaustive and patient is asked to perform ocular movements to find the exact ultrasound incidence angle to visualize the foreign body18, however ultrasound is useful in detecting small, nonmetallic posteriorly located foreign bodies that may not be detected by other methods19,20. ct is accurate in detecting and localizing intraocular, metallic, glass and stone foreign bodies,21 ct imaging offers short examination time and has the ability to obtain diagnostically useful coronal and sagittal reconstruction images21 on the other hand there is radiation dose delivered to the lens. in the presence of significant facial trauma it is very difficult to determine the cause of decreased visual acuity. significant vitreous hemorrhages, intraocular foreign bodies, chorioretinal detachment, lens dislocation and others all result in visual loss and require imaging for diagnosis. conclusion this study shows that ultrasound has high sensitivity and specificity in diagnosing traumatic ocular diseases and is superior to ct scan in diagnosing retinal detachment and choroidal detachment, while ct scan 151 detects foreign body, vitreous hemorrhage and lens dislocation more accurately than ultrasound. the results of this study support the combined use of ultrasound and ct scan imaging in managing patients with traumatic ocular injuries who are referred for radiological evaluation. however keeping in view the common availability, cost effectiveness and acceptably high sensitivity and specificity of ultrasound in detecting ocular traumatic pathologies the authors strongly propose liberal use of ultrasound in managing these patients. the importance of incorporating ocular ultrasound training for all radiologists, ophthalmologists and emergency department physicians cannot be overemphasized. author’s affiliation dr. sadaf imran resident radiology department of radiology national institute of child health, karachi dr. saima amin assistant professor department of radiology jinnah postgraduate medical centre, karachi dr. m imran hameed daula department of surgery pns shifa hospital, karachi reference 1. negrel ad, thylefors b. the global impact of eye injuries. ophthalmic epidemiol. 1998; 5: 143-69. 2. chiapella ap, rosenthal ar. 1 year in an eye casualty clinic. br j ophthalmol. 1985; 69: 865-70. 3. stephen a. shiver, mathew lyon, micheal blaivas. detection of metallic ocular foreign bodies with handheld sonography in a porcine model. j ultrasound med. 2005; 24: 1341-6. 4. blaivas m. bedside emergency department ultrasonography in the evaluation of ocular pathology. academera med. 2000; 7: 947-50. 5. bord sp, linden j. trauma to the globe and orbit. emerg med clin north am. 2008; 26: 97–123. 6. blaivas m theodor d, sierzenski p. a study of bedside ocular ultrasonography in the emergency department. academer med. 2002; 9: 791-9. 7. deramova, shah gk, baumal cr, et al. role of ultrasound biomicroscopy in ocular trauma. trans am ophthamol soc. 1998; 96: 355-65. 8. ultrasound guide for emergency physician, an introduction, beatrice hoffmann, md, phd, rdms. 9. katada k, kauczor hu, schuzer j, et al. multidetector ct protocol-developed for toshiba scanner, spring 2005. 10. novellinera, liebig t, jordan j, et al. computed tomography of ocular trauma. emerg radiol. 1994; 1: 56–67. 11. khan bs, khan md; a review of 100 cases of ectopialentis. presentation, management and visual prognosis, pak j of ophthalmol: 2002; 18: 3-9. 12. ganeshan dm. probing into retinal detachment – ultrasound is eminently useful as diagnostic tool. 2008; 31,. 13. pieramici dj. vitreo retinal trauma.ophthalmolclin north am. 2002; 15: 225-4. 14. kim s. lee comparison of ultrasound & intraoperative findings in patients with vitreous hemorrhage, invest ophthalmol vis sci. 2005; 46: 5436. 15. ce. gilbard cro 15.1, ct & us in lens dislocation & iof bs 18.5: 118. 16. munk pl, vellet ad, levin m, et al. sonography of the eye. am j roentgenol. 1991; 157: 1079-86. 17. berges o. orbital ultrasonography: principles and technique. in: newton th, ed. radiology of the eye and orbit. new york, ny: raven press. 1990: 6.1–6.20. 18. deramova, shah gk, baumal cr, et al. ultrasound biomicroscopy as a tool for detecting and localizing occult foreign bodies after ocular trauma ophthalmology. 1999; 106: 301-5. 19. deramova, shah gk, baumal cr, et al. role of ultrasound biomicroscopy in ocular trauma. trans am ophthamol soc. 1998; 96: 355-65. 20. lakitas a, prokesch r, scholda c, et al. orbital helical computed tomography in the diagnosis and management of eye trauma ophthalmology. 1999; 106: 2330-5. 21. dass ab, ferrone pj, chu yr, et al. sensitivity of spiral computed tomography scanning for detecting intraocular foreign bodies. ophthalmology. 2001; 108: 2326–8. microsoft word index-1.doc editorial amd current standard of care and the pakistani perspective the millennium started with a gift for the evergrowing blind population of the world, especially in the developed world, where age-related macular degeneration (amd) ranked as the leading cause of unpreventable blindness. millions were saved from going permanently blind with the onset of new therapies aimed towards preserving and improving vision in these patients. for many years the retina specialists were unable to treat choroidal neovascularization (cnv) in amd with good visual results. in the early 90’s some success was reported with laser photocoagulation treatment of small classic cnv lesions. but ultimately the concept of foveal photocoagulation which was recommended by the mps subfoveal study was rejected as the long term results were hopeless. alternate approaches in the mid and late 90 included submacular surgery with macular translocation and radiotherapy. very little functional benefit was accomplished in the majority of these patients while subjecting them to a high rate of potential adverse complications. the same was true for ttt (transpupillary thermotherapy), which never came up to the expectations. in 2000, the approval of verteporfin (visudyne) photodynamic therapy (pdt) heralded a new era in the treatment of cnv. visudyne was initially approved only for classic cnv where there was a clear cut treatment benefit; but in reality this treatment prevented vision loss and typically did not improve vision in the majority. pdt was the standard of care for neovascular amd in the period ranging from 2000 to 2005. at the same time pharmacologic therapy with antivascular endothelial growth factor (vegf) agents was undergoing development. it was demonstrated that vegf was an important mediator of neovascularization in human eyes with cnv and amd. the first commercially available anti vegf agent for intraocular use was pegaptanib (macugen) which became available in early 2005. it stabilized the visual status but substantial visual improvement was uncommon. in the middle of this decade intravitreal injections of avastin (bevacizumab) and later ranibizumab (lucentis) emerged as a superior treatment. fda approval of lucentis occurred in july 2006. lucentis is a drug derived from avastin and it has been demonstrated to be the first and only drug for cnv in amd that results in substantial and clinically relevant visual improvement avastin, a drug originally approved for colorectal carcinoma, has become widely adopted because in addition to potentially better visual results than either macugen or pdt, the drug is also much cheaper. at this point, jury is still out about which of the two contenders, avastin or lucentis, is the best. both induce regression of cnv and lead to significant improvement in vision. both drugs are fda approved but only one is labeled for intravitreal administration. lucentis is supported by clinical trials, and the other by many uncontrolled studies as well as virtual unanimity among retinal specialists. lucentis is smaller molecule with a shorter half-life and is approximately 100 times more expensive than avastin. age related macular degeneration treatments trials (catt), a multi-centre randomised clinical trial will assess the relative safety and efficacy of two treatments for subfoveal cnv. it is being conducted in 47 clinical centres across the us. this study will determine if avastin is similar to lucentis when given on a monthly basis. the drawback of avastin or lucentis is that they do not permanently close the cnv. most clinicians give three injections of avastin or lucenits at monthly or every six week intervals. they then watch the patients and give additional injections on an as needed basis. some patients however, need injections every month. patients get tired of these injections and each one of them has a small risk of endophthalmitis. therefore a treatment for amd that involves fewer or no injections is needed. irrespective of which form of treatment we use, we must understand that cnv in amd is a chronic disease that will require ongoing treatment, currently with injections. given our current available treatments, we now know when to treat; however, we still need better understanding of when to continue or discontinue treating to enhance safety and efficacy and to reduce costs. larger randomized clinical trials are currently underway, including trials combining pdt/vegf inhibitor (luv trial, denali, mont blanc), pdt/ vegf inhibitor/corticosteroid (radical, taper), and pdt/corticosteroid (veritas). ongoing research is exploring other complementary or alternative anti-vegf strategies. the vegf trap and gene suppression or small interfering rna (sirna) drugs for reducing vegf production or blocking vegf receptors are attractive concepts for development as monoor combined forms of therapy. these methods of treatment are still in developing stages. while rehabilitation of end stage amd patients has classically involved the use of low visual aids, all eyes are set on the development and ultimate availability of the retinal chip (the proverbial bionic eye) to help patients who have already gone to the scarring stage. while research from the west keep coming up with promises of newer and better treatments, we in pakistan, have been using pdt and anti vegf drugs, as mono-therapy and combination, with varying degrees of success. our initial experience of pdt monotherapy from 2001 to 2005 exhibited better outcomes than our international counterparts. this was due to the fact that we were treating more classic lesions that are expected to respond better. we joined the anti-vegf bandwagon with the advent of macugen and treated few patients with results similar to pdt i.e. stability of the lesions and not much improvement in the visual acuity. it was only after the advent of avastin and lucentis that we witnessed significant improvement in majority of the patients. the choice of the anti-vegf has largely depended on the financial status of the patients. lucentis is the drug of choice if financial constraints aren’t a consideration and avastin use is now a knee jerk reflex in the converse situation we in pakistan have witnessed that although we are developing country the behaviour of our urban population is similar to that of the developed world. amd is on the rise with increasing longevity of older population. we are also are observing an earlier onset of disease in our population. our government’s role should be to improve the facilities for amd patients as there are no retinal centres and patients don’t know where to go and to ensure the provision of treatment especially considering avastin is not so expensive (around rs. 300 per injection). doctors also need to be properly trained for these procedures. if proper protocols are not being followed, there is a likelihood of encountering serious sight and eye threatening complications. international literature shows unanimously that the complication and side effects reported were directly correlated with the technique rather than the type of injection. it is the responsibility of ophthalmic community to promote and monitor proper usage of these intravitreal injections. dr. azam ali microsoft word mustafa iqbal consensus report 158 consensus report retained intraocular foreign body pak j ophthalmol 2010, vol. 26 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . background intraocular foreign bodies (iofbs) account for almost 40% of penetrating ocular injuries1-3. 75% of the iofbs lodge in the posterior segment4. retained intraocular foreign bodies most commonly result from occupational activities and predominantly involve males in 3rd to 4th decade5. most sustain injury while hammering a metal with metal and 80% cases have metallic iofbs6. the hammer-chisel injury is the most common cause of the iofb in adults7. other emerging causes like fire arm injuries and blast injuries are becoming common. iofb causes damage to the eye by the following mechanisms8: • cause mechanical trauma to the eye • introduce infection • exert toxic effect the extent of ocular injury depends on: • size of the object • speed of impact (air gun vs. bbi) • composition of the object • impact site classification intraocular foreign bodies can be classified according to: 1. anatomical zone (entry and exit) 2. position of iofb 3. nature of iofb 1. zones of ocular injury9 • zone 1: isolated to the cornea (including the limbus). • zone 2: from limbus to a point 5mm posterior in sclera. • zone 3: posterior to the anterior 5mm of the sclera. 2. position of the iofb • iofb located in the anterior segment • in the cornea • in the anterior chamber • in the anterior chamber angle • intralenticular • iofb located in the posterior segment: • iofb located in the vitreous cavity • iofb floating into the vitreous after causing retinal trauma • iofb embedded in the retina/ sclera 3. nature of iofb • metallic e.g. copper, iron • glass • plastic • organic e.g. wood • stone complications iofbs can be inert but often cause serious damage inside the eye and must be removed promptly.10possible complications of iofb include11, 12: • corneal opacity • cataract • intraocular hemorrhage (hyphema, vitreous hemorrhage) • elevated intraocular pressure • retinal breaks • retinal detachment: rhegmatogenous or tractional. • proliferative vitreoretinopathy • hypotony • phthisis bulbi • endophthalmitis: more likely to occur with: • contaminated injury • retained iofb • rupture of lens capsule • delayed surgical repair • siderosis (due to iron iofb) • chalcosis (due to copper iofb) 159 management of iofb 1. history 2. clinical examination 3. investigations 4. surgery 1. history history is very important to determine the origin of the foreign body13. questions should be asked about the mechanism of injury and a high index of suspicion for the presence of iofb should be maintained12. 2. clinical examination complete ocular examination is important when possible and should always start with measurement of visual acuity and testing for the presence of relative afferent pupillary defect. poor initial visual acuity and the presence of afferent pupillary defect are most important prognostic factors at presentation9. possible site of entry and exit should be looked for13. posterior scleral rupture may be occult. signs of occult globe rupture include diffuse chemosis, asymmetric ac depth, low iop, hemorrhagic choroidal detachment, and vitreous hemorrhage9. indirect ophthalmoscopy through a dilated pupil may allow direct visualization of the iofb at first oportunity. applanation tonometry, gonioscopy and scleral depression should not be done in open globe injuries12 because they may result in extrusion of the intraocular contents. 3. investigations ct scan with thin slices is currently considered the gold standard for the detection, localization and characterization of both metallic and non-metallic iofbs. b-scan ultrasonography can be used to detect metallic iofb but sensitivity is user dependent. it is contraindicated in globes suspected of rupture. plain x-ray orbits may be used as a screening modality for iofbs but localisation of iofbs without limbal ring may pose diagnostic problems. mri is contraindicated in the detection of suspected metallic iofb. it may be considered when there is strong suspicion of a non-metallic foreign body not seen with ct scan or b scan ultrasonography14. 4. surgery the surgery for patients with iofb include: • primary repair (required in most cases). • removal of iofb timing of primary repair the wound should be closed as soon as possible12. wounds at particular risk of infection such as contaminated wound, iofb related injuries, vegetative injuries associated open globe injuries require more emergent care. delay in closure could increase not just the risk of infection but also the opportunity for an expulsive hemorrhage and extrusion of intraocular contents9. systemic and topical antibiotic therapy should be started as soon as possible15. tetanus prophylaxis should never be forgotten. timing of iofb removal if the fb is present in the anterior segment then it may be removed at the time of primary repair. removal of iofb from the posterior segment may be done at the time of primary repair or at an interval (surgeon’s clinical assesment). the timing of intervention is primarily determined by the risk of endophthalmitis. if the risk is high, immediate vitrectomy with removal of iofb is indicated.12 however if a patient presents to the vitreo-retinal surgeon with endophthalmitis and retained iofb, then the main indication for early removal of the iofb no longer applies. despite this some surgeons prefer immediate vitrectomy in patients presenting with endophthalmitis and retained iofb, to remove the iofb i.e. the presumed nidus of infection and debulk inflammatory debris in the vitreous. however, surgery in eye with active endophthalmitis is technically difficult and visualization of iofb is often problematic16. where there is no infection or retinal detachment then judicious delayed removal may be considered. early removal of iofb early removal of the iofb at the time of primary repair has the following advantages17: • single procedure • decrease in endophthalmitis rate • decrease in pvr rate many studies suggest that early vitrectomy and removal of iofb decreases the risk of infectious 160 endophthalmitis and proliferative vitreoretinopathy18,19. unless the iofb is removed and the wound repaired within 24hrs the patient’s risk of severe complications – such as endophthalmitis or vision loss – quadruples20. delay in iofb extraction, presence of intraocular hemorrhage, preoperative retinal detachment, primary surgical repair combined with iofb removal are the predictive factors for anatomic failure (postoperative retinal detachment is considered as the anatomic failure)21. good initial presenting va, early surgical intervention to remove iofb (within 24 hours) and ppv are predictive factors for good visual outcome. delayed removal of iofb delayed removal of iofb has several advantages. it decreases the risk of intraoperative bleeding and allows spontaneous separation of posterior hyaloid,23 making complete removal of the vitreous easier. this situation is more relevant to our set up. delayed removal of iofb may result in a significant increase in the development of endophthalmitis22. however delayed iofb removal with a combination of systemic and topical antibiotic coverage can result in good visual outcome without an apparent increased risk of endophthalmitis or other deleterious side effects15. in eyes with clinical features of infective endophthalmitis and a retained iofb immediate injection of intravitreal antibiotics with delayed removal of iofb is a possible alternative to immediate removal of iofb. this management may be associated with preservation of the eye and restoration of useful va16. in patients with iofb, final va doesn’t depend on the interval between injury and iofb removal, and with regard to the risk of endophthalmitis, iofb need not be considered an absolute indication for immediate intervention24. type of surgery the surgical approach for posterior segment iofb includes vitrectomy and removal of iofb by magnet or forceps. the best tool to extract an un-impacted ferrous iofb is a strong intraocular magnet. for nonmagnetic foreign bodies proper forceps are used. following iofb removal, a thorough peripheral vitrectomy should be performed, and an attempt to remove the posterior hyaloid should be made12. following is an algorithm for use of magnets, vitrectomy and scleral trap doors in the management of iofb. visualised non visualised vitreous magnetic (unimpacted, no evidence of retinal injury.) ext. magnet/ vitrectomy. vity, forceps, magnet non magnetic, unimpacted. vitrectomy, forceps vity, forceps intraretinal magnetic and non magnetic trap door/ vitrectomy, forceps trap door/ vitrectomy, forceps a key principle in removing any iofb from the posterior segment is obtaining excellent visibility. using an external magnet with poor visibility can cause a myriad of complications. external magnets are used for magnetic iofbs when the view is excellent and the iofb is not impacted or encapsulated by the organized vitreous. in these patients, vitrectomy is not necessarily required before using the external magnet10. when iofb is obscured by opacification of media, embedded within tissues or encapsulated by organized vitreous, non-magnetic grasping forceps are used to remove iofb. these patients always need vitrectomy. an encapsulated inert iofb may be left alone in selected cases. prognostic factors following factors affect the visual prognosis in patients with iofb5, 25-28. • initial visual acuity • rapd • mechanism of injury • wound size • zone of injury • intraocular hemorrhage (hyphema, vitreous hemorrhage) • presence or absence of endophthalmitis • uveal prolapse • pre-op retinal detachment • location of iofb • type of iofb • time of removal of iofb • pars plana vitrectomy 161 reference 1. cazabon s, dabbs tr. intralenticular metallic foreign body. j cataract refract surg. 2002; 28: 2233-4. 2. arora r, sanga l, kumar m, et al. intralenticular foreign bodies: report of eight cases and review of management. indian j ophthalmol. 2000; 48: 119-22. 3. coleman dj, lucas bc, rondeau mj, et al. management of intralenticular foreign body. ophthalmology. 1987; 94: 1647-53. 4. behrens-baumann w, praetorius g. intraocular foreign bodies. 297 consecutive cases. ophthalmologica. 1989; 198: 848. 5. dhir sp, mohan k, munjal vp, et al. perforating ocular injuries with retained intra-ocular foreign bodies. indian j ophthalmol. 1984; 32: 289-92. 6. sriprakash ks, sujatha bl, kesarwani s, et al. surgical intervention in retained intra-ocular foreign body: our experience. retina/vitreous session 2. aioc 2006 proceedings; 493-5. 7. lai yk, moussa m. perforating eye injuries due to intraocular foreign bodies. med j malaysia. 1992; 47: 212-9. 8. ahmadieh h, soheilian m, sajjadi h, et al. vitrectomy in ocular trauma factors influencing final visual outcome. retina 1993; 13: 107-13. 9. pieramici dj. open globe injuries are rarely hopeless. managing the open globe calls for creativity and flexibility of surgical approach tailored to the specific case. review of ophthalmology. 2005; 12: 6. 10. kalayoglu mv. evolviong use of intraocular magnets in ophthalmic surgery. ophthalmology web. 11. memon aa, iqbal ms, cheema a et al. visual outcome and complications after removal of posterior segment intraocular foreign bodies through pars plana approach. jcpsp. 2009; 19 : 436-9. 12. katz g, moisseiev j. posterior-segment intraocular foreign bodies: an update on management. risks of infection, scarring and vision loss are among the many concerns to address. retinal physician. 2009. 13. kanski jj. trauma. in: kanski jj clinical ophthalmology. a systemic approach 6th ed. butterworth heinemann. 2007; 84768. 14. nair uk, aldave aj, cunningham et jr. ophthalmic pearls: trauma. identifying intraocular foreign bodies. eyenet magazine oct 2007. edited by scott iu, fekrat s. 15. colyer mh, weber ed, weichel ed, et al. delayed intraocular foreign body removal without endophthalmitis during operations iraqi freedom and enduring freedom. ophthalmology. 2007; 114: 1439-47. 16. knox fa, best rm, kinsella f, et al. management of endophthalmitis with retained intraocular foreign body. eye 2004; 18: 179-82. 17. mittra ra, mieler wf. controversies in trhe management of open globe injuries involving the posterior segment. surv ophthalmol. 1999; 44: 215-25. 18. jonas jb, budde wm. early versus late removal of retained intraocular foreign bodies. retina. 1999; 19: 193-7. 19. mieler wf, ellis mk, williams df, et al. retained intraocular foreign bodies and endophthalmitis. ophthalmology 1990; 97: 1532-8. 20. kalayoglu mv. evolviong use of intraocular magnets in ophthalmic surgery. ophthalmologyweb. 21. erakgun t, egrilmez s. prognostic factors in vitrectomy for posterior segment intraocular foreign bodies. j trauma. 2008; 64: 1034-7. 22. chaudhary ia, shamsi fa, al-harthi e, et al. incidence and visual outcome of endophthalmitis associated with intraocular foreign bodies. graefes arch clin exp ophthalmol. 2008; 246: 181-6. 23. mieler wf, mittra ra. the role and timing of pars plana vitrectomy in penetrating ocular trauma. arch ophthalmol. 1997; 115: 1191-2. 24. karel i, diblik p. management of posterior segment foreign bodies and long-term results. european j ophthalmol. 1995; 5: 113-8. 25. szijarto z, gaal v, kovacs b, et al. prognosis of penetrating eye injuries with posterior segment intraocular foreign body. graefes arch clin exp ophthalmol. 2008; 246: 161-5. 26. de souza s, howcraft mj. management of posterior segment intraocular foreign bodies: 14 years’ experience. can j ophthalmol. 1999; 34: 23-9. 27. woodcock mg, scott ra, huntbach j, et al. mass and shape as factors in intraocular foreign body injuries. ophthalmology. 2006; 113: 2262-9. 28. wani vb, al-ajmi m, thalib l, et al. vitrectomy for posterior segment intraocular foreign bodies: visual results and prognostic factors. retina. 2003; 23: 654-60. principal author prof. mustafa iqbal glaucoma early diagnosis and appropriate management is important to preserve vision in glaucoma. prof. m lateef chaudhry editor in chief microsoft word rashid hassan alvi karachi 8 original article visual outcome and pattern of industrial ocular injuries rashid hasan alvi, mazhar-ul-hassan, naimatullah sial, umair qidwai, zia ghaffar aurangzeb, aziz ur rehman pak j ophthalmol 2011, vol. 27 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: rashid hasan alvi kvss site hospital manghopir road karachi received for publication march’ 2010 …..……………………….. purpose: to evaluate the industry related ocular injury pattern and visual outcome. material and method: the study was conducted in the kulsoom bai valika social security site hospital from nov. 2006 to nov. 2008. this study includes 200 patients fulfilling the inclusion criteria. all the patients were worked up according to the protocol. the follow up period was 3 months. results: a total of 200 persons presented with diagnoses of industrial ocular trauma. ocular injury requiring admission occurred in 25 cases (13%), the remaining 165 patients were treated on outpatient basis. the pattern of industrial ocular trauma was generally trivial. upon presentation 40 (21%) patients had visual acuity of 6/6 on snellen chart, while on final follow up 167 (88%) patients had a visual acuity 6/6 on snellen chart. conclusions: our study shows that the patients with industrial ocular injuries need urgent medical treatment. prompt medical management can prevent the permanent visual loss. cular trauma has always been and always will be a challenge to ophthalmologists1. injury is the commonest cause of monocular blindness2. worldwide more than half a million blinding injuries occur every year3-4. the overall financial cost is estimated to be hundreds of millions of dollar annually5. there is a bi modal age distribution of severe ocular trauma, with a large preponderance of injuries affecting males6-10. chiapella et al and vernon estimated that approximately half of all patients who present to an eye casualty department do so because of ocular trauma11-12. industrial accident statistics for 2005 indicated that ocular injuries accounted for 3% and it was attend for the last ten years13. industrial accident related ocular trauma comprise a relatively large proportion of the patients requiring ophthalmic review at emergency level in singapore14. it is commonly known that young adult males are more prone to ocular trauma and this has been traditionally endorsed to the relatively high risk-taking behaviour and the high proportion of work-related, assaultrelated and sports-related eye injuries in which there is a significant male pre ponderance15. the impact of eye injuries extend beyond the afflicted individual to social level in terms of loss of productivity and added costs to health care system. the quality of life of not only the patient, but also his families and friends is affected. it is perhaps a worthy reminder that the serious consequences of eye injuries such as visual impairment and physical disfiguration can also alienate the patient by imposing a barrier to social interaction both physically and psychologically. these repercussions are especially serious in the young individuals. another study has shown that work is an important cause of eye injury16. this study was conducted to evaluate the effects of eye in injuries in site, karachi. methods and materials a two years study was conducted from nov. 2006 to nov. 2008 at kulsoom bai valika social security hospital karachi. all patients who sustained ocular o 9 injures as a result of work related accident sewer included in the study. a specific history was taken about age, occupation, time of injury and type of object causing injury. patients had their visual acuity assessed by snellen chart. all patients had their anterior segments examined by slit lamp examination and iop measured by applanation tonometry and fundus examination carried out. data with regard to clinical condition during subsequent follow up visit, and final visual acuity upon discharge or last visit was also recorded. inclusion criteria all industrial ocular trauma brought to the hospital were included in the study. exclusion criteria 1. other causes of trauma such as road traffic accident, domestic assault, tennis ball and pellet injuries were not included in the study. 2. patients who received industrial ocular trauma and associated life threatening injuries were not included in the study. results a total of 200 patients presented with diagnoses of industrial ocular trauma during the study period. ten patients (5%) patients were lost to follow up. the average age of the patients was 24-38 years. all patients were male. management of the patients included removal of corneal foreign bodies, irrigation of eyes for those with chemical injury, followed by appropriate medical management and follow up in the out patients clinic. ocular injury requiring admission occurred in 25 cases (13%). six of them required emergency surgery under general anesthesia, 4 of these required corneal and scleral suturing, 2 cases required removal of foreign body, impaled in the cornea with anterior chamber collapse. one of the admitted patients had sealed corneal tear. nine of the admitted patients sustained severe chemical injury requiring intensive irrigation and topical medication. three patients had hyphema caused by blunt trauma, one had endophthalmitis, 4 patients had welding arc corneal burn. the remaining 165 patients were treated on out patient basis. they sustained superficial corneal and lid abrasion, management of these cases involved removal of superficial corneal or upper tarsal conjuctival foreign bodies and firm patch for 24 hours, superficial lid laceration required no suturing. six patients who did not require admission had mild chemical injury. management of these cases required intensive irrigation of the eye followed by appropriate topical medication and follow up in the out patient clinic. upon presentation 40 (21%) patients had visual acuity of 6/6 on snellen chart, 110 (58%) patients had a visual activity 6/9, 2 cases (1%) had a visual acuity 6/18, 17 cases (8.9%) had a visual acuity 6/24, 15 (7.9%) cases had a visual acuity 6/36, 5 (2.6% ) patients had a visual acuity < 6/60, 1(.52%) case had a visual acuity of light perception (pl + ve). on final follow up 167 (87.9%) patients had a visual acuity 6/6 on snellen chart, 5 (2.6%) patients had a visual acuity 6/9 on snellen chart, 7 (3.68%) cases of chemical injury those required admission had a visual acuity 6/12 on snellen chart, 7 (3.68%) of the admitted cases those sustained corneoscleral tear and intraocular foreign bodies (anterior chamber) had visual acuity of 6/18 on snellan chart, 2 (1%) of chemical injury out of 9 those required admission had visual acuity of 6/24 on snellen chart, 1 (0.52%) case of sealed corneal tear had visual acuity of 6/60 on snellen chart. 1 case (0.52%) of endophthalmitis did not improve and ended up with therapeutic evisceration. only 10 (5.26%) of the reporting patients had worn protective goggles. common causes of accidents were ill fitting or non-availability of protective eyewear and poor vision due to fogging from sweat. the electrical industry (where tube light and bulbs are manufactured) was the most common cause of superficial lid, corneal and conjunctival laceration. grinding, cutting metal, welding, hammering, drilling and chemical injury (car battery industry, soap industry and beverage industry) were the specific activities in the majority of the cases. average loss of days of work was 4.5 days. discussion careful examination and appropriate treatment are necessary because ocular traumatic emergencies may have a poor visual prognosis even when seemingly mild18. it has been observed that industrial ocular trauma is a characteristic of particular industry. manual occupational industries are a constant source of perforated ocular injuries with or without foreign 10 bodies19. in our study, the cases of ocular injuries that required admission were caused by high-speed machinery involving grinding drilling activities and chemical injuries. table-1: list of ocular injuries sustained. ocular injuries required admission n (%) ocular injures seen as outpatients n (%) lid laceration 0 09 (4.5) superficial lid conjunctival and corneal abrasion /laceration 0 150 (78.9) sealed corneal tear 1 (0.52) 0 scleral tear 2 (1.05) 0 full thickness corneal tear 3 (1.57) 0 intra ocular foreign body with anterior chamber collapse and corner tear 2 (1.05) 0 chemical injury 9 (4.7) 6 ( 3) hyphema 3 (1.57) 0 endophthalmitis 1 (0.52) 0 welding arc corneal burn 4 (2.10) 0 table-2: visual acuity readings no of patients n (%) visual acuity at presentation no of patients n (%) visual acuity upon discharge 40 (21.05) 6/6 167 (87.8) 6/6 110 (57.89) 6/9 05 (2.63) 6/9 02 (1.05) 6/18 07 (3.68) 6/12 15 (7.89) 6/36 07 (3.68) 6/18 17 (8.9) 6/24 02 (1.05) 6/24 05 (2.63) <6/60 01 (0.52) 6/60 01 (0.52) pl + ve 01 (0.52 npl 190 190 table 3: sources of injury source no of patient’s n (%) grinding 153 (76.5) welding 04 (2.01) hammering on metal 08 (4.02) drilling 06 (3.01) nailing 01 (0.52) chemicals 15 (7.5) blunt trauma 03 (1.57) negligence, lack of protection and poor vision due to fogging from sweat were the common causes of ocular injuries in our study. an earlier study by khan et al stated that criminally negligent attitudes, lack of protective devices and severe aggression were the causes of much ocular trauma in the khyber pakhtun khuwah20. the visual outcome of ocular injuries depends on the type of trauma sustained and the time lapse between injury and report to hospital emergency. average time after which the pts reported to the hospital was 1.2 days. ocular trauma in the industrial setting is largely preventable with the use of wellfitted protective eyewear and strict compliance. employees in every industry are at risk of eye injuries. occupational eye injuries can result in serious morbidity and great economic loss21. eye injuries remain a significant risk to worker’s health especially among men in jobs requiring intensive manual labour22. in our country there is an urgent need for better education on work place, safety measures and effective preventive strategies for both employers and their employees. conclusion the study shows that the patients with industrial ocular trauma need urgent medical treatment. prompt medical management can prevent the permanent visual loss. these patients are usually young males their injuries are generally minor and majority have good final visual acuity. these injuries are largely preventable with the use of well-fitted protective eyewear with good visibility and strict compliance on its use. this would greatly reduce the unnecessary loss 11 of work-days, economic loss and worker disability from ocular injury. author’s affiliation dr. rashid hasan alvi consultant eye surgeon kvss site hospital manghopir road karachi dr. mazhar-ul-hassan eye surgeon kvss site hospital manghopir road karachi dr. naimatullahsial eye surgeon kvss site hospital manghopir road karachi dr. umairqidwai eye surgeon kvss site hospital manghopir road karachi dr. zia ghaffar aurangzeb eye surgeon kvss site hospital manghopir road karachi dr. aziz ur rehman eye surgeon kvss site hospital manghopir road karachi reference 1. shahwanima, hameedk, jamalib. occular injuries: its etiology and consequences in balochistan. pak j ophthalmol. 2006; 22: 82-6. 2. editorial. progress in surgical management of ocular truama. british j ophthalmol. 1976; 60: 731. 3. negrelad, thyleforsb. the global impact of eye injuries. ophthalmia epidemiol. 1998; 5: 143-69. 4. macewencj. ocular injuries. jr coll surg edimb. 1999; 44: 317-23. 5. tielschjm, parvenlm. determinants of hospital charges and length of stay for ocular trauma. ophthalmology. 1990; 97: 2317. 6. glynn rj, seddon jm, berlin bm. the incidence of eye injuries in new england adults. arch ophthalmol. 1988; 106: 785-9. 7. desai p, mac even cj, baines p, et, al. epidemology and implication of ocular trauma admitted to the hospital in scotland. j epidemiol community health. 1996; 50: 436-41. 8. schein od, hibberd pl, shingleton bj, et al. the spectrum and burden of ocular injury. ophthalmology. 1988; 95: 300-5. 9. mac even cj. eye injuries a prospective surway of 56 71 cases. br j ophthalmol. 1989; 73: 888-94. 10. katz j, tielsch jm. life time prevalence of ocular injuries from the baltimore eye surway. arch ophthalmol. 1993; 111: 1564-8. 11. chiapella ap, rosenthalar. one year in eye casualty clinic. br j ophthalmol. 1985; 69: 865-70. 12. venon sa. analysis of all new cases see in a busy regional centre ophthalmic casualty department during 24 week period. jr soc med. 1983; 76: 279-82. 13. occupation safety and health division. oshd annual report 2005. works safety and health a new frame work. available at: www.mom.gov. sg / publish / etc media lib / mom-liabrary / work place safety / files 6. par. 16053. file. tmp / oshd annual report 2005. pdf. accessed february 2005. 14. ngo cs, leo sw. industrial accident related ocular emergencies in a tertiary hospital in singapore. singapore med j. 2008; 49: 280-5. 15. eye injuries in singapore-dont risk it. do more. a prospective study. jyh-haur woo, gangadhara sundar. ann acad med singapore. 2006; 35: 706-18. 16. dannenhergai, parverim, brechnerri, et al. penetration eye injuries in the work place. the national eye trauma system registry. arch ophthalmol. 1992: 110: 843-8. 17. baker rs, wilson mr, flowers cw jr, et al. demographic factors in a population based survey of hospitalized workrelated, ocular injury. am j ophthalmol. 1998; 122: 213-9. 18. boo s, oum, jong sl, young sh. clinical features of ocular trauma of emergency department. korean j ophthalmol. 2004; 18: 70-78. 19. shahwani ma, hameed k, barkat j. occularinjuries:its etiology and consequences in balochistan. pak j ophthalmol. 2006; 22: 82-6. 20. khan md, kundi n, mohammad z, et al. a 6 ½ years survey of intra ocular and intra orbital foreign bodies in the nwfp province, pakistan. br j ophthalmol. 1987; 71: 716-9. 21. chi–kung ho, ya–lin yen, cheng–hsien chang, et al. case control study in the prevention of occupational eye injuries. kaohsiung j med. 2008; 24:10-6. 22. mc call bp, horwitz ib, taylor oa. occupational eye injuries and risk reduction in kentakey workers, compensation claim analysis 1994 – 2003. inj prev: 2009; 15: 176-82. microsoft word editorial 174 editorial change at the helm ophthalmological society of pakistan was founded on the 19th december 1957 at the king edward medical college. in its meeting on the 16th november 1968 the society resolved that it should have a publication of its own publication in the tradition of american academy of ophthalmology. while raja mumtaz was appointed as the first editor, there was little expertise in publication of a scientific journal in pakistan at the time. the task of publication was therefore taken up by international member, an expatriate pakistani, living in the usa, dr. khalid j awan. he carried out this task admirably well for a period of eight years from 1985 to 1993. however by 1992 the society felt strong enough to start publication from pakistan. the task of publication was then entrusted to prof muhammad lateef ch. the first publication from pakistan came in january 1993. he carried on with the task as chief editor until he took over as the president of the osp center. for the next few years prof jahangir durrani was the chief editor of the pjo until he abruptly immigrated to the usa. the chief editorship of the pjo was then returned to prof lateef ch. with dr. tahir mahmood, as editor, as his understudy. in the beginning of 2011 prof lateef ch. announced his plans of retirement from the post of chief editor of pjo and the search for a new chief editor was started. the applicants for the post made a presentation to the central council in nathiagali and the new chief editor was announced during the lahore ophthalmo. so much for the history. the pjo has been in continuous publication since its inception. that is no mean achievement. for most of that period there was no institutional support for the journal. the financial support was also limited. often the publication of the journal was assisted from the chief editor’s own resources. most journals in pakistan publish no more that 200 to 300 copies. pjo is published in the quantity of 1300 copies ever quarter. pjo is sent to all members of the ophthalmic society by mail or courier. the pmdc and the who recognize the journal. its recognition by the hec is in progress. the team led by prof lateef ch. started of being it illiterate. however the pjo now has its own website, is open access, has an archive and a search engine for the archive. you can log on to the website and look for previous issues or search them by author or title or subject. it speaks volumes for the leadership qualities and the commitment of prof lateef ch. that he was able to bring together a team, which achieved all this. a team that often had strong dissenting voices. this is the last issue being published under the chief editorship of professor lateef ch. the task before the next chief editor and his team is just as hard. they have to maintain what they have and increase the impact factor of the journal. the final challenge before the new chief editor and is team is indexation with medline. on the plus side they now have solid institutional support. pjo has an office and support staff. there are many more doctors in pakistan whole have experience in scientific publication. on the negative side the culture of research does not exist in the country. for any diehard researcher the obstacles are hamalyian. the funds do not exist; very few people know the meaning of p value or the relevance of sample size. once a diligent researcher has gone past all these hurdles he or she soon finds that patients do not maintain follow-up. most researchers have poor skill at writing in english. while the hurdles are many the task is not insurmountable. a committed team can push the whole of ophthalmology forward. the authors can be cajoled, guided, helped and prodded into writing a better paper and correcting their english. while indexation in medline may appear distant, indexation in other regional and international indices can be achieved in not to distant future. the central council of the osp has given the new chief editor and his team four years to achieve a minimum editorial standard. the pjo has become the standard bearer of the ophthalmic community of pakistan, it cannot let the ophthamic community down. the new team will have to show that they are worthy of stepping into the shoes of their illustrious predecessor and carrying this standard forward. syed ali haider chief editor (elect) microsoft word yasir arfat 74 original article visual outcome after anterior segment trauma of the eye muhammad yasir arfat, hamid mahmood butt pak j ophthalmol 2010, vol. 26 no .2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: muhammad yasir arfat department of ophthalmology sir ganga ram hospital lahore received for publication july’ 2009 … ……………………… purpose: to find out the final visual outcome (snellen visual acuity) after initial management of ocular trauma and to determine the etiological factors responsible for ocular trauma and extent of injury. material and methods: this study was conducted in the department of ophthalmology, sir ganga ram hospital/fatima jinnah medical college, lahore from june 2004 to december 2004. all these patients presented in the out patient department of ophthalmology sir ganga ram hospital. detailed history was taken. complete clinical examination was done to record the findings and all patients were thoroughly investigated to reach the final diagnosis. all patients were treated on the basis of their diagnosis for the underlying cause. surgical procedures were performed where appropriate. every patient was followed for 6 months within the study period. results: fifty patients were included in the study. forty two (84%) were male while 8 (16%) were female patients with male to female ratio 5.25:1. all patients were between 5-30 years of age (mean ± sd 15.94 ± 6.03). different treatment options were used in the management of trauma. conclusion: complications of anterior segment trauma can be treated safely by medical and surgical methods. he ocular injury has always been important since early life and had been part of medical landscape in antiquity so much so that eye injuries has been mentioned in historical documents in the eber’s papyrus which was discovered in 1872 in the egyptian city of dead, which was written between 1553 and 1550bc1-3. the eye injury cases in this region are quite common. the anterior segment trauma is prevalent in poverty and literacy stricken population. duke elder has outlined variable and diverse sources of ocular trauma2. the ocular trauma pattern differs from one type of industry to other; urban to rural area e.g. chemical trauma is more prevalent in big cities agricultural area ocular trauma is of its own nature. the ocular trauma due to mechanical work is more prevalent in and around factory area such as lahore, karachi, gujranwala and sialkot. the blunt trauma is often seen in children, violence and sports ocular trauma in players while pressure waves (burnt tyre or bones) ocular trauma is seen in these workers. it has been estimated that 75% of all proceeds in ocular pathology laboratories are related to ocular trauma4. the modern trend of management has changed the results towards relatively better visual outcome as compared to last century results. good results are also due to easily available broad spectrum antibiotics, antiinflammatory and immunosuppressant drugs. the better outcome is also achieved due to proper tissue rehabilitation and prevention of complications by careful and timely surgical repair and restoration of anatomy5,6. the results of trauma has also improved due to proper supervision and follow up along with handling of complications especially after blunt or concussion ocular trauma which may cause maculopathy, macular hole, commotion retina, traumatic choroidal rupture. the aim of this study is to find out the visual outcome (snellen visual acuity) after initial management of trauma and to determine the etiological factors responsible for ocular trauma and extent of injury. t 75 material and methods this interventional, quasi experimental study was conducted at the ophthalmology department, sir ganga ram hospital, lahore from january 2004 to december 2004. fifty patients were enrolled for the study. no discrimination of gender and age was kept for admission. all patients were included after detailed history, physical examination, and thorough ocular examination. special attention was given about eye injury, causative agent and the damage caused. details of anterior segment trauma were recorded. the intraocular pressure was carefully recorded in blunt trauma cases7. general physical examination of the patient and laboratory tests for various investigations especially general anaesthesia, total leukocytic count, differential leukocytic count, haemoglobin, complete urine, x-ray chest (pa view) electrocardio-gram, electrolyte balance and kidney functions were done to avoid complications. in certain severely lacerated eyes, permission was sought for enucleation if necessary, to avoid sympathetic opthalmia8,9. patients were examined on the first postoperative day and further visits were scheduled at 1 week and 4 weeks interval. on each visit, visual acuity was recorded. data was entered and analyzed using spss version 11. the age was analyzed by descriptive with mean ± sd. the variables like age, sex, preoperative visual acuity, treatment, postoperative visual acuity and complications were analyzed as frequency and percentages. pre and postoperative visual acuity were analyzed and chi-square test was applied. a p value of less than 0.05 was considered as significant. results fifty patients were included in this study with age range 5-30 years with mean age was 15-16 years in majority of patients with a mean 15.94±6.03 (table 1). there was definite male predominance 42 (84%) as compared to female 8 (16%) with male to female ratio 5.25:1 (table 2). different agents were responsible for trauma. in majority of cases trauma occurred in domestic settings (table 4). preoperative visual acuity was recorded before treatment in all patients. npl in 1 (2%), pr + in 9 (18%) cases, projection was faulty in 4 (8%), 3/60 1 (2%), 4/60 1 (2%), cf 8(16%), hm 4 (8%), 6/60 2 (4%), 6/24 1 (2%), 6/18 3 (6%), 6/12 1 (2%) and 6/6 15 (30%) cases respectively (table 5). table 1: age distribution of patients (n=50) age (years) frequency n (%) 5 – 15 24 (48) 16 – 25 21 (42) > 25 5 (10) mean±sd = 15.84±6.03 table 2: sex distribution of patients sex frequency n (%) male 42 (84) female 8 (16) male to female ratio 5.25:1. table 4: agent of trauma agent of trauma frequency n (%) metalic particle 6 (12) pencil 6 (12) stick 6 (12) stone 5 glass piece 5 (10) nail 4 (8) ball 3 (6) fire arm injury 3 (6) wood piece 2 (4) bottle cap 1 (2) cloth hanger 1 (2) kite 1 (2) knife 1 (2) pipe 1 (2) plastic bullet 1 (2) rsa 1 (2) scissor 1 (2) toy 1 (2) wiper 1 (2) 76 table 3: laterality of the eye sight frequency n (%) left 17 (34) right 33 (66) table 5: preoperative visual acuity visual acuity frequency n (%) npl 1 (2) pr faulty 4 (8) pr+ 9 (18) hm 4 (8) cf 8 (16) 3/60 1 (2) 4/60 1 (2) 6/60 2 (4) 6/24 1 (2) 6/18 3 (6) 6/12 1 (2) 6/6 15 (30) table 6: treatment of patients treatment frequency n (%) conservative 11 (22) corneal tear repair 13 (26) corneal tear repair and i/a 4 (8) corneoscleral tear repair 3 (10) corneoscleral tear repair and iris reposition 2 (4) ecce + pcl 1 (2) fb removal 3 (6) i/a 3 (6) i/a + pcl 8 (16) icce 1 (2) scleral tear repair 1 (2) different treatment options were used in management of trauma. in 13 (26%) cases were treated as corneal tear repair was done, 11 (22%) cases were treated as conservatively. in 3 (6%) treated as corneoscleral tear repair, 4 (8%) were treated as corneal tear repair and i/a, 2 (4%) cases corneoscleral tear repair with iris reposition. in 1 (2%) ecce + pcl, fb removal in 3 (6%), i/a in 3 (6%) cases, i/a + pcl in 8 (16%), in 1 (2%) case icce and scleral tear repair was 1 (2%) (table 6). post-treatment visual was noted in npl 1 (2%), pr 16 (32%), projection faulty was in 4 (8%), 3/60 1 (2%), 4/60 1 (2%), cf 12 (24%), hm 5 (10%), 6/60 2 (4%), 6/24 3 (6%), 6/18 3 (6%), 6/12 1 (2%), 6/6 2 (4%) cases respectively (table 7). in comparison pre and postoperative visual acuity was not statistically significant. different complications were recorded, corneal opacity 12 (24%), corneal opacity and hyphema 1 (2%) corneal opacity and traumatic cataract 14 (28%) glaucoma 1 (2%) hyphema 11 (22%) retinal detachment, 3 (6%) and traumatic cataract 4 (8%) (table 8). table 7: postoperative visual acuity visual acuity frequency n (%) npl 1 (2) pr faulty 4 (8) pr+ 16 (32) hm 5 (10) cf 12 (24) 3/60 1 (2) 4/60 1 (2) 6/60 2 (4) 6/24 3 (6) 6/18 3 (6) 6/12 1 (2) 6/6 2 (40 discussion importance of ocular trauma as a major cause of blindness worldwide has recently been documented10,11 though reliable population-based data are difficult to obtain, especially in the developing countries. in this 77 study higher prevalence of ocular trauma in young male was 42 (84%) and female 8 (16%) with male to female ratio 5.25:1. in other studies this may be attributed to higher exposure of younger male to outdoor environment12,13. the frequency of trauma was high in right eye 33 (66%) as compared to left eye 17 (34%) (table 3). the major causative agent of trauma were metallic particle 6 (12%), pencil trauma 6 (12%), stick trauma 6 (12%) stone and glass trauma 5 (10%) respectively. penetrating trauma was the leading cause in the list of ocular emergencies in this study. majunatha reported that ocular injury is the third common cause of blindness following assault or accidents both occupational or sports in his study conducted in jamaica. table 8: complications of patients complications frequency n (%) corneal opacity & traumatic cataract 14 (28) corneal opacity 12 (24) hyphema 11 (22) traumatic cataract 4 (8) rd 3 (6) corneal opacity & hyphema 1 (2) glaucoma 1 (2) in majority of cases post treatment visual acuity was 6/6 to 6/60 in 37 (74%) 4/60 in 1 (2%) cf in 13 (26%) hm in 2 (4%), pr faulty in 4 (8%) and projection was positive in 2 (4%). complications were recorded as corneal opacity in 12 (24%) corneal opacity and hyphema in 1 (2%) corneal opacity and traumatic cataract 14 (28%). glaucoma in 1 (2%) hypema in 11 (22%), retinal detachment in 3 (6%) traumatic cataract in 4 (8%) and in 4 (8%) cases no complication was recorded. high incidence of traumatic emergencies seems to be related to lack of proper safety measures in sports, in the work place, poor implementation of traffic rules and regulations. to reduce the morbidity, expense, workload of health professionals and institutions, ultimate visual impairment and cosmetic disfigurement due to ocular emergencies, we have to achieve three goals: i. to prevent occupational and sports related ocular trauma. ii. proper and timely management of traumatic emergencies. iii. early detection and management of eye disease or conditions that can present later as ocular emergencies. these targets would be achievable if the community is made aware of the hazards and poor outcome related to ocular trauma. it would then be possible to take proper safety measures at the work place, in domestic environment and sports facilities. it remains the responsibility of the government to provide affordable and accessible health facilities to the community. in conclusion we find that ocular emergencies contribute heavily to the workload of the eye health care professionals. conclusion in this study 84% patients were male and 16% were female. this may be attributed to be higher exposure of young male to outdoor environment and young adults of working age group are more actively involved in sports and more likely to be working without proper safety measures. parents should remain vigilant as many injuries occurred in domestic settings. preventive measures and safety devices at work place would reduce the high percentage of occupational injuries. early and meticulous repair gave good visual results. therefore early referral is emphasized. author’s affiliation dr. muhammad yasir arfat senior registrar department of ophthalmology sir ganga ram hospital lahore dr. hamid mahmood butt prof. & head department of ophthalmology sir ganga ram hospital lahore reference 1. vigril a, afro iii, peter e. liggett lippincott, vitreo-retinal surgery of injured eye. chap. 1 pub raven, philadelphia 1999; 18. 2. duke elder ss. text book of ophthalmology. injuries. vol. 6. st. louis cv mosby, 1954; 645. 78 3. hirshberg j. the history of ophthalmology. in: verlog jp, borgh w editor. translated by blodi bonn fc germany. 1982; 6: 3. 4. hutton wi, fuller dg. factors influencing final visual results severely injured eyes. am j ophthalmol. 1984; 97: 715-22. 5. duke-elder s, cook c. normal and abnormal development part i. embryology. in: duke-elder s, ed. system of ophthalmology, vol. iii, london cv mosby. 1963; 23: 4. 6. qazi za. corneal endothelium tissue that demand respect editorial. pak j ophthalmol. 2003; 19: 1. 7. guthoff r. ultrasound in ophthalmology diagnosis, new york. gerog thieme vertag. 1991; 1. 8. makely ta jr, azar a. sympathetic ophthalmia, a long term follow up. arch ophthalmol. 1978; 96: 257-62. 9. hokin kh, pearson rv, lightman sl. sympathetic ophthalmia, visual results with modern immuno-suppressive therapy. eye 1992; 6: 453-5. 10. thyflefors b. epidemiological patterns of ocular trauma. nzi ophthalmol. 1992; 20: 95-8. 11. negrel ad, thylefors b. the global impact of eye injuries. ophthal epidil. 1998; 5: 143-69. 12. rober im, arentsen jj, loibson pr. traumatic wound dehiscence after penetrating keratoplasty. arch ophthalmol. 1980; 98: 1407-9. 13. topping th, stark wj, maumenee e, kenyon kr. traumatic wound dehiscence following penetrating keratoplasty. br j ophthalmol. 1982; 66: 174-8. microsoft word mustata iqbal case report 114 case report endogenous endophthalmitis associated with snake bite mustafa iqbal, bakhth samar khan, imran ahmad pak j ophthalmol 2009, vol. 25 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: mustafa iqbal department of ophthalmology khyber teaching hospital peshawar received for publication september’ 2008 … ……………………… a 50 years old patient with snake bite presented with endogenous endophthalmitis, was thoroughly investigated and treated. various ocular complications with snake bite have been reported before but endogenous endophthalmitis due to snake bite has not been described in literature. ndophthalmitis is a serious sight threatening condition. it may be of exogenous or endogenous origin. the incidence of endogenous endophthalmitis is 28%1. endogenous endophthalmitis caused by snake bite is rare although uveitis due to anti snake venom has been reported in literature2. whatever the cause may be, the consequences of endophthalmitis are very serious. despite appropriate therapy it results in severe visual loss in 30% patients and blindness in 18%3. we hereby report a case of endogenous endophthal-mitis that presented after snake bite and was treated optimally. case report a 50 years old patient presented to eye opd with complaints of defective vision and pain in right eye for 3 weeks. he had history of snake bite 4 weeks back. the bite was on index finger of left hand. he remained admitted in medical ward with heamaturia. his prothrombin time (pt) and activated partial thromboplastin time (aptt) were prolonged. he was successfully treated with medications and blood transfusion. there was no history of snake anti venom being used. on ocular examination visual acuity in right eye was perception and projection of light, pupil was reactive, anterior chamber was quite, vitreous had +4 e 115 cells. right fundal reflex was absent. on ophthalmo scan there was vitreous haziness and retina was flat in right eye. left eye was normal. vitreous tap was negative for red blood cells and bacterial culture. a diagnosis of endogenous endophthalmitis was made. patient was treated with topical quinolones, steroids and cycloplegics eye drops. systemic anti inflammatory, antibiotics, and intra-vitreal steroids plus vancomycin were given. the visual acuity improved to counting finger from 1 meter by the time this case report being prepared. discussion various ocular complications due to snake bite have been reported in literature but endogenous endophthalmitis has not been described. snake bite is a common problem in pakistan causing 20000 deaths per year. snake venom causes multisystem involvement and affects haemostatic mechanism as it can produce intravascular coagulation with consequent ischemic sequel to many organs4. the ophthalmic manifestations reported are subconjunctival hemorrhages, hyphema, vitreous hemorrhages, neurological disturbance in the form of ophthalomplegia and central retinal artery occlusion5. the uveitis and retinal necrosis have been reported due to anti snake venom6. endogenous or metastatic endophthalmitis can occur with any systemic disease like dental infections, ear infections, birth deliveries, renal diseases, vascular diseases and tuberculosis. endophthalmitis is a potentially devastating intra ocular infection. despite all modalities of treatment, the visual prognosis is poor, even preservation of eye ball is difficult and 29-50% of cases eyes has to be eviscerated or enucleated7,8. ophthalmo scan showing endogenous endophthalmitis right eye endogenous endophthalmitis (white pupil) our patient was diagnosed as a case of endogenous endophthalmitis. he was treated optimally. the outcome in this case was satisfactory and the patient is improving with eyeball preserved and some near vision retained. conclusion endogenous endophthalmitis may present in association with snake bite. early optimal treatment can yield good results. author’s affiliation dr.mustafa iqbal professor of ophthalmology 116 department of ophthalmology khyber teaching hospital peshawar dr. bakhth samar khan assistant professor department of ophthalmology khyber teaching hospital peshawar dr.imran ahmad post graduate trainee department of ophthalmology khyber teaching hospital peshawar reference 1. sigersma je., klont rr. endogenous endophthalmitis after otitis media. aj ophthalmol 2004; 137: 202-4 2. ari ab. patient with purely extra-ocular manifestations from pit viper snake bite. mil. med., 2001, 166, 667-9. 3. randal j. reducing risk of post operative endophthalmitis survey of ophthalmol. vol 49; march 2004; 55-9. 4. marsh na. snake venom affecting haemostatic mechanisma consideration of their mechanism, practical applications and biological significance. blood coagul. fibrinolysis, 1994, 5, 399410. 5. a bhalla central retinal artery occlusion: an unusual complication of snake bite. j.venom. anim. toxin incl. trop. dis., 2004, 10, 3, p.314. 6. buttes gp., ayan n., cami g. uveitis after snake bite. arch. pediatr., 1996, 3, 832-3. 7. cheese sp. endogenous endophthalmitis. curr opin ophthalmol 2001; 12: 464-70. 8. tsai yy., tseng sh. risk factors in endophthalmitis leading to evisceration/ enucleation ophthalmic surg. laser 2001; 32: 20812. microsoft word ps mahar 1 169 review article angiogenesis and role of anti-vegf therapy p.s. mahar, azfar n. hanfi, aimal khan pak j ophthalmol 2009, vol. 25 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: ps mahar isra postgraduate institute of ophthalmology al – ibrahim eye hospital malir, karachi received for publication september’ 2009 … ……………………… vascular endothelial growth factor (vegf) is the main culprit to initiate the cascade of angiogenesis in a variety of chorioretinal neovascular disorders such as neovascular age-related macular degeneration (armd) and various proliferative retinopathies. although vegf has an important role in maintaining the adequate blood flow to retinal pigment epithelium (rpe) and choriocapillaries, however its over-expression in response to hypoxia causes the growth of new vessels, these new vessels are fragile causing leakage and bleeding with promotion of scar tissue formation resulting in the visual loss. currently there are three anti-vegf agents available in the market, namely pegaptanib (macugen), ranibizumab (lucentis) and bevacizumab (avastin). in this article we look at all these drugs available with review of international literature to determine their usefulness. ascular endothelial growth factor (vegf) is a prime regulator of angiogenesis with diverse roles, both physiological as well as pathological during development and adulthood1. the physiological response is seen in healing wounds with restoration of blood flow, maintaining female reproductive cycle and formation of placenta with fetal development. while tumor growth, neovascular age related macular degeneration (armd) and various proliferative retinopathies are the prime example of its pathological response2. on cellular level, angiogenesis depends on a balance between positive regulators such as vascular endothelial growth factor (vegf), fibroblast growth factor (fgf), tumor necrosis factors – alpha (tnfalpha), interleukin – 8 (il-8) and negative regulators which are thrombospondin-1 (tsp-1), angiostatin and endostatin and plasminogen activator inhibitor – 1 (pai-1)3. angiogenic cascade is believed to be initiated due to hypoxia with release of vegf, fgf and other growth factors. these factors bind to endothelial cells of nearby capillaries thereby activating them. the activated endothelial cells proliferate, migrate and release various proteases. these enzymes increase permeability of basement membrane. the migrating endothelial cells also form new blood vessels in formerly avascular space. these newly formed vessels are fragile causing leakage and bleeding with promotion of scar tissue formation resulting in visual loss. the vegf family consists of structurally related growth factors namely vegf – a, vegf – b, vegf – c, vegf – d, vegf – e and placenta growth factor, all encoded by separate genes4. vegf – a, commonly referred to as vegf only, is the primary driver in angiogenesis and is the target of most current anti – vegf agents. apart from angiogenesis, it also increases the vascular permeability around 50,000 times more than histamine by inducing conformational changes at the tight junctions in the outer blood – retinal barrier. nine major vegf – a isoforms have been identified in humans: vegf 121, vegf 145, vegf 148, vegf 162, vegf 165, vegf 165b, vegf 183, vegf 189 and vegf 206. they all differ in property and functions and the number assigned to them actually correspond to the number of aminoacids present in their molecule. vegf 165 is the most abundantly expressed isoform and vegf 121 although less abundant is more mitogenic than vegf 1655. v 170 vegf is naturally expressed in retinal tissue with high levels in the retinal pigment epithelium (rpe). it plays protective role by maintaining adequate blood flow to rpe and photoreceptors. in diseased eyes, its over-expression with increased level occurs due to decrease in blood flow to choriocapillaries and retinal capillaries, resulting in oxidative stress and alteration in bruch’s membrane. recent development of anti – vegf agents has marked a major breakthrough in the treatment of chorioretinal neovascular disease. currently available anti – vegf agents include pegaptanib, ranibizumab and bevacizumab. pegaptanib sodium (macugen® eyetech/ pfizer) was the first anti angiogenic therapy to be approved by us food and drug administration (fda) for the treatment of all types of neovascular armd in december 2004. it is a rna aptamer, a modified oligonucleotide with a molecular mass of 50 kda and produced synthetically to block specifically vegf 1656. in vision study (vegf inhibitor study in ocular neovascularization), a total number of 1186 patients were treated with all types of neovascular armd in different doses of pegaptanib given every 6 weeks intravitreally. at 54 weeks, loss of fewer than 15 letter was seen in 70% of patients with 0.3mg, 71% of patients with 1mg and 65% of patients with 3mg dose, compared with 55% receiving sham injection. a gain of 15 letters were seen in 18% of patients receiving 0.3mg, 20% of patients getting 1mg and 13% of patients receiving 3mg compared with only 6% of patients with sham injection. the ocular complications included, endophthalmitis in 1.3%, iatrogenic cataracts in 0.7% and retinal detachment in 0.6% of patients7. currently for the treatment of neovascular armd, 0.3mg of pegaptanib is used intravitreally every 6 weeks for at least 1 year. ranibizumab (lucentis® genetech – novartis) is another anti – vegf agent approved by the fda for the treatment of patients with neovascular armd in june 2006. it is humanized antigen – binding fragment (fab) of a full length murine monoclonal antibody directed against all isoforms of vegf – a. it is produced in escherichia coli using recombinant dna technology and has a molecular mass of 49kda. due to its smaller molecular size, it can easily penetrate all layers of retina after an intravitreal injection. the average vitreous elimination half – life is also attributed to its smaller size and significant diffusion8. in marina study (minimally classic/ occult trial of the anti – vegf antibody ranibizumeab in the treatment of neovascular armd) 716 patients were given ranibizumab intravitreally every 4 weeks for 2 years. at one year, 94.5% of patients with 0.3mg, 94.6% with 0.5mg dose lost fewer than 15 letters compared with 62% of patients having sham injection. a gain of 15 letters were witnessed in 24.8% of patients with 0.3mg and 33.8% of patients receiving 0.5mg ranibizumab compared with 5% of patients having sham injection. all patients showing visual improvement maintained their vision for 2 years. ocular complications included endophthalmitis in 1% of cases and uveitis in 1.3% of patients9. another study, anti – vegf antibody for the treatment of predominantly classic choroidal neovascularization in amd (anchor) compared the use of intravitreal ranibizumab with photodynamic therapy (pdt) using visudyne. either intravitreal ranibizumab was given every month for 2 years or pdt on entry and every 3 months as needed accordingly to protocol. at 1 year 94.3% (0.3mg) and 96.4% (0.5mg) patients lost fewer than 15 letters compared with 64.3% using pdt. visual acuity also improved for 15 letters in 35.7% (0.3mg) patients and 40.3 % (0.5mg) patients against only in 5.6% patients in pdt group10. in pier study (phase iiib study of ranibizumab efficacy and safety in choroidal neovascularization due to armd) efficacy of reduced dosing of ranibizumab was investigated, given monthly for 3 months and thereafter once every 3 months for 12 months. patients gained vision during first 3 months with monthly injections but lost vision in following 9 months11. in the prospective oct imaging of patients with neovascular armd treated with intraocular lucentis (pronto) study, intravitreal injections of ranibizumab was given for 3 months and thereafter only upon sign of disease, actually based on serial oct findings. results at 12 months showed that 95% of patients lost fewer than 15 letter of visual acuity and 35% of patients gained 15 letter or more. although this was a small study but it demonstrated the usefulness of reduced dosing in conjugation with utility of oct12. the rhufab v2 ocular treatment combining the use of visudyne to evaluate safety (focus) trial, a phase 1 – ii, prospective, randomized, single masked study examined the efficacy of ranibizumab in combination with pdt using visudyne. patients with 171 predominantly classic subfoveal choroidal neovascular membrane (cnv) received pdt followed by monthly ranibizumab 0.5mg or sham injection for 2 years. pdt was repeated at 3 monthly interval according to the angiographic findings. at 12 months 90% of patients with combined pdt and ranibizumab lost fewer than 15 letters compared to 68% of patients in the pdt only group. 24% of patients gained 15 letters or more having combination therapy compared to 5% in pdt only group13. bevacizumab (avastin® genentech / roche) is a 149 kda humanized full – length monoclonal antibody to all isoforms of vegf – a, approved as intravenous infusion in combination with chemotherapy for metastatic colorectal cancer. it is derived from the same murine anti – vegf antibody as ranibizumab. before the fda approval of ranibizumab, retinal specialist all over the world started using bevacizumab: off label intravitrealy in variety of neovascular ocular disease like cnv, macular edema and proliferative diabetic retinopathy (pdr)14-19. intravitreal usage minimizes the risks of potential side effects associated with systemic exposure like arterial thromboembolic events (ate), hypertension and hemorrhage. interestingly preliminary studies have shown improvement both visually and anatomically in terms of reduced macular thickness. bevacizumab has been used intravenously as well as intravitrealy in patients with neovascular armd and has shown comparable results20. bevacizumab preparation is unpreserved and contains no ingredients that are toxic to eyes. it is used in dose of 1.2mg – 2.5mg, though optimal dosage remains unknown. bevacizumab has been tested in rabbit eyes with no evidence of retinotoxicity21. the serum half life of bevacizumab is 17-21 days. theoretically, the longer half life of bevacizumab compared to ranibizumab confers higher risk of systemic toxicity but no known serious adverse events have been reported in uncontrolled studies to date. though, longer half – life may also mean that less frequent administration is required. the short term results of bevacizumab therapy are comparable to that of ranibizumab in patients with neovascular armd, with improvement in visual acuity and reduction in retinal thickness22. nevertheless, its cost per dose as compared to ranibizumab is the main driving force compelling retinal specialist of our region to use bevacizumab instead of ranibizumab when patient’s financial issue come in way. the hypothesis that bevacizumab is as safe and effective as ranibizumab has not been established due to unavailability of controlled, double blind randomized clinical trials. currently national eye institute in us is conducting a “comparison of age – related macular degeneration treatment trial (catt). this clinical trial will directly compare ranibizumab and bevacizumab for the treatment of neovascular armd and may answer questions regarding the efficacy and dosage required for the bevacizumab. concerns regarding anti – vegf therapy frequency, duration and follow up: it is not known when it’s safe to stop the anti – vegf treatment. most of the trials have published their results between 1-2 year period with no long term data available beyond two years. in anchor and marina studies, patients received ranibizumab injection every month for 2 years with no designated clinical end point for the treatment. pier study, on the other hand tried to reduce the frequency of the injections, but results of this study appeared less impressive than the previous studies suggesting that by simply increasing the time period between injections may have compromised the visual end result. the currently ongoing sailor trial is expected to provide more information on the benefit and efficacy of variable dosing. cost single injection of pegaptanib in pakistan cost around rs. 60,000, while cost of one injection of ranibizumab mounts to rs. 85,000. bevacizumab comparatively is cheaper at rs. 3,500 per single dose. the cost of the injection is the main force driving retinal specialist to opt for bevacizumab, when one clearly understands the benefit and efficacy of ranibizumab proven through multiple international trials. the cost issue also becomes imperative when these injections are given repeatedly. safety the procedure related ocular complication such as endophthalmitis and retinal detachment are reported around 1% in marina and anchor trials. the pan -american collaborative retina study group (pacores) has recently reported 12 months safety data on 4303 injections of intravitreal bevacizumab given in 1310 eyes, with rate of endophthalmitis at 0.16% and retinal detachment at 0.02%. although these rates of complications are much less than the reported one in the early trials, but one still has to take 172 strict aseptic precautions giving these injections preferably in the operating room23. the international intravitreal bevacizumab safety survey, and internet based study from 70 centers in 12 countries has analyzed ocular and systemic adverse events related to more than 7000 injections. the event rates for corneal abrasions, lens injury, retinal detachment, uveitis, endophthalmitis, central retinal artery occlusion, sub retinal hemorrhage, rpe tears, transient ischemic attacks (tia), cerebro vascular accidents (cva) and death with no individual event rate exceeding 0.21%24. there are concerns regarding systemic drug related adverse events such as arterial thrombo embolism and myocardial infarction in patients undergoing anti – vegf treatment. in marina trial the rate of ischemic stroke was same in patients receiving ranibizumab and sham injections (1.3% in 0.3mg group, 2.5%in 0.5mg group and 0.8% in sham group). the incidence of myocardial ischemia was reported 2.5% in 0.3mg group, 1.3% in 0.5mg group and 1.7% in sham group. in sailor trial, there was 1.2% incidence of stroke with 0.5mg ranibizumab compared to 0.3% in 0.3mg group, suggesting a dose – dependent increase in the rate of thrombo embolic event. alexander and coworkers in retrospective analysis of us medicare data base from 2001 – 2003 have showed that, inpatient ischemic stroke rate for 15771 patients with neovascular armd was 3.5% compared to 3.6% in 44408 matched controls25. though, there may be a small risk of increased incidence of stroke in patients undergoing anti – vegf therapy, more data is required to settle this issue. and again benefits of this treatment outweighs any potential risks in that particular patient population. which vegf blockage as discussed earlier, vegf plays an important role not only in the disease state but also in maintaining the normal physiology of the circulation. so what is going to be the long term effect of this vegf blockage. although visual stability and recovery is more impressive with ranibizumab, it dose block all vegf isoforms compared to pegaptanib which only neutralizes vegf 165. in long term which anti – vegf blockage is associated with less complications is not known. conclusion anti-vegf therapy has become the first line treatment not only in neovascular armd but also in various proliferative retinopathies. as suggested by various trials, ranibizumab has the most impressive results regarding the visual stability and improvement, specially in neovascular armd. unfortunately because of the higher cost, specially in our country, we are seeing more and more use of bevacizumab in patients where anti-vegf treatment is necessary. once the results of catt trial are published, one will know the true effectiveness of bevacizumab compared to ranibizumab. although intravitreal injections are easy to use but one has to be careful avoiding procedure and drug related complications by using aseptic conditions and reducing the frequency of these injections without compromising the treatment benefits. author’s affiliation prof. p.s. mahar aga khan university, hospital karachi dr. azfar n. hanfi isra postgraduate institute of ophthalmology karachi dr. aimal khan isra postgraduate institute of ophthalmology karachi reference 1. ferrara n. vegf and the quest for tumour angiogenesis factors. nat rev cancer. 2002; 2: 795-803. 2. ferrara n. vascular endothelial growth factor. the trigger for neovascularization in the eye. lab invest. 1995; 72: 615-8. 3. kaiser pk. anti vascular endothelial growth agent and their development: therapeutic implications in ocular disease. am j ophthalmol. 2006; 142: 660-8. 4. ferrara n. vascular endothelial growth factor, basic science and clinical progress. endocr rev. 2004; 25: 581–611. 5. adamis ab, shima d. role of vascular endothelial growth factor in ocular health and disease. retina. 2005; 25: 111-8. 6. macugen amd study group. pegaptanib, 1 year systemic safety results from a safety – pharmacokinetic trial in patients with neovascular age-related macular degeneration. ophthalmology 2007; 114: 1702-12. 7. es gragoudas. pegaptanib for neovascular age related macular degeneration. n eng j med. 2004; 351: 27, 2805-16. 8. ferrara n. development of bevacizumab an anti vascular endothelial growth factor antigen binding fragment, as therapy for neovascular age – related macular degeneration. retina 2006; 26: 859-70. 173 9. rosenfeld pj. ranibizumab for neovascular age related macular degeneration. n eng j med. 2006; 355: 1419-31. 10. brown dm. ranibizumab versus verteporfin for neovascular age related macular degeneration n eng. j med. 2006: 355, 1432-44. 11. abraham p, hue h, shams n. pier: year 1 results of phase iii b study of ranibizumab efficacy and safety in choroidal neovascularization due to age-related macular degeneration. cannes retinal festival. 2006. cannes, france. 12. puliafito ca. an oct guided variable dosing regimen with ranibizumab in neovascular amd: two years results of the pronto study. presented at annual advanced vitreo – retinal techniques and technology conference. chicago il. 2007. 13. heir js. ranibizumab in combination with verteporfin photodynamic therapy in neovascular age-related macular degeneration (focus): year 1 results. arch ophthalmol. 2006; 124: 1532-42. 14. avery rl. intravitreal bevacizumab (avastin) for neovascular age-related macular degeneration. ophthalmology. 2006; 113: 36372. 15. bashshur zf. intravitreal bevacizumab for the management of choroidal neovasculaization in age-related macular degeneration. am j ophthamol. 2006; 142: 1-9. 16. chain w, lai ty, liu dt, et al. intravitreal bevacizumab (avastin) for choroidal neovascularization secondary to central serious chorio-retinopathy, secondary to punctate inner chroidopathy, or of idiopathic origin. am j ophthalmol. 2007; 143: 977-83. 17. maria oo jr, bonanomi mt, takahashi wy, et al. intravitreal bevacizumab for foveal detachment in idiopathic perifoveal telangiectasia. am j ophthalmol. 2007; 144: 296-9. 18. hurralde d, spaide rf et al. intravitreal bevacizumab (avastin) treatment of macular edema in central retinal vein obstruction, a short term study. retina 2006; 26: 279-84. 19. spaide rf, fisher yl. intravitreal bevacizumab (avastin) treatment of proliferative diabetic retinopathy complicated by vitreous hemorrhage. retina 2006; 26: 275-8. 20. michels s, rosenfeld pj et al. systemic bevacizumab (avastin) therapy for neovascular age-related macular degeneration. 12 week results of an uncontrolled, open – label clinical study. ophthalmology. 2005; 112: 1035-47. 21. manzano rp, peyman ga, khan p, et al. testing intravitreal toxicity of bevacizumab (avastin). retina 2006; 26: 257-61. 22. rosenfeld pj, moshfeghi aa, puliafito ca. optical coherence tomography findings after an intravitreal injection of bevacizumab (avastin) for neovascular age-related macular degeneration. ophthalmic surg lasers imaging. 2005; 36: 331-5. 23. wu l et al. twelve months safety of intravitreal injection of bevacizumab (avastin), results of the pan – american collaborative retina study group (pacores). graefes arch clin exp ophthalmol. 2007; 246: 81-7. 24. fung ae, rosenfeld pj, reichel e. the international intravitreal bevacizumab safety survey: using the internet to asses drug safety world wide. br j ophthalmol. 2006; 90: 13449. 25. alexander sl et al. annual rate of arterial thrumboembolic events in medicare neovascular age-related degeneration patients. ophthalmology. 2007; 114: 2174-8. microsoft word irfan shafiq 196 original article influence of central corneal thickness (cct) on intraocular pressure (iop) measured with goldmann applanation tonometer (gat) in normal individuals irfan shafiq pak j ophthalmol 2008, vol. 24 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … …………………… correspondence to: irfan shafiq a-2 / 304, rabia petal, abul hasan isphani road, karachi. received for publication january’ 2008 … ……………………… purpose: this study investigated the relationship between intraocular pressure (iop) and central corneal thickness (cct) in normal healthy individuals. material and methods: the central corneal thickness (cct) and intraocular pressure (iop) of 250 subjects (500 eyes) of age 11-54 years from general population were assessed. the iop was measured with goldmann applanation tonometer (gat) and cct was measured with orbscan ii scanning slit topographer. the relationship was assessed using spss software. results: the mean iop value was 15.35 mmhg and mean cct value was 531.50 µm in 250 subjects (500). the mean iop value was 15.16 mmhg sd ± 2.89 mmhg in men and 15.53 mmhg sd ± 3.11 mmhg in women. the mean cct value was 529.07 µm sd ± 35.19 µm in men and 533.75 µm sd ± 38.11 µm in women. no significant difference in cct and iop was found between male and female subjects or between the right and left eye. both genders had positive correlation between cct and iop. conclusion: cct was significantly correlated with iop. 197 easurement of intraocular pressure (iop) is one of the essential and routine examinations in every ophthalmology clinic. it means that every patient who comes to an ophthalmologist, his or her iop has to be checked. for this purpose, goldmann applanation tonometer (gat) is considered to be the gold standard. central corneal thickness (cct) is known to affect the accuracy of iop measurements by applanation tonometry1,2. a thicker cornea requires greater force to applanate and conversely, a thinner cornea is more easily flattened. a thin cornea is a significant risk factor for the development of glaucoma3. the gat is based on the imbert-fick law, which assumes that the cornea has a dry surface, is infinitely thin, and behaves as a “membrane” where the applanating pressure will equal the iop. in practice, a resistance force, because of the thickness of the cornea and a surface tension force, the result of the tear film, act upon the applanator causing this membrane assumption to be incorrect. these forces balance each other for the gat (applanation diameter of 3.06 mm) when the cct is 520µm, providing a “reference” value where the applanating pressure does equal the iop1. since the early 1970s there have been several reports on the relationship between cct and iop measured with the gat4,5. attempts at measuring the actual iop by manometry were described by ehlers et al. in 19751 and whitacre et al. in 19932. it has been reported that thinner corneas result in artificially lower iop readings and that thicker corneas cause artificially high iop readings, thus producing apparent normal tension glaucoma (ntg) and ocular hypertension (oht) respectively6. this has become more of a practical problem recently with the advent of photorefractive keratectomy for myopia7, where there is artificial thinning of the central cornea, possibly creating underestimates in central applanation tonometry. for the measurement of cct ultrasonic pachymetry is the most commonly used technique. recently, other sophisticated non-contact scanning slit based (orbscan) pachymetry instruments have been developed in an attempt to correlate the cct with the measured iop. the orbscan ii scanning slit topography (bausch and lomb, rochester, ny, usa) has multiple functions in the assessment of the cornea, including its thickness profile, anterior and posterior topography, elevation and anterior chamber depth. the usefulness of this system has been reported previously8. orbscan pachymetry measures corneal thickness like manual ultrasound pachymetry but it is more repeatable, simpler to perform, non-invasive and returns a map of corneal thickness rather than a point measurement. it combines a slit scanning system and a placido disk (with 40 rings) to measure the anterior elevation and curvature of the cornea and the posterior elevation and curvature of cornea, it offers a full corneal pachymetry map with white to white measurements. orbscan pachymetry is able to acquire over 9000 data points in 1.5 seconds and measure anterior chamber depth, angle kappa, pupil diameter, simulated keratometry readings and the thinnest corneal pachymetry reading9. various formulae have been generated to predict the effect of cct on iop. with the advent of excimer laser refractive surgery, an increasing number of patients will have iatrogenically thinned corneas. myopes have a 2–6-fold increased risk of developing glaucoma compared with nonmyopes, rising as their degree of myopia increases10,11. considering that if there are over 1 million refractive procedures performed per year, 10000–30000 of these patients may eventually develop glaucoma. the measurement of their iop is an integral part of their management, so strategies to accurately know the ‘true’ reading are vital. many ophthalmic practitioners currently do not use any form of pachymetry; however, as the number of patients with altered corneal structure increase, should corneal thickness measurement become part of the routine examination. in this study i evaluated the influence of cct on iop measurement made with the gat in normal healthy individuals. materials and methods this is a prospective cross sectional study of 500 eyes of 250 individuals conducted at the hashmani eye hospital, karachi between january, 2005 and january, 2006 for period of 12 months. the objects of this study were to evaluate the relationship of cct with iop and to determine the influence of cct on iop in normal individuals. iop and cct were recorded for both eyes of 250 normal subjects who had come for routine ophthalmic examination. iop was measured with the gat and cct was measured with orbscan ii topographer. the relation of measured iop and cct was analyzed by spss software. inclusion criteria healthy individuals with cct of any range and iop within normal range with no upper age limit were included in this study. m 198 informed consent was taken from every patient for measurement. exclusion criteria patients with glaucoma in one or both eyes, eyes with any corneal disorder like opaque or disfigured cornea, corneal ulcer, corneal inflammation, corneal dystrophy, corneal degeneration, keratoconus and large pterygium were excluded. eyes with history of any other ocular disease or surgery were also not included in this study. measuring iop the goldmann applanation tonometer was mounted on the end of the lever hinged on the slit-lamp. the patient's head and the microscope were positioned so that the bar was against the patient's forehead and well above the eyebrows, allowing for maximal separation of the patient's eyelids. a drop of proparacaine 0.5% (alcaine 2%) was instilled into the lower conjunctival cul-de-sac and fluorescein impregnated paper strip was touched to the tear film. with the cornea and tonometer biprism maximally illuminated by the cobalt light from the slit-lamp, the biprism was brought into gentle contact with the apex of the cornea. when contact with the eye had been established, the semicircular patterns were observed through the left ocular of the slit-lamp. the slit-lamp was then raised or lowered until the two semicircles were equal in size, and the tension dial was adjusted so that the inner edge of the upper and lower semicircles became aligned. ocular pulsations create excursions of the semicircular tear meniscus, and the pressure is read as the median over which the arcs glide. this is the desired end point at which a reading can be taken from a graduated dial. the reading on the dial was multiplied by 10 to obtain iop in mmhg. measuring cct for cct measurement, the patient’s chin was placed on the chin rest of orbscan ii topographer. the patient was asked to look at a blinking red fixation light. the examiner adjusted the optical head using a joystick to align and focus the eye so that the cornea was centered on the video monitor. the video image was then captured and measured anterior and posterior corneal elevation (relative to a best fit sphere), surface curvature and corneal thickness. pachymetry is determined by this instrument from the difference in elevation between the anterior and posterior surface of the cornea. this instrument averages pachymetry in nine circles of 2mm diameter that are located in the center of the cornea and at eight locations in the mid peripheral cornea (superior, superotemporal, temporal, inferotemporal, inferior, inferonasal, nasal, superonasal) each located 3mm form the visual axis. results out of 250 patients (500 eyes) included in this study, 120 (48%) patients were males and 130 (52%) patients were females. the minimum age of patient was 11 years, maximum was 54 years and mean age was 27.98 standard deviation (sd) ± 8.27 years. the minimum age of male patient was 17 years, maximum was 54 years and mean age was 29.28 sd ± 8.62 years. the minimum age of female patient was 11 years, maximum was 50 years and mean age was 26.78 sd ± 7.77 years. a total number of 500 eyes were investigated using the orbscan ii corneal topography system and gat. the minimum cct was 423 µm, maximum cct was 650 µm and mean cct was 531.5 µm sd ± 36.78 µm. the minimum iop was 8 mmhg, maximum iop was 21 mmhg and mean iop was 15.35 mmhg sd ± 3.01 mmhg. in this study 120 patients (240 eyes) were males. the minimum cct of male patients was 423 µm, maximum cct was 629 µm and mean cct was 529.07 µm sd ± 35.19 µm. the minimum iop was 8 mmhg, maximum iop was 21 mmhg and mean iop was 15.16 mmhg sd ± 2.89 mmhg. one hundred thirty patients (260 eyes) were females. the minimum cct of female patients was 425 µm, maximum cct was 650 µm and mean cct was 533.75 µm sd ± 38.11 µm. the minimum iop was 10 mmhg, maximum iop was 21 mmhg and mean iop was 15.53 mmhg sd ± 3.11 mmhg. the minimum iop of the right eyes was 10 mmhg, maximum iop was 21 mmhg and mean iop was 15.34 mmhg sd ± 3.04 mmhg. the minimum iop of the left eyes was 8 mmhg, maximum iop was 21 mmhg and mean iop was 15.36 mmhg sd ± 2.99 mmhg. the minimum cct of the right eyes was 423 µm, maximum cct was 650 µm and mean cct was 531.43 sd ± 37.50 µm. the minimum cct of the left eyes was 430 µm, maximum cct was 650 µm and mean cct was 531.58 sd ± 36.12 µm. patients were divided into eight groups. the findings of cct an iop are tabulated in table 2. 199 discussion there are several reports on the relationship between cct and iop12-15. wolfs et al.13, and herndon et al.15 also found significant correlation between iop and cct in their subjects. however, lam and douthwaite14 reported no significant relationship between cct and iop in their 45 hk-chinese subjects of age 19–23 years. our results show a statistically significant positive correlation between cct and iop and this is true for both male and female subjects. no significant difference was found in cct and iop between male and female subjects. the iop is an essential physiological parameter for diagnosis and management of glaucoma. goldmann applanation tonometry is one of the most common method used for measuring iop worldwide, even though many factors such as tear film, shape of the anterior cornea, corneal thickness or scleral rigidity can influence its accuracy in healthy corneas. it has been suggested that cct is a major source of error in applanation tonometry16,17, a thick cornea leading to an overestimation of iop and a thin one leading to an underestimation1,12,18-19. table 1: gender distribution, mean cct and mean iop. gender number mean cct mean iop right eye left eye right eye left eye mean sd mean sd mean sd mean sd male 240 529.25 35.95 528.89 34.57 15.13 2.88 15.18 2.90 female 260 533.44 38.90 534.06 37.46 15.53 3.17 15.52 3.07 total 500 531.43 37.50 531.58 36.12 15.34 3.04 15.36 2.99 table 2: relationship between cct and iop in different groups. groups cct iop no. of eyes mean no. of eyes mean sd 420-449 11 434.82 11 11.27 2.37 450-479 24 464.38 24 12.25 1.94 480-509 91 495.95 91 13.62 1.53 510-539 162 524.65 162 15.02 2.22 540-569 140 552.73 140 16.17 3.13 570-599 54 579.28 54 17.93 2.77 600-629 16 608.56 16 19.38 2.87 630-659 2 650 2 21 0.0 200 0 5 10 15 20 25 434 464 495 524 552 579 608 650 cct io p fig.1: relationship between iop and cct. we found the mean iop for both sexes combined to be 15.3 mmhg. this finding is similar to the 15.8 mmhg found in a previous icelandic population survey which used standardized schiötz tonometry20 and to the 15.2 mmhg found by klein et al., who surveyed using goldmann applanation tonometry21. we found the mean iop in females and males was 15.53 mmhg and 15.1 mmhg respectively. this finding is similar to the several large population samples surveyed using applanation tonometry22. mean cct we found was 531.5 µm for both males and females. this finding is statistically not different from previous japanese population study which showed 517.5 µm cct. conclusions central corneal thickness was significantly correlated with intraocular pressure in both men and women. a thick cornea leads to an overestimation of iop, and a thin one leads to an underestimation of iop. no significant difference in central corneal thickness and intraocular pressure was found between the right and left eyes or between male and female subjects. author’s affiliation irfan shafiq assistant professor department of ophthalmology dow university of health sciences & civil hospital, karachi reference 1. ehlers n, bramsen t, sperling s. applanation tonometry and central corneal thickness. acta ophthalmol. 1975; 53: 34-43. 2. whiotacre mm, stein ra, hassanein k. the effect of corneal thickness on applanation tonometry. am j ophthalmol. 1993; 115: 592-6. 3. gordon mo, beiser ja, brandt jd, et al. the ocular hypertension treatment study: baseline factors that predict the onset of primary open-angle glaucoma. arch ophthalmol. 2002; 120: 714-20. 4. kruse-hansen f, ehlers n. elevated tonometry readings caused by thick cornea. acta ophthalmol. 1971; 49: 775-8. 5. ehlers n, kruse-hansen. central corneal thickness in low tension glaucoma. acta ophthalmol. 1974; 52: 740-6. 6. copt rp, thomas r, mermoud a. corneal thickness in ocular hypertension, primary open-angle glaucoma and normal tension glaucoma. arch ophthalmol. 1999; 117: 14-6. 7. binder ps, bosem m, weinreb rn. scheimpflug anterior segment photography assessment of wound healing after myopic excimer laser photorefractive keratectomy. j cataract refract surg. 1996; 22: 205-12. 8. lattimore mr, kaupp s, schallhorn s, et al. orbscan pachymetry: implications of a repeated measures and diurnal variation analysis. ophthalmology 1999; 106: 977–81. 9. buratto l, brint sf. lasik principles and techniques. usa: slack incorporated. 1998: 151-66. 10. mitchell p, hourihan f, sandbach j et al. the relationship between glaucoma and myopia: blue mountains eye study. ophthalmology. 1999; 106: 2010-5. 11. perkins es, phelps es. open angle glaucoma, ocular hypertension, low tension glaucoma and refraction. arch. ophthalmol. 1991; 100: 1464-7. 12. foster pj, baasanhu j, alsbirk ph, et al. central corneal thickness and intraocular pressure in a mongolian population. ophthalmology. 1998; 105: 969–73. 13. wolfs rcw, klaver ccw, vingerling jr, et al. distribution of central corneal thickness and its association with intraocular pressure: the rotterdam study. am j ophthalmol. 1997; 123: 767–72. 14. lam akc, douthwaite wa. the effect of an artificially elevated intraocular pressure on corneal thickness in chinese eye. ophthalmol physiol opt. 1997; 17: 414–9. 15. herndon lw, choudhri sa, cox t, et al. central corneal thickness in normal, glaucomatous, and ocular hypertensive eyes. arch ophthalmol. 1997; 115: 1137–41. 16. whiotacre mm, stein ra. sources of error with use of goldmann-type tonometers. surv ophthalmol. 1993; 38: 1-30. 17. shah s. accurate intraocular pressure measurement: the myth of modern ophthalmology? ophthalmology. 2000; 107: 1805-7. 18. shields m. textbook of glaucoma, 3rd ed. baltimore: williams and wilkins, 1992. 19. doughty mj, zamam ml. human corneal thickness and its impact on intraocular pressure measures: a review and metaanalysis approach. surv ophthalmol. 2000; 44: 367-408. 20. bjornsson g. the primary glaucoma in iceland: epidemiological studies. acta ophthalmol supplement. 91: 689. 21. klein be, klein r, sponsel we, et al. prevalence of glaucoma. the beaver dam eye study. ophthalmol. 1992; 99: 1499–1504. 22. hollows fc, graham pa. intra-ocular pressure, glaucoma and glaucoma suspects in a defined population. br j ophthalmol. 1996; 50: 570–86. microsoft word r janjua 41 case report peri-ocular and facial multiple hereditary infundibulocystic basal cell carcinoma r janjua, qk ali, a p siddiqui pak j ophthalmol 2008, vol. 24 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: r janjua senior house officer department of ophthalmology scunthorpe general hospital cliff gardens, scunthorpe dn15 7bh, uk received for publication september’ 2007 …..……………………….. purpose: to report two cases of multiple hereditary infundibulocystic basal cell carcinoma (mhibcc) in two successive generations of a family and to discuss its management. design and methodology: this an observational case report in an institutional setting, reporting on two patients of successive generations referred by the department of dermatology. clinical management: both patients had cosmetically noticeable lesions for a very long time and did not look like typical basal cell carcinomas. due to uncertain clinical diagnosis biopsies were taken and on the basis of differing results, a controversy of was stirred up. histological slides and clinical photographs were sent for second opinion whereby, a definitive diagnosis was reached. conclusions: combination of minimally invasive surgery, cryotherapy and observation should form the basis of clinical and surgical management. this saves the patient from aggressive and unnecessary surgery that can be disfiguring. this is a diagnosis which should be kept at the back of one’s mind when faced with similar lesions with a family history. nfundibulocystic basal cell carcinoma (ibcc) is a newly described variant of basal cell carcinoma (bcc). there are only a few reports in current literature on its presentation, clinical course and management. ibcc with follicular differentiation was first reported in 19871 and the term infundibulocystic basal cell carcinoma was proposed in 19902. mhibcc as a distinct entity was first described in 19993. ibcc maybe found as a sporadic lesion, or as part of a hereditary syndrome with diffuse involvement and multiple tumors3. we present two cases of mhibcc in successive generations (mother and daughter) affecting the eyelid margins, periorbital skin and face. both patients underwent different modalities of treatment. the importance of correct diagnosis is mentioned which would aid in reducing unnecessary surgery, which can be disfiguring in a cosmetically sensitive area. materials and methods the patients were referred to the oculoplastic service from the dermatology department. the daughter was seen first, but she did not mention the fact that her mother also had similar lesions. the mother was seen a few weeks later and she gave a positive family history of similar lesions with similar distribution. after the diagnosis was established, informed consent for open publication was obtained from both patients. patient 1: a 43 yrs old woman was referred from dermatology for multiple fibro epithelial nodules and papules on the face, eyelids and back for the last 20 years. some of these lesions were pigmented as well. no palmer pits, frontal bossing, hypertelorism, scoliosis or other extra cutaneous findings were observed. her presumed diagnosis by the department of dermatology was sebaceous keratosis or fibroepitheloid polyps. some of the forehead lesions were treated with liquid nitrogen with acceptable i 42 results. we were requested to sort out her eyelid marginal and periocular lesions. when we examined the patient, it seemed that the lesions were more similar to lipoid proteinosis. fig 1 (patient 1 pre op), fig 2 (patient 1 pre op), fig 3 (patient 1 post op). no other ocular or systemic co-morbidity was noted except for mildly raised cholesterol for which she was being treated. her mother is affected but 2 sisters do not have any skin lesions. she has no children. she underwent excision biopsy and cryotherapy of some lesions. the histology report varied from bcc’s to trichoepitheliomas. the patient is under long-term review and is awaiting further treatment of lesions of concern to her. patient 2 was a 69 yrs old healthy female. she was also referred from dermatology department. she had multiple fibroepithelial nodules and lesions on face, eyelids and periocular skin. many of the lesions were pigmented. there was one large lesion on right upper eyelid. ocular examination was otherwise unremarkable. the patient had diet-controlled type ii diabetes for 2 years. she underwent shave excision/biopsy of the lesion on right eye upper lid and it was surprisingly reported as a completely excised bcc! fig 5 (patient 2 pre op), fig 6 (patient 2 post op), fig 7 (patient 2 post op). this stirred up controversy and therefore she underwent further multiple biopsies taken with narrow margins. histology report varied from incompletely excised bcc’s to trichoepitheliomas. both sets of histology slides together with clinical photographs were sent for expert opinion and they came back with a diagnosis of multiple hereditary infundibulocystic basal cell carcinomas (mhibcc). discussion bcc is the most common human malignancy which usually affects the elderly and caucasians. the most important risk factors are fair skin, inability to tan and chronic exposure to uv radiation. 90% of lesions involve the head and neck region. usually it is locally invasive but metastatic disease has been reported. bcc may be of various types, nodular, ulcerative, cystic, melanotic and sclerosing (morphae). sometimes multiple bcc may appear as part of syndromes e.g. xeroderma pigmentosum, nevoid basal cell carcinoma syndrome. tozawa and ackermann described a series of bcc’s with follicular differentiation in 1987 1. they studied 15 biopsy specimens and described them as small well circumscribed lesions in superficial dermis composed of basaloid neoplastic cells associated with infundibular cysts. interestingly only one specimen was from an eyelid. on the basis of presence of peripherally palisading basaloid cells they concluded that these were basal cell carcinomas with follicular differentiation. this generated a controversy in literature. in 1990 walsh and ackerman proposed the term infundibulocystic basal cell carcinoma on the basis of significant histological differences affecting solitary lesions only. in 1999 requina et al 3 described for the first time two families of patients with multiple infundibulocystic bcc’s as a distinct genodermatosis and they suggested the term mhibcc. clinically the lesions were said to occur mainly on the face. other reports in literature have reported infundibulocystic bcc’s lesions on the trunk, extremities head and neck. it maybe found as a sporadic lesion or as a hereditary syndrome with diffuse involvement and multiple tumors. typical presentation includes multiple pearly papules and dome shaped nodules, which may or may not be pigmented, scattered over the eyelid margins, periorbital skin, face, and the nasolabial folds. inheritance pattern appears to be autosomal dominant. the early stages of mhibcc show numerous small epithelial components, which arise from previously normal hair follicles4. most lesions tend to be superficial with no involvement of deep reticular dermis. buds and cords of basaloid and squamoid cells in radial and anastomosing pattern are typical. stroma is scant, myxoid and with a few infundibular and cystic structures containing melanized and cornified cells maybe seen3. absence of fibrocytes and scant stroma differentiates ibcc from trichoepithelioma, which tends to have an abundant and highly fibrous stroma with cribriform pattern2,3. table 1: key histopathological differentiation among hair follicle hamartoma (hfh), tricoepithelioma (te) and infundibulocystic basal cell carcinoma (ibcc) in fully developed lesions 6 features bfh te ibcc cell anastomosing some basaloid cells with hyperchromatic pleomorphic nuclei. a 43 composition basaloid cords and strands from lower portion of hair follicles peripherally palisading basaloid cells. few necrotic cells and rare mitosis. some peripherally palisading basaloid cells. several tiny cysts lined by follicular epithelium & some cornified cells. melanin pigment maybe present current literature is not clear on the course and management of mhibcc. the age of presentation, number of tumors and distribution appears to vary from case to case. these lesions appear to be less aggressive than other types of bcc and they tend to remain small for a long period of time or grow very very slowly and show little tendency to ulcerate3. a non-surgical expectant management has been advocated5, which has been partly employed in our patients. the lesions in our patients had been there for more than 15-20 years without any change in character. standard surgical procedure involves excision of lesions with 3mm clear margins. in mhibcc this approach is not practical given the large number of lesions located in cosmetically and functionally sensitive areas. in our patients the lesions were removed piecemeal with enough time between surgeries to allow skin healing and new tissue growth till such a time that the surgical results were cosmetically acceptable to the patient conclusion mhibcc lesions can pose a difficult problem to deal with surgically and should be included in differential diagnosis of multiple bcc, and in particular ophthalmologists should be aware of this relatively newly described entity. combination of minimally invasive surgery, cryotherapy and observation should form the basis of clinical and surgical management. this saves the patient from aggressive and unnecessary surgery that can be disfiguring. it is essential to furnish all relevant clinical history to the pathologists for accurate assessment and proper histological diagnosis. moreover, if a shave excision biopsy specimen is reported back as a completely excised bcc, it should alert the clinician to the possibility of infundibulocystic bcc and the pathologist should be asked to review the specimen in greater detail especially looking for histological features consistent with ibcc. acknowledgments / disclosure none of the authors has any financial or propriety interest in this article. funding support: none financial disclosures: none acknowledgments: we would like to acknowledge the following while writing this article: janice marshall for secretarial input, i think we need to acknowledge the pathologists conformity with author information since this was a case series, ethical committee approval was not required, although permission from the subjects was taken in accordance with the helsinki declaration. author’s affiliation r janjua senior house officer department of ophthalmology scunthorpe general hospital cliff gardens, scunthorpe dn15 7bh, uk qk ali consultant ophthalmic surgeon department of ophthalmology scunthorpe general hospital cliff gardens, scunthorpe dn15 7bh, uk a p siddiqui staff grade department of ophthalmology scunthorpe general hospital cliff gardens, scunthorpe dn15 7bh, uk reference 1. ackermann tt. basal cell carcinoma with follicular differentiation. am j dermatopathol. 1987; 9: 474-82 2. walsh n, ackerman a. infundibulocystic basal cell carcinoma: a newly described variant. mod.pathol. 1990; 3: 599-608. 3. requena l, farina m, robledo m, et al. multiple hereditary infundibulocystic basal cell carcinoma: a genodermatosis different from nevoid basal cell carcinoma. arch dermatol. 1999; 135:1227-35. 4. toyoda m, morahashi m. infundibulocystic basal cell carcinoma. eur.j dermatol. 1998; 8: 51-3 5. herman ar, klaus jb, greenberg ra, et al. multiple infundibulocystic basal cell carcinomas: case report of unique unilateral presentation. dermatol surg. 2003; 29: 436-9. 44 6. kelly sc, ermolovich t, purcell sm. nonsyndromic segmental multiple infundibulocystic basal cell carcinoma in an adolescent female. dermatol surg. 2006; 32: 1202-8. microsoft word tahira soomro 7 203 original article frequency and morphological patterns of malignant intra orbital tumors in various age groups tahira soomro, shahnaz imdad kehar, mohammad anwar pak j ophthalmol 2011, vol. 27 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tahira soomro department of pathology bmsi jpmc, karachi submission of paper june’ 2011 acceptance for publication november’ 2011 …..……………………….. purpose: to determine the frequency and morphologic types of intraorbital tumors. material and methods: a retrospective study conducted at the department of pathology basic medical sciences institute, jinnah postgraduate medical centre karachi. all intraorbital lesions received over a period of 5 years i.e. from jan 2005 to dec 2009 were reviewed. all specimens were formalin fixed, routinely processed for paraffin embedding, sectioned and finally stained with haematoxylin and eosin using standard procedures, when required special stains were performed. results: during study period total of 360 cases of intra orbital lesions were received. out of, which 115 (31.9%) were non-neo plastic and 245 (68.0%) were neo plastic lesions. retinoblastoma and squamous cell carcinoma were the most common malignant intraocular and intraorbital tumor with mean age of presentation 4 years and 55 years respectively. remaining cases include 16 cases of intraepithelial dysplasia, 10 cases of rhabdomyosarcoma, 6 cases each of sebaceous carcinoma and malignant lymphoma, 4 cases each of malignant melanoma, malignant fibrous histiocytoma and adenoid cystic carcinoma, 3 cases of optic glioma and 1 case of mucoepidermoid carcinoma. conclusion: a variety of tumors can involve the orbit. the incidence of neoplastic lesion exceeded that of non-neoplastic lesion. the data will be help full for ophthalmologist, pathologist and epidemiologist for comparison with other studies. he orbit is an anatomically complex structure containing different types of tissues. the structures present within the orbital cavity are the globe, lacrimal gland, extraocular muscles, smooth muscle, fibroadipose tissue, blood vessels, peripheral nerves, sympathetic ganglia, optic nerve and cartilaginous part of trochlea. the lacrimal gland is the only epithelial structure present within the orbit1,2. the orbital tumors present with a variety of sign and symptoms and are a great challenge for ophthalmologist in terms of diagnosis, imaging and management³. the presence of different structures within the orbit causes great confusion therefore systematic approach is necessary to classify the orbital tumors. the orbital cavity lesions vary from inflammation to different types of neoplastic lesions and greatly affect quality of life3,4. schematically orbital tumors can be classified as primary, secondary and metastatic. the primary lesions originating from orbit itself include epithelial tumors such as squamous cell carcinoma arising from conjunctiva and mostly seen in elderly patients. bone and soft tissue tumors including osteomas, fibrous dysplasia, aneurysmal bone cyst and osteogenic sarcoma are more common in younger age group. among the lymphoid tumors and vascular tumors, hemangioma, lymphangioma, hemangioperit 204 cytoma and avm of vessels are most common tumors in childhood. nerve sheath tumors within the orbit give rise to neurofibroma, schwannoma and malignant peripheral nerve sheath tumors. these tumors do not arise from optic nerve itself as schwann cells are not present, they arise from peripheral nerves which innervate the extraocular muscles. secondary orbital lesion, which extend to orbit from neighboring structures include eyelid, conjunctiva, intraocular structures, paranasal sinuses and nasopharynx²,5. metastatic tumors in children include neuroblastoma, ewing’s tumor, chloroma and langerhan´s cell and histiocytosis. in adults the tumors which metastasize to the orbit are from breast, prostate, kidney and carcinoid tumors of lung and gastrointestinal tract1,2,6. our study aims at reviewing the morphological pattern and determining the frequency of various intraorbitaltumors in different age groups. material and methods a retrospective study was conducted at the department of pathology basic medical sciences institute, jinnah postgraduate medical center to determine the frequency of intraorbital lesions received over a period of five years that is from january 01, 2005 to december 31, 2009. during this period total 399 cases were received. all specimens were formalin fixed, routinely processed for paraffin embedding, sectioned and finally stained with hematoxylin and eosin using standard procedures. when required, specials stains were performed. all lesions, which occupied the orbital cavity regardless of its site of origin were included. the lesions arising from orbital sides such as skin lesions from eyelids, which did not extend into orbital cavity, were excluded. results during the study period a totals of 399 cases were received out of which 39 were inconclusive due to inadequate material. of the remaining 360cases, 115 (31.9%) were non-neoplastic and 245 (68.0%) were neoplastic lesions. the bulk of the non-neoplastic lesions consisted of cystic lesions with 54 cases (46.9%) (table 1). the rest of cases comprised of inflammatory lesions 44 cases (38.2%), degenerative disorders 11 cases (9.5%), hemorrhage 04 cases (3.47%) and reactive hyperplasia 02 cases (1.7%). among the neoplastic lesions, 51 cases of benign neoplastic lesions and 194 cases of malignant lesions were found. table 2 shows benign neoplastic lesion. the most common benign neoplastic lesion found to be angiomatous lesion 22 cases (8.8%) followed by 07 cases of pleomorphic adenoma (2.8%). remaining cases include 6 cases of schwannoma (2.4%), 04 cases of compound naevus (1.6%), 03 cases of menigioma (1.2%) and 02 cases each of neurofibroma and intradermalnaevus (0.8%). the rare cases include xanthomatous lesion, lipoma, cystic teratoma, hemartoma and dermolipoma. the most common malignant tumor found to be retinoblastoma 73cases (37.6%) with mean age was 3.76 years with equal male to female ratio 1:1 followed by squamous cell carcinoma 67 cases (34.5%) with a mean age 55 years and male to female ratio 1.79 (table 3-5). remaining cases included 16 cases of intraepithelial dysplasia (8.2%), 10 cases (5.15%) of rhabdomyosarcoma, 6 cases each of (3.09%) of sebaceous carcinoma, and malignant lymphoma, 4 cases (2.06%) each of malingnant melanoma, malignant fibrous, histiocytoma and adenoid cystic carcinoma, 03 cases (1.5%) of optic glioma, one case (0.5%) of mucoepidermoid carcinoma. table 1: non-neoplastic lesions, n = 115 name of lesion no. of patients n (%) cystic lesions 54 (46.9) inflammatory 44 (38.2) degenerative 11 (9.5) hemorrhage 02 (1.7) reactive hyperplasia 04 (3.47) table 2: benign neoplastic lesion, n = 51 name of lesion no. of patients n (%) angiomatous 22 (8.9) pleomorphic adenoma 07 (2.8) schwannoma 06 (2.4) compound naevus 04 (1.6) maningioma 03 (1.2) neurofibroma 02 (0.8) intradermalnaevus 02 (0.8) miscellaneous 05 (2.04) 205 discussion orbital tumors are an important cause of proptosis, which may result in loss of vision. present study was designed to evaluate the various morphological patterns of intraorbital tumors and assess the frequencies of various tumors in different age groups. in our study, theincidence of neoplastic lesions exceeded that of non neoplastics lesions. among the neoplatic lesions, the age distribution of patients showed two peaks one around 04 years and another around 55 years8-10. of the patients with malignant ophthalmic tumors 58.7% were males and 41.2% females. a high percentage of malignant ophthalmic tumors was observed in paediatric age group due to retinoblastoma, which constituted 37%of all malignant ophthalmic tumors10,11,14. the average age of retinoblastoma was 3.8 years with equal male to female ratio. studies done in both pakistan and india also reported same age distribution but with male predominance,11,12 while in western countries the age of presentation is earlier. this earlier age of presentation in developed countries is probably due to better diagnostic facilities and increased awareness among public, which is lacking in our continent. table 1: malignant tumors name of lesion no. of patients n (%) retinoblastoma 73 (37.6) squamous cell carcinoma 67 (34.5) intraepithelial dysplasia 16 (8.2) rhabdomyo sarcoma 10 (5.15) sebaceous carcinoma 06 (3.09) malignant lymphoma 06 (3.09) malignant melanoma 04 (2.06) adenoid cystic carcinoma 04 (2.06) malignant fibrous histocytoma 04 (2.06) optic glioma 03 (1.5) mucoepidermoid carcinoma 01 (0.5) total 194 (79.18) table 5: distribution of malignant neoplastic lesion according to sex name of lesions no. of patients male female m:f ratio retinoblastoma 73 36 37 1:1 squamous cell carcinoma 67 43 24 1.79:1 intra epithelial dysplasia 16 11 05 2.2:1 rhabdomyosarcoma 10 05 05 1:1 sebaceous carcinoma 06 02 04 1:2 malignant lymphoma 06 06 0 6:0 malignant melanoma 04 03 01 3:1 adenoid cystic carcinoma 04 02 02 1:1 malignant fibrous histiocystoma 04 03 01 3:1 optic glioma 03 03 0 3:0 mucoepidermoid carcinoma 01 01 0 1:0 among the epithelial tumors, squamous cell carcinoma originating from conjunctiva in adults contributing to 34% of malignant ophthalmic tumors closer to some studies12,13. however singapore reports melanoma9 and nepal reports basal cell carcinoma11 as most common tumors. the mean age of squamous cell carcinoma in our study was 55 yrs with male to female ratio 1.79:113. intraepithelial dysplasia was seen predominantly in males mostly between 51-60 years as reported in other studies10. sebaceous gland carcinoma mostly arises from meibomian gland within eyelid and also from the conjunctival epithelium constitutes (3.09%) of intra orbital malignant tumors. due to its invasive nature, it is difficult to ascertain the exact origin. in the western population melanoma is one of the most common ocular malignancy. the frequency of malignant melanoma was relatively low in the present 206 table 4: distribution of malignant neoplastic lesions according to age name of lesion no. of patients 01 – 10 11 – 20 21 – 30 31 – 40 41 – 50 51 – 60 60 > retinoblastoma 73 73 — — — — — squamous cell carcinoma 67 — 2 7 6 9 19 24 intra epithelial dysplasia 16 — — 1 3 2 8 2 rhabdomyo sarcoma 10 9 1 — — — — — sebaceous carcinoma 06 — — — — 2 1 3 malignant lymphoma 06 — 1 — 1 1 — 3 malignant melanoma 04 — — — — 1 2 1 malignant fibrous histiocytoma 04 — — 1 1 1 1 — optic glioma 03 3 — — — — — — adenoid cystic carcinoma 04 — — — 2 — 2 — mycoepidermoid carcinoma 01 — — — — — — — total 194 85 04 09 13 17 33 33 fig. 1: malignant melanoma x 40 study. ocular melanoma mostly effects white or lightly pigmented individuals and rarely occurs among asian or black population14. we found 2.1% of our study cases to be malignant melanoma. these findings are closer to study in subcontinent10 but in contradiction to studies done in singapore and taiwan9,14 the frequency is lower. fig. 2: retinoblastoma x 40 among the mesenchymal tumors, rhabdomyosarcoma was observed as 5.15% in 1 to 10 yrs age group, which is lower in comparison with other pakistani studies12. the reason for lower number of cases might be due to the fact that our study is limited to a single medical institute. in adults, the most common 207 mesenchymal tumor was found to be malignant fibrous histiocytoma. our experience regarding malignant lymphoma show only 3.06% with mean age at diagnosis was 49 yrs. these results are also lower than other studies12,14. fig. 3: hemangiopericytoma x 40 fig. 4: benign angiomatouslesion x 40 among the neuroepithelial tumors, optic glioma constitutes 1.5% of malignant cases and found to be closer to other study in pakistan8. conclusion retinoblastoma was the most common ocular malignant tumor in paediatric age group in our study. squamous cell carcinoma is the commonest intra orbital malignancy in the older population. this data provides help and in also useful for clinicians and ophthalmologist for future references. author’s affiliation dr. tahira soomro m. phil student department of pathology, bmsi jpmc, karachi dr. shahnaz imdad kehar associate professor department of pathology, bmsi jpmc, karachi dr. mohammad anwar assistant professor department of pathology, bmsi jpmc, karachi reference 1. mercandetti m, cohen aj. tumors, orbital. available at http//emedicine.medscape.com. 2. cummings tj. advances in orbital tumors.www.uscap.org. 3. darasut te, lanzino g, lopes mb, et al. an introductory overview of orbital tumors. neurosurgical focus. 2001; 10: 1. 4. kumar r, adhikari rk, sharma mk, et al. pattern of ocular malignant tumors in bhairahwa, nepal. theint j ophthalmol and visual science. 2009; 7. 5. an introductory overview of orbital tumors: overview of orbital tumors available at http//www.medscape.com. 6. rosai and ackerman’s surgical pathology. 9thed, elsvier. newdelhi. p. 2730. 7. baig msa, dareshani s, ali ma, et al. squamous cell carcinoma of the conjunctiva: analysis of fifteen cases. j ayub med coll. 2009; 21: 146-7. 8. n uddin, mushtaq n, khan mah, et al. morphological spectrum of ophthalmic tumors in northern pakistan. j pak med assoc. 2001; 51: 19-22. 9. lee sb, eong kg, saw sm, et al. eye cancer incidence in singapore. br j ophthalmol. 2000; 84: 767-70. 10. sunderraj p. malignant tumors of eye and adnexa. indian j ophthalmol. 1991; 39: 6-8. 11. lavaju p, arya sk, sinha a, et al. pattern of ocular tumors in the eastern region of nepal. nep j ophthamol. 2009; 1: 9-12. 12. bhurgri y, muzzafar s, ahmed r, et al. retinoblastoma in karachi, pakistan. asian pacific j cancer prev. 2004; 5: 159-63. 13. pombejara fn, tulvatna w, pungpapong k. malignant tumor of the eye and ocular adnexae in thailand: a six year review at king chulalongkorn memorial hospital. asian biomedicine 2009; 3: 551-5. 14. cheng cy, hsu wm. eye-incidence of eye cancer in taiwan: an 18-year review. 2004; 18: 152-8. microsoft word p.s mahr 35 original article intraocular pressure control and post operative complications with mitomycin-c augmented trabeculectomy in primary open angle and primary angle-closure glaucoma p. s mahar, dilshad a laghari pak j ophthalmol 2011, vol. 27 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p.s mahar aga khan university hospital karachi received for publication november’ 2010 …..……………………….. purpose: to compare intraocular pressure (iop) control and post operative complications after trabeculectomy with mitomycin-c (mmc) in patients with primary open angle glaucoma (poag) and primary angle-closure glaucoma (pacg). material and methods: sixty patients of both genders with age range of 40 to 70 years, fulfilling the inclusion criteria were planned for trabeculectomy. the patients were selected from glaucoma clinic who were diagnosed as having poag or pacg with uncontrolled iop (more than 22mmhg) with topical anti glaucoma medication. thirty patients (30 eyes) were randomly enrolled in each group. the patient’s iop was assed at all post operative follow up visits i.e. at day 1, 1 week, 1 month, 6 months and 1 year with record of post operative complications. results: the mean iop in poag patients, preoperatively was measured at 22.93 + 3.9 mmhg. there was a mean drop of 10.63 ± 3.2 mm hg at 12 months post operatively. the mean iop in pacg group, registered at 22.13 sd ± 7.44 mmhg preoperatively. after surgery, mean iop dropped to 9.42 ± 2.1mm hg (please check this figure) at 12 months follow up. there was insignificant difference between post operative iops at different follow ups in both poag and pacg patients with p-value = 0.092 and 0.34 respectively. in early post operative phase, out of 30 patients, 18 (60%) had complications in pacg group and 9 (30%) patients had complications in poag group (p-value= 0.0379). in late post operative phase, 8 patients (26.6%) had complications with pacg and only 1 (3.3%) patient showed complication in poag group (p-value=0.0301). conclusion: mmc augmented trabeculectomy was beneficial in patients with poag and pacg with similar control of iop, although range of complications were on the high side in pacg group but statistically this was found insignificant (p-value=0.0301) airns was the first to describe the partial thickness trabeculectomy in 1967, and it still remains the standard procedure for patients who have failed on maximal medical therapy with uncontrolled intraocular pressure (iop)1. the use of intraoperative mitomycin-c (mmc) as an adjunct to standard trabeculectomy has increased the success rate of this procedure over the last couple of decades2-4. the final outcome of iop after trabeculectomy has been variable in different types of glaucoma, different age groups and different races. for example success rate is good in patients with poag than neovascular type of glaucoma5. people over the age of 40 years do well than the patients under 40 years, due to early fibrosis with failure of drainage procedure6. from the studies conducted on overseas asians, the success rate of trabeculectomy in this community appears to be c 36 lower than in caucasian7,8. african descendents in usa and europe have poor outcome to surgery with increased failure rate than their white counterparts9,10. the purpose of our study was to carry out trabeculectomy with mmc on our endogenous population over 40 years of age, either with primary open angle glaucoma (poag) or primary angle closure glaucoma (pacg), who showed high iop (>25mmhg) with maximal medical therapy and monitor their iop control and rate of complications over a period of one year. materials and methods this prospective, comparative case series was carried out at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, karachi from january 2005 to january 2006. the permission for the study was granted by institute’s ethics committee. sixty patients of both genders were recruited from the glaucoma clinic, with 30 patients having poag and 30 patients with the diagnosis of pacg (mentioning the criteria for diagnosis of poag and pacg). all these patients were using topical antiglaucoma medication with their iop still remaining uncontrolled over 25 mmhg. patients with diagnosis of pacg had already laser peripheral iridotomy (lpi) carried out. the patients with acute attack of angleclosure glaucoma, secondary glaucoma, pseudopahkic glaucoma and previous history of drainage surgery or tube-shunt procedure were excluded from the study. the pre-operative work up included a detailed ocular and medical history with slit-lamp biomicroscopic examination of anterior segment, goldman applanation tonometry, gonioscopy using goldman 2 mirror lens and dilated fundus examination with plus 90d lens. base line iop measurement was taken with mean of 2 highest values measured at 9:00 am and 4:00pm by goldman applanation tonometer (gat). all patients had their optic disc photographs taken and visual fields examined by humphrey automated perimeter. the trabeculectomy was performed under peribulbar anaesthesia using fornix based conjunctival flap. intra operative mmc was applied in concentration of 0.2 mg/ml (0.02%), for duration of 3 minutes in all patients to standardize the procedure. the details of the surgical procedure are described in the literature11. all patients received topical moxifloxacin 0.5% (vigamox-alcon belgium) for 4 weeks and dexamethosone 0.1% (maxidex-alcon belgium) for 8 weeks. to achieve the target iop (between 10-15 mmhg) in the early postoperative period, argon laser suture lysis was carried out according to the need in either group. the intraocular pressure (iop) was assessed at all postoperative follow up visits i.e. at day one, one week, one month, six months and one year in both groups. data analysis chi-square test of proportion was used to compare the complications in both groups at 5% level of significance. mean and standard deviation was computed for age and iop. independent sample t-test was used to compare the mean age and iop between each group. paired sample t-test was used to compare mean iop between pre and post operative follow up, while repeated measure anova was used to compare mean iop of different post operative follow up i.e. post-operative day 1, 1 week, 1 month, 6 months and 1 year. results out of 30 poag patients, 24 (80%) were male and 6 (20%) were female with male to female ratio of 4:1. in pacg group 13 (43.3%) patients were male and 17 (56.7%) were female with male to female ratio of 0.8 to 1%. the age range of participants was between 40-70 years with mean + sd 56.42 +11 years. the mean preoperative iop in poag patients was measured at 22.93 ± 3.9 mmhg. the post operative iop was found 13.23 sd ± 5.7 mmhg at day 1, 12.83 sd ± 5.71 mmhg at 1 month, 10.28 sd ± 4.27 mmhg at 6 months and 12.3 sd ± 4.81 mmhg at 12 months time. there was a mean drop of 10.63 ± 3.2 mmhg at 12 months postoperatively (table-1). the mean iop in pacg group registered at 22.13 sd ± 7.44 mmhg preoperatively. after surgery, mean iop measured 14.2 sd ± 5.79 mmhg at day 1, 12.17 sd ± 7.23 mmhg at 1 month, 12.13 sd ± 5.91 mmhg at 6 months and 12.71 sd ± 5.18 mmhg at 12 months time. this showed a mean drop of 9.42 ± 2.1 mmhg at 12 months postoperatively (table 1). comparison of preoperative and post operative iop (final follow up after 1 year) is shown in (fig. 1). 37 early postoperative complications were significantly high in pacg patients. out of 30 patients, 12 (40%) had complications in pacg group and 8 (30%) patients had complications in poag group (p-value =0.0379). early complications noted in both poag and pacg are shown in table 2. similarly, late postoperative complications were significantly high in pacg patients, out of 30 patients, 7 patients (23.3%) had complications, only 1 patient (3.3%) had complication in poag group. four (13.3%) patients were lost in the follow up. comparison of late postoperative complications are shown in (table 3). table 1: comparison of intra ocular pressure (iop) pre and post operatively in primary open angle glaucoma (poag) and primary angle closure glaucoma n = 60 poag mean± sd mmhg pacg mean± sd mmhg pre-operative 22.93± 3.9 22.13± 7.44 post operative (after one day ) 13.23± 5.7 (p < 0.0001) 14.2± 5.79 (p < 0.0001) post operative (after one month) 12.83± 5.71 (p < 0.0001) 12.17± 7.23 (p < 0.0001) post operative (after six months) 10.28± 4.27 (p < 0.0001) 12.13± 5.91 (p < 0.0001) post operative (after one year) 12.3± 4.81 (p < 0.0001) 12.71± 5.18 (p < 0.0001) table 2: early postoperative complications complication poag (n=30) pacg (n=30) flat bleb 4(13.3%) 6(20%) hypotony 1(3.3%) 2(6.7%) bleb leak 0 (%) 1(3.3%) shallow ant chamber 3(10%) 2(6.7%) raised iop 0 (%) 1(3.3%) table 3: late postoperative complications complication poag (n=30) pacg (n=30) vascularized bleb 1(3.3%) 0 (%) flat bleb 0 (%) 2(6.7%) shallow ant chamber 0 (%) 1(3.3%) late hypotony 0 (%) 2(6.7%) tenon cyst 0 (%) 2(6.7%) 0 10 20 30 poag pacg pre opp iop post opp iop pre opp iop post opp iop fig. 1: comparison between pre-operative and post operative intraocular pressure between poag and pacg groups discussion the large prospective studies such as ocular hypertension treatment study (ohts)12, collaborative normal tension glaucoma study (cntgs)13 and early manifest glaucoma treatment study (emgts)14 have demonstrated that lower iops are associated with reduced risk for progression of visual field damage and visual loss. despite the inception of multiple anti-glaucoma medications, trabeculectomy has still out performed the medical and laser treatment15,16. in this study, we performed trabeculectomy with mmc in two groups of patients, either with poag or pacg, having uncontrolled iop on anti-glaucoma therapy. we evaluated their iop control at mean follow up of 12 months and also monitored any complication in early and late post operative period. there was a mean drop of 10.63 ± 3.2 mm hg in poag group compared to 9.42 ± 2.1 mm hg in pacg patients. 38 sihota and co-workers17 studied 64 eyes of 64 patients with poag and pacg. the overall probability of success of trabeculectomy in controlling iop to < or = 21 mm hg with or without additional topical anti-glaucoma medication was 0.94 and 0.88 at 5 and 10 years respectively. there was no statistically significant difference in the qualified and absolute success rate for iop control between poag and pacg eyes. akafo18 published his results of 81 eyes undergoing trabeculectomy. with 43 eyes having poag, iop control less than 21 mm hg was witnessed in 29 (67%) eyes. on the other hand, 25 of 38 (65%) eyes with pacg required an average 1.5 different anti-glaucoma medications post op for the control of their iop. in this series of patients, those having pacg though required additional topical anti-glaucoma medication for their iop control, no adjunctive antimetabolite was used, which can be one reason for majority of the eyes requiring extra medication. palenga-pydn et al19 reported 59 eyes of 51 patients with long term results of trabeculectomy with mmc. a successful iop of 15 mm hg was obtained in 91% in both poag and pacg groups after 10 years follow up. poor success rate were reported in malaysia, where a study performed on 61 eyes of chinese and malay ethnicity, examined the results of unaugmented trabeculectomy at 2 years follow up20. these workers found 62% success (iop < 21 mm hg, no medications) for poag and around 45% for pacg patients. some of the poor results of trabeculectomy noted in literature can be due to un-augmented procedure performed without any use of anti-fibrotic agents. wu and yin21 randomly assign 40 eyes of 30 patients to receive un-augmented trabeculectomy or trabeculectomy augmented with 0.4 mg/ ml mmc. the mmc group had a 67 % drop in iop at one year compared to 33% drop in the controlled group. although the early and late complications were slightly on high side in group of patients with pacg but this was not found statistically significant. in early postoperative phase, flat bleb was noticed in 13.3% of poag patients and 20% pacg patients. while second most complication was hypotony seen in 3.3% of poag patients and 6.7% pacg patients. in a study of 5-fu and mmc-augmented trabeculectomy in a west african population, singh et al22 found no cases of hypotony maculopathy or choroidal detachment and only three cases of flat anterior chamber in 101 eyes. a report by ramakrishnan et al23 reported an incidence of only 0.7 % of hypotony in 778 indian eyes, which had under gone trabeculectomy with mmc. the cause for hypotony with anti-metabolite use is due to over filtration at the bleb site or under production of aqueous. in summary mmc augmented trabeculectomy was found beneficial in lowering the iop to similar level in patients with poag and pacg. at the end of one year mean follow up, the difference of complication between two groups was statistically insignificant. author’s affiliation prof. p. s. mahar aga khan university hospital karachi dr. dilshad a laghari aga khan university hospital karachi reference 1. cairns je. trabeculectomy-preliminary report of a new method. am j ophthalmol. 1968; 5: 673-7. 2. robin al, ramakrishnan r, krishnadas r, et al. a long term dose-response study of mitomycin in glaucoma filtration surgery. arch ophthalmol. 1997; 115: 969-74. 3. kupin th, juzych ms, shin dh, et al. adjunctive mitomycinc in primary trabeculectomy in phakic eyes. am j ophthalmol. 1995; 119: 30-9. 4. smith mf, doyle jw, nguyen qh, et al. results of intraoperative 5-flourouracil or low dose mitomycin-c administration initial trabeculectomy surgery. j glaucoma. 1997; 6: 104-10. 5. takihara y, inatani m, fukushima m, et al. trabeculectomy with mitomycin-c for neovascular glaucoma: prognostic factors for surgical failure. am j ophthalmol. 2009; 147: 912-8. 6. fontana h, nouri-mahdavi k, lumba j et al. trabeculectomy with mitomycin-c: outcomes and risk factors for failure in phakic open-angle glaucoma. ophthalmology. 2006; 113: 930-6. 7. tan c, chew pt, lum wl, chee c. trabeculectomy-success rates in singapore hospital. singapore med j. 1996; 37: 505-7. 8. ehrnrooth p, lehto i, puska p, laatikainen l. long term outcome of trabeculectomy in terms of intraocular pressure. acta ophthalmol scand. 2002; 80: 267-71. 9. mermoud a, salmon jf, murray ad. trabeculectomy with mitomycin-c for refractory glaucoma in blacks. am j ophthalmol. 1993; 116: 72-8. 10. freedman j, shen e, ahrens m. trabeculectomy in black american glaucoma population. br j ophthalmol. 1976; 60: 5734. 11. stalmans i, gillis a, lafaut a-s, et al. safe trabeculectomy, technique and long term outcome. br j ophthalmol. 2006; 90: 44-7. 12. kass ma, heuer dk, higginbotham ej, et al. the ocular hypertension treatment study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. arch ophthalmol. 2002; 120: 701-13. 39 13. collaborative normal-tension glaucoma study group. comparison of glaucomatous progression between untreated patients with normal-tension glaucoma and patients with therapeutically reduced intra ocular pressures. am j ophthalmol. 1998; 126: 487-97. 14. heijl a, leske mc, bengtsson b, et al. reduction of intraocular pressure and glaucoma progression: results from the early manifest glaucoma trial. arch ophthalmol. 2002; 120: 1268-79. 15. lichter pr, musch dc, gillespie bw, et al. interim clinical outcomes in the collaborative initial glaucoma treatment study comparing initial treatment randomized to medications or surgery. ophthalmol. 2001; 108: 1943-53. 16. investigators agis. the advanced glaucoma intervention study (agis): 9. comparison of glaucoma outcomes in black and white patients within treatment groups. am j ophthalmol. 2001; 132: 311-20. 17. sihota r, gupta v, agarwal hc. long term evaluation of trabeculectomy in primary open angle glaucoma and chronic primary angle closure glaucoma in an asian population. clin experiment ophthalmol. 2004; 32: 23-8. 18. akafo sk, goulstine db, rosenthal ar. long term post trabeculectomy intraocular pressures. acta ophthalmol. 1992; 70: 312-6. 19. palenga-pydyn d, grymin h, kowalska g. long term results of trabeculectomy on patients with open angle and angle closure glaucoma. clin oczna. 2004; 106: 176-8. 20. sharif fm, selvarajah s. the outcome of trabeculectomy for primary glaucoma in adult patients in ukm. med j malaysia. 1997; 52: 17-25. 21. wu l, yin jf. the efficacy of mitomycin-c for filtration surgery in refractory glaucoma. chin j ophthalmol. 1996; 32: 32-4. 22. singh k, byrd s, egbert pr, budenz d. risk of hypotony after primary trabeculectomy with anti-fibrotic agents in a black west african population. j glaucoma. 1998; 7: 82-5. 23. ramakrishnan r, robin al, krishnadas r, et al. low incidence of hypotony maculopathy following mitomycin trabeculectomy in pigmented indian eyes. ophthalmol. 1995; 102: 136. microsoft word faheem ullah shaikh 135 original article preoperative posterior segment evaluation by ultrasonography in dense cataract faheem ullah shaikh, ashok kumar narsani, shafi muhammad jatoi, ziauddin a. shaikh pak j ophthalmol 2009, vol. 25 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: faheem ullah shaikh department of ophthalmology liaquat university eye hospital, hyderabad received for publication october’ 2008 … ……………………… purpose: ultrasonography is an important tool for evaluating the posterior segment in eyes with opaque media. material and method: the study was conducted in the department of ophthalmology, civil hospital karachi from october 2005 to march 2006. in this study evaluation of two hundred and twenty seven eyes of 200 patients with dense cataract precluding visualization of fundus underwent examination by standardized b scan ultrasonography. presence of certain ocular risk factors believed to be associated with a high incidence of abnormal posterior segment on ultrasound was looked for. result:two hundred and twenty seven eyes of two hundred patients were included in the study. twenty-seven patients had bilateral cataract and 6 patients were only eyed. age range was 43 to 81 years with a mean age of 51 years. one hundred and sixteen (58%) patients were male and 84 (42%) females. on b-scan ultrasonography 18 (7.90%) eyes had finding suggestive of posterior segment pathology. the most common finding was posterior staphyloma in 8 (3.52%) eyes. out of the 200 patients 163 (81.5%) had no risk factor for abnormal posterior segment on ultrasonography, while 37 (18.5 %) were associated with systemic and ocular risk factors, among them diabetes, hypertension and early age, posterior synechiae, elevated intraocular pressure and keratic precipitates were frequently seen. conclusion: preoperative posterior segment evaluation with ultrasound in patients with dense cataract can be used to detect pathologies that may influence the surgical strategy and the postoperative visual prognosis t is only 50 years since ultrasound was first introduced to medical diagnosis; an astonishingly short period bearing in mind the impact this technique has exerted on all aspect of medical practices, including ophthalmology. baum and greenwood1 jointly reported the first application of “brightness modulated” b-scan in ophthalmology. they employed an immersion method. in 1972 bronson and turner described the first contact bscan2 making ultrasound an easy and patient friendly imaging modality. this, and other significant work by purnell3 and coleman et al4 laid to major expansion and popularization of b-scan. the more recent development of duplex scanners and colored doppler instruments in the 1980‘s has facilitate their use in ophthalmology. sergott, leib, williamson, baxter and guthoff were responsible for their wider application of doppler to ophthalmology5-7. its use has expanded to encompass biometric calculations, tissue characterization, diagnosis of complex vitro-retinal conditions and differentiation of intraocular masses8-11. in the orbit, ultrasound including doppler, is used for the investigation of extraocular muscles12,13 and retrobulbar optic nerve i 136 disease14,15 vascular anomalies16 and orbital mass lesions17,18. in 1990 pavlin and colleages described the first high frequency ultrasound (50-100mhz) in ophthalmology19. ubm has allowed us to investigate subtypes of glaucoma, lesions in the iris, cilliary body, sclera, and pars plana20. now ultrasound is considered an essential tool in the investigation and management of many ocular and orbital disorders21,22. the evaluation of eyes with opaque ocular media is one of the primary indication for the use of ocular ultrasonography23,24. therefore preoperative ultrasonography of the globe has been recommended prior to cataract extraction when the fundus cannot be visualized9. material and method this prospective, nonrandomized interventional clinical trial was conducted at department of ophthalmology civil hospital karachi over a period 6 months from october 2005 to march 2006. all eyes with dense cataract that preclude a direct visualization of the fundus were evaluated by b-scan ultrasonography. patient younger than 40 years of age, those with known presence of posterior segment pathology in eyes to be operated , afferent pupillary conduction defect, presence of old or recent penetrating or blunt ocular injury or previous ocular surgery were excluded from study. all registered patients were underwent preoperative examination protocol that includes determination of visual acuity, intraocular pressure, pupillary reaction, slit-lamp examination and biometry. certain risk factors such as diabetes mellitus, hypertension, posterior synechiae, corneal opacity, deviated eyes, keratic precipitate, iris coloboma were specifically looked for and noted. after completing ocular examination patients were evaluated by using the nidek ultra scan imaging system by one surgeon. a combination of axial, longitudinal, and transverse b-scan was used to study the eye. significant posterior segment pathology on ultrasonography was defined as that affects the postoperative visual result. after evaluation, patients with significant posterior segment pathology operated with informed consent about prognosis of vision. postoperatively every enrolled patient underwent direct examination of the posterior segment, to find out the pathology for further management. the chi-square test was used for analysis and the value of p< 0.05% was considered significant. result two hundred and twenty seven eyes of two hundred patients were included in the study. twenty-seven patients had bilateral cataract and 6 were only eyed. age range was 43 to 81 years with a mean age of 51 years. of the 200 patients 116 (58%) were male and 84 (42%) females. one hundred and twenty eight patients (64%) were from urban areas and 72 (36%) belongs rural area. one hundred and twenty six (55.51%) eyes had only hand movements, 32 (14.10%) had counting finger within two feet and 69 (30.40%) eyes had perception and projection to light in four quadrants. one hundred and sixty eyes (70.50%) had mature, 38 (16.74%) eyes had nuclear and 29 (12.80%) had hyper mature cataract. on b-scan ultrasonography 18 (7.90%) eyes had finding suggestive of posterior segment pathology. the most common finding was posterior staphyloma in 8 (3.52%) eyes followed by vitreous hemorrhage in 3 (1.32%) eyes, intravitreal membrane, chorioretinal thickening, retinal detachment each was in 2 (0.9%) eyes and one (0.45%) eye had optic disc edema. two hundred and nine eyes (92.10%) had no posterior segment pathology on ultrasound examination. of the 200 patients 163 (81.5 %) had no risk factor for abnormal posterior segment on b-scan ultrasonography, while 37 (18.5%) were associated with systemic and ocular risk factors. among them diabetes, hypertension, early age, presence of posterior synechiae, elevated intraocular pressure and keratic precipitates were frequently seen. statistically the value of the test of significance (pvalue) is of the order of 0.000, which is less than 0.05. this shows that there is association between agerelated mature cataracts and posterior segment pathologies. table 1: demographic data of 200 patients sex rural urban total male 38 78 116 female 34 50 84 total 72 128 200 137 table 2: frequency of posterior segment pathology ultrasonography obsevation frequency n (%) pathology observed posterior staphyloma vitreous haemorrhage intravitreal membrane chorioretinal thickening retinal detachment optic disc edema pathology not observed 8 (3.52) 3 (1.32) 2 (0.9) 2 (0.9) 2 (0.9) 1 (0.45) 209 (92.10) total 227 (100) discussion cataract is a one of the leading cause of treatable blindness in developing countries. many of these cases have advanced cataracts that preclude visualization of fundus prior to cataract surgery. such visualization is considered important to provide accurate prognosis for vision after cataract surgery. under such circumstances ultrasonographic examination can provide information regarding such abnormalities25 age range of patients in this study was 43 to 81 years. most of the patients (69.85%) were in the range of 50-70 years of age. this is the age where senile cataract is more common. this is more than the study mentioned in american academy of ophthalmology, which shows that the prevalence of cataracts is 50% in people between the ages of 65 and 74 years26. these age-related cataracts were more common in males (58%) than in females (42%). probably reason for this is that males have better access to the hospitals and economically more independent than females, who are mostly dependent upon males in our society. of the 227 eyes with cataract, 18 (7.90%) eyes were found to have some ultrasonically detectable posterior segment pathologies which was lower than the incidence reported in the study by anteby et al27 (19.6%) and very much less than that in the study by haile and mengistu28 who found 66% incidence of detectable abnormalities. on the other hand bello et al29 reported very small number of eyes (5.2%) had posterior segment pathology. ali si and rehman h. showed that 11% of the patients of non-traumatic age group were found to have significant posterior segment pathologies30. the most frequent disclosed abnormality was posterior staphyloma in 8 (3.52%) eyes, which is less than that reported by anteby et al27 (7.2%). salman25 et al reported very small number (2%) of posterior staphyloma. vitreous hemorrhage in our study was in 3 (1.32%) eyes. of these 02 were males and 01 was female. this is less than ali si and rehman h (2.93%) and anteby ii and colleagues (2.5%). while salmon et al reported (1%) of patients had vitreous haemorrhage in their study. retinal detachment was seen in 2 (0.9%) eyes in which 01 male and 01 was female. both of these had inferior detachment. anteby27 and colleagues documented retinal detachment in 4.5%, which is more than our study. while salman amjad et al reported 3 (0.7%) cases of retinal detachment, one of them has been associated with vitreous hemorrhage. chorioretinal thickening observed in 2 (0.9%) patients. both were females. this is more than ali si and rehman h (0.12%). this was probably because of choroiditis. intravitreal membrane seen in our study in 2 (0.9%) patients, these are not as visually significant as vitreous hemorrhage. 01 female patient (0.44%) was found to have optic disc edema. it could affect the visual outcome of the surgery, so it should be evaluated before surgery. in this study we observed that certain patients and ocular features could be used as predictors for pathological findings on ultrasonography. among the patient features studied, diabetes mellitus, hypertension and young age were associated with a significantly greater incidence of abnormalities on ultrasonography. when considering ocular features, presence of posterior synechiae, elevated intraocular pressure and keratic precipitates were associated with a significantly higher incidence of posterior segment pathology. ultrasonographic examination can provide information regarding the posterior segment pathology which helps in explaining accurate prognosis postoperatively though in some disorders such as branch and central retinal vein occlusion, macular hole, diabetic maculopathy, optic atrophy could not diagnosed preoperatively. thus, it is advisable that 138 patients undergoing cataract surgery should be warned of these limitations of ultrasonography. in conclusion preoperative posterior segment evaluation with ultrasound in patients with dense cataract can be used to detect pathologies that may influence the surgical strategy and the postoperative visual prognosis, author’s affiliation dr. faheem ullah shaikh senior registrar department of ophthalmology liaquat university eye hospital hyderabad. dr. ashok kumar narsani assistant professor department of ophthalmology liaquat university eye hospital hyderabad prof. shafi muhammad jatoi chairman & head department of ophthalmology liaquat university eye hospital hyderabad prof. ziauddin a. shaikh chairman & head department of ophthalmology duhs & civil hospital karachi reference 1. hagan jc, wyatt b. preoperative evaluation and workup of the cataract and intraocular lens implant patient. j ophthalmol nurs technol. 1993; 2: 123-8. 2. ukponmwan cu, marchien tt. ultrasonic diagnosis of orbito-ocular diseases in benin city, nigeria. niger postgrad med j. 2001; 8: 123-6. 3. khan aj. malignant melanoma. pak j ophthalmol. 1985;1: 3-5. 4. hayashi h, igarashi c, hayashi k. frequency of cilliary body or retinal breaks and retinal detachment in eyes with atopic cataract. br j ophthalmol. 2002; 86: 898-901. 5. blaivas m, theodore d, sierzenski pr. a study of bedside ocular ultrasonography in the emergency department. acad emerg med. 2002; 9: 791-9. 6. coleman dj, silverman rh, rondeau mj, et. al. correlation’s of acoustic tissue typing of malignant melanoma and histopathologic features as a predictor of death. am j ophthalmol. 1990; 110: 380-8. 7. green rl, byrne sf. diagnostic ophthalmic ultrasound in retina: vol i: ryan sj ed. toronto: the cv mosby company. 1998; 1: 191-273. 8. gentile rc, berninstein dm, leibmann j, et al. high resolution ultrasound biomicroscopy of the pars plana and peripheral retina. ophthalmology. 1998; 105: 478-84. 9. snell rs, lemp ma. clinical anatomy of eye. boston: balck well scientific publications, 1989:1 10. grayson m. diseases of the cornea. st louis: mosby, 1983. 11. lofstrom jb, bengtsson m. a practice of anaesthesia. physiology of nerve conduction and local anaesthesia drugs. 6th ed. london: wylie and churchill davidson’s. 1995; 172-88. 12. hogan m, alvarado j, weddell j. histology of the human eye. philadelphia: wb saunders, 1971. 13. yoneya s, tso mom. angio-architecture of the human choroid. arch ophthalmol. 1987; 105: 681. 14. perry hd, hatfield rv, tso mom. flourescein pattern of the choriocapillaries in the neonatal rhesus monkey. am j ophthalmol. 1977; 81: 197. 15. khalil ak. ultrastructural changes on the posterior iris surface. arch ophthalmol. 1996; 75: 407. 16. davson h. the bowman lecture, the little brain. trans ophthalmol soc uk. 1979; 99: 21. 17. hamilton rc. techniques of orbital regional anaesthesia. br. j. anaesthesia. 1995; 75: 88-93. 18. eisner g. biomicroscopy of the peripheral retina. new york: springer publishing co, 1973. 19. apple dj. anatomy and histopathology of the macular region. intl ophthalmol clin. 1981; 21:1. 20. gissen aj, cavino bg, gregus j. differential sensitivity of mammalian nerve fibers to local anaesthetic agents. anesthesiology. 1980; 467-74. 21. wise gn, dollery ct, hankind p. the retinal circulation. new york: harper & row publishers, 1971. 22. bellhorn rw. control of blood vessel development. trans ophthalmol soc uk. 1980; 100: 328. 23. rafferty ns. the ocular lens: structure, function and pathology. new york: marcel decker. 1985; 1-60. 24. kanski jj. clinical ophthalmology: a systematic approach. 5th ed. oxford: butterworth heinmann. 2003: 143. 25. amjad s, parmar p, vanila cg, et al. is ultrasound essential befote surgery in eyes with advanced cataracts?. journal postgraduate med. 2006; 52: 19-22. 26. american academy of ophthalmology: lens and cataract. san francisco 2000. 27. anteby ii, blumenthol ez, zamir e, et al. the role of preoperative ultrasonography for patients with dense cataract: a retrospective study of 509 cases. ophthalmic surg lasers. 1998; 29: 114-8. 28. haile m, mengistu z. b scan ultrasonography in ophthalmic disease. east afr med j. 1996; 73: 703-7. 29. bello to, adeoti co. ultrasonic assessment in preoperative cataract patients. niger postgrad med j. 2006; 13: 326-8. 30. ali si, rehman h. role of b-scan in preoperative detection of posterior segment pathologies in cataract patients. pak j ophthalmol. 1997; 13: 108-12. microsoft word p.s mahar 112 original article glaucoma burden in a public sector hospital p.s mahar, m aamir shahzad pak j ophthalmol 2008, vol. 24 no. 3 . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: p s. mahar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi received for publication august’ 2007 ………………………… purpose: to determine the demographic pattern and type of glaucoma presenting to our hospital and the modalities of medical and operative treatment performed materials and methods: case records of all patients registered at glaucoma clinic from 1st may 2002 to 30th april 2003 were reviewed. data was collected on a form and entered in spss. multiple variables were collected and analyzed. results: a total of 80,767 patients were seen in the hospital with different eye problems. the number of patients referred to the glaucoma division was analyzed and 447 patients were confirmed with the diagnosis of glaucoma (0.55%). their demography showed 287 (64.2%) patients were male and 160(35.8%) were female. age distribution showed 383 (85.7%) patients were 40 years or older. primary glaucoma was seen in 345 (77.2%) patients, out of which 186 (41.6%) had primary open angle glaucoma (poag) and 137 (30.67%) had chronic angle closure glaucoma (cacg). secondary glaucomas were seen in 102 (22.8%) patients. conclusion: primary open angle glaucoma was still the most prevalent type of glaucoma seen in our clinic but chronic angle closure glaucoma also involved a significant number of patients. most patients presented very late when their central vision was compromised or their glaucoma was detected at an early stage due to eye examination carried out due to some other ocular complaint. intensive medical and surgical treatment was shown to control the disease in most of the patients. 113 he glaucoma constitutes a group of disorders with diverse pathogenesis associated with an elevated intraocular pressure in majority of the cases with characteristics pattern of optic neuropathy and loss of visual field. it is one of the leading causes of blindness worldwide. although the number of people affected by the glaucoma varies in different countries, it is estimated that approximately 66.8 million people are affected worldwide, out of which 6.6 million are blind1. in western world the most prevalent form is primary open angle glaucoma (poag). in usa it is estimated that 2.47 million people are affected by poag, 130,450 of whom have become bilaterally blind2. the disease prevalence and morbidity may differ according to the race is well established. there are many studies suggesting that black american are more likely to become blind as a result of poag than their white counterparts3,4. since mongolian study conducted by foster et al5, it is estimated that chronic angle closure glaucoma (cacg) is as common as poag in south east asian population, with prevalence of cacg being calculated at 0.8%. the survey conducted by baasanhu and coworkers6 also showed that glaucoma was responsible for 35% of blindness in mongolia. a recent survey in pakistan about the causes of blindness was carried out by pakistan institute of community ophthalmology peshawar, in collaboration with international centre for eye health, london school of hygiene and tropical medicine7. in their preliminary report released in june 2005, they have cited glaucoma as the third major cause of blindness (7%) in people age 30 years and above without deliberating upon the type of glaucoma. unfortunately no epidemiological study has been done in this country to find the exact type of glaucoma most prevalent in our society. but going by published studies from singapore8, thailand9, and india10, prevalence of cacg should be as higher as that of poag in this part of the world. there are certain special features attributed to the cacg in asian population. the women were more often affected than men. a great number of patients with cacg were bilaterally or unilaterally blind compared with those patients having poag. cacg was also found more aggressive and visually destructive disease6,8. the objectives of our study were to determine the number of patients seen in the tertiary care glaucoma clinic, to differentiate the glaucoma patients into various subtypes of the disease, to evaluate the visual status of these patients at their initial presentation, to find the different modalities of treatment to control the disease process, and also to determine that how much glaucoma subjects constitute the total number of patients seen during that particular period in the entire eye hospital. material and methods this retrospective study was carried out at isra postgraduate institute of ophthalmology, al – ibrahim eye hospital, malir, karachi. case records of patients registered at glaucoma clinic for the time period 1st may 2002 to 30th aril 2003 were reviewed. all patient’s records had their best corrected visual acuity (bcva) charted in both eyes with biomicroscopic findings of anterior segment, goldman applanation tonometry readings and gonioscopic findings. majority of the patients had optic disc drawings present in their notes with some of the patients having optic disc photographs. at that particular time hospital did not have humphrey’s perimeter available so some of the fields were done on topcon perimeter with unsatisfactory results. a total number of 447 patients were diagnosed with glaucoma and seen in the clinic during the defined period. all the data was collected on a proforma and entered in spss 10.0. multiple variables were collected and analyzed. results during the study period a total of 80,767 patients were seen in the hospital with different eye problems. the number of patients referred to the glaucoma division was analyzed and 447 patients were confirmed with the diagnosis of glaucoma (0.55%). patient’s age ranged from 1 year to 90 years with the average age at 54.91 years and median age at 56 years. 383 patients (85.7%) were 40 years or above. distribution of various age groups is shown in (fig. 1). gender distribution showed male predominance with 287 (64.2%) male patients and 160 (35.8%) female patients (fig. 2). t 114 patient general health status revealed 29 patients with history of diabetes mellitus, 36 patients having raised blood pressure and 3 patients suffering with ischemic heart disease. primary glaucoma was the commonest type seen in 345 patients (77.2%). poag was diagnosed in 186 patients (41.6%) while cacg was seen in 137 patients (30.7%). 16 patients (3.6%) presented with acute attack of pacg and 6 patients (1.3%) had congenital glaucoma (fig. 3). secondary glaucomas were seen in 102 patients (22.8%) with secondary open angle glaucoma due to pseudo exfoliation syndrome present in 42 patients (9.4%), neovascular glaucoma was present in 19 patients (4.3%) and phacomorphic glaucoma was seen in 16 patients (3.6%). phacolytic glaucoma, steroid induced glaucoma, pseudophakic and aphakic glaucoma, all were seen in 5 patients (1.1%) each, with malignant glaucoma presenting in 4 patients (0.9%) and angle recession glaucoma diagnosed in one patient (0.2%) (fig: 4). both eyes were involved in 319 patients (71.4%) while 128 patients (28.6%) had only one eye affected. patients visual status at presentation showed, 202 patients (45.2%) had best corrected visual acuity (bcva) between range of 6/6 to 6/18 on snellen’s chart, 154 (34.5%) had vision of <6/18 to 6/60, 9 patients (2%) had vision of <6/60 to 3/60, 76 patients (17%) had < 3/60 vision and 6 patients (1.3%) visual status was not available (fig. 5). intra ocular pressure (iop) at presentation was between 10–20 mmhg in 78 patients (17.5%), between 21–30 mmhg in 142 patients (31.8%), between 31 to 40 mmhg in 122 patients (27.3%) and >40mmhg in 105 patients (23.5%) (fig. 6). group of patients showing iop range of 10 – 20 mmhg were already using various pressure lowering drugs with good control and were referred to us for further management. rest of glaucoma diagnosed cases, though some of them were using anti glaucoma medication were still not properly controlled. in anterior segment findings, 176 patients (39.4%) had clear media with no lens changes. 34 patients (7.6%) were pseudophakic, 5 patients (1.1%) were aphakic. of remaining 232 patients (51.9%), 163 patients (70.3%) had early lens changes of cortical or nuclear type, while 69 patients (29.7%) had more than +1 cortical or nuclear lens opacities. no other ocular pathology was recorded in these patients accounting for decreased vision. fundus records of patients revealed that 46 patients (10.3%) had cup disc ratio (cdr) of 0.3, 92 patients (20.6%) had cdr of 0.4-0.6 and 271 patients (60.6%) had cdr > 0.7. in 38 patients (8.5%) cdr was not recorded due to some media opacity. regarding management of glaucoma subjects, 222 patients (49.7%) were successfully managed with various iop lowering drugs, the topical beta blocker being the commonest drug used. 158 patients (35.4%) were exposed to surgery with 132 patients (29.5%) having trabeculectomy and 22 patients (4.9%) having combined trabeculectomy with cataract extraction and intra ocular lens implant. 4 patients (0.9%) required cyclo-destructive procedure. 67 patients (15%) had various types of laser procedures with 55 patients (12.3%) had laser peripheral iridectomy (lpi), 7 patients (1.6%) received laser peripheral iridoplasty (lpir), 3 patients (0.7%) had argon laser trabeculoplasty (alt) and 2 patients received (0.5%) pan retinal photocoagulation (prp) (fig. 7). discussion according to the national survey on blindness and visual impairment conducted by pakistan institute of community ophthalmology (pico) peshawar pakistan, the overall prevalence of blindness in pakistan is estimated at 1.05% to 1.09 % affecting 1.49 million to 1.54 million people7. glaucoma is the 3rd major cause, accounting for 7% of all projected blindness in the country7. unfortunately no epidemiological study has been carried out to establish the commonest type of glaucoma prevalent in the country. there are some hospital studies performed to identify the types of glaucoma. rizvi11 looked at 103 subjects with primary type of glaucoma attending a local hospital in one year period. he found cacg involving 57 patients (55.3%) compared to poag in 46 patients (44.7%), concluding that cacg was more common than poag. babar et al12 in a two years study found that, glaucoma accounted for 5.2% of all admissions in their hospital. in their study the numbers of male patients were more than females. the mean age at the time of presentation was 40 years. the most common type of glaucoma was of primary type (63.9%) with cacg constituting 28.9% and poag involving 22.4% of patients. the number of patients with secondary glaucomas was 36.1%. they concluded that the primary glaucoma was the most common type 115 of glaucoma presenting in the hospital setup and closed angle type being more common then the open angle variety. in our series of 447 patients primary glaucoma was the commonest seen in our clinic with poag involving 41.6% patients while cacg presenting in 30.7% patients. a hospital based study like ours does not truly indicates the exact prevalence of type of glaucoma but surely it dose suggest that cacg is not uncommon in this part of the world. non of our patients were diagnosed with normotensive glaucoma (ntg). we found it very interesting as recent survey conducted in punjab by inayat et al14 revealed 70.6% of their glaucoma subjects diagnosed with ntg. however there are numerous flaws in that study as none of the patients diagnosed with ntg had any 24 hours iop phasing and no central corneal thickness (cct) measurements were taken and there was no mention of these patients using any systemic beta blockers. in the similar context akram at al15 reevaluated the previously diagnosed patients of ntg attending eye clinic between aug 2001 aug 2004. most of these patients were found either with intracranial vascular pathology or intracranial space occupying lesions. in another study by baig et al16 3 patients with diagnosis of ntg using anti glaucoma therapy for long time were reevaluated. one of these patients was found having pituitary tumor, 1 patient had aneurysm of anterior cerebral artery compressing 116 2 7 19 36 110 153 120 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 0 t o 1 0 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 ov er 60 fig. 1: age distribution. 287 (54.21%) 160 (35.79%) female male fig. 2: gender distribution. 16 (3.58%) 137 (30.65%) 186 (41.61%) 6 (1.34%) congenital glaucoma poag cacg pacg fig. 3: distribution of primary glaucoma. 42 (9.39%) 0 5 10 15 20 25 30 35 40 45 50 ne ov as cu lar g lau co ma ph ac oly tic g lau co ma st er oid in du ce d g lau co ma ps eu do ph ak ic gl au co ma an gle re ce ss ion fig. 4: secondary glaucoma distribution. 76 (17.00%) 9 (2.01%) 164 (35.45%) 202 (45.19%) 6 (1.34%) nag 6/6-6-18 <6/18-6/60 <6/60-3/60 <3/60 fig. 53: visual acuity at presentation. 78 (17.45%) 142 31.77%) 122 (27.29%) 105 (23.49%) 0 20 40 60 80 100 120 140 160 10 20 21 30 31 40 > 40 fig. 6: intra ocular pressure at presentation. age in years age distribution c as es iop (mmhg) 117 222 (49.66%) 158 (35.35%) 67 (14.9%) 0 50 100 150 200 250 medical management surgical management lasers fig. 7: glaucoma management on the left optic nerve and 3rd patient had infarction in his right temporal lobe region involving optic tract. although ntg is a definite clinical entity but it remains poorly diagnosed in our country and we think it is not common in down south in pakistan. there are certain important aspects in our study, 17% of all glaucoma patients were legally blind, at the time of presentation, 2% patients had severely impaired vision while 34.5% patients had moderately impaired vision according to who classification13. in reference to the severity of the disease 50.8% patients had iop of more then 30 mmhg while 60.6% patients had significant cupping with cup disc ratio of more then 0.7. regarding management, 50% of our patient’s required surgical intervention mostly having drainage procedure. it was our impression that most patients presented either very late when their central vision was compromised or detected at an early stage due to some other ocular complains. early detection in our patients was mostly due to excellent setup of our primary screening program in our eye hospital where every patient has their eye pressure and posterior segment thoroughly examined. our study has certain weaknesses. it is hospital based, retrospective in nature, therefore it dose not represent truly the type of glaucoma prevalent in our society. for this purpose a proper epidemiological survey is required as carried out in other communities5,6,8-10. we also found 46 patients (10.3%) with cdr of 0.3 who were treated because of raised iop and labeled as poag. we assume this group of patients was having ocular hypertension (oh) rather then poag. if we adjust this group of patients from poag then prevalence of poag stands at 31.3% showing no difference of prevalence with cacg at 30.7%. our impression is that cacg is almost as important as poag as cause of blindness in our country. in contrast to poag, cacg can be prevented by bilateral laser iridectomies in individuals with occludable angles, a simple one time intervention. this makes cost of preventing cacg much less then the chronic treatment of poag. we think that the only way to prevent glaucoma on larger scale in our population is to run proper screening programs in the various communities. certain measures that we can take in hospital setup are. • educate patients, as common perception is that decreased vision in the old age is always due to formation of cataract. • effectively check iop of every patient over 35 years of age irrespective of her/his eye problem with close observation of those with family history of glaucoma. • encourage people with family history of glaucoma to get their eyes examined on regular basis. • patients using steroids in different forms should be closely monitored for iop change and optic disc damage. • establish out-reach clinics especially in backward areas to remove cataracts before patients developing secondary glaucomas. conclusion in our study the number of confirmed glaucoma patients constituted 0.55% of the total number of patients with different eye problems attending in one year period. primary glaucoma was the commonest type with poag and cacg diagnosed in majority of the patients. 17% of all glaucoma patients were legally blind at the time of presentation while 36.5% had visual acuity of less than 6/18. 50% of patients presented with iop of more than 30 mmhg and 60% patients had severe disease with cup disc ratio of more than 0.7%. surgical intervention was required in almost half of the patients as medical therapy failed to control their disease. we advise that all suspected patients with increased iop or optic disc changes should be referred to the glaucoma units/ glaucoma specialists, as high index of suspicion with proper eye examination is the only tool against this preventable blinding eye disease. 118 author’s affiliation prof: p.s. mahar isra postgraduate institute of ophthalmology al – ibrahim eye hospital malir, karachi dr. m. aamir shahzad isra postgraduate institute of ophthalmology al – ibrahim eye hospital malir, karachi references 1. quigley ha. number of people with glaucoma world wide. br j ophthalmol. 1996; 80: 389–93. 2. quigley ha, vitale s. modes of open angle glaucoma prevalence and incidence in the united states. invest ophthalmol vis sci. 1997; 38: 83–91. 3. hiller r, kahn ha. blindness from glaucoma. am j ophthalmol. 1975; 80: 62-71. 4. grant wm, burke jf. why do some people go blind from glaucoma. ophthalmology 1982; 89: 991-8. 5. foster pj, baasanhu j, alsbirk ph, et al. glaucoma in mongolia, a population based survey in horsgol province, north mangolia. arch ophthalmol. 1996; 114: 1235-41. 6. baasanhu j, johnson gj, burendei g, et al. prevalence and causes of blindness and visual impairment in mongolia, a survey of population aged 40 years and older. bull world health org 1994; 72: 771-6. 7. pakistan national blindness and low vision survey, results of prevalence and causes of blindness. pakistan institute of community ophthalmology, peshawar, pakistan (unpublished data). 8. foster pj, et al. the prevalence of glaucoma in chinese residents of singapore, a cross sectional population survey of the tanjog pagar district. arch ophthalmol. 2000; 118: 1105-11. 9. bourne rr, et al. prevalence of glaucoma in thailand, a population based survey in ram klao district, bangkok. br j ophthalmol. 2003; 87: 1069–74. 10. ramakrishan r, et al. glaucoma in a rural population of southern india, the aravind comprehensive eye survey. ophthalmology. 2003; 110: 1484-90. 11. rizvi sa. primary chronic angle closure glaucoma in pakistan. pak j ophthalmol. 2001; 17: 32-6. 12. babar tf et al. a two year audit of glaucoma admitted patients in hayatabad medical complex, peshawar. pak j ophthalmol. 2003; 19: 32-40. 13. www.who.int, www.who.org 14. inayat n et al. medical management of normal tension glaucoma. pak j ophthalmol. 2005; 21: 70– 3. 15. akram a, et al. critical reevaluation of previously diagnosed normal tension glaucoma patients – a three year study. pak j ophthalmol. 2006; 22: 68-73. 16. baig ma, et al. normal tension glaucoma, errors in diagnosis. pak j ophthalmol. 2002; 18: 23–5. microsoft word index-8.doc original article posterior capsular opacification after pmma and hydrophobic acrylic intraocular lens implantation muhammad moin, kashif raza, anwar ul-haq ahmad pak j ophthalmol 2009, vol. 25 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …………………………… correspondence to: mohammad moin department of ophthalmology fatima jinnah medical college, lahore received for publication march’ 2009 …………………………… purpose: to compare the incidence of posterior capsular opacification after implantation of hydrophobic acrylic and polymethylmethacrylate (pmma) intraocular lenses (iols). material & methods: a retrospective chart review of all patients undergoing phacoemulsification with implantation of posterior chamber iol by a single surgeon from february 2000 to april 2007 was done in this study. the operated eyes of the patients were divided into 2 groups. group a eyes were implanted a pmma iol (lx10 bd, alcon) while group b eyes were implanted a hydrophobic acrylic (acrysof multi-piece, alcon) iol. a detailed analysis of the charts was done to identify all the patients in both groups who presented with decreased visual acuity due to posterior capsular opacification (pco) more than 2 years after cataract surgery. the charts of these patients were further screened to identify those patients who had visually significant pco (best corrected visual acuity of <6/9) requiring yag posterior capsulotomy. patients with any posterior capsule plaque or rupture per-op, iol implantation in the sulcus and significant macular disease were excluded from the study. results: a total of 358 eyes underwent phacoemulsification with iol implantation. there were 166 eyes in group a in which 5.5 mm pmma iols (lx10 bd, alcon) were implanted and 192 in group b eyes in which hydrophobic acrylic iols (acrysof, alcon) were implanted. in group a, 39.(23.4%) eyes with pmma iol had decreased vision due to pco out of which only 10 patients (6%) underwent yag posterior capsulotomy for significant visual loss. in group b, 12 (6.2%) eyes with hydrophobic acrylic iol had decreased vision due to pco out of which only 3 patients (1.5%) underwent yag posterior capsulotomy for significant visual loss. conclusion: hydrophobic acrylic iols have a lower rate of posterior capsular opacification compared to pmma iols. isually significant posterior capsular opacification (pco), remains the most common long-term complication of modern cataract surgery1-2. it results in decreased visual acuity, impaired contrast sensitivity, glare and monocular diplopia. posterior capsular opacification (pco) occurs in up to 50% of eyes following cataract extraction3 and its treatment with nd:yag capsulotomy is not without complications. pco also has important implications in the developing world,4 where it may increasingly become a significant cause of treatable blindness. clinically, components of pco can be different-tiated, namely a ‘regeneratory’ and a ‘fibrotic’ com-ponent. regeneratory pco occurs more frequently. it is caused by residual lens epithelial cells (lecs) from the lens v equator region that migrate and proliferate in the space between the posterior capsule and the iol. fibrotic pco is caused by transdifferentiated (lecs) from the anterior capsule that gain access to the posterior capsule and cause whitening and wrinkling of the capsule2. both components lead to a decrease in visual function when they affect the central region around the visual axis. treatment of pco by neodymium: yag (nd:yag) laser capsulotomy is effective but can lead to other complications, including an increase in intraocular pressure, ocular inflammation, cystoid macular edema, and retinal detachment. besides, nd:yag laser capsulotomy does not improve visualization of the peripheral retina and increases the cost of cataract treatment. therefore, a great deal of effort has gone into developing new ways to prevent the formation of pco. these efforts include modification in lens design, lens material, surgical technique and other approaches. we demonstrate in our study the effects of lens design and material on pco after uncomplicated cataract surgery. materials and methods a retrospective chart review of all patients undergoing phacoemulsification with implantation of posterior chamber iol by a single surgeon from february 2000 to april 2007 was done in this study. the operated eyes of the patients were divided into 2 groups. group a eyes were implanted a pmma iol (lx10 bd, alcon) while group b eyes were implanted a hydrophobic acrylic (acrysof multi-piece, alcon) iol. a detailed analysis of the charts was done to identify all the patients in both groups who presented with decreased visual acuity due to posterior capsular opacification (pco) more than 2 years after cataract surgery. the charts of these patients were further screened to identify those patients who had visually significant pco (best corrected visual acuity of <6/9) requiring yag posterior capsulotomy. patients with any posterior capsule plaque or rupture per-op, iol implantation in the sulcus and significant macular disease were excluded from the study. all surgeries were performed by a single surgeon using the same surgical procedure that has been described previously. firstly, a 2.75 mm straight scleral incision was made for iol implantation. after incision, a continuous curvilinear capsulorrhexis, measuring approximately 5.5 mm in diameter, was accomplished using a bent needle and utrata forceps. after hydrodissection, endocapsular phacoemulsification of the nucleus and aspiration of the residual cortex were carried out. using a steel keratome, the wound was enlarged to 3.5 mm for acrylic and 5.5 mm for pmma iol implantation. the lens capsule was inflated with methylcellulose, after which the iol was placed into the capsular bag. after insertion, the viscoelastic material was thoroughly evacuated. in this series, all surgeries were uneventful and the iols were accurately implanted in the capsular bag. the patients underwent a complete ocular examination pre-operatively followed by post operative visits at 1 day, 1 week, 6 weeks and 3 months. all patients were told to report back to the clinic if there was any visual loss post operatively. seventy five percent (n=358) patients were followed up for more than 2 years which included the patients presenting with decreased vision due to posterior capsular opacification. results three hundred and fifteen eyes of 358 eyes underwent uncomplicated phacoemulsification with iol implantation under local anesthetic. the average age was 61 years with a range of 20 to 80 years. the average age and range for group a (pmma lens) patients was 61 years (range 30 to 86 years) and for group b (acrylic lens) patients was 62 years (range 20 to 90 years). there were 211 females (114 in group a and 97 in group b) and 147 males (52 in group a and 95 in group b) included in the study. there were 166 eyes in group a in which 5.5 mm pmma iol (lx10 bd, alcon) was implanted and 192 in group b eyes in which hydrophobic acrylic iol (acrysof, alcon) was implanted. in group a, 39 (23.4%) eyes with pmma iol had decreased vision due to pco out of which only 10 patients (6%) underwent yag posterior capsulotomy for significant visual loss. in group b, 12 (6.2%) eyes with hydrophobic acrylic iol had decreased vision due to pco out of which only 3 patients (1.5%) underwent yag posterior capsulotomy for significant visual loss. pco developed in 51 patients out of which 39 patients were in group a (pmma lens) and 12 patients in group b (acrylic lens). in group a patients 35 eyes developed elschnig pearls and only 4 developed posterior capsular fibrosis. in group b patients 11 eyes developed elschnig pearls and one patient had posterior capsular fibrosis showing a much higher rate of elschnig pearls in both groups. discussion in view of the large amount of cataract surgery being performed, posterior capsular opacification has important medical, social, and economic implications, and consequently, there is considerable interest in its prevention. capsular opacification stems from the continued viability of lens epithelial cells (lecs) remaining after removal of the nucleus and cortex. it may result in adherence of the anterior capsule to posterior capsule creating a closed space consisting of nucleated bladder cells (wedl cells) resulting in soemmerring’s ring or migration of epithelial cells across the anterior or posterior capsule, that may cause capsular wrinkling and opacification. lecs are capable of undergoing metaplasia with conversion to myofibroblasts. a matrix of fibrous and basement membrane collagen can be produced by these cells, contraction of which will cause wrinkles in the posterior capsule with resultant distortion of vision and glare. all of these processes are influenced by cytokines (interleukins i and 6), growth factors (transforming growth factor β, fibroblast growth factor, epithelial growth factor), and extracellular matrix proteins5. with the recognition of the role of lecs in pco, a wide variety of techniques have also been directed at attempting to remove residual cells during surgery. these have included meticulous hydrodissection, complete cortical aspiration, polishing of the anterior and posterior capsules, ultrasound aspiration, cryocoagulation, and osmolysis6. the fact that none of these techniques has been utilized as a routine surgical procedure reflects the difficulty in totally removing all lecs. attempts to remove lecs may simply damage those left in situ, which may then become activated and proliferate. the importance of the iol as a factor affecting the incidence of pco is well recognised.7 as a result of the clinical failure of both lecs removal and pharmacological intervention to reduce pco, emphasis has shifted towards the iol as a practical solution. recently, attention has been focused on the type of iol material. acrylic lenses have been reported as having very low rates of pco when compared with polymethylmethacrylate (pmma) and silicone8. this reduced incidence of pco has been attributed to a lower incidence of epithelial cells on the posterior capsule and their subsequent regression9. recent work worldwide strongly suggests that lens implant design rather than lens material may be the more important factor in the prevention of pco. the contribution of lens design has been illustrated in the past by the varying rates of pco between silicone lenses of a plate or loop haptic design10. in addition lenses with a plano convex optic (plano posterior) appear to have a lower rate of pco than biconvex lenses11.11 it has been suggested that the lack of a mechanical or barrier effect of the iol, which prevents lec proliferation and central migration, explains the high incidence of regeneratory pco reported with iol designs that hold the posterior capsule away from the lens optic to facilitate nd:yag capsulotomy12. similar findings have led to the concept of "no space, no cells" as a model for the prevention of pco by the iol3. in fact, nishi (xvth congress of the european society of cataract and refractive surgeons (escrs) nice, france, september 1998) has shown that migrating lecs from the equator of the capsular bag are inhibited at a sharp discontinuous bend. proliferation of lecs cultured in a well with a rectangular bottom ceases when a confluent cell layer is attained, due to contact inhibition. in contrast, lecs in culture do not develop contact inhibition when they meet a continuous u-shaped wall and continue to grow and climb higher. subsequently, a pmma iol with sharp rectangular haptic edges was designed which produced a sharp discontinuous bend in the capsule. this was found, in an animal model, to have a lower incidence of pco compared with an iol with a round haptic13. the sharp optic edge creates higher pressures on the posterior capsule and acts as a mechanical barrier to lens epithelial cell migration, whereas the rounded optic edge does not concentrate pressure in this manner and permits easy migration of these cells. polyacrylic lenses have a more defined and squarer edge profile, and this may be important in the lower rates of pco seen with this lens. a recent systematic review based on cochrane methodology included 26 prospective randomized controlled trials with a follow-up of at least 12 months and showed that in 5 of 7 studies, visual acuity was better in sharp-edged iols than in round-edged iol. the pco score was significantly lower with sharpedged iols but did not differ significantly between 1piece and 3-piece open-loop iols14. the concept of contact inhibition provided by a discontinuous capsular bend also explains the significant reduction of pco observed in patients receiving a pmma lens implant with a sharp rectangular edged optic. in a retrospective study of 372 eyes, the incidence of pco at 2 years was studied by comparing a sharp edged convex plano (cp) lens and a sharp edged biconvex (bc) lens with round edged bc and cp lenses15. pco was graded after retroillumination photography and showed a significantly reduced incidence in the sharp edged lenses, irrespective of optic convexity. a silicone iol with a sharp optic edge has similarly shown a reduced rate of pco, as reported by buratto and schmack at the escrs congress in 1998. scanning electron microscopy has demonstrated that most intraocular lenses have a smooth round optic edge. in contrast, the acrysof iol has a sharp rectangular optic edge16. despite all advantages, sharp-edged iols can also cause problems. in some cases after implantation of lenses with sharp posterior and anterior optic edges, an increased incidence of persistent edge-glare phenomena has been reported. intraocular lenses with a rectangularedge cause the light rays that are refracted through the peripheral iol to be more intense on the peripheral retina. round-edged iols disperse the rays of light over a larger surface area of the retina, leading to decreased glare. several aspects of surgical technique may also be relevant in reducing the incidence of pco. for example, the widespread use of small incision phacoemulsification surgery has seen the adoption of continuous curvilinear capsulorhexis (ccc), cortical cleaving hydrodissection, and precise "in the bag" iol placement, all of which are recognised factors affecting the incidence of pco. the dimensions of the ccc are particularly important and it is clear that the rhexis should overlap the optic to reduce optic-capsule capture. this phenomenon, where the optic is out, or partially out, of the capsular bag, is associated with an increase in pco17. not allowing the anterior and posterior capsule to fuse around the lens edge appears to facilitate migration of lecs from the anterior capsule onto the posterior capsule, and behind the lens optic where fibrosis occurs18. the finding that different lens materials show differing degrees of adhesion to the lens capsule19, illustrates a further factor which alters the lens-capsule interaction and may affect pco rate. our study quantitatively demonstrates that the degree of pco in the eyes with a pmma iol is more extensive than that in the eyes with a hydrophobic acrylic iol. specifically, pco in the presence of a pmma iol increased from the early postoperative period, but the increase virtually reached a peak by12 months after surgery. furthermore, the nd:yag capsulotomy rate was also worse with the pmma iol than with the acrylic iol. at one month after surgery, the best corrected visual acuity was the same between eyes with the pmma and those with the acrylic iol. thereafter, however, visual acuity in eyes with the pmma iol worsened significantly with time, so that the visual acuity in eyes with a pmma iol was worse than that in eyes with an acrylic iol in the later postoperative period. thus, our results clearly show that pco in the presence of a pmma iol impairs visual acuity more so than does that in the presence of an acrylic iol. the clearer posterior capsules with polyacrylic lenses are reflected in the significantly lower pco rates for this group (6.2% compared to 23.4% for pmma). treatment of pco by neodymium: yag (nd:yag) laser capsulotomy is effective but can lead to other complications, including an increase in intraocular pressure, ocular inflammation, cystoid macular edema, and retinal detachment. besides, nd:yag laser capsulotomy does not improve visualization of the peripheral retina and increases the cost of cataract treatment. therefore, a great deal of effort has gone into developing new ways to prevent the formation of pco. these efforts include modifications in lens design, lens material, surgical technique, and other approaches. on slit lamp examination, the pattern of pco with the pmma iol is different from that with the other types of iol. it is known that capsular fibrosis due to proliferation of fibroblast-like lecs is predominant in the early postoperative period. with the pmma iol, flat spindle shaped lecs invade the retrolental space from the early period. because these cells are well demarcated and not accompanied by fibrosis, they are considered to be lens fiber cells that might have originated at the lens equator. in general, the fiber cells grow and subsequently develop into elschnig pearls. however, with the pmma iol, swelling of the lens fiber cells is not so marked as to form a thick layer even during two year follow up. thus, early invasion of a flat layer of lens fiber cells is characteristic of pco after pmma iol implantation. as the proliferation pattern of lecs may not be influenced by the iol design, this distinct pattern of pco may be caused by the pmma optic material. hollick et20 al studied the visual outcome, neodymium:yag (nd:yag) capsulotomy rates, and percentage of posterior capsular opacification (pco) seen with polymethylmethacrylate (pmma), silicone, and polyacrylic intraocular lens implants 3 years after extracapsular cataract surgery with capsulorhexis. ninety eyes of 81 patients were examined at a british teaching hospital. they found that intraocular lenses made from polyacrylic are associated with a significantly reduced degree of pco and lower yag rates. there was a significant difference in percentage pco at 3 years among the lens types (p 5 0.0001). polyacrylic lenses were associated with less pco (10%) than silicone (40%) and pmma lenses (56%). the yag capsulotomy rate was 0% for polyacrylic, 14% for silicone, and 26% for pmma (p 5 0.05). hayashi et al21 found that the degree of posterior capsular opacification was significantly less in the hydrophobic acrylic iol (acrysof, ma60bm, alcon surgical, fort worth, tx, usa) compared to a hydrogel iol (hydroview, h60m). of the 100 eyes in each group, two (2%) in the acrylic group and 28 (28%) in the hydrogel group required nd:yag capsulotomy within 24 months after surgery. vock et22 al showed that the incidence of nd:yag capsulotomy in patients with 3 piece hydrophobic acrylic iol with sharp optic edges over 10 years was 42% (n=99) compared to 18% (n=44) in 3 piece silicone iol with round optic edges. ten years after surgery, acrylic iols seemed to lose their pco preventive effect, despite their sharp optic edges. in conclusion, the extent of pco after pmma iol implantation is substantially greater than that after hydrophobic acrylic iol implantation. the rate of nd:yag capsulotomy was also higher with the pmma iol than with the acrylic iol, reflecting the fact that deterioration of visual acuity due to pco was more pronounced in eyes with a pmma iol. the results of previous and current studies suggest that pmma material may allow active proliferation of lecs, possibly because of its hydrophilicity, and therefore may not be appropriate for use as an optic material. by reviewing past literature it is clear that pco rate is significantly higher with pmma iol than the acrylic iol, as is clearly shown by the following table. author’s affiliation dr. muhammad moin associate professor department of ophthalmology fatima jinnah medical college lahore dr. kashif raza department of ophthalmology fatima jinnah medical college lahore dr. anwar ul-haq ahmad department of ophthalmology fatima jinnah medical college lahore reference 1. schaumberg da, dana mr, christen wg, et al. a systematic overview of the incidence of posterior capsule opacification. ophthalmology 1998; 105: 1213-21. 2. kappelhof jp, vrensen gfjm. the pathology of after-cataract; a mini review. acta ophthalmol suppl. 1992; 205: 13–24. 3. apple dj, solomon kd, tetz mr. posterior capsule opacification. surv ophthalmol. 1992; 37: 73-116. 4. gillies m, brian g, la nauze j, et al. modern surgery for global cataract blindness: preliminary considerations. arch ophthalmol. 1998; 116: 90-92. 5. awasthi n, guo s, wagner bj. posterior capsular opacification: a problem reduced but not yet eradicated. arch ophthalmol. 2009; 127: 555-62. 6. nishi o. update/review: posterior capsule opacification. j cataract refract surg. 1999; 25: 106-17. 7. nishi o. incidence of posterior capsule opacification in eyes with and without posterior chamber intraocular lenses. j cataract refract surg. 1986; 12: 519-22. 8. ursell pg, spalton dj, pande mv, et al. relationship between intraocular lens biomaterials and posterior capsule opacification. j cataract refract surg. 1998; 24: 352-360. 9. hollick ej, spalton dj, ursell pg, et al. lens epithelial cell regression on the posterior capsule with different intraocular lens materials. br j ophthalmol. 1998; 82: 1182-8. 10. cumming js. postoperative complications and uncorrected acuities after implantation of plate haptic silicone and three piece silicone iols. j cataract refract surg. 1993; 19: 263-75. 11. yamada k, nagamoto t, yozawa h, et al. effect of intraocular lens design on posterior capsule opacification after continuous curvilinear capsulorhexis. j cataract refract surg. 1995; 21: 697700. 12. born cp, ryan dk. effect of intraocular lens optic design on posterior capsular opacification. j cataract refract surg. 1990; 16:188-92. 13. nishi o, nishi k, mano c, et al. the inhibition of lens epithelial cell migration by a discontinuous capsule bend created by a band shaped circular loop or a capsular bending ring. ophthalmic surg lasers. 1998; 29: 119-25. 14. buehl w, findl o. effect of intraocular lens design on posterior capsule opacification. j cataract refract surg. 2008; 34: 1976-85. 15. nagata t, watanabe i. optic sharp edge or convexity: comparison of effects on posterior capsule opacification. jpn j ophthalmol. 1996; 40: 397-403. 16. kohnen t, magdowski g, koch dd. surface analysis of acrylic and hydrogel iols. j cataract refract surg. 1996; 22: 1342-50. 17. hayashi k, hayashi h, fuminori n, et al. capsular capture of silicone intraocular lenses. j cataract refract surg. 1996; 22: 1267-71. 18. ravalico g, tognetto d, palomba ma, et al. capsulorhexis size and posterior capsule opacification. j cataract refract surg. 1996; 22: 98-103. 19. oshika t, nagata t, ishii y. adhesion of lens capsule to intraocular lenses of polymethymethacrylate, silicone, and acrylic foldable materials: an experimental study. br j ophthalmol. 1998; 82: 549-53. 20. hollick ej, ba, spalton dj, ursell, pande mv, et al. the effect of polymethylmethacrylate, silicone, and polyacrylic intraocular lenses on posterior capsular opacification 3 years after cataract surgery. ophthalmology. 1999; 106: 49–55. 21. hayashi k, hayashi h. posterior capsule opacification after implantation of a hydrogel intraocular lens. br j ophthalmol. 2004; 88: 182–5. 22. vock l, menapace r, stifter e, et al. posterior capsule opacification and neodymium:yag laser capsulotomy rates with a round-edged silicone and a sharp-edged hydrophobic acrylic intraocular lens 10 years after surgery. j cataract refract surg. 2009; 35: 459-65. microsoft word najia rahim 93 original article bacterial contamination among soft contact lens wearer najia rahim, husan bano, baqir s.naqvi pak j ophthalmol 2008, vol. 24 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: najia rahim lecturer dow college of pharmacy dow university of health sciences karachi received for publication november’ 2007 …..……………………….. purpose: to study the potential risks of acquiring microbial keratitis among soft contact lens wearer. methods and material: this prospective study was conducted from feb. 2005 to jan. 2006. samples were taken from contact lenses, contact lens storage cases and conjunctiva using sterile cotton swabs moistened with normal saline solution under aseptic condition. each swab obtained was inoculated into separate tubes with brain heart infusion (bhi) broth. inocula in bhi broth were incubated at 37°c for 24 hours. obtaining an inoculum from the incubated bhi broth and gently streaking it on blood agar, macconkey’s agar, cetrimide agar, vogel-johnson’s agar and nutrient agar did bacterial isolation. bacterial culture obtained was identified using gram’s staining, performing biochemical testing and on the basis of culture diagnosis by growing on selective media. results: during the present study, out of hundred contact lens wearer, 65%, 89% and 32% had their contaminated contact lenses, lens storage cases and conjunctiva, respectively. over all staphylococcus epidermidis was found to be the most frequent contaminant (39.8%) and pseudomonas aeruginosa was found to be next dominant organisms (34.9). conclusions: the major factor, which contributes to the infections among the contact lens wearer, is the contamination in their contact lens care system. pseudomonas infection is the most prevalent among contact lens wearer contact lens care system. icrobial keratitis is the most serious complication associated with soft contact lens usage1. it involves the entry and subsequent invasion of the corneal layers by the offending pathogens, which include structural as well as enzymatic components in which are responsible for the attachment of different bacteria to the cornea. as a result of increase stress imposed by the contact lenses on the cornea, the later is less able to defend itself against invading bacteria. thus, the bacterium effectively manages to overcome the eye’s weakened defenses, precipitating a fulminant infection2. p aeruginosa is the most frequent bacterial contaminant of contact lens care system, next are s epidermidis, staphylococcus aureus, coagulase negative staph3, fungi, protozoa (acanthamoeba) and viruses may also cause similar infection. a major factor that may be responsible for the development of keratitis among contact lens users is the microbial contamination of their lens care system. m 94 the lens care system includes the ophthalmic solution, lens cases and lenses used by the contact lens wearer. furthermore, several reported cases of such ocular infections have been implicated to be due to lens care system contamination. this may be attributed to improper cleaning of the contact lenses as well as the presences of contamination in the other items of lens care system. contamination of the lens cases or lens care solutions would most likely contaminate the contact lenses4. the present study is aimed at determining the potential risk of acquiring microbial keratitis among soft-contact-lens wearer in university student population by screening their contact lenses, storage cases and swabs from their conjunctival epithelium for the presence of bacteria. material and method the sample population was the faculty of pharmacy, university of karachi, undergraduate students wearing soft contact lenses. the reason for such choice was the accessibility of the subjects. only students using soft contact lens were considered subject volunteers, who had established a routine pattern of lens care. the participants were required to complete a questionnaire, which consisted of systematic question regarding type of lens, age, sex, wearing schedule as well as disinfection schedule. the study was prospective study and the study period was 12 months from feb 05 to jan 06. for sampling, the contact lenses were swabbed with sterile cotton swabs moistened with sterile normal saline solution. to take sample from eyes, sterile cotton swab was moistened with sterile normal saline solution and conjunctival epithelium was swabbed with it. each swab obtained was inoculated into separate tubes with brain heart infusion (bhi) broth. inocula in bhi broth were incubated at 37°c for 24 hours. obtaining an inoculum from the incubated bhi broth and gently streaking it on blood agar, macconkey’s agar, cetrimide agar, vogel-johnson’s agar and nutrient agar did bacterial isolation. plates were then incubated at 37°c. cultures were considered negative if no growth was detected within 48 hours of incubation. bacterial culture obtained was identified using gram’s staining, on the basis of culture diagnosis by growing on selective media and performing biochemical test including catalase, coagulase, and oxidase. the percentage contamination for each item of the lens care system and conjunctiva, and the frequency of occurrence of each bacterium were calculated after pooling all data. z-test (hypothesis testing between proportions) was employed to determine significant difference between calculated proportions. results out of hundred contact lens wearers, 65%, 89% and 32% had contaminated contact lenses, lens storage cases and conjunctiva, respectively. s. epidermidis 44.6%, p. aeruginosa 35.4%, s. aureus 12.3% and bacillus species. 7.7% were isolated from contact lenses. p. aeruginosa 41.6%, s. epidermidis 28%, escherichia coli 12.4%, bacillus species 10% and s. aureus 5.6% were isolated from contact lens storage cases. s. epidermidis 40.6%, p. aeruginosa 31.2%, s. aureus 9.4% and bacillus species 6.3% were isolated from conjunctival swabs from contact lens wearer. discussion in third world countries, lack of basic amenities provides a breading ground for geometrical progression of multifarious organisms in water, air and soil. normal conjunctival flora is either exogenous or endogenous in origin, which can be contracted from environment, physical contact or unhygienic habits of people. one of the physical contact is the use of contact lenses and also the unhygienic maintenance of the lenses. during this study a randomized sample of 100 normal looking eyes using contact lenses were subjected to bacteriological study, in order to investigate the possible contaminants of soft contact lenses, to identify pathogenic as well as nonpathogenic microorganisms, (table 1-4). it has been observed that 89% and 65% subjects had contaminated contact lens storage cases and contact lenses, respectively. the presence of contamination places the study group subjects at risk, since contamination of the lens care system as a major factor in the occurrence of eye infections among soft contact lens wearer. the high percent are contamination of lenses of the subjects can be attributed to the contamination in other items of the lens care system. during the present study, it was observed that 89% contact lens cases were contaminated. these result are significantly higher (p<0.05) then reported in 1996 i.e. 57.1%3. such results may be due to the improper and infrequent cleaning of the lens cases. most of the wearer of the study group 95 claimed that they cleaned their lens cases once a week. some wearers rinsed their lens case only with tap water, not with disinfectant lens care solution. the use of tap water and lack of air-drying of lens cases contaminate not only the cases but also the lenses, which are stored in them. thus, it has been suggested that lens cases must be washed with soap and clean water, disinfected with disinfectant solution, wiped with clean tissue paper and then air-dry keeping away from dust. table 1: percentage contamination in different items of contact lens care system & conjunctiva items tested no contaminated n (%) contact lens cases 100 89 (89) contact lenses daily wear extended wear 100 58 42 65 (65) 32/58 (55.2) 33/42 (78.6) conjunctival swabs 100 32 (32) table 2: organisms isolated from contact lens storage cases (total 89) organisms frequency n (%) p. aeruginosa 37 (41.6) s. epidermidis 25 (28.1) e. coli 11 (12.4) bacillus species 9 (10) s. aureus 5 (5.6) table 3: organisms isolated from contact lens (total 65) organisms frequency n (%) s. epidermidis 29 (44.6) p. aeruginosa 23 (35.4) s. aureus 8 (12.3) bacillus species 5 (7.7) table 4: organisms isolated from conjunctiva (total 32) organisms frequency n (%) s. epidermidis 13 (40.6) p. aeruginosa 10 (31.2) s. aureus 3 (9.4) bacillus species 2 (6.3) among the 65 contaminated lenses, more than half were extended wear, while the rest were daily wear. the significantly higher (p<0.05) incidence of contamination of extended wear over daily wear may be due to their higher water content which are likely to pick up debris, including microorganisms which have the potential to cause eye infections5. in addition size contamination of lenses, the chronic hypoxic stress due to prolonged contact between the lens and the eye of the wearer can compromise the epithelial barrier against the infections. such condition serves as an invitation to the potential pathogenic microorganisms6,7. before this study, it was reported that p. aeruginosa was the most common contaminant of contact lenses. but as asymptomatic subjects were analyzed during present study s epidermidis was found to be the most frequent contaminant (39.8%), which is also the most common microorganisms in the normal conjunctival flora8 i.e. 58%. nevertheless, conditions may occur during lens wear such as microscopic trauma in the corneal epithelium, reduction in tear volume as well as reduction of aerobic normal epithelial metabolism, may cause the bacterium to become opportunistic and cause infection9. p. aeruginosa was found to be next dominant organisms. it is a gram–ve rod that is considered as transient microorganisms in the normal healthy eyes. the transient flora is contracted from the environment and inhibits the conjunctiva for hours, days or weeks. member of transient flora are considered to be of little significance as long as the normal epithelial surface remain intact. it has been implicated in several lens wear complications including keratitis and corneal ulcers. the results of the present study are reflective of the observation that p. aeruginosa and s. epidermidis are the dominant bacteria that cause ocular infections among contact lens wearer. these finding are in confirmation with the earlier reports10. 96 s. aureus was isolated from 5.6% of contact lens storage case, 12.3% of contact lenses and 9.4% of conjunctiva. it was reported that 11.8% s. aureus was found in contact lens care systems of asymptomatic subjects3. bacillus species was isolated from 10.1% of storage cases, 7.7% of contact lenses and 6.3% of conjunctiva. few cases of bacillus keratitis among contact lens wearer were reported earlier11,12. as, bacillus spores survived multiple lens disinfection treatments. above results suggest that contact lens chemical disinfection systems should be capable of killing bacillus species. otherwise, these organisms remain a threat for contact lens wearer. other than, p. aeruginosa & staphylococcus species, e. coli were also frequently found in contact lens storage case, 12.4%. it may be due to lack of personal hygiene and contaminated home water supply13. conclusion contact lens wearers are at risk of acquiring microbial keratitis. extended wear contact lenses are frequently contaminated because of their high water content. contact lens practitioners should educate contact lens wearer on the risk of sight-threatening microbial keratitis, the need for patient compliance, and prompt assessment of contact lens-related complaints. author’s affiliation najia rahim lecturer dow college of pharmacy dow university of health sciences, karachi husan bano pharmaceutical sciences federal urdu university, karachi dr baqir s.naqvi department of pharmaceutics faculty of pharmacy university of karachi reference 1. venkata n, sharma s, gora r, et al. clinical presentation of microbial keratitis with daily-wear frequent replacement hydrogel lenses, a case series. clao j. 2002; 28: 165-8. 2. ewbank a. in search of solution in the magic kingdom. optician 1995; 210: 36-7. 3. lee ac, cabrera ec. microbial contamination of the lens care system. acta manilana. 1996; 44: 23-30. 4. huang e, lam d, fan d, et al. microbial keratitis in hong kong. trans r soc trop med hyg. 2001; 95: 361–7. 5. fowler sa, greiner jy, allansmith mr. attachment of bacteria to soft contact lenses. arch ophthalmol. 1979; 97: 4. 6. manthew td, frazer dj, minassian dc, et al. risks of keratitis and patterns of use with disposable contact lenses. arch ophthalmol. 1992; 110: 1559–62. 7. rushswurm id, scholz u, hanselmayer g, et al. contact lens induced keratitis associated with contact lens wear. acta ophthalmol. 2001; 79: 479-83. 8. starr rm, lally mj. antimicrobial prophylaxis for ophthalmic surgery. survey of ophthalmology. 1995; 39: 485-501. 9. mondino bj, weissman ba, frab md, et al. corneal ulcers associated with daily wear & extended wear contact lenses. am j ophthalmol. 1986; 102: 58. 10. kanpolat a. contamination in contact lens care system. clao j. 1992; 18: 105-7. 11. doniz bp, mondino bj, weissman ba. bacillus keratitis associated with contaminated contact lens care system. am j ophthalmol. 1988; 15: 195-7. 12. pinna a, sechi la, zanetti s, et al. bacillus cereus keratitis associated with contact lens wear. ophthalmology. 2001; 108: 1830–4. 13. larkin df, kilvington s, easty dl. contamination of contact lens storage cases by acanthamoeba and bacteria. br j ophthamol. 1990; 74:133–5. pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 169 original article prevalence of astigmatism in school going children rida ijaz, hijab ijaz, naeem rustam pak j ophthalmol 2017, vol. 33, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: rida ijaz department of ophthalmology, email:rida_2693@hotmail.com …..……………………….. purpose: to assess the prevalence of astigmatism, and most common type of astigmatism among school going children. study design: cross sectional observational study. place and duration of study: city district govt. girls high school, shadman and “department of ophthalmology” fmh college of medicine & dentistry, shadman lahore from september 2014to february 2015. materials and methods: after taking consent data was collected through a selfdesign performa at city district govt. girls high school, shadman lahore from 550 students. each eye was considered as a separate individual data. total 1098 eyes were taken for the study, age ranges 5 – 16 years. first visual acuity was measured monocularly by using snellen’s visual acuity chart. in case of substandard vision, pinhole test was done to assess the maximum improvement after correction. amount and type of astigmatism was assessed by using cycloplegic refraction. eyes with amblyopia, strabismus or other ocular pathologies were excluded. result: we examined 1098 eyes of the 550 students, with mean age of 10.31 ± 3.276 years including 255 (46.4%) male students and 295 (53.6%) female students. astigmatism was seen in 818 eyes (74.5%), out of which 0.5 – 1.00 diopter cylinder was the most common and was present in 454 eyes (41.3%), with the rule astigmatism was seen in 605 eyes (55.1%) and 355 (32.3%) had compound myopic astigmatism. conclusion: with the rule astigmatism and compound myopic astigmatism are more common among males and females and maximum in the age group of 14 – 16 years of age. key words: amblyopia, astigmatism, children, refractive error. stigmatism is refractive error in which the parallel rays of light coming from 6 meters entering the eye through the refractive medium do not focus on a single sharp point on the retina1. in astigmatism light rays do not refract equally in all meridians and do not focus equally in all meridians. due to unequal focusing, light comes to focus along a line instead of a point (astigma= no point) 2. corneal dioptric power is 40-45 d and lenticular power is little less than 20 d3. the average diameter of the cornea is 11 – 12mm (horizontal = 12mm, vertical = 11mm)4. cornea is more curved vertically due to pressure of the lids. increased curvature results in physiological myopic astigmatism of 0.5d in horizontal axis5. astigmatism changes relatively little during much of the life span tending to change towards against the rule astigmatism in the later years6. astigmatism is diagnosed by retinoscopy, which is objective method to assess refractive status of the eye7. a rida ijaz, et al 170 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology severe degree of astigmatism can be caused by diseases of cornea e.g. keratoconus and late effects of scarring from wound such as corneal incision following cataract surgery8. astigmatism can cause visual impairment in children, but it can be corrected9. materials & methods this was a cross sectional observational study. the study was conducted in six months from september 2014 to february 2015. after taking ethical approval from the hospital and school data was collected and it was only for research purpose. after taking consent from student’s data was collected through a selfdesign performa at city district govt. girl’s high school, shadman lahore from 550 students sample size was calculated by using formula of sample size= z1-a/22 sd2/d2 first visual acuity was assessed by using snellen’s visual acuity chart with patient seated at distance of 6 meters. if visual acuity was less than 6/6, which is the standard line of this chart then pinhole test was done. if vision improved to 6/6 in this test then the patients were considered to have refractive error. total refractive error was calculated using a retinoscope. for retinoscopy, patient’s pupil were dilated with cycloplegic drug i.e. 1% cyclopean three times with the interval of 10 minutes and retinoscopic reflex was noted after 90 minutes of instillation of first drop. by this method, type and amount of refractive error was calculated. patients whose eyes had amblyopia, strabismus or other ocular pathologies were excluded from this study. results in this study, there were 1098 eyes of 550 students with their mean ages were 10.31 ± 3.276 (range: 5 – 16 years) years. for study purpose it was stratified into four groups (5 – 7, 8 – 10, 11 – 13, 14 – 16 years) as shown in table 1 including 509 eyes of 255 (46.4%) male students and 589 eyes of 295 (53.6%) female students. from the total 1098 eyes having refractive error, only 280 eyes (25.5%) had no astigmatism and 818 eyes (74.5%) had astigmatism details of which are given in table 2. in this study, with the rule astigmatism was most commonly found in 605 eyes (55.1%) in which vertical meridian of cornea or lens is steeper than horizontal while least frequent astigmatism was against the rule which was found in 100 eyes (9.1%) of students and remaining 113 eyes (10.3%) had oblique astigmatism. compound myopic astigmatism 355 (32.3%) was more commonly present in students in both males and females eyes simple myopic astigmatism was seen in 151 (13.8%) eyes, mixed astigmatism was present in 92 (8.4%) eyes and compound hypermetropic astigmatism in 152 eyes (13.8%) of students. least common type of astigmatism was simple hypermetropic astigmatism that was seen in only 69 (6.3%) eyes of both males and females. using multinominal logistic regression analysis results found that mixed astigmatism belongs to reference category. students having age group range of 14 – 16 years are more likely to be non-astigmatic than mixed astigmatism as compared to other age groups. students having age group range of 14 – 16 years are most probable to have simple myopic table 1: age of patient vs type of astigmatism age of patient 5 – 7 years 8 – 10 years 11 – 13 years 14 – 6 years total type of astigmatism according to power meridian (pvalue=0.00) no astigmatism 44 78 80 78 280 myopic astigmatism 75 132 122 130 459 hypermetropic astigmatism 71 85 27 13 196 mixed astigmatism 60 56 35 12 163 total 250 351 264 233 1098 prevalence of astigmatism in school going children pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 171 type of astigmatism according to axis meridian (pvalue=0.00) no astigmatism 44 78 80 78 280 with the rule astigmatism 166 211 125 103 605 against the rule astigmatism 20 34 25 21 100 oblique astigmatism 20 28 34 31 113 total 250 351 264 233 1098 table 2: amount of astigmatism. amount of astigmatism 0.0 0.50-1.00dc 1.25-2.00dc 2.25-3.00dc 3.25-4.00dc >4.00dc no. of eyes 280 eye (25.5%) 454 eyes (41.3%) 179 eyes (16.3%) 99 eyes (9.0%) 48 eyes (4.4%) 38 eyes (3.5%) p-value= 0.00 astigmatism and compound myopic astigmatism than mixed astigmatism as compared to other age groups. students belonging to age group range of 14-16 years are more prone to have simple hypermetropic astigmatism than mixed astigmatism as compared to students who have age groups of 11 – 13 years. there is no significant result found in logistic regression in different age groups in compound hypermetric astigmatism than mixed astigmatism as shown in table 3. similarly oblique astigmatism was found to be a reference category and we found that students in age groups range of 5 – 7 years and 8 – 10 years are more likely to have with the rule astigmatism than oblique astigmatism as compared to the age group of 14 – 16 years and there is no significant result found in any age group for against the rule astigmatism and those who have no astigmatism as shown in table 4. table 3: type of astigmatism according to power meridiana predictor value no astigmatism simple myopic astigmatism simple hypermetropic astigmatism compound myopic astigmatism compound hypermetropic astigmatism b 95% ci b 95% ci b 95% ci b 95% ci b 95% ci 5 – 7 years -2.60*** 0.022.02 -1.79*** 0.050.47 -0.93 0.111.34 -2.70*** 0.020.18 -0.13 0.26-2.87 8 – 10 years -1.64** 0.070.52 -1.26** 0.090.81 -0.36 0.202.40 -1.63*** 0.070.52 0.50 0.49-5.53 11 – 13 years -1.51** 0.080.60 -1.26** 0.090.83 -1.52* 0.050.86 -1.63*** 0.070.53 -0.51 0.16-2.11 14 – 16 years ref.+ ref.+ ref.+ ref.+ ref.+ a. the reference category is: mixed astigmatism. + reference rida ijaz, et al 172 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology table 4: type of astigmatism according to axis meridiana predictor value no astigmatism with the rule astigmatism against the atigmatism b 95% ci b 95% ci b 95% ci 5-7 years -0.15 0.43-1.68 0.89** 1.31-4.53 0.38 0.633.38 8-10 years 0.08 0.59-1.98 0.79** 1.26-3.91 0.57 0.83-3.77 11-13 years -0.08 0.51-1.64 0.08 0.62-1.89 0.07 0.50-2.30 14-16 years reference reference reference a. the reference category is: oblique astigmatism. discussion astigmatism can occur in any age group, children and adults. previous studies have suggested that uncorrected astigmatism is associated with increased risk of myopia or amblyopia. early detection of astigmatism in pediatric populations is particularly important because of its potential influence on normal visual development10, 11. in this study, there was no relationship between gender and type of astigmatism according to axis and meridian in the above conducted study. and in study of china, there was also no significant difference in the occurrence of astigmatism between boys and girls12. amount of astigmatism does not change much after the age of 25. the changes in the shape of the cornea can happen quickly or may occur over several years.13 if astigmatism is left untreated in children then it can cause meridional amblyopia14. corneal topography is a valuable diagnostic tool for diagnosing subclinical keratoconus and for tracking the progression of the disease13. it is shown that, 280 eyes (25.5%) had no astigmatism, but 605 eyes (55.1%) had with the rule astigmatism, 100 eyes (9.1%) had against the rule astigmatism and 113 eyes (10.3%) had oblique astigmatism. in this study, there was simple myopic astigmatism in 151 (13.8%), compound myopic astigmatism in 355 (32.3%) students while mixed astigmatism in 92 (8.4%) students. in others simple hypermetropic astigmatism was in 69 (6.3%) and compound hypermetropic astigmatism was seen in 152 (13.8%) students. while in a study conducted in taiwan, 42.5% of school children had astigmatism. most of them (80%) had -1.0 d while 60% of them had myopic astigmatism15. of the 914 eyes with astigmatism, myopic astigmatism was present in 700 eyes (76.60%), hypermetropic astigmatism in 175 eyes (19.14%), and mixed astigmatism in 39 eyes (4.26%)16. a study held in canada in 2004 on preschool children included 129 children for their study. of the 129 subjects, 29 were classified as high astigmatism (-1 d of cylinder) in one or both eyes and the other 100 subjects were classified as normal astigmats17. a study held on native americans in 2010 included 1502 children. according to results, the prevalence of astigmatism of 2.00 diopters was 30% during infancy (6 months to 1 year of age) and was 23 to 29% in ages 2 to 7 years18. astigmatism can be treated by anyone of the following options; eye glasses, contact lenses and refractive surgery19. in refractive surgery corneal curvature is altered to change the focusing of the light rays on retina. radial keratotomy and photorefractive surgery are examples of refractive surgeries20. conclusion with the rule astigmatism and compound myopic astigmatism are more common among males and females and maximum in the age group of 14-16 years of age. if it is not treated timely then it will leads to amblyopia. therefore, proper screening can prevent a child from permanent visual loss due to amblyopia. author’s affiliation dr. rida ijaz bsc hons optometry and orthoptics, transitional doctor of optometry lecturer dept of optometry & vision sciences/ imperial college of business studies lahore dr. hijab ijaz prevalence of astigmatism in school going children pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 173 bsc hons optometry and orthoptics, transitional doctor of optometry senior lecturer dept of optometry & vision sciences/ the university of lahore dr. naeem rustam fcps, mbbs, assistant professor dept of optometry & orthoptics/fmh college of medicine & dentistry lahore role of authors dr. rida ijaz concept, design of study, data collection, data analysis, manuscript drafting, revision data analysis. dr. hijab ijaz data collection, manuscript drafting. dr. naeem rustam manuscript drafting, revision data analysis. references 1. abbasi s, imtiaz a, shah ar, quratulain zamir. frequency of amount and axis of astigmatism in subjects of rawalpindi, pakistan. j pak med assoc, (2013, november 11) 63, 1370-1373. 2. shukla, av. refractive errors, clinical optics pimers for ophthalmic medical personnel, dannvers usa, slack incorporated, (2009), 169. 1st edition. 3. duke, e. the refraction of the eye-physioogical optics, david abrams, duke-elder's practice of refraction. london, churchill livingston, (1993), 29.10th edition. 4. jogi, r. the cornea, basic ophthalmology. new delhi: jaypee brothers medical publishers, (2009), 107, 4th edition. 5. p.k. mukherjee, examination of the globe, cornea and sclera, clinical examination in ophthalmology, new delhi, elsevier health sciences, (2006), 126. 1st edition. 6. grosvenor, t. epidemiology f ametropia, primary care optometry. elsevier health sciences, 2007; 33. 5th edition 7. nick astbury, retinoscopy, clinical techniques in ophthalmology, churchill livingstone elsevier, (2006), 41, 1st edition. 8. john v. forrester, andrew david dick, et al. biochemistry and cell biology, the eye basic sciences in practice. elsevier, 2016; 209. 4th edition. 9. a.k. khurana, errors of refraction and binocular optical defects, shabina nasim. theory and practice of refraction. rohtak, haryana, india: elsevier health sciences, 2008; 80-81. 2nd edition. 10. huang, jiayan et al. risk factors for astigmatism in the vision in preschoolers (vip) study. optometry and vision science. 2014; 91(5), 514–521. 11. pascual m, huang j, et al. risk factors for amblyopia in the vision in preschoolers study. ophthalmology. 2013; 121(3), 622-9. 12. son c. huynh, annette kifley, kathryn a. rose et al. astigmatism in 12 year old australian children: comparison with 6 year old population, iovs, 2007 january; 48, 73-82 13. alhayek, adel, and pei-rong lu. corneal collagen crosslinking in keratoconus and other eye disease. international journal of ophthalmology, 2015; 407-418. 14. dsp fan, s k rao, eyy cheung et al. astigmatism in chinese preschool children: prevalence, change and effect on refractive development. biophthalmol.com, 2004; 928-941. 15. harvey, w, gilmarin, b. refractive examination, kim benson, pediatric optometry. london, butterworth hienemann optician, 2004; 25. 16. yungfeng shih, c. kate hsiao, yi-liang tung, luke l. et al. the prevalence of astigmatism in taiwan. optometry and vision sciences, 2004 february; 81, 9498. 17. sharif-ulhassan, k. ansari, mz. ali, a. et al. relative distribution and amount of different tyes of astigmatism in mixed ethnic populationn of karachi. pak j ophthalmol, 2009; 25, 1-8. 18. shankar, s. bobier, wr. corneal and lenticular components of total astigmatism in a preschool sample. optometry adnd vision science, 2004; 81, 536542. 19. erin m. harvey, dobson, v. et al. prevalence of astigmatism in native american infants and children. optoetry and vision sciences, 2010; 87, 400-405. 20. richard s snell, michael a. lemp, the eyeball, clinical anatomy of the eye. oxford, united kingdom, wiley-blackwell, 1997; 149. 2nd edition microsoft word khawaja khalid article 12 original article frequency of diabetes mellitus, impaired oral glucose tolerance test, hepatitis b surface antibody (hcv ab) in saudi population undergoing cataract surgery khawaja khalid shoaib, amjad ali khan, adnan qadir pak j ophthalmol 2008, vol. 24 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: khawaja khalid shoaib eye specialist cmh, kharian cantt. received for publication july’ 2007 …..……………………….. purpose: to assess the frequency of diabetes mellitus and serological markers of viral hepatitis in saudi arabian patients undergoing cataract surgery. material and methods: the medical records of all the patients who had undergone cataract surgery during the two years period extending from 2002 to 2003 at the ophthalmology unit of najran armed forces hospital programme (nafhp), kingdom of saudi arabia (ksa) were retrieved and records of 80 randomly selected patients were analyzed to find the frequency of diabetes mellitus (dm), impaired oral glucose tolerance test (igt), hepatitis b surface antigen (hbsag) and antibody to hepatitis c (anti hcv). results: the patients ranged in age from 44 to 93 years (mean: 72 years). they comprised of 45 males and 35 females. 12.5% patients were having igt while 25% patients were diabetic. of all the diabetic patients, 70% were known diabetics whereas 30% were newly diagnosed. hbsag was present in 2.5% of patients whereas hcv ab was detectable in 5.2% of cases. conclusion: cataract patients should undergo preoperative laboratory investigations to reveal any undiagnosed prevalent conditions like dm/igt and viral hepatitis, as hyperglycemia is a known etiological factor for infections and affects wound healing, whereas viral hepatitis can be transmitted to the surgeon or the paramedical staff. ataract surgery is an elective procedure in most of the cases, thus the eye surgeon has got time at his hands in order to detect and eliminate or control all important medical conditions like hypertension, asthma and dm that can produce per or post operative difficulties. the risk of developing cataract is more in diabetics than in non diabetics. retinal assessment is required for diabetic cataract patients, so that the surgeon can weigh the probable results of the cataract surgery and apprise the patient of the probable outcome. presence of serological markers for hepatitis makes the staff extra vigilant while dealing with such patients so as to avoid acquiring the infection. secondly it eliminates the responsibility of transmitting the disease in positive case from the medico legal point of view; this is in fact true for every type of surgery. c 13 material and methods the medical records of all the patients who had undergone cataract surgery during the two year period extending from 2002 to 2003 at the ophthalmology unit of najran armed forces hospital programme (nafhp), kingdom of saudi arabia (ksa) were retrieved. records of 80 randomly selected were analyzed to find the frequency of diabetes mellitus (dm), impaired oral glucose tolerance test (igt), hepatitis b surface antigen (hbsag) and antibody to hepatitis c virus (hcv ab). only the saudi patients were included in the study. cataracts resulting from penetrating injuries were excluded. finally 80 patients were randomly selected from the remaining operated patients. plasma glucose levels were. the diabetes expert committee criteria for evaluating the standard oral glucose tolerance test were followed (table 1)1. if fasting glucose was more than 110 mg/dl, the test was repeated and if the result was the same, glucose tolerance test was carried out with 75 grams glucose. hbsag was detected by using hbsag eia ii qualitative tests and antibodies to hcv were detected by using anti-hcv eia ii qualitative test. results a total of 80 randomly selected saudi patients were included in the study. the patients ranged in age from 44 to 93 years (mean: 72 years). they comprised of 45 males and 35 females. three (6.7%) out of 45 males had igt while 12 (26.7%) males had dm. seven (20%) out of 35 females had igt while 8 (22.9%) females had dm (table 2). ten (12.5%) patients had impaired glucose tolerance test, 2 (20%) patients out of these 10 had been diagnosed previously while 8 (80%) patients were diagnosed during preoperative laboratory investigations. twenty (25%) patients were diabetic, 14 (70% of diabetics) were known diabetics and 6 (30% of diabetics) were newly diagnosed i.e. cases who did not have any history of diabetes but were declared diabetic on performing the preoperative investigations (table 3). in presenile cataract (age 30 – 50 years) only 1 (16.7%) patient had igt and 1 (33%) had dm. hbsag was present in 2 (2.5%) patients out of 80 and anti hcv antibodies were detectable in 4 (5.2%) patients out of 77. discussion najran is a small city in the southern region of ksa and the operated cases were mostly retired army personnel, their wives or dependent parents of the serving soldiers so most of our patients can be considered to represent rural with low/modest income group. the risk of developing cataract is more in diabetics than in non-diabetics, moreover cataract formation and its rate of progression depends upon duration of diabetes.2 high glucose concentration in the aqueous leads to increased intracellular accumulation of glucose, which saturates the normal anaerobic glycolytic pathways. accordingly the polyol pathway is unregulated via aldose reductase, and polyols accumulate in the cells, thereby increasing the osmotic drag of water into the cell. activation of the osmoreceptor aquaporin o (mip 26) is then induced. this causes dysregulation of cellular metabolism, with reduction in the levels of cellular atp and glutathione. it results in secondary damage to the cell. in addition, the increased water content of the cell causes phase separation between proteins rich and protein poor regions of the cells and increased light scatter i.e. cataract3. table i. diabetes expert committee criteria for evaluating igt and dm. normal impaired glucose tolerance dm fasting < 110 110-125 ≥ 26 2 hours after glucose load (mg/dl) < 140 ≥140 < 200 ≥ 200 table 2. frequency of igt and dm igt (%) dm (%) males 6.7 26.7 females 20 22.9 total 12.5 25 table 3. newly or previously diagnosed cases. igt (%) dm (%) 14 newly diagnosed 80 30 previously diagnosed 20 70 hyperglycemia has been shown to impair the phagocytic function (leading to reduced resistance to infection) and wound healing.4 infections in persons with diabetes may not occur more frequently than in non diabetics but they tend to be more severe, possibly because of impaired leukocyte function, a frequent accompaniment of poor diabetic control.5 the best-known predictor of postoperative success is the preoperative severity of retinopathy.6 diabetic patient is more prone to have corneal abrasions, glaucoma, optic neuropathy and cranial nerves neuropathy. anterior segment complications are more common in diabetics like neovascularization of iris, pupillary block, posterior synechiae, pigmented precipitates on the implant and severe iritis7. posterior segment complications of diabetes include macular edema and ischemia, proliferative retinopathy, vitreous hemorrhage and retinal detachment. in our study the frequency of dm in males (26.7%) and in females (22.9%) was higher than prevalence found in other community based studies (e.g. m: f, 8.5:19.5 in>35 years of age)8. the reason for this high prevalence seems to be additive effect of diabetes mellitus and advancing age for development of cataract. the community based studies include all age groups (both healthy and diseased population) whereas all our patients (presenting with cataract) were above 44 years of age .moreover dm is one of the known etiological factors for cataract formation. so it can be said that frequency concluded in our study is for a certain age group or disease entity and not representative of the whole community. as the prevalence of diabetes mellitus increases with advanced age9,10, higher income10 and urban population9, we expect the prevalence to be still higher in urban, high-income cataract patients. 30 % of diabetics and 80% of igt were newly diagnosed in our study confirming the fact that a significant proportion of the patients were not aware of their disease (in some studies 65% of diabetic patients)9. in our study, frequency of igt was more in the females (20.9%) than males (6.7%) while frequency of dm was almost the same in the two sexes. the reported sex prevalence has been variable. slightly higher prevalence in females has been noted9, some noted prevalence double than the males10,11 and still others claimed more than the double8. higher prevalence of dm in the males has also been reported12. in presenile cataract patients (age: 30-50 years), only 1(16.7%) patient had igt and 2(33%) patients had dm, while in another study 20% had dm and 42% igt13. asia and africa have previously been classified as areas of high endemicity for hepatitis b virus (hbv). amongst the middle eastern countries, areas of low endemicity are bahrain, iran, israel and kuwait. intermediate endemicity is found in cyprus, iraq and united arab emirates. the countries of high endemicity include egypt, jordan, oman, palestine, yemen and saudi arabia. as all these countries reach a large proportion of their population with hepatitis b vaccination, therefore the infection rate is reducing, particularly in saudi arabia14. in our study, hbsag was positive in 2 (2.5%) out of 80 patients. it is less than observed figure in drug dependent patients in jeddah (6.7%) in non intravenous and 18.5% in intravenous users15. hcv ab was detectable in 4 (5.2%) patients out of 77, close to the finding of 5.9% in jeddah16 but more than the finding of 1.7% in blood donors17 and less than the figure of 68% in dialysis patients18.it was interesting to find higher frequency of hcv than hbc in our study while in blood bank of qaseem, saudi arabia, higher prevalence of hepatitis b than c was found19. this could be due to large number of patients included in their study and the observation that hcv positivity is seen more frequently in otherwise healthy individuals above 45 years of age20. testing for hb core antibody (ab) and for hcv by nucleic acid testing is likely to reveal more positive cases as has been observed by others21’22. the prevalence of hepatitis b core antibody positive donor was significantly higher in non – saudi (41.3%) compared with saudi nationals (16.7%)22. antihcv prevalence has been found to be more in egyptians than saudis16, 17 while less in asian15. male medical staff was found to have increased prevalence of hbv than medical students but same prevalence of hcv was observed in the two groups23. thus vaccination of medical staff has a definitive role in preventing the infection. author’s affiliation 15 lt. col. khawaja khalid shoaib eye specialist cmh, kharian cantt amjad ali khan najran armed forces hospital programmed (nafhp) kingdom of saudi arabia (ksa) adnan qadir najran armed forces hospital programmed (nafhp) kingdom of saudi arabia (ksa) reference 1. masharani u, karam jh. diabetes mellitus & hypoglycemia. in: lawrence m. tierney, jr., stephen, j. mcphee, maxine a. papadakis, editors. current medical diagnosis & treatment, 41st edition. lange medical books/mcgraw-hill. 2002: 120344. 2. chitkara dk. cataract formation mechanisms, in: myron yanoff. jay s duker editors. ophthalmology, mosby. 1999: 4.8. 1-4.8.8. 3. forrester jv, dick ad, mcmenamin pg, lee wr. editors. biochemistry and cell biology. the eye basic sciences in practice. second edition. w.b. saunders, 2002, 155-222. 4. frier bm, truswell as, shepherd j, et al. diabetes mellitus & nutritional & metabolic disorders, in: christopher haslett, edwin r. chilvers, john ctice of medicine, churchill livingstone, london 1999: 471-542. 5. daniel w. foster, diabetes mellitus, in: anthony s. fauci, eugene braunwald, kurt j. isselbacher, jean d.wilson, joseph b. martin, dennis l kasper, stephen l.hauser, dan l. longo, editors. harrison’s principles of internal medicine; vol.2 international edition, mc gray hill. 1998; 2060-81. 6. hykin pg, gregson rmc, stevens jd, et al. extracapsular cataract extraction in proliferative diabetic retinopathy. opthalmology.199; 100: 394-9. 7. benson we. diabetic retinopathy. in: myron yanoff, jay s duker, editors. opthalmology, mosby,1999: 8.20 1-8.20.10. 8. karim a, ogbeido do, siddique s, et al. prevalence of diabetes mellitus in a saudi community. saudi med j 2000; 21: 438-42. 9. al-nuaim ar. prevalence of glucose intolerance in urban and rural communities in saudi arabia.diabet med. 1997; 7: 595602. 10. bacchus ra, bell jl, madkour m, et al. the prevalence of diabetes mellitus in male saudi arabs. diabetologia 1982; 23: 330–2. 11. fatani hh, mira sa, el-zubier ag. prevalence of diabetes mellitus in rural saudi arabia. diabetes care. 1987; 10: 180–3. 12. warsy as, el-hazmi ma. diabetes mellitus, hypertension and obesity common multifactorial disorders in saudis. east mediterr health j. 1999; 5: 1236-42. 13. al sammarrai ar. the role of impaired glucose tolerance in patients with idiopathic presenile cataract in kuwait. saudi bulletin of ophthalmology. 1988; 3:208-9. 14. andre f. hepatitis b epidemiology in asia, the middle east and africa. vaccine 2000; 18: 20-2. 15. njoh j. the prevalence of hepatitis b surface antigen (hbsag) among drug dependent patients in heddah, saudi arabia. east afr med j.1995 mar; 72(3): 198-9. 16. fakeeh m, zaki am. hepatitis c: prevalence and common genotypes among ethnic groups in jeddah, saudi arabia. am j trop med hyg. 1999; 61: 889-92. 17. abdelaal m, rowbottom d, zawawi t, et al. epidemiology of hepatitis c virus: a study of male blood donors in saudi arabia. transfusion. 1994; 34: 135. 18. huraib s, al-rashed r, aldrees a, et al. high prevalence of and risk factors for hepatitis c in haemodialysis patients in saudi arabia, a need for new dialysis strategies. nephrol dial transplant. 1995; 10: 470-4. 19. mehdi sr, pophali a, al-abdul rahim ka. prevalence of hepatitis b and c and blood donors. saudi med j. 2000;21:9424. 20. daw ma, elkaber ma, drah am, et al. prevalence of hepatitis c virus antibodies among different populations of relative & attributable risk. saudi med j. 2002; 23: 1356-61. 21. akhter j, roberts gt, perry a, et al. use of nucleic acid testing for blood donor screening of human immunodeficiency virus and hepatitis c virus in the saudi population. saudi med j. 2001; 22: 1073-5. 22. al-sebayel mi, khalaf ha, ramirez cg. the prevalence of hepatitis b core antibody positivity in donors for liver transplantation in saudi arabia. saudi med j. 2002; 23: 298-300. 23. al-sohaibani mo, al-sheikh eh, al-ballal sj, et al. occupational risk of hepatitis b and c infections in saudi medical staff. j hosp infect. 1995; 31: 143-7. pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 113 case report quadrantic partial thickness sclerectomy for treatment of uveal effusion syndrome muhammad tariq khan, sidrah riaz, zaheer ud din aqil qazi pak j ophthalmol 2017, vol. 33, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. muhammad tariq khan associate professor (ophthalmology) head of vitreoretinal department akhtar saeed trust hospital, lahore email: stariq69@hotmail.com …..……………………….. purpose: to report our experience with partial thickness sclerectomy in patients diagnosed as idiopathic uveal effusion syndrome. study design: prospective case series place and duration of study: layton rehmatullah benevolent trust (lrbt) eye hospital, lahore january 2010 to august 2013. material and methods: four eyes of two patients (one male and one female) with bilateral idiopathic uveal syndrome were included in study. the diagnosis was clinical. results: both patients showed improvement clinically in visual acuity and in fundoscopy in term of retinal reattachment. conclusion: patient with uveal effusion syndrome responded better to surgical procedures like sclerectomy and didn’t respond to medical treatment. key words: uveal effusion syndrome, quadrantic sclerectomy, exudative retinal detachment, intraocular pressure (iop). t was 19631 when schepens and brockhurst coined the term “uveal effusion”. they reported choroidal and ciliary body detachment with exudation. in 1982, gass and jallow introduced term “idiopathic uveal effusion syndrome” to describe serous detachment of choroid, ciliary body and retina of unknown origin2. it is a rare ocular disorder affecting predominantly healthy young males and involvement is commonly bilateral. it is a diagnosis of exclusion. the exudative retinal detachment follows a typical pattern which begins inferiorly. the anterior fibers of sclera attaching the choroid are long and tangentially oriented than posterior fibers so more fluid accumulation is seen anteriorly3. other features are dilated episcleral vessels, blood in canal of schlemm, normal intraocular pressure (iop), elevation of sub retinal and cerebrospinal fluid (ccf) proteins4,5. marked anatomical alterations may be evident at the i muhammad tariq khan, et al 114 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology level of retinal pigment epithelium with so called “leopard spot” hyper pigmentation1. there is no evident intraocular inflammation1. the natural history of disease shows activation and remission pattern and if patient is not treated timely, there may be permanent visual loss due to structural damage to photoreceptors and intra-retinal fibrosis. the milder forms usually resolve but visual prognosis for eyes presenting with bullous retinal detachment is poor6. it responds poorly to medical treatment like corticosteroids and anti metabolites6 and non-surgical treatment. response to surgical options like scleral buckling and pars plana vitrectomy (ppv) is also not convincing. the successful retinal re attachment can be obtained by scleral thinning procedures like quadrantic partial thickness sclerectomy. materials and methods four eyes of two patients (one male and one female) with bilateral idiopathic uveal syndrome were included in study. the diagnosis was clinical. the patients with posterior scleritis, inflammatory orbital disease, arteriovenous fistula, pan retinal laser, recent retinal surgery, ocular trauma and ocular neoplasm were excluded. there was no history of taking drugs like sulfonamide and acetazolamide. the technique of sclerectomy involved the following steps. 360 degree peritomy around limbus is done. four recti muscles are secured with bridle sutures as for retinal buckling procedure. one quadrant is exposed at a time. after securing homeostasis a rectangular area is marked with scleral marker 7 mm from the limbus measuring 10mm horizontally and 8 mm vertically. with 15 no blade a partial thickness scleral flap, almost 80% in thickness is raised and removed. the scleral thickness at this place is now 20%. the procedure is repeated in all four quadrants. subretinal fluid may or may not be drained. the author recommends the drainage for early rehabilitation fig 1. fig. 1: diagramtic representation of the procedure. case 1 a young male presented with gradual decrease in vision in both eyes for the last six months. his vision quadrantic partial thickness sclerectomy for treatment of uveal effusion syndrome pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 115 was perception of light (pl) in both eyes with exudative retinal detachment seen on fundus examination, fig. 2. his intraocular pressure (iop) was 10 mm hg both eyes. quadrantic sclerectomy was done in both eyes with 1 week interval, fig. 3. subretinal fluid (srf) was drained in left eye but not in right eye. hypotony was managed in left eye with intravitreal c3f8 injection after srf drainage. fig. 2: preoperative fundus picture. case 2 a young female presented with gradual decrease in vision for the last 9 months. the vision was light perception (pl) in both eyes with normal iop (8 mm hg in right 6 mm hg in left). she was hypermetropic of +7 diopter sphere in both eyes. her axial length was 19 mm in both eyes. her right eye was operated and quadrantic sclerectomy but she didn’t report back for left eye surgery after 2 follow up visits. table 1: patient data showing pre and post-operative vision and iop. serial no. eye pre-operative post-operative visual acuity iop (mm hg) visual acuity iop (mm hg) 1 wk 3 wks 12 wks 1 wk 3 wks 12 wks case 01 male rt pl+ 10 6/36 6/24 6/24 10 10 10 lt pl+ 10 6/36 6/24 6/24 12 10 10 case 02 female rt pl+ 8 6/36 6/36 6/36 10 12 10 lt pl+ 10 -surgery not done results three eyes were operated and quadrantic sclerectomy was performed in these. male patient showed improvement in vision which was faster in left eye than right eye, in which sclerectomy was accompanied by srf drainage and intravitreal c3f8gas injection. patient’s vision improved from pl to 6/24 in four weeks postoperatively in left eye. in the right eye it improved to 6/24 in six weeks. this was the eye in which srf was not drained. his retina was attached in both eyes, fig. 4. he was examined at his last follow up visit on september 2014 and he had bilateral best corrected vision of 6/18 with normal iop. female was examined one and three weeks postoperatively. her vision improved from pl to 6/36 with glasses in her right eye. her retina was attached. she was lost in follow-up. both patients were followed one week, three weeks and twelve weeks postoperatively. muhammad tariq khan, et al 116 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology fig. 3: quadrantic sclerectomy. fig. 4: fundus picture 1 month postoperatively. discussion two patients with idiopathic uveal effusion syndrome were operated. it is a type of scleropathy affecting choroidal fluid dynamics. abnormally thick sclera and short axial length were common in both eyes. quadrantic sclerectomy in 3 eyes was successful in attaining retinal re attachment. following scleral resection all 3 eyes showed retinal re attachment and improvement in visual acuity. theories regarding pathogenesis of uveal effusion syndrome suggest that it is more common in nanophthalmic eyes7 where scleropathy is congenital and abnormally thick sclera8 compresses vortex veins leading to impeded drainage. similarly thick sclera is also seen in patients suffering from glycogen storage disease, mucopolysaccharidosis (hunter syndrome)9 where sclera is thick due to increased deposition of mucopolysaccharides. decompression of vortex veins was attempted by gass and he found that full thickness sclera incisions were effective in obtaining reattachment of retina, supporting the hypothesis that it was primarily scleral thickening causing uveal effusion by obstructing protein diffusion (mainly albumin) out of sclera and obstruction of vortex veins. the thick sclera hinders trans-scleral protein diffusion which results in protein accumulation in choroidal extra vascular space. in the absence of any known systemic disorder, abnormal deposition of different materials is the cause of scleral thickening10,11,12. the intraocular pressure is one of the factors which determines trans-scleral flow of proteins in the eye13,14,15. quadrantic sclerotomy was successful in treating uveal effusion syndrome by relieving choroidal effusion and non rhegmatogenous retinal detachment16,17. it supports the hypothesis that thick sclera prevents protein diffusion and decreasing scleral thickness can improve fluid outflow18. vortex vein decompression was first suggested by schaffer in 19756. success of scleral thinning procedure was also reported by brockhurst in 198019,20. conclusion patient with uveal effusion syndrome responded better to surgical procedures like sclerectomy and didn’t respond to medical treatment. author’s affiliation dr. muhammad tariq khan associate professor (ophthalmology) head of vitreoretinal department akhtar saeed trust hospital, lahore dr. sidrah riaz assistant professor (ophthalmology) akhtar saeed trust hospital, lahore dr. zaheer ud din aqil qazi, consultant ophthalmologist, lrbt eye hospital, lahore role of authors dr. muhammad tariq khan study design, manuscript drafting, surgery performed dr. sidrah riaz data collection, data analysis, article writing, composition dr. zaheer ud din aqil qazi manuscript review quadrantic partial thickness sclerectomy for treatment of uveal effusion syndrome pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 117 references 1. schepens cl and brockhurst rj: uveal effusion. i. clinical picture. arch ophthalmol. 1963; 70: 189-210. 2. gass jdm and sulayman j: idiopathic serous detachment of the choroid, ciliary body and retina (uveal effusion syndrome). ophthalmology, 1982; 89: 1018-32. 3. moses ra. detachment of ciliary body – anatomical and physical considerations. invest ophthalmol. 1965; 4: 935-41. 4. brockhurst rj, lam kw. uveal effusion. ii. report of a case with analysis of subretinal fluid. arch ophthalmol. 1973; 90: 399-401. 5. gass jd. uveal effusion syndrome: a new hypothesis concerning pathogenesis and technique of surgical treatment. trans am ophthalmol soc. 1983; 81: 246-60. 6. davies ewg. annular serous choroidal detachment. mod. probl. ophthal. 1979; 20: 2-5. 7. brockhurst rj: nanophthalmos with uveal effusion. arch ophthalmol. 1975; 93: 1289-99. 8. calhoun fp: the management of glaucoma in nanophthalmos. trans. am. ophthalmol. soc. 1975; 73: 98-122. 9. vine av: uveal effusion in hunter’s syndrome. retina, 1986; 6: 57-60. 10. forrester jv, lee wr, kerr pr, et al. the uveal effusion syndrome and trans-scleral flow. eye (lond) 1990; 4: 354-65. 11. uyama m, takahashi k, kozaki j, et al. uveal effusion syndrome: clinical features, surgical treatment, histologic examination of the sclera, and pathophysiology. ophthalmology, 2000; 107: 441-9. 12. ward rc, gragoudas es, pon dm, et al. abnormal scleral findings in uveal effusion syndrome. am j ophthalmol. 1988; 106: 139-46. 13. brubaker rf, pederson je. ciliochoroidal detachment. surv ophthalmol. 1983; 27: 281-9. 14. inomata h, bill a. exit sites of uveoscleral flow of aqueos humor in cynomolgus monkey eyes. exp eye res. 1977; 25: 113-8. 15. alm a, bill a. ocular circulation. in: moses ra, hart wm jr, editors. adler’s physiology of the eye. st louis: mosby; 1987: p. 199. 16. gass jd. uveal effusion syndrome. a new hypothesis concerning pathogenesis and technique of surgical treatment. retina, 1983; 3: 159-63. 17. johnson mw, gass jd. surgical management of the idiopathic uveal effusion syndrome. ophthalmology, 1990; 97: 778-85. 18. besirili cg, johnson mw. uveal effusion syndrome and hypotony maculopathy, retina 5th edition, elsevier 2013; page 1306. 19. brockhurst rj. vortex vein decompression for nanophthalmic uveal effusion. arch ophthalmol. 1980; 98: 1987-90. 20. casswell ag, gregor zj, bird ac. the surgical management of uveal effusion syndrome. eye (lond), 1987; 1: 115-9. microsoft word tahir masaud 136 original article myopia and near work activity in maderassa children in karachi tahir masaud arbab, saeed iqbal, sami ur rehman khan, manzoor a mirza. pak j ophthalmol 2008, vol. 24 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: tahir masaud arbab zamzama medical centre plot no 144 7th neelum lane 3rd zamzama street opp. zamzama park defence housing society phase v, karachi purpose: to determine the relationship of myopia and near work in maderassa children in karachi. material and methods: a cross-sectional study of 300 maderassa children aged 9 to 17 years was conducted in 3 maderassa in karachi. cycloplegic refraction, keratometry, and biometry measurements were performed. in addition the number of year’s child was studying in this maderassa, and near work activity (reading in hours per day) was also asked. results: of the 300 children in the sample, 118 (39.3%) were myopes, 33 (11%) hypermetropes, and 149 (49.6%) emmetropes. myopia was the most common type of refractive error. the average refractive error of these myopic eyes was -2 d. mild myopia ( -0.50 to -2.99 d) was found in 59.3 % of children, moderate myopia ( -3.00 to -5.99 d) in 30.5 % and severe myopia ( more than -6.00 d) in 10.1 %. association of near work activities and myopia emerged, as we divided the students in to 2 groups, group a children who were in the maderassa for more than 3 years, consists of 120 children and group b children who were in the maderassa for less than 3 years consist of 180 children. it was found that 50.83% of children in group a had myopia and the average refractive error of these myopic eyes was -3 d. 31.66 % of children in group b had myopia and the average refractive error of these myopic eyes was -1 d. conclusions: the study results suggest that myopia is a rather common refractive error in maderassa students. findings also indicate that myopia is probably correlated with educational level and excessive near work. 137 received for publication january’ 2008 … ……………………… yopia is defined as nearsightedness caused by an incongruity between the power of the optical elements of the eye and its axial length. the object image is projected in front of the retina, and corrective lenses are necessary to displace the image backward, thus producing a clear retinal image. although the causes of myopia are unclear, evidence supports both genetic and environmental components, among which are higher amounts of near work1,2 years of education3 and intelligence4.there has been a dramatic increase in myopia prevalence rates over the past few decades in asia5-7. the world-wide urban rural patterns derived from both incidence and prevalence data are consistent with the near work hypothesis that increased reading and computer use may be a risk factor for myopia8. the increase in rates has been remarkable in young asian children, suggesting that the rapid increase in myopia prevalence rates has been attributed to increases in reading activity and other environmental factors7. researchers in asia point to their rigorous schooling system and the long hours children spend studying as being responsible for the high rates of myopia in asia, rates that may be on the increase9,10. as myopia has onset and progression in childhood, it is important to focus research on these age groups. therefore, we examined the correlation of potential risk factor such as reading in 300 young maderassa children, aged 9 to 17 years. the present article reports the detailed evaluation of the reading with myopia and ocular biometry measures in these young subjects. material and methods we report cross-sectional study that consists of the entry data on maderassa children aged 9 to 17 years. the study was supported by 3 maderassas located in clifton area of karachi. 300 students studying in these maderassas participated in this study. as it was difficult for female maderassa children to come to the hospital for eye examination, so we selected male maderassa student only. the children eyes were examined during the first 2 weeks of february 2007. corrected and uncorrected distance visual acuity was measured using snellen’s chart. after instillation of 0.5% proparacaine, cycloplegia was induced in each eye with 3 drops 1% cyclopentolate instilled 5 minutes apart. at least 30 minutes after the last cycloplegic drop, autorefractometer (rm 8000b topcon) was used to obtain five consecutive refraction measurements. corneal curvature reading was obtained by keratometer (om4 topcon). ultrasound biometry measurements of axial eye length was performed using biometry machine (sonomed 100amodel), after 1 drop of 0.5% proparacaine. the study hours, time spent reading for all children studying in these 3 maderassas were similar, 10 hours per day. they start to hifz quran after fajr prayer till maghrib prayer and they have break for 2 hours in between 1 to 3 pm. as there was no age limit for joining the maderassa we divided the children in 2 groups, group a children who were in the maderassa for more than 3 years and group b children who were in the maderassa for less than 3 years. the measurements of refraction were analyzed as spherical equivalent. myopia was defined as a negative refractive error of at least -0.5 d. results in right and left eyes, analyzed separately, were found to be similar, thus only results of the right eye are presented. subjects were divided into three refractive error groups based on their se refractions; non myopes (se < -0.5d), mild myopes (se -0.5 to -2.99 d), moderate myopes (-3.00 to -5.99 d) and severe myopes (se -6.0 d or more). results prevalence of myopia initially 320 maderassa children were invited, 20 of them was excluded because of eye diseases other than refractive errors. among them 8 had strabismus, 8 had amblyopia, and 4 had corneal opacity. of the 300 children in the sample, 118 (39.3%) were myopes, 33 (11%) hypermetropes, and 149 (49.6%) emmetropes (table-1). myopia was found to be the most common refractive error. it was present in 39.4 % of the children. the average refractive error of these myopic eyes was -2 d. mild myopia (-0.50 to 2.99) was found in 59.3 % of children, moderate m 138 myopia (-3.00 to -5.99 d) in 30.5 %, and severe myopia (more than -6.00 d) in 10.1 % (table-2). ocular components eyes in children with higher myopia were more likely to have higher cylinder power, longer axial length, and steeper corneas than were eyes in children with lower myopia or no myopia. risk factors consistent with the development of myopia, the prevalence increased with advancing age (11% at age 9yrs, 29% at age 13 yrs and 39.3 % at age 17 yrs) (table-3). association of near work activities and myopia emerged, as we divided the students in to 2 groups: group a children who were in the maderassa for more than 3 years, consists of 120 children and group b children who were in the maderassa for less than 3 years consist of 180 children. it was found that children in group a had 50.83% of myopia (61 children out of 120 had myopia) and the average refractive error of these myopic eyes was -3 d. children in group b had 31.66 % of myopia (57 children out of 180 children had myopia) and the average refractive error of these myopic eyes was -1 d (table-4). table 1: prevalence of myopia no of patients (300) n (%) myopia 118 (39.3) hypermetropia 33 (11.0) emmetropia 149 (49.60 table 2: average myopic refractive error no of patients (118) n (%) mild myopia (-0.50 to -2.99) 70 (59.3) moderate myopia (-3.00 to -5.99 d) 36 (30.5) severe myopia (more than -6.00) 12 (10.1) table 3: prevalence of myopia with advancing age no of patients (300) n (%) age 9 years 33 (11) age 13 years 87 (29) age 17 years 118 (39.3) table 4: prevalence of myopia in group a and group b no of patients n (%) average refractive error group a (total 120) 61 (50.83) 3 diopters group b (total 180) 57 (31.66) 1 diopters discussion in this study, near work was significantly associated with myopia. children, who spend more time reading in hours per day, were more likely to have higher myopia. the prevalence of myopia in maderassa children in our study was 39.3% and it was higher in group a children which was 50.8%, it comprises children who were studying in maderassa for more than 3 years. in multicentre, population based studies of refractive error in children aged 5 to 15 years in china, chile and nepal, the prevalence rates of myopia were 16.2%, 5.8% and 0.3% respectively11-13. in a singapore-china study, the prevalence rate of myopia in singapore children was 36.7% compared to xiamen (china) which was 18.5%. singapore has highly competitive educational system, whereas xiamen school system is not so demanding, more near work activity may explain the difference in the prevalence rates14. an epidemiological study, concerning the prevalence of myopia among the student population (15-18 years old) of northern greece, myopia prevalence was 36.8%. it was found that myopia correlates strongly with near work and school performance15. boys in orthodox jewish schools were found to have higher rates of myopia (81.3%) compared with boys in general jewish schools (27.4%). orthodox schooling is characterized by sustained near vision 139 and frequent change in accommodation due to the swaying habit during study16. in xiamen, china the prevalence of myopia in urban school children was 19.3% and in rural school children was 6.6%. the average hours per day children spent in reading and writing outside of school was 2.2 hours in the city compared with 1.6 hours in the countryside. these data suggest the prevalence of myopia is higher in the city than in the countryside. one possible explanation for these different rates could be that school children in the city spend more time reading and writing outside of school compared with children in the countryside. myopic children in both the city and the countryside spent more time reading and writing compared with non myopic children. this increased near-work activity may contribute to the prevalence of myopia17. no study had been found in pakistan to assess the risk factors associated with myopia. till date only studies that are done are mostly screening programmes. a screening programme for vision in school was performed in the city of lahore, 1996-97. total of 1310 children examined in high and socioeconomic classes. the prevalence of refractive error is about 22.21% in the total screening population of school children from age 4-15 years18. to investigate the prevalence of refractive errors in school children, 10-16 years old children studying at schools of districts rawalpindi and islamabad were initially screened myopia was found to be three times more common (3.26%) than hypermetropia (0.99%)19. all these studies suggests that large amount of near work in childhood may contribute to the prevalence of myopia as was found in our study. the world-wide urban rural patterns derived from both incidence and prevalence data are consistent with the near work hypothesis that increased reading and computer use may be a risk factor for myopia. conclusion the study results suggest that myopia is a rather common refractive error in maderassa students. findings also indicate that myopia is probably correlated with educational level and excessive near work. author’s affiliation tahir masaud arbab sir syed college of medical sciences karachi saeed iqbal sir syed college of medical sciences karachi sami ur rehman khan sir syed college of medical sciences karachi manzoor a mirza sir syed college of medical sciences karachi reference 1. saw sm, chua wh, hong cy, et al. near work in early-onset myopia. invest ophthalmol vis sci. 2002; 43: 332-9. 2. mutti do, mitchell gl, moeschberger ml, et al. parental myopia, near work, school achievement, and children’s refractive error. invest ophthalmol vis sci. 2002; 4: 3633-40. 3. paritis n, sarafidou e, koiliopolus j, et al. epidemiologic research on the role of studying and urban environment in the development of myopia during school-age years. ann ophthalmol. 1983; 15: 1061-5. 4. teasdale tw, fuchs j, goldshmidt e. degree of myopia in relation to intelligence and educational level. lancet. 1988; 2: 1351-4 5. lin, lk, shih, yf, tsai, cb et al. epidemiologic study of ocular refraction among school children in taiwan optom vis sci. 1999; 76: 275-81. 6. lin, lk, chen, cj, hung pt, et al. national-wide survey of myopia among schoolchildren in taiwan acta ophthalmol suppl. 1988; 185: 29-33. 7. saw, sm, katz, j, schein, od, et al. epidemiology of myopia epidemiol rev. 1996; 18,175-87. 8. mutti do, mitchell gl, moeschberger ml, et al. parental myopia, near work, school achievement, and children refractive error. invest ophthalmol vis sci. 2002;43: 3633-40. 9. tay mth, au eong kg, ng, cy, lim, mk. myopia and educational attainment in 421, 116 young singaporean males ann acad med. 1992; 21: 785-91. 10. zhao j, pan x, sui r, et al. refractive error study in children: result from shunyi district, china am j ophthalmol. 2000; 129: 427-35. 11. zhao jl, pan xj, sui rf, et al. refractive error study in children: results from shunyi district, china. am j ophthalmol. 2000; 129: 427-35. 12. maul e, barroso s, munoz s, et al. refractive error study in children: results from la florida, chile. am j ophthalmol. 2000; 129: 445-54. 13. pokharel gp, negrel d, munoz sr, et al. refractive error study in children: results from mechi zone, nepal. am j ophthalmol. 2000; 129: 436-44. 14. saw sm, zhang mz, hong rz, et al. near-work activity, night-lights, and myopia in the singapore-china study arch ophthalmol. 2002; 120: 620-7. 15. mavracanas ta, mandalos a, peios d, et al. basil katsougiannopoulos prevalence of myopia in a sample of greek students acta ophthalmologica scandinavica. 2000; 78: 656–9. 140 16. zylbermann r, landau d, berson d. the influence of study habits on myopia in jewish teenagers j pediatr ophthalmol strabismus. 1993; 30: 319-22. 17. saw sm, hong rz, zhang mz, et al. near-work activity and myopia in rural and urban schoolchildren in china. j pediatr ophthalmol strabismus. 2001; 38: 149-55. 18. khan aa, hafeez t, hameed v. prevalence of refractive errors in school children ann king edward med coll. 1997; 3: 104-5. 19. afghani t, vine ha, bhatti a et al. al-shifa-al-moor (asan) refractive error study of one million school children. pak j ophthalmol. 2003; 19: 101-7. microsoft word munira shakir pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 22 original article transscleral diode laser cyclophotocoaglation for refractory glaucoma munira shakir, syeda aisha bokhari, shakir zafar, zeeshan kamil, syed fawad rizvi pak j ophthalmol 2012, vol. 28 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. munira shakir consultant ophthalmologist lrbt free bias eye hospital karachi korangi 2½, karachi …..……………………….. purpose: to assess the efficacy of contact transscleral cyclophotocoagulation for refractory glaucoma. material and methods: the study was conducted in l.r.b.t free base eye hospital from january 2008 to december 2010. all patients included in the study were diagnosed with refractory glaucoma with uncontrolled intraocular pressure on medical treatment. the study included 32 eyes of 30 patients who underwent transscleral diode laser cyclophotocoagulation (tsdlcpc) therapy. mean follow up was 21 months. outcome measures were intraocular pressure control and assessment of visual acuity and complications. results: the study included 32 eyes of 30 patients with refractory glaucoma who were treated with transscleral diode laser cyclophotocoagulation. there was significant decrease in intraocular pressure from 52.2 to 18.4 mmhg, with mean percentage reduction of 64.7%. visual acuity remained stable in 28 (87.5%) eyes, improved in 3 (9.37%) eyes and deteriorated in 1 (3.12%) eye. complications included early post procedure pain in 6 (26.6%) cases, moderate uveitis in 2 (6.6%) cases, hypotony in 4 (12.5%) cases, epithelial defect in 1 (3.12%) case and hyphema in 1 (3.12%) case. re-treatment was required in 10 (31.25%) patients, which included 6 (20.25%) eyes with neovascular glaucoma, 2 (6.255) eyes with silicone oil and 2 (6.25%) eyes with post-traumatic glaucoma. conclusion: transscleral diode laser cyclophotocoagulation is a safe and effective procedure for patients with refractory glaucoma, although re-treatment sessions may be required. ne of the leading causes of irreversible blindness worldwide is glaucoma1. when intraocular pressure (iop) remains uncontrolled despite medication, surgical intervention may be required to preserve optic nerve function2. with the advent of diode laser technology, management of uncontrolled intraocular pressure in advanced glaucomatous disease is being carried out by employing cycloablative therapy3. cycloablation lowers intraocular pressure by thermal destruction of ciliary body epithelium and stroma,4,5 coagulative necrosis with moderate reduction in vascularity6. transscleral diode laser cyclophotocoagulation (tsdlcp) has been shown to be a safe and effective modality as compared to other cyclophotocoagulative methods and cyclocryotherapy, which pose a significant risk of hypotony and phthisis due to excessive ablation of the ciliary body7,8. the type of laser to be used for transcleral cyclophotocoagulation is based on its scleral transmission. transmission through the sclera increases at long wavelength9. therefore, the most commonly used lasers are 810 nm diode and 1064 nm neodymium: yag10,11. tsdlcp is divided into “contact” in which the probe is placed directly over the conjunctiva and sclera and “non-contact” in which the energy is directed towards the sclera and conjunctiva at a slit lamp in conjunction with a lens which helps to minimize conjunctival burns12. the scleral transmission with contact application with the o munira shakir et al 23 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology 810 nm diode laser and the 1064 nm nd: yag laser is around 60%13. parameters such as pulse power and duration, total energy delivered per eye, total number of burns per session and sparing or not sparing a portion of the circumference treated with cyclodiode have been evaluated but with varying and contradictory results14,15. in addition, the age of the patient, cardiovascular status, history of diabetes, past surgical and cycloablative history, trabecular outflow status and response to ocular hypotensive medications must be evaluated to estimate the likely ciliary body function. thickened sclera may result in treatment failure, whereas; thinning of the sclera may require a reduced laser dose3. the outcome of cyclodiode therapy is, therefore, unpredictable and multiple treatments may be required to achieve the desired intraocular pressure level16. the current study was carried out to evaluate the efficacy of tansscleral diode laser cyclophotocoagulation in achieving intraocular pressure control and thereby, relieving pain of patients with refractory glaucoma. material and methods the study was conducted in the outpatient department of l.r.b.t free base eye hospital from january 2008 to december 2010. after informed consent, 32 eyes of 30 patients were selected for the study. out of which 18 (56.25%) were males and 12 (37.5%) were females. age ranged between 15 to 65 years. inclusion criteria included all patients diagnosed with refractory glaucoma (refractory glaucoma was defined as intraocular pressure > 21 mm hg on maximal tolerated medical therapy with or without previous surgical intervention), patients with best-corrected visual acuity ≤ 6/36 onsnellen chart testing and elevated intraocular pressure, patients with painful blind eye and patients whose general condition precludes invasive surgical procedures. exclusion criteria included patients < 15 years of age, patients with thin sclera or scleral atrophy, patients who had undergone previous transscleral cyclophotocoagulation and patients with a follow up of less than 3 months. complete data regarding patient demographics, pre and post procedure intraocular pressure, visual acuity, anti-glaucoma medications and complications was recorded. complete ocular examination, including adenexa, anterior segment with special emphasis on iris for signs of neovascularization, pupillary light reflex, posterior segment examination including the state of the vitreous, retina, macula and optic disc, intraocular pressure measurement with goldmann applanation tonometer and gonioscopy. the different etiologies of refractory glaucoma were as follows: 11 out of 32 (34.37%) eyes had neovascular glaucoma (nvg), 8 out of 32 (25%) patients had painful blind eye secondary to complicated cataract surgery, 5 out of 32 (15.62%) eyes had refractory glaucoma despite filtration surgery, 3 out of 32 ( 9.37%) were silicone filled eyes, 2 out of 32 (6.25%) eyes had post-traumatic glaucoma with scarring, 2 out of 32 (6.25%) patients were recruited because they were medically unfit for surgical procedure and 1 out of 32 (3.12%) eye had uveitic glaucoma. transscleral diode laser cyclophotocoagulation was performed with oculightsx with semiconductor diode laser system (810 nm wavelength) and a gprobe after administering retrobulbar or peribulbar anesthesia. duration was set at 1500 – 2000 ms (1.5 – 2 sec) and the initial power setting was 1500 – 1750 mw. power was increased in 250 mw increments till a “popping” sound was heard which indicates boiling of intracellular fluid with tissue disruption and can lead to increased post operative inflammation. the fiber optic tip of the g-probe was placed 1 – 1.5 mm from the limbus. the probe was held parallel to the visual axis and the foot plate was placed firmly against the sclera. initially 16 – 20 burns were given in the superior 180° with resultant energy of 3.5 j/shot. horizontal meridian (i.e. 3 and 9 o’clock positions) were spared to avoid the long ciliary nerves. if further treatment sessions were required then the remaining 180° was treated. post-procedure steroid-antibiotic eye drops and oral painkillers were prescribed. antiglaucoma medications were continued for a week. patients were followed the next day, after 1 week, weekly for 1 month and thereafter monthly for 2 years. success was defined as a final intraocular pressure < 22 mm hg or a decrease in intraocular pressure of > 30% from the pre-operative baseline value. improvement in visual acuity was defined as gain in ≥1 snellen line. deterioration in visual acuity was defined as loss of ≥1 snellen line. result a total of 32 eyes of 30 patients with refractory glaucoma were treated with transscleral diode laser cyclophotocoagulation. there were 18 (56.25%) males and 12 (37.5%) females with age ranging from 15-65 years. mean follow up was 21 months. treatment transscleral diode laser cyclophotoco-aglation for refractory glaucoma pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 24 outcomes were assessed on the following 3 parameters: control of intraocular pressure: preprocedure intraocular pressure was 31-40 mm hg in 7 (21.8%) eyes; 44 – 50 mm hg in 9 (28.12%) eyes; 51 – 60 in 12 (37.5%) eyes and 61 – 70 mm hg in 4 (12.5%) eyes. post-procedure intraocular pressure at final follow up was 10 – 14 mm hg in 8 (25%) eyes; 15 – 18 mm hg in 10 (31.25%) eyes; 19-22 in 10 (31.25%) eyes and 38-50 mm hg in 4 (12.5%) eyes. mean preoperative intraocular pressure was 52.2 mm hg whereas; mean post-operative intraocular pressure was 18.4 mm hg with a percentage reduction of 64.7%. success rate (iop between 5 – 21 mm hg) was noted in 87.5% patients at the last follow up. visual acuity: pre-procedure visual acuity was npl in 12 (37.5%) out of 32 eyes, pl in 9 (28.12%) out of 32 eyes, counting finger in 7(21.8%) out of 32 eyes, 6/60 in 3 (9.37%) out of 32 eyes and 6/36 in 1 (3.12%) out of 32 eye. post-procedure visual acuity was npl in 15 (46.8%) out of 32 eyes, pl in 7 (21.8%) out of 32 eyes, counting finger in 4 (12.5%) out of 32 eyes, 6/60 in 5 (15.6%) out of 32 eye and 6/36 in 1 (3.12%) out of 32 eye. visual acuity remained stable in 24 (75%) out of 32 eyes, improved in 3 (9.37%) out of 32 eyes and worsened in 5 (15.62%) out of 32 eyes. deterioration of vision was observed in 2 (6.25%) patients with nvg, i (3.12%) eye which was silicone oil filled, 1 (3.12%) eye with uveitic glaucoma and 1 (3.12%) eye with posttraumatic glaucoma with scarring. complications: early post-procedure pain was seen in 6 (20.25%) out of 32 eyes, hypotony in 4 (12.5%) out of 32 eyes.2 (50%) out of 4 eyes with hypotony ended up in phthysisbulbi, whereas the remaining 2 (50%) out of 4 eyes regained intraocular pressure ≥ 8 with conservative treatment after 6 weeks; moderate uveitis was observed in 2 (6.6%) out of 32 eyes, epithelial defect in 1 (3.12%) out of 32 eye and hyphema in 1 (3.12%) out of 32 eye. hyphema appeared in one patient with neovascular glaucoma. re-treatment was done in 10 (31.25%) of 32 eyes after 8 weeks, which included 6 (20.25%) eyes with nvg, 2 (6.25%) eyes with silicone oil and 2 (6.25%) eyes with post-traumatic glaucoma. discussion cyclodiode coagulation has proved to be an effective treatment modality for advanced and long-standing refractory glaucoma17,18. it acts by decreasing aqueous production regardless of trabecular function19. in the present study, the mean pre-procedure intraocular pressure was 52.2 mm hg which reduced to 18.4 mm hg after cyclodiode coagulation, giving a percentage intraocular pressure reduction of 64.7%. this is in accordance with other studies which have demonstrated a decrease of 20 – 60% in mean intraocular pressure3,20. the rate of success in this study was defined as a final intraocular pressure < 21 mm hg or a decrease in intraocular pressure by 30% from baseline intraocular pressure. transscleral diode laser cyclophotocoagulation in this study achieved a success rate of 87.5%. results in literature vary from 48% to 92%21-23. this success rate seemed to be related to higher power settings and increased number of treatments20. murphy et al, in their study evaluated the relation between total energy delivered during cyclodiode therapy for refractory glaucoma and a reduction in intraocular pressure over a range of laser energies, but they did not find any linear doseresponse relation which would help predict the outcome of cyclodiode therapy24. this finding is supported by previous reports25,26. in the current study visual acuity remained stable in 75%of cases, improved in 9.37% and deteriorated in 15.62% cases. similar findings were found in the study conducted by murphy et al. in their study visual acuity remained stable in 74.6% of the patients, improved in 5.3% and decreased in 19.8% of the patients24. however, in another study, 17 % eyes maintained stability, 29.1% exhibited improvement and 31.6% suffered deterioration27. the most serious side effects of cyclodiode therapy are hypotony and phthisis. it has been postulated that variables such as method of laser delivery, treatment parameters and follow up period might contribute to hypotony. also, high intraocular pressure before the procedure may result in ciliaryischemia which may induce ciliary body shutdown following cyclophotocoagulation. therefore one approach is to keep the initial setting of laser energy at a low level and to give multiple treatment sessions at 6 – 8 weeks, thus minimizing the risk of hypotony19. the rate of occurrence of hypotony varies widely in literature from 0 – 18%24. in the present study hypotony was seen in 12.5% of cases. other side effects observed were early postoperative pain in 20.25% of the eyes. moderate uveitis was seen in 6.6% of the eyes. mehmood et al also reported uveitis in 7% patients20. hyphema was encountered in one case (3.12%) that had neovascular glaucoma. other investigators also reported hyphema in neovascular glaucoma patients who underwent cyclodiode therapy28. re-treatment rate in the current study was munira shakir et al 25 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology fig. 1: glaucoma refractory to trabeculectomy fig. 2: traumatic glaucoma with surface scarring fig. 3: painful blind eye 31.25%. other studies show a re-treatment rate ranging from 22% to 45.8%16,24,29. re-treatment was done in 20.25% eyes with neovascular glaucoma, 6.25% eyes with silicone oil, and 6.25% eyes with traumatic glaucoma. other studies reveal that patients with neovascular glaucoma, post-traumatic glaucoma and post-vitreoretinal surgery glaucoma tend to need higher number of repeated treatment sessions16,24. conclusion to summarize, the current study showed that diode laser cyclophotocoagulation is an effective treatment option for refractory glaucoma of all etiologies. however, prospective trials are required to assess safety and long-term outcome. author’s affiliation dr. munira shakir consultant ophthalmologist lrbt free bias eye hospital karachi korangi 2 ½ karachi dr. syeda aisha bokhari associate ophthalmologist lrbt free bias eye hospital karachi korangi 2 ½ karachi dr. shakir zafar consultant ophthalmologist lrbt free bias eye hospital karachi korangi 2 ½, karachi dr. zeeshan kamil associate ophthalmologist lrbt free bias eye hospital karachi korangi 2½, karachi dr. syed fawad rizvi chief consultant ophthalmologist lrbt free bias eye hospital karachi korangi 2½, karachi reference 1. quigley ha, bromman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006; 3: 262-7. 2. lai js, tham cc, lam ds et al. surgical management of chronic closed angle glaucoma. asian pac j ophthalmol. 2003; 15: 5-10. 3. walland mj. diode laser cyclophotocoagulation: long-term follow up of a standardized treatment protocol. clin exp ophthalmol. 2000; 28: 263-7. 4. feldmann rm, el-harazi sm, lorusso fj et al. histopathological findings following contact trans scleral semiconductor diode laser cyclophotocoagulation in a human eye. j glaucoma. 1997; 2: 139-40. 5. neocker rj, kelly t, patterson e et al. diode laser contact trans scleral cytophotocoagulation: getting the most from the g-probe. ophthalmologic surg lasers imaging. 2004; 35: 124-30. transscleral diode laser cyclophotoco-aglation for refractory glaucoma pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 26 6. mckelvie pa, walland mj. pathology of cyclodiode laser: a series of nine enucleated eyes. br j ophthalmol. 2001; 85: 474-6. 7. oguriu a, takahashi e, tomita g, et al. transscleralcyclophotocoagulation with the diode laser for neovascular glaucoma ophthalmologic surg lasers. 1998; 29: 722-7. 8. schumann js, bellows ar, shingleton bj. contact transscleral nd: yag laser cyclophotocoagulation. mid-term results. ophthalmology. 1992; 99: 1089-95. 9. vogel a, dlugos c, nuffer r, et al. optical properties of human sclera, and their consequences for transscleral laser applications. laser surg med. 1991; 11: 331-40. 10. schlote t, derse m, rassmann k, et al. efficacy and safety of contact transscleral diode laser cyclophotocoagulation for advanced glaucoma. j glaucoma. 2001; 10: 294-301. 11. lin p,wollstein g, schuman js. contact transscleral laser cyclophotocoagulation. long-term outcome. ophthalmology 2004; 111: 2137-43; erratum in: ophthalmology. 112: 446 12. schuman js, noeker rj, puliafito ca, et al. energy levels and probe placement in contact transscleral semiconductor diode laser cylcophotocoagulation in human cadaver eyes. arch ophthalmol. 1991; 109: 1534. 13. raivio ve, puska pm, immonen ijr. cyclophotocoagulation with the transscleral contact red 670 nm diode laser in the treatment of glaucoma. acta ophthalmol. 2008; 86: 558-64. 14. chang sh, chen yc, li cy, et al. contact diode laser transscleralcyclophotocoagulation for refractory glaucoma: comparison of two treatment protocols. can j ophthalmol. 2004; 39: 511-6. 15. noureddin bn zein w, haddad c, et al. diode laser transscleralcyclophotocoagulation for refractory glaucoma: a 1year follow up of patients treated using an aggressive protocol. eye. 2006; 20: 329-35. 16. iliev me, gerber s. long-term outcome of transscleral diode laser cyclophotocoagulation in refractory glaucoma. br j ophthalmol. 2007; 91: 1631-5. 17. werner a, vick hp, guthoff r. cyto photocoagulation with diode laser. study of long-term results. ophthalmology. 1998; 95: 176-80. 18. threlked ab, johnson m. contact transscleral diode cyclophotocoagulation in refractory glaucoma: comparison between pediatric and adult glaucomas. ophthalmic surg lasers. 2001; 32: 100-7. 19. mehta r, puthuran g, krishnadas r, et al. efficacy of transscleral diode laser cyclophotocoagulation for refractory glaucoma in south indian population. asian j ophthalmol. 2006; 8: 232-5. 20. mahmood k, baig ra, baig mj, et al. transscleral diode laser cyclophotocoagulation for the treatment of refractory glaucoma. pak j ophthalmol. 2007; 23: 204-8. 21. schlote t, derse m, zierhut m. transscleral diode laser cyclophotocoagulation for the treatment of refractory glaucoma secondary to inflammatory eye disease. br j ophthalmol. 2000; 84: 999-1003. 22. egbert pr, fiadoyer s, budenz dl, et al. diode laser transscleralcyclophotocoagulation as a primary surgical treatment for primary open angle glaucoma. arch ophthalmol. 2001; 119: 345-50. 23. gupta v, agarwal hc. contact trans-scleral laser cyclophotocoagulation treatment for refractory glaucomas in the indian population. indian j ophthalmol. 2000; 48: 295-300. 24. murphy cc, burnett cam, spry pgd, et al. a two-center study of the dose-response relation for transscleral diode laser cyclophotocoagulation in refractory glaucoma. br j ophthalmol. 2003; 87: 1252-7. 25. benson mt, nelson me. cyclocrytherapy : a review of cases over a ten year period. br j ophthalmol. 1990; 74: 103-5. 26. wong eym, chew ptk, chee ckl, et al. diode laser contact transscleralcyclophotocoagulation for refractory glaucoma in asian patients. am j ophthalmol. 1997; 124: 797-804. 27. alipanahi r. long-term outcome of transscleral diode laser cyclophotocoagulation for refractory glaucoma. rawal med j. 2008; 33: 173-5. 28. tam fam am, chockalingam m, aquino m, et al. micropulsetransscleral diode laser cyclophotocoagulation in the treatment of refractory glaucoma. 29. afifi mn. dide laser cyclophotocoagulation. [online] 2010 [cited 2010]; available from: url: http://www.glaucomaegypt.org/glaucoma-news/2010-01.pdf. microsoft word raja sahib 108 obituary bravo raja sahib (1923-2010) on friday may 7th 2010 raja mumtaz quli khan passed away peacefully at his home in lahore. physically debilitated but mentally active and alert till his death. his death is most acutely felt by his family but poignantly experienced by all with whom he was associated as he was deeply admired by his students, patients, colleagues and friends. in him we have lost a giant in ophthalmology and the father of ophthalmological society of pakistan. his sad demise marks the end of an era. it is difficult to adequately document and narrate the characteristics and qualities which made him such a dedicated teacher, organizer and most of all a great friend known as raja sahib to all of us. he was an inspiration to his colleagues, to his students and children of his students who ultimately became his students. raja sahib was born in a wealthy, land owning family in a remote village of gadari near jehlum on july 16th 1923. he went to a local school which was a few miles from his village and he used to walk to school as there were no roads in that area, although with his personal effort and influence he got a road built but many years after leaving school when he had become raja sahib. did metric in 1938 and b.sc. form f.c college lahore in 1943 and joined galancy medical college amritser (prepartition) and after creation of pakistan joined k.e. medical college lahore. after completing his mbbs in 1948 from kemc he did his house job with prof. ramzan ali syed and then went to england and did his frcs in 1953 and came back to join his alma mater in 1956-57 as an assistant professor and he retired from the same institution in 1983. he also served at fjmc and pgmi (as professor of ophthalmology) and was medical director, lrbt till his death. raja sb. established the ophthalmological society almost single handedly in 1957 which has branches all over the country now. his efforts were instrumental in establishing the institute of ophthalmology lahore and al shifa trust eye hospital islamabad and certainly none of these would have been possible without his endurance and persistence. pakistan journal of ophthalmology was started in 1984 at lahore and, he was the pioneer chief editor. he had been president ophthalmological society of pakistan and was patron of lahore branch till his death. man of his caliber could not have gone un noticed and same was true for him. he received nuffield traveling scholarship for one year advanced training in uk. he was awarded the president of pakistan ramzan ali syed gold medal in 1986 for his meritorious services. he was secretary, surgeons’ society lahore branch. he received the distinguished services award from apao in 1981 for outstanding services in prevention of blindness. he was elected vice president apao 1974-84 and was president apao congress pakistan 1979. he was chief guest and guest of honor at various congresses held in different parts of pakistan. life member oxford congress and also life member pma lahore. 109 perhaps not known to many people he had won medals and certificates in sports including javelin throw, basket ball, weightlifting, body building, and volley ball, record holder in some sports at glancy medical college amritsar. raja sb had one brother and one sister but unfortunately both died in their early childhood and being the sole survivor of the family he inherited all the land holdings. but this was to be the only inheritance, as unlike most land owners he was more interested in helping others and he did so by generously donating his inheritance and his earnings to people in need. he established a girls high school at his village and donated generously towards libraries, schools, mosques and other charities. he helped post graduating doctors as well as people in his village so that financial constraints could not become a hurdle to progress for people around him. before his demise he was very concerned about raja mumtaz trust, eye society and scholarships that he had started for needy and deserving. many highly placed government officials and wealthy businessmen used to come to raja sb for treatment of their eye problems and along with the prescription each one received an earful of requests for betterment of the society and profession, for establishment of new institutes and hospitals for the needy poor people. he never asked anything for himself. when his friends, colleagues, students and patients gathered at kemu hall to pray for his departed soul every word spoken was about his honesty, integrity, dedication commitment to profession and his untiring struggle to help those who are in need. he was a good man. he really lived his life and he will long be remembered by everybody who ever came across him. he is survived by his caring wife, a loving adopted daughter and two lovely grandsons. may allah bless his soul in heavens, and give perseverance to the bereaved family to bear this great loss. raja sahib you have been our hero we will miss you but we will never forget you and we will try to follow your footsteps. when a great man dies, for years the light he leaves behind him, lies on the paths of men. (quote). dr. dil muhammad mirza and members of ophthalmological society of pakistan microsoft word uzma fasih 2 16 original article ‘dark adaptation’ a pitfall in evaluation of reliability of visual fields of second eye in glaucoma patients uzma fasih, arshad shaikh, nisar shaikh, m.s.fehmi, atiya rahman, asad raza jafri pak j ophthalmol 2010, vol. 26 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations ………………………… correspondence to: uzma fasih department of ophthalmology karachi medical & dental college abbasi shaheed hospital karachi received for publication march’ 2009 ……………………….… purpose: to analyze that dark adaptation may be a pitfall in evaluation of reliability of visual fields of second eye of glaucoma patients. materials & methods: the study was conducted in the department of ophthalmology, abbasi shaheed hospital from january 2007-june 2008. in this study evaluation of patients were randomly selected from the glaucoma clinic who went for routine perimetery for the first time. patients were examined in detail, diagnosis was established and were sent for field examination to assess the extent of damage by glaucoma .perimetery was done on octopus 300 series perimeter after setting all the parameters and under constant supervision. results: a total of 117 patients were examined from january 2007june 2008. a male preponderance was seen and majority of the patients belonged to 60-70 years age group making up to 37.4 %followed by 40-50 years age group i.e 25.6%. maximum number of patients have percentage of false positives and false negatives between the range of 0-5 % which shows that a large number of patients(62% patients in false positives and 79% patients in false negatives in their right eyes and 68.4% patients in false positives and 74.6% patients in false negatives in their left eyes) had a reliable field, 96(82%) patients had reliability factor in acceptable normal range their right eyes and 104(89%) patients had reliability factor in acceptable normal range in left eyes. it shows that majority of patients had a reliable field test. it is obvious that fields of left eyes were more reliable as compared to right eyes. conclusion: it was concluded that the results of second eye of the patients were more reliable as compared to the reliability of the results of first eye. this could be due to the phenomenon of dark adaptation .the second eye gets dark adapted behind the occluder as the patient proceeds the test for first eye, and thus produces better results when examined. so dark adaptation may be a pitfall in interpretation of reliability of visual fields of second eye. he eye operates over a large range of light levels. the sensitivity of our eye can be measured by determining the absolute intensity threshold, that is, the minimum luminance of a test spot required to produce a visual sensation. this can be measured by placing a subject in a dark room, and increasing the luminance of the test spot until the subject reports its presence. consequently, dark adaptation refers to how the eye recovers its sensitivity in the dark following exposure to bright lights. aubert (1865) was the first to estimate the threshold stimulus of the eye in the dark by measuring the electrical current required to render the glow on a platinum wire just visible. he found that the sensitivity had increased 35 times after time in the dark, and also introduce for the term "adaptation"1. t 17 dark adaptation forms the basis of the duplicity theory which states that above a certain luminance level (about 0.03 cd/m2), the cone mechanism is involved in mediating vision; photopic vision. below this level, the rod mechanism comes into play providing scotopic (night) vision. the range where two mechanisms are working together is called the mesopic range, as there is not an abrupt transition between the two mechanism. the dark adaptation curve shown below depicts this duplex nature of our visual system (fig. 1). the first curve reflects the cone mechanism. the sensitivity of the rod pathway improves considerably after 5-10 minutes in the dark and is reflected by the second part of the dark adaptation curve. one way to demonstrate that the rod mechanism takes over at low luminance level, is to observe the colour of the stimuli. when the rod mechanism takes over, coloured test spots appear colourless, as only the cone pathways encode colour. this duplex nature of vision will affect the dark adaptation curve in different ways and is discussed below. to produce a dark adaptation curve, subjects gaze at a pre-adapting light for about five minutes, then absolute threshold is measured over time (fig. 1). pre-adaptation is important for normalisation and to ensure a bi-phasic curve is obtained. from the above curve, it can be seen that initially there is a rapid decrease in threshold, then it declines slowly. after 5 to 8 minutes, a second mechanism of vision comes into play, where there is another rapid decrease in threshold, then an even slower decline. the curve asymptotes to a minimum (absolute threshold) at about 10-5 cd/m2 after about forty minutes in the dark1. factors affecting dark adaptation 1. intensity and duration of the pre-adapting light. 2. size and position of the retina used in measuring dark adaptation. 3. wavelength distribution of the light used. 4. rhodopsin regeneration. intensity and duration of pre-adapting light: different intensities and duration of the pre-adapting light will affect dark adaptation curve in a number of areas. with increasing levels of pre-adapting luminances, the cone branch becomes longer while the rod branch becomes more delayed. absolute threshold also takes longer to reach. at low levels of preadapting luminances, rod threshold drops quickly to reach absolute threshold (fig. 2)2. the shorter the duration of the pre-adapting light, the more rapid the decrease in dark adaptation (fig. 3). for extremely short pre-adaptation periods, a single rod curve is obtained. it is only after long preadaptation that a bi-phasic, cone and rod branches are obtained. size and location of the retina used: the retinal location used to register the test spot during dark adaptation will affect the dark adaptation curve due to the distribution of the rod and cones in the retinal (fig. 4). when a small test spot is located at the fovea (eccentricity of 0o), only one branch is seen with a higher threshold compared to the rod branch. when the same size test spot is used in the peripheral retina during dark adaptation, the typical break appears in the curve representing the cone branch and the rod branch (fig. 5-6). a similar principle applies when different size of the test spot is used. when a small test spot is used during dark adaptation, a single branch is found as only cones are present at the fovea. when a larger test spot is used during dark adaptation, a rod-cone break would be present since the test spot stimulates both cones and rods. as the test spot becomes even larger, incorporating more rods, the sensitivity of the eye in the dark is even greater. wavelength of the threshold light: when stimuli of different wavelengths are used, the dark adaptation curve is affected. from (fig. 7) below, a rod-cone break is not seen when using light of long wavelengths such as extreme red. this occurs due to rods and cones having similar sensitivities to light of long wavelengths (fig. 8). figure 8 depicts the photopic and scotopic spectral sensitivity functions to illustrate the point that the rod and cone sensitivity difference is dependent upon test wavelength (although normalization of spatial, temporal and equivalent adaptation level for the rod and cones is not present in this figure). on the other hand, when light of short wavelength is used, the rod-cone break is most prominent as the rods are much more sensitive than the cones to short wavelengths once the rods have dark adapted2. subjects were pre-adapted to 2000ml for 5 minutes. a 3 degree test stimuli was presented 7 degrees on the nasal retina. the colours were: ri (extreme red)=680 nm; rii (red)=635 nm; y (yellow)=573 nm; g (green)=520 nm; v (violet)=485nm and w white). 18 fig. 1. dark adaptation curve. the shaded area represents 80% of the group of subjects. fig. 2. dark adaptation curves following different levels of pre-adapting luminances. fig. 3. dark adaptation curves following different duration of a pre-adapting luminance. rhodopsin regeneration dark adaptation also depends upon photopigment bleaching. retinal (or reflection) densitometry, which is a procedure based on measuring the light reflected from the fundus of the eye, can be used to determine fig. 4. distribution of rod and cones in the retina. fig. 5,6: dark adaptation measured with a 2o test spot at different angular distances from fixation. the amount of photopigment bleached. using retinal densitometry, it was found that the time course for dark adaptation and rhodopsin regeneration was the 19 fig. 7. dark adaptation curve using different test stimuli of different wavelengths fig. 8. scotopic (rods) and photopic (cones) spectral sensitivity functions. (3) fig. 9. log relative threshold as a function of the percentage of photopigment bleached. same. however, this does not fully explain the large increase in sensitivity with time. bleaching rhodopsin by 1% raises threshold by 10 (decreases sensitivity by 10). in (fig. 9), it can be seen that, bleaching 50% of rhodopsin in rods raises threshold by 10 log units while the bleaching 50% of cone photopigment raises threshold by about one and a half log units. therefore, rod sensitivity is not fully accounted for at the receptor level and may be explained by further retinal processing on cone thresholds. with dark adaptation, we noticed that there is progressive decrease in threshold (increase in sensitivity) with time in the dark. as the threshold decreases and sensitivity increases the results of visual fields of second eye which has got dark adapted by this time may be much better or reliable as compared to the results of first eye3. table 1: gender distribution gender no: of patients n (%) male 77 (65.8) female 40 (34.2) table 2: age distribution age in years no of patients n (%) 10-20 3 (2.7) 20-30 6 (5.1) 30-40 9 (7.8) 40-50 30 (25.6) 50-60 18 (15.4) 60-70 44 (37.4) 70-80 7 (6) table 3: false positives in right & left eye range of false positives right eye left eye no of patients n (%) no of patients n (%) 0-5 72 (62) 80 (68.4) 5-10 0 (0) 1 (0.8) 10-15 28(2.4) 21 (17.9) 15-20 1 (0.8) 2 (18) 20 and above 16 (13.2) 13 (11.1) 20 table 4: false negative in right & left eye range of false negative right eye left eye no of patients n (%) no of patients n (%) 0-5 92 (79) 87 (74.6) 5-10 1 (0.8) 4 (3.4) 10-15 11 (9.2) 11 (9.2) 15-20 3 (2.5) 1 (0.8) 20 and above 10 (8.5) 14 (12) table 5: reliability factor reliability factor right eye left eye no of patients n (%) no of patients n (%) 0-5 57 (48.8) 67 (57.3) 5-10 29 (24.8) 28 (24) 10-15 10 (8.5) 9 (7.7) 15-20 6 (5.1) 5 (4.3) 20 and above 15 (12.8) 8 (6.75) light adaptation with dark adaptation, we noticed that there is progressive decrease in threshold (increase in sensitivity) with time in the dark. with light adaptation, the eye has to quickly adapt to the background illumination to be able to distinguish objects in this background. light adaptation can be explored by determining increment thresholds. in an increment threshold experiment, a test stimulus is presented on a background of a certain luminance. the stimulus is increased in luminance until detection threshold is reached against the background therefore, the independent variable is the luminance of the background and the dependent variable is the threshold intensity or luminance of the incremental test required for detection. such an approach is used when visual fields are measured in clinical practice4. materials nad methods the patients were randomly selected from the glaucoma clinic when they were registered and were sent for routine perimetric examination for the first time. before sending for field test these patients were thoroughly examined. the examination included detailed slit lamp examination, measurement of intraocular pressure by applanation tonometery, detailed fundoscopy to access the status of optic disc and gonioscopy where required. the type of glaucoma was diagnosed and patients were sent for routine perimetry. the inclusion criteria were new referral, no previous threshold visual field tests, absence of hearing or cognitive impairment, understanding language, and best corrected visual acuity of 6/36 or better in both eyes. the exclusion criteria were patients who had alraedy undergone the examination once, patients with hearing problems and patients with dense cataracts and corneal opacities. the perimetry was carried out on octopus 300 series perimeter using standard glaucoma g1 dynamic white on white programme, after instructing the patient properly. patient data regarding name, id, gender, visual acuity and intraocular pressure was fed in the computerized perimeter. the patients were seated comfortably and their spectacle number placed in the given socket. the pupil size was noted the patients were supervised throughout the test by well trained examiners and fixation was maintained by the electronic eye fixation control system in the perimeter through out the test as the reliability of visual fields depends largely upon quality of eye fixation. test duration, positive catch trials, negative catch trials and reliability factor were noted. the reliability of the results was accessed after a thorough review of reliability indices. results a total of 117 patients were examined from january 2007june 2008.the results are tabulated as follows: a male preponderance was seen and majority of the patients belonged to 60-70 years age group making up to 37.4 %followed by 40-50 years age group i.e 25.6%.the size of pupil noted in almost all the patients was in range of 3-7 mm which is a reliable range for normality. almost 90% of the patients completed the test in 69 minutes 8 % completed in 10-15 minutes and only2% took time more than 15 minutes. the number of false positive answers (positive response when no stimulus was presented) is 21 expressed as a percentage of total positive trials. false negative answers (negative response after presentation of brightest possible stimulus in an area where patient showed sensitivity on prior questions) are also expressed in percentage of total questions asked. false positives and negatives were calculated in both eyes and are tabulated. it is quite obvious from the tables that maximum number of patients have percentage of false positives and false negatives between the range of 0-5 % which shows that a large number of patients (62% patients in false positives and 79% patients in false negatives in their right eyes and 68.4% patients in false positives and 74.6% patients in false negatives in their left eyes) had a reliable field. the reliable range of rate of false positives and false negatives in octopus 300 series perimeter (the machine we used) is 10-15%. reliability factor rf indicates patients cooperation and is actually the percentage of sum of false positive and false negative answers divided by total number of catch trial questions. according to the settings of the perimeter we used value of rf should not be higher than 15%. a grade of 0 is excellent. it is evident from the table that 96(82%) patients had reliability factor in acceptable normal range their right eyes and 104(89%) patients had reliability factor in acceptable normal range in left eyes. it shows that majority of patients had a reliable field test. it is obvious that fields of left eyes were more reliable as compared to those of right eyes. discussion we conducted this study at eye department abbasi shaheed hospital from january 2007 june 2008 including 117 patients to analyze that dark adaptation may be a pitfall in evaluation of reliability of visual fields of second eye of glaucoma patients. a male preponderance was seen and majority of the patients belonged to 60-70 years age group making up to 37.4 %followed by 40-50 years age group i.e 25.6%. the size of pupil noted in almost all the patients was in range of 3-7 mm which is a reliable range for normality. it was observed that maximum number of patients have percentage of false positives and false negatives between the range of 0-5 % which shows that a large number of patients (62% patients in false positives and 79% patients in false negatives in their right eyes and 68.4% patients in false positives and 74.6% patients in false negatives in their left eyes) had a reliable field. the reliable range of rate of false positives and false negatives in octopus 300 series perimeter, the machine we used is 10-15%. according to the settings of the perimeter we used value of rf should not be higher than 15%. a grade of 0 is excellent. it was seen that 96(82%) patients had reliability factor in acceptable normal range their right eyes and 104(89%) patients had reliability factor in acceptable normal range in left eyes. it shows that majority of patients had a reliable field test. it is very obvious that fields of left eyes were more reliable as compared to right eyes. better reliability of second eye may be due to phenomenon of dark adaptation. the second eye was continously behind opaque occluder and was dark adapted while first eye was being examined. adams et al. found that the average sensitivity in the second eye tested was reduced by approximately 1.2 db (0.06 log units) relative to the first5.although this was attributed to a dichoptic contrast adaptation effect, subsequent work has suggested that the sensitivity loss results from a delay in light adaptation of the second eye after its opaque ocluder is removed.although such effects might be minimized with the use of a translucent occluder6. humphrey matrix perimeter (carl zeiss meditec; welch allyn) has recently become available, with a smaller target size of 5° that allows the sensitivity of the visual field to be sampled at finer spatial intervals. examination of the normative database for this instrument confirmed that sensitivity in the second eye was reduced (the "second-eye effect"). however, the improved spatial resolution of the test also showed that this second-eye effect was not equal across the visual field but was slightly greater in the temporal hemifield6. previous authors have noted a loss in perimetric sensitivity over time, with any attributing this to subject fatigue7-11 quanifying fatigue effect, however, have had limited temporal resolution. although it has been demonstrated that the adaptational state of the eye is a critical determinant of the second-eye effect, the role of light adaptation in mediating any progressive loss of sensitivity in the first eye has not been assessed6. conclusion it was concluded that the results of second eye of the patients were more reliable as compared to the reliability of the results of first eye. this could be due to the phenomenon of dark adaptation. the second eye gets dark adapted behind the occluder as the 22 patient proceeds the test for first eye, and thus produces better results when examined. so dark adaptation may be a pitfall in interpretation of reliability of visual fields of second eye. author’s affiliation dr. uzma fasih assistant professor department of ophthalmology karachi medical & dental college abbasi shaheed hospital, karachi dr. arshad shaikh professor & head of eye department department of ophthalmology karachi medical & dental college abbasi shaheed hospital, karachi dr. nisar shaikh assistant professor department of ophthalmology karachi medical & dental college abbasi shaheed hospital, karachi dr. m.s. fehmi associate professor department of ophthalmology karachi medical & dental college abbasi shaheed hospital, karachi dr. atiya rahman b 21 block 10, federal b area karachi dr. asad raza jafri senior registrar department of ophthalmology karachi medical & dental college abbasi shaheed hospital, karachi reference 1. pirenne mh. dark adaptation and night vision. chapter 5. in: davson, h. (ed), the eye, london, academic press. 1962; 2: 2. bartlett nr. dark and light adaptation. chapter 8. in: graham, c h. (ed), vision and visual perception. new york: john wiley and sons, inc. 1965. 3. davson h. physiology of the eye, 5th ed. london: macmillan academic and professional ltd. 1990. 4. stiles ws. colour vision: the approach through increment threshold sensitivity. proc nat acad sci. 1959; 75: 100-14. 5. adams bullimore ma, wall m, fingeret m. normal aging effects for frequency doubling technology perimetry. optom vis sci. 1999; 76: 582–7. 6. anderson aj, johnson ca. effect of dichotic adaptation on frequency doubling perimetry. optom vis sci. 2002; 79: 88–92. 7. heijl a. time changes of contrast thresholds during automated perimetry. acta ophthalmol. 1977; 55: 696–708. 8. heijl a, lindgren g, olsson j. normal variability of static perimetric threshold values across the central visual field. arch ophthalmol. 1987; 105: 1544–9. 9. johnson ca, adams cw, lewis ra. fatigue effects in automated perimetry. appl optics. 1988; 27: 1030–7. 10. searle aet, wild jm, shaw de, et al. time-related variation in normal automated static perimetry. ophthalmology. 1991; 98: 701–7. 11. hudson d, wild jm, o’neill ec. fatigue effects during a single session of automated static perimetry. invest ophthalmol vis sci. 1994; 35: 268–80. microsoft word nasrullah 63 original article surgically induced astigmatism comparison between forceps and injector delivery system for foldable iol in phacoemulsification nasrullah khan, atif mansoor ahmed, khalid waheed, tahir mahmood pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. nasrullah department of ophthalmology shaikh zayed hospital lahore submission of paper august’ 2010 acceptance for publication may’ 2011 …..……………………….. purpose: to compare surgically induced astigmatism between injector and forceps delivery system for intraocular lens implantation in phacoemulsification. methods: this quasi experimental study was carried out in ophthalmology department, shaikh zayed hospital, lahore. one hundred consecutive cataract patients were operated upon by phacoemulsification with acrylic foldable iol implantation. patients were randomly divided into two groups i.e. group i, injector delivery system and group ii forceps delivery system for iol implantation. preoperative and postoperative keratometric reading of the patients were taken by javal-schiotz keratometer. all patients were followed for 8 weeks. surgically induced astigmatism was calculated by vector method. results: the mean preoperative astigmatism k1 in group i was 0.545 d (±0.538) while in group ii was 0.615 d (±0.587). the mean postoperative astigmatism k3 in group i was 0.86 d (±0.580) and in group ii was 0.785 d (±0.670). the mean surgically induced astigmatism in group i was 0.998 d (±0.532) and 1.064 d (±0.757) in group ii. the difference in surgically induced astigmatism k2 in both groups was 0.066 d, not significant (p=0.625). conclusion: both injector and forceps delivery systems of iol were safe and equally acceptable with insignificant difference in surgically induced astigmatism. ataract is the commonest cause of treatable blindness throughout the world and for this reason cataract extraction is the commonest procedure done all around the globe1. aims of modern cataract surgery are minimal postoperative astigmatism, smaller incision size, and rapid visual rehabilitation2. phacoemulsification fulfils these aims and has therefore evolved as the preferred surgical procedure for cataract extraction over the past two decades3. it is one of the most innovative and popular techniques4. to implant foldable iols through small incision in phacomulsification popular methods are injector and forceps delivery systems. using an injector to insert acrylic iols may have an advantage because iol does not contact the lid or conjunctiva intraoperatively5. less wound manipulation occurs with an injector system and the wound required for implantation is smaller than with other methods6. some studies suggest that insertion of an acrylic lens with a forceps brings bacteria into eye7. surgically induced astigmatism is related to the type, length and location of the incision and closure techniques8,9. this study is the comparison of induced astigmatism between forceps and injector delivery systems for foldable iol implantation in phacoemulsification. material and methods this quasi experimental study was conducted in the ophthalmology department, sheikh zayed hospital, lahore from april 2005 to february 2006. 100 patients c 64 were selected for surgery by purposive nonprobability sampling with random allocation to the two groups of patients i.e. group 1 (injector delivery system for iol) and group 2 (forceps delivery system for iol). inclusion criteria for patients was age related cataract suitable for phacoemulisification with no associated anterior or posterior segment pathology. pre-operative evaluation of the patients included detailed ocular and systemic history with complete ocular examination including visual acuity assessment, extra ocular motility, slit lamp examination and dilated fundus examination. preoperative kerotometery (with javal shiorts keratometer) and axial length was recorded for biometry. all the patients except one male were operated under local anaesthesia in the form of peri-bulbar injection, using a mixture of 0.50% bupivacaine and 2% xylocain in 1:1. one patient was operated under general anaesthesia. a standard surgical procedure was followed in all the patients. after applying the lid speculum, continuous curvilinear capsulorehexis was done with a bent-tipped 27 gauge needle. a 2mm side port incision was made with 15° knife slightly below 180° to 3mm main 12 o’clock incision, on temporal side for right eyes and on nasal side for left eyes i.e. 8 o’clock position. hydrodissection was performed with 23 gauge cannula attached to 3 ml syringe filled with balanced salt solution (bss), endocapsular phacoemulsification using single handed phase-flip technique was performed and aspiration of the epinucleus was carried out. aspiration of the residual cortical matter was done with a manual simcoe’s cannula. the anterior chamber was reformed with the viscoelastic material. in group i patients foldable c-flex 570c acrylic iol was implanted with injector, which was provided with iol. no attempt was made to enlarge the incision. incision length was measured using a kohnen (g19136, gender) caliper. the caliper tips were inserted in the internal openings of the incision and were gently opened until modest tissue resistance was noted. the viscoelastic material was cleared out by irrigation with balanced salt solution and aspirated by manual cannula. all of the incisions were left suture less. in group ii, wound was slightly enlarged with 5.5 mm knife and iol was implanted using forceps. wound length was measured with caliper. all of the incisions were left suture less. post-operatively patients were examined next morning. detailed anterior segment examination was carried out with slit lamp. kerotometery readings were taken by javal-schiotz keratometer and noted. all the patients were prescribed with topical antibiotics and steroids combination (0.3% tobramycin and 0.1% dexamethasone). topical drops were given one drop x 2 hourly for first week. then these drops were tapered off gradually and terminated in 4 weeks. all the patients were examined on 1st, 2nd, 4th and 8th week postoperatively. uncorrected visual acuity, slit lamp examination for condition of wound, inflammatory signs in anterior chamber and any other complication was noted and k-readings were recorded on each visit. data was entered and analyzed by spss-10. catagoric variables like sex and complications were given as frequency and percentage. numerical variables like age, degree of astigmatism pre and postoperative were given by mean and standard deviation. keratometric readings were compared by applying student’s `t’ test with significance p value equal to or less than 0.05. results table 1 shows age distribution between 2 groups. age did not differ significantly between the 2 groups. there were 25 (50%) males, 25 (50%) females in group i and 19 males (38%), 31 females (62%) in group ii as shown in figure 1. wound size ranged 3.1-3.5 mm in group i, mean 3.21 and 3.44-4.0 mm in group ii, mean 3.72 mm (table 2). the difference in mean of wound size was 0.516 mm between two groups. the mean preoperative astigmatism k1 in group i was 0.545 d @ 135° and mean preoperative astigmatism k1 in group ii was 0.615 d @ 119.10°. the mean post-operative astigmatism k3 in group i was 0.86 d @ 109.8° and mean post-operative astigmatism k3 in group ii was 0.785 d @ 84.7°. the mean shift in angle in group i was 25.2° and in group ii was 34.4°. the mean surgically astigmatism k2 in group i was 0.998 d @ 94.44° and in group ii was 1.06 d @ 78.59° (tables 3). post-operative uncorrected va after 8 weeks in group i was 6/6 in 5 (10%) and in group ii was nil, 6/6p in group i was 1 (2%) and in group ii was 5 (10%), 6/9 in group i was 18 (36%) and in group ii was 11 (22%), 6/12 in group i was 13 (26%) and in group ii 65 was 14 (28%), 6/18 in group i was 7 (14%) and in group ii was 14 (28%), 6/24 in group i was 3 (6%) and in group ii was 4 (8%), 6/36 in group i was 2 (4%) and in group ii was 2 (4%), cf in group i was 1 (2%) and no patient (0%) was in group ii. the range of surgical induced astigmatism in group i was 0.25-2.09 d with 0.00-0.5 d in 10 (20%) patients, 0.50-1.00 d in 19 (38%), 1-1.5 d in 10 (20%), 1.5-2.0 d in 10 (20%) and >2 d in 1 (2%) (table 4). in group ii range of surgically induced astigmatism was 0.00-2.923 d with 0.00-0.5 d in 17 (34%), 0.5-1.00 d in 15 (30%), 1-1.5 d in 6 (12%), 1.5-2.0 d in 7 (14%) and >2 d in 5 (10%) (table 4). the mean difference in surgical induced astigmatism in two groups was 0.06 d, which was statistically insignificant (p>0.625). discussion with advancement in technique and technology, cataract surgery has become a procedure with fewer complications and more predictable visual outcomes. as a result the expectations of patients undergoing cataract surgery are not much below the patients undergoing refractive surgery. the ultimate limiting factors in optimum postoperative visual function, is often the amount of postoperative astigmatism. nevertheless, post-operative astigmatism remain one of the most unpredictable and difficult aspect of the modern cataract surgery. surgically induced astigmatism (sia) is related to the type, length and location of the incision and to the source of closure techniques8,9. with the widespread use of phacoemulsification, new surgical techniques to reduce the amount of astigmatism and facilitate visual recovery have been developed. self-sealing, small-incision surgery using a foldable intraocular lens has become popular, and the incidence of complications has significantly decreased10,11. foldable intraocular lenses and innovations in insertion forceps and injector delivery systems have enabled the use of unenlarged phacoemulsification incisions. the results showing sia after phacoemulsification in our study are almost similar to many other studies in similar setup. studies dealing with incision size indicated that the incision should be measured after iol implantation12. kohnen and coauthors12 reported that cataract incisions enlarged by approximately 11.0% with use of injectors for iol insertion. in a study conducted by mamalis13 showed that forceps inserted iols create larger change in wound diameter than lens inserted with an injector. as in our study wound size with forceps delivery system was slightly larger than with injector delivery system (0.516mm). knowing the proper size of a wound before implantation of a foldable iol is important in preventing corneal damage by uncontrolled wound extension14. in our study although the 3.2 mm keratome was used but wound was slightly enlarged in forceps delivery system so that uncontrolled wound extension would not occur. radner and coauthors15 and radner et al16 found that iol implantation through an incision that is too small intensifies corneal damage with tearing of stromal lamellae. kohnen et al12 evaluated the astigmatism changes in incision of different sizes; 3.5 mm and 4.00 mm (foldable lenses) and 5.00 mm (small optic pmma lenses). during the first post-operative week, the mean astigmatism was found to be (0.86 d) in 3.5 mm incision group, 0.93 d in 4.00 mm group and 1.6 d in 5 mm incision group. no difference in postoperative vector astigmatism was found at any postoperative examination in a study by pfleger et al17 who compared a 4.5 mm scleral incision group with a 3.5 mm scleral incision group. these studies showed that the difference in incision size in comparison group has to be 2 mm or more to be statistically significant. in our study the mean difference in wound size between two groups was less than 2 mm (0.516 mm) which was statistically insignificant (p>0.05). pfleger et al18 also studied small incision (3.2 mm) cataract surgery with foldable iol implants. the mean keratometric cylinder in their patients was 0.79 d. subsequent post-operative values recorded at one week, four weeks and 12 weeks were 0.84 d, 0.81 d and 0.74 d respectively. in a study conducted by rainer et al2 showed an sia of 0.78 d after 1 week, 0.18 d after 1 month, and 0.89 d after 3 month in supero-lateral clear corneal incision. yao et al19 conducted a study and stated that surgery was performed through a 3.2mm incision. the mean post-operative astigmatism was 0.89+/-0.83 d at the one week and+0.73+/-0.76 d at one month. 66 in our study the surgically induced astigmatism 0.999±0.53 in group i and 1.06±0.75 in group ii was slightly higher than all these studies which were mentioned above. this could be probably due to that we have taken the kerotometery readings by manual keratometer (javel-schiotz), which measures the central corneal power, and if these were measured with video keratoscopy the results could be more accurate. table 1: distribution of age in both groups age (years) group i (n=50) group ii (n=50) 40-50 9 (18.0) 9 (18.0) 51-60 19 (38.0) 21 (42.0) 61-70 19 (38.0) 9 (18.0) 71-80 2 (4.0) 10 (20.0) >80 1 (2.0) 1 (2.0) table 2: wound size in both groups wound size group i (n=50) group ii (n=50) 3.1-3.2 37 (74.0) 3.4-3.5 13 (26.) 13 (26.0) 3.6-3.7 14 (28.0) 3.8-4.0 23 (46.0) table 3: mean values in group 1 and 2 group i meas +sd group ii meas +sd p value k1 0.545±0.538 0.615±0.587 p>0.05 angle k1 135.0±54.79 119.10±53.24 p>0.05 k3 0.86±0.58 0.785±0.670 p>0.05 angle k3 109.80±42.86 84.70±50.43 p>0.01 k2 0.998±0.532 1.06±0.757 p>0.05 angle k2 94.44 78.59 k1 = pre-operative astigmatism in diopters k3 = post-operative astigmatism in diopters k2 = surgically induced astigmatism in diopters sd = standard deviation table 4: surgically induced astigmatism in groups 1 and 2 group i (n=50) group ii (n=50) 0.00-0.5 d 10 (20) 17 (34) 0.5-1.00 d 19 (38) 15 (30) 1-1.5 d 10 (20) 6 (12) 1.5-2 d 10 (20) 7 (14) >2 d 1 (2) 5 (10) range 0.25-2.09 0.00-2.923 25 25 19 31 0 5 10 15 20 25 30 35 group i group ii male female fig. 1: distribution of patients according to sex in our study, we did not encounter any serious complication as mentioned by hashmani et al20 in his first series and hussain et al4 have mentioned previously. only one case in group i developed postoperative endophthalmitis, which was excluded from this study. the data summarized here demonstrated that although there was a small difference in wound size in both group but surgically induced astigmatism was not significant in both groups. conclusion delivery of intraocular lens with injector and forceps was safe and equally acceptable statistically with statically insignificant difference in surgically induced astigmatism. author’s affiliations dr. nasrullah department of ophthalmology sheikh zayed hospital, lahore n um be r of p at ie nt s 67 dr. atif mansoor assistant professor department of ophthalmology sheikh zayed hospital lahore dr. khalid waheed associate professor services hospital lahore dr. tahir mahmood professor of ophthalmology shaikh zayed hospital lahore references 1. stenevi u, lundstrom m,thorburn w. an outcome study of cataract surgery based on natism registrar. acta ophthalmol 1997; 75: 688-91. 2. rainer g, menapace r, vass c. corneal shape changes after temporal supero lateral 3.0 mm clear corneal incisions. j cataract refract surg 1999; 25: 1121-6. 3. data vk, sidhu n. management of cataract: revolutionary change that occurred during last two decades. j indian med assoc1999; 8: 313-7. 4. hussain m, durrani j, nisar a. phacoemulsification: a review of 210 cases. pak j ophthalmol 1996; 12: 38-9. 5. takeshita t, yamada k, tanihara h. single-action implantation of a 3-piece acrylic intraocular lens with an injector. j cataract refract surg 2003; 29: 246-9. 6. asia ei, jubran rz, solberg y, et al. the role of intraocular lenses in anterior chamber contamination during cataract surgery. graefes arch clin exp ophthalmol 1998; 236: 721-4. 7. kohnen t, koch dd. experimental and clinical evaluationof incision size and shape following forceps and injector implantation of a three – piece high – refractive – index silicone intraocular lens. graefes arch clin exp ophthalmol. 1998; 236: 922-8. 8. simsek s, yasar t, demirok a. effect of superior and temporal clear corneal incisions on astigmatism after sutureless phacoemulsification. j cataract refract surg. 1998; 24: 515-8. 9. roman sj, auclin fx, chong-sit da, et al. surgically induced astigmatism with superior and temporal incisions in cases of within the rule preoperative astigmatism. j cataract refract surg. 1998; 24: 1636-41. 10. john t, sims m, hoffmann c. intraocular bacterial contamination during sutureless, small incision, single-port phacoemuslification. j cataract refract surg. 2000; 26: 1786-91. 11. muller-jensen k, barlinn b. corneal refractive changes after acrysof lens versus pmma lens implantation. ophthalmologica. 2000; 214: 320-3. 12. kohnen t, dick b, jacobe kw. comparison of the induced astigmatism after temporal clear corneal tunnel incisions of different sizes. j cataract refract surg. 1995; 21: 417-24. 13. mamalis n. incision width after phacoemulsification with foldable intraocular lens implantation. j cataract refract surg. 2000; 26: 237-41. 14. tekeshita t, yamada k, tanihara h. single-action implantation of a 3 piece acrylic intraocular lens with an injector. j cataract refract surg. 2003; 29: 246-9. 15. radner w, menapace r, zehetmayer m, et al. ultrastructure of clear corneal incision. part 1. effect of keratomes and incision width on corneal trauma after lens implantation. j cataract refract surg. 1998; 24: 487-92. 16. radner w, menapace r, zehetmayer m. ultrastructure of clear corneal incisions. part-ii. corneal trauma after lens implantation with the microstaar injector system. j cataract refract surg. 1998; 24: 493-9. 17. pfleger t, scholz u, skorpik c. postoperative astigmatism after no-stitch, small incision cataract surgery with 3.5 mm and 4.5 mm incisions. j cataract refract surg. 1994; 20: 400-5. 18. pfleger t, skorpik c, manapace r, et al. long term course of incudced astigmatism after clear corneal incisionin cataract surgery. j cataract refract surg. 1996; 22: 72-7. 19. yao k, jiang j, yang y. phacoemulsification and foldable intraocular lens implantation through a small sutureless incision. zhonghua yan ke zhi. 1997; 33: 103-5. 20. hashmani s, haider i, khan ma. phacoemulsification: result and complication during the learning. pak j ophthalmol. 1997; 13: 32-6. 156 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology original article association between visual impairment and socio-economic factors in karachi population saba alkhairy, zahra turab, arbaz riaz, ashar shah pak j ophthalmol 2017, vol. 33, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: saba alkhairy department of ophthalmology, dimc. duhs email:saba.alkhairy1@gmail.com …..……………………….. purpose: to determine a correlation between visual impairment and socioeconomic levels within the eye outpatient department (opd) of dow university hospital, ojha campus, karachi, pakistan. study design: cross-sectional study. place and duration of study: dow university hospital eye opd, karachi, from january 11 th 2016 to august 5 th 2016. material and methods: a detailed history of each patient was first obtained, followed by an initial test for visual acuity and refraction by an optometrist using snellen’s chart and auto refractometer rm 8800, model: 2005 topcon. after dilating with 1% tropicamide solution, the anterior/posterior segments were evaluated. the evaluation was performed by an ophthalmologist, who later subdivided the patients. each patient were subdivided based on a modified who categorization of visual impairment. 1 patients were organized into three groups; mild at 6/9 to 6/12, moderate at 6/18 to 6/24, and severe at 6/36 to 6/60. results: among 350 patients, 182 (52%) were males and 168 (48%) were females. the mean age was 54.71 ± 11.83 years. a majority of patients had mild visual impairment (n = 257, 73.4%) whereas 43 (12.3%) had severe visual impairment. socio-demographic characteristics such as age and education level were found to be significantly associated with visual impairment (p-value = 0.002) and (p-value = 0.024), respectively. conclusion: the results show a direct correlation between visual impairment and socioeconomic factors such as education, gender, and ethnicity. key words: visual impairment. socioeconomic disparity. ethnic division. ncome directly affects an individual’s access to health care2. the purpose of this study is to evaluate the degree to which an individual’s income and education plays a role in their visual health. vision is an essential requirement for independent living. the eyes, more than any other sensory organ, can debilitate an individual’s lifestyle3. vision is the simple reception of a light reflex from surrounding objects4. similar to the way other sensory organs behave, there are a number of physiological steps which convert light waves into chemical signals, sent through the visual pathway to be processed in the occipital lobe. it is estimated that 90% of the total population who suffer from impaired vision belong to low-income communities4, something that was directly supported by our findings in this research. furthermore, similar to other international communities, refractive errors and cataracts are the leading causes of impaired visual acuity5. the who definition of vision is based on four categories: normal 6/6, moderate 6/18, severe 6/60, and blind 3/60 to 1/606. i mailto:saba.alkhairy1@gmail.com association between visual impairment and socio-economic factors in karachi population pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 157 karachi is the most populous city in pakistan, located in the province of sindh5. the karachi population provides a diverse patient base, one that is representative of all ethnic groups found within the country7. this helps to ensure that the study remains unbiased and inclusive. pakistan is the sixth most populous country, and defined as a developing country by the world health organization5. it is also classified as a low-income nation by the world bank8. this in an important fact to be mindful about, since the core of this study is to show a direct correlation between income and visual health. this is important to recognize because the greater population is classified as low income, which means that the greater population is at risk for impaired vision. a 2007 research conducted by the pakistani national eye survey study group – found the leading cause of impaired vision to be cataract and refractive errors8. this not only mirrors other international communities, but also helps to narrow down the scope and focus of this paper. the correlation between income and education vis-á-vis visual acuity in pakistan, follow general trends as the rest of the international community. the data and research of this paper will further help support this correlation. it will be judicious of pakistani physicians to follow solution similar to international standards. income inequality is an important factor to consider. in developed nations, the debate is often centered on the quality of education. in pakistan this is not the case. due to an under developed social environment, the main focus is instead on availability of education and gender disparity. the theories of human capital development by researchers such as becker and mincer also apply to pakistan9. however, again due to lack of development in social infrastructure, it is difficult to come to a clear understanding. in recent years, a national study – pakistan integrated household survey – had made an attempt to fix and define the social sector by introducing new resources such as technical training and technology literacy10. this was meant to help increase the pool of information available for study, and to also allow those in pakistan to use international methods of research such as the mincerian method10. to develop a functional modern state, both genders must be equally educated11. currently this is not the case. figures presented by unesco (as of 2004) show that only 60% of girls are enrolled in a primary school10. at the secondary level, the percentage drops much lower to 32%18. lower education has a negative impact on an individual’s lifestyle and health. there clearly seems to be a direct correlation between education and income, supported by other research and publications as well17, a factor that would affect a patient’s physical and emotional well being. material and methods data on the individuals with regard to factors and vi results were derived from our research. our study comprises of a cross-sectional data of five ethnic groups. this is similar to the study conducted by win wah and arul earnest for the singapore epidemiology of eye disease program.3. in this study, three ethnic groups were focused on. the study was much larger compromising of a total 10,000 subject resulting in a comprehensive understanding of socioeconomic and vi interplay13. in contrast to the win wah and arul earnest study, we divided our education level into four rather than three13. patients visiting the eye opd at dow university ojha campus were tested for visual acuity by an auto refractometer rm 8800 model: topcon ps-61e385945that was made in japan, as well as a snellen chart by an optometrist. all patients were above 30 years of age. aside from age, no other factors were used to exclude any patients. 350 patients were randomly selected as they presented to the eye opd and were surveyed. those patients were divided into 5 ethnic groups because we wanted to study the level of education in each ethnic group. patients were then further subdivided by gender, level of education, and household income. education was categorized into four sections: ne (no education), primary, secondary, and higher. according to m.h. emamian’s article gap of visual impairment between economic groups, visual impairment is more prominent in lower socioeconomic communites14. each individual’s visual acuity was categorized based on four levels; best at 6/6 to worst at 6/60. an ophthalmologist further examined patients that were between 6/9 and 6/60. before examination, each patient’s eye was dilated with 1% tropicamide and left for 10-30 minutes. afterwards, the anterior and posterior segment was examined with a slit lamp microscope (topcon ps-61e385945made in japan). after the diagnosis was confirmed, each patient was asked if they would like to participate in a survey. patients were informed about the survey and told about the anonymous nature of the research, with their information recorded with their consent. all saba alkhairy, et al 158 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology information was kept confidential and each patient’s privacy was respected. each individual was asked about his or her gender, age, education, household income, and ethnic background. after the collection of data, the information was categorized and grouped by the researcher. post-categorization, the sub-categories were analyzed and reviewed by a professor. this method was used to ensure the validity of the data from the collection and categorization process. results among 350 patients, 182 (52%) were males and 168 (48%) were females, with a mean age of 54.71 ± 11.83 years. from our selected group, 114 (32.6%) patients were uneducated and 107 (30.6%) had attained higher education. according to unesco, the literacy for pakistan is defined as “one who can read newspapers and write a simple letter, in any language”15. the literacy rate is applied to age 10 and above. the literacy rate stands at 32.6% (n = 114) uneducated and 30.6% (n = 107) had higher education. the literacy rate for both sexes is 43.92% total15. the literacy rate was categorized into four sections: ne (no education), primary (grades 1 – 5), secondary (grades 6 – 12), and higher (college graduate). a similar proportion of participants 127 (36.3%) and 120 (34.3%) had a monthly household income of less than 20,000 pkr and between 21,000 to 40,000 pkr, respectively. a majority of patients had mild visual impairment (n = 257, 73.4%) whereas 50 (14.3%) and 43 (12.3%) had moderate and severe visual impairment, respectively (see table 1). table 1: baseline characteristics of the patients (n = 350). characteristics n % gender male 182 52.0 female 168 48.0 age (years) ≤ 50 141 40.3 51 – 60 102 29.1 > 60 107 30.6 ethnicity urdu 124 35.4 sindhi 94 26.9 punjabi 39 11.1 pashto 38 10.9 balochi/others 55 15.7 education level no education 114 32.6 primary 65 18.6 secondary 64 18.3 higher 107 30.6 income ('000') ≤ 20 127 36.3 21 – 40 120 34.3 > 40 103 29.4 visual impairment (bcva) mild 257 73.4 moderate 50 14.3 severe 43 12.3 chi-square tests were run to check the association of patients’ socio-demographic characteristics and their visual impairment. it was found that females (n = 25, 14.9%) were more likely to have severe visual impairment as compared to males (n = 18, 9.9%). age was significant in association to visual impairment (p-value = 0.002). it was noted that patients who were > 60 years of age, 20 (18.7%) had moderate, and 22 (20.6%) had severe visual impairment (see table 2). looking at socioeconomic characteristics such as education level and income, we found education level was significant in association to visual impairment (p-value = 0.024). patients with no education were positively associated with severe impairment (n = 21, 18.4%), and only 9 (8.4%) patients who belonged to higher education group had severe visual impairment. while, only 9 (8.7%) of the patients who received > 40,000 pkr monthly household incomes had severe visual impairment. however, income was not significant in association to visual impairment (see table 3). being an important and statistically significant association between visual impairment and socio-economic factors in karachi population pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 159 socioeconomic characteristic, further associations of education level were observed. it was found that female’s proportion (n = 78, 46.4%) of being uneducated was comparatively higher than male’s proportion (n = 36, 19.8%). it was also observed that the tendency of getting higher education was more prevalent in urdu speaking patients (n = 61, 49.2%) when compared to other ethnic groups (see table 4). table 2: demographic characteristics of patients by visual impairment (n = 350). characteristics total mild moderate severe p-value* n (%) n (%) n (%) gender male 182 137 (75.3) 27 (14.8) 18 (9.9) 0.363 female 168 120 (71.4) 23 (13.7) 25 (14.9) age (years) ≤ 50 141 106 (75.2) 22 (15.6) 13 (9.2) 0.002 51 – 60 102 86 (84.3) 08 (7.8) 08 (7.8) > 60 107 65 (60.7) 20 (18.7) 22 (20.6) ethnicity urdu 124 90 (72.6) 20 (16.1) 14 (11.3) 0.790 sindhi 94 68 (72.3) 14 (14.9) 12 (12.8) punjabi 39 27 (69.2) 06 (15.4) 06 (15.4) pashto 38 28 (73.7) 03 (7.9) 07 (18.4) balochi/others 55 44 (80.0) 07 (12.7) 04 (7.3) *p-value has been calculated using chi-square test table 3: socioeconomic characteristics of patients by visual impairment (n = 350). characteristics total mild moderate severe p-value* n (%) n (%) n (%) education level no education 114 77 (67.5) 16 (14.0) 21 (18.4) 0.024 primary 65 41 (63.1) 15 (23.1) 09 (13.8) secondary 64 53 (82.8) 07 (10.9) 04 (6.2) higher 107 86 (80.4) 12 (11.2) 09 (8.4) income ('000') ≤ 20 127 91 (71.7) 19 (15.0) 17 (13.4) 0.549 21 – 40 120 84 (70.0) 19 (15.8) 17 (14.2) > 40 103 82 (79.6) 12 (11.7) 09 (8.7) *p-value has been calculated using chi-square test saba alkhairy, et al 160 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology table 4: distribution of gender and ethnicity by education level (n = 350) characteristics total no education primary secondary higher n (%) n (%) n (%) n (%) gender male 182 36 (19.8) 40 (22.0) 40 (22.0) 66 (36.3) female 168 78 (46.4) 25 (14.9) 24 (14.3) 41 (24.4) ethnicity urdu 124 12 (9.7) 22 (17.7) 29 (23.4) 61 (49.2) sindhi 94 46 (48.9) 14 (14.9) 10 (10.6) 24 (25.5) punjabi 39 8 (20.5) 13 (33.3) 8 (20.5) 10 (25.6) pashto 38 24 (63.2) 6 (15.8) 6 (15.8) 2 (5.3) balochi/others 55 24 (43.6) 10 (18.2) 11 (20.0) 10 (18.2) demographic characteristics such as gender, age (categorized into three classes, 50 years, 51 – 60 years and 60 years), ethnicity, education level, and income (categorized into three classes, 20,000 pkr, 21,000 – 40,000 pkr and 40,000 pkr) were treated as independent variables. the response variable was visual impairment (vi), which was generated by measuring the best-corrected visual acuity (bcva) of the patient. bcva was categorized into mild, moderate, and severe. it was considered mild if bcva was between 6/9 and 6/12, moderate if bcva was between 6/18 and 6/24, and severe if bcva was between 6/36 and 6/60. descriptive analysis involved frequency distributions and percentages of all the categorical variables. inferential analysis involved chi square tests, which were used to check significant association between the outcome variable and independent variables. all test results having p-value less than or equal to 0.05 level were considered statistically significant. statistical package for social sciences (spss) version 16.0 was used for analysis. discussion in this cross-sectional study, patients older than 30 years of age were used to determine any correlation between visual acuity/eye health and various factors such as gender and income. the outcome was that 58% of males and 48% of females were found to have impaired vision. this finding stands in stark contrast to other study where females make up a greater population. anna kuis-ulldemolns conducted one such study. in her 2012 study of social inequalities in blinds and visual impairment, she also found that male were greater in numbers when visually impaired. yet, she also believed that genetic and hormonal factors could lead to a greater risk for visual impairment in women. our study also found that women are at a greater risk. not only because of genetic/hormonal factors but also due to lack of education and income inequality12. our study found that 18.4% (n=21) patients with no education had severe visual impairment while only 8.4% (n = 9) of patients with higher education had severe visual impairment. although not conclusive, it is evident that higher education does play a role in improving overall visual health16. this correlates with a korean study published in 2014 by tyler h.t. rim et al titled, prevalence and risk factors of visual impairment and blindness in korea, which had parallel findings with our study. this study went further and looked into other variables as well, such as employment and marital status17. it found that lower-class educated singles from the rural areas had an increased risk for visual impairment. although our study did not take into account urban/rural settings and marriage, it would not be a surprise to find similarities in pakistan. this is in contrast with a 2015 study conducted by keri l. norris et al in the greater atlanta area in united states, titled association of socioeconomic status with eye health among women with/without diabetes. she found that factors such as income and education did not have any statistically significant impact on visual impairment18. it is important at this point to be association between visual impairment and socio-economic factors in karachi population pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 161 mindful of the different locations of each study, and their respective impact on the result. nonetheless, it is beyond any doubt that factors such as income and education plus gender play a role in the overall visual health of a patient. education and visual acuity play a complex role, which is impacted by variables beyond our scope of research such as gender and ethnic background. this complexity was best highlighted in a recent article written by alison bruce titled impact of visual acuity on developing literacy at age 4 – 5 years. the main focus of the study was to understand the relationship between visual acuity and literacy around the city of bradford19. the objective of her study, along with the goals set, apply to pakistan. dr. alison bruce points out that early literacy is an important factor in the future of an educated individual, who in turn will have a higher standard of living and better health. education is directly impacted by visual acuity, and poor acuity will lead to poor education, resulting in lower social standards and lower health. alison bruce’s study takes a positive step into bringing statistical evidence to support and confirm this theory19. furthermore, the article strives to also quantify the impact of vision and literacy with socioeconomic factors19. the finding of the study was able to demonstrate that poor visual acuity is associated with reduced early development.19 another very important finding of the study was that the overall low visual acuity of children in the city of bradford was not related to their ethnic background19. the groups covered by the study – i.e. whites, pakistanis and others – all had similar visual acuity, rendering ethnicity as an insignificant factor. it goes on to isolate socioeconomic factors as the leading cause of low visual acuity, which in turn lowers the overall standard of living and health of an individual19. in a country such as pakistan, where ethnic tension has caused instability in the past, it is very important and enlightening to learn that ethnic background plays no role in the visual acuity and overall ability of children to learn19. access to a health care professional as well as education can, and will allow all children to have a better health and lifestyle. hein t.v. vu found in his study, impact of unilateral and bilateral vision loss on quality of life, those with uncorrected vision had a significantly poorer social and emotional function. although, this article focused solely on uni/bilateral vision loss; it is nonetheless representative of the difficulties brought to living by lower visual health/vision loss20. our study had certain limitations, which narrowed the focus of our research. it was focused on only a single center in karachi, and only a small sample size was used. the strength of the study was that people of various economic backgrounds were included. an extensive study with a greater number of patients would have had provided more extensive data from which better conclusions could have been reached. we recommend further studies to be conducted in the future with a much larger sample size and many more centers for more accurate results. conclusion the results show a direct correlation between visual impairment and socioeconomic factors such as education, gender, and ethnicity. author’s affiliation dr. saba alkhairy, fcps, assistant professor dimc, duhs zahra turab student, dimc, duhs arbaz riaz student, dimc, duhs ashar shah student, dimc, duhs role of authors dr. saba alkhairy manuscript review. zahra turab data collection and study design. arbaz riaz data collection and study design. ashar 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emerging voices from india. manohar publishers & distributors; 2015. 8. dineen b, bourne r, jadoon z, shah s, khan m, foster a et al. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey, 2007. 9. becker gs. investment in human capital: a theoretical analysis. journal of political economy, 1962 oct 1; 70 (5, part 2): 9-49. 10. memon g. education in pakistan: the key issues, problems and the new challenges. journal of management and social sciences, 2007; 3 (1): 47-55. 11. aikman s, unterhalter e, editors. beyond access: transforming policy and practice for gender equality in education. oxfam; 2005. 12. lansingh v, carter m, uldemonllins a, valencia l, eckert k. social inequalities in blindness and visual impairment: a review of social determinants. indian journal of ophthalmology, 2012; 60 (5): 368. 13. wah w, earnest a, sabanayagam c, cheng c-y, ong meh, wong ty, et al. composite measures of individual and area-level socio-economic status are associated with visual impairment in singapore. plos one. 2015 oct; 10 (11). 14. emamian m, zeraati h, majdzadeh r, shariati m, hashemi h, fotouhi a. the gap of visual impairment between economic groups in shahroud, iran: a blinder-oaxaca decomposition. american journal of epidemiology, 2011; 173 (12): 1463-1467. as cited by dineen b, bourne r, jadoon z, shah s, khan m, foster a et al. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. british journal of ophthalmology, 2007; 91 (8): 1005-1010. 15. rahman au, uddin s. statistical analysis of different socio economic factors affecting education of nw. fp (pakistan). journal of applied quantitative methods, 2009; 4 (1): 88-94. 16. bergan a. personal income distribution and personal savings in pakistan. growth and inequality in pakistan, 1972: 208-23. 17. rim tht, nam js, choi m, lee sc. prevalence and risk factors of visual impairment and blindness in korea: the fourth korea national health and nutrition examination survey in 2008-2010. acta ophthalmologica. 2014; 92 (4). 18. norris kl, beckles gl, chou c-f, zhang x, saaddine j. association of socioeconomic status with eye health among women with and without diabetes. journal of women's health, 2016; 25 (3): 231-6. 19. bruce a, fairley l, chambers b, wright j, sheldon ta. impact of visual acuity on developing literacy at age 45 years: a cohort cross-sectional study. bmj open. 2016; 6 (2). 20. vu htv, impact of unilateral and bilateral vision loss on quality of life. british journal of ophthalmology, 2005 jan; 89 (3): 360-3. 21. alkhairy s, siddiqui f, ul-hassan m. orbitofacial anthropometry in a pakistani population. pakistan journal of ophthalmology, 2016; 32 (1): 41-47. 22. nazs butt a. study on binocular vision assessment and refraction in patients of anterior segment corneal dystrophies. south asian journal of life sciences, 2015; 3 (1): 1-5. 23. ahmad k, zwi ab, tarantola djm, soomro aq, baig r, azam si. gendered disparities in quality of cataract surgery in a marginalised population in pakistan: the karachi marine fishing communities eye and general health survey. plos one, 2015; 10 (7). 24. bernabeo e, holmboe e. patients, providers, and systems need to acquire a specific set of competencies to achieve truly patient-centered care. health affairs, 2013; 32 (2): 250-258. 25. cosgrove d, fisher m, gabow p, gottlieb g, halvorson g, james b et al. ten strategies to lower costs, improve quality, and engage patients: the view from leading health system ceos. health affairs, 2013; 32 (2): 321-327. 26. lansingh v, spivey b, furtado j, winthrop k. training of an ophthalmologist in concepts and practice of community eye health. indian j ophthalmology, 2012; 60 (5): 365. microsoft word rao muhammad rashad qamar 128 original article outcome of levator resection in congenital ptosis with poor levator function rao muhammad rashad qamar, muhammad younis tahir, abid latif, ejaz latif pak j ophthalmol 2011, vol. 27 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: rao m. rashad qamar 29-b, medical colony, bahawalpur submission of paper december’ 2010 acceptance for publication august’ 2011 …..……………………….. purpose: purpose of the study is to evaluate the success of levator resection in congenital ptosis with poor levator function. material and methods: it was a single center, prospective, interventional case series. the study was carried out at department of ophthalmology, bahawal victoria hospital, bahawalpur from march 2008 to november 2010. we selected 50 cases from outdoor department by universal sampling technique. levator resection was carried out in all 56 cases (eyes) of congenital ptosis (with 06 bilateral cases) with poor levator function (less than 4mm) after taking informed written consent. patients were subjected to general anesthesia. data was collected on special proforma and was analyzed with the help of spss. results: the study population comprised of 56 eyes of 50 cases of congenital ptosis. male to female ratio was 3:1. two bilateral cases were females and four were males. age ranged between 04-32 years (mean = 14 years). about 75% patients were between 13 and 24 years. the results were excellent in majority (67.8%) with complete lid closure. good results were seen in 17.85% with only 7.14% with fair and poor outcome each. the major cosmetic defect in all cases was lid lag on extreme downward gaze. the operation is extremely laborious but fully justified by the good results. conclusion: levator resection in congenital ptosis with poor levator function is a viable option for cosmesis especially in unilateral cases. tosis is an abnormal low position of the upper eyelid which may be congenital or acquired. it is a common problem and is found in all age groups. primary congenital ptosis is present at birth and tends to be non progressive. it may be bilateral, isolated, or part of an associated syndrome. there is harmony between its severity and levator function. it is often due to the poor development of the levator muscle or its replacement by fibrosis, fat, or areolar tissue1. amblyopia is rare in congenital ptosis unless it is associated with severe unilateral ptosis, anisometropia, or strabismus2. anatomically ptosis may be classified as neurogenic (third nerve palsy, horner syndrome, and marcus gunn jaw-winking syndrome), myogenic (myasthenia gravis, myotonic dystrophy, ocular myopathy, simple congenital, or blepharophimosis syndrome), aponeurotic (involutional, postoperative), and mechanical (dermatochalasis, tumors, edema, anterior orbital lesions, and scarring)3. to classify a ptosis into one of these categories, a thorough medical history and physical examination must be performed and certain tests may be necessary. there are three classic al surgical procedures for the treatment of ptosis; frontalis suspension, levator resection and muller muscle-conjunctival resection. frontalis sling is considered as only option for poor levator function ptosis. we conducted this study to observe the usefullness of levator resection as primary surgical procedure in all congenital ptosis patients with poor upper lid excursion. material and methods study design: it was a single centre, prospective, interventional case series. the study was carried out in duration of more than two calendar years starting from march 2008 to november 2010. p 129 setting: the study was conducted at the department of ophthalmology, a tertiary eye care and teaching facility, at bahawal victoria hospital, bahawalpur, affliated with quaid-e-azam medical college bahawalpur. sample: we treated 56 eyes of 50 patients. all had poor levator function, good bell's phenomenon, normal pupil size and reaction to light and normal corneal sensitivity. males were 36 and 14 were female. age range was 04-32 years (mean: 14 years). diagnosis was based on history, old photographs, and routine ophthalmic examination. oculoplastic examination specific to ptosis was performed by the operating surgeon, this included, vertical palpebral fissure height, marginal reflex distance (mrd), levator excursion, lid crease height, bells phenomenon and ocular motility. all patients included were diagnosed as congenital ptosis. it also included checking head position, chin elevation, brow position, and brow action in attempted up gaze. all the patients had detailed systemic evaluation to rule out secondary causes of the ptosis. exclusion criteria were, absent bell’s phenomenon, disturbed or absent corneal sensitivity and dry eyes. surgery was performed by single surgeon (rrq). all patients were explained about the procedure and informed consent obtained. definitions excellent: 0 and +/0.5 mm and complete lid closure. good: +0.5 mm and +1.00 mm and complete lid closure. fair: + 1.00 mm and + 1.5 mm and complete lid closure. poor: greater than + 1.5 mm. technique of surgical intervention: levator resection was carried out through skin approach (blascovics technique). all patients were subjected to general anesthesia. after preparing and draping, an incision was marked at a level symmetric with the opposite eyelid usually 8-10 mm above the lid margin. a cut was made along the marked line using #15 scalpel blades. a blunt dissection was carried out towards lid margin to expose tarsal plate for reattachment of levator at the end of the surgery. the post orbicular facial plane was entered and orbital septum was exposed and confirmed by applying inward pressure at lower part of globe and pre aponeurotic fat popped up under septum. the septum was incised with sharp scissors and the attachments between the septum and aponeurosis were separated to prevent postoperative lagophthalmos. the aponeurosis and whitnall's ligament were revealed by brushing the pre aponeurotic fat pockets upward. this was followed by disinsertion of the aponeurosis from the tarsus. carrying blunt dissection, the muscle was dissected all the way to the whitnall's ligament. a 6.0 vicryl was passed through partial thickness of the tarsus, 3 mm from its upper border and above the central pupil posterior to the aponeurosis and retrieved through the whitnall's. two additional sutures were added between the tarsus and whitnall’s and placed medially and laterally. the three sutures were adjusted as needed. finally, the skin incision was closed with running 6.0 vicryl sutures. complications: major per operative complications faced were loss of proper facial plane, hemorrhage while separating aponeurosis from conjunctiva and button holes in conjunctiva. follow-ups: patients had a follow-up on day one, at 4 weeks, 6 months and then last follow up at 2 years. results goal was to adequately elevate the lid while minimizing the risk of lagophthalmos and exposure keratopathy/ulceration. in majority (85.65%) results obtained were good to excellent (table 1) with a welldefined symmetry in lid height and shape (fig 1-3). in four (7.14%) cases, results were cosmetically acceptable and patients were satisfied although graded as fair, however residual ptosis occurred in four cases (7.14%) and required further surgical procedure at a later date. reoperation was uncomplicated and final outcome was successful. the significant postoperative complications were over correction in one patient which was not significant to warrant reoperation. one female patient had forniceal prolapsed (fig 4) which was sutured and two patients had suture related granuloma, treated with antibiotics, which did not influence the final outcome. discussion embryologically, most of the connective tissue of upper lid is derived from mesenchyme15-17,21. the orbital septum is derived from mesenchyme of second arch15. suborbicularis fibro adipose tissue consists of multiple fibrous septa that merge posteriorly with the orbital septum and give orbital septum a multilayered quality, augmenting the contour of superior sulcus6,22. simple congenital ptosis is thought to be the result of 130 pre-op post-op fig 1: pre-op post-op post-op lid closure fig 2: fig 3: pre-op post-op fig 4: suture to forniceal prolapse table 1: outcome no. of patients n (%) excellent 38 (67.8) good 10 (17.85) fair 04 (7.14) poor 04 (7.14) total 56 (100) developmental dystrophy of levator muscle. normal muscle fibres are replaced by fibrous connective tissue without contractile properties. ptosis is more marked in an up gaze and the upper lid is relatively retracted in a down gaze16. ptosis can have a marked impact on a patient's functional status9 and lead to poor visual development in childhood with its damaging social and financial consequences in later life2. the goal of ptosis surgery was once described as one with elusive perfect result10. ptosis surgery in paediatric patients differed from adult surgery in that predictability of lid height in later group could be enhanced by using local 131 anaesthesia or adjustable sutures11,12. as there were no authentic published data regarding time taken to reach final lid height stability in primary congenital ptosis patients, we chose a maximum follow-up of 2 years as a stable end point. in ptosis surgery, a good cosmetic outcome is very important, this holds true for congenital myogenic ptosis as well. more than 100 techniques for the treatment of ptosis have been reported4-6. this means ptosis is difficult to treat, as the postoperative eyelid position may be unpredictable20. different surgical techniques have been laid out for the management of primary congenital ptosis. this depends upon severity of ptosis, laterality, and levator function. the surgical approach may include posterior resection for mild ptosis with normal levator function or levator aponeurosis resection for moderate-to-poor levator function and frontalis suspension for bilateral ptosis with poor to absent levator function8. in our patients, levator aponeurosis resection has given the best results with excellent patient satisfaction despite the fact that the levator function was extremely poor (<4 mm). although it has been reported that extra-large levator resection may lead to lagophthalmos, none of our patients has experienced this complication. the lagophthalmos may not be a problem as it depends on the orbicularis tone and function. every ptosis surgery has goals such as controlled height, contour, lid crease, lash position, and symmetry. we found that our patients achieved almost all such targets. in ptosis surgery, use of adjustable suture technique is popular in adults but not well tolerated in children. it is therefore important to consider an approach that gives good ptosis correction with cosmetically acceptable upper lid skin crease19. the ideal procedures in ptosis surgery are those that disturb normal anatomy the least and also allow for good results17. in this study an anterior approach was selected, thus avoiding conjunctiva, lacrimal gland and tarsus. in all cases, after incising skin, blunt dissection in a proper facial plane was carried out to reveal septum. incising septum gave the hold of aponeurosis and separation of it from underlying conjunctiva is critical to avoid bleeding from peripheral vascular plexus and saving conjunctiva from button holling. finally, muscle is attached to tarsus with 6-0 vicryl suture and skin is closed with the same type of suture. this technique appears to enhance the overall cosmetic outcome. conclusion in this series we treated 56 eyes of 50 patients with primary congenital ptosis and poor levator function with levator aponeurosis resection. all the patients achieved the desired result without any complications. although recent findings have shown the frontalis suspension technique is a commonly performed surgical correction of congenital ptosis, used widely in the repair of ptosis with poor levator function, we recommend that levator resection procedure to be considered as primary procedure for the correction of congenital ptosis with very poor levator function. author’s affiliation dr. rao muhammad rashad qamar associate professor of ophthalmology qamc/bvh, bahawalpur dr. muhammad younis tahir senior registrar of ophthalmology qamc/bvh, bahawalpur dr. abid latif senior registrar of ophthalmology qamc/bvh, bahawalpur dr. ejaz latif professor of ophthalmology qamc/bvh, bahawalpur reference 1. baroody m, holds jb, vick vl. advances in the diagnosis and treatment of ptosis. curropin ophthalmol. 2005; 16: 351-5. 2. anderson rl, baumgarter sa. amblyopia in ptosis. arch ophthalmol. 1980; 98: 1068-9. 3. finsterer j. aesthetic plast surg. ptosis: causes, presentation, and management. 2003; 27: 193-204. 4. jones lt. the anatomy of the upper eyelid ptosis surgery. am j ophthalmol. 1964; 57: 943-59. 5. jones lt, quickert mh, wobig ij. aponeurotic repair. arch ophthalmol. 1975; 8: 629-34. 6. mustardι jc. correction of ptosis by split level lid resection. clinplas surg.1978; 5: 533-5. 7. allard fd, durairaj vd. current techniques in surgical correction of congenital ptosis. middle east afr j ophthalmol. 2010; 17: 129-33. 8. jordan dr, anderson rl. the aponeurotic approach to congenital ptosis. ophthal surg. 1990; 21: 237-44. 9. federeci tj, meyer dr, lininger ll. correction of the vision related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. ophthalmology. 1999; 106: 1705-12. 10. carraway jh. cosmetic and functional considerations in ptosis surgery. the elusive "perfect" result. clinplas surg. 1988; 15: 185-93. 132 11. lindberg jv, vasquez rj, ckao gm. aponeurotic ptosis repair under local anesthesia. ophthalmology. 1988; 95: 104652. 12. collin jr, o'donnel ba. adjustable sutures in eyelid surgery for ptosis and lid retraction. br j ophthalmol. 1994; 78: 167-74. 13. complications of ptosis surgery and their management. in: mccord c, editor. eyelid surgery principles and techniques. chap. 11. philadelphia: lippincott-raven. 1995; 144-55. 14. anderson rl, jordan dr, dutton jj. whitnall's sling for poor function ptosis. arch ophthalmol. 1990; 108: 1628-32. 15. bremond-gignac ds, deplus s, cussenot o. anatomic study of orbital septum. surg radiol anat. 1994; 16: 121-4. 16. meyer dr, lindberg jv, wobig jl. anatomy of orbital septum and associated eyelid connective tissues. implications for ptosis surgery. ophthal plast reconstr surg. 1991; 7: 104-13. 17. jones lt. the anatomy of the upper eyelid and its relationship to ptosis surgery. am j ophthalmol. 1964; 57: 943-59. 18. berke rn, hackensack nj, wadsworth jac. histology of levator muscle in congenital and acquired ptosis. arch ophthalmol. 1955; 53: 413-28. 19. collin jro, o’donnell ba. adjustable sutures in eyelid surgery for ptosis and lid retraction. br j ophthalmol. 1994; 78: 167-74. 20. berke rn, hackensack nj. results of resection of levator muscle through skin incision in congenital ptosis. arch ophthalmol. 1959; 61: 177-201. 21. wolff e: anatomy of eye and orbit. philadelphia, blackiston company. 1954: 153-209. 22. anderson rc, beard c. the levatoraponeurosis: attachments and their clinical significance. arch ophthalmol. 1977; 95: 143749. 23. baylis hi, cies wa. identifying the orbital septum. arch ophthalmol. 1976; 94: 805. 24. mustarde j, callahan a, jones l. ophthalmic plastic surgery up-to-date. birmingham, aesculapius publishing. 1970; 6-12. 25. mcelvanney am, adhikary hp: congenital ptosis, a good cosmetic result with redefinition and suturing of the orbital septum. eye. 1996; 10: 548-50. microsoft word zaman shah 89 original article a review of 144 cases of dacryocystorhinostomy zaman shah, ibrar hussain, naeem khattak, mustafa iqbal pak j ophthalmol 2009, vol. 25 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: zaman shah nasser teaching hospital gahdhara university peshawar received for publication august’ 2008 … ……………………… purpose: to determine the surgical outcome of blocked lacrimal pathway. material and methods: this is a retrospective study of 144 patients admitted in naseer teaching hospital peshawar from january 2005 to december 2007. results: the age of the patients was in range from 06 to 60yrs. 45(31.25%) were male and 99(68.75%) were female. all of these cases were unilateral. 134(93.05%) of the total patients were operated under local anesthesia and the rest 10(6.94%) were under general anesthesia. the overall success rate was 62.5% in intubated patients and 93.75% without intubation conclusion: external dacryocystorhinostomy is still the cheapest and effective surgical procedure. atering and pus discharge is an annoying symptom of a patient who is suffering from blocked lacrimal pathway. the condition is characterized by positive regurgitation test, matting of the eye lashes and conjunctivitis. some time the condition get worse to acute form and result in pain and swelling. this subsides with the use of systemic antibiotics and analgesic but this is not the permanent solution of the disease. in children the disease occurs because of the delayed canalization of the lacrimal pathway. the obstruction could be in the various regions of the lacrimal pathway like the canalicular and nasolacrimal duct. the procedure of choice to cope with most of these conditions is dacryocystorhinostomy. the operation was first introduced by toti1 in 1942 and modified by bourguet2. all these patients initially follow medical treatment but the ultimate option is surgical management. material and methods this is a retrospective study of 144 patients admitted in naseer teaching hospital peshawar from january 2005 to december 2007. the common complaints of these patients were discharge from the affected eye. all these patients were hospitalized and detailed clinical examinations were carried out. the site of obstruction was evaluated with regurgitation and lacrimal sac irrigation test. other diagnostic procedure w 90 like dacryocystography and jones test were not performed. viral profile was carried out before surgery. most of the operations were carried out under local anesthesia using xylocaine 2% and also injected locally in those patients who underwent general anesthesia. this was done to avoid bleeding during surgical procedure. a nasal packed soaked with 4% xylocaine and two vials of injection adrenaline was applied in ipsilateral nasal cavity in almost all cases. about 02 cm vertical skin incision was given 8mm anterior to respective medial canthus and lacrimal fossa exposed. about 01cm circumferential bony window made between lacrimal fossa and middle meatus of the nasal cavity. nasal mucosa and lacrimal sac opened and flaps were made. anterior flap of the nasal mucosa and lacrimal sac were sutured using 4/0 catgut or 6/0 vicryl. post operative medications included systemic antibiotics, analgesic and tranxaminic acid. each patient discharged from the hospital after 24 hours postoperatively and was reviewed for syringing two days postoperatively in non intubated patients. in cases, where intubation was done, the lacrimal tube was removed after 06 months of surgery. the success criteria were absence of watering and patency of lacrimal pathway on syringing. results this study include 144 patients in which 45(31.25%) were male and 99(68.75%) were female (table 1). the age of the patients was between 06 to 60 years with 82% of cases between 31 and 40 years (table 2). unilateral cases were selected in all these patients. primary surgery was done in 138(95.83%) and secondary surgery was in 06(4.10%) patients. the commonest indication was chronic dacryocystitis, 131(90.97%). this is followed by mucocele, 09(6.25%) and canalicular obstruction 04(2.77%) (table 3). most of the patients were operated under local anesthesia, 134(93%) and only 10(6.94%) were under general anesthesia. 80(55.5%) patients were intubated and 64(44.4%) were without intubation. after 6 months follow up the success rate in intubated patients were in 50 (62.5%) and failure were in 30(37.5%). the success rate in non intubated patients were 60(93.75%) and failure were in only 04(6.25%). discussion external dcr, endoscopic dcr3, endoscopic laser nasal dcr4,5, dacryocystoplasty and endoscopic radiofrequency assisted dcr6 are the various procedure used to relieve lacrimal passage obstruction. the recent procedure is the endoscopic dcr, has the advantage of elimination of scar, preservation of canthal anatomy, bleeding, pain and morbidity but the disadvantages are the cost and lack of surgical skill7. in a study the success rate of external dcr was compared with endonasal endoscopic dcr, it was found that the success rate at one year after surgery was 75% for endonasal endoscopic dcr and 91% for external dcr8. in our study the success rates of external dcr with lacrimal tube intubation was 62.5% and without intubation it was 93.75%, this mean that the external dcr is still an effective procedure for chronic dacryocystitis. in our study the male were half, 45(31.35%) of the female, 99(68.75), the reason could be that the sac problems are more in female than male9. an anatomical reason for female predominance is narrow lumen of the bony canal, which was found to be the commonest site of obstruction in female10. in our study more than 90% of the patients were suffering from chronic dacryocystitis and the commonest site of obstruction was the naso lacrimal duct. table-1: gender no of patient’s n (%) male 45(31.25) female 99(68.75) table-2: age no of patient’s n (%) 06-20 12(8.30) 21-30 17(11.80) 31-40 82(56.94) 41-50 31(21.50) > 50 02(1.38) table-3: disease no of patient’s n (%) 91 cdc 131(90.90%) mucocele 09(6.25%) canalicular obstruction 04(2.77%) in a study by ali a11, 92% of patients were operated under general anesthesia, while in my study 93% of the patients were operated under local anesthesia keeping in mind the advantage and feasibility for most of these patients. the same was true for hurwitz study, a total of 120 patients, 98(81%) were operated under local anesthesia and 22(18.3%) were under general anesthesia12. in one of the study, soft tissue infection was found to occur in approximately 08% of the patients who did not receive systemic antibiotics after surgery13, so it was recommended to use systemic antibiotics to reduce the risk of infection. in our study all the patients were given amoxicillinclavillinic acid for 07 days. in patients without intubation we performed syringing on the second post operative day to know about the patency of the lacrimal passage and in intubated patients after the removal of tube 06 months of surgery. it has been noted by other colleagues as well that syringing in the first week is recommended for the success of the procedure. this was true in our study that the success of surgery was more than 93% in patients without intubation, as syringing has been done in the first week while the failure rates in intubated patients was 37.5%, as syringing was not possible. 30 (37.50%) out of the total 80(55.50%) of the intubated patients resulted into failure. most of the failures were noticed during the first 02-03 months of the surgery. the possible causes of failure could be due to the use of 4/0 catgut and silicon tube in the early procedures, to which the body showed lot of reaction. moreover silicon tubes available in the market were of low quality and the material was not pure. as this study has been conducted in one of the teaching hospital draining various parts of nwfp and eastern afghanistan and most of the patients are very poor, so they could not buy the good quality suture material and silicon tube. in patients where 6/0 vicryl were used as a sutural material showed less reaction and less failure, so the use of catgut was then abandoned. in pure cases of chronic dacryocystitis the use of bodkin tube was abandoned as well, this improved the success rate dramatically (93.75%). bodkin tube prolapse is not unusual and some time it become difficult to reposit it18.this dislodgement might be because of unsecured tube or the patients in this region are repeatedly looking in the mirror and pulling the lower lid to note the position of the tube. hopkisson secured the tube with a sleeve and observed tube prolapse only in one case out of his 47 patients series19. in order to prevent this complication the tube was secured to nasal mucosa using 4/0 black silk, but it was observed that the knot of 4/0 black silk slip away within two weeks in most of the cases and the tube was left hanging freely. some time in cases of prolapse tube the reposition of the tube become difficult. two of the prolapse tube was removed and syrining showed the failure of the procedure. the cause of failure of reposition of the tube was the obstruction of osteotomy site by the granulation tissue after reopening these cases. known causes of failure of dacryocystorhinostomy are obstruction of common canaliculi, closure of the osteotomy site, retained stent material and excessive scar formation within the rhinostomy14,15. the failed cases were reopened, it was found that the cause of failure was the closure of the osteotomy by the granulation tissue. in majority of the cases the canalicular system remained opened. various techniques were used to reduce the chance of failure in dacryocystorhinostomies including the use of mitomycin c16,17. conclusion 1. external dacryocystorhinostomy is still the most effective procedure for the patients with epiphora. 2. intubation is not recommended in case of naso lacrimal duct obstruction. 3. syringing is recommended on the second postoperative day, provided inflammation has been subsided. author’s affiliation dr zaman shah khyber eye centre kfc 2nd floor university road peshawar 92 dr ibrar hussain associate professor khyber teaching hospital peshawar prof. dr. naeem khattak naseer teaching hospital peshawar prof. mustafa iqbal khyber teaching hospital peshawar reference 1. toti a. nuovo metodo conservatore dicura radicale dele supporazioni cronide del sacco lacrimale. clin mod firenze. 1904; 10: 385-9. 2. duputydutemps l. bourguet. procede plastique de dacryocystorhinostomie et se resultants. ann ocul. 1921; 158: 241-61. 3. mortimore s, banhegy gy, karkanevatos a. endoscopic dacryocystorhinostomy without silicon stenting. jr coll surg edinb. 1999; 44: 371-3. 4. hutchesan ka, drack av. balloon dilatation for the treatment of resistant naso lacrimal duct obstruction. jaa post. 1997; 1: 241-4. 5. zelelioglu g, voutga sh. lacrimal sac dialatation in balloon dacryocystoplasty. ophthalmic surg laser 1999; 30: 61-2. 6. javate rm, compomanes bs. the endoscopic and the radiofrequency unit in dacryocystorhinostomy surgery. ophthal plast recongst surg. 1995; 11: 54-8. 7. struck hg. value of external dacrycystorhinostomy. klin monatsbl augenheikd. 1999; 215: 1-3. 8. hartikainen j, anitila j, puukkap, seppa h. prospective randamised comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. laryngoscope. 1998; 108: 1861-6. 9. mushtaq a. dacryocystorhinostoy with and without intubation. ophthalmol. 1992; 8: 39-42. 10. grover ak, bhatnagar a. modern ophthalmology by dutta lc. jaypee brothers first edition. 1994; 165. 11. abrar a, tabassum a. dacryocystorhinostomy. pak j ophthalmol. 2002; 18: 12. hurwitz jj, merkur s. de angelis. outcome of lacrimal surgery in older patients. can j ophthalmol. 2000; 35: 18-22. 13. walland mj, rose ge. soft tissue infection after open lacrimal surgery. ophthalmology. 1994; 101: 608-11. 14. allen k, berlin aj. dacryocystorhinostomy failure, associaltion with naso lacrimal silicon intubation. ophthalmic surgery. 1998; 89: 486-9. 15. mciachlan dl, shannan gm. results of dacryocystorhinostomy. analysis of reoperation ophthalmic surg. 1980; 11: 427-30. 16. shine csk, chiu ll, jason hst, et al. dacryocystorhinostomy with intraoperative mitomycin c. ophthalmology. 1997; 104: 86-90. 17. camara jg, bengzon av. the safety and efficacy of mitomycin c in endonasal and endoscopic laser assisted dacryocystorhinostomy. ophthal plast recontr surg. 2000; 16: 114-8. 18. jordan dr, bellan ld. securing silicon stents in dacryocystorhinostomy. ophthalmology surg. 1995; 26: 164-5. 19. hopkisson b, suherwardy j. sleeves for fixation of siliastic nasolacrimal tube. br j ophthalmol. 1995; 79: 164-5. guess who? 90 see next issue for answer 89 microsoft word editorial 26,4,2010 170 editorial trabeculectomy revisited glaucoma describes a group of eye diseases defined by a degeneration of the optic nerve with typical appearance of the optic nerve head leading to loss of visual function best seen by changes in the visual field. very often the intraocular pressure (iop) is increased above normal values. although this definition has been accepted for quite some time it had been unclear weather or not lowering of iop would prevent or stop glaucoma1. mean while two large studies have been conducted to prove that lowering iop in patients with ocular hypertension can prevent or at least delay the onset of glaucoma2,3. while the ohts (ocular hypertension treatment study) showed a reduction of the incidence of glaucoma of about 50 per cent by lowering iop, the egps (european glaucoma prevention study) failed to do so. however, only one medication was used in the egps, namely dorzolamide, while in the ohts one or several medications were allowed and changes could be made in them to reach a certain iop goal. on the down-side this study was performed in an un masked fashion. results from studies in glaucoma patients are more uniform: the agis4 revealed that lowering iop by surgical means reduced progression of glaucoma in an iop dependant fashion as did the emgt (early manifest glaucoma trial) which used the b-blocker betaxolol as the only medical agent5,6. lowering of iop seemed to be beneficial even in the case of normal tension glaucoma as shown by the results of the ntgs (normal tension glaucoma study) clearly outlining the value of iop lowering therapy7,8. thus, medical glaucoma therapy appears to be useful in the treatment of glaucoma and ocular hypertension. furthermore, studies have indicated that medical therapy may lead to fewer complications than surgical therapy7 and may still have a similar impact on the course of glaucoma,9 although the latter remains to be disputed. optimum management of the glaucomas begins with proper detection of these diseases and ends with appropriate supervised treatment for the individual patient. personnel and equipment are needed for monitoring these diseases at all levels (rural & urban) of the individual’s society. finally, the whole system has to be sustainable for the country's economy and for the individual who often bears a portion of, or the total cost of, his or her own treatment. it appears that each country has either decided on a mix of private or government health care delivery or has had it forced on them by circumstance. in our country many people cannot afford the continuous expensive medical treatment of glaucoma that is one of the important reasons of poor adherence and compliance. costs and availability of drugs prevent their use in many countries. there is also the factor of compliance of many populations who do not understand the necessity of keeping up with drugs for a lifetime. in many locations heat and lack of refrigeration destroy drops through degradation. for these reasons and many more, the dependability of patients receiving adequate medical therapy is very much in doubt. some locations with a more sophisticated populace may enjoy success in medical therapy equal to that of the first world but these people are the exception. surgery becomes the treatment of choice for most developing world countries for the above reasons and trabeculectomy is the commonest surgical procedure performed for control of intraocular pressure. historically, following the introduction of the ophthalmoscope by von helmholtz in 1851 and the subsequent observations of glaucomatous excavation of the optic nerve head, surgical measures were invented to answer the problem. as with medical therapy, the goal was to lower intraocular pressure enough to minimize the risk of further optic nerve damage. surgical procedures were invented to lower intraocular pressure either by increasing outflow or by reducing aqueous production. during the 50-year period starting in 1856 numerous new operations were introduced which contained all the future principles for surgical lowering of the intraocular pressure. the chronological order of the main innovations is presented in table. 171 chornology of some main innovations of glaucoma surgery year procedure author 1851 ophthalmoscope v. helmhoitz 1856 iridectomy v. graefe 1867 anterior sclerotomy de we cke r 1905 postop. digital massage dianoux 1905 cyclodialysis heine 1906 sclerectomy lagrange 1907 iridencleisis holth 1909 trephining elliot 1932 cyclodiathermy weve trabeculectomy, a guarded sclerostomy introduced by cairns in 196810, is the most widely used filtration surgery11. in recent years, important changes have been introduced in order to make trabeculectomy safer and also more efficient. the moorfields safe surgery system was developed by peng khaw in 200412, and was mainly geared towards reducing the risk of post operative complications and optimization of trabeculectomy. the antimitotic agents 5-fu and mmc are mainly used to inhibit scarring and subsequent iop increase after trabeculectomy. recently, a slow release mechanism of mmc has been published. mmc loaded hydrogels were shown to inhibit cell proliferation in an in vitro model. the important postoperative complications are:13 hyphema, wound leaks, flat anterior chamber requiring surgery, hypotony and its complications, maculopathy and choroidal detachment and late onset blebitis and endophthalmitis. surgery is often limited to trabeculectomy or a modulated trabeculectomy due to lack of other alternatives. the cost of most tube implants and other surgical expendables prevent their widespread use. follow up may be a single day or perhaps a few days, but no more. the chance of success decreases for such patients who will equate glaucoma surgery as being identical to cataract surgery in both restoration of sight and immediacy of results. for these reasons, the long term effectiveness of surgery is less than in the first world. exceptions do exist through outreach clinics found primarily in india and to a lesser extent in china. the majority of countries will operate on patients and send them to their own communities with little or no back up in local health care facilities beyond that offered in the major centre where surgery was done, one of the unfortunate but predictable byproducts of advances in cataract surgery to phacoemulsiflcation is an increase in the number of complications that occur as the technique is attempted or learned. dropped nuclei and corneal decompensation along with glaucoma resulting from these two complications directly or indirectly impact on the glaucoma load for developing world countries. unless solutions to these problems arc taught simultaneously with the phacoemulsiflcation, the result for many patients is the removal of one cause of blindness only to be replaced by another. guidelines for stopping anti-platelet aggregants before filtering surgery anti-platelet aggregants stop pre-operatively acetylsalicylic acid (asa) 2 weeks thienopyridine (ticlopidine 2 week & clopidogrel) dipyridamol 1 week non-steroidal anti-inflammatory (nsai) 1 week indications for the use of antimetabolites (5-fu or mmc) • increased risk for postoperative fibrosis: patients < 40 years of age afro-caribbean previous surgery involving the conjunctiva chronic uveitis • low target pressure (< 12 mmhg) general principles14 the different techniques of incisional surgery have different indications depending on the type of glaucoma. their adoption depends on: 1. target iop chosen for the individual situation 2. previous history (surgery, medications, degree of visual field loss) 3. risk profile (i.e. single eye, occupation) 4. preferences and experience of the surgeon 5. patient opinion, expectation and post operative compliance the future: tissue regeneration significant advances have been made in developing new treatments and refining existing treatments for 172 the prevention of scarring after disease, trauma or surgical intervention. in addition to traditional chemical drugs, the advent of new technologies such as dendrimers, antibodies, aptamers, ribozymes, matrix degrading enzymes, gene therapy with viral vectors and rna interference opens the door to a whole new generation of therapies to prevent fibrosis after glaucoma surgery. the ability to fully control fibrotic processes in the eye offers the tantalising prospect of a near 100% success of glaucoma surgery, with pressure around 10 mmhg associated with minimal progression over a decade as found in our long term mrc glaucoma surgery study. finally, most exciting is the prospect that neutralising the fibrotic response to disease and injury will allow us to revert to the "foetal" mode when regeneration is the "normal" process, such as shown in a recent report, which demonstrated that induction of bcl-2 gene expression together with down regulation of gliosis results in axonal regeneration in mice15. controlling inflammation and modifying matrix and environmental cell conditions may allow resident stem cells to migrate and differentiate into different retinal neurons like fish and amphibians, and may aid to regenerate a severely damaged complex retina16. ultimately, it is likely that our ability to fully modulate the scarring processes will lead towards a much more regenerative reparative process after injury and disease, both for scarring in the anterior segment and even the damaged retina and optic nerve17. the concept of non-penetrating glaucoma surgery essential for iop control in the postoperative management and converts deep sclerectomy basically into a penetrating procedure/hence, the term 'nonpenetrating’ is then no longer correct and may even be a misnomer. distinguishing between blebindependent and bleb-dependent glaucoma surgery may be more appropriate as 'micro'-penetration are an essential part in 'non-penetrating’ procedures. from the pathophysiological perspective, bleb-independent procedures might be the surgical answer for glaucoma as they avoid many problems related to trabeculectomy; however, they are limited in their ability to lower iop below episcleral venous pressure (approx. 10 mmhg). furthermore, they will remain subject to long-term biological changes in the tm and sc as the eye continues its repair mechanisms and tissue remodelling over the years. references 1. quigley ha. new paradigms in the mechanisms and management of glaucoma. eye 2005; 19:1241-8. 2. gordon mo, beiser ja, brandt jd, et al. the ocular hypertension treatment study: baseline factors that predict the onset of primary open-angle glaucoma. arch ophthalmol. 2002; 120: 714; 829-30. 3. miglior s, zeyen t, pfeiffer n, et al. results of the european glaucoma prevention study. ophthalmology. 2005; 112: 36675. 4. the advanced glaucoma intervention study (agis): 7. the relationship between control of intraocular pressure and visual field deterioration. the agis investigators. am j ophthalmol. 2000; 130: 429-40. 5. leske mc, heijl a, hussein m, et al. factors for glaucoma progression and the effect of treatment: the early manifest glaucoma trial. arch ophthalmol. 2003; 121: 48-56. 6. bengtsson b, leske mc, hyman l, et al. fluctuation of intraocular pressure and glaucoma progression in the early manifest glaucoma trial. ophthalmology. 2007; 114: 205-9. 7. the effectiveness of intraocular pressure reduction in the treatment of normal-tension glaucoma. collaborative normaltension glaucoma study group. am j ophthalmol. 1998; 126: 498-505. 8. comparison of glaucomatous progression between untreated patients with normal-tension glaucoma and patients with therapeutically reduced intraocular pressures. collaborative normal-tension glaucoma study group. am j ophthalmol. 1998; 126: 487-97. 9. lichter pr, musch dc, gillespie bw, et al. interim clinical outcomes in the collaborative initial glaucoma treatment study comparing initial treatment randomized to medications or surgery. ophthalmol. 2001; 108: 1943-53. 10. cairns je. trabeculectomy. preliminary report of a new method. am j ophthalmol. 1968; 66: 673-9. 11. edmunds b, thompson jr. salmon jf et al. the national survey of trabeculectomy. ii. variations in operative technique and outcome. eye 2001; 15(pt 4): 441-8. 12. wells ap, bunce c, khaw pt. flap and suture manipulation after trabeculectomy with adjustable sutures: titration of flow and intraocular pressure in guarded filtration surgery. j glaucoma. 2004; 13: 400-6. 13. edmunds b, thompson jr. salmon jf et al. the nationalsurvey of trabeculectomy. iii. early and late complications. eye. 2002; 16: 297-303. 14. incisional surgery. in: traverso ce, heijl a eds terminology and guidelines for glaucoma savona, italy, dogma. 2008: 15357. 15. cho ks, yang l, lu b et al. re-establishing the regenerative potential of central nervous system axons in postnatal mice. j cell sci. 2005: 118: 863-72. 16. singhal s, lawrence jm, bhatia b et al. chondroitin sul-fate proteoglycans and microglia prevent migration and integration of grafted muller stem cells into degenerating retina. stem celts. 2008: 26: 1074-82. 17. liy, lid, khaw pt et al. transplanted olfactory ensheathing cells incorporated into the optic nerve head ensheathe retinal ganglion cell axons: possible relevance to glaucoma. neurosci. lett. 2008: 440: 251-4. prof. syed imtiaz ali rawalpindi microsoft word shaukat ali chipa case report 174 case report angle closure glaucoma with myopia shaukat ali chhipa pak j ophthalmol 2009, vol. 25 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: shaukat ali chhipa university road medical services abc plaza,opp:baitul-mukkaram masjid, main university road karachi received for publication september’ 2008 … ……………………… reporting a case of 30 years old man who presented with pain and blurring in his right eye in an offsite ophthalmic consulting clinic of the aga khan university hospital. on the basis of history and clinical examination he was diagnosed as a case of primary angle closure glaucoma (pacg), although his refractive status was myopic. narrowing of anterior chamber angle and pacg are almost always associated with hyeropia. to my knowledge this rare combination of pacg and myopia has never been reported before in pakistan. the patient was managed as for a pacg. arrowing of the anterior chamber angle and angle closure glaucoma are typically associated with hyperopia. in pacg elevation of intraocular pressure (iop) occurs as a result of obstruction of aqueous outflow by partial or complete closure of the angle by the peripheral iris. a normal optic nerve head and visual field do not preclude a diagnosis of pacg. hyeropic eyes which are also frequently short have small corneal diameter and relatively short axial length are at increase risk of pacg1,2. myopia rarely is observed in patients with these conditions. no case series of such eyes has been reported in the literature. case report i am reporting a case of myopic patient having primary angle closure glaucoma. 30 years man presented with blurring and pain in his right eye for 2 days, which was initially severe as well as causing haloes around light. the severity was decreased with some oral medication in addition to topical timolol advised by general practitioner. patient had a history of medical management for elevated intraocular pressure in both eyes, which was clogged by him a couple of moths ago. there was no significant medical history and family history was also not contributory. vision in right eye was 20/200 with -3.50 d sph / -2.0 d cyl at 175 degrees, not improving further and 20/20 in left eye with -4.0d sph/ -1.25 d cyl at 175 degrees. slit lamp examination revealed circumciliary congestion, hazy cornea, mid-dilated pupil, and shallowing of anterior chamber with convex appearance of iris in the periphery of right eye. in the left eye there were no such signs except shallowing of anterior chamber with convex appearance of iris in the periphery. iop was 43 mmhg and 16 mmhg in right and left eyes respectively. after the initial examination patient was advised to lie down supine and treated as an acute congestive glaucoma by giving acetazolamide 500mg orally stat, pilocarpine 2% eye drops in both eyes and timolo 0.5% eye drops in right eye. reassessment after an hour revealed relative decrease in corneal haziness, decrease in dilation of pupil and very sluggish reaction of pupil was evident. the iop had dropped to 20 mmhg. gonioscopy findings were momentous, as the angle was grade 0 in three quadrants and grade 0-i in inferior quadrant of the right eye, while gonioscopy of the left eye exposed grade 0 in superior and temporal quadrants, grade i and ii in nasal and inferior quadrant respectively. yag laser iridotomy was advised in both eyes as an initial step and until then pilocarpine eye drops should be continued in both eyes. n 175 discussion when attempting to explain angle closure one should have in mind a system that facilitates the inclusion and understanding of the various mechanisms involved in iridocorneal apposition. the typical eye with primary angle closure glaucoma has a hyperopic refractive error, shorter than average axial length, larger than average lens thickness, and a smaller than average anterior chamber depth and volume3,4. the identification of correct pathophysiology directs the treatment to the appropriate underlying source of angle closure. the most common cause of angle closure is pupillary block5. in aging; increased lens thickness, forward movement of the anterior lens surface, and decrease in anterior chamber depth and volume causes relatively pupillary block, which makes it a disease of middle aged and older indivisuals1. review of literature has discovered almost no mention of such patients. lowe2 reported on 127 eyes of patients diagnosed with primary angle closure glaucoma, only 2 had myopia of more than -2.0 d. marchini6 reported a series of refraction in patients with angle closure glaucoma, none of the 54 patients had myopia. hagan and lederer7,8 reported a myopic patient who was initially reported to have pacg, but subsequently was observed to have lens subluxation. myopia and angle closure developed in two adults who had retinopathy of prematurity were reported by michael9. barkana5 have described 20 patients with a spectrum of ophthalmic conditions leading to myopia and angle closure. the primary relative pupillary block which is the cause for angle closure in the large majority of patients in the general population was identified in his 9 described patients. because angle closure in myopic patients is unusual and for the reason that gonioscopy in these patients may not be performed routinely the clinician must maintain a high index of suspicion. the case report of this patient illustrates that myopic refraction does not exclude the presence of angle closure and that this should be sought by careful gonioscopy. i advocate performing careful gonioscopy on all patients undergoing initial examination. author’s affiliation dr. shaukat ali chhipa university road medical services abc plaza, opp: bait-ul-mukkaram masjid main university road karachi. reference 1. bonomi l, marchini g, marraffa m, et al. epidemiology of angle-closure glaucoma: prevalence, clinical types, and association with peripheral anterior chamber depth in the egna-neumarkt glaucoma study. ophthalmology. 2000; 107: 998-1003. 2. lowe rf. aetiology of the anatomical basis for primary angleclosure glaucoma. biometrical comparisons between normal eyes and eyes with primary angle-closure glaucoma. br j ophthalmol. 1970; 54: 161-9. 3. friedman ds, gazzard g, foster p. ultrasonographic biomicroscopy, scheimpflug photography, and novel provocative tests in contralateral eyes of chinese patients initially seen with acute angle closure. arch ophthalmol. 2003; 121: 633-42. 4. tomlinson a, leighton da. ocular dimensions in the heredity of angle-closure glaucoma. br j ophthalmol. 1973; 57: 475-86. 5. barkana y, shihadeh w, oliveria c, et al. angle closure in highly myopic eyes. ophthalmology. 2006; 113: 247-54. 6. marchini g, pagliarusco a, toscano a. et al. ultrasound biomicroscopic and conventional ultrasonographic study of ocular dimensions in primary angle-closure glaucoma. ophthalmology. 1998; 105: 2091-8. 7. hagan jc iii, ledere cm jr. primary angle closure glaucoma in a myopic kinkship. arch ophthalmol. 1985; 103: 363-5. 8. hagan jc iii, ledere cm jr. genetic spontaneous late subluxation of the lens previously reported as a myopic kinkship with primary angle closure glaucoma. arch ophthalmol. 1992; 110: 1199-1200. 9. michael aj, pesin sr, kartz lj, et al. management of lateonset angle-closure glaucoma associated with retinopathy of prematurity. ophthalmology. 1991; 98: 1093-8. microsoft word tehmina jahangir 96 original article pattern of presentation and factors leading to ocular trauma tehmina jahangir, nadeem hafeez butt, uzma hamza, haroon tayyab, samina jahangir pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tehmina jahangir senior registrar eye unit i, aimc/jhl lahore received for publication february’ 2011 acceptance for publication may’ 2011 …..……………………….. purpose: to describe the pattern, extent and severity of ocular injuries and to identify the factors leading to ocular trauma in patients presenting at jinnah hospital, lahore. materials and methods: we did a cross-sectional study at the eye department of jinnah hospital, lahore over a period of six months from 25-092006 to 24-03-2007.one hundred patients who presented with eye injury through the outpatient or emergency routes were included in the study. they were examined by standard procedures to note the areas injured, type and extent of injury and impact on vision. results: the men in the age groups between 18 and 45 years were the most commonly affected group. only 3 % of the case had bilateral injury. the most common injury was penetrating trauma with sharp objects. domestic environment was the most common setting for trauma to occur. more than 3/4th of the patients had visual acuity worse than 6/60 at presentation. open globe injury counted for 57 % injuries. mechanical injuries were more common than thermal and chemical injuries combined. conclusion: systematic collection of standardized data on the occurrence of eye injuries can help the ophthalmologist play a key role in successfully preventing ocular trauma. preventive measures should be targeted at young men. cular trauma continues to be a significant cause of morbidity in terms of visual loss or impairment and diminished quality of life1. even the most minor injuries can cause pain and discomfort, lost wages and health care expenses. thus, it is important to identify the causes and extent of ocular trauma to recognize preventable factors. according to the data compiled by who’s blindness data bank, it is estimated that globally approximately 55 million eye injuries restricting activity for more than one day occur each year and 750,000 cases require hospitalization each year, including approximately 200,000 with open-globe injuries. there are approximately 1.6 million blind from injuries, additionally some 2.3 million people with bilateral low vision resulting from ocular trauma and almost 19 million people with unilateral blindness or low vision2. in the united states alone, over 2.4 million eye injuries occur yearly, with ocular trauma being the third most common ophthalmic indication for hospitalization3. in developing countries like pakistan, eye injuries are not only more common but also more severe in nature1. however, most ocular injuries and their complications can be prevented by appropriate safety precautions and early detection4. just a few years ago, ophthalmologists dealing with ocular trauma had no epidemiologic information to aid prevention and treatment efforts. the dilemma has now changed from a lack of epidemiologic data to uncertainty over how to reconcile the various studies into a coherent description of the ocular trauma o 97 epidemic. the primary goals of epidemiologic study of eye trauma are prevention and more effective treatment5. material and methods this cross-sectional study was carried out at the eye department of jinnah hospital, lahore over a period of six months from 25-09-2006 to 24-03-2007. one hundred patients presenting themselves with eye injury were included. we employed non-probability convenience sampling. patients of all ages and both sexes giving acute injury history affecting one or both eyes were included. exclusion criteria included: a coexisting ocular disease potentially affecting visual acuity; cases with prior ocular trauma and patients who had received surgical treatment for ocular trauma from elsewhere. cases presenting in opd and emergency of the department of ophthalmology with acute ocular injury of one or both eyes were registered. an informed consent was obtained from patients or their parents in cases of children, for permitting to use their data. their demographic profile was recorded, asking name, age, sex, profession, education, address etc. the history of injury was obtained to know the time, circumstances leading to injury and development of symptoms. they were examined by standard procedures to note the areas injured, type and extent of injury and impact on vision. the refractive errors if existing before and usage of glasses etc were enquired. any investigations indicated for confirming foreign body were conducted. the cases were assessed for identifying the management needs and prediction of damage to the eye. all this information was collected on a specially designed proforma. the information collected was entered in the spss version 11.0 and analyzed. socio-demographic variables such as categorical (sex) and numerical (age, education) data were analyzed. they were presented in statistical form as frequency distributions (sex), mean and standard deviation (age). history yielded descriptive data of time, place of accident, factors leading to it and types of symptoms. these were presented as proportions. the outcome of examination provided qualitative data on extent, site and type of injury and affect on vision. these were presented as tables of frequencies. the management needs were assessed, classifying types of actions and prognosis. causes of injury were associated with sex and tested for significance by applying chi square test. p value < 0.05 was taken as significant. results a total of one hundred ocular trauma patients, who presented to the jinnah hospital via emergency and outpatients department, were studied during a six months period from 25-09-2006 to 24-03-2007. the two commonest affected age groups were from 18 to 29 years (31%) and 30 to 45 years (24%). this was followed by children between 3-12 years (18%). the mean age was found to be 28.6 + 17.6 years (table 1). there were 75 male (75%) and 25 female (25%). male: female ratio was 3:1. out of one hundred, only 3 patients (3.0%) had bilateral injury. table 1: distribution of cases by age n = 100 age (year) no. of patients n (%) < 3 03 (03) 3-12 18 (18) 13-17 09 (09) 18-29 31 (31) 30-45 24 (24) 46-64 07 (07) > 65 08 (08) total 100 (100) mean±sd 28.6±17.6 table 2: distribution of cases by time elapsed between injury and treatment n = 100 time elapsed no. of patients n (%) less than 1 hour 23 (23) several hours 26 (26) next day 38 (38) several days 13 (13) total 100 (100) 98 majority of the patients 38 (38%) presented 24 hours after injury. this was followed closely by those who presented within several hours of sustaining trauma 26 (26%). a sizeable majority (23%) arrived within less than one hour after sustaining trauma (table 2). the most common source of injury was a sharp object (32%) resulting in penetrating globe trauma, followed by trauma with a blunt object (27%). burns of thermal and chemical nature accounted for 8 out of the one hundred cases. fireworks and hammer on metal injuries constituted an equal share (7%) each. a total of 6 patients presented with injuries due to motor vehicle crash (table 3). the most common place of injury was home 31 (31%) followed by industrial premises 23 (23%). fourteen patients (14%) presented with injuries sustained on the street and highway, while 12 (12%) had farming related injuries. places for recreation and sport like playgrounds etc. accounted for 10 (10%) of the 100 cases. only 2 (2%) of the injuries occurred at school (table 4). the visual acuity at presentation was light perception in 27 cases. twelve patients had no light perception at presentation, whereas in 21 cases the visual acuity was better than 6/60 (table 5). open globe injury accounted for 57% of the cases. the breakdown of these was: 28 had corneal lacerations, 24 had corneo-scleral lacerations and 5 had scleral wounds (fig. 1). in eighty four patients (84%), the injury was un-intentional while sixteen patients (16%) were victims of assault. a total of 75 injuries (75%) were preventable by protective eye wear (table 6). the right eye was involved in 45% of the patients, the left eye in 52%; while 3 patients (3%) had bilateral injury. burns were present in 15 (15%) patients. nine (9%) had thermal burns while chemical burns accounted for six (6%) of the total patients. lens damage in form of cataract was present in 34% of the injuries while the lens was displaced in 3% of the cases. anterior chamber abnormalities were present in 84% of the cases. the most common finding was iritis in 48% followed by hyphaema in 19%. uveal prolapse was present in 10 patients (10%).the lids were damaged in 64% cases. the most common finding was ecchymosis in 39% followed by laceration in 13% (fig. 2). thermal and chemical burns of the eye-lids accounted for 7% and 5 % of the total patients respectively. table 3: distribution of cases by source of injury n = 100 source of injury no. of patients n (%) sharp object 32 (32) blunt object 27 (27) burn 08 (08) fireworks 07 (07) hammer on metal 07 (07) motor vehicle crash 06 (06) pellet gun 03 (03) firearm 03 (03) fall 03 (03) nail, finger 03 (03) sports equipment 01 (01) total 100 (100) table 4: distribution of cases by place of injury n = 100 place of injury no. of patients n (%) home 31 (31) industrial premises 23 (23) street and highway 14 (14) farm 12 (12) place for recreation and sport 10 (10) public building 08 (08) school 02 (02) total 100 (100) table 7 presents the distribution of the source of injury according to the gender of the patients. trauma with a sharp object occurred in 23 of the 75 males (30.7%) while 9 out of the 25 females (36%) sustained injuries from a sharp object. a total of 21 males (28%) suffered from trauma due to a blunt object in contrast to only 6 females. firearm and pellet injuries occurred exclusively in males in this study (3 cases each). motor 99 vehicle crash accounted for 5 male (6.7%) and 1 female (4%) patient. similarly, they were six male patients with fireworks related injuries (8%) as compared to one female patient (4%). result of the chi-square analysis show that, in this study, the gender distribution of ocular trauma according to the cause was found statistically significant in males as compared to females (p= 0.054) table 5: distribution of cases by visual acuity at presentation n = 100 visual acuity no. of patients n (%) no light perception 12 (12) light perception 27 (27) hand movements 16 (16) counting fingers 06 (06) 1/60 to 6/60 18 (18) better than 6/60 21 (21) total 100 (100) table 6: distribution of cases by injury preventable by protective eyewear n = 100 protective eyewear no. of patients n (%) yes 75 (75) no 02 (02) uncertain 23 (23) total 100 (100) only one patient had blowout fracture of the orbital floor with entrapment of the inferior rectus muscle (fig. 3 and 4). discussion the impact of eye trauma is immense, whether measured in monetary terms, number of eyes lost, blind years or human suffering. although ocular trauma is an important worldwide cause of preventable monocular blindness, relatively little epidemiological information is available outside the united sates and developed countries. table 7: distribution of cases by source of injury according to the gender; n = 100 source of injury male (n = 75) female (n = 25) no. of patients n (%) no. of patients n (%) 07 (9.3) hammer on metal 23 (30.7) 09 (36) sharp object 03 (12) nail, finger 02 (2.7) 01 (4) fall 21 (28) 06 (24) blunt object 03 (4) firearm 03 (4) pellet gun 05 (6.7) 01 (4) motor vehicle crash 06 (8) 01 (4) fireworks 05 (6.7) 03 (12) burn 01 (4) chi square =18.04, p value=0.054 in this study, more than half of the eye injuries were in patients between 18 to 45 years, with 80% of the injuries in patients younger than 45 years. the distribution of injuries showed a male predominance with a male/female ratio of 3/1. the age and gender pattern observed in this study is consistent with the studies by babar et al7. their study revealed a male/female ratio of 4/1. approximately 3/4th of the sample population was 30 years or younger. similar results have been quoted by jan and associates8. the higher risk in men has been found in almost every population and hospital based study of ocular injury. this increased risk reflects a combination of a high incidence of work, assault and motor vehicle crash related ocular injuries9 studies on ocular trauma in rural nepal10 and tanzania11 reveal similar age and gender distribution. a study conducted by jan and associates in 200212, revealed that of the patients with eye injuries 85% were males and below the age of 40 years. these results are highly consistent with our study. 100 fig. 1: a typical inferior limbal laceration with uveal prolapse fig. 2: right eyelid laceration with involvement of medial canthus. fig. 3: a case of blow-out fracture of the left orbital floor. fig. 4: a case of blow-out fracture of the left orbital floor. only 3 of the 100 cases in our study were bilateral. these results correlate with those computed by babar et al in 2007. 7 in another study conducted by the same author on 1551 patients, the frequency of bilaterality was 2.9%13. approximately half of the patients had open globe injury (57%). these results are consistent with the findings of babar and associates who reported open globe injuries in 46% of their cases7. a medicaid enrollees based study conducted by chen et al also reported open globe injuries of the eyeball as one of the major type of ocular trauma in their report4 a four year review by iqbal and associates14 also determined open globe injuries to be leading the list of traumatic ocular emergencies (71.9%). in our study the most common place of injury was home (31%), followed by the industrial premises (23%). these results are consistent with those of khatry et al10 and serranco15. desai et al16 also reported similar results: home was the most common place for eye injury to occur (30.2%) followed by the workplace (19.6%). occupational ocular trauma in our study accounted for 46% of the cases, of these a quarter had farming related injuries (26%). although a vast majority of our population is involved in agriculture, the relatively low turnover of the patients is due to lack of awareness regarding the health care facilities and poor transport network from rural to urban areas. the most common source of injury was a sharp object in 32% of the cases followed by trauma with a blunt object (27%). thus penetrating and blunt were more common as compared to chemical, electrical and thermal injuries. these findings were consistent with 101 those of fasih and associates17. the typical sharp objects were: broken glass pieces, knives, scissors, nibs of pens and pencils. hammering on metal and nails is again a common and easily preventable cause of eye injury. its proportion in this study was 7%, which is comparable to the results of the hungarian eye injury registry18. fireworks are a major source wherever they are legal, 7% in this study. in hungary (where private fireworks use is forbidden by law), their rate is 0.1%19. motor vehicle collisions were responsible for 6% of the cases; this is in contrast to 12% in industrialized nations18. attesting to the fact that these were very serious injuries is the finding that the visual acuity at presentation was worse than 6/60 in 79% of the cases. a total of twelve eyes had no light perception at presentation. unintentional injuries made up majority of the eye injuries reported. in cases of the work-related injuries, none of the workers were using eye protection devices. they were either broken or not provided by the employer. over 3/4th of the injuries were preventable by protective eyewear. a staggering 92% of the injuries reported in this study were preventable by patient education alone. these figures reflect the vast opportunity for preventive measures to be introduced and public awareness increased regarding how to protect against eye trauma. this can be done through mass-media campaigns, public health workers and even by creating awareness at a grass root level in schools and vocational training centers. the chief weakness of this study is that it is not population based and hence does not give a true measure of the incidence and prevalence of ocular trauma in our population. appropriate and effective prevention requires developing and maintaining a comprehensive and standardized eye trauma surveillance system in a defined population. although an eye injury is a sudden and usually unanticipated event to the person involved, general trends can be identified if the surveillance is on a sufficiently large scale, such as the united states eye injury registry. its affiliates currently operate in 25 countries, allowing comparison of findings from different geographic locations and making it easier to highlight area amenable to prevention. among the many areas showing the benefits of systematic data collection and implementation of prophylactic measures are the effects of seat belt laws, which have reduced the incidence of eye injuries by 47 to 65%20. trauma to the eye is extremely common. this is especially so in developing countries like pakistan21. 5% of all ophthalmic admissions in the developed world result from ocular trauma, while in developing world this figure is much higher22. conclusion ocular trauma is a challenging problem; it has long been considered a result of random, unrelated, and unpreventable factors rather than a disease and, as such, has received far less attention. therefore it continues to be a significant cause of morbidity in terms of visual loss or impairment and diminished quality of life. however, neither prevention nor treatment can be optimized unless surveillance data on eye injuries is collected in a systematic manner. author’s affiliation dr. tehmina jahangir senior registrar eye unit i, aimc / jhl lahore professor nadeem hafeez butt professor of ophthalmology eye unit ii, aimc / jhl lahore dr. uzma hamza assistant professor eye unit i, aimc / jhl lahore dr. haroon tayyab registrar eye unit 1, aimc / jhl lahore professor samina jahangir professor and head department of ophthalmology aimc / jhl lahore reference 1. negrel ad. magnitude of eye injuries worldwide. j comm eye health. 1997; 10: 49-64. 2. negral ad, thylefors b. the global impact of eye injuries. ophthalmic epidemiol. 1998; 5: 143-69. 3. mieler wf. ocular injuries: is it possible to further limit the occurrence rate? arch ophthalmol. 2001; 119: 1712-3. 4. chen g, sinclair sa, smith ga, et al. hospitalized ocular injuries among persons with low socioeconomic status: a 102 medicaid enrollees – based study. ophthalmic epidemiol 2006; 13: 199-207. 5. danis rp. the birth of global ocular traumatology. ophthalmic epidemiol. 2000; 7: 85-6. 6. feist rm, farber md. ocular trauma epidemiology. arch ophthalmol. 1989; 107: 503-4. 7. babar tf, khan mt, marwat mz, et al. patterns of ocular trauma. jcpsp 2007, 17: 148-53. 8. jan s, khan s, khan mn, et al. ocular emergencies. jcpsp. 2004; 14: 333–6. 9. wong ty, tielsch jm. a population-based study on the incidence of severe ocular trauma in singapore. am j ophthalmol. 1999; 128: 345-51 10. khatry sk, lewis ae, schein od, et al. the epidemiology of ocular trauma in rural nepal. br j ophthalmol. 2004; 88: 456-60. 11. abraham d, vitale s, west s, et al. epidemiology of eye injuries in rural tanzania. ophthalmic epidemiol. 1999; 6: 8594. 12. jan s, khan s, mohammad s. profile of ocular emergencies requiring admission. pak j ophthalmol. 2002; 18: 72-5. 13. babar tf, khan mn, jan s, et al. frequency and causes of bilateral ocular trauma. jcpsp. 2007; 17: 679-82. 14. iqbal a, jan s, khan mn, et al. admitted ocular emergencies: a four year review. pak j ophthalmol. 2007; 23: 58-63. 15. serranco jc, chalela p, arias jd. epidemiology of childhood ocular trauma in a northeastern colombian region. arch ophthalmol. 2003; 121: 1439-45. 16. desai p, macewen cj, baines p, et al. epidemiology and implications of ocular trauma admitted to hospital in scotland. j epidemiol comm health. 1996; 50: 436-41. 17. fasih u, shaikh a, fehmi ms. occupational ocular trauma (causes management and prevention). pak j ophthalmol. 2004; 20: 65-73. 18. may d, kuhn f, morris r. the epidemiology of serious eye injuries from the united states eye injury registry. graefes arch clin exp ophthalmol. 2000; 238: 153-7. 19. kuhn f, morris r, witherspoon cd. serious fireworks related eye injuries. ophthalmic epidemiol. 2000; 7: 139-48. 20. cole md, clearkin l, dabbs t, et al. the seat belt law and after. br j ophthalmol. 1987; 71: 436-40. 21. thylefors b. epidemiological patterns of ocular trauma. aust nz j ophthalmol. 1992; 20: 95-8. 22. khan md, mohammed s, islam zu, et al. an 11 years review of ocular trauma in the north west frontier province of pakistan. pak j ophthalmol. 1991; 7: 15-8. microsoft word khawaja khalid shoaib 1 original article micro incision cataract surgery (mics)/ bimanual phacoemuslsification. initial problems and the solutions khawaja khalid shoaib pak j ophthalmol 2009, vol. 25 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: khawaja khalid shoaib head of eye department cmh kharian cantt received for publication may’ 2008 purpose: to describe the difficulties faced by a phacoemulsification (phaco) surgeon switching to micro incision cataract surgery (mics) bimanual phaco so that others are better prepared when starting the procedure. material and method: initial fifty cases of mics -bimanual phaco were analyzed to find out the problems encountered peculiar to the new procedure. all the complications that occur during the conventional co-axial phaco were excluded. operation time of twenty cases of mics was compared to operation time of twenty cases of coaxial phaco in various categories of cataract hardness. average effective phaco time (ept) of grade 2 cataract for mics and coaxial phaco were compared. results: spray of liquid emitting through wound, anterior chamber (a/c) collapse, increased operation time, increased size of irrigating chopper causing difficulty in manipulation and its sharpness resulting in rupture of posterior capsule, were encountered. operation times of mics were greater than coaxial group from 3.12 to 8.04 minutes for various categories of cataract hardness. ept of grade 2 cataract for mics was 3.92±2.07sec and coaxial phaco was 5.67±3.7sec. it means more operation time but less phaco for mics as compared to coaxial phaco. conclusion: in spite of enormous advantages of mics bimanual phaco, it has some problems which are unique to the procedure and phaco surgeon should be 2 … ……………………… ready to face them. icro incision cataract surgery (mics)/ bimanual phaco is the latest technique1 for cataract surgery, in which infusion is shifted from phaco tip to chopper so that both the incisions sizes are less than 2 mm. first operation was done by amar agarwal2 with 0.9 mm incision on 15th august 1998. later her sister, sunita agarwal joined her. they termed it phakonit (phaco needle incision tip). it has been found safe3-,7 as far as endothelial cell loss8-12 during the operation or anterior chamber flare9 after the operation is concerned by majority of surgeons. a few have reported central corneal endothelial cell loss13. in coaxial phaco, ultrasound (us) probe the sleeve around the metallic tip has two important functions: 1. it introduces bss. 2. it cools the tip so that corneal burns are avoided. in micro incision cataract surgery (mics)/ bimanual phaco, there is no sleeve. special features of the bimanual phaco are related to: 1. ultrasound (us) emission to prevent corneal burns phaco power is introduced in pulse/burst mode which enables discontinuous us emission or different systems are provided in the probe e.g. thermal protection (as in microflow). regarding increased incision temperature, the major contributors identified are: incision size, us power, duty cycle, aspiration flow rate, vacuum setting, tip design, and presence of an ophthalmic viscosurgical device (ovd). minor contributors included pulse frequency, bottle height and temperature of the infusate.13 2. fluidics high vacuum and high flow levels are necessary. as gravity alone can not maintain increased flow through smaller diameter instruments in some machines, air pump (fig.1) is required. 3. instruments knives 1.2-1.5 mm, irrigating choppers (nagahara, braga-mele, chang, fine, olson, aggarwal, walker, packard, el-kasaby, dk, farmer, rosen, nucleus claw, universal, kazuno, tsunoeka, ohki etc), fine capsulorhexis forceps and 20 g irrigation/aspiration canulas are required. advantages of mics due to decreased incision size (as compared to coaxial phaco) are: 1. astigmatism is reduced14-16. 2. strength of wound is better. 3. healing of the wound is rapid. material and method this study was carried out in eye department, cmh kharian from oct 2007 to march 2008. phaco machines admiral (a), pulsar ii (p) and oertli (o) were used. all the operations (mics bimanual phaco) were performed by the author. initial fifty cases were analyzed to find out the problems encountered peculiar to the new procedure. the patients included 40 males and 10 females. age ranged from 29 years to 80 years with mean of 61.1 years +10.47 (sd). all the complications which occur during the conventional co-axial phaco e.g. posterior capsular rupture during aspiration of viscoelastic or insertion/dialing of intraocular lens (iol) or trauma to iris by phaco tip etc, were excluded. anesthesia: having done about 1200 phaco under topical anesthesia (ta) in the last two years, author started mics under ta. 0.5% proparacaine (alcaine) one drop repeated four times at half minute intervals before making the first incision, was the only anesthetic used in all the cases. incision: clear corneal tunnel incision at the limbus was made. in the initial five cases when 1.5 mm keratome was not available, partial entry with 3.2 mm keratome was done. the rest of the cases were done with 1.5 mm keratome. after filling anterior chamber with sodium hyaluronate (visco supreme), second incision was made again with 1.5 mm kera-tome at about sixty degrees away from the first one. capsulorhexis: it was done with the bent needle of insulin syringe. infusion bottle: it was kept at maximum height (approximately 120 cm). phaco tip: 20 gauge thick tip which could be used with high vacuum, was used in all mics cases (fig. 1). choppers: different irrigating choppers were used (fig. 2,3). each time irrigating chopper was introduced first which snugly fitted in the incision and phaco tip was introduced through the other incision. m 3 phaco: in the first twenty five cases, nucleus was divided into four pieces by “divide and conquer technique” keeping the vacuum low (20-40 mm of hg). in the second step each piece was phacoemulsified with high vacuum (200-250 mm of hg). it required less experience with the chopper but used considerable phaco power. later on the rest of the cases were done with the “stop-and-chop technique” in which a single tunnel was made and the nucleus divided in two halves. each half was engaged by the phaco tip with high vacuum (200-250 mm of hg) and chopper made pieces just like making pieces of a cake. it required more experience with the chopper but used less phaco power. to prevent corneal burn intermittent use of phaco power was achieved by pressing the foot pedal to phaco position for brief intervals. later on phaco power was converted to pulse mode with increased interval between pulses. iol insertion: after the phaco was completed with two 1.5 mm incisions and irrigation /aspiration done, incision was enlarged to allow iol insertion. in most of the cases thin iol through 1.8 mm incision was inserted. viscoelastic was aspirated. injection of 0.1 ml of intracameral moxifloxacin (vigamox /megamox) and hydration of the wounds was done in every case. post operatively patient was advised moxifloxacin (vigamox /megamox) eye drops qid and fortipred / predforte eye drops qid for two weeks. cataract density was divided in five grades depending upon the density of cortical and nuclear opacities. grade 1 for minimum density and grade 5 for most dense cataracts. on every operation list a few cases of mics were randomly mixed with coaxial cases. all the coaxial cases were done with 19 g tip through 2.75 mm incision. forty patients were randomly selected for the two groups, last twenty cases out of the first fifty mics (group a) and coaxial phaco (group b) twenty cases. each group was subdivided according to grade of cataract (table 1). table 1: problems encountered and their solutions in the first fifty cases of mics bimanual phaco cases n (%) problems solutions 2(4) spray of liquid droplets emitted through wound decrease the phaco power 5 (10) anterior chamber (a/c) collapse/ shallowing / • infusion bottle height maximum (max) depth fluctuations • irrigating chopper with max flow • inflated bp cuff around infusion bottle • air pump connected to infusion bottle • incision size 1.5 mm 5 (10) difficulty in irrigating chopper manipulation experience required 1(2) sharpness of chopper choppers having blunt edges 50(100) increased operation time -high vacuum (250-300 mm of hg) -experience required total operating time: it was the time from the moment keratome touched the cornea to end of irrigation /aspiration of lens matter. average operation times (minutes) of the two groups (a and b) were compared for each grade of cataract. effective phaco time (ept): it is equivalent time to 100% of phaco power. it is calculated by multiplying total phacoemulsification time in seconds by the average power percent used. average ept of grade 2 cataract was compared for mics and coaxial phaco. results the problems encountered in the first fifty cases of mics bimanual phaco were (table 2): 1. spray of liquid droplets emitted through wound in the first two cases. 2. anterior chamber (a/c) collapse/ shallowing / depth fluctuations. in the first five cases, partial collapse a/c shallowing /fluctuations in its depth, occurred. 3. difficulty in irrigating chopper manipulation. it was noted, in first five cases. 4. sharpness of chopper. it resulted in rupture of posterior capsule in one case. 5. increased operation time. average operation times of mics were greater than coaxial group 4 from 3.12 to 8.04 minutes for various categories of cataract density (table 3). table 2: distribution of cases density of cataract (grade) no. of cases mics 20g no. of cases coaxial phaco 19g 1 1 2 12 9 3 4 4 4 2 2 5 1 5 table 3: average operation time density of cataract (grade) a= minutes + sd, mics 20g b= minutes + sd, coaxial phaco 19g difference between a & b (minutes) 1 8.52 2 10.51+2.23 7.39+ 0.7 3.12 3 14.82+3.4 8.9+ 1.2 5.92 4 16.37+1.4 9.1+ 1.6 7.27 5 18.44 10.4+ 3.98 8.04 fig. 1. diameter of phaco tips: (left) coaxial phaco 19g, (right) mics 20g fig. 2. different irrigating choppers fig. 3. magnified view of irrigating choppers tips fig. 4. (left)irrigation chopper with fast flow, (right) irrigation chopper with slow flow 5 fig. 5. air pump attached to infusion bottle having height 120 cm fig. 6. flow less without air pump(left) and increasing with air pump on (right). ept average ept of grade 2 cataract for mics was 3.92 + 2.07 sec and coaxial phaco was 5.67 + 3.7 sec (table 4) table 4: average ept density of cataract(grade) sec + sd mics 20g sec + sd coaxial phaco 19g 2 3.92+2.07 5.67+3.7 discussion the problems 1. spray of liquid droplets emitted through wound. it was because of the turbulence created by the vibrating phaco tip which was not covered by the sleeve. it was controlled by further decreasing the phaco power. for a and p this happened at phaco power above 20 % so we had to bring the phaco power to 15 %. 2. anterior chamber (a/c) collapse/ shallowing / depth fluctuations. initially this was thought to be due to decreased flow in the a/c. irrigating choppers were found to have different flow rates and the one which provided maximum flow was used (fig. 4). we used different techniques to increase the infusion pressure. at first inflated sphygmomanometer (bp) cuff was tried around the infusion bottle which gave good flow but an assistant was required to keep the pressure constant. later on the air pump (fig. 5, 6) was connected to infusion bottle to increase the flow. finally it was observed that (after the availability of 1.5 mm keratome) if the incision size is kept strictly under control (which allows the instruments to pass through incisions with slight difficulty), the a/c could be maintained with very little assistance from air pump. 3. difficulty in irrigating chopper manipulation. as it was larger in size, it took time to master its handling 4. sharpness of chopper. it was replaced with choppers having blunt edges. 5. operation time. increased operation time might be because of different reasons. firstly it might be due to smaller inner diameter of 20 g phaco tip and suction canula. secondly it might be partly because of learning curve of mics and partly due to the extra care when costly iol was involved. with increasing experience it was possible to increase the vacuum to 300 mm of hg which decreased the operation time but it still remained more than the coaxial phacoemulsification group. the difference was more marked for dense cataracts. others have also found prolonged phaco time in the dense cataracts.8 the mean operating time was found to be 11 min and 20 s when the nuclear hardness was of grade 3 or above (in a scale of 5)5. some have found operation time to be less in mics when compared with coaxial.17,18 surgical time of coaxial mics have also been found to be significantly higher than with conventional coaxial phaco19. ept decreased ept means less phaco for mics as compared to coaxial phaco and it has been noted by others also.12,17 in a study, the mean ept found was 4.3 sec with an average ultrasound of 5.7% when the nuclear hardness was of grade 3 or above (in a scale of 6 5).5 less phaco most probably is due to increased mechanical work by the chopper. conclusion mics bimanual phaco has enormous advantages including reduced astigmatism and rapid wound healing. at the same time it has some problems which are unique to the procedure and phaco surgeon should be ready to handle them. author’s affiliation lt. col. khawaja khalid shoaib head of eye department cmh kharian cantt reference 1. alió j, rodriguez-prats jl, galal a. advances in microincision cataract surgery intraocular lenses. curr opin ophthalmol. 2006; 17: 80-93. 2. agarwal a, agarwal a, agarwal s, et al. phakonit: phacoemulsification through a 0.9 mm corneal incision. j cataract refract surg. 2001; 27: 1548-52. 3. tham cc, li fc, leung dy, et al. microincision bimanual phacotrabeculectomy in eyes with coexisting glaucoma and cataract. j cataract refract surg. 2006; 32: 1917-20. 4. prakash p, kasaby he, aggarwal rk, et al. microincision bimanual phacoemulsification and thinoptx implantation through a 1.70 mm incision. eye. 2007; 21: 177-82. 5. assaf a, el-moatassem kotb am. feasibility of bimanual microincision phacoemulsification in hard cataracts. eye. 2007; 21: 807-11. 6. khng c, packer m, fine ih, et al. intraocular pressure during phacoemulsification. j cataract refract surg. 2006; 32: 301-8. 7. weikert mp. update on bimanual microincisional cataract surgery. curr opin ophthalmol. 2006; 17: 62-7. 8. mathys kc, cohen kl, armstrong bd. determining factors for corneal endothelial cell loss by using bimanual microincision phacoemulsification and power modulation. cornea. 2007; 26: 1049-55. 9. kahraman g, amon m, franz c, et al. intraindividual comparison of surgical trauma after bimanual microincision and conventional small-incision coaxial phacoemulsification. j cataract refract surg. 2007; 33: 618-22. 10. wilczynski m, drobniewski i, synder a, et al. evaluation of early corneal endothelial cell loss in bimanual microincision cataract surgery (mics) in comparison with standard phacoemulsification. eur j ophthalmol. 2006; 16: 798-803. 11. mencucci r, ponchietti c, virgili g, et al. corneal endothelial damage after cataract surgery: microincision versus standard technique. j cataract refract surg. 2006; 32: 1351-4. 12. kurz s, krummenauer f, gabriel p, et al. biaxial microincision versus coaxial small-incision clear cornea cataract surgery. ophthalmology. 2006; 113: 1818-26. 13. crema as, walsh a, yamane y, et al. comparative study of coaxial phacoemulsification and microincision cataract surgery. one-year follow-up. j cataract refract surg. 2007; 33: 1014-8. 14. elkady b, alió jl, ortiz d, et al. corneal aberrations after microincision cataract surgery.j cataract refract surg. 2008; 34: 40-5. 15. yao k, tang x, ye p. corneal astigmatism, high order aberrations, and optical quality after cataract surgery: microincision versus small incision. j refract surg. 2006; 22: 1079-82. 16. kałuzny j, kałuzny bj. z kliniki okulistycznej akademii medycznej w bydgoszczy. [microincision cataract surgery] [article in polish] klin oczna. 2005; 107: 426-30. 17. alió j, rodríguez-prats jl, galal a, et al. outcomes of microincision cataract surgery versus coaxial phacoemulification. comment in: ophthalmology. 2006; 113: 1687. 18. cavallini gm, campi l, masini c, et al. bimanual microphacoemulsification versus coaxial miniphacoemusification: prospective study. j cataract refract surg. 2007; 33: 387-92. 19. dosso aa, cottet l, burgener nd, et al. outcomes of coaxial microincision cataract surgery versus conventional coaxial cataract surgery. j cataract refract surg. 2008 ; 34: 284-8. microsoft word abstract vol. 25, 2,09 118 abstracts edited by dr. tahir mahmood corneal biomechanics, thickness and optic disc morphology in children with optic disc tilt lim l, gazzard g, chan y-h, fong a, kotecha a, sim e-l, tan d, tong l, saw s-m br j ophthalmol 2008; 92: 1461-6 central cortical thickness (cct) may be a surrogate marker for glaucoma susceptibility. structural changes in the optic nerve head have been shown to precede or even predict functional deficits in glaucoma, while correlations between cct and various optic nerve head morphological parameters have been demonstrated. cct is significantly correlated with retinal nerve fibre layer (rnfl) thickness in both normal subjects and ocular hypertensives, and a thin rnfl may predispose to glaucoma. larger optic discs are also more susceptible to glaucomatous damage, and in a study on 212 eyes of 137 adult primary open angle glaucoma (poac) patients described an inverse relationship between cct and disc size. similarly, on other study described negative correlations between cct and disc area, rim area, rim volume and rnfl area in 208 normal adult patients. in another study it was however found that large discs were instead associated with thicker cct in a population of 180 normal adult subjects. the reichert ocular response analyser (ora; reichert ophthalmic instruments, depew, new york) is a recently introduced device that measures the biomechanical properties of the cornea in vivo. the principal biomechanical parameter measured by the ora is corneal hysteresis (ch). low values of ch are often generally described to indicate a “soft” or “floppy” cornea-it is perhaps more accurate to say that a lower ch suggests that the viscous properties of the “visco-elastic” character are more prominent. cr is correlated with cct, such that a thicker cornea has a larger ch, or greater dampening properties, and it has also been proposed that ch may likewise be a surrogate marker of glaucoma susceptibility through a relationship with the resistance of the optic nerve head to intraocular pressure (iop) related deformation. lower cr but not cct was associated with visualfield progression in glaucomatous eyes. the purpose of this study was to determine the associations between corneal biomechanical parameters as measured by the reichert ocular response analyser (ora) and disc morphology and retinal nerve fibre layer thickness (rnfl) measured by the heidelberg retinal tomograph (hat) ii in singaporean children. this is a cross-sectional study conducted on a subset of children enrolled in the singapore cohort study of the risk factors of myopia (scorm). corneal hysteresis (ch), corneal resistance factor (cre) and central corneal thickness (cct) were measured with the ora. optic disc morphology and anfl thickness were assessed by the hrt ii, cycloplegic refraction and ultrasound a-scans were also performed, and disc tilt was assayed from stereo photographs. 102 subjects (mean age 12.01 (sd 0.57) years; range 11-14 years) were included in the study. the mean ch was 12.00 (1.40) mm hg, the mean crf was 11.99 (1.65) mm hg, and the mean cct was 581.12 (33.53) µm. eyes with tilted discs had significantly longer axial lengths and more myopic refraction than eyes without tilted discs. there were no significant correlations between ch, crf or cct and the hat ii parameters, after the application of the bonferroni correction. when stratified for disc tilt, however, the global disc area was significantly correlated with cct (r = -.49, p = 0.001). authors concluded with the remarks that the corneal biomechanical properties as measured with the ora do not vary with optic disc parameters or rnfl central corneal thickness is correlated with disc area in singaporean schoolchildren with tilled discs. this relationship may influence glaucoma risk in myopic subjects. correlation of lens density measured using the pentacam scheimpflug system with the lens opacities classification system ill grading score and visual acuity in age-related nuclear cataract pei x, bao y, chen y, li x br j ophthalmol 2008; 92: 1471-5. 119 cataract is a major public health issue, since it is the most prevalent condition afflicting patients who attend an optometric practice; according to the world health organization, it is one of the principal causes of blindness worldwide. accordingly, reliable assessment of cataract is indispensable to anyone engaged in an epidemiological study or a clinical trial. studies of cataract classification and quantitative measurement are vital for investigating the possible risk factors of cataract formation and evaluating the performance of anti-cataract drugs. clinically, the methods used for cataract assessment may be divided into two types, subjective and objective. the former includes the lens opacities classification system (locs), the wisconsin system, the wilmer system and the oxford system. the latter, based on scheimpflug photography or slit-lamp imagery includes the oxford scheimpflug, the topcon sl45, the zeiss scheimpiflug video camera and the nidek eas-1000” which had been used in clinical practice. locs hi is well recognised as an age-related cataract grading scheme and is widely used for clinical and research study. some studies have shown a good reproducibility with this method for cataract grading. however, it suffers, as do all other subjective assessments, from limitations rooted in observer bias and doubts concerning interobserver and intraobserver reliability. pentacam, a recently developed camera based on the scheimpflug principle, captures images of the anterior eye segment in order to create a precise, threedimensional view, and uses the digitally acquired data to evaluate the parameters of lens, cornea and anterior chamber. the purpose of this study was to investigate the relationship between lens density measured with pentacam and locs iii grading score as well as that between lens density and visual acuity in age-related nuclear cataract patients, with a view to evaluating the relative merits of the different approaches for the assessment of age-related nuclear cataract. lens density and grading score were evaluated in 138 cases (180 eyes) with age-related nuclear cataract. logmar visual acuity was tested with the early treatment diabetic retinopathy study chart. the correlations between lens density value and locs ill nuclear opacity (no) and nuclear colour (nc) grading score and that between lens density value and iogmar visual acuity were analysed. there was a linear increasing relationship between lens density value and locs ill grading score in nuclear cataract patients. lens density value had a stronger significant correlation with locs ill no score than that with nc score. the correlation between the nuclear lens density value and logmar visual acuity was stronger than that between no score and logmar visual acuity or between nc score and logmar visual acuity. authors concluded with the remarks that the lens density as a quantitative and objective parameter can present the degree of no and associated visual impairment due to nuclear cataract. the locs ill criterion as an economic cataract grading system provides data that are in satisfactory concordance with the results obtained using the pentacam scheimpflug system. second-line therapy with dorzolamide / timolol or latanoprost/timolol fixed combination versus adding dorzolamide/timolol fixed combination to latanoprost monotherapy konstas agp, mikropoulos d, dimopoulos at, moumtzis g, nelson la, stewart wc br j ophthalmol 2008; 92: 1498-1502 latanoprost (xalatan, pfizer, new york) was introduced in 1996 as the first ocular f2 prostaglandin analog. because of its generally improved efficacy compared with the prior first-line medicine, rimolol maleate, this class of medicine has become a commonly prescribed monotherapy in the united states and europe. nonetheless, despite the superior efficacy of prostaglandins, many glaucoma patients remain incompletely controlled and may need additional therapy to further reduce the intraocular pressure (lop). however, which medicine or preparation is best suited as second-line therapy remains controversial. in the united states second-line therapy is not uniform, and physicians prescribed in the following order of frequency: beta-blocker (46%), prostaglandins (23%), dorzolamide/timolol fixed combination (12%), dorzolamide (11%) and brimonidine (9%).’ in contrast, as a third-line therapy, 75% of respondents prescribed the combination of a prostaglandin and the dorzolamide/timolol fixed combination. europe has more fixed combinations available to help simplify therapy. consequently, second-line therapy more frequently involves changing from latanoprost to a fixed combination, which includes most commonly the dorzolamide or a prostaglandin 120 based fixed combination. unfortunately, the additional ocular hypotensive efficacy with a fixed combination, over latanoprost alone, may not be sufficient to control some patients. consequently; the question arises: would a dorzolamide/timolol fixed combination be a more effective addition to latanoprost than changing to a fixed combination alone? the purpose of this study was to evaluate openangle glaucoma patients, who were insufficiently controlled on latanoprost monotherapy, to determine the 24 h intraocular pressure (lop) efficacy and safety when changing them to dorzolamide/ timolol (dtfc) or latanoprost/timolol fixed combination (ltfc) or adding dtfc. consecutive adults with primary open-angle or exfoliative glaucoma who exhibit a mean baseline lop >21 mm hg on latanoprost monotherapy were randomised for 3 months to: dtfc, ltfc or dtfc and latanoprost. patients were then crossed over to the next treatment for periods 2 and 3. at the end of the latanoprost run-in and after each 3-month treatment period, patients underwent 24 h lop monitoring. thirty one patients completed this study. all three adjunctive therapies significantly reduced the lop at each time point and for the mean 24 h curve, except at 18:00 and 02:00 with dtfc and 02:00 with ltfc. when the three treatments were compared directly, the dtfc and latanoprost therapy demonstrated lower lops versus the other treatment groups, including: the mean 24 h pressure, maximum as well as minimum levels and individual time points following a modified bonferroni correction (p<0.0032). authors concluded with the remarks that this study showed dtfc, ltfc and the addition of dtfc to latanoprost significantly decrease the lop compared with latanoprost alone, but the latter therapy regime yields the greatest lop reduction. 121 microsoft word amil khan 155 original article frequency and patterns of eye diseases in retina clinic of a tertiary care hospital in karachi aimal khan, qamar riaz, fayaz soomro, umair qidwai, umer qazi pak j ophthalmol 2011, vol. 27 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: aimal khan al-ibrahim eye hospital/ isra postgraduate institute of ophthalmology karachi submission of paper june’ 2011 acceptance for publication august’ 2011 …..……………………….. purpose: to evaluate the frequency and pattern of eye diseases in retina clinic of a tertiary care hospital in karachi material and methods: a total number of 27,000 new patients were seen at the al ibrahim eye hospital (aieh), retina clinic between july 2009 and june 2010, their data was obtained from the ophthalmic outpatient attendance register. their records were analyzed for data according to age, sex and clinical diagnoses made after detailed fundus evaluation with binocular indirect ophthalmoscope and slit lamp using 20 d and 90 d lenses respectively. data was entered and analyzed for simple frequency using spss version 14.0. tests for significant inter group differences were performed using the chi square test with a p<0.001 considered statistically significant. results: out of 27,000, 3615 patients were registered in retina clinic. diabetic related retinal conditions were the most common cause (39.8%) for registration in the retina clinic. 648 (45% of total dr) patients had clinically significant macular edema (csme) and 102 (7%) eyes had advanced diabetic eye disease (aded). conclusion: there is a tremendous impact of increasing retinal blindness secondary to retinal diseases especially diabetic retinopathy in pakistan. the impression based on hospital practice is that the problem is on the rise. this entails the necessity for accessible comprehensive eye care services, establishment of human resources, screening and awareness of the disease and affordable eye health policy. etinal disease has had a low priority in prevention of blindness programmes in developing countries mainly because retinal diseases were considered an uncommon cause of blindness in the developing world1. in spite of the effort and expense involved in acquiring costly equipment and developing skilled human resource for retinal sub specialty, failure in justifying the treatment results of retinal disease has also contributed to the development and strengthening of this assumption2. in developing countries including pakistan cataract and corneal scarring were the most common cause of blindness. recently there has been a significant increase in the burden of vitreo-retinal disorders globally. with increased longevity and increased uptake of cataract surgical services, retinal diseases especially those due to diabetes and amd are coming up as important causes of blindness and visual impairment. previous reports from hospital based studies and general population surveys of causes of low vision have implicated vitreo-retinal diseases as the major public eye health burden. population-based surveys reported vitreo-retinal disorders to be responsible for 8.56% and 12.7% in iran3 and india4 respectively. the age and sex-adjusted prevalence of vitreo-retinal diseases in korean adults 50 years of age and older was 9.9%5. according to the pakistan national survey for blindness and visual impairment done in year 2002-03, posterior segment diseases r 156 accounted for 3.4% of total blindness and visual impairment. however the break up is not available. retinal diseases vary widely ranging from common but easily treatable to rare and untreatable. the purpose of our study is to generate data on frequency and pattern of retinal disease in patients aged above 16 years presenting at aieh. material and methods al ibrahim eye hospital provides tertiary level care to karachi and its suburbs as well as rural population of far-flung areas of sind. all services are provided free of charge except for cataract and vitreo-retinal surgery, which are done at nominal charges (to bear the cost of consumables). in addition to karachi and its suburbs, the hospital provides services to the rural population of districts of dadu, thatta in particular, as well as farflung areas of sindh in general. a total number of 27,000 new patients were seen at the aieh retina clinic between july 2009 and june 2010 as shown by the ophthalmic out patient attendance register. their records were analyzed for data on age, sex and clinical diagnoses made after detailed fundus evaluation with binocular indirect ophthalmoscope and slit lamp using 20 d and 90 d lenses respectively. data was entered and analyzed for simple frequency using spss version 14.0. tests for significant inter group differences were performed using the chi square test with a p<0.001 considered statistically significant. the study was conducted with adherence to institutional policy. ethical clearance from the ethics committee (institutional review board) of aieh was obtained prior to commencement of the study and patients’ privacy was maintained by excluding identification names and hospital numbers of patients from data analysis and manuscript preparation. result a total of 27,000 new patients visited al-ibrahim eye hospital, karachi, from june 2009 to june 2010, of which 3615 (13.4%) were registered in the retina clinic. out of these 3615 patients of the retina clinic, 2271 (62.8%) were males while 1344 (37%) were females. the mean age of the patients registered in the retina clinic was 46.57 years (sd=16.7). the minimum age of the patient registered in retina clinic was 7 years while the maximum age was 90 years. among males the average age was 47.2 years ((sd= 16.9) while in females it was 48.27 years (sd= 16.3). it appeared that the conditions are more common in 45 to 60 years age group. out of these 3615 patients 2304 were from karachi, 69 were from rural areas of balochistan province, 72 patients were from the urban areas of balochistan province, 24 were from punjab province, 5 from khyber pakhtoon khwa province while the rest of the patients belonged to rural areas of sindh province. out of 3615 patients 1736 (48%) had monocular involvement while rest of the 1879 (52%) patients had bilateral involvement. diabetic related retinal conditions were the most common cause (39.8%) for registration in the retina clinic followed by retinal detachment in 20.6% patients. distribution of different diseases that led to registration in the retina clinic is shown in (table 1). out of 1440 (39.8%) patients having diabetic retinopathy 648 (45% of total dr) patients had clinically significant macular edema (csme) and 102 (7%) eyes had advanced diabetic eye disease (aded). table 2 gives the relative frequency of different types of diabetic retinopathy according to the eye/s involved. of the total 648 patients with csme, 264 (18.3 %) patients had bilateral clinically significant edema while 384 (26.6%) had unilateral clinically significant edema. the following diagram shows the pattern of diabetic retinopathy. discussion the retinal disease pattern noted at aieh is comparable to those noted at other institutions of the developing world. vitreo-retinal disorders constituted a significant reason for presentation to eye clinics and tertiary eye department, ranging from 3.9% in southeastern nigeria7 to 12.5% in ethiopia8in nigeria vitreo-retinal disorders constituted a significant cause of ocular morbidity and vision loss with reported hospital prevalence rate of 13.0%9a study from malaysia has also reported retinal diseases to be responsible for 12% of patients presenting to outpatient department of eye units10. the male to female ratio was 1.7:1. this is again similar to the study done in ethiopia8. the higher male attendance of hospitals for healthcare in developing countries contributes to the male preponderance. 157 however greater uptake of cataract surgical service by males may be another reason for increased number of males with retinal diseases. since the study was aimed to find out the age, sex and diagnostic varieties in order to assess pattern of posterior segment disease in patients presenting at the aieh, other demographic and therapeutic details were not included. table1: frequency of different types of retinal diseases retinal disease no. of patients n (%) unilteral n (%) bilateral n (%) diabetic retionpathy 1440 (39.8) 384 (22.1) 687 (36.6) retinal detachment 744 (20.6) 649 (37.4) 158 (8.4) high myopia 336 (9.3) 22 (1.3) 341 (18.1) armd 335 (9.3) 168 (9.7) 438 (23.3) vitreous hemorrhage 192 (5.3) 192 (11.1) 0 (0) crvo 96 (2.7) 95 (5.5) 3 (0..2) brvo 95 (2.6) 71 (4.1) 1 (0.1) macular hole 48 (1.3) 21 (1.2) 68 (3.6) vasculitis 47 (1.3) 5 (0.3) 42 (2.2) fundus dystrophies 47 (1.3) 27 (1.6) 57 (3.0) cystoid macular edema 24 (0.7) 20 (1.2) 8 (0.4) neovascular glaucoma 23 (0.6) 29 (1.7) 5 (0.3) endophthalmitis 14 (0.4) 15 (0.9) 0 (0) others 174 (4.8) 38 (2.2) 71 (3.8) total 3615(100) 1736(100) 1879 (100) table 2: frequency of different types of diabetic retinopathy type of retinopathy no of patients percentage n =3615 percentage n=1440 bilateral npdr 624 17.3% 43.3% npdr + pdr 216 5.97% 15% bilateral pdr 192 5.3% 13.3% npdr + aded 192 5.3% 13.3% bilateral aded 96 2.6% 6.6% pdr + aded 120 3.3% 8.3% npdr = non-proliferative diabetic retinopathy pdr= proliferative diabetic retinopathy aded= advanced diabetic eye disease frequency of csme among patients having diabetic retinopathy 792 384 264 bilateral csme unilateral csme no csme fig. 1: bilateral clinically significant edema (csme) =264 (18.3 %) unilateral clinically significant edema (csme) =384 (26.6%) no clinically significant edema (csme) = 792 (55%) the mean age group in our study was 47 years in males while in females it was 48.6 years. it appeared that the conditions are more common in 45 to 60 years age group. this is similar to the findings from nigeria9and can be compared to the study done in malaysia where majority (61.9%) patients were above the age of 50 years. diabetic retinopathy was the most common cause for attendance in the retina clinic showing that 158 diabetic eye disease is emerging as a challenge. this is similar to the results from nepal eye hospital where diabetic related conditions were most common cause for visiting the retina opd11. in malaysia10 and nigeria9 diabetic retinopathy accounted for 9.7% and 9.6% retinal diseases respectively. this warrants timely screening, evaluation, treatment, follow up and education for diabetic related conditions. retinal detachment represented 20.6% of retinal diseases in this study as opposed to only 7% in nepal and 12% in malaysia.10 however this is close to the findings from ethiopia where retinal detachment accounted for the second largest group (24.5%) of diseases. retinal detachment surgeries with restoration of useful vision are reported to be successful in developing communities1. improvements in the capacity to detect and manage retinal detachment will prevent blindness in these economically viable age groups. armd accounted for 9.3% of retinal diseases. this is in contrast to the prevalence of 2.7% amd from ethiopia. the age adjusted prevalence of armd was 4.72 % in sri lanka12. in the second national blindness survey of pakistan (2002-2004) macular degeneration accounted for 2.8%1. this difference may be due to the fact that the current study was a hospital based study where patients have manifest retinal conditions. it appears that inspite of proliferation of various levels of posterior segment service facilities within the country and even the city the number of attendance in retina clinic at aieh is on rise. this on one hand stresses and justifies additional investments needed to tackle all kinds of posterior segment eye problems including the ones needing complex vitreo-retinal surgical procedures while on the other recommends general community awareness in order to reduce undue blindness and visual impairment due to avoidable causes. the results of this study gave an insight into the pattern of retinal eye diseases seen in a tertiary center in karachi. however in order to generalize the results it is necessary to conduct a larger multi center study or a population based study. conclusion there is a tremendous impact of increasing retinal blindness secondary to retinal diseases especially dr in pakistan. the impression based on hospital practice is that the problem is on rise. the set up for their evaluation and management especially surgical is expensive and for average pakistani population the treatment is not affordable unless subsidized by the hospital. this entails the necessity for accessible comprehensive eye care services, establishment of human resources, screening and awareness of the disease and affordable eye health policy. author’s affiliation dr. aimal khan al-ibrahim eye hospital isra postgraduate institute of ophthalmology karachi dr. qamar riaz al-ibrahim eye hospital isra postgraduate institute of ophthalmology karachi dr. fayaz soomro al-ibrahim eye hospital isra postgraduate institute of ophthalmology karachi dr. umair qidwai al-ibrahim eye hospital isra postgraduate institute of ophthalmology karachi dr. umer qazi al-ibrahim eye hospital isra postgraduate institute of ophthalmology karachi reference 1. yorston d and jalali s. retinal detachment in developing countries. eye. 2002; 16: 353–8. 2. yorston d. retinal diseases and vision 2020. community eye health. 2003; 16:19-20. 3. hatef e, fotouhi a, hashemi h, et al. prevalence of retinal diseases and their pattern in tehran: the tehran eye study. retina. 2008; 28: 755-62. 4. dandona l, dandona r, srinivas m, et al. blindness in the india state of andrapradesh. invest ophthalmol vis sci. 2001; 42: 908-16. 5. youm dj, oh hs, yu hg, et al. the prevalence of vitreoretinal diseases in a screened korean population 50 years and older. j korean ophthalmol soc. 2009; 50: 1645-51. 6. dineen b, bourne rra, jadoon z, et al.. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91: 1005–10. 7. eze bi, uche jn, shiweobi jo. the burden and spectrum of vitreo-retinal diseases among ophthalmic outpatients in a resource-deficient tertiary eye care setting in south-eastern nigeria. middle east afr j ophthalmol. 2010; 17: 246-9. 8. teshome t, melaku s, bayu s. pattern of retinal diseases at a teaching eye department, addis ababa, ethiopia. ethiop med j. 2004; 42: 185-93. 159 9. onakpoya oh, olateju so, ajayi ia. retinal diseases in a tertiary hospital: the need for establishment of a vitreoretinal care unit. journal of the national medical association. 2008; 100: 1286-9. 10. reddy sc, tajunisah i, low kp, et al. prevalence of eye diseases and visual impairment in urban population. a study from university of malaya medical centre. malaysian family physician. 2008; 3: 25-8. 11. karki db, malla ok, byanju rn, et al. analysis of 400 cases of posterior segment diseases visiting retina clinic of nepal eye hospital. kathmandu university medical journal. 2003; 1: 1615. 12. goold la, edussuriya k, selva d, et al. prevalence and determinats of age-related macular degeneration in central sri lanka: the kandy eye stury. br j ophthalmol. 2010; 94: 150-3. microsoft word abstract 26, 3,2010 165 abstracts edited by prof. tahir mahmood turnover rate of tear-film lipid layer determined by fluorophotometry mochizuki h, yamada m, hatou s, tsubota k br j ophthalmol 2009: 93: 1535-38. the precorneal tear film has traditionally been described as consisting of an outer lipid layer, a middle aqueous layer and an inner mucus layer. although this remains valid, some modifications have been proposed. in the current model of the tear film, the aqueous-mucin layer is covered by two thin layers of lipids. polar lipids such as phospholipids lie adjacent to the aqueous-mucin layer, and non-polar lipids such as cholesterol and wax ester are present at the tear-air interface. in addition, tears contain proteins that possess lipid-binding properties, such as tear lipocalin. although lipids in tears are primarily located in the tear-film lipid layer, some lipids are presumably bound by lipocalin in the aqueous layer. tear lipocalin is thought to have an important role in stabilising the tear-film lipid layer by transferring lipids to it from the aqueous layer. despite comprising a very small proportion of the overall tear-film thickness, the lipid layer is important for retarding evaporation and maintaining tear-film stability. where the lipid layer is absent or where the integrity of the lipid layer is compromised, the evaporation rate of tears increases, accompanied by tear-film instability. to assess the lipid layer of tears, several techniques have been developed, including observation of lipid layer characteristics by interferometric methods, quantitative measurement of meibomian lipid on the lid margin by meibometry and measurement of evaporation from the ocular surface. of these, observation of lipid layer characteristics by interferometric methods has been well established. in various pathological conditions, such as smeibomian gland dysfunction, the appearance of the lipid layer can change. lipid layer thickness, measured by interferometry, has been reported to correlate with tear-film evaporation, tear-film breakup time, and clinical symptoms. the concentration of lipocalin in tears from patients with meibomian gland dysfunction is significantly lower than in normal controls. thus, lipids in tears, both in the lipid layer and in the aqueous layer held by lipocalin, are important when considering the pathophysiology of evaporative dry eye, such as meibomian gland dysfunction. until now, however, there has been no information about the flow rate of tear-film lipid layer. the purpose of this study was to independently assess the turnover rates of aqueous and lipid layers of the tear film, two fluorescent dyes, fluorescein sodium and 5dodecanoylaminofluorescein (daf), which is a freefatty-acid conjugate of fluorescein, were applied to the right eye of 12 healthy volunteers. fluorescent intensity of the precorneal tear film was measured at the central cornea every minute for 10 min for fluorescein sodium, and every 5 min for 50 min for daf. the turnover rate was calculated by plotting fluorescent intensity against time in a semilog plot and expressed as %/min. turnover rates of fluorescein sodium and daf were 10.3 (sd 3.7)%/min and 0.93 (0.93 (0.36)%/min., respectively. the turnover rate of daf was significantly lower than that of fluorescein sodium (p<0.05, mann-whitney test). the turnover rate of daf positively correlated with that of fluorescein sodium (r=0.93, p<0.05). authors concluded with the remarks that our results indicate that the turnover of lipids in tears is much slower than the aqueous flow of tears, and that this lipid turnover is associated with the aqueous flow of tears in healthy adults. cataract surgery and primary intraocular lens implantation in children <2 years old in the uk and ireland: finding of national surveys solebo al, russell-eggitt i, nischal kk, moore at, cumberland p, rani js, b.j ophthalmol 2009; 93: 1495-1498. primary intraocular (iol) implantation has become accepted practice for older children with cataract. while primary iol implantation is being increasingly undertaken in children in the first 2 years of life, the long-term benefits and the factors associated with positive and negative outcomes are unclear. 166 the british isles congenital cataract interest group (bccig), a research network comprising british and irish ophthalmic consultants, was established in 1995 in order to study the incidence, detection, causes, management and outcomes of congenital and infantile cataract. a national epidemiological study to investigate outcomes following primary iol implantation in children < 2 years old with congenital and infantile cataract is now being undertaken through the bccig. the purpose of this study was current patterns of practice relating to primary intraocular lens (iol) implantation in children <2 years old in the uk and ireland are investigated. 76% of 928 surveyed ophthalmologists replied. 47 (7%) of the respondents operated on children aged < 2 with cataract. 41 (87%) of respondents performed primary iol implantation, but 25% would not implant an iol in a child under 1 year old. 88% of surgeons used limbal wounds, 80% manual capsulotomies, 98% posterior capsulotomies and 100% hydrophobic acrylic lenses. the srk/t formula was most commonly used (70%). exclusion criteria for primary iol implantation varied considerably and included microphthalmos (64% of respondents), anterior and posterior segment anomalies (53%, 58%), and glaucoma (19%). primary iol implantation in children <2 has been widely adopted in the uk and ireland. there is concordance of practice with regards to surgical technique and choice of iol model. however, there is some variation in eligibility criteria for primary lols: this may reflect a lack of consensus on which children are most likely to benefit. thus, there is a need for systematic studies of the outcomes of primary iol implantation in younger children. predicting visual success in macular hole surgery gupta b; laidlaw dah, williamson th, shah sp, wong r, wren s b.j ophthalmol 2009; 93: 1488-1491. data on the outcome of surgery facilitate informed preoperative patient counseling. most data on the outcome of idiopathic full thickness macular hole (iftmh) surgery have concentrated on techniques and rates of anatomical closure. the aim of this study was to identify factors predicting restoration of good visual acuity (va) (better than 20/40; 6/12 uk snellen) and to present these data in a clinically usable format for use in preoperative counseling. as surgical techniques are known to differ widely, in building the cohort we only included patients that had the same surgical technique and postoperative instructions, so that this study had one of the largest cohorts of patients undergoing standardised macular hole surgery. the purpose of this study was data on the outcome of surgery facilitate informed preoperative patient counselling. most studies on the outcome of surgery for idiopathic full thickness macular hole surgery have concentrated on rates of anatomical closure. the aim of this study was to identify factors predicting visual success (better than 20/40; 6/12 snellen) following macular hole surgery. a retrospective study of 133 patients undergoing standardised macular hole surgery with at least 3 months of postoperative follow-up. all patients underwent preoperative measurement of the maximum macular hole diameter using optical coherence tomography. multivariable regression analysis identified that age, preoperative visual acuity and macular hole size were significant predictors of visual success. the resulting model correctly classified the visual outcome of 80% of cases. predicted rates of visual success varied from 93% in patients <60 years old with visual acuity better than 6/24 and a hole diameter of <350 um, to 2% in patients those >79 years old with visual acuity of 6/60 or worse and hole diameter of >500 urn. authors concluded with the remarks that the results provide a simple and clinically useful model to employ when counseling patients on macular hole surgery. aqueous vascular endothelial growth factor as a predictor of macular thickening following cataract surgery in patients with diabetes mellitus hartnett me, tinkham n, paynter l, geisen p, rosenberg p, koch g, cohen kl am j ophthalmol 2009; 148: 895-901. cystoid macular edema (cme) and exacerbated diabetic macular edema (dme) can adversely affect visual outcomes following cataract sugery in patients with diabetes mellitus (dm). with technical improvements in cataract surgery, better glycemic control in patients with diabetes, and preoperative laser treatment for clinically significant macular edema (csme), long-lasting macular edema (me) 167 following cataract surgery is reported less often now than in the past, but the problem of postoperative me still exists. a 30% increase in the center point thickness as measured by optical coherence tomography (oct) was reported in 22% of patients with diabetes at 1 month postcataract extraction. more than half had resolution at 3 months in this study. however, delay in treatment of macular edema has been shown to reduce visual improvement following cataract extraction in some patients. therefore, preoperative measurements that identify patients at risk for me after cataract surgery may be beneficial to initiate treatment early and reduce vision loss from me. vascular endothelial growth factor (vegf) and insulin-like growth factor-1 (igf-1) have been implicated in the pathogenesis of me and diabetic retinopathy (dr). vegf is a vasopermeability factor and has been associated with dme. intravitreous injections of agents that neutralize the bioactivity of vegf have stabilized or improved visual acuity (va) and reduced central subfield thickness (csf) as measured by oct in phakic patients with dme12 and have had mixed reports in nondiabetic pseudophakic patients with cme. another study reported that elevated aqueous levels of vegf, il-6, and protein were associated with exacerbated fluorescein leakage in the maculas of diabetic patients 6 months following cataract surgery. a recent report showed that 8 patients with diabetes who had had intravitreous bevacizumab (avastin; genentech inc, south san francisco, california, usa) for csme prior to cataract surgery had reduced aqueous vegf levels at the time of surgery 2 months later, but only a transient reduction in csf. the efficacy of anti-vegf treatment for prevention or treatment of postoperative cme or exacerbation of csme from cataract surgery in patients with diabetes remains indeterminate and may require further study. the purpose of this study was to study association between serum and aqueous vascular endothelial growth factor (vegf) and insulin-like growth factor 1 ((igf-1) and macular edema measured with optical coherence tomography (oct) following phacoemulsification in diabetic patients. a pilot study of 36 consecutive diabetic patients undergoing planned phacoemulsification with iol in 1 eye by one surgeon at the university of north carolina consented to preoperative and postoperative oct central subfield (csf) thickness measurements andaqueous and blood samples for vegf and igf-1. four patient with clinically significant macular edema (csme) received laser preoperatively. spearman-rank correlations were performed between growth factors and mean csf or a clinically meaningful percent change in csf (>11% of preoperative measurement) at 1 and 6 months postoperatively. there were no surgical complications or new cases of csme following surgery. mean aqueous vegf in patients with retinopathy, determined preoperatively, increased with increasing level of severity. oatients with preoperative csme also had severe of worse retinopathy and the greatest means aqueous vegf. significant preoperative correlations existed between aqueous vegf and more severe retinopathy whether csme was present or absent (r=0.49; p=.007), and between aqueous vegf and csme (r=0.41; p=.029). at 1 month postoperative, aqueous vegf was positively correlated with > 11% change from preoperative csf regardless of csme status (r=0.47; p=.027). no noteworthy associations existed between csf and igf-1 values. authors concluded with the remarks that the aqueous vegf was significantly positively associated with a clinically meaningful change in csf in diabetic patients 1 month following cataract surgery. accounting for preoperative cdf was important. further study is indicated. the aim of glaucoma management is to preserve vision for remaining lifetime with least possible inconvenience, complications, and financial strain. prof. m lateef chaudhry editor in chief microsoft word sadia sethi 166 original article pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital sadia sethi, mohammad junaid sethi, nasir saeed, naimatullah khan kundi pak j ophthalmol 2008, vol. 24 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: sadia sethi department of ophthalmology khyber teaching hospital, peshawar received for publication january’ 2008 … ……………………… purpose: the objectives were to find out the pattern of eye diseases by age and sex and treatment given to them. material and methods: in this hospital based study all children coming to outpatient department of ophthalmology, khyber teaching hospital peshawar over a period of two weeks from 1st june 2007 to 14th june 2007 were examined. a total of 202 children in age of 0-16 were included in the study. informed consent was taken from all the patients. a standard performa was filled in for recording personal history examination results and treatment required. results: on average 20 children were examined daily. 60.8% were male, 39.1% were female. vernal keratoconjunctivitis was the most common disorder affecting 35.6% children followed by refractive errors involving 12.8% children. 39.6% of children attending eye outpatient were in age group 0-6 years, 46% were in age group 6-12 years while 14.3% were in age group 13-16 years. 59.2% children needed medical treatment, 28% required surgery while 12.8% required glasses. conclusion: vernal catarrh in this study was the most common occurring disorder due to hot summers. males were more affected than females. most children needed medical treatment. 167 aediatric ophthalmic disorders are important because of their impact on child’s development, education, future work, opportunities and quality of life. the global prevalence of blindness is 0.78/1000 and there are estimated 1.5 million blind children, three fourth of whom live in developing countries. childhood blindness is the second largest cause of blind person years, following cataract. globally about 70 million blind years are caused by childhood blindness. approximately 500,000 children becoming blind every year, one every minute and half of them die within one to two years of becoming blind. there is no reliable data from developing countries on prevalence of blindness. in these countries a high proportion of children who become blind die within a few years of becoming blind, either from systemic complications of the condition causing blindness i.e. vitamin a deficiency, measles, congenital rubella syndrome or because poor parents have more difficulty in caring for their blind children. material and methods we have studied all children coming to outpatient department of ophthalmology, khyber teaching hospital peshawar over a period of two weeks from 1st june 2007 to 14th june 2007. a standard performa was used. on anatomical basis the disorders were divided into disorders affecting conjunctiva, whole globe, cornea, lens, uvea, retina, optic nerve, ocular muscles, nasolacrimal system and refractive system. detailed ocular examination was done for decision making, teaching and training purposes. refraction was performed routinely under cycloplegia. anterior segment examination was done with slit lamp and torch. posterior segment examination was performed after dilating pupil using direct and indirect ophthalmoscope and fundus contact lenses. intraocular pressure was checked with perkins tonometer. squint assessment was done in detailed way using prisms and tests for steropsis. on treatment basis they were divided into those who were given medical treatment, those who received surgical treatment and those who received optical treatment. prognosis for vision was described as could be improved, likely to remain stable and likely to deteriorate. results we studied two hundred and two children with paediatric ophthalmic disorders. (60.8%) were male and (39.1%) were female (fig. 1). 46% were in age group 7-12 years while 39.6% belonged to age group 06 years, 14.3% belonged to age group 13-16 years (table 1). conjunctiva was involved in 42.5%. in conjunctival disorders; vernal catarrh was present in 35.6%, follicular conjunctivitis in 0.99%, bacterial conjunctivitis in 1.4%, sub conjunctival haemorrhage in 0.99%, vitamin a deficiency in 0.99% and pterygium in 0.99%. cornea and sclera was involved in 4.9%. in corneoscleral disorders corneal foreign body was present in 1.4%, corneal ulcer in 2.4%, corneoscleral repairs in 0.99%. disorders of whole globe were present in 3.9%, in disorders of the whole globe phthisis was present in 0.49%, orbital cellulites in 2.4%, and glaucoma in 0.99%. disorders of vitreous and retina accounted for 1.9%, they included maculopathy 0.99% and retinoblastoma 0.99%. disorders of lens were 8.9%. they were pre and post operative cataracts. ocular muscles were involved in 11.8% and of these 7% were convergent squints while 4.8% were divergent squints. lids were involved in 6.9% of the cases. in disorders of lids, blepharitis was present in 4.9%, chalazion in 0.99%, and stye in 0.49%. nasolacrimal duct was involved in 5.4%. refractive errors were present in 12.8% of the patients. we had no patient with optic nerve involvement in our study (fig. 2). table 1. age wise distribution of paediatric ophthalmic disorders age group numbers n (%) 0-6 80 (39.6) 7-12 93 (46) 13-16 29 (14.3) p 168 figure-1 sex wise distribution of paediatric ophthalmic disorders 39.10% 60.80% male female fig. 1: sex wise distribution of paediatric ophthalmic disorders 42.50% 4.90% 3.90% 0.49% 1.90% 0% 8.90% 11.80% 6.90%5.40% 12.80% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00% conjunctiva cornea and sclera w hole globe uvea vitreous and retina o ptic nerve lens o cular m uscles lids nld system refractive system fig. 2: anatomical classification of ophthalmic disorders medication was given to 59.2% of patients. medication and surgery was performed in 28% of the patients. optical correction was performed in 12.8% of the children. discussion the occurrence of paediatric ophthalmic disorders in this study was 19.2%; within the group 68.9% were male and 39.1% were female. these findings are quite similar to study done at lady reading hospital peshawar where 66.2% were male and 33.8% were female1.vernal catarrh was the most common disorder accounting for 35.6% of the cases. this high occurrence of vernal catarrh may be due to the fact that the study was conducted in summers and vernal catarrh is more common in summers. the disease is common all over the world but is most common in hot climate. in this study males i.e. 81% were predominantly affected than females 19%. similar male preponderance was found in another study at laytan rahmatullah benovelant trust swat2 and lady reading hospital peshawar3. in a survey among school children aged 6-10 years in south africa revealed a prevalence of vernal keratoconjunctivitis of 11.8% in boys and 8.3% in girls4. follicular conjunctivitis was present in 0.99%. the prevalence of trachoma as active disease has been reported in ethiopia was 29% kenya 59% gambia 29% malawi 49%, tanzania 69.8%, zambia 18%, australia 66.9% and sudan 65%5. trachoma is still a leading infectious cause of blindness and ocular morbidity in the world. corneal diseases accounted for 4.9% of paediatric ophthalmic disorders6. this is exactly the same to a study conducted in blind schools in north west frontier province where corneal diseases accounted for 4.9% of blindness in children admitted in blind schools7. this is much less in comparison to other reports in blind schools in pakistan and india where corneal diseases accounted for 12% and 26.4% respectively of all children with severe visual impairment/blindness8&9. in our study trauma accounted for half of the corneal disorders. in a study conducted at hayatabad medical complex peshawar showed that childhood ocular trauma accounted for 49% of the total ocular trauma admission10. in our study lens disorder accounted for 8.9% of the paediatric ophthalmic disorders. bilateral congenital cataract is the most common cause of treatable childhood blindness. nuclear cataract is usually present at birth and is non progressive whereas lamellar cataract usually develops later and is progressive11. it is estimated that incidence of bilateral cataract in childhood is at least 10 cases per million population per year. the major causes of bilateral cataract in south asia are rubella (25%), heredity (25%) and unknown (50%)12. refractive errors accounted for 12.8% of the paediatric ophthalmic disorders compared to the study carried out in india rural population 2.7%13, rural country outside of beijing, china 12.8%14 and urban area of santiago chile 15.8%15. refractive errors which account mostly for low vision and visual handicap are the third largest cause of curable blindness in pakistan16. in one study it was found out that refractive errors account for 8% cases of uniocular blindness in north west frontier province17. squints accounted for 11.8% of the paediatric ophthalmic disorders. another study in 169 tanzania shows the prevalence of squint was 0.5% and south of kavadi of pakistan shows prevalence of squint as 0.6% 18. a study at katmandu reported the prevalence of squint was 1.6%19. determinants of strabismus diagnosis are important because of the amblyogenic nature of certain concurrent squint20. esotropia is also more likely to be amblyogenic than exotropia21,22. the high occurrence of squint in our study may be due to the presence of a well established strabismology set up with a qualified paediatric ophthalmologist with special interest in strabismology available. congenital glaucoma was present in 0.99% of the cases. the incidence of congenital glaucoma varies among different geographic locations and ethnic groups, with the highest recorded incidence found in the gypsy population of slovakia (1:1250), and followed by the general populations of the middle east (1:2500) and the western nations (1:10,000)23-26. the inheritance pattern for congenital glaucoma is most commonly autosomal recessive with incomplete penetrance23,27,28. 39.6% of children attending eye outpatient were in age group 0-6 years, 46% were in age group 6-12 years while 14.3% were in age group 13-16 years. the pattern of underlying causes of childhood blindness varies considerably between developed and developing countries. the etiological pattern seen today in industrialized countries have so evolved that factors operating in prenatal period are now the most important. by contrast, in the poorest developing countries, factors operating postnatal continue to predominate. in industrialized countries the main cause of childhood blindness are cataract, glaucoma, retinopathy of prematurity, genetic diseases and congenital anomalies. in developing countries blindness in children is usually caused by conditions which cause scarring of the cornea such as vitamin a deficiency, measles, infection, conjunctivitis of newborn and harmful traditional eye practices. conclusions the most common eye problem was vernal catarrh. refractive errors presented the second most common cause of paediatric ophthalmic disorder. male were more affected than females. the most common age group affected was 7-10 years. most of the children required medical treatment squints were the most common disorder requiring surgical intervention followed by paediatric cataracts. recommendations 1. the who form should be used to record prevalence and causes of visual impairment and blindness in children. 2. urgent public heath education is required to create awareness about importance of breast feeding, proper and timely weaning, avoidance of x-rays, nonessential medications, harmful eye practices, genetic eye diseases. 3. immunization against infectious diseases. 4. routine refraction of children and provision of spectacles at low cost is recommended. 5. regular supply of vitamin a to vulnerable group may reduce the problem of vitamin a deficiency. 6. the provision of microbiology laboratory will help in diagnosis and management of infectious cases at eye department. 7. training of human resources to become orthoptists and paediatric ophthalmologists. 8. establishment of paediatric ophthalmology unit in eye department, khyber teaching hospital peshawar. author’s affiliation dr. sadia sethi assistant professor in ophthalmology, khyber teaching hospital, peshawar dr. mohammad junaid sethi district specialist, district head quarter hospital, landikotal dr. nasir saeed associate professor ophthalmology khyber teaching hospital peshawar prof. naimatullah khan kundi head, department of ophthalmology, khyber teaching hospital peshawar reference 1. sethi s, khan md. paediatric ophthalmic disorders. j postgrad medl inst 2001; 15: 144-50. 170 2. awais sm, sheik a. morbidity of vernal keratoconjunctivitis. pak j ophthalmol july 2001; 17: 120-3. 3. khan md, kundi nk. study of 530 cases of vernal conjunctivitis from north west frontier province. pak j ophthalmol. 1986; 2: 111-4. 4. forrer a. vernal keratoconjunctivitis. bullitin medicus mandi 1995; 56: 37-42. 5. jgordon jj, darwin mc. the epidemiology of eye diseases 2nded. london oxford: university press. 2003; 164-85. 6. taylar ki, taylor hr. distribution of azithromycin for treatment of trachoma. br j ophthalmol. 1999; 83: 134-5. 7. sethi s, khan md. survey of blind school in north west frontier province (an institutional based study). pak j ophthalmol. 2001; 17: 90-6. 8. afghani t. causes of childhood blindness and severe visual impairment survey of blind children from rural population and school for blind in urban area. pak j ophthalmol. 2003; 19: 4-25. 9. rahi js, sripathi s, gilbert ce,. childhood blindness in india causes in 1318 blind school students in nine states. eye 1995; 47: 545-50. 10. sethi s, khan md. childhood ocular trauma. j postgrad med inst 2001; 15:51-5. 11. zetterstrom c, lundvall a. cataract in children. cataract refract j 2005; 31: 824-40. 12. rahi js, sripathi, gilbert ce, foster a. the importance of perinatal factors in childhood blindness in india. develop med childhood neurology 1997; vol. 39: 449-55. 13. dandona r, srinvas minhaj a. refractive error study in children in rural population in india. investigat ophthalmol visual sciences 2002; 43: 615-22. 14. zhao j, pan aui. refractive error study in children. results from shunnyi district china. am j ophthalmol. 2000; 129: 42735. 15. barroso me. refractive error study in children: results from florida country chile. am j ophthalmol. 2000; 129: 445-55. 16. durani j. blindness statistics for pakistan. pak j ophthalmol. 1999; 15: 1-2. 17. khan ma, gullab a, khan md. prevalence of blindness and low vision in north west frontier province of pakistan. pak j ophthalmol. 1994; 10: 39-42. 18. wedner susamme hw, david ar, rebecca b, et al. prevalence of eye diseases in primary school children in rural areas of tanzania. br j ophthalmol. 2000; 84: 1291-97. 19. nepal bp, koirala s, adhi kary s, et al. ocular morbidity in school children in katmandu. br j ophthalmol. 2003; 87: 531-4. 20. robaei d, rose ka, oojaimi e. causes and associations of amblyopia in a population-based sample of 6-year old australian children. arch ophthalmol. 2006; 124: 878-84. 21. mohney bg, huffaker rk. common forms of childhood exotropia. ophthalmology 2003; 110: 2093-6. 22. mohney bg. common forms of childhood esotropia. ophthalmology 2001; 108:805-9. 23. francois j. congenital glaucoma and its inheritance. ophthalmologica. 1980; 181: 61-73. 24. gencik a, gencikova a, ferak v. population genetical aspects of primary congenital glaucoma. i. incidence, prevalence, gene frequency, and age of onset. hum genet 1982; 61: 193-7. 25. jaffar ms. care of the infantile glaucoma patient. in: reineck rd, editor. ophthalmology annual. new york: raven press; 1988: 15-37. 26. wagner rs. glaucoma in children. pediatr clin north am 1993; 40: 855-67. 27. gencik a. epidemiology and genetics of primary congenital glaucoma in slovakia. description of a form of primary congenital glaucoma in gypsies with autosomal-recessive inheritance and complete penetrance. dev ophthalmol. 1989; 16: 76-115. 28. bejjani ba, lewis ra, tomey kf. mutations in cyp1b1, the gene for cytochrome p4501b1, are the predominant cause of primary congenital glaucoma in saudi arabia. am j hum genet. 1998; 62: 325-33. guess who? 171 see next issue for answer. microsoft word tahir masaud arbab 201 original article hypertension as risk factor in diabetic retinopathy in type-2 diabetes tahir masaud arbab, sajjad hanif, saeed iqbal, manzoor a mirza pak j ophthalmol 2008, vol. 24 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: tahir masaud arbab zamzama medical centre, plot no 144, 7th neelum lane, 3rd zamzama street, opp. zamzama park, defence housing society, phase v karachi received for publication purpose: to evaluate hypertension as a risk factor for diabetic retinopathy in type 2 diabetic patients. material and methods: this case control study of 100 patients, using nonprobability purposive sampling, between 40-70 years of ages with equal sex distribution was conducted in the medical department of sir syed hospital, karachi, from august 2007 to october 2007. . all patients were screened for diabetic retinopathy. the patients with diabetic retinopathy were placed in group dr (diabetic retinopathy) and patients without retinopathy were placed in group ndr (non-diabetic retinopathy). blood pressure measurements were done in all these patients along with fasting blood sugar, random blood sugar and hb1c. the data was analyzed on spss for windows. the comparison of two groups i.e., case control was done by student t-test. correlation of hypertension to proliferative retinopathy was evaluated by odd ratio. results: the correlation between diabetic retinopathy was analyzed in 100 patients. systolic and diastolic blood pressures were significantly higher in patients with retinopathy (mean systolic 136 ± 16 mmhg and mean diastolic 84 ± 10 mmhg) than those without retinopathy (mean systolic 129 ± 17 mmhg and mean diastolic 78 ± 12 mmhg). there was significant correlation of diabetes retinopathy with systolic hypertension (p <0.02) and diastolic hypertension (p <0.007) conclusion. the study results suggest that there is strong association between 202 january’ 2008 … ……………………… diabetic retinopathy and hypertension. iabetes mellitus is a major health problem in western countries as well as in pakistan. pakistan, with its population of 140 million, is estimated to have about 7 million people with diabetes mellitus. currently it is 8th in the world according to who estimation for prevalence of diabetes mellitus and by the year 2025 is expected to rise to the 4th position1. diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. the chronic hyperglycemia of diabetes mellitus is associated with long term damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels2. blindness is one of the most feared complication of diabetes mellitus but also one of the most preventable. diabetes mellitus is the commonest cause of blindness in people aged 30-69 years. twenty years after the onset of diabetes mellitus, almost all patients with type 1 diabetes mellitus and over 60% of patients with type 2 diabetes mellitus will have some degree of retinopathy3,4. vision threatening retinopathy is rare in type 1 diabetes mellitus in the first 3-5 years of diabetes mellitus or before puberty4. even at the time of diagnosis of type 2 diabetes mellitus, about a quarter of patients have established background retinopathy3. the risk factors for the development of diabetic retinopathy are duration of diabetes mellitus, hyperglycemia, hypertension, pregnancy, and serum triglyceride level4. retinal hyperperfusion is a key source of injury in diabetic retinopathy associated with shearing damage to capillaries5. increased retinal blood flow is found with conditions that worsen diabetic retinopathy these include hypertension6, hyperglycemia, pregnancy and autonomic neuropathy. improved understanding of the role of hypertension in the pathogenesis of diabetic retinopathy presents both a challenge and an opportunity for ophthalmologists and other diabetic healthcare professionals to improve patient care. around 40% of patients with type 2 diabetes mellitus are hypertensive, the proportion increasing to 60% by the age 75. recent reports from the united kingdom prospective diabetes study (ukpds) have focused attention on the links between hypertension and sight loss in diabetes mellitus. these reports in type 2 diabetes mellitus accord with previous observational studies in type 1 diabetes mellitus and demonstrate both hypertension as a risk factor for diabetic retinopathy and the beneficial effects of tight blood pressure control5. the purpose of this study is to evaluate hypertension as a risk factor for diabetic retinopathy in type 2 diabetic patients. material and methods this case control study was done in diabetic clinic attached to medical department, sir syed hospital, karachi, from august 2007 to october 2007. the study was conducted on 100 patients, using non-probability purposive sampling, between 40-70 years of ages with equal sex distribution. all patients were screened for diabetic retinopathy using a welchallyn fundoscope. the same fundoscope was used for all further fundus examinations. the patients were examined with fully dilated pupils. the fundoscopic finding was verified with slit-lamp biomicroscopy with 90d lens. the patients with diabetic retinopathy were placed in group dr (diabetic retinopathy) and patients without retinopathy were placed in group ndr (non-diabetic retinopathy). after resting the patient in supine position for 5 minutes blood pressure measurements were also taken in all these patients using mercury sphygmomanometer. all patients were advised fasting blood sugar, random blood sugar and hba1c. the data was analysed on spss for windows. the comparison of two groups i.e., case control was done by student t-test. correlation of hypertension to proliferative retinopathy was evaluated by odd ratio. results of the 100 patient in the sample, the mean age of patient with diabetic retinopathy group was 52.5 ± 7 years while it was 52 ± 8 years for nondiabetic retinopathy group. duration of diabetes was it is 9 ± 5 years in diabetic retinopathy group and 8 ± 5 years in d 203 nondiabetic retinopathy group. regarding mean age and duration of diabetes mellitus there is not much difference between the two groups mean systolic blood pressure in diabetic retinopathy group (fig. 1) was 136 ± 16 mmhg while it was 129 ± 17 mmhg in nondiabetic retinopathy group (fig. 2) so it was quite obvious that patients in diabetic retinopathy group with retinopathy have higher mean systolic blood pressure than nondiabetic retinopathy group patients ( p< 0.02). the mean diastolic blood pressure in patients in diabetic retinopathy group (fig. 3) was 84 ± 10 mmhg and it was 78 ± 12 mmhg in nondiabetic retinopathy group (fig. 4), (p<0.007, cl 1.74 10.46). the mean of fasting blood sugar in diabetic retinopathy group (fig. 5) was 172 ± 64 gm/dl while it was 173 ± 61 gm/dl in nondiabetic retinopathy group (fig. 6). the mean hba1c in subjects with diabetic retinopathy group was 7.08 ± 0.3 while it was 7.004 ± 0.59 in nondiabetic retinopathy group. there was significant difference between the two groups in fasting blood glucose level and hba1c discussion we analyzed the association between diabetic retinopathy and blood pressure and found that patients with retinopathy had significantly higher systolic and diastolic hypertension than those without retinopathy. ishihara7 et al who had studied on 742 type 2 diabetic patients in which he correlated various variables with diabetic retinopathy. the correlation of diabetic retinopathy with systolic hypertension was significant (p<0.01) but when correlated with diastolic hypertension it was not significant. when diabetic retinopathy was correlated with age of the patient (p<0.05) and duration of diabetes mellitus (p<0.001) it was significant. the correlation of diabetes retinopathy with hba1c was also highly significant (p<0.001). similarly van leiden et al8 studied relationship of diabetic retinopathy with various risk factors in 233 individuals. his study gives p-value of <0.03 when diabetic retinopathy was correlated with age of patient but p-value was also <0.03 when diabetic retinopathy was correlated with hba1c, in both situations it was significant. in his study correlation of diabetic retinopathy with fasting blood sugar was also significant (p<0.08). his study also had significant correlation of diabetic retinopathy with systolic hypertension (p<0.02) but correlation of diabetic retinopathy with diastolic hypertension was not significant. in our study correlation was found not to be significant when diabetic retinopathy was correlated with age of the patient, duration of diabetes mellitus, fasting blood sugar and hba1c. but in our study there is significant correlation when diabetic retinopathy was correlated with systolic hypertension (p<0.02, cl 0.82 13.58) and when diabetic retinopathy correlated with diastolic hypertension (p<0.007, cl 1.74 10.46). in our study the two groups are well matched in terms of age, duration of diabetes, fasting blood glucose and hba1c. therefore this constituted a good cohort to study the effect of systolic and diastolic hypertension. one of the limitations of our study is the relatively small number of cases. therefore only the strongest associations with retinopathy are expected to be detected. conclusion the study results suggest that there is strong association between diabetic retinopathy and hypertension. author’s affiliation dr. tahir masaud arbab sir syed college of medical sciences karachi dr. sajjad hanif sir syed college of medical sciences karachi dr. saeed iqbal sir syed college of medical sciences karachi dr. manzoor a mirza sir syed college of medical sciences karachi reference 1. basit a, hydrie mzi, ahmed k, et al. prevalence of diabetes, impaired glucose and associated risk factors in a rural area of baluchistan province according to new ada criteria, jpma. 2002; 52; 357-60. 2. the expert committee on the diagnosis and classification of diabetes mellitus. report of the expert committee on the 204 diagnosis and classification of diabetes mellitus. diabetes care 2003; 26; s5-s20. 3. watkins pj. abc of diabetes retinopathy. bmj 2003; 326; 924-6. 4. fong ds, aiello l, gardner tw, et al. diabetic retinopathy. diabetic care. 2003; 26: s99-s102. 5. gillow jt, gibson jm, dodson pm. hypertension and diabetic retinopathy-what’s the story? br j ophthalmol. 1998; 83: 1083-7. 6. klein r, klein bek. blood pressure control and diabetic retinopathy. br j ophthalmology. 2002; 86: 365-76. 7. ishihara m, yukimura y, aizawa t, et al. high blood pressure as risk factor in diabetic retinopathy development in niddm patients. diabetic care. 1987; 10: 20-5. 8. van leiden h, dekker jm, moll ac, et al. risk factors for incident retinopathy in a diabetic and nondiabetic population: the hoorn study. arch ophthalmol. 2003; 121: 245 microsoft word mazharul hassan 79 original article relationship between central corneal thickness and intraocular pressure in selected pakistani population mazhar ul hassan, aziz ur rehman, munawar abbas, umar fawad, nasir bhatti, ashraf daud pak j ophthalmol 2010, vol. 26 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations ………………………… correspondence to: mazhar ul hassan consultant eye surgeon al-ibrahim eye hospital/ isra postgraduate institute of ophthalmology, old thana, malir, karachi received for publication july’ 2009 ………………………… purpose: to explore the relationship between central corneal thickness (cct) and intraocular pressure (iop) in selected pakistani population and to formulate recommendations for its application in clinical practice as well as future research. material and methods: the study was conducted at al-ibrahim eye hospital karachi for six months, on five hundred eyes of 250 adults attending the outpatient. after informed consent, all patients underwent a comprehensive assessment including medical and ophthalmic history and examination. intraocular pressure (iop) was measured with goldmann applanation tonometer and cct with ultrasonic pachymeter. results: mean cct in males was measured as 529.5 ± 33.6 (range 438-619 µm) and 524.1 ± 33.3 (range 443-623 µm) in females. mean iop in males was 12.75 ± 2.85 (range 8-20 mmhg) and in females 12.98 ± 2.39 (range 8-20 mmhg). there was a statistically significant association between cct and iop for normal subjects (pearson correlation coefficient r=0.136, p=0.022). however, no statistically significant relationship was found between cct and age (p=0.103). conclusion: cct is a significant predictor of iop. thin corneas lead to an underestimation and thick corneas, to an overestimation of intraocular pressure. pakistani population in our study has comparatively thinner corneas as compared to caucasian and african-american population. however further studies with sufficiently large sample size are needed to validate and to demonstrate its original value. he normal intraocular pressure varies from 1020 mmhg. goldmann applanation tonometer is considered to be the gold standard in measuring intraocular pressure1. it works according to imbert-fick principle, which states that for an ideal, dry, thin walled sphere, the pressure inside equals to the force necessary to flatten its surface divided by the area of flattening2. a pachymeter is a device that uses ultrasound to determine the thickness of the cornea in any given location. normal cct is 490-560 µm2. the clinical use of central corneal thickness measurements has become so important that it directly affects glaucoma management strategy in 15% of patients3, 4. various studies have been performed worldwide to study the significance of cct in measuring iop and glaucoma management. we want to perform a similar study to find out the relationship between central corneal thickness and intraocular pressure in pakistani individuals. materials and methods we conducted this study at al-ibrahim eye hospital (aieh), karachi. it was a prospective, non intervenetional, comparative study which included 500 eyes of 250 adults who attended the outpatient department over a period of 6 months. we used non-purposive, convenience sampling. as this was a descriptive study, therefore no sample size calculation was made. the inclusion criterion was age between 40 and 60 yrs t 80 regardless of the gender. we excluded patients with preexisting ocular pathologies, history of contact lens wear, history of intraocular surgery, laser or trauma, corneal astigmatism greater than 3 diopters, patients with systemic illness or taking any topical or systemic medications. the patients were selected from outpatient department of aieh. after informed consent, all patients underwent a comprehensive ophthalmic assessment which consisted of history regarding refractive errors, glaucoma, use of topical steroids, use of contact lenses, history of refractive surgery or laser. best corrected visual acuity was obtained followed by slit lamp examination to rule out anterior segment pathologies corneal pathologies and infections. after anesthetizing the eye with topical proparacaine 0.5% and using the fluorescein strips 2%, we measured iop in both eyes using goldmann applanation tonometer. we examined all the patients between 9:00am-12:00noon. we took three consecutive readings and the mean was noted. cct was measured with ultrasonic pachymeter (pac scan 300p digital biometric ruler). the ultrasound pachymeter was calibrated at the beginning of each day according to the manufacturer’s instructions. after anesthetising the cornea with topical proparacaine 0.5% and the patient looking in primary position of gaze, the pachymeter probe was placed on the centre of the cornea. five measurements were taken from each eye and the average was used for analysis. the data was entered in ms excel and was cleaned and analyzed using spss v. 10.0. mean ± sd was calculated for all quantitative variables. frequencies and percentage was computed for sex. pearson correlation test was applied to find the relationship between corneal thickness and intraocular pressure at p ≤ 0.05 level of significance. results out of 250 patients, 130 (52%) were males and 120 (48%) were females. most of the patients 83(33.2%) belonged to the age group of 40-44 years. the mean cct in males was 529.5 ± 33.6 (range 438-619µm) and 524.1 ± 33.3 (range 443-623µm) in females. the mean intraocular pressure in males was 12.75 ± 2.85 (range 8-20 mmhg) and 12.98 ± 2.39 (range 8-20 mmhg) in females. a significant association was found between central corneal thickness and intraocular pressure for normal subjects (pearson correlation coefficient r=0.136, p=0.022). there was no statistically significant relationship between the central corneal thickness and age. (p =0.103). table 1. mean intraocular pressure for both genders according to central corneal thickness n=250 cct (µm) male female n iop (mm hg) n iop(mm hg) < 525 61 12.67± 2.8 67 12.81± 2.25 525 – 575 58 12.75± 2.9 47 13.05± 2.35 > 575 11 13.5± 3.51 6 11± 4.2 cct = central corneal thickness mid values cct (µm) 62 5 60 5 58 5 56 5 54 5 52 5 50 5 48 5 46 5 44 5 n um be r o f p at ie nt s 70 60 50 40 30 20 10 0 16 35 49 59 46 27 9 5 fig. 1. distribution of central corneal thickness mean± sd = 527± 3.5 (range = 438 623 (µm) fig. 2. relationship between central corneal thickness and intraocular pressure pearson correlation coefficient (r) = 0.136, p= 0.022 discussion intraocular pressure is an important factor that has a significant influence in the diagnosis and follow-up of ocular hypertension and glaucoma patients. know 81 ledge of the central corneal thickness therefore, is important to know the validity of the intraocular pressure readings. to the best of our knowledge, this is the second hospital based study from pakistan to determine the effect of cct on iop5. dueker et al concluded that cct measured by ultrasound pachymetry is a reliable indicator of risk for progression of ocular hypertension to glaucoma. mixed evidence was found in terms of the association of cct with the presence of glaucoma, therefore the value of cct measurement as a screening tool for glaucoma appears to be negligible6. the ocular hypertension treatment study (ohts) established corneal thickness as a risk factor for glaucoma. in the opinion of kass, the ohts demonstrated that moderate iop reductions could be achieved and maintained during a median follow-up period of 72 months7. in a cross-sectional study arm of the ohts, brandt et al set out to determine if cct is related to race. cct was measured in 1301 patients with ocular hypertension8. ultrasonic pachymeters of the same make and models were used in all sites. the mean cct in caucasians was 573 µm, while the mean cct for african-american subjects was 555.7µm. the study demonstrated that african-american subjects have thinner corneas than white subjects. the effect of cct may influence the accuracy of applanation tonometry in the diagnosis, screening and management of patients with glaucoma and ocular hypertension. la ros reported a comparative study of cct of caucasians and african-americans in glaucomatous and non glaucomatous populations. a statistically significant difference was found between the central corneal thickness of african-americans (n=56) and caucasians (n=32) who had suspected or confirmed glaucoma from control populations of africanamericans (n=56) and caucasian (n=51) subjects who had no evidence of glaucoma, elevated intraocular pressure (iop) or optic nerve damage. it is proposed that the finding that african-americans have thinner corneas than caucasians may lead to lower applanation, intraocular pressure readings, and potentially result in an underestimation of the actual level of intraocular pressure9. the ocular hypertension treatment study is the first to establish corneal thickness as a risk factor for glaucoma. based on the results of this study, the american academy of ophthalmology preferred practice pattern on evaluation of the glaucoma suspect recommends measurement of corneal thickness with electronic pachymetry in evaluating the glaucoma suspect7,10. our study had 500 eyes of 250 subjects. the mean cct in males was 529.5 ± 33.6 and 524.1 ± 33.3 in females. in contrast the earlier studies had mentioned that the mean cct in caucasians was 573 µm, and 555.7µm in african-american subjects. figure 1 illustrates the normal gaussian curve for distribution of cct in our patients. it demonstrates that majority of patients had mean cct in the range of 525µm, which is smaller when compared to the other ethnicities. our study has the following limitation. firstly, the sample size is relatively small and may not be able to detect the exact relationship between iop and cct. secondly, we used convenience sampling and all the samples were taken from the hospital. therefore, our findings cannot be extrapolated to the general pakistani population. thirdly, our hospital is a charity hospital and majority of our patients belong to underprivileged group of society therefore our findings may be biased with factors such as socioeconomic status, occupation, exposure to sunlight etc. in conclusion, thin corneas lead to an underestimation and thick corneas, to an overestimation of intraocular pressure. cct is a significant predictor of iop. pakistani population has comparatively thinner corneas when compared to caucasian and africanamerican population. however further studies with sufficiently large sample size are needed to validate this finding and to demonstrate its value in the management of glaucoma. author’s affiliation dr. mazhar ul hassan al-ibrahim eye hospital / isra postgraduate institute of ophthalmology old thana, malir, karachi dr. aziz ur rehman al-ibrahim eye hospital / isra postgraduate institute of ophthalmology old thana, malir, karachi dr. munawar abbas al-ibrahim eye hospital / isra postgraduate institute of ophthalmology old thana, malir, karachi dr. umar fawad al-ibrahim eye hospital / isra postgraduate institute of ophthalmology old thana, malir, karachi 82 dr. nasir bhatti al-ibrahim eye hospital / isra postgraduate institute of ophthalmology old thana, malir, karachi. dr. ashraf daud al-ibrahim eye hospital / isra postgraduate institute of ophthalmology old thana, malir, karachi reference 1. 0kanski jj. clinical ophthalmology, fifth edition, edinburgh, elsevier science. 2003; 100: 196. 2. feltgen n, leifert d, funk j. correlation between central corneal thickness, applanation tonometry and direct intracameral intraocular pressure readings. br. j. ophthalmol. 2001; 85: 85-7. 3. weizer j s, stinnett s s, herndon l w. longitudinal changes in central corneal thickness and their relation to glaucoma status: and 8 year follow up study. br j ophthalmol. 2006; 90: 732-6. 4. doughty mj, zaman ml. human corneal thickness and its impact on intraocular pressure measures: a review and metaanalysis approach. surv ophthalmol. 2000; 44: 367-408. 5. mukhtar s. central corneal thickness and its relation with measured intraocular pressure. pak j ophthalmol. 2004; 20: 235. 6. dueker dk, singh k, lin sc, et al. corneal thickness measurement in the management of primary open angle glaucoma: a report by the american academy of ophthalmology. ophthalmology. 2007; 114: 1779-87. 7. kass ma, heuer dk, higginbotham ej, et al. the ocular hypertension treatment study: a randomized trial determines that topical ocular hypertensive medication delays or prevents the onset of primary open-angle glaucoma. arch ophthalmol. 2002; 120: 701-13. 8. brandt jd, beiser ja, kass ma, et al. central corneal thickness in the ocular hypertension treatment study (ohts). ophthalmology. 2001; 108: 1779-88. 9. la rosa fa, gross rl, orengo-nania s. cenral corneal thickness of caucasians and african americans in glaucomatous and nonglaucomatous populations; arch ophthalmol. 2001; 119: 23-7. 10. gordon mo, beiser ja, brandt jd, et al. the ocular hypertension treatment study: baseline factors that predict the onset of primary open angle glaucoma. arch opthalmol. 2002; 120: 714-20. microsoft word ibrar hussain 3 original article basal cell carcinoma presentation, histopathological features and correlation with clinical behaviour ibrar hussain, mahmooda soni, bakht samar khan, mohammad daud khan pak j ophthalmol 2011, vol. 27 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ibrar hussain department of ophthalmology, khyber teaching hospital peshawar received for publication january’ 2010 …..……………………….. purpose: this study was performed to determine the clinical presentation and histopathological types of basal cell carcinoma of eyelids and correlation with clinical behaviour. material and methods: the prospective study was carried out at the department of ophthalmology, postgraduate medical institute, hayatabad medical complex, peshawar from september 2001 to august 2002. thirty patients (30) with suspected basal cell carcinoma were enrolled from the outpatient department. they were admitted to ward and worked out as detailed history, examination, lab and radiological examination. in each case biopsy (incisional / excisional) were taken to study its histopathology. using epi info 2000 version spss program data was entered and analyzed. results: mean age of presentation was 55 years with male: female (57:43). clinically the nodular ulcerative type was commonest presentation (36.7%) followed by the nodular type (33.3%) and the third commonest presentation was nodular pigmented (30%). the lower lid was the most frequently affected site (63.3%) followed by the medial canthus (23.33%). the upper lid and lateral canthus were the least involved (6.67%) each. on histological examination the commonest was solid or nodular (56.67%), the second commonest was keratotic (basosquamous) type (13.33%) followed by multifocal (10%), pigmented and adenoid (6.67%) each. morphoea and the cystic type were the least common (3.33%) each. the margins were well defined in 80% of the solid tumour. conclusion: basal cell carcinoma commonly occurs in lower eyelid. nodular ulcerative is the commonest clinical presentation and the commonest histological presentation was also nodular with peripheral palisading. asal cell carcinoma (bcc) is the most common malignant tumour of the eyelid1,2. usually the lower lid is involved and exposure to sunlight is an important risk factor3,4. clinically several variants may be seen, nodular (fig. 1), noduloulcerative (fig. 2), cystic and plaque-like (morpheaform). histologically they are classified as nodular, adenoid, cystic, keratotic (basisquamous), morphea, multifocal and pigmented. the nodular and noduloulcerative types are composed of anastamosing nests and cords of proliferating epidermal basilar cells that originate from the basal cell layer of the epidermis. a palisade of nuclei (fig. 3) at the edge of the invasive tumour nest may be distinctive5. the cystic type is similar histologically to the nodular type, with the exception of central necrosis. cystic basal cell carcinomas frequently appear as blue eyelid cyst. in the morpheaform type, the tumour tends to penetrate into the dermis diffusely as branching cords of cells. in adenoid variety glands like formation is seen but there is no true secretory activity. in so called keratotic type there are keratotic whorls and horn cysts as a result of b 4 squamous differentiation of basal cells. it may be very difficult to clinically estimate the margins of a morpheaform basal cell carcinoma because of the diffuse infiltration of the skin. a superficial form (multifocal) and fibroepithiliomatous carcinoma of pinkus are the other variants of basal cell carcinoma. the other rare variants are the clear cell and mixed type (a noduloulcerative variety with an infiltrative component). histological examination and sub typing is recommended as some tumours such as the nodular sub type can be potentially invasive and aggressive6. basal cell carcinoma may masquerade as a number of different clinically benign conditions such as blephritis7, actinic keratosis8, keratoacanthoma, red eye9, hordeola, chalazia cutaneous horns10 and mucoepidermoid carcinoma of eye11. when tumours lack characteristic epidermal change, histopathological examination may be necessary to confirm the diagnosis. the rate of recurrence of basal cell carcinoma in the periorbital region is higher than in other areas. the lacrimal system is often invaded by basal cell carcinoma that originates in the periorbital as well as extensive destruction of the eyeball by basal cell carcinoma has been reported12,13. the risk of recurrence varies according to the adequacy of the surgical margins. successful management of basal cell carcinomas of the eyelid requires complete resection and the ophthalmic surgeon should design a plan to have the margins of resection checked by pathologist, either as a frozen section control of margins or by careful examination of the surgical margins by permanent sections or by moh’s micrographic surgery. various surgical techniques are used to reconstruct the eyelids. material and methods a one year prospective study was carried out at the department of ophthalmology, postgraduate medical institute, hayatabad medical complex, peshawar from september 2001 to august 2002. this study was conducted to understand the diseased pattern of basal cell carcinoma regarding its presentation, histopathological features and its correlation with clinical behaviour. the patients included in this study were admitted from the eye outpatient department of the hospital. some patients were referred from the plastic surgery and dermatology department. a prevalidated proforma was developed. the selected patients were admitted to the eye ward, were worked up according to the proforma. follow up was arranged at one week, one month, and six months. a detailed history, examination and laboratory, radiological investigations were carried out. a preoperative photograph was taken. after that surgery (incisional / excisional biopsy) was planned. data entry and analysis a questionnaire file was created in computer using epi info 2000 version (spss program) where the data was entered, carefully cleaned and analyzed. using same software the results were interpreted to see the relationship of different variables. it is a descriptive analysis. results a total of 30 patients were recruited in the study out of which 17 (57%) were male and 13 (43%) were female. the mean age of the sample patients was 55 years. the mean age amongst male and female was almost the same. clinically the nodular ulcerative type was commonest presentation (36.7%) followed by the nodular type (33.3%) and the third commonest presentation was nodular pigmented (30%) (table 1). the lower lid was the most frequently affected side (63.3%) followed by the medial canthus (23.33%). the upper lid and lateral canthus were the least involved (6.67%) each area. the margins were well defined in 80% of the solid tumour. all keratotic type tumours i.e., 100% had poorly defined margins. the basal cell carcinoma was fixed to underlying periorbita, eyeball or both in 27% of cases while 73% had no fixation to the deeper structures. on histological examination the commonest type was solid or nodular with peripheral palisading (56.67%), the second commonest was keratotic (basosquamous) type (13.33%) followed by multifocal (10%), pigmented and adenoid (6.67%) each. morphoea and the cystic type were the least common (3.33%) each (table 2). the correlation of clinical appearance of basal cell carcinoma with histological findings shows that more than half of each clinical type of bcc is of solid (nodular) variety on histopathology. in other words “solid” histopathological picture is the most common type of all bccs. other types are rare. the detail is shown in (table 3). 5 table 1: presenting clinical types of bcc types of lesions no. patients n (%) nodular ulcerative 11 (36.67) nodular 10 (33.33) pigmented 9 (30) total 30 (100) table 2: histological presentation no. patients n (%) solid (nodular) 17 (56.67) keratotic (basisquamous) 4 (13.33) multifocal 3 (10) adenoid 2) pigmented 2 (6.67) cystic 1 (3.33) morphea 1 (3.33) total 30 (100) discussion periocular basal cell carcinoma is the most common malignancy in humans in our region which more commonly involves the older male population4,13. it has a very likely association with increased exposure to sun, dry, dusty hot weather and fair complexion15. people with agricultural background seem to be increased risk. lower lid involvement is the highest followed by the medial canthal region and the upper lid16. simple excisional biopsy with a 3-5 mm clinically tumour free margin, followed by reconstruction and meticulous follow up is a good and safe method to manage these cases. the biological behavior of basal cell carcinoma (bcc) is usually benign and cure is almost always achieved by excision, electro desiccation and curettage, cryosurgery, or irradiation. rarely, the clinical course may be aggressive and regional or distant metastases can develop especially in patients who have had multiple local recurrences, necessitating exentration for local metastases. once distant metastases13,17 develop cure is no longer possible. early diagnosis is likely to make surgery easy with promising post operative results. basal cell carcinoma can also arise from the caruncle which contains sebaceous glands, hair follicles and lacrimal and sweat glands elements, however primary basal cell carcinoma of the caruncle is unusual and only four cases have been described in the literature18. another unusual presentation of basal cell carcinoma is that mimicking blepharitis7. other conditions to be considered in differential diagnosis include pre -malignant lesions such as actinic keratosis8, keratoacanthoma and inflammation and infectious diseases such as red eye9, hordeola, chalazia and cutaneous horns10 of the eyelid in elderly patients. among the malignant lesion mucoepidermoid11 carcinoma of the eye is rare and has a high degree of malignancy. it should be differentiated from other neoplasms such as basal cell carcinoma and squamous cell carcinoma. in our study the lower lid was the most frequently affected site (63.3%), followed by medial canthus (23.33%). the upper lid and lateral canthus were least involved (6.67% each). this mimics most of the international studies. in a study from australia16 on 819 patient 54% involved lower lid, 41% medial canthus and 5% upper lid. table 3: correlation of clinical appearance of b.c.c with histological findings clinical appearance solid (nodular) (17) n (%) adenoid (2) n (%) cystic (1) n (%) keratotic (4) n (%) morphea (1) n (%) multifocal (3) n (%) pigmented (2) n (%) noduloulcerative (11) 6 (45.5) 0 1 (9.1) 2 (18.2) 1 (9.1) 1 (9.1) 0 nodular (10) 6 (60) 2 (20) 0 0 0 2 (20) 0 pigmented (9) 5 (55.6) 0 0 2 (22.2) 0 0 2 (2.22) 6 pigmented noduloulcerative basal cell carcinoma involving the entire right lower lid basal cell carcinoma involved the medial canthus of right lid. (pigmented nodular type) in our study nodularulcerative type was commonest clinically type i.e., 36.7% followed by the nodular type (33.3%) and the third commonest presentation was nodular pigmented (30%). review of literature also shows noduloulcerative to be the commonest clinical presentation with nodular being the second commonest and the morphea is the least common. a study by niazi et al5 shows noduloulcerative as commonly occurring (65.22%) followed by nodular (21.74%) and morphea is the least common (13%)5. pigmented nodular basal cell carcinoma basal cell carcinoma with peripheral palisading in our study on histological examination the commonest was solid or nodular type (56.67%), the second commonest was keratotic (basosquamous) type (13.33%) followed by multifocal (10%), pigmented and adenoid (6.67%) each. morphoea and the cystic type were the least common (3.33%) each. a study by paavilainen7 shows that nodular is the commonest type (84.5%), sclerosing as second commonest (5.8%), micronodular (4.9%), keratotic (2.9%) and superficial 7 (1.9%). in australian study16, most common histological subtypes were nodulocystic (43%) and infiltrating (30%). comparison with these studies show that like in other parts of the world the nodular bcc is the commonest and morphea type is the least common histological type in our region as well. conclusion in this study the noduloulcerative was the commonest clinical appearance of basal cell carcinoma of the eyelids and histologically the nodular type was the commonest presentation. another study with a larger sample size and longer follow up period may validate these results. author’s affiliation dr. ibrar hussain associate professor ophthalmology khyber teaching hospital, peshawar dr. mahmooda soni consultant ophthalmologist city hospital peshawar dr. bakht samar khan assistant professor ophthalmology khyber teaching hospital, peshawar prof. mohammad daud khan ex. vice chancellor khyber medical university peshawar reference 1. aasi sz, leffell dj. cancer of the skin in: devita vt, hellman s rosenberg sa, ed. cancer: principals and practice of oncology, 7th ed. philadelphia: lippincott williams and wilkins. 2005: 1717-45. 2. cook be jr, bartley gb. epidemioligic characteristics and clinical course of patients with malignant eyelid tumours in an incidence cohort in olmsted county, minnesota. ophthalmology. 1999; 106: 746-50. 3. birt b, cowling i, coyne s. uvr reflections at the surface of the eye. j photochem photobiol b. 2004; 77: 71-7. 4. birt b, cowling i, coyne s, et al. the effect of the eye’s surface topography on the total irradiance of ultraviolet radiation on the inner canthus. j photochem photobiol b. 2007; 87: 27-36. 5. niazi fak, niazi mak. periocualr basal cell carcinoma: characteristics and distribution among patients. j rawal med coll. 2003; 7: 63-8. 6. seldam ten rek, helwig eb, sobin lh, et al. histological types of skin tumours. intr histologic class tumour no. 12, who geneva. 1974. 7. paavilainen v, aaltonen m, tuominen j, et al. hisological characteristics of basal cell carcinoma of the eyelid. ophthalmic res. 2007; 39: 45-8. 8. swan pg, weir j. is it blephritis? clin exp optom. 2005; 88: 113-4. 9. jacobs rj, phillips g. basal cell carcinoma mistaken for actinic keratosis. clin exp optom. 2006; 89: 171-5. 10. papalkar d, sharma s, francis ic, et al. red eye and a rodent ulcer. ophthal plast reconstr surg. 2006; 22: 131-2. 11. mencia-gutierrez e, guierrez-diaz e, redondo-marcos j, et al. cutaneous horns of the eyelid: a clinicopathological study of 48 cases. j cutan pathol. 2004; 31: 539-43. 12. zhang h, yan j, li y zhang p. mucoepidermoid carcinoma of the eyelid: a case report and review of the literature. yanke xue bao. 2005; 21: 152-7. 13. ostergaard j, boberg – ans j, prause ju, et al. primary basal cell carcinoma of the caruncle with seeding to the conunctiva. eye pathology institute, university of copenhagen, frederik v’s vej i11. 2100. 14. puri t, gunabushanam g, sharma r, et al. extensive bone metastases from basal cell carcinoma of the eye. singapore med j. 2006; 47: 811-13. 15. case report and review: lacrimal caruncle primary basal cell carcinoma. j cutan patho. 2005; 32: 502-5. 16. spraul cw, ahrwm, lang gk. clinical and histological features of 141 primary basal cell carcinomas of the periocular region and their rate of recurrence after surgical excision. klin monatsbl augenheilkd. 2000; 217: 207-14. 259 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology review article local chemotherapy for retinoblastoma hussain ahmed khaqan, abdul hye pak j ophthalmol 2017, vol. 33, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hussain ahmed khaqan assistant professor fcps, fcps (vr), frcs lgh/ pgmi lahore email: dr.khaqan@hotmail.com …..……………………….. the new treatment modalities of retinoblastoma have been very effective in saving the vision, salvaging the globe and improving the life expectancy of patients. the treatment options include chemotherapy, that can be intravenous chemotherapy, periocular chemotherapy, intravitreal chemotherapy and intraarterial chemotherapy, and local modalities i.e. transpupillary thermotherapy, cryotherapy, laser photocoagulation, radiation treatment using plaque brachytherapy or external beam radiation therapy (ebrt). the most common intravenous chemotherapy drugs are carboplatin, vincristine, and etoposide. the drugs for periocular chemotherapy are topotecan and carboplatin. for intravitreal chemotherapy the most commonly used drugs are methotrexate, topotecan and melphalan. for intra-arterial chemotherapy drugs used are melphalan, topotecan and rarely carboplatin. the treatment options can be used as single treatment or as adjuvant to consolidate treatment, depending upon the stage of disease. advanced stages of disease and orbital involvement have poor prognosis. key words: retinoblastoma, chemotherapy, treatment. n childhood malignancies retinoblastoma (rb) is the most common intraocular malignancy. it is more common in children before three years of age. retinoblastoma may be unilateral or bilateral, unilateral retinoblastoma is more common. it may be heritable or non-heritable. retinoblastoma may present as endophytic or exophytic tumor. diagnostic methods include examination under anesthesia, indirect ophthalmoscopy, b scan, ct scan, mri scan and retcam imaging. treatment of retinoblastoma is improving its outcomes and there is lot of progress. the new treatment modalities of treating retinoblastoma have been very effective in saving the vision, salvaging the globe and improving the life expectancy of patients1. the treatment options include chemotherapy, that can be intravenous chemotherapy, periocular chemotherapy, intravitreal chemotherapy and intra-arterial chemotherapy, and local modalities i.e. transpupillary thermotherapy, cryotherapy, laser photocoagulation, radiation treatment using plaque brachytherapy or external beam radiation therapy (ebrt). the most common intravenous chemotherapy drugs are carboplatin, vincristine, and etoposide. the drugs for periocular chemotherapy are topotecan and carboplatin. for intravitreal chemotherapy the most commonly used drugs are methotrexate, topotecan and melphalan. for intra-arterial chemotherapy drugs used are melphalan, topotecan and rarely carboplatin. the treatment options can be used as single treatment or as adjuvant to consolidate treatment, depending upon the stage of disease. advanced stages of disease and orbital involvement have poor prognosis. clinical features patients with retinoblastoma (rb) may have different clinical presentations including strabismus and leukocoria. in initial evaluation, it is important to differentiate rb from other similar diseases by using ultrasonography. coats disease, toxocariasis and persistent fetal vasculature (pfv) are common differential diagnosis of rb. recently 111 cases were analyzed for suspected rb, in which 68% patients were found to have rb, while rest of the 32% patients had other diseases with an alternate diagnosis of (pfv) 31% and coat’s disease (29%)2. i mailto:dr.khaqan@hotmail.c local chemotherapy for retinoblastoma pakistan journal of ophthalmology vol. 33, no. 4, oct – dec, 2017 260 classification of retinoblastoma has changed with advancement in treatment strategies. in the past reese-ellsworth (re) classification of retinoblastoma has been used to predict globe salvage and external beam radiation was the primary treatment modality at that time3. however, the r-e classification didn’t address sub-retinal and vitreous seeding. in order to predict better treatment outcomes, a modified classification was developed by adopting local consolidation treatment and chemo reduction. thus, the international classification of retinoblastoma was developed, with primary focus on focal and diffuse vitreous and sub-retinal seeds4,5. epidemiology in pediatric ocular malignancies, rb is highly curable tumor6. many epidemiological studies on rb showed that tumor affects 1 in 16000-18000 births approximately while 7000-8000 new rb cases are being reported annually worldwide7,8. retinoblastoma is an important primary intraocular tumor. the annual incidence rate of retinoblastoma is approximately 3.5 per million for children younger than 15 years of age9 and 11.8 per million for children younger than 4 years5,7. the combined incidence rate for children younger than 14 is estimated to be 53 – 60 per million6,9. in united states the survival rate approaches 100% while in other developing countries it is much lower. survival rate is 80 – 89%10-20, 83%17, 81%18,19 and 48% in latin america, iraq, china and india respectively20. it is much lower 20 – 46% in africa21,22. additionally, with the increasing population, especially in africa and asia, retinoblastoma is “getting more importance6. treatment the treatment options having less systemic side effects, better outcomes in term of saving vision, salvaging the eye and improving the life expectancy of the patient are getting more popularity and are used more frequently mostly in first world countries. local chemotherapy is more targeted and is discussed further: selective intra‑arterial chemotherapy: (siac) the need of selective intra-arterial chemotherapy is very high because of less systemic side effects although systemic chemo therapy and consolidation with focal treatments may have good treatment outcomes but on the other hand systemic chemotherapy may have very fatal side effects, so selective intra-arterial chemotherapy (siac) is one of the best options in which chemotherapy drug is delivered to the eye through ophthalmic artery and it is most targeted19. siac has minimal side effects as compared to systemic chemotherapy. in japan in 2004, scientists used a novel technique named as selective ophthalmic artery infusion (soai), in which drug was delivered at distal part of ophthalmic artery through trans femoral approach20,21. soai was later modified by abramson and gobin in which chemo drug was delivered in ophthalmic artery that was more precise and he named it super selective intraarterial chemotherapy (siac)22. the drug used by them was melphalan for siac and no serious side effects were observed. gobin et al used siaac in bilateral and unilateral advanced stage23. siac has high safety in terms of systemic and local side effects24. role of iac in recurrent disease was studied and it was observed that siac with melphalan alone or combined with topotecan has very encouraging outcomes and tumor control was achieved in 75% of cases and in 67% cases the globe was successfully salvaged25. chen m et al. presented the iac outcomes in infants less than three months of age. tumor regressed in 12 eyes out of 13 after 28 months. they reported this treatment as very promising for infants less than three months having retinoblastoma26. shields et al studied the outcomes of iac with melphalan in cases where intra-vitreal melphalan was given before or after iac. they observed high success in globe salvage when iac is consolidated with intra vitreal chemotherapy27. leal‑leal et al. gave topotecan and melphalan combine siac in advanced stages of tumor and they reported 55% prevention of enucleation in their patients28. a short study conducted in india showed complications and outcomes of siac in local patients. they used melphalan (3 mg/5 mg/7.5 mg) and topotecan (1 mg) (n = 4) or melphalan (3 mg/5 mg/ 7.5 mg) alone (n = 2). a mean of three iac sessions were given in each eye. they observed vitreous hemorrhage and diffuse choroidal atrophy in one case and they had good treatment response29. periocular chemotherapy carboplatin injection has been used for control of rb as periocular therapy along with systemic chemotherapy. periocular injection of topotecan hussain ahmed khaqan, et al 261 vol. 33, no. 4, oct – dec, 2017 pakistan journal of ophthalmology 0.18 mg/kg has been advocated in recent years in adjuvant with systemic chemotherapy. in comparison with intravenous route, same level of periocular chemotherapy can be achieved in 30 min within vitreous and doses that are 6 – 10 times that of intravitreous route with effect lasting for hours. to deliver the chemotherapy common route being used are subconjunctival or subtenon’s space location. because of recurrences of disease, periocular therapy is usually combined with systemic therapy in order to enhance the local dose in vitreous. complications of this local therapy include ecchymosis, periocular edema, ocular muscle fibrosis causing squint, atrophy of orbital fat and optic disc atrophy. long-term complications have not observed and yet to be published30. intravitreal chemotherapy vitreous seeds usually respond poorly to systemic chemotherapy, because of low drug concentration in vitreous due to being an avascular structure. intravitreal chemotherapy is basically used as salvage therapy in cases of persistent vitreous seeds31. the recommendations by inomata and kaneko were that melphalan is the most effective drug for seeds in retinoblastoma33. munier et al33 also used melphalan for vitreous seedlings in retinoblastoma in a dose of 20 – 30 µg/ 0.1 ml. the technique of intravitreal injection of melphalan was given 3-3.5 mm from limbus and triple thaw cryotherapy was done at injection site soon after taking out the needles to prevent needle tack seeding. the globe is rotated so that drug may be distributed in the vitreous equally. shield et al described high success rate of intravitreal chemotherapy and showed 100 percent results in 24 months follow up.34 topotecan can also be used for intra-vitreal chemotherapy in vitreous seedlings in concentration of 8 – 20 µg/0.04 ml and it has longer half-life than melphalan. combination of intra-vitreal chemotherapy is also practiced. the effect of intravitreal topotecan (8 – 20 µg of topotecan dissolved in 0.04 ml of balanced salt solution) combined with melphalan (40 µg of melphalan in 0.04 ml of diluent) was found to be safe in 9 eyes by ghassemi et al35. there are side effects of intra-vitreal chemotherapy that have been studied by different authors and found that safe dose 20 – 30 µg has preservation of normal retinal functions as studied on electroretinogram (erg), while others reported decreased erg amplitudes indicating permanent retinal toxicity36. conclusion local chemotherapy for retinoblastoma is safe and effective. authors affiliation dr. hussain ahmed khaqan assistant professor fcps, fcps (vr), frcs lgh/ pgmi, lahore dr. abdul hye professor fcps, mcps lgh/ pgmi, lahore role of authors dr. hussain ahmed khaqan article writing. dr. abdul hye proof reading and critical review. references 1. 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risk of dying of retinoblastoma in mexican children. med pediatr oncol. 2002; 38: 211–213. 13. leal-leal c, flores-rojo m, medina-sanson a, et al. a multicentre report from the mexican retinoblastoma group. br j ophthalmol. 2004; 88: 1074–1077. 14. naseripour m, nazari h, bakhtiari p, modarres-zadeh m, vosough p, ausari m. retinoblastoma in iran: outcomes in terms of patients’ survival and globe survival. br j ophthalmol. 2009; 93: 28–32. 15. kao ly, su ww, lin yw. retinoblastoma in taiwan: survival and clinical characteristics 1978–2000. jpn j ophthalmol. 2002; 46: 577–580. 16. chang cy, chiou tj, hwang b, bai ly, hsu wm, hsieh yl. retinoblastoma in taiwan: survival rate and prognostic factors. jpn j ophthalmol. 2006; 50: 242–249. 17. swaminathan r, rama r, shanta v. childhood cancers in chennai, india, 1990–2001: incidence and survival. int j cancer, 2008; 122: 2607–2611. 18. wessels g, hesseling pb. outcome of children treated for cancer in the republic of namibia. med pediatr oncol. 1996; 27: 160–164. 19. bowman rj, mafwiri m, luthert p, luande j, wood m. outcome of retinoblastoma in east africa. pediatr blood cancer, 2008; 50: 160–162. 20.. kaneko a, suzuki s. eye preservation treatment of retinoblastoma with vitreous seeding. jpn j clin oncol. 2003; 33: 601-7. 21. suzuki s, kaneko a. management of intraocular retinoblastoma and ocular prognosis. int j clin oncol. 2004; 9: 1-6. 22 abramson dh, dunkel ij, brodie se, kim jw, gobin yp. a phase i/ii study of direct intraarterial (ophthalmic artery) chemotherapy with melphalan for intraocular retinoblastoma initial results. ophthalmology, 2008; 115: 1398-404, 1404.e1. 23. gobin yp, dunkel ij, marr bp, brodie se, abramson dh. intra-arterial chemotherapy for the management of retinoblastoma: four-year experience. arch ophthalmol. 2011; 129: 732-7. 24. muen wj, kingston je, robertson f, brew s, sagoo ms, reddy ma. efficacy and complications of superselective intra-ophthalmic artery melphalan for the treatment of refractory retinoblastoma. ophthalmology, 2012; 119: 611-6. 25. abramson dh, marr bp, francis jh, dunkel ij, fabius aw, brodie se, et al. simultaneous bilateral ophthalmic artery chemosurgery for bilateral retinoblastoma (tandem therapy). plos one, 2016; 11: e0156806. 26. chen m, zhao j, xia j, liu z, jiang h, shen g, li h, jiang y, zhang j. intra-arterial chemotherapy as primary therapy for retinoblastoma in infants less than 3 months of age: a series of 10 cases. plos one 2016; 9: 11(8). 27. shields cl, say ea, pointdujour-lim r, cao c, jabbour pm, shields ja. rescue intra-arterial chemotherapy following retinoblastoma recurrence after initial intra-arterial chemotherapy. j fr ophtalmol. 2015; 38: 542-9. 28. shields cl, alset ae, say ea, caywood e, jabbour p, shields ja. retinoblastoma control with primary intraarterial chemotherapy: outcomes before and during the intravitreal chemotherapy era. j pediatr ophthalmol strabismus, 2016; 53: 275-84. 29. yannuzzi na, francis jh, marr bp, belinsky i, dunkel ij, gobin yp, et al. enucleation vs. ophthalmic artery chemosurgery for advanced intraocular retinoblastoma: a retrospective analysis. jama ophthalmol. 2015; 133: 1062-6. 30. rishi p, sharma t, koundanya v, bansal n, saravanan m, ravikumar r, et al. intra-arterial chemotherapy for retinoblastoma: first indian report. indian j ophthalmol. 2015; 63: 331-4. 31. c l shields, e m fulco, j d arias, c alarcon, m pellegrini, p rishi, s kaliki, c g bianciotto, and j. a shields. retinoblastoma frontiers with intravenous, intra-arterial, periocular, and intravitreal chemotherapy eye, 2013; 27: 253-264. 32. inomata m, kaneko a. chemo sensitivity profiles of primary and cultured human retinoblastoma cells in a human tumor clonogenic assay. jpn j cancer res. 1987; 78: 858-68. 33. brodie se, munier fl, francis jh, marr b, gobin yp, abramson dh. persistence of retinal function after intravitreal melphalan injection for retinoblastoma. doc ophthalmol. 2013; 126: 79-84. 34. shields cl, manjandavida fp, arepalli s, kaliki s, lally se, shields ja. intravitrealmelphalan for persistent or recurrent retinoblastoma vitreous seeds: preliminary results. jama ophthalmol. 2014; 132: 31925. 35. ghassemi f, shields cl, ghadimi h, khodabandeh a, roohipoor r. combined intravitrealmelphalan and topotecan for refractory or recurrent vitreous seeding from retinoblastoma. jama ophthalmol. 2014; 132: 93641. 36. francis jh, schaiquevich p, buitrago e, del sole mj, zapata g, croxatto jo, et al. local and systemic toxicity of intravitrealmelphalan for vitreous seeding in retinoblastoma: a preclinical and clinical study. ophthalmology, 2014; 121: 1810-7. https://www.ncbi.nlm.nih.gov/pubmed/?term=shields%252520cl%25255bauthor%25255d&cauthor=true&cauthor_uid=22995941 https://www.ncbi.nlm.nih.gov/pubmed/?term=fulco%252520em%25255bauthor%25255d&cauthor=true&cauthor_uid=22995941 https://www.ncbi.nlm.nih.gov/pubmed/?term=arias%252520jd%25255bauthor%25255d&cauthor=true&cauthor_uid=22995941 https://www.ncbi.nlm.nih.gov/pubmed/?term=alarcon%252520c%25255bauthor%25255d&cauthor=true&cauthor_uid=22995941 https://www.ncbi.nlm.nih.gov/pubmed/?term=pellegrini%252520m%25255bauthor%25255d&cauthor=true&cauthor_uid=22995941 https://www.ncbi.nlm.nih.gov/pubmed/?term=pellegrini%252520m%25255bauthor%25255d&cauthor=true&cauthor_uid=22995941 https://www.ncbi.nlm.nih.gov/pubmed/?term=rishi%252520p%25255bauthor%25255d&cauthor=true&cauthor_uid=22995941 https://www.ncbi.nlm.nih.gov/pubmed/?term=kaliki%252520s%25255bauthor%25255d&cauthor=true&cauthor_uid=22995941 https://www.ncbi.nlm.nih.gov/pubmed/?term=bianciotto%252520cg%25255bauthor%25255d&cauthor=true&cauthor_uid=22995941 https://www.ncbi.nlm.nih.gov/pubmed/?term=shields%252520ja%25255bauthor%25255d&cauthor=true&cauthor_uid=22995941 https://www.ncbi.nlm.nih.gov/pubmed/?term=shields%252520ja%25255bauthor%25255d&cauthor=true&cauthor_uid=22995941 microsoft word management corner qasim lateef 97 management corner ranibizumab: the clinician’s guide to commencing, continuing, and discontinuing treatment qasim lateef chaudhry pak j ophthalmol 2008, vol. 24 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . he national institute for health and clinical excellence (nice) guidance has recommendded ranibizumab in the treatment of wet age related macular degeneration (amd). the institute further recommended that a national protocol specifying criteria for discontinuation of ranibizumab is developed. criteria for discontinuation should include persistent deterioration in visual acuity and identifi-cation of anatomical changes in the retina that indicate inadequate response to therapy. the royal college of ophthalmologists (rcophth) recognised the need for such guidance and brought together a group of clinicians with expertise in the treatment of amd with ranibizumab, nice and department of health (dh) to develop this guide. it is confirmed that logmar (etdrs) vision charts, optical coherence tomography (oct) (oct 3 or higher specification equivalent), and stereo fundus fluorescein angiography (ffa) are the minimum requirements for adequate amd service delivery. it is considered inappropriate for a contemporary amd service to be contemplated without these basic requirements. when interpreting these guidelines it is important to recognise that clinical variations may occur at each stage in the management of any individual case, and that the decision to commence, re-treat or discontinue therapy rests with the clinician in consultation with the patient. a. criteria for commencement of treatment 1. diagnosis of active cnv lesion a diagnosis of choroidal neovascularisation (cnv) should be confirmed by ffa, except in cases of allergy that preclude this investigation, and oct (stratus oct 3 equivalent or higher specification) before commencement of therapy. 2. visual acuity the best corrected visual acuity (bcva) should be 6/96 (logmar 1.2 or 24 etdrs letters) or better in the eye to be treated. 3. structural damage to fovea it should be established that there is no significant permanent structural damage to the fovea in the eye under investigation before treatment is commenced. significant structural damage is defined as longstanding fibrosis or atrophy in the fovea, or a significant chronic disciform scar which, in the opinion of the treating clinician, would prevent the patient from deriving any functional benefit (i.e. prevent further loss of vision) from treatment. 4. recent progression of lesion cnv disease progression is defined as a) the appearance of sight threatening cnv which was not previously suspected or thought to be present or b) evidence of new haemorrhage and/or subretinal fluid (srf) or c) a documented recent visual decline in the presence of cnv or d) an increase in the cnv lesion size between visits 5. it is advised that the ranibizumab summary product characteristics (smpc), and the nice t 98 guidance on anti-vegf therapies in amd should be followed wherever possible. ranibizumab treatment is initiated with a loading phase of three injections at intervals of 4 weeks followed by a maintenance phase in which patients are monitored with etdrs (logmar) bcva, history and examination, and oct and/or angiographic examination. the interval between two doses should not be shorter than 4 weeks. it is expected that all patients will receive the 3 loading doses of ranibizumab, unless there are particular contraindications. 6. other considerations when commencing treatment a) bilateral active cnv lesions it is reasonable to treat both eyes in any one individual simultaneously, in the presence of bilateral active subfoveal cnv, as long as asepsis is observed. for such simultaneous bilateral intravitreal injections, a separate set of instruments must be used for each eye. similarly, separate vials of ranibizumab should be used for each eye. the patient should be made aware of the usual cumulative risks of sequential injections either to each eye on separate visits or to both eyes on the same visit. b) predominantly haemorrhagic lesions foveal haemorrhage or haemorrhage of greater than 50% of the total cnv lesion, are not considered reasons to withhold treatment. c) raised intraocular pressure elevated intraocular pressure (iop), even of >30mm hg, should not preclude treatment provided the iop is treated simultaneously. d) intraocular surgery it is advised that in the presence of wet amd and cataracts, the wet amd should be treated and cnv activity controlled before proceeding to cataract surgery, wherever possible. if cnv is diagnosed after intraocular surgery or there is reactivation, it is not necessary to allow 28 days recovery before commencing ranibizumab. attention, however, needs to be paid to the cataract wound. 7. criteria for not commencing treatment it is recommended that treatment with ranibizumab should not be commenced in the presence of: a) permanent structural damage in the fovea. b) evidence or suspicion of hypersensitivity to ranibizumab, or similar product. such evidence should lead to avoidance of therapy, and alternate treatments sought. b. criteria for continuation of treatment it is recommended that after the three loading doses, ranibizumab should be continued at 4 weekly intervals if: a) there is persistent evidence of lesion activity b) the lesion continues to respond to repeated treatment c) there are no contra-indications (see below) to continuing treatment. disease activity is denoted by retinal, subretinal, or sub-rpe fluid or haemorrhage, as determined clinically and/or on oct, lesion growth on ffa (morphological), and/or deterioration of vision (functional). c. criteria for temporarily discontinuing treatment (dose withholding) consider temporarily discontinuing treatment if: 1. there is no disease activity the disease should be considered to have become inactive when there is: a) persistent fluid in the absence of ffa leakage or other evidence of disease activity in the form of increasing lesion size, or new haemorrhage or exudates (i.e. no increase in lesion size, new haemorrhage or exudates) b) no re-appearance or further worsening of oct indicators of cnv disease activity on subsequent follow up following recent discontinuation of treatment. c) no additional lesion growth or other new signs of disease activity on subsequent follow up following recent discontinuation of treatment. d) no deterioration in vision that can be attributed to cnv activity. 99 2. there has been one or more adverse events related to drug or injection procedure including: a) endophthalmitis b) retinal detachment c) severe uncontrolled uveitis d) ongoing periocular infections e) other serious ocular complications attributable to ranibizumab (drug) or injection procedure f) thrombo-embolic phenomena, including mi or cva in the preceding 3 months, or recurrent thrombo-embolic phenomena which are thought to be related to treatment with ranibizumab g) other serious adverse events (sae) e.g. hospitalisation. d. criteria for permanent discontinuation of treatment consider discontinuing treatment permanently if there is: 1. a hypersensitivity reaction to ranibizumab is established or suspected 2. reduction of bcva in the treated eye to less than 15 letters (absolute) on 2 consecutive visits in the treated eye, attributable to amd in the absence of other pathology 3. reduction in bcva of 30 letters or more compared to either baseline and/or best recorded level since baseline as this may indicate either poor treatment effect or adverse event or both 4. there is evidence of deterioration of the lesion morphology despite optimum treatment. such evidence includes progressive increase in lesion size confirmed with ffa, worsening of oct indicators of cnv disease activity or other evidence of disease activity in the form of significant new haemorrhage or exudates despite optimum therapy over 3 consecutive visits. e. criteria for discontinuing treatment and discharging patient from hospital eye clinic follow up consider discharging the patient from long term hospital follow up if: 1. decision to discontinue ranibizumab permanently has been made 2. there is no evidence of other ocular pathology requiring investigation or treatment 3. there is low risk of further worsening or reactivation of wet amd that could benefit from restarting treatment e.g. very poor central vision and a large, non-progressive, macular scar. microsoft word index-1 225 indexes (volume 26, 2010) no.1. january……………………………………………..page 1 – 54 no.2. april………………………………………………. .page 55 – 111 no.3. july……………………………………………… …page 112 – 169 no.4 october…………………………………………… page 170 – 233 subject index abstracts 51-3, 104-7, 165-7, 221-4. adnexa • evaluation of eyelid lesions at a tertiary care hospital, jinnah postgraduate medical centre (jpmc), karachi 26: 83-86. cataract surgery • classification and evaluation of secondary posterior chamber iol implantation scleral fixation of iol 26: 148-53. • comparative study of effectiveness of subconjunctival injection of dexamethasone versus intracameral injection of dexamethasone in controlling immediate post-operative anterior uveitis after cataract surgery in cases of phacomorphic glaucoma 26: 114-7. • comparison of complications after primary and secondary anterior chamber intraocular lens implantation 26: 57-64. • editorial: the on-going evolution in cataract surgery 25: 1. • instrument to manage radial tear in continuous curvilinear capsulorrhexis (ccc) 26: 96-100. • phacoemulsification under topical anesthesia alone versus topical anesthesia with subconjunctival 26: 91-95. • positive impact of good visual outcome on the acceptance of cataract surgery in subsaharan african population 26: 133-7. • randomised controlled trial to evaluate the effects of intravitreal bevacizumab administration on visual outcome in diabetic patients with diabetic macular edema who underwent cataract surgery 26: 122-7. • visual outcome and complications of manual sutureless small incision cataract surgery 26: 32-39. conjunctivitis • demographic study of trachoma patients and their response to azithromycin 26: 87-90. • efficacy of supratarsal injection of triamcinolone acetonide (corticosteroid) for treating severe vernal keratoconjunctivitis (vkc) refractory to all conventional therapy 201-4. • prevalence of trachoma in upper sindh 26: 118-21. • supratarsal injection of triamcinolone for vernal keratoconjunctivitis 26: 28-31. congenital abnormalities • a boy with bilateral complete cryptophthalmos in pakistan with subsequent blaming and shaming for his mother 26: 48-51. • cornea • regression of corneal vascularization by laser treatment 26: 23-27. • visual outcome after deep lamellar keratoplasty in keratoconus 26: 210-5. diabetes • aerobic bacterial conjunctival flora in diabetic patients 26: 177-81. • duration of diabetes as a significant factor for retinopathy 26: 182-6. • prevalence of diabetic retinopathy in quetta balochistan 26: 187-92 editorial • the on-going evolution in cataract surgery 26: 1. • retinal vein occlusion management updated recommendations 26: 55-6. • the challenge of microbial keratitis in pakistan 26: 112-3. • trabeculectomy revisited 26: 170-2. glaucoma • a review of 100 cases of ectopia lentis with glaucoma: its types, presentation, management and visual prognosis 26: 7-11. 226 • assessment of anxiety and depression in primary open angle glaucoma patients (a study of 100 cases) 26: 143-7. • correlation between intra ocular pressure, central corneal thickness and glaucoma stage in patients with primary open angle glaucoma 26: 197-200. • ‘dark adaptation’ a pitfall in evaluation of reliability of visual fields of second eye in glaucoma patients 26: 16-22. • efficacy of goniotomy in management of primary congenital glaucoma 26: 173-6. • management of secondary glaucoma after pars plana vitrectomy (ppv) and silicone oil injection in rhegmatogenous retinal detachment 26: 12-15. • measurement and expression of exact intraocular pressure of patient’s eye(s) and to determine normal or pathological iop 26: 6568. • regression of corneal vascularization by laser treatment 26: 23-27. • relationship between central corneal thickness and intraocular pressure in selected pakistani population 26: 79-82. • role of laser peripheral iridoplasty in acute attack of primary angle closure glaucoma 26: 154-7. lacrimal • endoscopic dacrocystorhinostomy: a pakistani experience 26: 2-6. • the importance of excising or suturing the posterior mucosal flaps in external dacryocystorhinostomy 26: 69-73. lens • a review of 100 cases of ectopia lentis with glaucoma: its types, presentation, management and visual prognosis 26: 7-11. news and events: 26: 54, 110, 168, obituary • bravo raja sahib (1923-2010) 26: 108-109. orbit • relative uncommon cause of proptosis 26: 216-8. • reconstruction of empty sockets with sahaf’s orbital implant 26: 128-32. pterygium • to compare the recurrence rate of pterygium excision with bare-sclera, free conjunctival auto graft and amniotic membrane grafts 26: 138-42. retina • best vitelliform macular dystrophy with central retinal artery occlusion 162-4. refractive error • effect of lasik on endothelial cell count in patients treated for myopia 26: 39-43. refractive surgery • effect of lasik on endothelial cell count in patients treated for myopia 26: 39-43. retinal detachment • management of secondary glaucoma after pars plana vitrectomy (ppv) and silicone oil injection in rhegmatogenous retinal detachment 26: 12-15. silicon oil • management of secondary glaucoma after pars plana vitrectomy (ppv) and silicone oil injection in rhegmatogenous retinal detachment 26: 12-15. trauma • choroidal melanoma in ocular melanocytosis 26: 100-103. • retained intraocular foreign body 26: 158-61. • visual outcome after anterior segment trauma of the eye 26: 74-79. uveitis • management tips for uveitis 26: 44-47. visual fields • ‘dark adaptation’ a pitfall in evaluation of reliability of visual fields of second eye in glaucoma patients 26: 16-22. author index abbas m: relationship between central corneal thickness and intraocular pressure in selected pakistani population 26: 79-82. ahmad a: best vitelliform macular dystrophy with central retinal artery occlusion 162-4. ahmed i: comparison of complications after primary and secondary anterior chamber intraocular lens implantation 26: 57-64. ahmed j: instrument to manage radial tear in continuous curvilinear capsulorrhexis (ccc) 26: 96-100. ahmad k: a boy with bilateral complete cryptophthalmos in pakistan with subsequent blaming and shaming for his mother 26: 48-51. 227 ahmad k: central serous retinopathy in a male patient with takayasu disease – a rare presentation 26: 220-1. ahmed m: demographic study of trachoma patients and their response to azithromycin 26: 87-90. ahmad m: to compare the recurrence rate of pterygium excision with bare-sclera, free conjunctival auto graft and amniotic membrane grafts 26: 138-42. ahmad s: positive impact of good visual outcome on the acceptance of cataract surgery in subsaharan african population 26: 133-7. aimal khan: ocular complications after intravitreal bevacizumab injection in eyes with choroidal and retinal neovascularization 26: 205-9. akhter m: relative uncommon cause of proptosis 26: 217-9. akram a: management tips for uveitis 26: 44-47. akram a: duration of diabetes as a significant factor for retinopathy 26: 182-6. akram mi: efficacy of goniotomy in management of primary congenital glaucoma 26: 173-6. akram s: central serous retinopathy in a male patient with takayasu disease – a rare presentation 26: 220-1. ali a: central serous retinopathy in a male patient with takayasu disease – a rare presentation 26: 220-1. ali si. trabeculectomy revisited 26, 170-2. ali ss: efficacy of supratarsal injection of triamcinolone acetonide (corticosteroid) for treating severe vernal keratoconjunctivitis (vkc) refractory to all conventional therapy 26: 201-4. ameen ss: management tips for uveitis 26: 44-47. ansari hm: efficacy of goniotomy in management of primary congenital glaucoma 26: 173-6. aqil qazi za: visual effects of intravitreal triamcinolone acetonide injection in patients with refractory diabetic macular edema 26: 193-6. aqil qazi za: visual outcome after deep lamellar keratoplasty in keratoconus 26: 210-15. arbab tm: aerobic bacterial conjunctival flora in diabetic patients 26: 177-81. arfat my: visual outcome after anterior segment trauma of the eye 26: 74-79. arain tm: supratarsal injection of triamcinolone for vernal keratoconjunctivitis 26: 28-31. asghar a: management of secondary glaucoma after pars plana vitrectomy (ppv) and silicone oil injection in rhegmatogenous retinal detachment 26: 12-15. asgahr a: randomised controlled trial to evaluate the effects of intravitreal bevacizumab administration on visual outcome in diabetic patients with diabetic macular edema who underwent cataract surgery 26: 122-7. aslam s: endoscopic dacrocystorhinostomy: a pakistani experience 26: 2-6. awan ah: endoscopic dacrocystorhinostomy: a pakistani experience 26: 2-6. awan s: duration of diabetes as a significant factor for retinopathy 26: 182-6. azfar nafees hanfi: ocular complications after intravitreal bevacizumab injection in eyes with choroidal and retinal neovascularization 26: 205-9. babar am: prevalence of diabetic retinopathy in quetta balochistan 26: 187-92. badini aj: prevalence of diabetic retinopathy in quetta balochistan 26: 187-92. baig mj: effect of lasik on endothelial cell count in patients treated for myopia 26: 39-43. baig mj: efficacy of goniotomy in management of primary congenital glaucoma 26: 173-6. baig mj: visual effects of intravitreal triamcinolone acetonide injection in patients with refractory diabetic macular edema 26: 193-6. baig msa: efficacy of supratarsal injection of triamcinolone acetonide (corticosteroid) for treating severe vernal keratoconjunctivitis (vkc) refractory to all conventional therapy 26: 201-4. bano ni: efficacy of goniotomy in management of primary congenital glaucoma 26: 173-6. baseer a: demographic study of trachoma patients and their response to azithromycin 26: 87-90. baseer a: to compare the recurrence rate of pterygium excision with bare-sclera, free conjunctival auto graft and amniotic membrane grafts 26: 138-42. bhatti mn: management of secondary glaucoma after pars plana vitrectomy (ppv) and silicone oil injection in rhegmatogenous retinal detachment 26: 12-15. bhatti mn: regression of corneal vascularization by laser treatment 26: 23-27. bhatti n: relationship between central corneal thickness and intraocular pressure in selected pakistani population 26: 79-82. 228 bhutto ia: role of laser peripheral iridoplasty in acute attack of primary angle closure glaucoma 26: 154-7. butt hm: news and events 26: 168-9. butt hm: news and events 26: 110 butt hm: visual outcome after anterior segment trauma of the eye 26: 74-79. butt hm: news and events 26: 54 burney ja: efficacy of supratarsal injection of triamcinolone acetonide (corticosteroid) for treating severe vernal keratoconjunctivitis (vkc) refractory to all conventional therapy 26: 201-4. chaudhry ml: retinal vein occlusion management updated recommendations 26: 55-56. chaudhry ta: a boy with bilateral complete cryptoph-thalmos in pakistan with subsequent blaming and shaming for his mother 26: 48-51. chaudary wi: visual outcome after deep lamellar keratoplasty in keratoconus 26: 210-15. das g: prevalence of diabetic retinopathy in quetta balochistan 26: 187-92. daud a: randomised controlled trial to evaluate the effects of intravitreal bevacizumab administration on visual outcome in diabetic patients with diabetic macular edema who underwent cataract surgery 26: 122-7. daud a: relationship between central corneal thickness and intraocular pressure in selected pakistani population 26: 79-82. fahmi ms: comparison of complications after primary and secondary anterior chamber intraocular lens implantation 26: 57-64. farhat f: evaluation of eyelid lesions at a tertiary care hospital, jinnah postgraduate medical centre (jpmc), karachi 26: 83-86. fasih u: assessment of anxiety and depression in primary open angle glaucoma patients (a study of 100 cases) 26: 143-7. fasih u: comparison of complications after primary and secondary anterior chamber intraocular lens implantation 26: 57-64. fasih u: ‘dark adaptation’ a pitfall in evaluation of reliability of visual fields of second eye in glaucoma patients 26: 16-22. fayyaz m: positive impact of good visual outcome on the acceptance of cataract surgery in subsaharan african population 26: 133-7. fayyaz m: the importance of excising or suturing the posterior mucosal flaps in external dacryocystorhinostomy 26: 69-73. fawad u: relationship between central corneal thickness and intraocular pressure in selected pakistani lens implantation 26: 57-64. ghaffar z: evaluation of eyelid lesions at a tertiary care hospital, jinnah postgraduate medical centre (jpmc), karachi 26: 83-86. hasnain m: comparative study of effectiveness of subconjunctival injection of dexametha-sone versus intracameral injection of dexamethasone in controlling immediate post-operative anterior uveitis after cataract surgery in cases of phacomorphic glaucoma 26: 114-7. hassan m: randomised controlled trial to evaluate the effects of intravitreal bevacizumab administration on visual outcome in diabetic patients with diabetic macular edema who underwent cataract surgery 26: 122-7. hassan m: regression of corneal vascularization by laser treatment 26: 23-27. hassan m: relationship between central corneal thickness and intraocular pressure in selected pakistani population 26: 79-82. hamirani mm: assessment of anxiety and depression in primary open angle glaucoma patients (a study of 100 cases) 26: 143-7. hussain z: choroidal melanoma in ocular melanocytosis 26: 100-103. hussain z: visual outcome and complications of manual sutureless small incision cataract surgery 26: 32-39. hye a: reconstruction of empty sockets with sahaf’s orbital implant 26: 128-32. iqbal m: a review of 100 cases of ectopia lentis with glaucoma: its types, presentation, management and visual prognosis 26: 7-11. iqbal m: measurement and expression of exact intraocular pressure of patient’s eye(s) and to determine normal or pathological iop 26: 6568. iqbal m: retained intraocular foreign body 26: 15861. iqbal s: aerobic bacterial conjunctival flora in diabetic patients 26: 177-81. irshad z: a review of 100 cases of ectopia lentis with glaucoma: its types, presentation, management and visual prognosis 26: 7-11. irshad z: measurement and expression of exact intraocular pressure of patient’s eye (s) and to determine normal or pathological iop 26: 6568. 229 jafri ar: assessment of anxiety and depression in primary open angle glaucoma patients (a study of 100 cases) 26: 143-7. jafri ar: ‘dark adaptation’ a pitfall in evaluation of reliability of visual fields of second eye in glaucoma patients 26: 16-22. jamal q: evaluation of eyelid lesions at a tertiary care hospital, jinnah postgraduate medical centre (jpmc), karachi 26: 83-86. jan s: choroidal melanoma in ocular melanocytosis 26: 100-103. jan s: visual outcome and complications of manual sutureless small incision cataract surgery 26: 32-39. janjua ta: positive impact of good visual outcome on the acceptance of cataract surgery in subsaharan african population 26: 133-7. javed ea: phacoemulsification under topical anesthesia alone versus topical anesthesia with subconjunctival 26: 91-95. kadri wm: classification and evaluation of secondary posterior chamber iol implantation scleral fixation of iol 26: 14853. kamal mf: regression of corneal vascularization by laser treatment 26: 23-27. kamal z: reconstruction of empty sockets with sahaf’s orbital implant 26: 128-32. karim s: choroidal melanoma in ocular melanocytosis 26: 100-103. karim s: visual outcome and complications of manual sutureless small incision cataract surgery 26: 32-39. khalid mk: choroidal melanoma in ocular melanocytosis 26: 100-103. khalid mk: visual outcome and complications of manual sutureless small incision cataract surgery 26: 32-39. khalil m: best vitelliform macular dystrophy with central retinal artery occlusion 162-4. khan bs: a review of 100 cases of ectopia lentis with glaucoma: its types, presentation, management and visual prognosis 26: 7-11. khan bs: measurement and expression of exact intraocular pressure of patient’s eye(s) and to determine normal or pathological iop 26: 6568. khan fa: the importance of excising or suturing the posterior mucosal flaps in external dacryocystorhinostomy 26: 69-73. khan md: the challenge of microbial keratitis in pakistan 26: 112-3. khan mt: choroidal melanoma in ocular melanocytosis 26: 100-103. khan mt: visual effects of intravitreal triamcinolone acetonide injection in patients with refractory diabetic macular edema 26: 193-6. khan mt: visual outcome and complications of manual sutureless small incision cataract surgery 26: 32-39. khan mt: visual outcome after deep lamellar keratoplasty in keratoconus 26: 210-15. khan n: demographic study of trachoma patients and their response to azithromycin 26: 87-90. khan n: to compare the recurrence rate of pterygium excision with bare-sclera, free conjunctival auto graft and amniotic membrane grafts 26: 138-42. khan s: best vitelliform macular dystrophy with central retinal artery occlusion 162-4. khan t: effect of lasik on endothelial cell count in patients treated for myopia 26: 39-43. kundi nk: to compare the recurrence rate of pterygium excision with bare-sclera, free conjunctival auto graft and amniotic membrane grafts 26: 138-42. laghari d: role of laser peripheral iridoplasty in acute attack of primary angle closure glaucoma 26: 154-7. lal g: reconstruction of empty sockets with sahaf’s orbital implant 26: 128-32. latif e: supratarsal injection of triamcinolone for vernal keratoconjunctivitis 26: 28-31. mahar ps: role of laser peripheral iridoplasty in acute attack of primary angle closure glaucoma 26: 154-7. mahar p.s: randomised controlled trial to evaluate the effects of intravitreal bevacizumab administration on visual outcome in diabetic patients with diabetic macular edema who underwent cataract surgery 26: 122-7. mahar ps: regression of corneal vascularization by laser treatment 26: 23-27. mahmood k. effect of lasik on endothelial cell count in patients treated for myopia 26: 3943. mehmood k: visual effects of intravitreal triamcinolone acetonide injection in patients with refractory diabetic macular edema 26: 193-6. mahmood k: visual outcome after deep lamellar keratoplasty in keratoconus 26: 210-15. mahmood t: abstracts 26: 51-3, 104-7, 165-7, 221-4. 230 malik ba: visual effects of intravitreal triamcinolone acetonide injection in patients with refractory diabetic macular edema 26: 193-6. maliktg: best vitelliform macular dystrophy with central retinal artery occlusion 162-4. mazhar-uz-zaman soomro: relative uncommon cause of proptosis 26: 217-9 memon m: correlation between intra ocular pressure, central corneal thickness and glaucoma stage in patients with primary open angle glaucoma 26: 197-200. mazhry z: classification and evaluation of secondary posterior chamber iol implantation scleral fixation of iol 26: 148-53. memon ms: management of secondary glaucoma after pars plana vitrectomy (ppv) and silicone oil injection in rhegmatogenous retinal detachment 26: 12-15. mirza dm: obituary: bravo raja sahib (1923-2010) 26: 108-109. mirza ma: aerobic bacterial conjunctival flora in diabetic patients 26: 177-81. mohammad l: visual outcome and complications of manual sutureless small incision cataract surgery 26: 32-39. mohammad l: choroidal melanoma in ocular melanocytosis 26: 100-103. mohammad s: demographic study of trachoma patients and their response to azithromycin 26: 87-90. naqvi a: management tips for uveitis 26: 44-47. nasir bhatti: randomised controlled trial to evaluate the effects of intravitreal bevacizumab administration on visual outcome in diabetic patients with diabetic macular edema who underwent cataract surgery 26: 122-7. nawaz a: measurement and expression of exact intraocular pressure of patient’s eye(s) and to determine normal or pathological iop 26: 6568. naz ma: duration of diabetes as a significant factor for retinopathy 26: 182-6. niazi k: management tips for uveitis 26: 44-47. niazi mk: duration of diabetes as a significant factor for retinopathy 26: 182-6. pechuho ma: prevalence of trachoma in upper sindh 26: 118-21. p.s mahar: ocular complications after intravitreal bevacizumab injection in eyes with choroidal and retinal neovascularization 26: 205-9. qadeer s: aerobic bacterial conjunctival flora in diabetic patients 26: 177-81. qamar mr: supratarsal injection of triamcinolone for vernal keratoconjunctivitis 26: 28-31. qayyum a: prevalence of diabetic retinopathy in quetta balochistan 26: 187-92. qazi za: effect of lasik on endothelial cell count in patients treated for myopia 26: 39-43. qidwai u: ocular complications after intravitreal bevacizumab injection in eyes with choroidal and retinal neovascularization 26: 205-9. qureshi mh: prevalence of trachoma in upper sindh 26: 118-21. rahman a: comparative study of effectiveness of subconjunctival injection of dexametha-sone versus intracameral injection of dexamethasone in controlling immediate post-operative anterior uveitis after cataract surgery in cases of phacomorphic glaucoma 26: 114-7. rahman a: ‘dark adaptation’ a pitfall in evaluation of reliability of visual fields of second eye in glaucoma patients 26: 16-22. rahman a: management of secondary glaucoma after pars plana vitrectomy (ppv) and silicone oil injection in rhegmatogenous retinal detachment 26: 12-15. rahman a: regression of corneal vascularization by laser treatment 26: 23-27. riaz n: the on-going evolution in cataract surgery 25: 1. rajpur a: correlation between intra ocular pressure, central corneal thickness and glaucoma stage in patients with primary open angle glaucoma 26: 197-200. rehman a: relationship between central corneal thickness and intraocular pressure in selected pakistani population 26: 79-82. rehman a: randomised controlled trial to evaluate the effects of intravitreal bevacizumab administration on visual outcome in diabetic patients with diabetic macular edema who underwent cataract surgery 26: 122-7. rai p: regression of corneal vascularization by laser treatment 26: 23-27. riaz su: assessment of anxiety and depression in primary open angle glaucoma patients (a study of 100 cases) 26: 143-7. saeed m: evaluation of eyelid lesions at a tertiary care hospital, jinnah postgraduate medical centre (jpmc), karachi 26: 83-86. saeed n: editorial: the challenge of microbial keratitis in pakistan 26: 112-3. 231 sahaf ik: reconstruction of empty sockets with sahaf’s orbital implant 26: 128-32. sahi as: visual outcome after deep lamellar keratoplasty in keratoconus 26: 210-15. salman b: a boy with bilateral complete cryptophthalmos in pakistan with subsequent blaming and shaming for his mother 26: 48-51. sethi s: demographic study of trachoma patients and their response to azithromycin 26: 87-90. shahid r: relative uncommon cause of proptosis 26: 217-9. shaikh a: assessment of anxiety and depression in primary open angle glaucoma patients (a study of 100 cases) 26: 143-7. shaikh a: comparison of complications after primary and secondary anterior chamber intraocular lens implantation 26: 57-64. shaikh a: ‘dark adaptation’ a pitfall in evaluation of reliability of visual fields of second eye in glaucoma patients 26: 16-22. shaikh aq: prevalence of trachoma in upper sindh 26: 118-21. shaikh d: prevalence of trachoma in upper sindh 26: 118-21. shaikh n: ‘dark adaptation’ a pitfall in evaluation of reliability of visual fields of second eye in glaucoma patients 26: 16-22. shahzad t: management of secondary glaucoma after pars plana vitrectomy (ppv) and silicone oil injection in rhegmatogenous retinal detachment 26: 12-15. shafique mm: best vitelliform macular dystrophy with central retinal artery occlusion 162-4. shoaib kk: positive impact of good visual outcome on the acceptance of cataract surgery in subsaharan african population 26: 133-7. siddiqui sj: prevalence of trachoma in upper sindh 26: 118-21. syed z: management tips for uveitis 26: 44-47. talpur ki: correlation between intra ocular pressure, central corneal thickness and glaucoma stage in patients with primary open angle glaucoma 26: 197-200. tayyab m: endoscopic dacrocystorhinostomy: a pakistani experience 26: 2-6. ullah e: supratarsal injection of triamcinolone for vernal keratoconjunctivitis 26: 28-31. ullah mr: reconstruction of empty sockets with sahaf’s orbital implant 26: 128-32. wahab s: instrument to manage radial tear in continuous curvilinear capsulorrhexis (ccc) 26: 96-100. yaqub ma: the importance of excising or suturing the posterior mucosal flaps in external dacryocystorhinostomy 26: 69-73. zaman y: regression of corneal vascularization by laser treatment 26: 23-27. abstract index cataract surgery • aqueous vascular endothelial growth factor as a predictor of macular thickening following cataract surgery in patients with diabetes mellitus 26: 166. • cataract surgery and primary intraocular lens implantation in children <2 years old in the uk and ireland: finding of national surveys 26:165. • spectacle use after routine cataract surgery 26: 51 cornea • acanthamoeba keratitis: diagnosis and treatment update 2009 • comparison of outcomes of lamellar keratoplasty and penetrating keratoplasty in keratoconus 26: 52 • major shifts in corneal transplantation procedures in north china: 5316 eyes over 12 year 26: 51. • one-year outcomes of a bilateral randomised prospective clinical trial comparing prk with mitomycin c and lasik 26: 225. • rapid detection of acanthamoeba cysts in frozen sections of corneal scrapings with fungiflora y 26: 224. • use of anterior segment optical coherence tomography to study corneal changes after collagen cross-linking 26: 104. diabetes • intravitreal injection of pegaptanib sodium for proliferative diabetic retinopathy 26: 106. lacrimal • a simple and evolutional approach proven to recanalise the nasolacrimal duct obstruction 26: 105 • turnover rate of tear-film lipid layer determined by fluorophotometry 26: 165. 232 orbit • azathioprine for ocular inflammatory diseases 26: 222. refractive surgery • ten years after photorefractive keratectomy (prk) and laser in situ keratomileusis (lasik) for moderate to high myopia (controlmatched study) 26: 52. retina • aqueous vascular endothelial growth factor as a predictor of macular thickening following cataract surgery in patients with diabetes mellitus 26: 166. • macular thickness decreases with age in normal eyes: a study on the macular thickness map protocol in the stratus oct 26: 105. • predicting visual success in macular hole surgery 26: 166. uveitis • the effect of biomicroscope illumination system on grading anterior chamber inflammation 26: 223. microsoft word mazharul hassan 30 original article complication and visual outcome after peadiatric cataract surgery with or without intra ocular lens implantation mazhar-ul-hasan, umair a. qidwai, aziz-ur-rehman, nasir bhatti, rashid h. alvi pak j ophthalmol 2011, vol. 27 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mazhar-ul-hasan isra postgraduate institute of ophthalmology al ibrahim eye hospital gaddap town, malir karachi received for publication november’ 2010 …..……………………….. purpose: to compare the rate of complications and visual outcome after peadiatric cataract extraction with or without intraocular lens implantation. material and methods: a total of 202 consecutive children (281 eyes) aged 10 years and younger with unilateral or bilateral congenital cataract, treated and followed up at our institution between march 1st, 2008 and july 30th, 2009, were included in this prospective study. the study was performed at al-ibrahim eye hospital, karachi. results: most frequent early complication seen in patients after cataract surgery was striate keratopathy, which was observed in 90 (32%) eyes, while the most common late complication was posterior capsular opacification in 95 (34%), which required either yag laser capsulotomy or surgical capsulotomy. among the early complications striate keratopathy was most commonly noted in patients of age older than 1 year having cataract surgery without iol. around 50 % patients of psuedophakic groups have visual acuity better than 6/60 while only 26 % of aphakic group patients achieved vision of better than 6/60 with spectacle correction (p<0.05). conclusion: correction of aphakia after peadiatric cataract surgery with primary iol implantation results in improved visual acuity compared to spectacle correction but a higher rate of complications requiring reoperation. ataract in childhood is a most important cause of visual impairment and blindness. lack of vision in early years of life can adversely affect overall development of child with far reaching effects on personal, educational, occupational and social aspects1. consequently early detection and treatment is crucial for maximizing visual development and preventing amblyopia2. treatment of congenital/developmental cataract poses a challenge to the ophthalmologists, patients and parents in terms of visual development and rehabilitation3. advances and development of new microsurgical techniques and amblyopia management have improved the safety and effectiveness of peadiatric cataract treatment4,5. on the other hand, management of congenital cataract remains a challenge and postoperative complications are still common6,7. in last few years, many retrospective studies have reported varying prevalence’s of several postoperative complications after pediatric lensectomy. however, most of these studies have estimated the risk of secondary cataract formation or aphakic glaucoma separately, and there are only few reports that include other complications8,9). material and methods a total of 202 consecutive children (281 eyes) aged 10 years and younger with unilateral or bilateral congenital cataract treated and followed up at our institution between march 1st, 2008 and july 30th, 2009, were included in this prospective study. the study was performed at al-ibrahim eye hospital and indus hospital karachi. informed consent was taken from the c 31 guardians of the patients included in the study, as all patients included in this study were less than 10 years of age. exclusion criteria were ocular trauma, infection, congenital glaucoma, anterior segment dysgenesis, lowe syndrome, maternal rubella syndrome, trisomy 13, optic nerve or other fundus abnormalities, and prematurity. after detailed history and relevant investigations, ophthalmic checkup including visual acuity, slit lamp examination, fundus examination, retinoscopy, keratometery, b-scan ultrasonography and intra ocular lens power calculation wherever possible were done. intra ocular lens power was calculated by using srk ii formula. eyes of patients younger than 1 year were randomly allocated to either group a (patients in this group underwent lens material aspiration with anterior vitrectomy and intra-ocular lens implantation) and group b (patients in this group underwent lens material aspiration with anterior vitrectomy and without intra-ocular lens implantation). similarly, patients between the age of 1 year to 10 years were randomly allocated to either group c (patients in this group underwent lens material aspiration with anterior vitrectomy and intra-ocular lens implantation) and group d (patients in this group underwent lens material aspiration with anterior vitrectomy and without intra-ocular lens implantation). dilatation of pupil was done by using cyclopentolate 1% and phenylepherine 10% at 90, 60, 30 and 15 minutes preoperatively. in all cases irrigation and aspiration was done with wide anterior capsulotomy. primary posterior capsulotomy was done in all cases. in children with bilateral lens opacities requiring surgery, eye with poorer vision was operated first and surgery for second eye was done three months later. all cases remained on topical steroids and mydriatic for six weeks. patients were followed on 1st post operative day and 1st post operative week for early postoperative complications. patients were followed after 3 months, 6 months and 1 year. on follow up after 1 year, patients visual acuity, if possible, were noted so is the strabismus if present. visual acuity was assessed using the teller acuity cards test or the lea test depending on the age and with one eye occluded. all refraction readings were obtained after instillation of combination of cyclopentolate 1%, tropicamide 1%, and phenylephrine 2.5%. data was analyzed using spss version 17. frequencies of gender, age, and complications were noted. statistical analysis of the prevalence of several postoperative complications was performed by the fisher exact test. all tests were twotailed, and acceptable significance was recorded when p values were less than 0.05. results 281 eyes of 202 patients were included in the study. all the patients were in the age between 2 months to 10 years with mean age of 4.67 years. out of 202 patients included in the study, 124 (61%) were females while 78 (39%) were males. group a included 43 eyes while group b included 48 eyes. similarly group c and d included 102 and 88 eyes respectively. most frequent early complication seen in patients after cataract surgery was striate keratopathy, which was observed in 90 (32%) eyes, while the most common late complication was posterior capsular opacification in 95 (34%), which lead to either yag laser capsulotomy or surgical capsulotomy. frequencies of different complications are shown in figure 1 and 2, among the early complications striate keratopathy was most commonly noted in patients of age older than 1 year having cataract surgery without iol. similarly among the late complications posterior capsular opacification was noted more in cases of lens material aspiration with iol implantation in patients younger than 1 year. distribution of different complications in all the groups is shown in table 1. we noted that visual acuity after 1 year of follow up was much better in the pseudophakic groups than aphakic groups when they were corrected with spectacles. around 50 % patients of psuedophakic groups have visual acuity better than 6/60 while only 26 % of aphakic group patients achieved vision of better than 6/60 with spectacle correction (p<0.05) table 2. similarly, esotropia or exotropia of more than 8 prism diopters was noted more in the aphakic groups (46%) than in psuedophakic groups (14%) (p<0.05) (table 3). discussion in this study, we have tried to investigate the incidence of early and late postoperative complications after cataract surgery with or without iol implantation in children younger than 1 year and between 1 to 10 years. in this study the most frequent early postoperative complication was striate keratopathy, which was treated successfully in almost all the patients with topical steroids. on the other hand common late complications were aphakic glaucoma in aphakic eyes while posterior capsular opacification in psuedophakic eyes. in other studies the reported prevalence of aphakic glaucoma in 32 table 1: distribution of complications among all the study groups group a (lma+iol+av) <1 year n (%) group b (lma+av) <1 year n (%) group c (lma+iol+av) 1-10 years n (%) group d (lma+av) 1-10 years n (%) no of eyes 43 48 102 88 early complications fibrinous reaction 5 (12) 11(23) 13 (13) 13 (15) hyphema 0 1 (2) 0 0 striate keratopathy 10 (28) 22 (46) 22 (21.5) 36 (41) late complications retinal detachement 0 2 (4) 1 (0.98) 4 (4.5) aphakic/pseudophakic glaucoma 0 2 (4) 1 (0.98) 1 (1.12) posterior capsular opacification 35 (81) 18 (37) 34 (33) 8 (9) lma=lens matter aspiration av=anterior vitrectomy iol=intra ocular lens table 2: visual acuity among psueudophakic and aphakic groups psuedophakic group (145 eyes) n (%) aphakic group (136 eyes) n (%) 6/60 or better 73(50) 35(26) less than 6/60 20(14) 41(30) non recordable 52(36) 60(44) psuedophakic group (145) = group a (43) + group c (102) aphakic group (136) = group b (48) + group d (88) children after cataract surgery varies between 6% and 59%8,9. this variability has been linked to differences in the patient population, the type of cataract, the age at surgical correction, the definition of glaucoma, and the length of follow-up. the main reason of aphakic glaucoma is still poorly understood. it has been suggested that immaturity of the developing infant’s angle leads to increased susceptibility to surgical trauma. besides, the combination of difficult surgery, retained lens matter, and poor pupil dilatation may contribute to an increased postoperative inflammation leading to early-onset acute glaucoma. it seems reasonable that with improvement of surgical techniques, including extensive removal of lens matter and anterior vitrectomy, this subtype of aphakic glaucoma may become less common. it is well recognized that the peadiatric cornea reaches adult thickness at between two and four years of age10. there is increasing data that central corneal thickness (cct) has a clinically major effect on iop measurements in patients with pediatric glaucoma. nonetheless, the question of exactly how much to adjust the measured value remains controversial. therefore, our study cannot rule out the possibility that the iop was overestimated in some eyes. table 3: strabismus in psuedophakic and aphakic groups psueduphakic group (145 eyes) n (%) aphakic group (136 eyes) n (%) esotropia/exotro pia of more than 8 prism diopter 21 (14) 62 (46) psueduphakic group (145) = group a (43) + group c (102) aphakic group (136) = group b (48) + group d (88) 33 0 10 20 30 40 50 60 cataract surgery with iol cataract surgery without iol keratitis hyphema fibrinous reaction fig. 1: early complications of peadiatric cataract surgery n = 281 0 20 40 60 80 cataract surgery with iop cataract surgery without iol retinal detachment apkakic / psdudo phakic glaucoma posterior capsular opacification fig. 2: late complications of peadiatric cataract surgery in our study vitreous hemorrhage and retinal detachment were very rarely noted. one study by chen and associates reported a very low prevalence of 0.5%11. in our study, vitreous hemorrhages cleared significantly in each case within three weeks, we recommend conservative management in children for the first postoperative weeks. in our study, all children underwent posterior capsulorhexis and anterior vitrectomy. we observed secondary cataract formation in 90 eyes (34 %). one study by hosal and biglan, have shown an association of posterior capsulorhexis and anterior vitrectomy with a decreased risk of pco in children12. nonetheless, there is still no consensus about the management of the posterior capsule during cataract removal in children10. according to our results, we would recommend performing primary posterior capsulorhexis with anterior vitrectomy in young children without primary iol implantation. besides, we determined young age at the time of surgery to be a strong risk factor for the development of pco. this is also consistent with a study by hosal and biglan, who concluded the younger the child at cataract surgery, the greater the risk of secondary membrane formation12. although several authors,12 suggest that the presence of an iol increases the risk of secondary membrane formation, there is increasing evidence that a well-placed iol for example optic capture, can reduce the incidence of secondary cataract in children13,14. but, this is still a matter of controversy, and there are little data on children younger than 1 year of age. the surgical treatment of peadiatric cataract is constantly changing. it may be hypothesized that improved surgical techniques has contributed to a lower incidence of postoperative complications. further research will be required to investigate the ideal timing in peadiatric cataract surgery. conclusion correction of aphakia after peadiatric cataract surgery with primary iol implantation results in improved visual acuity compared to spectacle correction and less occurrence of strabismus, but a higher rate of complications requiring reoperation. further studies with a larger pediatric patient group are necessary to confirm the optimal treatment of aphakia after peadiatric cataract extraction. author’s affiliation dr. mazhar-ui-hasan isra postgraduate institute of ophthalmology alibrahim eye hospital karachi dr. umair a. qidwai isra postgraduate institute of ophthalmology alibrahim eye hospital karachi dr. aziz-ur-rehman isra postgraduate institute of ophthalmology alibrahim eye hospital karachi 34 dr. nasir bhatti isra postgraduate institute of ophthalmology alibrahim eye hospital karachi dr. rashid h. alvi isra postgraduate institute of ophthalmology alibrahim eye hospital karachi reference 1. wilson me, pandey sk, thakur j. paediatric cataract blindness in the developing world: surgical technique and intraocular lenses in new millennium. br j opthalmol. 2003; 87: 14-9. 2. lambort sp. management of monocular congenital cataract. eye. 1999; 13: 474-79. 3. angra, mohan sk. management of rubella cataract. ind j ophthalmol 1982; 302: 13-16. 4. lundvall a, kugelberg u. outcome after treatment of congenital bilateral cataract. acta ophthalmol scand. 2002; 80: 593–7. 5. robb rm, petersen ra. outcome of treatment for bilateral congenital cataracts. ophthalmic surg. 1992; 23: 650-6. 6. keech rv, tongue ac, scott we. complications after surgery for congenital and infantile cataracts. am j ophthalmol. 1989; 108: 136-41. 7. lundvall a, zetterström c. complications after early surgery for congenital cataracts. acta ophthalmol scand. 1999; 77: 677– 80. 8. chen tc, bhatia ls, halpern ef, et al. risk factors for the development of aphakic glaucoma after congenital cataract surgery. trans am ophthalmol soc. 2006; 104: 241–51. 9. rabiah pk. frequency and predictors of glaucoma after pediatric cataract surgery. am j ophthalmol. 2004; 137: 30-7. 10. ehlers n, sorensen t, bramsen t, et al. central corneal thickness in newborns and children. acta ophthalmol. (copenh) 1976; 54: 285–90. 11. chen tc, bhatia ls, walton ds. complications of pediatric lensectomy in 193 eyes. ophthalmic surg lasers imaging. 2005; 36: 6–13. 12. hosal bm, biglan aw. risk factors for secondary membrane formation after removal of pediatric cataract. j cataract refract surg. 2002; 28: 302–9. 13. koch dd, kohnen t. retrospective comparison of techniques to prevent secondary cataract formation after posterior chamber intraocular lens implantation in infants and children. j cataract refract surg. 1997; 23: 657–63. 14. kohnen t, lüchtenberg m. surgical treatment of congenital cataracts. ophthalmologe. 2007; 104: 566–71. microsoft word index-9.doc management corner pitfalls in intraocuar pressure measurement by goldmann-type applanation tonometers amjad akram, amir yaqub, asad jamal dar, fiaz pak j ophthalmol 2009, vol. 25 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …………………………… correspondence to: amjad akram consultant eye surgeon cmh, multan cantt received for publication may’ 2008 …………………….……… n recent years, applanation tonometry using the goldmann instrument has become the gold standard in the assessment of intraocular pressure. unfortunately, it is often not recognized that there are numerous sources of error that may significantly influence accuracy of goldmann-type applanation tonometers. it is very important that the clinician should be able to keep in mind these potential pitfalls while checking intraocular pressure. accuracy of goldmann-type applanation tonometers various experimental studies have shown that goldmann tonometers give accurate results when patient’s central corneal thickness is 0.52 mm1, thicker cornea lead to an over estimate of iop and thinner cornea to an under estimation of iop. ehler`s et al have calculated that a true iop of 20mmhg , a central corneal thickness(cct) of 0.45mm would lead to an error of -5.2mmhg and that a cct of 0.59 mm would lead to an error of +4.7mmhg. ehlers has estimated that iop is affected by ± 5mmhg for every 0.07mm change in cct above or below normal. the imbert fick law, the basis of goldmann tonometry the imbert fick law is considered to be the basis for applanation tonometry. it states that when a flat surface is pressed against a spherical surface of a container with a given pressure, an equilibrium will be attained when the force exerted against the spherical surface is balanced by the internal pressure of the sphere exerted over the area of contact between the sphere and the flat surface. it is assumed that the sphere applanated by the flat surface is thin, perfectly elastic, and perfectly flexible and that the only force acting against it is the pressure of the applanating surface. it is further assumed that the applanated area and subsequently displaced volume is small in relation to the total area and the volume of sphere. none of the presumptions of imbert fick law is true when applied to applanation tonometry, since the cornea offers resistance to indentation varying with its curvature and thickness and the presence or absence of corneal epithelial or stromal edema. tonometer tips do not contact the cornea alone, but also come in contact with precorneal tear film. the precorneal tear film produces capillary attraction, or repulsion, between it and object in contact with its meniscus. the volume displaced by any applanation tonometer will produce rise in iop varying in degree with ocular rigidity. the dimensions of the goldmann tonometer head were not determined on the basis of imbert fick law, but on the basis of empirical i experimentation by goldmann2. goldmann found that in the eye preparations he studied. an applanating area of 3mm diameter gave the best results; because with this area the corneal indentation was balanced by the capillary attraction of the precorneal tear film for the tonometer tip. an applanating area of precisely 3.06mm diameter was chosen because at that diameter, a force of 0.1 gram corresponded to an iop of 1mmhg. area of tonometer –tear film contact if there is adequate fluorescein in the precorneal tear film but there are excessive tears, then the fluorescent rings will be broader than normal. this will cause overestimation o f the iop by about 2 to 4.5 mmhg3. performing tonometry without fluorescein if tonometry is performed without fluorescein then an under estimation of iop by up to 5.5mmhg may be encountered4. if there is inadequate concentration of fluorescein in the tear film the iop may be significantly underestimated by 1.5 to 9.5mmhg5. there is evidence that application of fluorescein from paper strips doesn’t produce an adequate concentration of fluorescein in precorneal tear film6. corneal astigmatism when regular astigmatism is present, an elliptical contact with tonometer head occurs. this results in an under estimation of iop in with-the-rule astigmatism and an over estimation with against-the-rule astigmatism, with an error range of about -2.5 to +2.5 mmhg. two options exist to counteract this source of error: 1. align tonometer head at 43 degree to axis of astigmatism ( in negative cylinder). 2. average iop readings at 0 and 90 degrees. a. in regular astigmatism, the iop reading may be grossly inaccurate7. effect of corneal curvature steeper corneas need to be indented more to produce the standard area of contact, necessitating more force and therefore indicating a higher iop reading. it has been suggested that over the range of corneal curvature of 40 to 49 diopters, the error in iop reading is about 3mmhg8. effect of corneal oedema kaufman9 reported that goldmann applanation tonometry underestimates the iop in eyes with moderate corneal edema with errors in the range of 10 to 30 mmhg. this underestimation was attributed to the observation that the epithelium of edematous corneas is easier to indent than normal epithelium. effect of corneal thickness as already pointed out, thin corneas tend to produce underestimation and thick corneas produce overestimation of iop. clinical implication of this fact in patients with thin corneas may be wrongly diagnosed as normal tension glaucoma and thick corneas wrongly as ocular hypertensives; emphasizing importance of checking central corneal thickness on a routine basis in glaucoma clinics. scleral rigidity under physiological condition, scleral rigidity doesn’t have significant effect on iop when using applanation tonometer10. blepharospasm forceful lid closure may lead to a dramatic rise in iop and this may lead to gross errors in diagnosis and management of glaucoma. experiments by coleman and trokel11 revealed that closure of lids produce an iop increase of about 5mmhg and blepharospasm increased the iop to 80mmhg. arterial perfusion pressure marked reduction in iop can occur when arterial pressure perfusing the eye decreases. during periods of asystole or transient cardiac arrythmias, iop can decrease by 20%. ipsilateral carotid compression can reduce the iop by 10 to 20 mmhg12. this decline is due to loss of choroidal perfusion. central venous pressure restrictive clothing around the neck can increase iop. hence tight collars and ties should be loosened before positioning of the patient at the slit lamp12. eye position eye position can affect iop transiently. this transient rise is thought to be due to rectus muscle tone. the magnitude of effect of globe position on iop can be exaggerated in patients with restrictive orbital disease, for example thyroid eye disease. applanation of paracentral cornea (off axis) applanation of paracentral cornea occurs when the applanation tip contacts the non-central cornea. numerous studies have shown that a large change is not produced by having the tonometer tip contact the eccentric cornea. effect of repeated applanation attempts when iop is repeatedly measured in an eye over a short span of time, there is a reduction of iop and this can vary between -2 to -5 mmhg13. interobserver variability interobserver variability is an important source of error when the same patient is assessed by multiple individuals. calibration of tonometers this is a frequent but forgotten source of error in iop assessment with the goldmann type applanation tonometers .its therefore recommended that tonometer calibration should be checked at least once a year and preferably twice a year, following the techniques indicated in each tonometer`s operator’s manual. tips to avoid pitfalls 1. regularly check calibration of your tonometer. 2. if error is suspected, recheck iop with different machine. 3. use appropriate mixture of local anaesthetic and fluorescein. 4. ensure good illumination 5. eye should be in primary position and ensure correct patient position at the slit lamp. 6. compensate for corneal astigmatism if astigmatism greater than three diopters. 7. consider checking central corneal thickness. 8. do not consider iop in isolation author’s affiliation lt col amjad akram consultant eye surgeon cmh, multan cantt col amir yaqub consultant eye surgeon cmh, multan cantt brig asad jamal dar consultant eye surgeon cmh, rawalpindi brig fiaz classified eye specialist cmh, lahore cantt reference 1. ehlers n, brausen t, sperling s. applanation tonometry and central corneal thickness. acta ophthalmol (copenh). 1975; 53: 34-43. 2. goldmann h. applanation tonometry, in newel fw. glaucoma. transactions of the second conference. josiah macy, jr. foundation. 1957; 167-220. 3. goldmann h, schmidt t. uber applanationstonometrie. ophthalmologica. 1961; 141: 441-6. 4. hoffer kj. applanation tonometry without fluorescein. correspondence. am j ophthalmol. 1979; 88: 798. 5. moses ra. fluorescein in applanation tonometry. am j ophthalmol. 1960; 49: 1149-55. 6. grant wm. fluorescein for applanation tonometry. more convenient and uniform application. am j ophthalmol. 1963; 55: 1252-3. 7. kaufman he, wind ca, waltman sr. validity of mackaymarg electronis applanation tonometer in patients with scarred irregular corneas. am j ophthalmol. 1970; 69: 1003-7. 8. mark hh. corneal curvature in applanation tonometry. am j ophthalmol. 1973; 76: 223-4. 9. kaufman he. pressure measurement: which tonometer? invest ophthalmol. 1972; 11: 80-5. 10. schmidt taf. the clinical application of the goldmann applanation tonometer. am j ophthalmol. 1960; 49: 967-78. 11. coleman dj, trokel. direct-recorded intraocular pressure variations in a human subject. arch ophthalmol. 1969; 82: 63740. 12. bain wes, maurics dm. physiological variations in the intraocular pressure. trans ophthalmol soc uk. 1959; 79: 24960. 13. stocker fw. on changes in the intraocular pressure after application of the tonometer in the same eye and in the other eye. am j ophthalmol. 1958; 45: 192-6. pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 63 original article agreement between swept source oct based and scheimpflug / placido based biometry devices aamir asrar, bisma ikram, hina khan, maha asrar pak j ophthalmol 2017, vol. 33, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hina khan consultant ophthalmologist, head of ophthalmic diagnostic department, amanat eye hospital, islamabad, pakistan email: drhina@amanathospital.com purpose: to assess the agreement between a swept source oct based iol master 700 biometer and a dual scheimpflug ray tracing analyser, galilei g6. to measure various parameters of biometry in cataractous eyes. study design: prospective cross sectional. place and duration of study: amanat eye hospital, islamabad from april 2016 to june 2016. material and methods: the 206 eyes of 110 patients scheduled for cataract extraction (consecutive sampling) were subjected to scanning by both devices by a single trained operator. measurements recorded by each machine included keratometry (k), axial length (al), astigmatism, anterior chamber depth (acd), central corneal thickness (cct), lens thickness (lt), white to white (wtw) and intraocular lens (iol) power. the statistical package for social sciences software (spss version 22) and microsoft excel 2010 were applied to organize and tabulate the data collected. paired t test was applied with 95% confidence interval to determine the association between parameters calculated with iol master 700 and galilei 6. results: the mean age was 62.74 years (±12.78) sd. in the sample of 206, frequency of iol master 700 failure was 3 (1.46%) and frequency of galilei 6 failure was 59 (28.6%). high correlation was seen in cct (r = 0.976), wtw (r = 0.731) and lt (r = 0.958) measurements. however, there was statistically mailto:drhina@amanathospital.com aamir asrar, et al 64 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology …..……………………….. significant disagreement in keratometry (kavg.; p < 0.001) measurements and acd measurements and clinically significant difference in the mean al measurements which eventually impacted the iol power estimated by both devices. conclusion: significant disagreement between these two devices was noted and hence they cannot be used interchangeably keywords: biometry; swept source oct based iol master 700; galilei g6; intraocular lens; target refraction. ataract extraction in recent times has achieved unparalleled sophistication in surgical technique as well as iol design. this advancement necessitates accurate measurement of biometric parameters of the eye in order to correctly determine the iol power required for optimal visual results. modern optical biometry devices use either partial coherence interferometry (pci) or optical low coherence reflectometry (olcr) to measure parameters such as axial length, lens thickness and anterior chamber depth1. additionally incorporated techniques can also enable keratometry2. the iol master 500 (carl zeiss meditec) is considered the gold standard for modern biometry devices3-6. recently, the manufactures of iol master 500 have introduced the first-of-its-kind swept source oct based biometric device, the iol master 7007. several studies conducted in different settings, compared different biometric devices to seek the agreement between them8-10. in this study, the iol master 700 was compared with the galilei g6 (zeimer switzerland) to seek agreement between these two devices that work on very different principles to measure the same parameters i.e. k readings, axial length, lens thickness, acd and cct. most importantly the iol power estimate for achieving emmetropia provided by both devices was compared. measurement failure rates for these devices were also recorded. materials and methods all the patients referred to the diagnostics department, amanat eye hospital islamabad (equipped with both technologies) for biometry from april 2016 to june 2016 were included in this study. this prospective cross sectional study followed the tenets of declaration of helsinki. ethical review board of hospital approved the protocols of this study. all the participants were informed about the nature and purpose of the study. consecutive sampling technique was used to recruit the participants. a prior checkup was done, to ensure a good eye health, by an ophthalmologist. patients with previous refractive or intraocular surgery, any ocular diseases that may hinder vision or have a bearing on post operative refraction such as keratoconus, glaucoma, posterior staphyloma, corneal pathologies, optic atrophy, retinopathy, and silicon oil filled eye were excluded. parameters of 206 eyes of 110 patients were taken for sample. measurements parameter were included central corneal thickness (cct), white-to-white (wtw), flat keratometric value (k1), steep keratometric value (k2), mean keratometry c agreement between swept source oct based and scheimpflug / placido based biometry devices pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 65 (kavg.), anterior chamber depth (acd), lens thickness (lt), axial length (al) and iol power. to avoid any bias biometry were performed by single trained ophthalmic technologist. both machines were calibrated prior according to the manufacturer‟s instructions. srk-t formula was used to calculate the final iol power with both iol master 700 and galilei6. the reason of choosing srk-t was surgeon comfort level with this formula and also its benefits in shorter and longer eyes in predicting a target refraction ±1.0d11. iol master 700 measures 2.5 mm central corneal zone while the galilei g6 measures 3.0 mm central corneal zone. failure rate with both devices was recorded and cataract type was graded into nuclear (n), cortical (c) and posterior subcapsular (psc) cataract. the statistical package for social sciences software (spss version 22) and microsoft excel 2010 were applied to organize and tabulate the data collected. paired t test was applied with 95% confidence interval to determine the association between parameters calculated with iol master 700 and galilei g6. results there were 206 eyes of 110 patients; the mean age was 62.74 years (±12.78) sd; male participants were 49 (44.54%) and female participants were 61 (55.45%). in the sample of 206, frequency of iol master 700 failure was 3 (1.46%) and frequency of galilei g6 failure was 59 (28.6%). the iol master 700 and galilei 6 provided comparable mean cct measurements and difference was found to be insignificant (p = 0.854). the mean difference of wtw was found to be significant (p = 0.001). similarly, mean difference in keratometry measurements was found to be highly significant along different meridian (p < 0.001, n = 206). the mean difference between acd measurements was significantly high (p = 0.001, n = 198) (table 1) (figure 1). the mean difference between lens thickness was 0.033 mm which is insignificant (p = 0.079). similarly, mean difference between axial lengths was 0.39 ±2.941mm, this difference was not statistically significant (p = 0.11). moderate correlation existed between iol master 700 and galilei 6 (r = 0.39) in measuring axial lengths. the iol power measured with iol master 700 was 0.437 ± 1.436d greater on average than measured with galilei 6. this difference is highly significant with p < 0.001, n = 144 (table 1) (figure 1). the predictability of the iol power calculation with the iol master 700, and galilei 6 was similar (using the srk/t formula and the a-constant recommended by the manufacturers) in 26 eyes only, which makes it 18.05% of total sample size. the difference of 0.50 d was found in 71 eyes (49.31%); 1.00d was present in 25 eyes (17.36%); 1.5 d difference was found in 21 eyes (14.58%); and 2.50 d difference was observed in 1 eye (0.69%) (table 2). aamir asrar, et al 66 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology table 1: mean differences and sd of all parameters from both optical biometers, correlation and p value obtained from paired t test. parameter n iol master 700 mean ±sd galilei 6 mean ±sd correlation mean ± sd difference (iol master 700 –galilei 6) paired t test, p value (α = 0.05, 95% ci) central corneal thickness (cct) (µm) 206 553.72 ± 34.9 553.84 ± 29.0 r = 0.976 -0.118 ± 9.119 -0.185, p=0.854 white-to-white (wtw) (mm) 206 11.96 ± 0.46 12.03 ± 0.46 r = 0.731 -0.077 ± 0.337 -3.23, p=0.001 flat keratometric value (k1) (d) 206 43.23 ± 1.847 43.49 ± 1.82 r = 0.974 -0.253 ± 0.422 -8.483, p<0.001 steep keratometric value (k2) (d) 206 44.12 ± 1.91 44.38 ± 1.92 r = 0.969 -0.263 ± 0.48 -7.767, p<0.001 average keratometry (kavg.) (d) 206 43.67± 1.85 43.93 ± 1.85 r = 0.978 -0.259 ± 0.387 -9.518, p<0.001 anterior chamber depth (acd) (mm) 198 3.26 ± 0.451 3.32 ± 0.479 r = 0.876 -0.057 ± .234 -3.412, p=0.001 lens thickness (lt) (mm) 153 4.32 ± 0.766 4.28 ± 0.808 r = 0.958 0.033 ± 0.232 1.77, p=0.079 axial length (al) (mm) 147 24.33 ± 3.16 23.94 ± 1.621 r = 0.390 0.39 ± 2.941 1.609, p=0.110 iol power (d) 144 20.31 ± 2.758 19.87 ± 3.207 r = 0.895 0.437 ± 1.436 3.656, p<0.001 table 2: difference in iol powers, frequencies and percentages. difference in iol power (iol master 700 – galilei6) n = 144 percentage (%) 0 d (no difference) 26 18.05 +0.50 d 71 49.31 +1.0 d 25 17.36 +1.5 d 21 14.58 +2.5 d 1 0.69 failure rate of iol master 700 was 1.46% and galilei g6 was 28.6%. the highest failure rate was observed in grade 4 posterior sub capsular cataract with both biometric devices and then failure was observed in nuclear cataract (table 3). table 3: failure rate and type of cataract: number and percentages. biometry device cortical (c) n (%) nuclear (n) n (%) posterior subcapsular (psc) n (%) iol master 700 0 (0.00) 1 (33.3) 2 (6.67) galilei g6 9 (15.25) 21 (35.59) 29 (49.15) discussion the advancement in cataract extraction techniques has been so tremendous in recent years that it is no longer considered a surgical procedure meant solely for removal of lens opacification but rather a method of acquiring near perfect visual result catering in agreement between swept source oct based and scheimpflug / placido based biometry devices pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 67 addition for any refractive abnormalities that existed preoperatively. fig. 1: mean difference across all eyes in cct, wtw, k1, k2, kavg, acd, lt, al, iol power between iol master 700 and galilei-6. units are in mm excepts for cct, where units are in µm, and keratometric reading, where units are in diopters (d). to obtain this desired near perfect result, different iol designs have been introduced in the market catering for spherical and other aberrations, corneal astigmatism and accommodation. but such advancement in iol design must parallel an equal precision in estimating the required iol power to achieve emmetropia. additionally, it is now necessary to fill in the possible „misses‟ in pre-operative evaluation to lessen or extinguish the chance of any post-operative refractive surprise12. all biometric instruments are evaluated for repeatability before they become available for clinical practice. however, it is also necessary to compare one instrument with the others and establish agreement among them with the understanding that for any two devices to be used interchangeably, the degree of disagreement between them has to be clinically insignificant. in this study the iol master 700 is compared with the galilei g6 for agreement between their biometric estimates and the difference in the estimated iol power proposed by each to achieve emmetropia in the same eye. foremost, it was noted that the galilei 6 had considerably high failure rate (28.6%) in comparison to the iol master 700 (1.46%). this problem was encountered especially in the setting of dense cataract and posterior sub capsular cataracts (psc). other studies have reported similar failure rates for the g61315. since in psc the opacities are located nearer to the nodal point of the lens, pci or oclr based devises have faced considerable problems in measurements. the iol master 700 bypasses this problem by taking a longitudinal scan of the entire visual axis instead resulting in much higher acquisition for al even in the presence of dense cataracts and psc. this failure of acquiring scans by the galilei was independent of the k readings or the axial length of the eyes studied. k readings and the al measurements have the highest impact in iol power calculations. most iol power calculation formulas use al as well as keratometry measurements. some also require other parameters such as acd and white to white claiming more accurate calculations. the iol master employs a distance independent telecentric keratometer device and has, in this study, estimated a mean k reading (for both flattest and steepest k) which is 0.25 d (approximately) lower than the placido based g6. similar statistically significant disagreement has been reported by other studies as well16,17. the al estimates in our study were compared only for those eyes in which the g6 was able to give a result (i.e. 147 eyes out of 206). it was noted that the mean al was underestimated by the g6 by approximately 0.39 mm. this difference though not statistically significant (p value > 0.05) has important clinical bearing as even 0.6 mm off set in al can impact the iol power calculation by 0.5d which is significant in term of post operative visual result. the impact of this disagreement is reflected in the final iol power estimates for emmetropia using the srk formula where the same iol power was estimated by both devices in only 18% of eyes. the majority of iol estimates were offset by at least 0.5 diopters. the central corneal thickness (cct), lt and wtw estimates by both machines correlated well with each other with mean difference that is neither statistically nor clinically significant. the ability to measure cct is one main advantage of both these devices (not available on iol master 500). the mean difference in acd measurements acquired by the two devices showed statistically significant disagreement. this difference may be due to the different measuring technique and has also been reported by similar studies18-21. with the added fixation monitor of the iol master, measurement is aamir asrar, et al 68 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology taken only after ensuring that the visual axis is properly aligned (a feature that is exclusive to the iol master 700). with other devices based on slit lamp illumination such as the iol master 500 and g6, the slit source is projected temporally22. this off center measurement of acd may be a source of error23. it was observed during the course of this study that in addition to having minimum failure rate, the iol master 700 gave a unique advantage of directly visualizing the entire length of the visual axis making apparent such features as decentered, subluxated lenses and lens tilt that are possible causes of postoperative refractive surprises. also, by visualizing the foveal pit, it is possible to ensure correct alignment of the visual axis before measurements are taken that leads to unprecedented accuracy in results. in addition, gross abnormalities in the foveal image detected during biometry were noted and such patients were then subjected to a wider oct scan of the macular area where “missed” macular abnormalities were recorded. counseling the patient at this stage in pre-operative assessment proved easier and more fruitful as these patients had more realistic expectations of post-operative vision and were also more receptive to proposed retinal treatments. it remains to be seen which of the iol power predictions are more accurate in term of post operative refraction. this study is limited by the practical implementation of the results obtained by these biometric devices. indeed, this is a direction for future studies in which post-operative refraction is observed for iols suggested by these machines. conclusion this study establishes that there is a significant disagreement in biometric measurements obtained by the iol master 700 and the galilei g6. it is suggested in light of these that results of these two devices not be used interchangeably. conflict of interests: none. author’s affiliation dr. aamir asrar mbbs, frcs, fellowship in vitreo-retinal surgery, fellowship in corneorefractive surgery, chief consultant ophthalmologist, amanat eye hospital, islamabad, pakistan bisma ikram bsc (hons) optometrist and orthoptist, msph, research consultant, department of research and development, 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system with the iol master 500 optical biometry. paper presented at escrs meeting, 5–9 september 2015; barcelona, spain. 8. kummelil mk, das s, thakkar m, shetty r, shetty bk, haria d, kaweri l, deshpande k. repeatability and agreement of four biometers for measuring various anterior segment parameters. j vis sci. 2015; 1 (2): 9-14. 9. srivannaboon s, chirapapaisan c, chonpimai p, loket s. clinical comparison of a new swept-source optical coherence tomography–based optical biometer and a time-domain optical coherence tomography– based optical biometer. j cataract refract surg. 2015; 41: 2224–2232. 10. goebels s, pattmöller m, eppig t, cayless a2, seitz b, langenbucher a. comparison of 3 biometry devices in cataract patients.j cataract refract surg. 2015 nov; 41 (11): 2387-93. 11. karabela y, eliacik m, kaya f. performance of the srk/t formula using a-scan ultrasound biometry after phacoemulsification in eyes with short and long axial lengths. bmc ophthalmol. 2016; 16: 96. 12. tehrani m, krummenauer f, blom e, dick hb. evaluation of the practicality of optical biometry and applanation ultrasound in 253 eyes. j cataract refract surg. 2003; 29: 741–6. 13. freeman g, pesudovs k. the impact of cataract severity on measurement acquisition with the iol master. acta ophthalmol scand. 2005; 83: 439–42. 14. chylack lt, wolfe jk, singer dm, leske mc, bullimore ma, bailey il, friend j, mccarthy d, wu sy. the lens opacities classification system iii. the longitudinal study of cataract study group. arch ophthalmol. 1993; 111: 831–6. 15. jasvinder s, khang tf, sarinder kk, loo vp, subrayan v. agreement analysis of lenstar with other techniques of biometry. eye (lond). 2011; 25: 717– 24. 16. chen ya, hirnschall n, findl o. evaluation of 2 new optical biometry devices and comparison with the current gold standard biometer. j cataract refract surg. 2011; 37: 513–7. 17. kaswin g, rousseau a, mgarrech m, barreau e, labetoulle m. biometry and intraocular lens power calculation results with a new optical biometry device: comparison with the gold standard. j cataract refract surg. 2014; 40: 593–600. 18. hill w, angeles r, otani t. evaluation of a new iol master algorithm to measure axial length. j cataract refract surg. 2008; 34: 920–4. 19. kriechbaum k, findl o, kiss b, sacu s, petternel v, drexler w. comparison of anterior chamber depth measurement methods in phakic and pseudophakic eyes. j cataract refract surg. 2003; 29: 89–94. 20. elbaz u, barkana y, gerber y, avni i, zadok d. comparison of different techniques of anterior chamber depth and keratometric measurements. am j ophthalmol. 2007; 143: 48–53. 21. uçakhan öö, akbel v, biyikli z, kanpolat a. comparison of corneal curvature and anterior chamber depth measurements using the manual keratometer, lenstar ls 900 and the pentacam. middle east afr j ophthalmol. 2013; 20: 201–6. 22. huang j, liao n, savini g, bao f, yu y, lu w, hu q, wang q. comparison of anterior segment measurements with scheimpflug/placido photographybased topography system and iol master partial coherence interferometry in patients with cataracts. j ophthalmol. 2014: 540–760. 23. reddy ar, pande mv, finn p, el-gogary h. comparative estimation of anterior chamber depth by ultrasonography, orbscan ii, and iol master. j cataract refract surg. 2004; 30: 1268–71. microsoft word farah akhtar 118 original article the effect of trabeculectomy on corneal curvature farah akhtar pak j ophthalmol 2008, vol. 24 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: farah akhtar al-shifa trust eye hospital rawalpindi received for publication october 2008 … ……………………… purpose: to determine and evaluate pattern of changes in corneal curvature produced by trabeculectomy. material and methods: 50 consecutive eyes that had trabeculectomy operations were enrolled. the visual acuity, subjective refraction and keratometry readings were recorded pre-operatively and post operatively at one week and one month. all postoperative keratometry readings were compared with the preoperative values by paired t-test. all changes in subjective refraction were analyzed by vector analysis. results: after trabeculectomy only 29 patients (34 eyes) turned up for regular and timely follow up. vertical steepening was found in 19 eyes (p=.000 and p=0.009). vertical flattening was found in 15 eyes (p=.013 and p=0.022). horizontal steepening was found in 12 eyes (p=0.005 and p=0.13) and horizontal flattening was found in 22 eyes (p=.010 and p= 0.013). power vector analysis showed surgically induced change in subjective refraction with a mean of -1.14d (sd ± 1.53, p=0.000), cylinder with a mean of 1.80(sd ±1.41, p=0.000) and axis with a mean of 84.42 (sd ± 47.63, p=0.000). patients with visual acuity < 6/18 (11 eyes) did not complain of change in vision post operatively, while patients with visual acuity >6/18 complained of decreased vision post operatively. conclusion: the trabeculectomy procedure results in significant change of corneal curvature in both meridians. this effects post operative visual acuity which in turn may adversely effect the compliance of patients towards surgical treatment. 119 laucoma is the greatest mystery of ophthalmology. it is defined as “multifactorrial optic neuropathy with characteristic acquired loss of optic nerve fibers1 leading to specific patterns of visual field loss. it may or may not be associated with increased intraocular pressure. glaucoma is among the leading causes of blindness in the developing world2. glaucoma mainly managed surgically by performing trabeculectomy because of our socioeconomic conditions. it is guarded filtration technique developed in 1960s3,4. for the same reason trabeculectomy is being performed at early stages of disease when vision is fairly good 5. evaluating the out come of surgery in terms of visual rehabilitation present particular difficulties and even after successful trabeculectomy patients often complain of reduction in vision. we all know vision is regarded as the most precious of our senses and its loss is catastrophic. visual process is also most complex to study because it involves several different braches of science. the eye is an optical instrument i.e. photo sensor with brain as data processor. in eye, refraction mainly occurs at the level of cornea and lens and any change in curvature will affect vision. corneal astigmatism following cataract extraction is now well recognized 6. the purpose of this study was to evaluate whether trabeculectomy produces changes in corneal curvature or not. material and methods fifty eyes of forty patients without previous history of trauma or intraocular surgery who underwent a standardized fornix-based trabeculectomy were evaluated .there was no gender specification and age ranged from 40-80 years. there was no corneal abnormality preoperatively on examination. all patients had no post-operative shallow anterior chamber, macular oedema, retinal hemorrhages and changes in choroidal thickness associated with acute hypotony. procedures 1. pre-operative assessment included recording visual acuity (snellen’s chart), k-reading of central cornea (canon rk-5 auto refractor) and refraction. 2. cairns-type trabeculectomy was performed in all cases. fornix-based conjunctival flap was lifted and a partial tenonectomy performed. a 5×3mm partial thickness rectangular scleral flap was dissected and a 4 ×2 mm trabeculectomy done. a peripheral iridectomy was performed, and scleral flap was secured, then conjunctiva was closed. 3. postoperative assessment included recording visual acuity (snellen’s chart), k-reading of central cornea(canon rk-autorefractor) and refraction at 1week and 1month. 4. the result of kreading compared by t-test 7. 5. vector analysis for change in refraction done 8. results patients with very good post-operative intraocular pressure often complain of reduction in vision. patients with pre-operative visual acuity < 6/18 (11eyes) did not complain of change in vision postoperative, while patients with visual acuity > 6/18 did complain of decreased vision post-operatively. trabeculectomy affects corneal curvature in a complex manner. when results were compared by applying tests of significance i.e. 2-tailed and 1-tailed revealed that the results are highly significant except one .only 29 patients turned up for follow up timely and regularly. vertical steepening was as found in 19 eyes, (p=.000 p=.018 by 2 tailed test and p= .000, p=.009 by 1 tailed test). vertical flattening was found in 15 eyes, (p=.027, p=.045 by 2 tailed test and p=.013, p=.022 by 1 tailed test). horizontal steepening was found in 12 eyes, (p=.011, p=.27 by 2 tailed test and p=.005, p=.13 by 1 tailed test). horizontal flattening was found in 22 eyes, (p=.021, p=.026 by 2 tailed test and p=.010, p=.013 by 1 tailed test) (table 1). power vector analysis revealed significant change in refraction, specially astigmatic component (sphere1.14 ± 1.15) cylinder (1.80 ± 1.42) and axis (84.4 ± 47.6) and test of significance revealed that p= .000 by both 2 and 1 tailed test. vector analysis was done in 24 eyes as in 10 eyes refraction was not possible because of lenticular changes (table 2). table 1: vertical and horizontal steeping and flattening g 120 vertical horizontal steepening no. of eyes 22 flattening no. of eyes 15 steepening no. of eyes 22 flattening no. of eyes 15 2 tailed 1 tailed 2 tailed 1 tailed 2 tailed 1 tailed 2 tailed 1 tailed pair 1 d0-d1 0.000 0.000 0.027 0.013 0.011 0.005 0.021 0.010 d0-d2 0.018 0.009 0.045 0.022 0.27 0.13 0.026 0.013 • d0 = dioptric value pre-op • d1 = dioptric value one week post-op • d2= dioptric value one month post-op table 2: power vector analysis no mean standard deviation 2 tailed sphere 24 -1.14 (± 1.15) 0.000 cylinder 24 1.80 (± 1.42) 0.000 axis 24 84.42 (± 47.63) 0.000 discussion clinical study revealed that trabeculectomy produces significant changes in corneal curvature .wound gape following cataract extraction has been shown to produce an change in corneal curvature .since trabeculectomy also produces a form of wound gape9 ,a similar change would be expected post-operative. but changes in corneal curvature after trabeculectomy do not appear to behave as in the same manner as they do after cataract extraction, rather changes are very complex. an explanation for this difference in behavior may be the result of the partial thickness scleral flap created during trabeculectomy. moreover in trabeculectomy the surgically produced gape which is posteriorly placed and is overlaid by scleral flap which is capable of spreading any support from the sutures inserted into it over the whole of the wound gape. the overlying conjunctiva also gives support. this cannot be the entire explanation however, as in this study, the scleral flap sutures in trabeculectomy are not usually inserted under undue tension. the cause of induced astigmatism may be related to the use of cautry during surgery, producing a contraction of the sclera 10. the changes in corneal curvature affected the central cornea and achieved statistical significance level 11. these changes are adequate enough to have a significant affect on visual function in patients specially with good pre-operative visual acuity. astigmatism induces distortion of image. the retinal image in an uncorrected eye is distorted causing differential magnification in the two principal meridians. although oblique astigmatism produces only 0.4 degree of tilt per diopter mono-ocularly, it will produce major alterations in bin-ocular perception 12. corneal curvature changes has been reported by rosen et al(1992)13, claridge et al (1995)14, dietz et al(1997) 15 , mehmooda et al (2006) 16 etc. conclusion irregular corneal astigmatism after trabeculectomy is a annoying problem for both patient and surgeon. the impact of the procedure on the visual prognosis of glaucoma patients must therefore be carefully evaluated. long term studies are required to investigate modifications in surgery to minimize the curvature changes as these changes affect post-operative visual acuity which in turn may adversely affect the compliance of patients. small flap trabeculectomy (micro trabeculectomy) is recommended by s.a vernon 17 as it produces smaller changes in corneal curvature that resolve sooner than previous reports of larger flap technique. full counseling of the patient should be done and informed consent be made. patient should be warned of changes preoperatively as many will have normal vision prior to surgery and may be distressed by the significant changes that occur. this effects post operative visual acuity which in turn may adversely 121 effect the compliance of patients towards surgical treatment. author’s affiliation farah akhtar al-shifa trust eye hospital rawalpindi refrences 1. american academy of ophthalmology: primary open angle glaucoma; preferred practice, san francisco, 1996,the academy. 2. quigly ha: number of people with glaucoma world wide. br j oophthalmol. 1996; 80: 389. 3. sugar hs. experimental trabeculectomy in glaucoma. am j ophthalmol. 1961; 51: 623-7. 4. cairns je. trabeculectomy preliminary report of a new method. am j ophthalmol. 1968; 66: 637-8. 5. fraser s. trabeculectomy and anti-metabolites. br j ophthalmol. 2004; 88: 855-6. 6. wishert ms, wishert pk, gregor zj. corneal astigmatism following cataract extraction .br j ophthalmol. 1968; 70: 825-30. 7. “theory: why does this work , one-tailed vs. two-tailed” http://www.georgetown.edu/departments/psychology/resea rchmethods/statistics/inferential.htm. 8. thibos ln, wheeler w, horner d. a vector method for the analysis of astigmatic refractive errors. vision science and its applications, (optical society of america, washington, dc), 2, 14-7. 9. cunliffe ia, dapling rb, west j, et al. a prospective study examining the changes in factors that effect visual acuity following trabeculectomy. eye 1992; 6: 618-22. 10. cady s, ritch r. consultation section. j cataract refract surg. 2004; 30: 25. 11. hugkulstone ce. changes in kerotometery following trabeculectomy. br j ophthalmol. 1991; 75: 217-8. 12. morlet n, minassian d, dart j. astigmatism and the analysis of its surgical correction. br j ophthalmol. 2001; 85: 1127-38. 13. rosen wj, mannis mj, brandt jd. the effect of trabeculectomy on corneal topography. ophthalmol surg. 1992; 23: 395-8. 14. claridge kg, galbraith jk, bates at. the effect of trabeculectomy on refraction, keratometery and corneal topography. eye 1995; 9: 292-8. 15. dietz pj, oram o, kohnan t, et al. visual function following trabeculectomy effect on corneal topography and contrast sensitivity. j glaucoma. 1997; 6: 99-103. 16. ashi m, ahmed a,ahsan m, et al. jk-practitioner. 2006; 13: 17. vernon sa, zambarakji hj, potgieter f, et al. topographic and keratometric astigmatism up to 1 year following small flap trabeculectomy (micro trabeculectomy). br j ophthalmol. 1999; 83: 779-82. answer: apocrine hidrocystoma apocrine hidrocystoma is a very common solitary smooth cyst arising from the glands of moll along the eye lid margin. it is considered a true adenoma of the secretory cells of moll rather than retention cyst. these lesions typically are translucent or bluish and transilluminate. they may be multiple and often extend deep beneath the surface, especially in the canthal regions. treatment for superficial cysts is marsupialization. deep cysts require complete excision of the cyst wall. these cysts are also known as cystadenomas or sudoriferous cysts. basic and clinical science course, american academy of ophthalmology. 2004; 7: 167-8. microsoft word news and events 110 news and events vol. 26, 2, 2010 world ophthalmology congress 2010 xxxii international congress of ophthalmology 108th german society of ophthalmology date: 5-9 june 2010 venue: berlin, germany web. www.woc2010.org european society of cataract and refractive surgeons meeting (escrs) date: 4-8 september 2010 venue: paris, france 25th asia pacific academy of ophthalmology (apao) 15th national congress of the chinese ophthalmological society (cos) date: 16-19 september 2010 venue: beijing, china joint meeting: american academy of ophthalmology and middle east africa council of ophthalmology (meaco) date: 16-19 october 2010 venue: mc cormick place, chicago, usa web. www.aao.org/meeting lahore ophthalmo date: 24-26 december 2010 venue: pearl continental hotel lahore, pakistan secretary: dr. zahid kamal siddiqui secretariat: osp house 4-a lda flats, lawrence road, lahore. phone: 92-42-6363325 fax: 92-42-6363326 email: osplahore@hotmail.com american society of cataract and refractive surgery (ascrs) date: 27-31 january 2011 venue: mc cormick place, chicago, usa institute / courses pakistan institute of community ophthalmology, peshawar pakistan contact: professor shad mahmood rector pico, hayat abad medical complex peshawar college of ophthalmology and allied vision sciences (coavs) contact: prof. asad aslam khan principal/director general coavs, kemu / mayo hospital, lahore phone: 042-7355998 fax: 042-7248006 email: pipo@brain.net.pk pakistan institute of ophthalmology, al-shifa trust eye hospital, rawalpindi pakistan contact: secretary, pio, al-shifa trust eye hospital, jhelum road, rawalpindi pakistan phone: 92-51-5487830, 5487820-25 fax: 92-51-548827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt department of ophthalmology fatima jinnah medical college sir ganga ram hospital, lahore fax: 92-42-6363326 email: hamidbut@gmail.com mobile: 0300 – 4158962 sad demise of prof. raja mumtaz quli khan patron of osp lahore branch and ex head of the department of ophthalmology mayo hospital lahore passed away at lahore on friday 7th may 2010. • namaz-e-janaza was attended by thousand of his students, colleagues and fans at mansoora lahore on 7th may 2010 after juma prayer. • qull ceremony was held at the mosque near his home at education town, lahore on saturday, 8th may 2010. 111 • quran khawani at osp house was held by osp lahore branch on 9th may 2010. • joint condolence reference by osp lahore branch and king edward medical university was held at patiala block kemu, 12th may 2010. • quran khawani (chehlum) at mosque near his home education town, was held on 6th june 2010. osp lahore branch intends to publish a book to pay tributes to prof. raja mumtaz quli khan. those who wish to contribute please mail before 31st august’ 2010 to osp house. 4 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology original article intraocular lens power calculation in silicone oil filled eye: iol master versus a-mode acoustic biometry haroon tayyab, muhammad ali haider, tehmina jahangir pak j ophthalmol 2017, vol. 33 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: haroon tayyab assistant professor of ophthalmology sharif medical & dental college email: haroontayyab79@googlemail.com …..……………………….. purpose: to compare accuracy of intraocular lens (iol) master and a-mode acoustic biometry in patients undergoing phacoemulsification with intraocular lens implant and removal of silicone oil. study design: prospective non randomized case series. place and duration of study: al-ehsan eye hospital lahore / jinnah hospital, lahore. material and methods: this study was conducted on 30 patients with cataract and history of silicone oil in that eye as a consequence of previous vitreo-retinal surgery. pre and post operative axial length (axl) measurements were made using iol master and conventional a-mode acoustic biometry. accuracy and reliability of these techniques were compared by comparing post operative axial lengths and refractive errors. results: mean axl measured with iol master preoperatively was 23.62+/-0.36 mm. readings noted by iol master one month after so removal showed a mean of 23.58+/-0.29 mm. there was no statistically significant difference (pvalue 0.463). the pre and post operative axl measured by conventional acoustic a-scan showed statistically significant difference (p-value 0.004). preoperative axl was 23.34+/-0.58 mm and post operative axl was 23.97+/0.71 mm. post operative refractive error in iol master group was 0.70+/-0.32 diopter sphere (ds) whereas that of acoustic a scan group was 1.55+/-0.98 ds. this difference was statistically significant (p-value 0.038) at eight weeks interval. conclusion: iol master is superior and more accurate for calculating axl and post operative refractive error in so filled eyes when compared to a-mode acoustic biometry. keywords: iol master, silicone oil, axial length, phacoemulsification. ataract formation is one of the most frequent sequel after an uneventful pars plana vitrectomy (ppv) with/without silicone oil (so) endotamponade1. cataract after ppv is formed due high oxygen tension in vitreous cavity during surgery and exposure of crystalline lens to oxygen stress precipitates nuclear sclerosis2. if so is used as an endotamponade after ppv in a patient with crystalline lens, then it leads to interruption of normal metabolic environment of lens. also direct contact of so with lens may be responsible in accelerated cataract formation3,4. although may surgeons have reverted to the use of gas as a preferred endo-tamponade agent, so still holds a pivotal position when it comes to scenarios like proliferative vitreoretinopathy (pvr), giant retinal tears, trauma, and severe proliferative diabetic retinopathy, chronic uveitis with hypotony, retinal detachment due to a macular hole in highly c intraocular lens power calculation in silicone oil filled eye: iol master versus a-mode acoustic biometry pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 5 myopic eye, colobomatous retinal detachment etc5-7. due to advancements in microsurgical techniques for ppv and phacoemulsification, most surgeons are inclined to remove the cataract / implant intraocular lens (iol) at the time of silicon oil removal in one procedure. for that, we need an accurate iol power calculation in an eye filled with so. as far as conventional acoustic biometry is concerned, the speed of sound travelling in so is significantly slower than in vitreous cavity of phakic eyes; thus rendering a falsely longer axial length (axl) of so filled eyes if no correction factor is used8. even with the use of correction factors that may be built in the biometer, high levels of accuracy and repeatability are seldom achieved. newer biometers utilizing the principle of partial coherence interferometry (pci) (reflected interference signal from retinal pigment epithelium) are being used as standard tools for axl measurement in normal eyes with cataracts. these optical biometers are nearly 10 times more accurate and reliable than conventional methods9. recent evidence has suggested that pci principal is also more reliable and accurate for axl measurement so filled eyes as well10,11. we conducted this study to evaluate and compare the reliability and accuracy pci based biometers when compared to conventional acoustic biometers. material and methods this prospective non randomized clinical study was conducted at a private ophthalmic facility between july 2015 to january 2016. all patient included in this study were well informed about the nature and purpose of this study and informed consent was taken. hospital ethical committee approved this study. a total of 30 patients who had undergone ppv with so (rs-oil silicone oil 1000 cs; al.chi.mi.a srl., italy) injection for rhegmatogenous retinal detachment (rrd) were included in this study. patients with recurrent rrd and other factors that may influence the accurate calculation of axl were not included in this study. at the time of surgery, standard acrylic foldable intraocular lens was implanted in all patients. all patients had preoperative axl measurements by pci method using iol master (version 5; carl ziess meditec ltd, germany) and by conventional ascan ultrasound in so filled eye mode (quantel medical compact; quantel medical sa, france). the iol power was calculated using standard protocols and applying srk-t formula. no corneal or scleral sutures were applied at the end of the surgery. repeat axl length was measured using the above mentioned 2 techniques at one month after surgery. refraction was done using standard auto-refractor at 3 months after surgery. one patient had recurrent rrd after removal of so and was excluded from the study at 2nd month follow-up. accuracy of the axl reading between two techniques was evaluated by comparison of pre and post operative axl difference and comparison of the same between 2 machines. results were analyzed statistically using chisquare set and pearson’s correlation by software package spss 20.0 (spss inc., il, usa). results were declared statistically significant if p-value < 0.05. results out of 30 patients, one patient was excluded from final data analysis due to recurrent rrd. of 29 patients, 13 were female and 16 were male. mean age of the patients was 43.4 years with sd =/9.3 years. results are shown in table 1. table 1: axl results of two machines machine preop axl in mm 1 mth post so removal axl p value postop refractive error ds iol master 23.62+/0.36 23.58+/0.29 0.463 0.70+/0.32 acoustic a scan 23.34+/0.58 23.97+/0.71 0.004 1.55+/0.98 the mean axl measured with iol master preoperatively was 23.62+/-0.36 mm (range 19.72 26.83 mm). readings noted by iol master one month after so removal showed a mean of 23.58+/-0.29 mm (range 19.90 – 26.12 mm). there was no statistically significant difference (p-value 0.463). the pre and post operative axl measured by conventional acoustic a-scan showed a statistically significant difference (p-value 0.004). preoperative axl was 23.34+/-0.58 mm and post operative axl was 23.97+/-0.71 mm. when compared to post operative axl measured by acoustic a-scan, the pre operative axl measured haroon tayyab, et al 6 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology by iol master was again significantly different (pvalue < 0.003). post operative refractive error in iol master group was 0.70+/-0.32 ds where that of acoustic a scan group was 1.55+/-0.98 ds. the difference between these groups was statistically significant (pvalue 0.038). discussion our study showed that the there is a statistically significant difference in the pre and post operative axl measured by iol master and conventional acoustic a scan. also the post operative refraction was more accurate when iol master was used to calculate axl. although, not many studies have been conducted on this topic, yet almost all the research work done on this topic shows that iol power measurement done with iol master is superior to conventional acoustic method especially in cases where eyes were filled with so. one such observation was made by kunavisarut and colleagues.12 he showed that iol master has superior reliability and repeatability over immersion method of acoustic biometry when calculating axl and post operative refractive error in eyes planned for phacoemulsification + iol implant + removal of silicon oil in one procedure. his results showed preoperative mean axl of 23.91 ± 0.24 mm and 23.71 ± 0.59 mm by iol master and immersion a-scan, respectively, which demonstrated a statistically significant difference (p = 0.002). also, the post operative refractive error calculation was shown to be more accurate with iol master. in subgroup analysis, he showed that a preoperative axl outside ± 1 sd of the postoperative axl was associated with an aphakic lens status (p = 0.001 and axl > 25 mm (p = 0.042) in the immersion group. however, there were no such associations were noted in the iol master group. since, we did not include any aphakic preoperative patients in our study, we cannot compare our results in this subgroup analysis. another study showed that the preoperative axl measured with iol master was 0-1.2 mm longer (median 0.3 mm) than that measure after so removal postoperatively. our study also showed such a trend that mean preoperative axl measured with iol master was 0.04 +/ -0.29 mm than post operative measurements but our difference was statistically insignificant (p-value 0.463). they also concluded that preoperative axial lengths measured by a-scan at 980 m/s tended to be 0-1.5 mm (the median of 0.52 mm) shorter than those obtained after silicone oil removal. our study also showed a similar trend13. similar trends have also been documented in literature by other researchers that axl values obtained with the iol master after adjustment are more accurate than a-mode ultrasonography in silicone-filled eyes14. another interesting study affirming the superiority of iol master over a-mode utrasongraphy showed that conventional acoustic method of axl measurement in so filled eye yielded less accurate results in terms of post operative refraction when compared to iol master. but when the author employed same a-mode utrasongraphy intraoperatively after removal of so and before phacoemulsificatio, then the results were statistically not different when using iol master15. they concluded that when comparing predictability of intraoperative a-scan biometry and iol master biometry, the two techniques showed small predictive postoperative refractive errors without a statistically significant difference in the predictive errors of the two techniques. such an approach is also advocated by other studies to improvise in such situations where iol master is not readily available12,16. researchers have also proposed other methods of axl calculations in eyes with so. these methods include axl measurement in contralateral eye (with no history of anisometropia), intraoperative retinoscopy, magnetic resonance imaging (mri) and preoperative axl measurement in same eye with macula on retinal detachment17-22. but with the fairly widespread availability of pci bases technology, these above mentioned techniques have been superseded; although the surgeons should be aware of the other options available in case pci based machines are not available. another possibility is a two step operation where so is removed in stage one and then iol is implanted in stage 2 where a-mode acoustic biometry can give very predictable results in the absence is so. the short fall is that patient has to undergo 2 separate procedures with their known risks in mind and visual recovery is considerably delayed. our study was conducted under controlled conditions with all the a-mode biometrics performed by a single experienced user; although the chance of deviation still remained and could have influenced the final results. another shortcoming of this study was that we did not include eyes with very short and very long axial lengths where we could have documented the results of iol master in externe axl conditions. the strong point of this study was that same group of patients were tested twice for axl by two different intraocular lens power calculation in silicone oil filled eye: iol master versus a-mode acoustic biometry pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 7 methods which further authenticated the superiority of iol master over conventional a-mode biometry. conclusion we safely conclude that iol master is a safer, superior and more accurate method when calculating axl and predicting post operative refractive error in eye under going combined procedure of phacoemulsification with iol implant and removal of silicone oil. author’s affiliation dr. haroon tayyab mbbs, fcps (eye), fcps (vro), fico-fellowship vr surgery – japan. assistant professor of ophthalmology sharif medical & dental college. dr. muhammad ali haider mbbs, fcps (eye), fcps (vro), fellowship medical retaina – uk. assistant professor of ophthalmology – rahbar medical college. dr. tehmina jahangir mbbs, fcps (eye), fellowship vr surgery kemu senior registrar jinnah hospital lahore. role of authors dr. haroon tayyab stydy design, patient selection and study write-up. dr. muhmmad ali haider literature research. dr. tehmina jahangir statistical analysis. references 1. milazzo s. pathogenesis of cataract after vitrectomy. j fr ophtalmol. 2014 mar; 37 (3): 243-4. 2. holekamp nm, shui yb, beebe dc. vitrectomy surgery increases oxygen exposure to the lens: a possible mechanism for nuclear cataract formation. am j ophthalmol. 2005 feb; 139 (2): 302-10. 3. leaver pk, grey rh, garner a. silicone oil injection in the treatment of massive pre-retinal retraction. ii. late complications in 93 eyes. br j ophthalmol. 1979 may; 63 (5): 361-7. 4. deuchler s, singh p, müller m, kohnen t, ackermann h, iwanczuk j, et al. dealings between cataract and retinal reattachment surgery in pvr. j ophthalmol. 2016; 2016: 2384312. 5. nadal j, verdaguer p, canut mi. treatment of retinal detachment secondary to macular hole in high myopia: vitrectomy with dissection of the inner limiting membrane to the edge of the staphyloma and long-term tamponade. retina. 2012 sep; 32 (8): 1525-30. 6. ortisi e, avitabile t, bonfiglio v. surgical management of retinal detachment because of macular hole in highly myopic eyes. retina. 2012 oct; 32 (9): 1704-18. 7. wei y, li y, chen f. vitrectomy treatment of retinal detachments related to choroidal coloboma involving the disk. retina. 2014 jun; 34 (6): 1091-5. 8. hoffer kj. ultrasound velocities for axial eye length measurement. j cataract refract surg. 1994 sep; 20 (5): 554-62. 9. rajan ms, keilhorn i, bell ja. partial coherence laser interferometry vs. conventional ultrasound biometry in intraocular lens power calculations. eye (lond). 2002 sep; 16 (5): 552-6. 10. tehrani m, krummenauer f, blom e, dick hb. evaluation of the practicality of optical biometry and applanation ultrasound in 253 eyes. j cataract refract surg. 2003 apr; 29 (4): 741-6. 11. roessler gf, huth jk, dietlein ts, dinslage s, plange n, walter p, mazinani ba. accuracy and reproducibility of axial length measurement in eyes with silicone oil endo tamponade. br j ophthalmol. 2009 nov; 93 (11): 1492-4. 12. kunavisarut p, poopattanakul p, intarated c, pathanapitoon k. accuracy and reliability of iol master and a-scan immersion biometry in silicone oilfilled eyes. eye (lond). 2012 oct; 26 (10): 1344-8. 13. kas'yanov aa, sdobnikova sv, troitskaya na, ryzhkova eg. intraocular lens power calculation in silicone-filled eyes. vestn oftalmol. 2015 sep-oct; 131 (5): 26-31. 14. wang k, yuan mk, jiang yr, bao yz, li xx. axial length measurements before and after removal of silicone oil: a new method to correct the axial length of silicone-filled eyes for optical biometry. ophthalmic physiol opt. 2009 jul; 29 (4): 449-57. 15. el-baha sm, hemeida ts. comparison of refractive outcome using intraoperative biometry and partial coherence interferometry in silicone oil-filled eyes. retina. 2009 jan; 29 (1): 64-8. 16. el-baha sm, el-samadoni a, idris hf, rashad km. intraoperative biometry for intraocular lens (iol) power calculation at silicone oil removal. eur j ophthalmol. 2003 aug-sep; 13 (7): 622-6. 17. nepp j, krepler k, jandrasits k, hauff w, hanselmayer g, velikay-parel m, et al. biometry and refractive outcome of eyes filled with silicone oil by standardized echography and partial coherence interferometry. graefes arch clin exp ophthalmol. 2005 oct; 243 (10): 967-72. 18. frau e, lautier-frau m, labétoulle m, hutchinson s, offret h. phacoemulsification combined with silicone 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https://www.ncbi.nlm.nih.gov/pubmed/?term=lab%2525c3%2525a9toulle%252520m%25255bauthor%25255d&cauthor=true&cauthor_uid=10660316 https://www.ncbi.nlm.nih.gov/pubmed/?term=hutchinson%252520s%25255bauthor%25255d&cauthor=true&cauthor_uid=10660316 https://www.ncbi.nlm.nih.gov/pubmed/?term=offret%252520h%25255bauthor%25255d&cauthor=true&cauthor_uid=10660316 haroon tayyab, et al 8 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology oil removal through posterior capsulorhexis. br j ophthalmol. 1999 dec; 83 (12): 1406-7. 19. patwardhan sd, azad r, sharma y, chanana b, tyagi j. intraoperative retinoscopy for intraocular lens power estimation in cases of combined phacoemulsification and silicone oil removal. j cataract refract surg. 2009 jul; 35 (7): 1190-2. 20. bencic g, vatavuk z, marotti m, loncar vl, petric i, andrijevic-derk b, et al. comparison of a-scan and mri for the measurement of axial length in silicone oilfilled eyes. br j ophthalmol. 2009 apr; 93 (4): 502-5. 21. moin m, ali qk, aftab sa. intraocular lens calculation using the zeiss iol master (partial coherence laser interferometry). pak j of opthal 2005; 21(3):88-90. 22. grinbaum a, treister g, moisseiev j. predicted and actual refraction after intraocular lens implantation in eyes with silicone oil. j cataract refract surg. 1996 julaug; 22 (6): 726-9. https://www.ncbi.nlm.nih.gov/pubmed/?term=patwardhan%252520sd%25255bauthor%25255d&cauthor=true&cauthor_uid=19545806 https://www.ncbi.nlm.nih.gov/pubmed/?term=azad%252520r%25255bauthor%25255d&cauthor=true&cauthor_uid=19545806 https://www.ncbi.nlm.nih.gov/pubmed/?term=sharma%252520y%25255bauthor%25255d&cauthor=true&cauthor_uid=19545806 https://www.ncbi.nlm.nih.gov/pubmed/?term=chanana%252520b%25255bauthor%25255d&cauthor=true&cauthor_uid=19545806 https://www.ncbi.nlm.nih.gov/pubmed/?term=tyagi%252520j%25255bauthor%25255d&cauthor=true&cauthor_uid=19545806 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https://www.ncbi.nlm.nih.gov/pubmed/?term=treister%252520g%25255bauthor%25255d&cauthor=true&cauthor_uid=8844386 https://www.ncbi.nlm.nih.gov/pubmed/?term=moisseiev%252520j%25255bauthor%25255d&cauthor=true&cauthor_uid=8844386 microsoft word rao rashid q 140 original article role of orbital septum and sub orbicularis fibroadipose tissue in congenital ptosis surgery rao muhammad rashad qamar, qasim mansoor, mazhar-uz-zaman somro, imran atta-ulah pak j ophthalmol 2008, vol. 24 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: rao muhammad rashad qamar 29-b, medical colony bahawalpur received for publication january’ 2007 … ……………………… purpose. to analyze the role of orbital septum and suborbicularis fibroadipose tissue in making and defining upper lid skin crease in children who underwent ptosis surgery. material and methods. a retrospective study of 26 eyes of 22 children (age range 04 to 14 years) undergoing surgery over two year period was undertaken with regard to cosmetic outcome. a surgical technique by anterior approach employing orbital septum sutures during surgery in children is described. all surgery was performed by same ophthalmic surgeon under general anesthesia. a standard levator resection was undertaken, following which orbital septum and suborbicularis fibro adipose tissue was redefined and sutured with 6/0 vicryl. result. all patients achieved a well-defined lid crease postoperatively, with a good cosmetic outcome. the significant postoperative complications were stitch granuloma in two patients and mild residual ptosis occurred in five cases, requiring further procedure. conclusion: special attention to the suturing of orbital septum and suborbicularis fibro adipose tissue as a separate tissue layer during levator resection in congenital ptosis gives good lid crease definition which may enhance the overall cosmetic outcome. 141 t is an important consideration in congenital ptosis surgery to achieve bilaterally symmetrical upper lid skin crease in both height and shape. particular attention has to be paid to unilateral ptosis, as a failure to do so may give poor cosmetic outcome. the orbital septum along with fibrous septa in sub orbicularis oculi fibroadipose tissue plays an important role in defining the upper lid skin crease. an inadequately defined and misplaced skin crease typically gives rise to an asymmetrical appearance. a series of patients undergoing surgery for congenital ptosis is described. the orbital septum and submuscular fibroadipose tissue were sutured to define the lid crease. material and methods 22 children undergoing levator resection over a two year period were assessed with regard to postoperative cosmetic appearance. four cases were bilateral. the average age at the time of surgery was 4 years (range 6 months to 14 years). ten patients were male and 12 were female. average follow up was 2 years (range: 3 months to 4 years). all surgery was same performed by one consultant ophthalmic surgeon under general anesthesia. legends: 1. levator exposed, resected and sutured. 2. orbital septum sutured. 3apre operative ptosis 3bpostoperative good lid crease with acceptable ptosis correction the surgical technique comprised of separation of all layers and identification of suborbicularis fibroadipose tissue and orbital septum. the orbital septum was identified by grasping the tissue in question and pulling it inferiorly while palpating inner border of i 142 supraorbital rim. when the levator muscle exposed a rough measurement was taken by caliper keeping in mind the amount of levator resection needs to correct the given ptosis following standard levator resection, the orbital septum along with submuscular fibroadipose tissue was sutured with interrupted 6/0 vicryl and in few cases chromic catgut 6/0 was used for suturing of orbital septum. the overlying orbicularis was also repaired, and the skin was closed with interrupted 6/0 vicryl. a 4/0 silk tension suture was placed through margin of lower tarsus, taped to the forehead and removed after 24 hours. results in all patients a well-defined lid crease symmetrical in height and shape was obtained. the significant postoperative complications were suture related granuloma in two patients that did not influence the final outcome. good lid height and shape of skin crease was obtained in 17 patients, however residual ptosis occurred in 5 cases and required further surgical procedure at a later date. reoperation was uncomplicated and final outcome was successful. discussion embryologically, most of the connective tissue of upper lid is derived from mesenchyme1-4. the orbital septum is derived from mesenchyme of second arch1. anatomy of orbital septum is described differently both by anatomists and surgeons but generally it is accepted that orbital septum originates from arcus marginalis of frontal bone and inserts into levator aponeurosis inferiorly near the upper margin of tarsal plate and follows levator aponeurosis forward to skin24. suborbicularis fibroadipose tissue consists of multiple fibrous septa that merge posteriorly with the orbital septum and give orbital septum a multilayered quality2. simple congenital ptosis is thought to be the result of developmental dystrophy of levator muscle. normal muscle fibers are replaced by fibrous connective tissue without contractile properties. ptosis is more marked in an up gaze and the upper lid is relatively retracted in a down gaze5-6. in ptosis surgery, a good cosmetic outcome is very important, this holds true for congenital myogenic ptosis as well. ptosis surgery with adjustable suture is popular in adults but least tolerated in children, it is therefore important to consider an approach that gives good ptosis correction with cosmetically acceptable upper lid skin crease7. the ideal procedures in ptosis surgery are those that least disturb normal anatomy but also allow for good results3. in this study an anterior approach was selected, thus avoiding conjunctiva, lacrimal gland and tarsus3,5,8. in all cases, following levator resection, the cut edges of orbital septum were reapposed and sutured6,9. this technique appears to enhance the overall cosmetic outcome. alternative methods for defining the lid crease in congenital ptosis have been described, in particular closure of skin incision with deep bites to underlying levator aponeurosis3, 7. fibroadipose tissue appears to enhance the function of orbital septum by augmenting the contour of superior sulcus when eyelids are open. it is very important to locate anatomically where orbital septum fuses with levator aponeurosis2,4,10. it was observed that orbital septum fused with levator aponeurosis a few millimeters (2-4mm) above the supratarsal border. although slight variation does exist, therefore orbital septum not only contains orbital fat in the orbit but it also plays an important part in keeping cosmetically good upper lid crease. conclusion although many procedures have been described in the surgical management of congenital ptosis, little emphasis has been placed on maintaining the integrity of orbital septum. this study indicates that the placement of orbital septum sutures directly following levator resection may aid the formation of a well defined and positioned skin crease, thus enhancing the cosmetic outcome. author’s affiliation dr. rao muhammad rashad qamar assistant professor quaid-e-azam medical college bahawalpur dr. qasim mansoor eye surgeon uk dr. mazhar-uz-zaman somro eye surgeon khan pur, distt. rahim yar khan dr. imran atta-ulah eye surgeon haroon abad 143 reference 1. bremond-gignac ds, deplus s, cussenot o. anatomic study of orbital septum. surg radiol anat. 1994; 16: 121-4. 2. meyer dr, lindberg jv, wobig jl. anatomy of orbital septum and associated eyelid connective tissues. implications for ptosis surgery. ophthal plast reconstr surg. 1991; 7: 104-13. 3. jones lt. the anatomy of the upper eyelid and its relationship to ptosis surgery. am j ophthalmol. 1964; 57: 943-59. 4. wolff e: anatomy of eye and orbit. philadelphia, blackiston company. 1954: 153-209. 5. mustarde j, callahan a, jones l: ophthalmic plastic surgery up-to-date. birmingham, aesculapius publishing, 1970, 6-12. 6. mcelvanney am, adhikary hp: congenital ptosis, a good cosmetic result with redefinition and suturing of the orbital septum eye. 1996;10: 548-50. 7. collin jro, o’donnell ba. adjustable sutures in eyelid surgery for ptosis and lid retraction. br j ophthalmol. 1994; 78: 167-74. 8. berke rn, hackensack nj, wadsworth jac. histology of levator muscle in congenital and acquired ptosis. arch ophthalmol. 1955; 53: 413-28. 9. baylis hi, cies wa. identifying the orbital septum. arch ophthalmol. 1976; 94: 805. 10. anderson rc, beard c. the levator aponeurosis: attachments and their clinical significance. arch ophthalmol. 1977; 95: 143749. microsoft word tahir mahmood 16 original article prevalence of anti hepatitis c virus (hcv) antibodies in cataract surgery patients tahir mahmood, maimoona iqbal pak j ophthalmol 2008, vol. 24 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tahir mahmood department of ophthalmology sheikh zayed hospital lahore. received for publication january’ 2006 …..……………………….. purpose: to find out the prevalence of anti hcv antibodies in patients undergoing cataract surgery. material and method: all patients who were advised and scheduled for cataract surgery and were unknown for any liver disease were included in this study. each subject was serologically screened for anti hcv antibodies and only included in the study with the evidence of positive or negative report. results: out of 468 patients who reported for cataract surgery 52 (11.1%) turned out to be positive for hcv virus antibodies. in less than 60 years of age females were more whereas in above 60 years of age males and female were equally positive for anti hcv antibodies. prevalence of diabetes mellitus in hcv positive patients was 19.2%. conclusion: the percentage of patients who turned out positive for anti hcv antibodies, who were previously unknown for any liver disease, was significantly higher as compared to the prevalence of carrier state for hcv in general population. ataract is a preventable cause of blindness and cataract surgery is the most commonly performed procedure throughout the world to restore the vision. majority of the cataract surgeries are performed for senile cataract and patients are usually above the age of 50 years. in our population when patients report for poor vision due to cataract they also suffer from other medical problems like diabetes, hypertension etc which are more prevalent in our set up. screening for diabetes and hypertension is essential requirement for cataract surgery patients. in the last few years incidence of hepatitis has increased tremendously in our society. hepatitis may be caused by viruses, bacteria, drugs or excessive use of alcohol. the most important cause of hepatitis is virus, of which hepatitis b and c viruses are the most common which produce acute or chronic hepatitis. most common symptoms of hepatitis are jaundice, hepatic tenderness, hepatomegaly and in some patients spleenomegaly and lymphadenopathy1. hcv is a small rna virus. the average incubation period is 7-8 weeks with a range of 2-26 weeks. the infection leads to chronic carrier state in 60% of affected individuals2. presence of anti hcv antibodies in blood indicate that the person is infected with hcv and may transmit the virus to others. these carriers are the major threat for the spread of disease. the most common risk factors for the transmission of hcv are per cutaneous exposure to blood, major surgeries, dental treatments, intravenous drug abuse, tattooing, use of contaminated syringes, ear piercing, blood transfusion etc. apart from the carrier for hcv and threat for spread to other, hcv infection for the carrier is also serious, such as 20% of the infected patients develop c 17 cirrhosis and 10% of cirrhotic patients may develop hepatocellular carcinoma3. in surgical setup where unknown carriers of hcv are undergoing various procedures in which there is exposure of per cutaneous blood in the form of intravenous lines, application of local anesthesia, incision etc, surgeons, paramedical staff and other patients are at increased risk to get infected. one way of controlling the hcv infection is by screening all the surgical patients undergoing any type of surgical procedure. keeping this in mind we conducted this study to find out the incidence of anti hcv antibody positive patients undergoing cataract surgery that were previously unknown for any liver disease. material and methods this study was conducted in the department of ophthalmology, sheikh zayed hospital, lahore from july 2004 to feb’ 2005. all patients who were advised and scheduled for cataract surgery and were unknown for any liver disease were included in this study. each subject was serologically screened for hcv and only included in the study with the evidence of positive or negative report. in addition to anti hcv antibody status, status of diabetes mellitus and hypertension was also recorded. all patients who were serologically position for hcv were referred to physician for further investigation and management. results a total of 468 patients with serological reports were reported during the study period. of these 468 patients, 52 (11.1%) were serologically positive for anti hcv antibodies. out of 52 positive patients 25 (48.1%) were males and 27 (51.9%) were females. in male patients age range was from 30 to 81 year (mean 60.6 years, sd ± 17.7) and in female patients, age range was from 30 to 90 year (mean 58.3 years, sd ± 10.6) (table 1,2). out of 468, 72(15.4%) were diabetic, 59(12.6%) were hypertensive and 35(7.5%) were both diabetic and hypertensive. in anti hcv antibodies positive patients, out of 52, 10(19.2%) were diabetic [male = 5 (9.6%), female = 5 (9.6%)], 7 (13.5%) were hypertensive [male = 3 (5.8%), female = 4 (7.8%)] and 6 (11.5%) were both diabetic and hypertensive [male=1 (1.9%), female =5 (9.6%)]. total 6 (11.5%) male patients with diabetes were positive for anti hcv antibodies, whereas 10 (19.2%) female patients with diabetes were positive for anti hcv antibodies (table 2). discussion clinical manifestations of hepatitis c may be acute or chronic. acute hepatitis tends to be milder than those seen in patients infected with other hepatitis viruses. the disease is sub clinical and insidious in most cases. the most alarming aspect of hcv infection is its high rate of persistence and its ability to induce chronic liver disease. hcv is found worldwide with western world prevalence of 0.3% to 1.5% or more2. table 1: age and sex distribution age hcv positive total n(%) male n(%) female n(%) <50 4 (7.7 ) 6(11.5 ) 10(19.2 ) 50-59 4( 7.7) 8(15.4 ) 12(23.1 ) 60-69 10(19.2 ) 7( 13.5) 17(32.7) 70-79 6(11.5 ) 3(5.8 ) 9( 17.3) >80 1( 1.9) 3( 5.8) 4(7.7 ) total 25( 48.1) 27( 51.9) 52(100 ) table 2: co-morbidities sex anti hcv antibodies positive number n(%) out of 468 diabetic (dm) n (%)/52 hypertensive(htn) n (%)/52 dm +htn n (%)/52 age range (mean ± sd) male 25(5.3) 5(9.6) 3(5.8) 1(1.9) 30-81 (60.6 ± 17.5) 18 female 27(5.8) 5(9.6) 4(7.7) 5(9.6) 30-90 (58.3± 10.6) total 52(11.1) 10(19.2) 7(13.5) 6(11.3) regional variation exists in the prevalence of hcv infection4-6 from high endemic area (32.4%) to non endemic area (2.3%). in our study the prevalence of anti hcv positive serology was 11.1%. all the patients were not known for any liver disease. local studies report an incidence of 4.6% in general population6 in buner, nwfp, pakistan, 4% in blood donars7 from normal healthy population, 5.3% in pre employment medical examination8 and 7% in surgical patients9. in our study male to female ratio is nearly equal and there is no statistically significant difference. considering age, in less than 60 years of age, females are nearly twice serologically positive than males, whereas in above sixty years of age, males (56.7%) and females (53.3%) are nearly equally positive for anti hcv antibodies. incidence also increases as the age increases in study patients i.e. from 42.3% in less then 60 years of age to 57.7% in more than 60 years of age. high incidence with age is also reported in a study conducted in japan4. in our study 10 (19.2%) patients were diabetics, 7(13.5%) patients were hypertensive and 6(11.5%) have both diabetes and hypertension. in another study conducted by khokhar n, the reported incidence of diabetes in hepatitis patient was 17.3% which is not different from our observation10. in another study conducted by khurrum m et al reported 6% incidence of anti hcv antibodies in health care workers in a local hospital11. though specifically not many local reports about hcv positivity are available in the patients undergoing cataract surgery but incidence of 11.1% in our study is significantly alarming. this may be due to the fact that these patients do not represent a specific population; instead they are coming throughout the city of more than 7 million population and from other cities also. but the significance of these finding lies in special care while handling these patients who are unaware of serious nature and consequences of the carrier state to their families, surgeons, paramedics and community at large. conclusion unknown carriers of hepatitis c virus antibodies are a serious health threat especially to the people concerned with health care practices. it should be made mandatory to screen for anti hcv antibodies in each and every patient undergoing major eye surgery and specific history should be taken from the patient before minor procedures. special care should be taken while handling hcv positive patients in operation theatres and disposal of contaminated products properly. all these unknown carriers should be referred to physicians for further investigations and treatment. author’s affiliation tahir mahmood associate professor department of ophthalmology sheikh zayed hospital lahore maimoona iqbal senior medical officer department of ophthalmology sheikh zayed hospital lahore references 1 harrison pm, lau jyn, williams r. hepatology. postgrad med j., aug. 1991; 67: 719-41. 2 lone ds, aman s, aslam m. prevalence of hepatitis c virus antibody in blood donors of lahore. biomedica 1999; 15: 103-7. 3 khan a. endemic transmission of hepatitis c. j coll physician surg pak. 1995; 5: 12-3. 4 kiyosawa k, tanaka f, sodeyama t et al. transmission of hepatitis c in isolated area in japan: community acquired infection; the south kiso hepatitis study group. gastroenterology 1994; 106: 1596-1602. 5 tanaka h, hiyama t, okube y, et al. primary liver cancer incidence-rates related to hepatitis c virus infection: a correlational study in osaka, japan. cancer causes control. 1994; 5: 61-5. 6 muhammad n, jan a. frequency of hepatitis c in buner, nwfp. j coll physician surg pak. 2005; 15: 11-4. 7 ahmad j, taj as, rahim a, afzal s , rehman m. frequency of hepatitis b and hepatitis c in healthy blood donors of nwfp: a single center experience. j postgrad med inst. sept. 2004; 18: 343-52. 8 khokhar n, gill lm, malik gj. general prevalence of hepatitis c and hepatitis b virus infections in population. j coll physician surg pak. sept. 2004; 14: 534-6. 19 9 fayyaz h, yousaf l, sohail r, et al. screening for hepatitis c in gynecological patients. ann king edward med coll. sept. 2004; 10: 287-8. 10 khokhar n. association of chronic hepatitis c virus infection and diabetes mellitus. pakistan j med res. dec. 2002; 41: 155-8 11 khurrum m, hasan z, butt aua et al. prevalence of anti hcv antibodies among health care workers of rawalpindi and islamabad. rawal med j. jun 2003; 28: 7-11. microsoft word m. saed iqbal 59 original article visual outcome of clear lens extraction (phacorefractive) in myopia above -12.0 dioptres m saeed iqbal, mohammad khan pak j ophthalmol 2008, vol. 24 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad saeed iqbal laser vision centre c-1/5, allama shibli naumani road, bath island, clifton, karachi received for publication january’ 2007 …..……………………….. purpose: a non-comparative study to evaluate the visual outcome of clear lens extraction (phacorefractive) in myopic eyes of 12 dioptres and above using acrylic foldable intraocular lenses (iols). material and methods: the study was conducted in a private setup from jan 2004 to dec. 2006. forty eyes of 20 patients underwent clear lens extraction by phacoemul-sification using single piece acrylic foldable iol. twenty eight eyes were of males (70%) and 12 were of females (30%). their ages ranged between 21 years and 36 years, with mean age of 28.5 years. myopes of -12 d to -20.0 d with one year stability of myopia and contact lens wearing intolerance were included in this study. prophylactic 360 degree retinal argon laser photocoagulation was performed only where it was deemed necessary. all surgeries were performed by the same surgeon and were uneventful. results: preoperative spherical correction was between -12.0 to -20.0 d. postoperative spherical correction was -0.50 to -2.0 d. preoperative best spectacle-corrected visual acuity (bscva) was 6/12 or better in 50% of the eyes which increased to 70% postoperatively. no vision threatening complications were noted. conclusion: results of clear lens extraction with foldable acrylic iol implantation are satisfactory and practically acceptable. lear lens extraction (cle) for the correction of both myopia and hyperopia was first introduced by fukala in 18901. clear lens extraction by phacoemulsification is an acceptable method in refractive surgery2. the main problem with cle is higher chances of retinal detachment (rd) in myopes following surgery3. intact posterior capsule and implantation of iol in the bag lower the incidence of rd4-6. we present the results of a study including 40 myopic eyes of -12.0 dioptres to -20.0 dioptres for the visual outcome following cle and foldable acrylic iol implant. the purpose of the study was to evaluate the visual outcome of clear lens extraction (phacorefractive) in highly myopic eyes using foldable acrylic iols. material and methods c 60 this study was carried out in a private setup from jan 2004 to dec. 2006. during a period of three years (january 2004 to december 2006), 40 eyes of 20 patients were selected to participate in this study. each patient who was included in this study had stable myopia for at least one year and contact lens wearing intolerance. each patient had bilateral myopia ranging between -12.0 and -20.0 diopters with astigmatism no greater than 2.0 d. patients under the age of 21 years were excluded. also excluded were those with corneal diseases, cataract, glaucoma, uveitis or a history of retinal detachment. a detailed history was taken and complete eye examination, including anterior and posterior segment, was performed. special attention was given to the presence of any peripheral retinal lesions. the eyes deemed to be at risk with peripheral retinal degenerations or breaks were treated with 360 degree prophylactic argon laser photocoagulation atleast two weeks prior to surgery. previous refractive prescripttions were examined to confirm the stability. a counseling session was performed with patients and their attendants regarding surgical outcomes and chances of residual myopia. an informed consent was obtained. dioptric power of the posterior chamber iol was calculated by srk-t formula target of surgery was emmetropia. when the emmetropic lens was not available, our choice was to favour a slight residual myopia, as apposed to hyperopia. all surgeries were performed by the same surgeon using retrobulbar and/or topical anesthesia. after scrubbing the eye with 5% povidone iodine, sterile drapes were applied. a small scleral tunnel was created superotemporally 1 mm posterior to the limbus using slit knife 3.2 pointed bevel up. in all cases lens was aspirated with phacoemulsification using vacuum only. thin layers of cortex were removed using simco cannula. single piece acrysof iol (alcon) was implanted into the capsular bag with injector. subconjunctival injection of dexamethasone 0.5 mg and gentamycin 20 mg were given at the end of surgery and eye pad was applied. eye pad was removed next day. antibiotic steroid eye drops were advised. all patients were followed up on first postoperative day then at one week, one month and six months. refractive correction was checked at one month and then six months. results forty eyes of twenty patients were included in this study. all patients were screened according to inclusion and exclusion criteria. all patients were between 21-36 years of age (mean 28.5 years). out of forty eyes, twenty eight belonged to males (70%) while twelve were females (30%) (table i). patients were followed up one day after surgery, then one week, one month and six months postoperatively. follow up ranged between one week to six months (mean 3 months). on first postoperative day, no wound leakage or iris prolapse was noted. striate keratopathy was found in seven eyes (17.5%). this cleared up quickly during the follow up. anterior chamber reaction was present in ten cases (25%). three eyes (7.5%) behaved aggressively with exudative papillary membrane. partial descemet’s detachment adjacent to the incision was seen in six cases (15%). single stitch had to be applied in two cases (5%) due to the ragged margins of the incision. eleven eyes (27.5%) were diagnosed with posterior capsular opacification between ten to sixteen months postoperatively. they were treated with nd: yag laser for posterior capsulotomy (table 2). none showed any deleterious effect of yag capsulotomy. table i: patient’s profile (n=40) patients n (eyes) age in years male n (%) female n (%) 20 (40) 21-36 (mean 28.5) 14 (70) 6 (30) table 2: complications complications eyes n (%) striate keratopathy 7 (17.5) anterior chamber reaction 10 (25) exudative pupillary membrane 3 (7.5) partial descemet’s detachment 6 (15) ragged incision margin 2 (5) posterior capsular opacification 11 (27.5) table 3: pre and postoperative vision bscva preperative n (%) post-operative day 1 six months 61 eyes n (%) eyes n (%) eyes n (%) 6/6 -1(2.5) 1(2.5) 6/9 9 (22.5) 9(22.5) 12(30) 6/12 11 (27.5) 12(30) 15(37.5) 6/18 8(20) 7(17.5) 8(20) 6/24 10(25) 8(20) 3(7.5) 6/36 2(5) 3(7.5) 1(2.5) bscva= best spectacle corrected visual acuity preoperative visual acuity is detailed in tables 3. on first post-operative day, vision was 6/6p in one eye (2.5%) and 6/9p in nine eyes (22.5%). twelve patients gained 6/12 (30%), seven were 6/18 (17.5%), eight eyes (20%) had 6/24 vision while three were (7.5%) 6/36 (table 3). postoperative astigmatism was found in 18 eyes (45%) ranging from 0.75 to 2.5 d. three patients (7.5%) required spherical correction of -0.50 to -2.0d. majority of the patients were given reading additions according to their near requirements. at the end of four weeks postoperatively, final correction of glasses were prescribed. at the end of six months, best spectacle corrected visual acuity (bscva) was recorded (table 3). discussion clear lens extraction has gained acceptance around the world as form of treatment for high myopia. although our numbers were small, the results favour this assertion. there is a clear match with results obtained in other studies7. visual outcomes on long term followup remains stable. role of prophylactic argon laser photocoagulation was controversial1. that’s why only susceptible eyes were treated with argon laser prior to surgery. majority of the eyes improved and reached a final vision equal to or better than the preoperative levels. preoperative vision was 6/12 or better in 50% of the eyes (table 3) which increased to 70% postoperatively (table 4). this was probably because of elimination of aberrations introduced by high spectacle correction by the iol. gris et al8 reported bcva of 6/9 or better to have increased from 64.9% preoperatively to 88.5% postoperatively in their patients. in the study by vega et al9. final best spectacle corrected visual acuity (bscva) was better than preoperative bscva in 83.68%, equal in 12.63% and worse in 3.68% cases. at six months postoperatively, refraction was stable, the mean spherical correction being -1.25d with a range of -0.50 to -2.0 d7,8. guell et al2 also confirm the same results of clear lens extraction. their study mentions the improvement in bscva and mean postoperative spherical equivalent of -1.05d. in our hands, the complication rate was low and no vision threatening complication, like retinal detachment, was seen. clear lens extration through scleral tunnel with iol implantation has been found to be relatively safe in experienced hands10. counseling plays a crucial role in patient’s acceptance to the surgical outcomes especially residual myopia11. in our study, this helped a great deal. conclusion in experienced hands, clear lens extraction using phacoemulsification and implantation of acrylic foldable iol is a relatively safe and effective way to treat high myopia. author’s affiliation dr. muhammad saeed iqbal laser vision centre c-1/5, allama shibli naumani road bath island, clifton, karachi. dr. memon muhammad khan agha khan diagnostic centre garden east, karachi. reference 1. yanoff m, duker js. clear lens extraction. ophthalmology 1998; 1: 3.7.12-3.7.13. 2. guell jl, andres f, rodriguez a, et al. phacoemulsification of the crystalline lens and implantation of an intraocular lens for correction of moderate and high myopia: four year follow-up. j cataract refract surg. 2003; 29: 34-8. 3. goldberg mf. clear lens extraction for axial myopia: an appraisal. ophthalmology. 1987; 94: 571-82. 4. barraquer c, cavelier c, mejia lf. incidence of retinal detachment following clear lens extraction in myopic patients. arch ophthalmol. 1994; 112: 336-9. 5. verzella f. refractive microsurgery of the lens in high myopia. j refractive corneal surg. 1990; 6: 273-5. 6. buratto l. cataract surgery in high myopia. eur j implant ref surg. 1991; 3: 271-8. 62 7. lyle wa, jin gj. phacoemulsification with intraocular lens implantation in high myopia. j cataract refract surg. 1996; 22: 238-42. 8. gris o, guell jl, manero f, muller a. clear lens extraction to correct high myopia. j cataract refract surg. 1996; 22: 686-9. 9. vega lf, alfonso jf, villacampa t. clear lens extraction for the correction of high myopia. american academy of ophthalmology. 2003; 110: 2349-54. 10. helekamp nm, shigam g. case control study of endophthalmitis after cataract surgery comparing scleral tunnel and clear corneal wound. am j ophthalmol. 2003; 136: 2300-5. 11. abbot rl. the rising threat of medical malpractice in refractive surgery. highlights of ophthalmology. 2003; 31: 14. pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 61 editorial corneal collagen crosslinking in the management of keratoconus tommy cy chan, alvin l young pak j ophthalmol 2017, vol. 33 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . eratoconus is a bilateral, non-inflammatory corneal ectasia characterised by progressive corneal thinning and bulging, leading to progressive myopia, irregular astigmatism and corneal scarring1. the associated irregular astigmatism and stromal scarring have a significant negative impact on the quality of life of affected patients. a conservative approach in the management of keratoconus involves spectacles and contact lenses. surgical intervention including implantation of intra-corneal ring segments or corneal transplantation may be necessary when conservative means become intolerable or insufficient for visual needs2. there are still controversies in relation to the diagnosis and management of keratoconus (kcn)3. corneal collagen cross linking (cxl) is a treatment option for progressive keratoconus. it utilizes ultraviolet a irradiation (uva) and riboflavin to induce cross links within corneal stroma aiming to increase the tensile strength and stability of the cornea. the first clinical study was published in 2003 by wollensak et al. reporting a reduction of the maximum keratometry by 2 diopters (d) and of refractive error by 1 d in 70% of keratoconic eyes treated with cxl. it was also noted that progression was halted in all of the treated eyes4. it was not until recently in the usa, the food and drug administration approved the treatment cxl for kcn. however, the precise definition of progression remains controversial. most studies offered cxl to eyes when there is an increase in maximum keratometry (kmax) of 1 diopter or a change in either myopia or astigmatism of 1 d in 1 year5. corneal thickness of less than 400μm, severe corneal scarring or ocular surface disease, prior herpetic infection and pregnancy are contraindications for cxl. the initial clinical studies to utilize cxl in the treatment of progressive kcn employed the dresden protocol of 3 mw/cm2 irradiance for 30 minutes after corneal epithelial removal. it has been studied in detail and shown good results clinically and on corneal topography. wittig-silva et al. reported a change in kmax by -1.03 d over 3 years, whereas hashemi et al. reported a change in kmax by -0.16 d over 5 years6, 7. the key limitation of this conservative procedure was that it took a long time for adequate treatment. to overcome this problem, accelerated cxl using a higher irradiance with a shortened treatment duration had emerged. according to the bunsen-roscoe law of reciprocity, having a constant radiant exposure of 5.4 j/cm2, a higher irradiance dose should theoretically give the same treatment response. comparative studies between conventional and various accelerated cxl protocols revealed controversial results, given the great variability of the protocols proposed8. nevertheless, most studies reported the procedures to be safe to corneal endothelium. to facilitate diffusion of riboflavin into the corneal stroma, epithelium-off cxl, which involves epithelial debridement, is performed. this may lead to perioperative pain, abnormal wound healing and rarely infectious keratitis9. epithelium-on cxl was introduced as an attempt to circumvent the above. various techniques have been employed to enhance the penetration of riboflavin through intact corneal epithelium. these include the use of topical chemical enhancers, mechanical microabrasions over the corneal epithelium and iontophoresis10-12. however, clinical results with most epithelium-on cxl were not as promising as epithelium-off cxl. it has been demonstrated that a higher preoperative kmax was associated with greater corneal flattening after epithelium-on cxl in keratoconus10. k tommy cy chan, et al 62 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology intra-corneal ring segments and photorefractive keratectomy have been combined with cxl aiming to provide rapid visual improvement and stabilisation of kcn progression13,14. more defined patient selection criteria, long-term results and standardisation of treatment protocol are still needed to support these combined treatments. current evidence supports the role of cxl in halting keratoconus progression, albeit the relative lack of well conducted randomised control studies15. various modifications exist aiming to improve the effective and safety profile of these treatments. however, controversies remain regarding to the best timing of cxl, definition of disease progression, repeated cxl treatment, method of riboflavin administration, use of alternative chromophores, and treatment protocols. individualisation of treatment protocol may provide the best strategies for kcn patients. further studies are warranted to explore these fields in the future. authors affiliation dr. tommy cy chan m medsc, frcs department of ophthalmology and visual sciences, the chinese university of hong kong, hong kong hong kong eye hospital, kowloon, hong kong dr. alvin l young m medsc (hons), frcsirel chief of service department of ophthalmology & visual sciences, prince of wales hospital, the chinese university of hong kong; shatin, hong kong references 1. jhanji v, young al. keratoconus citations: battle of the bulge. asia pac j ophthalmol (phila) 2014; 3 (2): 65-66. 2. parker js, van dijk k, melles gr. treatment options for advanced keratoconus: a review. surv ophthalmol. 2015; 60 (5): 459-480. 3. gomes ja, tan d, rapuano cj, belin mw, ambrosio r, jr., guell jl, malecaze f, nishida k, sangwan vs, group of panelists for the global delphi panel of k, ectatic d. global consensus on keratoconus and ectatic diseases. cornea, 2015; 34 (4): 359-369. 4. wollensak g, spoerl e, seiler t. riboflavin/ ultraviolet-a-induced collagen crosslinking for the treatment of keratoconus. am j ophthalmol. 2003; 135 (5): 620-627. 5. chan tc, chow vw, jhanji v, wong vw. different topographic response between mild to moderate and advanced keratoconus after accelerated collagen cross-linking. cornea, 2015; 34 (8): 922-927. 6. wittig-silva c, chan e, islam fm, wu t, whiting m, snibson gr. a randomized, controlled trial of corneal collagen cross-linking in progressive keratoconus: threeyear results. ophthalmology, 2014; 121 (4): 812-821. 7. hashemi h, seyedian ma, miraftab m, fotouhi a, asgari s. corneal collagen cross-linking with riboflavin and ultraviolet a irradiation for keratoconus: long-term results. ophthalmology, 2013; 120 (8): 1515-1520. 8. chow vw, chan tc, yu m, wong vw, jhanji v. oneyear outcomes of conventional and accelerated collagen crosslinking in progressive keratoconus. sci rep. 2015; 514425. 9. abdelghaffar w, hantera m, elsabagh h. corneal collagen cross-linking: promises and problems. br j ophthalmol. 2010; 94 (12): 1559-1560. 10. chen s, chan tc, zhang j, ding p, chan jc, yu mc, li y, jhanji v, wang q. epithelium-on corneal collagen crosslinking for management of advanced keratoconus. j cataract refract surg. 2016; 42 (5): 738-749. 11. rechichi m, daya s, scorcia v, meduri a, scorcia g. epithelial-disruption collagen crosslinking for keratoconus: one-year results. j cataract refract surg. 2013; 39 (8): 1171-1178. 12. buzzonetti l, petrocelli g, valente p, iarossi g, ardia r, petroni s. iontophoretic transepithelial corneal crosslinking to halt keratoconus in pediatric cases: 15-month follow-up. cornea, 2015; 34 (5): 512-515. 13. alessio g, l'abbate m, sborgia c, la tegola mg. photorefractive keratectomy followed by cross-linking versus cross-linking alone for management of progressive keratoconus: two-year follow-up. am j ophthalmol. 2013; 155 (1): 54-65 e51. 14. saelens ie, bartels mc, bleyen i, van rij g. refractive, topographic, and visual outcomes of sameday corneal cross-linking with ferrara intracorneal ring segments in patients with progressive keratoconus. cornea, 2011; 30 (12): 1406-1408. 15. sykakis e, karim r, evans jr, bunce c, amissaharthur kn, patwary s, mcdonnell pj, hamada s. corneal collagen cross-linking for treating keratoconus. cochrane database syst rev. 2015 (3): cd010621. microsoft word m moin 2 139 original article role of temporary tarsorrhaphy using super glue in the management of corneal disorders muhammad moin, irfan qayyum, anwar ul-haq ahmad, mumtaz hussain pak j ophthalmol 2009, vol. 25 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: mohammad moin department of ophthalmology mayo hospital lahore received for publication january’ 2009 … ……………………… purpose: to evaluate the safety and efficacy of temporary tarsorrhaphy using super glue in the management of corneal disorders. material and methods: a retrospective chart review of 46 consecutive patients who underwent superglue tarsorrhaphy from june 1997 to june 1998 was performed. all patients were managed at the institute of ophthalmology, mayo hospital, lahore. this study included patients with painful non healing corneal ulcers, exposure keratopathy (secondary to moderate proptosis), dry eyes (to reduce surface area of evaporation) and post-operative patients with conjunctival flaps ± scleral grafts (to help take up of the graft). patients with corneal perforations, endopthalmitis or panophthalmitis were excluded from the study. temporary tarsorrhaphy was done using super glue technique in which the upper eyelashes were glued to the lower lid skin. the degree of lid closure was calculated according to the pre-existing corneal pathology. patients were followed up on a weekly basis for one month to check for reduction of pain, improvement of corneal pathology and duration of tarsorrhaphy. results: there were 50 eyes of 46 patients included in the study who underwent super glue tarsorrhaphy for various corneal pathologies. there were 36 males and 10 female patients with an average age of 40 years (range 10-60 yrs). thirty two eyes had keratitis (fungal, bacterial, disciform, dendritic), 5 had a persistent epithelial defect, 4 had exposure keratopathy secondary to moderate proptosis, 5 had conjunctival flap alone or combined with a scleral graft and 4 had dry eyes. in cases of keratitis the tarsorrhaphy remained intact for 2-3 weeks, in patients with proptosis it remained intact for 2 weeks and in cases of dry eyes and conjunctival graft it remained intact for 2-3 weeks. the most common complication seen in the majority of patients was loss of a few lashes after spontaneous opening of the tarsorrhaphy in 2-3 weeks time. three patients required early opening of the tarsorrhaphy which was done by cutting the eyelashes. no patient had spillage of the glue onto the cornea. conclusion: temporary tarsorrhaphy using super glue technique is a quick, painless and effective outdoor procedure in providing temporary relief in the management of different keratopathies, dry eyes and exposure keratopathy. arsorrhaphy is the fusion of upper and lower eyelid margins. it is one of the safest and most effective procedures for healing the corneal lesions which are usually difficult to treat1. it can also be performed to protect the cornea from exposure caused by inadequate eyelid coverage, as may occur in graves’s disease or facial nerve dysfunction such as in bells palsy2. it can also be used to aid in healing of indolent corneal ulceration sometimes seen with tear film deficiency, or 5th nerve dysfunction (neurotrophic lesion). tarsorrhaphy may be temporary or permanent. temporary can be done with sutures3; while in permanent raw tarsal edges are created to form a lasting adhesion. it may be total or partial, depending t 140 on whether only a portion of the palpebral fissure is occluded. finally, they are classified as lateral, medial or central, according to the location on the eyelid. we analyzed the results of temporary tarsorrhaphy by using superglue (cyanoacrylate). material and methods a retrospective chart review of 46 consecutive patients who underwent superglue tarsorrhaphy from june 1997 to june 1998 was performed. all patients were managed at the institute of ophthalmology, mayo hospital, lahore. temporary tarsorrhaphy was done using super glue technique. this study included patients with painful non healing corneal ulcers, exposure keratopathy (secondary to moderate proptosis), dry eyes (to reduce surface area of evaporation) and post-operative patients with conjunctival flaps ± sclera graft (to help take up of the graft). patients with corneal perforations, endopthalmitis or panophthalmitis were excluded from the study. a detailed history was taken to document the cause and severity of corneal pathology in each case. pre-operative examination included best corrected visual acuity (bcva), a detailed corneal examination for epithelial defect, ulcer or exposure keratopathy, anterior segment examination for hypopyon and measurement of proptosis in selected cases. patients were followed up on a weekly basis for one month. post-operative data included grading of pain, changes in corneal pathology (improvement of epithelial defect, ulcer, exposure keratopathy or dry eyes), duration of superglue tarsorrhaphy and documenttation of any complications. pain at presentation was taken as a baseline and following the procedure it was graded as worse, same or improved. the procedure included instillation of topical proparacaine (alcaine, alcon labs tx) in the conjunctival sac. this was followed by meticulous drying of the skin and application of super glue (cyanoacrylate) on the lower lid skin beneath the eyelashes. the patient was warned about a feeling of warmth on application of the super glue. then the patient was asked to close his eyelids tightly. this resulted in adhesion of the eyelashes to the lower lid skin producing an effective tarsorrhaphy. if there was insufficient adhesion of the lashes it could be reenforced with more superglue. the degree of lid closure was calculated according to the corneal pathology. results there were 50 eyes of 46 patients included in the study who underwent super glue tarsorrhaphy for various corneal pathologies. there were 36 males and 10 female patients with an average age of 40 years (range 10-60 yrs). forty two patients underwent unilateral tarsorrhaphy while 4 patients had bilateral tarsorrhaphy. bilateral tarsorrhaphy was done in 2 patients with dry eye and 2 patients with bilateral proptosis. the tarsorrhaphy remained stable for at least 2-3 weeks with spontaneous opening of the lids afterwards. out of 50 eyes 32 had infective keratitis (fig. 1, 2), 5 had a persistent epithelial defect, 4 had exposure keratopathy secondary to moderate proptosis, 5 had conjunctival flap alone or combined with a scleral graft and 4 had dry eyes. out of the 32 eyes having infective keratitis 10 had fungal keratitis, 15 had bacterial keratitis, 4 had disciform keratitis and 3 had dendritic keratitis. in cases of infective keratitis the tarsorrhaphy was done only after control of active stage of the keratitis. the aim of the treatment was to help in the healing phase of the keratitis. patients with persistent epithelial defect underwent tarsorrhaphy after having the epithelial defect for at least 5 days. proptosis was bilateral in 2 cases (thyroid eye disease) while 2 patients had unilateral proptosis (one with orbital inflammatory disease and one post orbitotomy patient). tarsorrhaphy done in patients with thyroid eye disease was a precursor to permanent procedure to check for its efficacy. it was done in orbital inflammatory disease (oid) and post orbitotomy patients to resolve inferior conjunctival prolapse associated with chemosis (fig. 3, 4, 5). there were 3 cases of conjunctival flaps done for descematoceles and 2 cases of conjunctitval flaps with scleral grafts for perforated corneal ulcers which were done as a last resort to save the shape of the eyeball until a donor cornea was available (fig. 6, 7). tarsorrhaphy was done along with the conjunctival procedure to improve its success. the 2 patients with dry eyes underwent this temporary procedure bilaterally to check if decreasing the palpebral fissure with permanent tarsorrhaphy would be of any help to these patients (fig. 8, 9). in cases of keratitis the tarsorrhaphy remained intact for 2-3 weeks, in patients with proptosis it remained intact for 2 weeks and in cases of dry eyes and conjunctival graft it remained intact for 2-3 weeks. eighty four percent of the eyes had relief of pain after the tarsorrhaphy. however, 2 patients had 141 aggravation of pain after the tarsorrhaphy (patients with keratitis) and 5 patients did not feel any difference after the tarsorrhaphy (4 patients with keratitis and 1 patient with proptosis). there was aggravation of pain in 2 patients with keratitis because the tarsorrhaphy had been done before achieving favorable response to topical medications in order to prevent corneal perforation in very large corneal ulcers with marked central thinning. in these cases the tarsorrhaphy was opened early by cutting the matted eyelashes at the base and treatment changed accordingly. the most common complication seen in the majority of the patients was loss of a few lashes after spontaneous opening of the tarsorrhaphy in 2-3 weeks time. three patients required early opening of tarsorrhaphy which was done by cutting the eyelashes. no patient had spillage of the glue onto the cornea. discussion tarsorrhaphy is a procedure in which the eyelids are fused together to narrow the palpebral fissure. it is one of the safest and most effective procedures for healing persistent epithelial defects or corneal ulceration. tarsorrhaphy is a more effective therapy than pressure patching in most cases, perhaps because of better oxygen delivery to the ocular surface. tarsorrhaphy may be temporary or permanent. temporary can be done with sutures3; while in permanent raw tarsal edges are created to form a lasting adhesion. they may be total or partial, depending on whether only a portion of the palpebral fissure is occluded. finally, they are classified lateral, medial or central, according to the position in the palpebral fissure. a lateral tarsorrhaphy is occasionally used to aid in lid closure and corneal coverage in patients who have significant exposure keratitis due to lagophthalmos caused by thyroid ophthalmopathy or any orbital tumour. this is usually performed in conjunction with orbital decompression or lid retraction surgery. a temporary tarsorrhaphy may be performed after these procedures when there continues to be significant symptoms or signs of corneal exposure despite adequate decompression or repair of lid retraction. it is occasionally used as a procedure to mask mild exophthalmos, but it usually stretches because of lid retraction pulling on the adhesions, which is not cosmetically acceptable. indications of tarsorrhaphy include facial nerve palsy, non healing corneal ulcer, lagophthalmos, dry eye syndrome, keratitis, kerato-conjuctivitis, proptosis, chemical burn, thyroid ophthalmopathy, impending perforation secondary to trauma, persistent epithelial defect and autoimmune (steven johnson syndrome, mooren's ulcer)4. botulinum toxin is also used to induce ptosis in some cases. but botulinum toxin may not be available universally because of constraints of cost and expertise. moreover, the induced ptosis is variable in its onset and duration, and there are risks associated with the injection. the tarsorrhaphy complications are usually failure of the lid adhesion or a stretching of the lid adhesion. misdirection of the lashes can occur after a tarsorrhaphy. there are seldom major complications such as hemorrhage or infection. all the forms of surgical tarsorrhaphy are time consuming, and there may be a risk of permanent scarring to the eyelids from surgery. tarsorrhaphy using superglue technique is another good alternative method for temporary tarsorrhaphy5,6,7. advantages of tarsorrhaphy with superglue are that it is easily available, non toxic to skin, can be done in the outpatient clinic, painless, and very cheap as no surgical materials are used. most frequent complication is temporary loss of eye lashes. temporary tarsorrhaphy using superglue usually lasts for weeks and can easily be repeated when necessary. with regard to safety, a previous case series has suggested that there is no long-term morbidity from superglue contact with the eye. the technique is not a replacement for surgical tarsorrhaphy; however, it may be considered as an alternative in certain situations. first, the technique can be used to provide short-term corneal protection prior to recovery of facial nerve palsy. second, it may serve as a temporary measure for exposure keratopathy while awaiting more definitive treatment. third, it is of value in patients who refuse surgical intervention. cyanoacrylate was discovered by harry coover at eastman kodak during world war ii when searching for a way to make plastic gun-sight lenses. it did not solve this problem, since it stuck to all the apparatus used to handle it. it was first marketed for industrial and domestic use in february 1955 as a product called "flash glue" which is still available today and now owned by gary shipko, president of super glue international, a united states based firm. it was patented in 1956 and developed into eastman 910 adhesive in 1958. cyanoacrylates are now a family of adhesives based on similar chemistry. 142 fig. 1: fungal keratitits fig. 2: after superglue tarsorrhaphy fig. 3: proptosis with chemosis (old) fig. 4: after superglue tarsorrhaphy fig. 5: after opening of tarsorrhaphy fig. 6:conjunctival flap + scleral graft 143 fig. 7: after superglue tarsorrhaphy fig. 8: severe dry eyes post sj syndrome fig. 9: after bilateral tarsorrhaphy table 1: disease no. of eyes infective keratitis (fungal, bacterial disciform, dendritic) 32 persistent epithelial defect 5 exposure keratopathy due to proptosis 4 conjunctival flap ± sclera graft 5 dry eyes (steven johnson syndrome) 4 table 2: disease duration of tarsorrhaphy repeat tarsorrhaphy infective keratitis 2-3 wks 2 cases exposure keratopathy due to proptosis 2 wks none conjunctival flap ± sclera graft 2-3 wks none dry eyes (steven johnson syndrome) 2-3 wks none infective keratitis 2-3 wks 2 cases table 3: disease > pain <>pain < pain keratitis(fungal, bacterial, disciform, dendritic) 2 4 26 epithelial defect 5 exposure keratopathy due to proptosis 1 3 conjunctival flap ± sclera graft 5 dry eyes (steven johnson syndrome) 4 total 2 5 43 the use of cyanoacrylate glues in medicine was considered fairly early on. eastman kodak and ethicon began studying whether the glues could be used to hold human tissue together after surgery. in 1964, eastman submitted an application to use cyanoacrylate glues to seal wounds to the united states food and drug administration (fda). soon 144 afterwards in 1966, cyanoacrylates were tested on-site in vietnam by a specially trained surgical team, with impressive results. the compound demonstrated an excellent capacity to stop bleeding, and during the vietnam war, disposable cyanoacrylate sprays were developed for use in the battlefield. the original eastman formula was not fda approved for medical use, however, because of a tendency to cause skin irritation and to generate heat. in 1998 the fda approved 2-octyl cyanoacrylate for use in closing wounds and surgical incisions. closure medical has developed medical cyanoacrylates such as derma bond, soothe-n-seal and band-aid liquid adhesive bandage. since we did not have an open wound there was no skin irritation seen with cyanoacrylate in our study. in its liquid form, cyanoacrylate consists of monomers of cyanoacrylate molecules. methyl-2cyanoacrylate (ch2=c(cn)cooch3 or c5h5no2) has a molecular weight equal to 111.1, a flashpoint of 79 °c, and 1.1 times the density of water. ethyl-2-cyanoacrylate (c6h7no2) has a molecular weight equal to 125 and a flashpoint of >75°c. to facilitate easy handling, adhesives made with cyanoacrylate are usually formulated so that the glue is more viscous and gel-like. generally, cyanoacrylate is an acrylic resin which rapidly polymerizes in the presence of water (specifically hydroxide ions), forming long, strong chains, joining the bonded surfaces together. because the presence of moisture causes the glue to set, exposure to moisture in the air can cause a tube or bottle of glue to become unusable over time. to prevent an opened container of glue from setting before use, it must be stored in an airtight jar or bottle with a package of silica gel. 2-octyl cyanoacrylate can also be used for small skin cuts/lid tears8, small corneal tears, small corneal perforations, 360o fornix formation. conclusion temporary tarsorrhaphy using super glue technique is a quick and effective outdoor procedure. it is a very effective and safe procedure in the management of non-healing epithelial defects and other surface problems, with a very high success rate and only minor complications. author’s affiliation dr. muhammad moin associate professor department of ophthalmology mayo hospital lahore dr. irfan qayyum department of ophthalmology king edward medical university mayo hospital lahore dr. anwar ul-haq ahmad department of ophthalmology king edward medical university mayo hospital lahore prof. mumtaz hussain department of ophthalmology mayo hospital lahore reference 1. cosar cb, cohen ej, rapuano cj, et al. tarsorrhaphy: clinical experience from a cornea practice. cornea. 2001; 20: 787-91. 2. bergeron cm, moe ks. the evaluation and treatment of upper eyelid paralysis. facial plast surg. 2008; 24: 220-30. 3. mcinnes aw, burroughs jr, anderson rl. temporary suture tarsorrhaphy. am j ophthalmol. 2006; 142: 344-6. 4. tzelikis pf, diniz cm, tanure ma et al. tarsorrhaphy: applications in a cornea service. arq bras oftalmol. 2005; 68: 103-7. 5. ehrenhaus m, d'arienzo p. improved technique for temporary tarsorrhaphy with a new cyanoacrylate gel. arch ophthalmol. 2003; 121: 1336-7. 6. leahey ab, gottsch jd, stark wj. clinical experience with nbutyl cyanoacrylate (nexacryl) tissue adhesive. ophthalmology. 1993; 100: 173-80. 7. donnenfeld ed, perry hd, nelson db. cyanoacrylate temporary tarsorrhaphy in the management of corneal epithelial defects. ophthalmic surg. 1991; 22: 591-3. 8. singer aj, quinn jv, hollander je. the cyanoacrylate topical skin adhesives. am j emerg med. 2008; 26: 490-6. 145                       fig 1. fungal keratitits                       fig 2. after superglue tarsorrhaphy                         fig 3. proptosis with chemosis (oid)    fig 4. after superglue tarsorrhaphy                                                              fig 5. after opening of tarsorrhaphy                146                       fig 6. conjunctival flap + scleral graft     fig 7. after superglue tarsorrhaphy                                 fig 8. severe dry eyes post sj syndrome             fig 9. after bilateral tarsorrhaphy  microsoft word news and evants 26,3,2010 168 news and events vol. 26, 3, 2010 annual meeting american academy of ophthalmology and middle east africa council of ophthalmology (meaco) date: 16-19 october 2010 venue: mc cormick place, chicago, usa web. www.aao.org/meeting royal australian and new zealand college of ophthalmologists (ranzco) annual general meeting and scientific congress date: 20-24 november 2010 venue: adelaide, australia lahore ophthalmo date: 24-26 december 2010 venue: pearl continental hotel lahore, pakistan secretary: dr. zahid kamal siddiqui secretariat: osp house 4-a lda flats, lawrence road, lahore. phone: 92-42-36363325 fax: 92-42-36363326 email: osplahore@hotmail.com association for research in vision and ophthalmology (arvo) annual meeting date: 1-5 march 2011 venue: florida, usa apao sydney date: 21-24 march 2011 venue: sydney, australia american society of cataract and refractive surgery (ascrs)/american society of ophthalmic administrators (asoa) symposium and congress date: 26-30 march 2011 venue: san diego, usa xvix congress of the european society of cataract and refractive surgeons (escrs) date: 17-20 september 2011 venue: vienna, australia annual meeting of american academy of ophthalmology (aao) date: 22-25 october 2011 venue: orlando, usa 33rd world ophthalmology congress (woc) date: 16-20 february 2011 venue: abu dhabi, united arab emirates institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091-9217376-80 fax: 92-42-6363326 email: pico@pes.comsats.net.pk punjab institute of preventive ophthalmology, lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042-37355998 fax: 042-37248006 email: pipo@brain.net.pk 169 pakistan institute of ophthalmology, al-shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al-shifa trust eye hospital, jhelum road, rawalpindi pakistan phone: 92-51-5487830, 5487820-25 fax: 92-51-5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt department of ophthalmology fatima jinnah medical college sir ganga ram hospital, lahore fax: 92-42-6363326 email: hamidbut@gmail.com mobile: 0300 – 4158962 microsoft word sadia bukhari 8 208 original article ocular trauma in children sadia bukhari, p s mahar, umair qidwai, israr ahmed bhutto, abdul sami memon pak j ophthalmol 2011, vol. 27 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sadia bukhari ophthalmology division isra postgraduate institute of ophthalmology/ al-ibrahim eye hospital, malir, karachi. submission of paper july’ 2011 acceptance for publication november’ 2011 …..……………………….. purpose: to evaluate the causes of ocular trauma, management and visual outcome in children. materials and methods: this prospective observational case series was conducted at the department of pediatric ophthalmology, isra postgraduate institute of ophthalmology / al-ibrahim eye hospital, karachi from november 2009 to october 2010. all patients of ocular trauma aging less than 15 years were included in the study. results: a total number of 173 children (174 eyes) presented with ocular trauma from november 2009 to october 2010. minimum age of presentation was 2 months, while the maximum age was 180 months with mean of 97.172 months (sd = 41.82). out of total number of children, 125 (72.25%) were male and 48 (27.75%) were female. blunt mode of trauma was the most frequently observed mode of injury among children and was, seen in 88 (50.6%) patients. the causes included vegetative material in 25 (14.4%) and wooden stick in 23 (13.2%) patients. fifty four (31%) patients were treated surgically while rest of the patients was treated medically. most common cause of decreased vision was disorganized globe seen in 21 (12.1%) patients followed by corneal opacity in 18 (10.3%) patients. conclusion: pediatric ocular trauma is a common cause of ophthalmic consultation. these injuries are mainly result of the blunt trauma. majority of patients are young boys. there is a need for increasing awareness among parents. cular trauma in children is a leading cause of visual morbidity. ocular injuries accounts for approximately 8-14% of total injuries suffered by children1,2. besides, direct damage to the ocular structures resulting in loss of vision, poor visual outcome may also due to dense amblyopia caused by prolonged period of light and formed vision deprivation2,3. children are more prone to injuries because of their inability to avoid hazards4. in general, male are more frequently reported to have eye injuries as compared to female due to their adventurous and aggressive nature5-8. etiologically such injuries are largely accidental. the infants and children, less than 3 years of age sustain fewer injuries due to close parental supervision9. older children injure themselves by spikes of toys, pencils, arrows, needles, thorns and stones. sports related injuries are common in children from 5-15 years of age10. injuries by animal tail and bird beak are common in rural areas. fire crackers and toy pistols on religious events such as eid and shab-e-barat lead to loss of many eyes every year. we conducted this study to help us in documenting the prevalence of this preventable cause of visual deterioration. materials and methods this prospective observational case series was conducted at department of paediatric ophthalmology, isra postgraduate institute of ophthalmology/al-ibrahim eye hospital, karachi, from november 2009 to october 2010. all children up to 15 years with ocular trauma were included in the study. the long standing trauma patients with prior management were excluded. all patients were examined in detail including complete history and ocular examination. visual acuity was measured at the time of presentation. o 209 children less than 2 years were examined using fixation and follow test patterns, while children between 2-5 years were examined on cardiff visual acuity charts, kay pictures and sheridan-gardner charts. the children above 5 years were examined with snellen’s chart and illiterate e chart. the ocular examination was carried out with the help of direct ophthalmoscope, slit lamp and hand held slit lamp. the fundus examination was carried out with the help of indirect ophthalmoscope in cases of clear ocular media with +20 diopter lens. the bscan mode ultrasonography was performed in patients with opaque ocular media for posterior segment examination. the non-cooperative and very young children were examined under general anesthesia. the patients with any insignificant ocular structural damage or simple subconjunctival hemorrhage were reassured and discharged. the superficial foreign bodies were removed using topical anesthesia (alcain –alcon, belgium). the corneal abrasions and superficial corneal lacerations with formed anterior chamber were treated by antibiotic drops (vigamox – alcon, belgium) and ointment (tobrex alcon, belgium) with patching of the eye. the corneal abscess were treated with topical fortified antibiotic drops (vancomycin 50mg/ml, amikacin 33mg/ml), topical antifungal (amphoteracin 0.05%) and cycloplegics (mydriacyl alcon, belgium). any child with uveitis was treated with topical (predforte allergan, pakistan), subtenon (triamcinolone acetonide, dexamethasone) or systemic corticosteroids (deltacortil) and cycloplegics (mydriacyl alcon, belgium). hyphaema was treated with conservative methods like complete bed rest, topical corticosteroids (predforte allergan, pakistan), and topical antiglaucoma medication (betalol sante, pakistan) whenever needed. any form of surgical intervention like anterior chamber paracentesis or trabeculectomy using mitomycin c was done in required cases. the surgical intervention was carried out under general anesthesia using operative microscope. all corneal lacerations were repaired with 10-0 nylon and scleral lacerations were sutured with 60 vicryl. in cases of multiple ocular structure damage, primary globe repair was done as early as possible and further management was carried out according to the severity and residual sequel. cataract surgery was performed usually after 6-8 weeks of primary repair using irrigation and aspiration of lens matter. for posterior capsular opacity (pco), posterior capsulotomy and anterior vitrectomy were performed. in cooperative patients with pco, yag-laser capsulotomy was substituted. the intraocular lenses (iol) were implanted in all cases using polymethylmethacrylate (pmma) 6.5mm optical diameter or scleral fixation lenses in case of absent posterior capsule. the grossly subluxated lenses were removed through pars plana approach and scleral fixated iols were implanted as a secondary procedure. the cases of posterior segment trauma, including posteriorly dislocated lens, vitreous hemorrhage, retinal detachment and intraocular foreign body were referred to vitreo-retinal services in hour hospital. cases, which required surgical intervention were managed by 3-port pars plana approach. final visual acuity was measured after 6 months. data analysis was performed using spss version 18.0. frequency of age, gender and eye involved were calculated with mean ± standard deviation. paired t test was used to compare the visual acuity before and after the management of the trauma. results one hundred and seventy three children attended our hospital with ocular trauma from november 2009 to october 2010. minimum age of patients was 2 month while the maximum age was 180 months with mean of 97.172 months (standard deviation=41.82). out of these 173 children, 125 (72.25%) were male and 48 (27.75%) were female table 1. the right eye was in eighty one (46.6%) patients and the left eye in 92 (52.9%). only 1 (0.6%) child had his both eyes involved. one hundred and seventy four eyes were evaluated. blunt mode of trauma was the most frequently observed mode of injury among children. it was seen in 88 (50.6%) patients. other modes are seen in (fig. 2). vegetative material and wooden stick were the most frequent causative agents. 25 (14.4%) patients had injury by vegetative trauma while 23 (13.2%) had it with wooden stick. other causative agents are shown in table 2. most common finding seen in patients after trauma was sub-conjunctival hemorrhage, which was seen in 20 (11.5%) patients followed by cataract in 14 (8%) patients. damage to multiple ocular structures was seen in 17 (9.8%) patients. other findings and their frequencies are shown in table-3. only 37.9 % patients were 6/18 or better at the time of presentation while after management it improved to 57.9% (p<0.05). fifty four (31%) patients were treated surgically while 119 (68.78%) were treated medically. (fig. 3) shows the frequencies of management options used. change in visual acuity after the management is shown in (fig.4). most common cause of decreased vision was disorganized globe which was seen in 21 210 (12.1%) of the patients, followed by corneal opacity in 18 (10.3%) of patients. other causes of decrease vision are shown in (fig. 5). table 1: gender and age frequencies gender no. of patients n (%) minimum age maximum age male 125 (72.25) 2 months 180 months female 48 (27.75) 24 months 176 months table 2: causative agents causative agent frequency n (%) vegetative material 25 (14.4) stores 13 (7.5) ball 8 (4.6) plastic pallet 7 (4.0) toys 4 (2.3) wooden stick 23 (13.2) fire cracker 5 (2.9) needle 9 (5.2) finger 1 (0.6) fist or hand 5 (2.9) kinfe 4 (2.3) iron rod 6 (3.4) animal horn / bird beak 7 (4.0) others 27 (15.5) missing 30 (17.2) total 174 (100) discussion ocular trauma is the leading cause of acquired monocular blindness in young patients. this prospective study focuses on the causes of eye injuries in children who presented to the department of pediatric ophthalmology in a tertiary eye center. we also evaluated the severity, primary management, initial and final visual acuity in these patients. children are more susceptible to the ocular trauma because of their immature motor skills and curious nature. a marked preponderance of injuries is seen in 6-10 years of age group11. adult supervision has been found to be an important factor in the prevention of injuries to children. infants and children of less than 3 years of age sustain fewer injuries because of close supervision by parents. in our study the mean age of child was high i.e. 97.172 months (8.09 years). the male children are affected more than female, because boys generally are granted more liberty than girls in our society and they tend to spend more time outside. in our study we also found higher number of male children affected i.e. 71.8% as compared to female i.e. 27.6%. the type of injury, its severity and initial visual table 3: frequency of ophthalmic findings ophthalmic findings frequency n (%) lid tear 5 (2.9) ecchymosis 6 (3.4) sub conj hg 20 (11.5) conj tear 3 (1.7) sclera tear 1 (0.6) corneal abscess 13 (7.5) corneal opacity / adherent leucoma 4 (2.3) corneal abrasion / laceration 7 (4.0) corneal tear 6 (3.4) corneal foreign body 12 (6.9) uveal prolapsed 9 (5.2) uveitis 5 (2.9) hyphema 12 (6.9) cataract 14 (8.0) subluxated lens 7 (4.0) dislocated lens 3 (1.7) endophthalmitis 7 (4.0) vitreous hemorrhage 1 (0.6) retinal detachment 7 (4.0) optic atrophy 2 (1.1) multiple ocular structure damage 17 (9.8) phthisis 3 (1.7) other 4 (2.3) painful blind eye 4 (2.3) macular / retinal edema 2 (1.1) total 174 (100 211 table 4: comparison of mechanism of ocular injuries mechanism of injury present study % of cases krishnan m and sreenivasan r % of cases mac. ewal et al % of cases blunt 51 30.80 65 penetrating 29 69.20 24 chemical 1 — 1 0 10 20 30 1st day within 3 days within 1 week 1 week 1 month 1 month 3 months missing % of patients fig. 1: duration of patient presentation after trauma missing 7% others 6% foreign body 6% chemical trauma 1% penetrating 29% blunt trauma 51% fig. 2: modes of trauma acuity are known prognostic factors for the final outcome. in our cohort of patients, most cases were not severe and did not cause any initial visual impairment. our study also showed that closed globe injuries were more common (50.6%) than open globe injuries (28%). chemical burns accounted for only 0.6% cases. our results are comparable to the results published by mc ewen and coworkers10. the percentage of patients sustaining close globe injuries in their series was 65% comparing to 24% receiving open globe injuries. in contrast krishnan12 found open globe injuries in more number in india at 69.20%. serrano and colleagues13 published epidemiology of ocular injuries involving children less than 15 years of age. in their series of 393 children, 64.9% patients were boys. the highest proportion of injuries (44.4%) occurred at home. closed-globe injuries were far more frequent than open-globe injuries for boys (82.4% vs 17.6%) and girls (83.8% vs 16.2%). most closed-globe injuries (223 [92.1%]) did not cause any final visual impairment in the affected eye whereas 26 open-globe injuries (55.3%) caused severe visual impairment. ocular trauma among 126 children in nepal and their visual outcome was reported by adhikari et al. 14 fifty seven percent of their reported children were male with open-globe injury registered in 5% of cases. the common agents of trauma were wood sticks and grass leaves. nine percent of the children had final vision of less than 6/60 and 5% with no perception of light after treatment. on the home front malik and coworkers 15 reported 200 cases of ocular trauma in children less than 15 years of age attending a local hospital in peshawar. in this study male children constituted 47% of the total cases. the injury caused by blunt object was seen in 64.05% (129) of children and mostly it was due to stone in 21.5% (71) cases. the visual acuity on arrival was perception of light only in 35.5% patients with open-globe injury. at the end of 2 months 13.5% eyes were physical. babar et al16 in a retrospective study looked at the medical records of 481 children of 0 10 20 30 40 50 60 s ur gi ca lly t re at ed m ed ic al ly t re at ed c yc ly oc rio /d io de la se r o th er f b r em ov al n on e frequency n um be r of p at ie nt s fig. 3: management options used 212 up to 16 years who had sustained ocular trauma. about 51% injuries were of open-globe type and 37.6% were closed-globe injuries. at the time of admission, 14.6% eyes were infected with 2.3% requiring evisceration or enucleation. 0 10 20 30 40 50 60 6/6-6/18 6/24-6/36 6/60-3/60 <3/60-pl npl va at presentation va after management fig. 4: change in visual acuity. 5%6%3% 13% 11% 62% noamal vision corneal opacity disorganized globe optic atrophy pthysis old retinal detachment fig. 5: normal vision / cause of decreased vision our study showed that vegetative material (branches of trees, thorns) and wooden sticks were the common causative agents. stones, sharp needles and cricket balls also cause grave ocular injuries. the injuries from plastic pallets (toy pistols) and fire crackers on religious events of eid and shab-e-barat accounted for significant number of ocular injuries and can lead to ocular damage either because of trauma but also due to late presentation because of government holidays on these events (table 2). the visual prognosis of eye injuries improves when prompt examination, diagnosis and treatment is provided. however socioeconomic, cultural and awareness factors may also play a role in receiving timely attention. twenty percent (20%) of children in this study received medical attention during 24 hours after injury, while 24.1% children presented after 72 hours. the open-globe injuries generally results in poorer visual outcome compared to close-globe trauma17. blunt trauma involving anterior segment has better visual outcome than when posterior segment is involved. the non-perforating vegetative trauma can cause corneal erosions and ulcers which can be complicated by polymicrobial infections leading to severe visual deterioration. therefore proper antimicrobial treatment is required at an early stage. the traumatic hyphaema is usually managed conservatively. the glaucoma resulting from trauma may have early, intermediate and delayed presentation. the lens injuries can lead to cataract formation or subluxation of crystalline lens. the perforating anterior segment trauma may cause corneal or scleral injury with varying degree of uveal tissue, lens and vitreous involvement. unrepaired cases may carry a potential risk of endophthalmitis and panophthalmitis. the reported incidence of posttraumatic endophthalmitis is high compared to intraocular surgery18. the posterior segment involvement adversely affects visual outcome. 17 it manifests as commotio retinae, choroidal rupture, macular hole, retinal breaks, retinal dialysis and retinal detachment. patients with traumatic retinal detachments need to be operated as early as possible. conclusion ocular trauma leads to diminution of vision, cosmetic blemishes and resultant personality defects. the most important aspect of pediatric trauma is prevention. the parents, caretakers and teachers have an important role to play in prevention of these injuries. playing with hazardous objects, toy pistols and fire crackers should be discouraged. the appropriate management by primary health care physician and general ophthalmologist, before ophthalmic consultation at tertiary eye care center, is a key factor in improving visual prognosis. author’s affiliation dr. sadia bukhari assistant professor isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi % o f p at ie nt s 213 dr. p s mahar professor of ophthalmology isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr. umair qidwai postgraduate student isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr. israr ahmed bhutto senior registrar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr. abdul sami memon senior registrar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi reference 1. scribano pv, nance m, reilly p et al. pediatric non-powder firearm injuries: outcomes in an urban paediatric setting. pediatircs. 1997; 100: e5. 2. takvam ja, midelfart a. survey of eye injuries in norwegian children. acta ophthalmol. 1993; 71:500-05. 3. world health organization. prevention of childhood blindness. causes of childhood blindness and current control measures 1992; 21-22, who, geneva. 4. negral ad, thlefors b. the global impact of eye injuries. ophthalmic epidemiology. 1998; 5:143-69. 5. neranen m, raivio i. eye injuries in children. br j ophthalmol. 1981; 65:436-38. 6. strahlman e, elman m, daub e, et al. causes of pediatric eye injuries. a population based study. arch ophthalmol. 1990; 108:603-06. 7. cascairo ma, mazow ml, prager tc. paediatric ocular trauma: a retrospective survey. j pediatric ophthalmol strabismus. 1994; 31:312-17. 8. nelson lb, wilson tw, jeffers jb. eye injuries in childhood: demography, etiology and prevention. pediatrics. 1998; 84:43841. 9. montanes cb, cuvea mc. eye injuries in childhood: ann. esp. pediatrics 1998; 48:625-30. 10. mac ewen cj, baines ps, desai t. eye injuries in children: the current picture. br j ophthalmol. 1999; 83:933-36. 11. al-bdour md, azab m. a childhood eye injuries in north jordan. int. ophthalmol. 1998; 22:269-73. 12. krishnan m, sreenivasan r. ocular injuries in union territory of pondicherry. clinical presentation indian j ophthalmol. 1998; 36:82-5. 13. serrano jc, chalela p, arias jd. epidemiology of childhood ocular trauma in north-east colombian region. arch ophthalmol. 2003; 121: 1439-45 14. adhikari rk, pokhrel h, chaudhary h, et al. ocular trauma among children in western nepal: agents of trauma and visual outcome. nep j ophthalmol. 2010; 2: 164-5. 15. malik ra, rahil n, hussain m, et al. frequency and visual outcome of anterior segment involvement in accidental ocular trauma in children. jpmi 2011; 25: 01: 44-8. 16. babar tf, jan s, gul l. pattern of pediatric ocular trauma in hayatabad medical complex, peshawar. pak j med res. 2006; 45: 6-9. 17. cascairo ma, mazow ml, prager tc. pediatric ocular trauma retrospective survey. j pediatric ophthalmol strabismus. 1994; 31:312-17. 18. meredith ta. post-traumatic endophthalmitis. arch ophthalmol. 1999; 117:52021. microsoft word consensus document on avastin for publication 103 consensus document consensus document on the use of avastin (bevacizumab) in retinal pathologies pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . back ground this document was created, debated, amended and approved by the members of the vitreoretinal association of pakistan. this exercise was carried out on behalf of the ophthalmic society of pakistan. the central council of the osp had expressed with concern that while the use of avastin was increasing exponentially, most ophthalmic practioners had limited knowledge and experience in the use of this drug. there was as yet no information available in textbooks. it was therefore incumbent on the people who had acquired the most knowledge of this drug to share their knowledge and the fruit of their experience for the benefit of patients. vitreo retinal association of pakistan (vrap) therefore took up this task. introduction the members of the vitreo-retinal association of pakistan recognize that bevacizumab (avastin) is a powerful anti vegf-a agent. its use in ophthalmology is currently off label, however it cannot be withheld from patients as it is 1. the only treatment available for certain disorders at a reasonable cost. 2. an effective adjunct to treatment of certain disorders where no on label treatment is available. like any other powerful agent it has certain side effects and the procedure of intra-vitreal injection can have complications, therefore is used carefully. as things stand today not enough textbook data is available on the use of this drug to guide fellow professionals. we therefore feel that it would be prudent to create a consensus document that pools our experience. it is also important to emphasise that new information is emerging and more experience is being acquired and therefore the guidelines or suggestions for use of intra-vitreal avastin are expected to change over time. bevacizumab (avastin) is an anti vegf-a agent. vegf (vascular endothelial growth factor) promotes endothelial cell proliferation and increases vascular permeability. it is therefore natural to assume that retinal vascular pathologies where the underlying problem is new vessel formation, increased leakage from capillaries or both could be potential targets for therapy with avastin. therefore the possible list of diseases which, could be subjected to treatment by avastin are: 1. choroidal neovascularization (cnv) 2. proliferative diabetic retinopathy (pdr) without vitreous haemorrhage. 3. proliferative diabetic retinopathy (pdr) with vitreous haemorrhage. 4. clinically significant macular oedema. 5. eales disease. 6. coats disease and other heredetary telengectasia 7. retinopathy of prematurity (rop). 8. central retinal vein occlusion (crvo)/ brvo. 9. neo-vascular glaucoma. however before we describe our cumulative experience in the management of these problems a word of caution would not be misplaced. avastin is non-specific and it closes down all collaterals and care should be taken when injecting patients who are at risk of either stroke or myocardial infarction (mi). they may still receive an injection as the reported 104 incidence of these complications is quite low. therefore informed consent is important. full aseptic measures need to be taken during the injection in an operating theatre as the recipients are either immunocompromised or develop a significant cumulative risk as they may require multiple injections. (appendix 1) in the pre-amble it is also important to emphasise that the effects of avastin on retinal vasculature are often transient. dose: the dose of avastin may be 1.25 to 2.5 mg. repeat: when indicated it may be repeated between four to six weeks after the first injection. role of avastin in 1. cnv: all forms of cnvs (secondary to armd, myopia and angioid streaks) respond to avastin injection. we recommend three injections at monthly intervals in the induction phase and later on injection may need to be repeated if the cnv does not resolve completely or recurs. oct and ffa judge the efficacy of treatment. however some cnvs do not respond at all to intravitreal avastin and some relapse early and fail to respond again. tachyphylaxis exists as well. combination therapy may be tried in these cases. 2. proliferative diabetic retinopathy (pdr) without vitreous haemorrhage: in pdr there is no cause to give an injection of avastin as primary and sole treatment if there is no vitreous haemorrhage. the treatment of pdr is pan retinal photocoagulation (prp) according to etdrs criteria. 3. proliferative diabetic retinopathy (pdr) with vitreous haemorrhage: at the present moment there is no established treatment modality that causes the vitreous haemorrhage to resolve. vitreous haemorrhage resolve either spontaneously or through surgery. avastin temporarily closes down new vessels and could be helpful in preventing recurrent vitreous haemorrhage. therefore avastin may have role in helping natural resolution by preventing small recurrent haemorrhages. however this effect would only be significant in someone who has a low density vitreous haemorrhage. natural resolution of dense vitreous haemorrhages is too unpredictable. avastin can also cause sudden closure of new vessels and make their fibrous component predominant. it can enhance the any pre-existing traction retinal detachment (trd) or create a trd if there was a strong fibro-vascular component at the posterior pole. we have also observed that if the natural vasculature is already compromised then intravitreal avastin may completely completly shut it down. we also feel that recurrent vitreous haemorrhages in eyes with adequate prp are indicative of an anatomical structural abnormality and in these cases conservative treatment probably has no value. in light of these observations we suggest that a single or maximum of two intravitreal injections of avastin may be used if the vitreous haemorrhage is of • fresh low density (dense enough not to allow prp, but still allows some retinal view or atleast a good red reflex). • flat retina on b scan. it should not be used • if the vitreous haemorrhage is old (in excess of 3 months / white vit haemorrhage) and not resolving. • in dense vitreous haemorrhage (haemorrhage with no retinal view) • pre-existing trd seen directly or on b scan. • recurrent vitreous haemorrhages especially those who have previously received avastin. 4. csmo: the primary treatment for csmo is focal laser treatment. in cases of intractable diabetic macular oedema i.e. macular thickening not responsive to laser treatment, especially that associated with cystoid macular oedema (cme) avastin, with or without triamcinolone, is a good adjunct to focal laser treatment. eyes with vitreous traction or taut hyloid face should not receive intra-vitreal injection. 5. crvo: blood vessels tend to re-canalize as the clot in the lumen of the vessel lyses. however the internal retinal layers may suffer permanent damage either due to ischemia or oedema. our overall experience is that no significant positive visual gain was achieved after intravitreal 105 injection of avastin in ischemic crvo. however the subject is still under study. some positive gains may be achieved in non-ischemic crvo. visual acuity and oct are important guides. 6. we have so far found that telengectasia in coats disease do not shutdown as a result of intravitreal avastin. it may however be used if macular edema has freshly developed in an eye secondary to coats disease. for para foveal telengectasia. 7. rop: rop is a most difficult area. the disease is incompletely understood; the infants are premature, very fragile, grossly underweight and often belong to previously infertile parents. the natural history of stage iv disease is not good. there is very limited data available world wide on this disease. great caution therefore needs to be exercised when using avastin in this disease. 8. chronic uveitis: needs more evaluation. 9. neo-vascular glaucoma: judicious use along with prp and other surgical procedures may be considered. glaucoma the future of glaucoma management may change entirely as genome-wide association studies succeed in discovering the ultimate cause of disease. m lateef chaudhry editor-in-chief microsoft word salahuddin ahmad 133 original article positive impact of good visual outcome on the acceptance of cataract surgery in subsaharan african population. salahuddin ahmad, khawaja khalid shoaib, muhammad fayyaz, teyyeb azeem janjua pak j ophthalmol 2010, vol. 26 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: salahuddin ahmad consultant eye specialist cmh gujranwala received for publication september’ 2009 …..……………………….. purpose: the aim of the study was to document the visual outcome of cataract surgery in sub-saharan african population and to correlate this with acceptance of cataract surgery in the same population. material and methods: this study was conducted in the level ii hospital un mission, feb 2006 to nov 2006. all the patient undergoing cataract surgery in our field hospital were recruited in study. the preoperative and postoperative visual acuity was compared. the numbers of surgeries performed per month were documented for each of the eight months. the patients filled a proforma about the level of satisfaction with their visual outcome at six weeks. results: a total of 141 eyes of 136 patients who completed the minimum 6 weeks follow-up were included in the study. the average age of the patients at surgey was 57 years (age ranged from 10-78 years). there were 88 (64.7%) females and 48 (35.3%) males. a corrected vision of 6/18 or better was achieved in 124 eyes (88%). an uncorrected vision of 6/18 or better was obtained in 102 eyes (72.3%) at their last follow up visit. more than 95% of the patients were satisfied with their visual outcome. the number of patient undergoing cataract surgery gradually increased and it was at the peak in the last two months. there were only 22 patients operated in the first four months compared to 119 in the last four months. conclusion: the cataract extraction with iol implantation gives good visual results, which in turn adds to the confidence of the potential cataract surgery patient. therefore more patients report for the cataract surgery and which would help in increasing the rate of cataract surgery in the african population. ataract is the leading cause of blindness; accounting for about half of all blindness in the world1. the average prevalence of blindness is about 0.7% in the world, ranging from 0.3% in western europe and north america, to more than 1% in parts of sub-saharan africa.1 the cataract surgery rate in most african countries is 100-500 per million per year2. more so most of the cataract surgery done in africa is icce without iol implantation and the resultant uncorrected aphakia is adding to the visually disabled patients3-5. the iol implantation has improved the visual outcome not only in the industrialized countries but also in some developing countries6-8. we did phacoemulsification or ecce with iol implantation in most of our cases and aim of the study was to document the level of patient satisfaction about their visual outcome. and to see if good post operative visual outcome influence the acceptance of cataract surgery in the african population. to the best of our knowledge, this has not been documented before so we undertook this study to help the policy makers of the who’s vision-2020 programme in chalking out the best route to the target. c 134 material and methods all the patients who had cataract surgery in level ii hospital of pakistan armed forces contingent were included in the study. a detailed ophthalmic examination (including visual acuity, pupillary examination, slit lamp biomicroscopy, and applanation tonometry) was carried out. the hardness of the cataract was documented. biometry was carried out for the estimation of lens power using the srk-t formula. the aim was to make the patients emetropic after intraocular (iol) implantation. a detailed medical examination by the medical specialist was also done to rule out serious systemic diseases. routine laboratory test included urine r/e, blood cp, and screening for hepatitis b, c and hiv. all the operations were carried out under peribulbar anaesthesia except in children where general anaesthesia was given. the skin was cleaned with 10% povidone iodine solution and eye was irrigated with 5% povidone iodine solution immediately before surgery. phacoemulsification was done in grade 1-4 and extracapsular cataract extraction in grade 5-6 nuclear sclerosis cataracts. phacoemulsification was done through a 3.2mm clear corneal incision placed at 10 o’clock just inside the limbus. a paracentesis was made at 2 o’ clock for the second instrument. the continuous curvilinear capsulorhexis (ccc) was done after filling the anterior chamber with viscoelastic (hydroxpropyl methylcellulose/ hpmc). hydrodissection was done to ensure free rotation of the nucleus. phacoemulsification surgery proceeded in the usual way, using a 'divide and conquer' technique. the phaco parameters used were 30 to 70% phaco power (depending on the hardness of the nucleus), 6080mmhg vacuum during trenching and 150250mmhg during emulsification. the aspiration rate was 20 ml/min and the bottle height at 60 cm throughout the procedure. the cortical matter was removed by manual irrigation and aspiration with simcoe cannula. the patients with hard nuclei had extracapsular cataract extraction, where a one-stepped clear corneal incision was made just inside the limbus from 2 o’ clock to 10 o’clock. the nucleus was expressed after can opener capsulotomy. the cortical matter was removed by manual irrigation and aspiration with simcoe cannula. the incision was closed with 3 to 5 interrupted 10/0 nylon sutures after iol implantation. the intraocular lens was placed in the bag or sulcus depending on the amount of capsular support available intraoperatively. in cases where there was no capsular support, primary anterior chamber (a.c.) iol was not implanted because of non-availability of the a.c. iol. bimanual automated anterior vitrectomy was performed in cases with posterior capsule rupture and vitreous loss. in cases, where there was small tear in posterior capsule without vitreous loss, anterior vitrectomy was not done. the patients were discharged same evening and seen again next morning. postoperatively, a steroid–antibiotic combination was used for first two weeks; only steroids were given in tapering doses for the next 1-3 weeks. follow-up was done after 1 week, 6 weeks and 3 months. the patients were refracted 6 weeks after surgery. the patients were asked to fill the proforma about the level of satisfaction with the help of local interpreters. the cataract surgery rate per month was documented for each of the eight months of the study period. statistical analysis was done using spss version 14 (spss inc., chicago, il, usa). descriptive statistics were used to describe the data. p-value <0.05 was considered statistically significant. results a total of 141 eyes in 136 patients were included in the study. the average age of patients at operation was 57 years (sd 9.1). there were 88 (64.7%) females and 48 (35.3%) males. the postoperative follow up was attended for 6 weeks in 141 eyes (100%), 3 months in 38 (27%) eyes and 6 months in only 13 eyes (9.2%). none were followed for more than six months because of the end of our tenure in sudan. the cataract surgery rate per month is depicted in the fig. 1. it is evident that the rate has gradually built up from 3 surgeries in the first month to 44 in the last month (p value <0.001). there was no surgery done in july 2006 because the surgeon was on holidays. during the last two months we performed more than half of all the surgeries in the study. surgery phacoemulsification was performed in 61 eyes (43.2%), ecce in 77 eyes (54.6%), icce in 3 (2.12%) eyes with sublaxated lens or hypermature cataract with gross zonular dehiscence. the single piece pmma iols were inserted in 136 eyes (in the bag in 131 eyes and in the sulcus in 5 eyes). the patients who had icce (3 eyes) or if the capsular support was inadequate (2 135 eyes), did not have any iol implant because of non availability of the anterior chamber (ac) iol which resulted in aphakia (5 eyes). the posterior capsule rupture occurred in 5 eyes (3.5%). vitreous prolapse was managed by anterior vitrectomy followed by in the sulcus iol implantation in 3 (2.12%) of these cases. visual results the majority of the patients had marked improvement in the vision as shown in the table 1. this table shows the preoperative and postoperative vision (uncorrected and corrected) in 141 eyes who completed 6 weeks’ follow up. the mean spherical error in these patients was ± 0.93d. preoperatively 112 of eyes (79.4%) had poor vision (best corrected acuity <3/60) compared to only 2 eyes (1.4%) postoperatively and a corrected vision of 6/18 or better was achieved in 124 eyes (88%) (p-value <0.001). an uncorrected vision of 6/18 or better was obtained in 102 eyes (72.3%) at their last follow up visit. six patients (4.2%) had a poor visual outcome (best corrected vision less than 6/60). the causes of poor vision in six eyes are given in table 2. all the patients who attended 6-week postoperative visit were given a proforma about the level of satisfaction and confidence on the surgical outcome and more than 95% of the patient gave positive feedback (fig. 2). and more than 90% admitted that they were not only sent by patients who already had cataract surgery in our hospital but also convinced by them that it will improve their quality of life. complications the most frequent complication was striate keratopathy followed by anterior uveitis (table 3). one patient had iris prolapse on first postoperative day which was reposed and additional corneal stitch was placed. there was no case of cystoid macular oedema or endophthalmitis or visually significant posterior capsule opacity. discussion the world health organisation estimated in 1994 that there were 38 million blind people in the world which increases by a million every year1. precise figures for the incidence of cataract blindness in africa are not available, but it is estimated that at least 600,000 africans become blind from cataract each year4. bilateral blindness is more likely to be because of central corneal opacities (44%) rather than cataract (22%)9. corneal opacity is usually secondary to trachoma, vitamin a deficiency, and keratoconjunctivitis9,10. table 1: preoperative visual acuity in 141 eyes and the postoperative visual outcome uncorrected and corrected 6 weeks after operation. visual acuity pre-operative no. of eyes n (%) post-operative visual acuity no. of eyes n(%) un-corrected corrected <3/60 112 (79.4) 2 (1.4) 2 (1.4) <6/60-3/60 24 (17) 14 (9.9) 4 (2.8) <6/18-6/60 5 (3.54) 23 (16.3) 11 (7.8) 6/18-6/6 0 102 (72.3) 124 (88) total 141 (100) 141 (100) 141 (100) table 2: causes of poor visual outcome cause of poor vision no. of eyes n (%) age related macular degenerations 2 (1.8) corneal opacities 1 (0.9) diabetic retinopathy 2 (1.8) hypermetropic amblyopia 1 (0.9) table 3: complications postoperative complications no. of eyes n(%) striate keratopathy 8 (5.68) iritis 5 (3.55) hyphema 1 (0.71) iris prolapse 1 (0.71) transient glaucoma 4 (2.84) the cataract surgery rate (csr) is unfortunately low at 100-500 per million population per year in most of african countries compared to 2500-3500 in the industrialised countries4. to tackle cataract blindness, the world health organization, the international 136 agency for prevention of blindness, and various governmental and non-governmental organisations, have launched "vision 2020-the right to sight." this aims to increase the number of cataract operations from about 10 million per year currently to over 30 million per year by 2020 (in africa to about 2000 per million per year)5. 3 4 6 9 13 21 35 44 0 5 10 15 20 25 30 35 40 45 50 mar-06 apr-06 may-06 jun-06 jul-06 aug-06 sept-06 oct-06 nov-06 csr fig. 1: cataract surgery rate of each of the eight months of study 122 14 5 0 20 40 60 80 100 120 140 highly satisfied satisfied unsatisfied fig. 2: the level of patient satisfaction about the visual outcome the cause of low rate of cataract surgery performed in africa as compared to the industrialised nation is multifactorial6-8. poverty and limited resources is one of the leading causes. that is why most of the cataract surgeries in africa are icce in free eye camps resulting in high complication rate and poor visual outcome. the uncorrected aphakia further adds to number of visually handicapped and unsatisfied patients11-13 which, results in poor acceptance of cataract surgery. therefore, the patients report for treatment when he is bilaterally blind with advanced cataract. this is evident in our study in which we performed more ecce than phacoemulsification because of the hard and hypermature cataracts which is just reverse in our population in pakistan where we perform phaco in most of our patients (>95%). the use of iol although associated with increased cost, results not only in good visual outcome and satisfied patients but also earlier intervention and increase in number of cataract operation14,15. this is true in industrialized nations as shown in a population based survey in australia where 89% of eyes achieved a corrected vision of 6/18 or better14, and in the uk national cataract survey 87% of operated eyes achieved corrected vision of 6/12 or better15. in kenya, a study reported 94.3% of patients achieving 6/18 or better after ecce and pciol16. this is also evident in our study where 88% patients achieved corrected visual acuity of 6/18 or better in a field hospital setting. the good result definitely had positive impact on the acceptance of cataract surgery in our study. initially, we had only one or two cases per list but after a few months our lists gradually improved because the patients of the area developed confidence in our treatment results. this is also admitted by most of the patients who filled the proforma that they convinced and brought or will bring more patients for surgery. during the last two months, there were hundreds of patients with cataract reporting to our hospital, so we had to give priority to patients with bilateral advanced cataracts in order to utilise our limited resources for the most deserving patients. more than three quarter of the patients came after 1 month for follow up and one third after 3 months which is higher than most studies in africa17. this is due to the fact that we were permanently based with easy access to the patient unlike most population based studies. conclussion our study demonstrates how important is the visual outcome for patients’ satisfaction, giving incentive to the potential cataract surgery patients to come forward for the surgery, which in turn improves the cataract surgery rate. therefore, we should concentrate on establishing eye hospitals with experienced cataract surgical team, good equipment and full range of iols in the remote areas of africa. this is how we can achieve the targets of the "vision 2020—the right to sight" initiative. n o. o f p at ie nt s o pe ra te d n o. o f p at ie nt s 137 author’s affiliation dr. salahuddin ahmad, consultant eye specialist combined military hospital gujranwala dr. khawaja khalid shoaib combined military hospital rawalpindi dr. muhammad fayyaz combined military hospital rawalpindi dr. teyyeb azeem janjua combined military hospital rawalpindi reference 1. thylefors b, negrel ad, pararajasegaram r et al. global data on blindness. bull world health organ 1995; 73: 115-21. 2. foster a. who will operate on africa's 3 million curably blind people? lancet 1991; 337: 1267-9. 3. foster a. cataract and "vision 2020—the right to sight" initiative. br j ophthalmol. 2001; 85: 635–7. 4. dandona l, dandona r, naduvilath tj, et al. populationbased assessment of the outcome of cataract surgery in an urban population in southern india. am j ophthalmol. 1999; 127: 650–8. 5. limburg h, kumar r. follow-up study of blindness attributed to cataract in karnataka state, india. ophthalmic epidemiol. 1998; 5: 211–23. 6. zhao j, sui r, jia l, et al. visual acuity and quality of life outcomes in patients with cataract in shunyi county, china. am j ophthalmol. 1998; 126: 515–23. 7. yorston d. are intraocular lenses the solution to cataract blindness in africa? br j ophthalmol 1998; 82: 469–71. 8. malik ar, qazi za, gilbert c. visual outcome after high volume cataract surgery in pakistan. br j ophthalmol. 2003; 87: 937-40. 9. rapoza pa, west sk, katala sj, et al. prevalence and causes of vision loss in central tanzania. int ophthalmol. 1991; 15, 123-9. 10. rapoza pa, west sk, katala sj, et al. etiology of corneal opacities in central tanzania int ophthalmol. 1993; 17, 47-51. 11. lewallen s, robertsh, hall a, et al. increasing cataract surgery to meet vision 2020 targets; experience from two rural programmes in east africa br j ophthalmol. 2005; 89: 1237-40. 12. shrestha mk, thakur j, gurung ck, et al. willingness to pay for cataract surgery in kathmandu valley. br j ophthalmol. 2004; 88: 319–20. 13. kessy jp, lewallen s. poverty as a barrier to accessing cataract surgery: a study from tanzania. br j ophthalmol. 2007; 91: 1114-6. 14. mccarty ca, nanjan mb, taylor hr. operated and unoperated cataract in australia. clin exp ophthalmol. 2000; 28: 77–82. 15. desai p, minassian dc, reidy a. national cataract surgery survey 1997–8: a report of the results of the clinical outcomes. br j ophthalmol. 1999; 83: 1336–40. 16. yorston d, foster a. audit of extracapsular cataract extraction and posterior chamber lens implantation as a routine treatment for age related cataract in east africa. br j ophthalmol. 1999; 83: 897–901. 17. cook cd, evans jr, johnson gj. is anterior chamber lens implantation after intracapsular cataract extraction safe in rural black patients in africa? a pilot study in kwazulu-natal, south africa. eye. 1998; 12: 821–5. family history is important risk of glaucoma is doubled if a parent has the disease and quadrupled if a sibling has glaucoma prof. m lateef chaudhry editor in chief microsoft word nasir bhatti 1 33 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology original article side effects and effectiveness of subconjunctival bevacizumab injection in patients with corneal neovascularization nasir bhatti, umair qidwai, umer fawad, munawar hussain, aziz ur rehman, mazhar ul hasan pak j ophthalmol 2012, vol. 28 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nasir bhatti isra postgraduate institute of ophthalmology/al-ibrahim eye hospital, malir, karachi …..……………………….. purpose: to evaluate the side effects and effectiveness of subconjunctival bevacizumab injection in reducing corneal neovascularization material and methods: patients selected according to inclusion and exclusion criteria were randomly allocated to either group 1 (patients were given subconjunctival bevacizumab injection) and group 2 (patients were given subconjunctival sham injection), its effectiveness in the form of decrease in neovascular area and side effects were compared between the two groups. results: 41 patients were included in each group. there was no statistical significance between the 2 groups in effectiveness of the subconjunctival injection as well as in the complications except decrease in the fibrinogen level which was observed in group 1. conclusion: subconjunctival bevacizumab injection failed to show significant improvement in either corneal neovascularisation or visual acuity. he cornea has the only one of its kind feature of being normally avascular, but under pathologic conditions, vessels march into the cornea from the limbal vascular plexus. a wide range of insults, including infection, inflammation, ischemia, degeneration, trauma, and loss of the limbal stem cell barrier, can results in corneal neovascularization (nv)1. even though corneal neovascularization can occasionally serve a advantageous role in the clearing of infections, wound healing, and arresting stromal melts,2 its disadvantages are abundant. corneal neovascularization leads to tissue scarring, edema, lipid deposition, and persistent inflammation that may significantly alter visual acuity3. corneal neovascularization accompanies the most frequent causes of corneal infectious blindness4,5. corneal neovascularization is also noteworthy in extended wear of hydrogel contact lenses6,7. corneal neovascularization not only reduces visual acuity but it also results in the loss of the immune privilege of the cornea, thus, increasing the chances of failure after penetrating keratoplasty8. preexisting corneal stromal blood vessels have been identified as strong risk factors for immune rejection after corneal transplantation9,10. existing treatments for corneal neovascularization, includes medications (such as steroids or nonsteroidal anti-inflammatory agents), laser photocoagulation, fine-needle diathermy, photodynamic therapy, or restoration of the ocular surface with the use of conjunctival, limbal, or amniotic membrane transplantation, have established variable and largely limited clinical success1. the uneven efficacy and innumerable adverse effects (cataract, glaucoma, and increased risk of infection) of topical and systemic corticosteroids are well recognized, but none of these treatments particularly target the molecular mediators of angiogenesis11. vascular endothelial growth factor (vegf) has found to be a key mediator in the process of neovascularization11. the important role of vegf in the pathophysiology of corneal neovascularization has been confirmed in experimental models of corneal neovascularization12. it has been revealed that vegf is up regulated in inflamed and vascularized corneas in humans and animal models13. t nasir bhatti et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 34 vascular endothelial growth factor inhibitors, such as pegaptanib sodium, ranibizumab, and bevacizumab, are at present used for the treatment of neovascular age – related macular degeneration14. lately, off-label use of topical as well as subconjunctival bevacizumab has also been well thought – out to be a new treatment modality for corneal neovascularization15-18. bevacizumab was demonstrated to inhibit corneal neovascularization after chemical injury in an experimental rat model15. in humans, a small number of studies have shown that topical bevacizumab can reduce corneal neovascularization in a few patients with significant corneal neovascularization16,17. however,data regarding the efficacy and side effects of sunconjunctival bevacizumab is lacking. the purpose of this study is to report the longterm (6-month) results of the side effects and, efficacy of treatment of clinically stable corneal neovascularization in patients using subconjunctival bevacizumab in a prospective, randomized clinical study. material and methods this was a randomized controlled study. side effects / efficacy of subconjuctivally administered bevacizumab in subjects with corneal neovasculari-zation was observed. this study was conducted at isra postgraduate institute of ophthalmology and approved by the ethical committee of isra postgraduate institute of ophthalmology. patients, who were selected in the study, signed an informed consent before any intervention. patients with clinically stable superficial corneal nv that extended farther than 2mmfrom the limbus were selected. patients older than 25 years, of either sex, were included. however, stable corneal neovascularization were only considered when there had no current or recent (less than 3 months) episode of corneal and ocular surface infection (bacterial, viral, fungal, or parasitic). patients with history of ocular surgery such as keratoplasty, amniotic membrane transplantation or ocular surface reconstruction, were excluded. similarly patients who had history of use of contact lens were also excluded. also excluded were the patients having persistent corneal epithelial defects. patients having age greater than 75 years, uncontrolled hypertension (defined as systolic blood pressure of > 150 mm hg or diastolic blood pressure of > 90 mm hg) were also excluded. history of a thromboembolic event (including myocardial infarction or cerebral vascular accident), diabetes mellitus and renal or liver abnormalities were also among the exclusion criterias. patients who had history of use of corticosteroid antithrombotic drugs or aspirin were not included. history of ocular or periocular malignancy, pregnancy or lactation were also among the exclusion criteria’s for the study. a written consent was taken from all the participants of the study. a subconjunctival injection of bevacizumab (0.2 ml of 1.25 mg / 0.05 ml) solution was formulated and aseptically prepared from commercially available intravenous bevacizumab (avastin; genentech inc, san francisco, california). patients were randomly divided into 2 groups, group a (patients will be injected with subconjunctival bevacizumab injection) and group b (patients in this group will be injected with sham / normal saline subconjunctival injection). injections were given at only single site, which was selected as the site of entry of main vessel into the cornea, in cases of diffuse vascularization the area of most dense neovessels was selected. only patients with superficial neovascularization were selected. patients included had corneal neovascularization secondary to infective, noninfective keratitis, corneal degeneration and trauma / foreign body. causative agents in most of the cases were microbes including bacteria and fungai, it also included trauma such as chemical burn, or instrumental injury. follow-up visits were scheduled after 1week, after first month, after 3 months and after 6 months. on every visit, comprehensive eye examinations were done including digital corneal photographs. blood pressure measurements were obtained in all visits. fibrinogen level, platelet count, prothrombin time (pt), and aptt were tested in blood at baseline (before injection) and at the 6th month follow up. main outcome measures ocular complications ocular side effects were monitored. all side effects (ocular and systemic) were recorded throughout the study. ocular adverse events were identified by eye examination, visual acuity testing, intraocular pressure, biomicroscopy and corneal fluorescein staining. systemic side effects were identified by physical examination, blood pressure recordings, and blood tests of fibrinogen level and platelet count. efficacy the primary efficacy variables were the size of neovascular area. by comparing baseline corneal side effects and effectiveness of subconjunctival bevacizumab injection in patients 35 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology photographs with follow-up photographs, the efficacy of bevacizumab in treatment of corneal nv was evaluated. matlab software was used to exactly compare the photographs. other efficacy variables such as the changes in best-corrected visual acuity were also recorded. statistical analysis was done using spss version 17. paired t test was used to compare baseline and 6th month recordings. results 82 patients were included in the study, 41 were in the group a (bevacizumab) while rest of the 41 were in the group b (sham). out of these 82 patients, 62 (76.5%) were males while 20 (23.5%) were females. they were between 45 years of age to 59 years of age with mean age of 53.23 years. (out of 41 patients, although) patients had decrease in the neovascular area in group a (decreased area was considered when there was decrease in area in mm), compared to only 1 in group b, but this difference is not significant statistically (p > 0.05), (table 1). similarly, 2 patients had improvement in visual acuity in group a, compared to only 1 in group b, but this difference is also not significant statistically (p > 0.05), (table 2). (visual improvement was considered when single line improvement was seen after the treatment in visual acuity) the only ocular complication observed was subconjunctival hemorrhage, which was almost equally observed in both groups, showing that it is injection related rather than drug related (table 3). among the systemic changes observed among the 2 groups, only serum fibrinogen level was decreased in group a (p = 0.003) after the injection. the systemic features observed among the 2 groups before and after the injection are shown in (table 4). table 1: efficacy of subconjuctival bevacizumab injection. (comparison between baseline, before injection, and after 6 months) reduction in neovascular area no reduction in neovascular area increase in neovascular area total group a (bevacizumab group) 3 34 4 41 group b (sham group) 1 34 6 41 n = 41 (in each group) table 2: best corrected visual acuity (comparison between baseline, before injection, and after 6 months) improveme nt in best corrected visual acuity no improvement in best corrected visual acuity decrease in best corrected visual acuity total group a (bevacizumab group) 2 38 1 41 group b (sham group) 1 39 1 41 table 3: ocular complications complication group a (bevacizumab) group b (sham) subconjunctival hemmorhage 05 06 table 4: sytemic complications group a (bevacizumab) group b (sham) fibrinogen level before the injection 286.88mg /dl p= 0.003 256.48mg/ dl p>0.05 after 6 months 255.01 mg/dl 255.01 mg/dl systolic blood pressure before the injection 142.22 p>0.05 134.34 p>0.05 after 6 months 146.00 133.20 diastolic blood pressure before the injection 88.89 p>0.05 89.32 p>0.05 after 6 months 91.23 90.13 platelet count before the injection 234500.00 p>0.05 233450.00 p>0.05 after 6 months 228875. 00 233875.0 0 discussion newly or already formed corneal neovascularisation increases the risk of subsequent graft rejection after corneal transplantation as well.19 medical and surgical therapies used to diminish corneal neovascularisation include corticosteroids, nonsteroidal anti-inflammatory agents, laser photocoagulation, and needle diathermy20. many of these therapies have not only confirmed limited success but multiple side effects have also been repoerted. anti-vegf therapy targeting corneal neovascularisation has recently nasir bhatti et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 36 showed triumphant results in animal experiments. in rat models, topical bevacizumab (4 mg/ml) applied twice daily for 1 week reduced chemically induced corneal neovascularisation21. anti-vegf antibody entrenched in neovascularized corneal stroma suppressed corneal nv22. such findings only indicate the potential of anti-vegf in controlling neovascularisation. vascular endothelial growth factor affects the metabolism,23 and may result in changes related with vascularization through intact tissue layers. it upregulates platelet activating factor, increases plasminogen activator gene expression in corneal epithelium24-26. plasminogen activator has a role in cell migration, cell adhesion, and tissue remodeling, it thus plays a key role wound healing and revival27,28. vegf also increases fibrinolytic activity of endothelial cells in fibrin matrices with the involvement of vegf receptor-2, tissue type plasminogen activator, and matrix metalloproteinases28. many studies have shown that anti-vegf is effective in suppressing new vessel formation and vascular leakage, which can improve visual function, but in this study we have not observed any significant improvement in either neovascularization or visual acuity. anti-vegf therapy is considered as a possible tool for controlling neovascularisation in many clinical fields, but our study showed no usefulness in corneal neovascularisation. although, fibrinogen level decreased after the injection, but no other systemic or ocular drug related complication was seen in our study, which shows that it is a safe drug. the main limitation of our study was that it was conducted in a single centre rather than multiple centers and patients of similar racial background were included in the study. conclusion subconjunctival bevacizumab in our study failed to prove its effectiveness in reducing the neovascular area in cases of corneal neovascularization when it was injected subconjunctivally. author’s affiliation dr. nasir bhatti isra postgraduate institute of ophthalmology/ al-ibrahim eye hospital, malir, karachi dr. umair qidwai isra postgraduate institute of ophthalmology/ al-ibrahim eye hospital, malir, karachi dr. umer fawad isra postgraduate institute of ophthalmology/ al-ibrahim eye hospital, malir, karachi dr. munawar hussain isra postgraduate institute of ophthalmology/ al-ibrahim eye hospital, malir, karachi dr. aziz ur rehman associate professor isra postgraduate institute of ophthalmology/ al-ibrahim eye hospital, malir, karachi dr. mazhar ul hasan assistant professor isra postgraduate institute of ophthalmology/ al-ibrahim eye hospital, malir, karachi reference 1. chang jh, gabison ee, kato t, et al. corneal neovascularization.curropinophthalmol. 2001; 12: 242-9. 2. conn h, berman m, kenyon k, et al. stromal vascularization prevents corneal ulceration. invest ophthalmol vis sci. 1980; 19: 362-70. 3. epstein rj, stulting rd, hendricks rl, et al. corneal neovascularization: pathogenesis and inhibition. cornea. 1987; 6: 250-7. 4. liesegang tj. epidemiology of ocular herpes simplex: natural history in rochester, minn, 1950 through 1982.arch ophthalmol. 1989; 107: 1160-5. 5. resnikoff s, pascolini d, etya’ale d, et al. global data on visual impairment inthe year 2002. bull world health organ. 2004; 82: 844-51. 6. lamer l. extended wear contact lenses for myopes: a followup study of 400cases. ophthalmology. 1983; 90: 156-61. 7. stark wj, martin nf. extended-wear contact lenses for myopic correction. archophthalmol. 1981; 99: 1963-6. 8. dana mr, streilein jw. loss and restoration of immune privilege in eyes with corneal neovascularization. invest ophthalmol vis sci. 1996; 37: 2485-94. 9. maguire mg, stark wj, gottsch jd, et al. collaborative corneal transplantation studies research group. risk factors for corneal graft failure and rejection in the collaborative corneal transplantation studies. ophthalmology 1994; 101: 1536-47. 10. williams ka, roder d, esterman a, et al. factors predictive of corneal graft survival: report from the australian corneal graft registry. ophthalmology. 1992; 99: 403-14. 11. folkman j. angiogenesis in cancer, vascular, rheumatoid and other disease. nat med. 1995; 1: 27-31. 12. amano s, rohan r, kuroki m, et al. requirement for vascular endothelial growth factor in woundand inflammation-related corneal neovascularization. invest ophthalmol vis sci. 1998; 39: 18-22. 13. philipp w, speicher l, humpel c. expression of vascular endothelial growth factor and its receptors in inflamed and vascularized human corneas. invest ophthalmol vis sci. 2000; 41: 2514-22. 14. kim ti, kim sw, kim s, et al. inhibition of experimental corneal neovascularization by using subconjunctival injection of bevacizumab (avastin). cornea. 2008; 27: 349-52. side effects and effectiveness of subconjunctival bevacizumab injection in patients 37 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology 15. manzano rp, peyman ga, khan p, et al. inhibition of experimental corneal neovascularisationby bevacizumab (avastin). br j ophthalmol. 2007; 91: 804-7. 16. kim sw, ha bj, kim ek, et al. the effect of topical bevacizumab on corneal neovascularization. ophthalmology 2008; 115: 33-8. 17. destafeno jj, kim t. topical bevacizumab therapy for corneal neovascularization. arch ophthalmol. 2007; 125: 834-6. 18. bahar i, kaiserman i, mcallum p, et al. subconjunctival bevacizumabinjection for corneal neovascularization. cornea. 2008; 27: 142-7. 19. volker-dieben hj, d’amaro j, kok-van alphen cc. hierarchyof prognostic factors for corneal allograft survival. aust nz j ophthalmol. 1987; 15: 11-8. 20. chang jh, gabison ee, kato t, et al. corneal neovascularization. curropin ophthalmol. 2001; 12: 242-9. 21. manzano rp, peyman ga, khan p, et al. inhibition of experimental corneal neovascularisation by bevacizumab (avastin). br j ophthalmol. 2007; 91: 804-7. 22. amano s, rohan r, kuroki m, et al. requirement for vascularendothelial growth factor in wound and inflammationrelatedcorneal neovascularization. invest ophthalmol vis sci 1998; 39: 18-22. 23. wu y, zhang q, ann dk, et al. increased vascular endothelial growth factor may account for elevated level of plasminogenactivator inhibitor-1 via activating erk1/2 in keloid fibroblasts. am j physiol cell physiol. 2004; 286: 905-12. 24. bernatchez pn, allen bg, gélinas ds, et al. regulation of vegf-induced endothelial cell paf synthesis: role of p42/44mapk, p38 mapk and pi3k pathways. br j pharmacol. 2001; 134: 1253-62. 25. tao y, bazan he, bazan ng. platelet-activating factor enhances urokinase – type plasminogen activator gene expression in corneal epithelium. invest ophthalmol vis sci. 1996; 37: 2037-46. 26. watanabe m, yano w, kondo s, et al. up-regulation of urokinase – type plasminogen activator in corneal epithelial cells induced by wounding. invest ophthalmol vis sci. 2003; 44: 3332-8. 27. irigoyen jp, muñoz-cánoves p, montero l, et al. the plasminogen activator system: biology and regulation. cell mollife sci. 1999; 56: 104-32. 28. blasi f. proteolysis, cell adhesion, chemotaxis, and invasiveness are regulated by the u-pa-u-par-pai-1 system. thromb haemost. 1999; 82: 298-304. microsoft word news and evants 26,4,2010 233 news and events vol. 26, 4, 2010 lahore ophthalmo date: 24-26 december 2010 venue: pearl continental hotel lahore, pakistan secretary: dr. zahid kamal siddiqui secretariat: osp house 4 – a lda flats, lawrence road, lahore. phone: 92 – 42 – 36363325 fax: 92 – 42 – 36363326 email: osplahore@hotmail.com association for research in vision and ophthalmology (arvo) annual meeting date: 1 – 5 march 2011 venue: florida, usa apao sydney date: 21 – 24 march 2011 venue: sydney, australia american society of cataract and refractive surgery (ascrs) / american society of ophthalmic administrators (asoa) symposium and congress date: 26 – 30 march 2011 venue: san diego, usa xvix congress of the european society of cataract and refractive surgeons (escrs) date: 17 – 20 september 2011 venue: vienna, australia annual meeting of american academy of ophthalmology (aao) date: 22 – 25 october 2011 venue: orlando, usa 33rd world ophthalmology congress (woc) date: 16 – 20 february 2012 venue: abu dhabi, united arab emirates institute / courses pakistan institute of community ophthalmology, peshawar – pakistan comprehensive range of courses for doctors, nurses and paramedics contact: professor shad muhammad professor and rector pico, hayat abad medical complex peshawar phone: 091 – 9217376 – 80 fax: 92 – 42 – 6363326 email: pico@pes.comsats.net.pk punjab institute of preventive ophthalmology, lahore, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: prof. asad aslam khan executive director college of ophthalmology and allied vision sciences, kemu / mayo hospital, lahore phone: 042 – 37355998 fax: 042 – 37248006 email: pipo@brain.net.pk pakistan institute of ophthalmology, al – shifa trust eye hospital, rawalpindi, pakistan comprehensive range of courses for doctors, nurses and paramedics contact: secretary, pio, al – shifa trust eye hospital, jhelum road, rawalpindi – pakistan phone: 92 – 51 – 5487830, 5487820 – 25 fax: 92 – 51 – 5487827 email: info@alshifa-eye.org.pk please send any suggestion about this section to: prof. hamid mahmood butt department of ophthalmology fatima jinnah medical college sir ganga ram hospital, lahore fax: 92 – 42 – 6363326 email: hamidbut@gmail.com mobile: 0300 – 4158962 pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 123 editorial leadership development in ophthalmology: investing in the future of the profession catherine green pak j ophthalmol 2017, vol. 33 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ver the last two decades, there has been widespread acknowledgement that the medical professionals of today and the future require a much broader skill set than just good clinical knowledge and expertise. these additional skills and competencies have been formally articulated by medical societies and organisations, for example the canmeds framework outlined by the royal college of physicians and surgeons of canada1 and the core competencies of the accreditation council for postgraduate medical education (acgme)2. healthcare organisations around the world have reiterated that effective leadership should be present at all levels, whether it is a clinical or academic field3. leadership, an intangible concept with many definitions, has been described as a “process of social influence in which one person can enlist the aid and support of others in the accomplishment of a common task”.leadership is about defining a vision for individuals, and setting values that are inspiring and lead the organisation in a strategic direction4. there is a growing body of evidence that medical leadership plays a critical role in the effectiveness of organisational change in the health sector5. clinicians are not only equipped to make calculated choices but also have the ability to make cutting edge decisions to establish the competency and excellence of healthcare6. one study demonstrated that medical institutions with higher contribution in management had about 50% more score on crucial performance drivers compared with institutions having very little clinical leadership7. physicians who are involved in development of their leadership skills are usually motivated to manage the important steps in patient management, build better knowledge and poise to start a transformation that is positive and endorse improved alignment of the team8. in ophthalmology, leadership is required in the clinical setting, both in direct patient care, which includes leading and managing teams, as well as at the institutional level of hospitals and health care organisations. educational leadership is required for education and training as well as academic research. organisational leadership is required for ophthalmic societies, through which advocacy efforts aimed at governments and healthcare decision-makers can be highly effective. concepts of leadership have evolved from the “great man theory”, which implies that great leaders are born and not made, arising when there is a great need, to an acceptance that leadership consists of definable skills that can be developed through experience, observation and education3. despite the widespread recognition of the need for and value of clinician leadership, as well as the benefits of training clinicians in these skills, most medical and surgical curricula remain focussed on clinical knowledge and skills, with less emphasis on teaching and assessment of non-clinical professional competencies, including leadership. ophthalmologists, having not been trained in leadership skills, may be reluctant to take on leadership roles: they have undertaken years of training for their clinical role, so many assume that months or years of training are needed before being able to be a competent leader6. as a result, opportunities to influence positive change may not be fully realised. recognising this shortfall, the ophthalmic profession has been pro-active in investing in o catherine green 124 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology leadership development. this drive started in the united states through the american academy of ophthalmology, which launched its leadership development program in 1998, with the goals of identifying individuals with the potential to become leaders in ophthalmology, providing orientation and skills to allow potential leaders to promote ophthalmology locally, nationally and internationally, and facilitating the promotion of program graduates into leadership positions locally, nationally and internationally9.since then, leadership development programs (ldps) in ophthalmology have expanded around the globe, with programs run by supranational and national ophthalmic organisations, including the ophthalmological society of pakistan. to maximise their effectiveness, programs should be based on adult learning principles10, acknowledging that participants are independent and self-directing, have experience that provides a rich resource for learning, value learning that integrates with the demands of everyday life, and prefer immediate, problem centred approaches. leadership programs usually incorporate a combination of methods to train and assess leadership skills3. these may include: 1. mentoring: off-line help by one person to another in making transitions in knowledge, work and thinking; 2. coaching: a shorter-term, goal-oriented process aimed at performance enhancement in specific areas; 3. networking: providing a wide range of contacts, perspectives and information; 4. stretch assignments: the individual is required to work outside their comfort zone to learn new skills, knowledge or behaviours; 5. action learning: joint problem solving of issues that arise in the workplace, during reallife projects or by observing and working with others; 6. multi-source or 360-degree feedback: views of peers, managers and other team members about leadership skills and competencies are obtained, collated and fed back to the individual, preferably by an accredited professional trained in this process. although the ophthalmology ldps around the world vary in structure, content and length, all cover the key aspects of leadership: self-awareness, awareness of others, communication skills, management skills, governance and advocacy, using a combination of the teaching methods outlined above. a key component of the programs is the requirement for participants to complete a self-directed project, the topic of which should be related to leadership, not clinical ophthalmology, and which fulfils the purpose of a stretch assignment. although some components can be learnt through reading or online study, much of leadership is experiential, which makes face-to-face interactive learning essential. this also creates opportunities for networking, as well as the creation of a community of practice11, where learning takes place through joint enterprise, shared repertoire and mutual engagement. in contrast to training, which teaches proven solutions to known problems, development is geared towards the future and involves learning the skills to tackle as yet undefined problems12. ldps are constrained by finite timelines and resources, but aim to prime participants for a lifelong journey of learning and self-transformation. whilst ophthalmology leadership development programs are now well established, there have been challenges to overcome, and challenges remain. it is known that clinicians may be sceptical about the value of spending time on leadership and there is discomfort with the difficulties proving its impact. clinicians may have established views of what constitutes robust evidence – rooted in evidence-based medicine for clinical interventions – and are less familiar with qualitative research methods, which they may regard as fundamentally ambiguous, even weak6. evaluation needs to be undertaken, not only to assist in continuous improvement of the programs, but to ensure that individuals and organisations can be convinced to invest in leadership development. adequate financial, human and time resources are required to ensure these programs are sustainable. kirkpatrick’s framework provides a structure through which to approach evaluation of the impact of ldps13. the framework evaluates effectiveness at four levels: reaction (satisfaction or happiness), learning (knowledge or skills acquired), behaviour (transfer of learning to the workplace) and results (impact on society). surveying participants for their reaction to participation has revealed widespread enthusiastic satisfaction and strong acknowledgement of the need for such programs. in terms of demonstration of learning through transfer to the workplace, there have been hundreds of ophthalmology ldp graduates around the world assuming leadership roles in their leadership development in ophthalmology: investing in the future of the profession pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 125 clinical and medico-political organisations, and it is through them that new ldps have been established. whilst most participants would have been selected into ldps for a demonstrated aptitude for leadership, many have reported accelerated progression to positions they would never have previously considered. the most powerful lens through which to evaluate effectiveness is the impact on society. ophthalmologists strive to improve access to the highest quality eye care in order to preserve and restore vision for the people of the world14. many ldp projects have directly achieved this. more difficult to measure is the indirect benefit to patients and the community from engagement of younger ophthalmologists earlier in their careers and providing them with the opportunity to accelerate the development of vital leadership, management and advocacy skills that they will continue to apply throughout their entire career. there are opportunities to add to the momentum of what has already been achieved by embedding the teaching, learning and assessment of leaderships skills in undergraduate and postgraduate medical and surgical curricula, as well as creating career pathways for clinicians that acknowledge, value and reward leaders. there is a well-established literature on leadership; in the same way that medicine and surgery have benefited from lessons learned from the aviation industry to improve quality and safety, there is much to be gained from collaborating with other professional groups, including business administration, from which much of the leadership evidence base has been developed. author affiliation catherine green mbchb, franzco, mmedsc royal australian and new zealand college of ophthalmologists and the royal victorian eye and ear hospital, melbourne references 1. royal college of physicians and surgeons of canada. the canmeds framework: royal college of physicians and surgeons of canada,; 2014 http://www.royalcollege.ca/portal/page/portal/rc/ca nmeds/framework. 2. accreditation council for graduate medical education. acgme mission, vision, and values: acgme; 2014. https://www.acgme.org/acgmeweb/. 3. patel vm, warren o, humphris p, ahmed k, ashrafian h, rao c, et al. what does leadership in surgery entail? anz journal of surgery, 2010; 80 (12): 876-83. 4. jones s, mccay l, keogh sb. the importance of clinical leadership. in: swanwick t, mckimm j, editors. abc of clinical leadership. oxford, uk: wiley blackwell, bmj books; 2011; 1-3. 5. ham c. improving the performance of health services: the role of clinical leadership. lancet, 2003; 361 (9373): 1978-80. 6. mountford j, webb c. when clinicians lead: mckinsey & company; 2009. http://www.mckinsey.com/industries/healthcaresystems-and-services/our-insights/when-clinicianslead. 7. castro pj, dorgan sj, richardson b. a healthier health care system for the united kingdom. mckinsey quarterly, 2008 (february). 8. stoller jk. developing physician-leaders: key competencies and available programs. the journal of health administration education, 2008; 25 (4): 307-28. 9. american academy of ophthalmology. leadership development program san francisco, 2017 [cited 2017 26 january]. available from: https://www.aao.org/about/leadershipdevelopment/overview. 10. knowles m. the modern practice of adult education. from pedagogy to andragogy. 2nd ed. englewood cliffs:: prentice hall/cambridge; 1980. 11. wenger e. communities of practice: learning, meaning and identity. new york: cambridge university press; 1998. 12. souba ww. building our future: a plea for leadership. world journal of surgery, 2004; 28 (5): 445-50. 13. kirkpatrick d. great ideas revisited: revisiting kirpatricks's four-level model. training & development, 1996; 50 (january): 54. 14. international council of ophthalmology. international council of ophthalmology san francisco: ico; 2017 [cited 2017 26 january]. available from: http://www.icoph.org/about.html. http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework https://www.acgme.org/acgmeweb/ http://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/when-clinicians-lead http://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/when-clinicians-lead http://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/when-clinicians-lead https://www.aao.org/about/leadership-development/overview https://www.aao.org/about/leadership-development/overview http://www.icoph.org/about.html microsoft word norin bano 1 corrected 173 original article efficacy of goniotomy in management of primary congenital glaucoma norin iftikhar bano, mariam irfan akram, harris muzammil ansari, mirza jamil ud din baig pak j ophthalmol 2010, vol. 26 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: norin iftikhar bano 1429 tufail road lahore cantt received for publication january’ 2010 …..……………………….. purpose: to assess the effectiveness of goniotomy in children suffering from primary congenital glaucoma. material and methods: 22 patients were selected from pediatric outdoor of lrbt free eye and cancer hospital, lahore. 37 eyes of those 22 patients underwent goniotomy. regular follow-up visits were planned after their surgery on which their intraocular pressure (iop), cup/disc ratio (cd ratio) and horizontal corneal diameters were recorded. final post-operative iop, cd ratio and corneal diameters were recorded on the 180th post-operative day. results: 37 eyes of 22 patients were operated. their demography showed that 14 patients (64%) were male and 8 patients (36%) were female. mean age of the patients was 9.54 months, ranging from 2 – 36 months. on 180th postoperative day, it was seen that iop decreased in 92% cases, cd ratio reversal occurred in 67.6% eyes and horizontal corneal diameters remained stable in 75.7% eyes. conclusion: goniotomy is an effective procedure to treat children having primary congenital glaucoma. rimary congenital glaucoma (pcg) is a group of disorders characterized by improper development of the aqueous drainage system of the eye. it is detected by raised intraocular pressure (iop). infantile eyes have elastic sclera and cornea, and therefore, stretch in response to raised iop resulting in an enlarged globe. the classic symptoms include epiphora, photophobia and blepharospasm, which are secondary to corneal edema. the signs and symptoms tend to be variable. pcg is the most common developmental glaucoma. its patients are classified according to age at which it is first diagnosed. patients detected at birth or within first month are known as newborn pcg, those during the first two years as infantile and older ones diagnosed thereafter are known as juvenile pcg1. pcg occurs in newborns of western countries 1 in 5000 to 1 in 220002. several theories have been proposed to suggest the pathogenesis of pcg. barkan’s theory suggested that pcg was due to an imperforate inner layer of pretrabecular tissue named barkan’s membrane4. another theory by anderson suggested that the defect responsible was premature or excessive collagen formation in the trabecular meshwork. this leads to resistance to the outflow of aqueous. the management of congenital glaucoma is primarily surgical. goniotomy and trabeculotomy are the commonly done procedures. the aim of goniotomy, introduced by barkan in 1936, is to circumferentially incise the trabeculum and therefore, reduce the resistance to the outflow of aqueous humour5. the objective of our study was to see that how effective goniotomy was in controlling iop, in causing reversal of cd ratio and in stabilizing corneal diameters. material and methods this was a quasi experimental study. all the patients included in this study were selected from pediatric outdoor of layton rahmatulla benevolent trust free eye and cancer hospital lahore. non-probability purposive sampling was done and a sample of 37 eyes of 22 patients was selected. inclusion criteria included p 174 patients having pcg who needed goniotomy as the surgical procedure to treat glaucoma. patients who were excluded were those who had horizontal corneal diameters more than 15 mm or the ones who had undergone any other ocular surgery or who had any coexisting ocular or systemic disease. after selecting the patients, informed consent was taken from the parents. demographic profile of the patients was noted including their name, age, sex and address. detailed history was taken from the parents. history of any previous eye or systemic disorders or surgeries was noted. special emphasis was given to the family history of glaucoma and eye disorders. parents were asked about the health of the rest of their children, if any. detailed ocular examination was completed under sedation. examination included detailed anterior segment and dilated fundus examination, measurement of iop and horizontal corneal diameters. iop was measured by using handheld perkin’s tonometer after anesthetizing the patient’s cornea with 0.5% proparacaine (alcaine) eye drops. measuring calipers were used to assess the horizontal corneal diameters. parents of the patients were counseled regarding the surgical procedure thereafter informed consent was taken. all goniotomies were done by one pediatric ophthalmologist. the surgery was done under general anesthesia. swan jacobs goniotomy lens was used to visualize the angle of the anterior chamber. paracenteses was done with a 22 gauge needle, after making a self sealing port with same needle. carbachol was injected to constrict the pupil. after bending needle at 90 degrees, it was attached with a syringe containing viscoelastic. anterior chamber was filled with viscoelastic and trabecular meshwork incised as far as possible. the surgeon then made another port, 90 degrees away from the first port, so that the remaining angle could be treated as far as possible. the anterior chamber was washed with balanced salt solution containing syringe attached with a hydrodissection canula. ports were hydrated in the end and an air bubble was left in anterior chamber. patients were prescribed topical antibiotic and steroid eye drops along with cycloplegics postoperatively. visits were planned on the 1st postoperative day, 1st and 2nd postoperative weeks, and 1st, 2nd and 6th postoperative months. on each follow-up visit, iop was recorded, cd ratio observed and horizontal corneal diameters measured. all data was recorded on a proforma specially designed for the study. data was analyzed using the computer software spss version 11. mean and standard deviation were calculated for the preoperative and post-operative iop. they were compared using paired ‘t’ test. p < 0.05 was considered significant. reversal of cd ratios and stabilization of horizontal corneal diameters were expressed as percentages. results sample was of 22 patients (37 eyes). majority of patients were male – 14 male patients (64%) and 8 female patients (36%). mean age of the patients was 9.5 months, ranging from 2 – 36 months, (figure 1). 15. bilateral surgery was performed on (68%) patients 7 patients (32%) were operated on one eye. mean pre-operative iop was 18.92 ± 5.08 mmhg, whereas mean postoperative iop was 12.03 ± 5.08 mm hg (figure 2). both these values were compared using paired ‘t’ test and p < 0.05, showing statistically significant difference. the iop decreased in 34 eyes (92%) after goniotomy and only 3 eyes (8%) had raised iop in spite of surgery. cd ratio reversal occurred in 25 eyes (68%). there was no change in cd ratio in 9 eyes (24%), while 3 eyes (8%) showed increased cd ratio even after goniotomy. (figure 3) horizontal corneal diameters remained stable in 28 eyes (76%) whereas, 9 eyes (24%) had increased corneal diameters after surgery. in our study, 9 eyes (24%) needed a repeat goniotomy while 2 eyes had to undergo trabeculectomy. discussion pcg is an uncommon disease. since it is very rare, it is often misdiagnosed or sub-optimally treated. it is estimated that if an ophthalmologist in a non-specialist center in the western world wanted to see a new case of pcg, it would be expected every 5 years6. a prospective, national population based study of pediatric glaucoma in the united kingdom showed some very interesting results regarding the ethnic 175 origin and the incidence of pcg. in a comparison of ethnic groups and type of glaucoma, it revealed that 75% of asian children (india, pakistan, bangladesh) with glaucoma had primary glaucoma compared to 33-43% of children of other ethnic origins. the highest incidence in defined ethnic group was in pakistani origin children, almost 9 times that of caucasians7. 5 3 1 1 3 2 1 1 1 1 1 2 0 1 2 3 4 5 6 -23 4 5 6 8 9 11 12 15 24 36 fig. 1: age at presentation m ea n in tr ao cu la r p re ss ur e / m m h g age in months mean pre-op iop 18.92 mmhg pre-op iop post-op iop mean post-op iop 12.03 mmhg 30 20 10 0 2 3 4 5 6 8 9 11 12 13 24 36 fig. 2: the management of pcg is mainly surgical. goniotomy is one of the procedures performed to treat pcg. goniotomy is a good option in cases of children having clear cornea and where the surgeon is familiar with the technique. success rates of goniotomy have ranged between 68 – 100%. its outcome being better in children than in adults4. our results are within this range. although surgery for pcg is effective, many patients require repeated surgeries to achieve the necessary control of iop8. in our study, 9 eyes (24%) needed a repeat goniotomy and 2 eyes (5%) later had trabeculectomy. goniotomy has one advantage over other filtering procedures: the conjunctiva remains undisturbed. therefore, a filtering procedure, such as trabeculectomy, can be done easily if required afterwards. enlarged corneal dimensions are thought to influence the prognosis of goniotomy. a corneal diameter more than 14mm is associated with bad prognosis in some reports6, 9, 10. in our study, the 3 eyes in which the iop increased despite surgery were the ones with corneal diameters more than 14mm. reversed 67.6% increased 8.1% no change 24.3% fig. 3: post-operative cup / disc ratio conclusion this study proves efficacy of goniotomy in cases of primary congenital glaucoma patients. it is a fresh reminder to pediatric glaucoma specialist that it is simple and effective procedure for primary congenital glaucoma with clear corneas, still leaving surgeon with rest of the options. author’s affiliation dr. norin iftikhar bano layton rahmatullah benevolent trust free eye & cancer hospital lahore dr. mariam irfan akram layton rahmatullah benevolent trust free eye & cancer hospital lahore dr. harris muzammil ansari institute of authors layton rahmatullah benevolent trust free eye & cancer hospital lahore mean age : 9.5 months n o. o f c hi ld re n 2 age in months 176 dr. mirza jamil ud din baig institute of authors layton rahmatullah benevolent trust free eye & cancer hospital lahore reference 1. walton d, katsavounidou g: newborn primary congenital glaucoma: 2005 update. j ped ophthalmol. and strab. 2005; 42: 333-41. 2. ohtake y, tanino t, suzuki y, et al. phenotype of cytochrome p4501b1 gene (cyp1b1) mutations in japanese patients with primary congenital glaucoma. br j ophthalmol. 2003; 87: 302-4. 3. butt nh: childhood blindness – etiological pattern and hereditary factors. pak j ophthalmol. 2002; 18: 92-4. 4. mincklet d, baerveldt g, ramirez ma, et al. clinical results with trabectome, a novel surgical device for treatment of open angle glaucoma. trans am ophthalmol soc. 2006; 104: 40-50. 5. khaw pt, freedman s, gandolfi s: management of congenital glaucoma.j glaucoma. 1999; 8: 81-5. 6. walton ds: primary congenital open angle glaucoma. chandler pa, grant wm eds.glaucoma. 1979; 2nd ed. 329-43. 7. papadopoulos m, cable n, rahi j, et al. eye study investigators: investigative ophthalmology and visual science. 2007; 48:4100-106. 8. burke jp and bowell r. primary trabeculectomy in congenital glaucoma. br. j ophthalmol. 1989; 73:186-190. 9. scheie hg. the management of infantile glaucoma. arch ophthalmol. 1959; 62: 35-54. 10. lister a. the prognosis in congenital glaucoma. trans ophthalmol soc uk. 1966; 86: 5-18. ordering imaging investigations imaging facilities despite being available now in most of the places are expensive and not without risks. these should be ordered to facilitate clinical localization and expectation of particular findings to reach proper diagnosis, plan appropriate management and provide more accurate prognosis of the history of the disease and only if the information is not available by simpler, safer and less expensive means. prof. m. lateef chaudhry editor in chief microsoft word younis tahir 175 original article comparative study of endothelial cell loss after phacoemulsification by using 2% hydroxypropyl methylcellulose (hpmc) versus 2.3% sodium hyaluronate (healon 5) muhammad younis tahir, rafay amin baig, khalid masood ashraf, moazam babar, z.a qazi pak j ophthalmol 2008, vol. 24 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … …………………… … correspondence to: muhammad younis tahir department of ophthalmology bahawal victoria hospital bahawalpur received for publication january’ 2007 purpose: to compare the protective effect of healon 5 and hpmc on corneal endothelium during phacoemulsification. material and methods: all eyes scheduled to have phacoemulsification surgery by single surgeon at same centre were selected. first group was operated while using hpmc as viscoelastic agent and second group of eyes underwent identical surgery while using healon 5 as viscoelastic agent. patients were followed up at 24 hours, one week, one month, and 3 months after surgery for corneal endothelial cell loss by using specular microscope. results: fifty eyes underwent surgery equally divided in two groups. in first group hpmc was used. the mean loss of corneal endothelial cells at 3 months was 8.67 %( 6.57%-13.61%). in second group healon 5 was used during surgery and the mean loss of corneal endothelial cells at 3 months was 8.05 %( 6.58%-10.94%). conclusions: the rate of corneal endothelial cell loss in patients undergoing phacoemulsification cataract surgery with hpmc or healon 5 does not vary much although healon 5 works better if there is advanced nuclear sclerosis. but in routine cases use of hpmc is a safe and cost effective. 176 … ……………………… ajor bulk of ophthalmic surgery is the cataract extraction1,2. viscoelastics form an essential tool in the modern day cataract surgery. various types of viscoelastics like cohesive and dispersive in nature are available in the market. all of them claim to provide maximum endothelial cell protection during surgery. but again quality is associated with a high price tag. in a developing country like pakistan where per capita income is low and health insurance is a rarity, use of these costly viscoelastics becomes a burden both for the patient and for the surgeon. especially when high volume cataract surgery is performed and resources are limited; its use becomes more and more difficult. we carried out this study to compare the endothelial protective effect of hpmc with healon 5. materials and methods this was a hospital based interventional comparative study launched at lrbt eye hospital lahore. we compared the endothelial protective effect of two viscoelastics. fifty patients selected from out patient department were randomly divided into two groups. group 1 received 2% hpmc and group ii received healon 5 during phacoemulsification. posterior limbal self-sealing incision was given and after continuous curvilinear capsulorrhesis, phacoemulsification was done with particular consideration given to phacoemulsification time (the total time used to manage the nucleus by ultrasonic tip). posterior chamber intraocular lens was implanted in all the patients. central corneal endothelial cell count was evaluated preoperatively and postoperatively by specular microscopy at day 1, week 1, one month and 3 months. statistical analysis was performed by the computer based spss (statistical package for social sciences (spss version 10.0) including: p value calculation with the help of student “t” test for corneal endothelial cell count preoperatively and postoperatively in both groups. results the mean central endothelial cell loss at the end of 3rd month was 8.67% with a range of 6.57-13.61% for group 1 (2% hydroxyl propyl methyl cellulose) and 8.05% with a range of 6.58-10.54% for group 2 (healon 5) with standard deviation of ± 384 cells/mm2 and p value of 0.976. a direct relationship was observed between phaco time and percentage of endothelial cell loss during phacoemulsification i.e. more the phaco time (phaco energy) to mange the nucleus, more the endothelial cell loss (table 1). discussion this prospective, randomized study was designed to compare the endothelial protective effect of 2% hydroxy propyl methyl cellulose and healon 5 in patients undergoing phacoemulsification with posterior chamber intraocular lens implantation. viscoelastic substances have assumed a major role in the anterior segment surgery especially phacoemulsification. early studies have shown that phacoemulsification appears to be more traumatic to the corneal endothelium than conventional form of cataract extraction. the proper use of viscoelastic substances and refinements in surgical technique had made it a popular technique for cataract extraction3. several viscoelastic agents are now available for use in anterior segment surgery. sodium hyaluronate is a repeating polymer of glucuronic acid and n-acetylglucosamine. healon 5 contains 2.3% sodium hyaluronate. it contains the same molecular mass of sodium hyaluronate (4 million) but has higher concentration (2.3 mg/ ml versus 1 mg /ml). healon 5 is highly viscous and has strong cohesive characteristics and can be difficult to remove, particularly from behind the intraocular lens (iol) in the capsular bag and high intraocular pressure peaks after surgery have been observed. space maintenance is significantly better with healon 5. healon is documented to protect corneal endothelium in three ways. mechanical protection as it is shock absorber due to its elasticity. biological protection due to habs (hayaluronic acid binding sites). chemical protection due to scavenger effect on harmful free radicals formed during phacoemulsification. 2% hydroxypropyl methylcellulose is another viscoelastic substance available. it is not elastic, has no shock absorbing ability. it is dispersive type of viscoelastic with limited coating ability. m 177 table 1: endothelial cell density groups pre-operation at week 1 at month 3 mean (cells/mm2) range (cells/mm2) mean (cells/mm2) range (cells/mm2) % loss mean (cells/mm2) range (cells/mm2) % loss group i 2514.48 2061--2846 2309.40 1900---2660 8.19 2297 1860---2620 8.67 group ii 2523.40 2048--3519 2325.12 1920---3250 7.87 2320 1900—3170 8.25 group i=2% hydroxypropyl methylcellulose group ii=healon 5 6.5 7 7.5 8 8.5 9 day 1 week 1 month 1 month 3 hpmc healon 5 fig. 1: percentage endothelial cell loss after phaco with hpmc and healon5. 2% hydroxypropyl methylcellulose has not got the same endothelial protective characteristics as healon 5 does but our results showed that at the end of 3 months the mean central endothelial cell loss was 8.67% (6.57-13.61%) for 2% hydroxypropyl methylcellulose group which is not significantly different from healon5 group i.e. 8.05% (6.58-10.94%). so, 2% hydroxypropyl methylcellulose also gives reasonable protection to the endothelium during phacoemulsification. our results are fairly close to the results given by “long-term endothelial cell loss following phacoemulsification: model for evaluating endothelial damage after intraocular surgery” conducted by werblin tp. university of virginia, charlottesville. this demonstrated that routine uncomplicated phacoemulsification surgery demonstrated a 9% endothelial cell loss 1 year postoperatively4. one study conducted at department of ophthalmology, humboldt university berlin, campus virchow klinikum, germany shows that the healon5 group had the lower mean endothelial cell loss (6.2%), than 2% hydroxypropyl methylcellulose5. another study conducted at meiwakai medical foundation, miyata eye hospital, miyakonojo, miyazaki, japan obtained that the mean rate of endothelial cell loss 3 months after surgery was 5.9% ± 5.3% in the healon group6. a similar study was carried out by lane ss et al. in which the protective effect of 3 different viscoelastics was determined (2% hydroxypropyl methylcellulose, viscoat and healon). specular microscopy showed no significant difference in cell loss between any of the group after 3 months postoperatively7. conclusions according to our results, the following conclusions and clinical implications can be drawn: 1. healon 5 offers greater endothelial cell protection than 2% hydroxypropyl methylcellulose particularly if high nucleus grading is present or the endothelial status is marginal. 2. the endothelial cell loss was not significantly different with the use of 2% hydroxypropyl methylcellulose (which is cost effective) as compared to healon 5, in patients with low nucleus grading on which un-complicated phacoemulsification was performed. 3. conceivably, healon 5 slightly greater protective capabilities would be useful in patients in whom: • increased manipulation of nuclear material is suspected. • the corneal endothelial cell density is marginal as in aged persons. • diabetic patients (in these patients endothelial cell density is normal but the other morph metric 178 parameters are disturbed i.e. pleomorphism and polymegathism.) author’s affiliation dr. muhammad younis tahir senior registrar ophthalmology bahawal victoria hospital bahawalpur dr. rafay amin baig resident medical officer lrbt lahore dr. khalid masood ashraf consultant lrbt mandra lahore dr. moazam babar mughal hospital lahore dr. z. a. qazi chief consultant lrbt lahore reference 1. khan qureshi mb, khan ma. facts about the status of blindness in pakistan. pak j ophthalmol. 1999;15:15-9. 2. helping the blind and visually handicapped (but not bypassing the hat around) (editorial). pak j ophthalmol. 1996; 12:77-8. 3. sugar j, mitchelson j, kraff m. the effect of phacoemulsification on corneal endothelial cell density. arch ophthalmol. 1978; 96: 446-8. 4. werblin tp. long-term endothelial cell loss following phacoemulsification: model for evaluating endothelial damage after intraocular surgery. refract corneal surg. 1993; 9: 29-35. 5. holzer mp, tetz mr, auffarth gu, et al. effect of healon5 and 4 other viscoelastic substances on intraocular pressure and endothelium after cataract surgery. j cataract refract surg. 2001; 27: 213-8. 6. miyata k, maruoka s, nakahara m, et al. corneal endothelial cell protection during phacoemulsification: lowversus highmolecular-weight sodium hyaluronate. j cataract refract surg. 2002; 28:1557-60. 7. lane ss, naylor dw, kullerstrand ls, et al. prospective comparison of effect of occucoat, viscoat and healon on intraocular pressure and endothelial cell loss. j cataract refract surg. 1991; 17: 21-6. microsoft word mazhar ul hasan corrected 1 68 original article assessment of the complications secondary to silicone oil injection after pars plana vitrectomy in rhegmatogenous retinal detachment in early post operative phase mazhar-ul-hassan, asif kazi, umair qidwal, aziz ur rehman, nasir bhatti pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mazhar-ul-hassan isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi submission of paper august ‘ 2010 acceptance for publication may’ 2011 …..……………………….. purpose: to assess the postoperative complications of silicone oil injection after pars plana vitrectomy in rhegmatogenous retinal detachment. materials and method: the study was carried out at vitreo-retinal unit of alibrahim eye hospital, from january 2009 to june 2009. 100 eyes with rhegmatogenous retinal detachment according to inclusion and exclusion criteria were included in the study. results: out of 100 patients included in the study, 43 had raised intraocular pressure, while the rest of 57 patients did not show any rise in intraocular pressure after three months of follow up, all 100 (100%) patients developed some form of change in their refractive status, only 6 (6%) patients developed band keratopathy till 3rd month of follow up, while only 8 (8%) had silicone oil emulsification in their eye in 3 month follow ups. conclusion: raised intraocular pressure and change in refractive status were the two most common complications seen in our study; both of these complications can be managed easily. he silicone oil is a useful tamponading material used in complex vitreoretinal surgery1. it is transparent, lighter than water (specific gravity of 0.97) and has a refractive index of 1.404. the silicone oil has a surface tension with water of 40 mn/m, which is less than that of a gas bubble.2 primary vitrectomy for rhegmatogenous retinal detachment is fast becoming a procedure of choice.3 the silicone oil is most frequently indicated in rhegmatogenous retinal detachments for cases complicated by proliferative vitreoretinopathy, giant retinal tears, rhegmatogenous or combined retinal detachment due to proliferative diabetic retinopathy, ocular trauma, retinal detachment complicated by iris neovascularization, patient noncompliance with positioning and postoperative fluid – gas exchange and need for air travel by patient. the use of silicone oil as an endo-tamponade for the treatment of complicated retinal detachment is common, but post operative complications can occur. 4 post operative complications are increased intraocular pressure (40.57%), changes in refractive status (100%), band keratopathy (21.73%), silicone oil emulsification (56%). to prevent these complications, the silicone oil has to be removed from eye after 3 to 6 months of injection. 5-7 this study is useful to determine the magnitude of the problems in series of cases in our setup, as local data and studies are not available. strategies could be made to minimize or cut down the complications. objective to assess the postoperative complications of silicone oil injection after pars plana vitrectomy in rhegmatogenous retinal detachment. t 69 materials and method the study was a descriptive case series and it was carried out at vitreoretinal unit of al-ibrahim eye hospital, from january 2009 to june 2009. 100 eyes with rhegmatogenous retinal detachment according to inclusion and exclusion criteria were included in the study. non-probability, purposive sampling was done. patients with rhegmatogenous retinal detachment, age above 25 years and ability to comply with study protocol were included. while, patients with previous surgery for rhegmatogenous retinal detachment, patients with non-rhegmatogenous retinal detachment, patients with previously diagnosed glaucoma, patients with uveitis and patients with band keratopathy or bullous keratopathy and any other corneal pathology were excluded from the study. patients for the study were selected from our outpatient department of vitreoretinal unit and after being diagnosed clinically (by indirect ophthalmoscopy), were enrolled according to the inclusion and exclusion criteria. in order to control confounding variables, exclusion criteria were strictly followed. purpose, procedure, benefits and risks of the silicon oil injection and pars-plana vitrectomy was explained to the patient and informed consent was taken. a proforma was filled which consisted of postoperative details either yes or no. ocular examination included best corrected visual acuity, refractive status, anterior segment examination with slit lamp, intraocular pressure measurement with goldman applanation tonometer and fundoscopy with slit lamp using 90d lens as well as indirect ophthalmoscopy using 20d lens. investigation included fundus photograph with fundus camera in eyes with clear media. consultants having minimum 5 year surgical experience performed pars plana vitrectomy. it was undertaken in local (retrobulbar and facial anesthesia) or general anesthesia. silicone oil 1000 cs (micromed co.) was injected in all eyes for prolonged intraocular tamponade. postoperative follow up was of 3 months. on each follow up, patients were examined for best corrected visual acuity, anterior segment examination with slit lamp, intraocular pressure measurement with goldman applanation tonometer and fundoscopy with slit lamp using 90 d lens as well as indirect ophthalmoscopy using 20 d lens with special emphasis on silicone oil related complications in rhegmatogenous retinal detached eyes including, increased intraocular pressure, changes in refractive status, band keratopathy, silicone oil emulsification. recognized postoperative complications of silicone oil were measured either yes or no. statistical analysis was done on spss version 10.0 on computer. frequency and percentages were computed for qualitative variables including gender increased intra ocular pressure, band keratopathy change in refractive status, emulsification and type of complications due to silicone oil. mean and standard deviation were computed for quantitative variables including age of patient. stratification was done with respect to grades of rhegmatogenous retinal detachment to see in put and outcome. results out of 100 patients included in the study, 54 (54%) were males, while 46 (46%) were females. mean age in our study was 58.33 years. minimum age was 45 years while maximum age was 83 years with standard deviation of 7.12. frequencies of silicone oil related complications 1. raised intra ocular pressure out of 100 patients included in the study, 43 had raised intraocular pressure; while the rest of 57 patients did not show any rise in intraocular pressure after three months of follow up (figure 1). 2. change in refractive status out of 100 patients included in the study, all 100 (100%) patients developed some form of change in their refractive status. 43 (43%) 57 (57%) 0 10 20 30 40 50 60 iop raised iop not raised fig. 1: increased intraocular pressure n = 100 iop = intraocular pressure (in mm hg) n um be r of p at ie nt s 70 3. band keratopathy out of 100 patients included in our study, only 6 (6%) patients developed band keraotopathy by 3rd month of follow up (figure 2). 4. silicone oil emulsification out of 100 patients included in the study, only 8 (8%) had silicone oil emulsification in their eye in 3 month follow up (figure 3). 6 (6%) 94 (94%) 0 10 20 30 40 50 60 70 80 90 100 band keratopathy no band keratopathy fig. 2: band keratopathy n = 100 8 (8%) 92 (92%) 0 10 20 30 40 50 60 70 80 90 100 silicon oil emulsification no silicone oil emulsification fig. 3: silicone oil emulsification n = 100 grades of rhegmatogenous retinal detachment out of 100 patients included in the study, 20 had pvr grade b, while rest of the 80 patients had pvr grade c. frequencies of different complications in relation to grades of retinal detachments are shown in (figures 4-7). discussion since the introduction of silicone oil, there have been multiple controversies concerning the safety of silicone 8 12 35 45 0 5 10 15 20 25 30 35 40 45 pvr type b pvr type c raised iop not raised iop fig. 4: increased in intraocular pressure in different grades of rhegmatogenous retinal detachment iop = intraocular pressure pvr = proliferative vitreo-retinopathy (type b and c) 0 10 20 30 40 50 60 70 80 pvr type b pvr type c change in refractive status not change in refractive status fig. 5: change in refractive status in different grades of rhegmatogenous retinal detachment pvr = proliferative vitreo-retinopathy (type b and c) oil for intraocular use. 8,9 for of these reasons, removal of silicone oil is typically advocated. prolonged silicone oil tamponade has been demonstrated to induce multiple anterior segment complications, including cataract, glaucoma, and keratopathy. 9 our study has shown the risk of many complications such as raised intraocular pressure, silicone oil emulsification and band keratopathy after silicone oil injection. similarly, one study also showed that silicone oil injection is associated with a high risk of complications9. close analysis of their findings shows that the improvement in visual function associated with successful reattachment of the retina by this method is maintained in the majority of cases, n um be r of p at ie nt s n um be r of p at ie nt s n um be r of p at ie nt s n um be r of p at ie nt s 71 0 10 20 30 40 50 60 70 80 pvr type b pvr type c band keratopathy no band keratopathy fig. 6: band keratopathy in different grades of rhegmatogenous retinal detachment pvr = proliferative vitreo-retinopathy (type b and c) 0 10 20 30 40 50 60 70 80 pvr type b pvr type c silicon oil emulsification no silicon oil emulsification fig. 7: silicone oil emulsification in different grades of rhegmatogenous retinal detachment pvr = proliferative vitreo-retinopathy (type b and c) and that complications, when they occur, do not necessarily cause progressive visual loss. in our study, we did not notice any lens related complications but many studies have reported cataract, as the commonest late complication of silicone oil injection but the lens changes are not usually dense enough to cause loss of navigational vision9,10. our study has reported a high risk of raised intra ocular pressure after silicone oil injection, while in another study the presence of silicone oil particles in the angle structures was a common finding but the incidence of raised intraocular pressure was not high and did not usually appear to be related to the presence of oil in the angle,10 on the other hand another study reported that raised iop was associated with the presence of oil particles within the anterior chamber11, one study reported this finding, as common in phakic as it is in aphakic eyes and it seems that presence of large number of such particles could lead to trabecular meshwork obstruction. 10 exact cause of this increase in pressure was not studied as it was beyond the scope of our study. our study also reported the risk of band keratopathy after silicone oil injection, similarly, in one study it was noted that in a few aphakic eyes in which there was a dehiscence in the vitreous remnant a large globule of silicone fluid came forward into the anterior chamber after surgery, causing a severe and often painful keratopathy.10 our study has shown changes in refractive power in almost all the patients. one study regarding the changes in refractive power after pars plana vitrectomy shows the hypermetropic shift in phakic or psuedophakic eyes included in the study.12 the main limitations of our study were that we used only one type of silicone oil that is 1000 cs, because of its use in our setup. results can vary with the use of other type (5000 cs) of silicone oil. similarly our follow up time was short, so complication that may occur later didn’t appear in this follow up time. we conclude that, while the technique of silicone oil injection is associated with a high risk of medium term complications, particularly raised intraocular pressure, band keratopathy and change in refractive status, but even then the usefulness of silicone oil as a tamponade cannot be denied. these complications can be managed by prescribing glasses for change in refractive status and giving medicine to control intraocular pressure or removal of oil from anterior chamber to prevent band keratopathy. conclusion use of silicone oil after vitrectomy in patients with rhegmatogenous retinal detachment, can be associated with multiple complications, of which change in refractive status and raised intra-ocular pressure were the most frequent complications. author’s affiliation mazhar ul hassan isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi n um be r of p at ie nt s 72 asif kazi isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi umair qidwal isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi aziz ur rehman isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi nasir bhatti isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi reference 1. de silva dj, lim ks, schulenburg we. an experimental study on the effect of encircling band procedure on silicone oil emulsification. br j ophthalmia. 2005; 89: 1348-50. 2. janet r, chang s. vitreous substitution. 2nd ed. albert dm jf, editor: philadelphia: w.b. saunders; 2000. 3. rehman n. primary vitrectomy for uncomplicated aphakic and pseudophakic retinal detachment. pak j opthalmol. 2000; 16: 148-52. 4. light dj. silicone oil emulsification in the anterior chamber after vitreoretinal surgery. optometry. 2006; 77: 446-9. 5. popovic ss, sikic j, pokupec r. intraocular pressure values following vitrectomy with silicone oil tamponade. acta med croatica. 2005; 59: 143-6. 6. quintyn jc, genevois o, ranty ml, et al. silicone oil migration in the eyelid after vitrectomy for retinal detachment. am j ophthalmol. 2003; 136: 540-2. 7. danker dl, parodies d, moy cm, et al. blepharoptosis and upper eyelid swelling due to lipogranulomatous inflammation caused by silicone oil. am j ophthalmol. 2005; 140: 934-6. 8. cibis p, becker b, okun e, et al. the use of liquid silicone in retinal detachment surgery. arch ophthalmol. 1962; 68: 590–9. 9. okun e. intravitreal surgery utilizing liquid silicone: a longterm follow-up. transactions of the pacific coast otoophthalmological society. 1968; 49: 141-59. 10. leaver pk, grey rh, garner a. silicone oil injection in the treatment of massive preretinal retraction. ii. late complications in 93 eyes. br j ophthalmol. 1979; 63: 361-7. 11. watzke rc. silicone retinopiesis for retinal detachment: a longterm clinical evaluation. archives of ophthalmology.1967; 77: 185-96. 12. gao q, chen x, ge j, et al. refractive shifts in four selected artificial vitreous substitutes based on gullstrand-emsley and liou-brennan schematic eyes. investigative ophthalmology and visual science. 2009; 50: 3529-34. microsoft word abstract vol. 25, 3,09 177 abstracts edited by dr. tahir mahmood the association between thyroid problems and glaucoma cross jm, girkin ca, owsley c, mcgwin jr g br j ophthalmol 2008; 92:1503-5. primary open angle (oac) glaucoma is a leading cause of vision impairment and blindness in the united states and worldwide. the incidence of glaucoma increases with age, and it is higher among african-americans than most other racial and ethnic groups. as a broad category, thyroid condition may potentially have an effect on the development of glaucoma. several case reports and case series have found an association with hypothyroidism, and a recent population-based study found that glaucoma was more common among thyroxine users and those with a history of thyroid surgery. however, that study comprised australians largely of european ancestry, thus limiting the generalizability of the results. other studies, however, have failed to find any significant association between hypothyroidism and glaucoma. thus, there is a lack of consistent epidemiological evidence on associations between hypothyroidism and glaucoma. additionally, though considerably less common, significant relationships have been demonstrated between thyroid-associated orbitopathy (graves orbitopathy/ophthalmology) with open-angle glaucoma, ocular hypertension (oht), and dysthyroid optic neuropathy (don). glaucoma is characterised by progressive optic nerve damage, resulting in the death of retinal ganglion cells, which ultimately impedes the transmission of visual impulses from the eye to the brain. although elevated intraocular pressure (lop) is a primary risk factor glaucomatous injury may occur at normal lop. there are a number of purported mechanisms by which thyroid disorders and their treatment are believed to affect the development of glaucomatous damage. in graves disease, lop may be raised as a result of contraction of the extraocular muscles against intraorbital adhesions or orbital congestion due to increased tissue volumes. in the case of hypothyroidism, excessive mucopolysaccharide accumulation within the trabecular meshwork acts like a surfactant, sticking together adjacent endothelial membranes. the purpose of this study was to evaluate the association between thyroid problems and glaucoma. a population-based cross-sectional sample with 12,376 participants from the 2002 national health interview survey. odds ratios (or) and 95% confidence intervals (cls) were used to quantify the association between a self-reported diagnosis of glaucoma and a self-reported history of thyroid problems, controlling for demographic characteristics and smoking status. the overall prevalence of glaucoma was 4.6%; 11.9% reported a history of thyroid problems. the prevalence of glaucoma among those who did and did not report thyroid problems was 6.5% and 4.4%, respectively (p = 0.0003). following adjustment for differences in age, gender, race and smoking status, the association between glaucoma and thyroid problems remained (or 1.38, 95% cl 1.08 to 1.76). authors concluded with the remarks that the results of this study lend support to the hypothesis that thyroid disorders may increase the risk of glaucoma. research should continue evaluating potential mechanisms underlying this relationship and whether the treatment of thyroid problems reduces subsequent glaucoma risk. hydroxychloroquine retinopathy screening semmer ae, lee ms, harrison ah, olsen tw br j ophthahno1 2008; 92: 1653-5 since the 1950s, antimalarial drugs have been used to treat various autoimmune diseases including systemic lupus erythematosus and rheumatoid arthritis. in the united states, hydroxychloroquine is the antimalarial drug of choice because of its low retinal toxicity. between 1960 and 2005, only 47 cases of hydroxylchloroquine retinopathy have been reported in the peer-reviewed literature. despite the existence of 178 unreported cases, hydroxychloroquine retinopathy is rare. the exact pathophysiology remains unknown, but daily dose, duration of therapy, renal function; liver function and patient age modify patient risk. the ophthalmology and rheumatology literature continually debate the most appropriate paradigm for hydroxychloroquine retinopathy screening. in 2002, the american academy of ophthalmology (aao) addressed this controversy by publishing preferred practice patterns (ppp) for hydroxychloroquine retinopathy screening. these evidence-based guide-lines attempted to maximise practicality and optimise the cost/benefit ratio of hydroxychloroquine retinopathy screening. they were designed as guidelines that physicians might choose to modify based on their clinical judgement, patient preference and medicolegal concerns. the ppp recommends baseline examination and risk assessment within the first year of therapy. there is no need for follow-up in the first 5 years for low-risk patients; however, the ppp recommend annual screening of high-risk patients. high-risk patients are those with: (1) daily hydroxychloroquine exceeding 6.5 mg/kg, (2) duration of therapy greater than 5 years, (3) age greater than 60, (4) obesity, (5) renal disease, (6) hepatic disease or (7) concurrent retinal disease. the ppp hydroxychloroquine retinopathy screening exams include a comprehensive ophthalmological evaluation with central visual-field assessment by either amsler grid or humphrey visual field (hvf) 10-2 perimetry (zeiss, dublin, ca). colour vision testing, fundus photography, fluorescein angiography and multifocal electroretinography (mferg) are considered optional. this investigation compared the current hydroxylchloroquine screening practices of community ophthalmologists to the guidelines outlined in the ppp. knowledge of risk factors and recommended follow-up frequencies were assessed along with the financial implications of current screening methods. the purpose of this study was to compare current hydroxychloroquine retinopathy screening practices with the published 2002 american academy of ophthalmology (mo) preferred practice patterns (ppp). a multiple-choice survey was distributed to 105 ophthalmologists to assess current screening practices and knowledge of patient risk factors, results were compared with the ppp guidelines. a cost analysis of the ppp and survey paradigms was conducted. sixty-seven (64%) of 105 surveys were completed. the majority (90%) of physicians screen for hydroxychloroquine retinopathy with either central automated threshold perimetry or amsler grid as recommended by the ppp. most survey respondents could not correctly identify the evidence-based risk factors. the majority screen more frequently than recommended: 87% screen high-risk patients and 94% screen low-risk patients more frequently than recommended in the ppp. the increased screening frequency of low-risk patients translates into an excess of $44 million in the first 5 years of therapy. if all patients were screened using exact ppp paradigm, savings could exceed $150 million every 10 years. authors concluded with the remarks that the ophthalmologists currently screen for hydroxychloroquine retinopathy correctly; however, their lack of familiarity with evidence-based guidelines may result in excessive follow-up. increasing awareness and implementation of the ppp could potentially reduce hydroxychloroquine retinopathy screening costs significantly. apodized diffractive versus refractive multifocal intraocular lenses: optical and visual evaluation zelichowska b, rekas m, stankiewicz a, cervmo a, montes-mic6 r j cataract refract surg. 2008; 34: 2036-42. advances in intraocular lens (iol) design have significantly improved the visual outcomes of cataract surgery. multifocal iols are designed to reduce dependence on eyeglasses after cataract surgery, and iols are gaining acceptance as potential refractive surgical options in selected patients. monofocal iols provide excellent visual function; however, their limited depth-of-focus means that for many patients, they do not provide clear vision at both distance and near. patients with traditional monofocal iols usually require glasses for near tasks such as reading. monovision techniques may be helpful for some patients but can sacrifice binocularity. introduction of the multifocal iol in the early 1980s provided the potential for a range of uncorrected vision from near to far. providing distance and near vision increases the depth of field and improves visual quality at near, visual quality that 179 improves with time. multifocality is the brain’s natural ability to adapt to near and far vision as it chooses, based on the object being viewed, between the 2 images (near and far) produced by the optical elements of the iol. these simultaneous-vision iols provide distance, intermediate, and near correction within the area of the eye’s pupil. when a person is viewing a distant object, a sharp retinal image is provided by the parts of the iol within the papillary area that have the distance correction; a somewhat blurred image is provided by the other parts of the iol as the images are superimposed on the retina. the decrease in contrast of the in-focus image is produced by the split of the total light energy between the far and near focus, while the simultaneous presence (superimposition) on the retinal of the in-focus image and out-of-focus image can produce as sort of retinal rivalry or confusion; however, this is overcome by the brain’s capability to use multifocality. multifocality theoretically implies that more stray light reaches the retina. however, psychometric measures show that perceived stray light is not different in eyes with monofocal iols, thus the importance of brain adaptation. the purpose of this study was to evaluate the optical and visual performance after implantation of refractive or apodized diffractive multifocal intraocular lenses (iols). uncorrected distance visual acuity, best distancecorrected visual acuity, best distance-corrected near visual acuity, distance contrast sensitivity under photopic conditions (csv-1000), residual refractive error, and wavefront aberrations (laoarwave hartmann-shack wavefront analyzer) were measured in 23 patients who had bilateral implantation of the acrysof restor sn60d3 iol and 23 patients who had bilateral implantation of the rezoom iol. at the 6-month postoperative visit, the mean photopic uncorrected distance acuity was 0.03 ± 0.05 (sd) in the restor group and 0.02 ± 0.06 logmar in the rezoom group (both approximately 20/20) (p = .569). in all patients, the mean photopic best distancecorrected acuity was 0.00 logmar (approximately 20/20) and the mean photopic best distance-corrected near acuity at 35 cm was 0.10 logmar. the photopic contrast sensitivity was within the standard normal range in both iol groups. the difference in photopic contrast sensitivity between groups was statistically significant (p<.001). higher-order aberrations, in particular coma and spherical aberrations, were significantly higher in the rezoom group (all p<.001). authors concluded with the remarks that the acrysof restor sn60d3 and rezoom iols provided good visual performance at distance and near under photopic conditions. optical quality measures were significantly worse in patients with rezoom iols. contrast sensitivity after refractive lens exchange with diffractive multifocal intraocular lens implantation in hyperopic eyes ferrer-blasco t, montes-mico r, cervifio a, alfonso jf, fernandez-vega l j cataract refract surg. 2008; 34: 2043-8. multifocal intraocular lenses (iols), in which multiple focal lengths are present within the optical zone, were designed to provide good uncorrected distance and near vision. they are available with diffractive optics or with zones of differing refractive power. these simultaneous-vision iols provide distance, intermediate, and near correction within the area of the ocular pupil. for distance vision, the parts of the iol that have the distance correction within the papillary area produce a sharp retinal image. other parts of the iol produced more blurred images that are superimposed on the retina. the roles of the corrections change when a near object is observed; in this case, the areas of the iol that have the near correction provide the correctly focused retinal image. in both situations, the unwanted effect of light in the out-of-focus image is to reduce the contrast of the infocus image. new optical designs applied to pseudoaccommodating iols combine refractive and diffractive optics to reduce the disadvantages of conventional refractive and diffractive iols in terms of contrast reduction. visual evaluation of the acrysof restor iol (alcon laboratories) has been performed in detail, and several large studies indicate that the quality of vision with the iol is good. the key question is whether the optical tradeoff inherent in a multifocal iol results in better or worse visual function than that with the natural lens. a recent study by montes-mico et al. found that aberration levels after implantation of the acrysof restor iol in patients having refractive lens exchange (rle) appear to be similar to those in the authors report that this iol yielded good photopic high-contrast, distance, and near visual acuity, 180 although intermediate vision was slightly impaired, as was vision of low-contrast objects. the purpose of this study was to evaluate distance and near contrast sensitivity under photopic and mesopic conditions before and after refractive lens exchange (rle) with implantation of a diffractive multifocal intraocular lens (iol). monocular contrast sensitivity function was measured with the functional acuity contrast test chart at distance and near under 3 luminance levels (85.0 cd/m, 5.0 cd/m, and 2.5 cd/m) before and after rle with bilateral acrysof restor iol implantation in 30 hyperopic eyes with presbyopia and low astigmatism (≤ 1.0 diopter). results after surgery were compared with those before surgery. six months postoperatively, the mean residual spherical equivalent refractive error was 0.21 diopter ± 0.19 (sd). the best corrected distance and near visual acuities were comparable to those before surgery. for distance vision, the safety index was 1.02 and the efficacy index was 0.91. for near vision, the values were 1.04 and 1.02, respectively. there were no statistically significant differences between preoperative and postoperative results at any distance or spatial frequency or under any lighting condition (p > .1, t test). authors concluded with the remarks that the refractive lens exchange with implantation of a diffractive multifocal lol gave good distance and near contrast sensitivity under photopic and mesopic conditions. although mesopic contrast sensitivity was reduced at distance and near compared to that under photopic conditions, the performance was comparable to that with the natural lens preoperatively. 181 apodized diffractive versus refractive multifocal intraocular lenses: optical and visual evaluation 25: 179. contrast sensitivity after refractive lens exchange with diffractive multifocal intraocular lens implantation in hyperopic eyes 25: 180. hydroxychloroquine retinopathy screening 25: 178. the association between thyroid problems and glaucoma 25: 178. microsoft word maria memon corrected 197 original article correlation between intra ocular pressure, central corneal thickness and glaucoma stage in patients with primary open angle glaucoma mariya memon, khalid iqbal talpur, arsalan rajpur, mohammad memon pak j ophthalmol 2010, vol. 26 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mariya memon senior lecturer department of ophthalmology. liaquat university of medical and health sciences jamshoro received for publication june’ 2010 …..……………………….. purpose: to determine the correlation between central corneal thickness (cct), intra ocular pressure (iop) and glaucoma stage as assessed by cup to disc ratio (cdr) in patients with primary open angle glaucoma (poag) material and method: patients with primary open angle glaucoma were included. patients under 35 years of age, with some corneal and retinal problems and secondary open angle glaucoma were excluded from study. after ultrasound pachymetry, intraocular pressure was measured using goldmann applanation tonometry. cup to disc ratio was assessed and disc photograph taken. pearson’s correlation coefficients were calculated to assess the associations between central corneal thickness, intra ocular pressure and vertical cup to disc ratio. p value lower than 0.05 was defined as statistically significant. results: one hundred and fifty three eyes of 86 patients with poag were examined. mean corneal thickness was 535 um and mean intra ocular pressure was 30mmhg. a significant negative correlation was detected between central corneal thickness and cup to disc ratio (r=-0.204, p=0.031). eighty-eight percent of patients with cct<500um and 80% patients with cct 500-519um presented with 0.7 to total cupping but as the cct increases, this ratio became equal or reverse. conclusion: glaucoma patients with thin central corneal thickness are more likely to be found at an advanced stage of the disease. under estimation of intra ocular pressure by goldmann applanation tonometry could be one causative factor. ntra ocular pressure (iop) is one of the most important parameters in the diagnosis and treatment of glaucoma. goldmann applanation tonometry (gat) is still the gold standard for its measurement1-2. a positive linear correlation between central corneal thickness (cct) and iop as determined by applanation tonometry has been described by several groups suggesting that gat results in under estimation in thin corneas and overestimation in thick corneas3-7. the ohts study defined decreased cct as one of the risk factors for ocular hypertensives to develop manifest glaucoma8. both reduced cct and enlarged cup to disc ratio (cdr) were found to be associated with progression to disease in ocular hypertensives. herndon et al9 described cct as a powerful clinical factor in determining glaucoma severity at initial examination by a glaucoma specialist. to further delineate the association, we evaluated the correlation between cct, iop and glaucoma stage as assessed by i 198 cup disc ratio in patients with primary open angle glaucoma (poag) materials and methods a random sample of primary open angle glaucoma patients was included in this study. all participants were recruited between july 2007 and june 2008 from outpatient department of ophthalmology lumhs. the diagnosis of poag was based on patients having iop of 22mmhg or higher at initial visit, characteristic glaucomatous optic neuropathy with diffuse or focal optic rim thinning, cupping or nerve fiber layer defect indicative of glaucoma and corresponding visual field loss. all pt with poag above 35 years of age were included but those below 35yrs of age, pt: with some corneal and retinal disease and secondary open angle glaucoma (pseudo exfoliation and pigmentary glaucoma) were excluded from this study. patients who had undergone any corneal surgery were not included in this study. all patients gave written informed consent before enrollment. gat was calibrated weekly and performed in the way described by goldmann and schmidt 1-2 using slit lamp (inami. japan). cct was assessed as an average of 5 consecutive measurements using an ultrasound pachymeter (opticon 2000 pacline italy). the regular visits included a thorough ophthalmologic examination of the anterior and posterior segments. cup-to-disc ratio (cdr) in both the vertical and horizontal dimension was reassessed through a dilated pupil with a +90 or +72 diopter lens having the patient in a sitting position at the slit lamp. data entered and analyzed on spss version 11.pearson's correlation coefficient were calculated to assess the association between cct, iop and cdr.a p value lower than 0.05 was defined as statistically significant. results a total of 153 eyes of 86 patients with primary open angle glaucoma were evaluated. out of that 60 were male and 26 female. patients were divided into four groups according to age to observe the difference of central corneal thickness (cct), intraocular pressure (iop) and vertical cup disc ratio (cdr) with increasing age (table 1). the mean differences of cct, iop and cdr was insignificant between different age groups. (p=0.839, 0.751 and 0.648 respectively). the mean values of age, iop,cct and cdr was 57.22 ± 10.6 yrs,29.4 ± 6.0mmhg,535 ± 33um and 0.71 ± 19 respectively. the mean differences of these values between gender was insignificant. (p=0.376, 0.297, 0.968 and 0.602 respectively) (table 2). according to cct values, patients were divided into subgroups. an increase in cct was associated with slight and insignificant (p=0.154) elevation of iop but majority of patients with thin cornea (<500-519um) presented with advanced stage of disease i.e advanced cup disc ratio as compared to patient with thick corneas (>540um) which was statistically significant (p=0.031) (table 3). eighty-eight percent of patients with cct<500um and 80% patients with cct 500-519um presented with 0.7 to total cupping but as the cct increases, this ratio became equal or reverse (table 4). discussion our glaucoma sample of 153 eyes revealed an average cct of 535 um. the effect of cct on ocular hypertension and normal tension glaucoma has already been well documented10-16. in our patients of poag who had a thinner cct tended to have more severe glaucomatous damage on initial examination. central corneal thickness was the most consistent predictor of degree of glaucomatous damage as measured by outcome variables. it has been suggested that a thicker cct may be protective against glaucomatous damage, since cct in ocular hypertensive patients tends to be thicker than a poag patients11-12, 16. it is well known that iop measured by applanation should be adjusted to correct for cct measurements that are higher or lower than the mean cct of approximately 545um in the general population14. in our study the iop is high in individuals with thick cornea (hence an early presentation at hospital and less advanced disease) and low in thinner cornea (this delaying referral until more advanced disease is evident). lyamu17 and leon18 reported cct as a better predictor than iop in identifying those at higher risk of developing poag when combined with some ocular risk factors. christoph et al19 found significant negative correlation between central corneal thickness and cup disc ratio (p>0.005).the mean cct was 538um±32um and surprisingly more excavated optic nerve heads (0.72±0.17) among asian population as compared to african americans and caucasians. in 199 our study the mean cct is 535um ±33um and mean cdr is 0.71 ± 0.19 (p 0.03). table 1: comparison between age groups age groups eyes 153 cct mean±sd iop mean±sd vcd mean±sd 35-44 21 530.8 ±29.6 27.9 ± 4.9 0.63 ± 0.17 45-54 35 538.9 ±35.8 29.3 ±7.2 0.76.0.17 55-65 63 535 ±37.2 30.4 ±6.5 0.72 ±0.21 above 65 34 533.7 ±23.9 28.7 ±5.9 0.73 ±0.18 p-values 0.839 0.751 0.648 *by pearson’s correlation. mean difference of cct, iop and vcd ration was insignificant between different age groups. table 2: comparison between gender male mean ± sd female mean ± sd pvalues age (years) 56.7 ± 11.2 58.7 ± 8.9 0.376 iop (mmhg) 29.8 ± 6.4 28.4 ± 6.1 0.297 cct (µm) 535.1± 29.6 534.8 ± 41.4 0.968 vcd ratio 0.71 ± 0.19 0.73 ± 0.2 0.602 table 3: iop and vcd in cct groups cct groups eyes 153 iop vcd mean ± sd mean ± sd < 500 µm 8 25.6 ± 6.0 0.75 ± 0.12 500 – 519 50 28.8 ± 5.4 0.77 ± 0.18 520 – 539 28 30.0 ± 8.0 0.68 ± 0.18 540 – 559 27 29.7 ± 6.1 0.67 ± 0.19 560 – 579 22 30.7 ± 7.4 0.67 ± 0.23 580 – 600 12 30.9 ± 4.5 0.68 ± 0.23 > 600 µm 6 30.3 ± 4.6 0.65 ± 0.26 p – values 0.154 0.031 pearson correlation (r) + 0.136 0.204 table 4: cd ratio vs cct cct groups eyes 153 cdr groups 0.3 – 0.6 80.7 – 1.0 < 500 µm 8 1 (12%) 7 (88%) 500 – 519 50 10 (20%) 40 (80%) 520 – 539 28 11 (40%) 17 (60%) 540 – 559 27 12 (45%) 15 (55%) 560 – 579 22 13 (59%) 9 (41%) 580 – 600 12 6 (50%) 6 (50%) > 600 µm 6 3 (50%) 3 (50%) in our study 88% of the patients with cct <500um and 80% of the patients with cct <520 presented with advanced cupping, similar findings are reported by tharwat et al20 that thin corneas (cct < 540 )are likely to develop greater glaucomatous optic nerve damage. the mean cct was 518±31 and mean cdr was 0.67±0.31 in thin cornea’s group. there is no universally acceptable and correct algorithm that is available as a cct-tonometric correction factor. thus it is difficult to obtain a true estimate of the effect of cct on iop and hence difficult to substantiate or negate any bias issue due to improper measurement of iop. neither can undebatable proof of any physiological biomechanical relationship between cct and the support structures of the optic nerve be determined. however results of the present study suggest that in eyes with glaucoma, thinner corneas are associated with morphological changes of the optic nerve head (increase cup depth and volume) .that might reflect an increase susceptibility to glaucomatous optic neuropathy. much remains unknown and many further studies are required to unravel the mysteries of the pathogenesis of glaucomatous optic neuropathy and any relationship that there may be with cct. use of alternative tonometers, such as the dynamic contourtonometer21 or the ocular response analyzer22, which have been reported to be independent of cct, may prove useful in future research. the present study has limitation in that this is a hospital based study and not a population based study. there may be some referral bias in our patient population. patients referred to a tertiary care hospital 200 may have more advanced, intractable glaucoma than those in the general population and therefore may not represent the majority of poag patients. conclusion a significant correlation was found between cct and cdr, indicating that patients with thin corneas are more likely to be found in an advanced stage of the disease. measuring cct in glaucoma patients may help identify those patients who are at higher risk of developing severe glaucomatous sequelae thus enabling the ophthalmologist to treat their disease more aggressively. author’s affiliation prof. khalid iqbal talpur chairman department of ophthalmology liaquat university of medical and health sciences. jamshoro. dr. mariya memon department of ophthalmology liaquat university of medical and health sciences. jamshoro. dr. arsalan rajpur department of ophthalmology liaquat university of medical and health sciences. jamshoro. dr. mohammad memon department of ophthalmology liaquat university of medical and health sciences. jamshoro. reference 1. goldmann h, schmidt t. on applanation tonography. ophthalmologica. 1965; 150: 65-75. 2. goldmann h, schmidt t. studien mittels. applanation tonographie. doc ophthalmol. 1966; 20: 184-213. 3. bhan a, browning ac, shah s. effect of corneal thickness on intra ocular pressure measurements with the pneumotonometer, goldmann applanation tonometer and tono pen. invest. ophthalmol vis sci. 2002; 43: 1389-92. 4. bron am, gareher cc, boutillon gs. falsely elevated intra ocular pressure due to increased central corneal thickness. greafes arch clin exp ophthalmol. 1999; 237: 220-4. 5. stodtmeister r, kron m, gaus w. iop measurement and central corneal thickness. br j ophthalmol. 2002; 86: 120-1. 6. copt rp, thomas r, mermoud a. corneal thickness in ocular hypertension, primary open angle glaucoma and normal tension glaucoma. arch ophthalmol. 1999; 117: 14-6. 7. whitacre mm, stein ra, hassanein k. the effect of corneal thickness on applanation onometry. am j ophthalmol. 1993; 115: 592-6. 8. gordon mo, beiser ja, brandt jd. the ocular hypertension treatment study: baseline factors that predict the onset of primary open angle glaucoma. arch ophthalmol. 2002; 120: 714 20. 9. herndon jw, weizer js, stinnett ss. central corneal thickness as a risk factor for advanced glaucoma damage. arch ophthalmol. 2004; 122: 17-21. 10. shah s, chatterjee a, mathai m. relationship between corneal thickness and measured intraocular pressure in a general ophthalmology clinic. ophthalmology. 1999; 106: 2154-60. 11. argus wa. ocular hypertension and central corneal thickness. ophthalmology. 1995; 102: 1810-12. 12. stodtmeister r. applanation tonometry and correction according to corneal thickness. acta ophthalmol scand. 1998; 76: 319-24. 13. copt rp, thomas r, mermoud a. corneal thickness in ocular hypertension, primary open angle glaucoma, and normal tension glaucoma. arch ophthalmol. 1999; 117: 14-6. 14. doughty mj, zaman ml. human corneal thickness and its impact on intra ocular pressure measures review and meta analysis approach. surv ophthalmol. 2000; 44: 367-408. 15. ehlers n, hansen fk. central corneal thickness in low tension glaucoma. acta ophthalmol (copenh). 1974; 52: 740-6. 16. herndon lw, choudhri sa, cox t. central corneal thickness in normal, glaucomatous, and ocular hypertensive eyes. arch ophthalmol. 1997; 115: 1137-41. 17. iyamu e, ituah i. the relationship between central corneal thickness and intraocular pressure: a comparative study of normal and glaucoma subjects. afr j med sci. 2008; 37: 345-53. 18. leon w, herndon md, jennifer s. central corneal thickness as a risk factor for advanced glaucoma damage. arch ophthalmol. 2004; 122: 17-21. 19. christoph k, shan l, joyee c. correlation between intraocular pressure, central corneal thickness, stage of glaucoma and demographic patient data. j glaucoma. 2006; 15: 91-7. 20. tharwat h. mokbel, asaad a. ghanem. correlation of central corneal thickness and optic nerve head topography in patients with primary open angle glaucoma. oman j ophthalmol. 2010; 3: 75-80. 21. kaufmann c, bachmann lm, thiel ma. comparison of dynamic contour tonometry with goldmann applanation tonometry. invest ophthalmol. vis sci. 2004; 45: 3118-21. 22. luce da. determining in vivo biomechanical properties of the cornea with an ocular response analyzer. j cataract refract surg. 2005, 31: 156-6. microsoft word khawaja khalid case report 100 case report benign retinal flecks with neuroretinitis muhammad dawood khan, khawaja khalid shoaib, inam-ul-haq, shahid hamid, kashif ali muhammad ahsan mukhta pak j ophthalmol 2008, vol. 24 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: khawaja khalid shoaib eye specialist cmh, kharian cantt received for publication july’ 2007 …..……………………….. leck retina is a heterogeneous category with massive mosaic hyaline excrescences of bruch membrane, leading to the appearance of multiple deep yellow to yellowish white lesions of variable size and shape in the ocular fundus. krill1 in 1977 identified 4 classes: fundus albipunctatus, inherited as either an autosomal dominant or autosomal recessive; fundus flavimaculatus, inherited as an autosomal recessive; familial drusen, inherited as an autosomal dominant and fleck retina of kandori2, inherited as an autosomal recessive. in a consanguineous arab palestinian family, sabel aish and dajani in 19803 observed what they interpreted to be a fifth category, familial benign fleck retina, inherited as an autosomal recessive. neuroretinitis is characterized by papillitis in association with inflammation of retinal nerve fiber layer. case report we are presenting a case of benign fleck retina with neuroretinitis. to the best of our knowledge there is no reported case of benign fleck retina with neuroretinitis. our patient, forty five years old male, presented with history of visual loss in the right eye for the last six weeks which was rapid in onset and painless. there was no history of night blindness and family history was also not contributory. vision in right eye was counting fingers at two meters, not improving further and 6/6 in left eye. there was gross impairment of color vision in the right eye with relative afferent pupillary defect. intraocular pressure was within normal limits in both eyes. fundoscopy (fig.1,2) revealed punctuate, welldemarcated, yellow-white flecks involving whole of the fundus except fovea in both eyes. right optic disc had gross pallor, marginal blurring, and reduction in number of micro vessels associated with resolving macular fan. left optic disc and macula were with in normal limits. there was no retinal pigmentation or vascular attenuation. ffa (fig. 3, 4) revealed hyperfluorescent spots in superotemporal perimacular vessels in both eyes in f 101 early venous phase. there was diffuse leakage at the disc at late phase in right eye. serum venereal disease research laboratory (vdrl) test was non reactive and treponema pallidum haemagglutination assay (tpha) was negative. all these findings were consistent with diagnosis of benign retinal flecks with neuroretinitis. fig. 1: fundus photograph of right eye fig. 2: fundus photograph of left eye fig. 3: fundus photograph and ffa right eye fig. 4: fundus photograph and ffa left eye case discussion benign fleck retina is a very rare autosomal recessive disorder, which is asymptomatic and therefore usually discovered by chance4. inheritance autosomal recessive signs • widespread, discrete, yellow-white, flecks at the level of the rpe which spare the fovea. • the flecks have variable shapes and extend to the far periphery5. erg electroretinogram is usually normal. prognosis 102 prognosis is excellent because the retinal changes are innocuous. neuroretinitis is the least common type of optic neuritis and is most frequently associated with viral infections, cat-scratch fever, syphilis and lyme disease. in most cases it is a self-limiting disorder, which resolves within 6-12 months. author’s affiliation brig. muhammad dawood khan combined military hospital kharian cantt col. khawaja khalid shoaib combined military hospital kharian cantt inam-ul-haq combined military hospital kharian cantt shahid hamid combined military hospital kharian cantt kashif ali combined military hospital kharian cantt muhammad ahsan mukhta combined military hospital kharian cantt reference 1. krill a. hereditary retinal and choroidal diseases: flecked retina disease. 2nd ed. hagerstown: harper and row; 1977. 739-819. 2. kandori f. very rare cases of congenital non-progressive night blindness with fleck retina. jpn j ophthalmol. 1959; 13: 384-6. 3. aish s, dajani b. benign familial fleck retina. br j ophthalmol 1980; 64: 652-9 4. isaacs tw, mcallister il, wade ms. benign fleck retina. letter to the editor. br j ophthalmol 1996; 80: 267-9. 5. kanski jj. clinical ophthalmology: a systematic approach. 5th ed. edinburgh: butterworth heinemann; 2003 obituary lt. gen mushtaq ahmed baig, mbbs mcps fcps hi (m) (1951-2008) february 25, 2008 will always remain in our memories as a very sad day. the news of a suicide bomb blast flashed across the media screens. little did we realize that this time the victim would be one of our dearest colleague, lieutenant general mushtaq ahmed baig, head of the army’s medical corps. a graduate of king edwards medical college, lahore, lt. gen. mushtaq ahmad baig joined army medical corp in january 1976. baig was awarded mcps in ophthalmology in 1977 and fcps ophthalmology in 1988 by college of physicians and surgeons pakistan. he was promoted as lieutenant general and appointed surgeon general pakistan army and director general medical services (inter services) on feb 8, 2007. presently he was serving as principal army medical college, rawalpindi. he was awarded hilal-e-imtiaz (military), in recognition of his meritorious services. in a reference held in his honour miss maryam mushtaq, the daughter of lieutenant general mushtaq ahmed baig shaheed described him as a “loving father, a caring husband, an obedient son, a responsible brother, an adept eye surgeon, a devoted soldier and above all a pious muslim”. he was a person who exuded great personal warmth and affection with a smiling and easy going approach to life. for a person of such a high rank it was a 103 rare trait. he was incisive in his thoughts and very organized in his work. he was a role model for medical profession. a large number of ophthalmologists trained by him are serving throughout the country and it would be apt to say that he lives through his work. the irreparable loss and gap produced by his martyrdom will take years to fill. he is survived by his wife, three sons and a daughter. on behalf of the ophthalmic community we extend our deepest sympathies to the bereaved family and pray that they bear the loss with fortitude and forbearance. prof. hamid mahmood butt prof. brig. asad jamal dar microsoft word editorial 26,1,10 1 editorial the on-going evolution in cataract surgery charles kelman (1930-2004), a brooklyn new yorker, introduced phacoemulsification in 1967 after being inspired by his dentist’s ultrasonic probe. no one at that time knew how this discovery would revolutionize cataract surgery in the times to come. one of the greatest advantages of this technique lies in the small size of the surgical wound. the race for the decreasing millimeters really took off soon after the popularisation of the technique especially with the introduction of foldable iol’s at the end of the 1980’s. the surgical technique of phacoemulsification itself got evolved enormously as the surgeons gained experience since its modern inception. excessive time was spent earlier on construction of scleral pockets and extra long tunnels to minimize surgically induced astigmatism only to be superceded by a gradual forward journey towards the limbus and then the clear cornea. the latter approach increased the incidence of intra-ocular infection compelling the more wary surgeons to retreat. the most favoured approach now is at the junction of anterior sclera with the posterior limbus which tends to have all the advantages of cornea as well as lesser astigmatism and higher degree of defence against endophthalmitis. the incision size has gone down to 2.2 mm in most of the cases which is astigmatically neutral. micro coaxial phaco tip and the smart sleeve have all made it possible making even relatively newer bimanual phaco almost obsolete! similarly the painstaking ‘sculpting’, ‘cracking’ and ‘divide and conquer’ techniques have been largely replaced by the modern horizontal and vertical chopping thus cutting the surgical time to a fraction of what it was earlier. the father of chopping technique is undoubtedly nagahara who first showed his video back in 1993. shortly after, akahoshi described his technique of karate pre-chop but it did not gain wide acceptance due to the potential risk of zonular stress. the real industrial revolution in the field of cataract surgery has been the development of iol technology as well as modernization of the phaco equipment and its fluidics (cool phaco, ozil and most recently ozil intelligent phaco are just a few examples). the main force behind all that being the ever increasingly demanding patient to the extent that cataract surgery is now evolving into more and more of a refractive procedure with the aim of least or no dependence on the spectacles! five of the most popular implantable lenses world wide are restor; rezoom , tecnis zm900, crystalens and acrysof toric. restor iol uses a combination of an apodized diffractive and refractive lens to focus light. rezoom has multifocal zones that focus light simultaneously. crystalens implant is the first accommodating lens to be approved by the fda. after implantation it moves by the tiny ciliary muscles to enhance the focusing ability thus best correcting vision for distance and intermediate distance. some patients may still need to wear reading glasses but the need is greatly reduced. however concerns do remain about the long term performance (7 years experience so far), behavior in capsular bag phimosis/pco scenario, and the cost. the first toric iol approved by fda was in 1998 (staar-plate haptic) and ever since the technology has matured enormously. the on-line lens power calculators have made the whole procedure very simplified and the results highly predictable; but having said that, none of the available iol’s is perfect as there can be some halos and glare at night and dusk time with some of them. for example, rezoom has good intermediate and distance vision but not as good near vision. crystalens is very good with distance and intermediate vision but not as srong with near vision. it is also a bit more cumbersome to implant. the original restor +4.00 suffers a bit from weaker intermediate vision but is strong at distance and near. restor +3.00 has improved the intermediate power while not sacrificing its excellent distance and reading powers, and is on the aspheric platform to improve night driving as well. for those patients who do not mind wearing glasses for part of their visual activity, the quality of life is splendid after modern cataract surgery! the search for the ideal and the flawless goes-on! prof. nadeem riaz microsoft word management corner 204 management corner optic neuritis tahir mahmood pak j ophthalmol 2008, vol. 24 no. 4 . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ptic neuritis is a term used to refer to inflammation of the optic nerve. when it is associated with a swollen optic disc, it is called papillitis or anterior optic neuritis. when the optic disc appears normal, the terms retrobulbar optic neuritis or retrobulbar neuritis are used. acute optic neuritis is by far the most common type of optic neuritis that occurs throughout the world and is the most frequent cause of optic nerve dysfunction in young adults. the annual incidence of acute optic neuritis is estimated in population-based studies to be between 1 and 5 per 100,000 1. the majority of patients with acute optic neuritis are between the ages of 20 and 50 years, with a mean age of 30 to 35 years; however, optic neuritis can occur at any age. females are affected more commonly than males by a ratio of approximately 3:12. clinical presentation the two major symptoms in patients with acute optic neuritis are loss of central vision and pain in and around the affected eye. loss of central visual acuity is reported by over 90% of patients. vision loss is typically abrupt, occurring over several hours to several days. progression over a longer time can occur but should make the clinician suspicious of an alternative disorder. the degree of visual loss varies widely from minimal reduction to complete blindness with no perception of light. the majority of patients describe diffuse blurred vision, although some recognize that the blurring is predominantly central. the visual loss is monocular in most cases, but in a small percentage, particularly in children, both eyes are simultaneously affected. pain in or around the eye is present in more than 90% of patients with acute optic neuritis. it is usually mild, but it may be extremely severe and may even be more debilitating to the patient than the loss of vision. it may precede or occur concurrently with visual loss, usually is exacerbated by eye movement, and generally lasts no more than a few days. the presence of pain is a helpful differentiating feature from other causes of optic neuropathies such as anterior ischemic optic neuropathy, which typically produces painless visual loss. up to 30% of patients with optic neuritis experience positive visual phenomena, called photopsias, both at the onset of their visual symptoms and during the course of the disorder. these phenomena are spontaneous flashing black squares, flashes of light or showers of sparks, sometimes precipitated by eye movement or certain sounds. examination of a patient with acute optic neuritis reveals evidence of optic nerve dysfunction. visual acuity is reduced in most cases, but varies from a mild reduction to no light perception. contrast sensitivity and color vision are impaired in almost all cases. the reduction in contrast sensitivity often parallels the reduction in visual acuity, although in some cases, it is much worse. the reduction in color vision is often much worse than would be expected from the level of visual acuity. visual field loss can vary from mild to severe, may be diffuse or focal, and can involve the central or peripheral field. indeed, almost any type of field defect can occur in an eye with optic neuritis, o 205 including central and cecocentral scotomas, altitudinal and arcuate defects, diffuse field loss, and even hemianopic defects. a relative afferent pupillary defect is demonstrable with the swinging flashlight test in all unilateral cases of optic neuritis. when such a defect is not 206 present, there is either a coexisting optic neuropathy in the fellow eye (eg, from previous or concurrent asymptomatic optic neuritis) or the visual loss in the affected eye is not caused by optic neuritis or any other form of optic neuropathy. patients with optic neuritis also can be shown to have a reduced sensation of brightness in the affected eye. this state can be ascertained either by simply asking them to compare the brightness of a light shined in one eye and then the other, or by more complex tests using polarized lenses or flickering lights of varying frequencies. about one third of patients with acute optic neuritis have some degree of disc swelling. the optic disc may be slightly or markedly blurred; however, the degree of disc swelling does not correlate with the severity of either visual acuity or visual field loss. disc or peripapillary hemorrhages and segmental disc swelling are less common in eyes with acute optic neuritis than in eyes with anterior ischemic optic neuropathy. the majority of patients with acute optic neuritis have a normal optic disc in the affected eye unless they have had a previous attack of acute or asymptomatic optic neuritis. over approximately 4 to 6 weeks, the optic disc in an eye with acute optic neuritis may become or remain normal or become pale, even as the visual acuity and other parameters of vision improve. the pallor may be diffuse or located to a particular portion of the disc, most often the temporal region. diagnostic studies studies in patients with presumed acute optic neuritis are usually performed for 1 of 3 reasons: (1) to determine if the cause of the optic neuropathy is something other than inflammation, particularly a compressive lesion; (2) to determine if a cause other than demyelination is responsible for inflammation of the optic nerve; or (3) to determine the visual and neurologic prognosis of optic neuritis. with the widespread availability of magnetic resonance imaging (mri), computed tomography (ct) has little or no role in the evaluation of patients with presumed optic neuritis. mri can reveal demyelinating lesions of the optic nerve, manifesting as foci of t2-bright signal, areas of enhancement, and even optic nerve enlargement. these lesions are nonspecific, and a similar appearance can be observed in patients with infectious and other inflammatory optic neuropathies. the most important application of mri in patients with optic neuritis, however, is the identification of signal abnormalities in the white matter of the brain, usually in the periventricular region, consistent with demyelination. mri is the strongest predictor of the eventual development of ms in patients with acute isolated optic neuritis3. other than mri, most diagnostic tests are unhelpful in differentiating acute demyelinating optic neuritis from the less common systemic and local infectious and inflammatory optic neuropathies. the vast majority of patients with optic neuritis caused by these latter disorders can be identified (or at least suspected) simply by performing a thorough history. therefore, diagnostic testing should be performed on a case-by-case basis to detect disorders such as syphilis, sarcoidosis, cat-scratch disease, lyme disease, or systemic lupus erythematosus. the role of cerebrospinal fluid (csf) analysis in the evaluation of patients with acute optic neuritis is not clear. although the presence of oligoclonal banding in the csf is associated with the development of ms, the powerful predictive value of brain mri for ms has reduced the role of lumbar puncture in the evaluation of patients with optic neuritis. lumbar puncture can help define a very low-risk population for ms if both csf and mri are normal4. csf studies in patients with optic neuritis are mostly useful to detect another inflammatory or infectious disorder. visual prognosis the natural history of acute idiopathic optic neuritis is to worsen over several days to 2 weeks and then to improve5. the improvement initially is fairly rapid. it then levels off, but further improvement can continue to occur up to one year after the onset of visual symptoms. the mean visual acuity one year after an attack of otherwise uncomplicated optic neuritis is 6/5, and less than 10% of patients have permanent visual acuity less than 6/12. other parameters of visual function, including contrast sensitivity, color perception, and visual field, improve in conjunction with improvement in visual acuity. most patients, even those who experience another attack of optic neuritis, retain excellent vision for at least 15 years after their first attack of optic neuritis. although the overall prognosis for visual acuity after an attack of acute optic neuritis is extremely good, some patients have persistent severe visual loss after a single episode. furthermore, even patients with improvement in visual function to "normal" may complain of movement-induced photopsias or tran207 sient loss of vision with overheating or exercise (uhthoff symptom). two major hypotheses regarding uhthoff symptom are that (1) elevation of body temperature interferes directly with axon conduction, and (2) exercise or a rise in body temperature changes the metabolic environment of the axon which, in turn, interferes with conduction. it is important to reassure a patient who has uhthoff symptom that the symptom never results in permanent visual loss. thus, if uhthoff symptom occurs in a patient during exercise, the patient should be told that she or he can continue to exercise without fear of experiencing permanent visual loss as a result. such a patient may, however, wish to keep a bottle of cold (or ice) water handy while exercising, because drinking it may result in immediate restoration of vision. about 25% of patients who experience an attack of acute optic neuritis will experience a second attack in that eye or a new attack in the previously unaffected eye. the risk of a recurrence or a new attack is substantially higher in patients treated with low-dose oral prednisone as opposed to patients who receive no treatment or who are treated with a 3-day course of high-dose (1 g/ day) intravenous methylprednisolone followed by a 2-week course of low-dose (1 mg/kg/day) prednisone6. neurologic prognosis the risk of developing ms in a patient who experiences an attack of acute optic neuritis is about 75% in women and 34% in men over the subsequent 15-20 years, with the risk being greatest in the first 5 years after the attack.7 without question, the most highly predictive baseline factor is • the presence of at least one lesion in the periventricular white matter of the brain mri. other risk factors for the development of ms are • white race • a family history of ms • a history of previously ill-defined neurologic complaints, and • a previous episode of acute optic neuritis. however, none of these factors affect the risk of developing ms as much as the results of mri. some investigators have found that the younger the age of onset of optic neuritis, the greater the subsequent risk for ms. winter onset of optic neuritis may also be a risk factor. conversely, patients with acute optic neuritis who have a normal brain mri, severe disc swelling, a macular star, or disc hemorrhages have a very low risk of developing ms, findings that emphasize the role of the ophthalmologist in defining the prognosis of optic neuritis. treatment of optic neuritis although corticosteroids are the main treatment option for patients with acute idiopathic optic neuritis, the prognosis for visual recovery after an attack of acute optic neuritis is excellent without treatment. if corticosteroids are used, treatment should be delivered first with 3 days of intravenous methylprednisolone in a dose of 1 g/day followed by a 2-week course of oral prednisone at a dose of 1 mg/kg/day with a taper over 3 days. this regimen does not affect the ultimate visual outcome of a patient, but it does speed recovery of vision compared with no treatment. it should also be emphasized that patients who experience an attack of acute optic neuritis should not be treated with low-dose oral prednisone alone. this mode of treatment does not result in a better visual outcome or a faster recovery than no treatment. moreover, it is associated with an increased rate of recurrent attacks of optic neuritis in the previously affected eye and an increased rate of new attacks of optic neuritis in the fellow eye, compared with patients who are not treated or patients who are treated with the iv/oral regimen5. another important aspect of treatment for acute optic neuritis is whether it may have an impact on the development of ms. of note, patients in the ontt who were treated with the intravenous followed by oral corticosteroid regimen had a reduced rate of development of clinically definite ms during the first 2 years following treatment8. this benefit of treatment was seen only in patients who had abnormal brain mri at the time of onset of the optic neuritis, and the clinical benefit of the intravenous treatment lessened over time such that by 3 years of follow-up, there was no significant difference in the rate of development of ms among treatment groups. reference 1. percy ak, nobrega ft, kurland lt. optic neuritis and multiple sclerosis: an epidemiologic study. arch ophthalmol. 1972; 87: 135-9. 2. balcer lj. optic neuritis. n engl j med. 2006; 354: 1273-80. 208 3. optic neuritis study group. the five-year risk of multiple sclerosis after optic neuritis. experience of the optic neuritis treatment trial. neurology. 1997; 49: 1404-13. 4. rolak la, beck rb, paty dw, et al. cerebrospinal fluid in acute optic neuritis: experience of the optic neuritis study group. neurology. 1996; 46: 368-72. 5. beck rw, cleary pa, backlund jc, et al. the course of visual recovery after optic neuritis: experience of the optic neuritis treatment trial. ophthalmology. 1994; 101: 1771-8. 6. beck rw, cleary pa, anderson mm jr, et al. a randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. n engl j med. 1992; 326: 581-8. 7. optic neuritis study group. the five-year risk of multiple sclerosis after optic neuritis. experience of the optic neuritis treatment trial. neurology. 1997; 49: 1404-13. 8. beck rw, cleary pa, trobe jd, et al. the effect of corticosteroids for acute optic neuritis on the subsequent development of multiple sclerosis. n engl j med. 1993; 329: 1764-9. quiz: dry eye answers: 1a 6a 2a 7a 3a 8a 4a 9a 5a 10a microsoft word shaukat ali chipa article 93 original article combined procedure in patients with pseudoexfoliation syndrome shaukat ali chhipa, muhammad saleh memon pak j ophthalmol 2009, vol. 25 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: shaukat ali chhipa, university road medical services, abc plaza, opp: bait-ulmukkaram masjid. main university road. karachi. received for publication september’ 2008 … ……………………… purpose: to observe the intraocular pressure and visual acuity before and after the combined procedure with an observation on the intraoperative complications in patients with pseudoexfoliation syndrome who had coexisting cataract and glaucoma. material and methods: the study was conducted in alibrahim eye hospital, malir, karachi from april 2002 to april 2004. thirty eyes of 28 patients with pseudoexfoliation syndrome have to combined procedure been included in the study. the main observations were preoperative and postoperative visual acuity, intraocular pressure, and intraoperative adverse event rates. results: a total of 30 eyes with pseudoexfoliation of 28 patients underwent planned combined procedure. sixteen (53.33%) eyes achieved 6/18 or better vision postoperatively. the mean preoperative intraocular pressure was 25 mm hg (range, 14 to 38 mm hg), which decreased to a mean postoperative intraocular pressure of 15.1 mm hg (range, 8 to 18 mm hg). intraoperative complications occurred in 4 (13.33%) eyes. conclusion: the combined procedure in pseudoexfoliation syndrome reduces intraocular pressure, improves visual acuity with minimal intraoperative complications. seudoexfoliation syndrome (pxs) is defined as a discrete clinical entity characterized by synthesis and progressive accumulation of fine white granular material in many ocular tissues. the first description of this condition appeared in scandinavian literature in 1917, when lindbergh described flaky material at the pupillary border in some patients with glaucoma1. throughout the anterior segment including the lens, iris, trabecular structures, conjunctiva, corneal endothelium, ciliary p 94 body, and zonules the pseudoexfoliative material may be detected histopathologically. the deposition of fibrillar eosinophilic material on the anterior lens capsule is the classic histopathologic feature of pxs2. pseudoexfoliative material appears to be a homogenous, eosinophilic, periodic acid-schiff positive staining substance under light microscopy, which indicates a material rich in polysaccharides3. it is now considered the most common identifiable specific entity leading to the development of glaucoma4. eyes with pxs have a greater frequency of complications at the time of cataract extraction, such as zonular dialysis, capsular rupture, and vitreous loss5. in the new millennium of rapid advancements and modifications in all fields of science and technology, the treatment of coexisting cataract and glaucoma by combined procedure (extracapsular cataract extraction with intraocular lens implantation and trabeculectomy) has produced favorable results6. combined procedure not only improves visual acuity (va) and control of intraocular pressure (iop), but also improves postoperative pressure spikes. long term benefits include decrease or no use of antiglaucoma medications, decrease in the progression of visual field loss and less frequent follow up7. recognition that the patient has pxs is of clinical significance, especially because it indicates an unstable iop that can lead to a serious glaucoma in which the optic nerve may become damaged rapidly and because of abnormalities in the lens capsule and zonules that can lead to phacodonesis and predispose to complications at the time of cataract extraction. potential causes of elevated iop in eyes with pxs include blockage of the meshwork by exfoliative material, blockage of the meshwork by liberated iris pigment, trabecular cell dysfunction, and coexisting primary open angle glaucoma. pupils of eyes with pxs dilate less and have greater incidence of capsular rupture, zonular dehiscence, and vitreous loss. postoperative complications of posterior capsular opacification, capsule contraction syndrome, intraocular lens decentration, and inflammation are also greater in eyes with pxs8,9. combined procedure can rehabilitate every proven case of glaucoma with a few years history of medication, if a cataract needs to be removed10. the rationale of the study was to observe in our setup the iop and va before and after the combined procedure and the intraoperative complications in patients with pxs. material and methods this case series of eyes with pseudoexfoliation syndrome, underwent extracapsular cataract extraction with posterior chamber intraocular lens implantation and trabeculectomy, was carried out in alibrahim eye hospital, malir, karachi. the study was carried out between april 2002 and april 2004. patients having coexisting cataract and glaucoma capsulare were reviewed at outpatients department and admitted for combined procedure. all selected patients were thoroughly evaluated. a detailed history of every patient was taken. special attention paid to the ocular history. patients were asked about trauma, inflammation, amblyopia, and retinal disease. refractive history was taken. questions were also asked regarding their general health. family history regarding ocular problems was also inquired. patients having cataract, which was sufficiently advanced to interfere with the performance of the patient’s daily routine, and intraocular pressure is either uncontrolled or poorly controlled (more then 22mm hg) with maximal tolerated medication with pxs were included in the study. patients who have had previous filtration surgery, preoperative corneal opacification, complicated and traumatic cataracts, subluxated or dislocated lenses, posterior segment pathology, and/or did not observe a regular follow up were excluded from the study. standard extracapsular cataract extraction with posterior chamber intraocular lens implantation technique was combined with trabeculectomy. senior and expert surgeons performed all the surgeries. consent for surgery was duly obtained from the patient, or close relative of the patient. all the patients were operated upon under local anesthesia. all the data were analyzed using statistical package for social sciences (spss) 13.0. results thirty eyes of 28 patients underwent combined extracapsular cataract extraction with posterior chamber intraocular lens implantation and trabeculectomy. out of 28 patients 20 (71.43%) were males and 8 (28.57%) were female. average age of patient was 65 years, with a range of 55-80 years. preoperatively 25 (83.33%) eyes out of 30 had 6/60 or worse vision. postoperatively 16 (53.33%) eyes had 6/18 or better vision and 12 (40%) eyes had vision between 6/24 and 6/36 (table 1). preoperative intraocular pressure range was between 14-38 mm hg, with an average of 25 mm hg. postoperative intraocular pressure range was between 8-18 mm hg, with an average of 15.1 mm hg (table 2). 95 preoperatively all eyes were on antiglaucoma medication, 5 (16.66%) eyes out of 30 eyes were on two antiglaucoma medicine. postoperatively, 28 (93.33%) eyes needed no antiglaucoma medication, while intraocular pressures of 2 (6.33%) eyes were control on single medicine. poor dilation of pupil was recorded in 14 (46.66%) eyes. intraoperatively 2 (6.66%) eyes had posterior capsular rupture with vitreous loss and 2 (6.66%) eyes had zonular dialysis. postoperatively, 10 (33.33%) eyes had fibrin exudation. one patient (3.33%) had retained lens matter. five (16.66%) eyes had shown pigment deposition on iol. five (16.66%) eyes developed posterior capsular opacification. discussion ophthalmologists have been facing the challenge of simultaneous management of cataract and glaucoma in our elderly population with pseudoexfoliation syndrome. the surgical management of coexisting glaucoma and cataract has changed a lot, raising critical management issues6,7. the benefits of combined procedure include, to avoid temporary increase in intraocular pressure in the initial postoperative period which is common after standard extra capsular cataract extraction, achieve long term improvement in iop control with one surgical procedure while removing the visual impairment, and save the patient one surgery11. the results of this study have been compared with national and international literature. the pxs usually affects the elderly and steady increase in prevalence occurs with advancing age1. our study also supports this, as 71.42% of patients were of age 61 years or more. although, a 32 years old lady was reported to be the youngest by khanzada12. poor pupillary mydriasis, a well-known feature of exfoliation syndrome can seriously hamper the surgeon’s view. poor dilation of pupil was recorded in 14(46.66%) eyes in our study, which was comparable to 47.45% in a local study carried out by ismail13, and 43.7% recorded by kuchle14. local production and deposition of pseudoexfoliative material may lead to characteristic clinical and ultrastructural changes, which actively involve all structures of the anterior segment of the eye1. these alterations may cause complication after surgical procedures. many reports have mentioned increased rate of intraoperative complications, that is, zonular dialysis, posterior capsular tear, and vitreous loss during cataract extraction in eyes with pxs. intraoperative complication like zonular dialysis (2 eyes-6.66%), posterior capsular tear (2 eyes-6.66%), vitreous loss (2 eyes-6.66%) are comparable to international figures of 4. 59% 14.8%14,15-17, 2.29% 7.6%14,17, 4.59% to 5.1%14,18, respectively. in zonular dialysis and posterior capsular tear without vitreous loss surgery was concluded favorably with posterior chamber iol in sulcus. postoperatively 16(53.33%) eyes had achieved 6/18 or better visual acuity. twelve (40%) eyes had achieved 6/24 or 6/36 visual acuity. the vision in all eyes was improved except in 1 (3.33%) eye, in which the preoperative and postoperative vision remained as hand motion, because of the glaucomatous optic atrophy. jacobi had also reported significant improvement in vision after combined procedure in pxs17. various studies have demonstrated that the clinical course in pseudoexfoliative glaucoma (pxg) is likely to be more serious as compared with primary open angle glaucoma19,20. level of iop, progression of visual defects, and glaucomatous optic neuropathy are more pronounced in pxg20. moreover, exfoliative eyes respond less readily to medical therapy, so that many of these require early surgery. jacobi reported that after combined procedure in eyes with pseudoexfoliation syndrome, the mean iop of 32.5 mm hg with a mean of 2.1 antiglaucoma medications was decreased to the mean iop of 18.1 mm hg with a mean of 0.2 antiglaucoma medications after 6 months17. in our study the mean iop of 25 mm hg with a mean of 1.16 antiglaucoma medications was decreased to the mean iop of 15.1 mm hg with a mean of 0.06 antiglaucoma medications. the intraocular pressure control after combined procedure in pxs was comparatively better in our patients. a number of studies have presented evidence of dysfunction of the blood aqueous barrier in pseudoexfoliation syndrome, with consecutive increase of aqueous flare and protein. clinical response of inflammatory reaction and fibrin formation in eyes with pseudoexfoliation following cataract extraction appears to be related to these ultrastructural changes21,22. dorslum compared postoperative complications in 136 eyes with pseudoexfoliation syndrome to 744 eyes without pseudoexfoliation syndrome23. he observed the postoperative iritis in 16.2% of eyes with pxs as compared to 3.8% of eyes without pxs. jacobi reported 38% fibrin exudation in patients of pxs undergone combined procedure17, 96 while in our study it was recorded in 33.33% of eyes which was analogous to other studies. the incidence of posterior capsular opacification in pxs described by kuchle was 25% after 6 months9. in our study this incidence was 16.66%. however, it is difficult to compare the rates of posterior capsular opacification in various studies because of high variation in follow-up time, definition of posterior capsular opacification, patient age, surgical techniques, and type of intraocular lens. conclusion the observations of this study indicate that the combined procedure for coexisting cataract and glaucoma in patients having pseudoexfoliation syndrome, reduces iop, improves visual acuity with minimal intraoperative complications. however, our observations are preliminary, and larger clinical trails with long-term follow-up in our setup will be necessary to establish the actual effectiveness and safety of combined procedure in pseudoexfoliation syndrome. author’s affiliation dr. shaukat ali chhipa university road medical services abc plaza, opp: bait-ul-mukkaram masjid main university road karachi reference 1. naumann goh, schloterz-schrehardt u, kuchle m. pseudoexfoliation syndrome for the comprehensive ophthalmologist: intraocular and systemic manifestations. ophthalmology. 1998; 105: 951-68. 2. prince am, ritch r. clinical signs of the pseudoexfoliation syndrome. ophthalmology. 1986; 93: 803-7. 3. ho sl, dogar gf, wang j, et al. elevated aqueous humour tissue inhibitor of matrix metalloproteinase-1 and connective tissue growth factor in pseudoexfoliation syndrome. br j ophthalmol. 2005; 89:169-73. 4. ritch r. exfoliation syndrome. the most common identifiable cause of open-angle glaucoma. j glaucoma 1994; 3: 176-78. 5. ritch r. exfoliation syndrome. curr opin ophthalmol 2001; 12: 124-30. 6. monezo jl, malonado mj, munoz g, et al. combined procedure for glaucoma and cataract. a retrospective study. j cataract refract surg. 1994; 20: 498-503. 7. honjo m, tanihara h, negi h, et al. trabeculectomy ab externo, cataract extraction and intraocular lens implantation: preliminary report, j cataract refract surg. 1996; 22: 601-6. 8. breyer dr, hermeking h, greke e. augenklinik, klinikum wuppertal. late dislocation of the capsular bag after phacoemulsification with endocapsular iol in pseudoexfoliation syndrome. ophthalmology. 1999; 96: 248-51. 9. kuchle m, amberg a, martus p, et al. pseudoexfoliation syndrome and secondary cataract. br j ophthalmol. 1997; 81: 862-6. 10. raymond p, le blanc. concurerent management of cataract and glaucoma. pak j ophthalmol. 1988; 5: 5-9. 11. simmons st, litoff d, dano a, et al. extracapsular cataract extraction and posterior chamber intraocular lens implantation combined with trabeculectomy in patients with glaucoma. am j ophthalmol. 1987; 104: 467-70. 12. khanzada am. exfoliation syndrome in pakistan. pak j ophthalmol. 1986; 2: 7-11. 13. ismail m. the incidence and management of pseudoexfoliation syndrome [dissertation], karachi: college of physicians and surgeons, pakistan. 2000:108. 14. kuchle m, viestenz a, martus p, et al. anterior chamber depth and complication during cataract surgery in eyes with pseudoexfoliation syndrome. am j ophthalmol. 2000; 129: 2815. 15. lumme p, laatikainen l. exfoliation syndrome and cataract extraction. am j ophthalmol. 1993; 116: 51-5. 16. avramides s, traianidis p, sakkias g. cataract surgery and lens implantation in eyes with exfoliation syndrome. j cataract refract surg. 1997; 23: 583-7. 17. jacobi pc, dietlein ts, krieglstein gk. comparative study of trabecular aspiration vs trabeculectomy in glaucoma triple procedure to treat pseudoexfoliation glaucoma. arch ophthalmol. 1999; 117: 1311-8. 18. scorolli l, scorolli l, campos ec, et al. pseudoexfoliation syndrome: a cohort study on intraoperative complications in cataract surgery. ophthalmologica. 1998; 212: 278-80. 19. landa g, pollack a, marcovich a, et al. results of combined phacoemulsification and trabeculectomy with mitomycin c in pseudoexfoliation versus non-pseudoexfoliation glaucoma. graefes arch clin exp ophthalmol. 2005; 243:1236-40. 20. brooks amv, gillis we. the presentation and prognosis of glaucoma in pseudoexfoliation of the lens capsule. ophthalmology. 1988; 95: 271-6. 21. walinder pek, olivius eop, nordell si, et al. fibrinoid reaction after extracapsular cataract extraction and relationship to exfoliation syndrome. j cataract refract surg. 1989; 15: 52630. 22. johnson dh, brubaker rf. dynamics of aqueous humor in the syndrome of exfoliation with glaucoma. am j ophthalmol. 1982; 93: 629-34. 23. drolsum l, haaskjold e, davanger m. results and complications after extracapsular cataract extraction in eyes with pseudoexfoliation syndrome. acta ophthalmol ( copenh ) 1993; 71: 771-6. 97 microsoft word management corner 25,1,09 1 management corner central retinal vein occlusion: current management options tahir mahmood pak j ophthalmol 2009, vol. 25 no. 1 . . . . . . . . .. . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . entral retinal vein occlusion (crvo), a common retinal vascular disorder, remains an important cause of visual loss. patients generally present with painless visual loss in the affected eye. the clinical appearance typically demonstrates 4 quadrants of intraretinal hemorrhages with dilated and tortuous retinal veins. macular edema, optic disc edema, and cotton-wool spots may be present to a variable degree. crvo is broadly divided into 2 clinical subtypes, based on the degree of ischemia: nonischemic crvo is typically associated with relatively better vision and a better prognosis for spontaneous visual improvement; ischemic crvo is typically associated with more profound visual loss on presentation, a relative afferent pupillary defect, and a relatively higher risk for neovascular glaucoma. nonischemic crvo may progress to ischemic crvo, typically within the first 3-9 months. crvo generally affects people over age 50 years. its pathogenesis is uncertain, although constriction of the central retinal vein at the level of the lamina cribrosa has been implicated1. many additional associated risk factors have been proposed, including hyperhomocysteinemia, various coagulation disorders (protein c deficiency, protein s deficiency, antithrombin iii deficiency, factor v leiden deficiency) and inflammatory mediators(c-reactive protein) and vascular factors (hypertension, diabetes mellitus).the evidence for these risk factors is not conclusive. the most common cause of visual loss in patients with crvo is macular edema. other causes of visual loss include macular ischemia and neovascular glaucoma. at this time, there is insufficient evidence to support any specific treatment to improve vision in crvo. reported treatment options for crvo systemic therapy systemic anticoagulation systemic immunosuppression photocoagulation panretinal photocoagulation (prp) chorioretinal venous anastomosis pharmacotherapy intravitreal triamcinolone acetonide/other corticosteroids intravitreal anti-vegf agents (eg, bevacizumab) pharmacotherapies combined with prp surgical therapy • pars plana vitrectomy (ppv) with removal of posterior hyaloid and/or internal limiting membrane • ppv with radial optic neurotomy/laminar puncture • ppv with retinal endovascular surgery • ppv with chorioretinal venous anastomosis treatment of crvo c 2 systemic therapy to date, no systemic intervention has been demonstrated to favorably affect the natural history of crvo. crvo has been reported in patients receiving chronic, therapeutic levels of warfarin, implying that this medication may be ineffective as prophylaxis2,3. similarly, other vascular agents, including streptokinase4, ticlopidine5, and pentoxifylline6, have been studied but have not shown significant efficacy. treatment with systemic tissue plasminogen activator (tpa) was reported in 96 patients, of whom 42% gained 3 or more lines of vision but 1 died of stroke7. many investigators have attempted treatment with hemodilution without convincing efficacy8. due to the suspected inflammatory association, several authors have attempted treatment with various immunosuppressive agents, particularly in younger patients. these have included systemic corticosteroids, cyclosporine, azathioprine, and alemtuzumab9,10. results to date are inconclusive. photocoagulation the central vein occlusion study (cvos) was a randomized clinical trial that found that macular grid photocoagulation did not improve visual acuity in patients with nonischemic crvo. in this study,11 final median visual acuity was 20/200 in treated eyes and 20/160 in control eyes. in eyes with at least 10 disc areas of retinal capillary nonperfusion, prophylactic scatter photocoagulation did not prevent the development of anterior segment neovascularization. the cvos concluded that it was safe to observe these eyes until early neovascularization of the iris or angle developed. neovascularization regressed after treatment in 56% of photocoagulation-naive eyes and 22% of eyes treated previously with scatter photocoagulation12. laser-induced chorioretinal venous anastomosis has been proposed to reduce macular edema and improve vision. in a recent report using combinations of wavelengths, anatomic success was achieved in up to 77% of cases13. among eyes in which an anastomosis was achieved, visual acuity improved 2 or more lines 82% of the time. other investigators, however, have reported significant complications with this technique, including vitreous hemorrhage and choroidal neovascularization14. pharmacologic therapy there are currently no us food and drug administration (fda)-approved pharmacologic therapies for crvo, but in the last several years triamcinolone and bevacizum14ab are used for crvo. although there are no randomized, controlled trials confirming their efficacy and safety, there have been a significant number of case series suggesting promise. triamcinolone acetonide is a corticosteroid that, in addition to its anti-inflammatory effects, may cause downregulation of vascular endothelial growth factor (vegf)15. bevacizumab is a full-length recombinant humanized antibody, active against vegf, and approved for use in colorectal cancer. in several case series both triamcinolone and bevacizumab were reported to improve macular edema associated with crvo, at least in the short term. in addition, bevacizumab appears to have activity against anterior segment neovascularization. therefore, either triamcinolone or bevacizumab may be effective to treat complications of nonischemic crvo, while bevacizumab may be effective to treat complications of ischemic crvo as well. intravitreal triamcinolone has also been administered for posterior segment diseases as exudative age-related macular degeneration (amd)16, diabetic macular edema17, pseudophakic macular edema18, and cystoid macular edema due to other causes, such as uveitis19. major risks of intravitreal triamcinolone include cataract progression, elevation of intraocular pressure (iop), and endophthalmitis. intravitreal triamcinolone may cause visually significant cataract in about half of treated eyes within 1 year20. elevation of iop to 24 mm hg occurs in about 40% of patients, typically within about 3 months21. elevated iop in response to intravitreal triamcinolone may be severe or intractable, leading to glaucoma surgery in some patients. the incidence of endophthalmitis following intravitreal triamcinolone has been estimated to be between 0.099% and 0.87% per injection22,23. pseudoendophthalmitis, which may be caused by migration of triamcinolone particles into the anterior chamber or an inflammatory reaction to the drug or a component in the vehicle of the drug, has also been reported. peribulbar, rather than intravitreal, triamcinolone acetonide appears to confer a lower risk for endophthalmitis and perhaps other complications, although intractable glaucoma requiring trabeculectomy has been reported following treatment with peribulbar triamcinolone for crvo. 3 the use of anti-vegf agents in retinal disease has become increasingly common since the approval of pegaptanib and ranibizumab for amd in 2004 and 2006, respectively. these agents are currently being studied for efficacy against macular edema due to crvo. the anti-vegf agent that is most studied in regard to crvo is bevacizumab. intravitreal injection of bevacizumab was first reported as a potential therapy for macular edema secondary to crvo in 200524. recurrent macular edema may occur in patients with crvo following treatment with bevacizumab; in some cases, the recurrent macular edema may be more severe than the pretreatment macular edema ("rebound" macular edema)25. bevacizumab does not appear to increase the risk for iop elevation or cataract progression. the incidence of endophthalmitis following intravitreal bevacizumab injection has been reported at 0.014% per injection26. intravitreal tpa has been studied, with mixed results. several studies reported improvement in visual acuity in some patients with crvo, although other investigators reported no significant benefit. surgical therapy pars plana vitrectomy (ppv) which involves not only removal of the vitreous but also removal of the posterior hyaloid and/or internal limiting membrane has been associated with improvement in vision in 60% to 79% of patients in small, nonrandomized series of both ischemic and nonischemic crvo27-29. radial optic neurotomy (ron) represents an attempt to treat the proposed constriction of the central retinal vein at the level of the lamina cribrosa. ron has been reported to have favorable anatomic and visual outcomes in several nonrandomized series30-32. combining ron with intravitreal triamcinolone does not appear to improve outcomes over ron without intravitreal triamcinolone.33 better visual results appear correlated with younger age (under 50 years).[86] major adverse events include visual field loss and, rarely, significant intraocular hemorrhage or central retinal artery occlusion. a related procedure, lamina puncture, was not shown to be effective in patients with crvo. retinal endovascular surgery (revs) involves ppv, followed by cannulation of a branch retinal vein and infusion of tpa. the procedure has been reported to improve vision by 3 or more lines in 54% to 72% of patients with nonischemic crvo34,35, but does not appear effective for patients with ischemic crvo. an alternative surgical approach is ppv with creation of a chorioretinal venous anastomosis using a microvitreoretinal blade, sometimes followed by placement of suture material to stimulate vascularization. this technique was reported to improve vision in 60% to 80% of patients in 2 small, nonrandomized series36,37. guidelines for treatment diagnosis i. complete ophthalmic examination a. special attention to the presence of neovascularization of the iris (nvi) or neovascularization of the angle (nva), including gonioscopy. ii. consider fundus photography, fluorescein angiography, and/or optical coherence tomography (oct) treatment i. ischemic crvo a. if nva or at least 2 clock-hours of nvi are present, consider panretinal photocoagulation (prp) b. if unable to perform prp (corneal edema, poor papillary dilation, media opacity), consider intravitreal injection of anti-vegf agent (such as bevacizumab) ii. nonischemic crvo a. if significant macular edema, consider intravitreal injection of triamcinolone acetonide or bevacizumab follow-up i. follow-up examinations, including gonioscopy, for 6-9 months following crvo ii. oct if monitoring treatment of macular edema while there is no proven treatment for macular edema associated with crvo to date, patients with nonischemic crvo and visual loss due to macular edema may be considered for treatment with either intravitreal triamcinolone or intravitreal bevacizumab. patients with ischemic crvo and signs of anterior segment neovascularization are managed with scatter photocoagulation, with or without adjunctive intravitreal bevacizumab. 4 references 1. williamson th. a "throttle" mechanism in the central retinal vein in the region of the lamina cribrosa. br j ophthalmol. 2006 27. 2. browning dj, fraser cm. retinal vein occlusions in patients taking warfarin. ophthalmology. 2004; 111: 1196-1200. 3. mruthyunjaya p, wirostko wj, chandrashekhar r, et al. central retinal vein occlusion in patients treated with longterm warfarin sodium (coumadin) for anticoagulation. retina. 2006; 26: 285-91. 4. kohner em, petti je, hamilton am, et al. streptokinase in central retinal vein occlusion: a controlled clinical trial. br med j. 1976; 1: 550-3. 5. houtsmuller aj, vermeulen ja, klompe m, et al. the influence of ticlopidine on the natural course of retinal vein occlusion. agents actions suppl. 1984; 15: 219-29. 6. de sanctis mt, cesarone mr, belcaro g, et al. treatment of retinal vein thrombosis with pentoxifylline: a controlled, randomized trial. angiology. 2002; 53: s35-s38. 7. elman j. thrombolytic therapy for central retinal vein occlusion: results of a pilot study. trans am ophthalmol soc. 1996; 94: 471-504. 8. mohamed q, mcintosh rl, saw sm, et al. interventions for central retinal vein occlusion: an evidence-based systematic review. ophthalmology. 2007; 114: 507-19. 9. beaumont pe, kang hk. ophthalmodynamometry and corticosteroids in central retinal vein occlusion. aust n z j ophthalmol. 1994; 22: 271-4. 10. willermain f, greiner k, forrester jv. intensive immunosuppression treatment for central retinal vein occlusion in a young adult: a case report. ocul immunol inflamm. 2002; 10: 141-5. 11. the central vein occlusion study group. evaluation of grid pattern photocoagulation for macular edema in central vein occlusion: the central vein occlusion study group m report. ophthalmology. 1995; 102: 1425-33. 12. the central vein occlusion study group. a randomized clinical trial of early panretinal photocoagulation for ischemic central vein occlusion: the central vein occlusion study group n report. ophthalmology. 1995; 102: 1434-44. 13. lu n, wang nl, li zh, et al. laser-induced chorioretinal venous anastomosis using combined lasers with different wavelengths. eye. 2006; 19. 14. bavbek t, yenice o, toygar o. problems with attempted chorioretinal venous anastomosis by laser for nonischemic crvo and brvo. ophthalmologica. 2005; 219: 267-71. 15. nauck m, roth m, tamm m, et al. induction of vascular endothelial growth factor by platelet-activating factor and platelet-derived growth factor is downregulated by corticosteroids. am j resp cell mol biol. 1997; 16: 398-406. 16. spaide rf, sorenson j, maranan l. photodynamic therapy with verteporfin combined with intravitreal injection of triamcinolone acetonide for choroidal neovascularization. ophthalmology. 2005; 112: 301-4. 17. martidis a, duker js, greenberg pb, et al. intravitreal triamcinolone acetonide for refractory diabetic macular edema. ophthalmology. 2002; 109: 920-7. 18. benhamou n, massin p, audren f, et al. intravitreal triamcinolone acetonide for refractory pseudophakic macular edema. am j ophthalmol. 2003; 135: 246-9. 19. kok h, lau c, maycock n, et al. outcome of intravitreal triamcinolone in uveitis. ophthalmology. 2005; 112: 1916-21. 20. thompson jt. cataract formation and other complications of intravitreal triamcinolone for macular edema. am j ophthalmol. 2006; 141: 629-37. 21. smithen lm, ober md, maranan l, et al. intravitreal triamcinolone acetonide and intraocular pressure. am j ophthalmol. 2004; 138: 740-3. 22. westfall ac, osborn a, kuhl d, et al. acute endophthalmitis incidence: intravitreal triamcinolone. arch ophthalmol. 2005; 123: 1075-7. 23. moshfeghi dm, kaiser pk, scott iu, et al. acute endophthalmitis following intravitreal triamcinolone acetonide injection. am j ophthalmol. 2003; 136: 791-6. 24. rosenfeld pj, fung ae, puliafito ca. optical coherence tomography findings after an intravitreal injection of bevacizumab (avastin) for macular edema from central retinal vein occlusion. ophthalmic surg lasers imaging. 2005; 36: 336339. 25. matsumoto y, freund kb, peiretti e, et al. rebound macular edema following bevacizumab (avastin) therapy for retinal venous occlusive disease. retina. 2007; 27: 426-31. 26. fung ae, rosenfeld pj, reichel e. the international intravitreal bevacizumab safety survey: using the internet to assess drug safety worldwide. br j ophthalmol. 2006; 90: 13449. 27. mandelcorn ms, nrusimhadevara rk. internal limiting membrane peeling for decompression of macular edema in retinal vein occlusion: a report of 14 cases. retina. 2004; 24: 34855. 28. leizaola-fernandez c, suarez-tata l, quiroz-mercado h, et al. vitrectomy with complete posterior hyaloid removal for ischemic central retinal vein occlusion: series of cases. bmc ophthalmol. 2005; 5: 10. 29. furukawa m, kumagai k, ogino n, et al. long-term visual outcomes of vitrectomy for cystoid macular edema due to nonischemic central retinal vein occlusion. eur j ophthalmol. 2006; 16: 841-6. 30. zambarakji hj, ghazi-nouri s, schadt m, et al. vitrectomy and radial optic neurotomy for central retinal vein occlusion: effects on visual acuity and macular anatomy. graefes arch clin exp ophthalmol. 2005; 243: 397-405. 31. opremcak em, rehmar aj, ridenour cd, et al. radial optic neurotomy for central retinal vein occlusion: 117 consecutive cases. retina. 2006; 26: 297-305. 32. hasselbach hc, ruefer f, feltgen n, et al. treatment of central retinal vein occlusion by radial optic neurotomy in 107 cases. graefes arch clin exp ophthalmol. 2007; 12. 33. opremcak em, rehmar aj, ridenour cd, et al. radial optic neurotomy with adjunctive intraocular triamcinolone for central retinal vein occlusion: 63 consecutive cases. retina. 2006; 26: 306-13. 34. weiss jn, bynoe la. injection of tissue plasminogen activator into a branch retinal vein in eyes with central retinal vein occlusion. ophthalmology. 2001; 108: 2249-57. 35. bynoe la, hutchins rk, lazarus hs, et al. retinal endovascular surgery for central retinal vein occlusion: initial experience of four surgeons. retina. 2005; 25: 625-32. 36. peyman ga, kishore k, conway md. surgical chorioretinal venous anastomosis for ischemic central retinal vein occlusion. ophthlamic surg lasers. 1999; 30: 605-14. 37. mirshahi a, roohipoor r, lashay a, et al. surgical induction of chorioretinal venous anastomosis in ischaemic central retinal vein occlusion: a non-randomised controlled clinical trial. br j ophthalmol. 2005; 89: 64-9. microsoft word mushtaq ahmad 160 original article safety and visual outcome of scleral sutured posterior chamber intraocular lenses (ss-pciol) mushtaq ahmad, sofia iqbal, nazullah, naz jehangir pak j ophthalmol 2011, vol. 27 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mushtaq ahmad department of ophthalmology hmc, peshawar submission of paper june 2011 acceptance for publication september’ 2011 …..……………………….. purpose: the aim of this study was to determine the safety and visual outcome of scleral sutured fixation of posterior chamber intraocular lenses. material and methods: this prospective and interventional study was conducted from april 2010 to april 2011 in the department of ophthalmology hayatabad medical complex peshawar. thirteen eyes of 13 subjects were enrolled for scleral sutured posterior chamber intraocular lens. there were three follow up visits at 1st post op day, at two months and at six months. results: a total of 13 eyes underwent scleral sutured posterior chamber intraocular lens. there were 10 male and 3 female patients. all patients had completed their six months follow-up. after six months nine patients (69.23%) out of 13 achieved 6/12 vision or better. three patients did not come for their follow-up visits and were excluded from the study. two patients had bleeding intra operatively from the scleral suture site. two patients had suture erosion, one patient had lens tilt due to vitreous tag postoperatively and one patient had cystoid macular edema. conclusion: the technique of scleral sutured posterior chamber intraocular lens insertion via the ab externo method with a thick scleral flap offers a low complication profile and should be considered as a viable option for secondary intraocular lens. ntraocular lenses were introduced in cataract surgery by sir harold ridley in 19491 and they became standard of care in the late 1980s. however, various models, fixation sites and techniques are recommended for difficult situations. fixation of intraocular lenses in cases of insufficient or no capsular support is challenging and requires good surgical techniques to resolve different situations2. in such a situation, the surgeon has four options, to leave the eye aphakic, to implant an anterior chamber intraocular lens (ac iol), to fixate a posterior chamber intraocular lens (pc iol) in the iris or to fixate a pc iol in the sclera. the potential issues of anisometropia, optical aberrations, and contact lens intolerance make aphakia a less than optimal solution in all but a few patients3. following the implantation of the first anterior chamber lens in 1952 by baron, multiple lens type were developed. however, even with a perfectly implanted ac iol, it is postulated that sub clinical uveitis secondary to lens-tissue contact creates inflammatory products that could be directly toxic to the endothelium and angle and could also result in cystoid macular oedema4. the rates of adverse outcomes associated with ac iol implantation are cystoid macular oedema (cme) (1% to 10%), corneal decompensation (1% to 7.8%) glaucoma (0 to 15%) and retinal detachment (0 to 4%). the frequency of endophthalmitis was reported to be 0.2%5. some surgeons prefer iris-sutured intraocular lenses. these techniques need sufficient iris stroma for fixation. furthermore, there could be a need for special intraocular lenses, which may not be available everywhere. in addition, urgency, extra cost, logistics, and adapted biometry are all possible complicating factors. these can cause cat-like pupil i 161 and iris chafing, with uveitis and/or pigment dispersion and secondary complications such as chronic inflammation and secondary glaucoma. recognition of the high rate of adverse events associated with closed-loop ac iols in the 1980s prompted the development of novel techniques for fixating an iol in the aphakic eye. in 1986, malbran and colleagues were the first to describe scleral sulcus fixation of pc iols6. in 2003, an american academy of ophthalmology sponsored report on iol implantation in the absence of capsular support wagoner and colleagues concluded that the scleral sutured posterior chamber iols were safe and effective in adults7. two major concerns with scleral fixation iols are posterior placement of the haptics in sulcus and longevity of the sutures. haptics correctly placed in the sulcus will most likely achieve stable fixation after fibrosis to the surrounding structures8. material and methods this prospective and interventional study was conducted from april 2010 to april 2011 in the department of ophthalmology, hayatabad medical complex peshawar. thirteen eyes of 13 subjects were enrolled from april 2010 to october 2010 for scleral sutured pciol. all of them had completed their six months follow-up. three follow-up visits were given at 1st post operative day, after two months and after six months. all patients were determined to have aphakia of insufficient or no capsular support. patients were asked to be a part of the study if they met the inclusion criteria, which primarily included the presence of aphakia with no capsular support, informed consent to participate in the study, and the follow-up visits. exclusion criteria were as follows: extremes of ages, only eye, pre-existing macular disease and amblyopia. patients were also excluded if they had a vitreo-retinal pathology. preoperative evaluation of the patients was done thorough history and examination. the aetiology, best corrected visual acuity (bcva) and intra and postoperative compli-cations were recorded on proforma. bcva and complications were noted at each follow-up visit. surgery was carried out by a single surgeon under local anaesthesia in adults and under general anaesthesia in children. local anaesthesia consisted of peribulbar injection of 1:1 mixture of 0.5% bupivacaine and 2% lignocaine with adrenaline (1:1000). limited conjunctival peritomy was carried out and 2 triangular scleral flaps 2/3rd of the scleral thickness and 180° apart were made at 3 and 9 o’clock with the base at the limbus and size 3mm from base to apex. a corneal incision with 3.2mm knife at 12 o’clock was given. anterior vitrectomy were carried out in all cases. 10/0 prolene suture was used in all cases for lens fixation. 10/0 nylon suture was used for scleral flap and corneal repair. conjunctiva sutured with 7/0 vicryl. a 27 gauge needle was passed through a sclera at 0.7mm scleral bed from the limbus on one side and a 10/0 prolene suture on a straight needle through opposite scleral bed. the prolene suture needle was engaged into the 27 gauge needle in the peripupillary plan. the 27 gauge needle was withdrawn along with the prolene needle. the corneal incision enlarged with scissor to accommodate the iol optic to 6.50mm. the suture was drawn out through the corneal incision. the suture was cut and each end tied to the haptics eyelets of the iol. sutures were pulled through the scleral bed and tied. scleral flaps were sutured with 10/0 nylon and conjunctiva with 7/0 vicryl. the corneal wound stitched with 10/0 nylon interrupted sutures. results a total of 16 eyes of 16 patients underwent scleral sutured pc iol. thirteen patients had completed their six months follow-up. three patients who did not complete their follow-up visits were excluded from the study. there were 10 male and three female patients. all of them had unilateral surgery. age ranged from 10 years to 65 years. out of 13 cases 9 (69.23 %) cases had left eye while 4 cases (30.76%) had right eye. indications for scleral sutured pc iol were complicated eye surgery with posterior capsule rupture in 8 cases (61.53%), traumatic lens subluxation in 3 cases (23.07%) and lens dislocation in one case (7.69%). nine patients (69.23%) achieved 6/12 or better visual acuity on 3rd post operative follow up visits. on 1st postoperative day the bcva was decreased due to corneal oedema. two patients (15.38%) had bleeding intraoperatively from fixation suture site. bleeding stopped spontaneously and cleared up as much as possible with anterior vitrectomy. in one patient 1st postop visual acuity was decreased but improved at 2nd follow-up visit. two patients (15.38%) had suture erosion, one patient (7.69) had lens tilt due to vitreous tag postoperatively and one patient (7.69%) had cystoid macular oedema. demographic profile, aetiology, pre and post operative best corrected visual acuity are shown in (table i). discussion currently no consensus exists on the question of optimal method for intraocular (iol) implantation without capsular support. scleral sutured iols require a precise surgical technique and prolonged surgical time. in the absence of adequate capsular support or in the presence of zonular dialysis various techniques of iol implantation are available. ac iols, iris-sutured pc iols, and scleral sutured pc iols are common methods of lens implantation for patients with little or no capsular support. studies have reported various benefits and complications for each procedure. however, the decision of which iol to be placed for each patient may introduce selection bias that could have affected study outcomes. for example, angle abnormalities and peripheral synechea may have precluded 162 ac iol placement in some patients, and patients with limited iris tissue may not get an iris-sutured lens. schein and colleagues compared all 3 intraocular lenses and found similar visual acuity outcome with all 3 types and a slight increase of cme with ss pc iols9. in our study out of 13 patients one patient got cystoid macular oedema and one patient had intraocular lens tilt, all the other patients achieved good visual acuity. all patients were followed up for six months and had stable visual acuity. the percentage of patients with stable or improved postoperative visual acuity is (69.23%) which is comparable to both iris-sutured lenses (72%) and aciol (71.4%–76%)10. in our study, we had one case of lens till, but there was no case of iol dislocation. previously published data report a lens tilt rate of 11% and dislocation rate between 0 and 10%11. the incidence of lens dislocation is 9.9% after an irissutured lens and 3% after ac iol implantation12. studies of the scleral sutured pc iol, in particular, have shown that it is a safe procedure that can improve visual acuity, but it can present various complications. the published complications include glaucoma, cme, retinal detachment, endophthal-mitis, lens tilt or dislocation, and suture exposure or breakage. all of these complications have been reported at variable frequencies following placement of iris-sutured iols, and all except suture exposure or breakage have been documented with ac iols. in uncontrolled and controlled studies, the risk of choroidal hemorrhage ranged from 0 to 22%13. in our study, only two eyes developed hemorrhage, which started in the scleral suture site. a new concern has been raised about the long-term safety of using 10-0 polypropylene as the suture material to fixate the iol haptic to the scleral wall. recent reports have indicated that prolene suture can undergo hydrolysis and degrade, leading to spontaneous subluxation of the scleralsutured iol in 10–27% of cases14. it is known, however, that a haptic sewn to the sclera, outside of the ciliary sulcus, will not form a fibrous membrane and that as many as 50% of scleral-sutured haptics are unintentionally sewn outside the ciliary sulcus. this case series provides evidence that ss pciol insertion can be performed with minimal postoperative complications. this technique appears to be a satisfactory method of visual rehabilitation. conclusion the technique of scleral sutured pc iol insertion via the ab externo method with a thick scleral flap offers a low complication profile and should be considered as a viable option for secondary iol implantation. ultimately, individual patient factors and surgeon preference and expertise should be a guide to decide as to which secondary iol is most appropriate for each patient. author’s affiliation dr. mushtaq ahmad registrar ophthalmology department hmc, peshawar dr. sofia iqbal associat prof. ophthalmology khyber girls medical college hmc, peshawar dr. nazullah assistant prof. ophthalmology bannu medical college, bannu dr. naz jehangir medical officer ophthalmology hmc, peshawar 163 table 1: laterality of the eye age sex aetiology preoperative bcva postoperative bcva after one day postoperative bcva after two months postoperative bcva after six months complications lt eye 35 yrs male trauma (traumatic lens subluxation) 6/60 6/24 6/12 6/9 none lt eye 60yrs male complicated surgery (posterior capsular rupture with vitreous loss) 6/36 6/36 6/24 6/9 none rt eye 13yrs male trauma (traumatic lens subluxation) 6/24 6/18 6/18 6/6 intraoperative vitreous bleed lt eye 35 yrs male marfan syndrome lens dislocation to ac 6/12 6/9 6/9 6/9 none rt eye 56yrs female complicated surgery (posterior capsular rupture with vitreous loss) 6/24 6/18 6/12 6/12 none lt eye 65yrs male psuedoexfoliation complicated cataract surgery (posterior capsular rupture vitreous loss) 6/18 6/36 6/18 6/18 suture erosion lt eye 60yrs female complicated surgery (posterior capsular rupture with vitreous loss) 6/12 6/24 6/12 6/12 suture erosion rt eye 60yrs female complicated surgery (posterior capsular rupture with vitreous loss) 6/24 6/36 6/18 6/18 intraoperative vitreous bleed rt eye 34 yrs male traumatic (traumatic posterior capsular rupture vitreous loss) 6/24 6/36 6/24 6/24 lens tilt due to vitreous tag lt eye 57yrs male complicated surgery(posterior capsular rupture with vitreous loss) 6/18 6/18 6/24 6/36 cme lt eye 11yrs male congenital lens aspiration ( no posterior capsular support aphakia) 6/18 6/12 6/12 6/12 none lt eye 14yrs male microspherophakia/ ectopia lentis 6/24 6/18 6/9 6/9 none lt eye 45yrs male multiple intraocular surgery (aphakic) 6/24 6/36 6/24 6/12 none 164 reference 1. ridley h: intra-ocular acrylic lenses. trans ophthalmol soc uk. 1951, 71: 617–21. 2. por ym, lavin mj. techniques of intraocular lens suspension in the absence of capsular/zonular support. surv ophthalmol. 2005; 50: 429-62. 3. oh h, chu y, woong known o. surgical technique for suture fixation of a single piece hydrophilic acrylic intraocular lens in the absence of capsular support. j cataract refract surg. 2007; 33: 962-5. 4. apple dj, brems rn, park rb. anterior chamber lenses. part i: complications and pathology and a review of designs. j cataract refract surg. 1987; 13: 157-74 5. wagoner md, cox ta, ariyasu rg. intraocular lens implantation in the absence of capsular support. a report by the american academy of ophthalmology. ophthalmology. 2003; 110: 840-59. 6. malbran es, malbran e jr, negri i. lens guide suture for transport and fixation in secondary iol implantation after intracapsular extraction. int ophthalmol. 1986; 9: 151-60. 7. wagoner md, cox ta, ariyasu rg, et al. intraocular lens implantation in the absence of capsular support: a report by the american academy of ophthalmology. ophthalmology. 2003; 110: 840-59. 8. manabe si, oh h, amino k. ultrasound biomicroscopic analysis of posterior chamber intraocular lenses with transscleral sulcus suture. ophthalmology. 2000; 107: 2172-8. 9. schein od, kenyon kr, odrick mq. a randomized trial of intraocular lens fixation techniques with penetrating ketaroplasty. ophthalmology. 1993; 100: 1437–43. 10. akpek ek, altan-yaycioglu r, karadayi k. long-term outcomes of combined penetrating keratoplasty with irissutured intraocular lens implantation. ophthalmology. 2003; 110: 1017-22. 11. akpek ek, altan-yaycioglu r, karadayi k, et al. long-term outcomes of combined penetrating keratoplasty with irissutured intraocular lens implantation. ophthalmology. 2003; 110: 1017-22. 12. donaldson ke, gorscak jj, budenz dl, et al. anterior chamber and sutured posterior chamber intraocular lenses in eyes with poor capsular support. j cataract refract surg. 2005; 31: 903-9. 13. walter ka, wood td, ford jg, et al. retrospective analysis of a novel method of transscleral suture fixation for posterior-chamber intraocular lens implantation in the absence of capsular support. cornea. 1998; 17: 262-6. 14. price mo, price fw, werner l, et al. late dislocation of scleral-sutured posterior chamber intraocular lenses. j cataract refract surg. 2005; 31: 1320-6. microsoft word tanveer anjum ch. case report 44 case report cases of subconjunctival hemorrhage after a joy ride roomasa channa, sana shoukat memon, tanveer a. chaudhry, khabir ahmad pak j ophthalmol 2008, vol. 24 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tanveer anjum chaudhry section of ophthalmology department of surgery aga khan university, karachi received for publication may’ 2007 …..……………………….. ubconjunctival hemorrhage is a benign condition that mostly resolves spontaneously on its own, even though it may be very alarming for the patients. multiple causes of subconjunctival hemorrhage-including local trauma, acute conjunctivitis and systemic hypertension have been reported in literature1, 2. cases we report here a series of four cases of subconjunctival hemorrhage that occurred following a gyroscopic ride. during easter break, a group of 4 college students, two boys and two girls, between the ages of 17-19 years, presented to the outpatient department of barnsley district general hospital with red eyes. couple of hours before presenting at the eye clinic, they reported going on a gyroscopic ride outside a local pub. after the ride, they noticed red patches in white of their eyes (table 1, fig. 1). they did not have any history of co-morbids, such as hypertension, diabetes, blood dyscrasias or clotting abnormalities. they were also not using any blood thinning medications, like aspirin or warfarin. general examination showed that vitals including blood pressures were within normal ranges. their visual acuity was normal. all four, but one patient had bilateral subconjunctival hemorrhages on the lateral or medial or both sides of the limbus (fig. 1). iop was normal and there was no reaction in the anterior chamber. their pupils were reacting normally and detailed retinal examination did not reveal any pathology such as retinal edema, hemorrhage or tear. laboratory investigations revealed normal bleeding and clotting profiles. patients were not given any medication, reassured and sent home. three of them returned for examination two weeks later. all hemorrhages had completely resolved. discussion eye hemorrhages and retinal tears caused by amusement rides and high intensity sports such as bungee jumping and roller coaster rides have been reported previously. during 1987-2000 one person in the united states had retinal tear and a possible cerebral edema and five others had eye hemorrhage after they rode a hand-powered ride called the “spaceball” which spins its occupants at a high speed. in addition, a boy aged 17 had vitreous hemorrhage after a gyroscopic ride3, 4. our case series is unique in that all four members of the group developed subconjunctival hemorrhage following a gyroscopic ride. to the best of our knowledge this is the first reported case series of subconjunctival hemorrhages s 45 associated with this type of ride. there is a possibility that many such cases of subconjunctival hemorrhage are not reported because they are not sight threatening. a gyroscope is a device consisting of a rotating heavy metal wheel pivoted inside a circular frame (fig 2). the wheel’s rotation enables it to retain its original orientation in space when the frame turns. the ride works on exactly the same principle and the high speed rotation of the passenger in multiple directions can cause rupture of the thin conjunctival vessels. fig. 1: location of subconjunctival hemorrhages in three of four cases fig. 2: a gyroscope: its structure and function conclusion although extreme sports are very attractive, mostly for the younger generation, they can result in eye trauma ranging from benign hemorrhage to a sightthreatening retinal damage. one should observe caution while thinking of indulging in such sports and seek medical advice immediately if there is any associated eye trauma. author’s affiliation dr. roomasa channa section of ophthalmology, department of surgery, aga khan university p o box 3500, stadium road karachi dr. sana shoukat memon section of ophthalmology, department of surgery, aga khan university p o box 3500, stadium road karachi dr. tanveer a. chaudhry section of ophthalmology, department of surgery, aga khan university p o box 3500, stadium road karachi dr. khabir ahmad section of ophthalmology, department of surgery, aga khan university p o box 3500, stadium road karachi reference 1. leibowitz hm. the red eye. n engl j med. 2000; 343: 345-51. 2. fukuyama j, hayasaka s, yamada k, et al. causes of subconjunctival hemorrhage. ophthalmologica. 1990; 200: 63-7. 3. jain bk, talbot em. bungee jumping and intraocular haemorrhage. br j ophthalmol. 1994; 78: 236-7. 4. morris cc. amusement ride-related injuries and deaths in the united states: 1987-2000. in: bethesda, md: us consumer product safety commission; 2001. microsoft word memon muhammad khan 1 original article management of complications of anterior uveitis memon mohammad khan, muhammad saeed iqbal, asad raza jafri, partab rai, javed hasan niazi pak j ophthalmol 2009, vol. 25 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: memon muhammad khan bungalow # 02, doctor mess, kulsoom bai valika social security s.i.t.e. hospital, karachi. received for publication march’ 2008 … ……………………… purpose: to study the prevalence of complications of anterior uveitis and share the experience of their management. material and methods: the study was conducted at jinnah post graduate medical centre, karachi from march 1998 to february 2003. all these patients presented in the out patient department of jinnah post graduate medical centre. the detailed history was taken. complete clinical examination was done to record the findings and all patients were thoroughly investigated to reach the final diagnosis. all patients were treated on the basis of their diagnosis for the underlying cause. surgical procedures were performed where appropriate. every patient was followed for one year within the study period. results: forty six eyes of 32 patients were included in the study. eighteen (56.25%) were male while fourteen (43.75%) eyes were of female patients. all patients were between 05-70 years of age (mean 37.5 years). thirty two eyes were recognized with complications of anterior uveitis. most common complication of anterior uveitis was cataract seen in seventeen cases (36.95%) followed by cystoid macular edema in 08 eyes (17.39%), glaucoma in 4 eyes (8.69%), exudative retinal detachment in 02 cases (4.34%) and one patient (2.17%) had developed vitreous haemorrhage. patients were treated medically and surgically. conclusion: complications of anterior uveitis can be treated safely by medical and surgical methods. 2 he term anterior uveitis is denoted so that iritis refers to the inflammation that is confined primarily to the iris and anterior chamber. conversely, cyclitis describes cellular reaction within the ciliary body and anterior vitreous. the phrase anterior uveitis encompasses the term iritis, cyclitis, and iridocyclitis. the anterior uveitis is most prevalent form of intraocular inflammation. an annual incidence of 8.1 new cases/100,000 population has been reported1. no local data has yet been recorded and many cases of acute and chronic anterior uveitis go undiagnosed. the anterior uveitis clinically can be of acute and chronic onset and can be granulomatous or non granulomatous. it can be bilateral or unilateral in presentation. uveitis is an important cause of visual handicap and blindness in the western world, accounting about 10 % of total blindness in the usa2. intraocular inflammation is not different from inflammation else where. acute inflammation may be inflicted by living or non living agents with breakdown of blood aqueous barrier and vasodilatation. circulating leucocytes in the peripheral blood migrate into the aqueous by chemotactic factors leading to the process of phagocytosis. these chemical mediators like histamine, bradykinin, the hageman factor, complement system, plasmin, prostaglandins and leukotrienes are released during inflammatory reaction. the sequelae of inflammation are resolution, suppuration and organization3. it can often be treated effectively in its active phase by medication. many complications of uveitis can be controlled by surgery or by drugs, for example, cataract and glaucoma4. a secondary cataract can often form in association with chronic uveitis. typically a posterior subcapsular cataract appears but anterior lens changes may also occur. long term use of corticosteroids for the treatment of uveitis may also cause posterior subcapsular cataract5. multiple mechanisms have been explained about the uveitic glaucoma but it is mainly due to the trabecular blockage by the inflammatory debris6. cystoid macular edema (cme) is a common condition associated with intraocular inflammation, vitreoretinal traction and vascular incompetence. different types of anterior and mainly posterior uveitis can result in cme. all these types of uveitis damage the blood-retina barrier which leads to the involvement of macula7. this study was conducted to observe the prevalence of complications of anterior uveitis in urban pakistani population and to share the experience of their management. material and methods forty six eyes of thirty two patients, suffering from anterior uveitis, presented in the out patient department of jinnah post graduate medical centre, karachi during the period from march 1998 to february 2003. all patients were registered and admitted in the hospital. the detailed history was taken. patient’s complaints about ocular pain, redness, halos, floaters or flashes were especially noted. questions were asked about joint pain, oral/genital ulcers, weight loss, urinary problems, chronic cough, trauma etc. previous surgical history, drug history or history of any ocular trauma was also investigated. clinical examination includes general and ophthalmic examination. ophthalmic examination was done giving special consideration to cornea for presence and appearance of keratic precipitates (kps), anterior chamber for the presence of aqueous cells and flare as well as for hypopyon and hyphema. the pupil was examined for posterior synechiae, occlusio and seclusio papillae, iris for rubeosis and inflammatory nodules, lens for secondary cataract, optic disc, macula and blood vessels for signs of posterior segment inflammations like papillitis, cystoid macular edema, vasculitis etc. general physical examination was performed to check the presence of any systemic disease in relation with ocular inflammation. all patients were thoroughly investigated to reach a final diagnosis. a list of general and specific laboratory tests was designed to investigate these patients. general tests include complete blood count (cbc), erythrocyte sedimentation rate (esr), blood sugar level, urine examination and stool examination. disease specific tests include anti nuclear antibodies profile (ana), ra factor, x-ray sacroiliac joint for ankylosing spondilitis, x-ray knee and small joints for juvenile chronic arthritis, barium studies for inflammatory bowel disease, angiotensin converting enzyme level (ace), lung and conjunctival biopsy for sarcoidosis, x-ray chest for sarcoidosis and tuberculosis, tuberculin test for tuberculoid disease, skin (pathergy) test for behcet’s disease, fta-abs (fluorescent treponemal antibody absorption test) and mha-tp and tpha (haemagglutination tests for t 3 treponema pallidum) to diagnose syphilis8. fundus fluorescein angiography (ffa) played important role for the diagnosis of posterior segment pathologies like cystoid macular edema. patients were treated on the basis of their diagnosis for the underlying cause. idiopathic cases were managed with steroids and cycloplegics. most of the cases improved with appropriate treatment. all patients were followed at regular interval and during those follow up visits. thirty two eyes were noted to have complications during their follow up period. most of the patients came with defective vision due to cataract. few cases of early cataract improved with refraction and they were prescribed glasses. rest of the cases was treated surgically. surgical procedure for cataract was performed under retrobulbar anesthesia when uveitis was inactive or under control with medications for at least three months before surgery. topical corticosteroids were given to the patients along with antibiotics three days before surgery9. phacoemulsification was performed on four eyes with implantation of acrylic foldable intra ocular lenses within the capsular bag. five cases were operated by extra capsular cataract extraction with implantation of pmma iols. corneal incision was used to enter the anterior chamber in all cases and three 10/0 nylon stitches were applied to close the incision. sub-tenon dexamethasone/gentamycin injection was given at the end of the surgery. post operative examination was done at day 1, one week, one month, six months and then one year. wound stability, anterior chamber reaction, presence of any pupillary membrane or posterior synechiae and refractive status of the eye was checked on each follow up. trabeculectomy with mitomycin c was done in two patients where medical treatment was failed to treat uveitic glaucoma. cystoid macular edema was treated with topical prednisolone acetate 1% every 2 hours for three weeks. in addition, severe and non responsive cases to topical steroids were treated with sub-tenon injections of triamcinolone (40 mg) at one month interval for three months. oral acetazolamide 500 mg/day was considered as adjunct to topical corticosteroids in persistent cases of cystoid macular edema11. intravenous steroids injections were given to the patients with exuadative retinal detachment and vitreous haemorrhage (table 4). results forty six eyes of thirty two patients were screened. eighteen (56.25%) were of male while fourteen (43.75%) eyes were of female patients. all patients were between 05-70 years of age with mean age of 37.5 years (table i). most of the patients presented between the ages of 21-30 years. eighteen patients (56.25%) presented with unilateral uveitis and fourteen were bilateral cases (43.75%) (table i). out these 46 eyes, 32 presented with complications. cataract was the most common complication seen in seventeen eyes (36.95%). second common complication was cystoid macular edema which developed in eight eyes (17.39%), four eyes (8.69%) were diagnosed with glaucoma, two eyes (4.34%) developed exudative retinal detachment and one eye (2.17%) developed vitreous haemorrhage (table 2). visual acuity was recorded before and after treatment. before treatment, nine eyes were 6/60 or less, eight were at 6/36 vision, nine at 6/24 and six eyes presented with 6/12 vision (table 3). after appropriate treatment, eleven eyes reached the maximum vision of 6/9, six eyes improved up to 6/12, one on 6/18 and seven up to 6/24. three eyes remained on 6/36 and four eyes were lost due to uncontrolled complications and severity of the disease because of the late presentation (table 3). table i: patients’ data n=32 gender male/female 18/14 mean age 37.5 years laterality unilateral 18 (56.25%) bilateral 14 (43.75%) table 2: common complications of anterior uveitis n=32 complications no. of eye n (%) cataract 17 (36.95) cystoid macular edema 8 (17.39) glaucoma 4 (8.69) exudative retinal detachment 2 (4.34) vitreous haemorrhage 1 (2.17) 4 three patients of cataract improved up to 6/9 and five to 6/12 with refraction and they were prescribed glasses. five cases were mature cataract and operated by extra capsular cataract extraction with rigid intraocular lens implantation, while four cases were operated by phacoemulsification with implantation of foldable intraocular lens. cystoid macular edema was treated with topical and sub-tenon corticosteroids and oral acetazolamide. three out of eight cases, improved one line on snellen chart after treatment. two patients of glaucoma responded well to medical therapy. their intra-ocular pressure was controlled and visual fields were satisfactory. two cases (4.34 %) of uncontrolled glaucoma were operated by filtration surgery with mitomycin c (table 4). out of two cases (4.34 %) operated for glaucoma by filtration surgery with mitomycin c, one eye showed worse surgical outcome after mmc application and went into hypotony. second surgically treated eye developed rise in intra ocular pressure after one year (table 4). table 3: visual acuity before and after treatment in eyes with complications n=32 visual acuity cataract cystiod macular edema glaucoma exudative retinal detachment vitreous haemorrhage pre-op post-op pre-op post-op pre-op post-op pre-op post-op pre-op post-op 6/60 or less 05 01 01 02 02 01 01 6/36 02 06 03 6/24 05 01 04 03 03 6/18 05 01 01 6/12 06 6/9 11 table 4: management of complications of anterior uveitis. no. of cases n=32 surgical ecce with iol 05 34.4% phacoemulsification with iol 04 trabeculectomy with mmc 02 medical refraction 08 65.6% steriods (topical & subtenon) for cme 08 anti glaucoma medicines 02 intravenous steroid therapy for exudative rd & vitreous haemorrhage 03 two eyes developed exudative retinal detachment and these were treated with injection of dexamethasone 12 mg intravenous once a day with oral cimetidine 400 mg twice a day. after two weeks, the retina was flat with leopard like appearance i.e hypo pigmented areas surrounded by hyper pigmentation especially at posterior pole. one eye had vitreous haemorrhage which was revealed on b-scan. the cause of vitreous haemorrhage was obscure. these three eyes did not improve due to their late presentation. discussion formation of secondary cataract is not an uncommon complication of chronic anterior uveitis. these are typically posterior subcapsular cataracts but calcium deposits may be observed on the anterior capsule or within the lens substance. in addition, cataracts have also been reported following prolonged treatment of 5 uveitis with corticosteroids5. outcome of surgical correction of these cases is sometimes different from routine cataract surgeries. although these cases may not be associated with severe uveitis in the early postoperative period but mild anterior segment inflammation settles over the period of time. to avoid such problems, it is recommended to perform surgery when uveitis is not active or controlled with medication for at least two to three months prior to the procedure. topical steroids should be started before surgery. ensure the implantation of iol in the capsular bag to prevent iris adhesions with iol9. in our study, seventeen eyes (36.95%) developed complicated cataract within 3-7 months of diagnosis. eight cases of immature cataract improved one line on snellen’s chart by refraction and they were prescribed glasses. nine cases were treated surgically. eight (88.88%) out of nine operated cases improved up to 6/9 vision (bscva) within two months while one eye achieved vision of 6/12. tejwani et al found that in complicated cataracts, 88.3% patients achieved a bscva of 6/9 or better after surgery12. the study also says that it is safe to perform ecce or phacoemulsification with intraocular lens implantation in cases of complicated cataract especially secondary to fuchs’ heterochromic cyclitis. it is best to treat active uveitis and then keep the patients on topical corticosteroids prior to the surgery to avoid severe attacks of inflammation post operatively. many eye disorders become complicated due to the development of cystoid macular edema (cme). uveitis is one of those eye diseases in which cystoid macular edema reduces visual acuity. a multitude of ocular inflammation and infections can lead to cme. these include idiopathic uveitis, intermediate uveitis, birdshot retinochoroidopathy, posterior sceritis, sarcoidosis, toxoplasmosis and behcet’s disease. the common underlying cause is an inflammatory mediated breakdown of blood-retinal barrier7. lardenoye et al, found cystoid macular edema as the major cause of visual loss in uveitis especially among elderly patients and those with chronic disease except in hla-b27 associated uveitis where its role is minimum13. in our study, 37.5% eyes had improvement of one line on snellen’s chart while 62.5% eyes did not show any response to the treatment. the relationship between the levels of iop and inflammation is complex. trabecular meshwork obstruction is the most common mechanism, for which many causes may potentiate one another. first the accumulation of white blood cells (especially macrophages and activated t lymphocytes), or their aggregations which may later form peripheral anterior synechiae and results in subsequent closed-angle glaucoma. second obstruction may arise from inflammatory debris such as proteins, fibrin etc. besides physical obstruction, these products increase aqueous viscosity, which may raise iop. third swelling of trabecular lamellae and endothelial cells may occur, with both physical narrowing of trabecular pores and dysfunction. finally, loss of and/or damage to the trabecular endothelial cells may become irreversible, with or with out lamellar scarring. this results in permanent reduction in conventional outflow6. the initial treatment of uveitic glaucoma is medical therapy. filtration procedures are indicated when glaucomatous eye does not show response to medical treatment. glaucoma associated with uveitis is well known to carry a high risk of surgical failure. the results of unaugmented trabeculectomy surgery appear to be effective in the initial post operative period but the risk of failure is present over the long term. recently, the antiproliferative agent (mitomycin c) has been suggested as an adjunct in trabeculectomy in high risk cases such as uveitic glaucoma, eyes with previous history of ocular surgery, aphakic and pseudophakic eyes14. in our experience, patients who responded well to medical therapy had their intra ocular pressure within normal limits but patients treated surgically with antiproliferative agent demonstrated worse surgical outcome. one eye went into hypotony and second developed raised iop within one year of surgical intervention. noble et al14 had the same experience in uveitic glaucoma patients who were treated surgically by trabeculectomy with the use of antiproliferative agent. late presentation with complications was found to be another reason leading to lack of visual improvement and then ending up with blindness. eyes with exudative retinal detachment were treated with steroids but the response was not adequate. although retina was flat but the appearance was not healthy. it was full of hypo and hyper pigmented areas at the posterior pole. one eye presented with vitreous haemorrhage which led to fibrosis in vitreous cavity and tractional bands pulling the retina from its normal position. 6 uveitis is an important cause of visual handicap and blindness all over the world in case of late presentation or lack of follow ups. it can often be treated effectively in its active phase by medication but many complications of uveitis can be controlled by surgery for examples, cataract and glaucoma. conclusion in conclusion, the study proves that, in this part of the world, the most common complication of anterior uveitis is cataract followed by cystoid macular edema, secondary glaucoma, exudative retinal detachment and vitreous haemorrhage. these complications can be effectively treated by medical or surgical ways. blindness could be a possible outcome if patients present late in the disease course. author’s affiliation dr. memon muhammad khan head and assistant professor department of ophthalmology kulsoom bai valika hospital s.i.t.e., karachi dr. muhammad saeed iqbal assistant professor ophthalmology sir syed college of medical sciences hospital qayyumabad, korangi raod karachi dr. asad raza jafri senior registrar ophthalmology karachi medical & dental college north nazimabad karachi dr. partab rai assistant professor ophthalmology chandka medical college larkana dr. javed hasan niazi head and associate professor department of ophthalmology jinnah post graduate medical centre karachi reference 1. john fv, jannet l, andrew d, et al. what determines the site of inflammation in uveitis and chorioretinitis? karophth souvenier. 1997: 52. 2. nussen blatt rb. the natural course of uveitis. br j ophthalmol. 1990; 14: 303-8. 3. lucas dr. inflammation, immunity and the eye. greer’s ocular pathology. 4th edition. oxford: blackwell scientific publication 1989; 12-3. 4. dick ad. the treatment of chronic uveitis. br j ophthalmol. 1994; 78: 1-2. 5. johns kj, feder rs, rosenfeld si, et al. pathology: lens and cataract. san francisco usa: american academy of ophthalmology. 1999-2000; 40-63. 6. goldberg i. ocular inflammatory and corticosteroid-induced glaucoma: ophthalmology. 1st ed. london: mosby international ltd. 1998; 12: 17.1-17.6. 7. ahmed i, ai e. cystoid macular edema: ophthalmology. 1st ed. london: mosby international ltd. 1998; 8.34.1-34.6. 8. kanski jj. uveitis: clinical ophthalmology. 5th edition. oxford: butterworth-heinamann ltd. 1994; 152-200. 9. hazari a, sangwan vs. cataract surgery in uveitis. indian j ophthalmol. 50: 103-7. 10. noble j, rabinovitch t, birt c. outcomes of trabeculectomy with intraoperative mitomycin c for uveitic glaucoma. can j ophthalmol. 2007; 42: 90. 11. yanoff m, duker js. cystoid macular edema. ophthalmology. 1998; 1: 8.34.5. 12. tejwani s, murthy s, virender s. cataract extraction outcomes in patients with fuchs’ heterochromic cyclitis. j cataract refract surg. 2006; 32: 1678-82. 13. lardenoye cwta, kooij bv, rothova a. impact of macular edema on visual acuity in uveitis. american academy of ophthalmol. 2006; 113: 1446-9. 14. noble j, rabinovitch t, birt c. outcomes of trabeculectomy with intraoperative mitimycin c for uveitic glaucoma. can j ophthalmol. 2007; 42: 93. microsoft word norin bano 2 corrected 12 original article 5-fluorouracil as an adjunct in glaucoma filtration surgery in younger age group norin iftikhar bano, tariq mehmood qureshi, muhammad tariq khan, harris muzammil ansari pak j ophthalmol 2011, vol. 27 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: norin iftikhar bano lrbt free eye & cancer hospital 436-a/i, township lahore received for publication june’ 2010 …..……………………….. purpose: to evaluate efficacy and complication of 5-flourouracil (5-fu) as an adjunct in trabeculectomy in young age group. material and methods: 86 eyes of 62 patients were included in the study. there were 48 male patients (55.81%) and 38 female patients (44.18%). age of patients were two year to fifteen year. duration of study was four years with average follow up of two years. study was conducted at lrbt eye hospital lahore. trabeculectomy was performed with conventional method. first subconjuctival injection of 5-fu (50mg/0.2ml) was given at the end of the procedure, second at the end of 1st week and the third at the end of 2nd week. additional 1-2 injections of 5-fu were given in more resistant cases. results: target iop was achieved in 83 (96.51%) of patients, 2 (2.32%) patients were given additional medication to achieve target iop and 1 (1.16%) did not achieve target iop. visual acuity remained stable in 69 (80.23%) patients, improved in 13 (15.12%) patients, while it deteriorated in 4 (4.65%) patients due to late complications. cup-to-disc ratio reversal was seen in 30% patients up to 14 years of age choroidal detachment occurred in 8 (9.30%) patients and was successfully treated with cycloplegics and pressure patching. choroidal drainage was done in only one patient. thin bleb was seen in 4 (4.65%) patients. blebitis occurred in 1 (1.16%) patient that led to endophthalmitis. 2 (2.32%) patients had retinal detachment. redo-trabeculectomy was done in 3 (3.48%) cases. rabeculectomy is a surgical procedure that lowers intraocular pressure (iop) by creating a fistula which allows aqueous outflow from the anterior chamber to the sub-tenon space. this fistula is protected or guarded by a superficial scleral flap1. the surgical trabeculectomy has been prototype glaucoma filtering procedure over the last three decades2. primary trabeculectomy is still a preferred surgical approach all over the world for cases in which a larger reduction in iop is the aim of treatment, especially when high iop persists, despite maximum tolerable anti -glaucoma medication3,7. at times, certain co-existing risk factors (e.g. young age, uveitis, trauma) can result in failure in even the primary trabeculectomy4. such cases therefore rationalize the adjunctive use of antimetabolites like mitomycin c, which has a proven efficacy in long term post trabeculectomy iop control, although has some serious complications5. 5flourouracil is a chemotherapeutic agent that specifically mediates its antiproliferative effect by antagonizing pyrimidine metabolism; hence is classified as an antimetabolite. 5-fluorouracil is active on the synthesis phase of cell cycle. fibroblastic proliferation is inhibited while fibroblastic attachment and migration are unaffected6. we conducted this study to overview the efficacy and complications of 5-fluorouracil as an adjunct in glaucoma surgery in younger age groups. t 13 material and methods this was a hospital based study conducted at the lrbt free eye and cancer hospital lahore from january 2005 to june 2010. patients with a minimum of two years follow up were included in this study. eighty six eyes of 62 patients were included in this study. patients with congenital glaucoma, glaucoma due to use of steroids, (responders), post traumatic glaucoma and those with previously failed trabeculectomy were included in the study. patients with neovascular glaucoma, active iritis or scarred superior fornix were excluded from the study. preoperative evaluation; for those upto six years of age 90% of examination was carried under sedation with chloral hydrate (500mg/5ml). during examination iop was measured with perkins applana-tion tonometer, corneal diameter with calipers and detailed fundus examination especially cup-disc ratio was done with indirect or direct ophthalmoscope. older cooperative children were examined routinely on slit lamp. preoperatively the intraocular pressure was controlled with topical beta blockers and topical carbonic anhydrase inhibitor, however in some cases a third topical anti-glaucoma drug like alpha agonist above the age of two year was also used. in some cases preoperative intravenous mannitol was used for rapid control of iop. operative procedure: trabeculectomy was performed in each eye according to a modification of the technique developed by watson and cairns. after making a fornix based conjunctival flap, partial thickness rectangular scleral flap (4mm wide by 3mm long.) was made, block of deep sclera (2mm wide by 1.5mm long) was excised and peripheral iridectomy performed. the superficial scleral flap was approximated; conjunctiva and tenon were sutured separately. subconjunctival injection of 5-fu (50mg/0.2ml) was given in a separate plane directed away from the fistula. eye washed thoroughly to remove any released 5-fu to prevent epithelial toxicity which was reported to be very high with 5-fu. second injection of 5-fu was given after first week and third after second week. additional 1-2 injections of 5-fu were given if found necessary. postoperative care: on the first postoperative day, intraocular pressure was recorded with computed airpuff tonometer. in cases of shallow anterior chamber a cycloplegic was used and if the anterior chamber was not formed properly, a pressure bandage with antibiotic eye ointment was used for another twenty four hours. postoperatively topical antibiotic and steroid eye drops were used every two to four hours in waking hours and antibiotic eye ointment at bed time if necessary. the treatment was tapered off according to condition of the eye on follow up visits. postoperative follow-up was at week 1, 2, 6 and at the 3rd month and then 6 monthly. at each visit visual acuity was recorded and slit lamp biomicroscopic examination was carried out to evaluate the condition of conjunctiva, cornea, anterior chamber, vitreous, macula and optic disc. applanation tonometry was done and corneal diameter was recorded. special emphasis was given at the condition of bleb i.e. which type of bleb is established and the vascularisation of the bleb, and to decide how many postoperative subconjunctival injections of 5-fu should be given. 5-fu used in concentration of 50mg/0.2ml with 27 gauge needle on insulin syringe, given 10 to 12 mm away from the bleb. total dose of 5-fu ranged from 15 to 25mg per patient. in 90% of the cases only three injections were required. results eighty six eyes of 62 patients were included in the study. there were 48 male patients (55.81%) and 38 female patients (44.18%) (table 1). duration of study was four years with average follow up of two years. table 1: age (years) number of eyes total eyes male female 2-5 18 15 33 6-10 17 10 27 11-15 13 13 26 total 48 38 86 target iop was achieved in 83 (97%) of patients, additional 2 (2%) patients also achieved target iop with agt and 1 (1%) did not achieve target iop (fig. 1). vision remained stable in 69 (80%) patients, in 13 14 (15%) patients it improved while in 4 (5%) it deteriorated (fig. 2). 1%2% 97% achieved achieved with agt not achieved fig. 1: target iop 0 50 100 stable improved deteriorated fig. 2: post trabeculectomy visual acuity 0 10 20 30 sh all ow a c ep ith eli al to xic ity ch or oid al de tac hm en t th in bl eb bl eb itis rd fig. 3: complications cup-to-disc ratio reversal was seen in 30% of the patients. shallow anterior chamber was seen in 20 eyes, treated with cycloplegics and pressure patching. epithelial toxicity was found in 4 patients that was reduced with the application of ointment for three days after injection of 5-fu. choroidal detachment occurred in 8 (9.30%) patients, most of these patients had microspheric lens. choroidal drainage was done in two cases, other six responded well with pressure patching, cycloplegics and steroids. thin bleb was seen in 4 (4.65%) patients. blebitis occurred in 1 (1.16%) patient that led to endophthalmitis. retinal detachment occurred in 2 (2.32%) patients. redo trabeculectomy was done in 3 (3.48%) cases because stitches were not released in time due to poor follow up (fig. 3). discussion the main cause of failure of filtering surgery is scarring of the filtering bleb. antimetabolites like 5-fu and mmc originally found to inhibit scarring through their inhibitory effect on fibroblasts, are efficacious after filtering surgery in preventing bleb fibrosis in eyes with poor surgical prognosis10. the prognosis of glaucoma surgery is poor in complicated cases such as previous failed trabeculectomy, inflammatory glaucoma, angle recession glaucoma, combined procedure, younger age group, history of topical anti glaucoma medication for more than three years, previous history of conjunctival surgery and individuals with dark skin. this effect is caused by inhibition of fibroblast proliferation or inhibition of cell migration and extracellular matrix production. as a result of its prolonged cytological toxicity, mmc is associated with development of potentially severe side-effects and complications as compared to 5-fu. it may lead to development of thin walled avascular bleb which may results in over filtration. late onset focal bleb leaks are three times more frequent with mitomycin c than with 5-fu13. such blebs are strongly associated with endophthalmitis. the posterior choroid becomes thickened in acute hypotony followed by choroidal detachment. sclerits is also reported in some patients13. although mmc is an effective antifibrotic adjunct with glaucoma surgery but there is a growing concern with hypotony, leaky ischemic blebs, and potentially increased risk of endophthalmitis. this has led us to re-evaluation of the use of 5-fu. in our study, a complete surgical success was considered to be an intraocular pressure of less than 21 mm hg without any anti-glaucoma medication after trabeculectomy with 5-fu. we also studied the safety of use of 5-fu. pressure rose in those cases in which we were unable to give inj. 5-fu due to choroidal detachment p er ce nt ag e of p at ie nt s p er ce nt ag e of p at ie nt s 15 or poor follow up of the patient. we had to redo in these cases in spite of 35 injections of 5-fu. chronic hypotony was seen in only one case in which the cause of glaucoma was angle recession, intravitreal c3f8 was injected, that brought the iop to 12mmhg but vision did not improve due to maculopathy. thin cystic bleb was seen in 4 cases that were managed with postoperative lubricants. blebitis was seen in one case, that child had iridocorneal endothelial syndrome. the present study has clearly demonstrated that 5-fu improves the surgical prognosis for patients at low to moderate risk as well as high risk for failure and indicates that 5-fu facilitates filtering bleb formation as well as with less complications. there is a significant benefit of 5-fu, in terms of bleb survival and clinical success as determined by iop. according to national survey of antimetabolite 93% of consultants are using 5-fu rather than mmc in united kingdom14. there are some differences between success rates of different studies yet our study results are comparable to that demonstrated in some of the previous studies. among previous studies, the pilot study of heuer and colleagues with postoperative subconjunctival injections daily for up to two weeks showed the success rate in previous failed trabeculectomy was found 81%16. although the results of these studies are comparable with our study yet the number of postoperative injections was quite higher compared to our study17. leibmann showed 77.8% 5 years success rate18. our complications with the use of 5-fu were less as compared with other studies. the cause seems to be less number of subconjunctival injections. conclusion the use of 5-fu as an adjunctive has a significant efficacy and low complication rate in glaucoma filtration surgery. author’s affiliation dr. norin iftikhar bano lrbt free eye & cancer hospital 436-a/i, township lahore dr. tariq mehmood qureshi lrbt free eye & cancer hospital 436-a/i, township lahore dr. muhammad tariq khan lrbt free eye & cancer hospital 436-a/i, township lahore dr. harris muzammil ansari lrbt free eye & cancer hospital 436-a/i, township lahore dr. khalid mehmood lrbt free eye & cancer hospital 436-a/i, township lahore reference 1. kanski jj. clinical ophthalmology. a systematic approach. 5th ed. oxford: butterworth heinemann. 2003: 259. 2. lama pj, fecther rd. antifibrotic and wound healing in glaucoma surgery. surv ophthalmol. 2003; 48: 314-46. 3. jalal t, mohammad s. three years retrospective study of patients undergone trabeculectomy in lady reading hospital peshawar. j postgrad med inst. 2004; 18: 487-94. 4. agis investigators. the advanced glaucoma intervention study (agis): 11. risk factors for failure of trabeculectomy and argon laser trabeculoplasty. am j ophthalmol. 2002; 134: 48198. 5. fraser s. trabeculectomy and antimetabolites. br j ophthalmol. 2004; 88: 855. 6. yorston d, khaw pt. a randomized trial of the effect of intraoperative 5-fu on the outcome of trabeculectomy in east africa. br j ophthalmol. 2001; 85: 1028-30. 7. iqbal z, khan n, islam zu. glucoma, presentation and management at khyber teaching hospital, peshawar. j postgrad med inst. 2002; 16: 211-4. 8. the fluorouracil filtering study group. fluorouracil filtering surgery study. one year follow up. am j ophthalmol. 1995; 108: 625-35. 9. ticho u, ophir a. late complications after glaucoma filtering surgery with adjunctive 5-fluorouracil. am j ophthalmol. 1993; 115: 506-10. 10. jamper hd, jabs da, quigley ha. trabeculectomy with 5fluorouracil for adult inflammatory glaucoma. am j ophthalmol. 1990; 109: 168-73. 11. khaw pt, doyale jw, sherwood mb. prolonged localized tissue effects from 5 minutes exposures to fluorouracil and mitomycin-c. arch ophthalmol. 1993; 111: 263-7. 12. khaw pt, sherwood b, mackay ld. 5 minute treatment with fluorouracil, floxuridine and mitomycin-c have long term effect on human tenon’s capsule fibroblasts. arch ophthalmol. 1992; 110: 1150-4. 13. lachkar y, leyland m, bloom p, et al. trabeculectomy with intraoperative sponge 5-fluorouracil in afro-caribbeans. br j ophthalmol. 1997; 81: 555-8. 14. lama pj, fechtner rd. antifibrotics and wound healing in glaucoma surgery. surv ophthalmol. 2003; 48: 314-46. 16 15. siriwardena d, edmunds b,wormald rpl, et al. national survey of antimetabolite use in glaucoma surgery in unitted kingdom. br j ophthalmol. 2004; 88: 873-76. 16. lachkar y, leyland m, bloom p, et al. trabeculectomy with intraoperative sponge 5-fluorouracil in afro-caribbeans. br j ophthalmol. 1997; 81: 555-8. 17. heuer dk, parrish rk, gressel mg. 5 fluorouracil and glaucoma filtering surgery: intermediate follow up of a pilot study. ophthalmology. 1986; 93: 1537-46. 18. goldenfeld m, krupin t, ruderman jm. 5 fluorouracil in initial trabeculectomy: a prospective, randomized, multicenter study. ophthalmology. 1994; 101: 1024-29. 19. greenfield ds, liebmann jm, jee j, et al. late onset bleb leaks after glaucoma filtering surgery. arch ophthalmol. 1998; 116: 443-7. 20. kitazawa y, kawase k, matsushita h. trabeculectomy with mitomycin-c. a comparative study with fluorouracil. arch ophthalmol. 1991; 109: 1693-42. 21. skuta gl, beeson cc. intraoperative mitomycin-c vs. postoperative 5-fluorouracil in high risk glaucoma filtering surgery. ophthalmology. 1992; 99: 438. 22. zacharia pt, depperman sr. ocular hypotony after trabeculectomy with mitomycin-c. arvobstracts ophthalmol vis sci philadelphia, js lippincott. 1993: 816. 23. kitazawa y, kawase k, matsushita h. trabeculectomy with mitomycin-c. a comparative study with fluorouracil. arch ophthalmol, 1991. 109: 1693-8. 24. suner ij, greenfild ds, miller mp, et al. palmberg pf, 1997. ophthalmology. 1997; 104: 207-14. 25. ehrlich r, snir m, lusky m, et al. augmented trabeculectomy in paediatric glaucoma. br j ophthalmol. 2005; 89: 165–8. microsoft word fouzia farhat 83 original article evaluation of eyelid lesions at a tertiary care hospital, jinnah postgraduate medical centre (jpmc), karachi fouzia farhat, qamar jamal, mahmood saeed, zia ghaffar pak j ophthalmol 2010, vol. 26 no. 2 . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: fouzia farhat senior lecturer sindh medical college karachi received for publication july’ 2009 …..……………………….. purpose: to review the pathological lesions of eyelid and to find out their relative frequency. materials and methods: the study was conducted during seven years between 1995 to 2001 at basic medical sciences institute (bmsi), jinnah postgraduate medical centre (jpmc), karachi. in this study evaluation of 258 cases of eyelid lesions were received during our study period. by examining 5µm thick slides prepared from paraffin embedded blocks and staining with different stains, histopathological diagnoses confirmed by performing microscopy was under x10, x40, and x100 magnification. results: a definite histopathological diagnosis was made in 238 cases. out of which 105 (44.11%) cases were benign, 87 (36.99%) cases malignant, 39 (16.39%) cases non-neoplastic tumour-like lesions, and 7 (2.94%) cases were pre-malignant lesions during our seven years study period. conclusion: all the clinically confusing and worrisome eyelid lesions should be immediately biopsied to get an exact diagnosis at cellular level. confirmation of surgical margin for tumour clarity cannot be over-emphasized in oculoplastic reconstructions. yelids are beautiful curtains provided by nature to protect the eyeballs. if we compare with any other organ of our body they have maximum variety of tissues per unit weight1. they are therefore affected by variety of benign lesions2. they may be epithelial, adnexal, vascular, neural, histiocytic, melanocytic or inflammatory in origin. moreover, eyelids are also affected by different systemic diseases3-4. thyroid ophthalmopathy, sarcoidosis, and lymphoproliferative disorders are quotable examples. many lesions are identified by clinical appearance and their behaviour by clinicians. however, they may pose diagnostic challenge when different lesions present in similar fashion, e.g. different pigmented lesions. secondly, when one type of lesion presents in different forms, e.g. eczema or basal cell carcinoma. thirdly, when the nature of lesion is uncertain, i.e. benign or malignant. lastly, many apparently inflammatory lesions may be due to hidden underlying malignancy5-7. moreover, malignancies are also common in periocular area8. materials and methods a total of 258 specimens of eyelid lesion were received during seven years period from 1995 to 2001. most of these specimens were sent by eye and plastic surgery departments of jinnah postgraduate medical centre, karachi. the specimens after gross examination were already fixed in paraffin section previously. the 5 µm thick slice prepared from each paraffin block was subjected to haematoxylin and eosin stain. in some cases other stains were also used to reach the diagnosis, as follows; pas stain in seven, trichrome in two, reticulin in two and fontana in one case. the e 84 slides were reviewed under scanner (x10), low power (x40), and high power (x100) magnifications of the compound microscope. for calculation of p value, goodman i & ii and sobel test applied. results in the current study, we received 258 specimens mainly from eye department of jpmc, karachi and to a lesser extent from plastic surgery department during seven years period, that is, from 1995 to 2001. three specimens were found to be autolyzed and 17 cases did not show any definitive pathological diagnosis, rest of the 238 (92.25%) cases were diagnosed on the basis of histopathological details of the specimens sent. out of 238 cases, we found 105 (43.93%) cases to be benign in nature while 87 (36.55%) were malignant. in 39 (16.39%) cases the histopathological diagnosis was non-neoplastic tumour like lesions. seven (2.94%) cases were pre-malignant in nature, as shown in (table 1). sex distribution of different type of eyelid lesions shows male preponderance in all the tumour and premalignant lesions. there is definite female preponderance seen in non-neoplastic tumour like lesions, all of which are inflammatory in nature, as shown in (table 1). among the benign lesions, most common were epidermal inclusion cyst, i.e. 28 (26.67%) out of 105 cases. the second common benign lesion was dermoid cyst which was 21.90%, i.e. 23 out of 105 cases. all the benign lesions in order of their frequency are shown in (fig. i). basal cell carcinoma was found to be the most common malignancy in our study, i.e. 49 (56.32%) cases out of 87. the next common malignancy is squamous cell carcinoma found in 18 (20.69%) out of 87 cases. after that sebaceous cell carcinoma was found in 13 (14.94%) cases out of 87 (fig. ii). the less common malignant cases are shown in fig. ii in the following order: • adenoid cystic carcinoma 03% • lymphoma 01% • malignant melanoma 01% • merkel cell tumour 01% • malignant fibrohistiocytoma 01% • poorly differentiated carcinoma 01% pre-malignant lesions were 7 (2.94%); they were bowen’s disease, actinic keratosis, and dysplasia. table 1: frequency and sex distribution of eyelid lesions received at department of pathology, bmsi, jpmc between 1995 to 2001 (n = 238) no. of cases n (%) benign lesions • male • female 105 (43.93) 56 (53.33) 49 (46.67) pre-malignant lesions • male • female 07 (2.94) 5 (71.43) 2 (28.57) tumour like non-neoplastic lesions • male • female 39 (16.39) 17 (43.59) 22 (56.41) malignant tumours • male • female 87 (36.55) 52 (59.77) 35 (40.23) p < 0.04 (goodman i & ii and sobel test applied) various eyelid malignancies are shown in figure ii. various tumour like non-neoplastic lesions were 16.39%, i.e. 39 out of 238 cases. chalazion was the most common among them, the remaining lesions are: • granuloma pyogenicum 11% • viral lesions 10% o verruca vulgaris 02% o molluscum contagiosum 08% • chalazion 13% • non-specific inflammation 05% discussion main sources of our specimens were departments of eye and plastic surgery, jpmc, karachi. weekly patient’s attendance in the opds of these two departments is not less than 1,500. if only two percent patients have eyelid lesions the number of eyelid patients reach 30 per week and 1,560 cases per year. during seven years this figure exceeds to10,000 patients having eyelid lesions. 85 28% 23% 17% 14% 9% 5% 3% 2% 2% 2% 0 5 10 15 20 25 30 35 ep de na ap ha ne se fi li ke fig. i: morphological study of eyelid lesions received at department of pathology, bmsi, jpmc between 1995 to 2001 49% 18% 13% 3% 1% 1% 1% 1% 1% 0 10 20 30 40 50 ba sq se ad ma ly po me ma fig. ii: morphological study of eyelid lesions received at department of pathology, bmsi, jpmc between 1995 to 2001 we received only 258 eyelid specimens for histopathological examination during our seven years study period between 1995 and 2001. only about 2.5% patients were subjected to histopathological examination. the reason is that most of these lesions are diagnosed by their appearance and clinical behaviour by clinicians. only worrisome lesions and the surgically excised tissue to check margin clarity are sent to histopathological examination. the same is explained by apple and stewart9 in their very large study of 1,403 eyelid specimens. in our study malignant eyelid lesions were 36.55%, which is similar to an extensive review over a period of 38 years, published by aurora and blodi10, who found one-third of their cases to be malignant. in all the malignant lesions of eyelid the most common was found to be basal cell carcinoma, i.e. 49 (56.32%) out of 87. it was common in older age people (51-60 years), which is co-incident with another study in our population11. there is higher incidence of this tumour in males, i.e. 27 (55.10%) out of total 49 cases. this finding does not match with other western studies in which female preponderance is much greater12. our study revealed solid basal cell carcinoma or undifferentiated basal cell carcinoma being predominant morphological pattern in our population, i.e. 36 (73.46%) cases out of 49 cases. this correlates well with western studies13. nizamuddin14 recorded in his study of malignant ophthalmological tumours in northern areas of pakistan and cited his results as out of 11 cases 7 (73.6%) showed solid basal cell carcinoma, 3 (27.3%) adenoid cystic, and 1 (9.1%) keratotic. incidence of squamous cell carcinoma in our study is 18 (20.69%) out of 87 of all the eyelid malignancies. four cases had xeroderma pigmentosum, which is an important intrinsic factor in development of this tumour specially in blocks15. sebaceous gland carcinoma seen in 13 (14.94%) out of 87 cases and found to be third common malignancy of eyelids. patients are mostly old with female preponderance although younger subjects are also affected. this was almost same as described in the literature16,17. the only difference is in our study in which female to male ratio was 5:8. the reason might be due to the fact that females are not brought for treatment to this tertiary eye care unit by their male counterpart, as our society is male dominant. this type of malignancy is very common in chinese population where every third eyelid malignancy is sebaceous gland carcinoma. american population has 15.5% while in our study it is between these two, i.e. 14.90%18. other less common malignant tumours found were adenoid cystic carcinoma (3%), malignant fibrohistiocytoma, lymphoma, poorly differentiated carcinoma, merkel cell carcinoma, and malignant melanoma all of them were one percent (one patient found to be if malignant melanoma). the white races are twelve times more prone to develop this malignancy due to lack of protective melanin19. there was not a single case of kaposi’s sarcoma. although it is quite common in western society as 24-30% patients of aids develop this tumour during the course of their disease20. most common benign tumour was epidermal inclusion cyst, i.e. 28 (26.66%) out of 105 cases, second 35% 30% 25% 20% 15% 10% 5% 0% p er ce nt ag e 50% 40% 30% 20% 10% 0% p er ce nt ag e malignant tumours 86 common was dermoid cyst which was 23 (21.9%). most of these cases were in the age of first decade of their life, 16 (69.57%) cases out of 23. this is same as described in literature21. appendageal tumour was found to be 14 (13.33%). most common among them was cyst of moll (sudoriferous cyst) while others were pleomorphic adenoma and pilomatrixoma. there were 17 (16.17%) cases of naevi, 5 (4.76%) cases of neurofibroma, and 3 (2.86%) cases of seborrhoeic keratosis. two (0.19%) cases were found each of fibroepithelial polyp and lipoma. keratoacanthoma is a benign tumour it is fast growing and alarms clinicians due to its apparent malignant behaviour22. we received 2 (0.19%) cases during seven year period from 1995 to 2001. conclusion all the clinically confusing and worrisome eyelid lesions should be immediately biopsied to get an exact diagnosis at cellular level. confirmation of surgical margin for tumour clarity cannot be over-emphasized in oculoplastic reconstructions. author’s affiliation dr. fouzia farhat senior lecturer sindh medical college karachi prof. qamar jamal former head & professor of pathology bmsi, jpmc, karachi dr. mahmood saeed former asstt. prof. ophthalmology, jpmc, karachi presently professor of ophthalmology shiekh zyed medical college rahim yar khan. dr. zia ghaffar former community ophthalmologist eye department, jpmc, karachi reference 1. warwick r. ocular appendages, in: warwick r. eugene wolef’s anatomy of the eye and orbit, including the central connections, development, and comparative anatomy of the visual apparatus. 7th ed. philadelphia: w.b. saunders. 1976: 181-4. 2. font rl. eyelids and lacrimal drainage system, in: spencer wh, ed. ophthalmic pathology: an atlas and textbook. philadelphia: w.b. saunders company. 1986; 3: 2149-2312. 3. wesley re and collin jw. basal cell carcinoma of the eyelid as an indication of multifocal malignancy. am j ophthalmol. 1982; 94: 591. 4. wiggs jl, jakobiec fa. eyelid manifestation of systemic disease, in: albert dm, jakobiec fa, robbinson nl, eds. principles and practice of ophthalmology. philadelphia: w.b. saunders. 1994; 3: 1859-67. 5. saeed m, niazi jh, khan nz, et al. carcinoma of eyelid presenting as recurrent chalazia. pak j ophthalmol. 1998; 14: 99-103. 6. saeed m, cheema am, shah sar, et al. surgical treatment of dry eye with parotid secretion. pak j otolaryngol. 1999; 15: 16-8. 7. saeed m, jamal q, farhat f, et al. squamous cell carcinoma of eyelid presenting as “unilateral blepharoconjunctivitis”. report of two cases. jcpsp. 2001; 11: 583-4. 8. caya jg, hidayat aa, weinets jm. a clinicopathological study of adenoid squamous cell carcinoma of the eyelid and peri-orbital region. am j ophthalmol. 1985; 99: 291. 9. apple dj, stewart l. conjunctiva and lids, in: ocular pathology. apple dj and rabb mf, eds. london: mosby. 1998; 5: 582-3. 10. aurora al, blodi fc. lesions of the eyelids. a clinicopathological study. surv ophthalmol. 1970; 15: 94-104. 11. jaradi aasm. malignant tumours of the skin: a dissertation. cpsp karachi. 1996. 12. holder rm, shah sb. skin cancer in african-americans. cancer. 333 (suppl.15): 970-2. 13. wade tr, ackerman ab. the many faces of basal cell carcinoma. j dermatol surg oncol. 1978; 4: 23-8. 14. nizamuddin s. study of malignant ophthalmological tumours in northern areas of pakistan. cpsp karachi. 1993: 80-8. 15. mora rg, perniliaro c. cancer of the skin in blacks. i. a review of 163 black patients with cutaneous squamous cell carcinoma. j am acad dermatol. 1981; 5: 535-43. 16. doxanas mt, green wr. sebaceous gland carcinoma. arch ophthalmol. 1984; 102: 245-9. 17. rao na, hidayat aa, mclean iw. sebaceous gland carcinomas of the ocular adnexa: a clinicopathologic study of 104 cases, with 5-year follow-up data. hum pathol. 1982; 13: 113-22. 18. ni c, dryja tp, albert dm. sweat gland tumours in the eyelids: a clinicopathological analysis of 55 cases. int ophthalmol clin. 1982; 22: 1-22. 19. rhodes ar, weinstock ma, fitzpatrick tb. risk factor for cutaneous predisposed individuals. jama. 1987; 31: 46-54. 20. friedman-kien ae, saltzman br. clinical manifestations of classical, endemic african and epidemic aids-associated kaposi’s sarcoma. j am acad dermatol., 1990; 22: 1237-50. 21. weiss ra. orbital disease, in: mccord cd, tanenbaum m, nunery wr, eds. oculoplastic surgery. 3rd ed. new york: raven press. 1995; 3: 417-76. 22. boynton jr, searl ss, caldwell eh. large periocular keratoacanthoma. the case for definitive treatment. ophthalmic surg. 1986; 17: 565-9. microsoft word index-10.doc case report cases of subconjunctival hemorrhage after a joy ride roomasa channa, sana shoukat memon, tanveer a. chaudhry*, khabir ahmad pak j ophthalmol 2009, vol. 25 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: tanveer a chaudhry section of ophthalmology, department of surgery, aga khan university, karachi received for publication february’ 2009 … ……………………… ubconjunctival hemorrhage is a benign condition that mostly resolves spontaneously on its own, even though it may be very alarming for the patients. multiple causes of subconjunctival hemorrhage-including local trauma, acute conjunctivitis and systemic hypertension have been reported in literature1,2. cases we report here a series of four cases of subconjunctival hemorrhage that occurred following a gyroscopic ride. during easter break, a group of 4 college students, two boys and two girls, between the ages of 17-19 years, presented to the outpatient department of barnsley district general hospital with red eyes. couple of hours before presenting at the eye clinic, they reported going on a gyroscopic ride outside a local pub. after the ride, they noticed red patches in white of their eyes (table 1 and fig. 1). they did not have any history of co-morbids, such as hypertension, diabetes, blood dyscrasias or clotting abnormalities. they were also not using any blood thinning medications, like aspirin or warfarin. general examination showed that vitals including blood pressures were within normal ranges. their visual acuity was normal. all four, but one patient had bilateral sub-conjunctival hemorrhages on the lateral or medial or both sides of the limbus (fig. 1). iop was normal and there was no reaction in the ac. their pupils were reacting normally and detailed retinal examination did not reveal any pathology of the posterior chamber such as retinal edema, hemorrhage or tear. laboratory investigations revealed normal bleeding and clotting profiles. patients were not given any medication, reassured and sent home. three of them returned for examination two weeks later. all hemorrhages had completely resolved. eye hemorrhages and retinal tears caused by amusement rides and high intensity sports such as bungee jumping and roller coaster rides have been reported previously. during 1987-2000 one person in the united states had retinal tear and a possible cerebral edema and five others had eye hemorrhage after they rode a hand-powered ride called the “spaceball” which spins its occupants at a high speed. in addition, a boy aged 17 had vitreous hemorrhage after a gyroscopic ride3, 4. our case series is unique in that all four members of the group developed subconjunctival hemorrhage following a gyroscopic ride. to the best of our knowledge this is the first reported case s series of subconjunctival hemorrhages associated with this type of ride. there is a possibility that many such cases of subconjunctival hemorrhage are not reported because they are not sight threatening. table 1. characteristics of the four cases with subconjunctival hemorrhage patient identif ication age sex location of the subconjunctival hemorrhage 1 17 m bilateral; medial and lateral aspects of sclera 2 17 m bilateral; lateral aspects of sclera 3 18 f unilateral; medial aspect of sclera 4 19 f bilateral fig. 1: location of subconjunctival hemorrhages in three of four cases a gyroscope is a device consisting of a rotating heavy metal wheel pivoted inside a circular frame (fig 2). the wheel’s rotation enables it to retain its original orientation in space when the frame turns. the ride works on exactly the same principle and the high speed rotation of the passenger in multiple directions can cause rupture of the thin conjunctival vessels. fig. 2: a gyroscope: its structure and function conclusion although extreme sports are very attractive, mostly for the younger generation, they can result in eye trauma ranging from benign hemorrhage to a sightthreatening retinal damage. one should observe caution while thinking of indulging in such sports and seek medical advice immediately if there is any associated eye trauma. author’s affiliation roomasa channa section of ophthalmology department of surgery aga khan university p o box 3500, stadium road karachi sana shoukat memon section of ophthalmology department of surgery p o box 3500, stadium road karachi tanveer a. chaudhry section of ophthalmology department of surgery p o box 3500, stadium road karachi khabir ahmad section of ophthalmology department of surgery p o box 3500, stadium road karachi reference 1. leibowitz hm. the red eye. n engl j med. 2000; 343: 345-51. 2. fukuyama j, hayasaka s, yamada k, et al. causes of subconjunctival hemorrhage. ophthalmologica 1990; 200: 63-7. 3. jain bk, talbot em. bungee jumping and intraocular haemorrhage. br j ophthalmol. 1994; 78: 236-7. 4. morris cc. amusement ride-related injuries and deaths in the united states: 1987-2000. in: bethesda, md: us consumer product safety commission; 2001. =================================================================================== continue guess who? answer mandatory for him to write his publications in danish. an antipathy against german, in those days the language of science, may have been gained in a childhood so filled with tension regarding nationalism. the scientific achievement that made the name bjerrum universally known was conceived during his work on the relationship between visual acuity and the perception of the bright stimuli in various retinal zones. in accordance with his own modest attitude, this discovery was published in 1889 in a small paper which in translation was called 'an addendum to the usual examination of the visual field of glaucoma'. at that time bjerrum was studying the visual field by means of small white objects. the idea of this investigation was to record the performance of every single functional unit of the retina. as a minimum such units in bjerrum's opinion would subtend a visual angle of one minute of arc (in the macular region). however, even a small test object would subtend a visual angle exceeding two degrees and accordingly cover a multitude of functional units. in order to obtain a better functional portrayal of the retina, bjerrum conceived the idea of enlarging the observation distance. initially, a standard preemptory was carried out by the aid of a perimeter arc with a radius of 30 cm and a 10 mm test object. a screen was placed next to the perimeter arc. the subsequent step was to move the chinrest table backwards to an observation distance of two meters and plot the visual field on the screen without the use of the perimeter arc. in this case an objection of 2 mm was employed. this last procedure was the first introduction of campimetry, which eventually gained worldwide use. by campimetry bjerrum demonstrated the very small glaucomatous scotomas later called the scotoma of bjerrum in recognition of its discovered. during his tenure as professor beginning in 1896 bjerrum directed the still private clinic on harbour street. although he possessed limited ability as a teacher, he impressed his students with his clinical honesty and the integrity of his scientific work. in his personal dealings and in his clinical and scientific work he displayed an impressive logic and intelligence, but never lost his modesty. his never failing responsibility formed a fashion for the coming generation of danish ophthalmologists. in 1910 when aged 59 years bjerrum retired but continued to reside in copenhagen. as previously mentioned, his origin from scheleswig remained important to him all of his life and resulted in a substantial national feeling that made him feel it a duty and honour to publish his scientific works in danish to avoid confusion with alien research. the scientific community fully realized that this was a danish paper. his national attitude also led to one of his final decisions. the termination of the first world war and the collapse of the german empire brought to the fore the matter of the occupied southern border districts in the post-war peace conference. in 1920, referendum was initiated to give the inhabitants of schleswig the opportunity to choose their future homeland. the electorate was those born in the district. already a sick and old man, bjerrum went from copenhagen to his native village to give his vote, and in this way he contributed to the homecoming of schleswig to the danish kingdom. jannik petersen bjerrum died the same year. bjerrum scotoma = a visual field defect characteristic of glaucoma. it is a nerve fiber bundle defect extending from the blind spot, sweeping around the macular region and ending in a straight line on the nasal side corresponding to the temporal raphe in the retina. reference: history of ophthalmology by kluwer academic publishers. microsoft word index-3.doc original article optic nerve involvement in retinoblastoma: role of computed tomography with and without contrast soufia farrukh, faroohi saghir, muhammad zubair, mughese amin pak j ophthalmol 2009, vol. 25 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations ………………………… correspondence to: soufia farrukh 27-b mediacl colony bahawalpur. received for publication march’ 2009 … ……………………… purpose: the study was designed to evaluate the role of contrast enhanced ct scan as a non invasive test in the detection of optic nerve involvement in retinoblastoma. material and methods: this retrospective study was conducted in bahawal victoria hospital, bahawalpur over a period of one year. 19 consecutive retinoblastoma patients underwent ct scan without and with i/v contrast. if the central retinal vessels were subjectively visualized with i/v contrast the optic nerve (on) was considered to be free of rb. 19 enucleated globes were also sent for histopathology, all the optic discs and nerves examined for presence or absence of tumor and the level of involvement. results: the correlation between visualization/enhancement of central retinal vessels and the presence or absence of optic nerve involvement histopathologically was found to be significant. (p=0.0006, fisher exact test). conclusion: in high spatial resolution enhanced ct with 1.5mm sections, non visualization of central retinal vessels reliably indicates optic nerve involvement with retinoblastoma. he diagnosis of rb is made primarily by indirect ophthalmoscopic examination with ultrasonography used as a confirmatory procedure. since most intra ocular rb contains calcium, sonography is ideal because even a small amount of calcium produces a significantly high internal reflectivity in usg1,2. however once rb infiltrates the on or extends into the orbit through sclera, sonography is ineffective because of shadowing artifact from intra ocular calcifications on the non calcific nature of extra ocular tumor. consequently other imaging procedures as ct or mri are considered better modalities for evaluation of extra ocular extension of rb3. of the two procedures ct is preferred because of mri’s relative insensitivity to calcifications3,4. (fig 1) both imaging procedures are valuable in detecting the presence of associated midline brain lesion, “trilateral rb5,6. the involvement of optic nerve indicates poor prognosis in rb, therefore special attention is directed towards investigation of optic disc area with imaging procedure7. in this study we evaluated the role of enhanced ct to demonstrate the involvement of optic nerve. material and method this retrospective study was conducted in bahawal victoria hospital, bahawalpur over a period of one year. ninteen patients with rb were selected for the study consecutively. two patients were referred by pediatric surgeon and one by plastic surgeon. ninteen eyes were studied with ct of the globe and orbits. high spatial resolution scans (1.5 mm section) were performed without and after administration of i/v contrast ultravist-300, 2ml/kg). multiplanar slices were obtained in enhanced scans. special attention was paid to visualization of central retinal vessels. if t central area of optic nerve (on) was enhanced anteriorly with intra venous contrast, central retinal vessels enhancement was labeled as ‘present’; (fig 2), if not visualized it was labeled as ‘absent’. if entire optic nerve was enhanced diffusely with contrast, not only central retinal vessels but entire nerve was considered ‘positive’. these categories were based on subjective interpretation by the radiologist and the ophthalmologist. fig. i: retinoblastoma right eye showing calcification (arrow). fig. ii: retinoblastoma right eye showing enhancement after contrast and calcification (arrow). ninteen globes were enucleated and fixed in 10% formaldehyde and sent for histopathgology. the optic disc was examined in at least 6 sequential sections for the presence or absence of rb. if tumor was identified within the nerve fiber layer of the on head the case was considered positive (anterior or posterior to lamina cribrosa) for optic nerve involvement; if not it was considered negative. results of 19 eyes, central retinal vessels enhancement was present in 8 (42.1%), absent in 8 (42.1%) and questionably present in 3 (15.8%). optic nerve enhancement was present in 3 (15.8%) and absent in 16 (84.2%) eyes. on histopathologiacl examination of 19 enucleated globes on involvement was negative in 10 (52.6%). rb was present anterior to lamina cribrosa in 1 (5.3%) and posterior to lamina cribrosa in 8 (42.1%). the correlation between the presence of central retinal vessels enhancement on ct and histopathological on involvement was studied in 19 eyes and found to be significant. all 8 cases (100%) in which crv enhancement was absent showed histopathologic tumor involvement posterior to lamina cribrosa. of 8 eyes in which central retinal vessels enhancement was present, 7 (87.5%) histopathological revealed non involvement of the on and in 1 case (12.5%) the on was involved with tumor anterior to lamina cribrosa. the correlation between visualization of central retinal vessels on enhanced ct scan and histopathologic on involvement (positive or negative) was highly significant (p = 0.0006, fisher exact test) whereas correlation between central retinal vessels visualization on enhanced ct scan and choroidal involvement on histopathological was found to be statistically in significant (p = 0.14). discussion during investigation for retinoblastoma, the two main aims are to establish the diagnosis and to determine the extent of the tumor7,9. most rb patients present with leucocoria and ophthalmoscopic recognition of rb. in a small percentage of cases, however, other conditions cause leucocoria; congenital cataract, toxocariasis, retinopathy or prematurity, phpv, and coats disease may be confused with rb8. a number of modalities including ultrasonography, ct and mri are helpful in establishing the diagnosis. because of the frequency of calcification, sonography is considered the most sensitive test for confirmation of diagnosis5,10,11. once diagnosis is established, the next step is to determine the boundaries of the tumor within the eye and whether there is extension into optic nerve, sclera and beyond the globe, for the later purpose ct and mri are superior to sonography because they offer better marginal details and are not affected by artifactual shadowing due to intra ocular calcification. (gd-dpta) enhanced mri provides good delineation of the tumor from adjacent fluid medium, better detecting tumor vascularity and better definition of orbital blood vessels but there are also limiting factors for studying optic nerve head with mri, including poor signal to noise ratio, reduced spatial resolution and thicker sections (usually 3 mm). the most serious short coming of mri in rb cases is its relative insensitivity towards calcification12. on the other hand, calcification can be detected by ct with a high degree of accuracy in approximately 90% of cases13. further advantages of ct are its easy enhancement capability and its potential for detecting the presence of calcified midline lesions. ct studies are also favored over mri due to relatively easier access and lower cost with mri reserved for more difficult cases14,15. the short acquisition time of orbital ct studies (seconds) compared with mri (minutes) decreases motion artifact. table 1: crv enhancement p/a/q on enhancement present/absent on involvement neg/ant lc/pos lc tumor h/p absent absent post. lc poorly differentiated, ++ca present absent negative poorly differentiated absent present post. lc diffuse necrosis present absent negative poorly differentiated absent absent post. lc extrascleral nodule questionable absent negative diffuse necrosis absent present post. lc poorly differentiated, necrotic, +ca absent absent post. lc poorly differentiated, ++ca absent absent post. lc diffuse necrosis, ++ca present absent negative diffuse necrosis, +++ca present absent negative well differentiated, ++ca present absent ant. lc well differentiated present absent negative necrosis, ++ca present absent negative necrosis, ++ca present absent negative poorly differentiated crv enhancement p/a/q on enhancement present/absent on involvement neg/ant lc/pos lc tumor h/p absent absent post. lc poorly differentiated, ++ca present absent negative poorly differentiated absent present post. lc diffuse necrosis crv, central retinal vessels; on, optic nerve; ca, calcium (+, ++, +++) using ultra thin (1.5 mm) sections to evaluate structures with a density significantly different from adjacent tissues, our results indicated improved visualization of the crv. although thin sections lead to low contrast resolution, this was not a disadvantage in our study because contrast enhancement was used. in 8 cases where tumor was posterior to lamina cribrosa architectural disruption of central retinal vessels with tortuosity and distension could be visualized histopathologically. any mass formation in the area such as rb or edema can easily produce distension with and without direct compression of the central retinal vein and/or artery, leading to their non visualization16. conclusion our study concluded that in high spatial resolution enhanced ct with 1.5 mm section, non visualization of central retinal vessels reliably indicates optic nerve invasion with rb. although advances in ct and mr angiography, echoplaner techniques and mr spectroscopy may eventually offer better and safer imaging modalities, it seems that utilization of enhanced ct with ultra thin sections is a reliable and practical addition to our current armamentarium for retinoblastoma management. author’s affiliation dr. soufia farrukh 27-b mediacl colony bahawalpur dr. faroohi saghir department of radiology qamc & bvh, bahawalpur dr. muhammad zubair associate professor pediatric surgery qamc & bvh bahawalpur dr. mughese amin assistant professor plastic surgery qamc & bvh bahawalpur reference 1. byrne sf, green rl. ultrasound of eye and orbit. st. louis: mosby, 1992: 196-200. 2. shields ga, michaelson jb, leonard bc, et al. b scan ultrasonography in the diagnosis of atypical retinoblastomas. can j ophthalmol. 1976; 11: 42-51. 3. mafee mf, goldberg mg, greenwold jm et al. retinoblastoma and simulating lesions: role of ct and mr imaging. radiol clin north am. 1987; 25: 667-82. 4. wilms g, marchal g, von fraeyenhoven l, et al. shortcoming and pitfalls of mri. neuroradiology. 1991; 33: 320-5. 5. blach le, mccormick e, abramson eh, et al. trilateral retinoblastoma – incidence and outcome: a decade of experience. int j radiat oncol biol phys. 1994; 29: 729-33. 6. nucci p, modorati g, pierrol l, et al. comparative evaluation of echography an cat in diagnosis of retinoblastoma. minerva pediatr 1989; 41:129-31. 7. kopelman je, mclean iw, rosenberg sh. multivariate analysis of risk factors for metastasis in retinoblastoma treated by enucleation. ophtrhalmology. 1987; 94: 371-7. 8. shields ja, shields cl. intra ocular tumors: a text and atlas. philadelphia: saunders, 1992: 341-62. 9. karcioglu za, al-masfer sa, jabak mh, et al. workup for metastatic retinoblastoma: a review of 261 patients. ophthalmology. 1997; 104: 307-12. 10. shields ja, stephens rf. ultrasonography in pediatric ophthalmology. philadelphia: saunders, 1982: 145-54. 11. shields ja, michaelson jb, leonard bc, et al. retinoblastoma in 18 years old male. j pediatr ophthalmol. 1976; 13: 275-7. 12. weber al, mafee mf. evaluation of the globe using computed tomography and magnetic resonance imaging. isr j med sci. 1992; 23: 145-52. 13. beets-tan rgh, hendricks mj, ramos lmp, et al. retinoblastoma: ct an mri. neuroradiology. 1994; 36: 59-62. 14. hermans r, marchal g, feenstra l, et al. spiral ct of the temporal bone: value of image reconstruction of submillimetric table increments. neuroradiology. 1995; 37: 150-4. 15. katz da, marks mp, napel sa, et al. circle of willis: evaluation with spiral ct angiography, mr angiography and conventional angiography. radiology. 1995; 195: 445-9. 16. hayreh ss, edwards j. ophthalmic artery and venous pressures: effects of acute intra cranial hypertension. br j ophthalmol. 1997; 55: 649-66. pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 1 editorial diabetic vitrectomy: less is more ahmed b. sallam pak j ophthalmol 2017, vol. 33 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ractional retinal detachment (trd) that threatens or involves the macula, is the second most common indication for pars plana vitrectomy in diabetic eyes1. the primary goals of vitreous surgery in tractional diabetic detachment include removal of vitreous hemorrhage, and the elimination of antero-posterior and tangential macular traction, thus stabilizing and increasing the vision. removing all membranes is believed to reduce the frequency of postoperative re-bleeding, and the risk of epiretinal membranes/trd recurrences. in proliferative diabetic retinopathy (pdr), fibrovascular tissue extends along the posterior hyaloid surface. this proliferation often causes changes in the vitreous gel that result in further traction on the retinal neovessels. diabetic trd surgery is one of the most difficult surgery that the retina surgeon encounters for several reasons. first, the posterior hyaloid is usually not detached from the retina and often the adhesions between vitreous/epiretinal membranes and the underlying retina are vascular and significantly strong. second, the ischemic nature of the diabetic retina makes it fragile and thin. accordingly, employment of high suction to induce posterior vitreous detachment (pvd) (as conventionally used in macular hole or retinal detachment surgery) or peeling of membranes (as in idiopathic epiretinal membranes cases) are not advised due to high risk of retinal tears and bleeding. finally, vitreoschisis, splitting of the posterior hyaloid layer, a consequence of anomalous pvd is present in a significant number of eyes with pdr related trd3. this phenomenon could make the identification of the plane between the posterior hyaloid difficult and the retina and explains why we sometimes encounter what appears as ‘layers of epiretinal membranes’ in eyes with diabetic trd intraoperatively. the correct surgical cleavage plane for dissection of epiretinal membranes is under the posterior leaflet of the split posterior hyaloid and accessing this plane makes dissection easier, quicker and safer. we routinely use intravitreal anti-vegf preoperatively in diabetic trd the membranes are completely fibrosed. anti-vegf decreases the risk of intraoperative bleeding as well as early postoperative hemorrhage2. we are cautious about its risk of increasing fibrosis so we tend to administer the injection 3-4 hours only before the vitrectomy surgery. we use 25g or 27g transconjunctival vitrectomy for most of our surgeries. for cases of diabetic vitreous hemorrhage and minimal or no diabetic membranes, we would start by inducing pvd (if not yet detached) over the optic disc using active suction with the vitreous cutter. we usually perform this step slowly and pay attention to whether abnormal vitreoretinal adhesions exist as employing suction on these areas may cause the retina to tear. if areas of pvd are present peripherally, these could be good areas to incise the hyaloid initially. in cases where the posterior hyaloid is difficult to separate from the retina with active suction, we find sharp dissection using a bent sharp needle or a retinal pick very helpful to penetrate the posterior hyaloid and elevate it off the retina. removal of vitreous hemorrhage is usually straightforward when the posterior hyaloid is separated. in the absence of peripheral retinal detachment, we usually do not perform vitreous base shaving. we believe that this an unnecessary step that does not improve the visual result and is associated with increased surgery time as well as risk of creating retinal tears or touching the crystalline lens touch. the only exception is in eyes with inferior vitreous base hemorrhage where ‘leaching’ of blood from this area may cause early postoperative bleeding and cautious shaving of the vitreous base inferiorly could therefore be of benefit. t ahmed b. sallam 2 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology when undertaking trd surgery, identification of the proper plane between the posterior hyaloid and the retina is crucial and greatly facilitates posterior hyaloid separation and membrane dissection. with this in mind, we usually start the dissection from the posterior pole and move outwards. vitreoschisis, if present, usually does not exist over the posterior pole and hence it is good area to to start dissection. after a very limited central vitrectomy mainly to clear the view from any vitreous hemorrhage, we stain the post hyaloid/epiretinal membranes with either trypan blue or icg. we then use a vitreoretinal forceps to peel the hyaloid/epiretinal membrane off the optic nerve edge. while peeling of diabetic fibrovascular membranes in diabetic vitrectomy is generally not advisable due to strong attachment of retina and membranes, in our experience, peeling over the optic disc is safe and is unlikely to cause problems apart from some risk of bleeding from the avulsed vessels. having exposed the ‘correct’ dissection plane that facilitates access to the fibrovascular epiretinal membranes, we would now use the vitreous cutter to remove the membranes, initially aiming for wide segmentation of membranes, and opening up spaces followed by further cutter based techniques such as, cut back delamination and trimming of membranes down to epicenters. for membranes in eyes where the posterior hyaloid is totally plastered down to the retina and where membranes are adherent down to the retina, we would switch to bimanual surgery, using a horizontal curved scissor and forceps with the help of an additional chandelier light. as membrane dissection continues, the posterior hyaloid would then start to separate and core vitrectomy can be completed. as for ilm peeling, we peel the ilm only in eyes where the macula remains wrinkled after erm removal and not routinely. caution needs to be exercised when peeling ilm in eyes with marked diabetic macular edema so as not to roof macular cysts and cause a macular hole. the best case scenario is to be able to finish the trd surgery after one has completely separated the posterior hyaloid and removed all retinal membranes without iatrogenic retinal tears. unfortunately this not possible to achieve in every case, at least in our hands. in our view the ‘second best’ is to remove central membranes (within and at the vascular arcades), trim the peripheral vitreous, leave peripheral membranes that are judged to be very adherent to underlying retina and still do not cause iatrogenic retinal tears. it takes a lot of experience to learn to resist the temptation of removing all epiretinal membranes and in particular to be able to do this before creating iatrogenic tears. however, if during membrane dissection, retinal tears do occur, it is then important not to stop but rather continue to remove all traction around the tear (s) even if this results in creating further retinal tears. causing retinal tears during dissection but successfully removing all traction around these tears and ending up with a gas tamponade is also a ‘second best,’ in our view. in the absence of retinal tears, we would perform laser photocoagulation while the eye is filled with saline. if retinal tears and rhegmatogenous detachment exist, we would then do the laser after air-fluid exchange or under perflurocarbon liquid (pfcl). in general, we prefer to do laser after air-fluid exchange unless retinal mobility was excessive and pfcl was needed to stabilize the retina during membrane dissection. the view under air could also be difficult in pseudophakic eyes with opened posterior capsule, and in these cases, we would also favor pfcl over air. we routinely apply laser up to the ora serrata in diabetic patients and also extend treatment to the pars plana at the entry sites to decrease the risk of entry site neovascularization, a cause for late postoperative bleeding. intraocular tamponade is usually not required in the absence of retinal tears. in cases where retinal tears exist, intraocular gas is usually preferred over silicone owing to superior tamponade effect and because silicone oil use in diabetic patients could trigger recurrent epiretinal membrane proliferation. however, we use silicone oil in cases that we end up with retinal tears that are associated with significant residual traction that could not be relieved and in complex cases that required retinectomies. data from a uk large cohort national database study that comprised 510 diabetic vitrectomies with delamination/ segmentation showed that approximately 60% of eyes required internal tamponade that included gas (mainly sulfurhexafluoride) in 63% of eyes, air in 18% and silicone oil in 19%4. in conclusion, we believe that‘ less is more’ when undertaking diabetic trd surgery. we would prefer to only remove the membranes over the macula and leave peripheral membranes and not to end up with lots of retinal tears that we failed to relieve traction around and have no alternative but to use silicone oil. in our view, gas tamponade is far superior to silicone oil in diabetic patients and the use of silicone oil in diabetic patients should be limited. diabetic vitrectomy: less is more pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 3 authors affiliations: ahmed b sallam md phd frcophth jones eye institute, university of arkansas for medical sciences, arkansas, us. email: asallam@uams.edu references 1. jackson tl, donachie ph, sparrow jm, johnston rl. united kingdom national ophthalmology database study of vitreoretinal surgery: report 1; case mix, complications, and cataract. eye, 2013; 27: 644-651. 2. el-sabagh ha et al. preoperative intravitreal bevacizumab use as an adjuvant to diabetic vitrectomy: histopathologic findings and clinical implications. ophthalmology, 2011; 118: 636-641. 3. schwatz sd, alexander r, hiscott p, gregor zj. recognition of vitreoschisis in proliferative diabetic retinopathy. a useful landmark in vitrectomy for diabetic traction retinal detachment. ophthalmology, 1996; 103: 323-328. 4. jackson tl, johnston rl, donachie ph, williamson th, sparrow jm, steel dh. the royal college of ophthalmologists' national ophthalmology database study of vitreoretinal surgery: report 6, diabetic vitrectomy. jama ophthalmol. 2016; 134: 79-85. mailto:asallam@uams.edu microsoft word editorial 55 editorial retinal vein occlusion management updated recommendations incidence of retinal vein occlusion (rvo) has been on the increase and a recent study has revealed that about sixteen million people worldwide have retinal vein occlusion and is the second only to diabetic retinopathy in producing blindness due to retinal vascular diseases. macular edema is the frequent cause of visual acuity loss in both central retinal vein occlusion (crvo) and branch retinal vein occlusion (brvo), the later being more common (80%). brvo occurs at the arterio-venous (av) crossing where-in the common adventitious sheath compression of the vein by the thickened arterial wall results in the vascular flow embarrassment, thrombus formation and occlusion. crvo occurs at or behind the lamina cribrosa where again the hardened artery in the common sheath presses on the vein to cause occlusion in the same way. important risks factors in rvo are high blood pressure, diabetes, glaucoma and age. branch vein occlusion study (bvos) found that brvo is self limiting in about one third of the cases and the recommendations are to observe them for three months and if there is no improvement by this time then light grid pattern laser spots should be applied to the affected area of the retina. this treatment showed improvement of about 2 lines in visual acuity compared to untreated controls. central vein occlusion study (cvos) found that crvo is relatively asymptomatic; visual acuity reduction due to macular edema is comparatively lesser than brvo. central retinal vein occlusion is categorized as non ischemic, ischemic and intermediate and observed that there is no proven treatment of crvo. in these cases laser application, though reduced macular edema, but did not improve visual acuity and hence recommended control of causative factors with observation until natural resolution. in marked peripheral non perfusion cases panretinal photocoaugulation (prp) may be required to prevent neovascularization and rubeotic glaucoma. in younger age crvo cases there may be clotting abnormalities due to various disorders hence they should be examined by hematologist, advised and managed accordingly with aspirin etc. with increasing incidence of main risk factors i.e hypertension and diabetes there is noticeable increase of rvo cases. there has also been an acute awareness that rvo management is not being adequately met and there is an urgent need for testing alternative and more effective modes of therapies besides mere observation and laser treatment recommended by bvos (since 1984) and cvos (since 1995). recently observations and recommendations of three new trials have been released. 1. score (standard care versus corticosteroids for retinal vein occlusion). 2. bravo (a study of efficacy and safety of ranibizumab (lucentis) injections in patients with macular edema secondary to brvo), 3. cruise (a study of efficacy and safety of ranibizumab (lucentis) injections in patients with macular edema secondary to crvo). in score trial steroids in the form of triamcinolone acetonide 1 mg and 4 mg and slow release dexamethasone implants were tried and compared with laser application. due to steroid side effects like cataract and glaucoma and keeping the risk benefit ratio into consideration, grid laser application was preferred over steroids in brvo in crvo low dose of steroids (1mg) was preferred over laser. despite low steroid dose (1mg) patients were kept under observation for any requirement of iop lowering drops. bravo and cruise trials use of anti vegf agents like ranibizumab (lucentis) resulted in the decrease of macular edema secondary 56 to brvo and crvo and was associated with significant visual acuity gains. the effect became evident soon after first injection. it was further observed that patients treated with ranibizumab (lucentis) alone were approximately three times more likely to be three-line gainers at 6 months than in sham group. which anti vegf agent? despite bevacizumab (avastin) being off label drug and ranibizumab (lucentis) being projected to be superior to bevacizumab (avastin) in formulation, majority of the ophthalmologists prefer avastin over lucentis; being nearly of equal efficacy and much less cost. what dose? various doses have been tried without very significant benefit of higher dose (avastin 1.25mg and lucentis 0.5mg) what protocol? in rvo vegf production is on going with resultant macular edema and neovascularization eventually and to counter it anti vegf injections are recommended at about monthly intervals currently till we develop more effective and longer lasting modalities. how long? start the treatment with immediate injection and then monthly injections till the situation is stabilized and then if need be give injections with treat and extend protocol (tapering treatment) by assessing visual acuity and macular edema (with oct) or resort to treating on as needed basis. role of laser role of laser is important in rvo as there is some element of more or less ischemia in nearly all cases with the tendency of neovascularization in the long run if anti vegf is not given indefinitely. patients with marked peripheral non perfusion should be kept under close observation or preferably prp should be done in time. when combining anti vegf with laser, the protocol should be anti vegf injection and after one week, once edema is reduced, laser application is carried out. edema in rvo is predominantly at superficial level in the inner retinal layers due to production of vegf by the ischemia of the photoreceptors and the aim of laser treatment is to apply it at the pigment epithelium layer level to cause ablation of photoreceptors to reduce vegf production. if there are retinal hemorrhages in rvo, the laser energy is absorbed by the blood in the superficial inner retinal layers destroying the nerve fiber layer causing damage rather than the required benefit of reducing vegf production by ablating photoreceptors. hence laser should be avoided in the presence of retinal hemorrhages till these clear with the passage of time or with anti vegf injections. when grid laser application is contemplated for macular edema it should be applied judiciously because it causes permanent ablation which cannot be retraced, hence in cases where macular edema is controlled with anti vegf or steroids, laser application maybe held off. risk factors important recommendations are to attend to the risk factors in rvo like hypertension, cardiovascular diseases, diabetes, obesity and glaucoma. combination therapy may be considered in resistant situation with anti vegf, laser and steroids (maybe deep sub tenon injection of triamcinolone acetonide) caution be wary of the complications of repeated intravitreal injections like endophthalmitis, retinal detachment, retinal hemorrhages, and lens damage. take precautions with proper aseptic protocol and timely detection and management if it happens. prof. m lateef chaudhry editor in chief microsoft word rao rashad qamar 28 original article supratarsal injection of triamcinolone for vernal keratoconjunctivitis muhammad rashad qamar, ejaz latif, tariq mahmood arain, ehsan ullah pak j ophthalmol 2010, vol. 26 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: rao muhammad rashad qamar 29-b, medical colony, bahawalpur. received for publication april’ 2009 … ……………………… purpose: to find out safety and effectiveness of supratarsal injection of triamcinolone in vernal keratoconjunctivitis (vkc). material and methods: this study was conducted from 1st february 2006 to 15th july 2007 in department of ophthalmology bvh, bahawalpur. eight hundred and eighty eyes of 440 diagnosed patients of vkc, of either sex and all ages were included in the study. patients with raised iop, post-herpetic corneal scar, tightly closed eyelids were excluded from the study. it was a prospective, uncontrolled trial. the patients were enrolled and given the first supratarsal injection of triamcinolone. their record was maintained and all the patients were followed up for obtaining the data about effectiveness and side effects of therapy. results: we treated 880 eyes of 440 patients, out of which 81.82% were males. mean age was 16 years (range: 2—42 years). all of the patients had itching of eyes and the rest of the clinical features were redness, cobble-stone papillae and tranta's dots. mean duration of disease was 18 weeks (range: 4 weeks to 6 months). patients were followed up and multiple injections were given to control the disease. transient redness was most common among the side effects of injection therapy. study shows 100% effectiveness of supratarsal injection of triamcinolone acetonide in vkc although recurrence was seen. conclusions: supratarsal injection of triamcinolone is safe, cost-effective and simple way of management of vkc. curative treatment for vkc still remains elusive. kc is a bilateral, recurrent, interstitial inflammation of the conjunctiva1 which affects children and young adults2. about 12.5% of ophthalmology visits in outpatient clinics have vkc3,4. more than 80% of patients are below 18 years of age5. boys are affected twice more than girls6. wide range of therapeutic modalities are currently available for the treatment of vkc. most of the patients show mild symptoms, usually relieved by over the counter medication. more severe cases may need topical nonsteroidal anti inflammatory drugs (nsaid), or topical steroids, mast cell stabilizers, or even oral steroids and cyclosporin. more recently, topical ketotifen fumarate, mipragoside levocabastatine hydrochloride, lodoxamide tromethamine, excimer laser, and surgical therapy have also been used7-11. however, most of these newer treatment modalities have been found relatively ineffective. systemic therapy with high doses of aspirin relieve some signs and symptoms, but tarsal cobblestone papillae and shield ulcers remain relatively unaffected12. more recently, successful use of supratarsal injection of corticosteroids has been reported in severe and refractory vkc13,14. triamcinolone is one of the effective corticosteroid in vkc and its role in ocular therapeutics is increasing day by day15. we have conducted this study to find out safety and effectiveness of supratarsal injection of triamcinolone in vkc. we also made an attempt to gauge its effectiveness by the age of the patient and by the severity and the duration of disease. v 29 material and methods this study was conducted from 1st february 2006 to 15th july 2007 in department of ophthalmology bvh, bahawalpur. eight hundred and eighty eyes of 440 diagnosed patients of vkc, of either sex and all ages were included in the study. patients with raised iop post-herpetic corneal scar and tightly closed eyelids were excluded from the study. it was a prospective, uncontrolled trial. the patients were enrolled and given the first supratarsal injection of triamcinolone. their record was maintained and all the patients were followed up for obtaining the data about effectiveness and side effects of therapy. following procedure of supratarsal injection was adopted as shown in fig. 1-7. fig. 1 fig. 2. fig. 3. fig. 4. fig. 5. fig. 6. fig. 7. 30 0 50 100 150 200 250 300 350 400 450 total males females total males females fig 8: sex distribution b/w 2‐4 y b/w 30‐42 y b/w 4‐30 y fig. 9: age distribution fig 10: results • every patient was explained about the course of treatment. • informed consent was taken. • conjunctiva was anesthetized with proparacaine 0.5% eye drops. • upper eyelid was everted. • one ml syringe with 26 gauge needle was used. • patient was asked to look down. • needle was inserted through conjunctiva. • one ml of triamcinolone acetonide 40 mg/ml (kenacortr – a) was injected. • pressure by pad was applied for 2 to 3 minutes. • topical combination drops were then instilled. results mean duration of disease was 18 weeks (range: 4 weeks to 6 months). patients were asked for follow up visits after 1 day, 1 week, 1 month, 6 months and 1 year. injection was repeated at 24 to 72 hours on recurrence of symptoms. multiple injections were given to control the disease. repeat injections were given 4 to 12 months apart (average 4). duration between repeat injections was more in patients who avoided rubbing and sunlight. transient redness was most common among the side effects of injection therapy. discussion vkc has got wide geographical distribution. it is more common in teenagers, especially boys. mostly it presents mild symptoms and does not attract much attention of either patient or the doctor. but severe symptoms are really disturbing to the patient as well as treatment of severe vkc is a difficult problem for the ophthalmologist16 because these patients develop disease related and/or iatrogenic complications. wide range of therapeutic modalities are currently available for the treatment of vkc. topical nonsteroidal anti inflammatory drugs (nsaid), or topical steroids, mast cell stabilizers, or even oral steroids and cyclosporin have been used previously. more recently, topical ketotifen fumarate, mipragoside levocabastatine hydrochloride, lodoxamide tromethamine, excimer laser, and surgical therapy have also been used7-11. holsclaw et al13 reported successful use of supratarsal injection of steroid in vkc. saini et al14 also observed similar results. satvir singh studied the effectiveness and side effects of supratarsal injection of steroids and labelled it as safe therapy5. recent studies have also shown that triamcinolone is equally effective than any other corticosteroid given as supratarsal injection14,16. our study shows its 100% effectiveness although it needed multiple injections. response was independent of age of the patient and of the severity and duration of disease. side effects were infrequent and well tolerable. recurrence was seen in all cases. although triamcinolone given as a supratarsal injection is effective in severe vkc yet as we have seen in this study that vkc recurred in all cases. so the results 0 10 20 30 itching redness trantas dots cobble stone papilae 31 curative treatment for vkc is still elusive. it needs further experimentation and research on the subject. conclusions • supratarsal injection of triamcinolone is safe, costeffective and simple way of management of vkc. • it is worth-considering in patients with poor compliance to drugs and those showing side effects/complications. • curative treatment for vkc still remains elusive. author’s affiliation muhammad rashad qamar assistant professor department of ophthalmology qamc & bvh bahawalpur prof. ejaz latif department of ophthalmology qamc & bvh bahawalpur dr. tariq mahmood arain associate professor department of ophthalmology qamc & bvh bahawalpur dr. ehsan ullah department of ophthalmology qamc, bahawalpur reference 1. theodre fh, schlossnan a. vernal conjunctivitis. in: ocular allergy. baltimore: waverly press inc. 1958; 98-137. 2. javadi m. focal points in treatment of vernal keratoconjunctivitis [in persian]. bina j ophthalmol (supplement). 1996; 4: 14-5. 3. bagheri a, khaksar m. epidemiology of vernal keratoconjunctivitis in kashan [in persian]. feiz. 1996; 2: 34-52. 4. allansmith mr. vernal conjunctivitis: duane's clinical ophthalmology. philadelphia: lippincot-raven; 1991; 4: 1-8. 5. singh s, pal v, dhull cs. supratarsal injection of corticosteroids in the treatment of refractory vernal keratoconjunctivitis. ind j ophthalmol. 2001; 49: 241-5. 6. allansmith mr, ross rn. ocular allergy and mast cell stabilizers. surv ophthalmol. 1986; 30: 229-44. 7. fujishima h, fukagawa k, satake y, et al. combined medical and surgical treatment of server vernal keratoconjunctivitis. jpn j ophthalmol. 2000; 44: 511—5. 8. verin ph, dicker id, mortemousque b. nedo cromil sodium eye drops are more effective than sodium cromoglycate eye drops for long-term management of vernal keratoconjunctivitis. clin exp allergy. 1999; 2: 529-36. 9. cameron ja, antonios sr, badr ia. excimer laser phototherapeutic keratectomy for shield ulcers and corneal plaques in vernal keratoconjunctivitis. j refract cataract surg. 1995; 11: 31—5. 10. sud rn, greval rs, bajwa rs. topical flurbiprofen therapy in vernal keratoconjunctivitis. indian j med sci. 1995; 49: 205-9. 11. mendicute j, aranzasti c, eder f, et al. topical cyclosporin a 2% in the treatment of vernal keratoconjunctivitis. eye. 1997; 11: 75-8. 12. abelson mb, butrus si, weston jh. aspirin therapy in vernal conjunctivitis. am j ophthalmol. 1983; 95: 502-5. 13. holsclaw ds, witcher jp, wong ig, et al. supratarsal injection of corticosteroid in the treatment of refractory vernal keratoconjunctivitis. am j ophthalmol. 1996; 121: 243-49. 14. saini js, gupta a, pandey sk, et al. efficacy of supratarsal dexamethasone versus triamcinolone injection in recalcitrant vernal keratoconjunctivitis. acta ophthalmol scand. 1999; 77: 515-8. 15. jermak cm, dellacroce jt, heffez j, et al. triamcinolone in ocular therapeutics. surv ophthalmol. 2007; 52: 503-22. 16. aghadoost d, zare m. supratarsal injection of triamcinolone acetonide in the treatment of refractory vernal keratoconjunctivitis. arch ira med. 2004; 7: 41-3. microsoft word abdul hye 2 180 original article post-keratoplasty glaucoma in secondary trans-scleral fixation of posterior chamber intra-ocular lens implant abdul hye, abrar ahmad bhatti, zahid kamal siddiqui, imran akram sahaf pak j ophthalmol 2011, vol. 27 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: abdul hye department of ophthalmology postgraduate medical institute lahore resubmission of paper august’ 2011 acceptance for publication september’ 2011 …..……………………….. purpose: purpose of this study was to observe the incidence of postkeratoplasty glaucoma in secondary scleral fixation of iol in patients of aphakia and pseudophakic bullous keratopathy (group i). these patients were compared, with clinically matched patients, undergoing penetrating keratoplasty with posterior chamber iol in the presence of capsular support (group ii). material and methods: 25 consecutive patients of bullous keratopathy in aphakic eyes without capsular support or in pseudophakic eyes with ac iols were included in this prospective study. penetrating keratoplasty was performed by suturing 0.25 mm larger donor corneal graft with interrupted 10/0 nylon monofilament sutures, after fixing the iol to the sclera with 10/0 prolene suture. the statistical analysis was performed using fisher’s exact test and chi-square test 2x2 table. the finding was considered significant at p value < 0.05. results: the post-operative visual acuity, in the study population as whole, ranged from < 0.05 to 0.33 snellen’s fraction (i.e. hand movement to 6/18 snellen’s va). a statistically significant improvement was noted (p-value < 0.05 using fisher’s exact test and chi-square analysis), when post-operative visual acuity was compared with pre-operative visual acuity in each group. however, comparing the study groups, there was no statistically significant difference in the post-operative visual acuity (p-value> 0.05). the incidence of post-operative glaucoma was 32% incidence of glaucoma in group i was 40% (10/25 patients) and in group ii was 24% (6/25 patients). the difference between the two groups in the post-operative incidence of glaucoma was statistically significant (p value<0.05). comparing the difference between pre-operative and post-operative incidence of glaucoma, it was statistically significant within the group i (p value<0.05) as a whole (p value < 0.05). conclusion: while trans-scleral fixation of posterior chamber intra-ocular lens has a place in eyes lacking capsular support it does lead to higher frequency of post-keratoplasty glaucoma. aised intra-ocular pressure, contributes to loss of corneal endothelial cells as well as to progressive optic nerve damage, and is a well known complication of penetrating keratoplasty. the incidence of post – keratoplasty glaucoma in aphakic eyes ranges from 42% to 89%1-2. corneal edema and bullous keratopathy in aphakic and pseudophakic eyes continue to remain the leading indication of penetrating keratoplasty3-7. in eyes without capsular support, scleral fixation of posterior chamber iol is r 181 preferred because the posterior chamber iol fixed to sclera are more physiological, is closer to nodal point of eye and acts as a barrier against the vitreous movements. scleral fixation pc iols play a definitive role in preventing cystoids macular edema and graft endothelial damage8-12. in addition, the penetrating keratoplasty procedures combined with closed loop anterior chamber iol failed in 60% of the patients in one study13. purpose purpose of this study was to observe the frequency of glaucoma (raised iop) after scleral fixation and scleral fixation in patients with aphakic and pseudophakic corneal edema and bullous keratopathy (group i). these patients were compared with clinically matched patients undergoing penetrating keratoplasty with posterior chamber iol in the presence of capsular support (group ii). material and methods 25 consecutive patients of corneal oedema and bullous keratopathy in aphakic eyes without capsular support or in pseudophakic eyes with ac iols were included in this prospective study. a complete ophthalmic and medical history was taken, and ophthalmological examination, including recording of va, measuring iop with applanation tonometer, and b-scan were performed (table 1-2). in group i, after removal of oedematous corneal button, adequate anterior vitrectomy was performed removing the vitreous from the anterior chamber and from behind the iris. a posterior chamber iol was fixed to sclera in an oblique plane, using 10/0 prolene suture with a small 8.0 mm needle, passed through the dilated pupil behind the iris emerging in an area of lamellar scleral flap 1.5 mm from the limbus and tied under the flap. penetrating keratoplasty was completed by suturing 0.25 mm larger donor corneal graft with interrupted 10/0 nylon monofilament sutures. in group ii, after removal of edematous corneal button, extra capsular cataract extraction was performed and posterior chamber iol was implanted either in the capsular bag or in the sulcus. penetrating keratoplasty was completed by suturing 0.25 mm larger donor corneal button in a fashion similar to the group i. post-operatively, a combination of tobramycin and dexamethasone eye drops was prescribed, to be used 2 hourly for 2 weeks and 4 hourly for 2 months. topical and oral anti-glaucoma medicines were added when required. all patients were followed for at least six months, and the post-operative visual acuity and iop were recorded and compared with pre-operative findings, not only within the group, but also with each other. the post-keratoplasty glaucoma was defined as iop more than 21 mm hg, when associated with noninflammatory corneal graft edema and/or optic nerve damage. the characteristic visual field changes and the glaucomatous optic neuropathy may not be evident due to corneal edema and visual distortion related to higher astigmatism. the statistical analysis was performed using fisher’s exact test and chi-square test 2x2 table. the finding was considered significant at p value < 0.05. results group i: twenty five eyes of 24 patients of aphakic or pseudophakic bullous keratopathy were studied. one patient had sequential bilateral surgery. the male patients were more than the females with a ratio of 3:1. average age of patients was 45.4 years, with a range of 9 years to 68 years. group ii: twenty five eyes of 25 clinically matched patients undergoing penetrating keratoplasty with posterior chamber iol in the presence of capsular support were included. the male patients were more than the females with a ratio of 2:1. average age of patients was 58.8 years, with a range of 23 years to 86 years. both groups of patients were studied and compared primarily in respect of preoperative and post-operative visual acuity and incidence of post-operative glaucoma. the comparison, between the groups, was performed using fisher’s exact test and chi-square analysis. a finding was considered significance at p value< 0.05. the improvement in the visual acuity: the preoperative visual acuity in both the groups ranged from perception of light to finger counting at one meter distance. comparing the study groups, there was no significant difference in the pre-operative visual acuity (p-value> 0.05). the post-operative visual acuity, in the study population as a whole, ranged from < 0.05 to 0.33 snellen’s fraction (i.e. hand movement to 6/18 snellen’s va). comparing the study groups, there was no significant difference in the post-operative visual acuity (p-value> 0.05 (table 3). however the 182 table 1: (group i) no id age/sex eye visual acuity pre-op post-op iop mmhg pre-op post-op remarks 1 rar 57/m r.e fc 6/12c 12 16 no glaucoma 2 mk 58/m l.e fc 6/18c 21* 32* uncontrolled glaucoma required trab. mmc 3 mp 26/m l.e hm 6/18 22* 21* controlled with topical r 4 ai 25/m l.e hm 6/18 20 39* uncontrolled glaucoma required trab. mmc 5 ma 31/m l.e fc 6/18c 12 16 no glaucoma 6 ha 68/m r.e hm 6/36 13 14 no glaucoma 7 sm 57/m r.e hm 6/60 15 15 no glaucoma 8 jb 56/f l.e pl 3/60 18 23 no glaucoma 9 pa 35/m r.e fc 6/12c 23* 21* controlled with topical r 10 bb 35/f r.e hm 6/36 10 09 no glaucoma 11 fk 23/m l.e hm 6/18 18 23* controlled with topical r ret.det. 6 month post-op. 12 mr 46/m l.e fc 6/12c 15 17 no glaucoma 13 h 32/m r.e hm 6/18 17 27* uncontrolled glaucoma required trab. mmc 14 rb 57/f l.e pl 3/60 24* 14* controlled with topical r 15 bb 35/f l.e hm 6/60 14 16 no glaucoma 16 sm 56/m l.e hm 6/36 24 14* controlled with topical r 17 ms 64/m l.e hm 6/36 14 12 no glaucoma 18 uf 32/m l.e fc 6/60 23* 28* uncontrolled glaucoma required trab. mmc 19 ni 09/m r.e pl 6/60 12 13 ret.det. 2 month post-op. 20 bb 57/f r.e hm 6/36 15 14 no glaucoma 21 rb 62/f l.e fc 6/18 18* 20* controlled with topical r 22 q 52/m r.e fc 6/18 12 13 no glaucoma 23 ia 42/m l.e fc 6/36 20 21 no glaucoma 24 ns 55/m l.e hm 6/36 15 14 no glaucoma 25 kd 65/m r.e hm 6/36 15 14 no glaucoma 183 table 2: (group ii) sr. n id age/sex eye visual acuity pre-op post-op iop mmhg pre-op post-op remarks 1 ag m/55 l.e hm 6/36 21 17* post-op. glaucomacontrolled with topical r 2 jd m/86 r.e fc 6/24 18 16* post-op. glaucomacontrolled with topical r 3 ar f/60 l.e 1/60 6/12 14 13 no glaucoma 4 mra m/70 r.e fc 6/18 14 15 no glaucoma 5 m f/65 l.e 1/60 6/24 20 17 no glaucoma 6 ar f/60 r.e 1/60 6/18 16 17 no glaucoma 7 bd m/65 r.e hm 6/36 12 13 no glaucoma 8 mi f/60 l.e hm 6/24 14 16 no glaucoma 9 ha m/56 r.e pl 6/24 15 15 no glaucoma 10 mu m/65 r.e pl hm 12 11 no glaucoma 11 ms m/65 r.e cf 6/36 15 17 no glaucoma 12 mnb m/27 r.e 5/60 6/36 10 11 no glaucoma 13 rg m/53 l.e 3/60 6/36 12 11 no glaucoma 14 rt f/25 r.e 2/60 6/24 12 12 no glaucoma 15 gs m/80 l.e cf 6/36 15* 16* pre-and post-op. glaucomacontrolled with topical r 16 kz m/57 l.e 4/60 6/6p 12 13 no glaucoma 17 ma m/58 l.e hm 6/18 13 13 no glaucoma 18 m f/50 l.e fc 6/12 12 13 no glaucoma 19 rb 62/f r.e fc 6/18 16* 20* pre-and post-op. glaucomacontrolled with topical r 20 mtb 66/m l.e 1/60 6/9 14* 16* pre-and post-op. glaucomacontrolled with topical r 21 ky 70/m l.e 1/60 6/9 13 12 no glaucoma 22 sn 23/f l.e pl 6/9 23* 14* pre-and post-op. glaucomacontrolled with topical r 23 ma 55/m l.e fc 6/24 14 15 no glaucoma 24 hb 72/f r.e hm 6/18 12 13 no glaucoma 25 rsa 47/m l.e fc 6/24 13 12 no glaucoma *iop with topical anti-glaucoma therapy. 184 improvement in the visual acuity in each study group, was statistically significant (p-value< 0.05), when postoperative visual acuity compared with pre-operative visual acuity. the incidence of post-keratoplasty glaucoma: (table 4). table 3: post-operative visual acuity visual acuity snellen’s chart/ snellen’s fraction group i (n=25) (%) group ii (n=25) (%) total (n=50) (%) from 6/18 to 6/6 11/25 11/25 22/50 from 6/18 to 6/60 12/25 13/25 25/50 less than 6/60 02/25 01/25 03/50 table 4: incidence of pre and post-operative elevated iop group incidence pre-operative post-operative patients n (%) patients n (%) pkp with scleral fixation of iol (group i n=25) 6/25 (24) 10/25 (40) pkp with ecce with iol in the bag /sulcus (group ii n=25) 4/25 (16) 6/25 (24) total 10/50 (20) 16/50 (32) the pre-operative frequency of glaucoma in group i, was 24% (i.e.6/25 patients) and in group ii, was 16% (i.e.4/25 patients), the total frequency of glaucoma being 20%. the difference between the two groups in the pre-operative incidence of glaucoma was not statistically significant (p value>0.05). the post-operative incidence of glaucoma in group i, was 40% (i.e.10/25 patients) and in group ii, was 24% (i.e.6/25 patients), the total incidence of postoperative glaucoma being 32%. there difference between the two groups in the post-operative incidence of glaucoma was statistically significant (p value<0.05). comparing the difference between preoperative and post-operative incidence of glaucoma, it was statistically significant within the group i (p value<0.05), and as a whole (p value<0.05), but not within the group ii (p value>0.05). discussion raised intra-ocular pressure contributes to loss of corneal endothelial cells as well as to progressive optic nerve damage and is a well known complication of penetrating keratoplasty. the incidence of postkeratoplasty glaucoma in aphakic eyes ranges from 42% to 89%1-2. the other risk factors for postkeratoplasty glaucoma are pre-existing glaucoma, previous graft, and incorrect surgical technique of keratoplasty. in this study pre-existing glaucoma (6/25 patients, 24%) in group i, contributed to the incidence of glaucoma. these patients had preoperative ac iol related gross angle distortion which causes secondary glaucoma and also increases the severity of bullous keratopathy. post-operatively 4 additional patients developed glaucoma, in addition to the existing cases. many investigators reported increased frequency of post-operative glaucoma after intra-capsular cataract extraction or after extracapsular cataract extraction with loss of posterior capsular support. zimmerman and co-workers14 postulated that the absence of crystalline lens and the zonules results in loss of support of the trabecular meshwork, resulting in raised iop. the increased number of postoperative glaucoma, in patients undergoing vitrectomy and scleral fixation of iol may be due the loss of support of trabecular meshwork, in addition to the factors related to the surgical procedure of keratoplasty like tight sutures, smaller or equal size of donor cornea etc. johnson et al15 and heidmann et al16, in two separate series of patients undergoing combined penetrating keratoplasty with trans-scleral fixation of iol for pseudophakic bullous keratopathy, reported a post-operative visual acuity of 20/40 or greater in 27% and 31% of eyes, with 11 to 13 months follow up, respectively. clear grafts were noted in 89% to 93% of cases. cystoid macular edema was seen in 31% and 36% of cases, which adversely affect the visual outcome. table 5: incidence of post-keratoplasty elevated iop: comparison with the reported studies richard c. troutman and others lyle wa and jin jc t l vander shaft and others holland ej and others present study incidence 34% 39% 46% 56% 40% 185 troutman and co-workers17 reported 34% (15 out of 44 patients) incidence of post operative glaucoma in a series of patients undergoing combined penetrating keratoplasty with trans-scleral fixation iol. these required anti-glaucoma medications except two, who required filtration procedures. lyle and jin18 reported 39% incidence of post operative glaucoma in patients undergoing combined penetrating keratoplasty with iol exchange for pseudophakic bullous keratopathy. similarly shaft and co-workers19 reported 46% incidence of post operative glaucoma in patients undergoing combined penetrating keratoplasty with exchange of original intra-ocular lens with a tripod posterior chamber iol sutured to the iris for pseudophakic bullous keratopathy. holland et al20 reported 30% (20 out of 66 patients) incidence of new onset of post operative glaucoma in patients undergoing combined penetrating keratoplasty with trans-scleral fixation iol for pseudophakic bullous keratopathy, while 39 out of 105 patients had pre-op glaucoma. so the total incidence of post operative glaucoma reported in this study was 56% (59 out of 105 patients). in the present study, the incidence of postkeratoplasty glaucoma is comparable with reported studies (table 5). the variable incidence of postoperative glaucoma in the above mentioned reported studies and the present study as well, may be due to the fact that pre-operative factors responsible for the glaucoma may vary in different studies22. per operative factors like varying surgical techniques by different surgeons or in-accurate surgical technique, like relatively smaller or equal size of donor cornealbutton23 may also have played a role as well as post-operative factors, like inflammatory sequelae, suturing technique, and drug induced elevation of iop may be responsible23. conclusion trans-scleral fixation of posterior chamber intra-ocular lens is suitable in cases lacking capsular support specially when combined with penetrating keratoplasty. in this study the frequency of the postkeratoplasty glaucoma in bullous keratoplathy is significantly higher in those patients who had undergone scleral fixation of iol. author’s affiliation dr. abdul hye associate professor department of ophthalmology postgraduate medical institute lahore dr. abrar ahmad bhatti department of ophthalmology postgraduate medical institute lahore dr. zahid kamal siddiqui associate professor department of ophthalmology postgraduate medical institute lahore prof. imran akram sahaf professor of ophthalmology department of ophthalmology postgraduate medical institute lahore reference 1. karesh jw, nirankari ms: factors associated with glaucoma after penetrating keratoplasty. am j ophthalmol. 1983; 96: 160. 2. daily ra. the effects of timolol meleate and acetazolamide on rate of aqueous formation in normal human subjects. am j ophthalmol. 1982; 93: 232. 3. arentsen jj, morgan b, green wr: changing indications for keratoplasty. am j ophthalmol. 1976; 81: 313. 4. mamilis n. penetrating keratoplasty: clinical indications and pathological findings. j catract refract surg. 1991; 17: 163. 5. robin jb. an update of indication of keratoplasty. arch ophthalmol. 1986; 104: 87. 6. smith re. penetrating keratoplasty: changing indications. arch ophthalmol. 1980; 98: 1226. 7. mamilis n. changing trends in the indications for penetrating keratoplasty. arch ophthalmol. 1992; 110: 1409. 8. heidmann dg, dunn sp: transclerally sutured intraocular lenses in penetrating keratoplasty. am j ophthalmol. 1992; 113: 619. 9. soong hk, meyer rf, sugar a: techniques of posterior chamber lens implantation without capsular support during penetrating keratoplasty. refract corneal surg. 1989; 5: 249. 10. soong hk. implantation of posterior chamber intraocular lens in the absence of lens capsule in penetrating keratoplasty. arch ophthalmol. 1989; 107: 660. 11. stark wj. posterior chamber intraocular lens implantation in the absence of capsular support. arch ophthalmol. 1989; 107: 1078. 12. arkin ms, steinert rf: sutured posterior chamber intraocular lenses. in jakobiec fa, adamis ap, editors: controversies in ophthalmology, vol 34, boston, 1994, little, brown. 13. speaker mg. psuedophakic bullous keratopathy: management of intraocular lens. ophthalmology. 1988; 95: 1260. 14. zimmerman t. transplant size and elevated iop, arch ophthalmol. 1978; 96: 2231. 186 15. johnson sm. results of exchanging anterior chamber lenses with sulcus fixed posterior chamber iols without capsular support in penetrating keratoplasty. ophthalmic surg. 1989; 20: 465. 16. heidmann dg, dunn sp. visual results and complications of transclerally sutured intraocular lenses in penetrating keratoplasty. ophthalmic surg. 1990; 21: 609. 17. richard c. troutman and others: combined penetrating keratoplasty and posterior chamber intraocular lens implantation in the absence of a lens capsule, tb. am. ophth. soc. vol. lxxxviii. 1990; 326-339. 18. lyle wa, jin jc. an analysis of intraocular lens exchange. ophthalmic surg. 1992; 23: 453-8. 19. schaft tlvd, rij gv, renardel jgc, et al. results of penetrating keratoplasty for psuedophakic bullous keratopathy with the exchange of an intraocular lens. br j ophthalmology. 1989; 73: 704-8. 20. holland ej, daya sm. penetrating keratoplasty and transcleral fixation of posterior chamber lens. am j ophthalmol. 1992; 114: 182-7. 21. bourne wm, davison ma. the effects of oversize donor buttons on postoperative iop and corneal curvature in aphakic penetrating keratoplasty. ophthalmology. 1982; 89: 242. 22. corneal surgery: theory, technique, and tissue/ edited by frederick s. brightbill 3rd ed. chapter 49, page 387, pathogenesis of post-keratoplasty glaucoma by catherine newton, and linda l. burk. microsoft word azizur rahman 1 40 original article comparison of raised iop after pars plana vitrectomy (ppv) using 1000 cst and 5000 cst silicone oil in rhegmatogenous retinal detachment azizur rahman, munawer hussain, muhammad fayaz, mazharul hassan, muhammad nasir bhatti, asif mashood qazi pak j ophthalmol 2011, vol. 27 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: azizur rahman isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, old thaana, malir, karachi received for publication november 2010 …..……………………….. purpose: to compare raised intraocular pressure after pars plana vitrectomy using 1000 cst and 5000 cst silicone oil. materials and methods: this interventional quasi experimental study was conducted at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi; from january 2008 to june2008.study included total 60 eyes of 60 patients fulfilling the inclusion criteria. all cases were worked up according to the protocol. after examination, patients were divided into two groups. group a were injected with 1000 cst silicone oil and group b were injected with 5000 cst silicone oil on randomized basis. patients were followed up at 1st day 1st week, 2nd week, 1st month, 2nd month 3rd month and 6th month. complete eye examination including iop measurement was done on each visit. data analysis was done by spss version 10.0 results: over a follow up period of 6 months, there was no significant difference in raised intraocular pressure after using 1000 cst and 5000 cst silicone oil injection. conclusions: difference in iop was observed between the study groups on three months follow-up. however, there was no significant difference in raised intraocular pressure after 6 months of the intervention. aised intraocular pressure (iop) is common in the immediate postoperative period after silicone oil injection in both phakic and aphakic eyes1,2. this rise in the iop is probably related to anterior chamber activity, obstruction to the aqueous flow by choroidal effusion, a buckle, or both. in most cases, it is short lived, easily controlled, and resolves spontaneously, but in some instances, particularly in highly myopic eyes, the angle closes permanently, and glaucoma becomes a chronic problem. glaucoma has long been recognized as a late complication of silicone oil injection. late silicone oil induced glaucoma is probably due to trabecular blockage by emulsified oil in the anterior chamber. there is no doubt that in a small number of aphakic eyes injected with silicone oil, it will come to occupy the anterior chamber, at least in the upper half or two third, preventing free flow of aqueous to the angle or blocking the pupil. persistently raised iop then becomes increasingly difficult to control medically, so that in such cases, permanent visual loss occurs due to optic atrophy as a result of failed medical treatment, or desperate surgical measures may have to be undertaken. despite the progress in vitreoretinal surgery and the importance of silicone oil as an adjunct for the treatment of complex forms of retinal detachment, controversy still surrounds the issue of selecting the proper oil viscosity for clinical use3,4. herein, we r 41 compare the rise in intraocular pressure after injecting 1000 cst and 5000 cst silicon oil. materials and methods the study included 60 eyes of 60 consecutive patients who underwent pars plana vitrectomy with silicone oil injection during january to june 2008 at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, karachi.the patients were 20-70 years old. those patients with previous history of retinal detachment surgery in the same eye, with primary or secondary glaucoma, and with traumatic or tractional retinal detachment were excluded. written informed consent was taken prior to procedure. preoperatively history was taken about any previous retinal detachment surgery and glaucoma surgery or medication. patients were selected from surgical retina clinic of alibrahim eye hospital. all patients underwent pars plana vitrectomy (ppv) with silicone oil injection. intra ocular pressure was checked with applanation tonometer. gonioscopy was done with goldman single mirror gonioscope. the intra ocular pressure was measured on 1st day, 1st week, 2nd week, 1st month, 2nd month, 3rd month and 6th month postoperatively. other anterior segment and posterior segment findings were noted on proforma and analyzed subsequently. patients were divided into two groups. group (a) were injected with 1000 cst silicone oil and group (b) were injected with 5000 cst silicone oil on randomized basis. sixty envelops were made, 30 of group a and 30 of group b. the patients were asked to pick up one envelop for group allocation. statistical analysis data analysis was performed through spss version10.0. the data was analyzed using fisher’s exact test, student’s t-test (unpaired), analysis of variance (anova) and post hoc scheffe’s test. statistical significance was taken at p ≤ 0.05. results among the 60 patients who received silicone oil injections, 51 (85%) were males and 9 (15%) females (m: f=5.7: 1). the gender distribution in subgroup of different viscosities of silicone oil is shown in fig. 1. mean age of patients who received 1000 cst silicone oil injection was 45.2±15.6 and of those who received 5000 cst silicone oil injection was 38.6±13 years. although it was higher in the group who received 1000 cst silicone oil injection but this difference was statistically insignificant (p=0.080). preoperative intraocular pressure (iop) of patients who received 1000 cst silicone oil injection was 12.67±4.05 and of those 5000 cst was 12.07±5.57, p=0.635. mean iop 3 months after surgery was significantly higher in the group of patients who received 5000 cst silicone oil injection (16.27±4.19 vs. 13.67±3.24, p=0.009). preoperative mean iop of 30 patients who received 5000 cst silicone oil injection was 12.1±5.6 which increased to 17.4±7.8 on postoperative day-1 and 17.3±7.0 on 1 week follow up. later on a decreasing trend of mean iop was seen after 2 weeks follow up but again it increased to 16.9±7.5 after one month, 16.1 ±5.1 at two months, 16.3 ±4.2 at 3 months and 14.3 ±2.8 at 6 months. preoperative mean iop of 30 patients who received 1000 cst silicone oil injection was 12.67±4.05 which increased to 14.9±6.7 on postoperative day-1 and 16.3±6.0 on 1 week follow up. later on a decreasing trend of mean iop was seen on 2 weeks, one month, two months, 3 months and 6 months of follow up. a significant difference between the preoperative mean iop and postoperative mean iop, taken on different time intervals, was observed at p≤0.05. repeated measure anova reveals statistically significant difference of trend of iop on different follow up readings (f=4.01, p=0.050) within and between the groups of patients who received 1000 cst versus 5000 cst silicone oil injection as shown in fig. 2. discussion since the invention of the vitrectomy surgery, the role of silicone oil as a vitreous substitute and retinal tamponade has expanded. various viscosities of silicone oil have been used and studies have shown no difference in the tamponading force of them3,5. low viscosity silicone oils are preferred by some surgeons because of easier surgical handling and removal from the vitreous cavity4,6,7. on the other hand, higher viscosity silicone oils are subject to decreased and delayed emulsification, so that the tamponading force lasts longer, which may provide better tamponade for some complex forms of retinal detachment that need a longer effect4. 42 n um be r of p at ie nt s gender group 27 24 3 6 0 5 10 15 20 25 30 male female 5000 cst 1000 cst fig. 1: gender distribution between two groups of silicone oil readings 6 mth3 mth2 mth1 mth2 wk1 wkday-1pre op m ea n in tr ao cu la r pr es su re 20 15 10 5 0 group 5000 cst 1000 cst fig. 2: trend of iop following 1000 cst versus 5000 cst on subsequent follow ups: early postoperative rise in the iop is common after ppv with silicone oil injection in both phakic and aphakic eyes. this rise in the iop is possibly related to anterior chamber inflammatory activity, obstruction to aqueous flow by choroidal effusion, a buckle or both8,9. the incidence of raised iop varies from 3-40%10-12. silicone study report observed a prevalence of chronically elevated iop of 8% in patients treated with conventional silicone oil13. in this study we compared the intraocular pressure after successful complex retinal detachment surgery following silicone oils of two different viscosities, 1000 cst and 5000 cst. the incidence of iop elevation after silicone oil injection has been described in case series using 1000 cst silicone oil. honavar et alreported the overall incidence of glaucoma after ppv and silicone oil injection at 40% (60 of 150 eyes)11. nguyen et al reported a 48% (24 of 50 eyes) incidence of glaucoma after ppv and silicone oil injection14. valone and mccarthy reported a 23% (11 of 48 eyes) incidence of glaucoma after ppv and silicone oil injection15. billington et al reported a 29% (16 of 55 eyes) incidence of glaucoma after ppv and silicone oil injection16. in a case series that included patients treated with 5000 cst silicone oil, henderer et al found elevated iop in 12.9% at 6 months, 21% at 1 year and 29.5% at 2 years12. our results suggested that difference of mean iop was statistically insignificant in both groups on day-1, one week, two weeks, one month, two months and six months. mean iop 3 months postoperatively was significantly higher in the group b patients who received 5000 cst silicone oil injection. preoperative mean iop of 30 patients who received 1000 cst silicone oil injection was 12.67±4.05 which increased to 14.9±6.7 on postoperative day-1 and 16.3±6.0 on 1 week follow up. later on a decreasing trend of mean iop was seen on 2 weeks, one month, two months, 3 months and 6 months of follow up. a significant difference between the preoperative mean iop and postoperative mean iop, taken on different time intervals, was observed at p≤0.05. preoperative mean iop of 30 patients who received 5000 cst silicone oil injection was 12.1±5.6 which increased to 17.4±7.8 on postoperative day-1 and 17.3 ±7.0 on 1 week follow up. later on a decreasing trend of mean iop was seen after2 weeks follow up but again it increased to 16.9 ±7.5 after one month, 16.1 ±5.1 at two months, 16.3 ±4.2 at3 months and 14.3 ±2.8 at6 months. a significant difference between the preoperative mean iop and postoperative mean iop after1stpostoperative week was observed while it was not statistically significant with mean iop taken on different time intervals at p≤0.05. conclusion difference in iop was observed between the study groups a & b on three months follow up. however, there was no significant difference in raised intraocular pressure after 6 months of the intervention. 43 however, a randomized controlled study is necessary to further evaluate and confirm this effect. author’s affiliation dr azizur rahman isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr munawer hussain isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr muhammad fayaz isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr mazharul hassan isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr muhammad nasir bhatti isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr asif mashood qazi isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi reference 1. popovic ss, sikic j, pokupec r. intraocular pressure values following vitrectomy with silicone oil tamponade. acta med.croatica. 2005; 59: 143-6. 2. al-jazzaf am, netland pa, charlec a. inciodence and management of elevated ontraocular pressure after silicone oil injection.j.glaucoma. 2005; 14: 40-6. 3. soheilian m, peyman ga, moritera t, et al. experimental retinal tolerance to very low viscosity silicone oil (100 cs) as a vitreous substitute compared to higher viscosity silicone oil (5000cs). international ophthalmology. 1995, 19: 57-61. 4. heiddenkummer hp, kampik a, thierfelder s. experimental evaluationof in vitro stability of purified polydimethylsiloxanes (silicone oil) in viscosity ranges from 1000 to 5000 centistokes. retina. 1992, 12: 828-32. 5. de juan e jr, mccuen b, tiedman j. intraocular tamponade and surface tension. surv ophthalmol. 1985, 30: 47-51. 6. crisp a, de juan e, tiedman j: effect of silicone oil viscosity on emulsification. arch ophthalmol. 1987, 105: 546-50. 7. parrel jm. silicone oil: physiochemical properties. in retina volume 3. edited by: glaser bm, michels rg. st. louis: cv mosby. 1989: 261-77. 8. gallemore rp, mccuen bw. silicone oil in vitreoretinal surgery. in: ryan sj, editor. retina. 3rd ed. st: louis: mosby. 2001; 2195220. 9. allingham rr. shield’s text book of glaucoma. 5th ed. philadelphia: lippincott, williams and wilkins. 2005: 410-33. 10. azen sp, scott iu, flynn jr hw, et al. silicone oil in the repair of complex retinal detachments. a prospective observational multicenter study. ophthalmology. 1998; 105: 1587–97. 11. honavar sg, goyal m, majji ab, et al. glaucoma after pars plana vitrectomy and silicone oil injection for complicated retinal detachments. ophthalmology. 1999; 106: 169–76. 12. henderer jd, budenz dl, flynn hw, et al. elevated intraocular pressure and hypotony following silicone oil retinal tamponade for complex retinal detachment: incidence and risk factors. arch ophthalmol. 1999; 117: 189–95. 13. barr cc, lai my, lean js, et al. ii postoperative intraocular pressure abnormalities in the silicone study. silicone study report 4. ophthalmology. 1993; 100: 1629-35. 14. nguyen qh, lloyd ma, heuer dk, et al. incidence and management of glaucoma after silicone oil injection for complicated retinal detachment. ophthalmology. 1992; 99: 1520-6. 15. valine j jr, mccarthy m. emulsified anterior chamber silicone oil and glaucoma. ophthalmology. 1994; 101: 1908-12. 16. billington bm, leaver pk. vitrectomy and fluid/silicone oil exchange for giant retinal tears: results at 18 months. graefes arch clin exp ophthalmol. 1986; 224: 7-10. microsoft word anjman gul memon 122 original article serum glycoproteins in diabetic and nondiabetic patients with and without cataract anjuman gul memon. ata ur rahman, nessar ahmed pak j ophthalmol 2008, vol. 24 no. 3 . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: anjuman gul memon department of biochemistry, ziauddin university, 4/b shahra-eghalib clifton, karachi-75600. received for publication purpose: to investigate the changes in serum glycoproteins from type 2 diabetic and non-diabetic patients with and without cataract. material and method: a total of 85 subjects were selected for this study and divided into four groups. the first group consisted of 21 healthy subjects, the second group consisted of 21 diabetic patients with no chronic complications, the third group consisted of 20 diabetic patients with cataract and the fourth group had 23 non-diabetic patients with cataract. the patients with and without cataract were selected on clinical grounds from the ziauddin university and jinnah postgraduate medical centre in karachi, pakistan. result: diabetic patients with and without cataract had significantly higher levels of plasma glucose, glycated hemoglobin, glycated plasma proteins and serum fructosamine. in addition to these parameters, the levels of hexosamine, sialic acid and serum total protein were higher in diabetic compared to non diabetic subjects with and without cataract. analysis of the protein fractions showed that alpha-1and -2 golbulins were higher in diabetic patients without complications compared to healthy subjects. serum alpha-1-globulin, alpha-2-globulin, beta globulins and gamma globulins were all significantly higher in diabetic patients with cataract compared to healthy subjects but not serum albumin. conclusion: the levels of serum glycoproteins in non-diabetic patients with cataract were not higher than those of healthy subjects thus mechanisms other than hyperglycaemia are responsible for the development of cataract in these patients. 123 september’ 2007 … ……………………… iabetes mellitus is a common endocrine disorder characterized by hyperglycemia, metabolic abnormalities and long-term complications afflicting the eyes, kidneys, nerves and blood vessels1. world-wide projections suggest that more than 220 million people will have diabetes by the year 2010 and the majority of these will suffer from type 2 diabetes mellitus2. in pakistan, diabetes mellitus is a major health problem affecting more than 16% of people over the age of 25 years in some areas with a further 10% suffering from impaired glucose tolerance3. cataract is a serious consequence of long-term diabetes and according to the who, affects about half of the 45 million blind people world-wide4. cataract is characterized by opacification of the eye lens affecting mainly the nuclear, cortical, and posterior subcapsular regions. pathological studies of cataractous lenses have revealed that cataracts are composed of protein aggregates that precipitate in the lens of the eye. the insoluble aggregates obstruct the passage of light through the lens preventing it from reaching the photoreceptors in the retina5. the lens crystallins may be divided into α-, βand γ-crystallins which are stable, water soluble proteins accounting for about 90% of the total protein content6,7. these ubiquitous crystallins are expressed early in life and must remain transparent throughout life despite the high protein concentration in the lens and the continued exposure to intra and extracellular oxygen derived free radicals5. diabetic cataract occurs much earlier than senile cataract and causes opacification of the lens and eventual loss of vision. it has been suggested that increased non-enzymatic glycosylation (glycation) of lens crystallins may cause conformational changes resulting in exposure of thiol groups to oxidation and cross-link formation8. furthermore, the lens crystallins have virtually no turnover and are ideal candidates for accumulation of glycation-derived cross-links. thus increased cross-linking of lens crystallins may cause aggregation producing the high molecular weight material responsible for opacification. increase glycation of serum proteins could cause an increase in the serum of circulating advanced glycation endproducts (ages). these ages are responsible for glycation-induced cross-linking of structural proteins and believed to underlie the pathogenesis of diabetic complications9. previous studies have also shown an increase in enzymatically glycosylated proteins such as alpha-2 glycoprotein fractions were increased in diabetic patients10. the aim of this study was to investigate changes in serum glycoproteins (both enzymatic and nonenzymatic) in diabetic and non-diabetic patients with and without cataract. materials and methods patients over 50 years of age were selected on clinical grounds from ziauddin university hospital, karachi and jinnah postgraduate medical centre, karachi. the study included a total of 85 subjects which were divided into four groups. group one consisted of 21 apparently healthy subjects who had no history of diabetes, cataract or any other major illness, like macro-vascular disease, retinopathy, tuberculosis, rheumatoid arthritis, liver disease or malignancy. group two consisted of 21 type 2 diabetic patients without any clinical evidence of chronic diabetic complications whereas group three had 20 type 2 diabetic patients with cataract. finally, group four consisted of 23 non-diabetic patients suffering from cataract. the age, sex, weight, duration of diabetes and treatment received were recorded. drugs were stopped 48 hours prior to any sample collection. physical examination including measurement of blood pressure and any family medical history was recorded. individuals were classified as having diabetes mellitus if they have a fasting plasma glucose concentration ≥ 7.0 or random plasma glucose level ≥ 11.1 mmol/l according to established criteria11. patients with a history of blurred vision or double vision and spots were examined with a slit lamp to determine the type of cataract. blood samples were collected from subjects after completing a consent form for each patient and explaining the nature of the study. blood glucose level determined by the glucose oxidase method12. the reagents were obtained from glucose enzymatique pap 7500 kit of biomerieux. for the estimation of glycated haemoglobin, haemolysate was prepared by treating blood with a detergent in a buffered medium and removal of the labile fraction. d 124 haemoglobins are retained by a cationic exchange resin. haemoglobin a1c is specially eluted after washing away the haemoglobin a1a and haemoglobin a1b fractions and is quantified by direct photometric reading at a wavelength of 415 nm. the kit was obtained from bio systems reagents and lnstruments, spain and based on an established procedure13. fructosamine was detected by the nitro-blue tetrazolium reaction. the kit was obtained from quimica clinia aplicada, spain. serum hexoamine was determined by cessi and pillego’s method14, total serum protein by the biuret method of reinhold15, sialic acid by natelson method16, and glycosylated proteins by the method of ma et al17. glycated plasma proteins were hydrolyzed with oxalic acid to release 5hydroxymethyl furfural which was detected by reaction with thiobarbituric acid. this method gives overall estimation of ketoamine linkages. serum protein electrophoresis18 was carried out by helena electrophoretic system, using a kit method (titan iii cat. no. 3023 obtained from helena laboratories). epi-info was used for statistical analysis of the data. epi-info is a statistical package available from the us centre for disease control and prevention. the statistical significance of the difference between two mean of various parameters between different groups was evaluated by student’s t test. the difference was regarded as highly significant if the p value was less than 0.001, statistically significant if the p value was less than 0.05, and non-significant if the p value was greater than 0.05. results the mean age of non-diabetic and diabetic patients with cataract were significantly higher (p<0.05) as compared with control subjects (table 1). fasting plasma glucose, hba1c, serum fructosamine, glycosylated plasma protein, serum hexosamine and serum sialic acid levels were significantly higher (p<0.05) in all diabetic patients with or without cataract as compared with control subjects (table 1). these parameters did not change (p>0.05) in nondiabetic patients with cataract as compared with control subjects (table 1). however, they were higher in diabetic patients when compared to non-diabetic patients with cataract (p<0.001; table 1). total serum protein, alpha-1 and alpha-2 globulins were significantly higher (p<0.05) in diabetic patients with or without cataract as compared with control subjects (table 1). beta globulin and gamma globulin were significantly higher (p<0.05) in non-diabetic patients and diabetic patients with cataract as compared with control subjects (table 1). table 1. the age, weight and concentration of blood analytes in non-diabetic and diabetic patients with and without cataract. parameters control subjects (21) diabetic patients without any complications (21) nondiabetic patients with cataract (20) diabetic patients with cataract (23) age (years) 53.81 ± 1.20 54.71 ± 1.40 59.83 ± 1.69 a 57.50 ±1.58 sex (f/m) 10/11 10/11 10/13 10/10 weight (kg) 64.30 ± 1.57 64.24 ± 1.62 65.22 ± 1.45 67.78 ± 1.55 a duration of diabetes (years) 9.29 ± 0.50 9.00 ± 1.00 fasting plasma glucose (mmol/l) 5.04 ± 0.13 7.83 ± 0.32 a 5.34 ± 0.18 9.32 ± 0.34 ab % glycosylated haemoglobin (hba1c) 4.98 ± 0.11 9.30 ± 0.37 a 5.04 ± 0.09 8.80 ± 0.34 ab serum fructosamine (mmol/l) 2.25 ± 0.08 3.72 ± 0.17 a 1.98 ± 0.07 3.05 ± 0.21 ab glycosylated plasma protein (absorbance /g) 6.20 ± 0.12 7.90 ± 0.30 a 5.85 ± 0.12 8.90 ± 0.34 ab hexosamine (mg/dl) 67.86 ± 3.12 102.94 ± 3.63 a 77.52 ± 3.31 118.80 ± 3.43 ab sialic acid (mg/dl) 35.36 ± 1.34 49.66 ± 1.78 39.22 ± 1.38 50.49 ± 1.76 ab 125 total serum protein (gm%) 7.32 ± 0.12 7.94 ± 0.17 a 6.94 ± 0.20 7.97 ± 0.12 ab serum albumin (gm%) 4.01 ± 0.10 4.03 ± 0.11 3.01 ± 0.09 3.57 ± 0.12 b alpha-1 globulin (gm%) 0.16 ± 0.02 0.38 ± 0.06 a 0.17 ± 0.02 0.36 ± 0.09 ab alpha-2 globulin (gm%) 0.77 ± 0.03 0.96 ± 0.05 a 0.87 ± 0.05 1.54 ± 0.56 a beta globulin (gm%) 1.00 ± 0.03 0.92 ± 0.06 1.08 ± 0.07 a 1.14 ± 0.07 a gamma globulin (gm%) 1.48 ± 0.07 1.67 ± 0.09 1.89 ± 0.12 a 2.01 ± 0.11 a a. significant as compared with control subjects b. significant as compared with non diabetic patients with cataract the correlation between fasting plasma glucose and hba1c in control subjects was r = 0.284, between fasting plasma glucose and hba1c in diabetic patients without cataract was r = 0.478, between fasting plasma glucose and hba1c in non-diabetic patients with cataract was r = 0.267 and between fasting plasma glucose and hba1c in diabetic patients with cataract was r = 0.467. the data of diabetic patients are currently available but main difference is that the values of non-diabetic patients with the same complication in the same age group were within normal limits and these parameters are not responsible for the complications. discussion diabetes mellitus and its complications constitute an important health problem in both developing and developed countries. cataract remains the commonest cause of blindness world-wide. in the present study, patients were selected with cataract and the possibility of other complications was excluded by the absence of any sign and symptoms on physical examination. changes in protein concentration and increased enzymatic glycation of various proteins in diabetic patients have been correlated with hyperglycemia, which in turn causes early functional alterations in different tissues. in the present study non-diabetic patients with cataract have normal values except beta and gamma globulin which are increased in nondiabetic patients with cataract. glycaemic related analytes increased in all diabetic patients with and without cataract and the levels did not change in nondiabetic patients with cataract and control subjects (table 1). the presence of cataract in non-diabetic patients did not affect the glycaemic related analytes, and increase in diabetic patients without complications, reflect that the diabetes was uncontrolled. they may be developing changes at the subclinical level which later on present as a complication. the relationship among hba1c, blood glucose concentrations and late complications has been established over the last 30 years19-21. serum fructsamine and glycated plasma protein concentrations have close correlation with hba1c because they reflect glycaemic control within the last 2 to 3 weeks and hba1c reflects glycaemic control for the last 4 to 6 weeks22,23. in the present study, serum fructosamine and glycated plasma proteins in diabetic patients also have a close correlation with hba1c. the degree of glycation of plasma proteins, as an alternative index of control and as reflection of possible structural alterations of tissue proteins leading to complications was associated with the diabetic state22. stratton et al 23 suggested that in patients with type 2 diabetes, the risk of diabetic complications was strongly associated with previous hyperglycemia. any reduction in hba1c is likely to reduce the risk of complications, with the lowest risk being in those with hba1c in the normal range. in the present study, the coefficient of variation of hba1c was higher in diabetic patients with cataract as compared with non-diabetic patients with cataract. it seems that there could be different mechanisms for the development of cataract in diabetic and non-diabetic patients. serum hexosamine and sialic acid levels were significantly increased in all diabetic patients and were non-significant in nondiabetic patients with cataract as compared with control subjects (table 1). other workers have made similar observations24,25. hangloo et al 26 found that age and sex had no influence on serum sialic acid levels. as sialic acid is incorporated into carbohydrate chains of glycoproteins and glycolipids in serum and tissues, the degree of incorporation of sialic acid has been reported to affect transvascular permeability and 126 accumulation of lipid in the arterial wall. sialic acid is conjugated with constituents of acute phase reactants, which are highly concentrated on surface of endothelial cells26. one likely hypothesis might be that the relationship between clinical condition and sialic acid concentration is due to the activity of a current inflammatory atherosclerotic process and/or to a direct damage to vascular endothelium causing sialic acid into the circulation27. serum hexosamine levels rise due to hexosamine biosynthetic pathway, which is involved in the pathogenesis of insulin resistance in patients with type 2 diabetes mellitus24,28,29. in the present study the values of hexosamine and sialic acid in non-diabetic patients with cataract were in normal limits, but the values were increased in diabetic patients with cataract and without complications. conclusion the uniform increase in fasting plasma glucose, glycosylated hemoglobin (hba1c), serum fructosemine, glycosylated plasma protein, serum hexosamine and serum sialic acid levels in diabetic patients indicates that the process of glycosylation depends upon hyperglycemia. the parameters do not rise in non-diabetic patients, and hence some other underlying mechanism may be responsible for the development of complications in these patients. author’s affiliation dr. anjuman gul memon department of biochemistry ziauddin university 4/b shahra-eghalib, clifton karachi-75600. professor m ata ur rahman international centre for chemical and biological sciences, hej research institute of chemistry university of karachi-75270. dr nessar ahmed school of biology, chemistry and health science manchester metropolitan university chester street, manchester m1 5gd united kingdom reference 1. nathan dm. long-term complications of diabetes mellitus. new engl j med. 1993; 328: 1676-85. 2. alberti kgmm, zimmet pz. definition, diagnosis and classification of diabetes mellitus and its complication. provisional report of a who consultations. diabetic med. 1998; 15: 539-53. 3. shera as, rafique g, khawaja ia, et al. pakistan national diabetes survey: prevalence of glucose intolerance and associated factors in shikarpur, sindh province. diabetic medicine. 1995; 12: 1116-21. 4. the world health report 1998: life in the 21st century: a vision for all, world health organization, 1998. 5. bloemendal h, jong w de, jaenicke r, et al. ageing and vision: structure, stability and function of lens crystallins. progress in biophysics and molecular biology 2004; 86: 407-85. 6. horwitz j. the function of α-crystallin in vision. seminars in cellular and developmental biology. 2000; 11: 53–60. 7. macrae t. structure and function of small heat shock/αcrystallin proteins: established concepts and emerging ideas. cellular and molecular life sciences. 2000; 57: 899–913. 8. kyselova z, stefak m, bauer v. pharmacological prevention of diabetic cataract. j diabetes and its complications. 2004; 18: 129-40. 9. ahmed n. advanced glycation endproductsrole in pathology of diabetic complications. diabetes research and clinical practice. 2005; 67: 3-21. 10. rahman ma, zafar g, shera as. changes in glycosylated proteins in log-term complications of diabetes mellitus. biomed and pharmacother 1990; 44: 229-34. 11. gabir mm, roumain j, hanson rl, et al. the 1997 american diabetes association and 1999 world health organization criteria for hyperglycemia in the diagnosis and prediction of diabetes. diabetes care. 2000; 23: 1108-12. 12. tietz nw: clinical guide to laboratory tests, 3rd ed., wb. saunders. company, philadelphia, pa. 1995; 268-73. 13. rochman h. hemoglobin a1c and diabetes mellitus. annals of clinical and laboratory science. 1980; 10: 111-5. 14. cessi c, pilliego f. the determination of amino sugars in the presence of amino acids and glucose. biochemical j. 1960; 77: 508-10. 15. varley h, gowenlock ah, bell m. practical clinical biochemistry, 5th ed, william heinemann medical books ltd, london. 1980; 545-7. 16. natelson s. microtechniques of clinical chemistry for the routine laboratory, 2nd ed, thomas springfield, illinois. 1961; 378-80. 17. ma a, naughton ma, cameron dp. glycosylated plasma proteins: a simple method for the elimination of interference by glucose in its estimation. clinica chimica acta 1981; 115: 111-7. 18. ralli ep, barbosa x, beck em, et al. serum electrophoretic patterns in normal and diabetic subjects. metabolism. 1957; 6: 331. 19. mclellan ac, thornalley pj, benn j, et al. glyoxalase system in clinical diabetes mellitus and correlation with diabetic complications. clinical science. 1994; 87: 21-9. 20. thornalley pj. the glyoxalase system: new development towards functional characterization of a metabolic pathway fundamental to biological life. biochemical j. 1990; 269: 1-11. 21. brownlee m, vlassara h, cerami a. advanced glycosylation endproducts in tissue and the biochemical basis of complications. new engl j med. 1998; 318: 1315-21. 22. skeie s, thue g, sandberg s. interpretation of hemoglobin a1c (hba1c) values among diabetic patients: implication for quality specifications for hba1c, clincal chemistry. 2001; 47: 1212-7. 23. stratton im, adler ai, neil ha, et al. association of glycaemia with macrovascular and microvascular complication of type 2 diabetes (ukpds 35). bmj 2000; 321: 405-12. 24. crook m. the determination of plasma or serum sialic acid. clinical biochemistry. 1993; 26: 31-8. 127 25. marsall s, bacote v, traxinger rr: discovery of a metabolic pathway mediating glucose induced desensitization of the glucose transport system: role of hexosamine biosynthesis in the induction of insulin resistance. j biological chemistry. 1991; 266: 4706-12. 26. hangloo vk, kaul i, zargar hu. serum sialic acid levels in healthy individuals. j postgraduate medicine. 1990; 36: 140-2. 27. lindberg g, eklund ga, gullberg b, et al. serum sialic acid concentration and cardiovascular mortality. br medical j. 1991; 302: 533-4. 28. span pn, pouwels njm, olthaar aj, et al. assay for hexosamine pathway intermediates (uridine diphosphate-nacetyl amino sugars) in small samples of human muscle tissue. clinical chemistry. 2001; 47: 944-6. 29. hawkin m: role of the glucosamine pathway in fat induced insulin resistance. j clinical investigation. 1997; 99: 2173-82. microsoft word editorial 26,3,10 112 editorial the challenge of microbial keratitis in pakistan microbial keratitis is a common sight threatening disease which occurs in all parts of the world. statistics of corneal blindness from different countries show a range from 5-77%1. the disease can cause a lot of pain, discomfort and lead to serious visual disability if not treated properly. the disease poses serious challenges to both public health and clinical ophthalmologists in terms of prevention, diagnosis, treatment and final visual rehabilitation. the pathogenic factors contributing to the causation of microbial keratitis include exogenous factors, altered host tissues, and the host response. the exogenous factors include invasion by microbes like bacteria, fungi, viruses and rarely some parasites. an initiating event in the form of trauma (physical, chemical or toxic) which results in break-down of epithelium integrity usually precedes the microbial invasion of the corneal tissue. the trauma may be macro or micro such as produced by contact lenses wear2. the altered host tissue is affected by exposure due to lid deformity, tear film abnormalities, post radiation keratitis, corneal epithelial and stromal edema and the role of the local immune mechanisms. other influences are altered corneal tissue secondary to diabetes as well as chronically diseased eyes such as following extensive surgery and other debilitating diseases or dry eyes syndrome. the role of host response is less specific or less well understood, but is affected by the degree of inflammation, hypersensitivity factors, corneal edema and the release of enzymes such as collagenase, either by corneal tissue or the invading inflammatory cells. the sequential progression in the pathogeneses of bacterial corneal infections includes adhesions of the organism to the superficial cornea, entry of the organism into the corneal tissue, multiplication and spread of the organism. the host inflammatory response is then evoked in which the organism encounters phagocyte cells and the host immune response. recent reports have described an apparent increased risk of development of bacterial keratitis in patients with extended wear soft contact lenses. the organisms in these cases are either pseudomonas or acanthamoeba. a fairly large number of fungi have been isolated from corneal ulcers. a review of published reports shows that the fungi encountered in cultures of material obtained from corneal ulcers mainly belong to the genera aspergillus, fusarium, penicillium and candida. for diagnostic purposes, it is recommended that meticulous scrapings of the infiltrate be performed including the base and edges of the ulcer or that a biopsy of the stromal abscess is taken. the material obtained from such scrapings should be inoculated on to multiple media like blood agar, chocolate agar, anaerobic media and sabouraud’s agar. material from the scrapping should be stained with gram’s, giemsa, ziel-neilson and other special stains. for fungal isolation, scrapping should be treated with 10-20% koh. in patients with culture proven keratitis, initial scrapings treated with koh or stained with gram’s or giemsa or other stains are diagnostic in 80-88% of cases. recently pcr has become an important diagnostic possibility3. the results of the gram’s stain can be used to select the initial therapy4. therapy of microbial keratitis should be directed towards the offending organism in the form of appropriate antibiotics and antifungal agents. other supplementary therapy includes non-steroidal antiinflammatory agents, steroids, atropine and anticollagenase5. surgical intervention in the form of simple epithelial debridement of the ulcer, conjunctival flap, lamellar keratectomy, keratoplasty and tarsorrhaphy may at time become necessary6. 113 non-availability of the corneal donor material is a problem in salvaging the vision. keratoplasty is not only an effective method in dealing with the indolent corneal infection but is also of importance in treating the complications. it is the only hope in dealing with a corneal opacity obstructing vision. frequently used keratoplasty can thus help in saving many eyes, structurally and functionally, which are invariably lost at present7. the pattern of microbial keratitis in a community largely depends upon the socio-economic status, the degree of development, access to medical services, personal and community hygiene, the availability of clean water and other basic requirements for living, awareness of the problem, the general nutritional status of the community, the prevalence of other infectious diseases, climate, and high frequency of predisposing factors like trauma. it can be seen that the problem of corneal blindness, specially the infective part is largely preventable8. there are no community health surveys to indicate true incidence of the disease in our country. over the counter sale of medicines and indiscriminate use of steroids and antibiotics is an important risk factor for microbial keratitis. communities need to be made aware about the principles of prevention of ocular ocular trauma and ocular infections. the ophthalmic technicians and lady health workers are two important cadres which can help in the primary prevention of the disease. there is scarcity of ocular microbiological services. although the national program for prevention and control of blindness in pakistan has provided equipment for setting up microbiology laboratories in the 7 centers of excellence in the country, the services are not yet established. in order to address the issue of microbial keratitis at national level, we would like to submit the following recommendations. 1. establish regional centers of ocular pathology. 2. initiate a health education campaign on prevention of ocular trauma and ocular infection. 3. establish a national register for ocular trauma. 4. establish at least four eye banks of international standards, one in each province to solve the problems of availability of corneal donor material. references 1. whitcher jp, srinivasan m, upadhyay mp. corneal blindness: a global perspective. bulletin of the world health organization, 2001, 79: 214–21. 2. hall bj, jones l. contact lens cases: the missing link in contact lens safety? eye contact lens. 2010; 36: 101-5. 3. shukla pk, kumar m, keshava gb. mycotic keratitis: an overview of diagnosis and therapy. mycoses. 2008; 51: 183-99. 4. khanal b, deb m, panda a. harinder singh sethi laboratory diagnosis in ulcerative keratitis. ophthalmic res. 2005; 37: 123-7. 5. jules l. baum initial therapy of suspected microbial corneal ulcers: i. broad antibiotic therapy based on prevalence of organism. survey ophthalmol. 1979;24: 97-105. 6. buxton jn, fox ml. conjunctival flaps in the treatment of refractory pseudomonas corneal abscess. ann. ophthalmol. 1986; 18: 315-8. 7. hill jc. use of penetrating keratoplasty in acute bacterial keratitis. br. j. ophthalmol. 1986: 70: 502-6. 8. hong lc. affluence and changing pattern of blindness in singapore. 1950-1980. in henkind p. (ed): acta xxiv international congress of ophthalmology. philadelphia, j.b. lippincott co. 1982: 1329-31. prof. nasir saeed peshawar prof. muhammad daud khan peshawar microsoft word tanveer ch case report 104 case report conjunctival malignant melanoma mimicking as a chalazion sana shoukat memon, roomasa channa, tanveer a. chaudhry, khabir ahmad pak j ophthalmol 2008, vol. 24 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tanveer a chaudhry section of ophthalmology department of surgery aga khan university karachi received for publication may’ 2007 …..……………………….. onjunctival melanoma is an uncommon tumour with an incidence of 0.3-0.8 cases / million population. it is likely to recur and carries an overall mortality rate of approximately 30 %. the mean age at diagnosis is 53 years (± 11 years) and like other tumours, its incidence increases with advancing age and sun exposure1,2. case a 35-year-old man was referred by his family physician to our eye clinic for the management of a chalazion on his right upper lid. according to the patient, he had a slowly growing painless swelling of recent onset over his right upper lid. he did not have any other complaints. eye examination revealed a firm, non-tender swelling in the middle of the right upper lid. on everting the upper lid, the lesion on the conjunctival side did not look like a typical chalazion (fig. 1). it was rather a vascular lesion, surrounded by a pigmented area. local lymph nodes were not palpable and no similar lesion was found elsewhere on his body. the rest of the systemic examination was unremarkable. after taking his consent, a complete resection of the lesion was performed under local anesthesia. histopathology of the lesion revealed a conjunctival malignant melanoma with clear edges. further biopsies were taken 3600 around the site of the lesion which also revealed clear edges. liver function tests and abdominal ultrasonography were normal. the patient was followed regularly and one and a half year after the initial excision there was no sign of recurrence. as mentioned earlier, conjunctival melanoma is a rare tumour, but is likely to recur and has a very high mortality rate-around 30%. advancing age and sun exposure are important risk factors. as our patient was relatively younger, the clinical suspicion for a malignancy was very low. the different presentations of conjunctival melanoma reported in literature include occurrence of bloody tears and rapidly c 105 growing mass3,4. however, to the best of our knowledge, this is the first case where conjunctival malignant melanoma was presenting as a chalazion. various lesions of the lids and eyes are confused as chalazion by physicians. ozdal et al reported that5, amongst the malignancies misdiagnosed as chalazia, the most common were sebaceous cell carcinoma and basal cell carcinoma. conjunctival melanoma was not mentioned as a possible misdiagnosis. fig: vascularised, pigmented lesion noted on lid eversion. conclusion chalazion is a common benign eyelid cyst which is easily treatable by an incision and curettage. rarely some malignancies can mimic chalazion in their presentation. every chalazion, especially the ones on the upper eyelid, should be thoroughly examined before treatment and in case of recurrence should be biopsied for histopathological examination. we suggest that although conjunctival melanoma is a rare tumour, the possibility of a significant differential for a slowly growing mass in the lid and early detection and treatment is vital due to the high mortality and metastases rates. author’s affiliation dr. sana shoukat memon section of ophthalmology, department of surgery, aga khan university p o box 3500, stadium road karachi dr. roomasa channa section of ophthalmology, department of surgery, aga khan university p o box 3500, stadium road karachi dr. tanveer a. chaudhry section of ophthalmology, department of surgery, aga khan university p o box 3500, stadium road karachi dr. khabir ahmad section of ophthalmology, department of surgery, aga khan university p o box 3500, stadium road karachi reference 1. lommatzsch pk, werschnik c. malignant conjunctival melanoma. clinical review with recommendations for diagnosis, therapy and follow-up. klin monatsbl augenheilkd. 2002; 219:710-21. 2. seregard s. conjunctival melanoma. surv ophthalmol. 1998; 42:321-50. 3. duchateau n, meyer a, hugol d, et al. nodular melanoma on primary acquired conjunctival melanosis. j fr ophtalmol. 2005; 28: 331-5. 4. biswas mc, dutta s, nath u, et al. malignant melanoma of conjunctiva-a case report. j indian med assoc. 2004; 102: 73064. 5. ozdal pc, codere f, callejo s, et al. accuracy of the clinical diagnosis of chalazion. eye 2004; 18: 135-8. microsoft word c.o omolase corrected case report 106 case report congenital heterochromia iridis in a nigerian girl child omolase charles oluwole, a. k. akinwalere, o. a. adeosun, b. o. omolase, m. y. majekodunmi pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: omolase charles oluwole federal medical centre pmb 1053,owo,ondo state nigeria submission of paper october’ 2010 acceptance for publication january’ 2011 …..……………………….. this report is that of a six month old nigerian girl child with complete heterochromia iridis. there was no associated hypo-pigmentation of her skin or hair. there is no history of similar occurrence in her family. the early presentation of the child may be due to the fact that the parents are enlightened. cycloplegic refraction done did not reveal any significant refractive error. however we intend to place the patient on coloured contact lens in the nearest future to reduce chromatic aberration to the barest minimum and to conceal the hypo pigmented iris most especially in view of the fact that the patient is a girl child. though congenital heterochromia iridis appears rare in our population, there is need to educate the general population about this ocular condition so that they can be more receptive to affected individuals. eterochromia iridis is an ocular condition in which there is difference in the colour of the irides of the two eyes or where part of one iris has a different colour from the remainder. it may be complete heterochromia iridis or partial/ sectoral heterochromia iridis. partial or sectoral heterochromia is less common than complete heterochromia iridis and it is typically found in autosomally inherited disorders such as hirschprung’s disease and waardenburg’s syndrome. heterochromia iridis arises from relative excess or lack of pigment within an iris or part of an iris which may be genetically inherited or due to mosaicism or acquired by disease/injury1. congenital heterochromia iridis is usually inherited as an autosomal trait. the colour of the iris is determined by the concentration and distribution of melanin pigments within the iris tissues2,3, thus any alteration in these factors may result in difference in colour of the iris2. the affected eye may be hyper pigmented (hyperchromic) or hypo pigmented (hypochromic). the conditions that could make the iris darker (hyperchromic) include lisch nodules, ocular melanosis, oculodermal melanocytosis (naevus of ota)4, pigment dispersion syndrome, sturge – weber syndrome characterized by a port wine stain naevus in the distribution of trigeminal nerve, neurologic signs and angioma of the choroid often with secondary glaucoma5,6. hypochromia iridis can arise from simple heterochromia iridis which is characterised by absence of other ocular or systemic problems. other causes include congenital horner’s syndrome and waardenburg’s syndrome7. other conditions that are associated with hypochromia iridis are piebaldism, hirshsprung disease, incontinentia pigmenti, parry –romberg syndrome .acquired heterochromia iridis may also be due to injury, inflammation, use of certain eye drops or tumours. acquired causes of hyperchromia iridis include siderosis, use of eye drops (prostaglandin analogues), melanoma of the iris, irido-corneal endothelium syndrome and iris ectropion syndrome4. the acquired causes of abnormally lighter iris are fuchs’ heterochromic iridocycyclitis, acquired horner’s syndrome, chronic iritis, juvenile xanthogranuloma, leukaemia and lymphoma4. central heterochromia iridis is an eye condition in which there are two different colours in the same iris. h 107 in view of the rarity of congenital heterochromia iridis in our population, we decided to report this case so as to draw the attention of the people to this ocular condition. case report a six month old nigerian female child presented to the eye clinic of federal medical center, owo, ondo state, nigeria in september, 2010 on account of discolouration of both eyes since birth. there was no other associated ocular complaint. there was no history of maternal illness in the course of her pregnancy. she was delivered at 35 weeks of gestation through emergency caesarean section at the university teaching hospital, ado ekiti, nigeria. the indication for the caesarean section was ante-partum haemorrhage and transverse lie. she had neonatal jaundice at the third week of life for which exchange blood transfusion was done. she was diagnosed of having glucose 6-phosphate dehydrogenase (g6pd) deficiency at the hospital. the patient is the last born of four children in a monogamous setting. both parents are school teachers. there is no history of similar occurrence in her family. examination of the patient revealed that she was yet to attain neck control at six months of age. there was no area of hypo-pigmentation on her skin or head (no white forelock on forehead). ocular examination revealed visual acuity of light tracking in both eyes. there was complete hypochromia iridis in both eyes and the pupils were briskly reactive. however anterior segment examination did not reveal any other abnormality. dilated pupil funduscopy revealed pink optic disc with a cup-disc ratio of 0.3 and normal vessels in both eyes. there was mild hypopigmentation of the retina. the macula appeared normal. the patient had cycloplegic refraction with the aid of gutt atropine but there was no significant refractive error thus no glasses were recommended. the patient was also seen by the paediatrician in view of delayed developmental mile stones. the patient was to be seen periodically at the eye clinic and she was to be placed on coloured contact lens later. discussion the human iris can have different colours. there are three true colours in the iris that determine the outward appearance; brown, yellow and grey. how much of each colour a person has, determines the appearance of his or her eye colour. 8 eye colour is a polygenic trait and it is determined by the amount of melanin in the iris. blue iris are due to lack of melanin while brown eyes indicate richness in melanin in the iris. 9 people who have dark hair and skin tend to have higher levels of melanin resulting in brown iris. however people with lighter skin and hair tend to have lower level of melanin which makes their iris lighter. people with heterochromia iridis tend to have chromatic aberration which could cloud their vision. this was the reason why we decided to refract the patient reported with a view of correcting any refractive error that could have been detected. the decision to request that the child be brought for periodic review was to appropriately manage the spherical aberration which is likely to be marked when the child is older. the need for the child to use coloured contact lens when she is old enough cannot be overemphasized. the coloured contact lens is expected to reduce chromatic aberration to the barest minimum and also help to conceal the hypopigmented iris. this measure was discussed with the mother and she accepted the measure based on the information she was given. the relative early presentation of the child is appreciated and is likely to be due to the fact that the parents are enlightened and well motivated. it is also likely to be due to the fact that the parents were bothered about the cosmetic challenge of hypochromia iridis most especially in a girl child. it is the considered opinion of the authors that the child may not derive pride from the striking appearance conferred by hypochromia iridis in the nearest future. there are few reports of heterochromia iridis in nigeria. the author for correspondence reported a case of simple heterochromia iridis in a 15 year old nigerian girl9. there was no associated systemic or ocular abnormality in the patient9. onabolu also reported two cases of waardenburg’s syndrome in a nigerian family10. both patients had white forelock, heterochromia iridis and sensory-neural deafness. 10 amoni et al reported two cases of waardenburg’s syndrome in nigeria. 11 a japanese review of 11 albino children with waardenburg syndrome found that all had sectoral / partial heterochromia iridis. 12 conclusion though congenital heterochromia iridis appears rare in our population, it is important to adequately address the ocular challenges associated with the condition. it is important to continue to motivate the parents of this child so that she can receive adequate care. the populace should also be educated about this ocular condition so that they can be more receptive. 108 fig 1: girl child with bilateral heterochromia iridis author’s affiliation dr. omolase charles oluwole department of ophthalmology federal medical centre, owo ondo state, nigeria dr. a. k. akinwalere department of ophthalmology federal medical centre, owo ondo state, nigeria o. a. adeosun department of ophthalmology federal medical centre, owo ondo state, nigeria b. o. omolase department of radiology federal medical centre, owo ondo state, nigeria m.y. majekodunmi department of ophthalmology federal medical centre, owo ondo state, nigeria reference 1. imesch pd, wallow ih, albert dm. the colour of the human eye: a review of morphologic correlates and some conditions that affect iridial pigmentation. surv ophthalmol. 1997; 2: 11723. 2. wielgus ar, sarna t. melanin in human irides of different colour and age of donors. pigment cell res. 2005; 18: l454-64. 3. prota g, hu dn, vincensi mr, et al. characterization of melanin in human iridis and cultured uveal melanocytes from eyes of different colours. exp eye res. 1998; 67: 293-9. 4. loewenstein j, scott l. ophthalmology: just the facts. new york: mc graw-hill; 2004. 5. vanemelen c, goethals m, dralands l, et al. treatment of glaucoma in children with sturge-weber syndrome. j pediatr ophthalmol strabismus. 2000; 37: 29-34. 6. sturge-weber syndrome; definition and much more answers. answers.com: accessed on 13th september, 2010. 7. wallis dh, granet db, levi l ‘‘when the darker eye has the smaller pupil ’’ jaapos. 2003; 7: 215-6. 8. seddon jm, sahagian cr, glynn rj, et al. evaluation of an iris colour classification system. invest ophthalmol vis sci, 1990; 31: 1592-8. 9. omolase co. simple heterochromia iridis: a case report .nigerian hospital practice. 2008; 2: 120-2. 10. onabolu oo. waardenburg’s syndrome in a nigerian family. nig j ophthalmol. 2002; 10: 32-4. 11. amoni ss, abdurrahman mb. waardenburg’s syndrome: a case report in 2 nigerians. j pediatr ophthalmol strabismus, 1979; 16: 172-5. 12. ohno n, kiyosawa m, mori h, et al. clinical findings in japanese patients with waardenburg’s syndrome type 2. jpn j ophthalmol. 2003; 47: 77-84. glaucoma comparing the advantages and disadvantages of bleb dependent glaucoma surgical techniques which have been performed for more than a century with the recent bleb independent techniques, trabeculectomy in its various modified forms is still the choicest procedure. m lateef chaudhry editor-in-chief microsoft word abstract vol. 24, 3,08 157 abstracts edited by dr. tahir mahmood learning curve of laser-assisted subepithelial keratectomy: influence on visual and refractive results teus ma, benito-llopis l de, sanchez-pina jm, j cataract refract surg 2007; 33: 1381-5. laser-assisted subepithelial keratectomy (lasek) has become a popular refractive surgery technique because of the absence of stromal flap-related complications associated with laser in situ keratomileusis (lasik) and because it allows treatment of thin corneas while achieving good safety, efficacy, and predictability. despite the disadvantages of lasek (ie, slower visual recovery and higher postoperative discomfort) versus lasik, the procedure has become the technique of choice in patients with thin corneal pachymetry, those at risk for trauma, and those with corneal surface problems such as dry eye, recurrent erosion syndrome, or basement membrane disease. when new surgical techniques are introduced into practice, it is important that the surgeon receive good training to enable him or her to perform the new procedure safely and effectively. nevertheless, such training is not always easy or available. when learning a new technique, some experienced surgeons encounter difficulties that can affect their initial results. two studies have reported the results after photorefractive keratectomy (prk) and lasik by surgeons training in the procedures and compared them with the results in the literature. one study reported the first lasik cases of 2 fellows in a refractive surgery program and compared them with the results after 1 year of fellowship. the purpose of this study was to study the effect of the learning curve of laser-assisted subepithelial keratectomy (lasek) on the visual and refractive results. this retrospective study comprised 56 eyes that had lasek for myopia. the eyes were among the first 143 that had lasek by the same surgeon with the same excimer laser and same nomogram. the 56 eyes were separated into 2 groups. group 1 included the first 28 eyes to have lasek by the surgeon. group 2 comprised the last 28 eyes in the series whose refracttive error could be matched with that in group 1. the outcomes in the 2 groups were compared. the mean preoperative spherical refraction was 3.90 diopters (d) ± 1.90 (sd) in group 1 and -3.70 ± 2.53 d in group 2 (p = .2). there were no significant differences in preoperative cylinder or best spectacle corrected visual acuity (bscva) between groups. the postoperative uncorrected visual acuity (ucva) was significantly worse in group 1 on 1 day and 7 days postoperatively (p = .02 and p = .03, respectively); there was no significant difference at 1 month and 3 months. the safety index (postoperative bscva/ preoperative bscva) and efficacy index (postoperative ucva/preoperative bscva) were better in group 2, although the difference was not statistically significant. the spherical refraction 3 months postoperatively was +0.50 ± 0.83 d in group 1 and + 0.10 ± 0.27 d in group 2 (p = .02); 75% of eyes and 96.42% of eyes, respectively, were within + 0.50 d of the intended correction (p = .01). seven percent of eyes in group 1 and no eye in group 2 lost 2 or more lines of bscva. authors concluded with the remarks that results indicate that the outcomes of lasek depend on surgeon experience. thus, caution is advised when interpreting lasek results without knowing the surgeon's level of experience. reference 1. yo c, vroman c, ma s, et al. surgical outcomes of photorefractive keratectomy and laser in situ keratomileusis by inexperienced surgeons. j. cataract refract surg. 200, 26: 510-5. 2. bowers pj jr, zeldes ss, price mo, et al. outcome of laser in situ keratomileusis in a refractive surgery fellowship program. j refract surg. 2004; 20: 265-9. visual performance and biocompatibility of 2 multifocal diffractive lols: six-month comparative study toto l, falconio g, vecchiarino l, scorcia v, marta di nicola md, ballone e, mastropasqua l j cataract refract surg 2007; 33: 1419-25 158 the restoration of near functional capacities is one of the main challenges of modern cataract refractive surgery and refractive lens exchange. several approaches have been attempted to correct presbyopia after crystalline lens removal based on the implantation of conventional monofocal intraocular lenses (lols) such as the monovision strategy and bilateral myopization; however, problems with binocular vision and loss of stereopsis have limited the use of these procedures. consequently, multifocal lols (miols) were designed to provide good uncorrected distance and near vision. multifocal lols have proved to be effective in ensuring distance and near visual performance because they produce a variable number of foci, either finite or infinite, depending on the lens design. however, the light dispersion due to refractive or diffractive optics leads to undesirable symptoms such as glare, halos, and reduction of contrast sensitivity. moreover, the spherical design of the commercially available miols leads to an increase in the overall spherical aberration of the eye due to a disruption of the cornea lens balance. this is responsible for a degradation in the retinal image quality and thus in the quality of vision. the purpose of this study was to evaluate the distance and near functional capacity, wavefront error and biocompatibility in patients with 2 diffractive multifocal intraocular lenses (miols). this prospective study comprised 28 eyes of 28 senile cataract patients having phacoemulsification and implantation of the tecnis zm900 miol (group 1) and the acrysof restor miol (group 2). the main outcome measures, over a 6-month follow-up period, were spherical equivalent, distance visual acuity at high and low contrast, near visual acuity, and defocus curve. wave-front error was evaluated in both groups. capsule opacification was also assessed. the high and low contrast uncorrected and best corrected visual acuity for distance did not show statistically significant differences between the 2 groups. the distance corrected near visual acuity was 1.86 ± 1.66 in group 1 and 1.93 ± 1.12 in group 2. the depth of focus was 4.5 diopters in both groups. the root mean square of total aberration and of spherical and coma aberrations were significantly lower in group 1 than in group 2. a higher percentage of patients with tecnis miols showed a more severe grade of anterior fibrosis. posterior opacification was minimal and not significantly different between the 2 groups. authors concluded with the remarks that diffractive miols were effective in improving functional capacity for distance and near and provided a good quality of vision due to a significant reduction in spherical aberration, particularly in the tecnis miols. the higher capsular biocompatibility of the restor miol compared with the tecnis miol could ensure long-term stability. central corneal thickness changes after phacoemulsification cataract surgery salvi sm, soong tk, kumar bv, hawksworth nr j cataract refract surg 2007; 33:1426-1428 the purpose of this study was to evaluate changes occurring in central corneal thickness (cct) immediately after uneventful cataract surgery. thirteen consecutive patients who had uneventful phacoemulsification surgery by the same experienced surgeon were prospectively evaluated for cct measurements 1 hour preoperatively and 1 hour, 1 day, and 1 week postoperatively. the unoperated eye also had cct measurements simultaneously on all occasions and served as a control. all patients provided informed consent. mean age of the patients was 69 years. central corneal thickness was 550.34 µm preoperatively, 626.39 µm at 1 hour, 585.80 µm at 1 day, and 553.80 µm at 1 week. in the control group, cct remained stable, within ±2 µm of preoperative readings. authors concluded with the remarks that central corneal thickness increased by approximately 13.81% in the immediate postoperative period (at 1 hour). it remained increased by 6.44% on day 1 compared with preoperative values and gradually reduced to preoperative levels by the 1 week postoperative period (0.57% difference). intraocular pressure (iop) measured postoperatively in the first week may be falsely elevated to some extent because of the increased corneal thickness in the immediate postoperative period; thus, not all iop rises have to be treated in this period in healthy uncompromised eyes. pulsed electron avalanche knife: new technology for cataract surgery priglinger sg, palanker d, alge cs, kreutzer tc, haritoglou c, grueterich m, kampik a br j ophthalmol 2007; 91: 949-54. the pulsed election avalanche knife (phak-fc, carl zeiss meditec, jena, germany) is a new electrosurgical 159 device, which has recently been introduced for "cold" and traction free dissection of tissue in liquid medium. similar to dielectric breakdown-based short pulsed laser technology, peak-fc works by induction of plasma in the conductive medium or in tissue generated by microsecond pulses of high electric field. short (up to 100 µs) bursts of electric pulses rapidly vaporize and ionize liquid and tissue in close proximity to the 50 µm wire microelectrode, leading to ablation or dissection of the surrounding tissue. as fc uses pulses not exceeding 100 µs in duration, the heat diffuses to the surrounding tissue only up to 7 µm, thereby inducing only a little thermal collateral damage. the peak-fc technique is therefore referred to as "cold" cutting. the heat confinement by use of short-pulse plasma-mediated discharges distinguishes peak technology from the conventional continuous radio-frequency devices such as wet-field hemostatic coagulator (medtronic, jacksonville, florida, usa), diacapsutom (erbe elektromedizin gmbh, tubingen, germany) or fugo blade (medisurg, norristown, pennsylvania, usa). it was successfully used for a variety of surgical maneuvers commonly encountered in patients undergoing vitreoretinal surgery. advantages of this new technology include sharply defined transaction and incision of epiretinal membranes, line coagulation of vascularised epiretinal tissue during surgery for diabetic traction detachment and traction-free dissecttion of attached or elevated retina. in these studies peak-fc has proven to be a promising culling device for intraocular surgery, allowing for a higher level of microsurgical precision. on the basis of promising experiences with peakfc in vitreoretinal surgery in the present study we evaluated the applicability of this new microsurgical tool for anterior segment surgery. the safety and efficacy of peak-fc were evaluated in various surgical maneuvers in patients undergoing surgery for capsulotomy in pediatric cataracts, mature or posttraumatic cataracts with zonulolysis, posterior iris synechiae after uveitis and massive anterior capsule opacification the purpose of this study was to evaluate the surgical applicability, safety and potential complications of peak-fc in complicated cataract surgery. the study included five children with congenital cataracts, two patients with advanced senile cataracts, six adults with mature cataracts, three of them with posterior iris synechiae, three patients with posttraumatic cataracts with zonulolysis, one patient with intumescent traumatic cataract and three patients with massive anterior capsule opacification. anterior and posterior capsulotomies, iris synechiolysis, dissection of anterior capsule opacification and fibrotic scar tissue were performed. peak-fc was set at voltages of 500-700 v, pulse duration of 0.1 m and repetition rate of 40-100 hz. anterior and posterior capsulotomies were successfully and safely performed in all eyes. the edges of capsulotomies appeared sharp, showing only limited collateral damage. peak-fc worked best by just gently touching the capsule, thereby avoiding tractional forces or pressure on the lens capsule. posterior iris synechiae could be released and anterior capsule opacification was dissected without complications. authors concluded with the remarks that peak-fc is a very helpful cutting device for complicated cases of cataract surgery, especially for mature and congenital cataracts, traumatic zonulolysis or anterior segment complications after intraocular inflammation. reproducibility and repeatability of central corneal thickness measurement in keratoconus using the rotating scheimpflug camera and ultrasound pachymetry sanctis ud, missolungi a, mutani b, richiardi l, grignolo fm am j ophthalmol 2007; 144: 712-8. keratoconus is the most frequent corneal ectatic dystrophy and is characterized by progressive non inflammatory corneal thinning with well described slit-lamp findings. in this disorder, corneal thickness measurement is used for diagnosis or staging, followup, and planning surgical procedures. currently, the clinical method most widely used to measure corneal thickness is ultrasound pachymetry; this has the advantages of ease of use, portability, and low cost and has been shown to have a high degree of intraexaminer, inter-examiner, and inter-instrument reproducibility in normal corneas. however, major limitations of ultrasound pachymetry are the need for cornea-probe contact, as well as the variability of measurements caused by probe misalignment or decentering and changes in the speed of sound in corneal tissues with different degrees of hydration. these limitations have led to the introduction of several optical technologies that offer the advantages of a non-contact technique and objective determination of the center of the cornea. among these, the rotating scheimpflug camera (pentacam oculus, wetzlar, germany) calculates thickness and 160 curvature values for the entire cornea, determining its front and back surfaces. recent studies have shown that, in normal corneas and in corneal grafts, this method provides central corneal thickness (cct) measurements that are reproducible, repeat-able, and comparable with those obtained with ultrasound pachymetry. in keratoconus, the corneal thinning and corneal shape irregularity may reduce the reproducibility and repeatability of the rotating scheimpflug camera and ultrasound pachymetry. moreover, in eyes with keratoconus, a low inter-examiner and intra-examiner variability in measuring corneal thickness is required: in clinical practice, this parameter frequently is remeasured in the same eye over time, and in some cases by different examiners, during disease monitoring. this study investigates and compares the inter-examiner reproducibility and the intra-examiner repeatability of the rotating scheimpflug camera and ultrasound pachymetry in measuring the central thickness of keratoconic corneas; it also assesses agreement between the two pachymetric methods in these eyes. the purpose of this study was to assess repeatability, reproducibility, and agreement of rotating scheimpflug camera (pentacam oculus, wetzlar, germany) and ultrasound pachymetry in measuring central thickness of keratoconic corneas. in 33 patients with keratoconus (one eye per patient), two examiners each used both pachymetric methods to measure central cortical thickness (cct); in the same session, measurements then were repeated by examiner 1 (a.m.). the difference between two examiners and between first and second measurements by examiner 1, with both methods and the difference between the two pachymetric methods in measuring central thickness of keratoconic corneas were noted. with the rotating scheimpflug camera, interexaminer correlation was higher (infra-class correlation coefficient [icc], 0.98 vs 0.76) and interexaminer variability was lower (95% limits of agreement [95% loa], -14.8 to 13.8 µm vs -18.0 to +49.5 µm) than with ultrasound pachymetry. both methods showed close first to second measurement correlation (icc, > 90), but the rotating scheimpflug camera had lower variability (95% loa, -14.5 to 14.2 µm vs -27.4 to 26.0 µm). mean cct was 478.9 ± 34.6 µm with the rotating scheimpflug camera and 486.6 ± 30 µm with ultrasound pachymetry. although the mean difference was small (-7.8 µm), the 95% loa (-43.8 to 28.2 µm) showed that the difference between the two methods can be considerable. authors concluded with the remarks that in keratoconic corneas, the rotating scheimpflug camera provides measurements of central thickness that are more reproducible and repeatable than those obtained with ultrasound pachymetry. the rotating scheimpflug camera seems to be suitable for disease staging and follow-up, when cornea thickness measurements may be repeated over time by different examiners. diverse clinical presentations of orbital sarcoid mavrikakis i, rootman j am j ophthalmol 2007; 144: 769-75. sarcoidosis is a multisystem granulomatous disease of unknown origin. it can occur at any age, but patients typically are between 20 and 40 years at the time of diagnosis. the distribution is worldwide and affects individuals of any ethnic or racial group. the highest prevalence is reported in white persons of northern european descent (50 to 60 per 100,000) and among african-americans (35 per 100,000). sarcoidosis is thought to be more prevalent in women than in men. it may affect practically any organ system, but pulmonary, dermatologic, and ocular involvement is the most common manifestations. ocular manifesttations include uveitis, chorioretinitis, conjunctival, and eyelid granulomas. more rarely, extraocular orbital tissues may be affected, with the lacrimal gland most commonly affected. extralacrimal involvement includes soft tissue orbital mass, extraocular muscle, and optic nerve sheath sarcoidosis in patients with purely orbital involvement, where there is no evidence of systemic disease, the term "sarcoidal reaction” is used. over time, we have been impressed with the broad range of presentation of orbital sarcoid. in view of this, we reviewed our experience and report herein the different clinical presentations. the purpose of this study was to review the clinical presentation, location, systemic features, management, and natural history of orbital sarcoid. twenty patients with sarcoid and sarcoidal reactions of the orbit underwent biopsy, excision of localized mass, and systemic and local treatment at a tertiary referral center. age, gender, onset, symptoms and signs, characterization of disease process, location, systemic disease, associated systemic features, management, and recurrence of the disease were identified. of the 20 patients studied, five were male and 15 were female. the mean age was 50.55 ± 16.43 years (range, 18 to 77 years). the most common symptom was the presence of a palpable mass, followed by eyelid swelling. review of the computed tomographic 161 scans revealed four main categories of presentation: lacrimal gland infiltration (n = 11; 55%), orbital mass (n = 4; 20%), optic nerve sheath and dural involvement (n = 4; 20%), and extraocular muscle involvement (n = 1; 5%). concurrent systemic sarcoidosis discovered after the diagnosis of orbital sarcoid was present in 10 cases (50%). the remaining showed no evidence of systemic disease at follow-up. angiotensin converting enzyme analysis was performed in 10 cases; in only two (20%) was elevated, and in the remaining eight, it was within normal levels. authors concluded with the remarks that orbital sarcoid has a diverse clinical presentation varying from lacrimal gland infiltration, soft tissue orbital mass, intraorbital and extraorbital optic nerve sheath and dural involvement, to extraocular muscle involvement. the orbital site most commonly involved was the lacrimal gland. microsoft word salahuddin ahmed 62 original article cataract surgery: is it time to convert to topical anaesthesia? salahuddin ahmed pak j ophthalmol 2008, vol. 24 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: salahuddin ahmed armed forces postgraduate medical institute (afpgmi) and cmh, rawalpindi received for publication september’ 2007 …..……………………….. purpose: to evaluate the efficacy and safety of topical anaesthesia for routine uncomplicated phacoemulsification with intraocular lens implantation surgery in pakistani patients. material and methods: 109 consecutive patients listed for routine cataract surgery were operated under topical anaethesia. patients received four doses of 0.5% proparacaine eye drops. a 10 point visual analogue pain scoring system was used to score pain just after instillation of drops and pain score during operation was recorded just after completion of surgery. intraoperative/ postopearive complications and surgeon’s difficulties attributable to operating conditions were recorded as was the incidence of chemosis and subconjunctival haemorrhage. results: the pain scores reported by the patients on instillation of drops was zero in 83 patients (76%) and only 26 patients (24%) complained of slight stinging sensation (score 1) with mean score of 0.24 (fig. 1). pain score during surgery was zero to 1 in 85 patients (78%), 2 to 5 in 20 patients (18%) and 5 to 7 in 4 patients (4%) with mean score of 1.52 (fig. 2). eight patients in the last two groups required supplemental subconjunctival bupivacaine injection above superior limbus. when inquired about choice of anesthesia for another similar operation, 102 patients (93.5%) preferred same technique of anaethesia. conclusion: it is right time to convert to topical anaesthesia for small incision cataract surgery which is an efficient and safe anaesthetic technique. ataract surgery is one of the most common elective surgical procedure performed in uk1 and the rest of the world. local anaesthesia is the preferred anaesthetic technique for this procedure as is revealed in a survey conducted by the royal college of ophthalmologists2. there are several local anaesthetic techniques available for cataract surgery including retrobulbar (intraconal)3, peribulbar (extraconal)4, sub-tenon’s5,6, subconjunctival7 and topical anaesthesia8. peribulbar or retrobulbar anaesthesia, while providing excellent analgesia and akinesia, have been associated with rare but numerous ocular compli-cations9 including diplopia10, orbital haemorrhage11, globe perforation12, central retinal vein or artery occlusion13, brainstem anaesthesia14,15, optic nerve trauma16, and ptosis17. the sub-tenon and subconjunctival anaesthesia do not cause above complications but are associated with high incidence of chemosis and subconjunctival haemorrhage18. in addition, preoperac 63 tive intravenous sedation is often required because patients find the injections painful and frightening. fichman8 first described a novel technique, topical anesthesia, which is not only free from all of the above complications but is also well tolerated by the patients. since its introduction, topical anesthesia has become increasingly popular, as indicated by the annual survey of the practice styles and preferences of members of the american society of cataract and refractive surgery. according to last year's survey, the use of topical anesthesia increased from 8% in 1995 to 63% in 1998 for high volume cataract surgeons19. there have been several reports of its safety and efficacy18,20-22. the topical anaesthesia has not been very popular in pakistan. but, with the increasing frequency of clear corneal phacoemulsification surgery, the time is ripe to convert to topical anaesthesia which is safe, time saving, cost-effective and preferred by both patient and surgeon. this study aims at finding its feasibility in our population. materials and methods from feb 2007 to june 2007, 109 consecutive patients out of continuous cohort of 130 cataract patients (52 males, 57 females with a mean age of 64) attending eye department combined military hospital rawalpindi were eligible for cataract surgery (phacoemulsification with intraocular lens implantation) using topical anaesthesia. all patients gave written informed consent to participate in the study. approval for the study was obtained from the hospital research ethics committee. the surgical procedure complied with the tenets of the declaration of helsinki. inclusion criteria were willingness to participate in the trial. exclusion criteria were dementia, deafness, eye-movement disorder, combination surgery, excessive anxiety, inability to understand the language of the surgeon, hypersensitivity to proparacaine and uncooperative patient. other contraindications to participation in the study included complex anterior segment pathological features that might make the surgical procedure difficult including the extensive corneal opacification/ corneal thinning, small pupil not dilating with mydriatic drops, old glaucoma surgery, pseudoexfoliation syndrome, and zonular dehiscence. technique of topical anesthesia six doses (approximately 40 µl per dose) of proparacaine hydrochloride 0.5% were used in total. they were instilled on the ocular surface (two drops on the cornea, and one each in the superior and inferior conjunctival cul de sac) 10 min before surgery. five minutes before surgery two further drops were instilled on the cornea and the eye was padded. the breakthrough pain during surgery allowed an additional 2 doses of 0.5% proparacaine drops. if this was not effective within 2 minutes, the patient received a subconjunctival injection, 0.1-0.2 ml of 0.75% bupivacaine. surgical technique all surgical procedures were performed by one experienced surgeon who had performed cataract surgery using topical anesthesia since 2002, using a standardized phacoemulsification technique. a superotemporal (for right eye) or superonasal (for left eye) clear corneal phaco port was made using a 3-step incision with a 3.2mm diamond phaco knife. this was followed by another side port incision 90° to the left of phaco port which was to be used for second instrument. routine phaco surgery was performed including viscoelastic injection, continuous curvilinear capsulorhexis, hydro-dissection, hydrodelineation, endocapsular phacoemulsification, aspiration of the remaining cortical lens material, in-the-bag implantation of foldable or 5.2mm pmma iol and, finally the visco-elastic substance was thoroughly cleared from the anterior chamber and capsular bag. the wound was secured by hydro tamponade and tested for leakage of fluid by gentle compression with a sponge, and only 15 patients required a suture to close the wound (13 of these patient had pmma iols and 2 patients had foldable iols). all patients received postoperative cefuroxime; intra-cameral 1mg/0.1ml and 100mg subconjunctival injection. during postoperative recovery, each patient received dexamethasone drops and moxifloxacin drops (both used at 6 hourly interval), the dosage of steroids being rapidly tapered off depending on the degree of postoperative inflammation. the uncontrolled eye movements were minimized by keeping the brightness of the operating microscope to minimum possible and the patients were asked to look just below the light of microscope. the surgeon kept continuous verbal contact with the patient and also warned the patient before performing certain potentially irritating preoperative and intraoperative steps like instillation of eye drops, introduction of phaco probe into the anterior chamber, iris 64 manipulation, hydro dissection, activation of the irrigation line, or iol implantation. pain evaluation each patient was shown a visual analogue pain scale with numerical and descriptive ratings from 0-1 (no pain to slight stinging) to 9-10 (severe pain), as described by stevens7 to rate their pain. patients were encouraged to use this pain scale to rate the level of pain felt preoperatively (on administration of anaesthetic drops), intraoperatively (verbal expression) and 30 minutes after operation. if patients were unable to read the printed numbers and descriptive text on the pain scale, a trained ophthalmic assistant read them to the patient. an independent observer (ophthalmologist) performed the pain score recording in all the patients. in addition, the surgeon also graded difficulties encountered attributable to the operating conditions which were recorded as "not difficult (grade 0)," "slightly difficult (grade 1)," "moderately difficult (grade 2)," "difficult (grade 3)," and "extremely difficult (grade 4)”. the surgeon was asked to complete the form immediately after surgery. results the pain scores reported by the patients on instillation of drops was zero in 83 patients (76%) and only 26 patients (24%) complained of slight stinging sensation (score 1) with mean score of 0.24 (fig. 1). pain score during surgery was zero to 1 in 85 patients (78%), 2 to 5 in 20 patients (18%) and 5 to 7 in 4 patients (4%) with mean score of 1.52 (fig. 2). eight of the patients in the last two groups required supplemental subconjunctival bupivacaine injection above superior limbus. only four patients experienced anxiety before anesthesia administration. the patients most commonly complained of discomfort on manipulation of the iris, distention of the anterior chamber, insertion of phaco probe, insertion and rotation of the iol. when inquired about choice of anesthesia for another similar operation, 102 patients (93.5%) wanted to have same anaethesia. the operating time ranged from 10 minutes to 35 minutes (mean 15 minutes). we believe that the low level of patient discomfort in our patients receiving topical anesthesia may also be explained by the speed with which phacoemulsification was performed and the caution we exercised during intraocular manipulation. no patients scheduled for peribulbar were considered unsuitable for the topical anesthesia except for the exclusion criteria already mentioned. in no case was topical anaesthesia changed to peribulbar anaesthesia. intraoperative conditions as judged by the surgeon are shown in fig. 3. in majority of the cases the surgeon did not have any significant difficulty (grade 0) to slight difficulty (grade 1). only one of the cases was really difficult (grade 4) and so we had to supplement with subconjunctival anaesthesia which was also done in 7 other patients who were experiencing pain on iris manipulation. pain score during instillation of topical anaesthesia 83 26 0 0 0 0 0 0 0 0 0 0 20 40 60 80 100 0 1 2 3 4 5 6 7 8 9 10 pain score n o. of p at ie nt s fig. 1 pain score during operation 68 17 7 8 5 2 1 1 0 0 0 0 10 20 30 40 50 60 70 80 0 1 2 3 4 5 6 7 8 9 10 pain score n o. of p at ie nt s fig. 2 65 surgeon's intraoperative difficulty 90 10 6 2 1 0 10 20 30 40 50 60 70 80 90 100 0 1 2 3 4 grades of dfficulty n o. o f p at ie nt s fig. 3 complications during surgery (one capsular rupture during phacoemulsification) were not related to the anaesthetic method. there were no severe complications observed in the first 24 hours. a transient pressure increase occurred most frequently (9 patients), fibrinous aqueous reaction was the second most frequent complication (6 patients) but was successfully treated by intensified topical corticosteroid application in each patient. corneal edema (mostly localized) leading to a transient loss in best-corrected visual acuity occurred in 5 patients which resolved in a week’s time. retained cortex substance was observed in 1 patient which was not associated with any sustained pressure rise, and eventually got absorbed spontaneously without any surgical intervention. discussion topical anaesthesia alone for cataract removal and intraocular lens implantation was first described by fichman. since its introduction, topical anesthesia has become increasingly popular, as indicated by the annual survey of the practice styles and preferences of members of the american society of cataract and refractive surgery. according to this survey, the use of topical anesthesia increased from 8% in 1995 to 63% for high volume cataract surgeons in 1998 and is on the increase due to patient’s demand19. although there are several reports establishing safety and efficacy of topical anasthesia18,20-22. fukasaku and marror23, comparing topical and peribulbar anaesthesia, and patel and colleagues24, comparing topical and retrobulbar anaesthesia, reported more intraoperative pain in patients receiving topical anaesthesia for cataract surgery. in recent years, topical anesthesia for cataract surgery has gained popularity as safe and atraumatic technique25. the benefits of topical anaesthesia over peribulbar or retrobulbar anaesthesia are: no risks of the needle techniques, the analgesia is immediate, no rise in ocular pressure21, 26, 27, no need for globe compression and no preoperative sedation is necessary. the main advantages of topical over sub-tenon's anaesthesia are the absence of chemosis and subconjunctival haemorrhage and a quicker visual recovery20. analgesia the administration of topical anesthesia was painless for all the patients (fig. 1); only 26 patients (23.8%) experienced mild stinging sensation on installation of the first dose only. roman et al20 conducted a doubleblind randomized placebo controlled trial comparing topical and sub-tenon’s anaesthesia for routine cataract surgery. although he documented that pain score was higher in the topical group compared to the sub-tenon group, none of the patients in topical group required supplemental anaesthesia during surgery and topical anaesthesia was well tolerated by patients. chittenden and colleagues28 and manners and burton29 recommended topical anaesthesia only if the cataract surgery was performed through a clear incision, as we did in all of our patients. people have tried different methods to improve the pain scores. lignocaine gel instead of drops gives low pain score due to prolonged contact time and better penetration30-33. although many surgeon use intra-cameral anaesthetic along with topical anesthesia there is no significant benefit documented34-36. the topical anaesthesia in our study was very effective; 78% of the patients reported no pain during surgery, 18% reported slight sensation to mild discomfort and only 4% reported mild to moderate pain which was relieved with supplemental subconjunctival anaethesia without resorting to peribulbar anaesthesia. the low level of discomfort in our patients receiving topical anesthesia is also explained by the speed with which phacoemulsification was performed and the caution we exercised during intraocular manipulation. although we recommend topical anaesthesia for standard cataract surgery but in cases of very anxious and uncooperative patients or patients whose pupillary dilatation is not sufficient (risk of iris chafing), or in very dense cataracts we favour peribulbar anaesthesia. during topical anaes66 thesia, if the patients feel any discomfort, we perform a supplementary sub-conjunctival anaesthesia. akinesia the lack of akinesia is the only drawback of the topical anesthesia but this is not only with topical but also with other anaesthetic technique including sub-tenon, peribulbar and retrobulbar. none of the patients had complete akinesia after sub-tenon anesthesia and complete eye movements remained after surgery in 37.6% as reported by roman et al20 and tsuneoka et al37. some surgeons find difficult to work without akinesia; however, as reported by many authors37,38 lack of akinesia does not cause intraoperative difficulties to experienced surgeons. stabilization of the globe is adequate during a two handed procedure (as during phacoemulsification). most of the time the patients did not have eye movement. if necessary, unwanted movements can be controlled by forceps fixation. lack of akinesia can even be helpful to the surgeon when asking the patient to look in a particular direction to expose a desired area. no complications have occurred during surgery because of ocular motility in our study. nevertheless, in cases of patients completely unable to cooperate (patients suffering from dementia or unable to understand the language), we would rather use peribulbar or retrobulbar anesthesia. the uncontrolled eye movements were minimized by keeping the brightness of the operating microscope to minimum possible and constant verbal contact with the patient. chemosis and subconjunctival haemorrhage chemosis was infrequent in our study seen in only 6% of patients and there was no patient with subconjunctival haemorrhage using the topical technique whereas there can be frequent chemosis and subconjunctival haemorrhage in sub-tenon anesthesia 39.4 % and 56% respectably20 whereas another study reports inevitable subconjunctival haemorrhage18. conclusion topical anaesthesia is a simple, safe, atraumatic technique. its benefits are numerous. the speed and ease of administering topical anesthesia coupled with the rapid visual recovery after surgery makes this method a suitable and safe choice. it can be proposed as a good alternative to peribulbar or retrobulbar anaesthesia and is likely to become the preferred type of anesthesia in phacoemulsification. surgical training and patient selection is the key to safe use of topical anaesthesia. patient preference for topical anesthesia is increasing steadily and warrants all efforts to move away from more invasive forms of anesthesia so that cataract surgery can genuinely be described as "minimally invasive". author’s affiliation dr. salahuddin ahmed assistant professor h. # 225, st. # 4 askari xi near qasim market rawalpindi cantt reference 1. report of the joint working party on local anaesthesia for intraocular surgery. london: royal college of anaesthetists and college of ophthalmologists, 2001. 2. eke t, thompson jr. national survey of local anaesthesia for ocular surgery in the united kingdom. ophthalmology. 2000; 107: 817. 3. ellis pp. retrobulbar injections. surv ophthalmol. 1974; 18: 425–30. 4. davis db ii, mandel mr. peribulbar anaesthesia: a review of technique and complications. ophthalmic clin north am. 1990; 3: 101-10. 5. hansen ea, mein ce, mazzoli r. ocular anaesthesia for cataract surgery: a direct sub-tenon’s approach. ophthalmic surg. 1990; 21: 696-9. 6. stevens jd. a new local anaesthetic technique for cataract surgery by one quadrant sub-tenon’s infiltration. br j ophthalmol. 1992; 76: 670-4. 7. smith r. cataract extraction without retrobulbar anaesthetic injection. br j ophthalmol. 1990; 74: 205-7. 8. fichman ra. use of topical anaesthesia alone in cataract surgery. j cataract refract surg. 1996; 22: 612-4. 9. davis db, mandel mr. efficacy and complication rate of 16224 consecutive peribulbar blocks, a prospective multicenter study. j cataract surg. 1994; 20: 327-37. 10. wylie j, henderson m, doyle m, et al. persistent binocular diplopia following cataract surgery: aetiology and management. eye 1994; 8: 543-6. 11. puustjarvi t, purhonen s. permanent blindness following retrobulbar haemorrhage after peribulbar anaesthesia for cataract surgery. ophthalmic surg. 1992; 23: 450-2. 12. duker js, belmont jb, benson wb. inadvertent globe perforation during retrobulbar and peri bulbar anaesthesia. ophthalmology 1991; 98: 519-26. 13. klein ml, jampol lm, condon pi, et al. central retinal artery occlusion after retrobulbar blockade. am j ophthalmol. 1982; 93: 573-7. 14. hamilton rc. brainstem anaesthesia as a complication of regional anaesthesia for ophthalmic surgery. can j ophthalmol. 1993; 27: 323-5. 15. javitt jc, addiego r, friedberg hl, et al. brain stem anaesthesia following after retrobulbar block. ophthalmology 1987; 94: 718-24. 67 16. peterson wc, yanoff m. complications of local ocular anaesthesia. int ophthalmol clin 1992; 32: 23-30. 17. alpar jj. acquired ptosis following cataract and glaucoma surgery. glaucoma 1982; 4: 66-8. 18. kershner rm. topical anaesthesia for small incision selfsealing cataract surgery. a prospective evaluation of the first 100 patients. j cataract refract surg. 1993; 19: 290-2. 19. leaming dv. practice styles and preferences of ascrs members: 1998 survey. j cataract refract surg.1999; 25: 851-9. 20. roman s, sit dac, boureau cm, et al. sub-tenon anaesthesia: an efficient and safe technique. br j ophthalmol. 1997; 81: 6736. 21. rocha g, turner c. safety of cataract surgery under topical anesthesia with oral sedation without anesthetic monitoring. can j ophthalmol. 2007; 42: 288-94. 22. ugur b, dundar so, ogurlu m, et al. ropivacain versus lidocaine for deep topical, nerve-block anaethesia in cataract surgery: a double-blind randomised clinical trial. clin experiment ophthalmol. 2007; 35: 148-51. 23. fukasaku h, marror ja. pinpoint anaesthesia: a new approach to local ocular anaesthesia. j cataract refract surg. 1994; 20: 468-71. 24. patel bck, burns ta, crandall a, et al. a comparison of topical and retrobulbar anaesthesia for cataract surgery. ophthalmology 1996; 103: 1196–1203. 25. jacobi pc, dietlein ts, jacobi fk. a comparative study of topical vs retrobulbar anesthesia in complicated cataract surgery. arch ophthalmol. 2000; 118: 1037-43. 26. grabow hb. topical anaesthesia for cataract surgery. eur j implant refract surg. 1993; 5: 20-4. 27. fichman ra. topical eyedrops replace injection for anaesthesia. ocular surgery news march. 1992; 20-1. 28. chittenden hb, meacock wr, govan jaa. topical anaesthesia with oxybuprocaine versus sub-tenon’s infiltration with 2% lignocaine for small incision cataract surgery. br j ophthalmol. 1997; 81: 288-90. 29. manners td, burton rl. randomised trial of topical versus sub-tenon’s local anaesthesia for small-incision cataract surgery. eye 1996; 10: 367–70. 30. bardocci a, lofoco g, perdicaro s, et al. lidocaine 2% gel versus lidocaine 4% unpreserved drops for topical anaesthesia in cataract surgery. ophthalmology 2003; 110: 144-9. 31. barequet is, soriano es, green wr et al. provision of anaesthesia with single application of lidocaine 2% gel. j cataract refract surg. 1999; 25: 626-31. 32. koch ps. efficacy of lidocaine 2% jelly as a topical agent in cataract surgery. j cataract refract surg. 1999; 25: 632-4. 33. assia ei, pras e, yehezkel m et al. topical anesthesia using lidocaine gel for cataract surgery. j cataract refract surg. 1999; 25: 635-9. 34. tan jhy, burton rl. does preservative-free lignocaine 1% for hydro dissection reduce pain during phacoemulsification? j cataract refract surg. 2000; 26: 733-5. 35. crandall as, zabriskie as, patel bck, et al. a comparison of patient comfort during cataract surgery with topical anesthesia versus topical anesthesia and intracameral lidocaine. ophthalmology. 1999; 106: 60-6. 36. gillow t, scotcher sm, deutsch j et al. efficacy of supplementary intracameral lidocaine in routine phacoemulsification under topical anesthesia. ophthalmology. 1999; 106: 2173-7. 37. tsuneoka h, ohki k, taniuchi o, et al. tenon's capsule anaesthesia for cataract surgery with iol implantation. eur j implant ref surg. 1993; 5: 29-34. 38. anderson cj. subconjunctival anaesthesia in cataract surgery. j cataract refract surg. 1995; 21: 103-5. erratum read the following on page 12 of pak j. ophthalmol 2008, vol. 24, no.1: as frequency of diabetes mellitus, impaired oral glucose tolerance test, hepatitis b surface antigen (hbsag) and hepatitis c virus antibody (hcv ab) in saudis undergoing cataract surgery instead of frequency of diabetes mellitus, impaired oral glucose tolerance test, hepatitis b surface antibody 68 (hcv ab) in saudis undergoing cataract surgery editor microsoft word qadeem soomro pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 38 original article outcome of rhegmetogenous retinal detachment surgery in uncomplicated pseudophakic eyes a. qadeem soomro, a. fattah memon, p.s. mahar pak j ophthalmol 2012, vol. 28 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p.s. mahar isra postgraduate institute of ophthalmology al ibrahimeyehospital, malir, karachi …..……………………….. purpose: to assess the anatomical reattachment and visual outcome in pseudophakic patients with rhegmatogenous retinal detachment (rd) after pars plana vitrectomy (ppv). material and methods: this case series study was conducted at isra postgraduate institute of ophthalmology from july 2004 to june 2006. thirty five eyes of 35 patients developed rhegmatogenous retinal detachment after uncomplicated extra capsular cataract extraction (ecce) with intraocular lens (iol) implant. all eyes went under 3 – port ppv with air fluid exchange and injection of silicon oil (so) for internal tamponade. results: there were 27 male (77%) and 8 female (23%) with 3.5:1 male to female ratio. twenty eyes (27%) had total, while 15 eyes (43%) had subtotal rd. the mean duration at which, retinal detachment was noticed after cataract surgery was 128 ± 243 days. at mean follow up of 1 year, improvement in visual acuity was seen in 23 (65%) eyes, 3 (9%) eyes showed no improvement and 9 (26%) eyes had deterioration in vision. the anatomic reattachment was registered in 31 (89%) eyes. conclusion: our results suggest that 3-port ppv with use of so is an effective procedure resulting in high proportion of cases showing successful anatomic reattachment and visual improvement. hegmatogenous retinal detachment (rd) although rare but remains a dreadful complication after cataract extraction and intraocular lens (iol) implantation1-3. retinal detachment develops in 0.5% to 1.0% of eyes, after modern cataract surgery4,5. however the incidence is higher after neodymium – yttrium – aluminum – garnet (nd – yag) laser posterior5,6. pseudophakic rhegmatogenous retinal detachment is commonly associated with the peripheral retinal breaks at the posterior edge of the vitreous base near ora serrata6. from a surgical point of view, this type of retinal detachment is difficult to treat, because of potentially poor my driasis, disturbing rim of anterior capsule, iol margin, residual lens matter, or any posterior capsule opacification, resulting in poor visualization of peripheral retina, and identification of retinal breaks7-9. the retinal breaks cannot be found in as many as 20% of pseudophakic retinal detachment6. the implication of non-visualized breaks in patients with pseudophakic retinal detachment is reported with the lower rate of surgical success10, 11. the treatment of pseudophakic rhegmatogenous retinal detachment is quite similar to that of phakic retinal detachment. the current treatment options are, use of pars plana vitrectomy (ppv)12, conventional scleral buckling procedure (sbp)6 and intraocular gas injection with associated retinopexy8,13. scleral buckling procedure in pseudophakic eyes is reported with persistent retinal re-detachment9,14. the main advantage of the primary vitrectomy over conventional buckling procedure, seems to be due to the r a. qadeem soomro et al 39 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology better intraoperative visualization of the peripheral retinal holes with controlled removal of vitreous traction and focused endolaser photocoagulation12,14. the ppv in conjunction with gas fluid exchange (gfx) and expression of subretinal fluid followed by the injection of silicon oil (so) has reported to be more effective as initial treatment of pseudophakic retinal detachment, when there is limited information about the retinal breaks15. the objective of our study was to assess the anatomical reattachment and visual outcome in a cohort of patients developing rhegmatogenous retinal detachment, with history of uncomplicated cataract surgery and iol implantation, after 3-port ppv with use of air fluid exchange and silicon oil tamponade. material and methods this interventional case series study was conducted at the isra postgraduate institute of ophthalmology, alibrahim eye hospital, karachi, from july 2004 to june 2006. a total of 35 eyes (35 patients), that underwent uncomplicated ecce with iol, followed by retinal detachment, were analyzed. after informed consent, pseudophakic patients with retinal detachment having proliferative vitreoretinopathy (pvr) grade c16. (full thickness retinal folds in either 1, 2 or 3 quadrants), were included in the study. patients with corneal opacity, traumatic retinal detachment and retinal detachment with pvr grade d16 (fixed retinal folds in 4 quadrants) were excluded. a detailed ocular history was taken about the nature and duration of symptoms, trauma, and the time period of cataract surgery and nd – yag posterior capsulotomy. a family history of retinal detachment was taken into account with any systemic illness. the ocular examination included, charting of bestcorrected visual acuity (bcva) in both eyes, anterior segment bio-microscopy with measurement of intraocular pressure (iop) using goldmann applanation tonometer. after pupillary dilatation, posterior segments of both eyes were examined with indirect ophthalmoscope with indentation, using +20 diopter lens and slit lamp biomicroscope, using +90 diopter lens and goldmann 3 – mirror lens. all the finding of history and examination were documented in a specific proforma, designed for this purpose. fundus diagram was made and retinal status was mentioned in terms of location of the breaks, extent of the retinal detachment, grading of pvr and associated chorioretinal degeneration. colored fundus photographs were taken in those eyes with clear media. the mean duration at which detachment was noticed was 128 ± 243 days, while mean duration from cataract surgery to retinal detachment was noticed at 3.12 ± 3.19 years. all patients were operated under local anesthesia. surgical technique patients underwent a standard 3 port parsplana vitrectomy with shaving and of the vitreous base. air fluid exchange was initiated to replace the infusion fluid and subretinal fluid (srf). the endolaser photocoagulation was applied with 2 to 3 rows around the breaks and 360 degrees of the peripheral retina. at the end of the procedure silicone oil was injected for prolonged internal tamponade. patients were examined on 1st postoperative day and were started on topical dexamethasone 0.1% (maxidex alcon, belgium) 2 hourly, diclofenac sodium 0.1% (naclof – novartis, switzerland) 6 hourly, ofloxacin 0.3% (exocin allergan, pakistan) 6 hourly and tropicamide 1% (mydriacyl – alcon, belgium) 6 hourly. patients were followed up in the surgical retina clinic at 1 week, 2 weeks, 4 weeks, 8 weeks and monthly interval afterwards. on each follow up visit, patients had detailed evaluation in terms of bcva, iop, anterior segment biomicroscopy and dilated fundus examination. the silicon oil was removed after 6 months postoperatively in each eye. results at 1 year mean follow up, 23 (66%) eyes had improvement in their visual acuity, while 3 (9%) eyes showed no improvement and 9 (26%) eyes had deterioration in vision (fig. 1). one eye had bcva of 6/6 – 6/12, twelve (34%) eyes had bcva of 6/18 – 6/60, nine (25.7%) had visual acuity between 5/60 – 3/60 and ten (29%) eyes had visual acuity of 2/60 – 1/60. the comparison of pre-operative and postoperative va is shown in table 1. the final anatomic reattachment was witnessed in 31 (89%) eyes, while 4 (11%) eyes had persistent retinal detachment (fig. 2). outcome of rhegmetogenous retinal detachment surgery in uncomplicated pseudophakic eyes pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 40 at the end of 1 year, out of the 35 eyes operated upon, 10 (29%) eyes developed raised iop, controlled with topical timolol 0.5% (betalolsante, pakistan), 1 (3%) eye developed macular pucker and 1 (3%) eye showed silicon oil in the anterior chamber table 2. discussion primary ppv is a preferred technique for repair of retinal detachment developing in pseudophakic eyes, as this technique permits a direct attack on the cause of retinal detachment by the release of vitreoretinal traction internally and by permitting a very gentle but effective intraocular tamponade. this technique also alleviates the non-physiological distortion of the globe and motility problems caused by the scleral buckling procedure. postoperatively, vitrectomised eyes without scleral buckle have very little conjunctival or lid edema and have significantly less discomfort. the outcome of the vitreoretinal surgery is generally reported by postoperative bcva and the retinal reattachment rate. the most common criterion in such analysis is whether the retina has remained attached for at least 6 months after the last procedure (anatomic success) and whether postoperative bcva has improved (visual success)10,17. according to these criteria, our group of patients with pseudophakic rhegmatogenous retinal detachment after an uncomplicated cataract extraction and posterior chamber iol implant showed anatomical and visual success in 89% and 65% respectively, after a median follow up of 1 year. in a case series of 101 enrolled patients with pseudophakic rhegmatogenous retinal detachment, undergoing similar surgical procedure, kivela1 and coworkers observed primary anatomical success rate of 74% and visual improvement at 74%. bartz schmidt14 reported 33 consecutive cases of pseudophakic retinal detachment with reattachment rate of 94% and visual improvement in 79% at mean follow up of one year. brazitikos15 described the overall reattachment rate of 100% and visual success rate of 78% in 14 eyes. gruterich and colleagues17 reported a series of 102 patients with pseudophakic retinal detachment undergoing ppv, showing overall reattachment rate of 99% with 69% of patients having improvement in va. in many eyes after the retinal detachment surgery, the visual outcome is less satisfactory than the anatomic result, mainly because of the permanent functional damage to the macula. the comparison of visual success after retinal detachment surgery therefore is difficult because of differences between the studies, due to different ocular diseases and different types and complication rates of preceding cataract surgery10. even though many factors have been found to influence the visual outcome of retinal detachment surgery, the most important predictor of visual recovery is preoperative visual acuity, which is largely related to the macular attachment, age of the patient, nd – yag capsulotomy, duration of the retinal detachment and configuration of the retinal detachment. in our study, 31 eyes (89%) had successful reattachment after ppv while 4 eyes (11%) were redetached again. out of these 4 eyes 3 eyes developed pvr that lead to redtachment while 1 eye was redetached because of formation of new break. the eyes which were re-detached were re-attempted to flatten the retina with exchange of silicon oil. the silicon oil was removed after 6 months postoperatively in each eye. none of the eye had redetachment of retina after removal of silicon oil. as far as the duration between cataract surgery and retinal detachment is concerned, 22 eyes in our series had history of cataract surgery at less than 2 years, out of which 19 (86%) eyes had successful reattachment and va improved in 20 (91%) eyes. although refraction was performed but spectacles were not prescribed till the removal of silicon oil. thirteen eyes had history of cataract surgery at greater than 2 years out of which 12 (92%) had successful reattachment and va improved in all 13 eyes. the number of eyes with total retinal detachment were 20 (57%), of which, 16 eyes had successful reattachment while 4 eyes got re-detachment postoperatively. those who developed sub-total retinal detachment, all remained attached over a follow up period of 1 year. they all had successful reattachment with visual improvement postoperatively. regarding postoperative complications. raised iop was noted in 10 (28%) eyes, which was controlled with topical aqueous suppressant and carbonic anhydrase inhibitors. silicone oil in anterior chamber was noted in 1 (3%) eye, while macular pucker developed in 1 (3%) eye. twenty three (66%) eyes did not develop any complication. although, number of eyes included in our series is small, but overall anatomical reattachment and visual improvement is comparable to other series reported in the literature. a. qadeem soomro et al 41 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology table-1: comparative evaluations of preoperative and postoperative bcva (p = 0.02) best corrected visual acuity pre-operative (n %) post-operative (after 1 year) (n %) 6/6 6/12 0 1 (3) 6/18 6/60 1 (2.85) 12 (34) 5/60 3/60 1 (2.85) 9 (25.7) 2/60 – 1/60 4 (11.4) 10 (29) cf 2 (5.7) 1 (3) hm 22 (63) 2 (5.7) pl 5 (14.3) 0 total 35 35 cf = counting finger, hm = hand movement pl = perception of light. table 2. post-operative complications complications no. of patients (n %) no 23 (66) raised iop 10 (28) macular pucker 1 (3) s.o in ac 1 (3) iop = intraocular pressure s.o in ac = silicon oil in anterior chamber 23 (65%)* 9 (26%) 3 (9%) 0 10 20 30 40 50 improvement deterioration no change fig. 1: relative improvement in best corrected visual acuity, 1 year after surgical procedure *shows significantly greater proportion at p = 0.022 (by applying sign test for paired set of qualitative variants: z= -2.3). 31 (89%) 4 (11%) 0 10 20 30 40 flate rd fig. 2: retinal status after 1 year flat = successful reattachment of retina rd = retinal re-detachment conclusion our results suggest that 3-port pars plana vitrectomy with endolaser photocoagulation and silicon oil tamponade is an effective procedure in psudophakic retinal detachment, resulting in high proportion of cases having successful anatomical and visual outcome. however, the time of presentation, preoperative visual acuity, pvr grade and extent of retinal detachment remain determining factors influencing the final outcome of anatomical and visual success. author’s affiliation dr. a. qadeem soomro isra postgraduate institute of ophthalmology, karachi dr. a. fattah memon isra postgraduate institute of ophthalmology, karachi prof. p. s. mahar isra postgraduate institute of ophthalmology, karachi reference 1. kivela t, ranta p. functional and anatomic outcome of retinal detachment surgery in pseudophakic eyes. am acad j ophthalmol. 2002; 109: 1432-40. 2. tielsch jm, legro mw, steinberg ep. risk factors for retinal detachment after cataract surgery. a population based control study. ophthalmology. 1996; 103: 1537-45. 3. javit jc, street da, tielsch jm. national outcomes of cataract extraction. retinal detachment and endophthalmitis after outpatient cataract surgery. ophthalmology. 1994; 101: 100-5. n um be r of p at ie nt s best corrected visual acuity (bcva) after 1 year n um be r of p at ie nt s (% ) ratina status outcome of rhegmetogenous retinal detachment surgery in uncomplicated pseudophakic eyes pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 42 4. javitt jc, vitale s, canner jk. national outcomes of cataract extraction. retinal detachment after in patient surgery. ophthalmology. 1991; 98: 895-905. 5. powell sk, olson rj. incidence of retinal detachment after cataract surgery and neodymium: yag laser capsulotomy. j cataract surg. 1995; 21: 132-5. 6. williams ga, aaberg tm. technique of scleral buckling, in ryan st, editor. retina. vol.3. 3rd ed. st: louis: mosby. 1994: 2013-4. 7. girard p, karpouzas i. pseudophakic retinal detachment, anatomic and visual results. graefes arch clin exp ophthalmol. 1995; 233: 324-30. 8. greven cm, sanders rj, brown gc. pseudophakic retinal detachments. anatomic and visual results. ophthalmology. 1992; 99: 257-62. 9. isernhagen rd, wilkinson cp. visual acuity after the repair of pseudophakic retinal detachments involving the macula. retina. 1989; 9: 15-21. 10. yoshida a, ogasawara h, jalkh ae. retinal detachment after cataract surgery. surgical results. ophthalmology. 1992; 99: 460-5. 11. wu wc, chang cw, chen mt. management of pseudophakic retinal detachment with undetectable retinal breaks. ophthalmic surg lasers. 2002; 33: 314-8. 12. rahman n: primary vitrectomy for uncomplicated aphakic and pseudophakic retinal detachments. pak j ophthalmol. 2000; 16: 148-53. 13. lauritzen db, weiter jj. interventions in pseudophakic rhegmatogenous retinal detachment. semin ophthalmol. 2002; 109: 199-205. 14. bartz schmidt ku, kirchhof b, heiman k. primary vitrectomy for pseudophakic retinal detachment. br j ophthalmol. 1996; 80: 346-9. 15. brazitikos pd, stangos nt, tsinopoulos it. primary vitrectomy with perflouro-n-octane use in the treatment of pseudophakic retinal detachment with undetectable retinal breaks. retina. 1999; 19: 103-9. 16. retina society terminology committee. the classification of retinal detachment with proliferative vitreoretinopathy. ophthalmology. 1983; 90: 121-5. 17. gruterich m, clemente c, muller aj, et al. multifaktorielle analyse des therapieerfolges der pseudophakieablatio. ophthalmology. 2000; 97:609-14. 18. marmor, mf. mechanisms of normal retinal adhesion. in: ryan sj, editor. retina. vol. 3. 3rd ed. st: louis: mosby. 2001: 1849-69. 19. foulds ws. the vitreous in retinal detachment. trans ophthalmol soc uk. 1975; 95: 412-6. 20. marmor mf, yao xy. retinal adhesiveness in surgically enucleated human eyes. retina. 1994; 14: 181-6. 21. green rw, sebag j. vitreoretinal interface. in: ryan sj, editor. retina. vol. 3. 3rd ed. st: louis: mosby. 2001: 1882-1960. 22. kishi s, shimizu k. posterior precortical vitreous pocket. arch ophthalmol. 1986; 224: 124-30. 23. michels rg, green wr. ultrastructural studies of vitreo macular traction syndrome, am j ophthalmol. 1989; 107: 17785. 24. bradbury mj. pathogenetic mechanisms of retinal detachment. in: ryan sj, ed. retina. vol 3. 3rd ed. st: louis: mosby. 2001: 1987-93. microsoft word nazullah khan 138 original article to compare the recurrence rate of pterygium excision with bare-sclera, free conjunctival auto graft and amniotic membrane grafts nazullah khan, mushtaq ahmad, abdul baseer, naimatullah khan kundi pak j ophthalmol 2010, vol. 26 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nazullah khan ophthalmology department khyber teaching hospital, peshawar purpose: to compare the recurrence rate in pterygium excision with bare sclera, conjunctival auto graft & amniotic membrane grafts. material and methods: patients presenting to the outpatients clinic of ophthalmology department in khyber teaching hospital with pterygium were included in this study. total 118 patients were included in this study. these patients were divided into three groups, group-a with bare sclera technique, group-b conjunctival auto graft & group-c amniotic membrane graft. cases were randomly selected on the basis of inclusion and exclusion criteria and details were recorded on a pre-developed proforma. all patients were operated under sub conjunctival anesthesia, injection xylocaine with adrenaline 0.25 cc was given into the head of pterygium and 0.5 cc of the same injection was administered at the donor site. in bare sclera (group-a) the pterygia were excised, the abnormal tissues were cleared from the sclera & the remaining area including the healthy conjunctiva was left as such. in conjunctival auto graft (group-b), the bare area first measured with caliper. then the auto graft of the same size was fashioned from the superio-temporal region of the bulbar conjunctiva and sutured with 10/0 nylon to the surrounding conjunctiva. in-group c, after excising the pterygium, the bare area and the conjunctival defects were covered with stitch amniotic membrane grafts using 10/0 nylon suture. at the conclusion, antibiotic drops and ointment were instilled in the eye and the eye was patched for 24 hours. each patient was followed for a period of six months. the primary outcome was to measure pterygium recurrence. the recurrence is defined as the 2mm or more re-growth of the fibro vascular tissue over the cornea. results: total 118 patients were included in this study. out of the 118 cases, 74 (63%) were male & 44 (37%) were female. 30 patients were operated with bare sclera technique, 34 were with conjunctival auto graft & in 54 eyes amniotic membrane was grafted. 139 received for publication november 2009 …..……………………….. 11 i.e. 36.6% recurrence was noted in-group a, in-group b, 3 (8.8%) cases developed recurrence & four (7.40%) developed corneal recurrence in-group c. the ages of the patients ranged from 15-60 years. conclusion: it was concluded that free conjunctival auto graft & amniotic membrane graft, are better and safe techniques, for prevention of recurrence after pterygium surgery as compared to bare sclera method. absorbing excessive stem and progenitor cells may be one of the mechanisms of reducing the recurrence rate using amniotic membrane. terygium appears as a fleshy vascular mass that occurs in the inter palpebral fissure. the typical pterygium is triangular in shape and is made up of a cap, head and body. it is more frequently located nasally rather than temporally1. the cause of pterygium is not known but those who work outside in the sun and wind are more prone to develop pterygium probably from conjunctival irritation2 and is more common in tropical & subtropical region with a reported prevalence of 2 to 7 % worldwide3. it is more frequent in areas with more ultraviolet radiation,4 especially uvr-a and uvr-b (290-400nm) is considered the most dangerous 5, 6. the mainstay of treatment is surgical. various surgical procedures are used to treat pterygium. total excision of the lesion was practiced in the ancient times, which still constitutes one of the methods of treatment. the excision of a pterygium with bare sclera was widely practiced because it was believed to be safe and simple. however, with time it becomes apparent that the recurrence rate was unacceptably high ranging from 24% to 89%8. the recurrence rate is significant and recurrent pterygia are often worse than primary ones9. a recurrent pterygium can be associated with decreased visual acuity due to involvement of visual axis and/or irregular astigmatism, extra ocular motility restriction and symblepharon (scarring and adhesions between palpebral and bulbar conjunctiva) formation10. kenyon et al, first described a conjunctival auto graft in 1985. they reported a recurrence rate of 5.3% and infrequent and relatively minor complications. the primary disadvantage of this procedure is the prolonged operative time as compared to the bare sclera technique11. the first use of amniotic membrane transplanttation (amt) in ophthalmology was by de rotth in 1940 who reported partial success in the treatment of conjunctival epithelial defects after symblepharon12. as a natural basement membrane, amniotic membrane contains various matrix proteins which facilitate the adhesion, migration and differentiation of epithelial cells and prevent their apoptosis. promotion of conjunctival epithelial wound healing, suppression of fibroblasts and reduced extracellular matrix production are thought to be the major mechanisms by which amniotic membrane transplantation inhibits recurrence of pterygia13. many other methods were implemented with the aim of improving the success rate, among them transplantation of the head of the pterygium, conjunctival flaps, lamellar keratoplasty, mucous membrane grafts, chemotherapy by thiotepa, radiation therapy by radon bulbs, radium plaques, beta irradiation ablation with erbium yag laser14 and smoothening the corneal surface with excimer laser 15 and antimetabolite such as 5-flourourocil, mitomycin c16 has been tried. several of them succeeded in lowering the recurrence rates but did so at the price of sight-threatening complications from the tissue damage associated with the treatment17. in general the results of surgery, whatsoever method is applied are best in old patients with thin atrophic and stationary pterygia. recurrences are quite common in young patients and in patients with active inflamed and rapidly growing pterygia, even with surgery and adjunctive treatment. material and methods a total of 118 patients were operated for pterygium with bare sclera, conjunctival auto graft and amniotic membrane graft, in the department of ophthalmology khyber teaching hospital, peshawar. the total duration of study was from aug. 2006 to july 2007. diagnosis of pterygia was made by clinical examination. after informed consent, cases were included in the study and were divided randomly into 3 the groups. patients between age between 15 and 60 years wre included in the study. other inclusion criteria were pterygium on nasal side of 3mm or more in size. p 140 ptregia that interfered with vision occluding visual axis or inducing astigmatism, when it is cosmetically disfiguring) and exclusion criteria (glaucoma, ocular surface abnormalities, lid abnormalities, ocular or adnexal infections, age below 15 years and above 60 years). history was taken on a pre developed proforma in which special enquiry was made about the chief complaints, occupation, duration of growth, and any previous medical or surgical treatment. complete ocular and systemic examination was performed. the state of the growth was asked whether it was stationary, slow growing or rapidly growing. all the procedures performed by same surgeon with six months followed up of the cases. all the operations were performed under microscope using topical and local subconjunctival anesthesia. no significant intraoperative complications were noted. all patients were followed up post operatively at one month, three month’s and six month’s intervals. results one hundred and eighteen cases were included in the study, 74 (63 %) were male and 44 (37 %) were female (table-1). age ranged between 15 to 60 years. they were divided into three groups. in group-a, the patients with bare sclera were included. in this group 30 cases were operated, out of which recurrence was noted in11 (36.6%) patients. in group-b, patients with conjunctival auto graft were included. in this group thirty four cases were operated and 8.8% recurrence rate was noted in this group. in group-c, 54 eyes with amniotic membrane graft were included, and recurrence occurred only in four (7.4%) cases. the complications noted in bare sclera technique included scleral necrosis in 2 patients (6.6%), conjunctival cyst in 3 cases (10%), sub-tenon granuloma in 4 cases (13.3) and symplepharon in 2 cases (6.6%). complication after free conjunctival auto graft were graft edema in 2 cases (6.6%), graft retraction in 3 patients (10%) and sub-tenon granuloma, in 4 cases (13.3%). there was no major case of scleral perforation, scleral melt or endophthalmitis in patients with amniotic membrane graft. three patients had graft retraction before 15 days, one patient developed graft retraction on 2nd day for which re-grafting was done. one patient developed conjunctival cyst, for which he was operated on again. table i. total no of recurrences (n=54) gender no. of patients n(%) male 74 (63) female 44 (37) total 118 table 2: groups wise patients groups no. of patients recurrence rate n (%) group-a 30 11 (36.6) group-b 34 03 (8.80) group-c 54 02 (7.40) 63% 37% female male graph-1 : distribution of patients by gender discussion pterygium is a protective mechanism18. it grows on to the cornea because of a chronic dellen initiated by tear film inadequacy. pterygium excision is often considered a trivial procedure, but without any adjunctive therapy, the recurrence rate after surgery may be as high as 69% especially in hot, dry and sunny atmospher19. while the definitive management of a pterygium is surgical, the ideal adjunctive procedure is still to be determined. suture less applications with fibrin glue have been aimed at making the procedure easier and more comfortable for the patient. 141 we did this comparative study and the conclusion was that simple excision of pterygium was associated with very high recurrence as compared to that of conjunctival auto graft or amniotic membrane graft. in similar study prabhasawat20 first compared amniotic membrane graft (n=54) to a retrospective study using conjunctival auto graft (n=122) in both primary and recurrent pterygium. they noted that the recurrence rate is 10.9% using amniotic membrane graft, which is still higher than 2.6% of conjunctival graft. nevertheless, both results of amniotic membrane grafts and conjunctival auto grafts are significantly better than the primary closer (n=20), which resulted in 45% high recurrence rate for primary pterygium which is comparable to our study. subsequently, solomon21. reported that by incorporating a larger removal of subconjunctival fibrosis tissue and injection of long acting steroids, amniotic membrane grafts achieved a lower recurrence rate of 3.0%, compatible with 2.6% of conjunctival auto grafts published by prabhasawat. similarly lateefur-rehman et al22 during follow up period, showed that recurrence of pterygia was high 41.33% in the patients with bare sclera method as compared to recurrence 33.33% while using 5-florourocil antimetbolite. mohammad saleem et al23 also show high results of recurrence 30% in pterygium with simple excision, as compared to that with mitomycin c drop. ashok kumar narsani et al24 showed that there was 7.69% recurrences in conjunctival auto graft as compared to 16.13% recurrences with mitomycin c i.e. the graft yielded better results, in another study conducted in iran, asadollah katbaab, md; et al25 claims only 2% recurrence after pterygium excision with amniotic membrane graft. in a study by fallah et al,26 conjunctival limbal auto graft with amt appeared to be more effective than intraoperative mmc with amt for treatment of recurrent pterygia. in our study the most common recurrence was noted in young patients, old patients had a lower recurrence rate. no association was found between pterygium recurrence and pterygium size, and patient sex. in conclusion we found that adjunctive therapy reduced the rate of recurrence compared to bare sclera technique. author’s affiliation dr. nazullah khan registrar ophthalmology department khyber teaching hospital peshawar dr. mushtaq ahmad registrar ophthalmology department hayatabad medical complex peshawar dr. abdul baseer trainee medical officer eye “a” unit, kth peshawar prof. naimatullah khan kundi head, department of ophthalmology khyber teaching hospital peshawar reference 1. michael r, edward gj, holland. management of pterygium. in: krachmer jh, mannis mj, holland ej. cornea vol 3: surgery of the cornea and conjunciva. new yark: mosby. 1997; 1873-85. 2. saleem m, muhammad l, ziaul islam. pterygium and dry eye, a clinical study. j postgrad med inst 2004; 18: 558-62. 3. donnenfeld ed, perry hd, fromer s, et al. subconjuctival mitomycin c as adjunctive therapy before pterygium excision. ophthalmology. 2003; 110: 1012-26. 4. moran dj, hollows fc. pterygium and ultraviolet radiation: a positive correlation. br j ophthalmol. 1984; 68: 343-6. 5. taylor hr, west sk, rosenthal fs, et al. corneal changes associated with chronic uv irradiation. arch ophthalmol.1989; 107: 1481-4. 6. detorakis et, zafiropoulos a, arvanitis da, et al. detection of point mutations at codon of kl-ras in ophthalmic pterygia. eye. 2005; 19: 210-4. 7. keizer rj. pterygium excision with or without postoperative irradiation, a double-blind study.documenta ophthalmologica. 1982; 52: 309-15. 8. jaros pa, deluise vp. pingueculae and pterygia. surv ophthalmol. 1988; 33: 1-9. 9. walkow t, anders n, antoni hj, et al. 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excision using 193-nm excimer laser smoothing and topical mitomycin c. ger j ophthalmol. 1992; 1: 429–31. 16. saeed n, zafer-ul islam, ali n. traoperative use of mitomycin-c for prevention of post operative pterygium recurrence. j postgrad med inst.2002; 16: 103-7. 17. varssano d, michaeli-cohen a, loewenstein a. excision of pterygium and conjunctival auto graft. isr med assoc j. 2002; 4: 1097-100. 18. paton. david, selected transaction of vi national symposium on cornea, ahmedabad academy of ophthalmology.1984; 181-3. 19. tarr kh, constable ij. late complications of pterygium treatment. br j phthalmol. 1980; 64: 496-505. 20. prabhasawat p, barton k, burkett g, et al. comparison of conjuctival auto graft, amniotic memberane grafts and primary closure for pterygium excision ophthalmology. 1997; 104: 97485. 21. soloman a, pires rtf, tseng scg. amniotic membrane transplantation after extensive removal of primary and recurrent pterygia. ophthalmology. 2001; 108: 449-60. 22. rahman l, baig ma, islam q. prevention of pterygium recurrence by using intra-operative 5-fluorouracil, pakistan armed forces medical j. 2008; 1. 23. saleem m, khan sb, shah z, et al. managing pterygium by excision and low dose mitomycin-c eye drops. gomal journal of medical sciences (gjms). 2008; 6: 24. narsani ak, jatoi sm, gul s, et al. treatment of primary pterygium with conjunctival auto graft and mitomycin c. a comparative study journal of liaquat university of medical & health sciences (jlumhs)l hyderabad. 2008. 25. katbaab a, ardekani ha, khoshniyat h, et al. amniotic membrane transplantation for primary pterygium surgery journal 24 of ophthalmic and vision research (j ophthalmic vis res). 2008; 3: 23-7. 26. fallah mr, golabdar mr, amozadeh j, et al. transplantation of conjunctival limbal auto graft and amniotic membrane vs mitomycin c and amniotic membrane in the treatment of recurrent pterygium. eye 2008; 22: 420-4. gonioscopy as therapy for each type of glaucoma must be specific in order to be effective the site and cause of impeded flow of aqueous humour must be determined hence it is essential to perform gonioscopy in every examination for glaucoma.it is a mistaken assumption that on slit lamp examination if the anterior chamber is not shallow the glaucoma must be open-angle type prof. m lateef chaudhry editor in chief microsoft word shahid jamal siddiqui 171 original article pattern of central serous chorioretinopathy (cscr) on fundus fluorescein angiography shahid jamal siddiqui, syed imtiaz ali shah, muhammad afzal pechuho , safdar ali abbasi, fouzia fateh shaikh. pak j ophthalmol 2008, vol. 24 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: shahid jamal siddiqui associate professor of ophthalmology banglow # 05 type ii cmc staff colony larkana purpose: to study the pattern of central serous chorioretinopathy (cscr) on fundus fluorescein angiography (ffa). material and methods: the hospital based descriptive study of 30 patients was conducted at the department of ophthalmology chandka medical college and hospital larkana, from december 2003 to february 2008. the patients were selected from the retina clinic. after history and complete ocular examination the clinical diagnosis of cscr was established. the fundus photographs and fluorescein angiography was done in all the 30 patients. before injecting fluorescein, test dose was given and pupils were dilated with tropicamide 1% and phenylepherine 10%. injection fluorescein sodium 25% 3ml i.e 250 mg/ml was given intravenously and multiple photographs were taken by the digital fundus camera. the patterns of cscr on fundus fluorescein angiography were observed and notified. results: in this hospital based descriptive study of 30 patients of cscr 27 were male (90%) and 03 were female (10%). the patients between 20-55 years of age were presented, with a mean age of 35.4 years. 26 patients had unilateral and 04 with bilateral disease. number of eyes was 34. all patients presented with blurred vision, positive relative central scotoma and dome shaped elevation at the macula. the duration of visual disturbances on presentation was three days to three months. on fundus fluorescein angiography of 30 patients hyper172 received for publication may’ 2008 … ……………………… fluorescence with ink-blot appearance was seen in 23 eyes (67.64%) and smoke-stack appearance in 11 eyes (30.35%). conclusion: ink-blot pattern is more frequently seen in cscr on fundus fluorescein angiography. entral serous chorioretinopathy (cscr) is characterized by idiopathic serous detachment of the sensory retina1. it is an exudative macular disease that predominantly affects young to middle aged men. the characteristic neurosensory detachment on the posterior pole is caused by leakage of fluid seen at the level of retinal pigment epithelium2. several theories have explained the mechanism and pathogenesis of cscr. in all of these theories increased choroidal vascular permeability is supposed to be the reason for the serous detachment of the retinal pigment epithelium (rpe)1,3-5. the fundus fluorescein angiography (ffa) findings are very important in the diagnosis of cscr. in cscr, there is a breakdown of the outer blood retinal barrier which allows the passage of free fluorescein molecules into the subretinal space6. various patterns of dye leakage are seen the most common are smoke-stack and ink-blot5. the unusual forms are inverse smoke-stack, diffuse rpe leakage (ooze), rpe atrophic tracts1,7. the objective of this study was to identify and see the various patterns of cscr on ffa. material and methods the hospital based descriptive study of 30 patients was conducted at the department of ophthalmology chandka medical college and hospital larkana. the patients were selected from the retina clinic. after history and complete ocular examination the clinical diagnosis of cscr was established. the fundus photographs and fluorescein angiography was done in all the 30 patients. a test dose of fluorescein was given and pupils were dilated with topical 1% and phenylepherine 10%. injection fluorescein sodium 25% 3ml i.e 250 mg/ml was given intravenously and multiple photographs were taken by the digital fundus camera. the patterns of cscr on fundus fluorescein angiography were observed and recorded. results in this hospital based descriptive study of 30 patients of cscr 27 were male (90%) and 03 female (10%). the patients presented were between 20-55 years of age, with a median age of 35.4 years. twenty six (86.66%) patients had unilateral and 04 (13.33%) were with bilateral disease (table-1). number of eyes was 34. all patients presented with blurred vision, positive relative central scotoma and dome shaped elevation at the macula (figures 1-a, 2-a, 3a). the duration of visual disturbances on presentation was three days to three months. on fundus fluorescein angiography of 30 patients, hyper-fluorescence with ink-blot appearance was seen in 23 eyes (67.64%) (figure 1-b) and smoke-stack appearance in 11 eyes (30.35%) (table-2 and figures 2-b and 2-c). discussion fundus fluorescein angiography (ffa) plays a crucial role in the understanding of different disease processes affecting the eye. a good knowledge of the changes occurring in the fluorescein angiogram is important for correct diagnosis and management of eye disorders. table 1: patients data total number of patients 30 male 27 (90%) female 03 (10%) age (range) 20-55 years mean age 35.4 years c 173 unilateral 26 (86.66%) bilateral 04 (13.33%) table 2: patterns of cscr on ffa fluorescein pattern number of eyes (34) n(%) ink-blot 23 (67.64) smoke-stack 11(32.35) our study of 30 cases of rural sindh population demonstrates that cscr is more common in males (90%) than females (10%). the patients between 20 – 55 years of age (mean age 35.4 years) were presented cynthia and colleagues have reported mean age of 55 years (range 35 – 78 years) in their study8. fundus fluorescein angiography (ffa) in 23 eyes (67.64%) revealed ink-blot appearance and in 11 eyes (32.35%) smoke-stack appearance in our study of 34 eyes with cscr, which demonstrate that ink-blot appearance is more frequent than smoke-stack appearance. kanski6 has reported that smoke-stack appearance is more common than ink-blot, whereas other studies by baig, peykan and their colleagues have reported ink-blot appearance more commonly seen in cscr on ffa than smoke-stack appearance1,9. fig. 1-a: fundus photographs showing bilateral cscr. 174 fig. 1-b: fundus fluorescein angiogram shows ink-blot appearance in bilateral cscr. fig. 2-a: fundus photograph of left eye showing dome shaped elevation at the macula. fig. 2-b: fundus fluorescein angiogram of left eye showing smoke-stack appearance. fig. 3-a: fundus photograph of right eye showing dome shaped elevation at the macula. 175 fig. 3-b: fundus fluorescein angiogram of right eye showing smoke-stack appearance. author’s affiliation dr: shahid jamal siddiqui associate professor department of ophthalmology chandka medical college & hospital larkana sindh. prof: syed imtiaz ali shah professor & head department of ophthalmology chandka medical college & hospital larkana sindh. dr. muhammad afzal pechuho assistant professor department of ophthalmology chandka medical college & hospital larkana sindh. dr. safdar ali abbasi department of ophthalmology chandka medical college & hospital larkana sindh. dr. fouzia fateh shaikh department of ophthalmology chandka medical college & hospital larkana sindh. reference 1. peykan t, turgut y, burak t, et al. unusual fundus fluorescein angiography findings in central serous chorioretinopathy. j of retina – vitreous. 2007; 15: 223–5. 2. michael t, elzbeita p, karl k, et al. topical fundus pulsation measurement in patients with active central serous chorioretinopathy. arch ophthalmol. 2003; 121: 975–8. 3. guyer dr, yannuzzi la, slakter js, et al. digital indocyanine green video angiography of central serous chorioretinopathy. arch ophthalmol. 1994; 112: 1057–62. 4. hayashi k, hasegava y, tokoro t. indocyanine green angiography of central serous chorioretinopathy. i nt ophthalmol. 1986; 9: 37-41. 5. haimovici r, rumelt s, melby j. endocrine abnormalities in patients with central serous chorioretinopathy. ophthalmology. 2003; 110: 698. 6. kanski jj: acquired macular disorders. in clinical ophthalmology 6th ed; butterworth hienemann. 2007; 468. 7. von ruckmann a, fitzke frederick w, fan joseph, et al. abnormalities of fundus autofluorescence in central serous retinopathy. am j ophthalmol 2002; 133: 780-6. 8. cynthia acr, lawrence a, yannuzzi et al: corticosteroids and central serous chorioretinopathy. ophthalmology 2002: 109: 1834. 9. baig msa, zafar m, rab m, ahmed j. role of fundus fluorescein angiography in the diagnosis of central serous chorioretinopathy. pak j surg. 2004; 20: 31-4. microsoft word uzma fasih 145 original article evaluation of reliability of visual field examination in glaucoma patients uzma fasih, arshad shaikh, nisar shaikh, m. s fehmi, asad raza jafri, atiya rahman pak j ophthalmol 2009, vol. 25 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………… correspondence to: uzma fasih assistant professor eye dept.karachi medical & dental college abbasi shaheed hospital karachi. received for publication october 2008 …..……………………… purpose: the purpose of our study was to evaluate the reliability of visual field examination in glaucoma patients undergoing perimetery for the first time on octopus 300 series perimeter. materials and methods: the study was conducted in the department of ophthalmology, abbasi shaheed hospital from january 2007-june 2008. patients were randomly selected from the glaucoma clinic who went for routine perimetery for the first time. patients were examined in detail, diagnosis was established and were sent for field examination to assess the extent of damage by glaucoma .perimetery was done on octopus 301 series perimeter after setting all the parameters and under constant supervision. results: a total of 117 patients were examined from january 2007june 2008. a male preponderance was seen and majority of the patients belonged to 60-70 years age group making upto 37.4 %followed by 40-50 years age group i.e 25.6%. maximum number of patients have percentage of false positives and false negatives between the range of 0-5 % which shows that a large number of patients(62% patients in false positives and 79% patients in false negatives in their right eyes and 68.4% patients in false positives and 74.6% patients in false negatives in their left eyes) had a reliable field96(82%) patients had reliability factor in acceptable normal range their right eyes and 104(89%) patients had reliability factor in acceptable normal range in left eyes. it shows that majority of patients had a reliable field test. it is also obvious that fields of left eyes were more reliable as compared to right eyes. conclusion: it was concluded that computerized perimetery could play an important role to diagnose and assess the progression of glaucoma provided its reliability lies within the indices set by the manufacturers of the perimeter. to make this test reliable one needs full cooperation and comfortable seating of the patient, better understanding of the test and accurate setting of the parameters of the machine so that there is less chance of false positive and false negative catch trials and reliability factor remains within normal limits. erimetery the evaluation of visual field ,is an important diagnostic test in ophthalmology, not only for managing glaucoma using static perimetery in the central 30 degree visual field but also for diagnosing and monitoring the progression of many other eye diseases. althogh the visual field examination is used in conjunction with other clinical findings such as intraocular pressure, and the assessment of structural changes at the optic nerve head and retina, perimetery remains indispensable test documenting visual function. after all; patients are not concerned about pressure or appearance of their discs but they are worried about maintaining vision1. the reliability (accuracy) of any given visual field exam is dependent upon the manner in which the patient responds to the test. if the patient is alert, understands what is expected of him, and follows directions, the chances of an accurate measure of his visual field are good. p 146 automatic perimetery is merely a computer assisted examination and not a fully automatic test because the results depend upon the patient’s cooperation and accuracy of answers to the question of whether or not a light stimulus was perceived. therefore automatic perimetery remains a subjective test and for this reason it is important to always realize that the visual field data is only as reliable as the ability of the patient to perform the examination1. visual field testing accuracy is important, especially when following glaucoma patients. the ophthalmologist has three primary sources of information that aid him in the diagnosis and treatment of glaucoma: the intraocular pressure reading, the appearance of the optic nerve head, and the results of visual field testing. the intraocular pressure is useful in gauging the effectiveness of therapy, but it does not tell much about the progress of the disease. thus, the ophthalmologist relies heavily on the appearance of the optic nerve head and the results of visual field testing to tell him if the patient's vision is getting worse or not. an accurate visual field test is very important tool in glaucoma assessment. automated perimeters have several methods of keeping track of the accuracy of the examination. these indicators can tell the operator if the test is going smoothly, or if adjustments need to be made. the indicators on the printout help the ophthalmologist to decide if the test was a valid measurement. fixation losses in order to get an accurate measurement of the sensitivity of any given portion of the peripheral retina, using an automated perimeter, the eye must remain stationary while it is to stare at. if the patient maintains fixation (looks at the target all the time), then the eye does not move. high fixation losses may indicate poor fixation. for this reason octopus 301 series perimeter used in our study is equipped with electronic eye fixation control system .while the eye monitor shows whether or not patient is fixating, mistakes are not correctable. the electronic control system interrupts the examination and signals examiner that patient is not fixating or is closing the eye. the system also senses when the patient blinks during a stimulus presentation and repeats the same question later during the test. basically the eye fixation control makes sure that only those stimuli are validated when the eye is well fixated and not blinking1. false positive catch trials the number of false positive answers (positive response when no stimulus was presented) is expressed as a percentage of total positive trials. in a situation where patient shows 20% false positive answers the other questions are also probably answered with the same rate of error. care should be exercised with the rate of false responses higher than 10-15%. this problem may appear with persons who are too eager to do well or patients who are too nervous or have not been instructed properly1. false negative catch trials false negative answers (negative response after presentation of brightest possible stimulus in an area where patient showed sensitivity on prior questions) are also expressed in percentage of total questions asked. patients with higher than 10-15% rate may need closer surveillance because they are no longer concentrating or are not in good condition1. reliability factor the reliability factor rf indicates the patients cooperation this value is calculated from positive and negative catch trial questions. it is expressed as percentage of the sum of false positive and false negative answers divided by total number of catch trial questions. it is the rate of incorrectly answered catch trials expressed as percent. if rf is 10% then rf value exceeds 10% results must be cautiously evaluated2. the rf value normally should not be higher than 15%.a grade of 0 is excellent1. pupil diameter the amount of light entering the pupil is controlled by the diameter of pupil .for example a change from 7 mm to 5 mm will reduce the amount of light entering the eye to half. as a rule it is understood that with 3mm or wider pupil diameters the results will be within normality .below this value a uniform depression of visual field in order of 1-3 db and as much as 3-4 db for a 1.5 mm pupil. this effect can be much greater in cataract patients. because of this it is extremely important to note the size of pupil for proper interpretation of fields and to compare it with previous results1. learning effect in their first test patients often hesitate to press the button when a faint stimulus near the threshold is 147 presented and in the follow up examination the sensitivity values tend to be higher. due to this learning effect a second examination is recommended in borderline cases3. fatigue effects due to long test duration the fatigue effect is usually seen in lengthy threshold examination which can take as long as 10-20 minutes. the fatigue effect consists of two components, the patient’s physical fatigue and the fatigue caused by increased strain upon visual system during long examination. when patient becomes tired his/her attention level will decrease and answers will become less reliable. to help alleviate this problem octopus perimeter has a staging technique system that is the total field examination is divided into 4 stages and after completing 1 stage we can give a pause. the data of this stage is saved and the examination is not disturbed then we can proceed to the next stage1. keeping these criteria in mind we conducted a study at eye department abbasi shaheed hospital. our study included 117 patients who were registerd at the glaucoma clinic and after routine examination were sent for perimetery for the first time. purpose of study the purpose of our study was to evaluate the reliability of visual field examination in glaucoma patients undergoing perimetery for the first time on octopus 300 series perimeter. materials and methods the patients were randomly selected from the glaucoma clinic when they were registered and were sent for routine perimetric examination for the first time. before sending for field test these patients were thoroughly examined. the examination included detailed slit lamp examination, measurement of intraocular pressure by applanation tonometery, detailed fundoscopy to access the status of optic disc and gonioscopy where required.the type of glaucoma was diagnosed and patients were sent for routine perimetry. the inclusion criteria were new referral, no previous threshold visual field tests, absence of hearing or cognitive impairment, understanding language, and best corrected visual acuity of 6/36 or better in both eyes. the exclusion criteria were patients who had alraedy undergone the examination once, patients with hearing problems and patients with dense cataracts and corneal opacities. the perimetry was carried out on octopus 301 series perimeter using standard glaucoma g1 dynamic white on white programme, after instructing the patient properly patient data regarding name, id, gender, visual acuity and intraocular pressure was fed in the computerized perimeter. the patients were seated comfortably and their spectacle number placed in the given socket. the pupil size was noted. the patients were supervised throughout the test by well trained examiners and fixation was maintained by the electronic eye fixation control system in the perimeter through out the test as the reliability of visual fields depends largely upon quality of eye fixation. test duration, positive catch trials, negative catch trial s and reliability factor were noted. the reliability of the results was assessed after a thorough review of reliability indices. results a total of 117 patients were examined from january 2007june 2008.the results are tabulated as follows: a male preponderance was seen and majority of the patients table 1 belonged to 60-70 years age group making up to 37.4 %followed by 40-50 years age group i.e 25.6% table 2.the size of pupil noted in almost all the patients was in range of 3-7 mm which is a reliable range for normality. almost 90% of the patients completed the test in 69 minutes 8 % completed in 10-15 minutes and only2% took time more than 15 minutes. the number of false positive answers (positive response when no stimulus was presented) is expressed as a percentage of total positive trials false negative answers (negative response after presentation of brightest possible stimulus in an area where patient showed sensitivity on prior questions) are also expressed in percentage of total questions asked. false positives and negatives were calculated in both eyes and are tabulated as follows table 3. it is quite obvious from the above tables that maximum number of patients have percentage of false positive and false negatives between the range of 05% which shows that a large number of patients (62% patients in false positives and 79% patients in false negatives in their right eyes and 68.4% patients in false positives and 74.6% patients in false negatives in their 148 left eyes) had a reliable field. the reliable range of rate of false positives and false negatives in octopus 301 series perimeter, the machine we used is 10-15%. table 1: gender distribution gender no of patient’s n (%) male 77 (65.8) female 40 (34.2) table 2: age distribution age no of patient’s n (%) 10-20 3 (2.7) 20-30 6 (5.1) 30-40 9 (7.8) 40-50 30 (25.6) 50-60 18 (15.4) 60-70 44 (37.4) 70-80 7 (6) table 3: false positives in right eye & left eye range of false positives % in right eye no of patient’s n (%) range of false positives % in left eye no of patient’s n (%) 0-5 72 (62) 0-5 80 (68.4) 5-10 0 (0) 5-10 1 (0.8) 10-15 28(2.4) 10-15 21(17.9) 15-20 1(0.8) 15-20 2 (18) 20 and above 16 (13.2 20 and above 13 (11.1) reliability factor table 4 rf indicates patients cooperation and is actually the percentage of sum of false positive and false negative answers divided by total number of catch trial questions .according to the settings of the perimeter we used value of rf should not be higher than 15%. a grade of 0 is excellent. it is evident from the table 4 that 96(82%) patients had reliability factor in acceptable normal range their right eyes and 104(89%) patients had reliability factor in acceptable normal range in left eyes. it shows that majority of patients had a reliable field test. it is also obvious that fields of left eyes were more reliable as compared to right eyes. table 4: reliability factor reliability factor no of patient’s rt. eye n (%) no of patient’s lt. eye n (%) 0-5 57 (48.8) 67 (57.3) 5-10 29 (24.8) 28 (24) 10-15 10 (8.5) 9 (7.7) 15-20 6 (5.1) 5 (4.3) 20 and above 15 (12.8) 8 (6.75) discussion perimetery; the evaluation of the visual field, is an important diagnostic test particularly in glaucoma, but also for diagnosing and monitoring the progression of many other eye diseases the computer supported static perimetery was introduced for the first time by fankhauser and it proved to be more practical as compared to the traditional manual goldman method4. but automatic perimetry remains a subjective test where the results depend upon patient’s collaboration and accuracy of the answers. as it serves as an essential tool in diagnosis and monitoring of progression of glaucoma so it should be as reliable as possible. we conducted a study at eye department abbasi shaheed hospital from january 2007–june 2008 to including 117 patients to evaluate the reliability of visual fields of the glaucoma patients who underwent perimetry for the first time. a male preponderance was seen and majority of the patients belonged to 60-70 years age group making up to 37.4%followed by 40-50 years age group i.e 25.6%. the size of pupil noted in almost all the patients was in range of 3-7 mm which is a reliable range for normality. it was observed that maximum number of patients have percentage of false positives and false negatives between the range of 0-5 % which shows that a large number of patients (62% patients in false positives and 79% patients in false negatives in their right eyes and 68.4% patients in false positives and 74.6% patients in false negatives in their left eyes) had a reliable field. 149 the reliable range of rate of false positives and false negatives in octopus 301 series perimeter, the machine we used is 10-15%. according to the settings of the perimeter we used value of rf should not be higher than 15%. a grade of 0 is excellent. it was seen that 96(82%) patients had reliability factor in acceptable normal range their right eyes and 104(89%) patients had reliability factor in acceptable normal range in left eyes. it shows that majority of patients had a reliable field test. it is also obvious that fields of left eyes were more reliable as compared to right eyes. the validity of information obtained from visual field tests depends upon the ability of the patient. how ever standardized reliability criteria have been adopted at 7th visual field symposium at amsterdam i.e fixation loss rate less than 20% false positive response rate less than 33% and false negative rate less than33% of test catch trials5. a study was conducted at dana centre for preventive ophthalmology, wilmer institute johns hopkins hospital, baltimore to evaluate the reliability indices of automted perimetric tests. they observed that 45% of the glaucomatous patients had unreliable fields with the use of manufacturer’s reliability criteria. the greater rejection rate was due to higher rate of false negative responses. while in our study it was observed that 18% patients had an unreliable field in their right eyes and 11.1% patients had an unreliable field in their left eyes. the rate of unreliable false positives (14% in right eye and 11% in left eye) and unreliable false negative responses (13 % for right eye and 13% for the left eye) seems to be equal6. a number of studies have shown that 29-45% of full threshold sap test results using the standardized reliability indices with most of the unreliable fields attributable to fixation losses6-10. so it is obvious that reliability of visual field depends largely on quality of eye fixation. for this reason the octopus perimeter which we used in our study is equipped with an electronic eye fixation control system. this system interrupts the examination and signals the examiner to correct the situation when the patient is not fixating. this system also senses when the patient blinks during a stimulus presentation and repeats the same question later during the test .basically the eye fixation control makes sure that only those stimuli are validated when the eye is well fixated and not blinking. katz et al found that 19% of normals, 28% of ocular hypertensives, and 37% of glaucoma patients were unreliable on their first c30–2 full threshold field11. it is also possible that test duration may influence the reliability and in particular may influence reliability in glaucomatous patients12-14. but fortunately today by using a faster strategy testing time can be reduced to 6-8 minutes with dynamic strategy or even as less to two minutes with top (tendency oriented perimetery) for full threshold data. even with normal strategy the test time can be significantly reduced to 6-9 minutes in cases where the field appears either well within normal limits or shows severe loss1. in our study almost 90% of the patients completed the test in 6-9 minutes. it is thought that continuous monitoring during the test may have a positive effect on reliability of field tests but studies of contineous patient monitoring show that it has neither any positive effect in individual reliability indices nor a positive group effect15-16. the octopus 301 perimeter we used does not need a dark room so the perimeterist can attend to other tasks and be still there to supervise the test without having any significant effect on reliability of the test. another important factor that may effect the reliability of the test is the patient instruction. a well instructed patient may perform well and may have a more reliable test as compared to a patient who does not have a proper understanding of the procedure. so it extremely important to spend sometime for careful and adequate patient instructions to have a reliable test result17. the benefits of careful patient instruction by technicians performing visual field tests has been repeatedly and frequently advocated. the constraints of time and resources, however, limit the extent and quality of information delivered to patients during routine visual field testing. the incorporation of a video guiding and reassuring the patient on taking the visual field test is an effective way of using available clinic time. a reduction in the number of patients requiring attendance for a “repeat visual field” can reduce demand on this frequently used service18. conclusions and suggestions how to avoid artifacts and improve field reliability because the complete perimetric examination is a rather elaborate procedure it is important to make sure 150 that time invested is well spent .therefore it pays to the maximum care to obtain reliable results by strictly following certain rules to avoid common pitfalls. • the examiner should note that patient is a good and active collaborator and had no difficulty in following the examination. • enter the patient data carefully and explain the procedure to the patient clearly. • inform the patient that not all the stimuli are visible and he should press the button only when the stimulus is visible. • explain the importance of making an effort to stay attentive. • tell the patient not to be concerned about making a mistake • .check the patient’s refraction and select corresponding thin rim lenses to be inserted in the given socket. note the correct position of cylinder axis. • moderate myopic patients who leave their contact lenses must inspect them before the test as dirty contact lenses result in artifacts. • make sure the patient’s eye to be tested is wide open to avoid artifacts. • a prominent nose, heavy brow or long eyelashes can also cause artifacts leading to misinterpretation of visual field. if such problem is faced turning or tilting patient’s head is recommended without losing fixation. • the occluder should be applied in such a way that patient feels comfortable. ask the patient to blink normally. • position the patient with the eye close to the trial lens to avoid artifacts as ring scotomas. • it is recommended that fixation mark be adjusted to dimmest light and is still visible to the patient. • make sure patient has no difficulty in pressing the button. • stay nearby during the procedure and inform the patient often about the progression of the test to encourage him to answer the questions properly. in the end we recommend a machine with such electronic devices which can sense the fixation losses themselves and help to rectify it to improve the reliability of the test. in addition these machines should be advanced enough to reduce the subjectivity of the test and improve the reliability. author’s affiliation dr. uzma fasih assistant professor eye dept.karachi medical & dental college abbasi shaheed hospital karachi dr.arshad shaikh professor & head of eye department eye dept.karachi medical & dental college abbasi shaheed hospital karachi dr. nisar shaikh assistant professor eye dept.karachi medical & dental college abbasi shaheed hospital karachi dr. m.s.fehmi associate professor eye dept.karachi medical & dental college abbasi shaheed hospital karachi dr. asad raza jafri senior registrar eye dept.karachi medical & dental college abbasi shaheed hospital karachi reference 1. walbert, ffranz, b hans, f josef. in automated perimetery visual field digest 5th edition. 2004; 3-103. 2. kaiser hj, flammer j. in visual field atlas, university eye clinic basal. 1992; 28. 3. marra g, flammer j. the learning and fatigue effect in automated perimetry. greaf’s arch clin exp ophthalmol. 1991; 229: 501-4. 4. fankhauser f, koch p, roulier a. on automation of perimetery. graef’s arch clin exp ophthalmol. 1972; 126-50. 5. heijl a, lindgren g, olsson j. reliability parameters in computerized perimetery. seventh visual field symposium, amsterdam. 1986. 6. katz j, sommer a. reliability indeses of automated perimetric tests. arch ophthalmol. 1988; 106: 1252-4. 7. bickler-bluth m, trick gl, kolker ae, et al. assessing the utility of reliability indices for automated visual fields. testing ocular hypertensives. ophthalmology. 1989; 96: 616–9. 8. nelson-quigg j, twelker jd, johnson ca. response properties of normal observers and patients during automated perimetry. arch ophthalmol. 1989; 107: 1612–5. 9. johnson ca, nelson-quigg m. a prospective three-year study of response properties of normal subjects and patients during automated perimetry. ophthalmology. 1993; 100: 269–74. 151 10. sanabria o, feuer wj, anderson dr. pseudo-loss of fixation in automated perimetry. ophthalmology. 1991; 98: 76–8. 11. katz j, sommer a, witt k. reliability of visual field results over repeated testing. ophthalmology. 1991; 98: 70–5. 12. heijl a, drance sm. changes in differential threshold in patients with glaucoma during prolonged perimetry. br j ophthalmol. 1983; 67: 512–6. 13. katz j, sommer a. asymmetry and variation in the normal hill of vision. arch ophthalmol. 1986; 104: 65–8. 14. hudson c, wild jm, o’neill ec. fatigue effects during a single session of automated static threshold perimetry. invest ophthalmol vis sci. 1994; 35: 268–8. 15. johnson ln, aminlari a, sassani jw. effect of intermittent versus continuous patient monitoring on reliability indices during automated perimetry. ophthalmology. 1993; 100: 76-84. 16. van coevorden re, mills rp, chen yy, et al. continuous visual field test supervision may not always be necessary. ophthalmology. 1999; 106: 178–81. 17. kutzko ke, brito cf, wall m. effect of instructions on conventional automated perimetry. invest ophthalmol vis sci. 2000; 41: 2006–13. 18. sherafat h, spry pdg, waldock a, et al. diamond jp effect of patient training video on visual field reliability.br j ophthalmol. 2003; 87: 153-6. microsoft word azizur rehman corrected 73 original article visual outcome and complications in ab-externo scleral fixation iol in aphakia azizur rahman, israr ahmed bhutto, sadia bukhari, mazharul hassan, muhammad nasir bhatti pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: azizur rahman isra postgraduate institute of ophthalmology, al-ibrahim eye hospital old thaana, malir, karachi submission of paper january’ 2011 acceptance for publication may’ 2011 …..……………………….. purpose: to assess the visual outcome and complications in patients after ab-externo scleral fixation of intraocular lens. materials and methods. this quasi experimental study was conducted at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi; from may 2006 to april 2007. study included total 30 eyes of 30 patients fulfilling criteria. all cases were worked up according to the protocol. all patients underwent ab-externo scleral fixation of iol. patients were followed up at 1st day, 1st week, 1st month, 2nd month and 3rd month. complete eye examination including best-corrected visual acuity and complications were noted on each visit. results: best corrected visual acuity improved in 29 (96.7%) patients while 26 (86.7%) patients showed bcva 6/12 or better. the most common intraoperative and postoperative complications observed were vitreous hemorrhage and astigmatism respectively. conclusion: ab-externo scleral fixation of an iol was found to be safe and showed favourable postoperative results. ntraocular lens (iol) implantation to correct the aphakia offers superior visual rehabilitation in comparison to aphakic spectacles or contact lens. in the absence of capsular support; anterior chamber lenses, iris fixated lenses and scleral fixated intraocular lenses may be considered. 1,2 placement of iol in the posterior chamber rather than anterior or iris fixated lenses reduces the risk of various complications, like keratopathy, damage to anterior chamber angle structure, pupillary block glaucoma, hyphema, uveitis, iris chafing, dislocation and pseudophakodonesis. 1,4 additionally, positioning lens closer to the rotational center of the eye, just anterior to the vitreous face, may reduce the centrifugal forces on the lens and stabilize the ocular contents, thereby decreasing the probability of complications such as iritis, cystoids macular edema (cme) and retinal detachment. 3,5 another advantage of positioning the lens closer to the nodal point and center of the eyes is the superior optical properties of the lens in this position. 3,6 there are two surgical techniques, namely ab-interno (inside out) and ab-externo (outside in). the abinterno technique involves the passage of needle from the inside of the eye to the outside through the sclera. 3,4,7,8 the ab-externo technique involves the passage of a needle from the outside of the eye to the inside through the sclera3. in the ab-externo method; scleral fixation of iol exactly in the ciliary sulcus can be achieved4,9. with this method, the surgeon’s view is never obscured. all the manipulation occurs in the iris plane. the surgeon can thus decrease the risk of vitreous hemorrhage. retinal detachment and lens malposition by avoiding the potential inaccuracies of suture placement those are inherent to the ab-interno technique3,10-13. material and method the study included 30 eyes of 30 consecutive patients who underwent ab-externo scleral fixation of iol during may 2006 to april 2007 at isra postgraduate i 74 institute of ophthalmology, al-ibrahim eye hospital, karachi. patients were selected from the general opd and cataract clinic of al-ibrahim eye hospital. the patients were 05-60 years old. those patients with visually significant ocular pathologies involving angle structure, cornea, retina, macular and optic nerve were excluded. written informed consent was taken prior to procedure. a detailed history of each patient was taken about any major illness, in general, and other ophthalmic problems in particular. detailed ophthalmic examination was carried out. best corrected visual acuity was checked using snellen’s notation. all patients underwent ab-externo scleral fixation of iol. surgical procedure after preparing the patient for surgery a conjunctival peritomy was created superiorly from 30’clock to 90’clock position. then, at the 3 and 90’clock positions, a partial-thickness limbal-based scleral flap that is 3mm high and 2mm wide. a 7 mm corneal scleral wound was made, and a complete anterior vitrectomy was performed. anterior chamber and retro-pupillary space was filled with viscoelastic. a straight needle carrying a 10-0 polypropylene suture was placed through the 09 o’clock scleral bed parallel to the iris and 0.8 mm to 2 mm posterior to the posterior surgical limbus. the needle tip was passed through the sulcus and behind the iris until it was visualized behind the pupil. in a similar manner, a 28-gauge needle was inserted through the 3 o’clock scleral bed. the barrel of the 28-gauge needle was inserted into the eye and the syringe was withdrawn from the eye (the syringe carried with it the straight needle and suture). a loop of this suture was with drawn through the corneal scleral wound. the loop of suture was cut, and securely tied one end to the superior haptic and the other to the inferior haptic. the lens was inserted into the sulcus, and rotated into position while removing slack from the attached sutures. second 10-0 polypropylene sutures were used on a half-circle needle to take a short bite in the 3 o’clock scleral bed just anterior to the first suture’s exit. the long end of the second polypropylene suture was tied to the hybrid suture; in a square knot with four throws. the same steps were followed in the 09 o’clock scleral bed. scleral flaps were closed, and the conjunctiva reapproximated. all patients were followed after one week and monthly for three months after the surgical procedure during each visit, best corrected visual acuity (bcva) was checked along with anterior segment examination using slit lamp. these findings were noted on proforma and analyzed subsequently. statistical analysis all calculation were done by spss version 17.0 frequencies percentages were calculated for qualitative variables like, gender, complications, visual outcome for pre and postoperative. me–nemar test was used to compare the difference between pre-operative best corrected visual outcome (bcva) and postoperative (bcva) with level of significance 0.05. results a total of 30 aphakic patients without capsular support were included in this study. average age of the patients was 34.8 years with (± sd = ±22.3 years) and rang = 660 years. out of 30 patients, 12 (40%) patients were age 10 34 years, 9 (30%) patients were between ages 35 – 59 years, (30%) patients were < 10 years and 2 (6.7%) patients had age > 59 years. there were 20 (67%) male and 10 (33%) female, (male: female = 1: 0.5) age and sex distribution presented in (fig. 1). out of 30 patients, 19 (63%) patients have history of surgery and 11 (37%) patients having the history of surgical trauma. post-operative visual acuity (va) improved significantly (p-value < 0.00001) as compared to the pre-operative (table 1). improvement in va was seen in 29 (96.7%) patients (fig. 2). best corrected visual acuity presented in (table 2). improvement was also seen in post-operative bcva, 6/6 was observed in 1 (3.3%) patient, 6/9 was observed in 14 (46.7%) patients, 6/12 was observed in 11 (36.7%) patients while 6/18 was observed in 3 (10%) patients and only 1 (3.3%) had bcva 6/60. mean ± sd iop was 13.7 ± 2.2 pre-operative and mean ± sd iop was 14.5 ± 1.8 post-operative. mean difference of iop was insignificant pre and post operatively (p-value = 0.086) (table 3). astigmatism was most common post-operative complication, seen in 7 (23.3%) patients, followed by uveitis in 5 (16.7%) patients, cystoid macular edema in 3 (10%) patients, hyphema in 2 (6.7%) patients, suture erosion in 2 (6.7%) patients and iol decentration was seen in 1 (3.3%) patients (table 4). 75 table 1: pre and post operative uncorrected visual acuity n = 30 visual acuity pre-operative n (%) post-operative n (%) p-value** 6/6 6/18 0 29 (96.7) < 0.00001 1/60 -5/60 18 (60) 0 ≥ 6/60 12 (40) 1 (3.3) *after three months **by sign test table 2: pre and post operative best corrected visual acuity (bcva) n = 30 bcva pre-operative n (%) post-operative n (%) 6/6 0 1 (3.3) 6/9 2 (6.7) 14 (46.7) 6/12 12 (40) 11 (36.7) 6/18 16 (53.3) 3 (10) 6/60 0 1 (3.3) bcva = best corrected visual acuity table 3: comparison of intraocular pressure n = 30 iop mean± sd p-value* pre-operative 13.7± 2.2 0.086 postoperative 14.5± 1.8 *paired t-test table 4: post operative complications n = 30 complications no. of patients n (%) astigmatism 7 (23.3) uveitis 5 (16.7) cystoid macular edema 3 (10) hyphema 2 (6.7) suture erosion 2 (6.7) iol decentration 1 (3.3) 2 5 9 3 8 1 1 1 0 1 2 3 4 5 6 7 8 9 10 < 10 10 34 35 59 > 59 male female fig. 1: distribution of age according to gender n = 30 29 (96.7%) 1 (3.3%) 0 5 10 15 20 25 30 35 40 improvement decrease fig. 2: post-operative visual outcome n = 30 3 (10) 1 (3.3) 0 2 4 vitreous hemorrhage hyphema fig. 3: intra-operative complications n = 30 in intra operative complications, vitreous hemorrhage was seen in 3 (10%) patients and hyphema in 1 (3.3%) patients (fig. 3). discussion optical rehabilitation of patient’s with monocular aphakic presents a therapeutic challenge when the n um be r of p at ie nt s age (years) n um be r of p at ie nt s n um be r of p at ie nt s (% ) 76 patient is unable to tolerate contact lenses for reduction of aniseikonia associated with aphakic glasses. variable options available include, epikeratophakia, anterior chamber iol implant, iris fixated intraocular lens and scleral fixated posterior chamber iol implant. among them scleral fixated pc iol implant can provide minimum magnification of image as compared to other options. in this study, 30 eyes of 30 patients were included. the gender distribution (67% males against 33% females) shows preponderance. the reason of this may be our rural social system where problems of female members of the family are often over looked. the mobilization of women to tertiary care units is also relatively difficult. in this study, the post-operative best corrected visual acuity of 6/12 or better was achieved in 26 (86.7%) patients who underwent ab-externo scleral fixation of iol. this is comparable with lee and yuen14 who reported best corrected visual acuity of 6/12 or better in 19 (76%) out of 25 cases. ghanem and colleagues15 reported postoperative bcva of 6/9 or better in 10 (71.43%) out of 14 eyes undergoing scleral fixation of iol. similarly, ozdek and co-workers16 reported the improvement of postoperative of bcva 6/12 or better in 14 eyes (93.3%) undergoing scleral fixation of iol. in this study, the most common post-operative complication was astigmatism in 7 eyes (23.3%). minimum astigmatism was 2.00 dc and maximum was 3.50 dc. mean astigmatism was 2.42 dc in this study. the cause of astigmatism was large corneal incision or tight sutures and iol decentration. ghanem and colleagues16 also reported astigmatism as most frequently occurring complication in 3 eyes (21.4%). similarly, sasahara and kiryu17 reported astigmatism in 12 eyes (13%). due to iris manipulation while doing scleral fixation of iol, we noticed anterior uveitis in 5 eyes (16.7%) which is comparable with the results of kwong et al and kanigowska k18. three eyes (10%) had postoperative bcva of less than 6/18 the reason of that was the development of cystoid macular edema which usually occurs due to vitreous manipulation during surgery. there were certain limitations of this study. this study does not have an epidemiological value as incidence and prevalence of aphakic with inadequate capsular support cannot be ascertained. this is because the sampling technique was non probability convenience. due to the unavailability of foldable scleral fixating iol and endoscope, we did not use them in this study. the positive findings of this study are that the results are comparable to other studies done in different regions, proving the efficiency of procedure. the lack of serious complication makes it an effective alternate to other methods of correct in the aphakic with inadequate capsular support. the negative findings of this study are that the outcome could be improved further by taking care of certain measures like using foldable iol instead of rigid pmma (polymethylmethacrylate) iol as the former can be inserted by giving small incision as compared to later one. this will ultimately reduce the postoperative astigmatism. similarly to insert the iol without tilting and preventing its decentration, the haptics should be placed precisely into the ciliary sulcus that can be accomplished by using an endoscope. however learning from mistakes assures evolution and improvement. conclusion in conclusion our results suggest that ab-externo scleral fixation of an iol was found to be safe and showed a favorable postoperative visual outcome in aphakic eyes. author’s affiliation dr azizur rahman isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr. israr ahmed bhutto isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr. sadia bukhari isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr. mazharul hassan isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi dr. muhammad nasir bhatti isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir, karachi 77 reference 1. young al, lenng-gys, cheng-ll, et al. a modified technique of scleral fixated intra ocular lenses for aphakic correction. nature publishing group eye. 2005; 19. 19-22. 2. teichmann kd. scleral fixation of intra ocular lenses. saudi j ophthalmol. 2003; 17: 157-73. 3. azar dt, clamen l, flakier p. secondary intra ocular lens implantation. in: principles and practice of ophthalmology. 2nd ed. philadelphia: w.b saunders company. 2000; 1514-36. 4. tayyab aa. secondary transscleral fixation of intra ocular lens implantation. pak j ophthalmol. 2004; 20: 139-42. 5. uthoff d, teichmann kd. secondary implantation of scleralfixated intraocular lenses. j cataract refract surg. 1998; 24: 94550. 6. mead md, seik-ea, sterinert rf. optical rehabilitation of aphakic in: principles and practice of ophthalmology. philadelphia: w.b saunders company. 1994; 641-56. 7. lewis js. ab-externo sulcus fixation. ophthalmic surg. 1991; 22: 692-5. 8. chakrabarti a, gandhi rk, chakrabarti m. ab-externo 4point scleral fixation of posterior chamber intraocular lenses. j cataract refract surg. 1999; 25: 420-6. 9. mittelviefhaus h, wiek j. a refined technique of transscleral suture fixation of posterior chamber lenses developed for cases of complicated cataract surgery with vitreous loss. ophthalmic surg. 1993; 24: 698-701. 10. bleckmann h, kaczmarek u. functional results of posterior chamber lens implantation with scleral fixation. j cataract refract surg. 1994; 20: 321-6. 11. wagoner md, cox ta, ariyasu rg, et al. intraocular lens implantation in the absence of capsular support: a report by the american academy of ophthalmology. 2003; 110: 840-59. 12. kaynak s, ozbek z, pasa e, et al. transscleral fixation of foldable intraocular lenses. j cataract refract surg. 2004; 30: 854-7. 13. kokame gt, yamamoto i, mandel h. scleral fixation of dislocated posterior chamber intraocular lenses: temporary haptic externalization through a clear corneal incision. j cataract refract surg. 2004; 30: 1049-56. 14. lee vy, yuen hk, kwok ak. comparison of outcomes of primary and secondary implantation of scleral fixated posterior chamber intraocular lens. br j ophthalmol. 2003; 87: 1459-62. 15. ghanem vc, ghanem ea, ghanem rc, et al. monoscleral fixation iol after extracapsular extraction of subluxated lenses in patients with marfan syndrome. arq bras oftalmol. 2004; 64: 763-7. 16. ozdek s, sari a, bilgihan k, akata f, et al. surgical treatment of hereditary lens subluxations. ophthalmic surg lasers. 2002; 33: 309-13. 17. sasahara m, kiryu j, yoshimura n. endoscope-assisted transscleral suture fixation to reduce the incidence of intraocular lens dislocation. j cataract refract surg. 2005; 31: 1777-80. 18. kanigowska k, grałek m, karczmarewicz b. [transsclerally fixated intraocular artificial lenses in children-analysis of longterm postoperative complications]. klinoczna. 2007; 109: 283-6. glaucoma according to the world health organisation glaucoma is the leading cause of preventable irreversible blindness worldwide. roughly 70 million of the world’s population are affected by glaucoma and according to most epidemiological studies, 50 percent are undiagnosed. the incidence of glaucoma being one percent among aged 40 years and four percent in people aged 80 years. population studies indicate that around 10 percent of patients diagnosed with glaucoma will go blind bilaterally and 20 percent will go blind unilaterally after 20 years. pakistan has a large percentage of younger population which will be aging in next few decades requiring timely measures for adequate management of glaucoma. m lateef chaudhry editor-in-chief microsoft word faisal murtaza 72 original article vitreon, a perfluorocarbon liquid as vitreous substitute in retinal detachment surgery faisal murtaza, alyscia miryam cheema, javed hassan niazi, imran ghayoor, tariq m aziz pak j ophthalmol 2009, vol. 25 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: faisal murtaza house # d-706 korangi 5 ½ karachi received for publication november’ 2007 purpose: to assess the role of perfluoroperhydrophenanthrene (vitreon) pfcl as an internal tamponade agent in complicated retinal detachment with regard to anatomical reattachment, visual outcome and complications. material and methods: this study was conducted in the department of ophthalmology j.p.m.c, karachi, for 1 year, from july 2000 to june 2001, in 30 eyes of 30 patients. patients with complicated retinal detachment who underwent three ports pars plana vitrectomy with vitreon (perfluoro-perhydro-phenanthrene) as an internal tamponade agent. results: the mean age was 31.9 years. 7 patients were female (23.3%) and 23 were male (76.6%). 20 patients were phakic (66.6%), 3 patients were aphakic (23.3%) and 7 patients were pseudophakic. eight patients were myopes (26.6%). ten patients had retinal detachment with pvr grade “c” in which break could not be localized preoperatively, 16 patients had inferior retinal detachment with posteriorly located breaks (53.3%), 1 patient had inferior tractional retinal detachment (3.3%) and 3 patients had retinal detachment associated with giant retinal tear (10%). majority of patients had visual acuity up to counting fingers. 16 eyes (53.3%). vitreon was used as an internal tamponading agent, which was later on replaced by silicone oil. redetachemnt of retina due to pvr (26.6%) was the commonest postoperative complication. the overall anatomical success rate was (93.3%) and visual success rate was (63.3%). conclusion: vitreon can be safely tolerated by the eye and is a good intra oprative hydrokinetic tool to flatten the retina. 73 ……………………… omplicated retinal detachment has always been a challenge for vitreoretinal surgeons. the last few years have seen major advances in viteroretinal surgery. with the introduction of hightech vitrectomy and intraoperative vitreoretinal tools, vitreoretinal surgeons are now in a better position to reattach the retina. besides conventional techniques1-6 various methods have been used to facilitate complicated retinal detachment surgery such as endophotocoagulation, internal drainage, internal tamponade and heavier than water liquids. in complicated retinal reattachment surgery, removal of subretinal or epiretinal membranes and elimination of other tractional elements is of immense importance. by using perfluorocarbon liquids this goal can be easily and successfully achieved. once the membranes and all tractional forces are thoroughly removed, internal tamponade keeps the retina attached for considerable period so that in the mean time adhesions can develop between retina and retinal pigment epithelium. the commonest cause of redetachement is proliferative vitreoretinopathy. the elimination of all tractional forces on the retina is the key to successful retinal reattachment7,8. material and methods this quasi experimental interventional study was carried out in the department of ophthalmology, j.p.m.c. karachi, for 1 year from july 2000 to june 2001. patients with complicated retinal detachment were recruited from j.p.m.c. eye opd. nonprobability convenient sampling was done. inclusion criteria: the inclusion criteria for the study was retinal detachment with pvr grade c, inferior rhegmatogenous retinal detachment, retinal detachment associated with posteriorly located breaks, tractional retinal detachment, retinal dialysis and retinal detachment with giant retinal tear. exclusion criteria: the exclusion criteria were retinal detachment with superiorly located breaks, superior retinal detachment, retinal detachment due to intraocular foreign body and vitreous hemorrhage due to diabetic retinopathy. all patients were admitted in the eye ward. a detailed history was obtained on a printed history proforma. particular attention was given to the history of any existing or previous ocular disorder, past history of ocular trauma, history of any ocular surgery particularly cataract, glaucoma or retinal reattachment surgery. all patients were asked about any systemic disease especially diabetes mellitus, hypertension and family history of ocular disorders. all patients were examined preoperatively, peroperatively and postoperatively. best corrected visual acuity was recorded. the extent of retinal detachment was recorded, pvr was graded according to the classification of pvr proposed by retina society in (1991)9-15. the detachment was drawn on a fundus chart showing details of retinal detachment, pvr and tears. the color codes were used as described by kanski (1999)1. in addition to material used for conventional retinal detachment surgery (360o encirelement band, radial and segmental circumferential explant) vitreous cutter, pfcl (vitreon), silicone oil (1000c.s) were made available in every case. patient’s profile thirty eyes of 30 patients were included in this study. the ages of the patients ranged from 11 years to 70 years (mean 31.9 years) (table 1). out of thirty patients, 7 were female (23.3%) and 23 were male (76.6%) (table 2). twenty patients (66.6%) were phakic, three patients were aphakic (10%) and seven patients were pseudophakic (23.3%) (table 3). eight patients were myopes (26.6%). ten patients had retinal detachment with pvr grade “c” (33.3%), sixteen patients had inferior retinal detachment with posteriorly located breaks (53.3%). out of these sixteen patients, one patient had a macular hole, one patient had inferior tractional retinal detachment (33.3%) and three patients had retinal detachment secondary to gaint retinal tear (10%) (table 4). visual status was hand movement in 13 patients (43.3%), counting finger in 16 patients (53.3%) and light perception in 1 patient (3.33%) preoperatively (table 5). out of 30 patients, breaks were not localized preoperatively in 10 patients due to extensive folding, fibrosis and total retinal detachment, however they were localized intraoperatively. table 1: age distribution minimum age 11 years c 73 maximum age 70 years mean age 31 years table 2: sex distribution no. of patients n (%) male 23 (76.6) female 7 (23.3) table 3: refractive status no. of patients n (%) phakic 20 (66.6) aphakic 3 (10) pseudophakic 7 (23.3) operative procedure under all aseptic measures, in l/a or g/a, 360o encirclement band was passed under the muscles and was tied with watzke’s sleeve and sutured 12mm behind the limbus. after performing core vitrectomy. pvd induced pfcl (vitreon) perfluoroperhydrophenanthrene was injected slowly by 20 gauge needle, quantity used varied from 1.5-3 cc average 3.5cc, 1mm above the optic disc. tip of the needle was kept within the center of the bubble to prevent dispersion of the bubble. vitreon bubble help in opening the funnel of the retinal detachment, flattening the retina and help to define further areas of traction which were removed by performing the vitrectomy and then continued peripherally and anteriorly to remove all the traction. in eyes with anterior pvr, vitrectomy with seleral indentation was done. epiretinal membranes which remained were removed with intraocular scissors and forceps. table 4: indication of surgery cause no. of patients n (%) total retinal detachment with pvr “c” 10 (33.3) subtotal inferior retinal detachment with posteriorly located breaks 16 (53.3) inferior tractional retinal detachment 1 (3.33) giant retinal tear 3 (10) table5: preoperative visual acuity visual acuity no. of patients n (%) h.m 13 (43.3) finger counting 16 (53.3) pl +ve 1 (3.33) table 6: postoperative visual acuity visual acuity no. of patients n (%) 6/24-6/60 13 (43.3) 5/60-1/60 11 (36.6) hm-pl +ve 6 (20) in case of inferior tractional retinal detachment, after pfcl (vitreon) injection, traction bands were devided with vitrectomy, endo-cautery was done on firovascular band to prevent intraocular bleeding. in case of retinal detachments associated with giant retinal tear, vitreon (pfcl) bubble filled the eye from posterior to anterior direction thus unfold the rolled over posterior flap of the tear. in all cases, subretinal fluid was not drained externally but drained internally through the preexisting retinal tear due to its high specific gravity. after the flattening of retina, endolaser done around the break and plomb applied externally at the break site. explants and 360o encriclement band were sutured with 5/0 ethibond. inferior iridectomy at 6 o’clock (ando basal iridectomy) was done in aphakic patients. vitreon was then replaced by silicone oil (1000c.s). quantity of silicone oil varied from 4-7cc, average being 5.5cc. scleral ports and conjunctive were closed with 6/0 vicryl. subconjuctival injection of gentamicin 20mg and dexamethasone 4mg was given to all patients at the end of procedure. eyes were atropinized and antibiotic drops and ointments were instilled. systemic antibiotics and steroids were given for 5 days. dressing was removed after 24 hours. 74 patients were instructed to maintain head down posture for at least 10-15 days. visual acuity, anterior segment examination, intraocular pressure and state of retina were noted during the patients stay in hospital for 4 to 5 days. the patients were followed in outpatients department after 1 week, 1 month, 3 months and 6 months. proper record of visual acuity, ocular findings, iop and fundus findings were maintained. results at the end of procedure, retina was attached in all patients (100%). during operation, a few problems were noted and managed accordingly. these complications have been shown in table 7. during surgery one patient developed lens touch (3.33%) which was obscuring the view, so lensectomy was done and iol was implanted at the end of surgery. one patient developed choroidal detachment, which was managed by injecting more vitreon in the eye. two patients (6.66%) had iatrogenic retinal tear, after completing the vitrectomy, endolaser was done around those breaks. during surgery, intraocular bleeding occurred in one patient (3.33%) from fibrovascular tissue, so more vitreon was injected to raise iop, that led to stoppage of bleeding, later on endocautery was done at the bleeding site. anatomical success was defined as “retinal reattachment beyond the scleral indentation” and visual success was defined as “improvement in visual acuity postoperatively”. the overall anatomical success rate was 93.3% (28 eyes). out of these 28 eyes, 22 eyes (73.3%) reattached with primary surgery, while 6 eyes (20%) underwent secondary surgery (table 8). the overall visual success rate was achieved in 19 eyes (63.3%), in 6 eyes (20%) visual acuity remained unchanged and another 5 eyes (16.6%) the visual acuity dropped to less than the preoperative level (table 9). table 7: preoperative complications complications no. of patients n (%) lens touch 1 (3.3) choroidal detachment 1 (3.3) iatrogenic retinal tear 2 (6.6) intraocular bleeding 1 (3.3) table 8: anatomical success rate (28 eyes 93.3%) no. of patients n (%) retina attached with primary surgery with secondary surgery 28 (93.33) 22 6 retina not attached 2 (6.6) table 9: visual success rate (19 eyes, 63.3) no. of patients n (%) post operative va same as preoperative level 5 (20) postoperative va improved to 2 or more lines 19 (63.3) postoperative va worse than the preoperative level 5 (16.6) table 10: postoperative complications complications no. of patients n (%) redetachment 8 raised iop 4 cataract 4 macular pucker 2 due to severe pvr, retina of 8 patients (26.6%) was redetached. out of 8 patients with redetachment, vitrectomy with scleral indentation and membrane peeling was done in 5 patients while vitrectomy with retinectomy in remaining 3 patients. with these extensive surgical maneuvers, retina of 6 patients became attached while 2 remain detached. until last follow up of these 8 patients, visual acuity of four patients (13.3%) improved, while in remaining 4 patients (13.3%) vision decreased to less than preoperative level. raised intraocular pressure 25-30 mmhg average 27.5 mmhg was noted in four eyes (13.3%) due to silicone oil in a/c, after removal of silicone oil and topical autiglaucoma medication intraocular pressure became normal. four patients (13.3%) developed cataract. phaco+iol implantation was done in these patients. two eyes developed 75 hypotony (6.66%) while two patients developed macular pucker (6.66%) that was noted after six months of follow up. one patient (3.33%) developed keratopathy due to silicone oil in a/c, silicone oil removed but vision not improved due to permanent severe corneal damage (table 10). after the mean follow up of 7 month the postoperative visual acuity ranged from 6/24 – 6/60 in 13 patients (43.3%), from 5/60 – 1/60 in 11 patients (36.6%) and from hand movement to light perception in 6 patients (20%) (table 6). in most of the patients, preoperative visual acuity was from pl-hm in 14 patients (46.6%) and cf 1 feet cf 3feet in 16 patients (53.3%) (table 5). in such patients, with severely and markedly decreased vision, the postoperative vision improved with functional success rate of 63.3% (table 9). conclusion our study on complicated retinal detachment surgery using vitreon (perfluoroperhydrophenanthrene) shows that vitreon can be safely tolerated by the eye and is a good intral operative tool to drain srf internally and to flatten the retina. the study also shows that there is a very large gap between patients and physicians and between general ophthalmologist and vitreoretinal surgeons. because of illiteracy, patient do not understand and realize the nature and outcome of the complicated r/d. delay in referral of these patients by general ophthalmologists and also undue delay on part of the patients are factors that contribute in the chronicity and severity of the disorder. vitreontinal surgery is a very expensive, time consuming and yet less rewarding procedure, it requires a teamwork and a joint venture to make it affordable, less expensive and thankful job. we need more co-operations from our society, concerned authorities and associations to help needy patients and public hospital. patients should be educated and made to realize their problems and nature of the vitreoretinal surgery. though vitreoretinal surgery is expensive, time consuming, back breathing and thankless job, even then need more ophthalmologists to take part in the services of humanity and hopeless needy patients. author’s affiliation dr. faisal murtaza assistant professor jinnah medical & dental college karachi dr. javed hassan niazi associate professor jinnah postgraduate medical center karachi. dr. alyscia miryam cheema assistant professor jinnah postgraduate medical center karachi. dr. imran ghayoor assistant professor liaquat national medical college and hospital, karachi dr. tariq m aziz professor of ophthalmology jinnah postgraduate medical center karachi. reference 1. kanski jj. retinal detachment. in: clinical ophthalmology. 4th ed, oxford: butterworth-heinemann; 1999: 354-94. 2. george, thomas. techniques of scleral buckling. in: retina. stephen j. ryan. 3rd ed, st. louis: mosby company. 1994: 19792017. 3. janet, stanley. vitreous substitutes. in: albert jackobiec. principles and practice of ophthalmology. philadelphia: wb saunders company. 1994: 1142-59. 4. frank jm, oils s: physicochemical properties. in: retina stephen j. ryan ed. st. louis: mosby company. 1994: 2131-49. 5. lowe kc. perfluorocarbon as oxygentransparent fluid. comp biochem physiol. 1987; 87: 825-38. 6. chang s. low viscosity liquid fluorochemicals in vitreous surgery. am j ophthalmol. 1987; 103: 38-43. 7. blinder kj, peyman ga, walid cj. vitreon: a new perfluorocarbon. br j ophthalmol. 1991; 75: 240-4. 8. wahab s, hashim m, mirza ma. role of perfluorocarbon liquids in complicated retinal detachment. pak j ophthalmol. 1988; 14: 15-21. 9. peyman ga, sullivan sb. perfluorocarbon liquids in ophthalmology. surv ophthalmol. 1995; 39: 375-95. 10. blinder kj, peyman ga, desi ur, et al. vitreon; a short-term vitreo retinal tamponade. br j ophthalmol. 1992; 76: 525-8. 11. cibis pa, becker b, okun e, canaas. the use of liquid silicone in retinal detachment surgery. arch ophthalmol. 1962;68:590-9. 12. mccuen bw, juan de, machermer r. silicone oil in vitreoretinal surgery. surgical techniques. retina. 1985; 5: 189-97. 13. miyamoto k, refojo mf, toleutinio fi, et al. perfluoroether liquid as a long term vitreous subsititute, an experimental study. retina. 1984; 4: 264-8. 14. chang s, zimmer mnj, lwamoto t, et al. experimental vitreous replacement with perfluorotributy lamine. am j ophthalmol. 1987; 103: 29-37. 15. walshe r, esser p, wiedermann p, et al. proliferative retinal disease myofibrodlasts cause chronic vitreoretinal. br j ophthalmol. 1992; 76: 550-2. 76 microsoft word darakhshanda 9 214 original article effects of primary chemotherapy, radiotherapy plus local treatments on regression patterns of posterior pole retinoblastoma darakhshanda khurram, naima zaheer, nusrat sharif pak j ophthalmol 2011, vol. 27 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: darakhshanda khurram paediatric ophthalmology alshifa trust eye hospital rawalpindi submission of paper september’ 2011 acceptance for publication november’ 2011 …..……………………….. purpose: to document the types of regression patterns of intraocular retinoblastoma following primary chemotherapy, radiotherapy and local treatments. material and methods: the medical records of 31 patients diagnosed with intraocular posterior pole retinoblastoma at the department of paediatric ophthalmology al-shifa trust, eye hospital, rawalpindi between january 2006 and january 2010 were reviewed retrospectively. the size of the tumour before and after the treatment (with chemotherapy, radiotherapy and local therapy) and types of regression patterns were evaluated. regression patterns were classified as type 0 (no residua), type 1 (fully calcified residua), type 2 (non calcified residua), type 3 (partially calcified), type 4 (flat scar). cases were also observed for any relapse of tumour. results: 37 eyes of 31 children were included in the study. out of which 6 (19.4 %) had bilateral presentation of posterior pole retinoblastoma and 25 (80.6%) had unilateral. tumour size, location and groupings were noted according to the international intraocular retinoblastoma classification. after treatment with chemotherapy, radiotherapy and local treatments the types of regressions noted were type 0 in 1 eye (2.7 %), type 1 in 2 eyes (5.4 %), type 2 in 7 eyes (18.9 %), type 3 in 19 eyes (51.3 %) and type 4 in 8 eyes (21.6 %). in 3 eyes tumour relapse occurred. conclusion: most large intraocular tumours showed type 3 regression pattern. small tumours resulted in flat atrophic scars. he primary aim of the management of retinoblastoma is to preserve life1. since the management of retinoblastoma has evolved over the past decade from enucleation to radiotherapy to current regimen of chemotherapy, children with retinoblastoma having access to modern medical care have a very good prognosis for survival with greater emphasis being given to salvaging the globe and preserving the vision2. eyes with massive retinoblastoma filing the globe without macroscopic or microscopic extra ocular disease are still managed with enucleation. systemic administration of chemotherapy has been noted to reduce tumour volume, allowing for consolidative ablation therapy with laser and cryotherapy3-5. current regimens include systemic injections of carboplatin, vincristin and etoposide. children receive intravenous drug administration every three weeks for four to nine cycles of chemotherapy along with local tumour laser or cryoablation. this combination therapy allows globe preservation in 85% of eyes with less advanced tumours that is those classified as reese-ellsworth group i to iv6. conservative approaches have been developed in order to increase the eye preservation t 215 rate and improve the visual prognosis7,8. retinoblastoma shows a variety of regression patterns after treatment. tumour regression was initially described following radiotherapy. on regression, the retinoblastoma assumes a smaller size with stable margins and, frequently, some degree of calcification. regression patterns include type 0, in which the tumour completely disappears, leaving no retinal scar. type 1, with a completely calcified mass appearing like cottage cheese. type 2, with a completely noncalcified mass. type 3, with a partially calcified mass and type 4, with a flat atrophic scar9,10. we conducted a retrospective study to evaluate the type of regression patterns seen in intraocular retinoblastoma grouped as a, b, c and d according to international intraocular retinoblastoma classification (iirc) after treatment with chemotherapy, radiotherapy and fovea sparing laser therapy11. material and methods in this study we observed the patterns of regression of posterior pole intraocular retinoblastomas following primary chemotherapy, radiotherapy and local treatment with laser therapy or cryotherapy. the study was approved by the ethical committee of the hospital. the medical records of the patients diagnosed with retinoblastoma at the paediatric ophthalmology department of al-shifa trust, eye hospital, rawalpindi, from january 2006 to january 2010 were reviewed retrospectively. of these patients, only the newly diagnosed cases of retinoblastoma, which were intraocular with posterior pole involvement (tumour entirely or partially in the area within the major vascular arcades), which had been treated with primary chemotherapy, radiotherapy and local treatments like laser therapy or cryotherapy were selected and included in this study. patients with evidence of group e presentation according to iirc, extra ocular extension, systemic metastasis or which had been treated with enucleation were excluded from the study. at our institution, following guidelines for examination and diagnosis in all the children with suspected retinoblastoma were observed. each patient was evaluated for age at diagnosis, familial or sporadic hereditary pattern of retinoblastoma and tumour laterality. firstly a limited non sedated examination with attention to visual acuity, pupillary examination, extra ocular movements was carried out and it gave an idea of whether the patient can fixate and to what extent eye motility was affected. it also helped in taking family history and assessing what therapies may be practical. all paediatric patients with suspicion of retinoblastoma underwent examination under anaesthesia, consisting of measuring intraocular pressure, portable slit-lamp examination for evidence of iris neovascularisation, hyphema, or hypopyon, indirect ophthalmoscopy with 360 degrees of sclera indentation and documenting all the lesions with drawings indicating the location and size of the tumours and presence and extent of vitreous or sub retinal seedlings and sub-retinal fluid. photographs of anterior chamber and fundus were taken of all the patients by ret cam. this was followed by diagnostic testing by ultra sound, ct scan and magnetic resonance imaging to exclude extra ocular extension and trilateral retinoblastoma where needed. each affected eye was classified according to the international intraocular retinoblastoma classification (iirc) and reese ellsworth classification of retinoblastoma. the potential risks and benefits of the planned treatment were discussed with the patient’s family and an informed consent was obtained. treatment options considered were chemotherapy (with carboplatin, vincristin and etoposide) and radiotherapy was considered for those patients who required further aggressive chemotherapy but had evidence of inadequate organ function of the kidney or liver. examination under anaesthesia was carried out every 6 weekly after the initiation of chemo reduction therapy and tumour consolidation was provided using local treatment with laser thermotherapy or cryotherapy until tumour control was achieved. cryotherapy was used in large tumours extending anteriorly and the adjuvant fovea sparing thermotherapy was provided using the indirect ophthalmoscope diode laser, with varied duration, power and spot size of 1.2mm. chemotherapy and radiotherapy were given in collaboration with clinical oncologist. the variables recorded for each patient included age at presentation and gender. the parameters noted of the retinoblastoma were laterality, tumour location (macular, extra macular, or both in cases of multiple tumours), tumour size (tumour area in disc diameters) and tumour grouping (a to e) according to iirc at the time of diagnosis. we planned our patient treatment according to the international intraocular retinoblastoma classification (iirc) which is based mainly on extent of tumour seeding in the vitreous cavity and subretinal space with minor consideration 216 table 1: international classification of retinoblastoma group sub group quick reference specific features a a small tumour retinoblastoma =3 mm in size* b b larger tumour retinoblastoma >3 mm in size* or macula macular retinoblastoma location (=3 mm to foveola) juxtapapillary juxtapapillary retinoblastoma location (=1.5 mm to disc) subretinal fluid clear subretinal fluid =3 mm from margin c focal seeds retinoblastoma with c1 subretinal seeds =3 mm from retinoblastoma c2 vitreous seeds =3 mm from retinoblastoma c3 both subretinal and vitreous seeds =3 mm from retinoblastoma d diffuse seeds retinoblastoma with d1 subretinal seeds >3 mm from retinoblastoma d2 vitreous seeds >3 mm from retinoblastoma d3 both subretinal and vitreous seeds >3 mm from retinoblastoma e e extensive retinoblastoma extensive retinoblastoma occupying >50 percent globe or neovascular glaucoma opaque media from haemorrhage in anterior chamber, vitreous, or subretinal space invasion of postlaminar optic nerve, choroid (>2 mm), sclera, orbit, anterior chamber * refers to 3 mm in basal dimension or thickness. of tumour size and location since the chemoreduction is effective despite these variables. the potential risks and benefits of the planned treatment were discussed with the patient’s family and an informed consent was obtained. examination under anaesthesia was carried out every 6 weekly after the initiation of chemoreduction therapy and tumour consolidation was provided using laser therapy or cryotherapy until tumour control was achieved. after the completion of chemotherapy the tumour regression patterns were then documented as type 0 (no residua), type 1 (fully calcified residua), type 2 (non calcified residua), type 3 (partially calcified), type 4 (flat scar). cases were followed at 4 monthly intervals till for the first year and relapse in any case if present was noted. in cases of tumour recurrences, further two to four cycles of chemotherapy were given in minor relapses and enucleation was carried out in cases of major relapses. data was analyzed by statistical program for social sciences spss version 17. results between january 2006 and january 2010, 37 eyes with intraocular retinoblastoma of 31 children were treated with chemoreduction, radiotherapy and local adjuvant methods. all eyes were classified according to iirc (table 1). the age of presentation ranged from 5 months to 9 years. the mean age at presentation in months was 34.48 ± 25.27. the frequencies and 217 table 2: the frequencies and percentages of gender and laterality variables frequency (n=31) n (%) gender males 19 (61.3) females 12 (38.7) laterality of retinoblastoma unilateral 2 (6.5) bilateral 29 (93.5) laterality of posterior pole retinoblastoma unilateral 25 (80.6) bilateral 6 (19.4) table 3: retinoblastoma grading, size and location variables frequency (n=37) n %) tumor grouping a 2 (5.4)% b 4 (10.8) c 5 (13.5) d 26 (70.3) e tumor size 1-5 dd 23 (62.2) 6-10 dd 13 (35.1) 11-15 dd 1 (2.7) tumor location macular 19 (51.4) extramacular 15 (40.5) mixed (macular + extramacular) 3 (8.1) percentages of gender and laterality in these 31 patients are given in table 2. out of 29 children (93.5%) with bilateral retinoblastoma 6 (20.7%) had bilateral presentation of posterior pole retinoblastoma and treatment was initiated to preserve both the eyes table 4: different treatment modalities and their percentages treatment modalities frequency n = 37 n (%) chemotherapy 6 (16.2) laser + chemotherapy 26 (70.3) laser + chemotherapy + radiotherapy 5 (13.5) 2.70% 5.41% 18.92% 51.35% 21.62% 0 10 20 30 40 50 60 type 0 n=1 type i n=1 type ii n=7 type iii n=19 type iv n=8 regression types fig. 1: types of regression in reinblastomas 91.89% 8.11% tumor relapse n=13 no tumor relapse n=34 fig. 2: relapse of retinoblastoma of these patients, while 23 (79.3%) patients presented with unilateral posterior pole retinoblastoma and the other eye needed enucleation due to advance presentation. two (6.5%) patients presented with unilateral retinoblastoma that involved posterior pole. the details of initial tumour features, iirc grading, p er ce nt 218 fig. 3: different retinoblastomas showing regression. sizes and locations are listed in table 3. majority of retinoblastoma presented in group d (70.3%). the basal diameter of all retinoblastomas ranged from 1 to 15 disc diameters (1mm to 23mm). the average basal diameter of the tumours involving macula was 5 disc diameter (7.5mm). the different treatment modalities and their percentages are shown in table 4. after primary chemotherapy, radiotherapy and local treatments the types of regression documented in those 37 eyes are shown in (fig 1). majority of retinoblastomas showed type 3 (n=19, 53.35%) and type 4 (n=8, 21.62%) regression. large tumours mostly regressed to type 3 (n=7, 18.92%). small tumours, which were consolidated with laser therapy or cryotherapy resulted in flat atrophic scars. only in 3 eyes (8.1%) the relapse of the retinoblastoma was documented (fig 2). the relapse was seen at the mean interval of 11 months (range of 2-48 months) after completing the initial treatment of chemotherapy. the relapse was seen in those tumours that were initially graded as group d according to iirc with subretinal and vitreous seeds and lying in close proximity of optic nerve head. these tumours showed type 2 and type 3 regression patterns. no relapse was recorded in type 0, type 1 and type 4. different tumours before and after treatment are shown in (fig 3). discussion there has been a significant change in the treatment approaches to retinoblastoma12,13. attempts to avoid enucleation and complications associated with external beam radiotherapy have focused on globe preserving techniques. systemic chemotherapy and focal treatments like laser photocoagulation and cryotherapy, are becoming the primary treatment modality14-16. the options for management of intraocular retinoblastoma include enucleation, external beam radiotherapy, plaque radiotherapy, laser photocoagulation, thermotherapy, cryotherapy and chemoreduction with or without adjuvant thermotherapy. eyes with large tumours, especially if associated with extensive subretinal fluid, subretinal seeds or vitreous seeds are managed with enucleation. however, eyes with less advanced retinoblastoma are being managed with non-enucleation measures, most commonly involving chemoreduction followed by focal tumour consolidation. currently used chemotherapeutic protocols involving intravenous administration of vincristin sulfate, etoposide and carboplatin have been proven effective in reduction of tumour size17. the tumour size and location are most important in predicting tumour regression patterns. according to iirc group e unilateral retinoblastoma should be enucleated, while group d eyes are safe to attempt a combination of chemotherapy, focal therapy and low dose radiation. the attempt to preserve an eye with retinoblastoma requires careful classification and selection of eyes with good prospect for success (iirc group a, b and some c)18. 219 abramson and colleagues first described the globe preserving treatment for unilateral retinoblastoma using radiotherapy. they stressed the need for proper patient selection19. they evaluated 89 eyes, which were treated with ebrt, for long term stability of regression patterns with a follow-up period of 7 years. they noted that the regression patterns slowly changed over time and that there was an increase in type 0, 1 and 4 patterns by approximately 10% each, whereas type 2 and 3 decreased by 19% and 8% respectively. in their observation smaller tumours were most likely to become type 0, while larger tumours were more likely to become type 1 pattern. singh et al reported the distribution of regression patterns of retinoblastoma treated with ebrt to be 18% for the type 0, 50 % for type 1, 17% for type 2 and 14% for type 320. they did not comment on type 4 regression patterns. regression patterns have changed as chemotherapy has replaced ebrt as the primary treatment. shields et al reported the regression patterns of retinoblastoma treated with chemotherapy to be 2% to 3% for type 0, 10% to 13% for type 1, 3% to 5% for type 2, 23% to 33% for type 3 and 51% to 57% for type 4 tumours21,22. in our study the regression pattern mostly observed was type 3 (51.53%) and type 4 (21.62%), which is comparable with the studies mentioned earlier. the relapse of retinoblastoma was seen in 3 eyes (8.11%). in these eyes the retinoblastoma initially regressed to type 2 and type 3. the presence of vitreous seeds and subretinal seeds were the factors resulting in recurrence of retinoblastoma in these eyes. however there are few limitations in our study. firstly, the extent of the tumour treated with laser therapy, it varied depending on its relation to the fovea and close proximity to the optic nerve head. secondly the changes in visual acuity were not assessed as most of our patients were infants. careful and diligent follow-up is the mainstay to ensure the success of retinoblastoma treatment. chemoreduction and local therapy helps in regression of retinoblastomas and can be considered as a treatment of choice especially in bilateral cases with one eye already requiring enucleation. author’s affiliation dr. darakhshanda khurram assistant professor, paediatric ophthalmology alshifa trust eye hospital rawalpindi dr. naima zaheer assistant professor alshifa trust eye hospital rawalpindi dr. nusrat sharif assistant professor alshifa trust eye hospital rawalpindi reference 1. sanders bm, draper gj, kingston je. retinoblastoma in great britain 1969-1980: incidence treatment and survival. br j ophthalmol. 1988; 72: 576-83. 2. kopelman je, mclean iw, rosenberg sh. multivariate analysis of risk factors for metastasis in retinoblastoma treated by enucleation. ophthalmology. 1987; 94: 371-7. 3. shields cl, shields ja. basic understanding of current classification and management of retinoblastoma. curr opin ophthalmol. 2006; 17: 228-34. 4. abramson dh. retinoblastoma in the 20th century: past success and future challenges the weisenfeld lecture. invest ophthalmol vis sci. 2005; 46: 2683-91. 5. murphree al villablanca jg, deegan wf 3rd, et al. chemotherapy plus local treatment in the management of intraocular retinoblastoma. arch ophthalmol. 1996; 114: 134856. 6. kingston je, hungerford jl, madreperla sa, et al. results of combined chemotherapy and radiotherapy for advanced intraocular retinoblastoma. arch ophthalmol. 1996; 114: 133947. 7. buckley eg, heath h. visual acuity after successful treatment of large macular retinoblastoma. j pediatr ophthalmol strabismus. 1992; 29: 103–6. 8. shields cl, de potter p, himelstein bp, et al. chemoreduction in the initial management of intraocular retinoblastoma. arch ophthalmol. 1996; 114: 1330–8. 9. ellsworth rm. the practical management of retinoblastoma. trans am ophthalmol soc. 1969; 67: 462-534. 10. abramson dh, jereb b, ellsworth rm. external beam radiation for retinoblastoma. bull n y acad med. 1981; 57: 787803. 11. murphree al. intraocular retinoblastoma: the case for a new group classification. ophthalmol clin north am. 2005; 18: 4153. 12. abramson dh, schefler ac. update on retinoblastoma. retina. 2004; 24: 828-48. 13. depotter p. current treatment of retinoblastoma. curr opin ophthalmol. 2002; 13: 331-6. 14. shields ja, shields cl, meadows at. chemoreduction in the management of retinoblastoma. am j ophthalmol. 2005; 140: 505-6. 15. shields cl, mashayekhi a, au ak, et al. the international classification of retinoblastoma predicts chemo reduction success. ophthalmology. 2006; 113: 2276-80. 16. chan hs, gallie bl, munier fl, et al. chemotherapy for retinoblastoma. ophthalmol clin north am. 2005; 18: 55-63. 17. friedman dl, himelstein b, shields cl, et al. chemoreduction and local ophthalmic therapy for intraocular retinoblastoma. j clin oncol. 2000; 18: 12-7. 18. mallipatna ac, sutherland je, gallie bl, et al. management 220 and outcome of unilateral retinoblastoma. jaapos 2009; 13: 546-50. 19. abramson dh, marks rf, ellsworth rm, et al. the management of unilateral retinoblastoma without primary enucleation. arch ophthalmol. 1982; 100: 1249-52. 20. singh ad, garway-heath d, love s, et al. relationship of regression patterns to recurrence in retinoblastoma. br j ophthalmol. 1993; 77: 12-6. 21. shields cl, mashayekhi a, carter j, et al. chemoreduction for retinoblastoma. analysis of tumour control and risk for recurrence in457 tumours. am j ophthalmol 2004;138:329-37. 22. shields cl, palamar m, sharma p, et al. retinoblastoma regression patterns following chemo reduction and adjuvant therapy in 557 tumours. arch ophthalmol. 2009; 127: 282-90. microsoft word hamid awan 2 original article endoscopic dacrocystorhinostomy: a pakistani experience shiraz aslam, abdul hamid awan, mohammad tayyab pak j ophthalmol 2010, vol. 26 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: shiraz aslam 111, e-1, hali road, gulberg-3, lahore received for publication march’ 2009 …..……………………….. purpose: to surgically create a new passage for the lacrimal fluid to flow into the nose from the eye using the endoscopic technique. material and methods: endoscopic dacrocystorhinostomy (dcr) was performed on selected patients (n=16) using a 4mm zero and 30 degree nasal endoscope and a camera system .the puncta dilated with punctum dilator and probing done before passing a light probe by ophthalmologist to enter the lacrimal system while the ent surgeon created a window medial to the lacrimal sac through bone and into the sac via the corresponding nostril. silicon (jones) tubes were used as stents and left in situ for six months. a regular follow up plan continues till eight months. results: seven males (43.8%) and nine females (56.3%) under went endoscopic dcr with their ages ranging from 10 to 67 years. all patients had epiphora, mostly in the left eye (43.8%). out of all, 37.5% of the patients had a deflected nasal septum towards the side of surgery while only 6.3% (septoplasty or smr) had to have their septum corrected before dcr could proceed. only two patients needed trimming of their middle turbinates to make more room for surgery. allergic rhinitis was common (25%) and so were itchy eyes (50%).all patients were relieved of their symptoms postoperatively (100%) two months post removal of the silicon tubes. conclusion: dcr should be done endoscopically now which gives no facial scars and is a safe and effective procedure (in the hands of an experienced surgeon) with a low morbidity and mortality. however, formal training is mandatory. acrocystorhinostomy has been a procedure which has seen a number of modifications since the first one done by toti1 in 1904 and later the intranasal version was carried out in 1989 by mcdonough and meiring2. dacrocystorhinostomy consists of creating a new surgical channel from the eye into the nose to overcome the blockage in the lacrimal sac or the lacrimal duct. this surgery was traditionally performed by the ophthalmologists who took an external route into the nose. the emergence of the hopkins rod telescope has provided the otolaryngologists the opportunity to use the camera system to visualize the medial aspect of the lacrimal sac from within the nose and thus avoid excessive tissue damage. however, ophthalmologist defined the upper lacrimal passages by passing fiber optic light probe up till obstruction, which helps the otolaryngologist to visualize and perform the procedure endoscopically. the obstruction whether it is due to congenital or acquired reasons such as trauma, infection or iatrogenic in nature can be divided into obstruction before the sac, at the sac and beyond the sac. the puncta are 0.3mm in diameter and are about 6mm from the medical canthus. the upper and lower cannaliculi are lined by non keratinized stratified squamous epithelium so that they can be dilated to about 2 to 3 times their diameter. the lacrimal sac is about 15mm in its vertical extension. the nasolacrimal duct is about 17mm long and opens into the inferior meatus of the nose. d 3 there is a valve at the junction of the lacrimal sac (rossenmuller) and the nasolacrimal duct. there is one at the lower end as well in the opening of the lower meatus (heisner). this helps to prevent lachrymal reflux. the blockage can be detected by either a fluorescein test or a dacrocystogram. however, syringing and probing is mandatory to assess the level of obstruction. there are two schools of thought world over, ones who believe in stenting and ones who do not3, 4. we follow the former. a silicone tube is placed as a loop in the two cannaliculi and the two ends are tied together in the nose. this is left in situ for six months. the aim of presenting our experience is to show that endoscopic dacrocystorhinostomy is the way forward now and should be the usual way of carrying out this surgery. materials and methods patients whose lacrimal system did not clear with at least three attempts at syringing by the ophthalmologists (a.ha, mt) were advised an endoscopic dacrocystorhinostomy. the patient was referred to the otolaryngologist (s.a) after a computerized tomogramphy scan of the paranasal sinuses according to the fess (functional endoscopic sinus surgery) protocol. an initial nasal endoscopy of the nose was carried out under local anesthesia to ascertain the surgical anatomy of the nose on the side of the proposed surgery and point out any hindrances and anatomical abnormalities. the surgery is carried out under hypotensive general anesthetic and the nose is extensively prepared preoperatively with xylometazoline 0.5% (5 sprays on the side of surgery) and further neurosurgical patties are soaked in 1:1000 adrenaline and placed at specific sites in the nose especially the mucosa overlying the frontal process of the maxilla) just anterior to and level with the axilla of the middle turbinate. the ophthalmologist (a.h.a, m.t) uses the lacrimal probe to assess the patency of the superior, inferior and common cannaliculi and enters the punctum of either of the lids usually with a punctum dilator. subsequently, a fiber optic light carrying probe replaces the punctum dilator and after negotiating its way through the cannaliculi and the common canaliculus enters the lacrimal sac. the otolaryngologist (s.a) dims the intensity of the light of his endoscope (zero or 30 degrees 4mm 18cm) which enables the external probe light to give a glow inside through the lachrymal bone at the site of the lachrymal sac. the otolaryngologist pin points the area of interest and after an injection of the local anesthetic, the mucosa is incised and removed using a keratome at the site of the lachrymal sac. the author (s.a) prefers to remove the mucosa rather than develop a small flap. the site of the lachrymal sac is slightly anterior to the root of the middle turbinate for which a stammberger backbiter or at times a drill (depending on the thickness of the bone) is used to remove the hard and thick frontal process of the maxilla overlying the lachrymal sac. subsequently, the light probes now show quite a bright glow and are used to tent the medial wall of the lachrymal sac. again, a keratome incises the whole vertical length of the sac which at times lets loose a considerable quantity of pus into the wound. the authors prefer to remove all the sac walls rather than just the medial incision and stenting. the silicon tube (dcr tube) is now passed through the puncta and into the nose through the empty area previously occupied by the lachrymal sac. the two tubes in the nostril are tied together several times making sure there is no possibility of these getting loose. the surgery site is lightly packed which is removed the following day. postoperative drugs include antibiotics for 7 days, oral steroids for 7 days, decongestant nose drops and antibiotic drops in the eye. there is hardly any postoperative pain of significance. the patient is sent home the next day and called for follow up after one week. the subsequent follow up visits are at two, four, six and finally eight months. the tube is removed by the otolaryngologist after six months and an endoscopic examination is carried out for documentation at the same time. results we present our experience on sixteen patients who under went dacrocystorhinostomy. there were seven males (43.8%) and nine females (56.3%) with a mean age of 45 years. the age minimum was 10 years and maximum was 67 years. 4 side of dcr frequency n (%) valid percent cumulative percent valid lt. dcr 9 (56.3) 56.3 valid rt. dcr 5 (31.3) 31.3 both dcr 2 (12.5) 12.5 total 16 (100) 100.0 dns surgery done frequenc y n (%) valid percen t cumulativ e percent vali d none 14 (87.5) 87.5 87.5 septoplast y done 1 (6.3) 6.3 93.8 smr done 1 (6.3) 6.3 100.0 total 16 (100) 100 age frequency n (%) valid percent cumulative percent valid 10.00 2 (12.5) 12.5 12.5 35.00 1 (6.3) 6.3 18.8 36.00 1 (6.3) 6.3 25.0 38.00 1 (6.3) 6.3 31.3 40.00 1 (6.3) 6.3 37.5 43.00 1 (6.3) 6.3 43.8 50.00 2 (12.5) 12.5 56.3 54.00 1 (6.3) 6.3 62.5 56.00 2 (12.5) 12.5 75.0 58.00 1 (6.3) 6.3 81.3 62.00 1 (6.3) 6.3 87.5 65.00 1 (6.3) 6.3 93.8 67.00 1 (6.3) 6.3 100.0 total 16 (100) 100.0 gender frequency n (%) valid percent cumulative percent valid male 7 (43.8) 43.8 43.8 female 9 (56.3) 56.3 100.0 total 100 100 fig 1. nasolacrimal ducts: blocked on the left side and patent on the right (coronal view of the face done with the fess protocol) fig.2. right dcr. (post op two weeks) lacrimal sac area is clear with both dcr tubes insitu. the duration of the symptoms was 6 months to two years. most of the dcr procedures were carried out on the left side (56.3%). in this series, most of the patients had the epiphora in their left eye (43.8%) with more females4 than males while 4(25%) patients had watering in both the eyes, again the females were in the majority. out of all the patients most (12, 75%) did not present with a mucocele while there were two each found in the male and female categories. 5 almost 88% did not have any postoperative bleeding. the nasal bleeding we did encounter was as a mild trickle in the patients who had to undergo corrective septal surgery (which is expected) or trimming of the middle turbinate. in 37.5% of the patients there was a deflection of the nasal septum on the side of the dcr while only 6.3%, which is one patient, underwent a septoplasty and another one a sub mucous resection of the septum. there was no need to trim back the anterior end of the middle turbinate on the side of the surgery in the majority (87.5%) of the patients and only two patients out of the lot had their middle turbinates trimmed to make room for the saccal surgery. out of the total number of patients, 25% had an allergic rhinitis while 50% complained of itchy eyes, more in the females9 than the male patients7. in our study 100% were symptom free at the eighth months post-surgery and removal of the silicon tubes. there were no patients with a stenosis. discussion endoscopic dcr should be the usual way of creating a new channel between the lacrimal sac and the nose in case of a lacrimal blockage, however; open surgery is still the norm in pakistan and even in the uk. however, our attempts to find a paper, or a report from pakistan (pakistani journals and pub med) on endoscopic dacrocystorhinostomy failed. females have been in majority (56.3%) in this study which is the usual consensus in several studies 5 which perhaps points towards long term cosmetic effects on the eyes. dcr is a safe procedure and despite some mild anterior nasal trickle (which is the norm in septal surgery) or slight adhesions or ecchymosis around the eye in one patient, we have not faced any major complications. in a study by küpper6 et al (2005), the commonest complication they came across was ecchymosis around the eye and slight adhesions. our study had the same complication (ecchymosis ) which was of almost of no consequence. the ecchymosis resolved itself leaving no lasting effects and the mild adhesions were slight enough not to merit any treatment. rasan7 et al (2008), in malaysia also concluded that the endoscopic dcr is “an easy, efficient treatment for nasolacrimal duct obstruction with minimal complications.” eloy8 et al in 1995, favoring the endoscopic route, claimed, it to be less traumatic to all surrounding structures especially to the medial canthal anatomy. a study by unlu9 et al. (2002), with 25 patients in 4 years had 2 patients with ecchymosis around the eye. similarly, the rate of ecchymosis in our study was quite low as well where we had only one 65 year old lady with difficult punctual dilatation resulting in ecchymosis around the eye which settled within a week. a randomized controlled trial run by hartikainen10 et al. in 1998 in finland carried out dcr procedures on 60 patients over a period of fifteen months out of which 6.25% of the patients required a nasal packing and hospital readmission for three days for excessive nasal bleeding. in the present study as well the postoperative bleeding rate was quite low (3 patients) however, none required nasal packing or hospital readmission. again in experienced hands, like wormald11 (2002), in australia (36 patients in 30 months) had only one patient who had obliteration of the sac postoperatively while yung12 (2002), in the uk (170 patients, 6 years) reported no complications at all. in our study at the end of the eighth follow up month there were no symptomatic patients. results close to the ones reported here have been cited in the world literature which rages from 80-99%. sham13 et al (2000) performed 17 dcrs and claimed a success rate of 88% with 7 revision procedures. weidenbecher14 et al (1994) showed a success rate of 79.12%.they supported our results as far as a low morbidity and safety of this procedure is concerned. there are several advantages of the endoscopic technique over the open one. the most important one is avoidance of a facial scar. other problems associated with the open technique such as excessive bleeding are also avoided while both sides can be operated upon at the same time. postoperatively, nasal endoscopy is an excellent technique to assess the operative results. the royal college of ophthalmologists advises that endoscopic dcr with a laser is less efficacious (success rates of 77-83%) which can cause serious complications such as infection and loss of sight. it is our experience as well that a laser, unnecessarily lengthens the time of the surgery and its use is best avoided. 6 onerci15 et al. ( 2000), in turkey, conducted a study in which experienced surgeons carried out surgery on 108 patients and inexperienced surgeons operated on 50 during a period of 8 years. they compared the performance of the two groups carrying out endoscopic dcrs and reported 11 complications by the experienced surgeons and 21 by the inexperienced surgeons. thus, it is imperative to undergo formal training in endoscopic nasal surgery and then in its advanced applications such as endoscopic dcr. it is important to thoroughly assess the patient preoperatively and take the patient through a standard follow up schedule. conclusions dcr should be done endoscopically which is a safe and effective procedure with a low morbidity and recurrence. it avoids the scar on the face and more ent surgeons should under go formal training in this technique. author’s affiliation dr shiraz aslam consultant ent and head of department of otolaryngology shalamar teaching hospital lahore dr abdul hamid awan consultant ophthalmologist and head of department of ophthalmology shalamar teaching hospital lahore dr. mohammad tayyab consultant ophthalmologist reference 1. griffiths jd. nasal catheter use in dacryocystorhinostomy. ophthal plast reconstr surg 1991; 7: 177-86. 2. mcdonogh m, meiring jh. endoscopic transnasal dacryocystorhinostomy. j laryngol otol 1989; 103: 585-7. 3. unlü h, öztürk f, mutlu c, et al. tarhan. endoscopic dacryocystorhinostomy without stents auris nasus larynx. vol. 27: 65-71. 4. mortimore s, banhegyi gy, lancaster jl, et al. endoscopic dacryocystorhinostomy without silicone stenting jr. coll.surg. edinb. 1999; , 44: 371. 5. sprekelsen mb, barberan mt. endoscopic dacryocystorhinostomy: surgical technique and results. laryngoscope. 1996; 106: 187-9. 6. küpper ds, cassiano r, resende dr, et al. valera,iracema moribe endoscopic nasal dacryocystorhinostomy: results and advantages over the external approach. brazilian j otolaryngology. 2005; 71: 356-60. 7. rasan mi, shailendra s, prepageran n, et al. endoscopic dacryocystorhinostomy, endoscopic dacryocystorhinostomy. medical journal of malaysia. 2008; 63: 143-5. 8. eloy p, bertrand b, martinez m, et al. endonasal dacryocystorhinostomy: indications techniques and results. rhinology. 1995; 33: 229-33. 9. unlu hh, toprak b, aslan a, et al. comparison of surgical outcomes in primary endoscopic dacryocystorhinostomy with and without silicone intubation. ann otol rhinol laryngol. 2002; 111: 704-9. 10. hartikainen j, antila j, varpula m, et al. prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. laryngoscope 1998; 108: 1861-6. 11. wormald pj. powered endoscopic dacryocystorhinostomy. laryngoscope. 2002; 112: 69-72. 12. yung mw, hardman-lea s. analysis of the results of surgical endoscopic dacryocystorhinostomy: effect of the level of obstruction. br j ophthalmol. 2002; 86: 792-4. 13. sham cl, hasselt av. endoscopic terminal dacryocystorhinostomy. laryngoscope. 2000; 110: 1045-9. 14. weidenbecher m, hosemann w, buhr w. endoscopic endonasal dacryocystorhinostomy: results in 56 patients. ann otol rhinol laryngol. 1994; 103: 363-7. 15. onerci m, orhan m, ogretmenoglu o, et al. long-term results and reasons for failure of intranasal endoscopic dacryocystorhinostomy. acta otolaryngol. 2000; 120: 319-22. microsoft word irfan qayyum case report 208 case report charge syndrome irfan qayyum, muhammad moin, tanveer chaudhry, mumtaz hussain pak j ophthalmol 2008, vol. 24 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: irfan qayyum king edward medical university mayo hospital lahore received for publication april’ 2008 … ……………………… a 2 yrs old female born at term presented to us with poor vision, inability to close her eyes since birth and enucleation of left eye at 1 month of age. on examination left orbit and socket were shrunken after enucleation. there was bilateral lid coloboma on medial half with symblephron and ankyloblephron formation. extra ocular movements were reduced due to conjunctival and corneal adhesion to the upper lid. there was right corneal opacity due to ankyloblephron and limbal vascularization along with exposure keratopathy, associated with conjunctival congestion. there was right lower lid ectropion. there was no uveal coloboma; lens was clear with good fundal glow. she had multiple other congenital anomalies associated with charge syndrome. n 1981, the term charge was created to describe a birth defect that had been recognized in children. charge stands for: coloboma (eye), heart defects of any type, atresia (choanal), retardation (of growth and/or development), genital anomaly and ear anomaly. it was recommended that diagnosis of the syndrome be based on the presence of four of these physical features. since then, physicians have recognized that this definition and rule for diagnosis do not take into account many other physical characteristics of charge syndrome, or the fact that some children with the syndrome did not meet the criteria for diagnosis. in addition, a gene associated with charge syndrome has been identified on chromosome 8. charge syndrome occurs in approximately 1 in 10,000 births worldwide, and usually the infant is the only child in the family with the syndrome. we describe a case of charge syndrome associated with coloboma and ankyloblephron formation in pakistani population. case report a 2 years old female child born at term with normal delivery presented to us with poor vision, epiphora, and inability to close her eyes since birth. enucleation of left eye had been done at 1 month of age for a congenital cystic eyeball. on examination her left orbit and socket were shrunken. there were bilateral upper lid colobomas on medial half with ankyloblephron formation. extra ocular movements were reduced due to conjunctival and corneal adhesion to upper lid. right corneal opacity was present due to ankyloblephron. limbal vascularization along with exposure i 209 keratopathy was present which was associated with conjunctival congestion. there was right lower lid ectropion. there was no uveal coloboma; lens was clear with good fundal glow. multiple other systemic congenital anomalies were seen on investigation. abdominal ultrasound showed congenital adrenal hypoplasia. echocardiography showed atrial septal defect. brainstem auditory evoked potentials (baep) showed bilateral decreased hearing sensation. ct brain showed normal midline structures with no hydrocephalus but a small cyst was seen in the frontal horn. her serum cortisol was 5.6 ug/dl(n=6 8.6ug/dl), plasma acth was 23.2 pg/ml (n=46 pg/ml), serum aldosterone was 61.7 ng/dl (n=4 31 ng/dl), serum progesterone was 4.9 ng/ml (n=<2 ng/ml), serum sodium was 140 mmol/l (n=136-148 mmol/l), serum potassium was 5.4 mmol/l (n=3.6 5.0 mmol/l), hemoglobin was 15.2 gm/dl, neonatal tsh was 2.5 mmol/l (n=0.01-6.3 mmol/l), blood glucose was 48 mg/dl (n=80-160 mg/dl), pt was 9.3 sec, aptt was 41.8 sec. the patient had been treated previously with artificial tears and lubricating ointments. dilating drops were being used to dilate the pupil beyond the central corneal opacity to improve vision. we operated on the patient’s right eye for the release of ankyloblephron from conjunctiva and cornea. the defect of conjunctiva was closed with advancement flaps. the edges of coloboma were made raw and the upper lid defect was closed by anchoring of tarsal plate to medial canthal tendon medially after releasing the lid laterally using reverse tenzel flap. postoperatively lagophthalmos decreased with improved extra ocular movements. there was vascularization of the cornea over the area of ankyloblephron release. keratoplasty is planned at a later stage. discussion charge is not an association, but a syndrome. it is characterized by very specific developmental anomalies of the optic vesicle, otic capsule, midline cns structures, and upper pharynx which result from abnormal differentiation, setting, interaction, and migration of neural crest cells which extends from the third to ninth week gestation1. charge syndrome can now be considered the leading cause of deaf blindness in infants and children, although there are differences in the severity of the expression of clinical features. diagnosis of charge syndrome is based on the physical symptoms the child has. the three most important symptoms are the 3 c’s: coloboma, choanal atresia, and abnormal semicircular canals in the ears. there are other major symptoms, such as the abnormal appearance of the ears that are common in charge syndrome but less common in other conditions. some symptoms, such as a heart defect, may also occur in other syndromes or conditions, and thus may be less helpful in confirming a diagnosis. an infant suspected of having charge syndrome should be evaluated by a medical geneticist who is familiar with the syndrome2-3. choanal atresia is present in 35-65 % of cases with charge syndrome. the back of the nasal sinuses on one or both sides narrowed (stenosis) or doesn't connect with the back of the throat (atresia). cranial nerve abnormality can also be seen in 90-100% which includes missing or decreased sense of smell, difficulty in swallowing in 70-90% of cases, facial paralysis (palsy) on one or both sides 50-90%. heart defect are seen in 75 % of cases. the most frequent type is septal defect. growth retardation is seen in 80 % of cases and is first detected when the infant fails to grow normally in the first six months of life. it is due to growth hormone deficiency. the child’s growth tends to catch up after infancy. mental retardation is seen in 70 %. iq may range from normal to severe retardation. underdeveloped genitals are seen 80-90% of males and 15-25 % of females. ear abnormalities are seen in 95-100 % of cases in which ear is malformed. problems in the inner ear, such as abnormal semicircular canals or nerve defects, may result in deafness (60-90%)4. some of the problems include central nervous system disorders, pituitary abnormalities, swallowing difficulties, urinary tract malformations such as abnormal kidney shape or location, backup of urine from the bladder into the kidney (reflux), posterior urethral valves, cleft lip and/or palate, degeorge sequence (congenital absence of the thymus and parathyroid glands), facial features include square shape of the face and head, flat cheekbones, facial asymmetry, wide nose with a high bridge, omphalocele, tracheophageal fistula, esophageal atresia. if the child has a suspected hearing problem the otolaryngologist and audiologist can evaluate the child to determine if there are surgical procedures and/or assistive listening devices that can be considered. since these children often suffer from chronic otitis media (fluid in the middle ear), they need to be monitored on a regular basis. additionally, 210 the teacher of the deaf and hearing impaired will be able to assist in making recommendations for educational modifications and strategies. a speech pathologist is also likely to be involved in helping the child with speech issues. the cause of charge is not known. it is not known to be related to illness, exposure to drugs or alcohol during pregnancy and typically it does not occur to more than one person in a family. it is very rare and cannot be predicted. it is important however, to discuss risks for passing charge syndrome to future generations with a trained geneticist. children with charge require a great deal of medical management. there are often numerous surgeries to repair heart defects, choanal atresia, the gastrointestinal tract, the esophagus, cleft lip or palate, etc. although many of these procedures are done when the child is a newborn, some of the less lifethreatening problems may not appear until later or may have to wait until later in the life of the child to be addressed. children with charge syndrome are often sickly, especially in the early years. they frequently experience colds that turn into pneumonia. even conditions that would be minor in most children may become serious conditions for them. a coloboma is a hole in one of the structures of the eye, such as the lens, eyelid, iris, retina, choroid or optic disc. the hole is present from birth and can be caused when choroid fissure fails to close up completely before a child is born. a coloboma can occur in one or both eyes. the incidence of coloboma is estimated at around 0.5 to 0.7 per 10,000 births, making it a relatively rare condition. eyelid coloboma is a full-thickness defect of the eyelid. although an eyelid coloboma can occur in many locations, the most common position is at the junction of the medial and middle third of the upper lid. no lid appendages or accessory structures are usually seen within the coloboma5-6. some children with charge have problems with visual acuity (either near or far-sighted) which usually can be corrected with glasses. however, some of these children may also have field losses which can cause problems for them in reading, travel, reading sign language or doing other visual tasks. a teacher of the visually impaired can help in making recommendations for educational modifications and strategies. corneal protection is the primary goal in the medical and surgical treatment of eyelid colobomas. modalities that can be used either for small defects or for large defects awaiting definitive surgical therapy include artificial tears and ointment, moist chamber optical bandages, bedtime patching, dilating drops to improve vision due to central corneal opacity. the surgical procedure used depends on the size and the location of the defect7. if the eyelid coloboma is small and well managed with topical lubrication, then surgery may be delayed until later in childhood. usually, it is corrected by direct closure. the edges of the defect are freshened with sharp incisions, and precise anastomosis is preformed. the lid margin is brought together using a 2-layer approximation of the tarsus and the skin. lateral cantholysis and placement of near-far, far-near sutures may be necessary to minimize horizontal tension. if the eyelid coloboma is large; immediate surgical closure is usually needed to prevent corneal compromise7. a 2-stage reconstruction may be required for those defects that occupy greater than 4050% of the lid. the surgical procedure used depends on the involved lid. in the lower lid the modified hughes procedure is used which includes upper lid tarso conjunctival flap with retroauricular skin flap. upper lid is constructed using modified cutler-beard procedure which includes lower lid tarso-conjunctival flap with retroauricular skin flap. alternate techniques for either the upper lid or the lower lid include a semicircular flap from the lateral canthal area (tenzel or modified tenzel flap) and a full-thickness lid rotational flap8-9. author’s affiliation dr. irfan qayyum king edward medical university mayo hospital lahore dr. mohammad moin king edward medical university mayo hospital lahore dr. tanveer a chaudary agha khan medical college krachi dr. mumtaz hussain king edward medical university mayo hospital lahore reference 1. damien s, alain verloes. "charge syndrome: an update." 211 european journal of human genet. 2007; 15: 389-99. 2. verloes, alain. "updated diagnostic criteria for charge syndrome: a proposal." am j med genetics. 2005; 133: 306-8. 3. crawford js. congenital eyelid anomalies in children. j pediatr ophthalmol strabismus. 1984; 21: 140-9. 4. marles sl, greenberg cr, persaud tv, et al. new familial syndrome of unilateral upper eyelid coloboma, aberrant anterior hairline pattern, and anal anomalies in manitoba indians. am j med genet. 1992; 42: 793. 5. collin jr. congenital upper lid coloboma. aust nzj ophthalmol. 1986; 14: 313. 6. ankola pa, abdel-azim h. congenital bilateral upper eyelid coloboma. j perinatol. 2003; 23: 166-7. 7. hauben dj, tessler z. one-stage reconstruction of a large upper lid defect in a newborn. plast reconstr surg. 1989; 83: 337-40. 8. putterman am. wedge resection of eyelid margin in the treatment of abnormal eyelid margins. arch ophthalmol. 1995; 113: 1458-9. 9. patipa m, wilkins rb, guelzow kw. surgical management of congenital eyelid coloboma. ophthalmic surg. 1982; 13: 212-6. microsoft word tariq farooq babar 97 original article clinical indications for evisceration and orbital implant trends tariq farooq babar, mahfooz hussain, mir zaman pak j ophthalmol 2009, vol. 25 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: tariq farooq babar eye specialist house no.123, street no. 6 f-1 phase 6, hayatabad peshawar received for publication september’ 2008 … ……………………… purpose: to assess the demographic characteristics and indications for evisceration. material and methods: this study was conducted in the department of ophthalmology, khyber institute of ophthalmic medical sciences, hayatabad medical complex, peshawar from january 2004 to october 2006. the demographic characteristics and indications for evisceration were analyzed. results: a total of 77 eyes of 76 patients underwent evisceration. male patients were 78.9% and female 21%. right eye was involved in 50% of cases and left in 48.6%. one patient (1.3%) had bilateral evisceration. 25% patients were below 16 year of age, while 30.2% patients were between 17 and 40 years and 44.7% were above 41 years of age. the most common indication for evisceration was traumatic endophthalmitis in 54.5%, followed by painful blind eye in 18%, postoperative endophthalmitis following cataract surgery in 14.2%, perforated corneal ulcer in 7.7% and endogenous endophthalmitis in 5%. spherical prosthesis implantation was carried out in 58.4%. extrusion of implant occurred in 26.6%. conclusions: trauma is the most common cause for evisceration followed by painful blind eye and postoperative endophthalmitis following cataract surgery. the victims are usually young males following ocular trauma and elderly following intra ocular lens implantation for age related cataract. spherical implant extrusion remains the most common complication. 98 ames beer is said to have been the first person who performed evisceration in 1817. it is a form of mutilating surgery involving removal of intra ocular contents through an incision in the cornea or sclera. the remaining tissues containing optic nerve, sclera, extraocular muscle and periorbita are left undisturbed 1. the major indication for evisceration is severe intraocular infection or suppurative endophthalmitis2. the advantages of evisceration over enucleation include superior final cosmetic outcome after fitting the prosthesis, minimally affects orbital contents and allows removal of infection without the potential risk of spread to subarachnoid space, where possibility of imeningitis is real2. frequency of extrusion of orbital implants appear3 also lower after evisceration. however sympathetic ophthalmia may be encountered after evisceration. the objectives of our study were to determine the demographic characteristics and clinical indications for evisceration and the orbital implant trends in our set up. material and methods this study was a cross-sectional descriptive case study. it was carried at khyber institute of ophthalmic medical sciences, hayatabad medical complex, peshawar from june 2004 to december 2006. the patients requiring evisceration were admitted and their particulars entered into a proforma. the sex, age and indication for evisceration were noted. the type of trauma blunt or penetrating was acquired from history. whether the trauma was associated with a foreign body was also determined. history of present or past intraocular surgery was also taken, especially cataract surgery with and without intra ocular lens implantation. if history pointed towards corneal ulcer – type and duration were looked for and in case of painful blind eye its cause was determined. b – scan was carried out to rule out intraocular tumour. in cases of endogenous endophthalmitis source of septicemia was investigated and blood cultures were taken. the type of surgery performed – with and without spherical ball implant was determined and their complications assessed. results a total of 76 patients underwent evisceration with one patient requiring bilateral evisceration. there were 60 male patients (78.9%) and 16 female (21%). right eye was eviscerated in 39 cases (50%) and left in 37(48.6%). nineteen patients (25%) were less than 16 years of age, with 23 patients (30%) between 17 and 41 years of age and remaining 34 patients (44.7%) were above 41 years of age. the indications for evisceration are given in table 1 with traumatic endophthalmitis as the most common indication in 42 eyes (54.5%). the causes for traumatic endophthalmitis are listed in table 2. all patients with postoperative endophthalmitis had cataract surgery with intraocular lens implantation. no association could be found for endogenous endophthalmitis. the various procedures offered are listed in table 3. extrusion of implant was observed in 12 eyes (26.6%). discussion the controversy regarding the advantages and disadvantages of enucleation versus evisceration continues unabated. in the past, enucleation was preferred for the fear of sympathetic ophthalmia after evisceration4. there are some recent studies that has demonstrated the high safety of evisceration and low risk of sympathetic ophthalmia5. during a period of 2 years and 7 months 77 eyes of 76 patients underwent evisceration in our department. su and yen reported a total of 2,779 primary orbital implants, comprising 1,919 (69%) enucleations and 860 (30.9%) eviscerations6. saeed et al7 traced 285 histopathology results from 1984 to 2003; 161 and 124 were evisceration and enucleation specimens respectively. comparison of the two 10 year periods (1984 – 93, 1994 – 2003) showed a preference for eviscerations over the 20 years period. table i: clinical indications for evisceration n = 77 clinical indications no. of eyes n (%) traumatic endophthalmitis 42 (54.5) painful blind and disfigured eye 14 (18.1) postoperative endophthalmitis 11 (4.2) perforated corneal ulcer 6 (7.7) endogenous endophthalmitis 4 (5.1) table 2: causes of traumatic endophthalmitis n = 42 j 99 inciting agent no. of eyes n (%) bomb blasty injury 9 (21.4) iron piece 7 (16.6) wood 4 (9.5) stick 3 (7.1) firearm injury/air gun injury 3 (7.1) stone 3 (7.1) thorn 3 (7.1) scissors 2 (4.7) nail 2 (4.7) mine blast 2 (4.7) knife 1 (2.3) unknown 3 (7.1) table 3: procedures performed n = 77 procedures no. of eyes n (%) evisceration with spherical implant large to medium size small size 45 (58.4) 27 (60) 18 (40) evisceration without implant 32 (41.5) tanuj et al4 electronically reviewed medical records of 52 patients who underwent evisceration. female patients outnumbered male counter parts [29 (55.8%) versus 23 (44.2%)]. in contrast males were predominently involved in the study by babar et al8. similarly in our study male patients were more than female [(78.9%) versus 21.0%]. the mean age at surgery was 52.8 + 24.0 years in tanuj et al4 study while the most common age encountered was above 60 years in 52% in babar et al8 study. in our study 25% patients were in paediatric age group, 30% between 17 and 40 years while 44.7% were above 41 years of age. the main indication for evisceration was traumatic endophthalmitis in 54.5% in our study. the common causes were bomb blast injury leading to irrepairably damaged globe with and without endophthalmitis and iron piece, wood, stick, firearm injury, stone, thorn etc causing severe endophthalmitis unresponsive to conservative regimen. painful blind eye was the second common indication for evisceration in 18%. this was followed by postoperative endophthalmitis following cataract surgery in 14%, perforated corneal ulcer in 7.7%. four cases (5.1%) had endogenous endophthalmitis, the cause which could not be ascertained. in tanuj et al4 study of comparing outcomes of enucleation and evisceration the bacterial keratitis and two (2.5%) mycotic corneal ulcer most common indications of eviscerations were blind painful eye in 58%, trauma 21%, endophthalmitis 20% and suprachoroidal haemorrhage in 2%. in babar et al8 study postoperative endophthalmitis was the most common indication for evisceration in 46.3% cases followed by trauma in 28.3% and corneal ulcer in 25.4%. shah desai et al9 studied the effectiveness of enucleation or evisceration in relieving pain from painful blind eyes and concluded that both are excellent in relieving pain. however, complications of surgery and orbital implants can cause recurrent pain. the procedures performed in our study were evisceration with spherical implant in 58.4%, and evisceration without implant in 41.5%. most implants inserted were spherical, sized 14 – 18 mm in diameter. the most common complication encountered was extrusion of implant in 26.6%. viswanathan et al10 evaluated current clinical practice in the united kingdom in the management of the anophthalmic socket. consultant ophthalmologists were surveyed by postal questionnaire. only 53% did enucleations or eviscerations. 92% inserted an orbital implant after primary enucleation, 69% after non-endophthalmitis evisceration, whereas 43% did so after evisceration for endophthalmitis. implant extrusion rates varies from surgeon to surgeon and range from 0% to 20% as concluded by liu11. alwitry et al12 analysed long term follow up of porous polyethylene spherical implants after enucleation and evisceration and revealed a significantly higher incidence of implant exposure after evisceration than after enucleation. in their opinion enucleation should be the procedure of choice when removing an eye to minimize the risk of subsequent complications, particularly orbital implant exposure. conclusions 100 ophthalmic trauma and painful blind eye are the leading indication for evisceration. evisceration for postoperative endophthalmitis still persists even in the new millennium. corneal ulcer and endogenous endophthalmitis although reversible can be an indication for evisceration. author’s affiliation dr. tariq farooq babar associate professor khyber institute of ophthalmic medical sciences hayatabad medical complex peshawar. dr. mahfooz hussain consultant ophthalmologist khyber institute of ophthalmic medical sciences hayatabad medical complex peshawar. dr. mir zaman senior registrar khyber institute of ophthalmic medical sciences hayatabad medical complex peshawar. reference 1. levine mr, fagien s. enucleation and evisceration. in: stewart wb. surgery of the eyelids, orbit and lacrimal system. volume 3, ophthalmology monographs 8, american academy of ophthalmology, 1995. 2. shore jw. evisceration. in: levine mr, ed: manual of oculoplastic surgery. new york: churchill livingstone. 1988: 189–94. 3. raflo gt. enucleation and evisceration. in: duane td, jaeger ea, eds: clinical ophthalmology. philadelphia: harper and row. 1986; 5. 4. nakra t, bensimon gj, douglas rs, et al. comparing outcomes of enucleation and evisceration. ophthalmology 2006; 113: 2270–5. 5. gurdal c, erdener u, irkee m, et al. incidence of sympathetic ophthalmia after penetrating eye injury and choice of treatment.ocul immunol inflamm. 2002; 10: 223–7. 6. su gw, yen mt. current trends in managing the anophthalmic socket after primary enucleation and evisceration. ophthal plast reconstr surg. 2004; 20: 274–80. 7. saeed mu, chang by, khandwala m, et al. twenty years review of histopathological findings in enucleated / eviscerated eyes. j clin pathol. 2006; 59: 153-5. 8. babar tf, masud z, iqbal a, et al. should ophthalmologist ever opt for mutilating operations like evisceration, enucleation and exenteration. pak j ophthalmol. 2003; 19: 113–7. 9. shah–desai sd, tyers ag, manners rm. painful blind eye: efficacy of enucleation and evisceration in resolving ocular pain. br j. ophthalmol. 2000; 84: 437–8. 10. viswanathan p, sagoo ms, olver jm. uk national survey of enuceation, evisceration and orbital implant trends. br j ophthalmol. 2006; 6: (epub ahead of print). 11. liu d. evisceration techniques and implant extrusion rates. a retrospective review of two series and a survey of asoprs surgeons. ophthal plast reconstr surg. 2007; 23: 16-21. 12. alwitry a, west s, king j, et al. long term follow up of porous polyethylence spherical implants after enucleation and evisceration. ophthal plast reconstr surg. 2007; 23: 11-5. microsoft word atif mansoor 1 original article combined phaco trabeculectomy vs combined ecce trabeculectomy with iol implantation atif mansoor ahmed, tahir mahmood, muhammad asif pak j ophthalmol 2009, vol. 25 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … …………………… … correspondence to: atif mansoor ahmed ophthalmology department shaikh zayed hospital lahore received for publication february’ 2008 … …………… ………… purpose: evaluation and comparison of iop control and visual outcome after phacotrabeculectomy and conventional combined surgery in cases of co-existing cataract and primary open angle glaucoma. material and methods: this case control prospective study included the review of 50 patients who had undergone combined phacoemulsification with iol implantation and trabeculectomy (phacotrab group and 50 who had undergone combined ecce, iol implantation and trabeculectomy (ecce trab group), over a period of 12 months. evaluation was based on iop control, visual outcome and rate of complications. results: postoperative iop in both groups fell significantly (p=<0.05) below the preoperative medically controlled iop. at initial 2 months postoperative iop was almost similar in bothgroups (mean iop in phacotrab group was 11 mm hg vs mean iop in ecce trab group as 13 mm hg i.e p= >.050). at 12 months, the iop in phacotrab group was lower than ecce trab group. postoperative visual recovery was much better and faster in phacotrab group than in ecce trab group. the frequency of complication was significantly higher in ecce trab group. conclusion: phacotrabeculectomy provides more effective and sustained iop control and early visual recovery as compared to ecce trabeculectomy. 2 ost common ophthalmic surgical procedure is cataract extraction with iol implantation which is either done by ecce or phacoemulsification technique. in eyes with coexisting cataract and primary open angle glaucoma, patient require cataract surgery due to visual disability and glaucoma surgery to control iop. there is rapid advancement in the management profile of these patients with the advent of microsurgical ophthalmic techiniques1-3. since small incision phacoemulsification has emerged as most ideal and widely accepted technique for cataract surgery, it is justified to apply this qualitatively superior technique to patients with coexisting cataract and glaucoma4-7. this study was carried out to evaluate and compare the efficacy of combined phacoemulsification trabeculectomy with iol implantation and ecce trabeculectomy with iol implantation in terms of iop control and visual outcome. material and methods our study included hundred patients of cataract with coexisting primary open angle glaucoma who were found suitable for combined surgery according to selection criteria. all the eyes selected had coexisting cataract and glaucoma and decision to perform combined procedure was based on either inadequate control of iop medically or a cataract causing significant reduction of visual acuity. the choice of phacotrabeculectomy or combined ecce with trabeculectomy was randomized. in each case details regarding the patients age, sex, diagnosis, duration and effect of antiglaucoma treatment were noted. ophthalmic evaluation also included recording of visual acuity, iop, anterior segment bimicroscopy, gonioscopy, visual field recording and fundus examination wherever possible. informed written consent of the procedure was taken. topical tropicamide 1% drops were administered every 15 min for 3 times starting 1 hour before surgery. the eye was anaesthetized with a peribulbar block with equal amounts of lignocain 2% and bupivacaine 0.5%. the surgical procedure including wound construction, postoperative medications and examination procedures were standardized for both techniques respectively. in phacotrabeculectomy 4/0 black silk superior rectus bridal sutures was used for maximum exposure of superior limbal and bulbar area. after fornix based conjunctival flap was fashioned superiorly, a 4mm wide partial thickness scleral flap was raised around 12’o clock position 2-3 mm behind limbus and it was extend 1mm into the celar cornea. after entering the cystotome into anterior chamber under the corneoscleral flap, a central continuous tear curvilinear capsulorhexis was performed. aqueous was replaced with viscoelastic and single stab paracentesis was made at 3’0 clock position when right eye was operated and at 9 0 clock when left eye was operated. a 3.2 mm keratome entered the anterior chamber through the corneoscleral pocket followed by hydro dissection. single handed chop and flip phacoemulsification was performed and cortical remnants were aspirated manually with simcoe cannula. the capsular bag was inflated with viscoelastic and through same 3.2 mm tunnel incision, single piece acrylic foldable iol was implanted with injector delivery system. the viscoelastic was aspirated out of the eye and the anterior chamber was formed with air before fashioning deep scleral window at limbal area approximately 2x2 mm in size. a peripheral button hole iridectomy was made at 12’o clock and two 10/0 nylon sutures were used to fix the partial thickness flap to scleral bed. the conjunctival flap was closed with interrupted 10/0 nylon sutures. gentacin 20mg and dexamethasone 4 mg was injected subconjunctively in the inferior fornix. the ecce trab procedure consisted of a 4/0 black silk superior rectus bridal suture, a superior fornix based conjunctival flap was raised. a partial thickness limbal based scleral flap of 4/4 mm dimentions was made posterior to 12 0 clock limbus and was extended 1mm forward into the clear cornea. either can opener or a larger continuous tear central culvilinear capsulorhexis anterior capsulotomy was made, with cortical cleavage hydrodissection and relaxing incisions for the latter technique. corneal scissors opened the corneosclearl incision on either side of partial thickness flap and nucleus was expressed. one 10/0 nylon suture was inserted and tied on each side of corneo scleral flap. after remaining cortex was aspirated manually, the pmma iol was implanted in the bag. the viscoelastic which was injected before the iol implantation, was removed and anterior chamber was formed with the air. a block of deep corneaoscleral tissue, beneath the scleral flap was removed and peripheral iridectomy at 12 o’clock was m 3 made. the partial thickness scleral flap was sutured to the scleral bed with two 10/0 nylon sutures. the conjunctival flap was closed with interrupted 10/0 nylon sutures and inferior fornix sub conjunctival injection of dexamethasone and gentamycin was given. postoperatively combination of dexamethasone and tobramycin was given topically to all the patients at 2 hourly intervals in first week and then tapered off over next 3 weeks. patients were reviewed regularly over 12 months period and at each visit their visual aquity, iop (by applanation tonometery) and postoperative complications were recorded. results were analysed using the students t-test. mean values were given with standard deviation. results our study comprised of 50 patients (50 eyes) in each group. the demographic and disease profile are given in table 1 showing significant difference of age between two groups and slightly increased female to male ratio. followup was completed for 1 year. intraocular pressure fell significantly after surgery on both groups (p>0.05). in first week iop was as low as 8-12 mm. hg in majority of patient in both groups (86% in phacotrab group and 64% in ecce trab group) (table 2). in subsequent weeks all the eyes show gradual rise in iop which finally stabilized around 2-3 months post operately well within the acceptable limit that is between 13-16 mm hg in majority eyes (table 2). at 12 months good iop control (i.e 13-16 mm hg) was noted in 78% cases of phacotrab as compared to 68% in ecce trab group without any medical or surgical interventions) which show more sustained control of iop in phacotrabeculectomy group. table 1: demographic and disease profiles of patients in the ecce trab and phaco trab groups. phaco trab ecce trab (n=50) p. value age (years) 45-83 (57.06 ±9.12) 61-95 (64.03±12.3) p < 0.05 sex (f:m) 1.38:1 1.08:1 p >0.05 visual acuity preoperative 6/12 or bettern n (%) 6/18 to 6/24 n(%) 6/36 to 6/60 n(%) cf and worse n (%) 12 (24) 33 (66) 4 (8) 1 (2) 7 (14) 20 (40) 22(44) 11(22) >0.05 preoperative iop (mm hg) 23.12 ± 4.55 24.52±7.6 p < 0.05 cup disc ratio mean ± sd 0.73±0.15 0.75±0.15 p=1 table 2: comparative evaluation of sequential changes in post-operative iop duration iop 8-12mm 13-16mm 17-21mm 22-30mm 30mm phaco trab n(%) ecce trab n(%) phaco trab n(%) ecce trab n(%) phaco trab n(%) ecce trab n(%) phaco trab n(%) ecce trab n(%) phaco trab n(%) ecce trab n(%) one week 43 (86) 31 (62) 6 (12) 15 (30) 1 (2) 2 (4) -1 (2) -1 (2) 3-4 week 38 (76) 17 (34) 11 (22) 26 (52) 1 (2) 5 (10) -1 (2) -1 (2) 2-6 month --42 (84) 37 (74) 7 (14) 11 (22) 1 (2) 1 (2) -1 (2) 6-12 months --39 (87) 34 (68) 10 (20) 14 (28) 1 (2) 2 (4) -- table 3: comparative evaluation of post-operative complication 4 complications onset duration (phacotrab) 50 cases n (%) (ecce trab) 50 cases n (%) hyphaema 1-3 days 1 (2) 3 (6) shallow ac 1-7 days 1 (2) 4 (8) uveitis 1-3 weeks 3 (6) 5 (10) significant striate keratitis 1-14 days 2 (4) 5 (10) high iop (without medication) 2-6 months 1 (2) 2 (4) posterior capsule opacification 6-12 months 2 (4) 5 (10) pupil capture with iol 0-3 months nil 3 (6) table 4: best corrected visual acuity (6-12 months) visual acuity phaco trab n (%) ecce trab n (%) 6/6-6/9 33 (66) 20 (40) 6/12-6/18 14 (28) 26 (52) 6/24-6/60 2 (4) 2 (4) cf or worse 1 (2) 2 (4) table 5: summary of results from other studies chia and goldberg wishart and austin stewart et al present study phaco-trab ecce-trab phaco-trab ecce-trab phaco-trab ecce-trab phaco-trab ecce-trab post op iop 13.3 ± 4.3 15.3 ± 4.5 17.4 16.8 15.1 ± 3.00 12.8 ± 3.6 11 ± 3.1 13 ± 3.9 post op astigmatism 1.46 ± 1.01 2.07 ± 1.46 1.48 2.90 post op. va better at each visit better at each visit better at each visit better at each visit complication rate more more more more although bothgroups exhibited significant visual improvement from baseline, more rapid improvement and stabilization of best corrected visual aquity was noted in phacotrabeculectomy group (table 3). at 2-3 months postoperatively in the phacotrabeculectomy group, the best corrected va of 6/12 or better was achieved in (66%) cases as compared to (40%) cases in ecce trab group which was statistically significant. at 12 months this patern was maintained. best corrected va of 6/24 or better was achieved in more than 80% cases of both groups. poor visual outcome of 6/36 or worse was seen in 4% cases of phacotrab group and 8% of ecce trab group which was attributed to preop advanced glaucomatous damage, failure to control ongoing glaucomatous damage and or development of posterior capsular opacification which was significantly more in ecce trab group. intra operative complications included iris chew in one case (2%) of phacotrabeculectomy and hyphaema in 2 cases (4%) in ecce trabeculectomy group. the posterior capsule was torn in one eye in phacotrabeculectomy group (2%) and in three eyes in ecce trab group (6%). vitreous loss was encountered in one of these 3 cases (2%). a posterior 5 chamber lens was used in all cases within the sulcus fixation. early postoperative complications were hyphaema striate keratopathy and shallow anterior chamber ranging between 2-10% cases in each group. shallow anterior chamber in one case (2%) of phaco trab group was due to excessive filtration with bleb leakage which was managed by applying an additional suture. delayed postoperative complications included posterior capsular opacification which was significantly higher in ecce trab group (10%) as compared to phacotrab group (4%) managed with yag laser capsulotomy. discussion trabeculectomy when combined with cataract extraction and iol implantation has been found effective and safe (1-14). the patients potentially benefit in terms of iop control, arrest of progressive glaucomatous damage and useful visual rehabilitation, also avoiding the risk of subsequent cataract extraction precipitating drainage failure or subsequent trabeculectomy in a site scarred by cataract surgery with its poorer success. the combined procecure also protects the patients from potentially dangerous iop spikes in glaucomatous eyes post cataract surgery15-16. the argument against combined prodedures is increased ocular manipulation leading to increase inflammation and increased risk of bleb failure and poor visual recovery. large incision for ecce trabelectomy is associated with significant astigmatism with its very prolonged stabilization curve in terms of visual recovery as compared to small incision for phacoemulsifitation trabeculectomy. phacotrabeculectomy has also provided superior qualitative and quantitative control of iop in terms of range and duration of iop control2 as compared to ecce trabeculectomy even after 12 months post-operatively. it was proved from the fact that iop remained between 8-12 mm hg in majority of cases after phacotrabeculectomy as compared to 12-16mm hg in ecce trabeculectomy one month postopera-tively and this pattern was maintained even at 12 months. also severity and incidence of uncontrolled glaucoma after the combined procedure was less in phacotrab group as compared to ecce trab group as one case in phaco trab group which had iop between 22-30 mm hg at 6-12 months. two patients in ecce trab group has iop close to or more than 30 mm hg. one of these patients required release of scleral suture and one patient required redo trabeculectomy when iop was not controlled medically. visual recorvery was also superior in terms of faster qualitative and quautitative gain after phacotra-bulectomy mainly due to least surgical trauma and ocular disruption (table-3). phaco traubeculectomy and ecce trabeculectomy were found to be effective and comparable in terms of incidence of intra operative and perioperative complications (table 4). summarized results from various studies comparing these two combined procedures are shown in (table-5), showing comparable outcome in our study in term of iop control, visual recovery and complication rates. in conclusion both phaco trab and ecce trab are safe and effective procedures but phaco trab has benefit of smaller incision, less ocular disruption and inflammation with faster visual recovery and better bleb survival with more effective iop control. author’s affiliation dr. atif mansoor ahmed assistant professor department of ophthalmology shaikh zayed hospital, lahore dr. tahir mahmood head department of ophthalmology shaikh zayed hospital, lahore dr. muhammad asif department of ophthalmology shaikh zayed hospital, lahore reference 1. gimbel hv, meyer d. small incision trabeculectomy combined with phacoemulsification and iol implantation. j. cataract refract surg. 1993; 19: 92-6. 2. parihar jks, gupta rp, sahoo pk, et al. phaco trabeculectomy versus conventional combined technique in coexisting glaucoma and cataract. mjafi 2005; 61: 139-42. 3. sheilds mb. another evaluation of combined cataract and glaucoma surgery. am j ophthalmol. 1993; 115: 806-11. 4. wedrich a, menapale r, radax u, et al. long term results of combined trabeculectomy and small incision cataract surgery. j cataract refract surg. 1995; 21: 49-54. 5. allan b, barret gd. combined small incision phacoemulsification and trabeculectomy. j cataract refract surg. 1993; 19: 97-102. 6. lyle wa, jin jc. comparison of a 3 and 6mm incision in combined phacoemulsification trabeculectomy. am j ophthalmol. 1991 111: 189-96. 6 7. allan b, barret gd: combined small incision phacoemulsification and trabeculectomy. j cataract refract surg. 1993; 19:97-108. 8. wischart pk, austin mw. combined cataract extraction and trabeculectomy. phacoemulsification compared with extracapsular techbnique. ophthalmic surg. 1993; 24: 814-21. 9. stewart wc, crinkley cm, carison an. results of trabeculec-tomy combined with phacoemulsification versus trabeculecto-my combined with extracapsular cataract extraction in patients with advanced glaucoma. ophthalmic surg. 1994; 25: 621-7. 10. sayyad f, helal m, maghraby a, et al. one site versus two site phacotrrabulectomy: a randomized study. j cataract refract surg. 1999; 25: 77-82. 11. percival spb. glaucoma triple procedure of extracapsular cataract extraction, posterior chamber lens implantation and trabeculectomy. br j ophthalmol. 1985; 92: 1506-16. 12. mccartney dl, memmen je, stark wj, et al. the efficacy and safety of combined trabeculectomy, cataract extraction and intraocular lens implantation. ophthalmology. 1988; 95: 754-63. 13. chia wla, goldberg i. comparison of extracapsular and phacoemulsification cataract extraction techniques when combined with iol placement and trabculectomy. australia and new zealand j ophthalmol. 1998; 26: 19-27. 14. longstaff s, warmald r, mozouer ra, et al. glaucoma triple procedures: efficacy of iop control and visual outcome. ophthalmic surg. 1990; 21: 786-93. 15. krupin t, feih me, bishop ki. postoperative iop rise in open angle glaucoma after cataract or combine cataract and filtration surgery. ophthalmology 1989; 96: 579-84. 16. mcguigan ljb, gottsch js, stark wj. extracapsular cataract extraction and posterior chamber lens implantation in glaucoma patients. arch ophthalmol. 1986; 104: 1301-8. microsoft word jamil barni corrected 201 original article efficacy of supratarsal injection of triamcinolone acetonide (corticosteroid) for treating severe vernal keratoconjunctivitis (vkc) refractory to all conventional therapy jameel a. burney, syed shahab ali, mirza shafiq ali baig pak j ophthalmol 2010, vol. 26 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: jameel ahmed burney a-23 saima villas, block b, north nazimabad. karachi.36679644 received for publication july’ 2010 …..……………………….. purpose: to determine the efficacy of supratarsal injection of triamcinolone acetonide for treating severe vernal keratoconjunctivitis (vkc) patients refractory to all conventional therapy. material and methods: the study was conducted at the eye department of sindh government qatar hospital orangi town karachi from january 2007 to april 2009. eighteen patients of vernal keratoconjunctivitis (vkc) resistant to all established therapy were included in the study. patients presenting with signs and symptoms of the disease were clinically evaluated. they were given 0.5 ml (20 mg) of supratarsal injection of triamcinolone acetonide. these cases were then evaluated and followed up for the relief of signs and symptoms of the disease and rise of intraocular pressure for a period of two years. results: all patients experienced dramatic symptomatic relief from the disease. reduction in cobblestone papillae by 50% was noted within three weeks after giving injection of corticosteroids in all patients. there was reduction in shield ulcer in 22% of patients and limbal involvement in 33% of patients in one to three weeks. no complications or side effects were observed. conclusion: the dramatic clinical improvement, symptomatic relief from the disease and lack of increase in intraocular pressure suggest that supratarsal injection of corticosteroids may be a valuable therapeutic approach for the treatment of refractory vkc. kc is typically a condition affecting young people at an average age of 12 years with a predilection to young boys1. wide range of therapeutic modalities are available for its treatment2. milder cases can often be treated with cold compresses, tear substitutes, topical vasoconstrictors3,4 or topical antihistamines5. more advanced cases may be treated with topical nonsteroidal anti inflammatory agents6,7 mast cell stabilizers8-10 and topical corticosteroids11. the treatment of severe vkc remains a difficult problem for the patient and physician. patients with advanced vkc with large cobblestone papillae, severe limbal involvement, or a shield ulcer which is rare but serious complication,12 pose especially difficult problem because they are often markedly symptomatic and debilitated by their condition2. due to the general frustration with the treatment of the refractory patients, new therapeutic agents have been tried and used in the treatment of advanced vkc. oral prostaglandin mediators, such as aspirin13,14 and suprofen15 have been used to alleviate some signs and symptoms of recalcitrant vkc. more recently, topical ketotifen fumarate16, levocabistine hydrochloride17, and lodoxamide18 appear to provide some relief in mild and moderately affected patients. however their efficacy has been similarly disappointing when applied to patients with severe refractory disease. there is a scant literature on this v 202 topic. we carried out a study in our department to use a technique of supratarasal injection of corticosteroids, which in our experience has been an effective and safe adjunct in the treatment of these patients whose disease is difficult to treat. material and methods total of 18 patients were included in the study with the signs and symptoms of sever vkc refractory to maximum medical therapy between the ages of 5 to 25 years. any patient with systemic disease, history of ocular trauma, cataract, raised intraocular pressure, ocular surgery, follow up less than 4 months and age below 5 and above 25 years were excluded from the study. each patient was treated by a stepwise protocol before selection for the study. all patients received topical sodium cromoglycate 4%, lodoxamide 0.1%, prednisolone acetate 0.125%. no patients were treated with topical cyclosporine or oral therapy. despite this treatment patients had symptoms including severe itching, foreign body sensation, ropy mucus discharge or photophobia that interfered with their daily routine. inadequate control of clinical signs included persistent severe giant cobblestone papillae (fig. 1), shield ulcer, persistent limbal conjunctival thickening and edema. such patients were then subjected to supratarsal injection of corticosteroid. written consent was taken from the patients or parents. injection was given either in local (l.a or topical) or general (g.a) anesthesia. with a cotton tipped applicator the superior tarsus was lifted away from the globe. a 27 gauge needle was used to inject 2.5 ml of 2% lidocaine with epinephrine. the needle was placed subconjunctivally 1mm above superior tarsal border as shown in (fig. 2), to avoid marginal arcade blood vessels which produced a ballooning of the potential space between conjunctiva and the muller’s muscle. after allowing sufficient time for anesthesia to take effect, a 27-gauge needle was positioned in the supratarsal space between conjunctiva and muller’s muscle and 0.5 ml of triamcinolone acetonide (20mg) was slowly injected (fig.2). eye pad was applied for 24 hours. after the injection patients were maintained on topical sodium cromoglycate 4% four times a day. if shield ulcers were present, prophylactic topical moxifloxacin was added. patients were followed up for the relief of symptoms as well as for resolution of clinical signs. resolution of cobblestone papillae was defined as a 50% decrease in the size or number of papillae. resolution of limbal involvement was considered complete with the disappearance of limbal edema, trantas’ dots and limabal papillae. resolution of shield ulcer was defined as complete healing of the epithelial defect. patients were also observed for the potential complications including blephrpotosis, skin depigmentation, infections, motility disturbances, conjunctival scarring and increase in intraocular pressure. results total of 18 patients were included in the study. age groups are shown in table 1. sex and presentation of vkc are shown in table 2. table 1: age group (years) no. of patients n (%) 5-10 8 (44.44) 10–25 10 (55.55) total 18 (100) table 2: sex no. of patients n (%) male 13 (72.22) female 5 (27.77) presentation limbal vkc 6 (33.33) shield ulcer 4 (22.22) all patients were treated with 0.5 ml of triamcinolone acetonide (20mg) and followed up for a minimum of four months to two years after injection. all patients experienced prompt and dramatic response of their debilitating symptoms especially photophobia after one to five days. the symptoms and clinical response was dramatic. a 50% decrease in cobblestone papillae occurred within 15 days for all patients. in fourteen of 18 patients complete disappearance of cobblestone papillae occurred after supratarsal injection. in the six patients with limbal vkc the edema and thickening, limbal papillae and trantas’ dots resolved in 30 days. in the four patients with shield ulcer the epithelial defect healed completely by three weeks after injection. after the treatment by supra tarsal injection, all the patients 203 were maintained on conventional therapy such as topical sodium chromoglycate 4%, lodoxamide 0.1%. two patients required repeat injection after seven weeks and became asymptomatic within 15 days. potential complications including blephrpotosis, skin depigmentation, infections, motility disturbances, conjunctival scarring and increase in intraocular pressure have not been observed. fig. 1: fig. 2: discussion vkc is not uncommon condition in our country. mild to moderate cases respond to conventional treatment however there remains a need for more effective treatment modalities in refractory cases of vkc. in the past severe refractory vkc has been treated by aggressive intervention including surgical excision of cobblestone papillae and cryotherapy of upper tarsus. such radical therapeutic modalities have been largely ineffective and have resulted in extensive scarring. current treatment options including tear substitutes, topical antihistamines, topical non steroidal antiinflammatory, mast cell stabilizers and topical corticosteroids are minimally effective in advanced disease. more recently oral prostaglandin mediators and new mast cell stabilizers have been used. in general the efficacies of these mediators have been disappointing when applied to refractory cases. agents such as topical cyclosporine have also been tried as adjunctive and monotherapy in these recalcitrant patients19,20. in those studies temporary symptomatic relief is particularly attained, but there is less effect on cobble stone papillae or shield ulcers. further, symptoms frequently recur on cessation of the cyclosporine. vkc usually resolves without complications unless it is over treated, treatment should be conservative and iatrogenic side effects should be avoided. any new therapeutic intervention should be designed with these considerations in the mind. supra tarsal injection was well tolerated by even the youngest individual. once one patient received the injection and experienced some symptomatic relief, their compliance with ongoing topical treatment regimen was much more constant. the increased compliance as the patient’s symptoms abated undoubtedly contributed to successful post injection treatment. these results of our study are similar to the study done by holsclaw et al2. results attained with the supratarsal injection of corticosteroid both in signs and symptoms were dramatic and prompt. the clinical resolution of cobblestone papillae was universal. more surprising was the resolution of limbal edema and shield ulcer despite their lack of proximity to the site of injection in all patients. although factors such as relief of symptoms and decrease in cobblestone papillae can be somewhat subjective, each patient attained such impressive symptomatic improvement and marked decrease in cobblestone papillae that the effect was dramatic. furthermore in fourteen patients complete disappearance of cobblestone papillae occurred after supratarsal injection. similarly the limbal edema and shield ulcer completely resolved in all patients with these features. in summary we used supratarsal injection of corticosteroid injection as a new therapeutic modality for treating refractory vkc. the procedure is well tolerated even in young patients. in our experience this technique provided prompt symptomatic relief in 204 100% of severely debilitated patients. clinical resolution of such varied features as large cobblestone papillae, limbal edema and shield ulcer was attained in the patients. the substantial improvement in this small series of patients, combined with the apparent lack of side effects, leads us to suggest that supratarsal injection of corticosteroid may prove to be a valuable addition to our therapeutic approach in treating refractory vkc. conclusion the results of our study are very encouraging. the dramatic clinical improvement, symptomatic relief from the disease and lack of increase in intraocular pressure suggest that supratarsal injection of corticosteroids may be a valuable therapeutic approach for the treatment of refractory vkc. since the study is on small scale and single centre, we recommend that the study should be done at multicentre and high scale to reach a definite conclusion. author’s affiliation dr. jameel a. burney chief ophthalmologist department of ophthalmology sindh govt. qatar hospital orangi town, karachi dr. syed shahab ali ophthalmologist department of ophthalmology sindh govt. qatar hospital orangi town, karachi dr. mirza shafiq ali baig associate professor department of ophthalmology unit-i dow university of health sciences & civil hospital, karachi reference 1. kanski jj. conjunctiva: vernal kerato-conjunctivitis. in: clinical ophthalmology. 6th edition. oxford: butterworth hienemann, 2007: 235-40. 2. holsclaw ds. whitcher, wong, morgolis. ajo supratarsal injection of corticosteroid in the treatment of refractory vernal keratoconjunctivitis. 1996; 121; 3: 243-49. 3. abelson mb, allansmith mr, friedliander mh. effects of topically applied ocular decongestant and antihistamine. am j ophthalmol. 1980; 90: 254-7. 4. abelson mb, butrus si, weston jh, et al. tolerance and absence of rebound vasodilation following topical ocular decongestant usage. ophathalmology. 1984; 91: 1364-7. 5. abelson mb, paradis a, george ma, et al. the effects of vasocon-a in the allergen challenge model of acute conjunctivitis. arch ophthalmol. 1990; 108; 520-4. 6. ballas z, blumenthal m, tinkelman d, et al. clinical evaluation of ketrolac tromethamine 0.5% ophthalmic solution for treatment of seasonal allergic conjunctivitis. surve ophthalmol. 1993; 38: 141-8. 7. tinkelman d,rupp g, kaufman h, et al. ketrolac tromethamine 0.5% ophthalmic solution in the treatment of seasonal allergic conjunctivitis: a placebo controlled trial. surve ophthalmol. 1993; 38: 133-40. 8. foster sc, duncun j. randomized clinical trial of topically administered cromolyn sodium for vernal kreatoconjunctivitis. am j ophthalmol. 1980; 90: 175-81. 9. hennawi ml. clinicl trial of with 2% sodium cromoglycate (opticrom) in vernal conjunctivitis. br j ophthalmol. 1980; 64: 483-6. 10. tabbara kf, arafat nt. cromolyl effects of vernal keratoconjunctivitis in children. arch ophthalmol. 1977; 95: 2184-6. 11. leibowitz hm, kupferman a. anti-inflammatory medication. int ophthalmol clin. 1980; 20: 117-34. 12. ozbek z, burakqazi az, rapuano cj. rapid healing of vernal schield ulcer after surgical debridment. a case report. cornea 2006; 25: 472-3. 13. abelson mb, butrus si weston jh. aspirin therapy in vernal conjunctivitis. am j ophthalmol. 1983; 95: 502-5. 14. meyer e, krause e, zonis s. efficacy of antiprostaglandin therapy in vernal conjunctivitis. br j ophthalmol. 1987; 71: 4979. 15. buckley dc, caldwell dr, reaves ta. treatment of vernal conjunctivitis with suprofen, atopical non-steroidal antiinflammatory agent. invest ophthalmol vis sci. 1986; 27: 29-37. 16. mikuni i, fujiwara t, togawa k. therapeutic effects of new, anti-allergic ophthalmic preparation [letter]. tokai j exp clin. 1982; 7: 279. 17. smith lm, southwick pc, derosia dr, et al. the effects of levocabastine, anew higly potent and specific hiatamine h1 receptor antagonist, in the ocular allergen challenge model of acute conjunctivitis. arvo abstract. invest ophthalmol vis sci. 1989; 30: 502. 18. chiou ly, chiou gcy. ocular anti-inflammatory action of a lipooxygenase inhibitor in the rabbit. j ocul pharmacol. 1985; 1: 383-90. 19. benezra d, pe’er j, brodsky m, et al. cyclosporin eyedrops for the treatment of severe vernal keratoconjunctivitis. am j ophthalmol. 1986; 101: 278-82. 20. secchi ag, tognon ms, leonardi a. topical uses of cyclosporin in the treatment of severe vernal keratoconjunctivitis. am j ophthalmol. 1990; 110: 641-5 microsoft word darakhshanda corrected 17 original article outcome of silicone oil removal in eyes undergoing 3-port parsplana vitrectomy darakhshanda khurram, dr. imran ghayoor pak j ophthalmol 2011, vol. 27 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: darakhshanda khurram house no.22, safari villa 1, rawalpindi received for publication july’ 2010 …..……………………….. purpose: the present study was designed to evaluate the outcome of silicone oil removal in eyes, which underwent vitreoretinal surgery using silicone oil as internal tamponade. material and method: a total of 50 patients who under went 3-port parsplana vitrectomy with silicone oil used as an internal tamponade were enlisted in the month of march 2005 and april 2005 and were followed for the period of twelve months till march 2006. all the patients were selected by a convenience type of non-probability purposive sampling. results: out of 50 patients, at the end of study period 31 achieved anatomical success that is the completely flat retina, 16 of these eyes achieved functional outcome, which was defined as attainment of va ≥ 5/200. 19 eyes suffered retinal redetachment, out of which in 8 eyes retinal redetachment occurred in 1st week and in rest subsequently. conclusion: retinal detachment after silicone oil removal is common. a fewer than half the detachments occur within the first week. etinal surgery has progressed from external tamponade via buckling and indentation to the concept of removing human vitreous and replacing it with an inert substance which act as an internal tamponade to keep two layers of retina apposed, thus attempting to close tears and relieving traction. instrumentation for pars plana vitrectomy were developed by machemer1 who, after the clinical experimental work of d. kasner, in 1960 proved that an eye could function without vitreous. injection of silicon oil after vitrectomy was tried first by haut2,3 in 1976, though cibis4,5 introduced silicon oil in retinal surgery and j. scott6,7 refined its use. current vitrectomy techniques and use of silicon oil tamponade to treat complicated retinal detachments have led to improvement in the success rate of retinal detachment surgery. the rate of recurrence of retinal detachment in eyes treated with silicon oil tamponade varies from 21.4%8,9 to 77%11-13. in our study we have tried to assess the complications arising from the removal of silicone oil. materials and methods fifty eyes of fifty patients, who underwent silicone oil removal after successful 3 port parsplana vitrectomy with silicone oil tamponade for various indications (table 1), in liaquat national hospital, were included in this observational prospective study. all the patients selected for this research were enrolled in this study after their consent, during march 2005 and april 2005, and were followed up for 12 months. the patients were enlisted for silicone oil removal either because of completely flat retina for at least 8 weeks or because of the development of complications associated with silicone oil retention. a detailed proforma was filled containing both their medical and ocular examination. all eyes underwent complete preoperative ocular examination and assessment of best-corrected visual r 18 acuity. preoperative data regarding age, sex, eye involved, details of first surgery i.e. parsplana vitrectomy, band encircling, membrane peeling, use of heavy liquids and silicone oil injection (1000 cs) were recorded. visual acuity, lens status, adequacy of endolaser photocoagulation was reviewed. one consultant performed all the surgeries. silicone oil was removed by oil-fluid exchange. when oil was removed by e ports plana technique, it needed oil air exchange. removal of lens by phaco and lensectomy were carried out followed by implanting intraocular lens in phakic and aphakic eyes. the need for more endolaser photocoagulation and cryotherapy were assessed on the operating table. ports were closed and conjunctiva sutured afterwards. patients were examined on first postoperative day, 1 week, and then 4 weekly intervals as in prescribed proforma till the end of study period. at the end of the study the data was compiled and evaluated statistically. anatomical success was defined as a completely flat retina that remains attached till the last follow-up. retinal redetachment due to focal or diffuse peripheral leaking breaks due to ongoing prolifrative vitreoretinopathy or intrinsic contraction of retina within twelve months of removal of silicone oil was considered a failure. functional outcome was studied as the recovery of ambulatory visual acuity of ≥ 5/200 at the last followup. refractive changes occurring after removal of silicone oil from phakic, aphakic and pseudophakic eyes were documented. results 50 eyes of fifty patients attending the out patient department of ophthalmology lnh were included in this prospective study. of these 37 were male, 13 female and 3 were below 18 years. the average age of patient was 43 years (range 8-72 years). in 10 patients visual acuity in fellow eye was count fingers. silicone oil was successfully removed from the eyes of 50 patients. the mean duration of intraocular silicone oil tamponade ranged from 2 months to 18 months. out of these patients who primarily underwent 3 port parsplana vitrectomy with silicone oil, 25 eyes had pvr, 7 eyes had giant retinal tear, 12 eyes had advanced diabetic eye disease, 3 had eye trauma and 3 eyes with other diagnosis included two with uveitis and one with eale’s disease. indications flat retina for at least 8 weeks is the most common indication and was present in 15 patients. in these patients no complication of silicone oil was found. there was absence of traction and active proliferation. the mean intraocular pressure in these patients was 17 mm of hg. the mean preoperative visual acuity was 6/48, (table 2). persistently high intraocular pressure of 25 mm of hg or more was the major indication of oil removal and was present in 20 patients. average baseline iop was found to be 42mm of hg (range 30-55mm of hg). in these patients persistently high iop was not controlled by standard iop lowering drugs. out of these patients two had developed relative afferent pupillary defect. emulsification of silicone oil occurred in 10 eyes. silicone oil presented in anterior chamber as inverse hypopyon in 2 patients. the mean duration of silicone oil tamponade in these eyes was 6 months. keratopathy occurred in 13 eyes in the form of persistent epithelial defects, stromal edema, and corneal opacity. out of which 8 were pseudophakic and 5 were aphakic. two patients developed band keratopathy and also needed chelation. cataract developed in 4 eyes. it was of nuclear type and hindered the proper visualization of fundus along with decreasing the visual acuity and needed removal. outcome of silicone oil removal main objective of the study was to determine the outcome of intravitreal silicone oil removal. in this regard the main complication we encountered in our study population was re-detachment which occurred in eyes after removal of silicone oil. in the immediate post operative period (with in first week), a fibrin response was seen in 2 eyes, vitreous hemorrhage was observed in two eyes and phthisis bulbi in 4 eyes, (table 3). anatomical outcome retina remained attached in 42 (84%) eyes during the first week after the removal of the silicone oil. however redetachment occurred in 11 eyes (22%) with macula off in 4 eyes within the first month of the follow-up. of these 19 (38%) eyes in which redetachment occurred, 7 underwent further operations. 19 table 1: silicone oil used indication group described indication no. of patients male female all diagnosis 50 37 13 pvr, all cases 25 pvr, uncomplicated 20 18 02 complicated 05 04 01 giant tear 07 05 02 diabetic retinopathy all cases 12 05 dr, with detachment 10 05 02 without detachment 02 02 trauma 03 03 00 miscellaneous 03 01 02 table 2: removal of silicone oil in the indicated group complications no. of patients n(%) raised iop 15 (30) oil emulsification 10 (20) cataract formation 4 (8) band keratopathy 2 (4) table 3: success rate after surgery success achieved no. of patients n (%) anatomical success 31 (62) visual success 14 (45) fuctional success of the 31 (62%) eyes with successful silicone oil removal and in which retina was stable till the last follow-up, 15 eyes had final visual acuity of < 6/60. two had optic atrophy due to intractable glaucoma, and rest had corneal complications. eleven eyes had final visual acuity between 6/60 and 6/18, and 3 had final visual acuity between 6/12 and 6/9. refractive outcome mean difference in refraction after silicone oil tamponade in phakic eyes was +6.00 d sph (+2.00 d sph to +8.00 d sph). mean refraction change in aphakic eyes with silicone oil was –5.50dsph (-3.50 d sph to-7.00 d sph). removal of silicone oil changed the refraction in aphakic eyes towards hypermetropia, mean +6.00dsph. discussion silicone oil is used as a long-term internal tamponading agent in complicated retinal detachment surgeries. unlike intraocular gas, silicone oil is a liquid polymer with no expansile property, and it is not absorbed. it is immiscible in water and perfluorocarbon liquid and creates a readily visible meniscus during intraoperative use. although silicone oil’s viscosity is greater than that of gas, its buoyancy and surface tension are far less than that of intraocular gas, and therefore it exerts less retinal tamponade. our concept for the use of silicone oil have evolved and changed with growing clinical experience and results of experimental studies. various preoperative variables that were analyzed for correlation with anatomical failure included indications of primary silicone oil use, history of trauma, number of previous surgeries, causes of failure, type of pvr, visual acuity, extent of retinal detachment. vitrectomy with silicone oil removal is also a preferred choice when dealing with retinal detachments occurring because of penetrating traumas especially for breaks which are too posterior to be adequately covered by an explant. regarding the data given in the literature, the rate of vitreoretinal complications after silicone oil removal, even in cases with a clinically stable appearing retinal situation, is rather high in severe proliferative vitreoretinopathy (pvr) and lower in most advanced cases of severe proliferative diabetic retinopathy requiring silicone oil tamponade. silicone oil removal has to be considered a procedure of ill defined risks, especially if silicone oil is really used as a last therapeutic resort in most severe cases of complicated retinal detachment. the benefits of silicone oil removal are better in those cases in which there is minimal pvr. exact criteria for the timing and safe removal of silicone oil in these complex vitreoretinal disorders still needs to be defined. the most authoritative study of silicone oil for pvr is by the silicone study group, which published 20 its results in 19928. in the primary surgery group they found no significant difference between perfloropropane gas and silicone oil in achieving visual acuity better than or equal to 5/200 (1.5/60). they also achieved macular attachment in 73% of the patients treated with perfluoropane versus 64% in-group 1 and 61% in-group 2 for silicone oil. it was stated that a longer tamponade of perfluoropropane was the reason for the higher success rate with c3f8. the use of silicone oil in pvr has stimulated the development of some newer approaches. federman and eagle9 reported a 360 posterior retinotomy in a series of 18 patients. visual acuity of 20/400 or better was achieved in 22% of the patients. in all instances the patients had at least two previous pars plana vitrectomies. the cases represented non-dissectable membranes, intraretinal fibrosis, incarcerated retina, or malpositioned choioretinal scars preventing reattachment by ordinary techniques. out of the 50 silicone oil filled eyes that underwent silicone oil removal, 31 eyes had completely flat retina after a follow-up period of 12 months. of these eyes 16 achieved functional success (defined as attainment of visual acuity of ≥ 5/200). the long term complication in this study was the presence of raised iop in about 30% of patients and only two patients developed band keratopathy which is in contrast to the silicone study in which glaucoma was observed in 8% of cases10 and band keratopathy was observed in 25% of patients11. the results of our study show that even if the indication is established very carefully, silicone oil removal results in a relatively high rate of complications of redetachment of the retina. in conclusion retinal detachment after silicone oil removal is common. a fewer than half the detachments occur within the first week and majority within the first month. re-detachment is more common after surgery for pvr than for pdr. author’s affiliation dr. darakhshanda khurram, alshifa trust eye hospital rawalpindi dr. imran ghayoor alshifa trust eye hospital rawalpindi reference 1. machemer r. massive peri-retinal proliferation. a logical approach to therapy. trans am ophthalmol soc. 1977; 75: 556. 2. haut j, ullern m, boulard ml, et al. utilisation du silicone intra oculaire apres vitrectomie comme traitement des retractions massive du vitre. bull soc ophthalmol fr. 1978; 361-5. 3. haut j, ullrn m, chatellier ph, et al. resultats de 200 cas d’injection intra oculaire de silicone associete a la vitrectomie. bull mem soc fr ophthalmol. 1979; 180-4. 4. cibis p a, okun e, canaan s. the use of liquid silicone in the retinal detachment surgery. arch ophthalmol. 1964; 590-2. 5. cibis pa. vitreous transfer and silicone injection. trans am acad ophthalmol. 1964; 983-7. 6. scott jd. the treatment of massive vitreous retraction by separation of pre-retinal membrane using liquid silicone. mod probl ophthalmol karger basal. 1975; 285. 7. scott jd. a rational for the use of liquid silicone. trans ophthalmol soc uk. 1977; 235. 8. silicone study group: vitrectomy with silicone oil or perfluoropropane gas in eyes with severe proliferative vitreoretinopathy: results of a randomized clinical trail: report 2 arch ophthalmol. 1992; 110: 780. 9. federman jl, eagle rc: extensive periretinal retinectomy combined with posterior 360-degree retinotomy for retinal reattachment in advanced proliferative vitreoretinopathy cases. ophthalmology. 1990; 97: 1305. 10. barr cc, lai my, lean js: postoperative intraocular pressure abnormalities in the silicon study: silicon study report 4 arch ophthalmology. 1993; 100:1629. 11. abrams gw, azen sp, barr cc. the incidence of corneal abnormalities in the silicone study: silicone study report 7 arch ophthalmology. 1995; 113: 764. 12. yeo jh, glaser bm, michels rg. silicon oil in the treatment of complicated retinal detachments: ophthalmology. 1987; 94: 1109. 13. cox ms, trese mt, murphy pl. silicon oil for advanced proliferative vitreoretinopathy: ophthalmology. 1986; 93: 646. microsoft word zahid hussain awan 165 review article blindness and poverty zahid hussain awan, p.s. mahar, m. saleh memon pak j ophthalmol 2011, vol. 27 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zahid hussain awan isra postgraduate institute of ophthalmology, karachi submission of paper august 2011 acceptance for publication september’ 2011 …..……………………….. isual impairment or loss of vision is considered to be the most feared disability. this stems from the fact that since ancient times, the sense of sight is thought to be the most important sense. in addition to being a serious public health concern, it also has a great impact on the social and economic wellbeing of an individual. blindness as a condition has fascinated man throughout history and continues to do so. in some cultures the blind is thought to be blessed with divine and psychic powers while in others blindness is considered a form of punishment for improper moral or social conduct. the negative perceptions about blindness result in social exclusion and rejection of the blind. the blind are left out of the decision making process and have limited opportunities for education and employment. this results in decreased self-esteem and a feeling of worthlessness. limited social contacts accompanied by loss of employment and a drastic change in lifestyle leads to depression. most of the world’s visually impaired population lives in the developing countries where basic health infrastructure is lacking or severely deficient and the health expenditure is insufficient in meeting the needs of its people. in addition, majority of people of developing countries are plagued by poverty and live below the poverty line. the situation in pakistan is not different from rest of the developing world. the annual gdp allocated to health in pakistan is 2%1 and 24%2 of its population lives below poverty line. whereas it is a well-known fact that when any form of disability is found amongst the economically deprived, the disability itself, through social and economic exclusion, further entangles the disabled into the web of poverty. while it has been studied that the prevalence of blindness is higher in the economically impoverished, the economic and social implications of poverty, compounded by visual impairment, has not been studied. visual impairment as defined by the international statistical classification of diseases, injuries and causes of death, tenth revision (icd-10)3, visual impairment encompasses both low vision and blindness (table i). low vision is defined as best corrected visual acuity worse than 6/18 and equal to or better than 3/60 in the better eye or visual impairment categories 1 and 2. a person with low vision is one who uses or is potentially able to use vision for the planning and/or execution of a task. v 166 blindness is defined as the best corrected visual acuity4 in the better eye of less than 3/60 or visual impairment categories 3, 4 and 5 (table 1). visual impairment – magnitude of the problem there are around 314 million visually impaired people in the world5. this figure comprises of 153 million people with uncorrected refractive error and 161 million people with best corrected refractive error. out of the 314 million visually impaired people worldwide, 45 million of them are blind – 37 million with best corrected refractive error and 8 million with uncorrected refractive error. although more than 82% of all blind people are 50 years and older, blindness in children is a vital problem worldwide. there are 1.4 million blind children below 15 years of age and more than 12 million children between 5 to 15 years of age that are visually impaired because of uncorrected refractive errors. 87% of the world’s visually impaired live in developing countries. in the eastern mediterranean region-d (emr-d), to which pakistan belongs, the prevalence of blindness in 2002 was 0.97% and prevalence of low vision was 2.9%. these prevalence figures do not take uncorrected refractive errors into account. in emr-d, the prevalence of visually impaired from uncorrected refractive error is 1.19% (age group: 5->50 years) and the prevalence of blindness from uncorrected refractive error in adults >50 years is 0.95% in rural and 0.4% in urban areas6. in pakistan, according to the pakistan national blindness and visual impairment survey7, the estimated number of blind individuals of all ages in the year 2003 was 1.25 million. the prevalence of blindness among individuals of all age groups was 0.9%. the age and gender standardized prevalence of blindness in adults 30 years and older was found to be 2.7%. the estimated numbers of blind individuals age 30 and above in the four provinces of pakistan is shown in (table 2). the prevalence of blindness in rural areas was more (3.8%) than prevalence in urban areas (2.5%). after adjustment for age difference, women were found to share a significantly greater burden of blindness and severe visual impairment. if the prevalence rate remains the same, the number of blind persons in pakistan in the year 2020 will be 2.4 million8. causes of blindness globally, the leading cause of blindness is cataract followed by uncorrected refractive error (table 3). 85% of all visual impairment globally is avoidable9. in pakistan, according to the pakistan national blindness and impairment survey, the leading cause of blindness in adults more than 30 years of age is cataract (table 4). while globally 39.1% of all blindness is attributable to cataract, in pakistan the burden of blindness due to cataract is significantly larger at 51.5%.85.4% of blindness is avoidable in pakistan. individuals with moderate visual impairment (<6/18 to ≥6/60) had refractive error (43%) and cataract (42%) as the cause of their visual impairment. economic burden of blindness disability has often been associated with poverty and the people with disability are amongst the “poorest of the poor10.” because of physical and social barriers, people with disability face loss of opportunity and are excluded because of institutional, environmental and attitudinal discrimination. there are several studies11,12 that indicate that people in the lowest socioeconomic group share a greater burden of blindness than those in the higher socioeconomic group. some eye diseases, such as trachoma, are known to be a direct consequence of poverty. blindness as a disability leads to unemployment resulting in loss of income, increased level of poverty, lower standard of living and decrease in affordability of health care services. this leads to a vicious cycle of poverty and blindness where majority of the people disabled by blindness are poor and their disability leads to a further decline in their economic productivity and quality of life (fig. i). blindness has a huge economic cost attached to it. the cost of blindness depends on the cause and duration of blindness as well as on the availability of family members and alternative sources of income. it also depends on number of economically productive individuals that are affected by blindness. the global economic productivity loss from unaccomodated blindness is projected to grow from $19 billion in the year 2000 to $ 50 billion in the year 2020. the global productivity loss from blindness and low vision combined is projected to grow from $ 42 billion in the year 2000 to $ 110 billion in the year 202013, 14. 167 table i: categories of visual impairment visual acuity with possible correction 0. category worse than equal to or better than 1. mild or no visual impairment 6/18, 20/70 2. moderate visual impairment 6/18, 20/70 6/60, 20/200 3. severe visual impairment 6/60, 20/200 3/60, 20/400 4. blindness 3/60, 20/400 1/60 or counts fingers at 1 meter 5/300 (20/1200) 5. blindness no light perception 6. undetermined or unspecified source: international classification of disease-10 (2007) table 2: provincial distribution of estimated number of blind adults province estimated number of blind individuals punjab 769,000 sindh 200,000 nwfp 114,000 baluchistan 52,000 total 1,140,000 source: prevalence of blindness and visual impairment in pakistan: the pakistan national blindness visual impairment survey (jadoon et al, 2006) the economic burden of visual impairment can be considerably lessened with appropriate interventions. the two leading causes of blindness, cataract and uncorrected refractive error, can be easily treated by cost-effective interventions such as surgery and eyeglasses. a study in india in the year 199815 suggested that if 52% of blindness in india that is due to cataract is corrected with an investment of $0.15 billion; the saving in annual gnp would be $1.1 billion. it has also been reported that after cataract surgery people become economically productive again16. another study estimates that if cataract surgery is provided to 95% of those who require surgery then 3.5 million disability adjusted life years (dalys) would be averted17.the global provision of eyeglasses would result in a net economic gain even if up to $1000 were spent per person18. table 3: global causes of blindness as a percentage of total blindness in the year 2004 cataract 39.1% uncorrected refractive error 18.2% glaucoma 10.1% age-related macular degeneration 7.1% corneal opacity 4.2% diabetic retinopathy 3.9% childhood blindness 3.2% trachoma 2.9% onchocerciasis 0.7% other 10.6% source: bulletin of world health organization 2008;86:63-70 social and psychological effects of blindness blind people experience social exclusion and are left out of decision making process. they are also deprived of academic achievements and schooling. it is thought that the predominant negative perceptions about blindness are the cause of this social exclusion. another factor that influences a blind person’s social status is the ability to contribute to household income. visually disabled unemployed persons face greater difficulty in being accepted in the local community. additionally, lack of support from government and social institutions hinders provision of a conducive environment for people affected by blindness to become a productive part of the society. family members of the visually impaired may undergo four reactions – denial, refusal, acceptance and overprotection. overprotection is thought to be the most counterproductive as it reinforces the 168 patient’s physical and financial dependence on others19, 20. the families must accept the condition of their relative and provide a supportive role to promote and encourage the autonomy of their blind relative. table 4: causes of blindness in pakistan as a percentage of total blindness avoidable causes cataract 51.5% corneal opacity 11.8% uncorrected aphakia 8.6% glaucoma 7.1% posterior capsular opacification 3.6% refractive error 2.7% diabetic retinopathy 0.2% total avoidable causes 85.4% unavoidable causes phthisis/absent globe 2.7% macular degeneration 2.1% optic atrophy 0.9% amblyopia 0.5% other 8.4% total unavoidable causes 14.6% source: causes of blindness and visual impairment in pakistan (dineen et al, 2007) blindness has great deal of emotional and psychological consequences. there are three types of responses to sight loss; acceptance, denial and depression/anxiety21. acceptance is the best response to any disability and denial serves as a defense mechanism which may actually prove helpful in coming to terms with blindness. depression as a physiological reaction may be encouraged and may even have a cathartic effect but it is also more likely to assume pathological characteristics22. in a study by fitzgerald23, 90% of the studied cases, reported depressed mood accompanied by symptoms of depression including suicidal ideation. in another study24, depressive symptoms were more common in blind than in deaf persons. the duration and severity of depression depends on the patient’s socioeconomic status. persons with moderate to high socioeconomic standings and young age maintain good social relations and avoid isolation. these characteristics are protective against the onset of psychopathology25. conclusion multiple studies reinforce the notion that any form of disability, including blindness, afflicts the poor. the economic cost of blindness results in further decline of the economic status of the individual, as well as, the entire family. the social discrimination of the blind alienates them from the society and results in depression and suicidal ideation. in order to reduce the economic costs associated with blindness and improve the quality of life, prevention is the best strategy. awareness programs should be arranged for the general population regarding eye care and diseases in general and blindness in particular. in addition, the government should provide optimum health services and ensure access to healthcare. health camps should be organized in all areas of the country where screening for eye diseases is also done. this way, through early diagnosis and intervention, blindness would be prevented. investment should also be made by the government in social sector. opportunities for education and support to the blind for attending school should be provided. also, opportunities should be created for the blind to be included in the work force and they should be provided with training to live independently. the families of the blind should be provided social support, training and guidance so that they can take good care of the social and emotional needs of their blind family member as well as themselves. if above recommendations are implemented, we would be able to ensure that the blind are given access to basic human rights and live their lives with dignity and as productive members of their families and community. 169 visual impairment poor health lack of ability to assertrig hts low level of develop ment low self esteem exclude d from formal and informa l limite d social contac ts low expect ation from comm unity lack of employ ment opport unities and limited access to basic health care lowest priority for resource s, such as food highest risk of illness, accident and impairment source: adapted from yeo and moore, 2003 poverty exclusion limited access to education andemploym ent limited access to land and shelter poor sanitation limited access to healthcare insufficient or unhealthy food excluded from political and legal process forced to accept hazardous working conditions unhygienic and overcrowded living conditions malnutrition and poor health – physicallyweak unable to assert rights loss of income excluded from political and legal processes fig. 1 income generating opportunities reduced 170 author’s affiliation dr. zahid hussain awan community ophthalmologist isra postgraduate institute of ophthalmology karachi prof. p.s mahar isra postgraduate institute of ophthalmology karachi dr. m. saleh memon director isra postgraduate institute of ophthalmology karachi reference 1. world health organisation, 2006; http://www.who.int/ ountries/pak/en/ 2. cia factbook 2010;http://www.theodora.com/wfbcurrent/ akistan/pakistan_economy.html 3. icd 10th revision, 2007:http://apps.who.int/classifications/ pps/icd/icd10online/ 4. the prevention of blindness. report of a who study group, geneva, world health organization, 1973 (who technical report series, no. 518). available: http://whqlibdoc.who.int/ trs/who-trs-518.pdf 5. resnikoff s, pascolini d, etya’ale d et al. global data on visual impairment in the year 2002. bulletin of the world health organization. 2004; 82: 844-51. 6. resnikoff s, pascolini d, mariottia sp, et al. global magnitude of visual impairment caused by uncorrected refractive errors in 2004. bulletin of the world health organization. 2008; 1: 86. 7. jadoon mz, dineen b, bourne rra, et al. prevalence of blindness and visual impairment in pakistan: the pakistan national blindness and visual impairment survey. iovs. 2006; 11: 47. 8. dineen b, bourne rra, jadoon mz, et al. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007. 9. yeo r, moore k. including disabled people in poverty reduction work: ‘‘nothing about us, without us.’’ world development. 2003; 31: 571–90. 10. dandona l, dandona r, srinivas m et al. blindness in the indian state of andhra pradesh investigative ophthalmology and visual science. 2001; 42: 908-16. 11. gilbert ce, shah sp, jadoon mz, et al. poverty and blindness in pakistan: results from the pakistan national blindness and visual impairment survey. bmj. 2008; 336: 29-32. 12. smith af, smith jg. the economic burden of global blindness: a price too high. br j ophthalmol. 1996; 80: 276–7. 13. kevin d. frick and allen foster. the magnitude and cost of global blindness: an increasing problem that can be alleviated; am j ophthalmol. 2003; 135: 471-6. 14. shamanna, br, dandona l, rao gn. economic burden of blindness in india. indian j ophthalmol. 1998; 46: 169-72. 15. javitt j, venkataswamy g, sommer a, et al. the economic and social aspect of restoring sight. acta: 24th international congress of ophthalmology jp lippincott, new york. 1983; 1308-12. 16. baltussen r, sylla m, mariotti sp. cost-effectiveness analysis of cataract surgery: a global and regional analysis. bull world health organ. 2004; 82: 338-45. 17. vision 2020: the right to sight. available: http://www.vision2020.org/main.cfm 18. shulz pj: reaction to the loss of sight, in psychiatric problems in ophthalmology, edited by pearlman j, adams g, sloan s. spring-field, il, charles c thomas. 1977; 60-73. 19. diego de leo, hickey pa, meneghel g, et al. cantor, blindness, fear of sight loss, and suicide. psychosomatics. 1999; 40. 20. adams l, pearlman t: emotional response and management of visually handicapped patients. psychol med. 1970; 1: 233-40. 21. riffenburgh rs. the psychology of blindness. geriatrics. 1967; 22: 127-33. 22. fitzgerald rg. reactions to blindness: an exploratory study of adults with recent loss of sight. arch gen psychiatry. 1970; 22: 370-9. 23. abolfotouh ma, telmesani a. a study of some psycho-social characteristics of blind and deaf male students in abha city, asir region, saudi arabia. public health. 1993; 107: 261-9. 24. ash ddg, keegan dl, greenough t. factors in adjustment to blindness. can j ophthalmol. 1978; 13: 15-21. microsoft word nazullah khan 87 original article demographic study of trachoma patients and their response to azithromycin nazullah khan, mushtaq ahmed, sadia sethi, abdul baseer, sabir mohammad pak j ophthalmol 2010, vol. 26 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nazullah khan department of ophthalmology kth, peshawar. received for publication july’ 2009 …..……………………….. purpose: to study demographics of trachoma patients and their response to azithromycin. material and methods: this was observation and clinical assessment study done for one year from june 2006 – june 2007. the study was carried out, in an out patient eye clinic at district bannu on eye patients, on random basis. the strategy investigated was the use of single dose azithromycin treatment for those who were found to be having clinically active trachoma, as well as all members of their household. all patients were followed for three months and followup was done at one week, one month and three months. results: 5000 patients were examined randomly during the year 2006-07 for various ocular ophthalmic problems, out of which 120 (2.4%) cases were having signs of acute trachoma. among these patients, 108 (90%) were female and 12 (10%) were male. with single dose treatment of azithromycin 96 (80%) patients completed their three months follow-up 103 (85.83%) completed one month follow-up and 117 (97.50%) completed 1st week follow-up. compliance of the patients was 100%. only two patients got recurrence after 2nd follow-up. conclusion: there is a very high frequency of trachoma patients in district bannu and the main victims of the disease were women folk of the community. it is concluded that a single dose of azithromycin is very effective for the treatment of trachoma. rachoma is the second leading cause of blindness worldwide1. according to the world health organization, currently 84 million people, mostly children, have active disease, and another 7.6 million people have trichiasis – a stage of trachoma in which the upper eyelid turns inward and one or more eyelashes rub against the eyeball2. an estimated 10% of the world’s population lives in endemic areas and is at risk of developing trachoma. global loss of productivity related to impaired vision and blindness from trachoma is thought to be as high as $us 5.3 billion annually3. more than 55 countries have been identified as endemic for trachoma, most of them in africa and asia4. transmission occurs from eye to eye via hands, clothing and other fomites. flies have been identified as a major vector for the spread of infection. recent molecular epidemiological research from the northern territory showed different chlamydia trachomatis strains in coastal compared with inland communities, indicating that trachoma transmission may occur more within communities or within groups of neighboring communities rather than between farflung, distant communities6. world health organization guidance for antibiotic treatment of trachoma currently includes a 6 week course of tetracycline ointment twice daily or single dose of azithromycin, on the other hand, has been shown to be effective against c. trachomatis with one dose administered orally7. azithromycin is in the azalide class of antibiotics. it has unique pharmacokinetic properties that make it ideal for treating trachoma; good oral bioavailability and distribution to t 88 tissues, sustained high tissue levels with low protein binding, and high intracellular concentration is important in treating chlamydia trachomatis with azithromycin8. world health organization recommends the “safe” strategy for the management of trachoma: surgery for trichiasis, antibiotics for active disease, facial hygiene, environmental improvement to reduce the transmission of the disease9-11. material and methods this study was based on clinical observations and examination of eye patients of either sex in an out patient clinic. the total duration of the study was from june 2006 to may 2007. cases selected randomly on the basis of inclusion criteria (age between one year to 60 years, acute cases without complication of trachoma) and exclusion criteria (age below one year and above 60 years, those allergic to macrolides, chronic trachoma with complications and pregnant women). these patients were divided into two groups in group-a were children one to 15 years and in group b were adults 16 to 60 years. diagnosis of trachoma made clinically with typical symptoms and signs. after confirmed clinical diagnosis of the trachoma condition in the patients, all the patients were put on the following recommended treatment protocol: 1. topical application of oxytetracyclin ointment q.i.d 2. azithromycim, 20mg/kg body weight in children and 1 gm. stat dose in adults all the patients were followed up for three months at one week, one month and three months. in this study no data on surgical indication, intervention, complication and success is included. results 5000 patients were examined randomly for various ocular/ ophthalmic problems, out of which 120(2.4%) cases were having typical signs of trachoma. in groupi, 36 (30%) were children and in group-ii, 84 (70%) were adults. out of 120 cases 96 (80%) patients completed their three months follow-up, 103 (85.83%) completed one month follow-up and 117 (97.50%) completed 1st week follow-up. compliance of the patients was 100%. only 2 (1.66%) patients got recurrence after 2nd follow-up. out of 120 patients 108 (90%) were female and 78% were house wives, 18% were students of islamic madrassa and 4% were below school going age. 12 (10%) were male (98%) of them were from islamic madrassa and (2%) were house man. (98%) of these patients were low socioeconomic condition and only (2%) have a satisfactory socioeconomic condition. discussion trachoma is a common infectious disease of eyes caused by an obligate intracellular organism, chlamydia trachomatis, which causes blindness throughout the world, by irreversible corneal destruction. this diseases is totally eradicated from the developed counties, and now trachoma was largely forgotten as a public health issue until recently, when a new antibiotic donation program, coupled with renewed focus by the world health organization (who), rekindled interest in eradicating blinding trachoma by the year 2020. trachoma continues to be hyper endemic in many of the poorest and most remote areas of africa, asia australia and middle east12. the pathogenesis of trachomatis microorganism causes mild to severe bulbar conjunctival congestion with inflammation and in most complicated cases the inverted eye lid made the eyes susceptible for entropion. during this study conducted majority of the patients were female in both age groups. many different antibiotics have been suggested and trialed for use against active trachoma13. single dose oral azithromycin was a more effective treatment for active trachoma than tetracycline ointment as applied by care givers14. according to world health organization (who) guidelines, all members of a community should receive mass antibiotic treatment when prevalence of active trachoma is greater than 10 percent among one to nine year old children15. in areas where prevalence is greater than 50 percent, mass antibiotic distribution may be viable tool for elimination of trachoma. this is illustrated in a study of three ethiopian villages including 710 patients who received mass oral azithromycin distribution area 30 months period, the mean prevalence declined from 43 to < 1 percent16-17. a randomized trial of 1452 patients in ethiopia showed that single dose azithromycin reduced postoperative trichiasis recurrence rates by one third compared with topical tetracycline (7 versus 10 percent)19. the benefit of perioperative azithromycin may be more significant 89 in severe trichiasis eyelashes touching the cornea or more than five lashes touching the globe20,21. trichiasis and entropion are more common in women than men, possibly because of recurrent infection with c. trachomatis resulting from close contact with children. when the eye lid, specially the upper one, was averted many follicles with congestion were present22. in our study most of the patients of trachoma were young females and professionally most of them were house wives and of low socioeconomic condition. women are at increased risk of active infection because of their care taking activities with young children. if compliance is inadequate with topical preparations, women may form a significant source of re-infection of the community. administration of the drug and monitoring of compliance was considerably easier with azithromycin, compared to tetracycline topical ointment. the results of these studies have clearly identified that azithromycin offers an important new weapon in antibiotic intervention for trachoma control. azithromycin has not been approved for use in pregnant women by the food and drug administration in the united states. face washing helps to interrupt the transmission of trachoma, since ocular and nasal secretions are potential sources of infection with c. trachomatis, improved facial cleanliness could reduce transmission to others, as well as reducing auto-reinfection. it is difficult to measure facial cleanliness accurately, many cross-sectional surveys have shown that children with clean faces are less likely to have trachoma, and are less likely to have severe trachoma23. conclusions it has been concluded that trachoma is a disease of poverty overcrowding and lack of cleanliness and the best treatment is single oral dose azithromycin and tetracycline ointment, improving water supply, latrine provision and fly control. good facial hygiene aims to reduce transmission, the risk of autoinfection in a community, and the risk of attracting flies. author’s affiliation dr. nazullah khan registrar ophthalmology department khyber teaching hospital peshawar dr. mushtaq ahmed registrar ophthalmology department hmc, peshawar dr. sadia sethi associate professor ophthalmology khyber teaching hospital peshawar dr. abdul baseer tmo, eye a unit khyber teaching hospital peshawar dr. sabir mohammad medical officer eye a unit khyber teaching hospital peshawar reference 1. thylefors b, negrel ad, pararajasegaram r, et al. global data on blindness. bull world health organ. 1995; 73: 115-21. 2. world health organization. report of the eighth meeting of the who alliance for the global elimination of trachoma. geneva: world health organization. 2004, 29-31. 3. frick kd, hanson cl, jacobson ga. global burden of trachoma and economics of the disease. am j trop med hyg. 2003; 69: 1-10. 4. whitcher jp, srinivasan m, upadhyay mp. corneal blindness: a global perspective. bull world health organ. 2001; 79:21421. 5. emerson pm, lindsay sw, alexander n, et al. role of flies and provision of latrines in trachoma control: clusterrandomised controlled trial. lancet. 2004; 363: 1093-8. 6. stevens mp, tabrizi sn, muller r, et al. characterization of chlamydia trachomatis omp1 genotypes detected in eye swab samples from remote australian communities. j clin microbiol. 2004; 42: 2501-7. 7. tabbara kf, abu-el asrar a, et al. single dose azithromycin in the treatment of trachoma. a randomized controlled study. ophthalmology. 1996; 103: 842-6. 8. foulds g, shepard rm, johnson rb. the pharmacokinetics of azithromycin in human serum and tissues. j antimicrob chemother. 1990: 25: 73-82. 9. baly r, lietman t. the safe strategy for the elimination of trachoma by 2020: will it work? bull world healt org. 2001;. 79: 233-6. 10. kuger h, solomon aw, bachan j, et al. a critical review of the safe strategy for the prevention of blinding trachoma. lancet infect dis. 2003; 3: 372-91. 11. emerson pm, cairncross s, bailey rl, et al. reveiwo of the evidence base for the “f” and “e” components of the safe strategy for trachoma control. trop med int health. 2000; 5: 5l5-27. 12. grayston jt, wang sp, yeh lj, et al. importance of reinfection in the pathogenesis of trachoma. rev infect dis. 1985; 7: 717-25. 13. richard jc, bowman, asillah, cv dehn, vm goode, et al. operational comparison of single-dose azitrhmycin and typical tetracycline for trachoma. inves ophthalmol and vis scien. 2003; 41; 4074-9. 90 14. soloman aw, zondervan m, kuper h, et al. trachoma control: a guide for programme managers. world health organization 2006. 15. melese m, alemayehu w, lakew t, et al. comparison of annual and biannual mass antibiotic administration for elimination of infections trachoma jama. 2004; 299: 778. 16. gill da, lakew t, alemayehu w, et al. complete elimination is difficult goal for trachoma programs in severely affected communities. clin infect dis. 2008; 46: 564. 17. melese m, chidam bambaram jd, alemayehu w, et al. feasibility of eliminating ocular chlamydia trachomatous in repeat antibiotic mass treatments. jama. 2004; 292: 721. 18. west sk, alemayehu w, munoz b, et al. azithromycin prevents recurrence of severe trichiasis following trichiasis surgery: randomized trial in ethiopia. arch ophthalmol. 2006; 124: 309. 19. west s, alemayehu w, munoz b, et al. azithromycin prevents recurrence of severe trichiasis following trichiasis surgery: star trial ophthalmol epidimiol. 2007; 14: 273. 20. zhang h, kandel rp, atakari hk, et al. impact of oral azithromycin in recurrence of trachomatous trichiasis in nepal over 1 year. br j ophthalmol. 2006; 90: 943. 21. mabey d, fraser-hurt n. antibiotics for trachoma (cochrane review). cochrane database syst rev. 2002; 1: cd001860. 22. grayston jt, wang sp, yeh lj, et al. importance of reinfection in the pathogenesis of trachoma. rev infect dis. 1985; 7: 717-25. 23. schemann jf, sacko d, malvy d, et al. risk factors for trachoma in mali. int j epidemiol. 2002; 31: 194-201. microsoft word tahir masaud arbab 121 original article topical use of cyclosporine in the treatment of vernal keratoconjunctivitis tahir masaud arbab, manzoor a mirza pak j ophthalmol 2011, vol. 27 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tahir masaud arbab zamzama medical centre, plot no 144, 7th neelum lane, 3rd zamzama street, opp. zamzama park, defence housing society, phase v karachi submission of paper august’ 2010 acceptance for publication september’ 2011 …..……………………….. purpose: to study the efficacy and safety of topical 2% cyclosporine in patients with vernal keratoconjunctivitis. material and methods: this is a placebo-controlled, clinical trial to evaluate the effects of topical 2% cyclosporine on patients with vernal keratoconjunctivitis. twelve patients were placed in the cyclosporine treatment group and eight patients were placed in the placebo group. all patients had a wash out period of one week in which they were advised not to instill any eye drop. after this period, patients underwent a detailed ophthalmic examination with specific note being made of itching, tearing, photophobia, mucous discharge and foreign body sensation. specific signs looked for on slit lamp biomicroscopic examination included conjunctival hyperemia, punctuate keratitis, trantas dots, limbal edema and papillae. patients were assigned at random to one of the study groups, either cyclosporine 2% eye drops or placebo eye drops administered four times daily to the both eyes. patients were examined weekly for a total follow-up period of 6 weeks. results: there were 18 males and 2 females in the study. patients had mean age of 11.6 years (range 7 to 19 years). there was a statistically significant decrease in symptoms and in the conjunctival hyperemia, punctate keratitis, and trantas dots in the group of patients treated with cyclosporine. no adverse effects were noted in the cyclosporine treated group. conclusion: topical cyclosporine appears to be safe and effective for treatment of vernal keratoconjunctivitis. ernal keratoconjunctivitis (vkc) is a chronic allergic conjunctivitis. the disease is usually bilateral and is more common among males. the signs and symptoms of vkc usually occur from april to august, although some patients have a perennial form of the disease1. the spectrum of disease differs in tropical and temperate countries2. the reported risk of visual loss is generally greater in tropical countries, which is about 10%3,4. the precise immunopathogenic mechanism is unknown but is thought to be more complex than a simple type 1 hypersensitivity reaction. the trophic changes are due to enhanced fibroblast proliferation and collagen deposition in epithelium and substantia propria caused by eosinophil and mast cell degranulation5. therapy for vkc includes the use of topical vasoconstrictors, antihistamines, inhibitors of mast cell degranulation and corticosteroids. the most effective treatment for vkc is topical corticosteroids, but it carries considerable risk of complications. corneal morbidity along with steroid related complications may lead to permanent visual impairment. therefore there is need for an alternative, effective, safe drug that can decrease the morbidity from this potentially blinding disease. cyclosporine is a non steroidal immunomodulating agent, which has been used widely in the treatment of such ocular inflammatory conditions as v 122 noninfectious, corticosteroid resistant, sight threatening uveitis and corneal graft rejection. cyclosporine can selectively suppress a variety of t lymphocyte function and has a unique ability to selectively suppress the synthesis and production of interleukin 26-8. in experimental animals, cyclosporine has been shown to suppress ige production in mice by interfering with t cell-dependent mechanism9. topical cyclosporine has been used in prevention of corneal graft rejection10 and treatment of ligneous conjunctivitis11. cyclosporine 2% eye drops has been used successfully in the treatment of patients with severe vernal keratoconjunctivitis12-14. we used topical cyclosporine in treatment of 20 patients with severe vernal keratoconjunctivitis. many of the patients were sensitive to high dosages of topical corticosteroids, with no other drug being effective in controlling their clinical signs and symptoms. the topical use of cyclosporine was assumed to be useful in these patients as a substitute or as a sparing factor for corticosteroids. material and methods the study was undertaken at sir syed hospital, karachi, from april 2009 to june 2010. twenty patients with a history of severe vkc who provided informed consent were included in the study. all cases had been previously treated with a variety of topical drops in the form of mast cell stabilizers, antihistamines, antiinflammatory drugs and steroids for at least one year before enrollment. patients with shield ulcer, epithelial defect, associated ocular or systemic diseases; those taking oral medicines were excluded from the study. all patients had a wash out period of one week in which they were advised not to instill any eye drop. only commercially available saline was given to the patients to be instilled if needed. after this period, patients underwent a detailed ophthalmic examination with specific note being made of itching, tearing, photophobia, mucous discharge and foreign body sensation. specific signs looked for on slit lamp biomicroscopic examination included conjunctival hyperemia, punctate keratitis, trantas dots, limbal edema and papillae. patients were assigned at random to one of the study groups, either cyclosporine 2% eye drops four times daily or placebo eye drops four times daily were administered to both eyes. a weekly record of their symptoms and signs was kept for a period of 6 weeks. all patients had a total follow-up period of 6 weeks. the grading system was followed for categorizing symptoms and signs of vkc. these were graded on a scale of 0-3 using the method described by bleik et al14. patients subjectively graded their symptoms and the questionnaire was completed by the examiner, who also recorded the signs. grading of symptoms symptoms of itching, tearing, photophobia, discharge and foreign body sensation were recorded for a period of 6 weeks. the symptoms were recorded at a scale of 0 indicating no symptoms, 1+ = mild symptoms of discomfort noticed (mostly just noticeable), 2+ = moderate discomfort noticed most of the day but did not interfere with daily routine activities, 3+ = severe symptoms disrupting daily routine activities and patient staying at home most of the time. grading of signs conjunctival signs hyperemia was graded as follows: 0 = no evidence of bulbar hyperemia, 1+ = mild bulbar hyperemia, 2+ = moderate bulbar hyperemia, and 3+ = severe bulbar hyperemia. upper palpebral conjunctiva was graded as follows: 0 = no papillary hypertrophy of the palpebral conjunctiva, 1+ = mild papillary hypertrophy, 2+ = moderate papillary hypertrophy (edema of the palpebral conjunctiva with hazy view of the deep tarsal vessels), 3+ = severe papillary hypertrophy where the papillary hypertrophy was in more than 50% of the surface. corneal signs punctate keratitis was graded as follows: 0 = no evidence of punctate keratitis, 1+ = one quadrant of punctate keratitis, 2+ = two quadrants of punctate keratitis, and 3+ = three or more quadrants of punctate keratitis. limbal signs trantas dots were graded as follows: 0 = no evidence of dots, 1+ = 1 to 2 dots, 2+ = 3 to 4 dots, 3+ = more than 4 dots. limbal infiltration. grading for limbal infiltration was as follows: 0 = no evidence of limbal infiltration, 123 1+ = less than 900 of limbal infiltration, 2+ = less than 1800 of limbal infiltration but more than 900, and 3+ = more than 1800 of limbal infiltration. medications one treatment regimen consisted of cyclosporine 2% eye drops, and the placebo eye drops. the bottles of cyclosporine and placebo eye drops were labeled appropriately. the cyclosporine used in this study was taken from agha khan hospital pharmacy. patient withdrawal none of the patients had adverse reactions to the topical medications that required withdrawal of the patient from the study. results age and sex distribution there were 18 males and 2 females in the study. patients had mean age of 11.6 years (range 7 to 19 years). twelve patients were placed in the cyclosporine treatment group and eight patients were placed in the placebo group. symptoms itching: eleven patients (91.6%) who were administered cyclosporine had decrease in itching, compared with 2 in the control group (25%). tearing: improved in 9 patients (75%) who were administered cyclosporine and 2 of the patients (25%) in the control group. photophobia: ten patients (83%) reported marked improvement in photophobia in the cyclosporine group and no patient (0%) reported any improvement in photophobia in the placebo group. discharge: decreased in 10 patients (83%) who were administered cyclosporine and 2 of the patients (25%) in the control group. foreign body sensation: improved in 10 patients (83%) who were administered cyclosporine and 2 of the patients (25%) in the control group. conjunctival signs conjunctival hyperemia: bulbar conjunctival hyperemia improved in 10 of 12 patients (83%) who were administered cyclosporine and 2 out of the 8 patients (25%) in the control group. papillary hypertrophy: showed no improvement with the use of cyclosporine. corneal signs punctate keratitis: eleven patients (91.6) out of 12 showed improvement with cyclosporine compared to1 of 8 patients (12.5%) treated with topical placebo drops. limbal signs trantas dots: showed decrease in number in 9 of 12 patients (75%) treated with cyclosporine compared with 1 of 8 patients (12.5%) in the group treated with placebo. limbal infiltration and edema improve in 9 patients (75%) treated with cyclosporine with 2 patients (12.5%) treated with placebo drops. discussion vernal keratoconjunctivitis is a common disorder in our part of the world. most of the patients show mild systems, usually relieved by over the counter medications. some patients show severe form of disease that may lead to distress in patient life. management of vkc in tropical countries like ours is not easy because of the safety and cost as well as the easy availability of over the counter medicines. mast cell stabilizers have not shown good results from middle east and africa15,16. topical steroids are effective but unsupervised treatment leads to unsuspected steroid induced glaucoma and cataract17. visual loss occurs because of corneal complications from the disease or because of the use and abuse of topical corticosteroids, which may lead to steroid-induced glaucoma and steroid-induced cataract. because the condition eventually resolves, usually after adolescence, the treatment should be conservative and aimed at preventing potential complications. continuous search for safe and effective therapy for vernal keratoconjunctivitis is highly desirable. in this short-term clinical trial, we demonstrated that topical administration of cyclosporine 2% eye drops is a safe and effective therapy for vernal keratoconjunctivitis. it was well tolerated by all of our patients and it is an effective therapeutic modality in controlling the symptoms and signs of both conjunctival tarsal and limbal forms of vernal keratoconjunctivitis. the symptoms responded more readily and in a more substantial way to the treatment. 124 table 1. effect of topical cyclosporine on symptoms in patients with vernal keratoconjunctivitis symptoms s. nodurg sex/age itching tearing photophobia discharge foreign body sensation before after before after before after before after before after 1 pla m (12 yrs) 3+ 2+ 3+ 3+ 3+ 3+ 2+ 3+ 1+ 2+ 2 pla f (9 yrs 3+ 3+ 2+ 3+ 2+ 2+ 3+ 2+ 1+ 1+ 3 csa m (8 yrs) 3+ 1+ 3+ 1+ 2+ 0 3+ 1+ 2+ 0 4 csa m (13 yrs) 3+ 1+ 3+ 0 3+ 0 3+ 1+ 2+ 1+ 5 pla m (14 yrs) 3+ 3+ 2+ 2+ 2+ 3+ 2+ 3+ 1+ 1+ 6 csa m (17 yrs) 3+ 3+ 3+ 3+ 3+ 3+ 2+ 2+ 2+ 2+ 7 pla m (8 yrs) 3+ 3+ 3+ 3+ 3+ 3+ 3+ 2+ 3+ 2+ 8 pla m (15 yrs) 3+ 1+ 3+ 1+ 2+ 2+ 3+ 3+ 3+ 0 9 csa m (11 yrs) 3+ 1+ 3+ 1+ 3+ 1+ 0 0 2+ 1+ 10 csa m (11 yrs) 3+ 2+ 3+ 2+ 3+ 2+ 3+ 1+ 3+ 0 11 csa m (9yrs) 3+ 1+ 1+ 1+ 1+ 1+ 2+ 2+ 1+ 1+ 12 pla m (12 yrs) 3+ 1+ 1+ 0 0 0 0 0 0 0 13 csa m (13 yrs) 3+ 1+ 3+ 1+ 3+ 1+ 0 0 0 0 14 csa m (14 yrs) 3+ 0 3+ 0 3+ 0 1+ 1+ 2+ 0 15 pla m (7 yrs) 2+ 3+ 3+ 3+ 3+ 3+ 1+ 1+ 2+ 2+ 16 csa m (19 yrs) 3+ 1+ 3+ 2+ 2+ 2+ 3+ 1+ 2+ 0 17 csa m (12 yrs) 3+ 0 2+ 1+ 1+ 0 0 0 1+ 0 18 pla m (11 yrs) 3+ 3+ 2+ 2+ 1+ 1+ 3+ 3+ 1+ 1+ 19 csa f (11 yrs) 3+ 2+ 2+ 2+ 2+ 1+ 1+ 0 1+ 0 20 csa m (7 yrs) 3+ 0 1+ 2+ 2+ 0 3+ 0 2+ 0 csa = cyclosporine; pla = placebo before = before treatment; after = 6 weeks after initiation of treatment cyclosporine had a remarkable effect on most of the signs of vernal keratoconjunctivitis. there was decrease in punctate staining of cornea, limbal infiltration and in number of trantas dots. the number and size of giant papillae were not influenced by the use of topical cyclosporine and showed little change in the relatively short time of our trial, but a decrease in the conjunctival edema and hyperemia was noted in the group of patients treated with topical cyclosporine. similarly jamal bleik and khalid tabbara14 in a placebo-controlled, clinical trial evaluated the effects of topical 2% cyclosporine on patients with vernal keratoconjunctivitis for period of 6 weeks. no adverse effects and no detectable levels of cyclosporine were noted in the blood in the cyclosporine treated groups. they reported marked improvement in symptom and signs in patients treated with topical cyclosporine and concluded that topical cyclosporine is safe and effective for the short-term treatment of vernal keratoconjunctivitis. ather jameel et al18 evaluated the effects of topical 2% cyclosporine eye drops in patients with active vernal keratoconjunctivitis. in his study all patients were treated with 2% cyclosporine eye drops for a period of 6 weeks. his results showed a statistically significant improvement in itching, photophobia, mucous discharge, conjunctival hyperemia, punctate keratitis and trantas’ dots after 6 weeks treatment period. topical cyclosporine has been, in our patients, an excellent substitute for corticosteroids. (91.6%) of patients had decrease in itching, 75% and 83% of patients had improvement in tearing and photophobia respectively. 83% of patients showed decreased in discharge. 125 table 2. effect of topical cyclosporine on signs in patients with vernal keratoconjunctivitis signs s. no drug eye conjunctival hyperemia punctate keratitis trantas dots limbal edema before after before after before after before after 1 pla os 2+ 2+ 1+ 1+ 3+ 3+ 3+ 3+ pla od 2+ 2+ 1+ 1+ 2+ 3+ 2+ 2+ 2 pla os 2+ 2+ 2+ 2+ 2+ 2+ 1+ 1+ pla od 2+ 2+ 3+ 3+ 1+ 1+ 1+ 1+ 3 csa os 2+ 1+ 3+ 1+ 3+ 0 2+ 1+ csa od 2+ 1+ 3+ 1+ 2+ 0 2+ 1+ 4 csa os 2+ 1+ 2+ 0 3+ 1+ 3+ 1+ csa od 2+ 1+ 2+ 1+ 3+ 1+ 3+ 1+ 5 pla os 3+ 3+ 2+ 2+ 3+ 3+ 3+ 3+ pla od 3+ 3+ 2+ 2+ 2+ 2+ 3+ 3+ 6 csa os 2+ 3+ 3+ 3+ 3+ 3+ 3+ 3+ csa od 2+ 2+ 3+ 3+ 3+ 3+ 3+ 3+ 7 pla os 3+ 2+ 1+ 2+ 3+ 0 3+ 2+ pla od 3+ 2+ 1+ 2+ 3+ 0 3+ 2+ 8 pla os 3+ 2+ 3+ 3+ 3+ 3+ 3+ 2+ pla od 3+ 2+ 3+ 2+ 3+ 3+ 3+ 2+ 9 csa os 3+ 2+ 1+ 0 3+ 0 3+ 1+ csa od 3+ 2+ 1+ 0 0 0 2+ 1+ 10 csa os 3+ 3+ 1+ 0 0 0 1+ 0 csa od 3+ 3+ 1+ 0 0 0 1+ 0 11 csa os 2+ 2+ 2+ 1+ 3+ 3+ 3+ 3+ csa od 2+ 2+ 3+ 2+ 3+ 3+ 3+ 3+ 12 pla os 1+ 1+ 1+ 1+ 0 0 2+ 1+ pla od 1+ 1+ 2+ 1+ 0 0 2+ 1+ 13 csa os 2+ 2+ 3+ 3+ 0 0 3+ 3+ csa od 2+ 2+ 3+ 3+ 2+ 2+ 3+ 3+ 14 csa os 3+ 0 3+ 0 3+ 0 3+ 0 csa od 3+ 0 3+ 0 3+ 0 3+ 0 15 pla os 1+ 3+ 3+ 3+ 0 0 1+ 3+ pla od 1+ 3+ 0 3+ 0 0 1+ 3+ 16 csa os 2+ 1+ 3+ 1+ 0 0 3+ 1+ csa od 2+ 1+ 3+ 1+ 0 0 3+ 1+ 17 csa os 3+ 0 3+ 0 1+ 0 2+ 0 csa od 3+ 0 3+ 0 3+ 0 3+ 0 18 pla os 3+ 3+ 3+ 3+ 1+ 1+ 3+ 3+ pla od 3+ 3+ 3+ 3+ 3+ 3+ 3+ 3+ 19 csa os 1+ 2+ 1+ 3+ 0 0 1+ 2+ csa od 1+ 2+ 0 1+ 0 0 1+ 2+ 20 csa os 2+ 1+ 3+ 0 3+ 0 3+ 0 od 2+ 1+ 3+ 0 3+ 0 3+ 0 csa = cyclosporine; pla = placebo. before = before treatment; after = 6 weeks after initiation of treatment 126 bulbar conjunctival hyperemia improved in 83% of patients and 91.6 of patients showed improvement in corneal punctuate keratitis. trantas dots decreased in 75% patients and there was improvement in limbal infiltration and edema 75% of patients treated with cyclosporine. cyclosporine appears to be safe and effective for short-term treatment of vernal keratoconjunctivitis. literature shows that topical cyclosporine is not absorbed into the systemic circulation in sufficient concentration to reach therapeutic or toxic dosages and therefore is not associated with any systematic side effects. topical cyclosporine appears to carry none of the serious, sight threatening complications of topical steroids, such as glaucoma, cataract and exacerbation of corneal infection19. cyclosporine an immunosuppressive agent, most commonly used in organ transplantation has a selective inhibitory effect on helper t-lymphocytes proliferation and production of interleukin-2. it is therefore inhibitory to many t-cell dependent inflammatory mechanisms. cyclosporine also has direct inhibitory effects on eosinophil activation and release of granule proteins and cytokines and both direct and indirect inhibitory effects on mast cell activation, cytokine, and mediator release, which are likely to be important to its role in the treatment of allergic inflammation6-8. two types of mast cells have been recognized in humans based on neutral protease composition20 and t-lymphocyte dependency21. the t-lymphocytedependent mast cells contain tryptase but not chymase whereas the t-lymphocyte independent mast cells contain both tryptase and chymase22. patients with active vkc have a significant increase in the tlymphocyte-dependent mast cells in the epithelial cells of conjunctival biopsy specimens23. the exact mechanism of action of cyclosporin on the mast cell is unknown but it may be postulated that cyclosporin modulates the local ige production by the b cell via its effects on the t-helper cells and possibly by influencing the t-lymphocyte-dependent mast cells9. the current cost of cyclosporine may restrict its use to severe form of vernal keratoconjunctivitis. other topical conservative therapy may be considered for mild forms of the disease. topical cyclosporine represents an important addition to the therapeutic armamentarium for severe vernal keratoconjunctivitis, which until now was only sensitive to corticosteroids. author’s affiliation dr. tahir masaud arbab sir syed college of medical sciences karachi prof. manzoor a mirza sir syed college of medical sciences karachi reference 1. friedlaender mh. allergy and immunology of the eye. harper and row: hagerstown; 1979; 185-8. 2. tuft sj, cree ia, woods m, et al. limbal vernal keratoconjunctivitis in the tropics. ophthalmology. 1998; 105: 489-93. 3. sandford-smith jh. vernal eye disease in north nigeria. trop geogr med.1979; 31: 321-8. 4. baryishak yr, zavaro a, monselise m, et al. venal keratoconjunctivitis in an israeli group of patients and its treatment with sodium cromogylate. br j ophthalmol. 1982; 66: 118-22. 5. smolin g. o'connor. ocular immunology. 3rd ed. little brown: boston. 1986; 135-92. 6. kaufmann y, chang ae, robb rj, et al. mechanism of action of cyclosporine a: inhibition of lymphokine secretion studied with antigen-stimulated t cell hybridomas. j immunol. 1884; 133: 3107-11. 7. larsson el. cyclosporine a and dexamethasone suppress t cell responses by selectively acting at distinct sites of the triggering process. j immunol. 1980; 124: 2828-33. 8. nussenblatt rb, palestine ag. cyclosporine: immunology, pharmacology and therapeutic uses. surv ophthalmol. 1986; 31: 159-69. 9. okudaira h, sakurai y, terado k, et al. cyclosporine ainduced suppression of ongoing ige antibody formation in the mouse. int arch allergy appl immunol. 1986; 79:164-8. 10. hunter pa, wilhelmus kr, jones br. cyclosporin a applied topically to the recipient eye inhibits corneal graft rejection. clin exp immunol. 1981; 45: 173-7. 11. holland ej, chan c-c, kuwabara t, et al. immunohistologic finding and results of treatment with cyclosporine in ligneous conjunctivitis. am j ophthalmol. 1989; 107: 160-6. 12. benezra d, pe’er j, brodsky m, cohen e. cyclosporine eye drops for treatment of severe vernal keratoconjunctivitis. am j ophthalmology. 1986; 101: 278-82. 13. sechi ag, tognon ms, leonardi a. topical use of cyclosporine in the treatment of vernal keratoconjunctivitis. am j ophthalmology. 1990; 110: 641-5. 14. bleik jh, tabbara kf. topical cyclosporine in vernal keratoconjunctivitis. ophthalmology. 1991; 98: 1679-84. 15. abu el-astar am, van den oord jj, geboes k, et al. immunopathological study of vernal keratoconjunctivitis. graefes arch clin exp ophthalmol. 1989; 227: 374-9. 16. easty d, rice ns, jones br. disodium cromogylate in the treatment of vernal keratoconjunctivitis. trans ophthalmol. soc uk. 1971; 91: 191-9. 17. khan md, kundi n, saeed n. a study of 530 cases of vernal conjunctivitis from the north western frontier province of pakistan. pak j ophthalmol. 1986; 2: 111-4. 127 18. jameel a, moin m, hussain m. role of cyclosporine eye drops in allergic conjunctivitis. pak j ophthalmol. 2009; 25: 104-9. 19. hoang-xuan t, prisant o, hannouche d, et al. systemic cyclosporin a in severe atopic keratoconjunctivitis. ophthalmology. 1997; 104: 1300-5. 20. irani aa, schechter nm, craing ss, et al. two types of human mast cells that have distinct neutral protease composition. proc natl acad sci usa. 1986; 83: 4464-8. 21. craig ss, schechter nm, schwartz lb. ultra structural analysis of human t and tc mast cells identified by immunoelectronmicroscopy. lab invest. 1998; 58: 682-91. 22. irani aa, craig ss, de bois g, et al. deficiency of the tryptase-positive, chymase-negative mast cell type in gastointestinal mucosa of patients with defective t lymphocyte function. j immunol. 1987; 138: 4381-6. 23. irani am, butrus si, tabbara kf. human conjunctival mast cells: distribution of mcr and mcrc in vernal conjunctivitis and gaint papillary conjunctivitis. j allergy clin immunol. 1990; 86: 34-40 microsoft word tariq khan case report 44 original article retinal pigment epithelium rip following serial intravitreal injections of avastin® muhammad tariq khan, tariq mehmood qureshi, khalid mehmood, jawad bin yamin butt pak j ophthalmol 2011, vol. 27 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad tariq khan lrbt free eye & cancer hospital, 436-a/i, township, lahore received for publication june’ 2010 …..……………………….. nti-vascular endothelial growth factor (antivegf) therapy has tremendously improved the management of wet age-related macular degeneration (amd). with an increase in the usage of such agents over the last few years, complications have also been noted. it has been reported that retinal pigment epithelium (rpe) rip can occur following intravitreal injection of bevacizumab and other antivegf agents1,2. we would like to share our experience with intravitreal injection of bevacizumab (1.25 mg/0.05 ml) in a patient of amd with pigment epithelial detachment (ped). case report a 65-year-old male presented a year back with complaints of central scotoma in the both eyes. vision at presentation was cf in the right eye and 6/36 in the left eye. he was diagnosed of having bilateral subfoveal choroidal neovascularization (cnvm) on 27th september 2007. he took second opinion and received injection lucentis® twice and injection avastin® eight time in his right eye and injection lucentis® three times and injection avastin® ten times in his left eye. during that period his vision kept on fluctuating. he presented to us on 1st january 2010 with decrease vision in his both eyes. examination revealed a large ped at the macula in the right eye with hard exudates and drusen and a large ped at the macula in the left eye (fig. 1,2). fundus fluorescein angiography (ffa) revealed a large ped corresponding with the clinical picture, with ill-defined stippled late leakage temporal to the disc. optical coherence tomography (oct) of right eye showed a large ped with overlying subretinal fluid (fig. 3). in the left eye well-defined vshaped depression (marked) in the contour of the ped corresponding to the tomographic 'notch' delineated the superior high-domed ped from the adjacent shallow-domed ped. this feature was seen when the oct scan was taken through the area of stippled hyper fluorescence and this area has been suggested to be indicative of the presence of an occult membrane3 (fig. 4). based on the above features (oct and ffa correlation), a diagnosis of fibrovascular ped with occult membrane was made. the patient was explained the different modalities of treatment. the patient chose to undergo intravitreal bevacizumab injection. two months post injection of intravitreal bevacizumab, his vision recovered to 6/36 in right eye and 6/18 in left eye and clinically, ped reduced in size. a 45 he remained stable for three months after which he had recurrence of the symptoms. his vision was 6/36 in right eye and his vision dropped to 6/36 in the left eye. the ped had re-occurred at the same location and was comparable to the size on initial presentation. a fundus fluorescein angiography was done which confirmed the large rpe rip within the ped margins (fig. 5). optical coherence tomography was repeated which, when taken through the area of the rip showed interruption of the rpe layer and hyper-reflective double layering of the rpe layer indicative of the rolled but flattened rpe rip at the edge of the ped4 (fig. 6,7). discussion pigment epithelial detachments have been known to develop rpe rips, either spontaneously or following laser photocoagulation and photodynamic therapy. it is usually seen to occur at or along the border of the serous rpe detachment on the side opposite to the location of the choroidal neovascular membrane (cnvm). spontaneous peds are explained by the hydrostatic pressure of leaking exudates from the subrpe occult membranes, leading to the formation of rpe detachments as well as the acute rpe tears or rips. the rpe tears post laser and photodynamic therapy are explained by contraction of the fibrovascular tissue comprising the membrane5,6. retinal pigment epithelial tears are not unique to avastin® and have been seen in patients treated with pegaptanib (macugen®), ranibizumab (lucentis®), and photodynamic therapy (verteporfin). such retinal tears have also been seen in patients who have not had any prior therapy. however, given the rapid increase in treatment options available to treat amd over the past couple of years, the number of patients presenting with retinal tears is increasing. one hypothesis for what might cause retinal tears is that the amd leaves the retina compromised and weakened, but at the same time, newer treatments offer a more rapid resolution of retinal oedema and thickening. if vitreo-macular traction; a condition where the vitreous in the eye becomes very "sticky" and adheres tightly to the retina is resolved too quickly, it can tear the retina as the vitreous becomes more fluid and pulls away from the retina. this alternation may predispose to retinal pigment epithelial weakening, and subsequent tears. anti-vegf agents act by reducing angiogenesis and arresting the cnvm and thus the same pathology of fibrovascular tissue contraction may be at work in rpe rips following anti-vegf therapy. thus the risk of an rpe rip should be considered with treatment with anti-vegf agents in cases with fibrovascular peds. in our case, the occult cnvm was located in the subfoveal area and the rpe rip was seen at both the borders of the ped. the free edge of the rpe had rolled under and retracted towards the area of neovascular tissue. author’s affiliation dr. muhammad tariq khan lrbt free eye & cancer hospital 436-a/i, township, lahore dr. tariq mehmood qureshi lrbt free eye & cancer hospital 436-a/i, township, lahore dr. khalid mehmood lrbt free eye & cancer hospital 436-a/i, township, lahore reference 1. spandau uh, jonas jb. retinal pigment epithelium tears after intravitreal bevacizumab for exudative age-related macular degeneration. am j ophthalmol. 2006; 142: 1068-70. 2. shah cp, hsu j, garg sj, et al. retinal pigment epithelial tear after intravitreal bevacizumab injection. am j ophthalmol. 2006; 142: 1070-2. 3. sato t, iida t, hagimura n, et al. correlation of optical coherence tomography with angiography in retinal pigment epithelial detachment associated with age related macular degeneration. retina 2004; 24: 910-4. 4. giovannini a, amato g, mariotti c, et al. optical coherence tomography in the assessment of retinal pigment epithelial tear. retina 2000; 20: 37-40. 5. stereoscopic atlas of macular diseases diagnosis and treatment. j donald m gass. 4 th ed. mosby publication: chapter 3, section on armd, p. 88-91. 6. axer-siegel r, ehrlich r, rosenblatt i, et al. photodynamic therapy for occult choroidal neovascularization with pigment epithelium detachment in age-related macular degeneration. arch ophthalmol. 2004; 122: 453-9. microsoft word tahir arbabar corrected 177 original article aerobic bacterial conjunctival flora in diabetic patients tahir masaud arbab, saleem qadeer, saeed iqbal, manzoor a. mirza pak j ophthalmol 2010, vol. 26 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tahir masaud arbab sir syed college of medical sciences, karachi, received for publication march’ 2010 …..……………………….. purpose: to study the aerobic conjunctival flora of diabetic patients and its relation to the presence and level of diabetic retinopathy and the duration of the disease. material and methods: 80 patients form sir syed diabetic clinic with no evidence of ocular surface disease were included. these diabetic patients were compared with 50 nondiabetic subjects. all patients underwent slit-lamp evaluation, conjunctival scrapings, and indirect ophthalmoscopy. results: the frequency of positive conjunctival cultures was significantly higher in the diabetic group than in nondiabetic group (95% vs. 72%, p<0.001). among diabetic patients, a significantly higher frequency of positive cultures was detected in those with diabetic retinopathy than those without retinopathy (p=0.001). neither the duration of the diabetes nor the hypoglycemic therapy correlated with the culture results. staphylococcus epidermidis was the most common microorganism isolated, and its identification was more frequent in patients with retinopathy than those without diabetic retinopathy. conclusion: diabetic patients have a significantly higher number of positive conjunctival cultures. the presence of diabetic retinopathy was correlated with an increase in positive cultures and a higher proportion of staphylococcus epidermidis. he term “normal microbial flora” refers to population of microorganisms that dwell within the eyes of healthy individuals. these microorganisms play an important and specific role in maintaining health and normal conjunctival function. these bacteria, when disturbed, can promptly reestablish themselves1. it was found that indigenous bacterial flora inhibits the establishment of foreign pathogenic bacteria by elaborating antibacterial substances and by competing for space and nutrients1. it is an established fact that gram-positive organisms, particularly coagulase-negative staphylococci, are the main residents of normal eye. they are the predominant cause of postoperative infections2. the conjunctival flora may be altered under special circumstances, as in new-borns, acquired immune defiency patients, contact lens wearers, and patients using immunosuppressive drugs 3-5. diabetes mellitus is a multifactorial disease associated with blindness caused by retinopathy and its complications, and also other abnormalities in other parts of the eye6-9. diabetic patients have been reported to have an increased prevalence of postoperative endophthalmitis than nondiabetic patients10, 11. speaker et al, demonstrated a correlation between the external flora and intraocular infection. in his study using genotypic analysis in the identification of the etiologic agent of endophthalmitis, reported that in 82% of cases the microorganism identified in the vitreous was genetically identical to an isolate recovered from the conjunctiva, lid, even the nasal mucosa of the patient12. gram-negative bacteria and coagulase-negative staphylococcus have been reported as common causes of endophthalmitis in diabetic patients 10, 13. however, the surface flora of the diabetic patients is not specifically addressed in the literature. t 178 the purpose of this study is to analyze the aerobic bacterial flora of diabetic patients and to compare it to that of nondiabetic patients, describing its variations according to the presence and extent of diabetic retinopathy, and the duration of the disease. materials and methods this study was carried out by the department of ophthalmology and diabetic clinic at sir syed hospital quyyumabad, karachi, from january to october 2009. a past medical history was taken. patients with ocular symptoms, or other systemic disease were excluded. slit-lamp examination was performed on each patient with particular attention to any evidence of dry eye, blepharitis, anterior segment infection, inflammation, or lens opacity prohibiting fundus examination. the patients were taken from diabetic clinic at sir syed hospital with a known history of diabetes mellitus for which the patient was under the care of a physician. all control patients were selected from department of ophthalmology, which has to undergo cataract extraction and had a normal blood sugar test on their preoperative evaluation. only controls within the age range of the diabetic group were included. a prior consent was obtained before taking eye culture swabs from each subject. swabs were taken from conjunctiva of both eyes of patients. all precautionary measures were taken to avoid lid margin and eyelashes while taking the swab. swabs were taken from conjunctiva of each patient, using sterile stuart’s swabs, which were placed in stuarts transport medium for onward transfer to microbiology laboratory. swabs were streaked on culture media. culture media used were sheep blood agar, chocolate agar, macconkeys agar, fungal media, mycobiotic agar and sabouraud 4% dextrose agar. the gram-staining was done for each swab. culture media were incubated at 37 degrees c to permit bacterial growth and held for 3 days to ascertain either “growth” or “no growth”. sabouraud 4% dextrose agar and mycobiotic agar were incubated at 25 degrees c and were held for 2 weeks to observe either growth trend. indirect ophthalmoscopy was performed on all subjects after culture was taken, and the patients were classified as, normal (without retinopathy), nonproliferative diabetic retinopathy, and proliferative diabetic retinopathy. statistical package for social sciences “spss-15.0” was used for data analysis. the results were presented in terms of frequencies and percentages. chi-square test was applied to compare the study parameters between diabetic and non-diabetic groups and group of culture results. p-value ≤ 0.05 was considered statistically significant difference. results 80 patients form sir syed diabetic clinic with no evidence of ocular surface disease were included. these diabetic patients were compared with 50 nondiabetic subjects. a predominance of male subjects was present in both diabetic group (70%) and nondiabetic group (60%). the mean age was 58 (± 9) years in the diabetic group and 57 (± 8.6) years in nondiabetic group. there was no significant difference in age distribution among the diabetic retinopathy subgroup. the mean duration of diabetes mellitus was 8.7 (± 3.5) years. sixty-one patients were taking oral hypoglycemic agents, and 19 were using insulin. in the diabetic group, the ophthalmoscopic examination detected 21 patients (26.2%) without diabetic retinopathy, 47 patients (58.7%) with nonproliferative diabetic retinopathy, and 12 patients (15.0%) with proliferative diabetic retinopathy. only 4 (5%) patients of diabetic group had negative cultures compared with 14 (28%) patients in the nondiabetic group. significantly higher (p<0.001) number of diabetics had bilateral positive culture (i.e. 75%) as shown in table 1. a significantly higher frequency positive cultures was identified among diabetic patients with retinopathy, 60 patients (75%), compared with those without retinopathy, 16 patients (20%). among the subjects with positive cultures in both eyes, a significantly higher proportion was identified among the patients with diabetic retinopathy (npdr or pdr) when compared with those without retinopathy (p=0.001) (table 2). there were no significant differences in the prevalence of positive cultures when diabetic group was stratified by disease duration (less than 5 years versus 5 years or more), type of hypoglycemic agent, gender, or age. the most common isolated bacteria in diabetic and nondiabetic groups were staphylococcus epider 179 midis. the other isolates are described in table 3. the only difference among the isolates was a higher proportion of staphylococcus epidermidis among diabetic 61 patients (80.2%) as compared to nondiabetic 22 (61.1%) patients (p=0.031). the number of different organisms identified in the same patient differed between diabetic and nondiabetic groups (p<0.001). it was also more likely to have two or more organisms in the same subject among diabetic patients with npdr or pdr than in diabetic patients without retinopathy (p<0.001) (table 4). the isolation of staphylococcus epidermidis was also more frequent in patients with diabetic retinopathy than those without retinopathy (p=0.002) (table 5). table 1: conjunctival cultures in diabetic and nondiabetic subjects conjunctival cultures diabetic n (%) nondiabetic n (%) negative 04 (5.0) 14 (28) positive/unilateral 16 (20.0) 12 (24) positive/bilateral 60 (75.0)* 24 (48) total 80 (100) 50 (100) *significantly higher proportion of positive conjunctival culture in diabetic subjects (p<0.001). table 2: positive conjunctival cultures in diabetic subjects according to the level of diabetic retinopathy level of retinopathy positive conjunctival cultures absent n (%) npdr n (%) pdr n (%) unilateral 9 (56.2) 6 (12.2) 1 (9.0) bilateral 7 (43.7) 43 (87.7)* 10 (90.9)* total 16 (100) 49 (100) 11 (100) *significantly higher proportion of bilateral conjunctival culture in npdr and pdr subjects (p=0.001). table 3: bacteria isolated from conjunctiva of diabetic and nondiabetic subjects diabetic (n=76) n (%) nondiab etic (n=36) n (%) p-value staphyloccocus epidermidis 61 (80.2)* 22 (61.1) 0.031 diphtheroids 17 (22.3) 12 (33.3) 0.216 staphylococcus aureus 10 (13.1) 4 (11.1) 0.760 streptococcus nonheamolytic 2 (2.6) 1 (2.7) 0.999 moraxella 1 (1.3) 0 (0) 0.999 staphylococcus coagulase-negative 2 (2.6) 1 (2.7) 0.999 neisseria species 1 (1.3) 0 (0) 0.999 *shows significantly higher proportion at 5% level of significance. table 4. conjunctival culture results according to the number of different organisms isolated from the same subject retinopathy level culture results non diabetic (n=50) n (%) diabetic (n=80) n (%) absent (n=21) n (%) npdr (n=47) n (%) pdr (n=12) n (%) negative 14(28.0) 4 (5.0) 4 (19.0) 0 (0) 0 (0) one organism 19(38.8) 46(57.5)* 15(71.4) 27(57.4) ┼ 4(33.3) 2 or more organism 14(34.0) 30(37.5) 2 (9.5) 20(42.5) 8(66.6)┼ *significantly higher proportion of at least 1 organism on culture result in diabetic subjects (p<0.001). discussion in the present study, we evaluated the conjunctival aerobic bacterial flora in diabetic patients, stratified by the presence and extent of retinopathy, versus nondiabetic subjects. the hypothesis was that diabetic 180 patients not only might have a higher incidence of bacterial pathogens cultured from the conjunctiva but also that the severity of diabetes mellitus might be a predictor for bacterial colonization. table 5: identification of staphylococcus epidermidis according to the presence of diabetic retinopathy diabetic retinopathy conjunctival cultures absent n (%) present n (%) negative 8 (38.0) 5 (8.4) positive/unilateral 7 (33.3) 16 (27.1) positive/bilateral 6 (28.5) 38 (64.4)* *significantly higher proportion of bilateral conjunctival culture in patients with diabetic retinopathy (p=0.002). the prevalence of positive cultures in nondiabetic subjects found in this study is similar to that previously reported in nondiabetic patients 14, 15. however, the proportion of positive cultures in the diabetic group (95.0%) was significantly higher and was similar to cultures in immunodeficient patients16. all immunodeficient patients studied by friedlander, in 1980, demonstrated positive conjunctival cultures16. comeric-smith et al analyzed the lids of hiv patients and obtained growth in 100% of cultures compared with only 33% of the non-hiv subjects 17. in contrast, gritz et al, studying the hiv patients flora, did not detect a significant difference in positive cultures when hiv patients were compared with controls18. in our study, only the presence of diabetic retinopathy correlated with the prevalence of positive cultures. no other variables (hypoglycemic therapy, age, and disease duration) correlated with the culture results. we recognize that the accuracy of disease duration may have been compromised by inaccurate information provided by the patient. studies of the number of different bacterial species in diabetic patients are not addressed in the literature. in patients with diabetic retinopathy, the identification of two or more organisms was significantly more frequent, indicating that the presence of retinopathy might be a marker for altered conjunctival flora. staphylococcus epidermidis was the most frequent organism isolated from diabetic and nondiabetic groups, consistent with the previous reported of walker and claoue 19. the frequency of staphylococcus epidermidis isolated from the conjunctiva of nondiabetic subjects (61.1%) in our study was similar to that reported from nondiabetic patients 14, 20. akhter jamal khan21 studied the normal conjunctival flora in karachi and obtained cultures from 800 patients. his results showed staphylococcus epidermidis (57.7%) was the most common bacteria, followed by diphtheroids sp (26.6%). shehla rubab22 compared the indigenous microbial flora of the eye to that found in conjunctival and corneal infections at al-shifa trust hospital at rawalpindi. she found out that in the control group of 700 eyes, the microorganism detected included staphylococcus epidermidis in 57.7%, staphylococcus aureus in 22.5%, streptococcus pneumoniae in 8.3% and diphtheroids in 3.3% of cases. in our study, among the diabetic patients, the isolation of staphylococcus epidermidis was significantly more frequent (85.0%). table 5 shows that the presence of retinopathy was also a marker for a high frequency of staphylococcus epidermidis isolation. the importance of coagulase-negative staphylococcus in the flora is that it has frequently been identified as a causative agent of endophthalmitis. several authors have described series of endophthalmitis cases caused by staphylococcus epidermidis 23-27. in 1997, johnson et al detected a higher frequency of coagulase-negative staphylococcus in diabetic patients with endophthalmitis when compared with nondiabetic subjects28. assuming that a significant number of endophthalmitis cases are related to resident flora 12, staphylococcus epidermidis as a causative agent may be linked to the high frequency of this microbe in conjunctival flora. the presence of retinopathy may indicate a more significant risk for this infection. this study has demonstrated that it was associated with higher frequency of staphylococcus epidermidis identification (91.5%). if our findings are correct, the presence of diabetic retinopathy is correlated with a higher prevalence of staphylococcus epidermidis on the conjunctival 181 surface. as such, retinopathy may signal an increased risk of endophthalmitis. coagulase-negative staphylococcus and gramnegative bacteria are described as the most frequent etiologic agents in diabetic subjects in various endophthalmitis series10, 13, 24. despite the fact that the incidence of postoperative infection is small relative to frequency of ophthalmic surgery, infection is most common in diabetic patients, and it may predict a poor visual outcome 10, 11, 24. the high prevalence of organisms in the conjunctival flora of diabetic patients, as demonstrated in this paper, may play a role in the higher susceptibility to postoperative infection. this study demonstrates that diabetes, and specifically the presence of diabetic retinopathy signals a higher prevalence of potentially pathogenic bacteria in the conjunctival flora. author’s affiliation tahir masaud arbab sir syed college of medical sciences karachi saleem qadeer civil hospital hyderabad dr. saeed iqbal sir syed college of medical sciences karachi prof. manzoor a. mirza sir syed college of medical sciences karachi reference 1. jawetz e, melnnick lj, adelberg ae, et al. medical microbiology 18th ed, prentice hall i international, usa. 1989: 18: 275-8. 2. starr mb. prophylactic antibiotics for ophthalmic surgery. surv of ophthalmology. 1983; 27: 353-73. 3. millerb, ellis p. conjunctival flora in patients receiving immunosuppressive drugs, arch ophthalmol. 1977; 95: 2012-4. 4. fleiszig s, efron n. microbial flora in eyes of current and former contact lens weares. j clin microbiol. 1992; 30: 1156-61. 5. campos m, silva i, rehder j, et al. anaerobic flora of the conjunctival sac in patients with aids and with anophthalmia compared with normal eyes. acta ophtalmologica. 1994; 72: 241-5. 6. armaly m, baloglou p. diabetes mellitus and eye changes in anterior segment. arch ophthalmol. 1976; 77: 485-92. 7. klein be, klein r, moss se. intraocular pressure in diabetic persons. ophthalmology. 1984; 91: 1356-60. 8. klein be, klein r, moss se. prevalence of cataracts in a population-based study of persons with diabetes mellitus. ophthalmology. 1985; 92: 1191-6. 9. sadun a. neuro-ophthalmic manifestations of diabetis. ophthalmology. 1999; 106: 1047-8. 10. philips wb, tasman ws. postoperative endophthalmitis in association with diabetes mellitus. ophthalmology. 1994; 101: 508-18. 11. cohen sm, flynn hw, murray tg, et al. endophthalmitis after pars plana vitrectomy, the postvitrectomy endophthalmitis study group. ophthalmolgy. 1995; 102: 705-12. 12. speaker m, milch f, shah m, et al. role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. ophthalmology. 1991; 98: 639-49. 13. liao hr, lee hw, leu hs, et al. endogenous klebsiella pneumoniae endophthalmitis in diabetic patients. can j ophthamol. 1992; 27: 143-7. 14. cason i, winker c. bacteriology of the eye. arch ophthalmol. 1954; 51: 196-9. 15. smith c. bacteriology of the healthy conjunctiva. br. j. ophthalmol. 1954; 38: 719-26. 16. friedlaender mh, masi rj, osumoto m, et al. ocular microbial flora in immunodeficient patients. arch ophthalmol. 1980; 98: 1211-3. 17. comeric-smith s, nunez j, hosmer m, et al. tear lactoferrin level and ocular bacterisl flora in hiv positive patients. adv asp med biol. 1994; 350: 339-44. 18. gritz dc, scott tj, sedo sf, et al. ocular flora of patients with aids compared with those of hiv negative patients. cornea. 1997; 16: 400-5. 19. walker c, claque c. incidence of conjunctival colonization by bacteria capable of causing postoperative endophthalmitis. j r soc med. 1986; 79: 520-1. 20. rodin f. bacteriologic study of human conjunctival flora. am j ophthalmol. 1945; 28: 306-14. 21. akhter jk, akram s, saleem m, et al. aerobic bacteriology of normal conjunctival flora. pak j ophthalmol. 2004; 20; 3: 91-5. 22. shehla r, haroon a, wajid ak. comparison of indigenous microbial flora of the eye to that found in conjunctival and corneal infections in a hospital based study. pak j ophthalmol. 2006; 22: 2: 97–107. 23. puliafito ca, baker as, haaf j, et al. infectious endophthalmitis: a review of 36 cases. 1977-1980. ophthalmology. 1982; 89: 921-9. 24. davis jl, koidou-tsiligianni a, pflugfelder sc, et al. coagulase-negative staphylococcal endophthalmitis, increase in antimicrobial resistance. ophthalmology. 1988; 95: 1404-10. 25. rowsey jj, newsom d, sexton d, et al. endophthalmitis: current approach. ophthalmology. 1982; 95: 1404-10. 26. olsen j, flynn h, forster r et al. results in the treatment of postoperative endophthalmitis. ophthalmology. 1983; 90: 6929. 27. driebe w, mandelbaum s, forster r. pseudophakic endophthalmitis: diagnosis and management. ophthalmology. 1986; 93: 442-8. 28. johnson mw, doft bh, kelsey sf et al. the endophthalmitis vitrectomy study. relationship between clinical presentation and microbiologic spectrum. ophthalmology. 1997; 104: 261-72. microsoft word abstracts vol. 24,1, 08 47 abstracts edited by dr. tahir mahmood central corneal thickness measurements using orbscan ii, visante, ultrasound, and pentacam pachymetry after laser in situ keratomileusis for myopia thomas ho, cheng ack, rao sk, lau s, leung cks, lamdsc j cataract refract surg 2007; 33: 1177-82 accurate measurement of corneal thickness is important in corneal refractive procedures, especially laser in situ keratomileusis (lasik), which is currently the most popular approach for the correction of refractive errors. this measurement allows determination of the extent of safe stromal ablation possible because it is now believed that iatrogenic keratectasia can result from excessive tissue removal in the stromal bed. this may be particularly important in patients who had laser refractive surgery with suboptimal outcomes and are being considered for an enhancement procedure. the current gold standard for corneal pachymetry is applanation ultrasound (us) pachymetry, although errors caused by the indentation of the cornea have been reported. concerns about the possibility of patient discomfort, epithelial damage, and spread of infections with contact methods also exist. today, several non contact devices that allow assessment of corneal thickness are available. the orbscan (orbtek, bausch & lomb) corneal topography system measures corneal thickness by analyzing images of the anterior and posterior corneal reflecting surfaces based on slit-scanning technology and videokeratography. using an acoustic adjustment factor, which can be customized for each unit, the second version of orbscan (orbscan ii) gives results comparable to those of us pachymetry in pre-lasik patients. however, it has been reported that in postlasik patients, orbscan measurements underestimate corneal thickness despite the use of a customized acoustic factor. the visante device (carl zeiss meditec) uses highresolution, non contact optical coherence tomography (oct), customized for anterior segment evaluation. it allows assessment of corneal thickness across the entire corneal surface without direct contact. the image-acquisition system provides a video image of the examined zone and stores the last 7 images at a rate of 8 frames per second. at the end of the examination, the software interprets the selected image and the image is reconstructed to provide pachymetry information. the pentacam device (oculus, germany) uses the scheimpflug principle to acquire cross-sectional images of the cornea and lens. it has been used in the assessment of cataract and for measuring corneal curvature and thickness. it is a rotating camera that offers a noninvasive assessment of the anterior segment of the eye. data on topographic corneal thickness, curvature, anterior chamber angle, volume, and height are calculated from up to 25 000 data points. the purpose of this study was to compare corneal pachymetry assessment using 4 measurement methods in eyes after laser in situ keratomileusis (lasik) for myopia. fifty-two consecutive patients (103 eyes) who had lasik for the correction of myopia had orbscan ii (bausch & lomb), visante (carl zeiss meditec), pentacam (oculus, inc.), and ultrasound (us) pachymetry (sonomed, 200p) 6 months after surgery. the mean postoperative pachymetry measured by us, orbscan (0.89 acoustic factor), pentacam, and visante pachymetry were 438.2 µm ± 41.18 (sd), 435.17 ± 49.63 µm, 430.66 ± 40.23 µm, and 426.56 ± 41.6 µm, respectively. compared with the us measurement, pentacam and visante measurements significantly underestimated corneal thickness by a mean of 7.54 ± 15.06 µm (p<.01) and 11.64 ± 12.87 µm (p<.01), respectively. there was no statistically significant difference between us and orbscan measurements. authors concluded with the remarks that pentacam and visante measurements of corneal thickness 6 months after lasik were significantly less than those obtained using orbscan and us pachymetry, although all 4 measurement methods showed a high correlation with each other. 48 phacotrabeculectomy: assessment of outcomes and surgical improvements george j.c. jin, md, phd, alan s. crandall, md, jason j. jones, md j cataract refract surg 2007; 33: 1201-1208 since the term phacotrabeculectomy was first introduced in the literature in 1991, the combined procedure of phacoemulsification, posterior chamber intraocular lens (iol) implantation, and trabeculectomy has been advocated for treating coexisting glaucoma and cataract. with the improvement in both phacoemulsification and trabeculectomy, phacotrabeculectomy continues to gain popularity among ophthalmic surgeons. the purpose of this study was to evaluate the outcomes and progress after phacotrabeculectomy at the same clinical setting and/or performed by the same surgeon over the past decade. this retrospective study included 60 eyes of 43 patients who had phacotrabeculectomy at a single institute between 1999 and 2005. a modified phacotrabeculectomy surgical technique was used that included a 2-site incision approach, fornix-based flap, use of mitomycin c, acrylic intraocular lens implantation, sutured scleral and conjunctival flaps, and sutured temporal clear corneal incision. over a mean 30-month follow-up, 57 of the 60 eyes (95%) achieved intraocular pressure (iop) control (< 21 mm hg) with or without medication. thirty eyes (50%) had an iop of 15 mm hg or lower, and 34 (57%) had an iop reduction of at least 30%. the iop decreased from a preoperative mean of 23.1 mm hg on a mean number of 1.67 glaucoma medications to a mean of 14.9 mm hg on a mean of 0.23 medication at the final follow-up (p<.001 for iop decrease and for reduction in number of medications). fifty-two eyes (87%) obtained a best spectacle-corrected visual acuity of 20/40 or better. dysesthetic blebs requiring surgical revision and bleb hemorrhage (each occurring in 2 eyes, 3.3%) were seen in this study, but not previous studies. authors concluded with the remarks that the surgical technique used in this study appears to be effective and superior to a previous technique at restoring visual acuity, lowering iop, and reducing the postoperative complication rate. prospective visual evaluation of apodized diffractive intraocular lenses alfonso jf, fernandez-vega l, baamonde mb, montes-mico r j cataract refract surg 2007; 33: 1235-43 multifocal intraocular lenses (lols) are designed to reduce dependence on eyeglasses after cataract surgery and are gaining acceptance as a potential refractive surgical option in selected patients. monofocal lols provide excellent visual function; however, for many patients, the lol’s limited depth of focus means that they cannot provide clear vision at both distance and near. patients with traditional monofocal lols usually require glasses for near distance tasks such as reading. monovision techniques may be helpful in some patients but involve sacrifices in binocularity. multifocal lols, which were introduced in the early 1980s, may offer patients the potential for a range of uncorrected vision from near to far. multifocality is the brain's natural ability to adapt to near and far vision as it chooses between the 2 (near and far) images produced by the different optical elements of the iol, depending on what it is looking at. these simultaneous-vision lols provide distance, intermediate, and near correction within the area of the ocular pupil. when a distant object is being viewed, a sharp retinal image is provided by the parts of the iol within the pupillary area that have the distance correction and a somewhat blurred image by the other parts of the iol, these images being superimposed on the retina. the decrease in contrast of the in-focus image is produced by the split of total light energy between the far focus and near focus, while the contemporary presence (superimposition) on the retina of an in focus image and out-of-focus image can produce a sort of retinal rivalry or confusion that is overcome by the brain’s selection of the best retinal image and capability to use multifocality. many studies to overcome this drawback have been performed. one proposed solution is to direct different amounts of the refracted-diffracted light on the different foci, thus favoring distance or near vision. another approach comes from the pupil and the optical design of the iol, which create different amounts of light on the different foci depending on 49 pupil diameter. however, reduced image contrast and unwanted visual phenomena, including glare and halos, have been associated with multifocal iol performance. newer multifocal iol models have improved the visual outcomes over those achieved with older designs; however, the visual performance of these lols has not been fully evaluated. a popular currently used diffractive multifocal iol is the acrysof restor (alcon). recent studies report satisfactory visual results with this iol. however, no studies have been performed to assess the visual performance of this new iol in a large population over a long follow-up period. the purpose of this study was to evaluate distance, intermediate, and near visual performance in patients who had multifocal apodized diffractive intraocular lens (iol) implantation. the best corrected distance visual acuity, best distance-corrected near visual acuity, intermediate visual acuity, distance contrast sensitivity under photopic and mesopic conditions, and patient satisfaction were measured in 325 patients and 335 patients who had bilateral implantation of the model sa60d3 iol (acrysof restor, alcon) and model sn60d3 iol (acrysof natural restor), respectively. at the 6-month postoperative visit, binocular best corrected distance acuity with the restor iol and the natural restor iol was 0.034 logmar ± 0.004 (sd) and 0.019 ± 0.020 logmar, respectively (~20/20). binocular best distance-corrected near acuity was 0.011 ± 0.012 logmar and 0.035 ± 0.013 logmar, respectively (~20/20). intermediate visual acuity with both iol models worsened significantly as a function of the distance of the test (p<.01). photopic contrast sensitivity was within the standard normal range with both lols. under mesopic conditions, contrast sensitivity with both lols was comparable to that with monofocal lols and lower, particularly at higher spatial frequencies, than under photopic conditions. no statistically significant differences in visual acuity or photopic and mesopic contrast sensitivity were found between the 2 iol models (p>.1). a patient satisfaction questionnaire showed that both lols performed well and were comparable in satisfaction regarding distance, intermediate, and near activities under different lighting conditions. authors concluded with the remarks that acrysof restor iol and acrysof natural restor iol provided good visual performance at distance and near under photopic and mesopic conditions. intermediate vision with both models was reduced compared with distance and near vision. visual acuity and contrast sensitivity: acrysof restor apodized diffractive versus acrysof sa60at monofocal intraocular lenses vingolo em, grenga pl, lacobelli l, grenga g j cataract refract surg 2007; 33: 1244-7. the treatment of presbyopia is a challenge for ophthalmic surgeons. the choices include implanttation of multifocal intraocular lenses (lols). according to the current literature, these lols improve near vision without a major adverse effect on distance vision. in addition, the functional status and quality of life of patients with multifocal lols have been reported to be better than in patients with monofocal lols. however, significant shortcomings, such as halos, glare, and loss of contrast sensitivity, especially in dim light, have been reported with multifocal lols. the acrysof restor apodized diffractive iol (alcon) has a single-piece biconvex optic. the optic is of a high-refractive-index (1.55) hydrophobic, flexible, acrylic material with ultraviolet wavelength absorbing properties. the anterior surface has apodized diffractive concentric rings in the central 3.6 mm area, distributing light for a full range of vision. step heights decrease smoothly from 1.3 mm in the central zone to 0.2 mm at the diffractive periphery. the iol incorporates a +4.0 diopter (d) addition (add) lens plane equal to a + 3.2 d at the spectacle plane. this allows optimum near vision approximately 31 cm from the eye. the 2 technologies in the restorapodization and the diffractive optic reduce the light transmission loss that is common with other diffractive iols. the purpose of this study was to compare the visual acuity and contrast sensitivity in eyes with the acrysof restor multifocal intraocular lens (iol) (alcon) and eyes with the monofocal acrysof sa60at iol. one hundred eyes had phacoemulsification cataract extraction and implantation of a restor multifocal iol in the capsular bag. inclusion criteria were corneal astigmatism less than 1.5 diopters (d), myopia less than 4.0 d, and no associated ocular disease. a complete ophthalmic examination, 50 including uncorrected visual acuity, best spectaclecorrected visual acuity, and contrast sensitivity, was performed 6 months postoperatively. results were compared with those in 40 eyes with the acrysof monofocal iol single-piece iol. in the multifocal group, 90 eyes (90%) had an uncorrected distance visual acuity of 20/25 or better (logmar <0.10) and an uncorrected near visual acuity at 35 cm of j3 or better (logmar 0.14). the multifocal group and monofocal group had similar distance uncorrected and best corrected visual acuities; however, the multifocal group had significantly better near uncorrected acuity. the mean contrast sensitivity values were 18.28 db (static program) and 17.95 db (dynamic program) in the multifocal group and 19.18 db (static program) and 21.2 db (dynamic program) in the monofocal group. authors concluded with the remarks that restor multifocal iol provided a satisfactory full range of vision; 92% of the patients achieved total spectacle independence. contrast sensitivity was lower than with the sa60at monofocal iol. intraocular lens centration and visual outcomes after bag-in-the-lens implantation verbruggenkhm, rozema jj, gobin l, coeckelbergh t, groot vd, tassignon mj, j cataract refract surg 2007; 33: 1267-2. many intraocular lens (iol) designs have been developed since ridley's original model in 1949. the conventional iol implantation technique consists of inserting the iol in the capsular bag, which is called the lens-in-the-bag (lib) implantation technique. this method inevitably leads to a large area of contact between the iol biomaterial and capsular bag. the capsular bag response, described as a foreign-body reaction of lens epithelial cells (lecs) against the iol biomaterial, results in the stimulation of lecs lying at the surface of the anterior capsule, causing anterior capsule opacification (ago), and of equatorial lecs, causing posterior capsule opacification (pco). posterior capsule opacification can be very mild or severe according to the biomaterial. in cases of severe pco, patients have a reduction in visual acuity, which can be treated by a neodymium: yag (nd: yag) laser capsulotomy. the lowest nd: yag laser capsulotomy rates found in the literature reach 10.4% 5 years after surgery. a bag-in-the-lens (bil) iol (model 89a, morcher) was introduced in 2000. the bil iol consists of a central optic surrounded by a groove defined by 2 oval heptics perpendicularly oriented to each other. the purpose of this study was to examine the centration and visual outcomes after cataract surgery using the bag-in-the-lens (bil) implantation technique. this study comprised 180 eyes of 125 patients who had cataract surgery with implantation of the bil intraocular lens (iol) between march 2002 and september 2005. postoperative data at 5 weeks, 6 months, and 1 year were evaluated. the geometric center of the iol, measured on a red reflex slitlamp photograph, was compared with the geometric center of the pupil and the limbus. the mean decentration compared with the limbus was 0.304 mm ± 0.17 (sd) at a mean angle of -24.9 ± 113.3 degrees. compared with the dilated pupil, the mean deviation was 0.256 ± 0.15 mm at a mean angle of -5.2 ± 119.0 degrees. the amount of decentration was stable during the postoperative follow-up period. there was no correlation between the amount of decentration and the visual outcomes (pupil: r = -0.07, p = .494; limbus: r = 0.11, p = .304). authors concluded with the remarks that surgeon controlled bil centration was predictable 5 weeks and unchanged 6 months and 1 year postoperatively. it can therefore be concluded that capsular bag healing has no influence on bil iol centration over time. microsoft word index-4.doc original article immersion vs contact biometery for axial length measurement before phacoemulsification with foldable iol irum abbas, atif mansoor ahmad, tahir mahmood pak j ophthalmol 2009, vol. 25 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …………………………… correspondence to: tahir mahmood department of ophthalmology shaikh zayed hospital lahore received for publication purpose: to compare the findings of contact and immersion techniques of biometry before cataract surgery material and mathods: this cross sectional comparative study was conducted in the department of ophthalmology shaikh zayed hospital, lahore for six months from 1-10-2007 to 31-03-2008. one hundred patients meeting the inclusion criteria were selected for this study. immersion measurements were performed before contact measurements. for contact measurements, unreliable readings were discarded with the standard deviation of final set <0.12. for immersion measurements, unreliable readings were discarded with standard deviation of the final set <0.12. two sets of measurements for both immersion and contact biometery were performed by two operators. mean and standard deviation of measurement sets were compared. results: the first operator immersion mean was 22.99±0.90 as compared with second operator immersion mean was 22.99±0.88 with no significant difference. the first operator immersion standard deviation (sd) was 0.034±0.022 as compared with second operator immersion sd was 0.032±0.021 with no significant difference. the first operator contact mean was 22.74±0.94 as compared with second operator contact mean was 22.75±0.91 with no significant difference. the first operator contact sd was 0.058±0.025 as compared with second operator contact sd was 0.059±0.027 with no significant difference. december’ 2008 ……………………….…… conclusion: there is no significant difference in the findings of contact and immersion techniques when controlling the confounding factor and performed by experienced operators. ver the last fifty years the main objective of cataract extraction has been transformed form merely improving the quality of vision to that improving the quality of life1. a significant improvement in the refractive outcome of cataract surgery is from a more precise measurement of pre operative intraocular distances and therefore a more accurate prediction of the intraocular lens power could be achieved2. to optimize the accuracy of predicting the postoperative refraction, formulae have been developed to calculate the iol (intraocular lens) power3. although good surgical techniques with low complication rates are important, biometry is often the most critical factor in obtaining the expected refractive results4. biometry involves keratometric measurement of curvature of the cornea and also the measurement of axial length5. there are two methods of axial length measurement currently is practice, one is acoustic biometry and other one is called optical biometry. in acoustic biometry ultrasonic waves follow the optical axis of eye. in optical biometry partial coherence laser interferometer measure the axial length along the visual axis5. ultrasound biometry may be performed either by directly putting the probe on the cornea called as contact technique or by using water bath method called as immersion technique6. immersion ultrasound is generally considered superior to contact technique. the absence of corneal depression as a confounding factor reduces the risk of inter-technician variability7. in our study the repeatability of contact and immersion ultrasound biometry of axial length was compared. the mean and standard deviation of the measurement sets were compared, and the differences between repeat measures were calculated. material and methods this cross sectional comparative study was conducted in department of ophthalmology, shaikh zayed hospital, lahore. for six months from 1-10-2007 to 3103-2008. sample selection: non-probability purposive sampling. inclusion criteria 1. patients presenting with age related cataract between the ages of 40 to 90 years diagnosed on the basis of slit lamp examination. 2. both sexes. 3. patients who have potential for good visual acuity. 4. axial length between 21mm and 27mm. exclusion criteria 1. patients with known corneal curvature abnormalities such as previous penetrating keratoplasty or refractive procedures. 2. patients with poor visual prognosis due to retinal pathology e.g. diabetic and hypertensive retinopathy or macular degeneration. 3. allergy to topical anaesthetic. 4. preoperative refractive error greater than 4.00 d sphere or 2.00 d cylinder. one hundred patients meeting the inclusion criteria were identified from the eye outpatient department (opd). diagnosis was made on the basis of history, measurement of visual acuity and slit lamp examination. a demographic profile of all the patients admitted for cataract surgery was noted on a proforma attached. immersion measurements were performed before contact measurements so corneal applanation did not influence the immersion technique. for immersion measurements, a scleral immersion shell (prager shell) was used to support the probe and normal saline was used as the coupling fluid. an automated sequence of 8 readings was taken. unreliable readings was discarded with standard deviation of the final set <0.12. for contact measurements, an automated sequence of 8 measurements were taken according to preset amplitude and timing criteria for ultrasound reflection. unreliable readings were discarded with the standard deviation of final set <0.12. o a measurement set was defined as a group of readings taken by one operator with one technique at one time. each eye had four measuremnet sets, two performed by contact and two by immersion by two different operators of adequate experience and the number of readings was recorded. all the collected information was entered into spss version 12 and analyzed. the study variables were age, sex, keratometry, side of eye and axial lengths. descriptive statistics were calculated. mean and standard deviation was calculated for numerical data like age, keratometry results and axial length. qualitative variables like sex and side of eye were presented as proportion and percentages. statistical significance of any observed difference between the findings of two techniques were determined by using paired ‘t’ test. statistical significance for all comparesons were given as p value ≤0.05. results the demographic and disease profile of patients is shown in (table 1). the comparison of mean and sd of first operator first immersion reading and 2nd operators first immersion readings show no significant different (p>0.05) (table 2, 3). the comparison of mean and sd of first operator second immersion redings with 2nd operator 2nd immersion reading show no significant difference (p>0.05) (table 4,5). the comparison of mean and sd of 1st operator first contact biometery reading and 2nd operator first contact reading show no significant difference (table 6,7). the comparison of mean and sd of 1st operators 2nd contact and 2nd operators 2nd contact show no significant difference (table 8,9). table 1: demographic and disease profiles of patients age (mean ± sd) sex male/female 60.35 ± 7.92 946:54 (1.1) keratometery (mean ± sd) 1st operator 2nd operator 44.01 ± 1.36 44.77 ± 1.49 cataract (n=100) right eye left eye 51 49 table 2: comparison of first mean immersion (axial length) between two operators (n=100) mean immersion range operator 1 operator 2 no of patients n (%) no of patients n (%) 21.0-22.0 11 (11.0) 11 (11.0) 22.1-23.0 38 (38.0) 39 (39.0) 23.1-24.0 36 (36.0) 40 (40.0) 24.1-25.0 13 (13.0) 8 (8.0) 25.1-26.0 2 (2.0) 2 (2.0) mean±sd 22.99±0.90 22.90±0.88 p 0.85, key the clinical biometric findings between measurements of immersion technique and contact table 3: comparison of first standard deviation of immersion between two operators (n=100) standard deviation of immersion operator 1 operator 2 no of patients n (%) no of patients n (%) 0-0.5 87 (87.0) 83 (83.0) 0.6-1.0 13 (13.0) 17 (17.0) mean±sd 0.034±0.022 0.032±0.021 p 0.57 table 4: comparison of second mean immersion between two operators (n=100) mean immersion range operator 1 operator 2 no of patients n (%) no of patients n (%) 21.0-22.0 11 (11.0) 12 (12.0) 22.1-23.0 38 (38.0) 37 (37.0) 23.1-24.0 41 (41.0) 40 (40.0) 24.1-25.0 8 (8.0) 8 (8.0) 25.1-26.0 2 (2.0) 2 (2.0) mean±sd 22.82±2.27 23.0±0.90 p 0.37 table 5: comparison of second standard deviation of immersion between two operators (n=100) immersion sd range operator 1 operator 2 no of patients n (%) no of patients n (%) 0-0.5 76 (76.0) 86 (86.0) 0.6-1.0 24 (24.0) 14 (14.0) mean±sd 0.056±0.024 0.034±0.021 p 0.23 technique were compared. the mean axial length was found to be 22.92 ± 1.20mm with the immersion table 6: comparison of first mean contact between two operators (n=100) mean contact range operator 1 operator 2 no of patients n (%) no of patients n (%) 21.0-22.0 17 (17.0) 19 (19.0) 22.1-23.0 49 (49.0) 42 (42.0) 23.1-24.0 26 (26.0) 33 (33.0) 24.1-25.0 6 (6.0) 4 (4.0) 25.1-26.0 2 (2.0) 2 (2.0) mean±sd 22.74±0.94 22.75±0.91 p 0.66 table 7: comparison of first standard deviation contact between two operators (n=100) sd contact range operator 1 operator 2 no of patients no of patients n (%) n (%) 0-0.5 50 (50.00 48 (48.0) 0.6-1.0 48 (48.0) 49 (49.0) 1.1-1.2 2 (2.0) 3 (3.0) mean±sd 0.058±0.025 0.059±0.0.27 p 0.41 table 8: comparison of second mean contact between two operators (n=100) mean contact range operator 1 operator 2 no of patients n (%) no of patients n (%) 21.0-22.0 22 (22.0) 18 (18.0) 22.1-23.0 38 (38.0) 41 (41.0) 23.1-24.0 32 (32.0) 34 (34.0) 24.1-25.0 9 (9.0) 6 (6.0) 25.1-26.0 1 (1.0) 1 (1.0) mean±sd 22.76±0.94 22.76±0.92 p 0.97 table9: comparison of second standard deviation contact between two operators (n=100) sd contact range operator 1 operator 2 no of patients n (%) no of patients n (%) 0-0.5 45 (45.0) 49 (49.0) 0.6-1.0 48 (48.0) 47 (47.0) 1.1-1.2 2 (2.0) 4 (4.0) mean±sd 0.032±0.022 0.058±0.027 p 0.89 technique and 22.75 ± 0.92 mm with the contact technique, using the same transducer probe. the difference of 0.17mm was not significant statistically. the mean standard deviation between recurrent measures in same eye was found to be 0.039 ± 0.034 with the immersion technique and 0.058 ± 0.025 with the contact technique. the difference of 0.02 was not significant statistically. the contact and immersion a-scan techniques produce comparable measures of the magnitude of eye axial length. measurements of eye axial length obtained by the immersion technique averaged 0.17 mm longer than those obtained by the contact technique was confirmed in eyes subjected to repeated measurements. both techniques give consistent results, but the difference between axial lengths measured by the two techniques has implications for choice of intraocular lens power. discussion cataract extraction with implantation of intraocular lens is one of the most frequently and successfully performed ophthalmic procedures. visual impairment is by far the most common indication for cataract surgery7. patients stress for perfect refractive outcome with early visual rehabilitation. although good surgical techniques with low complication rates are important, biometry is often the most critical factor in obtaining the expected refractive results3. the most critical step in biometry is precise measurement of axial length, defined as the distance between the anterior corneal surface and the sensory retina2. although contact method is most commonly used but it is cumbersome to the patient due to direct contact of probe with cornea also increasing the risk of corneal erosion. if the probe is pressed against the cornea an abnormally short axial length is recorded resulting in inaccurate calculation of intraocular lens power and refractive outcome is not as expected. immersion technique eliminates corneal depression. if both techniques are performed carefully by experienced operators the chances of inter operator error are less and the results are comparable. in our study the mean age of the patients is 60.35 ± 7.92 years. as compared with the study of edge and navon8 the mean age of the patients was 62.4 ± 15.7 years. in our study there is slight increased female to male as apposed to navon and edge8 where the males gender was higher. in our study, mean axial length by immertion technique was 22.92± 1.2 as compared with the study of kronbauer et al10 the mean axial length was found to be 23.19±1.32 using the same transducer probe, which is comparable with our study. immersion standard deviation (sd) 0.039±0.034 comparable with the study of kronbauer et al10 the mean standard deviation between recurrent measures was found to be 0.04 with the immersion technique. in our study contact mean 22.75±0.92 compared with the study of kronbauer et al10 the mean axial length was found to be 22.93±1.32 with the contact technique. in our study, contact sd was 0.058±0.025 comparable with the study of kronbauer et al9 the mean standard deviation was found to be 0.19 with the contact technique. immersion v/s contact difference in axial length measurements. hennessy et al10 compared the repeatability and agreement of contact and immersion ultrasound biometry of axial length. axial length measurement was longer with the contact method than with immersion by 0.03 mm. the repeatability of the 2 techniques was similar. watson and armstrong11 evaluated those measurements of eye axial length obtained by the immersion technique averaged 0.1 mm longer than those obtained by the contact technique. both techniques give consistent results, but the difference between axial lengths measured by the two techniques has implications for choice of intra-ocular lens power9. conclusion there is no significant difference in the repeated findings of contact and immersion techniques when controlling the confounding factor and performed by experienced operators. when the measurement set was repeated, the precision of contact ultrasound biometry was comparable to that of immersion, with no clinically significant difference in mean axial length measurements. author’s affiliation irrum ibbas trainee registrar department of ophthalmology shaikh zayed hospital, lahore dr. atif mansoor ahmad assistant professor department of ophthalmology shaikh zayed hospital, lahore prof. tahir mahmood head department of ophthalmology shaikh zayed hospital, lahore reference 1. hennessy mp, franzco, chan dg. contact versus immersion biometry of axial length before cataract surgery. j cataract refract surg. 2003; 29: 2195-8. 2. connors r, boseman p, olson rj. accuracy and reproducibility of biometry using partial coherence interferometry. j cataract refract surg. 2002; 28: 235-8. 3. hoffmann pc, hutz ww, eckhardt hb, et al. intraocular lens calculation and ultrasound biometry: immersion and contact procedures. klin monatsbi augenheilkd. 1998; 213: 161-5. 4. kiss b, findl o, menapace r, et al. refractive outcome of cataract surgery using partial coherence interferometer and ultrasound biometry. j cataract refract surg. 2002; 28: 230-34. 5. findl o, kriechbaum k, sacu s, et al. influence of operative experience on the performance of ultrasound biometry compared to optical biometry before cataract surgery. j cataract refract surg. 2003; 29: 1950-5. 6. packer m, fine h, hoffman sr, et al. immersion a scan compared with partial coherence interferometry. j cataract refract surg. 2002; 28: 239-42. 7. mansoor q, hussain sa, hameed w. effect of axial length measurement by partial coherence interferometer and ultrasound a scan on postoperative predicted refraction. a prospective study. pak j ophthalmol. 2004; 20: 136-8. 8. edge r, navan s. axil length and posterior staphyloma in saudi arabian cataract patrents. j cataract refract surg. 1999; 25:91-5. 9. kronbauer al, kronbauer fl, kronbauer cl. comparative study of the biometric measurements made by immersion and contact techniques. arq bras oftalmol. 2006; 69: 875-80. 10. hennessy mp, franzco, chan dg. contact versus immersion biometry of axial length before cataract surgery. j cataract refract surg. 2003; 29: 2191-8. 11. watson a, armstrong r. contact or immersion technique for axial length measurement? aust nzj ophthalmol. 1999; 27: 49-51. microsoft word muhammad husnain 114 original article comparative study of effectiveness of subconjunctival injection of dexamethasone versus intracameral injection of dexamethasone in controlling immediate post-operative anterior uveitis after cataract surgery in cases of phacomorphic glaucoma muhammad hasnain, abdul-rahman pak j ophthalmol 2010, vol. 26 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad hasnain rai medical complex, 148-a main road, satellite town, sargodha received for publication august’ 2009 …..……………………….. purpose: to compare the effectiveness of subconjunctival injection of dexamethasone with intracameral injection of dexamethasone in controlling immediate postoperative anterior uveitis after cataract surgery in patients of phacomorphic glaucoma. materials and methods: sixty patients of phacomorphic glaucoma underwent conventional extracapsular cataract extraction (ecce) with intraocular lens (iol) implantation by same surgeon. they were divided into two groups comprising of 30 patients each. patients in group a, received subconjuctival injection of deamethasone while patients in group b received intracameral injection of dexamethasaone at the end of surgery. patients were examined on 1st and 3rd post-operative day on slitlamp for signs of anterior uveitis. results: on 1st post-operative day, in group a findings were, cells in ac ≤ +2 (17 patients, 57%), cells in ac ≥ +3 (11 patients, 36%), membrane in ac (19 patients, 63%) while in group b findings were, cells in ac ≤ +2 (14 patients, 47%), cells in ac ≥ +3 (13 patients, 43%), membrane in ac (21 patients, 70%). the data was analyzed statistically by applying t test using spss version 8. it showed that there was no statistically significant difference in results between group a and group b on 1st and 3rd post-operative day. conclusion: intracameral injection of dexamethasone provides an equally effective alternative to subconjunctival injection of dexamethasone peroperatively and avoids the adverse effects associated with subconjunctival injection. hacomorphic glaucoma" is lens-induced secondary angle closure glaucoma which results from mature cataract or intumescent cataract which blocks the angle by a forward push of the iris1,2. in the european races, there is a gradual shrinkage of lens with development of cataract and thereby a progressive deepening of the anterior chamber occurs3. phacomorphic glaucoma is "p 115 unusual in those people. on the other hand, cataract in indians seems to become intumescent rather commonly4 and lens gets thickened through the process of cataractogenesis5. it appears that in these cases there is an acute angle closure by forward push of the iris root rather than a physiologic pupil block and iris bombe as seen in acute closed angle glaucoma. this is encountered more in developing countries, where patients present late. they tend to wait until the cataract becomes mature, because it is common belief among these patients that cataract should not be operated on until vision drops to the level of hand movements or light perception6. often, patients will present with acute onset of ocular redness and pain with an edematous cornea and elevated iop. there will be a shallow anterior chamber. extracapsular cataract extraction, either with or without lens implantation, remains the most common procedure to correct phacomorphic glaucoma7. immediate argon laser peripheral iridoplasty (alpi), replacing systemic antiglaucomatous medications, appears to be safe and effective first-line treatment of acute phacomorphic angleclosure. alpi obviates the need to operate in highly inflamed eyes in an emergency setting8. this is followed by cataract extraction as definitive treatment9. extracapsular cataract extraction (ecce) with heparin surface modified (hsm) posterior chamber intraocular lens (pciol) implantation may be carried out in an attempt to optimize visual acuity gains in patients with phacomorphic glaucoma10. single-port, sutureless transconjunctival limited pars plana vitrectomy may be done to facilitate phacoemulsification in eyes with a shallow anterior chamber and high intraocular pressure11. our hospital is charity based, located in rural area of shahpur sadar, district sargodha. its main focus is underprivileged population of central punjab. due to negligence about eye diseases, poor financial condition and absence of a person to escort them, patients with cataract delay cataract surgery till many patients feel severe pain in the eye and present in opd as phacomorphic glaucoma. purpose of study to compare the effectiveness of subconjunctival injection of dexamethasone 0.5 ml (2 mg) with intracameral injection of dexamethasone 0.1 ml (0.4 mg) in controlling immediate post-operative anterior uveitis following cataract surgery. materials and methods this was a hospital based interventional comparative study conducted at lrbt shahpur sadar from 01-122006 to 30-05-2008. all patients with senile cataract presenting with phacomorphic glaucoma were included in the study. patients with history of diabetes mellitus, history of anterior uveitis, previous anterior segment surgery and single functioning eye were excluded from study. total numbers of patients included in the study were 60. all patients underwent extracapsular cataract extraction with posterior chamber intraocular lens implantation by same surgeon. they were randomly divided into two groups. group a comprised of 30 patients and received subconjunctival injection of dexamethasone 0.5 ml (2 mg) at the end of surgery, while group b consisted of 30 patients who received intracameral injection of dexamethasone 0.1 ml (0.4 mg) at the end of surgery. pre-operatively detailed history was taken, visual acuity noted and anterior segment examination carried out by slit lamp. ciliary congestion, corneal edema, keratic precipitates (kp), flare and cells in anterior chamber, inflammatory membrane formation and posterior synechiae were noted. fundal glow was checked with distant direct ophthalmoscopy. fundus examination carried out with 90 dioptre lens in the fellow eye where possible. intraocular pressure was checked with goldmann applanation tonometer and gonioscopy carried out with gonio lens. glycerine was applied topically in cases of corneal edama to obtain relatively clear view for gonioscopy. preoperatively patients were treated medically to control iop using levobunolol eye drops b.i.d, tablet acetazolamide 250 mg q.i.d and tablet kcl once daily. intravenous mannitol was given when iop was more than 30 mm of hg. topical dexamethasone eye drops qid were used to control intraocular inflammation. post-operatively eye pad was removed at morning on 1st postoperative day and patients were examined by the same surgeon following the same protocol as used in preoperative evaluation. patients were advised dexamethasone and tobramycin combination eye drops 1 hourly for 3 days, then 2 hourly for 1 week, then 4 hourly for 2 weeks and then q.i.d for 1 month. dexamethasone and tobramycin combination eye ointment was advised at bed time for 6 weeks. patients were again examined on 3rd postoperative day. 116 results out of total 60 patients, 27 patients were male while 33 were female. average age of presentation was 63.25 years. duration of pain ranged from 1 day to 2 months. patients presenting with no perception of light were 4 (7%), normal perception of light but faulty projection were 18 (30%) and normal perception and projection of light were 38 (63%). mean iop was 32.88 mm of hg. nine patients (15%) were already on iop lowering medication at the time of presentation. table 1 shows clinical findings of group a on 1st post-operative day. in 2 patients (7%), flare and cells in ac could not be assessed because of corneal edema. table 2 shows clinical findings of group b on 1st postoperative day. in 3 patients (10 %), flare and cells in ac could not be assessed because of corneal edema. the data has been analyzed statistically by applying t test using spss version 8. it shows that there is no statistically significant difference in results between group a and group b. table 1: group a: on 1st postoperative day features no. of patients n (%) ciliary congestion 30 (100) corneal edema 19 (63) kps 1 (3) flare in ac ≤ +2 16 (53) flare in ac ≥ +3 12 (40) cells in ac ≤ +2 17 9 (57) cells in ac ≥ +3 11 (36) membrane in ac 19 (63) posteroir synechiae 4 (13) discussion in our study out of total 60 patients, 27 patients were male while 33 were female (male to female ratio 1:1.2). in a similar study by jain1 out of 86 patients, 40 were males and 46 were females: (male to female ratio 1:1.15), while rijal12 in his study at nepal eye hospital, kathmandu, has recorded male to female ratio 1:1.2. in our study average age at presentation was 63.25 years, duration of pain ranged from 1 day to 2 months and mean iop was 32.88 mm of hg. jain has reported 62 years average age at the time of presentation, duration of pain varying from one day to three months and mean iop of 45.50 mm of hg. low mean iop in our study was probably due to the fact that nine patients (15%) in our study were already on iop lowering medication at the time of presentation. table 2: group b: on 1st postoperative day features no. of patients n (%) ciliary congestion 30 (100) corneal edema 21 (70) kps 1 (3) flare in ac ≤ +2 15 (50) flare in ac ≥ +3 12 (40) cells in ac ≤ +2 14 (47) cells in ac ≥ +3 13 (43) membrane in ac 21 (70) posteroir synechiae 6 (20) table 3: group a: on 3rd postoperative day features no. of patients n (%) ciliary congestion 20 (67) corneal edema 11 (37) kps 0 (0) flare in ac ≤ +2 20(67) flare in ac ≥ +3 10 (33) cells in ac ≤ +2 19 (63) cells in ac ≥ +3 11 (37) membrane in ac 12 (40) posteroir synechiae 6 (20) post-operatively, severity of uveitis was measured by ciliary congestion, keratic precipitates (kps), flare in anterior chamber (ac), cells in ac, membrane formation in ac and posterior synechiae (ps). the 117 result shows that severity of uveitis was similar in both groups. although in group a, on ist postoperative day membrane in ac formed in 19 cases as compared to 21 cases in group b, the difference is not statistically significant. similarly on 3rd post-operative day, these two groups donot show statistically significant difference regarding parameters of uveitis. table 4: group b: on 3rd postoperative day features no. of patients n (%) ciliary congestion 22 (73) corneal edema 12 (40) kps 0 (0) flare in ac ≤ +2 19 (63) flare in ac ≥ +3 11 (37) cells in ac ≤ +2 20 (67) cells in ac ≥ +3 10 (33) membrane in ac 14 (47) posteroir synechiae 5 (5) on 3rd post-operative day corneal edema was present in 37% cases in group a and 40% cases in group b. pradhan d in his study at sagarmatha choudhary eye hospital, lahan, nepal, has reported corneal edema in 25.5% cases13. in pubmed we did not find any study in which subconjunctival injection of dexamethasone has been compared with intracameral injection of dexamethasone for control of immediate postoperative anterior uveitis after cataract surgery, so direct comparison cannot be made with a similar study. further multicenter clinical trials are needed to confirm the results of this study. during cataract surgery in cases of phacomorphic glaucoma, subconjunctival injection of dexamethasone is usually given per-operatively to control accompanying anterior uveitis. it can lead to subconjunctival hemorrhage postoperatively which may be alarming to many patients. in addition it can lead to accidental perforation of globe. all these problems can be avoided by intracameral injection of dexamethasone. no clinically adverse effects have been found after intracameral injection. conclusion intracameral injection of dexamethasone provides an equally effective alternative to subconjunctival injection of dexamethasone per-operatively and avoids the pain associated with subconjunctival injection. author’s affiliation dr. muhammad hasnain consultant ophthalmologist lrbt eye hospital, shahpur district sargodha dr. abdul rahman medical officer lrbt eye hospital, shahpur district sargodha references 1. jain is, gupta a, dogra mr, et al. phacomorphic glaucomamanagement and visual prognosis. indian j ophthalmol. 1983; 31: 648-53. 2. sowka j. phacomorphic glaucoma: case and review. optometry. 2006; 77: 586-9. 3. lowe, r.f., angle closure glaucoma and cataract east arch. ophthalmol., 1, 80-83, 1973. 4. prajna nv, ramakrishnan r, krishnadas r, et al. lens induced glaucomas-visual results and risk factors for final visual acuity. indian j ophthalmol. 1996; 44: 149-55. 5. wright kw. clinical manifestations of the glaucoma. in:textbook of ophthalmology 1st ed. baltimore: williams & wilkins. 1997; 597-624. 6. tomey kf, al-rajhi aa. neodymium:yag laser iridotomy in the initial management of phacomorphic glaucoma. ophthalmology. 1992; 99: 660-5. 7. rao sk, padmanabhan p. capsulorhexis in eyes with phacomorphic glaucoma. j cataract refract surg. 1998; 24: 882-4. 8. yip pp, leung wy, hon cy, et al. argon laser peripheral iridoplasty in the management of phacomorphic glaucoma. ophthalmic surg lasers imaging. 2005; 36: 286-91. 9. tham cc, lai js, poon as, et al. immediate argon laser peripheral iridoplasty (alpi) as initial treatment for acute phacomorphic angle-closure (phacomorphic glaucoma) before cataract extraction: a preliminary study. eye. 2005; 19: 778-83. 10. das jc, chaudhuri z, bhomaj s, et al. combined extracapsular cataract extraction with ahmed glaucoma valve implantation in phacomorphic glaucoma. indian j ophthalmol. 2002; 50: 25-8. 11. dada t, kumar s, gadia r, et al. sutureless single-port transconjunctival pars plana limited vitrectomy combined with phacoemulsification for management of phacomorphic glaucoma. j cataract refract surg. 2007; 33: 951-4. 12. rijal ap, karki db. visual outcome and iop control after cataract surgery in lens induced laucomas. kathmandu univ med j (kumj). 2006; 4: 30-3. 13. pradhan d, hennig a, kumar j, et al. a prospective study of 413 cases of lens-induced glaucoma in nepal. indian j ophthalmol. 2001; 49: 103-7. pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 69 original article does prolonged botulinum toxin a treatment decrease its duration of action? muhammad moin, asif manzoor pak j ophthalmol 2017, vol. 33, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad moin yaqin vision eye center lahore email: mmoin7@gmail.com …..……………………….. purpose: to find out the results of prolonged botulinum toxin a on its duration of action in patients with blepharospasm and hemifacial spasm. study design: prospective case series. place and duration of study: yaqin vision center from 2010 to dec 2016. material and methods: all patients of both genders who were treated with botulinum toxin for treatment of hemifacial spasm and blepharospasm were included in the study. patients were divided into 2 groups, group 1 included all patients who had 2-5 injection while group 2 included all patients who had 5-19 injections of botulinum toxin a. patients with secondary blepharospasm due to drugs, ocular and neurological disorders were excluded from the study. patients with blpharospasm were injected botulinum toxin a at 7 periocular sites on both sides while patients with hemifacial spasm were injected at 7 periocular and 6-7 perioral sites (orbicularis oris, levator labi, zygomaticus major, mentalis and platysma). onset of effect of botulinum toxin a and duration of action was recorded for all patients. results: total 257 injections were given to 40 patients with an average of 6.43 injections (range 2-19). the mean age of patients was 51 ± 12.1 years. male to female ratio was 1:1.1. mean onset of action in group 1 was 3.81 ± 2.6 days and in group 2 was 3.92 ± 3.4 days after injection. average 51.13 units of botulinum toxin a were injected in each injection. mean duration of botulinum toxin a efficacy in group 1 was 3.43 ± 1.5 months and in group 2 was 3.26 ± 1.6 months. non-significant p-values of 0.41 for onset and 0.23 for duration muhammad moin, et al 70 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology were found. conclusion: after prolong use of botulinum injection mean duration of action remains almost same. keywords: blepharospasm, hemifacial spasm, botulinum toxin lapherospasm is the insidious onset of involuntary spasm of muscles affecting eyelid closure. it is usually bilateral but may be asymmetric and may be associated with some neurological disorders. severity may range from mild symptoms to severe debilitating disease1. age of onset of blepharospasm is fifth to sixth decade of life in twothird patients and gradually deteriorates with time. females are more affected with 3 to 1 ratio2. patients may have risk factors for development of symptoms like a stressful event in life or problem at work. sensory tricks can be used by the patients to improve their dystonia. the most common sensory tricks are touching above the eyes, singing, talking and humming3. environmental factors like antipsychotic/ anti-emetic drugs or history of head trauma can precipitate focal dystonia due to damage to basal ganglia or cortical/subcortical circuits of brain4. hemifacial spasm is a neuromuscular disease in which unilateral brief or persistent involuntary contractions occur in the muscles that are innervated by the facial nerve starting around eyes and then progress to cheek, mouth and neck5,6. its prevalence has been estimated at 9.8 cases per 100 000 individuals7. different treatment options like surgical and medical are available for the treatment of blepharospasm and hemifacial spasm but botulinum neurotoxin injection is the most established treatment modality8,9. botulinum neurotoxin a is produced by clostridium botulinum and is the most potent toxin known to humans. it causes flaccid paralysis by inhibiting release of acetylcholine from neuromuscular junction10. botulinum toxin injection gives temporary relief of symptoms and needs to be repeated 3-6 monthly. the purpose of our study is to find out the results of prolonged use of botulinum toxin injection on its duration of action in patients of blepharospasm and hemifacial spasm. material and methods the study was prospective case series that was conducted at yaqin vision center, lahore from jan 2010 to dec 2016 after taking ethical committee approval of the hospital. all patients of hemifacial spasm and essential blepharospasm of both gender and age >25 years were included in the study. patients were divided into 2 groups, group 1 included all patients who had 2-5 injection while group 2 included all patients who had 5-19 injections of botulinum toxin a (botox, allergan). grouping was done according to the follow up of the patients. patients with secondary b does prolonged botulinum toxin a treatment decrease its duration of action? pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 71 blepharospasm due to drugs, ocular and neurological disorders were excluded from the study. in all patients ct scan/mri of the brain was done for any facial nerve compression or tumor involving posterior fossa before injection. botulinum type a injections were given after assessing their requirements on the basis of guidelines given by jankovic et al2 and severity of blepharospasm as shown in table 1. informed consent was taken from all the patients before injection. after taking standard precautions patients with blepharospasm were injected botulinum type a at 7 periocular sites on both sides while patients with hemifacial spasm were injected at 7 periocular and 6-7 perioral sites (orbicularis oris, levator labi, zygomaticus major, mentalis and platysma) as shown in figure 1. periocular sites selected were nasally & temporally above the eye brow, upper lid (pre-tarsal area), lower lid (pre-tarsal area) and one inferio-lateral to inferior canthus on the orbital rim. patients were asked about the onset of effect of botulinum type a injection and duration of action on follow up visits. spss version 22 statistical package was applied for descriptive and analytic analysis. results among forty cases of facial dystonia who got more than one botulinum toxin a injection, 27 (67.5%) cases were of essential blepharospasm and 13 (32.5%) cases of hemifacial spasm. there were 19 males and 21 females (1:1.1) with average age of 51 years as shown in table 2. total 257 injections were given to 40 patients with an average of 6.43 injections (range 2-19). average 51.13 units of botulinum toxin were injected in each injection. table 3 and table 4 shows mean onset & mean duration in group 1 and group 2 according to gender distribution and disease group. mean onset of action in group 1 was 3.81 ± 2.6 days and in group 2 was 3.92 ± 3.4 days after injection. mean duration of botulinum toxin a efficacy in group 1 was 3.43 ± 1.5 months and in group 2 was 3.26 ± 1.6 months. results of t-test analysis showed a nonsignificant p-value of 0.41 for onset and 0.23 for duration of botulinum toxin a as shown in table 5.. figure 2 and 3 show pre-disposing factors and relieving factors of facial dystonia. additional factor observed in the study was effect of weather on symptoms of facial dystonias. 35% cases had worsening of symptoms in summer while only 2.5% had worsening of symptoms in winter/cold. weather had no effect on 62.5% patients with facial dystonias. most common complication of botulinum toxin a injection was ptosis in 4.6%. other complications included dry eyes in 1.1%, headache in 0.7%, upper lip droop in 1.5%, upper eyelid bruising in 1.5%, facial deviation in 1.1%, and mild paralytic ectropion of lower lid in 0.7% of the patients. table 1: grading of severity of blepharospasm. blepharospasm severity 1) none 2) slight. increase blinking in response to external stimulus 3) mild, spontaneous lid flutter 4) moderate, very noticeable spasm of eyelids only 5) severe, incapacitating eyelids and facial muscles spasm. fig. 1: sites for botulinum toxin injection in hemifacial spasm (left half of face) and blepharospasm (right half of face). table 2: mean age of the patients. facial dystonia mean age (years) average male female blepharospasm 53 (n=13) 54.86 (n=14) 53.96 (n=27) muhammad moin, et al 72 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology hemifacial spasm 46.83 (n=6) 43.14 (n=7) 44.84 (n=13) average 51.05 (n=19) 50.95 (n=21) 51 (n=40) fig. 2: predisposing factors. fig. 3: relieving factors. discussion essential blepharospasm is an involuntary spasm of eyelid muscles affecting patients in fifth and sixth decade of life and predominantly affect females than table 3: mean onset (in days) of action of botulinum toxin a. mean onset (days) group 1 (n=23) mean onset (days) group 2 (n=17) average male female male female blepharospasm 3.85 ± 2.3 2.9 ± 0.79 2.7 ± 1.17 4.31± 3.14 3.56± 2.4 hemi-facial spasm 3.18 ± 2.4 8.6 ± 4.0 2.84 ± 1.4 5.25± 5.1 4.5 ± 4.2 average 3.66 ± 2.3 4.04 ± 2.9 2.74 ±1.23 4.71± 4.1 table 4: mean duration (in months) of efficacy of botulinum toxin. mean duration (days) group 1 (n=23) mean duration (days) group 2 (n=17) average male female male female blepharospasm 3.4 ± 1.5 2.8 ± 1.15 3.2 ± 1.2 3.34 ± 1.5 3.25 ± 1.4 hemi-facial spasm 4.45 ± 1.6 3.6 ± 0.55 3.2 ± 1.4 3.3 ± 2.2 3.4 ± 1.9 average 3.73 ± 1.6 2.96 ± 1.1 3.2 ± 1.25 3.31 ± 1.8 table 5: group 1 versus group 2. does prolonged botulinum toxin a treatment decrease its duration of action? pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 73 group 1 (n=23) group 2 (n=17) pvalue mean onset (days) 3.81 ± 2.6 3.92 ± 3.4 0.41 mean duration (months) 3.43 ± 1.5 3.26 ± 1.6 0.23 male with 3:12. it is most common adult-onset dystonia affecting about 16-133 cases per million11. hemifacial spasm is unilateral spasm of facial muscle supplied by facial nerve. it usually affects middle aged people but can present in younger age with clinical presentation similar to adult onset12. botulinum neurotoxins produced by clostridium botulinum cause the disease botulism, in which prolonged muscle paralysis occurs. in low dose purified botulinum neurotoxin can be used to treat medical diseases which have uncontrollable muscle contractions. there are seven different strains a, b, c, d, e, f and g. a novel in vivo mouse was given botulinum neurotoxins a, b and e which showed that botulinum a has longer duration of action than botulinum neurotoxin b while botulinum neurotoxin e had the shortest duration of action13. in 1989 fda approved botulinum toxin a (botox) for the treatment of strabismus and blepharospasm14. later in 2002 it was approved by fda for frown lines between the eyebrows15. in 2010 fda approved botox for prophylaxis of headaches in adults with chronic migraines16. alternate options of botulinum toxin in blpharospasm are surgical myectomy17 and drugs like tricyclic anti-depressants and anti-cholinergic18 but these could not get much success and popularity. botulinum toxin a (botox) is available in pakistan in vial containing 100 units19. botulinum toxin is not a cure for focal dystonias but it gives temporary relief and needs to be injected repeatedly. flynn et al20 in their study described that botulinum toxin a (botox) used for glabellar lines had a duration of effect for 3-5 months in females and 4-6 months in males. in a study by mejia et al21 45 patients of cervical, cranial and facial dystonias were followed up for a mean of 32 visits and mean of 16 years. there was no significant difference in onset and duration of response to treatment. a retrospective analysis22 of 235 patients of hemifacial spasm, blepharospasm and cervical dystonia who received botulinum toxin a for ten years showed that highest response rate at 5 years was similar to response at 2 years. patient satisfaction increased after 5 years of treatment with an average benefit of 75.8%. hallet23 said that botulinum toxin a injection toxin is distributed by convection and little diffusion. toxin uptake depends on activity and temperature. encouraging unwanted muscle contraction after injection helps while cooling decreases uptake. usually effect of injection finished in 2 months and at 3 months normal muscle strength returns. another study by shoaib et al24 showed that after botulinum toxin a (botox) injection for blapherospasm and hemifacial spasm onset of action started within 12 days. mean duration of action was 12.77 +/4.68 weeks. in our study we gave up to 19 injections with mean onset of injection starting at 3.64 days. mean duration of action of a botulinum injection was 3.44 months after which there was need of repeating botulinum injection. similar to other studies our study showed no significant changes in duration of action after prolonged use of botulinum toxin a injections in cases of blepharospasm and hemifacial spasm with minimum complications. conclusion botulinum toxin a injection (botox) is treatment of choice in cases of facial dystonia as it is safe and shows good efficacy when used in periocular and facial muscles with minimal complications. it can be used for prolonged period with consistent results over the years. careful use of botox injections can help patients with facial dystonias to live a normal symptoms free life. author’s affiliation prof. muhammad moin frcs (edin), frcophth consultant ophthalmologist yaqin vision eye center, lahore. dr. asif manzoor fcps, consultant ophthalmologist, yaqin vision eye center, lahore. role of authors prof. muhammad moin muhammad moin, et al 74 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology manuscript design, study design, critical review. dr. asif manzoor data analysis, statistical analysis, manuscript writing. references 1. waller rr, kennedy rh, henderson jw kesty kr. management of blepharospasm. trans am ophthalmol soc. 1985; 83: 367–386. 2. jankovic j, orman j. blepharospasm: demographic and clinical survey of 250 patients. annals of ophthalmology 16 (4): 371-6. may 1984. 3. peckham el, lopez g, shamim ea. clinical features of patients with blepharospasm: a report of 240 cases. eur j neurol. 2011 mar; 18 (3): 382-386. 4. martino d, defazio g, abbruzzese g, girlanda p, tinazzi m, fabbrini g, et al. head trauma in primary cranial dystonias: a multicentre case-control study. j neurol neurosurg psychiatry, 2007 mar; 78 (3): 260–3. 5. rosenstengel c, matthes m, baldauf j, fleck s, schroeder h. hemifacial spasm conservative and surgical treatment options. dtsch arztebl int. 2012 oct; 109 (41): 667-673. 6. lu ay, yeung jt, gerrard jl, michaelides em, sekula rf, bulsara kr. hemifacial spasm and neurovascular compression. the scientific world journal. vol. 2014 (2014), article id 349419. 7. nilsen b, le kd, dietrichs e. prevalence of hemifacial spasm in oslo, norway. neurology, vol. 63: 8, 1532– 1533, 2004. 8. hellman a, torres-russotto d. botulinum toxin in the management of blepharospasm: current evidence and recent developments. ther adv neurol disord. 2015 mar; 8 (2): 82-91. 9. singh s. botulinum toxin in hemifacial spasm: revisited. indian j plast surg. 2013 jan-apr; 46 (1): 159160. 10. horwath-winter j, bergloeff j, floegel i, hallerschober em, schmut o. botulinum toxin a treatment in patients suffering from blepharospasm and dry eye. br j ophthalmol. 2003 jan; 87 (1): 54-56. 11. valls—sole j, defazio g. blepharospasm: update on epidemiology, clinical aspects, and pathophysiology. front neurol. 2016; 7: 45. 12. tan ek, chan ll. young onset hemifacial spasm. actaneurol scand. 2006 jul; 114 (1): 59-62. 13. keller je. recovery from botulinum neurotoxin poisoning in vivo. neuroscience, 2006 may 12; 139 (2): 629-37. epub 2006 feb 20. 14. basar e, arici c. use of botulinum neurotoxin in ophthalmology. turk j ophthalmol. 2016 dec; 46 (6): 282-290. 15. nayyar p, kumar p, nayyar pv. a singh. botox: broadening the horizon of dentistry. j clin diag res. 2014 dec; 8 (12): ze25-ze29. 16. gooriah r, ahmed f. on a botulinum toxin a for chronic migraine: a critical appraisal. ther clin risk manag. 2015; 11: 1003-1013. 17. pariseau b, worley mw, anderson rl. myectomy for blepharospasm 2013. curr opin ophthalmol. 2013 sep; 24 (5): 488-93. 18. cloud lj, jinnah ha. treatment strategies for dystonia. expert opin pharmacother. 2010 jan; 11 (1): 5-15. 19. moin m, khalid s. fixed dose botulinum toxin therapy for blepharospasm. pak j ophthalmol 2016, vol.32 no.2, apr-jun, 2016. 20. flynn tc. botulinum toxin: examining duration of effect in facial aesthetic applications. am j clin dermatol. 2010; 11 (3): 183-99. 21. mejia n., vuong k., jankovic j. long-term botulinum toxin efficacy, safety, and immunogenicity. mov. disord. 2005; 20: 592–597. 22. hsiung gyr., das sk., ranawaya r., lafontaine al., suchowersky o. long-term efficacy of botulinum toxin a in treatment of various movement disorders over a 10-year period. mov. disord. 2002; 17: 1288–1293. 23. hallet m. explanation of timing of botulinum neurotoxin effects, onset and duration, and clinical ways of influencing them. toxicon. 2015 dec 1; 107 (0 0): 6467. 24. shoaib kk, haq iu, khan md. use of botulinum toxin a (botox) in different facial dystonias. j coll physicians surg pak. 2009 nov; 19(11): 742-3. https://www.ncbi.nlm.nih.gov/pubmed/?term=keller%20je%5bauthor%5d&cauthor=true&cauthor_uid=16490322 https://www.ncbi.nlm.nih.gov/pubmed/16490322 microsoft word partat rai 1 original article surgical excision and reconstruction of primary basal cell carcinoma (pbcc) of eyelid (clinical control excision method) partab rai, syed imtiaz ali shah, mahesh kumar, ashoke kumar, memon muhammad khan, saeed iqbal pak j ophthalmol 2009, vol. 25 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: partab rai department of ophthalmology chandka medical college hospital larkana purpose: to evaluate the patients with pbcc of eye lid and to demonstrate outcome of clinically controlled tumor excision method and to correct significant functional and cosmetic blemish. material and methods: this study was conducted in the department of ophthalmology, chandka medical college hospital, larkana from sept. 2001 to feb.’ 2008. in this study evaluation of 24 patients of 45 years to 80 years old with histological diagnosis of pbcc involving the eye lid and/or its margins was done. all patients under went with tumor excision and immediate reconstruction using clinical control excision method with the operating biomicroscope under local anaesthesia. the surgical procedures used were selected by on the size & location of the tumor. postoperative follow up examinations were carried out at 1st week then after at 1, 3, 6 and 12 months, later on annually for a further 5 years and longer. tumors location, size, type, recurrence and postoperative complications were evaluated. results: the primary tumor location was on the lower lid 10 (41.66%) cases, upper lid 7 (29.16%) cases, medial canthus 4 (16.66%) cases and lateral canthus 3 (12.50%) cases. the size of tumors at presentation was, tumor involving 1/4 of the eye lid 2 (8.33%) cases, 1/3 of lid 6 (25.00%) cases, 1/2 of lid 6 (25.00%) cases, 2/3 or more of lid in 3 (12.50%) cases, 1/4 medial canthus 2 received for publication march’ 2008 … ……………………… 4 (16.66%) cases and 1/4 lateral canthus 3 (12.50%) cases. the type of the tumor was nodulo ulcerative in 15 (62.50%) cases, sclerosing 5 (20.83%) cases and superficial multicentric 4 (16.66%) cases. the recurrence of the tumor was noticed in 3 (12.50%) cases. conclusion: early presentation of patient in the initial stage of the tumor will allow simple primary wound closure with less functional tissue loss and this also resulted in decreased risk of tumor recurrence and cosmetic blemish. asal cell carcinoma (bcc) is a locally invasing malignant tumor arising from basal cells present in deepest layer of the epidermis of skin1. it is the commonest cutaneous malignancy of the eye lid, accounting for 80 90% of cases2. these tumors typically appear on sun-exposed skin like face, ears, neck, scalp, shoulders and back3. bcc generally grows slowly, invading and destroying the adjacent tissues and metastasis is rare (less than 0.1%)4. although the exact etiology of bcc is unknown, but following well-established relationship exits between bcc and ultraviolet light (uvl) induced damage of the pilosebaceous unit , pluripotent cells (cells which have the capacity to form hair)5. on the skin sunlight exposure leads to dna cross linking between thymidine residues. while dna repair removes most uvinduced damage, not all cross links are excised. there is, therefore, cumulative dna damage leading to mutations. apart from the mutagenesis, sunlight depresses the local immune system, possibly decreasing immune surveillance for new tumor cells. some believe that the decrease in the ozone layer is allowing more ultraviolet radiation from the sun to reach the earth’s surface6. therefore, chronic over exposure to the sun is the cause for most bcc specially on the hairbearing areas of skin, but risk can increase with certain following genetic and environmental factors. genetic factors • light (fair) colored skin. • blue or green eyes. • blond or red hair. • xeroderma pigmentosum: this autosomal recessive disease results in the inability to repair uv induced dna damage. skin pigmentany changes are seen early in life followed by the development of bcc, squamous cell carcinoma and malignant melanoma. other features include corneal opacities, eventual blindness, and neurological deficits. • nevoid bcc syndrome: (basal cell nevus syndrome, gorlin syndrome): this autosomal dominant disorder results in the early formation of multiple odontogenic keratocytes, palmoplanter pitting, intracranial calcification, and lid anomalies. various tumors such as medulloblastomas, meningioma, fetal rhabdomyoma and ameloblastoma also can occur. environmental factors • historically, men are affected twice as often as women. the higher incidence in men is probably due to increased recreational sun-exposure (e.g. sun bathing, outdoor sports, fishing, boating) and occupational sun-exposure (e.g. farming, construction). • patients often complain of a slowly enlarging lesion that does not heal and that bleeds when traumatized. basal cell carcinoma can usually be diagnosed with a simple biopsy and is fairly easy to treat when detected early7-10. the treatment possibilities include; shave, curettage and cautery11, total clinically controlled excision12, mohs micrographically controlled excision13, photodynamic therapy14, imiquimod cream15, cryotherapy16, radiotherapy17 and laser surgery18. b 3 material and methods this study was conducted from september 2001 to february 2008 at the ophthalmology department of chandka medical college and hospital larkana. all the 24 patients were admitted in the eye ward from the eye out-patient department. after getting detailed history of these patients they were thoroughly examined, photographed and treated surgically under local anesthesia. the diagnosis of tumor was based on histopathology of excised tumor. patients with involvement of lid with or without canthus were included in this study and patients with involvement of site other than lid were referred to plastic surgeon and excluded from the study. before surgical repair of the tumor the following basic principles of eye lid reconstruction were kept in mind. • replacement of involved tissue with similar tissue. • maintenance of integrity and mobility of upper lid (levator function). • establishment of aesthetic balance. • provision of protective lining, stable skin cover and internal lid support. the surgical treatment for pbcc depends on its size, location and the preference or expertise of the surgeon. the tumor involving 1/4th size of lid was treated by direct primary closure in 2 (8.33%) cases, 1/3rd by direct closure with lateral canthotomy and cantholysis in 6 ( 25.00%) cases, 1/2 by tenzel’s semicircular flap from lateral canthal region in 6 ( 25.00%) cases, 2 /3 or more by mustarde cheek rotation flap in 3 (12.50%) cases, lid-medial canthal tumors by glabellar flap in 4 (16.66%) cases, and lidlateral canthal tumors by tenzel’s semicircular flap from lateral canthal region with full thickness skin graft from postauricular region in 3 ( 12.50%) cases (table-1). all tumors with surrounding 3-4 mm safety zone were excised and immediately reconstructed using clinical control excision method with the operating biomicroscope alone. the conjunctiva was undermined and mobilized from fornix. in autologus skin graft cases the pressure bandage and suture technique was applied. the lid margins were brought together by 2 layer approximation of the tarsus with 5/0 prolene suture and skin with 6/0 black silk suture. the eye was padded after applying traction suture in the normal lid. eye dressing was removed on the next day and topical antibiotic drops (ciprofloxacin) and eye ointment (tobramycin) was given. postoperatively patients were kept on oral antibiotics (cephradine 500 mg x tds) and analgesics ( ibuprofen 400 mg x tds) for 5 days. the skin stitches were removed on the 10th postoperative day. postoperative follow up examinations were carried out at 1st week, then after at 1, 3,6 and 12 months, later on annually for a further 5 years and longer. table 1: showing size of tumor and their treatment. tumor size treatment no of patients n (%) 1/4 size of eyelid direct primary closure 2 (8.33). 1/3 size of eyelid closure with lateral canthoomy and cantholysis 6 (25) . 1/2 size of eyelid tenzel’s semicircular flap from lateral canthal region. 6 (25). 2/3 size and more of eyelid mustarde cheek rotation flap 3 (2.50) 1/4 medial canthus tumor glabellar flap 4 (16.66) 1/4 lateral canthus tumor tenzel’s semicircular flap from lateral canthal region with full thickness skin graft from post auricular region. 3 (2.50) table 2: showing age, sex, laterality, occupation and skin complex of patients with pbcc of lid. number of patients 24 age (range) 45 to 80 years. sex male female 13 (54.16%) 11 (45.83%) laterality rt. eye lid involved lt. eye lid involved all cases had unilateral involvement. 16 (66.66%) cases 08 (33.33%) cases occupation farmer 14 (58.33%) 4 labourer 10 (41.66%) skin complex less fair skin dark skin 16.66.66% 08(33.33%) results total 24 patients with biopsy proven pbbc of lids were included in this study. the age range was from 45 years to 80 years. 13(54.16%) cases were male and 11(45.83%) cases were female. all cases had unilateral involvement. the right eye lid was involved in 16( 66.66%) cases and left eye lid was involved in 8( 33.33%) cases. the occupation wise 14(58.33%) cases were farmer and 10(41.66%) cases were labourer. the skin complex of 16(66.66%) cases was less fair and of 8 (33.33%) cases was dark (table 2). the tumor location was on the lower lid 10(41.66%) cases, upper lid 7(29.16%) cases, medial canthal region 4(16.66%) cases and lateral canthal region 3(12.50%) cases. the types of the tumor were seen noduloalcerative 15(62.50%) cases, sclerosing (morphoeic) 5(20.83%) cases, and superficial multicentric 4(16.66%) cases. the recurrence of the tumor was seen from the medial canthus with sclerosing type in 1(4.66%) case, noduloulcerative type in 1(4.66%) case and from lateral canthus with sclerosing type in 1(4.16%) case after 6 to 12 months of primary surgery (table 3). all three first time recurrent cases were treated again by skin regrafting from other post auricular region. after the second operation again second time recurrence was observed in all three cases within next six months due to indepth extension, later on which were send to oncologist for adjuvant treatment such as radiotherapy. the postoperative complications and their treatment is shown in (table 4). table 3: showing location, size, type and recurrence of pbcc. n (%) location of tumor lower eye lid upper eye lid lid-medical canthal region lid-lateral canthal region 10 (41.66%) cases 07 (29.16%) cases 04 (16.66%) cases 03 (12.50%) cases size of tumor 1/ 4 size of the eye lid 02 (8.33%) cases 1 /3 size of eye lid 1/2 size of eye lid 2/3, or more size of the eyelid 1/4 medial canthal tumor 1/4 lateral canthal tumor 06 (25.00%)cases 06 (25.00%) cases 03 (12.50%) cases 04 (16.66%) cases 03 (12.50%) cases. type of tumor noduloulcerative sclerosing (morphoeic) superficial multicentric 15 (62.50%) cases. 05 (20.83%) cases 04 (16.66%) cases recurrence of tumor from medial canthus sclorzing 1 case nodulo ulcerative 1 case from lid-lateral canthus sclorzing 1 case 02 (8.33%) cases 01 (4.16%) case discussion collin jro, reported in his study, that the incidence of pbccs increases with age and with no sex predilection, similarly in our study the mean age of patients was 62.5 years with male: female ratio of 1.1:1.0. in our study males and females are nearly equally affected because of similar outdoor services in the exposed sun as labourer or farmer19. although both environmental and hereditary factors are known to increase the risk of developing pbcc20, but in our study no doubt all patients were labourers and farmers but with less fair and dark skin. like the study of doxanas mt et al21,22, we also found an even location of the pbcc of lid. the relatively high incidence of pbcc in the lower lid and medical canthal area could perhaps be explained by local conditions other than sun exposure. perhaps the presence of thin epithelium in the medial canthal area allows more uvr to reach the cell of basal layer. table 4: showing postoperative complications and their treatment. complication no of cases n (%) treatment preseptal cellulitis 05 (20.83) intravenous antibiotics (cepharadine 500 mg x 8 hourly, gentamycine 80 mg 8 hourly) for five 5 days. corneal abrasion from lid margin suture cut ends 04 (16.66). removal of irritating suture at lid margin exposure keratopathy 04 (16.66) artificial tears and lubricants 1 hourly. restriction of eye lid function 04 (16.66) release of suture tension ectropion 03 (12.50) release with full thickess arm skin graft. partial loss of skin graft due to hemaoma collection 02 (8.33) secondary intention healing. epidermal loss 01 (4.16) antiseptic dressing. however the large difference in tumor localization between the upper and lower eye lids is difficult to explain on these grounds21,22. in our study 41.44% of pbcc and in study of gunlindgren et al 68% of pbcc were mainly located on the lower eye lids23. the lack of association between relative uvr exposure on the eye lids and pbcc location indicates that uvr exposure only partially explained the etiology of periorbital pbcc and there are probably other, yet unidentified, factors that contribute to the development of these tumors24. it is evident from recurrences that pbbc on the medial-canthus is more likely to recur than one located anywhere else in the lid region. this may be due to the complex anatomy of medial-canthal tendon, of the canalicular system, and 6 fig. 1: 60 years old male with right lower lid pbcc fig. 2: 45 years old male with right lower l id pbcc preoperativ e photograp h preoperative photograph fig. 3: 55 years old female with left u pper eye lid pbcc preoperative photograph postoperative photograph postop erative pho tograph postoperative photograph 7 preoperative photograph postoperative photograph fig. 4: 60 years old female with left eye medial canthal pbcc of the orbital septal attachments. not only are these predisposed to early indepth extension of the tumor, but the lacrimal drainage system induces the surgeon to be more cautious during tumor excision than in the case at other location in the lid region25. like the study of stefan pieh et al, we notice that greatest risk of recurrence exists for pbbc in the medial canthus, for those with an indepth extension, and for the sclerosing type. the recurrence rate increases after every operation for high risk cases, consideration should be given to adjuvant treatment such as radiotherapy25. according to previously published reports, residual tumors remain the margins of resection after upto 50% of surgical pbcc excisions performed without intraoperative histological control excision method (moh’s technique)26,27, but at our place where moh’s technique facility is not available, we have seen only 12.50% recurrence rate in the 5 years and more followup period with clinical control excision method. r.m conway et al seen 9.7% recurrence rate of pbcc with clinical control excision method28. the persons with hereditary and environmental risk factors are advised to avoid sunlight exposure by the choice of out door activities, seeking shadow, facing away from sun, wearing hat and sunglasses29. conclusion early presentation of patient in the initial stage of the tumor will allow simple primary wound closure with less functional tissue loss and this also result decreased risk of tumor recurrence and cosmetic blemish. author’s affiliation dr. partab rai assistant professor department of ophthalmology chandka medical college and hospital larkana prof. syed imtiaz ali shah department of ophthalmology chandka medical college and hospital larkana ashoke kumar assistant professer department of ophthalmology liaquat university of health & medical science jamshoro, hyderabad dr. muhammad saeed iqbal assistant professor ophthalmology sir syed college of medical sciences hospital qayyumabad, korangi raod karachi dr. memon mohammad khan assistant professor & head of ophthalmology department kulsoom bai walika social security serives site area mangho peer karachi dr. nasir bhatti assistant professor isra postgraduate institute of ophthalmology old than village memon ghoth maleer, karachi 8 reference 1. abeloff md, armitage jo, niederhuber je, et al. clnical oncology. 3rd edi. orlondo, fl: churchill livingstone; 2004: 449-5-452. 2. aurora al, blodi fc. lesions of the eye lid. a clinicopathological study. surv ophthalmol. 1970; 15: 94-104. 3. dahl e, aberg m, rausing a, et al. basal cell carcinoma. cancer 1992; 70: 108. 4. lober cw, fenske na. basal cell, squamous cell and sebaceous gland carcinomas of the periorbital region. j am acad dermatol. 1991; 25: 685-90. 5. miller sj. etiology and pathogenesis of bcc. clin. dermatol 1995; 13: 527-36. 6. habif tp. clinical dermatology. 4th edi. st. louis, mo: mosby, inc. 2004; 724–35. 7. diepgen tl, mahler vm. the epidemilogy of skin cancer. br t demator. 2002; 146: 1-6. 8. lear jt, tan bb, smith ap, et al. risk factors for basal cell carcinoma in the uk: case-control study in 806 patients. j r soc med. 1997; 90: 371-4. 9. gallagher rp, hill gb, bajdik cd, et al. sunlight exposure, pigmentary factors, and risk of nonmelanocytic skin cancer. arch dermatol. 1995; 131: 157-63. 10. ramachandran s, fryer aa, smith ag, et al. cutaneous basal cell carcinomas: distinct host factors are associate with the development of tumors on the trunk and on the head and neck. cancer 2001; 92: 354-8. 11. silverman mk, kopf aw, bart rs, et al. recurrence rates of treated basal cell carcinomas. part 2: curettageelectrodessication. j dermatol surg oncol. 1991; 17: 720-6. 12. silverman mk, kopf aw, bart rs, et al. recurrence rates of treated basal cell carcinomas. part 3: surgical excision. j dermatol surg oncol. 1992; 18: 471-6. 13. row de, carroll rj, day cl jr. mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. j dermatol surg oncol. 1989; 15: 424-31. 14. peng q, warloe t, berg k, et al. s-aminolevulinic acidbased photodynamic therapy. cancer. 1997; 79: 2282-308. 15. marks r, gebauer k, shumack s, et al. imiquimod 5% cream in the treatment of superficial basal cell carcinoma: results of a multicentre 6-week dose-response trail. j am acad dermatol. 2001; 44: 807-13. 16. kuflik eg, gage a. the fiver-year cure rate achieved by cryosurgery for skin cancer. j am acad dermatol. 1991; 141: 1002-4. 17. silverman mk, kopf aw, gladstein ah, et al. recurrence rates of treated basal cell carcinomas. part 4: x-ray therapy. j dermatol surg oncol. 1992;18: 549-54. 18. saccini v, lovo gf, arioli n. carbon dioxide laser in scalp tumor surgery. laser surg med. 1941; 42: 6-11. 19. collin jro. basal cell carcinoma in the eye lid region br j ophthalmol. 1976; 60: 806–10. 20. krickler a, armstrong bk. english dr sun exposure and non-melanotic skin cancer. cancer cause control. 1994; 5: 367-92. 21. doxanas mt, green wr, iliff ce. factors in the successful surgical management of basal cell carcinomas of the eyelids. am j ophthalmol. 1981; 91: 726-36. 22. lederman m. radiation treatment of cancer of the eyelids. br j ophthalmol. 1976; 60: 794-805. 23. gunlindgren, brain l diggey. olle larkobasal cell carcinoma of the eye lids and solar ultraviolet radiation exposure. br. j ophthalmol. 1998; 1412–5. 24. lindgren g, diffey bl, larkö o, et al. basal cell carcinoma of the eye lids and solar uvr exposure. br j ophthalmol. 1998; 82: 1412–5. 25. pieh s, kuchar a, novak p, et al. long term result after surgical basal cell carcinoma excision in the eyelid region. br j ophthalmol. 1999; 83: 85-8. 26. einaugler rb, henkind p. basal cell epithelioma of the eye lid: apparent incomplete removal. am j ophthalmol. 1969; 67: 413-7. 27. rakofsky si. the adequacy of surgical excision of basal cell carcinoma. ann ophthalmol. 1990; 75: 275-9. 28. conway rm, themel s, holbach lm. surgery for primary basal cell carcinoma including the eye lid margins with intra operative from section control: comparative interventional study with a minimum clinical follow up of 5 years. br j ophthalmol. 2004; 88: 236-8. 29. sliney dh. uv radiation ocular exposure dosimetry. doc ophthalmol. 1995; 88: 243-54. quiz: glaucoma answers: 1. a 2. b 3. d 4. a 5. d 6. b 7. a 8. d 9. b 10. c 11. a 12. d 9 13. d 14. b microsoft word ps mahar 1 109 case report sympathetic ophthalmitis: a case presentation and review of the literature p. s. mahar, aimal khan, dilshad laghari, sadaf ambreen pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p. s. mahar isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi submission of paper december’ 2010 acceptance for publication may’ 2011 …..……………………….. sympathetic ophthalmitis (so) is a rare, bilateral granulomatous uveitis occurring after perforating eye injury or ocular surgical procedure to one eye. the pathophysiology of this entity is not clearly understood but an autoimmune hypersensitivity reaction against exposed ocular antigens in the injured eye is believed to be responsible for this disease. in this article, we present a patient with clinical diagnosis of so and review the literature. ympathetic ophthalmitis (so) is defined as a bilateral granulomatous uveitis of unknown etiology, occurring after penetrating trauma or intraocular surgery. it is believed to represent a form of autosensitization of ocular tissue following a perforating injury to one eye. its exact incidence is not known but is thought to be 1.9% after trauma and 0.007% after intraocular surgery1. so is an uncommon disease due to improved surgical techniques employed in the repair of ocular injuries and early enucleation of the blind eye. the risk of developing so in severely traumatized eyes with no visual potential that are not enucleated is exceedingly low2. numerous surgical procedures such as 23-guage vitrectomy3, cataract extraction4, retinal detachment surgery5, penetrating keratoplasty6 and trabeculectomy7 have been complicated by so. we report a case of so seen in our outpatient department (opd) at isra postgraduate institute of ophthalmology / al-ibrahim eye hospital, karachi. case report a 30 year old male, plumber by profession was seen in opd with complaint of gradual painful loss of vision in his right eye of 10 days duration. about 25 days back, this patient sustained penetrating trauma to his left eye with a piece of wood. the patient did not have any significant medical and surgical history. on examination, his best corrected visual acuity (bcva) was hand movements (hm) in right eye and no perception of light (npl) in left eye. his right eye, on biomicroscopic examination showed multiple muttonfat keratic precipitates (kps) with 2-3 plus cells and flare in the anterior chamber (fig. 1 & 2).the pupil was fixed and dilated with multiple posterior synechie (ps) formation. the intraocular pressure (iop) measured 12 mm hg. the fundus examination revealed optic disc edema and serous retinal detachment (fig. 3). the patient’s left eye was pthysical with vertical full thickness corneal laceration (fig. 4). the patient went under laboratory investigations of complete blood count (cbc), erythrocyte sedimentation rate (esr), rapid plasma regain (rpr), venereal disease research s 110 laboratory (vdrl), fluorescent treponemal antibody absorption test (fta – abs), toxoplasmosis igg and igm, angiotensin converting enzyme (ace) and antinuclear antibody (ana) test. patient also had xray chest, b-scan (fig. 5), fundus flourescein angiography (ffa), (fig. 6) and optical coherence tomography (oct). all laboratory tests including xray chest were within normal limits. a clinical diagnosis of so was entertained and patient was commenced on tablet prednisolone 60 mg / day in divided doses (1 mg / kg body weight), prednisolone 1% drops (predforteallergan, pakistan), several times a day and atropine 1% twice a day (ophth-atropine ophth, pakistan). at two weeks patient’s vision had improved to 6/24 with anterior chamber getting quite and reduction in the number of kps. the optic disc margin, though still appeared blurred but swelling had subsided significantly. subretinal serous fluid also had decreased with b-scan appearing normal. patient’s systemic and topical treatment continued. at four week follow up, patient’s bcva appeared stable at 6/18 on snellen’s quotations. discussion the etiology of so has not been completely understood, but the underlying pathophysiology is believed to be an autoimmune reaction against the exposed ocular antigens from the inciting eye8. the location of such antigens remains controversial and may be found in the uveal tissue, retina or choroidal melanocytes. the immunologic studies have shown cd4 helper and inducer t cells during the early phase of inflammation compared to infiltration by cd8 suppressor and cytotoxic t cells in the later stage. there are b lymphocytes also found in some patients9. lymphocytes from patients with so were demonstrated to respond to several uveo-retinal antigens. although no circulating antiretinal s-antigen antibodies were found, the serum from patients with so showed antiretinal antibodies directed against the outer segment of photoreceptors and the muller cells, when placed over normal human retinal tissue10. it has also been hypothesized that a purulent infection within the eye would destroy the uveal tissue in such a way that so would not develop. however some cases have been reported in eyes with endophthalmitis or fungal keratitis, indicating that the infection may not offer any prevention against development of so11. the so can occur between two weeks and three months after an ocular injury, although it can develop as early as several days and as late as 50 years, majority of cases present within first three months. classically, the inflammation is granulomatous with multiple mutton-fat kps adhered to corneal endothelium. the iris can be thick and sticky with ps formation. the iop can be normal or fluctuating upwards or downwards due to the inflammatory involvement of ciliary body and trabecular meshwork. the vitreous is usually infiltrated with moderate to severe cellular reaction. the fundus can show swollen optic disc and multiple yellow-white lesions in the periphery, corresponding to the presence of dalenfuchs nodules, which may not be seen in almost 50% of the cases. serous retinal detachment or macular edema may be present with subretinal neovascularization. on fundus flourescein angiography (ffa), the optic nerve head shows hyperemia and dye leakage more pronounced in the late frames. there are multiple hyperflourescent areas of choroidal leakage corresponding to the presence of dalen-fuchs nodules. the less common appearance on ffa is that of early hyperflourescent lesions with staining in the late phase. this type of picture is thought to be related to whether the dalen-fuchs nodules have an intact or disrupted over lying retinal pigment epithelium (rpe)12. extra ocular findings such as pleocytosis of cerebro-spinal fluid, hearing loss, alopecia, poliosis and vitiligo have been reported with so, although these findings are more common in vogt koyanagi harada (vkh) disease. the sequelae of the ocular inflammation include secondary glaucoma, cataract, optic atrophy, retinal detachment with subretinal fibrosis and choroidal atrophy. so is characterized by a diffuse granulomatous, non-necrotizing inflammation involving entire uveal tract. the choroid is thickened with lymphocytic infiltration along with the presence of eosinophils and plasma cells. typically, the choriocapillaris is spared. the dalen-fuchs nodules representing migrated and transformed rpe cells are typical but not pathagnomonic and may be present in other disease such as: vkh syndrome. these nodules are collection of epitheloidhistocytes and lymphocytes, present between rpe and bruch’s membrane13,14. 111 fig. 1. multiple mutton-fat keratic precipitates in right eye fig. 2. multiple mutton-fat keratic precipitates in right eye seen with slit beam fig. 3. swollen optic disc and serous retinal detachment in right eye fig. 4. severe lacerated cornea with pthysical left eye fig. 5. serous retinal detachment in right eye on ultrasonic b-scan fig. 6. hyperfluorescent disc in late venous phase in right eye 112 it is important to rule out the other causes of granulomatous uveitis before a diagnosis of so can be entertained. although diagnosis of so is clinical, histopathology can be confirmatory. autoimmune disease like vkh, sarcoidosis, and multifocal choroiditis can have similar presentation. intraocular lymphoma and bilateral phacoanaphylaxis can also have a similar picture. infections like tuberculosis and syphilis should always be excluded. conclusion so is a rare but a significant complication of penetrating ocular injury. in addition to systemic and intravitreal steroid therapy, immunosuppressive drugs also play a significant role in the medical management of this disease. the patient’s medical treatment needs to be carefully monitored to reduce any side effects and improve visual prognosis. author’s affiliation p. s. mahar isra postgraduate institute of ophthalmology karachi aimal khan isra postgraduate institute of ophthalmology karachi dilshad laghari isra postgraduate institute of ophthalmology karachi sadaf ambreen isra postgraduate institute of ophthalmology karachi reference 1. liddy bsl, stuart j. sympathetic ophthalmitis in canada. can j ophthalmol. 1972; 7: 157-60. 2. brackup ab, carter kd, nerad ja et al. long term follow up of severely injured eyes following globe rupture. ophthalmic plast reconstr surg. 1991; 7: 1994-7. 3. cha dm, woo sj, ahn j, et al. a case of sympathetic ophthalmia presenting with extraocular symptoms and conjunctival pigmentation after repeated 23-guages vitrectomy. ocular immunalinflamm. 2010; 18: 265-7. 4. kinyoun jl, bensinger re, chuang el. thirty year history of sympathetic ophthalmia. ophthalmol. 1983; 90: 59-62. 5. wang wj. clinical and histopathalogical report of sympathetic ophthalmia after retinal detachment surgery. br j ophthalmol. 1983; 67: 150-2. 6. maheshwari s, rao v. sympathetic ophthalmia following therapeutic penetrating keratoplasty. asian j ophthalmol. 2007; 9: 89-91. 7. shammas hf, zubyk na, stanfield ta. sympathetic uveitis following glaucoma surgery. arch ophthalmol. 1977; 95: 63841. 8. kilmartin dj, dick ad, forrester jv. sympathetic ophthalmia risk following vitrectomy. should we council patients. br j ophthalmol. 2000; 84: 448-9. 9. shah dn, piacentini ma, burnier mn, et al. inflammatory cellular kinetics in sympathetic ophthalmia: a study of 29 traumatized (exciting) eyes. oculimmunolinflamm 1993; 1: 25562. 10. chan cc, palestine ag, nussenblatt rb, et al. anti-retinal auto antibodies in vogt-koyanagi-harada syndrome, behcet’s disease and sympathetic ophthalmia. ophthalmology. 1985; 92: 1025-8. 11. rathinam sr, rao na. sympathetic ophthalmia following postoperative bacterial endophthalmitis: a clinicopathologic study. am j ophthalmol. 2006; 141: 498-507. 12. sharp dc, bell ra, patterson e, et al. sypmpathetic ophthalmia, histopathalogic and angiographic correlation. arch ophthalmol. 1984; 102: 202-35. 13. jakobiec fa, marboe cc, knowles dm, et al. human sympathetic ophthalmia: an analysis of the inflammatory infiltrate by hybridoma-monoclonal antibodies, immunochemistry, and correlative electron microscopy. ophthalmology. 1983; 90: 76-95. 14. chan cc, benezra d, rodrigues mm, et al. imunohistochemisty and electron microscopy of choroidal infiltrates and dalen-fuchs nodules in sympathetic ophthalmia. ophthalmology. 1985; 92: 580-90. microsoft word raj kumar advani 143 original article phacoemulsification under topical with intracameral vs retrobulbar and sub-tenon anesthesia raj kumar advani, faiz mohammad halepota pak j ophthalmol 2008, vol. 24, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: raj kumar gul advani 1403/c sagar eye clinic nawa tak mohalla larkana received for publication june’ 2007 … ……………………… purpose: to assess and compare the advantages of topical with intra-cameral anesthesia over retrobulbar or subtenon anesthesia in phacoemul-sification surgery. material and methods: the topical anesthesia supplemented by intra cameral anesthesia was attempted on 537 cataract operations with phacoemul-sification surgery method. our technique is described with additional precautions. results: all those patients operated under topical drops and intra-cameral xylocain surgery remained comfortable during surgery and felt no pain or any other discomfort throughout the procedure except in two cases, who felt pain during implanting folding lens. all patients were happy and they liked the same procedure for contralateral eye. conclusion: during postoperative queries patients expressed satisfaction with cataract surgery under topical anesthesia. ataract blindness has been recognized for many centuries with potential surgical intervention varying from couching, extra capsular by needle pricking first ecce, than intra capsular cataract extraction, with the introduction of cryo extraction, this became most popular method. these obtained limited success due to the complica-tions like vitreous prolapse, retinal detachment, macular edema, aphakic glaucoma1, and also due to optical abbresions2. planned extra capsular cataract extraction method was performed in 1700s by jacques daviel. ridley implanted the first iol implantation in 1949, which required intact posterior capsule for iol support. in early 1970s ecce began to replace icce. c 144 later invention of phaco emulsification by kelman and with refinement of technology in late 1980s and early 1990s such as development of capsular rhexus, small size iol, folding, and injectable intraocular lens has changed the scenario. presently, it is the most common procedure throughout the world. with the change in design, material, viscoelastic and in the bag implantation has revolutionized the out come1. this procedure carried out under both local and general anesthesia3. day care cataract surgery needs a local anesthesia and its demand is increasing4 the major demand of cataract surgery are analgesia and akinesia. facial nerve block and retrobulbar injection fulfill these demands when surgery is carried out under local anesthesia5. now-a-days surgery is being performed under topical anesthesia and we supplemented it with intracameral anesthesia, it provides sufficient anesthesia similar to regional block (subtenon, retrobulbar, peri bulbar). it provides better visual outcomes immediately. this study was conducted to assess and compare the advantages of topical with intra-cameral anesthesia over retrobulbar or subtenon anesthesia in phacoemulsification surgery. material and methods this study was conducted at the sagar eye clinic larkana from 2001 to 2006. keratometry was done by topcon keratometer, and axial length was measured by a-scan with ocuscan alcon and srk ii formula was used to calculate iol power. total 537 cases are reported. in all cases universal ii alcon phacoemulsification was system used. mostly cases were done under topical and intra-cameral anesthesia but retro bulbar subtenon anesthesia was reserved for uncooperative patients or having communication problem. patients were directed to look at microscopic light through out the procedure. tab. xanax 0.5 mg was given two hour before surgery to relieve anxiety during surgery. local anesthetic drops were instilled every ten minutes for three times before surgery. after all aspect measures, three steps 2.7mm main port was made at 10 o 'clock position with keratome on scleral site. side port was made by 15 degree knife. capsulo rhexus was performed under viscoelastics, followed by hydro dissection and hydro delineation with 1% xylocain preservative free (2% xylocain + ringer lactate solution 50: 50 ratio), this solution, was also instilled on the cornea by assistant during the procedure. in hard nucleus and posterior sub capsular type hydrodissection was done with more care and hydrodelineation was not done. 0.9mm micro tip was used with phaco power 70% and vaccum between 270-300. nucleus was divided in two pieces and rotated for further division; cortex was removed with irrigation and aspiration canula. after cataract extraction, incision was enlarged to 5.25mm or 6.5mm and small or 6.5mm size lens implanted in the bag, stromal hydration was performed. in some cases one suture was applied to avoid fish mouthing or approximate the margin. acrysof multi piece lols were implanted with folding holding forceps through 3.4mm incision and single piece with royale injector through 2.7 mm incision. postoperatively all patients were seen on next day, one week later and after three months, astigmatism was assessed by cannon auto refractometer r-f 10m, and subjective refraction. all patients were asked about their satisfaction from the procedure and pain intensity recorded. results all those patients operated under topical drops and intra-cameral xylocain surgery remained comfortable during surgery and felt no pain or any other discomfort throughout the procedure except in two cases, who felt pain during implanting folding lens. on inquiring about topical anesthesia, all patients were happy and they liked the same procedure for contralateral eye. all the patients were fully satisfied who were previously operated on the contralateral eye for same procedure with other anesthesia. subtenon anesthesia caused conjunctival chemosis, which resulted in difficult surgery and postoperative red eye while retrobulbar anesthesia was painful and both caused more anxiety and discomfort to the patient. one patient developed sudden cough during the procedure resulting in posterior capsular tear and vitreous in anterior chamber and some cortical matter left with posterior capsular flap. anterior vitrectomy was performed with vitreous cutter and foldable acrysof multiple piece iol was implanted. postoperative vision was good (6/9), round pupil with some visual disturbance due to posterior capsular floating flap, later lost to follow-up. he was diabetic, cardiac and arthritic patient also. some patients required anterior vitrectomy due to the posterior capsular tear and vitreous prolapse, which was dealt with under same topical procedure conveniently or comfortably and no additional anesthesia was needed. 145 in all cases of small central tear posterior capsular iol was implanted and in three giant tear cases posterior capsular iol was implanted in the sulcus and in four cases, patient's were left aphakic for secondary procedure. they were lost to follow-up. one patient developed uncontrolled painful glaucoma (iop 60 mmhg) one week post-operatively and vitreous was observed in anterior chamber. he was reoperated, anterior vitrectomy was done and eye became quite with normal iop (10 mmhg). (table 1-4) discussion the goal of cataract surgery is to perform safe, economical, short duration, complication free and comfortable operation to the patient with least or no postoperative hospital stay. it can be performed by phacoemulsification under topical anesthesia or no anesthesia as performed by amar agarwal6. nadeem et al3 injected 0.2-0.4 ml xylocaine sub conjunctively at 12 o’ clock position 3mm away from the limbus. we, performed most of our cases by phacoemulisification under topical anesthesia, and without superior rectus suture. eye movements were controlled by second instrument, chopper, through side port. table 1: continuous capsulorhexus 482 partial rhexus and partial can opening 55 table 2: anesthesia subtenon anesthesia 35 retrobulbar 13 topical & intracameral 489 table 3: complication and additional procedures complication and procedures n (%) iris chewing 13 (2.4) dropped nucleus 3 (0.6) posterior capsular rent 23 (4.3) vitreous loss 18 (3.4) p/c rent during iol implantation 7 (1.3) vitrectomy: open sky method 11 (2) vitrectomy with vitrectomy cutter 7 (1.3) p/c: posterior capsule table 4: post-operative complications complication n (%) up-drawn pupil 9 (1.7) vitreous in a/c 1 (0.2) de-centered iol 3 (0.6) it is pain free and excludes chances of retro bulbar hemorrhage, globe perforation, optic nerve sheath hemorrhage, optic nerve penetration, retinal detachment, inferior rectus muscle contracture and injury to inferior oblique muscle, central retinal artery and vein occlusion and optic atrophy. despite of experience and taking all measures to control the risk factors it is not sure that eyeball movements will be controlled3. retrobulbar anesthesia is a blind procedure and has been conventionally used for eye surgery since ages. in our cases some patients felt so severe pain with retrobulbar anesthesia that they were reluctant for same procedure on other eye. facial block is also painful and causes temporary deviation of mouth angle which causes, psychological anxiety to patients during the surgery so he or she must be assured properly. sub tenon anesthesia is safer than retro bulbar but in our cases it caused severe conjunctival chemosis and become difficult to perform surgery. so we reserved the procedure for uncooperative patients, it causes post operative red eye, unacceptable to patients. although sub tenon anesthesia provides better control of pain but its application is more painful and causes chemosis and subconjunctival haemorrhage7, which causes difficulty in surgery as well as post-operative red eye resulting in anxiety and unsatisfied patient. martini e was also satisfied with topical anesthesia in his study8. in our cases for local anesthesia we started counseling patients from first clinic visit and explained them about the procedure to be performed and assured them that he or she will not feel a pain but only sensations during the surgery. we gave one tablet xanax 0.5mg two hours before surgery to relieve 146 anxiety. on operation table patients were instructed to restrict their eye movements and to look at microscope light. we gave intracameral anesthesia with 1% xylocain which provided sufficient anesthesia and completed the procedure uneventfully. some patients felt pain with multiple piece folding lens perhaps due to tight or small incision. patients were asked questions regarding feeling of pain or sensation. we observed that patients remained calm and quiet during the procedure with an additional procedure of anterior vitrectomy performed without further anesthesia. some patients did not believe that surgery has been completed till the padding of the eye. we used the hydro dissection as intra cameral xylocain 1% injection (2% xylocain and ringer lactate solution 50:50). apple dj has stated that hydrodissection technique is a very useful and important surgical step in enhancing the removal of cortex and lens epithelial cells, reducing the pco9, so we used it for dual purpose, hydrodissection or hydrodelineation as well as anesthesia. we reduced phaco power to avoid heat production and endothelial burn, and used high vacuum power to aspirate the nucleus. topical anesthesia is mostly reserved for foldable iol but in our cases with addition of intra cameral, it provided sufficient anesthesia that we performed phacoemulsification with folding iol implantation as well as 6.5mm rigid pmma lenses very comfortably and safely. author’s affiliation dr. raj kumar advani ophtalmologist sagar eye clinic larkana prof. faiz mohammad halepota exchairman ophthalmology luhms hyderabad reference 1. gottsch jd, stark wj. rob and smith, ophthalmic surgery; 5th ed. 1999 arnold.pp175-196. 2. elikington ar, frank hj. clinical optics. optical problems in aphakia with spectacles. second edition. black well scientific publications. london. 3. nadeem ar, ali e, qureshi na. subconjunctival anesthesia for conventional cataract extraction. pak j ophthalmol. 1999; 15: 152-6. 4. redmond rm, dalas nl. extra capsular cataract extraction under local anesthesia without retro bulbar injection (comments). br j ophthalmol. 1990; 74: 203-4. 5. roper hall mj. infiltration regional anesthesia and akinesia for eye operations. in stallard eye surgery. 7th edition butter worth. london 1989: 44-63. 6. agarwal a, agarwal a, agarwal s. no anesthesia cataract surgery (technique) pak j ophthalmol.1999; 15: 157-64. 7. kaderii b, aevi r. comparison of topical and sub conjunctival anesthesia in intra vitrial injections administration. eur j ophthalmol. 16: 718-21. 8. marteli e, cavallini gm, campi l, et al. lidocain versus proparacaine for topical anesthesia in cataract surgery. j cat. ref. surg. 2002; 28: 1018-22. 9. apple dj, solomon kd, tetz mr, et al. posterior capsular opacification. surv ophthalmol. 1992; 37: 73-116. microsoft word abstruct 24,2,08 107 abstracts edited by dr. tahir mahmood low-dose mitomycin c as a prophylaxis for corneal haze in myopic surface ablation thornton i, puri a, xu m, krueger rr am j ophthalmol 2007; 144: 673-81. although it was introduced experimentally in refractive surgery more than 15 years ago, mitomycin c (mmc) was introduced clinically only recently as a topical adjunctive therapy to overcome the development of corneal haze alter photorefractive keratectomy (prk). the rationale for its use relies on its potent cytostatic effect, blocking deoxyrihonucleic acid and ribonucleic acid replication, and protein synthesis. although effective, mmc has been shown to produce notable complications in scleral and corneoscleral procedures, including peripheral keratolysis and scleral melting. although these effects have not been shown to occur in cases of topical mmc use with surface laser ablation, some concern still exists for subclinical effects resulting from mmc toxicity to keratocytes, endothelial cells, and intraocular structures. reports of keratocyte apoptosis, endothelial cell dropout, and detection of mmc in the anterior chamber have been reported, leading to the question of possible long-term effects. the initial topical dosage of mmc after surface laser ablation, 0.02% for two minutes, has been proposed empirically based on its historical use in filtering procedures for glaucoma and pterygium excisions at slightly higher concentrations that later were reduced. consequently, both histologic and clinical studies are now being conducted to consider the effectiveness, safety, and mechanism of mmc use to explore the best concentration and exposure time. most investigators have attempted to use the same concentration, 0.02%, but with shorter times to reduce the potential toxicity of longer exposures. the purpose of this study was to evaluate the efficacy of low-dose (0.002%) mitomycin c (mmc) vs no prophylactic mmc (control) in reducing corneal haze after surface laser ablation. ninety-two eyes with no mmc application and 83 eyes with 0.002% mmc application during laser epithelial keratomileusis (lasek) were analyzed in a retrospective chart review with one month, two months, three months, six months, one year, and two years of postoperative follow-up. postoperative haze, visual acuity, and efficacy ratio (effr) then were analyzed statistically. the no-dose mmc and low-dose mmc groups were statistically similar except for a thinner corneal pachymetry (p < .001), higher spherical equivalent error (p = .006), and smaller ablation zone (p = .009) in eyes not treated with mmc when subjected to univariate analysis. multivariatc analysis was used to overcome the preoperative statistical differences among the two groups. eyes treated with low-dose mmc (0.002%) demonstrated statistically less haze at all postoperative time points and in each myopic subgroup (p < .001). the postoperative uncorrectcd visual acuity (ucva) and effr, however, showed no difference between the groups, except for better effr with mmc at one month (p < .001) and two months (p = .034). authors concluded with the remarks that low-dose mmc (0.002%) in eyes after lasek results in less corneal haze than in eyes not receiving this agent. concerns regarding the potential toxicity of mmc make a 10-fold less concentration more desirable in refractive surgery. further comparative study of low vs higher-dose mmc is recommended to characterize its clinical benefit fully incidence of cataract surgery from 1980 through 2004: 25-year population-based study erie jc, baratz kh, hodge do, schleck cd, burke jp j cataract refract surg 2007; 33: 1273-7. there is continued interest in estimating trends in the magnitude of cataract surgery within the united states population. as the u.s. population ages, it is estimated that the number of persons with cataracts will rise to approximately 30 million by 2020, an increase of 50%. treatment for cataracts already accounts for a substantial proportion of vision related medicare costs. further growth in the number of cataract 108 surgeries required to meet an increasing cataract burden will affect future health care spending. few population-based studies have reported cataract surgery incidence rates in the us or in other countries, and none has a study period long enough to adequately span the conversion from extracapsular cataract extraction (ecce) techniques to phacoemulsification. incidence data for cataract surgery are useful in planning future eye-care delivery needs and are advantageous over crosssectional prevalence data in more accurately estimating changes in annual demand. an efficient source of obtaining cataract surgery incidence data is the rochester epidemiology project (rep). the rep databases record all patientphysician encounters within a stable, well-defined geographic area for which the rep has complete data capture. the usefulness of the rep databases in providing accurate population based data has been reported. the purpose of this study was to estimate sexand age-specific incidence rates of cataract surgery in a defined united states population and evaluate the change in incidence over time. during the study period, 10245 cataract extractions were performed in 7141 residents of all ages. overall, the age-adjusted cataract surgery incident rate per 100000 residents was 548 (95% confidence interval [cl], 534-561) for women, 462 (95% cl, 447-478) for men, and 511 (95% cl, 501-521) for all residents. the incidence of cataract surgery increased 500% among women and 467% among men during the study period (p<.001). overall, the incidence of cataract surgery was highest in residents 70 years and older (3538 surgeries [95% cl, 3322-3764] per 100000 residents). authors concluded with the remarks that population-based study found a substantial increase in incident cataract surgery among olmsted county residents during the 25-year study period. the rate of cataract surgery increased in a nearly linear fashion during a period when phacoemulsification replaced extracapsular cataract extraction in the community. outcomes of radiofrequency in advanced keratoconus lyra jm, trindade fc, lyra d, bezerra a j cataract refract surg 2007; 33: 1288-95. surgical correction of keratoconus using thermal energy has long been a challenge for ophthalmologists. several researchers have attempted to treat keratoconus by applying heat to its apex, thus flattening it and creating firm scar tissue and leukoma. applying hot cautery causes massive collagen destruction and corneal tissue melting. thermokeratoplasty for keratoconus was abandoned because of complications and poor predictability. in the mid1970s, thermokeratoplasty was modified and reintroduced by gasset and kaufman. their technique consisted of the insertion of a 115°c probe at the apex of the cone. however, other authors report considerably lower success rates and a high incidence of morbidity after thermokeratoplasty. radiofrequency was recently reintroduced to correct hyperopia. it consists of the delivery of radio frequency energy through the corneal stroma using a probe tip. corneal tissue resistance to the passage of radiofrequency energy heats the collagen, causing it to shrink. temperatures ranging from 65°c to 75°c denature corneal tissue in a controlled and stable way. the tip is inserted deep into the corneal stroma (80%) to create a uniform cylinder. to correct hyperopia, the spots are placed in the circumference of the mid cornea and midperipheral cornea (6.0, 7.0, and 8.0 mm optical zones). the resulting collagen shrinkage has a "belt-tightening" effect, increasing the curvature of the central cornea. this approach does not rely on the heated tip used by fyodorov and others in their thermokeratoplasty techniques. the purpose of this study was to evaluate the use of radiofrequency energy to correct advanced keratoconus. in this prospective comparative study, radiofrequency was applied to 25 eyes of 21 consecutive patients. one group comprised patients with a kreading between 54.0 diopters (d) and 58.0 d; 8 thermal spots were placed at the 4.0 mm optical zone. the other group comprised patients with a k-reading greater than 58.0 d; 16 spots were applied at the 4.0 mm and 5.0 mm optical zones. the minimum followup was 18 months in all patients. differences between preoperative and postoperative uncorrected visual acuity, best spectacle-corrected visual acuity (bscva), manifest refraction, and k-readings were clinically and statistically evaluated. at end of the 18-month follow-up, the mean bscva in the 8-spot group improved from 20/100 (0.71 ± 0.25 logmar) preoperatively to 20/40 (0.32 + 109 0.11 logmar) and in the 16-spot group, from 20/200 (1.03 ± 0.30 logmar) to 20/60 (0.62 ± 0.22 logmar). the mean manifest refractive spherical equivalent (mrse) improved from -7.70 d ± 5.20 (sd) preoperatively to -6.82 ± 4.41 d after 18 months in the 8-spot group and from -11.33 ± 6.70 to 8.38 ± 5.12d, respectively, in the 16-spot group. the mean best contact lens-corrected visual acuity was 20/30 (0.18 ± 0.24 logmar) in the 8-spot group and 20/40 (0.31 ±0.19 logmar) in the 16-spot group. a dense corneal scar was seen in 1 patient in the 16-spot group at the 6month follow-up. authors concluded with the remarks that radiofrequency appeared safe for the treatment of advanced keratoconus. contact lens fitting was stable in all cases. intracorneal rings for keratoconus and keratectasia ertan a, colin j j cataract refract surg 2007; 33: 1303-14. noninflammatory corneal thinning disorders, such as keratoconus, pellucid marginal corneal degeneration (pmcd), and keratoglobus, are characterized by progressive corneal thinning and are among the most common abnormalities refractive surgeons encounter. with the advancement of thinning, the cornea becomes more irregular and ectatic. to date, the therapeutic options for patients with corneal ectasia have been limited to spectacles and contact lenses, while in advanced stages of the disease the accepted approach is penetrating keratoplasty (pkp). despite the good results of pkp in keratoconus, there are reported complications such as allograft rejection, significant endothelial cell loss (especially when the life expectancy is long), irregular astigmatism, side effects caused by long-term use of topical corticosteroids (eg, secondary glaucoma, cataract), and recurrence of keratoconus. the literature reports several alternative methods to treat keratoconus such as thermal keratoplasty, epikeratoplasty, photorefractive keratectomy, laser in situ keratomileusis (lasik), and deep lamellar keratoplasty. recently, intrastromal corneal ring segments have been designed to achieve refractive adjustment by flattening the cornea. the changes in corneal structure induced by additive technologies can be roughly predicted by the barraquer thickness law; that is, when material is added to the periphery of the cornea or an equal amount of material is removed from the central area, a flattening effect is achieved. in contrast, when material is added to the center or removed from the corneal periphery, the surface curvature is steepened. the corrective result varies in direct proportion to the thickness of the implant and in inverse proportion to its diameter. the thicker and the smaller the device, the higher the corrective result. intrastromal corneal ring segments were designed to achieve refractive adjustment by flattening the cornea. recently, they have been used to reshape keratoconic corneas to improve uncorrected visual acuity, best corrected visual acuity, and contact lens tolerance and to delay or prevent the need for keratoplasty. intracorneal ring segments have several distinct and important advantages. new thicknesses and different ring sizes and the use of femtosecond lasers to dissect channels inside the cornea will likely improve the surgical outcomes. this article reviews the latest data published or presented at meetings on the correction of keratoconus and keratectasia by intracorneal ring segments. microsoft word asfandyar asghar.doc 187 original article management of pseudophakic retinal detachment asfandyar asghar, waseem jafri, aziz ur rahman, abdul fattah pak j ophthalmol 2007, vol. 23 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: asfandyar asghar isra postgraduate institute of ophthalmology al ibrahim eye hospital malir, karachi. received for publication november’ 2006 …..……………………….. objective: to evaluate the functional and anatomical outcome of retinal detachment surgery in pseudophakic eyes material and methods: non comparative interventional case study was conducted at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir karachi from 1st january to december 2005. study include 23 pseudophakic eyes of 23 patients with pseudophakic retinal detachment, who underwent three ports pars plana vitrectomy with silicone oil tamponade and endolaser. postoperatively 3 months follow up was carried out. results: 22 of 23 pseudophakic eyes (95.65%) achieved anatomical success. 20 pseudophakic eyes (86.95%) showed postoperative visual acuity improvement 1 or more lines ranged from 0.025-0.33 (1/60 – 6/18). post operative complications include raised iop in 14 eyes (60.86%), epiretinal membrane formation in 10 eyes (4.3%) and re-detachment in 01 eye (4.3%). conclusion: pseudophakic retinal detachment (rd) is always a complicated sort of detachment due to poor visualization of retinal breaks. therefore scleral buckling (sb) alone is not sufficient to treat the rd. three ports pars plana vitrectomy with silicone oil tamponade along with endolaser around the retinal breaks or 360o endolaser is an effective procedure to treat pseudophakic rd. hegmatogenous retinal detachment (rd) remains a common problem after cataract extraction and intra ocular lens (iol) implantation1,2-9. in fact, it is the most common potentially blinding complication of this procedure. rd develops in 0.5% to 1.0% of eyes even after modern cataract surgery1-9. thus, it is far more common than are bacterial endophthalmitis and expulsive hemorrhage, which likewise may permanently affect vision and quality of life after cataract extraction1,8. the anatomic and visual outcome of pseudophakic rd surgery are not easy to compare because of different ways of expressing the results. nevertheless, several series of silicone oil tamponade for complicated rd recorded visual acuity equal to or better than 0.025 (1/60) in a percentage ranging from 45% to 63%10-14. the purpose of this study was to see the anatomic and functional outcome of rd surgery in pseudophakic eyes at isra postgraduate institute of ophthalmology. material and methods 23 eyes of 23 patients who underwent pseudophakic rd surgery from 1 january 2005 upto december 2005 at isra postgraduate institute of ophthalmology, were r 188 included in this study. phakic, aphakic or pseudophakic rd surgery with anterior chamber intraocular lens were excluded. patients were informed about the procedure and written consent was taken. pre operative evaluation included detailed history, visual acuity; slit lamp biomicroscopy-anterior segment and fundus examination carried out with 90d. peripheral retinal evaluation performed with indirect ophthalmoscope and goldmann three mirror contact lens. the number, type, (atrophic hole or horseshoe tear) position, (anterior, equatorial and posterior to the equator) size of break and grade of proliferative vitreo retinopathy were determined pre operatively. most of the rd surgery were performed under general anesthesia but some under local anesthesia by different surgeons. three ports pars plana vitrectomy (ppv) was performed using biom (binocular indirect ophthalmo microscope). in all eyes central and peripheral vitreous was removed, followed by removal of all vitreous traction on retinal tears. in eyes where retinal break could not be localized even after intra operative scleral depression for 360o, drainage retinotomy was performed in the nasal quadrant. endocautery was performed on the margin of break, retina flattened with air, sub retinal fluid (srf) was aspirated with flute needle or with high extrusion needle. two rows of argon laser were applied around the retinotomy site or around the break after fluid air exchange. 360o prophylactic endolaser was performed in eyes where break can’t be localized. air was exchanged with silicone oil (5000 centistokes) as long internal tamponade agent. sclerotomies were closed carefully with 6/0 vicryl suture. visual acuity (va), anterior segment, posterior segment examination and iop were recorded after 24 hours, one week, two weeks, one month and three months after the surgery. silicone oil was not removed from any eye till last follow up of the study. the data was statistically analyzed by using spss version 10. all categorical response variable including type of rd, pre and postoperative va and complication were given in frequencies and percentage; wilcoxon sign rank test was applied to compare significance of proportion in these variable at p<0.05 level of significance. results 23 post operative pseudophakic eyes (23 patients) with rd were followed for 3 months. 18 patients were men (78.26%) and 5 were women (21.73%). mean patient age was 52.00 years (range 31-75 years). all eyes included in the study were pseudophakic with a pciol. posterior lens capsule was intact in 18 eyes (78.26%) and posterior capsular rent were found in 3 patients and in 2 patients neodymium yttrium aluminum garnet laser (nd:yag laser) capsulotomy had been done at the time of presentation. all eyes had macular detachment pre operatively. type of pseudophakic rrd are shown in table i. 14 eyes (60.86%) had causative breaks located between 10 o‘clock and 2 o’clock position. 5 eyes (21.73%) had causative break located between 3 o’clock and 9 o’clock position. 4 (17.39%) eyes no causative break was localized pre-operatively and intraoperatively. preoperative visual acuity is shown in table 2. post operative visual acuity are shown in table 3. numbers of patients in which post operative visual acuity improved, not improved and deteriorated on 1st day, 1st week, 2nd week, 1st month, 3rd month are shown in table 4. complications preoperatively and post operatively shown in table 5. discussion goal of rd surgery in general is to close the retinal breaks and release vitro retinal traction. the best method to treat a rd is one which is relatively safe and controlled, involves minimal manipulation and minimal intra and post operative complication15. scleral buckling (sb) procedures may pose a problem because of poor visualization due to poor mydriasis, cortical remanants, capsular opacification, glare or pitting from the intra ocular lens implant, corneal opacification, or vitreous opacities may make identification difficult, especially because anterior breaks more commonly occur in pseudophakic and aphakic rds16. the principles of sb are to reduce vitreo retinal traction and to seal the retinal breaks17. the anatomic success rate in aphakic eyes has been 85% as reported by norton18. in pseudophakic eyes results varied between 82% to 95% as reported by ho and tolentino19 and johnston20 et al. machemer21 in 1970 revolutionized intra ocular surgery with the introduction of pars plana vitrectomy. kloti22 in 1983 reported the use of vitrectomy in conjunction with internal drainage of sub retinal fluid and use of intravitreal tamponade. 189 pars plana vitrectomy has been performed alone23,24 or in combination with sb procedures25 for the management of pseudophakic rd. different types of retinopexy, such as cryo therapy, argon and diode laser alone or both, were use in these studies. different tamponade agents such as air, sf6 (sulphurhexafluoride), c2f6 (perfluoroethane), c3f8 (perfluoropropane) and silicone oil were applied in these series. most authors did not provide a complete description of causative breaks in terms of size, position and type. in all these series the initial re– attachment rate varied from 64.5% to 100%23-25. table 1: type of rrd: clinical presentation of pseudophakic rd type of rrd with grades pvr with macula off no. of patients n (%) total rrd pvr c1 – c6 13 (65.52) subtotal rrd pvr b-c2 4 (17.39) inferior rrd pvr b – c3 6 (26.08) *rrd: rhegmatogenous retinal detachment, * pvr: proliferative vitreo retinopathy table 2: pre operative visual acuity of subjects pre operative visual acuity no. of patients n (%) pl +ve 3 (13.04) hm 6 (26.08) 0.025 9 (39.13) 0.05 2 (8.6) 0.1 2 (8.6) 0.2 1 (4.3) table 3: post operative visual acuity of subjects post operative visual acuity n0. of patients n (%) 0.33 – 0.1 14 (60.86) 0. 05 0.25 6 (26.08) no improvement 3 (13.04) *0.33 = 6/18, 0.25=6/24, 0.2=6/30, 0.1=6/60, 0.05=3/60, 0.025=1/60 in present study, the results of 23 eyes of 23 patients with pseudophakic rds with causative break localized or could not be localized treated with primary ppv with internal tamponade are reported. all patients who underwent primary vitrectomy had pseudophakic rd with pvr grade b-c6 according to machemer classification26. out of 23 eyes, breaks were table 4: number of patients improved, not improved or deteriorates in 03 months follow up improvement n (%) no improvement n (%) deterioration n (%) p value 1st post op day 8 (34.78) 11 (47.82) 4 (17.39) 0.33 post op va 1st wk 17 (73.91) 5( 21.73) 1 (4.3) 0.001 post op va 2nd wk 20 (86.95) 3 (13.04) 0 0.001 post op va 1st mth 19 (82.60) 4 (17.39) 0 0.001 post op va 3rd mth 20 (86.95%) 3 (13.04%) 0 0.001 *post op va= post operative visual acuity *wk= week, mth=month table 5: complications per operative no. of patients n (%) active bleeding at retinotomy site 02 (8.6) post operative raised iop 14 (60.86) epiretinal membrane formation 1 (4.3) re detachment 1 (4.3) no complication 5 (21.73) 190 localized in 19 eyes (82.60%), in 14 eyes (60.86%) majority of breaks localized were in superior quadrant between 10 – 02 o’clock position. 5 eyes (21.73%) had causative break located between 3-9 o’clock positions. in 4eyes (17.39%) no causative break could be localized pre operatively and intra operatively. in aphakic and psuedophakic rds, the incidence of non visualized break has been reported as 7% to 16% and 5% to 22.5%,27-29 respectively. posterior capsular rents were found in 3 patients and in 2 patients nd: yag laser capsulotomy had been done at the time of presentation. nd: yag laser capsulotomy increases the risk of rd four times,4,5,30,31 but posterior capsulotomy also improves visibility of retinal breaks. posterior capsulotomy can also be done just before or during the surgery to improve identification of peripheral retinal breaks. in this study retinal breaks were not found in 4 eyes (17.3%). the anatomic success rate in eyes with non visualized breaks is thought to be lower than average. in our study, the anatomic success rate did not differ32-35. anatomical success at the last follow up was achieved in 22 pseudophakic eyes (95.65%) in one eye (4.34%) there was inferior recurrence of rd due to pvr after 3 weeks of rd surgery. anatomical success rate previously reported ranged from 75% to 100%36,37. functional result in 20 pseudophakic eyes (86.95%) showed post operatively va improvement 1 or more lines ranged from 0.025-0.33 (1/60-6/18) at follow up examination. 14 eyes (60.86%) had va better than or equal to 0.1 (6/60). in 3 patients (13.04%), va after rd surgery did not improve because in 1 eye re detachment occurred with macular involvement. two eyes anatomical success was achieved but functional success could not be achieved probably because these rds were more than two months old. the results in term of visual function are not easy to compare because of the different ways of expressing the results. nevertheless, several series of silicone oil tamponade for complicated rd recorded va equal to or better than 0.025 (1/60) in a percentage ranging from 45% to 63%10-14. we observed increased iop is a common complication in our series i.e. 60.86%. all patients with raised iop were controlled with anti glaucoma medication. in most studies, early transient iop rise was the most common complication of primary vitrectomy combined with fluid gas exchange. in the studies by bartz schmidt38 et al and speicher39 et al this rate was reported to be 48% and 17.4% respectively. probably the high percentage in our series was due to use of high viscosity silicone oil. macular epiretinal membrane in our series developed in 4.3% of patients. martinez-castillo40 reported 5% patients developed macular epiretinal membrane. ahmadieh41 reported increased incidence of epiretinal membrane during the 6 months follow period. no cases of keratopathy and emulsification of silicone oil were noted in our series probably because of short follow-up period in the study and use of high viscosity silicone oil. our study had several limitations. one limitation was the sample size and short follow up period. another limitation was the use of high viscosity silicone oil (5000 centistokes) that was not compared with standard silicone oil (1000 centistokes). based on our experiences in this study one should do prospective randomized controlled study to compare high viscosity silicone oil and standard silicone oil in case of complicated rd. conclusion pseudophakic retinal detachment (rd) is always a complicated sort of detachment due to poor visualization of retinal breaks. therefore scleral buckling (sb) alone is not sufficient to treat the rd three ports pars plana vitrectomy with silicone oil tamponade along with endolaser around the retinal breaks or 360o endolaser is an effective procedure to treat pseudophakic rd. authors affiliations asfandyar asghar isra postgraduate institute of ophthalmology al-ibrahim eye hospital malir, karachi waseem jafri isra postgraduate institute of ophthalmology al-ibrahim eye hospital malir, karachi azizur rahman isra postgraduate institute of ophthalmology al-ibrahim eye hospital malir, karachi abdul fattah isra postgraduate institute of ophthalmology al-ibrahim eye hospital malir, karachi 191 references 1. javitt jc, street da, tielseh jm. national outcomes of cataract extraction. retinal detachment and endophthalmitis after outpatient cataract surgery. cataract patient outcomes research team. ophthalmology 1994; 101: 100-5. 2. javitt jc, vitale s, canner jk. national outcomes of cataract extraction. i. retinal detachment after inpatient surgery. ophthalmology 1991; 98: 895-902. 3. nielsen ne, naeser k. epidemiology of retina detachment following extra capsular cataract extraction: a follow-up study with an analysis of risk factors. j cataract refract surg. 1993; 19: 675-80. 4. 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aphakic retinal detachment. ophthalmology 2005; 112: 1421-9. microsoft word saeed iqbal   127 original article outcome of laser in situ keratomeliusis (lasik) in low to high myopia: review of 200 cases muhammad saeed iqbal, adil salim jafri, p.s. mahar pak j ophthalmol 2008, vol. 24 no. 3 .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: muhammad saeed iqbal d-255 block-4, federal ‘b, area karachi received for publication october’ 2007 purpose: to evaluate the visual outcome and complications of laser in situ keratomeliusis (lasik) in low to high myopia (-2 to-10 diopters). material and methods: a retrospective, non comparative analysis of 200 patients records was done who had lasik procedure for myopia at laser vision center, karachi, from oct. 2004 to sept. 2006. inclusive criteria were myopia between -2 to -10d and astigmatic not more than 0.5 d. visual acuity at 1 month and 6 month and complication where recorded at six months. results: 200 patients (400 eyes) were included in this study. 70 patients (140 eyes) were male while 130 patients (260 eyes) were female. patients’ age ranged between 19-50 years with mean age at 34 years. all patients had myopia between -2.0ds to -10.0ds with astigmatism of no more than 0.5d. pre operatively, 373 eyes had best spectacle corrected visual acuity (bscva) of 6/9 or better. at six months post lasik, 346 eyes (92.7%) gained their vision back without correction, thirty eight (9.5%) eyes had one line decrease on snellen’s acuity chart. no eye was recorded with decreased vision of more than a line. dry eyes were found to be the most common problem followed by glare and myopic regression. conclusion: results indicated that lasik prove it as a safe and acceptable procedure for the treatment of low to high myopia with no serious side effects.   128 … ……………………… pectacles and contact lenses are the primary choice of refractive error correction among myopic patients, but in past decade refractive surgery has gained interest even among successful contact lens wearers1. in the history of refractive surgery, an important development has occurred in the use of excimer systems offering the possibility to change the anterior corneal refractive power through a controlled stromal ablation2. laser in situ keratomeliusis (lasik) is the most commonly performed technique for surgical correction of myopia and myopia with astigmatism3. the procedure is performed by the excimer laser by removing the tissues with liberation of sufficient energy with a specific wavelength (193nm) to interrupt the tissue’s intermolecular bundles in a short time in order to avoid any harm to the surrounding tissues4. the lasik technique inflicts two surgical traumas: the microkeratome cut and the stromal ablation by the excimer laser. due to the surgical trauma, tissue repair and a healing process will be induced2. lasik proved to have a less aggressive healing process (cicatrisation) and consequently less complication in relation to other mechanical surgeries such as radial keratotomy4. this retrospective study was carried out at the laser vision centre, karachi and was designed to make a description on the result of lasik in view of its visual outcome and complications. material and methods the study was conducted on 200 selected patients fulfilling the inclusion criteria and followed for a minimum of six months period between october 2004 to september 2006. the inclusion criteria were stable myopia for at least one year, contact lens wearing intolerance, age between 18-50 years, central corneal thickness of 500600 microns, patients with keratometric readings between 38-48 diopters and absence of progressive myopia. patients with severe dry eyes, chronic lid, conjunctival and corneal diseases, cataracts, glaucoma, uveitis or history of retinal detachment were excluded. each patient had bilateral myopia between -2.0 and -10.0 diopters with astigmatism of no greater than -0.5d. detailed history and complete eye examination of anterior and posterior segment was performed. special attention was given to the status of tear film and cornea. schirmer’s test was performed in suspicious cases and results recorded. ultrasonic pachymetry (echopach-phakosystem inc. canada) was done on each eye to see the central corneal thickness (cct) and corneal topography (eyesys 2000–usa) was performed to check any corneal curvature abnormalities. all patients under went dilated fundus examination for the presence of any peripheral retinal lesions or breaks, which can be sealed through argon laser photocoagulation prior to lasik. refractive stability was established by reviewing previous examination records3. a counseling session was carried out with each patient and attendants regarding patient’s expectations with the procedure, surgical outcome, chances of residual myopia, regression, dry eyes and glare etc5. prophylactic argon laser photocoagulation was performed, either 360 degrees or locally to surround the lesion, according to the nature and extent of retinal pathology. only those patients were selected whose corneal thickness was sufficient to carry out the procedure. contact lenses were discontinued for at least one week prior to the surgery. initially, topical ofloxacin (exocin-allergan pakistan) and then fourth generation flouroquinolone, moxifloxacin 0.5% (vigamoxalcon usa) was routinely used for the surgical prophylaxis6. all surgeries were performed by the same surgeon using topical anesthesia (alcaine – alcon belgium). after scrubbing the eye with 5% povidone iodine, sterile draping was applied. fornix was irrigated with balanced salt solution and secretions were wiped through sterile brush. a marker with gention violet was applied on the cornea for flap repositioning. microkeratome suction ring size was decided according to the corneal curvature. all lasik procedures were performed with a flap thickness of 160 microns and at least 250 microns of residual stromal bed. corneal flap was created with mk 2000 microkeratome (nidek – japan) making hinge on the s   129 nasal side. the flap was lifted on the hinge with the help of special cannula and the stromal bed was dried with fine brush to prevent under correction as laser energy will be otherwise utilized to dry the wet stromal bed. eye was centered and the patient was instructed to focus on the green light. excimer laser (summit apex plus svs – usa) was programmed with a 6.0 mm treatment zone diameter and then ablation was applied in the centre of the cornea. at the end of laser emission, stromal bed and under surface of the flap was irrigated with balanced salt solution (bss) to wash away any debris. the flap was reposited back in position aligning the marker lines applied pre-operatively. antibiotic and steroid eye drops were instilled at the end of the procedure. eyes were rechecked on slit lamp after 15 minutes to confirm the flap position and absence of debris under the flap. patients were told about the precautions to be taken in next 12 – 24 hours. in addition to antibiotic eye drops, prednisolone 1% (predforte – allergan pakistan) and artificial tears (tears naturale ii – alcon belgium) were advised to be used onwards for one, three and six weeks post operatively. use of lubricants was encouraged as needed throughout the study. all cases were examined next day, one week, one month, three months and then six months post lasik. visual acuity and intra ocular pressure (iop) were checked at every visit. results 200 patients (400 eyes) underwent uneventful lasik surgery. all patients were operated on both eyes.70 patients (140 eyes) were male while 130 patients (260 eyes) were female (table i) (fig. 1). pre-lasik, best spectacle corrected visual acuity (bscva) of 6/6 was achieved by 324 eyes. 49 eyes reached 6/9, 19 were up to 6/12 and 8 eyes were improved to 6/18 (table 2) (fig. 2). table i. patients data (n=400) no. of patients no. of eyes male 70 140 female 130 260 table 2: preoperative vision (n=400). pre lasik bscva no. of eyes n (%) 6/6 324 (81) 6/9 49 (12.2) 6/12 19 (4.75) 6/18 08 (02) 6/24 nil one day post-lasik, 249 eyes reached the unaided vision of 6/6, 77 eyes achieved visual acuity of 6/9, 44 eyes achieved 6/12 vision, 26 eyes improved to 6/18 and 04 eyes improved to 6/24 vision on snellens’ quotation. at one month, 272 eyes were 6/6, 67 eyes reached 6/9 vision, 50 eyes saw 6/12, 09 eyes were able to read up to 6/18 while vision of 02 eyes remained on 6/24. final visual acuity recorded at six months showed, 286 eyes establishing vision at 6/6. the numbers of eyes at 6/9 were reduced to 60. forty eyes reached 6/12 vision, 12 eyes achieved 6/18 and 02 eyes gained maximum vision of 6/24 (table 3). we came across a number of side effects during the follow up period. incidence of mild to moderate dry eyes was highest as it developed in 212 eyes (53%), more in female than in male patients. recovery period of dry eyes was 3 – 5 months (mean 4 months). all patients were kept on tears natural ii eye drops during the recovery period. frequency of artificial tears or lubricant drops was decided according to the intensity of the problem. the second common side effect was glare which developed in 114 (28.5%) eyes. it reduced in intensity over the period of 6 – 7 months. 30 eyes (7.5%) developed myopic regression of 0.50 to -2.75 diopters (mean -1.62 d) within eight weeks of lasik. microstriae7 were seen in 22 cases (5.5%) which were visually insignificant. 22 eyes (5.5%) showed response to the steroid eye drops and developed raised iop. this was managed by minimizing the frequency of steroids or withdrawal of steroid drops while adding the topical beta blockers to lower the iop within normal limits. irregular astigmatism of -1.0 dc to -2.0 dc was found in 4 eyes (1%) and 4 eyes (1%) had hyperopic shift of +0.50ds to +1.0 ds. bacterial keratitis was seen in both eyes of a single patient (table 4).   130 table 3: post lasik visual acuity (n=400) post lasik visual acuity no. of eyes at one day n (%) no. of eyes at one month n (%) no. of eyes at six months n (%) 6/6 249 (62.25) 272 (68) 286 (71.5) 6/9 74 (18.5) 67 (16.75) 60 (15) 6/12 44 (11) 50 (12.5) 40 (10) 6/18 26 (6.5) 09 (2.25) 12 (03) 6/24 04 (01) 02 (0.5) 02 (0.5) table 4. incidence of side effects (n=400) side effects no. of eyes n (%) dry eye 212 (53) glare 114 (28.5) myopic regression 30 (7.5) raised intraocular pressure (iop) 22 (5.5) microstriae 2 (5.5) astigmatism 04 (01) hyperopic shift 04 (01) bacterial keratitis 02 (0.5) no. of eyes 260 no. of eyes 140 male female fig. 1: 0 50 100 150 200 250 300 350 6/6 6/9 6/12 6/18 6/24 post-lasik no. of eyes post-lasik no. of eyes at one day post-lasik no. of eyes at one month post-lasik no. of eyes at six months fig. 2: discussion over the last decade many reports have shown excellent outcome in terms of predictability, efficacy and safety after lasik. in our clinical trial, results of lasik were satisfying and encouraging although a number of patients complained of few problems but overall the visual outcome was satisfactory for the patients. in our study of 200 cases (400 eyes), 373 eyes with pre operative bscva of 6/9 or better, 346 eyes retained their vision without correction at six months post lasik. this shows success in 92.7% cases who were satisfied with their visual outcome after the lasik procedure. out of 400 eyes, 38 (9.5%) eyes had one line decrease on snellen’s chart. no eye was recorded with a decreased vision of more than a line. balazsi et al 8reported that at six months after lasik, uncorrected visual acuity was 6/9 or better in 94.6% eyes. their study also indicated that 11.3% eyes showed 1 line decrease in vision after six months of lasik. most common side effect of lasik was found to be dry eyes in our series. this is because of neurotrophic epitheliopathy as a result of the serving of corneal nerves with the keratome blade, decrease in conjunctival and corneal sensitivity and a change in the tear lipid layer9. in our study, 53% of cases developed dry eyes within one week after the procedure. this was reduced to 40% at six weeks and most of the patients stopped their lubricants between 3-5 months as they had minimum or no symptoms of dry eyes. visual acuity   131 de paiva et al10 found the incidence of dry eyes at 47.06% in a series of patients one week after lasik which reduced to 41.18% at one month. artificial tears were found to be most commonly used treatment for dry eyes11. in our series 28.5% patients complained of glare after surgery at night, especially from oncoming car headlights. tahzib et al12 showed that 52.8% of their patients were victim of glare after lasik and believed to be more bothersome for night driving. previous studies have designated the pupil size as a significant predictor of glare and halos after lasik especially in first post operative month. however, six months postoperatively, pupil size is no longer found to be a significant predictor13. tahzib et al 12further added that precise role of pupil size and its exact relationship to night vision complaint remain unknown and controversial. regression is more prevalent in patients with high myopia and this should not be confused with progressive myopia. careful review of the patient’s ocular history may reveal this condition and these patients should be counseled properly. we came across 7.5% of patients during the study follow up, having regression of -0.50 ds to -2.75ds. chayet et al14 reported almost the same incidence of regression in their study involving 7.6% of total patients in their series at the end of the third month. it is important to keep patients profession and life style in consideration before carrying out lasik to avoid such problems as glare etc. the computer users for longer periods of time must be informed about dry eyes. likewise, people dependent on night life or driving at night times should also be made aware regarding glare. the decrease in vision of 1 line on snellen’s chart is mainly because of myopic regression but other factors like astigmatism and hyperopic shift (overcorrection) are also responsible for this problem. conclusion lasik is an internationally acceptable modality for the treatment of myopia at present time. although there are certain side effects such as dry eyes and glare but fortunately these complains are transient in nature and usually settle down within six months post lasik. in our series of 200 patients, 92.7% of all patients achieved good vision without any need for glasses. we advise a thorough discussion with the patient and his/her family to make them fully aware of the possible outcome of lasik including certain unwanted symptoms. we feel counseling plays an important role in negating patients fear for serious complications as well as discouraging patient’s unreal expectation about the out come of the procedure. author’s affiliation muhammad saeed iqbal d255, block-4, federal ‘b’ area karachi adil salim jafri sir syed college of medical sciences laser vision centre karachi p. s. mahar isra postgraduate institute of ophthalmology aga khan university hospital karachi reference 1. garamendi e, pesudovs k, elliot db. changes in quality of life after laser in situ keratomileusis for myopia. j cataract refract surg. 2005; 31:1537-43. 2. fernandez mr, tackman rn. healing changes and secondary findings with confocal microscopy. lasik-lasek: new horizons in quality of vision. ist ed. panama: international communications 2003; 51-7. 3. michael d, lembach rg, bullimore ma, et al. a prospective randomized clinical trial of laser in situ keratomileusis with two different lasers. am j ophthalmol. 2005; 140: 173-83. 4. reyes ar, sanchez-galeana ca. laser tissue effect. lasiklasek: new horizons in quality of vision. ist ed. panama: international communications. 2003; 43-50. 5. abbot rl. the rising threat of medical malpractice in refractive surgery. highlights of ophthalmology. 2003; 31: 14. 6. ramos-esteban jc, tauber s. the role of antibiotic prophylaxis with fourth generation flouroquinolones in lasik and prk. highlights of ophthalmology. 2004; 32: 12-5. 7. sharma n, ghate d, agarwal t, et al. refractive outcomes of laser in situ keratomileusis after flap complications. j cataract refract surg. 2005; 31: 1334-7. 8. balazsi g, mullie m, lasswell m, et al. laser in situ keratomeliusis with a scanning excimer laser for the correction of low to moderate myopia with and without astigmatism. j cataract refract surg. 2001; 27:1942-51. 9. anonymous. corneal sensitivity and dry eye following lasik. highlights of ophthalmology. 2002; 30: 8-9. 10. de paiva cs, chen z, koch dd, et al. the incidence and risk factors for developing dry eye after myopic lasik. am j ophthalmol. 2006; 141: 438-45. 11. murube j. management of dry eye-part 2 medical treatment. highlights of ophthalmology. 2005; 33: 2-5.   132 12. tahzib ng, boostma sj, eggink fagj, et al. functional outcomes and patient satisfaction after laser in situ keratomileusis for correction of myopia. j cataract refract surg. 2005; 31: 1943-51. 13. schallhorn sc, kaupp se, tanzer dj. pupil size and quality of vision after lasik. ophthalmology 2003; 110: 1606-14. 14. chayet as, assil kk, montes m, et al. regression and its mechanism after laser in situ keratomeliusis in moderate and high myopia. ophthalmology. 1998; 105: 1194-9.   133 microsoft word arshad ali lodhi 68 original article latanoprost 0.005% v/s timolol maleate 0.5% pressure lowering effect in primary open angle glaucoma arshad ali lodhi, khalid iqbal talpur, mahtab alam khanzada pak j ophthalmol 2008, vol. 24 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: arshad ali lodhi department of ophthalmology liaquat university eye hospital hyderabad received for publication july’ 2007 …..……………………….. purpose: to compare the pressure lowering effect of latanoprost 0.005% and timolol maleate 0.5% in the newly diagnosed patients of primary open angle glaucoma. material and method: this open label, comparative study was conducted in the department of ophthalmology, liaquat university of medical & health sciences jamshoro / hyderabad, from jan 2006 to march 2006. 58 patients (96 eyes) who qualified at the screening examination and meet the eligibility criteria were then assessed for best corrected visual acuity, base line iop with applanation tonometery, angle grading with gonioscopy, anterior and posterior segment examination with slit lamp bimicroscopy.the patient’s base line cup / disc ratio and visual fields were also recorded for follow up assessment then the patients advised to instill latanoprost 0.005 % once daily in evening in eye that was randomly selected and timolol maleate 0.5 % twice daily in the contralateral eye of same patient to exclude all demographic systemic and ocular factors that may influence the iop. patients were followed on 1st week, 3rd week, 1.5 months, 2.0 months, 2.5 months and 3.0 months then compared the pressure lowering effects of both drugs. results: out of 58 patients 30 (51.7%) were male and 28 (48.3%) were female and mean age was 60.5 years. during our study the base line iop for timolol maleate was 25.8 mmhg and for latanoprost was 25.6 mmhg. during three months treatment the mean reduction in iop was 6.55 mmhg (26.7%) timolol maleate and 7.41 mmhg (28.9%) in the patients receiving latanprost. the post-treatment iop was 19.25 mmhg (p-value = 0.0001) in patients receiving timolol maleate and 18.18 mmhg (p-value 0.0001) in patients receiving latanoprost the difference between the values of reduction in iop from base line iop was 0.86 mmhg. conclusion: the iop lowering effect of latanoprost was 2.2% greater than timolol maleate in newly diagnosed patients of primary open angle glaucoma. aised intra ocular pressure (iop) is a risk factor, contributing to optic nerve damage and subsequent visual field loss in patient with glaucoma or ocular hypertension1-3. glaucoma effects as many as 67 million people word wide and is a leading cause of vision loss and blindness4. to prevent the progression of glaucoma and to preserve vision, mean iop should be reduced to a r 69 target pressure that is patient dependent, and diurnal iop fluctuations should be minimized. most patients can be treated with single drug but some require multiple drug therapy. unfortunately tachyphylaxis is common with many of currently available drugs. since last two decades timilol maleate 0.5% has becomes first line therapy for the reduction of iop5, and is often used in combination with topical carbonic anhydrase inhibitors, alpha – agonist or prostaglandin analogues in those patients whose control of iop requires more than one medication. though the number of available drugs has increased significantly during the last 10 years, an ideal agent has not yet been found. because of their effectiveness and prolonged action prostaglandin analogues have recently provoked great interest. prostaglandin (pgf 2α) analogues comprise a new class of ocular hypotensive agents. they reduce iop at least as effectively as β – adrenergic agonists such as timilol maleate which are the standard treatment for open angle glaucoma and ocular hypertension, but lack their undesirable systemic effects6-8. the pgf 2α analogue (latanoprost) after installation in the eye is hydrolyzed by esterases in the cornea to active free acid9. the nanomolar concentration of free fatty acid has preferential affinity and full agonist activity for the fp receptors with no meaningful affinity and activity at other receptors10-11. the fp receptors are abundant in the longitudinal ciliary muscle of the human eye and iris sphinter11. the activation of these receptors by prostaglandin pgf 2α or it’s analogues triggers a cascade of events that increases the uveoscleral out flow of aqueous humour12-13, some author suggest that activation of fp receptor has a variety of mechanism to lower the iop, including relaxation of ciliary muscle 14, the induction of matrix metalloproteinases15, and subsequent degradation of extracellular matrix protein, and release of endogenous prostaglandins16. this study was designed to compare the pressure lowering effects of latanoprost 0.005 % and timolol maleate 0.5 % in the newly diagnosed patients with primary open angle glaucoma. material and methods this prospective open label, comparative study was conducted on 58 patients (96 eyes) at liaquat university eye hospital, hyderabad during 3 month period from 1st january to 31st march 2006. the patients selected from out patients’ department of liaquat university eye hospital, hyderabad as a newly diagnosed patient of primary open angle glaucoma (poag). the each patient screened out after getting consent and all data was recorded in a printed proforma according to following inclusion and exclusion criteria. inclusion criteria above 40 year of age, any sex and race if diagnosed as poag, with mean iop range from 24-36 mmhg in each eye during screening time. exclusion criteria excluded those patients having; 1. best corrected visual acuity worse than 6/24. 2. intra ocular pressure greater than 36 mmhg. 3. cup / disc ratio > 0.8. 4. severe central field loss. 5. inability to undergo applanation tonometery. 6. clinically significant progressive retinal diseases. 7. ocular inflammation and infection within past three months. 8. ocular trauma within past six months. 9. ocular laser surgery within past three months. 10. severe ocular pathology (like dry eye) and systemic disease (uncontrolled cardiovascular, bronchial asthma and chronic obstructive pulmonary disease) that precluded safe administration of topical β blocker, prostaglandin analogue. 11. significant hypersensitivity to prostaglandin and it’s analogue, topical or systemic β blocker. 12. use of topical nsaid two weeks before the screening. 13. use of glucocoriticoid therapy 2-4 week before the screening. patients who qualified at the screening examination and meet the eligibility criteria were then assessed for best corrected visual acuity, base line iop with applanation tonometery, angle grading with gonioscopy, anterior and posterior segment examination with slit lamp biomicroscope. the patient’s base line cup / disc ratio and visual fields were also recorded for follow up assessment. patients were advised to instill latanoprost once daily in evening in one eye that was randomly selected and timolol maleate twice daily in the contralateral eye of same to exclude all demographic systemic and ocular factors that may influence the iop. then patients were followed on 1st week, 3rd week, 1.5 months, 2.0 months, 2.5 months and 3.0 months to compare the pressure lowering effects of both drugs. 70 results out of 58 patients 30 (51.72%) were male and 28 (48.27%) were female (table-1) and mean age was 60.5 years (table-2). there was no statistically significant difference between age, sex and race in the study population. during our study the base line iop for timolol maleate was 25.8mmhg (fig. 1) and for latanoprost was 25.6 mmhg (fig. 2). during three months treatment the mean reduction in iop was 6.6 mmhg (26.7%). timolol maleate and 7.4 mmhg (28.9%) in the patients receiving latanprost (table 4). these values of reduction in iop from base line iop were statistacially significant for both drugs because the post-treatment iop was 19.25 mmhg (p-value = 0.0001) in patients receiving timolol maleate and 18.18 mmhg (pvalue 0.0001) in patients receiving latanoprost (table 3). the difference between the values of reduction in iop from base line iop was 0.86 mmhg that was not statistically significant. the side effect (table 5) of the treatment were ocular stinging in two patients with latanoprost and conjunctival congestion in two patients receiving timolol maleate 0.5%, so both treatment were well tolerated with no statistically significant difference between the two drugs. discussion our study showed that the use of latanoprost has superiority over timolol maleate to reduce the iop in newly diagnosed patients with open angle glaucoma. this is especially interesting in view of the fact that latanoprost has 2.2 times more efficacy in reducing iop as compared with timolol maleate and was instilled once daily unlike timolol maleate which was instilled twice daily. the value of iop reduction in our study with timolol maleate was 6.6 mmhg (26.7%) and is comparable to the results of previous studies with timolol maleate19-20. a study of 391 patients with primary open angle glaucoma or ocular hypertension showed that the efficacy of timolol maleate twice daily to reduce the base line iop was 7 mmhg (26%)19. table 1: gender distribution gender patients n (%) female 30 (51.7) male 28 (48.3) total 58 (100) table 2: patients’ age in years age range (years) patients n (%) 41—45 4 (6.9) 46—50 4 (6.9) 51—55 14 (24.1) 56—60 16 (27.6) 61—65 12 (20.7) 66—70 2 (3.4) 71—75 2 (3.4) 76—80 4 (6.9) total 58 (100) 25.8 19.7 19.4 18.9 18.9 19.2 19.4 0 5 10 15 20 25 30 io p [m m h g] b a s e l in e io p 1s t w e e k 3r d w e e k 1. 5 m o n t h 2. 0 m o n t h 2. 5 m o n t h 3. 0 m o n t h duration of treatment response of timolo 0.5% base line iop 1st week 3rd week 1.5 month 2.0 month 2.5 month 3.0 month fig. 1 25.6 18.9 18.6 17.8 17.6 18 18.2 0 5 10 15 20 25 30 io p [m m h g ] b a s e l in e io p 1s t w e e k 3r d w e e k 1. 5 m o n t h 2. 0 m o n t h 2. 5 m o n t h 3. 0 m o n t h duration of treatment response of latanoprost 0.005% base line iop 1st week 3rd week 1.5 m onth 2.0 m onth 2.5 m onth 3.0 m onth fig. 2 71 table 3: responder analysis in iop reduction during three months treatment name of drug base line iop iop (mmhg) change during three month treatment reduction in iop [mean] 1st week 3rd week 1.5 month 2.0 month 2.5 month 3.0 month [mean] timolol 0.5% 25.8 19.7 19.4 18.9 18.9 19.2 19.4 19.3 latanoprost 0.005% 25.6 18.9 18.6 17.8 17.6 18.0 18.2 18.2 table 4: values of mean iop reduction name of drug range mean % difference timolol maleate 0.5% 6.1– 6.9 mmhg 6.6 mmhg 26.7 0.86 mmhg latanoprost 0.005% 6.7– 8.0 mmhg 7.4 mmhg 28.9 table 5: advers effects during three month treatment drugs no of cases side effects timolol maleate 0.5% 2 conj. congetion latanoprost 0.005% 2 ocular stinging total 4 in our study results of timolol maleate (mean reduction in iop 6.6 mmhg) is comparatively equal with the results of rouland jf study (mean reduction in iop 7.0 mmhg) for timolol maleate 0.1% gel once daily versus conventional timolol maleate 0.5% solution twice daily in 210 patients with primary open angle glaucoma or ocular hypertension17. in our study the efficacy of latanoprost in iop reduction was 7.4 mmhg (28.9%) that may be compared with findings with latanoprost, a prostaglandin f 2α analogue approved for use in patients with open angle glaucoma or ocular hypertension21. the study of patel ss, regarding efficacy and tolerability of latanoprost reported that the installation of latanoprost in the evening were more effective that in the morning that treatment over 3-6 months lowered iop by 27% to 35% relative to base line6. these results can be compared with our study results of latanoprost to reduce the base line iop by 28.9% during three months. a study of halpern mt showed that the average iop was lower for patients receiving latanoprost than timolol meleate (18.7 mmhg versus 20.5 mmhg respectively)18 these results can support our study results that the average iop was lower more for patients on latanoprost than patients on timolol (18.2 mmhg versus 19.3 mmhg respectively). conclusion our study showed that when used as primary therapy, latanoprost insitlled once daily in the evening reduced mean iop significantly 2.2% more than timolol maleate instilled twice daily. both the drugs were generally well tolerated and safe for use in newly diagnosed patients of primary open angle glaucoma. author’s affiliation dr. arshad ali lodhi assistant professor department of ophthalmology liaquat university eye hospital hyderabad dr. khalid iqbal talpur associate professor department of ophthalmology liaquat university eye hospital hyderabad 72 reference 1. vogel r, crick rp, newsom rb et al. association between intraocular pressure and loss of visual field in chornic simple glaucoma. br j ophthalmol. 1990; 74: 3-6. 2. sommer a. intraocular pressure and glaucoma. am j ophthalmol. 1989; 107:186-8. 3. asrani s, zeimer r, wilensky j, et al. large diurnal fluctuations in intraocular pressure are an independent risk factor in patients with glaucoma. j glaucoma 2000; 9: 134-42. 4. quigley ha. the travoprost study group. number of people with glaucoma worldwide. br j ophtalmol 1996; 80: 389-3. 5. nania so, landry t, tress mv, et al. evaluation of travoprost as adjunctive therapy in patients with uncontrolled intraocular pressure while using timolol 0.5%. am j opthalmol 2001; 132: 860-8. 6. patel ss, spencer cm. latanoprost a review of its pharmacological properties clinical efficacy and tolerability. drugs aging. 1969:363-78. 7. camras cb. the united states study group. comparison of latanoprost and timolol in patients with ocular hypertension and glaucoma. a six-month, masked, multicenter trail in the united states. ophthalmology. `1996; 103; 138-47. 8. alm a, stjernschantz j. the scandinvian latanoprost study group. effects on intraocular pressure and side effects of 0.005% latanoprost applied once daily, evening or morning: a comparison with timolol. ophthalmology. 1995; 102: 1743-52. 9. bito l, baroody r. the ocular pharmacokinetics of eicosanoids and their derivatives. i: comparison of ocular eiconoid penetration and distribution following topical application of f2α-isopropyl ester. exp eye res 1987; 44: 217. 10. davis tl, sharif na. quantitative autoradiographic visualization of and pharmacology of fp-prostaglandin receptors in human eyes using the novel phosphor-imaging technology. j ocul pharmacol ther. 1999; 4: 323-33. 11. sharif na, davis tl, williams gw. [3h] al-5848 ([3h] 9beta-(+)-fluprostenol). carboxylic acid of travoprost (al6221), a novel fp prostaglandin to study the pharmacology and autoradiographic localization of the fp receptor. j pharm pharmacol. 1999; 6: 685-94. 12. camras cb. mechanism of the prostaglandin-induced reduction of intraocular pressure in humans. adv prostaglandins thromboxane leukot res. 1995; 23:519-25. 13. schachtschabel u, lindsey jd, weinreb rn. the mechanism of action of prostaglandins on uveoscleral outflow. curr optin ophthalmol. 2000; 11: 112-16. 14. goh y, hotehama y, mishima hk. characterization of ciliary muscle relaxation induced by various agents in cats. invest ophthalmol vis sci. 1995; 36: 1188-92. 15. weinreb rn, kashiwagi k, kashiwagi f, et al. prostaglandin increase matrix metalloproteinase release from human ciliary smooth cells. invest ophthalmol vis sci. 1997; 38: 2770-2. 16. yousufzai syk, ye z, abdel-latif aa. prostaglandin f2a and its analogs induce release of endogenous prostaglandins in iris and ciliary muscles isolated from cat and other mammalian species exp eye res 1996; 63: 305-10. 17. rouland jf, mandrino pm, elena pp, et al. timolol 0.1% gel (nyogel 0.1%) once daily versus conventional timolol 0.5% solution twice daily: a comparison of efficacy and safety. ophthalmologica. 2002; 216: 449-54. 18. halpern mt, covert dw, robin al. projected impact of travoprost versus both timolol and latanoprost on visual field deficit progression and cots among black glaucoma subjects. trans. am ophthalmol soc. 100; 2002: 109-18. 19. levobunolol study group levobunolol; a four year study of efficacy and safety in glaucoma treatment. ophthalmology 1989; 96: 642-5. 20. silverstone de, arkfeld d, cowan g, et al. long term diurnal control of intraocular pressure with levobunolol and with timolol glaucoma. 1985; 7:138-40. 21. xalatan sterile ophthalmic solution (pharmaciaupjohn) physicians desk reference for ophthalmic medicines 2001; 29: 315-6. microsoft word asad raza jafri 179 original article clinical presentations of benign intraconal tumors asad raza jafri, muhammad saeed iqbal, memon muhammad khan, partab rai pak j ophthalmol 2008, vol. 24 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: asad raza jafri flat # 105/1, asaish apartment, block-16, gulistan-e-johar, 75290 karachi received for publication march’ 2008 … ……………………… purpose: to determine the clinical presentations of benign intraconal orbital tumors for early diagnosis and prompt treatment. material and methods: this study was conducted in the department of ophthalmology, jinnah post graduate medical centre, karachi from march 2004 to february 2006.total 30 patients of all age groups with axial proptosis and mass in the intraconal region seen on ct scan or mri were included and followed for one year. patients’ presenting complains and clinical examination (ocular/systemic) were noted. diagnosis of disease was confirmed on the histopathology of excised mass. results: the commonest clinical presentation was axial proptosis in all (100%) cases followed by decreased visual acuity in 18 (60%) cases, corneal exposure in 5 (16.66%) cases, choroidal folds in 4 (13.33%) cases and complete loss of vision in 3 (10%) cases caused by compression of optic nerve. histopathology showed lymphangioma in 11 (36.66%) cases, cavernous heamangioma in 9 (30%), neurofibroma in 4 (13.33%), schwannoma in 3 (10%), heamangiopericytoma in 2 (6.66%) and optic nerve glioma in 1 (3.33%) case. conclusion: early diagnosis on the basis of clinical presentation, imaging and histopathologically can prevent lose of vision and other complications. 180 rbit is a closed cavity with compact arrangement of different tissues derived from all three germinal layers, containing the globe, extra-ocular muscles, fat, vascular tissue, nerves, glandular and connective tissue which are essential for ocular functions. a wide variety of pathologies and space occupying lesions can be seen in any age, sex and race1. sub-dividing the orbit into intra and extra-conal compartment is clinically correct but is not formulated on anatomic ground because no structure separates these two areas. major fibrous septa connect the extraocular muscles to the periosteum and do not form a continuous inter-muscular membrane in the orbit2,3. intra-conal space refers to an area bounded by the four recti muscles extending from the posterior surface of the globe to the annulus of zinn at the apex of the orbit. tumors within the muscle cone lead to an axial proptosis in most cases, which by compressing the optic nerve may cause a decrease in the visual acuity4 and may also cause limitation of extraocular movements. these are usually benign growths specially cavernous haemangioma5, which is the most common arising from a preexisting but non-patent vascular malformations6. others include haemangiopericytoma7, lymphangioma, schwannoma8, optic nerve glioma and optic nerve sheath meningioma. assessment of the space-occupying lesion within the muscle cone needs certain modalities of radiological imaging such as plain x-ray orbit, ophthalmic b-scan ultrasonography, computed tomography (ct scan) and magnetic resonance imaging (mri) of orbit and brain9. if the intra-conal lesion is causing compressive effects over the optic nerve, it requires immediate treatment so that vision can be saved. restoration of the eyeball to its normal position with the preservation of vision, ocular motor functions and cosmesis are the main goals of surgical intervention. the purpose of the study was to highlight the importance of early presentation and early referral of patients with intraconal tumors to the respective departments which can help to prevent both visual and more importantly physical morbidity. material and methods this study was conducted at the department of ophthalmology, jinnah postgraduate medical centre, karachi, during the period of two years from march 2004 till february 2006. total 30 cases were included in this study and followed for duration of one year. the data was recorded in spss version 10. inclusion criteria were any patient with axial proptosis and patient with mass in intraconal region on ct scan or mri. patients presenting with non axial proptosis and patients with mass extending outside the intraconal region on imaging were not included in the study. all patients were admitted in eye ward jpmc. a detailed history was obtained on a printed proforma. particular attention was given to the history of any existing or previous ocular disorder, past history of trauma and any previous ocular or orbital surgery. all patients were inquired about any systemic illness especially diabetes mellitus, hypertension, and hyperthyroidism. the ocular examination was started with assessment of best corrected far and near visual acuity for each eye. anterior segment was examined with slit lamp biomicroscope, giving special emphasis on the condition of the cornea and pupil abnormalities like rapd. iop was recorded with applanation tonometer in primary and up gaze. retinal examination was performed by the indirect ophthalmoscope using +20d lens and on slit lamp biomicroscopy with +90d lens. in orbital examination, axial proptosis was measured with hertel exophthalmometer10 and any associated horizontal and vertical displacements were measured with the help of scale. ocular motility defect associated with any diplopia was also recorded. ear, nose and throat examination was done in all patients to rule out the presence of any para-nasal sinuses or nasopharyngeal mass which could be the possible etiological factor in producing proptosis10. the systemic examination (especially chest and abdomen) was performed to search for primary neoplasm elsewhere in the body10 and vice versa. following investigations were done: • complete blood and esr • serum tsh, t3, t4 • x-ray orbits • ophthalmic b-scan ultrasonography (usg). • ct scan/mri (orbit and brain) • x-ray chest • abdominal usg o 181 excisional biopsy and then histopathological studies assisted to reach the final diagnosis. results of these 30 patients 18 (60%) were male and 12 (40%) were female (fig. 1) with a mean age of 35 years (ranging from 10–60 years). all these 30 patients (100%) presented with axial proptosis. beside this, second common presentation was decreased visual acuity in 18 (60%) cases followed by corneal exposure in 5 (16.66%) cases, choroidal folds in 4 (13.33%) cases and complete loss of vision in 3 (10%) cases (table 1). defective vision of these patients was documented. twelve patients (40%) presented with best corrected vision of 6/18 or better, 02 patients (6.67%) presented with vision of 6/60 to 6/36, vision of 12 patients (40%) was between 1/60 to 5/60, 01 patient (3.3%) had perception of only hand movement while 03 patients (10%) had absence of projection of light (table 2). in addition to clinical presentation, diagnosis of all cases was confirmed as intraconal tumors on the basis of ultrasonography and ct/mri scan imaging (fig. 2). each case was treated surgically and histopathological studies further confirmed the diagnosis. table 1: clinical presentation of intraconal tumors n = 30 clinical presentation no. of patients n (%) axial proptosis 30 (100) decreased visual acuity 18 (60) corneal exposure 5 (16.7) choroidal folds 4(13.3) complete loss of vision 3 (10) table 2: visual acuity at the time of presentation n= 30 best corrected visual acuity no. of patients n (%) projection of light absent 3 (10) projection of light present 0 (0) hand movement perceived 1(3) between 1/60-3/60 7(23) between 4/60-5/60 5 (17) between 6/60-6/34 2 (7) between 6/18-6/9 12(40) table 3 histopathological diagnosis n = 30 histopathological diagnosis no. of patients n (%) lymphangioma 11 (37) cavernous haemangioma 9 (30) neurofibroma 4 (3) schwanoma 3 (10) haemangiopericytoma 2 (7) optic nerve glioma 1 (3) histopathological studies reported that the most common intraconal tumor is lymphangioma (fig. 3) which was found in 11 (36.66%) cases. nine (30%) cases were proved to be cavernous haemangioma (fig. 4). neurofibroma was present in 04 (13.33%) cases, schwanoma in 03 (10%) cases, haemangiopericytoma in 02 (6.66%) and optic nerve glioma in 1 (3.33%) case (table 3). 12 / 40% 18 / 60% female male male: female = 1.5: 1 fig. 1: sex distribution n = 30 182 fig. 2: axial view – showing multiple intraconal cystic lesions discussion the orbital tumors increase orbital volume and cause a mass effect. although a mass may be histologically benign but it can invade intraorbital or adjacent orbital structures and can cause significant damage. a wide variety of pathological processes and space occupying lesions can be seen in any age, sex and race1. when dealing with the benign intraconal orbital tumors one must keep in mind that they are slow growing usually presenting with the forward displacement of globe11, because of their tendency to lead irreversible loss of vision due to the mass effect on the optic nerve. direct optic nerve compression, globe indentation with induced hyperopia, or increased intracranial pressure with optic nerve compression may be responsible for visual symptoms12. christante13 in his study reported that out of 57 patients, proptosis was the main presenting complaint in 80% of cases while 40% had visual deterioration. zhang14 in his study reported 17 (77.27%) out of 22 patients with visual impairment as the first presenting symptom. thorn-kany15 in his study of 8 patients reported that seven cases presented with a painless proptosis and in one case with a failing of visual acuity of the concerned eye. selva d16, in his study of 5 cases has reported that all cases presents with a history of progressive painless proptosis and ct scan revealed homogenous intraconal mass. in our study the most common clinical presentation was axial proptosis in all the 30 (100%) cases while visual loss was found in 18(60%) of cases. early surgery for removal of the tumor was favored after onset of symptoms. fig. 3: lymphangioma fig. 4: cavernous haemangioma shields ja17, reported the most commonly diagnosed intraconal tumors were lymphoid tumor (139 cases; 11%), cavernous haemangioma (77 cases; 6%), lymphangioma (54 cases; 4%) and optic nerve glioma (48 cases; 4%). wright18 suggested that lymphangiomas are variants of venous malformations but clinical, haemodynamic and histopathologic studies strongly suggest that lymphangiomas are distinct orbital hamartomas19. these are benign tumors and often present during childhood, the largest reported series by jones20 involving 62 cases. we have 2 cases of cavernous haemangioma and 1 case of neurofibroma. it was easy to reach at exact tissue diagnosis after histopathological opinion except in the cases of lymphangioma where the multiple cystic lesions were found on ct scan and preoperatively. when tissue specimens were reviewed by histopathologist, different vascular channels and cystic spaces filled with blood or fluid were noted. on the basis of clinical, radiological and histopathological findings, we were able to label these patients as lymphangioma. conclusion the most common clinical presentation of intraconal tumors is axial proptosis but there are some uncommon presentations which can lead to misdiagnosis of such orbital masses. tumor location and radiological findings can provide important information regarding the diagnosis of a tumor prior to biopsy or tumor resection. this will help in the determination of treatment strategy. prompt referral of the patient to the department with facility for arbital surgery plays crucial role in this regard. 183 author’s affiliation dr. asad raza jafri senior registrar ophthalmology karachi medical & dental college north nazimabad, karachi dr. muhammad saeed iqbal assistant professor ophthalmology sir syed college of medical sciences hospital qayyumabad, korangi raod, karachi dr. memon mohammad khan assistant professor ophthalmology kulsoom bai valika hospital, s.i.t.e., karachi dr. partab rai assistant professor ophthalmology chandka medical college and hospital larkana reference 1. munir-ul-haq m. a statistical analysis of 581 primary orbital tumors in pakistan. pak j ophthalmol. 1987; 3: 111-20. 2. whitnall se. anatomy of human organs and accessory organs of vision. 2nd ed. london: oxford university press. 1932. 3. koorneff l. new insight in the human orbital connective: results of new anatomic approach. arch ophthalmol. 1977; 95: 1269. 4. shields ja, blackwell b, augsburger jj. classification and incidence of space-occupying lesions of the orbit. a survey of 654 biopsies. arch ophthalmol. 1984; 102: 1606-11. 5. hood ci. cavernous hemangioma of the orbit. a consideration of pathogenesis with an illustrative case. arch ophthalmol. 1970; 83: 49-53. 6. cabrera vargas me, perez aj, diaz ac, et al. orbital hemangiopericytoma: a case with involvement of the intraconal space. arch soc esp oftalmol. 2000; 75: 701-4. 7. tsuzuki n, katoh h, ohnuki a, et al. cystic schwannoma of the orbit: case report. surg neurol. 2001; 5: 384. 8. asif m, shafiq k, ahmed m, et al. orbital masses: incidence and clinical presentation. pak j ophthalmol. 1998; 14:149-152. 9. fafowora of, cookey-gam ai, obajimi mo. radiological evaluation of orbital tumors in ibadan, nigeria. afr j med sci. 1996; 25: 361-4. 10. khurana ak. investgations of orbital space occupying lesions, in modern ophthalmology by lc datta. jaypee brothers publishers, new delhi, 1st edition. 1994: 89-102. 11. geoffrey j, gladstone, frank a, john ds. intraconal tumors of the orbit. 4th edition w.b. saunders company. 1994; 13: 99. 12. cockerham kp, cockerham gc, stutzman r, et al. the clinical spectrum of schwannomas presenting with visual dysfunction: a clinico-pathologic study of three cases. surv ophthalmol.1994; 44: 226-34. 13. cristane l. surgical treatment of meningioma of the orbit and optic canal: a retrospective study with particular attention to visual outcome. acta neuroarchiv. 1994; 126; 27-32. 14. zhang ch, zhang tc, zhong js, et al. early diagnosis of the tumors in orbital apex and optic nerve. zhongua yan ke za zhi. 2004; 40: 34-6. 15. thorn-kany m, arrue p, delisle mb, et al. cavernous hemangiomas of the orbit: mr imaging. neuroradiol. 1999; 26: 79-86. 16. selva d, strianeses d, bonavolonta g, et al. orbital venous lymphatic malformations (lymphangiomas) mimicking cavernous hemangiomas. am j ophthalmol. 2001; 131: 364-70. 17. shields ja, shields cl, scartozzi r. survey of 1264 patients with orbital tumors and simulating lesions. ophthalmology. 2004; 111: 997-1008. 18. wright je. orbital vascular anamolies. trans am acad ophthalmol otolaryngol. 1974; 78: 606. 19. rootman j, hay e, grace d. orbital adnexal lymphangioma: a spectrum of haemodynamically isolated vascular hamartoma. ophthalmol. 1986; 93: 1558. 20. jones is. lymphangioma of ocular adnexa. an analysis of 62 cases. trans am ophthalmol soc 1959; 57: 602. microsoft word aneequallah baig 19 original article epitheliotrophic effect of autologous serum in persistent corneal epithelial defects aneeq ullah baig mirza, naheed ghani, abdul bari khan pak j ophthalmol 2008, vol. 24 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: aneeq ullah baig mirza department of ophthalmology iimct/ railway teaching hospital, rawalpindi received for publication purpose: to evaluate the efficacy and complications of autologous serum in cases of persistent corneal epithelial defect (ped). material and methods: patients with ped unresponsive to conventional lubricant treatment were included in this clinical, prospective study which was conducted at iimct and railways teaching hospital. patients were examined on day 1 and appropriate treatment including lubricant therapy was instituted. subsequently, they were examined after 3 weeks and started on 20% autologous serum eye drops in cases of ped. all the other previously used lubricant therapy was stopped. then, they were examined every 2 weeks for the next three visits. at each visit, in addition to routine eye examination some additional tests were performed i.e. slitlamp examination for corneal epithelial defects, marginal tear strip evaluation, schirmer’s test without anesthesia, tear film breakup time, fluorescein and rose bengal staining and corneal sensitivity. the healing was defined as effective if occurred within 2 weeks of initiating serum therapy, partially effective if occurred within one month and ineffective if didn’t occur within one month. results: a total of 17 eyes in 10 patients were studied. the local spectrum of indications was severe vernal limbitis with keratopathy (6 eyes, 35.3%), keratoconjunctivitis sicca (7 eyes, 41.1%), drug toxicity (1 eye, 5.9%), lime instillation (2 eyes, 11.8%) and trophic ulcer (1 eye, 5.9%). healing in 9 eyes occurred within 2 weeks and in 3 eyes within further 2 weeks. in 5 eyes, healing didn’t occur within one month. all the patients were able to complete the follow-up of the study. accordingly, healing was declared as effective in 9 out of 17 eyes (52.9%), partially effective in 3 out of 17 eyes (17.7%) and ineffective in 5 out of 17 eyes (29.4%). there were no adverse effects except for one red eye without discharge. response rate was excellent in all except those with severe keratoconjunctivitis sicca (kcs) and below-normal schirmer’s test value before serum therapy. the mean duration of ped before initiating serum therapy was compared between the effective and ineffective groups. independent sample t-test was applied and the difference was found to be highly insignificant (p value 0.537). conclusion: autologous serum was considered effective in majority of the cases with ped recalcitrant to conventional lubricant therapy due to the presence of essential factors. healing depended more upon the etiology than the duration of 20 march’ 2007 …..……………………….. ped. due to scarcity of literature on serum therapy, further studies are required to establish the efficacy 21 orneal epithelial surface may be damaged in a variety of conditions like kcs, mechanical and chemical trauma, corneal infections, neurotrophic keratopathy, corneal dystrophies and long-term topical steroid therapy. moreover, there may be defective regeneration of healthy corneal epithelium in cases of limbal stem cell deficiency and vernal limbitis. various pharmacological lubricant preparations used to treat ped include hydroxypropylmethylcellulose (hpmc), polyvinyl alcohol, povidine and sodium hyaluronate. recently, autologous serum1,2 and umbilical cord serum therapy3 have shown promising results in the treatment of ped. surgical options for the management of dry eyes and ped include punctal occlusion, lateral and central tarsorrhaphy and amniotic membrane transplantation 4,5. serum is the fluid component of blood minus its clotting factors and cellular components. the natural tears have optical, mechanical, antimicrobial and nutritional properties. they contain epidermal growth factor (egf), fibronectin and vitamin a which help in proliferation, migration and differentiation of corneal epithelial cells6. egf may also help in reepithelialization due to its anti-apoptotic properties7,8 . serum also contains lysozyme, igg and complement which may reduce the risk of infection. autologous serum eye drops are non-allergenic with properties similar to the natural tears. they have also been used for cases of keratoconjunctivitis sicca9,10. vitamin a is found in higher concentrations in serum as compared to tears. it may help in decreasing the squamous metaplasia in cases of kcs11. poon et al conducted a clinical pilot study to compare the in-vitro toxicity of serum drops with unpreserved hypromellose (hydroxypropylmethylcellulose 0.3%) on corneal epithelial cell cultures12. serum drops were found to have reduced toxicity compared with unpreserved hypromellose. the morphology and atp levels of cultured cells exposed to serum were maintained better as compared to hypromellose. both are found to be well established parameters of viability of the cells and used for evaluation of cellular toxicity13,14. the present study was conducted to evaluate the efficacy of autologous serum eye drops in cases of ped resistant to conventional lubricant therapy. material and methods all the patients with ped not responding to conventional lubricant dry eye therapy were included in this study. the study design was prospective. the case recording was done between sept’ 2004 and aug’ 2006. at the initial visit, detailed history was taken, specifically asking for previous topical treatment and duration. eye examination included visual acuity, slitlamp examination for corneal epithelial defects, marginal tear strip evaluation, schirmer’s test without anesthesia, tear film breakup time (but), fluorescein and rose bengal staining and corneal sensitivity. appropriate lubricant treatment for dry eyes was instituted. the patients were subsequently examined after three weeks and started on autologous serum eye drops, if the corneal epithelial defects had not healed. at the same visit, previously used dry eye treatment was stopped to monitor the isolated effect of autologous serum. the protocol for autologous serum eye drops preparation was strictly followed in each case. in collaboration with pathology department of the hospital, patients’ blood was drawn under sterile conditions. it was centrifuged at 1500 revolutions per minute for five minutes2. once the serum was separated, it was diluted with 0.9% normal saline to make a 20% preparation. this 20% preparation of serum was placed in multiple ultraviolet protected bottles under absolute sterile conditions. no preservative was added to the serum. in order to ensure sterility, patients were instructed to place all the bottles in the freezer compartment at -4°c. the bottle to be used the next day was to be put in the refrigerator (lower) compartment at +4°c, one night earlier. the frequency of instillation was adjusted at 2, 6 or 8 hourly, depending upon the severity of ped. each bottle was to be discarded at the end of the day, in order to avoid any contamination. then the patients were examined every two weeks for the next three visits. at each visit, the same protocol for eye examination was maintained as the initial one. the healing was graded as effective, partially effective or ineffective. if healing of all epithelial lesions occurred within two weeks of initiating serum therapy, it was declared effective. healing between 2-4 weeks was declared partially effective and no healing within one month meant ineffective treatment. mean duration of ped before serum therapy was compared between effective and ineffective groups and independent sample t-test applied. c 22 results this study comprised of 17 eyes belonging to 10 patients. all had persistent corneal epithelial defects in spite of previous lubricant therapy. there were 7 males and 3 females in the study. the ages ranged between 6 and 72 years (mean 34.2 years). all the patients aged 30 years or above had ped secondary to severe dry eyes or topical drug toxicity. in the patients below 30 years of age, ped was seen as a result of severe vernal limbitis with keratopathy, lime burns and trophic ulcer (table 1). table 1: diagnosis in various age groups age (yrs) no. of eyes diagnosis 12 2 vernal limbitis with keratopathy 72 1 kcs 58 1 drug toxicity 70 2 kcs 22 2 lime instillation 6 1 trophic ulcer 55 2 kcs 6 2 vernal limbitis with keratopathy 11 2 vernal limbitis with keratopathy 30 2 kcs the patients with kcs and trophic ulcer were already on artificial tears eye drops, with non-healing corneal epithelium, at the time of inclusion in the study. after a further 3 weeks trial of topical lubricant treatment and persistence of epithelial defects, all the eyes were put on autologous serum therapy. in nine eyes, total healing of corneal epithelium was seen within two weeks. another three eyes healed in the following two weeks. five eyes didn’t heal within one month. no patient skipped follow up visit. therefore, healing was declared effective in 9 (52.9%), partially effective in 3 (17.7%) and ineffective in 5 (29.4%) out of 17 eyes, table 2 and fig. i. no adverse effects were noted except for one red eye without discharge, seen three days after initiation of serum therapy. table 2: percentage of healing pattern healing pattern no. of eyes n (%) effective 9 (52.9) partially effective 3 (17.7) ineffective 5 (29.4) fig. i: healing pattern percentage results were better with good schirmer’s test value. however, two eyes with total absence of tears (schirmer’s value 0) also showed effective results. all the eyes with ineffective healing had below-normal schirmer’s test value before serum therapy (table 3). response rate was excellent in all except those with kcs (table 4). the mean duration of ped before initiating serum therapy was 106.2 days. in the effective group, it was 94.8 ± 67.1 days, while in the ineffective group, it was 117.6 ± 57.4 days. independent sample t-test was applied between the effective and ineffective groups and the difference in the mean duration of ped before initiating serum therapy was found to be highly insignificant (p value 0.537). discussion corneal epithelium may be damaged in a variety of clinical situations. some of these which may result in non-healing epithelial defects include kcs, neurotrophic keratitis, exposure keratopathy, limbal stem cell failure, post-infectious corneal ulcers, topical drug toxicity, alkali burns, corneal dystrophies and diabetes mellitus15. effective partially effective ineffective 23 table 3: summary of individual cases no. no. of eyes duration of ped (days) diagnosis schirmer’s test value in mm treatment (serum eye drops) healing time (days) effectivity right left 1 2 98 vernal limbitis 26 29 qid 10 both eyes effective 2 1 112 kcs 0 qid 14 r eye effective 3 1 14 drug toxicity 0 tds 7 l eye effective 4 2 28 kcs 0 0 qid 28 r eye 60 l eye r-partially effective l-ineffective 5 2 14 lime instillation 25 25 2 hourly 2 both eyes effective 6 1 168 neurotrophic keratopathy 21 qid 3 r eye effective 7 2 168 kcs 7 0 2 hourly none ineffective 8 2 168 vernal limbitis 30 35 2 hourly 12 both eyes effective 9 2 168 vernal limbitis 30 34 2 hourly 21 both eyes partially effective 10 2 112 kcs 0 0 2 hourly none ineffective r = right, l = left table 4. response rate in different pathological conditions diagnosis no. of eyes effective and partially effective/total vernal limbitis with keratopathy 6 6/6 severe kcs 7 2/7 drug toxicity 1 1/1 lime instillation 2 2/2 neurotrophic keratopathy 1 1/1 apart from persistent ocular discomfort, ped pose a potential threat to vision. management of ped includes removal of etiological factors combined with promotion of epithelial healing. any lid abnormality which may be responsible for ped such as chronic blepharitis, entropion, trichiasis or lagophthalmos should be corrected. various preparations of ocular lubricants in the form of eye drops or gels are prescribed to promote epithelial healing. non-healing lesions require additional strategies in the form of conservation of existing tears (punctal occlusion, tarsorhaphy), prevention of mechanical trauma (bandage contact lens, tarsorhaphy) and promotion of epithelial healing by using autologous serum eye drops and amniotic membrane4,5 or limbal stem cell trasplantation16,17. seitz et al18 have recommended the use of autologous serum for ped secondary to neurotrophic keratopathy. similarly, das et al19 have recommended the use of autologous serum for delayed epithelial healing in eyes with lattice corneal dystrophy, undergoing phototherapeutic keratectomy. in our study, there were 7 males and 3 females. the mean age was 34.2 years. the factors responsible for ped were kcs, severe vernal limbitis with keratopathy, topical drug toxicity, alkali burns and neurotrophic keratopathy. the commonest cause of ped in older age group was kcs. the patients with dry eyes and neurotrophic keratopathy were already on artificial tears treatment at the time of presentation. the mean duration of ped before initiating serum 24 treatment was 106.2 days. in the effective and ineffective groups, it was 94.9 and 117.6 days respectively. independent sample t-test depicted the difference to be highly insignificant (0.537). in 9 eyes out of 17, ped healed within 2 weeks of initiating serum therapy and the treatment was declared effective. out of these, 2 had a schirmer’s test value of 0 before serum therapy. five eyes didn’t heal even after one month and were included in the ineffective group. four out of these had a pre-serum schirmer’s test value of 0. results tend to be poorer in cases with total absence of tears. all the cases healed within one month except those with kcs. only two eyes with kcs healed within one month out of a total of 7 (table 4). in the study of autologous serum for ped by al young et al2, there were ten patients with a gender ratio of 7m : 3f which resembled our study. the mean age was 36.8 years (range 17-73). treatment was effective in 6 eyes out of 10(60%) as compared to 52.9% in our study. case series of tsubota et al20 depicted healing of 43.8% within 2 weeks. in al young series, 2 eyes out of 10 (20%) did not heal after one month while another 20% defaulted follow-up. in our study, the treatment was in-effective (poor healing after one month) in 29.4% of eyes and there were no defaulters. no adverse effects were reported in their study as compared to a single case of red eye in ours. there was no significant difference in the mean duration of ped before initiating serum therapy in effective and ineffective groups. however, healing depended more upon the etiology in our study (table 4). patients with kcs exhibited poorer healing. al young et al2 observed that delayed onset of autologous serum treatment might be associated with tendency of poorer healing. in the prospective study of poon et al12, success was defined as closure of epithelial defects beyond one month. seven eyes out of 15 healed within one month (46.7%) as compared to 70.6% in ours. a concentration of 50 or 100% serum was used in their study. in our cases, 20% serum eye drops were used. in their study, three patients developed microbial infections that required cessation of serum therapy. alvarado valero et al21 studied the effect of 20% autologous serum on ped and squamous metaplasia in 17 eyes. the epithelial defects healed within 2 weeks in 6 eyes (35.2%). this figure was much less than our study (52.9%) with the same concentration of serum. the duration of ped before serum therapy was 36 days. using impression cytology technique, they observed involution of squamous metaplasia in 6 of 7 eyes, 28 days after initiation of serum eye drops. de souza et al22 studied autologous serum therapy for ped in 70 eyes. out of these, 45 had corneal epithelial defects secondary to penetrating keratoplasty. a complete corneal re-epithelialization was achieved in 57 of 70 eyes (81%) after 3 to 45 (mean 15±12) days. they also concluded that eyes with accompanying deep stromal defects were not good candidates. tears contain nourishing, antimicrobial, mechanical and optical properties6. serum contains essential components in comparable concentrations to tears. these include egf (epidermal growth factor), tgfβ (transforming growth factor β), pdgf-ab (platelet derived growth factor), neuropeptides (substance p), insulin-like growth factor, fibronectin and vitamin a. the growth factors, fibronectin and vitamins support proliferation, migration and differentiation of corneal and conjunctival epithelium. the tgf-β family are fibrogenic cytokines responsible for fibroblast activation in wound healing23. the natural substitutes used as tears are superior to artificial tears because their ph, osmolality and biomechanical properties resemble natural tears. secondly, they contain essential nutrients, like growth factors and vitamins. thirdly, bacteriostatic components are present such as igg, lysozyme and complement. fourthly, there are no preservatives in natural substitutes24. nistor and nistor25 observed improvement in fluorescein and rose bengal scores, non-allergenicity and nonimmunogenicity with the use of autologous serum for ped. autologous serum can induce faster epithelial healing than artificial tears, which leads to a decrease in keratocyte apoptosis and migration of fibroblasts and myofibroblasts in the wound site, a decrease in migration of inflammatory cells and consequently, inhibition of cytokine release26. this could help in improving the long-term refractive results in eyes undergoing lasik. the cellular morphology and atp levels are better preserved in the cells exposed to serum drops as compared to unpreserved hypromellose12. in the study of schrader et al27 combination of serum eye drops and hydrogel bandage contact lenses were used in cases of ped, which had not responded well to previous amniotic membrane transplantation or keratoplasty. five of six eyes healed after a treatment period of 14.2± 8.9 days. in one eye, the ped reduced in size and took 90 days to resolve 25 completely. random control clinical trial between autologous serum and umbilical cord serum for ped has shown that umbilical cord serum leads to faster healing of ped compared to autologous serum3. liu et al24 observed that using a longer clotting time resulted in an increased concentration of all the epitheliotrophic factors in the serum. moreover, the density of epithelial microvilli was greater when a longer clotting time was adopted. they concluded that clotting time, centrifugation and diluents have a significant impact on the composition and epitheliotrophic effects of serum. a clotting time of ≥120 min, a sharp centrifugation (3000xg for 15 min) and dilution with bss (balanced salt solution) enhance the ability of serum to help proliferation, migration and differentiation of corneal epithelial cells. sauer et al28 have concluded that if serum drops are applied by trained personnel, the absence of contamination can be ensured up to the fourth day. the additional application of prophylactic antibiotic drops can help avoid infection even if refrigerated non-preserved serum is used up to 7 days. we ensured sterility by preparing the serum under absolute sterile conditions, storing the serum bottles in the freezer at -4°c, shifting the bottle to be used into the refrigerator compartment at 4-8°c and discarding that bottle by the end of the day. conclusion we consider autologous serum to be effective in majority of cases with ped recalcitrant to conventional lubricant therapy due to the presence of essential factors. healing depended more upon the etiology than the duration of ped before serum therapy, in our study. author’s affiliation aneeq ullah baig mirza assistant professor ophthalmology iimct / railway teaching hospital rawalpindi naheed ghani (clinical ophthalmologist) iimct / railway teaching hospital rawalpindi, pakistan. abdul bari khan associate professor of (microbiology) iimct / railway teaching hospital rawalpindi, pakistan. reference 1. geerling g, hartwig d. autologous serum-eye-drops for ocular surface disorders. a literature review and recommendations for their application. ophthalmology. 2002; 99: 949-59. 2. young al, cheng aco, ng hk, et al. the use of autologous serum tears in persistent corneal epithelial defects. eye 2004; 18: 609-14. 3. vajpayee rb, mukerji n, tandon r, et al. evaluation of umbilical cord serum therapy for persistent corneal epithelial defects. br j ophthalmol. 2003; 87: 1312-6. 4. hanada k, shimazaki j, shimmura s, et al. multilayered amniotic membrane transplantation for severe ulceration of the cornea and sclera. am j ophthalmol. 2001; 131: 324-31. 5. kruse fe, rohrschneider k, volcker he. multilayer amniotic membrane transplantation for ocular surface disorder. ophthalmology. 1999; 106: 1504-10. 6. geerling g, maclennan s, hartwig d. autologous serum eye drops for ocular surface disorders. br j ophthalmol. 2004; 88: 1467-74. 7. collins mk, perkins gr, rodriguez tarduchy g, et al. growth factors as survival factors: regulation of apoptosis. bioessays. 1994; 16: 133-8. 8. rodeck u, jost m, kari c, et al. egf-r dependent regulation of keratinocyte survival. j cell sci 1997; 110: 113-21. 9. fox ri, chan r, michelson j, et al. beneficial effect of artificial tears made with autologous serum in patients with keratoconjunctivitis sicca. arthritis rheum. 1984; 29: 577-83. 10. tseng scg, tsubota k. important concepts for treating ocular surface and tear disorders. am j ophthalmol. 1997; 124: 825-35. 11. tsubota k, goto e, fujita h, et al. treatment of dry eye by autologous serum application in sjogren's syndrome. br j ophthalmol. 1999; 83: 390-5. 12. poon ac, geerling g, dart jkg, et al. autologous serum eyedrops for dry eyes and epithelial defects: clinical and in vitro toxicity studies. br j ophthalmol. 2001; 85: 1188-97. 13. pasternak as, miller wm. first-order toxicity assays for eye irritation using cell lines: parameters that affect in vitro evaluation. fundam appl toxicol. 1995; 25: 253-63. 14. wang xm. a new microcellular cytotoxicity test based on calcein am release. human immunol 1993; 37: 264-70. 15. albert dm, jakobiec fa. principles and practice of ophthalmology. w.b. saunders co. philadelphia, 2000. 16. kenyon kr, tseng scg. limbal autograft transplantation for ocular surface disorders. ophthalmology. 1989; 96: 709-23. 17. kenyon kr. limbal autograft transplantation for chemical and thermal burns. dev ophthalmol 1989; 18: 53-8. 18. seitz b, gruterich m, cursiefen c, et al. conservative and surgical treatment of neurotrophic keratopathy. ophthalmology. 2005; 102: 15-26. 19. das s, langenbucher a, seitz b. delayed healing of corneal epithelium after phototherapeutic keratectomy for lattice dystrophy. cornea. 2005; 24: 283-7. 20. tsubota k, goto e, shimmura s, et al. treatment of persistent corneal epithelial defect by autologous serum application. ophthalmology. 1999; 106: 1984-9. 21. alvarado valero mc, martinez toldos jj, et al. treatment of persistent epithelial defects using autologous serum application. arch soc esp oftalmol. 2004; 79: 537-42. 22. ferreira de souza r, kruse fe, et al. autologous serum for otherwise therapy resistant corneal epithelial defects prospective report on the first 70 eyes. klin monatsbl augenheilkd. 2001; 218: 720-6. 26 23. haber m, cao z, panjwani n, et al. effects of growth factors (egf, pdgf-bb and tgf-beta 1) on cultured equine epithelial cells and keratocytes: implications for wound healing. vet ophthalmol. 2003; 6: 211-7. 24. liu l, hartwig d, harloff s, et al. an optimised protocol for the production of autologous serum eye drops. graefes arch clin exp ophthalmol. 2005; 243: 706-14. 25. nistor m, nistor c. autologous serum utilization in patients with lacrimal hyposecretion and persistent epithelial defects of corneaclinical study. oftalmologia. 2005; 49: 30-3. 26. esquenazi s, he j, bazan he, et al. use of autologous serum in corneal epithelial defects post-lamellar surgery. cornea. 2005; 24: 992-7. 27. schrader s, wedel t, moll r, et al. combination of serum eye drops with hydrogel bandage contact lenses in the treatment of persistent epithelial defects. graefes arch clin exp ophthalmol. 2006; 244: 1345-9. 28. sauer r, bluthner k, seitz b. sterility of non-preserved autologous serum drops for treatment of persistent corneal epithelial defects. ophthalmology. 2004; 101: 705-9. picture quiz answer bietti's corneoretinal dystrophy bietti's corneoretinal dystrophy, also called crystalline retinopathy, is a congenital disease with autosomal recessive type of inheritance involving the cornea and retina. the patients present usually during their third decade with mild to moderate decrease in visual acuity and some visual field loss. night vision is markedly affected too. on examination, vision can range from 6/6 to hand motion. color vision is abnormal suggesting tritan deficiency. the cornea has sparkling crystals mostly at the peripheries. the fundus also has small shiny crystals all over posterior pole, which has rpe atrophy. electron microscope crystal analysis reveals ultra structural resemblance to lipids within fibroblasts. fluorescein angiography shows transmitted hyperfluorescence in the area of crystals. adjacent areas with no crystals show confluent loss of rpe and choriocapillaris. erg is normal with white light but abnormal with blue light. eog is usually subnormal. visual fields are affected only in advanced stages, the earliest defects being pericentral scotomas. unfortunately, like many other retinal conditions, there is no known treatment up till now. microsoft word editorial.doc 175 editorial refractive surgery.……rethinking the progress in laser refractive surgery has entered an interesting state of recommendations and practices. reference to my editorial views in volume 22 number 4, october 2006 issue of p.j.o. about correction of the most prevalent refractive error “presbyopia”, it still remains the most difficult and enigmatic refractive error to be corrected by all the measures known so far including presbylasik monovision, scleral expanding procedures, conductive keratoplasty, ltk, refractive iol’s etc. while correction of hyperopia more than +4d with laser refractive surgery is sill not being recommended. over the years laser refractive surgery in myopia and myopic astigmatism has been gradually evolving to achieve safer outcomes aiming at better visual results and meeting the expectations of the patients also. in the beginning p.r.k. (photo refractive keratectomy) with excimer laser was the widely practiced procedure, but soon there were objections to pain, haze, slow visual recovery, regression etc, hence the development and significantly rapid trasition to lasik (laser in situ keratomileusis) where a superficial flap of 120-180 micron is raised with a mechanical keratome and laser is applied in the stromal bed, then flap is replaced giving pain free rapid visual rehabilitation without significant haze and regression. one group of refractive surgeons are still strongly advocating p.r.k. because by performing surface ablation we could safely remove at times more of corneal tissue, though with immediate complications of pain and delayed visual recovery but avoiding the flap related complications, the most important being the development of ectasia due to disturbed biomechanics of cornea which is an awful complication when it happens though it is rather rare in lasik. the lasik procedure at present remains very popular with patient preference due to no pain, rapid visual recovery and lesser wound healing complications by the preservation of the vital layers of bowman’s membrane along with underlying tough corneal stromal layers and by making a thinner flap of about 120 microns to be able to save enough residual stroma (about 300 micron or more) to overcome the danger of ectasia. to achieve this much thin flap with mechanical keratome is now possible with new keratomes like x.p without any significant chances of button-holing and other flap related complications. this much thin flap of 120 microns or even thinner can be safely achieved with femtosecond intralase laser, where flap thickness is also uniform compared to mechanical keratomes created flaps which are thicker in the periphery and thinner centrally hence more prone to complications. while there are efforts to develop a mechanical keratome which can safely create a further thinner and uniform flap, there are other developments like lasek and epilasik where only epithelial flap is raised to perform ablation, saving sufficient stroma to avoid the later complication of ectasia but these epithelial flaps are not easy to make and tend to develop flap related problems. during this period customized treatments with or without wavefront guidance gained popularity with a promise of bionic vision that is better than 6/4 etc. but soon there were some disappointments as we did not understand the corneal biomechanics precisely as yet and were also over sold by the trade and manufactures hence this tendency faded out for some time but eventually has reemerged with better understanding of corneal biomechanics coupled with enhanced precision of technology and now is being incorporated in both p.r.k and lasik.with safer and excellent results. at present there are two distinct groups of refractive surgeons, the p.r.k adherents which are concerned with biomechanics of lasik like flap related complications, ectasia, and the lasik proponents concerned with problems of wound healing, haze, regression, pain and delayed visual recovery in surface ablation. while there is serious rethinking going on in refractive surgery whether to revert back to p.r.k or continue lasik as such with creation of a thin flap of 176 120 microns or so with mechanical keratome there is another important development taking place with the evolution of a new technique where a thin flap of 90 to 100 micron is created with femtosecond intralase laser again preserving the vital bowman’s membrane and important tough anterior stromal material underneath it eventually saving enough residual stroma (more than 300 microns). this procedure called sbk (sub bowman membrane keratomileusis) is being favourably considered by both p.r.k. and lasik proponents as it overcomes most of the objections of p.r.k and lasik and achieving the best of both procedures. the only reservation is the cost effectiveness as it entails another femtosecond laser which is as costly as excimer laser and despite making flaps with femtosecond intralase laser a very thin flap about 80 micron or so is still not without flap related problems always. the sbk at times called superficial lasik by some (where flap thickness is about 80 microns) is gaining popularity and certain manufactures are thinking of developing a machine with both excimer and femtosecond facilities. refractive surgeons all over are keenly awaiting further clinical data and published studies of sbk and surface lasik to be able to decide what is safer and better for our patients, while draining about the day they will be able to perform intralamellar ablations. m lateef chaudhry editor in chief pakistan journal of ophthalmology microsoft word zia muhammad 43 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology original article timing of probing for congenital nasolacrimal duct obstruction zia muhammad, muhammad tariq, khwaja khalid shoaib, zia ul islam pak j ophthalmol 2012, vol. 28 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zia muhammad mardan medical complex teaching hospital mardan …..……………………….. purpose: to study the outcome of conservative treatment and of probing and irrigation in congenital naso-lacrimal duct obstruction in infants and children. material and methods: eighty one eyes of 63 patients were studied. children were divided into three groups. group i included infants from 0-6 months, group ii included infants from 7 – 12 months and group iii included infants above one year. results: in group i out of 38 patients, 35 (55.5%) were relieved of symptoms of epiphora and discharge with conservative treatment. in group ii, out of 17 infants, 11 (17.4) were relieved of symptoms with conservative treatment. in group iii, only one patient (1.58%) out of 9p responded to conservative treatment. conclusion: spontaneous resolution of naso-lacrimal duct obstruction occurs in most of the cases with conservative treatment and massage. in the remaining patients not responding to the conservative approach, probing and irrigation is successful in the majority of infants. nfants with congenital naso-lacrimal duct obstruction present with a watery eye, and an increased tear lake, mattering of the eyelashes, and mucus in the medial corner of the eyelids. congenital naso-lacrimal duct obstruction is common and occurs in about 5% to 6% of infants1,2. congenital obstruction of the naso-lacrimal system is most common at the level of the valve of hasner3,4. although it opens spontaneously during the first year of life5, in 5% to 15% of cases the obstruction persists and requires surgical intervention. in the majority of cases, the cause of failure of conservative treatment is an improper technique of lacrimal sac massage6. probing of the naso-lacrimal duct is highly effective in relieving the symptoms of epiphora and discharge in infants who do not clear spontaneously with medical treatment and massage. the obstruction and the resultant continued tearing and discharge are not only unsightly and a potential source of ocular infection, it also causes a lot of anxiety to young parents who are inexperienced and apprehensive about their newborn babies.7 we therefore, advise probing and irrigation of the naso-lacrimal passages to relieve the babies of the symptoms before one year of age. we conducted this study to assess the outcome of conservative treatment and of probing and irrigation in congenital nasolacrimal duct obstruction in infants and children. material and methods four thousand five hundred patients were examined from november 2009 to june 2010 in one outpatient setup. out of these, 63 patients (1.4%) were found to be suffering from congenital naso-lacrimal duct obstruction. these patients were advised topical antibiotics drops and ointments and the parents were given instructions about the massage at the lacrimal area. in some of the infants, while demonstrating the method of massage to the parents, a popping sensation was felt with the massaging finger and the obstruction was felt relieved instantly. all patients were recalled in 3 – 4 weeks time for evaluation. if the condition showed no improvement, the patient was either treated surgically when more than 6 months of i zia muhammad et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 44 age, or the medical treatment and massage was continued when the infant was under the age of 6 months. in infants and children, older than 6 months, not responding to medical treatment and massage, were subjected to syringing and probing under a brief forane anaestheia. a special lacrimal cannula 7 cm long, with smooth rounded distal end, with two side openings at the end, was used to irrigate and probe the naso-lacrimal passages. after dilating the lower punctum with a punctum dilator, the passages were irrigated with saline. this cannula was then passed initially vertically, then horizontally and finally downwards and slightly posteriorly. the anesthetist was then requested to turn the baby on the side, and the fluid was pushed to confirm the opening of the duct. the fluid was seen coming through the nostril of the same side. antibiotic drops were instilled and the parents were advised to continue the medical treatment for another 2-3 weeks. the infant was reexamined after this period to evaluate the results of surgical treatment. results a total of 63 infants were diagnosed with congenital naso-lacrimal duct obstruction. out of these 55 (87.3%) had unilateral obstruction, while 8 (12.69%) had bilateral naso-lacrimal duct obstruction. thirty eight patients (60.3%) were in the 0-6 months age group, 17 infants (26.9%) were 7-12 months and 8 patients (12.7%) were above 12 months. forty seven infants (74.60%) received spontaneous relief with medical treatment and massage. these included 35 infants (55.5%) in the 0-6 months age group and 11 infants (17.4%) in the 7-12 months age group and one patient in the above one year age group (table 2). sixteen infants (25.39%) required surgical intervention to relieve the symptoms of epiphora. all probing were done at 6 months of age and above. first probing was successful in 13 infants (81.25%) while 3 infants (18.75%) required re-probing. all the infants who were re-probed were cured. discussion congenital naso-lacrimal duct obstruction is a common congenital anomaly even in full term infants and is due to delay in the normal development of the system. neonates have tear secretion at birth and 96% to 98% have a totally patent and functional drainage system at birth. the 2% to 4% who do not have an intact lacrimal drainage system, have a thin residual membrane at the distal end of the naso-lacrimal duct. this membrane dissolves in 80% to 90% of infants within the first few months of life, either spontaneously or with medical treatment and massage8,9. surgical intervention in the form of probing and irrigation of the naso-lacrimal duct is required only in 1% to 2% of cases not responding to medical treatment and massage. acute dacryosystitis and mucocele is uncommon in the neonates but can occur occasionally and is probably the only indication for immediate lacrimal duct probing in the neonatal period8. probing of the naso-lacrimal duct is highly effective in relieving the obstruction in infants who do not respond to medical treatment and massage. however, there is some difference of opinion about how early to resort to probing to resolve the situation. some authors advocate probing as early as four months of age after a trial of topical antibiotics and massage have failed.11 others12 recommend waiting to see if there is spontaneous clearance of the obstruction. if there is no relief by 12-14 months, probing is performed on an outpatient basis under a short general anaesthesia. our routine is to intervene anytime after 6 months and preferably before one year of age as the likelihood of spontaneous resolution is fairly high before 6 months of age (table 2) and continued tearing and discharge in not only unpleasant for the baby but a constant source of psychological stress and worry to the young parents who are inexperienced and apprehensive about their new born baby. we also feel that early probing reduces the chances of secondary cellulitis due to prolonged obstruction, which may minimize the success of subsequent probing. in our series of 63 infants, 47 (74.60%) relieved spontaneously with antibiotics and massage. the spontaneous recovery was high in the 0-6 months age group (55.5%) and low in the 7-12 months age group (17.4%). only one of the patients above age 12 months showed spontaneous recovery (table 2). sixteen infants (25.39%) who did not respond to medical treatment and massage for 4 – 6 weeks, were subjected to probing and irrigation. these included 2 (3.17%) from the 0 – 6 months, 6 (9.52%) in the 7-12 months and 8 (12.7 %) in the patients above one year age group (table 3). timing of probing for congenital nasolacrimal duct obstruction 45 vol. 28, no. 1, jan – mar, 2012 pakistan journal of ophthalmology first probing relieved 13 (81.25.47%) out of 16infants of epiphora and discharge. three infants (4.76%) required repeat probing. all infants were relieved with the repeat probing. table 1: age and sex distribution age male female total n (%) 0-6 months 20 18 38 (60.32) 7-12 months 11 06 17 (26.98) above 12 months 06 02 8 (12.69) table 2: infants responding to conservative treatment 47 (74.60%) out of 63 patients age male female total n (%) 0-6 months 19 16 35 (55.55) 7-12 months 09 02 11(17.46) above 12 months 01 0 01 (1.59) table 3: infants requiring probing 16(25.39%) out of 63 patients age male female total n (%) 0-6 months 01 01 02 (3.17 ) 7-12 months 03 03 06 (9.52 ) above 12 months 05 03 08 (12.69) table 4: results of successful initial probing 16 patients (25.39 %) age no. of patients n (%) relieved 0-6 months 02 (12.5) 02 7-12 months 06 (37.5) 06 above12 months 08 (50) 08 table 5: no of infants requiring repeat probing age no. of patients n (%) relieved 0-6 months 7-12 months 01 (male) 01 above12 months 02 (female) 02 spontaneous resolution of the naso-lacrimal duct obstruction can occur with topical antibiotics and proper hydrostatic massage of the sac area. forty seven (74.6%) of our patients had spontaneous recovery with topical antibiotics and massage. in 9 infants (7 in the 0-6 months age group and 2 in the 712 months age group), while demonstrating the method of massage to the parents, a popping sensation was felt with the massaging finger and the obstruction was felt relieved instantly. this recovery was confirmed from the family on telephone couple of weeks later in all the infants. the lower spontaneous resolution rate in our patient may be due to late presentation, improper massage technique and poor compliance. peterson and robb5 believe that conservative treatment, if practiced properly and regularly, can relieve epiphora in the majority of infants with congenital naso-lacrimal duct obstruction. other observers11, 13 had the same findings. robb12 achieved a 90% cure rate after initial probing rising to 96% after second probing. other observers6,14 achieved similar results. our results are almost the same as the above mentioned workers. according to robb12 the success of probing is not related to the infants’ age at the time of probing. he believes the cause of unsuccessful probing is due to abnormal anatomy rather than the usual membranous obstruction at the lower end of the naso-lacrimal duct. he recommends simple probing as the procedure of choice for naso-lacrimal duct obstruction in the first five years of life. mittelman15 however believes that probing is more likely to be successful if done below one year of age (95%) as compared to those done above one year of age (73%). our clinical impression is that age at the time of probing is an important factor in achieving optimal results. we believe that the persistent infection in the naso-lacrimal duct resulting from untreated obstruction leads to fibrosis of the naso-lacrimal canal causing failure of probing later in life. conclusion we agree with the general recommendation that all infants with congenital naso-lacrimal duct obstruction be conservatively treated with topical antibiotics and regular and proper hydrostatic massage of the lacrimal sac till the age of 6 months. if there is no response to this conservative approach, careful probing under a brief general anaesthesia should be performed before the infant is one year of age to achieve optimal results. zia muhammad et al pakistan journal of ophthalmology vol. 28, no. 1, jan – mar, 2012 46 author’s affiliation dr. zia muhammad associate professor of ophthalmology, mardan medical complex teaching hospital mardan dr. muhammad tariq senior registrar department of ophthalmology mardan medical complex teaching hospital mardan col. dr. khwaja khalid shoaib head of department of ophthalmology c.m.h. mardan cantt prof. zia-ul-islam professor of ophthalmology bacha khan medical college mardan reference 1. chaabouni m, zayani a, chebihi s, et al. congenital obstruction of lacrimal ducts in 578 children. arch fr pediatr. 1993: 50: 107-9. 2. paul to, shephered r. congenital naso-lacrimal duct obstruction: natural history and the timing of optimal intervention. j pediatr ophthalmol strabismus. 1994; 31: 362-7. 3. jones lt, wobig jl. surgery of the eyelids and lacrimal system. birmingham (alabama), aesculapius publishing company. 1976; 162-7. 4. viers er. lacrimal disorders, diagnosis and treatment. st. louis, the c.v. mobsy company. 1976; 37-46. 5. petersem, ra, robb. rm. the natural course of congenital obstruction of the naso-lacrimal duct. j pediat ophthal strabismus. 1978; 15: 246-50. 6. khan n, khan mn, jan s, et al. congenital naso-lacrimal duct obstruction: presentation and management. pak j ophthalmol. 2006; 22: 74-8. 7. nasir j, mohyuddin m, bhatti sa. non massaging management of congenital and infantile naso-lacrimal duct obstruction. pak j ophthalmol. 2007; 23: 84-6. 8. muhammad z, m. daud khan md. timing of probing in naso-lacrimal duct obstruction in infants and children. pak j ophthalmol. 1994; 10: 9. mehmood t: watery eyes, pak j ophthalmol. (editorial), 2006; 22: 58-9. 10. scot we, fabre ja, ossoinig k. congenital mucocele of the lacrimal sac. arch ophthalmol. 1979; 97: 1556-8. 11. kushner bj. congenital naso-lacrimal system obstruction. arch ophthalmol. 1982; 100: 597-600. 12. robb rm. probing and irrigation for congenital naso-lacrimal duct obstruction. arch ophthalmol. 1986; 104: 378-9. 13. daniel ma, jakobiec fa. principles and practice of ophthalmology, clinical practice. w b saunders, philadalphia. 1994: 2812-20. 14. halepota fm, dahri gr, anjum n, et al. results of lacrimal probing in infants and children. pak j ophthalmol. 2000; 16: 47-50. 15. mittelman d. probing and irrigation for naso-lacrimal duct obstruction (letters to the editor) arch ophthalmol. 1986; 104: 1125. microsoft word abstracts 212 abstracts edited by dr. tahir mahmood wearing swimming goggles can elevate intraocular pressure morgan wh, cunneen ts, balaratnasingam c, yu dy br j ophthalmol 2008; 92: 1218-21 swimming is a popular form of exercise with many swimmers wearing goggles to improve underwater visibility. tension from the goggle headband keeps the goggles in place. this force acting on the goggles may compress orbital vasculature and other structures to cause an elevation in intraocular pressure (iop). continuously elevated iop is a significant risk factor for glaucoma development and progression. there is no previous information regarding the effects of swimming goggles upon iop. there are case reports of migraine, supraorbital neuralgia, eyelid swelling, skin irritation and diplopia associated with wearing goggles. one study found that the air pressure between a swimming goggle and the eye decreased as one subject placed his goggle on and off. the authors wanted to determine if goggle wear resulted in immediate changes to iop and if these changes were sustained for the duration of goggle wear. they were also interested in determining the goggle characteristics that were associated with any iop changes. they performed a pilot study to test the immediate effect of wearing goggles upon iop and used measurements of the subjects orbits and swimming goggles to generate a predictive model of iop change. a subsequent validation study involving more subjects and using a greater range of goggles tested the validity of this predictive model. the validation study also added to the data from the pilot study and allowed them to clarify if iop changes upon goggle application were sustained or varied while wearing goggles for an extended period of time. the purpose of the study was to examine the acute effects of wearing swimming goggles upon intraocular pressure (iop). this research consisted of a pilot study and a validation study. holes were drilled into the faces of 13 different goggles to allow iop measurement by applanation tonometry. iop was measured before goggle wear, 2 min after goggle application, 20 min after goggle application and after goggle removal. the pilot study (n=15) was initially performed to investigate changes in iop while wearing five different types of swimming goggles. anatomical and goggle design parameters from the pilot study were then used to generate a predictive model and design a validation study (n=20). the validation study tested the predictive model, examined iop changes using another eight goggles and clarified whether iop changes were sustained for the duration of goggle wear. iop increased while wearing goggles by a mean pressure of 4.5 mm hg (sd 3.7, p <0.001) with this pressure rise being sustained for the duration of goggle wear. a smaller goggle face area (p=0.13), was consistently associated with greater iop elevation. authors concluded with the remarks that these measurements were not taken while swimming, but they suggest that some swimming goggles can elevate iop. efficacy and safety of capsular bending ring implantation to prevent posterior capsule opacification menapace r, sacu s, georgopoulos m, findl o, rainer g, nishi o j. cataract refract surg. 2008; 34: 1318-28 adding a sharp posterior edge to intraocular lenses (iols) has significantly reduced the formation of regeneratory after cataract on the posterior capsule behind the optic and the subsequent need for neodymium: yag (nd:yag) laser capsulotomy. however, the barrier effect of sharp edged iols occasionally fails and generally wears off over time. this is caused by 2 weakness of the concept. the first is that the persistence of the barrier effect of the posterior optic edge is dependent on the formation of 213 a permanent circumferential capsular bend at the posterior optic edge, which results from capsular bag closure. capsular fusion and subsequent bend formation are counteracted by broad haptic junctions (junction phenomenon) or by overly long and rigid loops that ovally distort the capsular bag and are sometimes incomplete (primary barrier failure) for unknown reasons. in the long run, fusion and bending may secondarily be reversed by the proliferative pressure of delayed soemmering ring formation if collagenous sealing of the capsular leaves at the optic rim is not firm enough to resist redivision (secondary barrier failure). second, a prerequisite to bend formation is circumferential overlap of the optic by the anterior capsule leaf, which is not always achieved. incomplete overlap results in early retro-optical lens epithelial cell (lec) ingrowth. capsulorhexis-optic overlap that is too small may give way to anterior capsule retraction with consequent anterior optic buttonholing and fibrosis of the retro-optical posterior capsule, while overlap that is too large unnecessarily reduces the free optic zone, especially when fibrotic capsulorhexis contraction ensures. this explains the 10 year cumulative nd:yag laser capsulotomy rate of more than 40% found with the most widely used hydrophobic acrylic iol. the purpose of the study was to determine whether a capsular bending ring (cbr) with a rectangular cross-section and sharp edges moves the barrier to the very equator and avoids contact between the capsulorhexis and optic to prevent posterior capsule opacification (pco) and anterior capsule fibrosis. a 0.7 mm high, open poly (methyl methacrylate) cbr was implanted in 60 eyes (patients) in a prospective randomized intraindividul trail. the impact of additional cbr implantation on pco and anterior capsule fibrosis was compared to that of intraocular lens (iol) implantation alone using objective scoring. no cbr-related surgical complications occurred. the objective pco score and area were statistically significantly reduced in the cbr group. in patients with complete follow-up, the mean pco score (scale 1 to 10) at 1, 2 and 3 years was 0.8, 1.7 and 2.1 respectively, in the cbr group and 2.6, 3.9, and 4.6 respectively, in the no cbr group. the number of quadrants affected by pco was 0.9, 1.5, and 1.8 versus 3.2, 3.8, and 3.8. barrier failures with the cbr were caused by the inherent slight edge blunting and occasional eyelet gaping. laser capsulotomies were performed in the no-cbr group only. capsule stress folds and fibrotic anterior capsule opacification were also greatly reduced. the best corrected visual acuity was better in the cbr group. authors concluded with the remarks that capsular bending ring implantation was an effective and safe adjunct to in the bag iol fixation. with improvements in technology and design securing exquisitely sharp edges and circumferential capsular bending independent of the capsular bag diameter, this concept has the potential to prevent pco and anterior capsule fibrosis. intraocular pressure on the first postoperative day as a prognostic indicator in phacoemulsification combined with deep sclerectomy garcia-perez jl, rebolleda g, munoz-negrete fj j. cataract refract surg. 2008; 34: 1374-8 the incidence of open-angle glaucoma increases with patient age, and cataract and glaucoma frequently develop in the same patient. in addition, there is an increased risk for cataract in patients with glaucoma, and glaucoma surgery significantly increases the risk for development of cataracts. for these reasons, there has been an increasing trend toward performing a combined procedure for both diseases. nevertheless, the decision to do sequential or combined cataract and glaucoma surgery depends on several individual patient factors including the degree of visual impairment, target intraocular pressure (iop), stage of glaucoma, and patient age and life expectancy. deep sclerectomy and viscocanalostomy are nonpenetrating filtration procedures to surgically treat glaucoma. isolated or combined with phacoemulsification, both procedures may offer good success rates, minimizing the risk for postoperative complications associated with trabeculectomy or phacotrabeculectomy. regarding the efficacy of these nonpenetrating filtration procedures, the results are controversial. the purpose of the current study was to evaluate whether the iop value 24 hours after combined phacoemuslfication-nonpenetrating deep sclerectomy can also be considered a prognostic indicator. the purpose of the study was to study the intraocular pressure (iop) as a prognostic indicator on 214 the first day after combined phacoemulsification and nonpenetrating deep sclerectomy. this retrospective study included 70 eyes of 70 patients who had combined phacoemulsificationnonpenetrating deep sclerectomy with a reticulated hyaluronic acid implant. visual acuity, iop, and slitlamp examinations were performed preoperatively and 1 and 7 days and 1, 3, 6, 12, and 24 months postoperatively. a split point of 9.0 mm hg on the first postoperative day was used. the need for medication and postoperative neodymium: yag goniopuncture was also recorded. the mean preoperative iop was 22.5 mmhg ± 5.2 (sd). the mean postoperative iop was 11.6 ± 8.1 mmhg, 16.4 ± 4.7 mmhg, and 17.0 ± 5.3 sd mmhg at 1 day, 12 months, and 24 months, respectively. a greater success rate was observed in terms of survival (p= .006, log rank test) in patients with an iop of 9 mmhg or less on the first postoperative day; these patients also had a significantly reduced need for glaucoma treatment (p=0.15) and goniopuncture (p.009. authors concluded with the remarks that an iop of 9mm hg or less on the first postoperative day might serve as a positive prognostic indicator in combined phacoemulsification with deep sclerectomy. vision-related quality of life in patients with pituitary adenoma okamoto y, okamoto f, hiraoka t, yamada s and oshika t am j ophthalmol 2008; 146: 318-22. pituitary adenoma, which account for 17.4% of all brain tumors, is the third most frequently diagnosed brain tumor, following intracranial meningioma and glioma. the development of pituitary tumors may compress surrounding structures such as optic nerve and cranial nerves iii, iv, and vi, leading to visual field (vf) defects including bitemporal hemianopia, visual disturbance, and ocular motility abnormalities. the frequency of vf defects associated with pituitary adenoma varies, ranging from 9% to 32% as reported in the literature. visual disturbance is reported to be present in 4% to 16% of patients with pituitary adenoma and ocular motility abnormalities in 1% to 6% of patients. in addition to traditional objective assessments of patients such as clinical examinations and laboratory data collection, subjective assessment of the daily activities and well being of patients has become increasingly important in recent medical practice. the tool for quantitative evaluation of the vision related quality of life (vr-qol), the 25 item national eye institute visual function questionnaire (vfq-25), has been used to track the outcome of many ocular diseases such as cataract, glaucoma, age related macular degeneration (amd), epiretinal membrane, diabetic retinopathy, keratoconus, and macular hole. as for patients with pituitary adenoma, the existing studies have assessed the quality of life and well being of patients with pituitary adenoma, the well being of patients by using general health related quality of life measures. the purpose of the study was to evaluate the vision related quality of life (vr-qol) in patients with pituitary adenoma. a vr-qol questionnaire was distributed to 154 patients with pituitary adenoma and 81 normal controls. these were presurgical patients. vr-qol was measured using the 25-item national eye institute visual function questionnaire (vfq-25). the influence of various factors on vfq-25 score was assessed, including age, logarithm of the minimum angle of resolution best corrected visual acuity (logmar bcva), critical flicker fusion frequency, humphrey static perimetry scores, and the duration of ocular symptoms. the vfq-25 composite score was significantly lower in patients with pituitary adenoma than in the normal controls (p<.001), with significant differences in all subscales except for color vision. the vfq-25 composite score in patients with pituitary adenoma was significantly correlated with logmar bcva, mean deviation (md) and corrected pattern standard deviation (cpsd) of humphrey perimetry, critical flicker fusion frequency, and the duration of ocular symptoms. stepwise multiple regression analysis revealed that md score in the better seeing-eye (r = 0.69; p < .001) and the duration of ocular symptoms associated with pituitary adenoma (r = -0.36; p < .001) were significantly related to the vfq-25 composite score. authors concluded with the remarks that the vrqol is significantly deteriorated in patients with pituitary adenoma. the degree of visual field defect in better seeing-eye and duration of ocular symptoms 215 were found to be significantly related to the decline of vr-qol in these patients. microsoft word omolase charles _case report_ corrected 46 case report unilateral microphthalmos with associated retina detachment in a nigerian child co omolase, my majekodunmi, ak akinwalere, bo omolase pak j ophthalmol 2011, vol. 27 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: omolase charles oluwole federal medical centre pmb 1053, owo, ondo state nigeria received for publication august’ 2010 …..……………………….. this report is that of a two year old nigerian child who presented to the eye clinic of federal medical centre, owo in june, 2010 on account of small left eye noticed since birth. examination carried out revealed no perception of light in the left eye, left microphthalmos with associated retinal detachment. the right eye was normal. systemic examination did not reveal any associated congenital anomaly. there is no history of similar occurrence in her family but the mother had a febrile illness with associated rashes suspicious of rubella in the course of the pregnancy. retina surgery was not advised in view of the no perception of light in the affected eye. there is need for adequate antenatal care to prevent some congenital anomalies. icrophthalmos is a rare congenital anomaly of the eye. it is a developmental arrest of ocular growth1. microphthalmos means small eye. the total axial length of the eye in microphthalmos is at least 2 standard deviation below age-similar control1. the reduction in the axial length of the eyes is due to stunted growth of the anterior or posterior segments of the eye or both segments. microphthalmos can be classified into simple/pure microphthalmos in which case there is absence of major ocular malformations and complex in which there are ocular abnormalities2. microphthalmos usually ranges from mild to extreme reduction of total axial length of the eyes3. most cases of non-syndromic microphthalmos are sporadic4-6. environmental factors can also be responsible for non syndromic microphthalmos7. microphthalmos has been reported to be associated with other ocular abnormalities like congenital cataract, sclerocornea and dysgenesis of the anterior chamber8. posterior microphthalmos is a form of microphthalmos in which there is reduction of total axial length of the eyes, normal cornea diameter resulting in high hypermetropia and a papillomacular retinal fold2,9,10. it differs from nanophthalmos in which there is microphthalmos, microcornea and a tendency towards uveal effusion. we highlight in this case report the case of a two year old child who presented with left microphthalmos associated with retina detachment. there are few reports of similar presentation in this part of the world. case history a two year old nigerian girl was brought to our eye clinic in june, 2010 with the history of small left eye noticed by the mother since birth. there was no antecedent trauma. pregnancy history revealed that mother had rashes that were suggestive of rubella at the seventh month of pregnancy and she was managed at a private hospital. the mother had full term pregnancy delivered via spontaneous vagina delivery. perinatal and post natal periods were uneventful. she is the third of three children in a monogamous family and there is no history of similar occurrence in her siblings. examination of the eyes revealed that the patient could track light with the right eye while she could not perceive light with the left eye. the anterior and posterior segments of the m 47 right eye were essentially normal. however there was microphthalmos and cyclotropia of the left eye. the vertical and horizontal diameters of the right eye were 10.5mm and 11mm respectively while it was 6mm vertically and 7mm horizontally on the left. the lens of both eyes was clear. dilated funduscopy done on the left eye revealed extensive retina detachment involving the macula while the fundus on the right was essentially normal. b scan ultrasonography done revealed an ap diameter of 19mm on the right and 12mm on the left. the ultrasonography confirmed retina detachment on the left side. general and systemic examination done did not reveal any other anomaly. the condition of the left eye was explained to the mother in details. however retinal surgery was not advised in view of the inability of the left eye to perceive light. the child was however to come for periodic review by the ophthalmologist and follow up by the paediatricians. discussion in congenital microphthalmos, the orbital growth is deficient.11 it can thus lead to facial asymmetry. the overall prevalence of congenital microphthalmos and nanophthalmos has been estimated at 1 to 1.5 per 10,000 births11,12. microphthalmos is unilateral in 75% of cases11. no consistent hereditary basis has been found11. extrinsic causes such as maternal rubella or environmental teratogens are often suspected13. other infectious agents such as toxoplasmosis, herpes and cytomegalovirus have been reported to be associated with microphthalmos14,15. the case reported was said to be the first in nuclear and extended family of the patient. however, the history of flu-like illness with associated rashes and fever in the mother at the seventh month of pregnancy was suggestive of rubella. the authors could not be categorical on this suspicion in view of the fact that relevant serological investigations were not done at the private hospital where the mother of the patient sought treatment. was the possibility to do rubella serology in mother/child to substantiate suspicion (diagram).this brings to force the importance of antenatal care in preventing complications arising in course of pregnancy which could adversely affect the baby after delivery. the late presentation of the child could also have contributed to the poor prognosis of restoration of vision in the affected eye. microphthalmos with associated retina detachment is said to be rare and this assertion is buttressed by the fact that the authors are not aware of similar reports in nigeria. however chen et al reported a case of microphthalmos with associated retina detachment and choroidal coloboma in a 28 year old patient in taiwan who complained of deterioration in vision in his right eye since early childhood16. there have been few reports of micropthalmia with autosomal recessive inheritance10,17. bateman also reported three generations of dominantly inherited non-colobomatous microphthalmos18. vingolo et al reported five generation pedigree with 14 subjects affected with bilateral microphthalmos not associated with other ocular or systemic signs3. the reported cases had microcornea3. these findings tally with our own and that of weiss et al who reported the association of microcornea with a total length less than 18mm2. chukwuka et al reported a case of bilateral microphthalmos in port harcourt, nigeria19 just as in this case there was no other associated congenital anomaly in the former case. the role of b scan ultrasonography in the management of patients with microphthalmos cannot be overemphasized. the introduction and recent advancement in ultrasonographic techniques20 has allowed for accurate evaluation of the anterior and posterior segments of the eyes2. the ultrasonography done in this patient actually contributed to the evaluation of the patient. in view of the challenging nature of the management of microphthalmos, there is need to work closely with the families of affected patients to ensure that the affected individuals are given adequate support. there is need for adequate antenatal care to prevent some congenial anomalies. fig. child with left sided microphthalmos 48 author’s affiliation c.o. omolase department of ophthalmology federal medical centre, owo ondo state, nigeria. m.y. majekodunmi department of ophthalmology federal medical centre, owo ondo state, nigeria a.k. akinwalere department of ophthalmology federal medical centre, owo ondo state, nigeria b.o.omolase department of radiology federal medical centre owo, ondo state, nigeria reference 1. kim jw, boes da, kinyoun jl. optical coherence tomography of bilateral posterior microphthalmos with papillomacular fold and novel features of retinoschisis and dialysis. am j ophthalmol. 2004; 138: 480-1. 2. weiss ah, kousseff bg, ross ea, et al. simple microphthalmos. arch ophthalmol. 1989; 107: 1625-30. 3. vingolo em, steindl k, forte r, et al. autosomal dominant simple microphthalmos. j med genet. 1994; 31: 721-5. 4. frazer gr, friedman ai. the causes of blindness in childhood. baltimore john hopkins university press. 1967; 59-60. 5. sjogren t, larsson t. microphthalmos and anophthalmos with and without coincident oligophrenia.acta psychiatr neurol scand. 1949; 56: 1-103. 6. zeiter hj. congenital microphthalmos. apedigree of four affected siblings and additional report of forty four sporadic cases. am j ophthalmol. 1963; 55: 910-22. 7. guyer dr, green wr. bilateral extreme microphthalmos. ophthalmic paediatr genet. 1984; 4: 81-90. 8. ghose, singh np, kaur d et al. microphthalmos and anterior segment dysgenesis in a family. ophthalmic paediatr genet. 1991; 12: 177-82. 9. khairallah m, messaoud r, zaouali s, et al. posterior sgment changes associated with posterior microphthalmos ophthalmology. 2002; 109: 569-74. 10. spitznas m, gerke e, bateman jb. hereditary posterior microphthalmos with papillomacular fold and high hyperopia. arch ophthalmol. 1983: 101: 413-17. 11. krastionova d, kelly mb, mihaylova m. surgical management of the anophthalmic orbit, part 1: congenital plast reconstr surg. 2001; 108: 817-26. 12. dolk h, busby a, armstrong bg. geographical variation in anophthalmia in england. 1988-94 bmj 1998; 317: 905-9. 13. o’keefe m, webb m, pashby rc, et al. clinical anophthalmos. br j ophthalmol. 1987; 71: 635-8. 14. meenken c, assies j, van nieuwenhuizen o, et al. longterm ocular neureological involvement in severe congenital toxoplasmosis. br j ophthalmol. 1995; 79: 581-4. 15. tsutsui y, kashiwai a, kawamura n, et al. microphthalmia and cerebral atrophy induced in mouse embryos by infection with murine cytomegalovirus in midgestation. am j pathol. 1993; 143: 804-13. 16. chenms, ho tc, chang cc, et al. retinal detachment in a patient with microphthalmos and choroidal coloboma. j formos med assoc. 2007; 106: 965-8. 17. fledelius hc, rosenberg t. extreme hypermetropia and posterior microphthalmos in three siblings .an oculo metric study in: ossoing kc, nijhoff m, eds. ophthalmic echography. dordrecht: nj junk. 1987: 87-91. 18. bateman jb. microphthalmos. int ophthalmol clin. 1984; 24: 87107. 19. chukwuka io, pedro-egbe cn. bilateral congenital microphthalmos port harcourt medical journal. 2008; 2: 278-281. 20. stewart dh, streeten bh, bockhurst rj, et al. abnormal sclera collagen in nanophthalmos. an ultrastructural study arch ophthalmol. 1991; 109: 1017-25. microsoft word irfan qayyum 78 original article role of initial preoperative medical management in controlling post-operative anterior uveitis in patients of phacomorphic glaucoma irfan qayyum malik, m. moin, a. rehman, mumtaz hussain pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irfan qayyum malik eye unit ii mayo hospital lahore submission of paper january 2011 acceptance for publication may 2011 …..……………………….. purpose: to determine the role of initial preoperative medical treatment in controlling severe post operative anterior uveitis after cataract surgery in patients of phacomorphic glaucoma. material and method: after diagnosis of phacomorphic glaucoma patients were divided into two groups. group a included 30 eyes which were operated very next day after controlling intraocular pressure only. group b included 30 eyes which were given anti-glaucoma andfour hourlytopical steroid drops to reduce inflammation for at least 5 days and then they were operated. patients in both the groups were operated by extra capsular cataract extraction technique with intra ocular lens implantation by a single surgeon. evaluation of patients on slitlamp for the signs of postoperative inflammation in both the groups was done on the first three post operative days while the patients were in the ward. follow up visits were done after one week, three weeks and finally after six weeks postoperatively. results: the study was conducted on 60 eyes at eye department, mayo hospital lahore. on first postoperative day group a slitlamp findings showed, +2 cells in 3eyes, 27 eyes showed >+3 cells,27 eyes showed corneal edema, 12 eyes showed membrane in a/c, and 7 eyes showed hypopyon. while in group b slitlamp findings showed, +1 cells in 7 eyes, +2 cells in 20eyes, 3 eyes showed >+3 cells,2 eyes showed corneal edema, 2 eyes showed membrane in a/c, and no eye showed hypopyon. the data was analyzed statistically by applying t test using spss version 8. conclusion: preoperative reduction of inflammation in phacomorphic glaucoma helps to minimize post operative complications due to anterior uveitis. hacomorphic glaucoma is a type of lensinduced glaucoma in which there is pathologic rise in intraocular pressure (>21mmhg) precipitated by the shape and size of the lens. it is acute secondary angle closure glaucoma which results from sudden hydration of lens that blocks the angle by a forward push of the iris and ciliary body resulting in shallowing of the anterior chamber. rapid lens swelling may result in pupillary block or forward displacement of the lens-iris diaphragm. 1phacomorphic glaucoma may be manifested by pain, blurred vision, rainbow coloured halos around lights, nausea and vomiting. the iop rise to relatively high levels and causes corneal epithelial edema. initial management of phacomorphic glaucoma includes reduction of the intraocular pressure with topical b adrenergic antagonist, pilocarpine (parasympathomimetic), carbonic anhydrase inhibitors and osmotic agents2. p 79 phacomorphic glaucoma is a relatively common occurrence in the subcontinent3. it is a surgical emergency. lens extraction with intra ocular lens implantation is the treatment of choice for phacomorphic glaucoma4. visual outcome is dependent on timely management. its results are often marred by pressure related optic atrophy and post operative uveitis5. fibrin release, which leads to membrane formation, posterior synechiae and pupil block glaucoma is commonafter cataract surgery for the treatment of phacomorphic glaucoma. we conducted this study to determine the role of initial preoperative medical treatment in controlling post operative anterior uveitis after cataract surgery in patients of phacomorphic glaucoma. material and method this hospital based interventional comparative study was conducted on 60 eyes at eye department mayo hospital lahore from 1-08-09 to 31-07-10. the duration of study was one years. patients of both gender who presented with symptoms of pain, redness and decreased vision and were diagnosed as phacomorphic glaucoma were included in the study. patients of phacomorphic glaucoma having faulty projection of light, patients in which after initial medical treatment pupillary miosis was not achieved due to synechiae formation, in which iop was not controlled persistently by medical therapy due to the permanent angle closure, with history of diabetes, with any previous history of trauma, history of anterior uveitis, with previous glaucoma history, with any past ocular surgical history were excluded from the study. after the diagnosis of phacomorphic glaucoma, patients were admitted in the ward. patients were randomly divided into two groups. group a included the patients who were operated on the very next day after control of just the iop. while in group b, patients were given anti-glaucoma to lower the intra ocular pressure and topical steroid drops to reduce inflammation for at least 5 days and then they were operated on. in both the groups, timolol eye drops were used twice a day, and tablet acetazolamide 250 mg was given tid. intravenous mannitol or oral glycerin was given in patients in whom the iop was more than 30 mmhg. 4% pilocarpine eye drops were used intensively when mannitol/glycerin was given then used qid, to open the angle after achieving miosis. intraocular inflammation was controlled with topical dexamethasone eye drops 4 hourly. group a patients were operated very next day after control of just the iop. while in group b patients both antiglaucoma and topical steroid eye drops were given for at least 5 days. the aim was to control the iop as well as intra-ocular inflammation. once there was minimal ciliary congestion, clear cornea, anterior chamber was devoid of reaction and pupil had constricted. patients in both the groups underwent extra capsular cataract extraction (ecce) with intra ocular lens (iol) implantation by a single surgeon. patients were evaluated for signs postoperative inflammation on the first three post operative days while patients were in the ward, and after one and three week of discharge. postoperatively patients were advised topical tobramycin and dexamethasone eye drops 2 hourly for 1 week, then 4 hourly for three weeks and then tid for next three weeks. if required antiglaucoma drugs were also added. results out of 60 eyes, 26 eyes were of male while 34 eyes were of female. duration of pain ranged from 1day to 1 ½ month. preoperatively in all the eyes visual acuity was counting finger to perception of light with projection in all quadrants. in group a mean intraocular pressure on presentation was 37.25 mmhg and after preoperative treatment it was controlled to 14.50 mmhg. while in group b preoperative mean intraocular pressure was 38.75 mmhg and after initial preoperative medical treatment mean iop was 15.25. after 6 weeks postoperative mean iop in group a pts was 21.75mmhg (with anti-glaucoma therapy) due to membrane formation, posterior synechiae, pupil block and iris bombe. while postoperative mean intraocular pressure in group b pts was 17.25 mmhg without antiglaucoma therapy. table 1&2 shows preoperative clinical findings of both groups. while table 3 shows preoperative clinical findings of group b patients, in which initial medical therapy was given. table 4 shows that in group a on first postop day slitlamp findings were, +2 cells in 3eyes, 27 eyes showed >+3 cells, 27 eyes showed corneal edema, 12 eyes showed membrane in a/c, and 7 eyes showed 80 hypopyon. while in group b (table 5) slitlamp findings showed, +1 cells in 7 eyes, +2 cells in 20eyes, 3 eyes showed >+3 cells,2 eyes showed corneal edema, 2 eyes showed membrane in a/c, and no eye showed hypopyon. table 1: preoperative findings of group a patients feature no of patients n (%) ciliary congestion 30 (100) corneal edema 30 (100) keratic precipitates (kps) 30 (100) flare in a/c 30 (100) cells in a/c + 1cells 0 + 2 cells 0 + 3 cells 30 (100) status of pupil mid dilated 26 (86) miosed 04 (13) mean iop 37.25 table 2: preoperative findings of group b patients feature no of patients n (%) ciliary congestion 30 (100) corneal edema 30 (100) keratic precipitates 30 (100) flare in a/c 30 (100) cells in a/c + 1cells 0 + 2 cells 0 + 3 cells 30 (100) status of pupil mid dilated 28 (93) miosed 02 (6) mean iop 38.75 in group a (table 6) on first postoperative day, 1 pt achieved good (>6/18) visual acuity, 2 pts achieved borderline (6/24-6/60), 27 achieved poor visual acuity (<6/60).while in group b (table 7) on first postoperative day, 5 pt achieved good (>6/18) visual acuity, 15 pts achieved borderline (6/24-6/60), 10 achieved poor visual acuity (<6/60). the data was analyzed statistically by using spss version 8. table 3: preoperative findings of group b patients after initial medical management feature no of patients n (%) ciliary congestion 2(6) corneal edema 1 (3) keratic precipitates 3 (10) flare in a/c 30 (100) cells in a/c + 1cells 24 (80) + 2 cells 05(16) + 3 cells 01 (3) status of pupil mid dilated ---- miosed 30 (100) mean iop 15.25 preoperative photograph of group b pt preoperative photograph of group b pt after initial management discussion in our study, out of 60 eyes, 26 eyes were of males while 34 eyes were of females. this is almost consistent to the previous studies which showed that phacomorphic glaucoma is more common in females5. in our study average at presentation was 61.75 years and duration of pain ranged from 1 day to 1 ½ month. 81 table 4: postoperative findings of group a patients findings 1st postop day n (%) 3rdpostop day n (%) after 1 wk n (%) after 3 wk n (%) after 6 wk n (%) no a/c details visible 05 (16) 01(3) ------ ---- cells no cells ------03 (10) 11 (36) 11 (36) +1 ---01 (3) 11 (36) 18 (60) 19 (63) +2 03 (10) 09 (30) 15 (50) 01 (3) ---- >+3 27 (90) 20 (66) 01 (3) ------- flare 30 (100) 30 (100) 21 (70) 09 (30) 05(16) membrane 12 (40) 09 (30) 06 (20) 05 (10) 04 (13) hypoyon 07 (23) 05(16) ---------- corneal edema 25 (83) 19 (30) 02(6) ------- kps 10(33) 07 (23) 02(6) -------- posterior synechiae 10(33) 10(33) 07 (23) 06 (20) 04 (13) pupil block 12 (40) 09 (30) 06 (20) 05 (10) 04 (13) iris bombe -----------------05 (10) 04 (13) table 5: postoperative findings of group b patients (after preop medical management) findings 1st postop day n (%) 3rdpostop day n (%) after 1 wk n (%) after 3 wk n (%) after 6wk n (%) no a/c details visible ---------------- ---- cells no cells ----07 (23) 21 (70) 29 (96) 30 (100) +1 07 (23) 13 (43) 08 (26) 01 (3) ---- +2 20(66) 09(30) 01 (3) -------- >+3 03 (10) 01 (3) ------------ flare 30 (100) 23 (76) 11 (36) 01 (3) ---- membrane 02(6) 01 (3) ------------ hypoyon -------------------- corneal edema 02(6) ------------ ---- kps 01 (3) 01 (3) ------------ posterior synechiae ---------------- ---- pupil block ----------------------- iris bombe ------------------------- table 6: best corrected visual acuity of group a patients best corrected va 1st postop day n (%) 3rd postop day n (%) after 1 wk n (%) after 3 wk n (%) after 6 weeks n (%) good >6/18 1 (3) 2 (6) 4 (13) 6 (20) 6 (20) borderline 6/246/36 2 (6) 3(10) 6 (20) 7 (23) 8 (26) poor <6/60 27 (90) 25 (83) 20 (66) 17 (56) 16 (56) 82 table 7: best corrected visual acuity of group b patients best corrected va 1st postop day n (%) 3rd postop day n (%) after 1 wk n (%) after 3 wk n (%) after 6 weeks n (%) good >6/18 5 (16) 5 (16) 7 (23) 9 (30) 11 (36) borderline 6/246/36 15 (50) 17 (56) 18 (60) 19 (63) 17 (56) poor <6/60 10 (33) 8 (26) 5 (16) 2 (6) 2 (6) our study showed that preoperatively in both the groups there was high iop and severe inflammation, so antiglaucoma and anti inflammatory medication was given. group a patients were operated very next day after just the control of iop, but group b patients were given that treatment for at least 5 days and then they were operated. as a result, postoperative inflammation was less in group b patients as compared to group a patients. pradhan d in his study at sagarmatha choudry eye hospital, lahan, nepal reported that sometimes, severe postoperative corneal edema is found in patients of lens induced glaucoma6. on first postoperative day severe corneal oedema was found in group a patients while it was minimal in group b patients. a study was done in nepal to determine the causes of poor outcome in patients presenting with phacomorphic glaucoma. it showed that there is significantly higher risk of poor visual outcome postoperatively in which the glaucoma was present for more than 5 days7.our study showed that early visual outcome was better in group b as compared to group a patients due to severe postoperative corneal edema, anterior chamber reaction, membrane formation. the reason of poor visual outcome was also identified, and it showed that many patients in group a developed postoperative glaucoma due to membrane formation, posterior synechiae and iris bombe, leading to shallowing of anterior chamber and formation of peripheral anterior synechiae. poor visual outcome was also noted in some patients of group b due to glaucomatous optic atrophy. generally patients are being operated on the same day or very next day just after controlling of iop and postoperative inflammation which is very common in patients of phacomorphic glaucoma leading to membrane formation, posterior synechiae and pupil block glaucoma if inflammation is not controlled properly preoperatively. we also operated one group of patients the very next day of presentation. and in second group we properly controlled the iop and inflammation for at least 5 days and then they were operated, when cornea was clear, there was normal iop and there were no signs of inflammation. and as a result we got the results almost identical to normal age related cataract surgery. in this study, we included the patients in whom, after our medical treatment iop was persistently controlled and pupil was miosed and there were no peripheral anterior synechiae. patients in which iop was persistently raised due to the synechiae formation were excluded from the study and these patients were operated under mannitol immediately. in the past multiple studies has been done which showed that cataract extraction with intraocular lens implantation in the setting of meticulous preoperative control of inflammation can optimize visual outcome in adults and children with uveitis8. however there are no studies published in local or international literature in which role of initial medical therapy to control postoperative inflammation in cases of phacomorphic glaucoma has been the subject of study. there are studies which showed that antiglaucoma and topical steroids should be given to patients of phacomorphic glaucoma but the duration and the efficacy of this management on reducing severe postoperative anterior uveitis is not clearly mentioned. so further multicenter trials are needed to confirm the results of this study. our study showed that post operative severe inflammation which is sometimes one of the major problems of phacomorphic glaucoma surgery leading to membrane formation, posterior synechiae and pupil block glaucoma is much reduced if inflammation is properly controlled pre operatively. conclusion we conclude from this study that timely management and proper preoperative reduction of inflammation produces less post operative complications due to anterior uveitis. 83 author’s affiliation dr. irfan qayyum malik eye unit ii mayo hospital lahore dr. m. moin eye unit ii mayo hospital lahore dr. a. rehman eye unit ii mayo hospital lahore prof mumtaz hussain eye unit ii mayo hospital lahore reference 1. sowka j. phacomorphic glaucoma: case and review. optometry. 2006; 77: 586-9. 2. rijal ap, karki db. visual outcome and iop control after cataract surgery in lens induced glaucomas. kathmandu univ med j (kumj). 2006; 4: 30-3. 3. murthy gv, gupta sk, bachani d, et al. current estimates of blindness in india. br j ophthalmol. 2005; 89: 257-60. 4. prajna nv, ramakrishnan r, krishnadas r, et al. lens induced glaucomasvisual results and risk factors for final visual acuity. indian j ophthalmol. 1996; 44: 149-55. 5. philips ci. etiology of angle closure glaucoma. br j ophthalmol. 1972; 56: 248. 6. pradhan d, hennig a, kumar j, et al. a prospective study of 413 cases of lens induced glaucoma in nepal. indian j ophthalmol. 2001; 49: 103-7. 7. jain is, gupta a, dogra mr, et al. phacomorphic glaucomamanagement and visual prognosis. 1983; 31: 648-53. 8. jancevski m, foster cs. cataracts and uveitis. discov med. 2010; 9: 51-4. microsoft word uzma fasih 4-1 143 original article assessment of anxiety and depression in primary open angle glaucoma patients (a study of 100 cases) uzma fasih, m.munir hamirani, asad raza jafri, s urooj riaz, arshad shaikh pak j ophthalmol 2010, vol. 26 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: uzma fasih b-21 block 10 federal b area karachi received for publication october’ 2009 …..……………………….. purpose: the purpose of our study was assessment of anxiety and depression in primary open angle glaucoma patients. materials and method: this study was conducted in the department of ophthalmology abbasi shaheed hospital from may 2006 to august 2007 in collaboration with psychiatry department. patients who had undergone thorough investigation and examination and diagnosed as patients of primary open angle glaucoma were selected randomly from the glaucoma clinic. these patients were evaluated through hospital anxiety and depression scoring method. it has been translated in urdu language for better understanding of patients and was filled by the patients themselves. results: one hundred patients of primary open angle glaucoma were included in our study, 76% percent were male and 24% were female. the average age was 56.21±13.37 years. anxiety in poag patients was observed in 33% cases and depression was observed in 24% cases. it is quite obvious that levels of anxiety were high among the patients of primary open angle glaucoma. conclusion: large majority of patients with physical disorders including glaucoma suffers from hidden psychiatric disorders that often go undetected. depression and anxiety constitute greater percentage of this combined psychiatric disorder in physically ill patients. moreover prevalence of anxiety is more in patients of primary open angle glaucoma as compared to depression. laucoma is a heterogeneous group of conditions involving cupping and atrophy of optic nerve head, characteristic visual field loss and often but not invariably a raised intraocular pressure1. glaucoma is the third largest cause of blindness world wide after cataract and trachoma. who estimated that about 105 million people suffer from glaucoma around the world and an estimated 5.2 million are blind from it. it was also found that 24% of the sufferers of primary open angle glaucoma were blind in at least one eye2. this may be because there is no cost effective and reliable method of detecting and treating the disease in large populations. the burden of blindness from different types of glaucoma is high. therefore making the diagnosis of a disease such as glaucoma that can lead to blindness may have an emotional impact on the patient. just as psychological stress can translate into illness that warrants treatment, likewise some physical illnesses also create psychological sequel that precipitate psychiatric disorder severe enough to require specialist treatment3. on the other hand a large majority of patients with physical disorders including glaucoma suffer from hidden psychiatric disorders that are often undetected by their attending primary care physician4. depression and anxiety constitute greater percentage of these combined psychiatric disorders in physically ill patients5. g 144 the role of emotional factors in glaucoma has received wide recognition by investigators and clinicians. demours as early as 1818 commented on psychic influences that may play a predominant role in glaucoma6. later workers such as miller, piers, riplay and wolf and others added further clinical and experimental elaboration of this concept and berger has reviewed the literature in this aspect7-10. glaucoma probably more than any other eye disease has been considered to be a psychosomatic disorder11. this fact has often been overlooked that eye conditions generally are likely to involve psychological factors. schlagel and hoyt cited the opinions of several ophthalmologists with regard to the percentage of eye cases involving emotional difficulties. they reported percentages range from 40100 indicating the prevalence of psychological factors in eye diseases in opinion of leading ophthalmologists11. miller, piers, riplay and wolf have described specific personality features in glaucoma as compulsive traits, over meticulousness, over conciousness and perfectionism6-8. others have commented on moody, anxious and hypochondriac trends in these patients. these findings are quite valuable to establish the fact that glaucoma may be a psychosomatic disease. these patients are usually evaluated on hospital anxiety and depression scale. zigmond and snaith (1983) developed had scale specifically for use with physically ill patients. it is a brief instrument containing seven items each for anxiety and depression which are rated on 4 point scale. somatic items are excluded and concept of depression is based on anhedonic state reflecting loss of pleasure. this scale is considered to be the best indicator of biogenic or drug responsive depression. a clinical diagnosis anxiety or depression is likely if total score of 11 or over is obtained on one of the two subscales. a score of 8-10 is considered borderline and a score of 7 or less is normal12. materials and methods subjects for the study were recruited from among the patients attending the glaucoma clinic at eye department abbasi shaheed hospital from may 2005august 2006. all participants underwent comprehensive ophthalmological examination. best corrected visual acuity was measured for each eye. intraocular pressure was measured with goldman applanation tonometer. gonioscopy was done to assess the status of angle of anterior chamber. visual fields were evaluated on octopus 301 perimeter. only the patients with reliable visual fields were included in the study. each participant had a complete fundus examination to rule out additional ocular abnormalities. anxiety and depression were measured using had scale for anxiety and depression. the patients were evaluated through had scoring for anxiety and depression. it has been translated in urdu for better understanding of the questions asked13. the patients were asked to fill the proforma themselves and select the first quick response on the questionnaire anxiety and depression were evaluated according to the parameters of had scale. demographic characteristics consisting age, gender, marital status, level of education, quality of life and occupation were obtained from patients using a separate data collection sheet. results a total of 100 patients of primary open angle glaucoma were included in our study. 76% patients were male and 24% patients were female (fig. 1). most commonly presenting age group was between 51-70 years followed by above 70 years of age as shown in figure 2. the average age of the patients was 56.21±13.37 years (95%ci: 53.56 to 58.86). similarly average had scored for anxiety and depression are also presented in (table 1). table 1: statistics of study variables study variables mean (sd) 95%ci minimum maximum observation age (years) 56.21(13.37) 53.56 to 58.86 16 – 85 had scoring anxiety 9.01(4.11) 8.20 to 9.82 1 – 21 had scoring depression 7.62(4.64) 6.70 to 8.54 0 – 20 anxiety and depression was evaluated by using questionnaire according to had scale. had score greater than and equal to 11 was observed in 33% cases which shows anxiety in poag patients, borderline cases of anxiety were observed in 21% (had score 8 to 10) and 46% were normal which had score ≤ 7. similarly clinically diagnosed (had score ≥ 11) cases of depression were 24%, borderline cases (had score 8 to 10) were 29% and patients with normal had scoring were 47% as shown in figure 3. 145 male female fig. 1: gender distribution of patients with primary open angle glaucoma 6% 21% 42% 31% 0 5 10 15 20 25 30 35 40 45 50 pe rc en ta ge o f p at ie nt s ≤ 30 31 to 50 51 to 70 > 70 age groups (years) fig. 2: age distribution patients with primary open angle glaucoma it is quite obvious that levels of anxiety are high while levels of depression low among the patients of primary open angle glaucoma. discussion long term treatment of primary open angle glaucoma could be stressful for patients apart from frequent and multiple hospital visits, cost of drugs transportation and other expenses source of anxiety and depression. it is quite obvious that levels of anxiety (36%) are high as compared to levels of depression (30%). as primary open angle glaucoma is a disease which can potentially result in bilateral blindness. patients may have been anxious about losing their job and becoming unable to earn their living due to loss of visual functions. hamelin et el described that glaucoma patients showed either an anxious or passive reaction to the announcement of diagnosis of glaucoma14. 46% 21% 33% 0 5 10 15 20 25 30 35 40 45 50 p er ce nt ag e ≤ 7 8 to 10 ≥ 11 had score for anxiety 47% 29% 24% 0 5 10 15 20 25 30 35 40 45 50 p er ce nt ag e ≤ 7 8 to 10 > 11 had score for depression fig. 3: assessment of hospital anxiety and depression scoring of primary open angle glaucoma patients in regard to anxiety demially et el reported that anxious personality traits and anxiety disorders were more prevalent in patients of severe primary open angle glaucoma15. compared to that of depression that was 10.9%16. 146 another study carried out in university of benin teaching hospital benin city nigeria showed prevalence of anxiety 10% and that of depression 6% in patients of primary open angle glaucoma17. this study shows that prevalence of anxiety is higher than that of depression in patients of primary open angle glaucoma similar to our study. erb etal in their study of psychiatric manifestations in patients with primary open angle glaucoma, noted that while glaucoma patients had higher scores on depression than their outpatient counterparts and the cataract control group, the outpatient glaucoma group had statistically significant higher score for psychosomatic complaints. the score on all three parameters (depression, psychosomatic complaints, and emotional stability) were normal for the cataract patients18. another study conducted in greece showed that anxiety and depression levels were significantly higher in patients of primary open angle glaucoma than those in healthy controls. anxiety and depression scores in patients with glaucoma did not differ significantly from the scores in patients with coronary disease19. cumurucu et al reported that there was no significant difference between anxiety levels of poag and control groups but it was found that anxiety was more prevalent in poag group20. a study conducted in korea also demonstrates that degree of anxiety and depression was significantly higher in glaucoma patients group. a psychological self training in daily life in addition to medical and surgical treatment can help to reduce anxiety and depression21. the trend of varying psychopathologic findings in glaucoma patients could well be the result of perceived helplessness and hopelessness among these patients suffering from an "incurable" visual problem; the initial anxiety being the result of efforts to find a final cure to a threatening visual loss after previous disappointing remedies. there is therefore a need to explore the emotional state of glaucoma patients in order to help improve their quality of life. conclusions it was concluded from the study that patients of primary open angle glaucoma do suffer from hidden psychiatric disorders that are often undetected by their attending primary care physician. among these disorders anxiety and depression are more common. our study shows that prevalence of anxiety is higher than that of depression in patients of primary open angle glaucoma. it is therefore suggested that in addition to evaluation and treatment of glaucoma these patients should also undergo thorough psychological assessment to reveal their psychological disorders, which should then be properly addressed. author’s affiliation dr. uzma fasih assistant professor eye dept. karachi medical & dental college abbasi shaheed hospital karachi dr. m. munir hamirani professor & head of psychiatry department abbasi shaheed hospital karachi dr. asad raza jafri senior registrar eye dept. karachi medical &dental college abbasi shaheed hospital karachi dr. s urooj riaz house officer psychiatry department abbasi shaheed hospital karachi dr. arshad shaikh professor & head of eye department eye dept. karachi medical &dental college abbasi shaheed hospital karachi reference 1. world health organization. press office fact sheet. 1997; 143: 2. 2. foster pj advances in understanding of primary open angle glaucoma as a cause of primary glaucomatous optic neuropathy. comm. eye health. 2001; 14: 37. 3. oheari ju. psychological stress and emotional disorders. afr j med. 1992; 11: 234-5. 4. bridges k, goldbergd. somatic presentation of depressive illness. in freeling p, dowery l jand malkin jc. the presentation of depression: current approaches uk royal college of general practitioners. 1987: 36, 9-11. 5. burton rh, freeling p. unrecognized depression in general practice. ripley hs and wolf hg. life situations emotions and glaucoma psychosom med. 1950; 215. in freeling p,dowery l jand malkin jc.(eds). the presentation of depression :current approaches u.k royal college of general practitioners 1987:36,12-16 147 6. demours ap traite des maladies des yeuix, paris 1818, 70. cited by duke elder ws. textbook of ophthalmology st louis mosby. 1941, 3339. 7. millers sjh. symptomatology of congestive and simple glaucoma brit m j. 1962; 1: 456. 8. piers g. glaucoma in alexander f and french tm. studies in psychosomatic mediscience newyork ronald. 1948: 555-6. 9. ripley hs, wolf hg. life situations, emotions and glaucoma in psychosomatic mediscience newyork ronald. 1950: 215. 10. berger as. zimet cn>personality factors of patients with primary glaucoma a medicopschosocial exploration psychosomatic mediscience newyork ronald. 1959; 21: 389. 11. schlagel tf, hoyt m. pschsomatic ophthalmology bltimore, williams and wilkins. 1957; 3. 12. lloyd gg. psychological precursors of physical illness in text book of general hospital psychiatry churchill living stone uk. 1991; 15. 13. mumford db, tareen ia, bajwa ma, et al. translation and evaluation of urdu version of hospital anxiety and depression scale acta psychiatr scand. 1991; 83: 81-5. 14. hamelin l,blatrix c,brion f et al. how patients react when glaucoma is diagnosed. j f ophthalmol. 2002; 25; 795-8. 15. demially p, zoutc c, castro d. personalities and chronic glaucoma. j f ophthalmol. 1989; 12: 595-601. 16. mabuchi f, yoshimara k, kashiwagi ket al. high prevalance of anxiety and depression in patients with primary open angle glaucoma. j glaucoma. 2008: 17: 552-7. 17. dawodo oa, otakpor an, ponmwan cu. common psychiatric disorders in glaucoma patients as seen at university of benin teaching hospital benin city nigeria. j. medical and biomedical research. vol 3 1:42-7. 18. erb c, batra a, bromer a, et al. psychiatric manifestations in patients with primary open angle glaucoma. ophthalmology. 1993; 90: 635-9. 19. mitsonis c, dimopoulos n, psarrav, et al. depression and anxiety in patients with glaucoma: a prospective, casecontrol study annals of general psychiatry 2006, 5: 10-20. 20. cumuru t, cumuru be, celikal fc et al. depression and anxiety in patients o with psedoexfoliation glaucoma. gen hosp psychiatry. 2006; 28: 509-15. 21. ha ms, chang mh, lee jh. observation on anxiety and depression of glaucoma patients. j korean ophthalmol soc. 2002; 43: 281-9. 84 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology original article a survey of patient satisfaction with lasik sharmeen akram, maheen akhter syed, salim mahar, salman naveed sadiq, fatima naqvi pak j ophthalmol 2017, vol. 33, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sharmen akram aga khan university hospital karachi email: sharmeen.akram@aku.edu …..……………………….. purpose: to assess patient satisfaction following laser in situ keratomileusis (lasik). study design: descriptive, cross-sectional study. place and duration of study: laser vision center, karachi, from jan 2012 to april 2016. material and methods: all patients who underwent laisk procedure in one or both eyes by two surgeons from jan 2012 to april 2016 at a refractive center (laser vision) in karachi and agreed to participate in the survey were included. these patients were surveyed telephonically to establish their degree of satisfaction with lasik and to enquire about postoperative use of glasses, and symptoms of night vision problems and if they would recommend this procedure to others. patient anonymity was assured. descriptive statistics were calculated using spss version 19. results: a total of 52 people who had undergone laisk procedure in one or both eyes were interviewed. 12 (23.1%) were males and 40 (76.9%) were females. their mean age was 29.83 ± 5.14 years. in our survey, the overall spectacle independence for distance was 90.4%. visual disturbance was reported by 19.2% of participants. the satisfaction level of patients post lasik was 86.5%. conclusion: our results are comparable to worldwide studies, which also show a high postlasik patient satisfaction. key words: lasik, patient satisfaction, spectacle independence, surveys 85 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology aser in situ keratomileusis (lasik) surgery is one of the most common refractive procedures performed in developed countries where more than half of the adult population has refractive errors1. its popularity is due to its pain-free nature, early visual recovery, predictability of results and low rate of complications2-6. multiple studies have been conducted regarding patient satisfaction after lasik procedure17-12. in order to understand patient satisfaction due to this procedure various factors contributing to it must be looked at such as unaided vision, improved cosmetic appearance, better participation in sport and other daily activities9,13. to our best of knowledge no such study has been documented in pakistan. the aim of this study was to assess patient satisfaction after lasik procedure performed at a refractive center in karachi. material and methods this was a cross-sectional survey. all patients, aged 20 years or older and of either gender, who underwent laisk procedure in one or both eyes by two surgeons from jan 2012 to april 2016 at a refractive center (laser vision) in karachi were included in this study. after obtaining informed verbal consent, a structured telephone interview was conducted with the participants to collect data on socio-demographics (age, gender, occupation), spectacle/contact lens use(pre and post lasik), visual disturbances such as halos, starburst and glare (preand post-lasik) and satisfaction (satisfied/not satisfied). of the two hundred patients called, only 52 patients agreed to be interviewed. ibm spss statistics version 19 (statistical package for social sciences) was used to enter and analyze the data. this was a descriptive analysis. means and sds were calculated to describe quantitative data. counts and proportions were computed to describe categorical data. results a total of 52 people were interviewed. their mean age was 29.83 ± 5.14 years (range 20-50 years). 12 (23.1%) were males and 40 (76.9%) were females. an overall spectacle independence for distance was reported to be 90.4% (table 1). visual disturbance such as halos, starburst and glare post lasik was reported to be 19.2 %. daily activities post lasik got affected in 21.2% of the patients. however, the overall satisfaction level post-lasik was 86.5% (table 1) and in spite of daily activities being affected, many participants were satisfied (table 2). overall 88.5% participants said they would recommend lasik surgery to others (figure 1). table 1: spectacle independence, visual disturbance, effect on daily activities and patients’ satisfaction after lasik surgery (n = 52). characteristic frequency percent spectacle independence yes 47 90.4 no 5 9.6 visual disturbance yes 10 19.2 no 42 80.8 daily activities not effected 41 78.8 affected 11 21.2 satisfaction satisfied 45 86.5 not satisfied 7 13.5 discussion multiple studies have been reported on patient satisfaction and various surgical procedures. eye being one of the six senses patient, satisfaction, following any eye surgery is of utmost importance. as refractive surgery especially the lasik procedure deals with normal eye, the satisfaction level assessment becomes very important following this procedure. the lasik surgery is a safe procedure but not risk free and rare complications when reported by a small number of dissatisfied patients can give an unbalanced negative attitude about the surgical procedure14-16. therefore to evaluate genuine patient satisfaction many surveys have been done1,7,8,17-20. table 2: satisfaction among those whose daily activities got affected. characteristic satisfaction p* satisfied freq (%) not satisfied freq (%) l sharmeen akram, et al 86 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology daily activities unaffected 38 (92.7) 3 (7.3) 0.029 got affected 7 (63.6) 4 (36.4) *p-value calculated using fisher's exact test figure 1: when asked if they would recommend lasik to others (n=52). it is important to understand the various reasons for the satisfaction postlasik such as unaided good vision, cosmesis1,12,13,21. current estimates of patient satisfaction with lasik range from 82% to 98%17,19. our study showed 86.5% patient satisfaction post lasik, with 88.5% of the patients willing to recommend the procedure (figure 1). 19.2% patient reported visual disturbances such as halos, starburst and glare, similar symptoms were also reported in other studies in the range of 12-57% of patient18,22. in spite of these symptoms, the satisfaction levels remained high 84.6%. in our study 90.4% of the patients reported spectacle independence which was the main factor for patient satisfaction-after the procedure. various reasons for patient satisfaction have been discussed in different studies; an unaided vision seems to be one of the most important factors7,12. factor creating bias in such a study is when the physician administers satisfaction questionnaires. to minimize this bias the survey was conducted by a resident and a medical student. limitations to our study were that the survey was done over a long follow up period. long-term followup results in difficult recall in accurately comparing the patient’s preoperative and present quality of vision. another limitation of our study is that objective quantification of night vision problems is still a challenge and limits accuracy study results. 19.2% of our patients reported visual disturbances however in spite of this satisfaction level was high and daily activities were not affected in most. our results are comparable to worldwide studies, which also show a high postlasik patient satisfaction. acknowledgement laser vision centre. author’s affiliation dr. sharmeen akram mbbs, fcps assistant professor aga khan university hospital karachi dr. maheen akhter syed mbbs resident aga khan university hospital karachi dr. salim mahar mbbs, frcophth, frcs senior lecturer aga khan university hospital karachi dr. salman naveed sadiq mbbs resident aga khan university hospital karachi dr. fatima naqvi student medical college, aga khan university hospital karachi role of authors dr. sharmeen akram study design, manuscript drafting and critical review. a survey of patient satisfaction with lasik pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 87 dr. maheen akhter syed 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jabbur ns, sakatani k, o'brien tp. survey of complications and recommendations for management in dissatisfied patients seeking a consultation after refractive surgery. j cataract refract surg. 2004; 30 (9): 1867-74. 15. levinson ba, rapuano cj, cohen ej, hammersmith km, ayres bd, laibson pr. referrals to the wills eye institute cornea service after laser in situ keratomileusis: reasons for patient dissatisfaction. j cataract refract surg. 2008; 34 (1): 32-9. 16. morse js, schallhorn sc, hettinger k, tanzer d. role of depressive symptoms in patient satisfaction with visual quality after laser in situ keratomileusis. journal of cataract & refractive surgery, 2009; 35 (2): 341-6. 17. tahzib ng, bootsma sj, eggink fa, nabar va, nuijts rm. functional outcomes and patient satisfaction after laser in situ keratomileusis for correction of myopia. j cataract refract surg. 2005; 31 (10): 1943-51. 18. bailey md, mitchell gl, dhaliwal dk, boxer wachler bs, zadnik k. patient satisfaction and visual symptoms after laser in situ keratomileusis. ophthalmology, 2003; 110 (7): 1371-8. 19. lazon de la jara p, erickson d, erickson p, stapleton f. visual and non-visual factors associated with patient satisfaction and quality of life in lasik. eye (lond). 2011; 25 (9): 1194-201. 20. yu j, chen h, wang f. patient satisfaction and visual symptoms after wavefront-guided and wavefrontoptimized lasik with the wavelight platform. journal of refractive surgery, 2008; 24 (5): 477-86. 21. khan-lim d, craig jp, mcghee cn. defining the content of patient questionnaires: reasons for seeking laser in situ keratomileusis for myopia. journal of cataract & refractive surgery, 2002; 28 (5): 788-94. 22. neeracher b, senn p, schipper i. glare sensitivity and optical side effects 1 year after photorefractive keratectomy and laser in situ keratomileusis. journal of cataract & refractive surgery, 2004; 30 (8): 1696-701. https://www.ncbi.nlm.nih.gov/pubmed/?term=ying%20ms%5bauthor%5d&cauthor=true&cauthor_uid=19344821 https://www.ncbi.nlm.nih.gov/pubmed/?term=french%20jw%5bauthor%5d&cauthor=true&cauthor_uid=19344821 https://www.ncbi.nlm.nih.gov/pubmed/?term=donnenfeld%20ed%5bauthor%5d&cauthor=true&cauthor_uid=19344821 https://www.ncbi.nlm.nih.gov/pubmed/?term=lindstrom%20rl%5bauthor%5d&cauthor=true&cauthor_uid=19344821 https://www.ncbi.nlm.nih.gov/pubmed/?term=joint%20lasik%20study%20task%20force%5bcorporate%20author%5d https://www.ncbi.nlm.nih.gov/pubmed/?term=joint%20lasik%20study%20task%20force%5bcorporate%20author%5d https://www.ncbi.nlm.nih.gov/pubmed/?term=de%20luise%20vp%5bauthor%5d&cauthor=true&cauthor_uid=11772601 https://www.ncbi.nlm.nih.gov/pubmed/?term=koch%20dd%5bauthor%5d&cauthor=true&cauthor_uid=11772601 microsoft word tariq khan 32 original article visual outcome and complications of manual sutureless small incision cataract surgery muhammad tariq khan, sanaullah jan, zakir hussain, samina karim, muhammad kamran khalid, lal mohammad pak j ophthalmol 2010, vol. 26 no.1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: muhammad tariq khan 2-lakhkar khan road university town peshawar received for publication may’ 2009 … ……………………… purpose: to determine the surgically induced astigmatism and complications of manual sutureless small incision cataract surgery (sics). material and methods: the study was conducted in the department of ophthalmology, khyber institute of ophthalmic medical sciences (kioms), postgraduate medical institute (pgmi), hayatabad medical complex (hmc), peshawar. in this study evaluation of 150 eyes of 134 patients were included in this study. cataract surgery was performed in all cases by manual sutureless small incision technique. patients were thoroughly examined and visual acuity & keratometry were recorded pre-operatively and at follow-up visits. the type and amount of astigmatism were calculated from the keratometry readings. any complications found during surgery or on follow up visits were also recorded. results: final best-corrected visual acuity 6-months post-operatively was ≥ 6/18 in 86.8 % of cases as compared to pre-operative va (≤ 6/60) in 82% of eyes. astigmatism was noted to be significant or high in 50 % cases. this study proved that course of time has no significant effect on the final amount of postop astigmatism in eyes operated by manual sics. other complications included hyphema noted in 17 (11.3 %) cases, posterior capsule rupture in 5 (3.3 %) cases, endophthalmitis in 2 cases (1.3 %) at 1st post-op day. third case, who had developed panophthalmitis presented 1-week post-operatively and affected eye was eventually eviscerated. conclusions: manual sics is a safe and effective procedure with rapid visual rehabilitation. the amount of post-operative astigmatism was high in significant number of cases. the final best-corrected visual outcome was good in most of cases. ccording to who estimates of global data on blindness, there are an estimated 38 million blind people worldwide, and a further 110 million with low vision who are at risk of becoming blind. age-related cataract accounts for nearly half of these blind individuals, and is particularly common in developing countries. who reports that there is a backlog of cataract of approximately 15.8 million people with an annual increase of over 2 million newly cataract-blind patients1. blindness rate in pakistan is unacceptably high (1.78% of the total population), of which 66.7% are blind because of cataract2. phacoemulsification is now standard technique routinely performed for cataract extraction in developed countries, as it offers early visual rehabilitation and better un-aided visual acuity than the conventional sutured planned extracapsular cataract extraction (ecce). owing to the expenses of equipment and consumables, and the high proportion of eyes with densely mature cataracts, phacoa 33 emulsification has had a limited role in many developing countries including pakistan. in order to obtain the advantages of a self-sealing sutureless incision with least surgically induced astigmatism at a low cost, developing world ophthalmologists have adopted alternatives to phaco-emulsification. manual sutureless small incision cataract surgery (sics) has been proved to be an equally effective and a highly cost-effective alternative to instrumental phaco with a low complications rate3,4. it is generally noticed that the incidence of postoperative astigmatism is more when cataract extraction is done through the corneal incision and the more anterior the incision the greater the induced astigmatism5. different studies from local and international studies had reported that manual sutureless small incision cataract surgery is an encouraging technique and that good visual results can be obtained in over 85% of cases with some associated complications like post-operative astigmatism, per-operative hyphema and irido-dialysis, etc6,7,8,9. the purpose of this study was to produce local evidence regarding visual outcome, surgically induced astigmatism and technique-related complications of manual sutureless sics. material and methods this study included 134 patients (150 eyes) at khyber institute of ophthalmic medical sciences (kioms), pgmi, hayatabad medical complex, peshawar, pakistan. all surgeries included in the study, were performed by the principal author. pre-operative examination like visual aquity, detailed slit lamp examination, iop check, a scan and keratometry was carried out for all cases. type of cataract was recorded on the basis of morphology as immature, mature, hypermature (morgagnian), intumescent, and large nucleus. keratometric findings of all the eyes were recorded pre-operatively and then at all follow-up visits. keratometric findings were noted in diopters and the axis was mentioned. the type and amount of astigmatism was calculated from keratometry findings pre-operatively and at all follow-up visits. on each follow-up visit, un-aided visual acuity (uava), bestcorrected visual acuity (bcva), significant signs (like a/c reaction, corneal striate, wound deformity, hyphema, etc), and any significant symptoms (like eye pain, double vision, fb sensation, etc) were recorded. astigmatism was recorded as negative cylinder values. astigmatism was graded and classified according to holmström’s gradation as, no astigmatism, when it was < 0.25 d non-significant, when it was ≥ 0.25 d but <1.00 d significant, when it was ≥ 1.00 d but < 2.00 d high, when it was ≥ 2.00 d the axes of astigmatism were divided into three classes,“with the rule” (minus cylinder at 180o ±15o ), “against the rule” (minus cylinder at 90o ±15o ) and “oblique” (minus cylinder at 16 – 74o & 106 – 164o). all the surgeries were performed within either micro-surgical training center’s operation theatre or within the main operation theatre of the khyber institute of ophthalmic medical sciences. the eye to be operated would properly be dilated by putting mydriatic drops. mixed peri-bulbar and retro-bulbar anesthesia was given by injecting mixture of lignocaine and bupivacaine at two different sites superiorly and inferiorly. the eye and peri-ocular skin would properly disinfected by painting with povidone-iodine solution. after proper draping, surgeon would approach from superior or temporal side, depending upon the keratometry readings. after conjunctival section, gentle cautry was done to stop any bleed. any of the four types of scleral incision (smile, straight, frown, inverted v shaped ) was given at a distance of about 2 mm from the limbus, with a number 15 blade. the external width of the incision was 6-8 mm according to the expected size of the nucleus. sclero-corneal tunnel was made with a crescent knife and entry into the anterior chamber with a 3.2 mm keratome. the internal opening of the incision was wider, so as to facilitate the nucleus delivery. before entering into the ac, a side port was made at the limbus, at right angle to the plane of approach with the same 3.2 mm keratome. anterior chamber was filled with visco-elastic substance by injecting it through the side port. anterior capsulotomy was done with the help of a self-made cystitome and a capsular forcep. hydro-maneuvers were performed in almost all cases and nucleus was delivered either by hydro-expression or by viscoexpression. cortical matter was then washed out with simcoe’s cannula and rigid, single-piece poly methyl methacrylate (pmma) iol was implanted within the bag or in the cilliary sulcus. three step scleral wound was then checked for its self sealing character and conjunctiva approximated by closing with gentle 34 cautry. visco-elastic material was washed out through the side port, and anti-septic dressing was done. cases were examined at the first post-operative day, 1-week post-op, 6-weeks post-op, and 6-months post-operatively with a slit-lamp and/ or direct/ indirect ophthalmoscope for any significant sign. ztest (normal test) and chi-squared test were applied to the data. in order to see the stabilization of refractive status in the operated eyes, chi-squared test was applied in testing the hypothesis for time-elapse after surgery and bcva. spss (statistical package for social sciences) version 8.0 was used in data analysis and graphs formation. results all 134 patients were divided into three categories according to age. 40 (29.9%) patients were found to fit in category-i (age 40 to 59 years), 81 (60.4%) patients in category-ii (age 60 to 79 years), and 13 (9.7%) patients in category-iii (age 80 years and above). the mean age of all the patients was found to be 67.18 years. out of all 134 patients, 77 (57.5%) were males and 57 (42.5%) were females. out of 150 eyes operated, 82 (54.7%) were right eyes and 68 (45.3%) were left eyes. site of incision was superior in 57 (38.0%) cases, while in 93 (62.0%) cases, temporal incision was given. type of incision given in 13 (8.7%) cases was smile, in 41 (27.3%) cases was straight, in 43 (28.7%) cases was frown and in 53 (35.3%) cases, inverted v shapedv (chevron) type of incision was given. minor intra-operative complications were not documented. amongst the note-worthy per-operative complications, 23 (15.3%) cases bled from the tunnel causing intra-operative hyphema was noted. these cases were only let to leave operation theatre, when the bleeding had stopped. in 6 (4.0%) cases, some degree of irido-dialysis occurred, none of them to the extent to need repair. in 5 (3.3%) cases, posterior capsule (pc) got ruptured. the astigmatism, calculated from pre-operative keratometry findings was found to be with-the-rule (wtr) in 73 (48.7%) eyes, against-the-rule (atr) in 27 (18.0%) eyes, and oblique in 32 (21.3%) eyes. no astigmatism was found in 18 (12.0%) eyes preoperatively. type of astigmatism preoperatively and on every follow up visit is shown in table i. details regarding amount of astigmatism with different type of astigmatism is shown in (table 2). it is worth to note that during follow up visits, significant no of patients were lost. on 1st postoperative day, all 150 eyes were examined but at 1 week post-operative visit 114 (70%) eyes of 107 (79.9%) were examined, at 6 weeks, post-operatively, 98 (65.39%) eyes of 91 (67.9%) patients were available for assessment and on final visit (6 months postoperatively) only 68 (45.3%) eyes of 64 (47.8%) patients showed for follow up. regarding complications, 17 (11.3%) eyes were found having hyphema at the 1st post-op follow-up examination. hyphema resolved in 11 (7.3%) cases in one week and in all cases 6-week post-operatively. post-operative endophthalmitis was diagnosed in 2 (1.3%) cases on 1st post-op day, which were successfully treated. another one case, presented 1week post-operatively with panophthalmitis. this eye had to be eventually eviscerated. corneal complications (like significant corneal edema and striate keratopathy) were noted in 19 (12.7%) patients at 1st post-op day. most of these cases were cleared up by the 1-week post-op, after topical steroids and antibiotics usage. in 5 (3.33%) cases, intra-ocular pressure (iop) was found to be more than the upper level of normal (i.e. above 21 mm hg) on 1st post-op day. 3 (2.0%) of these cases were put on topical iop lowering drugs for about a week and were properly monitored. none of these cases was having increased iop, when they presented 1-week post-operatively. during the six months follow-up period, 7 (4.7%) eyes were found having significant posterior capsule opacification (pco) to the extent that nd: yag capsulotomy had to be done to clear the visual axis. one case was diagnosed with cystoid macular edema (cme) at 6-week post-op and yet another with bullous keratopathy at 6-months post-op follow-up visit. details of complications in the post-operative follow up is given in (table 3). un-aided visual acuity (uava) both pre-operatively and post-operatively is shown in table iv while best corrected visual acuity (bcva) is shown in (table 4). discussion in this study, we tried to assess the safety, efficacy in terms of visual recovery and induced astigmatism in eyes undergoing cataract surgery by the technique of manual sutureless small incision cataract surgery. 35 table i: types of astigmatism (n=150) visits no: of eyes examined n (%) wtr* astigmatism n (%) atr** astigmatism n (%) oblique astigmatism n (%) no astigmatism n (%) pre-op 150 (100) 73 (48.7) 27 (18.0) 32 (21.3) 18 (12.0) 1st day post-op 150 (100) 90 (60.0) 36 (24.0) 15 (10.0) 9 (6.0) 1-week post-op 114 (76.0) 73 (64.0) 22 (19.3) 11 (9.6) 8 (7.0) 6-weeks post-op 98 (65.3) 62 (63.3) 19 (19.4) 8 (8.2) 9 (9.2) 6-months post-op 68 (45.3) 44 (64.7) 14 (20.6) 5 (7.4) 5 (7.4) *wtr -with-the-rule ,**atr -against-the-rule, pre-op—preoperatively, post-op—post operatively table 2: amount of astigmatism (n=150) visits no: of eyes n (%) wtr astig n (%) atr astig n (%) oblique astig n (%) no astig n (%) nonsignificant significant high nonsignificant significant high nonsignificant significant high 0.25<id ≥1.0d <2.00d 2.00d 0.25<id ≥1.0d <2.00d 2.00d 0.25<id ≥1.0d <2.00d 2.00d <0.25d pre-op 150(100) 31 (20.7) 25 (16.7) 17 (11.3) 9 (6.0) 7 (4.7) 11 (7.3) 11 (7.3) 14 (9.3) 7 (4.7) 18 (12.0) 1st day post-op 150(100) 39 (26.0) 32 (21.3) 19 (12.7) 14 (9.3) 15 (10.0) 7 (4.7) 7 (4.7) 5 (3.3) 3 (2.0) 9 (6.0) 1-week post-op 114(76.0) 34 (29.8) 26 (22.8) 13 (11.4) 9 (7.9) 7 (6.1) 6 (5.3) 5 (4.4) 4 (3.5) 2 (1.8) 8 (7.0) 6-weeks post-op 98 (65.3) 30 (30.6) 21 (21.4) 11 (11.2) 8 (8.2) 6 (6.1) 5 (5.1) 3 (3.1) 2 (2.0) 3 (3.1) 9 (9.2) 6-months post-op 68 (45.3) 21 (30.9) 15 (22.1) 8 (11.8) 6 (8.8) 4 (5.9) 4 (5.9) 2 (2.9) 1 (1.5) 2 (2.9) 5 (7.4) pre-op 150 (100) 31 (20.7) 25 (16.7) 17 (11.3) 9 (6.0) 7 (4.7) 11 (7.3) 11 (7.3) 14 (9.3) 7 (4.7) 18 (12.0) *wtr -with-the-rule,**atr--against-the-rule,***oblique astig –oblique astigmatism table 3: post-operative complications post-op hyphema n (%) post-op endophthalmitis n (%) corneal edema/ striate n (%) post-op iop rise n (%) pco n (%) cme n (%) bullous keratopathy n (%) 17 (11.3) 3 (2.0) 19 (12.7) 5 (3.3) 7 (4.7) 1 (0.7) 1 (0.7) iop: intra-ocular pressure, pco: posterior capsule opacification, cme: cystoid macular edema 36 table 4: un-aided visual acuity (n=150) visits no of eyes examined n (%) uava ≥ 6/18 n (%) uava ≤ 6/18-6/60 n (%) uava ≥ 6/60 hm n (%) uava ≤ hm-pl n (%) pre-op 150 (100) 03 (2.0) 24 (16.0) 97 (64.7) 26 (17.3) 1st day post-op 150 (100) 41 (27.3) 65 (43.3) 23 (15.3) 21 (14.0) 1-week post-op 114 (76.0) 73 (64.0) 26 (22.8) 11 (9.6) 04 (3.5) 6-weeks post-op 98 (65.3) 65 (66.3) 22 (22.4) 09(9.2) 02 (2.0) 6-months post-op 68 (45.3) 47 (69.1) 16 (23.5) 05 (7.4) 00 uava: un-aided visual acuity, hm: hand movement, pl: perception of light table 5: best corrected visual acuity (n=150) visits no of eyes examined n (%) uava ≥ 6/18 n (%) uava ≤ 6/18-6/60 n (%) uava ≥ 6/60 hm n (%) uava ≤ hm-pl n (%) pre-op 150 (100) 14 (9.3) 61 (40.7) 49 (32.7) 26 (17.3) 1st day post-op 150 (100) 58 (38.7) 51 (34.0) 20 (13.3) 21 (14.0) 1-week post-op 114 (76.0) 84 (73.7) 17 (14.9) 09 (7.9) 04 (3.5) 6-weeks post-op 98 (65.3) 79 (80.6) 11 (11.2) 06 (6.1) 02 (2.0) 6-months post-op 68 (45.3) 59 (86.8) 06 (8.8) 03 (4.4) 00 bcva: best-corrected visual acuity, hm: hand movement, pl: perception of light phacoemulsification is the universally accepted and most widely practiced technique of cataract surgery in the developed countries; however, it cannot be widely adopted in the developing world because of the financial and technological constraints. in this regard, manual sutureless small incision cataract surgery technique turns out to be a safe, effective and costeffective alternative3, 4. before this study, several studies from different parts of the world have been published on various aspects of the manual small incision cataract surgery10-14. hennig and co-authors selected 500 patients out of 14,500, upon which they operated. the un-corrected visual acuity was 6/18 or better in 76.8% of the patients at discharge, which declined to 70.5% at 6weeks and 64.9% at 1-year follow-up. best-corrected visual acuity was 6/18 or better in 96.2% of eyes at 6weeks and in 95.9% at 1-year15. in our study, uncorrected visual acuity was 6/18 or better in 73 (64%) eyes at 1 week post-operatively and in 65 (66.3%) eyes at 6 weeks post-operatively. best-corrected visual acuity was 6/18 or better in 79 (80.6%) of eyes at 6weeks in this study. rangaraj and co-author16 found corneal striate in 7% cases while in our study it was present in 19 (12.7%) cases. the sics involves touching of the iris at some point of time. this may lead to higher inflammation and cystoid macular edema.17 but in our study one case was diagnosed with cystoid macular edema at 6 weeks postoperatively. in a study conducted by huang and tseng18 from taiwan, most common type of surgically induced astigmatism was wtr astigmatism. similar result was found in our study in which wtr astigmatism was present in 73 (64%) cases. shaumber and co-authors found posterior capsule opacification in 11.8% cases after 1 year19. in this study the incidence of posterior capsule opacification was lower (4.7% cases). bartov and his colleagues presented a technique of planned manual sutureless cataract extraction in which scleral tunnel was made wide enough to allow a 37 nucleus of any size to settle in the tunnel. after making the nucleus as small as possible by sufficient hydro-procedure, they would lodge it in the scleral pocket to be manually picked or fragmented and removed from there through a constant sized 5.0 mm chevron incision. they concluded that a nucleus of any size can be extracted through the same constant 5.0 mm incision with minimal post-operative corneal astigmatism20. lagreze and co-authors studied the effect of technique and type of incision on the increase of iop after cataract surgery. they concluded that sutureless scleral tunnel incision produces the lowest postoperative increase in iop and should be considered for patients with glaucomatous damage21. in our cases iop was raised more than 21 mmhg in 5 (3.3%) cases on 1st post-operative day. although the cases in which sutures were applied were excluded from our study but gimbel et al found that wound architecture and whether sutures are used or not, has a little effect on overall corneal astigmatism 1-year post-operatively.11 in our study, we choose the site of incision before surgery on the basis of keratometric findings in vertical and horizontal meridians. for a pre-existing with-the-rule (wtr) astigmatism, we selected a superior approach and for pre-existing against-therule (atr) astigmatism, we selected temporal incision. for cases with pre-operative non-significant or no astigmatism, we randomly selected temporal approach, keeping in consideration that natural eyelid pressure emphasizes “against-the-rule shift” (which is comparatively more intolerable) with a superior incision in elderly population, and that because of the elliptical cornea, superior incision would be closer to the center of the cornea than the temporal one, thus liable to cause more post-op astigmatism. in contrast to some previous studies, in which against-the-rule (atr) astigmatism was the predominant type postoperatively, in our study we found more with-the-rule (wtr) astigmatism, may be because of the adopted temporal approach in more cases (62.0 %). type of incision and type of capsulotomy were randomly selected in our cases. mean pre-operative astigmatism was 0.78 d, while mean post-operative astigmatism 6-months postoperatively was 1.76 d. mean surgically induced astigmatism, six months post-operatively, calculated by simple subtraction method was 0.98 d. this value is greater than previous studies conducted by huang and tseng18 (0.69 d), bartov et al20 (0.54 d), zvia burgansky et al 17 (0.16 ± 0.98 d), and muralikrishnan et al16 (1.33 d – vector analaysis method). the reason for the more amount of surgically induced astigmatism may be factors related to the grade of surgeon (the author, being a senior resident). the mean post-operative un-aided visual acuity (uava) ≥ 6/18 in our study was 27.3% at 1st post-op day and 69.1 % at 6-months post-operatively. similarly, post-op best-corrected visual acuity (bcva) was 6/18 or better in 38.7% cases at 1st day post-op and in 86.8% cases at 6-months post-op. the main reason for the decreased unaided visual acuity is thought to be the surgery-induced astigmatism, followed by post-op corneal edema and anterior chamber reaction. a hennig and co-authors 15 reported intra-operative hyphema in 9.4 % of cases and posterior capsule (pc) rupture in 0.2 % cases. in our study, intra-operative hyphema happened in 15.3 % cases, in 4.0 % cases some degree of irido-dialysis occurred, and in 5 cases (3.33 %) posterior capsule tear was noted. we assume that surgeon’s inadequate experience of the technique may be the cause for the increased incidence of intra-operative complications. among the post-operative complications, other than induced astigmatism, 11.3 % cases were found having post-op hyphema at the 1st day post-op examination. this hyphema had resolved in 7.3 % of cases till the 1week post-op and in all cases till the 6-week post-op follow-up. therefore hyphema did not result in significant adverse effect and was mostly spontaneously resolved in due course of time. post-operative endophthalmitis occurred in 3 cases (2%), in which two responded well to the therapy, which was instituted from the 1st post-op day. the third case, contracted infection after 24 hours of surgery and presented at 7th day after operation. this eye had to be eviscerated eventually. multi factors, both intrinsic and extrinsic are thought to be responsible for the high incidence of post-operative endophthalmitis in poor socio-economic set-ups like ours. conclusions 1. manual small incision cataract surgery is a safe and effective technique of extra-capsular cataract extraction that can be confidently adopted. 2. surgically induced astigmatism and per-operative hyphema are the main complications of this technique. 3. almost all grades of nuclear sclerosis and all sizes of cataractous lenses can be dealt with this technique. 38 4. early rehabilitation of the patients because of the early stabilization of the refractive status of the eye and no suture-related problems are some of the advantages of this technique. 5. early diagnosis and early institution of treatment decreases the risk of loss of eye because of postoperative endophthalmitis. 6. we can manipulate the pre-existing pre-operative astigmatism as well as can minimize postoperative one, by following the keratometry readings for planning the site and type of incision before cataract surgery. 7. post-operative hyphema in case of manual sics is a benign condition, which usually do not cause increase in intra-ocular pressure. it usually gets absorb by 1-week post-operatively with almost no sequellae. author’s affiliation dr. muhammad tariq khan trainee medical officer (vitreo-retinal ophthalmology) khyber institute of ophthalmic medical sciences pgmi, hayatabad medical complex, peshawar dr. sanaullah jan senior registrar khyber institute of ophthalmic medical sciences pgmi, hayatabad medical complex, peshawar dr. zakir hussain trainee medical officer khyber institute of ophthalmic medical sciences pgmi, hayatabad medical complex, peshawar dr. samina karim trainee medical officer khyber institute of ophthalmic medical sciences pgmi, hayatabad medical complex, peshawar dr. muhammad kamran khalid district eye specialist lakki marwat, nwfp, pakistan dr. lal mohammad 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med coll. 2003; 9: 224-6. 7. rao sk, lam ds. a simple technique for nucleus extraction from the capsular bag in manual small incision cataract surgery. indian j ophthalmol. 2005; 53: 214-5. 8. gokhale ns, sawhney s. reduction in astigmatism in manual small incision cataract surgery through change of incision site. indian j ophthalmol. 2005; 53: 201-3. 9. venkatesh r, das m, prashanth s, et al. manual small incision cataract surgery in eyes with white cataracts. indian j ophthalmol. 2005; 53: 173-6. 10. vazquez la, panesso jl. surgically induced astigmatism. a comparison of different cataract incisions and closures. p r health sci j. 1993; 12: 99-103. 11. gimbel hv, sun r, debroff bm. effects of wound architecture and suture technique on postoperative astigmatism. ophthalmic surg lasers. 1995; 26: 524-8. 12. ruit s, paudyal g, gurung r, et al. an innovation in developing world cataract surgery: sutureless extracapsular cataract extraction with intra-ocular lens implantation. clin experiment ophthalmol. 2000; 28: 274-9. 13. guzek jp, ching a. small-incision manual extra-capsular cataract surgery in ghana, west africa. j cataract refract surg. 2003; 29: 57-64. 14. gogate pm, deshpande m, wormald rp, et al. extra-capsular cataract surgery compared with manual small incision cataract surgery in community eye care setting in western india: a randomized controlled trial. br j ophthalmol. 2003; 87: 667-72. 15. hennig a, kumar j, yorston d, et al. sutureless cataract surgery with nucleus extraction: outcome of a prospective study in nepal. br j ophthalmol. 2003; 87: 266-70. 16. venkatesh r, das m, parashanth s, et al. manual small incision cataract surgery in eyes with white cataracts. ind j ophthalmol. 2005; 53: 173-6. 17. ruit s, tabin g, chang d, et al. a prospective randomized clinical trial of phacoemulsification vs. manual sutureless small incision extracapsular cataract surgery in nepal. am j ophthalmol. 2007; 143: 32-8. 18. huang fc, tseng sh. comparison of surgically induced astigmatism after sutureless temporal clear corneal and scleral frown incisions. j cataract refract surg. 1998; 24: 477-81. 19. shaumberg da, dana mr, christen wg, et al. a systemic overview of the incidence of posterior capsular opacification. ophthalmology. 1998; 105: 1213-21. 20. bartov e, isakov i, rock t. nucleus fragmentation in a scleral pocket for small incision extracapsular cataract extraction. j cataract refract surg. 1998; 24: 160-5. 21. lagreze wd, bomer tg, funk j. effect of surgical technique on the increase in intraocular pressure after cataract extraction. ophthalmic surg lasers. 1996; 27: 169-73. microsoft word zeeshan akmil 10   221 original article comparison of conjunctival autograft and intra-operative application of mitomycin-c in treatment of primary pterygium zeeshan kamil, syeda aisha bokhari, fawad rizvi pak j ophthalmol 2011, vol. 27 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zeeshan kamil flat # 1, first floor b-300 block 6 k.a.e.ch.s, karachi submission of paper september’ 2011 acceptance for publication december’ 2011 …..……………………….. purpose: the purpose of this study was to evaluate and compare recurrence rate in treating primary pterygium by two different techniques: pterygium excision with intra-operative application of mitomycin c versus pterygium excision and conjunctival autograft. material and methods: the patients were selected from the out-patient department of l.r.b.t free base eye hospital, karachi from 1st december 2009 to 30th november 2010. eighty patients with primary pterygium were included in this study with age ranging between 20-50 years. patients were randomly allocated into two groups: group a consisted of 40 patients who were operated on for pterygium excision and conjunctival autograft. group b consisted of 40 patients who were operated for pterygium excision and intra-operative application of mitomycin c (0.02%). complications and recurrences were assessed and compared. results: in group a, there were 2 (5%) recurrences noted with minor complications in 6 (15%) of the cases. in group b, there were 9 (22.5%) recurrences noted along with minor complications in 10 (25%) of the cases. conclusion: pterygium excision with conjunctival autograft is a superior technique in terms of lower rates of recurrences and complications as compared to pterygium excision with intra-operative use of mitomycin c. terygium is a common disorder in many parts of the world, with reported prevalence rate ranging from 0.3 to 29%. epidemiological studies suggest an association with chronic exposure to sunlight; with an increased geographical prevalence within a peri-equatorial ‘pterygium belt’ of latitudes of 37 degrees north and south of the equator1. clinically pterygium is a fibrovascular wing-shaped encroachment of conjunctiva onto the cornea2. ptregium is thought to result primarily from ultraviolet light induced damage to connective tissue underlying the conjunctiva. the pathological changes consist of elastoid degeneration of the collagen and appearance of sub-epithelial fibrovascular tissue. the cornea shows destruction of the bowman’s layer by fibrovascular in-growth frequently with mild inflammatory changes. the overlying epithelium maybe normal, thick or thin and may show dysplasia. ultraviolet b light in solar radiation has been found to be the most significant environmental factor in pterygium pathogenesis1. a recent study has suggested that p-53 and human papilloma virus may also be implicated in pterygium pathogenesis. ultraviolet radiation can cause mutation in genes such as the p-53 tumor suppressor gene, resulting in its abnormal expression in pterygial epithelium. these findings suggest that pterygium is not just a degenerative lesion, but could be a result of uncontrolled cell proliferation3. tseng et al have also speculated that pterygium may represent an area of localized limbal stem cell deficiency4. p   222 indications for surgery include visual impairment, cosmetic disfigurement, motility restriction, recurrent inflammation and interference with contact lens wear5. pterygium is graded on the extent of corneal involvement. type 1 extends less than 2mm on to the cornea, type 2 involves up to 4 mm of the cornea and type 3 invades more than 4 mm of the cornea and involves the visual axis6. surgical management includes simple excision with bare sclera technique, excision with adjunctive measures like intra-operative and post-operative beta radiation, thiotepa drops, intra-operative mitomycin c and various techniques of conjunctival autografting7. the reported recurrence rates of these techniques vary widely, from 5% for pterygium excision with conjunctival autografting, to 89% for simple excision1,5. ablation with erbium or yag laser,8 and smoothening the corneal surface with excimer9. laser has been tried but the results are not encouraging. mitomycin c is an antineoplastic-antibiotic alkylating agent isolated from fermentation filtrate of streptomyces caespitosus. it selectively inhibits dna replication by forming covalent linkages with guanosine residues in dna, inhibits cellular rna and protein synthesis. therefore, it prevents mitosis leading to cell death and interferes with collagen synthesis, thus preventing recurrence after pterygium surgery10,11. since its first use in pterygium treatment by kunitomo and mori in 1963,12 different concentrations, administration modes and dosing schedules of mitomycin c have been used in different studies. although generally proven simple and effective, toxicity remains a concern. complications reported with intra-operative or post-operative use of mitomycin c are pain, iritis, secondary glaucoma, cataract, punctuate keratitis, chemosis, delayed conjunctival healing, conjunctival granuloma and scleral and corneal melting11,13. many of these reported serious complications involved use of high concentrations (0.04 – 0.1%), prolonged post-operative topical use and/or larger cumulative dosages resulting from poor drug compliance11,13,14. young al et al have recommended intraoperative use15. the concentrations of intra-operative mitomycin c application used in most of the studies range from 0.01% to 0.04% with 0.02% applied for three months being the commonest dosage used16. applying mitomycin c at the time of surgery provides clear advantage, such that the surgeon has control over the medication delivery and, moreover, single, direct scleral bed application does not expose the entire ocular, nasal, nasolacrimal or oropharyngeal surfaces to the drug17. conjunctival autograft placed at the limbus acts as a barrier to re-growth of the pterygium. the graft taken from the supero-temporal bulbar conjunctiva contains limbal stem cells which result in rapid healing, smooth and lustrous surface without corneal neovascularizatoin and restoration of ocular integrity in a short term. the aim of study was to find a treatment option for primary pterygium which would result in lower recurrence rate. materials and method this experimental clinical study was conducted at lrbt free base eye hospital, karachi from 1st december 2009 to 30th november 2010. eighty patients were included in this study with age ranging between 20 and 50 years. inclusion and exclusion criteria are shown in table 1. informed consent was taken from the patients. a performa was used to record information. the patients included in this study had pterygium of primary nature. the diagnosis of primary pterygium was made on the basis of clinical examination and history of any surgical treatment. patients were inquired specially about their occupation, duration of exposure, onset of pterygium, ocular symptoms and history of glaucoma, diabetes and hypertension. best corrected visual acuity was recorded after refraction, and retinoscopy was performed to assess preoperative astigmatism. the local examination on slit lamp included examination of the area around the orbit, eyelids (for infection, deformities, entropion and trichiasis), examination of conjunctiva for presence of symblephron, active inflammation, nature of pterygium, extent of pterygium, degree of vascularization observed as well as tear film abnormality, fluorescein staining of cornea and corneal scarring. intraocular pressure was checked by applanation tonometer. fundus examination was carried out to see the macula and optic disc. after examination patients were randomly divided into two groups i.e. group a (40 cases) to undergo surgical excision followed by conjunctival autograft transplantation and group b (40 cases) to undergo simple surgical excision using bare sclera technique with intra-operative application of mitomycin c 0.02% for three minutes. all the surgeries were performed under the microscope using topical and local sub-conjunctival   223 anaesthesia. in group a patients, the pterygium head was detached from the cornea, and the pathological conjunctiva with the underlying tenon’s tissue was excised with scissors. no extended excision of the tenon’s tissue under the remaining conjunctiva was performed. the cornea was scraped clear, the sclera cleared from the connective tissue and any bleeding vessels were cauterized. the autologous conjunctival graft was harvested at the supero-temporal bulbar conjunctiva and shifted to the recipient site with all precautions. the graft was secured in position with 10/0 nylon interrupted sutures. the donor area was simply left to regenerate. in group b patients, pterygium excision was done with bare sclera technique in the same manner as in group a patients. haemostasis was achieved by minimal cautery. standardized piece of round filter paper of 4 mm diameter was soaked with freshly prepared mitomycin c 0.02% and applied on the bare sclera for 3 minutes. the area was then gently rinsed with balanced salt solution. in both the groups’ post-operative treatment was started on the first post-operative day with steroid-antibiotic combination eye drops, four times daily and ointment at night. all the patients were examined on follow-ups on the first post-operative day, 4th day and then at weekly intervals for up to 1 month and thereafter every month for up to 3 months. total duration of follow up in this study was three months. results eighty patients with age ranging between 20-50 years were included in this study. most of the patients in this study were between 20-35 years (67.5%). mean age was 32.57 years. men were more common in this study over the women by 65%. outdoor workers were seen to be greatly affected by the pterygium (75.5%). pterygium, 3 mm or more in size, encroaching the cornea were included in this study. greater number of patients 65 (81.2%) had pterygium of 3-5 mm in size. refraction and retinoscopy were done for all the patients. all the patients had with-the-rule astigmatism. in group a recurrence was observed in 2 (5%) cases between 4th and 8th week after surgery. no per-operative complications were seen. there were no untoward effect was observed at the supero-temporal limbal region (graft dissected area), which was subsequently replaced by growth of adjacent tissue during the follow up period. following complications were observed and subsequently managed: graft edema 4 (10%) cases and conjunctival cyst 2 (5%) cases. on the other hand, in group b, pterygium recurred in 9 (22.5%) cases within 8 weeks of surgery. post-operative complications were ocular irritability in 5 (12.5%) cases, which settled with instillation of topical steroids within 4 days. mild scleral thinning was observed in 2 (5%) cases, conjunctival granuloma in 3 (7.5%) cases which was excised after 2 months. table 1: inclusion criteria • age between 20 to 50 years • pterygium size 3 mm or more • pterygium interfering with vision either by occluding visual axis or inducing astigmatism • cosmetic disfigurement inclusion criteria • one eyed patients • glaucoma • ocular surface abnormalities • chronic ocular infection and chronic dacryocystitis • recurrent pterygium table 2: comparing recurrence rates in group a and group b group a n = 40 group b n = 40 2 (5%) 9 (22.5%) table 3: post-operative complications in group a and group b group a n = 40 group b n = 40 graft edema 4 (10%) ocular irritability 5 (12.5%) conjunctival cyst 2 (5%) mild sclera thinning 2 (5%) — conjunctival granuloma 3 (7%) total: 6 (15%) total: 10 (25%) higher recurrence rate was seen in patients undergoing pterygium excision with intra operative   224 mitomycin c as compared to pterygium excision with conjunctival autograft (p=0.048). recurrence rates and post-operative complications in the two groups are summarized in table 2 and table 3 respectively. discussion pterygium is an excessive proliferation of fibrovascular tissue over the exposed ocular surface and frequently leads to almost irreversible visual loss. it is a worldwide disease which is particularly common in tropical and sub-tropical regions such as pakistan. exposure of ultraviolet light is the most important risk factor in its development. 18 the definitive management of pterygium is surgical but bare sclera technique carries a recurrence rate, which varies from 55.9% to 89%13. thus, the ideal adjunctive procedure is still to be determined. the purpose of this study is, therefore, to find the most ideal procedure in terms of minimal recurrence rates. in the current study the recurrence rate in group a (patients who underwent pterygium excision followed by conjunctival autograft) was 5%. baig et al showed a similar result recurrence rate of 9.09% in their study19. narsani et al showed that there was 7.69% recurrence with conjunctival autograft technique20. quraishy mm documented 6.6% recurrence for primary pterygium21. khan et al showed 8.8% recurrence rate in their study22. massaoutis in his study documented 5.25% recurrence rate in conjunctival autografting for primary pterygium23. post-operative complications in this group were mild which were well managed. in group b (patients who underwent simple surgical excision using bare sclera technique with intraoperative mitomycin c 0.02%), recurrence rate was 22.5% with post-operative complications in 25% of the cases. koranyi g et al showed 38% recurrence rate with intra-operative mitomycin c application in their study in 201023. ma et al used post-operative mitomycin c and sharma et al compared mitomycin c with conjunctival autograft, but neither showed any statistical difference in the recurrence rates,25,26 whereas young et al also compared intra-operative mitomycin c with conjunctival autograft but they found a statistically significant difference in recurrence rates between the two groups15. narsani also compared conjunctival autograft with intra-operative mitomycin c and he also found statistically significant difference in the recurrence rates between the two groups. in this study, we compared pterygium excision and conjunctival autograft, and pterygium excision with intra-operative mitomycin c (0.02%) and found significant higher in recurrence rate in group b as compared to group a (p=0.048). conclusion this study was carried out to find a treatment option for primary pterygium which would result in lower recurrence rate. group a, which consisted of patients undergoing pterygium excision with conjunctival autograft, showed a lower recurrence rate of 5% as compared to group b which consisted of patients undergoing pterygium excision with intra-operative 0.02% mitomycin c (22.5%). based on the above findings we conclude that pterygium excision with conjuctival autograft is a superior technique for the treatment of primary pterygium, in terms of lower recurrence rate and minor post-operative complications. larger controlled studies are required. author’s affiliation dr. zeeshan kamil associate ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi. dr. syeda aisha bokhari associate ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi. dr. fawad rizvi chief consultant ophthalmologist l.r.b.t free base eye hospital, karachi korangi 21/2, karachi. reference 1. taylor hr, west s, munoz b et al. the long-term effects of visible light on the eye. arch ophthalmol. 1992; 110: 99-104. 2. wong ak, rao sk, leug at et al. inferior limbal conjunctival auto-graft transplantation for recurrent pterygium. indian j ophthalmol. 2000; 48: 21-4. 3. reisman d, mc fadden jw, lu g. loss of heterozygosity and p53 expression in pterygium. cancer lett. 2004; 206: 77-83. 4. tseng scg, chen jjy, huang ajw et al. classificatoin of conjunctival surgeries for corneal diseases based on stem cell concept. ophthalmol clin north am. 1990; 3: 595-610. 5. sebban a, hirst lw, kyanston b, et al. pterygium recurrence rate at the princess alexandra hospital, aust nz j ophthalmol. 1991: 19: 203-6. 6. conjunctiva in: kanski jj. clinical ophthalmology a systemic approach london: butterworth heineman. 2003; 242-4.   225 7. frucht-perry j, iiser m, hewmo i. single dose of mitomycin c for prevention of recurrent pterygium: preliminery report. cornea. 1994; 13: 411-3. 8. koryani g, seregard s, kopp ed. cut and paste: a no suture, small incision approach to pterygium surgery. br j ophthalmol. 2004; 88: 911-4. 9. seiler t, schnella b, wollensak j. pterygium excision using 193-nm excimer laser smoothing and topical mitomycin c. ger j ophthalmol. 1992; 1: 429-31. 10. nabawi ks, ghonim ma, ali mh. evaluation of limbal conjunctival auto-graft and low – dose mitomycin c in the treatment of recurrent pterygium. ophthalmic surg lasers imaging. 2003; 34: 193-6. 11. sanchez-torin jc, rocha g, yelin jb. meta-analysis on the recurrent rates after bare sclera resection with and without mitomycin c use and conjunctival autograft placement in surgery for primary pterygium. br j ophthalmol. 1998; 82: 6615. 12. kunitomo n, mori s. studies on the pterygium. part iv. a treatment of the pterygium by mitomycin c instillation. nippon ganka gakkai zassbi. 1963; 67: 601-7. 13. raiskup f, solomon a, landau d, et al. mitomycin c for pterygium: long-term evaluation. br j ophthalmol. 2004; 88: 1425-8. 14. wong va, law fch. use of mitomycin c with conjunctival autograft in pterygium surgery in asian-canadians. ophthalmology. 1999; 106: 1512-5. 15. young al, leung gy, wong ak, et al. a randomized trial comparing 0.02% mitomycin c and limbal conjunctival autograft after excision of primary pterygium. br j ophthalmol. 2004; 88: 996-7. 16. oguz h, baser e, gurler b. intraoperative application versus postoperative mitomycin c eye drops in pterygium surgery. acta ophthalmol scand. 1999; 77: 147-50. 17. manning ca, kloess pm, diaz md, et al. intraoperative mitomycin c in primary pterygium excision. a prospective randomized trial. ophthalmology. 1997; 104: 844-8. 18. mackenzie fd, hirst lw, battistutta d, et al. risk analysis in the development of pterygium. ophthalmology. 1992; 19: 105661. 19. baig msa, khokhar ar, ali ma et al. conjunctival autograft for primary and recurrent pterygium. pak j surgery. 2008; 24: 173-6. 20. narsani ak, jatoi sm, gul s et al. treatment of primary pterygium with conjunctival autograft and mitomycin c. a comparative study. j liaquat uni med health sci. 2008; 184-7. 21. quraishy mm, talpur k. conjunctival autografting for pterygium. med spectrum. 2000; 21: 9-10. 22. khan n, ahmed m, baser a, et al. to compare the recurrence rate of pterygium excision with bare sclera, free conjunctival autograft and amniotic membrane graft. pak j ophthalmol. 2010; 26: 138-42. 23. koranyi g, artesan d, seregard s et al. intraoperative mitomycin c versus autologous conjunctival autograft in surgery of primary pterygium with four year follow up. acta ophthalmol. 2010; 1-5. 24. chen pp, ariyasu rg, kaza v et al. a randomized trial comparing mitomycin c and conjunctival autograft after excision of primary pterygium. am j ophthalmol. 1995; 120: 151-60. 25. ma dh, see lc, liau sb, tsai rj. amniotic membrane graft for primary pterygium: comparison with conjunctival autograft and topical mitomycin c treatment. br j ophthalmol. 2000; 84: 973-8. 26. sharma a, gupta a, ram j et al. low-dose intraoperative mitomycin c versus conjunctival autograft in primary pterygium surgery: long-term follow up. ophthalmic surg lasers 2000; 31: 301-7. microsoft word haroon rashid.doc 122 original article two years review of intraocular lens power calculation in ophthalmology department of saidu teaching hospital, swat haroon rashid, abid naseem, faiz ur rahman pak j ophthalmol 2007, vol. 23 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: haroon rashid department of ophthalmology saidu medical college saidu sharif, swat. received for publication august’ 2006 …..……………………….. purpose: to determine the mean power of intraocular lens (iol), keratometeric readings and axial length of the eyeball in patients admitted for cataract surgery with iol implantation. materials and methods: a retrospective review of the intraocular lens power calculation record of patients admitted for cataract surgery with iol implantation in ophthalmology department of saidu teaching hospital, saidu sharif, swat over a period of two years from 1st january 2004 to 31st december 2005 was undertaken. results: out of 1359 cases of cataract surgery with iol implantation admitted during the study period, 649 (47.75%) were male whereas 710 (52.25%) were female. the mean age was 58.71 years. right eye was operated in 697 (51.3%) cases, while 662 (48.7%) cases were operated on left eye. mean keratometeric (k1 and k2) readings were 42.65 d and 42.48 d respectively and ranged from 36 d to 52 d in each. mean axial length of eyeball was 22.52 mm with range from 18 mm to 29.31 mm. mean power of iol with 118.0 a constant was 23.17 d with range from 6.50 d to 36.00d. conclusions: majority (62.2%) of patients reported in 6th–7th decade of life (51–70 years of age) and they avoid surgery in extreme summer, winter and ramadan. mean k1 & k2 readings were 42.65 d & 42.48 d respectively. mode (most common) k1 & k2 readings were 43 d & 42 d respectively. mean & mode axial lengths of eyeball were 22.52 mm & 22 mm respectively. mean & mode powers of iol with 118.0 a constant were 23.17 d & 23.50 d respectively. ataract is the most common treatable blindness in the world. pakistan faces the same situation with cataract being the leading cause of blindness, contributing to 66.7% of total 1.78% blindness1. while according to recent national survey of blindness and low vision, cataract contributes 53% of total 1.05% blindness (unpublished). intraocular lens (iol) implant in cataract surgery is a revolutionary break-through in ophthalmology. awareness regarding iol implant is very high and almost every patient demands for it during his/her cataract operation. the power of the iol to be implanted during cataract surgery to achieve a desired amount of postoperative refraction is routinely calculated preoperatively. calculation of iol power has been simplified by srk i, srk ii, srk/t and holladay formulae available in a variety of biometers. the srk c 123 ii formula has been widely used for iol power calculation. corneal curvature (k-readings), axial length of eyeball and a-constant are the only measurement required in srk ii formula. iol manufacturer provides a-constant. the two ocular parameters that need to be measured are axial length and k-readings; k-readings are obtained on either digital or manually operated keratometer. in children and in supine position hand held keratometer is used2. axial length in mm is obtained on a-scan of ultrasonography, which is available in all currently marketed biometers. accurate measurement of ocular axial length is extremely important for accurate iol power calculation since axial length measurement is the major identifiable source of error in iol power calculation. it is commonly recommended that multiple a-scan readings be averaged to obtain an accurate estimate of ocular axial length; however a high quality single axial length taken on biometer is also acceptable3. axial length of eyeballs filled with silicon oil is over estimated by ultrasonic a-scan as compared to eyes with normal vitreous. a conversion factor of 0.71 when used in exiting biometry formula (srk/t) allows calculation of exact iol power in silicon oil-filled eyes4. the objectives of the study were to determine the mean power of intraocular lens, keratometeric readings and axial length of the eyeball in patients admitted for cataract surgery with iol implantation. materials and methods a retrospective review of the iol power calculation record of the patients admitted for cataract surgery with iol implantation in our department over a period of two years was undertaken. all patients admitted for cataract surgery with iol implantation in our department are registered and their iol power calculation record is maintained in a register. keratometry; especially diopteric power of vertical and horizontal corneal meridian (k1 & k2) respectively of every case was measured with keratometer and recorded. axial length of eyeball in mm was taken with the help of a-scan and power of iol was calculated by using srk-ii formula and a constant of 118.0 was used in calculations. age, sex, laterality and date of iol power calculation were also recorded in the register. data of the patients was stored in spss (statistical package for social sciences) 8.0 for windows statistical package. statistical analyses of continuous data were made. frequency of patients admitted for cataract surgery with iol implantation in different months was made. mean, standard deviation, median, mode and range of age, keratometeric readings, axial length and power of iol were determined. laterality and sex distribution of patients were also determined. results total 1359 cases of cataract surgery with iol implantation admitted during the study period were analyzed; 649 (47.75%) were male whereas 710 (52.25%) were female. the mean age was 58.71 years with standard deviation (sd) of 18.23 years. median and mode age was 60 years and range was 97 years (3 years to 100 years). majority (62.2%) of patients reported at the age between 51 – 70 years. age distribution is given in figure 1. right eye was operated in 697 (51.3%) cases, while 662 (48.7%) cases were operated on left eye. in year 2004, 726 (53.42%) cases and in year 2005, 633 (46.58%) cases were operated. monthly distribution of these cases is given in figure 2. 65 46 25 31 135 429 416 183 29 0 50 100 150 200 250 300 350 400 450 500 10 & b elo w 11 . 20 21 30 31 40 41 50 51 60 61 70 71 80 81 & a bo ve age in years n o. o f c as es fig. 1: age distribution mean power (in diopter) of vertical corneal meridian (k1) was 42.65 d with sd of 2.1 d. median k1 reading was 42.6 d and mode was 43 d with range of 16 d (36 d to 52 d). similarly mean power (in diopter) of horizontal corneal meridian (k2) was 42.48 d with sd of 2.17 d. median k2 reading was 42.5 d and mode was 42 d with range of 16 d (36 d to 52 d). keratometeric reading distribution is given in (table i). mean axial length of the eyeball was 22.52 mm with sd of 1.13 mm. median axial length reading was 22.51 mm and mode was 22 mm with range from 18 mm to 124 29.31 mm. axial length of eyeball distribution is given in (table 2). mean power of iol with 118.0 a constant was 23.17 d with sd of 2.47 d. median power of iol was 23.00 d and mode was 23.50 d with range of 29.50 d (6.50 d to 36.00 d). iol power distribution is given in (table 3). 23 47 156 117 76 75 25 39 58 26 31 53 13 20 45 82 94 73 39 47 77 22 64 57 0 50 100 150 200 ja n fe b ma r ap r ma y ju n ju l au g se p oc t no v de c months n o. o f c as es 2004 2005 fig. 2: monthly distribution. discussion though cataract is a senile change in crystalline lens but can occur in early age group due to variety of reasons. majority (62.2%) of our patients reported in 6th – 7th decade of life (51 – 70 years of age). our study revealed that seasonal influence is still in the minds of cataract patients. majority of them report for surgery during march, april, may (just after winter or before summer) and in the month of september just after summer or before ramadan and winter season. they avoid surgery in extreme weather and prefer moderate season. naz5 also reported this in his study. large numbers of cases usually reported in month of march (156 in year 2004), but only 45 cases of cataract surgery reported in march 2005 due to rains and flood in malakand division. we found in our study that mean diopteric power of vertical meridian (k1) and horizontal meridian (k2) of cornea was 42.65 (sd 2.1) d and 42.48 (sd 2.17) d respectively. hoffer6 published a series of 450 cases in which mean keratometry reading was 43.83 (sd 1.56) d, while in an other study done by elder7 mean keratometry reading was 43.29 (sd 1.57) d. the range of keratometry readings was 16 d (36 d – 52 d) in our study. this was comparable to the previous studies done by naz5 in which the keratometry readings ranged from 39.50 d – 50 d; and by elder7 in which the range was 40.25 d – 47.87 d. in our study mean axial length of eyeball was 22.52 (sd 1.13) mm. while in different studies the mean axial length ranged from 22.76 – 23.56 mm4,6-8. table i: keratometeric readings distribution. reading in diopters k1 k2 no. of cases n (%) no. of cases n (% 37.99 & below 20 (1.47) 42 (3.09) 38 39.99 92 (6.77) 102 (7.50) 40 41.99 299 (22.00) 296 (21.78) 42 43.99 555 (40.84) 560 (41.20) 44 45.99 322 (23.69) 292 (21.48) 46 47.99 56 (4.12) 58 (4.26) 48 & above 15 (1.10) 9 (0.66) k1 = power of vertical corneal meridian in diopters. k2 = power of horizontal corneal meridian in diopters. table 2: axial length distribution. axial length in mm no. of cases n (%) axial length in mm no. of cases n (%) 18 – 19.99 14 (1.03) 23 – 23.99 330 (24.28) 20 – 20.99 56 (4.12)% 24 – 24.99 61 (4.49) 21 – 21.99 331 (24.35) 25 – 26.99 26 (1.91) 22 – 22.99 537 (39.51) 27 & above 4 (0.294) table 3: power of iol distribution. power of iol in diopters no. of cases n (%) power of iol in diopters no. of cases n (%) 14.50 & below 11 (0.81) 22.00 – 22.50 242 (17.80) 15.00 – 17.50 17 (1.25) 23.00 – 23.50 346 (25.46) 18.00 – 18.50 18 (1.34) 24.00 – 24.50 254 (18.70) 19.00 – 19.50 19 (1.40) 25.00 – 25.50 88 (6.475) 20.00 – 20.50 65 (4.78) 26.00 – 29.50 131 (9.64) 21.00 – 21.50 144 (10.6) 30.00 & above 24 (1.76) iol = intraocular lens 125 this finding was also comparable to the studies done by naz5 in which the axial lengths of eyeballs measured with a-scan ultrasound varied from 21 to 28 mm; while in another study done by roters8 the range of axial length was 18.67 – 34.05 mm. a study conducted in china showed range of axial length from 19.53 – 33.74 mm9. in our study mean iol power with 118.0 a constant was 23.17 d. the range of iol power was 6.50 d to 36.00 d. this corresponds to the studies of naz5 in which iol power ranged from 4.00 d to 35.00 d; while in elder7 study iol power ranged from 12.00 d to 27.00 d. conclusions • majority (62.2%) of patients reported in 6th – 7th decade of life (51 – 70 years of age). • patients avoid surgery in extreme winter (jan feb), summer (july – aug) and ramadan. • mean k1 was 42.65 d with sd of 2.1 d. • mode k1 reading was 43 d. • similarly mean k2 was 42.48 d with sd of 2.17 d. • mode k2 reading was 42 d. • both k1 and k2 readings ranged of 16 d (36 d to 52 d). • mean axial length of eyeball was 22.52 mm with sd of 1.13 mm. • mode axial length reading was 22 mm with range from 18 mm to 29.31 mm. • mean power of iol with 118.0 a constant was 23.17 d with sd of 2.47 d. • mode power of iol was 23.50 d with range from 6.50 d to 36.00 d. acknowledgement we are thankful to prof. shad mohammad for his generous time, help and guidance in the completion of this study and for his critical review of the manuscript. author’s affiliation dr. haroon rashid associate professor department of ophthalmology saidu teaching hospital, saidu medical college saidu sharif, swat dr. abid naseem senior registrar department of ophthalmology saidu teaching hospital, saidu medical college saidu sharif, swat dr. faiz ur rahman assistant professor department of ophthalmology saidu teaching hospital, saidu medical college saidu sharif, swat reference 1. second five year national plan for the prevention of blindness, pakistan, 1999 – 2003. ministry of health. 2. tromans c, haigh pm, biswas, lloyed ic. accuracy of intraocular power calculation in paediatric cataract surgery. br j ophthalmol 2001; 85: 939-41. 3. raj ps, ilango b, watson a. measurement of axial length in calculation of intraocular lens power. eye 1998; 12: 227-9. 4. murray dc, potamitis t, good p, etc. biometry of the silicone oil-filled eye. eye 1999; 13: 319-24. 5. naz ma. review of 1100 cataract cases reported at ophthalmic clinics in military hospital (mh) rawalpindi and combined military hospital (cmh) lahore. pak j ophthalmol 2004; 20: 143-7. 6. hoffer kj. the hoffer q formula: a comparison of theoretical and regression formulas. j cataract refract surg 1993; 19: 700-12. 7. elder mj. predicting the refractive outcome after cataract surgery: the comparison of different iols and srk-ii v srk-t. br j ophthalmol. 2002; 86: 620-2. 8. roters s, hellmich m, szurman p. prediction of axial length on the basis of vitreous body length and lens thickness. retrospective echobiometric study. j cataract refract surg 2002; 28: 853-9. 9. gao y, liu xl. application of srk ii formula and measurement of a constant of km intraocular lens. chung hua yen ko tsa chih 1994; 30: 331-4. 74 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology original article frequency of complications of silicone oil in the surgical treatment of rhegmatogenous retinal detachment mir ali shah, bilal khan, faisal nawaz, mubashir rahman pak j ophthalmol 2017, vol. 33, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mir ali shah lady reading hospital, peshawar. email: drmashahpsh@gmail.com purpose: to determine the frequency of complications of silicone oil used for internal tamponade in the treatment of rhegmatogenous retinal detachment (rrd). study design: prospective case series. place and duration of study: department of ophthalmology lady reading hospital peshawar from january 2013 to may 2014. material and methods: all those patients who were admitted with rrd with proliferative vitreoretinopathy (pvr) grade c due to myopia, pseudophakia and trauma in which silicone oil 1000 centistoke was used for internal tamponade were included in the study. patients with fresh rd, age less than 16 years and more than 70 years and repeat surgery were excluded from the study. after taking approval from ethical research committee, data collection process was started and documentation was done according to the designed proforma including age, gender, etiology and complications. data was analyzed by spss version 16 and represented in the form of charts and graphs. results: 300 eyes of 300 patients were included in this study in which 190 (63.33%) were males and 110 (36.67 %) were females having age range from 16 to 70 years and mean age was 40 ±5 sd. the most common cause of retinal detachment was trauma having 170 (56.66%) while the least common was aphakia having 40 (13.33%) cases. the most frequent complication was cataract formation noted in all phakic patients followed by increased intra ocular pressure frequency of complications of silicone oil in the surgical treatment of rhegmatogenous retinal pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 75 …..……………………….. present in 210 (70%) cases. prolapse of uveal tissue through pars plana sclerotomy site was seen in 1 (0.33%) patient. conclusion: silicone oil used for internal tamponade leads to cataract formation in almost all cases followed by secondary glaucoma. key words: silicone oil. retinal detachment. trauma. cataract. intraocular pressure. etinal detachment is a condition in which the sensory retina is separated from the retinal pigment epithelium (rpe).1 there are mainly three types of retinal detachments in which the most common is rhegmatogenous retinal detachment. out of all these three, rhegmatogenous retinal detachment2 is the most common and the common risk factors for rhegmatogenous retinal detachment are axial myopia, aphakia/pseudophakia, nd yag laser capsulotomy, lattice degeneration of retina and trauma.3 typically these patients present with symptoms such as flashes of light, floaters, peripheral visual field loss, and blurred vision.4 the main principle of retinal detachment is to close all retinal breaks and approximate sensory retina with rpe. it is treated surgically by two approaches, the external or standard approach which is done by scleral buckling by using solid silicone material or sponges and is indicated for uncomplicated retinal detachment.5 the second approach is called internal approach by doing vitrectomy and using silicone oil or long-acting gases. it is indicated for complicated cases such as those with pvr grade c, giant retinal tears, coloboma of choroid, and penetrating ocular trauma.6,7 silicone oil injection mainly serves two functions. the first is the displacement of the retina toward the eye wall by its surface tension effect and volume displacement, and the second is to a lesser degree the tamponade of the superior retina by its buoyancy force.8 it is transparent, lighter than water (specific gravity of 0.97) and has a refractive index of 1.404. the silicone oil has a surface tension with water of 40 mn/m, which is less than that of a gas bubble.9 although silicone oil has many advantages but it is not free of complications like cataracts, band keratopathy, recurrent inferior retinal detachment, pupillary block glaucoma, closure of the inferior iridectomy, fibrous epiretinal and sub retinal proliferations, pain, subconjunctival migration of oil, increased intraocular pressure(40.57%) and changes in refractive status of the eye.9,10 rationale of the current study is to know about the frequency of complications which occur due to silicone oil in internal approach for retinal detachment in this area. this study is important for creating local statistics of the complications due to silicone oil. furthermore it will open a gateway for future researchers on this topic and help in the patient’s best evidence based care. material and methods this prospective study was conducted in the department of ophthalmology lady reading hospital peshawar from jan 2013 to may 2014 with total duration of 17 months. after taking approval from ethical research committee data collection process was started in all those patients who were admitted in the mentioned duration with retinal detachment due to myopia, pseudophakia and trauma for whom silicone oil was used for internal approach and documentation was done according to the preformed proforma including age, gender, etiology and complications while excluding the patients younger than 16 years, greater than 70 years and fresh cases of retinal detachment. data was analyzed by spss version 16 software and represented in the form of charts and graphs. all the patients underwent thorough history, detailed clinical evaluation like visual acuity, pupillary reflex for presence or absence of relative afferent papillary defect (rapd), measurement of intra ocular pressure(iop) and fundus examination to locate the breaks and viability of the retina. b scan ultrasound was performed when there was poor fundus view. before surgical intervention patients underwent preoperative blood tests including random blood glucose r mir ali shah, et al 76 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology level, viral serology (hbsag and anti-hcv ab). an informed consent was taken from each patient explaining the prognosis and inclusion in the study. all the patients were followed for 6 months post operatively for complications of silicone oil by repeated follow ups at regular intervals and by measuring iop, visual acuity and fundoscopy at each visit. approval was taken from the hospital ethical committee, “postgraduate medical institute, institutional research and ethics board”. frequency of complications due to silicone oil used for internal tamponade in the treatment of retinal detachment was noted. results a total of 300 eyes of 300 patients were included in this study. males were 190 (63.33%) while 110 (36.67 %) were females (table 1). the age range was 16-70 years with mean age 40 ± 5 sd. trauma was the leading cause of rrd present in 170 (56.67%) followed by myopia in 90 (30 %) and pseudophakia in 40 (13.33%) (table 2). table 1: gender distribution of patients (n = 300). etiology of retinal detachment no of patients percentage male 190 63.33 female 110 36.67 total 300 100 after 6 months follow-up of using silicone oil for retinal detachment, cataract formation was the most common complication present in all 100% cases, followed by rise in intra ocular pressure in the same eye in 210 (70%). recurrence of retinal detachment was present in 78 (26%), emulsified oil in 10 (3.33%), while band keratopathy, blocked ando’s iridectomy and phthisical eye each in 5 (1.66%). table 2: causes of retinal detachment: (n = 300). etiology of retinal detachment no of patients percentage pseudophakic 40 13.33 % myopia 90 30 % trauma 170 56.66% table 3: complications of silicone oil (n = 300). complication no of patients percentage cataract 300 100 increased iop 210 70 recurrent rd 78 26 oil emulsification 10 3.33 band keratopathy 5 1.66 blocked ando’s iridectomy 5 1.66 phthisical eye 5 1.66 sub conjunctival silicone oil 2 0.66 uveal prolapse 1 0.33 silicone oil under the conjunctiva and prolapse of uveal tissue through pars plana was seen in 2 (0.66%) and 1 (.33%) respectively. (table 3). discussion since the introduction of silicone oil, there have been multiple controversies concerning its safety ideally for intraocular use. for these reasons, removal of silicone oil is ideally advocated as prolonged silicone oil tamponade has been demonstrated to induce multiple anterior segment complications including cataract, glaucoma and keratopathy. 11,12,13,14,15,16 in our study 300 patients were recruited in 17 months with 190 males and 110 females (males; females 1.72: 1). study conducted by khoroshilova-maslova et al also showed more males than females by using silicone oil in retinal detachment which is similar to our results.11 similarly in many other international studies males are more than the females using silicone oil.12,13,14 in our study age range was 16-70 years with mean age 40 ± 5. study conducted by hassan mu et al has showed range as 45-83 years with mean age of 58.33 ± 7.12 sd years.10 frequency of complications of silicone oil in the surgical treatment of rhegmatogenous retinal pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 77 the main reason of difference in younger patients in our study and other studies is that the most common cause of retinal detachment was trauma which is more common in young age. the other etiologies like myopia and other factors can cause rrd late. this is why the majority of patients were of younger age as compared to others. among all 300 cases the most common cause was trauma having 170 (56.66%) followed by myopia with 90 (30%) cases and pseudophakia in 40 (13.33%) cases. haimann and colleagues have documented the most common cause of retinal detachment as myopia having 40-50% followed by aphakia with 30-40% cases and 10-20% was due to the ocular trauma. 17 similarly according to rehman et al in his study conducted on 1159 patients with retinal detachments, the three most common causes were myopia , aphakia/pseudophakia and trauma reported as aphakia/pseudophakia having 795 (68.56%), 136 (11.7%) had myopia of variable degree and 74 (6.4%) had a history of blunt trauma.18 our region has suffered more from terrorism as compared to the other parts of the world therefore most of our patients were brought with blunt trauma to the different body organs including eye with bomb blasts injuries. the other difference of etiologies is that majority of the population in our region have low educational status as compared to punjab and other parts of the country/world due to which peoples suffer more from accidents and social crimes. when we followed our patients for 6 months post operatively for the complications of silicone oil we found that the most common complication was cataract which occurred in all (100%) cases, followed by increase in intra ocular pressure which occurred in 210 (70%) and recurrence of retinal detachment having frequency of 78 (26%) of cases, emulsified oil in anterior chamber in 10 (3.33%), while band keratopathy, blocked ando’s iridectomy and phthisical eye each 5 (1.66%) cases and minimum number of cases had uveal prolapse. abbas et al has showed in their study that the most common complication of silicone oil is cataract formation which was observed in 46 (85.18%) out of 54 patients followed by the raised intra-ocular pressure (iop >25 mm hg) occurred in 28 (40.57%) which is similar to our study.19 hoerauf et al, rizzo et al showed that most common complication was inflammation of the anterior chamber.20,21 while other studies have documented emulsified oil in anterior chamber as the most common complication in the retinal detachment surgery by internal approach but in our study it was 10 (3.33%).22,23 in all these studies the sample size of the patients was less and the period of follow up was less or slightly more than our study. conclusion in our set up retinal detachment mostly occurs due to trauma in young to middle age males. when silicone oil is used for internal tamponade for retinal detachment then it provides good results in terms of reattachment but the visual outcome can be compromised due to multiple factors like cataract formation, increased intraocular pressure, recurrence of retinal detachment and band keratopathy. author’s affiliation dr. mir ali shah associate prof. lady reading hospital, peshawar dr. bilal khan retina fellow lady reading hospital, peshawar dr. faisal nawaz retina fellow lady reading hospital, peshawar dr. mubashir rehman retina fellow lady reading hospital, peshawar role of authors prof. mir ali shah study design, critical analysis mir ali shah, et al 78 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology dr. bilal khan data collection dr. faisal nawaz manuscript writing dr. mubashir rehman manuscript writing references 1. jalali s. retinal detachment. community eye health 2003; 16: 25-6. 2. gabbey ae. retinal detachment. healthline, 2012; 13 (20): 47-9. 3. johnson z, ramsay a, cottrell d, mitchell k, stannard k. triple cycle audit of primary retinal detachment surgery. eye, 2002; 16 (5): 513-8. 4. gariano rf, kim ch. evaluation and management of suspected retinal detachment. am fam physician, 2004 apr 1; 69 (7): 1691-9. 5. no author listed. vitrectomy with silicone oil or perfluoropropane gas in eyes with severe proliferative vitreoretinopathy: results of a randomized clinical trial. silicone study report 2. arch ophthalmol. 1992; 110: 780–92. 6. thompson ja, snead mp, billington bm, barrie t, thompson jr, sparrow jm. national audit of the outcome of primary surgery for rhegmatogenous retinal detachment. ii. clinical outcomes. eye, 2002; 16 (6): 7717. 7. lucke k. silicone oil in surgery of complicated retinal detachment. ophthalmologe. 1993; 90 (3): 215-38. 8. morescalchi f, costagliola c, duse s, gambicorti e, parolini b, arcidiacono b, et al. heavy silicone oil and intraocular inflammation. biomed res int. 2014; 8 (7): 146-62. 9. federman jl, schubert hd. complications associated with the use of silicone oil in 150 eyes after retinavitreous surgery. ophthalmology, 1988; 95 (7): 870-6. 10. hassan mu, kazi a, qidwal u, rehman au, bhatti n. assessment of the complications secondary to silicone oil injection after pars plana vitrectomy in rhegmatogenous retinal detachment in early post operative phase. pak j ophthalmol. 2011; 27 (2): 68-72. 11. khoroshilova-maslova ip, nabieva mk, leparskaia nl. morphogenesis of complications after long-term intraocular silicon oil filling clinical histopathological study. vestn oftalmol. 2012 jul-aug; 128 (4): 57-61. 12. bacin f, kemeny jl, deschamps m, gagyi s. treatment with silicone oil in complicated retinal detachment. anatomo-pathological test of 2 enucleated eyes. j fr ophtalmol. 1996k; 19 (1): 13-8. 13. berker n, batman c, ozdamar y, eranil s, aslan o, zilelioglu o. long-term outcomes of heavy silicone oil tamponade for complicated retinal detachment. eur j ophthalmol. 2007 sep-oct; 17 (5): 797-803. 14. brunner m, lang c, valmaggia c. heavy tamponade in complicated inferior retinal detachment. lin monbl augenheilkd. 2012; 229 (4): 407-10. 15. cibis p, becker b, okun e, et al. the use of liquid silicone in retinal detachment surgery. arch ophthalmol. 1962; 68: 590–9. 16. okun e. intravitreal surgery utilizing liquid silicone: a long term follow-up. transactions of the pacific coast oto-ophthalmological society. 1968; 49: 141-59. 17. haimann mh, burton tc, brown ck. epidemiology of retinal detachment. arch ophthalmol. feb 1982; 100 (2): 289-92. 18. rehman nu. review of 1159 cases of retinal detachment surgery. pak j ophthalmol jul 1998; 14 (3): 108-13. 19. abbas m, qureshi n, ishaq n, choudhary mm. complications associated with the use of 5000 centistoke silicon oil after pak armed forces med j mar 2007; 57 (1): 49-55. 20. hoerauf h, roider j, kobuch k, laqua h. perfluorohexylethan (o62) as ocular endotamponade in complex vitreoretinal surgery. retina, 2005; 25 (4): 479– 88. 21. rizzo s, genovesi-ebert f, belting c, foltran f, gandolfo e, lesnoni g et al. long-term vitreous replacement with perfluorohexyloctane and silicone oil: preliminary reports of a multicentric study. ophthalmologica. 2005; 219 (3): 147–53. 22. gremillion jr cm, peyman ga, liu kr, naguib ks. fluorosilicone oil in the treatment of retinal detachment. br j ophthalmo. 1990; 74 (11): 643–6. 23. sandner d, engelmann k. first experiences with highdensity silicone oil (densiron) as an intraocular tamponade in complex retinal detachment. graefes arch clin exp ophthalmol. 2006; 244 (5): 609–19. microsoft word aimal khan corrected 205 original article ocular complications after intravitreal bevacizumab injection in eyes with choroidal and retinal neovascularization aimal khan, p.s mahar, azfar nafees hanfi, umair qidwai pak j ophthalmol 2010, vol. 26 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: aimal khan isra postgraduate institute of ophthalmology al – ibrahim eye hospital malir, karachi received for publication october’ 2010 …..……………………….. purpose: to assess the ocular complications after intra-vitreal bevacizumab (avastin) injection in eyes with choroidal and retinal neovascularization. materials and method: this study was conducted in isra post-graduate institute of ophthalmology, al-ibrahim eye hospital, karachi. the patients were selected through simple random sampling. this was a quasi experimental study. it was conducted from 21.07.2007 to 20.07.2008. all the 200 patients with neovascularization who fulfilled the inclusion criteria, were selected on outpatient basis and were treated with intravitreal bevacizumab on day care basis. they were re-examined the next day and evaluated for complications. data was collected according to proforma and analysis was done using spss version 17.0. results: study was conducted on 200 patients with choroidal and retinal neovascularization. average age of patients was 53.7 with (±sd =11.7) years (range = 25 – 83 years). the most common indication of intravitreal bevacizumab was diabetic retinopathy found in 110 (55%) patients. complications were seen only in 24 (12%) patients. sub conjunctival hemorrhage was the most common but least serious complication found in 12 (50%) patients, followed by corneal abrasion in 4 (16.7%), while raised iop, vitreous hemorrhage, transient mild uveitis and lens injury was seen in only 2 (1%) patients. conclusion: adverse effects of intravitreal bevacizumab are mostly procedure related but few may be drug related. the procedure is generally safe but there are risks involved. to minimize the risk careful attention to injection technique and appropriate post injection monitoring are essential. the short term results suggest that intravitreal bevacizumab is safe procedure. eovascularization of the choroidal and retinal tissue are the leading cause of blindness in developed countries1. vascular endothelial growth factor has been identified as a major angiogenic stimulus in variety of retinal and choroidal neovascularization2. vascular endothelial growth factor is homodimeric glycoprotein and is a growth factor specific for endothelial cells3. not only it promotes the growth and survival of vascular endothelial cells, but it also causes conformational changes of tight junctions of retinal vascular endothelial cells leading to increased vascular permeability4. advances in our understanding of pathogenesis of choroidal and retinal neovascularization have facilitated the development of drugs specifically directed against vascular endothelial growth factor. bevacizumab (avastin) is a humanized monoclonal antibody to vascular endothelial growth factor approved for the treatment of colorectal cancer. it has n 206 been used systemically and intravitreally for the treatment of retinal and choroidal neovascular diseases since july 2005. however, systemic administration of bevacizumab has a small but significant risk of thromboembolism in patients with cancer5. several studies have not shown any evidence of ocular toxicity after the use of intravitreal bevacizumab at or beyond the therapeutic levels expected with the standard dose of intravitreal bevacizumab used in routine care of patients6. few of the self-reported adverse events from various institutions in an internet-based survey were corneal abrasion, lens injury, endophthalmitis, retinal detachment, inflammation or uveitis, cataract progression, acute vision loss, central retinal artery occlusion, sub retinal hemorrhage, retinal pigment epithelium tears but none of the adverse event rate exceeds 0.12%7. since no work has been carried out before on this issue in our local setup, this study would be important in decision making regarding the safety of intravitreal bevacizumab in choroidal and retinal neovascular disorders. material and method the study was carried out at al-ibrahim eye hospital, malir, karachi from 21.07.2007 to 20.07.2008. two hundred patients with clinical evidence of choroidal and retinal neovascularization were included in the study. it was a quasi experimental study and sampling was done by non-probability purposive sampling technique. patients who with diagnosed choroidal and retinal neovacular, and age 30 years or older were included in the study. patients who had any ocular conditions other than neovascularization in the study eye that can affect the vision and/or safety e.g. glaucoma, corneal dystrophy, uvietis, retinal detachment were excluded from the study. informed and written consent was taken after thorough discussion of possible benefits and complications. baseline assessment included best corrected visual acuity (bcva) using snellen acuity chart, anterior segment examination using a slit lamp; intraocular pressure with goldman applanation tonometer, dilated fundus examination using slit lamp with +90 diopters lens and indirect ophthalmoscope with +20d lens. the aga khan university hospital pharmacy prepared 1.25mg (0.05 ml) injections in an insulin syringe for each patient from commercially available 4 ml vial of bevacizumab (25mg/ml) under aseptic techniques. the eyes to be treated were prepared with 5% povidone-iodine solution. topical anesthesia was administered using proparacaine hydrochloride 1% ophthalmic drops. the site of the injection was measured with the help of a caliper. using a 27 –gauge needle, 0.05ml of bevacizumab was injected intravitreally through the pars plana 3.5 mm from the limbus. after the injection, intraocular pressure was measured along with the slit lamp examination of anterior segment. patients were instructed to use topical ciprofloxacin 0.3% four times a day for one week. patients were followed at 1, 4, 8 and 12 weeks after the first injection. at each visit, bcva was measured along with the slit lamp examination of the anterior segment, intraocular pressure measurement and dilated fundus examination with both slit lamp microscope and indirect ophthalmoscope, with special emphasis on ocular complication. subsequent injections were given at monthly intervals (maximum three injections) depending upon response of choroidal or retinal neovascularization. statistical analysis was carried out with spss version10.0. frequencies and percentages were computed for qualitative variables like gender, complications, diagnosis, visual acuity and age groups. mean and standard deviation was computed for quantitative variables like age, acute vision loss and iop. sign test was used to compare the proportions of pre and post-operative visual acuity. chisquare test was used to compare the proportions of pre and post-operative complication (presence or absence of a complication). paired t-test was used to compare the mean iop pre and post operatively. independent sample t-test was used to compare the mean age between genders. p < 0.05 was considered level of significance. results a total of 200 patients with choroidal and retinal neovascularization disorders were included in this study. mean age of patients was 53.7 (±sd =11.7) years, (range = 25 – 83 years). out of 200 patients, 140 (70%) were males and 60 (30%) were females (m: f = 1: 0.4). the most common indication of intravitreal bevacizumab were diabetic retinopathy found in 110 (55%) patients, followed by exudative armd in 52 207 (26%) patients, brvo in 12 (6%) patients, myopic cnv and crvo found in 8 (4%) patients, eale’s disease in 6 (3%) patients while angoid streak and cnv sec. to cscr was found in only 2 (1%) patient.table-1. of the 200 patients, 88 (44%) patients with right eye affected, 74 (37%) patients with left eye affected, and both eyes involved in 38 (19%) patients. significant improvement was seen in visual acuity after intravitreal bevacizumab injection. out of 200 patients improvement was seen in 132 (66%) patients which is significantly high (p-value < 0.0001), decreased in 20 (10%) patients while 48 (24%) patients remained stable (fig. 1). insignificant complications were seen after intravitreal bevacizumab injection. of the 200 patients, complications were seen only in 24 (12%) patients. (fig.2). of the 12% complications, sub-conjunctival hemorrhage was the most common but least serious complication, found in 12 patients, followed by corneal abrasion in 4, raised iop in 2 patients, vitreous hemorrhage in 2 patients, transient mild uveitis was seen in 2 patients and lens injury was seen in 2 patients as well (table 3). insignificant increase was seen in iop post operatively (p-value = 0.083). pre-operative mean iop was 15.46± 2.57 and post-operative mean iop was 15.27± 2.7 (table 3) neovascularization of the choroidal and retinal tissue are the leading cause of blindness in developed countries.1vascular endothelial growth factor has been identified as a major angiogenic stimulus in variety of retinal and choroidal neovascularization2. vascular endothelial growth factor is homodimeric glycoprotein and is a growth factor specific for endothelial cells3. not only it promotes the growth and survival of vascular endothelial cells, but it also causes conformational changes of tight junctions of retinal vascular endothelial cells leading to increased vascular permeability4. advances in our understanding of pathogenesis of choroidal and retinal neovascularization have facilitated the development of drugs specifically directed against vascular endothelial growth factor. bevacizumab (avastin) is a humanized monoclonal antibody to vascular endothelial growth factor approved for the treatment of colorectal cancer. it has been used systemically and intravitreally for the treatment of retinal and choroidal neovascular diseases since july 2005. however, systemic administration of bevacizumab has a small but significant risk of thromboembolism in patients with cancer5. several studies have not shown any evidence of ocular toxicity after the use of intravitreal bevacizumab at or beyond the therapeutic levels expected with the standard dose of intravitreal bevacizumab used in routine care of patients 6. few of the self-reported adverse events from various institutions in an internet-based survey were corneal abrasion, lens injury, endophthalmitis, retinal detachment, inflammation or uveitis, cataract progression, acute vision loss, central retinal artery occlusion, sub retinal hemorrhage, retinal pigment epithelium tears but none of the adverse event rate exceeds 0.12%7. since no work has been carried out before on this issue in our local setup, this study would be important in decision making regarding the safety of intravitreal bevacizumab in choroidal and retinal neovascular disorders. table 1: diagnosis no. of patients n (%) dr 110 (55) armd 52 (26) myopic cnv 8 (4) crvo 8 (4) brvo 12 (6) eale's disease 6 (3) cnv secondary to cscr 2 (1) angoid streak 2 (1) table 2: distribution of complications n = 200 no. of patients n (%) s.c.h 12 corneal abrasion 4 raised iop 2 vitreous h 2 transient mild uveitis 2 lens injury 2 208 table 3: comparison of intra ocular pressure pre and post operatively iop mean standard deviation p-value* pre-operative 15.46 2.57 0.083 post operative 15.27 2.7 0 50 100 6/60 6/18-6/36 preoperative vision fig. 1: pre and post injection visual acuity distribution n = 200 12 88 seen not seen fig. 2: complications chi-square value = 112.5, (df = 1) p-value < 0.0001 chi-square value = 112.5, (df = 1) p-value < 0.0001 discussion bevacizumab has been used on “off-label” basis since the fall of 2005. since it is of much lower cost than either lucentis and macugen (fda approved antivegf), it is used as first line treatment in most macular degeneration patients. since no work has been carried out before on this issue in our local setup, this study would be important in decision making regarding the safety of intravitreal bevacizumab in choroidal and retinal neovascular disorders. the most common indications of bevacizumab in one paper by lihteh wu et al9 were diabetic retinopathy and cnv of several etiologies. the main indications in our study were diabetic retinopathy (55%) followed by cnv (31%) of various etiologies as well. in our study sub-conjunctival hemorrhage was 6% as compared to lihteh wu et al9 who reported 19.47%. it was procedure related and resolved in 8 to 10 days without any consequences. a e fung et al7 experienced the complication in 0.03% of patients. another procedure related complication faced was corneal abrasion in 2% cases which spontaneously resolved in 2 to 3 days with the use of lubricants. a e fung et al7 and shima c et al10 has reported this complication in 0.15% and 0.28% cases respectively. avastin injection caused a rise in iop, which was a probably volume related. it never occluded the central retinal artery and it fell to below 30 mmhg in all eyes spontaneously within 15 minutes11,8. in our study there were just 2 cases of raised iop which did return to normal with glaucoma medication thus necessitating checking iop after injection as a precaution. vitreous hemorrhage is a risk of intra-vitreal injection. the etiology was unclear. it was probably attributable either to procedure or the underlying pathologic condition for which the injection was administered like proliferative diabetic retinopathy. 1% of our patients suffered the complication of vitreous hemorrhage which was managed by pars plana vitrectomy. lihteh wu et al9 has reported the complication in only 0.02% cases. we experienced inflammatory response in the form of mild uveitis in 1% of cases who responded well to corticosteroids. in the study of kiss c et al12, no inflammatory response was detected clinically. the slight reduction in anterior chamber flare was due to anti-inflammatory effect of anti-vegf therapy. on the other hand another study by lihteh wu et al,9 have reported 0.09% uveitis. iatrogenic traumatic cataract is a risk of intravitreal injection if the needle contacts or penetrates the lens capsule. we observed 1% procedure related lens injury resulting in cataract formation. shima c et al10 and fung et al7 reported 0.14% and 0.01% lens injury respectively. 209 bacterial endophthalmitis is an expected and dreadful complication of intra-vitreal injection. we did not observe this complication at all. lihteh wu et al9 have observed this complication in 0.16% of patients. there are several other complications associated with intra-vitreal bevacizumab injection such as retinal detachment, retinal pigment epithelial tear, acute vision loss, central retinal artery occlusion, mild surface discomfort, progressive sub retinal hemorrhage, cataract progression, transient hypotony which were observed in studies of lihteh wu et al9 and a e fung et al.7 none of these complications were observed in our study. many of the studies reviewed are retrospective and lack randomization or controls, resulting in under reporting of the true prevalence of any given complications. main limitations of our study were that it was a short term study, it lacks randomization and there were no controls. conclusion complications of intra-vitreal bevacizumab are mostly procedure related but few may be drug related. the procedure is generally safe but there are risks involved. to minimize the risk careful attention to injection technique and appropriate post injection monitoring are essential. the short term results suggest that intra-vitreal bevacizumab is safe, but long term randomized control trial is recommended. author’s affiliation dr. aimal khan isra postgraduate institute of ophthalmology al – ibrahim eye hospital, malir karachi prof. p.s mahar isra postgraduate institute of ophthalmology al – ibrahim eye hospital, malir, karachi dr. azfar nafees hanfi isra postgraduate institute of ophthalmology al – ibrahim eye hospital, malir, karachi dr. umair qidwai isra postgraduate institute of ophthalmology al – ibrahim eye hospital, malir karachi reference 1. marano rj, rakoczy pe. treatments for choroidal and retinal neovascularization: a focus on oligonucleotide therapy and delivery for the regulation of gene function. clin experiment ophthalmol. 2005; 33: 81-9. 2. adamis ap, shima dt. the role of vascular endothelial growth factor in ocular health and disease. retina. 2005; 25: 111-8. 3. ferrara n, gerber hp, lecouter j. the biology of vegf and its receptors. nat med. 2003; 9: 669-76. 4. otani a, takagi h, oh h, et al. vascular endothelial growth factor family and receptor expression in human choroidal neovascular membranes. microvasc res. 2002; 64: 162-9. 5. salesi n, bossone g, veltri e, et al. clinical experience with bevacizumab in colorectal cancer. anticancer res. 2005; 25: 3619-23. 6. spitzer ms, wallenfels-thilo b, sierra a, et al. antiproliferative and cytotoxic properties of bevacizumab on different ocular cells. br j ophthalmol. 2006; 90: 1316-21. 7. fung ae, rosenfeld pj, reichel e. the international intravitreal bevacizumab safety survey. br j ophthalmol. 2006; 90: 1344-9. 8. hollands h, wong j, bruen r, et al. short term intraocular pressure changes after intravitreal injection of bevacizumab. can j ophthalmol. 2007; 42: 807-11. 9. lihteh wu, maria a, martinez-castellanos, et al. 12 month safety of intravitreal injection of bevacizumab: results of the panamerican collaborative retina study group (pacores). graefes arch clin exp ophthalmol. 2008; 246: 81-7. 10. shima c, sakaguchi h, gomi f, et al. complications in patients after intravitreal injection of bevacizumab. acta ophthalmol. 2007; 17. 11. falkenstein ia, cheng l, freeman wr. changes of intraocular pressure after intravitreal injection of bevacizumab (avastin). retina. 2007; 27: 1044-7. 12. kiss c, michels s, prager f, et al. evalvation of anterior chamber inflammatory activity in eyes treated with intravitreal bevacizumab. retina. 2006; 26: 877-81. microsoft word jamshad ahmed 1 original article retinitis pigmentosa: genetics and clinical presentation jamshed ahmed, aurangzeb shaikh, ziauddin ahmed shaikh pak j ophthalmol 2009, vol. 25 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: jamshed ahmed h #700, 1st floor pib colony karachi purpose: to evaluate clinical presentation and inheritance patterns in patients of retinitis pigmentosa. material and methods: this study was conducted in the department of ophthalmology, dow university of health sciences, civil hospital karachi and sindh government lyari greneral hospital karachi from october 2002 to march 2008. ophthalmic examination was performed on 112 patients and their family members to identify affected individuals and to characterize the disease phenotype. family pedigree was obtained. some family members also had fundus photographs and fluorescein angiography. results: legal blindness at the time of presentation was found in 104(46.4%) eyes while 76 (33.9 %) eyes have visual impairment. visual field was constricted on confrontation in 44 (39.3%) cases. regarding modes of inheritance, autosomal dominant was found in 5 (4.5%) autosomal recessive in 78(69.6%) and x-linked in 7 (6.3%). twenty two (19.6%) cases were sporadic. typical retinitis pigmentosa picture was found in 97 (86.6%) while 15 (13.3 %) patients showed atypical picture in which 6 (5.35%) cases of pericenteric rp, 5(4.46%) cases of usher’s syndrome and 2(1.78%) cases of retinitis punctata albescence. one case of bardet-biedl syndrome and one case of cockayne's syndrome was found. conclusions: there is a high prevalence of blindness among patients of retinitis pigmentosa. autosomal recessive mode of inheritance is the most common. blindness from retinitis pigmentosa can be prevented by early diagnosis and by 2 received for publication june’ 2008 … ……………………… motivating the patients to avoid cousin marriages. etinitis pigmentosa is a generic name given to a group of hereditary disorders characterized by progressive loss of photoreceptor and retinal pigment epithelium (rpe) function1. the prevalence is approximately 1 in 4,000 and about 1.5 million peoples are affected world-wide2. retinitis pigmentosa is the commonest retinal dystrophy affecting young individual, causing progressive loss of visual acuity and visual fields and making them visually handicapped3,4. different classifications of retinitis pigmentosa have been described by different authors based on mendelian pattern of inheritance. mode of inheritance in these patients has a definite impact on progression of vision loss5. propose of this study was to highlight the clinical presentation and inheritance patterns in our population and compare this to the populations of other countries. material and methods from october 2002 to march 2008, one hundred and twelve (112) patients of retinitis pigmentosa were examined in the ophthalmic outpatient department of dow university of health sciences, civil hospital karachi and sindh govt. lyari general hospital karachi, pakistan. basic socio-demographic data was recorded on a prescribed performa. family history and history of contagiousness was obtained from all patients and pedigree was analyzed. an effort was made to examine whole family members. according to the mode of inheritance the patients were categorized into the following broad classes6,7. autosomal dominant (ad): all subjects in this category showed vertical transmission of the disease for at least two generations. unaffected members did not transmit the trait to their offspring. both males and females were at equal risk. autosomal recessive (ar): one or more subjects were affected. parents are unaffected. patients with parental consanguinity were included in this class. x-linked (xlrp): subjects affected were males. females were carriers. vertical transmission of the trait for at least two generations was observed. affected males did not transmit the disease to their offspring. sporadic or isolated (iso): this category included subjects with no known genetic history. a single individual was involved. all the patients underwent complete ophthalmic examination including assessment of visual acuity using snellen’s acuity chart, retinoscopy to find out refractive errors, color vision, visual fields by confrontation, applanation tonometry and slit lamp biomicroscopy of both anterior and posterior segment. fundus examination was done with direct and indirect ophthalmoscope, goldman triple mirror and +90 d. non-contact lens. colored fundus photography and fundus fluorescein angiography was performed in selected cases. data entry and analysis was done in spss (statistical package for social sciences, usa) version 11.00 for windows. results one hundred and twelve patients with a clinical diagnosis of retinitis pigmentosa were selected for analysis. age of the patients ranged from 4 years to 90 years with a mean age of 28.86 years (sd± 16.52), 91 (81.3 %) patients were below the age of 40 years (fig.1) females (74) (66.07%) were found to be more than males 38 (33.93%) (fig.2). fifty two (46.4%) patients were from local population wile 60 (53.6%) were referred from other areas and hospitals. visual acuity ranged from 6/6 to no perception of light with a mean of 6/24 (table 1). one hundred and four (46.4%) eyes were legally blind at the time of presentation while 76 (33.9 %) eyes have visual impairment (table 1). visual field was constricted on confrontation in 44 (39.3%) cases. intraocular pressure was found raised in 2 (1.78%) cases. refractive errors were found in 53 (56.2%) patients with myopia in 48 (42.9%), hypermetropia in 15 (13.4%) and astigmatism in 17 (15.2%) r 3 (table 2). positive family history was found only in 60 (53.6%) (table 3) patients while history of cousin marriage was found in 81 (72.3%) patients (table 4). regarding modes of inheritance, autosomal dominant was found in 5 (4.5%), autosomal recessive in 78(69.6%) and x-linked in 7 (6.3%). twenty two (19.6%) cases were sporadic (table 5). ninty seven (86.6%) patients have typical retinitis pigmentosa while 15 (13.3 %) patients showed atypical picture in which 6 (5.35%) cases of pericenteric rp, 5 (4.46%) cases of usher’s syndrome and 2 (1.78%)cases of retinitis punctata albescence. one case of bardet-biedl syndrome and one case of cockayne's syndrome was found (table 6). cause of blindness was found to be cataract in 59 (52.7%) patients, glaucoma in 2 (1.78%), atrophic maculopathy in 42 (37.5%), cellophane maculopathy in 32 (28.5%) and combined cellophane and atrophic maculopathy in 10 (8.9%) patients (table 7).vitreous was degenerated in 76 (67.8%) patients. keratoconus was found only in one (0.9%) patient and optic nerve head drusen was found in one (0.9%) patient. discussion retinitis pigmentosa, the most common retinal dystrophy, affects retinal function adversely in working age group making them visually handicapped2,8. mean age of presentation reported in western literature is 24 years while in our study it was 28.86 years (p=0.002)9. this indicates a late table 1: categories of vision in both eyes visual acuity frequency n (%) 3/60 or below 104 (46.4) 3/60 to 6/60 31 (13.8) 6/60 to 6/18 45 (20.1) 6/18 to 6/6 44 (19.6) total 224 (100) table 2: distribution of refractive errors refraction frequency n (%) emmetropia 32 (28.6) astigmatism 17 (15.2) hypermetropia 15 (13.4) myopia 48 (42.9) total 112 (100) table 3: family history frequency n (%) positive 60 (53.6) negative 52 (46.4) total 112 (100) 0 10 20 30 40 10 or b elo w 10 --2 0 20 -30 30 -40 40 -50 50 -60 60 -70 ab ov e 70 fig. 1: categories of age table 4: consanguineous marriages frequency n (%) absent 31 (27.7) present 81 (72.3) total 112 (100) table 5: distribution of modes of inheritance modes of inheritance frequency n (%) autosomal dominant 5 (4.5) autosomal recessive 78 (69.6) x-linked 7 (6.3) sporadic 22 (19.6) p er ce nt 4 total 112 (100) table 6: distribution of types of retinitis pigmentosa types of rp frequency n (%) typical retinitis pigmentosa 97 (86.6) atypical retinitis pigmentosa o pericenteric rp o usher’s syndrome o retinitis punctata albescence o laurance moon biedl syndrome 15 (13.4) 6 (5.35) 5 (4.46) 2 (1.78) 1 (0.9) o cockayne syndrome 1 (0.9) total 112 (100) table 7: state of maculae maculopathy frequency n (%) atrophic 49 (43.8) celluphane and atrophic 15 (13.4) celluphane maculopathy 15 (13.4) normal maculae 27 (24.1) pigmentary 6 (5.4) total 112 (100) table 8: proportions of genetic types country autosomal recessive autosomal dominant x-linked sporadic study year of study switzerland finland russia england usa india pakistan 90 37 27.9 15 83.9 35.1 69.6 9 19.5 12.7 39 10.1 4.5 1 4.5 1.1 25 6 6.3 … 39 40.0 21 … 27.15 19.6 ammann et al14. viopio et al14. panteleeva14 jay14 boughman et al14. vinchurkar et al15. this study 1965 1964 1969 1972 1980 1996 2008 66.07% 33.93% females males fig. 2: patients gender presentation in our population. in this study there is amale preponderance which might be due to social and cultural background. most of the patients in this study (81.3%) are below the age of 40 years, this indicates that working age group is mainly affected. regarding modes of inheritance autosomal recessive was most common found in 69.6% patients. different studies give different proportions (table 8).this might be related to more cousin marriages in our society10, different ways to classify this disorder and difference in recording patterns. in our study 46.4% eyes were legally blind at the time of presentation compared to 25% in western literature11. we found cataract or lens extraction in 52.7% cases which is almost similar to reported in litrature12. conclusion • retinitis pigmentosa is a common blinding disease. • electrodignostic facilities should be available at least in a tertiary care hospital for early diagnosis of this disease. • this disease can be prevented in part by avoiding • cousin marriages 5 author’s affiliation dr. jamshed ahmed assistant professor department of ophthalmology unit-lll dow university of health sciences & sindh govt. lyari general hospital karachi dr aurangzeb shaikh research associate prevention and control of blindness cell dow university of health sciences & civil hospital karachi dr. ziauddin ahmed shaikh professor & head department of ophthalmology dow university of health sciences karachi reference 1. kanski jj. clinical ophthalmology: fundus dystrophies. 6th ed. oxford: butterworth-heinemann. 2007:663-690. 2. dryja tp. doyne’s lecture: rhodopsin and autosomal dominant retinitis pigmentosa. eye 1992; 6: 1-10. 3. adhi mi, ansari aa, aziz mu, et al. clinical audit of fundus fluorescein angiogram. pak j ophthalmol. 1997; 13: 3-7. 4. adhi mi, ahmed j. frequency and clinical presentation of retinal dystrophies. pak j ophthalmol. 2002; 18: 106-10. 5. boughman ja, fishman ga. a genetic analysis of retinitis pigmentosa. br j ophthalmol. 1983; 67: 449-54. 6. cavender jc, ai e, lee st. hereditary macular dystrophies. in: tasman w, jaeger ea eds. daune’s clinical ophthalmology: diseases of the retina. philadelphia: jb lippincott. 1994: 1-29. 7. bird ac. retinal photoreceptor dystrophies: edward jackson memorial lecture. am j ophthalmol. 1995; 119: 543-62. 8. fishman ga, stone e, gilbert ld, et al. clinical features of a previously undescribed codon 216 (proline to serine) mutation in the peripherin/ retinal degeneration slow gene in autosomal dominant retinitis pigmentosa. ophthalmology 1994; 101: 1409-21. 9. berson el, sandberg ma, rosner b, et al. natural course of retinitis pigmentosa over a three-year interval. am j ophthalmol. 1985; 99: 240-51. 10. butt nh. childhood blindness aetiological pattern and hereditary factors. pak j ophthalmol. 2002; 18: 92-4. 11. grover s , fishman g a, anderson rj, et al. visual acuity impairment in patients with retinitis pigmentosa at age 45 years or older 12. fishman ga, anderson rj, lourenco p. prevalence of posterior subcapsular lens opacities in patients with retinitis pigmentosa. br j ophthalmol. 1985; 69: 263–6. 13. boughman ja, conneally pm, nance we. population genetic studies of retinitis pigmentosa. am j hum genet. 1980; 32: 223-35. 14. vinchurkar ms, sathye sm, dikshit m. retinitis pigmentosa genetics: a study in indian population. indian j ophthalmol. 1996; 44: 77-82. microsoft word uzma fasih 3 57 original article comparison of complications after primary and secondary anterior chamber intraocular lens implantation uzma fasih, ishtiaque ahmed, arshad shaikh, m.s. fahmi pak j ophthalmol 2010, vol. 26 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: uzma fasih department of ophthalmology karachi medical & dental college abbasi shaheed hospital karachi received for publication march’ 2009 ………………………… purpose: to assess and compare the complications of primary and secondary implantation of flexible open loop anterior chamber intraocular lenses. materials and methods: the study was conducted in the department of ophthalmology, abbasi shaheed hospital from january 2007-june 2008. in this study evaluation of 60 patients with flexible open loop ac iols were divided into equal groups. .in group l (n=30) an ac iol was implanted primarily and in group ll (n=30) secondary implantation was done after two months of complicated ecce. follow up period was from 1 to 8 weeks. the best corrected visual acuity and complications within two months were obtained. result: mean post operative best corrected visual acuity in group l was lower than group ll .best corrected visual acuity of 6/18 or better was achieved in 13 of 30 in group l and 19 of 30 in group ll. the difference was not statistically significant (p>0.05) post operative complications were significantly lower in group ll (p<0.05). in group l 30 eyes had a total of 92 complications while 30 eyes had 58 complications in group ll. conclusion: flexible open loop ac iols are suitable for both primary and secondary implantations to correct aphakia .secondary implantation of flexible open loop ac iols after complicated ecce seems to have more favourable visual outcomes and a lower complications rate than primary implantations in complicated ecce cases. ataract is the commonest age related disease in most countries world wide1,2. there are approximately 45 million blind people in the world. at least 80% of these people live in developing countries and more than half are blind as a result of cataract. these areas are under privileged in terms of medical services. ophthalmology is even scarcely available speciality in such areas of the world3. pakistan with total population of over 170 million the number of blind people is 2 million. of these 1,3 million are estimated blind due to cataract4,5. by the year 2020 the elderly population of 60 years or above is expected to double from today’s number increasing the number of blind even more6-8. cataract can be surgically removed by two methods. in one method, the lens is removed along with the capsule and is named as intracapsular cataract extraction (icce). the second method spares the posterior capsule and is called extracapsular cataract extraction (ecce)9. after removal of cataractous lens, artificial lens implantation or aphakic spectacles can be used for refractive outcome10. when aphakic spectacles are provided the visual acuity may be good, but the patient faces problems of enlarged images, prismatic and aberrational effects, limited visual fields, roving ring scotomas and impaired judgment of distance leading to clumsiness with simple tasks, also there is no prospect of binocular vision if other eye is phakic with good vision11. c 58 contact lens overcomes many of these problems, but most of the aphakic patients are old and slow to adopt and learn. these lenses are unsuitable for use in dusty environment and usually discontinued within two years .with contact lens also there is problem of binocularity and this problem can be improved with an intraocular lens12. it is generally agreed that inserting an iol in the eye during surgery is a better method of correcting refraction than using spectacles. planned extracapsular cataract extraction with primary insertion of posterior chamber iol (pc iol) is at present also another procedure for managing cataract. in complicated cases with insufficient capsule and lost zonular support it is not possible to insert a posterior chamber intraocular lens (pc iol)3. the alternate is an anterior chamber lens (ac iol) or sclerally fixed pc iol13,14. an ac iol can be primarily or secondarily implanted. primary ac iol is implanted at the time of cataract removal by intracapsular cataract extraction or extracapsular cataract extraction with ruptured capsule where as secondary ac iol is implanted at a later attempt10,15. both are associated with various known complications like corneal edema, endothelial damage, keratopathy, raised intraocular pressure, cystoid macular edema, pupil distortion, uveitis, retinal detachment etc15-21. some surgeons prefer to implant flexible open loop ac iol in the absence of capsular support4,6, while others advise scleral fixed pc iol22. despite some advantages of scleral fixation of pc iol such as safety in long term because it preserves the corneal endothelium, minimizing an aniseikonia in contralateral eye that are phakic or pseuduphakic22,23, they also have some disadvantages for example; the suturing technique is more difficult than with ac iol implantation, intraocular manipulation is often excessive even with newer improved techniques24. implantation of modern flexible open loop ac iol regained popularity and is valuable alternative to scleral fixated pc iol15. but, whether it should be implanted primarily or secondarily is still controversial. to address this controversy the study was carried out in the department of ophthalmology, abbasi shaheed hospital karachi to determine whether after vitreous presentation and in presence of in-sufficient capsular support primary ac iol implantation or later secondary ac iol is better in term of post operative complications and visual outcomes. this study highlighted the frequency of complications and serves important guideline for postoperative care. objective of study 1. to compare the early post operative complications of both, primary and secondary anterior chamber intraocular lens implantation. 2. to compare the improvement of visual acuity in both procedures. material and methods 1. setting the study was performed in department of ophthalmology abbasi shaheed hospital karachi .all surgeries were performed by one surgeon. 2. duration of study the study was completed in 1 year period. the patients were followed on regular basis as mentioned in the protocol. 3. study design it was a quasi experimental study 4. sample size sixty patients were included in the study .the patients were divided in two equal groups. the group i was implanted with primary ac iol, where as in group ii secondary ac iol were implanted. 5. sample technique the sample technique was non-probability convenience sampling. 6. sample selection selection of samples was done on the basis of inclusion and exclusion criteria which are following. inclusion criteria 1. age ranging between 20-75 years 2. both genders 3. posterior capsule break 4. healthy retina with good visual potential exclusion criteria 1. central corneal opacity 2. optic atrophy 3. uncontrolled glaucoma 4. retinal detachment 5. advanced diabetic retinopathy 6. eyes with anterior segment disruption too much for accepting an ac iol. patients planned for cataract extraction with iol implantation were admitted through out patient department of abbasi shaheed hospital. initially a complete history was taken regarding the indication of 59 surgery. detailed ocular examination of the patients was carried out and routine investigations were done. sixty patients were included in the study with ruptured posterior capsule they were divided in two groups group i 30 patients primary ac iol was implanted where as group ii rendered aphakic called after two months for secondary ac iol implantation. post operatively both groups were followed on regular basis and complications were noted. the follow up schedule was first postoperative day, after one week, three weeks, five weeks, and eight weeks respectively. more follow-ups were done if needed. on each visit visual acuity was noted by standard snellens chart, best corrected vision after retinoscopy and aphakic glasses was recorded. iop was measured by goldman applanation tonometer. anterior segment examinations were done by slit lamp and fundus examination was done by direct and indirect ophthalmoscope. for secondary ac iol implantation patients among the second group who fulfilled the inclusion criteria were selected and implanted with secondary ac iol after two months. the patients were followed up postoperatively as scheduled above. the complications were noted down. statistical analysis data analysis was performed through spss version10.0. male: female for presentation of gender distribution was computed. age was presented by mean ± s.d and students t-test was applied to compare it between two groups. all categorical variables including ,preoperative visual acuity, visual acuity at subsequent follow up visits, and early postoperative complications presented by frequencies and percenttages. chi-square test was applied to compare proportions of genders, postoperative visual acuity on subsequent follow up visits and postoperative complications. statistical significance was taken at p<0.05. results total 37(61.7%) male and 23(38.3%) females were included in the study with male to female ratio 1.6:1. there were 16(53.3%) males and 14(46.7%) females in primary ac iol group. among 30 patients who underwent secondary ac iol there were 21 (70%) males and 9(30%) females .gender distribution between two groups was thus statistically significant at p<0.05. out of 60 patients 41(68%) had right eye cataract while 19 (32%) patients had cataract in left eye. types of cataract were observed. 33(40%) had senile cataract, 23(38.3%) had secondary cataract and 4(6.67%) had traumatic cataract. average age of the patients who underwent primary ac iol group was comparatively less than average age of the patients who underwent secondary ac iol group (56.93+5.25 vs58.03 ± 5.97), however this difference of means was not statistically significant at p<0.05 (table-1). preoperative visual acuity was examined. majority of the patients in both groups (respectively 73.3% and 80%) had va from perception of hand movement to 6/60. a majority (96.7%) of patients of secondary ac iol group had visual acuity between 6/12-6/60. after surgery (aphakic correction) (table -2). on first day after surgery 10(33.3%0 patients of primary ac iol group and 7(23.3%0 patients of secondary ac iol group had va 1/60-5/60.mjority of patients of both groups (respectively 60% in group i and 66.7% in group ii) had va 6/60-6/24. none of the patients of either group had va 6/9-6/6, data revealed statistically insignificant difference of va between two groups on first day after surgery (table-3). postoperative one week follow up revealed a slight improvement in visual acuity but still, majority of the patients of both groups (respectively 56.7% and 53.3%) had visual acuity 6/60-6/24 and none of the patient of either group had visual acuity 6/9-6/6 (table 4) postoperative three weeks’ follow up revealed gradual improvement in va as 28 (93.3%) patients of both groups now had va 6/60-6/12 and one patient of secondary ac iol group had va 6/9.however, difference between two groups regarding visual outcome was insignificant at p< 0.05 (table 5). almost same pattern of va was observed on postoperative follow up visit after 5 weeks (table 6). on final postoperative follow-up visit eight weeks after surgery showed a drastic improvement in va as compared with that of one day after surgery. two (6.7%) patients of secondary ac iol group and none of patient of primary ac iol group had va 6/9. seventeen(56.7%) patients of secondary ac iol group and 13 (43.3%) patients of primary ac iol group had va 6/18 -6/12. only two (6.7%) patients of primary ac iol group and none of the patients of secondary ac iol group had va 1/60-5/60. however, difference between two groups regarding visual outcome was insignificant at p<0.05 (table-7). 60 table 1. comparison of demographic variables between two groups demograph variables group-a (n=30) group b (n=30) p-value age(years) 56.93±5.25 58.03±5.97 0.452 table 2. best corrected visual acuity before surgical procedures best corrected visual acuity primary ac iol n=30 patients n (%) secondary ac iol n=30 patients n (%) secondary before iol implantatio n (aphakic correction) patients n (%) perception of hand movement 5 (16.7) 4 (13.3) 0 (0) 1/60-5/60 8 (26.7) 10 (33.3) 1 (1.33) 6/60 9 (30) 10 (33.3) 4 (13.3) 6/36 6 (20) 3 (10) 5 (16.7) 6/24 4 (13.3) 3 (10) 5 (16.7) 6/18 1 (3.33) 0 (0) 11 (36) 6/12 0 (0) 0 (0) 4 (13.4) ac iol: anterior chamber intraocular lens table 3. comparison of visual acuity first day after surgical procedure visual acuity primary ac iol n=30 patients n (%) secondary ac iol n=30 patients n (%) 1/60-5/60 10 (33.3) 7 (23.3) 6/60-6/24 18 (60) 2 (6.7) 6/18-6/12 2 (6.7) 3 (10) 6/9-6/6 0 (0) 0 (0) ac iol: anterior chamber intraocular lens early postoperative complications in both groups are detailed in table 8. early transient corneal oedema was the commonest complication observed in both groups (60.0%vs.46.7% p=o.48) respectively in primary ac iol and secondary aciol, followed by iritis (50% vs.20%p=0.32) endothelial decompensation (26.7% vs.10% p=0.13) while suture erosion, iridodialysis and pseudophakic bulbous keratopathy were observed in only primary ac iol group among one patient each. an insignificant pattern of complications was observed between both groups at p<0.05. table 4. comparison of visual acuity one week after surgical procedure visual acuity primary ac iol n=30 patients n (%) secondary ac iol n=30 patients n (%) 1/60-5/60 06 (20) 05 (16.7) 6/60-6/24 17 (56.7) 16 (53.3) 6/18-6/12 07 (23.3) 09 (30) 6/9-6/6 0 (0) 0 (0) ac iol=anterior chamber intraocular lens table 5: comparison of visual acuity three weeks after surgical procedure visual acuity primary ac iol n=30 patients n (%) secondary ac iol n=30 patients n (%) 1/60-5/60 02 (6.7) 01 (3.3) 6/60-6/24 18 (60) 16 (53.3) 6/18-6/12 10 (33.3) 12 (40) 6/9-6/6 0 (0) 0 (0) ac iol=anterior chamber intraocular lens table 6: comparison of visual acuity five weeks after surgical procedure visual acuity primary ac iol n=30 patients n (%) secondary ac iol n=30 patients n (%) 1/60-5/60 02 (6.7) 0 (0) 6/60-6/24 16 (53.3) 14 (46.7) 6/18-6/12 12 (40) 14 (46.7) 6/9-6/6 0 (0) 2 (6.7) ac iol=anterior chamber intraocular lens 61 table 7. comparison of visual acuity eight weeks after surgical procedure visual acuity primary ac iol n=30 patients n (%) secondary ac iol n=30 patients n (%) 1/60-5/60 02 (6.7) 0 (0) 6/60-6/24 15 (50) 11 (36.7) 6/18-6/12 13 (43.3) 17 (56.7) 6/9-6/6 0 (0) 2 (6.7) ac iol=anterior chamber intraocular lens total number of complications encountered in primary ac iol group was 92 and of secondary ac iol group were 58. significant difference was observed regarding the proportions of total number of complications encountered in two groups (p=0,001). discussion there are number of favourable reports on flexible open loops ac iol in the literature25-27 but few have compared primary and secondary implantations25,28. in this study it has been tried to compare primary and secondary ac iol implantation. thirteen of thirty eyes (43.33%) in our study in primary implantation (group i) achieved a bet corrected va of 6/18 or better. this result is comparable with previous studies. in the literature this va level has been reported from 35% to 82% of primary implantation29-31. in our study this is 43.33% which is comparable with previous studies. in terms of visual acuity result, the cases of secondary ac iol insertion following complicated ecce had more favourable outcomes than the case with primary iol implantations that underwent complicated ecce. these results are consistent with david et al32. they reported that 56% of eyes with secondary implantation achieved a good va (20/40 or better) compared with 35% cases of primary ac iol after complicated ecce. our studies showed 63.33% of secondary implantation achieved va of 6/18 or better whereas 43.33% primary implantations achieved va of 6.18 or better. these results are comparable but david’s study shows va of 20/40 or better. although we had poor visual outcome than david. in our study the lower rate of good va in primary and secondary cases may be associated with complicated surgery and it may be due to prolonged surgical time and increased inflammation. table 8. early postoperative complications postoperative complications primary ac iol n=30 patients n (%) secondary ac iol n=30 patients n (%) p-value early transient corneal edema 18 (60) 14 (46.7) 0.48 iritis 15 (50.0) 11 (36.7) 0.43 early transient raised iop 10 (33.3) 6 (20) 0.32 endothelial decompensation 8 (26.7) 3 (10) 0.13 iris capture and pupil decentration 6 (20) 4 (13.3) 0.53 vitreous prolapse inac 5 (16.7) 3 (10) 0.48 intraoperative heamorrhage in ac 5 (16.7) 2 (6.67) 0.26 early shallow ac 5 (1.67) 3 (10.0) 0.48 cystoid macular edema 5 (1.67) 2 (6.67) 0.26 ugh syndrome 5 (1.6) 2 (6.67) 0.26 reversible fibrin reaction 4 (13.3) 2 (6.67) 0.41 late secondary glaucoma 3 (10) 1 (3.33) 0.32 suture erosion 1 (3.33) 0 (0) iridodialysis 1 (3.33) 0 (0) pseudophakic bulbous keratopathy 1 (3.33) 0 (0) the percentage of eyes achieving final va equal to or better than their best corrected preoperative va was 83% in secondary ac iol implantation (group ii). this is consistent with previous studies that reported a high rate of good vision26,29,32,33. the reduction of best corrected va may be due to subclinical cystoid macular edema although that was not clearly diagnosed in this group. in this study there 62 were no serious preoperative complications except vitreous loss experienced in either groups. sight threatening complications consisted of cystoid macular edema (5 in group i and 2 in group ii), secondary glaucoma (3 in group i and 1 in group ii) and psudophakic bulbous keratopathy (1 in group i) were observed. these complications were also experienced by ali abrar, hussain m. and huseyin bayramlar34. both the severe and total complications rate were higher in group i. (92 in group i and 58 in group ii.) and this may be associated with higher vitreous loss rate that necessitated vitrectomy and prolonged surgical time35. eyes undergoing primary ac iol implantation are already at a significantly greater risk of cystoid macular edema, retinal detachment, postoperative endothelial decompensation, postoperative inflammatory glaucoma34,35. patients undergoing secondary ac iol implantation are presumably healthier group of eyes that have been pre selected on the basis of their visual potential, absence of inflammation, glaucoma or anterior chamber abnormalities including peripheral anterior synechiae. in their study david et al31 found lower rates of cystoid macular edema and pseudophakic bulbous keratopathy in their secondary implantation group weene29 also reported no retinal complications in secondary implantation cases. he proposed that this might be due to vitreous liquefaction and posterior vitreous detachment that occurs in most cases of aphakia, specially after one year29. this may explain why the results of secondary implantation are better when one or more years have elapsed after cataract surgery36, but in our study we did secondary implantation after two months this may explain our higher complication rate. the complications in the either group, such as early transient corneal edema, iritis, endothelial decompensation, intraoperative heamorrhage, pupil deformation and cystoid macular edema, may be related to sizing and placement of the lens implant rather than the presence of lens itself. in another study conducted by richards and williams it was found that serious complications like persistence of cystoid edema 4.6%, retinal detachment 1.3% and endophthalmitis 0.7%, but in our study no complication of retinal detachment or endophthalmitis was observed. this might be due to better sterilization techniques and another reason is that we conducted our study on 60 patients while they conducted their study on 153 patients37. we had no major complication in relation to vitreous in ac and open sky vitrectomy. in term of va presence of vitreous in ac should not be a contraindication to secondary lens implantation38. with open sky technique small strands of vitreous may be left in anterior chamber, it is recommended that vitrectomy should be done with microsurgical technique. a high incidence of retinal detachment was reported by wong in cases requiring anterior vitrectomy39. harward showed that neither vitreous manipulation nor a previous history of trauma had significant effect on change between pre and post operative vision32. we did not use specular microscope for counting endothelial cells preoperatively and postoperatively. leatherbrow demonstrated a mean endothelial cell loss of 15.6%after secondary implantation40. it was recommended that intraocular lens implantation should be avoided in patients having endothelial count of less than 1000 cells per sq.mm41. because of high complication rate of ac iol42 some surgeons advocate implanting scleral fixated pc iols and not using ac iols in the absence of posterior capsular support25,43-46. in their prospective comparative study however melluci, tayyab a, hussain m47,48 found a higher complication rate in scleral fixated lenses than in open loop ac iols. the surgical technique of scleral fixated lenses need elaborate skills and aggressive intraocular manipulation, not always mastered by average cataract surgeons. however flexible open loop ac iol are easier and faster to implant in the anterior chamber and vitreous manipulation not always necessary47. when vitreous is lost during cataract surgery, sufficient vitreous cleaning is necessary to obtain more favourable results in secondary and specially in primary ac iol implantation. conclusion in conclusion using an open loop flexible ac iol for both primary and secondary implantation is a suitable way to treat aphakia. although ac iol either primary or secondary implantation caries some hazards but it is preferable to perform the procedure to restore patient binocular single vision .on the basis of our study secondary implantation of flexible open loop ac iol seems to have more favourable outcomes and lower complication rates overall than primary implantation. further studies including larger follow up may help us to draw this conclusion more clearly. 63 author’s affiliation dr. uzma fasih assistant professor eye department karachi medical & dental college abbasi shaheed hospital, karachi dr. ishtiaque ahmed eye department karachi medical & dental college abbasi shaheed hospital, karachi dr. arshad shaikh professor & head of eye department eye department karachi medical & dental college abbasi shaheed hospital, karachi dr. m.s.fahmi associate professor eye department karachi medical & dental college abbasi shaheed hospital, karachi reference 1. klein be,klein r, moss se. changes in visual acuity associated with cataract surgery. the beaver dam eye study ophthalmology. 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implantation: a specular microscopic study. j am intraocul soc.1978; 4: 107-9. 42. auffarth gu, wesendahl ta, brown sj, et al. are there acceptable anterior chamber intraocular lenses for clinical use in 1990s? an analysis of 4104 explanted anterior chamber intraocular lenses. ophthalmology. 1994; 101: 1913-22. 43. malbran es, malbran e jr, negri i. lens guide suture for transport and fixation in secondary iol implantation after intracapsuler extraction. int ophthalmol. 1986; 9: 151-60. 44. sen ha, smith pw. current trends in suture fixation of posterior chamber intraocular lenses. ophthalmic surg. 1990; 21: 689-95. 45. hussain m, moin m, ramzanm, et al. scleral fixation of pcl in aphakes. ann ke med coll. 2003; 9: 130-2. 46. tayyab aa, sahi t, iqbal mz, et al. secondary transscleral fixation of intraocular lens implantation. pak j ophthalmol. 2004; 20: 139-42. 47. koenig sb, apple dj, hyndiuk ra. pentrating keratoplasty and intraocular lens exchange: open loop anterior chamber lenses versus sutured posterior chamber lenses. cornea 1994; 13: 418-21. microsoft word bakhat samar khan 1 7 original article a review of 100 cases of ectopia lentis with glaucoma: its types, presentation, management and visual prognosis bakht samar khan, zubeda irshad, mustafa iqbal pak j ophthalmol 2010, vol. 26 no.1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations ….………………………… correspondence to: bakht samar khan assistant professor department of ophthalmology khyber medical college peshawar pakistan received for publication march’ 2009 ….………………………… purpose: to examine the clinical profile of glaucoma associated or caused by ectopia lentis, its types and management and visual prognosis. material and methods: the medical record of 100 consecutive patients suffering from ectopia lentis and glaucoma admitted in eye unit of khyber teaching hospital, peshawar from june 2002 to december 2007 were reviewed retrospectively. the clinical records were analyzed. the main parameters were type of glaucoma, its management, visual prognosis and iop control. results: no age and sex was exempted. main types of glaucoma were pupillary block 26.92% (35 eyes), angle anomaly 18.46% (24 eyes), glaucoma due to lens in the anterior chamber 16.92% (22 eyes), traumatic glaucoma 14.61% (19eyes), phacolytic glaucoma in 10% (13 eyes) followed by mixed type of glaucoma 16.16% (18 eyes). in 87.69% (114 eyes) surgical intervention done as peripheral iredectomy in 33.08% (43 eyes), trabeculectomy 13.85% (18 eyes), phacotrabeculectomy in 9.23% (12eyes), lensectomy in 23.08% (30 eyes) and lensectomy with vitrectomy in 8.46% (11 eyes). glaucoma was completely relieved in 74.62% cases while 25.48% (43 eyes) needed antiglaucoma medication. visual acuity was improved in 70.77% (92 eyes). amblyopia, optic disc cupping and optic atrophy were the main causes of visual failure. conclusion: glaucoma in ectopia lentis patients is very common. in more than 80 % cases need surgical intervention like crystalline lens removal plus glaucoma surgery. even after surgery chances of refractory glaucoma is there. ctopia lentis or displaced crystalline lens syndrome may be congenital or acquired .in either case it is associated with a number of ocular and systemic complication. the ocular complications are mainly glaucoma, cataract and uveitis. lund and sjontoft conducted study in1950 and found glaucoma in 25% of cases. various type of glaucoma’s associated with ectopia lentis are, pupillary block, angle anomaly, phacolytic, traumatic angle recession, primary angle closure, primary open angle and mixed type. glaucoma is a serious blinding disease as who data in 1990 has reported is the third leading cause of blindness in the world. the management of glaucoma associated with ectopia lentis is often difficult and challenging. the current management strategies until lately were aimed at reduction of intra ocular pressure by topical eye drops containing beta-adrenergic antagonist, cholinergic agonists, adrenergic agonists or carbonic anhydrase inhibitor and prostaglandins analougues or in combination with systemic carbonic anhydrase inhibitors and hyperosmotics. failure of medical therapy is followed by laser or surgical intervention. the main surgical interventions are peripheral iridectomy, trabeculectomy with or without antimetae 8 bolites, lensectomy with or without vitrectomy and phacotrabeculectomy. material and methods all the patients of ectopia lentis associated with glaucoma (intraocular pressure more than 22mmhg) admitted to eye ward from june 2002 to dec.2007 were studied. the history charts chosen were analyzed for relevant data. this includes age, sex and visual acuity. history revealed ectopia lentis to be congenital or acquired. ocular examination was done with respect to visual acuity, anterior chamber examination i.e. corneal edema, peripheral anterior syncline, anterior chamber depth, iris atrophy, lens dislocation (luxation)/ subluxation and its site. intraocular pressure measurement with applanation/ goldmann tonometer taken at the time of admission and discharge. gonioscopy finding were recorded. posterior segment assessment including disc cupping, neovascularization, atrophy and hemorrhage. systemic examination was performed with specific anomalies of cardiovascular system, musculoskeletal system and nervous system in view. where needed electrocardiography, echocardiography, full blood count, esr, urine examination, bleeding time, clotting time, sodium nitroprusside test, homocystine level in urine and plasma were also done. the treatment modalities were studied. anti glaucoma therapy was given to control glaucoma. in majority cases it was not successful. surgical intervention was done. these were mainly iridectomy, trabeculectomy, lensectomy, phacotrabeculectomy and vitrectomy. results one hundred and thirty eyes of one hundred consecutive patients having ectopia lentis with glaucoma, hospitalized for management in khyber teaching hospital were studied. out of these one hundred patients, seventy-seven were male and twenty three were female. bilateral glaucoma was present in thirty patients and unilateral in seventy (table 1). age distribution no age was exempted. up to age 10 years there were 19 patients (19%), in 11-19 years age group 37 patients (37%), in 20 to 39 years group 22 patients (22%) while 40 years and above 22 patients (22%) (table 2). type of glaucoma pupil block glaucoma in 35 eyes (26.92%), angle anomaly in 24 eyes (18.46%), glaucoma due to lens in the anterior chamber in 22 eyes (16.92%), traumatic glaucoma in 19 eyes (14.61%), phacolytic glaucoma in 13 eyes (10%) mixed type glaucoma in 09 eyes (6.92%), primary open angle and closed angle in 05 eyes (3.85%) and 03 eyes (2.31%) respectively (table 3). table 1: sex and glaucoma sex no of patients n (%) male 77 (77) female 23 (23) total 100 (100) table 2: ages and glaucoma age (years) no of patients n (%) up to 10 19 (19) 11-19 37 (37) 20 to 9 22 (22) 40 to 59 17 (17) 60 and above 05 (05) total 100 (100) table 3: types of glaucoma types no. of eyes n (%) angle anomaly 24 (18.46) pupil block 35 (26.92) photolytic 13 (10) glaucoma with lens in anterior chamber 22 (16.92) angle closure glaucoma 03 (14.61) open angle glaucoma 05 (2.31) trauma and angle recession 19 (3.85) lensectomy and vitrectomy 09 (6.92) 9 therapeutic intervention in majority cases ectopia lentis with glaucoma was unable to be controlled with anti glaucoma medication. in 114 eyes (87.69%) needed surgical intervention as peripheral iredectomy in 43 eyes (33.08%), lensectomy in 30 eyes (23.08 %), trabeculectomy in 18 eyes(13.85%), phacotrabeculec-tomy in 12 eyes (9.23%) and lensectomy with vitrectomy in 11 eyes (8.46%) eyes (table 4). glaucoma was controlled in 97 eyes (74.62%) while in 43 eyes (25.48%) it remained uncontrolled and needed additional anti glaucoma medication (table 5). visual acuity was improved to 6/6-6/12 in 69 eyes (53.85%), up to 6/36 in 23 eyes (17.69%), up to 3/60 in 12 eyes (9.23%) and perception of light in 26 eyes (20%) (table 6). table 4: management and glaucoma s.no type of treatment no of eyes n (%) a medical 16 (11.3) b surgical • peripheral/iridectomy • trabeculectomy • lensectomy • phaco trabeculectomy • lensectomy and virectomy 114 (87.69) • 43 (33.08) • 18 (13.85) • 30 (23.8) • 12 (9.23) • 11 (8.46) table 5: glaucoma status glaucoma status no of eyes n (%) controlled 97 (74.62) uncontrolled 33 (25.48) table 6: visual prognosis and glaucoma vision eyes n (%) pl 26 (20) pl + 3/60 12 (9.23) up to 6/60 23 (17.69) up to 6/12 69 (53.08) discussion the crystalline lens is implicated as causative element in producing several forms of glaucoma. these include lens dislocation/subluxation (ectopia lentis), lens intumescent cataract glaucoma, classical pupillary block glaucoma, lens particle glaucoma, phacoanaphylaxis and phacolytic glaucoma1. various studies showed glaucoma association is an established fact2-3. glaucoma has been reported in patients with ectopia lentis as part of the syndromes like marfan, weill marchesani, homocytineurea and aniridia4. fibrilin -1 (fbn-1) gene mutations screening analysis shows ectopia lentis with secondary glaucoma is positive as compare to normal control people. this type of genetic and molecular understanding provide information for genetic counseling5. glaucoma in ectopia lentis patients has been reported as 41.5%6. cross and jerret has reported the presence of glaucoma as 25 %7 while in another study the glaucoma has been reported as 25 % in marfan syndrome8. maumenee reported glaucoma as 129/1000 in patients of ectopia lentis as compared to normal population where it was 40/1000. the ectopia lentis is mainly associated with secondary type of glaucoma although primary angle closure and open angle glaucoma has also been reported9. the secondary glaucoma’s are associated or aggravated by angle anomaly in congenital type and traumatic angle recession in traumatic type. no age and sex is exempted from ectopia lentis and glaucoma. glaucoma was noticed in 59% in age group of 20-39 years. ectopia lentis and its induction of gluacoma appear in second and third decade of life because of changes in zonules and hperplastic cillary body. this causes forward displacement of iris accompanied by unequal lens zonuler tension leading to angle closure or pupillary block glaucoma or it may appear due to abnormal structure of anterior chamber10. the crystalline lens is the main culprit causing raised intraocular pressure particularly when it is displaced anteriorly, causing pupil block glaucoma. this condition was noticed in 26.92 % of cases. in our study pupilary block glaucoma was highest followed by angle anomaly and lens in the anterior chamber with glaucoma. in study of harrison et al angle anomaly and pupillary block were the main glaucoma variety11. ectopia lentis or lens displaced syndrome associated with glaucoma remains a therapeutic challenge for ophthalmologists. if it is of congenital origin then presence of other ocular condition like angle anomaly and aniridia or systemic condition like 10 homocytinuria further complicate the condition. on other hand traumatic variety with hypaema and angle recession is also difficult to manage. medical treatment may be helpful to control intraocular pressure temporarily in cases like angle closure, open angle or traumatic glaucoma. but insuffient to control glaucoma in majority of types,12 which need surgical intervention like peripheral iredectomy, trabeculectomy/ phacotrabeculectomy, anterior vitrectomy and lensectomy. in our study 11.3% cases of glaucoma were controlled with medication while 88.7 % cases needed surgical intervention. in 74.62% glaucoma was cured. while 25.48% cases still needed medication. peripheral iredectomy is useful in pupullary block glaucoma. if peripheral iredectomy fails, lensectomy with or without intraocular implantation is done. the intraocular pressure becomes normal13. harrison and his colleagues studied forty five patients with ectopia lentis in homo cystinuria. sixty two patients had lens into the anterior chamber or pupil block glaucoma. eighty-four surgical procedures were done. peripheral iredectomy was not successful alone. lensectomy and trabeculectomy were the choice of operation11. in another case angle closure glaucoma with progressive myopia due to ectopia lentis was treated with propyhlactic lensectomy. that proven most effective9. kluppel et al operated 23 eyes having decreased visual acuity and uncontrolled secondary glaucoma. main surgical procedure was lensectomy and transcleral posterior chamber intraocular lenses implantation suture technique. visual acuity improved in 17/23 eyes (73.91%). the decrease visual acuity in remaining 26.09 % eyes were due to amblyopia. gluacoma was controlled in 100 % of cases14. 80% weill marchesani syndrome have glaucoma, which responds poorly to medical treatment alone. peripheral iredectomy, ppl (pars plana lensoctomy), lensectomy with anterior vitrectomy and trabeculectomy are surgical procedure of choice15. lensectomy done in patients having “glaucoma with spherophakia” where glaucoma was uncontrolled with patent peripheral iredectomy and medical treatment. right eye visual acuity was 6/6. intra ocular pressure was normal without glaucoma therapy. left eye visual acuity was 6/9 and normal intra ocular pressure13. in polish journal klin oczna it has been reported that in 116 eyes of ectopia lentis parsplana lensectomy, vitrectomy and scleral fixation intraocular implanttation done. visual acuity improved in 89% of cases while glaucomatous optic atrophy and amblyopia were the main cause of decreased visual acuity16. in our study visual acuity improved in 92 eyes (70.77%) while in 38 eyes (29.23%) the glaucomatous optic cupping was the main cause of decreased visual acuity. the glaucoma was relieved in 74.62% eyes. in conclusion ectopia lentis is very challenging clinical field. glaucoma association makes it further complex. in more than 80 % cases need surgical intervention like crystalline lens removal plus glaucoma surgery. even after successful surgery chances of refractory glaucoma is there. author’s affiliation dr. bakht samar khan assistant professor department of ophthalmology khyber medical college peshawar dr. zubeda irshad lecturer girls medical college peshawar prof. mustafa iqbal department of ophthalmology khyber medical college peshawar reference 1. ellant jp, obstabum sa. lens induced glaucoma. doc ophthalmol. 1992; 81: 317-38. 2. cross he, jenson ad. ocular manifestation in the marfan syndrome and homocystinuria. am j ophthamal. 1973; 5: 405-20. 3. epstein dl. glaucoma associated with congenital and spontaneous dislocation of the lens. in chandler and grant’s glaucoma 1986; 3: 320-31. 4. willi m, kutl, cotlier e. pupillary block glaucoma in the merehesani syndrome. arch ophthalmol. 1973; 90: 504-8. 5. deng t. dong b, zhang x, et al. late onset bilateral lens dislocation and glaucoma associated with a novel mutation in fbn1 mol.vis. 2008; 14: 1229-33. 6. khan, khan. a review of 100 cases of ectopia lentis presentation, management, and visual prognosis. pak j ophthalmol. 2002; 18: 3-7. 7. jarret wh. dislocation of the lenses. arch ophthalmol. 1967; 78: 289-96. 11 8. khan bs, khan mn, islam z. marfan syndrome ocular manifestation and management. pj ophthalmol. 2004; 20: 5760. 9. dagi lr, walton ds. anterior lens subluxation, progressive myopia, angle closure glaucoma: recognition and treatment of atypical presentation of ectopia lentis. j aapos. 2006; 10: 345-50. 10. kanski jj. clinical ophthalmology: a systemic approach: ch. 8 lens, ectopia lentis. 5 th. ed. uk; butterworth heinemann. 2003. 189-91. 11. harrison da, mullaney pb, mesfer sa, et al.. management of ophthalmic complication of honocystinuria. ophthalmology. 1998; 105: 1886-90. 12. taylor jn. weill marchesani syndrome complicated by secondary glaucoma. case management with surgical lens extraction. aust n z j ophthalmol. 1996; 24; 275-8. 13. wishast c. lensectomy in the management of glaucoma in spherophakia. journal of cataract and refractive surgery. 2003;.28: 1061-4. 14. kluppel m. sundmacher r, althaus c. surgical management of marfan associated and idiopathic lens dislocation . ophthalmologe. 1977; 94: 739–44. 15. faivre l, dollfus h, lyonnet s et al. review article .clinical homogeneity and genetic heterogeneity in weill marchesani syndrome amj med gen. 2003; 123: 214-207. 16. kanigowska k, gralek m, klimczak-slaczak d. the estimation of functional results after surgical treatment for ectopia lentis in children. klinoczna. 2005; 107: 460-3. pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 79 original article resolution of macular oedema in diabetic patients following avastin (bevacizumab) intravitreal therapy ata-ur-rehman, saba alkhairy, farnaz siddiqui, mirza shafiq ali baig pak j ophthalmol 2017, vol. 33, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ata ur rehman dept of ophthalmology liaquat national hospital pechs, karachi email: dr_ataurrehman@hotmail.com purpose: to estimate the effectiveness of intravitreal avastin (bevacizumab) treatment in the reduction of macular oedema in diabetic patients. study design: prospective cohort study. place duration of study: outpatient department (opd) of the ophthalmology department of liaquat national hospital (lnh) between the period april 2013 march 2015. material methods: a total of 66 eyes of 44 patients (both type 1 type 2 diabetics) were selected who were advised their first intraocular avastin in one or both eyes with clinically visible angiographically confirmed macular oedema and those who did not have a prior history of grid laser photocoagulation. all subjects were treated by intravitreal avastin (bevacizumab) 1.25 mg injection. best-corrected visual acuity, slit lamp examination and fundus fluorescein angiography were examined before after intravitreal injection. results: a total of 66 eyes of 44 patients (both type i type ii diabetes) without any prior history of avastin were included in the study. there were 26 (59%) males 18 (41%) females. the edema was seen completely resolved in 8 patients (12.2%), partially resolved 44 (66.7%) not resolved in 14 (21.21%). there was no adverse reaction seen in any eye except four eyes had mild anterior chamber inflammation which were treated with topical corticosteroid and one eye developed sub-conjunctival haemorrhage. the visual acuity improved in ata-ur-rehman, et al 80 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology …..……………………….. 59 out of 66 eyes (89%) based on the increased number of lines read by the patient on snellen chart and in only 7 eyes there was no improvement during a mean follow-up period of 6 months. conclusion: intravitreal bevacizumab injection provides significant improvement in visual acuity as well as reduction of macular oedema therefore may consider as a primary treatment of diabetic macular oedema. keywords: anti-vascular endothelial growth factor; bevacizumab; diabetic macular edema; diabetic retinopathy. iabetes mellitus can lead to diabetic retinopathy (dr) it is one of the commonest cause of blindness world wide1,2. good glycemic control blood pressure control play an important role in the reduction of risk of development as well as progression of diabetic retinopathy. proliferative diabetic retinopathy macular oedema are the most visually disabling complications of diabetic retinopathy3,4,5. macular edema can develop at any stage of diabetic retinopathy it can lead to visual loss. both proliferative non proliferative dr may show diabetic macular oedema (dme), which is classified as either focal, if edema is caused by a focal leakage from microaneurysms, or diffuse, if there is generalized leakage from retinal capillaries with abnormal permeability throughout the posterior pole6,7,8. vascular endotheial growth factor (vegf) leads to disruption in the blood retinal barrier increased vascular permeability which results in macular oedema therefore, anti-vegf treatment inhibits the neovascularization diabetic macular oedema9. vegf play an important role in the pathogenesis of diabetic retinopathy diabetic macular oedema, antivegf agents are beneficial in the management of such conditions which have shown in multiple recent studies. it has been proved that intravitreal bevacizumab injection is inexpensive accessable in the management of diabetic macular oedema, it can be used along with laser photocoagulation. however, its clinical superiority compared with intravitreal ranibizumab other intravitreal anti vegf in terms of diabetic macular oedema regression the improvement of best corrected visual acuity are still unproven needs further analysis studies10. bevacizumab (avastin) is a humanized monoclonal antibody against vegf it binds inhibits all the biologically active forms of vegf. bevacizumabis is a food drug administration (fda) approved treatment for metastatic colorectal cancer. it also showed beneficial effects in patients having choroidal neovascularization, iris neovascularization, vitreous haemorrhage macular oedema. however in persistent diffuse diabetic macular oedema there are only few studies that have shown the advantageous effects of intravitreal bevacizumab therapy11.12. the objectives of the study were 3 folds. to know the effectiveness of intravitreal avastin treatment in the reduction of diabetic macular oedema. to gain information about the number of avastin applications required to resolve dme in order to stabilize visual acuity (va). to know the overall reduction in the rate of severe visual loss from dme both in the effectively d resolution of macular oedema in diabetic patients following avastin (bevacizumab) intravitreal therapy pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 81 treated eyes in those eyes in which macular oedema was not resolved in spite of repeated injections. materials methods the study was performed simultaneously at the ophthalmology department lnh and at the eye clinic between april 2009 – march 2015. this was a small prospective cohort study of 66 eyes of 44 diabetic patients of either sex age presented at the opd and fulfilled the inclusion criteria. patients were selected from the eye opd presenting to the hospital. all screened diabetic patients underwent visual acuity assessment using snellens chart, slit lamp biomicroscpy for fundus examination with 90d lens, fundus flourescein angiography and laboratory investigations to assess their glycemic control. the selection criteria included those patients of both genders of ages between 45 to 75 years that were known diabetics who had manifest macular edema both on slit-lamp examination and ffa. these patients had reasonably clear media, received intra-vitreal treatment for the first time in a particular eye without previous laser photocoagulation. the exclusion criteria included patients with presence of neovessels at disc, neovessels elsewhere ischemic maculopathy and those who had a history of previous laser photocoagulation. patients were further categorized into 3 groups. group 1 consisted of individuals with best corrected visual acuity of 6/60 or less, group 2 consisted of individuals with best corrected visual acuity of 6/36 or 6/24 while group 3 consisted of individuals with best corrected visual acuity of 6/18 or better. treatment procedure included use of intravitreal avastin, 1.25mg in 0.05 ml given to all patients on monthly basis for 3-6 months depending on the response of the drug. in bilateral cases injections were given 2-7 days apart. moxifloxacin was started 1 day before injection and was continued for 3 days after the therapy. acetazolamide 250 mg stat was also given. all patients were followed-up on the very next day, at 4 weeks then monthly for 6 months. they were instructed to report immediately for any untoward reaction which was already explained to them. the data was entered and analyzed on ibm spss package version 21. frequency and percentages were calculated for categorical variables like gender, best corrected visual acuity (bcva) etc. the kruskalwallisnon parametric test was used to compare the bcva in different groups before and 3 months after avastin. a p-value ≤ 0.05 was considered as statistically significant. results there were a total of 66 eyes of 44 patients all of whom were diabetic. there were 26 (59%) males and 18 females (41%). the best corrected visual acuity (bcva) in the eye to be treated (pre avastin bcva) was 6/18 visual acuity in 12 eyes (18%), 6/24 in 30 eyes (46%), 6/36 in 14 eyes (21%), 6/60 in 8 eyes (12%) and 3/60 in 2eyes (03%) (table 1). all 66 eyes were divided into 3 groups based on pre-avastin bcva. group 1 consisted of 10 eyes in whom bcva was 6/60 or less, group 2 consists of 44 eyes in whom bcva was 6/36-6/24 group 3 consists of 12 eyes in whom bcva was 6/18 or better (table 2). table 1: best corrected va of subjects before avastin. bcva number of eyes (n = 66, %) 6/18 12 (18.18) 6/24 30 (45.45) 6/36 14 (21.21) 6/60 8 (12.12) 3/60 2 (3.03) table 2: groups of subjects according to bcva. groups number of eyes (n = 66, %) bcva 1 10 (15.15) 6/60 or less 2 44 (66.67) 6/36-6/24 3 12 (18.18) 6/18 ata-ur-rehman, et al 82 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology in group 1, after 3 months of avastin treatment, bcva improved from 6/60 or less to 6/9 in 2 eyes, 6/12-6/18 in 4 eyes, 6/24-6/36 in 2 eyes and there was no improvement in 2 eyes (p < 0.005). in group 2, after 3 months of avastin treatment, bcva improved from 6/36 – 6/24 to 6/6 6/9 in 6 eyes, 6/12-6/18 in 24 eyes, 6/24 in 12 eyes and there was no improvement in 2 eyes (p <0.001). in group 3, after 3 months of avastin treatment, bcva improved from 6/18 to 6/9 in 3 eyes, 6/12 in 6 eyes and no improvement was observed in 3 eyes (p = 0.01) (table 3). all 66 eyes received 3 injections each while 24 eyes received 3 additional injections (table 6). effect of avastin treatment on dme whether it was completely resolved or partially resolved or not resolved at all based on clinical examination, ffa investigation and on post avastin bcva assessment was studied. in 8 (12.12%) eyes edema was completely resolved, in 44 (66.67%) it was partially resolved and in 14 (21.12%) it was not resolved at all (table 4). discussion diabetic eye disease is one of the commonest causes of blindness in pakistan13. it occurs due to changes in tiny blood vessels of the retina. 1. visual impairment in diabetic patients is mostly caused by macular oedema as well as the disruption of inner blood-retinal barrier. dme results from a series of biochemical cellular table 3: comparison of bcva in groups before and 3 months after avastin. groups pre-avastin bcva 3 months post avastin bcva pvalue 1 6/60 or less (n=10, 15.15% ) 6/9 (n=2, 20%) 6/12-6/18 (n=4, 40%) 6/24-6/36 (n=2, 20%) no improvement (n=2, 20%) <0.005 2 6/36-6/24 (n=44, 66.67%) 6/6-6/9 (n=6, 13.64%) 6/12-6/18 (n=24, 54.55%) 6/24 (n=12, 27.27%) no improvement (n=2, 4.54%) <0.001 3 6/18 (n=12, 18.18%) 6/6 (n=0, 0.0%) 6/9 (n=3, 25.0%) 6/12 (n=6, 50.0%) no improvement (n=3, 25.0%) 0.01 resolution of macular oedema in diabetic patients following avastin (bevacizumab) intravitreal therapy pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 83 table 4: post avastin outcome on oedema resolution. avastin outcome number of eyes (n = 66, %) edema completely resolved 8 (12.12) edema partially resolved 44 (66.67) edema not resolved 14 (21.21) case 1 . • . pre avastin angiogram showing extensive macular edema & va was 6/36. . • . post avastin angiogram of the same patient, after 3 avastin applications va improved to 6/6 changes, causing progressive leakage and exudation. focal grid photocoagulation used to be the standard of care for diabetic maculopathy. however, the availability of new agents raises the possibility of improvements if significant benefits can be validated in randomized clinical trials14. aozkir showed that intravitreal bevacizumab injection appears to be effective in the primary treatment of dme. in his study, 24 eyes showed an improvement in va with a decrease in fluorescence in leakage on ffa which was consistent with our study15. another study showed that with doses of 1.25 mg and 2.5 mg of avastin as primary treatment of diabetic macular edema there was an anatomical functional improvement in 55.1% of eyes16. still another study done by kumar et al also showed an improvement in bcva at 3 months with a significant decrease in macular thickness17. another study by khan et al showed the mean bcva of 0.726 logmar was improved to 0.452 logmar at the 3rd month after intravitreal bevacizumab18. there are other anti vegfs that are used in the treatment of diabetic macular edema like ranibizumab and aflibercept but bevacizumab remains the best option, in terms of price and value over aflibercept and ranibizumab for treatment of diabetic macular edema17. a few side effects were observed in our patients. although there were no systemic side effects. four patients developed mild anterior chamber reaction and 1 patient developed sub-conjunctival hemorrhage. another study quoted that side effects such as endophthalmitis, intraocular inflammation, retinal detachment, iop rise, sub-conjunctival hemorrhage and systemic side effects such as myocardial infarction and stroke may even occur. therefore close monitoring is advised of these patients who were treated with anti vegf18. there were a few limitations in our study. first, the follow-up time was relatively short, but visual and anatomical responses were apparent during the follow-up time. second, there is no control group in this study, but it can be argued that the enrolled eyes served as their own controls because the preand post-treatment vas and oedema map values of the same patients were compared. third, va was measured on a snellen chart as opposed to the more standardized accepted etdrs chart. however, all eyes were tested with the same correction throughout the follow-up period. conclusion from this small study of 44 diabetic patients in whom macular oedema was treated with avastin without ata-ur-rehman, et al 84 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology supportive grid laser photocoagulation, it has been evident that primary intra-vitreal avastin at doses of 1.25 mg seems to provide stability or improvement in va and ffa in dme at 6 months. intravitreal avastin injection provides remarkable improvement in visual acuity of diabetic patients and regression of macular oedema. author’s affiliation dr. ata ur rehman assistant professor department or unit: ophthalmology dr. saba alkhairy assistant professor department or unit: ophthalmology dr. farnaz siddiqui assistant professor department or unit: ophthalmology prof. mirza shafiq ali baig professor department or unit: ophthalmology role of authors dr. ata ur rehman study design, manuscript writing. dr. saba alkhairy manuscript revision. dr. farnaz siddiqui data collection. prof. mirza shafiq ali baig critical analysis. references 1. klein be. overview of epidemiologic studies of diabetic retinopathy. ophthalmic epidemiol. 2007; 14: 179–183. 2. pascolini d, mariotti sp. global estimates of visual impairment: 2010. br j ophthalmol. 2012; 96: 614–618. 3. nicholson bp, schachat ap. a review of clinical trials of anti-vegf agents for diabetic retinopathy. graefes arch clin exp ophthalmol. 2010; 248: 915–930. 4. klein r, klein be, moss se. visual impairment in diabetes. ophthalmology. 1984; 91: 1–9. 5. soheilian m, garfami kh, ramezani a, yaseri m, peyman ga. two-year results of a randomized trial of intravitreal bevacizumab alone or combined with triamcinolone versus laser in diabetic macular edema. retina. 2012; 32: 314–321. 6. lang ge, lang sj, klinik und therapie des diabetis chenmakulaödems. klinische monatsblatterfür augenheilkunde 2011; 228: 1–13. 7. lang ge. diabetic macular edema. ophthalmologica. 2012; 27: 21–29. 8. stefanini fr, arevalo jf, maia m. bevacizumab for the management of diabetic macular edema, world journal of diabetes. 2013; 4: 19–26. 9. ozkiris a, evereklioglu c, oner a, erkilic k. pattern electroretinogram for monitoring the efficacy of intravitreal triamcinolone injection in diabetic macular edema. doc ophthalmol. 2004; 109: 139-145. 10. ozkiris a, evereklioglu c, erkilic k, tamcelik n, mirza e. intravitreal triamcinolone acetonide injection as primary treatment for diabetic macular edema. eur j ophthalmol. 2004; 14: 543-549. 11. presta lg, chen h, o'connor sj, chisholm v, meng yg, krummen l et al. humanization of an antivascular endothelial growth factor monoclonal antibody for the therapy of solid tumors other disorders. cancer res. 1997; 57: 4593-4599. 12. chen y, wiesmann c, fuh g, li b, christinger hw, mckay p et al. selection analysis of an optimized antivegf antibody: crystal structure of an affinity-matured fab in complex with antigen. j mol biol. 1999; 293: 865881. 13. shaikh a, fahemullah s, ziauddin a, jamshed a. prevalence of diabetic retinopathy influence factors among newly diagnosed diabetics in rural urban areas of pakistan. pakistan journal of medical science, 2008; 24: 6. 14. yannis m, paulus mark s, blumenkranz, md. panretinal photocoagulation for treatment of proliferative diabetic retinopathy. american academy of ophthalmology 2013. 15. ozkirs a. intravitreal bevacizumab (avastin) for primary treatment of diabetic macular oedema. the scientific journal of royal college of ophthalmologists. 2009; 23 (3): 616-620. 16. arevalo jf, fromow-guerra j, quiroz-mercado h, et et al. primary intravitreal bevacizumab (avastin) for diabetic macular edema. results from the pan-american study group at 6 months follow up. ophthalmology 2007; 114: 743-750. 17. kumar a, sinah s. intravitreal bevacizumab treatment of diffuse macular edema in an indian population. indian j ophthalmol. 2007; 55: 451-455. 18. khan a, amir ac, zahid c. intravitreal bevacizumab for treatment of diabetic macular edema. pak j ophthalmol 2012; 28: 3-9. 19. deepak c. bevacizumab offers best value of anti-vegf drugs to treat dme. endocrinology news. 2016. 20. ghasemi k, nguyen qd. adverse events complications associated with intravitreal injections of anti vegf agents. eye, 2013; 27: 787-794. microsoft word index-12.doc abstracts edited by dr. tahir mahmood factors affecting outcome of punctoplasty surgery: a review of 205 cases shahid h, sandhu a, keenan t, pearson a br j ophthaimol 2008; 92: 1689-92 punctoplasty (alternatively know as the one-, two or three-snip procedure) is a common procedure carried out by ophthalmic surgeons for punctal stenosis in the management of symptomatic epiphora. it is a simple procedure that may be carried out by both oculoplastic specialists and general ophthalmic surgeons. this study reviews the indications, surgical techniques and outcomes of punctoplasty surgery for 205 patients in a 4-year period. the aim was to identify factors that might lead to an improved surgical outcome. the influence of surgical technique, grade of operating surgeon and the choice of postoperative topical medication were assessed. authors identified all patients who underwent punctoplasty surgery from april 2002 to june 2006 within the royal berkshire nhs trust, uk. no patient had an additional procedure simultaneously. hospital records were used to ascertain the proportion of patients who were appropriately assessed preoperatively, the anatomical and functional success rates for surgery and the patient satisfaction rate. we assessed the influence of surgical technique, grade of operating surgeon and the use of postoperative topical medication on these outcomes. eighty-two per cent of patients had an appropriate preoperative assessment. amongst these, the anatomical and functional success rates for punctoplasty surgery were 91% and 64%, respectively. the patient satisfaction rate was 71%. the grade of surgeon did not significantly affect outcome of punctoplasty (p = 0.4). the use of topical steroids postoperatively did not significantly improve surgical outcome (p 0.7). there was no significant difference in anatomical success between a two-snip versus a threesnip punctoplasty technique (p = 0.7). however, in the presence of anatomical success the two-snip procedure gave significantly greater functional success (p = 0.03). authors concluded with the remarks that this is the largest reported consecutive case series of isolated punctoplasty surgery. overall anatomical success was high and the surgical technique, grade of surgeon and choice of postoperative medication did not significantly alter the outcome. without adequate preoperative assessment a significant proportion of patients may undergo surgery inappropriately. even with an adequate assessment anatomical success is not always followed by resolution of epiphora. changes in corneal wavefront aberrations in microincision and small-incision cataract surgery tong n, he jc, lu f, wang q, qu j, zhao ye j cataract refract surg. 2008; 34:2085-90 in microincision cataract surgery (mics), the incision is approximately 1.5mm, which is about half the size of the incision in small-incision cataract surgery (sics). because of the smaller incision, mics is expected to have less effect than sics on the optical quality of the corneal. this has been shown in studies of corneal astigmatism, which found less induced astigmatism with mics than with sics. at present, the most widely used technique for evaluating corneal optical quality is corneal topography, which produces color maps that show, among other things corneal astigmatism. another technique, wavefront analysis, allows quantitative characterization of localized changes in the corneal shape with zernike polynomial functions from the same set of the corneal topography data, given that the system is carefully calibrated. the purpose of this study was to evaluate effect of incision size on the optical quality of the anterior cornea by comparing the changes in corneal wavefront aberrations between microincision cataract surgery (mics) and small incision cataract surgery (sics). this prospective randomized clinical study included 36 eyes having mics (1.5 mm) and 38 eyes having sics (3.0 mm). anterior corneal topography was measured preoperatively and 3 to 6 months postoperatively. the data were used to calculate anterior corneal zernike aberrations (through the 6th order) for a 6.0 mm central area. in the mics group, 2 corneal zernike aberrations (trefoil and tetrafoil) changed significantly from preoperatively to postoperatively (both p<.0001). in the sics group, in addition to trefoil and tetrafoil, oblique astigmatism (p<.0001), secondary oblique astigmatism (p = .001), and vertical tetrafoil (p = .001) changed significantly. the sics group had greater changes than the mics group in oblique astigmatism (p = .0001), oblique trefoil (p = .0035), and vertical tetrafoil (p = .0023). the changes in the sics group were significantly greater than in the mics group in the total root mean square (rms) (p = .007) and higher-order rms (p = .023) of corneal wavefront aberrations. authors concluded with the remarks that cataract surgery-related changes in corneal wavefront aberrations were dependent on incision size. the mics technique had advantages over the sics technique in minimizing the effect of the incision size on the optical quality of the cornea. higher-order aberrations induced by nuclear cataract lee j, kim mj, tchah h j cataract refract surg. 2008; 4: 2104-9 cataract is a major cause of visual decline in older people. of the many kinds of opacities, nuclear cataracts have a strong relationship to the aging process. older people have decreased visual function as nuclear sclerosis progresses due to the change in the refractive index, which can in turn result in refractive errors. however, the deterioration in visual function in these patients cannot be entirely explained by spherical or cylindrical refractive errors. nuclear cataract can also decrease visual function by affecting contrast sensitivity. deterioration in contrast sensitivity can be explained in terms of scatter and increased higher-order aberrations (hoas). scatter is more relevant to the peripheral cortex than the central lens. thus, scatter affects visual function, especially in those with cortical cataract. because scatter is unlikely to contribute to contrast sensitivity in eyes with nuclear cataract, hoas may play a more important role in decreased contrast in patients with this type of cataract. the introduction of wavefront sensors in clinical practice has provided clinicians with an effective method of examining visual quality in more objective and definitive terms. one such method is to measure hoas. in this study, we analyzed hoas in entire eyes and in the internal optics (lenses) in patients with various grades of nuclear cataracts. the purpose of this study was to measure higherorder aberrations (hoas) in the entire eye and in the internal optics (lens) in patients with nuclear cataract. a visual function analyzer that combines raytracing aberrometry and corneal topography was used to measure wavefront aberrations in 33 eyes of 20 patients who had nuclear cataract. the wavefront maps of the entire eye were similar to those of the internal optics. the average root mean square (rms) of hoas in the entire eye and in the internal optics was 1.59 µm and 2.13 µm, respectively, with an optical zone of 6.5 mm. the predominant hoa in the entire eye and the internal optics was coma; the mean rms of coma was 0.98 µm in the entire eye and 1.28 µm in the internal optics. the spherical aberration of the internal optics correlated negatively with the grade of nuclear cataract (r = 0.450, p = .009). authors concluded with the remarks that most hoas in eyes with nuclear cataracts were due to the internal optics; coma was the predominant hoa. the grade of nuclear cataract was negatively correlated with the amount of spherical aberration. these findings may explain the subjective symptoms in patients with nuclear cataract. estimation of the effective lens position using a rotating scheimpflug camera ho jd, liou sw, tsai rjf, md, tsai cy j cataract refract surg. 2008; 34: 2119-27 intraocular lens (iol) power calculations are difficult in eyes that have had refractive surgery. there are 2 main sources of errors. first, inaccurate calculation of the corneal power from the anterior corneal radius can occur when the standardized keratometric index of 1.3375 is used. second, incorrect estimation of the post cataract surgery iol position (effective lens position [elp]) by third-generation or fourth-generation theoretical iol power calculation formulas can occur when the corneal power value after refractive surgery (kpost) is used. this leads to underestimation of the elp and thus of iol power, resulting in hyperopia even when the postoperative corneal power is derived by a clinical history method. to overcome these problems, several methods have been proposed, of these, the double-k clinical history method seems to be promising. in this method, the keratometry (k) value before refractive surgery (kpre) is used for elp estimation, and kpost is used for the iol power calculation by the vergence formula. this approach improves the accuracy of the iol power calculation after laser in situ keratomileusis (lasik) and photorefractive keratectomy (prk). although it is a good method, the double-k clinical history method requires knowledge of historical data, including the kpre value. if the kpre value is unavailable, it will be difficult to obtain the elp used in the third-generation or fourth-generation formulas and thus difficult to apply the double-k method. the purpose of this study was to describe a nohistory method of estimating the effective lens position (elp) for double-k intraocular lens (iol) power calculation in eyes that had previous refractive surgery. the corneal height (hm) and anterior chamber diameter (agm) in 106 unoperated eyes were measured using a rotating scheimpflug camera. the theoretical anterior corneal radius (rrt) was then derived from hm and agm by regression and rearrangement of the fyodorov equation. the elp estimate was then calculated from rrt. the performance of this elp estimation method in doublek iol power calculation and the performance of other methods were compared retrospectively in 11 eyes having cataract surgery that had previous refractive surgery. the refractive results 9 to 12 weeks after cataract surgery were selected for data analysis. the new elp estimation method, combined with the besst formula or the savini et al. method for estimating post refractive-surgery corneal power (kpost) in the double-k srk/t formula, provided the best iol power prediction results. the mean arithmetic and absolute iol prediction errors were -0.05 ± 0.62 diopters (d) and 0.49 ± 0.34 d, respectively, when combined with the besst formula and 0.03 ± 0.73 d and 0.60 ± 0.36 d, respectively, when combined with the savini et al. method. with either combination, all 11 eyes were within ± 1.00 d of the refractive prediction error. authors concluded with the remarks that this elp estimation method may be helpful for iol power calculation in post refractive surgery eyes when historical data are unavailable. microsoft word cat 27, 2,11 113 cat cat (t) is out of the bag rehman siddiqui pak j ophthalmol 2011, vol. 27 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: remzan siddiqui shahzad eye hospital (pvt) ltd. b-2, block 16. gulshan-e-iqbal, karachi, pakistan june’ 2011 …..……………………….. he much anticipated results of comparison of amd treatment trial (catt) were out a few weeks ago. catt study is a landmark trial in comparative clinical research. indeed, the study was not sponsored by the pharmaceutical industry instead it was supported by national eye institute (nei), usa. dr martin and his colleagues are to be applauded for undertaking such a high quality study. for this study to take place various laws governing use of medications and reimbursement in the usa had to be amended. the study was published in new england journal of medicine1 and an editorial by dr. philip rosenfeld (the father of avastin) was published in the same issue2. background nei launched the catt study in 2008 to compare avastin and lucentis for treatment of neovascular amd. the aim of the study was to compare monthly lucentis, monthly avastin, as needed (prn) lucentis and prn avastin treatment regimens. patients were randomly assigned and treated with one of the four regimens. catt is a non-inferiority study. under the rules of the trial, patients treated with avastin could read on average of up to five fewer letters on an etdrs chart than those treated with lucentis and avastin would still be considered "non-inferior". to allow for six pair-wise comparisons with a 99% confidence interval, a sample size of 300 patients in each group was required (n=1200). in prn groups, after a single injection, further injections were given on an as needed basis. patients were followed up every month with clinical examination and oct. note that unlike pronto study3, the patients in the prn arms, were not given 3 loading injections at the start. injections were repeated whenever deemed appropriate based on the clinical and oct findings. it is worth noting that the study had much broader “real world” inclusion criteria of “active amd”, compared to previous amd studies where the inclusion criteria had been quite narrow. results the study has now reported one-year results for 1,185 patients treated at the 43 clinical centers in usa. when considering 5 letters difference as a clinically meaningful effect, there was no statistical difference between the groups. note that in previous trials for amd a meaningful effect was defined as 3 or more lines on edtrs (15 letters). therefore, the study was powered to pick even a small difference between the efficacy of lucentis and avastin. the groups were also similar in other visual acuity measures as well: those who gained 3 lines, avoided 3 lines loss, or achieved at least 20/40 vision. the mean decrease in central retinal thickness was t 114 greater in the lucentis-monthly group (196 µm) than in the other groups (152 to 168 µm, p=0.03 by analysis of variance). does this translate into reduced vision at the final follow up (month 24) is yet to be seen. in the first year of the study, time domain oct was used. in the second year of this study spectral domain oct will be used. higher resolution sd-oct may result in increased detection of fluid and subsequent treatment. because patients in the fixed monthly dosing arm received injections every month regardless of the oct, using a higher resolution sdoct is likely to have a selective effect on the prn arms of the study. safety issues in contrast with the one-year results, which suggested that lucentis might be somewhat safer than off-label avastin, major adverse events during the trial's second year appeared to be about equal. in the nejm manuscript one year adverse events were reported. however, at the arvo annual meeting principal authors of the study reported that rates of death, stroke, and all arterio-thrombotic events were equal between the two drugs during the trial's second year (p>0.20) (table 2). this is reassuring, as these side effects have been highlighted as areas of concern in previous studies. the frequency of serious adverse events (saes) (= hospitalisation for any cause) was marginally higher in avastin compared to lucentis group (24.1% vs. 19.0%; risk ratio, 1.29; 95% confidence interval, 1.01 to 1.66). there was no statistical difference when the 4 groups were compared separately, however when avastin monthly and as needed groups, and lucentis monthly and as needed arms, were stacked up there was a marginal difference (p=0.04). however, in a study of multiple comparisons, one would expect a p value of <0.01 to be statistically significant. the study was not powered to pick up rare but serious adverse events. it is estimates that a study to prove safety differences between the drugs, if any, would require a much larger sample size of up to 20,000 patients. the differences in this study are probably a chance finding because: 1. there were imbalances in baseline health between avastin and lucentis patients. more of the former had diabetes, hypertension, congestive heart failure and other medical conditions. additionally, patients in avastin group were one year older. 2. excess events were broadly distributed across many disease categories (eg. pneumonia, surgical procedures, fractures, etc). these were not identified in previous cancer trials as areas of concern – when avastin was used at 500 times higher dosage. 3. there were more saes for both drugs when they were used less (eg. in prn groups). does this mean that we are putting our patients at increased risk of a hip fracture or urinary tract infection by treating less often? most would agree that it is unlikely the events are even remotely related. let us not forget previous drug safety controversies, including rosiglitazone and the cox-2 inhibitors. small increases in risk seen in controlled clinical trials and in epidemiological studies were not followed up appropriately. therefore, continued pharmaco-vigilance and further robust studies are needed to prove any real safety differences between the two drugs. cost lucentis $2,000 (about rs 80,000 in pakistan) per injection. avastin$50 (rs 1000-3,500 in pakistan) per injection in addition to providing effective and safe treatment to our patients, we must remain mindful of the health economic implications of high-cost therapies. roche sells lucentis in the united states and novartis in other countries. sales of the drug for each company were about $1.5 billion last year. anti-vegf non-responders we know that there are patients who simply do not respond to anti-vegf treatment. it is possible that some unknown genetic factors determine this response. the catt study will hopefully help answer this question as well. all patients in the trial underwent genetic testing. the results will be matched against drug response and outcomes. the genetic information gathered will be extremely important in understanding different treatment response. perhaps patient specific genetic profiling will allow us to customize most appropriate treatment for individual patient. 115 table 1: mean gain in visual acuity and number of injections at 1 year. lucentis avastin no of injections fixed monthly regimen 8.5 8.0 11.7 vs 11.9 as needed regimen 6.8 5.9 6.9 vs 7.7 table 2: adverse events data for two years follow up. lucentis avastin p value all cause mortality 2.8% 2.9% p=1.00 arteriothrombotic events 2.2% 1.7% p=0.68 stroke 1.2% 1.2% p=1.00 future i am open to the fact that efficacy findings of these two vegf inhibitors for neovascular amd may not transfer to patients with other conditions, such as rvo and dme, and that these drugs may behave differently for individual patients. catt study proved that avastin is non-inferior to lucentis in wet amd. 4 the onus is now on lucentis to prove it's superiority over avastin in other clinical scenarios requiring vegf inhibition. authors affiliation rehman siddiqui shahzad eye hospital (pvt) ltd. b-2, block 16, gulshan-e-iqbal, karachi-75300, pakistan references 1. catt research group, martin df, maguire mg, ying gs, grunwald je, fine sl, jaffe gj. ranibizumab and bevacizumab for neovascular age-related macular degeneration. n engl j med. 2011 19; 364: 1897-908. free full text http://www.nejm.org/doi/pdf/10.1056/nejmoa1102673 2. rosenfeld pj. bevacizumab versus ranibizumab for amd. n engl j med. 2011; 364: 1966-7. 3. lalwani ga, rosenfeld pj, fung ae, et al. a variable-dosing regimen with intravitreal ranibizumab for neovascular agerelated macular degeneration: year 2 of the pronto study. am j ophthalmol. 2009; 148: 43-58. 4. aao statement on catt study. http://www.aao.org/ newsroom/release/20110428.cfm accessed 12/06/2011. glaucoma after cataract surgery the iridocorneal angle may become wider reducing the iop somewhat. m lateef chaudhry editor-in-chief microsoft word uzma fasih 133 original article safety and efficacy of subtenon anesthesia in anterior segment surgeries uzma fasih, waqar ul huda, m.s fehmi, arshad shaikh, nisar shaikh, atiya rahman, asad raza jafri pak j ophthalmol 2011, vol. 27 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: uzma fasih spencer eye hospital unit 2 karachi medical and dental college submission of paper november’ 2010 acceptance for publication august’ 2011 …..……………………….. purpose: the objective of the study was to evaluate the complications of subtenon anesthesia in patients undergoing anterior segment surgeries materials and methods: the study was conducted in the department of ophthalmology, abbasi shaheed hospital, from january 2009 to june 2010. 150 patients were selected amongst those presenting in outpatient department for anterior segment surgery using non-probability consecutive sampling technique. patients were scheduled for elective ophthalmic procedures with an expected duration of less than 60 min. patients with clotting abnormalities, impaired mental status, uncontrolled glaucoma, were excluded from the study. 2 ml of 2% xylocaine with adrenaline (plain xylocaine where adrenaline was contraindicated) was injected using a subtenon cannula in supratemporal quadrant of the eye ball. we recorded complications including patient discomfort, inadequate anesthesia, conjunctival chemosis, subconjunctival haemorrhage, reterobulbar haemorrhage. results: a total of 150 patients were operated under subtenon anesthesia. majority of the procedures performed were extra capsular cataract extraction (55.3%) followed by trabaculectomy (24%). most common complication in our study was subconjunctival haemorrhage (48%) followed by conjunctival chemosis (37%). other complications like inadequate anesthesia were seen in 12 (8%) patients and inadequate akinesia in 18 (12%) patients. a second injection was required in 12 (8%) patients. simultaneous use of topical anesthetic was recorded in 18 (12%) patients. reterobulbar haemorrhage occurred in a small percentage (2%) of patients in our study. in addition pupillary constriction after delivering the nucleus 45 (30%) patients and positive vitreous pressure leading to raised intra ocular pressure and iris prolapse 3 (2%) patients were also recorded. 58(39%) patients complained of pain and discomfort during the injection. conclusion: majority of complications encountered in this study were minor like subconjunctival heamorrhage, conjunctival chemosis, inadequate anesthesia and akinesia. major complications like reterobulbar heamorrhage and positive vitreous pressure leading to raised intraocular pressure during the surgery were uncommon but present. subtenon anesthesia though safe is not devoid of complications. here are substantial international variations in the care and provision of ophthalmic regional anesthesia1-5. in 1884 herman knapp was the first to describe the reterobulbar block6. the complications related to needle block, such as retrobulbar haemorrhage, globe perforation, retinal vascular obstruction, cardio-respiratory arrest and even death, although rare, have been reported7,8. t 134 in 1970s peribulbar block was developed for clinical use9. further techniques like topical and subtenon anesthesia10 were developed in an attempt to minimize potentially serious complications with retero bulbar and peribulbar anesthesia11-13. sub-tenon’s block is a simple alternative 14 to a sharp needle block. subtenon space is a potential space between the tenon capsule and sclera with capacity of about 1.5 ml. it extends from corneoscleral limbus anteriorly to the optic nerve posteriorly. it is an ideal space where local anesthetic can diffuse to secure complete anesthesia of the globe as all the sensory nerves from the eye cross this space. additionally the local anesthetic percolates through the thin area of the tenon capsule around the optic nerve and has anesthetic effects in the orbit. the exact frequency of the use of this technique is not known. it is commonly practiced in certain parts of the world15, 16 but only 7% of ophthalmic departments in the uk practiced this block in 19974,5. its use now appears to have increased17. the technique was first described by turnbull in 188418 and later by swan in 195619. although it is a very safe and effective procedure and common complications of sub-tenon’s block are mainly minor, although rare major complications have also been reported. we conducted this study to evaluate this procedure. materials and methods a total of 150 patients were recruited using non probability consecutive sampling technique from patients presenting in outpatient department who were planned for anterior segment surgery from january 2009 to june 2010. after recruitment written informed consent was taken and patients were admitted and prepared for surgery. patients undergoing procedures having less than 60 minutes duration were included in the study. the patients with clotting abnormalities, impaired mental status, uncontrolled glaucoma, recent surgical procedure on the same eye were excluded. topical proparcaine 0.5% was instilled thrice with one minute interval five minutes before subtenon anesthesia for all patients. subtenon space was opened using westcott scissors to expose white sclera in the supro temporal quadrant of the eye ball. 2 ml of 2% xylocaine with adrenaline (plain xylocaine where adrenaline was contraindicated) was injected using a subtenon cannula mounted onto a 5 ml syringe. we recorded complications including patient discomfort, inadequate anesthesia, conjunctival chemosis, subconjunctival haemorrhage and retrobulbar haemorrhage both peroperatively and postoperatively. results a total of 150 patients were operated under subtenon anesthesia. 56% patients were male and 44% were female. (table 1) majority of the patients (45%) were between 50 and 60 years, whereas, 27.3% were between 40 to 50 years of age. (table 2) majority of the procedures performed were extra capsuler cataract extraction (55.3%) followed by trabculectomy 24% (table 3). common complications we encountered were subconjunctival haemorrhage 48% followed by conjunctival chemosis 37%. other complications like inadequate anesthesia were seen in 12 (8%) patients and inadequate akinesia in 18 (12%) patients, repeat injections in 12 (8%) patients were also recorded. simultaneous use of topical anesthetic was recorded in 18 (12%) patients. reterobulbar heamorrhage occurred in a small percentage (2%) of patients in our study. in addition pupillary constriction after delivery of the nucleus occurred in 45 (30%) patients and positive vitreous pressure leading to raised intra ocular pressure and iris prolapse occurred in 3 (2%) patients. 58 (39%) patients complained of pain and discomfort during the injection. discussion we conducted this study to assess the complications secondary to subtenon anesthesia. the complications encountered with this method were minor and easily manageable but occasional major complications were also encountered. most common complication encountered in our study was sub-conjunctival haemorrhage (48%). the incidence of haemorrhage has been reported to vary from 20 to 100% in other studies and may depend on the type of cannula used20. conjunctival haemorrhage may be caused by conjunctival dissection. this can be minimized by careful conjunctival dissection, application of cautery and use of topical epinephrine. patients should be warned of the possibility of this complication preoperatively. 39% patients complained 135 of discomfort and pain during the injection. pain experienced during various ophthalmic blocks depends on multiple factors. table 1: gender distribution sex no. of patients n (%) male 82 (56) female 68 (44) table 2: age distribution age in years no. of patients n (%) 20-30 2 (1.3) 30-40 2 (1.3) 40-50 51 (34) 50-60 60 (40) 60-70 35 (23.3) table 3: surgical procedures performed under subtenon anesthesia procedure no. of patients n (%) trabeculectomy 36 (24) ecce with iol 83 (55.3) phaco with iol 31 (20.7) the incidence of pain during sub-tenon injection reported in various studies can be up to 44%14,20. premedication or sedation of patients during subtenon injection did not help to prevent pain in these studies. preoperative explanation of the procedure, good surface anesthesia, gentle technique, slow injection of warm local anesthetic agent and reassurance are considered good practice and may reduce the discomfort and anxiety during the injection22. conjunctival chemosis was seen in 37% of the patients. the incidence of chemosis varies from 25% to 60%14,20 with a posterior cannula and the incidence increases to 100% with shorter cannulae21. chemosis occurs due to anterior injection of the anesthetic agent. this usually occurs if a large volume of local anesthetic is injected and if the tenon’s capsule is not dissected properly21. chemosis may not be confined to the site of injection and has been known to spread to other quadrants as well21. chemosis usually resolve after the application of digital pressure, and no intraoperative problems have been reported secondary to it. significant chemosis may compromise the surgical procedure for glaucoma. table 4: complications of subtenon anesthesia complications no. of patients n (%) difficulty to reach subtenon space 18 (12) repeat injection 12 (8) 3.inadequate anesthesia 12 (8) inadequate akinesia 18 (12) patient discomfort and pain during injection 58 (39) subconjunctival haemorrhage 72 (48) conjunctival chemosis 55 (37) reterobulbar haemorrhage 3 (2) positive vitreous pressure leading to raised intraocular pressure and iris prolapse 3 (2) pupillary constriction after delivering the nucleus 45 (30) simultaneous use of topical anesthetic 18 (12) anesthesia with sub tenon block was adequate in most of the cases, but 8% of the patients required augmentation with more injection. in our study inadequate akinesia was seen in 12% of the patients. in other studies akinesia was variable and was not complete23. akinesia is volume dependent and if 4-5 ml local anesthetic agent is injected, a large proportion of patients develop akinesia22. superior oblique muscle and lid movements may also remain active in a significant number of patients22. we encountered difficulty in reaching sub-tenon space in 12% of the patients as compared to the study conducted at larkana in which it was noticed in 10.8% of the patients. this difficulty was probably due to 136 improper patient selection and inadequate anesthesia. it was easily overcome by explaining the procedure to the patient and reassurance. positive vitreous pressure leading to raised intraocular pressure and iris prolapse were found in 2% patients. similar results were (3.2%) were seen in a study from larkana24. complications like short term muscle paresis, globe perforation and cardio respiratory arrest due to central spread of local anesthetic have been reported but we did not encounter this complication in our study21, 25. reterobulbar heamorrhage occurred in 3 (2%) patients in our study. this complication has also been reported in other studies26-28. we selected supero-temporal quadrant for subtenon anesthesia in our study. access from all quadrants has been reported, supero-temporal by fukasaku and marron, superonasal and inferotemporal by roman and colleagues14 and the medial canthal side by ripart and colleagues24. it is not known how frequently these quadrants are used for access. we found supero-temporal quadrant anatomically safe and adequate. moreover, this site is covered by the upper lid, hiding the subconjunctival heamorrhage and thus prevents anxiety on first postop day. conclusion in our study subtenon anesthesia was safe and effective method for anterior segment intraocular surgery but not devoid of complications. though majority of complications were minor and easily manageable but some major complications like reterobulbar heamorrhage and positive vitreous pressure with iris prolapse may have adverse effects on the outcome of surgery. author’s affiliation dr. uzma fasih associate professor spencer eye hospital unit ii karachi medical and dental college dr. waqar ul huda trainee registrar spencer eye hospital unit ii karachi medical and dental college dr. m.s fehmi professor spencer eye hospital unit ii karachi medical and dental college dr. arshad shaikh professor spencer eye hospital unit ii karachi medical and dental college dr. nisar shaikh associate professor eye department abbasi shaheed hospital unit 1 karachi medical and dental college dr. atiya rahman assistant professor spencer eye hospital unit ii karachi medical and dental college dr. asad raza jafri assistant professor eye department abbasi shaheed hospital unit 1 karachi medical and dental college reference 1. norregaard jc, schein od, bellan l et al. international variation in anesthesia care during cataract surgery: results from the international cataract surgery outcomes study. arch ophthalmol. 1997; 115: 1304-8. 2. hansen te. current trends in cataract surgery in denmark – 1998 survey. acta ophthalmol scand. 1999; 77: 685–9. 3. eke t, thompson jr. the national survey of local anaesthesiafor ocular surgery. i. survey methodology and currentpractice. eye 1999; 13: 189–95. 4. eke t, thompson jr. the national survey of localanaesthesia for ocular surgery. ii. safety profiles of localanaesthesia techniques. eye 1999; 13: 196–204. 5. leaming dv. practice styles and preferences of ascrs members – 2003 survey. j cataract refract surg. 2004; 30: 892– 900. 6. altman a j, albert dm, fournier ga. cocainn’s use in ophthalmology: our 1oo year heritage, surv ophthalmol. 1985; 29: 300-6. 7. rubin ap. complications of local anaesthesia for ophthalmicsurgery. br j anaesth. 1995; 75: 93-6. 8. hamilton rc. complications of ophthalmic anesthesia. ophthalmol clin north am. 1998; 11: 99–114. 9. davis db, mandel mr. posterior peribubar anesthesia :an alternative to reterobulbar anesthesia j cataract refract surg: 1986: 12: 182-4. 10. rous sm. simplified subtenon anesthesia: miniblock with maxiblock effect. j cataract refract surg. 1999; 25: 10-5. 11. haider sa. survey of the practice of cataract surgery under local anesthesia in england and wales. pak j ophthalmol. 1998: 14; 104-7. 12. tatum pl, defalque rj. subarachnoid injection during reteobulbar block: a case report aana j. 1994: 62; 49-52. 137 13. mount am, seward hc. scleral perforation during peribulbar anesthesia eye. 1993: 7: 766-7. 14. roman sj, chong sit da, boureau cm. sub-tenon’s anaesthesia: an efficient and safe technique. br j ophthalmol. 1997; 81: 673–6. 15. elder m, leaming d. the new zealand cataract and refractive surgery survey 2001. clin exp ophthalmol. 2003; 31: 114-20. 16. hansen te. current trends in cataract surgery in denmark – 1998 survey. acta ophthalmol scand. 1999; 77: 685–9. 17. eke t, thompson jr. safety of local anaesthesia for cataract surgery: why we should look again. eye 2003; 17: 127-8. 18. turnbull cs. the hydrochlorate of cocaine, a judicious opinion of its merits. med surg rep. 1884; 29: 628–9. 19. swan kc. new drugs and techniques for ocular anesthesia. trans am acad ophthalmol otolaryngol. 1956; 60: 368. 20. verghese i, sivraj p, lai yk. the effectiveness of sub-tenon’s infiltration of local anaesthesia for cataract surgery. aust new zeal j ophthalmol. 1996; 24: 117–20. 21. kumar cm, dodds c. evaluation of greenbaum sub-tenon’s block. br j anaesth. 2001; 87: 631–3. 22. kumar cm, williamson s, manickam b. a review of subtenon’s block: current practice and recent development european journal of anaesthesiology. 2005; 22: 567–77. 23. guise pa. sub-tenon anesthesia: a prospective study of 6,000 blocks. anesthesiology. 2003; 98: 964–8. 24. shah ais, siddiqui js, deepar dm, et al. subtenon anesthesia in anterior segment surgey. pak j ophthalmol. 2006; 22: 186-8. 25. mount am, seward hc. scleral perforations during peribulbar anesthesia. eye 1993; 7: 766-7. 26. ripart j, jean j, bassoul b, et al. ophthalmic regional anesthesia medial canthal episcleral (subtenon) single injection block anesthesiology. 2004; 100; 370-4. 27. olitsky se, juneja rg. orbital haemorrhage after theadministration of sub-tenon’s infusion anaesthesia. ophthalmic surg lasers. 1997; 28: 145–6. 28. rahman i, ataullah s. retrobulbar haemorrhage aftersubtenon’s anesthesia. j cataract refract surg. 2004; 30: 2636-7. microsoft word ejaz ahmad javed 91 original article phacoemulsification under topical anesthesia alone versus topical anesthesia with subconjunctival infiltration of 2% lignocaine ejaz ahmad javed pak j ophthalmol 2010, vol. 26 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ejaz ahmad javed ophthalmology department) dhq & allied hospital. pmc faisalabad. received for publication july’ 2009 …..……………………….. purpose: to compare and determine patients and surgeon’s comfort and satisfaction in phacoemulsification under topical anesthesia with proparacain hydrochloride 0.5% versus subconjunctival infiltration of 2% lignocaine. material and methods: the study was conducted in the department of ophthalmology allied and dhq hospitals, pmc faisalabad from may 2008 to june 2009. 90 patients of cataract divided into two groups, a and b each containing 45 patients were included in this study. phacoemulsification was performed on group a under topical anesthesia with proparacaine hydrochloride 0.5% and on group b under topical anesthesia alongwith subconjunctival infiltration of 2% lignocaine. all the patients in both groups were operated by same surgeon. the surgeon and patients satisfaction score was entered in a standardized performa. results: 40 patients (88.89 %) in group a, felt no pain while 5 patients(11.11%) felt pain up to the extent that 0.5 cc of 2 % lignocaine was needed to infiltrate at the phaco port site in the conjunctiva and then the procedure of phacoemulsification was completed comfortably and pain free. in one patient (2.22%) in group a, the nucleus dropped into the vitreous and was referred to vitroretinal surgeon for further management. the mean phaco time was 2.1 minutes while mean operation time was 25 minutes. in group b, the patients were operated after infiltration of 0.5 cc 2 % lignocaine injection in the conjunctiva at phaco port site. all the patients were operated pain free while 10 patients (22.22%) in this group showed bleeding at the phaco port site. this bleeding was managed with a swab on gentle pressure for two minutes. the mean phaco time was 2.0 minutes and mean operation time was 25.0 minutes. the extension of ccc was seen in 5 patients(11.11% ) in group a and 2 patients(4.44 ) in group b .the posterior capsule rent was seen in 2 patients (4.44% ) in a group and in 2 patients(4.44% ) in group b. conclusion: the subconjunctival infiltration of 2% lignocaine injection near phaco port site is superior to topical anesthesia with proparacaine hydrochloride during phacoemulsification in ensuring patient’s and surgeon’s comfort. none of the patients in any group showed the complications as sometimes seen in periocular or retrobulbar anesthesia. 92 ritten history of cataract spans over 20 centuries. an african’s and an arabic oculist translated into latin cataracta meaning; some thing poured underneath something the waterfall1. early surgeons, performing couching had no idea of pushing something behind the pupil was the human lens. in 16th century atoine jan and michel pierre identified from autopsy specimen that the cataract was truly the crystalline lens itself2. the written proof of couching came from susruta an indian surgeon3. daviel performed extracapsular extraction from inferior limbus in sitting position4. pierre francos shifted incision to the upper limbus while sitting on head side of patient. the pharmacological mydriasis and planned iridectomy was introduced by carl himly5. the next break through came in intracapsular surgery with the development of chemical zonulysis using an enzyme -chymotrysin6. aphakic correction with contact lens started established from 1940. harold ridlely implanted first synthetic lens on november 29, 19497. first feeling of intact supports for iol was urged by cornelius binkhorst. kelman introduced his phacoemulsifier in 1967 but many intracapsular surgeons were not convinced8. after that robert sinskey and john sheets were more popular in small incision ultrasonic surgery9. howard gimbel introduced capsulorhexis first time10. small incision closing sutures introduced by john shepherd and later by howard fine11. kelman performed phacoemulsification into anterior chamber and d. calvard, kratz t performed phacoemulsification into the papillary plane12. endocapsular phacoemulsification was introduced by shephard13. several studies have demonstrated that topical anesthesia provides satisfactory analgesia, comparable with regional blocks (retrobulbar, peribulbar and subtenon,s anesthesia)14. materials and methods the ninety patients having cataract were divided into two groups a and b each having 45 patients. the age of patients ranged between 50 to 70 years. both male and female patients with anterior, posterior, nuclear, cortical or grade 1 to 3 cataract were included in the study. following patients were excluded from the study; • having history of trauma and ocular surgery • having corneal opacity • uncooperative patients • claustrophobic patients pre operative ocular and systemic assessments along with routine investigations were carried out. all the surgeries were done by the same doctor. the preoperative medicines included,1 tab. diamox, 1 tab. neo-k,1 tab. valium 5 mg, 1 tab. levoflaxacine and these were given an hour before starting surgery to each patient. every patient’s pupil was dilated with eye drops of alcaine, mydracyl and isonephrine, half an hour before start of surgery. a written informed consent was obtained from each patient on the day of surgery. the out come measures and criteria consisted of; 1. patient satisfaction; a. very happy b. happy c. angry 2. ease of surgery a. phaco time b. operative time d. conversion to ecce 3. complications a. extension of ccc b. posterior capsule rent c. vitreous loss and nucleus drop the group a patients were operated under topical anesthesia (proparacaine hydrochloride 0.5%, alcaine) instilled 6 times with interval of 5 minutes between each drop, after dilating the pupil before start of surgery. patients were instructed to keep their eyes closed after instilling drops. the patients were instructed to lie supine on operating table with opened eyes while at the same time keeping their eyes stable. at operating table no topical, intracameral or subconjunctival anesthesia was given. one limbal 3.2 mm phaco port and two side ports about 0.8 mm were fashioned. the ccc was done with cystitome after filling anterior chamber with methyl cellulose. hydro dissection and hydro delineation were done properly and then phaco started with observation of good phaco techniques and tips. total phaco and surgery completion time, complications if any and satisfaction score was noted and recorded in the performa. w 93 the patients in group b were prepared in the same manner as above except in addition a 0.5 cc 2% lignocaine injection was infiltrated subconjunctivally near phaco port. no other type of analgesia was given. then phaco time, total operation time, complications and satisfaction points were recorded in the performa. results there were 45 patients in group a. the age of the patients was between 50 to 70 years (detail is shown in the table). out of 45 in group a only 5 patients (11.11%) felt pain so severe that they required injection fo 0.5 cc of 2 % lignocaine at the phaco site and then the procedure was carried out. the extension of ccc was seen in 5 patients (11.11 %) out of total 45 patients while posterior capsule rent was seen in 2 patients (4.44%) this complication was managed with anterior vitrectomy and implantation of 6.5 mm iol in the sulcus and incision was closed with 3 interrupted 10/0 sutures. in one patient nucleus dropped in the vitreous and was referred to vitreoretinal surgeon for further management. the average phaco time was 2.1 minutes while total operative time was 25 minutes. in group b there were 45 patients and all of them were given 0.5 cc injection in the conjunctiva at the phaco port site. none of the patients felt remarkable pain. the 10 patients (22.22 %) out of 45 got bleeding at site of injection, which was managed with a micro swab pressure for 2 minutes. the extension of ccc was seen in 2 cases (4.44%) while posterior capsule rent was seen in 2 patients (4.44%) that was managed with vitrectomy and 6.5 mm iol in the sulcus and the closure of incision was done with 3 interrupted 10.0 stitches. no nucleus was dropped in the vitreous. the average phaco time 2 minutes and total operative time was 25 minutes. discussion cataract is most common form of treatable blindness. the most effective treatment modality now is extracapsular cataract extraction with iol implanttation. the phacoemulsification is the best option among small incision extracapsular cataract extraction and then foldable iol implantation. there are different procedures to attain akinesia and analgesia e.g general and local anesthesia (topical, subconjunctval, subtenon, facial, peribulbar, retrobulbar etc). the general anesthesia needs a long list of investigations for patient’s fitness and at the same time expert anesthetist is required. the general anesthesia may cause more complications in old age in contrast to local anesthesia. age and sex determination group age range age n (%) sex n (%) group a 50-60 20 (44.44) 35 (77.78) 61-70 25 (55.56) 10 (22.22) group b 50-60 22 (48.89) 38 ((84.44) 61-70 23 (51.11) 70 (155.56) satisfaction score parameters topical group sub. conj. group mean phaco time 2.1 min 2.0 min mean operating time 25.0 min 25.0 min pain score 11.11% 0 .00% extension of ccc 11.11% 4.44% posterior cap. rent 4.44% 4.44% nucleus drop 2.22% 0.00% bleeding at phaco port 0.00% 22.22% foldable iol 74.77% 88.89% rigid iol 20.00% 11.11% the periocular anesthesia, weither retrobulbar or peribulbar carries with it the risk of globe perforation and retrobulbar hemorrhage14. there are other available reports about the complications of peribulbar anesthesia as optic nerve transaction and brain stem anesthesia15. an other alarming complication noted was diplopia16. the conversion from peribulbar to topical anesthesia created a lot of questions and reservations in the mind of surgeons due to lack of akinesia. it is very difficult to do phacoemulsification on a patient who is hard of hearing. therefore we also excluded the patients who were hard of hearing especially from 94 our topical group a. in one study an author mentioned phacoemulsification on a patient who was hard of hearing17. power of iol implanted iol power in diopters group a n (%) group b n (%) 0 to 10 0 (0) 0 (0) 10.5 to 15 2 (4.44) 3 (6.66) 15.5 to 20 4 (8.88) 6 9 (13.33) 20.5 to 25 25 (55.55) 27 (60) 25.5 to 30 12 (26.66) 7 (15.56) 30.5 to 35 1 (2.22) 2 (4.44) total 44 (97.78) 45 (100) all the patients disliked peribulbar anesthesia due to needle puncture or pain. but all the patients were happy with subconjunctival or topical anesthesia. some surgeons found patients had pain and stress in the topical and peribulbar anesthesia18. our phaco time and operation time was comparable to another study. in another study it was concluded that both the topical and sub-tenon anesthesias were well accepted methods of providing local anesthesia for small incision self-sealing phaco emulsification cataract surgery the topical anesthesia was less invasive and quicker to administer than sub-tenon infiltration but all the acceptance lied on the patient’s comfort during the procedure18 the topical anesthesia was compared with subtenon anesthesia in a study and the surgeon needed augmentation of topical anesthesia with subconjunctival injection of 2% lignocaine, 2 mm posterior to the superior limbus, to facilitate painless cautery of the scleral vessels19. but we needed no cautery in our study. we needed subconjunctival lignocain injection for extension of incision in three cases. fichenhas investigated the blood pressure, pulse rate and respiratory rate of patients during surgery under topical anesthesia and has found no major changes in these parameters20. lignocaine 2% gelly has been used for providing topical anesthesia in phaaco emulsification in various studies21. conclusions we concluded the following facts; topical anesthesia 1. is safe and time saving. 2some patients felt pain and lignocaine injection was needed. 3it is convincing and patients showed good compliance. 4lack of akinesia was controlled by patient co operation and phaco technique. 5iop remained the same 6phaco time and operation time was same as in sub-conjunctival group. 7it caused no post operative redness. author’s affiliation dr. ejaz ahmad javed senior registrar ophthalmology department dhq & allied hospital, pmc faisalabad references 1. vas ta. cataract surgery in the course of the centuries. netherl ophthalmol soc, 166 the meeting. ophthalmologica. 171; 81: 1971. 2. kirby db. surgery of cataract, 1st edition philadalphia; jb lippincort. 1950; 22. 3. richard p, floyd. history of cataract surgery; principles and practice of ophthalmology, albert jakobi. 1994, 1: 605-13. 4. daviel j. surune nouvella method de querirla cataract par extraction ducrystalline. mem acad r chir pasis 2; 337; 1753. 5. duke elder s. system of ophthalmology, diseases of the lens and vitreous, glaucoma and hypotony, 1st ed. vol. 11 st. louis c v. mosby. 1969; 248-64. 6. bauaquer j. zonulolysis, contribution a lacirugia del cristalino ann med. 1958; 38:255. 7. ridley h. intraocular acrylic lenses, a recent development in the surgery of cataract. br j ophthalmol. 1952; 36: 113. 8. emery jm, little th. phacoemulsification and aspiration of cataract, 1st ed; st. louis c v mosby. 1979. 9. sinkey rm, cain w jr. the posterior capsule and phcoemulsification am. intraocular implant soc. 1978; 4: 26 10. gimbel hv. capsulotomy method eases intra-bag-posterior chamber iol ocul surg news. 1985; 20. 11. fine ih. infinity suture in koch pc. davisan ja (eds), text book of advanced phacoemulsification techniques 1st ed. tholofare n j slack. 1991; 383. 12. calvard dm, kratz rp. endothelial cell loss following phacoemulsification in the papillary plane. j am intraocular implant soc t. 1981; 334. 95 13. shephard j. in situ fracture phacoemulsification method, phaco, pi. 1989. 14. haider sa, khaqan ha. topical versus periocular anesthesia for cataract surgery what is best? pak j ophthalmol. 2005, 21: 15. 15. hay a, flynn hw, hoffmann ji, et al. needle perforation of the globe during retrobulbar and peribubar injection, ophthalmology. 1991; 98: 1017-24. 16. gomez –arnou ji, yan gucla j, gozalez a, et al. anesthesia related diplopia after cataract surgery. br j anesthesia. 2003; 90: 189-93. 17. 18-19-nielsen pj. a prospective evaluation of anxiety and pain with topical analgesia or retrobulbar anesthesia for small incision cataract surgery. eur j implant refract surgery. 1995; 7: 6-10. 18. h b chitlenden, wr, meacock j aa. govan topical anesthesia with oxybuprocain versus sub-tenon,s infiltration 2% lignocaine for small incision cataract surgery. br j ophthalmol. 1997; 81: 288-90. 19. manners td, burton rl. randomised trial of topical versus subtenant’s local anesthesia for small incision cataract surgery, eye. 1996; 367-70. 20. fichman ra. use of topical anesthesia alone in cataract surgery. j cataract refract surg. 1996; 22: 612-4. 21. barequet is, soriano fs, green wro, et al. provision of anesthesia with single application of lidocaine 2% gell. j cataract refract surg.1999; 25: 828-31. microsoft word saeed iqbal 1 original article secondary intraocular lens implantation muhammad saeed iqbal, tahir m. arbab, memon muhammad khan, partab rai, asad raza jafri pak j ophthalmol 2009, vol. 25 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: muhammad saeed iqbal associate professor ophthalmology sir syed college of medical sciences hospital, qayyumabad, korangi raod, karachi received for publication march’ 2008 … ……………………… purpose: to evaluate the visual outcome of secondary anterior and posterior chamber intraocular lens (iol) implantation and to compare their results. material and methods: the study was conducted from july 2003 to december 2005. forty eyes of 40 patients were selected for secondary intraocular lens implantation. twenty two patients (55%) were male while 18 patients (45%) were female. age range was between 5 years to 62 years with mean age of 33.5 years. anterior chamber implantation was performed in 20 patients with ruptured posterior capsule (group i) while posterior chamber implantation was done in 20 patients with intact posterior capsule (group ii). all patients were followed for six months after surgery. results: in comparison to preoperative vision, 24 cases (60%) had improvement by one or more lines on snellen’s chart after surgery while 10 cases (25%) remained on the same vision level as they were with aphakic glasses. visual acuity of 06 patients (15%) was dropped by two lines on snellen’s chart after surgery. secondary posterior chamber iol results were better and associated with fewer complications as compared to secondary anterior chamber iol implantation. conclusion: despite few complications which are more with anterior chamber iols than posterior chamber iols, secondary intraocular lens implantation is a better way to get rid of thick aphakic glasses and to restore binocular vision. 2 he objective of an eye surgeon is to give patients a comfortable vision, minimize post operative astigmatism and quick recovery after surgery. although we have been pushed into the new world with latest technologies for cataract surgery but still, as part of third world, we see some of the patients who were left aphakic due to the complicated surgery or trauma in which the surgeons decided to postpone the iol implantation to a later date. moreover, patients who have had icce without iol implantation may ask for secondary iol implantation after years of wearing contact lenses and aphakic glasses1. these thick aphakic lenses induce telescopic effects, aniseikonia and compromised depth perception and visual field2. contact lenses are good alternative of thick and heavy aphakic glasses. a large field of vision and less peripheral image distortion is provided by contact lenses as they are closer to the pupil entrance. aniseikonia resulting from anisometropia is minimized by contact lenses. its best example is use of these lenses in monocular aphakia. regardless of the advantages, the thickness of these lenses greatly limits their gas transmissibility and corneal neovascularization is a common complication3. an ethical and good solution to this problem is secondary intraocular lens implantation. it can be done in the anterior and posterior chamber depending upon the presence or absence of posterior capsular support. although the ultimate decision lies in the hands of operating surgeon at the time of the procedure with adequate intraocular visualization, preoperative evaluation allows better surgical planning4. the purpose of the study was to evaluate the visual outcome of secondary anterior and posterior chamber intraocular lens (iol) implantation and to compare their results. material and methods this study was carried out at the department of ophthalmology, sir syed college of medical science’s hospital, karachi and at the author’s private set up. secondary iol implantation was performed in 40 patients (40 eyes) from july 2003 to december 2005. patients with lack of binocularity due to aphakia in one eye and phakia/pseudophakia in the fellow eye, patients previously operated for congenital cataract and traumatic cataract, which led to monocular/binocular aphakia, were included in this study. exclusion criteria included central corneal opacity, glaucoma, uveitis and posterior segment diseases. detailed history was obtained especially regarding indication of previous surgery. visual acuity with aphakic glasses was noted. slitlamp examination was performed to assess the anterior and posterior segment, paying special attention to the type of previously undertaken surgical procedure. biometry was performed using srk ii formula5. we divided these 40 cases in two groups on the basis of status of posterior capsular support. twenty patients (50%) were selected for anterior chamber iol implantation (group i) in which there was no or minimum posterior capsular support while 20 patients (50%) were selected for posterior chamber iol (group ii) who had intact posterior capsule. all surgeries were performed under retrobulbar anesthesia except 04 (10%) cases of congenital cataract where general anesthesia was given. eye was scrubbed using 5% pyodine, putting some solution in the cul-de-sac as well. sterile draping was applied. corneal incision of 6.5 mm was given in every patient using disposable 3.2 mm knives. after filling the anterior chamber and capsular bag with viscoelastic solution, posterior chamber iol (pmma) was implanted onto the posterior capsule. viscoelastic solution was aspirated by simco’s cannula. the technical ease or difficulty of secondary implantation depends mainly on how much capsular support was left behind primarily at the time of cataract surgery6. in eyes with large posterior capsular tear, anterior vitrectomy was performed to clean the vitreous from anterior chamber. pupil was miosed using miostat and an anterior chamber iol was inserted in front of the pupil. prophylactic peripheral iridectomy was done in all cases at 11o’ clock position, 10-0 nylon suture used to close the wound. subconjunctival injection of steroid/antibiotic was given. sterile dressings were applied at the end of the surgery. eye pad was removed on next day and patients were kept on steroid/antibiotic combination eye drops for 4-6 weeks. patients were asked to visit on regular follow ups at one week, one month, three months and then at six months post operatively. results forty eyes of 40 patients were included in this study. twenty two patients (55%) were male while 18 t 3 patients (45%) were female (table-1). age group was between 5 years to 62 years with mean age of 33.5 years. out of these 40 patients, 20 (50%) were primarily operated for senile cataract, 16 (40%) patients were operated for traumatic cataract while 4 patients (10%) were operated for congenital cataract. we divided these 40 cases in two groups on the basis of status of posterior capsular support. 20 patients (50%) were selected for anterior chamber iol implantation (group 1) while 20 patients (50%) were selected for posterior chamber iol (group 2). at the end of eight weeks, patients were given final refractive prescription. at the end of 3 months, best corrected vision was recorded for both groups. in group i, visual acuity of 10 patients (50%) increased up to 6/9 while preoperatively it was 6/18 with aphakic glasses. best corrected vision of 06 patients (30%) remained same (6/18) after secondary iol implantation. vision in four patients dropped to 6/60 while it was 6/24 with aphakic glasses preoperatively (table 2). in group ii, 14 patients (70%) improved to 6/6p in comparison to preoperative vision of 6/12 with aphakic correction. vision in 04 patients (20%) remained same as it was preoperatively i.e 6/12. best corrected visual acuity of 02 patients (10%) was found to be decreased from 6/18 preoperatively to 6/36 postoperatively (table 3). table 1: patients data n=40 gender no of cases n (%) male 22 (55) female 18 (45) total 40 (100) table 2: pre and post operative best corrected visual acuity of patients with secondary anterior chamber iol implantation (group i) n =20 no. of patient n (%) pre operative vision post operative vision 10 (50) 6/18-6/12 6/9 6 (30) 6/18 6/18 4 (20) 6/24 6/60 table 3: pre and post operative best corrected visual acuity of patients with secondary posterior chamber iol implantation (group ii) n=20 no. of patient n (%) pre operative vision post operative vision 14 (70) 6/12 6/6 p 4 (20) 6/12 6/12 2 (10) 6/18 6/36 nine patients (45%) developed complications after anterior chamber iol implantation. among them, commonest problem was post operative astigmatism (1.0d to 3.25dc) which was seen in 04 patients (20%), 02 patients (10%) developed post operative uveitis which resolved with topical steroid treatment. one patient (5%) developed raised iop which was controlled by beta blocker eye drops. hyphema was seen in 1 case (5%) of anterior chamber implantation in early post operative period and 1 patient (5%) had cystoid macular edema (table 4). regarding complications of posterior chamber iol implantation, 3 patients (15%) had post operative astigmatism and 1 patient (5%) developed uveitis. hyphema was present in 1 case (5%) while iris prolapse was seen in 1 case (5%) on first post operative day which was immediately repositioned (table 4). table 4: complications of secondary anterior chamber (group i) and posterior chamber iol implantation (group ii) complication group 1 n=20 n (%) group ii n=20 n (%) post operative astigmatism 4 (20) 3 (15) post operative anterior uveitis 2 (10) 1 (5) raised intraocular pressure 1 (5) nil hyphema 1 (5) 1 (5) iris prolapse nil 1 (5) cystoid macular 1 (5) nil 4 edema discussion in the past many decades, aphakia was treated by either spectacles or contact lenses. the results were satisfying but spectacles made life difficult because of their weight, image magnification and distortion6. the next choice was contact lenses which provided wider visual field and were effective even in patients with unilateral aphakia. many elderly patients found it difficult to cope with the necessary hygienic regimens. there was also an appreciable incidence of corneal infection7. secondary intraocular lens implantation is the most appropriate alternative to the contact lenses in this situation. ecce with intact posterior capsule provides support for posterior chamber implants8. while anterior chamber intraocular lens implantation is among the options for the cases with ruptured posterior capsule or after icce. the procedure of the secondary iol implants may lead to few complications but experienced surgical hand, appropriate use of viscoelastic and better quality of intraocular lenses have contributed to a decreased incidence of complications and visual status has improved. our study results showed that patients with posterior implants have better visual outcome as compared to the anterior chamber implants. fourteen cases (70%) were improved to 6/9 or better vision in group ii while 10 patients (50%) of group i had the same result. overall, 24 cases (60%) developed improvement of one or more lines on snellen’s chart postoperatively in comparison to their preoperative vision. ali et al9 reported nearly the same results. in their study 62.07% cases had improvement of one or more line on snellen’s chart postoperatively while 34.48% of their cases did not improve after surgery and had the same vision as it was preoperatively with aphakic glasses. in our study, the vision was same postoperatively in 10 patients (25%) as compared to preoperative vision. shammas et al10 reported that 53% of their cases had improvement on snellen’s chart while 42% developed no change in postoperative vision compared to preoperative best corrected vision. in view of postoperative complications, astigmatism was the most common problem seen in7 patients (17.5%) followed by anterior chamber reaction which was present in 3 cases (7.5%). cystoid macular edema was seen in 1 case (2.5%) with anterior chamber iol. ali et al9 had this problem in 6.89% cases. hykin et al11 concluded in their report that anterior chamber lenses are associated with more complications than posterior chamber lenses. in our study we also found that the results were slightly better with posterior chamber iols in comparison to anterior chamber iols but together these two sites for secondary intraocular lens implantation can provide appreciable results. conclusion based on our results, we came to the conclusion that although anterior or posterior chamber secondary iol implantation carries some hazards but still it is preferable to perform the procedure to restore patients’ binocular single vision and visual field, to improve the quality of vision and prevent image distortion created by aphakic glasses. author’s affiliation dr. muhammad saeed iqbal assistant professor ophthalmology sir syed college of medical sciences hospital qayyumabad, korangi raod, karachi dr. tahir arbab assistant professor ophthalmology sir syed college of medical sciences hospital qayyumabad, korangi raod karachi dr. memon mohammad khan assistant professor ophthalmology kulsoom bai valika hospital s.i.t.e., karachi dr. partab rai assistant professor ophthalmology chandka medical college and hospital larkana dr. asad raza jafri senior registrar ophthalmology karachi medical & dental college north nazimabad, karachi reference 1. droslum l. long term follow up of secondary, flexible, openloop, anterior chamber intraocular lenses. j cataract refract surg. 2003; 29: 498-503. 5 2. thall eh, miller km, rosenthal p, et al. clinical refraction: optics, refraction and contact lenses. san francisco usa: american academy of ophtalmology. 1999-2000; 159. 3. thall eh, miller km, rosenthal p, et al. clinical refraction: optics, refraction and contact lenses. san francisco usa: american academy of ophtalmology. 1999-2000; 168-95. 4. de silva dj, nischal kk, packard rb. preoperative assessment of secondary intraocular lens for aphakia: a comparison of two techniques. j cataract refract surg 2005; 31: 1351-6. 5. retzlaff ja, sanders dr, kraff m. lens implant power calculation. 3rd ed. new jersey: thorofare 1990; 4. trivedi rh, wilson me, facciani j. secondary intraocular lens implantation for pediatric aphakia. j aapos 2005; 9: 346-52. 6. kanski jj. cornea: clinical ophthalmology: a systematic approach. 6th ed. philadelphia: butterworth heinemann elsevier ltd. 2006; 249-310. 7. spigleman av, lindstorm rl, nicholas bd, et al. implantation of posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens implant. ophthalmic surg. 1988; 396-8. 8. stark wj, goodman g, goodman d, et al. posterior chamber intraocular lens implantation in the absence of posterior capsular support. ophthalmic surg. 1988; 19: 240-3. 9. ali a, ahmed t, sharif-ul-hasan k. secondary intraocular lens implantation. pak j ophthalmol. 2001; 17: 74-8. 10. shammas hj, milkie cf. secondary implantation of anterior chamber lenses. j am intraocular implant soc. 1983; 9: 313-6. 11. hykin pg, gardner id, corbett mc, et al. primary or secondary anterior chamber lens implantation after extracapsular cataract surgery and vitreous loss. eye 1991; 5: 694-8. microsoft word irfan shafiq.doc 221 original article pseudoexfoliation (pex) glaucoma over the age of 40 years; a hospital based study irfan shafiq, khwaja sharif-ul-hasan pak j ophthalmol 2007, vol. 23 no.4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irfan shafiq eye unit i, dow university health sciences civil hospital karachi received for publication april’ 2007 …..……………………….. purpose: to determine the prevalence of pseudoexfoliation (pex) glaucoma in patients over the age of 40 years who presented at eye department of baqai medical university hospital, karachi for examination. material and method: this hospital based prospective case study was carried out at the department of ophthalmology, baqai medical university hospital, karachi from august 2000 to january 2004. a total of 3195 patients of 40 years and above were examined on slit-lamp for evidence of pex syndrome and glaucoma and those found to be having the disease were subjected to further thorough examination including visual acuity, goldmann applanation tonometry, gonioscopy, slit lamp examination before and after dilatation of the pupil, fundus examination and visual field examination. results: out of 3195 patients 58 (1.81%) were found to be having pex syndrome, out of which 21 patients showed pex glaucoma. out of 3195 patients 1807 (56.55%) males and 1388 (43.44%) were females. male to female ratio of pex was 2:1. the prevalence increased with advancing age. conclusions: pex syndrome and glaucoma is more common in males and increases with advancing age. hen an eye with pseudoexfoliation (pex) develops glaucoma the condition is referred to as pseudoexfoliative glaucoma, exfoliative glaucoma or capsular glaucoma1. glaucoma results from combination of exotrabecular and endotrabecular pex material, increased aqueous protein and deposition of pex material on trabecular meshwork and corneal endothelial proliferation2. study showed that eyes with pex had a 5 fold increased risk of glaucoma. this risk was independent of other known glaucoma risk factors including intraocular pressure (iop)3. the first description of pex syndrome reported in scandinavian literature in 1917, when lindberg, a finnish ophthalmologist described the appearance of flakes at the pupillary border of the iris in 30 out of 60 patients having chronic simple open angle glaucoma. he believed the flakes to be the result of earlier inflammation4. in 1925, swiss ophthalmologist alfred vogt established the association of the condition with glaucoma and originated the term “glaucoma capsulare” for it5. another swiss author malling in 1923 reported the presence of changes in the anterior lens capsule in 40% of his patients with chronic glaucoma and thought that exfoliation and glaucoma were associated6. in 1956, sunde proposed the term “exfoliation syndrome” to signify multiple tissues involvement as opposed to the previous belief that the anterior lens capsule is involved7. streeten et al studied extra ocular sites for the evidence of pex material and their study suggests that pex may be the ocular manifestation of a systemic derangement in the elastic tissue synthesis closely related to elastosis8. now it has been established that in pseudoexfoliation syndrome there is bluish-white w 222 flaky material deposition at the pupillary border, membrane like deposits on the anterior lens capsule in the center and as granular deposits on the periphery of the lens. in the angle, on zonules and on ciliary processes, it is seen as white gray fluffy masses, while on the corneal endothelium it appears as gray small keratic precipitates (kps)9. pex material appears to be produced by the equatorial lens capsule, iris pigment epithelium and non-pigmented ciliary epithelium secondary to abnormal basement membrane produced by ageing epithelial cells10. the disease is of insidious onset with minimal symptoms, so the ophthalmologist should look for early signs when the patient either presents with monocular glaucoma or some other ocular problem11. there is also involvement of the conjunctiva, skin, heart, lung, liver, kidney, cerebral meninges and gall bladder and histological studies show that the material is deposited in these tissues12. the material has also been demonstrated in the walls of the short posterior ciliary arteries13. it is both histochemically and ultra structurally similar to amyloid10. pex can cause glaucoma, poor pupillary dilatation, posterior capsular rupture, vitreous loss, phacodonesis10 and keratopathy14. as the disease was first described in the scandinavian countries especially in norway and finland, the initial impression was that it was more prevalent in that region than elsewhere15. however a careful search for the disease in other countries led to accumulation of information from all over the world and the condition is reported from other countries16. variations in the prevalence of pex syndrome have been reported. in one study, aasved reported incidence of pex of 4.0% in england, 4.7% in germany and 6.3% in norway17. in pakistan the prevalence has been reported as 1.2% in persons over 40 years of age and 5.1% in those over 60 years of age18. there are multiple factors affecting the prevalence of the disease. this is a disease of old age. the usual age prevalence is between 60 and 80 years of age19. its prevalence steadily increases after the age of 60 with a mean age in early 70’s20. however with decreasing frequency it is also found in the young individuals and the youngest patient reported is at the age of 32 years from pakistan21. it occurs equally in both sexes but is found some years earlier in males than females20. hereditary factors in the form of autosomal dominant trait or xlinked with poor penetrance are postulated by some authors22. hla linkage with pex is identified for 14 antigens. eleven antigens (hla a1, a33, b8, b47, b51, b53, b57, b62, dr3, dr12, and dr13) are statistically significantly common in the pex while three antigens (hla b12, b17 and dr2) are significantly less common. this hla association is evidence for a genetic component to the development of pex23. familial occurrence and hypothesis that pex syndrome is genetically inherited are reported24. clinical classification of the various stages of pex is based mainly on the findings of the anterior lens capsule2. suspect early pex (exfoliative material: precapsular layer) masked pex (posterior synechiae with other obvious cause) definite mini pex (focal defects in precapsular layer nasally and superiorly) classical pex (late stage) (figure i) variable data is available regarding raised iop and glaucoma in pex syndrome. in one study ocular hypertension was present in 15% of patients having pex syndrome, while glaucoma was present in 7% of patients having pex syndrome25. irvine in a review of literature reported the figures as 14%-90% from different authors4. in pakistani survey 30% patients with pex syndrome had an iop more than 20mmhg18. the subsequent occurrence of raised iop in patients having pex syndrome and normal iop at the initial examination is 5% at 5 years and 15% at 10 years26. if one eye has glaucoma and fellow eye shows pex, the risk of glaucoma in the fellow eye within 5 years is about 50%26, while some reports put the figures at 720% in 5 years and 9-24% in 10 years1. in those having bilateral pex syndrome but unilateral glaucoma, 2126% will develop glaucoma in the other eye in next 5 years1. material and methods this prospective analytic study was undertaken at the department of ophthalmology, baqai medical university hospital karachi from august 2000 to january 2004. inclusion criteria, all patients 40 years of age and above came in eye o.p.d of baqai medical university hospital with various ocular problems. exclusion criteria, patients below the age of 40 years. 223 a total of 3195 patients, 40 years of age and above attending the out patient department for various ocular problems were screened for pex syndrome and pex glaucoma. the initial examination consisted of slit-lamp biomicroscopy for evidence of pex material on the edge of pupil or lens in undilated state and in those having suspicion of the disease, the pupils were dilated and repeat slit-lamp examination was performed (figure 1,2). those patients having pex syndrome were further examined in detail, according to an examination protocol and all the findings were entered in the especially designed proforma for this study. the examination included complete history, general physical and systemic examination and full ocular examination. the ocular examination included visual acuity testing, slit-lamp examination of the anterior segment, transillumination, gonioscopy, applanation tonometery and fundus examination. visual fields were recorded in those with high iop and/or cupping of the disc (figure 2). results out of 3195 patients examined 1807 (56.55%) were males and 1388 (43.44%) were females. in age group 40-49 years, total 1332 patients were examined, 705 (52.92%) were males and 627 (47.07%) females. in age group 50-59 years, total 922 patients examined, 508 (55.09%) were males and 414 (44.90%) were females. in age group 60-69 years, 552 patients examined, 334 (60.50%) were males and 218 (39.49%) were females. in age group 70 and above, total 389 patients were examined, 260 (66.83%) were males 129 (33.16%) were females (table 1). table i: total number of male and female patients examined in different age groups. age groups males females total 40-49 years 705 627 1332 50-59 years 508 414 922 60-69 years 334 218 552 70 & above 260 129 389 total patients 1807 1338 3195 a total number of 6390 eyes of 3195 patients were examined for pseudoexfoliation (pex) syndrome and glaucoma. those having pex syndrome were 58 (1.81%) out of which 21 patients had pex glaucoma (0.65%). out of 58 patients with pex syndrome 41 (70.68%) were males and 17 (29.31%) were females. those having pex glaucoma were 21 out of which 14 (66.66%) were males and 7 (33.33%) were females (graph i & table 2). in age group 40-49 years, total 1332 patients were examined and 5 cases (0.37%) of pex syndrome and 1 case (0.07%) of pex glaucoma were detected. in age group 50-59 years, total 922 patients were examined and 7 cases (0.75%) of pex syndrome and 2 cases (0.21%) of pex glaucoma were detected. in age group 60-69 years, total 552 patients were examined and 17 cases (3.07%) of pex syndrome and 6 cases (1.08%) of pex glaucoma were detected. in age group 70 and above, total 389 patients were examined and 29 cases (7.45%) of pex syndrome and 12 cases (3.08%) of pex glaucoma were detected (graph ii & table 3). discussion earlier prevalence studies are biased due to the detection of the condition in the scandanavian countries and most of the earlier authors believed that the condition is more prevalent in the scandanavian countries27. however one study of 2058 patients over age 60 examined by a single investigator in three countries, aasved reported similar prevalences pex of 4.0% in england, 4.7% in germany and 6.3% in norway17. although wide variation in the prevalence of pex syndrome and glaucoma have been reported, these variation may be due to differences in the definition of disease, population studied, age and sex distribution and examination techniques1. studies from this subcontinent are those of irvine 8% at madras, india4, 9% cases from simla india28 are available. in pakistan the prevalence has been reported as 1.2% in persons over 40 years of age and 5.1% in those over 60 years of age18. our figure of pex syndrome and pex glaucoma are 1.8% and 0.65% respectively in general population of 40 years and above are comparable to the other study in this part of the world of 1.2% in patients over 40 years of age. the increased prevalence in our study may be due to the higher number of elderly patients examined rather than true difference. in this study prevalence of 3.07% in persons 60-69 years age group and 7.45% in persons 224 70 years and above group is comparable to that of aasvad’s study17 and study from pakistan29. as the disease usually affects the elderly and a steady increase in prevalence occurs with advancing age20. our data also supports this observation. the disease is thought to occur in an earlier age group in some communities, the youngest in our study is a 42 years old male having unilateral pex syndrome. while from pakistan a lady of 32 years of age is reported as the youngest21. male or female preponderance is not yet settled, some studies have shown that pex is more common among men, several american and european series have indicated that pex is more common in women1. for pakistan a previous study reported a male preponderance with a ratio of male to female of 3:118. our study also substantiates the previous results and shows male preponderance with a ratio of male to female of 2:1. laterality of the condition is also not settled and various reports speak of different figures 57% unilateral cases in one study, while figures from pakistan are 20% unilateral in one18 and 25% in another study21. in our study the prevalence is unilateral in 34.37% of the patients. variable data is available regarding glaucoma in pex syndrome. irvine in review of literature reported the figures as 14%-90% from different authors4. in pakistani survey 30% patients with pex syndrome had an iop more than 20mmhg. our study shows 36.2% association of glaucoma with pex syndrome which is higher than data available. it may be due to late age of presentation of pex syndrome. the fact that diagnosis of the condition depends on thoroughness of examination because the disease is asymptomatic. this may be the cause of differences in the prevalence reported by different authors. conclusion pseudoexfoliation glaucoma more commonly occurs in males and its prevalence depends on age and it increases with the age of patients. table 2: prevalence of pseudoexfoliation glaucoma and syndrome in different gender. gender examined pseudoexfoliation syndrome pseudoexfoliation glaucoma no. of eyes no. of eyes no. of patients no. of eyes prevalence (%) no. of patients no. of eyes prevalence (%) male 1807 3614 41 82 2.26 14 28 0.77 female 1338 2776 17 34 1.27 7 14 0.52 total 3195 6390 58 116 1.81 21 42 0.65 table 3: prevalence of pseudoexfoliation glaucoma and syndrome in different age group. age groups examined pseudoexfoliation syndrome pseudoexfoliation glaucoma no. of patients no. of eyes no. of patients no. of eyes prevalence (%) no. of patients no. of eyes prevalence (%) 40-49 years 1332 2664 5 10 0.37 1 2 0.07 50-59 years 922 1844 7 14 0.75 2 4 0.21 60-69 years 552 1104 17 34 3.07 6 12 1.08 70 & 389 778 29 58 7.45 12 24 3.08 225 above total 3195 6390 58 116 1.8 21 42 0.65 fig. 1: schematic representation of clinical classification of pex syndrome. photograph showing membrane like deposition of pex material on lens capsule. photograph showing granular like deposition of pex material at pupillary border. fig. 2: showing visual field defect in a patient with pex glaucoma. 226 total number of patients 3137 58 patients without pex patients with pex graph 1: showing total number of patients with and without pseudoexfoliation (pex) syndrome. 1327 5 915 7 535 17 360 29 0 200 400 600 800 1000 1200 1400 number of pts 40-4 9 y ears 50-5 9 y ears 60-6 9 ye ars 70 & abo ve age distribution of pex pts without pex pts with pex graph 2: showing pseudoexfoliation glaucoma in different age group. author’s affiliation dr. irfan shafiq assistant professor eye unit i, dow university health sciences civil hospital karachi. prof. khwaja sharif-ul-hasan professor and chairmen ophthalmology department baqai medical university hospital karachi. references 1. skuta gl. pseudoexfoliation syndrome. in tasman w and jaegar e.a (eds) “duane’s clinical ophthalmology”. volume 3 chapter 54b. philadelphia: j b lippincott company. 1997: 1-10. 2. gottfried oh. naumann, ursula schlotzer-schrehardt & michael kuchle. pseudoexfoliation syndrome for the comprehensive ophthalmologist. intraocular and systemic manifestations. ophthalmology. 1998; 105: 951-968. 3. mitchell p, wang jj, hourihan f. the relationship between glaucoma and pseudoexfoliation. arch ophthalmology. 1999; 117: 1319-24. 4. irvine r. exfoliation of the lens capsule (glaucoma capsularis). arch ophthalmol. 1940; 23: 138-60. 5. cebon l, redmond rjs. pseudoexfoliation of lens capsule and glaucoma. br j ophthalmol. 1976; 60: 279-82. 6. davork-theobald g. pseudoexfoliation of the lens capsule. am j ophthalmol. 1954; 37: 1-12. 7. layden we, shaffer rn. exfoliation syndrome. am j ophthalmol. 1974; 78: 835-41. 8. streeten bw, dark aj, wallace rn, et al. pseudoexfoliative fibrillopathy in the skin of patients with ocular pseudoexfoliation. am j ophthalmol. 1990; 110: 490-9. 9. gifford h jr. a clinical and pathological study of exfoliation of the lens capsule. am j ophthalmology. 1958; 46: 508-24. 10. kanski jj. “glaucoma”. in kanski jj. (ed). “clinical ophthalmology” 4th edition. london: butterworths. 1999: 217-9. 11. bartholomew rs. pseudocapsular exfoliation in the bantu of south africa. br j ophthalmol. 1975; 55: 693-9. 12. gottfried oh. naumann, ursula schlotzer-schrehardt & michael kuchle. pseudoexfoliation syndrome for the comprehensive ophthalmologist. intraocular and systemic manifestations. ophthalmology. 1998; 105: 951-68. 13. dickson dh, ramsey ms. fibrillopathia epitheliocapsularis. a review of the nature and origin of pseudoexfoliative deposits. trans ophthalmol. soc. uk. 1979; 99: 284-92. 14. gottfried oh, naumann, schlotzer-schrehardt u. keratopathy in pseudoexfoliation syndrome as a cause of corneal endothelial decompensation. a clinicopathologic study. ophthalmology 2000; 107: 1111-24. 15. gifford h jr. a clinical and pathological study of exfoliation of the lens capsule. am j ophthalmol. 1958; 46: 508-24. 16. epstein dl. exfoliation and open-angle glaucoma. in chandler and grant’s “glaucoma”. epstein dl. (ed) 3rd edition. philadelphia: lea and febigner, 1986: 191-7. 17. aasved h: the geographical distribution of fibrillopathia epitheliocapsularis, so-called senile exfoliation or pseudoexfoliation of the anterior lens capsule. acta ophthalmol. 1969; 47: 792. 18. mohammad s, kazmi n. subluxation of the lens and ocular hypertension in exfoliation syndrome. pak j ophthalmol. 1986; 2: 77-8. 19. ben s. fine and myron yanoff. lens capsule. ocular histology. 2nd ed. harper and row publishers, 1979: 133-54. 20. duke-elder s. disease of the lens and vitreous; glaucoma and hypotony. in duke elder s (ed). “ system of ophthalmology”. volume xi st. louis: the c.v. mosby and company, 1969: 4257. 21. khanzada am. exfoliation syndrome in pakistan. pak j ophthalmol. 1986; 2: 7-9. 22. tarkkanen aha. exfoliation syndrome. trans. ophthalmol. soc. uk. 1986; 105: 233-6. 23. fitz simon js, mulvihill j, kennedy s, et al. association of hla type with pseudoexfoliation of the lens capsule. br j ophthalmol. 1996; 80: 402-4. 227 24. ventura acs, bohnke m, mojon ds. central corneal thickness measurements in patients with normal tension glaucoma, primary open angle glaucoma, pseudoexfoliation glaucoma, or ocular hypertension. br j ophthalmol. 2001; 86: 702-5. 25. coburn ag, gross rl. pseudoexfoliation syndrome. in sarita r.j. (ed). clinical signs in ophthalmology. volume xii no. 3. st louis: mosby year book inc. 1990: 2-16. 26. kanski jj. “glaucoma”. in kanski jj. (ed). “clinical ophthalmology” 4th edition. london: butterworths. 1999: 217-9. 27. forsius h. prevalence of pseudoexfoliation of the lens in finns, lapps, icelanders, eskimos and russians. trans. ophthalmol. soc. uk. 1979; 99: 296-8. 28. sood gc, sofat bk, mehrotra sk. capsular exfoliation syndrome. br j ophthalmol. 1973; 57: 120-4. 29. shafiq i, sharif-ul-hasan k. prevalence of pseudoexfoliation syndrome in a given population. pak j ophthalmol. 2004; 20: 49-52. 126 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology original article effect of diabetes mellitus on central corneal thickness – a comparative study qamar-ul-islam pak j ophthalmol 2017, vol. 33, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: qamar-ul-islam pns shifa/bahria university med & dental college (bumdc) karachi email: qamarulislam71@gmail.com …..……………………….. purpose: to compare central corneal thickness (cct) of diabetes mellitus (dm) patientswith age matched subjects without dm and to evaluate the correlation of cct with glycemic status, duration of dm and severity of diabetic retinopathy (dr). study design: cross sectional comparative study. place and duration of study: eye department, pns shifa karachi from march 2016 to february 2017. material and methods: patients with ages between 20 to 80 years of either gender who were diagnosed to have dm were recruited in the study. control group comprised of age matched healthy volunteers who did not have dm. cct was evaluated in each subject with non-contact specular microscope (sp-3000 p, topcon corporation, japan) and all the findings were endorsed on a pre designed performa. spss version 13.0 was used for analysis of data. result: two hundred and fifty two eyes (126 diabetic patients and 126 healthy controls) were evaluated. both groups were age and gender matched (p > 0.05). mean cct of diabetic population was 512.21 ± 32.68 µm while mean cct of control group was 498.83 ± 28.98 µm (p = 0.001). difference in cct values between subgroups of patients with no dr, with npdr and pdr was statistically non-significant (p = 0.810). pearson’s correlation analysis showed that duration of dm (r = 0.022, p = 0.809), hba1c (r = 0.103, p = 0.251), and severity of dr (r = 0.022, p = 0.805) did not show any significant correlation with cct. conclusion: significantly thicker cct was found in patients with dm as compared to healthy age matched controls. key words: specular microscopy, central corneal thickness, diabetes mellitus. ith the advent of precise and better noninvasive measurement tools, central corneal thickness (cct) measurement has become a vital ocular parameter due to its importance as an indicator of corneal health and integrity. accurate cct measurement (pachymetry) has diagnostic and therapeutic implications in various conditions like ectatic corneal dystrophies (keratoconus, pellucid marginal degeneration), contact lens related problems, dry eyes, diabetes mellitus, glaucoma and refractive surgery (lasik)1. for years, ultrasound pachymetry remains the gold standard method for measurement of cct, but newer non-invasive methods of pachymetry like scheimpflug system, specular microscopy, spectral domain oct demonstrated acceptable repeatability and reproducibility. corneal morphological parameters including cct vary with age, gender, race and ethnicity. tayyab et al and islam et al reported mean cct of normal pakistani population using specular microscope as 503.96 µm and 505.72 µm respectively2,3. diabetic keratopathy is a known entity that affects approximately 70% of diabetic population and include decrease in corneal endothelial cell density (ced) and hexagonality, increase in cct, polymegethism, w mailto:qamarulislam71@gmail.com effect of diabetes mellitus on central corneal thickness – a comparative study pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 127 pleomorphism, higher corneal auto fluorescence and lower corneal sensitivity4,5. cct has a positive correlation with intra ocular pressure (iop) measured by goldman applanation tonometry and this effect on measured iop can be clinically significant6. thicker cct in diabetes mellitus should be taken into consideration while measuring iop in diabetics. several studies had showed variable results while comparing cct measurements in diabetics with normal subjects. significantly higher cct values in diabetic population as compared to healthy age matched controls had been reported by various authors4,7-9. however, there are studies that showed no significant difference in cct values between diabetics and normal population5,10,11. available data from pakistan on the subject is limited. this study was aimed to compare cct between patients with dm and non-diabetic control subjects and to analyze the correlation of cct in relation to diabetes duration, glycemic status and severity of dr. materials and methods this was a cross sectional comparative study conducted at eye department, pns shifa naval hospital karachi from march 2016 to february 2017. patients with ages between 20 to 80 years of either gender who were diagnosed to have dm were recruited in the study through non probability convenience sampling, after approval by ethical review committee of hospital. written informed consent was obtained from each subject before enrolment and study was conducted in accordance with the declaration of helsinki12. sample size was found to be 126 in each group using power of test as 80, level of significance as 0.5, mean cct value as 566.7 µm in dr group, and 550µm in control group and population sd as 35.77. the diagnosis of dm was based on criteria of the american diabetes association (ada) and included all the patients who were already under treatment of physician13. control group comprised of age matched healthy volunteers who did not have dm (subjects with fasting blood sugar of less than 110 mg/dl). subjects with history of intraocular surgery / trauma / retinal laser, corneal opacity or dystrophy, glaucoma, pseudoexfoliation, uveitis, use of contact lens, and use of topical eye drops were excluded. sub groups of patients included those with no dr, non-proliferative dr (npdr) and with proliferative dr (pdr) on the basis of diagnosis by a consultant ophthalmologist. complete ocular examination including visual acuity assessment, auto refraction, slit lamp bio microscopic examination and non-contact iop measurement was done in each subject. cct was evaluated in each subject with noncontact specular microscope (sp-3000 p, topcon corporation, japan) by a single experienced examiner between 09:00 – 11:00 am. three images from central cornea of eye with worse retinopathy stage in diabetic group and randomly selected one eye in control group were captured. an average of three readings was used for final analysis. all the findings including demographic data, glycemic status and cct were endorsed on a pre designed proforma. spss version 13.0 was used for analysis of data that was tested for normality before analysis. for quantitative variables descriptive statistics i.e. means ± standard deviation (sd) and for qualitative variables frequencies and percentages were used. chi square test was used to compare frequencies and percentages, while independent sample ‘t’ test and one way analysis of variance (anova) were used to compare means ± sd between groups. association of cct with dm duration, hba1c, and severity of dr was analyzed using pearson’s correlation coefficient test. a p value < 0.05 was considered statistically significant. results data of 252 eyes (126 diabetic patients and 126 healthy controls) was evaluated. mean age of diabetic population was 54.16 ± 9.70 years (range: 30-75 years), while mean age of control group was 52.00 ± 12.37 years (range: 32 – 80 years). demographic and clinical profile of both groups is given in table 1. both groups were matched in terms of age (p = 0.12) and gender (p = 0.30). mean fasting plasma glucose level was significantly higher in diabetic group (p < 0.01). mean cct of diabetic population was 512.21 ± 32.68 µm (range: 403 – 623 µm), while mean cct of control group was 498.83 ± 28.98 µm (range: 412 – 559 µm) [p = 0.001]. patients with no dr, with npdr and pdr did not show statistically significant difference in mean cct values (table 2). however, patients with no dr were significantly younger and had lower hba1c levels as compared to patients with npdr and pdr (table 2). moreover, comparison cct values between diabetic groups according to duration of dm and/or hba1c levels did not showed significant difference (table 3). duration of dm was significantly correlated with type of dr (r = 0.421, p < 0.01), hba1c level (r = 0.175, p = 0.050), age (r = 0.305, p < 0.01) and severity of dr (r = 0.616, p < 0.01). however, pearson’s qamar-ul-islam 128 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology table 1: demographic and clinical profile of study population. parameter diabetic (n = 126) control (n = 126) p value age (years) 54.16 ± 9.70 52.00 ± 12.37 0.125 gender male female 76 (60.31%) 50 (39.68%) 67 (53.17%) 59 (46.82%) 0.309 type of dm type 1 type 2 44 (34.90%) 82 (65.10%) duration of dm < 10 years > 10 years 60 (47.60%) 66 (52.40%) plasma glucose (f) mg/dl 184.73 ± 75.90 97.52 ± 12.41 < 0.01 hba1c level (%) 6.97 ± 1.12 table 2: clinical profile and cct values according to severity of dr. parameter no dr (n = 42) npdr (n = 46) pdr (n = 38) p value age (years) 49.74 ± 10.76 56.80 ± 8.49 55.84 ± 8.24 0.001 plasma glucose (mg/dl) 180.00 ± 83.56 179.76 ± 71.16 196.00 ± 73.33 0.553 hba1c (%) 6.51 ± 1.07 7.06 ± 1.23 7.36 ± 0.86 0.002 cct (µm) mean ± sd 512.60 ± 37.01 509.91 ± 28.24 514.55 ± 33.30 0.810 table 3: comparison of groups according to dm duration and hba1c level. parameter age (years) glucose (mg/dl) cct (µm) duration (years) < 10 years > 10 years p value 52.08 ±10.91 56.05 ± 8.08 0.021 181.06 ± 73.71 188.07 ± 78.25 0.607 513.99 ± 33.20 510.59 ± 32.38 0.563 hba1c (%) ≤ 7.5 >7.5 p value 53.78 ± 9.79 54.98 ± 9.57 0.522 158.03 ± 57.95 242.15 ± 78.68 < 0.01 510.98 ± 31.74 514.85 ± 34.89 0.538 correlation analysis showed that duration of dm, hba1c, and severity of dr did not showed any significant correlation with cct. moreover, plasma glucose level showed weak but significant correlation with cct (r = 0.155, p = 0.014). discussion the relationship between dm and cct is very important as the current burden of dm in pakistan is approximately 7.0 million people and this figure is expected to rise by the year 2040 to an alarming 14.4 effect of diabetes mellitus on central corneal thickness – a comparative study pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 129 million making pakistan the 8th highest country in terms of burden of dm14. it is postulated that hyperglycemia may cause endothelial dysfunction with resultant stromal hydration and swelling of cornea that leads to higher cct values in diabetic population15. evaluation of corneal morphological parameters including cct has been done worldwide with conflicting reports. corneal morphological parameters do differ among various races and ethnic groups with age being the major confounding factor. in this study, both groups were age matched to eliminate the age related bias in cct measurement among groups. in our study, mean cct of diabetic population was significantly higher as compared to normal controls (512.21 ± 32.68 µm vs. 498.83 ± 28.98; p = 0.001). significantly thicker cct values in diabetic population as compared to healthy controls had been reported in various other studies4,7-9,15-19. modis et al in their study found significantly higher cct values in type i diabetics as compared to controls, whereas in type ii diabetics the difference was not statistically significant20. roszkowska et alreported that pachymetric values were significantly altered in both type 1 and type 2 diabetic groups, with values being higher in type 1 diabetics21. on the contrary, there are studies which documented that diabetic subjects did not differ from non-diabetic controls with regard to cct5,10,11,22,23. habib et al in their study found no significant difference in pachymetry values between diabetic and non-diabetics in pakistani population24. in our study, severity of dr did not have a significant effect on cct. ozdamar et al 8, inoue et al10 and el-agamy et al22 also reported that all diabetic groups (no dr, npdr and pdr) had no significant difference in pachymetry values. whereas, parekh et al reported that cct values were significantly higher in patients with moderate to severe npdr and pdr as compared to patients with no or mild dr23. regarding comparison of cct values in patients with dm duration of ≤ 10 years and those with dm duration of > 10 years, no statistically significant difference was detected. briggs et al and habib et al reported thicker corneas in patients with > 10 years of dm but the difference was statistically non significant18,24. however, lee et al and urban et al reported significantly higher cct in diabetics with > 10 years of duration4,25. in our study, comparison of the mean values of cct in diabetic patients with hba1c ≤ 7.5% and those with hba1c > 7.5% showed no significant difference. similar results are quoted by el-agamyet al22 in their work, whereas, gupta et al19 in their study reported significantly thicker corneas in patients with hba1c levels of > 7.0%. correlation between cct and various systemic and ocular variables such as duration of dm, plasma glucose level, hba1c level and severity of dr had been extensively evaluated worldwide. in our study, duration of dm, hba1c, and severity of dr did not showed any significant correlation with cct. nonsignificant correlation of duration of dm, hba1c, and severity of dr with corneal endothelial parameters had been found in various studies worldwide5,7,22. however, there are studies that showed significant correlation of cct with duration of dm, hba1c level and severity of dr4,23,25 the strength of this study was the appropriate sample size, age matched groups, and prospective data collection. limitations of the study include lack of multivariate analysis, not performing gold standard test (glucose tolerance test) to exclude diabetes in controls and not taking into account possible confounding factors like smoking, iop and corneal diameter. results of this study provide a greater insight into the understanding of corneal morphology in diabetic population especially in the context of preoperative evaluation and glaucoma diagnosis. in fact, blue mountains eye study showed persons with diabetes are thought to be at higher risk of glaucoma26. therefore it is recommended that thicker cct associated with dm must be taken into consideration while measuring iop in diabetics. conclusion mean pachymetry values were found to be significantly thicker in diabetic population as compared to healthy controls. however, duration of dm, hba1c, and severity of dr did not showed any significant correlation with cct. author’s affiliation dr. qamar-ul-islam classified eye spec /assoc prof pns shifa/bahria university med & dental college (bumdc) karachi. role of author dr. qamar ul islam study conception, design and interpretation of the data, the drafting of the article or critical revision for important intellectual content. qamar-ul-islam 130 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology references 1. almubrad tm, osuagwu ul, al abbadi i, ogbuehi kc. comparison of the precision of the topcon sp3000p specular microscope and an ultrasound pachymeter. clinical ophthalmology (auckland, nz) 2011; 5: 871-876. doi:10.2147/opth.s21247. 2. 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kettesy b, berta a. evaluation of the corneal endothelium in patients with diabetes mellitus type i and ii. histolhistopathol 2010; 25 (12): 1531-7 doi: 10.14670/hh-25.1531. 21. roszkowska am, tringali cg, colosi p, squeri ca, ferreri g. corneal endothelium evaluation intype i and type ii diabetes mellitus. ophthalmologica 1999; 213: 258–261. 22. el-agamy a, alsubaie s. corneal endothelium and central corneal thickness changes in type 2 diabetes mellitus. clinical ophthalmology (auckland, nz). 2017; 11:481-486. doi: 10.2147/opth.s126217. 23. parekh r, ranganath kn, suresh kp, dharmalingam m. corneal endothelium count and thickness in diabetes mellitus. int j diab dev ctries 2006; 26 (1): 2426. 24. habib mk, zaheer n, sharif n, hassan s, malik h. effect of diabetes on central corneal thickness. alshifa j ophthalmol. 2014; 10 (2): 77-85. 25. urban b, raczy nska d, bakunowicz-aazarczyk a, raczynska k, krwtowska m. evaluation of corneal https://www.ncbi.nlm.nih.gov/pubmed/27353987 https://www.ncbi.nlm.nih.gov/pubmed/27353987 https://www.ncbi.nlm.nih.gov/pubmed/27353987 http://dx.doi.org/10.1016/j.sjopt.2017.02.009 https://www.ncbi.nlm.nih.gov/pubmed/?term=brandt%20jd%5bauthor%5d&cauthor=true&cauthor_uid=11581049 https://www.ncbi.nlm.nih.gov/pubmed/?term=beiser%20ja%5bauthor%5d&cauthor=true&cauthor_uid=11581049 https://www.ncbi.nlm.nih.gov/pubmed/?term=kass%20ma%5bauthor%5d&cauthor=true&cauthor_uid=11581049 https://www.ncbi.nlm.nih.gov/pubmed/?term=gordon%20mo%5bauthor%5d&cauthor=true&cauthor_uid=11581049 https://www.ncbi.nlm.nih.gov/pubmed/11581049 https://www.ncbi.nlm.nih.gov/pubmed/20051882 https://www.ncbi.nlm.nih.gov/pubmed/20051882 https://www.ncbi.nlm.nih.gov/pubmed/20051882 https://www.ncbi.nlm.nih.gov/pubmed/?term=inoue%20k%5bauthor%5d&cauthor=true&cauthor_uid=11853716 https://www.ncbi.nlm.nih.gov/pubmed/?term=kato%20s%5bauthor%5d&cauthor=true&cauthor_uid=11853716 https://www.ncbi.nlm.nih.gov/pubmed/?term=inoue%20y%5bauthor%5d&cauthor=true&cauthor_uid=11853716 https://www.ncbi.nlm.nih.gov/pubmed/?term=amano%20s%5bauthor%5d&cauthor=true&cauthor_uid=11853716 https://www.ncbi.nlm.nih.gov/pubmed/?term=oshika%20t%5bauthor%5d&cauthor=true&cauthor_uid=11853716 https://www.ncbi.nlm.nih.gov/pubmed/11853716 http://dx.doi.org/10.1097/ico.0b013e31823f8e00 http://www.diabetesatlas.org/ https://www.ncbi.nlm.nih.gov/pubmed/?term=su%20dh%5bauthor%5d&cauthor=true&cauthor_uid=17964654 https://www.ncbi.nlm.nih.gov/pubmed/?term=wong%20ty%5bauthor%5d&cauthor=true&cauthor_uid=17964654 https://www.ncbi.nlm.nih.gov/pubmed/?term=wong%20wl%5bauthor%5d&cauthor=true&cauthor_uid=17964654 https://www.ncbi.nlm.nih.gov/pubmed/?term=saw%20sm%5bauthor%5d&cauthor=true&cauthor_uid=17964654 https://www.ncbi.nlm.nih.gov/pubmed/?term=tan%20dt%5bauthor%5d&cauthor=true&cauthor_uid=17964654 https://www.ncbi.nlm.nih.gov/pubmed/?term=shen%20sy%5bauthor%5d&cauthor=true&cauthor_uid=17964654 https://www.ncbi.nlm.nih.gov/pubmed/?term=shen%20sy%5bauthor%5d&cauthor=true&cauthor_uid=17964654 https://www.ncbi.nlm.nih.gov/pubmed/?term=shen%20sy%5bauthor%5d&cauthor=true&cauthor_uid=17964654 https://www.ncbi.nlm.nih.gov/pubmed/?term=loon%20sc%5bauthor%5d&cauthor=true&cauthor_uid=17964654 https://www.ncbi.nlm.nih.gov/pubmed/?term=foster%20pj%5bauthor%5d&cauthor=true&cauthor_uid=17964654 https://www.ncbi.nlm.nih.gov/pubmed/?term=aung%20t%5bauthor%5d&cauthor=true&cauthor_uid=17964654 https://www.ncbi.nlm.nih.gov/pubmed/?term=singapore%20malay%20eye%20study%20group%5bcorporate%20author%5d https://www.ncbi.nlm.nih.gov/pubmed/?term=singapore%20malay%20eye%20study%20group%5bcorporate%20author%5d https://www.ncbi.nlm.nih.gov/pubmed/?term=singapore%20malay%20eye%20study%20group%5bcorporate%20author%5d https://www.ncbi.nlm.nih.gov/pubmed/17964654 http://dx.doi.org/10.1016/%20j.jcrs.2008.12.013 http://dx.doi.org/10.7555/jbr.30.20140075 http://dx.doi.org/10.5958/2395-1451.2016.00029.9 effect of diabetes mellitus on central corneal thickness – a comparative study pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 131 endothelium in children and adolescents with type 1 diabetes mellitus. mediators inflamm. 2013. article id 913754, 6 pages http://dx.doi.org/10.1155/2013/913754 26. mitchell p, smith w, chey t, healey pr. open-angle glaucomaand diabetes: the blue mountains eye study, australia. ophthalmology, 1997; 104: 712– 8. http://dx.doi.org/10.1155/2013/913754 microsoft word tahir mahmood 147 management corner diabetic macular edema tahir mahmood pak j ophthalmol 2008, vol. 24 no. 3 . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iabetes mellitus and its systemic and ophthalmic complications represent an enormous public health threat in the 21st century. the ophthalmic complications of diabetes are the leading cause of blindness in adults. numerous major clinical trials have demonstrated that complications of diabetes, including diabetic eye disease, can be reduced with adequate control of blood glucose, blood pressure, and hemoglobin a1c (hba1c) levels, but unfortunately, as many as 30% to 40% of patients with diabetes are currently undiagnosed and are not being monitored and treated to control their disease and prevent systemic complications. one of the most common causes of vision loss in patients with diabetes is diabetic macular edema (dme). all patients with diabetes are at risk of developing dme. the onset is usually insidious and painless, and manifests with blurring of central visual acuity. the severity may range from mild and asymptomatic to profound loss of vision. dme is a general term defined as retinal thickening within two disc diameters of the foveal center; it can be either focal or diffuse in distribution. focal edema is often associated with circinate rings of hard exudates (lipoprotein deposits) resulting from leakage from microaneurysms. diffuse edema represents more extensive breakdown of the blood-retinal barrier, with leakage from both microaneu-rysms and retinal capillaries. cystic changes may appear within the macula, representing focal coalescence of exudative fluid. clinically significant macular edema (csme) is a form of dme that was precisely defined by the early treatment diabetic retinopathy study (etdrs). csme exists if any of the following criteria are met: • any retinal thickening within 500 µm of the foveal center; • hard exudates within 500 µm of the foveal center that are associated with adjacent retinal thickening (which may lie more than 500 µm from the foveal center); • an area of retinal thickening at least 1 disc area in size, any part of which is located within 1 disc area of the foveal center. making the diagnosis of dme requires a careful ocular retinal examination. the optimal examination technique is biomicroscopy under stereopsis with high magnification. this examination should be performed on all diabetic patients to avoid missing subtle and asymptomatic cases of dme. as adjuncts to clinical examination, both fluorescein angiography and optical coherence tomography (oct) can be useful in evaluating dme. the prevalence of dme among diabetics approaches 30% in adults who have had diabetes for 20 years or more, and varies with the stage of diabetic retinopathy. it can occur at any stage of diabetes and can predate the appearance of other findings of diabetic retinopathy. in eyes with mild nonproliferative retinopathy, the prevalence of dme is 3%. this rises to 38% in eyes with moderate to severe nonproliferative retinopathy, and reaches 71% in eyes with proliferative retinopathy. untreated, 20% to 30% of patients with dme will experience a doubling of the visual angle within 3 years; with current treatment, this risk drops by 50%. diabetic retinopathy becomes nearly ubiquitous with long-standing diabetes. after 20 years with the disease, 60% of type 2 diabetics and virtually 100% of d 148 type 1 diabetics will manifest some form of retinopathy. poor control of blood sugar increases the risk of diabetic retinopathy, and diabetic nephropathy may be a marker for retinopathy. systemic hypertension is a risk factor for the development of both diabetic retinopathy and dme, and hyperlipidemia increases the risk of leakage and exudative deposits in the macula. the hallmark of diabetes mellitus is hyperglycemia, and chronic hyperglycemia lies at the root of all complications of diabetes through its detrimental effects on blood vessels, leading to vascular dysfunction and eventually vascular occlusion. diabetes is likely also a chronic low-grade inflammatory disease, a recent finding that may have important therapeutic implications. chronic inflammation may also promote vascular dysfunction and occlusion. hypoxia is the natural consequence of vascular dysfunction, and local hypoxia occurs in diabetic eye disease as a consequence of retinal vascular dysfunction. in response to local hypoxia, affected tissues in the retina and elsewhere upregulate the production of growth factors, such as vascular endothelial growth factor (vegf). vegf is a potent angiogenic stimulus, but it also induces vascular permeability. in fact, vegf was initially called vascular permeability factor, and its pro-permeability activity has been shown to be 50,000 times more potent than that of histamine. this action of vegf may be mediated by reductions in the levels of occlusion at tight junctions within the retinal vessels, leading to impaired cellular interactions and adhesion, with resulting breakdown of the blood-retina barrier and accumulation of extracellular fluid. on a cellular level, hypoxia results in thickening of the basement membrane of the vascular endothelium, and also in a reduction of the supportive pericytes lining retinal blood vessels. these changes also promote incompetence of the retinal vasculature, with leakage of extracellular fluid and the manifestation of macular edema. the ideal treatment for dme is primary prevention. prevention does not always work, and retinopathy and dme are often the initial presenting signs of diabetes. once csme exists, treatment is recommended. the etdrs clearly demonstrated that timely treatment with photocoagulation significantly reduces vision loss associated with diabetic retinopathy. in the diabetic retinopathy study (drs), panretinal photocoagulation reduced the incidence of severe vision loss from proliferative retinopathy by 50%, and macular grid and/or focal photocoagulation reduced the incidence of moderate vision loss from csme by 50%. despite laser photocoagulation, however, 12% of eyes with csme still experienced vision loss of 3 or more lines within 3 years. laser photocoagulation became the standard of care in the treatment of dme primarily as a result of the findings of the etdrs. in general, green wavelength is employed. other wavelengths have also been utilized; while they may be advantageous in specific cases, there is no evidence that the choice of wavelength impacts visual outcomes. the green wavelength is readily absorbed by hemoglobin, which has the advantage of improved uptake when photocoagulating microaneurysms but may limit its uptake at the level of the retina in eyes with mild or moderate vitreous hemorrhage. in such cases, red or infrared wavelengths, provided by krypton or diode lasers, may be more efficacious and have the benefit of passing more easily through media opacities such as cataracts. in addition, longer wavelengths, such as the 810-nm diode, may be better suited for treatment of diffuse macular edema close to the foveal center, because they can produce deep burns while sparing the inner neurosensory retina, minimizing the risk of perifoveal scotomas. laser photocoagulation may work through its absorption by melanin granules in the retinal pigment epithelium (rpe) and choroid and also by hemoglobin especially in microaneurysms. the use of laser photocoagulation results in significant improvement of oxygen supply to the inner retina directly from the choroid, which eventually reduces neovascularization. microaneurysms, the sources of leakage in dme, are targeted by the laser, and hemoglobin in the microaneurysms absorbs the laser energy. this promotes thrombosis within the microaneurysm, halting further leakage. in general, laser photocoagulation prevents further vision loss but does not routinely restore vision already lost to dme. therefore, laser photocoagulation should be performed when a patient is first diagnosed with csme. also, panretinal photocoagulation for proliferative diabetic retinopathy can acutely worsen dme. in eyes with both dme and proliferative retinopathy, it is often useful to perform macular treatment at the same time as, or even before, panretinal photocoagulation. 149 the technique for macular photocoagulation in eyes with dme begins with identifying the areas of retinal thickening and leakage. fluorescein angiography can be utilized as an adjunct to determine these areas (and areas of nonperfusion). focal treatment involves discretely treating every identifiable microaneurysm to stop further leakage. for diffuse macular edema treatment, grid treatment is applied over areas of retinal thickening to promote resorption of existing edema. the foveal avascular zone is fastidiously avoided to prevent central scotomas. usually, no treatment is placed within 500 microns of the center of the fovea. the advantages of photocoagulation have been made clear by the etdrs, in which laser photocoagulation was shown to halve the risk of doubling the visual angle, from 24% to 12% over 3 years. however, macular photocoagulation is not without risks. complications of macular laser treatment include paracentral scotomas, lateral creep of juxtafoveal laser scars into the fovea, accidental foveal photocoagulation, subfoveal fibrosis, and choroidal neovascularization at the sites of laser scars. in addition, there can be residual massive hard exudates after the resolution of edema, and patients often experience color vision impairment. in eyes with media opacities precluding photocoaguation, or eyes refractory to photocoagulation, vitrectomy is an alternative approach to treatment of dme. initially advocated for clearing of media opacities and relief of retinal traction, vitrectomy techniques have advanced, leading to more complex indications for treatment of dme. vitrectomy facilitates greater blood flow through retinal vessels. vitrectomy can be useful in eyes with dme if there is evidence of vitreomacular traction. there is a higher rate of posterior vitreous detachment in eyes without dme than in diabetic eyes with dme. supplementing vitrectomy with the removal of the internal limiting membrane may improve outcomes. vitrectomy is not without complications. cataract formation is common, retinal detachments and recurrent vitreous hemorrhage may occur; and intraocular pressure (iop) may rise, leading to glaucoma. inhibition of vegf has become a topic of interest in recent years in the area of age-related macular degeneration. the properties of vegf, and the consequences of its inhibition, also suggest a role for this approach in the management of dme. in the pathophysiologic cascade leading to dme, chronic hyperglycemia leads to oxidative damage to endothelial cells as well as to an inflammatory response. the ensuing ischemia results in overexpression of a number of growth factors, including not only vegf but also insulin-like growth factor-1, angiopoeitin-1 and -2, stromal-derived factor-1, fibroblast growth factor-2, and tumor necrosis factor. synergistically, these growth factors mediate angiogenesis, protease production, endothelial cell proliferation, migration, and tube formation. tumor necrosis factor-alpha (tnf-alpha) and vegf play a role in the early stages of angiogenesis, with tnfalpha promoting leukocyte adhesion and vegf promoting leukostasis, resulting in ischemia. blockade of all involved growth factors will likely be necessary to completely suppress the detrimental effects of ischemia, but even isolated blockade of vegf may have beneficial effects on dme. vegf increases vascular permeability by relaxing endothelial cell junctions, which increases permeability and leakage. inhibition of vegf blocks this effect to some extent. pegaptanib sodium (macugen) is an anti-vegf aptamer, a small piece of rna that self-folds into a shape that binds to and blocks the effects of vegf, one isoform of the vegf family of molecules. the drug is approved by the fda for the treatment of age-related macular degeneration, and it has recently been studied in a trial for dme. ranibizumab (lucentis) is an antibody fragment that also binds and blocks the effects of vegf. unlike pegaptanib, ranibizumab binds and inhibits all isoforms of vegf. ranibizumab is also approved by the fda for the treatment of age-related macular degeneration. bevacizumab (avastin) is the full antibody from which ranibizumab is derived. this anti-vegf molecule is fda approved for systemic treatment of metastatic colon cancer, but not for any ophthalmic indications. its use in conditions such as age-related macular degeneration, diabetic retinopathy, and dme is currently off-label. anti-vegf therapy for dme shows promise in preliminary studies. larger studies are ongoing. vegf inhibition may represent an important component of dme therapy in the future. improvements in drug delivery will be necessary in order to avoid repeated intravitreal injections and the cumulative risk of endophthalmitis associated with this route of administration. 150 increasingly, corticosteroids have been employed to treat macular edema. recently, intravitreal injection of triamcinolone acetonide has become a popular treatment, subsequently, a number of corticosteroidbased intravitreal implants have been developed to provide a sustained release of drug and make repeated intravitreal injections unnecessary. currently following corticosteroid-based intravitreal implants are under development: dexamethasone implant is a small biodegradable pellet designed to be injected in the operating room or the examination lane using a 20-gauge needle through the pars plana, delivering the drug in sustained release over approximately 1 month. a statistically significant reduction in both central macular thickness and leakage by fluorescein angiography was also seen in implanted eyes versus controls, with a notable doseresponse effect favoring the higher dose. triamcinolone acetonide has been reported to be effective in the management of macular edema, because it suppresses inflammation, reduces extravasation of fluid from leaking blood vessels, inhibits fibrovascular proliferation, and down-regulates production of vegf. triamcinolone can be administered by several routes, including intravitreal depot injection, periocular injection, posterior subtenon injection, and intravitreal implant. after depot injection, corticosteroid action peaks at 1 week, with residual activity persisting for 3 to 6 months. intravitreal injection of triamcinolone is associated with significant adverse events, including elevated intraocular pressure in up to half of injected eyes and cataract formation, as well as injection-related complications such as endophthalmitis and retinal detachment. periocular injections reduce the risk of serious complications such as endophthalmitis, but the duration of effect is shorter, and the therapeutic efficacy of triamcinolone administered by this route against dme is unclear. fluocinolone acetonide has also been incorporated into an implant and has several properties that make it a logical choice for incorporation into a sustainedrelease drug delivery device. the drug has low solubility, ensuring slow delivery of drug over a long period of time and increasing the useful lifespan of the device once implanted. the low solubility also decreases the amount of corticosteroid in the anterior chamber as the drug will preferentially clear by passing out through the retina – more soluble compounds will achieve higher aqueous levels. fluocinolone acetonide is a potent corticosteroid, which reduces the amount of drug required to be incorporated into the device, consequently minimizing device size. furthermore, fluocinolone acetonide has a short half-life in the systemic circulation, reducing the likelihood of systemic side effects. the fluocinolone acetonide intravitreal implant is fda approved for the treatment of chronic noninfectious posterior segment uveitis. corticosteroid-based intravitreal implants provide effective treatment for dme while avoiding the risks associated with repeated transscleral injections into the eye. implants under investigation utilize corticosteroids with different properties, which will ensure that the best compounds are utilized in the final implants approved for public use. larger studies are needed to clarify the long-term safety and efficacy profiles of some of these implants. conclusion diabetic macular edema represents a significant public health challenge. many patients are undiagnosed and untreated, and even those treated with standard therapy may respond poorly and progressively lose vision. insight into the pathophysiology of dme has led to novel treatments, including anti-vegf and corticosteroid-based treatment strategies. drug delivery into the vitreous cavity remains an important limitation of many of these new treatments, as the risks of endophthalmitis, retinal detachment, and other adverse events become cumulative with repeated intravitreal injections. injectable and/or implantable drug delivery devices may offer the benefits of chronic therapy while reducing the adverse events associated with repeated drug delivery. 151 microsoft word hashim qureshi 118 original article prevalence of trachoma in upper sindh muhammad hashim qureshi, shahid jamal siddiqui, muhammad afzal pechuho, dureyakta shaikh, abdul qadir shaikh pak j ophthalmol 2010, vol. 26 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad hashim qureshi department of ophthalmology ghulam muhammad mahar medical college sukhar received for publication august 2009 …..……………………….. purpose: to determine the prevalence of trachoma in upper sindh. material and methods: we did cross sectional study simultaneously at ghulam muhammad mahar medical college sukkur, chandka medical college larkana and civil hospital jacobabad from 1st jan 2007 to 20th april 2009. patients suffering from clinical features of active trachoma and trachomatous trichiasis were examined. we diagnosed patients on clinical grounds using w.h.o simplified grading system. result: nine thousand and six patients with trachoma were diagnosed, eight thousand seven hundred (96.6%) with active trachoma and 306 (3.40%) with trichaisis. active trachoma was highly prevalent in female children (48.97%) while trachomatous trachiasis was predominantly seen in adult females (6.7%). conclusion: active trachoma is still an avoidable vision threatening challenge in upper sindh. a collaborated wide ranging integrated community based approach must be implicated to reach elimination of trachoma by the year 2020. rachoma has been known to mankind since the 27th century bc1. it is caused by chlamydia trachomatous serotypes a,b ba and c that leads to chronic bilateral follicular kerato conjunctivitis2. it is highly infectious disease and its sources of infection and re infection are flies, fingers and faces with dirty secretions3,4. infection occurs generally in early childhood peaking around 5-7 years of age and in adulthood leads to conjunctival scarring, trichaisis and ultimately blindness due to corneal opacification5. trachoma is associated with poverty, poor personal and community hygiene, poor healthcare and lack of clean water facilities3-5. trachoma is prevalent all over world particularly africa, south east asia and middle east6. globally about 40 million people are suffering from active trachoma and are in need of treatment7. the knowledge of updated estimate of prevalence in a community is mandatory for management of this preventable blinding disease6’7. the purpose of our study is to establish the prevalence of trachoma in upper sindh. material and methods the cross sectional study was carried out simultaneously at ghulam muhammad mahar medical college sukkur, chandka medical collage larkana and civil hospital jacoabad. patients were registered at eye opd of these hospitals from 1st january 2007 to april 2009. a team of two doctors one each at ghulam muhammad mahar medical college sukkur and chandka medical collage larkana and one ophthalmologist with an assistant at civil hospital jacoabad examined the patients. detailed history and complete eye examination of anterior and posterior segments were performed. patients suffering from clinical features of trachoma ware examined thoroughly using a printed proforma provided by prevention and control of blindness cell, dow medical college and civil hospital karachi. the diagnosis of trachoma was made on clinical grounds using w.h.o. simplified grading system1,2,5. patients with active trachoma and trachomatous trichiasis were included in the study while patients with trachomatous corneal opacity were excluded. t 119 who simplified grading system of trachoma 2 (fisto) grading clinical findings remarks trachomatous follicle (tf) trachomatous inflammation with 5 or more follicles of at least 0.5 mm diameter on the upper central tarsal conjunctiva. a few follicles at limbos implies active trachoma, needs treatment. recovers with no or minimal scarring trachoma intense (ti) trachoma inflammation intense with numberous follicles and papillae. thickening of the upper tarsal conjunctiva obscures more than 50% of the deep conjunctival vessels. pannus formation stage of severe disease needs urgent treatment but with high risk of complications trachomatous scarring or cicatricial trachoma (ts) upper tarsal conjunctival linear, band shaped or star shaped scarring arts line. limbal follicles heal with pits hebert’s pits old, now inactive infection trachomatous trichiasis (tt) presence of at least one misdirected eye lash rubbing the eye ball needs corrective surgery trachomatous opacities (to) presence of a corneal opacity covering part of the pupillary margin implies permanent damage caused by trachomatous trichiasis results a total number of 9006 patients with trachoma were examined. eight thousand seven hundred (96.6%) cases of active trachoma were seen. trachomatous trichiasis was reported in three hundred six (3.40%) patients. female patients were 5566 (61.80%). demographic characteristics of the patients have been shown in the (table 1). age and gender distribution of active trachoma has been shown in the (table 2). active trachoma was present mainly in female children under the age of 10 years, (33.2%), almost double than the male children (15.75). the prevalence of active trachoma decreased as the age increased. patients with age more than 30 years had relatively very low prevalence of active trachoma 625 (7.1%). trachomatous trichaisis was highly prevalent in adulthood especially after 30 years of age (81.37%). only four cases (1.31%) were noted between 10-14 years of age. female patients with trichiasis predominated in all age strata (67.9%). over all prevalence of trichiasis was (3.39%) (table 3). discussion trachoma is the disease of poverty and poor sanitation 1-4. globally about 400 million people have trachoma6-7. in 2003 who estimated 84 million cases of active trachoma world wide7,6. sp mariotti6 reported 40 million cases of active trachoma in the world. about 8.2 million cases of trachomatous trichiasis have been estimated8. six million people have trachoma induced blindness or severe visual loss world wide7,8. this accounts for 2.9% of worlds blind people (resnikoft 2008)7. trachoma is prevalent in pakistan9. about 0.806 million people had active trachoma and 71700 people were suffering from trichiasis6,9. we carried out our study in upper sindh where about 70% of the population lives in rural areas10. we examined eight thousand seven hundred cases of active trachoma and three hundred six patients of trichaisis. our study showed trachoma was highly prevalent in children less than ten years of age (48.97%). this is relatively low prevalence rate as compared to other investigators. anthony et al5 reported 81% of prevalence of active trachoma in children less than 10 years of age. in a study in central tanzania11 higher prevalence rate was probably due to the fact that those studies were done in hyperendemic areas. our study showed increased prevalence in female patients (67.47%) almost double than the male patients. this is comparable to those reported by other investigators who reported 53% to 80% prevalence in female patients and 25%-45% prevalence in male patient6-8,11-14. 120 table 1: demographic characteristics of patients n=9006 age years male n=(%) female n=(% total n=(%) 1-4 960 (10.64) 1475 (16.37) 2435 (27.04) 5-9 1105 (12.27) 2160 (24.00) 3265 (36.25) 10-15 655 (7.27) 995 (11.05) 1650 (18.32) 16-30 565 (6.27) 670 (7.44) 1235 (13.71) >30 164 (1.82) 265 (2.95) 429 (4.76) total 3449 (38.32) 5566 (61.80) 9006 (100) table 2: active trachoma n=8700 age years male n=(%) female n=(% total n=(%) 1-9 1370 (15.75) 2890 (33.21) 4260 (48.97) 10-15 1030 (11.84) 1660 (19.1) 2690 (30.92) 16-30 300 (3.45) 825 (9.48 1125 (12.93) >30 130 (1.49) 495 (5.69) 625 (7.18) total 2830 (32.53) 5870 (67.47) 8700 (100) table 3: trachomatous trichaisis n=306 age years male n=(%) female n=(% total n=(%) >30 162 (52.94) 87 (28.43) 249 (81.37) 15-29 43 (14.05) 10 (3.27) 53 (17.32) 10-14 3 (0.98) 1 (0.33) 4 (1.31) total 208 (76.97) 98 (32.03) 306 (100) the prevalence of trachomatous trichaisis was (3.39%) with female predominance (67.97%) in all age strata. this is in contrast to other studies that reported showing >80% prevalence in females8,13. our study showed that the trachoma was primarily a disease of childhood, infection started in early life and complications began to appear in adulthood. in our study only four cases (1.31%) of children with trichiasis were seen in 10-14 years of age while (98.70%) cases of trichaisis were seen in adults mainly after 30 years of age (81.37%), this is comparable to those reported by other investigators,13-16. in upper sindh relatively low rate of prevalence of active trachoma and trachomatous trichiasis was mainly due to efforts taken by who in collaboration with prevention and control of blindness ministry of health pakistan in 20026,9,17. the author was then district focal person of that programme in district jacobabad. the credit of this monumental achievement obviously goes to the who safe (s=surgery, a= antibiotic, f=face washing e=environmental cleanliness) strategy and plan of global elimination of blinding trachoma (get) by the year 202017. on the other hand, active trachoma and trichiasis is still prevalent in rural areas of upper sindh and adjacent balochistan, where people from afghanistan have been migrating. the need of the hour is that trachoma control plan must be started in the country to eliminate trachoma from the country and achieve the targets of get 2020. conclusion prevalence of trachoma in upper sindh and adjacent balochistan is an avoidable sight threatening challenge. safe strategy and get 2020 plan of who in collaboration with health ministry of pakistan should be implemented effectively. the co-operation of local ngo, community health workers, mass media, local political leaders and workers and keeping in view the local cultural traditions help from elders of rural areas should be sought for patients’ education regarding trachoma awareness, personal hygiene and environmental cleanliness. author’s affiliation muhammad hashim qureshi assistant professor department of ophthalmology ghulam muhammad mahar medical college sukhar dr. shahid jamal siddiqui associate professor department of ophthalmology chandka medical collage & hospital larkana dr. muhammad afzal pechuho assistant professor department of ophthalmology chandka medical collage & hospital larkana 121 dr. dureyakta shaikh assistant professor department of ophthalmology ghulam muhammad mahar medical college sukkur sindh dr. abdul qadir shaikh department of ophthalmology chandka medical collage & hospital larkana reference 1. garcia-ferrer fj, ivan r. vaughn dg, et al. general ophthalmology, mc graw hill lange company. 2008; 17: 103411. 2. parsons diseases of the eye, elsevier company. 2007; 20: 166-9. 3. sandy cairn cross mice mciwem. trachoma and water. j community eye health. 199; 12: 58-9. 4. emerson pm, baily rl. trachoma and fly control. j community eye health. 1999; 12: 57. 5. solomon aw, rosanna w, foster pa et al. diagnosis and assessment of trachoma clinical microbiology review 2004; 17: 982-1011. 6. sp mariotta d, pascolline j. rose, nuss baumer-trachoma global magnitude of a preventable cause of blindness. dr j ophthalmol. 2009; 93: 563-8. 7. resnikoff s, pascolline p, mariotti sp. global magnitude of visual impairment caused by uncorrected refractive errors in 2004. bulletin of world health organ. 2008; 86: 63-70. 8. ngondi j, mark h. risk factors for trachomatous tyrichiasis in children cross sectional house hold surveys in southern sudan. transactions of the royal society of tropical medicine and hygiene. 2009; 103: 305-14. 9. pakistan national blindness and low vision survey. results of prevalence and causes of blindness. pakistan institute of community ophthalmology peshawar pakistan (unpublished data). 10. www. sindh. gov. pk./dpt/population 11. west sk, munoz b, turner vm, et al. the epidemiology of trachoma in central tanzania. internaltional j epidemiology. 1991; 20: 1088-92. 12. land pc, hailu g, todd j. active trachoma in children aged three to nine years in rural communities in ethiopia. prevalence, indicators, and risk factors. transactions of the royal socieyt of tropical medicine and hygiene 2005; 99: 120-7. 13. wondium a, beliqa a. prevalence of trachomatous trichiasis in the community of alaba distric southern ethiopia. east african medical journal. 2003; 80: 365-8. 14. hsich yh, bobo ld, quinn, et al. a survey of trachoma. 6 years follow up of children aged 1-2 years a j epidemiology. 2000; 152-204. 15. ranson mk, even tg. the global (burden of trachomatous visual impairment i. assessing prevalence. international ophthalmology. 1996; 19: 261-70. 16. rabiu m, ablose a. magnitude of trachoma and barriers to up take of lid surgery in a rural community of northern nigeria. ophthalmic epidemiology. 2001; 8: 181-90. 17. report of seventh meeting of who alliance for the global elimination of blinding trachoma. geneva. 2003; 6-8. target iop target pressure is that range of iop attained with treatment which is expected to prevent further glaucomatous damage. in general for all high tension glaucoma cases aim for iop to be in the range of • -low twenties if the damage already is mild • -high teens if the damage already is moderate • -low teens if the damage already is severe in normal tension glaucoma the rationale to treat is based on the risk and evidence of progressive visual field loss, neuropathy and functional visual deterioration while the target iop required is much lower than in high tension glaucoma and there is proven evidence of stoppage of further field loss and neuropathy deterioration in majority of the properly treated group. prof. m lateef chaudhry editor in chief microsoft word mian shafique 2 original article modified limbal incision: an easy and safe window for extraocular muscle surgery mian m. shafique, nadeem h. butt, muhammad khalil, tayyaba gul pak j ophthalmol 2008, vol. 24 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mian m. shafique department of ophthalmology lahore medical & dental college lahore received for publication june’ 2007 …..……………………….. purpose: to find out the advantages and disadvantages of modified limbal incision as an approach to horizontal extraocular muscles during squint surgery and its comparison with ‘over the muscle’ conjunctival incision. material and methods: total of 67 patients of squint were included in this prospective study which was conducted between march 1999 and october 2002. both male and female patients of all age groups and all types of squints were included. these patients were admitted for surgery after proper assessment including history, examination and investigations. in 36 patients modified limbal incision was given in the conjunctiva (group-i) while remaining 31 patients underwent ‘over the muscle’ conjunctival incision for approaching the extraocular muscles (group-ii). results: approach to the extraocular muscles was easy in 94.5% cases with modified limbal incision as compared to 80.5% (25 out of 31) in over the muscle incision. no help of assistant was required for suturing of the wound during the modified limbal approach while it was required in 59% (17/31) of cases in groupii. although conjunctiva was congested in good number of patients in both groups on first post op day, yet more patients were comfortable in first group than in second group. removal of stitches in modified limbal approach was almost non existing while in comparison stitches had to be removed in almost one third of cases in the other group. conclusion: modified limbal conjunctival incision is a safe and quick approach to operate on extraocular muscles both in esotropia and exotropia, equally good for recessions and resections. although majority of patients postoperatively have red eyes yet most of the patients are relatively more comfortable as compared to “over the muscle incision”. only two stitches are required to close the incision. mostly there is no need to remove these stitches. n c i s i o n and surgery have been part and parcel of each other since ages. without an incision it was not possible to enter and deal with the tissue to be operated. as the incision healed it almost always left a scar mark which many a times was not acceptable cosmetically. for the sake of cosmetic appearance, the size of incision was reduced but at the expense of reduced exposure of tissues under surgery. a galaxy of researchers kept on working in search of a safe and small incision till we reached the era of endoscopic surgery. strabismus surgery is the ultimate answer to many varieties of squint. the commonly done procedures are recessions and resections, although advancei 3 ment and plication are not uncommon. all of these procedures are done on extraocular muscles. to expose extraocular muscles different conjunctival incisions are preferred1,2. commonly used approaches are limbal, paralimbal, over the muscle or fornix. where limbal incision poses difficulty in comfortable and full exposure of extraocular muscle, ‘over the muscle approach’ has more post operative complications i.e. excessive scarring. so there was a need to try a special approach which provides us good exposure of extraocular muscles during surgery, has least post operative complications and is cosmetically acceptable also. we tried a ‘modified incision’ at the limbus and compared its advantages and disadvantages during the squint surgery as well as postoperatively with ‘over the muscle incision’. material and methods this study was conducted in department of ophthalmology fatima jinnah medical college and sir ganga ram hospital, lahore from march 1999 to october 2002. a total of 67 patients of all age groups, both sexes and all types of squint were included in the study. all the patients underwent detailed assessment including history, examination and investigations. during the surgical procedure patients were randomly divided into two groups. in 36 patients ‘modified limbal incision’ was given in the conjunctiva (group-i) while remaining 31 patients underwent ‘over the muscle incision’ for approaching the extraocular muscles (group-ii). the modified limbal incision comprised of a curved portion at the limbus for length of 3 clock hours just apposing the insertions site of the muscle to be tackled and two radial extensions from each end of the curved part. each radial extension was 5mm long, one along each border of horizontal muscle. for medial rectus of right eye the curved part was at the limbus from 1.30 o’ clock to 4.30 o’ clock and each radial extension from the ends of this curve was almost at right angle to the limbus as is shown in fig 1. at the end of procedure the incision was closed by two simple interrupted stitches of 6/0 vicryl, one at each end of curved part at the limbus i.e. 1.30 o’ clock and 4.30 o’ clock for medial rectus surgery of right eye. for other horizontal muscles the corresponding sites were used for incisions and stitches. both the incisions were closed by 6/0 vicryl interrupted stitches (fig2). special events like difficulty in exposing and clearing the muscles from the fascia, excessive bleeding and difficult suturing were recorded during the surgery. each patient was followed postoperatively on first post op day, 7th post op day and at the end of one month to note any post operative problems like increased discomfort, excessive watering, lid swelling, conjunctival redness, need for re-stitching, need to remove stitches and stitch granuloma. results total no of patients in the study were 67. age of the patients ranged from 5 years to 24 years. males and females were almost equal in number (33 vs. 34). 39 patients had esotropia while remaining 28 were suffering from exotropia. total no of muscles tackled were 130. recession was done on 83 muscles whereas 47 muscles were resected. out of these 70 were exposed with modified limbal incision (group-i) and 60 with over the muscle incision (group-ii). (table 1). during the surgery we did not find any difficulty in approaching the extra ocular muscles in 94.5% (34 out of 36) cases with modified limbal incision , in only 2 patients we had to spend extra time in clearing and exposing the muscle. one out of these 2 also had excessive bleeding on the table. in comparison, easy access to extra ocular muscles was recorded in 80.5% cases (25 out of 31) in over the muscle incision while in 6 patients(19.5%) exposure was difficult. two out of these 6 had excessive bleeding (table 2). interestingly, the suturing of the wound during the modified limbal approach was quite easy without any help from the assistant in all cases while we had to seek the help of the assistant in 54.8% (17/31) of cases in group-ii (table 2). table 1: over all view (total no. of cases 67) type of squint no of pts no of recessions no of resections no of modified limbal incisions no of over the muscle incisions no of incisions esotropia 39 48 (9 bil mr 26 (4 only 44 (2 only mr 30 (2 only mr 74 4 recession) recession) recession) recession) exotropia 28 35 (7 bil lr recession) 21 26 30 56 total 67 83 47 70 60 130 bil=bilateral; mr=medial rectus; lr=lateral rectus table 2: experience during surgery (total no. of cases 67) during surgery modified limbal approach (36) over the muscle approach (31) no of patients n (%) no of patients n (%) easy access to extraocular muscles 34 (94.5) 25 (80.6) excessive bleeding during surgery 1 (2.8) 2 (6.5) difficult suturing 0 (0) 17 (54.8) post operatively on day one, increased discomfort and excessive watering was complained by 13.9% patients in group-i while it was much higher (67.8% and 51.6% respectively) in group-ii. on post op examination on day one, lid swelling was noted in 5.6% in group-i and in 9.7% cases in group-ii. conjunctival redness on first post op day was very commonly seen in both groups although it was significantly less in group-i (77.8%) as compared to patients of group-ii (96.8%). no patients in both the groups required re-stitching in our series. removal of stitches was required in 1 (2.8%) patient of group-i and 9 (29%) patients in group-ii. one patient (3.2%) in group-ii also developed stitch granuloma which was not recorded in any of the patients in group-i. discussion strabismus is a very common disorder in the childhood and if not treated may continue through the adulthood and old age. in majority of these patients the treatment is surgical mostly in the form of either recession or resection of extraocular muscles. whatever adjustment is made with the muscles, these have to be exposed first. to reach the extraocular muscle tendon and belly we have to make a window in the overlying membranes, namely conjunctiva, subconjunctival tissue and tenon’s capsule. these three layers are very close to one another near the limbus and wide apart as we move away from it. a variety of incisions have been tried, some near the limbus3 others parallel to limbus but near the fornix4 and some in between these two ends (para-limbus)5. fig 1: diagram showing modified limbal incision fig. 2: two stitch closure of modified limbal incision 5 fig 3: post operative conjunctival redness in modified limbal approach table 3: post operative comparison post operative problems modified limbal approach (36) over the muscle approach (31) no of patients n (%) no of patients n (%) increased discomfort 5 (13.9) 21 (67.8) excessive watering 5 (13.9) 16 (51.6) lid swelling 2 (5.6) 3 (9.7) conjunctival redness 28 (77.8) 30(96.8) need for restitching 0 (0) 0 (0) need to remove stitches 1 (2. 8) 9 (29) stitch granuloma 0 (0) 1 (3.2) still others have tried radial incisions6. we in our study used a modified limbal incision which has benefits of both limbal and radial incisions and compared it with fornix or over the muscle approach. the tenon’s capsule also called the ‘fascia of the eyeball’ along with its extensions around the extraocular muscles serves as a socket in which the eye ball can move smoothly in all directions. its role in post operative complications has been extensively studied4,7,8. any approach which preserves the relations of tenon’s capsule and its various extensions will have minimal complications7. any distortion and damage to this fascia will lead to a range of complications including marked post operative scarring. there is a good chance to reduce the scarring between conjunctiva, tenon's capsule, muscle and sclera after surgical treatment of rectus and oblique muscles if a careful reconstruction of tenon's capsule is made9. in the present study the modified limbal incision is made at the limbus cutting sharply both the conjunctiva and the tenon’s capsule by one single snip along the limbus with two small radial cuts at its each end. the anatomy of tenon’s capsule is minimally disturbed as there is no tearing and distortion involved during exposure of extraocular muscles. this has provided us with easy access to extraocular muscles in high majority of cases with minimal complications on the operating table (table 2) and during the postoperative period (fig 3 and table 3). in comparison the other incision which is made by cutting the conjunctiva and tenon’s capsule separately over the muscle itself disturbs the anatomy of the facial system as it involves tearing and shearing of this tissue in order to save the muscle from sharp cuts of scissors during its exposure. that is why ‘over the muscle approach’ is associated with many postoperative complications in our study (table 3). other researchers are convinced that “the conjunctival and tenon's capsule incisions should not be made directly over the muscle; this will result in scarring of the muscle to tenon's capsule or of tenon's capsule to the muscle insertion stump, promoting restriction” 4. closure of wound in this study was done with 6/0 vicryl interrupted stitches. it was in the form of just two stitches at the limbus, at junction of radial cuts with the curved part of incision in modified limbal approach (fig 2). we never required any assistance to apply these two stitches in this incision. this is in contrast to ‘over the muscle approach’ where proper stitching required assistance in majority of the cases. post operative discomfort was much less in modified limbal approach as compared to ‘over the muscle approach’. although use of fibrin glue has been advocated as an attractive alternative for closing the conjunctival incision in strabismus surgery,10,11 yet results of closing the wound with 6/0 vicryl in 6 modified limbal incision in our study were found comparable with the fibrin glue. conclusion modified limbal conjunctival incision for strabismus surgery is an easy and safe approach. it provides an easy access to the extraocular muscles and there are minimal postoperative complications as compared to ‘over the muscle approach’. the incision only requires two stitches to re-appose its edges and there is no need to remove these stitches. author’s affiliation dr. mian m. shafique associate professor department of ophthalmology lahore medical & dental college lahore dr. nadeem h. butt associate professor department of ophthalmology allama iqbal medical colleg lahore dr muhammad khalil assistant professor department of ophthalmology lahore medical & dental college lahore dr tayyaba gul senior registrar department of ophthalmology lahore medical & dental college lahore reference 1. callear ab, eaqlinq em. “a novel conjunctival incision for horizontal strabismus surgery” eye.1996; 10: 405-6. 2. mojon ds. “comparison of a new, minimally invasive strabismus surgery technique with the usual limbal approach for rectus muscle recession and plication.” br j ophthalmol. 2007; 91: 76-82. 3. caputo ar, guo s, derespinis p, et al. “simplified limbal incision for extraocular rectus muscle surgery.” ophthalmic surg. 1991; 22: 406-8. 4. price rl. “role of tenon's capsule in postoperative restrictions.” int ophthalmol clin. 1976; 16: 197-207. 5. santiago ap, isenberg sj, neumann d, et al. “the paralimbal approach with deferred conjunctival closure for adjustable strabismus surgery.” ophthalmic surg lasers. 1998; 29:151-6. 6. velez g. “radial incision for surgery of the horizontal rectus muscles.” j pediatr ophthalmol strabismus. 1980; 17: 106-7. 7. o'donoghue hn, smith ab. “importance of tenon's capsule in squint surgery.” trans ophthalmol soc u k. 1982; 102: 492-4. 8. ludwig ih. “scar remodeling after strabismus surgery.” trans am ophthalmol soc. 1999; 97: 583-651. 9. stark n. “surgery of tenon's capsule in squint operations.” klin monatsbl augenheilkd. 1992; 201: 178-80. 10. biender b, rosenthal g. “conjunctival closure in strabismus surgery: vicryl versus fibrin glue. ophthalmic surg lasers: 1996; 27: 976. 11. dedeya s, kamlelsh ms. “strabismus surgery: fibrin glue versus vicryl for conjunctival closure” acta ophthalmol. scand. 2001: 79: 515-7. microsoft word mirza shafiq ali baig 1 original article trabeculectomy: a long term follow-up of 455 cases mirza shafiq ali baig, jamshed ahmed, mohammad shafique khan pak j ophthalmol 2008, vol. 24 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: mirza shafiq ali baig department of ophthalmology dow university of health sciences, karach received for publication february’ 2008 purpose: to evaluate the outcome and complications of trabeculectomies performed at two tertiary care hospitals. material and methods: a prospective case series of 455 cases of trabeculectomies performed at the civil hospital and lyari general hospital karachi from 2000 to 2006. the preoperative and postoperative ocular data of 150 eyes in 120 patients is evaluated. results: average follow-up period was 36.2 months with a minimum of 3 months and maximum of 60 months. only 33% completed follow –up of at least two years so included in the analysis. success, defined by a postoperative iop ≤ 21 mm hg or a decreased postoperative iop of at least 25% from preoperative pressure if the preoperative iop was already ≤21 mm hg, was observed in 121 eyes (82.6 %) at last follow-up without any medication. notable complications included hyphema of more than 5 days duration in 11(7.3%), shallow anterior chamber in 6(4.7%), hypotony in 7(4.7%), choroidal detachment in 2(1.3%), uncontrolled intraocular pressure, requiring further intervention, in 7(4.7%) and endophthalmitis in 1(0.7%). at 2 year follow-up cataract formation was observed in 32(21.7%) cases. conclusions: results of this study suggest that the outcomes of trabeculectomies performed in this region have a high success rate, comparable with previous studies in the literature. rates of complications are overall similar to those found in the published literature. poor follow-up and non affordability for drugs makes trabeculectomy as a method of first choice. 2 … ……………………… rabeculectomy, introduced by cairns1 in 1968 and modified by watson2 in 1970 is still a gold standard for the surgical management of various types of glaucoma. it is successful in controlling the intraocular pressure without many of the serious operative and postoperative complications. in our working conditions it becomes a procedure of first choice because of poor follow-up, low socioeconomic status and non-affordability to the cost of medical treatment. purpose of our study is seeing the efficacy, document the complications and compare our results with those reported in the literature. material and methods all patients undergoing trabeculectomy at the department of ophthalmology dow university of health sciences and sindh government lyari general hospital and civil hospital karachi from january 1997 to december 2006 inclusive, and who were available for follow-up for at least two years , were studied. a total of 120 patients (150 eyes) were included in the study. informed consent was obtained from all participants before entry into study. they were divided into various glaucomatous groups based on the preoperative clinical and gonioscopic appearance (table 1). four groups accounted for 80% of cases (table 1): primary open angle, acute angle closure, chronic angle-closure and normal tension glaucoma’s. technique the surgical procedure is based on that described by watson. most of the operations were performed by the author under microscope. the operations were carried out under local anesthesia in adult and under general anesthesia in pediatric patients. a 4-0 silk superior rectus bridle suture was placed under direct visualization. in most cases a limbus based conjunctival flap was fashioned and in a few cases fornix based flap was made. homeostasis was maintained with a wet field cautry avoiding the conjunctival flap. a 4x4 mm superficial rectangular or triangular scleral flap was fashioned and dissected well into the clear cornea at the surgical limbus, a paracentesis tract was made if high intraocular pressure is anticipated, a deep sclerotomy of 1x3 mm was performed and a window was created by vannas scissor. peripheral iridectomy was performed. scleral flap was sutured with 10-0 nylon and conjunctival flap wit 8-0 silk sutures. a sub-conjunctival injection of 2 mg betamethasone and 20 mg of gentamycin was given and a light pad and shield was applied. the patients were discharged on third or fourth day with following post operative medications: • atropine1% eye drops twice daily. • ofloxacin eye drops four times a day. • dexamethasone eye drops four times a day follow up patients were called for follow up weekly for one month then monthly for six months and then every six months to record visual acuity, iop, and document any complication. data was analyzed by spss (v-11) for windows. results there were 356 patients (455 eyes) in this study (table 1) but only 120 patients with 150 (33%) eyes were available for follow up for at least two years. average follow-up period was 36.2 months with a minimum of 3 months and maximum of 60 months. age ranged from 3 months to 73 years with a mean of 42.6 years. seventy five (62.5%) were males while forty five (37.5%) were females (fig. 1). eighty eight (58.7%) had primary open angle glaucoma, twenty three (15.3%) had primary angle closure glaucoma, congenital glaucoma accounted for 12(8%) cases, other type of glaucoma’s were aphakic 4(2.7%), pseudophakic 3(2%), steroid induced 2(1.3%), normal tension 8(5.3%), neovascular 3(2%), glaucoma capsulare 4 (2.7%) and angle recession 3(2%).( table 2). table 1: preoperative diagnosis of glaucomas types frequency n (%) aphakic glaucoma 10 (2.2) steroid induced glaucoma 4 (0.88) congenital glaucoma 22(4.83) glaucoma capsulare 10 (2.2) normal tension glaucoma 20(4.38) t 133 neovascular glaucoma 12(2.63) primary angle closure glaucoma 77(16.94) pseudophakic glaucoma 12(2.64) primary open angle glaucoma 278(61.1) traumatic glaucoma 10 (2.2) total 455 (100) mean preoperative intraocular pressure was 30.4 mm of hg. the results of this study at 12 months post operatively revealed that out of the 150 eyes 83 (55.3%) achieved a pressure of 15 mm of hg or less. in addition 38(25.3%) eyes achieved a pressure between 15 and 21 mm of hg. total success rate without any medication was found to be 80.6%. while in 29 (19.3%) eyes pressure remained above 21 mm of hg. (table. 3). sub conjunctival drainage of aqueous is indicated by bleb formation. in our study good bleb was apparent in 131(87.3%) eyes (fig. 2) while shallow or absent bleb was present in 19(12.7%) eyes (table 4). short term minor complications includes anterior uveitis in 7 (4.7%), hyphema of more than 5 days duration in 11(7.3%), shallow anterior chamber in 6(4.7%), hypotony in 7(4.7%), choroidal detachment in 2(1.3%), uncontrolled pressure in 7(4.7%) and endophthalmitis in 1(0.7%). at 2 year follow-up cataract formation was observed in 32(21.7%) cases (table 5). table 2: type of glaucomas available for follow-up types frequency n (%) aphakic glaucoma 4 (2.7) steroid induced glaucoma 2 (1.3) congenital glaucoma 12 (8.0) glaucoma capsulare 4 (2.7) normal tension glaucoma 8 (5.3) neovascular glaucoma 3 (2.0) primary angle closure glaucoma 23(15.3) pseudophakic glaucoma 3 (2.0) primary open angle glaucoma 88(58.7) traumatic glaucoma 3 (2.0) total 150(100) table 3: intraocular pressure at last follow-up iop range frequency n (%) below 10 mm of hg 4 (2.7) 11-15 79(52.7) 16-21 38(25.3) 22-25 17(11.3) above 30 12 (8.0) total 150(100) table 4: type of blebs at last follow-up bleb type frequency n (%) cystic 15(10) good bleb 116(77.3) no bleb 13(8.7) shallow bleb 6(4.0) total 150(100) table 5: post operative complications complications frequency n (%) no complication 77 (51.3) anterior uveitis 7 (4.7) cataract formation 32(21.3) choroidal detachment 2 (1.3) endophthalmitis 1(.7) hypotony 7(4.7) hyphema 11(7.3) shallow anterior chamber 6 (4.0) uncontrolled pressure 7 (4.7) total 150(100) 134 38 62 males females fig. 1: sex distribution fig 2: left eye six months after trabeculectomy. arrow showing good drainage bleb. discussion mean age in our study is 42.6 years which is less than reported in other studies (49.4)3 and (60.9)4. the intraocular pressure was normalized in 121(80.6%) of eyes without the addition of any therapy. these results are consistent with those reported by many previous authors (84 %) 5, 6. hypotony (iop<10 mmhg) of more than one moth duration was reported in 4.7% of 150 eyes which is lower than reported (9.9%) in other series7. the incidence of hyphema of more than 5 days duration is 7.3% in this series. other authors have reported an overall incidence of hyphema more than reported in this series8. the incidence of cataract after classic fistulising procedures has been reported to be 66% in a recent study after a follow up of 36 months. this study included all types of cataracts classified according to the locs iii (lens opacity classification system iii) classification9. the incidence of cataract in this series producing a decrease in visual acuity of more than 2 snellen’s lines is 21.7%. this lower incidence is due to the fact that we included only those patients who asked for visual rehabilitation due to cataract formation. other complications reported in this series are shallow anterior chamber, anterior uveitis, choroidal detachment and uncontrolled intraocular pressure had almost same incidences reported in other series10,11. one case (0.7%) developed chronic endophthalmitis. this complication has not been reported in many series3,5,8. one thing that deserve worth mentioning is a poor long term follow up. only 33% patients were available at 2 years of follow up. this could be due to social and economical situations prevailing in this region. conclusion in summary, it appears from this study, that trabeculectomy is an important surgical procedure in the treatment of glaucoma. it is a procedure with serious complications but in our society it might be a procedure of first choice. author’s affiliation dr. mirza shafiq ali baig associate professor department of ophthalmology unit-1 dow university of health sciences karachi dr. jamshed ahmed department of ophthalmology unit-1 dow university of health sciences karachi dr. mohammad shafique khan senior registrar department of ophthalmology unit-1i dow university of health sciences karachi reference 1. cairns te. trabeculectomy-preliminary report of a new method. am j ophthalmol. 1968; 66: 673-9. 2. watson p. trabeculectomy-a modified ab extern technique. ann ophthalmol 1970; 2: 199-205. 3. ashaye ao, komolafe oo. post-operative complication of trabeculectomy in ibadan, nigeria: outcome of 1 year followup. eye. 2007; 12 (in press). 4. lai js, poon as, tham cc, et al. trabeculectomy with beta radiation: long-term follow-up. ophthalmology. 2003; 110: 1822-6. 135 5. chan ck, lee s, sangani p, et al. primary trabeculectomy surgery performed by residents at a county hospital. j glaucoma. 2007; 16: 52-6. 6. lamping ka, bellows ar, hutchinson bt, et al. long-term evaluation of initial filtration surgery. ophthalmology.1986; 93: 91-101. 7. mills kb. trabeculectomy: a retrospective long-term follow-up of 444 cases. br j ophthalmol. 1981; 65: 790-5. 8. alemu b. trabeculectomy: complications and success in iop control. ethiop med j. 1997; 35: 1-11. 9. husain r, aung t, gazzard g, et al. effect of trabeculectomy on lens opacities in an east asian population. arch ophthalmol. 2006; 124: 787-92. 10. jalal t, mohammad s. three years retrospective study of patients undergone trabeculectomy in lady reading hospital peshawar. j postgrad med inst sep. 2004; 18: 487-94. 11. dorcs bj, sultan m, tajammul a. trabeculectomy; a comparison between pressure patching and bleb repair in management of early onset leaking bleb. professional med j. 2006; 13: 676-9. 136 microsoft word ejaz ahmed javed 26 original article familial ectrodactyly and its ocular associations ejaz ahmad javed, muhammad sultan pak j ophthalmol 2008, vol. 24 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ejaz amad javed dhq, allied hospital pmc, faisalabad. received for publication june’ 2007 …..……………………….. purpose: to report a novel family of ectrodactyly and its associations with eye pathology. material and methods: this observational and analytical study was conducted at allied hospital, punjab medical college (pmc), faisalabad, from march 15 to april 15, 2007. a detailed history, examination and investigation of three families of ectrodactyly were completed. results: all members of three families had same findings in hands and feet. all were mentally sharp. they were all suffering from myopia and cataract. conclusion: the familial ectrodactyly is associated with myopia and cataract. no other eye findings were seen. he word “ectrodactyly” is derived from the greek “ektrona” (abortion) and “dactylos” (finger) literally “abortion of a finger”. the ectrodactyly, commonly known as “lobster claw syndrome”1, sometimes known as “karsch-neugebauer syndrome”, is a rare congenital deformity of the hand where the middle digit is missing and the hand is cleft. ectrodactyly is an inherited dysmelia, and often occurs in both the hands and the feet. its inheritance pattern is autosomal dominant. it affects about 1 in 90,000 babies, with males and females equally are affected. the type i, the most frequent form has been found to be a mutation on chromosome 7 in a region that contains two homeobox genes, dlx5 and dlx62. the associated eye findings are seen in many systemic diseases and also in familial ectrodactyly but these are uncommon and rare. some of these associated ocular findings have already been reported but our associated findings (myopia and cataract) have never been reported in the literature earlier. material and methods three families with ectrodactyly were evaluated and detailed history of birth, medical, surgical and family history was taken including history of drugs, irradiation and maternal ailment. examination included visual acuity, refraction, slit lamp, posterior segment examination, tonometry and gonioscopy was performed. the investigations e.g. blood complete examination, urine complete examination, esr, blood sugar random, growth hormones estimation, ra factors, ana, vdrl, urine for reducing substances, rbc hexokinase enzyme, urine chromatography and calcium and phosphorus determination was done. results in all the members of three families had the same findings of hands and feet. all the members were healthy and mentally sharp. in family no. 1, one affected father having unaffected wife had five children (m4 + f1 ). all the five children had hands abnormalities (100 %). out of five, 2 (40 %) had feet and eye findings (myopia + lens changes), while 3(60%) were unaffected. in family no. 2, affected female having unaffected husband was bearing four t 27 children. all of them had hands and feet abnormalities (100 %). her one affected male child died at the age of five years. out of living four, 2 (50 %) had eye findings (myopia + lens changes) and 2 (50 %) were unaffected. the third family comprised of affected mother and normal husband. this family also had four children. all had hands and feet abnormalities, but 2 (50 %) had eye findings (myopia + lens changes) and other 2 (50 %) were normal (table 1-4). we examined three families. these were close relatives and had close and inter marriage system (marriages between two families on exchange basis). the other pedigree shown in diagram was made by history. they narrated that problem started after a great grandmother who had hands and feet abnormalities. close inter marriage system increased the frequency of occurrence of pathology. none of the patients had other eye pathologies except lens changes and myopia. also, none of the patients had uveitis, glaucoma, ectopia lentis, and retinal detachment. no patient had marfanoid features, blond hair, mental retardation, hirsutism, moon face, mouth or feet ulcers, pathological fractures, serositis, hepatomegaly, lymphadenopathy etc. discussion ectrodactyly is a congenital defect that causes malformation of the hands alone or with feet. in this condition, the middle finger or middle toe is missing. currently there are several treatments, which can normalize the appearance of the hands, yet they will not function precisely the same way as regularly formed hands. some people with ectrodactyly use prosthetic hands to avoid the rude stares of others. the “upton” a micro surgeon, said that toes are spare parts available for transfer. he used the children’s tiny toes to make tiny thumbs. he rooted up all the tendons, nerves, arteries, bones, so attempted to make a thumb with good sensation and some movements. the eye findings in male patients of ectrodactyly are very rare. the association of ectrodactyly with absence of meibomian glands was noted by almedia sf4. the ocular surface disorders and shortened tear film breakup time in ectrodactyly were attributed to the absence of meibomian glands, leading to lipid layer deficiency in the tear film with a concomitant increase in tear evaporation5. the absence of lacrimal puncta in both eyes of 27 years old woman of ectrodactyly was seen, when she presented with epiphora and ocular pain6. in our study the ocular associations of myopia and cataract were persistently noted in all affected patients of ectrodactyly which have never been reported earlier. the bilateral cataract is often inherited; autosomal dominant being the most common inheritance pattern7. systemic diseases can cause bilateral cataract and approximately 5% to 10% of bilateral cataract is associated with a systemic disorder8 e.g. idiopathic (60%), hereditary (30%) autosomal dominant, autosomal recessive or x-linked systemic disorders (5%) lowe’s syndrome, galactosemia, trisomy, alport’s syndrome, myotonic dystrophy, marfan’s syndrome etc, also cause bilateral lens pathology. marfan’s syndrome, homocystinuria and weilmarchesani’s syndrome have systemic features and lens anomalies. marfan’s syndrome inherited in an autosomal dominant manner, is characterized by wide spread skeletal abnormalities including arachnodactly9. the marfan’s syndrome has cardiovascular abnormalities. but none of our study cases had such anomalies10. table 1: sex wise distribution sex no of patients % male 9 60 famale 6 40 total 15 100 table 2: eye pathologies (myopia + lens changes) no of patients % affected 3 20 unaffected 12 80 total 15 100 table 3: sex distribution of total cases sex no of patients % male 25 54.3 famale 21 45.7 total 46 100 28 table 4: affected sex distribution 22 out of total 46 (47.82%) sex no of patients % male 10 21.7 famale 12 26.1 total 22 47.8 homocystinuria inherited in an autosomal recessive manner, is an inborn error of metabolism involving a deficiency of cystathionine synthetase. these patients typically suffer from vascular thrombotic problems and most of these patients also have ectopia lentis11. none of the patients in our study showed such embolic problems. the weilmarchesani’s syndrome12 exhibits a picture of brachycephaly, short stature, ectopia lentis and micro spherophakia, but no such pathology was seen in our study patients. conclusion the ectrodactyly (lobster claw syndrome) is a rare congenital deformity of the hands and feet. its inheritance pattern is autosomal dominant. it affects both males and females. typically person with ectrodactyly has a cleft where the middle finger or toe adopts a condition that gives the hand or foot the appearance of a lobster claw, but ectrodactyly patients can have any number of unusual arrangements of the digits. but all of our study patients had similar pattern of hands and feet abnormalities and also the same eye findings (myopia + cataract). the association of many ocular problems e.g., punctal atresia, trichiasis, punctate epithelial erosions and nasolacrimal duct atresia, has been described in the literature but no such findings were seen in our patients. the deformity of hands and feet can be treated surgically to improve functions and appearance. the prosthetics may be used and genetic counseling should be given to the parents about the condition. this inheritable deformity does not affect the mental capabilities of the patients rather the affected members are mentally sharp, intelligent and active. although the ectrodactyly is rare autosomal dominant inheritable disease, but may be very rarely sporadic (with no family history of this malformation). the association of the ectrodactyly with myopia and cataract is also rare. a lot of investigations, genetic workout and screening are required. the treatment of myopia with glasses and cataract with cataract extraction with posterior chamber lens implantation were promising and satisfactory. author’s affiliation dr. ejaz ahmad javed senior registrar dhq, allied hospital, pmc faisalabad. dr. muhammad sultan associate professor head of the department of ophthalmology dhq, allied hospital, pmc faisalabad reference 1. webster’s new world, medical dictionary, medterms medical world of day. xml, 2004. 2. levi g. causative gene for human “lobster claw” syndrome; centre national de la research scientifiqu (cnrs), museum of natural history in paris, 20-50, 2002. 3. macmedan d. usa today, “embracing her inner freek”, 16-22005. 4. articles r, almedia sf, solari hp. ectodermal dysplasia, ectrodactyly and clefting syndrome: ocular manifestations of this syndrome in a case report. arq bras oftalmol. 2007; 70: 1258. 5. matsumoto y, dogru m, goto e, et al. increased tear evaporation in a patient with ectrodactyly ectodermal dysplasiaclecfting syndrome. jpn j ophthalmol. 2004; 48: 372-5. 6. mondino bj; bath pe; foos ry, et al. absent meibomian glands in the ectrodactyly, ectodermal dysplasia, cleft lippalate syndrome. am j ophthalmol. 1984; 97: 496-500. 7. knnath. pedriatic lens abnormalities in; strabismus and pediatric ophthalmology, p 329–30. 8. francois j. syndromes with congenital cataract, 16th jackson memorial lecture. am j ophthalmol. 1961; 52: 207. 9. cross he, gansen ad. ocular manifestations in the marfan’s syndrome and homocystinuria am j ophthalmol. 1973; 75: 405. 10. jarrett wh ii. dislocation of the lens. a study of 166 hospitalized cases. arch ophthalmol. 1967; 78: 289-96. 11. apple dj, rabb mf. lens and pathology of intra-ocular lenses, ocular pathology, 4th ed. 1989. 112– 6. 12. mc-gavin js. weill marchesani syndrome brachymorphism and ectopia lentis. am j ophthalmol. 1966; 62: 820. microsoft word adnan afaq case report.doc 161 case report solar retinopathy adnan afaq, m. zia-ul-haque ansari, khwaja sharif-ul-hassan pak j ophthalmol 2007, vol. 23 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: adnan afaq department of ophthalmology baqai medical university, 51-deh tor, gadap road, near toll plaza, super highway karachi-74600, pakistan received for publication march’ 2007 …..……………………….. solar retinopathy is a well recognized clinical entity of retinal damage caused by direct or indirect viewing of the sun. synonymous terms includes foveomacular retinitis, eclipse retinopathy, and solar retinitis. we are presenting this interesting case report of a middle aged male patient presented in the eye opd with the complaints of gradual dimness of vision, metamorphopsia and scotomas. on examination best-corrected visual acuity was od 6/18 os 6/24. anterior segment examination was unremarkable in both eyes; however, metamorphopsia and paracentral scotomas were documented on amsler’s grid in both eyes. on fundoscopy, bilateral round foveal lesions were noted. probing questions were asked to help determine the cause of these remarkable macular findings. the man turned out to be a ritual sun gazer and a witch doctor! the patient was advised strongly against sun gazing and was put on placebos. at the end of 6 months, snellen’s visual acuity improved to od 6/6 (p) os 6/12. metamorphopsia and scotomas persisted and no physical change in the macular lesions was detected. olar retinopathy is a well recognized clinical entity of retinal damage caused by direct or indirect viewing of the sun. synonymous terms include foveomacular retinitis, eclipse retinopathy, and solar retinitis1. case report a 56 year old man came to the eye opd, baqai medical university hospital, with the complaints of gradual dimness of vision over a period of 2-3 weeks associated with metamorphopsia and paracentral scotomas. past ocular and systemic histories were unremarkable. on examination visual acuity was od 6/18 os 6/24; no further improvement was noted with pinhole test or with refraction. intra ocular pressure was 16mm hg in both eyes and extraocular movements were full in range. there was no rapd in either eye and rest of the anterior segment examination was unremarkable in both eyes; however, metamorphopsia and paracentral scotomas were documented in both eyes on amsler’s grid (black lines on white background). on fundoscopy, bilateral round foveal lesions were noted. od showed a lamellar macular hole at fovea 1/3rd disc diameter (photographs 1 & 2) and os revealed a 1/3rd disc diameter round lesion marked in the center by a red apex and surrounded by a gray halo (photographs 3 & 4). optic discs were normal in both eyes and no cells were detected in the vitreous in either eye. the peripheral fundi were also unremarkable in both eyes. after these remarkable macular findings, probing questions were asked as to the use of any ocular or systemic drugs, family history of any significant eye disease, viewing of solar eclipse, blunt ocular trauma, automobile accident (whiplash injury) etc. finally history of sun gazing for almost 1 hour/day, regularly at dawn stretching back to almost a month was elicited. s 162 fig. 1: right eye: lamellar macular hole fig. 2: right eye: lamellar macular hole (red-free photo) the patient turned out to be a ritual sun gazer and a witch doctor. the patient was advised strongly against sun gazing. placebos (topical lubricants) were given and follow up was scheduled at 1-month interval. on repeated scheduled follow-ups visual acuity steadily improved in both eyes; however, no change was noted in the metamorphopsia or scotomas in either eye, also no change was detected in the size and appearance of the macular lesions. fig. 3: left eye: de-pigmented macular lesion surrounding a red apex fig. 4: left eye: de-pigmented macular lesion surrounding a red apex (red-free photo) at the end of 6 months, snellen’s visual acuity improved to od 6/6 (p) os 6/12. metamorphopsia and scotomas persisted and no physical change in the macular lesions was detected. unfortunately the patient lost to follow up. discussion the first clinical description of retinal damage in association with the viewing of an eclipse was by saint-yves in 17222. foveomacular retinitis was 163 originally described as a distinct clinical syndrome of unknown cause consisting of bilateral decreased vision and foveal lesions in young military personnel3. in many instances, however, a history of sun gazing was subsequently elicited4. many of these patients were diagnosed with psychiatric disorders5. other cases occur in military personnel who have followed the flight of air planes near the sun6. photic retinopathy has also been described in association with direct sun gazing by sunbathers, and patients with psychotic disorders, as part of religious rituals, and in association with the use of drugs such as lysergic acid diethylamide (lsd)7. the appearance and clinical course in each instance was identical. various factors have been implicated in determining the severity of the retinal lesions. increasing length of exposure is a risk factor8. however severe lesions have been described in individuals with minimal exposure, and vice versa. it has been suggested but not proved that increasing fundus pigmentation protects against the photic damage9. patients with uncorrected high refractive errors may be protected. in the presence of amblyopia and strabismus, the dominant eye is more susceptible to damage9. younger patients may be at increased risk because of the transmissibility through clear media. lsd induce mydriasis and cycloplegia which make the drug abuser more susceptible to severe retinal burn10. prior to 1970, the cause was believed to be due to thermal damage produced by the absorption of infrared rays by the rpe11. it is postulated that the principal mechanism of photochemical damage is from retinal irradiance by high energy wavelengths, including short wavelength-visible blue light and lower levels of uv-a or near-uv radiation (320400nm). symptoms of solar retinopathy usually develop within 1 to 4 hour after exposure and include decreased vision, metamorphopsia, micropsia, and central or paracentral scotomata of 1 to 7 degrees. patients may also present with chromatopsia, photophobia, after image, and frontal and temporal headache with orbital or retro orbital pain. acutely, vision usually ranges from 6/12 to 6/36 but may be worse. there is no correlation between the severity of the fundus lesion and the visual acuity12. the fundus examination is variable. although usually bilateral, unilateral cases are not uncommon. the typical lesion is a small yellow spot with a surrounding gray zone in the foveolar or parafoveolar area within the first few days after exposure. in mild cases however, little or no change can be noted. the foveal reflex may be lacking but becomes more distinct as the lesion resolves. after several days, the yellow spot becomes reddish with a halo of surrounding pigmentary change by 10 to 14 days, this lesion fades and is usually replaced by a red, well circumscribed, faceted lamellar hole or depression. the oval lamellar depression, which has a diameter of 100µ to 200µ is believed to be permanent and is highly suggestive of previous episode of sun gazing13. several lesions may be present suggestive of multiple exposures. similar lesions have been produced by blunt trauma and whiplash injury. fluorescein angiography is often normal in the early and late stages of the disease. visual acuity usually improves to 6/6 to 6/9 by 6 months.14 even with improvement in visual acuity, residual metamorphopsia and central or paracentral scotomas may persist. tso15 has studied the histopathologic features of lesions in patients who gazed at the sun for 1 hour prior to enucleation for uveal melanoma. approximately 2 days after sun gazing, most of the injury involved the rpe. necrosis, pigment granule irregularity, and focal detachments of the retinal pigment epithelium were described. in one patient who demonstrated early leakage on fluorescein angiography, a focal detachment of the sensory retina was found at the site of the lesion. the photoreceptors were intact. the rpe adjacent to the lesion lost its apical pigment granules and extended along bruch’s membrane beneath the detached rpe. after 48 hours to 5 days, there is photoreceptor destruction. much of this damage is reversible and may explain the ability of many patients to recover good visual function after sun gazing16. oral corticosteroids have been used in the treatment of acute lesions associated with severe visual loss. however, no beneficial effect has been clearly demonstrated. appropriate protective measures when viewing an eclipse and education about the hazards of direct sun gazing are of utmost importance in the prevention of this disease. conclusion sun gazing, ritual or otherwise, is a well-recognized cause of photic damage to the retina. this case report 164 has been presented to highlight the hazards of direct or indirect sun gazing and to negate the generalized misconception among the general public as well as doctors that solar retinopathy occurs only after viewing solar eclipse. author’s affiliation dr. adnan afaq assistant professor of ophthalmology baqai medical university, karachi. dr. m. zia-ul-haque ansari assistant professor of ophthalmology baqai medical university, karachi. prof. khwaja sharif-ul-hassan professor of ophthalmology baqai medical university, karachi. reference 1. delapaz ma, damico dj: photic retinopathy. in principles and practice of ophthalmology 1994 by albert dm, jakobiec fa, vol. 2, chapter 90, 1032-1036. 2. duke-elder ss: radiational injuries, in system of ophthalmology, vol.14, part 2 st louis, cv mosby, 1972, 888. 3. cordes fc: a type of foveo-macular retinitis observed in the us navy. am j ophthalmol 27: 803-816,1994. 4. grey rhb: foveo-macular retinitis, solar retinopathy and trauma. br j ophthalmol 62; 543-546, 1978. 5. ewald ra: sun gazing associated with the use of lsd. ana ophthalmol 3:15-17, 1971. 6. rosen e: solar retinitis. br j ophthalmol; 2:3-35, 1948. 7. fuller dg: severe solar maculopathy associated with the use of lsd; am j ophthalmol 81: 413-416, 1976. 8. yanuzzi la, fisher yl, krueger a, slakter j: solar retinopathy; a photobiological and geophysical analysis. trans am ophthalmol soc 85; 120-154, 1987. 9. penner r, mc nair jn: eclipse blindness. am j ophthalmol 61; 1452-1457, 1966. 10. schatz h, mendelblatt f: solar retinopathy from sun gazing under the influence of lsd. br j ophthalmol 57; 270-273, 1973. 11. cordes fc: eclipse retinopathy. am j ophthalmol 31; 101-102, 1948. 12. dhir sp, gupta a, jain is: eclipse retinopathy. br j ophthalmol 65: 42-45, 1981. 13. gass jdm: stereoscopic atlas of macular disease. 3rd ed, vol 2, st louis, cv, 1987, pp570-579. 14. mac faul pa: visual prognosis after solar retinopathy. br j ophthalmol 53:534-541, 1969. 15. tso mom, lapiana fg: the human fovea after sungazing. trans american academy ophthalmol otolaryngol 79: op788795, 1975. 16. agarwal lp, malik srk: solar retinitis. br j ophthalmol 43: 360-370, 1959. microsoft word index-5.doc original article neodymium: yag laser capsulotomy rates following implantation of silicone and acrylic intraocular lenses muhammad kashif hanif, syed abid hassan naqvi, uzma ansari, haseeb ahmed khan, muhammad kamran saeed pak j ophthalmol 2009, vol. 25 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: muhammad kashif hanif classified eye specialist cmh malir, karachi received for publication january’ 2009 … ……………………… purpose. the objective of this study is to compare the frequency of neodymium yag laser capsulotomy in eyes receiving silicon foldable posterior chamber intraocular lenses with those receiving acrylic foldable posterior chamber intraocular lenses. material and methods. this comparative study was carried out at ophthalmology department c.m.h. karachi from august 2007 to august 2008. sixty patients were included in this study. thirty patients were included in-group a who opted for acrylic foldable iols and thirty patients in group b who opted for silicon foldable iols. all the patients underwent phacoemulsification procedure with 3.2mm clean corneal self-sealing incision. then they were followed for one year. during follow up on each visit visual acuity was taken, slit lamp examination was performed for posterior capsular opacification and cases selected for nd yag laser capsulotomy having posterior capsular opacification sufficient to cause decrease in visual acuity more than 2 lines. chi-square test was used to calculate frequency of yag laser capsulotomy in both groups. results. in group a one patient was diagnosed as having clinically significant posterior capsular opacification (pco) enough to reduce visual acuity of two lines (snellen chart) requiring nd: yag laser capsulotomy at the end of one year and in group b three patients were diagnosed as having clinically significant posterior capsular opacification (pco) enough to reduce visual acuity of two lines (snellen chart) requiring nd:yag laser capsulotomy at the end of one year. conclusion. pco and frequency of nd: yag laser capsulotomy was more common in eyes receiving silicone iols than eyes receiving acrylic iols. osterior capsule opacification (pco) following cataract surgery is the manifestation of migration and proliferation of lens epithelial cells onto the central region of the posterior capsule1. posterior capsular opacification (pco) is the commonest complication of cataract surgery with a frequency of between 10% and 50% by 2 years postoperatively2 and the rate seems to have remained unchanged over the recent years3. early posterior capsular opacification seems to be multi-factorial in origin4. at surgery it is physically impossible to remove all lens epithelial cells from the capsular bag; those that remain proliferate and undergo metaplasia. in an aphakic eye, they cover the posterior capsule after surgery and can be thought of conceptually as the normal wound healing response5. this causes reduction of visual acuity and the need for intervention once again at the hospital level that may be disturbing, especially for the elderly. in view of these problems, there is now considerable interest in strategies to reduce pco. the presence of a posterior chamber intraocular lens (iol) p in the capsular bag has been known to reduce the risk of pco development6-9, probably by acting as a mechanical barrier against the migration of proliferating lens epithelial cells on the posterior capsule2, 6-10, and/or minimizing capsule wrinkling and limiting the space available for lentoid formation.11. these effects are thought to be enhanced when an iol has more contact with the posterior capsule1. experimental and clinical studies have shown that polishing of posterior capsule during surgery, and a sharp optic edge can prevent the invasion of lens epithelial cells into the retrolental space, may lead to less pco12-16. small (4.5 to 5.0 mm) capsulorhexis and capsular bag implantation of 5.5 mm acrylic iol are likely to reduce the pco incidence when compared with the 6.0 to 7.0 mm capsulerhexis17. nd: yag laser capsulatomy is a method of choice to treat this complication18. this study has been planed to find out the frequency of neodymium yag laser capsulotomy after phacoemulsification with implantation of acrylic and silicone foldable posterior chamber intraocular lenses. hence, we will be able to find out a way to reduce the chances of development of posterior capsular opacification and decrease the number of patients coming again to hospital for treatment. material and methods sixty eyes of 60 patients scheduled to have iol implantation were initially randomized into 2 groups based on iol type: silicone, and acrylic. of the 60 eyes, 60 completed the follow-up. the pco density in these eyes was measured 1 week, 1 month, 11/2, 2,4,6,9 and 12 months postoperatively. visual acuity and the frequency of nd: yag laser capsulotomy was examined. it was a hospital based comparative study. sixty patients were selected from the outpatient department on the basis of non-probability convenience sampling who fulfilled the inclusion and exclusion criteria. written consent was obtained. chisquare test was used to calculate frequency of yag laser capsulotomy in both groups. all surgery was performed between august 2007 and august 2008 .tight inclusion criteria were used to define the presence of senile cataract in otherwise normal eye in-patients over 50 years of age. exclusion criteria were a history of previous intraocular surgery or laser treatment, diabetes mellitus requiring medical control, glaucoma, previous uveitis, or any posterior segment pathology precluding a postoperative vision of 6/12 or better. patients using topical medications (apart from lubricants) and any patients taking systemic steroids were excluded. all patients were assessed preoperatively and postoperatively by the same person. visual acuity was taken, slit lamp examination was performed for posterior capsular opacification and cases selected for nd yag laser capsulotomy having posterior capsular opacification sufficient to cause decrease in visual acuity more than 2 lines. a written informed consent was obtained from each patient and then these were randomly divided into group a having foldable acrylic implant or group b having silicon foldable iols. surgical technique and medication were standardized. 3.2mm clean corneal self sealing incision with continuous curvilinear capsulorhexis measuring approximately 5.5mm in diameter was performed by a single surgeon using peribulbar anesthesia. after hydrodissection, endocapsular phacoemulsification of the nucleus and aspiration of the residual cortex were performed. the capsule was inflated with viscoelastic substance, after which the iol was placed into the capsular bag using intraocular lens injector. after capsular polishing, the viscoelastic material was washed and wound was secured by hydro temponade tested for leakage by gentle compression with sponge. all surgeries were uneventful and the iols were accurately placed in the capsular bag. acrysof is a proprietary copolymer of phenyl ethyl acrylate and phenyl ethyl methacrylate cross linked with 1.4 butanediol diacrylate. the angle of flexion of the haptics was 10 degrees with the polyacrylic lenses and 5 degrees for silicone. healon was thoroughly removed by irrigation with bss. subconjunctival cefuroxime 125 mg was given at the end of the operation. any surgical complications such as capsulorhexis rim tear, zonular dehiscence, and failure to place the iol into the capsular bag, posterior capsular rupture, or vitreous loss led to patient exclusion. postoperatively all patients used antibiotic steroid combination drops four times a day for 02 months. no non-steroidal anti-inflammatory preparation was used pre-, peri-, or postoperatively. during follow up, on each visit visual acuity was taken and slit lamp examination was performed for posterior capsular opacification and cases were selected for nd yag laser capsulotomy having posterior capsular opacification sufficient to cause decrease in visual acuity by more than 2 snellen’s lines. table 1: frequency of nd yag laser capsulotomy after cataract surgery in acrylic vs. silicon foldable iol types of iol number of patients developing pco number of patients developing requiring nd;yag %age of patients acrylic foldable iols 01 01 3.33% silicone foldable iols 03 03 10% table 2. gender distribution gender acrylic foldable iol silicone foldable iol no. of patients %age of patients male 24 24 48 80% female 6 6 12 20% table 3. chi-square tests value df asymp. sig. (2-sided) exact sig. (2-sided) exact sig. (1-sided) pearson chi-square 1.071b 1 301 countinuity correctiona .268 1 605 likelihood ratio 1.118 1 290 fisher’s exact test 612 306 n of valid cases 60 a. computed only for a 2x2 table b. 2 cells (50.0%) have expected count less than 5. the minimum expected count is 2.00.s results sixty patients of age related cataract were included in the study, grouped into a and b. the patients included in group a were those who opted for acrylic foldable intraocular lens and group b those who opted for silicone foldable intraocular lens. out of which 80% were male and 20% were female in the ratio of 4:1. the patients’ age ranged from 50 to 80 years with a mean value of 65 years. our study showed that out of 30 patients in group a those who opted for acrylic foldable intraocular lens only one patient was diagnosed as having clinically significant posterior capsular opacification enough to reduce visual acuity by two lines (snellen chart) requiring nd: yag laser capsulotomy at the end of one year and out of 30 patients in group b those who opted for silicone foldable intraocular lens three were patient diagnosed as having clinically significant posterior capsular opacification enough to reduce visual acuity by two lines requiring nd:yag laser capsulotomy at end of one year. clinically signifycant posterior capsular opacification and frequency of nd: yag laser capsulotomy was different in both groups; 3.33% in the acrylic group and 10% in the silicone group. the posterior capsule remained clear in 96.67% of the acrylic and 90% of the silicone iol eyes. in the silicone iol group, pco was more common in eyes. eyes with acrylic iol showed difference in significant pco. our study was clinically significant. discussion posterior capsular opacification is the opacification of posterior capsule after cataract extraction due to proliferation of anterior epithelial lenticular cells on the posterior capsule sufficient to cause a significant decrease in vision. early posterior capsular opacification seems to be multi-factorial in origin4. at surgery it is physically impossible to remove all lens epithelial cells from the capsular bag; those that remain proliferate and undergo metaplasia. posterior capsular opacification after surgery can be thought of conceptually as the normal wound healing response. this causes reduction of visual acuity and the need for intervention once again at the hospital level that may be disturbing, especially for the elderly. graph 1. nd;yag laser capsulotomy noyes c ou nt 40 30 20 10 0 intraocular lens group-a group-b graph 2. graph 3. % of nd: yag laser capsulotomy male=80female=20% graph 4. sex distribution by keeping these problems in view, there is now considerable interest in ways to reduce pco. our study was planed to find out the frequency of neodymium yag laser capsulotomy after phacoemulsification with implantation of acrylic and silicon foldable posterior chamber intraocular lenses. hence we are able to find out a way to reduce the chances of development of posterior capsular opacification and decrease the number of patients coming again to hospitals for treatment. our study shows that the material from which an iol is made influences the frequency of nd: yag laser capsulotomy. it was more common in eyes receiving a silicone iol than an acrylic iol. in our study frequency of nd: yag laser capsulotomy was less common in eyes receiving the foldable acrylic iol. there was comparison of the foldable acrylic iol with the foldable silicone iol, by callebaut showed that intraocular lenses made from hydrophobic acrylic material are associated with a significantly reduced rate of nd: yag laser capsulotomies as compared with intraocular lenses made from hydrophilic acrylic material 19 .our duration of study was one year so the percentage of yag laser capsulotomy was low as compared to mentioned study. in our study clinically significant posterior capsular opacification (pco) and frequency of nd: yag laser capsulotomy was 3.33% in the acrylic group and 10% in the silicone group. intraocular lenses made from polyacrylic are associated with a significantly reduced degree of pco and lower yag rates20. therefore, pco in eyes with a group-b group-a c ou nt 40 30 20 10 0 nd;yag laser capsulo no yes intraocular lens nd;yag laser capsulotomy no yes c ou nt 40 30 20 10 0 intraocular lens group-a group-b female male silicone iol was significantly more extensive than in those with acrylic iol and resulted in marked impairment of visual acuity. j hollick et al studied the influence of intraocular lens (iol) material on the process of (lecs) lens epithelial cells migration21. lens epithelial cells (lecs) were seen in 93% of silicone and 97% of pmma iols at 90 days, compared with 46% of polyacrylic (p<0.001)21. at year 2 lecs were present in all patients with silicone or pmma lenses, whereas 62% of patients with polyacrylic iols had lecs (p<0.001)21. of those patients with lecs at day 90 lec regression occurred in 8% with silicone iols and 15% of pmma cases, compared with 83% of patients with polyacrylic iols (p<0.0001)21. the presence of lecs on the posterior capsule was considerably lower with polyacrylic than pmma or silicone iols and lec regression occurred more frequently21. the lower incidence of lecs and the higher rate of regression may explain why pco formation appears to be reduced with polyacrylic lenses. this has important clinical implications for the prevention of pco21. this study which showed that the material from which an iol is made influences whether lecs are present on the posterior capsule after cataract surgery and can affect the behavior of these cells. the presence of lecs on the posterior capsule at 90 days and 2 years was considerably lower with polyacrylic lenses than pmma or silicone (p<0.001). polyacrylic iols have been reported to be associated with a low incidence of pco22-23 and the observation that the cells causing pco are significantly less likely to be present on the posterior capsule with this lens supports these studies. the mechanism by which iol material influences lec behaviour is unknown but could be explained by either mechanical or material related effects. the higher refractive index of polyacrylic (1.55) compared with silicone (1.41-1.46) and pmma (1.49) allows these iols to have much thinner optics, suggesting that physical bulk cannot be the explanation for the reduced lec migration24. polyacrylic iols have a more defined and squarer optic edge than the other two implants and one study showed a significant decrease in pco with sharp optic edges 25. the authors suggest that the sharp edge acts as a mechanical barrier to lens epithelial cell migration onto the posterior capsule. this could be of importance in decreasing the number of cells on the posterior capsules with polyacrylic iols but would not explain the phenomenon of lec regression and the stability of the anterior capsule on the iol26. preclinical studies on acrysof showed no evidence that it was toxic to lecs27. macrophages can readily be seen on the anterior surface of some iols postoperatively, particularly in diabetic or uveitic patients, and are thought to be an indication of a foreign body reaction.28. in one study no macrophages were seen when lec regression occurs, suggesting that regression was not a necrotic process21. iols made of this polyacrylic have a tacky surface. indirect evidence for an adhesive relation between polyacrylic iols and the capsule has been provided by measuring anterior capsular movement on the lens optic24. it has been shown that the anterior capsule is much more stable on the anterior surface of a polyacrylic lens than pmma or silicone and only minor capsule movement occurs with time, possibly as it is stuck to the anterior iol surface26. t neuhann presented a paper that there were a number of anecdotal accounts from surgeons which suggest that if polyacrylic iols have to be explanted for anisometropia they become adherent to the capsule soon after surgery and are relatively difficult to explant in comparison with pmma or silicone lenses29. ernest ph. study which showed that 50 eyes that had an nd: yag capsulotomy, 17 were in the acrysof group and 33 were in the phacoflex ii group30. all differences between groups were statistically significant (p<.05) with conclusion that the acrysof ma30ba iol was associated with less pco proliferation and thus fewer nd: yag laser posterior capsulotomies than the phacoflex ii si-40nb silicone (amo) intraocular lenses (iols)30. pohjalainen t, vesti e, uusitalo rj, laatikainen l. study showed that in a consecutive series of 80 cataract eyes central pco was equally common in eyes receiving a silicone or an acrylic iol31. in the silicone iol group, however, significant pco was more common if there was concurrent ocular disease, while with the acrylic iol concurrent ocular disease did not seem to increase the risk of pco31. study of ursell et al. showed that there was a significant difference in percentage of pco at 2 years among the three lens types (p < .0001). the acrysof lenses were associated with less pco (median 11.75%) than pmma (43.65%) and silicone (33.50%) lenses (p < .001 and p = .025, respectively). the difference between pmma and silicone lenses was not statistically significant with conclusion that intraocular lenses made from acrysof were associated with a significantly reduced degree of pco32. study of k hayashi and h hayashi showed that posterior capsule opacification in eyes with a hydrophilic hydrogel iol is significantly more extensive than that in eyes with a hydrophobic acrylic iol, and results in a significant impairment of visual acuity33. keeping in view all these studies, our study was showing results which were clinically significant but not statistically due to less duration. conclusion in a consecutive series of 60 cataract operated eyes, pco and frequency of nd: yag laser capsulotomy was more common in eyes receiving a silicone iol than eyes receiving acrylic iols. the degree of pco after silicone iol implantation progressed significantly with time, while the progression after acrylic iol implantation was slight. therefore, pco in eyes with a silicone iol was significantly more extensive than in those with a acrylic iol and resulted in marked impairment of visual acuity clinically though not significant statistically. silicone iols induced pco is faster than acrylic iols, with fibrosis the most common type in the silicone group. precautions should be taken to prevent damage during nd: yag laser capsulotomy in eyes with a silicone iol. author’s affiliation dr. muhammad kashif hanif classified eye specialist cmh malir, karachi dr. syed abid hassan naqvi classified eye specialist cmh malir, karachi dr. uzma ansari department of ophthalmology cmh malir, karachi dr. haseeb ahmed khan department of ophthalmology pns, karachi dr. muhammad kamran saeed classified eye specialist paf, karachi reference 1. apple dj, solomon kd, tetz mr. posterior capsule opacification. surv ophthalmol. 1992; 37: 73-116. 2. kappelhof jp, vrensen gfjm. the pathology of after-cataract. a minireview. acta ophthalmol. 1992; 205: 13-24. 3. schaumberg da, dana mr, christen wg, et al. a systematic overview of the incidence of posterior capsular opacification. ophthalmology. 1998; 105: 1213-21. 4. iqbal z, palimar p. risk factors for early posterior capsular opacification and morbidity following nd-yag laser capsulotomy. pak j ophthalmol. 2002; 18: 98-101. 5. spalton dj. posterior capsular opacification after cataract surgery. eye. 1999; 13: 489-92. 6. nishi o. incidence of posterior capsule opacification in eyes with and without posterior chamber intraocular lens. j cataract refract surg. 1986; 12: 519-22. 7. hansen te, otland n, corydon l. posterior capsule fibrosis and intraocular lens design. j cataract refract surg. 1988; 14: 383-6. 8. fezzotti r, caporossi a. pathogenesis of posterior capsular opacification. part i. epidemiological and clinico-statistical data. j cataract refract surg. 1990; 16: 347-52. 9. zetterström c, kugelberg u, lundgren b. after-cataract formation in newborn rabbits implanted with intraocular lenses. j cataract refract surg. 1996; 22: 85-8. 10. lindstrom rl, harris ws. management of the posterior capsule following posterior chamber lens implantation. am intra-ocular implant soc j. 1980; 6: 255-8. 11. nasisse mp, dykstra mj, cobo lm. lens capsule opacification in aphakic and pseudophakic eyes. graefes arch clin exp ophthalmol. 1995; 233: 63-70. 12. nishi o, nishi k. preventing posterior capsule opacification by creating a discontinuous sharp bend in the capsule. j cataract refract surg. 1999; 25: 521–6. 13. nishi o, nishi k, wickstrom k. preventing lens epithelial cell migration using intraocular lenses with sharp rectangular edge. j cataract refract surg. 2000; 26: 1543–9. 14. nishi o, nishi k, akura j. speed of capsular bend formation at the optic edge of acrylic, silicone, and poly (methyl methacrylate) lenses. j cataract refract surg. 2002; 28: 431–7. 15. kruger aj, schauersberger j, abela c. two-year results: sharp versus rounded optic edges on silicone lenses. j cataract refract surg. 2000; 26: 566–70. 16. buehl w, findl o, menapace r. effect of an acrylic intraocular lens with a sharp posterior optic edge on posterior capsule opacification. j cataract refract surg. 2002; 28: 1105–11. 17. aykan u, bilge ah, karadayi k, et al. the effect of capsulorhexis size on development of posterior capsule opacification: small (4.5 to 5.0 mm) versus large (6.0 to 7.0 mm). eur j ophthalmol. 2003; 13: 541-5. 18. awan a, kazmi sh, bukhari sa. intraocular pressure changes after nd-yag laser capsulotomy. j ayub med coll abottabad 2001; 13: 3-4. 19. javdani sm, huygens mm, callebaut f. neodymium: yag capsulotomy rates after phacoemulsification with hydrophobic and hydrophilic acrylic intraocular lenses. bull soc belge ophtalmol. 2002; 283: 13-7. 20. hollick ej, spalton dj, ursell pg, et al. the effect of polymethylmethacrylate, silicone, and polyacrylic intraocular lenses on posterior capsular opacification 3 years after cataract surgery. ophthalmology. 1999; 106: 49-54. 21. hollick j, spalton j, ursell g, et al. lens epithelial cell regression on the posterior capsule with different intraocular lens materials. br j ophthalmol. 1998; 82: 1182-8. 22. oshika t, suzuki y, kizaki h. two year study of a soft intraocular lens. j cataract refract surg. 1996; 22: 104-9. 23. ursell pg, spalton dj, pande mv. the relationship between intraocular lens biomaterials and posterior capsule opacification: a 2 year prospective randomised trial comparing pmma, silicone and polyacrylic lenses. j cataract refract surg. 1998; 24. 24. pandey sk, apple dj, werner l, et al. posterior capsule opacification: a review of the aetiopathogenesis, experimental and clinical studies and factors for prevention. indian j ophthalmol. 2004; 52: 99-112. 25. nagata t, wantanabe i. optic sharp edge or convexity: comparison of effects on posterior capsular opacification. jpn j ophthalmol. 1996; 40: 397-403. 26. ursell pg, spalton dj, pande mv. anterior capsule stability in eyes with intraocular lenses made of poly (methyl methacrylate), silicone and acrysof. j cataract refract surg. 1997; 23: 1532-8. 27. ando h, ando n, oshika t. cumulative probability of neodymium: yag laser posterior capsulotomy after phacoemulsification. j cataract refract surg. 2003; 29: 2148-54. 28. kim mj, lee hy, joo ck. posterior capsule opacification in eyes with a silicone or poly (methyl methacrylate) intraocular lens. j cataract refract surg. 1999; 25: 251-5. 29. neuhann t. foldable iols: different materials and different designs. presentation at the xivth congress of the european society of cataract and refractive surgeons, gothenburg sweden 1996. 30. ernest ph. posterior capsule opacification and neodymium: yag capsulotomy rates with acrysof acrylic and phacoflex ii silicone intraocular lenses. j cataract refract surg. 2003; 29: 1546-50. 31. pohjalainen t, vesti e, uusitalo rj, et al. posterior capsular opacification in pseudophakic eyes with a silicone or acrylic intraocular lens. eur j ophthalmol. 2002; 12: 212-8. 32. ursell pg, spalton dj, pande mv, et al. relationship between intraocular lens biomaterials and posterior capsule opacification. j cataract refract surg. 1998; 24: 352-60. 33. hayashi k, hayashi h. posterior capsule opacification after implantation of a hydrogel intraocular lens. br j ophthalmol. 2004; 88: 182-5. =================================================================================== guess who? answer jannik peterson bjerrum danish ophthalmologist. born 1851, died 1920 jannik petersen bjerrum was born 26th december 1851 in skarbak, a village in the most southern part of jutland in the border district between the danish kingdom and the duchy of schleswig-holstein. this was a highly disputed area and the object of numerous political debates and military battles. in 1848 just before bjerrum was born, a local rebellion evolved into a war between the danish king and the germanoriented duke. this war ended with a glorious danish victory, and schleswig-holstein remained a part of denmark, but only for a short period. in 1864 another war started, now between germany (and austria) and denmark. in short order this campaign ended in a total danish defeat, and southern jutland, almost one third of the kingdom, was incorporated in the new german empire where it remained until 1920. thus bjerrum was born in denmark, but grew up in germany. he left the cathedral school of ribe, denmark 1869 and completed his medical degree in 1876 in copenhagen. inspired by hansen grut, he soon became interested in ophthalmology and was appointed hansen grut's assistant in 1879. bjerrum's scientific concern was the relationship between visual perception of form and the resolving power in localized areas of the retina. he demonstrated this in his thesis entitled ' undersøgeleser over formsans og lyssands i forskellige øjensyngdomme (investigations on the form sense and light sense in various eye diseases). this title is deliberately given in danish to indicate that through his entire lifetime it was (continue see page 227) microsoft word kamran khalid.doc 177 original article clinical risk factors for proliferative vitreoretinopathy-i muhammad kamran khalid, sardar bahadar khan, sanaullah jan, muhammad daud khan pak j ophthalmol 2007, vol. 23 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad kamran khalid house no: 1592/c, hayatullah street dera ismail khan received for publication september’ 2006 …..……………………….. purpose: to evaluate clinical variables as risk factors for proliferative vitreoretinopthy (pvr). materials & methods: this cross-sectional comparative study was conducted at khyber institute of ophthalmic medical sciences (kioms), hayatabad medical complex (hmc), peshawar from 1st august 2002 to 31st dec 2002. fifty patients of rhegmato-genous retinal detachment (rrd) were included randomly in our study. they were evaluated for the presence of both risk factors & pvr grading. chi-square test was used to measure the difference in exposure rates & odds ratio was calculated to estimate the strength of association between risk factors & outcome. results: duration of retinal detachment (rd)>1month (p<0.05) was found to be statistically significant risk factor for pvr grade c or more. the exposure rates in closed globe injury, aphakia & pseudophakia and peripheral retinal degenerations were statistically not significant (p>0.1). none of the patients was giving a family history of rd so this variable was out of comparison procedure. conclusion: duration of rd >1 month is associated with high risk of high grade pvr, so this factor should be considered as important prognostic factor in the management of rrd. hegmatogenous retinal detachment (rrd) is one of the common ophthalmic emergencies in our country. it may cause severe visual loss if not detected early and treated in time. a lot of current research is going on to improve the outcome of retinal reattachment surgery. a number of sophisticated instruments and techniques are developed to overcome the problems in the field of microsurgical vitreoretina. one of the most challenging hurdles on achieving a better outcome is that of proliferative vitreoretinopathy (pvr), which is considered as one of the most common cause of failure of surgical retinal reattachment. the exact pathogenesis of pvr is still under active research. workers have compared it to normal wound healing or tissue repair process but at an abnormal site.1 damage to the blood-ocular barrier is considered critical to the formation of pvr because serum-derived chemo attractants and mitogens have been found in these membranes. retinal pigment epithelium (rpe) cells are essential in the formation of pvr because they are always found in preretinal membranes of rrd2,3. this may explain the greater frequency of pvr in rrd of long duration, giant retinal tears and multiple retinal tears. rpe cells undergo metaplastic changes into r 178 macrophages or fibroblast-like cells4. the tobacco dust seen in vitreous is formed of pigment clumps & in part represents migrating rpe cells. retinal glial cells are also found in pvr membranes. they are thought to be derived from muller cells or astrocytes and form more rigid membranes than rpe cells5,6. fibroblasts or fibrocytes are also found in pvr membranes. in case of penetrating injuries they are thought to enter into the eye through the wound. in case of non-traumatic rrd, they are thought to arise from different sources like optic nerve head, perivascular fibrocytes, glia or hyalocytes. other inflammatory cells like monocytes and lymphocytes are also found. research workers are also trying to determine risk factors for both preoperative & postoperative pvr7,8. these include clinical, surgical and biochemical risk factors. it is interesting to note that many of these variables are known risk factors for retinal detachment itself. our study focuses on evaluation of certain clinical variables as risk factors of preoperative pvr. these variables may contribute to the development of complicated rd and ultimately postoperative pvr. this study was conducted to evaluate various clinical variables including duration of symptoms, closed-globe injury, aphakia or pseudophakia, peripheral retinal degenerations and family history of rd as risk factors of preoperative pvr. materials and methods a total of 50 patients of rrd, admitted at khyber institute of ophthalmic medical sciences (kioms), hmc, peshawar were included in the study. a comprehensive proforma was designed & completed for every patient. initially a detailed history about the nature and duration of visual complaints, previous ocular surgery, trauma and family history of rd was taken. it was followed by a thorough ocular examination including checking of pupillary reactions, refractive errors and anterior segment examination with the help of a slit lamp. phakic status of the eye and signs of anterior uveitis were also evaluated. it was followed by a detailed posterior segment examination with fully dilated pupils with the help of an indirect ophthalmoscope, slit-lamp indirect examination using 78d or 90d lens and goldmann 3-mirror contact lens. it was a cross-sectional comparative study. after describing the data obtained, cross tabulations were made between dependent variable (pvr) and independent variables (risk factors under study). chisquare test was applied for statistical significance. odds ratio was calculated to estimate the strength of association between risk factor and outcome (pvr). results a total of 50 cases of rrd were included in our study. 39 (78%) were male and 11 (22%) were female patients. mean age was 36.8 years and age range was 7-85 years -85yrs. patients presented as early as with in 1 week of onset of symptoms to as late as >1 year of onset of symptoms. mean duration between onset of symptoms and presentation was 12.8 weeks (min=1week & max=95weeks). 43(86%) were phakic, 4(8%) aphakic & 3(6%) were pseudophakic. 27(54%) had no peripheral retinal degeneration (prd) & 23(46%) had prd. 47(94%) had no history of closed-globe injury & 3(6%) had a history of closed-globe injury. none of the patients had a family history of rd. frequency distribution of pvr is shown (table 1). for the sake of understanding of statistical analysis, the grades of pvr were divided into two groups i.e. (a+b) and (c+d). it is also logically acceptable when the management of pvr is taken into consideration. similarly, patients were divided into two groups regarding their duration of symptoms i.e. those presenting within one month & those presenting after one month. patients either aphakic or pseudophakic were both taken as “aphakic”. relationship between pvr and the risk factors under study are shown in cross tabulation (tables 25). tests for statistical significance i.e. chi-square value & degree of freedom (df), p-value and odds ratio (or) are shown along with each table. table 1: pvr (frequency distribution) grade frequency n (%) a 3 (6) b 28 (56) c 18 (36) d 1 (2) 179 total 50 (100) it is evident from the preceding tables that there is a statistically significant (p<0.05) difference between the grades of pvr of those presenting within first month of visual symptoms to those presenting after one month. the cases were 5.7 times (or=5.689) more exposed to the risk factor (duration of >1month) than the controls. table 2: duration: pvr cross tabulation duration pvr total n(%) a+b n(%) c+d n(%) < 1 month 16 (32) 3 (6) 19 (38) > 1 month 15 (30) 16 (32) 31 (62) total 31 (62) 19 (38) 50 (100) chi-square value= 6.41, df= 1, p<0.05, or= 5.68 table3: status of lens: pvr cross tabulation lens status pvr total n(%) a+b n(%) c+d n(%) phakic 27 (54) 16 (32) 43 (86) aphakic 4 (8) 3 (6) 7 (14) total 31 (62) 19 (38) 50 (100) chi-square value= 0.082 df= 1, p<0.05 table 4: closed-globe injury: pvr cross tabulation closed-globe injury pvr total n(%) a+b n (%) c+d n(%) no 30 (60) 17 (34) 47 (94) yes 1 (2) 2 (4) 3 (6) total 31 (62) 19 (38) 50 (100) chi-square value= 1.113, df= 1, p<0.05 table 5: peripheral retinal degeneration (prd): pvr cross tabulation prd pvr total n(%) a+b n (%) c+d n(%) no 15 (30) 12 (24) 27 (54) yes 16 (32) 7 (14) 23 (46) total 31 (62) 19 (38) 50 (100) chi-square value= 1.035, df= 1, p<0.05 in case of rest of the risk factors i.e. aphakia & pseudophakia, closed-globe injury and peripheral retinal degenerations, the exposure rates were not statistically significant (p>0.05) between cases and controls. none of the patients was giving a family history of rd so this variable was out of comparison procedure. discussion in our study, patients from almost all age groups were included (mean = 36.8 years) but those with age around 60 years were predominant (mode = 60 years), which may indicate that rrd is mainly a disease of old age. male patients were predominant (78%), but as it is a hospital-based study with no defined drainage territory, nothing significant can be concluded from this result. our study has shown that a duration of visual symptoms of >1 month is a significant risk factor for pvr grade c or more. this is in accordance with the results of other international studies8-11. the rest of the variables studied are apparently not significant risk factors for grade c&d but it is in contrast to the findings of certain other studies e.g. hooymans et al12 & nagasaki et al11 have shown aphakia & pseudophakia as risk factors of high grade pvr. these differences may be because of small sample size of our study. if studied carefully it can be seen that all these significant risk factors are associated with dispersion of rpe cells in the vitreous and breakdown of blood retinal barrier which are the main factors involved in the pathogenesis of pvr. closed-globe injury and peripheral retinal degenerations were not significant risk factors for pvr grade c or more which is also supported to some extent by cardillo et al13. there is a possibility that these patients are often concerned about their vision or might have lost vision in one eye due to rd, so they present very early. it should be recalled that these variables are known risk factors for retinal breaks leading to rrd. 180 we would like to recommend that special attention should be given to the management of rrd having high risk features to prevent postoperative pvr & ultimate surgical failure. therefore, the trend towards primary vitrectomy with internal tamponade even for cases of pvr grade b, in some of the cases may be justified. identification of such risk factors and their prognostic values will assist vitreoretinal surgeons in better planning and better predicting the results of their surgical techniques. it will also help patients’ better understanding the value of going through the agony of surgical interventions. carefully designed case-control studies or cohort studies will augment the role of various risk factors in the development of pvr. conclusions our study has clearly shown that patients of rrds with duration of more than one month are at increased risk of developing high grade pvr. patients with aphakia or pseudophakia, history of closed-globe injury, peripheral retinal degenerations and family history of rd were not at increased risk of developing high grade pvr. author’s affiliation dr muhammad kamran khalid medical officer dhq teaching hospital d.i. khan dr sardar bahadur khan assistant professor of ophthalmology, gomal medical college d.i. khan dr sanaullah jan senior registrar, kioms hayatabad medical complex peshawar professor muhammad daud khan rector, kioms hayatabad medical complex peshawar references 1. weller m, wiedemann p, heimann k. proliferative vitreoretinopathy-is it anything more than wound healing at wrong place? int ophthalmol. 1990; 14: 105-17. 2. kampik a, kenyon kr, michels rh. epiretinal and vitreous membranes. a comparative study of 56 cases. arch ophthalmol. 1981; 99: 1445-54. 3. kirchhof b, sorgente n. pathogenesis of vitreoretinopathy. modulation of retinal pigment epithelial cell functions by vitreous macrophages. dev ophthalmol. 1989; 16: 1-53. 4. clarkson jg, green wr, massof d. a histopathologic review of 168 cases of preretinal membrane. am j ophthalmol. 1977; 84: 117. 5. jerdan ja, pepose js, michels rg. proliferative vitreoretinopathy membranes. an immunohistochemical study. ophthalmology 1989; 96: 801-10. 6. charteris dg, hiscott p, robey hl. inflammatory cells in proliferative vitreoretinopathy subretinal membranes ophthalmology 1993; 100: 43-6. 7. asaria rh, kon ch, bunce c, et al. how to predict proliferative vitreoretinopathy: a prospective study. ophthalmology 2001; 108: 1184-6. 8. nagasaki h, shinagawa k, mochizuki m. risk factors for proliferative vitreoretinopathy. prog retin eye res. 1998; 17: 7798. 9. la heij ec, derhaag pf, hendrikse f. results of scleral buckling operations on primary rhegmatogenous retinal detachment. doc ophthalmol. 2000; 100: 17-25. 10. garard p, mimoun g, karpouzas i, et al. clinical risk factors for proliferative vitreoretinopathy after retinal detachment surgery. retina 1994; 14: 417-24. 11. nagasaki h, ideta h, uemura a, et al. comparative study of clinical factors that predispose patients to proliferative vitreoretinopathy in aphakia. retina 1991; 11: 204-7. 12. hooymans jm, de lavalette vw, oey ag. formation of proliferative vitreoretinopathy in primary rhegmatogenous retinal detachment. doc ophthalmol. 2000; 100: 39-42. 13. cardillo ja, stout jt, labree l, et al. post-traumatic proliferative vitreoretinoathy. the epidemiologic profile, onset, risk factors and visual outcome. ophthalmology 1997; 104: 1166-73. microsoft word editorial 25,3,09 124 editorial the role of ophthalmological society of pakistan in research and development in ophthalmology in pakistan research is a prescribed method of uncovering or discovering the mysteries of nature. it is therefore truly considered the spring of knowledge and understanding and the only straight road which leads to scientific and technological growth and development. the knowledge explosion that we have witnessed in the 20th century and is continuing over in the 21st century is the result of enhanced global commitment and improved ways and means for research and development. the resultant enhanced growth and development has benefited all sectors of knowledge and education including biomedical sciences, with tremendous positive impact on patient care and treatment. however most of the developing countries are watching with envy the fast growth and development of technologically advanced countries. they have failed to catch up with developed countries for the following interlinked reasons. 1. lack of vision 2. lack of national commitment 3. inability to create systems which govern research from the word go, formulating a research question and leading on to project preparation, conduct, completion, publication and application. the real question before us is: can we do it?, if so how? what role can the ophthalmological society of pakistan play? the answer to the first question is yes, provided we make a firm national resolution act on the following ten points: 1. make national commitment. 2. create national vision 3. fix national priorities through an in depth consultative process. 4. create national structures for policy making, implementation, and governance including coordination, collaboration and audit. 5. create provincial and institutional bodies to support the national bodies. 6. create national and international linkages. 7. provide adequate and non discminatory financial and administrative support to public and private universities and institutions engaged in research. 8. universities and institutions committed to research must create an enabling environment for research scholars both at home, at the institute and in the laboratory. 9. research scholars must prepare smart strategies to answer their research questions, publish their research in respectable journals in the prescribed time period. the research scholars should also ensure that the research findings make a base for technological growth and development with impact on the welfare of the society. 10. the top national research scholars must be generously recognized through national awards. the role of osp in promoting national research in ophthalmology and ophthalmic disorders leading to visual disability and /or blindness: osp is committed to the following goals and objectives: 1. enhance the knowledge, skills and attitude of ophthalmologists and ophthalmic allied health personnel. 2. create opportunities, encourage, support and manage their cme and cpd activities. 3. create opportunities, encourage and support research and development in ophthalmology and vision sciences. in order to achieve its 3rd goal and objective, osp has so far taken the following steps: 1. it is encouraging research for residents and fellows in ophthalmology and vision sciences. 2. it is extending financial support for research in ophthalmology and vision sciences through the osp research foundation. 125 3. to further encourage research in ophthalmology, osp has created a specific medal for excellence in research which is conferred on deserving scholars on annual basis. 4. to support research in ophthalmology, it has created a fund called osp research fund. 5. to create opportunities for exchange of research findings among research scholars, osp arranges four or five regular regional meetings and one national meeting every year. to support publication of research articles, osp sponsors a national journal of ophthalmology. to redouble its efforts in promotion of meaningful research in ophthalmology and vision sciences, osp may seriously consider taking the following additional steps: 1. the council may allow and support the formation of an interest group or pakistan association for research in ophthalmology and vision sciences on the lines of association for research in ophthalmology and vision sciences (arvo) of usa. 2. the group membership should be open to members from all backgrounds related to ophthalmology and vision sciences. 3. the group will need to be encouraged to create strong national and international linkages. 4. the group will be expected to prepare a strategic plan for promotion of research in ophthalmology and vision sciences under the umbrella of osp 5. the group will be expected to prepare smart strategies to implement and manage the plan. it is sincerely hoped that the above road map will put us on a straight road to success and ophthalmology will set yet another trend for others to follow. prof. m daud khan peshawar microsoft word mazhar soomro case report corrected 216 case report relative uncommon cause of proptosis mazhar-ul-zaman soomro, masood akhter, ruqaiya shahid pak j ophthalmol 2010, vol. 26 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mazhar-ul-zaman soomro shifa eye clinic, khanpur rahim yar khan received for publication september’ 2009 …..……………………….. hin bony plates of the para nasal sinuses make two thirds of the walls of the orbit. a lesion in para nasal sinus may affect the orbit and at times cause displacement of the globe by decreasing orbital volume. the purpose of this case is to reemphasise the importance of rhinological examination and sinus radiology as one of the preliminary investigations in all cases of proptosis so that proper diagnosis could be made early and effective treatment instituted in time. case report a young frail female farzana 16years by age presented to out patient department with complaint of progressive proptosis of right eye with swelling of right cheek. she had no history of rhinorrhea or chronic sneezing. on examination her vision was 6/6 in both eyes. anterior chamber was quiet. pupil was reactive and equal on both sides. fundus examination revealed no abnormality. extaocular movements were normal. on ultrasonography there was a mass behind the globe pushing it forward. ct sacn showed opacity in the ethmoidal sinus extending to the orbit with destruction of lamina properia. mri was done with t1w, t2w, flair and fat supperssion sequence. it showed a soft tissue density in the ethmoidal sinus and orbital junction which measured 23x25x35 mm. it was irregular in shape, poorly demarcated and showed heterogeneous signal intensities. definition of nasal septum, turbinates and lateral wall of the nose was partially lost. the lesion was pushing the eye ball in opposite site. the lesion was extending superiorly upward to base of skull but no intracranial extension. orbital muscles were inseparable from space occupying lesion in the vicinity. her esr was raised, blood sugar was within normal limit, hb was 7gm% and monteaux test was negative. she was sent to ent surgeon for further management she was operated at ent department bahawal victoria hospital, bahawalpur and the mass was sent for histopathological examination to agha khan lab, karachi. it revealed fibrous tissue fragments lined by respiratory epithelium, exhibiting chronic granulomatous inflammation, comprising of multinucleated giant cells. no evidence of necrosis was present. on special stain (periodic acid schiff) thin walled septate fungal hyphae were seen in the giant cells, and these fungi were resistant to diastase. in some areas the fungal hyphae were also seen invading the surrounding soft tissue. zheil nelson’s stain was negative for acid fast bacilli. cultures were recommended for definite fungal species identification. she was put on antifungal treatment and propotis has subsided. t 217 b. scan discussion although sinusitis affects up to 20% of individuals during the course of their lives, fungal infections of the sinuses are relatively uncommon. the first reported case was by plaignaud in 1791. a detailed clinical description of aspergillus fumigatus of the nasal cavity was first described in 1885 by schubert. the first description in the u.s. was by mackenzie in 1893, but it wasn’t until 1961 that sevetsky and waltner presented the first actual series of cases in the literature. fungal infection has emerged as a more vital health problem in modern times because of increased travel into and out of endemic areas, immune deficient states such as aids, immunosuppression for transplantation and from chemotherapy. the more prevalent use of long-term, broad-spectrum antibiotic therapy and poorlycontrolled diabetes also remains a problem. however, improved means of clinical detection and laboratory diagnosis have more clearly identified affected individuals. microscopic view fungi are found mainly in air, dust, soil, plants, and decaying organic matter. they adhere to dust particles and are inhaled and deposited on the nasal and paranasal sinus mucosa and may spread to orbit causing proptosis. the warm, moist environment of the upper respiratory tract is an ideal environment for the proliferation of these organisms. however, they are rarely pathogenic because host resistance is high except under favorable growth conditions in highly susceptible individuals. fungi are closely related to bacteria. they possess a unique property called dimorphism, meaning that they may exist both as a spore form and as a branching, mycelial form, depending on environmental conditions. there is a wide range of morphologic types. the presence or absence of segmentations or septa of the hyphae often distinguish the species. the hyphae branch like a tree from a central stem or from a common node such as rhizopus. the terminal buds may exhibit a spherical sporangia or are arrayed in clusters like the conidiophores of aspergillus. these fungi grow best 218 on sabouraud’s agar. they are, however, difficult to grow and it may take weeks to produce identifiable colonies. the most commonly seen mycotic organisms in the western world are aspergillus, mucor, rhizopus, and alternaria. diagnosis is best made by tissue biopsy, staining of the specimen followed by microscopic examination and culture. occasionally a smear can be stained and examined, thereby precluding the need for biopsy. even koh preparations can sometimes produce identification of the organism. fungal specific stains such as periodic acid-schiff (pas), or grocot's methenamine silver (gms) are most often necessary for definitive diagnosis. conclusion fungal granoloma of ethmoidal sinus is relatively uncommon cause of propotosis. if ophthalmologist comes across such a case then, it can be best managed in a multidisciplinary way. author’s affiliation dr. mazhar u zaman soomro ophthalmic surgeon shifa eye clinic khanpur dr. masood akhter ent surgeon b.v. hospital, bahawalpur dr. ruqaiya shahid resident of 4th year at histopathology aga khan university hospital karachi reference 1. abdulrahman aa, mushira e, zeyad m et al. chronic invasive aspergillosis of theparanasal sinuses in immunocompetent hostsfrom saudiarabia. am j trop. med hyyg. 2001; 65: 83-6. 2. seiff sr, choo ph, carter sr. role of localamphotericin b therapy for sino-orbital fungal infections. ophthal plast reconstr surg. 1999; 15: 28-31. 3. adams nf. infections involving the ethmoid, maxillary and sphenoid sinuses and the orbit due to aspergillus fumigatus.archives of surgery. 1933; 26: 999. 4. sen dk, mohan h, gupta dk. fungal granuloma of the orbit. orient, arch. ophthalmol. 1969; 7: 106. microsoft word qasim lateef 101 original article giant retinal tears in children: associations and outcomes qasim lateef chaudhry, syed ali haider pak j ophthalmol 2009, vol. 25 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . see end of article for authors affiliations … ……………………… correspondence to: qasim lateef chaudhry department of ophthalmology lahore general hospital lahore received for publication december 2008 … ……………………… purpose: giant retinal tear (grt) as a cause of retinal detachment is uncommon in children. their associations and surgical outcome in children of 16 years and less are not well described. material and methods: all patients who presented with retinal detachment due to grt between 1998 and 2004 were included in the study. they underwent 3 ports pars plana vitrectomy, 360 encirclement with 2.5 mm band and fluid perfluorocarbon liquid silicone oil exchange. results: 12 patients, 8 boys and 4 girls with an age range of 5-16 years presented and underwent surgery during this period. high myopia, sticklers’ syndrome, weil marchisani syndrome, trauma and anterior segment cleavage disorder were the principal associations. in five patients the fellow eye was already npl due to chronic retinal detachment. 7 patients had minimal or no pvr (proliferative vitreo-retinopathy) while the others ranged from stage b to c2 pvr. while all except one retina were re-attached per-operatively, at six months only 4 retinas remained fully attached. both children under 10 years of age had a poor outcome. conclusion: retinal detachment, due to grt, in children often has poor outcome due to aggressive evolution of pvr and difficulty in posturing. younger age may be associated with poorer outcome. 102 ears that extend 90° or more around the circumference of the retina are called giant retinal tears1,2. vitrectomy with internal tamponade is the treatment of choice for them. due to wide exposure of retinal pigment epithelium (rpe), pvr3 is more common in retinal detachment due to grt. in adults grt is often associated with myopia and sticklers syndrome among others. at least in adults with grt in one eye, 12% incidence of giant tear formation in the fellow eye has been reported4. the incidence, associations and outcome of giant tears of the retina in the population under 16 years of age are not well described as the frequency of rhegmatogenous retinal detachment in children is reported to be 1.7-5.9%5-7 of all retinal detachments. our aim is to study the associations and surgical outcome of retinal detachment in patients under 17 years of age. material and methods in a prospective hospital based interventional case series spanning seven years from 1998-2004 we studied all children who presented with a rhegmatogenous retinal detachment to the retinal unit of the lahore general hospital. type of retinal tear, associated ocular and systemic features and outcome of surgery were recorded. the minimum follow-up was six months. the main outcome measure was anatomic retinal re-attachment. results in this five year period 83 children under 16 years of age were treated for retinal detachment. of them 12 (14%) children (8 boys & 4 girls), had retinal detachment due to a grt. their age ranged from 5-16 years (table 1). the time from onset of retinal detachment to presentation ranged from 13 to 90 days and the distance patients traveled to seek treatment ranged from 0 to 200 miles. the significant associations (table 2) were high myopia in three patients, sticklers syndrome in three patients, weil marchisani syndrome, cataract surgery, trauma and anterior segment cleavage disorder in one patient each. no association was found in two patients. seven patients had minimal or no pvr (proliferative vitreo-retinopathy), one patient had stage b and 4 patients were in various levels of stage c (table 3). while all except one retina was re-attached per-operatively, at six months only 4 retinas remained fully attached. both children under 10 years of age had a poor outcome. the fellow eye was already no light perception in 5 patients (41%) due to chronic retinal detachment. at the end of six months only four out of 12 retinas were anatomically fully attached. one patient underwent three re-operations for recurrent retinal detachment. silicone oil could be removed successfully in only one patient. discussion posterior vitreous detachment (pvd) and abnormal vitreo-retinal adhesions are considered the principal underlying reasons for retinal detachment. the incidence of retinal detachment rises as the frequency of pvd increases8. in children as the vitreous is intact, so the frequency of retinal detachment is also low. retinal detachment due to grt is especially uncommon in children and therefore this problem is not well documented in the literature. the eye department of the lahore general hospital is a tertiary referral center in punjab, the most populous province (70 million) of pakistan. this center has special interest in vitreo-retinal surgery in an area with otherwise limited facilities for retinal problems. due to a large referral base we were able to gather this case series. we report a series of 12 patients who presented to us over a period of 7 years with retinal detachment due to grt. a total of 83 patients less than 16 years of age were operated on during this period. in this series 14% of all paediatric retinal detachments were due to grt. the time delay from onset of retinal detachment to presentation ranged from 13 to 90 days. this is explained in part by the distance the patients had to travel to seek treatment i.e. 0-200 miles. poverty, limited access to facilities and perhaps late reporting by children9,10 were other significant factors. table 1: age of children presenting with grt age no. of patients 5-6 years 1 patient 7-8 years nil 9-10 years 2 patients 11-12 years 1 patient 13-14 years 4 patients t 103 15-16 years 4 patients table 2: associations of giant retinal tears associations no. of patients high myopia 3 patients sticklers syndrome 3 patients weil marchisani syndrome 2 patients trauma 1 patient anterior segment cleavage syndrome 1 patient cataract surgery 1 patient no association 1 patient table 3: stage of pvr at presentation stage of pvr no. of patients no or stage a pvr 7 patients stage b pvr 1 patient stage c pvr 4 patients 10 out of 12 patients had a significant ocular or systemic association, the most common being myopia and sticklers syndrome table 1. two patients had no clear cut association. of great concern were the findings that, 5 out of 11 patients had their fellow eye already affected by retinal detachment and had no light perception. two out of three patients with sticklers and the only one with weil marchisani belonged in this group. the delay in presentation and the nature of the disease meant that 4 out of 12 had stage c pvr on presentation. a reflection of the aggressive nature of the disease is witnessed in the anatomical surgical outcome. while per-operative retinal re-attachment was achieved in 11 out of 12 cases, at the end of six months only 4 retinas (33%) were still fully attached. silicone oil could be removed successfully in only one patient. one of these patients has had three reoperations involving membrane peel and retinectomy and cataract extraction to preserve retinal attachment. both patients under 10 years of age re-detached irreversibly. previous studies evaluating the surgical outcome after grt show variable success rate. scott iu et al 11 achieved an anatomical success rate of 68 % in their case series of 34 children under 16 years of age with grt and preservation of ambulatory vision in 53 % of these children following vitrectomy and internal tamponade with silicon oil at 6 months. in a similar aged population karel i et al 12 had a success rate of 82 % at 2 years which declined to 45 % at 5 years in 24 eyes of 22 children. the principal cause of failure in our study was the aggressive pvr13. inability to induce pvd anterior to the equator would perhaps be another cause. residual vitreous may have provided the scaffold, which resulted in shortening antero-posteriorly as well as circumferentially. inability to maintain posture for internal tamponade by silicone oil probably also played an important part14. in conclusion grt in the paediatric age group though uncommon have a significant chance of affecting both eyes and has a poor prognosis in terms of anatomical outcome in the medium term. author’s affiliation dr. qasim lateef chaudhry senior registrar department of ophthalmology lahore general hospital lahore prof. syed ali haider department & institution department of ophthalmology lahore general hospital lahore reference 1. schepens cl, dobbie jg, mcmeel jw. retinal detachments with giant retinal breaks: preliminary report. trans am acad ophthalmol otolaryngol. 1962; 66: 471-8. 2. schiff w, chang s, reppucci v, et al. surgical management of giant retinal tears. in: guyer dr, eds. retina-vitreous-macula. vol 2, eds. pennsylvania: wb saunders. 1999: 1338–49. 3. ghosh yk, banerjee s, savant v, et al. surgical treatment and outcome of patients with giant retinal tears. eye 2004; 18: 996– 1000. 4. freeman hm. fellow eyes of giant retinal breaks. trans am ophthalmol soc. 1978; 76: 343-82. 5. winslow rl, tasman w. juvenile rhegmatogenous retinal detachment. ophthalmology. 1978; 85; 607-818. 6. akabane n, yamamoto s, tsukahara i, et al. surgical outcomes in juvenile retinal detachment. jpn j ophthalmol. 2001; 45; 409-11. 104 7. butler tkh, kiel aw, orr gm. anatomical and visual outcome of retinal detachment surgery in children. br j ophthalmol. 2001; 85: 1437-9. 8. foos ry, wheeler nc: vitreoretinal juncture. synchysis senilis and posterior vitreous detachment. ophthalmology. 89: 1502, 1982. 9. sadeh ad, dotan g, bracha r, et al. characteristics and outcomes of pediatric rhegmatogenous retinal detachment treated by segmental scleral buckling plus an encircling element. eye 2001; 15: 31-3. 10. fivgas gd, capone a. paediatric rhegmatogenous retinal detachment. retina. 2001; 21: 101-6. 11. scott iu, flynn hw jr, azen sp, et al. silicone oil in the repair of pediatric complex retinal detachments: a prospective, observational, multicenter study. ophthalmology. 1999; 106: 1399-407. 12. karel i, michalickova m, kuthan p. long-term results of pars plana vitrectomy and silicone oil in large retinal tears in children. cesk slov oftalmol. 1997; 53: 147-54. 13. weinber dv, lyon at, greenwald mj, et al. rhegmatogenous retinal detachments in children: risk factors and surgical outcomes. ophthalmology. 2003; 110: 1708-13. 14. wang nk, tsai ch, chen yp, et al. pediatric rhegmatogenous retinal detachment in east asians. ophthalmology. 2005; 112: 1890-5. pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 9 original article clinical results of deep anterior lamellar keratoplasty in treatment of advanced keratoconus; big bubble technique bushra akbar, rana intisar-ul-haq, mazhar ishaq, paree chera, kashif siddique pak j ophthalmol 2017, vol. 33 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: bushra akbar post graduate trainee ophthalmology department of ophthalmology, armed forces institute of ophthalmology, rawalpindi, pakistan email: dr.bushra.akbar@gmail.com …..……………………….. purpose: to evaluate refractive results and complications of deep anterior lamellar keratoplasty (dalk) using anwar's big bubble technique in advanced keratoconus. study design: quasi experimental study. place and duration of study: armed forces institute of ophthalmology, rawalpindi from november 2015 to december 2016. material and methods: seventeen eyes of seventeen patients with advanced keratoconus who underwent dalk using anwar's big bubble technique with1 year postoperative follow up were included in study. uncorrected and corrected distant visual acuities (udva, cdva, snellen acuity converted to logmar notation), spherical equivalent se (diopters d)], refractive astigmatism [(ast, d)], slit lamp biomicroscopy and endothelial cell count (ecd) were recorded at baseline and at 1, 6 and 12 months postoperatively. intra and postoperative complications were documented. results: the mean patient age was 26.29 ± 10.403 years including 12 males (76.47%) and 4 (23.53%) females. the mean baseline logmar udva and cdva were1.376 ± 0.286 and 1.211 ± 0.228, which significantly improved at all test points to final logmar udva and cdva of 0.964 ± 0.183 and 0.647 ± 0.279 at 1 year (p = 0.000, 0.000 respectively). improvement in ast was only significant at 1 year (p = .0.0) while changes in se were not significant (p = .0.330). no significant ecd loss (p) or rejection was recorded at any postoperative exam. conclusion: dalk using anwar’s big bubble technique has shown lesser complications in terms of endothelial rejection and endothelial cell loss with satisfactory refractive results in young keratoconus patients and we recommend it to be a preferred surgical technique over penetrating keratoplasty, despite its technical challenges and steep surgical learning curve. key words: deep anterior lamellar keratoplasty, anwar's big bubble, refractive outcome, advanced keratoconus. eratoconus is a degenerative, noninflammatory corneal ectatic disorder characterized by progressive central, paracentral stromal thinning, protrusion and visual deterioration due to myopia, myopic astigmatism and irregular astigmatism. early to moderate cases of keratoconus are managed with spectacles, rigid gas permeable contact lenses, providing satisfactory visual rehabilitation and the disease progression can be effectively halted by corneal collagen cross linking. however, keratoconus affects mainly young working population, advanced cases requires surgical intervention due to non satisfactory and intolerant fitting of contact lens, extreme corneal thinning k bushra akbar, et al 10 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology restricting the corneal cross linking or intracorneal ring segments, and apical scarring in the visual axis, with a resultant very poor or unacceptable vision1. common surgical options include pkp and dalk. dalk is a selective form of layered keratoplasty, which involves the removal and replacement of diseased layers of cornea while retaining the recipient healthy endothelium1,2,3. this preservation of endothelium minimized the incidence of endothelial allograft rejection and concomitantly the dose and duration of postoperative steroids administration and the complications associated with its use2,3. pkp remained procedure of choice for all keratoplasty indications for decades, despite its draw backs, largely due to its superior visual outcomes and a longer surgical experience2,3,4. visual outcome is predominantly influenced by corneal transparency both in pkp and dalk, however the visual recovery was significantly compromised in dalk by scattering of light at donor host interface irregularity owing to residual stroma adherent to descemet's membrane5,6. many surgical methodologies has been described for separation of stroma from descemet's membrane and endothelium in dalk to achieve optimal interface, starting with barraquer microkeratome and malbran ''peeling off technique” based on deep stromal dissections7,8. to the best of our knowledge, this is the first study in pakistan on clinical outcomes of dalk using anwar's big bubble technique in advanced keratoconus. we aim to share our initial clinical experience in terms of refractive outcomes and complications at 1 year after dalk using anwar's big bubble technique in pakistani eyes with advanced keratoconus to generate local data and pave a way for guidelines regarding surgical interventions in treatment of advanced keratoconus in pakistan. methods and materials this quasi experimental study enrolled consecutive patients of advanced keratoconus who underwent successful dalk using anwar's big bubble technique at armed forces institute of ophthalmology from november 2015 to nov 2016 after approval of local ethical committee. an informed consent was obtained from all the participants of study. inclusion criteria included patients with advanced keratoconus between 18 and 30 years of age. advanced keratoconus was defined as grade 4 disease according to the retics classification1 (insufficient corneal thickness for icrs implantation or cxl with persistent contact/scleral lenses intolerance and poor cdva of 0.6). exclusion criteria included eyes with corneal scarring and opacity involving descement‟s membrane and endothelium (healed hydrops) other ocular co morbidity (amblyopic, strabismus, posterior segment pathology), systemic diseases, neurological problems, or any topical or systemic medications that may affect visual acuity, intraoperative complications meriting a conversion to penetrating keratoplasty or failure to achieve big bubble, requiring completion of dalk by lamellar dissection. preoperative and postoperative ocular examinations at 1, 6 and 12 months included udva, cdva (measured on snellen visual acuity chart, converted to logmar notation), se, ast, slit lamp biomicroscopy and dilated fundus examination. ocular investigations included corneal topography (dual scheimpflug based corneal topography, galilei g4), specular microscopy (topcon sp-3000, usa) for endothelial cell density analysis and anterior segment optical coherence tomography (asoct, topcon maestro 2000, japan) for assessment of trephination depth in superficial corneal opacities. dalk using anwar's big bubble technique was done by a single corneal surgeon in all patients under general anaesthesia. the geometric center of the recipient cornea was marked after draping and eye lid speculum insertion as per standard clinical techniques. a partial thickness trephination of 8.0 mm (range 8.0 8.50 mm) diameter at predicated depth in corneal stroma (350 to 500 microns) was achieved via moria suction trephine with guard (moria, france) making sure centration at all times. a 30-gauge needle, bent at 60 degrees 5 mm from the tip with bevel facing down, attached to a 3 ml syringe was used to inject the air, 3 to 4 cm from the entry site, into deep stroma to achieve big bubble, that separates the stroma and the descemet's membrane, evidenced as a semi opaque central disk with a sudden ease on resistance of the plunger. deepest stromal layers were gently dissected from center to periphery into 4 quarters by angled blunt tipped holland dalk scissors (dalk set, katena usa). these dissected deep stromal layers were then excised with holland dalk right and left scissors (dalk set, katena, usa) to expose the clear and shiny descemet's membrane. the wound edges were then trimmed as vertically as possible to minimize post-operative astigmatism. donor corneas were procured by hospital corneal and retrieval program and transported in mccarey kaufmann medium. donor corneas deemed fit based clinical results of deep anterior lamellar keratoplasty in treatment of advanced keratoconus; big bubble pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 11 on negative infectious serology (hiv, hepatitis) and optical clarity, were only used for dalk in our study. donor graft of 0.25 mm larger than recipient bed was trephined with endothelial side up on teflon block. the endothelium was stained with trypan blue and peeled off with methylcellulose sponge. the donor graft was then sutured onto the recipient bed with sixteen 10-0 nylon interrupted sutures (alcon laboratories usa). postoperatively, patients were advised topical antibiotics moxifloxacin (vigamox, alcon) 4 hourly and topical steroids prednisolone acetate 1% (predforte, allergan) eye drops 6 hourly gradually tapered over a period of 6 weeks. suture removal and manipulation was done between 24 to 27 weeks after 2nd postoperative exam at 6 months and suture removal was completed till 12 months, one week prior to the last follow up exam in all patients. meanwhile, only loose or infected sutures were removed or replaced if required. data analysis was done using spss version 20. quantitative data was described as mean ± standard deviation and nominal data as frequencies. paired sample ttest was used to analyze change in the parameters over baseline at post -operative test points of 1, 6 and 12 months. p value of <0.05 with 95% confidence interval was considered statistically significant. results seventeen eyes of 17 patients were included in this study who underwent dalk using big bubble technique and completed a minimum follow up of 12 months. big bubble was achieved in (94.11%) 17/18 of eyes. two eyes were excluded from the study due to failed big bubble (5.88%) 1/18 with subsequent manual stromal lamellar dissection in one eye and an intraoperative macro perforation requiring conversion to pkp in the other eye. no other intraoperative or postoperative complication was recorded. the mean age was 26.29 ± 10.40 years. there were 13 (76.47%) males and 4 (23.53%) females. suture manipulation was done in 3 eyes and mean suture manipulation time was 25.588 ± 1.325 (range 24 – 28) weeks. the mean suture removal time was 11.555 ± 0.472. mean baseline logmar udva was 1.376 ± 0.286 which significantly improved over all postoperative test points of 1, 6 and 12 months with a final udva of 0.964 ± 0.183 at 1 year. (p = 0.001, 0.000, 0.000 respectively) table 1. mean baseline logmar cdva 1.211 ± 0.228 improved significantly at all predetermined test points to a mean logmar cdva of 0.647 ± 0.279 (p = 0.000, 0.000, 0.000 respectively) at 12 months table 1. the mean pre op se -3.806 ± 1.358 and ast-3.205 ± 2.653 although showed a reduction over post-operative test points but it was not significant (p > 0.05) except for a postoperative astigmatism at 1 year (p = 0.010). table 1. ecd evaluated by specular microcopy did not show any significant loss over the postoperative follow up (p = 0.082) table 1. no signs of endothelial decompensation or rejection were reported in any eye over 1 year follow up in our study. table 1: refractive results after deep anterior lamellar keratoplasty using anwar‟s big bubble technique. study parameters preoperative post operative mean ± sd 1 month 6 months 12 months udva (logmar) 1.376 ± 0.286 1.079 ± 0.331 1.061 ± 0.263 0.964 ± 0.183 p value 0.001* 0.000* 0.000* cdva(logmar) 1.211 ± 0.228 0.982 ± 0.174 0.782 ± 0.237 0.647 ± 0.279 p value 0.000* 0.000* 0.000* se(d) -3.806 ± 1.358 -4.741 ± 1.150 -4.080 ± 2.432 -3.092 ± 2.420 p value 0.325 0.864 0.330 ast(d) -3.205 ± 2.653 -3.455 ± 0.806 -3.161 ± 0.905 -2.088 ± 1.441 p value 0.869 0.836 0.010* (*) p value<0.05, paired sample t test bushra akbar, et al 12 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology fig. 1a: anterior segment photograph after big bubble dalk in advance d keratoconus 1 week follow up. fig. 1b: post big bubble dalk anterior segment photograph in advance keratoconus. discussion archila, in 1985, performed stromal dissection with aid of 1 cc air injection above the descemet's membrane, with subsequent spatula dissection of overlying recipient stroma9. sugito and kundo introduced hydro delamination of residual stromal fibers followed by delamination of hydrated stromal fibers from the descemet's membrane10. melles et al conceptualized the technique of lamellar dissection depth by exchanging aqueous with air and creating an optical air endothelium interface, that acts as convex mirror and reflects the depth of instrument in stroma coupled with viscodissection of lamellar plane to bare descemet‟s membrane11,12. anwar and teichmann described the famous big bubble technique, where a large air bubble facilitates the separation of descemet's membrane from stroma after initial partial stromal trephination with resultant optimal interface, totally baring descemet's membrane13. this limited postoperative interface haze, provided excellent visual results, early visual rehabilitation in keratoconus14. despite its steep learning curve and technical challenges, clinically significant advantages of anwar‟s big bubble dalk has shifted the paradigm from pkp to dalk amongst corneal surgeons across the globe for endothelium and descemet‟s membrane sparing corneal disorders13-17. however very few tertiary care centers in pakistan are offering selective layered keratoplasties at present in contrast to other developing countries of south east asia15,16. keratoconus has been the leading indication for keratoplasty in many populations and geographical zones in the last few decades. this paradigm shift in indications has been probably the outcome of developmental state and socioeconomic profile of population, clinical significant advantages of dalk and improvement of eye banks and surgical sophistication18.19,20. we performed dalk in seventeen eyes of advanced keratoconus using big bubble technique with a 1-year post-operative follow up. big bubble was achieved in 17 (94.1%) eyes out of 18 eyes and only one eye 5.88% required layer by layer stromal dissection that was comparable to or better than similar studies13-17. only one eye (5.88%) required conversion to pkp due to intraoperative macro perforation. anwar in his study reported perforation in 16 (9%) eyes out of 181 eyes and conversion to pkp in one eye, feizi et al reported a conversion rate of 2.3% in 103 eyes. this success rate of big bubble formation and conversion rate in our study can be considered acceptable for a being beginners in challenging surgical learning curve13,14. the mean gain in udva and cdva from 1.1376 ± 0.286 to 0.964 ± 0.18 and 1.211 ± 0.228 to 0.647 ± 0.279 one year in our study is comparable to results reported by feizi et al14. gain of more than 3 snellen lines in cdva was achieved in 94.44% of eyes similar to gain of more than 2 lines in 91% of eyes reported by danosoury23. a cdva of 20/70 in 40% and 20 /40 in 30% of eyes was achieved as compared to 20 /40 or better achieved in 77.8% of eyes in similar clinical trials of dalk using big bubble technique14. similarly the se and ast showed reductions over the follow up test points14. in current study, astigmatism of more clinical results of deep anterior lamellar keratoplasty in treatment of advanced keratoconus; big bubble pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 13 than 4 d in 17% of eyes was documented in accordance with high post dalk ast in 26% of eyes in previous similar trials at 1 year that was managed with relaxing incisions and adjustment sutures14. these differences in refractive results and post dalk refractive error in our study compared to previous similar clinical studies in international studies may be explained by variations in factors affecting post dalk refractive status like suturing techniques, mean time of suture removal, suture manipulation for high cylindrical errors, refraction at variable duration after suture removal and our limited surgical expertise21,24. moreover the quality of vision can also be negatively affected by interface haze even if stroma fully excised and no interface haze is detectable on slit lamp22. this can be seen as selective stromal reflectivity on confocal microscopy and decreased contrast sensitivity6. the reason being not completely understood and speculated to be excessive healing response22. no case of subepithelial or stromal graft rejection or endothelial cell was reported in this study which was less than reported immunologic rejection of 3 to 8% after dalk, and 14.3% reported by feizi et al6,24,25. this may be attributed to our careful patient selection excluding allergic co-morbidities, explained by feizi et al in his study, that led us to an obvious advantage of early tapering of steroids and no complications post operatively of raised intraocular pressures. lu et el26 have shown that dalk with big bubble technique using femto laser is a new safe, effective and accurate technique for treating patients having keratoconus. the major limitations of this study is a small sample size, relatively shorter duration of follow. we strongly feel that large prospective multi center trials on big bubble dalk recruiting larger number of advanced keratoconus patients with a long term follow up to increase surgical experience and will help to generate standardized data on clinical results, recurrence of disease and factors predicting refractive outcomes in our population. dalk using anwar‟s big bubble technique has shown lesser complications in terms of endothelial rejection and endothelial cell loss, with satisfactory refractive results in young keratoconus patients, and we recommend it to be a preferred surgical technique over penetrating keratoplasty, despite its technical challenges and steep surgical learning curve. conclusion dalk using anwar's big bubble technique has shown lesser complications in terms of endothelial rejection and edothelial cell loss with satisfactory refractive results in young keratoconus patients and we recommend it to be a preferred surgical technique over penetrating keratoplasty, despite its technical challenges and steep surgical learning curve. author’s affiliation dr. bushra akbar department of ophthalmology, armed forces institute of ophthalmology, rawalpindi, pakistan dr. rana intisar-ul-haq department of ophthalmology, armed forces institute of ophthalmology, rawalpindi, pakistan dr. mazhar ishaq department of ophthalmology, armed forces institute of ophthalmology, rawalpindi, pakistan dr. paree chera department of ophthalmology, armed forces institute of ophthalmology, rawalpindi, pakistan dr. kashif siddique statistician, research (academic affairs), king salman armed forces hospital, ksa role of authors dr. bushra akbar study design, data acquisition, interpretation, and analysis of data, manuscript drafting. dr. intisar-ul-haq study design, critical review. dr. mazhar ishaq critical review. dr. paree chera data collection, interpretation and manuscript drafting dr. kashif siddique study design, interpretation, analysis of data and critical review references 1. arnalich-montiel f, alió del barrio jl, alió jl. corneal surgery in keratoconus: which type, which technique, which outcomes? eye and vision. 2016; 3(2); 1-14. 2. terry m. the evolution of lamellar grafting techniques over twenty-five years. cornea, 2000; 19 (5): 611-616. 3. funnell c, ball j, noble b. comparative cohort study of the outcomes of deep lamellar keratoplasty and bushra akbar, et al 14 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology penetrating keratoplasty for keratoconus. eye. 2005; 20 (5): 527-532. 4. jones m, armitage w, ayliffe w, larkin d, kaye s. penetrating and deep anterior lamellar keratoplasty for keratoconus: a comparison of graft outcomes in the united kingdom. investigative opthalmology & visual science, 2009; 50 (12): 5625-9. 5. fontana l, parente g, sincich a, tassinari g. influence of graft–host interface on the quality of vision after deep anterior lamellar keratoplasty in patients with keratoconus. cornea, 2011; 30 (5): 497-502. 6. feizi s, javadi m, rastegarpour a. visual acuity and refraction after deep anterior lamellar keratoplasty with and without successful big-bubble formation. cornea, 2010; 29 (11): 1252-1255. 7. barraquer j. lamellar keratoplasty (special techniques). ann ophthalmol. 1972; 4: 437–469. 8. polack f. lamellar keratoplasty: malbran‟s “peeling off” technique. arch ophthalmol. 1971; 86: 293-296. 9. archila e. deep lamellar keratoplasty dissection of host tissue with intrastromal air injection. cornea, 1985; 3: 217-218. 10. sugita j, kondo j. deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement. br j ophthalmol. 1997; 81: 184-188. 11. melles g, rietveld f, beekhuis w, binder p. a technique to visualize corneal incision and lamellar dissection depth during surgery. cornea, 1999; 18 (1): 80-86. 12. melles g, lander f, rietveld f, remeijer l, beekhuis w, binder p. a new surgical technique for deep stromal, anterior lamellar keratoplasty. the british journal of ophthalmology, 1999; 83 (3): 327-333. 13. anwar m, teichmann kd. big-bubble technique to bare descemet„s membrane in anterior lamellar keratoplasty. j cataract refract surg. 2002; 28: 398-403. 14. feizi s, javadi m, jamali h, mirbabaee f. deep anterior lamellar keratoplasty in patients with keratoconus: big-bubble technique. cornea, 2010; 29 (2): 177-182. 15. tan dth, mehta js. future of lamellar corneal transplantation. cornea, 2007; 26: s21-s28. 16. fogla r. deep anterior lamellar keratoplasty in the management of keratoconus. indian journal of ophthalmology, 2013; 61 (8): 465-8. 17. söğütlü sarı e, kubaloğlu a, ünal m, piñero llorens d, koytak a, ofluoğlu a et al. penetrating keratoplasty versus deep anterior lamellar keratoplasty: comparison of optical and visual quality outcomes. british journal of ophthalmology, 2012; 96 (8): 1063-1067. 18. de sanctis u, alovisi c, baucheiro l, caramello g et al. changing trends in corneal graft surgery: a ten-year review. int j ophthalmol. 2016; 9 (1): 48-52. 19. rezaei kanavi m, javadi m, motevasseli t, chamani t, rezaei kanavi m, kheiri b et al. trends in indications and techniques of corneal transplantation in iran from 2006 to 2013; an 8-year review. j ophthalmic vis res. 2016; 11 (2): 146. 20. altay y, burcu a, aksoy g, singar ozdemir e, ornek f. changing indications and techniques for corneal transplantations at a tertiary referral center in turkey, from 1995 to 2014. clinical ophthalmology, 2016; 10: 1007-1013. 21. javadi m, feizi s, mirbabaee f, rastegarpour a. relaxing incisions combined with adjustment sutures for post-deep anterior lamellar keratoplasty astigmatism in keratoconus. cornea, 2009; 28 (10): 1130-1134. 22. feizi s, javadi m, mohammad-rabei h. an analysis of factors influencing quality of vision after big-bubble deep anterior lamellar keratoplasty in keratoconus. american journal of ophthalmology, 2016; 162: 66-73. 23. cheng y, visser n, schouten j, wijdh r, pels e, van cleynenbreugel h et al. endothelial cell loss and visual outcome of deep anterior lamellar keratoplasty versus penetrating keratoplasty: a randomized multicenter clinical trial. ophthalmology, 2011; 118 (2): 302-309. 24. el-danasoury a. big bubble deep anterior lamellar keratoplasty (bb-dalk). international ophthalmology clinics, 2013; 53 (1): 41-53. 25. feizi sjavadi m. factors predicting refractive outcomes after deep anterior lamellar keratoplasty in keratoconus. american journal of ophthalmology, 2015; 160 (4): 648-653. 26. lu y, chen x, yang l, xue c, huang z. femtosecond laser assisted deep anterior lamellar keratoplasty with big-bubble technique for keratoconus. indian j ophthal 2016; 64(9): 639-642. https://www.ncbi.nlm.nih.gov/pubmed/?term=de%20sanctis%20u%5bauthor%5d&cauthor=true&cauthor_uid=26949609 microsoft word zks. m alam.review.doc 73 original article comparison of visual acuity and astigmatic changes in phacoemulsification with posterior chamber foldable vs non foldable intraocular lens implant mohammad alam, zafar iqbal pak j ophthalmol 2007, vol. 23 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mohammad alam department of ophthalmology khyber teaching hospital, peshawar. received for publication june’ 2006 …..……………………….. purpose: to compare visual acuity and astigmatic changes in phacoemulsification with posterior chamber foldable versus non-foldable iol implants. materials and methods: this comparative study was conducted in the ophthalmology department of khyber teaching hospital, peshawar from january 2001 to june 2002. we selected 50 patients with age related cataract and divided them into two groups a & b, each comprising of 25 patients. all of these patients underwent cataract removal by phacoemulsification. in group-a, foldable posterior chamber iol while in group-b, non foldable posterior chamber iol were implanted in the bag. visual acuity and astigmatic changes were recorded on first post operative day, end of first week and at the end of first month. results: at the end of first month, in group-a, 84% of patients had best corrected visual acuity of 6/6 and 16% of patients had 6/9. in group-b, 80% of patients had best corrected visual acuity of 6/6, 16% had 6/9 while 4% had 6/12. at the end of first month, in group-a, 92% of patients had astigmatism between 0 – 0.9d and 8% had 1 – 1.9d. in group-b, 76% of patients had astigmatism between 0 – 0.9d, 16% had 1 – 1.9d while 8% had 2 –2.9d. conclusions: in both groups, visual acuity is comparable, however astigmatic changes are more in the non-foldable iol’s as compared to the foldable iol’s group. ataract is a major cause of blindness in old age group1. every year millions of people need surgery for this disease. surgical management of cataract has a long history spanning over 20 centuries passing through various methods and procedures. charles kelman (1967) dramatically revolutionized cataract surgery by describing ultrasonic fragmentation of cataract called phacoemulsification (kpe)2. he first showed his work in the american academy of ophthalmology (aao) c 74 meeting in 1969 whereas the first human eye was operated upon in 1971. phacoemulsification results in much reduced post-operative astigmatism even with non foldable iol3,4, as compared to standard extra capsular cataract extraction (ecce) with posterior chamber iol implants. there is good visual acuity, less inflammation and early convalescence. initially it has difficult learning curve5 with complications like endothelial damage, posterior capsule rupture, vitreous loss and the dropping of nucleus into the vitreous. as the microsurgical technique has improved and better viscoelastics are available the rate of complications has decreased. depending upon the size of iol, incision size is variable. for foldable iol, a standard 3.2mm incision is given while in case of nonfoldable iol, the size needs to be increased to 5.5mm. in foldable iol cases there is no need to suture the wound but in case of non foldable iols, sometimes a single suture is applied to seal the wound. phacoemulsification can be done either by sceral or corneal wound. materials and method we selected 50 patients of age related cataract and divided them into two groups a and b for foldable and non-foldable iol respectively. out of these 50 patients 31 were male and 19 female with the age range of 45 year to 75 years. exclusion criteria patients with 1. diabetes mellitus 2. hypertension 3. glaucoma. 4. previously operated eyes. the preoperative visual acuity and astigmatism were comparable between the two groups (table 1,2). to avoid bias all the surgeries were done by a single skilled surgeon and all the observations were recorded by a single observer. preoperatively pupils were dilated with mydriacyl 1% and phenylephrine 10% eye drops. all of these patients were operated under local peribulbar anesthesia with a corneal tunnel incision. in group a, a 3.2mm incision was given and in all patients continuous curvilinear capsulorhexis (ccc) was made. a site port was made with a 15º knife. after hydrodissection the nucleus was fragmented with phacoemulsification and fragments aspirated out. the remaining cortical matter was washed out with automated i/a cannula. in all the cases, an iol was implanted in the bag. in 11 patients stromal hydration was done to seal the wound. in-group b, the same procedure was adopted, however the incision size was enlarged to 5.5mm after which a non-foldable iol was implanted in the bag. in 9 patients a single suture was used to seal the wound. these sutures were removed after a week. in remaining patients only stromal hydration was done to seal the wound. all the patients were given gentamicin and dexamethasone injection sub-conjunctivally, they were put on steroid and antibiotics eye drops and advised oral pain killers for one week. post-operative assessment was done on first post-operative day, end of first week and then end of first month. table 1: preoperative va group a group b cf 16 (64%) 15 (60%) 6/60 4 (16%) 5 (20%) 6/36 5 (20%) 3 (12%) 6/24 2 (8%) table 2: preoperative astigmatism astigmatism diopters (d) group a group b 0-0.9 d 17 (68%) 16 (64%) 1-1.9 d 5 (20%) 5 (20%) 2-2.9 d 3 (12%) 3 (12%) 3-3.9 d 4-4.9 d 5 and above d 1 (4%) results on 1st postoperative day; in group a, 72% of patients had visual acuity of 6/18 or better. whereas in group b, only 52% of patients had visual acuity (va) of 6/18 or better (table 3). at 1st week; in group a, 88% of patients had va 6/18 or better. whereas in group b, 96% of patients had va 6/18 or better. at the end of 1st month; in group a, 96% of patients had va 6/18 or better. whereas in group b, 100% of 75 patients had va 6/18 or better. after one month; in group a, 84% patients had best corrected va (bcva) of 6/6 while 16% had va 6/9. in group b, 80% of patients had va 6/6, 16% 6/9 while 4% had va 6/12. the following were astigmatic changes in dioptre (d) (table 4). on the 1st postoperative day, in group a, 48% of patients had astigmatism of 0-0.9 d, 36% had 11.9d, 12% 2-2.9d and only 4% had 3-3.9 d. in-group b, 60% patients had 0-0.9 d, 6% 1-1.9 d and 24% 2-2.9d. at the end of 1st week; in group a, 84% patients had astigmatism of 0-0.9 dc and 16% 1-1.9 dc. in group b, 76% patients had 0-0.9 dc, 16% 1-1.9 dc, 4% 2-2.9 dc and 4% 3-3.9 dc. at the end of 1st month; in group a, 92% had astigmatism of 0-0.9 dc while 8% had 1-1.9 dc. in group b, 76% had 0-0.9 dc, 16% 1-1.9 dc while 8% 22.9 dc. discussion phacoemulsification is an established procedure for cataract extraction resulting in early visual outcome. there is less astigmatism and early convalescence provided the surgeon is skilled. initially rigid nonfoldable iols were implanted but with the introduction of foldable iols this procedure has become more fruitful. in our study the results of both foldable and non-foldable iols regarding va at the end of 1st month are comparable and there is not much difference between the two. in the study by iftikhar and kiani4, it has been concluded that sutureless phacoemulsification with implantation of 6mm pmma intraocular lenses is a safe procedure with acceptable levels of post-operative astigmatism. however, it is still higher as compared to foldable iol. moreover, no comment has been made regarding visual outcome. in the study by khan et al6, the uncorrected va is less but they had better result regarding astigmatism. foldable iol have better results in some other studies. in the study of agarwal et al7, the best corrected va at the end of 1st month was found to be 6/6 in 76% and 6/9 in 24% of the patients of phaco with foldable iol7. the results of our study as compared to their study are better. in this study astigmatism at the end of one month was comparable to our group a patients but better than table 3: postoperative visual acuity group a group b va 1st post operative day 1st week 1st month best corrected 1st post operative day 1st week 1st month best corrected cf 2 (8%) 1 (4%) 6/60 1 (4%) 6/36 4 (16%) 1 (4%) 1 (4%) 6/24 1 (4%) 2 (8%) 1 (4%) 9 (36%) 1 (4%) 6/18 8 (32%) 1 (4%) 1 (4%) 4 (16%) 7 (28%) 3 (12%) 6/12 4 (16%) 5 (20%) 2 (8%) 3 (12%) 5 (20%) 4 (16%) 1 (4%) 6/9 2 (8%) 10 (40%) 6 (24%) 4 (16%) 1 (4%) 6 (24%) 6 (24%) 4 (16%) 6/6 4 (16%) 6 (24%) 15(60%) 21 (84%) 5 (20%) 6 (24%) 12(48%) 20 (80%) table 4: postoperative astigmatism in dioptre cylinder (dc) group a group b astigmatism 1st post operative day 1st week 1st month 1st post operative day 1st week 1st month 76 0-0.9dc 12 (48%) 21 (84%) 23 (92%) 15 (60%) 19 (76%) 19 (76%) 1-1.9dc 9 (36%) 4 (16%) 2 (8%) 4 (16%) 4 (16%) 4 (16%) 2-2.9dc 3 (12%) 6 (24%) 1 (4%) 2 (8%) 3-3.9dc 1 (4%) 1 (4%) group b. li s, liu y study8 has better visual acuity in phaco with iol at the end of one week. it shows visual acuity of 6/9 or better in 72.72% of patients. generally foldable iol have good visual acuity at international level. the study of xie et al9 shows visual acuity of 6/6 in 65.3% patients at the end of 1st week which is better than our study. phacoemulification has an effect on the visual acuity and astigmatism in foldable and non-foldable iol7. the study of khan et al6 shows visual acuity of both foldable and nonfoldable iol of 6/6 – 6/12 in 58% patients, 6/18 in 18% and lesser than 6/18 in 24% patients. these results are not comparable to our study. however the astigmatism changes are less in both group a and group b patients. conclusion our study shows that final visual acuity in both foldable and non-foldable iol groups are comparable to each other. patients have early visual recovery with early convalescence. however the astigmatism changes are more in non-foldable group than the foldable group. therefore proper planning and careful technique can give very satisfactory results with both foldable and non-foldable iol in phaco cataract extraction. in a developing country like pakistan a large number of people can not afford cost of the foldable intraocular lenses implants. hence, phacoemulsification with non-foldable iol implants which costs the same as ecce with pc iol implant, is a recommended surgical option for these patients. author’s affiliation dr. mohammad alam department of ophthalmology khyber teaching hospital peshawar dr. zafar iqbal associate professor department of ophthalmology khyber teaching hospital peshawar reference 1. khan md, qureshi mb, khan ma. facts about the status of blindness in pakistan. pak j ophthalmol. 1999; 1: 15-9. 2. kelman cd: phacoemulsification and aspiration: a new technique of cataract removal. am j ophthalmol. 1967; 64: 23. 3. levy jh, pisaca no am, chadwick k. astigmatic changes after cataract surgery with 5.1 mm vs 3.5 mm sutureless incisions. j cataract refract surg. 1994; 20: 630-3. 4. iftikhar s, kiani sa. sutureless phacoemulsification with implantation of 6mm pmma iols. pak j ophthalmol. 2004; 20: 74-6. 5. biro z. complications during the learning curve of phacomulsification. ann ophthalmol. 1998; 30: 370-4. 6. iftikhar s, kiani sa. sutureless phacoemulsification with implantation of 6mm pmma iols. pak j ophthalmol. 2004; 20: 74-6. 7. khan aa, ahmad s, sarwar s, chohan am. phacoemulsification: a comparative analysis of the firsthundred and subsequent 150 cases. pak j ophthalmol. 1998; 14: 83-5. 8. agarwal a, agarwal a, agarwal a, et al. no injection, no stitch, no pad cataract surgery technique. pak j ophthalmol. 1998; 14: 22-7. 9. li s, liu y. cataract extraction by phaco using in situe fracture technique. chung hua yen ko tsa chih. 1996; 32: 92-4. 10. xiel, caoj, yaoz. a clinical investigation of foldable iol implantation. chung hua yen ko tsa chih. 1997; 33: 325-7. glaucoma diagnosis and management should not be based on a single intraocular pressure (iop) measurement. multiple iop readings at various times of the day are more contributory and iop should be correlated with corneal thickness especially in myopes. 77 prof. m lateef chaudhry microsoft word index 2008 215 indexes (volume 24, 2008) no.1. january…………………………………………………..page 1-52 no.2. april……………………………………………………..page 53-109 no.3. july………………………………………………………page 110-162 no.4 october………………………………………………….page 215-220 subject index abstract: 24: 47-50, 24: 106-8, 24: 157-61, adnexa • ocular myiasis 24: 151-2 • charge syndrome 24: 208 cataract surgery • cataract surgery: is it time to convert to topical anaesthesia? 24: 62-7 • comparative study of endothelial cell loss after phacoemulsification by using 2% hydroxypropyl methylcellulose (hpmc) versus 2.3% sodium hyaluronate (healon 5) 24: 175-8 • frequency of diabetes mellitus, impaired oral glucose tolerance test, hepatitis b surface antibody (hcv ab) in saudi population undergoing cataract surgery 24: 12-5 • modified limbal incision: an easy and safe window for extraocular muscle surgery 24: 2-6 • phacoemulsification under topical with intarcameral vs 1 retrobulbar and sub-tenon anesthesia 24: 143-6 • prevalence of anti hepatitis c virus (hcv) antibodies in cataract surgery patients 24: 16-8 • visual outcome of clear lens extraction (phacorefractive) in myopia above -12.0 dioptres 24: 59-61 contact lens • bacterial contamination among soft contact lens wearer 24:93-6 cornea • epitheliotrophic effect of autologous serum in persistent corneal epithelial defects 24: 25-19-25 • goldmann applanation tonometer (gat) in normal individuals 24: 196-200 • influence of central corneal thickness (cct) on intraocular pressure (iop) measured with recurrence of pterygium with conjunctival autograft versus mitomycin c 24: 29-33 conjunctiva • cases of subconjunctival hemorrhage after a joy ride 24: 44-5 • conjunctival malignant melanoma mimicking as a chalazion 24: 103-4 diabetes • serum glycoproteins in diabetic and nondiabetic patients with and without cataract 24: 122-6 editorial • current status of orbital implants in pakistan 24:1 • management of dry eye syndrome 24: 110-1 • management of retinal detachment according to risk factors 24: 53-4 genetics • familial ectrodactyly and its ocular associations 24:26-8 glaucoma • comparison of intraocular pressure lowering effect of 0.5% levobunolol and 0.5% timolol maleate after nd:yag laser capsulotomy 24: 1935 • glaucoma burden in a public sector hospital 24: 112-7 • latanoprost 0.005% v/s timolol maleate 0.5% pressure lowering effect in primary open angle glaucoma 24: 68-72 • management tips for glaucoma 24: 37-40 • secondary glaucoma causes and management 24: 86-92 • the effect of trabeculectomy on corneal curvature 24: 118-21 • trabeculectomy: a long term follow-up of 455 cases 24: 132-5 intraocular lens • scleral fixation of intraocular lens 24: 184-92 laser 216 • is the nd: yag laser a safe procedure for posterior capsulotomy? 24: 73-78 eye disease • pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital 24: 166-70 malignancy • peri-ocular and facial multiple hereditary infundibulocystic basal cell carcinoma (mhibcc) 24: 41-3 orbit • clinical presentations of benign intraconal tumors 24: 179-83 • out come of sahaf enucleation implants in 60 patients 24: 34-6 ptosis • role of orbital septum and sub orbicularis fibroadipose tissue in congenital ptosis surgery 24: 140-2 quiz • quiz: 24: 46 • quiz 24: 105 • quiz 24: 156 • quiz 24: refractive • outcome of laser in situ keratomeliusis (lasik) in low to high myopia review of 200 cases 24: 12731 refractive error • myopia and near work activity in maderassa children in karachi 24: 136-9 retina • benign retinal flecks with neuroretinitis 24: 100-2 • clinical risk factors for proliferative vitreoretinopathy-ii 24: 55-8 • management corner: diabetic macular edema 24: 147-50 • management corner: ranibizumab: the clinician’s guide to commencing, continuing, and discontinuing treatment 24: 97-9 • optic neuritis 24: 204-7 • role of fundus fluorescein angiography in preproliferative diabetic retinopathy 24: 7-11 • strategy for the management of rhegmatogenous retinal artery macroaneurysm with hard exudate 24: 153-5 • retinal detachment with proliferative vitreoreinopathy 24: 79-85 • serous chorioretinopathy (cscr) on fundus fluorescein angiography 24: 171-4 author index abbasi sa: pattern of central serous chorioreinopathy (cscr) on fundus fluorescein angiography 24: 171-4 advani rk:: phacoemulsification under topical with intar-cameral vs retrobulbar and sub-tenon anesthesia 24: 143-6 ahmed j:: trabeculectomy: a long term follow-up of 455 cases 24: 132-5 ahmad k:: cases of subconjunctival hemorrhage after a joy ride 24: 44-5 ahmad k:: conjunctival malignant melanoma mimicking as a chalazion 24: 103-4 ahmed n:: serum glycoproteins in diabetic and nondiabetic patients with and without cataract 24: 122-6 ahmed s:: cataract surgery: is it time to convert to topical anaesthesia? 24: 62-7 akhtar a:: the effect of trabeculectomy on corneal curvature 24: 118-21 akram a:: management tips for glaucoma 24: 37-40 ali k:: benign retinal flecks with neuroretinitis 24: 100-2 ali qk:: peri-ocular and facial multiple hereditary infundibulocystic basal cell carcinoma (mhibcc) 24: 41-3 arbab tm:: myopia and near work activity in maderassa children in karachi 24: 136-9 ashraf km: comparative study of endothelial cell loss after phacoemulsification by using 2% hydroxypropyl methylcellulose (hpmc) versus 2.3% sodium hyaluronate (healon 5) 24: 175-8 attaullah i:: ocular myiasis 24: 151-2 attaullah i:: role of orbital septum and sub orbicularis fibroadipose tissue in congenital ptosis surgery 24: 140-2 babar m: comparative study of endothelial cell loss after phacoemulsification by using 2% hydroxypropyl methylcellulose (hpmc) versus 2.3% sodium hyaluronate (healon 5) 24: 175-8 bano h:: bacterial contamination among soft contact lens wearer 24: 93-6 baig msa:: trabeculectomy: a long term follow-up of 455 cases 24: 132-5 baig ra: comparative study of endothelial cell loss after phacoemulsification by using 2% 217 hydroxypropyl methylcellulose (hpmc) versus 2.3% sodium hyaluronate (healon 5) 24: 175 butt nh: modified limbal incision: an easy and safe window for extraocular muscle surgery 24: 2-6 channa r:: cases of subconjunctival hemorrhage after a joy ride 24: 44-5 channa r:: conjunctival malignant melanoma mimicking as a chalazion 24: 103-4 chaudhry ql:: ranibizumab: the clinician’s guide to commencing, continuing, and discontinuing treatment 24: 97-9 chaudhry t: charge syndrome 24: 208-11 chaudhry ta:: cases of subconjunctival hemorrhage after a joy ride 24: 44-5 chaudhry ta:: conjunctival malignant melanoma mimicking as a chalazion 24: 103-4 cheema a:: role of fundus fluorescein angiography in preproliferative diabetic retinopathy 24: 7-11 dabir sa:: is the nd: yag laser a safe procedure for posterior capsulotomy? 24: 73-8 dabir sa:: recurrence of pterygium with conjunctival autograft versus mitomycin c 24: 29-33 dar aj:: management tips for glaucoma 24: 37-40 fasih u:: secondary glaucoma causes and management 24: 86-92 fm:: phacoemulsification under topical with intarcameral vs retrobulbar and sub-tenon anesthesia 24: 143-6 fehmi ms:: secondary glaucoma causes and management 24: 86-92 gandapur msk:: clinical risk factors for proliferative vitreoretinopathy-ii 24: 55-8 ghani n:: epitheliotrophic effect of autologous serum in persistent corneal epithelial defects 24: 19-25 gul s:: is the nd: yag laser a safe procedure for posterior capsulotomy? 24: 73-8 gul s:: recurrence of pterygium with conjunctival autograft versus mitomycin c 24: 29-33 gul t: modified limbal incision: an easy and safe window for extraocular muscle surgery 24: 2-6 haider si:: retinal artery macroaneurysm with hard exudate 24: 153-5 hamid s:: benign retinal flecks with neuroretinitis 24: 100-2 hashmani s: retinal artery macroaneurysm with hard exudate 24: 153-5 iqbal ms:: outcome of laser in situ keratomeliusis (lasik) in low to high myopia review of 200 cases 24: 127 -31 hussain m: charge syndrome 24: 208-11 hye a:: out come of sahaf enucleation implants in 60 patients 24: 34-6 iqbal m:: prevalence of anti hepatitis c virus (hcv) antibodies in cataract surgery patients 24: 16-8 iqbal ms: clinical presentations of benign intraconal tumors 24: 179-83 iqbal ms:: visual outcome of clear lens extraction (phacorefractive) in myopia above -12.0 dioptres 24: 59-61 jafri ar: clinical presentations of benign intraconal tumors 24: 179-83 jafri as:: outcome of laser in situ keratomeliusis (lasik) in low to high myopia review of 200 cases 24: 127 -31 janjua r:: peri-ocular and facial multiple hereditary infundibulocystic basal cell carcinoma (mhibcc) 24: 41-3 jatoi sm:: recurrence of pterygium with conjunctival autograft versus mitomycin c 24: 29-33 jatoi sm:: is the nd: yag laser a safe procedure for posterior capsulotomy? 24: 73-8 javed ea:: familial ectrodactyly and its ocular associations 24: 26-8 khalil m: modified limbal incision: an easy and safe window for extraocular muscle surgery 24: 2-6 khalid mk:: clinical risk factors for proliferative vitreoretinopathy-ii 24: 55-8 khalil m:: strategy for the management of rhegmatogenous retinal detachment with proliferative vitreoretinopathy 24: 79-85 khan aa:: frequency of diabetes mellitus, impaired oral glucose tolerance test, hepatitis b surface antibody (hcv ab) in saudi population undergoing cataract surgery 24: 12-5 khan ab:: epitheliotrophic effect of autologous serum in persistent corneal epithelial defects 24: 19-25 khan kd:: benign retinal flecks with neuroretinitis 24: 100-2 khan m:: visual outcome of clear lens extraction (phacorefractive) in myopia above -12.0 dioptres 24: 59-61 khan md:: clinical risk factors for proliferative vitreoretinopathy-ii 24: 55-8 khan mm: clinical presentations of benign intraconal tumors 24: 179-83 khan ms:: trabeculectomy: a long term follow-up of 455 cases 24: 132-5 khan sr:: myopia and near work activity in maderassa children in karachi 24: 136-9 khanzada ma:: is the nd: yag laser a safe procedure for posterior capsulotomy? 24: 73-8 218 khanzada ma:: latanoprost 0.005% v/s timolol maleate 0.5% pressure lowering effect in primary open angle glaucoma 24: 68-72 khanzada ma:: recurrence of pterygium with conjunctival autograft versus mitomycin c 24: 29-33 kundi nk: pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital 24: 171-4 lal g:: out come of sahaf enucleation implants in 60 patients 24: 34-6 latif i:: ocular myiasis 24: 151-2 lodhi aa:: latanoprost 0.005% v/s timolol maleate 0.5% pressure lowering effect in primary open angle glaucoma 24: 68-72 mahar ps:: glaucoma burden in a public sector hospital 24: 112-7 mahar ps:: outcome of laser in situ keratomeliusis (lasik) in low to high myopia review of 200 cases 24: 127 -31 mahmood t:: prevalence of anti hepatitis c virus (hcv) antibodies in cataract surgery patients 24: 16-8 mahmood t:: diabetic macular edema 24: 147-50 mahmood t:: abstracts, 24:106-8, 157 mahmood t:: quiz: 24: 46, 105, 156, mahmood t: optic neuritis 24: 204-7 mahmood t: comparison of intraocular pressure lowering effect of 0.5% levobunolol and 0.5% timolol maleate after nd:yag laser capsulotomy 24: mahsud h:: clinical risk factors for proliferative vitreoretinopathy-ii 24: 55-8 malik tg:: strategy for the management of rhegmatogenous retinal detachment with proliferative vitreoretinopathy 24: 79-85 mazhri z: scleral fixation of intraocular lens 24: 18492 mansoor q:: role of orbital septum and sub orbicularis fibroadipose tissue in congenital ptosis surgery 24: 140-2 memon ag:: serum glycoproteins in diabetic and non-diabetic patients with and without cataract 24: 122-6 memon ss:: cases of subconjunctival hemorrhage after a joy ride 24: 44-5 memon ss:: conjunctival malignant melanoma mimicking as a chalazion 24: 103-4 mirza aub:: epitheliotrophic effect of autologous serum in persistent corneal epithelial defects 24: 19-25 mirza ka:: management of retinal detachment according to risk factors 24: 53-4 mirza ma:: myopia and near work activity in maderassa children in karachi 24: 136-9 moin m: charge syndrome 24: 208-10 mukhta ma:: benign retinal flecks with neuroretinitis 24: 100-2 naqvi bs:: bacterial contamination among soft contact lens wearer 24: 93-6 narsani ak:: is the nd: yag laser a safe procedure for posterior capsulotomy? 24: 73-8 narsani ak:: recurrence of pterygium with conjunctival autograft versus mitomycin c 24: 29-33 nisar s: comparison of intraocular pressure lowering effect of 0.5% levobunolol and 0.5% timolol maleate after nd:yag laser capsulotomy 24: 193-5 nnoooorraannii ss:: role of fundus fluorescein angiography in preproliferative diabetic retinopathy 24: 7-11 qadir a:: frequency of diabetes mellitus, impaired oral glucose tolerance test, hepatitis b surface antibody (hcv ab) in saudi population undergoing cataract surgery 24: 12-5 qadri wm: scleral fixation of intraocular lens 24: 184-92 qamar rmr:: ocular myiasis 24: 151-2 qamar rmr:: role of orbital septum and sub orbicularis fibroadipose tissue in congenital ptosis surgery 24: 140-2 qayyum i: charge syndrome 24: 208-10 qazi za: comparative study of endothelial cell loss after phacoemulsification by using 2% hydroxypropyl methylcellulose (hpmc) versus 2.3% sodium hyaluronate (healon 5) 24: 175-8 pechuho ma: pattern of central serous chorioretinopathy (cscr) on fundus fluorescein angiography 24: 171-4 rahim n:: bacterial contamination among soft contact lens wearer 24: 93-6 rehman d: comparison of intraocular pressure lowering effect of 0.5% levobunolol and 0.5% timolol maleate after nd:yag laser capsulotomy 24: 193-5 rahman a:: serum glycoproteins in diabetic and nondiabetic patients with and without cataract 24: 122-6 rai p: clinical presentations of benign intraconal tumors 24: 179-83 saeed n: pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital 24: 174-4 219 sahaf ia: current status of orbital implants in pakistan 24: 1 sethi mj: pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital 24: 171-4 sethi s: pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital 24: 171-4 shafiq i: influence of central corneal thickness (cct) on intraocular pressure (iop) measured with goldmann applanation tonometer (gat) in normal individuals 24: 196-200 shafique mm: modified limbal incision: an easy and safe window for extraocular muscle surgery 24: 2-6 shafique mm:: strategy for the management of rhegmatogenous retinal detachment with proliferative vitreoretinopathy 24: 79-85 shah s:: retinal artery macroaneurysm with hard exudate 24: 153-5 shah sia: pattern of central serous chorioretinopathy (cscr) on fundus fluorescein angiography 24: 171-4 shahid m:: management tips for glaucoma 24: 37-40 shahzad ma:: glaucoma burden in a public sector hospital 24: 112-7 shaikh a:: secondary glaucoma causes and management 24: 86-92 shaikh ff: pattern of central serous chorioretinopathy (cscr) on fundus fluorescein angiography 24: 171-4 shaikh n:: secondary glaucoma causes and management 24: 86-92 siddiqui ap:: peri-ocular and facial multiple hereditary infundibulocystic basal cell carcinoma (mhibcc) 24: 41-3 siddiqui sj: pattern of central serous chorioretinopathy (cscr) on fundus fluorescein angiography 24: 171-4 siddiqui zk:: management of dry eye syndrome 24: 110-1 siddiqi zk:: out come of sahaf enucleation implants in 60 patients 24: 34-6 shoaib kk:: benign retinal flecks with neuroretinitis 24: 100-2 shoaib kk:: frequency of diabetes mellitus, impaired oral glucose tolerance test, hepatitis b surface antibody (hcv ab) in saudi population undergoing cataract surgery 24: 12-5 somro mz:: ocular myiasis 24: 151-2 somro mz:: role of orbital septum and sub orbicularis fibroadipose tissue in congenital ptosis surgery 24: 140-2 sultan m:: familial ectrodactyly and its ocular associations 24: 26-8 tahir my: comparative study of endothelial cell loss after phacoemulsification by using 2% hydroxypropyl methylcellulose (hpmc) versus 2.3% sodium hyaluronate (healon 5) 24: 175-8 talpur ki:: latanoprost 0.005% v/s timolol maleate 0.5% pressure lowering effect in primary open angle glaucoma 24: 68-72 ullah n:: strategy for the management of rhegmatogenous retinal detachment with proliferative vitreoretinopathy 24: 79-85 abstracts index cataract surgery • central corneal thickness changes after phacoemulsification cataract surgery 24: 158 • efficacy and safety of capsular bending ring implantation to prevent posterior capsule opacification 24: 212 • incidence of cataract surgery from 1980 through 2004: 25-year population-based study 24: 106 • pulsed electron avalanche knife: new technology for cataract surgery 24: 158 cornea • central corneal thickness measurements using orbscan ii, visante, ultrasound, and pentacam pachymetry after laser in situ keratomileusis for myopia 24: 47 • intracorneal rings for keratoconus and keratectasia 24: 108 • outcomes of radiofrequency in advanced keratoconus 24: 107 • reproducibility and repeatability of central corneal thickness measurement in keratoconus using the rotating scheimpflug camera and ultrasound pachymetry 24: 159 glaucoma • intraocular pressure on the first postoperative day as a prognostic indicator in phacoemulsification combined with deep sclerectomy 24: 213 • phacotrabeculectomy: assessment of outcomes and surgical improvements 24: 48 • wearing swimming goggles can elevate intraocular pressure 24: 212 intraocular lens 220 • intraocular lens centration and visual outcomes after bag-in-the-lens implantation 24: 50 • prospective visual evaluation of apodized diffractive intraocular lenses 24: 48 • visual acuity and contrast sensitivity: acrysof restor apodized diffractive versus acrysof sa60at monofocal intraocular lenses 24: 49 • visual performance and biocompatibility of 2 multifocal diffractive lols: six-month comparative study 24: 157 vision vision-related quality of life in patients with pituitary adenoma 24: 214 orbit diverse clinical presentations of orbital sarcoid 24: 160 refractive • learning curve of laser-assisted subepithelial 24: 157 • keratectomy: influence on visual and refractive results 24: 157 • low-dose mitomycin c as a prophylaxis for corneal haze in myopic surface ablation 24: 106 microsoft word ayyaz hussain awan case report.doc 100 case report traumatic optic neuropathy ayyaz hussain awan pak j ophthalmol 2007, vol. 23 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ayyaz hussain awan consultant ophthalmologist pns shifa karachi received for publication february’ 2006 …..……………………….. purpose: to present a case of unilateral indirect traumatic optic neuropathy (ton) and stress the importance of early megadose steroid treatment. material and methods: a 15 years old boy presented with loss of vision left eye following a road traffic accident 4 weeks back. on examination of the left eye his visual acuity was no perception of light and relative afferent papillary defect (rapd) was positive. anterior and posterior segment examination was normal. there were no retinal hemorrhages. the patient was diagnosed as a case of left indirect ton. all investigations were within normal limits except vep, which showed an abnormal response in the left eye. results: on examination at 6 weeks post-trauma there was 15-200 exotropia left eye with poor recovery. visual acuity in the left eye remained npl and rapd was positivite. on fundoscopy the optic disk was yellow white in color with normal appearing retinal vessels. conclusion: ton is a neuro-ophthalmic emergency and early intervention is crucial. intravenous megadose methylprednisolone (mp) within 8 hours of ton can save useful vision in some cases. raumatic optic neuropathy (ton) is an uncommon but a devastating cause of permanent visual loss following contusive injuries to the head, particularly to the forehead. the impact transmits a shockwave to the optic canal, damaging the optic nerve. typically the optic nerve head and fundus are initially normal, the only objective finding being a relative afferent pupillary defect (rapd)1. case report a 15 years old boy presented with loss of vision in the left eye following a road traffic accident which occurred four weeks back. there was history of loss of consciousness for 1-1½ hours and bleeding from the wound on the left forehead. on examination there was a scar mark on the left forehead. on ocular examination visual acuity in the left eye was no perception of light (npl) and relative afferent pupillary defect (rapd) was positive. ocular movements were full with no visible tropia. on slit lamp examination anterior segment was normal. fundus examination showed a healthy disc with a cup disc ratio (cd ratio) of 0.3 and a normal macula. intraocular pressure (iop) was 16mm of hg in the left eye. visual acuity in the right eye was 6/6 with a normal anterior and posterior segment examination. a provisional diagnosis of ton (le) was made. on investigation, blood complete, urine routine, blood sugar (r) and x-ray skull were within normal limits. ocufen (flubriprofen) eye drops were started 6 hourly in the left eye and prednisolone 60 mg was given in 4 divided doses orally for one week. patient was asked to report back after having a computed tomography (ct) and magnetic resonance imaging (mri) scan of the brain and orbit and visually evoked potential (vep). he reported back after 2 weeks (6 weeks posttrauma). on examination visual acuity was npl in the left eye with a 150 200 exotropia showing a poor recovery. optic disc was pale yellow. ct and mri t 101 scan of brain and orbit were within normal limits. vep examination on checkerboard pattern reversal stimulation and flash technique showed an abnormal result. there was prolonged p-100 latency on left side is suggestive of left optic pathway dysfunction. however there was presence of waves on p-100 flash technique showing at least relative integrity of optic pathway but having less specificity and sensitivity. right optic pathway was intact. discussion ton is divided into direct and indirect injuries. direct injuries have a worse prognosis and occur when an object penetrates the orbit and damages the optic nerve2,3. indirect ton is a closed injury produced by force imparted to the skull and transmitted into the optic nerve. injury mechanisms are classified as primary and secondary. primary mechanisms result in permanent axonal injury at the moment of impact. in contrast, secondary4,5 mechanisms cause damage to the optic nerve axons subsequent to the force of impact. intracanalicular optic nerve is the most common site for ton followed by intracranial optic nerve and injuries that involve the chiasma6. injuries anterior to where the central retinal artery enters the nerve disturb the retinal circulation7 shown by presence of a cherry red spot or central retinal edema. partial or complete optic nerve avulsions from the globe produce a partial, or respectively, a complete ring of hemorrhage at the optic nerve head8 followed by massive proliferation of connective tissue around the disc. posttraumatic rupture of the posterior ciliary arteries is seen as disturbance of the retinal pigment epithelium.various visual field defects are an inferior altitudinal defect with macular and upper field sparing, central and paracentral scotomas, nerve fiber bundles defects and generalized constriction and depression9. computed tomography (ct) scanning with axial and coronal views may reveal specific pathology compromising the optic nerve, including optic nerve sheath hematoma, presumed arachnoid cyst, fractures involving the greater or lesser wing of the sphenoid, subperiosteal hematoma, hemorrhage affecting the orbital apex, ethmoid or sphenoid sinus and pneumocephalus.10,11 mri can detect presence and longevity of hemorrhage within the optic nerve sheath, swelling of the optic nerve in the tight optic canal, and thickening of the optic nerve sheath. the vep is commonly used to study or detect various disorders of the afferent visual pathway. the idea of using very high doses of corticosteroids (megadose) to treat ton was incorporated from research and clinical practice in treating spinal cord and brain injuries. the second national acute spinal cord injury study (nascis ii) was a multicenter, randomized, double-blind, placebocontrolled study of patients with acute spinal cord injury designed to test the usefulness of megadose steroids in acute spinal cord injury. patients were randomized to one of three treatment arms within 12 hours of injury: placebo, naloxone, and methylprednisolone (mp). mp was administered as an initial dose of 30 mg/kg followed by a continuous infusion of 5.4 mg/kg/hour. treatment with mp within 8 hours resulted in a statistically significant improvement in motor and sensory function compared to placebo-treated patients12. the rationale for high-dose steroid use is based on the ability of steroids to reduce trauma-induced edema, microvascular spasm, and nerve cell necrosis. in case of ton when there is no contraindication to steroid use, a loading dose of mp 30 mg/kg intravenously, followed by 15 mg/ kg administered 2 hours later, and then 15 mg/kg every 6 hours is recommended. if visual function improves, the steroid doses are continued for an additional 5 days, then tapered rapidly. when no improvement occurs within 48 to 72 hours, steroid administration is discontinued without a tapering dose13. optic canal decompression is advocated when a trial of high-dose steroids does not produce a favorable response14 or there is presumed impingement of the optic nerve by bone fragments15 and in cases of delayed visual loss. the surgery is performed by a variety of approaches, including transethmoidal, transantral, transnasal, supraorbitalcranial and uncommonly via a lateral facial approach16. conclusion megadose corticosteroids in cases with ton presenting within 8 hrs of injury and optic nerve decompression for the relief of optic nerve swelling in cases with impingement of the optic nerve by bone fragments especially in cases with delayed visual loss has been favored. even though questions have been raised regarding the value of these treatments they are the only option and hope available for the patient and doctor both. 102 author’s affiliation ayyaz hussain awan classified eye specialist pns hafeez (naval hospital) sector e-8, islamabad reference 1. kanski, jj. clinical ophthalmology. 5th ed., philadelphia. butterworth-heinemann, 2003; 670. 2. feist rm, kline lb, morris re. recovery of vision after presumed direct optic nerve injury. ophthalmology. 1987; 94: 1567-9. 3. wang bh, robertson bc, girotto ja. traumatic optic neuropathy: a review of 61 patients. plast reconstr surg. 2001; 107: 1655-64. 4. walsh fb, hoyt wf. clinical neuro-ophthalmology, 3rd ed., vol. 3. baltimore: williams & wilkins. 1969: 2380. 5. steinsapir kd, goldberg ra. traumatic optic neuropathy. surv ophthalmol. 1994; 38: 487-518. 6. crompton mr. visual lesions in closed head injury. brain 1970; 93: 785-92. 7. hedges tr, gragoudas es. traumatic anterior ischemic optic neuropathy. ann ophthalmol. 1981; 13: 625-8. 8. park jh, frenkel m, dobbie jg, et al. evulsion of the optic nerve. am j ophthalmol. 1971; 72: 969-71. 9. hughes b. indirect injury of the optic nerves and chiasma. bull johns hopkins hosp. 1962; 98-126. 10. guy j, sherwood m, day al. surgical treatment of progressive visual loss in traumatic optic neuropathy. report of two cases. j neurosurg. 1989; 70: 799-801. 11. manfredi sj, raji mr, sprinkle pm. computerized tomographic scan findings in facial fractures associated with blindness. plast reconstr surg. 1981; 68: 479-90. 12. kenneth d, steinsapir md, robert a. comprehensive ophthalmology update, llc. 2005; 6: 11-21. 13. spoor tc, hartel wc, lensink db, et al. treatment of traumatic optic neuropathy with corticosteroids. am j ophthalmol. 1990; 110: 665. 14. spoor tc. penetrating orbital injuries. adv ophthalmic plast reconstr surg. 1988; 7: 193. 15. ramsay jh. optic nerve injury in fracture of the canal. br j ophthalmol. 1979; 63: 607-10. 16. goldberg ra, steinsapir kd. extracranial optic canal decompression: indications and technique. ophthal plast reconstr surg. 1996; 12: 163-70. surgery is more effective in lowering iop but the immediate and late complications particularly cataract changes have to be considered and of particular importance is the postoperative bleb management. prof. m lateef chaudhry microsoft word shahid wahab 96 original article instrument to manage radial tear in continuous curvilinear capsulorrhexis (ccc) shahid wahab, jamshed ahmed pak j ophthalmol 2010, vol. 26 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: shahid wahab 45-b s.m.c.h.s karachi-74400 received for publication november’ 2009 …..……………………….. purpose: to evaluate the surgical outcome difficulties and complications of managing radial tear in continuous curvilinear capsulorrhexis by using lunar punch. material and methods: a prospective case series of sixteen patients who developed tear in the continuous curvilinear capsulorrhexis during cataract surgery at eye unit-iii of sindh govt. lyari general hospital and dow university of health sciences karachi from july 2008 to june 2009. upon recognition of a radial extension of the anterior capsule. lunar punch was introduced beneath the radial tear by rubbing over the lens cortex and punched to convert it into a lunar edge. after this maneuver capsulorrhexis was completed in a usual manner. after securing the capsulorrhexis the procedure of phacoemulsification was performed in the usual manner. results: there were ten (62.5%) males and six (37.2) females with a mean age of 45.5 years. predisposing factors for extension of capsulorrhexis were shallow anterior chamber in 1(6.3%) cases, inexperienced surgeon in 6(37.6%) cases, inadequate local anesthesia in 1(6.3%) cases, intumescent cataract in 1.(63%) cases, positive vitreous pressure in 3(18.8%) cases, hypermature cataract in 2(12.2%) cases and weak zonules in 2(12.2%) cases. some complications resulted during and after the procedure were postoperative striate keratopathy in 3 (18.8%) cases, vitreous loss in one (6.3%) case and lens dislocation in one (6.3%) case. eleven (68.8%) cases had no complication. we achieved success in fourteen (87.5%) cases. conclusion: managing radial tear in ccc by using lunar punch is a safe and effective procedure, which can be adopted easily and effectively adial tears during continuous curvilinear capsulorrhexis (ccc) are one of the most unwanted events that a surgeon may experience during cataract surgery. many authors to handle this problem have described different techniques. attempted redirection of the tear advocated by mackool1. completing the procedure from opposite side by making a tear of larger size2. all theses maneuver fails when the tear extends up to the zonular attachment and the surgeon is left with no choice to covert it into extra capsular cataract extraction3. another developing technique is to suture the anterior capsule but the results in human subjects are still awaited4. integrity of the posterior capsule is needed for good centration of intraocular lens, prevention of their tilting and more recently for correct fixation of multi focal and accommodating intraocular lenses5,6. there are many predisposing factors which may leads to a radial tear in the capsulorrhexis such as a shallow anterior chamber, weak zonules as seen in pseudoexfoliation syndrome (pex), high positive vitreous pressure, intumescent and hypermature cataracts, pediatric cataracts and a surgeon with minimal experience performing capsulorrhexis7. keeping all these facts in mind we describe a new technique to deal with radial tears even if it extends up to the zonular attachments by using an instrument called lunar punch (fig 1-2). r 97 background/principle circular opening in a trampoline does not extend while the small linear tear extends, in the same way as if the edge of a cloth is loosing thread and we cut the cloth in a zigzag pattern it will no longer be losing threads and become stable. spear shaped edges have a potential to extend while round edges does not. material and methods this study was conducted at the department of ophthalmology unit-iii of dow university of health sciences karachi from july 2008 to june 2009. surgical technique upon recognition of a radial extension of the anterior capsule, needle or forceps was immediately withdrawn, viscoelastic 2% injected to fill the anterior chamber via the incision. incision was enlarged to 3.0 mm.. when injecting viscoelastic into the anterior chamber care was taken not to overfill. lunar punch of 3.0mm with lower lip of the central tip was introduced beneath the radial tear by rubbing over the lens cortex and punched the capsule to convert it into a lunar edge (fig.3). after this maneuver capsulorrhexis was completed in a usual manner. in situations when the tear extended beneath the iris, an iris hook was used to retract the iris, visualizing the extent of the tear and punching method used in the same way. after securing the capsulorrhexis the procedure of phacoemulsification was performed in the usual manner. success was defined as completion of ccc without extension of radial tear or vitreous loss. data was entered and analyzed on spss version 15 for windows. frequency distribution tables were used to present the data. mean and standard deviation were used for continuous variables. categorical variables were presented as proportions and percentages. results from july 2008 to june 2009 sixteen patients developed radial extension of capsulorrhexis who were managed by lunar punch. there were ten (62.5%) males and six (37.2) females. mean age of the patients was 45.5 years. predisposing factors for extension of capsulorrhexis (table i) were shallow anterior chamber in 1(6.3%) cases, inexperienced surgeon in 6(37.6%) cases, inadequate local anesthesia in 1(6.3%) cases, intumescent cataract in 1.(63%) cases, positive vitreous pressure in 3(18.8%) cases, hypermature cataract in 2(12.2%) cases and weak zonules due to pseudoexfoliation in 2(12.2%) cases. difficulties encountered during this maneuver were difficulty to introduce the lunar punch due to shallow anterior chamber and thickness of the punch in two (12.2%) cases and formation of tear between eleven and one o’clock in two (12.2%) cases for which an incision at 6 o’clock was made to overcome the problem. some complications resulted during and after the procedure were (table 2) postoperative striate keratopathy in 3 (18.8%) cases, vitreous loss in one (6.3%) case and lens dislocation in one (6.3%) case. eleven (68.8%) cases had no complication. we achieved success in fourteen (87.5%) cases. table 1: predisposing factors for formation of radial tear in ccc. factors frequency n (%) shallow anterior chamber inexperienced surgeon inadequate local anesthesia intumescent cataract positive vitreous pressure hypermature cataract weak zonules due to pseudoexfoliation total 1 (6.3) 6 (37.6) 1 (6.3) 1 (6.3) 3 (18.8) 2 (12.5) 2 (12.5) 16 (100) table 2: intra-operative and post-operative complications complications frequency n (%) vitreous loss lens dislocation striate keratopathy no complication total 1 (6.3) 1 (6.3) 3 (18.8) 11 (68.8) 16 (100) discussion cataract surgery is a state of art surgery. there is an all or none law effective in this procedure. capsulorrhexis is the main stay in this procedure. majority of capsulorrhexis are done easily but if vitreous pressure is high then it can extend peripherally. beginner’s fear for the extension of 98 fig. 1: the lunar punch fig. 2: magnified tip of the lunar punch. fig. 3: (wahab s and ahmed j) lunar punch in the anterior chamber. fig. 4: principle of extension of tear in round edge fig. 5: biomechanics of capsule and zonules showing zonular pull (thick black arrows), elasticity of capsule (thin arrows), vitreous pressure (hollow white arrow) capsular extension in periphery. this lunar punch is useful to stop the extension. the principle is based on the round edge as shown in (fig. 4). biomechanics of the capsule and zonules play the role in extension of elastic capsule which is encircled with pulling zonules outwards (fig. 5). spear shaped edge of the tear is converted into round edge with the lunar punch. it is a cost effective procedure. since costly alternatives are bipolar diathermy and vitrectomy probe by which we can take help. both are costly and not available always. this lunar punch can work even if the tear has extended in the zonular area. disadvantages are that it is thick and sometimes difficult to introduce in shallow anterior chamber of the hypermetropic eyes. this can be managed by making the punch finer by decreasing the thickness of the tip. one should not deepen the anterior chamber too much because it could be counter productive. capsulorrhexis should be started at six o’clock position so that extension could easily be managed by the punch. extension at six o’clock should be avoided because for that a new wound will be required at six o’clock to introduce the punch. this instrument can be useful in the armamentarium of a cataract surgeon. limitations are deep sunken eyes. other alternatives could be radio frequency diathermy, pulsed electron avalanche knife8, fugo plasma blade and vitrectomy cutter. conclusion successful capsulorrhexis can be done without extension of capsular flap running behind the iris and lens equator. spear shaped edge is converted to smooth round edge, which does not extend peripherally. 99 author’s affiliation dr. shahid wahab professor of ophthalmology dow university of health sciences sindh govt. lyari general hospital karachi dr. jamshed ahmed assistant professor of ophthalmology dow university of health sciences sindh govt. lyari general hospital karachi reference 1. mackool rj. personal phacoemulsification techniques. in: buratto l, werner l, zanini m, apple dj, editors . phacoemulsification: principles and techniques. second edition. thorofare, usa: slack incorporated. 2002. 363-73. 2. bragamele r. my capsulorrhexis flap tore radially how should i preoceed? in chang df, kim t, oetting t a, editors. curbside consultation in cataract surgery: 49 clinical questions: thorofare, usa: slack incorporated. 2007; 86-8. 3. fishkind wj. complications in phacoemulsification: avoidance, recognition, and management. 1st ed. thieme: 2002;. 42. 4. kleinmann g, chew j, apple dj, et al. suturing a tear of the anterior capsulorrhexis.br j ophthalmol 2006;90:423-426 5. menapace r, kriechbaum fo, koeppl kc. accommodating intraocular lenses: a critical review of present and future concepts. graefe's archive for clinical and experimental ophthalmology. 2007; 245: 473-89. 6. sarikkola a, uusitalo r, laatikainen l. quality of vision after amo array multifocal intraocular lens implantation . journal of cataract & refractive surgery. 2004; 30: 2483–93. 7. mohammadpour m. management of radial tears during capsulorrhexis. techniques in ophthalmology. 2006; 4: 56-9. 8. priglinger sg, heritoglou c, palanker d, et al. pulsed electron avalanche knife for capsulotomy in congenital and mature cataract. j cataract & refractive surg. 2006; 32: 1085–8. microsoft word nasir bhatti 152 original article outcome of penetrating keratoplasty from a corneal unit in pakistan muhammad nasir bhatti, yawar zaman, p.s. mahar, azizur rahman, muhammad fazal kamal, mazhar-ul-hassan, partab rai pak j ophthalmol 2009, vol. 25 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: muhammad nasir bhatti d-232, block-4, near sultani darbar f.b area karachi received for publication november’ 2008 … ……………………… purpose: to evaluate the outcome of penetrating keratoplasty (pkp) at a corneal unit in pakistan. material and methods: penetrating keratoplasty (pkp) alone or triple procedure (pkp combined with extracapsular cataract extraction and intraocular lens implantation) was performed in 30 eyes of 30 patients at al-ibrahim eye hospital/isra postgraduate institute of ophthalmology, karachi from january 2003 to december 2007. the outcome was evaluated in terms of graft survival (number of clear grafts at final follow-up) and final best-corrected visual acuity. results: out of 30 patients underwent pkp. 73.3% were male and 26.7% female. mean recipient age was 38.1 years (range 14-82). leading indication of pkp was corneal scar (46.7%). pkp alone was performed in 70% patients and 30% patients had triple procedure. mean follow-up period after surgery was 12.3 months (range1-36). overall graft survival was 61%. excluding failed grafts, final best-corrected visual acuity achieved was: 20/40 or better in 33.3% patients, 20/50 20/150 in 41.7% patients and 20/200 or worse in 25% patients. keratoconus had most favorable outcome with graft survival of 88.9% and final visual acuity of 20/40 or better in 55.6% patients. graft survival and final bestcorrected visual acuity of 20/40 or better in remaining indications were, corneal scar (78.6% & 14.3%), pseudophakic bullous keratopathy (75% & 25%), and other indications (66.7% & 0.0%). conclusion: this series showed that pkp is an effective procedure for corneal disease with poor vision. visual outcome was good especially in cases of keratoconus. enetrating keratoplasty is a corneal transplant procedure in which full thickness host corneal tissue is replaced with donor corneal tissue1. aims of pkp include improvement in visual acuity, pain relief or even simply saving an eye. but visual improvement is the objective of majority of corneal grafts. advances in the field of microsurgery, ocular immunity and eye banking have made pkp one of the most common transplant procedures in the world2-4. corneal opacity is the second leading cause of blindness, identified in a recent survey conducted in pakistan5. the purpose of this study was to evaluate the outcome of pkp at a corneal unit in pakistan. material and methods sall the patients underwent penetrating keratoplasty (pkp) at al-ibrahim eye hospital/isra postgraduate institute of ophthalmology, from january 2003 to december 2007 were included. age, gender, eye, indication of pkp and bestcorrected visual acuity constituting the preoperative data were recorded in a predesigned proforma. the type of procedure was defined as pkp alone and triple procedure (pkp combined with an extracapsular cataract extraction and intraocular lens implantation). p 153 postoperative data included the length of followup time after surgery (patients were followed until they lost to follow-up or died), graft clarity at final follow-up, final bestcorrected visual acuity and complications. graft survival was defined as number of clear grafts at final follow-up and graft failure as number of grafts with irreversible loss of optical clarity. data analysis data analysis was done by spss (10.0 version). related frequencies and percentages were calculated. mean was calculated for age and length of follow-up period after surgery. kaplan-meier curve was plotted to estimate the cumulative probability of graft survival. chi-square test was used to compare the graft survival and final best-corrected visual acuity with other studies. the level of significance was set at 5%. results thirty eyes of thirty patients underwent pkp during 5 years study period. mean recipient age was 38.1 years (range 14-82). there were more males 22 (73.3%) as compared to females 08 (26.7%) (table 1). leading indication of pkp was corneal scar 14 (46.7%) followed by keratoconus 09 (30%) and pseudophakic bullous keratopathy 04 (13.3%) (table 2). preoperative best-corrected visual acuity in all patients was 20/200 or worse. pkp alone was performed in 21 (70%) patients and 09 (30%) patients had triple procedure. mean follow-up period after surgery was 12.3 months (range 1-36). overall graft survival was 61.0% at the final follow-up (mean 12.3 months). see figure-1. eyes with keratoconus had highest graft survival 08 (88.9%), followed by corneal scar 11 (78.6%), pseudophakic bullous keratopathy 03 (75.0%) and other indications 02 (66.7%). table 1: characteristics of patients underwent pkp characteristics no. of patients n (%) right eye 16 (53.3) left eye 14 (46.7) male 22 (73.3) female 08 (26.7) age, years (range) 38.1 (14-82) follow-up, months (range) 12.3 (1-36) table 2: indications of pkp at al-ibrahim eye hospital no. of patients n (%) corneal scar 14 (64.7) keratoconus 9(30) pseudophakic bullous keratopathy 4(13.3) keratoglobus 1 (3.3) macular corneal dystrophy 1 (3.3) congenital hereditary endothelial dystrophy 1 (3.3) total 30 (100) table 3: outcome by indications outcome keratoconus corneal scar pseudophakic bullous keratopathy other indications graft survival (number of clear grafts at final follow-up ) 8 (88.9 %) 11 (78.6 %) 3 (75 %) 2 (66.7%) final best-corrected visual acuity 20/40 or better 20/50 – 20 /150 20/200 or worse 5 (55.6) 3 (33.3) 1 (11.1) 2 (14.3) 4 (28.6) 8 (57.1) 1 (25) 2 (50) 1 (25) 0 (0) 1(33.3) 2 (66.7) 154 final best-corrected visual acuity (after eliminating failed grafts) of 20/40 or better was achieved in 08 (33.3%) patients, 20/50 20/150 in 10 (41.7%) patients and 20/200 or worse in 06 (25%) patients. in keratoconus, 05 (55.6%) patients achieved final best-corrected visual acuity of 20/40 or better, followed by patients with corneal scar 02 (14.3%). in patients with pseudophakic bullous keratopathy, 01 (25%) patient achieved 20/40 or better vision. outcome by indications is given in (table 3). complications encountered in patients were: persistent epithelial defect in 04 (13.3%), bacterial keratitis in 04 (13.3%), endophthalmitis in 02 (6.7%), primary graft failure in 02 (6.7%), reversible graft rejection episodes in 02 (6.7%), retrocorneal membrane in 01 (3.3%) and wound dehiscence in 01 (3.3%) (table 4). table 4: complications of pkp at al-ibrahim eye hospital complication frequency n(%) persistent epithelial defect 4 (13.3) graft infection 4 (13.3) endophthalmitis 2 (6.7) primary graft failure 2(6.7) reversible graft rejection episodes 2 (6.7) retrocorneal membrane 1 (3.3) wound dehiscence 1 (3.3) discussion penetrating keratoplasty (pkp) is an effective treatment for corneal diseases with poor vision. the outcome of pkp depends upon indications, operative techniques and postoperative care. this study presents the results of 30 eyes of 30 patients who received corneal grafts at al-ibrahim eye hospital/isra postgraduate institute of ophthalmology, during 5 years period from january 2003 to december 2007. penetrating keratoplasty alone was performed in 70% patients and 30% patients had triple procedure in our series. this distribution of procedures is similar to the data for sweden6 and kuwait7, where 71% and 66% of patients had pkp alone. comparing graft survival and final visual acuity between studies is difficult due to difference in population size and follow-up time. however; overall graft survival was 61% at the final follow-up (mean 12.3 months), compared with 64% at the last follow-up (mean 21.9 months) reported by randleman jb8 and 76% at one year reported by wiggins re9. final best-corrected visual acuity (after eliminating failed grafts) of 20/40 or better was achieved in 33.3% patients, 20/50 20/150 in 41.7% patients and 20/200 or worse in 25% patients. statistically, there is no significant difference on comparison with visual acuity reported in previous studies9, 10 using similar exclusion criteria. (p-value >0.05) fig. 2. fig. 1: graft survival after pkp at al-ibrahim eye hospital fig. 2: final visual acuity comparison among this study and wiggins8, vail9 155 outcome of pkp in patients with keratoconus was good with 88.9% grafts remaining clear at final followup. final best-corrected visual acuity of 20/40 or better was achieved in 55.6% patients. this is comparable to the study of randleman jb8 who reported 87.5% clear grafts at final visit and final best-corrected visual acuity of 20/40 or better in 56.2% cases but lower than the figures reported by lim l11. although; the corneal scar was the leading indication in our series but the graft survival was less than keratoconus (78.6%) and 14.3% patients had final bestcorrected visual acuity of 20/40 or better. our results are better in comparison with randleman jb8 who reported 66.7% clear grafts at final visit and final best-corrected visual acuity of 20/40 or better in 13.3% patients with corneal scar. pseudophakic bullous keratopathy (pbk) was with the least favorable outcome. graft survival was 75% and 25% patients achieved final best-corrected visual acuity of 20/40 or better. these figures include visual acuity of failed grafts. randleman jb8 reported 76.5% clear grafts at final follow-up and only 17.7% patients achieved final best-corrected visual acuity of 20/40 or better. al marjan7 reported graft survival rate of 24%. penetrating keratoplasties are sometime beset by various complications. in our series, the rate of complications was highest in pseudophakic bullous keratopathy (pbk) group and lowest in keratoconus group. regarding individual complications, persistent epithelial defect and bacterial keratitis were the most frequent complications encountered (13.3%). persistent epithelial defect (epithelial defect for more than eight days) in our series is similar to the study of shimazaki j12 (12.0%). the postoperative defect in epithelial layer may occur because of loss of epithelium during donor cornea storage, intraoperative trauma, or any kind of minute trauma during postoperative period, tear film abnormalities, ocular surface disorders, or the effect of medication (especially with preservatives). in our series, bacterial keratitis occurred more as compared to other studies13. this is probably related to suture related problems (loose/broken suture or exposed knots) because when a loose or broken suture is left unattended, it may lead to mucous accumulation and becomes nidus for the microorganisms. siganos cs14 evaluated the presence of broken or loose suture and concluded that eroded sutures harbor bacteria and should be removed as early as possible. most of the patients in our series belonged to remote rural areas which lack the facilities of trained ophthalmologists. the incidence of endophthalmitis was considerably high (6.7%) in our series as compared to figures for kuwait7 and rest of the world15. these cases were reported after 6 months of the follow-up. high risk patients for pkp included eye rubbers and those who were unable to access eye care reliably16. both of these cases shared above mentioned factors and had unsatisfactory compliance and poor follow-ups. also they belonged to lower socioeconomic group with poor living conditions and inadequate hygiene. primary graft failure is a rare but major complication of pkp. in our series, 02 (6.7%) cases were observed in comparison with 21 (2.7%) cases reported by mead md17. this was probably related to poor quality of donor material. reversible graft (endothelial) rejection episodes were observed in 02 cases (6.7%). these occurred 9-11 months postoperatively and both grafts regained clarity after topical and systemic steroid treatment. similar rates are reported by küchle m18 and al marjan7. other complications encountered were: wound dehiscence and inflammatory retrocorneal membrane which are also reported in literature. this series showed that pkp is an effective procedure for the corneal disease with poor vision. visual outcome was good especially in cases of keratoconus. similar studies in future will help in developing better understanding about the outcome of pkp in developing countries especially in pakistan. author’s affiliation dr. muhammad nasir bhatti isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi dr. yawar zaman isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi prof: p.s. mahar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi dr azizur rahman fcps isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi 156 dr muhammad fazal kamal isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi dr. mazhar-ul-hassan isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi dr. partab rai isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi reference 1. verdier dd. penetrating keratoplasty. in: krachmer jh, mannis mj, holland ej, editors: cornea. vol. iii: surgery of cornea and conjunctiva. st. louis: mosby, 1997: 1581-92. 2. eye bank association of america. 2003 eye banking statistical report. washington, dc: eye bank association of america. 3. human organ and tissue transplantation. report by the secretariat. executive board, eb112/5, 112th session, provisional agenda item 4.3. world health organization. may 2003. available: www.who.int/gb/ebwha. 4. wang mx, karp cl, selkin rp, et al. corneal and conjunctival surgery. in: yanoff m, duker js, augsburger jj. ophthalmology. 2nd ed. st. louis, mo: mosby, 2004: 495. 5. dineen b, bourne rr, jadoon z, et al. pakistan national eye survey study group. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91: 1005-10. 6. claesson m, armitage wj, fagerholm p, et al. visual outcome in corneal grafts: a preliminary analysis of the swedish corneal transplant register. br j ophthalmol. 2002; 86: 174-80. 7. al-marjan ji, pandova mg, reddy ss, et al. outcomes and indications for penetrating keratoplasty in kuwait. saudi j ophthalmol. 2005; 19: 87-92. 8. randleman jb, song cd, palay da. indications for and outcomes of penetrating keratoplasty performed by resident surgeons. am j ophthalmol. 2003; 136: 68-75. 9. wiggins re, cobo m, foulks gn. results of penetrating keratoplasty by residents. arch ophthalmol. 1990; 108: 851-3. 10. vail a, gore sm, bradley ba, et al. corneal graft survival and visual outcome. ophthalmology. 1994; 101: 120-7. 11. lim l, pesudovs k, coster dj. penetrating keratoplasty for keratoconus: visual outcome and success. ophthalmology 2000; 107: 1125-31. 12. shimazaki j, saito h, yang hy, et al. persistent epithelial defect following penetrating keratoplasty: an adverse effect of diclofenac eyedrops. cornea 1995; 14: 623-7. 13. wagoner md, al-swailem sa, sutphin je, et al. bacterial keratits after penetrating keratoplasty: incidence, microbiological profile, graft survival, and visual outcome. ophthalmology. 2007; 114: 1073-9. 14. signos cs, solomon a, pery jf. microbial finding in suture erosion after penetrating keratoplasty. opthtalmology. 1997; 104: 0 516-6. 15. taban m, behrens a, newcomb rl, et al. incidence of acute endophthalmitis following penetrating keratoplasty: a systematic review. arch ophthalmol. 2005; 123: 605-9. 16. frantz j, insler m, hagenah m, et al. penetrating keratoplasty for keratoconus in down’s syndrome. am j ophthalmol. 1990; 109: 143-7. 17. mead md, hyman l, grimson r, et al. primary graft failure: a case control investigation of a purported cluster. cornea. 1994; 13: 310-6. 18. küchle m, cursiefen c, nguyen nx, et al. risk factors for corneal allograft rejection: intermiadiate results of a prospective normal-risk keratoplasty study. graefes arch clin exp ophthalmol. 2002; 240: 580-4. 157 fig. 1. graft survival after pkp at al-ibrahim eye hospital 158 fig. 2. final visual acuity comparison among this study and wiggins8 ,vail9. final visual acuity % 0 10 20 30 40 50 20/40 or better 20/50 to 20/150 20/200 or worsee vail wiggins this study 159 microsoft word sultan ahmed case report.doc 227 case report carotid cavernous sinus fistula with nonpulsatile exophthalmos sultan ahmad, muhammad khalil, tayyaba gul malik, mian muhammad shafique, khalid farooq pak j ophthalmol 2007, vol. 23 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sultan ahmad eye department lahore medical and dental college, lahore. received for publication august’ 2006 …..……………………….. we report a case of post traumatic carotid artery cavernous sinus fistula with a special feature of non pulsatile exophthalmos in the presence of bruit. arotid-cavernous fistula (ccf) is an abnormal connection between the carotid arterial system and the venous vessels in the cavernous sinus. this occurs when the walls of the arteries and veins break down and combine together into one vessel. as a result, blood flows backwards in the vein1-3. d.l. barrow and colleagues classified ccf into four types4. type 1: direct fistula between the internal carotid artery and the cavernous sinus. type ii: indirect fistula between the meningeal branches of the internal carotid artery and cavernous sinus. type iii: indirect fistula between the meningeal branches of the external carotid artery and cavernous sinus. type iv: indirect fistula between the branches of both internal carotid artery and external carotid artery and cavernous sinus. case report a 25 years old asian male presented with protrusion of his right eye 20 days after a road traffic accident. (rta). he remained unconscious for few hours and underwent surgery for his right knee joint which was fixed with wiring. 20 days after rta he started developing gradual onset, slowly progressive protrusion of his right eye unassociated with any ocular or periorbital pain. he gave history of noises in the head but there was no diplopia, fever and vomiting. systemic history was unremarkable. on ocular examination, his bcva was finger counting on right side and 6/6 on left side. intraocular pressures were 17 and 12 mmhg respectively. there was right proptosis of 10 mm which increased on bending and valsalva’s maneuver. there were no visible pulsations of the eyeball. lids were edematous and severe conjunctival chemosis and keratinization was seen (fig. 1, 2). there were no signs of exposure keratopathy. color vision was normal. extra ocular movements of the right eye were restricted in all gazes (fig. 3). right pupil was mid-dilated and non-reactive to light and accommodation. left pupil was round and reacting normally to light and accommodation. c 228 on palpation there was no thrill and tenderness temperature of the skin was normal. corneal sensations were impaired on the right side. there was no palpable periorbital mass. on auscultation there was medium pitched bruit over the eyeball which was synchronous with arterial pulse. it was absent on fig. 1: prolapsed, congested and chemosed conjunctiva of right eye (lateral view). fig. 2: closer view. arrow indicates dilated fixed pupil and post traumatic cataract. fig. 3: restricted extra ocular movements of right eye. fig. 4: doppler ultrasound of right orbit. red arrow shows turbulence in right superior ophthalmic vein. white arrow pointing towards dilated right superior ophthalmic vein. fig. 5: ct axial view orbit: red arrow indicating dilated superior ophthalmic vein on right side. blue arrow shows dilated right cavernous sinus. 229 fig. 6: ct coronal view skull. dilated superior ophthalmic vein (red arrow) and swollen extra ocular muscles (blue arrow). temple and forehead. on slit lamp examination conjunctiva was severely congested with tortuous, dilated blood vessels. corneal endothelial dusting was present. anterior chamber was normal in depth and quiet. few pigments were seen floating with mild flare. pupil was vertically oval and fixed. lens was opaque. no micropulsations of eye ball were seen on applanation. fundus examination of right eye was not possible because of cataract. left eye was normal with normal fundus with no vascular abnormalities. b-scan of right eye was performed which showed anechoic vitreous. retina was normal. orbital fat edema and dilated superior ophthalmic vein of the right eye was quite obvious. doppler ultrasound showed turbulent flow in superior ophthalmic vein (fig. 4). patient was subjected to computerized tomographic scan which revealed protruded eyeball with swollen extra ocular muscles. superior ophthalmic vein was dilated (fig. 5, 6). mandible of the right side was fractured. on the basis of these clinical findings and investigations, the diagnosis of post traumatic direct carotid cavernous sinus fistula was made. carotid angiography was planned but the patient refused further investigations. discussion although the common presentation of direct carotid cavernous sinus fistula is the classic triad of pulsatile proptosis, conjunctival chemosis & flushing noise in the head5. there are situations in which any of these may be absent or they are subtle enough to be detected clinically. e.g. in low flow fistulas chemosis, pulsation or flushing noise/ bruit may be absent. how ever in direct type with high flow fistula it is rather infrequent to find a marked proptosis without pulsation as in our case. possibilities regarding absence of pulsation may be due to: 1. superior ophthalmic vein thrombosis6 2. very large or very small fistula size 3. retrograde flow towards intracranial circulation 4. bilateral involvement the best way to find out the exact etiology is cranial angiography which was unluckily not done. doppler flow of orbital circulation revealed high turbulence and dilatation of superior ophthalmic vein which indicated absence of thrombosis in superior ophthalmic vein. as the bruit in our patient was medium pitched, depicting moderate sized fistula, the possibility of very large and very small fistula was negated. retrograde flow towards intracranial circulation should have some neurological deficit and or signs of raised intracranial pressure which were absent in our case. there was no bilateral involvement as obvious from the ct scan. the exact mechanism for the absence of pulsations remains a mystery. conclusion cranial angiography is the gold standard for carotid cavernous sinus fistulas to establish the size of fistula, status of blood flow in the vessels and presence or absence of thrombosis. even in the absence of angiography, ct scan and doppler studies are helpful in the diagnosis. author’s affiliation brig.(rtd.) sultan ahmad associate professor, eye department lahore medical and dental college, lahore. dr. muhammad khalil assistant professor ophthalmology department lahore medical and dental college, lahore. dr. tayyaba gul malik ophthalmology department lahore medical and dental college, lahore. dr. mian muhammad shafique associate professor ophthalmology department lahore medical and dental college, lahore. dr. khalid farooq assistant professor radiology department lahore medical and dental college lahore 230 references 1. kupersmith mj. neuro-vascular neuro-ophthalmology. berlin, springer-verlag, 1993. 2. fleishman ja, garfinkel ra, beck rw. advances in the treatment of carotid cavernous fistula. int ophthalmol clin. 1986; 26: 301. 3. parkinson d. carotid cavernous fistulas: direct repair with preservation of the carotid artery: technical note. j neurosurg. 1973; 38: 99. 4. barrow dl, spector rh, braun if, et al. classification and treatment of spontaneous carotid-cavernous sinus fistulas. j neurosurg. 1985; 62: 248-56. 5. kanski jj. carotid cavernous fistula: clinical ophthalmology. 2003; 574. 6. miller nr. walsh and hoyt's clinical neuro-ophthalmology, 4th ed. baltimore, williams & wilkins, 1991. microsoft word mazhar somro case report 151 case report ocular myiasis ijaz latif, rao rashid qamar, imran attaullah, mazhar u zaman soomro pak j ophthalmol 2008, vol. 24 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: mazhar u zaman soomro shifa eye clinic khanpur distt; r.y.khan received for publication april’ 2008 … ……………………… maggot in lacus lacrimalis cular myiasis is uncommon in developed countries but this is common in under developed area of world where standard of living and hygiene is poor. myiasis is the infestation of human being by the larvae, which for certain period feed on host’s dead or living tissue, liquid body substances and may cause a different type of clinical entities. in ocular infestation, clinical picture may vary from allergic conjunctivitis with tearing to corneal ulcer with photophobia. maggots in eye are rare in developed and even in under developed areas due to awareness and relatively easy access to ophthalmic facility as compared to past. but this entity is still present and sometime ophthalmologist come across such type of situation. case report a small child of 2 years of age visited the clinic with her parents with complaint of watering and redness of the eye which was not responding to treatment as she was treated by general practioner by considering it conjunctivitis. she had the history of injury on back of head and maggots on it. she was treated by a doctor and it healed. at the time of examination, the scalp wound was healed with a scar. on ophthalmic examination, conjunctiva was congested. lids were a little edematous, cornea was clear. a small object was moving to and fro at lacus lacrimalis area. patient was taken to minor operation theater and thorough o 152 examination of the eye was made and it revealed a small maggot moving in and out in its hole. after instillation of a drop of topical anesthetic (alcain usa), it was removed with the help of forceps. the maggot was examined by local entomologist and this was found to be a larva of musca domestica. on the next day patient was discharged with topical antibiotic as well as systemic antibiotic. on subsequent followup she was perfectly alright. discussion ocular myiaisis is divided into orbital, internal or external, based on site of larval infestation. larva with invading habits cause orbital and internal ophthalmic manifestation leading to destructive ophthalmic manifesttation. external ophthalmic myiasis refers to superficial infestation of ocular tissue including conjunctiva. there are three families which cause ophthalmic infestation i.e; oesttridae, calliphoride and sarcophagidae. internal ophthalmic myiasis is blinding disease as compared to external disease. in infestation with larva, browning habits may lead to sever loss of vision. all these flies are oviparous and eject their eggs on manure and dead tissue leaving them to hatch to larvae (maggots). they have appearance of white worms with segmentation. these eggs hatched when these are deposited to conjunctiva, as in this case eggs may deposited to conjunctiva by hands of baby from scalp wound or directly to eye by musca domestica. in primary ocular myiasis the early form of lesion is in the form of conjunctivitis and corneal ulceration and subsequently penetration to conjunctiva leading to destructive orbital or internal ophthalmic myiasis. though our case escapes this terrible fate but was leading to it if appropriate action was not taken at proper time. exact taxonomic classification of these larvae is important as potential risk of intraocular penetration. removed larvae should be preserved in 70% alcohol and sent to specialist for examination. except mechanical removal of these larvae, there is no other therapy described. topical application of anesthetic is said to paralyze the maggots. scalp wound maggot author’s affiliation dr. ijaz latif professor of ophthalmology b.v. hospital bahawalpur dr. rao rashid qamar assistan professor b.v. hospital bahawalpur dr. imran attaullah ophthalmologist thq hospital haroon abad dr. mazhar u zaman soomro shifa eye clinic khanpur, distt. r.y. khan references 1. sigaukee beebe we, gander rm, cavuoti d, et al. case report: ophthalmic myiasis externa in dallas county,taxas. am j trop med hyg. 2003; 68: 46-7. 2. elliot rh. quoted by ivaramasubramaniam and sadanand. br j ophthalmol. 1968; 52: 64. 3. frency cc, fox hc. med j aust. 1974; 61: 310. 4. kaljevic v, maksomovic v. acta ophthalmol ugost. 1973; 11: 351. 153 5. guzmann. 1910, quoted by duke elder. sys of ophthalmol. 1965; 8: 426. henery kimpton, london. microsoft word mirza jamilud din 39 original article effect of lasik on endothelial cell count in patients treated for myopia mirza jamil ud din baig, khalid mahmood, tariq khan, zaheer uddin aqil qazi pak j ophthalmol 2010, vol. 26 no.1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mirza jamil ud din baig layton rahmatullah benevolent trust 436 a/1 township lahore received for publication june’ 2009 …..……………………….. purpose: to compare pre and postoperative endothelial cell counts in patients undergoing laser in situ keratomeliusis (lasik) for the treatment of myopia. material and methods: this hospital based descriptive study was carried out in the corneo-refractive unit of layton rahmatullah benevolent trust (lrbt) eye hospital, lahore. duration of the study was 6 months from 24-05-2005 to 24-112005. it took 2 months for the data collection and 4 months for the follow up. 100 eyes of 50 patients underwent lasik. postoperative endothelial cell counts were noted after 1 week, 1 month, 3 months and 4 months. statistical analysis of the data was done using computer software spss version 10.0. results: 50 patients (100 eyes) were included in this study. 64% of the patients were female and 36% were male. mean age was 24.54 years ranging from 2035 years. out of 50 patients, 29 patients (58%) had myopia between 2-5 diopters, 8 patients (16%) between 5-7 d and 13 (26%) between 8-10 d. the range of myopia was 2-10 d. mean spherical equivalents before lasik was 3.95 d. mean corneal thickness before lasik was 515 µm. conclusion: corneal endothelial cell count was unchanged 1 week, 1 month, 3 months and 4 months after the lasik. yopia is a form of refractive error in which parallel rays of light come to a focus in front of retina. myopia has been found to be patterned in its occurrences in different races and ethnic groups with a prevalence of 25% for caucasian, 13% for african american and asians have often been found to have myopia as high as 40%1. according to a local survey held from 1992-97, myopia was found three times more common than hyperopia in school children2. myopia can be corrected with spectacles, contact lenses, or refractive surgery. spectacles when used in myopic patients have certain limitations because they cause image minification and "barrel" distortion along with prismatic image displacement. contact lenses have optical benefits like image magnification, elimination of prismatic object displacement with its attendant "barrel" distortion, and the elimination of image degradation. they are cosmetically acceptable but have their own side effects such as being a constant source of infection and corneal warpage. refractive surgery is the latest treatment modality. in 1983, trokel introduced a new technology to correct myopia that was photorefractive keratectomy (prk), which involves the use of 193-nm argon fluoride excimer laser3. prk is a procedure in which corneal epithelium is removed with the help of a knife and stroma is treated with excimer laser to reshape the cornea. with the success achieved with prk for the treatment of myopia, studies of more improved techniques were done. in recent times, the most exciting and prevalent method evolved for correction of refractive errors is the laser in-situ keratomileusis (lasik). the actual lasik procedure involves formation of a flap with the help of a microkeratome. a hinge is left at one end of this flap and the flap is folded back to reveal stroma. pulses from a computercontrolled laser reshape the stroma. the flap is then replaced4. lasik though a more complicated procedure has a good and predictable outcome, instant recovery and m 40 stability of vision5. lasik is safe and effective for myopia between -1.5 to –15.0 d6. a number of corneal surgeries have been known to be associated with a decrease in endothelial cell count postoperatively. an example is radial keratotomy7. several clinical studies have demonstrated the safety, efficacy and stability of lasik8,9. the aim of this prospective study was to ascertain, in our set up, the available information regarding the effect of lasik on endothelial cell count. material and methods this study was conducted on 100 eyes of 50 patients selected from the corneo-refractive unit of lrbt eye hospital, lahore. the study was completed in 6 months time from 24-05-2005 to 24-11-2005. during the first 2 months all selected cases were operated. their outcome was then assessed over the next 4 months. the inclusion criteria were: age between 20-35 years. best corrected visual acuity of 6/9 or better. no more than 0.50 d change in refractive error for at least 1 year before lasik surgery. the exclusion criteria were: patients with keratoconus, corneal ectasias and other diseases causing corneal scarring. patients having cataract, glaucoma, retinal disease or any systemic disease. informed consent was taken and a detailed history was then taken covering all important aspects. complete ocular examination was done including va, refraction, slit lamp examination, keratometry, corneal topography, pachymetry, pupil size and applanation tonometry. slit lamp examination of anterior segment was done to look for pre-existing corneal disease. dilated fundus examination was also done to look for any retinal disease. keratometry and corneal topography were performed on every patient pre-operatively, to reveal sub clinical keratoconus, a contraindication for refractive surgery. for refractive error over 5 d, back vertex distance was measured in order to evaluate the refractive power of the cornea. in all cases specular microscopy was performed before operation and on each visit postoperatively. the konan noncon robo (sp 6000) specular microscope was used. it is a non-contact, specular microscope which counts the endothelial cells/mm2 in the centre of the cornea. the endothelial cell density was measured by variable frame method and sampling error was reduced by analyzing as many cells as possible (100150 cells/frame). bilateral lasik was then performed on all patients using excimer laser summit technology ireland b.v. model (infinity ls kynar). the patient was positioned on the excimer laser table. laser calibration and programming was done. the operative eye was draped and other was patched. a lid speculum was applied and a topical anaesthetic (0.5% proparacaine) instilled. a corneal marker was used to mark the peripheral cornea. the hanastome 8.5 mm suction ring (bausch & lomb surgical, irvine, ca, u.s.a) was positioned on the eye and suction applied. intraocular pressure of greater than 65 mm hg was confirmed to obtain a resection that is uniform and regular and has an appropriate diameter. the hansatome microkeratome blade with a 160 um depth plate was then advanced to create a nasally hinged flap. suction was then released (after a total duration of less than 30 second for all eyes), and the microkeratome blade and suction ring were removed from the surgical field. smooth tipped forceps were used to fold back the flap onto nasal conjunctiva. the patient was then properly aligned under the laser down tube and asked to fixate at green fixation light. the eye was moved into position such that the incoming beam was centred on the patient's entrance pupil. excimer laser was then used to ablate the corneal stroma. all ablations were performed with a laser pulse rate of 6 to 10 hz and energy of 160 mj/cm2 using aspheric multizone treatments. the interface was then irrigated with 2-3 ml balanced saline solution in a 5 ml syringe. the corneal flap was then replaced and allowed to settle for 30 seconds. moist merocel sponges were then used to gently reposition the flap to its original position using the corneal markings. 0.3 % topical ofloxacin, 0.1% diclofenac sodium, and 0.1% fluoromethalone were instilled in the eye and the eyelid speculum was removed. the patients were then examined on 1st post-op day, then at 1 week, 1 month, 3 months and 4 months. non contact specular microscopy was then performed to check the endothelial cell count which was compared with that of the preoperative value. data was analyzed with the help of computer software spss version 10.0.descriptive statistics were calculated. the means and standard deviations were calculated for age and endothelial cell count (ecc). 41 the mean ± sd of ecc at each visits i.e. preoperatively and postoperative was calculated. the preoperative ecc was compared with postoperative ecc on the follow up visits by using paired “t” test. p< 0.05 was taken as significant. results a sample of fifty patients (100 eyes) was taken from the corneo-refractive unit of lrbt eye hospital, lahore. a single surgeon carried out all surgeries. all patients were followed up for the period of 4 months. follow up was excellent and only 3 patients did not turn up for the last follow up visit. mean age of the patients was 24.54 years. thirty nine patients (78%) were from 20 to 25 years of age and eleven patients (22%) were from 26 to 35 years (table 1). the majority of the patients were female (fig. 2). the range of myopia was between 2-10 d (table 2). 58% of the patients had myopia between 2-5 d, 16% between 6-7 d and 26% between 8-10 d. mean spherical equivalent before lasik was –3.95 d. mean corneal thickness before lasik was 515 µm. mean endothelial cell count before and after lasik is shown in table 3. figure 3 is the graphical representation of the same data. pre lasik mean endothelial cell count was 2464.76 ± 109.64. at four months post lasik it was found to be 2435.78 ± 113.79. there is a less than 1% loss in endothelial cell count before and 4 months after lasik which is clinically and statistically insignificant (p=0.1). no significant complication was noted. a few patients complained of mild pain for 1-2 days after the procedure. discussion few studies have been done to evaluate the effect of lasik on corneal endothelium in which the ablation is in mid stroma. pallikaris and siganos have reported a decrease of 8.67% in endothelial cell count 12 months after lasik in their study of 10 eyes10. they did not perform morphometric analysis. this decrease was considered insignificant. the results of the study however show a decrease of less than 1% up to 3 months after laser. decrease at 6 months is a little more than 1%. this may be due to the younger age of patients in study. perez-santonja et al reported a significant increase in cell density; decrease in coefficient of variation along with a significant increase in hexagonality11. study included 45 eyes and follow up was one year. they also suggest that the cessation of contact lens wear may be responsible for positive modifications of cell density and morphometric indices. because of the inability of the corneal endothelium to regenerate, only a migration of endothelial cells from the peripheral to the central cornea could explain such modifications. the decline in peripheral cell density reported after prk also supports this hypothesis. table 1: age and gender distribution age (years) no of patients n (%) male female 20-22 14 (28) 4 10 23-25 25 (50) 11 14 26-30 6 (12) 2 4 31-35 5 (10) 2 3 table 2: refractive status of patients refractive error (dioptres) no. of patients n (%) 2-5 29 (58) 6-7 8 (16) table 3: mean endothelial cell count with standard deviation (pre and post lasik) mean endothelial cell count ± standard deviation pre lasik 2464.76±109.64 1 week 2456.24±117.47 (p=0.100) 1 month 2453.84±110.91 (p=0.102) 3 months 2453.32±106.63 (p=0.115) 4 months 2435.78±113.79 (p=0.074) in another similar study perez-santonja et al studied same parameters in 33 eyes of 19 patients who underwent lasik to correct myopia of 8.25 to 18.5 d and reported no detrimental changes to endothelium at 3 and 6 months12. in fact they also showed improvements in endothelial cell count and coefficient of variation. they also ascribed their changes to cessation of contact lens wear. jones et al in a prospective study of 98 eyes undergoing lasik for the correction of 2.75-14.5 dioptres of myopia found no significant change in endothelial cell density or coefficient of variation.13they, however, observed 1% 42 decrease in hexagonal cell at 3 months which they consider insignificant. they further reported that contact lens wear did not predispose the cornea to further endothelial damage by lasik. 39, 78% 6, 12% 5, 10% 20-25 years 26-30 years 31-35 years fig. 1: age distribution n=50 male female fig. 2: gender distribution n=50 fig. 3: comparison of mean endothelial cell count (pre and post lasik) a study by kim et al is different from other studies mentioned so for14. they studied human corneal endothelial changes immediately after lasik (within 15 minutes) both by slit lamp examination and non contact specular microscopy. they revealed acute morphologic changes in the corneal endothelium that rapidly resolved. the authors believe that these changes may represent transient and reversible endothelial cell edema. various mechanisms of endothelial cell injury after excimer laser ablation of the cornea have been proposed including mechanical trauma caused by shock waves, ultraviolet exposure and thermal damage15,16. kim et al suggested that in addition to these factors, increased intraocular pressure induced by the suction ring may also contribute to this damage. a case has been reported in literature where endothelial decompensation occurred after lasik in a patient having fuchs’ endothelial dystrophy17. this patient had endothelial dysfunction without edema in one eye and with edema in the other eye. both eyes decompensated to different extents after the surgery. the eye without edema developed persistent edema after surgery whereas the eye that already had edema decompensated completely after surgery requiring penetrating keratoplasty. the immediate increase in corneal edema the day after surgery clearly shows a relation between lasik and endothelial damage. any of the factors already described may be responsible for this effect. in my study carried out at lrbt there was no significant loss of endothelial cells at 1week, 1 month, 3 months and 4 months post lasik. i did not have the facility of morphometric analysis i.e. the coefficient of variation (cv) and hexagonality. my results are, however, comparable to the international studies so far as the endothelial cell count is concerned. a difference exists regarding the age groups between my study and the studies carried out in the developed countries. age range in these studies is up to 55 years whereas we did not perform the procedure in patients more than 35 years old. based on the studies so far although it is safe to assume that lasik is unlikely to cause endothelial damage at least in healthy eyes but at the same time the case reported above emphasises the care refractive surgeons must exercise in selecting the patients for refractive surgery. long-term follow-up studies are needed to confirm endothelial safety at 5 and 10 years. 2464.769231 2456.240385 2453.846154 2453.326923 2435.785714 2420 2425 2430 2435 2440 2445 2450 2455 2460 2465 2470 pre 1 week 1 month 3 months 4 months 19, 39% 31, 62% m ea n e nd ot he lia l c el l c ou nt 43 conclusion there is no clinically or statistically significant loss of endothelial cell count up to four months after laser in situ keratomileusis used for the correction of myopia. author’s affiliation dr. mirza jamil ud din baig layton rahmatullah benevolent trust free eye & cancer hospital 436 a/1 township, lahore dr. khalid mahmood layton rahmatullah benevolent trust free eye & cancer hospital 436 a/1 township, lahore dr. tariq khan layton rahmatullah benevolent trust free eye & cancer hospital 436 a/1 township, lahore dr.zaheer uddin aqil qazi layton rahmatullah benevolent trust free eye & cancer hospital 436 a/1 township, lahore reference 1. angle j, wissmann da. the epidemiology of myopia. am j epidemiology. 1980; 111: 220-8. 2. afghani t, vine ha, bhatti a, et al. al-shifa-al-noor (asan) refractive error study of one million school children. pak j ophthalmol. 2003; 19: 101-7. 3. trokel s, srinivansan r, braren r. excimer laser surgery of the cornea. am j ophthalmol. 1983; 96:710-15. 4. stein ha, cheskes ac, stein rm. the excimer fundamentals and clinical use. new jersey: slack. 1995. 5. mahmood t, awan ah. lasik for high myopia. pak j ophthalmol. 2003; 19: 72-6. 6. yang xj, yan ht, nakahori y. evaluation of effectiveness of lasik and prk for myopia: a met-analysis. j med invest. 2003; 50: 180-6. 7. kawano h, uesugi y, nakayasu k, et al. long term follow up for bullous keratopathy after sato-type anterior posterior corneal refractive surgery. am j ophthalmol. 2003; 136: 1154-5. 8. pallikaris ig, siganos ds. excimer laser in situ keratomileusis and photorefractive keratectomy for correction of high myopia. j cataract refract surg. 1994; 10: 498-510. 9. fiander dc, tayfour f. excimer laser in situ keratomileusis in 124 myopic eyes. j cataract refract surg. 1995; 11: 234-8. 10. pallikaris ig, siganos ds. excimer laser in situ keratomileusis and photorefractive keratectomy for correction of high myopia. j cataract refract surg. 1994; 10: 498-510. 11. perez-santonja jj, sakla hf, alio jl. evaluation of endothelial cell changes 1 year after excimer laser in situ keratomileusis. arch ophthalmol. 1997; 115: 841-6. 12. perez-santonja j, sakla hf, gobbi f. corneal endothelial changes after laser in situ keratomileusis. j cataract refract surg. 1997; 23:177-83. 13. jones ss, azar rg, cristol sm, et al. effect of laser in situ keratomileusis (lasik) on the corneal endothelium. am j ophthalmol. 1998; 125: 465-71. 14. kim t, sorenson al, krishnasamy s, et al. acute corneal endothelial changes after laser in situ keratomileusis. cornea. 2001; 20: 597-602. 15. seiler t. current evaluation of myopia correction with the excimer laser. ophthalmology. 1995; 92: 379-84. 16. seiler t, mcdonnell pj. excimer laser photorefractive keratectomy. surv ophthalmol. 1995; 40: 89-118. 17. vroman dt, solomon kd, holzer mp. endothelial decompensation after laser in situ keratomileusis. j cataract refract surg. 2002; 28: 2045-9 pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 21 original article role of full correction of myopia in regulation of intra ocular pressure in young persons munawar ahmed, murtaza sameen, mahtab alam khanzada, arshad ali lodhi, azfar ahmed mirza pak j ophthalmol 2017, vol. 33 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: munawar ahmed assistant professor, department of ophthalmology, liaquat university of medical & health sciences jamshoro email: munawar_404@yahoo.com …..……………………….. purpose: to evaluate effects of full myopic correction on intra ocular pressure (iop) in young persons. study design: prospective observational clinical study. place and duration of study: department of ophthalmology (lumhs) from may 2014 to may 2016 material and methods: using independent simple random sample selection technique 65 patients (15 35 years) of either sex having simple spherical myopia -1.0 to -4.0 d, and iop 14 to 20 mm hg, wearing glasses for the first time were enrolled for the study. after verbal / written consent initial refraction was done with auto-refractometer followed by subjective correction. iop was measured with applanation tonometer. best corrected visual acuity and back vertex distance was noted. fully corrected prescription using duochrome test was given for full time wear. after one week, the refraction was reconfirmed with glasses, and iop was measured immediately after removing the glasses. follow up was done after one month and three months. each time iop was measured immediately after removing the glasses. results: out of 65 registered patients 52 completed three months follow up criteria of this study. among these 52 patients reduction of iop was observed in 45 (86.54%), and mean reduction of iop was 2.8790 mm hg (16.7062%). in remaining 7 (13.46%) patients there was no or little response. only 10 (19.23%) patients complained of eye strain, which was relieved after few days. after three months follow up data was processed on spss version 14.0 and p-value was 0.003 (< 0.05), which is quite significant. conclusion: myopia should not be under corrected in young persons, as full correction is more effective in restoring accommodation and reducing iop than under correction. key words: myopia, refraction, iop, full correction, young patients. ormal circulation of aqueous humor plays important role in regulation of intra ocular pressure1. intra ocular pressure is increased when accommodation is abolished either by cycloplegics, or by myopia, even when the anterior chamber angle is fully open. the longitudinal fibers of cilliary muscle, which are attached to scleral spur are also relaxed and no longer produce any affect on trabecular meshwork and result in increase in intra ocular pressure. iop is decreased when pilocarpine is used in open angle glaucoma by inducing accommodation. when normal accommodation is reduced or totally lost in myopia and restored by full refractive correction, it results in reduction of intra ocular pressure especially in young persons2. during normal accommodation the resistance to aqueous out n munawar ahmed, et al 22 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology flow is reduced, anterior chamber becomes shallow and pushes the aqueous through the trabecular meshwork and reverse happens in disaccommodation; resistance to outflow is increased, anterior chamber deepens and aqueous from posterior chamber is sucked into anterior chamber3. therefore repeated accommodation plays important role in regulation of iop. if myopic persons are left uncorrected for longer time, it can result in cilliary muscle atrophy, exo-deviation, headache and giddiness along with increased intra ocular pressure. under correction of myopia also produces greater degree of progression of myopia4, actually under correction of myopia is myopigenic5. similar mechanism operate in primary open angle glaucoma which usually occurs after the age of forty years when presbyopia starts due to decreased cilliary body function, an aging process which cannot be reversed. in emmetropic persons, yellow green light is focused on the retina, which is natural phenomenon of colour preference for focusing the images on the retina, but myopics are under corrected (reading better in red on duochrome test) which can lead to so many problems. several clinical studies have also established relation between intra ocular pressure and myopia6. long standing uncorrected or under-corrected myopia will not tolerate full correction immediately after wearing spectacles due to disuse weakness of cilliary muscle. in time accurate refraction and constant wear of glasses can manage all these problems. along with visual impairment, refractive errors are also a significant cause of morbidity besides having social and economic impact. ammetropia results from an imbalance between the refractive power and the axial length of the eyeball.7 the multi-factorial nature of myopia and glaucoma poses a major challenge in understanding their mechanisms of pathology. myopia is the most common human ocular disorder worldwide and is caused by abnormal growth of the eye resulting in refractive error.8 myopia also increases risk for other vision impairing diseases including glaucoma9. as prevalence of simple myopia is highest in asia and commonly affects young and working age group. to prevent complications and to provide comfortable working ability, we have conducted this study which involves simple procedure of accurate refraction and will prevent so many persons from ill effects of myopia and loss of accommodation. material and methods by independent simple random sample selection technique total 65 patients from 15 to 35 years old of either sex having spherical myopia -1.0 to -4.0 d, and intraocular pressure 14 to 20 mm hg, and wearing glasses for the first time were enrolled for study. inclusion criteria were no sign of presbyopia, clear media, normal anterior chamber depth and pakistani citizens by birth. after taking consent, patients were informed about duration and procedure of research. initial refraction was done with auto-refractometer and then confirmed with retinoscopy and refined manually with cross cylinder for astigmatic correction and duochrome test for spherical correction to achieve equally readable in red and green at 6 meter for full correction of myopia. inter pupillary distance, back vertex distance, and visual acuity were noted. slit lamp examination of anterior and posterior segment was done. intra-ocular pressure was measured with applanation tonometer. full correction of myopia (equally readable in red and green on duochrome test at 6 meter) was prescribed and constant wear was advised. after one week, refractive correction was reconfirmed with glasses, and intra ocular pressure was measured immediately after removing the glasses. further follow up was done after one month and three months, each time intra ocular pressure was measured immediately after removing the glasses, complaint if any was noted and results were compiled. patients with incomplete follow up were not included in the data analysis. results out of sixty-five patients, fifty two completed three months follow up. the demographic data of patients is given in table no: 1. majority of our patients were females 40 (76.93%) and remaining 12 (23.07%) were males. among these 52 patients reduction of iop was observed in 45 (86.54%) patients, in remaining 7 (13.46%) patients there was no or little response. initial table 1: demographic data n 52. males 12 (23.07%) females 40 (76.93%) average age in years 22.45 (sd 1.3327) range of myopia -1.0 to -4.0 d mean myopia 2.37 d standard deviation 1.07101 role of full correction of myopia in regulation of intra ocular pressure in young persons pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 23 iop of these patients was more than 18 mm hg and their ages were more than 30 years. only 10 (10.23%) patients complained of eye strain which was relieved after few days of wearing spectacles. mean intra ocular pressure before myopic correction was 17.2331 mm hg with a standard deviation of 1.34931; mean intraocular pressure after full myopic correction was 14.3541 mm hg with a standard deviation of 1.15210. mean reduction of iop was 2.8790 mm hg (16.7062%) which is more or less equal to pilocarpine when used in open angle glaucoma. the results were therefore significant and p-value was 0.003 (< 0.05) when processed on spss versions 14.0. the summary of results is given in table 2. table 2: summary of result after full myopic correction at 3 months follow up n = 52. females 40 76.93% males 12 23.07% mean iop 14.3541 83.2937% mean reduction of iop 2.8790 16.7062% standard deviation 1.15210 p-value 0.003 discussion aqueous humor dynamics depends on cilliary muscle and trabecular meshwork function which in turn are related with the refractive state of eye and play important role in regulation of intra ocular pressure. the prevalence of myopic refractive error is highest in the asian population. an association between open angle glaucoma and myopia is well established, this relation is reported for children10,11, in young adults12 and presbyopic adults13. the relation between intra ocular pressure and myopia varies with age and ethnicity. we have done this study on younger age group between 15 to 35 years who were born in pakistan and majority of these patients were females. whether patient is myopic, presbyopic or dilated with potent cycloplegic, the ultimate effect is loss of cilliary muscle function and decrease in aqueous outflow due to decreased pull of longitudinal fibers of cilliary muscle, which are attached to scleral spur. patients who do not show reduction in their intraocular pressure after full correction of myopia, they may have trabecular meshwork abnormality or ciliary muscle weakness. edwards and brown reported that in children who were not myopic at age of 7 years but became myopic at the age of 9 years also showed increase in iop and there was no change in iop in non-myopic children over the same age and time period14,15. it is also observed that moderate myopes show greater increase in intra ocular pressure and higher peak values (19.8 mm hg) as compared to emmetropes and low myopes (18.6 and 18.7 mmhg). this may be due to abnormal auto-regulation of ocular blood pressure in myopes of moderate and greater severity and can result in ocular hypertension or glaucoma16. similar finding are observed in our study, patients who had myopia more than -2.0 d their intra ocular pressure was also more as compared to the patients having myopia less than -2.0 d. similar effects can be produced with cycloplegics which produce complete loss of accommodation and result in elevation of iop in certain eyes in absence of angle closure. this type of response occurs in 23% with open angle glaucoma and 2% in normal individuals. any patient who has normal anterior chamber angle and shows elevation of iop after routine dilatation with potent cycloplegics should considered an open angle glaucoma suspect.17. it means normal accommodation plays important role in regulation of intra ocular pressure. this normal physiology is altered in myopia but can be returned to normal by accurate refraction in young persons. full correction of myopia will keep the cilliary body muscle healthy and will delay the onset of presbyopia. further more constant wear of accurate glasses can reduce iop and in turn can limit the progression of myopia in young persons, prevents exophoria / exotropia, relieves head ache, and can delay onset of open angle glaucoma, because cillary muscle remains active. under-correction of myopia not only ineffective in regulating the intra ocular pressure but also ineffective in controlling the progression of axial myopia18. some studies have mentioned transient rise of iop during early phase of accommodation but this occurs usually in animal models19. two affects are produced with the myopia, defocusing of retina and decrease in accommodation20, both these function are restored with full correction of myopia especially in young persons. the procedure of refraction is already being done since long time but no one has evaluated its effects on the physiology of eye. this is first time that we have noted these facts and prevented the young people from many complications of myopia by simple procedure that is full correction of myopia. munawar ahmed, et al 24 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology conclusion accurate and full myopic correction plays important role in regulation of intra ocular pressure and aqueous humour dynamics. it can limit the progression of myopia, delay the onset of presbyopia and open angle glaucoma. it can prevent development of exophoria, exotropia, and related eye strains and headache. therefore myopia should not be under corrected in young persons, as full correction is more effective in reducing iop than under correction. author’s affiliation dr. munawar ahmed assistant professor, department of ophthalmology, liaquat university of medical and health sciences jamshoro. dr. murtaza sameen liaquat university of medical and health sciences jamshoro. dr. mahtab alam khanzada liaquat university of medical and health sciences jamshoro. dr. arshad ali lodhi liaquat university of medical and health sciences jamshoro. dr. azfar ahmed mirza liaquat university of medical and health sciences jamshoro role of authors dr. munawar ahmed conducted the main research, examination of patients on each follow up visit, collection of data, and discussion with co-authors, compiled the results and written main script of the article. dr. murtaza sameen arranged spectacles for poor patients and helped in literature research. dr. mahtab alam khanzada data collection and helped in main script writing. dr. arshad ali lodhi, referred the patients who fulfilled the selection criteria to main author. dr. azfar ahmed mirza counseling of the patients, and guided the patients about the research procedure. references 1. manik goel, renata g picciani, richard k lee, sanjoy k bhattacharia. aqueous humor dynamics: a review open ophthalmol j. 2010; 4: 52-59. 2. yan liu, huibin ly xiaodan jiang, xiaodan hu, mingzhou zhang, xuemin li. intraocular pressure changes during accommodation in progressing myopes, stable myopes and emmetropes plos one, 2015; 10 (10): e0141839. 3. kaufman pl, ba´ra ´ny eh. loss of acute pilocarpine effect on outflow facility following surgical disinsertion and retrodisplacement of the ciliary muscle from the scleral spur. in the cynomolgus monkey. invest ophthalmol. 1976; 15: 793–807. 4. christina a. esposito; cody peterson; cory coronado; balamurali vasudevan; cenneth ciuffreda. undercorrection of myopia increases myopic progression –a retrospective study. investigative ophthalmology and visual science, 2012; 53: 4446. doe: 5. balamurali vasudevana, christina espositoa, cody petersona, cory coronadoa, kenneth j. ciuffredab. under-correction of human myopia – is it myopigenic?: a retrospective analysis of clinical refraction data. j optom. 2014; 7 (3): 147-52. 6. a j lee, s-m saw, g gazzard, a cheng, and d t h tan. intraocular pressure associations with refractive error and axial length in children br j ophthalmol. 2004; 88 (1): 5–7. 7. muhammad zia-ul-haque ansari, abrar ali, adnan afaq, tabassum ahmed, khawaja sharif-ul-hassan. relative distribution of refractive errors an audit of retinoscopic findings pak j ophthalmol, 2007; 23 (3): 144-150. 8. bloom ri, friedman ib, chuck rs. increasing rates of myopia: the long view. curr opin ophthalmol. 2010; 21: 247–248. 9. loyo-berrios ni, blustein jn. primary-open glaucoma and myopia: a narrative review. wmj, 2007; 106 (95): 85–89. 10. quinn ge, berlin ja, young tl, ziylan s, stone ra. association of intraocular pressure and myopia in children. ophthalmology, 1995; 102: 180–5. 11. abdalla mi, hamdi m. applanation ocular tension in myopia and emmetropia.br j ophthalmol. 1970; 54: 122– 5. 12. edwards mh, brown b. intraocular pressure in a selected sample of myopic and non myopic chinese children. optom vis sci. 1993; 70: 15–7. 13. nomura h, ando f, niino n, shimokata h, miyake y. the relationship between intraocular pressure and refractive error adjusting for age and central corneal thickness. ophthalmic physiol opt, 2004; 24: 41-5. 14. edwards mh, brown b. iop in myopic children: the relationship between increase in iop and the development of myopia. ophthalmic physiol opt. 1996; 16: 243–6. 15. ruth e manny, g lynn mtchell, susan a cotter, lisa http://www.journalofoptometry.org/en/under-correction-human-myopia-is/articulo/s1888429613000885/#aff0005 http://www.journalofoptometry.org/en/under-correction-human-myopia-is/articulo/s1888429613000885/#aff0005 http://www.journalofoptometry.org/en/under-correction-human-myopia-is/articulo/s1888429613000885/#aff0005 http://www.journalofoptometry.org/en/under-correction-human-myopia-is/articulo/s1888429613000885/#aff0005 http://www.journalofoptometry.org/en/under-correction-human-myopia-is/articulo/s1888429613000885/#aff0010 role of full correction of myopia in regulation of intra ocular pressure in young persons pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 25 a jones-jordan, robert n kleinstein, donald o mutti et al. intraocular pressure, ethnicity, and refractive error. optom vis sci. 2011; 88 (2): 1445-1453. 16. xin xu, li li, ruidan cao, ye tao, qun guo, jia geng, yongzhi li, zuoming zhang. intraocular pressure and ocular perfusion pressure in myopes during 21 min head-down rest asem, 2010; 81 (4): 418-422. 17. laurence s. harris, md. cycloplegic-induced intraocular pressure elevations: a study of normal and open-angle glaucomatous eyes. arch ophthalmol. 1968; 79 (3): 242-246. 18. kahmeng chung; norhani mohidin; daniel j. o‘ leary under-correction of myopia enhances rather than inhibits myopia progression vision research, 2002; 42 (22): 2555-2559. 19. l yan, l hubbin, l xuemin. accommodation induced intra ocular pressure changes in progressing myopes and emmetropes eye, 2014; 28: 1334-1340. 20. peter m. allen, daniel j. o‘ leary accommodation functions: co-dependency and relation to refractive error vision research, 2006; 46 (4): 491-505. microsoft word zia ul mazhiry 148 original article classification and evaluation of secondary posterior chamber iol implantation scleral fixation of iol zia ul mazhry, wasif m. kadri pak j ophthalmol 2010, vol. 26 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zia ul mazhry wapda hospital complex 210 feroz pur road lahore received for publication december’ 2009 …..……………………….. purpose: aim of the study was to evaluate secondary pc iol implantation in terms of: variation of surgical procedure required to manage different situations, visual outcome and postoperative complications. methods: fifty eyes of 45 patients having traumatic or surgical aphakia were included in the study over the period of 5 years from oct. 95 to nov. 2000. the status of posterior capsule varied from intact, partially deficient or totally absent. similarly the technique varied from simple synechiolysis to anterior vitrectomy combined with simple implantation to single or double haptic trans-scleral fixation. single piece pc iol was used in most of the patients while multi piece pc iol was used very occasionally. no ac iol was implanted or included for exchange in this series. postoperative follow up ranged from 6 to 60 months, average being 26.5 months. results: surgical technique needed to be varied according to the situation. it ranged from simple implantation on an intact pc (6 eyes), synechiolysis and implantation in 3 eyes, capsulotomy with anterior vitrectomy and implantation (11 eyes), trans-scleral iol fixation in 26 eyes and retrieval with fixation of dislocated iol in 4 eyes. average visual acuity was in the range of 6/9-6/12. the most common complication was glaucoma (8 cases) followed by vitreous hemorrhage (4 cases with trans-scleral fixation) and hyphaema (2 cases), which resolved in al the patients with no residual complication. conclusion: secondary pc iol implantation is an effective and safe technique for visual rehabilitation of aphakic patients. one should be ready and well versed with the variations of surgical technique required while carrying out such procedures. he preferred lens for aphakic rehabilitation is a posterior chamber lens. major therapeutic advantage of a posterior chamber iol over anterior chamber iol is its position away from delicate anterior chamber structures especially the corneal endothelium and aqueous out flow channels. moreover the posterior chamber iol is positioned in the focal point of the eye and is close to the rotational axis of the eye. this ensures good refraction and minimal pseudophacodonesis1, 2. secondary pc iol implantation in aphakics is an established procedure. the most suitable candidate for this procedure is a patient who had had uncomplicated extra capsular cataract extraction in the past. the posterior capsule is intact and pupil is mobile with no anterior or posterior synechiae. however most of the patients, going to have secondary intraocular lens implantation, are far form this ideal situation. the eyes are usually already compromised secondary to inadvertent surgical t 149 trauma in the past. the scenario may be complicated by borderline endothelial cell counts, lack of iris tissue and iridocapsular adhesions. vitreous touch and vitreous wick along with all associated problems like cme is not an uncommon finding3-6. iol exchange is another indication for secondary iol implantation. dislocation or subluxation of the posterior chamber lenses may occur secondary to postoperative trauma to the eye or zonular dehiscence not recognized at the time of primary lens implantation. repositioning or retrieval and fixation of the same lens transsclerally or iol exchange, can be a procedure of choice in these situations7-13. the status of posterior capsule may vary from intact to partially deficient or totally absent. similarly the technique has to be varied from simple implantation to synechiolysis to anterior vitrectomy combined with single or double haptic trans-scleral fixation of pc iol. this study is focused on evaluation of variations of surgical procedure required to manage different situations encountered in secondary iol implantation. it also reviews the visual outcome and postoperative complications. material and methods fifty eyes needing secondary pc iol implantation were included regardless of age or sex. we tabulated the following data for each patient. age, sex, type of antecedent surgery, interval between antecedent surgery and presentation and surgical procedure used. pre and postoperative visual acuity was also recorded along with postoperative complications. follow up ranged from 6 to 60 months, average being 26.5 months. preoperative evaluation included history taking in detail, recording of best-corrected v/a, anterior segment slit lamp biomicroscopy, funds examination and applanation tonometery. b-scan was performed where media did not permit direct fundus examination to rule out retinal pathology. anterior segment photographs were taken wherever possible. various techniques used can be generalized under following headings: 1. simple secondary pc iol (secpc iol): routine implantation of intra ocular lens in eyes with intact posterior capsule and no anterior or posterior synechiae along with clear visual axis (fig-1). 2. sulcus dissection/synechiolysis and pc iol implantation (sd & pc iol): in eyes with intact posterior capsule but with anterior or posterior synechiae and clear/opaque visual axis (fig-2). 3. intra shelf pc iol implantation (is pc iol) with anterior vitrectomy in eyes with central rent in posterior capsule or densely opaque visual axis (fig-3). 4. single haptic scleral fixation (shsf pc iol) in eyes with partially deficient posterior capsule with peripheral rent extending for less than 180 (fig-4). 5. double haptic scleral fixation (dhsf pc iol) in eyes missing posterior capsule completely. (fig-5) 6. retrieval & fixation of dislocated iol (r&sf pc iol) in eyes with rented posterior capsule and subluxated / dislocated pseudophacos (iol). in postoperative evaluation special stress was given to recording the, condition of the wound, endothelial status with specular reflection and grading of anterior chamber activity, iol status and condition of the vitreous. iop assessment was performed and documented as a routine. follow up schedule was at first post operative day, weekly for two weeks, fortnightly for two months and then monthly at least for 6 months. results 50 eyes of 45 patients needing secondary intraocular lens implantation were included in the study and evaluated for visual outcome and complications. average age was 51 years ranging from 5 to 78 years. the follow up ranged from 6-60 months and average follow up was 26.5 months. the characteristics of the patients are listed in (table 1). out of 50 eyes operated 34 were of males and 16 were of females. indications wise the patients were divided into six major groups. 1. aphakics with intact pc, 6 eyes (no anterior or posterior synechiae and clear visual axis) 2. complicated aphakia with intact pc, 3 eyes (with anterior or posterior synechiae but clear visual axis). 3. aphakic eyes with central rent in pc, 11 eyes or densely opaque visual axis. 4. partially deficient posterior capsule, with peripheral rent extending less than 180 degrees, 2 eyes. 5. totally missing posterior capsule 24 eyes 6. posterior capsular rent subluxated pseudophacos 4 eyes 150 most of eyes presented with rented or totally absent posterior capsule (41 eyes) and pc was intact only in 9 eyes. surgical procedures required also varied similarly and were again divided into six major groups (table 2). a. simple secondary implantation of pc iol 6 (12%) (secpc iol). b. synechiolysis/sulcus dissection 3 (6%) and pc iol implantation (sd&pc iol) c. intrashelf implantation with anterior 11(22%) vitrectomy (is pc iol) d. single hapatic fixation (shsf pc iol) 2 (4%) e. double hapatic scleral fixation 24(48%) (dhsf pc iol) f. retrieval & scleral fixation of 4 (8%) dislocated pc iol (r&sf pc iol) the postoperative visual acuity was dependent on the eye’s pre operative visual potential. in our study 5 patients had pre-existing macular problems. secondary intra ocular lens implantation was considered in these patients to improve the quality of vision and to manage the vitreous wick and vitreous touch syndromes. table 3 (graph1) shows the preoperative and postoperative visual acuity. forty (80%) eyes were 6/36 or better preoperatively while 47 eyes (94%) were in the same range postoperatively. the eyes in the range of 6/60 or less were 10 (20%) preoperatively, while only three (6%) eyes were in that range postoperatively. only one eye had postoperative visual loss secondary to retinal detachment. the median acuity, in general was 0.1 (6/60) preoperatively and 0.5 (6/12) postoperatively. the preoperative median va was again 0.1 (6/60) in all the groups except the group of patients who had planned secondary scleral fixation of iol that was 0.5 (6/12). the obvious reason was that the most of them were aphakic patients with full aphakic correction. average va in general was 0.25 preoperatively and 0.54 postoperatively. median postoperative va was comparable in cases of primary -vssecondary iol fixation i.e. (6/12 vs. 6/9). and it was on poorer side in miscellaneous group (6/18). this fact was related to number and amount of surgical handling involved in these already compromised eyes. the most common complication was glaucoma in 8 eyes (16%) followed by vitreous hemorrhage in 4 eyes (8 %) and hyphaema in 2 eyes (4%). vitreous hemorrhage cleared in all the patients within 1-3 weeks with no residual complications while hyphaema resolved within 3-7 days in all the cases. clinically significant iol tilt occurred one case (2%) and the iol had to he repositioned. the gross iol tilt in one patient was related to history of trauma accompanied by vitreous hemorrhage. (table 4 and graph 2). table 1: patients’ characteristics patients’ characteristics age range 5-78 years males 32 females 13 avg. follow up 26.5 months table 2. surgical procedures simple secimplantation of iol (secpc iol) 6(12%) sulcus dissection & implantation (sd &pc iol) 3(6%) intra shelf implantation with ant.vit. (is pc iol) 11(22%) single haptic scleral fixation (shsf pc iol) 2(4%) double haptic scleral fixation (dhsf pc iol) 24(48%) retrieval & fixation/exchange of dislocated iol (r&sf/x pc iol) 4(8%) table 3. comparison of pre and post op visual a 6/6–6/9 6/12–6/18 6/24–6/36 6/60 preop va 16 (32%) 14 (28%) 10 (20%) 10 (20%) postop va 25 (50%) 16 (32%) 6 (12%) 3 (6%) discussion aphakic patients may opt for secondary iol insertion because of objective or subjective intolerance of contact lenses and/or spectacle correction.14 management of aphakic patients with intact posterior capsule is quite simple and straightforward. however secondary iol implantation in eyes lacking enough capsular support remains challenging and controversial. 151 table 4.postoperative complications glaucoma 8 (16%) vit. he 4 (8%) hyphaema 2 (4%) iol tilt (visually insignificant) 1 (2%) traumatic subluxation 1 (2%) preoperative characteristics intended surgical plan intact clear pc with mobile dilated pupil simple secondary pc iol implantation secpc iol poorly dilating pupil secondary to synechiae sulcus dissection pc polishing and pc iol implantation sd &pc iol scenario2+ central rent in posterior capsule sulcus dissection, pc polishing, anterior vitrectomy and intrashelf pc iol implantation is pc iol partially deficient posterior capsule with peripheral rent extending for less than 180 sulcus dissection, anterior vitrectomy and single haptic sclera fixation of pc iol shsf pc iol subluxated /dislocated pc iol with rented posterior capsule retrieval & scleral fixation/ exchange of iol with anterior vitrectomy/ ppv r&sf/x pc iol simple 2 implantation of iol . fig. 1. simple secondary pc iol (secpc iol) both posterior chamber (traditionally sulcus supported and scleral fixated) and anterior chamber synechiolysis and implantation fig-2. sulcus dissection synechiolysis and pc iol implantation (sd &pc iol) intrashelf implantation with anterior vitrectomy fig. 3. intra shelf pc iol implantation (is pc iol) single haptic fixation fig-4. single haptic sclera fixation (shsf pc iol) double haptic fixation fig 5. double haptic scleral fixation (dhsf pc iol) (angle-supported and iris clip) iols have been implanted secondarily. 15 secondary iols are difficult to place in the capsular bag because of anterior and 152 posterior capsular fusion secondary to fibrosis. although sulcus-supported posterior chamber iols needs adequate capsular support, they have a reduced complication rate in comparison with scleral fixated or anterior chamber iols. the capsular remnant provides an excellent support scaffold, even in the absence of a 360-degree ring; although it may remain adherent to the posterior surface of the iris, the remnant may be used to reconstruct the ciliary sulcus and provide adequate support for a posterior chamber iol16. preoperative evaluation of patients having secondary iol implantation is important to enable accurate surgical planning, including choice of the iol and informed patient consent. 17,18,19 in patients in whom inadequate dilation precludes the detection of capsular support, our study suggests that ciliary sulcus-supported secondary iol implantation should be considered preoperatively, with the final decision lying with the surgeon with direct visualization of the sulcus20-22. in our study, we used the following classification for surgical planning and evaluation: 1. simple secondary pc iol (secpc iol): routine implantation of intra ocular lens in eyes with intact posterior capsule and no anterior or posterior synechiae along with clear visual axis). 2. synechiolysis/sulcus dissection and iol implantation (sd &pc iol) in eyes having intact posterior capsule but with anterior or posterior synechiae and clear visual axis). 3. intra shelf pc iol implantation (is pc iol) with anterior vitrectomy in eyes with central rent in posterior capsule or densely opaque visual axis (see photograph-1). 4. single haptic sclera fixation (shsf pc iol) in eyes with partially deficient posterior capsule with peripheral rent extending for less than 180. 5. double haptic scleral fixation (dhsf pc iol). in eyes missing posterior capsule completely. (see photograph-2). 6. retrieval & scleral fixation/exchange of dislocated iol (r&sf/x pc iol) in eyes with rented posterior capsule and subluxated/ dislocated pseudophacos (iol). uthoff and teichmann (1998) have concluded secondary intraocular lens implantation with scleral fixation was a safe procedure. more than 90% of their patients regained or improved their pre-operated visual acuity.23 another study reports mean visual acuity (va) improved from 6/18 to 6/9. 25 in our study 40 (80%) eyes were 6/36 or better preoperatively while 47 eyes (94%) were in the same range postoperatively. the eyes in the range of 6/60 or less were 10 (20%) preoperatively while only three (6%) eyes were in that range postoperatively. only one eye had postoperative visual loss secondary to retinal detachment. the median acuity, in general was 0.1 (6/60) preoperatively and 0.5 (6/12) postoperatively. the preoperative median va was again 0.1 (6/60) in all the groups except the group of patients who had planned secondary scleral fixation of iol that was 0.5 (6/12). the obvious reason was that the most of them were aphakic patients with full aphakic correction. average va in general was 0.25 preoperatively and 0.54 postoperatively. median postoperative va was comparable in cases of primary iol implantation. postoperative complications associated with secondary iol implantation include glaucoma, vitreous hemorrhage, hyphaema, macular edema and iol decenteration or tilt and endophthalmitis etc19-24. daus w, tetz m, buschendorff p reported the following complications during their mean postoperative follow-up of 15 (range 3-45) months. there were 6-limited anterior chamber and 1 vitreous hemorrhage that resolved spontaneously. two iols required surgical repositioning with scleral suturing because of postoperative iol subluxation. a delayed but reversible fibrin reaction was seen in 1 eye, while 1 eye developed a cystoid macular edema with reduction of va from 20/30 to 20/6025. the most common complication observed in our study was glaucoma in 8 eyes (16%) followed by vitreous hemorrhage in 4 eyes (8 %) and hyphaema in 2 eyes (4%). vitreous hemorrhage appeared more frequently in our study though it cleared inconsequentially in all the patients. the probable reason was trans-scleral fixation in almost half of the patients. clinically significant iol tilt occurred one case (2%) and the iol had to he repositioned. the gross iol tilt in one patient was related to history of trauma accompanied by vitreous hemorrhage. conclusion the choice of the surgical procedure depends on the degree of involvement, of the bag-zonular system. preoperative evaluation of patients having secondary pc iol implantation is important to enable accurate surgical planning. in patients where inadequate dilation precludes the detection of capsular support, 153 our study suggests that ciliary sulcus-supported secondary iol implantation should be considered preoperatively, with the final decision lying with the surgeon with direct visualization of the sulcus. we suggest the following approach for secondary pc iol implantation: secondary pc iol implantation is an effective and safe technique for visual rehabilitation of aphakic patients. one should be ready and well versed with the variations of surgical technique required while carrying out such procedures. author’s affiliation dr. zia ul mazhry consultant eye surgeon and head of eye department wapda hospital complex 210 feroz pur road lahore pakistan prof. wasif m. kadri professor emeritus post graduate medical institute and services hospital lahore reference 1 apple dj, rabb mf. ocular pathology; clinical applications and self-assessment. 4th ed. st. louis: mosby year book inc. 1991: 1-11, 112-65. 2 bleckmann h, kaczmarek u. functional results of posterior chamber lens implantation with scleral fixation. j. cataract refract surg. 1994; 20: 321-6. 3 hussein m, mehmood h, durrani j, et al. secondary implantation of iol. pak j ophthalmol. 1995; 11: 26-31 4 sulewski me, gottsch jd, haller ja, et al. posterior chamber intraocular lens implantation without capsular support. in: schachat a.p. ed. current practice in ophthalmology. st. louis, missouri. mosby year book inc. 1992: 125-44. 5 lane ss, agapitos pj, lindquist td. secondary intraocular lens implantation. in: lindquist t.d., lindstrom r.l. ed. ophthalmic surgery; loose leaf and update service. st. louis: mosby. 1994: g-0 to g-14. 6 wong sk, koch dd, emery jm. secondary intraocular lens implantation. j cataract refract surg. 1987; 13: 17-20. 7 osher rh, cionni rj. what to do when: intraocular lenses misbehave. review of ophthalmology. 1994; 1: 42-7. 8 arkin ms, steinert rf. sutured posterior chamber intraocular lenses. in: jacobiec fa, adamis ap, volpe nj. eds international ophthalmology clinics. controversies in ophthalmology: current therapies & emerging technologies. boston: little, brown and company. 1994; 34: 67-86. 9 chan ck. an improved technique for management of dislocated posterior chamber intraocular lens implants. ophthalmology. 1992; 99: 51-7. 10 fanous mm, friedman sm. ciliary sulcus fixation of a dislocated posterior chamber intraocular lens using liquid perfluorophenanthrene. ophthalmic surg. 1992; 23: 551-2. 11 maguire am, blumenkranz ms, ward tg, et al. scleral loop fixation for posteriorly dislocated intraocular lenses: operative technique and long term results. arch ophthalmol. 1991; 109: 1754-8. 12 panton rw, sulewski me, parker js, et al. surgical management of subluxated posterior chamber intraocular lenses. arch ophthalmol. 1993; 111: 919-26. 13 smiddy we. dislocated posterior chamber intraocular lens: a new technique of management. arch ophthalmol. 1989; 107: 1678-80. 14 galentine pg, cohen ej, laibson pr, et al. corneal ulcers associated with contact lens wear. arch ophthalmol. 1984; 102: 891–4. 15 evereklioglu c, er h, bekir na, et al. comparison of secondary implantation of flexible open-loop anterior chamber and scleral-fixated posterior chamber intraocular lenses. j cataract refract surg. 2003; 29:301–308. 16 dahan e, salmenson bd, levin j. ciliary sulcus reconstruction for posterior implantation in the absence of an intact posterior capsule. ophthalmic surg. 1989; 20: 776–80. 17 dick hb, augustine aj. lens implant selection with absence of capsular support. curr opin ophthalmol. 2001; 12: 47–57. 18 hahn tw, kim ms., kim jh. secondary intraocular lens implantation n aphakia. j cataract refract surg. 1992; 18: 174-9. 19 hussein m, mehmood h, durrani j, et al. secondary implantation of iol. pak. j ophthalmol. 1995; 11: 26-31. 20 sulewski me, gottsch jd, haller ja, et al. posterior chamber intraocular lens implantation without capsular support. in: schachat a.p. ed. current practice in ophthalmology. st. louis, mosby year book lnc. 99: 125-44. 21 lane ss, agapitos pj, lindquist td. secondary intraocular lens implantation. in: lindquist t.d., lindstrom r.l. eds. ophthalmic surgery; loose leaf and update service. st. louis: mosby. 1994: g-0 to g-14. 22 wong sk, koch dd, emery jm. secondary intraocular lens implantation. j cataract refract surg. 1987; 13: 17-20. 23 uthoff d, teichmann kd. secondary implantation of scleralfixated intra ocular lenses. j catatact refract surg. 1998; 24: 945-50. 24 scott iu, flyman hw. endophthalmitis after secondary intraocular lens implantation. a case control study. ophthalmology. 1995; 102: 1925-31. 25 daus w, tetz m. buschendorff p secondary posterior chamber lenses. implantation in intact, partially intact and missing posterior lens capsule ophthalmology. 1994; 91: 498-502. microsoft word zia ul mazhry 184 original article scleral fixation of intraocular lens zia ul mazhri, wasif m qadri pak j ophthalmol 2008, vol. 24 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: zia ul mazhry 511e 1 wapda town lahore received for publication january’ 2008 … ……………………… purpose: evaluation of a simplified technique of scleral fixation of posterior chamber iol in terms of visual outcome and complications. material and methods: fifty eyes of 48 patients with sclerally fixated iol were included in the study. in general these eyes were lacking adequate posterior capsular (pc) support for routine posterior chamber intraocular lens implantation. 9/0 nylon (ethicon), 10/0 polypropylene(proline) and occasionally 10/0 nylon were the sutures used for transscleral fixation of the lens heptics. transscleral suture passage was performed with ab externo cum ab interno technique in 21 patients and modified ab externo technique in 29 patients anterior core vitrectomy was performed as a routine accompaniment. the follow up ranged from 8-36 months and average follow up was 21.4 months. results: visual outcome was quite good. average visual acuity was in the range of 6/9-6/12, which is quite comparable to other kinds of implantations. the most common complication was vitreous hemorrhage and hyphaema, which resolved in all the patients with no residual complications. conclusion: scleral fixation of iol is an effective but surgically demanding technique. there is no reason to become somewhat over conscious about the slightly higher risk of complications with scleral-sutured pc iol. most of these complications can be avoided or minimized by proper selections of materials used and adopting the proper technique. 185 or routine pc iol implantation an intact posterior capsule is mandatory. anterior chamber intraocular lenses are commonly placed into the eyes lacking adequate capsular or zonular support. these lenses have been noted to carry high risk of post operative complications like corneal endothelial damage, uveitis, glaucoma, hyphaema (ugh), and cystoid macular edema1-5. in response to the real and potential problems associated with anterior chamber lenses, alternative techniques for implanting the more successful posterior chamber in the absence of posterior capsular support were sought. some have suggested suturing a posterior chamber lens to the iris, but this may result in iris chafing, uveitis, and pupillary constriction4,6. to avoid these complications and still achieve a posteriorly placed lens position, methods to transsclerally fixate posterior chamber lenses to the ciliary sulcus have been developed. malbran and coauthors were the first to report transscleral sulcus fixation of posterior chamber lenses in aphakic patients who had had previous intra capsular cataract extraction1,2,4. although scleral fixation techniques are still evolving, early results have been encouraging and these techniques are becoming more widespread. posterior chamber intraocular lenses directly fixated to sclera have been used in a variety of situations such as planned secondary iol insertion and surgical complications at the time of primary cataract surgery. fixation of iol may also be considered safe while managing subluxated or dislocated crystalline lens or in iol exchange procedure2,7-9. technique of scleral fixation of iol has not been widely practiced in pakistan. this study was aimed at evaluation of simplified locally practicable technique in terms of visual outcome and complications. we have found it quite useful and effective alternative to secure a posterior chamber iol in eyes lacking posterior capsule partially or totally. material and methods a prospective study was planned and carried out between july 1994 to june 1997. fifty eyes of fortyeight patients were included in the study with the following criteria. age sixteen (empirical) years and above with as no sex limitation were considered. the patients were divided into following groups according to the clinical presentation and the nature of the procedure required: 1. primary scleral fixation of iol a) patients who had capsular rupture during planned extra capsular cataract extraction. b) the patients presenting with dislocated or subluxated crystalline lenses. (11 eyes=22%) 2. secondary iol implantation patients wanting secondary implantation in aphakic eyes lacking adequate posterior capsular support. 3. miscellaneous • penetrating keratoplasty combined with scleral fixation of iol. the patients needing keratoplasty for aphakic or pseudophakic bullous keratopathy where an implant was desired. • retrieval and scleral fixation of a dislocated or subluxated posterior chamber iol. • intraocular lens exchange procedures patient having pseudophakia with a high refractive error leading to anisometropia that was not manageable with routine measures. the patients with chronic uveitis, diabetic retinopathy, bleeding disorder and high axial myopia were excluded. a complete ocular examination was carried out stressing on: corneal endothelial status (guttata), presence of synechiae, ramnants of the posterior capsule and anterior vitreous cavity. taking all the features into account, the surgical plan was clearly mentioned. anterior segment photographs were taken where ever possible. srk-i formula was used to calculate the power of the lens implant. in most of the cases rayner 752 u single piece iol was used with 7 mm optical diameter and 13.5 mm over all diameter. occasionally multipiece lens with 6.5 mm optic 13-13.5 mm over all diameter was also used, where single piece lens was not available. +0.50-1.0 d was added to the calculated emmetropic iol power to compensate for the slightly posterior placement of sclerally-fixated iol 6,10 . in the present study, 9/0 nylon (ethicon), 10/0 polypropylene (proline) were the sutures used for transscleral fixation of the lens heptics. 10/0 nylon was used for wound closure and conjunctival stitches. however 10/0 nylon was also used occasionally f 186 where no other suture was available especially in cases of scleral fixation after posterior capsular rent during routine ecce. the surgical procedure differed slightly from patient to patient. the initial steps were the same as for a routine ecce through a scleral tunnel incision. depending upon the situation membranectomy, lensectomy or cryo extraction of the subluxated lens was done. anterior vitrectomy is mandatory in all cases. the most important step in this procedure is the transscleral suture passage. this was achieved using one of the two methods. • ab externo cum ab interno technique in this case one entry was made outside in whereas the other was inside out. 23 g needle was used for this purpose which passed through the eye. straightened needle of the nylon suture was passed through it, needle withdrawn, suture cut into two and tied to the iol. • modified ab externo technique in this technique which is a modified version of the above mentioned method the nylon suture is cut into two before passing through the eye. 1 cc disposable needle with 26-30 g needle is used; the cut suture ends threaded into the needle and pulled out under vision. thus in this method both entries were made from outside in. after tying the lens the implant was rotated into position by gentle traction on the sutures. the suture tied to itself and knots burried under the already raised scleral flaps. wound was closed, ac formed and conjunctiva approximated routine post operative medication was continued for four to six weeks postoperatively depending upon the situation. conjunctival sutures were removed one week post operatively. follow up examinations were generally undertaken on postoperative day 1, 3,7,15 and every month there on, for at least six months post operatively. results fifty eyes of 48 patients with sclerally fixated iols were included in the study and evaluated for visual outcome and complications. average age was 51 years ranging from 17 to 76 years. the follow up ranged from 8-36 months and average follow up was 21.4 months. the preoperative characteristics of the patients are listed in table 1. table 1: preoperative characteristics characteristic no. of patients n (%) females 15 (30) males 35 (70) right eyes 29 (58) left eyes 21 (42) average age (years) 51 age range (years) 17-76 pre-existing glaucoma 3 (3) pre-existing cme or macular scar 4 (8) retinal breaks or dialysis 2 (4) adherent leukoma 2 (4) iridodialysis 2 (4) basal iridectomy 2(4) marphanoid features 2(4) ppv and injected silicon oil 1 (2) amblyopia 1(2) pale optic disc 1(2) out of 50 eyes operated 35 were of males and 15 were of females. three patients had pre-existing glaucoma while 4 patients had pre-existing cme/ macular scar. two patients each had retinal breaks/ dialysis, adherent leukoma, iridodialysis, basal iridectomy and marphanoid type of dislocation. one eye each was there with ppv with silicon oil injection, amblyopia and pale optic disc. indications wise the patients were divided into three major groups. (table 2, graph.1) table 2: indications for scleral fixation indication no. of patients n (%) primary scleral fixation a) pc rent during routine ecce b) management of subluxated or dislocated crystalline lenses. 21 (42) 10 (20) 11 (22) secondary scleral fixation of iol 22 (44) 187 miscellaneous: a) aphakic bullous keratopathy b) iol exchange c) dislocated or subluxated iol 7 (14) 2 (4) 1 (2) 4 (8) table 3: pre operative and post operative visual acuity range of visual acuity pre op. n (%) post op. n (%) 6/6 to 6/12 13(26) 36(72) 6/18 to 6/36 10(20) 8(16) 6/6o to 1/60 15(30) 5(10) cf, hm, pl 12(24) --- npl ---1(2) the post operative visual acuity was dependent on the eye's pre operative visual potential. in our study 4 patients had pre-existing macular problem. scleral fixation of iol was considered in these patients to improve the quality of vision and to provide all important peripheral vision. table 3 shows the preoperative and post operative visual acuity. twenty three (46%) eyes were 6/36 or better preoperatively while 44 eyes (88%) were in the same range postoperatively. the eyes in the range of 6/60 or beyond were 27(54%) preoperatively while only six (12%) eyes were in that range postoperatively. only two eyes had postoperative visual loss, one secondary to retinal detachment and the other secondary to graft rejection. table 4: post operative complications complications no. of patients n (%) hyphema 5(10) vitreous haemorrhage 8(16) glaucoma 3(6) retinal detachment 2(4) cme 2(4) nonseptic vitritis 2(4) iol tilt + 3(6) iol dislocation 1(2) iol tilt ++ 1(2) suture erosion 3(6) limbal suture abscess 1(2) high post op refraction 1(2) graft rejection 1(2) transient striate keratopathy 2(4) endophthalmitis __ graph 2 shows the pre and postoperative median visual acuity in general and in various groups. the median acuity, in general was 0.1 (6/60) preoperatively and 0.5 (6/12) postoperatively. the preoperative median va was again 0.1 (6/60) in all the groups except the group of patients who had planned secondary scleral fixation of iol that was 0.5 (6/12). the obvious reason was that the most of them were aphakic patients with full aphakic correction. average va in general was 0.25 preoperatively and 0.54 postoperatively. median postoperative va was comparable in cases of primary vs secondary iol fixation i.e. (6/12 vs 6/10) and it was on poorer side in miscellaneous group (6/18). this fact was related to number and amount of surgical handling involved in these already compromised eyes. table 4 shows the post operative complications associated with transscleral fixation of iol (graph 3). the most common complication was vitreous haemorrhage in 8 eyes (16%) followed by hyphaema in five eyes (10%). vitreous haemorrhage cleared in all the patients within 1-3 weeks with no residual complications while hyphaema resolved within 3-7 days in all the cases. iol tilt occurred in 4 cases (8%) but it was significant clinically only in one case (2%) and it induced no astigmatic error in the remaining three patients. the gross iol tilt in one patient was related 188 to history of trauma accompanied by vitreous haemorrhage. delayed subluxation of iol occurred in one patient (2%). he was one and a half year post operative when he received some kind of blunt trauma. on examination inferior heptic was found to be fallen back into vitreous cavity and iol was hanging along the superior heptic. post operative glaucoma, striate keratopathy, retinal detachment, cme and aseptic vitritis occurred in two eyes each (4%). fixation suture erosion was seen in three patients. in these patients no scleral flap was raised to bury the fixation sutures. other infrequent complications included limbal suture abscess and high post operative refractive error in one eye each. one of the patients who received corneal graft combined with scleral fixation of iol, had graft rejection 5 months postoperatively. the corneal graft perforated later on and the patients got npl from that eye secondary to intractable glaucoma. discussion designs, fixation sites and indications for iol implantation have changed a lot since their introduction by harold ridley in late 1940s. posterior chamber iol has become clearly the treatment of choice these days. for routine posterior chamber iol implantation an intact posterior capsule is mandatory. anterior chamber iols tried in cases lacking enough posterior capsular support have been noted to carry high risk of post operative complications1-5. to avoid these complications, methods to transsclerally fixate, posterior chamber lenses to the ciliary sulcus, have been developed. malbran and co-authors were the first to report transscleral sulcus fixation of posterior chamber lenses in aphakic patients who had had previous intracapsular cataract extraction2,4,7. after that many surgeons around the world have suggested various alternatives using different kinds of sutures, needles and iol designs. mostly these special devices are not available locally. idea behind my study was evaluation of a simplified technique of scleral fixation of iol in terms of visual outcome and postoperative complications. almost all types of situations mentioned in the literature for scleral fixation of iol were considered in this study. most of the eyes in this study were there with previous history of aphakia planned as secondary iol, (22 eyes), the fact, probably related to still widely practiced icce in pakistan. the eyes having subluxated or dislocated crystalline lenses (11 eyes) along with eyes having posterior capsular rent during routine ecce comprised the second major group (planned as primary scleral fixation 10 eyes). the original surgical technique used in this study was modified after lewis11,12. we used a locally available 10/0 nylon or 9/0 or 10/0 proline suture carried by a manually straightened needle. a 23 gauge hollow needle passed across the eye was used to retrieve the suture across the eye. in this technique a bigger gauge needle was used and one entry was made from inside out. another modification was made after basti et al13. (from patient no 21-50) to minimize the risk of decentration and damage to ciliary vasculature. in this technique 26-30 gauge hollow needles were used and both the entries were made from outside in. this technique is found to be very simple and reproducible any where because nothing special is required. fixation sutures were placed under conjunctiva in 17 patient and suture erosion was noted in 3/17 patients. no suture erosion was noted in remaining 33 patients in whom scleral flaps were fashioned and fixation suture knots were buried underneath it. in 30 patients sutures were tied 1.5 mm posterior to the limbus. post operative ac depth was found to be on higher side in these cases. duffey14, apple15, lubniewski16, r.l. bergren17 and many others have suggested ideal fixation site for this procedure is ciliary sulcus that lies about 1.00 mm posterior to limbus. lee and et al18. have reported no significant difference in post operative ac depth and refraction with varying degrees of suture to limbal distances. horiguchi and hiros19 have suggested a little complicated way to localize ciliary sulcus by transillumination. our clinical assessment of ac depth and postoperative refraction has convinced us that ideal site for fixation suture is 1.00 mm posterior to the limbus. this does affect the post operative refraction. so +1.00d was added to the emmetropic iol power in group a and +0.5d in group b to compensate for slightly posterior placement of iol in the sclerally fixated eyes as compared to routine pc iol implantation. 9/0 nylon or 10/0 prolene sutures were used in most of the cases. in few patients, however 10/0 nylon was used where the preferred sutures were not available. considering long term dependency of the 189 stability of iol on fixation sutures, ideal suture for fixation remains prolene. our study provides useful data about the long term follow up after scleral fixation of iol. our follow up ranged from 8 to 36 months with average of 21.4 months. only 1 patient had a follow up of less than 8 months who actually died 4 months after the surgery. the post operative visual acuity was dependent on the eye's pre operative visual potential. in our study 4 patients had pre existing macular problem and 1 patient had amblyopia. scleral fixation of iol was considered in these patients to improve the quality of vision and to provide all important peripheral vision. 2 patients were there with adherent leukoma and corneal opacity sparing the visual axis, but post operative visual acuity could not be improved due to scar induced astigmatism. conjunctival peritomy, 7-12 mm partial thickness scleral incision, partial thickness scleral flaps at 2 & 8 o’clock for fixation sutures deep anterior core vitrectomy visual outcome in our study was still comparable to and even better than reported in various studies. post operative visual acuity was better or equal to pre operative visual acuity in 48/50 (96%) patients in our study. considering the number of patients, it seems to be quite comparable and even better as reported in various other series2. stark and et al. have reported 23/24 (95.8%)14. while agapitos and lindstrom20 have reported a little poor result i.e. 12/17 (70.58%) in their study. kreshner rm21 has reported 21/30 eyes in the range of 6/12 or better post operatively, while in our study 36/50 (72%) were in the same range post operatively. no.1: no.2: no.3: fig. a: ab externo ab cum interno fixation suture pass no.1: 190 no.2: no.3: fig. b: modified externo ab fixation suture pass spherical equivalent of post operative refraction was in the range of + 2.00d to -6.00d. average refraction was -0.70 d of myopia. one patient with iol exchange had post operative refraction of -6.00 d. refractive surgery was suggested to correct anisometropia but the patient refused. vitreous haemorrhage (16%) and hyphema (10%) was the most frequent complication in our study which is slightly on higher side if compared to other studies. the incidence decreased from 20% to 13.3 % after modification of the technique after basti et al13. hidemann and dunn reported 11% incidence of vitreous haemorrhage and hyphaema22. qazi reported 8.3% incidence of vitreous haemorrhage in his study23. holland and colleagues24 reported no vitreous bleeding in their 115 cases. arkins and steinert22 have discussed the incidence of post operative bleeding in scleral fixation of iol to be varying from 0-22% in various studies. in our study vitreous haemorrhage cleared within three to four weeks with no residual complications. free suture ends tield to the site of maximum convexity on iol haptics incidence of glaucoma was on lower side (4%) as compared to other studies by arkins and steinert22 and holland and co-workers24. this decrease may be related to better selection of the patients as most of the patients were planned as primary or secondary scleral fixation combined with anterior vitrectomy only. only 7 patients were there with complicated nature of surgery like iol exchange or penetrating keratoplasty with iol etc. one out of four patients in our study needed trabeculectomy later on while glaucoma was of transient nature in remaining three patients. incidence of cme is reported to be quiet high in some of the studies as reported by arkins and steinert22 (9-36%). it was only 2% in our study while 6% has been reported by mccluskey and harrisburg2 in their 32 patients. qazi mentioned 1.66% in his study23. ours was in agreement with him and interestingly it was comparable to even routine pc iol implantation (2%)2. 5-10% incidence of iol tilt or decentration has been reported in the literature22. in our study it was 8% and it was clinically significant only in one eye. this decentration occurred 2 weeks post operatively and was related to trauma and accompanied by vitreous haemorrhage. delayed subluxation of iol occurred in one patient (2%). he was one and a half years post operative when he received some kind of blunt trauma. on examination inferior heptic was found to be fallen back into vitreous cavity and iol was hanging along the superior heptic. initially fixation suture knots were buried just under conjunctiva. 3 out of 17 patients had suture erosion. in rest of the patients sutures were buried under scleral flaps and no suture erosion was noted in this group. in our study we had no patient with suture 191 track endophthalmitis, which is one of the most fearsome complications after suture erosion as reported in other studies2,25,26. the incidence of suture erosion and suture track endophthalmitis can be minimized to almost nil by securing the knots properly under scleral flaps. further more this also helps in avoiding the accidental cutting of the fixation suture. in spite of the fact that quite a few eyes had compromised endothelial status preoperatively (specular reflection), but no corneal decompensation was noted. this is one of the major advantages of sclerally fixated iol over an iol placed in anterior chamber. although introduction of modern flexible open loop anterior chamber iol has reduced this problem, still the anterior chamber angle and corneal endothelium mind a lot about any thing placed in their vicinity. incidence of retinal detachment was 4%. it has been reported to vary from 2.7 to 5.4% in various studies22,24. the fact that whether detachment was related to scleral fixation itself, could not be established. too posterior placement of fixation suture may increase the risk of retinal detachment16,22. choroidal effusion was noted in 2 patients (4%) which resolved by itself with no serious sequelae. we were lucky enough to have no suprachoroidal haemorrhage. aseptic vitritis was observed in 2 patients which was easily controlled with intensive topical steroids. we had no case of post operative endophthalmitis in our study, although many studies are suggestive of higher incidence of endophthalmitis in relation to scleral fixation or secondary iol implant than otherwise25. one of the patients who received corneal graft combined with scleral fixation of iol, had graft rejection 5 months postoperatively. the corneal graft perforated later on and the patient was npl from that eye secondary to intractable glaucoma. for comparison of the complications with other studies. conclusion it is impossible with the available information, to reach a firm conclusion regarding sclerally fixated pc lenses. the visual result for most patients with scleralsutured lenses is comparable to that with other lens types. moreover, there is no reason to become somewhat over conscious about the slightly higher risk of complications with scleral-sutured pc iol. these possible complications include an apparently higher risk of vitreous haemorrhage, hyphaema, glaucoma, lens tilt and decentration, retinal detachment, suture exposure and endophthalmitis, and persistent cystoid macular edema. as we have discussed earlier most of these complications can be avoided or minimized by adopting the proper technique. many variables might be changed that could possibly result in a better method for suturing posterior chamber lenses. for example, a change in suture type may help avoid suture breakage and lens dislocation. it may be possible to localize the ciliary sulcus more precisely to ensure that the heptics are positioned in this location; if the heptics are in the sulcus and away from the pars plana, retinal detachment rates may decrease. it may also be possible to improve the coverage of the polypropylene suture knot, thereby preventing exposed suture and suture tract endophthalmitis. refinement in surgical technique may decrease the incidence of lens decentration. a study of routine postoperative use of anti-inflammatory drugs such as fluorbiprofen (ocufen) or diclofenac (voltaren) may show a decrease in the incidence of persistent cystoid macular oedema. changes in the extent or method of vitrectomy also may lessen the incidence of cystoid macular oedema and possible retinal complications. author’s affiliation dr. zia ul mazhry 511e 1, wapda town lahore prof. wasif m. kadri eye unit 1 services hospital lahore reference 1. hahn tw, kim ms, kim jh. secondary intraocular lens implantation in aphakia. j cataract refract surg. 1992; 18: 174-9. 2. mccluskey p, harrisberg b. long term results using scleralfixated posterior chamber intraocular lenses. j cataract refract surg. 1994; 20: 34-9. 3. shock jp lens, in: vaughan dg, asbury t, et al. general ophthalmology. 13th ed. east norwalk: appleton and lange. 1992: 176. 4. shapiro a, leen mm. external transscleral posterior chamber lens fixation. arch ophthalmol. 1991; 109: 1759-60. 5. hussain m, mehmood h, durrani j, et al. secondary implantation of iol. pak. j ophthalmol. 1995; 11: 26-31. 6. solomon k, gussler jr, gussler c, et al. incidence and management of complication of transsclerally sutured posterior chamber lenses. j cataract refract surgery. 1993; 19: 488-93. 7. bleckmann h, kaczmarek u. functional results of posterior chamber lens implantation with scleral fixation. j cataract refract surg. 1994; 20: 321-6. 192 8. girard lj, nino n, wasson n, et al. scleral fixation of a subluxated posterior chamber intraocular lens. j cataract refract surg. 1989; 14: 326-7. 9. smiddy we, sawusch mr, obrien tp, et al. implantation of scleral-fixated posterior chamber intraocular lenses. j cataract refract surg. 1990; 16: 691-6. 10. sulewski me, gottsch jd, haller ja, et al. posterior chamber intraocular lens implantation without capsular support. in: schachat a.p. ed. current practice in ophthalmology. st. louis, missouri. mosby year book inc. 992: 125-144. 11. panton rw, sulewski me, parker js, et al. surgical management of subluxated posterior chamber intraocular lenses. arch ophthalmol. 1993; 111: 919-26. 12. smiddy we. dislocated posterior chamber intraocular lens: a new technique of management. arch ophthalmol. 1989; 107: 1678-80. 13. basti s, tejaswi pc, sing sk, et al. outside-in transscleral fixation for ciliary sulcus intraocular lens placement. j. cataract refract surg. 1994; 20: 89-92. 14. duffey rj, holland ej, agapitos pt, et al. anatomic study of transscleral sutured intraocular lens implantation. am j ophthalmol. 1989; 108: 300-9. 15. apple dj, rabb mf. ocular pathology; clinical applications and self assessment. 4th ed. st. louis: mosby year book inc. 1991: 1-11, 112-65. 16. lubniewski aj, holland eg, van meter ws, et al. histological studies of the eyes with transsclerally sutured posterior chamber intraocular lenses. am j ophthalmol. 1990; 110: 237-43. 17. bergren rl. four point fixation technique for sutured posterior chamber intraocular lenses. arch ophthalmol. 1994; 12: 148587. 18. lee jh, chang jh. suture to limbal distances in eyes with posterior chamber intraocular lens implanted by scleral fixation. j cataract refract surg. 1993; 19: 278-83. 19. horiguchi m, hiros h, koura t, et al. identifying the ciliary sulcus for suturing a posterior chamber intraocular lens by transillumination. arch ophthalmol. 1993; 111: 1693-5. 20. agapitos rj, lindstrom rl. transscleral ciliary sulcus fixation of posterior chamber intraocular lens implants. aust nzj ophthalmol. 1989; 17: 169-72. 21. kreshner rm. simple method of transscleral fixation of a posterior chamber intraocular lens in the absence of lens capsule. j cataract refract surg. 1994; 10: 647-51. 22. arkin ms, steinert rf. sutured posterior chamber intraocular lenses. in: jakobiec fa, adamis ap, volpe nj. eds international ophthalmology clinics. controversies in ophthalmology: current therapies and emerging technologies. boston: little, brown and company. 1994; 34: 67-86. 23. qazi za. retrospective study of 62 patients with transscleral fixation of iol (paper presented at lahore ophthalmo 95 held by ophthalmological society of pakistan in december 1995). 24. holland ej, daya sm, evenglista a, et al. penetrating keratoplasty and transscleral fixation of posterior chamber lens. am j ophthalmol. 1992; 114: 182-7. 25. scott iu, flyman hw, feuer w. endophthalmitis after secondary iol implantation. a case control study. ophthalmology. 1995; 102: 1925-31. 26. heilskov t, joondeph rc, olson kr, et al. late endophthalmitis after transscleral fixation of a posterior chamber intraocular lens. arch ophthalmol. 1989; 107: 1427. microsoft word editorial 1 editorial current status of orbital implants in pakistan anophthalmic socket reconstruction should start at the time of primary surgery. an orbital implant is regarded as the first step for making platform for an ocular prosthesis. not long ago quite a few ophthalmologists in pakistan believed that no implantation should be done at the end of evisceration for endophthalmitis thinking that infection may persist. however, now mostly an appropriate sized acrylic ball is implanted after evisceration and a conformer is inserted. evisceration and acrylic ball implantation is also used by some surgeons in the cases of painful blind eye. similarly after enucleation for ocular malignancy no implantation was done with a false belief that recurrence of tumour may be masked. on the contrary it is now believed that an implant makes detection of recurrence much easier. however, previously available implants had several problems. allen implant has truncated front surface with sharp edges. hence, it not only gives poor volume replacement but there is also an increased risk of wound dehiscence and implant exposure. some surgeons have used acrylic ball wrapped in various donor materials. each material has problems of its own. sclera is scarcely available in pakistan and there is associated risk of microbial transmission. other autogenous materials like fascia lata, temporalis fascia and pericranium have been tried for wrapping the implants. there are several reports of exposure and infection with merselene mesh. all these materials have the associated problem of extended surgical time and risk of disease transmission. as some of these patients undergo postoperative chemo or radiotherapy, there is an added risk of delayed wound healing in donor area. a relatively recent addition to the implants is a family of bio-integrable implants. these implants have minute pores that invite fibro-vascular in growth, hence it becomes part of body or bio-integrates. these implants have advantage of possibility of a peg insertion which allows the prosthesis to be directly connected to the bio-integrated implant and hence improved motility. the implants of this category include hydroxyapatite, medpor, biopore and bioceramic. hydroxyapatite is made up of a naturally occurring coral. it has the associated difficulties of wrapping material. there is also a green lobby against damage to the natural life. other problems associated with these implants are recurrent infection, exposure and cost. an average bio-integrable implant costs approximately us$1000 in pakistan. once the cost of services is added, it becomes out of reach for most of the patients not only in pakistan, but also in other developing countries. the pegging can also be associated with recurrent granuloma formation and dislocation; hence only 10% of these implants get pegged anyway. moreover, some authorities are quite skeptical about the claims of improved motility with the peg. secondary orbital implantation is encountered with even more problems, like exposure, migration and infection. with the onset of implant manufacturing in pakistan the cost has become bearable. moreover; indigenously developed implants like sahaf and ofi (omnifit orbital implant) implants have tried to address quite a few of the problems for pakistani patients. locally manufactured implants are readily available at a fraction of the cost of porous implants which are available after 6 weeks of placement of the order. some of the locally available implants incorporate a magnet, which can be later coupled with a piece of metal in prosthesis to increase motility. reference 1. kelman cd: phacoemulsification and aspiration: a new technique of cataract removal. am j ophthalmol. 1967; 64: 23. 2. saeed m, monis m, cheema am, et al. surgical treatment of anopthalmic socket an experience with 42 intra -orbital implants. j coll physcians surgeon pak. 2000; 10: 175-8. 3. trichopoulos n, augsburger jj. enucleation with unwrapped porous and nonporous orbital implants: a 15-year experience. ophthal plast reconstr surg. 2005; 21: 331-6. 4. ashworth j, brammar r, inkster c. leatherbarrow. a study of the hydroxyapatite orbital implant drilling procedure. eye. 1998; 12: 37-42. 5. jordan dr. problems after evisceration surgery with porous orbital implants: experience with 86 patients. ophthal plast reconstr surg. 2004; 20: 374-80. 6. current trends in managing the anophthalmic socket after primary enucleation and evisceration. ophthal plast reconstr surg. 2004; 20: 274-80. 7. kamal z, girdharilal aa. a review of sahaf orbital implants 1. pak j ophthalmol. 2007; 21: 331-6. microsoft word jagdish bhatia original article eye changes and risk of ocular medications during pregnancy and their management jagdish bhatia, mohammad naqaish sadiq, taqdees anwar chaudhary, agdish bhatia pak j ophthalmol 2007, vol. 23 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: jagdish bhatia specialist department of ophthalmology rustaq hospital, po box: 421 pc: 329, rustaq sultanate of oman. received for publication 2006 …..……………………….. purpose: to review various eye changes during pregnancy and potential risks of eye medications to the mother and her fetus. methods and materials: we performed a literature search through internet using the medical search headings, effect of pregnancy in eyes, ocular changes in pregnancy, eye medication in pregnancy. we also performed a manual search using references from these articles, review articles and standard text books and manufacturers product advice. data extraction: all relevant articles including the original articles, review papers, case studies, and relevant book chapters were extracted and reviewed. conclusion: little has been published to evaluate the eye changes in pregnancy. eye changes in pregnancy are a well established entity in the field of ophthalmology. the risk of giving ophthalmic medicines to pregnant woman is low. the effects of pregnancy on the eyes and there management are reviewed in this article. key words: fetus, ocular changes, ophthalmic medications, physiological eye changes, pathological eye changes, pregnancy. uring pregnancy, various physiological changes take place in body due to the hormonal effects of the placenta. these hormones have effects on most organ systems, including the eyes. this article outlines both normal physiological changes in eye during pregnancy and pathological changes in the eye that can occur from pregnancy. moreover a brief discussion of ocular medications and their potential effects on the fetus are reviewed. through this article we review the following: • the physiological changes in eyes during pregnancy • pathological effects of pregnancy in eyes. • effect of ophthalmic medications in pregnancy. the physiological changes in eyes include the following: the intra-ocular pressure: the normal intra-ocular pressure (the fluid pressure within the eye) may decrease slightly due to certain hormonal and circulatory change1,2. the decrease in intra ocular pressure may persist for several months post-partum. this could be advantageous to patients suffering from glaucoma, a condition where the raised intra-ocular pressure damages the optic nerve that transmits visual information to the brain. contact lens intolerance: the sensitivity of the pregnant mother’s cornea also decreases significantly due to the associated fluid retention of ocular tissues (especially during the last trimester of pregnancy) (1,2) this may cause problems for contact lens wearers who d may traumatize their corneas more than usual, resulting in red, irritated eye and relative contact lens intolerance. change in refraction: the tendency of fluid retention affects your refraction. this means that your current spectacles or contact lenses may be temporarily either too weak or too strong, depending upon your specific refractive error. it is usually a temporary change, and you need not get your eyes re-tested during the later stages of pregnancy and for at least the first 6 weeks after child birth. unless the patient is insisting, it is best to defer prescribing new glasses until several weeks postpartum. dry eyes: some women experience dry eyes during pregnancy. this is usually temporary and goes away after delivery. lubricating eye drops which are safe to use during pregnancy can lessen the discomfort of dry eyes. pathological effects of pregnancy on eyes include the following diabetic patients: pregnancy can have an adverse outcome on the state of pre-existing diabetic retinopathy. the worsening of the disease depends on the severity of diabetic retinopathy before pregnancy. early stages of diabetic retinopathy usually stay quite stable, but the more advanced stages (especially the proliferative diabetic retinopathy stages) tend to progress fast during pregnancy. gestational diabetes poses a very low risk for the development of retinopathy. usually eye examination is not required for pregnant woman who had developed gestational diabetes1,2. in patients who had nonproliferative diabetic retinopathy, studies demonstrated that as many as 50 % of them may show an increase in their nonproliferative retinopathy, which often improves by the third trimester and postpartum. approximately 520 % of these patients develop proliferative changes, the risk being higher in those patients who had severe nonproliferative retinopathy at beginning of their pregnancy. an ophthalmologic examination at least once every trimester is recommended1,2. studies on patients with proliferative diabetic retinopathy have shown that a progression of disease may occur in as many as 45 % of them. however, in those patients who had laser treatment before pregnancy, the risk of progression was reduced by 50 %. hence; initiation of laser photocoagulation is recommended prior to pregnancy. in patients with proliferatve diabetic retinopathy, monthly ophthalmic examinations are warranted. proliferative diabetic retinopathy may regress at the end of the third trimester or postpartum. pan retinal laser photocoagulation is effective during pregnancy in inducing regression of proliferative retinopathy. almost all retinal specialists would aggressively treat patients with high-risk characteristics of proliferative retinopathy as defined by the diabetic retinopathy study. in patients with proliferative diabetic retinopathy that does not meet the high risk criteria, some would treat one or both eyes, given the fact that some patients have progressed rapidly during pregnancy. patients with proliferative diabetic retinopathy cesarean section should be considered to prevent vitreous hemorrhage due to valsalva maneuver used during labor. proliferative diabetic retinopathy are definitely not an indication to terminate the pregnancy. diabetic macular edema may develop or worsen during pregnancy. it may be reasonable to observe such patients until they reach postpartum, especially given that studies have shown that most cases have resolved spontaneously after delivery1,2. it is therefore important for woman with advanced diabetic eye disease to seriously take their visual future into consideration when planning their pregnancy and these decisions should only be made after consultation with their ophthalmologist. the proliferative or advanced diabetic eye changes should be treated and stabilized before planned pregnancy. pregnancy induced hypertension (pre-eclampsia): the onset of hypertension in an otherwise normotensive pregnant woman, with generalized edema and/or proteinurea is termed pregnancy induced hypertension (pih) or pre-eclampsia. if these changes are associated with seizures, then the disorder is classified as eclampsia.the incidence of pih in otherwise healthy women is approximately 5% and is more common in primigravidas. the onset of this disorder usually is after 20th week of gestation. pih has various maternal and fetal consequences, including ocular sequelae in up to one third of cases. the most common ocular complaint is visual blurring; however other symptoms have been reported, including photopsias, scotomas, and diplopia. the protean ocular manifestations include retinopathy, optic neuropathy, serous retinal detachment and occipital cortical changes. the changes that occur in pih induced retinopathy are similar to changes from hypertensive retinopathy. the most common finding is focal arteriole narrowing, which also may be diffuse. other changes may include retinal hemorrhages, retinal edema, cotton wool spots, nerve fiber layer infarcts and vitreous hemorrhage and papilledema. a positive correlation exists between the severity of pih and degree of retinopathy, however most changes are reversible once pih resolves. cortical blindness has also been seen in association with severe preeclamsia/eclampsia around the time of delivery. in the past, changes in retinal vessels were considered a risk factor for placental insufficiency and fetal mortality and induction for delivery3. both an old and a recent study of patients with pre-eclampsia and eclampsia, found that those patients with retinal hemorrhages and cotton wool spots had a higher rate of fetal mortality4. central serous retinopathy (csr): although not typical, csr has been reported to occur during pregnancy5. although more common in third trimester, it has been reported to occur in the first and second trimesters. the diagnosis is clinical one. observation is the treatment of choice as the condition resolves spontaneously in first few months postpartum and has been known to occur in future pregnancies. a weak plus lens (hyperopic correction) may provide temporary visual assistance. intracerebral and other tumors: pituitary adenomas: with pregnancy, previously asymptomatic pituitary adenomas or micro adenomas may enlarge and result in various ophthalmic symptoms, such as headache, visual field change, and / or visual acuity loss. it is recommended that pregnant patients with pituitary adenomas and micro adenomas have monthly ophthalmic follow up with visual field assessment to rule out enlargement. symptomatic pituitary adenomas may require the combined efforts of an ophthalmologist, obstetrician, neurosurgeon, and endocrinologist to decide upon medical, surgical, or radiation treatment. one potentially visual threatening complication of pituitary adenomas is the sudden increase in pituitary size from infarction or hemorrhage referred to as pituitary apoplexy. this condition may present as a sudden onset of headache, visual loss, and / or ophthalmoplegia. pregnancy is one of several potential risk factors for its occurrence. the management of such patients includes a neurosurgical opinion for potential surgical decompression. meningioma of pregnancy: meningiomas are benign, slow growing tumors. meningiomas may have a very aggressive growth pattern during pregnancy that is difficult to manage. they may regress postpartum but may regrow during subsequent pregnancy. often ophthalmic symptoms of decreased vision or visual field loss are the first manifestations. since most of these tumors regress in size postpartum, those patients who are asymptomatic or with mild symptoms can be observed and left untreated. for those patients who require it, treatment usually is surgical. indications for timing and type of intervention require individual analysis. occlusive vascular disorders: it is well appreciated that pregnancy represents a hypercoagulable state in which both clotting factors and clotting activity are increased, through various changes that occur with platelets, clotting factors, and arterio-venous flow dynamics. such changes may be related to the development of central retinal artery and vein occlusion in eye. both branch and central retinal artery occlusions have been reported to occur in pregnancy. retinal vein occlusions are less common than arterial occlusions. toxoplasmic retinochoroiditis: pregnant patients with old toxoplasmic retinochoroiditis are usually concerned about the possibility of transmitting toxoplasmosis to the fetus, but in general they need not to be concerned. congenital toxoplasmosis in the fetus generally results only from active infection of the mother that develops during that pregnancy. the presence of toxoplasmic retinochoroiditis or chorioretinal scars in the mother is regarded as evidence of congenital infection of the mother herself, and does not indicate a new active infection of the mother. in recurrent disease, there are usually pre-existing maternal antibodies that are believed to protect the fetus. therefore, the fetus should not be at risk for contracting congenital toxoplasmosis and its related birth defects from a mother with toxoplasmic retinochoroiditis or chorio-retinal scars. these patients usually are treated in a similar fashion to patients who are not pregnant. however spiramycin has been recommended as a safer effective alternative. miscellaneous disorders: ptosis (drooping of upper eyelid) has been reported to occur during and after normal pregnancy and is usually unilateral. the mechanism is thought to be due to defects that develop in levator aponeurosis from fluid, hormonal, and other changes from the stress of labour and delivery. uveitis: the immunosuppressive effects and high steroid levels present in pregnant women may cause improvement in uveitis during pregnancy, with exacerbation after delivery. this has been noted in patients with sarcoidosus6 and vogt koyanagi-harada syndrome7. conjunctival blood vessels: changes in conjunctival blood vessels have been described toward the end of pregnancy. these changes include a granularity of conjunctival venules, mild spasm of conjunctival arterioles, and decreased visualization of conjunctival capillaries. excessive vomiting during pregnancy can cause conjunctival petechiae. ophthalmic medications in pregnancy “doctor, i am pregnant. can i still use this eye drops?” this is probably one of the most common questions asked by pregnant women when they visit not only to their ophthalmologist, but also their obstetrician or even family physician. perhaps it is also one of the few questions that even ophthalmologist and other doctors of various specialties might have difficulty in answering, especially when they have to present evidence to convince their patients. limited data have been published regarding the potential risk of eye medications to the mother and fetus. when one wishes to administer ophthalmic pharmacologic agents during pregnancy, there should be a clear indication for them. although most ophthalmic medications, in the doses used and the topical mode of administration, have not been implicated in an adverse fetal outcome, thought should go into using drugs only as necessary. however recommendations are summarized as per the fda guide lines below for commonly used eye medication. anti-glaucoma medications: topical beta blockers: (e.g., timolol eye drops) fda risk category c in first trimester while d in 2nd and 3rd trimester. b blockers can cause intrauterine growth retardation if used in 2nd and 3rd trimester and persistent neonatal blockade if used near term. should be avoided during pregnancy8,9. topical and systemic carbonic anhydrase inhibitors (eg, acetazolamide, dorzolamide) are contraindicated during pregnancy because of potential teratogenic effects10. prostaglandin analogs (eg, latanoprost) fda risk category c. not well studied, and the reports that do exist are conflicting. the use of latanoprost / trvoprost is generally contraindicated in pregnant women8,9. mydriatics (dilating drops): use of occasional dilating drops during pregnancy for the purposes of ocular examination is safe. however, repeated use is contraindicated because of potential teratogenic effects of both parasympatholytics (eg, atropine) and sympathomimetics (eg, epinephrine)10. topical corticosteroids: (prednisolone) fda risk category b. although systemic corticosteroids are contraindicated in pregnancy, topical steroids have not been reported to have an adverse effect on pregnancy (10), but the safety of their use has not absolutely been established. therefore, use with care during pregnancy. avoid their prolong use in pregnancy. anti-infection preparations: topical chloramphenicol: fda risk category is not available. it is used widely to treat superficial eye infection because of its spectrum and low cost. many concerns, however, have been documented about this drug’s serious side effects-namely aplastic anemia and ‘grey baby syndrome’. a review article in 2002 concluded that the risk of these serious side effects is low and they are unlikely to occur if patients adhere to the prescribed dose and duration of the treatment.chloramphenicol if given to mother shortly before labor may cause “grey baby syndrome” with cyanosis and hypothermia.chloramphenicol treatment should be avoided during the last week of pregnancy and breast feeding. gentamicin eye drops: fda risk category c. should be avoided in pregnancy. drug should be given only if the potential benefit outweighs the potential risk8,9. ciprofloxacin eye drops: fda risk category c. should be used only if the potential benefit outweighs the potential risk8,9. tetracycline eye ointment: fda risk category d. positive evidence of human fetal risk exists8,9. topical erythromycin: fda risk category b. controlled studies done on animals does not indicate risk to fetus. however no adequate and well controlled studies done on pregnant women. generally considered safe to use in pregnancy8-10. antibiotics which are safe during pregnancy are amoxicillin, ampicilline, benzylpenicilline, cabenicilline, cloxacilline, erythromycine and vancomycin. antibiotics which should be avoided during pregnancy are, gentamycin, streptomycin, neomycin, and kenamycin, flourinated quinolones like norfloxacilline and ciprofloxacilline are not considered safe during pregnancy. antiviral eye preparations (acyclovir eye ointment): fda risk category b. topical acyclovir has not been studied in pregnant woman. however this medicine has not been shown to cause birth defects or other problems in animal studies. so it is considered generally safe for eye application. systemic acyclovir should only be used during pregnancy if potential benefit justifies the potential risk to fetus8,9. fluorescein dye: fda risk category b. no known teratogenic effects of fluorescein during pregnancy exist. most of the retinal specialist avoids fluorescein angiography during pregnancy, especially first trimester. topical anesthetic: no known contraindications exist to use of topical anesthetic drops in pregnancy10. anti-allergic eye drops: sodium cromoglycate 2% (fda risk category b) eye drop is safe to use in pregnancy while antihistaminic eye drops containing naphazoline (fda category c) are better avoided8,9. conclusion little has been published to evaluate the true risk in the use of eye medication during pregnancy the overall level of evidence for risk giving ophthalmic drugs to pregnant women is low. most of the available evidence is based on only individual case reports and animal studies. the topic of this article provides a practical overview for pregnant women and their treating doctors. little has been published to evaluate the eye changes in pregnancy; however most of the physiological eye changes are reversible and doesn’t warrant urgent ophthalmic help. fortunately the pathological eye changes during pregnancy discussed above are extremely rare and occasionally seen in daily ophthalmic practice. opinions from obstetrician, ophthalmologists, and family physicians are essential to ensure safe pregnancy. author’s affiliation dr.jagdish bhatia specialist, department of ophthalmology rustaq hospital, po box: 421, pc: 329, rustaq sultanate of oman mohammad naqaish sadiq consultant ophthalmic surgeon department of ophthalmology rustaq hospital, sultanate of oman taqdees anwar chaudhary consultant gynaecologist sultan qaboos university hospital sultanate of oman agdish bhatia consultant gynaecologist sultan qaboos university hospital sultanate of oman references 1. somani s, iqbal ike k ahmed. pregnancy, special considerations. www.e-medicine.com/oph, 2005; november 7. 2. janet s. sunness, arturo santos. pregnancy and the mother’s eye. duane’s clinical ophthalmology. 1997; 32: 1-19. 3. sadowsky a, serr dm, landau j. retinal changes and fetal prognosis in the toxemias of pregnancy. obstet gynecol. 1956; 8: 426. 4. uto m, uemura a. retinochoroidopathy and systemic state in toxemia of pregnancy. acta soc ophthalmol. 1991; 95: 1016. 5. bedrossian rh. central serous retinopathy and pregnancy. am j ophthalmol. 1974; 78: 152. 6. chumbley lc, kearns tp. retinopathy of sarcoidosis. am j ophthalmol. 1972; 73: 123. 7. steahly lp. vogt-koyanagi-harada syndrome and pregnancy. ann ophthalmol 1990; 22: 59. 8. chung cy, kwok akh, chung kl. use of ophthalmic medications during pregnancy. hong kong med j. 2004; 10: 191-4. 9. drugs in pregnancy and lactation: www.safefetus.com 10. samples jr, meyer sm. use of ophthalmic medications in pregnant and nursing women. am j ophthalmol 1988; 106 : 616-23. 88 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology original article pattern of ocular trauma in tertiary care hospital hussain ahmad khaqan, hassan raza chaudhry, sadia ilyas, abdul hye pak j ophthalmol 2017, vol. 33, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hussain ahmad khaqan eye department lgh/pgmi, lahore e.mail: drkhaqan@hotmail.com purpose: to analyze the etiology and outcomes of ocular trauma. study design: cross sectional descriptive study. place and duration of study: eye department lahore general hospital, lahore from 1st january 2016 to 28th february 2017. material and method: a total of 180 patients hospitalized with ocular trauma were included in the study. study was conducted at the department of ophthalmology, lahore general hospital lahore from 1st january 2016 to 28th february 2017 and data was collected through pre-designed proforma. the data collected composed of age, sex, etiology, pre-treatment and post-treatment visual acuity. patients were stratified in 3 groups a, b and c with respect to pretreatment visual acuity. results: a total of 180 patients with ocular trauma were included in the study. in group a 124 (68.8%) patients had pre-treatment visual acuity pl +ve to 6/60. after treatment visual acuity improved in all patients including 21 (16%) patients with visual improvement to 6/36, 90 (72.5%) patients improved to 6/60 and 13 (10.4%) patients gained vision to hm. in group b 43 (23.8%) patients had pre-treatment visual acuity between 6/36-6/12 out of which 12 (27.9%) patients had vision improved to 6/12, 20 (46.5%) patients had vision gain to 6/24 and 11 (25.5%) patients gained 6/36 vision. in group c 13 (7.2%) patients had pre-treatment visual acuity 6/9-6/6 out of which vision of 2 (15.3%) patients improved to 6/6 and 11 (84.6%) patients gained to 6/9 vision. conclusion: metallic foreign body and road traffic accident were the most pattern of ocular trauma in tertiary care hospital pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 89 …..……………………….. common cause of ocular trauma and improvement in post treatment vision was directly proportional to the severity of pretreatment visual loss. key worlds: trauma, foreign body, vision, etiology, road traffic accident, metallic. cular trauma is a common and unfortunate but preventable disease1. trauma to eyeball forms an important cause of visual impairment in children and in persons associated with various occupations such as welders, electricians and people in glass and steel industry. domestic accidents and assaults each account for approximately one third of injuries2. ocular trauma is the second leading cause of visual loss in us. according to a survey the incidence of ocular trauma in usa is 2.4 million per a year2. ocular trauma includes penetrating and blunt injuries. penetrating injuries are at higher risk of developing endophthalmitis as compared to blunt trauma3. blunt trauma is associated with skin or corneal abrasion, hyphema, posterior vitreous detachment, vitreous hemorrhage and retinal detachment in majority of cases4. injuries caused by sharp objects result in better visual outcome than those caused by blunt objects and injuries limited to anterior segment have better prognosis than those involving the posterior segment5. pediatric age group accounts for a large proportion of ocular trauma . most of the times the source of trauma were household objects i.e knives, fork, pencil, etc6. in young age group road traffic accidents and physical abuse came out to be the leading cause of ocular trauma7. this study was undertaken to identify etiological factors, prognostic indicators and determine effective methods of management. material and method study was conducted at department of ophthalmology, unit 2, lahore general hospital lahore from 1st january 2016 to 28th february 2017. a total of 180 patients with ocular trauma were included in the study. pre-operative assessment was done by visual acuity, pupillary reactions, extra-ocular motility, slit lamp anterior segment examination and indirect ophthalmoscopy for fundus examination. each patient with penetrating ocular injury underwent ctscan orbit and brain to rule out the presence of foreign body. b scan was done in patients with no fundus view. data was collected on pre designed proforma. data included name, age, sex, etiology, pre-treatment va, type of foreign body, investigations done and surgical procedure. patients were stratified in three groups on the basis of pre-treatment va. group a had va pl+ve6/60 and included 124 patients, group b had va 6/36-6/12 and included 43 patients and group c had va 6/9-6/6 and included 13 patients. post treatment visual acuity was recorded in all patients. data was analyzed by using spss (statistical package for social sciences) version 22. frequencies and percentages were computed for all categorical variables while mean and standard deviations were computed for all numerical variables. results 52 (28.8%) patients less than 10 years of age presented with ocular trauma. 147 (81.6%) male presented with ocular trauma as compared to females 33 (18.3%). a total of 53 (29.4%) patients had metallic foreign body trauma, 37 (20.5%) patients had road traffic accident trauma to eye. in group a 124 (68.8%) patients had pre-treatment visual acuity pl +ve to 6/60. after treatment visual acuity improved in all patients including 21 (16%) patients vision improved to 6/36, 90 (72.5%) patients vision improved to 6/60 and 13 (10.4%) patients vision gain was hm. in group b 43 (23.8%) patients had pre-treatment visual acuity between 6/36-6/12 out of which 12 (27.9%) patients had vision improvement to 6/12, 20 (46.5%) patients gained vision to 6/24 and 11 (25.5%) patients gained 6/36 vision. in group c 13 (7.2%) patients had pretreatment visual acuity of 6/9-6/6 out of which 2 (15.3%) patients had vision improvement to 6/6 and o hussain ahmad khaqan, et al 90 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology 11 (84.6%) patients gained 6/9 vision. there were 109 (44.4%) patients who had right eye trauma while 44 (55.6%) had left eye trauma. lid lacerations were associated with all road traffic accidents. table 1: demographic characteristic of patients. variables n (%) total patients admitted (n = 1667) ocular trauma patients 180 (10.79%) eye affected (n = 180) right eye 109 (60.5%) left eye 71 (39.4%) gender male 147 (81.6%) female 33 (18.3%) table 2: stratification of visual acuity with respect to pre and post-treatment condition. visual acuity pre-treatment post-treatment pl – 6/60 124 (68.8%) 21 (16%)-6/36 90 (72.5%) -6/60 13 (10.4%) –hm 6/36 – 6/12 43 (23.8%) 12 (27.9%)6/12 6/96/6 13 (7.2%) 20 (46.5%)-6/24 11 (25.5%)-6/36 2 (15.3%)-6/6 11 (84.6%)-6/9 table 3: cause of injury source no of patients (%) glass 6 (7.5%) knife 30 (20.5%) screw driver 2 (2.5%) mirror 3 (3.37%) pen 4 (5.1%) rta 37 (20.5%) scissor 2 (2.5%) pencil 9 (11.2%) syringe needle 1(1.25%) needle 2 (2.5%) broken saucer 1 (1.2%) blade 2 (2.5%) knitting needle 3 (3.75%) clipper 2 (2.5%) metal piece ( metal grinder) 53 (29.4%) beak of bird 2 (2.5%) nail 13 (7.2%) hammering 9 (5.1%) table 4: stratification with respect to age group. age group (yr) number (%) ≤ 10 58 (28.8%) 11 – 20 42 (23.3%) 21 – 30 51 (28.3%) > 30 29 (16.1%) as total 180 cases were enrolled and 53 were metal piece injury and 1 case was of syringe needle injury so metal piece injury came out to be statistically significant (p˂ 0.005). discussion ocular trauma is the leading cause of acquired monocular blindness in children and young adults with a male preponderance; the former accounting for pattern of ocular trauma in tertiary care hospital pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 91 20% to 50% of all ocular injuries8. in our study 88.8% were male and 24% of patients were lying in less than 10 year of age group. a review, undertaken for planning purposes in the who program for the prevention of blindness, suggests that around 55 million eye injuries responsible for restricting activities for more than one day, occur annually; they account for 750,000 hospitalized cases each year while our study included 180 patients suffering from ocular trauma from jan 2016 to feb 2017. there are approximately 200,000 open-globe injuries; with around 1.6 million people blind from such injuries, 2.3 million people with bilateral poor vision from this cause, and almost 19 million people with unilateral blindness or low vision9 and in our study 10 patients got hm visual acuity. our study focuses on the causes of eye injuries, age group mostly affected, gender and final visual acuity in these patients. young and children are more susceptible to the ocular trauma, in our study 30.5% children and 50% young age groups were involved because of their occupational hazards, immature motor skills and curious nature. a marked preponderance of injuries is seen in 6-10 years of age group. adult supervision has been found to be an important factor in the prevention of injuries to children. infants and children of less than 3 years of age sustain fewer injuries because of close supervision by parents. in our study the mean age of child was high (8.09 years). a study was conducted in cairo where 146 unilateral and 3 bilateral cases of ocular trauma were included10 while unilateral involvement occurred in 100% of cases in our study. males are affected more than females, because boys generally are granted more liberty than girls in our society and they tend to spend more time outside11. in our study we also found higher number of males affected compared to females (88.8%). a study concluded that the most frequent finding among ocular trauma in their setting was laceration by sharp object and blunt ocular trauma12 and in our hospital the most frequent finding was corneal laceration and mostly caused by glass, mirror and knife. the results obtained suggested that socioeconomic and socio cultural status and family negligence are important factors in eye injuries in children that occur during games13. factors predicting final visual outcome after open globe trauma include mechanism or type of injury, preoperative visual acuity14, time lag between trauma and surgery15, relative afferent pupillary defect16, size and location of the wound, hyphema17, lens rupture18, vitreous loss, vitreous hemorrhage, retinal detachment19, intraocular foreign body20. prompt visit to hospital and appropriate management21,22 at time is the key to avoid the loss of preventable vision as well as restoration of anatomy22. at the time of presentation the mean visual acuity was less than 6/60 which was consistent with other surveys held in usa23, singapore24 and iran25. the final visual acuity was related to pre-operative vision. timely and appropriate management of ocular trauma may improve the prognostic value and restoration of ocular anatomy. damage by ocular trauma may cause blindness which is preventable. so, after getting injury early treatment may prevent from gross visual morbidity provided pre-treatment visual acuity is better. conclusion metallic foreign body and road traffic accident were the most common cause of ocular trauma and improvement in post treatment vision was directly proportional to the severity of pretreatment visual loss. author’s affiliation dr. hussain ahmad khaqan fcps (ophth), fcps (vr), frcs assistant professor lgh, lahore dr. hassan raza ch post graduate resident lgh, lahore dr. sadia ilyas post graduate resident lgh, lahore prof. abdul hye professor lgh, lahore role of authors dr. hussain ahmad khaqan surgical procedure, performa design dr. hassan raza ch data analysis, article writing dr. sadia ilyas data collection hussain ahmad khaqan, et al 92 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology prof. abdul hye proforma design references 1. wong ty, tielsch jm. epidemiology of ocular trauma. in: tasman w, jaeger ea, eds. duanes clinical ophthalmology. revised ed. philadelphia: jb lippincott 1998; 5: chapter 56: 1-13. 2. american academy of ophthalmology. eye health statistics. accessed september 7, 2016. 3. long j, tann t. orbital trauma. ophthalmol clin north am. 2002 jun; 15 (2): 249-53. 4. kuhn f, morris r, witherspoon cd. birmingham eye trauma terminology (bett): terminology and classification of mechanical eye injuries. ophthalmol clin north am. 2002 jun; 15 (2): 139-43. 5. kuhn f, maisiak r, mann l, mester v, morris r, witherspoon cd. the ocular trauma score (ots). ophthalmol clin north am. 2002 jun; 15 (2): 163-5. 6. s dulal, jb ale, yd sapkota. profile of pediatric ocular trauma in mid western hilly region of nepal. nep j oph 2012; 4 (1): 134-137. 7. bailey rn, indian rw, zhang x, geiss ls, duenas mr, saaddine jb et al. visual impairment and eye care among older adults—five states, 2005. mmwr morb mortal wkly rep 2006; 55 (49): 1321–1325. 8. mcgwin g jr, xie a, owsley c. rate of eye injury in the united states. arch ophthalmol. 2005; 123 (7): 970976. 9. dang s. eye injuries at work. american academy of ophthalmology [online.] february 22, 2016. 10. soliman mm, macky ta. pattern of ocular trauma in egypt. arch clin exp ophthalmol (2008) 246: 205.205– 212. 11. mccormack p.ed. penentrating injury of the eye. br j ophthalmol. 1999; 83: 1101-4. 12. esmaeli b, elner s, schark a, et al. visual outcomes and ocular survival after penetrating trauma. ophthalmology, 1996; 102: 393-400. 13. kim jh, yang sj, kim ds, kim jg, yoon yh. fourteen-year review of open globe injuries in an urban korean population. j trauma, 2007; 62 (3): 746–749. 14. tielsch jm, parver l, shankar b. time trends in the incidence of hospitalized ocular trauma. arch ophthalmol. 1989; 107: 519-523. 15. joanne k et al. ocular trauma in the united states. arch ophthalmol. 1992; 110 (6): 838-842. 16. gilbert cm, soong hk, hirst lw. a two year prospective study of penentrating ocular trauma at the wilmer ophthalmological institute. annals of ophthalmology, 1987; 19 (3): 104-106. 17. shokunbi mt, agbeja am. ocular complications of head injury in children. child's nerv syst 1991; 7: 147−149. 18. nash ea, margo ce. patterns of emergency department visits for disorders of the eye and ocular adnexa. arch ophthalmol. 1998; 116: 1222-1226. 19. roh s, patron me. images in clinical medicines. ocular trauma due to a water-bottle cap. n engl j med 2008 may 22; 358 (21): 2265. 20. richard j, peter a. visual outcomes after blunt ocular trauma. ophthalmology; aug 2013: 1588–1591. 21. eagling, em. ocular damage after blunt trauma to the eye. its relationship to the nature of the injury. br j ophthalmol. 1974; 58: 126–140. 22. jones, np, hayward jm, khaw pt et al. function of an ophthalmic "accident and emergency" department: results of a six month survey. br med j (clin res ed). 1986; 292: 188–190. 23. shoja mr, miratashi am. pediatric ocular trauma. aeta medica iranica 2006. 2006; 44 (2): 125–30. 24. cillino s, casuccio a, di pace f, pillitteri f, cillino g. a five-year retrospective study of the epidemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in a mediterranean area. bmc ophthalmol. 2008; 8: 6. 25. brophy m, sinclair sa, hostetler sg, xiang h. pediatric eye injury-related hospitalizations in the united states. pediatrics. 2006; 117 (6): e1263–71. microsoft word editorial 25,2,09 68 editorial repeat enhanced wake up call endophthalmitis post operative endophthalmitis is a grave complication with disastrous consequences refer to a review article on this important topic by khawaja khalid shoaib page 111 of present issue and an unusual case report of endogenous endophthalmitis by mustafa iqbal etc at page 116 also present issue of pjo by prof. m lateef chaudhry editor-in-chief. recently increasing incidence of endophthalmitis is being observed after cataract surgery. possible factors may be • inadequate sterilization due to frequent electricity breakdowns. • socio-economic factors compelling cutting corners in standard practices leading to reusing leftover fluids, viscoelastics, repeated usage of blades, knives, cannulas and perhaps lesser observance of phaco hand pieces sterilization for each procedure. • hot weather • undue reliance on efficacy of antibiotic drops claimed by drug companies i wish to remind all the colleagues regarding the standard surgical practices which have evolved over the time for safer cataract surgery in particular. 1. preop thorough general examination of the patient, the surgical field, eye and its adnexa especially lacrimal passages and adoption of standard aseptic measures and precautions. 2. preop use of antibiotic drops in both eyes for about a few days. 3. pyodine iodine 10% solution for operative site preparation, particularly its application to lid margins and eye lashes. 4. pour a few drops of 5% pyodine in conjunctival sac for 3 minutes before surgery and then wash out. 5. management of incision in cases where it is not properly constructed particularly after using blunt knife, in young myopic and elastic corneo-scleral cases, wound burns, by applying a suture (sleep stitch) besides wound hydration etc. 6. use intracameral or subconjunctival antibiotic or irrigate the conjunctival sac with antibiotic solution. i prefer subconjunctival to intracameral to avoid dosage calculation errors though it may be some what painful or cause unsightly subconjuntival hemorrhage at times. 7. after removal of speculum at the conclusion of surgery again instill a few drops of 5% pyodine in conjunctival sac. 8. use opsite or some other drape to cover the lid margins and eyelashes during surgery. 9. do not let a pool of fluid collect in the conjunctival sac in deep set eyes and in cases where conjunctival swelling occurs due to subconjunctival collection of irrigating solution. 10. avoid performing hydration of wound in a pool of fluid in conjunctival sac. 11. start post operative antibiotic and steroid drops around six hours after surgery. 12. remove all the lenticular remanants in the capsular bag, and anterior chamber and angle recess etc. 13. avoid posterior capsular tear and if it does happen then the anterior and posterior segments should be meticulously cleaned and managed. 14. use injectors for inserting intraocular lens in foldables. 15. take special cautions in temporal clear corneal incisions. i also requested a very talented and experienced ophthalmologist professor shahid wahab of karachi 69 to give his valuable guidelines regarding early detection and timely management of endophthalmitis which are as follows. postcataract surgery endophthalmitis cataract surgery is most frequently performed procedure. endophthalmitis is the most serious complication of intra ocular surgery. prevention of this is most important issue. predisposing factors are indiscriminate use of steroids. poor hygiene, gaps in sterilization, diabetes, no stitch surgery & high reliability on antibiotics. there is a increased risk in summer months1. management depends upon history & symptoms such as pain, decreased vision & redness. in 30% cases there is no pain. on examination, lid swelling, conjunctival congestion/ chemosis, corneal shine may become dull, hypopyon is present in most of the cases. on diagnosis prompt action is mandatory. anterior chamber and vitreous tap should be done in strict aseptic measure. the european society of cataract & refractive surgery, endophthalmitis study2 clearly indicates that intracameral antibiotic agents should play a role in endophthalmitis prophylaxis. third generation cephalosporine is better than others. cefuroxime injection lowers the chances of bacterial contamination by a factor of 5. this means that the risk rate is reduced to less than 5 in 10,000 cases. in practical terms,3 taking 750 mg of cefuroxime powder and diluting it by yourself to a concentration of 1 mg/0.1 ml exposes you to all of the risks of kitchen pharmacy, with errors in dilution, a possible induction of toxic anterior segment syndromes and the frightening possibility of contamination, for example with pseudomonas, against which cefuroxime is not effective. escrs has recommended intra cameral antibiotics, they have proved it in an extensive study. american ophthalmologists do not agree with these findings. endophthalmitis is a horrifying thing to happen. in my opinion, there is always a lapse/gap in the care of the patient at any one stage. a big team is involved in the care of the patient. to find a gap, we have to follow the patient from the first visit to the stage of endophthalmitis. in history, we might have missed some thing like diabetes, decreased immunity, patient may be on steroids for long time. once i encountered a patient who was using antibiotics for three months, status of lacrimal sac and ear infection is also important. the gaps can be the following; • poor hygiene • dilating drops bottle touching eye lashes of the patients in clinic ( cross infection) • no preoperative prophylactic drops • instilling of drops in surgery • proper scrubbing of all staff • pre op: cleaning of surgical area and eye lashes • opsite use • povidone-iodine 5% wash • corneal abrasion • gaps in surgical procedure a. pooling of fluid in the medial canthus b. bad practices by surgeon c. posterior capsular rupture d. long duration of surgery • lack of downward displacement of air removal from theatre ( in some theatres there is a fan being used) • sterilization of instruments / methylcellulose reuse • phaco probe reuse • secure wound/suture less wound should not breath with blinking • no post op: sub conjunctival injection • no post op slit lamp examination to see any sign of infection • proper follow up/medication • teaching patients how to instill drops • teaching patients how to clean the eye • load shedding / summer / sweating • education & counseling of patient for hygiene • cleaning hands before instilling drops / infection in tooth or ear infection • eye camps having endophthalmitis is a bad experience for surgeon, patient and his family. some surgeons have gone to the extreme and care swings to two extreme ends. one surgeon thought that it occurs because of tooth infection so he used to get all doubtful teeth removed before surgery. some surgeons think that prophylactic antibiotics preop & sub conjunctival is not necessary. first it should not happen. if at all it happens there should be early diagnosis & management. after all, 70 the ultimate responsibility is of the surgeon who interfered with the quiet eye. overall recovery depends on the virulence of the organism and keen interest & knowledge of surgeon. research is done to bring new medication & vitrectomy machines. i think research should be done to improve standards of work and find out the gaps in a procedure where so many people are involved. we are talking now the evidence based ophthalmology. i think we are not collecting evidence properly. we must have registry where all endophthalmitis cases are reported. few months back in one hospital, there were forty endophthalmitis cases in one day. prophylaxis only by antibiotics, pre, peri and post operative will not solve the problem, it may reduce the incidence. cause of endophthalmitis is a gap, in one step of the whole procedure. giving antibiotics will not solve the problem. we have to standardize the procedure and make a strict checklist of each step like even up to the post operative patient’s poor hygiene. guidelines for acute post operative endophthalmitis background information: endophthalmitis is an inflammatory condition of the intraocular cavities (ie, the aqueous or vitreous humor) usually caused by infection. noninfectious (sterile) endophthalmitis may result from various causes such as retained native lens material after an operation or from toxic agents. the 2 types of endophthalmitis are endogenous (ie, metastatic) and exogenous. endogenous endophthalmitis results from the hematogenous spread of organisms from a distant source of infection (eg, endocarditis). exogenous endophthalmitis results from direct inoculation as a complication of ocular surgery, foreign bodies, and/or blunt or penetrating ocular trauma. most cases of exogenous endophthalmitis (about 60%) occur after intraocular surgery. when surgery is implicated in the cause, endophthalmitis usually begins within 1 week after surgery. in the united states, postcataract endophthalmitis is the most common form, with approximately 0.1-0.3% of operations having this complication, which has increased over the last 3 years. management of endophthalmitis prompt clinical diagnosis: history patients with acute postoperative endophthalmitis typically present within 6 weeks of intraocular surgery with moderate to severe eye pain and decreased vision. physical • the hallmark findings on ophthalmic examination are posterior and anterior chamber inflammation. • hypopyon is present in most cases. • other important findings include conjunctival hyperemia and chemosis, corneal edema, wound abnormalities, eyelid or orbital inflammation. • in rare circumstances, patients may develop chronic, infectious endophthalmitis months to years after intraocular surgery. these patients exhibit indolent inflammation, which is initially responsive to corticosteroids, but over time, become refractory to therapy. although conjunctival hyperemia, corneal edema, and anterior and posterior chamber inflammation are often present, rapid deterioration of vision and hypopyon are not seen frequently. once the diagnosis has been made, or strongly considered, prompt action is needed. final visual outcome is heavily dependent on timely recognition and treatment. perform ac and vitreous tap within one hour of clinical diagnosis perform vitreous tap in operation theatre under strict aseptic conditions using phaco/vitrector or portable vitrector. also perform ac tap for microbiology. microscopy and gram stain results are available after one hour, pathogen culture results after 24 hours and antibiotic sensitivity testing results after 24 to 48 hours using conventional methods. inject empirical choice of antibiotics instill intravitreal antibiotics at the same time using separate syringes and 25 or 30 g needles for each drug either directly through pars plana or by injecting through the sclerotomy wound if present. vancomycin hydrochloride (vancocin, vancoled, lyphocin) adult 71 intravitreal: 1 mg in 0.1 ml subconjunctival injection: 25 mg pediatric not established ceftazidime (ceptaz, fortaz, tazicef, tazidime) third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against grampositive organisms; higher efficacy against resistant organisms. arrests bacterial growth by binding to one or more penicillin-binding proteins. adult intravitreal: 2.25 mg in 0.1 ml subconjunctival: 100 mg pediatric not established dos and don’ts of intravitreal antibiotics: o never return the diluted drug to the same or original vial for further dilution. o never dilute at greater than 1 in 10. o do not use syringes more than once. o do not reuse bottles. o avoid use of drugs with preservatives if possible. o do not point the needle towards the retina. o do inject the drugs slowly over 1 to 2 minutes intravitreal dexamethasone? to minimize acute inflammation associated with the bacterial process there is a current view to inject unpreserved dexamethasone 0.4mg in 0.1ml intravitreally at the same time as the antibiotics. how to prepare intra vitreal drugs? vancomycin (1mg/0.1ml). reconstitute one vial of 250 mg and make up to 10 ml with sterile normal saline in a sterile bottle with lid. mix well. withdraw 2ml accurately and add to 3ml of sterile normal saline in a sterile bottle with lid. mix well. use 0.1ml. ceftazidime (2mg/0.1ml). reconstitute one vial of 500mg and make upto 10ml with sterile normal saline in saline in a sterile bottle with lid. mix well. withdraw 2ml accurately and add to 3ml of sterile normal saline in a sterile bottle with lid. mix well. use 0.1ml. when to repeat intravitreal antibiotics? intravitreal antibiotics can be repeated as necessary according to the clinical response at intervals of 48 to 72 hours. systemic antibiotics for acute virulent endophthalmitis begin adjunctive systemic therapy with the same antibiotics as those used intravitreally for 48 hours to maintain higher levels within the posterior segment of the eye. role of systemic corticosteroids oral administration of prednisolone (1mg/kg body weight) one day after intravitreal antibiotic therapy may be considered. referral to vitreoretinal surgeon if possible do refer to a vitreoretinal surgeon for an opinion on a full vitrectomy. medical treatment has advantage of time over completeness. while it ignores fundamental surgical principles of ‘’where there is pus, let it out’’ and provides a smaller sample, it permits earlier injection of intravitreal antibiotics and earlier microbiology. it also buys time pending the availability of a vitreoretinal surgeon and vitreoretinal operating room. observe the patient keep the patient under strict supervision, which may even merit admission and observe for the signs of inflammation. however keep in mind that usually inflammation becomes worse before becoming better again. references 1. rubio ef. climatic influence on conjunctival bacteria of patients undergoing cataract surgery. eye 2004; 18: 778-784 2. barry p, seal dv, gettinby g, et al. escrs study of prophylaxis of post operative endophthalmitis after cataract surgery: preliminary report of principal resultfrom a european multicenter study; the escrs endophthalmitis study group. j cataract refract surg 2006; 32:407-410 3. barry p. september 12, 2006 escrs endophthalmitis study confirms cefuroxime's role in reducing infection risk http://www.osnsupersite.com/view.aspx?rid=18342 prof. shahid wahab karachi 72 microsoft word mahtab alam 73 original article is the nd: yag laser a safe procedure for posterior capsulotomy? mahtab alam khanzada, shafi muhammad jatoi, ashok kumar narsani, syed asher dabir, siddiqa gul pak j ophthalmol 2008, vol. 24 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mahtab alam khanzada department ophthalmology liaquat university eye hospital hyderabad. received for publication october’ 2007 …..……………………….. purpose: to evaluate the complications during and following nd: yag laser posterior capsulotomy. material and methods: this study was conducted in the department of ophthalmology liaquat university of medical & health sciences, hyderabad, from april 2006 to july 2007. three hundred and twenty patients with significant pco, after performing pre-laser assessment were subjected to laser treatment. nd: yag laser posterior capsulotomy was carried out with q-switched, syl 9000 yag laser system, under topical anesthesia with abraham’s capsulotomy lens. these patients were assessed for post-laser visual acuity and possible complications just after one hour of laser treatment and at the end of first week, 2nd week and 4th week. the post laser treatment was advised to each patient as needed. result: out of 320 patients 200 (62.5%) were males and 120 (37.50%) were females. the mean time interval between cataract surgery and nd: yag laser posterior capsulotomy was 2.5 years. during and following nd: yag laser capsulotomy out of 320 patients 30 patients (9.37%) developed intraocular lens (iol) pitting, ten patients (4.68%) developed rise in intraocular pressure (iop), two patients (0.62%) showed rupture in anterior vitreous face(avf), two patients (0.62%) developed cystoids macular edema(cme). the best corrected visual acuity (va) of 6/9 – 6/6 was achieved in 310 eyes (96.87%); where as only 10 eyes (3.12%) did not have significant improvement in visual acuity. conclusion: the nd: yag laser capsulotomy is a safe, effective out patient procedure to create an opening in opaque posterior capsule for the improvement in vision. n last two decades resurgence of refined techniques of extra capsular cataract extraction (ecce) surgery not only reduced the rate of complications like cystoids macular edema (cme), vitreous loss and retinal detachment (rd) compared to intra-capsular cataract extraction (icce) surgery, but the intact posterior capsule also encouraged the implantation of posterior chamber (pc) intraocular lens (iol) for achieving good vision. posterior capsule opacification (pco) is the most common complication after ecce surgery1-3. incidence of pco is about 18% to 50% by two years post operatively1,14. it causes reduction in visual acuity (va) and contrast sensitivity by obstructing the view or by scattering the light that is perceived by patients as glare1,2,5. it also decreases the field of view during therapeutic and diagnostic procedures6, and also causes uni-ocular diplopia6. i 74 nd: yag laser posterior capsulotomy is the most frequently performed procedure after ecce surgery because pco is a natural consequence of ecce surgery. the use of nd: yag laser for posterior capsulotomy has been gradually replacing surgical capsulotomy7, because it is safe effective out patient procedure8,9. although cheap and less invasive than surgical capsulotomy this procedure is never the less thought to be associated with numerous complications which are infrequent but most of them have serious implications on the patients vision. these include raised intraocular pressure10-16, cystoids macular edema10-12,14,17-20, retinal detachment11,14,15,18,21 anterior vitreous destruction and opacification13,22, iol damage and decentration10,14,24,25, posterior sub-luxation of iol into vitreous cavity24, lowering of endothelial cell count of the cornea8 and macular haemorrhage26. the purpose of our study was to evaluate the complications during and following nd: yag laser posterior capsulotomy in eyes free of pre-existing ocular pathology like glaucoma and diabetic retinopathy that might preclude accurate analysis of post laser complications. material and methods three hundred and twenty patients for this quasi experimental study were randomly selected from the out-patients department of liaquat university of medical and health sciences, eye hospital, hyderabad, from april 2006 to july 2007. only those patients who had significant pco and met the following inclusion and exclusion criteria were included. inclusion criteria 1. elderly patients having uneventful extra capsular cataract extraction (ecce) with posterior chamber iol implant. 2. patients having more than three months follow-up after cataract surgery. 3. patients having decreased best corrected vision of two or more lines. exclusion criteria 1. patients below 15 years of age. 2. simple extra capsular cataract extraction. 3. dislocated iol. 4. iol implant in traumatic cataract. 5. patients having combined procedure (trabeculectomy with pc iol). 6. patients diagnosed as a case of diabetic retinopathy or any other retinal disease. 7. cases with postoperative complications such as endophthalmitis. the pre-laser best correct visual acuity (bcva) was assessed with snellen’s chart. on slit lamp examination intraocular pressure with haag streit applanation tonometer, anterior and posterior segment abnormal findings were recorded, in all patients on printed proforma. after performing pre-laser assessment, the patients were subjected to laser treatment. before treatment 1% tropicamide (mydriacyl) eye drops were instilled to dilate the pupil and the cornea was anaesthetized with topical application of either 0.5% proparacaine hydrochloride (alcaine) or 0.4% benoxinate hydrochloride (novesine) eye drops using abraham’s posterior capsulotomy lens. qswitched nd: yag laser (syl9000 yag laser system) was used to make a hole of 2-3mm in the posterior capsule using 1.5 to 5mj per pulse. the energy and pulses were increased gradually according to thickness of capsule until an opening was achieved. following the capsulotomy 0.1% diclofenic sodium (naclof) eye drops were advised thrice in a day for one week and antiglaucoma therapy was advised when needed. then patients were reviewed for assessment of best-corrected visual acuity and for possible complications just one hour after the treatment and at the end of 1st week, 2nd week and 4th week. results out of 320 patients who underwent nd: yag laser posterior capsulotomy, 200 (62.5%) were male and 120 (37.50%) were female (table-1). the mean time interval between cataract surgery and nd: yag laser posterior capsulotomy was 2-5 years (table-2). complications were encountered in 13.8% (44 eyes). this ratio is very small because power setting were very low and we increased the pulses and energy (table 3) according to thickness of pco and response in each case. the number of pulses required in creating an opening in the posterior capsule varied from 3 to 5 and averaged 24 and the energy level ranged from 1.5 to 5 mj and mean was 3.2 mj (table 4). the total energy delivered (total energy = power into total number of pulses) to get a significant opening in the posterior capsule varied between 12 to 180 mj and averaged 48.8 mj (table 4). 75 table 1: gender distribution sex no. of cases n (%) male 200 (62.5) female 120 (37.5) total 320 (100) thirty out of 320 patients (9.4%) developed iol pitting during laser capsulotomy without significant decrease in va (table 5). ten out of 320 patients (3.1%) developed raised iop within 24 hours laser treatment. post laser iop measured 8 to 10 mmhg more than normal (table 5). table 2: time interval between pco development and nd: yag laser treatment time interval (years) no. of cases n (%) 01 80 (25) 02 120 (37.5) 03 70 (21.9) 04 50 (15.6) total 320 (100) table 3: summary of energy level used for capsulotomy energy level (mj) no. of cases n (%) 1.5 – 2.0 90 (28.1) 2.1 – 2.5 60 (18.8) 2.6 – 3.0 50 (15.6) 3.1 – 3.5 60 (18.8) 3.6 – 4.0 20 (6.3) 4.1 – 4.5 25 (7.8) 4.6 – 5.0 15 (4.7) total 320 (100) two out of 320 patients (0.6%) showed ruptured anterior vitreous face with forward displacement of vitreous in anterior chamber (ac) between pupil margin and haptic (5.25 mm) of small size iol (table 5). two patients (0.6%) developed cme especially in those patients who presented early than other cases for nd: yag laser capsulotomy. in these patients the va was good (6/9) initially but declined gradually to 6/36 (table 5). table 4: summary of total energy level used for capsulotomy energy level (mj) no. of cases n (%) 12 – 36 96 (30.0) 37 – 60 102 (31.9) 61 – 84 56 (17.5) 85 – 108 40 (12.5) 109 – 132 16 (5.0) 133 – 156 5 (1.6) 157 – 180 5 (1.6) total 320 (100) table 5: complications of nd: yag laser type no. of cases n (%) iol pitting 30 (9.4) raised iop 10 (3.1) vitreous in ac 2 (0.6) cystoids macular edema 2 (0.6) total 44 (13.8) table 6: comparison of pre & post yag laser visual acuity visual acuity pre laser n (%) post laser n (%) cf – 6 / 60 40 (12.5) 05 (1. 6) 6 / 36 – 6 / 24 100 (31.2) 03 (0.9) 6 18 – 6 / 12 180 (50.0) 02 (0.6) 6 / 9 – 6 / 6 00 (0.0) 310 (96.9) total 320 (100) 320 (100) 76 discussion nd: yag laser posterior capsulotomy is a frequently performed procedure after ecce surgery because pco is the most common complication after cataract surgery and more frequent in children and younger adults27-30 although the latest techniques of cataract surgery are being used. in the study of 320 cases the time interval between cataract surgery and nd: yag laser posterior capsulotomy was 2.5 year (range 1 to 4 years), while it was reported as 2.49 year by hasan ks, et al14, and two year in a national study31. we know that yag laser capsulotomy is cheap, effective and safe procedure but not free from complications. during laser treatment complications that we faced were; 1. iol damage (iol pitting). hassan ks et al has noted iol pitting 19.8% in a study of 86 eyes14 and haris ws noted 11.7% significant marks on iol during laser capsulotomy in 342 eyes32. these results are comparatively high with our results that were 9.4% (30 eyes) in 320 eyes and none of them accounted for significant visual impairment. the retro-focusing of laser aiming beam can reduce the risk of iol damage19 but we observed that in spite of retro focusing the high energy level can damage the low quality iol. 2. rasied intra ocular pressure: the incidence of raised iop after laser capsulotomy has been documented in the different studies30,32-35. different explanations which have been given for the pressure rise following nd: yag laser treatment include the deposition of debris in the trabecular mash work30,36 pupillary block37,38, and inflammatory swelling of the ciliary body or iris root associated with angle closure35. one author in a study of laser posterior capsulotomies at moorfileds eye hospital london, noted 13 patients to have iop over 23mmhg and 9 patients to have iop between 30-48mmhg, within 2-3 hours after laser capsulotomy. in this group of 24 patients there was a tendey for iop to rise when higher pulse energies were used, particularly when these exceeded 1.5 mj and the raised iop was generally controlled with antiglaucuma therapy19. hussain mm in his study of 125 eyes treated with nd: yag laser for capsulotomy noted 25-30 mmhg rise in iop in 1.6% cases13, where hassan ks et al noted 6 mmhg elevation in iop after laser capsulotomy, 37.9% in aphakic eyes out of 29 eyes and 16.07% in pseudophakic eyes out of 57 eyes13. average 10 mmhg rise in iop in one third of patients with nd: yag laser has been recorded by some authors30,34. in our study rise in base line iop was 8-10 mmhg in 10 eyes (3.1%) during 1st 24 hours after laser treatment and all of these reached to normal level within three days with topical betablocker (0.5% timolol meleate) twice a day and oral acetazolamide 250mg thrice a day. in our patients the incidence of elevation in iop was very low because we used very low energy level and less number of pulses for capsulotomy. 3. rupture of anterior vitreous face (avf) with forward displacement of vitreous in anterior chamber. it has been noted that yag laser energy focused on the posterior capsule produces liquefaction of vitreous22, in the same way as occurs if the laser focuses into the mid vitreous. this major change in the vitreous structure provides other mechanisms for dynamic vitreous traction and squeal of retinal breaks and detachments19. rupture of the avf permits forward displacement of vitreous in aphakic patients, this may increase dynamic traction on the retina. forward displacement of vitreous can also be seen in eyes with iol, a knuckle of vitreous insinuating itself around the iol and appearing at the pupil margin. this complication may be associated with pupil distortion and iol displacement. such event may be the cause of chronic iris irritation and could certainly promote cystoids macular edema19. one author noted 10 out of 24 patients with ruptured avf after posterior capsulotomy but no vitreous in ac19, and haris ws reported vitreous in ac in 15 eyes (4.4%) out of 342 eyes32. in this study we noted two cases (0.62%) of ruptured avf with vitreous in ac, especially in eyes with small haptic iol. va was not affected in such cases, however long term follow up is necessary to see the risk of vitro-retinal traction. 4. cystoid macular edema: we noted the incidence of cme in two eyes (0.6%), while hussain mm reported cme 0.8% in the study of 125 pseudophakic eyes treated with nd: yag laser capsulotomy13. haris ws noted 16 eyes (4.4%) out of 342 eyes with cystoids macular edema32. 77 in such cases the possible mechanism of cme is still unclear but it is suggested that in response to yag laser the prostaglandin released from anterior segment and reached the retina through vitreous that alters the permeability of paramacular capillaries to develop cme31. continuous iris irritation by displaced vitreous in ac around the pupil margin may promote cme28. delay in nd: yag laser capsulotmy by 90 days after cataract surgery allows full recovery of the blood aqueous barrier and can reduce the rate of cystoids macular edema39. in our study the best corrected va of 6/9 6/6 was achieved in 310 eyes (96.9%) (table 6), where as only 10 eyes (3.1%) did not achieve significant improvement in va because of pre-existing fundus pathology which was not detected due to thick posterior capsule opacification. as we discussed the incidence of complication during and following nd: yag laser but the pathogenesis of most of them yet not clear like cme. our experience shown that it is unnecessary to use higher energy level, we therefore aimed to achieve satisfactory opening of the posterior capsule while keeping the initial energy setting and amount of total energy used as low as possible. table 3 and 4 shows that the energy level setting was no higher than 5 mj and the total energy level used for capsulotomy did not exceed 180 mj. the total energy level and retro focusing of aiming beam is the cause of less number of complications in our study, so we can suggest that nd: yag laser capsulotomy is a safe and reliable procedure to improve the pre laser visual acuity. conclusion the nd: yag laser treatment is obviously an effective technique to improve the hindered vision by pco. it is not free from complications, so it is advised to be conscious of the extra damage to ocular tissues following nd: yag laser capsulotomy. it is also suggested that energy level should be kept to a minimum level to avoid severe complications. author’s affiliation dr. mahtab alam khanzada ophthalmologist department of ophthalmology liaquat university eye hospital hyderabad. prof. shafi muhammad jatoi chairman & head department of ophthalmology liaquat university eye hospital hyderabad. dr. ashok kumar narsani assistant professor department of ophthalmology liaquat university eye hospital hyderabad dr. syed asher dabir ophthalmologist department of ophthalmology liaquat university eye hospital hyderabad dr. siddiqa gul ophthalmologist department of ophthalmology liaquat university eye hospital hyderabad reference 1. apple dj, solomon kd, tetz mr. posterior capsule opacification. surv ophthalmol. 1992; 37: 73-116. 2. paulsson le, sjostrand j. contrast sensitivity in the presence of a glare light. theoretical concepts and preliminary clinical studies. invest ophthalmol vis sci. 1980; 19: 401-6. 3. sundelin k, sjostrand j. posterior capsule opacification 5 years after extracapsular cataract extraction. j cataract refract surg. 1999; 25: 246-50. 4. ursell pg, spalton dj, pande mv et al. relationship between intraocular lens biometerials and posterior capsule opacification. j cataract refract surg. 1998; 24: 352-60. 5. tan jc, spalton dj, arden gb. comparison of methods to assess visual impairment from glare and light scattering with posterior capsule opacification. j cataract refract surg. 1998; 24: 1626-31. 6. kanski jj. clinical ophthalmology, a systemic approach. 4th edition: butterworth-heinemann, london 1999; 169-70. 7. murril ca, stanfield dl, van brockiln md. capsulotomy. optom clin. 1995; 4: 69-83. 8. sherrard es, kerr muir mg. damage to corneal endothelium by q switched nd: yag laser posterior capsulotomy. trans ophthalmol soc uk. 1985; 104: 524-8. 9. latif e, khalid m, aaqil m, et al. use of topical apraclonidine to prevent intraocular pressure elevation following nd: yag laser posterior capsulotomy. pak j ophthalmol 1999; 15: 108-12. 10. steinert rf, puliafito ca, kumar sr. cystoid macular edema retinal detachment and glaucoma after nd: yag laser posterior capsulotomy. am j ophthalmol. 1991; 112: 373-80. 11. stark wj, worthen d, holladay jj, et al. neodymium yaglaser; a fda report. ophthalmology 1985; 92: 209-12. 12. bath pe, fankhauseir f. long term results of nd: yag laser posterior capsulotomy with the swiss laser. j cataract refract surg. 1986; 12: 150-3. 13. hussain mm. complications after nd: yag laser capsulotomy. pak j ophthalmol. 1996; 12: 13-5. 78 14. hasan ks, adhi mi, aziz m, et al. nd:yag laser posterior capsulotomy. pak j ophthalmol. 1996; 12: 3-7. 15. baratz kh, cook be, hodge do. probability of nd: yag laser capsulotomy after cataract surgery in olmsted county, minnesota. am j ophthalmol. 2001; 131: 161-6. 16. liesegegang tj, bonrne wm, ilstrup dm. secondary surgical and neodymcin-yag laser decision. am j ophthalmol. 1985; 100: 510. 17. lewis h, singer tr, hanscom ta, et al. a prospective study of cystoid macular edema after neodymium yag-laser capsulotomy. ophthalmology 1987; 94: 478-82. 18. winther-nielsen a, johansen a, pedersen gk, et al. posterior capsule opacification and neodymium: yag capsulotomy with heparin-surface-modified intraocular lenses. j cataract refract surg 1998; 24: 940-4. 19. ficker la, steel ad. complications of nd: yag laser posterior capsulotomy. trans ophthalmol soc. uk 1985; 104: 529-32. 20. bukelman a, abrahami s, oliver m, et al. cystoid macular edema following. neodymium yag laser capsulotomy a prospective study. eye 1992; 6: 35-8. 21. piest kl, kincaid mc, tetz mr. localized endophthalmitis a newly described cause of the so–called toxic lens syndrome. j cataract refract surg. 1987; 13: 498-510. 22. lerman s, thrasher b, moran m. vitreous changes after neodymium yag laser irradiation of the posterior lens capsule or mid vitreous. am j ophthalmol. 1984; 97: 470-5. 23. dick b, schwenn o, stoffelns b, et al. lat dislocation of a plate haptic silicone lens into the vitreous body after nd: yag kapsulotomie; a case report. ophthalmologe 1998; 95: 181-5. 24. nielsen ne, naeser k. epidemiology of retinal detachment following extracapsular cataract extraction; a follow up study with an analysis of risk factor. j cataract refract surg. 1993; 19: 675-80. 25. javitt jc, tielsch jm, canner jk. national outcomes of cataract extraction; increased retinal complication associated with nd: yag laser capsulotomy. ophthalmology 1992; 99: 1487-97. 26. majeed a, bangash t, muzaffar w, et al. macular hemorrhage: an unusual complication of nd: yag laser capsulotomy. pak j ophthalmol. 1998; 14: 118-20. 27. fagadau wr, maumence ae, stark wj jr, et al. posterior chamber intraocular lenses at the wilmer institute: a comparative analysis of complications and visual results. br j ophthalmol. 1984; 68: 13-8. 28. emery jm, wilhelmus ka, rosenburg s. complications of phacoemulsification. ophthalmology. 1978; 85: 141-50. 29. pearce jl. modern simple extracapsular surgery. trans ophthalmol soc uk. 1979; 99: 176-82. 30. kraff mc, sanders dr, lieberman hl. intraocular pressure and the corneal endothelium after neodymium-yag laser posterior capsulotomy. relative effects of aphakia and pseudophakia. arch ophthalmol. 1985; 103: 511-4. 31. kundi nk, younas m. nd-yag laser posterior capsulotomy. j med sciences. 1998; 8: 90-4. 32. harris ws, herman wk, fagadau wr. management of the posterior capsule before and after the yag laser. trans ophthalmol soc uk. 1985; 104: 533-5. 33. richter cu, arzeno g, pappas hr, et al. intraocular pressure elevation following nd: yag laser posterior capsulotomy. ophthalmology 1985; 92: 636-40. 34. channell mm, beckman h. intraocular pressure changes after neodymium-yag laser posterior capsulotomy. arch ophthalmol. 1984; 102: 1024-6. 35. macewen cj, dutton gn, holding d. angle closure following neodymium-yag (nd-yag) laser capsulotomy in the aphakic eye. br j ophthalmol. 1985; 69: 795-6. 36. vine ak. ocular hypertension following nd-yag laser capsulotomy: a potentially blinding complication. ophthalmic surg. 1984, 15: 283-4. 37. parker md, clofeine gs, stocklin rd. marked intraocular prressure rise following nd-yag laser capsulotomy. ophthalmic surg. 1984, 15: 103-4. 38. ruderman jm, mitchell pg, kraff m. pupillary block following nd-yag laser capsulotomy. ophthalmic surg. 1983, 14: 418-9. 182 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology original article effect of contact lens wear on tear film break up time (tbut) among contact lens users rabia ammer pak j ophthalmol 2017, vol. 33, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: rabia ammer, department of allied health sciences school of optometry/ the university of faisalabad email: rabbia.ammer@gmail.com …..……………………….. purpose: to determine the effect of contact lens wear on tear film break up time (tbut) and to find out correlation between tear film break up time (tbut) with type of contact lens wear, daily wearing time of contact lens, years of contact lens use and power of contact lens. study design: cross-sectional study and convenient sampling was used. place and duration of study: this study recruited the sample from madinah teaching hospital faisalabad, e plomer optics and punjab optics lahore. the study was conducted in 4 months from 05-04-2016 to 05-08-2016. materials and methods: tbut determined by using slit lamp and fluorescein strips. spss version 23 was used for data analysis. inferential statistics was reported for variables. results: a sample of 100 (67 females and 33 males) contact lens users recruited for the study. mean age of sample was 30.10 ± 7.86 years. mean daily wearing time of contact lens was 9.82 ± 2.19 hours/day and mean of years of contact lens use was 8.35 ± 5.81 years. 67% of 100 contact lens users had abnormal (less than 10 sec.) tear film break up time (tbut). a significant negative correlation of tbut was found with daily wearing time of contact lenses (r = -.251), years of contact lens use (r = -.542) and minus power of contact lens (r=-.330). no significant association of tbut was found with type of contact lens and plus power of contact lens. conclusions: tbut decreases with increase in daily wearing time, years of contact lens use and high minus power of contact lens, while type of contact lens and plus power of contact did not significantly affect the tbut. key words: contact lens, tear film break up time, tbut, tear film stability. he ocular surface consists of various glandular tissues, which secrete the tear film that coats and protect the ocular surface1. the tears are distributed by normal, non-voluntary action of eyelid and each blink refreshes the pre-corneal tear film. when blinking is held, evaporation of aqueous layer of tear film started which causes thinning of the tear film in a localized area. subsequently dry spots are formed in tear film when the tears evaporate2. tear film stability is usually measured by its lack of stability, by a test called tear film break-up time (tbut)1. tbut is the time taken in seconds for the tear film to break following a blink cessation2. tear break up time tbut of 15-45 sec is considered normal while less than 10 sec is abnormal2 and less than 5 sec is suggestive of symptoms of dry eye disease 1. the physical placement of a contact lens over the ocular surface divides the tear film into two parts, i.e. a pre-lens tear film and a post-lens tear film and it forms a new interface within the ocular atmosphere. t effect of contact lens wear on tear film break up time (tbut) among contact lens users pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 183 this division and new interface induce changes in biophysical properties of tear film3. when a contact lens is placed on the eye, it affects the stability of tear film, evaporation rate of tears, thickness of lipid layer and volume of tears. the contact lens use mainly alters the normal sequence of tear film function and cause distractions in quantity and quality of the tear film, which lead to contact lens intolerance4.both rgp and soft contact lenses interfere with the tear film stability and decreases the tbut. rgp contact lenses reduce tbut up to 4 to 6 sec whereas soft contact lenses decrease tbut up to 4 to 10 sec5.this study is conducted to determine the effect of contact lens wear on tear film break up time (tbut) and to find out correlation between tear film break up time (tbut) with type of contact lens wear, daily wearing time of contact lens, years of contact lens use and power of contact lens. material and methods: it was a cross-sectional study and convenient sampling technique was used to collect the sample of 100 contact lens users. the study was conducted in 4 months from 05-04-2016 to 05-08-2016. data were collected from 3 different settings; madinah teaching hospital faisalabad, e plomer optics and punjab optics, lahore. for ethical concerns, approval of study obtained from the ethical review board of the university of faisalabad in accordance with the principles of declaration of helsinki. subjects aged 15 to 55 years, those used contact lenses for more than 1 year and without any complain / symptom related to contact lens use were included in the study. subjects suffering from any disease of the cornea or conjunctiva and those used contact lenses for less than 1 year, excluded from the study. an informed consent form delivered to gain consent from participants for their voluntary participation by briefly describing the study topic, its purpose, duration and assuring for confidentiality of respondents personal information. subject’s demographic details, history related to the type, daily wearing time, power and years of contact lens use were recorded in specially designed selfstructured performa. a detailed slit lamp examination was performed in a consistent, orderly fashion from eyelid to cornea to determine any ocular pathology. to measure tear film break-up time (tbut), the subject was asked to look upward and sodium fluorescein was applied to the sclera at lower fornix by using fluorescein strip moistened by normal saline and then subject was asked to blink several times. after that subject was instructed to avoid blinking and the tear film was observed between blinks with a slit lamp under cobalt blue light and time noted between a complete blink and the appearance of the first black dry spot. spss version 23 was used for data analysis. descriptive and inferential statistics were generated and reported for variables. results a sample of 100 contact lens users recruited in which female contact lens users were 67 (67%) and male contact lens users were 33 (33%). age of contact lens users ranged from 16 to 55 years with mean age of 30.10 ± 7.86 years. the study subjects were wearing different types of contact lenses. 54% of subjects were soft contact lens users, 17% were soft cosmetic contact lens users, 14% were rgp contact lens users, 12% were soft toric contact lens users and 3% were silicone hydrogel contact lens users. the daily wearing time of contact lens determined in this study ranged from 4 to 16 hours/day and mean value was 9.82 ± 2.19 hours/day. the years of contact lens use found in this study ranged from 1.5 to 30 years with a mean value of 8.35 ± 5.81 years. in this study very high proportion of contact lens users was myopic (96 %) and used contact lenses of minus power. minus power of contact lens ranged from -0.50 to -17.00 d with a mean value of -4.46 d ±3.69 d. the proportion of hyperopic contact lens users was less (4 %) and plus power of contact lenses ranged from +2.00 to +5.00 d with a mean value of +4.00d ±1.35 d. tbut value was ranging from 4 to 18 sec with a mean value of 9.14 ± 2.89 seconds in contact lens users. in males average tbut was 8.88 ± 2.50 sec and in female it was 9.27 ± 3.08 sec. the results determined that 67% of contact lens users had abnormal tbut and 33% had normal tbut. no significant (p = > 0.05) association was found between tbut and types of contact lenses (table 1). a significant (p = .012) negative correlation was found between tbut and daily wearing time of contact lenses (table 2). regression model shows that with 1 hour increase in daily wearing time, tbut decreased by -.332 times (figure 1). a highly significant (p = .000) negative correlation was found between tbut and years of contact lens use (table 2). regression model shows that with 1 year increase in contact lens use, tbut decreased by .270 times (figure 2). rabia ammer 184 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology table 1: association between tbut and types of contact lenses. type of contact lens tbut (sec) total abnormal (≤ 10) normal (>10) soft 32 22 54 hard 10 4 14 soft toric 8 4 12 silicone hydrogel 3 0 3 soft cosmetic 14 3 17 total 67 33 100 pearson chi-square 4.878 p-value .300 table 2: significant correlation of tbut. daily wearing time of cl (hours/day) years of cl use (years) minus cl power (d) tbut (sec) pearson correlation -.251* -.542** -.330** sig. (2-tailed) .012 .000 .001 n 100 100 96 *. correlation is significant at the 0.05 level (2-tailed). **. correlation is significant at the 0.01 level (2-tailed). a strong significant (p = .001) negative correlation was found between tbut and minus power of contact lens (table 2). regression model shows that with -1 d increase in power of contact lens, tbut decreased by -.263 times (figure 3). no significant (p > 0.05) association was found between corneal changes and plus power of contact lens. disscussion in this study a decreased value of tbut was found in majority of contact lens users. the results determined that 67% of contact lens users had abnormal tbut. the reason might be that the contact lens induced hypoxia interfered with tear film stability and resulted in shortened tbut. these results were similar to the studies of sweeney et al.1, craig et al.3, eghosasere et al.4, du toitet al.6, thai et al.7, glasson et al.8, nichols and sinnot9, riley et al.10, stapleton et al.[11], janine et al.12, guillon and maissa13, jansen et al.14, shrestha et al.15, young et al.16, kastelanet al.17, gupta et al.18 and pili et al.19. however these findings were contrary to the results reported by santodomingo-rubido et al.20 study. this could be due to the regional, racial or environmental differences. in this study no significant association was found between tbut and type of contact lens. the study results were similar to craig et al.3 and thai et al.7 studies. but contrary to sweeney et al.1, eghosasere et al.4, riley et al.10, kastelan et al.17 studies which found association between tbut and type of contact lenses. the reason might be that more than half of total subjects used soft contact lenses and proportions effect of contact lens wear on tear film break up time (tbut) among contact lens users pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 185 of other types of contact lens users were less, therefore, could not find any significant association. fig. 1: regression model of tbut and daily wearing time of contact lenses (showed that as the daily wearing time of contact lens increased, the tbut value decreased). fig. 2: regression model of tbut and years of contact lens use (showed that as the number of years of contact lens use increased, the tbut value decreased). fig. 3: regression model of tbut and minus power of contact lenses (showed that as the minus power of contact lens increased, the tbut value decreased) in this study a significant negative correlation was found between tbut and daily wearing time of contact lenses. the reason could be that increased daily wearing time of contact lens caused more hypoxia which adversely affected the tear film stability. these results were in line with those reported by kastelan et al.17 study. in this study a highly significant negative correlation was found between tbut and years of contact lens use. this might be due to the reason that prolonged use of contact lenses resulted in chronic hypoxia which unfavorably affected the tear film stability. no other study could be found to sufficiently discuss the results. in this study a strong significant negative correlation was found between tbut and minus power of contact lens. the reason could be that high power contact lenses were thicker which reduced oxygen permeability and caused hypoxia which lead to reduce tbut. no other study was found to sufficiently discuss the results. in this study no significant association was found between corneal changes and plus power of contact lens. these insignificant results could be due to very less number of hyperopic contact lens users in the study. no other study was found to sufficiently discuss the results. rabia ammer 186 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology conclusion it is concluded that long term use of contact lenses decreased the stability of tear film and thus tbut. tbut was more affected with increase in daily wearing time, years of contact lens use and high minus power of contact lens. author’s affiliation dr. rabia ammer bsc optom, mphil optom. department of allied health sciences/ school of optometry/ the university of faisalabad. role of authors dr. rabia ammer concept, design of study, sample selection. data collection, data entry, data analysis, critical review, drafting and revision of manuscript. references 1. sweeney d, millar t, raju s. tear film stability: a review. experimental eye research, 2013; 117: 28-38. 2. williams l. anatomy and physiology of the anterior segment. module1. anterior segment of the eye. the iacle contact lens course. the international association of contact lens educators sydney, australia, 2000; 1 (1): 3-80. 3. craig pj, willcox dpm, arg¨ueso p, maissa c, stahl u, tomlinson a, wang j, yokoi n, stapleton f. the tfos international workshop on contact lens discomfort: report of the contact lens interactions with the tear film subcommittee. invest ophthalmol vis sci. 2013; 54 (11): tfos123. 4. eghosasere i, joy ei, joy oi. effect of soft contact lens materials on tear film stability and central corneal radius of curvature: a comparative study of polymacon and lotrafilcon b. sierra leone j biomed res. 2011; 3 (3): 144-150. 5. terry r. corneal oxygen requirements and the effects of hypoxia. module 6. the cornea in contact lens wear. the iacle contact lens course. the international association of contact lens educators sydney, australia, 2000; 1 (1): 3-36. 6. du toit r, situ p, simpson t, fonn d. the effects of six months of contact lens wear on the tear film, ocular surfaces, and symptoms of presbyopes. optom vis sci. 2001; 78 (6): 455-462. 7. thai l, tomlinson a, doanem. effect of contact lens materials on tear physiology. optom vis sci. 2004; 81 (3): 194-204. 8. glasson m, stapleton f, willcox, m. changes to tear film parameters during wear of hema-based hydrogel lenses. ocul surf. 2005; 3 (1): 66. 9. nichols jj, sinnott tl. tear film, contact lens, and patient-related factors associated with contact lens– related dry eye. invest ophthalmol vis sci. 2006; 47 (4): 1319-1328. 10. riley c, young g, chalmers r. prevalence of ocular surface symptoms, signs, and uncomfortable hours of wear in contact lens wearers: the effect of refitting with daily-wear silicone hydrogel lenses (senofilcon a). eye contact lens, 2006; 32 (6): 281-286. 11. stapleton f, stretton s, papas e, skotnitsky c, sweeney df. silicone hydrogel contact lenses and the ocular surface. ocul surf. 2006; 4 (1): 24-43. 12. janine a, smith aj, albeitz j, begley c, caffery b, nichols k, schaumberg d, schein o. the epidemiology of dry eye disease: report of the epidemiology subcommittee of the international dry eye work shop. ocul surf. 2007; 5 (2): 93-107. 13. guillon m, maissa c. contact lens wear affects tear film evaporation. eye contact lens, 2008; 34 (6): 326330. 14. jansen m, begley c, himebaugh n, port n. effect of contact lens wear and a near task on tear film break-up. optom vis sci. 2010; 87 (5): 350-357. 15. shrestha g, sujakhu d, shrestha jb, shrestha jk. tear film evaluation in contact lens wearers and non wearers. journal of institute of medicine, 2012; 34 (2): 14-20. 16. young g, chalmers r, napier l, kern j, hunt c, dumbleton k. soft contact lens-related dryness with and without clinical signs. optom vis sci. 2012; 89 (8): 1125-1132. 17. kastelan s, lukenda a, salopek-rabatic j, pavan j, gotovac m. dry eye symptoms and signs in long-term contact lens wearers. coll antropol. 2013; (37) 1: 199– 203. 18. gupta a, shah m, samanta a. effect of extrinsic controls on blinking and tear film stability among soft contact lens wearers. international journal of medicine & health research, 2014; 1 (1): 1-7. 19. pili k, kaštelan s, karabatic m, kasun b, culig b. dry eye in contact lens wearers as a growing public health problem. psychiat danub. 2014; 26 (3): 528-532. 20. santodomingo-rubido j, wolffsohn js, gilmartin b. changes in ocular physiology, tear film characteristics, and symptomatology with 18 months silicone hydrogel contact lens wear. optom vis sci. 2006; 83 (2): 73-81. microsoft word irshad haider case r 153 case report retinal artery macroaneurysm with hard exudate syed irshad haider, sharif hashmani, sadaf shah pak j ophthalmol 2008, vol. 24 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: syed irshad haider hashmanis hospital jm-75, off m.a.jinnah road jacob line karachi received for publication february’ 2008 … ……………………… we report a case of retinal artery macroaneursym with hard exudates diagnosed at hashmani hospital, karachi. patient was a 60 year old woman with a history of hypertension. she reported to us for visual problems. on dilated fundus examination of right eye, fusiform arteriolar dilatation, central macular exudation, retinal hemorrhage along the superior temporal arcade was found. retinal macroaneurysm was suspected by history, fundus finding and confirmed by fundus fluorescein angiography findings. etinal macroaneurysm is a localized dilatation of a retinal arteriole which usually occurs in the first three orders of the arterial tree. it has a predilection for elderly hypertensive women and involves one eye in 90% of case. histological findings include macrovascular abnormalities (e.g. widening of the periarteriol capillary free zone, capillary dilation, nonperfusion, intra-arterial collaterals have been identified. histological studies of the macroaneurysm show a break in the arterial wall, surrounded by a laminated layer of fibrin-platelet clot and blood. lipidladen macrophages, hemosiderin, and fibrogial reaction are also observed. the pathophysiology formation of retinal macroaneurysm is associated with systemic hypertension in approximately 75% of patients and atherosclerotic disease, but serum lipid abnormalities also have been reported. about 10% of patient has focal arterial wall atheroma occurring at defect in the wall, which may be sites at risk of aneurysm formation. the aneurysm is sites of leakage of exudates and hemorrhage in the macula. over time or after acute hemorrhage, spontaneous thrombosis and closure of the aneurysm may occur, in some cases, the artery may return to normal. r 154 case report a 60 years old women presented with decreased vision in right eye. there was history of hypertension. on ocular examination the visual acuity (va) in her right eye was 6/60 while in left eye was 6/12. the right eye was which could not be improved with glasses but left eye va improved with glasses to 6/9. on silt lamp biomicroscopy examination the anterior segment of both eyes were normal. intraocular pressure (iop) was 16mmhg right eye and was 18 mm hg left eye. on dilated fundus examination with +90d lens revealed right eye a saccular or fusiform arteriolar dilatation and associated retinal hemorrhage with hard exudation at the macula. the left eye fundus was normal. in fluorescein angiography findings during the venous phase demonstrating delayed filling of the retinal macroaneurysm with fluorescien dye. the aneurysm is obscured partially by the presence of hemorrhage, but filling by the dye enhance visualization. during late phase showing complete filling of retinal macroaneurysm with late leakage. discusion a retinal macroaneursym are acquired, dilatation of the large arterioles of the retina. this condition occurs most commonly in the sixth to seventh decade of life. the most common risk factor is hypertension generalized arterial sclerosis, serum lipid abnormallities, vulsalva maneuver. the clinical features of macroaneurysm are impairment of central vision due to macular edema and hard exutadates formation. sudden visual loss resulting from vitreous hemorrhage is uncommon. on fundus examination a saccular or fusiform arteriolar dilatation, associated with retinal hemorrhage is present in 50% of cases. chronic leakage resulting in retinal edema with accumulation of hard exudates at the fovea is common and may result in permanent loss of central vision. the 155 management of retinal macroanesysms are control hypertension, serum lipids and laser photocoagulation, laser hyaloidotomy. differential diagnosis: hard exudates at the posterior pole • background diabetic retinopathy. • exudative age-related macular degeneration. • exudative telangiectasia. • old retinal branch vein occlusion. • small retinal capillary haemangioma. • radiation retinopathy. deep retinal or subretinal hemorrhages at the posterior pole. • choroidal neovascularization. • vulsulva retinopathy. • idiopathic polypoidal choroidal vasculopathy. • blunt ocular trauma. • choroidal melanoma. • terson syndrome associated with subarachnoid hemorrhage. conclusion the visual prognosis is excellent for many patient. the natural history of macroaneurysm suggests that most close spontaneously with restoration of near normal vision. chronic macular exudation and hemorrhage can lead to vision loss, which is an indication to consider laser photocoagulation. a study suggest that patient with pre-retinal hemorrhage or vitreous hemorrhage due to retinal macroaneurysms have a good visual prognosis, however, patients with submacular hemorrhage have a poor visual prognosis. author’s affiliation dr. syed irshad haider hashmanis hospital, jm-75, off m.a. jinnah road, jacob line karachi dr. sharif hashmani hashmanis hospital, jm-75, off m.a. jinnah road, jacob line karachi dr. sadaf shah hashmanis hospital, jm-75, off m.a. jinnah road, jacob line karachi microsoft word abstract 23,1,2007 abstracts edited by dr. tahir mahmood photorefractive keratectomy with intraoperative mitomycin-c application lee dh, cluing hs, jeon yc, boo sd, yoon yd, kim jg j cataract refract surg. 2005; 31: 2293-8. photorcfraclive kcratcctomy (prk) has been a valuable retractive surgery technique; however, its popularity decreased as laser in situ keratomileusis (lasek) was introduce to the refractive surgery field. laser in situ keratomiieusis has the advantage of little pain and rapid visual rehabilitation as well as reduced complications associated with corneal haze in high myopia. but it has also many disadvantages such as flap-related complications, dry eye, and ectasia. recently, surface ablation is being performed as laserassisted subepithelial keratectomy (lasek) or advanced surface ablation. the pain is less, but haze is a major limitation of prk or lasek for moderate to high myopia. several studies have been performed in an attempt to reduce or inhibit the formation of corneal haze. mitomycin-c (mmc) is known to reduce corneal haze after prk or radial karatotomy. it can also prevent the recurrence of haze alter previous surgical complications. the purpose of the present study was to evaluate the safety and efficacy of the prophylactic use of intraoperative application of mmc during prk. this retrospective noncomparative case series included 536 patients (1011 eyes) who had had prk with intraoperative application of mmc using the nidek ec-5000 excimer laser. preoperative and postoperative best spectacle-corrected and uncorrected visual acuities, spherical equivalent (se) refraction, corneal haze graded by slitlamp biomicroscopy, and endothelial cell density measured by specular microscopy were evaluated. the mean preoperative se was -7.82 diopters (d) ± 2.64 (sd); 72% of eyes (732) were more than 6.00 d, and 28% (287) were more than -9.00 d. the mean follow-up was 13 months (range 6 to 27 months). six months postoperatively, the mean postoperative se was -0.14 ± 0.62 d; 86% were within ± 0.50 d and 93% were within ± 1.00 d of desired refraction. eighty-six percent had 20/20 or better visual acuity, and 98% were 20/40 or better. regression of more than 1.00 d occurred in 78 eyes (7.6%), and it was more common in eyes with a preoperative se of 9.00 d or worse (18%). haze occurred in 32 eyes (3.17%), but in most cases it was limited to grade 1. grades 2 and 3 haze occurred in 3 eyes and 2 eyes, respectively. the postoperative endothelial cell density measured by specular microscopy did not show a significant difference from preoperative measurements. delayed epithelial healing was observed in 2 eyes. authors concluded with remarks that photorefractive keratectomy with intraoperative application of mmc was a safe procedure that produced excellent visual outcomes with few complications. clinical results of the blue-light filtering acrysof natural foldable acrylic intraocular lens marshall j, cionni rj, davison j, ernest p, lehmann r, maxwell a, solomon k j cataract refract surg 2005; 31: 2319-23. in 2003 the u.s. food and drug administration (fda) approved the use of acrysof natural intraocular lens (iol.) (alcon laboratories, inc.) for the replacement of the human lens to achieve visual correction of aphakia in adult patients. the chemical composition acrylale/methacrylate material of the acrysof natural iol is identical to that of the original acrysof singlepiece iol previously available but with the addition of a proprietary covalently bound yellow polymerizable chromophore. the concentration of the chromophore in the iol results in a transmission curve that best resembles that of a 25-year-old natural crystalline lens. before fda approval, the acrysof natural iol underwent extensive clinical testing to evaluate the safety and effectiveness of the iol when implanted bilaterally in the capsular bag after phacoemulsification. with the addition of the chromophore, the iol became a yellow-tinted lens; thus, concerns were raised as to how the lens would perform with respect to color perception and contrast sensitivity in patients receiving the iol. the acrysof single-piece iol, which was also implanted bilateral in the capsular bag after phacoemutlsilication, served as the control group. the purpose of this study was to verify the safety and effectiveness of the new acrysof natural (alcon laboratories, inc.) blue-light filtering intraocular lens (iol), which was designed to achieve a lighttransmission spectrum similar to that of the natural human crystalline lens. in this prospective randomized patient-masked multicenter study, 150 patients received the acrysof natural iol and 147 patients received the acrysof single-piece iol as a control. patients with bilateral age-related cataracts who were willing and able to wait at least 30 days between cataract procedures and had verified normal preoperative color vision were eligible for the study. standardized surgery included a 4.0 to 5.0 mm capsulorhexis and phacoemulsification. all lenses were inserted in the capsular bag, with verification of in-the-bag placement of both haptics. in all bilateral implantation cases, the same model iol was used in each eye. postoperatively, contrast sensitivity and color perception were measured up to 180 days and up to 1 year (for visual acuity) after implantation. no statistically significant differences were discovered between the 2 patient groups in visual acuity, contrast sensitivity evaluated under mesopic and photopic conditions, or the number of patients who passed the farnsworth d-15 color perception test. there were no lens-related adverse events in either group. authors concluded with the remarks that the bluelight filtering acrysof natural iol was equivalent to the conventional acrysof lens in terms of postoperative visual performance. additional longterm clinical studies should show whether the iol actually provides the theoretical benefits to retinal health. evidence for the use of nutritional supplements and herbal medicines in common eye diseases west al, oren ga, morol se am j ophthalmol 2006; 141: 157-66. complementary and alternative medicine (cam) is defined as a group of diverse medical and health care systems, practices, and products that presently are not considered to be part of conventional (allopathic) medicine. the national center for complementary and alternative medicine of the national institutes of health (nih) classifies the cam therapies into the following categories: alternative medical systems, mind body interventions, biologically based therapies, manipulative and body based methods, and energy therapies. in the united states, there is increasing scrutiny on monitoring herbal medicines and nutritional supplements, which are not monitored the same way as prescription medicines. they come under the dietary supplement and health education act of 1994, which requires the statement, “these products and these statements have not been evaluated by the food and drug administration. these products are not intended to diagnose, treat, cure or prevent any disease. consult a health care professional before using these or any product during pregnancy or if you have a serious medical condition”. there has been a tremendous growth in the use of biologically-based therapies. these are substances found in nature, such as herbs, foods, vitamins, minerals, and other animal-derived products. between 1990 to 1997, cam use increased among the us population from 34% to 42%, with a nearly four-fold rise in herbal remedies. a follow-up study showed that cam use remained stable through 2002, with an estimated use in approximately 72 million adults in the united states. given this epidemiologic information on cam use and its economic impact on medical care costs, physicians should become more knowledgeable about cam use among their patients, some of whom do not disclose their use to their physicians. because of the widespread use, ophthalmologists will be faced with patients who may experience adverse effects either directly or from interactions with prescribed medications. in addition, there may not be evidence for the use of these products. the ocular side-effects from herbal medicines and nutritional supplements have been described recently. the purpose of this writing is to provide a perspective by reviewing the evidence for the role of nutritional supplements and herbal medicines in the common causes of visual impairment. published studies and information found in pubmed, international bibliographic information of dietary supplements, and selected websites were reviewed for the role of nutritional and herbal medicines in the treatment of age-related macular degeneration, cataract, diabetic retinopathy, and glaucoma. the studies were evaluated systematically for their study design, study population, benefits, risks, biases, and criteria for the categorization of the level of evidence. the available evidence does support the use of certain vitamins and minerals in patients with certain forms of age-related macular degeneration. for cataracts, the available evidence does not support these supplements to prevent or treat cataracts in healthy individuals. for diabetic retinopathy and glaucoma, the available evidence does not support the use of these supplements. in the category of herbal medicines, the available evidence does not support the use of herbal medicines for any of these ocular diseases. because of the widespread use of nutritional supplements and herbal medicines, ophthalmologists should be aware of their use so that they can inform patients properly when the supplements and herbal medicine are being used for eye disease. retinopathy of prematurity: the life of a lifetime disease tasman w, patz a, mcnamara ja, kaiser rs, trese mt, smith bt am j ophthalmol 2006; 141: 167-74. retinopathy of prematurity was originally designated retrolental fibroplasia (rlf) by terry, who in 1942 first connected the condition with premature birth. by 1950, rlf had become the largest cause of child blindness in the united states and throughout the technologically developed world. terry’s designation of rlf was based on the pathologic findings in advanced cases, which suggested to him and to dr frederick verhoeff that the basic pathologic condition involved a proliferation of the embryonic hyaloid system. owens and owens examined premature infants from birth and found no abnormality of the hyaloid system and concluded that the condition developed postnatally. as the pathogenesis and clinical course of rlf became better appreciated, the term retinopathy of prematurity was substituted. the purpose of the review article is to provide information on retrolental fibroplasias (rlf), later known as retinopathy of prematurity. review of the literature on the subject and a first person account of what was then rlf by one of the authors (a.p.) who was involved in the earliest days in research regarding rlf. in 1942, elevated levels of oxygen were thought to play a major role in the development of the disease; at that time, no treatment was available. during the lifetime of this disease, other possible causes have been investigated. these include vitamin e as a prophylaxis against retinopathy of prematurity and the efficacy of light reduction to prevent retinopathy of prematurity. it has been shown that the light reduction does not play a role in reducing the progression of retinopathy of prematurity. vitamin e studies were inconclusive; some studies show a positive effect and others do not. a major advance occurred with the development of the international classification of ophthalmology in 1984, which laid the groundwork for collaborative studies to determine whether cryotherapy of the avascular zone of retina would reduce the incidence of blindness in newborn infants, when compared with control subjects. the study showed that cryotherapy was effective; this was followed by laser photocoagulation when lasers became portable enough to take to the neonatal intensive care unit. at the same time, improved surgical techniques moved from scleral buckling for retinal detachment to vitrectomies (some lens sparing) for more desperate cases that had progressed to stage 4 and stage 5 retinopathy of prematurity. late changes in adults who were born before any treatment and are now baby boomers ran the gamut from the dragging of the retina in the posterior pole to retinal detachment, cataract, and myopia. authors concluded with remarks that retinopathy of prematurity is a lifetime disease for which preventive and better treatment modalities continue to evolve. amblyopia: diagnostic and therapeutic options carolyn wu, hunter dg am j ophthalmol 2006; 141: 175-84. amblyopia is the leading cause of visual impairment in children, affecting up to 4% of the general population. with early detection and treatment, most cases of amblyopia are reversible, and the most severe forms of the condition can he prevented. in recent years, some long-established assumptions about the diagnosis and treatment of amblyopia have been called into question, with implications at the scientific, clinical, economic, and political levels. this perspective provides an overview of the current state of knowledge of amblyopia and highlights recent advances in the diagnosis and treatment of this silent, blinding, but preventable condition. increased awareness of amblyopia and better screening techniques are required to identify children who are at risk for amblyopia at a younger age. randomized, controlled trials have established atropine penalization as a viable alternative to occlusion therapy, have suggested that less treatment may be better tolerated and as effective as more traditionally used dosages, and have found no compelling evidence that treatment is beneficial clinically for older (over age 10) children with amblyopia. authors concluded with remarks that early detection and treatment of amblyopia can improve the chances for a successful visual outcome. considering that the conditions that place a patient at risk for amblyopia can be identified, that amblyopia responds to treatment, and that well-tolerated treatments for the condition are now recognized, it is not unreasonable to imagine that, in the near future, severe amblyopia could be eliminated as a public health problem. long-term changes in corneal surface configuration after penetrating keratoplasty hayashi k, hayashi h am j ophthalmol 2006; 141: 241-47. computer-assisted videokeratography is most useful in the assessment of corneal surface configuration because it provides many advantages over keratometry. corneal topographic analysis is essential for assessment of corneal configuration before many types of corneal surgery and can substantially show any changes arising from the surgery. specifically, fourier series harmonic analysis has been applied recently to videokeratography data and has helped to clarify even minute changes in the corneal configuration attributable to ante-dot segment surgeries including keratoplasty, photore-fractive keratectomy, cataract surgery, pterygium surgery and trabeculectomy. it is known that the corneal configuration changes with time after penetrating keratoplasty (pk). knowledge of temporal changes in the configuration of the transplanted cornea is of particular importance in making the decision of when astigmatic keratotomy should be performed, and when compression sutures should be placed. many previous studies using videokeratography reported the topographic pattern of the transplanted cornea and the effect of suture removal on corneal shape after pk. however, only one study described short-term topographic changes of the graft after pk, and that study involved only eight patients, each of whom had keratoconus. the purpose of the study described herein was to examine the long-term longitudinal changes in corneal surface configuration after pk. to quantitatively evaluate even minute changes, authors used fourier analysis of videokeratography data. additionally, temporal changes in visual acuity were examined and correlated with the corneal surface configuration. one hundred thirty eyes of 130 consecutive patients who were scheduled for pk using 16 interrupted 10-0 nylon sutures were recruited. spherical equivalent power, regular astigmatism component, irregular astigmatism (asymmetry and higher-order irregularity) component of the central cornea as determined by fourier analysis of videokeragraphic data, spectacle corrected visual acuity, and spherical equivalent were examined at 1 week, and at 1, 3, 6, 9, 12, 18, and 24 months after pk. spherical equivalent power increased considerably for up to 1 month after pk, but thereafter showed no further appreciable change up to the final follow-up at 24 months. the regular astigmatism component decreased markedly for up to 6 months after pk, while the total irregular astigmatism (sum of the asymmetry and higher-order irregularity) component decreased considerably up to approximately 3 months, and then these showed no further relevant change for up to 24 months. spectaclecorrected visual acuity also improved markedly until approximately 3 months after pk, after which it was virtually stable. furthermore, important correlations were found between regular and irregular astigmatism and the spectacle-corrected visual acuity. authors concluded that corneal surface configuretion after pk appears to be stable by approximately 6 months after pk, concurrent with postkeratoplasty stabilization of visual acuity move stem cells from the mouth to the eye tseng scg am j ophthalmol 2006: 141: 356-7. when the ocular surface is severely damaged by chemical/thermal burns, stevens-johnson syndrome with or without toxic epidermal necrolysis, ocular cicatricial pemphigoid, and other conditions, patients frequently experience annoying photophobia and corneal blindness. aside from progressive inflammatory and cicatricial complications to the entire ocular surface, a leading cause of corneal blindness is the loss of limbal epithelial stem cells cytologically defined as “limbal stem cell deficiency”. during the last 15 years, a number of basic research and clinical studies have helped establish several surgical reconstructive procedures for treating limbal stem cell deficiency. they are limbal conjunctival autograft, limbal conjunctival allograft, keratolimbal allograft, and amniotic membrane transplantation. the aforementioned surgical procedures also propelled ophthalmology into the burgeoning field of regenerative medicine. these procedures are based on the premise that adult stem cells can perform relentless self-renewal to generate their progeny. for the first time in ophthalmology, these procedures transplant the stem cell-containing limbal epithelium to generate the corneal epithelium. although limbal conjunctival autografts yield overwhelmingly high success rates, keratolimbal allografts and conjunctival limbal allografts attain a relatively low long-term (3 to 5 years) success rates of approximately 50%. despite continuous oral administration of cyclosporine a, allograft rejection is the first major obstacle when allogeneic limbal epithelial stem cells are transplanted. although adult stem cells hold considerable promise for the treatment of a number of diseases in regenerative medicine, the second major obstacle has been to obtain sufficient numbers of autologous or allogeneic stem cells. on the ocular surface, the prevailing solution to overcome this obstacle relies on ex vivo expansion. moving the oral mucosal tissue to the eye has long been practiced in the surgical procedure of mucous membrane transplantation. experimentally, gipson and associates transplanted cultured oral mucosal epithelium to the rabbit corneal surface. to treat bilateral total limbal stem cell deficiency without the concern of allograft rejection, kinoshita and nakamura cleverly first proposed transplanting ex vivo expanded autologous oral mucosal epithelial progenitor cells to the ocular surface. a cultivation protocol similar to that used for expanding limbal epithelial stem cells was used with the goal of overcoming the last major obstacle, that is, to modulate the plasticity of ex vivo expanded progenitor cells to see if they may adopt the corneal epithelial phenotype in the corneal milieu. microsoft word aneeq ullah baig 140 original article results and complications of photorefractive keratectomy aneeq ullah baig mirza, khalid masood ashraf pak j ophthalmol 2006, vol. 22 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: aneeq ullah baig mirza assistant professor ophthalmology islamic international medical college/ railway teaching hospital, rawalpindi received for publication november’ 2005 …..……………………….. purpose: to evaluate the results and identify the complications after photorefractive keratectomy (prk). materials and methods: this retrospective study was conducted at laser vision center, model town, lahore. it comprised of 200 patients(400 eyes) that underwent prk on summit apex plus excimer laser from 20th feb 2004 to 3rd june 2005. all consecutive patients with complete relevant data were included in the study. three months postoperatively, the uncorrected visual acuity and complications in each eye, were recorded. the overall result was designed, based upon the postlaser uncorrected vision, residual refractive error, quality of vision and complications. results: out of 400 eyes, 383(95.9%) had a best corrected visual acuity of 6/9 or better preoperatively. at three months postoperatively, 369 eyes (92.3%) had an uncorrected vision of 6/9 or better. 51 eyes (12.8%) lost 2 or more lines of uncorrected visual acuity postoperatively. the main complications affecting the quality of vision postoperatively were under correction in 33 eyes (8.3%), poor contrast, shades, haloes and glare in 15 eyes (3.8%) and dry eye symptoms in 34 eyes (8.5%). the overall result was excellent in 311 eyes (77.8%). conclusion: we believe that prk is a reasonably safe and effective procedure for the correction of low to moderate myopia. he primary motivation behind prk is decreased dependence upon glasses and better cosmesis. it is effective for low to moderate myopia, myopic astigmatism and low grades of hypermetropia. prk employs 193nm argon fluoride excimer laser which ablates the anterior corneal stroma to a new radius of curvature, thus correcting ammetropia1. cornea has an extremely high absorption coefficient at 193nm. 193-nm photon has sufficient energy to directly break carbon-carbon and carbonnitrogen bonds that form the peptide backbone of corneal collagen molecules2. before proceeding with prk, one must exclude progressive myopia, history of autoimmune disease and dermel keloid formation. computerized videokeratography is essential for preoperative detection of subclinical keratoconus and contact lens induced corneal warpage3. the most frequently reported complications include glare, haloes, difficulty with night vision, decreased contrast sensitivity, transient increase in intraocular pressure (iop), mild subepithelial haze t 141 and myopic regression. the corneal haze appears after a few weeks, peaks in intensity at 1 to 2 months and gradually disappears in the following 6 to 12 months. as a parameter of efficacy the dioptric refractive outcome is less meaningful than uncorrected visual acuity. visual improvement after prk is slow but the severity of complications is far less as compared to lasik. materials and methods a retrospective study of 400 eyes (200 patients) who underwent photorefractive keratectomy from 20th feb 2004 to 3rd june 2005 at laser vision center, model town, lahore was conducted. all patients with complete relevant data consecutively, were included in the study. the following data was collected from the patient’s profile: name, age, sex, pre-laser refraction and bestcorrected visual acuity, whether or not contact lens wearer, any other positive finding, laser settings, use of mitomycin-c intraoperatively for high myopic eyes, complications of the procedure, unaided visual outcome 3 months post laser and any residual refractive error. based upon the above data, the number of patients and percentage in different visual groups pre and postoperatively was calculated. the percentage of cases with lost 2 or more lines of uncorrected visual acuity three months post-laser was calculated. the overall result was designed based upon the final uncorrected visual acuity, residual refractive error and quality of vision. it was graded and categorized as follows: excellent: visual acuity of 6/6 or comparable (postlaser uncorrected vision equal to the pre-laser corrected vision), emmetropia, good quality vision and no complications. good: visual acuity of 6/6 to 6/7.5, residual refractive error < 1.0 d, good quality vision and no complications or lost 1 line of pre-laser vision. fairly good: visual acuity of 6/6 to 6/9, residual refractive error of –1.0 to –1.50ds, good quality vision and no complications or lost 2 lines of pre-laser vision. fair: visual acuity of 6/6 to 6/12, residual refractive error < -1.50ds with complaints of haze, decreased contrast, glare etc or lost 3 lines of pre-laser vision. poor: visual acuity of 6/6 to 6/18, residual refraction > -1.50 d and complaints of haze, decreased contrast, glare etc or lost four lines of pre-laser vision. results of the 200 patients studied 78(39%) were males and 122(61%) were females. 78 patients were contact lens wearers while 122 were not (graph1). majority of the patients were in 20 to 24 years age group (41.5%) and 25-29 years age group (35%) (table 1). the pre-laser best corrected vision was 6/9 or better in 383 eyes (95.8%) (table 2). the unaided vision 3 months post-laser was 6/9 or better in 369 eyes (92.3%) (table 3). 51 eyes (12.8%) lost 2 or more lines of uncorrected visual acuity postoperatively (graph 2). the main complications of the procedure were under correction in 33 eyes (8.3%), dry eye symptoms in 34 eyes (8.5%) and complaints of poor contrast, shades, haloes or glare in 15 eyes (3.8%) (table 4 and graph 3). minimal haze was seen in 85 eyes (21.3%). since it did not effect the vision, it was not considered a complication. the overall result was graded excellent in 311 eyes (77.8%) (table 5 and graph 4). discussion prk employs 193nm argon fluoride excimer laser to ablate and reshape the anterior corneal stroma. it is reasonably safe and effective for the treatment of mild to moderate myopia. the purpose of this study was evaluation of the results and identification of complications of prk. our study consisted of 400 eyes with myopia ranging between –1.0 and –11.0d. at three months post-operatively 369 eyes(92.3%) achieved an uncorrected vision of 6/9 or better. 72.5% had an uncorrected visual acuity of 6/6. 12.8% of the eyes had a post laser uncorrected vision of 6/9 or less (which was considered as 2 or more lines lost). the last figure was much higher than the previous studies because of two reasons. firstly, we took under consideration the post-laser uncorrected vision instead of best corrected vision. as the motivation for prk is to get rid of glasses, the significance of post-laser uncorrected vision cannot be overemphasized. secondly, considering the sensitive nature of the procedure, an acceptable below normal result was taken, when the vision was less than 6/6 but better than 6/9. in our 142 study, 2 or more lines lost, meant an uncorrected vision of 6/9 or less rather than 6/12 or less. in the summit phase iii study, 701 eyes with myopia between –1.50 and –6.0d were enrolled4. of these patients, 90.7% had an uncorrected visual acuity of 6/12 or better. 66.3% had an uncorrected visual acuity of 6/6 or better. less than 1% lost 2 or more lines of best corrected visual acuity. in the visx food and drug administration study of 691 eyes with myopia ranging from –1.0 to –6.0d, 85% of the eyes had a visual acuity of 6/12 or better5. 1% of the eyes lost 2 more lines of best corrected visual acuity. table 1: percentage of myopic eyes and different age group age in years frequency (%) cumulative (%) 1 5 1 9 1 6 . 0 ( 4 . 0 ) 4 . 0 2 0 2 4 1 6 6 . 0 ( 4 1 . 5 ) 4 5 . 5 2 5 2 9 1 4 0 . 0 ( 3 5 . 0 ) 8 0 . 5 3 0 3 4 4 6 . 0 ( 1 1 . 5 ) 9 2 . 0 3 5 3 9 2 4 . 0 ( 6 . 0 ) 9 8 . 0 4 0 4 4 8 . 0 ( 2 . 0 ) 1 0 0 . 0 t o t a l 4 0 0 ( 1 0 0 ) t a b l e 2 : p r e l a s e r b e s t c o r r e c t e d v i s u a l a c u i t y vision frequency (%) cumulative (%) 6/18 5 (1.3) 1.3 6/12 12 (3.0) 4.3 6/9 37 (9.3) 13.5 6/7.5 17 (4.3) 17.8 6/6 329 (82.3) 100.0 total 400 (100) t a b l e 3 : p o s t l a s e r u n c o r r e c t e d v i s u a l a c u i t y vision frequency (%) cumulative (%) 6/60 1 (0.3) 0.3 6/36 1 (0.3) 0.5 6/24 1 (0.3) 0.8 6/18 3 (0.8) 1.5 6/12 25 (6.3) 7.8 6/9 58 (14.5) 22.3 6/7.5 21 (5.3) 27.5 6/6 290 (72.5) 100.0 total 400 (100) t a b l e 4 : c o m p l i c a t i o n s complications frequency (%) none 278 (69.5) moderate haze 3 (0.8) scarring 3 (0.8) undercorrection 33 (8.3) overcorrection 7 (1.8) poor contrast, shades, haloes, glare 15 (3.8) night vision problem 7 (1.8) dry eye symptoms 34 (8.5) raised intraocular pressure (iop) 4 (1.0) pain on reading 4 (1.0) near vision problem 10 (2.5) epithelial erosions 2 (.5) total 400 (100) t a b l e 5 : o v e r a l l r e s u l t results frequency (%) cumulative (%) p o o r 3 ( 0 . 8 ) 0 . 8 f a i r 3 7 ( 9 . 3 ) 1 0 . 1 f a i r l y g o o d 3 1 ( 7 . 8 ) 1 7 . 9 g o o d 1 8 ( 4 . 5 ) 2 2 . 4 e x c e l l e n t 3 1 1 ( 7 7 . 8 ) 1 0 0 143 t o t a l 4 0 0 ( 1 0 0 ) the main complications seen at 3 months postlaser visit were, under correction in 33 eyes (8.3%) complaints of poor contrast, shades, glare or haloes in 15 eyes (3.8%) and dry eye symptoms in 34 eyes (8.5%). the most serious of the complications was corneal scarring seen in 3 eyes (0.8%). 2 of the eyes were high myopes with pre-laser refractive error of –11.0d in both eyes. pre-laser best-corrected vision was 6/12 in each eye. post-laser uncorrected vision no 39.0% yes 61.0% fig. 1: percentage of contact lens wearers 0 20 40 60 80 100 no yes fig. 2: percentage of cases which lost 2 or more lines of uncorrected visual acuity none epithlelial erosions near vision problem pain on reading raised iop dry eye symptoms night vision problem poor contrast,shades overcorrection undercorrection scarring moderate haze fig. 3: complications after prk was 6/36 and 6/60 respectively. 0.02% mitomycin-c was applied upon both the eyes for 2 minutes (on the table). one eye with a pre-laser best-corrected vision of 6/6 with –6.50d developed corneal scarring. the post-laser uncorrected visual acuity was 6/9. most of the studies have indicated that an increased amount of attempted correction is associated with an increased incidence and severity of haze and regression as well as decreased best-corrected visual acuity6. topical intraoperative application of 0.02% mitomycin-c can reduce haze formation in high myopic eyes undergoing prk7. subepithelial corneal haze typically appears after 1 month, peaks in intensity and gradually disappears in the coming 6 to 12 months. histological studies have shown that corneal haze develops as a result of deposition of glycolsaminoglycans, non lamellar collagen and increase in number and activity of stromal keratocytes8. topical tranilast can reduce corneal haze by suppressing transforming growth factor (tgf) beta 1 synthesis in keratocytes after photorefractive keratectomy9. the complaints of decreased contrast sensitivity, ghost images, glare and haloes are related to peripheral spherical aberrations and pupillary diameter. the amount of spherical aberration introduced into the eye after prk, increases with increased level of attempted correction. theoretically, the ideal ablation pattern requires additional flattening of the peripheral part of ablation to prevent these aberrations10. p er ce nt 144 post-laser dry eye symptoms zone in the form of lid heaviness, burning eyes and grittiness was quite common. ocular surface dryness is related to decreased corneal sensitivity, which is more pronounced in post-lasik eyes as compared to postprk eyes. it might be related to the difference in early postoperative level of tear nerve growth factor, which is a potent nerve growth stimulator11. the visual efficacy after prk depends upon the final uncorrected visual acuity, emmetropia or level of ammetropia, quality of vision and complications. the quality of vision was assessed based upon subjective complaints regarding contrast sensitivity, haze, poor night vision, glare and haloes. accordingly, the overall result was categorized as excellent, good, fairly good, fair and poor. conslusion we conclude that prk is a reasonably effective procedure for correction of myopia. no serious ocular complications are seen in low to moderate myopic eyes. author’s affiliation aneeq ullah baig assistant professor ophthalmology islamic international medical college/ railway teaching hospital, rawalpindi khalid masood ashraf laser vision center, lahore reference 1. salz jj: radial keratotomy versus photorefractive keratectomy. in thompson fb, mc donnell pj: color atlas/text of excimer laser surgery: the cornea. new york, lgako-shoin, 1993, 6375. 2. puliafito ca, wong k, steinert rf: quantitative and ultrastructural studies of excimer laser ablation of the cornea at 193nm and 248 nanometers. lasers surg med. 1987; 7: 155-9. 3. wilson se, klyce sd: screening for corneal topographic abnormalities before refractive surgery. ophthalmology. 1994; 147-52. 4. thompson kp, steinert rf, stulting rd: photorefractive keratectomy with the summit excimer laser: the phase-iii u.s. results. in salz jj (ed): corneal laser surgery. st.louis, mosbyyear book, 1995; 57-63. 5. seiler t, mc donnell pj: excimer laser photorefractive keratectomy. surv ophthalmol. 1995; 40: 89-118. 6. tayler hr, mc carty ca, aldred gr: predictability of excimer laser treatment of myopia. arch ophthalmol. 1996; 114: 248-51. 7. gambato c, ghirlando a, moretto e, et al. mitomycin c modulation of corneal wound healing after photorefractive keratectomy in highly myopic eyes. ophthalmology. 2005; 112: 208-18. 8. malley ds, steinert rf, puliafito ca, et al: immunofluorescence study of corneal wound healing after excimer laser anterior keratectomy in the monkey eye. arch ophthalmol. 1990; 108: 1316-22. 9. song js, jung hr, kim hm: effects of topical tranilast on corneal haze after photorefractive keratectomy. j cataract refract surg. 2005; 31: 1065-73. 10. schwiegerling j, snyder rw. corneal ablation patterns to correct for spherical aberration in photorefractive keratectomy. j cataract refract surg. 2000; 26: 214-21. 11. lee hk, lee ks, kim hc, et al: nerve growth factor concentration and implications in photorefractive keratectomy vs laser in situ keratomileusis. am j ophthalmol. 2005; 139: 965-71. microsoft word amjad akram 68 original article critical reevaluation of previously diagnosed normal tension glaucoma patientsa three year study amjad akram, nadia azad, salah ud din, mazhar ishaq, amer yaqub, sameer shahid ameen pak j ophthalmol 2006, vol. 22 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: amjad akram 61, iftikhar janjua colony kharian cantt gujrat received for publication march’ 2005 …..……………………….. purpose: the objective of this study was to reevaluate the previously diagnosed patients of normal tension glaucoma, visiting eye department of military hospital rawalpindi, to confirm whether they really had normal tension glaucoma or not. material and methods: all diagnosed normal tension glaucoma patients with routine follow-ups were given a thorough ophthalmic evaluation including best corrected visual acuity, slit lamp examination, stereoscopic disc evaluation using a 90 dioptre lens, humphrey 30-2 statistic threshold perimetry, central corneal thickness measurement using ultrasonic pachymetry, goldmann applanation tonometry, and gonioscopy. visual field testing was carried out using the 30-2 humphrey field analyser (hfa). phasing of iop was done and ct scan and mri were arranged wherever neuroophthalmological lesions were suspected. after thorough evaluation of each patient and ruling out all other conditions mimicking ntg the actual frequency of normal tension glaucoma was determined. results: it was found that out of 30 patients evaluated only two patients qualified to be labeled as ntg. conclusion: if ntg is considered a diagnosis of exclusion chances of making diagnostic mistakes should be minimized. key words: normal tension glaucoma, applanation tonometry, central corneal thickness, intraocular pressure. ormal tension glaucoma (ntg) has been described as a condition in which there is typical pathological cupping of optic nerve head with corresponding field defects but with an intraocular pressure within the accepted statistically normal range. ntg is an entity that has created a lot of confusion among ophthalmologists for many decades. its diagnosis can be very challenging and it has served as a real brainteaser for many eye doctors. we were motivated to carry out this study by a similar study conducted in israel in 1993, wherein 90% of previously diagnosed ntg patients were found to have mimicking lesions of optic nerve highlighting the importance of neuro-imaging in such patients1, so we decided to carry out a similar reevaluation of our own ntg patients. n 69 material and methods we carried out a hospital based descriptive study at department of ophthalmology, military hospital, rawalpindi starting august 2001 till august 2004. thirty patients of diagnosed normal tension glaucoma who fulfilled the inclusion criteria were selected from the outpatient department on the basis of convenience sampling. data was analyzed using statistical package for social sciences (spss) software method. chi square test was used for nominal data. inclusion criteria patients who had been diagnosed as normal tension glaucoma by an ophthalmologist at any time were included in the study. this included patients diagnosed by consultants, registrars and residents in training. examination examination was carried out according to the proforma and it included both local and systemic examination and direct questions were asked regarding ocular and medical history, any history of anemia, blood loss, and raynaud’s phenomenon. ocular examination all patients were given a thorough ophthalmic evaluation including best corrected visual acuity, slit lamp examination, stereoscopic disc evaluation using a 90 dioptre lens, humphrey 30-2 static threshold perimetry, central corneal thickness measurement using ultrasonic pachymetry, goldmann applanation tonometry, and gonioscopy. twenty four hour phasing of iop was also done. water drinking test was done when considered appropriate. visual field testing was carried out using the 302 humphrey field analyser (hfa). visual fields were repeated whenever the test results were unreliable or edge defects were present. ct scan and mri were arranged whenever neuroophthalmological lesions were suspected or water drinking test and phasing tests were negative. systemic examination the systemic examination of all the patients was carried out placing special emphasis on cardiovascular status and neurological evaluation. results thirty patients were included in the study, out of which 26 (86.7%) were male and 4 (13.3%) were female in the ratio of (table 1) (fig. 1). the patients’ age ranged from 22 to 73 years with a mean value of 42.6 years. our study showed that out of 30 patients diagnosed as ntg at some stage in their life by any ophthalmologist, we were only able to label two (6.7%) patients as ntg. in the remaining 28 patients (93.3%) we were able to demonstrate a mimicking lesion or no pathology at all (table 2, fig. 2). out of these 28 patients 7 (25%) were found to have no ocular or neurological pathology. while 21 (75%) out of these 28 patients were found to have various ocular and neurological lesions accounting for excavation of optic disc and visual field defects. eight patients (26.7%) were found to have pituitary tumor on ct scan giving rise to advanced cupping of disc bilaterally in the presence of normal iop. four patients (13.3%) actually had primary open angle glaucoma and iop was revealed more than 21 mm of hg on diurnal phasing for 24 hours. three patients (10%) were found to be suffering from various neurological lesions which were discovered on ct/ mri scan namely temporoparietal hemorrhage, astrocytoma of left parieto-occipital area and demyelination plaques. three patients (10%) had anterior ischemic optic neuropathy, which was revealed on humphrey perimetry as altitudinal defects. one patient (3.3%) suffered from papillitis, which was discovered on retrieval of the old notes. one patient (3.3%) was found to have ethambutol toxicity giving rise to bitemporal hemianopia. this information was revealed when past history was explored. ct scan brain was normal. one patient (3.3%) had high myopia with associated large discs and was falsely labeled as ntg while visual fields were grossly normal. table 1: gender distribution of patients gender no. of patients n (%) male 26 (86.7) female 04 (13.3) table 2: prevalence of normal tension glaucoma no. of patients previously diagnosed as no of patients with mimicking lesions n (%) no of patients labeled as ntg n (%) 70 ntg 30 28 (93.3) 02 (6.7) table 3: frequency of neurological lesions in diagnosed patients of ntg type of lesion no. of patients n (%) ntg 02 (6.7) neurological lesions 11 (36.7) others 17 (56.7) seven patients (23.3%) had no pathology at all, as visual fields were perfectly normal. initial edge defects were part of the learning curve on perimetry and disappeared on subsequent tests. analysis of data data in this study was nominal so chi square test was applied. majority of patients in the study initially diagnosed as ntg were not actually suffering from ntg but disc cupping was due to other causes which mimic ntg and for this group the value of test of significance (p value) is of the order of p<0.05. only two patients justified to be labeled as ntg and for this group the value of test of significance (p value) is of the order of p<0.001. these all show that hypothesis in our study is an alternate hypothesis. discussion normal tension glaucoma (ntg) is a subset of primary open angle glaucoma (poag), with characteristic glaucomatous cupping and field loss, an open drainage angle, and an intraocular pressure (iop) consistently within the normal range2. there are several factors that lead to estimation of artificially low iop and resulting in ophthalmologist making a wrong diagnosis. it is recommended that before labeling a patient with ntg several other mimicking lesions must be ruled out. some of the patients actually suffering from primary open angle glaucoma go undiagnosed and land up in normal tension glaucoma group when we make diagnosis on single iop reading and do not take into account diurnal variation in iop. female male fig. 1: graphic distribution of patients according to gender study by yamagami j, araie m, aihara m, yamamoto s reported that mean of the iops recorded at the outpatient clinic in ntg patients had high correlation with the mean or peak of the iops recorded over a 24 hour period3. poag is a significant mimicker of ntg as shown in our study where 4 patients actually had poag that was revealed on diurnal phasing for 24 hours. 1 3 1 1 7 23 8 4 papillitis old ant ischemic optic neuropathy ethambutol toxicity high myopia nad ntg other neurological lesions pituitary tumor poag fig. 2: graphic distribution of patients according to final diagnosis normal range iops on diurnal phasing (off treatment for > 6 weeks) suspicious / abnormal discs abnormal vf normal vf (refer to neurologist if poor disc / field correlation, if pallor exceeds cupping) confirmed ntg ntg suspect establish baseline data baseline reproducible vf by threshold perimetry. establish baseline data check optic disc size and c/d ratio against 71 baseline “damage causing” iop 3 d optic disc imaging look for progression serial iops (for progressive increased) serial optic disc examination/analysis (+look for disc haemorrhages) serial visual fields (3 x per year) subjective deterioration normative hrt database look for change serial optic disc exam/analysis serial visual fields progression detected (objective or subjective exclude treatable risk factors (eg nocturnal hypotension, vasospasm, abnormal rheology) reduction of baseline iop by 25-30% alogrithm for the practical management of a patient with confirmed or suspected normal tension glaucoma. (kamal d, hitchings r. normal tension glaucoma―a practical approach. br j ophthalmol 1998; 82: 835-40. the progressive nature of glaucoma should always be borne in mind as this will help to distinguish true ntg from an isolated ischemic event, which may mimic it in terms of optic disc and visual field appearances4. five cases of anterior ischemic optic neuropathy secondary to biopsy proven giant cell arteritis are presented in the study by sebag j et al. in each case, cupping of the optic disc, which closely resembled glaucomatous cupping, was observed in the affected eye. these cases indicate that arteritic ischemic optic neuropathy can result in optic disc cupping, which closely resembles glaucomatous cupping. the similarities in the appearance of cupping of these discs with that seen in eyes with glaucoma suggest that the pathogenesis of cupping in glaucoma and in arteritic ischemic optic neuropathy may share some common mechanisms. likewise orgul s, gass a and flammer j. described a patient with arteritic anterior ischemic optic neuropathy who developed disc cupping within 4 months after an acute episode. this patient never had elevated intraocular pressure5. the end-stage optic disc appearance in arteritic aion secondary to giant cell arteritis is cupping, whereas segmental or diffuse pallor without cupping is the typical disc appearance after non arteritic aion6-8. a study was carried out in japan which showed that angiographic picture of the optic disc in low tension glaucoma is clearly different from that in aion9. there should be little difficulty under most circumstances in making the clinical differentiation between a disc that has suffered ischemic optic neuropathy and a disc that has suffered pressureinduced damage, although occasional instances of ischemic optic neuropathy may be classified as lowtension glaucoma on the basis of field loss and cupping without elevated intraocular pressure10. similarly in our study 3 out of 30 patients actually suffered from anterior ischemic optic neuropathy in the past. when a person believed to have normal tension glaucoma continues to get worse despite treatment, it is likely that optic neuropathy is due to other causes. of these other causes masses in the region of pituitary gland deserve special mention. these entities are not rare and can mimic disc and field changes in patients with glaucoma11. baig ma et al12 reported cases in which normal tension glaucoma was presented as multiple mimicking lesions. a case of ntg was reported in which visual deterioration continued despite anti glaucoma therapy so x-ray pituitary fossa was ordered which showed ballooning of pituitary fossa due to pituitary tumor. likewise another case is reported which was diagnosed as having unilateral normal tension glaucoma and was revealed to have aneurysm of the anterior cerebral artery compressing on the left optic nerve on mri scan. yamabayashi s, yamamoto t, sasaki t and tsukahara s reported a case of low tension glaucoma with primary empty sella where a congenitally empty sella turcica allowed for the chiasm to herniate downward into the sella causing field defects and nerve pathologies13. kamal and hitchings do not recommend routine scanning of every ntg patient with ct and mri as they found that the incidence of intracranial disease was not greater than that expected for the general population in ntg clinics14. another study found two out of 53 patients to have intracranial lesions in a group referred for evaluation of probable ntg15. stroman et al16 examined mri results of 20 ntg patients and compared them with those of patients undergoing imaging who had no ocular findings and found the prevalence of space occupying intracranial abnormalities was similar for both groups. however the presence of diffuse small vessel ischaemic changes was more common in the ntg group, a finding supported by a later study.17 in our study we have found 11 patients to be suffering from various neurological lesions. out of these 8 patients had pituitary tumors and the rest three had astrocytoma of parietal lobe, temporoparietal hemorrhage and demyelination plaques. although commonest cause of bitemporal hemianopia is pituitary tumor, however ethmbutol toxicity can also give rise to such field defects. in our study we also found one case of bitemporal hemianopia with ethambutol toxicity falsely labeled as normal tension glaucoma18. 72 there are a host of masquerading conditions that present with field defects that are non-progressive. baseline measurements should best rely on the second testing session, since mean deviation and mean sensitivity are somewhat poorer when subjects with no prior visual field experience are first tested on the frequency doubling technology instrument. this may be especially true for the purpose of following patients over time19. earlier experience with computerised perimetry is important for test results. sizeable minority of normal subjects do not produce a normal test result at the first test20. sensitivity values are below normal in the mid periphery of field of inexperienced subjects while paracentral area is entirely normal. mostly results of a subsequent test on another day will be normal. most perimetric learning takes place between first and second sessions. if concentric contraction is encountered in the first test of patient with suspect glaucoma, one can always regard the result as an indication of normal field, which can most likely be confirmed on next visit20. likewise in our study 7 patients showed edge defects that disappeared on subsequent testing repeated after 3 and 6 months. eyes with large discs are often falsely labeled as glaucomatous. in eyes with small discs, field defects are often present while optic disc topography is still normal.21 in our study we also found that a case with large discs due to high myopia was falsely being treated as normal tension glaucoma while iop and visual fields were normal. if the ophthalmologist makes enough effort most cases of ntg can be properly ascribed to other diseases like burnt-out poag, arteritic aion, diurnal variations in poag, chronic angle closure glaucoma, compressive lesions, non-glaucomatous optic neuropathy, previously high iop, optic nerve hypoplasia, tilted discs, optic pits and colobomas, large physiologic cup (megalopapillae), optic nerve drusen and secondary glaucomas (pigmentary glaucoma, glaucomatocyclitic crisis) 22. conclusion we do not deny the existence of normal tension glaucoma however if normal tension glaucoma is considered a diagnosis of exclusion chances of making mistakes are minimized. if the ophthalmologist tries to rule out mimicking lesions first before labeling a patient as normal tension glaucoma and starting anti glaucoma therapy, most cases of "ntg" can be correctly ascribed to another disease. stress should be placed on complete eye examination and history, measurement of diurnal pressure curve, general medical exam and neuro-evaluation, serial fields and fundus photographs. emphasis should always be placed on the correlation between the pattern of cupping and the location of the field disturbance when "topographically" evaluating visual field defects. although a number of entities should be considered when evaluating a patient with cupping associated with normal intraocular pressure, a careful history and ocular examination may help distinguish glaucomatous from non-glaucomatous mechanisms of optic nerve head injury. we also recommend from our study experience, performing neuroimaging i.e. mri/ ct before ultimately labeling a patient with normal tension glaucoma. author’s affiliations maj amjad akram military hospital rawalpindi dr nadia azad military hospital rawalpindi maj salah ud din military hospital rawalpindi col mazhar ishaq military hospital rawalpindi. lt col amer yaqub military hospital rawalpindi. lt col sameer shahid ameen military hospital rawalpindi. references 1. gutman i, melamed s, ashkenazi i, et al. optic nerve compression by carotid arteries in low-tension glaucoma. graefes arch clin exp ophthalmol. 1993; 231:711-7. 2. levene r. low tension glaucoma. a critical review and new material. surv ophthalmol. 1980; 24: 621-64. 3. yamagami j, araie m, aihara m, et al. diurnal variation in intraocular pressure of normal-tension glaucoma eyes. ophthalmology. 1993; 100: 643-50 4. sebag j, thomas jv, epstein dl, et al. optic disc cupping in arteritic anterior ischemic optic neuropathy resembles glaucomatous cupping. ophthalmology. 1986; 93: 357-61 73 5. orgul s, gass a, flammer j. optic disc cupping in arteritic anterior ischemic optic neuropathy. ophthalmology. 1994; 208: 336-8. 6. danesh-meyer hv, savino pj, sergott rc. the prevalence of cupping in end-stage arteritic and nonarteritic anterior ischemic optic neuropathy. ophthalmology. 2001; 108: 593-8. 7. hayreh ss, jonas jb. optic disc morphology after arteritic anterior ischemic optic neuropathy. ophthalmology. 2001; 108:1586-94. 8. sonty s, schwartz b. development of cupping and pallor in posterior ischemic optic neuropathy. int ophthalmol. 1983; 6: 213-20 9. abe h, hasegawa s, takagi m, et al. fluorescein angiographic findings regarding the optic disc in cases of low-tension glaucoma and the chronic stage of anterior ischemic optic neuropathy. nippon ganka gakkai zasshi. 1993; 97: 1225-30. 10. quigley h, anderson dr. cupping of the optic disc in ischemic optic neuropathy. trans am acad ophthalmol otolaryngol. 1977; 83: 755-62. 11. hitchings ra. fundamentals of clinical ophthalmology: glaucoma. bmj publishing group. 2000. 12. baig ma, akram a, ishaq m, et al. normal tension glaucoma errors in diagnosis. pak j ophthalmol 2002; 18: 23-5. 13. yamabayashi s, yamamoto t, sasaki t, et al. a case of low tension glaucoma with primary empty sella. br j ophthalmol. 1988: 72, 852-5. 14. kamal d, hitchings r. normal tension glaucoma a practical approach. br j ophthalmol. 1998; 82: 835-40. 15. stewart wc, reid kk. incidence of systemic and ocular disease that may mimic low-tension glaucoma. j glaucoma. 1992; 1:27. 16. stroman ga, stewart wc, golnik kc, et al. magnetic resonance imaging in patients with low-tension glaucoma. arch ophthalmol. 1995; 113: 168-72. 17. demaiily p, cambert f, plouin f. do patients with low-tension glaucoma have particular cardiovascular characteristics? surv ophthalmol. 1994; 38: 65-75. 18. karmon g, savir h, zevin d, et al. bilateral optic neuropathy due to combined ethambutol and isoniazid treatment. ann ophthalmol. 1979; 11: 1013-7. 19. horani a, frenkel s, yahalom c, et al. the learning effect in visual field testing of healthy subjects using frequency doubling technology. j glaucoma. 2002; 11: 511-6. 20. heijl a, lindgren g, olsson j. the effect of perimetric experience in normal subjects. arch ophthalmol. 1989; 107: 816. 21. heijl a, molder h. optic disc diameter influences the ability to detect glaucomatous disc damage. acta ophthalmol. 1993; 71: 122-9. 22. sowka j. normal tension glaucoma: mystery, myth or reality? [online] 2004 [cited sep 2004] available from url: http://www.nova.edu/-jsowkq/ntg.html. 21 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology original article association of intima-media thickness of internal carotid artery with ocular pseudoexfoliation oguz guvenmez, asim kayiklik pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: oguz guvenmez, md special internal medicine clinic, adana, turkey e-mail: oguzguvenmez001@hotmail.com …..……………………….. purpose: to compare the internal carotid artery intima-media thickness (caimt) in patients with ocular pex and healthy controls and to show that ocular pex may be related to atherosclerosis, or not. study design: cross-sectional study. place and duration of study: department of ophthalmology in adana ortadogu hospital, adana, turkey. the study was conducted between january 2017 and january 2018. material and methods: there were 32 participants in the study. in the biomicroscopic anterior segment examination, 16 patients were diagnosed with pseudoexfoliative material on the pupil margin or anterior lens capsule. these patients formed the first group (group i).16 non-pex patients were accepted as a control group (group ii). patients with systemic disease such as hypertension, diabetes mellitus were excluded from the study. caimt was measured and noted in all participants. carotid artery doppler usg was used to measure caimt. the data were compared by statistical analysis. results: in group i and group ii, the age of the patients did not differ significantly (p > 0.05). in group i and group ii, gender distribution was not significant (p > 0.05). in group i, caimt was significantly higher than in group ii (p < 0.05). conclusion: ocular pex appears to be associated with atherosclerosis. keywords: ocular pseudoexfoliation, atherosclerosis, carotid artery. therosclerosis, a systemic vascular disease, is a progressive common health problem all over the world1. this disease may not show any clinical symptoms, but it can be a sign of serious disease2. atherosclerosis is a phenomenon of dysfunction in the endothelial cells and accumulation of some substances in tunica intima.3 these substances include lipoprotein particles. they are foamy macrophage cells resulting from the collection of leukocytes. thus, smooth muscle cells in the tunica media begin to form atheroma plaques4,5. this may lead to both cardiovascular disease and pseudoexfoliation syndrome6. ocular pseudoexfoliation (pex) is the detection of fibrillar extracellular matrix accumulation on the anterior segment of the lens, pupil circumference, iris epithelium or zonules during the anterior segment examination7. the mechanism and the etiology of pex formation has not been fully understood. furthermore, the relationship of ocular pex with systemic diseases has been demonstrated in various studies8-14. many diseases can be diagnosed early with internal carotid artery intima media thickness a association of intima-media thickness of internal carotid artery with ocular pseudoexfoliation pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 22 (caimt).9 ultrasonography technique is an inexpensive, easy and non-invasive method through which intima media thickness is measured10. many studies have been conducted to measure intima media thickness in diabetics, obesity, and renal failure patients and dyslipidemia11,12. the aim of this study is to compare the internal carotid artery intima-media thickness (caimt) in patients with ocular pex and healthy individuals, and to show that ocular pex may be related to systemic diseases such as atherosclerosis, or not. material and methods our study was a cross-sectional clinical study which included 32 patients with or without ocular pex (40-80 years of age) who were admitted to the department of ophthalmology in adana ortadogu hospital between january 2017 and january 2018. the patients were admitted to our clinic with the complaint of low vision. the ethical approval was obtained from the ethics committee of adana city hospital in adana in turkey and informed consent was obtained from the all participants. in the biomicroscopic anterior segment examination, 16 patients were diagnosed with pseudoexfoliative material on the pupil margin or anterior lens capsule. these patients formed the first group (group i). other 16 non-pex patients were accepted as a control group (group ii). patients with systemic disease such as hypertension, diabetes mellitus were excluded from the study. caimt was measured and noted in all participants. carotid artery doppler usg was used to measure caimt. the data was compared by statistical analysis. mean, standard deviation, median lowest, highest, frequency and ratio values were used in descriptive statistics of the data. the distribution of the variables was measured with the kolmogorovsimirnov test. independent sample t test was used to analyze the quantitative independent data. χ² test was used for the comparison of normally distributed categorical variables. spss 22.0 program was used in the analysis. results the demographic variables of the sample are presented in table 1. in group i and group ii, the age of the patients did not differ significantly (p > 0.05). in group i and group ii, gender distribution was not significant (p > 0.05). in group i, caimt was significantly higher than in group ii (p < 0.05) (table 2 and figure 1). table 1: demographic variables of the sample. min-max median mean ± sd/n% age 43.0 – 78.0 64.0 61.2 ± 9.7 sex male female 16 16 50% 50% fig. 1: the comparison of caimt between the groups. table 2: the comparison of group i and group ii. group 1 group ii p mean ± sd/n% median mean ± sd/n% median age 61.5 ± 9.6 64.0 60.8 ± 10.2 64.0 0.845 sex male female 9 7 56.3% 43.8% 7 9 43.8% 56.3% 0.480 caimt (mm) 0.77 ± 0.12 0.80 0.66 ± 0.09 0.64 0.004 oguz guvenmez, et al 23 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology discussion pseudoexfoliation syndrome (pexs) is a clinically diagnosed disease and its etiopathogenesis has not been determined yet. however, there are studies showing that there is a relationship between pexs and systemic diseases. in addition, pex is a common agerelated systemic metabolic vascular disease affecting the elastin microfibrillar tissue. it is characterized by white grey extracellular flaky material in the anterior segment.15according to microscopic findings, pex materials have been found in blood vessel wall, which could affect the function and elasticity of blood vessels, as shown by increased carotid artery stiffness16 and reduced brachial artery endothelial cell function17. schumacher et al. reported that five ocular pex patients who were sampled from the aortic artery had significant pex accumulation in the vessel intima media9. cahill et al. conducted another study which demonstrated the systemic involvement of pex. they showed the deposition of fibrilsin in the tectorial membrane of the inner ear. bilateral sensorineural hearing loss was observed in the majority of patients with pex, regardless of age and glaucoma18. in a study in which the relationship between pex and diabetes mellitus was investigated, there was no relationship between pex and diabetes. in this study pex ethiopathogenesis was attributed to genetic and biochemical factors14. in a study by ekström et al, the relationship between pexs and aortic aneurysm was investigated, but no association was found between the two diseases19,20. increased arterial wall thickness and changes in the vascular structure, expressed as caimt, have been identified as predictors of unexpected cardiovascular events. caimt has been shown to be an early marker of endothelial tissue damage and an early sign of atherosclerotic vascular disease21,22. caimt is highly correlated with the presence of coronary pathology and myocardial infarction. carotid disease is seen in 30-60% of people with peripheral vascular disease. approximately 50-60% of patients with carotid disease have advanced coronary disease, while only 10% of patients with coronary artery disease have advanced carotid disease23. therefore, we believe that early detection of increased caimt will have an important role in prevention of cardiological and neurological diseases. conclusion there is a positive link between caimt and ocular pex in our study. since caimt is associated with atherosclerosis, there may also be an association between ocular pex and atherosclerosis. in this context, with a simple eye examination, it can be learned whether the patients have a risk of coronary artery disease, or not. this may also help in the early diagnosis of atherosclerosis. however, future studies pointing this subject are needed to clarify these findings. conflict of interests all authors declare that they have no conflict of interests. author’s affiliation oguz guvenmez, md special internal medicine clinic, adana, turkey. asim kayiklik, md department of ophthalmology, adana ortadogu hospital, adana, turkey. author’s contribution oguz guvenmez, md study design, interpreting results, writing manuscript. asim kayiklik, md collecting data, statistical analysis, writing manuscript. references 1. ross r. atherosclerosis. in: mcgee j, isaacson pg, wright na, editors. oxford textbook of pathology. vol. 2, oxford: oxford university press; 1992: 798-812. 2. mcgill hc jr, mcmahan ca. determinants of atherosclerosis in the young. pathobiological determinants of atherosclerosis in youth (pday) research group. am j cardiol. 1998; 82: 30-6. 3. rafieian-kopaei m, setorki m, doudi m, baradaran a, nasri h. atherosclerosis: process, indicators, risk factors and new hopes.int j prev med. 2014; 5: 927-46. 4. kuller l, borhani n, furberg c, gardin j, manolio t, o’leary d, et al. prevalence of subclinical atherosclerosis and cardiovascular disease and association with risk factors in the cardiovascular health study. am j epidemiol. 1994; 139: 1164-79. 5. touboul pj, hennerici mg, meairs s, adams h, amarenco p, bornstein n, et al. mannheim carotid intima-media thickness consensus (2004-2006). an association of intima-media thickness of internal carotid artery with ocular pseudoexfoliation pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 24 update on behalf of the advisory board of the 3rd and 4th watching the risk symposium, 13th and 15th european stroke conferences, mannheim, germany, 2004, and brussels, belgium, 2006. cerebrovasc dis. 2007; 23: 75-80. 6. siordia ja, franco j, golden tr, dar b. ocular pseudoexfoliation syndrome linkage to cardiovascular disease. curr cardiol rep. 2016; 18: 61. 7. küchle m, amberg a, martus p, nguyen nx, naumann go. pseudoexfoliation syndrome and secondary cataract. br j ophthalmol. 1997; 81: 862-6. 8. shrum kr, hattenhauer mg, hodge d. cardiovascular and cerebrovascular mortality associated with ocular pseudoexfoliation. am j ophthalmol. 2000; 129: 83-6. 9. su tc, chien kl, jeng js, chen mf, hsu hc, torng pl, et al. age and gender-associated determinants of carotid intima-media thickness: a community-based study. j atheroscler thromb. 2012; 19: 872–80. 10. jaroch j, loboz grudzien k, bociaga z, kowalska a, kruszynska e, wilczynska m, et al. the relationship of carotid arterial stiffness to left ventricular diastolic dysfunction in untreated hypertension. kardiol pol. 2012; 70: 223–31. 11. takiuchi s, rakugi h, fujii h, kamide k, horio t, nakatani s, et al. carotid intima-media thickness is correlated with impairment of coronary flow reserve in hypertensive patients without coronary artery disease. hypertens res. 2003; 26: 945–51. 12. schumacher s, schlötzer-schrehardt u, martus p, lang w, naumann go. pseudoexfoliation syndrome and aneurysms of the abdominal aorta. the lancet, 2001; 3: 357: 359-60. 13. rinvold a. pseudoexfoliation and aortic aneurysms. the lancet, 2001; 357: 2139. 14. psilas kg, stefaniotou mj, aspiotis mb. pseudoexfoliation syndrome and diabetes mellitus. acta ophthalmol (copenh), 1991; 69: 664-6. 15. streeten b, gibson s, dark a. pseudoexfoliative material contains an elastic microfibrillar-associated glycoprotein. trans am ophthalmol soc. 1986; 84: 30420. 16. visontai z, merisch b, kollai m, holló g. increase of carotid artery stiffness and decrease of baroreflex sensitivity in exfoliation syndrome and glaucoma. br j ophthalmol. 2006; 90: 563. 17. naji m, naji f, suran d, gracner t, kanic v, pahor d. systemic endothelial dysfunction in patients with pseudoexfoliation syndrome. klin monbl augenheilkd, 2008; 225: 963-7. 18. cahill m, early a, stack s, blayney aw, eustace p. pseudoexfoliation and sensorineural hearing loss. eye, 2002; 16: 261-6. 19. ekström c, wilger s, wanhainen a. pseudoexfoliation and aortic aneurysm: a long-term follow-up study. acta ophthalmol. 2019; 97 (1): 80-83. 20. besir fh, yazgan s, celbek g, aydın m, yazgan ö, erkan me, et al. normal values correlates of carotid intima-media thickness and affecting parameters in healthy adults. anadolu kardiyol derg. 2012; 12: 427-33. 21. mayet j. is carotid artery intima-media thickenning a reliable marker of early atherosclerosis? j cardiovasc risk, 2002; 9: 77-81. 22. jadhav um. carotid intima media thickness as an independent predictor of coronary artery disease. indian heart j. 2001; 53: 458-62. 23. magyar mt, szikszai z, balla j, valikovics a, kappelmayer j, imre s. early – onset carotid atherosclerosis is associated with increased intima – media thickness and elevated serum levels of inflammatory markers. stroke, 2003; 34: 58-63. pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 93 original article role of nd:yag laser in the management of premacular subhyloid hemorrhage irum raza, chaudhary nasir ahmad, tehseen mahmood mahju pak j ophthalmol 2017, vol. 33, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irum raza doms, fcps vitreo-retina fellow department of ophthalmology, king edward medical college & mayo hospital, lahore. e-mail: eyemiss@ymail.com purpose: to evaluate the role of early nd:yag laser hyaloidotomy in the management of premacular subhyaloid hemorrhage. study design: prospective interventional case series. place and duration of study: ophthalmology department, king edward medical university and mayo hospital, lahore from 1st july, 2015 to 31st december, 2015. material and methods: there were total 20 patients of premacular subhyaloid hemorrhage who underwent nd:yag laser hyaloidotomy. all were followed up on 2nd day, 1st week and 2nd week. detailed examination was done to note the improvement of vision, clearance of macula, absorption of hemorrhage and any complication occurred. data was analyzed by spss version 20 and presented in the form of tables. results: among included patients, 8 were males (40%) and 12 were females (60%). mean and standard deviation for patients' age was 36.55 ± 14.50 with range of 20-65 years. maximum patients (50%) were from the younger age group of 20-35 years. most common etiology of hemorrhage was pdr (40%). macula was cleared in 15 patients (75%) but visual acuity was improved in only 13 patients (65%) because of underlying maculopathies. the mean amount of energy of laser used was 7.67 ± 2.55 with a range of 4-12 mj. the hemorrhage took 4 weeks on average to be absorbed from vitreous. complication in the form of taut epimacular membrane was noted in only one patient. irum raza, et al 94 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology …..……………………….. conclusion: nd:yag laser hyaloidotomy is a safe, cheap, non-invasive and early visual rehabilitory procedure. key words: nd:yag laser, hyaloidotomy, premacular subhyaloid hemorrhage. remacular subhyaloid hemorrhage is an ocular condition in which blood accumulates in front of macula behind the posterior vitreous face. it can be caused by proliferative diabetic retinopathy (pdr), hypertensive retinopathy, retinal artery macroaneurysm, blood dyscrasias, age-related macular degeneration (amd) and valsalva maculopathy1. it causes profound sudden loss of vision. it is a self-limiting condition and can resolve on its own. however spontaneous resorption of the blood entrapped in the subhyaloid space is slow and may result in long-lasting visual hampering2. if it persists for longer period, can lead to pigmentary damage to the macula, toxic damage to the retina due to the prolonged contact with iron and haemoglobin, epimacular membrane formation or even macular traction3. various management options for this entity include observation, neodymium:yag (nd:yag) laser hyaloidotomy and pars plana vitrectomy.4 as it is associated with permanent macular changes before the hemorrhage gets spontaneously resolved and management of underlying cause with potential risks of damage to ocular structures is instituted, early intervention becomes crucial. although pars plana vitrectomy is likely to have the best anatomic outcome, the well known complications limit its immediate adoption in the majority of scenarios. nd:yag laser hyaloidotomy is a non-invasive, cheap, and safe method, which enables the drainage of the premacular subhyaloid haemorrhage into the vitreous, facilitates absorption of blood cells and improves the vision immediately by the clearance of the obstructed premacular area5. it is found to be efficacious in 93.33% cases6. the rationale of this study was to establish the early role of nd:yag laser in the management of premacular subhyaloid hemorrhage so as to avoid the permanent macular damages which may occur in case of conservative observational approach. materials and methods this prospective interventional case series was carried out in ophthalmology department, king edward medical university and mayo hospital, lahore from 1st july, 2015 to 31st december, 2015. there were total 20 patients of premacular subhyaloid hemorrhage. they were selected with the help of non probability purposive sampling technique. inclusion criteria were onset of symptoms within 2 weeks, 3-5 disc diameters of hemorrhage and phakic patients with excellent posterior segment view. while exclusion criteria was previous treatment for any maculopathy, associated vitreous hemorrhage and visual acuity better than 6/60. proper permission was taken from institutional ethical committee to conduct this study. patients were selected from out-door patient department (opd) of ophthalmology department of mayo hospital, lahore. a formal informed consent was taken from the patients after brief description of method, duration and possible outcome failure of treatment. they were ensured about the safety of procedure and also that the confidentiality of data would be maintained. after fulfilling the inclusion and exclusion criteria, patients were enrolled in this study. after enrollment, the detailed history was taken about the onset of reduced vision. systemic inquiry was carried out in detail. pre and post-treatment best corrected visual acuity, slitlamp examination, intraocular pressure and fundoscopy were done. special attention was paid to note any possible etiology. once diagnosis was made, patients underwent nd:yag laser hyaloidotomy with the help of triple-mirror contact lens. initially energy was set at 3 milli joules (mj) and was increased depending upon the reaction. laser was applied at anterior dependent surface of hemorrhage away from fovea. end point was when anterior surface of hemorrhage was ruptured and blood trickled into the vitreous. patients were called for follow ups on 2nd day, 1st week and 2nd week. on each visit, visual acuity was assessed and detailed fundus examination was done to find out underlying pathology and any complication occurred during procedure. p role of nd:yag laser in the management of premacular subhyloid hemorrhage pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 95 all the recordings were made in the proforma designed (copy attached). all the data was entered and analyzed with the help of computer software spss version 20 to find out frequencies and percentages of study variables i.e. gender, etiology of haemorrhage. descriptive statistics were applied to calculate mean and standard deviation for the age of the patients and amount of energy of laser applied. confounding variables like age, gender and etiology were controlled by stratification. results total 20 patients were included in study. the mean and standard deviation of age was 36.55 ± 14.50 while the age range was 20-65 years. patients were divided into three different age groups. this division and its effect on the final outcome are shown in table 1. this table shows that most of the patients belonged to younger age group and the patients who didn’t showed improvement were from the older age group. table 1: age of patients and its effect on outcome. age group no. of patients improvement of visual acuity clearance of macula 20-35 years 10 (50%) 8 (80%) 8 (80%) 36-50 years 8 (40%) 4 (50%) 6 (75%) 51-65 years 2 (10%) 1 (50%) 1 (50%) table 2: gender distribution and its effect on outcome. gender no. of patients improvement of visual acuity clearance of macula male 8 (40%) 5 (62.5%) 6 (75%) female 12 (60%) 8 (66.67%) 9 (75%) table 3: etiology of hemorrhage and its effect on outcome. etiology no. of patients improvement of visual acuity clearance of macula pdr 8 (40%) 4 (50%) 6 (75%) valsalva maneuver 4 (20%) 4 (100%) 4 (100%) trauma 3 (15%) 2 (66.67%) 2 (66.67%) blood dyscrasias 2 (10%) 1 (50%) 1 (50%) amd 1 (5%) 0 (0%) 0 (0%) crvo 1 (5%) 1 (100%) 1 (100%) idiopathic 1 (5%) 1 (100%) 1 (100%) gender distribution of patients is shown in table 2 with its effect on final outcome. male:female ratio in this study was 1:1.5. visual acuity was labeled as improved when there was at least 3 steps improvement according to snellen’s system of visual acuity assessment. percentage of improvement of visual acuity was better in females but macular clearance was equal in both genders. table 3 describes in detail the etiology of subhyaloid hemorrhage and its response to the nd:yag laser. pdr was the most common etiology. only 50% patients of pdr showed improvement of irum raza, et al 96 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology visually acuity. other maculopathies were found in the remaining cases. they were managed according to the nature of maculopathy. cases of valsalva maneuver, crvo and idiopathic etiology gave excellent response. efficacy of procedure was defined in terms of macular clearance of hemorrhage and it’s trickling in to the vitreous. according to this definition, procedure was found effective in 15 out of 20 (75%) cases. surprisingly the dispersed hemorrhage took very late i.e. 4 weeks on average to be cleared from vitreous. complication was noted in only one case of trauma where hemorrhage dispersed into vitreous and led to formation of taut membrane. this case was then dealt surgically. discussion premacular subhyaloid hemorrhage results in an acute and profound decrease in vision7,8,9. different etiologies including vasoproliferative diseases (e.g., diabetic retinopathy), vascular anomalies (e.g., retinal macroaneurysms), or rare conditions like valsalva maneuver, terson syndrome and leukemias can cause these hemorrhages2,10,11,12. each cause can lead to a hemorrhage into the vitreoretinal interface. still attached, posterior hyaloid membrane results in formation of a premacular hemorrhagic bubble, which will cause decreased vision and/or a central scotoma. it can resolve on its own but observation may result in unwanted sequelae leading to permanent damage to macula. that is why, early removal of the hemorrhage is important13. various therapeutic options include the intravitreal administration of sf6 gas, nd:yag laser hyaloidotomy or a pars plana vitrectomy14,15,16. opening the posterior hyaloid membrane by laser (referred to as hyaloidotomy) presents a minimally invasive technique introduced for the first time in 1988 by faulborn17. one year later it was also used by gabel. since that, it has become a popular method due to its non-invasiveness. we also used this in our study. in this study, we performed this method on 20 patients of premacular subhyaloid hemorrhage. etiologies included pdr, trauma, valsalva maneuver and miscellaneous causes. the percentage of these etiologies is almost similar to those found in study of murtaza et al6 with exception of trauma. this is possible as both these studies were performed in same country. the hyaloidotomy was successful and blood trickled into vitreous from where it was cleared within 4 weeks. our final follow up of study was at 2nd week. that is why, our results are contrary to findings of ahmedabadi18 and murtaza, et al6. other possible reason may be relatively younger ages of our patients in which blood dispersed into vitreous is absorbed slowly because of less liquefaction. more number of diabetic patients in our study can also make the difference as blood is absorbed very slowly in diabetic patients due to aggressive nature of disease process. visual acuity was found to be improved in 13 cases (65%) according to the defined criterion. it is lower than that (75%) found in study of ulbig et al19. it is because the final follow-up of patients in their study was longer than that in our study. one patient had visual acuity of 6/6 (5%) while vision of 10 patients (50%) was between 6/9-6/12. this is similar to that of faisal and colleagues6 (56.66%) and renni et al10 (66.67%). this is however in comparison to results of study of shashidhar et al20 (92.85%). this comparison has emerged due to the difference in etiologies of premacular subhyaoid hemorrhage. most of patients in our study were that of pdr and trauma where as these were the least common etiologies in shashidhar’s study. there were other macular changes besides subhyaloid hemorrhage in our patients which had limited the final visual acuity. final outcome was assessed on the basis of displacement of hemorrhage away from the macula and its clear visualization which may or may not be associated with improved vision. our results are less than other studies6,10,12,16. the only possible reason is the shorter duration of study and earlier follow up than those of others. this short duration study showed that nd:yag laser hyaloidotmy is effective in macular clearance and improvement of vision if no associated maculopathy is present. conclusions early nd:yag laser treatment should be considered for recent premacular subhyaloid hemorrhages. its benefits include early visual rehabilitation, visualization of the underlying fundus, early access for macular photocoagulation, the avoidance of surgical vitrectomy and avoidance of potential toxic macular changes. long term follow ups of laser treated cases are important. randomization with deferral of procedure or vitrectomy can exactly map out merits and demerits. additionally, comparison with intravitreal anti-vegf (vascular endothelial growth role of nd:yag laser in the management of premacular subhyloid hemorrhage pakistan journal of ophthalmology vol. 33, no. 2, apr – jun, 2017 97 factors) injections can also highlight its marvelous effects. author’s affiliation dr. irum raza doms, fcps vitreo-retina fellow department of ophthalmology, king edward medical college & mayo hospital, lahore. dr. chaudhary nasir ahmad fcps, fellowship vitreo-retina assistant professor department of ophthalmology, king edward medical college & mayo hospital, lahore. dr. tehseen mahmood mahju ms (ophth), fellowship vitreo-retina senior registrar department of ophthalmology, king edward medical college & mayo hospital, lahore. role of authors dr. irum raza patients’ selection, data collection and analysis. dr. chaudhary nasir ahmad literature search and references. dr. tehseen mahmood mahju research design and research supervision. references 1. dağlioğlu mc, coşkun m, i̇lhan n, tuzcu ea, ari m, ayintap e, et al. posterior hyaloidotomy by nd:yag laser application in a patient with postpartum depression caused by valsalva retinopathy. case rep ophthalmol. 2013 jan-apr; 4 (1): 64-8. 2. o'hanley gp, canny cl. diabetic dense premacular hemorrhage. a possible indication for prompt vitrectomy. ophthalmology, 1985; 92 (4): 507-11. 3. rathor mk, tirkey e, chandravanshi sl, shivdas j. premacular subhyaloid hemorrhage drainage by frequency-doubled (532nm) nd: yag laser. delhi j ophthalmol. 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70: 298-313. 10. rennie ca, newman dk, snead mp, flanagan dw. nd:yag laser treatment for premacular subhyaloid haemorrhage. eye (lond). 2001; 15: 519-24. 11. khadka d, sharma ak, shrestha jk, pant b, pant s, shrestha a. nd:yag laser treatment for sub-hyaloid hemorrhage in childhood acute leukemia. nepal j ophthalmol. 2012 jan-jun; 4 (1): 102-7. 12. khadka d, bhandari s, bajimaya s, thapa r, paudyal g, pradhan e. nd:yag laser hyaloidotomy in the management of premacular subhyaloid hemorrhage. bmc ophthalmol. 2016 apr 18; 16: 41. irum raza, et al 98 vol. 33, no. 2, apr – jun, 2017 pakistan journal of ophthalmology 13. matonti f, donadieu v, hoffart l, dornadin a, nadeau s, roux s, et al. early treatment with nd:yag laser for valsalva retinopathy: results of five cases and literature review. j fr ophtalmol. 2013 sep; 36 (7): 604-9. 14. campos j, campos a, mendes s, neves a, violante l, castro sousa jp. premacular hemorrhage treatment with nd:yag laser: a clinical case. arch soc esp oftalmol. 2015 jan; 90 (1): 44-6. 15. gao l, dong c. sub-inner limiting membrane haemorrhages. lancet. 2013 aug 10; 382 (9891): 535. 16. liu z, pan x, bi h. treatment of valsalva retinopathy. optom vis sci. 2014 nov; 91 (11): e278-81. 17. faulborn j. behandlung einer diabetischen praemaculaeren blutung mit dem q-switched neodym:yag laser. spektrum augenheilkd. 1988; 2: 335. 18. ahmadabadi mn, lashay ar, karkhaneh r, manaviat mr, amini a, razaghi a, et al. nd:yag laser application in premacular subhyaloid hemorrhage. arch iranian med. 2004; 7 (3): 206-9. 19. ulbig mw, mangouritsas g, rothbacher hh, hamilton am, mchugh jd. long-term results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed nd:yag laser. arch ophthalmol. 1998; 116 (11): 1465-9. 20. shashidar, bn vishwanath, shujatha s. effectiveness of drainage of pre-macular sub-hyaloid hemorrhage into vitreous cavity with nd:yag laser. inter j of gen med & pharm. 2014 sep; 3 (5): 29-32. pak j ophthalmol. 2020, vol. 36 (4): 448-450 448 brief communication double arcus senilis sana nadeem 1 1 department of ophthalmology, foundation university medical college/fauji foundation hospital, rawalpindi abstract arcus senilis is the commonest of the corneal degenerations and presents as a whitish or yellowish band in the corneal periphery, associated with the deposition of lipoproteins in the corneal stroma. it is separated from the limbus by a clear zone. it is most commonly associated with aging. other associations are hyperlipidemia, particularly in men less than 50 years (arcus juvenilis). however, a double arcus is very rare and only few case reports are found in literature. i present a case of 68-year-old man with diabetes mellitus and 35 pack years of smoking who presented to us in the outpatient department. he had double corneal arcus in both eyes. there was a distinct clear line between the two arci. the case is presented with a brief discussion on the traditional risk factors, possible pathogenesis and literature review. key words: arcus senilis, gerontoxon, arcus juvenilis. how to cite this article: nadeem s. double arcus senilis. pak j ophthalmol. 2020; 36 (4): 448-450. doi: https://doi.org/10.36351/pjo.v36i4.884 introduction corneal arcus (gerontoxon or arcus lipoides) is the stromal deposition of a greyish white or yellow band of opacification about 1 mm wide in the peripheral cornea. the clear zone between it and the limbus, about 0.3 mm wide, is called the lucid interval of vogt. its central border is diffuse, and the peripheral border is sharper. it is circumferential, beginning superiorly and inferiorly, gradually spreading to the nasal and temporal regions, and is most dense superiorly. the arcus is almost always a bilateral condition, but may be asymmetric in carotid vascular disease, being less on the involved side, and is increased in eyes with chronic hypotony. in males, it occurs increasingly from the age of 40 years; is seen in 90% of normal men between 70 – 80 years of age, and in almost all above 80 years. in females, it is seen similarly, but correspondence: sana nadeem department of ophthalmology, foundation university medical college/fauji foundation hospital, rawalpindi email: sana.nadeem018@gmail.com received: september 12, 2019 accepted: march 2, 2020 with a 10 year delay. 1 double arcus senilis is a very rare entity and we are submitting this report from pakistan. case presentation a 68-year-old man with a history of diabetes mellitus for the past 10 years, hypertensive and a smoker of filtered cigarettes of 35 pack years, presented to our eye opd of fauji foundation hospital, rawalpindi. it is a tertiary care, teaching hospital affiliated with the foundation university medical college. the patient had mild blurring of vision. best corrected vision od was 6/6 and 6/12 os. on examination, he had bilateral double arcus senilis, with a circular, clear zone between the two. there was a clear area between the limbus and arcus peripherally as well [figures 1, 2]. the outer arcus was separated from the limbus by a clear zone. the inner arcus was complete but thinner as compared to the outer arcus. the arci involved almost full stromal thickness temporally and nasally, but 2/3 rds stromal thickness superiorly and inferiorly. [figure 3]. he had bilateral mild nuclear sclerosis and intraocular pressures were 29 mm hg od and 33 mm hg os with goldmann applanation tonometry. he had mailto:sana.nadeem018@gmail.com sana nadeem 449 pak j ophthalmol. 2020, vol. 36 (4): 448-450 open angles on gonioscopy by shafer classification (grade iv) bilaterally; and central corneal thickness (cct) was 530 µm od and 529 µm os. cup disc ratios (cdrs) of 0.8 od and 0.6 os were observed. he was started on cosopt ® eye drops (dorzolamidetimolol) twice a day, and perimetry and optical coherence tomography (oct) of the optic nerve head and retinal nerve fibre layer, was ordered immediately, which confirmed the diagnosis of primary open angle glaucoma. fig. 1: a. double arcus senilis in the right eye, with a clear zone separating the two arci. b. scleral scatter enhancing the arcus. fig. 2: a. double arcus in the left eye (focal illumination). b. diffuse illumination showing two complete rings. fig. 3: a. inferior corneal optical section shows about 2/3 rds of stromal thickness involvement by the arcus. b. peripheral corneal optical section showing full thickness stromal involvement by both arci. routine investigations were ordered, complete blood picture (cbc) which was normal, random blood sugar (rbs) was uncontrolled (20.8 mmol/l), and so was hba1c at 10.3%. serum cholesterol (4.8 mmol/l) and hdl (1.08 mmol/l) were normal, and serum triglycerides (4.3 mmol/l) and serum ldl (3.6 mmol/l) were high. lfts, rfts and urine re were normal. he was referred to a medical specialist for diabetes and hypertension control and altered lipid profile. currently, his medical condition is well controlled on oral therapy. his double corneal arcus is stable at the moment and intraocular pressures are well controlled on cosopt bd. discussion arcus senilis is the most common corneal degenerations, and although visually innocuous, needs discussion, especially if double arci are seen in any individual. the deposits of arcus senilis are made up of cholesterol, phospholipids, and triglycerides. 2 lipid material leaks from the limbal capillaries from the deep scleral vascular plexus, and is deposited in the corneal periphery, but its central flow is halted by a functional barrier in the cornea, which keeps the larger molecules from being deposited centrally. 1,3 arcus senilis is most commonly associated with aging. other associations are hyperlipidemias, particularly in men less than 50 years (arcus juvenilis), who also have an increased risk of cardiovascular disease. male gender, smoking, and hypertension are other associated risk factors. 4 in older patients, including diabetics; arcus senilis does not increase mortality. 5 the mechanism of corneal arcus senilis formation involves increased permeability of the limbal blood vessels as a result of aging, thus allowing lipid molecules to diffuse into the stroma based on size and polarity; the lucid interval of vogt being clear due to the lipid absorption into the circulation at the corneal periphery, as a result of closer proximity to the vascular arcade. 3,6 these lipid particles are similar to those isolated from atherosclerotic plaques, but with the absence of foam cells. 7 the pathogenesis of a double corneal arcus is still unclear; the inner arcus is thinner and smaller, as compared to the larger peripheral arcus, suggesting phenomenon similar to those seen in the formation of immunodiffusion rings 3 , and that the lipid molecules may diffuse differently according to size and polarity. double arcus senilis pak j ophthalmol. 2020, vol. 36 (4): 448-450 450 traditional risk factors for gerontoxon are old age, male gender, high body mass index, high total cholesterol, ldl, or triglycerides, and smoking. additional risk factors described are systemic inflammatory markers like higher crp (c-reactive protein), peripheral arterial disease, and chronic renal disease. 2,4,8,9 double arcus senilis is very rare, with only few cases reported in literature. literature review revealed the first two cases to be reported in 2002 by agarwal 5 in india, which were both elderly individuals with normal blood sugar and lipid profiles. the third case was reported in 2004 in israel, in an old man with hypercholesterolemia. the fourth case was reported in 2007 by vaikkakara 9 in uk, in an elderly lady, who was eventually diagnosed with the milk alkali syndrome. conflict of interest authors declared no conflict of interest. references 1. lundström m, barry p, henry y, rosen p, stenevi u. evidence-based guidelines for cataract surgery: guidelines based on data in the european registry of quality outcomes for cataract and refractive surgery database. j cat refract surg. 2012; 38 (6): 1086-1093. 2. raj km, reddy pa, kumar vc. significance of corneal arcus. j pharm bioallied sci. 2015; 7 (suppl. 1): s14-s15. doi: 10.4103/0975-7406.155765. 3. hashemi h, khabazkhoob m, emamian mh, shariati m, fotouhi a. a population-based study of corneal arcus and its risk factors in iran. ophth epidemiol. 2014; 21 (5): 339-344. 4. moss se, klein r, klein be. arcus senilis and mortality in a population with diabetes. am j ophthalmol. 2000; 129 (5): 676-678. 5. agrawal s, agrawal j, agrawal tp. double-ring corneal arcus. j cataract refract surg. 2002; 28 (10): 1885-1886. doi: 10.1016/s0886-3350(02)01672-3. 6. gaynor pm, zhang wy, salehizadeh b, pettiford b, kruth hs. cholesterol accumulation in human cornea: evidence that extracellular cholesteryl ester-rich lipid particles deposit independently of foam cells. j lipid res. 1996; 37 (9): 1849-1861. 7. wu r, wang jj, tai es, wong ty. cardiovascular risk factors, inflammation, and corneal arcus: the singapore malay eye study. am j ophthalmol. 2010; 150 (4): 581-587. 8. ang m, wong w, park j, wu r, lavanya r, zheng y, et al. corneal arcus is a sign of cardiovascular disease, even in low-risk persons. am j ophthalmol. 2011; 152 (5): 864-871. 9. vaikkakara s, james ra, pearce sh, talks sj. a second corneal arcus? postgrad med j. 2007; 83 (977): 153. doi: 10.1136/pgmj.2007.057141. author’s designation and contribution sana nadeem; assistant professor: concept, design, literature research, manuscript preparation, manuscript editing, manuscript review. .…  …. 26 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology original article headache: investigate or not to investigate? tayyaba gul malik, khalid farooq, eiman ayesha pak j ophthalmol 2017, vol. 33 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyaba gul malik professor of ophthalmology rashid latif medical college email: tayyabam@yahoo.com …..……………………….. purpose: to analyze the need of neuro-imaging in patients presenting with headache. study design: retrospective observational study. place and duration of study: heart and body scan and ghurki trust teaching hospital, lahore 2008 to 2015. material and methods: we retrospectively reviewed clinical and neuro-imaging charts of 5289 patients, who were sent to radiology department for neuroimaging from 2008 to 2015. the major complaint was headache but associated signs and symptoms included vertigo, weakness of limbs, unconsciousness, proptosis, road traffic accident (rta), seizures, visual disturbance, neck stiffness, diplopia, memory loss, ataxia, blood from ear, carcinoma, vomiting, cranial nerve palsy, tinitis, sleep problems and numbness. results were divided into normal imaging, ent problems, space occupying lesions of brain, vascular pathologies of brain and miscellaneous. results: there were 5289 patients. the age ranged from 6 to 80 years (mean 48 years) and male to female ratio was 1:1.2. normal neuro-imaging was seen in 67.25% of the total patients. space occupying lesions of brain were seen in 16% patients, 7.3% had vascular pathology of brain, 5.05% had ent problems and 4.36% had miscellaneous findings. patients having headache associated with proptosis or bleeding from ears had 100% positive results of neuro-imaging. headache with sleep disturbances had lowest yield (7.7%). conclusion: history of headache not associated with any other signs and symptoms should not be an indication for neuro-imaging. key words: neuro-imaging, headache, space occupying lesions of brain. se of neuro-imaging techniques has widely increased in the past decade. one of the commonest indications for neuro-imaging is headache, which can be either primary or secondary. no matter whether it is primary or secondary, it is one of the commonest chief complaints encountered by an ophthalmologist, physician and emergency care practitioners. there is a need to understand which patients require neuro-imaging and which do not. despite different guidelines for ct and mri of brain for headaches, there is an increased tendency towards unnecessary imaging. keeping in view the cost of neuroimaging in a poor country like pakistan and the adverse effects of this imaging, this retrospective analysis was done. materials and methods we retrospectively reviewed medical records and neuro-radiological data of 5289 patients with headache. the inclusion criterion was the patients with headache, who were referred from ophthalmology, medical and emergency departments for neuro-imaging. neuro-imaging included ct scan and mri. patients with incomplete medical records were excluded from the study. u headache: investigate or not to investigate? pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 27 the data, which was analyzed included age, sex, other clinical symptoms associated with headache and neuro-imaging results. headache was the chief complaint. other associated symptoms included vertigo, generalized or localized weakness of limbs, unconsciousness, proptosis, road traffic accidents, seizures, neck stiffness, visual disturbance, diplopia, memory loss, ataxia, blood from ear, malignancy, vomiting, cranial nerve palsy, tinitis, sleep problems and numbness of limbs. positive percentage yield of neuro-imaging for each symptom associated with headache was calculated. results there were 5289 patients and male to female ratio was 1:1.2. headache associated with proptosis and blood from ear had 100% yield. percentage yield of other symptoms is given in table 1 in descending order of frequency. in this particular study, 67.25% patients of headache had normal results on neuro-imaging. 16% (n = 847) had space occupying lesions of brain, 7.3% (n = 387) had vascular pathologies, 5.05% (n= 267) had ent problems and 4.36% (n = 231) had miscellaneous neurological results. on analyzing the neuro-imaging results, space occupying lesions included intra cranial neoplasm, intracranial hemorrhage, metastasis, tuberculoma, brain abscess, sub-dural hemorrhage, arachnoid cysts and colloid cyst. vascular lesions were ischemic infarcts, carotid stenosis, cavernous sinus thrombosis, dural sinus thrombosis and av malformation. positive ent findings included sinusitis, dns, nasal polyps and otitis media. multiple sclerosis, brain contusion, meningitis, pseudotumour cerebri, arnold chiari malformation and encephalitis were classified as miscellaneous. table 1: clinical features associated with headache and percentage yield in neuro-imaging. clinical features associated with headache total number of patients with clinical feature normal imaging abnormal imaging percentage abnormal proptosis 11 0 11 100 blood from ear 1 0 1 100 memory loss 60 6 54 90 malignancy 46 9 37 80.4 unconsciousness 136 41 95 69.85 weakness 348 113 235 67.53 diplopia 24 9 15 62.5 ataxia 35 14 21 60 visual disturbance 9 4 5 55.56 vomiting 730 349 381 52.2 seizures 154 76 78 50.65 neck stiffness 66 39 27 40.9 vertigo 756 479 277 36.64 cranial nerve palsy 24 16 8 33.33 rta 71 48 23 32.4 numbness 101 70 31 30.69 tinitis 28 24 4 14.3 sleep problems 26 24 2 7.69 tayyaba gul malik, et al 28 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology discussion according to who, headache is among the ten most disabling conditions worldwide1. in the past two decades, rate of neuro-imaging has increased in patients with headache. in a research, it was seen that the rate of neuro-imaging increased from 5.1% of all annual headache visits in 1995 to 14.7% in 20102. similarly, a large review of 3026 scans of patients with headache showed that only a minority of patients suffered from a serious disease that was diagnosed with cerebral imaging.3 there are several studies which showed a very low yield in cases of isolated headaches4,5,6. in this particular study we included patients who had headache associated with other signs and symptoms with a positive imaging yield of 32.75%. headache associated with proptosis and blood from ear had 100% yield. memory loss was the second important factor, which showed positive results on neuroimaging. sleep disturbance with headache proved to be the least important for neuro-imaging. the patients with sleep disturbance had other neurological problems as well. rising neuro-imaging trends led the american headache society and american academy of neurology to recommend avoidance of neuro-imaging studies in patients with stable headache that met criteria of migraine7,8. similarly, certain guidelines were suggested for emergency neuro-imaging as well9,10. european federation of neurological sciences also gave guidelines for headache neuroimaging11. neither such guidelines exist in developing countries, nor american and european guidelines followed in these countries. this particular study forms a basis, which can draw attention to the importance of making neuro-imaging criteria for headache. in this study, proptosis, memory loss and history of any malignancy proved to be the most important features associated with headache that needed neuro-imaging. neuro-imaging in patients of headache with a history of malignancy, was also recommended by other authors12. patients with visual disturbances had 55.56% chance of having abnormal imaging. it is, therefore, recommended that every patient who comes to ophthalmology department should be investigated for the cause of decreased vision and fundoscopy must be done to rule out papilledema. patients with headache with papilledema or neurological visual field defects should be sent for neuro-imaging. similarly 33.33% patients of headache with cranial nerve palsies had positive ct and mri. all patients with cranial nerve palsies do not require neuro-imaging unless there are other findings which support neuro-imaging or resolution does not occur till 3 to 6 months13,14. in this study, vomiting, seizures and neck stiffness with headache had 52.2%, 50.65% and 40.9% chance of positive neuro-imaging respectively. vomiting and headache can be a feature of migraine but when associated with other neurological signs or head injury, is an indication for neuro-imaging. in a prospective study of 152 patients, vomiting was associated with positive ct findings in 40–45% of cases15. however, vomiting after minor head injury had been a subject of interest for emergency medicine experts. similarly, not every patient of rta needs a neuro-imaging scan. nice (national institute of health and clinical excellence) guidelines suggest ct head imaging within 1 hour after trauma if there is more than one episode of vomiting post-head injury in adults and three or more episodes in child16. unconsciousness, weakness, diplopia and ataxia also had high yield on neuro-imaging in our study. many researchers have given “red flags” for headache17,18,19. these include abnormal neurological examination (others than typical aura), new headache in older patients, headache increasing in frequency and severity, worst headache ever, sudden onset of headache, new-onset headache in a patient with risk factors for hiv infection or cancer, papilloedema, headache subsequent to head trauma, history of dizziness or lack of coordination and headache worsening with valsalva manoeuvre. apart from these red flags, risk of exposure to ionizing radiations should also be discussed with the patient. studies have shown that the risk of cancer increases by 0.005% for a 45 years old patient when exposed to ionizing radiations20. so, un-necessary neuro-imaging can harmful and should be avoided. conclusion every case of headache does not require neuroimaging. as we do not have standard criteria for neuro-imaging in cases of headache, already existing rules of imaging can be followed in our setups, till the time new neuro-imaging criteria are developed matching our requirements. further studies should be done to set guidelines in our part of the world to save patients from unnecessary expenses and hazards of neuro-imaging. headache: investigate or not to investigate? pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 29 authors affiliation dr. tayyaba gul malik fcps ophthalmology professor of ophthalmology rashid latif medical college. dr. khalid farooq fcps. (diagnostic radiology) professor, department of radiology lahore medical and dental college, lahore dr. eiman ayesha fourth year mbbs punjab medical college, faisalabad role of authors dr. tayyaba gul malik data analysis, interpretation and script writing. dr. khalid farooq data acquisition and data analysis. dr. eiman ayesha data analysis and script writing. references 1. stovner lj, hagen k, jensen r et al. the global burden of headache: a documentation of headache prevalence and disability worldwide. cephalalgia 2007; 27 (3): 193– 210. 2. callaghan bc, kerber ak, pace rj, et al. headaches and neuroimaging, high utilization and costs despite guidelines. jama intern med. 2014; 174 (5): 819-821. 3. evans r. diagnostic testing for the evaluation of headaches. neurol clin. 1996; 14: 1–26. 4. jordan je, ramirez gf, bradley wg, et al. economic and outcomes assessment of magnetic resonance imaging in the evaluation of headache. j natl med assoc. 2000; 92: 573–78. 5. tsushima y, endo k. mr imaging in the evaluation of chronic or recurrent headache. radiology, 2005; 235: 575–79. 6. purdy ra, kirby s. headaches and brain tumors. neurol clin. 2004; 22: 39–53. 7. loder e, weizenbaum e, frishberg b, silberstein s. american headache society choosing wisely task force. choosing wisely in headache medicine: the american headache society's list of five things physicians and patients should question. 2013; 53 (10): 1651-9. 8. silberstein sd. practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the quality standards subcommittee of the american academy of neurology. neurology, 2000; 55 (6): 754–762. 9. detsky me, mcdonald dr, baerlocher mo, tomlinson ga, mccrory dc, booth cm. does this patient with headache have a migraine or need neuroimaging? jama. 2006; 296: 1274–83. 10. silberstein sd. practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the quality standards subcommittee of the american academy of neurology. neurology, 2000; 55: 754–62. 11. sandrini g, friberg l, coppola g, et al; european federation of neurological sciences. neurophysiological tests and neuroimaging procedures in non-acute headache. eur j neurol. 2011; 18 (3): 373381. 12. sze g, johnson c, kawamura y, et al. comparison of singleand triple-dose contrast material in the mr screening of brain metastases. ajnr am j neuroradiol. 1998; 19: 821–28. 13. murchison ap, gilbert me, savino pj. neuroimaging and acute ocular motor mononeuropathies: a prospective study. arch ophthalmol. 2011; 129 (3): 3015. 14. chi sl, bhatti mt. the diagnostic dilemma of neuroimaging in acute isolated sixth nerve palsy. curr opin ophthalmol. 2009; 20: 423–9. 15. abdul rahman ys, al den as, maull ki. prospective study of validity of neurologic signs in predicting positive cranial computed tomography following minor head trauma. prehosp disaster med. 2010; 25 (1): 59-62. 16. commissioned by the national institute of health and clinical excellence. head injury: triage, assessment, investigation and early management of head injury in infants, children and adults. united kingdom: national collaborating centre for acute care, 2007. 17. holle d, obermann m. the role of neuroimaging in the diagnosis of headache disorders. ther adv neurol disord. 2013; 6 (6): 369–374. 18. kernick dp, ahmed f, bahra a et al. imaging patients with suspected brain tumour: guidance for primary care. br. j. gen. pract. 2008; 58 (557): 880–885. 19. hainer bl, matheson em. approach to acute headache in adults. am fam physician, 2013; 87 (10): 682-687. 20. brenner dj, hall ej. computed tomography – an increasing source of radiation exposure. n engl j med 2007; 357: 2277-84. http://jamanetwork.com/searchresults?author=brian+c.+callaghan&q=brian+c.+callaghan http://www.ncbi.nlm.nih.gov/pubmed/?term=american%20headache%20society%20choosing%20wisely%20task%20force%5bcorporate%20author%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=american%20headache%20society%20choosing%20wisely%20task%20force%5bcorporate%20author%5d https://www.ncbi.nlm.nih.gov/pubmed/?term=holle%20d%5bauthor%5d&cauthor=true&cauthor_uid=24228072 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3825114/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3825114/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3825114/ microsoft word ashok kumar 29 original article recurrence of pterygium with conjunctival autograft versus mitomycin c ashok kumar narsani, shafi muhammad jatoi, mahtab alam khanzada, syed asher dabir, siddiqa gul pak j ophthalmol 2008, vol. 24 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ashok kumar narsani department of ophthalmology liaquat university eye hospital hyderabad. received for publication august’ 2007 …..……………………….. purpose: to compare the recurrence rate of conjunctival autograft and mitomycin c adjuvant in pterygium excision. material and method: this quasi experimental study was conducted in the department of ophthalmology, liaquat university of medical & health sciences jamshoro / hyderabad, from november 2004 to april 2006. one hundred twelve eyes of 105 patients with primary and recurrent pterygium were treated with conjunctival autograft and mitomycin c 0.02% intraoperatively for 5 minutes, under the topical anesthesia. patients were followed postoperatively for a period of 6-12 months to find the recurrence of pterygium and complications. all the surgeries were performed by one surgeon. result: one hundred twelve eyes were randomized to receive conjunctival autograft (cag n=70) and mitomycin c (mmc n = 42). there were 4 recurrences (5.7%) in the cag group and 8 recurrences (19%) in the mmc group. there was statistically significant difference in the recurrence rate between the two groups. the post operative complications in mmc were two punctuate epithelial keratitis, two conjunctival cysts, one conjunctival granuloma and one dellen. no significant complication was encountered in conjunctival autograft group. conclusion: simple excision of pterygium followed by conjunctival autograft has the lowest recurrence rate and minimal incidence of complications as compared to intraoperative use of mitomycin c. terygium is a fibrovascular wing shaped encroachment of conjunctiva on to the cornea1. although the pathogenesis remains obscure, the ultraviolet radiations (uvr), especially uvr-a and uvr–b (290-400 nm) is considered the most dangerous2-4. it is also more frequent in hot, dry, windy, dusty and smoky environments5,6. there is also a hereditary factor that may be responsible7. the main histopathological changes in primary pterygium are elastotic degeneration of conjunctival collagen8. the complaints which it may give rise are foreign body feeling, visual loss due to corneal astigmatism or growth over the pupil and cosmetic problems9. anti inflammatory drugs and lubricants have an important role minimizing the patients discomfort but do not cure the disease. ablation with erbium, yag laser10 and smoothening the corneal surface with excimer11 laser has been tried but the results were not encouraging. surgical removal is the treatment of choice. recommended surgical management includes simple excision with or without adjunctive measures like postoperative beta p 30 irradiation, thiotepa drops, intraoperative and postoperative mitomycin c and various techniques of conjunctival grafting12-17. after surgical removal whichever method is used there are still many recurrences. however autologous conjunctival grafting seems to be the best method, giving both low recurrence rate and high safety18-20. kenyon et al21, first described a conjunctival autograft in 1985. they reported a recurrence rate of 5.3%, and infrequent and relatively minor complications. the primary disadvantage of this technique is the prolonged operative time required when compared to the bare sclera technique. these disadvantages are out weighted; however by the lack of sight threatening complications and the relatively low recurrence rate, this procedure gained popularity in many centers21. kunitomo and nori22 were the first to report the promising effect of mitomycin c on the recurrence rate of pterygium. the application of intraoperative 0.02.% mitomycin c for the 5 minutes is efficient in reducing the recurrence rate to a minimum23. in our study we compared the recurrence rate of two different techniques. material and methods one hundred twelve eyes of 105 patients with primary and recurrent pterygium were registered at the tertiary referral center, department of ophthalmology, liaquat university of medical and health sciences, jamshoro, hyderabad. patients were randomized in to two groups. group 1 (to receive conjunctival autograft) and group 2 (to receive intraoperative 0.02% mitomycin). these patients had been questioned and medical data reviewed in details that none had major systemic disease such as collagen vascular disorder, diabetes mellitus. complete ocular examination including visual acuity, intraocular pressure, extraocular movements, biomicroscopy documentation of pterygium size and dilated fundoscopy was performed to assure that none of them had major eye disease such as dry eye, cicatrical pemphigoid, glaucoma or vitreoretinal disease. all patients were followed for 6 to 12 months to assess the recurrence rate and complications. the ocular surface was anesthetized in all patients with topical installation of proparacaine hydrochloride 0.5% in combination with an additional sub conjunctival injection in the bed of pterygium on the bulbar side with 0.5 ml of 2% lidocane hydrochloride with 0.001% adrenaline. the complete excision of the head of the pterygium from the cornea was done by bard parker 15 no blade and the body of pterygium was dissected and excised by conjunctival scissors. in recurrent pterygium a thorough dissection was done to remove adherent fibrovascular tissue from scleral surface avoiding damage to rectus muscle. in group 1 (cag) area of the bare sclera was measured after pterygium excision. a free conjunctival graft was harvested from the superior conjunctiva. dissection began from fornix to limbus. the graft was flipped over on the cornea and tenon’s attachment at limbus was meticulously dissected. the flap was then excised taking care to include the limbal tissue. the graft was then moved on to the scleral bed maintaining limbus to limbus orientation. the four corners were anchored with episcleral bites using 8/0 vicryl suture. in group 2 (mmc), intraoperative mitomycin (0.02%) was applied to the bare sclera for 5 minutes. the site of application was then thoroughly irrigated with at least 100ml of ringer lactate solution. the conjunctiva peripheral to the excised pterygium was undermined and the edges were sutured 2-3 mm from the limbus. post operative topical combination of corticosteroid antibiotic ointment was used and pad was applied for 24 hours. antibiotic and corticosteroid were used 4 times a day for a month and the tapered during the following 2-3 months. follow-up visits were scheduled for post operative days 1,7,14, 30 and then every 2 months. the recurrence was defined as post operative fibrovascular regrowth crossing the corneoscleral limbus by 1.0 mm or more and this constituted treatment failure. all the information was filled on a performa. data was analyzed on spss version 10.0. results we analyze the recurrence rate of two different surgical procedures for pterygium excision. the demographic and the clinical details are summarized in table 1. a total of 112 eyes (70 cag, 42 mmc) of 105 patients (70 cag, 35 mmc) were studied. there were 4 (5.7%) recurrences in the group 1 (cag),one at 2 months , two at 6 months and one at 8 months (table 2). there were 8 (19%) recurrences in group 2 (mmc), three within 4 months, two at 5 months, two at 6 months and one at 9 months. the difference in recurrence rate was statistically significant. no significant complications were noted in group 1 (cag) except varying level of discomfort, foreign body sensation, tearing, and redness for some period in few patients. there were two punctate epithelial keratitis, two conjunctival cysts, one granuloma and one dellen 31 in group 2 (mmc). no scleral thinning, necrosis, perforation or any other visually significant complication was encountered in either group. discussion in the treatment of pterygium various surgical techniques have been employed. the main problem encountered after various pterygium treatment modalities concerns the unpredictable rates and timing of recurrences 24. a recurrent pterygium can be associated with decreased visual acuity due to involvement of visual axis and /or irregular astigmatism, extraocular motility restriction and symblepharon formation25. the simplest technique of bare sclera excision alone proved unsatisfactory because of high recurrence rates (30-70%)26.adjunctive treatment after bare sclera excision with beta irradiation reduced recurrence rates to as low as 0.5%-10%27, but was associated with significant complications such as scleral necrosis. in 1985, kenayn et al 21 published report describing conjunctival autografting as a promising technique in the treatment of pterygium. they documented the recurrence rate of 5.3% in the primary pterygium group. since then a number of papers on the success of conjunctival grafting have been published with various success rates. it is believed that surgical trauma and subsequent postoperative inflammation activated subconjunctival fibroblasts, the proliferation of fibroblast and vascular cells and deposition of extracellular matrix proteins which in turn contribute to the pterygium recurrence28. compared with the bare sclera method, conjunctival autograft is more technically demanding procedure, surgeon factors such as experience, techniques etc may have a profound influence on the recurrence rate. more over conjunctival grafts including limbal epithelium generally yield better results because it will help to restore its barrier function29. in 1998, lewallen30 published report of a randomized trial of the conjunctival autografting technique for pterygium removal. she documented a lower recurrence rate (21%) in grafted cases compared with controls done by the bare sclera technique (37%). riodan-eva et al31 of moorefield eye hospital london supported lewallens finding when they reported a statistically significant reduction in recurrences rate following conjunctival autografting for pterygium. they quoted a probability of recurrences of 14% with this procedure at 36 months after surgery. in 2005 fahmi et al32 reported 13.3% recurrence rate with conjunctival autograft. in our study recurrence rate was found to be 5.7%. an alternate to conjunctival graft technique to improve out come is use of mitomycin c. mitomycin c is an alkylating antineoplastic agent produced by strains of streptomyces caespinosus which inhibits synthesis of dna, rna and proteins33. the current regime of mitomycin c is 0.02% for 5 minutes have been found to be effective34, 35. in this series the mmc recurrence rate was 19% in compare with 38% reported by chen et al19 and 10.5% by maning et al36 with the application of 0.4 mg / ml for 3 minutes. ma et al (post operative mmc) and sharma et al also compared mmc with conjunctival graft but neither showed any statistical difference28,37. however failure of these studies to show any difference between mmc and conjunctival autograft. the results of our study reporting an advantage of conjunctival autograft over mitomycin c. our results are compatible with national and international studies. conclusion in conclusion simple excision of pterygium followed by conjunctival autograft has the lowest recurrence rate and minimal incidence of complications as compared to intraoperative mitomycin c. table 1: demographic and clinical data of patients in group 1 and group 2. groups (n) age range (years) mean age (years) sex n (%) laterally n (%) population type n (%) pterygium type n (%) male female right left rural urban primar y recurrent cag (70) 20-70 44.6 42 60) 28 (40) 46 (66) 24 (34) 48(69) 22 (31) 52 (74) 18 (26) mmc 26-62 43 25 (60) 17 (40) 26 (62) 16(38) 26 (63) 16 (37) 31 (74) 11 (26) 32 (42) cag+mmc (112) 20-70 44.3 67 (60) 45(40) 72 (64) 40(36) 74 (67) 38 (33) 83 (74) 29 (26) table 2: number of recurrences of cag v mmc cag (n = 70) mmc (n = 42) ag+mmc (n = 112) 2 months 1 0 1 4 months 0 3 3 6months 2 4 6 8months 1 0 1 10 months 0 1 1 1 year 0 0 total 4(5.7) 8(19) 12(10.7) author’s affiliation dr. ashok kumar narsani assistant professor department of ophthalmology liaquat university eye hospital hyderabad. prof. shafi muhammad jatoi chairman and head department of ophthalmology liaquat university eye hospital hyderabad. dr. mahtab alam khanzada department of ophthalmology liaquat university eye hospital hyderabad. dr. syed asher dabir department of ophthalmology liaquat university eye hospital hyderabad. dr. siddiqa gul department of ophthalmology liaquat university eye hospital hyderabad. reference 1. wong ak, rao sk, leug at, et al. inferior limbal – conjunctival autograft transplantation for recurrent pterygium. indian j of ophthalmol. 2000; 48: 21-4. 2. taylor hr, west sk, rosenthal fs, et al. corneal changes associated with chronic uv irradiation. arch ophthalmol. 1989; 107: 1481-4. 3. detorakis et ,zafiropoulos a, arvanitis da, et al. detection of point mutations at codon 12 of kl-ras in ophthalmic pterygia . eye 2005; 19: 210-4. 4. moran dj, hollows fc. pterygium and ultraviolet radiation: a positive correlation. br j ophthalmol. 1984; 68: 343-6. 5. nakaishi h , yamamoto m , i shida m, et al. pingueculae and pterygia in motorcycle policeman. ind health. 1997; 35: 325-9. 6. norn m, franck c. long-term changes in the outer part of the eye in welders. prevelence of spheroid degeneration, pinguecula, pterygium, and corneal cicatrices. acta ophthalmol (copenh). 1990; 69: 382-6. 7. booth f. heredity in one hundred patients admitted for excision of pterygia. aust n z j ophthalmol. 1985; 13: 59-61. 8. spencer wh. ophthalmic pathology: an atlas and textbook. 3rd edition. philadelphia: wb saunders. 1985; 174-6. 9. de keizer rj. pterygium excision with or without postoperative irradiation, a double-blind study. doc ophthalmologica. 1982; 52: 309-15. 10. koranyi g, seregard s, kopp ed. cut and paste: a no suture, small incision approach to pterygium surgery. br j ophthalmol. 2004; 88: 911-4. 11. seiler t, schnelle b, wollensak j. pterygium excision using 193-nm excimer laser smoothing and topical mitomycin c. ger j ophthalmol. 1992; 1: 429–31. 12. sebban a, hirst lw, kynaston b, et al. pterygium recurrence rate at the princess alexandra hospital. aust n z j ophthalmol. 1991; 19: 203-6. 13. mackenzie fd, hirst lw, kynaston b, et al. recurrence rate and complications after beta-irradiation for pterygia. ophthalmology. 1991; 98: 1776-81. 14. joelson ga, muller p. incidence of pterygium recurrence in patients treated with thiotepa. am j ophthalmol. 1976;81:891-2. 15. singh g, wilson mr, foster cs. long term follow up study of mitomycin eye drops as adjunctive treatment of pterygia and its comparison with conjunctival autograft transplantation. cornea. 1990; 9: 331-4. 16. frucht-pery j, ilsar m, hemo i. single dose of mitomycin c for prevention of recurrent pterygium: preliminary report. cornea 1994; 13: 4113. 17. rao sk, lekha t, mukesh bn, et al. conjunctival-limbal autograft for primary and recurrent pterygia: technique and results. indian j ophthalmol.1998; 46; 203-9. 18. kenyon kr, wagoner md, hettinger me. conjunctival autograft transplantation for advanced and recurrent pterygium. ophthalmology 1985; 92: 1461–70. 19. chen pp, ariyasu rg, kaza v, et al. a randomized trial comparing mitomycin c and conjunctival autograft after excision of primary pterygium. am j ophthalmol. 1995; 120: 151–60. 20. prabhasawat p, barton k, burkett g, et al. comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. ophthalmology. 1997; 104: 974–85. 21. arssano d, michaeli-cohen a, loewenstein a. excision of rpterygium and conjunctival autograft. isr med assoc j 2002, 4:1097-100. 22. unitomo n, nori s. studies on pterygium. part iv. a treatment of pterygium by mitomycin c instillation. nippon 33 ganka gakkai zasshi. 1963; 67: 601-7. 23. avisar r, arnon a, avisar e, et al. primary pterygium recurrence time. isr med assoc j. 2001; 3: 836-7. 24. frau e, labetoulle m, lautier-frau m, et al. corneo conjunctival autograft transplantation for pterygium surgery. acta ophthalmol scand. 2004; 82: 59-63. 25. shimazaki j, shinozaki n, tsubota k. transplantation of amniotic membrane and limbal autograft for patients with recurrent pterygium associated with symblepharon. br. j ophthalmol. 1998; 82: 235-40. 26. youngson rm. recurrence of pterygium after excision. br j ophthalmol. 1972; 56:120. 27. mackenzie fd, hirst lw, kynaston b, et al. recurrence rate and complications after beta irradiation for pterygia. ophthalmology 1991; 98:1776-81. 28. ma dh, see lc, liau sb, tsai rj. amniotic membrane graft for primary pterygium: comparison with conjunctival autograft and topical mitomycin c treatment. br j ophthalmol. 2000; 84: 973-8. 29. young al, leung gy, wong ak, et al. a randomised trial comparing 0.02% mitomycin c and limbal conjunctival autograft after excision of primary pterygium. br j ophthalmol. 2004; 88: 995-7. 30. lewallen s. a randomised trial of conjunctival autografting for pterygium in the tropics. ophthalmology 1989; 96: 1612-4. 31. riordan-eva p, kielhorn i, ficker la, et al. conjunctival autografting in the surgical management of pterygium. eye 1993; 7: 634-8. 32. fahmi ms, sayed j, ali m. after removal of pterygium role of mitomycin and conjunctival autograft .ann abbasi shaheed hosp karachi med dent coll. 2005; 10: 757-61. 33. saifuddin s, zawawi ae. scleral changes due to mitomycin c after pterygium excision: a report of two cases. indian j ophthalmol 1995; 43: 75-6. 34. lam ds, wong ak, fan ds, et al. intraoperative mitomycin c to prevent recurrence of pterygium after excision: a 30-month follow-up study. ophthalmology. 1998; 105: 901–4. 35. manning ca, kloess pm, diaz md, et al. intraoperative mitomycin in primary pterygium excision. a prospective, randomized trial. ophthalmology. 1997; 104: 844–8. 36. tseng sc. concept and application of limbal stem cells. eye 1989; 3: 141–57. 37. sharma a, gupta a, ram j, et al. low-dose intraoperative mitomycin-c versus conjunctival autograft in primary pterygium surgery: long term follow-up. ophthalmic surg lasers 2000; 31: 301–7. reporting visual acuities table of equivalent visual acuity measurements snellen visual acuities 4 meters 6 meters 20 feet decimal fraction logmar 4/40 6/60 20/200 0.10 +1.0 4/32 6/48 20/160 0.125 +0.9 4/25 6/38 20/125 0.16 +0.8 4/20 6/30 20/100 0.20 +0.7 4/16 6/24 20/80 0.25 +0.6 4/12.6 6/20 20/63 0.32 +0.5 4/10 6/15 20/50 0.40 +0.4 4/8 6/12 20/40 0.50 +0.3 4/6.3 6/10 20/32 0.63 +0.2 4/5 6/7.5 20/25 0.80 +0.1 4/4 6/6 20/20 1.00 0.0 4/3.2 6/5 20/16 1.25 -0.1 4/2.5 6/3.75 20/12.5 1.50 -0.2 4/2 6/3 20/10 2.00 -0.3 from ferris fl iii, kassoff a, bresnick gh, bailey i. new visual acuity charts for clinical research. am j ophthalmol 1982; 94: 91-96. 34 microsoft word m naqaish sadiq case report.doc 103 case report unilateral retinitis pigmentosa in one eye and tilted hypoplastic disc in the other eye (two in one disease) muhammad naqaish sadiq, jagdish bhatia, ashraf ei batarny, upender k wali pak j ophthalmol 2007, vol. 23 no .2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mohammad naqaish sadiq consultant ophtalmologist & head department of ophthalmology rustaq hospital p.o.box.67 pc 329. sultanate of oman. received for publication november’ 2006 …..……………………….. we report a case of 32 year old woman who presented with night blindness in her right eye and defective vision in her both eyes. on basis of history, clinical examination, vep and visual fields, she was diagnosed as a case of advanced unilateral retinitis pigmentosa in her right eye and hypoplasia of optic nerve in left eye with tilted disc and situs inverses. we describe this unique combination of retinal dystrophy in one eye and congenital anomaly of optic disc in other eye as two in one disease. to our knowledge this rare combination of two retinal pathology has never been reported before. ince the initial description of this disease by pedraglia in 18651 the so called unilateral pigmentary degeneration of the retina has so for been observed in about 100 cases. however this clinical entity still represents an enigma and its existence and relationship to the bilateral form are debated. tilted disc is related to incomplete closure of the optic fissure. this results due to oblique insertion of the optic nerve into the globe. this is a bilateral condition in 80% of patients and associated with moderate to severe hypoplasia or dysplasia of optic nerve. there is thinning of the retina, choroids and sclera along with infero-nasal peripapillary crescent (fuchs coloboma) and situs inversus of the vessels emerging from the disc. the condition is also associated high amount of myopic oblique astigmatism with refractive and meridonial amblyopia resulting in veriable impairment of visual acuity. to our knowledge this unique combination of retinal dystrophy in one eye and tilted disc with congenital hypoplasia in the other eye of the same patient has never been reported in the literature. we describe it as two in one disease and it was a casual finding in our clinic. case report a 32 year old omani female patient presented in our eye clinic in june’ 2001, for complete blindness in her right eye at night. she had history of migraine for which she was already under pharmacological treatment. her past and family history was unremarkable. ophthalmic examination revealed her best corrected visual acuity in the right eye 6/12 p with 0.5 dsp/-1 dcl @ 160, and in the left eye 6/24 with 5 dcy @ 30, normal iop and normal anterior segment. s 104 her fundoscopic examination revealed a pale disc in her right eye, markedly attenuated retinal arterioles and clumps of bone spicules pigments scattered in the mid periphery in all quadrants (fig. 1). the macula appeared normal in this eye. the fundoscopic examination of left eye revealed a hypoplastic small tilted disc, generalized retinal atrophy, anisometrpic oblique myopic astigmatism with inferonasal peripapillary atrophic cresent. the arterioles showed a bright and normal reflex and macula was normal. no pigmentary disturbance was found anywhere in this retina (fig. 2). visual field examination by a goldmann perimeter demonstrated a severe loss of peripheral visual field in right eye costricted to 30 degree resulting in tubular vision, where as central vision was spared. visual field in left eye revealed minimal temporal visual field defects (fig. 3-a and 3-b). vep using mono-ocular pattern stimulus reversing at a rate of 2 hz, showed a delay in the p 100 potential on the left side compared to the right, indicating optic nerve pathology in left eye (fig. 4-a and 4-b). the results of syphilis serology were negative. erg maximum response (rod+cone) was markedly subnormal in right eye and normal in left eye (fig. 5-a). 30 hz flicker response (cone response) was markedly reduced in right eye and normal in left eye (fig. 5-b). patient has been under observation at our clinic since last five years. uptill 5 years of follow up her ocular findings are unchanged and visual acuity is stable in both eyes. discussion the etiology of unilateral retinitis pigmentosa is unknown and there has been no proof that it is inherited. fundus photography, visual field testing, erg and dark adaptation are necessary to confirm the diagnosis of unilateral retinitis pigmentosa. many cases of unilateral retinitis pigmentosa have been reported since pedraglia's initial account1, but as reports began to accumulate, the concept that this is a true retinal heredo-degeneration was questioned. in 1952, francois and verriest2 on the basis of a review of 56 patients reported in the literature concluded that only half of them were authentic cases. they then proposed following four criteria which a presumptive case of unilateral retinitis pigmentosa must satisfy: 1. functional changes and an ophthalmoscopic appearance typical for a primary pigmentary degeneration must be present in the affected eye. 2. symptoms of a tapeto-retinal dystrophy must be absent in the fellow eye with a normal erg. 3. an inflammatory cause in the affected eye must be excluded. 4. the period of observation must be long enough to rule out a delayed onset in the fellow eye (over 5 years). the case presented satisfies the mentioned criteria in all respects. there are a few retinal conditions which mimics the picture of true retinitis pigmentosa. pseudo retinitis pigmentosa can be caused by trauma, chorioretinitis, drugs, retinal detachments etc. regarding the first possibility, the patient history was negative for ocular injury, so that this cause could be excluded. francois and verriest2 have mentioned a list of fourteen possible exogenous agents, mostly infectious, which could produce the similar retinal condition. in particular, syphilitic chorioretinitis may resemble retinitis pigmentosa and can be unilateral3. however, the results of serological studies of our patient were all negative. various drugs can cause a pigmentary retinopathy, among which are thioridazine4 chloroquine5 and hydroxychloroquine. in this case, the patient had not taken any of these drugs. retinal detachment may show profound retinal disturbances on settling. the fundus appearance and the patient's history, however, did not show any evidence in support of t h i s possibility. a reasonably long follow up d i d not reveal delayed bilateral involvement. therefore we describe it unilateral r e t i n i t i s pigmentosa. there are reports of association of u n i l a t e r a l r e t i n i t i s pigmentosa w i t h glaucoma6. exfolia tion syndrome7, and amblyopia. t i l l today this f i n d i n g of unilateral retinitis pigmentosa in one eye and tilted hypo plastic disc in other eye has probably never been described, therefore the association of unilateral r e t i n i t i s pigmentosa and hypoplastic t i l t e d disc in other eye could be regarded as exceptional. partial amblyopia in left eye is most probably due either to anisometropia or astigmatism. we are the first to report t h i s exceptional and u n i q u e association and we describe it as "two in one disease". on the basis of the present study it is not possible to state if there is a s i g n i f i c a n t association between the two conditions. nevertheless, the possibility of relationship in the pathogenesis of both unilateral retinitis pigmentosa and hypoplastic tilted disc in other eye cannot be excluded. further research is 105 required to find the nature and pathogenesis of this association. fig. 1: fig. 2: fig. 3a-3b: fig. 4a-4b: fig. 5a: fig. 5b: author’s affiliation muhammad naqaish sadiq consultant & head department of ophthalmology rustaq hospital, po box 67, pc 329 sultanate of oman jagdish bhatia specialist ophthalmology department of ophthalmology rustaq hospital, po box 67, pc 329 sultanate of oman ashraf ei batarny head of retina department magrabi eye and ear hospital muscat, oman upender k wali specialist ophthalmology department of ophthalmology sultan qaboos university hospital sultanate of oman reference 1. pedraglia. klinische beobachtungen. retinitis pigmentosa. klin mbl augenheilk. 1865; 3: 114-7. 2. francois j. verriest g. retinopathie pigmentaire unilaterale. ophthalmologica. 1952; 124: 65-8. 3. smith jl, singer ja, moore mb jr, et al. seronegative ocular and neurosyphilis. am j ophthalmol. 1965; 59: 753-62. 4. weekley rd. pigmentary retinopathy in patients receiving high doses of a new phenothiazine. arch ophthalmol. 1960; 64: 65-8. 5. bernstein hv, ginsberg j. the pathology of chloroquine retinopathy. arch ophthalmol. 1964; 71: 238-41. 6. krill ae, iser g. unilateral retinitts pigmentosa with glaucoma. arch ophthalmol. 1959; 61: 626-30. 106 7. paolo de felice g, bottoni f, et al. unilateral retinitis pigmentosa associated with exfoliation syndrome. international ophthalmology. 1988; 11: 219-26. pakistan journal of ophthalmology, 2020, vol. 36 (1): 38-42 38 original article pediatric cataract surgery audit at a tertiary care center in karachi rabia khawar chaudhry 1 , nasar qamar khan 2 , weijai kumar dembra 3 , areej riaz 4 , gaintry vickash 5 1,3,4,5 department of ophthalmology, jinnah postgraduate medical centre, 2 hashmani hospital, karachi abstract purpose: to perform pediatric cataract surgery audit at a tertiary care center in karachi. study design: descriptive observational study. place and duration of study: from january, 2016 to july, 2018 at ophthalmology department of jinnah postgraduate medical center, karachi. material and methods: all patients with congenital cataract were included in study regardless of presence or absence of systemic association. patients who were lost to follow up at three months were excluded from the study. hospital records were reviewed retrospectively and data on patient demographics, preoperative presentations, intraoperative complications and postoperative visual outcomes was documented on predesigned proformas. all patients underwent lens aspiration, posterior capsulotomy and anterior vitrectomy. surgeries were performed under general anesthesia. preoperative and postoperative visual acuity was assessed with ability to fix and follow light/objects, kay picture test and snellen’s chart according to patient’s age. results: three hundred and twenty six eyes underwent surgery for congenital cataract and sixty for traumatic cataract. number of male patients was 54.93% and female was 45.07%. the average age of patients with congenital cataract was 5.01 years and that for traumatic cataract was 7.8 years. amblyopia, nystagmus and strabismus were the commonest ocular comorbidities. uncorrected visual acuity ranged from 6/18 to light perception preoperatively. postoperatively 55% children with congenital cataract and 15% children with traumatic cataract had visual acuity better than 6/24. conclusion: early surgery in congenital cataract gives good visual outcomes. in traumatic cataract extraction, the final visual outcome depends on other effects of trauma on ocular structures. key words: congenital cataract, traumatic cataract, posterior capsulotomy. how to cite this article: chaudhry rk, khan nq, dembra wk, riaz a, vickash g. pediatric cataract surgery audit at a tertiary care center in karachi, pak j ophthalmol. 2020; 36 (1): 38-42. doi: https://doi.org/10.36351/pjo.v36i1.898. introduction control of blindness in children is a priority area in world health organization’s vision 2020–the right to sight program 1 . approximately 1.5 million children are blind worldwide and 75% of them belong to developing countries 2 . the estimated prevalence of correspondence to: rabia chaudhry consultant ophthalmologist, jinnah postgraduate medical center, karachi email: rabiachaudhry19@gmail.com blindness in pakistani children is 10 per 10,000 3 . studies have shown that majority of causes of childhood blindness are either preventable or treatable 4 . cataract, among them, remains the leading treatable cause of childhood blindness 5,6 . globally 520% of blindness in children is attributable to congenital cataract 6 . in a study conducted in peshawar, pakistan revealed that 23% of visually handicapped children had congenital cataract 7 . unlike adult cataract, the management of cataract in children involves not only extraction of cataract and https://doi.org/10.36351/pjo.v36i1.898 chaudhry rk, et al 39 pakistan journal of ophthalmology, 2020, vol. 36 (1): 38-42 implantation of intraocular lens but also includes postoperative refractive error correction and amblyopia therapy for which regular long term follow up is required 8-11 . delay at presentation and loss to follow up due to lack of awareness and other socioeconomic factors are major hurdles in visual rehabilitation of children with cataracts 4 . this retrospective study reviews the preoperative presentations, procedures done and the postoperative outcomes of pediatric cataract surgery at jinnah postgraduate medical center, karachi. material and methods all patients between 2 months to 14 years who presented to pediatric ophthalmology, outpatient department of jinnah postgraduate medical center, karachi and underwent surgery for congenital or traumatic cataract from january, 2016 to july, 2018 were recruited in this study. patients were selected through convenience sampling. all patients with congenital cataract were included regardless of presence or absence of systemic association. patients who were lost to follow up at three months were excluded. hospital records were reviewed retrospectively and data on patient demographics, preoperative presentations, intraoperative complications and postoperative visual outcomes was documented on predesigned proformas. the study was approved by ethical review board of jinnah postgraduate medical center. cataract existing at birth or developing within first four weeks of birth was considered congenital. cataract developing any time after blunt or penetrating trauma was labeled as traumatic cataract. all patients underwent lens aspiration, posterior capsulotomy and anterior vitrectomy. posterior capsulotomy was not done in those cases of traumatic cataract where the posterior capsule was already deficient. intraocular lens (iol) was implanted in the same sitting in children older than one year of age whereas children less than one year old underwent a second surgery for intraocular lens implantation after one year of age. patients left aphakic were prescribed aphakic glasses. intraocular lens power was calculated using srk ii formula. calculated iol power was reduced 20% in children less than one year of age and 10% in children 2-8 years of age. surgeries were performed under general anesthesia by an experienced pediatric ophthalmologist. postoperatively all patients were put on topical steroid and antibiotics for six weeks and oral steroids for one week. preoperative and postoperative visual acuity was assessed with ability to fix and follow light/objects, kay picture test and snellen’s chart according to patient’s age. results a total of 386 eyes of 279 patients were operated. gender and age distribution is shown in table 1 and 2 respectively. average age of patients with congenital cataract was 5.01 years whereas for traumatic cataract it was 7.8 years. table 1: gender distribution. gender males females total traumatic 32 (53.34)% 28 (46.66%) 60 (100%) congenital 180 (55.22%) 146 (44.78%) 326 (100%) 212 (54.93%) 174 (45.07%) 386 table 2: age distribution. age congenital cataract traumatic cataract 2 months 4 years 213 (65.34%) 10 (16.67%) 5 years 9 years 66 (20.24%) 28 (46.67%) 10 years 14 years 47 (14.42%) 22 (36.66%) 326 (100%) 60 (100%) at presentation, uncorrected visual acuity ranged from 6/18 to light perception. all patients presented with leucocoria. amblyopia (30.98%), nystagmus (4.6%), strabismus (3.2%), microphthalmos (0.9%) and glaucoma (2.4%) were the associated ocular comorbidities in congenital cataract. six children with congenital cataract had systemic association of cerebral palsy, four had patent ductus arteriosus, one had tetralogy of fallot and one had homocystinuria. four patients with congenital cataract had positive torch (toxoplasma, rubella, cytomegalovirus, herpes simplex) profile. eighty percent cases of traumatic cataract were secondary to penetrating injuries and twenty percent were secondary to blunt trauma. in case of penetrating injuries, the primary corneal perforation repair had been done 1-2 months prior to the cataract surgery. details of different procedures performed are given in table 2. no intraoperative complications were recorded. all patients presented at 1 week for postoperative evaluation, 80% at 4 weeks and 60% at 12 weeks pediatric cataract surgery audit at a tertiary care center in karachi pakistan journal of ophthalmology, 2020, vol. 36 (1): 38-42 40 postoperatively. the follow-up rate declined with time which precluded proper refraction and amblyopia management. complications at 1 week included corneal edema (0.002%), retinochoroidal detachment (0.002%), anterior chamber reaction (0.051%) and iol capture (0.005). twelve weeks post-operatively (table 4 and 5), table 3: procedures done. procedures no. of cases lens aspiration alone 98 (25.4%) lens aspiration + iol 188 (48.5%) secondary iol in bag 89 (23.1%) scleral fixation 11 (2.7%) after the management of complications and amblyopia, 83% children with congenital cataract had visual acuity ranging from 6/6 to 6/60 and 17% had visual acuity ranging from 6/60 to light perception. as for traumatic cataract, 40% had postoperative vision better than 6/60. table 4: postoperative visual acuity at 3 months for congenital cataract. age 6/6 6/24 6/36 – 6/60 5/60 – 3/60 2/60 – pl total 2 mo – 4 yrs 140 (65.72%) 55 (25.82%) 16 (7.52%) 2 (0.94%) 213 5 yrs – 9 yrs 30 (45.45%) 20 (30.30%) 14 (21.21%) 2 (3.04%) 66 10 yrs – 14 yrs 10 (21.28%) 15 (31.92%) 19 (40.42%) 3 (6.38%) 47 total 180 (55.22%) 90 (27.61%) 49 (15.03) 7 (2.14%) 326 table 5: postoperative visual acuity at 3 months for traumatic cataract. age 6/6 – 6/24 6/36 – 6/60 5/60 – 3/60 2/60 – pl total 2 mo – 4 yrs 2 (20%) 2 (20%) 5 (50%) 1 (10%) 10 5 yrs – 9 yrs 3 (10.72%) 6 (21.42%) 18 (64.29%) 1 (3.57%) 28 10 yrs – 14 yrs 4 (18.18%) 7 (31.82%) 7 (31.82%) 4 (18.18%) 22 total 9 (15%) 15 (25%) 30 (50%) 6 (10%) 60 discussion in children, the most common cause of blindness is cataract 4,12 . approximately 5-20% of childhood blindness is attributable to pediatric cataracts worldwide 6 . the only treatment for cataract is surgery. for congenital cataracts, the average age at presentation was 5.01 years. late presentation was mainly due to lack of awareness and poor socioeconomic backgrounds. delay in presentation was a major hurdle in visual rehabilitation as amblyopia developed in most cases presenting after 3 years and earlier in those having dense cataracts. good visual outcome was achieved in most children who presented early and did not have any associated ocular comorbidity whereas in the presence of nystagmus and strabismus, visual acuity was only slightly improved. previous studies 8,9 too showed that nystagmus and strabismus at presentation compromised the final visual outcome. similar results were found in a study conducted by latif et al, where it was revealed that improvement in visual acuity was seen in 96% of children presenting in 3-5 years of age whereas only in 2% of cases presenting in 6-8 years of age 13 . in case of traumatic cataracts 14-16 , visual outcome was affected by the type of trauma. most cases were of penetrating trauma where a corneal tear had been repaired in a prior surgery. this resulted in corneal scarring and astigmatism that reduced the degree of final visual improvement. in cases of cataract secondary to blunt trauma, often the presentation was late resulting in amblyopia. therefore, awareness should be raised to prevent ocular trauma and to get an early ophthalmological examination done in case of any ocular injury. one child with congenital cataract developed corneal edema from the first postoperative day, which was managed with hypertonic saline eye drops but still resulted in corneal decompensation and opacification. choroidal and retinal detachment was seen in one child who underwent scleral fixation. fibrinoid reaction 17 was seen in 20 children and it was more commonly observed after traumatic cataract extractions in our study. it was managed successfully with topical and systemic steroids and in a few cases with sub-conjunctival mydricaine injection. intraocular lens catch was seen in two children at one week and it required redialling. other studies showed posterior capsular opacification to be a common complication 1820 , but we avoided it in all cases by posterior capsulotomy and anterior vitrectomy at the time of primary surgery. the rate of posterior capsular opacification is very high in children and the primary aim of cataract surgery is to get a clear visual axis. therefore, posterior capsulotomy with anterior vitrectomy has become the gold standard in treatment of congenital cataract 18-21 . chaudhry rk, et al 41 pakistan journal of ophthalmology, 2020, vol. 36 (1): 38-42 most of the patients came for follow up visits till one month but after that follow up rate declined. this hindered the management of amblyopia where needed. after management of postoperative complications and amblyopia therapy, latif et al reported that 51% of eyes achieved best-corrected visual acuity (bcva) > 6/24 13 . kim et al reported improved visual acuity in 51.7% of patients 6 . lai et al showed improvement in 50% of patients 21 . magnusson et al reported 50% of children achieved improvement in vision after surgery 22 . our study showed comparable results with visual acuity better than 6/24 in 55% cases of congenital cataract and in 15% cases of traumatic cataract. it is important to raise awareness regarding early surgery of childhood cataract and also to teach parents of children with cataract to maintain good follow up so that maximal improvement in vision can occur. awareness should also be raised among parents/ guardians regarding prevention of childhood ocular trauma and about getting early ophthalmology opinion after any ocular injury. conclusion this study concludes that early cataract surgery gives a good visual outcome in congenital cataract whereas in case of traumatic cataract extraction, the visual outcome depends on other manifestations of trauma. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution rabia khawar chaudhry; consultant ophthalmologist: data collection, manuscript writing, final manuscript review. nasar qamar khan; consultant ophthalmologist: data collection, manuscript writing, final manuscript review. weijai kumar dembra; consultant ophthalmologist: data collection, manuscript writing, final manuscript review. areej riaz; postgraduate resident: manuscript writing, final manuscript review. gaintry vickash; postgraduate resident: manuscript writing, final manuscript review. references 1. gogate p, gilbert c. blindness in children: a worldwide perspective. community eye health, 2007; 20 (62): 32-33. 2. sethi s, sethi mj, saeed n, kundi nk. pattern of common eye diseases in children attending outpatient eye department khyber teaching hospital. pak j ophthalmol. 2008; 24: 166-71. 3. mahdi z, munami s, shaikh za, awan h, wahab s. pattern of eye diseases in children at secondary level eye department in karachi. pak j ophthalmol. 2006; 22: 145-51 4. umar mm, abubakar a, achi i, alhassan mb, hassan a. pediatric cataract surgery in national eye centre kaduna, nigeria: outcome and challenges. middle east afr j ophthalmol. 2015; 22 (1): 92-96. 5. chandna a, gilbert c. when your eye patient is a child. community eye health, 2010; 23 (72): 1-3. 6. kim kh, ahn k, chung es, chung ty. clinical outcomes of surgical techniques in congenital cataract. korean j ophthalmol. 2008; 22 (2): 87-91. 7. butt ia, jalisl m, waseem s, abdul moqeet, inamul-haq m. spectrum of congenital and developmental anomalies of eye. al shifa j ophthalmol. 2007; 3: 5660. 8. shah ma, shah sm, shah ah, pandya js. visual outcome of cataract in pediatric age group: does etiology have a role. eur j ophthalmol. 2014; 24 (1): 76-83. 9. sethi s, sethi mj, hussain i, kundi nk. causes of amblyopia in children coming to ophthalmology outpatient department, khyber teaching hospital, peshawar. j pak med assoc. 2008; 58 (3): 125-8. 10. lim z, rubab s, chan yh, levin av. management and outcomes of cataract in children: the toronto experience. j aapos. 2012; 6 (3): 249–254. 11. amaya l, taylor d, russell-eggitt i, nischal kk, lengyel d. the morphology and natural history of childhood cataracts. surv ophthalmol. 2003; 48 (2): 125–144. 12. foster a, gilbert c, rahi j. epidemiology of cataract in childhood: a global perspective. j cataract refract surg. 1997; 23 (s.1): 601–604. 13. latif k, shakir m, zafar s, rizvi sf, naz s. outcomes of congenital cataract surgery in a tertiary care hospital. pak j ophthalmol. 2014; 30 (1): 28-32. 14. sharma ak, aslami an, srivastava jp, iqbal j. visual outcome of traumatic cataract at a tertiary eye care centre in north india: a prospective study. j clin diagn res. 2016; 10 (1): 5-8. pediatric cataract surgery audit at a tertiary care center in karachi pakistan journal of ophthalmology, 2020, vol. 36 (1): 38-42 42 15. adlina ar, chong yj, shatriah i. clinical profile and visual outcome of traumatic paediatric cataract in suburban malaysia: a ten-year experience. singapore med j. 2014; 55 (5): 253–256. 16. kinori m, tomkins-netzer o, wygnanski-jaffe t, ben-zion i. traumatic pediatric cataract in southern ethiopia–results of 49 cases. j aapos. 2013; 17: 51215. 17. nishi o. fibrinous membrane formation on the posterior chamber lens during the early postoperative period. j cataract refract surg. 1988; 14 (1): 73-7. 18. vasavada a, desai j. primary posterior capsulorhexis with and without anterior vitrectomy in congenital cataracts. j cataract refract surg. 1997; 23 (s1): 64551. 19. petric i, lonèar vl. surgical technique and postoperative complications in pediatric cataract surgery: retrospective analysis of 21 cases. croat med j. 2004; 45: 287-91. 20. astle wf, alewenah o, ingram ad, paszuk a. surgical outcomes of primary foldable intraocular lens implantation in children: understanding posterior opacification and the absence of glaucoma. j cataract refract surg. 2009; 35 (7): 1216-22. 21. lai j, yao k, sun zh, zhang z, yang yh. long term follow-up of visual functions after pediatric cataract extraction and intra ocular lens implantation. zhonghua yan ke za zhi. 2005; 41 (3): 200-4. 22. magnusson g, abrahamsson m, sjostrand j. changes in visual acuity from 4 to 12 years of age in children operated for bilateral congenital cataract. br j ophthalmol. 2002; 86 (12): 1385-9. .…  …. microsoft word shahid jamal siddiqui 157 original article intravitreal injection of triamcinolone acetonide for diabetic macular edema shahid jamal siddiqui, syed imtiaz ali shah, muhammad afzal pechuho, abdul waheed memon pak j ophthalmol 2009, vol. 25 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: shahid jamal siddiqui department of phthalmology chandka medical college & hospital, larkana received for publication september’ 2008 … ……………………… purpose: to determine the clinical outcome of an intravitreal injection of triamcinolone acetonide in the treatment of diabetic macular edema. material and methods: the study included 16 patients (32 eyes) who were diagnosed with clinical significant macular edema and treated with laser photocoagulation both grid and focal, received intravitreal triamcinolone acetonide injection 4mg/0.1ml under topical anaesthesia. the visual acuity was recorded before and after injection with 1 to 3 months of followup. applanation tonometery was performed and readings recorded before and after injection. results: in this prospective study of 16 patients (32 eyes) with clinical significant macular edema (csme) unresponsive to laser photocoagulation 11 patients were male (68.75%) and 5 female (31.25%) from 35 to 62 years of age, average age 52.25 years. visual outcome after laser photocoagulation remained same in 19 eyes (59.37%), improved in 6 eyes (18.75%) and decreased in 7 eyes (21.87%). visual outcome after intravitreal injection of triamcinolone acetonide improved in 18 eyes (56.25%) and remained same in 14 eyes (43.75%). conclusion: intravitreal injection of 4mg/0.1ml triamcinolone acetonide may be beneficial for improving vision in patients with clinical significant macular edema (csme) who are unresponsive to conventional laser photocoagulation. iabetic retinopathy is the most common cause of newly diagnosed legal blindness amongst the working population in the industrialized world today1. diabetic macular edema is the common cause of visual impairment in diabetic retinopathy that produces loss of central vision2,3. according to the results of the study on the early treatment of diabetic retinopathy, diabetic macular edema has usually been treated by focal laser photocoagulation of leaking circumscribed retinal areas4. whereas in eyes with diffuse diabetic macular edema, laser treatment cannot be focused on localized retinal leakage spots since entire macula is involved, therefore grid laser is recommended but has been controversial, since studies proving the efficacy of treatment have not yet been published5. in view of the uncertainties in the treatment of diabetic macular edema, the aim of our present study is to assess the efficacy of an intravitreal injection of triamcinolone acetonide in reducing macular edema and improving visual acuity. material and methods this study was conducted at the department of ophthalmology, chandka medical college larkana. span of study was from january 2008 to september 2008. the study included 16 patients (32 eyes) selected from retina clinic who were diagnosed with clinical significant macular edema and treated with laser photocoagulation both grid and focal macular laser, received intravitreal triamcinolone acetonide injection 4mg/0.1 ml under topical anaesthesia. the following protocol was observed: 1. visual acuity was measured before and after injection. 2. intraocular pressure was recorded before and after injection. d 158 3. before injection patients were prescribed systemic and topical antibiotic prophylactically, ciprofloxacin 500mg orally 3 days before and after injection along with topical moxifloxacin 0.3% three to four times a day, three days before and after injection. 4. oral acetazolamide 250mg bd before and after injection along with topical beta blockers twice a day to maintain the intraocular pressure and to prevent post injection rise of intraocular pressure. the intravitreal injection was given in the operation theatre under topical anaesthesia with strict protocol of sterilization. preoperative drapping and washing the area with 5% povidone iodine solution. intravitreal injection 4mg/0.1ml of triamcinolone acetonide was given transconjunctival inferotemporal about 3.5mm away from the limbus. after the injection pad and bandage was applied and the patients were directed to come for followup after one week, 1 month upto 3 months. visual acuity was measured and improvement was notified and intraocular pressure was also measured and recorded. results in this study of 16 patients (32 eyes) with clinically significant macular edema unresponsive to laser photocoagulation, 11 were male (68.75%), 5 female (31.25%) from 35 to 62 years of eye, average age was 52.25 years (see table 1). visual outcome after laser photocoagulation remained same in 19 eyes (59.37%) decreased in 7 eyes (21.87%) and improved in 6 eyes (18.75%) (table 2). visual outcome after intravitreal injection of triamcinolone acetonide improved in 18 eyes (56.25%) and remained same in 14 eyes (43.75% see table-3 and (fig. 1-2). table 1: patients data no. of patients 16 no. of eyes 32 age group 35-62 years average age 52.25 years. male 11 (68.75%) female 05 (31.25%) table 2: visual outcome after laser photocoagulation improved 06 (18.75%) eyes decreased 07 (21.87%) eyes remained same 19 (59.37%) eyes table 3: visual outcome after intravitreal injection improved 18 (56.25%) eyes remained same 14 (43.75%) eyes discussion diabetic macular edema is one of the main reason for reduced visual acuity in patients with diabetic retinopathy. according to the results of the study on the early treatment of diabetic retinopathy, diabetic macular edema has usually been treated by focal laser photocoagulation of leaking circumscribed retinal areas, unless the whole macular region is diffusely affected4,5. in eyes with diffuse macular edema grid laser treatment is recommended. in the early treatment of diabetic retinopathy, laser photocoagulation of eyes with diabetic macular edema reduced the risk of moderate visual loss by 50%4. these results demonstrated that 12% of eyes treated with laser photocoagulation developed moderate visual loss. the frequency of an unsatisfactory outcome following laser photocoagulation in eyes with diabetic macular edema has developed interest in other treatments. the use of corticosteroid to treat diabetic macular edema follows from the observation that the increase in retinal capillary permeability that results in diabetic macular edema may be caused by a break down of blood retinal barriers mediated in part by vegf (vascular endothelial growth factor)6. antonetti and his colleagues demonstrated that vegf may regulate vascular permeability by increasing the phosphorylation of tight junction proteins such as occluden and zonula occluden7. corticosteroids with anti-inflammatory properties inhibit the expression of vegf gene8. intravitreal injection has been proposed as a way to efficiently deliver corticosteroid to the posterior portion of the eye in close proximity to the retina. the typical dose in triamcinolone acetonide used to treat eyes with diabetic macular edema is 4mg/0.1 ml 9. patients experience rapid and dramatic resolution of macular edema and improvement in visual acuity10. 159 fig. 1 a: fundus photograph of the patient with csme before injection fig. 1 b: fundus photograph of the same patient with csme after injection fig. 2 a: fundus photograph of the same patient with csme before injection fig. 2 b: fundus photograph of the same patient with csme after injection martidis and his colleagues reported results using intravitreal triamcinolone acetonide injection in 16 eyes with macular edema due to diabetic retinopathy. all the 16 eyes had persistent macular edema after laser photocoagulation. optical coherence tomography in these patients demonstrated that the mean thickness of the central macula decreased from 540µm before injection to 242µm after injection (the normal average thickness of the central macula is 175µm). visual acuity was improved by 2.4 and 1.3 lines (from the baseline value)9. jones et-al in their study of 26 eyes described the results of intravitreal injection triamcinolone acetonide with diabetic macular edema, the fluorescien angiography showed decreased flourescien leakage after intravitreal injection in all patients and visual acuity was also improved from a mean of 20/165 at baseline to mean of 20/105. in comparison 16 patients followed in a control group who received laser photocoagulation showed no improvement in visual acuity5. the results of our present study of 16 patients (32 eyes) suggest that the intravitreal injection of triamcinolone is beneficial as a treatment for diabetic macular edema. our study shows improvement of visual acuity in 18 eyes (56.25%) and remained same in 14 eyes (43.75%) with no increase in post injection intraocular pressure. although the results would have been best documented by oct but this facility was not available in our setup. conclusion intravitreal injection of 4mg/0.1ml triamcinolone acetonide is beneficial for improving vision in patients with clinical significant macular edema (csme) who are unresponsive to conventional laser photocoagulation. 160 author’s affiliation dr: shahid jamal siddiqui associate professor department of ophthalmology chandka medical college & hospital larkana sindh. prof. syed imtiaz ali shah department of ophthalmology chandka medical college & hospital larkana sindh. dr. muhammad afzal pechuho assistant professor department of ophthalmology chandka medical college & hospital larkana sindh. dr. abdul waheed memon assistant professor department of ophthalmology chandka medical college & hospital larkana sindh. reference 1. national diabetes data group. diabetes in america, 2nd ed. nih publ. no 95-1468. us govt. printing office: washington; 1995. 2. michael s. intravitreal injection of triamcinolone an emerging treatment for diabetic macular edema. in diabetes care american diabetes association. 2004; 27: 1794-7. by. 3. vedentham v, kim r. intravitreal injection of triamcinolone acetonide for diabetic macular edema: principles and practice. indian j ophthalmol. 2006; 54: 133-7. 4. early treatment diabetic retinopathy study research group. photocoagulation for diabetic macular edema: early treatment diabetic retinopathy study report no:1. arch ophthalmol. 1985; 103: 1796-1806. 5. jonas j, kressig i, sofker a, et al. intravitreal injection of triamcinolone for diffuse diabetic macular edema. arch ophthalmol. 2003; 121: 57-61. 6. aiello lp, bursell se, clermont a, et al. vascular endothelial growth factorinduced retinal permeability is mediated by protein kinase c in vivo and suppressed by an orally effective bisoform – selective inhibitor. diabetes. 1997; 46: 1473-80. 7. antonetti d, barber a, hollinger l, et al. vascular endothelial growth factor induces rapid phosphorylation tight junction proteins occluden and zonular occluden. j bio chem. 1999; 274: 23463-7. 8. nauck m, karakidlakis q, perruchoud ap, et al. corticosteroids inhibit the expression of the vascular endothelial growth factor gene in human smooth muscle cells. euro j pharmacol. 1998; 341: 309-15. 9. martidis a, duker js, greenberg pb, et al. intravitreal triamcinolone for refractory diabetic macular edema. ophthalmology. 2002; 109: 920-7. 10. jonas j, sofker a: intraocular injection crystalline cortisone as adjunctive treatment of diabetic macular edema. am j ophthalmol. 2001; 132: 425-7. 161 figure 1 figure 1a: fundus p figure 1b: fundus ph injection 162 figure 2 figure 2b: fundus photograph of the same patient with csme after injection figure 2a: fundus photograph of the same patient with csme before injection 163 microsoft word amjad akram 44 review article management tips for uveitis amjad akram, sameer shahid ameen, abid naqvi, zulfiqar udin syed, khizar niazi pak j ophthalmol 2010, vol. 26 no.1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: amjad akram consultant eye surgeon cmh multan cantt received for publication november’ 2008 …..……………………….. omprehensive literature on uveitis is available in abundance. in this article we present practical tips for uveitis management. the points highlighted are targeted at ophthalmologists who are in their early years of training. it has been presumed that the postgraduate trainees do have some background knowledge of uveitis. for the seniors the points will simply serve as revision. points regarding history taking in uveitis 1. symptoms of uveitis may be absent in some situations especially when associated with juvenile rheumatoid arthritis (still s disease) but most patients with iritis complain of photophobia, pain redness of eye and blurred vision. 2. posterior uveitis tends to be less painful or totally painless and is associated with varying degrees of visual reduction depending upon whether macula is involved or not. 3. sometimes patients with posterior uveitis may only complain of floaters. 4. one should inquire about ocular injury, use of topical medications and previous ocular infection (e.g. herpes). 5. questions regarding symptoms of possible associated systemic disease may require an almost complete review of symptoms. one should at least ask about following symptoms: joint pains or swelling, low back pain, swollen lymph nodes or glands, cough, sinusitis, fever, skin rash, genital lesions, gastrointestinal dysfunction, exposure to infectious agents (i.e. tb syphilis, herpes simplex etc) and headache or other neurological symptoms1. ophthalmic considerations in uveitis 1. in any patient with uveitis the ophthalmologist must be sure that there is no ocular cause for the inflammation before systemic work up is considered e.g. phacoanaphylactic glaucoma, fuchs uveitis etc. 2. a variety of intraocular tumors may also mimic uveitis eg retinoblastoma may cause hypopyon, iris nodules and cells in the aqueous humour. leukemia, lymphoma may mimic uveitis. 3. during management and follow up of patients with uveitis, one should strive to avoid a variety of complications. these include band keratopathy, cataracts, cystoid macular oedema, preretinal macular fibrosis, secondary glaucoma and exudative/ tractional retinal detachment. medical considerations in uveitis 1. a variety of specific infectious agents have to be considered i.e tuberculosis, syphilis herpes simplex and torch infections (in pediatric age group). c 45 2. collagen vascular diseases may be associated with uveitis. 3. despite the many causes of uveitis, the majority of patients with isolated uveitis and no history suggestive of systemic disease are otherwise healthy. 4. posterior uveitis may also be unassociated with systemic problem however under appropriate settings recognized causes of posterior uveitis such as tb, sarcoidosis, syphilis, whipple’s disease, wagener’s granulomatosis, sle, lymphoma etc must be considered more seriously. 5. complete blood count, esr, immunoglobulin electrophoresis and rheumatoid factor may be of some value depending upon the clinical situation. 6. sometimes serological tests for leptospirosis and brucellosis may be needed under certain difficult situations. 7. an x ray chest film maybe useful in the diagnosis of tuberculosis and sarcoidosis. 8. a skull x ray maybe useful in determining changes due to histiocytic lymphoma and congenital toxoplasmosis. 9. anterior chamber cytologic examination maybe helpful to differentiate histiocytic lymphoma from inflammatory uveitis. 10. parasites may be seen in stool specimen. uveitis and the skin ‘no examination of a uveitis patient is complete without examination of the skin.’ the above mentioned statement cannot be overemphasized considering the galaxy of conditions having dermatological involvement and also having association with uveitis e.g. sarcoidosis, tb, behcet’s syndrome, psoriasis, vogt koyanagi harada syndrome, leprosy etc. uveitis and glaucoma 1. patients with uveitis should be presumed to be suffering from secondary glaucoma until proved otherwise. many patients with uveitis especially anterior uveitis may be having secondary glaucoma due to associated trabeculitis. the patient may not necessarily have corneal edema or cupping and raised iop may be the only sign of secondary glaucoma. therefore it is prudent to check intraocular pressure in every patient with uveitis and it should be checked repeatedly even as the disease is being controlled by steroids. since steroids themselves can give rise to secondary glaucoma. 2. in a patient who has a combination of keratitis and uveitis (keratouveitis) associated with raised iop; always keep in mind possibility of herpes as a cause. this is because herpes associated keratouveitis frequently develop trabeculitis giving rise to secondary raised iop. 3. if difficulty arises in differentiating acute anterior uveitis from acute angle closure glaucoma do not give topical drugs which alter pupillary size. a topical steroids in order to combat the inflammatory response along with iop lowering medication. when diagnosis becomes clear, specific therapy can be started. 4. consider posner schlossman syndrome when diagnosing acute angle closure glaucoma and vice versa, since both conditions may appear similar but have some differences in treatment. investigations in a uveitis patient 1. a battery of investigations is not likely to be helpful in every patient. investigations in a particular patient with uveitis should be tailored in the light of history and examination of the patient. 2. generally speaking investigation of a uveitis patient is only indicated if systemic pathology is being suspected for example there is no point to carry out investigations in a straight forward case of fuch’s uveitis syndrome. 3. when confronting a uveitis patient, after taking a good history, carry out a general physical examination. comprehensive investigations are unlikely to be helpful if history and general physical examination are not contributory. 4. generally speaking patients falling under the following categories may be considered for investigation. a. patients with recurrent attacks of uveitis. b. patients with bilateral disease. c. patients with granulomatous type of uveitis (from guidelines for investigating uveitis from royal college of ophthalmologist). anterior uveitis and posterior uveitis 1. any patient with anterior uveitis should be presumed to be suffering from posterior uveitis until proved otherwise. therefore pupil should be dilated and posterior segment examination carried out to exclude the latter. many patients who primarily have posterior uveitis may also exhibit signs of anterior segment involvement. if the clinician only examines the 46 anterior segment, he may miss posterior segment findings and a wrong diagnosis of ‘anterior uveitis only’ may be made. 2. before labeling a patient as fuch’s uveitis, one must exclude pars planitis because sometimes both conditions may have similar anterior segment findings. therefore pupil should be dilated and snow banking looked for2. 3. make every possible effort to break posterior synechae in patients with acute anterior uveitis at their first visit; this maybe the only chance of breaking them. 4. in some patients, the presence of posterior uveitis maybe suspected if the anterior vitreous contains cells or flare and may be confirmed by examining the posterior segment. arthritis and uveitis 1. any child with still’s disease should be examined to exclude chronic anterior uveitis even though the child may be asymptomatic. 2. rheumatoid arthritis in adults is not a recognized association of uveitis. however ocular complications of rheumatoid arthritis may secondarily cause uveitis3. uveitis and tuberculosis 1. tuberculosis should always be considered high in the differential diagnosis when dealing with uveitis in the subcontinent. 2. the granulomatous uveitis produced in tb is very similar to the granulomatous uveitis, in other conditions therefore other evidence of tb has to be sought through history, clinical examination and investigations to label a person as tuberculous uveitis. 3. when interpreting mantoux test in a uveitis setting it is not only important to see whether patient is mantoux positive or negative but also it is important to see how exaggerated is the response with minimum dilution of mantoux reagent. an exaggerated response with minimum dilution points towards an active tuberculous focus in the body. uveitis due to toxoplasmosis 1. toxoplasmosis is the commonest cause of posterior uveitis worldwide. 2. in serological testing for toxoplasmosis, a negative test has more diagnostic value rather than a positive test. a negative test implies that the patient has not been exposed to the toxoplasma antigen, therefore uveitis in such a setting is not likely to be due to toxoplasmosis. 3. when treating ocular toxoplasmosis predniosolone should only be used under the therapeutic cover of specific antiparasitic therapy4. 4. aids patients with ocular toxoplasmosis may show minimum vitreous reaction whereas in immunocompetent patients vitritis is quite marked. 5. pyrimethamine (daraprim) should be avoided in the treatment of ocular toxoplasmosis in an aids patient since it causes neutropenia. 6. pregnant females with ocular toxoplasmosis are recommended to use spiramycin since other drugs are likely to be harmful to the foetus. uveitis and drugs 1. following drugs may induce uveitis metipranolol rifabutin latanoprost cidofovir epinephrine drops 2. central serous retinopathy is an important but overlooked complication of systemic steroid therapy. 3. cyclosporin a should be avoided in patients above 50 years of age since it is not well tolerated by patients who are middle aged and beyond. cmv retinitis cmv retinitis is the most common intraocular infection in an aids patient5. reticulum cell sarcoma masquerading as uveitis in patients who develop ‘uveitis primarily after the age of 50 years, consider cns lymphoma which may mimic uveitis. classic signs of intraocular lymphoma are vitreous veils and vision better than you would expect for that degree of vitritis. uveitis due to infective causes uveitis due to infective causes remains one of the main reasons for the adequate investigations of patients presenting with intraocular inflammation since specific treatment may result in a cure and failure to detect intraocular infection can be disastrous. 1. generally speaking uveitis due to infection should be suspected under the following circumstances a. presence of a concurrent or recent infective disease or surgery 47 b. uveitis presenting at extremes of age c. uveitis that fails to respond as expected d. patients with uveitis from parts of world where specific infections are common. 2. uveitis related to fungal infections (candida, aspergillus) are almost always seen in patients with long-term venous access (i.e.) drug abusers or patient in intensive care6. juxtapapillary chorioretinitis this is chorioretinitis occurring adjacent to the optic disc. it is no different from chorioretinitis occurring elsewhere in the fundus. its importance lies in the fact that owing to close proximity to the optic disc, it can cause diagnostic confusion with entities like anterior ischemic optic neuropathy, papillitis, papilloedema etc. it has been the experience of the authors where one initially diagnosed case of juxtapapillary choroiditis later on turned out to be metastasis from a malignancy in the abdomen. aids due to its varied modes of intraocular presentation, aids can be considered in differential diagnosis of any intraocular inflammation just as neurosyphilis used to be considered in differential diagnosis of any pathology of cns. author’s affiliation lt. col amjad akram consultant eye surgeon cmh multan cantt col sameer shahid ameen consultant eye surgeon cmh rawalpindi major abid naqvi consultant eye surgeon cmh malir cantt lt col zulfiqar udin syed consultant eye surgeon cmh attock major khizar niazi cmh rawalpindi reference 1 hedges tr. consultation in ophthalmology 1st edition manlygraphic publishers pte ltd 1988; 55-7. 2 murray pi. the bluffer’s guide to uveitis. eye news 2005; 12: 20-4. 3 henkind p, gold dh. ocular manifestations of rheumatoid disorders, natural and iatrogenic rheumatology. 1973; 4: 13. 4 stanford mr, see se, jones lv, et al. antibiotics for toxoplasmic retinochoroiditis evidence based systematic review. ophthalmology. 2003; 110: 926-31. 5 daniel hg, thomas aw, peter ls. cytomegalovirus infection in daniel hg, thomas aw eds the eye in systemic disease. lippincott williams and wilkins. 2001: 230-3. 6 stanford m. uveitis due to infective causes. eye news 2006; 13: 8-16. 238 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology short communication chronic rhinorrhea tayyaba gul malik, muhammad khalil, qurrat-ul-ain pak j ophthalmol 2016, vol. 32 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyaba gul malik associate professor of ophthalmology lahore medical and dental college, lahore e-mail: tayyabam@yahoo.com …..……………………….. a 15 – year old boy, resident of lahore, was referred by medical department to eye opd, for evaluation of his right drooping lid and double vision. it was associated with running nose and severe temporal headache. past history revealed head trauma with loss of consciousness for ten minutes, eleven years back. it was followed by running nose on bending down. he had several episodes of meningitis after that trauma which settled without squeal. on examination, he had pupil involving third nerve palsy and chemical analysis of nasal discharge revealed csf rhinorrhoea. the patient was referred to neurosurgical department for management. conclusion: careful history, examination and investigations remain key to the sensible management of patients. patients with recurrent meningitis should be evaluated for a csf leak. keywords: csf rhinorrhoea, third nerve palsy, intra cranial hypotension, traumatic csf leak. sf rhinorrhea is a potentially devastating condition that can lead to a myriad of complications leading to morbidity and mortality. csf formed by the choroid plexus and drained through the arachnoid villi, circulates in a closed system. any disruption between the sino-nasal cavity and the anterior and middle cranial fossae will result in discharge of csf into the nasal cavity. complications include intracranial infections, cranial nerve palsies and pneumocephalus. case report we report a case of 15 – year old pakistani male referred from medical department for evaluation of double vision and drooping of his right eyelid for four days. it was associated with fever, severe headache and running nose. probing into past history revealed that he had a fall from roof eleven years back. he had loss of consciousness for ten minutes. it was relieved without any medical support but was followed by an episode of vomiting which contained blood. years passed by without any investigations and medication except some drugs for rhinorrhea. the patient continued to have recurrent attacks of meningitis during the last eleven years, which settled with medications without any residual morbidity. this time he had fever but it was associated with drooping of right eye and double vision. on examination, there was visual acuity of 6/6 and intra-ocular pressures of 10mm of mercury in each eye. right pupil was fixed and dilated. left pupil was round, regular and normally reacting to light and accommodation. slit lamp examination and fundoscopy was unremarkable. both optic discs were normal (no signs of papilledema). we diagnosed it as ‘pupil involving third nerve palsy’ in right eye. other cranial nerves were intact except olfactory, which was damaged on both sides. no other neurological deficit was detected. other systems were normal. nasal discharge was clear, watery and increased with bending and straining. we referred our patient to ent department for rhinorrhea. csf rhinorrhea was suspected and nasal discharge was sent for chemical examination. chemistry of nasal discharge was consistent with csf. we performed mri, which showed fluid tract from cribriform plate of left ethmoid sinus through left frontal sinus, left anterior ethmoidal cells into left nasal cavity. there was dural tear and fracture of cribriform plate of left side. medical management for c mailto:tayyabam@yahoo.com chronic rhinorrhea pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 239 his fever was sought and we referred the patient to neuro-surgery department for surgical management of fractured cribriform plate. fig. 1: patient with right third nerve palsy. fig. 2: dilated and fixed pupil of right eye. discussion approximately 500 ml of csf is produced daily. csf produced at the choroid plexus, circulates through the subarachnoid space and is reabsorbed via the arachnoid villi. normal csf pressure is approximately 10 – 15 mm hg. any breach in this closed loop of csf circulation will lead to its leakage resulting in different conditions; e.g, otorrhea, rhinorrhea and oculorhea.1 csf leaks are broadly classified as spontaneous, traumatic and iatrogenic.2 traumatic csf leak is either immediate or delayed. immediate csf leaks are easy to diagnose but delayed fistulas may remain undetected. our patient had delayed csf rhinorrhea and it remained undetected for almost eleven years. such delayed cases may result in complications, which include intracranial hypotension (ich), headache and cranial nerve (cn) disorders. it is presumed that these complications are related to sagging of the brain and brainstem and traction on the dura3. fig. 3: t2 weighted mri showing tract of csf leak on left side this particular patient had intermittent csf leak and chronic headache. csf leak was taken as allergic rhinitis and he continued to take medicines for that purpose. prior to presenting in our department he had severe headache and profuse discharge from the nose which led to third nerve palsy. there are many case reports of cranial nerve palsies due to intracranial hypotension irrespective of the cause. although trauma is the most discussed cause of ich, other causes are also described in literature which include; lumbar discectomy4, csf shunt procedures5, spontaneous intracranial hypotension6. the most commonly encountered cranial nerve deficit from intracranial hypotension is sixth nerve palsy7. it is proposed that sixth nerve due to its long course is more vulnerable to damage when brainstem sags down as a result of decreased intracranial pressure8. second common nerve to be involved in ich is third nerve as in our case9,10. sometimes cranial nerve palsy is the only presenting sign of spontaneous ich multiple cranial nerve palsies can also occur. in the absence of any cranial nerve palsy, diagnosis of a tayyaba gul malik, et al 240 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology delayed csf leak becomes difficult unless an accurate history is taken and proper examination is done. intermittent cases of csf leak (as in our case) might be due to accumulation of csf in one of the paranasal sinuses which later drain with changes in head position. this is called reservoir sign. there are other signs which can help in localizing site of csf leak. our patient had anosmia on both sides, which pointed towards a defect in the anterior cranial fossa. optic nerve function deficits are indicative of lesions in posterior ethmoid sinuses but this nerve was spared in our case. meningitis is a very important complication of csf leak. this particular patient had multiple attacks of meningitis but only conservative management was done without looking for the cause of recurrent attacks. hence, cases of recurrent attacks of meningitis must be thoroughly investigated for any csf leak to prevent mortality and morbidity. conclusion the patient was referred to us for management of third nerve palsy. prompt referral to ent and neurosurgical department saved patient from morbidity and mortality. careful history, examination and investigations remain key to the sensible management of patients. patients with recurrent meningitis should be evaluated for a csf leak. author’s affiliation dr. tayyaba gul malik associate professor of ophthalmology lahore medical and dental college, lahore. dr. muhammad khalil associate professor of ophthalmology lahore medical and dental college, lahore. dr. qurrat ul ain medical officer ghurki trust teaching hospital, lahore role of authors dr. tayyaba gul malik data collection & manuscript writing dr. muhammad khalil manuscript writing dr. qurrat ul ain data acquisition references 1. apkarian aq, hervey jumper sl, trobe jd. cerebrospinal fluid leak presenting as oculorrhea after blunt orbitocranial trauma. j neuroophthalmol. 2014; 34 (3): 271-3. 2. lau d, lin j, park p. cranial nerve iii palsy resulting from intracranial hypotension caused by cerebrospinal fluid leak after paraspinal tumor resection: etiology and treatment options. the spine journal, 2011; 4: 10-13. 3. jones aa, stambough jl, balderston ra, et al. longterm results of lumbar spine surgery complicated by unintended incidental durotomy. spine, 1998; 14: 443446. 4. joo jd, yoon sh, kim kj, jahnq ta, kim hj. isolated abducens nerve palsy due to cerebrospinal fluid leakage following lumbar discectomy: a rare clinical entity. eur spine j. 2013; 22 (suppl. 3): 421-3. 5. maus v, petridis ak, doukas a, mehdorn hm. isolated facial palsy as a hallmark of csf over drainage in shunted intracranial arachnoid cyst. acta neurochir. 2011; 153 (5): 1141-2. 6. lozano pl, escalante as, corbella c, ysamat mm. cranial nerve vi palsy and spontaneous intracranial hypotension. neurologia. 2010; 25 (1): 67-9. 7. zada g, solomaon tc, giannotta sl. a review of ocular manifestations in intracranial hypotension. neurosurg focus, 2007; 23 (5): e8. 8. li g, zhu x, zhang y, zhao j, han z, hou k. cranial nerve palsy secondary to cerebrospinal fluid diversion. clin neurol neurosurg. 2016; 143: 19-26. 9. canovas a, san mj, lopez me, masjuan vj. third cranial nerve palsy due to intracranial hypotension syndrome. neurologica. 2008; 23 (7): 462-5. 10. warner gt. spontaneous intracranial hypotension causing a partial third cranial nerve palsy: a novel observation. cephalgia. 2002; 22 (10): 822-3. http://www.ncbi.nlm.nih.gov/pubmed/24621864 http://www.ncbi.nlm.nih.gov/pubmed/26882270 pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 61 editorial pediatric cataract surgery: current trends and concepts cataract is an important factor in visual disability in children across the globe leading to significant deficiency in neurological milestones of a child. pediatric cataract can affect three to six per 10,000 live births1 which accounts for approximately 200,000 children affected across the world. congenital cataract presents in the first year of life while developmental cataract is seen after infancy or trauma. factors such as onset age, laterality, cataract morphology, ocular associations and systemic diseases will decide the plan of management of a pediatric cataract. a lot of factors are important in pediatric cataract surgery to obtain good visual results. these include excessive postoperative uveitis, growth of eye ball with increasing age, calculation of intraocular lens power, glaucoma secondary to surgery, opacification of the posterior capsule and amblyopia2,3. family history, antenatal history, morphology of cataract and baseline laboratory investigations have shown that cataracts are idiopathic in 60% of children. investigations for toxoplasma, rubella, herpes simplex, varicella and syphillis should be done in all cases with a history of infection of the mother during pregnancy, deafness, microcephaly, developmental delay and cardiac abnormalities. on the other hand unilateral cataract usually does not warrant extensive laboratory tests. galactosemia and viral infections (torch, toxoplasmosis, rubella, cytomegalovirus and herpes simplex) need to be ruled out in well children with bilateral cataracts. while in toddlers who are well we need to screen for deficiency of galactokinase. in unwell children with jaundice and failure to thrive galactosemia is present when reducing substances are present in their urine and erythrocyte assays are abnormal4. in unwell children lowe syndrome (oculocerebrorenal syndrome) is seen when patients have congenital glaucoma, developmental delay and hypotonia. urine should be checked in them for amino acids. certain conditions require serum calcium, phosphorus and glucose based on the systemic examination of the child. general assessment of health of the child by a pediatrician are also done in all such cases. amongst all the congenital cataracts, 8 – 29% are genetically transmitted with autosomal inheritance in most of the cases. therefore a geneticist should be involved in the evaluation of inheritance and identification of any associated syndromes. non-surgical management the need for cataract surgery depends on the visual function. close observation can be done for lens opacities which have a diameter of less than 3 mm. patching and glasses should be used for the associated amblyopia. other types of anterior polar or pyramidal cataracts are visually insignificant but need correction only if lenticular astigmatism is significant. the use of dilating agents can be considered for central visually significant opacities. surgical management it is now well established that removal of cataracts which are unilateral should be done by 4 – 6 weeks and bilateral cataracts by 6 – 8 weeks can prevent amblyopia and nystagmus5. contact lenses, aphakic glasses or primary intraocular lens implantation are options for optical correction after removal of the cataract. choosing an appropriate iol power to achieve postoperative emmetropia is still a challenge. most of the iol calculations have to be done under anesthesia and a study has suggested that immersion biometry is more reliable than contact technique for iol power calculation in pediatric population. in doing unilateral cataracts it is important to keep in consideration the refractive status of the other eye. the infant aphakic treatment study (iats) suggested holladay 1 and srk/t for the eyes of infants. in 5 years refractive errors ranging from +5.0 to -19.00d were seen and it concluded that the failure to foresee axial increase in pediatric eyes was the main muhammad irfan khan 62 vol. 32, no. 2, apr – jun, 2016 pakistan journal of ophthalmology reason for such a broad variety of errors of refraction6,7. iol implantation, design and material primary implantation of iol is still controversial; however in a few tertiary centers in the uk, primary implantation of iol is the procedure of choice excluding microphthalmic and phpv eyes. since the iats most of the treating centers have deferred the use of iol in the newborn and would implant them after the age of one year. in the last few years acrylic iols have moved ahead of polymethy methacrylate (pmma) iols. in children the foldable acrylic iols are better because of greater biocompatibility, smaller size and slow onset of posterior capsule opacification formation. 93% of the pediatric ophthalmologist in the developed countries uses hydrophobic intraocular lenses. single pieces lens are placed in the bag whereas the three piece iols are placed in the sulcus or the bag. the use of iols in uveitic cataracts should be avoided but heparin coated pmma lenses have reported lower rates of inflammation8. management of posterior capsule good postoperative visual outcome after pediatric cataract surgery is seen in patients with clear visual axis. an intact capsule opacifies 100% in less than 4 years. it is very important to perform primary posterior capsulotomy and anterior vitrectomy in all pediatric patients9. postoperative management in children there is an exaggerated inflammatory response, it is absolutely crucial to use intraoperative steroids such as kenalog (half the adult dose) given as orbital floor. post operative they should use topical steroids 2 hourly for a week then gradually taper it down over a period of 6 weeks. the use of tropine is also helpful; firstly prevent membrane formation on the lens surface and also aides in view of the posterior pole and checking the refraction, in the postoperative clinic visits. secondary glaucoma it is one of the most feared complications and is commonly seen in infants. iats and other studies have shown that intraocular lens implantation usually does not protect from secondary glaucoma. a study by mataftsi et al, however has found that the risk of glaucoma after cataract surgery in infants appears to be related with intervention during the first month of the baby10. visual rehabilitation contact lenses, aphakic glasses and intraocular lens implantation, are the main treatment options for visual development. glasses are well tolerated by children up to the age of 4 years. contact lenses are very popular among children and they can be changed according to the ocular growth. clinicians prefer to use rigid gas permeable contact lenses in most of the cases. silsoft lenses by bausch and lomb are popular in the developed nations but its use in a developing nation would be very costly. recent developments researchers in china and at the university of california, san diego have used stem cells successfully. pre existing lens epithelial cells are able to regenerate with a new surgical procedure. in a human trial involving this procedure it was found out that after three months a clear and regenerated biconvex lens was seen in all 12 infants under the age of 2 years11. pediatric cataract surgery is challenging in all aspects, it is very important to emphasize to parents that removing the cataract is only one part of the procedure which is then followed by refractive adaptation, treating amblyopia and regular follow ups. the use of appropriate postoperative steroids is very important to prevent adhesions and membrane formation, which then may necessitate a secondary procedure. references 1. holmes jm, leske da, burke jp, hodge do. birth prevalence of visually significant infantile cataract in a defined us population. ophthamic epidemiol. 2003; 10: 67-74. 2. jasman aa, shaharuddin b, noor ra, ismail s, ghani za, embong z. prediction error and accuracy of intraocular lens power calculation in pediatric patients comparing srk ii and pediatric iol calculator. 3. lim z, rubab s, chan yh, levin av. pediatric cataract: the toronto experienceetiology. am j ophthalmol. 2010: 149: 887-92. 4. beigi b, o’keefe m, bowell r, naughten e, badawi n, lanigan b. ophthalmic findings in classical galactosaemia – a prospective study. br j ophthalmol. 1993; 77: 162-4. pediatric cataract surgery: current trends and concepts pakistan journal of ophthalmology vol. 32, no. 2, apr – jun, 2016 63 5. birch ee, subramanian v, patel cc, stager d jr. preoperative visual acuity and contrast sensitivity in children with small, partial or non-central cataracts. j aapos. 2013; 17: 357-62. 6. lambert sr, lynn mj, dubios lg, et al. axial elongation following cataract surgery during the first year of life in the infant aphakia treatment study. invest ophthalmol vis sci. 2012; 53: 7539-45. 7. lambert sr, lynn mj, hartmann ee, et al. comparison of contact lenses and intraocular lenses correction of monocular aphakia during infancy: a randomized clinical trail of hotv optotype acuity at age 4.5years and clinical findings at age 5 years. jama ophthamol. 2014; 132: 676-82. 8. basti s, aasuri mk, reddy mk et al. heparin surface modified intraocular lens in pediatric surgery: prospective randomized study. j cataract refrac surg. 1992; 25: 782-7. 9. kugelberg m, zetterstrom c. pediatric cataract surgery with or without anterior vitrectomy. j cataract refract surg. 2002; 28: 1770-3. 10. mataftsi a, haidich ab, kokkali s, et al. postoperative glaucoma following infantile cataract surgery: an individual patient data meta-analysis. jama ophthalmol. 2014; 132: 1059–67. 11. lin h, ouyang h, zhu j, huang s, liu z et al. lens regeneration using endogenous stem cells with gain of visual function. nature. 2016; 531: 323-8. dr. muhammad irfan khan consultant ophthalmologist moorfields eye hospital dubai, uae received: april 12, 2016: accepted: june 08, 2016 microsoft word sorath noorni.doc 181 original article management of ectopia lentis in children ssoorraatthh nnoooorraannii,, aayyeesshhaa kkhhaann,, sshheehhllaa rruubbaabb,, kkhhaaiirr aahhmmeedd cchhoouuddhhaarryy pak j ophthalmol 2007, vol. 23 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sorath noorani pediatric ophthalmologist pcb cell, eye opd, civil hospital karachi received for publication july ‘ 2007 …..……………………….. purpose: to study the etiology, mode of presentation and visual outcome of ectopia lentis after lensectomy in pediatric age group. materials and methods: this prospective, non comparative, interventional study was conducted in the department of pediatric ophthalmology, al shifa trust eye hospital, rawalpindi, pakistan, from november 2005 to october 2006. fifty patients, 2.5 to16 years of age, who presented with subluxated lenses both syndromic and non syndromic, were included in the study. patients with secondary subluxation of lenses were excluded. patients were selected for surgery having best corrected visual acuity 6/30 or less, pupil block glaucoma, cataract or clear subluxated lenses bisecting the pupil. surgical technique used was within the bag lensectomy and anterior vitrectomy via limbal approach. aphakia was treated with glasses or contact lenses followed by amblyopia treatment. results: ninety six eyes of 50 patients were included in the study. twenty six patients (52%) were male and 24 were (48%) female. all had bilateral subluxated lenses. twelve patients (24%) had familial ectopia lentis, 11(22%) had marfan’s syndrome, 24 (48%) cases were sporadic, 2 patients (4%) had weil marchesani syndrome and 1 (2%) patient had suspected homocystineuria. within the bag lensectomy was performed on 54 out of 96 eyes (56%) of 34 patients. twenty nine (54%) out of 54 eyes had bcva less than 6/30, 7(13%) eyes presented with pupil block glaucoma, 11 (20%) eyes had cataractous subluxated lens, 4 (7.5%) eyes had clear subluxated lenses bisecting the pupil and anterior dislocation in 3 eyes (5.5%) . other twenty eight eyes (18 pts) out of 96 eyes were given refractive error correction and kept on follow up for progression of subluxation and intraocular pressure monitoring. preoperatively 32 (59%) out of 54 eyes had visual acuity of hand movements to 6/60 and 22 (41%) eyes had 6/48 to 6/30. postoperatively bcva ranged between 6/18 to 6/15 in 29 (54%) eyes, 6/12 to 6/7.5 in 09 (17%) eyes, 6/48 to 6/24 in 5 (9%) eyes. eleven (20%) eyes achieved 6/60 or less. forty three (80%) out of 54 eyes showed post operative improvement in bcva ranging from two to nine lines on etdrs chart. conclusion: within the bag lensectomy via limbal approach is a safe and effective procedure for management of ectopia lentis in pediatric age group. aphakia corrected by glasses or contact lenses is not ideal but safer than scleral fixation of iol and implantation of anterior chamber iol in children. 182 ctopia lentis is a condition in which the lens is displaced because of weakened or broken zonules1. berryat described the first reported case of lens dislocation in 1749 and stellwag subsequently coined the term ectopia lentis in 18561. the lens is considered dislocated or luxated when it lies completely outside the lens pattelar fossa, in the anterior chamber, free floating in the vitreous or directly on the retina. the lens is described as subluxated when it is partially displaced but contained within the lens space. in the absence of trauma, ectopia lentis should evoke the suspicion for concomitant ocular disorder or hereditary systemic disease such as marfan’s syndrome, homocystinuria or weil marchesani syndrome and less commonly with hyperlysenimia and sulfite oxidase deficiency. subluxation of a familial type or idiopathic essential ectopia lentis occurs with no other detectable ocular or systemic abnormalities2. if the lens zonules have loosened uniformly, the lens will assume a spherical shape (spherophakia) and the thickened lens will induce myopia. poor vision secondary to ectopia lentis is most commonly caused by anisometropic amblyopia, irregular astigmatism and extreme myopia (lenticular). when lens abnormality is localized to one area, astigmatism results3. forward dislocation of the lens into the pupil or anterior chamber may cause pupil block with acute or chronic angle closure glaucoma. dislocation into the vitreous causes intermittent blurring of vision and vitreous traction on the retina with leakage of lens proteins into the vitreous which may cause chronic vitritis and chorioretinal inflammation. edge of the subluxated lens transects the central pupil and distorts the retinal image. in these cases where lens prevents clear use of both phakic or aphakic portions of pupil, lensectomy is required4. the main purpose of this study was to evaluate the visual outcome of children with ectopia lentis in children after within the bag lensectomy surgery followed by aphakic optical correction and amblyopia treatment. materials and methods this study was carried out at paediatric ophthalmology unit of al-shifa trust eye hospital rawalpindi from november 2005 to october 2006. a total number of 96 eyes of 50 patients ranging between the ages of 2.5 years to 16 years were included in the study. follow up period was one month to eleven months. secondary subluxations due to buphthalmos or trauma were excluded. a structured questionnaire was designed to record biodata, history, presenting complaints, examination findings and investigations. evaluation of patients included detailed history, unaided visual acuity (phakic or aphakic) using cardiff cards, lea symbols and etdrs chart in an age appropriate manner, slit lamp examination, intraocular pressure with goldmann applanation tonometer or tonopen was recorded. dilated fundoscopy was performed on all patients. sedation with syrup trichloryl (chloral hydrate 50mg/kg body weight) was used for iop recording and fundus examination in children under 4 years of age. routine investigations for general anesthesia, cardiac assessment of patients with marfan’s syndrome and urine for metabolic screening to exclude homocystinuria in one patient were advised. within the bag lensectomy via limbal approach was the surgical technique used in this study. pupil was dilated using, cyclopentolate 1% drops applied three times half an hour before surgery. all surgeries were perfomed under general anesthesia. after all aseptic measures, anterior chamber maintainer was introduced at the temporal side of limbus. a separate limbal entry wound for vitreous cutter was made. the procedure was started with circular anterior capsulotomy using the cutting mode of vitrectomy machine (vitrectorhexis) with low aspiration. the main aspect of within the bag lensectomy technique is total aspiration of nucleus and cortical material within the capsular bag. attempts to keep the posterior and anterior capsule intact were made until the entire lenticular material was aspirated and bag was emptied. lens capsule, zonules and the anterior vitreous were then removed using a high speed cutting mode with medium aspiration power. on completion of the procedure limbal wounds were closed with 10/0 nylon suture. subconjunctival antibiotic and steroid combination was given. post operatively, topical steroids, antibiotics and cycloplegics were advised. patients were followed postoperatively 1 day, 1 week, 4 weeks, 6 weeks and each follow up visit included iop monitoring, best corrected visual acuity (bcva) with glasses or contact lenses, patching treatment for amblyopia and monitoring the improvement of vision. results out of 50 patients, 26 were male and 24 were female. the age of children ranged between 2.5 years to 16 e 183 years (mean 9.4 years). table 1 represents the age of all 50 patients and table 2 represents ages of 34 patients who had undergone lensectomy. sporadic cases were 24 (48%), 12 patients (24%) had familial ectopia lentis, 11 patients (22%) had marfan’s syndrome, weil marchesani syndrome 2 patients (4%). one patient (2%) was suspected to be case of homocystinria table 3. out of 96 eyes lensectomy was performed on 54 eyes (56.25 %) of 34 patients, 28 eyes (29.17 %) of 18 patients having bcva ranging from 6/24 to 6/9.5 were kept in follow-up group. fourteen eyes (14.58 %) of nine patients were lost to follow-up. surgical indication for within the bag lensectomy in 54 eyes were, bcva 6/30 or less in 29 eyes (54%), pupil block glaucoma in 07 eyes (13%), cataractous subluxated lens in 11 eyes (20%), clear subluxated lens bissecting the pupil 04 eyes (7.5%), anterior dislocation 03 eyes (5.5%). fourteen eyes presented with glaucoma. seven eyes with pupil block glaucoma, 04eyes with angle closure glaucoma and 03 eyes had associated open angle glaucoma. nine eyes had controlled iop after lensectomy but 05 eyes needed trabeculectomy with mmc as a secondary procedure. preoperatively 54 eyes selected for lensectomy were classified in 2 groups. group-i included 32 eyes (60%) and group-ii had 22 eyes (40%) (table 4). postoperatively there was a significant improvement in bcva, as shown in (table 5). table 1: age of patients presented with ectopia lentis (no = 50) age in years no. of patients n (%) < 05 05 (10) 5-10 25 (50) 11-15 16 (32) 15-16 04 (8) table 2: age of patients undergone lensectomy (54 eyes of 34 patients) age in years no. of patients n (%) 0 – 5 06 (11) 5 – 10 31 (57) 11 – 15 12 (22) 15 – 16 05 (10) table 3: etiology of ectopia lentis in 50 patients etiology of ectopia lentis no of patients n (%) sporadic 24 (48) familial ectopia lentis 12 (24) marfan syndrome 11 (22) weil marchesani syndrome 02 (04) suspected homocysteinuria 01 (02) table 4: pre operative visual acuity in 54 eyes visual acuity no. of patients n (%) hm – 6/60 32 (59) 6/48 – 6/30 22 (41) table 5: post-operative best corrected visual acuity in 54 eyes visual acuity no. of patients n (%) hm – 6/60 11 (20) 6/48 – 6/24 05 (09) 6/18 – 6/15 29 (54) 6/12 – 6/7.5 09 (17) eleven eyes (20%) showed no significant improvement due to presence of poor prognostic factors. causes of postoperative poor vision (hm to 6/60) in 11 eyes were presence of preoperative corneal opacity in 01 eye (9%), irreversible amblyopia in 03 eyes (27%), preoperative glaucomatous optic nerve damage in 06 eyes (55%), while 1 eye had postoperative retinal detachment. surgical complications occurred in 04 out of 54 operated eyes. peroperatively posterior drop of lens fragments in one eye managed successfully by 3 port pars plana vitrectomy, retinal detachment within three weeks post operatively in 01 eye. choroidal detachment occured in both eyes of a patient who had weil marchasani syndrome and combined surgery (lensectomy and trabeculectomy with mmc) was 184 perfprmed for ectopia lentis and glaucoma, but settled completely with conservative treatment in both eyes. discussion ectopia lentis is perhaps the most common congenital lenticular anomally other than cataract1. usually bilateral, this condition may be caused by extensive malformation of zonular ligaments. ectopia lentis can occur as an isolated condition, as an association with other ocular disorders; or as a part of a systemic mesodermal disease, as in marfans syndrome or weil marchesani syndrome. it can also occur as a complication of general metabolic disorders, such as homocystinuria, hyperlysenimia and combined xanthine and sulfite oxidase deficiency. it has also been reported with ehler-danlos syndrome, sturge weber syndrome5 and stickler syndrome6. of the systemic disorders associated with ectopia lentis, marfan’s syndrome, weil marchesani syndrome and homocystinuria account for over 75% of the observed lens displacement7. in this study, sporadic cases were 24 (48%), familial ectopia lentis in 12 patients (24%) and ectopia lentis in systemic disorders was seen in 14 patients (28%) . of these, systemic disorders associated with ectopia lentis, marfans syndrome (figure 1) in 11 patients (22%), weil marchesani syndrome in 2 patients (4%) and homocystinuria in 1 patient (2%). surgery was performed on 54 eyes and the bcva 6/30 or less was found to be the commonest mode of presentation in 29 eyes (54%). this was followed by cataractous subluxated lens 11 eyes (20%) as shown in figure 2, pupil block glaucoma 7 eyes (13%), clear subluxated lens bisecting the pupil 4 eyes (7.5%) as shown in figure 3 and anterior dislocation 3 eyes (5.5%) as shown in figure 4. fig. 1: marfans syndrome fig. 2: cataractous subluxated lens fig. 3: clear subluxated lens bisecting the pupil fig. 4: anterior dislocation of lens surgical treatment of ectopia lentis has traditionally been associated with poor visual outcome and a high complication rate in the past8. numerous 185 techniques were used in the past but most of presented results were not encouraging8. intracapsular or extracapsular extraction, used in the times when automated vitrectomy was not available, often caused uncontrolled vitreous loss and retinal detachment9. cross and jensen10 reported an improvement in visual acuity in 51%, vitreous loss rate in 30% and post operative detachment rate in 15% of 84 eyes of patients with marfan’s syndrome and homocystinuria who underwent lens removal using a variety of surgical techniques (aspiration, intracapsular removal and extracapsular removal). subluxated lenses can be removed with closed eye lensectomy using vitrectomy instruments from either the anterior segment through the limbal incision or through the pars plana4. modern microsurgical techniques yield very good results following either limbal or pars plana approach lensectomy for ectopia lentis11,12. retinal detachment, a frequent problem prior to lensectomy procedures using vitreous cutting instrument, is now a rare complication13. contact lenses or spectacle correction of subsequent aphakia is effective and relatively straight forward. in one large study by halpert and benezra13, the best corrected visual acuity of approximately 90% of eyes with ectopia lentis was found to have improved by 2 snellen’s lines or more following lensectomy. in 1979, peyman and associates14 reported on the first series of patients with ectopia lentis managed with pars plana lensectomy demonstrating good results and fewer complications. similar results are also reported by behki r, neol and clarke15. reese and weingeist12 performed the removal of dislocated lens through a pars plana approach, obtaining satisfactory outcome in all 12 operated eyes. plager and associates16 also reported similar encouraging results where over 90% achieved a visual acuity of 20/40 or better. both approaches are effective, and the selection depends on the comfort of the surgeon and familiarity with the technique.3 in our study we used within the bag lensectomy technique via limbal approach on 54 eyes. the main aspect of within the bag lensectomy is total aspiration of nucleus and cortical material within the capsular bag until the whole bag is emptied to prevent the posterior drop of lens fragments. a closed system endosurgical technique allows the anterior chamber to remain maintained, preserves normal anatomical relationships and prevents scleral and vitreous collapse17. postoperative aphakic spectacles and contact lenses showed significant improvement in visual acuity. in our series, the postoperative bcva showed improvement in 43 (80%) out of 54 eyes. bcva 6/18 and better was achieved in 38 eyes (71%). behki, neol and clarke15 treated a series of nine children (15 eyes) with limbal lensectomy. improvement in postoperative bcva was documented in all operated eyes ranging from 20/20 to 20/50. shortt and associates18 reported the results of pars plana lensectomy for ectopia lentis in 24 eyes of 13 patients. post operatively visual acuity was 6/9 or better in 17 of 22 eyes and 6/12 or better in 19 of 22 eyes. anteby, isaac and benezra19 performed lensectomy via limbus and pars plana approach for ectopia lentis on 38 eyes and achieved a visual acuity (va) 20/60 or better in 35 of 38 eyes 92.1%. another study by halpert and benezra13 reported improvement of va of 20/40 or better in 54 of 59 (92%) operated eyes. they concluded that good and stable visual outcome can be obtained using within the bag lensectomy technique either through pars plana or limbal approach. alternative methods to glasses or contact lenses for correction of aphakia are available but their application for children still remains to be tested19. high iop, corneal decompensation or both have developed in 80% of the children after follow up of 10 years with anterior chamber iols20. scleral fixation of iol could be another option instead of a/c iols in children. however frequent complications are encountered with this technique20. buckley in 1999,21 reported on the use of scleral sutured iols in children and concluded that this procedure had increased rate of complications. benezra20 reported complications of scleral sutured iols in children, suture erosion and dislocation of iol occurred 3 years after implantation of iol, necessitating iol removal. in another case,20 an intractable chronic inflammation developed 18 months after surgery and alleviated only after removal of scleral fixated iol. sclerally fixated and in the bag fixation has been described in small series of children aged 8 to 11 years with marfan’s syndrome.22 short term follow-up suggested improved post operative visual acuities; however anterior dislocation of iol into a/c was reported. most paediatric ophthalmologists currently feel that, given the abnormal zonules in children with ectopia lentis and the limited capsular support for an iol, the post operative refractive correction of the children undergoing lens surgery should remain 186 contact lenses or spectacles23. visual improvement occurs in nearly all cases but may be delayed reflecting long eshtablished ametropic amblyopia24. hing and coworkers25 in their study, concluded that a child should have the lens removed and should wear aphakic correction as soon as the level of vision is inadequate for normal life or the situation of the lens is such as to make amblyopia likely. pfeifer and mikek8 described a surgical technique based on the use of cionni endocapsular tension ring, dry irrigation aspiration of lens material, centration of the capsular bag and foldable iol implantation into the bag with no serious intraoperative or postoperative complications. the final bcva improved in 9 out of 11 eyes. more studies on use of the modified capsular tension ring are required to provide pseudophakia as an ideal treatment of ectopia lentis in pediatric age group. conclusion within the bag lensectomy via limbal approach is a safe and effective technique for removal of subluxated lens in paediatric age group. this technique avoids major surgical complications. post-operative aphakia corrected by spectacles or contact lenses is not ideal but is safer than other available alternatives like scleral fixation of iol implant or anterior chamber iol implant in children. in future iol implantation with the help of modified capsular tension ring can be considered in paediatric age group to provide better optical correction. acknowledgements i thank professor ziauddin shaikh, head of department ophthalmology civil hospital karachi, for his help and support in writing this paper. i also thank orbis international for their support in this study. author’s affiliation ddrr.. ssoorraatthh nnoooorraannii ppeeddiiaattrriicc oopphhtthhaallmmoollooggiisstt ppccbb cceellll,, eeyyee ooppdd cciivviill hhoossppiittaall,, kkaarraacchhii ddrr.. aayyeesshhaa kkhhaann hheeaadd ooff ppeeddiiaattrriicc oopphhtthhaallmmoollooggyy ddeeppaarrttmmeenntt aall sshhiiffaa ttrruusstt eeyyee hhoossppiittaall,, rraawwaallppiinnddii ddrr.. sshheehhllaa rruubbaabb ppeeddiiaattrriicc oopphhtthhaallmmoollooggiisstt aall sshhiiffaa ttrruusstt eeyyee hhoossppiittaall,, rraawwaallppiinnddii ddrr.. kkhhaaiirr aahhmmeedd cchhoouuddhhaarryy ttrraaiinneeee ppeeddiiaattrriicc oopphhtthhaallmmoollooggyy aall sshhiiffaa ttrruusstt eeyyee hhoossppiittaall,, rraawwaallppiinnddii reference 1. eifring cw, eifring de: ectopia lentis: http: // www.emedicine.com/ oph /topic 55.htm. 2. marin s. inherited eye diseases: diagnosis and clinical management. new york: mp dekker, 1991:131-2. 3. tesser ra, hess db, buckley eg: pediatric cataracts and lens anomalies. in: nelson l b, olitsky s (ed). harley’s pediatric ophthalmology, 5 th ed. pennsylvania: lippincott williams and wilkins. 2005; 255-84. 4. wright kw. lens abnormalities. in: wright kw, (ed). pediatric ophthalmology and strabismus, 2nd ed. new york: springer. 2003; 450-80. 5. filato v, guyer dr, lustbuder jm, et al. dislocation of lens in a patient with sturge weber syndrome. ann ophthalmol. 1992; 24: 260-2. 6. schlote t, iker m, knorr m, et al. coloboma and subluxation of lens in stickler (marshall) syndrome. klin monatsbl augenheilkd. 1997; 210: 227-8. 7. cross he. differential diagnosis and treatment of dislocated lenses. in: bergsma d, bron aj, cotlier e (eds). the eye and inborn error of metabolism. newyork, alan r. liss, 1976: 33546. 8. pfeifer v, mikek k. ectopic lens extraction in children. zdraw vestn 2002; 71: 11-4. 9. merriam jc, zheng l. iris hooks for phacoemulsification of the subluxated lens. j cataract refract surg. 1997; 23: 1295-7. 10. cross he, jensen ad. ocular manifestation in the marfan’s syndrome and homocystinuria. am j ophthalmol. 1973; 75: 405-20. 11. salehpour o, lavyt, leonard j. the surgical management of non-traumatic lenses. j pediatr ophthalmol strabismus. 1996; 33: 8-13. 12. reese pd, weingeist ta. pars plana management of ectopia lentis in children. arch ophthalmol 1987; 105:1202-4. 13. halpert m, ben ezra d. surgery of the hereditary subluxated lenses in children. ophthalmology 1996; 103: 681-6. 14. peyman ga, raichand m, goldberg mf, et al. management of subluxated and dislocated lenses with vitrophage. br j ophthalmol. 1979; 63: 771-8. 15. behki r, neol lp, clarke wn. limbal lensectomy in management of ectopia lentis in children. arch ophthalmol. 1990; 108: 809-11. 16. plager da, parks mm, halveston em, et al. surgical treatment of subluxated lenses in children. ophthalmology 1992; 99: 1018-21. 17. steven b, koeing, md; william f et al. management of ectopia lentis in a family with marfan’s syndrome. arch ophthalmol. 1996; 114: 1058-61. 18. shortt aj, lanigan b, o’keefe m. pars plana lensectomy for the management of ectopia lentis in children. j pediatr ophthalmol strabismus. 2004; 41: 289-94. 19. anteby i, isaac m, benezra d. heriditary subluxated lenses: visual performances and long-term follow-up after surgery. ophthalmology. 2003; 110: 1344-8. 20. benezra d. iols for unilateral pediatric aphakia: early lenses and long-term follow-up. eur j implant refractive surg. 1990; 2: 285-7. 21. buckley eg. scleral fixated (sutured) posterior chamber iol implantation in children. jaa pos 1999; 3: 289-94. 187 22. vadala p, capozzi p, fortunato m, et al. intraocular lens implantation in marfan’s syndrome. j pediatr ophthalmol and strabismus. 2000; 37: 206-8. 23. ian c. lloyd. the lens. in: david taylor, (ed). pediatric ophthalmology and strabismus, 5th ed. london: elsevier 2005; 432-40. 24. speedwell l, russelleggitt i. improvement in visual acuity in children with ectopia lentis. j. pediatr. ophthalmol strabismus. 1995; 32: 94-7. 25. hing s, speedwell l, taylor d. lens surgery in infancy and childhood. br j ophthalmol. 1990; 74: 73-7. pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 221 original article stress and phacosurgeon: an unavoidable association saba alkhairy, farnaz siddiqui, mazhar-ul-hasan, asad azeem mirza, syed muhammad adnan pak j ophthalmol 2016, vol. 32 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: saba alkhairy department of ophthalmology dow university of health sciences. email: saba.alkhairy1@gmail.com …..……………………….. purpose: to study the physical symptoms of stress and its association with surgical experience in a surgeon performing phacoemulsification. study design: an analytical study. place and duration of study: multi center study in different parts of the city karachi, pakistan from may 2016 to september 2016. material and methods: different phaco surgeons were requested to fill in a questionnaire which described the physical symptoms of stress such as headache, dry mouth, palpitations etc which one experiences while doing phacoemulsification surgery and also inquired about the surgical experience. the surgeons were all qualified ophthalmologists categorized into three groups based on their surgical experiences and the stress level. they were classified as low, moderate and high based on number of physical symptoms and the association between experience and stress level was analyzed. results: a total 25 phaco surgeons filled the questionnaire. there were 22 males and 3 females. category a with less than 5 years working experience were 9 (36%) in number while there were 6 (24.0%) in category b (6 – 14 years working experience) and 10 (40.0%) in category c (more than 15 years working experience). stress level was found to be the highest in 6 – 14 years working experience 3 (12.0%). conclusion: phacoemulsification has a steep learning curve and an ophthalmologist experiences a high level of stress during the learning phase as well as afterwards. keywords: phacoemulsification, physical symptoms, stress, ophthalmologist. ataract surgery is one of the most commonly performed surgery in the world and the predicted number of people to develop cataract by 2020 is an alarming 30 million1. the standard procedure performed for removal of cataract is a technique which employs ultrasonic waves to break and emulsify the cataract and this process is known as phacoemulsification2. although phacoemulsification is considered as a safe surgical technique corneal endothelial damage can occur and this can lead to bullous keratopathy with unpredictable post operative visual acuity3. this causes a phaco surgeon to strive to do the best surgery possible with minimal damage to surrounding tissue so that better visual acuity results can be obtained. in this process phaco surgeons suffer from severe professional distress and burnout. burnout symptoms include impaired decision making power, body fatigue, guilt, depersonalization and a constant awareness of personal failure. various studies have been conducted on doctors of different sub-specialties and have shown a high burnout rate amongst surgeons ranging from 30 to 38%4-7. without a doubt the life of a surgeons is very stressful. in a paper written by sy kraft approximately 8000 doctors were surveyed in 2010 and an alarming 501 admitted to thoughts of suicide8. surgeons have to endure long unpredictable working hours with c saba alkhairy, et al 222 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology minimal sleep and rest. they are under constant pressure to meet the high expectations of his patients and fail to have mental peace even after work and at home. as a result of this not only does their family life suffer such as marital discord but they also experience physical exhaustion, mental fatigue, drug addiction, poor performance, depression, and a growing sense of anxiety that gradually starts to consume them and leads to slow self deterioration and may even lead to suicide. the purpose of this study is to identify the signs and symptoms of stress in surgeons and the correlation of it to their working experience in years. also we intend to create awareness amongst the medical personnel to introduce effective surgical training programs for young budding doctors in particular to minimize stress during surgery, to hold group discussions/workshops regularly in which doctors can discuss personal, social, psychological and professional problems they encounter and ways to manage stress and to help surgeons map a career pathway that integrates personal and professional goals so as to achieve both personal and work satisfaction. to our knowledge no similar study has been conducted in our country on surgeons performing phacoemulsification. material and methods this was an analytical questionnaire based study. a questionnaire was developed and consisted a total of 12 questions. it included gender, working experience in years, step in which posterior capsule rent occurs the most, physical symptoms experienced while doing surgery such as dry mouth, chest pain/palpitation, dry mouth, stomach cramps, hand tremors, changes in breathing (shallow/rapid), headache, aches/tense muscles, cold and sweaty hands and/or excessive sweating. this questionnaire was taken to various centers in different parts of the city and only qualified consultant ophthalmologists were asked to fill it. there was a space made available in the questionnaire for comments. in order to study the association between working experience and stress the doctors were categorized into three groups: category a with more 5 years working experience, category b with 6 to 14 years working experience and category c with more than 15 years working experience. stress was further categorized into three levels: mild, moderate and high based on the number of physical symptoms. mild stress was classified as a group that experienced at least one physical or no physical symptoms, moderate group consisted of individuals that had two to three physical while high stress level were those that experienced four or more physical symptoms. the data was analyzed on ibm spss version 21.0 and the results were presented as frequency and percentages for gender, surgical work experience, and pc rent, and physical symptoms. stress level was computed using physical symptoms. it is categorized as a person having one physical symptom as mild, two or three as moderate, four and above as high. statistical association was performed between gender and surgical experience versus stress level using chisquare. graphs were made for physical symptoms and between surgical experience and stress level. a pvalue of 0.05 or less was considered statistically significant. results total 25 subjects were analyzed having at least one physical symptom. table 01 reported that males were 22 (88.0%) and females were 3 (12.0%). people having less than 5 years or more than 15 years’ experience are higher i.e. 9 (36.0%) and 10 (40.0%) respectively. for pc rent cortex removal and nuclear removal are found to be 11 (44.0%) and 10 (40.0%) respectively. figure 01 shows that the most common physical symptoms found were changes in breathing 11 (44.0%) followed by dry mouth 10 (40.0%), hand tremor 8 (32.0%), palpitation or chest pain, headache, and stomach cramps (table 02). table 03 describes association of stress level with gender and surgical experience. both mild and moderate stress level were found in males but in females there was high stress level. about surgical experience having more than 15 years have mild stress level i.e. 6 (24.0%). six to 14 years experience have high stress level i.e. 3 (12.0%) and last less than 5 years surgical experience has moderate stress level i.e. 6 (24.0%). for each experience range there were different stress levels which are shown in figure 02. the p-value was 0.041 and was found to be significant. discussion surgery is one of the most stressful occupations out there. different surgeons experienced different levels of stress and showed a strong association with surgical experience. the stress symptoms varied in different individuals and to different degrees. claude bernard stress and phacosurgeon: an unavoidable association pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 223 table 1: descriptive statistics. n = 25 (%) gender male 22 (88.0) female 3 (12.0) surgical work experience < 5 years 9 (36.0) 6 14 years 6 (24.0) > 15 years 10 (40.0) pc rent nucleus removal 10 (40.0) cortex removal 11 (44.0) lens insertion 4 (16.0) table 2: descriptive statistics for physical symptoms. physical symptoms n = 25 (%) changes in breathing 11 (44.0) dry mouth 10 (40.0) palpitation / chest pain 7 (28.0) stomach cramps 2 (8.0) hand tremor 8 (32.0) headache 3 (12.0) stated that the maintenance of life is significantly dependent on keeping our internal milieu constant despite a change in external environment9. thus it is important to recognize the stress associated with surgery and to take measures to reduce it. strategies for reducing stress include identifying the factors leading to stress, building strong relationship with colleagues/family/friends, resting your mind and body and getting help when you feel out of control10. table 3: relationship between gender and surgical experience with stress level characteristics stress level total p-value mild (n = 9) n (%) middle (n=1) n(%) high (n = 5) n (%) gender male 9 (36.0) 10 (40.0) 3 (12.0) 22 0.081~ female 0 (0) 1 (4.0) 2 (8.0) 3 surgical experience < 5 years 1 (4.0) 6 (24.0) 2 (8.0) 9 0.041*~ 6 15 years 2 (8.0) 1 (4.0) 3 (12.0) 6 > 15 years 6 (24.0) 4 (16.0) 0 (0) 10 * significant at 5% ~ cell proportion > 20% & one cell has expected frequency less than 1 saba alkhairy, et al 224 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology in a similar study done on a smaller scale by yamamoto et al titled ‘the intra-operative stress experienced by surgeons and assistants’ proved that stress level based on heart rate and urine adrenaline levels showed a characteristic pattern relative to the experience of the surgical personnel11. another study done on the management of intra-operative stress by sonal arore et al emphasized the need to identify stressors in oneself and others and that there should be implementation of structured training in management of intra-operative stress12. another study proved that a brief period of mental practice decreased the body’s cardiovascular and neuro-endocrine response to stress13. a study done to compare the stress levels between consultants and residents during cardiac surgery concluded that there was no association between surgical experience and stress levels14. cordula in his study showed that junior surgeons struggled to cope with intra-operative stress while senior surgeons had formulated strategies to help them cope with it in a better way15. other studies validated this and contrary to the above mentioned study showed that stress was reduced with surgical experience16,17. our study concluded that surgeons with surgical experience of more than 15 years had mild stress level i.e. 6 (24.0%), those with 6 -15 years experience had high stress level 3 (12.0%) and those with less than 5 years surgical experience had moderate stress level 6 (24.0%). in our study we found females to have higher intra-operative stress levels versus males but this may not be true representation as females were considerably less in number as compared to males. this is consistent with other studies that concluded autoimmune diseases, chronic pain, depression and anxiety disorders are relatively more prevalent amongst women18-21. the limitations of this study was that it was a single city study, there was a small sample size, there was unequal representation of men and women and objective parameters of stress such as heart rate variability, urine adrenaline levels, sympatho-vagal response etc was not measured. conclusion surgeons experience immense stress while performing surgeries. it is important to recognize the symptoms of stress and to introduce interventions such as structured training, supervision during surgeries, knowledge of how to manage intra-operative complications effectively, practice of breathing exercises, positive thinking, good health and nutrition and other methods to combat stress. author’s affiliation dr. saba alkhairy assistant professor, department of ophthalmology, dow university of health sciences, karachi. dr. farnaz siddiqui assistant professor department of ophthalmology, dow university of health sciences, karachi. prof. dr. mazhar-ul-hasan department of ophthalmology, dow university of health sciences, karachi. prof. dr. asad azeem mirza department of ophthalmology, dow university of health sciences, karachi. syed muhammad adnan lecturer & research in charge department or unit: nide karachi role of authors dr. saba alkhairy study design, data collection, manuscript writing. dr. farnaz siddiqui data collection, result analysis. dr. mazhar-ul-hasan manuscript review. dr. asad azeem mirza data collection. syed muhammad adnan manuscript review. references 1. uy, h.s, edwards k, curtis. n. femtosecondphacoemulsification: the business and the medicine. cur opin ophthalmol. 2012; 23: 33-9. 2. devgan u. surgical techniques in phacoemulsification. curr opin ophthalmol. 2007; 18: 19-22. stress and phacosurgeon: an unavoidable association pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 225 3. takahashi h. free radical development in phacoemulsification cataract surgery .j nippon med sch. 2005; 72: 4-12. 4. campbell da, sonnad jr, eckhauser ss, et al. burnout among american surgeons. surgery 2001; 130: 696-705. 5. harms ba, heise cp, gould jc, starling jr. a 25 year old single institute analysis of health, practice, and fate of general surgeons. ann surg. 2005; 242: 520-9. 6. kuere hm, eberlein tj, pollock re et al. career satisfaction, practice patterns and burn out amongst surgical oncologists: report on the quality of life of members of the society of surgical oncology. ann surg oncol. 2007; 14 3043-53. 7. bertges yost we, shelman ar, aroufi ma, boulijoud ms. a national study of burnout among american transplant surgeons. transplant proc. 2005; 37: 13991401. 8. kraftsy. surgery most stressful occupation; high suicide rate. jama network. 2011. 9. adams db, bacelli g, mancia g, zanchetti a. cardiovascular change during naturally elicited fighting behavior in the cat. am j physiol. 1968: 216: 1226-35. 10. kiecolt glaser j. glaser r. how stress affects your health. american psychological association. 2016. 11. yamamoto a, hara t, kikuchi a, hara t, fujiwara t. intra-operative stress experienced by surgeons and assistants. ophthalmic surg lasers. 1999; 30: 27-30. 12. sonal arora et al. management intra-operative stress. american journal of surgery. 2009;.197; 537-43. 13. arora s, agarwall r, moran a. mental practice: effective stress management training for novice surgeons. j am coll surg. 2011; 212: 225-33. 14. kuhn ew, choi yh, schonnher m. intra-operative stress in cardiac surgery: attending versus residents. j surg res. 2013; 182: 43-9. 15. cordula m, roger l, maria w, krishna m, ara d. the effects of stress on surgical performance. the am j of surgery, 2006; 191: 5-10. 16. bohm b, rotting n, schnewenk w et al. a prospective randomized trial on heart rate variability of the surgical team during laprascopic and conventional sigmoid resection. arch surg. 2001; 136: 305-10. 17. kikuchi k, okuyama k, yamamoto a. intra-operative stress for surgeons and assistants. j ophthalmic neuro technol. 1995; 14: 168-70. 18. holden c. sex and the suffering brain. science 2005; 308: 1574. 19. kjantie e, phillips di. the effects of sex and the hormonal status on the physiological response to acute psychosocial stress. pscycho neuroendocrinology, 2006; 31: 151-78. 20. kudielka bm, krischbaum c. sex difference in hpa axis responses to stress. a review. biol psychol. 2005; 69: 113-32. 21. lundberg u. stress hormones in health and illness. the roles of work and gender. psychonuero endocrinology, 2005; 30: 1017-21. microsoft word hashimqureshi_1_correctsent 1 original article non phaco sutureless cataract surgery with small scleral tunnel incision using rigid pmma iols muhammad hashim qureshi pak j ophthalmol 2007, vol. 23 no.1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad hashim qureshi department of ophthalmologist civil hospital jacobabad. received for publication januanry’ 2006 …..……………………….. purpose: a non-comparative study to experience the results of non-phaco sutureless small incision scleral tunnel cataract surgery using rigid polymethylmethacrylate (pmma) intraocular lenses (iols). material and method: the study was conducted at civil hospital jacobabad and author’s private clinic. 200 eyes of 190 patients underwent sutureless small incision cataract surgery using rigid pmma iols. 105 eyes were of males (52.5%) and 95 were females (47.5%) patients with mean age of 67.5 years. patients with age related cataracts having no history of eye surgery and no ocular or systemic disease were included in the study. results: keratitis was the commonest operative complication (36. 5%) irregular and ragged scleral tunnel was the next (19%). surgically induced astigmatism ranged from + 0.5 to + 3.25d (1.87d mean) with good visual results (6/6 to 6/18) in 91% of cases after 4 week of follow up. conclusion: due to high cost and difficult learning curve of phaco surgery small incision scleral tunnel sutureless cataract operation is a good alternative. it produces good visual results, quick rehabilitation and has an easy learning-curve. he main objective of all eye surgeons is to minimize surgically induced astigmatism and achieve rapid postoperative visual recovery after cataract surgery1. no doubt phaco is really useful to achieve this objective if equipment is available. unfortunately phaco is not widely used in third world countries due to expensive equipment, difficult and prolonged learning curve and rising poverty line. a good and effective alternative to this goal is non phaco sutureless scleral tunnel small incision for cataract surgery2. this study was carried out at the department of ophthalmology civil hospital jacobabad and at the author’s private clinic. the purpose of study was to experience the results of sutureless cataract surgery using scleral tunnel small incision with the implantation of rigid pmma iols. i present my experience in 200 cases using this technique. material and methods a total of 190 patients (200 eyes) under went cataract surgery during the period from march 2004 to june 2005. patients having age related cataract without previous eye surgery and no pre existing ocular disorder or controlled systemic disease were included in this study. t 2 a detailed history was taken and complete examination of anterior and posterior segments and systemic evaluation of every patient was done. diopteric power of posterior chamber iols was calculated using srk ii formula after recording the keratometric and axial length measurements. all surgeries were performed by the author using peri-bulbar or posterior sub-tenon anesthesia. in every operation two special disposable knives were used, crescent knife bevel up 2.25 mm (alcon or visitec) and slit knife 3.2 pointed bevel up (alcon or visitec). after surgical scrubbing, sterile drapping and bridle suture placement, a fornix based conjunctival flap was made. sclera was bared of tenon and minimum necessary cautery was then applied. the location and length of the incision was marked by a caliper set at 5.5mm to 7mm scales3,4. all cases were approached superotemporally and frown shaped groove 0.25mm deep was made in the sclera with surgical knife no.15. the most anterior and central point of the groove was 2mm away from the peripheral corneal vascular arcade, the peripheral ends were approximately 4mm away from the peripheral vascular arcade. the length of the groove was 5.5 – 7mm depending upon the hardness of the nucleus. after completion of the groove, the crescent knife was engaged in the center of the groove, advancing the knife within sclera anteriorly and extending 1mm into the stroma of the clear cornea. the scleral tunnel was then extended from side to side at the lateral ends of the groove. after the completion of scleral tunnel, a pointed slit knife 3.2 was introduced in the centre of the tunnel and the corneal stroma was perforated with its tip to enter the anterior chamber. with outside in motions of the knife, the internal corneal cut was extended on either sides laterally to make internal corneal valve1,2,6. anterior chamber was filled with viscoelestic and capsulotomy was`done. after hydrodissection and hydridelineation the nucleus was mobilized, loosened and displaced into the anterior chamber from where it was expressed out by hydroexpression with simco cannula or viscoexpression. the remaining cortical matter was aspirated out. anterior chamber and capsular bag was filled with visco-elastic and posterior chamber pmma iol. (5.5 6mm) was implanted with in the bag. visco-elestic was then aspirated out by a two-way cannula. the wound was checked for any leakage and the conjunctival flap was repositioned and cauterized. at the end a subconjunctival injection of gentamycin 20 mg and 0.5-mg dexamethasone was given and an eye pad applied. results two hundred eyes of 190 patients underwent this study. all patients had age related cataract with age ranging from 55 years to 80 years (mean 67.5 years). out of 200 eyes, 105 eyes were of males (52.5%) and 95 were of females (47.5) (table 1). the follow up was done on first postoperative day then at one week, one month and three-months postoperatively. table 1: patient’s profile no ofpatients age in years sex male female 190 (200 eyes) 55-80 (mean 67.5 ) 52.2% 47.5% table 2: operative complications (200 eyes) complications numbers (%) striate keratopathy 73 (36.5) irregular internal corneal valve 21 (10.5) ragged and notched wound edges 17 (8.5) uneven tunnel 10 (5) capsulotomy extension 10 (5) button hole in the outer flap of scleral tunnel 8 (4) partial descemet membrane detachment 8 (4) hyphema 8 (4) eccentric iols 5 (2.5) iris prolapse 4 (2) capsular disinsertion with vitreous prolapse 3 (1.5) iris disinsertion 1 (0.5) ragged and notched edges of scleral wound developed in 17 cases (8.5%). button hole in the sclera was seen in 8 cases (4%). uneven and improper scleral 3 tunnel developed in 10 cases (5%), rregular internal corneal valve incision encountered in 21 patients (10.5%). eight (4%) developed hyphema during operation. iris prolapse was seen in 4 cases (2%). iris disinsertion was seen in one case (0.5%), apsular disinsertion with vitreous prolapse encountered in 3 cases (1.5%), apsulotomy extension occurred in 10 cases (5%). the tunnel had to be enlarged in 15 patients (7.5%) where nucleus was unexpectedly hard and large to pass through usual 6mm tunnel. in 5 cases (2.5%) one stitch was applied due to uneven and ragged tunnel and to prevent iris prolapse and anterior chamber collapse (table 2). partial descemet membrane detachment adjacent to the inner corneal valve incision seen in 8 cases (4%). on first postoperative day no wound leakage was seen in any case. no case of wound infection or endophthalmitis was noted. anterior chamber was well maintained and pc iol was in the bag except in 18 cases (9%) where it was tilted or eccentric. eccentric iols were noted in 5 cases (2.5%). tilted iols was noted in three cases (1.5%). striate keratopathy was the most common complication seen in 73 cases (36.5%). this complication was high in initial days of the surgery when the surgeon was in the learning phase. as the time passed by more confidence and expertise gained complication rate and severity declined. now no central corneal edema is seen and mild peripheral keratitis in one in ten cases (1%) which clears in a few days. the wound stability led to quicker rehabilitation and encouraging visual results. on first postoperative day the vision was 6/6 in 23 patients (11.5%) 6/60 in 35 patients (17.5%) with average 6/12 unaided in 142 patients (71%). mean surgically induced astigmatism (defined as the change in the corneal curvature determined by the difference between the preoperative and postoperative keratometry measured by simple subtraction)5,6 was found to be + 1.87d (range + 0.5 to + 3.25d). at the end of 4 weeks postoperatively final correction of glasses was prescribed. after three months of follow up the best corrected visual results were as follows: best corrected visual acuity patients percentage 6/6 49 (24.5%) 91% 6/9 85 (42.5%) 6/12 28 (14%) 6/18 20 (10%) 6/24 13 (6.5%) 9% 6/36 3 (1.5%) 6/60 2 (1%) discussion one of the basic rights of an individual is to have good health facilities within his or her reach and it includes sight. cataract is one of the leading cause of preventable blindness in third world countries and this is due to poverty on one hand and increasing cost of good cataract surgery particularly phaco on the other hand. phaco surgery is difficult to learn because the machine and its accessories are expensive and their maintenance is costly. the ultimate cost is paid by the patients. eye surgeons have been trying to have good alternative to phaco and these attenpts now seem to be successful. non phaco small incision scleral tunnel surgery has considerably encouraging and comparable visual results, low learning curve and cost effectiveness1,2. the complication rate is low and no vision threatening complication is seen showing that the scleral tunnel surgery is relatively safe7. in the study by henning1 the visual results are rewarding and encouraging and are in accordance with the guidelines and recommendations given by world health organization (w.h.o) (table 3) immediate postoperative visual results were low due to keratitis but it was transient and after a few days the cornea became clear and vision improved. this complication and decreased visual results were seen in initial days of learning after a few weeks when the author gained confidence and experience no central corneal edema was seen and visual recovery improved. table 3: w.h.o guide lines and recommendations for postoperative outcome of cataract surgery with intraocular lens implantation. vision outcome uncorrected corrected good 6/6 6/18 80%+ 90% + 4 border line < 6/18-6/60 15% < 5% poor < 6/60 < 5% < 5% conclusion cataract extraction using phacoemulsification is superior to small incision cataract surgery but this is a good alternative in remote rural areas of pakistan where cataract population is high but near to the poverty line. this is the way we can provide our people quality vision care facility at affordable price and at their door steps. author’s affiliation dr. muhammad hashim qureshi al noor eye clinic, gul hospital old municipality road, jacobabad reference 1. hennig a. suturaless non phaco cataract surgery. a solution to reduce world wide cataract blindness. community eye health. 2003; 16: 48. 2. smith jsf. sutureless cataract surgery. principals and steps. community eye health. 2003; 16: 51–3. 3. stamper rl. clinic of north america. 1995; 8: 432–7. 4. lal h, sethi a. manual of phaco technique, text and atlas. cbs publishers delhi india first edition 2003; 42–4. 5. anders n, pham dt, antoni hj. sak w. postoperative astigmatism and relative strength of tunnel incision, a prospective clinical trial. j cataract refract surg. 1997; 23: 6. morlet n, minassian d, dart j. astigmatism and the analysis of its surgical correction. astigmatism and analysis of its surgical correction. br j ophthalmol. 2001; 85: 1127–8. 7. helekamp nm, shigam g. case control study of endophthalmitis after cataract surgery comparing scleral tunnel and clear corneal wound. am j ophthalmol. 2003; 136: 2300-5. 5 pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 252 original article long term follow-up of cases of uveal effusion syndrome treated with partial thickness sclerectomies muhammad tariq khan, sidrah riaz, haroon tayyab, abdul majeed malik pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. muhammad tariq khan ophthalmology department akhtar saeed trust hospital, email: stariq69@hotmail.com …..……………………….. purpose: to report the effect of partial thickness sclerectomy in patients with idiopathic uveal effusion syndrome. study design: interventional case series. place and duration of study: multi-center study at lrbt eye hospital, medicare hospital and mayo hospital, lahore from january 2010 to august2015. material and methods: total six eyes of four patients (two males and two females) with bilateral idiopathic uveal syndrome were included in the study. the diagnosis was clinically confirmed on b scan ultrasonography, which confirmed relatively short axial length, exudative retinal detachment and scleral thickening. the surgical procedure included 360 degrees peritomy, followed by partial thickness sclerotomies measuring 4 x 6 mm placed in between the recti muscles. results: all six (6) patients showed clinical improvement in visual acuity. preoperative visual acuity was perception of light (pl) in all cases which improved to 6/36-6/24 at 12 weeks follow up. on fundoscopy and b scan ultrasound there was resolution of exudative retinal detachment after partial thickness sclerectomies in all cases. the intraocular pressure was high (26 mm hg) in only one case which improved to 18 mm hg at 12 weeks follow-up. all other cases had iop within normal limits pre and post operatively. conclusion: partial thickness sclerectomy is an effective treatment option for patients of uveal effusion syndrome not responding to medical treatment. key words: uveal effusion syndrome, sclerectomy, exudative retinal detachment (rd), intraocular pressure (iop), t was 1958 when von graefe1, verhoeff and waite2 defined spontaneous serous detachment of choroid. in 1963, schepens and brockhurst3 coined the term “uveal effusion”. they reported spontaneous exudative detachment of choroid and ciliary body. in 1982, gass and jallow introduced the term “idiopathic uveal effusion syndrome” (ues) to describe idiopathic serous detachment of choroid, ciliary body and retina4. it is a rare ocular disorder affecting predominantly healthy young males and involvement is commonly bilateral. albumin in the choroidal capillaries draws fluid into blood vessels and maintains relative dehydration of the suprachoroidal space. fenestrated capillaries of the choroid allow albumin to escape into the extra vascular space. to maintain the colloid osmotic gradient, albumin leaves the choroid across the sclera and this trans-scleral protein flow is facilitated by intraocular pressure. this equilibrium is disturbed by neoplastic and inflammatory diseases leading to accumulation of protein, mostly albumin, in the extra vascular space of the choroid. the higher colloid osmotic pressure reduces movement of fluid from the suprachoroidal space into the choroidal capillaries leading to accumulation in suprachoroidal fluid and serous ciliochoroidal effusion. scleral thickness, scleral i mailto:stariq69@hotmail.com muhammad tariq khan, et al 253 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol composition and the number of scleral emissary channels obstructs diffusion of protein out of eye, reduces aqueous flow through uveo-scleral outflow and vortex vein compression in nanophthalmic eyes leading to osmotic pressure gradient, which causes fluid accumulation in the subretinal space, resulting in secondary serous retinal detachment. it is a diagnosis of exclusion. the clinical features are nonrhegmatogenous retinal detachment (rd) with marked shifting fluid. retinal detachment often begins inferiorly like other exudative detachments. fluid accumulation is always more anteriorly because anterior fibers attaching choroid to sclera are long and tangentially oriented whereas posterior fibers are short5. other features are dilated episcleral vessels, blood in canal of schlemm, normal intraocular pressure (iop), elevation of sub retinal fluid protein levels and elevated levels of cerebrospinal fluid (ccf) proteins. striking changes may be evident at level of retinal pigment epithelium with so called “leopard spot” hyper pigmentation3. there is no evidence of intraocular inflammation except from few vitreous cells, which are present occasionally3. the natural history of disease is usually prolonged with remission and without treatment; patients may experience permanent loss of vision. the milder forms usually resolve but visual prognosis for eyes presenting with bullous retinal detachment is poor6. jackson et al revealed that ues can be associated with reduced trans-scleral albumin permeability.7 it is divided into 3 types: type 1 is nanophthalmic eyes and high hyperopic patients. type 2 is nonnanophthalmic eyes with abnormal sclera, normal eyeball and small refractive errors. type 3 is nonnanophthalmic eye with normal sclera. nanophthalmic eyes plus presence of clinically detectable thickened and rigid sclera is a good predictor for histological abnormal sclera and provides good response to surgery8. trelstad et al found that in uveal effusion syndrome, the sclera showed histo-chemical abnormalities: the bundles of collagen fibers in the sclera had a markedly irregular arrangement and varied in width. they also noted abnormal deposition of glycosaminoglycan among the collagen bundles.9 the diagnostic value of ffa and icga and oct is limited in uveal effusion syndrome and serves mostly to exclude other etiologies. spectraldomain optical coherence tomography may show focal thickening of the retinal pigment epithelium layer corresponding to the areas of leopard spots10. it responds poorly to medical treatment like corticosteroids and anti metabolites4 and non-surgical treatment. medical therapy has been described as a possible first step before surgical approach and includes topical prostaglandin analogs and/or oral carbonic anhydrase inhibitors11,12. although brockhurst described good surgical results with decompression of vortex veins, but limitations like difficulty to isolate the veins and vein rupture made this procedure complicated and so was not preferred13. successful surgeries, with no risk/damage to vortex vein, like use of express shunt for choroidal drainage in ues has also been documented14. uyama et al. reported that a small sclerectomy under the scleral flap could be effective in both type 1 and type 2 ues because the abnormal sclera and increased resistance to the trans-scleral outflow of intraocular fluid are thought to be the main causes of these disorders.1 the full-thickness drainage sclerectomy resulted in resolution of ues, including type 3 ues, and a subsequent improvement in visual acuity. the effect may come from indirect decompression of vortex veins by relaxing scleral tension15. some reports have shown that 10 mg dexamethasone given intravenous (iv) prior to surgery also improves the surgical outcome. a recent report showed that combining iv steroids with partial thickness sclerectomies yielded excellent anatomic results. the final visual gains were moderate in this report16. response to surgical options like scleral buckling and pars plana vitrectomy (ppv) is also not convincing. successful retinal re-attachment of nonrhegmatogenous retinal detachment requires a scleral thinning procedure, including quadrantic partial thickness sclerectomies. the purpose of this case series was to study the effect of partial thickness sclerectomy in patients with idiopathic uveal effusion syndrome. materials and methods over the period of five years, six eyes of four patients (2 males and 2 females) with bilateral idiopathic uveal syndrome were included in study. the diagnosis was clinical. they had no evidence of posterior scleritis, orbital inflammatory disease, arteriovenous fistula, recent pan retinal photocoagulation, retinal surgery, recent ocular trauma, ocular neoplasm or drug reaction to sulfonamides or acetazolamide. the surgical procedure included 360 degrees peritomy, followed by partial thickness sclerctomies measuring 4 x 6 mm placed in between the recti long term follow-up of cases of uveal effusion syndrome treated with partial thickness sclerectomies pak j ophthalmol vol. 35, no. no. 4, oct – dec, 2019 254 muscles. the sclerectomies were performed in all quadrants with the anterior border just anterior to the insertion of the recti muscles. all patients were followed up for one week, three weeks and twelve weeks postoperatively. case 1 a young male presented with gradual decrease in vision (perception of light) for last 6 months. his intraocular pressure (iop) was 10 mmhg in both eyes. quadrantic sclerectomies were done in both eyes with 1 week interval. subretinal fluid (srf) was drained in left eye but not in right eye. hypotony was overcome in left eye with intravitreal c3f8 injection after srf drainage. he showed progressive vision improvement over 3 months and his exudative retinal detachment also improved over 12 weeks. case 2 a young female presented with gradual decrease in visual acuity for last 9 months. her visual acuity was light perception (pl) both eyes and iop was 8 mmhg in right and 6 mm hg in left eye respectively. she was wearing hypermetropic glasses of +7 ds in both eyes. her axial length was 19 mm in both eyes. her right eye was operated with quadrantic sclerectomies, her vision improved in that eye. she was advised same surgical procedure for the left eye but she did not report back for left eye surgery after 2 follow up visits. case 3 a 28 years old young lady with bilateral pseudophakia, presented with decreased vision, (counting fingers od and 6/60 os). her record showed iol power was +33 diopters od and +36 diopters os. she was under-corrected per-operatively with a residual post operative refractive error of + 8 d and +10 d glasses. axial length was 18 mm in both eyes. iop was recorded as 15 mmhg on presentation. she had bilateral exudative retinal detachment on b scan. she underwent bilateral quadrantric sclerectomies under general anesthesia. case 4 a 26 years old male presented in opd with gradual decrease in vision. his vision was 6/60 od and 6/12 os. iop was 26 mm hg od and 18 mm hg os. axial length was 18.14 mm od and 18.03 mm os. cd ratio was 0.2 in both eyes. auto refractometer showed hypermetropia of +18 d and +18.5 d. on b scan 360 degrees choroidal detachment was observed in right eye. left eye was normal. results six eyes of four patients were operated and quadrantic sclerectomies was performed in these. the results are shown in table 1. case 1 showed improvement in vision, which was faster in left eye than right eye, in which sclerectomy was accompanied by srf drainage and intravitreal c3f8 gas injection under general anesthesia. his vision improved from pl to 6/24 four weeks postoperatively in left eye and from pl to 6/24 six weeks postoperatively in right eye without srf drainage. his retina was attached in both eyes. he was examined on his last follow-up visit on september 2014 and he had visual acuity of 6/18 with normal iop in both eyes. case 2 was examined one and three weeks postoperatively after sclerectomy under general anesthesia. her vision improved from pl to 6/36 with glasses in her right eye. her retina was attached. she did not return for surgery of the second eye. case 3 was pseudophakic female who was operated for both eyes with an interval of 3 months. quadrantic sclerectomies were done under general anesthesia. she showed gradual visual improvement over a period of 12 weeks. her exudative retinal detachment also improved. case 4 was a hypermetropic male who underwent 2 sclerectomies in superotemporal and inferotemporal quadrant in right eye under local anesthesia and sedation. his vision improved and exudative detachment also improved on b scan. table 1: pre and post-operative visual acuity and iop of the patients. sr. # pre-operative post-operative visual acuity iop (mm hg) visual acuity iop (mm hg) 1 week 3 weeks 12 weeks 1 week 3 weeks 12 weeks case 01 male right eye pl+ve 10 6/36 6/24 6/24 10 10 10 left eye pl+ve 10 6/36 6/24 6/24 12 10 10 case 02 right eye pl+ve 8 6/36 6/36 6/36 10 12 10 muhammad tariq khan, et al 255 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol female left eye pl +ve 10 surgery not done case 03 female right eye pl+ve 8 6/36 6/36 6/36 10 12 10 left eye pl +ve 10 6/36 6/24 6/24 12 12 12 case 04 female right eye pl +ve 26 6/60 6/36 6/36 20 18 18 left eye pl +ve 18 6/12 surgery not done fig. 1: preoperative fundsu picture case 1. fig. 2: first postoperative day case 1. fig. 3: fundus picture – 1 month postoperatively case 1. fig. 4: one of the four quadrant sclerectomies. discussion there are multiple treatment modalities used for treatment of uveal effusion syndrome. some ophthalmologists tried medical treatment for uveal effusion syndrome with oral steroid. shield et al treated 104 eyes of uveal effusion syndrome with corticosteroids17 bausili et al used co2 laser18 and control was achieved in 95% cases in reports but long term follow-up of cases of uveal effusion syndrome treated with partial thickness sclerectomies pak j ophthalmol vol. 35, no. no. 4, oct – dec, 2019 256 according to others, surgical treatment was only effective option for treatment of idiopathic uveal effusion syndrome. we have found that surgical sclerectomies using partial thickness resection was very effective. we operated 6 eyes of 4 patients with idiopathic uveal effusion syndrome. four quadrant sclerectomies in 5 eyes and 2 quadrant sclerectomies in the 6th eye was successful in attaining retinal reattachment. following partial scleral resection all 6 eyes showed improvement in visual acuity. it was comparable with other studies done at other centers in london, usa and bangladesh19,20,21. theories regarding pathogenesis of uveal effusion syndrome suggest that it is more common in nanophthalmic eyes11 where scleral pathology is congenital and abnormally thick sclera compresses vortex veins leading to impeded drainage. similarly, thick sclera is also seen in patients suffering from glycogen storage disease, mucopolysaccharidosis (hunter syndrome) where sclera is thick due to increased deposition of mucopolysaccharides. gass attempted vortex vein decompression in a series of eyes and found that full thickness scleral incisions were effective in causing retinal re-attachment, supporting the hypothesis that it was primarily scleral thickening causing uveal effusion by a barrier effect to diffusion of extra vascular protein (albumin is major protein) out of sclera and obstruction of vortex veins. abnormal scleral composition increases resistance to transcleral protein outflow, which in turn leads to accumulation of protein in extra vascular space of choroid causing higher colloidal osmotic pressure. prostaglandin analogs and steroids have been tried with varying success. surgical management also has various modifications and is usually successful although visual results are moderate. choroidal effusion and non rhegmatogenous retinal detachment can be successfully treated in patients with uveal effusion syndrome by quadrantic partial thickness sclerectomies20,21. the disappearance of serous fluid after partial thickness sclerectomies is consistent with hypothesis that abnormally thick sclera prevents outflow of protein and suggests that removal of excess extra vascular protein may be improved by reducing scleral thickness and resistance to fluid outflow. vortex vein decompression as a possible mechanism of uveal effusion in nanophthalmic eyes following glaucoma filtration surgery was first suggested by schaffer in 197522. in 1980, brockhurst reported successful use of scleral thinning procedure with vortex vein decompression in treatment of nanophthalmic ciliochoroidal effusion23. another case of bilateral ues was reported where the surgeon combined partial thickness scleral flaps with full thickness sclerectomies and reporting stable anatomic and visual results in the follow up period24,25. limitation of our study was the small number of cases. large scale studies need to be conducted to further compare different surgical techniques. we also recommend that surgeons need to review the available literature before contemplating any specific surgical procedure for this rare condition. conclusion given that ues is a very rare disorder, we still do not have clear guidelines regarding its complete management. partial thickness sclerectomy is an effective treatment option for patients of uveal effusion syndrome not responding to medical treatment. financial disclosure there is no financial interest of authors. references 1. von graefe a. zur diagnosis des beginnenden intraocularen krebses. arch ophthalmol. 1858; 4: 21802229. 2. verhoeff fh, waite jh. separation of choroid with report of spontaneous case. trans am ophthalmol soc. 1925; 23: 120-139. 3. schepens cl, brockhurst rj. uveal effusion. i. clinical picture. arch ophthalmol. 1963; 70: 189-210. 4. gass jdm, sulayman j. idiopathic serous detachment of the choroid, ciliary body and retina (uveal effusion syndrome). ophthalmology, 1982; 89: 1018-32. 5. moses ra. detachment of ciliary body – anatomical and physical considerations. invest ophthalmol. 1965; 4:935-41. 6. davies ewg. annular serous choroidal detachment. mod. probl. ophthal. 1979; 20: 2-5. 7. jackson tl, hussain a, salisbury j, sherwood r, sullivan pm, marshall j. transscleral albumin diffusion and suprachoroidal albumin concentration in uveal effusion syndrome. 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eye (lond). 2014; 28 (8): 1028-31. 13. brockhurst rj. vortex vein decompression for nanophthalmic uveal effusion. arch ophthalmol. 1980; 98: 1987–1990. 14. yepez jb, arevalo jf. ex-press shunt for choroidal fluid drainage in uveal effusion syndrome type2: a potentially novel technique. jama ophthalmol. 2015; 133 (4): 470-1. 15. kong m, kim jh, kim sj, kang sw. full-thickness sclerotomy for uveal effusion syndrome. korean j ophthalmol. 2013; 27 (4): 294-298. 16. jin w1, xu y2, wang w1, yang a1. diagnosis and a minimum effective management for nanophthalmic uveal effusion syndrome. indian j ophthalmol. 2016; 64 (8): 593-4. 17. shields cl, roelofs k, di nicola m, sioufi k, mashayekhi a, shields ja. uveal effusion syndrome in 104 eyes: response to corticosteroids-the 2017 axel c. hansen lecture. indian j ophthalmol. 2017; 65: 1093104. 18. bausaili mm, raja h, kotowski j, nadal j, salomoa dr, keenum d, et al. use of fiberoptic guided co2 in treatment of uveal effusion. retina case brief rep. 2017; 11: 191-4. 19. wang bz, clark b, mckelvie p, matthews bj, buttery rg, chandra a, et al. four quadrant sclerectomies for uveal effusion syndrome. eye (lond), 2015; 29: 588-9. 20. ozgonul c, dedania vs, cohen sr, besirli cg. scleral surgery for uveal effusion. retina, 2017; 37: 1977-83. 21. shah pr, yohendran j, hunyor ap, grigg jr, mccluskey pj. uveal effusion: clinical features, management, and visual outcomes in a retrospective case series. j glaucoma, 2016; 25: e329-35. 22. calhoun fp. the management of glaucoma in nanophthalmos. trans. am. ophthalmol. soc. 1975, 73: 98-122. 23. abell rg1, kerr nm, vote bj. bilateral nanophthalmic uveal effusion syndrome: clinical presentation and surgical management. retin cases brief rep. 2013 fall; 7 (4): 386-90. 24. schneiderman te, johnson mw. a new approach to the surgical management of idiopathic uveal effusion syndrome am j ophthalmol. 1997; 123: 262-263. 25. elagouz m, stanescu-segall d, jackson tl. uveal effusion syndrome. surv ophthalmol. 2010; 55: 134-145. author’s affiliation dr. muhammad tariq khan associate professor (ophthalmology) head of vitreoretinal department akhtar saeed trust hospital, lahore dr. sidrah riaz associate professor (ophthalmology) akhtar saeed trust hospital, lahore dr. haroon tayyab assistant professor king edward medical university, lahore dr. abdul majeed malik professor of ophthalmology akhtar saeed medical & dental college, lahore author’s contribution dr. muhammad tariq khan study design, manuscript drafting, data collection, data analysis, performed surgeries. dr. sidrah riaz data collection, data analysis, article writing, manuscript review. dr. haroon tayyab data collection, manuscript drafting, manuscript review. dr majeed malik data analysis, manuscript review. https://www.ncbi.nlm.nih.gov/pubmed/?term=jin%20w%5bauthor%5d&cauthor=true&cauthor_uid=27688282 https://www.ncbi.nlm.nih.gov/pubmed/?term=xu%20y%5bauthor%5d&cauthor=true&cauthor_uid=27688282 https://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20w%5bauthor%5d&cauthor=true&cauthor_uid=27688282 https://www.ncbi.nlm.nih.gov/pubmed/?term=yang%20a%5bauthor%5d&cauthor=true&cauthor_uid=27688282 https://www.ncbi.nlm.nih.gov/pubmed/27688282 https://www.ncbi.nlm.nih.gov/pubmed/?term=abell%20rg%5bauthor%5d&cauthor=true&cauthor_uid=25383821 https://www.ncbi.nlm.nih.gov/pubmed/?term=kerr%20nm%5bauthor%5d&cauthor=true&cauthor_uid=25383821 https://www.ncbi.nlm.nih.gov/pubmed/?term=vote%20bj%5bauthor%5d&cauthor=true&cauthor_uid=25383821 https://www.ncbi.nlm.nih.gov/pubmed/25383821 microsoft word farrukh majeed.doc 192 original article frequency of normal-tension glaucoma in suspected cases of primary open angle glaucoma farrukh majeed, shoaib tauheed, iram saddiqa aamir, alina atif, rehana majeed pak j ophthalmol 2007, vol. 23 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. farrukh majeed 2-c, flat #6, khayaban-e-nishat, 10th street, phase 6, dha, karachi. received for publication december 2006 …..……………………….. purpose: to study the frequency of normal-tension glaucoma (ntg) in suspected cases of primary open angle glaucoma (poag). materials and methods: a descriptive cross-sectional study was done of 150 patients who attended the glaucoma clinic during one year from january 2005 to january 2006. a detailed history was obtained and a thorough ophthalmic examination was performed, including gonioscopy, ophthalmoscopy, applanation tonometery and automated perimetery. results: out of 150 patients of poag 33 patients (22%) were found to have ntg with mean age 56 ±9.21 years. mean age of poag group was 52.5% (±8.7). of the 33 cases of normal-tension glaucoma 22 patients (66.6%) were male and 11 cases (33.4%) were female, while in poag 82(70%) were male and 35 (30%) were female. family history of glaucoma was positive in 42% of ntg cases and 32% of poag. 82% of ntg and 79.4% of htpoag population were ametropic, with mean cup-to-disc ratio 0.5 ±0.24 and mean iop was 15.13 ± 3.60 mmhg in ntg and 28 mmhg (±6.5), 0.46 (±0.22) in poag. maximum iop in ntg group was 21 mmhg and minimum iop was observed as 08 mmhg, while these values observed as 50 mmhg and 10 mmhg respectively in poag. decreased vision was main complaint of ntg patients, headache was observed in maximum number of poag patients. conclusion: ntg remains a difficult diagnosis for ophthalmologist who favors the argument that raised iop is essential for the diagnosis of poag. ntg changes the definition of glaucoma and our concept of iop as a sole etiological factor is now out dated. the overall frequency of ntg in the current study was 22% among suspected cases of poag. laucoma is the second leading cause of blindness world wide1. glaucoma cases are expected to hit 80 million by 2020; of these 74% will have primary open angle glaucoma2 (poag). poag is an asymptomatic, progressive optic neuropathy characterized by enlarging optic disc cupping and visual field loss3. it has been proven by many studies3,4 that poag exhibits two patterns of visual field defects: a relatively diffuse and putatively more intra ocular pressure (iop) dependant type and a localized and putatively less iop dependent type. g 193 normal-tension glaucoma (ntg) is a variety of poag clinically defined5 as “a condition in which iop is less than 21mmhg associated with typical glaucomatous optic neuropathy and corresponding visual field changes”. in glaucoma iop is a major risk factor in the development and progression of disease, however, in ntg other risk factors are considered more important, as iop, by definition, remains within statistically normal limits6,7. we can say that, ntg is simply a form of poag in which one of the sign (iop) is absent3. ntg comprises a significant proportion of the generic grouping of poag, although this proportion varies between samples and possibly between different populations8. many studies have been done regarding ntg. according to those studies frequency of ntg is not low accounting for one third of poag in west9, 11 and two third among japanese at the time of screening12. however, in our country we still lack epidemiologically valid data on ntg. purpose of this study is to find out the frequency of ntg among suspected cases of poag. material and methods this was a cross-sectional study of descriptive type, conducted in the department of physiology, dow university of medical and health sciences karachi, civil hospital karachi in collaboration with glaucoma clinic at al-ibrahim eye hospital karachi. out of all glaucoma patients who visited glaucoma clinic from january 2005 to january 2006, those who satisfied the following criteria were included in this study. • open angles of drainage. • glaucomatous cupping of optic nerve head and loss of neuroretinal rim. • visual field defects compatible with glaucomatous cupping. • absence of any secondary cause for glaucomatous optic neuropathy. • patients of ntg having iop less than 21mmhg without any treatment, after confirmation by visual field analysis with humphrey field analyzer. those with cataract or any other eye disease producing optic neuropathy, congenital eye diseases, or previous medical, surgical or laser treated eyes were excluded from this study. in all the patients presenting with history of glaucoma in glaucoma clinic visual acuity was checked using snellen’s chart, after that eyes were examined using slit lamp to visualize anterior chamber of eye as well as interior of the eye either by using contact lenses or direct ophthalmoscope. although contact lenses provide good view of chamber angles8, but to confirm the diagnosis a separate gonio lens was used. later in all those patients with open angles and glaucomatous optic disc changes iop was measured using goldmann applanation tonometer. visual field were analyzed by the help of humphrey visual field analyzer using 30-2 program, after calibration and standardizations according to manual of manufacturer. consent of all patients was taken and confidentiality maintained. a detailed questionnaire of all patients was filled, this individual record sheet of the patients were than processed for data analysis. the data collected for present study was entered and verified by using the spss version 10.0 software packages. descriptive statistics were computed. relative frequencies (percentages) of groups were shown, result expressed as mean ± sd/sem. results a total of 150 patients of all ages and both sexes were selected by convenient sampling. out of these patients one hundred and four were male (69.4%) and forty six were female (30.6%). in ntg group 22 (66.6%) were male and 11 (33.4%) were female, while in poag 82(70%) were male and 35 (30%) were female. from these, ntg was found to be present in 33 cases (22%) of poag cases, while rest of the population of nonntg group is from high tension primary open angle glaucoma (htpoag) 117 cases (78%) (table 1). age ranges from 35-75 years in study population and mean age was found to be 56 years (±9.21) in the group of ntg and 52.5% (±8.7) in htpoag group. comparison of frequencies of various age groups among ntg and htpoag was described in table 2. family history of glaucoma was positive in 42% of ntg patients and 32.4% in htpoag groups (table 2). ocular examination revealed that 82% of ntg and 79.4% of htpoag population were ametropic. mean cup-to-disc ratio was 0.5 (±0.24) in ntg and 0.46 (±0.22) in htpoag group. cup-todisc ratio more than 0.5 was observed in about 64% eyes with ntg and 34% with htpoag (table 3). mean iop in ntg group was 15.13 mmhg (±3.60) while it was 28mmhg (±6.5) in htpoag group. maximum iop level in ntg was 21mmhg and in htpoag it was found as high as 50 mmhg, minimum iop level was as low as 8 mmhg 194 and 10 mmhg in ntg and in htpoag respectively (table 3). maximum number of patients with ntg presented with decreaseed vision (42%), while headache was the main complaint (25%) among htpoag group (fig. 1). discussion the type of poag with normal iop levels was first observed in 1875 by a great ophthalmologist von grafes12. since the introduction of term ntg for such type of low-pressure glaucoma, it was subject of debate among many ophthalmologists who favors the argument that raised iop is essential for diagnosis of poag13. table 1:.demographics of study population ntg* group n= 33 htpoag** group n= 117 age (years) mean 56 52.5 sd ±9.21 ±8.7 minimum 37 35 maximum 75 75 male 22(66.6) 82(70) female 11(33.4) 35(30) positive family history of glaucoma 14(42.4) 38(32.4) table 2: comparative analysis of frequency of ntg and htpoag in various age groups age(years) ntg * group n (%) htpoag ** group n (%) ≤40 3(9) 20(17) 40.1-50 5(15) 30(25) 50.1-60 15(46) 57(49) >60 10(30) 10(9) in our study out of total 150 patients of poag 33 patients (22%) have iop less than 21mm hg and 117(78%) patients had iop more than 21mm hg. so the prevalence of ntg was about 22% in our study. according to another study carried out in japan the incidence of glaucoma was much higher than the rest of the world. it has been reported that prevalence of ntg among japanese at the time of screening was accounting for two third of cases, i.e. 2% of japanese total population14. according to tajimi a study carried out in japan by iwase et al included randomly selected subjects of more than 40 years13. among these 3021 participants prevalence of poag is 3.9% out of which 92% of patients had iop less than 21 mmhg which is about 3.6% of total population examined. this incidence is much higher than our results but this shows that prevalence of ntg is highest in japan probably because of their tendency for iop to fall with increasing age15 instead of lowering down like rest of the world. table 3: occular examination of study population ntg* group htpoag** group ametropic 27(82) patients 93(79.4) patients cup-to-disc ratio mean 0.5 0.46 sd ±0.24 ±0.22 ≤0.5 42(63.6) eyes 79(33.7)eyes >0.5 24(36.3) eyes 155(66.2) eyes mean iop 15.13 mmhg 28mmhg sd ±3.60 ±6.5 minimum 8 mmhg 10 mmhg maximum 21 mmhg 50 mmhg 195 9% 25% 15.50% 15.50% 20% 12.50% 12.50% 15% 9% 42% 12%12% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% decrease vision headach pain in eyes watering of eyes frequent changes in glasses others ntg htpoag fig. 1: frequencies of various presenting occular symtoms in ntg and htpoag** groups *ntg = normal-tension glaucoma **htpoag= high tension primary open angle glaucoma in the west incidence of ntg is not low, accounting for one third to half of poag cases16. sommer17 states that 20-25% of glaucomatous neuropathy develops with normal iop; this incidence is very near to our study. in rotterdam study, which was a population based study carried out in netherlands, out of 3062 eligible participants of 55 years of age or older, the over all prevalence of poag was 1.10%. of these patients about 39% had iop less than 21 mm hg18 with male predominance. the results of this study are comparable to ours, in our study frequency of ntg among individuals between 50 to 60 years is 46% and 30% in patients more than 60 years of age. the swedish dalby study found ntg in 61% of the total poag cases19. in another population based survey carried out in same set up including 760 people 65 to 74 years of age, 18% of individuals of poag had iop less than 21 mmhg20. in the barbados eye study21 including 3427 patients, about half of the newly diagnosed poag patients had iop less than 21 mmhg which are about 1.2% of total population. in this study incidence rate of poag increased from 1.25% at ages 40 to 49 years to 4.2% at ages of 70 years or more, tending to be higher in men than women (2.7% vs 1.9%). this study revealed high risk of low pressure poag in the population of african origin, especially in older adults. in our present study incidence of both poag and ntg increased with age as observed in this study, though the incidence of ntg was much higher than our study but in barbados study participation rate is different though the diagnostic criteria were same. the incidence of poag in patients attending glaucoma clinic in a major eye hospital in india22 is much less than angle closure glaucoma (acg) (37:63), ntg accounting for 0.62% hospital referral, peak presentation in seventh decade. mean age for presentation was 60.04 years, with male representing 74% cases. a remarkably low number of ntg cases were noted in this study as compare to rest of the world including ours, may indicate that most of the population were affected by acg and over all rate of poag is less. though there is male predominance like our study but the mean age is bit more than ours indicating delay in diagnosis. according to another study23 carried out at alshifa eye hospital islamabad, among total hospital admissions ntg was responsible for 3.0% of total hospital visit. this study did not explain frequency of ntg among poag cases and demographics of study population, so lacking much valuable knowledge in this respect. it is believed that ntg occurs more commonly and severely in women, levene review of the relevant studies found an over all higher female prevalence ranging from 6% to 75%6. the beaver dam eye study24 found equal prevalence among both genders. there is a preponderance of females in moorfield normal-tension glaucoma group with a ratio of 2:1 in all age groups13, while in low-pressure glaucoma treatment study25 out of 190 patients with ntg 60% were females. in another study carried out in moorfield eye hospital by noureddin et al26, out of 84 patients with low-tension glaucoma 69% were females. fontana et al27, also found the same in their clinical study on 54 patients out of which 34 (63%) patients were females. these studies show that prevalence of ntg is more among females than male glaucoma patients, which is not seen in our study. although one study indicated that in younger samples, newly diagnosed males with normal-tension glaucoma may show more severe field loss than in similar age females28. in our study there are more (22, 64%) males with normal-tension glaucoma than females (11, 26%). this may be because of our socio-economic setup and lack of visits to hospitals by females. the incidence of normal-tension glaucoma increases with age13. in our study mean age for normaltension glaucoma was 56 years (range 37-75 years). 196 while fontana et al27, reported mean age around 59 years, lake et al29, reported 70 years, plange et al30, considered 51 years, noureddin et al26, found 66 years, krupin et al25, found mean age around 65 years. ntg is considered as a disease of elderly8, in our study only 9% of the patients were below the age of 40 years, 15% between 41 to 50 years, while maximum incidence of disease 46% were between 51 to 60 years and 30% were more than 60 years of age. in the beaver dam eye study24 the prevalence of ntg increases from 0.2% in 43 to 54 years of age group to 1.6% in those over 75 years of age. however, there is significant minority of the patients who are below the age of 50 years. while in japan, shiose et al14, observe that four times as many patients in the over 40 year age group have ntg as having htg, accounting for 2% of the total japanese population. this theory was also supported by beaver dam eye study24 but its frequency is less than that in japan. aung t et al31 found in their study carried on 108 normal-tension glaucoma patients that 66 patients were more than 60 years of age while only 42 were less than 60 years category. in an italian study 40 years of age found a prevalence of 0.6%, showing that 33% had ntg out of poag10. like many other diseases glaucoma runs in families, several cases of both ntg and htpoag may occur in the same family12. the presence of a positive family history of glaucoma has been reported in 5% to 40%11. there appear to be a genetic component related to the development of ntg31,32. the molecular mechanism underlying ntg is still unknown. a study carried out to find out the phenotype of ntg patients with and without opa1 polymorphism suggested that, out of 108 patients with ntg positive family history was present in (35 cases) 32.4%31. in another study carried out by anderson et al33, out of 136 patients with ntg positive family history of glaucoma was present in 53 cases (39%). in our study family history of glaucoma was positive in 42% of the cases with ntg while in htpoag family history was positive in 32.4% of the cases. this may prove that ntg runs in families with history of glaucoma. though numerous data presented regarding frequency of poag throughout the world, thorough investigation regarding ntg is still required. follow up of these patients is very important to observe the pattern of progression of disease and differentiate ntg from other forms of glaucoma at different stages of disease. public awareness on normal-tension glaucoma should be increased to address the challenges of disease and similar studies should be conducted in other areas to establish frequency of ntg in various cities of our country. author’s affiliation dr. farrukh majeed physiology department dow university of health sciences, karachi prof. dr. shoaib tauheed head department of physiology dow university of health sciences, karachi dr. iram saddiqa aamir head department of physiology dow university of health sciences, karachi dr. alina atif head department of physiology dow university of health sciences, karachi dr. rehana majeed assistant professor, department of pediatrics isra university hospital, hyderabad reference 1. resnikoff s, pascolini d, ale de, et al. global data on visual impairment in the year 2002. bull of who 2004; 82: 844-51. 2. quigley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j opthalmol. 2006: 90: 262-7. 3. distelhorst js, hughes gm. open angle glaucoma. am fam physician. 2003; 67: 1937-44. 4. schulzer m, drance sm, carter cj, et al. biostatistical evidence for two distinct chronic open angle glaucoma populations. br j ophthalmol. 1990; 74: 196-200. 5. baig ma, akram a, ishaq m, et al. normal tension glaucoma errors in diagnosis. pak j ophthalmol. 2002; 18: 23-5. 6. levene rz. low tension glaucoma: a critical review and new material. surv ophthalmol. 1980; 24: 621-64. 7. hitchings ra. low tension glaucoma –its place in modern glaucoma practice. br j ophthalmol. 1992; 76: 494-6. 8. anderson dr, drance sm, schulzer m. collaborative normal tension glaucoma study group. natural history of normal tension glaucoma. ophthalmology 2001; 108: 243-53. 9. kroese m, burton h. primary open angle glaucoma. the need for a consensus case definition. epidemiol community health. 2003; 57: 752-4. 10. bonomi l, marchini g, marraffa m, et al. prevalence of glaucoma and intra ocular pressure distribution in a defined population. the egna-neumarkt study. ophthalmology 1998; 105: 209-53. 11. iware a, suzuki y, araie m, et al. the prevalence of primary open angle glaucoma among japanese. the tajimi study. ophthalmology 2004;111: 1641-8. 12. weingeist ta, liesegang tj, grand mg, et al. glaucoma. basic and clinical science course, san francisco. american academy of ophthalmology. 1999; 5: 22-54. 13. kamal d, hitchings ra. normal tension glaucomaa practical approach. br j ophthalmol. 1998; 82: 835-40. 197 14. shoise y, kitazawa y, tsukahara s, et al. epidemiology of glaucoma in japan-a nation wide glaucoma survey. jpn j ophthalmol. 1991; 35: 133-55. 15. nakano t, tatemichi m, miura y, et al. long term physiological changes of intra ocular pressure: a 10-year longitudinal analysis in young and middle aged japanese men. ophthalmology 2005; 112: 609-16. 16. hollow fc, graham pa. intra ocular pressure, glaucoma, and glaucoma suspect in a defined population. br j ophthalmol. 1996; 50: 570-86. 17. sommer a. doyne lecture. glaucoma: facts and fancies. eye 1996; 10: 293-301. 18. dielemans i, vingerling jr, wolfs rcw, et al. the prevalence of primary open angle glaucoma in and population based study in the netherlands. the rotterdam study. ophthalmology. 1994; 101: 1851-5. 19. bengtsson b. the prevalence of glaucoma. br j ophthalmol. 1981; 65: 46-9. 20. ekstrom c. prevalence of open angle glaucoma in central sweden. the tierp glaucoma survey. acta ophthalmol scand. 1996; 74: 107-12. 21. leske mc, connell am, nemesure b, et al. incidence of open angle glaucoma: the barbados eye studies group. arch ophthalmol. 2001; 119: 89-95. 22. jaychandra d, sharad b, zia c, et al. profile of glaucoma in a major eye hospital in north india. indian j ophthalmol. 2001; 49: 25-30. 23. malik nm. related incidence of different types of glaucoma in pakistan. al-shifa med bull. 1995; 1: 4-5. 24. klein bek, klein r, spansel we, et al. prevalence of glaucoma: the beaver dam eye study. ophthalmology 1992; 99: 1499-504. 25. krupin t, liebmann jm, greenfields ds, et al. the low pressure glaucoma treatment study (logts) study design and baseline characteristic of enrolled patients. ophthalmology 2005; 112: 376-85. 26. noureddin bn, poinoosawmy d, fietzke fw, et al. regression analysis of visual field progression in low tension glaucoma. br j ophthalmol. 1991; 75: 493-5. 27. fontana l, armas r, poinooswamy d, et al. unilateral field loss in normal tension glaucoma-a longitudinal followup study. invest ophthalmol vis sci. 1997; 2631: 321-5. 28. shiraki r, uchida h, ishida k, et al. difference of optic disc topography between low-tension group and high-tension group in normal-tension glaucoma patients. nippon ganka gakkai zasshi. 2005; 109: 19-25. 29. lake s, liverani e, desai m, et al. normal-tension glaucoma is not associated with the common apolipoprotein e gene polymorphisms. br j ophthalmol. 2004; 88: 491-3. 30. plange n, remky a, arend o. colour doppler imaging and fluorescein filling defects of the optic disc in normal-tension glaucoma. br j ophthalmol. 2003; 87: 731-6. 31. aung t, okada k, poinoosawmy d, et al. the phenotype of normal tension glaucoma patients with and without opa1 polymorphism. br j ophthalmol. 2003; 87: 149-52. 32. razaie t, child a, hitchings r, et al. adult onset primary open angle glaucoma caused by mutations in optineurin. science. 2002; 295: 1077-9. 33. anderson dr, drance sm, schulzer m. factors that predict the benefit of lowering intra ocular pressure in normal-tension glaucoma. the collaborative normal-tension glaucoma study group. am j ophthalmol. 2003; 136: 820-9. microsoft word ayyaz hussain article.doc 126 original article comparison of analgesia in subtenon and peribulbar anesthesia ayyaz hussain awan, abdul rauf pak j ophthalmol 2007, vol. 23 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ayyaz hussain awan eye department pns hafeez, (naval hospital) sector e-8, islamabad received for publication september’ 2006 …..……………………….. purpose: to compare degree of analgesia in subtenon and peribulbar local anesthesia in patients undergoing extra capsular cataract surgery. material and methods: quasi-experimental interventional study carried out in department of ophthalmology, pns shifa, karachi extending from october 2004 to march 2005. 100 patients undergoing extra capsular cataract extraction were randomly divided into two groups comprising 50 patients each. group i was given subtenon and group ii peribulbar local anesthesia respectively. patients were asked about pain scoring during surgery and degree of analgesia was marked on a specified performa. results: analgesia was effective and immediate with minimal volume of anesthetic agent and procedure was less painful in subtenon local anesthesia as compared to peribulbar local anesthesia. there is no need for globe compression and preoperative sedation. the use of topical anesthesia prior to subtenon local anesthesia makes this technique almost pain free. incidence of top up anesthesia is less in subtenon anesthesia then in peribulbar anesthesia. conclusion: the subtenon anesthesia is more effective with fewer complications as compared to peribulbar anesthesia due to the cannula used being blunt and the infiltration being superficial as compared to peribulbar route. urgery of the lens has been practiced for at least several thousand years. nowadays cataract extraction by phacoemulsification is the most popular technique, but due to cost of the machine and long learning curve, extra capsular cataract extraction (ecce) is still being practiced in large number of centers in our country. current discussion in the ophthalmic literature suggests an increased interest in various techniques of local anesthesia and day case surgery1, as the outcome of day case and routine surgery are the same2,3. retrobulbar block (rb) with injection inside and peribulbar block (pb) with injection outside the muscle cone respectively, are the two most commonly used techniques4 of local anesthesia. due to various complications encountered in rb it is being progressively replaced by pb. subtenon infiltration (st) anesthesia is another type of local anesthesia in which anesthetic agent is delivered into subtenon space by a blunt cannula, topical anesthesia is used prior to infiltration making it almost pain-free. it is safe and effective as compared to rb5 and pb6. complete akinesia is rare and this is sometimes limiting7 however the addition of hyaluronidase significantly improves the quality of motor blockade achieved with st8. topical anesthesia (ta) is in extremely wide use nowadays for intraocular surgery9 however the intraoperative pain and discomfort is more marked as compared with paraocular block10. patient’s cooperation in ta is extremely important because there is no akinesia. s 127 materials and methods a quasi-experimental interventional study was designed in department of ophthalmology, pns shifa, karachi to compare the degree of analgesia in st and pb, in patients undergoing ecce. the subjects included in the study comprised of armed forces personals and their families. duration of the study was 6 months (october 2004 to march 2005) using non probability convenience sampling of first 100 patients between the ages of 5065 years requiring cataract extraction with posterior chamber intraocular lens (pciol) implantation. patients less then 50 years of age, suffering from diabetes mellitus or any other systemic disease and those with a known history of adverse reaction to lignocaine were excluded from the study. the degree of analgesia in both types of local anesthesia was measured on the basis of grading mentioned as under: 0=no pain, no sensation 1=slight sensation or discomfort but no pain 2=slight pain 3=moderate pain 4=intense pain a comprehensive performa was devised to record patient’s particulars, the technique of local anesthesia and for pain scoring. the 100 patients selected were randomly divided into two equal groups, each comprising 50 patients. group i, was given a 2-3ml mixture (2:3) of 2% xylocaine and 0.75% bupivacaine st anesthesia and group ii, was given a mixture (2:3) of 2% xylocaine and 0.75% bupivacaine by pb technique with facial block (van lint method). need for supplement anesthesia was also recorded. groupwise data collected from these hundred patients was included for final analysis. for the st anesthesia, after four drops of topical anesthetic, the patient’s eye was prepared, draped and lid speculum inserted. in the inferonasal quadrant, 10mm posterior to the limbus, blunt subtenon cannula was slided into the subtenon space through a buttonhole made in conjunctiva and tenon’s capsule and 2-3ml of local anesthetic was injected and pad applied for 3-4 minutes. the pb anesthesia was delivered by two point technique. facial block was given by van lint technique. the orbit was entered at the junction of lateral 1/3 and medial 2/3 of lower lid, just above the orbital margin keeping the 25g needle bevel facing the globe. 1-2 ml of anesthetic solution (2:3 mixture of 2% xylocaine and 0.75% bupivacaine) was injected anterior to the equator and another 4-5 ml past the equator out side the muscle cone. then superior to eye ball at the junction of lateral 2/3 and medial 1/3 of upper eye lid, 1.5-2 ml of anesthetic solution was injected. eye padded and pressure bandage was applied for 15-20 minutes. computer based spss 8.0 was used to analyze the results. frequency and percentages were computed to present all categorical variables including m:f for presentation of gender, degree of analgesia and augmentation of anesthesia needed. chi square test was applied to compare sex and degree of analgesia between the two groups. fisher’s exact test was applied to compare augmentation of anesthesia needed between two groups of patients. statistical significance was assumed at p<0.05. age was presented by mean ± sd and t-test (unpaired) was used to compare it between the two groups. results there were 50 patients in group-i who received st and 50 patients in group-ii that received pb anesthesia. the two groups were almost similar in terms of age and sex distribution. the mean age in group i was 58.78 years ± 2.65 and in group ii it was 58.25 years ± 2.19. the female: male ratio in group i was 1:1.94 and in group ii was 1:2.12. so in term of female: male ratio and age distribution there was no significant difference between the two groups (table 1). 32 patients in group i and 12 patients in group ii did not experience any pain or discomfort during surgery, 14 patients in group i and 22 patients in group ii experienced slight discomfort but no pain, 3 patients in group i and 12 patients in group ii had slight pain and 1 patient in group i and 4 in group ii had moderate intensity of pain during surgery (table 2). there was statistically significant difference in pain score between two groups (p=0.001). the degree of analgesia was better with st anesthesia than with pb anesthesia (table-2). one patient in group i and 7 patients in group ii required supplement anesthesia (table 4). the delivery of supplement anesthesia was by the same technique. here again significantly less number of patients in st group required supplement anesthesia as compared to pb anesthesia. the mean volume of anesthetic agent used was significantly less in st anesthesia than in pb anesthesia (p < 0.001). 128 table 1: age and sex distribution parameters group i group ii age mean (± sd) 58.78 (± 2.65) 58.25 (± 2.19) sex male female male female 33 17 34 16 table 2: study results grading of analgesia group i n (%) group ii n (%) no pain, no sensation 32 (64) 12 (24) slight sensation or discomfort but no pain 14 (28) 22 (44) slight pain 3 (6) 12 (24) moderate pain 1 (2) 4 (8) total 50 (100) 50 (100) during administration of pb anesthesia majority of patients experienced moderate to severe intensity of pain. the use of few drops of topical anesthesia prior to st anesthesia made this technique almost pain free and the anesthesia was immediate. analgesia was effective, immediate, anesthetic volume minimal and procedure less painful in st as compared to pb, anesthesia technique. there was no need of globe compression and no preoperative sedation was necessary. incidence of top up anesthesia was less in st then in pb anesthesia. no patient suitable for pb anesthesia was found unsuitable for st anesthesia. table 3: efficacy of block group 1 n (%) group ii n (%) total n (%) block successful 49 (98) 43 (86) 92(92) augmentation 1 (2) 7 (14) 8 (8) total 50 (100) 50 (100) 100(100) in complications, conjunctival chemosis and mild subconjunctival hemorrhage occurred in 05 patients in st anesthesia in our study. this complication reduced as the study progressed and further control of conjunctival chemosis and subconjunctival hemorrhage can be ensured if the anesthetic solution is truly delivered into the subtenon space and not in to the anterior subconjunctival space. however these complications did not affect the visual outcome and resorbed in 5-7 days. in pb group 1 patient developed post operative ptosis which settled with conservative treatment. discussion retrobulbar anesthesia was first described in 1884 when hermann knapp used a cocaine injection posterior to the globe to perform an enucleation. it provides akinesia of the extraocular muscles by blocking cranial nerves iii, iv, and vi and anesthesia of the conjunctiva, cornea, and uvea by blocking the ciliary nerves. due to the complications of rb block like retrobulbar hemorrhage, globe perforation, injury to optic nerve, extraocular muscle and elevator muscle, central nervous system symptoms like disorientation, unconsciousness, convulsions and respiratory arrest, it has been progressively replaced by pb anesthesia first described by davis & mandel in 198611. in pb anesthesia, anesthetic solution is delivered by a relatively short and sharp needle outside the muscle cone12 farther the globe, optic nerve, dural sheaths and optic foramen13. however imperfect blockade requires supplemental injections. a larger volume of anesthetic (6-10 ml) is deposited into the orbit, which may initially result in tense eyelids. ocular compression is then used to help spread the anesthetic and soften the globe. pb anesthesia, while providing effective analgesia and akinesia, also has been associated with unique complication of a brown’s syndrome and other rare ocular complications14. in addition, preoperative intravenous sedation is often required because patients find the injection painful and frightening. recently there has been renewed interest in st anaesthesia15,16 first described as early as 1884 by turnbull17. subtenon technique is efficient, simple, easy to learn, reproducible and has low rate of complications18. hyaluronidase is added to anesthetize a greater area with the same amount and concentration of anesthetic agent, and to reduce the induction time. hyaluronidase, an enzyme, catalyses the depolymerization of hyaluronic acid to a tetrasaccharide and potentially increases diffusion of local anesthetic through tissue planes. the analgesic 129 effect of st anesthesia is dose dependant and 3ml is the optimal dose19. pain relief is better than by pb anesthesia as was proved by kollarits et al. 20, briggs et al.21 and vanden berg in 200422 in their respective studies. conclusion in this study two independent samples matched for age, gender and diagnosis were randomized to receive either standard 2-point pb or st anesthesia. keeping in view the results of our study and other studies it is found that st anesthesia provides better analgesia than pb anesthesia. it can be used as a good alternative to pb and rb anesthesia in both anterior and posterior segment surgery. another study is required, to see to what extent and by which means akinesia by st anesthesia can be improved. author’s affiliation surg cdr ayyaz hussain awan classified eye specialist eye department pns hafeez, (naval hospital) sector e-8, islamabad surg lt cdr abdul rauf senior registrar eye department pns shifa, karachi reference 1. iqbal z, baig ma. the effect of hyaluronidase on the quality of ocular akinesia in subtenon local anesthesia in cataract surgery: a hospital based study. pak armed forces med j. 2003; 53: 1647. 2. strong np, wigmore w, smithson s, et al. day case surgery. br j ophthalmol. 1991; 75: 731-3. 3. davies b, tyers ag. do patients like day case cataract surgery? br j ophthalmol. 1992; 76: 262-3. 4. mudassir m, butt kj, zaidi n, et al. a comparison of peribulbar and retro bulbar anesthesia in cataract surgery. ann ke med coll. 2000; 6: 399–400. 5. khoo bk, lim th, yong v. subtenant’s versus retro bulbar anesthesia for cataract surgery. ophthalmic surg lasers. 1996; 27: 773-7. 6. azmon b, alster y, lazar m, et al. effectiveness of sub tenon’s versus peri bulbar anesthesia in extra capsular cataract surgery. j cataract refract surg. 1999; 25: 1646-50. 7. la marnierre e, mage f, alberti m, et al. comparison between greenbaum’s parabulbar anesthesia and ripart’s subtenon anesthesia in the anterior segment surgery. j fr ophthalmol. 2002; 25: 161-5. 8. rowley sa, hale je, finley rd. sub-tenon’s local anesthesia: the effect of hyaluronidase. br j ophthalmol. 2000; 84: 435-6. 9. roman s, auclin f, ullern m. topical versus peribulbar anesthesia in cataract surgery. j cataract refract surg. 1996; 22: 1121-4. 10. uusitalo rj, maunuksela el, paloheimo m, et al. converting to topical anesthesia in cataract surgery. j cataract refract surg. 1999; 25: 432-40. 11. davis db, mandel mr. posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia. j cataract refract surg. 1986; 12: 182-4. 12. marianne ef. anesthesia: atlas of complications in ophthalmic surgery .1st ed. 1993; 1: 7-18. 13. weiss jl, deichman cb. a comparison of retrobulbar and periocular anesthesia for cataract surgery. arch ophthalmol. 1989; 107: 96-8. 14. davis db, mandel mr. efficacy and complication rate of 16224 consecutive peribulbar blocks, a prospective multi-center study. j cataract surg. 1994; 20: 327–37. 15. hansen ea, mein ce, mazzoli r. ocular anesthesia for cataract surgery: a direct subtenon’s approach. ophthalmic surg 1990; 21: 696–9. 16. greenbaum s. parabulbar anesthesia. am j ophthalmol 1992; 114: 776. 17. turnbull cs. the hydochlorate of cocaine, a judicious opinion of its merits. (editorial) med surg rep (boston). 1884; 29:628–9. 18. merle h, suchocki d, donnio a, et al. evaluation of single injection caruncular sub-tenon’s anesthesia. j fr ophthalmol. 2002; 25: 130-4. 19. tokuda y, oshika t, amano s, et al. anesthetic dose and analgesic effects of sub-tenon’s anesthesia in cataract surgery. j cataract refract surg. 1999; 25: 1250-3. 20. kollarits cr, jaweed s, kollarits fj. comparison of pain, motility and preoperative sedation in cataract phacoemulsification patients receiving peribulbar and subtenon’s anesthesia. ophthalmic surg laser. 1998; 29: 462-5. 21. briggs mc, beck sa, esakowitz l. sub-tenon’s versus peribulbar anesthesia for cataract surgery. eye 1997; 11: 639-43. 22. van den berg aa. an audit of peribulbar blockade using 15mm, 25mm and 37.5mm needle and subtenon’s injection. anesthesia. 2004; 59: 775-80. 30 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology original article effect of blood pressure on intraocular pressure in primary open angle glaucoma uzma fasih, erum shahid, arshad sheikh pak j ophthalmol 2017, vol. 33 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr.uzma fasih associate professor, eye department, karachi medical & dental college abbasi shaheed hospital karachi email: yousufuzma@hotmail.com …..……………………….. purpose: to determine the effect of change in blood pressure on intraocular pressure in primary open angle glaucoma patients coming to a tertiary care hospital. study design: cross sectional descriptive study. place and duration of study: ophthalmology department karachi medical and dental college abbasi shaheed hospital from january 2015-june 2016. material and methods: patients were registered through non probability consecutive sampling technique. patients with primary open angle glaucoma were included, secondary and angle closure glaucoma were excluded. intraocular pressure and blood pressure was recorded. data was collected and analyzed by using statistical package for social sciences (spss 21). kruskal wallis test was used to compare systolic blood pressure with median intraocular pressure of both eyes. mann whitney test was used to compare diastolic blood pressure with median intra ocular pressure of both eyes. results: there were 379 patients with mean age of 59.68 ± 11.37 sd. males were 188 (49.6%). mean iop of right eye was 18.00 mm hg ± 5.81 and left eye was 19 mm hg ± 5.87. the median difference in inter quartile range (iqr) of iop with systolic blood pressure category > 140 mm hg was 18 (16 – 19) mm hg for right eye (p<0.001) was statistically significant. the median difference in iqr of iop at diastolic blood pressure category 90–110 mm hg was 18 (16 – 22) mm hg for right eye and was also statistically significant. median iqr of iop right and left eye in males were statistically not significant as compared to females (0.908 & 0.978). conclusion: the intraocular pressure in primary open angle glaucoma patients increased with increase in blood pressure. key words: primary open angle glaucoma, diastolic blood pressure, systolic blood pressure, intraocular pressure. lthough the effect of iop in poag is not clearly understood but increased iop has always been one of the major risk factors in development and progression of poag. almost all the experimental models for glaucoma show involvement of raised iop. many studies have given an improved understanding of the risk factors involved in poag. recently many new risk factors have been discovered which include thin central corneas, blood pressure and dibetes mellitus1,2. effect of low or high blood pressure in developing poag is not clearly understood. however the blue mountain eye study3, egna neumarkt glaucoma study4 and rotterdam eye study5 reported that patients of systemic hypertension are vulnerable to develop poag. in cases of chronically elevated blood pressure, rise in peripheral resistance and small vessal pathology can decrease optic nerve head perfusion. a effect of blood pressure on intraoculr pressure in primary open angle glaucoma pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 31 on the other hand in light of vascular theory of development of poag decrease in bp particularly during elevated intraocular pressure can change optic nerve head perfusion pressure leading to retinal ganglion cell ischemic damage6. pyrecto ver studies couldn’t demonstrate any significant relationship7. thus there is variability among the results of various studies which should not be surprising because relationship of iop and bp is complex and is effected by many factors as effect of bp on iop, use of antihypertensive and anti glaucoma drugs and hypertension duration. we conducted this study to determine the effect of diastolic and systolic blood pressure on iop in patients with poag in a tertiary care hospital. since no similar local studies have been conducted and published in our population up to our knowledge, so it will enhance our understanding of the disease and management plans in primary open angle glaucoma. material and methods the study was conducted at ophthalmology department of abbasi shaheed hospital and karachi medical and dental college from january 2015-june 2016. it was a cross sectional descriptive study. it was started after approval from ethical review committee of the hospital. patients were registered through non probability consecutive sampling technique from outpatient department. sample size calculated was 3798 using open epi sample size calculators for demographic studies version 3, keeping confidence interval 95% and margin of error 5%. patients with poag, 40 years and above, clear corneas to facilitate gonioscopy, glaucomatous optic disc and glaucomatous visual field defects were included in the study. those patients having normal tension glaucoma, corneal opacities where gonioscopy was not possible, past ocular surgeries, close angle glaucoma and secondary open angle glaucoma were excluded from the study. written and informed consent was taken from the patients. detailed medical history was obtained. an ocular examination was conducted which included measurement of visual acuity, refraction, slit lamp examination and fundoscopy. diagnosis of poag was established by measurement of intraocular pressure with help of applanation tonometer, gonioscopy, typical glaucomatous field defects, glaucomatous optic nerve head damage and optical coherence topography (oct). topical anesthesia was instilled in each eye. fluorescein strips were used for few seconds. tonometer was adjusted at 10 mm hg. measurement was taken and recorded when the mires were just overlapping each other. procedure was repeated in the fellow eye. blood pressure of all the patients was measured and recorded with help of manual mercury sphygmomanometer. three consecutive readings were taken in sitting position and for right side of the arm. mean of the three readings was taken into consideration. all the findings were recorded on the predesigned proforma. data analysis was done on statistical package for social sciences (spss 21). frequencies and percentages were computed for categorical data like age, gender, stages of hypertensive retinopathy, diabetics and tobacco users. whereas means and median were calculated for continues data like iop and blood pressure on parametric test kruskal wallis test was used to compare systolic blood pressure with median intra ocular pressure of right and left eye. p-value less than 0.05 was taken as statistically significant. mann whitney test was used to compare diastolic blood pressure with median intra ocular pressure of both eyes. mann whitney test was also used to compare intraocular pressure, systolic and diastolic blood pressure with gender. p-value less than 0.05 was taken as statistically significant. results 379 patients in our study and their mean age was 59.68 ± 11.37. males were188 (49.6%) and females were 191 (50.4%). mean intraocular pressure of right eye was 18.00 ± 5.81 and left eye was 19.00 ± 5.87. mean systolic blood pressure of the patients was 146.86 ± 17.99 and diastolic pressure was 91.66 ± 9.63. frequencies of tobacco users, diabetics and grading of hypertensive retinopathy were computed and given in table 1. statistical analysis showed the difference in median iqr (inter quartile range) of iop in both eyes in systolic blood pressure category>140 mm hg was statistically significant. median iqr (inter quartile range) of iop right eye in systolic blood pressure category > 140 mm hg was 18 (16 – 19) mm hg (p = 0.015). median iqr (inter quartile range) iop of left eye in systolic blood pressure category > 140 mm hg was also significant 19 (16 – 22) mm hg (p < 0.001) (table 2 and fig. 1). furthermore, the median (inter quartile) difference of iop right eye in diastolic blood pressure category uzma fasih, et al 32 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology 90 – 110 mm hg was 18 (16 – 22) mm hg which was statistically significant as compared to that of diastolic blood pressure category< 90 mm hg (p < 0.001). the iop left eye was also significantly higher 20 (16 – 24) mm hg in diastolic blood pressure category 90 – 110 mm hg (p < 0.001) (table 3 and fig 2). the visual fields and oct of these patients showed glaucomatous changes. we also observed that median (iqr) of iop right eye and left eye in males were not statistically significant as compared to females (0.908 & 0.978) given in table 4. the median (iqr) systolic blood pressure in males were statistically not significant as compared to table 1: demographics of the patients enrolled in the study. demographic characteristics n (%) age* 59.68 ± 11.37 iop* right eye 18.00 ± 5.81 left eye 19.00 ± 5.87 blood pressure * systolic blood pressure 146.86 ± 17.99 diastolic blood pressure 91.66 ± 9.63 gender ¥ male 188 (49.6%) female 191 (50.4%) grading of htn retinopathy¥ grade 0 95 (25.1%) grade 1 181 (47.8%) grade 2 95 (25.1%) grade 3 8 (2.1%) diabetics patients¥ diabetics 103 (27.2%) non diabetics 276 (72.8%) tobacco¥ tobacco user 207 (54.6%) non tobacco user 172 (45.4%) *continuous variables are presented as mean+/-s categorical variables are presented as frequencies and percentages table 2: comparison of systolic blood pressure with iop. systolic bp no. of samples iop right eye iop left eye < 120 mm hg 44 16 (15 20) 16 (14 20) 120 140 mm hg 111 16 (14 – 20) 16 (12 20) > 140 mm hg 224 18 (16 19) 19 (16 22) p-value 0.015 < 0.001 p-value was calculated by kruskal wallis test. median iqr were presented for continuous variables p-value less than 0.05 was taken as significant table 3: comparison of diastolic blood pressure with iop. diastolic bp no. of samples iop right eye iop left eye < 90 mm hg 220 16 (14 18) 16 (14 22) 90 110 mm hg 159 18 (16 -22) 20 (16 24) p-value < 0.001 < 0.001 p-value was calculated by mann-whitney test. median iqr was presented for continuous variables *p-value less than 0.05 was taken as significant table 4: comparison of iop and bp with gender. parameter gender pvalue male (n=188) female (n=191) iop right eye 18 (14 19) 16 (15 20) 0.908 iop left eye 17 (16 22) 18 (14 22) 0.978 systolic bp 151 (140 60) 150 (130 160) 0.697 diastolic bp 90 (85 100) 90 (80 95) 0.051 p-value was calculated by mann whitney test. median (iqr) was presented for continuous variables. females p = 0.697. the statistical analysis also revealed that diastolic blood pressure in males were higher as effect of blood pressure on intraoculr pressure in primary open angle glaucoma pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 33 compared to females but the difference was not clinically significant(p = 0.052) given in table 4. statistical analysis showed the difference in median iqr (inter quartile range) of iop in both eyes in systolic blood pressure category>140 mm hg was statistically significant. discussion glaucoma has significant effects on health and economy of almost all the sectors of our society. glaucoma is a disease where normal balance between iop and bp in choroidal vessals supplying the optic nerve head and the reterolaminar portion of optic nerve is disrupted which results in vascular insufficiency at the optic nerve and reterolaminar portion of optic nerve. thus resulting in pathological changes in optic disc, optic nerve and typical visual field defects9. the exact pathogenesis of poag remains unclear but raised iop is one of the major risk factor in addition to other factors that affect the blood supply of optic nerve head. the etiology of poag is multifactorial. but some factors like blood pressures are modifiable which can be controlled to halt the progression of glaucomatous damage1. we conducted this study to see the effect of systolic and diastolic bp on iop in patients of poag. total number of patients was 379 and their mean ages were 59.68 ± 11.37. males were188 (49.6%) and females were 191 (50.4%). mean intraocular pressure of right eye was 18.00 ± 5.81 and left eye was 19 ± 5.87. mean systolic blood pressure of the patients was 146.86 ± 17.99 and diastolic pressure was 91.66 ± 9.63. in our study the patients with systoloic blood pressure of more than 140mm hg have significant rise in iop of right and left eye with p value of less than 0.005. similarly sadiqulla et al have reported an increase in iop with rise in bp in diagnosed patients of poag. they have reported an iop of 29 mm hg in systolic bp category of 40-149 mm hg and an iop of 32 mm hg in systolic bp category of >160 mm hg8. this difference in mean iop could be due to large sample size and the patients we included were already on anti glaucoma medications. leske and et al have also documented a positive relationship between high diastolic bp and iop in patients with poag10. a large number of studies including caucasians (blue mountain eye study, egna neumarkt glaucoma study and the rotterdam eye study) africans (barbados eye study) and asians (tanjong pagar study) found that systemic hypertension increases susceptibility to glaucoma1,3,4,5. as these studies have large sample size with various ethnic backgrounds so they have a wide applicability. a meta-analysis conducted in 2014 found the association between association between blood pressure and intraocular pressure. sixty observational studies were included in it. almost all studies have reported a positive association between bp and iop. the average increase in iop with a 10 mm hg increase in systolic blood pressure was 0.26 mm hg, and average rise of iop with 5 mm hg diastolic blood pressures was 0.17 mm hg. 11 while our study reported the rise of iop in systolic group and diastolic group but it was more marked in diastolic group. a literature review revealed most of the studies showing a strong relationship between glaucoma and high blood pressure while there are certain studies that have linked glaucoma with high blood pressure1. this association between glaucoma and high blood pressure seems controversial because high bp should give an increased ocular perfusion pressure so it should provide a protective effect. although there is a positive relationship between bp and iop, there is small change in iop with rising bp. so the risk of development of glaucoma with increase in blood pressure couldn’t be completely associated with bp driven rise in iop12. the authors of baltimore eye survey reported that association between glaucoma and bp is age dependent. they speculated that the optic nerve is aided from increased blood pressure when blood vessels are normal in young age, but as vassals become atherosclerotic, rigid and with age the resistance to blood flow will be increased, there will be oxygen deficiency, disturbed vascular auto regulation and nutrient exchange at capillary beds so high blood pressure is no longer effective. impaired auto regulation means that there is a decreased ability of eye to resist episodes of decreased ocular perfusion pressures and over the passage of time the cumulative effect can cause loss of ganglion cells 12. on the other hand an increase in blood pressure results in elevation of cilliary artery pressure, thus increasing the aqueous production and resulting in rise of intraocular pressure. as rise in arterial pressure can cause a small rise in venous pressure, so aqueous clearance will be reduced, which is also a contributing factor towards a high iop13,14. the los angeles latino eye study1 reported that both high systolic and low diastolic blood pressures uzma fasih, et al 34 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology have an association with an increased prevalence of poag15. the barbados eye studies, thessaloniki eye study and early manifest glaucoma trial reported an association of poag with low blood pressure .rapid and large reductions in blood pressure result in reduced ocular perfusion pressure which increases the risk for glaucoma1,16,17. clinically it is important that not only iop but also the blood pressure status of the patients in poag should be taken in consideration. onakoya and dielemans have reported a positive association between systemic hypertension and poag in their studies18,19. it is important to avoid over or under treatment of chronic hypertensive patients to get an optimal ocular perfusion pressure range. glaucoma is believed to be a vascular disease. we can actually visualize arterioles at retina which supply the ganglion cells. an increase in bp may lead to increase ganglion cell death which may be a contributing factor towards glaucoma. it is important here to highlight that in our study we had 47.8% patients with grade 1 hypertensive retinopathy and about 25.1% patients had grade 2 hypertensive retinopathy, along with established diagnosis of poag. so rise in blood pressure could be a contributory factor towards glaucomatous damage. it was reported in a study that patients having with hypertensive retinopathy presented with greater intraocular pressure readings as compared to those who had no hypertensive retinopathy20. since we did not have any similar studies in our population to compare the results so we have to compare the results with that of the developed countries. conclusion intraocular pressure in patients with primary open angle glaucoma rises as there is a rise in systolic as well as diastolic blood pressure. intraocular pressure is not affected by genders. so it is important to have a good control of blood pressure in patients of poag to halt or slow down the progression of glaucomatous optic nerve damage. author’s affiliation dr. uzma fasih associate professor, fcps eye department, karachi medical & dental college abbasi shaheed hospital karachi dr. erum shahid senior registrar, mcps, fcps eye department, karachi medical & dental college abbasi shaheed hospital karachi dr. arshad shaikh mcps, fcps professor& head of eye department eye department karachi medical & dental college abbasi shaheed hospital karachi role of authors: dr. uzma fasih data collection, literature search, manuscript writing and editing. dr. erum shahid literature search, data analysis, editing. dr. arshad shaikh conception and design, final editing and approval of manuscript. references 1. leske mc, wu sy, hennis a, honkanen r, nemesure b. risk factors for incident open-angle glaucoma: the barbados eye studies. ophthalmology 2008; 115: 85–93. 2. chen pp. risk and risk factors for blindness from glaucoma. curr opin ophthalmol 2004; 15: 107–111. 3. mitchell p, lee aj, rochtchina e, wang jj. open-angle glaucoma and systemic hypertension: the blue mountains eye study. j glaucoma 2004; 13: 319–326. 4. bonomi l, marchini g, marraffa m, bernardi p, morbio r, varotto a. vascular 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blood pressure, perfusion pressure, and open-angle glaucoma: the los angeles latino eye study. invest ophthalmol vis sci 2010; 51: 2872–2877. 16. topouzis f, coleman al, harris a, jonescu-cuypers c, yu f, mavroudis l, anastasopoulos e et al. association of blood pressure status with the optic disk structure in non-glaucoma subjects: the thessaloniki eye study. am j ophthalmol 2006; 142: 60– 67. 17. leske mc, heijl a, hyman l, bengtsson b, dong l, yang z. predictors of long-term progression in the early manifest glaucoma trial. ophthalmology 2007; 114: 1965– 1972. 18. onakoya ao, ajuluchhkwu jn, alimi hl. primary open angle glaucoma and intraocular pressure in patients with systemic hypertension. east afr med j. 2009 feb; 86 (2): 74-8. 19. dielemans l, vingerling jr, algra d, hofman a, grobbee de. primary open-angle glaucoma, intraocular pressure, and systemic blood pressure in the general elderly population. the rotterdam study ophthalmology, 1995 jan; 102 (1): 54-60. 20. sakata k, maia m, matsumoto l. analysis of the intraocular pressure in diabetic, hypertensive and normal patients (glaucoma project) arq. bras. oftalmol. são paulo june 2000; 63 (3): 223-226. http://www.ncbi.nlm.nih.gov/pubmed?term=zhao%20d%5bauthor%5d&cauthor=true&cauthor_uid=24879946 http://www.ncbi.nlm.nih.gov/pubmed?term=cho%20j%5bauthor%5d&cauthor=true&cauthor_uid=24879946 http://www.ncbi.nlm.nih.gov/pubmed?term=kim%20mh%5bauthor%5d&cauthor=true&cauthor_uid=24879946 http://www.ncbi.nlm.nih.gov/pubmed?term=guallar%20e%5bauthor%5d&cauthor=true&cauthor_uid=24879946 http://www.ncbi.nlm.nih.gov/pubmed/24879946 http://onlinelibrary.wiley.com/doi/10.1111/cxo.2011.94.issue-2/issuetoc 122 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology original article frequency of neurogenic strabismus in alibrahim eye hospital, karachi shua azam, priyanka, muhammad qasim pak j ophthalmol 2019, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: shua azam m. phil optometry senior lecturer isra school of optometry, al-ibrahim eye hospital, karachi email: optomshuaazam@gmail.com …..……………………….. purpose: to determine the frequency of neurogenic strabismus presenting at the orthoptics clinic in al-ibrahim eye hospital, malir karachi. study design: cross-sectional study. sampling technique: non-probability convenient sampling. place and duration of study: orthoptics clinic of al-ibrahim eye hospital (aieh) karachi, pakistan from may to october, 2018. material and methods: this study included 349 subjects age ranged from 5 to 75 years. all ocular examinations for strabismus were performed, including cover test, prism cover test and hess chart. demographic features and etiologies were recorded, and the causes of extra ocular muscle palsies were grouped as; trauma, diabetes, hypertension and others. spss version 20.0 was used to analyze the data. results: frequency of neurogenic strabismus was found to be 6%. out of 21 subjects, 8 (38.1%) subjects had diabetes, followed by 2 (9.5%) subjects with hypertension, 5 (23.8%) subjects with ocular trauma and 6 (28.6%) subjects with other causes. the most commonly affected side was the right eye seen in 13 (61.9%) subjects. the most common ocular motor nerve involved was abducent (sixth) nerve in 13 (61.9%) subjects, followed by oculomotor (third) nerve in 4 (19%) subjects. out of the patients with third nerve palsy 3 (14.3%) subjects had pupil sparing and only 1 (4.8%) subject had no pupil sparing. conclusion: sixth nerve was the most common nerve involved and most common etiology was uncontrolled diabetes. keywords: neurogenic strabismus, cranial nerve palsies, paralytic strabismus. trabismusis is a very common ocular cause of visual impairment in optometry and ophthalmology. the prevalence of strabismus worldwide is reported as 5.7%1. strabismus or squint is a disorder in which the eyes are not properly aligned with each other. it involves a lack of coordination between muscle movements of two eyes. it can be due to either an imbalance of muscles or disruption in the nerve supply2. paralytic or incomitant strabismus occurs when there is limitation of ocular movement. palsy disrupts the maintenance of binocular single vision and due to loss of fusional amplitude resulting in diplopia (double vision) which may be compensated by abnormal head posture3. many different treatment options are available to resolve the issue, including occlusion, refractive correction, prisms, vision therapy and surgical intervention4. a paralytic deviation undergoes several stages. the first stage is characterized by limitation of movement affecting one muscle, as a rule and secondly by over action of contralateral synergist. during this stage the law of equal innervation exhibits. the third stage is contracture of ipsilateral antagonist that shows the reciprocal innervation to the muscle. and lastly, secondary inhibition of contralateral s frequency of neurogenic strabismus in al-ibrahim eye hospital, karachi pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 123 antagonist occurs because the contracted antagonist in affected eye requires less innervation. all these stages result in an angle of deviation which increases on movement of the eyes in the direction of limitation and decreases when they move away from the affected side. moreover secondary deviation is seen which is always greater than primary deviation. secondary deviation is assessed by fixing the affected eye while primary deviation is assessed by fixing the normal eye4. the paralysis of abducent nerve can be either congenital or acquired5 and the most common cause of 4th nerve palsy is congenital6. common causes for pupil-sparing pathologies are diabetic neuropathy, myasthenia gravis, atherosclerosis, chronic progressive ophthalmoplegia and vasculopathies. on the other hand, the most common causes of non-pupil sparing oculomotor palsy are tumor, followed by vascular lesions (posterior communicating aneurysms, and then distal basilar artery aneurysms)7. the rationale of the study was to collect data about cases with neurogenic strabismus so that we can manage them better. this study was carried out to identify patients in the orthoptic clinic who had ocular motility problems due to the neurogenic causes. material and methods it was hospital-based, cross-sectional study conducted at orthoptics clinic of al-ibrahim eye hospital (aieh) karachi, pakistan by using non-probability, convenient sampling technique from may to october 2018. ethical approval was given by research ethical committee (rec) of isra postgraduate institute of ophthalmology. 349 patients who visited orthoptics clinic during period of data collection were included. the inclusion criteria were subjects between 5-75 years of age who had manifest neurogenic strabismus, no history of previous squint surgery or other ocular disease. subjects with history of trauma, diabetes and hypertension were included as well. the exclusion criteria included subjects with latent and puesdo strabismus and syndromes. all the subjects were examined after obtaining fully informed written consent. the protocol for examination for all patients included the demographic data, history of onset, type of squint. all this was retrieved from the case notes. history revealed whether the patient had trauma, diabetes or hypertension. visual acuity of every patient was checked and recorded separately both for near and distance, with and without glasses. then orthoptic assessment was done to evaluate the type of palsy which included cover/uncover test, ocular motility, prism cover test and pupillary reflex test. cover test was assessed to check the eye affected in primary position, angle and type of tropia with occluder and fixation targets both in distance and near. extra-ocular motility test in all gazes was checked first in versions to check any limitation (underactions) with secondary angle of deviation (overactions) and then ductions were checked by occluding one eye to confirm the limitation of gaze. hess chart was performed to make the final diagnosis by correlating all the tests results. the anterior segment was also examined with a slitlamp by an ophthalmologist to exclude any ocular disease and the refraction (dry or cycloplegic) was also assessed by optometrist. data analysis was done on statistical package for social sciences (spss) version 20.0. all continuous variables were presented as mean ± standard deviation. the entire categorical variables were shown as frequency and percentages. statistical charts were presented in the form of bar chart & pie chart. results a total of 21 subjects among 349 subjects fulfilled the inclusion criteria for the study. among them, 5 were females, and 16 were males. the mean age of onset was 35.3 years, ranging between 5-75 years. the frequency of neurogenic strabismus was found to be 6%. out of 21 subjects, 8 (38.1%) subjects were found to have diabetes, 2 (9.5%) subjects had hypertension, 5 (23.8%) subjects had ocular trauma and 6 (28.6%) subjects had other causes as shown in figure 1. the most affected eye was right eye in 13 (61.9%) subjects as shown in figure 2. at the end of the examination the most commonly seen manifest deviation on cover test was esotropia in 13 (61.9%) subjects, followed by exotropia in 4 (19%), hypotropia in 2 (9.5%), hypertropia in 1 (4.8%) and combined in 1 (4.8%) subject as shown in figure 3. the diagnosis of all subjects on hess chart and other tests showed the most common ocular motor nerve involved was abducent (sixth) nerve in 13 (61.9%) subjects, followed by oculomotor (third) nerve in 4 (19%) subjects. out of the patients who had third nerve palsy 3 (14.3%) subjects had pupil sparing while only 1 (4.8%) subject had no pupil sparing. double elevator palsy was seen in 2 (9.5%) subjects, there was a single case (4.8%) of fourth nerve palsy and combined nerve involvement was seen in 1 (4.8%) subject as shown in figure 4. shua azam, et al 124 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology fig. 1: frequency of causes of palsies. fig. 2: distribution of affected eye. fig. 3: frequency of manifest type of deviation on cover test. fig. 4: frequency of distribution of palsies tested on hess chart. table 1: palsy versus gender cross tabulation. palsy versus gender cross tabulation type of palsy gender total male female third nerve palsy with no pupil involvement 1 0 1 third nerve palsy with pupil involvement 3 0 3 fourth nerve palsy 1 0 1 sixth nerve palsy 10 3 13 double elevator palsy 1 1 2 combined 0 1 1 total 16 5 21 frequency of neurogenic strabismus in al-ibrahim eye hospital, karachi pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 125 discussion many studies are available which were conducted in different clinics of the world and show variety of results. according to a survey of 2007, the higher prevalence of paralytic strabismus was found to be 10%8 and a study in turkey showed low prevalence about 4.75%9. however, in this study the frequency of neurogenic strabismus was found to be 6% as compared to the study that done in gaza which constitutes 7.8%10. as such the differences in strabismus frequencies are due to changes in parameters used for diagnosis, ethnicity and time duration. in this study, the frequency of neurogenic strabismus was more common in males. in males, it was 72.2% and in females 23.8%, which correlates with studies conducted in lahore that showed the same ratio of males (74.3%) and females (25.7%)11,12. in the present study, right eye was more affected in 62%, while left eye in 38% and there was no case of bilateral involvement. while in previous studies left eye was commonly affected as compared to right eye9,13. in this study, the most common cause was found to be diabetes. previous studies showed the common cause of etiology was vascular diseases which includes hypertension and diabetes both14-17. whereas, trauma was also common cause in many studies8,18,19. a similar study in india showed the most common nerve involved was 6th nerve in 46.7%, followed by 3rd nerve 23.3%, combined nerve involvement 20% and 4th nerve 10%8,14. a study in korea, showed the third nerve was commonly affected nerve among all12. another study in korea, showed the equally affected ratio of 6th and 4th nerve palsies13. many studies giving the prevalence of third, fourth, and sixth nerve palsies had higher incidence of sixth nerve palsy followed by third and then fourth nerve palsies11,20. in some studies fourth nerve was more prevalent6,21. a study was conducted in china, which included all patients who had head trauma that showed the highest incidence of paralysis of third nerve (54.8%) followed by fourth nerve (45.2%) of all cases22. conclusion the sixth nerve was the most commonly involved nerve in our patients. the most common etiology was uncontrolled diabetes. conflict of interest none. acknowledgements special thanks to professor dr. mohammad saleh memon dr. abdul hameed talpur author’s affiliation shua azam mphil optometry senior lecturer isra school of optometry, al-ibrahim eye hospital karachi priyanka bs vision sciences optometrist intern al-ibrahim eye hospital karachi muhammad qasim mph. bs vision sciences assistant professor isra school of optometry, al-ibrahim eye hospital karachi author’s contribution shua azam study design, article review, manuscript writing. priyanka review of literature data collection. muhammad qasim data analysis and critical review. references 1. khorrami-nejad m, akbari mr, khosravi b. the prevalence of strabismus types in strabismic iranian patients. clinical optometry, 2018; 10 (1): 19-24. 2. behera s, bijaya kd, chowdhury rk, sar m. a clinico-anatomical study of strabismus in a tertiary care hospital. journal of dental and medical sciences, 2014; 13 (1): 32-35. 3. anson am, davis h. diagnosis and management of ocular motility disorders, 3rd ed. blackwell science ltd: uk; 2001. 4. dasinger kd. intermittent exotropia: management options and surgical outcomes. j of beh opt. 2012; 23 (2): 44. 5. kasturi n. congenital sixth nerve palsy with associated anomalies. indian j ophthalmol. 2017; 65 (1): 1056-7. 6. sekeroglu ht, febo, turan ke, arslan u et al. etiology of fourth and sixth nerve palsies: a single ophthalmology clinic’s perspective. international shua azam, et al 126 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology journal of ophthalmology and clinical research 2014; 1 (1): 1-3. 7. lai g, rodriguez mi, scumpia aj. oculomotor nerve palsy secondary to cavernous internal carotid aneurysm. clin pract cases emerg med. 2018 jan 9;2(1):93-94. 8. stidwill d. epidemiology of strabismus. opthalmic and physiological optics, 2007; 17 (6): 536-539. 9. niyaz l, gul a and ariturk n. frequency and etiology of paralytic strabismus. austin journal of clinical ophthalmology, 2015; 2 (1): 1-2. 10. abuimara a. relative prevalence of various types of strabismus in patients attending ngo's medical centers in gaza strip. science journal of public health, 2015; 3 (1): 1-5. 11. valsa ts, susan p, sreelatha kc. clinical profile of third, fourth, and sixth cranial nerve palsies presenting to a tertiary care ophthalmic center. international journal of scientific study, 2017; 5 (3): 93-97. 12. suman a, nabin p, gauri ss, ananda ks. clinical profile of extraocular muscle palsy: a retrospective study. optometry & visual performance, 2013; 1 (6): 198-201. 13. taju s, kebede w. causes of cranial nerves iii, iv and vi paralysis among ethiopian patients presented at menelik ii hospital. ethiopian medical journal, 2017; 56 (1): 23-29. 14. ho th, lin hs, lin mc, sheu sj. acquired paralytic strabismus in southern taiwan. j chin med assoc. 2013 jun; 76(6): 340-3. 15. kiyoung k, sung rn. clinical course and prognostic factors of acquired third, fourth, and sixth cranial nerve palsy in korean patients. korean journal ophthalmology, 2018; 1 (1): 1-7. 16. ji sj, dae hk. risk factors and prognosis of isolated ischemic third, fourth, or sixth cranial nerve palsies in the korean population. journal of neuroophthalmology, 2015; 35 (1): 37-40. 17. kumar kh, bhanu kbc, ashok r. clinical study of 3rd, 4th and 6th cranial nerve palsies leading to visual disturbances. international journal of contemporary medical research 2018; 5 (4): 10-12. 18. anayat a, sadiq maa. ocular motility problems after head trauma. ophthalmology pakistan, 2015; 5 (3): 5053. 19. park uc, kim sj, hwang jm, yu ys. clinical features and natural history of acquired third, fourth, and sixth cranial nerve palsy. eye (lon) 2008; 22 (5): 691-696. 20. rowe f. prevalence of ocular motor cranial nerve palsy and associations following stroke. eye, 2011; 25 (1): 881-887. 21. bolutine o, tinly c, grotte r. paralytic strabismus in south african black and mixed race children – a 15year clinic-based review. ophthalmic epidemiology, 2012; 19 (6): 396-400. 22. guichen li, xiaobo z, sun y, gao x, zhang y, houn k. ocular movement nerve palsy after mild head trauma. world neurology, 2016; 94 (1): 296-302. http://www.ovpjournal.org/uploads/2/3/8/9/23898265/ovp1-6_article_adhikari_web.pdf http://www.ovpjournal.org/uploads/2/3/8/9/23898265/ovp1-6_article_adhikari_web.pdf http://www.ovpjournal.org/uploads/2/3/8/9/23898265/ovp1-6_article_adhikari_web.pdf http://www.ovpjournal.org/uploads/2/3/8/9/23898265/ovp1-6_article_adhikari_web.pdf pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 15 original article outcomes of early pars plana vitrectomy for acute post operative endophthalmitis with or without silicone oil hussain ahmad khaqan, abdul hye, saher abdul hye, hassan raza chaudhary, farrukh jameel pak j ophthalmol 2017, vol. 33 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hussain ahmad khaqan eye department lgh/pgmi, lahore email: drkhaqan@hotmail.com …..……………………….. purpose: to evaluate the anatomical and functional outcomes of pars plana vitrectomy (ppv) in acute post operative endophthalmitis with or without endotamponade. study design: quasi experimental study. place and duration of study: lahore general hospital, lahore from march 2011 to march 2016. material and methods: one hundred and twelve patients of acute post-surgical endophthalmitis were included in the study. patients were randomized into two groups after no clinical improvement was seen post primary vitreous tap and intravitreal vancomycin and ceftazidime. in group 1 patients undergoing ppv with endotamponade (silicon oil) were included while in group 2 patients undergoing ppv without endotamponade were included. study was divided in two phases. in first phase 30 patients underwent ppv without endotamponade and 30 patients with endotamponade. considering the results of phase 1, rest of the 52 patients underwent ppv with endotamponade in phase 2. removal of silicone oil in all patients was done at 12 weeks. results: in first phase of study 23 (76.66%) patients in group 2 showed retinal detachment within four weeks of follow up, while no patient (0%) in group 1 showed retinal detachment within four weeks of follow up. later 6 (7.31%) patients in group 1 showed retinal detachment within four weeks of silicone oil removal. in second phase all 52 patients showed no retinal detachment after undergoing ppv with endotamponade as in group 1. overall 82 patients underwent ppv with endotamponade including first and second phase and only 6 patients got retinal detachment. conclusion: early ppv with endotamponade should be preferred to ppv without endotamponade in cases of acute postoperative endophthalmitis due to statistically significant improvement in anatomical and functional outcomes. key words: endophthalmitis, pars plana vitrectomy, endotamponade, retinal detachment, silicone oil. ndophthalmitis is one of the most devastating vision threatening intraocular inflammation1. there are two main routes for inoculation of this condition i.e. exogenous and endogenous. exogenous endophthalmitis can be due to postoperative, posttrauma, or post-intravitreal injections due to ocular contamination by infective agents from the external environment1. endogenous endophthalmitis is less common and is caused by spread of microbes through blood from different parts e hussain ahmad khaqan, et al 16 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology of the body. endophthalmitis causes severe anatomical and functional damage of intraocular structures leading to marked visual deterioration2. acute post-operative endopthalmitis usually occurs within 5-6 weeks of an intra-ocular surgery. most of the cases occur after cataract surgery3,4. after cataract surgery the incidence of acute-postoperative endophthalmitis ranges from 0.03% to 0.2% in different publications5–12. ocular surgeries other than cataract i.e. penetrating keratoplasty5,13,14 scleral buckling15 and glaucoma drainage device implantation16 show less incidence of acute postoperative endophthalmitis as compared with post cataract surgery. there are many treatment options for this sight threatening condition including intra-vitreal antibiotics, pars plana vitrectomy (ppv) and adjunctive systemic antibiotics. endophthalmitis vitrectomy study (evs) provides us the guidelines for the treatment of endophthalmitis with respect to vision at presentation. ppv is generally recommended in patients presenting with light perception (lp) vision while in patients presenting with visual acuity of better than lp intra-vitreal antibiotics is recommended17. ppv can be performed with and without endotamponade (silicon oil). a study was conducted to evaluate the efficacy of ppv with endotamponade (silicon oil) and they found silicon oil having intrinsic bactericidal properties18. another study was conducted which showed silicone oil a beneficial adjunct to vitrectomy in the treatment of endophthalmitis. in pars plana vitrectomy with silicone oil endotamponade all the patients were found to have better visual outcomes19. as endophthalmitis causes diffuse tissue necrosis and postoperative retinal detachment so endotamponade plays an important role in securing visual and anatomical outcomes19. a study was done to compare the post ppv outcomes with and without endotamponade in the treatment of endophthalmitis. there was markedly increased incidence of post operative retinal detachment in ppv without endotamponade20. this study was done to evaluate and quantify the effect of endotamponade, in preventing post ppv retinal detachment, done for endophthalmitis. the results will benefit the surgeons and patients in achieving good visual outcomes. material and methods a total of 112 subjects with acute post-operative endophthalmitis were enrolled in this study on the basis of evs recommendations. this was a quasi experimental study conducted at lahore general hospital, lahore pakistan, from 2011 to 2016. sample size was calculated by who standard formula with 95% confidence interval. written and informed consent was taken from all participants. approval of the ethical committee of lahore general hospital, lahore was obtained. a detailed history and evaluation of all the participants was done systemically to identify any risk factors causing endophthalmitis. all participants were randomly divided in two equal groups. in first phase 30 patients of group 1 underwent ppv with oil and 30 patients of group 2 underwent ppv only. second phase started 4 weeks after first phase and rest of all 52 patients underwent ppv with endotamponade (table 2). 23 g ppv with and without silicon oil was done and patients were evaluated at first day, first week, first month, third months and sixth months. oil was removed after 2 months. on every follow up visual acuity, iop and fundus examination were recorded. statistical package spss version 15.0 was used for data analysis. results total 112 patients with acute post-operative endophthalmitis were enrolled in this study. 75 (66.90%) were male and 37 (33.03%) were female. mean age of participants was 48 years. 6 patients (7.31%) out of total 82 patients who underwent ppv with endotamponade in group 1 showed retinal detachment on removing silicon oil after 4 postoperative weeks. 23 (76.66%) patients who underwent ppv alone in group 2 presented with retinal detachment during first four weeks follow up (table 2). in first phase of study 23 (76.66%) patients out of 30 who underwent ppv only (group 2) showed retinal detachment within first four weeks of follow up, while among 30 patients of group 1 who underwent ppv with endotamponade, no patient showed retinal detachment in first four weeks post operatively . later 06 (7.31%) patients in group 1 showed retinal detachment within four weeks of silicone oil removal (fig 1). in second phase rest of 52 patients underwent ppv with endotamponade. no patient showed retinal detachment at first 4 weeks follow up (fig 2). patients outcomes of early pars plana vitrectomy for acute post operative endophthalmitis pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 17 with detachment underwent redo surgery for ppv with endotamponade of silicone oil. oil was removed after 2 months. 76 (92.68%) participants showed improved vision (6/36-6/60) in group 1 and in group 2 07 (23.33%) participants showed improved vision (6/36-6/60). table 1: patient distribution in the study phases. first phase group 1 group 2 n 30 30 rd 6 23 % 20% 76.6% second phase group 1 group 2 n 52 0 rd 0 0 % 0% 0% table 2: results of the two groups. combined group 1 group 2 total patients 82 30 rd 6 23 % 7.31% 76.6% 0 5 10 15 20 25 group 1 group 2 figure 1: retinal detachment ratio in two groups. 0 20 40 60 retinal detachment no retinal detachment figure 2: after removal of oil ratio of retinal detachment in second phase. discussion considerable differences were observed between two groups in our study. at fourth post-operative week and sixth post-operative month after surgery, group 1 (who underwent pars plana vitrectomy with silicone oil endotamponade had better visual and functional outcomes and less need to repeat surgery. the results were in favor of conclusions from previous studies19. it shows the significance of endotamponade with silicone oil for endophthalmitis. pars plana vitrectomy has improved the anatomical and functional outcomes of endophthalmitis from a success rate of 33%21 to 40%22. role of surgical management (ppv with endotamponade) in improving visual function has been shown by many studies and plays an important role in securing the useful vision of patients. as compared with the surgical outcomes from similar studies our study showed more acceptable results. success rate of this study 92.68% in group 1 compared with 30% by another study showed the importance of endoteponade23. improved functional and anatomical outcome of pars plana vitrectomy with endotamponade (silicon oil) could be explained as follows: eradication of microbes by antibiotics is assisted by silicon oil18. a study was published which showed that silicone oil has inhibitory effect on most of the microorganisms including aerobes, facultative aerobes and anaerobes18. postoperative examination and additional laser treatments can be done effectively as silicon oil keeps the media clear. because of good surface tension, silicon oil pushes the retina against the eye wall, hence giving a good tamponade and sealing the retinal breaks effectively19. in severely infected eyes to perform pars plana vitrectomy carries some hazards. unexpected damage to the retina can occur due to retinal detachment no of patients hussain ahmad khaqan, et al 18 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology obscuration of the view because of opaque media. in endophthalmitis retina becomes infected, necrosed and fragile and can undergo iatrogenic injury or traction during surgery. after surgery there can be necrosis of retina secondary to persistant intraocular inflammation. postoperative hypotony can result due to ciliary body damage. these issues may cause retinal detachment19,24. considerable difference in retinal detachment after pars plana vitrectomy was seen in our study in eyes with endophthalmitis. 76.66% participants showed retinal detachment at first post-operative week in group 2. all eyes required re-operation with silicone oil endotamponade to obtain better visual outcomes by restoring the anatomical aspects. in the group 1, there were 6 cases of retinal detachment that occurred later after removing silicon oil. proliferative vitreo-retinopathy (pvr) plays an important role in the late complications in treating endophthalmitis. in group 1 all the six cases who got retinal detachment where repaired with silicone oil endotamponade and pvr was the main cause for retinal detachment24. among 82 participants with oilfilled eyes of group 1, silicon oil was removed in all cases at 2 months. progressive pvr was responsible for recurrent retinal detachment, causing new breaks or tractions emphasizing the need for endotamponade with silicon oil25. retinal breaks and tractions were responsible for recurrent detachments after surgery25. these recurrent detachments had very poor prognosis and these eyes became phthisical. in group 2 the parameters which show guarded prognosis i.e. macular fibrosis, inoperable retinal detachment, phthisis bulbi, evisceration were considerably higher than that of group 1. in every case vitreous and aqueous tap was done and sent for culture sensitivity and gram/giemsa staining. vitreous examination provided more positive results as compared to aqueous sample examination (92% in vitreous tap; 78% aqueous tap). staphylococcus aureus was isolated in most of the cases ( 41.5%), followed by streptococcus pneumoniae ( 20.5%), and pseudomonas aeruginosa (25%). in south east asia region, the most common pathogens were gram negative rods klebsiella from hepatobiliary infections are the major cause of endophthalmitis in south east asia region while gram positive cocci i.e. staphylococcus and streptococcus are the leading cause of endophthalmitis in the region of europe and america18. in the study, we found that endotamponade with silicon oil is an important tool for adequate attachment of retina after pars plana vitrectomy. severity of endophthalmitis is determined by certain signs like preoperative visual acuity, hypopyon height, vitreous opacity, and fundus involvement. these signs signify poor visual, functional and anatomical outcomes. early pars plana vitrectomy for post-surgical endophthalmitis with poor red reflex and vision of light perception show dramatic effects, already shown by endophthalmitis vitrectomy study17. conclusion early pars plana vitrectomy with endotamponade resulted in statistically significant improvement in anatomical and functional outcomes compared to pars plana vitrectomy without endotamponade in cases of acute postoperative endophthalmitis. authors affiliation: dr. hussain ahmad khaqan assistant professor ameer-ud-din medical college pgmi lahore general hospital, lahore. pakistan. prof. abdul hye ameer ud din medical college, pgmi lahore general hospital, lahore. pakistan. dr. saher abdul hye house officer, ameer-ud-din medical college pgmi lahore general hospital, lahore. pakistan. dr. hassan raza chaudhary post graduate resident, ameer ud din medical college, pgmi lahore general hospital, lahore. pakistan. dr. farrukh jameel medical officer ophthalmology, ameer ud din medical college, pgmi, lahore general hospital, lahore. pakistan. role of authors: dr. hussain ahmad khaqan study design, analysis and manuscript writing. outcomes of early pars plana vitrectomy for acute post operative endophthalmitis pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 19 prof. abdul hye critical review dr. saher abdul hye data collection dr. hassan raza chaudhary statistical analysis dr. farrukh jameel data collection references 1. mamalis n. endophthalmitis. j cataract refract surg. 2002; 28 (5): 729–730. 2. smith sr, kroll aj, lou pl, ryan ea. endogenous bacterial and fungal endophthalmitis. int ophthalmol clin. 2007; 47 (2): 173–183. 3. moloney tp, park j. microbiological isolates and antibiotic sensitivities in culture-proven endophthalmitis: a 15-year review. br j ophthalmol. 2014; 98 (11): 1492–1497. 4. verbraeken h. treatment of postoperative endophthalmitis. ophthalmologica. 1995; 209 (3): 165– 171. 5. wykoff cc, parrott mb, flynn hw, jr, shi w, miller d, alfonso ec. nosocomial acute-onset postoperative endophthalmitis at a university teaching hospital (2002–2009) am j ophthalmol. 2010; 150 (3): 392. 6. miller jj, scott iu, flynn hw, jr, smiddy we, newton j, miller d. acute-onset endophthalmitis after cataract surgery (2000–2004): incidence, clinical settings, and visual acuity outcomes after treatment. am j ophthalmol. 2005; 139 (6): 983–987. 7. ravindran rd, venkatesh r, chang df, sengupta s, gyatsho j, talwar b. incidence of post-cataract endophthalmitis at aravind eye hospital: outcomes of more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols. j cataract refract surg. 2009; 35 (4): 629–636. 8. freeman ee, roy-gagnon m-h, fortin e, gauthier d, popescu m, boisjoly h. rate of endophthalmitis after cataract surgery in quebec, canada, 1996–2005. arch ophthalmol. 2010; 128 (2): 230–234. 9. moshirfar m, feiz v, vitale at, wegelin ja, basavanthappa s, wolsey dh. endophthalmitis after uncomplicated cataract surgery with the use of fourthgeneration fluoroquinolones: a retrospective observational case series. ophthalmology, 2007; 114 (4): 686–691. 10. jensen mk, fiscella rg, moshirfar m, mooney b. thirdand fourth-generation fluoroquinolones: retrospective comparison of endophthalmitis after cataract surgery performed over 10 years. j cataract refract surg. 2008; 34 (9): 1460–1467. 11. friling e, lundström m, stenevi u, montan p. six-year incidence of endophthalmitis after cataract surgery: swedish national study. j cataract refract surg. 2013; 39 (1): 15–21. 12. keay l, gower ew, cassard sd, tielsch jm, schein od. postcataract surgery endophthalmitis in the united states: analysis of the complete 2003 to 2004 medicare database of cataract surgeries. ophthalmology, 2012; 119 (5): 914–922. 13. alharbi ss, alrajhi a, alkahtani e. endophthalmitis following keratoplasty: incidence, microbial profile, visual and structural outcomes. ocul immunol inflamm. 2013; 22 (3): 218–223. 14. taban m, behrens a, newcomb rl, nobe my, mcdonnell pj. incidence of acute endophthalmitis following penetrating keratoplasty: a systematic review. arch ophthalmol. 2005; 123 (5): 605–609. 15. tay e, bainbridge j, da cruz l. subretinal abscess after scleral buckling surgery: a rare risk of retinal surgery. can j ophthalmol. 2007; 42 (1): 141–142. 16. al-torbak aa, al-shahwan s, al-jadaan i, alhommadi a, edward dp. endophthalmitis associated with the ahmed glaucoma valve implant. br j ophthalmol. 2005; 89 (4): 454–458. 17. endophthalmitis vitrectomy study group results of the endophthalmitis vitrectomy study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. arch ophthalmol. 1995; 113 (12): 1479–1496. 18. ozadamar a, aras c, ozturk r, akin e, karacorlu m, ercikan c. in vitro antimicrobial activity of silicone oil against endophthalmitis-causing agents. retina. 1999; 19 (2): 122–126. 19. azad r, ravi k, talwar d, rajpal, kumar n. pars plana vitrectomy with and without silicone oil tamponade in post-traumatic endophthalmitis. graefe’s arch clinexp ophthalmol. 2003; 241 (6): 478–483. 20. do t, hon d, aung t, hien nd, cowan cl jr. bacterial endogenous endophthalmitis in vietnam: a randomized controlled trial comparing vitrectomy with silicone oil versus vitrectomy alone. clin ophthalmol. 2014 aug 28; 8: 1633-40. 21. wong js, chan tk, lee hm, et al. endogenous bacterial endophthalmitis. ophthalmology, 2000; 107 (8): 1483–1491 22. jackson tl, eykyn js, graham em, graham em, stanford mr. endogenous bacterial endophthalmitis: a 17-year prospective study and review of 267 reported cases. surv opthalmol. 2003; 48 (4): 403–423. 23. yoon yh, lee su, sohn jh, lee se. result of early vitrectomy for endogenous klebsiella pneumonia endophthalmitis. retina. 2003; 23 (3): 366–370. 24. kuhn f, gini g. ten years after... are findings of the endophthalmitis vitrectomy study still relevant today? graefe’s arch clin exp ophthalmol. 2005; 243 (12): 1197–1199. 25. cowley m, conway bp, campochiaro pa, kaiser d, gaskin h. clinical risk factors for proliferative vitreo retinopathy. arch ophthalmol. 1989; 107 (8): 1147–1151. hussain ahmad khaqan, et al 20 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology 26. cowley m, conway bp, campochiaro pa, kaiser d, gaskin h. clinical risk factors for proliferative vitreoretinopathy. arch ophthalmol. 1989; 107 (8): 1147–1151. 157 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol original article ocular manifestations in hiv/aids patients undergoing highly active antiretroviral therapy muhammad abdul rehman akram, mazen ahmed alzahrani, asim mahmood, thamer basodan, eman oudah alghamdi, ali alansari pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad abdul rehman ophthalmology clinic of east jeddah hospital, western region, saudi arabia email: abdulrehmandoctor@yahoo.com …..……………………….. purpose: to study human immunodeficiency virus (hiv) / acquired immunodeficiency syndrome (aids) related ocular manifestations in patients undergoing highly active anti-retroviral therapy (haart) in jeddah, saudi arabia. study design: descriptive study. place and duration of study: ophthalmology clinic of east jeddah hospital. kingdom of saudi arabia, during 2016-2017. material and methods: all patients who were positive for hiv/aids and taking highly active anti-retroviral therapy seen in the department of infectious diseases of our hospital were included in the study. the data for the 47 hiv/aids positive referrals was collected from the infectious diseases department by taking history, clinical examinations, and laboratory investigations. the ophthalmological examination consisted of adnexal examination, best corrected visual acuity, intraocular pressure (iop), anterior and posterior segment examination, b-scan and mri. results: there were 47 patients included in the study. there was one patient each of retinal necrosis, anterior uveitis “and” neovascular glaucoma, pterygium, sixth nerve palsy, bacterial conjunctivitis and adenoviral conjunctivitis. two cases presented with hiv microangiopathy, blepharitis, cortical blindness after brain abscess, herpes infection, kaposi sarcoma and cytomegalovirus (cmv) retinitis. three patients presented with meningitis and six with dry eyes. eight patients presented with cataracts and ten with refractive errors tuberculosis. conclusion: ocular manifestations of hiv infection are relatively infrequent in patients on haart as this has reduced the hiv-related complications in ophthalmology. keywords: human immunodeficiency virus, acquired immunodeficiency syndrome, highly active anti-retroviral therapy. ids is caused by hiv and may affect any part of the body1. nearly 36.7 million people are living with hiv/aids, and the mortality rate worldwide was 1.1 million reported cases up to 20152. kingdom of saudi arabia is one of the least affected states in the world hiv map3,4. since hiv leads to disruption of the immune system, all body parts are susceptible to infection, including eye. healthy hiv patients are not liable to encounter eye issues identified with a decreased immune system. however, 70 percent of patients with aids experience ocular diseases5. a ocular manifestations in hiv/aids patients undergoing highly active antiretroviral therapy pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 158 eye complications, as a result of suppressed immune system consist of hiv retinopathy, tiny hemorrhages and cotton wool spots in the retina. one of the severe eye problems associated with aids is cytomegalovirus (cmv) retinitis, which is seen in some individuals who have further developed stages of aids where cd4 lymphocyte count is < 50 cells/µl. it shows consistent inflammation of the retina, often leading to retinal deterioration and visual loss within few months. cmv retinitis can lead to a detached retina, causing severe vision loss unless treated surgically6. kaposi's sarcoma is an uncommon type of malignancy that happens in patients with aids. this growth can cause violet sores to form on eyelids, and purple, plump lesions to develop on the conjunctiva. kaposi’s sarcoma may appear unexpectedly, although it mainly does not hurt the eye, and can be easily treated7. research has demonstrated that increased number of cases presenting with conjunctival squamous cell carcinoma is related to exposure to daylight combined with infection with the human papilloma virus infection (hpv) sometimes identified with hiv disease8. the occurrence of eye diseases, related with a sexually transmitted disease, might be more typical in patients with hiv, such as herpes infection, toxoplasmosis, gonorrhoea, chlamydia, candida, microsporidia and pneumocystis5. the objective of this study is to determine hiv/acquired immunodeficiency syndrome (aids) related ocular manifestations during a one year study conducted at east jeddah hospital, jeddah, saudi arabia. material and methods a one year retrospective study was conducted in the clinic of east jeddah hospital, in the western region of kingdom of saudi arabia during 2016-2017. all patients who were positive for hiv/aids and taking highly active anti-retroviral therapy seen in the infectious disease of our hospital were included in the study. all patients with other infectious diseases were excluded from the study. the data for the 47 hiv/aids positive referrals was collected from the infectious diseases department by taking history, clinical examinations and laboratory investigations. the ophthalmological examination consisted of adnexal examination, best corrected visual acuity, intraocular pressure (iop), anterior and posterior segment examination, b scan and mri. results there were 47 patients diagnosed and treated with an eye-related problem due to aids. there were single cases of retinal necrosis, anterior uveitis, neovascular glaucoma, pterygium, sixth nerve palsy, bacterial conjunctivitis and adenoviral conjunctivitis each. two cases presented with hiv microangiopathy, blepharitis, cortical blindness after brain abscess, herpes infection, kaposi sarcoma, cytomegalovirus (cmv) retinitis and two patients presented with molluscum contagiosum. three patients presented with tuberculous meningitis, and six with dry eyes. eight patients presented with cataracts, and ten with refractive errors (figure 1). fig. 1: pie chart of the ocular manifestations of hiv/aids at east jeddah hospital, jeddah, ksa. the descriptive statistics of observed patients is shown in table 1. ocular manifestations also occur in patients with different viral load levels. all severe blinding complications we encountered, presented in newly-diagnosed patients with high viral loads and a cd4 count less than 100. the balance of male/female patients in our study is shown in fig 2. the frequency of males living with hiv/aids is almost threefold the number of female patients. out of 10 patients, seven were male. http://www.aao.org/eye-health/diseases/detached-torn-retina muhammad abdul rehman akram, et al 159 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol table 1: descriptive statistics of observed patients. n minimum maximum mean std. deviation variance statistic statistic statistic statistic std. error statistic statistic age 47 9 74 49.85 2.197 15.064 226.912 cd4 47 18 1392 530.11 47.345 324.582 105353.445 valid n (list wise) 47 fig. 2: hiv/aids patients presented in eye unit east jeddah hospital. fig. 3: the correlation coefficient of cd4 ratio with the complication and hiv manifestations. the correlation coefficient of cd4 ratio with the complication and hiv manifestations is shown in fig. 3, which shows a strong positive correlation between cd4 and hiv manifestation. discussion in 2007, there were almost 33 million people diagnosed with hiv throughout the world. out of which 95% deaths occurred in the developing countries9. it is usually transmitted via sexual contact, contact with infected blood or blood products (specifically by sharing of needles) and from the infected mother to child in utero. diagnosis is by detection of virus-specific antibodies confirmed by a blood test and monitoring by pcr. to date, kingdom of saudi arabia is a low hivprevalence nation. there is an active testing program in place for non-saudis, who apply for or renew work contracts (34%), for new residents (23%) and prisoners (15%). a significant portion of non-saudi hiv cases, as a rule, have ready access to testing4. kingdom of saudi arabia has kept up a coordinated effort to keep up-todate with the national aids program (nap), un agencies, and local civil society organizations (cso)9. in this study, we tried to find out eye manifestations of hiv/aids in patients ranging from 9-74 years with a mean of 49.85 years. out of these 76.6% of them were male. the presenting cases were split: 21% with reflective errors, 17% with cataracts, 13% with dry eyes, 6% with tb meningitis and, 4% with cmv retinitis, kaposi sarcoma, herpes infection, cortical blindness, blepharitis and hiv microangiopathy. whereas a diagnosis of adenoviral conjunctivitis, bacterial conjunctivitis, sixth nerve palsy, pterygium, anterior uveitis and retinal necrosis presented in 2% of the total patients. this result could be explained by the fact that in saudi arabia male adult patients are more affected by hiv ocular manifestations dependent upon cd4+ t-lymphocyte counts. generally, kaposi sarcoma, herpes zoster ophthalmicus, candidiasis, and lymphoma have been commonly seen in earlier stages. comparative to other studies, tuberculosis, toxoplasmosis and pneumocystis were observed in advanced cases. cytomegalovirus retinitis and mycobacterium-avium complex infection were noted in patients with severely reduced cd4 counts6. ocular manifestations in hiv/aids patients undergoing highly active antiretroviral therapy pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 160 majority of cases seen in the current study (mean cd4 530.11) presented with significant dry eyes. in six patients (13% of the sample) dry eye syndrome was present. the causes of dry eye can vary from blepharitis to lacrimal glands disturbance. according to acharya et al5-20, occurrence of lid infections is higher in these patients. lid lubrication was maintained for longer than usual periods and omega 3 was recommended to be taken in multivitamin form and from natural plant sources. the second leading ocular manifestation related to patients living with hiv/aids in our study was occurrence of cataracts, 17% presented earlier than non-hiv/aids-affected populations-7. herpes zoster ophthalmicus is documented as occurring in early and advanced stages of hiv/aids and at 4.3% among our study. we noted 2.0% of patients with outer retinal necrosis, characterized by fulminant vitreous inflammation, often leading to blindness of both eyes consecutively. there have been several studies, in africa illustrating high prevalence in groups similar to our study cohort9-10 reflecting the efficiency of maintaining haart therapy with reduced ocular complications related to hiv/aids18—17-19. kaposi sarcoma (ks) is a multifocal vascular tumor, the most common cancer related to hiv 11-14 and is related to the herpes virus 8 (hhv-8) infection. kaposi's sarcoma may cause lesions in multiple sites such as lymph nodes, skin, liver, spleen, lungs, and digestive tract12,15,16. although kaposi sarcoma can occur at any time, it tends to manifest at cd4 count < 350 cells/mm3 13-21. conclusion in our one year study, 47 patients were observed with dominant incidences of dry eyes, cataracts, and refraction. haart treatment is responsible for decreasing the hiv related complications in ophthalmology. the treatment with haart is highly effective in controlling disease, but it is not enough for the prevention of some ocular complications, some of which may lead to irreversible blindness, if untreated. therefore, we strongly recommend obtaining a strategy for visiting an ophthalmologist early on after diagnosis. we strongly recommend that if a patient is living with a diagnosis of hiv/aids, they should see their ophthalmologist immediately if they experience blurred vision, floating spots or "spider-webs," flashlights or blind spots. acknowledgements the authors gratefully acknowledge east jeddah hospital for providing support for this study. references 1. academy of ophthalmology, 2017. how does hiv/ aids affect the eye. american [cited 28 july 2017]. http://www.aao.org/eye-health/diseases/how-doeshiv-aids-affect-eye. 2. who 2016. global health sector strategy on hiv/aids 2016.url:http://http://www.who.int/gho/hiv/en/. 3. mazroa ma, kabbash ia, felemban sm, stephens gm, al-hakeem rf, zumla ai et al. hiv case notification rates in the kingdom of saudi arabia over the past decade (2000-2009). plos one. 2012;7(9):e45919. doi: 10.1371/journal.pone.0045919. epub 2012 sep 26. pmid: 23049892; pmcid: pmc3458799. 4. global aids response progress report, 2017. kingdom of saudi arabia: ministry of health; [cited20 july 2017]. http://journals.plos.org/plosone/article?id=10.1371/jo urnal.pone.0045919 5. kim ys, sun hj, kim th, kang kd, lee sj. ocular manifestations of acquired immunodeficiency syndrome. korean j ophthalmol. 2015;29(4):241-8. doi: 10.3341/kjo.2015.29.4.241. 6. arantes te, faria e, garcia cr, saraceno jjf, muccioli c. clinical features and outcomes of aids-related cytomegalovirus retinitis in the era of highly active antiretroviral therapy. arq bras oftalmol. 2010; 73 (1): 16-21. doi: http://dx.doi.org/10.1590/s000427492010000100003. 7. kempen jh, sugar ea, varma r, dunn jp, heinemann mh, jabs da et al. risk of cataract among subjects with acquired immune deficiency syndrome free of ocular opportunistic infections. studies of ocular complications of aids research group. opthamology 2014; 121 (12): 2317-24. 8. rathi sg, ganguly kapoor a, kaliki s. ocular surface squamous neoplasia in hiv-infected patients: current perspectives. hiv aids (auckl). 2018 mar 14; 10: 33-45. doi: 10.2147/hiv.s120517. pmid: 29559813; pmcid: pmc5857154 9. unaids (joint united nations global aids programme). global report: unaids report on the global aids epidemic 2013. accessed at www.unaids.org/en/media/unaids/contentassets/doc uments/epidemiology/2013/gr2013/unaids_global_re port_2013_en.pdf on july 23, 2014. 10. margolis tp, milner ms, shama a, hodge w, seiff s. herpes zoster ophthalmicus in patients with human immunodeficiency virus infection. am ophthalmol, 1998; 125 (3): 285–291. 11. rubinstein pg, aboulafia dm, zloza a. malignancies in hiv/aids: from epidemiology to therapeutic challenges. aids. 2014 feb 20; 28 (4): 453-65. doi: 10.1097/qad.0000000000000071. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0045919 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0045919 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0045919 http://dx.doi.org/10.1590/s0004-27492010000100003 http://dx.doi.org/10.1590/s0004-27492010000100003 muhammad abdul rehman akram, et al 161 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol 12. rasmussen ld, kessel l, molander ld, pedersen c, gerstoft j, kronborg g et al. risk of cataract surgery in hiv-infected individuals: a danish nationwide population-based cohort study. clin infect dis. 2011; 53 (11): 1156-1163. doi: 10.1093/cid/cir675 13. vaishnani jb, bosamiya ss, momin am. kaposi’s sarcoma: a presenting sign of hiv. indian j dermatol venerol leprol. 2010 mar-apr; 76 (2): 215–8. 14. cheung mc, pantanowitz l, dezube bj. aids-related malignancies: emerging challenges in the era of highly active antiretroviral therapy. oncologist. 2005; 10: 412426. 15. franceschi s, lise m, clifford gm, rickenbach m, levi f, maspoli m et al. swiss hiv cohort study. changing patterns of cancer incidence in the earlyand late-haart periods: the swiss hiv cohort study. br j cancer, 2010; 103: 416-422. 16. gopal s, achenbach cj, yanik el, et al. moving forward in hiv-associated cancer. j clin oncol. 2014; 32: 876-880. 17. guiguet m, boué f, cadranel j, lang jm, rosenthal e, costagliola d et al. clinical epidemiology group of the fhdh-anrs co4 cohort. effect of immunodeficiency, hiv viral load, and antiretroviral therapy on the risk of individual malignancies (fhdh-anrs co4): a prospective cohort study. lancet oncol. 2009; 10: 11521159. 18. thompson ma, aberg ja, cahn p, montaner js, rizzardini g, telenti a et al. antiretroviral treatment of adult hiv infection: 2010 recommendations of the international aids society-usa panel. jama. 2010; 304: 321-333. 19. rutayisire dl, saiba se. ocular manifestations related to hiv/aids at kigali university teaching hospital. rwanda, rawanda med j. 2010; 68 (4):47-51. 20. balne pk, agrawal r, au vb, lee b, loo e, tong l et al. dataset of longitudinal analysis of tear cytokine levels, cd4, cd8 counts and hiv viral load in dry eye patients with hiv infection. data brief. 2017; 3 (11): 152154. doi: 10.1016/j.dib.2017.01.014. 21. nancy fc. is kaposi’s sarcoma occurring at higher cd4 counts over the course of the hiv epidemic? 2011 url:https://www.ncbi.nlm.nih.gov/pmc /articles/ pmc2978255/ author’s affiliation dr. muhammad abdul rehman akram ophthalmology clinic of east jeddah hospital, western region, saudi arabia dr. mazen ahmed alzahrani ophthalmology clinic of east jeddah hospital, western region, saudi arabia dr. asim mahmood multan medical and dental college, multan pakistan dr. thamer basodan ophthalmology clinic of east jeddah hospital, western region, saudi arabia eman oudah alghamdi ophthalmology clinic of east jeddah hospital, western region, saudi arabia dr. ali alansari infectious disease clinic of east jeddah hospital, western region, saudi arabia author’s contribution muhammad abdul rehman study design, data collection, manuscript writing and critical analysis. dr. mazen ahmed alzahrani co author participated in discussion and collected the data. dr. asim mahmood review analysis dr. thamer basodan data collection. eman oudah alghamdi done optometry examination of the patients dr. ali alansari infectious disease clinic, maintaining haart therapy. https://www.ncbi.nlm.nih.gov/pmc%20/articles/%20%20pmc2978255/ https://www.ncbi.nlm.nih.gov/pmc%20/articles/%20%20pmc2978255/ https://www.ncbi.nlm.nih.gov/pmc%20/articles/%20%20pmc2978255/ pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 85 original article post cataract surgery refractive error in myopic patients using srk/t versus holladay 1 formula for iol power calculation sidra anwar, atif mansoor ahmad, irum abbas, zyeima arif pak j ophthalmol 2019, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. sidra anwar trainee registrar department of ophthalmology, federal postgraduate medical institute/shaikh zayed hospital lahore email:sidraanwar@gmail.com …..……………………….. purpose: to compare post-operative mean refractive error with sandersretzlaff-kraff/theoretical (srk-t) and holladay 1 formulae for intraocular lens (iol) power calculation in cataract patients with longer axial lengths. study design: randomized controlled trial. place and duration of study: department of ophthalmology, shaikh zayed hospital lahore from 01 january 2017 01 january, 2018. material and methods: a total of 80 patients were selected from ophthalmology outdoor of shaikh zayed hospital lahore. the patients were randomly divided into two groups of 40 each by lottery method. iol power calculation was done in group a using srk-t formula and in group b using holladay1 formula after keratomery and a-scan. all patients underwent phacoemulsification with foldable lens implantation. post-operative refractive error was measured after one month and mean error was calculated and compared between the two groups. results: eighty cases were included in the study with a mean age of 55.8 ± 6.2 years. the mean axial length was 25.63 ± 0.78mm, and the mean keratometric power was 43.68 ± 1.1 d. the mean post-operative refractive error in group a (srk/t) was +0.36d ± 0.33d and in group b (holladay 1) it was +0.68 ± 0.43. the mean error in group a was +0.37d ± 0.31d as compared to +0.69d ± 0.44d in group b. conclusion: srk/t formula is superior to holladay 1 formula for cases having longer axial lengths. key words: phacoemulsification, intraocular lens power, longer axial length, biometry. ataract and refractive errors are the leading causes of reversible blindness in the world1-3. in a study4 it was found that one fifth (20.9%) of the adult pakistani population suffers from cataract. according to the pakistan national blindness and visual impairment survey5 cataract remains the leading cause of blindness in pakistani population. in all cases of uncomplicated cataract, intraocular lens implantation after phacoemulsification is the treatment of choice6-8 and emmetropia is the refractive target in most patients9. achievement of desired postoperative refraction is a better measure of surgeon skill than the post-operative visual acuity10 which is also dependent on retinal and optic nerve status9. the post-operative refractive outcome of surgery depends not only on surgeon factors, site and type of lens implanted but most of all on accurate pre-operative biometry11-14. the major source of error (35.5%) in c sidra anwar, et al 86 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology biometry is the inaccuracy in the prediction of iol power calculation formulae. the calculation of the dioptric power of an intraocular implant has evolved over the past few decades such that there are multiple calculation formulae giving variable results in different axial length ranges. aristodemou et al15 cited the hoffer q formulae being most accurate for axial lengths below 21.5 mm and srk/t for those above 26 mm. there was no statistical difference in accuracy of different formulae in the medium axial length range. multiple studies have shown variable accuracy for different formulae in the longer axial length range with best results found with haigis16-18, holladay 116,19 and srk/t20. there is high prevalence of axial myopia (longer axial length) in pakistan21 and all over the world22. with recent advances in surgical and biometric techniques, post-operative emmetropia in previously myopic patients has become not only desirable but also achievable. this study is designed to compare the accuracy of prediction of two formulae by comparing the postoperative mean refractive error in the two groups of patients. holladay 1 and srk/t have previously been studied and found to give good results in multiple studies comparing them with other formulae, but these have not been compared with each other in a subset of pakistani population with longer axial lengths. currently, these formulae are two of the most widely used formulae locally. therefore, it is important to test their accuracy of prediction in all ranges of axial lengths, with the aim to define the formula preference in non-average axial length groups. material and methods this was a randomized controlled trial conducted at the department of ophthalmology, shaikh zayed hospital, lahore over a period of one year starting from 01 january, 2017. a total of 80 eyes having cataract, with axial length falling between 24.5 mm and 27 mm were selected through non-probability consecutive sampling. patients of both genders in the age range of 40-70 years having cataract for more than 6 months and falling in the desired axial length range were included. patients were divided randomly into two equal groups, a and b by lottery method. after informed consent was taken, keratometric readings of all subjects were taken by a single operator using automated keratometer. a-scan biometry using immersion technique was used to measure the axial length of the eye to be operated upon. these keratometric readings and axial length measurements were entered in the alcon accuscan (software version 1.15). the power of the intraocular lens implant to be used was calculated by using srk/t formula and holladay 1 formula in group a and b respectively. all the patients underwent phacoemulsification with foldable intraocular lens implant done by single surgeon with 3.2 mm incision given at 10-12 o’clock. mean refractive error was defined as the difference between the value predicted by formulae and the actual postoperative refractive errors calculated after one month of surgery by auto refractometer and confirmed by retinoscopy and converted to spherical equivalent.the collected data was entered into spss version 17. values were recorded as mean ± sd of quantitative variables like age, axial length and mean refractive errors. qualitative data like gender was presented in the form of frequency and percentages. independent sample t-test was used to compare mean refractive error in both groups. p value ≤ 0.05 was considered as significant. data was stratified for age, gender and axial length to address the effect modifiers. post-stratification independent sample ttest was used to check the significance with p-value ≤ 0.05 significant. results eighty eyes of eighty subjects were included in the study, out of which 48 (60%) were male and 32 (40%) were female patients. twenty five (31.25%) males were included in group a and 23 (28.75%) in group b, while 15 (18.75%) females were placed in group a as compared to 17 (21.25%) in group b. their ages ranged from 46 years to 70 years with a mean of 55.8 ± 6.2 years (table 1). table 1: distribution of patients by gender. sex frequency (n) percentage % male group a 25 31.25% group b 23 28.75% total 48 60% female group a 15 18.75% group b 17 21.25% total 32 40% the mean axial length was 25.63 ± 0.78 mm, with a minimum of 24.55 mm and maximum of 27 mm. fifty five (68.75%) of the patients had an axial length ≤ 26 post cataract surgery refractive error in myopic patients using srk/t versus holladay 1 formula for iol pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 87 mm, whereas 25 (31.25%) had axial length greater than 26 mm. group a showed a mean axial length of 25.61 ± 0.74 mm and group b had a mean of 25.64 ± 0.82 mm. the p value (0.376) was found to be insignificant (table 2). table 2: distribution of patients according to axial length. axial length (mm) mean sd range p value overall 25.63 0.78 24.55-27 0.376 group a 25.61 0.75 24.56-27 group b 25.64 0.82 24.55-27 postoperative mean refractive error described in terms of the spherical equivalent ranged from -0.25 d to +1.75 d with a mean of +0.52 d ±0.41 d. group a showed a mean of +0.36 d ± 0.33 d and group b had a mean of +0.68 ± 0.43 (table 3). the p value according to independent sample t-test was 0.087 (> 0.05 = insignificant). the mean refractive error (me) showed an overall mean value of +0.53 ± 0.41 d. the mean refractive error among different patients ranged from a minimum of -0.23d to a maximum of +1.88 d. group a (srk/t) had a mean value of me equal to +0.37 d ± 0.31 d, ranging from -0.23 d to +0.89 d. the other group, b (holladay 1) had a mean value of me, +0.69 d ± 0.44 d, ranging from +0.01 to +1.88. the above data showed that holladay 1 formula has a tendency to give slightly hyperopic results and the p value (p = 0.03) was found to be significant (table 4). table 3: distribution of patients according to postoperative spherical equivalent. post-op spherical equivalent mean ± sd p value overall +0.52 ± 0.41d 0.087 group a +0.36 ± 0.33d group b +0.68 ± 0.43d the mean of me of males in group a was +0.41 ± 0.33 d and for group b it was +0.65 ± 0.36 d. the difference was seen to be insignificant (p = 0.473). whereas, the females in group a showed a mean refractive error (me) of +0.30 ± 0.29d and those in group b had me equal to +0.73 ± 0.54 d with the p value (0.031) found to be significant (table 5). table 4: comparison of patients by mean refractive error between both groups. mean of me (mean refractive error) standard deviation standard error of mean p value group a 0.37 0.31 0.049 0.03 group b 0.69 0.44 0.0697 table 5: stratification of data by gender and mean refractive error. gender groups mean refractive error (me) p value n mean ± sd male a 25 +0.41 ± 0.33d 0.473 b 23 +0.65 ± 0.36d female a 15 +0.30 ± 0.29d 0.031 b 17 +0.73 ± 0.54d table 6: stratification of data by age and mean refractive error. age (years) groups mean refractive error (me) p value n mean ± sd 40 – 55 a 23 +0.36 ± 0.32d 0.82 b 18 +0.62 ± 0.34d 56 – 70 a 17 +0.38 ± 0.32d 0.029 b 22 +0.73 ± 0.51d patients were divided into two groups based on age. the younger group (40-55 years) had a mean me of +0.36 ± 0.32 d in group a and +0.62 ± 0.34 d in group b, with an insignificant p value (0.82). in comparison, the older group showed a mean me of +0.38 ± 0.32d sidra anwar, et al 88 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology in group a and +0.73 ± 0.51 d in group b. the difference in mean refractive error in the two groups in the older aged individuals was significant (p = 0.029) (table 6). two groups based on axial length were made and cases were divided accordingly. the subjects with comparatively shorter axial lengths (24.5-25.5 mm) falling in table 7: stratification of data by axial length and mean refractive error. axial length (mm) groups mean refractive error p value n mean ± sd 24.5-25.5 a 29 +0.35 ± 0.30d 0.53 b 26 +0.50 ± 0.34d 25.51-27 a 11 +0.40 ± 0.36d 0.98 b 14 +1.04 ± 0.40d group a (srk/t formula) showed a mean refractive error of +0.35 ± 0.30 d and those in group b (holladay 1) had a mean refractive error of +0.50 ± 0.34 d, with an insignificant p value(0.53). in the group with longer axial lengths (25.51-27 mm) group a individuals had a mean refractive error of +0.40 ± 0.36 d as compared to +1.04 ± 0.40d in group b. with a p value of 0.98, the difference between the two groups was seen to be insignificant (table 7). discussion this study was designed to compare the error in the refractive outcome of patients having longer axial lengths, while using two different biometric formulas (srk/t and holladay 1). it was found that there was a significant difference in the post-operative mean error among the two groups with holladay 1 formulae giving slightly greater hyperopic results.the cases were stratified into subgroups based on gender, age and axial length and it was found that the mean refractive error was significantly higher in female and older aged individuals in group b (holladay 1), but the difference in mean refractive error in the subgroups of axial lengths was insignificant. these results are consistent with previous studies. bang et al17 found srk/t formulae to be superior to holladay 1 in longer axial lengths. el-nafees et al20 similarly concluded that srk/t gave the lowest mean error, but their results were not significant. these two studies were limited by their sample size. the most extensive study as yet done by aristodemou et al15 found srk/t formula to have lowest mean refractive errors for longer axial lengths with significant differences for axial length longer than 27 mm. in contrast to our results, mitra et al19, in their retrospective study found holladay 1 to be superior to srk/t for individuals with longer axial lengths. this study as well as other studies that have been conducted is limited by their small sample size. other limiting factors in this study were the small range of axial lengths studied and small number or formulae being compared. there is need for more comprehensive studies to be conducted in the future that incorporate a greater number of cases and a broader range of axial lengths and biometric formulae. conclusion this study has shown srk/t formula for be superior to holladay 1 formula for cases having longer axial lengths, with a significantly smaller mean refractive error. to get more statistically significant results, more comprehensive studies need to be conducted on this subject. conflict of interest: none. author’s affiliation dr. sidra anwar mbbs, trainee registrar department of ophthalmology, sheikh zayed hospital, lahore. dr. atif mansoor ahmad mbbs, fcps, frcs, associate professor department of ophthalmology, sheikh zayed hospital, lahore. dr. irum abbas mbbs, fcps, assistant professor department of ophthalmology, sheikh zayed hospital, lahore. dr. zyeima arif mbbs, medical officer department of ophthalmology, sheikh zayed hospital, lahore. post cataract surgery refractive error in myopic patients using srk/t versus holladay 1 formula for iol pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 89 role of authors dr. sidra anwar data collection, compilation, writing the manuscript dr. atif mansoor ahmad analysis, critical review, interpretation of results dr. irum abbas literature review, critical review dr. zyeima arif literature review references 1. jonas jb , george r, asokan r, flaxman sr, keeffe j, leasher j et al. prevalence and causes of vision loss in central and south asia: 1990-2010. br j ophthalmol. 2014 may; 98 (5): 592-8. 2. khairallah m , kahloun r, flaxman sr, jonas jb, keeffe j, leasher j, et al. prevalence and causes of vision loss in north africa and the middle east:19902010. br j ophthalmol. 2014 may; 98 (5): 605-11. 3. keeffe j , taylor hr, fotis k, pesudovs k, flaxman sr, jonas jb, et al. prevalence and causes of vision loss in southeast asia and oceania: 1990-2010. br j ophthalmol. 2014 may; 98 (5): 586-91. 4. shah sp, dineen b, jadoon z, bourne r, khan ma, johnson gj, et al. lens opacities in adults in pakistan: prevalence and risk factors. ophthalmic epidemiol. 2007 nov; 14 (6): 381-9. 5. dineen b, bourne rr, jadoon z, shah sp, khan ma, foster a, et al. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007 aug; 91 (8): 1005-10. 6. spiteri av, aggarwal r, kersey tl, sira m, benjamin l, darzi aw, et al. development of virtual reality training curriculum for phacoemulsification surgery. eye (lond) 2013; 10: 1038. 7. schriefl sm, stifter e, menapace r. impact of low versus high fluidic settings of the efficacy and safety of phacoemulsification. acta ophthalmol. 2013; 92 (6). 8. joseph s, ravilla t, bassett k. gender issues in a cataract surgical population in south india. ophthalmic epidemiol. 2013; 20 (2): 96-101. 9. moshirfar m, mccaughey mv, santiago-caban l. corrective techniques and future directions for treatment of residual refractive error following cataract surgery. expert rev ophthalmol. 2014; 9 (6): 529– 537. 10. simon ss, chee ye, haddadin ye et al. achieving target refraction after cataract surgery. ophthalmology; 121 (2): 440-444. 11. sahin a, hamrah p. clinically relevant biometry. curr opin ophthalmol. 2012; 23 (1): 47–53. 12. sheard r. optimising biometry for best outcomes in cataract surgery. eye (lond). 2014; 28 (2): 118–125. 13. wang j k, hu c y, chang s w. intraocular lens power calculation using the iol master and various formulas in eyes with long axial length. int j ophthalmol. 2013 april; 6 (2): 150-4. 14. reitblat o, assia ei, kleinmann g, levy a, barrett gd, abulafia a. accuracy of predicted refraction with multifocal intraocular lenses using two biometry measurement devices and multiple intraocular lens power calculation formulas. clin experiment ophthalmol. 43: 328-334. 15. aristodemou p, cartwright nek, sparrow jm, johnston rl. formula choice: hoffer q, holladay 1, or srk/t and refractive outcomes in 8108 eyes after cataract surgery with biometry by partial coherence interferometry, j cataract & refract surg 2011, 37(1); 6371. 16. abulafia a, barrett gd, rotenberg m, kleinmann g, levy a, reitblat o, et al. intraocular lens power calculation for eyes with an axial length greater than 26.0 mm: comparison of formulas and methods. j cataract refract surg. 2015 mar; 41 (3): 548-56. 17. bang s, edell e, yu q, pratzer k, stark w. accuracy of intraocular lens calculations using the iol master in eyes with long axial length and a comparison of various formulas. ophthalmology, 2011 mar; 118 (3): 503-6. 18. ghanem a a, elsayed h m. accuracy of intraocular lens power calculation in high myopia. oman j ophthalmol. 2010 sep-dec; 3 (3): 126–130. 19. mitra a, jain e, sen a, tripathi s. a study regarding efficacy of various intraocular lens power calculation formulas in a subset of indian myopic population. indian j ophthalmol 2014 jul; 62 (7): 826–828. 20. el-nafees r, moawad a, kishk h, gaafar w. intraocular lens power calculation in patients with high axial myopia before cataract surgery. saudi journal of ophthalmology, 2010; 24: 77–80. 21. shah sp, jadoon mz, dineen b, bourne rr, johnson gj, gilbert ce, et al. refractive errors in the adult pakistani population: the national blindness and visual impairment survey. ophthalmic epidemiol. 2008 mayjun; 15 (3): 183-90. 22. fricke tr, jong m, naidoo ks, et al. global prevalence of visual impairment associated with myopic macular degeneration and temporal trends from 2000 through 2050: systematic review, meta-analysis and modelling. br j ophthalmol. 2018; 102 (7): 855–862. 46 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology original article efficacy of intralesional triamcinolone acetonide for the treatment of chalazion tanweer hassan khan, shakir zafar, waqar-ul-huda pak j ophthalmol 2017, vol. 33 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: waqar-ul-huda associate ophthalmologist, lrbt free tertiary eye care hospital korangi, karachi email: waqarhuda@yahoo.com …..……………………….. purpose: to assess the resolution of chalazion after intralesional injection of triamcinolone acetonide at tertiary care hospital in karachi. study design: case series. place and duration of study: lrbt free tertiary eye care hospital karachi from january 2016 to june 2016. material and methods: a case series was done in 62 eyes of 62 patients using intralesional injection of triamcinolone acetonide in patients of chalazion. the patients included in the case series were those who had chalazion and presented to outpatient department from january 2016 to june 2016. the patients were included using non-probability purposive sampling technique. the size of the chalazion was measured by using measurement rings of different sizes. resolution of chalazion after intralesional injection of triamcinolone acetonide at 2 weeks was noted. data analysis was done using spss version 13.0. results: fifty (80.6%) patients showed complete resolution of the lesion with single injection of triamcinolone acetonide. complete resolution of chalazion after treatment was directly associated with the duration of chalazion. with longer duration of the lesion complete resolution of the lesion decreased. conclusion: intralesional triamcinolone acetonide injection is very useful in resolving chalazion of different sizes, so this treatment can be used as a convenient treatment option for chalazion. keywords: chalazion, intralesional, triamcinolone acetonide chalazion is a lipogranulomatous lesion of the eyelid that develops due to the retention of meibomian gland secretion. the granuloma contains various inflammatory cells, including epithelioid and giant cells, neutrophils, eosinophils, and lymphocytes. the condition affects people of all ages and is one of the common eye diseases. approximately 25% of chalazion resolves by itself1. the use of warm compresses and hygiene of the lids2, intralesional steroid injection3,4, and incision and curettage are the different treatment options. treatment with warm compresses and lid hygiene are based on patient compliance, while incision and curettage is a relatively painful procedure and needs local anesthesia or general anesthesia especially in children. intralesional corticosteroid therapy of chalazion is not a new procedure5. intralesional triamcinolone acetonide injection of chalazion is an effective, easy and a safe method6. this study will give an effective alternative option for chalazion in patients like children, patients with allergy to local anaesthetics and in those who have fear for operation theatre environment and surgery. it is particularly suitable for chalazion located close to the lacrimal punctum. a efficacy of intralesional triamcinolone acetonide for the treatment of chalazion pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 47 material and methods: a case series including 62 patients was done using intralesional injection of triamcinolone acetonide in patients of chalazion. the patients included in the case series were those who had chalazion and presented to outpatient department from january 2016 to june 2016. the patients were categorized with respect to the duration of the lesion into 3 categories i.e. less than 2 months, between 2 and 3 months and more than 3 months. the patients were also categorized with respect to size of the lesion in to 2 groups. i.e. less than 5 mm and 5 or more. sizing of the lesion was done using measurement rings of different sizes. the patients included in the study were having chalazion diagnosed clinically on either upper or lower eyelid with slit lamp biomicroscope, 15 years of age so that the injection could be easily injected intralesionally under topical anesthesia and of either gender. the patients excluded from the study were those having infected chalazion, previously medically or surgically treated lesions, patients with any associated predisposing ocular or systemic co-morbidity. the patients were included using non-probability purposive sampling technique. informed written consent was taken after explaining the purpose and procedure of the study. the size of the chalazion was measured by using measurement rings of different sizes. the conjunctiva was first anaesthetized with proparacaine hcl eye drops. triamcinolone acetonide 0.1 ml diluted with lignocaine to a concentration of 5mg/ml was injected through the conjunctiva into the lesion with the 30-guage needle7. on examination, if there was no palpable mass on the eyelid, it was considered as complete resolution of chalazion after 2 weeks. these findings were entered into the proforma. data analysis was done using spss version 13.0. results most of the patients were between 31 to 50 years of age that is 60.2% as shown in figure 1a. the average age of the patients was 38.7 ± 14.2 years. out of 62 patients, 27 (44%) were male and 35 (56%) were female. similarly average duration of chalazion and size of chalazion were 2.8 ± 1.8 months and 4.5 ± 3.0 mm respectively as presented in table 1. fig. 1a: age distribution of the patients. table 1: variables mean ± sd 95% ci age (years) 38.7 ± 14.2 37.5 to 42.3 duration of chalazion (months) 2.8 ± 1.8 2.3 to 4.2 size of chalazion (mm) 4.5 ± 3.1 4.12 to 5.82 duration of chalazion was 2 to 3 months in 35 (57%) patients, above 3 months in 15 (24%) and below 2 months in 12 (19%) patients as shown in figure 1b. similarly size of chalazion was less than and equal to 5 mm in 40 (65%) cases while greater than 5 mm were observed in 22 (35%) cases as shown in figure 2. results of resolution of chalazion after intralesional injection of triamcinolone acetonide at 2 weeks is presented in figure 3. fifty (80.6%) patients experienced complete resolution of the lesion with treatment of single injection while remaining 12 patients exhibited no response to the treatment. tanweer hassan khan, et al 48 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology fig. 1b: duration of chalazion. fig. 2: size of chalazion. fig. 3: resolution of chalazion after intralesional injection of triamcinolone acetonide at 2 weeks. data was also analyzed with respect to age groups, size and duration of chalazion as presented in table 2 to 4. complete resolution of chalazion was high that is 72.7% to 96% in all age groups whereas it was low in above 50 years of age (44.4%) as shown in table 2. table 2: resolution of chalazion after intralesional injection of triamcinolone acetonide with respect to age groups. age groups n resolution of chalazion yes n = 50 no n = 12 16 to 20 years 5 4 (80%) 1 (20%) 21 to 30 years 11 8 (72.7%) 3 (27.3%) 31 to 40 years 25 24 (96%) 1 (4%) 41 to 50 years 12 10 (83.3%) 2 (16.7%) > 50 years 9 4 (44.4%) 5 (55.6%) complete resolution was 100% in those patients whose duration of chalazion was below 2 months and 85.7% in those patients whose duration were between 2 to 3 months while it was observed low (53.3%) in those patients who tolerated above 3 months as shown in table 3. table 3: resolution of chalazion after intralesional injection of triamcinolone acetonide with respect to duration of chalazion. duration of chalazion n resolution of chalazion yes n = 50 no n = 12 < 2 months 12 12(100%) 0 (0%) 2 to 3 months 35 30 (85.7%) 5 (14.3%) > 3 months 15 8 (53.3%) 7 (46.7%) complete resolution of chalazion was high in those patients whose size of chalazion was less than and equal to 5 mm as shown in table 4. discussion chalazion is one of the most common eyelid lesions presenting in the outpatient department in daily efficacy of intralesional triamcinolone acetonide for the treatment of chalazion pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 49 routine clinics. it normally presents as a firm nodular, painless swelling extending either anteriorly toward the skin or posteriorly toward the conjunctiva8. table 4: resolution of chalazion after intralesional injection of triamcinolone acetonide with respect to size of chalazion. size of chalazion (mm) n resolution of chalazion yes n=50 no n=12 ≤ 5 mm 40 38 (95%) 2 (5%) > 5 mm 22 12 (54.5%) 10 (45.5%) in a study9, it was shown that more than 25% chalazion resolve by itself, but the others are dubious to resolve without any treatment. the usual standard management of these lesions is by incision and curettage, which is often a minor surgical procedure but causes discomfort and distress to the patient. there is a study10, in which they have compared the three methods of treatment of chalazion, intralesional triamcinolone acetonide injection, incision and curettage and the combination of incision, curettage and intralesional triamcinolone acetonide injection. the results demonstrated that the intralesional triamcinolone acetonide injection was a rapid and most effective method of treatment10. this is consistent with the results of our study. several studies have showed the result of intralesional or subcutaneous steroid injection for the treatment of chronic chalazion with reported success and resolution in up to 95% of the cases. in our study we have found resolution of chalazion from 73% to 96%. there is a study done by ben simon gi11, evaluated the safety and efficiency of intralesional triamcinolone acetonide (ta) injection in chalazion. they showed that, intralesional injection of ta in primary and recurrent chalazia is effective in achieving lesion regression. this is again consistent with our study results. in a similar study12, kaimbo assessed the efficacy of intralesional corticosteroid injection in the management of chalazia and brought to a conclusion that intralesional corticosteroid injection appears to be effective in managing chalazion12. khanna13 also showed similar results in one study. intra-lesional corticosteroid treatment for the same is still simple, economical and a convenient procedure without any major complication14,15. the intralesional corticosteroid injection was considered to be the most reasonable one due to several reasons. there is no need for eye padding, less painful, more economical, does not require much skill, does not need local anesthesia and can be performed in children. dexamethasone, a water soluble drug has been tried in few studies but the results were not encouraging16. there is an important study done in pakistan17, in which they have compared the outcome of intralesional corticosteroid injection and surgical treatment of chalazia. 79% of patients in surgical treatment group and 62% of patients in steroid injection group at first visit after two weeks showed success in chalazion resolution. the success in surgical treatment group improved to 89% of patients after second operation and to 80% of patients in steroid injection group after second injection of the steroid given at second week17. these results are also comparable with the results of our study. in the absence of a control group in the current study, it is important to highlight that our guidelines merely represent our clinical experience, and the efficacy of triamcinolone acetonide injection versus natural remission cannot be evaluated. our finding is in line with earlier studies in which steroid injection resulted in a 50% to 95% success rate and in clinical remission of the chalazion18,19. our study was in contrast to prasad and gupta20 who compare subconjunctival total removal with incision, curettage, and intralesional steroid injection. several issues make surgery a less desirable option for many patients, especially in the younger age group; for instance, patients may have psychological fear of surgery as opposed to medical treatment or an injection21. certainly, as a recent survey by a canadian group22 suggests chalazion surgery should be treated with the same respect as any other operation. there have been very rare reported complications such as retinal and choroidal vascular occlusion23 and inadvertent globe penetration, skin depigmentation at the site of injection and delayed post-injection hemorrhage in an elderly hypertensive patient24,25. depigmentation changes are described in a minority of patients19. in general, our patients were satisfied with the triamcinolone acetonide injection and in most cases, they preferred repeated injections to surgery. tanweer hassan khan, et al 50 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology conclusion intralesional triamcinolone acetonide injection is very useful in resolving chalazion of different sizes, although it is almost 100% effective when the chalazion size is smaller and of lesser duration. this treatment can be used in future as a convenient treatment option especially for small sized chalazion. author’s affiliation dr. tanweer hassan khan associate ophthalmologist, lrbt free tertiary eye care hospital korangi karachi. dr. shakir zafar consultant ophthalmologist, lrbt free tertiary eye care hospital korangi, karachi. dr. waqar-ul-huda associate ophthalmologist, lrbt free tertiary eye care hospital korangi, karachi. role of authors dr. tanweer hassan khan formulating the protocol, data analysis, writing of manuscript. dr. shakir zafar manuscript review. dr. waqar-ul-huda formulating the protocol, data analysis, writing of manuscript. references 1. cottrell d, bosanquet r, fawcett i. chalazions: the frequency of spontaneous resolution. bmj. 1983; 287 (6405): 1595-1595. 2. perry h, serniuk r. conservative treatment of chalazia. ophthalmology 1980; 87 (3): 218-221. 3. pizzarello l, jakobiec f, hofeldt a, podolsky m, silvers d. intralesional corticosteroid therapy of chalazia. american journal of ophthalmology. 1978; 85 (6): 818-821. 4. singh dua h, nilawar d. nonsurgical therapy of chalazion. american journal of ophthalmology. 1982; 94 (3): 424 -425. 5. leinfelder p. depo-medrol in treatment of acute chalazion. american journal of ophthalmology. 1964; 58 (6): 1078. 6. ahmad s, baig m, khan m, khan i, janjua t. intralesional corticosteroid injection vs. surgical treatment of chalazia in pigmented patients, j coll physicians surg pak. 2006; 16 (1): 42-44. 7. colon m, sutula f. congenital eyelid abnormalities. in: albert dm, jacobiec fa, eds. principles and practice of ophthalmology. philadelphia: wb saunders company, 1995: 1693. 8. cottrell d, bosanquet r, fawcett i. chalazions: the frequency of spontaneous resolution. bmj. 1983; 287 (6405): 1595-1595. 9. cottrell d, bosanquet r, fawcett i. chalazions: the frequency of spontaneous resolution. bmj. 1983; 287 (6405): 1595-1595. 10. thabit a. m, ismat h. o. three methods of treatment of chalazia in children. saudi medical journal. 2001; 22 (11): 968-972. 11. bensimon g, huang l, nakra t, schwarcz r, mccann j, goldberg r. intralesional triamcinolone acetonide injection for primary and recurrent chalazia: is it really effective? ophthalmology. 2005; 112 (5): 913-917. 12. kaimbo w. intralesional corticosteroid injection in the treatment of chalazion. journal français d'ophtalmologie. 2004; 27 (2): 149-153. 13. khanna k, mittal o. non-surgical treatment of chalazion. indian journal of ophthalmology. 1981; 29 (2): 83-85. 14. castress j. stressborg t. corticosteroid injection of chalazia acta ophthalmologica. 2009; 61 (5): 938-942. 15. pizzarello l, jakobiec f, hofeldt a, podolsky m, silvers d. intralesional corticosteroid therapy of chalazia. american journal of ophthalmology. 1978; 85 (6): 818-821. 16. panda a, angra s. intra lesional corticosteroid therapy of chalazia. indian journal of ophthalmology. 1987; 35 (4): 183-185. 17. ahmad s, baig m, khan m, khan i, janjua t. intralesional corticosteroid injection vs. surgical treatment of chalazia in pigmented patients. j coll physicians surg pak.2006; 16 (1): 42-44. 18. khurana a, ahluwalia b, rajan c. chalazion therapy. intralesional steroids versus incision and curettage. acta ophthalmol. 1988; 66: 352– 354. 19. mohan k, dhir s, munjal v, jain i. the use of intralesional steroids in the treatment of chalazion. ann ophthalmol. 1986; 18: 158–160. 20. prasad s, gupta a. subconjunctival total excision in the treatment of chronic chalazia. indian j ophthalmol 1992; 40 (4): 103–105. 21. li r, lai j, ng j, et al. efficacy of lignocaine 2% gel in chalazion surgery. br j ophthalmol 2003; 87 (2): 157– 159. 22. smythe d, hurwitz jj, tayfour f. the management of chalazion: a survey of ontario ophthalmologists. can j ophthalmol. 1990; 25: 252–5. 23. thomas el, laborde rp. retinal and choroidal vascular occlusion following intralesional corticosteroid injection of a chalazion. ophthalmology 1986; 93: 405–7. 24. hosal bm, zilelioglu g. ocular complication of intralesional corticosteroid injection of a chalazion. eur j ophthalmol 2003; 13: 798–9. 25. procope ja, kidwell ed jr. delayed postoperative hemorrhage complicating chalazion surgery. j natl med assoc. 1994; 86: 865–6. http://www.pakmedinet.com/author/salahuddin+ahmad http://www.pakmedinet.com/author/mushtaq+ahmed+baig http://www.pakmedinet.com/author/muhammad+azam+khan http://www.pakmedinet.com/author/inamul+haq+khan http://www.pakmedinet.com/author/teyyeb+azeem+janjua http://www.pakmedinet.com/jcpsp http://www.pakmedinet.com/jcpsp http://www.pakmedinet.com/jcpsp http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22ben%20simon%20gj%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22huang%20l%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22nakra%20t%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22schwarcz%20rm%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22mccann%20jd%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22mccann%20jd%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22mccann%20jd%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22goldberg%20ra%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus javascript:al_get(this,%20'jour',%20'ophthalmology.'); http://www.pakmedinet.com/author/salahuddin+ahmad http://www.pakmedinet.com/author/mushtaq+ahmed+baig http://www.pakmedinet.com/author/muhammad+azam+khan http://www.pakmedinet.com/author/inamul+haq+khan http://www.pakmedinet.com/author/teyyeb+azeem+janjua http://www.pakmedinet.com/jcpsp http://www.pakmedinet.com/jcpsp http://www.pakmedinet.com/jcpsp pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 51 original article comparison of patching for strabismic and anisometropic amblyopia sumaira aamir, aamir asrar, mubashir jalis, sadaf ishtiaq, bisma ikram pak j ophthalmol 2017, vol. 33 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ms. sumaira aamir optometrist and orthoptist combined military hospital (cmh), rawalpindi-pakistan email: sumairajoya321@gmail.com …..……………………….. purpose: to compare the effectiveness of patching for the treatment of strabismic and anisometropic amblyopia among 4-10 years old children. study design: prospective case series. place and duration of study: amanat eye hospital from may 2014 to november 2014. material and methods: prospective case series was conducted in 100 children among the age group 4 – 10 years. cycloplegic refraction was done by the use of cyclopentolate eye drops 1.0% in every child. after best-corrected refraction in the amblyopic eye, patients were instructed to use glasses strictly along with patching of the good eye. patching was done for the time period of 2 hours, 3 hours and 6 hours according to the severity of amblyopia. results: the mean age and sd of the patients was 7.09 years±1.821sd. there were 56% male and 44% female. there was an insignificant difference in bestcorrected visual acuity for strabismic and anisometropic amblyopia among three and six months patching result. vision improvement was seen in 75% patients while 25% did not improve after three months of the patching treatment. after further three months of patching treatment and at the end of 6 months, further vision improvement was observed in 51% patients while 49% did not improve. vision improvement at six months after 3 months of further patching treatment was comparatively less than the initial three months of patching treatment. conclusion: improvement of vision in first three months of patching treatment was comparatively greater than further 3 months of patching (at the end of six months) among patients with strabismic and anisometropic amblyopia. key words: amblyopia, patching therapy, strabismus, anisometropia. mblyopia is a visual disorder due to the ineffectiveness of eye and brain working together. it is the most common causes of decreased vision among children and younger adults. it is always associated with strabismus, anisometropia or form deprivation early in life1. amblyopic patients have poor spatial acuity, low contrast sensitivity and reduced sensitivity to motion2. about 90% of work in the children’s eye services is related to amblyopia3. the standard treatment for amblyopia is occlusion therapy, which involves patching of the dominant eye to encourage the use of an amblyopic eye. in young children, this treatment is quite effective with 75% of the children showing improvement in visual acuity4. however, its effectiveness decreases in older children and adults5. adults with amblyopia6 are currently offered no treatment in clinical practice, due to the finding that patching of the fellow eye is ineffective after the age of 10 years7, presumably due to the lack of plasticity in the adult visual cortex8. however, recent studies have shown that monocular functions of the amblyopic eye can be partly recovered as a result of intensive training of the amblyopic eye, which in turn suggests the a https://en.wikipedia.org/wiki/eye https://en.wikipedia.org/wiki/brain sumaira amir, et al 52 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology existing of some degree of plasticity in adult amblyopes at the monocular site9,10. poor response to amblyopia treatment includes older age, worse visual acuity and strabismus. compliance is another factor that can have the major effect on the final outcome of treatment for amblyopia. the level of compliance with occlusion treatment has been found to be poor11,12. in addition to clinical parameters, it has been related to factors involving communication with the parents and patients13,14. education of the parents with written information concerning amblyopia, the critical period and treatment reduced the level of non-compliance. the objective of the study was to evaluate the efficacy of patching treatment in terms of best corrected visual acuity in strabismic and anisometropic amblyopic patients after the follow-up period of 3 months and 6 months among 4-10 years age group. material and methods a prospective study was conducted in the settings of amanat eye hospital, rawalpindi. consecutive sampling technique was used to collect the sample of 100 children from may 2014 to november 2014 who presented with amblyopia and were 4-10 years old. there were 50 patients who presented with anisometropia and 50 with strabismus. properly informed consent was taken from parents of the amblyopic patients. an approval was taken from the hospital ethical committee. inclusion criteria were, age of 4-10 years, no improvement with best-corrected refraction in one eye than other, amblyopia associated with strabismus and anisometropia, cycloplegic refraction, no history of the previous patching. exclusion criteria included neurological impairment, nystagmus, macular and optic nerve disease. monocular and binocular visual acuity was taken by using snellen’s chart at the distance of 6 m. after pupillary reactions and ocular motility were assessed, cover-uncover test and prism cover test were performed in strabismic patients. cycloplegic refraction was done by the use of cyclopentolate eye drops 1.0% in every child. after obtaining the bestcorrected refraction in the strabismic and anisometropic patients, they were instructed to use glasses along with patching of the good eye to encourage the use of an amblyopic eye. patching was done for the time period of 2 hours, 3 hours and 6 hours according to the severity of amblyopia. the patients who were responding to the occlusion therapy, patching time was reduced. detailed information and instructions to the parents and children regarding poor compliance to patching therapy and visual outcomes of patching therapy were explained. patients were followed up at 3 months and 6 months for evaluating improvement in visual acuity with patching treatment, no patching was done for more than 6 months. statistical analysis was performed by using spss version 22.0. visual acuities were converted to log mar for statistical analysis. pre and post-op visual acuity before and after the patching treatment was compared using independent sample t-test. all the results were evaluated at the confidence interval of 95%. p-value < 0.05 was considered to be statistically significant. results the mean age of the patients was 7.09 years ± 1.821 sd. there were 56% males and 44% females. right eye was affected in 57% and left eye was affected in 43% of the participants. an independent sample t-test was conducted to compare the best-corrected visual acuity after three months of patching treatment in strabismic and anisometropic amblyopic patients. there was an insignificant difference in best-corrected visual acuity for strabismic and anisometropic patching treatment with p value = 0.894 at 95% ci = (-0.0830 to 0.0950). the effect size was small (0.01). the results of threemonths patching treatment in the amblyopic eye are shown in table 1. graphical representation showed total vision improvement in strabismic and anisometropic amblyopia after three months of patching treatment, as vision improved in 75% and did not improve in 25% ( figure 1). independent sample t-test reported that there was an insignificant difference among strabismic and anisometropic amblyopia after six months of patching treatment with p-value = 0.815 at 95% ci = (-0.0745 to 0.0945). the effect size was small (0.01). six months patching treatment visual results were shown in table 2. graphical representation showed vision improvement in strabismic and anisometropic amblyopia after six months of patching treatment, as http://www.nature.com/articles/srep02638#ref5 comparison of patching for strabismic and anisometropic amblyopia pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 53 table 1: results of initial three-months patching treatment in amblyopic eye. type of amblyopia vision improved percentage vision did not improved percentage p-value (effect size) strabismic amblyopia 38 76% 12 24% 0.894(0.01) anisometropic amblyopia 37 74% 13 26% table 2: results of further 3 months of patching treatment in amblyopic eye seen at the end of 6 months. type of amblyopia vision improved percentage vision did not improve percentage p-value (effect size) strabismic amblyopia 24 48% 26 52% 0.815 (0.01) anisometropic amblyopia 27 54% 23 46% vision improved vision did not improved fig. 1: three months patching result. 48 48.5 49 49.5 50 50.5 51 vision improved vision did not improved fig. 2: six months patching result. vision improved in 51% and did not improve in 49% (figure 2). graphical representation showed that the results of vision improvement were comparatively less in strabismic and anisometropic amblyopia with six months patching treatment as shown in figure 3. 0 10 20 30 40 50 60 70 80 three-months patching treatment six-months patching treatment vision improved vision did not improved fig. 3: three and six months patching result. discussion this comparative study assessed the strabismic and anisometropic amblyopic patching therapy among the age group 4-10 years. correction of refractive error sumaira amir, et al 54 vol. 32, no. 1, jan – mar, 2016 pakistan journal of ophthalmology with spectacles along with the patching treatment results in significant improvement in visual acuity. it is generally believed that the critical period for visual development in humans ends at the age of 6 to 7 years. some eye care professionals believed that amblyopia treatment is effective until 9 or 10 years. the american academy of ophthalmology preferred practice pattern for amblyopia recommends treatment up to age 10 years15. oliver et al16 reported that children older than 8 years showed a significant improvement in their visual acuity, almost as good as that in younger children. rutstein and fuhr17 reported that age above 8 years, visual acuity of 6/12 or better could be obtained in only 27% of patients. however, in this study visual acuity of 6/12 or better could be obtained in 30% of patients older than 8 years. epelbaum et al18 reported that the results of patching therapy could be observed best when patching treatment is done before three years of age in strabismic amblyopia. rutstein et al19 reported that the visual acuity improvement is somewhat lesser in patients older than seven years than in younger patients. however, in this study there was a child aged 8 years presented with anisometropia, best corrected visual acuity 6/24 after giving patching trial of 6 hours, visual acuity improved to 6/12 and then after six months reached to 6/7.5 .visual improvement initially was faster in the patching group, but after six months analysis the difference of both patching group was small. various studies have favored amblyopia treatment at the age < 6 – 7 years20,21 but few studies have reported better outcomes in older children22,23. this study results showed that the visual outcomes were independent of the patient's age, suggesting that the amblyopia can be treated successfully beyond the age that is considered to be the critical period for the visual development. increased prevalence of blindness in the population is still a reality in this part of the world. one way of preventing future blindness is to detect amblyopia at an early stage and give adequate patch treatment. this could be done by school health care, at eye clinics, in the local health center, thus preventing blindness for a low cost. the limitations of the study include smaller sample size and shorter follow-ups. conclusion this study concludes that the improvement of vision after three months of initial patching treatment was comparatively greater than further 3 months of patching (at the end of 6 months) among patients with strabismic and anisometropic amblyopia. author’s affiliation ms. sumaira amir optometrist and orthoptist combined military hospital (cmh), rawalpindipakistan dr. aamir asrar mbbs, mrcophth, frcs, fellowship in vitreoretinal surgery, fellowship in corneo-refractive surgery, chief consultant ophthalmologist, amanat eye hospital, islamabad–pakistan. dr. mubashir jalis mbbs, mcps, fcps, fellow-ship in pediatric ophthalmology, associate professor islamabad medical and dental hospital, consultant ophthalmologist, amanat eye hospital, rawalpindipakistan ms. sadaf ishtiaq optometrist and orthoptist, msph, al-shifa school of public health, rawalpindi-pakistan ms. bisma ikram optometrist and orthoptist, msph, amanat eye hospital, rawalpindi-pakistan role of authors ms. sumaira amir concept, research design, sample collection, data collection, manuscript writing and data analysis. dr. aamir asrar sharing of data and manuscript review. dr. mubashir jalis sharing of data. ms. sadaf ishtiaq data analysis. ms. bisma ikram data analysis. references 1. de zarat br, tejedor j. current concepts in the management of amblyopia. clin ophthalmol. 2007; 1: 403-14. comparison of patching for strabismic and anisometropic amblyopia pakistan journal of ophthalmology vol. 32, no. 1, jan – mar, 2016 55 2. stewart ce, moseley mj, stephens da, fielder ar, the motas cooperative. the treatment dose-response in amblyopia therapy: results from the monitored occlusion treatment of amblyopia study (motas) invest ophthalmol vis sci. 2004; 45: 3048-54. 3. astle at, mcgraw pv, webb bs. can human amblyopia be treated in adult hood. strabismus. 2011; 19: 99-109. 4. repka mx, beck rw, holmes jm, et al. pediatric eye disease investigator group. a randomized trial of patching regimens for treatment of moderate amblyopia in children. arch ophthalmol. 2003; 121: 603–611. 5. scheiman mm, hertle rw, beck rw, et al.; pediatric eye disease investigator group. randomized trial of treatment of amblyopia in children aged 7 to 17 years. arch ophthalmol. 2005; 123: 437–447. 6. levi dm. prentice award lecture 2011: removing the brakes on plasticity in the amblyopic brain. optom vis sci. 2012; 89: 827–838. 7. scheiman, m. m. et al. randomized trial of treatment of amblyopia in children aged 7 to 17 years. arch ophthalmol. 2005; 123: 437–447. 8. huang, c. b., zhou, y. & lu, z. l. broad bandwidth of perceptual learning in the visual system of adults with anisometropic amblyopia. proc natl acad sci usa, 2008; 105: 4068–4073. 9. levi, d. m. & li, r. w. perceptual learning as a potential treatment for amblyopia: a mini-review. vision res. 2009; 49: 2535–2549. 10. li, r. w., ngo, c., nguyen, j. & levi, d. m. videogame play induces plasticity in the visual system of adults with amblyopia. plos biology, 2011; 9: 7339-750. 11. stewart ce, moseley mj, stephens da, et al. treatment dose-response in amblyopia therapy: the monitored occlusion treatment of amblyopia study (motas).invest ophthalmol vis sci. 2004; 45: 3048-54. 12. newsham d. parental non-concordance with occlusion therapy. br j ophthalmol. 2000; 84: 957-62. 13. stewart ce, stephens da, fielder ar, et al. objectively monitored patching regimens for treatment of amblyopia: randomised trial. bmj 2007; 335: 707. 14. loudon se, fronius m, looman cwn, et al. predictors and a remedy for non-compliance with amblyopia therapy in children measured with the occlusion dose monitor. invest ophthalmol vis sci. 2006; 47: 4393-400. 15. amblyopia preferred practice pattern,. american academy of ophthalmology, san francisco, california; sept 2012. 16. oliver m, neumann r, chaimovitch y, gottesman n, shimshoni m. compliance and results of treatment for amblyopia in children more than 8 years old. am j ophthalmol. 1986; 102: 340–345. 17. rutstein rp, fuhr ps. efficacy and stability of amblyopia therapy. optom vis sci. 1992; 69: 47–54. 18. epelbaum m, milleret c, buisseret p, dufier jl. the sensitive period for strabismic amblyopia in humans. ophthalmology. 1993; 100: 323–7. 19. rutstein rp, fuhr ps. efficacy and stability of amblyopia therapy. optom vis sci. 2003; 69: 747–54. 20. de zarate br, tejedor j. current concepts in the management of amblyopia. clin ophthalmol 2007; 1:403-14. 21. astle at, mcgraw pv, webb bs. can human amblyopia be treated in adulthood. strabismus. 2011; 19: 99-109. 22. wallace dk; pediatric eye disease investigator group, edwards ar, cotter sa, beck rw, arnold rw, astle wf, et al. a randomized trial to evaluate 2 hours of daily patching for strabismic and anisometropic amblyopia in children. ophthalmology, 2006; 113: 90412. 23. pediatric eye disease investigator group. randomized trial of treatment of amblyopia in children aged 7 to 17 years. arch ophthalmol. 2005; 123: 437-47. pak j ophthalmol. 2020, vol. 36 (2): 136-140 136 original article role of vitamin d in near sightedness yasir iqbal 1 , aqsa malik 2 , rabbia shabbir 3 , atteaya zaman 4 , masooma talib 5 1,5 watim medical and dental college, rawat, rawalpindi, 2 department of biochemistry, medical college, mirpur, 3 department of biochemistry, hitec. imc dental college, taxilla, 4 federal medical and dental college, islamabad abstract purpose: to determine the levels of vitamin d in children with myopia and to compare them with age matched controls. study design: case control study. place and duration of study: the study was conducted in naseer memorial hospital, dadhyal azad kashmir from march 2016 to march 2017. methods: two hundred patients were selected using convenient sampling technique and were divided two groups (group i myopic and group ii control). myopia was labeled if after subjective refraction a spherical equivalent (se) of −0.50 diopters (d) or more was found. vitamin d levels were measured by radioimmunoassay technique with diasorin sr® kit following the user’s manual. vitamin d levels less than 20 ng/ml were considered vitamin d deficient following the standards of american academy of pediatrics. the collected data was entered in the statistical package for social sciences (spss) version 21 for analysis. independent t–test was used to determine the significant difference of means between controls and patients. p-values less than 0.05 were considered significant. results: mean age of controls and myopes were 10.65 ± 3.9 and 10.20 ± 2.5 years respectively. vitamin d levels in myopic children were found to be 14.95 ± 3.75 ng/ml and there was no significant difference in mean values of vitamin d levels in myopic and control group. conclusion: we found no difference in vitamin d levels of myopic and non myopic children and concluded that vitamin d has no role in development or progression of myopia. key words: vitamin d, myopia, refractive error, objective refraction. how to cite this article: iqbal y, malik a, shabbir r, zaman a, talib m. role of vitamin d in near sightedness, pak j ophthalmol. 2020; 36 (2): 136-140. doi: 10.36351/pjo.v36i2.990 introduction types of refractive errors are myopia, hyperopia and astigmatism. 1 in myopia, the person is able to see near objects and the distant ones are blurry hence the term correspondence: yasir iqbal watim medical and dental college, rawat, rawalpindi email: yazeriqbal@gmail.com received: january 24, 2020 accepted: march 8, 2020 near sightedness. it can occur at any age like in childhood or adolescence and even in old age. there is no gender predisposition and is affected globally. 2 it can be classified as physiologic and pathologic. the cause of physiological myopia can be high curvature of the cornea, nuclear sclerosis and elongated eyeball or combination of these factors with the absence of any other ocular pathology. 3 the cause of pathologic myopia is abnormal lengthening of the eyeball leading to thinning of the sclera wall and other complications. another classification is based on age of onset. it tends to run in the families and no occupational association has been found. mailto:yazeriqbal@gmail.com yasir iqbal, et al 137 pak j ophthalmol. 2020, vol. 36 (2): 136-140 myopia is prevalent in 20% of the population worldwide and is estimated that 12% children are affected. 2 in pakistan its prevalence is 6% in adults and in children it is reported as high as 21%. 4,5 the figure is on the rise every year and is presenting as major global health problem. 2 not only it has a social impact on the individual, making the person unable to perform the tasks of desire, it acts as a factor in adding individuals with less productivity. 6 furthermore, myopia is a risk factor for other visually blinding diseases like glaucoma and retinal detachment which further implicates on the health system. for these reasons the pathophysiology of development of myopia remained a hot debate since ages. the pathophysiology of myopia had been associated with many myths. reading books in dim light or while lying on bed, watching too much television and even deficiency of vitamin a had been proclaimed but no scientific reason was found. some researchers advocate genetic predisposition and have identified numerous genetic loci linked with myopia whereas others have attributed to less outdoor activity and vitamin d deficiency. 7.8 vitamin d, once considered a vitamin, is now being treated as a hormone. many studies have demonstrated vitamin d having effects on biological processes like calcium and phosphorus metabolism regulation as well as cell proliferation and differentiation, immune regulation and neurogenesis. 9,10 it is found to be associated with cardiovascular diseases, cancers, autoimmune and infectious diseases. about 90% of the vitamin d is derived from the skin and around 10% from diet. there are two forms of vitamin d, vitamin d3 (cholecalciferol) and vitamin d2 (ergocalciferol). vitamin d3 is derived from the skin after exposure to ultraviolet light. after absorption from intestines and the synthesis by skin, vitamin d is converted into 25 (oh) d in the liver. if the 25 (oh) d levels are greater than or equal to 30 ng/ml it is considered as normal and less than this is considered as vitamin d deficiency. 11 recently time spent outdoors has become area of interest in myopia research. researchers have found low incidence of myopia in those who spent more time outdoors as compared to the ones who are more involved in indoor activities, which led to the concept that vitamin d might be a possible moderator of this association. 8 researchers have reported high incidence of myopia in children aged 5 to 15 years. 12 therefore, in this study we compared vitamin d levels of myopic and non-myopic children in order to determine whether vitamin d has a role in myopia pathophysiology or not. methods it was an observational case-control study conducted at naseer memorial hospital, dadyal azad kashmir, from march 2017 to march 2019. the study was conducted according to the guidelines of declaration of helsinki. a formal verbal consent from the children and their parents was taken before the commencement of the study. after fulfilling the inclusion and exclusion criteria, patients were selected using convenient non-probability sampling technique and were divided two groups (group i myopic and group ii control). selection criteria for group i was; children of any gender with age between 5 to 15 years and diagnosed with physiological myopia. group ii were age-matched controls. subjects with history of ocular surgery, eye diseases like glaucoma, uveitis, retinal disease, cataract, systemic disease, any therapeutic regimen or steroid use were excluded from the study. demographic information i.e., age, gender and history of systemic disorders were recorded. children underwent complete ocular examination including visual acuity, detailed slit lamp examination, intraocular pressure measurement and ophthalmoscopy before cycloplegic retinoscopy was done. myopia was labeled if after subjective refraction a spherical equivalent (se) of −0.50 diopters (d) or more was found (mild myopia if se less than −3.0 d; moderate myopia if greater than or equal to −3.0 d; and high myopia was defined as more than or equal to −6.0 d). children with myopia were included in group i whereas those having astigmatism and hyperopia was excluded. children with no refractive error were included in the control group. informed consent was taken from the parents of all participants. for assessment of vitamin d levels, 2cc of venous blood was collected and after centrifugation serum was stored at −20°c temperature in laboratory freezer for further analysis. vitamin d levels were measured by radioimmunoassay technique with diasorin sr® kit following the user’s manual. vitamin d levels less than 20 ng/ml were considered vitamin d deficiency following the standards of american academy of pediatrics. the collected data was entered in the statistical role of vitamin d in near sightedness pak j ophthalmol. 2020, vol. 36 (2): 136-140 138 package for social sciences (spss) version 21 for analysis. gender was expressed as percentages and frequency whereas numerical variables like age and vitamin d levels were expressed as mean and standard deviation. independent t–test was used to determine the significant difference of means between controls and patients. p values less than 0.05 was considered as significant. results a total of 1587 children in between the age of 5 – 15 years were examined during the study period. after fulfilling the inclusion /exclusion criteria, 100 children were selected by simple convenient sampling method for each group. group i consisted of 47.18% males and 52.11% females whereas in group ii were 55.82% males and 44.17% females. the mean ages of controls and myopics were 10.65 ± 3.9 and 10.20 ± 2.5 years respectively. the age difference between the two groups was statistically insignificant (table 1). in group i, 79.4% had mild myopia, 19.6% had moderate myopia and 0.6% had high myopia. the vitamin d levels in myopic children were found to be 14.95 ± 3.75 ng/ml and there was no significant difference in mean values of vitamin d levels in myopic and control group. table 1: descriptive statistics for the myopia and control. group i (myopia) n = 100 group ii (control) n = 100 p-value mean age (years ± sd) 10.20 ± 2.5 10.65 ± 3.9 0.789 gender male 47.18% 55.82% 0.675 female 52.11% 44.17% 0.647 serum vitamin d levels (ng/ml) 15.95 ± 3.75 16.02 ± 5.11 0.625 spherical equivalent refractive error (d) -3.08 ± 2.45 +0.25 ± 0.26 not applicable discussion the pathogenesis of myopia has been a hot debate since ages. its association with excessive near work and less outdoor activity has been advocated by many. 13 atta z et al found myopia in 52.6% of the children studying in madrasas and proposed less outdoor activity to be associated with myopia. 14 similarly, pan cw found that children involved more in outdoor activity have less chances of myopia. 15 similar idea was advocated by tideman jw et al. 16 but the question remained unanswered that how outdoor activity affects refractive error development. it was proposed that better quality of retinal image is attained while viewing distant objects with a small pupil size and accommodative errors may be inhibiting ocular growth and decreasing the risk of myopia. 17 however, evidence from animal models did not support this hypothesis. another proposed hypothesis was an increase in retinal dopamine secretion in response to bright light during outdoors suppresses axial elongation but again no scientific evidence was presented. vitamin d is a vital element for absorption of calcium in the intestines and plays a significant role in the growth of bones along with mineral and calcium homeostasis. 9 the commonly used indicator of vitamin d status is serum 25 (oh) d concentrations. researchers have found a strong association between serum 25 (oh) d concentrations and myopia advocating greater time spent outdoors reduces the risk of myopia. sherwin jc et al reported low serum concentrations of vitamin d in myopes. 8 similarly, low vitamin d concentration was reported by tideman jw et al in patients with high axial length. 16 how vitamin d prevents myopia remains to be answered. one theory is that, as deficiency of vitamin d leads to alteration of intracellular ca level and subsequently causes impaired contraction and relaxation of the ciliary muscles thus leading to myopia. 18 another theory is calcium deficiency secondary to lack of adequate vitamin d levels leading to head and orbit deformity and consequently myopia of prematurity but against this was the finding of no change in refractive status of low birth weight infants after extra-enteral ca supplementation. 18 vitamin d is also thought to affect pathological scleral growth and myopia via retinoic acid. retinoic acid and vitamin d receptors form heterodimers which participate in signaling and cell-cycle regulation but data based studies are lacking. 17 in our study, we found no difference in vitamin d levels of myopics and age matched control. same finding was reported by another researcher, according to whom myopes prefer to stay indoors and consequently have low 25 (oh) d3 levels therefore serum 25 (oh) d3 is simply a biomarker of sun exposure. 19 hence outdoor activity might be mediating myopia prevention via some other pathway instead of vitamin d. analysis done by williams km et al also negated the hypothesis that outdoor activity protects yasir iqbal, et al 139 pak j ophthalmol. 2020, vol. 36 (2): 136-140 against myopia by vitamin d levels. 20 furthermore, he objected that if outdoor activity is protective against myopia it should slow the progression in those who already have myopia. these questions are yet to be answered. in our study the participants had below normal mean 25 [oh] d concentrations and were below the accepted normal value of 20 ng/ml. this is in contrast to other studies in which only myopes had low levels of vitamin d. 15,16 this might be due to other factors like ethnicity, outdoor activity and diet. vitamin d deficiency is reported more in african americans compared to caucasians and more in the regions of middle east, china, mongolia, and the indian subcontinent. 21 the confounder of ethnicity was not addressed in our study. likewise, high vitamin d levels and less incidence of myopia is advocated to be associated with more outdoor activity and to higher dietary intake of vitamin d. 16 mutti et al found no association. 17 according to mutti et al the prevalence of myopia is on the rise in asian population despite the vitamin d rich fish diet. therefore, further researchis needed to identify relevant biological connections between vitamin d and myopia. the diet confounder was also not taken into account in our study. limitation of the study is that it was an observational study not a randomized trial. the confounding factors like time spent outdoors, seasonal variation of measurement and sunlight exposure, dietary habits and demographic variables were not taken into account. conclusion we found no difference in vitamin d levels of myopic and non myopic children and concluded that vitamin d has no role in development or progression of myopia. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest references 1. iqbal y, niazi fk, niazi ma. frequency of eye diseases in school age children. pak j ophthalmol. 2009; 25 (4):147-150 2. morgan i, he m, saw s, krueger r, lam d. myopia. asia pac j ophthalmol. 2016; 5 (6): 383-385. 3. kumar a, chawla r, kumawat d, pillay g. insight into high myopia and the macula. indian j ophthalmol. 2017; 65 (2): 85-91. 4. abdullah as, jadoon mz, akram m, awan zh, azam m, safdar m, et al. prevalence of uncorrected refractive errors in adults aged 30 years and above in a rural population in pakistan. j ayub med coll. 2015; 27 (1): 8-12. 5. latif mz, khan ma, afzal s, gillani sa, chouhadry ma. prevalence of refractive errors; evidence from the public high schools of lahore, pakistan. j pak med assoc. 2019; 69 (4): 464-467. 6. guo w, woodward ma, heisler m, blachley t, corneail l, cederna j, et al. risk factors for visual impairment in an uninsured population and the impact of the affordable care act. clinics in surgery, 2016; 134: 802-809. 7. li m, zhai l, zeng s, peng q, wang j, deng y, et al. lack of association between lum rs3759223 polymorphism and high myopia. opt vis sci. 2014; 91 (7): 707-712. 8. sherwin jc, hewitt aw, coroneo mt, kearns ls, griffiths lr, mackey da. the association between times spent outdoors and myopia using a novel biomarker of outdoor light exposure. invest ophthalmol vis sci. 2012; 53 (8): 4363-4370. 9. bhatt n, ali a, waly mi. non-skeletal benefits of vitamin d. canad j clin nutr. 2019; 7 (1): 141-159. 10. meehan m, penckofer s. role of vitamin d in aging adult. j aging gerontol. 2014; 2 (2): 60–71. 11. tangpricha v, koutkia p, rieke sm, chen tc, perez aa, holick mf. fortification of orange juice with vitamin d: a novel approach for enhancing vitamin d nutritional health. am j clin nutr. 2003; 77 (6): 1478-1483. 12. wu pc, huang hm, yu hj, fang pc, chen ct. epidemiology of myopia. the asia pac j ophthalmol. 2016; 5 (6): 386-393. 13. polling jr, verhoeven vj, tideman jw, klaver cc. duke-elder’s views on prognosis, prophylaxis, and treatment of myopia: way ahead of his time. strabismus, 2016; 24 (1): 40-43. 14. atta z, arif as, ahmed i, farooq u. prevalence of refractive errors in madrassa students of haripur district. j ayub med coll. 2015; 27 (4): 850-852. 15. pan cw, qian dj, saw sm. time outdoors, blood vitamin d status and myopia: a review. photoch photobio sci. 2017; 16 (3): 426-432. role of vitamin d in near sightedness pak j ophthalmol. 2020, vol. 36 (2): 136-140 140 16. tideman jw, polling jr, voortman t, jaddoe vw, uitterlinden ag, hofman a, et al. low serum vitamin d is associated with axial length and risk of myopia in young children. eur j epidemiol. 2016; 31 (5): 491-499. 17. mutti do, marks ar. blood levels of vitamin d in teens and young adults with myopia. opto vis sci. 2011; 88 (3): 377. 18. carroll wf, fabres j, nagy tr, frazier m, roane c, pohlandt f, et al. results of extremely low birth weight infants randomized to receive extra enteral calcium supply. j pediat gastroenterol nutr. 2011; 53 (3): 339. 19. guggenheim ja, williams c, northstone k, howe ld, tilling k, st pourcain b, et al. does vitamin d mediate the protective effects of time outdoors on myopia? findings from a prospective birth cohort. invest ophthalmol vis. sci. 2014; 55 (12): 8550-8558. 20. williams km, bentham gc, young is, mcginty a, mckay gj, hogg r, et al. association between myopia, ultraviolet b radiation exposure, serum vitamin d concentrations, and genetic polymorphisms in vitamin d metabolic pathways in a multicountry european study. jama ophthalmology, 2017; 135 (1): 47-53. 21. van schoor nm, lips p. worldwide vitamin d status. best pract res clin endocrinol metab. 2011; 25 (4): 671-680. authors’ designation and contribution yasir iqbal; associate professor: study design, data collection, manuscript writing, final review. aqsa malik; assistant professor: study design, manuscript writing, final review. rabbia shabbier; lecturer: study design, final review. atteaya zaman, assistant professor: study design, final review. masooma talib; assistant professor: study design, final review. .…  …. pakistan journal of ophthalmology vol. 35, no. 3, jul – sep, 2019 198 original article dry eye disease and pterygium munir baig, rabeeya munir pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: munir baig department of ophthalmology, azad jammu kashmir medical college, muzaffarabad. email: drmuniramjad@gmail.com …..……………………….. purpose: to find the changes in tear film and ocular surface in patients with pterygium. study design: a descriptive cross sectional study. place and duration of study: federal government services hospital islamabad during june 2013 to december 2014. material and methods: dry eye questionnaire (deq-6) was administered by a trained researcher and de tests were performed in all 256 willing subjects (136 with pterygium+120 control) age 30-76 years, by a single surgeon under same physical conditions after taking the consent and approval from hospital ethical committee. diagnosis was made on presence of both symptoms and tear film parameters. statistical analysis by simple percentages. results: dry eyes (de) were found in 73 (53.7%) of the pterygium cases and 28 (23.5%) of the normal patients. in this study, 55 (40.5%) patients were symptomatic, defined as reporting 1 or more de symptoms often or all the time. there were 53 (39%) patients that showed corneal fluorescein staining (cfs) and 69 (51%) showed plugging/mucous threads in both groups. of 136 eyes with pterygium there were 91 (67%) males and 45 (33%) females. out of these 50 (36.7%) patients showed normal tear film and 86 (63.2%) showed deranged functions. moreover, among the 120 control eyes there were 73 (61%) males and 47 (39%)] females. out of these 86 (72.3%) patients were normal and 34 (27.7%) had abnormal functions. these values were reduced indicating altered tear film in these patients. conclusion: pterygium disturbs tear functions causing dry eye like symptoms. key words: dry eye, pterygium, tear film instability, ocular surface. terygium means a wing in greek and it was first mentioned by hippocrates. it is a fleshy, pink growth on the conjunctiva also called surfer’s eye. both pterygium and pinguecula are abnormal growths on ocular surface1. pterygium has a worldwide distribution but it is common after exposure to ultraviolet radiations in warm and dry weather2. sailors, skiers and sports people have a high incidence of pterygia due to reflected uv lights. pterygium is also more common in new zealand3 in ozone layer depletion areas. wolff in 1946, emphasized that meibomian glands are the proper glands of the cornea which have moved out of the way in the benefit of vision4. smooth precorneal tear film formed after blinking protects the ocular surface to maintain quality of vision5. the knowledge about dry eye diseases has improved during last decade. dry eye is tear film disorder damaging interpalpebral ocular surface and causing unstable tear film6. dry eye is also defined as a disturbance of lacrimal functional unit which consists of lacrimal glands, ocular surface including eyelids, meibomian glands, conjunctiva, cornea, goblet cells, and ocular nerves7. dry eye is a common disease, affecting about 5– 30% of subjects aged 50 years and older (dews 2007)6. the beaver dam population based study reported incidence of 14% in adults over 48-91 years8. in p munir baig, et al 199 vol. 35, no. 3, jul – sep, 2019 pakistan journal of ophthalmology australia it is about 7% in elderly people9. in indonesia it is 27.5% with more prevalence in older subjects, with pterygium and smokers10. the purpose of this study was to find out the relationship between tear film changes and pterygium. material & methods there were 136 patients of 30-76 years attending the eye opd of federal government services hospital islamabad from june 2013 to december 2014 having nasal pterygium and 120 normal volunteers of same age, gender and geographical distribution from refraction clinic who were selected and evaluated after taking their consent. patients with any surgery, any systemic disease, lacrimal system disease, contact lens or drops use and refractive errors were excluded from the study. 1. do your eyes ever feel dry? 2. do you ever feel a gritty or sandy sensation in your eye? 3. do your eyes ever have a burning sensation? 4. are your eyes ever red? 5. do you notice much crusting on your lashes? 6. do your eyes ever get stuck shut in the morning? fig. 1: deq-6 questionnaire. a 6 item standardized dry eye questionnaire (deq-6) (figure 1) was administered and scored by a trained researcher. tear film breakup time (tbut), schirmer's test (st), corneal fluorescein staining (cfs) for presence of conjunctival injection, punctate epithelial erosions (pee) and meibomian gland dysfunction (mgd) were assessed by a single surgeon under the same physical conditions. the patients and controls were divided into two groups; group1 in whom both fluorescein break up time and schirmer's tests were normal and group11 in whom either or both tests were abnormal. the eye with the larger pterygium was evaluated amongst bilateral pterygia. the diagnosis was made on the presence of three out of five parameters. all data was entered into spss version 17 and analyzed for frequencies/percentages. results of 256 subjects, age 30-76 years, 64.8% were urban, 69.9% were educated government servants, 22% were smokers and 29.6%were laborers. there were 19 (14.1%) subjects who showed pterygium in both eyes while 117 (85.9%) had pterygium in one eye (table 1). table 1: baseline characters in cases and control. pterygium subjects n = 136 normal eyes n = 120 male 91 (67%) male 71 (59%) female 45 (33%) female 49 (41%) dry eye 73 (53.6%) 27 (23%) irritation 91 (67%) redness 39 (33%) urban 92 (67.4%) 74 (32.6%) average pterygium width 5.5mm smokers 33 (24.2%) 22 (18%) right/left eyes 58/78 ----- of 136 eyes with pterygium 50 (37.5%) showed normal tear film and 86 (62.5%) showed derranged functions whereas among 120 control eyes 86 (72.3%) were normal and 34 (27.7%) had abnormal tear functions. these values were reduced indicating tear film instability in these patients. burning was the most common symptom reported among 91 (67%) patients in the case group. both genders during the fourth decade had more numbers of pterygia. moreover indoor workers were affected more in both groups (table 2). table 2: age and gender wise distribution of cases and controls. age group eyes with pterygium = 136 normal s = 120 in years male female male female 30-39 12 6 14 8 40-49 29 15 24 16 50-59 25 13 22 15 60-69 19 11 9 5 70-76 6 2 5 total 91 (67%) 45 (33%) 71 (59%) 49 (41%) at limbus the average pterygium width was 5.5 mm and average corneal involvement was 4.0 mm. dry eye tests showed low tear film breakup time tbut (< or = 10 seconds) and low schirmer test st (<or =5 mm/5min.) in 86(63%) and 46 (34%) of subjects respectively (table 3) where the mean tbut and st values were 8.56 seconds and 12.19 mm respectively and in control group it was 22.25 seconds and 18.50 mm/5min. there were 53 (39%) patients who showed corneal fluorescein staining cfs and 69 dry eye disease and pterygium pakistan journal of ophthalmology vol. 35, no. 3, jul – sep, 2019 200 (51%) showed plugging/mucous threads in both groups. dry eye tests in cases and controls are shown in table 4. table 3: tbut percentages. tbut <10 secs 10-15 sec >15sec abnormal borderline normal n= (%) (n= (%) (n= (%) cases 86 63% 30 22 % 20 14.7% control 16 13.3% 13 11.1% 91 75.5% table 4: dry eye tests in cases and controls. dry eye tests n= (%) control n-= (%) normal tbut, 16 12% 94 78.3% normal schirmer’s normal tbut, 27 20% 8 6.7% abnormal schirmer’s, abnormal tbut, 40 29% 8 6.6% normal schirmer’s abnormal tbut, 53 39% 10 8.3% abnormal schirmer total 136 100 120 100 discussion the pathogenesis of pterygium is not understood completely. in equatorial regions ultraviolet radiations cause pterygium formation specifically uv-b radiations. studies show that p53 tumor suppressor gene undergoes mutations leading to abnormal limbal epithelium proliferation. the possible risk factors are age, hereditary factors, chronic inflammation, smoking, lower education, high refractive errors, sunlight, heat and micro trauma11. it is common in the general population and progresses slowly but has little effect on vision. in our study most of the cases of pterygium were found in the fourth decade (40-49 years). it is similar to another study12. in advanced age excessive exposure to sun light causes the formation of pterygium. but, recent studies denied any relation of age with the pterygium incidence13. in our study pterygium was seen more in patients with indoor activities contrary to the study of viso et al, (2011)14. in islamabad the indoor laborers (53%) suffered more than outdoor labourers (47%) with pterygium because in islamabad they used to work 4-5 hours/day in the kitchen. similarly, new studies denied any relationship between nature of work and pterygium2. the tear film breakup time using fluorescein break is used to measure the tear film quality15. our study indicated abnormal tbut test in 62.2% of pterygium eyes and in 27.7% of eyes without pterygium. another study reported reduced tbut test in 30.3% of pterygium group and 21.9% eyes without that16. another study reported tbut instability in 39.7% eyes with pterygium and in 23% eyes without it17. bekibele et al18 mentioned lower tbut values in pterygium patients than normal eyes similar to our study. our results revealed reduced st values in 34% of patients of pterygium group similar to the study of roka et al, 201319. conversely, the study of kampitak and leelawongtawun showed that the st results did not change in pterygium patients20. tear functions improved as tbut and schirmer test were prolonged. li et al found improvement in tear function in patients after pterygium excision21. however, li and colleagues noticed that there is no difference in schirmer test values after pterygium operations. li et al. reported both tear quality and quantity decrease in pterygium group with a decrease in goblet cell population. turkyilmaz et al.22 found that the mean goblet cell density was increased 1 month after excision. moreover, ye et al reported that both tear film break-up time and schirmer test were different in study and control groups similar to our study23. in the literature no cases of pterygium were found in children below the age of 5 years. this study revealed that 67% males were more affected than 33% females. one study2 noticed no gender dependence. another study from rural dali in china noticed an increased pterygium formation in females than men24. the lifestyle of labor between the genders may be the reason. a study by peng et al in tibet reported that women were at a higher risk than men related with their lifestyle. in tibet, women were more often involved in outdoor activities and jobs25. it has been found that excessive use of drops containing preservatives can destroy goblet cells and the ocular surface resulting in de16. a pterygium induces astigmatism if larger than 3 mm. more than 3.5 mm lesions can result in more than 1 d of astigmatism causing blurring of vision. also interestingly our study showed that the prevalence of pterygium increased with age until 69 years of age and then declined similar to another study26. in this study 51% subjects showed lid plugging and mucous threads. this mucus pattern brings changes in the munir baig, et al 201 vol. 35, no. 3, jul – sep, 2019 pakistan journal of ophthalmology ocular surface. mucin reduces the surface tension of tears and increases the wettability of the hydrophobic lipoprotein epithelial surface23. this study was done to know the dry nature of the eyes having pterygium. other studies have proved that pterygium excision improved tear osmolarity and tear film functions which were deteriorated again with the recurrence of pterygium26. in this study when normal subjects were compared with pterygium patients, both tear film breakup time and schirmer's test showed changed values. the tear film changes cause dellen formation leading to focal dryness. the limitation of our study was that it was conducted in a single center. further studies need to be done with larger sample size to improve the generalizability of the results. conclusion there is a relation between tear film functions, ocular surface changes and pterygium. the function of meibomian gland is derranged in pterygium patients which initiates dellen formation which leads to dryness. pterygium disturbs tear functions causing dry eye like symptoms. references 1. johnson rd, pai vc, hoft rh. historical approaches to pterygium surgery, including bare sclera and adjunctive beta radiation techniques. in: hovanesian ja, editor. pterygium: techniques and technologies for surgical success. thorofare, nj: slack incorporated; 2012: 2012: 27–36. 2. asokan r, venkatasubbu rs, velumuri l, lingam v, george r. prevalence and associated 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https://www.ncbi.nlm.nih.gov/pubmed/?term=klein%20be%5bauthor%5d&cauthor=true&cauthor_uid=24388838 https://www.ncbi.nlm.nih.gov/pubmed/?term=klein%20be%5bauthor%5d&cauthor=true&cauthor_uid=24388838 https://www.ncbi.nlm.nih.gov/pubmed/?term=klein%20be%5bauthor%5d&cauthor=true&cauthor_uid=24388838 https://www.ncbi.nlm.nih.gov/pubmed/?term=klein%20r%5bauthor%5d&cauthor=true&cauthor_uid=24388838 https://www.ncbi.nlm.nih.gov/pubmed/?term=dalton%20ds%5bauthor%5d&cauthor=true&cauthor_uid=24388838 dry eye disease and pterygium pakistan journal of ophthalmology vol. 35, no. 3, jul – sep, 2019 202 sekeryapan b, durmus m. effect of pterygium surgery on tear osmolarity. j ophthalmol. 2013; 2013: 863498. 23. ye f, zhou f, xia y, zhu x, yan wu y. evaluation of meibomian gland and tear film changes in patients with pterygium indian j ophthalmol. 2017 mar; 65 (3): 233– 237. 24. zhong h, cha x, wei t, lin x, li x, li j et al. prevalence of and risk factors for pterygium in rural adult chinese populations of the bai nationality in dali: the yunnan minority eye study. invest ophthalmol vis sci, 2012; 53: 6617-6621. 25. lu p, chen x, kang y, ke l, wei x, zhang w. pterygium in tibetans: a population-based study in china clin exp ophthalmol. (2007); 35 (9): 828-833. 26. kheirkhah a, safi h, molaei s, nazari r, behrouz mj, raju vk. effects of pterygium surgery on front and back corneal astigmatism. can j ophthalmol. 2012; 47: 423–8. author’s affiliation munir baig department of ophthalmology, azad jammu kashmir medical college muzaffarabad dr. rabeeya munir oral biology islamic international dental college islamabad author’s contribution munir baig study design, manuscript writing, data collection dr. rabeeya munir manuscript writing and critical analysis. https://www.ncbi.nlm.nih.gov/pubmed/?term=ye%20f%5bauthor%5d&cauthor=true&cauthor_uid=28440253 https://www.ncbi.nlm.nih.gov/pubmed/?term=zhou%20f%5bauthor%5d&cauthor=true&cauthor_uid=28440253 https://www.ncbi.nlm.nih.gov/pubmed/?term=xia%20y%5bauthor%5d&cauthor=true&cauthor_uid=28440253 https://www.ncbi.nlm.nih.gov/pubmed/?term=zhu%20x%5bauthor%5d&cauthor=true&cauthor_uid=28440253 https://www.ncbi.nlm.nih.gov/pubmed/?term=wu%20y%5bauthor%5d&cauthor=true&cauthor_uid=28440253 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5426129/ microsoft word tayyaba gul 79 original article strategy for the management of rhegmatogenous retinal detachment with proliferative vitreoretinopathy tayyaba gul malik, naeem ullah, mian muhammad shafiq, muhammad khalil pak j ophthalmol 2008, vol. 24 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyaba gul malik ophthalmology department ghurki trust teaching hospital lahore received for publication january’ 2007 …..……………………….. purpose: to device a strategy for the proper surgical management of rhegmatogenous retinal detachment with proliferative vitreoretinno-pathy. material and methods: this prospective study was carried out in the ophthalmology department of sir ganga ram hospital. in this study, twenty-five cases were selected. the cases were divided into three groups according to the surgical techniques. in the first group, scleral buckling was done. in the second group, pars plana vitrectomy was done and silicone oil was used for internal tamponade. in the third group pars plana vitrectomy with internal as well as external tamponade was done. follow-up was for a minimal of six months. results: anatomical attachment was achieved in 84% cases. with grades b and c we had 100% results. regarding functional results, the final visual acuity was > 6/60 in 12% cases. it was between 1/60 and 6/60 in 52% and perception and projection of light or finger counting in 28% cases. projection became faulty in two cases, which developed extensive pvr post-operatively. there were few post-operative complications. cellophane maculopathy was seen in 8% cases and secondary glaucoma due to post-operative uveitis in 4% cases. 16% had retinal re-detachment and macular pucker was observed in 4% cases. there were 8% cases in which posterior sub-capsular opacities were seen. no gross complications were seen in 60% cases. conclusion: cases of pvr grade b can be well managed with scleral buckling procedures. in patients who present with pvr grade c, the chances of further progression of the proliferative process are highest. eyes with pvr grade d were once considered as blind eyes are well managed with pars plana vitrectomy, airfluid exchange and with external or internal tamponade. he evolution of retinal detachment operation is one of the most remarkable chapters in the history of ophthalmology. gonin’s1 operation for repair of the detached retina ranks with daviel’s cataract extraction and von graefe’s iridectomy for acute glaucoma as the three greatest surgical treatments for blindness. retinal detachment with proliferative vitreoretinopathy (pvr) is not a single t 80 disease entity rather it consists of cascades of events, so that sometimes it becomes very difficult to mark boundaries between its different grades. the objective of the study is to device a strategy for the proper surgical management of the disease. material and methods the study was carried out in the ophthalmology department of sir ganga ram hospital during the year 1997-1998. it involved the analysis of patients attending the hospital with retinal detachment complicated by pvr. throughout the study, retina society grading19832 was followed. however, for the purpose of reference, up-dated classification of pvr is also mentioned in each case. as we were usually encountered with grades b, c and d, so, only these cases were included. a total of twenty five cases were studied and five cases were selected for each grade i.e., grades b, c, d1, d2 and d3. once the patient was admitted in the ward, following care-taking steps were taken: 1. ocular and systemic history 2. visual acuity testing 3. slit-lamp biomicroscopic examination 4. applanation tonometry. 5. fundus examination with indirect ophthalmoscope and goldmann 3-mirror or mainster lens for minor details. 6. fundus drawings the details of fundus examination of patients are shown in (table 1-3). surgical procedures depending upon the type of surgical procedure, the cases were divided into three groups. group 1: cases in which retinocryopexy and scleral buckling were done. group 2: cases in which pars plana vitrectomy with internal tamponade (with silicone oil) was performed. group 3: cases in which pars plana vitrectomy with internal and external tamponade was carried out. instrumentation and surgical procedures for group 1: this group included four patients with pvr grade b and one patient with pvr grade c. they underwent scleral buckling procedure with drainage of the subretinal fluid under general anesthesia. retinocryopexy was done to the retinal breaks and the areas of lattice degeneration. a double row was applied just posterior to the breaks. most patients underwent a segmental silicone sponge or 360o encirclement was done in rest of the patients of this group. instrumentation and surgical procedures for group ii: in this group pars plana vitrectomy with silicone oil was carried out in all cases. instrumentation and surgical procedures for group iii: in this group, pars plana vitrectomy was performed with internal as well as external tamponade. pars plana vitrectomy and scleral buckling procedures were exactly the same as for group i and group ii. post operative inflammatory reaction was controlled with topical steroids. topical antibiotic therapy was given to prevent the infection. the patients were followed up for at least 6 months. results results of group i in this group, retinocryopexy and scleral buckling procedures were performed in five patients. anatomical attachment was achieved with the primary procedure in 100% cases. 80% cases had final visual acuity between 1/60 and 6/60 while 20% cases had more than 6/60 (table 2). cellophane maculopathy was the only complication, which was encountered in this group. it was seen in two cases (40%). results of group ii in this group pars plana vitrectomy was performed. details are shown in table 3. anatomic results were 100 % in this group. the only complication seen in this group was raised intraocular pressure (iop) and post operative anterior uveitis (seen in only one patient). topical ß-blockers with steroids and carbonic anhydrase inhibitors were given for one week. the reaction in anterior chamber settled and iop returned 81 to normal. anti glaucoma therapy was stopped and steroids were tapered off. results of group iii there were a total of twelve patients in whom pars plana vitrectomy was performed with external as well as internal tamponade. three patients with retinal dialysis were also included in the same group. for details refer to table 4. final re-attachment was achieved in eight patients (66.7%). in six out of these eight (75%), retina was attached with the primary surgery. while, in rest of the two (25%) cases, multiple surgeries were required to achieve the results. table 1: clinical data of group 1 cases eye retinal detachment breaks pvr status of other eye corrected visual acuity pre-operative postoperative case 1 right sub-total (111 o'clock) 7 and 10 o'clock + scattered areas of lattice b retina attached. 6 flat holes inferiorly. + lattice degeneration on temporal side fc 6/60. case 2 right total 5 o'clock b nad* pl+ pr+ 4/60. case 3 left total 5 o'clock b nad* hm 6/60. case 4 right sub-total (3 8 o'clock) a row of large retinal breaks from 4-7 o'clock + scattered areas of lattice. b scattered areas of lattice 6/36. 6/60. case 5 right sub-totat (3-8 o' clock) a large break at 6 o'clock with fibrous cuff. c nad* fc 6/18. fc = finger counting hm = hand movements pl+pr+ =perception and projection of light nad =no abnormality detected table 2: clinical data of group ii cases eye breaks pvr status of other eye corrected visual acuity pre-operative postoperative case 1 right a horse-shoe tear at 6 o'clock. 5 small breaks in line from 11-1 o'clock at the periphery. d1 no perception of light fc 3/60. case 2 left 4,7 and 1 o'clock c nad pl+ pr+ 6/36. case 3 left macular hole d3 macular degeneration pl+pr+ fc case 4 left 2 breaks quadrilateral in shape at 10 o'clock c pthisical fc 6/60. case 5 left macular hole d2 nad pl+pr+ 6/60. case 6 right 10 o'clock d3 nad pl+pr+ 6/36. 82 case 7 right two macular holes, one of them exactly at fovea. d3 nad pl+pr+ pl+pr+ case 8 right a large operculated horse-shoe tear at 10 o'clock. another small break just anterior to it. c posterior staphaloma. myopic degeneration pl+pr+ 6/60. fc = finger counting hm = hand movements pl+pr+ =perception and projection of light table 3: clinical data of group iii cases eye breaks pvr status of other eye corrected visual acuity pre-operative postoperative case 1 right 5 o' clock d1 myopic degeneration. areas of lattice + paving stone degeneration pl+ pr+ 6/60. case 2 left inferomedial to the disc at 7 o'clock c nad pl+ pr+ 1/60. case 3 left 5 o'clock d2 long standing r.d. with pvr d2 fc 1/60. case 4 left 350o dialysis.superior retina inverted and folded upon itself. disc was hidden behind the fold. choroid was visible in three quadrants. b pthisis bulbi pl+ pr+ fc case 5 right at 1,3,4,6,7,9 and 11 o'clock in the periphery d2 pthisis bulbi pl+ pr+ hm case 6 left macular hole d1 long standing r.d with pvr-d2 pl+ pr+ 1/60. case 7 left two breaks at 10 o'clock. another small break at 5 o'clock d3 retinal reattachment surgery already done. retina attached pl+ pr+ fc case 8 left multiple breaks from 1-5 o' clock. areas of lattice from 911 o'clock d3 total r.d. with pvr d2 pl+ pr+ pl+ pr faulty case 9 left a large temporal dialysis from 7-8 o'clock (270o) d1 nad pl+ pr+ 1/60. case 10 left an operculated break at 6 o'clock. area of lattice with multiple breaks from 12-1 o'clock. a giant tear at 7-8 o'clock d2 pthisis bulbi hm fc case 11 right two operculated breaks at 6 o'clock d2 nad fc fc case 12 right a large temporal dialysis from 7-11 o'clock d1 areas of white without pressure in the superonasal quadrant. pl+ pr+ pl+ pr faulty rd = retinal detachment 83 fc = finger counting hm = hand movements pl+pr+ = perception and projection of light anatomical attachment was not achieved in four (33.33%) cases. macular pucker was seen in only one case; the patient with retinal dialysis of 350•. the early post-operative visual acuity was 6/36, because of macular pucker it dropped to finger counting. significant posterior sub-capsular opacities were noticed in two patients. both of them had post traumatic retinal dialysis. irrigation and aspiration was done in these cases. table 4: anatomic and functional results pvr anatomical results % functional results n (%) b 100 pl+pr+/hm/fc (20) 1/60 to 6/60 (80) >6/60 (0) c 100 pl+pr+/hm/fc (0) 1/60 to 6/60 (60) > 6/60 (40) d1 60 pr faulty (20) 1/60 to 6/60 (80) >6/60 (0) d2 80 pl+pr+/hm/fc (60) 1/60to 6/60 (40) >6/60 (0) d3 80 pl+pr+/hm/fc (60) 6/60 (20) pr faulty (20) table 5: percentage of complications complications no. of cases n (%) cellophane maculopathy 2 (8) anterior uveitis and secondary glaucoma 1 (4) re-detachment 4 (16) macular pucker 1 (4) posterior sub-capsular 2 (8) opacities no gross complication observed 15 (60) discussion surgical management of rhegmatogenous retinal detachment with pvr involves marching up a step ladder of history taking, ocular and systemic examination and reaching to a most suitable surgical strategy which can bring optimal visual functioning to the patient. in this study twenty-five cases of pvr were studied. regarding the epidemiological data, retinal detachment with pvr was more common in teen age group. there were 12 patients (48%) who were under 20 years of age, 7 cases (28%) were between 20-40 and only 6 patients (24%) were above 40 years. the most common cause of retinal detachment in teen ages was trauma. 40% patients had history of ocular injury either recent or remote. all these patients were less than 40 years. depending upon the type of surgical procedure, the cases were divided into three groups. in group i, retinocryopexy was done and external tamponade with silicone sponge was sufficient to attach the retina. four patients of pvr grade b and one patient of pvr grade c were included in this group. in group ii, pars plana vitrectomy was done in all cases and silicone oil was used for internal tamponade. different studies have shown that silicone oil has better retinal attachment rates when compared with sf6 and air. in group iii, pars plana vitrectomy with internal as well as external tamponade was done. in these cases retinocryopexy and scleral buckling was preceded by pars plana vitrectomy. these techniques were modified where and when required, e.g., perfluorocarbon liquid (d-k line) was used in one case of retinal dialysis of 350o. cases with very extensive pvr as well as two other cases of retinal dialysis were managed without perfluorocarbon for financial reasons. 84 considering the anatomical results, final retinal attachment was achieved in 21 cases (84%). in 19 patients (76%), retina was attached with primary surgery either with scleral buckling or pars plana vitrectomy or both. in two cases (8%), multiple procedures had to be tailored to achieve the required results. if the results are defined in terms of grades of pvr, it is seen that the anatomical results are 100% with grades b and c, 60% for d1 and 80% for d2 and d3. it can be compared with the results of pournaras cj and donati g8 in which retinal attachment was achieved in 79% cases of grade b and 47% cases of grade c after one surgical procedure. functional results depend upon a number of different factors including, pre-operative visual acuity, condition of macula, macular hole, amount of pvr, age of the patient and duration of retinal detachment. in our setup patients usually present late. although anatomical results were excellent, functional results were not very promising because of the late medical consultation by the patients. final visual acuity after 6 months was > 6/60 in 3 cases (12%). it was between 1/60 and 6/60 in 13 patients (52%), perception and projection, hand movements or finger counting in 7 cases (28%) and 2 cases (8%) resulted in faulty projection. one of the patients in whom macula was attached at admission, the post-operative visual acuity was 6/6 during the second week. after six months it dropped to 6/18 because of cellophane maculopathy. similarly, the other case in which macula was attached at admission had post-operative visual acuity of 6/24 which was 6/60 after six months because of cellophane maculopathy. it is interesting to mention here that cellophane maculopathy was not seen in cases in which macula was detached although macular pucker was observed in one case of retinal dialysis of 3500. this observation of cellophane maculopathy is similar to the study done by uemura a9 who compared pre-operative detached macula cases with intact macula cases. he found that the occurrence of epimacular membranes was higher in intact macula cases; being 68% at 12 months after surgery. silicone oil was the only substance, which was used for internal tamponade. there is a wealth of information available pertaining to the complications of silicone oil, which are described by many surgeons; e.g. complicated cataract, secondary glaucoma, keratopathy and retinal toxicity. there are people who prefer to remove silicone oil after few months. according to harry willshaw, liquid silicone oil should be removed in every case if possible10. but in my study, no such complications were encountered during the six months follow-up. so, it seems reasonable not to remove silicone oil until and unless some complication occurs. posterior sub-capsular opacities developed in two cases, which were managed through extracapsular cataract extraction. pars plana vitrectomy is an invasive procedure and chances of post-operative uveitis are always there. this problem was seen in only one case, which was tackled with steroidal and non-steroidal anti inflammatory agents. secondary glaucoma was also seen in this patient and it was managed with ßblockers. the most serious of all complications was inferior retinal redetachment. it was seen in two cases of pvr grade d. initially, pars plana vitrectomy with silicone oil was done. silicone oil because of its upward buoyancy, provided sufficient tamponade to the superior retina but the inferior retina remained detached. on fundus examination, epi-retinal membranes were found to be causing traction. epiretinal membrane peeling was carried out and segmental scleral buckle was applied to the inferior retina. retinal attachment could not be achieved. this revealed that silicone oil tamponade was insufficient in cases of inferior retinal detachment. all those cases in which either there was an inferior retinal detachment or cases of total retinal detachments with inferior breaks, scleral buckling was performed for external tamponade with or without pars plana vitrectomy depending upon the grade of pvr. bonnet m11 states that the incidence of postoperative pvr in rhegmatogenous retinal detachment has decreased, but it seems that it is still the most important cause of retinal re-detachment, specially anterior pvr if it remains undetected during the first surgical procedure. in any case of pvr, the usual surgical strategies include: sealing of retinal breaks, removal of epiretinal membranes and pars plana vitrectomy, performing retinectomy at the site of retinal stiffening and applying scleral buckle but there are some cases in which, even after all these heroic procedures, sub-retinal fibrosis and retinal shortening continues and there is no hope of retinal attachment. if multiple surgical procedures are 85 performed in these cases, there is rather acceleration of the proliferative process. as the clinical spectrum of the disease is becoming more obvious and the thoughtful speculation on its pathogenesis is increasing, it is hoped that there will be some solution to this detrimental problem. conclusions proliferative vitreoretinopathy is a multi-faceted disease with different modes or grades of presentation. there are no hard and fast rules, which can be applied to the surgical management of these grades, rather each patient is an individual case and surgical strategy would depend upon a number of factors. this study of twenty-five cases of rhegmatogenous retinal detachment with proliferative vitreoretinopathy has led to draw certain conclusions. cases of pvr grade b can be well managed with scleral buckling procedures. in patients who present with pvr grade c, the chances of further progression of the proliferative process are highest. the cases which needed ppv with internal as well as external tamponade were patients of rd with pvr grades c and d, having inferior breaks, all cases of retinal dialysis and patients with extensive sub-retinal fibrosis. inferior retinal detachments sometimes prove to be a lifelong sentence. complications related to silicone oil are not seen within the first six postoperative months. author’s affiliation dr. tayyaba gul malik assistant professer department of ophthalmology ghurki trust teaching hospital lahore dr. naeem ullah professor of ophthalmology sir ganga ram hospital lahore dr. mian muhammad shafiq assistant professor department of ophthalmology ghurki trust teaching hospital lahore. dr. muhammad khalil assistant professor department of ophthalmology ghurki trust teaching hospital lahore. references 1. george fh, edward bm, edward wdn. retinal detachment, a manual: am acad of ophthalmol. 1979; 10-3. 2. harry w. practical ophthalmic surgery.1993; 140. 3. schepens charles l. retinal detachment and allied diseases. 1983; 1: 410. 4. petersen j. the physical and surgical aspects of silicon oil in vitreous cavity. graefes arch clin exp. ophthalmol. 1987; 225: 452. 5. lucke k. silicon oil in surgery of complicated retinal detachment. ophthalmology. 1993; 90: 215-38. 6. machmer r. the importance of fluid absorption, traction, intraocular currents and chorioretinal scars in the therapy of rhematogenous retinal detachment. am j ophthalmol. 1984; 98: 681. 7. kennedy cj, parker ce, mcallister il. retinal detachment caused by retinal dialysis. aust nzj ophthalmol. 1997; 25: 2530. 8. fournaras cj, donati g. intraocular surgery for secondary retinal detachment in pvr. klin-monatsbi-augenheiled.1995; 206: 339-42. 9. uemura a. development of epimacular membrane following rhegmatogenous retinal detachment surgery. nippon ganka gakkai zasshi. 1994; 98: 994-7. 10. harry w. practical ophthalmic surgery.1993; 155. 11. bonnet m, guenoun s, yaniali-a, et al. has the incidence of post-operative pvr in rhegmatogenous retinal detachment decreased? j fr ophthalmol. 1996; 19: 696-704. 12. harry w. practical ophthalmic surgery. 1993; 150-62. microsoft word shehla rubab 97 original article comparison of indigenous microbial flora of the eye to that found in conjunctival and corneal infections in a hospital based study shehla rubab, haroon awan, wajid ali khan pak j ophthalmol 2006, vol. 22 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations .…………………………….. correspondence to: shehla rubab paediatric ophthalmologist al-shifa trust eye hospital jhelum road, rawalpindi received for publication june 2005 .…………………………….. purpose: to determine the normal indigenous microbial flora and to compare it with pathogens, which cause conjunctivitis and keratitis. material and methods: a case-control prospective hospital based study was done. the control group (350 persons) included patients waiting for cataract surgery, hospital personnel, visitors and accompanying persons, while the cases group (150 persons) comprised of individuals with bacterial conjunctivitis, fungal and bacterial keratitis. gram and giemsa staining was performed on all specimens from conjunctival swabs and corneal scrapings. blood, chocolate and sabouraud’s agars were used to grow the bacteria and fungi. sensitivity of yielded bacteria was checked against antibiotics using standard sensitivity discs. results: the study demonsrtated a male preponderance in both groups. common organisms found in the control group were staph. epidermidis, staph. aureus, strep. pneumoniae and diptheroides spp, while those found as pathogens were staph. aureus, strep. pneumoniae, staph. epidermidis and strep. pyogenes in the conjunctivitis group and strep. pneumoniae, staph. aureus, hemophilus spp. and pseudomonas in the keratitis group. in the cases group, over 80% of staph. aureus showed sensitivity against gentamicin, chloramphenicol and cephradin. about 80% of pneumococci were sensitive to chloramphenicol, cephradin and erythromycin. the presence of staph. epidermidis in the control group was highly significant (p<0.000). staph. aureus did not show any significant difference in the either groups. strep. pneumoniae, staph. pyogenes, pseudomonas and fungi had a significantly higher prevalence in the keratitis and conjunctivitis groups. conclusions: gentamicin and chloramphenicol are still an effective and economical first line treatment for most cases of conjunctivitis and keratitis. key words: ocular commensals, ocular opportunistic pathogens, microbial flora of the eye, conjunctivitis, keratitis, eye infections. 98 acterial and fungal infections are an important but complex group of ocular diseases. a variety of infective processes may involve the eye. the source of bacteria or fungus can be local i.e. from the lids or conjunctival sac, or it may be from a remote site like sinuses or nasopharynx. bacterial or fungal keratitis can result in severe visual impairment or even blindness. thus, it is vital to understand the pathogenic mechanisms of infective disease, role of commensals, bacterial resistance and newer antibiotics that are more specific in their coverage. data from different geographical areas differ with regard to the leading cause of bacterial and fungal infections. this study was performed to determine the normal indigenous microbial flora and to compare it with pathogens, which cause conjunctivitis and keratitis. material and methods a prospective case control study was conducted at alshifa trust eye hospital, rawalpindi over one year period. this is a tertiary care and referral eye hospital and who collaborating centre for prevention of blindness with modern facilities for examination and diagnosis. all laboratory work was done at the alshifa reference laboratory for blindness caused by infections (eye lab). eye lab is well equipped and has all the facilities for diagnosis of ocular infections. patients for the study were drawn from the outpatient clinics of the hospital. all newly diagnosed and consecutive patients attending the outpatient clinics with conjunctivitis or keratitis were considered for the study. the controls were selected randomly from accompanying persons, hospital personnel and patients with no corneal and conjunctival disease. 150 patients with corneal and conjunctival infection and 350 healthy controls were studied all patients and controls recruited for the study had a complete external eye examination on slit-lamp and where indicated, posterior segment examination with indirect ophthalmoscope. the sample size for subjects and controls were calculated using the epi-info version 6 program to give results with 95% confidence interval. specimen collection protocol a. controls conjunctival swabs were taken from both inferior fornices and the lid margins of both eyes. cultiplast cotton swabs were used for specimen collection. b. conjunctivitis in case of patients with conjunctivitis, swabs were taken from both eyes. the lower eyelid of the infected eye was pulled down gently and the swab rolled across the inferior tarsal conjunctiva and fornix. the same procedure was repeated in the other eye. cultiplast cotton swabs were used for specimen collection. c. keratitis in case of keratitis, material was collected with a sterilized kimura spatula. the kimura spatula was sterilized in an autoclave. the infected eye was anaesthetized with 0.5% proparacaine eye drops. the necrotic material was first debrided and infected material collected from the base and the advancing edge of the ulcer. gram and giemsa staining was performed on all the specimens. blood agar, chocolate agar and sabouraud's agar were used to grow the bacteria and fungi. sensitivity of yielded bacteria was checked against antibiotics using standard sensitivity discs. an informed consent was taken from all subjects and controls. the data obtained was recorded on a questionnaire and all information kept confidential only to be used for academic purposes. the study was approved by the ethics and research board of alshifa trust eye hospital, rawalpindi. results the study was conducted in two groups. one group (cases) included 150 patients with microbial conjunctivitis and keratitis. the other group (control) comprised of 350 individuals with healthy conjunctiva and cornea. in the control group (350 individuals), there were 182 males and 168 females. the male to female ratio was 1.1:1. the distribution of healthy individuals in different age groups is shown in table-1. in the cases group, out of 150 patients, there were 90 males and 60 females, giving a ratio of 3:2. the distribution of patients in different age groups is given in (table 1). b 99 in 150 affected patients (300 eyes), the right eye was involved in 58 patients while the left eye was involved in 63 patients and both eyes in 29 patients. the common presenting complaints included redness in 85 patients (56.7%), watering in 70 patients (46.7%), pain in 68 patients (45.3%), reduced vision in 44 patients (29.3%), discharge in 33 patients (22%) and other complaints like itching and blepharospasm in 5 patients (3.3%). 27 patients (18%) had a history of trauma causing a corneal ulcer. in the cases group, the common clinical findings included mild conjunctivitis in 58 patients (38.7%), purulent conjunctivitis in 22 patients (14.7%), corneal ulcer in 36 patients (24%), corneal abscess in 17 patients (11.3), hypopyon in 14 patients (9.3), descemetocele in 5 patients (3.3%) and corneal perforation in 4 patients (2.7%) (table 2). visual acuity of all the individuals was checked at the time of examination. visual acuity of patients with keratitis are shown in table 3. 52 (74.3%) out of 70 affected eyes with keratitis were suffering from severe visual impaired or blindness (<6/60 to no perception of light). in the control group, 700 eyes of 350 individuals were tested for normal conjunctival flora. in 120 patients (34.3%), the micro organisms detected included staphylococcus epidermidis in 69 individuals (57.5%), staphylococcus aureus in 27 individuals (22.5%), streptococcus pneumoniae in 10 individuals (8.3%), diptheroides spp. in 4 individuals (3.3%), streptococcus viridans in 3 individuals (2.5%), haemophilus spp. in 2 individuals (1.7%), e. coli in 2 individuals (1.7%) and non-filamentous fungi (candida albicans) in 3 individuals (2.5%) (table 4) 80 out of 150 patients (cases group) presented with conjunctivitis. in 52 individuals (65%), a positive growth was obtained while 28 persons (35%) had false negative results. in the conjunctivitis patients that had a positive yield, the common organisms were staphylococcus aureus in 15 patients (28.8%), streptococcus pneumoniae in 13 patients (25.1%), staphylococcus epidermidis in 11 patients (21.2%) streptococcus pyogenes in 5 patients (9.6%), diptheroides spp. in 3 patients (5.8%), pseudomonas spp. in 2 patients (3.8%) and neisserria gonorrhoeae in one patient (1.9%), filamentous and non-filamentous fungi (candida albicans) in one patient each (1.9%) (table 4). 70 patients (cases group) presented with keratitis. causative agents were detected in 40 patients (57.1%). 30 patients showed false negative results. in these 30 patients (42.9%) keratitis was present clinically but no micro organism was detected. the causative agents detected in 40 (57.1%) patients were as follows streptococcus pneumoniae in 10 patients (25%), staphylococcus aureus in 7 patients (17.5%), pseudomonas spp. in 4 patients (10%), staphylococcus epidermidis in 3 patients (7.5%), streptococcus pyogenes in 3 patients (7.5%), haemophilus spp. in 5 patients (12.5%), filamentous fungi in 5 patients (12.5%) and non-filamentous fungi (candida albicans) in 3 patients (7.5%) (table 4). 700 swabs were taken from 700 eyes of the control group. a positive growth was detected in 147 swabs (21%) of 120 persons (240 eyes). staphylococcus epidermidis was detected in 86 swabs (58.5%), staphylococcus aureus in 34 swabs (23.1%), streptococcus pneumoniae in 13 swabs (8.8%), streptococcus viridans in 4 swabs (2.7%), diptheroides spp. in 4 swabs (2.7%), haemophilus spp. in 2 swabs (1.4%), e. coli in 2 swabs (1.4%) and candida albicans in 3 swabs (2.4). conjunctival swabs were taken from both eyes of 80 individuals who presented with conjunctivitis. 120 swabs were taken from affected eyes and 40 swabs were taken from healthy eyes. out of 120 swabs from affected eyes, 70 swabs (58.3%) showed positive growth. out of 40 swabs from healthy eyes, 12 swabs (30%) showed positive bacterial growth. in the 120 swabs taken from affected eyes, staphylococcus aureus was detected in 25 swabs (20.8%), staphylococcus epidermidis in 17 swabs (14.2), streptococcus pnuemoniae in 12 swabs (10%), streptococcus pyogenes in 6 swabs (5%), pseudomonas spp. in 2 swabs (1.7%), diptheroides in 2 swabs (1.7%), and neisseria gonorrhoae in 1 swab (0.8% each) (table 10). in 6 patients (12 eyes) with conjunctivitis, multiple organisms were detected. in 3 patients, staphylococcus aureus was found in one eye and staphylococcus epidermidis in the other eye. the 4th patient had streptococcus pyogenes in one eye and staphylococcus aureus in the other. the fifth patient revealed streptococcus pneumoniae in one eye and diptheroides spp. in the opposite eye. the sixth patient had a growth of escherichia coli in one eye and staphylococcus aureus in the fellow eye. polymicrobial growth was detected in one eye of one patient. the culture from the conjunctival swab grew staphylococcus aureus, staphylococcus epidermidis and diptheroides spp. 100 conjunctival swabs were taken from diseased as well as healthy eyes of the patients presenting with keratitis. a positive growth was obtained from 8 conjunctival swabs from diseased eyes and 4 conjunctival swabs from healthy eyes. the growth pattern was similar to that detected from corneal scrapings in case of diseased eyes. out of 53 corneal scrapings, 40 (75.4%) gave a positive yield. streptococcus pneumoniae was detected in 10 (18.8%) scrapings, staphylococcus aureus in 7 (13.2%) scrapings, haemophilus spp. in 5 (9.4%) scrapings, pseudomonas spp. in 4 (7.5%) scrapings, staphylococcus epidermidis in 3 (5.7%) scrapings, streptococcus pyogenes in 3 (5.7%) scrapings, filamentous fungi in 5 (9.4%) scrapings and non-filamentous fungi (candida albicans) in 3 (5.7%) scrapings. conjunctival swabs taken from 70 eyes with keratitis revealed streptococcus pneumoniae in 4 swabs table 1: age distribution by sex age in years control group cases group males females total males females total 0 4 9 4 13 10 3 13 5 9 7 4 11 8 4 12 10 19 9 6 15 6 4 10 20 29 12 6 18 14 5 19 30 39 14 5 19 11 2 13 40 49 12 17 29 12 11 23 50 59 33 33 66 8 11 19 60 69 47 64 111 13 11 24 70 – 79 30 16 46 5 5 10 80 – 89 6 7 13 2 3 5 90 100 4 5 9 1 1 2 total 183 167 350 90 60 150 table 2: type and frequency of clinical findings clinical findings male female total n (%) corneal ulcer 22 14 36 (23.1) corneal abcess 7 10 17 (11) hypopyon 8 6 14 (9) corneal perforation 3 1 4 (2.6) descemetocele 3 2 5 (3.2) mild conjunctivitis 32 26 58 (37.2) purulent conjunctivitis 15 7 22 (14.1) total 90 66 156 table 3: visual acuity of effected eyes with keratitis visual acuity no. of effected eyes n (%) 6/6 6/ 18 3 (4.3) < 6/18 6/60 15 (21.4) < 6/60 3/ 60 20 (28.6) < 3/60 pl + 29 (41.4) npl 3 (4.3) total 70 (5.71%), haemophilus species in 2 swabs (2.85%) and staphylococcus aureus and pseudomonas spp. in 1 swab each (1.42%). the growths obtained through the conjucntival swabs in these 8 eyes corresponded to the growth obtained from corneal scrapings. conjunctival swabs were also taken from healthy eyes of patients presenting with keratitis. staphylococcus aureus and staphylococcus epidermidis were 101 obtained from 2 swabs each (2.85% each). in one patient with keratitis, haemophilus spp. was detected in the corneal scraping of one eye while staphylococcus aureus was found in the conjunctival swab taken from the fellow eye. polymicrobial growth was detected in one eye of one patient with keratitis. candida albicans and staphylococcus aureus were isolated from the corneal scrapings from the affected eye. the type and frequency of microorganisms detected, was reviewed in different age groups. in the control group, staphylococcus aureus and staphylococcus epidermidis were common among the 50-79 years age group in the case group, staphylococcus aureus was found in almost all age groups and streptococcus pneumoniae was common in children (0-4 years). antibiotic sensitivity was checked against all the organisms detected, using standard sensitivity discs. in the control group, about 70% of staphylococcus epidermidis were sensitive to gentamicin, chloramphenicol, cephradin and erythromicin. more than 70% of staphylococcus aureus were sensitive to gentamicin, chloramphenicol and cephradin. in contrast, 60% of pneumococci showed resistance against gentamicin (table 5). in the cases group, more than 80% of staphylococcus aureus showed sensitivity against gentamicin, chloramphenicol and cephradin. about 80% of pneumococci were sensitive to chloramphenicol, cephradin and erythromicin. sensitivity of staphylococcus epidermidis against cephradin was more than 70% (table 5). the prevalence of differe nt organisms was subjected to statistical analysis using the chi square test (χ2). compared to the control group, the prevalence of any microbial growth in patient with conjunctivitis (52/80, 65%) was highly significant at α = 0.01 with p<0.000. furthermore, compared to the control group, the prevalence of any microbial growth in patients with keratitis (40/70, 57%) was also highly significant at α = 0.01 with p<0.005 (table 6).the detection of staphylococcus epidermidis in the control group was highly significant (p<0.000), as compared to the keratitis and conjuctivitis groups table 6. staphylococcus aureus did not show any significant difference in its prevalence in the control, keratitis or conjuctivitis groups (table 6). streptococcus pneumoniae had a significantly higher prevalence in the keratitis group (p<0.012) and the conjunctivitis group (p<0.006) as compared to the control group (table 6). fungi, strep pyogenes and pseudomonas spp. all demonstrated a significantly higher prevalence in the keratitis and conjunctivitis groups compared to the control group (table 6). discussion ocular infections are one of the leading causes of blindness throughout the world. in pakistan, blinding infections caused by bacteria, fungi, viruses and parasites are a major public health problem. ocular infections are responsible for blindness in both eyes in 260,000 people and in one eye in about 390,000 people 1. there are 2.4 million people blind in both eyes, 2.5 million people blind in one eye and 5 million have visual impairment. therefore, almost 10 million people are visually handicapped in pakistan. among these corneal opacities cause blindness in 13% of 10 million people. over 300,000 people are blind from corneal opacities due to infection2. a population based ocular survey was conducted in nwfp (north western province of pakistan) in 1994. it revealed that 1.99% of the population of nwfp was blind in both eyes and 1.90% was blind in one eye by who standards. corneal opacities were a cause of blindness in 11% of the affected population in the northern zone and 12% of the affected population in the southern zone of nwfp3. other studies done elsewhere have also emphasized the importance of corneal infections as an important cause of visual loss. daghfous and colleagues found that in the rural areas of southern tunisia, corneal blindness was the second commonest cause for sight loss and responsible for almost 25% of all cases of blindness. one of most frequent etiologies was corneal ulcer4. a population-based survey was conducted in tanzania to determine the prevalence of major blinding disorders. corneal opacities were responsible for 44% of bilateral and 39% of monocular blindness. corneal infection was one of the major causes5. our study showed a preponderance of male patients with anterior segment infections (male: female = 3:2). a possible cause for this could be that since men are the main bread-earners of the family, they cannot afford for their disease to be prolonged, thus causing financial problems. on the other hand, women tend to remain with the families to perform their duties and oftentimes do not report in the 102 hospital for mild to moderate infections. another contributory factor could be their dependence on the males for their treatment. there is also a clear predominance of males (72%) in the paedriatic age group (0-9 years). this is consistent with similar work done by cruz and associates in florida, in which they found a male preponderance of 68% 6. more than halves of the males were between 20-70 years of age and about 50% of the females were between 40-70 years, indicating that these age groups are prone to corneal and conjunctival infections. out of 150 patients in the cases group, 25 patients (18 males, 7 females) were in the paedriatic age group (0-9 years). about two-thirds of the population lives in the rural areas and children are often exposed to a dry and dusty environment. insufficient supply of clean water may also be a contributing factor. furthermore, parents are more conscious about the health of their children and tend to report early to the hospital for their treatment. most of the patients with corneal infections presented as ulcerative keratitis (36 cases). the second most common presentation was corneal abscess (17 cases). on a review of recent literature from western countries, similar presentations have been found by other workers7-9. mehmood a in his study on corneal infections found that almost equal number of cases presented with ulcer and abscess 10. this difference may partly be explained by the heightened community awareness campaigns in the last few years with patients now seeking medical advice early. table 4: type and frequency of microorganisms organisms no of individuals control n (%) conjunctivitis n (%) keratitis n (%) total n (%) staph. epidermidis 69 (57.5) 11 (21.2) 3 (7.5) 83 (39.2) staph. aureus 27 (22.5) 15 (28.8) 7 (17.5) 49 (23.1) strep. pneumoniae 10 ( 8.3) 13 (25) 10 (25) 33 (15.6) diptheroides spp. 4 ( 3.3) 3 (5.8) 0 (0) 7 (3.3) strep. viridans 3 ( 2.5) 0 (0) 0 (0) 3 (1.4) hemophilus spp. 2 ( 1.7) 0 (0) 5 (12.5) 7 (3.3) e. coli 2 ( 1.7) 0 (0) 0 (0) 2 (0.9) neisseria gonorrhoeae 0 (0) 1 (1.9) 0 (0) 1 (0.5) strep. pyogenes 0 (0) 5 (9.6) 3 (7.5) 8 (3.8) pseudomonas 0 (0) 2 (3.8) 4 (10) 6 (2.8) fungi (candida spp.) 3 ( 2.5) 1 (1.9) 3 (7.5) 7 (3.3) filamentous fungi 0 (0) 1 (1.9) 5 (12.5) 6 (2.8) total 120 (100) 52 (100) 40 (100) 212 (100) table 5: antibiotic sensitivity of bacteria antibiotics staph epidermidis staph aureus pneumococci control group cases group control group cases group control group cases group s n (%) r n(%) s n (%) r n(%) s n (%) r n(%) s n (%) r n(%) s n (%) r n(%) s n (%) r n(%) 103 gentamicin 67 (78) 19 (22) 9 (64) 5 (36) 27 (79) 7(21) 19(86) 3(14) 5(38) 8(62) 13(57) 10(43 ) chloramphenicol 60 (70) 26 (30) 77 (50) 77 (50) 257 (73) 97 (27) 187 (82) 47 (18) 117 (85) 27 (15) 217 (91) 27 (9) cephradin (velosef) 707 (81) 167 (19) 107 (71) 47 (29) 267 (76) 87 (24) 207 (91) 27 (9) 107 (77) 37 (23) 207 (84) 37 (13) erythromycin 627 (72) 247 (28) 97 (64) 57 (36) 197 (56) 157 (44) 167 (73) 67 (27) 97 (69) 47 (31) 217 (91) 27 (9) tobramycin 607 (70) 267 (30) 87 (57) 67 (43) 247 (70) 107 (30) 177 (77) 57 (23) 107 (77 37 (23) 177 (74) 67 (26) cloxacillin 65 (76) 21 (24) 9 (64) 5 (36) 21 (62) 13 (38) 15 (68) 7 (32) 9 (69) 4 (31) 18 (78) 5 (22) penicillin 62 (72 24 (28) 8 (57) 6 (43) 22 (65) 12 (35) 12 (55) 10 (45) 10 (77) 3 (23) 19 (83) 4 (17) s= sensitive r= resistant table 6: level of significance of microbial detection in control versus keratitis and conjunctivitis groups types of microbes control n (%) keratitis n (%) conjunctivitis n (%) test of significance=x2 keratitis vs control conjunctivitis vs control staph. epidermidis 69 (57.5) 3 (7.5) 11 (21.2) p <.000 p <.000 staph. aureus 27 (22.5) 7 (17.5) 15 (28.8) n.s n.s strep. pneumoniae 10 (8.3) 10 (25) 13 (25.1) p <.012 p <.006 diptheroides spp 4 (3.3) 0 (0) 3 (5.8) n.s p <.028 strep. viridans 3 (2.5) 0 (0) 0 (0) n.s n.s haemophilus spp 2 (1.7) 5 (12.5) 0 (0) p <.011 n.s e. coli 2 (1.7) 0 (0) 0 (0) n.s n.s fungi 3 (2.5) 8 (20) 2 (3.8) p <.000 p <.03 strept. pyogenes 0 (0) 3 (7.5) 5 (9.6) p <.012 p <.012 pseudomonas spp 0 (0) 4 (10) 2 (3.8) p <.000 p <.003 n. gonorrhoea 0 (0) 0 (0) 1 (1.9) n.a n.s 120 (100) 40 (100) 52 (100) x2 -chi square n.s -not significant na -statistical analysis not advised due to very small numbers the common organisms detected in the control group were staph. epidermidis (58.5%), staph. aureus (22.5%), strep. pneumoniae (8.3%) and diptheroides spp. (2.7%). this suggests that these microorganisms are commonly found in the conjunctival sac of the pakistani population in this region of the country. this compares well with other studies on the normal flora of the conjunctival cul-de-sac. locatcher-khorazo and seegal studied the normal flora of 10,000 healthy eyes and isolated staph. epidermidis (37%), staph. aureus (17%), diptheroides (1%), combination of these three organisms (35%) and miscellaneous growth in (9%)11. gritz et al studied the conjunctival flora of 42 persons. they isolated staph. epidermidis in 54.8% and diptheroides in 9.5% subjects. but they did not detect any staph. aureus. this may be due to the small sample size of their study12. larkin and leeming studied the normal ocular flora of 34 individuals and compared it with that of contact lens users. staph. epidermidis was the most prevalent species among healthy individuals. they also found corynebacterium spp. in 6 individuals. this however, was not detected in our series13. 104 the types of bacteria were almost similar in all age groups. staph. epidermidis was the most common organism followed by staph. aureus and strep. pneumoniae. thiel and schumacher studied ocular flora of 135 persons of various age groups (3-90 years). they found characteristic changes in the flora at different stages of life, which suggested that with increasing age, aerobic cocci were found less frequently and the proportion of anaerobic cocci increased14. diptheroides spp. was detected in 3.3% of normal individuals. soudakoff in 1954 cultured diptheroides from 2.8% of eyes in his los angeles based series15. the frequency of diptheroides detection was found to increase with increasing age. this pattern has also been found in other studies16,17. weis et al studied normal flora of 91 children and found staphylococci, corynebacteria and alpha hemolytic streptococci as predominant organisms18. corynebacteria were not encountered in our series. other species like strep. viridans, haemophilus and e.coli were detected less frequently. perkin and coworkers in their study of the flora of 90 healthy eyes, found propionibacterium acnes and anaerobic diptheroides predominantly, and lactobacillus spp., eubacterium spp. and peptostreptococcus spp. less frequently19. thiel and schumacher detected megasphaera elsdenii, bacteroides urolyticus, bacteroides pneumosintes, stomatococcus mucilaginosos and group anf corynebacterium for the first time in the eye14. no fungi were detected in the paedriatic and younger age groups in our study. candida albicans was detected in 3 individuals above 40 years. filamentous fungi were not detected as normal commensals of the culdesac. this is in contrast to the study conducted by rao and rao who detected aspergillus spp. from normal conjunctiva20. 80 of 150 patients presented with conjunctivitis. 65% yielded a positive growth. studies done previously have found that 32% 88% of patients with external ocular bacterial infections have positive cultures21,22. in our study, staph. aureus was the most common organism detected in 28.8%. strep. pneumoniae and staph. epidermidis were found in 25.1% and 21.8% respectively. our results differ from those of spitzy et al, who studied 120 patients with conjunctivitis and found staph. epidermidis as the most common cause of bacterial conjunctivitis followed by staph. aureus23. in a series by grabsons et al, staph. epidermidis was again the most prevalent (74%) followed by staph. aureus (12%)24. weiss et al studied 95 children with acute conjunctivitis. the major pathogens cultured from conjunctival specimens were haemophilus influenzae, strep. pneumoniae and moraxella. the common organisms in the paediatric age group (0 9 years) in this study were strep. pneumoniae, staph. epidermidis and staph aureus. this indicates that strep pneumoniae is one of the common organisms that causes conjunctival infection in children18. work done by mahajan et al also supports strep. pneumoniae as a cause of bacterial conjunctivitis in children25. diptheroides, pseudomonas spp. and n.gonorrhoeae were detected in a small percentage of patients. it is possible that these are opportunistic organisms that are able to cause ocular infection. the lowered resistance of these eyes against infection may have played a role in predisposing them to microbial keratitis. fungi (filamentous and candida spp.) were also found in a small number of cases with conjunctivitis (1.9%). this finding is significant because oftentimes conjunctivitis is thought to be bacterial and a possible fungal cause is neglected. it also emphasizes the need for a conjunctival culture before instituting treatment. 70 out of 150 patients presented with keratitis. 52 (74.3%) out of 70 affected eyes with keratitis were either severely visually impaired or blind by world health organization standards (<6/60 to no perception of light). a significant number of eyes with corneal infection end up blind. out of 927 keratoplasties done at a toronto hospital in canada, 4.3 % were due to bacterial infections26. we used a sterilized kimura spatula for specimen collection in case of corneal ulcers. cotton swabs were used for conjunctival specimens. microorganisms were detected more frequently when corneal ulcers were scraped with a spatula. banson and lanier have shown that calcium alginate swabs give a better yield than spatulas for detecting microorganisms in corneal ulcers27. jacob et al found that a bard parker blade no.15 was as efficient as a calcium alginate swab for detection of bacteria. however, the swabs were more efficient in case of mycotic ulcers28. conjunctival swabs were also taken along with corneal scrapings in keratitis patients. a positive growth was obtained from 8 conjunctival swabs from diseased eyes. the isolates detected from both 105 specimens were similar. wahl et al also found an association between corneal and ipsilateral conjunctival isolates29. strep. pneumoniae was the most common organism causing keratitis (25%). it was followed by staph. aureus (17.5%), haemophilus spp. (12.5%) and pseudomonas spp. (10%). this compares well to work done by tassaduq1 a few years earlier who found strep. pneumoniae (27.4%), staph. epidermidis (19%) and staph. aureus (9.5%). ammous and noorsunba in kuwait, on the other hand, found staph. epidermidis to be predominant followed by pseudomonas and strep. pneumoniae30. another study showed staph. epidermidis as the most common isolate followed by staph. aureus and pseudomonas29. strep. pneumoniae appears to be more prevalent as a cause of ulcerative keratitis in our population. pseudomonas spp. was not a common cause of keratitis in our study. in a series from south florida, p. aeruginosa was found to be the single most common organism responsible for corneal ulceration31. we found pseudomonas mostly in older patients (above 50 years) with keratitis. ormerod also found pseudomonas along with strep. pneumoniae as a common cause of microbial keratitis in older patients32. in the paediatric age group, strep. pneumoniae was the most common organism causing infections of the conjunctiva and cornea. it was followed by staph. aureus and staph. epidermidis. pseudomonas was not detected in children in this study. in a large series at bascom palmer eye institute in florida, the most common organisms were pseudomonas (34%). staph. aureus (20%) and fungi (18%)6. 8 out of 70 patients (11.4%) with corneal ulcer presented with fungal keratitis. in 5 patients, filamentous fungi were detected and in 3 patients nonfilamentous fungi (candida albicans) were isolated. filamentous fungi like aspergilus spp. are the most common cause of fungal keratitis in india33. aspergilus has been found to be the most prevalent fungus in other studies as well34,35. the high prevalence of aspergilus spp. may be due to the fact that spores of aspergilus can survive the hot and dry weather of these countries. no fungus was detected in children in our study. a probable cause for this could be the small sample size, since the overall prevalence of childhood mycotic keratitis is about 10.8% according to panda et al. panda et al in india studied 211 cases of childhood mycotic keratitis and found in decreasing frequency aspergilus spp., followed by fusarium, alternaria, curvularia and penicillium36. the sensitivity of all the isolates was checked against gentamicin, chloramphenicol, erythromycin, tobramycin, cloxacillin and penicillin. in the control group, more than 70% of staph. epidermidis showed sensitivity against all these drugs. about 70% of staph. aureus showed sensitivity against these drugs except penicillin. this indicates effectivity of these drugs for staphylococcal infections. more than 45% of staph. aureus were resistance against penicillin. in case of staph. epidermidis, the sensitivity was about 60% against these drugs except for chloramphenicol (50%). a significant number of staphylococci showed resistance against gentamicin, 14% in case of staph. aureus and 36% in case of staph. epidermidis. with changing sensitivity patterns, ophthalmologists should be aware of the strains that are resistant to gentamicin37. similarly erythromycin resistant staphylococci causing conjunctivitis have also been reported38. 73%-90% of pneumococci in the control group were sensitive against chloramphenicol, erythromycin, tobramycin, cloxacillin, penicillin and cephradin. the resistance to erythromycin and chloramphenicol was 8.6%. mahajan et al in india found pneumococcal resistance to erythromycin and chloramphenicol to be 17.6% and 31% respectively25. significant number of pneumococci 43% showed resistance against gentamicin in our study. about 66% of pseudomonas were sensitive to gentamicin and cloxacillin. however, more than 50% showed resistance to chloramphenicol, cephradin, erythromycin, tobramycin and penicillin. gentamicin is highly effective against pseudomonas keratitis and it has been the mainstay in the treatment of pseudomonas corneal ulcer39. the resistance of pseudomonas to tobramycin in our series was 50%. a resistance to tobramycin has been found in many gentamicin-resistant strains of pseudomonas in other studies40. staph epidermidis was the most common organism detected from normal individuals. it was also found in patients with external ocular infection. the role of staph. epidermidis as a commensal of the cul-de-sac is highly suggestive and that it can cause infection of the conjunctiva and cornea. the second most common organism in healthy individuals and in patients with keratitis was staph. aureus. it was the most common organism causing conjunctivitis. they 106 are probably not pathogens since they are found with equal or greater frequency in normal eyes41,42. strep. pneumoniae was not detected in the control group, but was found in patients with conjunctivitis (25%) and keratitis (25%). this indicates that staph. pneumoniae is a pathogen and not a commensal. similarly, pseudomonas was not detected in conjunctival swabs of healthy persons but was present in cases of conjunctivitis and keratitis, indicating the pathogenicity of pseudomonas. other microbes like haemophilus spp., diptheroides spp., strep. pyogenes and n.gonorrhoeae were detected in a very small number of cases. conclusion the key findings of this study may be summarized as below: the common organisms found harboring the normal conjunctival sac as commensals were staph. epidermidis (57.5%), staph. aureus (22.5%), strep. pneumoniae (8.3%) and diptheroides spp (3.3%). the common organisms found as pathogens in the conjunctivitis group were staph. aureus (28.8%), strep. pneumoniae (25.1%), staph. epidermidis (21.2%), and strep. pyogenes (9.6%). the common organisms found as pathogens in the keratitis group were strep. pneumoniae (25%), staph. aureus (17.5%), hemophilus spp. (12.5%), and pseudomonas spp. (10%). in the control group, about 70% of staph. epidermidis were sensitive to gentamicin, chloramphenicol, cephradin and erythromicin. in the control group, over 70% of staph. aureus were sensitive to gentamicin, chloramphenicol, and cephradin, while 60% of pneumococci showed resistance to gentamicin. in the cases group, over 80% of staph. aureus showed sensitivity against gentamicin, chloramphenicol, and cephradin. about 80% of pneumococci were sensitive to chloramphenicol, cephradin and erythromicin. staph. epidermidis the most common organism detected in all age groups of healthy individuals. conjunctival swabs are helpful in detection of microorganisms in case of conjunctivitis and keratitis. scraping with kimura spatula is a better way of specimen collection than cotton swabs in case of keratitis. fungi are an important cause of keratitis and conjunctivitis. the detection of staphylococcus epidermidis in the control group was highly significant (p<0.000), as compared to the keratitis and conjuctivitis groups suggesting its presence as a normal commensal. staphylococcus aureus did not show any significant difference in its prevalence in the control, keratitis or conjuctivitis groups suggesting its role as an opportunistic pathogen. streptococcus pneumoniae had a significantly higher prevalence in the keratitis group (p<0.012) and the conjunctivitis group (p<0.006) as: compared to the control group indicating it to be a pathogen. fungi, strep. pyogenes and pseudomonas spp. all demonstrated a significantly higher prevalence in the keratitis and conjunctivitis groups compared to the control group, suggesting their roles as pathogens. there is an overriding need to establish specialised ocular microbiology laboratories in every eye hospital or eye unit. these ocular microbiology services can be provided by existing general microbiology personnel provided they have adequate training. ophthalmologists and general practitioners need to be aware of the conjunctival commensals and pathogens causing conjunctivitis and keratitis. there is also a need to disseminate information to ophthalmologists at teriary and secondary levels about changing microbiological sensitivity patterns. it is reassuring to confirm that gentamicin and chloramphenicol are still an effective and economical first line treatment for most cases of conjunctivitis and keratitis. a thorough understanding of the differences in the conjunctival flora of healthy and diseased eyes is essential for ophthalmologists. this knowledge can play an important role in interpretation of clinical culture results and in management of potential pathogens colonizing the ocular surface. it is also of particular concern when planning surgery since sterility at the time of surgery presumably decreases the frequency of postoperative infection. authors affiliation dr. shehla rubab paediatric ophthalmologist 107 al-shifa trust eye hospital jhelum road, rawalpindi dr. haroon awan country representative sight savers international pakistan dr. wajid ali khan chief consultatnt al-shifa trust eye hospital jhelum road, rawalpindi references 1. tassaduq n. al-shifa reference laboratory for blindness caused by infection. al-shifa medical bulletin. 1995; 1: 6-7. 2. memon ms. prevalence and causes of blindness in pak. j pak med assoc, 1992; 42: 196. 3. zia-ul-islam. population based ocular survey in north west frontier province, pakistan. peshsawar: top printers, 1994. 4. daghfous mt, ayed s, daghfous f, et al. cornea blindness in tunisia, prevalence and causes. pcv int trach pathol ocul trop subtrop sante publique, 1990; 67: 147-52. 5. rapoza pa, west sk, katala sj et al. etiology of corneal opacification in central tanzania, int. ophthalmol, 1993; 17: 4751. 6. darrel rw, menon a, modak s et al. topical norfloxacin in the treatment of staphylococcal aureus corneal ulcer in the rabbit. cornea, 1987; 5 : 205-9. 7. cruz oa, sabir sm, capo h et al. microbial keratitis in childhood. ophthalmology. 1993; 100: 192-6. 8. buehler po, schein od, stamler jf et al. the increased risk of keratitis among disposable soft contact lens users. arch ophthalmol. 1992; 110: 1555-8. 9. aristimuno b., nirankari vs, hemady rk et al. spontaneous ulcertive keratitis in immuno compromised patients. am j ophthalmol. 1993; 115: 202-8. 10. mehmood a. aetiology and management of bacterial and fungal keratitis [dissertation] rawalpindi, al-shifa trust eye hospital rawalpindi, 1994. 11. locatcher-khorazo d, seegal bc. microbiology of the eye, st. louis, mosby, 1972: 13-7. 12. gritz dc, scott tj, sedo sf, et al. ocular flora of patients with aids compared with those of hivnegative patients. cornea 1997; 16: 400-4. 13. larkin dfp, leeming jp. quantitative alteration of commensal eye bacteria in contact lens wearers. eye 1991; 5: 70–4. 14. thiel hj, schumacher u. normal flora of human conjunctiva examination of 135 persons of various ages, klin monatsble augenheilkd (germany), 1994; 205: 348-57. 15. soudak off ps. bacteriologic examination of the conjunctiva. am j ophthalmol. 1954; 38: 374–6. 16. khorazo d, thompson r. the bacterial flora of normal conjunctiva. am j ophthalmol. 1935; 18: 1114-6. 17. thomas rs, isenberg sj, leonard apt. conjunctival anaerobic and aerobic bacterial flora in paediatric versus adult subjects. br j ophthalmol. 1988; 72: 448-51. 18. weiss a, brinser jh, nazar sv. acute conjunctivitis in childhood. j pediatr. 1993; 122: 10-4. 19. parkin r, kundsin rb, pratt hm. bacteriology of normal and infected conjunctiva. j clin microbiol. 1975: 147. 20. rao pns, rao kn. a study of normal conjunctival flora (bacterial and fungal) and its relation to external ocular infections. ind j ophthalmol. 1972; 20: 164. 21. jacobson ja, call nb, kasworm em, et al. safety and efficacy of tropical norfloxacin versus tobramycin in the treatment of external ocular infection. antimicrob agent chemother, 1988; 32: 1820-4. 22. leibowitz hm, pratt mv, flastad ii, et al. human conjunctivitis diagnostic evaluation. arch ophthalmol. 1976: 1747-9. 23. spitzy hv, baugartner i, mettinger ae, et al. corneal ulcer current analysis for specialized ambulatory care of a clinic. klin monatsble augenheilkd (germany), 1992; 200: 251-6. 24. grabson t, mino-de-kasper h, klauss v. coagulase negative staphylococci in normal and chronically inflamed conjunctiva. ophthalmology, 1995; 92: 793-801. 25. mahajan vm, bareja v, parkash k, et al. pneumococci in ocular diseases of children and their treatment. an trop paediatr, dec 1997; 7: 270-3. 26. liu e., slomovic a.r. indication for penetrating keratoplasty in canada, 1986 1995. cornea 1997; 4: 414-9. 27. banson wh, lanier jd. comparison of technique for culturing corneal ulcer. ophthalmology 1992; 99: 800-4. 28. jacob p, gapinathan u, sharma s, et al. calcium alginate swabs versus bard parker blade in the diagnosis of microbial keratitis. cornea 1995; 14: 360-4. 29. wahl jc, katz hr, abrams da. infectious keratitis in baltimore. ann ophthalmol. jun. 1991; 23: 234-7. 30. ammous mw, noorsunba ms. the nature of the ulcerative keratitis in kuwait. apmis suppl, 1988; 3: 104-6. 31. liesegang tj, forster rf. pectrum of microbial keratitis in south florida. am j ophthalmol. 980; 90: 38. 32. ormerod ld. causes and management of bacterial keratitis in the elderly. can j ophthalmol. 1989; 24: 112-6. 33. chander j, sharma a. prevalence of fungal ulceration in northern india. infection, 1994; 22: 57-9. 34. arora r, venkateswarlu k, mahajan vm. keratomycosis retrospective histopathologic and microbiologic analysis. ann ophthalmol. aug. 1988; 20: 366-10. 35. khairallah sh, byrne ka, tabbara kf. fungal keratitis in saudi arabia. doc ophthalmol. 1992; 79: 269-76. 36. panda a, sharma n, das g, et al. mycotic keratitis in children: epidemiologic and microbiologic evaluation. cornea 1997; 16: 295-8. 37. mader th, maher kl, stulting rd. gentamicin resistance in staphylococcal corneal ulcer. cornea, sep. 1991; 10: 408-10. 38. headberg k, ristinen tl, soler jt, et al. outbreak of erythromycin resistant staphylococcal conjunctivitis in a new born nursery. pediatr infect dis j, apr. 1990; 9: 268-73. 39. furginele fp, kiesel r, mytyn l. pseudomonas infections of rabbit cornea treated with gentamicin-a preliminary report. am j ophthalmol 1965; 60: 818-22. 40. crowe cc, sander e. is there complete cross-resistance of gram negative bacilli to gentamicin and tobramycin. antimicrob agents chemother, 1972; 2: 415-6. 41. brook j. anaerobic and aerobic bacterial flora of acute conjuctivitis in childlren. arch ophthalmol. 1980; 98: 833-5. 42. gigliotti f, williams wt, haydens fg, et al. dickens m. et al. etiology of acute conjunctivitis in children. j pediatr 1987; 5. microsoft word m khalil case report.doc 165 case report recovery of post traumatic brown’s syndrome muhammad khalil, tayyaba gul malik, mian muhammad shafique, muhammad moin, muhammad khalil rana pak j ophthalmol 2007, vol. 23 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad khalil lahore medical and dental college, lahore received for publication march’ 2007 …..……………………….. rown’s syndrome1, 2, 3 is a motility defect which is characterized by an inability to raise the adducted eye above the horizontal midline, less or no elevation deficit in abducted position. there is slight down shoot of the adducting involved eye with widening of the palpebral fissure on adduction. exodeviation usually increases as the eyes are moved upward in the midline (v-pattern). case report a seven years old male child presented with an abnormal head posture after trauma by donkey’s hoof two months back. there was no history of pain, tenderness and double vision. the patient gave no history of any previous ocular, periocular or orbital surgery. systemic evaluation revealed no evidence of sinusitis and juvenile chronic arthritis. family history was unremarkable. on general physical examination child was very much co-operative and well appearing with no signs of acute distress. there was a scar mark of trauma at the junction of medial and middle third of the left eyebrow. there was left-sided head turn with a slight chin up position (fig. 1). left eye was slightly hypotropic. extra ocular movements showed restricted elevation in adduction of left eye (fig. 2). there was no tenderness and palpable mass in the trochlear region of left eye. visual acuity was 6/6 in both eyes. pupils were round and normally reacting to light. eyelids, adnexa and anterior segment examination showed no abnormality. fundi were normal. forced duction test was positive. on the basis of the above clinical findings the patient was diagnosed as a case of brown’s syndrome. the parents were reassured and the patient was put on oral syrup of ibuprofen (1 tsf * tds). the child was called for follow up after one month who showed improvement in subsequent visits and after three months there was complete recovery (fig. 3, 4). discussion brown’s syndrome also known as superior oblique tendon sheath syndrome was first described by harold w brown in 1950. he hypothesized that b 166 brown’s syndrome occurred as a result of innervational deficit to inferior oblique muscle with secondary contracture of the anterior sheath of superior oblique tendon. electromyography did not support the idea4. later, brown hw5 redefined the disease and categorized it into congenital (short anterior sheath of superior oblique tendon) and simulated sheath syndrome (all cases caused by anomaly other than short anterior sheath of superior oblique tendon). in mid 1970s, park6 and crawford disagreed the idea of short anterior tendon sheath. they proposed that brown’s syndrome was caused by tight or short superior oblique tendon. electromyographic studies confirmed this idea. fig. 1: left sided head tilt with slight chin up position fig. 2: left hypotropia in primary position and limitation of elevation in adduction of left eye (left brown’s syndrome). it is interesting that some greek doctors have attributed the arrogant posture of alexander the great7, 8 to this syndrome. in the lancet (april 1996) john lascaratos from athens university report that alexander the great might have suffered from brown’s syndrome of left eye as he had to hold his head with raised chin, face turned to right and neck tilting to the left. fig. 3: normal head position after recovery fig. 4: normal extra ocular movements after recovery so far various etiologies of brown’s syndrome have been described. iannaccone a has reported a family with three siblings having unilateral late onset brown’s syndrome. congenital brown’s syndrome has been reported in monozygotic twin girls9 with reversed asymmetry (mirror image). delayed development of trochlea is also reported to be the cause of brown’s syndrome10. acquired cases of brown’s syndrome are related to peritrochlear scarring and adhesion caused by chronic sinusitis11, trauma, blepharoplasty12, trochleitis with superior oblique myositis, adult rheumatoid arthritis, juvenile chronic arthritis, systemic lupus erythematosis13, superior nasal orbital mass, glaucoma implant and scleral buckling procedures. the conditions included in the differential diagnosis of brown’s syndrome are primary superior oblique over action, inferior oblique paresis and monocular elevation deficit. forced duction test is 167 negative in superior oblique over action and inferior oblique paresis. there is v-pattern exotropia in brown’s syndrome while patients with primary superior oblique over action and inferior oblique paresis have a-pattern exotropia in down gaze and apattern esotropia in up gaze respectively. in monocular elevation deficit14, elevation is worse in all positions. no laboratory tests are required in the work up of congenital brown’s syndrome while in acquired cases systemic lupus erythematosis, juvenile rheumatoid arthritis and rheumatoid arthritis should be excluded. management of brown’s syndrome includes pharmacotherapy with oral nsaids and local corticosteroids injections in the trochlear region. it is usually indicated in acquired cases of active inflammation which can be post traumatic, related to periocular surgeries or rheumatoid arthritis. the exact mechanism of action is not known but may inhibit cyclooxygenase15 activity and prostaglandin synthesis, inhibition of leukotrienes synthesis, lysozomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions. surgical treatment is indicated when there is chin elevation and severe limitation of elevation in adduction, which interfere with quality of life. surgical procedures16, 17 include superior oblique tendon lengthening, tendon expander technique, tenotomy, and superior oblique recession while sheathectomy and superior oblique trochlear luxations have been abandoned. few cases of spontaneous resolution of congenital as well as acquired brown’s syndrome have been reported in the literature. in t.j. kaban’s18 series 10% cases of the presumed congenital brown’s syndrome experienced a complete spontaneous resolution. luigo capasso19 and coworkers reported a case of bilateral brown’s syndrome in a four years old girl. after seven months there was spontaneous resolution in right eye while her left eye did not show any significant change over thirty-six months of follow up. gregersen and rindziunski20 described ten cases of brown’s syndrome out of which three developed normal motility after sometime. waddell21 reported resolution of brown’s syndrome in 24 out of 36 (67%) patients who showed improvement from 1 to 14 years after the initial diagnosis. according to wn clarke22, brown’s syndrome associated with over action of contra lateral inferior oblique muscle probably begins as bilateral brown’s syndrome, followed by spontaneous improvement of brown’s syndrome on one eye and subsequent secondary inferior oblique over action. our case of brown’s syndrome developed post traumatic brown’s syndrome which resulted from inflammation of the superior oblique tendon. the condition resolved after 3 months when the inflammation had subsided. it can be correlated with the study of helveston23 and associates who described fluid accumulation and vascular distention in the sheath as the cause of limitation of superior oblique tendon motion through the trochlea. when inflammation is controlled, fluid is absorbed and vascular distention settles down leading to resolution of brown’s syndrome. oral nsaids (as in our case) accelerate the control of inflammation. conclusion cases of post traumatic brown’s syndrome should be observed for spontaneous recovery. author’s affiliations dr. muhammad khalil assistant professor lahore medical and dental college lahore. dr. tayyaba gul malik senior registrar lahore medical and dental college lahore dr. mian muhammad shafique associate professor lahore medical and dental college lahore dr. muhammad moin assistant professor institute of ophthalmology king edward medical university lahore. prof. muhammad khalil rana professor of ophthalmology lahore medical and dental college lahore references 1. brown hw: congenital structural muscle anomalies. in allen jh (ed): strabismus ophthalmic symposium 1. st louis: cv mosby. 1950: 205 2. brown hw: isolated inferior oblique paralysis: an analysis of 97 cases. trans am ophthalmol soc. 55:1957; 415 168 3. brown hw: in haik gm (ed): strabismus symposium of the new orleans academy of ophthalmology. st louis: cv mosby, 1962 4. brown hw: true and simulated superior oblique tendon sheath syndromes. doc ophthalmol 34:1973; 123 5. brown hw: true and simulated superior oblique tendon sheath syndromes. doc ophthalmol 1973; 34 (1):123-36 6. park mm, m: superior oblique tendon sheath of brown. am j ophthalmol 1975 jan; 79(1): 82-6 7. hw brown: strabismus symposium 1. st. louis, mosby, 1950: 205-236. 8. brown hw: congenital structural motor anomalies in strabismus. in allen jh (ed): ophthalmic symposium 1, st louis: cv mosby, 1950:205-229 9. katz nnk, whitmore pv, beauchamp gr: brown's syndrome in twins. j pediatr ophthalmol strabismus: 1981; 18:32 10. lauer s.a., sauer h, pak sm: brown’s syndrome diagnosed following repairs of an orbital roof fracture: a case report. j. craniomaxillofacial trauma 1998; 4(4) : 20-2 11. hermann js. acquired brown’s syndrome of inflammatory origin. arch ophthalmol: 1978;96:1228-32 12. levine mr, boyton j, tenzel rr, miller gr: complications of blepharoplasty. ophthalmic surg 1975;6: 47-53 13. whitefield l, isenberg da, brazier dj, forbes j: acquired brown’s syndrome in systemic lupus erythematosis. br. j. rheumatol: 1995;34:1092-4 14. kanski jj: clinical ophthalmology (5th ed): 2003;549 15. wright kw: brown’s syndrome diagnosis and management. trans am ophthalmol soc 1999; 97:1023-109 16. scott ab, knapp p: surgical treatment of the superior oblique tendon sheath syndrome. arch ophthalmol: 1972 sept; 88(3): 282-6 17. wright kw: color atlas of ophthalmic surgery-strabismusphiladelphia, pa: lippincott; 1991:201-219 18. tj kaban, k smith, rb orton et al: natural history of presumed congenital brown’s syndrome. arch ophthalmol 1993 july; vol 111 no. 7 19. capasso luigi, torre angelo, gagliardi vincenzo, magli adriano: spontaneous resolution of congenital bilateral brown’s syndrome ophthalmologica: 2001; 215: 372-375 20. gregersen e, rindziunski: brown's syndrome, a longitudinal long-term study of spontaneous course. acta ophthalmol:1993; 71:371 21. waddell e: brown's syndrome revisited. br orthop j: 1982; 39:17 22. clarke wn, noel lp: brown's syndrome with contralateral inferior oblique overaction: a possible mechanism. can j ophthalmol: 1993; 28:213 23. helveston em, merriam ww, ellis fd et al: the trochlea: a study of the anatomy and physiology. ophthalmology: 1982; 89:124 microsoft word nazullah khan 74 original article congenital nasolacrimal duct obstruction: presentation and mangement nazullah khan, mohammad naeem khan, sanaullah jan, shad mohammad pak j ophthalmol 2006, vol. 22 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: sanaullah jan h.no: 455, street no.18 sector: e-2, phase 1 hayatabad, peshawar received for publication june’ 2005 …..……………………….. purpose: to study presentation of congenital nasolacrimal duct obstruction and its outcome after conservative treatment and probing. material and methods: 100 eyes of 81 children were studied. children were divided into two groups. in group 1, children upto age of 6 months were included. they were initially treated conservatively with massage and topical antibiotics. in 2nd group children between age 6 months to 3 years were included. they all had conservative treatment but had not responded to it. so they underwent probing. results: in first group, out of 25 patients with 30 involved eyes, 83% were relieved of symptoms with conservative treatment. in 2nd group, out of 56 children with 70 involved eyes, 87% responded to 1st probing, 9% responded to 2nd probing while 4% were not relieved even with 3rd probing. the overall success in both conservative treatment and probing was 97%. conclusion: most of the children with congenital nasolacrimal duct obstruction are relieved with conservative treatment. in the remaining unsuccessful cases probing is done, which is successful in majority of children. ongenital nasolacrimal duct (nld) obstruction is present in 4-6% of otherwise normal newborn children. it is due to the failure of canalization or persistence of membrane at the lower end of the nasolacrimal duct. a sticky and watery eye with regurgitation of fluid or pus on pressure over lacrimal sac confirms the diagnosis. however, it is important to exclude congenital glaucoma and other causes of watering eye in infants. although congenital nld obstruction can be distressing for both the child and parents, but fortunately there is a high rate of spontaneous resolution during the first few months of life1. many of the persistent cases respond to conservative treatment with lacrimal sac massage and topical antibiotic drops2. in a large majority of cases, the cause of failure of conservative treatment is an improper technique of lacrimal sac massage. in unresponsive cases, probing of the nld is required. probing is performed under general anaesthesia and it is preferable to probe through upper punctum to avoid any inadvertent damage to the lower punctum and canaliculus. probing is contraindicated during the acute phase of dacryocystitis because the edematous, inflamed mucosa can get injured, leading to fibrosis and stricture. in very few cases, even probing may not achieve a permanent opening of the nld. in such cases silicone tube intubation of lacrimal passages is required to achieve a permanent cure. the aim of this study is to find presentation of nasolacrimal duct obstruction and its outcome after conservative treatment and probing. c 75 material and methods this is a prospective observational and comparative study, conducted in the department of ophthalmology, pgmi, lady reading hospital peshawar from june 1997 to july 1999. a total of 100 eyes were treated in 81 patients. for purpose of management, children were divided into two groups depending upon their age at presentation. group 1 patients were treated conservatively. group 2 patients were treated with probing under general anaesthesia. inclusion criteria for patients in 1st group were children with nld obstruction, no associated major co-morbidity or systemic disease and age range of 1 day to 6 months. inclusion criteria for patients in 2nd group were children with nld obstruction, no associated major co-morbidity or systemic pathology, no previous treatment other than conservative and age limit between 6 months to 3 years. careful and detailed history was taken regarding the presenting complaints. family history and history of previous treatment were recorded. careful evaluation was carried out to rule out other ophthalmological and systemic causes of epiphora. in group 1, the children were treated conservatively with proper lacrimal massage and topical antibiotics. strict observation and follow up was maintained for at least 3 months. probing was performed after 6 months of age in those patients who didn’t respond to conservative treatment. patients in group 2 had already taken conservative treatment elsewhere. probing was carried out in all these effected eyes under general anaesthesia (ga). probing was performed through upper canaliculus and was confirmed with metal – to –metal touch in the inferior meatus of the nose. all the patients were discharged on the same day and were followed after 15th, 45th and 90th day of treatment in both the groups. the parents were directed to continue lacrimal massage and instillation of antibiotic (tobramycin) eye drops even after successful probing till next visit. results 100 eyes of 81 patients were evaluated in the study. out of these, 52 (64.2%) were male and 29 (35.8%) were female patients. nineteen (23.5%) had bilateral nld block and 62 (76.5%) cases had unilateral involvement. twelve (14.8) children presented with epiphora only while 69 (85.2%) patients came with watering with purulent discharge. group i: twenty-five (30.9%) children were included in this group. patients in this group were initially treated conservatively with proper lacrimal massage and topical antibiotics. in this group out of 25 children, 16 (64%) were male and 9 (36%) were females. age distribution of children in this group is shown in figure 1. twenty (80%) cases were having unilateral involvement and 5 (20%) cases had bilateral nld block. right eye was involved in 16 (53.3%) cases and left eye in 14 (46.7%) cases. results of group 1 cases after the 90th day of follow up are shown in (table 1). the success rate of conservative treatment at different visits is shown in figure 2. group ii: 56 (69.1%) children between ages of 6 months to 3 years were included in this group. male patients were 36 (64.3%) and 20 (35.7%) were female patients. age distribution of patients in this group is shown in figure 3. forty-two (75%) cases had unilateral involvement while 14 (25%) had bilateral involvement. the right eye was involved in 34 (48.6%) cases and 36 (51.4%) had involvement of the left eye. all patients in this group had received conservative treatment elsewhere before presenting to us. all of them underwent probing under ga. outcome of treatment by probing at the final day of follow up is shown in table 2. thus in the 2nd group total of 67 eyes were cured. the success rate was 87.1% after one probing and 66.7% after the second probing in the eyes where the first probing failed (table 3). patients were instructed to continue lacrimal massage even after probing and some of cases with residual symptoms were relieved. the probing was done under ga. in 59 (84.3%) cases the end of the probe encountered low resistance with a feeling of sudden release due to puncture of the membrane at the lower end of the nasolacrimal duct. in 8 (11.4%) cases continued resistance was felt throughout the length of nasolacrimal duct upto nasal cavity. no major complications due to probing had occurred. 76 minor bleeding was observed in 20% of cases during probing. discussion congenital nasolacrimal duct obstruction (cnldo) is a common disorder of the lacrimal system. it is usually caused by failure of canalization of epithelial cells that form the nasolacrimal duct at its entrance into the nose (valve of hasner). its features include an excessive tear lake, overflow of tears onto the lids and cheek and reflux of mucoid material that is produced in the lacrimal sac3. we studied 100 eyes of 81 patients. twelve (14.8) cases presented with epiphora without discharge. remaining 85.2% presented with increased lacrimation mixed with mucopurulent discharge. out of 81 patients, 52 (64.2%) were male patients and 29 (35.8%) female. sixty-two (76.5%) had unilateral involvement and 19 (23.5%) had bilateral involvement. these figures are comparable to the study done by halipota et al 4 who reported that 65% of cases were male and 35% female. further, in his study, 71% cases were unilateral and 29% bilateral, while robb5 observed bilateral involvement in 15.4% of patients. table 1: result of group i patients procedure no of eyes successful n (%) failed n (%) conservative 30 25 (83.3%) 05(16.7%) probing (after 6 month of age) 05 05 (100%) 00% table 2: outcome of group ii patients after probing procedure no of eyes successful n (%) failed n (%) 1st probing 70 61(87.1%) 09 (12.9%) 2nd probing 09 06 (66.7%) 03 (33.3%) 3rd probing 03 00 03 (100%) table 3: age wise results of successful probing age in months no of eyes n (%) 07-09 30 (44.8) 10-14 19 (28.4) 16-18 15 (22.4) 18-24 2 (3) 24-36 1 (1.5) total 67 (100) spontaneous resolution of nasolacrimal duct obstruction occurs with conservative treatment. by conservative treatment we meant gentle massage and topical antibiotics. with application of proper lacrimal massage, the success rate increases with passage of time. the success is judged by reduction in watering of the eyes6. peterson and robb7 also observed that with conservative treatment, if practiced appropriately and regularly, majority of the patients with congenital nasolacrimal duct obstruction can be relieved as seen in their out patient department. kushner in 1982, franckel in 1988 and nucci and colleagues in 1989 had the same observation8. 0 2 4 6 8 10 0-2 b c fig. 1: group i age-wise distribution 26.03% 60.00% 83.03% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 1st 2nd 3rd fig. 2: group i success rate at different visits 0-2 2-4 4-6 months n o. o f c hi ld re n visits s uc ce ss r at e 77 0 5 10 15 20 25 30 a b c d fig. 3: group ii age-wise distribution the success rate with conservative treatment in our study is 83%. it is slightly less than spontaneous canalization reported in about 95% of cases with conservative treatment if carried out appropriately9. some of the reasons for low success rate by conservative treatment in our study include illiteracy, poor compliance, improper massage technique, and fear of trauma to eyeball during massage. in the second group, probing was carried out because they had not responded to conservative treatment. out of total 70 eyes, 61 (87.1%) cases responded to 1st probing. nine (12.9%) cases failed to open by 1st probing. out of these patients, 3 cases were even not relieved with 3rd probing and were listed for dcr with intubation. in the successful cases majority of the patients are of 7-9 months of age. in our study we observed that with increasing age especially beyond 14 months, the success rate of probing decreased. beyond the age of 2 years the failure rate is almost 100%. stager et al10 observed 94% success in patients of less than 9 months of age. the success rate decreased to 84% in the children older than 9 months of age. other studies have also shown that probing failure risk increases with increasing age11,12. delay in probing past 12 months of age is associated with decreased success rate as noted by katowitz and welsh13. results of probing after 18 months of age are comparatively poor as observed by havins and wilkins14. on the contrary, some studies have reported success with probing in children upto 5 years of age15-18. after probing we continued with lacrimal massage and instillation of antibiotic eye drops and waited for 3 months before the subsequent intervention. some of the patients with residual symptoms were relieved with this treatment. sturrock, macevan and young also observed that after successful probing there might be some residual symptoms in upto 30% of patients. conclusion congenital nasolacrimal duct obstruction is a common paediatric pathology seen in ophthalmology out patient. conservative treatment in these cases is very effective with massage of lacrimal sac area followed by topical antibiotic eye drops. probing is carried out in unresponsive cases after the age of 6 months and has very good results. we recommend that parents should be properly guided about conservative treatment and lacrimal sac message probing should be performed in those cases where there is no improvement with proper continuous conservative treatment. author’s affiliation dr nazullah khan medical officer eye unit, khyber teaching hospital, peshawar dr mohammad naeem khan consultant ophthalmologist khyber institute of ophthalmic medical sciences, hayatabad medical complex, peshawar dr sanaullah jan senior registrar khyber institute of ophthalmic medical sciences, hayatabad medical complex, peshawar professor shad mohammad khyber institute of ophthalmic medical sciences, lady reading hospital, peshawar references 1. sturrock sm, mac ewan cj, young jd. long-term results after probing for congenital nasolacrimal duct obstruction. br j ophthalmol. 1994; 78: 892-94. 2. ghuman t, gonzales c, mazon ml. treatment of congenital nasolacrimal duct obstruction. am j orthopt. 1999; 49: 161-6. 3. richard-e behrmann md, robert-m kleigman md, et al. nelson textbook of pediatrics, 16th edition. wb saunders. 2000; 1917-8. 4. halipota fm, dahri gr, anjum n, et al. results of lacrimal probing in infants and children. pak j ophthalmol. 2000; 6: 4750. 5. robb r. success rates of nasolacrimal duct probing at time intervals after one year of age. ophthalmology.1998;105:1307-0. 6. tsai c, kan h, kao s, et al. efficacy of probing the nasolacrimal duct with adjunctive mitomycin-c for epiphora in adults. ophthalmology 2002; 109: 172-4. 6-12 12-18 18-24 24-36 months n o. o f c hi ld re n 78 7. perterson ra, robb rm. the natural course of congenital obstruction of nasolacrimal duct. j paedr-ophthalmolstrabismus. 1978; 15: 246-50. 8. daniel ma, jakobiec fa. principles and practice of ophthalmology, clinical practice. wb saunders, philadelphia. 1994: 2812-20. 9. kanski jj. clinical ophthalmology 5th edition. butterworth heinemann, oxford. 2003: 50-1. 10. stager d, baker jd, frey t, et al. office probing of congenital nasolacrimal duct obstruction. ophthalmic surg. 1992; 23: 4824. 11. paul to, shepherd r. congenital nasolacrimal duct obstruction. natural history and timing of optimum intervention. j paed ophthalmol strabismus. 1994; 31:362-7. 12. kashkouli mb, kassaee a, tabatabaee z. intial nasolacrimal duct probing in children under age 5: cure rate and factors affecting 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vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology original article optic nerve diseases and its systemic associations mubashir rehman, akhundzada muhammad aftab, sher akbar khan, imran ahmad pak j ophthalmol 2017, vol. 33, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mubashir rehman eye department lgh/pgmi, lahore e.mail: drmubashirrehman78@gmail.com …..……………………….. purpose: to determine optic nerve diseases and its systemic associations. study design: descriptive cross sectional study. place and duration of study: eye departments of lady reading hospital peshawar and khyber teaching hospital peshawar from jan 2015 to oct 2015. material and methods: a total of 44 patients were examined. detailed history was taken from every patient after which complete ocular examination including recording of visual acuity, checking pupillary reactions and fundoscopy with special attention to optic nerve head appearance and recording of color vision and light brightness sensitivity was carried out. specific ophthalmic and systemic investigations were performed. results: seven (15.91%) patients had naion, 6 (13.64%) had demyelinating optic neuritis, 2 (4.54%) had toxic optic neuropathies, 2(4.54%) had nutritional optic neuropathy, 3 (6.82%) had pituitary macroadenoma and 3 (6.82%) had benign intracranial hypertension, 2 (4.54%) had arteritic anterior ischemic optic neuropathy, 2 (4.54%) pseudo-foster kennedy syndrome, 1 (2.27%) had paraneoplastic syndrome, 1 (2.27%) had superior saggital sinus thrombosis, 1 (2.27%) had occipital lobe infarct, 1 (2.27%) had brain metastasis, 1 (2.27%) had craniopharyngioma, 1 (2.27%) had bilateral thalamic ischemia and1 (2.27%) had hydrocephalus. conclusion: patients presenting with optic nerve diseases may have serious systemic associations so for accurate diagnosis and management every patient presenting with optic nerve disease must be properly evaluated. key words: optic nerve, optic neuritris, optic neuropathy. ne of the frequent causes of visual loss encountered by ophthalmologists is optic neuropathy1. clinically, it can appear as an isolated entity due to local pathologies of the optic nerve or associated to a variety of systemic illnesses2. optic neuropathy may be unilateral or bilateral and usually presents with swelling of the optic disc or atrophic optic disc. however it is not uncommon for an optic nerve disease that optic nerve head appear clinically normal but it may cause other signs of optic nerve damage such as decreased visual acuity and defective color vision or light brightness sensitivity or presence of relative afferent papillary defect3. optic neuropathy has a number of local and underlying systemic causes including ischaemia, demyelinating disease, multiple sclerosis, systemic lupus erythematosus (sle), sarcoidosis, behçet’s disease, vasculitis, and several infections including lyme disease, syphilis and cat scratch fever2. recognition of the underlying cause can not only change the visual prognosis but also the neurological consequences. thus ophthalmologist should therefore be familiar not only with the various entities that can cause optic neuropathy but also should have knowledge of relative systemic investigations to diagnose a systemic illness which may be the cause for o optic nerve diseases and its systemic associations pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 175 optic nerve damage4. in most cases, careful clinical evaluation and appropriate investigations, can lead to a specific diagnosis5. similarly as the optic nerve dysfunction may be the presenting sign of a systemic illness, knowledge of clinical evaluation of the optic nerve and appropriate and relative investigations is also important for physicians because physicians may be the first person to encounter such patient and if misdiagnosed this entity can end up in blindness and optic atrophy apart from systemic sequel4. purpose of our study was to find out various local as well as underlying systemic causes giving rise to optic nerve damage and to emphasize the significance of early diagnosis and hence timely management with the help of clinical signs and relative ophthalmic as well as systemic investigations which can not only prevent blindness but also help diagnosis and management of underlying systemic disease. material and methods it was a descriptive cross sectional study carried out at department of ophthalmology of lady reading hospital peshawar and khyber teaching hospital peshawar from jan 2015 to october 2015. a total of 44 patients including males and females were examined. sample size was calculated using 95% confidence interval and 10% margin of error, under who sample size estimation. all patients presenting with sudden or gradual loss of vision with optic nerve involvement evident by decrease vision, presence of affarant pupillary defect, defective color vision, reduced light brightness sensitivity and contrast sensitivity and optic nerve appearance, were included in the study. patients with all other causes of decreased vision with or without presence of affarant papillary defect e.g. diabetic and hypertensive retinopathy, central retinal vein occlusion, central retinal artery occlusion and retinal detachment were excluded from the study. detailed history was taken from every patient after which complete ocular examination including recording of visual acuity, pupillary reactions, intraocular pressure, recording of color vision and light brightness sensitivity and fundus examination with special attention to optic nerve head appearance was carried out for every patient. specific ophthalmic investigations like automated visual field analysis (humphrey) and optical cohenrence tomography (oct) (optic nerve protocol) were carried out where needed. systemic investigations in collaboration with physicians were performed for individual cases based upon their history, ophthalmic and systemic examination. all the analysis was done in spss version 20.0. for categorical variables like gender, and local and systemic associations, frequencies and percentages were calculated. for numeric variables like age, mean ± standard deviation was calculated. all the results were presented in the form of tables. results a total of 44 patients were included in this study. age distribution is shown in table 1. mean age was 44.09 years with sd ± 17.47. gender distribution was analyzed as n = 24 (54.54%) of patients were males and n = 20 (45.46%) were females. table 1: age distribution. age frequency percentage 10 – 20 years 2 4.54% 21 – 30 years 9 20.46% 31 – 40 years 12 27.28% 41 – 50 years 4 9.10% 51 – 60 years 5 11.36% 61 – 70 years 10 22.72% 71 – 80 years 2 4.54% total 44 100% mean age was 44.09 years with sd ± 17.47 out of 44 patients, 25 (56.81%) patients had local optic nerve pathology resulting in either optic disc swelling or optic disc atrophy. while 19 (43.19%) patients had underlying systemic illness resulting in either optic disc swelling, papilledema or optic disc atrophy. leading cause of local optic disc pathologies resulting in optic disc swelling was non arteritic anterior ischemic optic neuropathy (naion) 7 (15.91%), followed by demyelinating optic neuritis 6 (13.64%). a complete breakdown of different local causes is given in table 2. local optic disc pathologies resulting in pale disc included; 2 (4.54%) patients had anterior ischemic mubashir rehman, et al 176 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology table 2: local optic disc pathologies causing swollen disc. disease frequency percentage presentation non arteritic anterior ischemic optic neuropathy 7 15.91% swollen disc demyelinating optic neuritis 6 13.64% swollen disc optic neuritis 2 4.54% swollen disc arteritic anterior ischemic optic neuropathy 2 4.54% swollen disc pseudo-foster kennedy syndrome 2 4.54% rt swollen and lt pale disc optic nerve drusen 1 2.27% swollen disc total 20 45.46% table 3: systemic associations of bilateral swollen discs/ papilloedema. table 4: systemic associations of bilateral pale discs. disease frequency percentage presentation pituitary macroadenoma 3 6.82% bilateral temporal disc pallor nutritional optic neuropathy due to vit b12 deficiency 2 4.54% bilateral temporal disc pallor nutritional optic neuropathy due to tobacco amblyopia 1 2.27% bilateral temporal disc pallor occipital lobe infarct 1 2.27% bilateral temporal disc pallor craniopharyngioma 1 2.27% bilateral pale discs bilateral thalamic ischemia 1 2.27% bilateral pale discs hydrocephalus 1 2.27% bilateral pale discs total 10 22.72% optic neuropathy, 2 (4.54%) had traumatic optic neuropathy, while 1 (2.27%) patient with pale disc was undiagnosed. 3 (6.82%) patients with underlying systemic diseases resulted in swollen disc; 1 (2.27%) patients had toxic optic neuropathy due anti-tuberculous drugs, 1 (2.27%) had paraneoplastic syndrome secondary to squamous cell carcinoma of lung and 1 (2.27%) had neurosarcoid. leading causes for patients with underlying systemic diseases resulting in bilateral swollen discs or papilloedema included; 3 (6.82%) benign intracranial disease frequency percentage presentation benign intracranial hypertension 3 6.82% bilateral swollen discs (papilloedema) superior saggital sinus thrombosis 1 2.27% bilateral swollen discs (papilloedema) brain metastasis 1 2.27% bilateral swollen discs (papilloedema) known case of chronic renal failure 1 2.27% bilateral swollen discs total 6 13.64% optic nerve diseases and its systemic associations pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 177 hypertension, followed by superior saggital sinus thrombosis 1 (2.27%), and brain metastasis 1 (2.27%). complete breakdown of all the systemic causes has been shown in table 3. patients with underlying systemic diseases resulting in pale discs included; 3 (6.82%) had pituitary macroadenoma, 2 (4.54%) had nutritional optic neuropathy due to vitamin b12 deficiency. further details of this group are given in table 4. discussion a variety of intrinsic, intraorbital, intracranial, or systemic diseases can lead to optic nerve damage1. misdiagnosis of optic nerve diseases is not uncommon and can lead to sight as well as life threatening conditions6. reduced blood flow to the optic nerve’s ganglion cells can lead to ischemic optic neuropathy which may be either non-arteritic (naion) or arteritic (aion). naion may result from a variety of underlying systemic conditions while aion is caused by giant cell arteritis (gca)7. most common form of ischemic optic neuropathy is naion. risk factors include hypertension, diabetes, hyperlipidemia, atherosclerosis, nocturnal hypotension, sleep apnea, certain medications and small discs. behbehani r in his study on ischemic optic neuropathies commented on the appearance of the optic disc4. according to him the optic disc is usually swollen in non-demyelinating optic neuritis and naion. in addition, in naion, disc swelling can be sectoral or diffuse and associated with peripapillary hemorrhages. a small cup-to-disc ratio is seen in the fellow eye. while patients with aion due to gca shows diffuse “chalky white” swelling of the disc with cotton wool spots4. in addition patients with naion have afferent pupillary defect and corresponding visual field loss8. although any type of visual field defect can occur with any type of optic neuropathy, in ischemic optic neuropathies altitudinal visual field defects are more common9. in our study the criteria we used for diagnosing nonarteritic anterior ishchemic optic neuropathy (naion) was relevant clinical history, decreased visual acuity, presence of relative afferent pupillary defect, diffuse or sectoral optic nerve head swelling consistent with non arteritic anterior ischemic optic neuropathy and altitudinal field defect on humphery’s visual field. all patients with non arteritic anterior ischemic optic neuropathy (naion) in our study were uncontrolled diabetics with hyperlipidemia. humphrey’s visual fields showed altitudinal field defect in four of these patients. giant cell arteritis (gca) should strongly be considered in patients older than 60 years with features of ischemic optic neuropathy10. patients with gca typically experience headache, scalp tenderness, jaw claudication, weight loss, fever and malaise. complete blood count, erythrocyte sedimentation rate (esr), and c-reactive protein (crp) should always be performed in all such cases. esr and crp when combined increases the specificity (97.0%) and sensitivity (99%) for diagnosis. thrombocytosis is also a positive finding in patients with gca7. our criteria for diagnosing arteritic anterior ischemic optic neuropathy was positive clinical history with special emphasis to jaw claudication, headache, scalp tenderness and weight loss, reduced visual acuity, presence of afferent pupillary defect, edematous optic nerve head consistent with arteritic anterior ischemic optic neuropathy, raised esr and creactive proteins and histological confirmation of giant cell arteritis on temporal artery biopsy. in our study both patients with arteritic anterior ischemic optic neuropathy had raised esr and creactive proteins and temporal artery biopsy revealed calcification. the only patient of pseudo-foster kennedy syndrome in our study had optic atrophy on one side and swollen disc on other side with altitudinal field defect on humphery’s visual fields on the side of swollen disc with normal mri brain and orbits. optic neuritis refers to an infective, inflammatory, or demyelinating process affecting the optic nerve. it usually presents in the second to fourth decades of life11. most common cause of optic neuritis is multiple sclerosis (ms)12. it usually presents with acute unilateral vision loss, pain on eye movement, presence of afferent pupillary defect and visual field defects. optic nerve head may be swollen in the acute stage but if the optic nerve inflammation is retrobulbar than appearance of the optic nerve head is unremarkable. optic nerve head may show signs of pallor when the acute stage subsides11. behbehani r showed in his study that in retrobulbar demyelinating optic neuritis, optic disc is normal in 65% of cases and even if optic disc is swollen is it is usually diffuse and of mild degree4. presence of severe optic disc swelling with peripapillary hemorrhages and exudates should point to an alternative diagnosis such as non arteritic aion or infiltrative optic neuropathy4. our criteria for diagnosing demyelinating optic neuritis was positive clinical history, reduced visual acuity, presence of http://www.ncbi.nlm.nih.gov/pubmed/?term=behbehani%20r%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=behbehani%20r%5bauth%5d mubashir rehman, et al 178 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology relative afferent papillary defect, color vision and light brightness sensitivity defect, visual field defect and positive mri findings. in our study all patients with demyelinating optic neuritis had positive mri report of high signal intensity lesions in the intra orbital portion of optic nerves in addition to other positive finding of optic nerve damage. two patients in our study with non demyelinating optic neuritis were diagnosed on clinical basis with reduced visual acuity, color vision and light brightness sensitivity defect, presence of relative afferent papillary defect and swollen optic disc with normal investigations. optic nerve head drusen consists of calcific hyaline-like material within the optic nerve head substance. at an early age these are called as “buried drusen” as these are not usually visible. at later age these enlarge and come closer to the surface of optic nerve head and become more visible. b-scan show high acoustic reflectivity due calcific deposits and is the most reliable method for diagnosis13. in our study patient with optic nerve drusen presented with bilateral crowded disc resembling papilloedema but had positive finding on b-scan of high acoustic reflectivity. long-standing optic nerve damage such as caused by nutritional or toxic optic neuropathies, compressive, traumatic or hereditary optic neuropathies can give rise to a pale optic disc. this can also occur when an acute inflammatory or ischemic stage of optic neuropathy subsides14. toxic or nutritional and hereditary optic neuropathies selectively affecting the papillo-macular bundle can give rise to temporal optic disc pallor as mentioned by behbehani r in his study4. patients with traumatic optic neuropathy usually have suffered facial or orbital trauma. main clue to the diagnosis is presence of rapd. to detect fractures of the optic canal, and to rule out orbital hemorrhage, ct scan orbit is the investigation of choice15. in our study both the patients with traumatic optic neuropathy presented to us very late due to other injuries occurred during road traffic accident. both had decreased visual acuity, presence of relative afferent papillary defect and optic disc pallor on the affected side with normal ct scan brain and orbits. figure 1 shows fundus photos of patient with traumatic optic neuropathy. different drugs and nutritional deficiencies can also cause optic nerve damage. top on the list are ethambutol and amiodarone. tobacco, methanol and ethanol are also in the list16. tobacco-alcohol amblyopia is the consequence of toxic effect of tobacco superimposed on nutritional deficiency state.17 nutritional optic neuropathy mainly occurs due to vitamin deficiency. deficiency of thiamine (vitamin b1), riboflavin (vitamin b2), niacin (vitamin b3), pyridoxine (vitamin b6), cyanocobalamin (vitamin b12) have all been implicated16. in our study among patients with toxic and nutritional optic neuropathies one was heavy smoker with tobacco amblyopia and had bilateral temporal disc pallor with central scotoma on humphrey’s visual fields, one had toxic optic neuropathy resulting from anti-tuberculous drugs and two had nutritional optic neuropathy due to vitamin b12 deficiency. our criteria for diagnosing nutritional optic neuropathies were reduced visual acuity, temporal or complete disc pallor and serum b12 level below normal limits. both our patients with nutritional optic neuropathy due to vitamin b12 deficiency were low in b12 level with bilateral temporal disc pallor. figure 1: patient with traumatic optic neuropathy showing left pale disc. http://www.ncbi.nlm.nih.gov/pubmed/?term=behbehani%20r%5bauth%5d optic nerve diseases and its systemic associations pakistan journal of ophthalmology vol. 33, no. 3, jul – sep, 2017 179 swollen disc left lower lobe consolidation mri chest showing growth in left lung figure 2: patient with paraneoplastic syndrome. bilateral swollen discs (papilloedema) mri showing non visualization of superior saggital sinus. figure 3: patient with superior saggital sinus thrombosis. mubashir rehman, et al 180 vol. 33, no. 3, jul – sep, 2017 pakistan journal of ophthalmology both small cell and non-small cell carcinoma of the lungs can cause optic neuropathy as a result of paraneoplastic syndrome. patients usually present with gradual decrease of vision associated with bilateral disc swelling before the signs of the systemic malignancy are evident18. in our study patient with paraneoplastic syndrome presented with left swollen disc. findings were not consistent with local optic disc pathologies so we decided to perform systemic evaluation in collaboration with our physician colleagues. on routine investigations x-ray chest showed left lower lobe consolidation. mri chest was advised which showed growth in left lung for which biopsy was performed which proved to be squamous cell carcinoma of lung, figure 2. in our study criteria for diagnosing benign intracranial hypertension was positive clinical history of headache, presence of papilloedema, normal mri with absence of intracranial mass lesion or enlargement of ventricles, raised opening pressure of csf on lumber puncture or clinical trial of acetazolamide with improvement of sign and symptoms in those patients who were unwilling for lumber puncture. out of three patients, in our study, two had raised opening pressure of csf on lumber puncture while one patient was advised lumber puncture but was reluctant. diagnosis in this case was made on clinical basis and showed improvement with oral acetazolamide. three patients presented to us with papilloedema, including superior saggital sinus thrombosis, brain metastasis and one undiagnosed patient who had chronic renal failure and investigations were incomplete due to lack of follow-up. figure 3 shows papilloedema secondary to superior saggital sinus thrombosis with positive mri finding of non visualization of superior saggital sinus. compressive optic neuropathy usually results in gradual and progressive visual loss19. common causes include pituitary adenomas, meningiomas, intracranial aneurysms, craniopharyngiomas and gliomas of the anterior visual pathway20. although knowledge of visual field defects leads in the localization of the lesion, mri of the brain and orbit is require for accurate diagnosis19. in our study seven patients presented with progressive visual loss and bilateral disc pallor which included three cases of pituitary macroadenoma and one each; occipital lobe infarcts, craniopharyngioma, bilateral thalamic ischemia and hydrocephalus. all these cases had positive findings on humphrey’s visual fields and mri brain and orbits. conclusion optic nerve diseases may have serious systemic associations and whether localized or associated with systemic illnesses, it has serious ophthalmic and systemic sequel so every patient with optic nerve disease must be properly examined and proper investigations must be performed for accurate diagnosis and management. author’s affiliation dr. mubashir rehman mbbs, fcps, (ophthalmology) assistant professor, nowshera medical college and hospital, nowshera. dr. akhundzada muhammad aftab mbbs, fcps, (ophthalmology) senior registrar, khyber teaching hospital, peshawar. dr. sher akbar khan mbbs, fcps, (ophthalmology) district specialist, saidu group of teaching hospital sawat. dr. imran ahmad mbbs, fcps, (ophthalmology) assistant professor, gaju khan medical college, swabi role of authors dr. mubashir rehman patient’s selection, data collection, results & discussion dr. akhundzada muhammad aftab patient’s selection, data collection, results & discussion dr. sher akbar khan patient’s selection, data collection, results & discussion dr. imran ahmad literature search refrences 1. o'neill ec, danesh-meyer hv, connell pp, trounce 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kheng yaw chong, and visvaraja subrayan. compressive optic neuropathy: a unique presentation of sweet syndrome. indian j ophthalmol. 2013; 61: 140–141. 20. cheour m, mazlout h, agrebi s, falfoul y, chakroun i, lajmi h, kraiem a. compressive optic neuropathy secondary to a pituitary macroadenoma. j fr ophtalmol. 2013; 36: 101-4. http://www.ncbi.nlm.nih.gov/pubmed/?term=behbehani%20r%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=o%27neill%20ec%5bauthor%5d&cauthor=true&cauthor_uid=21126771 http://www.ncbi.nlm.nih.gov/pubmed/?term=danesh-meyer%20hv%5bauthor%5d&cauthor=true&cauthor_uid=21126771 http://www.ncbi.nlm.nih.gov/pubmed/?term=kong%20gx%5bauthor%5d&cauthor=true&cauthor_uid=21126771 http://www.ncbi.nlm.nih.gov/pubmed/?term=hewitt%20aw%5bauthor%5d&cauthor=true&cauthor_uid=21126771 http://www.ncbi.nlm.nih.gov/pubmed/?term=coote%20ma%5bauthor%5d&cauthor=true&cauthor_uid=21126771 http://www.ncbi.nlm.nih.gov/pubmed/?term=mackey%20da%5bauthor%5d&cauthor=true&cauthor_uid=21126771 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http://www.ncbi.nlm.nih.gov/pubmed/?term=hayreh%20ss%5bauthor%5d&cauthor=true&cauthor_uid=17219123 http://www.ncbi.nlm.nih.gov/pubmed/?term=zimmerman%20mb%5bauthor%5d&cauthor=true&cauthor_uid=17219123 http://www.ncbi.nlm.nih.gov/pubmed/17219123 http://www.ncbi.nlm.nih.gov/pubmed/17219123 http://www.ncbi.nlm.nih.gov/pubmed/17219123 http://www.ncbi.nlm.nih.gov/pubmed/?term=hayreh%20ss%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=atkins%20ej%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=newman%20nj%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=biousse%20v%5bauth%5d http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20006051 http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20006051 http://www.ncbi.nlm.nih.gov/pubmed/?term=p%c3%a9rez-cambrod%c3%ad%20rj%5bauthor%5d&cauthor=true&cauthor_uid=25000867 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http://www.ncbi.nlm.nih.gov/pubmed/20420177 http://www.ncbi.nlm.nih.gov/pubmed/?term=koay%20cl%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=chew%20fl%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=chong%20ky%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=chong%20ky%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=chong%20ky%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=subrayan%20v%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=cheour%20m%5bauthor%5d&cauthor=true&cauthor_uid=23623769 http://www.ncbi.nlm.nih.gov/pubmed/?term=mazlout%20h%5bauthor%5d&cauthor=true&cauthor_uid=23623769 http://www.ncbi.nlm.nih.gov/pubmed/?term=agrebi%20s%5bauthor%5d&cauthor=true&cauthor_uid=23623769 http://www.ncbi.nlm.nih.gov/pubmed/?term=falfoul%20y%5bauthor%5d&cauthor=true&cauthor_uid=23623769 http://www.ncbi.nlm.nih.gov/pubmed/?term=chakroun%20i%5bauthor%5d&cauthor=true&cauthor_uid=23623769 http://www.ncbi.nlm.nih.gov/pubmed/?term=chakroun%20i%5bauthor%5d&cauthor=true&cauthor_uid=23623769 http://www.ncbi.nlm.nih.gov/pubmed/?term=chakroun%20i%5bauthor%5d&cauthor=true&cauthor_uid=23623769 http://www.ncbi.nlm.nih.gov/pubmed/?term=lajmi%20h%5bauthor%5d&cauthor=true&cauthor_uid=23623769 http://www.ncbi.nlm.nih.gov/pubmed/?term=kraiem%20a%5bauthor%5d&cauthor=true&cauthor_uid=23623769 http://www.ncbi.nlm.nih.gov/pubmed/23623769 http://www.ncbi.nlm.nih.gov/pubmed/23623769 http://www.ncbi.nlm.nih.gov/pubmed/23623769 microsoft word zahid kamal 34 original article out come of sahaf enucleation implants in 60 patients zahid kamal siddiqi, girdhari lal, abdul hye pak j ophthalmol 2008, vol. 24 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zahid kamal siddiqi eye unit i lahore general hospital lahore. received for publication december’ 2007 …..……………………….. purpose: to give an overview of surgical outcome of sahaf enucleation implant in 60 patients. material and methods: a descriptive prospective study was done of patients visiting the department of ophthalmology in lahore general hospital, lahore from june 2003 to may 2006. pmma sahaf implant was used in all cases after enucleation. results: a total number of 60 patients were included. intraocular tumor was most important cause for enucleation. the second most common disorder was trauma. three initial cases (5 %) had necrosis of the conjunctiva leading to exposure of implant, which needed reinforcement by autogenous fascia lata. later all those cases who had thin tenon’s fascia had a reinforcement by sclera or autogenous fascia lata. conclusion: all patients had excellent cosmetic results, with out any serious side effects. ahaf enucleation implant is a new pmma orbital implant. it has unique two piece design. posterior hemispherical portion of sahaf enucleation implant gives support to hold recti muscles and anterior convex curvature supports the prosthesis. (fig. 1) it is inert, cost effective, with no cutting edges and easily available in pakistan. multiple sizes are available to restore volume (fig. 2), enhance ocular motility and support prosthesis after enucleation. the three most common indications for enucleation are intraocular malignancy; trauma and a blind painful eye1. evisceration, enucleation and exenteration are indeed mutilating procedures. however, they are still resorted to, in order to save the other eye, to relieve the patient from agonizing pain or save the life of the patient2. orbital implants mainly being used are allen implants, silicone implants and porous implants3. spherical nonporous and nonpegged porous enucleation implants provide similar prosthesis motility when they are implanted using similar surgical techniques4. the top three reasons for implant choice are surgical outcome, cost, and experience5. primary orbital implant with adequate sized allen type acrylic after tension-free closure of tenon and conjunctiva give fairly acceptable cosmetic results6. however, the sharp cutting edges of the implant combined with tilt when rubbed with prosthesis results in cutting of conjunctiva exposure and extrusion. the objective of this study was to assess outcome of newly introduced and locally made sahaf enucleation implant. methodology this descriptive and prospective study was conducted in the department of ophthalmology s 35 lahore general hospital lahore, from may 2003 to june 2006. all those patients who need enucleation were included in this study and patients with recurrent tumors with extra-ocular extension were excluded. hospital patient entry registers were used to collect the data and all entries were made on specific performa. all relevant information then entered into the computer for analysis. material and methods the procedure was explained and written consent for eye removal was taken from patient or parents of child. all the patients were operated under general anesthesia. after conjunctival peritomy recti muscle were secured with 5/0 vicryl and cut from their insertion. posterior portion of implant was inserted and all recti tendons were passed through it (fig. 3). horizontal and vertical recti were sutured with each other. anterior portion placed over posterior and closure was done in two layers (tenon’s and conjunctiva). the anterior part was wrapped in sclera or fascia lata in some cases. after 5 days dressing was opened. volume replacement of the socket was measured by comparing it with normal eye. motility was graded 0-3 (grade 0= no motility, grade 1=100, grade 2=100-300, grade 3=>300) in horizontal and vertical meridian. cosmetic satisfaction was assessed by patient’s comments and doctor’s observation. the data was analyzed according to age, gender, diagnosis, and management. simple descriptive analysis was carried out. results this study comprised of a total number of 60 cases, out of which, 45 (75%) were male and 15 (25%) were female. the age range was 2-65 years (median 12 years). the underlying pathology included retinoblastoma 36 (60%), malignant melanoma 4 (6.66%), painful blind eye 12 (20%) and phthisis bulbi 8 (13.3%) eyes. three initial cases had necrosis of the conjunctiva leading to exposure of implant, which needed reinforcement by autogenous fascia lata. 1515 fig 1: sahaf enucleation implant (left open, right closed) fig 2: different sizes of sahaf implant fig 3 : diagrammatic presentation of sahaf implant in socket fig 4: technique of implantation 36 fig 5::posoperative fill of the socket after sahaf implant. in one case the anterior part of the implant was extruded. later all those cases who had thin tenon’s fascia had a reinforcement by sclera or autogenous fascia lata. all cases had satisfactory socket fill (fig .4). discussion socket reconstruction following enucleation with the use of intraorbital implants provides better cosmesis and prosthetic motility. porous hydroxy apatite implants from the natural coral give excellent results but have certain drawbacks like need of scleral wrapping and repeated infection. other commercially available porous implants like medpor (porex surgical, newnan, ga, usa), derived from synthetic linear high-density polyethylene have similar problems. moreover they are expensive and not readily available in pakistan. the sahaf implant is readily available to the ophthalmologists in pakistan whereas the porous implants have to be imported a process that takes several weeks. in the present study we have used sahaf enucleation implant made up of pmma. in all the cases, sahaf implants with same design and different sizes were used. muscle-integrating options were found stable within the orbital socket and provided desired volume replacement. all patients had healthy socket and adequate fornices. three cases showed minor postsurgical mild exposure problems, which were managed by reinforcement using autogenous fascia lata. all these three patients were on chemotherapy. one with extruded anterior part had combined chemo and radiotherapy. in future we plan to put a scleral or fascia lata cover in all cases with possibilities of chemo or radiotherapy. it also gives better adjustment initially to conformer and later to the prosthesis. the technique of implantation is easy. although 90% of the patients had good implant motility. remaining patients had fair motility. the pmma-based sahaf enucleation implants give homogenous outer surface. to overcome exposure problem in the present study, we used special smooth anterior surface of the implants which was covered in tenon and conjunctiva. peculiar anterior surface of implant is smooth. the availability of different sizes allows good orbital fill (fig. 4). multiple sized posterior part helps in adapting to any muscle length. the multiple sizes of anterior part allow completing the orbital fill accurately. the problem of growing orbit is also solved by exchanging the front part of larger sizes as the child grows with minimal intervention. the present study indicates that the sahaf pmma orbital implant is safe and cosmetically acceptable after enucleation in human subjects. however, further long-term studies with larger number of patients are necessary. author’s affiliation dr zahid kamal siddiqi assistant professor eye unit i lahore general hospital, lahore. dr girdhari lal pgr, eye unit-i lahore general hospital, lahore dr abdul hye associate professor eye unit i lahore general hospital, lahore. reference 1. moshfeghi dm, moshfeghi aa, finger pt. enucleation. surv ophthalmol. 2000; 44: 277-301. 2. babr tf, masud z, iqbal a, et al. should ophthalmologist ever opt for mutilating operations like evisceration, enucleation and exenteration? pak j ophthalmol. 2003; 19: 113-7. 3. ducasse a, segal a, gotzamanis a, et al. tolerance of orbital implants. retrospective study on 14 years. j fr ophthalmol. 2001; 24: 277-81. 4. custer pl, kennedy rh, woog jj, et al. meyer orbital implants in enucleation surgery. ophthalmology. 2003; 110: 2054-61. pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 298 author communication tree sap induced corneal and lens crystals sana nadeem pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. sana nadeem assistant professor email: sana.nadeem@fui.edu.pk, …..……………………….. this is a peculiar case of localized, silvery, iridescent crystal deposition in the cornea and lens, discovered twenty seven years after injury with an overhanging tree branch with sap exposure. the corneal tear at the time of injury was self sealing and there was also associated lens trauma, both managed conservatively on an inpatient basis, and leading subsequently to a corneal scar and localized cortical cataract, respectively, both demonstrating fine, silver, interspersed crystals. key words: crystals, cornea, lens, trauma, cataract, corneal scar. lant trauma may exert its effects by mechanical forces, chemical injury or a hypersensitivity reaction. crystalline keratopathy due to plant sap exposure was reported for the first time in 1973 by ellis1, who described needle-like crystals in the corneal epithelium and stroma in a boy, who accidentally splashed his eyes with the sap of dieffenbachia, an ornamental houseplant. these needle-like crystals or raphides2, are found within the leaves and stems of this plant, and are composed of calcium oxalate, which cause an explosive keratoconjunctivitis upon contact with eyes. the other species3,4 of plants known to cause crystalline keratopathy are arisaema, colocasia, pinellia, phylodendron, and alocasia, although raphides are also found in other philodendron plants of the araceae family, and may cause similar findings.2 the more common cause of crystal deposition in the cornea is infectious crystalline keratopathy, first reported in 1983 by gorovoy5 et al in a corneal transplant, attributed to stromal colonization of gram-positive cocci along a suture tract. subsequently, there have been numerous such cases, classically described as branching, needle-like stromal crystals; associated most frequently with penetrating keratoplasty, but also with incisional surgeries like keratotomy, contact lens wear, chemical burns, and even topical anesthetic abuse.6,7 culprits identified are most commonly bacteria; streptococcus viridians most often, but s. pneumoniae, haemophilus aphrophilus, peptostreptococcus, pseudomonas aeruginosa, and numerous others; but fungi like candida and alternaria species have been isolated as well6. schnyder corneal dystrophy, cystinosis, tyrosinemia, gout, bietti crystalline dystrophy, multiple myeloma, monoclonal gammopathy, gold, and drugs, are other causes of corneal crystals8. scant case reports of self-induced corneal crystals can also be found, with one man admitting to injecting blue eyeshadow9 into his corneas. however, a crystalline traumatic cataract has never been described before in literature. we report a case of crystalline keratopathy with associated similar crystalline cataract as a result of tree sap injury, decades prior to discovery. case report a 51-year-old hospital staff worker with no known comorbids presented in the outpatient department of fauji foundation hospital, which is a tertiary care teaching hospital, affiliated with the foundation university medical college; with complaints of p mailto:sana.nadeem@fui.edu.pk sana nadeem 299 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol grittiness and redness of the left eye for a few days. on examination, his visual acuity was 6/6 in the right eye and 6/12 in the left; his symptoms were attributed to an inflamed pterygium of the left eye. however, it was discovered on routine slit lamp examination, that his left cornea had a sickle shaped distribution of fine, iridescent, silvery crystals in a full thickness, paracentral corneal scar extending from 5:30 to 8:30 o’clock (figure 1 a-e). fig. 1: a. corneal crystals in a sickle shaped scar and sphincter damage (white asterisks) b. larger deposits on lateral illumination c. full thickness crystal deposition d. inflamed pterygium (black asterisk) and brownish deposits intermixed with crystals. brownish deposits were also seen at some places intermixed with the crystals. this finding was correlated by the patient, to a tree branch injury which occurred in 1991, twenty seven years back, when he got hit accidentally, by an overhanging tree branch while travelling on the roof of a large vehicle at night. he did not see the tree in the dark and could not identify the type of tree; however, he did recall some substance being instilled in his eye leading to severe inflammatory symptoms. he was rushed to and admitted at that time in a local hospital and was managed conservatively with topical and systemic antibiotics or steroids, presumably, because he was unaware of the nature of the medicines and could not recall their names. he denied self-medication or instillation of any chemical into his eye. on further examination, he had a quiet anterior chamber, but iris sphincter damage was visualized from 7 o’ clock to 8:45 o’ clock, with loss of the pupillary ruff, and a hint of a localized cataract. upon dilatation of pupil, similar iridescent crystals were seen dispersed inside the localized oval, traumatic cortical cataract at 5 o’ clock position (figure 2). fig. 2: iridescent crystalline traumatic cortical cataract. fig. 3: anterior segment oct (as-oct) of the left cornea, showing the full thickness scar measuring 652 µm, with refractile crystals dispersed in the stroma. the central corneal thickness is 681 µm. the rest of the lens was clear. anterior segment oct (as-oct) was done which showed full thickness corneal scar, with stromal dispersion of crystals (figure 3), and the cortical lenticular opacity with crystals as well (figure 4). tree sap induced corneal and lens crystals pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 300 fig. 4: a. as-oct of the lens showing the anterior cortical cataract (1095 µm in size), with interspersed crystals. b. cataract is located 840 µm from the anterior lens capsule. the fundus examination was normal. the right was normal except for a mild pterygium. intraocular pressures were 11 mm hg od and 12 mm hg os. he was given topical tobramycin-dexamethasone drops thrice a day for two weeks for the inflamed pterygium. routine investigations performed were blood complete picture, random blood sugar, renal function tests, and urine routine examination, which were all normal. the crystals did not interfere with vision, nor seemed infectious, so were not sought to be treated, neither was the traumatic, crystalline cataract, which was not in the pupillary area. the crystals were stable until the last follow-up. discussion trees and plants with milky sap are a common place. such plants can be ornamental, or used in medicines or food. about 12 families, 20 genera and more than 5000 species of milky latex sap occur in the world. the toxicity from the sap is attributed to essential oils, alkaloids, amino acids, proteins, glycerides, plant acids, peptides, saponins, terpenes, furano-coumarins, and poly-acetylene compounds. local or oral use can have profound toxic effects. skin contact can lead to a blistering reaction, while contact with eyes can cause a severe keratoconjunctivitis, uveitis, corneal scarring and even permanent visual loss9,10. dieffenbachia plant typically has ejector pods containing raphides, which if lightly squeezed, result in an explosive ejection2 of these needle-like calcium oxalate crystals, which penetrate the corneal epithelium; allowing further chemical injury by oxalic acid and plant proteins. this gun like effect allows these crystals to penetrate deep into the cornea. all the six species of the araceae family1-4; dieffenbachia, arisaema and colocasia, alocasia, pinellia, and phylodendron; reported previously to cause corneal crystals, are small ornamental plants, but in this case, our patient was hit by a tall tree, whose nature is obviously unknown to us; and could, but possibly does not belong to this family; as these are small ornamental plants, and not at all tall. we would have liked to identify the tree, but the injury occurred decades ago, in the dark night, and the patient could not identify or recall the type of tree at all, and also because of the severe symptoms caused by it, he was rushed to a hospital. the offending plant caused a penetrating injury to the eye, resulting in a full thickness corneal tear and the sap penetrated both the cornea and the lens capsule as well, to cause crystallization in both the corneal stroma, and also within the small, cortical cataract. although, plants from the araceae family are found in pakistan10, it is difficult in this case to identify the offending plant. dieffenbachia typically causes fine, blue9, needle like crystals within the corneal stroma, which resolve with topical steroid and antibiotic therapy. our patient had fine and silvery crystals, rather than needle-like, which are probably not of the same nature as calcium oxalate. deposition of these crystals deep into the anterior lens cortex, also suggests an explosive mechanism of ejection of plant sap, similar to the dieffenbachia plant. the crystals in our patient differ from other causes of crystalline keratopathy, especially infectious; where the crystals are also needle like. association of the crystals to the corneal scar and cataract point to tree sap injury, rather than other metabolic causes or drugs, which lead to bilateral deposits, and have been ruled out on the basis of history and investigations. sana nadeem 301 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol plant sap exposure is an extremely interesting cause of corneal crystals, and in this case lenticular crystals as well; which is unknown to many ophthalmologists, and must be kept in mind while evaluating a patient who presents to us with corneal crystals. in addition, the ophthalmologists need to be aware of the constituents of these milky sap plants and their sequelae, in order to effectively treat such cases. the patients should be asked to identify the culprit plant and bring the offending leaf with them. upon identification, it is important to report these plants in order to increase awareness and prevent injury. the need arises to wear protective glasses and gloves while working in the garden, and to rinse the splashed areas immediately, in the event of accidental exposure. such patients with eye exposure presenting to the hospital need to be irrigated with normal saline immediately, followed by meticulous steroid and antibiotic therapy to suppress keratoconjunctivitis, which in the majority of cases is self-limiting9. in conclusion, crystals in the eye have abundant causes, the common ones have been discussed frequently. however, cataract inflicted by tree sap injury must also be kept in mind while evaluating these cases. references 1. ellis w, barfort p, mastman gj. keratoconjunctivitis with corneal crystals caused by the diffenbachia plant. am j ophthalmol. 1973 jul; 76 (1): 143-147. 2. seet b, chan wk, ang cl. crystalline keratopathy from dieffenbachia plant sap. br j ophthalmol. 1995; 79: 98-99. 3. tang ew, law rw, lai js. corneal injury by wild taro. clin exp ophthalmol. 2006 dec; 34 (9): 895-6. 4. hsueh kf, lin pu, lee sm, hsieh cf. ocular injuries from plant sap of genera euphorbia and dieffenbachia. j chin med assoc. 2004; 67 (2): 93-98. 5. gorovoy ms, stern ga, hood ci, allen c. intrastromal noninflammatory colonization of a corneal graft. arch ophthalmol. 1983 nov; 101 (11): 1749-52. 6. yanoff m, duker js. ophthalmology. third edition. mosby: st. louis, 2009: p 264. 7. porter aj, lee ga, jun as. infectious crystalline keratopathy. surv ophthalmol. 2018 jul-aug; 63 (4): 480-499. 8. weiss js, khemichian aj. differential diagnosis of schnyder crystalline dystrophy. dev ophthalmol. 2011; 48: 67-96. 9. lembach rg, ringel dm. factitious bilateral crystalline keratopathy. cornea, 1990 jul; 9 (3): 246-8. 10. ahmad s. a study of poisonous plants of islamabad area, pakistan. pak j sci ind res. ser. b. 2012; 55 (3): 129137. author’s affiliation dr. sana nadeem assistant professor, department of ophthalmology, foundation university medical college/fauji foundation hospital, rawalpindi author’s contribution dr. sana nadeem data collection, manuscript design, literature review, final review. 63 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology review article meibomian gland dysfunction sameera irfan pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sameera irfan frcs, consultant sam.irfan48@gmail.com …..……………………….. dry eyes is a common, chronic condition that has a prevalence of about 550%. 1 according to the dry eye workshop ii report (dews ii report), published in 2017, the updated definition of dry eye disease is, “a multifactorial disease of the ocular surface characterised by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.” the tear film & ocular surface society (tfos) released their report on the international work on meibomian gland dysfunction (mgd) 2 in 2011, which defined mgd, classified it and considered it as the primary cause of dry eye disease worldwide. previously dry eye disease was considered as an aqueous deficiency problem, but after this report by tfos, there is a paradigm shift towards “not producing enough lipids to retain the tears that are being produced”. this has led to a huge impact on the treatment protocols which were previously focused on managing the sequelae and symptoms of dry eyes rather than targeting directly on the underlying cause, the mgd. it has now been accepted worldwide that dry eye occurs when the ocular surface system cannot adequately protect itself from the desiccating stress due to the lack of a healthy meibomian gland secretion. this article is mainly focussed on the meibomian gland dysfunction, discussing the normal anatomy of the glands, how they are affected by disease, its implications on the ocular surface and finally, the various treatment strategies. key words: blepharitis, dry eyes, meibomian gland dysfunction, blepharospasm. he term meibomian gland dysfunction (mgd) was described for the first time by korb and henriquezin in the early 1980s3. its prevalence appears to be much higher in asian populations4, i.e. greater than 60% while in caucasians, it spans from 3.5% to 19.9%. there was no firmly established definition of mgd before 2011 when the international workshop on mgd defined it5 as “a chronic, diffuse abnormality of the meibomian glands, characterised by the terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. it may result in an alteration of the tear film, symptoms of ocular irritation, clinically apparent inflammation, and ocular surface disease”. mgd is generally considered by the clinicians as posterior blepharitis6. the term “blepharitis” means inflammation of the eyelids. as the eyelid is anatomically made up of two lamallae, anterior and posterior, the blepharitis is also divided into an anterior and a posterior variety. the term “anterior blepharitis” is referred to as the inflammation of lid-margin anterior to the grey line i.e. of the skin, eyelashes, and lash follicles. the term “posterior blepharitis” means the inflammation of structures posterior to the grey line; that includes the meibomian duct orifices, meibomian glands, tarsal plate, and the blepharo-conjunctival junction. frequently, a mixed variety may be seen as the inflammatory process spreads from one structure to the next. anatomy & physiology of meibomian glands the meibomian glands were first described in detail by heinrich meibom7 in 1666. they are modified sebat meibomian gland dysfunction pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 64 ceous glands8 with a tubulo-acinar structure. each gland consists of a cluster of 10-15 secretory acini opening into a long central duct via tiny ductules. there are 30-40 glands in the upper tarsal plate, each gland about 5.5 mm long while there are 25 glands in the lower tarsal plate, each being 2 mm long. they are densely innervated by the sympathetic and parasympathetic nerves (via the v nerve) as supplying the lacrimal and accessory lacrimal glands, thereby ensuring an optimal composition of the tear film. there is also a strong hormonal control mediated by estrogens, androgens, progestins, retinoic acid, growth factors and neurotransmitters. the secretion of meibomian glands is called meibum9 which is primarily made up of nonpolar lipids (about 90%, comprising of wax, sterol-esters and triacylglycerols), while less than 10% are polar amphiphilic lipids (hydroxy fatty acids), and a small amount of proteins and electrolytes. the tear film lipid is a multilayered structure comprising of a thin layer of polar lipids that resides at the aqueous–lipid interface and acts as a surfactant (essential for the uniform spreading and stability of the tear film). this is covered by a thick layer of non-polar lipids that forms the lipid–air interface and resists the evaporation of aqueous component of the tear film. the mode of meibum secretion is holocrine, which means that the secretions are produced in the cytoplasm of a cell; the cell membrane ruptures to release the secretion into the gland’s lumen while the cell itself is destroyed in the process. the secretion from multiple acini are poured via tiny ductules into the central duct that opens at the grey line of the lid margin. a thin strip of orbicularis muscle fibres, called the riolan’s muscle, surrounds the terminal part of the central duct and the few terminal acini present close to the lid margin.10,11 during a blink, the pre-tarsal orbicularis muscle generates a uniform compression of the tarsal plate and of the enclosed meibomian glands, thereby promoting the flow of secretion towards the duct opening by a milking action. meibum is squirted out of the duct openings by the contraction of riolan muscle. meibum is normally liquid at body temperature and coats the lid margins thus making their movement smooth over the ocular surface and is delivered to the tear meniscus. from there it is picked up by the upper lid margin (as it comes down during a blink and picks up the tear meniscus) and is spread uniformly over the aqueous layer of the tear-film thus preventing its thinning and evaporation in-between the blinks, and making the tear film stable. after an absence of blinking, meibum accumulates within the ducts and is delivered in increased amounts when a person wakes up in the morning12. this accounts for the diurnal variation in meibum secretion and the excess amount of oil in the pre corneal tear film makes the vision misty and blurred in the morning. to summarise, the functions of healthy meibomian lipids are:13 i: to make the optical surface of the cornea smooth at the air-lipid interface. ii: they reduce the evaporation of the tear film. iii: they enhance the stability of the tear film. iv: they allow a uniform spread of the tear film over the cornea. v: they prevent the spillover of tears from the lower meniscus over the lid margin. vi: they prevent contamination of the tear film by sebum. vii: the lipids help seal the apposing lid margins during sleep. pathophysiology of mgd mgd is a complex disease that is caused by the interplay of hormonal, microbial, metabolic and environmental factors14. it is classified according to the rate of gland secretion: a: hypo-secretion of meibum occurs due to: 1: obstruction of meibomian duct opening by conjunctival scarring seen in ocular pemphigoid, chemical burns, stevens johnson’s syndrome. 2: duct obstruction by desquamated epithelial cells, clumped together forming plaques, due to hyperkeratinisation of the lid margin. this results in stasis of meibum within the duct; the back pressure produces cystic dilation of the glands, the pressure compresses the acini and causes their atrophy. this results in further hypo-secretion. hyperkeratinisation is commonly the result of hormonal imbalance as a part of the ageing process, decreased expression of androgen receptors (hormonal therapy), blink abnormality, contact lens wear or medications. 3: hypo-secretion with thick, altered meibum may be produced in seborrheic dermatitis, acne rosacea and as a side-effect of medications (antisameera irfan 65 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology histamines, anti-depressants, hormone replacement therapy, isotretinoin for acne). it is important to keep in mind the double vicious cycle14 in which obstruction due to a thick, viscous meibum or hyper-keratinisation of meibomian ducts leads to back pressure and atrophy of acini, with a further decreased secretion of meibum; this makes the meibum more vicid and enhances further obstruction. in addition, stasis of meibum inside the ducts promotes the growth of commensal bacteria, which produce lipases that cause meibum degradation and release of toxic chemicals. these factors aggravate the primary hyper-keratinisation and compositional disturbance of meibum and result in a progressive mgd. chronic obstruction leads to degeneration of the secretory gland tissue and even if the primary obstruction is later resolved by therapeutic approaches, the damage is permanent. b: hyper-secretion of meibum: is seen in meibomitis (meibomian gland inflammation) in which excessive amount of meibum is produced that has an altered chemical composition and is toxic to the ocular surface. this is due to meibocyte abnormalities seen as result of ageing, staph aureus or demodex folliculorum infection, environmental factors (hot, dry climate). moreove nutritional disorders such as generalised malnutrition, a diet low in omega-3 fatty acids, protein deficiency, vitamin a deficiency have all been associated with the production of a poor quality meibum. risk factors for mgd15 1: ageing & hormonal imbalance: this is the most common cause of mgd. receptors for sex hormones (androgen and estrogen) are present within the meibomian glands while meibocytes (the epithelial cells lining the acini) contain enzymes which are necessary for the synthesis and metabolism of sex steroids. androgens stimulate the secretion of meibum by promoting the synthesis of lipids and proteins, suppress meibomian gland inflammation and keratinisation of the ducts, while estrogens reduce/thicken the secretion and promote inflammation. with increasing age, there is a decline in androgen production in both genders. similarly in autoimmune disease like rheumatoid arthritis, sjögren's syndrome and systemic lupus erythematosus, androgen production is reduced in the body. in post-menopausal women, the level of androgen production declines by the ovaries and adrenal glands causing meibomian glands to atrophy.16 ageing of the meibomian glands results in a decreased cell renewal and differentiation of meibocytes, with reduced gland size, and an increased infiltration of inflammatory cell. these changes lead to generalised atrophy of meibomian glands and deficiency of meibum. similar changes in meibomian glands have been observed in androgen-depleted states in individuals on antiandrogen therapy for benign prostatic hypertrophy or prostate cancer. 2: gender: more common in women17 particularly with oily skin conditions, post-menopausal state and hormonal imbalance due to polycystic ovaries. the key ingredient of many anti-ageing cosmetics that are used for peri-ocular skin is retinoid acid 18. it suppresses the action of androgens on meibomian glands leading to their atrophy. 3: environment: hot, dry environment with low humidity results in structural and functional changes in meibocytes; there is an excessive proliferation of basal cells of the acini, a high protein/lipid ratio in the meibum that increases its viscosity and has a negative impact on the stability of the tear film. increased production of meibum causes dilation of ducts as well as depletion of the number of functioning meibocytes (being a holocrine secretion), with subsequent gland atrophy and hypo-secretion. exhaustion of the basal cells leads to the atrophy of acini and meibomian gland dropout. 4: topical medications19,20: all topical medications contain preservatives to enhance their shelf life. the most commonly used preservative is benzalkonium chloride, which is most toxic to the ocular surface. in addition, anti-glaucoma medications like beta blockers, prostaglandin analogs, carbonic anhydrase inhibitors result in an altered morphology of meibomian glands and a decrease in the number of meibocytes. chemical formulations containing adrenaline or phenylephrine promote keratinisation of the lid margin and blockage of meibomian ducts. retinoic acid reduces meibum production and alters its quality. 5: dietary factors: malnutrition (explained above) alters quality of meibum. the use of oral fatty acids improves the quality and expressibility of meibum. specifically, the intake meibomian gland dysfunction pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 66 of omega-3 fatty acids improves the quality of meibum with a decrease in the saturated fatty acid content of meibum. it decreases the ocular surface inflammation. foods rich in omega-3 fatty acids are flaxseed oil, and olive oil and oily fish like tuna and cod. 6: microbial infection: cholesterol esters present in meibum promote the growth of commensal organisms on the eyelid margin, in particular staphylococcus aureus. the bacterial lipases, in turn, break down the neutral fats and cholesterol esters, releasing glycerides and free fatty acids into the tear film, destroying the mucin layer and making the cornea hydrophobic. this makes the tear film unstable. the free fatty acids also stimulate hyperkeratinisation of the lid margins, with keratin plugs adding to the blockage of meibomian ducts. 7: infestation with the demodex mite: demodex mite is a microscopic ectoparasite of the humanskin and constitutes a part of the normal flora. it produces disease when its cell population increases which has been detected in about 46.8% of mgd patients.21,22. it is of two distinct varieties: demodex folliculorum that infests the eyelash follicles, and demodex brevis that burrows deep into the sebaceous and meibomian glands. it causes a direct mechanical damage to the epithelial cells of eyelash follicles (by feeding on them), and by laying eggs at the base of eyelashes, causing follicular distention and misdirected lashes. d. brevis mechanically blocks the orifice of meibomian ducts and produces a granulomatous reaction inside the glands resulting in a chlazion.23 therefore, it should be considered in the differential diagnosis of every ocular surface disease. diagnosis can be made by random epilation of nonadjacent eyelashes placed on a glass slide, mounted with a coverslip with the addition of a droplet of oil, sodium fluorescein, peanut oil, or 75% alcohol which helps release embedded demodex in the hair follicles. 8: contact lens wear 24: the pre-corneal tear film is approximately 3 microns thick; the average central thickness of a contact lens is 30 microns. when the contact lens is worn, the tear film is split both above and below the lens, its thickness is altered resulting in excessive evaporation and further thinning. contact lenses cause a direct mechanical trauma to the lid margin by constant rubbing, desquamating the epithelium, plugging the meibomian duct orifices resulting in gland atrophy. also, chronic ocular surface inflammation affects the gland morphology and function, with secretion of altered meibum that adds to the ocular surface inflammation. all these changes worsen as the duration of contact lens wear increases. 9: congenital anomalies of meibomian glands: a reduction in the number or complete absence of meibomian glands maybe seen in turner syndrome, ectodermal dysplasia with cleft-lip/palate (ecc syndrome). rudimentary meibomian glands maybe visible as yellow streaks on the conjunctival surface of the tarsal plate. dystichiasis (aberrant row of eyelashes) maybe present at birth in which meibomian glands are replaced by an extra row of eyelashes at the grey line. the misdirected eye lashes cause ocular surface trauma as well as meibum deficiency. dystichiasis can also occur secondary to repeated rubbing of eyelids that occurs in vkc, chronic allergic conjunctivitis or in the autosomal dominant lymphoedema. rubbing induces metaplasia of meibocytes to form eyelash follicles. clinical presentation of mgd mgd, in its early stages, is asymptomatic and may remain undiagnosed. it only becomes symptomatic when it has worsened enough to cause tear-film instability or eyelid inflammation. its symptoms and signs are varied and include changes due to: a: altered morphology of the lid margin, altered meibum secretion, bacterial overgrowth and gland dropout. b: tear film instability. c: ocular surface inflammation symptoms & signs the most common symptom is visual fluctuation that occurs during visual tasks associated with decreased blinking, such as driving, reading, staring at a computer screen or watching television. this results in blurred vision, reduced focusing ability, and diplopia. despite the presence of a dry eye, a foreign body sensation and paradoxical reflex tearing may occur (as the lacrimal gland function is normal and dry spots on cornea stimulate the reflex), particularly when patients are exposed to low environmental humidity and blowing air. chronic lid margin inflammation is manifested by sameera irfan 67 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology symptoms of lid discomfort, pain, redness and irritation. the symptoms related to ocular surface inflammation are burning, itching, frequent blinking and photophobia which gradually worsens to severe blepharospasm.25 in a study, mgd and dry eyes were the most common causative factors for blepharospasm.26 the symptoms of ocular irritation tend be worse in the morning because of prolonged exposure of the ocular surface to toxic meibum and hyper-osmolar tears (due to poor clearance of the tear film) during sleep. these symptoms also get worsened after the insertion of punctal plugs due to poor tear clearance. the most troublesome symptom is chronic burning with or without associated photophobia. this is presumably attributable to the presence of inflammatory mediators or to increased tear osmolarity in the pre-corneal tear film. itching of eyelids is more commonly present in atopic patients. morphological changes should be assessed on slit lamp examination and documented27. i: lid margin: thickening, hyperaemia, telangiectasia, keratinisation, foaminess or frothing at the canthal angles and along the lid margin. presence of scales along eyelash follicles should be noted (keeping in mind demodex infestation). ii: meibomian duct orifice: plugging with thick meibum, notching (indicating lost/atrophic glands), distichiasis. iii: meibum quality is assessed by gently pressing the lid margin with a finger or a cotton-tipped applicator, and noting the ease with which meibum is expressed and its texture. meibomian gland expressibility (mge) is a clinical score28 that helps in assessing the severity of disease at initial presentation, and how it improves with treatment. this is calculated by finding the number of glands that can be expressed with mild pressure either with a cotton-tipped swab or a commercially available device that is specifically formulated for this purpose. five glands in the nasal, middle, and lateral thirds of the lower eyelid (total 15 glands) are expressed and scored at each visit. a score of zero indicates a complete blockage of ducts and total absence of meibum. a score of 15 indicates that the glands are expressible throughout the lower eyelid. patients with mge score 0-5 are always symptomatic, and those with a score of 7 or more, are usually asymptomatic. the quality of secretion is noted whether clear, opaque, vicid, cheesy. mgd is graded accordingly:29 grade 0: normal, clear meibum is seen squirting out of the duct orifices with each blink and can be easily expressed by lightly touching the lid margin. grade 1 mgd: meibum looking opaque, viscous and needs pressure on the lid margin to be expressed. patient is asymptomatic at this stage and has no corneal staining. mge score is more than 7. grade 2 mgd: meibum becomes more thick, cheese like, expressed with difficulty; frothing may be noted at the lid margins (indicates lipid breakdown by bacterial lipases). patient may be asymptomatic or may have slight discomfort of lid margins, mild conjunctival hyperaemia, mild corneal staining detected by fluorescein at the inferior limbus and an mge score of 7. grade 3 mgd: plugging of ducts with thick meibum that cannot be expressed by pressure. mge score is 37. excessive frothing at the canthal angles or the lid margins is noted. patient is moderately symptomatic with irritable lid margins, injected, watery eyes with inferior corneal and conjunctival staining. grade 4 mgd: meibomian gland dropout is detected by the presence of notching at the grey line and by transillumination with a pen-light through everted eyelids or by infrared photography. mge score 0-3. at this stage patient presents with severe dry eye symptoms and corneal staining. iv: ocular surface signs: damage to the ocular surface can result from avariety of closely linked factors like increased tear-film evaporation that causes hyperosmolar tears and mediates the release of proinflammatory mediators in the tear-film like cytokines, leukotriens, as well as decreased lubrication of the conjunctival surface of the eyelids prevent their smooth excursion over the eyeball. these result in an irritable eye and the symptoms overlap with the dry eye disease. mgd is considered as themain contributor to an evaporative dry eye disease, but an increased tear production (measured with schirmer’s test) may be noted in patients with mgd. this is due to a compensatory reflex tearing due to ocular surface abnormalities and discomfort. diagnostic tests:30 1: administer a symptoms questionnaire, ocular surface disease index (osdi).31 this questionnaire assesses symptoms of photophobia, ocular/ eyelid pain, blurring of vision, problems with reading/driving/watching tv. meibomian gland dysfunction pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 68 2: measure blink rate and blink interval: blinking normally occurs once every 3-4 seconds (15-20 times /minute) in most people. however, during reading or staring at a computer/cellphone screen, the blink rate slows to 4.5 per minute, or once every 13.5 seconds. blinking has a significant role in the secretion of meibum into the tear film, as already explained. if the blink rate is slowed or blinks are incomplete (the upper lid fails to close onto the lower lid), the lipid layer will build up at the lid margin and meibomian glands will be used less over time. this could lead to meibomian gland atrophy if unidentified. 3: measure lower tear meniscus height and its clarity. normal lower tear meniscus is 1.00-2.00 mm. it can simply be measured by narrowing the vertical beam of a slit lamp or by meniscometry: an instrument measures the tear meniscus height, its radius and cross-sectional area. 4: mge score: expressibility of meibum, noting its quality and grading the mgd. 5: measure tear osmolarity:32 (measuring the concentration of solutes/salts). as the aqueous component of the tear-film evaporates, the concentration of solutes (mainly salts) increases. this test has become a critical part of dry eye management. it requires only a microlitre sample of tears (0.2 μl) collected by a micro-pen from the lateral canthal tear meniscus. it is placed in an instrument, called the osmometer, which gives the reading in a minute. the disadvantages are the need for an expensive equipment and its constant maintenance. the osmolarity of both eyes is measured; a difference of 8 mosm/l or more in the tear osmolarity between the two eyes is considered abnormal. the osmolarity score of 300 mosm/l or greater in the higher scoring eye is considered abnormal. from 300-320 mosm/l, is graded as mild; from 320-340 mosm/l, is graded as moderate; and greater than 340 mosm/l, is graded as a severe dry eye disease. 6: ocular surface staining by fluorescein: it stains the corneal stroma under the desquamated epithelium but does not stain a dry spot (it becomes hydrophobic after losing its mucin coating), and appears as a blue spot in the uniform green fluorescence of the tear film. fluorescein pools in the areas of epithelial erosions/thinning. the area of ocular surface stained should be noted as an interpalpebral staining is due to excess evaporation of aqueous while an inferior limbal staining is due to a toxic meibum production. rose bengal and lissamine green stain dead / devitalised epithelial cells and healthy cells that have lost their mucin coating. the conjunctiva is more intensely stained than the cornea. therefore, early or mild cases of dry eye disease can be detected more easily with these dyes. 7: tear-film break up time (tfbut): it is assessed by instilling a drop of fluorescein stain in the conjunctival sac and using a slit lamp with cobalt blue illumination. time is noted between the last blink and the appearance of a black island in the normal green fluorescence of the tear film, or the first dry spot on the cornea. the test is performed prior to the instillation of anaesthetic eye drops (as they are toxic to the corneal epithelium and produce dry spots). normal tfbut is 15-45 seconds. if it is > 5 seconds, the patient is usually asymptomatic, but when it becomes less than 2 seconds, the patients are almost invariably symptomatic. 8: blink dynamics need to be noted: the examiner evaluates, by inspection on a slit-lamp, whether the upper lid closes on to the lower lid with a blink, the frequency of partial and complete blinks, the area of ocular surface (cornea and conjunctiva) that remains exposed with each complete blink. 9: schirmer’s test:33 it is of two types: schirmer i performed without the topical anaesthesia and schirmer i performed after topical anaesthesia. s i test performed after topical anaesthesia measures only the basal lacrimal secretion. it is highly specific and sensitive for a dry eye disease due to aqueous deficiency. after instilling a topical anaesthetic, a thin strip of filter paper (5 x 35 mm) is placed in the inferior cul-desac in the lateral canthus. the excess tears should be wiped off prior to measuring the basal aqueous production. this distinguishes a dry eye due to less aqueous production from the one due to excess aqueous evaporation (due to mgd). s i test can be performed without the anaesthesia: this measures the basal tear secretion (which is from the accessory lacrimal glands) as well as the reflex secretion from the main lacrimal gland which is stimulated by the irritating nature of the filter paper. less than 10 mm of wetting after 5 minutes is diagnostic of atd. the test is relatively specific, but it is poorly sensitive. schirmer ii test is performed without the anaesthesia. the nasal mucosa is stimulated by a cotton sameera irfan 69 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology wisp or a pungent odour and the amount of tear production (both reflex and basal) are noted. this should only be performed in patients in whom schirmer i test fails to demonstrate tear production (in kcs). 10: meibography: document morphology and meibomian gland count in upper and lower lids by infra-red camera, confocal microscopy, spectraldomain optical coherence tomography. normal meibomian glands are long, vertical, extending from the lid margin to the end of tarsal plate. they become dilated and tortuous in early/mild disease. in disease of intermediate duration/ moderate severity, the gland dropout increases with loss of identifiable gland architecture. in prolonged / severe disease, all glands are markedly shortened or absent. management and treatment of mgd34 i: patient education: this is the most important part of treatment in order to ensure compliance to therapy. patients need to be educated regarding the chronic nature mgd, its prolonged therapy, affect of diet (flaxseed oil, fish oil, and olive oil), environment dryness/humidity and the drying effects of topical or systemic medications. ii: lid hygiene: lids should be scrubbed gently with diluted baby shampoo applied on cotton-tipped applicator, and rinsed with lukewarm water. this removes toxic foamy meibum and reduces microbial load. iii: warm compresses or application of heat is the mainstay of therapy. normal meibum is liquid at body temperature, but denatured meibum becomes thick, dry and hard. it blocks the duct opening as well as the whole lumen of the ducts. heat therapy dissolves the thick meibum, and to be effective, the glands have to be consistently heated to at least 45°c (113°f). this can be done with application of a warm wet towel or cotton pads, soaked in hot (not boiling) water; with the eyes closed, the hot towelis held onto the eyelids for 2 minutes. it is made wet again with hot water and the process repeated five times, so that total heat application is for 10 minutes. this needs to be done daily for at least a month. it can also be done with commercially available heat masks, or devices (lipi flow thermal pulsation system, mibo thermaflow)35 that helps the liquefaction of meibum and massages it upwards towards the ducts from where it can be easily expressed. iii: gentle massage: after the application of heat, upper eyelid should be massaged downwards with the fingers, while the lower lid massaged upwards to establish meibum flow out of the glands. iv: blinking exercises: they help improve meibum flow and tear-film spread over the ocular surface by contraction of pre-tarsal orbicularis and riolan muscle. patients should be advised to do 10 good blinks at a time; the eyes should be fully closed for 2 seconds, then squeezed for another 2 seconds. this should be done for every hour of digital device use. iv: topical lubricants: they help to relieve ocular surface irritation by replenishing the tear film. preservative-free preparations should be preferred to prevent further damage to the ocular surface. v: topical or systemic antibiotics to control infections: low-dose oral doxycycline (50-100 mg/day for 6 weeks) helps to reduce inflammation in the eyelid tissue, it is anti-angiogenic and helps in restoring healthy meibum secretion. azithromycin 250 mg once daily is also affective in patients allergic to doxycycline. vi: topical cyclosporin eyedrops (0.5%)36 or tacrolimus ointment / skin cream 0.03%: cyclosporine as well as tacrolimus are highly specific immunomodulator drugs that primarily affects tlymphocytes. they are used as steroid-sparing agents as they have all the anti-inflammatory affects but without the side-effects of prolonged steroid use. they increase the production of aqueous, improve goblet cell count and reduce meibomian gland inflammation. in addition, tacrolimus cream applied to the lid margin reduces vascular congestion, telengiactasia, and improves the quality of meibum produced. to have these affects, therapy has to be continued for 2-4 months. the tear-film break-up time has shown to improve with this therapy. vi: treating demodex mite infestation:37 management involves reduction in the number of demodex mites; total eradication is not required as it is a part of the normal skin flora. this can be achieved by a combination of lid scrubs (scrubbing the eyelids twice daily with baby shampoo diluted with water to yield a 50% dilution and applying an antibiotic ointment at night until resolution of symptoms) and removal of the eyelash collarettes with the use of a cotton-tipped applicator and lid foam. demodex mites are resistant to a wide range of anmeibomian gland dysfunction pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 70 tiseptic agents including 10% povidone-iodine, 75% alcohol and erythromycin. the most effective and commonly used treatment is tea tree oil. chemically, it is terpinen-4-oil –a terpene with antimicrobial, antifungal, and antiseptic properties. there are many commercially available products that contain tea tree oil like shampoo, soap, ointment, skin cream. hypochlorous acid and mercury oxide 1% ointment is also effective. patients should be instructed to avoid oil-based cleansers and greasy makeup as they can provide further "food" for the mites. they should discard the previously used make-up, use hot water to wash their clothes, and a hot dryer to dry them. vii: intra-ductal probing: it clears the obstruction of the ducts and allows the meibum to flow thereby reducing the intra-ductal pressure (idp), inflammation, lid congestion with improvement of symptoms. viii: intense pulsed light (ipl): this also liquifies the meibum and improves its drainage by delivering a combination of heat and gentle pressure to the eyelids. it is an in-office therapy and requires 1-2 sessions. the international workshop on mgd recommended a staged treatment algorithm, depending upon the grade of mgd. grade 1: i: patient education regarding mgd, diet, environment. ii: lid hygiene. iii: warm compresses. grade 2: i: advise patient to use humidifiers in airconditioned rooms, and increase dietary intake of omega 3 fatty acids, or use dietary supplements containing linoleic acid (vegetables, fruits, nuts, grains and seeds; linseed oil) or docosahexaenoic acid (dha) 1000 mg daily. ii: warm compresses followed by firm lid massage . iii: blinking exercises. iv: topical lubricants. v: topical tetracycline / azithromycin eye ointment massaged to lid margin38. vi: oral tetracycline, 50-100 mg or azithromycin, 250 mg daily for a month39. grade 3: all in grade 2 plus: i: add anti-inflammatory therapy for dry eyes (topical cyclosporin 0.5%, tacrolimus 0.03%)40,41 ii: ductal probing. grade 4: all of grade 3 therapy. conclusion mgd is an extremely common clinical entity and is the leading cause of an evaporative dry eye. it should be specifically looked for and treated in its early stages even in an asymptomatic patient; if untreated, it progresses to meibomian gland atrophy and drop out which is an irreversible stage. the goal of therapy is to improve the flow and the quality of meibum so as to restore the stability of the tear film. since the therapy has to be continued for 2-3 months, patient education is mandatory to ensure compliance. author’s affiliation dr. sameera irfan frcs, consultant author’s contribution dr. sameera irfan literature review, manuscript writing & review. references 1. jp craig. tfos dews ii report executive summary tear film & ocular z www.tearfilm.org/public/tfosdewsii-executive.pdf 2017 2. craig jp, nichols kk, akpek ek, et al. tfos dews ii definition and classification report. ocul surf. 2017; 15 (3): 276-83. 3. korb dr, henriquez as. meibomian gland dysfunction and contact lens intolerance. j am optom assoc. 1980; 51: 243-51. 4. schaumberg da, nichols jj, papas eb, et al. the international workshop on meibomian gland dysfunction: report of the subcommittee on the epidemiology of, and associated risk factors for, mgd. invest ophthalmol vis sci. 2011; 52: 1994–2005. 5. nelson jd, shimazaki j, benitez-del-castillo jm, et al. the international workshop on meibomian gland dysfunction: report of the definition and classification subcommittee. invest ophthalmol vis sci. 2011; 52: 1930-7. 6. mcculley jp, dougherty jm, deneau dg. classification of chronic blepharitis. ophthalmology, 1982; 89: 1173–1180. 7. yeotikar ns, zhu h, markoulli m, nichols kk, naduvilath t, papas eb. functional and morphologic sameera irfan 71 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology changes of meibomian glands in an asymptomatic adult population. invest ophthalmol vis sci. 2016; 57: 3996-4007. 8. wang y, dong n, wu h. zhonghua yan ke za zhi. meibomian gland morphology, 2014 apr; 50 (4): 299302. 9. shine we, mcculley jp. polar lipids in human meibomian secretions. curr eye res. 2003; 26: 89–94. 10. knop e, knop n, schirra f. meibomian glands. part ii: physiology, characteristics, distribution and function of meibomian oil. ophthalmology, 2009 oct; 106 (10): 88492. 11. knop e, knop n, miller t, sullivan da. the international workshop of meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. invest ophthalmol vis sci. 2011; 52 (4): 1938-78. 12. chew ck, hykin pg, jansweijer c, dikstein s, tiffany jm, bron aj. the casual level of meibomian lipids in humans. curr eye res. 1993 mar; 12 (3): 255-9. 13. craig j, tomlinson a. importance of the lipid layer in human tear film stability and evaporation. optom vis sci. 1997; 74: 8–13. 14. baudouin c, messmer em, aragona p, et al. revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. br j ophthalmol. 2016; 100: 300-6. 15. schaumberg da, nichols jj, papas eb, tong l, uchino m, nichols kk. the international workshop on meibomian gland dysfunction: report of the subcommittee on the epidemiology of, associated risk factors for, mgd. invest ophthalmol vis sci. 2011; 52 (4): 1994-2005. 16. gutgesell vj, stern ga, hood ci. histopathology of meibomian gland dysfunction. am j ophthalmol. 1982; 94: 383–387. 17. truong s, cole n, stapleton f, golebiowski b. sex hormones and the dry eye. clin exp optom. 2014; 97 (4): 324-36. 18. karlsson t, vahlquist a, kedishvili n, törmä h. 13cis-retinoic acid competitively inhibits 3 alphahydroxysteroid oxidation by retinol dehydrogenase rodh-4: a mechanism for its anti-androgenic effects in sebaceous glands? biochem biophys res commun. 2003 mar 28; 303 (1): 273-8. 19. c. baudouin, a. labbé, h. liang, a. pauly, and f. brignole-baudouin, “preservatives in eyedrops: the good, the bad and the ugly, ”progress in retinal and eye research, 2010; vol. 29, no. 4: pp. 312–334. 20. e. viso, f. gude, and m. t. rodríguez-ares, “the association of meibomian gland dysfunction and other common ocular diseases with dry eye: a populationbased study in spain, ”cornea, 2011; vol. 30, no. 1: pp. 1–6. 21. kheirkhah a, casas v, li w, raju vk, tseng sc. corneal manifestations of ocular demodex infestation. am j ophthalmol. 2007; 143 (5): 743–749. 22. liang l, liu y, ding x, ke h, chen c, tseng scg. significant correlation between meibomian gland dysfunction and keratitis in young patients with demodex brevis infestation. br j ophthalmol. 2017 oct 21; epub. 23. yam jc, tang bs, chan tm, cheng ac. ocular demodicidosis as a risk factor of adult recurrent chalazion. eur j ophthalmol. 2014; 24 (2): 159–163. 24. korb dr, henriquez as. meibomian gland dysfunction and contact lens intolerance. j am optom assoc. 1980; 51: 243-51. 25. irfan s. is benign essential blepharospasm a “benign”& or an “essential” condition? major review paper. the american journal of cosmetic surgery, 2018; vol. 35 (2) 83–91. 26. irfan s. minimal orbicularis myectomy: does it relieve spasms in benign essential blepharospasm? american j of cosmetic surgery, 2015; 32(3):178-186. 27. amano s. mgd working group: definition and diagnostic criteria for meibomian gland dysfunction. j eye (atarashii ganka). 2010; 27: 627–631. 28. yeotikar ns, zhu h, markoulli m, nichols kk, naduvilath t, papas eb. functional and morphologic changes of meibomian glands in an asymptomatic adult population. invest ophthalmol & vis sci. august 2016; 57 (10): 3996. 29. foulks gn, bron aj. meibomian gland dysfunction: a clinical scheme for description, diagnosis, classification, and grading. ocul surf. 2003; 1: 107–126. 30. wolffsohn js, arita r, chalmers r, et al. tfos dews ii diagnostic methodology report. ocul surf. 2017; 15 (3): 539-74. 31. özcura f, aydin s, helvaci mr. ocular surface disease index for the diagnosis of dry eye syndrome. ocular immunology and inflammation, 2007; 15 (5): 389-393. 32. tomlinson a, khanal s, ramaesh k, diaper c, mcfadyen a. tear film osmolarity: determination of a referent for dry eye diagnosis. invest ophthalmol & vis sci. october 2006; vol. 47: 4309-4315. 33. li n, deng xg, he mf. comparison of the schirmer i test with and without topical anaesthesia for diagnosing dry eye. int j ophthalmol. 2012; 5 (4): 478–481. 34. jones l, downie le, korb d, et al. tfos dews ii management and therapy report. ocul surf. 2017; 15 (3): 575-628. 35. dell sj. intense pulsed light for evaporative dry eye disease. clin ophthalmol. 2017; 11: 1167-73. 36. perry hd, doshi-carnevale s, donnenfeld ed, kornstein hs. topical cyclosporine use in meibomian gland dysfunction. ophthalmology, 2003; 110: pp. 1,578–1,581. 37. cheng am, sheha h, tseng sc. recent advances on ocular demodex infestation. curr opin ophthalmol. 2015; 26 (4): 295–300. 38. foulks gn, borchman d, yappert m, kim sh, mckay jw. topical azithromycin therapy for meibomian gland dysfunction: clinical response and lipid alterations. cornea, 2010 jul; 29 (7): 781-8. meibomian gland dysfunction pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 72 39. kashkouli mb, fazel aj, kiavash v, nojomi m, ghiasian l. oral azithromycin versus doxycycline in meibomian gland dysfunction: a randomised doublemasked open-label clinical trial. br j ophthalmol. 2015 feb; 99 (2): 199-204. 40. rubin m, rao sn. efficacy of topical cyclosporin 0.05% in the treatment of posterior blepharitis.j ocul pharmacol ther. 2006 feb; 22 (1) :47-53. 41. nivenius e, van der ploeg i, jung k, chryssanthou e, van hage m, montan pg. tacrolimus ointment vs. steroid ointment for eyelid dermatitis in patients with atopic keratoconjunctivitis. eye (lond). 2007 jul; 21 (7): 968-75. 25 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology foriginal article complications of different intravitreal anti vegf injections at multiple centers observing different protocols hussain ahmad khaqan, tariq khan, haroon tayyab, tariq khan marwat, muhammad qasim lateef, muhammad tayyab pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hussain ahmad khaqan associate professor department of ophthalmology post graduate medical institute, ameer-ud-din medical college, lahore general hospital, lahore email: drkhaqan@hotmail.com …..……………………….. purpose: to analyze the intra vitreal anti vegf complications observing different intravitreal injection protocols. study design: this is an open label, prospective, multicenter cohort study. place and duration of study: the audit was conducted at five different hospitals from september 2016 to march 2018. material and methods: all intravitreal injections of bevacizumab, ranibizumab and aflibercept were included irrespective of the context of the injections. questions were asked in the designed proforma regarding use of povidone iodine, sterile drapes, opsite, speculum, sterilized instruments, pre-operative and post-operative antibiotics. data was also collected about scrubbing before the procedure, use of cap and mask during the procedure and whether injection was given in operation theater or in an office based setup. complications, whether systemic or ocular, were enumerated and their management was also noted down. results: a total of 2,854 injections were given to 2,289 patients by 10 different surgeons in 5 different institutes. there were 6 surgeons who did not prescribe pre-operative antibiotics, 4 surgeons did not use cap and mask during the procedure, while 2 surgeons did not use opsite during the procedure. office based injections were given by 1 surgeon while all the others administered injections in an operation theater. complications included subconjunctival hemorrhage, in 184 cases, sterile inflammation in 78 cases, transient rise in iop in 53 eyes and 1 case each of endophthalmitis, lens touch and retinal detachment. conclusion: the ocular and systemic complications number is low and comparative to the available literature after injecting different intra-vitreal anti vegf. key words: intravitreal injection, anti-vegf, endophthalmitis, bevacizumab, ranibizumab, aflibercept. ntra-vitreal injections of anti-vascular endothelial growth factors (vegf) have become the mainstay of treatment for various diseases of the posterior pole including proliferative diabetic retinopathy (pdr)1, choroidal neovascularization (cnv)2, diabetic macular edema (dme)3, retinal vein occlusion (rvo)4 and exudative age-related macular degeneration (examd)5. vegf plays a cardinal role in regularizing the angiogenesis6. overproduction of vegf is associated with diseases like pdr7, cnv8 and rvo9. this antiangiogenic therapy inhibits vegf production thus resulting in reversal and prevention of further i complications of different intravitreal anti vegf injections at multiple centers using different protocols pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 26 neovascularization10. currently three most popular anti-vegf being administered including bevacizumab (avastin®, genentech, san francisco, ca), ranibizumab (lucentis®, genentech, san francisco, ca) and aflibercept (eylea®, regeneron, tarrytown, new york, usa). bevacizumab is a fully-humanized monoclonal antibody against vegf-a, which was primarily approved as an adjuvant to the treatment of metastatic colorectal carcinoma11. it is currently being used as an off-label drug for the treatment of retinal diseases11. as it is not available in individual doses by the manufacturer, it is being compounded by the pharmacies into ready to use syringes. ranibizumab is a humanized monoclonal antibody fragment against vegf-a12. united states food and drug administration approved it for the treatment of retinal diseases. it is commercially available as single dose vial, packaged specifically for use as intravitreal injection. aflibercept (previously known as vegftrap) is a recombinant fusion protein, which acts against vegf-a, vegf-b and placental growth factor13. it has longer duration of action and higher binding affinity thus theoretically making it superior to both ranibizumab and bevacizumab13. it is also commercially available as a single dose vial, packaged specifically for use as intravitreal injection. despite widespread global use of intra-vitreal injection technique, there are no standard guidelines for the technique. there is no consensus on the use of sterile drapes, speculum, masks and pre-operative or post-operative antibiotics. avery et al proposed some guidelines in 2014 after a consensus of panel of experts14. the major ocular complications of intravitreal injections include endophthalmitis12, sterile inflammation10, retinal detachment, and vitreous hemorrhage11. albeit rare but intra-vitreal injection of anti-vegf drugs can also cause serious systemic side effects. these include acute hypertension, cerebrovascular accidents and myocardial infarction15. in this study we are presenting a multicenter audit of intra-vitreal injections of anti-vegf, so that we can compare different techniques of different surgeons and their outcomes and complications. material and methods this is an open label, prospective, multicenter study. data was collected from 5 different hospitals. 10 different surgeons performed the procedures. patients of both gender, suffering from a retinal disease that required intra-vitreal anti-vegf were included in the study. patients younger than 18 years of age and patients older than 18 years of age suffering from other ocular diseases along with retinal disease were excluded from the study. the study followed the tenets of the declaration of helsinki. before administration of the injection, an informed consent was obtained from all the patients. all the patients receiving bevacizumab injections were made aware of the fact that this injection is used as an off-label drug. possible ocular and systemic complications of all the anti-vegf were explained. the total number of intravitreal injections of bevacizumab, ranibizumab and aflibercept given from september 2016 to march 2018 were tabulated irrespective of the context of the injections. these injections were given for different retinal pathologies including proliferative diabetic retinopathy, retinal vein occlusions, exudative age related macular degeneration and macular edema due to various other entities. a proforma was devised to obtain information about the hospital protocol following the procedure. questions were asked in the proforma regarding use of povidone iodine, sterile drapes, opsite, speculum, sterilized instruments, pre-operative and postoperative antibiotics. data was also collected about scrubbing before the procedure, use of cap and mask during the procedure and whether injection was given in the operation theater or in an office based setup. type of anti-vegf drug used was also mentioned in the proforma. complications, whether systemic or ocular, were enumerated and their management was also noted down. in the case of bevacizumab injection attention was paid to the compounding pharmacies and maintenance of cold chain. all patients underwent complete ocular and systemic examination. ocular examination included best corrected visual acuity (bcva), applanation tonometry, slit lamp examination and indirect ophthalmoscopy at baseline and then monthly at each follow-up. systemic examination included recording of blood pressure, random blood sugar levels and a consultation with an internist. results a total of 2,854 injections were given to 2,289 patients from september 2016 to march 2018. a total of 10 different surgeons performed the procedures in 5 different institutes. 1,724 patients received unilateral hussain ahmad khaqan, et al 27 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology injections while 565 patients received bilateral injections. out of 2,289 patients, 1,236 were male and 1,053 patients were female. table 1: distribution of differentanti-vegf injections. type of intravitreal injection number (n) (%) bevacizumab 2,321 (81.32%) ranibizumab 513 (17.97%) aflibercept 20 (0.70%) total 2,854 table 2: indications for treatment. disease number (n) (%) pdr 953 (33.4%) dme 832 (29.1%) ex amd 785 (27.5%) rvo 211 (7.4%) others 73 (2.5%) out of total 2,854 injections, 2,321 were bevacizumab, 513 were ranibizumab and 20 were aflibercept (table 1). indications for the injections are summarized in table 2. regarding perioperative procedure details, slight variations were noted among the surgeons. most common variable condition was the use of pre-operative antibiotics. there were 6 surgeons who did not prescribe pre-operative antibiotics. 4 surgeons reported that they did not use cap and mask during the procedure, while 2 surgeons reported that they did not use opsite during the procedure. office based injections were given by 1 surgeon while all the others administered injection in an operation theater. every surgeon followed all the other steps in same manner. table 3 provides an insight about the number of cases for each step and its correlation with endophthalmitis if any. table 3: distribution of injection protocol. protocol yes (n) no (n) povidone iodine 2,854 (100%) 0 opsite 2,282 (80%) 572 (20%) sterile drape 2,854 (100%) 0 sterilized instruments 2,854 (100%) 0 cap 2,001 (70.1%) 853 (29.9%) mask 2,093 (73.3%) 761 (26.7%) scrub 2,854 (100%) 0 operation theater based 2,560 (89.7%) 294 (10.3%) office based 294 (10.3%) 2,560 (89.7%) pre-op antibiotics 932 (32.7%) 1,922 (67.3%) post-op antibiotics 2,854 (100%) 0 most common ocular complication reported was subconjunctival hemorrhage, which was observed in 184 cases. sterile inflammation was noted in 78 cases, which was managed by topical steroid eye drops. transient raised iop was noted in 53 eyes and was managed by topical anti-glaucoma medication. 1 case each of endophthalmitis, lens damage and retinal detachment were reported. 6 patients suffered from acute hypertension, 2 patients had cerebrovascular accidents while 1 patient had myocardial infarction. all of these patients survived the incidents. complications with regard to injection type are tabulated in table 4. table 4: complications. name bevacizumab ranibizumab aflibercept ocular subconjunctival hemorrhage 117 (5%) 63 (12.3%) 4 (20%) raised iop 40 (1.72%) 12 (2.34%) 1 (5%) lens touch 1 (0.04%) 0 0 sterile inflammation 45 (1.94%) 32 (6.23%) 1 (5%) endophthalmitis 1 (0.04%) 0 0 retinal detachment 0 1 (0.2%) 0 systemic acute hypertension 3 (0.13%) 2 (0.4%) 1 (5%) myocardial infarction 1 (0.04%) 0 0 cerebrovascular accidents 1 (0.04%) 0 1 (5%) complications of different intravitreal anti vegf injections at multiple centers using different protocols pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 28 discussion this study aims to give an insight about different protocols for intra-vitreal injections being followed in different hospitals and their outcome. since there are scarce specific guidelines for the procedure, there are variations in the pre and peri-procedural steps among different surgeons. avery et al14 published guidelines after consensus of a panel of experts. some of the points on which there was a consensus were, 1) use of povidone iodine (5-10%) at the injection site was recommended, 2) pre, peri and post-injection antibiotics were considered unnecessary, 3) use of sterile or non-sterile gloves was recommended, 4) no evidence for the support of use of sterile drape was found and 5) use of surgical mask and monitoring of pre and post injection iop was also recommended. the points on which there was no consensus were 1) application of povidone iodine to eyelids and eyelashes, 2) use of speculum and 3) need for pupillary dilation14. in our study application of 5% povidone iodine to eyeball as well as eyelashes, use of speculum, sterile drapes, sterile gloves, scrub, and prescription of postop antibiotics was done in all cases. although use of cap and mask, application of opsite and administration of pre-operative antibiotics were variable, but these variables had no statistical significance in terms of outcomes of the injections. although uncommon, endophthalmitis is the most feared complication of intravitreal injections. sigford et al did a literature review and out of 445,503 injections administered they found out that risk for endophthalmitis after ranibizumab injection was 0.029% and that after bevacizumab was 0.058%12. in comparison of amd treatment trial (catt) the rates reported for post injection endophthalmitis were 0.7% for ranibizumab and 1.4% for bevacizumab5. the higher reported incidences of endophthalmitis in bevacizumab group indicate there may be a problem in the compounding procedures. in our study rate of endophthalmitis for bevacizumab, ranibizumab and aflibercept were 0.04%, 0% and 0% respectively which are in line with the results of the other studies. one case, which had endophthalmitis, underwent parsplana vitrectomy with final visual outcome of 6/18 in that eye. other reported ocular side effects include subconjunctival hemorrhage16, sterile inflammation10, retinal detachment and tears11, lens damage, raised iop17 and intraocular hemorrhage. frequency of uveitis was found out to be 0.09%15 and 0.4%16 in two large retrospective studies. one study reported trd in 11 eyes following 211 injections (5.2%)18. several studies have also reported occasional cases of raised iop after intra-vitreal injection of anti-vegf requiring the use of anti ocular hypertensive agents17,19. we observed 184 cases of subconjunctival hemorrhage, 78 cases of sterile inflammation and 53 cases of transiently raised iop. all the cases were managed with topical medications. our findings were consistent with other published literature. cerebrovascular accidents, myocardial infarction and acute hypertension are the major side effects reported in the literature15. systemic absorption of anti-vegf can give rise to these complications. in one study 22.4% of the patients showed hypertension20. in our study raised blood pressure was noted from few hours after injection to 2 weeks after injection. fung et al did an internet-based survey to assess the systemic adverse effects of intravitreal injection. out of 7,113 injections for 5,228 patients, they reported 2 deaths, 5 cerbrovascular accidents and 15 cases of hypertension21. several other clinical trials comparing different anti-vegf have reported mortality rate of 24% in both experimental and control group. in our study we experienced 6 cases of hypertension, 2 cases of cerebrovascular accidents and 1 case of myocardial infarction but no mortality was noted. the limitations of this study are low cohort and lack of longer follow-up. to assess the long-term complications, much longer follow-up is needed. conclusion the ocular and systemic complications number is low and comparative to the available literature after injecting different intra-vitreal anti-vegf and observing different pre-operative, per-operative and post-operative protocols by ten different surgeons at five different centers. author’s affiliation dr. hussain ahmad khaqan associate professor of ophthalmology department of ophthalmology lahore general hospital/ ameer ud din medical college/ postgraduate medical institute, lahore dr. muhammad tariq khan associate professor of ophthalmology department of ophthalmology hussain ahmad khaqan, et al 29 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology akhtar saeed medical and dental college, lahore dr. haroon tayyab assistant professor of ophthalmology department of ophthalmology king edward medical university/ mayo hospital, lahore dr. muhammad tariq khan marwat associate professor of ophthalmology department of ophthalmology khyber girls medical college, peshawar dr. muhammad qasim lateef associate professor of ophthalmology department of ophthalmology jinnah hospital, lahore dr. muhammad tayyab doctors hospital, lahore author’s contribution dr. hussain ahmad khaqan study design, manuscript writing, critical review, injecting surgeon dr muhammad tariq khan study design, literature search, data collection, injecting surgeon dr. haroon tayyab literature search, manuscript writing, manuscript editing, injecting surgeon dr. muhammad tariq khan marwat data collection, manuscript editing, statistical analysis, injecting surgeon dr. muhammad qasim lateef literature search, statistical analysis, critical review, injecting surgeon dr. muhammad tayyab data collection, literature search, critical review, injecting surgeon references 1. adamis 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inflammation associated with intravitreal anti-vegf pharmacotherapy. mediators inflamm. 2013; 2013: 943409. 21. hurwitz h, fehrenbacher l, novotny w, cartwright t, hainsworth j, heim w, et al. bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. new england journal of medicine, 2004; 350 (23): 2335-2342. 22. fung a, rosenfeld p, reichel e. the international intravitreal bevacizumab safety survey: using the internet to assess drug safety worldwide. british journal of ophthalmology, 2006; 90 (11): 1344-1349. microsoft word shahzad iftikhar 1 original article safety of intrcameral moxifloxacin ophthalmic solution for antibacterial prophylaxis in cataract surgery shahzad iftikhar, rabia bashir, zeba matin, badar ud din ather naeem, raja abrar, rasheed jaffri pak j ophthalmol 2009, vol. 25 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations … ……………………… correspondence to: shahzad iftikhar assistant professor (eye) foundation university medical college jhelum road, rawalpindi purpose: to evaluate the safety profile of intracameral moxifloxacinin 0.5% ophthalmic solution in terms of anterior chamber (ac) reaction and endothelial toxicity. material and methods: this prospective study was conducted in the department of ophthalmology fauji foundation hospital, rawalpindi, from december 2006 to november 2007 and comprised of 200 patients. the patients were divided into two groups. group 1 received 0.1 ml of intracameral moxifloxacin 0.5 % ophthalmic solution at the conclusion of the surgery and the patients in the group 2 were not given the intracameral antibiotic. none of the patients was given postoperative sub conjunctival antibiotic and steroid injection. all patients were examined for ac reaction and pachymetry was done preoperatively and postoperatively (first day, first week and 4 weeks postoperatively). anterior chamber reaction and pachymetry values between the two groups were compared .statistical analysis was done by using paired sample t test. p value of less than 0.05 was taken as significant. results: there was no statistically significant difference in corneal oedema (measured by pachymetry) between the two groups on the first postoperative day (p=624), and one month postoperatively (p=0.186). anterior chamber reaction on the 1st postoperative day was not different in both groups (p=0.610). at 4 weeks there was no reaction in any patients and corneal thickness was also 2 received for publication may’ 2008 … ……………………… restored to preoperative level. conclusion: intracameral moxiloxacin 0.5% ophthalmic solution seems to be safe in terms of ac reaction and endothelial toxicity. ostoperative endophthalmitis is one of the most feared complications of cataract surgery as it seriously compromises vision. although timely diagnosis and delivery of appropriate treatment do help in management1, but in our set up the diagnosis is usually delayed as patients present late due to multiple reasons. it is in the last two decades that the prevelance of the staphylococcus epidermidis as a common cause of endophthalmitis has been recognized. the organisms which were previously considered to be harmless commensals are quite capable of causing endopthalmitis2. multiple studies have been carried out to evaluate the bacterial contamination of anterior chamber fluid aspirates after surgery. srinivasan r and collegues found 15% of ac aspirates to be positive for bacterial growth in which the staphylococci species was the commonest3. none of their patients developed infection as probably the inoculum size, host response, prophylactic antibiotics and improvement in the surgical technique have their role. improvements in technique of surgery and prophylactic measures have had a beneficial effect, but despite this the incidence of endophthalmitis after cataract surgery has increased from 1994-2001 with reported incidence of 2.15 per 1000 cases4. thus there still remains the need for protective antibiotics to combat the rise in the incidence of endophthalmitis and to treat the patients in a better way. in addition to topical antibiotics many surgeons use intracameral antibiotics to prevent the infection. among the antibiotics which are given intracameraly, most common are vancomycin and cefuroxime5. although retrospective analysis suggest that there has been decrease in the risk of endophthalmitis with vancomycin 6. vancomycin has also been shown to increase the risk of cystoid macular oedema after cataract surgery7. moreover, there are reports of emergence of resistant strains of many bacteria8. because of all these facts the routine prophylactic use of vancomycin in cataract surgery is now discouraged worldwide9. cefuroxime and cefazoline are two other medicines which are being used as intracameral antibiotics. the recent publication of escrs study has demonstrated that cefuroxime significantly decreases the risk for developing endophthalmitis after phacoemulsification cataract surgery10. both of these as well as vancomycin are available as systemic preparations. they have to be reconstituted before delivery into the eye. reconstitution of a drug increases the risk of toxic anterior segment syndrome (tass).11 tass is an acute inflammation of anterior segment after cataract surgery. a variety of substances have been implicated including inappropriately reconstituted intraocular preparations. incorrect ph and incorrect osmolality can also cause tass. another problem with vancomycin and cephalosporins is that they have time dependant efficacy. as the concentration of drug in ac decreases four times in first hour, so, this makes them a poor choice. considering the problems associated with the vancomycin and cephalosporins, the new antibiotic under consideration is moxifloxacin which is a forth generation fluoroquinolone. forth generation quinolones have already surpassed the second generation as the antibiotics of choice in cataract surgery12. they have a wide spectrum of activity and they carry a lower risk of resistance developing against them. moxifloxacin is available as self preserved ophthalmic solution. the self preserved nature of the medicine has led to its use as prophylactic intracameral injection. fluoroquinolones are concentration dependant drugs. if they are put in ac in high enough dose they rapidly kill the bacteria. no special preparation is required for intracameral delivery, no millipore filter is needed and the syringe is easily identifiable by the faint yellow colour of the solution. earlier studies had shown no toxicity with intracameral or intravitreal injection of moxifloxacin in animal eye13. the aim of this study is to check the safety profile of 0.5% moifloxacin available as self preserved vigamox (alcon) and, given as intracameral injection during cataract surgery. material and methods this case control comparative study was conducted at fauji foundation hospital rawalpindi from december p 3 2006 to november 2007. 200 patients were enrolled for the study. 100 patients (cases) were injected with the medicine i.e intracameral moxifloxacin at the end of the surgery and they were put in group 1 whereas, 100 patients (controls) were operated in routine way and were placed in group 2. none of the patients were given sub conjunctival antibiotic and steroid injection at the end of the sugery. patients with glaucoma, retinopathy, maculopathy, media opacity other than cataract, uveitis and corneal endothelial disease were not included in the study. patients who suffered intra operative complications or those who had prolonged or difficult surgery were also excluded from the study. preoperative examination included uncorrected and corrected visual acuity, slit lamp examination, tonometry, fundoscopy and pachymetry. all patients were admitted one day prior to surgery. biometry was done on the day of admition. on the day of surgery pupils were dilated with 1% tropicamide and 10% phenylephrine. fifty two percent of surgeries were performed under local and 48% were done in topical anesthesia. phacoemulsification was performed by single surgeon through 3.2 mm clear corneal incision and 5.25 mm pmma iol was implanted after enlarging the incision. no suture was applied in any case. the prophylactic regime to reduce the risk of infection included topical 10% povidone-iodine on the periorbital skin, 5% povidone iodine in the conjunctival sac and eye lashes, drapping of the eyelashes and periorbital region, topical antibiotic drops one day prior to and on the day of surgery. at the start of the operating day a new bottle of moxifloxacin was opened and the contents of newly opened bottle were aspirated in 10 cc syringe by the operating assistant. 0.1 ml of 0.5 % pure moxifloxacin was aspirated in each of 1 cc tuberculin syringe before every case. the undiluted solution was injected in the anterior chamber at the end of the surgery. postoperatively, for the infection control, the patients were given combination of topical 3 mg/ml tobramycin with 1 mg/ml dexamethasone every 2 hours along with systemic ciprofloxacin 500 mg twice daily for five days. patients were examined on the first postoperative day and further visits were scheduled at 1 week and 4 weeks interval. on each visit visual acuity was recorded, slitlamp examination was done for ac reaction. it was expressed as cells and flare and graded using hogan and kimura grading system. pachymetry was done on each visit. data was entered and analysed using spss version 14. student t-test was used to analyse the data. a p value of less than 0.05 was considered significant. results all patients completed the followup. mean age of our patients in group 1 was 59 ± 6.22 (sd) and 58.75 ± 6.86 (sd) in group 2. all patients had variable corneal oedema on 1 st postoperative day as demonstrated by pachymetry. the mean preoperative pachymetry in group 1 was 519.56 ± 25.52 and group 2 was 517.30 ± 22.80. on first postoperative day it was 552.29 ± 26.26 in group 1 and 550.90 ± 21.30 in group 2. the difference in preoperative and postoperative 1st day pachymetry was significant in both groups (p=0.00). at one month, the pachymetry was 531.01 ± 26.76 group1 and 517.68 ± 21.87 in group 2. the difference between the preoperative and one month post operative corneal thickness was insignificant (p=0.32 and 0.672 respectively). corneal thichness of two groups after 1st day and one month of surgery was almost the same, and the difference was found to be statistically insignificant (p=0.624 and p=0.186). the difference in anterior chamber reaction in terms of cells and flare in both groups is insignificant (p=0.610 for cells and p=0.566 for flare) on the first postoperative day. at final visit there was no reaction in any patients. table 1: corneal thickness observed by pachymetry (in micrometers) (n=100) means and standard deviation group 1 group 2 mean sd mean sd pre operative 519.56 25.52 517.30 22.80 post operative 1st day 552.29 26.26 550.90 21.30 post operative 1 month 521.01 26.78 517.68 21.87 table 2: anterior chamber reaction observed as cells and flare (n=100) means and standard deviation group 1 group 2 4 mean sd mean sd cells 1.97 0.76 1.92 0.74 flare 1.34 0.59 1.33 0.57 table 3: paired sample t test (n=100) means, standard deviation and significance group-1 verses group-2 mean sd significance post operative corneal thickness (1st day) 1.390 28.26 0.624 post operative corneal thickness ( 1 month) 4.080 30.64 0.186 cells 0.050 0.978 0.610 flare 0.010 0.174 0.566 discussion the first report of successful prophylactic intracameral antibiotic injection was published in 197714. it did not recieve significant attention and despite of the efficacy of this technique it was not considered until 2002 when montan et al published their report in which they described a decreased rate of postoperative endophthalmitis with intracameral injection of 1 mg of cefuroxime15. of the prophylactic methods for cataract surgery only povidone iodine is recommended16. if applied alone it reduces conjunctival flora by 91% for colony forming and 51% for species. if it is used along with topical antibiotic, it produces synergistic effect and leads to sterilization of 83% of the eye17. despite its efficacy the rate of endophthalmitis increased after 1994. so, there was a need for protective antibiotic to check this rise in the rate of endophthalmitis. topical antibiotics which gained popularity in the last few years for infection prophylaxis after cataract surgery were fluoroquinolones. in 2002 survey of the members of american society of cataract and refractive surgery. leaning noted that 86% of respondents were using second generation fluoroquinolones18, whereas in a 2003 survey, only 21% were using second generation and 61% were using forth generation fluoroquinolones19. the reason for this change was increasing resistance towards the second generation drugs. kowalski et al reported in 2001 that none of the staphlococcus aureus isolated from endophthalmitis isolates were sensitive to second generation fluoroquinolones20. these problems led to the development of forth generation antibiotics. these antibiotics have got a wider spectrum of activity against gram positive organisms which are the most common pathogens causing endopthalmitis. in addition they have a good coverage against gram negative organisms and anaerobes12. moxifloxacin is found to be superior in terms of potency to gatifloxacin21. it seems to be a better choice as a prophylactic antibiotic as it has got lowest minimal inhibitory concentration (mic). mather et al did a retrospective study of 93 bacterial endophthalmitis isolates. he found that the mic levels for moxifloxacin ranged form 0.06-0.19 mg/ml12. lindsay has shown in his study that moxifloxacin has good aqueous penetration when given four times a day starting two days prior to surgery and that its concentration exceeds mic levels for most common pathogens22. this shows that moxifloxacin can be an effective prophylavtic antibiotic even given through topical route. but, another important consideration is prevention of development of resistant strains which may develop with prophylactic use of an antibiotic. the drug level at which the development of resistant strains can be prevented is called mutation prevention concentration (mpc). it is another parameter of evaluation of potency of an antibiotic. frequent and suboptimal use of an antibiotic increases the risk of development of resistant mutants. the mpc of fluoroquinolones is 8-10 times their mic23. achieving concentrations higher than this almost ensures the prevention of mutation. with topical use the aqueous concentration of moxifloxacin levels or slightly exceeds its mpc, whereas with intracameral injection it achieves and ensures much higher concentration than its mpc (0.38 2.16mg/ml). we injected 0.1 ml of pure vigamox 0.5% ophthalmic solution without dilution in the ac at the end of the surgery. this is equilant to 0.5 mg of moxifloxacin. bolinao and his collegues used the same concentration and calculated the concentration of moxifloxacin in ac to be 952 mg/ml, which is 300 times its mic and atleast 30 times its mpc23. our concern was to check the effect of intracameral moxifloxacin on cornea for which we examined the cornea clinically for striate and quantitatively by performing pachymetry before and after surgery. the other concern was effect of moxifloxacin on blood aqueous barrier and whether it causes inflammation or not. the patients were 5 examined for aqueous flare and cells on the first post operative day and on the scheduled visits. the patients were followed for four weeks because in previous studies it has been suggested that wound healing is complete in four weeks and preoperative corneal thickness is also restored in four weeks. moreover as the eye is usually quiet and the patients have no problem after that time, we loose follow up mostly after 4-6 weeks of surgery. we found that the patients who were injected with intracameral moxifloxacin had almost the same ac reaction as controls and that the corneal thickness that occurred after the surgery was not significantly different in two groups. corneal thickness was restored to the pre operative levels and there was no sign of inflammation in ac at four weeks of surgery. this suggests that intracameral moxifloxacin is not toxic to endothelium and it does not cause significant inflammation. the results of our study are supported by espiratu et al who used the same concentration of intracameral moxifloxacin23. sleve a.arshinoff has also recommended the routine use of intracameral moxifloxacin although he has used much lesser concentration of the antibiotic in ac24. conclusion intracameral moxifloxacin 0.5% ophthalmic solution appears to be non toxic to eye in terms of ac reaction and endothelial damage. author’s affiliation dr shahzad iftikhar assistant professor foundation university medical college rawalpindi dr rabia bashir assistant professor foundation university medical college rawalpindi dr zeba matin assistant professor shifa international hospital islamabad dr badar ud din ather naeem professor foundation university medical college rawalpindi dr raja abrar registrar foundation university medical college rawalpindi dr rasheed jaffri registrar foundation university medical college rawalpindi reference 1. jonson mw, doft bh, kelsey sf. the endophthalmitis vitrectomy study; relationship between clinical presentation and microbiologic spectrum;the endophthalmitis study group. ophthalmology 1997;104: 261-72. 2. walker cb, claoue cm. incidence of conjunctival colonization by bacteria capable of causing postoperative endophthalmitis. j r soc med. 1986; 79: 520-21. 3. srinivasan r, reddy ra, rene s, et al. bacterial contamination of anterior chamber during iol surgery. ijo 1999; 47: 185-9. 4. west es, behrens a, mcdonnell pj, et al. the incidence of endophthalmitis after cataract surgery among the u.s. medicare population between 1994 and 2001. ophthalmology 2005; 112: 1388-94. 5. gimbel hv, sun r, de brof bm. prophylactic intracameral antibiotics during cataract surgery: the incidence of endophthalmitis ad endothelial cell loss. eur j implant refract surg. 1994; 6: 280-5. 6. masket s. preventing, diagnosing, and treating endophthalmitis (guest editorial). j cataract refract surg. 1998; 24: 725-6. 7. gimbel hv, sun r. prophylactic intracameral vancomycin and cme (letter). ophthalmology. 2000; 107: 1614-5. 8. seppala h, al-juhaish m, jarvinen h, et al. effect of prophylactic antibiotics on antimicrobial resistance of viridans streptococci in the normal flora of cataract surgery patients. j cataract refract surg. 2004; 30: 307-15. 9. centers for disease control. staphylococcus aureus resistance to vancomycinunited states, 2002. mmwr morb mortal wkly rep 2002; 51:565-67. 10. seal dv, barry p, gettinby g, et al. escrs study of prophylaxis of postoperative endophthalmitis after cataract surgery: case for a european multicenter study; the escrs endophthalmitis study group. j cataract refract surg. 2006; 32: 396-406. 11. holley gp, alam a, kiri a, et al. effect of indocyanine green intraocular stain on human and rabbit corneal endothelial structure and viability; an invitro study. j cataract refract surg. 2002; 28: 1027-33. 12. mather r, karenchak lm, romanowski eg, et al. forth generation fluoroquinolones: new weapons in the arsenal of ophthalmic antibiotics. am j ophthalmol. 2002; 133: 463-6. 13. kowalski rp, romanowski eg, mah fs, et al. intracameral vigamox (moxifloxacin 0.5%) is non toxic and effective in preventing endophthalmitis in a rabbit model. am j ophthalmol. 2005; 140: 497-504. 14. peyman ga, sathar ml, may dr. intraocular gentamicin as intraoperative prophylaxis in south india eye camps. br j ophthalmol. 1977; 61: 260-2. 15. montan pg, wejde g, koranyi g, et al. prophylactic intracameral cefuroxime; efficacy in preventing endophthalmitis after cataract surgery. j cataract refract surg. 2002; 28: 977-981. 6 16. ciulla ta, starr mb, masket s. bacterial endophthalmitis prophylaxis for cataract surgery; an evidence based update. ophthalmology. 2002; 109: 13-24. 17. isenberg sj, apt l, yoshimoro r. efficacy of topical povidoneiodine during the first week after ophthalmic surgery. am j ophthalmol. 1997; 124: 31-5. 18. leaming dv. practice styles and preferences of ascrs members2002 survey. j cataract refract surg. 2003; 29: 141220. 19. leaming dv. practice styles and preferences of ascrs members2003 survey. j cataract refract surg. 2004; 30: 892900. 20. kowalski rp, karenchak lm, romanowski eg. infectious diseases: changing antibiotic susceptibility. ophthalmol clin north am. 2003; 16: 1-9. 21. kim dm, stark wj, obrien tp, et al. aqueous penetration and biological activity of moxifloxacin 0.5% ophthalmic solution and gatifloxacin 0.3% solution in cataract surgery patients. ophthalmology. 2005; 112: 1992-6. 22. ong-tone l. aqueous humor penetration of gatifloxacin and moxifloxacin eye drops given by different methods before cataract surgery. j cataract refract surg. 2007; 33: 59-62. 23. espiritu crg, caparas vl, bolinao jg. safety of intracameral moxifloxacin 0.5% ophthalmic solution in cataract surgery patients. j cataract refract surg. 2007; 33: 63-8. 24. obrien ot, arshinoff s, mah f. perspectives on antibiotics for postoperative endophthalmitis prophylaxis: potential role of moxifloxacin. j cataract refract surg. 2007; 33: 1790-180. 291 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol author communication isolated simultaneous bilateral adie’s pupil summaya khan, muhammad azeem khizer, saleh khurshied pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad azeem khizer armed forces institute of ophthalmology rawalpindi, pakistan email: m.azeem7@gmail.com …..……………………….. adie’s pupil, an efferent pupillary defect is caused by injury to parasympathetic pupillomotor nerve supply to iris sphincter muscle. more commonly seen in young adult females with up to 80% cases having unilateral involvement. according to literature, adie’s pupil may occur alone or as a part of a systemic condition or may be associated with a syndromic presentation. bilateral adie’s pupil in a female at initial presentation with mild visual symptoms and no syndromic association is sparsely reported in literature. keywords: adie’s pupil, anisicoria, tonic pupil. die’s pupil is a common cause of anisocoria. it is an efferent pupil defect, which causes loss of reaction to light of iris sphincter muscle, the reason being the injury to the postganglionic parasympathetic nerves. such patients may be asymptomatic but suffer from accommodative symptoms or photophobia with difficulty in focusing. signs are anisocoria with light near dissociation and loss of accommodation and abnormal response to light, which may be missed or misdiagnosed in a busy clinical setting. reports of tonic pupils in literature date back to early 20th century, with half of the patients being females. in later years, adie, moore and holmes reported 46 more cases out of which 42 were females. according to reports, this disease has a predominance of women with 20-40 years old age group but has also been reported in children with a possibility of familial incidence1. in 20% of the 220 cases from literature, both eyes were involved. the incidence of the condition is reported to be 4-7 per 100,000 per year2. we present a case of a 30 years old female with bilateral adie’s tonic pupils. case report a 30 years old female presented with a 3-month history of photophobia and blurring of near vision, both of which had gradually increased over time. the patient had no other ocular or systemic complaints. no significant ocular history was present. her medical history was insignificant and there was no history of usage of any systemic or topical medication. on examination her visual acuity was 6/6 for far and n6 for near in both eyes (ou). although she was n6 ou, she required 15-20 seconds of constant effort at the near target to see the line clearly. the pupils showed anisocoria with a pupillary diameter of 7mm on right side and 8mm on left (fig. 1) with patient focusing on a distant target in a moderately lit room with no response to light stimulus bilaterally. segmental contractions of iris were not seen in either eye. the patient had light near dissociation on both sides with a pupillary diameter of 4mm on right side and 5mm on left side when looking at near target for 60 seconds, which reverted to previous pupillary size fig 1: picture showing bilateral dilated pupils prior to instillation of topical 0.1% pilocarpine drops. after 30 seconds of cessation of fixation to near target. in a dimly lit room, after instillation of 0.1% a isolated simultaneous bilateral adie’s pupil pak j ophthalmol vol. 35, no. no. 4, oct – dec, 2019 292 pilocarpine, examination after 30 minutes revealed a pupillary diameter of 5 mm on right side and 4mm on left (fig. 2). rest of the examination was unremarkable and no evidence of iris trauma or pigment dispersion were found. fig 2: picture showing bilateral constricted pupils 30 minutes after instillation of topical 0.1% pilocarpine drops. detailed neurological examination did not reveal any abnormality. opinion of the neurologist was sought, radiological and lab investigations were done, including mri brain and visual pathways with contrast, with none of them revealing any abnormality. based on history, examination and investigations, a diagnosis of bilateral adie’s pupil was made. the patient was counselled regarding the condition and was offered prepared topical 0.1% pilocarpine eye drops. the patient perceived resolution of her complaint of photophobia with the usage of the offered eye drops in both eyes once daily and was satisfied with the treatment offered. she was also offered hyperopic correction for near vision, but was not interested in using near glasses. discussion adie's syndrome is mostly a disease of young adults. most patients with adie's pupil have a variable accommodative paralysis at the onset, which is the main cause of their complaints. in 1812, ware3 described a 30 to 40-year-old woman with a right pupil showing light near dissociation. in 1902, saenger4 described a 34-year-old woman with bilateral light-near dissociation, her left pupil was larger than the right and after accommodation, it took around 10 minutes for left pupil to return to its original size. also in 1902, strasburger5 reported a patient whose both pupils were not reacting to light, however, both pupils reacted to near target but very late, and a delay was noted in relaxing accommodation when refocusing back to a far target. strasburger also noted other neurological signs and symptoms with an early stage of multiple sclerosis considered the most likely diagnosis. drouet et al. and millar et al6 reported bilateral adie's pupil in a patient during an attack of migraine. the authors discussed postganglionic dysfunction as a cause of transient mydriasis. our patient had no history of migraine and the pupils were not transiently dilated. jivraj and johnson7 reported a case of a young girl who had acute unilateral tonic pupil, which became bilateral 2 months later and found a rare association of neurosyphilis with the condition. our patient reported with simultaneous bilateral involvement and was found to be seronegative for syphilis. an association between bilateral adie’s pupil with sjögren's syndrome has been reported in many cases8 with high prevalence in females. our patient was not found to have any associated feature of the syndrome. several cases with bilateral adie's pupil along with autonomic dysfunction and diminished or absent tendon reflexes have been reported in literature. holmes g et al.9 described bilateral adie’s pupil in 3 patients, who had signs of autonomic dysfunction (known as holmes-adie syndrome). our patient had no evidence of any autonomic dysfunction and had normal deep tendon reflexes. presence of bilateral adie's pupil is a relatively rare initial presentation and in such bilateral cases are commonly reported to present unilaterally and proceed to involve the other pupil after an interval of few weeks to few months. our case is relatively rare that our patient had simultaneous bilateral adie’s pupil on initial presentation but with mild visual symptoms. on the other hand, majority of the cases with bilateral involvement occur in females and in a younger age group, which is similar to our case. a similar case was reported by indranil and shroff10 but their patient was a male with a longer duration of more severe visual symptoms which is not commonly reported. patient was not found to have any other systemic predisposing conditions or associations and was supported and evidenced by relevant radiological and lab investigations. keeping in mind the differential diagnosis and after proper evaluation, a final diagnosis of bilateral adie’s pupil was made. references 1. lambert sr, yang ll, stone c. tonic pupil associated with congenital neuroblastoma, hirschsprung disease, and central hypoventilation syndrome. am j ophthalmol 2000; 130: 238-240. summaya khan, et al 293 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol 2. martinelli p. holmes-adie syndrome. lancet. 2000; 356: 1760-1761. 3. ware j. observations relative to the near and the distant sight of different persons. philos trans r soc london, 1812: 31-50. 4. saenger a. ueber myotonische pupillenbewegung. neurol zentralblatt. 1902; 21: 837-839. 5. strasburger j. pupillenträgheit bei accommodation und convergenz. neurol zentralblatt. 1902; 21: 738-740. 6. millar e, habib m, gnanaraj l. bilateral tonic pupil secondary to migraine in a child. j pediatr ophthalmol strabismus, 2010; 47: e1–2. 7. jivraj i, johnson m. a rare presentation of neurosyphilis mimicking a unilateral adie's tonic pupil. semin ophthalmol. 2014; 29: 189–91. [pubmed: 23952008]. 8. bachmeyer c, zuber m, dupont s, blance p, dhote r, mas jl. adie syndrome as the initial sign of primary sjogren syndrome. am j ophthalmol. 1997; 123: 691692. 9. holmes g. partial iridoplegia associated with symptoms of other diseases of the nervous system. trans ophthalmol soc uk, 1931; 51: 209–28. 10. saha i, shroff cm, gupta c, verma r. an interesting case of simultaneous bilateral adie's tonic pupil. oman j ophthalmol. 2018; 11 (1): 82–84. author’s affiliation summaya khan armed forces institute of ophthalmology rawalpindi, pakistan muhammad azeem khizer armed forces institute of ophthalmology rawalpindi, pakistan saleh khurshied army medical college, rawalpindi author’s contribution summaya khan conception, design, final approval. muhammad azeem khizer literature search, acquisition of data, drafting, revision. saleh khurshied manuscript drafting, final review. 36 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology original article reliability of rubrics in mini-cex anam arshad, muhammad moin, lubna siddiq pak j ophthalmol 2017, vol. 33, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: anam arshad postgraduate trainee, postgraduate medical institute lahore. email: anam_1038@hotmail.com …..……………………….. purpose: to study the reliability of rubrics in mini clinical exercise (cex) in ophthalmic examination. study design: observational cross sectional study. place and duration of study: our study was conducted at the ophthalmological society of pakistan, lahore branch on sep 17, 2015. material and methods: 16 raters were recruited from the candidates eligible for fellowship exit exam. all these raters were provided with a rubric to evaluate the clinical performance of cover/uncover (squint assessment) test. . every rater gave scores (2-5) for 12 steps of the clinical examination. all scores were entered into spss version 20 and cronbachs’ alpha coefficient of inter rater reliability and internal consistency of scores was determined. results: 16 raters having age range from 26-35 years with mean age of 29.4 sd ± 1.99 took part in this study. out of them 7 were male and 9 were female. the cronbach alpha (0.972) was found to be very significant after analyzing the scores of the sixteen raters in spss. the intra class correlation co-efficient was found to be .967. descriptive statistics showed that sixteen raters gave a rating between 3.3 to 4.0 for each step of the rubric. conclusion: rubrics are effective in achieving a high inter rater reliability in mini-cex and make it a very useful tool in assessment of clinical skills. keywords: rubrics, mini-cex, inter rater reliability, variability. linical skills of residents in many specialty training programs have been assessed by using mini-clinical evaluation exercise (minicex). this tool provides both assessment and education for residents in training1 and its validity has been established2. the mini-cex is also a feasible and reliable evaluation tool for post graduate residency training3. the number of feedback comments make the c javascript:void(0); javascript:void(0); javascript:void(0); reliability of rubric in mini-cex pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 37 mini-cex a useful assessment tool4. to some extent, such a tool may predict the future performance of medical students5. the mini-cex has been well received by both learners and supervisors6. resident performance which is valid is required by all program directors for certification of competence of all trainees completing their residency7,8. however, assessments which are valid in assessing clinical skills can be challenging9. long case clinical evaluation exercise (cex) has been proven to be unreliable in a research conducted by the american board of internal medicine (abim) because the interrater and inter-case reliability is quite high10,11,12. validity of mini-cex scores could be better if the inter rater reliability was improved which would also lead to reduction in resident-patient encounters13. consistency of examiner ratings is necessary to improve reliability of assessment14. use of topic-specific analytical rubrics can improve the reliability of performance scoring of assessments especially with examples and/or training of raters15. introduction of rubrics in assessment make the criteria and expectations very clear and also facilitate self-assessment and feedback. this is the reason why learning is promoted and instruction is enhanced by the use of rubrics15. we undertook this study to find out the reliability of rubric in mini-cex as a reliable tool of assessment. materials and methods our study was conducted at the ophthalmological society of pakistan, lahore branch on sep 17, 2015. it was observational cross sectional study by randomized non-probability consecutive convenient sampling technique. sixteen raters were recruited from the candidates eligible for fellowship exit exam, who were attending a pre examination preparatory course on clinical ophthalmology. a consent was signed by the raters and their names and all other details were kept confidential. all these raters were provided with a rubric set to evaluate the clinical performance of cover/uncover (squint assessment) test, figure 1. all the raters gave scores to the steps of single clinical performance by junior resident. every rater gave scores (2-5) for 12 steps of the clinical examination method. all scores were entered into spss version 20 and cronbachs’ alpha coefficient of inter rater reliability and internal consistency of scores was determined. raters with incorrectly filled forms were excluded from the study. a demonstration about how to fill the rubric was given to all the participants before the actual test. figure 1: resident assessment form (cover/uncover test). skill novice (score 2) beginner (score 3) advanced beginner (score 4) competent (score 5) total score introduction not introduced introduced as doctor didn’t ask patient name introduced as doctor ask patient name inquired patients name and well being informed consent no consent didn’t explain procedure didn’t insist on fixation didn’t ask about refractive error fully explained the procedure examination level didn’t adjust inaccurate adjustment awkward adjustment accurate proper adjustment visual acuity not assessed assessed for near only assessed for far and near asked for snellens. assessed unaided and aided va recorded va hirschberg didn’t perform didn’t ask patient to look at spot light asked to fixate at light but light not held properly and asked to fixate light held centrally and stable javascript:void(0); javascript:void(0); javascript:void(0); anam arshad, et al 38 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology centrally near target didn’t given target not held at working distance target held at working distance target held at working distance with stability cover test didn’t cover covered deviating eye covered fixating eye completely covered fixating eye with occluding uncover test didn’t perform observed uncovered eye observed covered eye observed covered eye and measured secondary deviation alternate cover test didn’t perform performed but too rapidly or slowly performed with proper time for cover and uncover performed with proper time repetition of steps for far targets didn’t perform didn’t gave specific target gave specific target steps incomplete gave specific target and completed examination steps repetition of steps with glasses didn’t inquire about glasses repeated with glasses for far only or near only repeated with glasses for far and near repeated with glasses and explain completely thank the patient didn’t thank the patient thanked the patient thanked the patient with smile thanked the patient and shook hand results the study included 16 raters having age range from 26 – 35 years with mean age of 29.4 sd ± 1.99. out of them 7 were male and 9 were female. there are 12 steps to be scored by the raters, every step carried 5 marks, missing a particular step by the candidate was recommended by the rubric to be scored as zero. if the step was performed by the candidate its proficiency was scored guided by the rubric from one to five score. the cronbach alpha (0.972) was found to be significant after analyzing the scores of the sixteen raters in spss, table 2. the intra class correlation coefficient was found to be .967, table 3. descriptive statistics showed that sixteen raters gave a rating between 3.3 to 4.0 for each step of the rubric, table 4. table 1: demographic data. characteristics groups number age < 28 28 – 32 4 9 > 32 3 gender male female 7 9 experience in ophthalmology < 4 years 4 – 6 years > 6 years 2 10 4 number 16 table 2: reliability statistics. cronbachs’ alpha number of raters 0.972 16 table 3: intra class correlation coefficient. 95% confidence interval intra class correlation (icc) lower bound upper bound reliability of rubric in mini-cex pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 39 average measures .967 .932 .989 one-way random effect table 4: inter rater reliability: mean and standard deviation. rater mean standard deviation number 1 3.3 ± 0.77 12 2 4.0 ± 1.1 12 3 4.2 ± 1.1 12 4 3.4 ±. 90 12 5 3.7 ± 1.1 12 6 3.5 ± 1.0 12 7 3.5 ± 1.0 12 8 3.2 ± .75 12 9 3.8 ± .93 12 10 3.3 ± .88 12 11 3.4 ± .79 12 12 3.4 ± 90 12 13 4.0 ± 1.2 12 14 3.5 ± 1.0 12 15 3.6 ± 1.1 12 16 3.7 ± 1.2 12 discussion high reliability of assessment of medical examiners has been shown by several researchers when rubric is introduced15,16. on the other hand the reliability has never been found to decrease when rubrics are used. therefore, rubrics are being used by a lot of teachers on the assumption that grading objectivity is enhanced, especially regarding the performance of the students. this leads to the postulation that when rubrics are not used in assessment, there is more subjectivity because of the examiner's only subjective judgment of the performance of the students. consequently teachers usually prefer to incorporate a rubric in all their assessments17. but there are cases where inconsistent scores are produced even when rubrics are used due to many problems. inter-rater reliability scores can be affected by many factors, including “the objectivity of the task/item/scoring, the difficulty of the task/item, the group homogeneity of the examinees/raters, speediness, number of tasks/items/raters, and the domain coverage”. poor reliability of the raters has been seen when there is poor training of raters, insufficient detail in the rubric, or "failure of the examiners to internalize the rubrics"18. raters with diverse levels of scoring capacity do not look at different results or performance features, but their understanding about the criteria of scoring has many levels19. injustice and bias is removed in assessments by using rubrics because criteria for scoring a student performance are clearly defined. the details given in the various score levels of the rubrics act as a guide in the process of evaluation. designing a good rubric scoring can eliminate the occurrence of discrepancies between different raters20. the reliability of scoring across students is enhanced by rubrics, along with the consistency between different raters. another advantage of using a rubric is that a valid decision of performance assessment is achieved which is not possible with rating done conventionally. complex competencies can be assessed according to the desired validity by using rubrics21. in our study, the cronbach’s alpha coefficient for 16 raters was found to be 0.972, showing that there is a relatively high internal consistency of the raters. reliability coefficient of 0.70 or higher is considered "acceptable" in most research situations according to the institute for digital research and education ucla los angeles. d’antoni et al; calculated inter rater reliability of 3 examiners that judged 66 first year medical students using mmar(mind mapping assessment rubric) and calculated cronbachs’ alpha coefficient of 0.3822. fallatah et al assessed the reliability and validity of sixth year medical students at king abdulaziz university by four examiners (2 seniors and 2 juniors) and internal-consistency reliabilities for the total assessment scores were calculated. cronbachs’ alpha for the four parts of the total assessment score on both long and short cases (2012) or osce (2013) was 0.63 and 0. 83 for 2012 and 201323. daniel et al studied inter-rater reliability in evaluating the micro surgical skills of ophthalmology residents and alpha cronbachs’ found to be 0.7224. golnik et al observed that ophthalmic clinical evaluation exercise (ocex) is a reliable tool for the faculty to assess clinical competency of residents, alpha cronbachs’ reliability coefficient was 0.8125. anam arshad, et al 40 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology conclusion rubrics are effective in achieving a high inter rater reliability in mini-cex and make it a very useful tool in assessment of clinical skills. author's affiliation dr. anam arshad postgraduate trainee, postgraduate medical institute, lahore. prof. muhammad moin prof of ophthalmology, postgraduate medical institute lahore. dr. lubna siddiq senior registrar, department of ophthalmology, postgraduate medical institute lahore. role of authors dr. anam arshad collection of data and manuscript writing. prof. muhammad moin study design, manuscript review. dr. lubna siddiq statistical analysis. references 1. malhotra, s., hatala, r., and courneya, c.a. internal medicine residents' perceptions of the mini-clinical evaluation exercise. med teach. 2008; 30: 414–419. 2. kogan, j.r., holmboe, e.s., and hauer, k.e. tools for direct observation and assessment of clinical skills of medical trainees: a systematic review. jama. 2009; 23: 1316–1326. 3. durning, s.j., cation, l.j., and jackson, j.l. the reliability and validity of the american board of internal medicine monthly evaluation form. acad med. 2003; 78: 1175–1182. 4. pernar, l.i., peyre, s.e., warren, l.e. et al. mini-clinical evaluation exercise as a student assessment tool in a surgery clerkship: lessons learned from a 5-year experience. surgery. 2011; 150: 272–277. 5. ney, e.m., shea, j.a., and kogan, j.r. predictive validity of the mini-clinical evaluation exercise (mcex): do medical students' mcex ratings correlate with future clinical exam performance? acad med. 2009; 84: s17–s20. 6. nair, b.r., alexander, h.g., mcgrath, b.p. et al. the mini clinical evaluation exercise (mini-cex) for assessing clinical performance of international medical graduates. med j aust. 2008; 189: 159–161. 7. holmboe es, hawkins re, huot sj. effects of training in direct observation of medical residents’ clinical competence: a randomized trial. ann intern med. 2004; 140: 874–81. 8. norcini jj, blank ll, duffy fd, fortna gs. the minicex: a method for assessing clinical skills. ann intern med. 2003; 138: 476–81. 9. kogan jr, bellini lm, shea ja. feasibility, reliability, and validity of the mini-clinical evaluation exercise (mcex) in a medicine core clerkship. acad med. 2003; 78 (10 suppl): s33–5. 10. herbers je jr., noel gl, cooper gs, harvey j, pangaro ln, weaver mj. how accurate are faculty evaluations of clinical competence. j gen intern med. 1989; 4: 202–8. 11. kroboth fj, hanusa bh, parker s, et al. the inter-rater reliability and internal consistency of a clinical evaluation exercise. j gen intern med. 1992; 7: 174–9. 12. noel gl, herbers je jr., caplow mp, cooper gs, pangaro ln, harvey j. how well do internal medicine faculty members evaluate the clinical skills of residents. ann intern med. 1992; 117: 757–65. 13. cook da, dupras dm, beckman tj, thomas kg, pankratz vs. effect of rater training on reliability and accuracy of mini-cex scores: a randomized, controlled trial. gen intern med. 2009 jan; 24 (1): 74– 79. 14. ogunbanjo ga. adapting mini-cex scoring to improve inter-rater reliability. 2009; 43 (5): 484-485. 15. johnsson a, svingby g. the use of scoring rubrics: reliability, validity and educational consequences. educational research review. 2007; 2 (2): 130–144. 16. silvestri, l., & oescher, j. using rubrics to increase the reliability of assessment in health classes. international electronic journal of health education. 2006; 9: 25–30. 17. spandel, v. in defense of rubrics. english journal. 2006; 96 (1): 19–22. 18. colton, d. a., gao, x., harris, d. j., kolen, m. j., martinovich-barhite, d., wang, t., et al. reliability issues with performance assessments: a collection of papers. act research report series. 1997; 97-3. 19. wolfe, e. w., kao, c., & ranney, m. cognitive differences in proficient and nonproficient essay scorers. written communication. 1998; 15 (4). 20. moskal, b. m., & leydens, j. a. scoring rubrics development: validity and reliability. practical assessment, research, and evaluation. 2000; 7 (10). 21. morrison, g. r., & ross, s. m. evaluating technologybased processes and products. new directions for teaching and learning. 1998; 74. 22. d'antoni et al; bmc medical education 2009 9: 19: 10.1186/1472-6920-9-19. 23. fallatah et al; bmc medical education2015 15:10. 10.1186/s12909-015-0295-4. http://www.sciencedirect.com/science/journal/1747938x reliability of rubric in mini-cex pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 41 24. daniel et al; skills acquisition and assessment after a microsurgical skills course for ophthalmology residents. ophthalmol. 2009; 116 (2): 257-262. 25. golink kc et al; the ophthalmic clinical evaluation exercise: reliability determination. 2005; 112 (10): 16491654. 43 pakistan journal of ophthalmology, 2020, vol. 36 (1): 43-47 original article dry eye in patients using topical antiglaucoma therapy nabila zulfiqar 1 , muhammad sufyan aneeq ansari 2 , khurram nafees 3 rabia nawaz 4 , manzra shaheen 5 1-5 department of ophthalmology, fatima memorial hospital, shadman, lahore abstract purpose: to determine the frequency of dry eye in glaucoma patients using topical anti-glaucoma therapy. study design: descriptive observational study. place and duration of study: study was conducted in outpatient department of fatima memorial hospital shadman, lahore, from october 2016 to february 2017. material and methods: in this study, 61 diagnosed cases of glaucoma were included. patients with significant dermatological problems that may be associated with dry eye such as rosacea and blepharitis were excluded from the study. the individuals were assessed by consultant ophthalmologist for dry eye syndrome having symptoms of stinging and burning sensations itching, watering, irritation, due to regular use of topical antiglaucoma drugs. a written consent was taken from every patient before the test. the ocular surfaces of the patients were evaluated using tear film break-up time test and basal schrimer’s test. patients having tbut less than 11 seconds were categorized as having dry eye. the degree of dryness was categorized as mild, moderate and severe dry eye. results: among 61 patients of glaucoma using topical anti-glaucoma therapy, 22 (36.1%) were male and 39 (63.9%) were female. mean age of the patients was 50.76 ± 15.67 years. on the basis of tear film break-up time test, 49 (81%) patients had tear break-up time less than 10 seconds and 12 (19%) patients were normal. on the basis of schrimer`s test 51 (83.66%) patients had dry eye. conclusion: topical use of anti-glaucoma therapy affects tear film stability and its functions leading to dry eye syndrome. key words: anti-glaucoma therapy, dry eye syndrome, tear film break-up time, basal schrimer`s test. how to cite this article: zulfiqar n, ansari msa, nafees k, nawaz r, shaheen m. dry eye in glaucoma patients using topical anti-glaucoma therapy, pak j ophthalmol. 2020; 36 (1): 43-47. doi: https://doi.org/10.36351/pjo.v36i1.980. introduction glaucoma is the second leading cause of visual impairment around the world 1-3 . it is a chronic disease that damages optic nerve and produces defects in the visual field which, in the last stage, can cause correspondence to: muhammad sufyan aneeq ansari department of ophthalmology, fatima memorial hospital, shadman, lahore e-mail: msaansari@hotmail.com blindness. treatment of glaucoma involves lifelong follow up 3,4 . for primary open-angle glaucoma (poag) patients, first-line of treatment comprises of medical management. topical hypotensive drops are the standard type of treatment, which are regularly utilized for longer duration in various dosing 3,5,6 . these drugs along with treatment may also have some side effects like allergic reactions, osd (ocular surface disease), tear film abnormalities, corneal epitheliopathy, punctate epitheliopathy, medically resistant herpetic https://doi.org/10.36351/pjo.v36i1.980 dry eye in glaucoma patients using topical anti-glaucoma therapy pakistan journal of ophthalmology, 2020, vol. 36 (1): 43-47 44 keratitis, chronic inflammation, impaired wound healing, squamous metaplasia with high prevalence rate in diabetic and hypertensive patients 7 . osd may result in poor effectiveness of glaucoma treatment leading to irreversible damage to eyes 8 . osd (ocular surface disease) and inflammation have been commonly seen with the long term utilization of ioplowering medication. symptoms include discomfort upon instillation and between instillations such as burning/stinging, foreign body sensation, watering, irritation, dry eye sensation and eyelid itching 7-11 . one of the major components of osd is dry eye syndrome. dry eye is a multifactorial disease of the tears and ocular surface that is related with distress, visual disturbance and tear film disturbance with potential to harm the ocular surface 12-14 . the incidence of dry eye syndrome increases with age, number and duration of anti-glaucoma medications 13 . there are several objective methods that have been used for assessing ocular surface health in glaucoma patients. these tests are: tear break up time (tbut), schrimer’s test, fluorescein clearance test (fct), rose bengal ocular surface staining, bio microscopy, impression cytology and confocal microscopy 7,8,15 . this study was conducted to find out the frequency of dry eyes in glaucoma patients who are using topical anti-glaucomatous drugs. material and methods this observational study was conducted on the already diagnosed glaucoma patients from the ophthalmology outpatient department of fatima memorial hospital shadman, lahore. a total of 61 glaucoma patients were included in the study, 22 were males and 39 were females. all of these individuals were using topical anti-glaucoma therapy for more than 1 year. patients with significant dermatological problems that may be associated with dry eye such as rosacea and blepharitis were excluded from the study. the individuals were assessed by consultant ophthalmologist for dry eyes by enquiring about symptoms of stinging and burning sensations, itching, watering, irritation, due to regular use of topical antiglaucoma drugs. a written consent was taken from every patient before the test. two tests were performed by the ophthalmologist to assess dry eye syndrome. 1) basal schirmer’s test 2) tear film breakup time test (tbut). schirmer’s ii test was performed by placing a small piece of schrimer’s strip inside the lower eyelid (inferior fornix) after putting a drop of local anaesthetic. the eyes were closed for 5 minutes. the paper strip was then removed and the amount of moisture was measured. normal value of wetting of schirmer’s strip was ≥ 15 mm after 5 minutes. patients with wetting values of schirmer’s strip less than or equal to 14 mm were labelled in the category of dry eye. individuals having wetting values between 14-9 mm were having mild dry eye and those having wetting values of 8-4 mm had moderate dry eye. individuals having wetting values of ≤ 4 mm of strip were categorized as severe dry eye syndrome. second test, which was performed, was to measure the tbut; a small fluorescein strip was placed in the lower fornix of eye. the patients were asked to close the eyes for some time and then open it and blink the eyes. the strip was then removed and the cornea was scanned with cobalt blue illumination of slit lamp. the time between the last blink and the appearance of the first dry spot in the tear film was recorded in seconds. patients having tbut less than 11 seconds were categorized as having dry eye. individuals having tbut 10-8 sec was categorized as having mild dry eye syndrome. individuals with tbut 7-5 sec had moderate dry eye syndrome and those having tbut ≤ 4 sec had severe dry eye. data was entered and analysed by using spss v22 (ibm corp). the continuous variable such as age was expressed as mean ± sd. the categorical variables such as gender, symptoms of dry eye and severity of dry eye were expressed in the form of frequencies. results a total of 61 glaucoma patients were included in the study who were on topical anti-glaucoma therapy. among these 22 (36.1%) were males and 39 (63.9%) were females. the mean age of the patients was 50.76 ± 15.67 years. glaucoma patients presented in the opd with different symptoms of dry eye. out of 61 patients, 29 (47.5%) patients had burning and stinging sensations, 12 (19.7%) patients presented with only itching. nine (14.8%) patients were complaining of watering and irritation and 11 (18%) patients had dry eye sensations. tear film breakup time test was performed with fluorescein stain and the results showed that 12 zulfiqar n, et al 45 pakistan journal of ophthalmology, 2020, vol. 36 (1): 43-47 (19.7%) patients had no dry eye. whereas 17 (27.9%) patients had mild dry eye and 22 (36.1%) patients were diagnosed with moderate dry eye. only 10 (16.4%) patients had severe dry eye. another test, basal schirmer test was also done to evaluate the severity of dry eye syndrome. results showed that 16 (26.2%) patients had mild dry eye and 24 (39.3%) patients had moderate dry eye. eleven graph 1: graphical distribution of symptoms of dry eye. graph 2: graphical distribution of severity of dry eye by tbut. graph 3: severity of dry eye syndrome by basal schirmer’s test. (18%) patients were diagnosed with severe dry eye (refer to graphs 1, 2 and 3). discussion although topical anti-glaucoma drugs are always the first line therapy for the treatment of glaucoma but long-term use of topical medication in chronic ophthalmic conditions such as glaucoma, may antagonistically influence the visual surface .16,17 . however, the severity of the toxic effects of preservatives in ophthalmic suspensions is still under investigation 14,18 . the long term use of these topical medications have the potential to cause corneal and conjunctival changes, resulting in dry eye syndrome, sub-conjunctival fibrosis, epithelial apoptosis, and goblet cell loss 5,7 . in this particular study there were 22 (36.1%) males and 39 (63.9%) were females which is comparable to a study conducted in 2013 by suzana kovačević et al. there were total of 60 patients, 28 (46%) were male and 32 (54%) were female, age 45– 70 years (median 54.5y) 4 . a high prevalence of symptoms and signs of dry eye syndrome were found in glaucoma patients which hampers the efficacy of the drug and quality of life 9,19 . in 2001, pisella et al. reported that the individuals using preserved anti-glaucoma medication had complaints of burning and stinging (37%), foreign body sensation (28%), dry eye sensation (22%), watering (20%), and eyelid itching (17%) 11 . our results are consistent with the above study. tbut test evaluates the stability of the pre corneal tear film, and in different studies comparing signs, symptoms and predictive tools for dry eye disease and ocular surface disorders it is shown to be the most reliable test combined with vital staining. tbut of 6.4 ± 5.9 seconds in glaucoma individuals using topical anti-glaucoma therapy was also reported by baffa lina do prado et al. in 2007 indicating ocular surface alterations due to anti-glaucoma therapy 20 . in the present study, tbut of 6.4 ± 2.2 seconds was seen in glaucoma patients on topical anti-glaucoma therapy and the results are comparable to the above study. another study conducted by manusaini et al showed level 1 severity of dry eye in 34% (n = 17 eyes) and levels 2 and 3 severity was present in 66% (n = 33 eyes) individuals who were on anti-glaucoma therapy 7 . our results also confirm this. dry eye in glaucoma patients using topical anti-glaucoma therapy pakistan journal of ophthalmology, 2020, vol. 36 (1): 43-47 46 leung et al reported that 29% of patients had no symptoms of dry eye. mild to moderate level of osd was found in 27% glaucoma patients and severe tear deficiency was present in 35 (35%) patients 9 . this is comparable to the present study in which 10 (16.4%) patients had no dry eye. glaucoma being second leading cause of visual impairment has a long-term impact on the quality of life. we cannot stop the medication of the patients throughout their life, which do have certain side effects such as dry eye syndrome. the association of dry eye syndrome makes the compliance questionable. we can detect this early and treat it concomitantly which would result in better outcome. the limitations of the study was its small sample size. the patients included in the present study (glaucoma patients) were from the same locality. another limitation was that we did not compare the dry eye tests before and after the use of anti-glaucoma therapy. only the patients who were already using anti-glaucoma therapy were included in our study. conclusion there is high rate of dry eye in glaucoma patients using topical anti-glaucoma therapy. the patients should be on regular follow-ups with their ophthalmologists to detect the dry eye complications related with anti-glaucoma therapy. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution nabila zulfiqar; optometrist: concept and study design, analysis and interpretation of data, manuscript write up, literature research. muhammad sufyan aneeq ansari; assistant professor: concept and study, final review of manuscript. khurram nafees; assistant professor: concept and design of manuscript, final review. rabia nawaz; optometrist: manuscript drafting and revision of content, final review. manzra shaheen; optometrist: critical final review. references 1. hollands h, johnson d, hollands s, simel dl, jinapriya d, sharma s. do findings on routine examination identify patients at risk for primary openangle glaucoma? the rational clinical examination systematic review. jama. 2013; 309 (19): 2035-42. 2. glaucoma is second leading cause of blindness globally. world health organization, 2004. 3. katelan s, tomi m, mete soldo k, salopek-rabati j. how ocular surface disease impacts the glaucoma treatment outcome % j bio med res int. 2013; 2013: 7. 4. kovacevic s, canovic s, pavicic ad, kolega ms, basic jk. ocular surface changes in glaucoma patients related to topical medications. collegium antropologicum. 2015; 39 (1): 47-9. 5. baudouin c, renard j-p, nordmann j-p, denis p, lachkar y, sellem e, et al. prevalence and risk factors for ocular surface disease among patients treated over the long term for glaucoma or ocular hypertension. eur j ophthalmol. 2012; 23 (1): 47-54. 6. aydin kurna s, acikgoz s, altun a, ozbay n, sengor t, olcaysu oo. the effects of topical antiglaucoma drugs as monotherapy on the ocular surface: a prospective study. j ophthalmol. 2014; 2014: 460483. 7. saini m, vanathi m, dada t, agarwal t, dhiman r, khokhar s. ocular surface evaluation in eyes with chronic glaucoma on long term topical anti-glaucoma therapy. int j ophthalmol. 2017; 10 (6): 931-8. 8. yuksel n. evaluation of ocular surface disease associated with glaucoma patients. eur ophth rev. 2013; 7 (2): 81–3. 9. leung ew, medeiros fa, weinreb rn. prevalence of ocular surface disease in glaucoma patients. j glaucoma. 2008; 17 (5): 350-5. 10. vinutha bv, himamshu nvv, niveditha h, pooja p, liji p, smitha prevalence of ocular surface disease in glaucoma patients using anti-glaucoma medications. j evol med dent sci. 2013; 2 (23): 430814. 11. pisella pj, pouliquen p, baudouin c. prevalence of ocular symptoms and signs with preserved and preservative free glaucoma medication. br j ophthalmol. 2002; 86 (4): 418-23. 12. the definition and classification of dry eye disease: report of the definition and classification subcommittee of the international dry eye work shop 2007. the ocular surface, 2007; 5 (2): 75-92. 13. pflugfelder sc, baudouin c. challenges in the zulfiqar n, et al 47 pakistan journal of ophthalmology, 2020, vol. 36 (1): 43-47 clinical measurement of ocular surface disease in glaucoma patients. clin ophthalmol. (auckland, nz). 2011; 5: 1575-83. 14. lee aj, lee j, saw sm, gazzard g, koh d, widjaja d, et al. prevalence and risk factors associated with dry eye symptoms: a population based study in indonesia. the br j ophthalmol. 2002; 86 (12): 1347-51. 15. gomes b, turiel pr df, marques fp, bernardo fp, safady mva, portes alf, et al. sinais e sintomas de doença da superfície ocular em usuários de hipotensores oculares tópicos. arquivos brasileiros de oftalmologia. 2013; 76: 282-7. 16. arici mk, arici ds, topalkara a, guler c. adverse effects of topical anti-glaucoma drugs on the ocular surface. clin exp ophthalmol. 2000; 28 (2): 113-7. 17. herreras jm, pastor jc, calonge m, asensio vm. ocular surface alteration after long-term treatment with an anti-glaucomatous drug. ophthalmology, 1992; 99 (7): 1082-8. 18. costagliola c, prete ad, incorvaia c, fusco r, parmeggiani f, di giovanni a. ocular surface changes induced by topical application of latanoprost and timolol: a short-term study in glaucomatous patients with and without allergic conjunctivitis. graefes arch clin exp ophthalmol. 2001; 239 (11): 809-14. 19. stewart wc, stewart ja, nelson la. ocular surface disease in patients with ocular hypertension and glaucoma. curr eye res. 2011; 36 (5): 391-8. 20. baffa ldp, ricardo jrds, dias ac, módulo cm, braz am, paula jsd, et al. tear film and ocular surface alterations in chronic users of antiglaucoma medications. arquivos brasileiros de oftalmologia. 2008; 71: 18-21. .…  …. microsoft word editorial 118 editorial march of time innovations in cataract removal methods have been and are an ongoing process all along. transitions from couching to intracapsular, extracapsular, iol transplantation and somewhat recently to phacoemulsification were undertaken with traditional anxiety and reluctance because of the realization that progress is inevitable and while remaining static would mean becoming decades behind the progressing world. as a matter of fact if one has not changed his surgical technique in the last three to four years he is already left behind one generation, likely to be labeled as outdated and under a serious threat of getting out of business. once convinced of the benefits of phacoemulsification and having crossed the hurdle of learning curve we soon became comfortable and confident with this technique passing on the benefits of phacoemulsification to our patients who are now lot more happy, satisfied and unsacred of undergoing cataract surgery. we kept on improving our techniques every now and then from divide and conquer to chopping with lesser use of ultrasonic power aided by pulse, burst and now micro pulse, micro burst modes, along with availability of better machines providing safer fluidic controls etc. the main advantage of phaco over ecce was smaller incision with more secure wound, less induced astigmatism with fewer post operative complications particularly the dreaded post operative endophthalmitis. 6.5mm phaco incision size required for rigid iol was soon reduced to 3.2 mm with the availability of foldable lenses and in this technique the phaco tip had an irrigation sleeve over it hence called co-axial phaco emulsification. further reduction in incision size to less than 2mm required irrigation through chopping instrument while the phaco tip was used without a sleeve to negotiate through very small incision and hence called bimanual or non coaxial technique and through this small incision thin rollable lenses could be inserted with all the advantages of micro incision surgery (phaconit or micro incisions surgery). with the availability of even thinner rollable iol, there is further tendency towards even smaller incision (micro incisions about 1.5 mm and even recently about 700 micron micro phaconit) using the bimanual or non co-axial technique. despite these enthusiastic recommendations of micro incision and bimanual technique the dilemmas with it are no less trivial due to inherent problems of wound leakage around the sleeveless tip, insufficient infusion through chopper with more chances of chamber instability, instances of wound burn and chattering of leas pieces, with resultant sub optimal operative outcomes. hence a newer thinking is developing with the recommendations of constructing micro incision (sub 2 mm even upto 1.5 mm similar to bimanual technique) but with micro coaxial system using finer tips with thinner and narrow bore sleeves retaining the benefits of coaxial system along with micro incisions providing better fluidic control, securer wounds, practically astigmatism neutral, with lesser incidence of post operative complications retaining the possibility of using thin reliable iols with already proven stable and predictable optical qualities or choice of implanting newer thinner foldable lenses. m lateef chaudhry editor in chief pakistan journal of ophthalmology microsoft word m moin case report 108 case report association of maxillary osteoma with choroidal osteoma muhammad moin, najam-ul-hasnain khan pak j ophthalmol 2006, vol. 22 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: muhammad moin assistant professor department of ophthalmology king edward medical college lahore received for publication september’ 2005 …..……………………….. steomas of the paranasl sinuses are common slowly growing lesions and often appear as asymptomatic finding on radiological examination. they represent the most common benign neoplasm of the nose and paranasal sinuses1,2. we report a case of a young male who had a maxillary osteoma extending into the orbit and a choroidal osteoma on the same side. this association of orbital and choroidal osteoma has not been reported before in literature. case report a 16 yr old male presented in our outpatient department with slowly progressive painless proptosis of the right orbit with decreased vision for 1 ½ years. this was associated with epiphora and nasal discharge from the right side. on examination his visual acuity was 6/9 and 6/6 in the right and left eye respectively. the right globe was proptosed 4 mm, displaced 4-5 mm superiorly and 2-3 mm laterally. there was slight limitation of down gaze on the right side with a negative forced duction test. a hard rounded swelling was felt at the junction of the floor and the medial wall of the right orbit. the sensation in infra orbital nerve area intact. fundus examination revealed a yellowish-orange, peripapillary placoid fundus lesion on the right side with pseudopod-like edges associated with areas of retinal pigment epithelium atrophy, indicating choroidal osteoma (fig. 1). anterior rhinoscopy showed hypertrophy of the inferior turbinate. b-scan echography revealed placoid lesion of the posterior ocular coats next to the optic nerve characterized by localized areas of high ultrasound reflectivity with a corresponding retrobulbar orbital shadowing (fig. 2). computed tomography of the orbit demonstrated plate-like thickening with calcification of the choroid that was isodense with the normal skeletal bone. moreover there was a dense, well outlined lesion involving the anterior floor of the right orbit and the anterior wall of the right maxillary antrum (fig. 3). o 109 mild compression of the right globe was seen. systemic examination did not reveal any significant findings and serum calcium was found to be normal. considering the cosmetic deformity, displacement of the globe, epiphora and the potential for further growth it was decided to go ahead with right partial fig. 1: choroidal osteoma of right eye fig. 2: b scan shows choroidal osteoma as intense white signal below optic nerve head. fig. 3: maxillary osteoma of right side on ct scan fig. 4: gross picture of the removed osteoma maxillectomy combined with a dacryocystorhinostomy. osteotomies were made to remove the lesion with 2 mm margin of normal bone (fig. 4). post operatively there was resolution of the hyperglobus and epiphora. discussion paranasal osteomas3 are benign, slow growing bony tumors that usually appear in patients between 15 and 40 years of age and arise mainly from the facial and skull bones. patients may have facial asymmetry, facial pain, headaches, chronic sinusitis, exophthalmos, nasal obstruction, or displacement of an eye. the frontal sinus is the most common site of origin of paranasal sinus osteomas, followed in frequency by the ethmoid4 and maxillary sinuses. the sphenoidal sinus is the least frequently involved. these are presumed to arise from junctional points of 110 membranous and cartilagenous bones. the etilogy of osteomas is debated but the most commonly accepted theories are embryologic, traumatic or infections. these lesions may vary in diameter from few millimetres to more than 3 cm in size. the lesion may be cancellous or compact type bone. therapy is indicated only when the osteoma produces symptoms or if it is seen to enlarge on successive radiographs5. choroidal osteoma is a benign, ossifying tumour typically found in healthy young females6. usually it is unilateral, localized in the posterior pole of the eye, near the optic disc and the macula6-8. its aetiology is unknown: it may be caused by osseous metaplasia of the retinal pigment epithelium, or it may represent a kind of choristoma. it has not been reported to be associated with orbital osteomas. conclusion association of orbital and choroidal osteoma should always be checked when either of the two lesions are seen. author’s affiliation dr. muhammad moin department of ophthalmolgy king edward medical college lahore dr. najam-ul-hasnain khan professor of otolaryngology lahore general hospital/ postgraduate medical institute lahore references 1. earwaker j. paranasal sinus osteomas; a review of 4 cases. skeletal radiology. 1993; 22: 417-23. 2. hehar ss, jones ns. fronto-ethmoid osteoma: the place of surgery. the journal of laryngology and otology. 1997; 111: 372-5. 3. boysen mj. osteomas of the paranasal sinuses. otolaryngol. 1978; 7: 366-70. 4. mansour am, salti h, uwaydat s, et al. ethmoid sinus osteoma presenting as epiphora and orbital cellulitis: case report and literature review. surv ophthalmol. 1999; 43: 413-26. 5. namdar i, edelstein dr, huo j, et al. management of osteomas of the paranasal sinuses. am j rhinol. 1998; 12: 393-8. 6. shields cl, shields ja, augsburger jj. choroidal osteoma. surv ophthalmol. 1988; 33: 17-27. 7. browning dj. choroidal osteoma: observations from a community setting. ophthalmology. 2003; 110: 1327-34. 8. aylward gw, chang ts, pautler se, et al. a long-term followup of choroidal osteoma. arch ophthalmol. 1998; 116: 1337-41. microsoft word mazhar-u-zaman soomro.doc 133 original article safety, acceptability and efficacy of periconal as compared to retrobulbar anesthesia in cataract surgery mazhar-u-zaman soomro, imran attaullah, rao rashad qamar pak j ophthalmol 2007, vol. 23, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mazhar-u-zaman soomro shifa clinic 9–a model town khan pur distt. rahim yar khan received for publication june’ 2006 …..……………………….. purpose: to assess the safety, acceptability and effectiveness of periconal versus retro bulbar along with facial anesthesia in cataract surgery. material and method: a prospective, comparative study was designed to find out the safety, acceptability and effectiveness of periconal (transconjunctival route) and retro bulbar along with facial block for patients undergoing cataract surgery. one hundred and fifty patients were included in this study. the patients were divided in two equal groups. one group received periconal block (transconjunctival route) while other facial along with retro bulbar block. the anesthetic used was a mixture of xylocaine and bupivacaine in equal proportion. the quantity used was 3 ml for group a and 7-10 ml for group b. a questionnaire was filled for all patients and analyzed to compare two groups. results: total 150 patients were divided in two equal groups. group a; 72 patients were comfortable at the time of injection while in group b, 71 patients complained of pain. as for as anesthesia, akinesia and analgesia are concerned, results are comparable. conclusion: by analyzing the facts and figures in our study, we came to conclusion that periconal anesthesia (transconjunctival route) is an effective, acceptable and safe approach for anesthesia, akinesia and pain at the time of injection and during the surgery. reventable blindness is one of the many health problems affecting the developing countries. the estimate of global blindness is 45 million people. about 135 million have low vision. high prevalence of blindness is in asia and africa mainly due to cataract. in pakistan age related cataract remains the single major cause of blindness, contributing to 66.7% of the total 1.78% blindness. all the provinces of pakistan show almost the same percentage of cataract blindness as 70% in punjab, 73.6% in sindh, 57.10% in balochistan and 70% in nwfp. cataract is the most common cause of preventable blindness in pakistan. different types of anesthesia are used to perform cataract surgery like general anesthesia, topical anesthesia, facial block with retro bulbar block, periconal block and topical. cataract surgery is usually done under local anesthesia and this is the most preferred method by all ophthalmic surgeons. periconal anesthesia has replaced retrobulbar anesthesia due to its complications like orbital hemorrhage, brain anesthesia, eye ball perforation etc. single site transconjunctival local anesthesia is preferable type due to less pain at the time of injection, safety, acceptability and effectiveness. material and method a study was conducted to compare the safety, efficacy and acceptability of anesthesia and akinesia in retro bulbar along with facial block and periconal block. p 134 in this study 150 patients were recruited having age related cataract. the needles used were 25 g x 1.5 inch in retro bulbar; and in periconal block 24 g/ 1inch. local anesthetic agents used was mixture of 50% bupivacaine and 50% lignocaine. quantity of anesthetic agent was 7 ml in retro bulbar group while 3 ml in periconal group. a written consent was obtained from every patient. patients were divided in two groups a & b. in a group, patients received periconal block and in group b, retro bulbar block along with facial block was given. in group a; one drop of proparacaine (alcain, alcon laboratories usa) was instilled before injecting mixture. exclusion criteria were language barrier, mentally handicapped, deaf and dumb, children and contractures. all surgeries were done by a single surgeon. type of surgeries were ecce, ecce with intraocular lens implant (iol); phaco with iol. group a n (%) group b n (%) phaco with iol 40 (53.3) 43 (57.3) ecce with iol 25 (33.3) 21 ((28) ecce 10 (13.3) 11 (14.7) total 75 (100) 75 (100) a questioner was designed with the following protocol. analgesia 0 no pain/ discomfort 1 slight pain but tolerable 2 mild pain but still tolerable 3 moderate pain relieved by topical anesthesia 4 severe pain require more injection anesthesia excellent perfect anesthesia no pain good patient felt pain but tolerable fair patient felt pain and additional topical drops required to continue poor not able to continue surgery additional injection required akinesia excellent no movement at all good slight movement not interfering surgery fair moderate movement poor gross movement need further anesthetic agent to continue surgery sex distribution group a n (%) group b n (%) male 37 (49.3) 35 (46.7) female 38 (50.7) 40 (53.3) total 75 (100) 75 (100) anesthesia group a n (%) group b n (%) excellent 70 (93.3) 69 (92) good 3 (4) 2 (2.7) fair 2 (2.7) 4 (5.3) total 75 (100) 75 (100) analgesia pain score group a n (%) group b n (%) total n (%) 0 68 (90.7) 66 (88) 134 (89.3) 1 4 (5.3) 3 (4) 7 (4.7) 2 3 (4) 5 (6.7) 8 (5.3) 3 0 (0) 1 (1.3) 1 (0.7) 4 0 (0) 0 (0) 0 (0) total 75 (100) 75 (100) 150 (100) observations analgesic effect was evaluated by verbal description of patients and akinesia and anesthetic effect by observation of the surgeon and the questionnaire was filled at the end of each operation. in a group, patients received single site anesthetic agents through transconjunctival route in lower fornix after a drop of local anesthetic. in group b; facial block was followed by retro bulbar block. acceptability 95% patients were comfortable at the time of injection in group a, while 98% patients were not comfortable at the time of injection in group b. 135 discussion cataract surgery gets a large share in routine list of ophthalmic surgeon. there are different types of local anesthesia used for this type of surgery like retro bulbar along with facial, periconal two sites, single site periconal and topical anesthesia. historically cataract surgery was performed without anesthesia. topical anesthesia was used by karl kollar in 1884 as he used cocaine as an anesthetic agent. retro bulbar anesthesia was first described by herman knapp in 1884 as he used 4 % cocaine as ocular anesthetic agent for enucleation. walter atkin introduced retrobulbar anesthesia in 1945. there are broad selection of ophthalmic anesthesia needles. in retro bulbar special needles atkin style 25 g x 1.5 inch, 23 g x 1.5 inch are used. in periconal type of needles used are 25 g x 3/4 inch, 27 g x ¾ inch periconal, 25 g x 1 inch retro bulbar/ periconal. concepts and mode of anesthesia are changing for last decades; there was a need to search for a safe, acceptable and effective way of anesthesia. a collaborative study was conducted at shifa eye clinic khan pur and bvh bahawalpur for this purpose. there are different ways to achieve anesthesia for cataract surgery like general anesthesia, retro bulbar along with facial block, periconal, topical and subtenon anesthesia all around the world. general anesthesia needs special preparation of patients like nothing per oral for at least 6 hours and needs anesthetist to do his job. it has been reserved for children and mentally handicap patients and patients with nodding of heads. so local anesthesia is preferred by most of the ophthalmic surgeons due to its safety and acceptability to patients. there is a change from local anesthesia with sedation from 45 % in 1991 to 6 % in 1996 and local anesthesia alone from 20 % in 1991 to 86% in 1997. periconal anesthesia is replacing retrobulbar along with facial block due to its complication like orbital hemorrhage perforation of eye ball, injection to optic nerve etc. low volume of the anesthetic agents used in periconal block along with short and blunt needle make less chances of orbital hemorrhages than retrobulbar anesthesia. usually periconal anesthesia, injection containing the local anesthetic agent is introduced superonasally and inferonasally by piercing the skin. skin is the most pain sensitive part of the body. in our study, this part of the body was bypassed by injecting the cocktail in lower fornix through transconjunctival route. we have found the results are comparable between the two groups as for as pain, movements of eye ball are concerned. so, periconal anesthesia (transconjunctival route) after single drop of alcain is safe, acceptable and effective to patients and surgeon. author’s affiliation dr. mazhar-u-zaman soomro ophthalmic surgeon shifa clinic 9–a, model town, khan pur dr. imran attaullah postgraduate registrar eye ward, b. v. hospital bahawalpur dr. rao rashad qamar assistant professor eye ward, b.v. hospital bahawalpur reference 1. siddiqui ap, awan hr, minto h. current status of low vision rehabilitation in pakistan. pak j ophthalmol. 1996; 12: 95-7. 2. davis bd 2nd, mandle mr. efficacy and complication rate of 16,224 consecutive peribulbar blocks. a postoperative multicentric study. j cataract refract surg. 1994; 20: 327-37. 3. nicoll jm, acharya pa, ahlen k, et al. central nervous system complication. anesthesia analg 187; 66: 1298-1302. 4. hay a, flynn hw jr, hofman ji, rivera ah. needle penetration of globe during retrobulbar and peribulbar injection. ophthalmology. 1991; 98: 1017-24. 5. ben david b. complication of regional anesthesia: an overview. anesthesia din north america. 2000; 665-7. 6. american academy of ophthalmology section 11 1998-9; 81-3. 7. forestor jv. local anesthesia for eye surgery br j ophthalmol. 1992; 76: 705. 8. phaecoemulsification, laser cataract surgery and foldable iol by agarwal 2nd edition 2000; 86-93. 9. yoshimoto m, matsumoto s. orbital varix rupture during cataract surgery. j cataract refract surg. 2004; 30: 722-5. 10. griffiths jd, pilli s, luspbader jm. the effect of retrobulbar anesthesia on optic nerve function arvo. abstract 1356. invest ophtrhalmol vis sci. 1994; 35: 1544. 11. grrembaum s. anesthesia for cataract surgery. in: greenbaum s, ed, ocular anesthesia. philadelphi, pa, wb saunders, 1997; 30-3. microsoft word 22. sana nadeem mm 298 pakistan journal of ophthalmology, 2020, vol. 36 (3): 298-301 author communication lateral rectus superior compartment palsy sana nadeem1 1department of ophthalmology, foundation university medical college &fauji foundation hospital, rawalpindi abstract lateral rectus palsy with hypotropia constitutes a portion of sixth nerve palsy cases in which only the superior part of the lateral rectus is affected. we present such a case in a 10-year-old young pakistani lady who presented with a peculiar appearing right esotropia and hypotropia due to acquired lateral rectus palsy along with apparent ipsilateral superior rectus underaction. neuroimaging confirmed atrophy of the superior part of lateral rectus as compared to the inferior half. the superior rectus muscle was normal, along with other extraocular muscles. this confirmed our suspicion of superior compartment lr palsy. augmented superior rectus transposition to the lateral rectus along with adjustable bimedial recessions and bilateral inferior oblique myectomies were done to restore her cosmetic appearance. key words: lateral rectus palsy, sixth nerve palsy, esotropia, hypotropia, transposition, strabismus. how to cite this article: nadeem s. lateral rectus superior compartment palsy. pak j ophthalmol. 2020; 36 (3): 298-301. doi: 10.36351/pjo.v36i3.934 introduction compartmentalization of extraocular muscles has been studied extensively by demer1 and clark2, who put forth evidence that individual muscles have different functions corresponding to different fiber groups. the lateral rectus (lr) muscle is believed to have a dual embryonic origin and the abducent nerve (cranial nerve vi) is believed to innervate the lateral rectus by two or more trunks, with separation seen from as far as the cavernous sinus to the muscle itself, in autopsies. this is believed to divide the lateral rectus into two separate compartments: superior and inferior; and a sixth nerve palsy, either complete or partial, may affect any one of these. this holds true for other extraocular muscles as well. physiological behaviour of extraocular muscles correspondence to: sana nadeem foundation university medical college &fauji foundation hospital, rawalpindi email: sana.nadeem018@gmail.com received: october 10, 2019 revised: may 4, 2020 accepted: may 4, 2020 studied through special mri techniques also favors neuromuscular compartmentalization. selective pathology of the different compartments can yield peculiar strabismus patterns, leading to erroneous diagnosis. the majority of sixth nerve palsies affect the superior compartment more than the inferior compartment of the lateral rectus, characterized by an esotropia with coexisting ipsilateral hypotropia. this may pose the diagnostic dilemma of a vertical muscle palsy in addition to the lr palsy1-3. we present a case of lr superior compartment syndrome in a 10-year-old girl who presented with a right sided acquired esotropia with hypotropia, accentuated upon abduction. case presentation a 10-year-old girl presented to the eye opd of fauji foundation hospital, rawalpindi; which is a tertiary care teaching hospital affiliated with the foundation university medical college; with a right sided esotropia and inability to turn the right eye outwards of 1½ year duration, consequent to a severe febrile illness. old hospital records were unavailable. previous photographs showed that she was orthotropic lateral rectus superior compartment palsy pakistan journal of ophthalmology, 2020, vol. 36 (3): 298-301 299 fig. i: right superior compartment lateral rectus palsy with v-pattern esotropia and hypotropia. the hypotropia increased on abduction. there is apparent right superior rectus underaction, bilateral inferior oblique overaction and superior oblique underaction. fig. 2: a. coronal t1w mri of the orbits showing atrophy of the right superior half of lr (white arrow) b. post contrast images c. post contrast t2w coronal section of the orbit and extraocular muscles d. axial t2w mri of the brain showing a normal pons (asterisk). prior to the event. on examination, her unaided visual acuity was 6/6 bilaterally. on prism cover testing, she had a right esotropia (ret) of 75 prism diopters (pd) along with a right hypotropia (rhot) of 5 pd in primary distance gaze, ret of 62 pd and rhot of 2 pd in upgaze, ret of 80 pd and rhot of 2 pd in sana nadeem 300 pakistan journal of ophthalmology, 2020, vol. 36 (3): 298-301 fig. 3: post-operative appearance at 1 year. downgaze, ret of 60 pd and rhot of 10 pd in right gaze and ret of 70 pd and rhot of 9 pd in left gaze. the esotropia had a ‘v’-pattern of 18 pd. at near fixation, she had a ret of 80 pd and no hypotropia. she had a right lr underaction of -3 to -4, a right medial rectus (mr) overaction of +2, right superior rectus (sr) underaction of -2.5, bilateral inferior oblique overaction of +3, left lr underaction of -2 and bilateral superior oblique underaction of -1.5 (figure 1). she had a right face turn. she was thus diagnosed with a right partial abducent nerve palsy and there was suspicion of a right superior rectus palsy. titmus fly test showed stereopsis at 160 seconds of arc. worth 4 dots testing showed alternating suppression. anterior segment was normal. her fundus examination although normal showed bilateral fundus extorsion. we presumed that the cause of the sixth nerve palsy was infectious, possibly meningitis. systemically she did not have any co-morbid conditions. a thorough investigative workup was done. complete blood picture was normal, esr was 24, plasma glucose and thyroid profile was normal. urine routine examination, liver function tests and renal function tests were normal. neurological examination was normal. a thin section mri orbit & brain with contrast (2.5 mm) was ordered, which showed normal pons and failed to reveal a lesion along the path of the abducent nerve. the right lr muscle was atrophied as compared to the left lr; and its superior half was smaller as compared to the inferior half on coronal sections (figure 2). the superior rectus muscle was normal, along with other extraocular muscles. this confirmed our suspicion of superior compartment lr palsy. we performed a bimedial recession of 7 mm (right eye on an adjustable suture with a final adjustment to 5 mm). an augmented transposition of the right sr to the lr with a non-absorbable ethibond 5/0 augmentation suture, 12 mm behind the insertions was done, incorporating 1/4th of both the muscle bellies. bilateral inferior oblique myectomies were also performed in a single setting. at 1 year postoperatively, she was well aligned, very happy although an elevation deficit in upgaze was persistent which we attributed to sr transposition, and inferior oblique myectomy (figure 3). discussion abducent nerve is the sixth cranial nerve and solely innervates the lateral rectus muscle. it primarily functions to abduct the eye. its nucleus lies within the pons, ventral to the floor of the fourth ventricle, and its fasciculus leaves the brainstem at the ponto-medullary junction. the basilar part passes upwards near the skull base and is crossed by the anterior inferior cerebellar artery. it pierces dura below the posterior clinoids and passes the petrous tips, through the dorello canal to enter the cavernous sinus, lying in close proximity to the cranial nerves iii, iv and v1, and the internal carotid artery. it enters the orbit via the superior orbital fissure within the annulus of zinn. a sixth nerve palsy can be caused by any insult along its long course. causes of acquired sixth nerve palsy in children are trauma, neoplasms, infections, lateral rectus superior compartment palsy pakistan journal of ophthalmology, 2020, vol. 36 (3): 298-301 301 vasculopathies, aneurysms, arteriovenous malformations, raised intracranial pressure, demyelination or iatrogenic; to name a few4,5. the abducent nerve has a bifid innervation structure to divide the lateral rectus into two functional neuromuscular compartments; superior and inferior. this compartmentalization allows the lr to have additional vertical and torsional actions in addition to abduction, due to differential contraction of these compartments during ocular counter-rolling, vertical ductions and vertical vergence. thus, a lesion along the abducent pathway may affect only one compartment of the lr to cause a compartmental palsy. the lateral rectus superior compartment palsyis a newer subtype of abducent palsy, exhibiting asymmetric atrophy of the superior compartment only, resulting in vertical and torsional abnormalities concurrent to the abduction limitation. this results in paralytic esotropia coexistent with ipsilateral hypotropia and excyclotropia; with the hypotropia increasing in abduction. this was clearly seen in our case. this may occur in both complete and partial palsies of the sixth nerve. surface coil thin section coronal mri studies have confirmed the existence of such palsies, and have shown significant reduction in the maximum cross-sections of the superior compartment1,2,5,6. treatment of an acute lr palsy is alternate occlusion, botox to the medial rectus and requires observation for six months to one year, to allow for spontaneous resolution to occur. surgery for nonresolving abducent palsies depends upon the degree of deviation and whether the palsy is complete or partial; it involves either recession of the contralateral synergistic muscle (mr), recession of the direct antagonist (ipsilateral mr), lr resection, or contralateral antagonist resection (lr). in cases of complete palsies, temporal transposition procedures of the vertical rectii may be done, like hummelsheim or jensen. operating on multiple muscles especially the vertical rectii in conjunction with the horizontal rectii may pose a risk of anterior segment ischemia. a recent therapy for lr palsy is augmented transposition of the sr to the lr with a non-absorbable suture7-10. we thus performed a bimedial recession with an augmented sr transposition, as we have found this to be safer and effective, and because lr function has completely returned, this also supports the hypothesis of a superior compartment lr paresis. inferior oblique overaction was treated by myectomies, which improved her bothersome up shoots on adduction. conflict of interest authors declared no conflict of interest. author’s designation and contribution dr. sana nadeem; assistant professor: concept, data collection, patient management, manuscript writing. references 1. demer jl. compartmentalization of extraocular muscle function. eye, 2015; 29: 157-162. 2. clark ra, demer jl. lateral rectus superior compartment palsy. am j ophthalmol. 2014; 157 (2): 479-487. 3. clark ra, demer jl. isolated superior compartment lateral rectus palsy: a new pathophysiologic diagnosis defined by magnetic resonance imaging. j aapos. 2013; 17 (1): e3-e4. https://doi.org/10.1016/j.jaapos.2012.12.012 4. bowling b. kanski’s clinical ophthalmology. a systematic approach. eight edition. elsevier: china, 2016; 828-9. 5. clark ra. strabismus: sixth nerve palsy. https://www.aao.org/disease-review/strabismsu-sixthnerve-palsy (accessed 3 june 2019) 6. demer jl, clark ra, da silva costa rm, kung j, yoo l. expanding repertoire in the oculomotor periphery: selective compartmental function in rectus extraocular muscles. am n y acad sci. 2011; 1233: 8-16. 7. lyle tk, gross ag. diagnosis and management of paralysis of the extrinsic ocular muscles with special reference to surgical treatment in 219 cases. br j ophthalmol. 1951; 35 (9): 511-548. 8. hoyt cs, taylor d. paediatric ophthalmology and strabismus. fourth edition. elsevier: china, 2013: 847850. 9. mehendale ra, dagi lr, wu c, ledoux d, johnston s, hunter dg. superior rectus transposition and medial rectus recession for duane syndrome and sixth nerve palsy. arch ophthalmol. 2012; 130 (2): 195-201. 10. akar s, gokyigit b, pekel g, demircan a, demirok a. vertical muscle transposition augmented with lateral fixation (foster) suture for duane syndrome and sixth nerve palsy. eye (lond). 2013; 27 (10): 1188-95. .……. pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 60 author communication case report on horner’s syndrome following thyroidectomy syeda sidra gillani, ahmad zeeshan jamil pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: syeda sidra gillani optometrist m. phil, fiacle dhq teaching hospital sahiwal/ sahiwal medical college (smc) email: shahnoor2020@gmail.com …..……………………….. we report a case of 37-year-old pakistani punjabi woman who visited the eye department of dhq teaching hospital sahiwal with complaint of drooping of right upper eyelid following the thyroidectomy. this is to highlight the importance of proximity of thyroid gland and sympathetic trunk. hence, to make surgeon more vigilant to avoid risk of injury to sympathetic trunk so that potentially stressing cosmetic disfigurement can be avoided. moreover, this would help the surgeon to undertake measures to lessen the risk of injuring the sympathetic runk while doing the thyroidectomy. key words: horner’s syndrome, miosis, ptosisthyroidectomy. iosis and ptosis are the two commonest features of horner’s syndrome. moreover, it may or may not be associated with ipsilateral facial anhydrosis and dilatation of vessels. it is probably the outcome of traumatized ipsilateral cervical sympathetic chain. up to now a thorough knowledge of the cause and pathophysiology is not unknown. once it is diagnosed, the management is conservative. horner’s syndrome is reported to be rarest complication subsequent to thyroidectomy and a few cases are reported worldwide. we would like to report such a case in pakistan where thyroid disorders are abundant and thyroidectomy is a common surgical procedure1,2. case history a 37-year-old pakistani punjabi woman visited eye department of dhq teaching hospital sahiwal with complaint of drooping of right upper eyelid. after taking complete history it became evident that patient had developed unilateral partial ptosis as well as miotic pupil following the thyroidectomy which is done for a benign multinodular goiter. there was no history of facial anhidrosis reported by the patient. on examination it was found there was mild fig. a: photographs of patient showing right ptosis and surgical mark of thyroidectomy. ptosis in right eye with miosis. marginal reflex distance was found to be 2 mm in right eye and 4 mm in left eye. palpebral fissure height was measured to be 6 mm in right eye which was 3 mm less than palpebral fissure height of left eye and normal lid position and retraction. there was no history of anhydrosis, normal sensation and full extra ocular motility in all cardinal position of gaze. moreover, m syeda sidra gillani, et al 61 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology both eyes were centrally placed in the orbit and no dystropia was noted. fig. b: photographs of patient showing right miosis while patient is looking in up gaze. a clinical diagnosis of horner’s syndrome was made with phenylephrine 1% which was prepared by diluting 10% phenylephrine and instilled in both eye. it produced dilatation in a horner’s syndrome and minimal dilatation in normal pupil because of denervation hyper-sensitivity. therefore it became clear that lesion was interrupting the postganglionic fibers. discussion horner's syndrome usually presents with miosis, eyelid ptosis, enophthalmos and vascular dilatation disorder. besides, facial anhidrosis may or may not be present. in 1853, it was firstly described by bernard, and after that johann horner reported it in 18694. in spite of the fact that there is huge literature which describes horner's syndrome is result of pressure caused by majority of benign goiter to cervical sympathetic chain but there may be less than 30 cases of the reported horner's syndrome after thyroidectomy so far. at the very first in 1865, kappeler explained that horner's syndrome might occur after thyroid surgery. a first case of horner's syndrome post thyroidectomy was reported by the kaelin in early 1900’s5. horner's syndrome with conventional surgical procedure of thyroidectomy is quite possible and however the late reports propose that comparative dangers of harm to sympathetic innervation are related with minimal invasive surgery also. then, harding et al. has lately described the horner's syndrome following minimal invasive parathyroidectomy, on the other side meng with his partners have revealed horner's syndrome following video assisted surgery6. a possible explanation behind horner's syndrome following thyroid surgery are, the sympathetic chain may get stretched during lateral retraction or compressed by a hematoma post operatively, ligation of inferior arterial trunk of thyroid can cause ischemia induced damage to neural tissue. besides, communication between sympathetic innervation and laryngeal nerve may get affected due to its repetitive identification during procedure. anatomically, the middle cervical ganglion and sympathetic truck are very close and relation is quite variable either present in front or behind the inferior thyroid artery. that’s why middle cervical ganglion and sympathetic truck are profoundly prone to complications in thyroidectomy. solomon et al. proposed that blood supply to the sympathetic trunk originated from the inferior thyroid trunk or its branches and ligation of these vessels may cause prompt devascularization and ischemic damage to the sympathetic chain prompting horner's syndrome7. de quervain says that sympathetic chain gets stretched when the lateral retraction of carotid sheath is done to expose the lateral aspects of gland and other close structures. this stretching is sufficient to cause damage to the chain and subsequently neuropraxictype trauma occurs8. in a recently published case series by harding et al. reports that the more complicated surgery higher would be the risk of horner's syndrome. for instance in malignant thyroid disease which involves level iii lymph node dissection and large goiters with retrosternal extension chances of horner's syndrome are relatively higher6. it is observed that there is no uniform pattern for onset of horner's syndrome subsequently thyroidectomy. most of the literature confirms that horner's syndrome starts at 2nd to 4th postoperative day which reflects the possibility of various etiologies. but here in this case we are unable to describe the exact onset of symptoms due to vague medical history given by the patient and lack of medical record. patient here did not show any ipsilateral inability of facial sweating and cutaneous vascular dilatation as noted in most of such cases. the exact reason behind is not known so far. conclusions this case report features an uncommon however particularly important complication of very common surgery done by general and endocrine and otorhinolaryngology specialists. in spite of the fact case report on horner’s syndrome following thyroidectomy pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 62 that it is a rare complication but the specialist should be careful during the procedure because it can cause a noteworthy cosmetic problem, which could last long. author’s affiliation syeda sidra gillani bsc(hons)optometry/m.phil optometry optometrist dhq teaching hospital sahiwal dr. ahmad zeeshan jamil associate professor of ophthalmology mbbs, mcps, fcps, frcs, fcps (vro) sahiwal medical college/dhq teaching hospital sahiwal author’s contribution syeda sidra gillani concept of study, drafting of manuscript. dr. ahmad zeeshan jamil critical review and literature search. references 1. seneviratne sa, kumara ds, drahaman amp. horner’s syndrome: an unusual complication of thyroidectomy: a case report. journal of medical case reports, 2016; 10 (1): 300. 2. cozzaglio l, coladonato m, doci r, travaglini p, vizzotto l, osio m, et al. horner's syndrome as a complication of thyroidectomy: report of a case. surgery today, 2008; 38 (12): 1114-6. 3. danesh-meyer hv, savino p, sergott r. the correlation of phenylephrine 1% with hydroxyamphetamine 1% in horner’s syndrome. british journal of ophthalmology, 2004; 88 (4): 592-3. 4. horner jf. übereine form von ptosis. klinmonatsbl augenheilkd. 1869: 7. 5. kaelin w. über störungen von seiten des halssympathicus bei einfacher struma und im anschluß an deren operative behandlung. langenbecks arch surg. 1915: 134. 6. harding jl, sywak ms, sidhu s, delbridge lw. horner’s syndrome in association with thyroid and parathyroid disease. anz j surg. 2004: 74. 7. solomon p, irish j, gullane p. horner's syndrome following a thyroidectomy. j otolaryngol. 1993; 22 (6): 454-6. 8. quervain f. weiteres zur technik der kropfoperation. langenbecks arch surg. 1915: 134. pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 235 short communication it all lies in her eyes haroon tayyab, jawaria akhtar pak j ophthalmol 2016, vol. 32 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: haroon tayyab house # suh-24. askari xi, cobbe lane, near qasim market, rawalpindi. e.mail: haroontayyab79@gmail.com …..……………………….. eye colour is one of the most notable traits in determining facial features. in this case report, we present a 19 year old girl with isolated congenital heterochromia iridis. she presented to outdoor patient department for a routine check up. on detailed examination, we did not find any ocular or systemic abnormality. isolated heterochromia iridis is an exceedingly rare condition world wide and in our population as well. ophthalmologist should be aware of this condition and should be able to rule out different syndromes and ocular/systemic conditions that may be associated with it. key words: heterochromia iridis, melanin, fuch’s heterochromic uveitis. eterochromia iridis is a term coined for a clinical situation when there is a difference in the colour of both iris. the normal iris can be of darker (hyperchromia) or lighter (hypochromia) hue. and there can be many genetic or acquired factors that can lead to heterochromia iridis1. heterochromia iridis happens due to relative loss or gain of melanin pigment granules in the effected eye. these pigment granules reside in melanocytes whose number remains constant. the amount of melanin in each melanocyte is genetically regulated. this loss or gain of pigment can be congenital or acquired and isolated or composite with other systemic conditions2. there are many systemic conditions that can lead to sectoral or complete heterochromia iridis e.g, fuch’s heterochromic uveitis, congenital horner’s syndrome, waardenburg’s syndrome, hypomelanosis of ito and linear scleroderma3-5. those conditions leading to hypochromia iridis include waardenburg’s syndrome, horner’s syndrome, incontinentia pigmenti, fuch’s heterochromic uveitis etc6. the effected iris can be darker in colour in certain acquired or congenital conditions like siderosis, topical use of prostaglandin analogue for glaucoma, nevus of ota, sturge weber syndrome, pigment dispersion syndrome etc. isolated congenital heterochromia iridis is an exceedingly rare condition and there is no literature evidence to report its incidence. henceforth, we report this rare ocular condition to document its presence in pakistani population. case report this 19 year old female presented to the outdoor patient department (opd) of sharif medical city hospital, raiwind, lahore in june 2016 for a routine checkup. she came to the opd with her mother and one sibling and the family had been aware to two different iris colours since birth. according to the fig. 1: isolated congenital heterochromia iridis in a 19 year old girl. h mailto:haroontayyab79@gmail.com haroon tayyab, et al 236 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology mother, the child was born at her home (village in raiwind) with the assistance of a midwife through spontaneous vaginal delivery. the child was full term and had uneventful antenatal course. the only significant postnatal event was neonatal jaundice. her vaccination record was sketchy and mother could not recall about completing her daughter’s vaccination. the patient had no significant ocular complaint at the time of her presentation. the patient had 2 siblings (both females) and their eyes colour was dark brown. the parents also had brown coloured eyes and they were second order cousins. fig. 2: anterior segment optical coherence tomograph of left hypochromic eye of 19 year old girl. on examination, the patient had 20/20 visual acuity in both eyes with minimal or no refractive error after cycloplegic refraction. her anterior segment examination was unremarkable apart from stark difference in colour of her iridis (figure 1). posterior segment examination showed mild hypo pigmentation of left fundus with normal optic disc, macula and retinal periphery. her intraocular pressure was 14 mm hg and 16 mm hg in right and left eye respectively. the patient was also checked by a female doctor for any hypopigmentaion on rest of the body but results were negative. the patient was also thoroughly examined for the presence of any signs that may direct us towards any of the syndromes (fuch’s heterochromic uveitis, horner’s syndrome. waardenburg’s syndrome) mentioned above but her examination was completely unremarkable apart from heterochromia iridis. an anterior segment optical coherence tomography was also performed delineate the anatomy of iris and anterior segment; and also to rule out iris tumours and cysts which may render iris hypo pigmented (figure 2). the patient was not concerned about the heterochromia but was still offered the choice of using cosmetic contact lens if she desired so. an informed consent was taken from the patient for publishing her rare ocular condition along with pictorial reference to her heterochromia iridis. discussion the different iris colours are based on the presence of amount of brown and yellow pigment with distinguishes iris based on predominant colour which may be blue, grey, green or various hues of brown.7 patients having dark brown iris are rich in melanin whereas other shades of iris colour have relatively lower melanin content; blue colour completely lacking melanin. it may be inherited, or caused by genetic mosaicism or chimerism. the scientific consensus is that a lack of genetic diversity is the primary reason behind heterochromia. this is due to a mutation of the genes that determine melanin distribution at the 8htp pathway, which usually only become corrupted due to chromosomal homogeneity2. very early reports from the start of century supported the idea that eye colour was inherited as a mendelian trait. it approved the notion that blue eyes were autosomal recessive where brown eyes were autosomal dominant traits. this doctrine suggested that two blue eyed parents could not give birth to a brown eyed child but later reports nullified this idea. it was then perceived that eye colour is a polygenic trait. chromosomal studies implicated multiple genes playing a role in determining eye colour but the most notable of them came out to be oca-2 gene located on the long arm of chromosome 15. apart from causing heterochromia iridis, its mutation has also been linked with oculocutaneous albnism, angleman and prader willi syndromes8. although, heterochromia iridis has been reported multiple times in association with other syndromes, its literature evidence is minimal when reported as the only clinical finding. similar to our case, one case of 15 year old nigerian girl was reported by omolase where the only clinical finding was heterochromia iridis with normal ocular and systemic examination9. he also reported a case of bilateral hypochromia iridis with normal ocular and systemic examination in a 6 months old nigerian girl10. kocak reported a very interesting case of heterochromia iridis in a 5 year old girl who also had wooly hair nevus and ipsilateral pigmentary https://en.wikipedia.org/wiki/biological_inheritance https://en.wikipedia.org/wiki/mosaicism https://en.wikipedia.org/wiki/chimerism it all lies in her eyes pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 237 demarcation lines. wooly hair nevus refers to a clinical entity where a patch of scalp hair is hypopigmented and curlier than rest of scalp hair. this constellation of symptoms is also a solitary occurrence with no other such reference in literature. the rest of ocular and systemic examination in this patient was unremarkable.3 other reported cases of heterochromia iridis have been associated with rare systemic syndromes; the most notable of them being waardenburg’s syndrome6. conclusion we reported this rare case to entice interest of ophthalmologists in this rare clinical presentation. since heterochromia iridis is also associated with other ocular and systemic clinical conditions, so such a patient always warrants a complete examination to rule out any sinister condition associated with heterochromia iridis. author’s affiliation dr. haroon tayyab assistant professor of ophthalmology sharif medical & dental college dr. jawaria akhtar resident department of ophthalmology sir ganga ram hospital lahore role of authors dr. haroon tayyab patient selection and case report write up dr. jawaria akhtar literature research references 1. ur rehman h. heterochromia. cmaj. 2008; 26; 179: 447-8. 2. imesch pd, wallow ih, albert dm. the color of the human eye: a review of morphologic correlates and of some conditions that affect iridial pigmentation. surv ophthalmol. 1997; 41: s117-23. 3. kocak ay, kocak o. a case of woolly hair nevus associated with pigmentary demarcation lines and heterochromia iridis: coincidence or a new association? int j trichology, 2015; 7: 123-4. 4. quinlan k, shwayder t. cafe au lait macule associated with heterochromia iridis. pediatr dermatol. 2005; 22: 177-8. 5. pallotta r, saponari a. hyperpigmented patch associated to heterochromia iridis. pediatr dermatol. 2005; 22: 572; author reply 572. 6. jiménez gómez n, ballester martínez ma, urrutia hernando s, jaén olasolo p. heterochromia iridis, congenital deafness and skin pigmentary abnormalities: waardenburg syndrome. med clin (barc). 2014; 142: e11. 7. seddon jm, sahagian cr, glynn rj, sperduto rd, gragoudas es. evaluation of an iris color classification system. the eye disorders case-control study group. invest ophthalmol vis sci. 1990; 31: 1592-8. 8. rennie ig. don't it make my blue eyes brown: heterochromia and other abnormalities of the iris. eye (lond). 2012; 26: 29-50. 9. omolase co. simple heterochromia iridis: a case report. nigerian hospital practice, 2008; 2: 120-2. 10. omolase co, akinwalere ak, adeosun ao, omolase bo, majekodunmi my. congenital heterochromia iridis in a nigerian girl child. pak j ophthalmol. 2011; 27: 106-8. https://www.ncbi.nlm.nih.gov/pubmed/?term=ur%252520rehman%252520h%25255bauthor%25255d&cauthor=true&cauthor_uid=18725617 https://www.ncbi.nlm.nih.gov/pubmed/?term=imesch%252520pd%25255bauthor%25255d&cauthor=true&cauthor_uid=9154287 https://www.ncbi.nlm.nih.gov/pubmed/?term=wallow%252520ih%25255bauthor%25255d&cauthor=true&cauthor_uid=9154287 https://www.ncbi.nlm.nih.gov/pubmed/?term=albert%252520dm%25255bauthor%25255d&cauthor=true&cauthor_uid=9154287 https://www.ncbi.nlm.nih.gov/pubmed/?term=kocak%252520ay%25255bauthor%25255d&cauthor=true&cauthor_uid=26622156 https://www.ncbi.nlm.nih.gov/pubmed/?term=kocak%252520o%25255bauthor%25255d&cauthor=true&cauthor_uid=26622156 https://www.ncbi.nlm.nih.gov/pubmed/?term=quinlan%252520k%25255bauthor%25255d&cauthor=true&cauthor_uid=15804313 https://www.ncbi.nlm.nih.gov/pubmed/?term=shwayder%252520t%25255bauthor%25255d&cauthor=true&cauthor_uid=15804313 https://www.ncbi.nlm.nih.gov/pubmed/?term=pallotta%252520r%25255bauthor%25255d&cauthor=true&cauthor_uid=16354268 https://www.ncbi.nlm.nih.gov/pubmed/?term=saponari%252520a%25255bauthor%25255d&cauthor=true&cauthor_uid=16354268 https://www.ncbi.nlm.nih.gov/pubmed/?term=jim%2525c3%2525a9nez%252520g%2525c3%2525b3mez%252520n%25255bauthor%25255d&cauthor=true&cauthor_uid=24029453 https://www.ncbi.nlm.nih.gov/pubmed/?term=ballester%252520mart%2525c3%2525adnez%252520ma%25255bauthor%25255d&cauthor=true&cauthor_uid=24029453 https://www.ncbi.nlm.nih.gov/pubmed/?term=urrutia%252520hernando%252520s%25255bauthor%25255d&cauthor=true&cauthor_uid=24029453 https://www.ncbi.nlm.nih.gov/pubmed/?term=urrutia%252520hernando%252520s%25255bauthor%25255d&cauthor=true&cauthor_uid=24029453 https://www.ncbi.nlm.nih.gov/pubmed/?term=urrutia%252520hernando%252520s%25255bauthor%25255d&cauthor=true&cauthor_uid=24029453 https://www.ncbi.nlm.nih.gov/pubmed/?term=ja%2525c3%2525a9n%252520olasolo%252520p%25255bauthor%25255d&cauthor=true&cauthor_uid=24029453 https://www.ncbi.nlm.nih.gov/pubmed/?term=seddon%252520jm%25255bauthor%25255d&cauthor=true&cauthor_uid=2201662 https://www.ncbi.nlm.nih.gov/pubmed/?term=sahagian%252520cr%25255bauthor%25255d&cauthor=true&cauthor_uid=2201662 https://www.ncbi.nlm.nih.gov/pubmed/?term=glynn%252520rj%25255bauthor%25255d&cauthor=true&cauthor_uid=2201662 https://www.ncbi.nlm.nih.gov/pubmed/?term=sperduto%252520rd%25255bauthor%25255d&cauthor=true&cauthor_uid=2201662 https://www.ncbi.nlm.nih.gov/pubmed/?term=gragoudas%252520es%25255bauthor%25255d&cauthor=true&cauthor_uid=2201662 https://www.ncbi.nlm.nih.gov/pubmed/?term=rennie%252520ig%25255bauthor%25255d&cauthor=true&cauthor_uid=21979861 29 pakistan journal of ophthalmology, 2020, vol. 36 (1): 29-32 original article central corneal thickness in females using oral contraceptive pills samia iqbal 1 , khizar bashir 2 , minahal mateen 3 , mateen amir 4 , iftikhar ahmad 5 1,2,4,5 university of lahore teaching hospital, 3 services hospital-lahore abstract purpose: to compare the central corneal thickness in females using oral contraceptive pills (ocp) with age matched controls. study design: descriptive observational study. place and duration of study: department of ophthalmology, university of lahore teaching hospital, from august 2018 to december 2018. material and methods: fifty-one females who used ocp within last one year and 38 age-matched controls were included in this study after approval from the ethical review board. females with any systemic disease, pregnancy and lactating mothers were excluded from the study. females with ocular diseases, like trachoma, cataract, keratitis, uveitis, corneal dystrophies, keratoglobus, keratoconus, ocular trauma, and high refractive errors were also excluded. each subject underwent full ocular examination including best-corrected visual acuity using snellen acuity chart and bio-microscopic examination of anterior segment and the fundus. central corneal thickness (cct) was measured with ultrasonic pachymeter and the intraocular pressure was measured with noncontact tonometer at the time of examination. the data was collected by self-designed proforma and analyzed by using spss version 20. results: mean age of the females using ocp was 31.4 ± 6.8 years and mean age of age-matched controls was 32.9 ± 5.5 years (p = 0.38). mean central corneal thickness values were higher in ocp group when compared to controls (541.8 ± 31.39 μm and 518.7 ± 36.7 μm, respectively). p value was 0.004, which was statistically significant. the mean iop value was 14.5 ± 2.6 mm hg in ocp group and 14.4 ± 2.8 mm hg in the control group (p = 0.86), which was not statistically significant. conclusion: central corneal thickness values are significantly higher in patients using ocp. key words: oral contraceptive pills, central corneal thickness, intraocular pressure. how to cite this article: iqbal s, bashir k, mateen m, amir m, ahmad i. central corneal thickness in females using oral contraceptive pills, pak j ophthalmol. 2020; 36 (1): 29-32. doi: https://doi.org/10.36351/pjo.v36i1.916 introduction an average cornea is between 540 µm and 560 µm thick. a thick cornea is 565 µm or more and a very thick cornea being greater than 600 µm. 1 address for correspondence: samia iqbal doctor of optometry, university of lahore teaching hospital, lahore email: samiaiqbal988@gmail.com measuring central corneal thickness (cct) is important for numerous ophthalmic procedures including refractive surgery. corneal thickness variations are seen in keratoconus and after long-term use of contact lens. 2 use of the oral contraceptive pills (ocps) is common during reproductive years 3 . the hormone known as gonadotropin play a role in corneal diseases and in females the central corneal thickness may be affected by female hormones. studies have shown that https://doi.org/10.36351/pjo.v36i1.916 central corneal thickness in females using oral contraceptive pills pakistan journal of ophthalmology, 2020, vol. 36 (1): 29-32 30 hormonal changes during oral contraceptive pill (ocp) use may affect central corneal thickness (cct) 4 . numerous data exist to describe the manifestation of a diversity of ocular diseases in females using (ocps) 5,6 . however, the consequences of gonadotropin and ovarian hormones on corneal biomechanics are uncertain. in this study, we tried to find out association between oral contraceptive pills and central corneal thickness (cct). material and methods it was comparative observational study. we examined fifty-one young women using ocp who visited the eye department for a routine ocular examination. thirtyeight controls not using ocp or not having used any form of hormonal birth control, at any period of their life were also included in the study. all the subjects having any other systemic disease were excluded from the study. pregnant and lactating women were also not included in either group. subjects having ocular problems like trachoma, cataract, keratitis, uveitis and corneal issues like keratoglobus and keratoconus, trauma and high refractive errors were excluded from the study. each subject underwent full ocular examination including best-corrected visual acuity using snellen visual acuity chart and bio-microscopic examination of anterior segment and retina. the ultrasonic pachymeter was used to measure cct and the intraocular pressure was measured with non-contact tonometer at the time of examination. results the mean ages were 32.9 ± 5.5 years for control group and 31.4 ± 6.8 years for ocp group (p = 0.38). mean central corneal thickness values were significantly higher in ocp group as compared to that of the control group (541.8±31.39 μm and 518.7±36.7 μm, respectively) (p = 0.004). the mean iop value was 14.4±2.8 mm hg in control group and 14.5 ± 2.6 mm hg in ocp group (p = 0.86). further details are depicted in tables 1 and 2. table 1: age distribution in subjects using contraceptive pills and controls. ocp group frequency percent valid percent cumulative percent valid 20-30 28 54.9 54.9 54.9 31-40 14 27.4 27.4 45.1 41-45 9 17.6 17.6 100.0 total 51 100.0 100.0 control group frequency percent valid percent cumulative percent valid 20-30 24 63.1 63.1 54.9 31-40 8 21.0 21.0 84.1 41-45 6 15.7 15.7 100.0 total 38 100.0 100.0 table 2: comparison between the two groups. variables control group ocp group p value valid age (years) (20 – 45) 32.9 ± 5.5 (20 – 45) 31.4 ± 6.8 0.38 cct 541.8 ± 31.39 (480-625) 518.7 ± 36.7 (430 – 572) 0.004 iop 14.4 ± 2.8 (9.7 – 21.4) 14.5 ± 2.6 (9.2 – 21.1) 0.86 ocp = oral contraceptive pills cct = central corneal thickness iop = intraocular pressure discussion many studies have been done to see the possible association between central corneal thickness and the levels of hormones throughout oral contraceptive pills use in young females. 7,8 recent study suggested that an increase has been noted in the use of contraceptive pills for contraception in females of reproductive age group 9,10 . in this study, our findings revealed that cct values were significantly higher in patients with ocp use. ocp use is not only associated with drastic ocular diseases like retinal vascular occlusions but there are other studies showing that the central corneal thickness and intraocular pressure were also affected by the use of ocp 11,12 . oral contraceptive pills affect the central corneal thickness and intraocular pressure which erroneously make these females as glaucoma suspects 13 . the duration of ocp use is also an important factor. however, the american academy of ophthalmology, in new orleans, came out with a research stating that women having these pills for three years or more are facing double the risk of developing glaucoma, which is one of the leading causes of blindness. contrary to that, a recent study in pakistan indicated that ocp even if used for six months to one year causes a statistically significant increase in iop (although not clinically significant) 14 . iqbal s, et al 31 pakistan journal of ophthalmology, 2020, vol. 36 (1): 29-32 the central corneal thickness appears to increase around ovulation until the completion of menstrual cycle. the central corneal thickness changes in the midst of the menstrual cycle as the cornea is most thin toward the beginning of the cycle and thickest toward the end 15,16 . this can be attributed to the presence of estrogen receptors in human corneas. 17 in another study, cornea seemed to be thickest either at the beginning or the end of the menstrual cycle because of the variation in ovarian and gonadotropin hormones 18 . although oral contraceptive use does not appear to increase the risk of eye diseases such as conjunctivitis, keratitis, iritis, lacrimal disease, strabismus, cataract, glaucoma and retinal detachment but there is some evidence that ocp use was found to be a risk factor for retinal vascular occlusion in invitro fertilization patients 19 . hormonal changes occurring regularly during gestation may also have a severe impact on the progression of keratoconus 20 . hence, females using ocp must be warned of the possible complications of these medicines and cct must be considered while measuring iop in these patients. conclusion our findings revealed that central corneal thickness values were significantly higher in patients using ocps. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest authors’ designation and contribution samia iqbal; doctor of optometry: study design, data collection, analysis, manuscript writing and final review. khizar bashir; head of department, optometry and vision sciences: data collection, analysis and final review. minahal mateen: medical officer: study design and final review. mateen amir; professor of ophthalmology: study design and final review. iftikhar ahmad; assistant professor: study design and final review. references 1. wong ac, wong cc, yuen ns, hui sp. correlational study of central corneal thickness measurements on hong kong chinese using optical coherence tomography, orbscan and ultrasound pachymetry. eye (lond), 2002; 16 (6): 715–21. 2. ondas o, keles s. central corneal thickness in patients with atopic keratoconjunctivitis. med sci monit. 2014; 20: 1687–90. doi:10.12659/msm.890825. 3. daniels k, daugherty j, jones j. current contraceptive status among women aged 15-44: united states, 2011-2013. nchs data brief. 2014; 173: 1–8. 4. vessey mp, hannaford p, mant j, painter r, frith p, chappel d. oral contraception and eye disease: findings in two large cohort studies. br j ophthalmol. 1998; 82 (5): 538–42. 5. kawase k, tomidokoro a, araie m, iwase a, yamamoto t. tajimi study group; japan glaucoma society. ocular and systemic factors related to intraocular pressure in japanese adults: the tajimi study. br j ophthalmol. 2008; 92 (9): 1175–9. 6. su dh, wong ty, foster pj, tay wt, saw sm, aung t. central corneal thickness and its associations with ocular and systemic factors: the singapore malay eye study. am j ophthalmol. 2009; 147 (4): 709– 716.e1. 7. westhoff cl, torgal ah, mayeda er, stanczyk fz, lerner jp, benn ek, et al. ovarian suppression in normal-weight and obese women during oral contraceptive use: a randomized controlled trial. obstet gynecol. 2010; 116 (2 pt 1): 275–83. 8. leske mc, heijl a, hyman l, bengtsson b, dong l, yang z. emgt group. predictors of long-term progression in the early manifest glaucoma trial. ophthalmology, 2007; 114 (11): 1965–72. 9. giuffrè g, di rosa l, fiorino f, bubella dm, lodato g. variations in central corneal thickness during the menstrual cycle in women. cornea, 2007; 26 (2): 144–6. 10. soni ps. effects of oral contraceptive steroids on the thickness of human cornea. am j optom physiol opt. 1980; 57 (11): 825–34. 11. stojanov o, stokic e, sveljo o, naumovic n. the influence of retrobulbar adipose tissue volume upon intraocular pressure in obesity. vojnosanit pregl. 2013; 70 (5): 469–76. 12. mori k, ando f, nomura h, sato y, shimokata h. relationship between intraocular pressure and obesity in japan. int j epidemiol. 2000; 29 (4): 661–6. 13. zafra pérez jj, villegas pérez mp, canteras jordana m, miralles de imperial j. intraocular central corneal thickness in females using oral contraceptive pills pakistan journal of ophthalmology, 2020, vol. 36 (1): 29-32 32 pressure and prevalence of occult glaucoma in a village of murcia. arch soc esp oftalmol. 2000; 75 (3): 171– 8. 14. malik tg, nadeem h, ayesha e, alam r. effect of short-term use of oral contraceptive pills on intraocular pressure. pak j ophthalmol 2019; 35 (3): 184-87. doi: https://doi.org/10.36351/pjo.v35i3.966. 15. sen e, onaran y, nalcacioglu-yuksekkaya p, elgin u, ozturk f. corneal biomechanical parameters during pregnancy. eur j ophthalmol. 2014; 24(3): 314–9. 16. abramov y, borik s, yahalom c, fatum m, avgil g, brzezinski a, et al. does postmenopausal hormone replacement therapy affect intraocular pressure? j glaucoma, 2005; 14 (4): 271–5. 17. dong sy, si yb, zhang yy, zhao gm. risk factors analysis of primary open angle glaucoma in women. zhonghua yan ke za zhi. 2013; 49 (2): 122–5. 18. paterson gd, miller sj. hormonal influence in simple glaucoma. a preliminary report. br j ophthalmol. 1963; 47: 129–37. 19. kass ma, sears ml. hormonal regulation of intraocular pressure. surv ophthalmol. 1977; 22 (3): 153–76. 20. aggarwal rs, mishra vv, aggarwal sv. oral contraceptive pills: a risk factor for retinal vascular occlusion in in-vitro fertilization patients. j hum reprod sci. 2013; 6 (1): 79–81. .…  …. https://doi.org/10.36351/pjo.v35i3.966 microsoft word tayyab afghani case reports.doc 230 case report death from diamox: three case reports tayyab afghani, sultan asif kiani, m abdul moqeet khan pak j ophthalmol 2007, vol. 23, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyab afghani director projects and publications consultant ophthalmologist in orbit and oculoplastics al-shifa trust eye hospital jhelum road, rawalpindi received for publication may’2007 …..……………………….. iamox –acetazolamide is an inhibitor of enzyme carbonic anhydrase and a nonbacteriostatic sulfonamide. it is widely used in ophthalmic practice to prevent and control abnormal rise in intra-ocular pressure in glaucoma, pre-operative prophylaxis in intra-ocular surgery, prophylaxis after yag laser, cystoid macular edema and retinal arterial occlusion etc. it is also used in nonophthalmic practice like acute mountain sickness1, peptic ulcer2, idiopathic intracranial hypertension in pregnancy3, chronic hydrocephalus4, epilepsy5, obstructive sleep apnea6 etc. diamox is not without its adverse reactions7-11. common side effects include parasthesias and git disturbances, while occasional side effects are transient myopia, photosensitivity, urticaria, melena / hematuria etc. diamox has certain rare but fatal complications as well which include steven johnson syndrome, erythema multiforme, toxic epidermal necrolysis, metabolic acidosis, anaphylaxis, acute delirium and depression. we report three cases, where use of diamox in an eye care setup proved fatal. the practice of pre-op diamox in cataract surgery has since been stopped at al-shifa. case reports case one, march 2004 a 60 years old male was admitted for cataract surgery at pakistan institute of medical science (pims) islamabad. routine systemic exam & lab profile was normal. pre-op 500 mg of diamox was given. patient got restless on the morning of the operation and complained of increased micturition. in the ward, located on the first floor patient looked confused and lost. he went to toilet and “walked out” of window and died of head injury. case two – january 2006 a 65 years old female admitted for cataract surgery at al-shifa trust eye hospital, rawalpindi. routine systemic exam & lab profile was normal. pre-op 500 mg of diamox was given. patient got restless on operation table and surgery was postponed. in the d 231 ward, located on the first floor patient looked confused and lost. he “walked out” of window and died of head injury. case three – july 2006 a 60 years old male underwent uneventful cataract surgery at al-shifa trust eye hospital. patient got restless afterwards in the ward, looked confused and lost. the patient then attempted to “go out” of ward windows but was restrained by the ward staff. patient recovered over night and was discharged without any complication. discussion in all three cases, the abnormal behavior of the patients was a result of delirium or acute confusional state as a rare adverse reaction of diamox. delirium12 is defined as disturbance of consciousness or reduced clarity of awareness of the environment and occurs along with reduced ability to focus, sustain, or shift attention. there is a change in cognition (e.g., memory deficit, disorientation, language disturbance, perceptual disturbance). 14-56% of hospitalized elderly patients (10-22% at admission: and additional 10-30% of cases after admission) may develop delirium13. post-op delirium in general is 5-10% and as high as 42% following orthopedic surgery14. mortality from delirium has been reported from 22-76%15. delirium develops over a short period (hours to days) and tends to fluctuate during the course of the day12. almost any medical illness, intoxication, or medication can cause delirium. mostly multi-factorial, medications are the most common reversible cause of delirium15. in studies of elderly hospital patients, drugs have been reported as the cause of delirium in 11 to 30% of cases16. any drug can cause delirium but the worst offenders are anticholinergics (atropine, tropicamide, etc.), benzodiazepines (diazepam etc.) and tricyclic antidepressants (tofranil etc.)16. delirium in elderly hospital patients is a well recognized phenomenon, but delirium in eye care setting has been reported less often (table 1). anticholinergics and benzodiazepines are the common drugs implicated19-21 and are in common use in eye care setting. other precipitating factors reported in an eye care setting are alcohol restriction17 in heavy drinkers, sensory deprivation due to dark atmosphere of the eye ward and markedly decreased vision18. however diamox delirium has been reported only once and that only in non-ophthalmic literature10. death from delirium in an eye care setting has been reported once before18. it is interesting to note that mechanism of death had been identical to that of our two reported cases. patients walked out of window in a state of altered awareness and disorientation, probably considering the window as an exit or door and died of head injury. it is interesting to note that studies have also shown delirium to be precipitating factors for 10% of falls among older people in residential care facilities22. the mechanism of delirium still is not fully understood23. delirium results from a wide variety of structural or physiological insults. the main hypothesis is reversible impairment of cerebral oxidative metabolism and multiple neurotransmitter abnormalities. the diamox delirium has been attributed to electrolyte imbalance resulting in metabolic acidosis7,10. young patients with normal renal functions have been reported8 to develop metabolic acidosis after treatment for glaucoma and joint pain with a combination of salicylates and carbonic anhydrase inhibitors in normal doses. carbonic anhydrase inhibitors appear to interact with salicylates to produce serious metabolic acidosis in patients without the predisposing factors generally considered to constitute risks. that is why it is recommended that treatment combining salicylates and carbonic anhydrase inhibitors is either kept to a minimum or avoided8. when delirium is diagnosed or suspected, the underlying causes should be sought. despite every effort, no cause for delirium can be found in approximately 16% of patients12. components of delirium management include supportive therapy and pharmacological management24. fluid and nutrition should be given carefully because the patient may be unwilling or physically unable to maintain a balanced intake. for the patient suspected of having alcohol toxicity or alcohol withdrawal, therapy should include multivitamins, especially thiamine. environmental modifications including reorientation techniques or memory cues such as a calendar, clocks, and family photos may be helpful. the environment should be stable, quiet, and well-lighted. support from a familiar nurse and family should be encouraged. family members and staff should explain proceedings at every opportunity, reinforce orientation, and reassure the patient. sensory deficits should be corrected, if necessary, with eyeglasses and hearing aids. physical restraints should be avoided. delirious patients may 232 pull out intravenous lines, climb out of bed, and may not be compliant. perceptual problems lead to agitation, fear, combative behavior, and wandering. severely delirious patients benefit from constant observation (sitters), which may be cost effective for these patients and help avoid the use of physical restraints. these patients should never be left alone or unattended. recommendations 1. the incidence of delirium in an eye care set-up requires greater awareness, possible changes in pre-medication, and a longer observation period in the very old. 2. avoid poly-pharmacy and follow the principle of ‘start low and go slow’. it is worth mentioning that use of diamox in patients already using aspirin may be disastrous due to precipitation of metabolic acidosis. 3. the concept of diamox as a pre-medication in cataract surgery needs to be freshly looked into. 63% of surgeons do not use any iop lowering agents in uk25. single topical doses of timolol gel or latanoprost / travoprost have been found to be equally effective as replacement of pre-operative diamox26. 4. the concept of day care surgery in eye units must be promoted. an early return to familiar, more illuminant atmosphere at home from the dark, chilly and unfamiliar atmosphere of hospital indoors will significantly reduce the risk of delirium in elderly patients. table 1: delirium in an eye care setting year ref. no total patients studied no. with delirium precipitating factor out-come 1902 17 single one alcohol restriction lost eye 1916 18 not mentioned many sensory deprivation 2 died/fall 1977 10 single single diamox safe 1979 19 27 2 anticholinergic safe 1993 11 three 3 not mentioned safe 1994 20 350 6 (1.7%) anticholinergic safe 2002 21 296 13 (4.4%) benzodiazepines and age safe 2006 current three three diamox 2 died/fall author’s affiliation dr. tayyab afghani consultant ophthalmologist orbit and oculoplastics al-shifa trust eye hospital jhelum road, rawalpindi dr. sultan asif kiani consultant ophthalmologist orbit and oculoplastics al-shifa trust eye hospital jhelum road, rawalpindi dr. m. abdul moqeet khan department of cornea and refractive surgery al-shifa trust eye hospital jhelum road, rawalpindi reference 1. carlsten c, swenson er, ruoss s. a dose-response study of acetazolamide for acute mountain sickness prophylaxis in vacationing tourists at 12,000 feet (3630 m). high alt med biol. 2004; 5: 33-9. 2. shahidzadeh r, opekun a, shiotani a, et al. effect of the carbonic anhydrase inhibitor, acetazolamide, on helicobacter pylori infection in vivo: a pilot study. helicobacter. 2005; 10: 136-8. 3. lee ag, pless m, falardeau j, et al. the use of acetazolamide in idiopathic intracranial hypertension during pregnancy. am j ophthalmol. 2005; 139: 855-9. 4. garcia-gasco p, salame gamarra f, tenllado doblas p. complete resolution of chronic hydrocephalus of adult with acetazolamide. med clin (barc). 2005; 124: 516-7. 5. mihaly a, bencsik k, nogradi a. pharmacological inhibition of brain carbonic anhydrase protects against 4-aminopyridine seizures. acta physiol hung. 1994; 82: 99-108. 6. tojima h, kunitomo f, kimura h, et al. effects of acetazolamide in patients with the sleep apnoea syndrome. thorax. 1988; 43: 113-9. 233 7. epstein dl, grant wm. carbonic anhydrase inhibitor side effects. serum chemical analysis. arch ophthalmol. 1977; 95: 1378-82. 8. cowan ra, hartnell gg, lowdell cp, et al. metabolic acidosis induced by carbonic anhydrase inhibitors and salicylates in patients with normal renal function. br med j (clin res ed). 1984; 289: 347-8. 9. kodjikian l, durand b, burillon c, et al. acetazolamideinduced thrombocytopenia. arch ophthalmol. 2004;122:1543-4. 10. rowe to. acetazolamide delirium. letter to the editor: am j psychiatry. 1977; 134: 587-8. 11. sekimoto m, hayasaka s, noda s, et al. psychiatric complications after ocular surgery. ophthalmologica. 1993; 206: 113-4. 12. alagiakrishnan k, wiens ca. an approach to drug induced delirium in the elderly. postgrad med j. 2004; 80: 388-93. 13. rigney ts. delirium in the hospitalized elder and recommendations for practice. geriatr nurs. 2006; 27: 151-7. 14. o’keeffe st, ni chonchubhair a. postoperative delirium in the elderly. br j anaesth. 1994; 73: 673-87. 15. inouye sk, charpentier pa. precipitating factors for delirium in hospitalized elderly persons. predictive model and interrelationship with baseline vulnerability. jama 1996; 275: 852-7. 16. lipowski zj. delirium (acute confusional states). jama 1987; 258: 1789-92. 17. pooley tr. two unusual complications following cataract extraction, (i) death, after cataract extraction, from diabetes, (2) delirium tremens following extraction of cataract . trans am ophthalmol soc. 1902; 9: 518-25. 18. bruns hd. the ambulant after-treatment of cataract extraction; with a note on post-operative delirium and on striped keratitis. trans am ophthalmol soc. 1916; 14: 473-82. 19. summers wk, reich tc. delirium after cataract surgery: review and two cases. am j psychiatry. 1979; 136: 386-91. 20. chaudhuri s, mahar rs, gurunadh vs. delirium after cataract extraction: a prospective study. j indian med assoc. 1994; 92: 268-9. 21. milstein a, pollack a, kleinman g, et al. confusion/delirium following cataract surgery: an incidence study of 1-year duration. int psychogeriatr. 2002; 14: 301-6. 22. kallin k, jensen j, olsson ll, et al. why the elderly fall in residential care facilities, and suggested remedies. j fam pract. 2004; 53: 41-52. 23. inouye sk. the dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. am j med. 1994; 97: 278-88. 24. inouye sk, bogardus st, charpentier pa, et al. a multicomponent intervention to prevent delirium in hospitalized older patients. n engl j med. 1999; 340: 669-76. 25. zamwar u, dillon b. postoperative iop prophylaxis practice following uncomplicated cataract surgery: a uk-wide consultant survey. ophthalmol. 2005; 5: 24. 26. arici mk, erdogan h, toker i, et al. the effect of latanoprost, bimatoprost, and travoprost on intraocular pressure after cataract surgery. j ocul pharmacol ther. 2006; 22: 34-40. pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 294 author communication a curious orbital lesion in a young girl saba alkhairy pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. saba alkhairy mbbs, fcps consultant ophthalmic surgeon email: saba.alkhairy1@gmail.com …..……………………….. a 15-year old girl presented with a slow growing mass in the orbit with normal visual acuity. we followed the patient for a year and closely observed the increase in size of the mass for over a year both clinically and radiologically. the mass grew gradually with no effect on her visual acuity, which was 6/6 in both eyes using snellen chart; pupillary reactions were normal with no afferent papillary defect and her extraocular movements were full. her anterior segment and posterior segment of the eye including the optic disc and macula and the intraocular pressure remained within normal limits. we removed the mass surgically on the request of the patient, as the mass had caused significant disfigurement. it was a multidisciplinary approach by an ent and an eye surgeon for the effective and complete removal of the lesion. we did a frontal orbitotomy under general anesthesia and the mass recovered was sent for biopsy. the biopsy report concluded the mass to be juvenile psammomatoid ossifying fibroma. key words: orbit, psammomatoid ossifying fibroma, frontal orbitotomy. extraconal orbital tumors in children exhibit both a diagnostic and radiological challenge to the ophthalmologists. the orbital tumors or lesions in children can present as hematological malformations such as hemangiomas and lymphangiomas. orbital varix however are found in an older age group and tend to present with intermittent proptosis; size of the lesion increasing on valsalva maneuver. other primary tumors include fibrous dysplasia, rhabdomyosarcoma, and optic nerve glioma. rhabdomyosarcoma is the most common mesenchymal neoplasm of orbit in children.1 metastatic tumors include neuroblastoma, wilm’s and ewing’s sarcoma. inflammatory lesions include pseudotumor and myositis. dermoid cyst may also present both in a pediatric as well as the adult population. a differential diagnosis of a rapidly growing proptosis may also be infectious conditions such as orbital cellulitis. clinical presentation combined with the characteristic imaging features of the disease can narrow the differential diagnoses. imaging modalities most often used to examine these masses include b scan ultrasound, computed tomography (ct), and magnetic resonance imaging (mri) especially for lesions involving the optic nerve and orbital apex2. case study a 15-year old girl presented with painless proptosis of right eye for the past one year (figure 1). she denied any history of increase in proptosis on bending, any history of trauma, any visual obscurations or any associated headache, nausea or vomiting. she did not have fever and had no systemic symptoms either such as loss of appetite, weight loss, lethargy, bone pain etc. on examination, her right eye was proposed with a measurement of 24 mm by hertel exophthalmometer while left eye was 21 mm. anterior segment was normal with no corneal edema, no chemosis or no dilated and tortuous vessels on the conjunctiva. the pupillary reactions were normal with no relative afferent pupillary defect. posterior segment was normal in both eyes with normal disc and macula and no choroidal folds or disc/macular edema. her extra ocular movements were normal and she had intra ocular pressure of 15 mm hg in both eyes. on palpation, no mass was palpable and no thrill was saba alkhairy 295 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol noted. the preauricular and submandibular lymph nodes were not enlarged and were normal on palpation. fig. 1: right eye proptosis. ct scan imaging revealed a lobulated peripherally enhancing mass involving the right orbital roof causing significant bony expansion. it measured 3.8 x 3.2 × 4.9 cm. it had caused effacement of posterior ethmoidal cells with intra orbital extraconal extension causing compression and displacement of right superior and medial recti resulting in proptosis of globe (figure 2 and figure 3). fig. 2 & 3: axial and coronal ct scans of patient with contrast showing an enhancing lesion causing downward globe displacement and occupying the frontal sinus and almost all of the orbital region. a combined orbital and ent surgery was performed on the patient under general anesthesia. an fig. 4: frontal orbitotomy with incision made just beneath the eyebrow along its whole length. incision was made just beneath the eyebrow along its length to gain access to the superior orbit and the frontoethmoidal region. soft tissue was dissected until the periosteum was reached which was divided with no. 11 scalpel blade. the periosteum was separated from the underlying bone with a freer periosteum elevator. frontal osteotomy was done using a round fluted burr (figure 4). this allowed an entry to the supra orbital space and the mass was identified and removed piece meal from the orbital, frontal and ethmoidal region and was found to be pink fleshy and firm in consistency (figure 5). the mass was sent for biopsy. the wound was closed in 3 layers: the periosteum and muscles with vicryl 6/0 and the skin with prolene 5/0 interrupted sutures. a redivac drain was also placed in the wound and was removed after 24 hours as the fluid collected was 30 ml only. patient was given oral broad spectrum antibiotics and steroids and an antibacterial ointment for topical use for 10 days. skin sutures were removed after 8 days. histological analysis revealed the mass to be composed of fibroblastic cells arranged in sheets with prominent psammomatous bodies, favouring juvenile psammomatous ossifying fibroma. a curious orbital lesion in a young girl pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 296 fig. 5: fleshy mass excised from the orbit piece meal and sent for histological analysis. fig. 6: photomicrograph: showing numerous spindleshaped cells arranged in fascicular storiform pattern (asterix) with irregular strands of trabeculae with plump osteoblast, spheroidal ossicles with basophilic center and eosinophilic periphery resembling psammoma-like bodies (arrow). h & e × 40 × 7. discussion ossifying fibroma (of) is a benign tumor of bone that has the tendency for aggressive growth, bony destruction, and potential for regrowth3. juvenile ossifying fibroma (jof) is an atypical lesion that can be differentiated from other types of ossifying fibromas on the basis of age of presentation, common location and their aggressive growth3. it may exhibit vigorous growth and has a problem of recurrence4. mofty explained that there are two different histological types, trabecular juvenile ossifying fibroma and psammomatous ossifying fibroma, based on their histological appearance and their tendency to occur in a particular age. they are commonly found during the age of 8.5-12 years and 16-33 years. the former representing the trabecular juvenile ossifying fibroma and the latter representing the psammomatous subtype5. the word “psammoma” is from a greek word “psammos” which means “sand”6. psammoma-like bodies are seen to have a dark border of lucent particles from which small slender sharp pointed bodies and needle-like crystalloids emanating toward the outer edge7. treatment of juvenille psammomatous ossifying fibroma consists of complete surgical excision of the lesion as an inadequate excision may pose a problem with the mass reccurring locally8,9,10. acknowledgements the author wishes to thank dr prof tariq rafi for being the major contributor to the case. financial support nil. conflict of interest none references 1. rodrigues m, tostes v, caran em, camargo m, camargo mv, silva fa. differential diagnosis of orbital tumors in children. int j radiol radiat ther. 2017; 3 (4): 252-256. 2. rao aa, naheedy jh, chen jy, robbins sl, ramkumar hl. a clinical update and radiologic review of pediatric orbital and ocular tumors. j oncol. 2013;2013:975908. doi: 10.1155/2013/975908. epub 2013 mar 12. 3. regezi ja, sciubba jj, jordan rck. oral pathology – clinical pathologic correlations. 5th ed. india: elsevier publishers, 2009: p. 283. 4. neville bw, damm dd, allen cm, bouquot je. oral and maxillofacial pathology 3rd ed. india: elsevier publishers, 2009: p. 648. https://www.hindawi.com/58645692/ https://www.hindawi.com/58645692/ https://www.hindawi.com/58645692/ https://www.hindawi.com/58645692/ https://www.hindawi.com/58645692/ https://www.hindawi.com/58645692/ saba alkhairy 297 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol 5. thankappan s, nair s, thomas v, sharafudeen kp. psammomatoid and trabecular variants of juvenile ossifying fibroma. indian j radiol imaging, 2009; 19: 116–9. 6. nwizu nn, george md, chen f. an aggressive psammomatoid ossifying fibroma presenting as a sphenoethmoidal mass. n am j med sci. 2010; 3: 24–27. 7. prabhu j, nagaraj v, mukhtar a. juvenile psammomatoid ossifying fibroma (jpof) of proximal radius: a rare entity. open orthop. j. 2017; 11: 583-588. 8. smith sf, newman l, walker dm, papadopoulos h. juvenile aggressive psammomatoid ossifying fibroma: an interesting, challenging, and unusual case report and review of the literature. j oral maxillofac surg. 2009; 67: 200–6. 9. marx re, stern d. carol stream, il. quintessence publishing co inc. fibro-osseous diseases and systemic diseases affecting bone, in: oral and maxillofacial pathology: a rationale for diagnosis and treatment, 2003: p. 781. 10. zhang zy, min mp, liu y, jiang hq, zhang j. a large psammomatoid ossifying fibroma with proptosis: a case report. mol clin oncol. 2017; 6 (2): 167-69. author’s affiliation dr. saba alkhairy, mbbs, fcps consultant ophthalmic surgeon author’s contribution dr. saba alkhairy treating physician. preparing of manuscript. literature search. final review. microsoft word rasheed qamar 2.doc 77 original article phacomorphic glaucoma: an easy approach abdul rasheed qamar pak j ophthalmol 2007, vol. 23 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: abdul rasheed qamar assoc. prof. of ophthalmology university college of medicine 1-km raiwind road, lahore received for publication april’2006 …..……………………….. purpose: to study an alternative method to reduce intraocular pressure in phacomorphic glaucoma at the time of cataract extraction. design: this is a prospective interventional study from clinical practice. material and method: in 18 patients of phacomorphic glaucoma a modified controlled paracentesis was performed to decrease the intraocular pressure. results: in all the patients the intraocular pressure was reduced, so that the cataract extraction could be performed immediately after the modified paracentesis. hacomorphic glaucoma is more common in developing countries1. many patients first time consult for treatment when they have already developed phacomorphic glaucoma. for example in a study in india 3.91% of the cataract patients reported with phacomorphic glaucoma2. this is partly because of the reason that most of the patients through centuries of tradition feel that a mature cataract is the proper stage for the cataract operation3. however when phacomorphic glaucoma has developed most of these patients are forced to report immediately because of the pain and sudden loss of vision4. at this stage of the disease the treatment essentially consists of two steps. 1. to reduce intraocular pressure 2. cataract surgery. the intraocular pressure is usually reduced medically5 but some of the authors have reported successful results with neodymium –yag laser irodotomy3. the medical treatment normally consists of: 1. acetazolamide 500mg by intravenous injection. 2. glycerine 1-1.5 g / kg body weight. 3. 20% mannitol infusion. 1-2gm / kg body weight. however medical treatment is uncomfortable, time consuming and not always successful. materials and methods in a prospective interventional case series of 18 patients, between 2003 to 2005, i have used controlled paracentesis to reduce the intraocular pressure immediately before cataract extraction. procedure patients are prepared as for normal cataract extraction. however because postoperative inflammatory response is more common in these patients, intense topical steroids are administered preoperatively. it is better not to operate under topical anesthesia because the eye with phacomorphic glaucoma is very sensitive and the patient is usually apprehensive. with a no. 11 blade a small nick is made on “clear cornea” about half thickness of the cornea. i being right handed make this nick superotemporally in the right eye and superonasally in the left eye. a disposable insulin syringe with attached fixed 27 gauge needle is taken. the plunger should not be p 78 pulled back. the needle is gradually inserted into the anterior chamber at the site of the nick with its bevel anteriorly to avoid occlusion by the iris. when the tip of the needle has just entered the anterior chamber, index finger is placed at the back of the plunger to avoid a gush of aqueous into the syringe (fig 1). fig. 1: the insulin syringe is used to remove the aqueous from the anterior chamber. normally there is very high pressure in the anterior chamber (large arrow). to prevent sudden gush of aqueous a counterforce is applied on the plunger of the syringe (small arrow). this counter force is then very slowly released to allow aqueous into the syringe. now the pressure on the plunger with the index finger is gradually released to allow the influx of the aqueous into the syringe. when 0.3 to 0.5 ml of aqueous has entered the syringe the cornea starts clearing. the iop can be assessed by indenting the cornea with a blunt instrument. normally no suction force is required. however if the pressure in not considered satisfactory the tip of the needle with its bevel still anterior should be taken close to the pupil and very slight suction applied to remove the aqueous trapped behind the iris. once iop is considered to be satisfactory, the syringe is removed. now the cataract extraction can be completed in a usual manner. i performed phacoemulsification in all cases. because the iris is already inflamed, a bold peripheral iridectomy is a must at the end of the procedure. if cataract is removed with phacoemulsification, iridectomy is difficult because of the tunnel incision. in this case a separate small incision should be made for the iridectomy. i don’t stitch this incision. results in all the patients, the iop was reduced sufficiently to make the cornea clear and immediately proceed with the cataract extraction. four of my patients had complications which are not directly related with the procedure to reduce iop. they are as follows: posterior capsule rupture 1 patient fibrinous exudate in ac 4 patients postoperative glaucoma 2 patients discussion the ultimate treatment of phacomorphic glaucoma is the cataract extraction7. control of intraocular pressure which is usually very high in these cases, is a prerequisite of surgery. normally intraocular pressure is reduced medically5, but it is time consuming and unpredictable. the nausea and vomiting which is associated with the medical treatment adds to the miseries of a patient who is already in agony. moreover in certain situations it is not possible to wait for the medical treatment to be effective, like when the patient is already too late or when operating a very heavy list of an eye camp. the intraocular pressure in these patients should be brought down very gradually otherwise there is a risk of expulsive hemorrhage. so any uncontrolled paracentesis is dangerous. the procedure i have described is only a modified controlled paracentesis in true sense. in fact the crux of the procedure is the slowness. the surgery in phacomorphic glaucoma is associated with more complications than surgery in normal cataract7. fibrinous exudate in ac is one of the most common complication reported in literature5,7. in spite of the fact that intense topical steroids were administered preoperatively 4 of my patients developed fibrinous exudates which were then treated by systemic steroids. i don’t like subconjunctival or subtenon injections in these patients because the eyes are very sensitive and systemic steroids are more effective for fibrinous exudates in anterior chamber as the basic cause is the broken blood aqueous barrier. two patients developed post-operative glaucoma. this was controlled medically. gonioscopy showed that angle was open and there was heavy pigmentation of the trabecular meshwork. i am not sure this was because of initial inflammatory process 79 or developed because of apposition of the iris with angle structures during pre-operative period. i performed phacoemulsification in all patients. phacoemulsification was easy in these soft cortical cataracts. however i feel extracapsular or even intracapsular cataract extraction can also be performed in usual manner once the iop is controlled. conclusion in conclusion it is recommended not to waste time in medically reducing the intraocular pressure in phacomorphic glaucoma. the intraocular pressure can be controlled reliably by the controlled paracentesis described. the patient should be straightway taken to the operation theatre and intraocular pressure reduced intraoperatively. author’s affiliation abdul rasheed qamar associate professor of ophthalmology university college of medicine 1-km raiwind road, lahore reference 1. kanski jj. butterworthheineman 4th edition, 1999; 229. 2. angra sk, pradhan r. cataract induced glaucoma an insight into management. indian j ophthalmol. 1991; 39: 97–101. 3. tomey kf, al-rajhi aa. neodymium: yag laser iridotomy in the initial management of phacomorphic glaucoma. ophthalmology. 1992; 99: 660–5. 4. krishnadas r, ramakrishnan r. secondary glaucomas: the tasks ahead community eye health. 2001; 14: 40-2. 5. mckibbin m, gupta a, atkins ad. cataract extraction and intraocular lens implantation in eyes with phacomorphic or phacolytic glaucoma. j cataract refract surg. 1996; 22: 633-6. 6. gressel mg. lens-induced glaucoma. in: tasman w, jaeger e, eds. duane’s clinical ophthalmology. 5th ed. philadelphia: lippincott williams & wilkins. 1998: 554. 7. johnson cn. heparin prophylaxis for intraocular fibrin. ophthamology. 1987; 94: 597– 601. in glaucoma target iop is considered that pressure where further optic nerve damage is unlikely. recommended level of target iop is below 13mm of hg. prof. m lateef chaudhry pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 191 editorial integrated ophthalmic trauma units: adopting an orphan discipline in ophthalmology rupesh agrawal, sundaram natarajan, gangadhara sundar pak j ophthalmol 2016, vol. 32 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cular and ophthalmic trauma has increased tremendously in this world of modernization due to road traffic accidents and many other day to day mishaps. the world health organisation (who) had reported an annual occurrence of approximately 55 million eye injuries with incapacitation for more than one day. there are more than 1.6 million blind people secondary to ocular trauma with an additional 2.3 million having bilateral visual morbidity. 19 million people experience unilateral blindness or low vision from preventable injury1. moreover, there is a global annual incidence rate of 3.5 open globe injuries per 100,000 persons, resulting in approximately 203,000 open globe injuries annually worldwide2. globally, males are more prone to sustain open globe injuries (80%) than females, most commonly from projectile objects at work or home settings, while females and elderly patients are more likely to experience globe rupture, most often from falls. generally, work-related injuries result from foreign matter striking or being rubbed into the eye, and hence, manual labourers in production industries are most at risk. other mechanisms of injury include assault, sports, traffic accidents, fireworks and gunshot wounds. the majority of intraocular foreign bodies (iofb) are small projectiles from metal and glass3-5. a similar demographic pattern is seen in children– the majority of them being boys aged 3 – 6 years experiencing pointed metallic objects such as scissors, knives, writing instruments at home or school settings. other causative objects include wooden objects, toys, fire crackers. scenes of injury include streets, daycare centres and playgrounds6-8. predisposing and associated factors to globe rupture include rural residence, alcohol consumption, cigarette smoking, previous ocular procedures such as cataract surgery, penetrating keratoplasty and lasik (laser-assisted in situ keratomileusis) 9-12. ocular trauma thus has a significant socioeconomic impact on the individual, family and society in general. in the era of super specialization where we are uncomfortable managing disorders outside our ophthalmic sub-specialty, it is imperative that we as ophthalmologists and even nonophthalmologists are formally trained in the emergency and primary management of ocular trauma before referral to an appropriate institution with specialist for advanced management. trauma thus cuts across all specialties where broad principles with specific practice patterns should be enforced. ocular trauma is an important component of ophthalmic trauma. ophthalmic trauma is a term hardly if ever used in literature, but in its true sense constitutes both ocular and adnexal trauma. while the literature is rife with terminology in ocular trauma, adnexal trauma is often not taken into consideration as they are poorly addressed by the ophthalmologist and sometimes delegated to non-ophthalmic specialties. we would therefore like to propose use of the term ophthalmic trauma in lieu of ocular trauma to encompass all aspects of trauma that involve the globe and the surrounding adnexal tissue. the asia pacific ophthalmic trauma society (apots) was thus constituted to promote the awareness about ophthalmic trauma in the asia-pacific region, where the incidence of ophthalmic trauma is significantly higher. rest of the editorial will particularly emphasize on use of term “ophthalmic trauma”. o rupesh agrawal, et al 192 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology optimal care of a patient with ophthalmic trauma is only possible if there is a well-orchestrated team and care system to manage complex ocular and adnexal injuries. we herewith propose an integrated pathway and care design to optimize outcome in a patient with ophthalmic trauma. an interesting and poorly acknowledged entity is iatrogenic ocular and adnexal injury which constitutes a significant cause of morbidity caused and managed by the ophthalmologist and other related head and neck surgical specialties. “iatrogenic trauma” constitutes all the postoperative surgical cases with surgically induced trauma and poorly managed open globe injury cases. most scientific ophthalmic conferences appear to address the various intraoperative complications and their management, without addressing them as „iatrogenic ophthalmic trauma‟. dineen et al reported >12% of blindness due to the sequelae of cataract surgery constituting iatrogenic (surgical) and avoidable trauma13. the model proposed below is about strategic planning of the existing resources available at tertiary eye care centres. with the kind of polytrauma load handled by all the tertiary eye care hospitals, heads of all the tertiary eye care institutes/hospitals should set the tone for exclusive dedicated ophthalmic trauma centres. these centres will not only serve the patients and community but can also impart training to young ophthalmologists and physicians from accident and emergency departments in the field of ophthalmic trauma. we propose that dedicated ophthalmic trauma specialist team will triage, work up & manage all the patients with history of ophthalmic trauma and will subsequently manage the complex cases with help of their subspecialty colleagues (vitreo-retina, cornea, glaucoma, vitreo-retinal, oculoplasty and neuroophthalmology colleagues). complex adnexal trauma involving the upper and mid face may also benefit from collaboration between the ophthalmologist / oculoplastic surgeon and craniomaxillofacial teams. distinct role of ophthalmic trauma care unit: 1. streamlining, triaging the patients with ophthalmic trauma. 2. emergency attendance and management of patients with ophthalmic trauma. adopt strict guidelines including do's & don'ts. 3. sharing/reducing the work-load of other subspecialty colleagues. 4. improving the quality of care and monitoring outcomes of ophthalmic trauma patients. 5. database for research, which will help propose guidelines for prevention of ocular and adnexal trauma to reduce the incidence of preventable ophthalmic trauma. 6. central office for ophthalmic trauma registry. 7. impart training and fellowship to young ophthalmologists and emergency room physicians. 8. conduct public forum / cme for awareness about ophthalmic trauma 9. foster collaboration and ties in field of ophthalmic trauma between national and international organizations and societies of related surgical subspecialties. all the above listed objectives can be attained by setting the proposed ophthalmic trauma care centres at the internationally established tertiary eye and multispecialty institutions. we suggest that the proposed dedicated ophthalmic trauma care units can seek guidance and collaborate with national, regional and international professional societies dedicated to ophthalmic trauma. some of these include the international society of ocular trauma (isot), asia pacific ophthalmic trauma society (apots), american society of ocular trauma (asot), ocular trauma society of india (otsi) and chinese ocular trauma society (cots). working with international organizations will foster knowledge, research and collaboration. as open globe injuries present with management dilemmas with many unresolved controversies, the proposed multidisciplinary dedicated unit can setup guidelines and an algorithmic approach to manage those complex injuries and to prevent ocular morbidity and optimize outcome by preventing iatrogenic trauma. the unit could work in close coordination with primary and secondary care units and will recognize and guide the junior ophthalmologists in management of ophthalmic injuries, thereby aiding streamlining of management of affected patients. we have come a long way in the field of ophthalmology from intracapsular cataract surgery to femtosecond laser assisted surgery and from subjective macular assessment to non-invasive assessment of retinal vasculature using optical coherence tomography angiography. the outcome of globe injuries have improved with better understanding of complications and improvement in surgical techniques. despite numerous advances in integrated ophthalmic trauma units: adopting an orphan discipline in ophthalmology pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 193 technology and knowledge, a considerable number of eyes still end up getting enucleated or eviscerated following unsuccessful primary or secondary surgical repair. factors that lead to such unfortunate outcomes are manifold. 1. ophthalmic trauma is still being managed by the junior most „residents in training‟ with inadequate training and supervision. this results from the fact that ophthalmic traumatology is yet to become an recognized discipline within ophthalmology. 2. inadequate and incomplete evaluation and scoring to assess prognosis often results in acceptance of suboptimal or even poor outcomes. most ophthalmologists are unfamiliar with the terminology of ophthalmic trauma and consider ocular trauma score (ots) purely as just a research tool rather than a great scale for prognostication. 3. poor communication between various disciplines of ophthalmology, and lack of timely referrals to appropriate specialists or higher centres with subspecialty expertise compound the problem. 4. lastly, there are no attempts to maintain an eye injury registry. all of the above can be easily addressed and justified based on scientific and evidence based outcomes, socioeconomic benefits but needs leadership amongst heads of ophthalmic units with political will as well. we can prevent significant ocular morbidity due to this devastating entity. the concept of a traumatic repair and prevention of iatrogenic trauma needs to be ingrained into the strategic planning in ophthalmic trauma management to achieve optimal outcome. specialty training of the fellow ophthalmologists with focused structured training in ophthalmic trauma at one of the recognized centres in each country can be one of the steps forward in optimizing the outcome in afflicted patients and further streamline the care of traumatized eyes. medico-legal litigation can be minimized by good documentation, establishing rapport with the patient and family and following the basic principles in management of ophthalmic trauma. dedicated efforts need to be put in to buildup trauma registry and get the real life epidemiological data on ophthalmic trauma. one of the most neglected parts in ophthalmic trauma is very weak epidemiological data. concentrated efforts should be made by the national societies to mandate the reporting of eyes with all open globe and other severe globe injuries in coordination with one of the international societies of ophthalmic trauma. the epidemiologic data hence generated will guide the regulatory agencies about the impact and burden of this problem and in terms of health economics research will pave the way for boosting-up healthcare policy and resources to prevent this gigantic but preventable cause of blindness. the data generated will also highlight any obvious regional and national causes and safety tools than need to be devised accordingly. in summary, let us, each one of us, recognize, treat and further develop ophthalmic trauma as a distinct subspecialty and become the torch bearers to serve our patients even better. author’s affiliation dr. rupesh agrawal department of ophthalmology, national healthcare group eye institute, tan tock seng hospital, singapore. moorfields eye hospital, nhs foundation trust, london, uk. dr. sundaram natarajan director and chief vitreoretinal surgeon, aditya jyot eye hospital, mumbai, india. dr. gangadhara sundar do, frcs ed, fams diplomate, the american board of ophthalmology head and senior consultant, orbit and oculofacial surgery, national university hospital assistant professor, department of ophthalmology, national university of singapore, singapore. references 1. state of the world sight. international agency for the prevention of blindness, 2010 report. 2. negrel ad, thylefors b. the global impact of eye injuries. ophthalmic epidemiol. 1998; 5 (3): 143-69. 3. koo l, kapadia mk, singh rp, sheridan r, hatton mp. gender differences in etiology and outcome of open globe injuries.j trauma. 2005; 59 (1): 175-8. 4. liu cc, tong jm, li ps, li kk.epidemiology and clinical outcome of intraocular foreign bodies in hong kong: a 13 – year review. int ophthalmol. 2016; apr. 4 [epub ahead of print] 5. williams df, mieler wf, abrams gw, lewis h. results and prognostic factors in penetrating ocular injuries with retained intraocular foreign bodies. ophthalmology, 1988; 95 (7): 911-6. 6. tok o, tok l, ozkaya d, eraslan e, ornek f, bardak y. epidemiological characteristics and visual outcome rupesh agrawal, et al 194 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology after open globe injuries in children. j aapos. 2011; 15 (6): 556-61. 7. rostomian k, thach ab, isfahani a, pakkar a, pakkar r, borchert m.open globe injuries in children. j aapos. 1998; 2 (4): 234-8. 8. gunes a, kalayc m, genc o, ozerturk y. characteristics of open globe injuries in preschool children. pediatr emerg care, 2015; 31 (10): 701-3. 9. sheng i, bauza a, langer p, zarbin m, bhagat n. a 10 – year review of open-globe trauma in elderly patients at an urban hospital. retina. 2015; 35 (1): 105-10. 10. vinger pf, mieler wf, oestreicher jh, easterbrook m. ruptured globes following radial and hexagonal keratotomy surgery. arch ophthalmol. 1996; feb; 114 (2): 129-34. 11. chua d, wong w, lamoureux el, aung t, saw sm, wong ty. the prevalence and risk factors of ocular trauma: the singapore indian eye study. ophthalmic epidemiol. 2011; 18 (6): 281-7. 12. wang jd, xu l, wang yx, you qs, zhang js, jonas jb. prevalence and incidence of ocular trauma in north china: the beijing eye study. acta ophthalmol. 2012; 90 (1): 61-7. 13. dineen b, bourne rr, jadoon z, shah sp, khan ma, foster a, gilbert ce, khan md. pakistan national eye survey study group. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007 aug; 91 (8): 1005-10. microsoft word sadiafarooq_1_correctedsent 1 original article evaluation and management of steroid induced glaucoma in vernal keratoconjunctivitis patients saadia farooq, aslam malik pak j ophthalmol 2007, vol. 23 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: saadia farooq assistant professor shifa college of medicine islamabad received for publication march’ 2006 …..……………………….. purpose: to study the behaviour and management of steroid induced glaucoma in vernal keratoconjunctivitis (vkc) patients in our setup. material and methods: sixteen patients of vkc with steroid induced glaucoma were enrolled in this study presented to al shifa trust eye hospital during year 2005. clinical signs and symptoms, management and outcome of these patients was observed for up to six months. results: with steroid induced glaucoma the pressure elevation is gradual. therefore, like primary open angle glaucoma, very few symptoms exist. cases in which intraocular pressure did not normalize upon cessation of steroids, needed medical and surgical intervention. conclusion: in vkc patients, most effective drug, steroid should be carefully administered, and only for brief periods, to avoid secondary development of glaucoma. all patients who use chronic corticosteroid medication in any capacity should have a full ophthalmologic evaluation during the course of treatment. ernal keratoconjunctivitis is a bilateral chronic inflammation of the conjunctiva. the disease affects children between three to sixteen years of age, though it may appear earlier than that and continue into adulthood. in the majority of the cases, symptoms resolve at puberty. although the name vernal suggests a seasonal spring time occurrence, frequently the disease persists throughout the year1. intense itching, irritation, burning and photophobia (sensitivity to light) are the main symptoms of the disease. corneal involvement leads to complaints of reduced vision. the disease is characterized by giant flat topped papillae of the upper tarsal conjunctiva leading to the clinical picture of cobblestones. the limbal form is characterized by conjunctival hyperemia, papillae at the corneoscleral (limbal) border and tranta’s dots. the diagnosis is generally based on the signs and the symptoms of the disease. antiallergic drops, steroids and ocular hygiene are the main stay of treatment for vernal catarrh patients. steroid induced intraocular pressure (iop) elevation typically occurs within a few weeks of beginning steroid therapy. in the majority of cases, the iop lowers spontaneously to the baseline within a few weeks to months upon stopping the steroid. in rare instances the iop remains elevated. the study of steroid induced glaucoma in vernal keratoconjunctivitis patients is important for two reasons. many patients who receive glucocorticoid therapy are susceptible to the development of ocular hypertension, v 2 which if unrecognized can lead to glaucomatous optic neuropathy and the irreversible loss of vision. in addition, it helps us in evaluating the efficacy of different treatment options available for the management of steroid induced glaucoma 2. materials and methods a prospective study was carried out on vernal keratoconjunctivitis patients with steroid induced glaucoma, coming to glaucoma department (al-shifa trust eye hospital) and shifa college of medicine in the year 2005. all cases were seen and dealt by the same surgeon. evaluation of the patient included detailed history, visual acuity, intraocular pressure measurement, slit lamp examination of the anterior segment, gonioscopy, dilated fundus examination for optic disc evaluation, and humphrey’s visual field analysis (30-2) of both eyes. diagnosis of vernal conjunctivitis was based on the typical history and characteristic signs and symptoms. associated glaucoma was labeled when the patient had elevated intraocular pressure with typical optic disc cupping and corresponding visual field defects. signs and symptoms of steroid induced glaucoma were noted and compared with those of primary open angle glaucoma. patients with persistently elevated pressures and ongoing disc damage were treated first medically .beta blockers, carbonic anhydrate inhibitors (topical and systemic), prostaglandin analogues, and sympathomimetics were used variably in patients depending upon the target pressure and the affordability by the patient. those with maximal tolerable medical treatment and intraocular pressures greater than the target pressures were surgically treated. trabeculectomy with mitomycin c (limbal based flap, 0.01% mitomycin applied for 2 minutes at the scleral bed before making the internal window and paracentesis) remained the surgical procedure of choice in all. patients were then followed for up to six months and postoperative complications were noted. patients who had settled intraocular pressures after discontinuing steroid treatment alone, and without any supportive treatment were followed on three monthly basis, and intraocular pressure and optic disc cupping was noted. in suspicious cases visual field examination was also repeated to monitor the progression of glaucomatous optic neuropathy. results there were 16 patients and all had bilateral disease (32 eyes). among them 4 (25%) were females and 12 (75%) were males. visual acuity at presention in six patients was 6/6 to 6/12 in the better eye), in 6 patients was 6/18 to 6/24 in the better eye and in 4 patients was less than 6/60 in the better eye. all patients had open angle glaucoma on gonioscopy. no pain was reported, perhaps due to the gradual rise in pressure. decreased vision was attributed to the associated corneal changes. none of them were aware of the associated disease process unless told. at presentation 4 patients (25%) had iop between 20 and 30mmhg while 12 patients (75%) had iop greater than 35mmhg. four patients (25%) had early glaucomatous damage (cupping less than 0.7) and 12 (75%) had advanced glaucomatous damage (cupping more than 0.7). when steroids were discontinued there was return of iop to normal in 4 patients (25%) while in the rest 12 (75%) patients there was no change in iop when steroids were stopped. in patients with initial iop greater than 35 mm hg the iop remained above the target level despite combination treatment (systemic acetazolamide, topical beta blocker, sympathomimetics / prostaglandins analogue). trabeculectomy with mitomycin c was performed in 12 (75%) patients (all uncontrolled on medical treatment). iop on first postoperative day was 6-8 mm hg in all 12 patients. three patients had preservation of their postoperative visual acuity, 7 had 1 to 2 line improvement as the pressure was lowered and 2 patients showed one to two lines falls in visual acuity. one case had failed bleb and redo surgery was performed. one case had persistent ocular hypotony, one had thinning of the bleb and conjunctival grafting was done. six had associated cataract formation and needed surgery for those. ten patients had successful intraocular pressure control at six months discussion vernal keartoconjunctivitis is an allergic eye disease that especially affects young boys. the most common symptoms are itching, photophobia, burning and tearing. the most common signs are giant papillae, superficial keratitis, and conjunctival hyperemia. the clinical management of vkc requires a swift diagnosis, correct therapy, and evaluation of the prognosis. the diagnosis is generally based on the 3 signs and symptoms of the disease, but in difficult cases can be aided by conjunctival scrapings, demonstrating the presence of infiltrating eosinophils3. (eye 2004 -18, 345-351). during this study we examined and counseled the children. patients had visited different clinics during the course of the disease. steroids were used without counseling about the disease. patients continued to use the steroids, because of the immediate relief in symptoms4. they had no awareness of the steroid associated complications. while on topical steroids, they were visited different clinicians, but steroid related rise in intraocular pressure was missed. patients that came to us with advanced steroid induced glaucoma (irreversible) and had been on this treatment for many years. hence injudicious use of steroids and improper examination in between lead to steroid induced complications. in vernal keratoconjunctivitis patients, therapeutic options are many. in most cases topical therapy should be chosen on the basis of the severity of the disease. the most effective drug steroids, should however be carefully administered, and only for brief periods, to avoid secondary development of glaucoma. a 2% solution of cyclosporine in olive oil or in castor oil should be considered as an alternative5. the long term prognosis of patients is generally good; however 6% of patients develop corneal damage, cataract or glaucoma3. (eye 2004; 18: 345-351). glucocorticoid therapy can cause elevated intraocular pressure in many susceptible individuals, who are often referred to as “steroid responders”. approximately 40% of the general population can develop iop elevation (>5mm hg) after topical ocular administration of a potent glucocorticoid for 4-6 weeks. a smaller percentage of these individuals (46%) experience a large increase in intraocular pressure (>15 mmhg). this iop elevation usually progresses over the course of weeks to months of therapy and generally reverses after discontinuation of the glucocorticoid administration, although there are reports of irreversible iop elevation6. most of the patients in the study group did not complain of pain, headache, or halos around light with rise in intraocular pressure. one likely explanation could be the gradual rise in pressure that occurs in steroid induced glaucoma; therefore, like primary open angle glaucoma very few symptoms exist6. few of them were aware of the decrease in vision, but they and the clinician they visited mistook it to be due to the corneal involvement in vernal catarrh. clark reported many features of steroid induced glaucoma that mimic primary open angle glaucoma (poag). exact pathophysiology of steroid induced glaucoma is unknown. it is known that steroid induced iop elevation is secondary to increased resistance to aqueous outflow. some evidence indicates that the defect could be increased accumulation of glycosaminoglycan or trabecular meshwork-inducible glucocorticoid response (tigr) protein, which could mechanically obstruct the outflow. other evidence points toward corticosteroid induced cytoskeletal changes that could inhibit pinocytosis of aqueous humor or inhibit the clearing of glycosaminoglycans, resulting in accumulation of this substance. glucocoticoid induced ocular hypertension can occur with a wide variety of routes of administration, including oral, topical, intraocular, periocular, nasal or inhalation. the propensity to induce ocular hypertension is dependent on the potency of the anti-inflammatory glucocorticoid, the frequency of administration, the dose and the duration of the treatment. if unrecognized, this steroid induced ocular hypertension can lead to secondary open angle glaucoma that in many ways mimics poag5. although the glucocorticoid induced ocular hypertension is generally reversible upon discontinuation of steroid therapy, the glaucomatous optic neuropathy is irreversible. it was found that when glaucoma did not reverse on cessation of steroids treatment, medical management was not sufficient in most cases to achieve the target pressures and surgical treatment was generally needed. features steroid glaucoma poag open angle + + reversibility of elevated iop + increased outflow resistance + + genetic component + + morphologic changes in trabecular meshwork including ecm deposition in trabecular + + 4 meshwork trabeculectomy with antimetabolites was chosen as the standard treatment (mitomycin c was used in all). indications for the use of anti-metabolite included younger age and conjunctival congestion in most of the patients. it remained an effective method of treatment in advanced steroid induced glaucoma. long term follow up proved trabeculectomy with mmc as an effective method for control of intraocular pressure in vernal catarrh patients. improvement in vision postoperatively in seven patients was due to the resolution of corneal oedema seen on presentation due to raised intraocular pressure. conclusion individual counseling backed up by patient information leaflets is critical in breaking the cycle of inadequate treatment of vkc. treatment in vkc should be titrated against the severity of the disease, those with milder symptoms and no corneal involvement may be given mast cell stabilizers. these must be used three to four times daily, even when there are no symptoms to stabilize the mast cells and to prevent the release of histamine. they are of no value when symptoms occur because their effect is not immediate. if used well, they can limit or stop the use of steroids7. they do not have any of the side effects of steroids and can be used for prolonged periods. patients on topical corticosteroid therapy should receive follow up care at regular intervals by an ophthalmologist to monitor the ocular condition and intraocular pressures. steroid induced iop elevation typically occurs within 2 to 6 weeks of beginning of steroid treatment. drugs that have the potential of inducing glaucoma should only be used if truly indicated; if drugs must be used iop must be monitored closely. untreated glaucoma can lead to permanent visual damage and blindness. authors affiliations dr. saadia farooq assistant professor shifa college of medicine islamabad professor aslam malik professor and section head shifa college of medicine islamabad references 1. clark af. steroids, ocular hypertension and glaucoma j. glaucoma. 1995; 4: 354-69. 2. johnson dh, gottanka. ultra structural changes in the trabecular meshwork of the human eyes treated with glucocorticoid arch ophthalmol 1997; 115: 375-83. 3. bonini s, coassin m, aronni s et al. vernal keratoconjunctivitis. eye 2004; 18: 345-51. 4. skuta gl, morgan rk. corticosteroid induced glaucoma. the glaucomas.1996; 1177-88. 5. bonini s, schiavone et al. vernal keratoconjunctivitis revisited: a case series of 195 patients with long term follow up. ophthalmology. 2000; 107: 1157-63. 6. wordinger rj and clark af. effects on glucocorticoids e on the better understanding of the glaucoma. prog ret eye res. 1999; 18: 629-67. 7. saini js, gupta a. pandey, efficacy of supratarsal dexamethasone versus triamcinolone injection in recalcitrant vernal keratoconjunctivitis. acta ophthalmol. 1999; 77: 515-8. 90 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology original article frequency of the ophthalmological disorders associated with headache muhammad asharib arshad, syed abdullah mazhar, nazish ali, ahsan zil-e-ali, manzra shaheen pak j ophthalmol 2019, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad asharib arshad final year mbbs fmh college of medicine and dentistry, shadman, lahore email: asharibarshad@hotmail.com …..……………………….. purpose: to determine the frequency of ophthalmological disorders associated with headache. study design: cross-sectional study. place and duration of study: this study was conducted in the outpatient department of fatima memorial hospital from january 2018 to july 2018. material and methods: the sample population was selected through nonprobability, convenience sampling technique. a proforma was filled that included questions about the characteristics of headache and the ocular findings on examination. complete eye examination was done by a consultant ophthalmologist. the various disorders related with headache were divided into the following categories that included ocular, non-ocular, combined ocular and combined ocular with non-ocular causes. statistical analysis was done using spss version 23. results: out of the 180 patients, 127 (70.6%) were females and 53 (29.4%) were males. the mean age was 25.02 ± 12.89 years ranging from 5 to 80 years. in the ocular causes, the most common were asthenopias present in 83 (46.11%) patients. these included 29 (16.1%) patients of convergence insufficiency, 18 (10%) patients with hypermetropia, 15 (8.3%) patients with myopia, 7 (3.9%) patients with presbyopia and 4 (2.2%) patients with increased mobile and computer usage. the patients who suffered from other ocular causes such as keratoconus and hypertensive retinopathy were 2 each (1.1%) and the number of patients presenting with acute uveitis, blepharitis, retinal detachment and squint were 1 each (0.6%). in the non-ocular causes, 61 (33.9%) patients presented with migraine. conclusion: most of the patients with ocular causes had refractive errors and majority of the patients with non-ocular causes had migraine. keywords: headache, asthenopia, refractive errors, migraine. eadache is one of the most common presenting complaint of patients but still it is not adequately treated1. according to a study conducted to assess the global burden of headache, it was estimated that headache and accompanying presentations affect approximately half of the population of the world2. to focus on this pandemic, leading organizations of the world collaborated with the world health organization (who) to establish, ‘lifting the burden: the global campaign to reduce the burden of headache worldwide’3. a cross-sectional study conducted to study the prevalence of headache in pakistan proposed that pakistan has a higher percentage of headache cases. it reported a prevalence of 76.6% in one year, which is noticeably above the global average h frequency of the ophthalmological disorders associated with headache pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 91 of 46%4. in a study conducted in eight countries, vowels et al. concluded that headache was one of the most frequently reported pain in patients5. the first physicians to evaluate the patients presenting with headache accompanied by visual disturbances are ophthalmologists. that being said, to make a definite diagnosis and to manage patients adequately it requires the ophthalmologist to have a thorough knowledge of headache disorders, a comprehensive history and a complete clinical examination6. a survey conducted on more than 250 ophthalmologists involved in training courses related to headache determined that around 50 patients consult an ophthalmologist with concerns related to headache in a month7. in a study conducted in france, the highest proportion of patients with headache consulting an ophthalmologist were 19.2% of the total8. patients with headache consulting an ophthalmologist commonly have migraine, facial pain syndromes, cranial neuropathies with pain, ocular and orbital disease9. the most common disorder related to headache apparently is migraine, that has a significant female predominance with a prevalence of 5-25%9. however, the frequency of ophthalmological disorders associated with a headache has not been clearly defined in literature. the relationship of age and gender to the frequency of ophthalmological disorders associated is still not clear. this study investigates the frequency of the ophthalmological disorders associated with headache and the relationship with age and gender. material and methods this cross-sectional descriptive study was conducted in outpatient department of fatima memorial hospital from january 2018 to july 2018. the sample population was selected through non-probability, convenience sampling technique. all the patients with headache presenting in other departments were referred to the eye department if it was vision related or originated in the eye. all patients who presented in the outpatient department and those who were referred from other departments were included in our study. there was no age limit set for patients to be included in our study. patients who had a history of ocular trauma were not included in the study. patients who had psychiatric illnesses were also not included in our study. the sample size was calculated by taking a prevalence of 36% from a study done in india10, to be 180 by taking confidence interval at 95%, power of the study at 80% and alpha at 7% using the formula: the disorders related with headache were divided into ocular, non-ocular, combined ocular and combined ocular with non-ocular causes. the data was collected on a proforma with parameters including the characteristics of pain and the findings on ocular examination. these characteristics of pain included onset, duration, time since headache, dominant head region involved and the radiation of the headache. on ocular examination, multiple diseases and conditions were diagnosed (table 1). this clinical examination of the patient with headache comprised of the evaluation of visual acuity by snellen chart, refraction and if required specialized assessment for intraocular pressure by goldmann applanation tonometry and visual field by perimetry performed by a consultant ophthalmologist. data analysis was done using spss version 23. the frequency of the ophthalmological disorders associated with headache was recorded. results of the 180 patients, 127 (70.6%) were females and 53 (29.4%) were males. this shows that there is predominance of females in the patients presenting in the outpatient department with headache. the mean age was 25.02 ± 12.89 years ranging from 5 to 80 years. the details are shown in table 1. table 1: frequency of various disorders related to headache. ocular causes number percentage asthenopia 83 46.11 anisometropia 1 .6 astigmatism 9 5.0 convergence insufficiency 29 16.1 hypermetropia 18 10.0 mobile and computer usage 4 2.2 myopia 15 8.3 presbyopia 7 3.9 other ocular causes 9 5 acute uveitis 1 .6 blepharitis 1 .6 muhammad asharib arshad, et al 92 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology hypertensive retinopathy 2 1.1 keratoconus 2 1.1 retrobulbar optic neuritis 1 .6 retinal detachment 1 .6 squint 1 .6 non-ocular causes 71 39.44 frontal sinusitis 4 2.2 epilepsy 1 .6 migraine 61 33.9 stress headache 5 2.8 ocular and non-ocular abnormalities combined 14 7.78 migraine and astigmatism 5 2.8 migraine and convergence 8 4.4 migraine and myopia 1 .6 combined ocular (more than one ocular cause) 3 1.67 astigmatism and convergence 2 1.1 astigmatism and hypermetropia 1 .6 total 180 100.0 discussion headache and ocular pain are the persistent complaints of patients in ophthalmic practice. a study conducted in india concluded that the highest proportion of patients (36%) that presented with headache had an underlying ophthalmic cause10. the percentage of females (70.6%) in our study was reasonably greater than (29.4%) males. an indian study reported that the percentage of females (53.55%) was higher compared to males that was (43.55%)10. another study conducted in nepal in 2012 also determined that the patients who presented with headache due to ophthalmic cause had female predominance11. headache is more prevalent in females due to emotional variability and stress in a society dominated by males. the major entity in the ocular disorders was asthenopia. the highest proportion of patients who presented with headache had refractive errors, 72 (40%). our results were quite similar to a study conducted in france that reported refractive errors in 44% of the patients who had headache12. another study conducted in nepal also reported that 44% of patients who presented with headache in ophthalmology department had refractive error. convergence insufficiency was found in 29 (16.1%) of the patients. convergence insufficiency is quite common in the general population with a reported incidence of 2 to 17%13. work done by dusek et al demonstrated that patients who had difficulty in reading with no underlying intellectual or psychological problem may be due to convergence insufficiency14. presbyopia is another cause of asthenopia. in our study 7 (3.9%) of the patients had presbyopia. a study conducted in 2017 estimated that around 1.09 billion people are suffering from functional presbyopia15, from which around 26 million people have near vision impairment as they were not properly treated16. however, in a study conducted by kaimbo et al. the proportion of patients was 11% that was much higher than our study12. the number of patients with headache due to the use of mobile and computer were 4 (2.2%). in another study conducted in pakistan the reported cases with headache due to mobile and computer usage were 4.76%17. their results were quite similar to our study. the mechanism behind headache due to prolonged usage of computer is due to the dry eyes, abnormalities of the surface of the eye and accommodative spams18. an important feature of asthenopia is its relation to the visual effort so when treating an incomprehensible case of headache as general medical patient, the likelihood that patient might have asthenopia should always be kept in mind18. the patients with other ocular causes such as keratoconus and hypertensive retinopathy were 2 (1.1%) each and the number of patients presenting with acute uveitis, blepharitis, retinal detachment and squint were 1 (0.6%) each. in our study 1 (0.6%) patient of retrobulbar optic neuritis was seen. in another study conducted in pakistan in 2017, retrobulbar optic neuritis was seen in 0.26% of the patients17. patients suffering from retrobulbar optic neuritis present with a normal optic disc in the initial course of the disease with symptoms of loss of vision and pain during extra-ocular movements19. proper follow-up of the patients having retrobulbar optic neuritis should be done as there is likelihood that the patient might have remission of the disease, particularly if they have multiple sclerosis20. among the non-ocular causes migraine was present in 61 (33.9%) of the patients. migraine without symptoms of aura is present in more than half of the patients with migraine headaches. migraine with symptoms of aura, previously called the classic migraine, is established in 10-35% of the migraine headaches. classic migraine consists of symptoms of aura, headache and post-headache period. the precise pathophysiology of the headache during migraine is not clearly defined in literature. some studies have supported the notion that the structures of the central nervous system play an important role in mechanism of headache in migraine patients9,21. a french study reported that 3.9% of the patients had migraine which frequency of the ophthalmological disorders associated with headache pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 93 is very low as compared to our study12. work done by bolay et al. determined that females had a greater predisposition towards migraine22. patients presented with combined ocular and non-ocular causes included 8 patients (4.4%) with migraine and convergence insufficiency, 5 (2.8%) with migraine and astigmatism and 1 (0.6%) presented with migraine and myopia. so the management of patient with headache presenting in the ophthalmology department requires a great deal of conjecture from the clinician caring for such patients as the patient might suffer from ocular, non-ocular and combined causes. the diagnosis of stress headache was not made in the patients until other possible causes were ruled out. furthermore, it is not a norm that patients with headache originating from the eye should have a red eye. patients with ocular disorders such as stye, optic neuritis, papilloedema, acute dacrocystitis and infected chalazion have a white eye. on the contrary, patients having allergic rhino-conjunctivitis present with a red eye. headaches with white eye on ocular examination excluding refractive errors do not point towards a neurological cause of headache. a majority of cases of headache that are of ophthalmic origin such as errors of refraction mostly present to neurologists and have to undertake needless investigations that lead to waste of money and time of the patient21. so headache with visual symptoms should be evaluated by an ophthalmologist, prior to expensive diagnostic work up to rule out a possible neurological cause. ophthalmologists are considered to be competent in treating headache23. the limitation of our study was that it was conducted in one hospital. more studies are required to produce generalizable results. conclusion the majority of patients who had associated ocular causes had refractive errors whereas the most common cause of headache associated with non-ocular causes was migraine. they could be diagnosed by taking a proper history and conducting a thorough ocular examination. furthermore, proper evaluation of a person with headache should be done as there could be a combined ocular and non-ocular origin of the headache that could be missed. author’s affiliation muhammad asharib arshad final year mbbs fmh college of medicine and dentistry, shadman, lahore dr. syed abdullah mazhar mbbs, fcps, mrcs senior registrar department of ophthalmology rashid latif medical college, lahore dr. nazish ali associate professor of zoology, government college of women, model town, lahore dr. ahsan zil-e-ali department of pathology, punjab rangers teaching hospital, lahore manzra shaheen optometrist fmh college of medicine and dentistry, shadman, lahore author’s contribution muhammad asharib arshad conceived and designed the research, assessed the cases and wrote the paper. dr. syed abdullah mazhar collected the data, did the literature search, drafted the manuscript and assisted in writing the paper. dr. nazish ali analyzed the data and revised the manuscript. dr. ahsan zil-e-ali revised the original manuscript and assisted in writing the paper. manzra shaheen involved in data collection. references 1. world health organization. (2011). atlas of headache disorders and resources in the world 2011. geneva: world health organisation. http://www.who.int/iris/handle/10665/44571. 2. stovner l, hagen k, jensen r, katsarava z, lipton r, scher a, et al. the global burden of headache: a documentation of headache prevalence and disability worldwide. cephalalgia. 2007; 27 (3): 193-210. 3. steiner tj. lifting the burden: the global campaign against headache. lancet neurol. 2004; 3 (4): 204-5. 4. herekar aa, ahmad a, uqaili ul, et al. primary headache disorders in the adult general population of pakistan a cross sectional nationwide prevalence survey. j headache pain, 2017; 18 (1): 28. http://www.who.int/iris/handle/10665/44571 muhammad asharib arshad, et al 94 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology 5. vowles ke, rosser b, januszewicz p, morlion b, evers s, eccleston c. everyday pain, analgesic beliefs and analgesic behaviours in europe and russia: an epidemiological survey and analysis. eur j hosp pharm sci pract. 2014; 21 (1): 39-44. 6. dafer rm, jay wm. headache and the eye. curr opin ophthalmol. 2 009; 20 (6): 520-4. 7. wilhelm h, heinze a. the headache patient at the ophthalmologist's. klin monbl augenheilkd. 2004; 221 (4): 247-52. 8. lanteri-minet m, auray jp, el hasnaoui a, dartigues jf, duru g, henry p, et al. prevalence and description of chronic daily headache in the general population in france. pain, 2003; 102 (1-2): 143-9. 9. headache classification subcommitee of the international headache society: the international classification of headache disorders. 2nd ed. cephalgia 2004; 24: 9-160 [internet]. 2004. 10. jain s, chandravanshi sl, dukariya l, tirkey er, jain sc. clinical study of headache with special reference to ophthalmic causeint j med sci public health, 2015: 2015. 11. marasini s, khadka j, sthapit prk, sharma r, nepal bp. ocular morbidity on headache ruled out of systemic causes—a prevalence study carried out at a community based hospital in nepal. j optom. 2012; 5 (2): 68-74. 12. kaimbo dk, missotten l. headaches in ophthamology. j fr ophtalmol. 2003; 26 (2): 143-7. 13. trieu lh, lavrich jb. current concepts in convergence insufficiency.curr opin ophthalmol. 2018; 29 (5): 401-6. 14. dusek wa, pierscionek bk, mcclelland jf. an evaluation of clinical treatment of convergence insufficiency for children with reading difficulties. bmc ophthalmol. 2011; 11: 21. 15. bourne rra, flaxman sr, braithwaite t, cicinelli mv, das a, jonas jb, et al. magnitude, temporal trends, and projections of the global prevalence of blindness and distance and near vision impairment:a systematic review and meta-analysis. lancet glob health, 2017; 5 (9): e888-e97. 16. fricke tr, tahhan n, resnikoff s, papas e, burnett a, ho sm, et al. global prevalence of presbyopia and vision impairment from uncorrected presbyopia: systematic review, meta-analysis, and modelling. ophthalmology, 2018; 125 (10): 1492-9. 17. fasih u, shaikh a, shaikh n. aetiology of headache in clinical ophthalmic practice at a tertiary care hospital of karachi. j pak med assoc. 2017; 67 (2): 166-70. 18. blehm c, vishnu s, khattak a, mitra s, yee rw. computer vision syndrome: a review. surv ophthalmol. 2005; 50 (3): 253-62. 19. lepore fe. the origin of pain in optic neuritis. determinants of pain in 101 eyes with optic neuritis. arch neurol. 1991; 48 (7): 748-9. 20. hong d, bosc c, chiambaretta f. progression of nerve fiber layer defects in retrobulbar optic neuritis by the macular ganglion cell complex. j fr ophtalmol. 2017; 40 (9): 777-87. 21. olesen j, burstein r, ashina m, tfelt-hansen p. origin of pain in migraine: evidence for peripheral sensitisation. lancet neurol. 2009; 8 (7): 679-90. 22. bolay h, ozge a, saginc p, orekici g, uluduz d, yalin o, et al. gender influences headache characteristics with increasing age in migraine patients. cephalalgia. 2015; 35 (9): 792-800. 23. wilhelm h. eye pain and headache from the perspective of an ophthalmologist. ophthalmologe. 2011; 108 (12): 1111-5. microsoft word abstracts vo. 23,2,07.doc 106 abstracts edited by dr. tahir mahmood wavefront-guided ablation: evidence for efficacy compared to traditional ablation netto mv, dupps jrw, wilson se am j ophthalmol 2006; 141: 360-8. adaptive optics was initially proposed almost 50 years ago as an attempt to improve telescopic visualization of stars. later, advanced wavefront sensors with adaptive optics and deformable mirrors were designed to identify and correct the human eyes lower and higher order aberrations. subsequent studies showed that adaptive optics facilitated a considerable increase in contrast sensitivity at high spatial frequencies because of correction of monochromatic aberrations. these findings generated a surge of interest in wavefront technology, and its application to customized corneal laser treatment. only a few years later, wavefront-guided ablation has become widely available for laser vision correction in humans. thus, it is now routine to measure the optical aberrations of the eye beyond sphere and cylinder with the ultimate goal of achieving an ideal optical correction and improving the quality of the retinal image. according to recent statistics, approximately 55% of north american refractive surgeons have wavefront analyzers in their practice and routinely perform wavefront-guided ablations. but do custom results justify the intense promotion? are we able to fulfill the promise of optimal vision through the application of wavefront data or is there at least evidence that wavefront-guided treatments provide major advantages over modern conventional laser treatments? nearly 3 years have passed since the fda first approved wavefront-guided treatment in the united states, and multiple proprietary platforms for wavefront-guided ablation are now in use. along with the rapid development of these systems and the accompanying marketing to both surgeons and patients, there has been a dramatic increase in expectations of what laser vision correction can achieve. however, several limitations persist and the goal of aberration free or "super" vision, at least for most of the patients, is still far from reality. while wavefront-guided treatments are customized in the sense that treatment is directed at patient specific aberrations, the same treatments not infrequently lead to unpredictable visual outcomes at rates that are similar to conventional ablations attributable to factors such as variability in wound healing and biomechanical factors related to the cornea. accordingly, a custom treatment does not guarantee a custom outcome for a given patient. however, when surgeons become more familiar with a particular wavefront-based platform and their personal nomograms are refined, very good visual results may be achieved in most of the patients. this, however, is also true of optimized conventional ablations. the purpose of this study was to provide an evidence based overview of wavefront-guided refractive surgery outcomes, benefits, and limitations. more than 400 reports investigating wave-front applications in refractive surgery exist, but studies comparing the outcomes of wavefront-guided treatment with conventional treatment are few in number. available studies do not overwhelmingly demonstrate superior visual results attributable to a wavefront-guided approach. while wavefront-guided refractive surgery provides excellent results, evidence is limited that it outperforms conventional laser in situ keratomileusis that incorporates broad ablation zones, smoothing to the periphery, eye trackers, and other technological refinements. however, it is evident that wavefrontcustomized ablation holds a promising future and merits ongoing investigation. topical ocular hypotensive medication and lens opacification: evidence from the ocular hypertension treatment study herman dc, mae o. gordon mo, beiser ja, chylack lt, lamping ka, schein od, soltau jb, kass ma am j ophthalmol 2006; 142: 800-10. for decades, clinicians have questioned whether topical ocular hypotensive medication initiates or 107 accelerates cataract formation. an increased prevalence of lens opacities has been reported in some case control studies of participants with glaucoma or ocular hypertension. furthermore, a recent large, welldefined population based sample and a recent clinical trial found a higher incidence of nuclear sclerosis among participants treated with topical ocular hypotensive medications. the ocular hypertension treatment study (ohts) found a higher incidence of cataract extraction among participants randomized to topical ocular hypotensive medication compared with participants in the observation group. to further investigate the possible role of topical ocular hypotensive medication in initiating or accelerating lens opacification in ohts, authors compared the medication and observation groups during follow-up with regard to the rate of cataract extraction and combined cataract/filtering surgery and change from baseline in visual function, refraction, and visual symptoms. in addition, a onetime assessment of the lens of each eye of participants was completed by masked examiners using the lens opacities classification system iii (locs iii). the purpose of this study was to determine whether topical ocular hypotensive medication is associated with refractive changes, visual symptoms, decreased visual function, or increased lens opacification. in this multi-center clinical trial authors compared the medication and observation groups of the ocular hypertension treatment study (ohts) during 6.3 years of follow-up with regard to the rate of cataract and combined cataract/filtering surgery, and change from baseline in visual function, refraction, and visual symptoms. a one-time assessment of lens opacification was done using the lens opacities classification system iii (locs iii) grading system. an increased rate of cataract extraction and cataract/filtering surgery was found in the medication group (7.6%) compared with the observation group (5.6%) (hazard ratio [hr] 1.56; 95% confidence interval [ci] 1.05 to 2.29). the medication and observation groups did not differ with regard to changes from baseline to june 2002 in humphrey visual field mean deviation, humphrey visual field foveal sensitivity, early treatment of diabetic retinopathy study (etdrs) visual acuity, refraction, and visual symptoms. for the medication and observation groups, logs iii readings were similar for nuclear color, nuclear opalescence, and cortical opacification. there was a borderline higher mean grade for posterior subcapsular opacity in the medication group (0.43 ± 0.6 sd) compared with the observation group (0.36 ± 0.6 sd) (p = .07). authors noted an increased rate of cataract extraction and cataract/filtering surgery in the medication group as well as a borderline higher grade of posterior subcapsular opacification in the medication group on locs iii readings. authors found no evidence for a general effect of topical ocular hypotensive medication on lens opacification or visual function. modulation transfer function and pupil size in multifocal and monofocal intraocular lenses in vitro kawamorita t, uozato h j cataract refract surg 2005; 31: 2379-85. multifocal intraocular lenses (iol) are designed to increase depth of field and to enhance near vision for cataract patients. the effectiveness of multifocal lols in enhancing quality of vision has been shown in many clinical studies. the refractive design of the array sa-40n iol (allergan), a typical multifocal iol, has a beneficial effect on near vision. however, many problems, including loss of corrected visual acuity at near distance and contrast sensitivity, glare, halos, and dependence on pupil size have been reported. pupil size affects the relative power distributions of the light generated by the zonalprogressive design of the array iol, whose concentric zones of progressive aspheric surfaces provide repeatable distributions of the power. furthermore, controls of optical aberration, diffraction, retinal illuminance, pupil centration, and the stiles-crawford effect are affected by pupil size. therefore, pupil size is expected to have an effect on the modulation transfer function (mtf), which is defined as the amplitude of the image contrast divided by the amplitude of the object contrast and is a function of spatial frequency. the aim of this study was to investigate the relationship between pupil size and near and far mtfs in a multifocal iol in vitro. the results were used to predict the visual performance of patients with a multifocal iol. a refractive multifocal iol (array sa-40n, allergan) and a monofocal iol (phacoflex si-40nb, amo) were evaluated using the opal vector system 108 and a model eye with a variable effective aperture. with effective pupil diameters of 2.1, 3.0, 3.4, 3.9, 4.6, 5.1, and 5.5 mm, the in-focus and defocus mtfs were measured in the multifocal and monofocal lols. with increases in effective pupil diameter, the far mtf progressively decreased at all spatial frequencies. in contrast, the near mtf began to increase at effective pupil diameter 2.1 mm, showed a peak at 3.4 mm, and decreased at diameters greater than 3.4 mm. the ratio of near mtf to far mtf showed an increase with larger effective pupil diameters and at lower spatial frequencies. the authors concluded with remarks that with a zonal progressive multifocal iol, the pupil size effected a trade-off between the far and near mtfs: the near mtf increased at the expense of the far mtf at large pupil sizes (effective pupil diameter >3.4 mm). to enhance near vision with a multifocal iol, the desirable effective pupil diameter should be 3.4 mm or larger. first safety study of femtosecond laser photodisruption in animal lenses: tissue morphology and cataractogenesis krueger rr, kuszak j, lubatschowski h, myers ri, ripken t, heisterkamp j cataract refract surg 2005; 31:2386-94. the problem of presbyopia is a universal one that is believed to affect more than 130 million people in north america currently. the condition of presbyopia is described as the gradual loss of the accommodative response of the lens with age. that accommodative response, described by von helmholz as the release of resting tension in the natural crystalline lens to induce a more spherical lenticular shape, is subject to an agerelated loss of function beginning in the mid 40s, primarily caused by a loss of the elastic properties of the natural crystalline lens. although a number of potential options for the surgical correction of presbyopia exist, there is no widespread accepted method for restoring accommodation that does not also involve invasive lens exchange surgery with experimental materials or mechanisms. as a result, a new intralenticular strategy has been proposed in which focused light energy is directed into the substance of the lens to change the modulus of elasticity in aging lenses (photo-phaco modulation) or reduce the lens volume in locations that can change the refractive error or accommodation ability (photophaco reduction). the purpose of this study was to determine through safety studies the tissue effects and potential cataractogenesis of laser modification of the crystalline lens (photophaco modulation). six fresh porcine lenses and 6 living rabbit eyes (with the contralateral eye as a control) were radiated with a low-energy femtosecond laser to induce lens fiber disruption. after 3 months, the rabbit eyes were extracted and tested for light scatter and lens function and fixed for histology and ultrastructure. after laser treatment, all lenses displayed a tightly packed array of intralenticular bubbles, which resolved with time. in the porcine eyes, the bubbles coalesced unless spacing of 9 µm or greater was applied at an energy of 2 µj. in the rabbit eyes, an energy of 1 µj and spacing of 10 um was chosen for transcorneal delivery, showing minimum bubble coalescence. after 3 months, the rabbit lenses showed good transparency, with only 1 rabbit having cataract formation unrelated to the laser. laser scanning studies show essentially identical values for the back focal length and sharpness of focus (variability of back focal length). ultrastructurally, the rabbit eyes showed a 0.5 um electron dense border layer with adjacent normal lens architecture. femtosecond laser photodisruption of the ocular lens yields a self-limited lesion with bubbles that resolve with time. in living animal eyes, no cataract formation was found with no loss of lens function or induced light scatter after 3 months. these results suggest that use of a low-energy femtosecond laser might be safe when modifying the lens for presbyopia correction. smoking and cataract: review of causal association kelly sp, thornton j, edwards r, sahu a, harrison r j cataract refract surg 2005; 31: 2395-2404. age related cataract is usually a gradual, progressive opacification of the crystalline lens resulting in impaired visual function. the 1998 world health report estimated that there were over 19 million people blind from cataract, which represented 43% of global blindness. the definitive management for cataract is surgical extraction with intraocular lens implantation. as yet, no medical treatment has proven to prevent, delay, or reverse the development of 109 cataract in otherwise healthy human eyes. cataract causes major visual impairment among affected individuals and results in significant health resource consumption for populations and society. identifying modifiable risk factors for cataract is thus important and may help establish preventative measures. increasing age is the most important risk factor for cataract, possibly because of the accumulation of lens damage with age together with an age-related decline in protection against oxidative damage in the eye. other risks for cataract include environmental factors, for example exposure to ultraviolet radiation.' systemic diseases have an important role in cataract formation. in some studies, high alcohol consumption was associated with increased risk for cataract, but no association was found in other studies. there has been considerable interest in the possible protective role of dietary antioxidants and supplements in age-related cataract, but evidence of effectiveness to date is equivocal. in 2 clinical trials, high-dose antioxidant supplementation did not delay cataract formation, but in a third study, supplementation did delay progression. several risk factors for the development of cataract have been identified. this review evaluates epidemiologic literature that has examined tobacco smoking as a risk factor for cataract formation using established causality criteria. twenty-seven studies were included in this review. evidence suggests that smoking has a 3-fold increase on the risk for incident nuclear cataract development. there was also evidence of dose response, temporal relationship, and reversibility of effect. there was limited evidence of an association between smoking and posterior subcapsular cataract, but little or no association with cortical cataract. thus, the literature review indicated a strong association between smoking and the development of cataract, particularly nuclear cataract. the association fulfills the established criteria for causality. the association between smoking and other types of cataract is less distinct and requires further evaluation. correction of hyperopia by intracorneal lenses two-year follow-up ismail mm j cataract refract surg 2006; 32:1657-60. intracorneal implants or inlays have been investigated for the past 40 years, starting with barraquer in 1964. he used flint glass, but anterior stromal necrosis occurred followed by extrusion of the implant. dohlman et al. recognized the importance of water and nutrient movement across the cornea from the aqueous humor. this led mccarey and andrews to use hydrogel hydroxyethyl methacrylate (hema) to increase the solute permeability of the intracorneal implant material. later, mcdonald et al. reported excellent tissue biocompatibility in non-human primates with hydrogel lenses (permalens) with a water content of 71%. in a 5-year follow-up, they observed persistent clarity, lack of inflammatory reaction, absence of vascularization, and normal endothelium. however, glucose transport decreased significantly with greater implant thickness; to obtain the desired refractive effect, the authors determined the implant should be 270 to 340 um. clinical results of intracorneal hydrogel implants were promising, but the main limitations were the surgical instruments and the thickness of the implant. with the recent advances in automated microkeratome technology, hinged lamellar flap dissections are simpler and more reliable. this has led to the popularity of laser in situ keratomileusis (lasik) for the treatment of refractive errors. additionally, it is well established that the corneal flap can be lifted and repeated ablation can be performed for enhancements. however, for hyperopia, lasik presents a significant number of complications, including decentration, regression, and undercorrection. fenestrated hydrogel intracorneal implants (permavision, anamed inc.) were developed to address the limitations reported with the earlier, relatively thick hydrogel lenses. they are composed of more than 78% water content and a refractive index that is substantially close to the refractive index of corneal tissue (1.376). the thickness ranges from 15 to 45 um according to dioptric power. the lens is designed to correct hyperopia up to +6 diopters (d). in a previous study, confocal microscopy follow-up of several animals implanted with permavision lenses was conducted. excellent compatibility was seen, but with relative keratocytic proliferation around only the lens. this study assessed the safety and efficacy of this lens in a controlled clinical study in human sighted eyes. the purpose of this study was to assess the safety and efficacy of intracorneal lenses as a surgical alternative for the correction of hyperopia. twenty-three eyes of 21 patients who had a mean hyperopia of 4.3 diopters (d) ± 0.71 (sd) (range +2.5 to 110 +6.0 d) received permavision lenses (anamed inc.), which are made of a highly permeable hydrogel with a water content of 78% and a refractive index close to that of corneal tissue (1.376). the moria m2 microkeratome was used to make a 160 µm corneal flap with a diameter of ± 8.5 mm. the intracorneal lens was placed beneath the flap after minimal interface irrigation. clinical examination showed mild corneal edema and a myopic shift during the first week postoperatively. in 17 eyes (73.9%), the postoperative uncorrected visual acuity was similar to the preoperative best corrected visual acuity (bcva); 1 eye (4.3%) lost 1 line of preoperative bcva. in 5 eyes (21.7%), various degrees of lens opacification with some degree of corneal haze were seen after uneventful follow-up. decentration of 0.5 to 1.0 mm was seen in 2 eyes (8.6%), 1 of which had the lens explanted because of significant opacification. induced astigmatism was evident in 1 eye (-1.5 d). a total of 16 eyes (69.6%) were within +0.5 d of target, and 20 eyes (86.9%) were within +1.0 d (87%). no flap melting or extrusion of the lens was recorded in 24 months of follow-up. night halos and glare were reported in 3 eyes; all had a lens diameter of 5.0 mm. authors concluded that intracorneal hydrogel lenses were tolerated relatively well by stromal tissue, providing a reasonably stable and predictable way to correct moderate hyperopia. however, induced astigmatism, stromal opacification, decentration, and night halos and glare occurred in a significant number of eyes. to ensure safety, deep flap cuts are preferred and these eyes should be watched carefully to avoid decentration of the lens in the early postoperative period. pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 127 original article a spectrum of ophthalmic diseases in a tertiary care hospital in peshawar, kpk; a 10-year retrospective study muhammad rafiq afridi, khalid saifullah baig, omer nasim, salman khan pak j ophthalmol 2019, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: omer nasim ophthalmology unit rehman medical institute (rmi), peshawar email: discover.omer@gmail.com purpose: to assess the frequency of different eye morbidities in the patients presenting at a tertiary care hospital in peshawar. study design: cross sectional study. place and duration of study: ophthalmology unit of rehman medical institute (rmi), peshawar from february 2004 to month of march 2014. material & methods: this research involved accessing the data bank kept by the hospital. all ocular morbidities seen during the study period was included in the study while those who presented with the diseases of the eye due to some other systemic condition were excluded. patients were categorized according to their gender and year of admission. the age categories were divided into 5 groups, 0-20, 21-40, 41-60, 61-80, 81-100 years’ category. the data collected was analyzed using ms excel 2013. results: a total of 1869 patients were examined out of which 49.92% were male and 50.07% were female. the ocular examination revealed that out of the 1869 patients, 57.30% of the patients suffered from cataract, 4.86% patients suffered from pterygium, 4.76% suffered from strabismus, 1.65% patients suffered from glaucoma and the remaining 31.43% suffered from various spectrum of diseases. female preponderance was more than males in the sense of general morbidity of ocular disorders. muhammad rafiq afridi, et al 128 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology …..……………………….. conclusion: cataract was found to be the most common ocular morbidity found in all age groups. keywords: pterygium, glaucoma, cataract, strabismus. he presentation of eye diseases varies widely all over the globe1,2. specific diseases are common in certain age brackets, races and occupations.2-4. early diagnosis is required in most eye morbidities to prevent loss of sight and to have better prognosis.5 vision is essential for daily activities and any visual impairment is serious and debilitating disability6. while some eye morbidities are easily cured and others if not prevented or treated promptly can lead to loss of vision and permanent blindness, therefore it is of paramount importance to find out the trend of eye diseases7. large amount of data is available on anticipation and treatment of the visual deficiency in every single remote district of the world, yet almost no data is accessible on the pervasiveness of visual ailments in tibetan who live in the remote zones of the tibetan plateau8. the prevalence of visual impairment is expected to be higher in the developing countries due to the low level of healthcare services in many of the countries9. prevalence mapping concerning the weight of a condition (e.g., visual debilitation) at a specific area at a point or period is essential. accurate prevalence gauges are expected to help in the accessibility of human services, related financial expenses, and personal satisfaction associated with having the condition. information of such caliber is a basic part in arranging future investigations, having controlled clinical preliminaries in anticipation and appropriate treatment of the morbidity. currently there is very little data on the prevalence of eye diseases in the north western part of pakistan the purpose of this research was to discover the pattern of eye ailments in ophthalmology department of rehman medical institute peshawar. material & methods a descriptive retrospective study was done of patients visiting the ophthalmology unit of rehman medical institute peshawar from february 2004 to march 2014 by accessing the registers kept by the hospital. patients were categorized according to their gender and year of admission. the age categories were divided into 5 groups, 0-20, 21-40, 41-60, 61-80, 81-100 years category. a total number of 1869 patients were found during the ten-year retrospective study. all patients aged 1-100years who were admitted in ophthalmology department in rml peshawar, having ocular morbidity were included in the study while those presenting with diseases of the eye along with other systemic diseases were excluded. the data collected was analyzed using ms excel 2013. after the collection of data, all the data was entered into ms excel 2013 and the analyzed results t https://meshb.nlm.nih.gov/record/ui?name=pterygium https://meshb.nlm.nih.gov/record/ui?name=glaucoma https://meshb.nlm.nih.gov/record/ui?name=cataract https://meshb.nlm.nih.gov/record/ui?name=strabismus a spectrum of ophthalmic diseases in a tertiary care hospital in peshawar, kpk; a 10-year retrospective pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 129 are presented as simple frequencies and tables. the data analyzed was based on the number of patients admitted to the eye unit and the variables under study included major diagnoses i.e. cataract, glaucoma, strabismus and pterygium. results the investigation revealed that out of the 1869 patients 49.92% were male and 50.07% were female. 57.30% of the patients suffered from cataract, 4.86% patients suffered from pterygium, 4.76% suffered from strabismus, 1.65% patients suffered from glaucoma and the remaining 31.43% suffered from various other diseases (table 1 and 2). table 1: frequency of diagnoses diseases frequency (n) percent (%) cataract 1071 57.30 pterygium 91 4.87 strabismus 89 4.76 glaucoma 31 1.65 others 587 31.43 total 1869 100.0 the third age group i.e. 41 – 60 years presented with the highest proportion of diseases (38.80%), while above 81 years group accounted for the least proportion of disease i.e. 1.87% patients (table 3). cataract was the most common disease found in all age groups of patients. table 2: distribution of diseases on the basis of gender. gender cataract pterygium strabismus glaucoma others total male 515 53 51 19 339 977 (52.27%) female 554 38 38 12 245 887 (47.46%) other 02 00 00 00 03 05 (0.27%) total 1071 91 89 31 587 1869 (100%) table 3: prevalence of diseases on the basis of age of patients. age (years) cataract pterygium strabismus glaucoma others total 0-20 102 6 63 11 239 421 (22.53%) 21-40 83 46 24 7 101 261 (13.96%) 41-60 452 36 1 8 145 642 (34.35%) 61-80 410 3 00 5 96 514 (27.50%) 81 and above 24 00 00 00 1 25 (1.34%) nil 00 00 01 00 5 6 (0.32%) total 1071 91 89 31 587 1869 (100%) discussion the major ocular morbidity observed in the study was cataract with 1071 patients i.e. 57.3%. females (51.73) were more affected than males (48.08). the age group most affected was 41-60 years with 452 patients (42.24%) of all cataract cases. quite similar results were found in a study conducted by ahmed et al. at hayatabad medical complex peshawar where cataract accounted for 57.5% patients10. opacification of the crystalline lens of the eye causes total or partial blindness11. cataract is the leading cause of loss of vision and blindness worldwide and is prevalent in both developed and developing countries.\12 cataract, in fact being highly treatable with minimally invasive surgeries, still accounts for half the world’s cases of reversible blindness. in most developing countries, blinding cataract is not only prevalent but is also more severe. and, unfortunately, the curative operative procedures are insufficient13. a pterygium (from the greek, pterygos, “little wing”) is a wing-shaped, fibrovascular growth that originates from the bulbar conjunctiva and that can chronically spread to the corneal limbus and beyond14,15. the total number of cases with pterygium in our study were 91 out of which 58.24% were males and 41.76% were females. the age group most affected was 21-40 years with 50.06% patients. in another study held in barbados, the prevalence rate was 11.6%16. yet muhammad rafiq afridi, et al 130 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology another study showed a prevalence rate of 10.1%, both of which were quite higher than ours17. the prevalence rate of squint in our study was 4.76% with 57.30% males and 42.70% females. the age group most commonly affected was 0-20 years with 70.79% prevalence rate. strabismus is a problem caused by one or more dysfunctional eye muscles18. in a study conducted in hayatabad medical complex peshawar, squint was reported in 2.0% cases which is less than ours10. in another study conducted in riyadh ksa, prevalence of strabismus was also less than that of our study i.e. 1.9% vs. 4.7%19. globally, the second leading cause of blindness is glaucoma20. it is difficult to define glaucoma precisely, partly because the term amalgamates a wide array of diseases. all types of glaucoma have a characteristic optic neuropathy that is associated with visual field loss as harm advances, and in which intraocular pressure is a key factor that can be modified21,22. our study showed the prevalence rate of 1.66% with 61.29% males and 38.71% females. the age group most affected was between 0-20 years. the ratio of glaucoma in this study was found to be low as compared to another study conducted in peshawar i.e. 1.66% as compared to a study conducted in hayatabad medical complex where the prevalence of glaucoma was found to be 4.5%10. limitations of this study incorporate the study design (retrospective), the site being of a solitary tertiary care hospital and all information was gatered from an inpatient treatment facility. along these lines, a populace-based study would give more dependable information on ocular morbidities which would incorporate information from the general outpersistent administrations. conclusion female preponderance was more than males in the sense of general morbidity of ocular disorders. the most common eye morbidity was found to be; cataract which does not require any long-term medical treatment. the second most common disease found was pterygium which was different from most other studies while doing the literature review. glaucoma was found to be least common eye morbidity in our study. author’s affiliation muhammad rafiq afridi associate professor, consultant ophthalmologist rehman medical institute (rmi), peshawar, pakistan khalid saifullah baig student, mbbs, final year rehman medical college, peshawar, pakistan omer nasim house officer, accident & emergency (a&e) rehman medical institute, peshawar, pakistan salman khan house officer, general surgery rehman medical institute, peshawar, pakistan author’s contribution muhammad rafiq afridi conceived, and designed, did the editing, review & final approval of the manuscript khalid saifullah baig data collection, statistical analysis &manuscript writing a spectrum of ophthalmic diseases in a tertiary care hospital in peshawar, kpk; a 10-year retrospective pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 131 omer nasim data collection/correction, manuscript writing & editing of the manuscript salman khan data correction, computer generation of the data bank references 1. topalovo av. incidence of eye diseases in different parts of the world. ophthalmology, 1984; 6: 374-77. 2. ajayeoba ai, scott sco. risk factors associated with eye disease in ibadan, nigeria. afr j biomed res. 2002; 5: 1-3. 3. canavan ym, oflaherty mj, archer db, elwood jh. a 10-year survey of eye injuries in northern ireland, 196776. british journal of ophthalmology, 1980; 64 (8): 618– 25. 4. alakija w. eye morbidity among welders in benin city, nigeria. public health, 1988 jul; 102 (4) :381–4. 5. simon jw, kaw p. commonly missed diagnoses in the childhood eye examination albany medical college, albany, new york. am fam physician, 2001; 64: 623-29. 6. pi l-h, chen l, liu q, ke n, fang j, zhang s, et al. prevalence of eye diseases and causes of visual impairment in school-aged children in western china. journal of epidemiology, 2012; 22 (1): 37–44. 7. khatri b, kashif a. pattern of common eye diseases in children in a tertiary eye hospital, karachi. pak j ophthalmol. 2014; 30 (04): 193-98. 8. pakbin m, katibeh m, pakravan m, yaseri m, soleimanizad r. prevalence and causes of visual impairment and blindness in central iran; the yazd eye study. journal of ophthalmic and vision research, 2015; 10 (3): 279. 9. oduntan, a. prevalence and causes of low vision and blindness worldwide. african vision and eye health, 2005; 64 (2): 44-57. 10. ahmad n, aamir a.h, hussain i, ghulam s. annual prevalence of various diseases in hospitalized patients in a teriary level teaching hospital at peshawar. pak j med res 2004; 43: 166-71. 11. jacobs ds. cataract in adults [internet]. uptodate. 2017. available from: https://www.uptodate.com/contents/cataract-inadults. 12. al-swailmi fk. global prevalence and causes of visual impairment with special reference to the general population of saudi arabia. pakistan journal of medical sciences, 2018; 34 (3): 751–6. 13. liu y-c, wilkins m, kim t, malyugin b, mehta js. cataracts. the lancet. 2017; 390 (10094): 600–12. 14. schein od. the epidemiology of eye disease. new england journal of medicine, 1998 nov; 339 (20): 1482– 3. 15. hashemi h, khabazkhoob m, yekta a, jafarzadehpour e, ostadimoghaddam h, kangari h. the prevalence and determinants of pterygium in rural areas. journal of current ophthalmology, 2017; 29 (3): 194–8. 16. aminlari a, singh r, liang d. management of pterygium. eye net mag. 2010; 14 (11): 37–8. 17. nemesure b, wu s-y, hennis a, leske mc. nine-year incidence and risk factors for pterygium in the barbados eye studies. ophthalmology, 2008; 115 (12): 2153–8. 18. ang m, li x, wong w, zheng y, chua d, rahman a, et al. prevalence of and racial differences in pterygium. ophthalmology, 2012; 119 (8): 1509–15. 19. alsaqr a, abusharha a, fagehi r, almutairi a, alosaimi s, almalki a, et al. the visual status of adolescents in riyadh, saudi arabia: a population study. clinical ophthalmology, 2018; 12: 965–72. 20. fan s. strabismus. xpharm: the comprehensive pharmacology reference, 2009;: 1–3. 21. glaucoma is second leading cause of blindness globally. bulletin of the world health organization, 2004 nov; 82 (11): 811–90. 22. bowling b. glaucoma. in: kanski’s clinical ophthalmology a systematic approach, 8th ed. 2016. https://www.uptodate.com/contents/cataract-in-adults https://www.uptodate.com/contents/cataract-in-adults microsoft word atiya rehman.doc 198 original article validity of symptoms as screening tool for dry eye atiya rahman, kamran yahya, tabussum ahmed, khwaja sharif-ul-hasan pak j ophthalmol 2007, vol. 23 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: atiya rahman iv-a, 9/1 nazimabad karachi received for publication december’ 2006 …..……………………….. purpose: to determine the role of symptoms in diagnosing dry eye among those aged 40 years and above, who attended the out patient department of ophthalmology at baqai medical college karachi. material and methods: this study was conducted from april 2001 to december 2002. 100 patients were selected on the basis of symptomatology proforma, consisting six most common symptoms of dry eye such as dryness, grittiness, burning, redness, crusting and sticking of eyelashes. those patients suffering from any two of these six symptoms were screened and included in the study group. this group was then subjected to three diagnostic tests such as schirmer’s test, rose bengal staining of the ocular surfaces and tear film breakup time. the sensitivity and specificity of these tests was determined for the diagnosis of dry eye. result: 52 out of hundred patients were females and 48 were males. the most commonly reported symptoms of burning sensation and redness were present in 70 patients often or all of the time and 30 patients reported these symptoms to be present rarely or sometimes. 200 eyes which were subjected to the diagnostic tests, 168 eyes had positive result and 32 eyes had negative result. taking schirmer’s test as the gold standard the sensitivity of rose bengal test is 92.85 % and fluorescein break up time test is 21.42 %. conclusion: this study reveals that symptoms assessment plays an important role in diagnosing dry eye syndrome and as the age increases the tear secretion decreases. there is strong correlation between symptoms, schirmer’s test and rose bengal test. the rose bengal test is the second important test used for diagnosing dry eye syndrome among those aged above 40 years. ver fifty years ago henrik sjogren described a disease characterized by autoimmune damage to lacrimal gland tissue, decreased tear secretion and ocular surface disease called ‘keratoconjunctivitis sicca’ (kcs). it is now recognized that kcs or dry eye refers to, or is a component of variety of disorders. it is characterized by ocular surface disease that results from any condition or circumstance that decreases tear secretion or increases tear film evaporation1. the terms “dry eye” and “keratoconjunctivitis sicca” are synonymous 2. the pre–ocular tear film–air interface is the principal refractive surface of the eye. the maintenance of stable quality tear film is of paramount importance with regard to good vision. tear film consists of three layers. the most superficial layer of o 199 tear film is lipid layer, 0.11µm thick produced by the meibomian glands. the middle layer the widest at 7.0µm is the aqueous layer produced by the main lacrimal gland as well as accessory lacrimal glands of krause and wolfring. aqueous tear deficiency is the most common cause of dry eye3. aqueous layer constitutes over 90 % of tear film4. the layer closest to the cornea is the mucin layer 0.02 – 0.05µm thick, produced by conjunctival goblet cells. each layer of tear film can be affected by different diseases, each causing clinically dry eye or keratoconjunctivitis sicca3. dry eye conditions have been classified into two major categories: 1. tear deficient dry eye (tdde), in which there is deficiency of lacrimal component of tears. 2. evaporative dry eye (ede), where the cause is excessive evaporation. tear deficient dry eye can further be separated into sjogren syndrome (ss) dry eye, an autoimmune disorder affecting the lacrimal and salivary glands and non sjogren syndrome that encompasses the range of other causes of tear deficiency. evaporative dry eye is caused by alteration or deficiency in lipid secretion by meibomian glands resulting in increased evaporation of aqueous tear from ocular surface. the leading cause is meibomian gland dysfunction5. dry eye syndrome can lead to vision threatening complications therefore early diagnosis is important. symptom assessment plays a large role in the diagnosis of dry eye6. ocular fatigue has been described as a major symptom of dry eye7. ocular irritation is one of the most common complaints of patients8. other common symptoms of dry eye are burning sensation and sandy – gritty sensation etc. symptoms tend to be worse secondary to environmental extreme during winter and on exposure to indoors heating system. patient may complaint of excessive tearing due to reflex secretion 3. importance of multiple tests in evaluation of tear film disorder is acknowledged with patient history, dry eye questionnaire, tear film breakup time, ocular surface staining and schirmer’s test being the preferred diagnostic tools9. material and methods this study was carried on 100 patients who attended the out patient department at baqai medical university hospital. they aged 40 years or above and presented with any two symptoms mentioned in the dry eye questionnaire such as grittiness, redness, burning sensation, crusting on the eye lashes and morning stickiness. each time the patient indicated the presence of a symptom he or she was asked whether the symptom was experienced rarely, sometimes, and often or all of the time. additional factors regarding severity and exacerbating conditions (e.g. season, wind, time of the day) were also asked. history of any previous illness such as rheumatoid arthritis, sjogren syndrome, and diabetes mellitus was recorded. use of any drugs or hormone replacement therapy was also taken into account. those patients aged below 40 years and having conjunctival and corneal infection were excluded from the study. the clinical examination included visual acuity recording, schirmer’s test, slit lamp examination of anterior segment, examination of cornea after fluorescein staining, tear film breakup time test and rose bengal staining. the sequence of examination was as follow: 1. visual acuity assessment by snellen’s chart. 2. schirmer’s test. test was performed by using sterile schirmer’s (filter paper) strips which are 5mm x 35mm (figure 1). the test results were considered positive if length of wetting obtained was less than 5 mm or less in 5 minutes. 3. slit lamp examination of anterior segment. to see the presence of conjunctival congestion, conjunctival discharge, mucus filaments and dryness of bulbar conjunctiva. 4. fluorescein staining. fluorescein strips (figure 1) were used, staining was recorded and tear meniscus was measured. 1mm height of meniscus was taken as normal. 5. tear film breakup time test. it was recorded after fluorescein staining. the test was considered positive if average tear film breakup time was less than 6 seconds. 6. rose bengal staining. it was performed by using sterile rose bengal paper strips from which it was released by drop of saline (figure 1). the oxford grading scheme was used for grading ocular surface damage. the grading chart is made up of five panels, each of which represents typical gradations of stain on either cornea or conjunctiva. grading is done as 0, i, ii, iii, iv and v depending on number of dots per panel. minimum being grade 0 and maximum score is v. (figure 2). results 200 between april 2001 and december 2002, 100 patients 40 years of age or older were evaluated for dry eye at the out patient department of ophthalmology at baqai medical university hospital. 200 eyes of these patients were subjected to schirmer’s test; rose bengal test and tear breakup time test. 30 patients presented with any two symptoms from the dry eye questionnaire to be present rarely or sometimes, 70 patients had had any two symptoms to be present often or all of the time. 18 patients aged 60 – 69 years reported two or more symptoms to be present rarely or sometimes and 42 patients reported two or more symptoms to be present often or all of the time. out of those patients aged between 50 – 59 years 08 patients reported the symptoms to be present rarely and sometimes and 18 patients had them often or all of the time. among patients belonging to age group 40 – 49 years 04 had symptoms rarely and sometimes and 10 had them often or all of the time (table 1). fig. 1. rose bengal strip, fluorescein strip and scherimer tear test strip. fig. 2. grading of corneal and conjunctival staining (oxford scheme) (bron a.j. the doyne lecture reflection on the tears eye 1997, 11, 592) out of 200 eyes, which were subjected to three diagnostic tests, 168 eyes had positive results and 32 eyes had negative results (table 2). among those aged 60 – 69 years 78.6 % had schirmer’s test positive, 73.6 % had rose bengal tests positive and 50 % had tear film breakup time tests positive, patient aged 50 – 59 years, 17.8 % had schirmer’s test positive, 13.2 % had rose bengal tests positive and 16.6 % had tear breakup time tests positive and patient aged 40 – 49 years 3.6 % had schirmer’s test positive, 13.2 % had rose bengal tests positive and 33.4 % had tear film breakup time tests positive (table 3). table 1: symptoms age wise age rarely or sometimes often or all of the time total 40 – 49 04 10 14 50 – 59 08 18 26 60 – 69 18 42 60 total 30 70 100 table 2: eyes with diagnostic tests total eyes positive diagnostic test negative diagnostic test 200 168 32 table 3: positive diagnostic tests age wise 201 age schirmer’s test rose bengal test tear break up time test no. (%) no. (%) no. (%) 40 – 49 04 (03.6) 20 (13.2) 08 (33.4) 50 – 59 20 (17.8) 20 (13.2) 04 (16.6) 60 – 69 88 (78.6) 112 (73.6) 12 (50.0) total 112 152 24 grading of rose bengal staining was done following oxford scheme and it was found that 20 % of eyes had grade 0 on staining, 46 % had graded i, 0.5 % had grade ii, 1.0 % had grade iv and 0.5 % grade v. (table 4). taking schirmer’s test as gold standard, screen test analysis showed that the sensitivity of rose bengal was 92.85 % and specificity was 14.28 % (table 5). sensitivity of tear film break up time test was 21.42 % and specificity was 78.57 % (table 6). table 4: grading of rose bengal staining according to oxford scheme no. of eyes n (%) grading 40 (20.0) 0 92 (46.0) i 17 (8.5) ii 02 (1.0) iv 01 (0.5) v table 5: sensitivity and specificity of rose bengal test. schirmer’s +ve schirmer’s– ve rose bengal +ve rose bengal – ve 104 a 48 b 08……..c 08 d sensitivity= a/(a+c) x 100 specificity= d/(d+b) x 100 table 6: sensitivity and specificity of tear break up time test schirmer’s +ve schirmer’s – ve tbut +ve tbut – ve 24 a 12 b 88 c 44 d sensitivity= a/(a+c) x 100 specificity= d/(d+b) x 100 discussion dry eye is a major tear deficiency disorder that affects millions of people world wide10. it is a distressing problem which is often overlooked and under diagnosed. the patient presents for the assessment and treatment when the condition is moderate to severe and symptoms become intolerable11. the development of dry eye is based on changes in composition of tear film which consists of the outermost lipid layer from the meibomian glands, the middle aqueous layer from the lacrimal gland, and the inner most mucinous layer from the goblet cells of the conjunctiva. a large variety of diseases associated with dry eye includes blink disorders, disorders of eyelids, autoimmune diseases, blephritis12, which cause dysfunction of the meibomian glands13 and trachoma causing obliteration of the lacrimal ducts in the superior conjunctival fornices there by blocking secretion14. dry eye is a significant feature of diabetes mellitus, which may be attributed to decrease corneal sensitivity, neuropathy involving innervations of lacrimal gland and loss of goblet cells15. clinically dry eye can be divided into three stages. in the first stage the patient has symptoms but no signs are present, in the second stage the symptoms of stage i, along with reversible signs such as small erosions and ulcers in the corneal epithelium, mucous secretion, and hyperemia of the nasal and temporal bulbar conjunctiva are present and the third stage which has the symptoms and signs of first and second stages, along with irreversible signs such as corneal leucomas, and ulcerations12 which can lead to sight threatening corneal complication14. diagnosis of dry eye is often difficult, a number of diagnostic tests have been performed to establish the diagnosis of dry eye. the two tests used most frequently in clinical practice are schirmer’s test and rose bengal test. according to european study group criteria, the presence of symptoms and either an abnormal rose bengal test or schirmer’s test is required to diagnose dry eye syndrome. these 202 diagnostic tests have limited value if performed individually or in the absence of symptoms11. in the study performed in australia by mc carty et al reported that most of the patients presented with the symptoms of foreign body sensation, discomfort, itching, tearing and photophobia11. toda et al reported patients complaining of itchy feeling16, where as adolfo et al stated that ocular irritation being the most common complaint of the patient presenting to the ophthalmologists8. most of our patients presented with redness and burning sensation which were either present often or all of the time. 60% of the patients experiencing these symptoms were between 60 – 69 years of age. schein and associates have reported that 15% of individuals older than 65 years presented with complaint of irritation17. according to mc carty et al as the age increases the tear secretion decreases11. environmental factor such as poor quality of air and prolonged work at video display terminal can cause eye irritation8. in our set up most of the patients came from the villages around baqai medical university hospital, so exposure to heat, dust and air pollution may be attributed towards the symptoms of redness and burning sensation. the patients suffering from dry eye often complaint of ocular fatigue and heavy eye sensation10, but no such complaint was reported in our patients. among the three diagnostic tests performed which were schirmer’s test, rose bengal test and tear film breakup time, it was found that among those aged 60 – 69 years, 78.6 % had schirmer’s test positive, 73.6 % had rose bengal test positive and 50.0 % had decreased tear film breakup time. the schirmer’s test is the most popular test performed for dry eye and to perform this test there is no need for any additional equipment18. it measures the aqueous layer of the tear film produced by the lacrimal gland. schirmer’s test has high specificity as shown by study done by fareis et al11 so taking it as the gold standard. the sensitivity of rose bengal test is found to be 92.85 % and that of tear film breakup time test is 21.42 %, this shows that rose bengal test has high sensitivity as also indicated in the study11. rose bengal staining reflects the epithelial cell deprived mucin6, whereas tear film breakup time test indicates the stability of the lipid layer of tear film9. among patients who had positive rose bengal test, grading was done according to oxford scheme19. most of the eyes had grade 0 and grade i staining pattern which indicates that most of the cases were borderline and were detected early on the basis of symptomatology, so this shows that symptoms play an important role in diagnosing dry eye. it has been shown previously that there is lack of corelation between symptoms, schirmer’s test and rose bengal test17, but our study reveals that there is a strong relationship between symptoms and diagnostic tests such as rose bengal test and schirmer’s test. conclusion this study reveals that symptom assessment is an important tool for dry eye diagnosis and as the age increases the tear secretion decreases. schirmer's test is more specific so taking it as standard the sensitivity of rose bengal is found to be 92.85 % indicating that it is the second most important test in establishing the diagnosis of dry eye syndrome. there is strong correlation between symptoms, schirmer’s test and rose bengal test and the tear film breakup time test is least discriminating among the three diagnostic tests (schirmer’s test, rose bengal test and tear breakup time test) performed. author’s affiliation dr. atiya rahman senior registrar department of ophthalmology baqai medical university, karachi dr. kamran yahya department of ophthalmology baqai medical university, karachi dr. tabussum ahmed consultant ophthalmologist ahmed eye clinic federal b area, karachi. dr. khawaja sharif–ul–hasan professor and chairman department of ophthalmology baqai medical university, karachi reference 1. geffrey p,. gilbard. dry eye disorder. clinical practice principles and practice of ophthalmology albert and jakobiec. w. b. saunders company. 1994; 1: 257–74. 2. bron aj. the doyne lecture reflections on the tears. eye 1997; 11: 583–602. 3. disorder of ocular surface. basic and clinical science course. american academy of ophthalmology. 1997–98; 8: 155. 203 4. lemp ma. diagnosis and treatment of tear deficiencies. clinical ophthalmology duane. 1980; 14: 1–10. 5. horwath–winter j, gerghold a, schmut o, et al. evaluation of the clinical course of dry eye syndrome. pak j ophthalmol. 2004; 20: 43–5. 6. nichole kk, nichols jj, zadnik k. frequency of dry eye diagnostic test procedures used in various modes of ophthalmic practice. cornea. 2000; 19: 477-82. 7. toda i, fujishima h, tsubota k. ocular fatigue is the major symptom of dry eye. acta ophthalmol (copenh). 1993; 71: 347–52. 8. afonso aa, monroy d, stern me, et al. correlation of tear fluorescein clearance and schirmer’s test scores with ocular irritation symptoms. ophthalmology 1999; 106: 803–10. 9. korb dr. survey of preferred tests for diagnosis of the tear film and dry eye. cornea 2000; 19: 483–6. 10. goto e, yagi y, matsumoto y, et al. impaired functional visual acuity of dry eye patients. am j ophthalmol. 2002; 133: 181-6. 11. mc carty ca, bansal ak, livingston pm, et al. the epidemiology of dry eye in melbourne, australia. ophthalmology 1998; 105: 1114–8. 12. boyd bf. the important developments in dry eye. highlights of ophthalmology. 2001; 29: 54-66. 13. mathers wd, lane ja, sutphin je, et al. model for ocular tear film function. cornea 1996; 15: 110-9. 14. clinical aspects of ocular surface disorders. basic and clinical science course. american academy of ophthalmology. 2004; 8: 63-100. 15. dogru m, katakami c, inoue m. tear function and ocular surface changes in non insulin-dependent diabetes mellitus. american academy of ophthalmology. 2001; 108: 586-91. 16. fujishima h, toda i, shimazaki j, et al. allergic conjunctivitis and dry eye. br j ophthalmol. 1996; 80: 994-7. 17. schein od, tielsch jm, munoz b, et al. relation between sign and symptoms of dry eye in the elderly. ophthalmology 1997; 104: 1395-1401. 18. kaye sb, sims g, willoughby c, et al. modification of the tear film index and its use in the diagnosis of sjogren’s syndrome. br j ophthalmol. 2001; 85: 193-9. 19. gilbard gp. dry eye disorder. clinical principles and practice of ophthalmology albert and jackobiec. w. b. saunders company. 1994; 1: 257-74. microsoft word abstracts vol. 23,3, 07.doc 169 abstracts edited by dr. tahir mahmood glaucoma progression is associated with decreased blood flow velocities in the short posterior ciliary artery zeitz o, galambos p, wagenfeld l, wiermann a, wlodarsch p, praga r, matthiessen e t, richard g, klemm m br j ophthalmol 2006;90:1245-8. besides increased intraocular pressure (iop), a disturbed microcirculation at the level of the optic nerve head as well as a primary neurodegenerative component are thought to contribute to glaucomatous optic neuropathy. to gain insight into the pathophysiological relevance of haemodynamic disturbances on the course of disease progression, in this study it was hypothesised that there are inferences in haemodynamics of patients having glaucoma with progressive versus stable disease, which are independent of iop and systemic blood pressure. an altered perfusion of the optic nerve head has been proposed as a pathogenic factor in glaucoma. peak systolic velocity (psv), end diastolic velocity (edv) and resistivity index in the short posterior ciliary artery (spca), central retinal artery (cra) and ophthalmic artery were recorded in 114 consecutive patients having glaucoma with an intraocular pressure (iop) < 21 mm hg, as well as in 40 healthy volunteers, by colour doppler imaging (cdi). of the 114 patients with glaucoma, 12 showed glaucoma progression (follow-up period: mean 295 (standard deviation (sd) (18) days). cdi measurements in these patients showed decreased psv and edv in the spca (p<0.001 and p<0.05, respectively) and decreased psv in the cra compared with patients with stable glaucoma and healthy controls (p<0.05). no differences in flow velocities were found for the ophthalmic artery. iop and systemic blood pressure was similar in all the three groups. authors concluded that progressive glaucoma is associated with decreased blood flow velocities in the small retrobulbar vessels supplying the optic nerve head. the detected difference could represent a risk factor for progression of glaucomatous optic neuropathy. surgical embolus removal in retinal artery occlusion garcia-arumf jg, martinez-castilio v, boixadera a, fonoliosa a, corcostegui b br j ophthalmol 2006; 90: 1252-5. retinal artery occlusion (rao) is a potentially devastating visual disorder, usually caused by blockage of a vessel by emboli or atheroma. the emboli, which are visible in 20-40% of eyes, mainly originate in the carotid arteries (74.5%) and are comprised of cholesterol. fibrin-platelet emboli (15.5%) and calcific emboli from the cardiac valves (10.5%) are also relatively frequent,' whereas emboli caused by corticosteroid use, cardiac myxoma and intravenous drug misuse are uncommon. the site of the pathological process determines whether the central retinal artery (lamina cribrosa), a branch retinal artery or the cilioretinal artery will be affected. experimental studies have shown that irreversible retinal damage occurs by 24 hrs after central rao. numerous treatment approaches have been attempted to improve vision in eyes with rao, but none has proved particularly effective. in i990, peyman and gremillion surgically removed one embolus in a patient with branch rao of 60 h duration, with a visual acuity improvement to 2/200. the purpose of this study was to assess the anatomical outcome, safety and functional effectiveness of surgical embolus removal in seven consecutive patients with rao. prospective study of seven patients with rao of <36 h duration. all eyes underwent pars plana vitrectomy and a longitudinal incision of the anterior wall of the occluded arteriole in an attempt to remove the embolus. outcome measures included visual acuity and arteriolar reperfusion, as evaluated with fluorescein angiography. 170 surgical removal of the embolus was achieved in six of the seven (87.5%) patients, visual acuity improved from a median of 20/400 (range: hand movements 20/25) to 20/ 40 (range: hand movements 20/25), and reperfusion of the occluded vessel was angiographically confirmed in four of the six patients in whom the embolus was successfully removed. authors concluded that surgical removal of retinal arterial emboli seems to be an effective and safe treatment for rao, but a randomised and controlled clinical trial will be necessary to establish an evidence base for the role, if any, of this intervention. bilateral cataract surgery and driving performance wood jm, carberry tp br j ophthalmol 2006; 90:1277-80. older people comprise the fastest growing sector of the driving population; this has important implications for road safety as they are also reported to have high crash rates per distance travelled. however, not all older driver’s are unsafe, and many continue to drive safely well into older age. recent research has sought to identify tests that can accurately differentiate between safe and unsafe drivers, recognizing that it is functional rather than chronological age that best predicts driving ability, as well as seeking interventions, which can extend the time that older drivers can drive safely. cataract surgery has been suggested as an intervention that can potentially improve the performance of older drivers. a growing body of evidence suggests that older drivers with cataracts are less safe to drive than their counterparts without cataracts. people with cataracts experience more problems when driving, drive shorter distances and avoid challenging driving situations nevertheless, despite limiting their driving exposure, drivers with cataracts have 2.5 times more crashes than controls, and crash involvement is predicted by deficits in contrast sensitivity. further evidence comes from closed-road and open-road studies, which have shown that drivers with either simulated or true cataracts have considerably impaired driving performance compared with controls. the presence of cataracts has also been associated with driving cessation. the positive benefits of cataract surgery on vision and quality of life have been widely reported; however, fewer studies have investigated the impact of cataract surgery on real-world activities such as driving. crash rates have been shown to halve after cataract surgery compared with controls, suggesting that cataract surgery can result in tangible benefits to road safety. self-reported improvements in driving have been described within 1 year and 5 years after surgery, and the driving subscales of the activities of daily vision scale improve alter cataract surgery, particularly for night driving. this study investigated the effect cataract surgery on real-world measures of driving performance for patients undergoing bilateral cataract surgery within a 3-month period, and determined how well these measures related to changes in visual performance. 29 older patients with bilateral cataracts and 18 controls with normal vision were tested. all were licensed drivers. driving and vision performance were measured before cataract surgery and after second eye surgery for the patients with cataract and on two separate occasions for the controls. driving performance was assessed on a closed-road circuit. visual acuity, contrast sensitivity, glare sensitivity and kinetic visual fields were measured at each test session. patients with cataract had significantly poorer (p<0.05) driving performance at the first visit than the controls for a range of measures of driving performance, which significantly improved to the level of the controls after extraction of both cataracts. the change in contrast sensitivity after surgery was the best predictor of the improvements in driving performance in patients with cataract. authors concluded with remarks that cataract surgery results in marked improvements in driving performance, which are related to concurrent improvements in contrast sensitivity. insights into the age-related decline in the amplitude of accommodation of the human lens using a nonlinear finite-element model schachar ra, abolmaali a, le t br j ophthalmol 2006; 90: 1304-9. the aetiology of the age-related decline in accommodative amplitude is not established. mathematical modeling b offers the opportunity of evaluating some of the lens parameters responsible for 171 presbyopia. this study uses the non-linear finite element method (fem) in parametric assessment to determine the effect of varying the geometric and material properties of the lens on the ability of zonular traction to change central optical power (cop). the purpose of this study was to understand the effect of the geometric and material properties of the lens on the age-related decline in accommodative amplitude. using a non-linear finite-element model, a parametric assessment was carried out to determine the effect of stiffness of the cortex, nucleus, capsule and zonules, and that of thickness of the capsule and lens, on the change in central optical power (cop) associated with zonular traction. convergence was required for all solutions. increasing either capsular stiffness or capsular thickness was associated with an increase in the change in cop for any specific amount of zonular traction. weakening the attachment between the capsule and its underlying cortex increased the magnitude of the change in cop. when the hardness of the total lens stroma, cortex or nucleus was increased, there was a reduction in the amount of change in cop associated with a fixed amount of zonular traction. increasing lens hardness reduces accommodative amplitude; however, as hardness of the lens does not occur until after the fourth decade of life, the agerelated decline in accommodative amplitude must be due to another mechanism. one explanation is a progressive decline in the magnitude of the maximum force exerted by the zonules with ageing. acute endophthalmltis in eyes treated prophylactically with gatifloxacin and moxifloxacin deramo va, lai jc, fastenberg dm, udell ij am j ophthalmol 2006; 142: 721-5. endophthalmitis is an uncommon, but serious, consequence after intraocular surgery and can lead to severe visual loss. recent studies have suggested that the incidence after cataract extraction has increased over the last decade. fluoroquinolones are a class of broad-spectrum, bactericidal antibiotics that cover many gram-positive, gram-negative, and anaerobic organisms. they are commonly used to treat ocular infections and are widely used as prophylactic agents before and following intraocular surgery to prevent endophthalmitis. second and third generation fluoroquinolone antibiotics, such as ciprofloxacin, ofloxacin, and levofloxacin, have excellent gram-negative coverage, but they are less potent against gram-positive organisms, notably staphylococcus and streptococcus isolates. recently, two fourth generation antibiotics, gatifloxacin and moxifloxacin, have been developed. both are available for topical ophthalmic use: 0.3% gatifloxacin (zymar; allergan, inc, irvine, california, usa and 0.5% moxifloxacin (vigamox; alcon laboratories, inc. fort worth, texas, usa). gatifloxacin and moxifloxacin shown to have increased activity against both fluoroquinolone sensitive and fluoroquinolone resistant gram-positive organisms. antibiotic resistance is a clinically significant issue. increasing resistance of staphylococcus aurcus (s. aureus) and other gram-positive organisms to ciprofloxacin and ofloxacin has been noted in several studies. levofloxacin does not appear to have more activity against these resistant organisms. recent reports have shown that a relatively high level of in vitro resistance to fourth-generation fluoroquinolone antibiotics may exist in methicillin-resistant staphylococcus aureus (mrsa) ocular surface isolates and in archived mrsa isolates. the purpose of this study was to examine the prophylactic use of fourthgeneration fluoroquinolones and bacterial sensitivity to gatifloxacin, moxifloxacin, and earlier generation fluoroquinolone antibiotics in cases of acute endophthalmitis. forty-two eyes of 42 patients with acute endophthalmitis occurring within six weeks after cataract surgery were identified. all patients were seen in a referral vitreoretinal practice over a two-year time interval. the number of patients using prophylactic gatifloxacin or moxifloxacin and results of bacterial culture and sensitivity to all fluoroquinolone antibiotics were recorded. thirty-one of 42 eyes (74%) were treated with perioperative gatifloxacin or moxifloxacin and 24 eyes (57%) were continuously taking one of these antibiotics at the time of diagnosis. nineteen eyes (45%) had a positive bacterial culture. the most frequent organism isolated was coagulase-negative staphylococcus. sensitivities were performed for 14 gram positive organisms, and sensitivities to 172 ciprofloxacin (50%), ofloxacin (44%), levofloxacin (46%), gatifloxacin (38%), and moxifloxacin (38%) were noted. five organisms were resistant to gatifloxacin and moxifloxacin with a minimum inhibitory concentration of 8 µg/ml. all gram-positive organisms were sensitive to vancomycin. median visual acuity improved from hand motions to 20/40 at last follow-up. authors concluded with the remarks that acute endophthalmitis can develop after cataract surgery despite the prophylactic use of fourth-generation fluoroquinolone antibiotics. gram-positive organisms causing acute endophthalmitis are frequently resistant to all fluoroquinolones, including a significant number of cases resistant to gatifloxacin and moxifloxacin. atopic disease and herpes simplex eye disease: a population-based case-control study prabriputaloong t, margolis tp, lietman tm, wong ig, mather r, gritz dc am j ophthalmol 2006; 142: 745-9. following peripheral inoculation, herpes simplex viruses (hsv) undergo retrograde axonal transport and establish life long latent infections in sensory neurons of the trigeminal and dorsal root ganglia. intermittent reactivation of hsv from latently infected neurons leads to peripheral shedding of infectious virus, which under favorable conditions cause inflammation and lesion formation on the skin and mucosal surfaces. shedding of hsv in and around the eye occurs frequently and can cause sight threatening ocular disease including keratitis, iritis, and retinitis. rarely, reactivation of hsv causes encephalitis or disseminated infection. clinical observation suggests that atopic disease is a risk factor for severe and recalcitrant hsv infection. patients with chronic or disseminated hsv skin disease, including eczema herpeticum, frequently have a history of atopic dermatitis, as do patients with bilateral hsv ocular disease. furthermore, it has been our experience that atopic patients with hsv ocular disease often require higher doses of antiviral therapy courses or longer antiviral treatment or both, compared with patients without atopy. the goal of the current study was to determine if atopy is a risk factor for the development of ocular herpes simplex virus disease. to accomplish this, authors performed a retrospective case control study using population-based data from the kaiser permanente healthcare program of northern california and compared the prevalence of atopic disease among patients with ocular herpes simplex infection to age matched controls drawn from patients visiting the same eye clinics and from the health plan membership communities. electronic database search for hsv ocular disease and subsequent chart review determined study eligibility. two age matched control groups (one population-based and one clinic based) were randomly chosen. medical record review determined the presence of atopy. severe atopic disease was defined by diagnostic code or illness requiring an emergency room visit, hospitalization, or treatment with a systemic corticosteroid. presence of hsv eye disease, presence of atopy, and characterization of atopy severity. hsv eye disease was found in 172 patients. hsv cases had a greater prevalence of atopy (34%, 58/172) than the clinic-based (25%, 43/172) or the populationbased controls (21%, 36/172, odds ratio (or) 1.5, 95% confidence interval (ci) 0.9 to 2.6 and or 1.9, 95%, ci 1.1 to 3.3, respectively). the association of hsv ocular disease with severe atopy was even greater, with a history of severe atopic disease in 13% (22/172) of patients with hsv ocular disease as compared with 6% (11/172) of patients in the clinic control group and 3% (5/172) of patients in the population control group (or 2.0, 95% ci 0.7 to 5.9 and or 4.8, 95% ci 1.6 to 19.2, respectively). authors concluded that patients with hsv ocular disease are more likely to have a history of atopic disease, especially severe atopic disease, than agematched controls. wavefront analysis and contrast sensitivity of aspheric and spherical intraocular lenses: a randomized prospective study rocha km, soriano es, chalita mr, yamada ac, bottos k, bottos j, morimoto l, nose w am j ophthalmol 2006; 142:750-6. modern cataract surgery and lens replacement attempt not only to restore visual acuity, but also to improve visual function and protect the retina against light toxicity. 173 deficiencies on optical quality of vision not detected by visual acuity measurement can be effectively evaluated by wavefront analysis and contrast sensitivity rest. wavefront technology can quantity low and high-order aberrations (hoa) present in an optical system. the high-resolution imaging in ophthalmic optics can be affected by high order aberrations such as coma and spherical aberration. conventional spherical intraocular lens (lols) can degrade imaging quality, increasing the spherical aberration of the optical system. the light rays at the peripheral zones of a positive lens are refracted with larger angles and intersect the optical axis closer to the lens than the paracentral rays, producing positive spherical aberration. aspherical iol designs can optimize image quality by limiting rays diffraction. they have been describe to improve visual function by means of reducing spherical aberration. the benefits of an iol with short wave absorbing chromophores in terms of elevating the threshold for photochemical damage may provide more retinal protection than usual lols. it was also described that uv-absorbing lols do not cause contrast sensitivity and chromatic vision disturbance. the acrysof iq iol includes blue light filter properties associated with a posterior aspheric design. this randomized prospective study aims to clarity the relationships between total and high-order wavefront aberrations (coma, spherical aberration, and other terms of hoa and contrast sensitivity under photopic and mesopic conditions in eyes implanted with three different iols: acrysof iq (aspheric iol with blue light filter), acrysof natural (spherical iol with blue light filter), and advanced medical optics (amo) sensar (spherical iol with no blue light filter). sixty patients were randomized to receive three iol types: alcon acrysof iq (40 eyes), acrysof natural (40 eyes), and advanced medical optic (amo) sensar (40 eyes). complete ophthalmologic examination including uncorrected visual acuity (ucva), best-spectacle corrected visual acuity (bscva), corneal topography, and wavefront analysis were performed pre-operatively, 30 days, and 90 days postoperatively. pelli-robson chart test and functional acuity contrast testing (fact-optec6500) were performed approximately 50 days after surgery. statistical analyses were performed using analysis x2, analysis of variance (anova), and multiple comparisons tukey test. after 90 days, all eyes had postoperative bscva ≥20/32. the acrysof iq iol showed statistically significant less induction of spherical aberration (p < .001) when compared with the amo sensar and the acrysof natural lols. the amo sensar presented significantly less spherical aberration then the acrysof natural (p < .05). the acry sof iq also had lower values of total and high-order aberration (hoa) (p < .05) when compared with the amo sensar and the acrysof natural. the mean values of trefoil 9, coma, and hoa root mean square (rms) decreased between one and three months (p < .001, p < .001, p = .023, p < .001, respectively) in all groups. mean pelli-robson contrast sensitivity values in photopic condition were similar between the groups. the acry sof iq showed better results in 3cpd spatial frequency in mesopic condition using fact-optec 6500 (p = .008), although there were no statistical differences in photopic and mesopic with glare conditions. microsoft word imran akram 111 case report spontaneous late lens subluxation masquerading as acute angle closure glaucoma imran akram pak j ophthalmol 2006, vol. 22 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: imran akram vitreoretinal fellow stoke mandeville hospital, aylesbury buckinghamshire hp21 8al uk received for publication october’ 2005 …..……………………….. case report a 45 year old lady was referred to the eye clinic in 1996 by her optician who had noticed a rapid increase in her myopia and was querying keratoconus. she had previously been emmetropic and wore only reading glasses. no signs of keratoconus were seen although it was noted that she had thick crystalline lenses. intraocular pressures were normal. pupils were not dilated for ocular examination. there was no iridodonesis. refraction showed the right eye had a 2.00 cyl axis 7, while the left eye had a -4.50 cyl axis 90.keratometry showed minimal astigmatism in either eye and thus the astigmatism was attributed to lenticular changes.with this correction she saw 6/6 in each eye. 5 months later she was re-referred by her gp complaining of misting over her right eye for a few days and symptoms what she described as “migraine” around the right eye. visual acuities were rt 6/9 and lt 6/6. intraocular pressures were 30mmhg and 20mmhg right and left eye respectively. the right anterior chamber was significantly shallow. on gonioscopy the drainage angle was completely closed in the right eye and only partially open in the left eye. a diagnosis of sub-acute angle closure glaucoma was made and she was commenced on guttae pilocarpine 1% qds to both eyes. she was booked for bilateral yag laser iridotomy for the following week. however, before that she came in as an emergency with the right intraocular pressure elevated at 55mmhg. she was admitted and the raised iop treated medically with intravenous acetazolamide and topical beta-blockers. this was followed by bilateral yag iridotomy. following this her intraocular pressures stabilized around the early 20’s in the right eye and below 112 20mmhg in the left. visual fields were full despite the right disc appearing to be more cupped than the left. over the next 4 years the right intraocular pressure gradually crept up to 27mmhg and in january 2001 she was commenced on guttae latanaprost nocte to the right eye which brought the pressure down to the mid-teens. subsequently the intraocular pressure remained well controlled in both eyes. at her 6 monthly clinic review in march 2003 she complained of deterioration of vision in both eyes which her optician had correctly attributed to the development of cortical lens opacity in both eyes. in order to better visualize her lens opacity, her pupils were dilated for the first time. this revealed that both lenses were subluxated. the left was displaced superiorly and the right slightly nasally as well as superiorly (fig 1). her general health was fine and there was no family history of eye problems. she had no clinical features of marfans or weil marchesani syndromes. left cataract extraction was carried out three weeks later. the surgical technique involved superior clear corneal section and paracentesis followed by continuous curvilinear capsulorhexis. there was no zonular support so iris hooks were employed to lift up the capsular bag (fig. 2). an uneventful divide and conquer type phacoemulsification was performed. a capsular tension ring was then introduced to support the capsular bag. this was followed by aspiration of soft lens matter and introduction of an acrysof foldable iol in the bag. the section was then hydrated. unaided visual acuity on the first post operative day was 6/6. the fellow eye underwent a similar uneventful operation six weeks later. corrected visual acuity was 6/6 in both eyes. discussion spontaneous dislocation of the crystalline lens is a known feature of certain systemic conditions notably marfans syndrome, weil marchesani syndrome and homocysteinurea. the first two of these have well defined clinical features suggestive of the diagnosis. in the absence of any systemic condition however, spontaneously dislocated lens may present as progressive myopia, shallowing of anterior chamber and occasionally glaucoma1. spontaneous dislocation of the lens occurring later in life may be an inherited condition, an observation first made by vogt in 1905. vogt and other subsequent workers have described several pedigrees throughout the 20th century. more recently malbran et al2 described seven adult members of two families with dislocated lenses and labeled these as genetic spontaneous late subluxation of the lens (gslsl). hagan and lederer3 described three relatives who were myopic and apparently had primary angle closure glaucoma. they later reported the same patients again4 revealing that the underlying pathology was infact lens subluxation and that these were also cases of gslsl. our patient does not as yet have any family history of similar eye problems. her mode of presentation however is very similar to cases of fig. 1a & b: edge of subluxated crystalline lens visible through dilated pupil 113 fig. 2: iris hooks used to support casular bag gslsl. she has normal axial lengths and never wore glasses prior to developing the lens-induced myopia. we suggest that ectopia lentis should always be considered in cases of unexplained adult-onset progressive myopia as well as narrow angle glaucoma occurring in individuals known to be myopic. we also draw attention to the surgical technique used. whereas in the past most subluxated cataracts were removed via intracapsular technique followed by anterior chamber lens implant, the use of iris hooks and capsular tension ring in combination with small incision phacoemulsification can give very satisfactory results, allowing in-the-bag insertion of posterior chamber implants. author’s affiliation imran akram ophthalmology department stoke mandeville hospital aylesbury hp21 8al, uk references 1. mcculloch c. hereditary lens dislocation with angle closure glaucoma. can j ophthalmol. 1979; 14: 230-34. 2. malbran es, croxatto jo, d’alessandro c, charles de. genetic late spontaneous subluxation of the lens. ophthalmology 1989; 96: 223-9. 3. hagan jc iii, lederer cm jr. primary angle closure glaucoma in a myopic kinship. arch ophthalmol. 1985; 103:363-5. 4. hagan jc iii, lederer cm jr. genetic spontaneous late subluxation of the lens previously reported as a myopic kinship with primary angle closure glaucoma. arch ophth 1992; 110: 1199-1200. pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 205 original article clinical and demographic characteristics of intraocular foreign body injury in a referral center: 3 years experience ibraheem waheed ademola, nazmum naha, ibraheem anifat boladale pak j ophthalmol 2016, vol. 32 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ibraheem waheed ademola retina fellow (2016) ispahani eye institute, dhaka, bangladesh consultant department of ophthalmology lautech teaching hospital ogbomoso oyo state nigeria email: hanny4demmy@gmail.com …..……………………….. purpose: to describe clinical and demographic features of patients with intraocular foreign body (iofb) injuries in a referral center. study design: retrospective case review place and duration of study: from january, 2013 to december, 2015 at department of vitreo-retinal surgery, ispahani islamia eye institute and hospital, dhaka, bangladesh materials and methods: we retrospectively reviewed 64 case files of patients who were treated for iofb injuries between january, 2013 and december, 2015. data on age, sex, ocular laterality, nature of foreign body, entry point/ visual acuity, injury to surgery time, presence of endophthalmitis and siderosis bulbi were extracted and evaluated. results: case files of 64 patients consisting 64 eyes were analyzed. the age of the patients ranged between 2-55 years. males were mostly affected accounting for 95.3% of all cases. left eye was slightly more affected (33, 51.6% versus 31, 48.4). the commonest entry site was cornea accounting for (60.9%). majority (81.1%) of the cases had entry visual acuities which were equal or worse than 6/60. intraocular foreign bodies were identified to be metallic (iron) in 63 (98.4%) of the cases. conclusion: intraocular foreign body injury is common among male working age group. there is need to formulate appropriate policy to reduce this cause of avoidable blindness. key words: intraocular, foreign body, entry site, endophthalmitis, evisceration. cular trauma is a major public health issue1. most commonly, it occurs at work, at home, during sport activities, motor vehicle crashes or interpersonal trauma. reported risk factors are male gender, workplace, road accidents, alcoholism and lower socioeconomic class2,3. it is a significant but preventable cause of blindness worldwide4. ocular trauma has an impact on the healthcare system and also the wider economy due to time off work. negrel and thylefors reported that worldwide 1.6 million people are blind secondary to ocular injuries, 2.3 million have low visual acuity bilaterally and another 19 million people are with unilateral blindness5. this study was conceived and conducted with a view of providing useful information and insight into epidemiology of ocular trauma in our community. it is anticipated that the information that will be provided by this study will enhance better understanding of the burden and the risk factors associated intraocular foreign body injury in our community. and with improved understanding, the policy maker will be much more equipped to design targeted campaigns and develop effective plans for disseminating eye o mailto:hanny4demmy@gmail.com ibraheem waheed ademola, et al 206 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology injury prevention material to the public in order to reduce the burden of avoidable blindness from this cause. material and methods we retrospectively reviewed the medical charts of 64 consecutive patients who presented with posterior segment intraocular foreign body over 3 years at our institution. the following data were collected from the medical records: age and sex, time elapsed between initial injury and surgery, preand post-operative best corrected visual acuity (bcva), entry wound, details of the surgical procedures, nature of the foreign body, presence of endophthalmitis and retina detachment. data was entered using statistical product and service solutions (spss) software version 15, (ibm corp., armonk, ny, usa). categorical data are presented in mean, median and range while noncategorical data were represented in proportion and percentages and figures. a p value less than 0.05 was considered statistically significant. results case files of 64 patients consisting 64 eyes were examined in the study. their age ranged between 2 -55 years with a mean and median age of 25.1 ± 9.24 and 24.5 years respectively. males were more affected than the female patients (95.3% versus 4.7%). further details of the demographic characteristics of the cases were as shown in table 1. table 1: demographic characteristics factors years/frequency age years minimum 2 maximum 55 median 24.5 mode 35 number (%) gender male 61 (95.3) female 3 (4.7) occupation student artisans 64 (100.0) affected eye right 31 (48.4) left 33 (51.6) right and left eyes were involved in 33, 51.6% and 31, 48.4% respectively. entry visual acuity was worse or equal to 6/60 in 81.1% of the cases. other details are as shown in table 2. table 2: visual acuities of the patients number of subjects (%) visual acuity at presentation after first intervention 6/6 -6/12 3 5 6/18-6/36 16 11 ≤ 6/60 81 84 as shown in table 2, over 80% of cases remained with uncorrected visual ≤ 6/60 after first intervention. the entrance wound sites in descending order were cornea (39, 60.9%), undetermined (13, 20.3%), sclera (11, 17.2%) and sclera cornea (1, 1.6%). intraocular foreign bodies were identified to be metallic (iron) in 63 (98.4%) cases while plastic object was found in one eye. of all the cases reviewed, 1 eye (1.7%) was eviscerated due to extensive injury and 1 had initial endophthalmitis which was treated with intra-vitreal antibiotics along with intraocular foreign body removal. eighteen (18, 28%) of the eyes were aphakic as the time of review. discussion studies on epidemiology of ocular trauma including intraocular foreign body injury are essential ingredient for attainment of vision 2020; elimination of avoidable clinical and demographic characteristics of intraocular foreign body injury in a referral center pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 207 blindness. this is because such studies provide data that help stake holder / policy makers to either adjust ongoing interventional policies or design appropriate new program. consistently, most previous studies showed that ocular trauma is most frequent in young men6, 7. for example napora et al. evaluated the intraocular and intra-orbital foreign bodies characteristics in 62 patients with iofb injury. the authors found out that majority of the patients were male with a mean age of 38.1 years8. in another large retrospective cohort study carried out at moorfields eye hospital by wickham et al., a mean age of 34.6+/-12.4 years was reported9. also, maneschg et al. examined the prognostic factors and visual outcome for open globe injuries with intraocular foreign bodies. they reported all their patients to be male with mean age of 28 ± 12.3 years10. in concordance with these previous authors, majority of the patients in our study were also young males with mean age of 35 years. reasons have been advanced to justify this observation. koo et al. posited that this occurrence might be due to higher occupational exposure, higher involvement in dangerous sports and hobbies, alcohol use and risk taking behaviour in young men11. we attribute this finding to the fact that young men are usually more active and adventurous. additionally, men are the major breadwinners in most family settings in the studied population and as such they are more prone to occupational eye injury. in intraocular foreign body injury (iofbi), the entry wound is of significance. this is because to a certain extent the visual outcome is dependent on it. demircan et al. examined 70 cases of ocular injuries with intraocular foreign bodies to determine the results of surgical management. in their report, cornea was the site of penetration in over 3/5th of the studied population accounting for 82.9% while sclera was involved in only few cases12. in our study, the most frequent entrance wound site was cornea (60.9%). this value is lower when compared with some previous report13, 14 but similar to others8. in this retrospective study, final (last visit) visual acuity was worse or equal to 6/60 in over 80% of the cases. we found this to be similar to that reported by naporal et al.8, but in contradistinction to the report of ehlers et al6. we ascribe the poor entry visual acuity in majority of the cases to long injury to surgery time due to the late presentation. our position was well corroborated by several studies wherein delayed removal of iofb was found to be associated with poor visual and anatomical outcomes including the development of infectious endophthalmitis and retinal detachment15-17. contrarily, there are authors who posited that delayed iofb removal does not have negative impact on the final visual outcomes of intraocular foreign body injury18-20. alternatively, our finding could also be a symbol that the initial injuries in most of the cases were very severe as evidenced by the poor entry visual acuities. poor visual acuity at presentation has been shown to be a negative prognostic factor in the visual outcome of iofb injury3, 21. however, it is noteworthy that certain significant numbers of the cases are aphakic and have not presented for further visual rehabilitation. evidences from many previous studies are unanimous in indicting ferromagnetic object as the most frequent object involved in intraocular foreign body injuries. values such as 91%, 85.3%, and 85.5% were previously reported by woodcock et al.22, feghhi et al10 and napora et al8 respectively. similarly, the results of our study showed over 4/5th (98.4%) of the objects to be ferromagnetic in nature. we believe this finding is related to the type of occupation of the studied population who are mostly artisan workers involved in iron/steel rod modifications. according to napora et al. tool-related activities, particularly hammering, were more likely to cause iofb injuries8. among others, the injury to surgical intervention time (ist) has been shown to be paramount in the clinical outcome of intraocular foreign body injury. and the earlier the foreign is removed, the better23. however, in many developing nations including the index study site, factors such as ignorance, poor accessibility to health care facility, high hospital cost and poverty to mention but a few often militate against appropriate/short ist. in this study, the mean ist was 66.5 ± 1.14 days (range, 1 – 653 days). this value is dissimilar to that reported by many earlier investigators such as erakgun and egrilmez and falavarjani et al who reported a mean ist of 5.3 days (range, 1 day to 240 days) and 24 ± 43.1 days respectively23,24. infectious endophthalmitis is one of the most dreadful complications of intraocular foreign body injury. an incidence of 0 – 13.5% has been previously reported25. in this study we had 3 (4.7%) cases of endophthalmitis associated with the injury. while our value is lower than that reported by some previous investigators7,12, it is higher than some others24. we opine that the development of endophthalmitis in the 4 cases may be due to long injury to surgical ibraheem waheed ademola, et al 208 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology intervention time. it could also be due to unhealthy eye care practices though this was not examined in this study. limitations of the study include its retrospective nature and the small sample size despite these limitations, our results revealed some useful information related to intraocular foreign body injury in our country. conclusion there is need for increase awareness about wearing safety glasses at work to reduce the burden of this avoidable blindness. acknowledgement thanks to the entire staff of the ispahani islamia eye institute and hospital for making this work a success. author’s affiliation ibraheem waheed ademola retina fellow (2016) ispahani eye institute, dhaka, bangladesh. consultant department of ophthalmology lautech teaching hospital ogbomoso oyo state nigeria. nazmum naha consultant department of vitreoretina surgery ispahani islamia eye institute and hospital dhaka, bangladesh ibraheem anifat boladale consultant jericho specialist clinic ibadan oyo state nigeria role of authors dr. ibraheem waheed ademola conception, literature research, data collection, analysis, manuscript write-up dr. nazmum naha conception, data collection, supervision of manuscript write-up dr. ibraheem anifat boladale analysis, manuscript write-up supervision references 1. pandita a, merriman m. ocular trauma epidemiology: 10-year retrospective study. n z med j. 2012; 125: 61-9. 2. thylefors b. epidemiological patterns of ocular trauma. aust nz j ophthalmol. 1992; 20: 95-8. 3. cillino s, casuccio a, et al. a five-year retrospective study of the epidemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in mediterranean area. bmc ophthalmol. 2008, 8: 6. 4. pandita a, merriman m. ocular trauma epidemiology: 10-year retrospective study. n z med j. 2012; 125: 61-9. 5. negral ad, thylefors b. the global impact of eye injuries. ophthalmic epidemiology 1998; 5: 43-69. 6. kunimoto dy, ittoop s, maguire ji, ho ac, regillo cd. metallic intraocular foreign bodies: characteristics, interventions, and prognostic factors for visual outcome and globe survival. am j ophthalmol. 2008; 146: 427-33. 7. de souza s, howcroft mj. management of posterior segment intraocular foreignbodies: 14 years' experience. can j ophthalmol. 1999; 34: 23-9. 8. napora kj, obuchowska i, sidorowicz a, mariak z. intraocular and intraorbital foreign bodies characteristics in patients with penetrating ocular injury. klin oczna. 2009; 111: 307-12. 9. wickham l, xing w, bunce c, sullivan p. outcomes of surgery for posterior segment intraocular foreign bodies-a retrospective review of 17 years of clinical experience. graefes arch clin exp ophthalmol. 2006; 244: 1620-6. 10. maneschg oa, resch m, papp a, németh j. prognostic factors and visual outcome for open globe injuries with intraocular foreign bodies. klin monbl augenheilkd. 2011; 228: 801-7. 11. koo l, kapadia mk, et al. gender differences in etiology and outcome of open globe injuries. j trauma. 2005; 59: 175-8. 12. demircan n, soylu m, yagmur m, akkaya h, ozcan aa, varinli i. pars plana vitrectomy in ocular injury with intraocular foreign body. j trauma. 2005; 59: 12168. 13. baba a, zbiba w, korbi m, mrabet a. [epidemiology of open globe injuries in the tunisian region of cap bon: retrospective study of 100 cases]. j fr ophtalmol. 2015; 38: 403-8. 14. jonas jb, knorr hl, budde wm. prognostic factors in ocular injuries caused by intraocular or retrobulbar foreign bodies. ophthalmology. 2000; 107: 823-8. 15. thompson jt, parver lm, enger cl, mieler wf, liggett pe. infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. national eye trauma system. ophthalmology. 1993; 100: 1468-74. 16. chaudhry ia, shamsi fa, al-harthi e, al-theeb a, elzaridi e, riley fc. incidence and visual outcome of endophthalmitis associated with intraocular foreign bodies. graefe's arch clin exp ophthalmol. 2008; 246: 181-6. clinical and demographic characteristics of intraocular foreign body injury in a referral center pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 209 17. colyer mh, weber ed, weichel ed, dick js, bower ks, ward tp, et al. delayed intraocular foreign body removal without endophthalmitis during operations iraqi freedom and enduring freedom. ophthalmology, 2007; 114: 1439–47. 18. bai h, yao l, meng x, wang yx, wang db. visual outcome following intraocular foreign bodies: a retrospective review of 5-year clinical experience. eur j ophthalmol. 2011; 21: 98-103. 19. ferrari tm, cardascia n, di gesu i, catella n, recchimurzo n, boscia f. early versus late removal of foreign bodies. retina. 2001; 21: 92-3. 20. imrie fr, cox a, foot b, macewen cj. surveillance of intraocular foreign bodies in the uk. eye (lond). 2008; 22: 1141-7. 21. woodcock mg, scott ra, huntbach j, kirkby gr. mass and shape as factors in intraocular foreign body injuries. ophthalmology. 2006; 113: 2262-9. 22. erakgun t, egrilmez s. prognostic factors in vitrectomy for posterior segment intraocular foreign bodies. j trauma. 2008; 64: 1034-7. 23. falavarjani kg, hashemi m, modarres m, parvaresh mm, naseripour m, nazari h, fazel aj. vitrectomy for posterior segment intraocular foreign bodies, visual and anatomical outcomes. middle east afr j ophthalmol. 2013; 20: 244-7. 24. mester v, kuhn f. intraocular foreign bodies. ophthalmol clin north am. 2002; 15: 235-42. microsoft word 10. abdul rafio soomro mm 236 pakistan journal of ophthalmology, 2020, vol. 36 (3): 236-240 original article visual outcome in pars plana vitrectomy for acute postoperative endophthalmitis after cataract surgery abdul rafio soomro1, fayaz ahmed soomro2, munawar hussain3, abdul qadeem soomro4 nazia qidwai5, anas bin tariq6 1-6al-ibrahim eye hospital, isra postgraduate institute of ophthalmology, karachi abstract purpose: to determine the visual outcomes in patients undergoing pars plana-vitrectomy (ppv) for acute postoperative endophthalmitis after cataract surgery. study design: quasi experimental study. place and duration of study: isra postgraduate institute of ophthalmology, alibrahim eye hospital, malir, karachi for a period of 2 years. material and methods: thirty-three patients were selected using non-probability convenient sampling technique. patients with acute postoperative endophthalmitis after cataract surgery diagnosed clinically and on b-scan, with visual acuity of only perception of light were included while patients with better visual acuity and any other types of endophthalmitis were excluded. ppv was performed in all cases and the patients were examined postoperatively on 1st day, 3rd day, 1, 2 and 3 weeks after surgery. during these follow ups, visual acuity was recorded, detailed slit lamp and fundus examination was performed. using spss version 20.0, chi-square test was applied to test for significance keeping p-value of < 0.05 as significant. results: out of 33 patients 19 (57.6%) were males and 14 (42.4%) were females. mean age of the patients was 54.50 ± 14.14 years. on 1st post-operative day 8 patients (24.2%) showed improvement of visual acuity from perception of light to finger counting while 02 (6.1%) patients reported visual acuity of 6/60. on final visit at 3rd week postoperatively, 19 patients (57.6%) had visual acuity of finger counting, 08 patients (24.2%) had hand movement and 06 (18.2%) patients reported a visual acuity of 6/60. conclusion: ppv for acute post-cataract endophthalmitis if performed at appropriate time can result in favourable outcomes in terms of visual acuity. key words: pars plana vitrectomy, endophthalmitis, cataract surgery. how to cite this article: soomro ar, soomro fa, hussain m, qadeem a, soomro, qidwai n, tariq ab. visual outcome in pars plana vitrectomy (ppv) for acute postoperative endophthalmitis after cataract surgery. pak j ophthalmol. 2020, 36 (3): 236-240. doi: 10.36351/pjo.v36i3.991 introduction endophthalmitis is a purulent intraocular inflammation correspondence to: anas bin tariq al-tibri medical college, karachi email: anastariq93@gmail.com received: january 31, 2020 accepted: may 4, 2020 revised: february 29, 2020 of the eye (vitreous and aqueous) that affects the vision. prevalence of clinical endophthalmitis ranges from 0.04% to 0.15%. the culture proven endophthalmitisis 0.02% and 0.08% worldwide1. however, the prevalence of endophthalmitis in pakistan is 5.1 – 7.5%, according to various local reports2,3. endophthalmitis results from a rapidly growing infection or invasion of micro-organisms into visual outcome in pars plana vitrectomy for acute postoperative endophthalmitis after cataract surgery pakistan journal of ophthalmology, 2020, vol. 36 (3): 236-240 237 the eye often after intraocular surgery. moreover, it may be caused by open-eye injury or by infection of cornea. bacteria are the most common cause of endophthalmitis, followed by fungi and less commonly parasites4. the inflammatory response caused by microorganisms and their toxins lead to immediate and irreparable damage to photoreceptors or other retinal cells and may persist even after the infection has settled. endophthalmitis is classified according to the duration, the way microorganisms enter the eye and the form of agents (e.g. bacteria, fungi) involved in the pathogenesis of the disease5. two types of endophthalmitis can be differentiated depending on the route in which the microorganisms enter the eye: exogenous and endogenous6. exogenous endophthalmitis can also be categorized as postoperative endophthalmitis or post-traumatic endophthalmitis, depending on the etiology. the most common form of endophthalmitis is postoperative endophthalmitis. this accounts for about 70% of all cases of endophthalmitis. it occurs when the whole thickness of the cornea or sclera is penetrated during intraocular surgery and occasionally after extraocular procedures such as suturing of a scleral buckle, strabismus surgery, pterygium surgery and corneal suture removal. approximately 90% of post-operative endophthalmitis occur after cataract surgery as it the most common intraocular surgery. most common agents responsible for postoperative endophthalmitis are staphylococci and streptococci7. incidence of endophthalmitis depends on risk factors, which include old age (> 85 years of age), rural living, male gender, and immunosuppressive conditions like diabetes mellitus. after infection, signs and symptoms appear rapidly, typically within one or two days, or sometimes up to six days after surgery. clinical features include eye pain that gets worse after procedure or eye injury, reduced vision, redness, pus, swollen eyelids, blurred vision, discomfort and photophobia8. endophthalmitis is diagnosed by investigations such as vitreous culture and b-scan ultrasonography. nearly 30% of post-operative endophthalmitis patients are culture-negative therefore, isolating the causative organism is the mainstay of treatment. for tests like gram staining, culture, polymerase chain reaction (pcr) analysis, sampling of aqueous or vitreous humor must be done at the first visit9. intraocular administration of antibiotic is regarded as the basic step in endophthalmitis management. controversy exists regarding simultaneous use of intravitreal injection of dexamethasone. a wide spectrum of antibiotics such as vancomycin, ceftazidime and amikacin are administered intravitreally as treatment. however, in case of fungal endophthalmitis; amphotericin b, miconazole and voriconazole are the drugs of choice10. pars plana vitrectomy (ppv) is the standard treatment for refractory and fulminant acute postcataract surgery endophthalmitis. immediate vitrectomy is suggested in the cases of progressively deteriorating visual acuity or endophthalmitis induced by virulent bacteria11. the endophthalmitis vitrectomy study (evs) considers pars plana vitrectomy only for patients with visual acuity of light perception whereas some studies suggest early pars plana vitrectomy for all patients with post-operative endophthalmitis12. the purpose of our study was to determine the visual outcomes in patients undergoing pars plana-vitrectomy (ppv) for acute post-operative endophthalmitis after cataract surgery. material and methods a quasi experimental study with non probability convenient sampling technique was conducted on 33 patients at isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi during a span of 2 years to determine the visual outcome after pars plana vitrectomy in acute postoperative endophthalmitis following cataract surgery. patients with acute postoperative endophthalmitis after cataract surgery diagnosed clinically and on bscan and having visual acuity of light perception were included in the study. whereas, patients with any other endophthalmitis, traumatic or endogenous were excluded. after taking consent, data of the patients was collected from outpatient department (opd), cataract clinic and surgical retina clinic at al-ibrahim eye hospital. patients were explained the method and significance of the research. patients were asked about complaints, glaucoma history, night blindness, surgery, trauma, drugs, contact lens and history of taking medicines. tests included visual acuity, slit abdul rafio soomro, et al 238 pakistan journal of ophthalmology, 2020, vol. 36 (3): 236-240 lamp biomicroscopy, regurgitation test, pupillary reactions and fundus examination. standard 3-port pars plana vitrectomy was performed and intravitreal injections of vancomycin and amikacin were administered. patients were examined post-operatively on 1st day, 3rd day, 1, 2 and 3 weeks after ppv. during these examinations, visual acuity was checked with snellen chart. other tests included a detailed slit lamp and fundus examination. alcon accurus microtome vitrectomy machine with endo-illumination, disposable suction cutting vitrectomy cutter, endodiathermy and infusion cannula were used. laser was done with alcon ophthalas 532 eyelite frequency doubled nd: yag laser photocoagulator with disposable endolaser probe. vitreous substitutes were balanced salt solution, perflouro carbon liquid (octadecaflourodecahydronaphthalene 98% micromed) and silicon oil (polydimethyl siloxane 100% – rs oil) with viscosity of 1000 – 5000 cst. analysis of data was carried out using spss version-20.0. all categorical variables including preoperative visual acuity, visual acuity on subsequent follow-up examinations, and early post-operative complications were identified by frequencies and percentages. results out of 33 patents 19 (57.6%) were males and 14 (42.4%) were females. mean age of the patients was 54.50 ± 14.14 years. most of the patients 51.5% were 55-60 years of age. the mean time between endophthalmitis and ppv was 7.03 ± 1.97 days. table 1: visual recovery according to time. variable n (%) 1st postoperative day perception of light-hand movement 23 (69.69%) vision improvement 8 (24.24%) 6/60 2 (6.06%) 1st week postoperative perception of light-hand movement 20 (60.60%) visual improvement 6 (18.18%) 6/60 7 (21.21%) 3rd week postoperative perception of light-hand movement 19 (57.57%) vision improvement 8 (24.24%) 6/60 6 (18.18%) out of 33 patients, 23 (69.7%) patients reported visual acuity between perception of light and hand movement on the 1st postoperative day. eight patients (24.2%) showed improvement of visual acuity from perception of light to finger counting while 02 (6.1%) patients reported visual acuity of 6/60. on the 7th postoperative day, 20 (60.6%) patients reported visual acuity of perception of light to hand movement while 06 (18.2%) patients reported improvements in their visual acuity and 07 (21.2%) patients reported a visual acuity of 6/60. on the final visit that is on 21st postoperative day, 19 patents (57.6%) had visual acuity of finger counting, while 08 patients (24.2%) showed visual improvement of only hand movement. only 6 (18.2%) patients reported a visual acuity of 6/60 (table 1). discussion visual outcomes after pars plana vitrectomy (ppv) have been reported to vary in literature. generally, outcomes have been found to be worse than that after cataract surgery, probably due to underlying retinal pathology and its association with a poor visual potential. even though good visual outcomes have been observed in a few patients, but some large studies have shown poor post-operative visual improvement among these patients. in this study although slight but definite improvement in visual acuity was reported among 31 (93.9%) patients. the improvements were from perception of light and hand movement to finger counting. in a study by dave vp et al, the mean visual acuity at the time of presentation of endophthalmitis was 6/240 with mean duration of endophthalmitis being 4 ± 6.89 days. after treatment, slight but insignificant improvement in visual acuity was reported showing that in only 50% of the cases, mean visual acuity had improved to 6/90 having a p-value of 0.3113. in contrast, our study reported a visual improvement in 90% of cases. higher mean age, duration of endophthalmitis and the poorer preoperative visual acuity can explain this difference. a study on 70 patients of acute endophthalmitis undergoing therapeutic ppv reported a significant improvement (p-value < 0.001) in visual acuity of patients from 6/120 at pre-operative stage to finger counting and hand movements. however, the significant improvement in visual outcomes was reported in only 33% of patients14. similarly, a case series of 05 patients by leng t et al also reported an improvement of visual acuity to around 6/30 in the visual outcome in pars plana vitrectomy for acute postoperative endophthalmitis after cataract surgery pakistan journal of ophthalmology, 2020, vol. 36 (3): 236-240 239 patients; nevertheless, the sample size was very small to comment further15. a study by kunimoto et al reported an improvement in visual acuity from perception of light to counting fingers, which was similar to our findings16. in contrast another study reported overall poor outcomes with final visual outcome being perception of light, no light perception or evisceration17. in another study by maneschg oa et al, the mean visual acuity before ppv was hand movement (hm) and light perception (lp) which did not significantly improve after ppv18. narsani ak in a study on 97 patients reported a visual acuity of 6/60 or worse in 80 (82.5%) patients at presentation and at post-operative follow up at 9th week found an improvement in visual acuity better than 6/60 in 75 (77.3%) patients. while 6 (6.2%) patients ended up in no perception of light19. on the contrary, thapa r et al reported another study of 34 patients of acute endophthalmitis treated with ppv having a mean age of 56 ± 19.5 years and mean duration of endophthalmitis of 13 ± 11.6 days. after a mean follow-up duration of 4.3 months, visual acuity was found to improve in two-thirds (67.67%) of cases with a good vision of 6/18 or better in 17.6% of patients20. similarly, in our study, improvement in visual acuity was reported in 93% of cases, however improvement was limited and mean follow up time in our study was 3 weeks as compared to 4.3 months follow up time period in the above study. in another study by park et al, on 28 patients, 29.6% eyes were eviscerated21. in a study investigating 250 patients of post-cataract surgery endophthalmitis undergoing ppv, 51.6% of patients reported to have a final visual acuity of 6/1222. likewise, another study reported that 49% of patients showed visual acuities of 6/1223. among some other studies done in asia, a study in india reported a final visual acuity of 6/12 in 29.41% patients while a study in singapore reported a final best corrected visual acuity of 20/40 in 50.5% of the cases24,25. the reported visual outcomes of patients undergoing ppv for post-cataract surgery endophthalmitis have been seen to vary from study to study. differences of mean age, gender, nationality, time and duration of diagnosis and presentation, surgical expertise all tend to have an effect on the final outcome of the patients. globally, post-operative endophthalmitis remains one of the most serious complications of cataract surgery. therefore, early diagnosis and surgical intervention using ppv is a necessity in optimizing visual outcomes. the limitations of the study include a limited sample size, short follow-up period where visual acuity might have been better or more improved in a longer follow-up. the study might not be immune from observer as well as selection bias. further studies on a larger sample size and with prolonged follow-up time might help in estimating the improvement in visual outcomes of the patients. however, due to the condition’s relative rarity, it is difficult to study large number of cases. conclusion ppv for acute post-cataract endophthalmitis if performed at appropriate time can result in favourable outcomes in terms of visual acuity. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution abdul rafio soomro; consultant ophthalmologist: study design, manuscript writing, final review. fayaz ahmed soomro; senior consultant ophthalmologist: concept, design & final approval of study. munawar hussain; assistant professor: concept, design & corrections of the study. abdul qadeem soomro; associate professor: concept & design of study, final approval of study. nazia qidwai; associate professor: concept & final approval of study. anas bin tariq; lecturer: data collection, data analysis & write-up. references 1. lalitha p, sengupta s, ravindran rd, sharma s, joseph j, ambiya v et al. a literature review and update on the incidence and microbiology spectrum of post-cataract surgery endophthalmitis over past two decades in india. ind j ophthalmol. 2017; 65 (8): 673. abdul rafio soomro, et al 240 pakistan journal of ophthalmology, 2020, vol. 36 (3): 236-240 2. li x, zarbin ma, bhagat n. pediatric open globe injury: a review of the literature. j emerg trauma shock, 2015; 8 (4): 216. 3. junejo sa, ahmed m, alam m. endophthalmitis in paediatric penetrating ocular injuries in hyderabad. j pak med assoc. 2010; 60 (7): 532-5. 4. lumi x, petrovski g, vasileva b, thaler a. endophthalmitis prevention, diagnosis procedures and treatment. optometry, 2016; 2 (1): 2476-2075. 5. barry p, cordovés l, gardner s. escrs guidelines for prevention and treatment of endophthalmitis following cataract surgery: data, dilemmas and conclusions. paper presented at the european society of cataract and refractive surgeons. dublin, ireland, 2013. 6. ojaimi e, wong dt. endophthalmitis, prevention and treatment. in: zaidi fh. cataract surgery rijeka: in tech. 2013: 265-284. 7. durand ml. endophthalmitis. clin microbiol infect. 2013; 19 (3): 227-234. 8. hashemian h, mirshahi r, khodaparast m, jabbarvand m. post-cataract surgery endophthalmitis: brief literature review. j curr ophthalmol. 2016; 28 (3): 101-5. 9. jabbarvand m, hashemian h, khodaparast m, jouhari m, tabatabaei a, rezaei s. endophthalmitis occurring after cataract surgery: outcomes of more than 480 000 cataract surgeries, epidemiologic features, and risk factors. ophthalmology, 2016; 123 (2): 295-301. 10. gower ew, keay lj, stare de, arora p, cassard sd, behrens a, tielsch jm, schein od. characteristics of endophthalmitis after cataract surgery in the united states medicare population. ophthalmology, 2015; 122 (8): 1625-32. 11. dave vp, pathengay a, schwartz sg, flynn jr hw. endophthalmitis following pars plana vitrectomy: a literature review of incidence, causative organisms, and treatment outcomes. clin ophthalmol. (auckland, nz). 2014; 8: 2183. 12. torabi h, tabatabai sa, khodabande a. treatment outcomes of post cataract surgery endophthalmitis in a tertiary referral center in iran. j curr ophthalmol. 2018; 30 (2): 152-5. 13. dave vp, pathengay a, basu s, gupta n, basu s, raval v, et al. endophthalmitis after pars plana vitrectomy: clinical features, risk factors, and management outcomes. the asia pac j ophthalmol. 2016; 5 (3): 192-5. 14. sridhar j, yonekawa y, kuriyan ae, joseph a, thomas bj, liang mc, et al. microbiologic spectrum and visual outcomes of acute-onset endophthalmitis undergoing therapeutic pars plana vitrectomy. retina, 2017; 37 (7): 1246-59. 15. leng t, miller d, flynn hw jr, jacobs dj, gedde sj. delayed-onset bleb-associated endophthalmitis (1996-2008): causative organisms and visual acuity outcomes. retina, 2011; 31 (2): 344–5. 16. kunimoto dy, kaiser rs. wills retina service. incidence of endophthalmitis after 20 and 25 gauge vitrectomy. ophthalmology, 2007; 114: 2133–7. 17. park jc, ramasamy b, shaw s, prasad s, ling rh. a prospective and nationwide study investigating endophthalmitis following pars plana vitrectomy: incidence and risk factors. br j ophthalmol. 2014; 94: 529−33. 18. maneschg oa, volek é, németh j, somfai gm, géhl z, szalai i, et al. spectral domain optical coherence tomography in patients after successful management of postoperative endophthalmitis following cataract surgery by pars planavitrectomy. bmc ophthalmology, 2014; 14 (1): 76-84. 19. narsani ak, nagdev pr, lohana mk, jatoi sm, gilal i. incidence and visual outcome of acute postoperative endophthalmitis. j ayub med coll. 2011; 23 (2): 100-3. 20. thapa r, paudyal g. clinical profile and visual outcome following pars planavitrectomy in acute postoperative endophthalmitis. nep j ophthalmol. 2011; 3 (2): 102-8. 21. park jc, ramasamy b, shaw s, ling rh, prasad s. a prospective and nationwide study investigating endophthalmitis following pars planavitrectomy: clinical presentation, microbiology, management and outcome. br j ophthalmol. 2014; 98 (8): 1080-6. 22. pijl bj, theelen t, tilanus ma, rentenaar r, crama n. acute endophthalmitis after cataract surgery: 250 consecutive cases treated at a tertiary referral center in the netherlands. am j ophthalmol. 2010; 149 (3): 482-7. 23. kim wj, kweon ey, lee dw, cho nc. postoperative endophthalmitis following cataract surgery over an eight-year period. j korean ophthalmol soci. 2008; 49 (11): 1771-8. 24. lalitha p, rajagopalan j, prakash k, ramasamy k, prajna nv, srinivasan m. post-cataract endophthalmitis in south india: incidence and outcome. ophthalmology, 2005; 112 (11): 1884-9. 25. wong ty, chee sp. the epidemiology of acute endophthalmitis after cataract surgery in an asian population. ophthalmology, 2004; 111 (4): 699-705. .……. pakistan journal of ophthalmology, 2020, vol. 36 (1): 62-66 62 original article visual function tests as a cost effective screening tool for diabetic retinopathy faryal ahmed 1 , faraz iftikhar malik 2 , chaudhary ehtsham azmat 3 , ambreen gul 4 , ali raza 5 1,2,3 rawalpindi medical university and allied hospitals 4,5 department at ophthalmology unit, holy family hospital, rawalpindi abstract purpose: to find out the importance of visual function tests as cost effective screening tools for diabetic retinopathy. study design: descriptive, cross sectional study. place and duration of study: ophthalmology unit of holy family hospital, from september 2018 to november 2018. material and methods: two hundred and forty-two patients were selected by convenience sampling technique and were divided into three groups. two groups of diabetics with and without retinopathy and one group of nondiabetics age-matched controls. after relevant history, patients were examined for visual acuity, color vision and contrast sensitivity using snellen’s chart, 24 plates ishihara chart and pelli robson chart respectively. staging of retinopathy was done after mydriasis. results: diabetic patients irrespective of type and stage, when compared with non-diabetic patients had a greater percentage of abnormal visual function tests. a 6/6 visual acuity was observed in 38.2% of non diabetics as compared to only 8.6% diabetics without retinopathy and 7.5% of diabetics with retinopathy. color vision abnormalities were detected in only 8.6% of non diabetic patients. however, 11.1% of diabetics without retinopathy and 23.7% with retinopathy showed abnormalities of color vision. the percentage of abnormal contrast sensitivity was 76.2% for diabetics with retinopathy and 60.4% for diabetics without retinopathy and 27.1% for non-diabetic patients. conclusion: evaluation of visual acuity, color vision and contrast sensitivity are cheap and easy tests that can be used to screen for diabetic retinopathy thereby allowing early interventions to prevent development of serious ocular diabetic complications. key words: visual acuity, color vision, contrast sensitivity, diabetic retinopathy. how to cite this article: ahmed f, malik fi, azmat ce, gul a, raza a. visual function tests as a cost effective screening tool for diabetic retinopathy, pak j ophthalmol. 2020; 36 (1): 62-66. doi: https://doi.org/10.36351/pjo.v36i1.887. introduction diabetes mellitus is the leading cause of legal and irreversible blindness throughout the world 1 . diabetic correspondence to: faryal ahmed, house officer rawalpindi medical university and allied hospitals email: faryal.ahmed8@gmail.com eye disease pertains diabetic retinopathy, cataract, glaucoma, macular edema with diabetic retinopathy (dr) being the most common ocular complication. visual function changes appear in diabetics before any appreciable structural abnormalities can be detected by ophthalmoscopy and fluorescein angiography 2,3 . these changes include impaired visual acuity (va), abnormal contrast sensitivity (cs) and defects in color vision (cv). https://doi.org/10.36351/pjo.v36i1.887 mailto:faryal.ahmed8@gmail.com ahmed f, et al 63 pakistan journal of ophthalmology, 2020, vol. 36 (1): 62-66 different tests have been devised to predict the development of dr 4,5 . of which, visual function tests are being recognized as sensitive screening tools before the development of clinically detectable dr and it may differentiate between various causes of visual loss. the number of diabetics in pakistan ranges from 6.2 million with one in every three diabetics suffering from diabetic eye disease. the purpose of this study is to find the determinative ability of visual function tests as cost effective screening tools in patients with dr. material and methods a hospital based, cross sectional study was carried out among three groups of patients; 2 groups of diabetics, of which one had diabetic retinopathy and the other had normal fundi. the third group was non-diabetic group. this study was conducted from september 2018 to november 2018 at ophthalmology unit of holy family hospital, rawalpindi. the sample size was calculated by using the who sample size calculator. while keeping the level of confidence at 95%, absolute precision at 0.5% and prevalence at 19.5%, the minimum required sample size turned out to be 242. all 242 patients, of age group 25 to 65 years were examined for their visual acuity, color vision, contrast sensitivity and stage of diabetic retinopathy. patients with cataract, glaucoma, macular disorders, anterior segment pathologies and those having + 4/5 spherical ds or above were excluded from the study. informed consent was taken from all the subjects after explaining to them the purpose of the study. the data was collected with the help of a structured questionnaire. the questionnaire was formulated to collect demographic details of all patients with their diabetic status, visual acuity, contrast sensitivity and color vision. the diabetics were asked about type of diabetes, duration of diabetes, control of diabetes and the kind of treatment they were taking. the diabetic patients were classified on the basis of presence or absence of diabetic retinopathy. all diabetics were examined for stage of diabetic retinopathy using slit lamp biomicroscopy, 90d lens and fundus photography following mydriasis. in this study, eyes were classified as no diabetic retinopathy (dr), non-proliferative diabetic retinopathy (npdr), proliferative diabetic retinopathy (pdr) and macular edema. visual acuity of all patients was measured using a snellen chart at a distance of 6 m. color vision was tested using ishihara 24 plates chart. the color vision was regarded as normal when greater than equal to 13 plates were read normally and abnormal when less than 9 plates were read normally. the plates were held at an arm’s length (25 to 30 cm) from patient’s eyes. contrast sensitivity (cs) was assessed by using pelli robson contrast sensitivity acuity chart. testing was carried out at a distance of 1 m (40 inches) with patients wearing their distance correction 6,7 . pelli robson chart consists of horizontal lines of capital letters (6 per line), in which the contrast of letters decreases with each line. this chart tests patient’s ability to detect letters that are gradually less contrasted against a white background. each group has 3 letters of same contrast level, the score, a single number, is a measure of patient’s log cs. thus a score of 2 means, that the subject was able to read at least 2 of 3 letters with a contrast of 1%. cs = 100% or log 2. normal score of contrast sensitivity was 2.0; that is 100%. those who had a score below 1.5 were abnormal and this was recorded as decrease in cs 8 . spss version 22 was used to analyze all the data. for all the variables, frequencies and percentages were calculated and charts were made. for statistical analysis of the data one sample bimonial test was used. using this test the colour vision and contrast sensitivity among three groups of non diabetics, diabetics without retinopathy and diabetics with retinopathy was analysed keeping ci of 95% and significance level of 0.05. results a total of 242 patients were included in this study. out of these patients, 161 patients were diabetic and 81 were non diabetic. out of 161 diabetic patients, 27 (16.8%) were type 1 and 134 (83.2%) were type 2 table 1: general characteristics of patients (242). variable frequency percentage gender males 90 37.2% females 152 62.8% total 242 100% diabetic status non diabetics 81 33.4% diabetics with 81 33.4% visual function tests as a cost effective screening tool for diabetic retinopathy pakistan journal of ophthalmology, 2020, vol. 36 (1): 62-66 64 variable frequency percentage no retinopathy diabetics with retinopathy 80 33.0% total 242 100% type of diabetes type i 27 16.8% type ii 134 83.2% control status good 33 13.6% average 70 28.9% poor 58 24% diabetics. one hundred and fifty-two (62.8%) patients among this study were female and 90 (37.2%) were male. patients from 25 to 65 years were included in this study with the age group 61-65 years was featured the most with 16.12%, followed by 46-50 and 56-60 years respectively. this research shows that when diabetic patients, irrespective of type and stage are compared with nondiabetic patients, had a greater percentage of abnormal visual function tests. for details of distance visual acuity, color vision and contrast sensitivity among the three groups, refer to figure 2, table 2 and table 3. it was also evident from our results that of all the visual function tests, contrast sensitivity is affected the most in diabetic patients. comparing all the three visual function tests, cs stands the most important in screening of the diabetic eye disease. 0.00% 20.00% 40.00% 60.00% no diabetes diabetics w ithout retinopathy diabetics w ith retinopathy diabetic status fig. 2: relationship between diabetic status and the perfect eye (6/6 va) of the patients. table 2: relationship between the diabetic status and color vision of the patients. stage of diabetes cv right (>/=13) n (%) cv right (<9) n (%) cv left (>/=13) n (%) cv left (<9) n (%) no diabetes 74 (91.3%) 7 (8.6%) 74 (91.3%) 7 (8.6%) diabetics without retinopathy 72 (88.8%) 9 (11.1%) 74 (91.3%) 7 (8.6%) diabetics with npdr 55 (80.8%) 13 (19.1%) 52 (85.2%) 9 (14.7%) diabetics with pdr 9 (75%) 3 (25%) 3 (18.75%) 3 (18.75%) diabetics with macular edema 0 (0%) 0 (0%) 0 (0%) 3 (100%) table 3: relationship between the diabetic status and contrast sensitivity of the patients. stage of diabetes cs right (>/=1.5) n (%) cs right (<1.5) n (%) cs left (>/=1.5) n (%) cs left (<1.5) n (%) no diabetes 65 (80.2%) 16 (19.7%) 59 (72.8%) 22 (27%) diabetics without retinopathy 39 (48.1%) 42 (51.8%) 32 (39.5%) 49 (60.4%) diabetics with npdr 25 (36.7%) 43 (63.2%) 16 (26%) 45 (73.7%) diabetics with pdr 3 (25%) 9 (75%) 3 (18.75%) 13 (81%) diabetics with macular edema 0 (0%) 0 (0%) 0 (0%) 3 (100%) ahmed f, et al 65 pakistan journal of ophthalmology, 2020, vol. 36 (1): 62-66 discussion the present study revealed an association between impaired visual function tests and the diabetic status of the patients. this study showed that visual acuity markedly decreased with the development of diabetes and that diabetics with increasing stage of diabetic retinopathy are less likely to have 6/6 visual acuity. reduction in the visual acuity in diabetic patients can be ascribed to increasing stage of dr, hazy cornea and variation in refraction caused by unstable glucose levels in the blood 9 . various studies have shown that visual acuity can be assessed by different tools and that visual acuity is sufficient to measure the visual impairment in diabetic patients 10,11 . according to the study published in 2015 there is a marked association between the acquired color vision deficiency and high blood glucose levels 12 . the findings in our study showed that deficiency in color vision is linked to the diabetic status of the patient and as the stage of diabetic retinopathy increases, the likelihood of abnormal color vision also increases. patients with macular edema are unable to differentiate among short wavelengths of color and thus perform poor on color vision test. it has been demonstrated in another research that diabetic maculopathy was more likely to cause abnormal color vision 13 . the most authentic justification of this impression is that macula is responsible for central vision and most of the cones are located at macula. increased blood glucose levels impair macular function to transmit light which affect short wavelength cones giving impaired color vision. davies and ong conducted studies and revealed a significant color vision deficiency in subjects with retinopathy especially in the yellow blue spectral region 14,15 . similarly wong et al discovered a positive correlation between color discrimination and extent of retinopathy 16 . sixty-five percent of the patients who had diabetic retinopathy had abnormal 100-hue test and those with end stage dr especially macular edema were affected the most. in a separate study, verrotti et al also found that subjects who had pdr were unable to perform on color vision test 17 . the present study established that non diabetics have better contrast sensitivity than the diabetic patients, diabetics with no retinopathy performs better on pelli robson chart than the diabetics with npdr, pdr and macular edema. starvo and wood used a high contrast bailey lovie chart and pelli robson chart in 20 type ii diabetic patients and 24 age matched control subjects and established that the loss of cs is more in patients with retinopathy compared to the control subjects 2 . according to abrishami et al study, the loss in cs is not only attributed to the retinal changes but also to lens changes 18 . in the present study we have excluded all the subjects with lens changes. a study by macki and walsh emphasized on the cs threshold. according to them cs threshold is seen to be increased in diabetic group who had pdr or background dr more than in patients with no retinopathy 19 . this finding is consistent with our results that loss in cs is attributed to the diabetic status and increasing stage of dr of the patients. lobo et al and lovestam adrian et al both showed a relationship of loss of cs with degree of retinopathy 20,21 . the reason behind decrease in cs in diabetics is not clear. the possible mechanism, which can be accepted theoretically, is the abnormal accumulation of fluid in retina or impairment of neural functions in retina by overloading aldose reductase system. cs is a function of the retina and cs impairment is associated with degree of retinopathy. this makes cs a beneficial tool in finding early retinal changes. the findings of our study are concurrent with previous studies that the leading complication of diabetes is diabetic retinopathy in which all the visual function defects are observed 22,23 . the limitations of this study included limited time frame to evaluate the diabetes, visual acuity, color vision, contrast sensitivity. furthermore, it was conducted in a single center and the subjects enrolled in this study were mostly illiterate which makes the results of charts reading less effective. conclusion visual function tests are easy to perform and can be used to screen the patients with dr in basic health units and diabetic clinics. by using these tests diabetic retinopathy can be treated at early stage. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest visual function tests as a cost effective screening tool for diabetic retinopathy pakistan journal of ophthalmology, 2020, vol. 36 (1): 62-66 66 authors’ designation and contribution faryal ahmed; house officer: study design, data collection, manuscript writing, final review. faraz iftikhar malik; house officer: data analysis, manuscript writing. chaudhary ehtsham azmat; house officer: data analysis, manuscript writing. ambreen gul; senior registrar: study concept, final review. ali raza; professor: final review. references 1. howes sc, caelli t, mitchell p. contrast sensitivity in diabetics with retinopathy and cataract. aus j ophthalmol. 1982; 10 (3): 173-178. 2. stavrou e. wood jm. letter contrast sensitivity changes in early diabetic retinopathy. clin exp optom 2003; 86 (3): 152-6. 3. olafsdottir e, stefansson e. biennial eye screening in patients with diabetes without retinopathy: 10-year experience. br j ophthalmol. 2007; 919120: 1599-601. 4. ali hm, draman n, mohamad wm, embong z, ali mh, yaakub a et al. predictors of proliferative diabetic retinopathy among patients with type 2 diabetes mellitus in malaysia as detected by fundus photography. j taiba uni med sci. 2016; 11 (4): 353358. 5. stiff aw, curtis tm, chen m, medina rj, mckay gj, jenkins a, et al. the progress in understanding and treatment of diabetic retinopathy. prog retin eye res. 2016; 51: 156-86. 6. thayaparan k, crossland md, gary s. clinical assessment of two new contrast sensitivity charts. br j ophthamol. 2007; 91 (6): 749-52. 7. owidzka m, wilczynski m, omulecki ww. evaluation of contrast sensitivity measurements after retrobulbar optic neuritis in multiple sclerosis. graefes arch clin exp ophthalmol. 2014; 252 (4): 673-7. 8. parede t, torricelli a, mukai a, netto m, bechara s. quality of vision in refractive and cataract surgery, indirect measurers: review article. arq. bras. oftalmol. 2013; 76: 6. 9. cooke jb, cochrane al. a practical guide to low vision management of patient with diabetes. clin exp optom. 2001; 84: 155-161. 10. muneeswar g. nittala, laxmi gella, rajiv raman and tarun sharma. measuring retinal sensitivity with the micro-perimeter in patients with diabetes, retina (philadelphia, pa.), 2012; 32 (7): 1302-9. 11. feitosa-santana c, oiwa nn, paramei gv, bimler d, costa mf, lago m, et al. colour space distortions in patients with type 2 diabetes mellitus. visual neurosci. 2006; 23: 663-8. 12. radwan tm, ghoneim em, ghobashy wa, orma aa. assessment of colour vision in diabetic patients. intern j ophth res. 2015; 1 (1): 19-23. 13. shin yj, park kh, hwang jm, wee wr, lee jh, lee ib et al. a novel colour vision test for detection of diabetic macular edema colour vision test to detect macular edema. invest ophthalmol vis sci. 2014; 55: 25-32. 14. davies n, morland a. extent of foveal tritanopia in diabetes mellitus. br j ophthalmol. 2003; 87 (6): 7426. 15. ong gl, ripley lg, newsom rs, casswell ag. assessment of colour vision as a screening test for sight threatening diabetic retinopathy before loss of vision. br j ophthalmol. 2003; 87 (6): 747-52. 16. wong r, khan j, adewoyin t, sivaprasad s, arden gb, chong v. the chroma test, a digital color contrast sensitivity analyzer, for diabetic maculopathy: a pilot study. bmc ophthalmol. 2008; 8: 15. 17. verrotti a, lobefalo l, chiarelli f, mastropasqua l, ciancaglini m, morgese g. colour vision and persistent microalbuminuria in children with type-1 (insulin-dependent) diabetes mellitus: a longitudinal study. diabetes res clin pract. 1995; 30 (2): 125-30. 18. abrishami m, heravian j, derakhshan a, mousavi m, banaee t, daneshvar r, moqhaddam ho. abnormal cambridge low-contrast grating sensitivity results associated with diabetic retinopathy as a potential screening tool. east mediterr health j. 2007; 13 (4): 810-8. 19. mackie sw, walsh g. contrast and glare sensitivity in diabetic patients with and without panretinal photocogulation. ophthalmic physiol opt. 1998; 18 (2): 173-81. 20. lobo cl, bernardes rc, figueira jp, abreu jr, cunha-vaz jg. three year follow-up study of bloodretinal barrier and retinal thickness alterations in patients with type 2 diabetes mellitus and mild nonproliferative diabetic retinopathy. arch ophthalmol. 2004; 122 (2): 211-7. 21. lövestam-adrian m, svendenius n, agardh e. contrast sensitivity and visual recovery time in diabetic patients treated with panretinal photocogulation. acta ophthalmol scand. 2000; 78 (6): 672-6. 22. alió jl, krueger rr, bidgoli s. the world burden of refractive blindness. j refract surg. 2016; 32 (9): 5824. 23. wolff be, bearsejr ma, schneck me, dhamdhere k, harrison ww, barez s, et al. colour vision and neuroretinal function in diabetes. doc ophthalmol. 2015; 130 (2): 131-9. .…  …. 56 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology short communication capillary hemangioma of conjunctiva: a rare ocular surface growth anubhav chauhan, lalit gupta, shveta chauhan pak j ophthalmol 2017, vol. 33 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: anubhav chauhan senior resident, deptt. of ophthalmology, dr yashwant singh parmar govt. medical college, nahan, district sirmour, himachal pradesh, india. email:chauhan.anubhav2@gmail.com we report a case of a 17 year old mentally retarded male with a previous history of seizures who presented with a painless, progressively increasing mass in the right lateral conjunctival region. histopathologic examination of the excised mass revealed it to be a capillary hemangioma. keywords: hemangioma, ocular, oral, excision. 17 year old male was brought by his father with a history of a painless, progressively increasing mass in the right eye since three months. the patient was a known case of mild mental retardation. the patient was receiving treatment for gingivitis in the form of tablet metronidazole from dental department. the patient’s prenatal, perinatal, postnatal and family histories were all unremarkable. there was no history of any other systemic disease, trauma, seizures, ocular infection and surgery. his visual acquity was 6/24 in both the eyes without any improvement on pinhole; pupillary reactions, ocular movements, fundus and intraocular pressure were normal bilaterally. examination of her right eye revealed a reddish, pedunculated, smooth, mobile mass with its surface revealing multiple blood vessels. it was located in the bulbar conjunctiva near the limbus at 8 o’clock position and was of 9mm x 8mm size (figure 1). the slit lamp examination of the left eye was normal. routine blood and urine examinations were normal. an excision biopsy of the mass under local anaesthesia was planned. a preoperative general physical and systemic examination was carried out by the medical specialist and a go ahead was given for surgery. excision biopsy of the mass was done (figure 2) and the patient was started on topical antibiotic-steroid eye drops. the patient reported back to us after two weeks postoperatively along with the histopathological report which revealed the conjunctival mass to be capillary hemangioma (figure 3). the patient was added timolol drops to decrease the incidence of recurrence of the lesion. figure 1: patients photograph showing the lesion. a mailto:chauhan.anubhav2@gmail.com capillary hemangioma of conjuctiva: a rare ocular surface growth pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 57 figure 2: patients photograph-first postoperative day. figure 3: histopathological report. discussion conjunctival vascular tumours are not common and a few examples of the lesions commonly found in this group are pyogenic granuloma, lymphangioma, and capillary hemangioma1. a haemangioma is a developmental malformation of blood vessels and is an example of a hamartoma. it may be capillary, venous or arterial. its incidence is reported as 1-2% of all benign growths of the conjunctiva2. conjuctival hemangiomas are rare tumors3 which are present at birth as reddish elevated lesions increasing in size over the next few months and then spontaneously involuting by 4–5 years of age4. these tumors can be asymptomatic or may cause visual impairment if large sized. capillary hemangiomas show a greater preponderence in females (especially with a history of chorionic-villus sampling during pregnancy) and premature or low-birth-weight infants. they have an association with cardiorespiratory and hematologic disorders5. histopathological examination shows proliferative vessels lined by endothelial cells without nuclear atypism. they generally locate to the superior orbit and lids. acquired capillary hemangioma of the periocular region is very rare. the main differential diagnoses are pyogenic granuloma, angiosarcoma, and acquired tufted angioma of the eyelids6. the treatment modalities currently available include intralesional and systemic steroids, bleomycin, interferon-α, topical timolol maleate, oral propranolol, laser treatment and surgical excision7. caution should be taken in using beta blockers in patients of hemangioma with cardiorespiratory disorders as worsening of respiratory and cardiac symptoms can occur8. authors affiliation dr. anubhav chauhan m.s ophthalmology), senior resident, dept. of ophthalmology dr yashwant singh parmar govt. medical college, nahan, district sirmour, himachal pradesh, india. dr. lalit gupta m.s ophthalmology),assistant professor, dept. of ophthalmology dr yashwant singh parmar govt. medical college, nahan, district sirmour, himachal pradesh, india. dr. shveta chauhan bachelor of dental surgery),pine castle, near mist chamber, khalini, shimla 171002, himachal pradesh, india role of authors dr. anubhav chauhan concept, study design, data acquisition and manuscript writing. dr. lalit gupta drafting, literature research and manuscript preparation dr. shveta chauhan manuscript editing, data analysis, and patient photographs anubhav chauhan, et al 58 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology references 1. lubahn jg, lee rk, karp cl. resolution of conjunctival sessile hemangioma with topical timolol. cornea 2014; 33 (1): 99–100. 2. rao mr, patankar v l, reddy v. cavernous haemangioma of conjunctiva (a case report). indian j ophthalmol. 1989; 37: 37-8. 3. loya n, kremer i, goldenfeld m, swetliza e. solitary conjunctival hemangioma presenting as a chocolate cyst. arch ophthalmol. 1988; 106 (10): 1457. 4. honavar sg, manjandavida fp. tumors of the ocular surface: a review. indian j ophthalmol. 2015; 63: 187203. 5. bang gm, setabutr p. periocular capillary hemangiomas: indications and options for treatment. middle east afr j ophthalmol. 2010 ; 17 (2): 121–128. 6. kıvanç sa, olcaysu oo, gelincik i. acquired capillary hemangioma of the eyelid in a 49-year-old woman from turkey. indian j ophthalmol. 2014; 62 (9): 969–970. 7. ohnishi k, tagami m, morii e, azumi a. topical treatment for orbital capillary hemangioma in an adult using a β-blocker solution. case rep ophthalmol. 2014; 5: 60-65. 8. ambika h, sujatha c, kumar yh. topical timolol: a safer alternative for complicated and uncomplicated infantile hemangiomas. indian j dermatol. 2013; 58 (4): 330. pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 162 original article frequency of helicobacter pylori in patients with primary open angle glaucoma zeeshan khan oozeerkhan, muhammad arshad mahmood, mohamud walid peerbux, muhammad sufyan aneeq ansari, faisal mahmood pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zeeshan khan oozeerkhan senior registrar department of ophthalmology al-aleem medical college, gulab devi hospital, lahore email: zeeshankhan1121@gmail.com …..……………………….. purpose: to find out the frequency of helicobacter pylori (h. pylori) antibody in the serum of people with established poag. study design: cross sectional study. place & duration of study: lrbt free eye hospital, lahore from 1 st july 2012 to 1 st january 2013. material and methods: all patients attending the glaucoma unit of the outpatient department with primary open angle glaucoma willing to be included in the study were enrolled using consecutive sampling. after collecting demographic information of the patients 3 ml of venous blood was withdrawn. later on processing was done using the chemiluminescent enzyme immunoassay of the immulite 2000 systems analyzers h. pylori igg detection kit. quantitative variable such as age was presented as mean and standard deviation while qualitative variables such as gender and h. pylori status (positive or negative) were expressed as frequencies and percentages. results: there were 100 patients included in the study with mean age of 50.45 ± 6.16 years. there were 49 (49%) male and 51 (51%) female patients. the mean antibody level of patients was 3.80 ± 2.57 with a range of 9.39. the minimum and maximum antibody level were 0.07 and 9.46 respectively. there were 75 (75%) patients having primary open angle glaucoma who were diagnosed positive with h. pylori. conclusion: the study shows high frequency of h. pylori antibody in patients with open angle glaucoma. key words: optic neuropathy, open angle glaucoma, helicobacter pylori. laucoma is the terminology used to describe a disease which is characterized by optic neuropathy together with loss of visual field as damage progresses, and in which intraocular pressure is seen as the main modifying risk factor1. poag is the most commonly encountered type of glaucoma and one of the most frequent causes of irreversible visual loss in adults. it is usually asymptomatic and diagnosed when the condition has progressed sufficiently to cause the patient to present with irreversible decreased vision. it can also be diagnosed in patients during routine screening process. the pathology of poag has been attributed to 2 main reasons which include augmented hindrance at the level of the trabeculum, causing raised iop leading to direct damage of retinal nerve fibers as they exit the lamina cribrosa and the other is ischemia of the optic disc due to compromised microvasculature which may be due to loss of capillaries, altered blood flow, interference between delivery of nutrients or removal of metabolic products. more recently, some studies are suggesting the possibility of immunemediated mechanisms in the pathogenesis of poag.1 g zeeshan khan oozeerkhan, et al 163 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol h.pylori is a non-sporing, curvilinear gramnegative flagellated rod that colonizes the gastric mucosa. it has strong associations with diseases such as peptic ulcer, chronic gastritis, carcinoma of the stomach and gastric mucosa associated lymphoid tissue (malt) lymphoma. extragastric manifestations were seen in patients with hepatic and pancreatic diseases.23 its prevalence and distribution worldwide is variable but it has been detected in gastric mucosa of the population of the developing countries. nowadays many tests are available for the detection of h.pylori, some are invasive (gastric endoscopy and mucosal biopsy) and other noninvasive (urease breath test, serum antibody detection, fecal bacterial detection).2 h.pylori causes apoptosis of the gastric mucosa by the increased expression of the fas-cell death receptor and sensitivity to fas-mediated apoptosis. h.pylori antibodies circulating found in the blood cross the blood-aqueous barrier to enter the aqueous humor and cross-react with antigens on ciliary body epithelium. apoptosis of the trabecular meshwork cells can be triggered through fas/fasl pathway.3-5 a clinical study carried out at aravind eye hospital, madurai, india showed that there was a marked elevation in serum antibody titer against h.pylori in poag (70%).3 in peking university, beijing, china, a study was done to establish a causality between helicobacter pylori and poag and found the frequency of helicobacter pylori to be 54.2% positive.6 another study carried out at ahepa hospital, greece revealed a frequency of 88% helicobacter pylori in patients of poag.7 the rationale of this study is that, since no data is available in pakistan regarding the frequency of helicobacter pylori in poag, and multiple international research articles have been observed to show variability in their respective data, this study will set a baseline data in our population and also bring focus to a serious health issue and appropriate intervention that neeeds to be carried out. it is has been established that about 60 million people globally are being treated for glaucoma and amongst which 8.4 million are blind in both eyes8,9. many factors, including presence of h.pylori, which is associated with the occurrence of alzheimer’s disease, gastritis, gastric ulcers, and gastric carcinomas, have been implicated as the pathophysiology.10-12 recently, researchers have globally directed attention to this issue; however, the variable results have left the subject without a definitive conclusion. further questions that will require answers are whether there is an association between h.pylori infection and poag, and if ever these two diseases have a causal relationship or if they coincidentally have common triggering factors.9 h.pylori was detected by13 c-urea breath test in a study and was found to be higher in patients with glaucoma (54.2%) than in control group (20.8%) [p = 0.017]. there was no statistical significance regarding the overall visual field loss and cd ratio of patients whether they were h.pylori-positive or h.pylorinegative.13 in thessaloniki, a study observed that iop was the sole risk factor involved with poag and pseudoexfoliative glaucoma, but the strong presence of h. pylori infection in glaucoma patients of this area is also coincidentally high, hence demonstrating a common factor with probable association with poag and pseudoexfoliative glaucoma in greece.14 the test was positive if anti-h.pylori antibody was 1.1u/ml and above. the aim of this study is to obtain the frequency of h.pylori antibody in serum of patients of established poag. material and methods a cross sectional study was carried out at lrbt free eye and cancer hospital, lahore, for a duration of 6 months, from 01-07-2012 to 01-01-2013. with 95% confidence level, 9% margin of error and 70.0% expected percentage of positive results for helicobacter pylori antibody in serum, 100 patients of poag were selected from the glaucoma unit. non probability purposive sampling was used. criteria for patient selection were age 40 to 60 years, both genders and patients with established poag. patients with history of ocular trauma or any systemic diseases or any systemic medications were not included. patients with history of any ocular pathology other than primary open angle glaucoma e.g. corneal ulcer, uveitis, retinal detachment, vitreous hemorrhage were also excluded from this study. through consecutive sampling, a total of 100 patients fulfilling the inclusion criteria were taken from the glaucoma unit of lrbt free eye and cancer hospital lahore. informed consent was taken from all patients. demographic information of patients (name, age, gender) was taken and then 3 ml of venous blood frequency of helicobacter pylori in patients with primary open angle glaucoma pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 164 from each subject was drawn, and processed through the chemiluminescent enzyme immunoassay of the immulite 2000 systems analyzers h.pylori igg detection kit from siemens healthcare diagnostics inc., united kingdom. to avoid bias, all tests were carried out at shaukat khanum memorial cancer hospital & research centre (skmch & rc) only. reports were regarded as positive or negative and recorded on the proforma. all the data collected was entered into spss version 22 and it was analyzed through its statistical package. the quantitative variables such as age was presented as mean and standard deviations while qualitative variables such as gender and h.pylori status (positive or negative) were expressed as frequencies and percentages. results the mean age of patients was 50.45 ± 6.16 years with age range of 20 years. the minimum and maximum ages were 40 and 60 years respectively (table 1). there were 49 (49%) male and 51 (51%) female patients. the male to female ratio was almost same (table 2). table 1: descriptive statistics of age (years). age (years) mean 50.45 std. deviation 6.16 range 20.00 minimum 40.00 maximum 60.00 table 2: frequency distribution of gender. frequency percent male 49 49 female 51 51 total 100 100.0 the mean antibody level of patients was 3.80 ± 2.57 with range of 9.39. the minimum and maximum antibody level was 0.07 and 9.46 respectively (table 3). according to operational definition helicobacter pylori antibody was present in 75 (75%) patients. (table 4). table 3: descriptive statistics of antibody level. antibody level mean 3.80 std. deviation 2.57 range 9.39 minimum 0.07 maximum 9.46 table 4: frequency distribution of helicobacter pylori antibody. frequency percent yes 75 75.0 no 25 25.0 total 100 100.0 discussion pathogenesis of glaucoma due to h.pylori infection is hypothesized to be through the following mechanisms. 1) promoting platelet and plateletleucocyte aggregation. 2) releasing pro-inflammatory and vasoactive substances, such as cytokines, eicosanoids and acute phase proteins involved in a multitude of disorders mentioned in weinreb and khaw’s report. 3) stimulating monocytes to induce a tissue factor-like pro-coagulant activity, 4) development of cross mimicry between endothelial and h.pylori antigens. 5) producing oxidative stress and circulating lipid peroxides and 6) promoting apoptotic cascade. these variables may also initiate or worsen the progression of glaucomatous neuropathy and other neurodegenerative disorders (gbs, parkinsonism)15. glaucoma is differentiated from other forms of acquired optic nerve pathologies by the typical optic disc cupping. in glaucoma, the rim of the optic nerve gradually thins over time, thereby enlarging the optic nerve cup. this is called optic disc cupping. it results from the loss of axons of the retinal ganglion cells, combined with glial tissue and vascular architecture. the remaining rim maintains a pinkish color. with the exception of arteritic ischemic optic neuropathy, an immune-mediated inflammatory entity in which cupping maybe observed, other optic nerve diseases lose their pink color and there is no cupping16. the key factor in the pathogenesis of poag is believed to be iop primarily. other lesser understood risk factors have been included in its pathophysiology, such as; ischemia of the optic disc, vascular dysfunction or dysregulation (peripapillary and http://www.shaukatkhanum.org.pk/ http://www.shaukatkhanum.org.pk/ zeeshan khan oozeerkhan, et al 165 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol systemic). these factors are believed to cause direct damage to the optic nerve tissue or augment its risk of getting more damaged. recent studies suggest that alteration in endothelium-dependent vascular regulation, decreased blood supply to the ocular tissues, and cytokines can induce glaucoma related optic nerve damage10,17. chen h et al found out that in their experimental model with mice, that iop related t cell infiltration occurs in the retinal layers after transient raise in iop which persists even after the iop has been brought down to normal levels22. the prevalence of poag varies geographically, racially and is affected by various demographic factors. it was estimated in one study that 1.6 million people of 40 years of age and above in the united states have poag. the age adjusted prevalence rates of poag were 4 times higher in african-americans in comparison to caucasians in this survey. also, rates among african-americans were as low as 1.23% in the 40-49 years group to as high as 11.26% in the 80 years or older, and caucasians varied from 0.92% to 2.16%, respectively18. until now, there has not been extensive investigation to determine the prevalence of h.pylori in glaucoma patients. until recent, kountouras and associates reported a higher figures of h.pylori in greek patients with poag as compared to a control group, a suggestion was made for a possible link between glaucoma and poag in their population14. studies from india and china have shown the frequency of h.pylori in patients of poag to be 70% and 54.2% respectively6,19. a survey estimated 0.5% of the population of developed countries and a variable of 3-10% in developing countries are more likely to become infected with h.pylori21. considering the fact that in our developing country, where the health facilities, diagnostic measures and treatment strategies are lacking already, early detection of such infections and their eradication can help greatly in the management of primary open angle glaucoma (poag). in pakistan, no study has been conducted to see the frequency of h.pylori in poag population. multiple international studies have shown variability in their results. hence, we aimed to conduct this study with our primary objective to determine the frequency of h.pylori antibody in serum of patients with established poag. the mean age of patients was 50.45 ± 6.16 years with age range of 20 years. the minimum and maximum ages were 40 and 60 years respectively. there were 49 (49%) male and 51 (51%) female patients. the male to female ratio was almost same. ida dielemans and coworkers showed in their study that the overall prevalence of poag was 1.10%. the prevalence increased from 0.2% in the 55-59 years group, to 3.3% in the 85-89 years group. men were found be 3 times more prone than women (odds ratio, 3.6) 19,20. another study conducted in iran showed that mean age of patients of poag was 61.11 ± 11.1 with a female to male ratio to be 7:13. furthermore, they showed that the average concentration of anti-h. pylori igg antibodies of patients with poag was 0.44 ± 0.64 u/ml.5 in our study, the mean antibody level of patients was 3.80 ± 2.57 with range of 9.39. the minimum and maximum antibody level was 0.07 and 9.46 respectively. the helicobacter pylori antibody was present in 75 (75%) patients. another study showed that patients with glaucoma had a more strong presence of h.pylori infection than controls, 36 (88%) of 41 glaucoma cases, including 6 patients who tested negative in the gastric mucosa urease test, and in 14 (47%) of the 30 control subjects. the mean serum ig g anti–h.pylori level was also more in poag population (35.6 ± 31.1 u/ml) than in the control group (17.03 ± 18.1 u/ml; p = .002)7. another study showed that 43 of their 51 poag cases (84.3%) and 17 of their 35 control subjects (48.6%) were tested positive for h. pylori21. zeng et al suggested through their meta-analysis that there is strong association between h. pylori and open angle glaucoma24. few studies found no correlation between h.pylori and poag. this is based on the fact that eradication of h.pylori did not help increase or decrease the prevalence of poag in those patients. a study by noche et al saw that there was no statistical significance in their case-control study regarding the prevalence of h.pylori in the poag group and the normal group, 74% and 87% respectively25,26. the results of current study were compatible with other international studies and showed a higher than normal frequency of h.pylori in a population of poag. the results urge for making it essential to detect the presence of this bacteria and pursue its eradication among such patients. this could potentially help in better clinical management of the disease. frequency of helicobacter pylori in patients with primary open angle glaucoma pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 166 the limitation of our study was the small sample size and single center used for data collection. further studies are required to obtain more generalizable results. conclusion the results of our study show that the frequency of helicobacter pylori antibody is h.pyloci antibody is as high as a 75% in patients with primary open angle glaucoma. we must focus on this serious health issue and should start appropriate intervention to prevent helicobacter pylori antibody at an early stage of this disease. references 1. kanski jj, glaucoma bb, gabbedy r, cook l. clinical ophthalmology a systemic approach. 7th ed. china: elsevier; 2011: 380. 2. kumar v, abbass ak, fausto n, aster j. robbins and cotran. pathologic basis of diseases. 8h ed. india: elsevier; 2010: 776-787. 3. deshpande n, lalitha p, krishna das sr, jethani j, pillai m, robin a, karthik. helicobacter pylori igg antibodies in aqueous humor and serum of subjects with primary open angle and pseudo-exfoliation glaucoma in a south indian population. j glaucoma, 2008; 17 (8): 605-10. 4. zaidi m, jilani f, gupta y, umair s, gupta m. association between helicobacter pylori and open angle glaucoma: current perspective. nepalese journal of ophthalmology, 2009; 1 (2): 129-35. 5. razeghinejad mr, kamali-sarvestani e, farvardin m, pourhabibi a. aqueous levels of anti-helicobacter pylori igg antibody in patients with primary open angle and pseudoexfoliation glaucoma. iran j immunol. 2006; 3: 86-90. 6. hong y, zhang c, duan l, wang w. relationship between helicobacter pylori infection and open angle glaucoma in china. asian j ophthalmol. 2007;9:205-8. 7. kountouras j, mylopoulos n, chatzopoulos d, zavos c, boura p, konstas ag, et al. eradication of helicobacter pylori may be beneficial in the management of chronic open-angle glaucoma. arch intern med. 2002; 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110 (5): 922-5. 14. kountouras j, mylopoulos n, boura p, bessas c, chatzopoulos d, venizelos j, et al. relationship between helicobacter pylori infection and glaucoma. ophthalmology, 2001; 108 (3): 599-604. 15. kountouras j, zavos c, chatzopoulos d. primary open-angle glaucoma: pathophysiology and treatment. the lancet. 2004; 364 (9442): 1311-2. 16. hayreh ss, jonas jb. optic disc morphology after arteritic anterior ischemic optic neuropathy. ophthalmology, 2001; 108 (9): 1586-94. 17. haefliger io, dettmann e, liu r, meyer p, prünte c, messerli j, et al. potential role of nitric oxide and endothelin in the pathogenesis of glaucoma. survey of ophthalmology, 1999; 43: s51-s8. 18. tielsch jm, sommer a, katz j, royall rm, quigley ha, javitt j. racial variations in the prevalence of primary open-angle glaucoma: the baltimore eye survey. jama. 1991; 266 (3): 369-74. 19. dielemans i, vingerling jr, wolfs rc, hofman a, grobbee de, de jong pt. the prevalence of primary open-angle glaucoma in a population-based study in the netherlands: the rotterdam study. ophthalmology, 1994; 101 (11): 1851-5. 20. zavos c, kountouras j, sakkias g, venizelos i, deretzi g, arapoglou s. histological presence of helicobacter pylori bacteria in the trabeculum and iris of patients with primary open-angle glaucoma. ophthalmic research, 2011; 47 (3): 150-6. 21. parsonnet j. the incidence of helicobacter pylori infection. aliment. pharmacol. ther. 1995; 9 (suppl. 2): 45-51. 22. chen h, cho ks, vu thk, et al. commensal microflora-induced t cell responses mediate progressive neurodegeneration in glaucoma [published correction appears in nat commun. 2018 sep 20; 9 (1): 3914]. nat commun. 2018; 9 (1): 3209. published 2018 aug 10. doi:10.1038/s41467-018-05681-9. 23. rabelo-gonçalves em, roesler bm, zeitune jm. extragastric manifestations of helicobacter pylori infection: possible role of bacterium in liver and pancreas diseases. world j hepatol. 2015;7(30):2968– 2979. doi:10.4254/wjh.v7.i30.2968. 24. zeng j, liu h, liu x, ding c. the relationship between helicobacter pylori infection and open-angle glaucoma: a meta-analysis. invest ophthalmol vis sci. zeeshan khan oozeerkhan, et al 167 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol 2015; 56: 5238–5245. 25. chen hy, lin cl, chen wc, kao ch. does helicobacter pylori eradication reduce the risk of open angle glaucoma in patients with peptic ulcer disease? medicine (baltimore). 2015; 94 (39): e1578. doi:10.1097/md.0000000000001578 26. noche cd, njajou o, etoa fx. no association between cagaand vaca-positive strains of helicobacter pylori and primary open-angle glaucoma: a case-control study. ophthalmol eye dis. 2016; 8: 1–4. published 2016 feb 17. doi:10.4137/oed.s35895. 27. gravina, a., zagari, r., musis, c., romano, l., loguercio, c. and romano, m. (2018). helicobacter pylori and extragastric diseases: a review. world journal of gastroenterology, 24(29), pp.3204-3221. author’s affiliation dr. zeeshan khan oozeerkhan mbbs, fcps senior registrar department of ophthalmology al-aleem medical college, gulab devi hospital, lahore dr. muhammad arshad mahmood mbbs, fcps, professor of ophthalmology al-aleem medical college, gulab devi hospital, lahore dr. mohamud walid peerbux mbbs, fcps, registrar al-shifa trust eye hospital, rawalpindi dr. muhammad sufyan aneeq ansari mbbs, fcps, assistant professor fatima memorial hospital, lahore dr. faisal mahmood mbbs, fcps, vr trainee lahore general hospital, lahore author’s contribution dr. zeeshan khan oozeerkhan concept, design, data collection dr. muhammad arshad mahmood data analysis, critical review dr. mohamud walid peerbux statistical analysis, critical review. dr. muhammad sufyan aneeq ansari data collection, manuscript writing dr. faisal mahmood data collection, manuscript review. microsoft word zareen mahdi 145 original article pattern of eye diseases in children at secondary level eye department in karachi zareen mahdi, shahnawaz munami, ziauddin ahmed shaikh, haroon awan, shahid wahab pak j ophthalmol 2005, vol. 22 no.3 . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …………….……………….. corrrespondence to: zareen mahdi community ophthalmologist, prevention & control of blindness cell, eye opd, civil hospital, karachi. received for publication july’ 2005 …………….……………….. purpose: to asses the pattern of common eye diseases in children of 0-15 years of age attending an out patient eye department, sindh government hospital, new karachi. material and methods: a modified who/pbl eye examination proforma in respect of each child was filled in for recording of personal history, examination results and treatment required. the pattern of eye diseases affecting the children of new karachi causing blindness and visual impairment according to age and sex were assessed. results: a total of 520 children of which 57.1% were male and 42.9 % female were examined and recorded squint 17.7% was the most common ocular morbidity followed by bacterial conjunctivitis 14.8%, vernal catarrh 12.1%, trauma 9.6%, blephritis 7.9%, vitamin a deficiency 7.5%, lid problems 7.5% (chalazion, stye), corneal ulcers and corneal opacity accounted for 9.4% ,nasolacrimal duct block 3.7%, trachoma 2.3%, and cataract 1.4%. out of 520, 334 children in age group 7-15 i.e. 64.2% were examined for refractive errors and 56.8 %found to be visually impaired. others causes were less than 1%. conclusion: the distribution of male and female children was similar in different age groups. the number of eye disease was highest in children age group 7-15 i.e. 64% followed by age group 1-6, i.e. 27.5%, and children less than 1 year were 8.3%. ccording to a recently concluded population census in 1998, pakistan has an estimated population of 142 million in 2003. it is estimated that 40% of the population is below 16 years of age. the prevalence of blindness in children in pakistan is estimated to be about 10 per 10,000 children, which means there are about 60,000 blind children. a further 100,000 to 180,000 children are estimated to have low vision1. the high incidences of consanguineous marriages together with maternal infections and environmental factors are responsible for the significant proportion of congenital/developmental abnormalities in these children. other causes of childhood blindness include nutritional factors and trauma2. in poor countries of the world corneal scarring due to vitamin a deficiency, ophthalmia neonatrum trachoma and use of harmful traditional practices (tp) predominates3. increasingly, refractive errors is being recognized as an important cause of visual impairment in both children and adults, the type and magnitude of refractive errors clearly changes with advancing age and also appears to be changing overtime , with recent a 146 cohort having higher prevalence than earlier one . visual acuity is the most appropriate screening test to identify individual with visual impairment due to uncorrected refractive errors5. material and methods this was a hospital-based study; and cross sectional in term of time and orientation and descriptive in methodological design. all children 0-15 years attending outpatient at eye opd in sindh government hospital new karachi, were included in study. the survey thus commenced on 1st july and extended to 10th august 2002 i.e. 36 days. logistics and ethical considerations were discussed before the start of the study with the medical superintendent and head of the ophthalmology department of sindh government hospital new karachi and they extended full cooperation and the required equipment during the entire survey period. against the estimated 540 children, a total of 520 children were examined. the subjects were children in the age group 0-15 attending outpatient in eye department of sindh government hospital, new karachi. on an average 12 children attended the said opd daily from 9a.m to 1p.m daily. all children examined were found to have single ocular problems while a few children had more than one ocular problem. during the study, a detailed history of each child, father’s occupation, immunization, was asked. children of 0-3 years were examined with a magnifying loop. the visual acuity of all children from age group 0-6 years was excluded, due to time limitation and technique. all children of age group 715 were examined on slit lamp and visual acuity checked with illiterate snellen e chart directly and with pinhole. children who showed improvement with pinhole were referred, with findings on an outpatient slip, for refraction to the head of ophthalmology department and children who showed no improvement were also referred to the ophthalmologist for direct and indirect ophthalmoscopy, to exclude any pathology. on anatomical basis the disorders were divided into the diseases affecting the lid, whole globe, cornea, lens, uvea, retina, optic nerve. data was entered daily in the evening on the computer using epi info 2000 version. the data was cleaned, analyzed using the same software, results were drawn and recommendations were suggested. result a total of children 520 of which 57.1% were male and 42.9% female were examined and recorded (table 1). few of all children examined had one or more ocular problems. 30 % consanguinity was found, in all examined subjects. one child was mentally retarded and two were found to be physically handicapped. the proportion of diseases as shown in (table 2) were squint both convergent and divergent i.e. 17.7% table 1: distribution of children 0-15 years by age & sex age (yrs) male n (%) female n (%) total n (%) < 1 23 (7.7) 20 (8.9) 43 (8.3) 1 – 6 86 (29) 57 (25.6) 143 (27.5) 7 – 15 188 (63.3) 146 (65.5) 334 (64.2) total 297 (100) 223 (100) 520 (100) table 2: proportion of children (0-15) with diseases diseases male n (%) female n (%) total n (%) squint 58 (19.5) 34 (15.2) 92 (17.7) bacterial conjunctivitis 42 (14.1) 35 (15.7) 77 (14.8) vernal catarrh 51 (17.2) 12 (5.4) 63 (12.1) trauma 34 (11.4) 16 (7.2) 50 (9.6) blepharitis 7 (2.4) 34 (15.2) 41 (7.9) vitamin. a deficiency 31 (10.4) 8 (3.6) 39 (7.5) lid problem (chalazion, stye) 10 (3.4) 29 (13) 39 (7.5) corneal ulcer 23 (7.7) 5 (2.2) 28 (5.3) corneal 13 (4.4) 8 (3.6) 21 (4.1) 147 opacity nasolacrimal duct block 4 (1.3) 15 (6.7) 19 (3.7) trachoma 5 (1.7) 7 (3.2) 12 (2.3) cataract 4 (1.4) 3 (1.4) 7 (1.4) other <1% 15 (5.1) 17 (7.6) 32 (6.1) total 297 (100) 223 (100) 520 (100) was the most common ocular morbidity followed by bacterial conjunctivitis 14.8%, vernal catarrh 12.1 %, trauma 9.6 %, the etiology (table 3) of the trauma in this study was 50% due to foreign bodies, (like iron particle, plastic, glass piece, paint, glue, tyre burst) 10% due to lime burn, 10% stick injury, and 30 % occurred at home (by rubber bands, needles, fire crackers, while playing with others). blepharitis 7.9 %, vitamin a deficiency 7.5 % and it was mainly due to malnourishment, poverty and large family sizes. lid problems (chalazion, stye) 7.5%, corneal ulcers and corneal opacity accounted for 5.3% and 4.1% respectively, additionally corneal ulceration and scar were due to bacterial conjunctivitis, viral (herpes) conjunctivitis, presence of foreign bodies and trauma, exact details for these few cases in terms of frequencies and percentages is not presented in this document. naso lacrimal duct block cases 3.6%, trachoma 2.3%, cataract 1.4% and other miscellaneous disease less than 2%, among them few important one include, a case of panophthalmitis, drooping of eyelid, oclusio pupillae, nystagmus, macular degeneration and conjunctival cyst and retinoblastoma. the frequency of eye diseases was highest in children age group 7-15 years in 334 i.e. 64.2%, followed by age group1-6 years 143 i.e. 27.5% and < i year 43 i.e. 8.3 % (table 4). out of 520, children 334 in the age group 7-15 only were examined for refractive error, and the frequency was 56.8%. of the total refractive errors 50% were found to be myopic and 50% were hypermetropic (fig. 1). refractive error was found predominately in male children i.e. 70% and 30% in female children (fig 2). medication (eye drops) were provided to all who needed it. children suffering from vitamin a deficiency were provided vitamin a capsules but no one turned up for follow up. all children of cataract and refractive error were referred to ophthalmologist for further evaluation1. discussion total children 520 were examined, of which 57.1% males and 42.9% were females children. all of them had eye diseases; number of children had more than one ocular problem. consanguinity was found in 30 %of cases. squint was registered among highest number of children 17.7% and followed by bacterial conjunctivitis i.e. 14.8%. the leading cause of monocular blindness was trauma. 148 table 3: major causes of trauma causes male n (%) female n (%) total n (%) foreign bodies 20 (40) 5 (10) 25 (50) home injuries 8 (16) 7 (14) 15 (30) lime burn 2 (4) 3 (6) 5 (10) stick injury 4 (8) 1 (2) 5 (10) total 34 (68) 16 (32) 50 (100) table 4: distribution of disease in different age group disease < 1 (y) n (%) 1-6 (y) n (%) 7-15 (y) n (%) total n (%) squint 2 (4.7) 10(7) 80 (24) 92 (17.7) bacterial conjuncti vitis 16 (37) 31(21.6) 30 (9) 77 (14.8) vernal catarrh 0 (0) 14(9.8) 49 (14.7) 63 (12.1) trauma 4 (9.3) 12(8.4) 34 (10.2) 50 (9.6) blephritis 0 (0) 1(.7) 40 (11.9) 41 (7.9) vitamin a deficiency 0 (0) 29(20.2) 10 (3) 39 (7.5) lid problem(chala zion,stye) 2 (4.7) 11(7.7) 26 (7.8) 39 (7.5) corneal ulcer 3 (7) 9(6.3) 16 (4.8) 28 (5.3) corneal opacity 0 (0) 4(2.8) 17 (5) 21 (4.1) naso lacrimal duct block 8 (18.6) 9(6.3) 2 (6) 19 (3.7) trachoma 0 (0) 2(1.4) 10 (3) 12 (2.3) cataract 2 (4.7) 1(.7) 4 (7) 7 (1.4) others < 1% 6 (14) 10(7.1) 16 (4.8) 32(6.1) total 43 (100) 143(100) 334 (100) 520 (100) 50% 50% myopia hypermatropia fig. 1: types of refractive errors age 7-15 years total = 190 70% 39% 0% 10% 20% 30% 40% 50% 60% 70% male female male female fig. 2: refractive errors in age group (7-15) years by sex. total children =334 both convergent and divergent squints were discovered in 92 i.e 17.7 % children. squints are common all over the world but do not have any special association with developing countries or tropical environments6. there are many possible causes of squint. squints develop in children where there is no obvious defect or refractive error in the eye. convergent squints were more common than divergent squints. most of them had convergent squint associated with refractive errors. out of total, there were 24% squints in age group (7-15years), associated with refractive errors, 75 % children had convergent squints whereas 25 % were having divergent squint. children with squint were referred to the hospital ophthalmologist for further evaluation. hyper 149 matropic squints were found to be 80 % in age group 0-15 years i.e. 520 and 50% hypermatropic were of total refractive errors i.e. 190, the reason is that hypermetropes were ignored due to illiteracy and squint occurred whereas myopic were noticed by others, so parents seek early treatment. in our study, 80% were hypermetropes; this is also emphasized by abrahamasson et al where the patient with convergent squint had a pronounced hypermetropia7. this relation of esotropia to hypermetropia has also been reported by duke–elder8. the proportion of squint in our study is similar to study by chaturved s found, the apparent/latent squint was 7.4%9. in our study squints were almost same proportion in both sexes i.e. 19.5% in male and 15.2% in female children. futhur studies will be needed to find out reason and mechanism identified so these children can be detected early. it was observed that squints were due to illiteracy and uncorrected refractive errors in children, whose parents cannot afford glasses. the government/ ngos should provide literacy and spectacles to young children, who have refractive errors, so they do not develop squint. squints managed by glasses may need corrective surgery as well. in this study the bacterial conjunctivitis was found in patients 77 (14.8%), the second highest peadiatric ophthalmic disorder. bacterial conjunctivitis was diagnosed on the presence of purulent discharge in eye. the same results were obtained by awan and usman i.e. 34.18%10. in our study 37 % were <i year, 4.3 % were between age group 1-6, and 0.9 % were in age group 7-15. conjunctivitis of the newborn is a very serious problem in many parts of the developing world. the great damage to sight is infection, which involves the cornea. as the condition usually affects both eyes, the tragedy of an otherwise healthy child becoming blind is avoidable11. bacterial conjunctivitis could be due several factors i.e. due to over crowding, poor hygiene, poor nutrition and lack of health education of mothers, as the children’s were coming from very poor community having large family size, and in most of families absence of mothers from home as they were also working. in addition to bacterial conjunctivitis cases allergic conjunctivitis, viral conjunctivitis, and hemorrhagic conjunctivitis were also observed but they were all less than 1%. vernal keratoconjunctivitis is a recurrent, bilateral, external, ocular inflammation primarily affecting boys and young adults living in warm, dry climates12. the disease was fond in 63 patients i.e. 12.1%. similar finding 11% of vernal catarrh was also reported by medi13. in this study 17% male were affected more than females who were 5%. high prevalence of disease in male also found in khan study14. in our study, 14.7% children in age group 7-15 years were affected predominantly, this is supported by a. sharma, and the peak incidence of vernal catarrh was in age 11-13 years15. trauma was observed in 9.6 % cases. in our study male were found to be dominant i.e. 68% like other studies by chan et al16, thylefors17 and khan et al18. a countrywide population based surveys in nepal reported that 7.7 % of all monocular blindness is due to trauma, and this was one of the causes of childhood blindness in eastern mediterranean countries19. jan et al also found also found, 9.5% of trauma in hospital base study20. in our study 50%, injuries were due to foreign bodies, 10% was due to lime burn, 10 % stick injury and 30% occurred at home. among the cases of trauma, a major portion of accidents occurred at home, a factor also documented by desai et al21. the proportion of corneal ulcer / opacity in children was 5.3% and 4.1% respectively i.e. 9.3%. tayab afghani in a survey of blind school shows 12% corneal diseases as cause of blindness22. rahi at blind school in india shows 26.4% of corneal diseases responsible for visual impairment and blindness23. corneal ulcers in this study were mostly due to foreign body, bacterial keratitis, and herpes infections and also due to lime burn, vitamin a deficiency may be a contributing factor to corneal opacity, which was found in 7.5% children and which could not be confirmed due to lack of laboratory support. according to who report about 3 million children have clinically xerophalmia through out the word24. majority of corneal ulcers follow the occurrence of often trivial corneal abrasions. in study by jatoi s causes of corneal ulcers were found to be trauma in 63.5% of cases25. in pakistan, various studies have been carried out which have so far suggested vitamin a deficiency as a problem. no in-depth survey has been carried out. a survey in four district of punjab covering 21 villages 150 showed prevalence of vitamin a deficiency in children as 6.4 % however that in children 5-6 years of age was 50 %, while 17% of cases were from 2-3 years and 4-5 years and 12% from 3 to 4 years27. cataract in this study was 1.4% of cases, including all types, congenital, traumatic, and developmental and it found to be the cause of monocular blindness. trachoma cases accounted for only 2.3%, frequency being 12 out of 520 children. of these 1.7% were male and 3.2 % in female children. eyelid problems (chalazion, stye) in our study was 39 i.e. 7.5%. blephritis was discovered in 41 (7.9%) of case, the proportion was high in females i.e. 15.2 %, and mostly involves age group 7-15 years. in countries with warm climate, the prevalence of staphylococci is as high as 95% in culture, and sub clinical and mild lid infections are quite common28. refractive errors were seen in high proportion i.e. 334 (56.8 %) in children age group 7-15 years. a population based study conducted by memon in 198790 showed that 11.4% of blindness was due to refractive errors and amblyopia29. in our study, visual impairment was found predominantly in males i.e. 70% and female were 30%. the prevalence of refractive errors in school study in nepal is 2.9%, in china 12.8%, in chile 15.8%. comparing to these studies proportion is higher in our study30. it is recommended that visual acuity should be perform in all primary and secondary school students. daily refraction at hospital by training more refractionist and low vision workers. acknowledgement authors indebted to dr. haroon awan, country manager, sightsavers international (ssi) for his continuous advice in the development and production of this paper. thanks also to prof. shahid wahab, lyari general hospital, karachi for guidance and support for completion of this work. author’s affiliation dr. zareen mahdi community ophthalmologist prevention & control of blindness cell eye opd civil hospital, karachi. dr. shahnawaz munami community ophthalmologist prevention & control of blindness cell eye opd civil hospital, karachi. prof. ziauddin ahmed shaikh chairman department of ophthalmology dow university of health sciences karachi. prof. shahid wahab lyari general hospital karachi dr. haroon awan country manager references 1. current status of aetiology, prevalence and distribution of childhood blindness in pakistan. a report, 2003 pakistan, sight savers international; 18. 2. pakistan national programme for the prevention of blindness. first five year plan 1994-1998, national committee for the prevention of blindness, ministry of health, special education and social welfare islamabad. 3. preventing blindness in children, report of a who/iabp scientific meeting hyderabad, india, 13-17 april 1999; who/pbl/00.77; 3. 4. prevention of childhood blindness world health organization. geneva; 1992; 20. 5. elimination of avoidable visual disability due to refractive errors; report of an informal meeting geneva 3-5 july 2000 who/pbl/0079; 6-10. 6. sanford j eye diseases in hot climate 3rd edition; butter worth– heinemann, oxford. 1997; 290. 7. abrahamson m, fabin,g, sjostrand j. refractive changes in children developing convergent or divergent strabismus. br j ophthalmol. 1992; 76: 723-7. 8. duke elder’s. abnormal ocular motility: “a system of ophthalmology” vol vi.london: kimpton. 1973; 577-641. 9. chaturvedi s, aggarwal op. pattern and distribution of ocular morbidity in primary school children of rural d asia pacific j public health 1999; 11: 30-3. 10. awan ah, usman j. acute bacterial conjunctivitis in southern punjab. pak j ophthalmol. 2000; 16; 30. 11. prevention of child hood blindness: community eye health no 4: international center for eye health. 1998; 23. 12. jack j. kanski clinical ophthalmology 5th edition: butterworth heinemann, international edition 2003: 73. 13. kawuma m. “the clinical picture of vernal keratoconjunctivitis in uganda;” community eye health. 2001; 14: 67. 14. khan md, kundi, saeed n, gulag a, et al a study of 530 cases of vernal. conjunctivitis from north west frontier province of pakistan. pak j ophthalmol. 1986, 2; 111-4. 15. sharma a, gupta r, ram j, gupta a. topical ketorolac 0.5 % solution for the treatment of vernal keratoconjunctivitis. indian j ophthalmol. 1997; 45: 177. 16. chan to, keefe m, bowell r, et al. childhood penetrating eye injuries. ir med j. 1995; 88: 168-70. 17. thylefors b. epidemiological pattern of ocular trauma. aust n z j ophthalmol. 1992; 20: 95-8. 18. khan md, islam z, khattak mn. an 11 ½ year review of ocular trauma in the north west frontier of pakistan. pak j ophthalmol. 1991: 7; 15-8. 19. tabbara kf. blindness in eastern mediterranean countries: br j ophthalmol. 2001; 85: 771-5. 151 20. jan s, khan s, mohammad s. hyphaem due to blunt trauma, jcpsp 07/13, 2003; 398. 21. desai p, mac ewen cj, vaines p, et al. incidence of blinding outcome. br j ophthalmol. 1996: 80; 592-6. 22. afghani t. causes of childhood blindness and severe visual impairment – survey of the blind children from a rural population and schools for blind in an urban area. pak j ophthalmol. 2000; 16: 16. 23. rahi j, sripathi s, gilbert c, et al. childhood blindness in india causes in 1318 blind school student in nine states eye 1995: 545-50. 24. f.d, sight and life slides on vitamin a deficiency disorders (vadd), third edition 2001, switzerland; 4. 25. jatoi s, qureshi m, laghari n, et al. etiological diagnosis of infective ulcerative keratitis. pak j ophthalmol. 2002; 18: 40. 26. control of vitamin a deficiency and xeropthalmia. world health organization geneva 1982; 21. 27. shah sra. dissertation on magnitude of vitamin a deficiency in poor communities of four selected districts of punjab (pakistan). pico/0006/98: 25. 28. biswas j, madhavan h. blephritis and lid ulcer as initial ocular manifestation in acquired immunodeficiency syndrome patient: indian j ophthalmol. 1997; 45: 234. 29. memon s. prevalence and causes of blindness in pakistan jpma, 1992. 30. report of informal meeting, geneva 3-5. 2000, who. pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 195 original article efficacy and complications of modified laser iridotomy in primary angle closure glaucoma azfar ahmed mirza, noor bakht nizamani, mahtab alam khanzada, khalid iqbal talpur pak j ophthalmol 2016, vol. 32 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: azfar ahmed mirza, department of ophthalmology, liaquat university eye hospital, jail road, hyderabad, 71000, sindh email: drazfarahmed@gmail.com …..……………………….. purpose: to evaluate the efficacy and immediate complications of modified laser iridotomy in primary angle-closure glaucoma. study design: case series. place & duration of study: department of ophthalmology, liaquat university of medical & health sciences, hyderabad, pakistan from november 2011 to may 2012. material and methods: in this study 115 patients of 41 to 60 years, with diagnosis of primary angle closure glaucoma were included, while patients with secondary angle closure glaucoma and all those patients in whom angle was not visible due to corneal opacity or haze were excluded from the study. prior to laser therapy all patients were explained about the procedure and a written consent was obtained. a combination of argon and yag for laser iridotomy (modified laser iridotomy) was used in all the patients. the patients were followed-up at 1 st day, 1 st week, and 4 weeks after treatment with slit lamp examination and intraocular pressure measurement. the data was entered and analyzed using spss version 16.0. results: 88 patients (76.5%) had intraocular pressure reduction of more than 8 mm hg and14 (12.17) patients had reduction in iop 5 to 8 mm hg, while only 13 (11.3%) patients had reduction of less than 5 mm hg after 4 weeks. among the complications, iritis was the most frequent complication noted, 95 (82.6%) patients had iritis on day one, which reduced to 03 (2.61%) patients after 4 weeks. conclusion: modified laser iridotomy (argon followed by nd: yag laser) is an effective treatment option for primary angle closure glaucoma, with few reversible side effects. key words: angle closure, glaucoma, laser procedures, iridotomy laucoma is one of the leading causes of severe visual impairment and blindness worldwide1. primary angle-closure glaucoma (pacg) is a major cause of irreversible blindness globally particularly in asia where it represents the major form of glaucoma2. an estimate shows that 55.3 million people worldwide will be blind owing to pacg by 20203. pacg needs an urgent management to lower the intraocular pressure (iop) and minimize the risk of vision loss4. the last decade has seen a paradigm shift in the treatment of angle-closure glaucoma from incisional surgery to laser surgery as the preferred method for creating an opening in the irides5. this is because of no need of using retrobulbar anesthesia, anterior chamber maintainer, absence of the risk of infective endophthalmitis and it can be applied as an outpatient procedure6. g mailto:drazfarahmed@gmail.com azfar ahmed mirza, et al 196 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology neodymium-yttrium-aluminum-garnet (nd: yag) laser iridotomy is effective in reducing iop in people with pacg7. nd:yag is a better option than argon because of easy iris penetration and a lower incidence of iridotomy closure8. its efficacy is greater in light colored irides, but in dark irides alone it is associated with high risk of failure and complications, like iris hemorrhage occurring in about 40%, which is severe enough to postpone the procedure9,10. argon laser pre-treatment significantly reduces iris haemorrhage11. the modified laser iridotomy (mli) is an advanced technique to treat the pacg and it uses the benefits of both lasers and avoids their disadvantages and complications12. therefore in dark asian irides, it is probably the best technique to be used12. a study from pakistan on the efficacy of argon followed by nd:yag laser reported that this technique was useful in controlling iop in 75% cases after 6 months of follow-up. they reported postoperative complications like iritis in 80% cases followed by raised iop in 45% cases, hyphema in 35% and corneal damage in 5% cases6. the rationale of this study is to find out if nd:yag laser combined with argon laser significantly reduces iris hemorrhage and achieves higher rate of single treatment success in pacg5,12. this would greatly benefit the patients and also result in less post-operative visit so reducing overall burden of patients in the outpatient department. material and methods this study was carried out at department of ophthalmology, liaquat university of medical and health sciences, hyderabad, from november 2011 to may 2012. patients of 40 to 60 years age, with diagnosis of pacg were included in the study. all those patients in whom angle was not visible due to corneal opacity or haze, secondary angle closure glaucoma, severe progressive type of glaucoma in which angle was not visible were excluded from the study. after taking history regarding previous attack, treatment and surgery of glaucoma snellen visual acuity was measured in all subjects prior to doing fundoscopy. a slit lamp examination was carried out, looking for ischemic sequelae of angle closure and signs of secondary glaucoma. intraocular pressure (iop) was measured with a tonometer (goldmann model, haag-streit, bern, switzerland). the median of three tonometer readings were recorded as a base line iop for each eye. gonioscopy was performed with a three mirror goldmann gonioscopy lens to record the width of the irido-trabecular recess in the four quadrants. the angle was graded as occludable or open. an occludable angle was defined as one in which three quarters of the posterior pigmented trabecular meshwork was not visible in the primary position of gaze without indentation. primary angle closer glaucoma was diagnosed in eyes with an occludable angle and glaucomatous optic neuropathy. evidence of glaucomatous optic neuropathy was defined as a cup: disc ratio (cdr) of > 0.7 or > 0.2 cdr asymmetry. dynamic (indentation) gonioscopy using three mirrors goldmann lens was performed to assess the presence or absence of peripheral anterior synechiaes (pas) in each quadrant. prior to laser therapy all patients were explained about the procedure and a written consent was obtained. a combination of argon and nd: yag for laser iridotomy was used in all the patients. nd: yag laser abraham iridotomy lens was used with methylcellulose as a coupling solution. the laser settings were, a power of 1000mw of argon laser with a spot size of 50 microns requiring 50-80 numbers of shots. the laser settings for nd: yag laser were a power of 4 – 6 mj requiring 3 – 5 shots. the iris tissue was thinned to 20% thickness with argon laser. after this the 2 – 3 shots of nd: yag laser was applied into the depth of the crater to complete the iridotomy, so that the anterior lens capsule was visible through the opening made by the iridotomy. one hour after the laser iop was checked and all the patients were discharged on topical steroid (prednisolone acetate) eye drops four times a day and a topical beta blocker eye drops twice a day for five days. the patients were followed up at 1st day, 1st week, and 4 weeks after the treatment. at each visit the patients were examined for visual acuity, iop measurement using applanation tonometry, anterior chamber reaction was noted, patency of iridotomy and gonioscopy was performed to confirm the extent of peripheral anterior synechiae. the data was entered and analyzed using spss version 16.0. frequencies and percentages were calculated for categorical variables like gender, raised iop, iritis, hyphema and corneal damage. mean and standard deviation (sd) were computed for quantitative variable like age. data was stratified based on age and gender to see the effect of modified laser iridotomy. after laser treatment if the iop efficacy and complications of modified laser iridotomy in primary angle closure glaucoma pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 197 decreased greater than 8 mm hg from the baseline iop the procedure was labeled as efficacious, good if 5 – 8 mm hg decrease and poor if less than 5 mm hg decrease. results there were 115 patients with pacg, 51 (44.3%) were males while 64 (55.7%) were females. average age of the patients included in the study was 52.95 (± 4.52) years, with range of 41 – 60 years. the age, gender, laterality and age distribution among genders is shown in table 1. stratification based on age, gender and side of eye to see the effect modifier is shown in table 2, table 3 and table 4. one day after laser 35.7% table 1: patient characteristics n = 115 characteristics n (%) gender m:f = 1: 1.2 male 51 (44.3) female 64 (56.7) laterality right 67 (58.3) left 48 (41.7) age at presentation (years) mean ± sd 52.95 ± 4.5 min – max 41 – 60 males mean ± sd 53.25 ± 4.1 min – max 42 – 59 females mean ±sd 53.17 ± 4.8 min – max 41 – 60 age groups 41-50 years males females 50-60 years males females 09 12 42 52 eyes, while four weeks later 76.5% eyes had iop reduction of more than 8 mm hg (figure 1). one day and one week after laser, iritis (82.6% and 10.43%) was the most frequent complication noted (figure 2). after four weeks of treatment none of the patients had hyphema, while rise in iop was noted only in 1 (0.87%) patient. fig. 1: intraocular pressure reduction after laser n = 115. fig. 2: complications after laser iridotomy n = 115. discussion glaucoma is a silent thief of vision which affects scores of people worldwide. pacg is the most dangerous type with profound irreversible loss of vision. in asians pacg is the more prevalent form of glaucoma1. in mongolia the prevalence of pacg is 1.4%13, with more than 6.55% of population having occludable angle. there are a number of treatment options available for pacg, like anti-glaucoma medicines, laser modalities and surgical options. anti-glaucoma medicines are expensive and require regular follow up and good compliance, while surgical options are azfar ahmed mirza, et al 198 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology table 2: stratification based on age to see the effect modifier n= 115 iop reduction of > 8 mm hg iop reduction of 5-8 mm hg iop reduction of <5 mm hg p value day 1 age group 40 – 50 8 12 1 0.008 age group 50 – 60 33 27 34 week 1 age group 40 – 50 15 6 0 0.011 age group 50 – 60 53 21 20 week 4 age group 40 – 50 19 2 0 0.049 age group 50 – 60 69 12 13 table 3: stratification based on gender to see the effect modifier n= 115 iop reduction of > 8 mm hg iop reduction of 5-8 mm hg iop reduction of < 5 mm hg p value day 1 males 22 11 18 0.044 females 19 28 17 week 1 males 27 14 10 0.480 females 41 13 10 week 4 males 41 6 4 0.550 females 47 8 9 table 4: stratification based on laterality to see the effect modifier iop reduction of > 8 mm hg iop reduction of 5 – 8 mm hg iop reduction of < 5 mm hg p value day 1 right eye 20 10 20 0.044 left eye 21 29 15 week 1 right eye 32 16 11 0.480 left eye 36 11 09 week 4 right eye 40 05 05 0.550 left eye 48 09 08 reserved for advanced glaucoma and have a high rate of failure especially in case of pacg. in developing countries like pakistan, glaucoma has a high burden on both patients and economy due to which most patients are not compliant and lost in follow up. here comes the significance of looking for treatment options in which patients do not need to be followed frequently and also patients do not require expensive anti glaucoma medications. in cases of pacg, such treatment option with one time treatment, no frequent follow ups and no need of expensive anti-glaucoma medication required would be in the form of laser peripheral iridotomy (lpi)14. lpi works by relieving the relative pupillary block and thus relieving pacg. but lpi may not work in non-pupillary block pacg. efficacy and complications of modified laser iridotomy in primary angle closure glaucoma pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 199 lpi can be done by argon laser which causes photocoagulation of the iris tissue resulting in shrinkage and charring of iris. but the lpi done by argon laser alone showed higher failure rate particularly in dark irides14. it also resulted in many complications including corneal endothelial burns, endothelial cell loss and retinal burns. around 10% of the patients developed endothelial cell loss15. after these failure results and complications were observed, argon laser was replaced with yag laser lpi, which works by photodisruption16. light pigmented irides showed much better results with yag lpi as compared to the darkly pigmented irides because they required less energy22. yag had less closure rate than argon lpi but like any other procedure it had some problems like the use of higher energy levels in dark irides, iritis, corneal burns, reduction in endothelial cell count, diplopia and hemorrhage16-18. if lpi is performed with lower energy and peripherally it can prevent endothelial cell loss, diplopia and hemorrhage. considering the pros and cons of individual use of argon and yag laser, a modified argon yag laser iridotomy (mli) was tried. this method was especially useful in dark irides which otherwise require high energy levels with individual lasers19,20. with mli almost half energy was needed which resulted in less complications and the iridotomy was large and round in contrast with slit opening of yag lpi. in our study, initially after 1 day iridotomy was effective in lowering iop more than 8 mm hg from baseline iop in 35.7% of patients which improved to 59.1% after 1 week and finally to 76.5%. similarly over 30% of patients had reduction in iop of <5 mmhg on day 1, which reduced to 17% on week 1 and finally to 11% after 4 weeks. this shows that iop lowering effect of mli may take 1 month to be fully effective. as far as complications are concerned, we observed four different complications including iritis, hyphema, corneal burns and rise in iop. we observed that only 1.74 % of patients had iop rise after one day of mli which reduced to 0.87% after one week. as stated in a study by harada, iris hemorrhages was observed in 17 % of patients when yag laser was used, but in our study only 10.43 % of patients had hyphema (on day 1) 21. in one recent study, they compared iridotomy outcomes in dark irides by using 1064 nm pulsed nd: yag either with pretreatment of double frequency yag laser (just like argon laser). they observed that when single frequency yag was performed alone it resulted in 43% iris hemorrhages, but when it was pretreated with double frequency yag this complication was reduced to 13% only (p=0.0126). around 2 out of 30 of patients in the standard treatment group (only single frequency yag was used for lpi) were abandoned due to significant hemorrhage22. this is a high frequency of complications as compared to what we have reported in our study. this shows that sequential argon laser before yag lpi is not only equally beneficial but results in much lower complications rate as compared to isolated yag lpi. iritis has been a well reported complication of both yag and argon lpi but only 3 patients in our study who underwent mli had iritis after 4 weeks23. schwartz reported a 75% success rate following mli which is comparable to our study (76.5%). other studies have showed variable frequencies of successful iridotomies in terms of lowering iop24. conclusion modified laser iridotomy (argon followed by nd: yag laser) technique is excellent for pacg, permitting effective iop reduction in most of the patients. although iritis was a frequently observed complication on day one after laser but with topical steroids it resolved in almost all the patients by week four. thus, it is an effective treatment option for pacg, with few reversible side effects. author’s affiliation dr. azfar ahmed mirza department of ophthalmology, liaquat university of medical & health sciences, jamshoro/hyderabad, pakistan dr. noor bakht nizamani department of ophthalmology, liaquat university of medical & health sciences, jamshoro/hyderabad, pakistan dr. mahtab alam khanzada department of ophthalmology, liaquat university of medical & health sciences, jamshoro/hyderabad, pakistan dr. khalid iqbal talpur department of ophthalmology, liaquat university of medical & health sciences, jamshoro/hyderabad, pakistan azfar ahmed mirza, et al 200 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology role of authors dr. azfar ahmed mirza study design, collected data, did critical appraisal of findings. dr. noor bakht nizamani drafted the manuscript, statistically analyzed data and reviewed literature. dr. mahtab alam khanzada data analysis and interpretation, critically reviewed the manuscript. dr. khalid iqbal talpur conceptualized the study and approved the final version references 1. quigley ha. broman at. the number of the people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006; 90: 262-7. 2. foster pj, oen ft, machin ds, ng tp, devereux jg, johnson gji. the prevalence of glaucoma in chinese resident of singapore: a crosssectional population survey tanjong pagardistrict. archophthalmol. 2000; 118: 1105-11. 3. he m, foster pj, johnson gji. angle-closure glaucoma in east asian and european people. different diseases? eye. 2006; 20: 3-12. 4. casson rj, newland hs, muccke j, megovern s, abraham lm, shein wi. gonioscopic findings and prevalence of occludable angles in a burnese population: the meiktila eye study. br j ophthalmol. 2007; 91: 856-9. 5. baig r, khan a. clinical outcome of iridotomy with argon-yag laser at a tertiary care center in karachi, pakistan jpma. 2010; 60: 220-3. 6. gray rh, naime jh, ayliffe wh. efficiency of ndyag laser iridotomies in acute angle closure glaucoma. br j ophthalmol. 1989; 73: 182-5. 7. ammarm, rahman h, butt ia, ghani n. role of yag laser iridotomy as initial treatment of primary angle closure. rawal med j. 2005; 30: 300-7. 8. quigley ha. long-term follow-up of laser iridotomy. ophthalmology.1981; 88: 218-24. 9. moster me, schwartz lw, spacth gi, wilson rp, mcallister ja, poryzeesem. laser iridotomy, a controlled study comparing argon and nd: yag. ophthalmol. 1986; 93: 20-4. 10. robin al, pollack ip. a comparison of nd: yag and argon laser iridotomies. ophthalmol. 1984; 91: 1011-6. 11. goins k, schmeisser e, smith t. argon laser pretreatment in nd: yag iridotomy. ophthalmic surg. 1990; 21: 497-500. 12. de silva dj, gazzard g, foster pj. laser iridotomy in dark irides. br j ophthalmol 2007; 91: 222-5. 13. foster pj, baasanhu j, alsbirk ph. glaucoma in mongolia-a population-based survey in hövsgöl province, northern mongolia. arch ophthalmol. 1996; 114: 1235-41. 14. schwartz lw, rodrigues mm, spaeth gl, et al. argon laser iridotomy in the treatment of patients with primary angle-closure or pupillary block glaucoma: a clinicopathologic study. ophthalmology. 1978; 85: 294309. 15. berger bb. foveal photocoagulation from laser iridotomy. ophthalmology. 1984; 91: 1029-33. 16. kielkopf jf. laser-produced plasma bubble. phys rev e stat nonlin soft matter phys. 2001; 63 (pt 2) :016411 [medline] 17. kumar rs, baskaran m, friedman ds, et al. effect of prophylactic laser iridotomy on corneal endothelial cell density over 3 years in primary angle closure suspects. br j ophthalmol. 2013; 97: 258-61. 18. ho t, fan r. sequential argon-yag laser iridotomies in dark irides. br j ophthalmol. 1992; 76: 329–31. 19. wu sc, jeng s, huang sc, lin sm. corneal endothelial damage after neodymium: yag laser iridotomy. ophthalsurg lasers. 2000; 31: 411-6. 20. harada t, mizuno k, awaya s. contribution of the argon laser in iridotomy using the yag laser. j frophtalmol. 1989; 12: 545-8. 21. de silva dj, day ac, bunce c, gazzard g, foster pj. randomised trial of sequential pretreatment for nd:yag laser iridotomy in dark irides. br j ophthalmol. 2012; 96: 263-6. 22. schwartz lw, moster mr, speath gl, wilson rp, poryzees e. neodymium-yag laser iridectomies in glaucoma associated with closed or occludable angles. am j ophthalmol. 1986; 15; 102: 41-4. 23. agulto mb, bacsalkme, lat-luna mml. a prospective, randomized comparison of nd:yag and sequential argon-yag laser iridotomy in filpinoeyes.philipp j ophthalmol. 2004; 29: 131-5. 24. hsiao ch, hsu ct, shen sc, chen hs. mid-term follow-up of nd:yag laser iridotomy in asian eyes. ophthalmic surg lasers imaging. 2003; 34: 291-8 http://lib.bioinfo.pl/pmid:3728623 http://lib.bioinfo.pl/pmid:3728623 http://lib.bioinfo.pl/pmid:3728623 http://lib.bioinfo.pl/pmid:3728623 microsoft word m moin 124 original article tarsal fixation of fascia lata in frontalis sling ptosis surgery muhammad moin pak j ophthalmol 2006, vol. 22 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: muhammad moin department of ophthalmology, king edward medical college, lahore. received for publication september’ 2005 …..……………………….. purpose: to evaluate the results of tarsal fixation of fascia lata in frontalis sling ptosis surgery design: interventional case series. material and methods: retrospective review of all cases of ptosis surgery performed between january 2000 and june 2005 in one of the units of institute of ophthalmology, mayo hospital, lahore. patients with levator function of less than 4 mm in the worst affected eye were included. all patients undergoing frontalis sling with materials other than fascia lata and all children under 5 years were excluded. bilateral frontalis sling was performed only in cases having ptosis on both sides while unilateral surgery was done in other cases. results: out of 108 cases of ptosis frontalis sling for the correction of poor function ptosis was performed on 57 eyelids of 41 patients. out of 41 cases of poor function ptosis 16 cases (39 %) were bilateral and 25 cases were unilateral (12 right and 13 left). thirty six patients had simple congenital ptosis with poor levator function, 3 patients had jaw winking unilateral ptosis and 2 cases had blepharophimosis syndrome. all patients had severe ptosis with average preoperative margin to reflex distance (mrd) of – 0.95 ± 1.33 mm. all eyelid in unilateral cases and worst eye in bilateral cases had poor levator function averaging 3.8 ± 1.35 mm in average levator function in better eyelid of bilateral cases was 4.25 ± 2.29 mm. amblyopia was seen in 8 patients and strabismus was seen in 6 patients. average post-operative mrd with brow up was 3.55 ± 0.73 mm and with brow down was 2.15 mm at 3 months after surgery. unilateral cases had results comparable to bilateral cases although it took the patients a few months before learning to keep the 2 sides at equal height. all patients had a well formed lid crease and were happy with the postoperative lid height. no patient had lagophthalmos of more than 2 mm. two cases undergoing unilateral surgery had slippage of the sling which needed to be readjusted at the end of the first week. five eyes had mild exposure keratopathy initially which was resolved with lubricants over 1 month. mild nasal peaking was seen in 4 eyelids which was apparent only on the limit of brow action and was cosmetically acceptable to the patient. conclusion: tarsal fixation of fascia lata sling produces a deep lid crease with reliable correction of poor function ptosis. 125 ongenital poor function ptosis has been managed in different ways over the years. unilateral cases have been treated using bilateral frontalis sling with or without extirpation of the normal levator muscle on the unaffected site. various materials including fascia lata1,2, palmaris tendon3, deep temporal fascial graft4, mersilene5,6, gortex7, silicone rods8-10 and different sutures11 have been used to fashion the frontalis sling. recently frontalis muscle advancement12 has been used to bypass the sling. autogenous fascia lata remains the time tested material over the years with best biocompatibility. the technique for making a sling has also been quite varied. some people use a lid crease incision with tarsal fixation of the fascia lata compared to others who use supralash stab incisions to pass the fascia lata beneath the orbicularis without anchorage13. fox pentagon14 or crawford double triangle15 are the two different methods of passing the fascia lata. in our series we report tarsal fixation of the fascia lata using a modified fox pentagon to correct poor function congenital ptosis. materials and methods retrospective review of 108 cases of ptosis surgery at the institute of ophthalmology, mayo hospital, lahore showed that frontalis sling for the correction of poor function ptosis was performed on 57 eyelids of 41 patients. all patients were photographed pre and post operatively using a digital camera and the pictures were stored in a computer database. all patients were seen first day, first week, first month and 3 months post-operatively. few patients had a follow up of one year. the pre-operative and last post-operative photographs was analysed on a computer database to check for pre-operative mrd, levator function and lagophthalmos. post-operative mrd with brow up and brow down, lagophthalmos and lid contour was also analysed. patients with levator function of less than 4 mm in the worst affected eye were included. all patients undergoing frontalis sling with materials other than fascia lata and all children under 5 years were excluded. difficulty in assessment of pre and post-operative measurements and inadequate length of fascia lata were the reasons for excluding children less than 5 years. autogenous fascia lata was harvested in all patients using a fascia stripper through a 2.5 cm incision. frontalis sling was made using a modified fox pentagon and fascia lata was sutured to the tarsal plate using a lid crease incision. tarsal fixation of the lid crease was also done in all cases to form a deep lid crease (fig. 1). the affected lid was raised to a level just below the superior limbus in all cases as they had good bell’s phenomenon and severe ptosis. bilateral frontalis sling was performed only in cases having ptosis on both sides while unilateral surgery was done in other cases. all patients were told to practice lifting their brows in front of the mirror to control the amount of lift required. results out of 41 cases of poor function ptosis 16 cases (39 %) were bilateral and 25 cases were unilateral (12 right and 13 left). thirty six patients had simple congenital ptosis with poor levator function, 3 patients had jaw winking unilateral ptosis and 2 cases had blepharophimosis syndrome. patients with jaw winking ptosis underwent levator excision along with frontalis sling. jaw winking was reduced but not abolished. cases of blepharophimosis syndrome underwent correction of telecanthus 6 months before ptosis surgery. telecanthus was corrected using double z plasty and plication of the medial canthus tendon. all patients had severe ptosis with average preoperative margin to reflex distance (mrd) of – 0.95 ± 1.33 mm (table 1). all eyelids in unilateral cases and worst affected eye of bilateral cases had poor levator function averaging 3.8 ± 1.35 mm. mean levator function in better eyelid of bilateral cases was 4.25 ± 2.29 mm. table 2 gives a breakdown of the levator function in all cases. amblyopia was seen in 8 patients and strabismus was seen in 6 patients. post-op mrd was measured with brow down and up. average postoperative mrd with brow up was 3.55 ± 0.73 mm and with brow down was 2.15 mm at 3 months after surgery (table 3). all patients had poor or absent lid crease pre-operatively. tarsal fixation of the lid crease incision above the fascia lata produced a deep lid crease in all cases. unilateral cases had results comparable to bilateral cases although it took the patients a few months before learning to keep the 2 sides at equal height (fig. 2-4). all patients were happy with the postoperative lid height. no patient had lagophthalmos of more than 2 mm but they were advised to use lacrilube eye ointment (allergan pharmaceuticals) daily at night time indefinitely. complications (table 4) included slippage of the sling in 2 patients which needed to be readjusted at the end of the first week. five patients had mild exposure keratopathy initially which was resolved with c 126 lubricants over one month. mild nasal peaking was seen in 4 cases which was apparent on the limit of brow action. it was cosmetically acceptable to the patient. discussion the surgical approach to congenital ptosis is generally based on the amount of levator function. patients with congenital ptosis have been grossly divided into three groups based on the levator function: (1) those with poor levator function of 4 mm or less, (2) those with fair levator function of 5-7 mm, and (3) those with good levator fuction greater than 8 mm16. fig. 1: tarsal fixation of fascia lata fig. 2: pre-operative photo, rt simple congenital ptosis fig. 3: post-operative photo, rt frontalis fascial lata sling fig. 4: pre-operative photo, bilateral simple congenital ptosis fascia lata slings have been primarily used for the permanent surgical correction of congenital ptosis with poor levator function (0 to 4 mm). levator resections and levator aponeurotic advancements have been performed in cases with fair (5 to 7 mm) or good (>8 mm) function16. for cases of severe unilateral congenital ptosis with poor levator function, the decision as to the type of surgery that should be performed is problematic. beard17 advocates the removal of the normal levator muscle in the opposite eyelid, thereby converting the case to one of severe bilateral ptosis, and then performing bilateral frontalis suspension to obtain symmetry. callahan18 suggested the use of bilateral slings (while leaving the normal levator muscle intact) so the normal eyelid does not move down on down gaze, thus making the lids more symmetrical. some authors have performed unilateral brow suspensions 127 on the ptotic lid, while others have advocated super maximum (>30 mm) levator muscle resection19. whitnall’s sling technique20 provides another alternative for cases with levator function ranging from 3 to 5 mm. congenital poor function ptosis is commonly seen as unilateral or bilateral dysfunction of the levator muscle. we found that unilateral cases (68%) were more common than bilateral cases (32%). we found the average levator function to be 3.8 mm in worst affected eye of our cases and poor function to be present in 55% of all cases of ptosis. it can be associated with jaw winking22 which was seen in 5 % cases. bilateral poor function ptosis can be associated with blepharophimosis syndrome which was seen in table 1: pre-op mrd mm no of cases n (%) -3 9 (15.8) -2 12 (21.1) -1 12 (21.1) 0 15 (26.3) 0.5 1 (1.8) 1 7 (12.3) 1.5 1 (1.8) table 2: levator function mm no. of cases n (%) 2.00 7 (12.3) 3.00 8 (14.0) 4.00 39 (68.4) 5.00 1 (1.8) 6.00 1 (1.8) 12.00 1 (1.8) table 3: pre-op mrd levator function (worst affected eye) post-op mrd brow up post-op mrd brow down -0.95 ± 3.8 ± 1.35 mm 3.55 ± 2.15 mm 1.33 0.73 mm table 4 complications no. of patinets management exposure keratopathy 5 resolved with lubricants in 1 month slippage of sling 2 re-tightened 1 week postoperative nasal peaking 4 on extreme lifting of brow only 3% of our cases. dystrophy of the levator muscle produces retraction of the upper lid on down gaze due to the inability of the muscle to relax. this lid lag on down gaze becomes more pronounced in cases of frontalis sling. fatty infiltration of the levator muscle was also seen clinically during surgery in majority of the cases. we performed unilateral sling surgery in all cases of poor function ptosis with good cosmetic results (postoperative mrd 3.55 mm with brow up) mahmood h21 achieved good results in 87.5 % of patients with poor levator function of 2-4 mm by performing 15-26mm of levator resection. anderson rl et al20 found that whitnall's sling is best suited for cases where the opposite fissure height is 9 mm or less and levator function of the ptotic eyelid is 3 to 5 mm. fascia lata can be harvested from autogenous source or donor lyophilized1 or irradiated material can be used. other materials are also used for frontalis sling which include palmaris tendon graft3, deep temporalis fascia graft4, merseline mesh5,6, gortex7, silicone rods8-10, supramid11 or various other sutures. fascia lata has the advantage of having the best biocompatibility with least chances of extrusion or granuloma formation. it is more time intensive compared to other techniques. silicone rod has an advantage of being elastic and is the material of choice in chronic external ophthalmoplegia to overcome residual lagophthalmos. suture sling is usually used in children less than five years of age because of inadequate length of fascia lata. mersiline mesh is the preferred material of some surgeons but it does have a tendency to extrude and produce granulomas. frontalis muscle advancement12 is a new procedure 128 which has been showed to be quite effective in poor function ptosis. lid crease incision with tarsal fixation was used in our cases which has the advantage of forming a deep lid crease and making a secure attachment to the tarsal plate. lash ptosis when present can be easily corrected with this technique. other frequently used technique is supralash stab incisions. it has the advantage of producing minimum disturbance of the lid structures and keeping the levator insertion intact which is disinserted in the lid crease technique. lid crease incision has been found to be superior to supralash stab incision in a study of 27 patients by yagci a13. we found tarsal fixation to be helpful in obtaining a deep lid crease and everting the lashes in our cases. modified fox pentagon14 was used in all our cases in which the tip of the pentagon was at the superior border of the brow. it has the advantage of being simple and accurate when used with lid crease incision. crawford double triangle15 is the other method of performing the procedure which gives good control of contour of the lid. the length of fascia lata required in technique was about 12 mm which was removed through a 2.5 cm incision using a fascia stripper. long incisions to expose the total length of the fascia lata are rarely used because of cosmetic reasons. the preferred height of the operated lid after frontalis sling depends upon the degree of ptosis and the degree of bell’s phenomenon. this will determine the amount of postoperative lagopthalmos. patients with poor levator and good bell’s phenomenon should have their lids raised to a level just below the upper limbus. while patients with poor bell’s phenomenon are at risk of developing significant postoperative lagophthalmos and their lids should be lifted just enough to clear the visual axis. generally younger patients tolerate more lagophthalmos than older patients. all our patients had lagophthalmos of < 2mm which prevented exposure keratopathy. conclusion tarsal fixation of frontalis sling provides reliable correction of poor function ptosis. the passage of the sling material behind the orbital septum by direct visualization in the eyelid crease approach is one of the main factors affecting the surgical success of the frontalis sling operation. author’s affiliation muhammad moin assistant professor department of ophthalmology king edward medical college lahore. reference 1. broughton wl, matthews jg 2nd, harris dj jr. congenital ptosis. results of treatment using lyophilized fascia lata for frontalis suspensions. ophthalmology. 1982; 89: 1261-6. 2. esmaeli b, chung h, pashby rc. long-term results of frontalis suspension using irradiated, banked fascia lata. ophthal plast reconstr surg. 1998; 14: 159-63. 3. wong cy, fan ds, ng js, et al. long-term results of autogenous palmaris longus frontalis sling in children with congenital ptosis. eye. 2005; 19: 546-8. 4. tellioglu at, saray a, ergin a. frontalis sling operation with deep temporal fascial graft in blepharoptosis repair. plast reconstr surg. 2002; 109: 243-8. 5. zafar ullah m, sahi t, tayyab aa. merselene mesh use as a frontalis sling in ptosis surgery. pakistan j med res. 2003; 42: 126-8. 6. mehta p, patel p, olver jm. functional results and complications of mersilene mesh use for frontalis suspension ptosis surgery. br j ophthalmol. 2004; 88: 361-4. 7. steinkogler fj, kuchar a, huber e, et al. gore-tex soft-tissue patch frontalis suspension technique in congenital ptosis and in blepharophimosis-ptosis syndrome. plast reconstr surg. 1993; 92: 1057-60. 8. hussain mm. correction of congenital ptosis using silicone material for frontalis suspension. pak j ophthalmol. 1995; 11: 115-7. 9. carter sr, meecham wj, seiff sr. silicone frontalis slings for the correction of blepharoptosis: indications and efficacy. ophthalmology. 1996; 103: 623-30. 10. bernardini fp, de conciliis c, devoto mh. frontalis suspension sling using a silicone rod in patients affected by myogenic blepharoptosis. orbit. 2002; 21: 195-8. 11. liu d. blepharoptosis correction with frontalis suspension using a supramid sling: duration of effect. am j ophthalmol. 1999; 128: 772-3. 12. ramirez om, pena g. frontalis muscle advancement: a dynamic structure for the treatment of severe congenital eyelid ptosis. plast reconstr surg. 2004; 113: 1841-9. 13. yagci a, egrilmez s. comparison of cosmetic results in frontalis sling operations: the eyelid crease incision versus the supralash stab incision. j pediatr ophthalmol strabismus. 2003; 40: 213-6. 14. fox sa. correction of ptosis. new orleans academy of ophthalmology symposium on surgery of the ocular adnexa, the cv mosby co. st. louis, 1966. 15. crawford js. use of fascia lata in the correction of ptosis. adv ophthalmic plastic reconstr surg. 1982; 1: 221. 129 16. nesi fa, levine mr, lisman rd. smith’s ophthalmic, plastic and reconstructive surgery, 2nd edition, st. louis, mo. mosbyyear book inc. 1998: 18; 355-78. 17. beard c. a new treatment for severe unilateral congenital ptosis and for ptosis with jaw-winking. am j ophthalmol. 1965; 59: 252-8. 18. callahan a. correction of unilateral blepharoptosis with bilateral eyelid suspension. am j ophthalmol. 1972; 74: 321-6. 19. epstein ga, putterman am. super-maximum levator resection for severe unilateral congenital blepharoptosis. ophthalmic surg. 1984; 15: 971-9. 20. anderson rl, jordan dr, dutton jj. whitnall's sling for poor function ptosis. arch ophthalmol. 1990; 108: 1628-32. 21. mahmood h, durrani j, kadri wm, m, chaudhry ma. levator resection in congenital ptosis with poor levator function. pak j ophthalmol. 1997; 13: 103-7. 22. bullock jd. marcus-gunn jaw-winking ptosis: classification and surgical management. j pediatr ophthalmol strabismus. 1980; 17: 375-9. microsoft word ejazahmedjaved[1]correctedsent.doc 80 original article diagnostic applications of “b-scan” ejaz ahmed javed, aamir ali ch., iftikhar ahmad, mehmood hussain pak j ophthalmol 2007, vol. 23 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ejaz ahmed javed dps colony race course road near new civil lines faisalabad received for publication may’ 2006 …..……………………….. purpose: to evaluate the diagnostic importance of ‘‘b-scan’’ in opaque media where other routine instrumental producers were unreliable materials and methods: the ‘‘b-scan’’ was done on 463 eyes of 463 patients at madina medical centre, university of faisalabad, during the period march 2005 to march 2006. there were 339(73.2%) male and 124(26.8%) female patients. the age ranged between 6 months to 80 years. a specialized proforma was developed to record the data. most of the patients were referred from different clinics and hospitals of the punjab. results: the maximum number of the participants had age between 21 years to 30 years. out of 463 patients 20 had only corneal pathology, 90 had only mature cataract, 60 had only vitreous hemorrhage, 68 had only retinal detachment, 51 tractional retinal detachment, 4 had retinoblastoma, 2 optic nerve anomaly, 2 choroidal pathology, 2 persistent hyperplastic primary vitreous (phpv).163 patients has multiple signs e.g. corneal pathology, catract, vitreous hemorrhage and retinal detachment. asteroid hyalosis was seen in 1 patient. conclusions: b-scan proved to be a valuable diagnostic modality in opaque media and had remarkable prognostic importance. ltrasound technology, also known as sonar, echography or acoustic imaging, was developed during world war i as a method of detecting under water objects, including submarines1. the ultrasound is based on physical principles of tissue acoustic impedance mismatch and pulse echo technology. echoes are produced at adjoining tissues interfaces that have differential acoustic impedance. the greater the difference in acoustic impedance, the stronger the echo. the ultrasound waves have a frequency greater than 20 khz2. in standard ophthalmic ultrasound, frequencies are in the range of 8 to 10mhz. this high frequency produces short wave lengths, which allow visualization of smaller ocular structures, while abdominal ultrasound has lower frequency (1 to 5mhz) which produces longer wave length and penetrates deeper tissues3. the reflected echoes are received, amplified, produced electronically and displayed in visual format as an “a-scan” or a “b-scan”4. the a-scan is a one-dimensional, time amplitude display. the height of the spike indicates the amplitude and strength of echo. the b-scan presents echoes as dots rather than spikes, intensity of dots relates to the intensity of reflection. it produces a two dimensional, cross sectional display of the globe and orbit. the weaker echoes are noted from vitreous cells and stronger echoes from retinal tissues, sclera and calcifications5. so the b-scan can be used for the following ocular problems6. • evaluation of anterior or posterior segment in eyes with opaque media. • to assess dimensions of ocular tumors. • to differentiate pvd and rd from vitreous hemorrhage etc. u 81 • to evaluate orbital disorders • to detect and locate intra-ocular foreign bodies. materials and methods this was a retrospective and observational study on 463 cases having opaque media due to trauma, diabetes mellitus, hypertension, congenital or acquired mature cataract, corneal dystrophy, leukocoria and eale’s disease. the study was conducted at madina medical centre, the university of faisalabad from march 2005 to march 2006. the patients were collected from out patient department (opd) of madina medical centre and from referral from other clinics and hospitals. a proforma was made to record the data. history of decreased vision was the commonest presentation. it was evaluated further as history of trauma, working environment or tools, bleeding disorders, past medical or surgical history, decreased vision, diabetes, hypertension, vitrectomy or any other surgical procedures. a general evaluation included general examination, visual acuity, intraocular pressure, slit lamp examination (sle), slit lamp bio-microscopy (in case of mild media opacity), indirect ophthalmoscopy (in case of mild media opacity) and then b-scan (occuscan, alcon, usa) was performed and routine systemic investigations were done where indicated e.g. blood pressure, blood sugar, lipid profile, bleeding time, clotting time, blood complete examination, rafactor, ana factor, x-ray chest p/a view, x-ray orbit (in case of intraocular foreign body). results the patients that required “b-scan” examination had an age range between 6 months to 80 years. the maximum number of patients 101 (21.8%) had age range between 11 years to 20 years. the minimum number of patients was 5 (1.1%) with age range between 71 years to 80 years. history of trauma was more common in age range between 11 to 30 years. there were 339 (73.2%) male while 124 (26.8%) were female patients. twenty (4.3%) patients had corneal pathology, e.g. traumatic scarring, dystrophy, post viral or bacterial corneal opacity, abscess, or descemetocele. ninety (19.4%) patients had mature cataract while 60 (13%) patients had vitreous hemorrhage; the patients of retinal detachment were 68 (14.7%), and 51 (11%) had tractional retinal detachment. four patients (0.9%) had retinoblastoma and 2 (0.4%) had optic nerve anomaly. while 2 patients (0.4%) had choroidal thickening, 2 patients (0.4%) had phpv. asteroid hyalosis was seen in 1 patient (0.2%). 163 patients (31.2%) had multiple pathologies, in the anterior as well as posterior segment. discussion trauma either blunt or penetrating causing corneal, lens, iris, vitreous or retinal damage is common in male patients between age 11–30 years. because patients in this age range are more active and do outdoor games or activities. this incidence is also common in other published studies7,8. the b-scan examination of eyes having mature cataract also aids in cataract surgery9. vitreous hemorrhage is commonly seen in patients with diabetes, hypertension, eale’s disease, traumatic accidents, retinal tear or breaks or idiopathic. if vitreous hemorrhage is in nonresolving stage then vitreo-retinal surgeon is very much concerned to go for vitrectomy and further management that is impossible without prior b-scan ultrasonography. similarly intraocular foreign bodies also demand immediate b-scan examination especially if the foreign body is of iron, zinc, copper or aluminum because these foreign bodies are very reactive and toxic to photoreceptor cells of retina10. but you can delay on b-scan for inert foreign bodies e.g. stone, sand, glass, porcelain, plastic, cilia10. post traumatic endophthalmitis is commonly seen in penetrating injuries, associated with intra ocular foreign bodies, also in rural setting or in non hospital based eye camps11. conclusions ultrasonography has developed since 1956 as an essential diagnostic aid12. b-scan is an important device for the identification of vitreo-retinal disorders, foreign bodies, intraocular tumors, congested orbital structures. its results are accurate (90%) in experienced hands. this is comparable to international standards. recent advances in ultrasound technology permit gray-scale and doppler scans to be combined. the therapeutic application of b-scan is being used experimentally to produce filtration operations, to disperse vitreous hemorrhage, and to coagulate 82 tumors in the eye. the fruits of these research efforts should be continually emerging. fig. normal scan of a patient with mature cataract. scan shows clear vitreous and flat retina, optic nerve shadow is clearly defined. fig. retinoblastoma fig. asteroid hyalosis fig. total retinal detachment. author’s affiliation dr. ejaz ahmed javed consultant ophthalmologist madina medical centre university faisalabad, sargodha road faisalabad dr. aamir ali ch. madina medical centre university faisalabad, sargodha road faisalabad dr. iftikhar ahmad madina medical centre university faisalabad, sargodha road faisalabad dr. mehmood hussain madina medical centre university faisalabad, sargodha road faisalabad 83 reference 1. richard l, hart lj. ultrasound diagnosis of the eye and orbit; principle and practice of ophthalmology. 1997; 5: 98. 2. byrne sf, green rl. ultrasound of the eye and orbit, louis, mosby, 1992. 3. caroline r, baum ul; ophthalmic ultrasonography, ophthalmic secrets, 1998; 38. 4. fisher yl. diagnostic ophthalmic ultrasonography in tasmanw. jaeger ea: duane’s clinical ophthalmology.; vol. 2, philadelphia. jb. lippin cott. 1990. 5. ossoinig kc. quantitative echography. the basis of tissue differentiation. jclin ultrasound. 1974; 2: 33. 6. pavlin cj, sherar h. et al. clinical use of ultrasound biomicroscopy. ophthalmology. 1991; 98: 287. 7. butt nh. hye a et al. management of fire cracker injuries. pak j ophthalmol. 2005; 21: 152. 8. avery jg, jackson rh. accidents with fire works. children and their accidents, london, edward arnold. 1993; 81-4. 9. bronson nr, fisher yl, pickering nc. ophthalmic contact bscan ultrasonography for the clinician baltimore williams & wilkins. 1980. 10. danial j. american academy of ophthalmology section 12, retina & vitreous; intraocular foreign bodies. 2003; 272. 11. danial j. american academy of ophthalmology section 12 (retina & vitreous) post operative endophthalmitis. 2003; 274. 12. richard l, dallow and lois. ultrasound diagnosis of the eye and orbit; principles and practice in ophthalmology. 1997; 3553. in chronic simple glaucoma with the availability of increasingly effective medical treatment combinations, tendency is towards medical treatment. if it is not effective enough to stop glaucoma damage or cannot be carried out for various other reasons (cost-intolerance, nonavailability etc.) surgery has to be carried out. prof. m lateef chaudhry microsoft word editorial 23,2,07.doc 57 editorial glaucoma revisited glaucoma being the commonest cause of irreversible blindness all over the world is rather complex disorder requiring timely detection and optimal management to preserve the remaining vision. whatever vision has been lost is permanent and irreversible, hence the need for earliest detection and appropriate management. in our part of the world the incidence of angle closure and open angle glaucoma seems nearly equal. while the chronic simple glaucoma (poag) is branded as slow, insidious, asymptomatic disease and angle closure glaucoma as acute symptomatic disorder, we have to bear in mind a few important facts. 1. not all angle closure glaucomas present as acute symptomatic disorder. 2. angle closure glaucoma can cause visual loss in very short period and delay in its management is disastrous. 3. angle closure glaucoma is a different type of disorder requiring immediate specific management with inexpensive miotics like pilocarpine, followed by non-invasive laser iridotomy or simple surgical intervention like peripheral iridectomy, achieving permanent cure in most of the cases. on the contrary chronic simple glaucoma requires very expensive, life long medications with systemic side effects or complex surgical interventions with less than desired outcomes with chances of early and late complications. while very expensive time consuming at times unreliable and inconclusive diagnostic tests are required for chronic simple glaucoma, the most important and inexpensive test to diagnose angle closure glaucoma is gonioscopy which unfortunately is usually ignored. perimetry also despite being time consuming and expensive is an important and necessary investigation in glaucoma though its role in diagnosis of early glaucoma is unreliable. it is very useful in differentiating typical and diagnostic glaucoma visual field defects from visual field defects of other disorders like hemianopias and pituitary tumors etc. perimetry is again of limited help in follow up of established glaucoma cases unless it is precisely correlated with disc changes. the most important investigation in glaucoma is the appearance of optic disc, provided the size of the disc and position of cup is taken into consideration. the cup disc ratio is still an important criterion in diagnosis and follow up of glaucoma if the size of the cup, with its location, shape, eccentricity and distance between the edge of the cup and neural rim is properly recorded. recently more stress is laid on the relationship of disc size with neural rim size, recording the rim size at its narrowest part and if absent document its position and extent in follow ups to evaluate the disc damage likelihood index. m lateef chaudhry editor in chief pakistan journal of ophthalmology ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- glaucoma guidelines: see page no: 68 see page no: 72 see page no: 76 see page no: 79 see page no: 83 see page no: 91 see page no: 99 see page no: 102 pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 41 original article the frequency and causes of visual impairment and blindness among middle and older population farnaz siddiqui, saba alkhairy, mazhar-ul-hassan pak j ophthalmol 2017, vol. 33 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: farnaz siddiqui flate #f-6, hassan center gulshan-e-iqbal block 16, karachi email: siddiqui.farnaz@gmail.com. …..……………………….. purpose: to estimate the frequency and causes of visual impairment and blindness in middle and older age groups. study design: cross sectional study. place and duration of study: eye department of dow university hospital (ojha campus), dow international medical college, dow university of health sciences, karachi, pakistan from january 2010 to october 2010. material and methods: 1000 subjects of aged ≥ 40 years were included in the study. we collected data from previous records in which patients had undergone complete ophthalmic examination including visual assessment by using snellen’s visual acuity chart, examining the anterior segment by slit lamp and dilated fundoscopy through slit lamp biomicroscopy with 90d lens. the causes of visual impairment and blindness were recorded from collected medical data. statistical analysis was done by spss version 21. results: the 1000 subjects records were analyzed. the frequency of visual impairment and blindness were 142 (14.2%) and 49 (4.9%) respectively. major causes of visual impairment were cataract 61 (43.0%) and refractive errors 44 (31.0%). refractive errors 19 (38.8%) and cataract 18 (36.7%) were the main causes of blindness. there was a significant difference for the causes of visual impairment and blindness with normal individuals (p-value < 0.01). conclusion: the burden of visual impairment and blindness remains a major health problem in our society and government need to establish multiple policies and programs to prevent and control the visual impairment and blindness. key words: causes, visual impairment, blindness. ifferent eye disorders if left untreated lead to end stage of functional blindness. the prevalence and causes of these disorders differ markedly throughout the world. the percentage of blindness is particularly severe in asia1. according to world health organization (who), the definition of blindness is corrected vision of less than 3/60 (20/400) in better eye, or a decrease in visual field to less than 10 from fixation in each eye and definition of low vision is corrected vision of less than 6/18(20/60) but equal to or better than 3/60 in better eye2. the visual acuity of less than 6/60 (20/200) is also used as a definition of blindness in many developed countries3,4,5. according to who estimations, currently there are 285 million people are visually impaired world wide in 2010, 39 million are blind and 246 million have low vision.6 the individuals having blindness might increase up to 76 million by 2020. about 90% of individuals having visual impairment are belong to under developed countries7,8. most of the blind people are in older age group 50 years and above (82%). according to the global estimate work, the infectious d farnaz siddiqui, et al 42 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology diseases causing visual impairment is decreased for the last few years but the incidence of chronic noninfectious diseases causing visual impairment are supposed to increase in number. about 80% of all visual impairment can be prevented and treated. cataract and refractive error are the most common causes of visual impairment and major cause of blindness is cataract9,10. data collected from the last few years from many countries shows that there has been significant improvement in prevention and treatment of visual impairment and this was achieved through a number of successful international and local public-private partnerships. the principle aim of my study was to estimate the frequency and causes of visual impairment and blindness in middle and older age population. material and methods this study was conducted from january 2010 to october 2010 in the ophthalmology department of dow university hospital, dow international medical college, karachi, pakistan. inclusion criteria were the individuals of aged 40 or > 40 years to 70 or > 70 years and visual acuity of 6/18 to ≤ 3/60. exclusion criteria were the individuals of aged < 40 years and patients who had previously undergone ocular surgeries. these subjects had gone through detailed eye examination which included measurement of visual acuity, auto refraction, intraocular pressure measurement, slit lamp examination and dilated fundoscopy by slit lamp biomicroscopy through 90d lens. a well trained optometrist had assessed the visual acuity and auto refraction. uncorrected and corrected visual acuity assessment were done by using snellen’s visual acuity chart. best corrected visual acuity was obtained by optimal refraction subjectively after objective auto refraction. goldmann applanation tonometry was done to measure the intraocular pressure. slit lamp examination was done to look for eye lid pathologies, corneal and lens opacities to rule out the cause of visual impairment (< 6/18 3/60) and blindness (< 3/60) according to who criteria for definition of visual impairment and blindness. detailed fundal examination was done by slit lamp biomicroscopy through 90d lens to look for vitreous and retinal pathologies. blindness was assessed as those individuals were reported visual acuity (va) < 3/60, and also those reported counting fingers (cf), hand movement (hm), perception light (pl), and no perception light (npl) were also categorized as “blindness”. “visual impairment” (vi) was computed as those individuals who reported va<6/18-3/60. all analysis were performed using statistical analysis software spss version 21.frequencies and proportions were reported for categorical variables including outcome measures blindness and visual impairment. chi-square analysis was used to assess the association between blindness and visual impairment with effect of age and gender and the results were reported. the causes of visual impairment and blindness were also assessed. chi-square analysis was also used to compare the different causes of visual impairment and blindness with normal individuals. the p-value of ≤0.05 was considered statistically significant. result the 1000 subjects were examined. out of 1000 subjects 532 (53.2%) subjects were male and 468 (46.8%) subjects were female. 49 (4.9%) persons were have blindness (va < 3/60), in which 40 (4.0%) persons were found to have unilateral blindness and 9 (0.9%) were found to have bilateral blindness and 142 (14.2%) were have visual impairment (va < 6/18 3/60), in which 87 (8.7%) were having unilateral visual impairment and 55 (5.5%) were having bilateral visual impairment (table 1). the frequency of visual impairment and blindness were 142 (14.2%) and 49 (4.9%) respectively (table 2). the effect of age and gender on blindness and visual impairment were shown in (table 3). most of blindness and visual impairment was found above the age of 50 years. causes of blindness and visual impairment were given in table 4. the leading causes of blindness were refractive errors 19 (38.8%), cataract 18 (36.7%) and diabetic retinopathy 9 (18.4%). major causes of visual impairment were cataract 61 (43.0%) and refractive errors 44 (31.0%). comparison between the causes of visual impairment and blindness with normal individuals were shown in table 5 with a significant pvalue of less than 0.01. discussion the current study showed that cataract, refractive errors and diabetic retinopathy are the common causes of visual impairment and blindness presenting to ophthalmology department, dow university hospital (ojha campus), karachi. the frequency of visual the frequency and causes of visual impairment and blindness among middle and older population pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 43 table 1: frequency of blindness and visual impairment (n = 1000). normal 795 bilateral blindness 9 0.9% bilateral vi 55 5.5% unilateral blindness 40 4.0% unilateral vi 87 8.7% blindness + vi 14 1.4% vi: visual impairment table 2: frequency of blindness and visual impairment (n = 1000). n % normal 795 79.5% blindness 49 4.9% vi 142 14.2% blindness + vi 14 1.4% vi: visual impairment table 3: blindness and visual impairment regarding age and sex. (n = 205). blindness n (%) visual impairment n (%) both conditions n (%) p-value* age group 40 – 49 14 (28.6) 29 (20.4) 2 (14.3) 0.798 50 – 59 16 (32.7) 41 (28.9) 4 (28.6) 60 – 69 12 (24.5) 43 (30.3) 5 (35.7) 70 + 7 (14.3) 29 (20.4) 3 (21.4) sex male 26 (53.1) 76 (53.5) 7 (50.0) 0.969 female 23 (46.9) 66 (46.5) 7 (50.0) p-value* calculated by using chi-square analysis table 4: causes of blindness and visual impairment. (n = 205). causes blindness n(%) visual impairment n(%) both conditions n(%) diabetic retinopathy 9 (18.4) 19 (13.4) refractive error 19 (38.8) 44 (31.0) 9 (64.3) conjunctivitis 2 (4.1) 13 (9.2) 1 (7.1) cataract 18 (36.7) 61 (43.0) 4 (28.6) corneal opacity 1 (2.0) 5 (3.5) farnaz siddiqui, et al 44 vol. 33, no. 1, jan – mar, 2017 pakistan journal of ophthalmology table 5: causes of blindness and visual impairment with normal individuals (n = 1000). causes blindness normal p-value diabetic retinopathy 28 (13.7) 118 (14.8) < 0.01 refractive error 72 (35.1) 449 (56.5) conjunctivitis 16 (7.8) 122 (15.3) cataract 83 (40.5) 97 (12.2) corneal opacity 6 (2.9) 9 (1.1) vi: visual impairment p-value* calculated by using chi-square analysis impairment and blindness among adults ≥ 40 years to older age groups > 70 years were 142 (14.2%) and 49 (4.9%) respectively. the study conducted in north kordofan state, sudan7 showed that 8.37% prevalence of blindness of bilateral eyes and 9.06% prevalence of visual impairment of bilateral eyes. the results are comparable to our study in which the frequency of visual impairment was higher as compare to frequency of blindness. another study conducted in sudan11 showed the prevalence of blindness in northern state was 4.90%, 7.38% in sinnar and 14% in kassala. our study showed the decrease in the frequency of blindness as compare to above quoted studies may be because of overall increase in the availability of eye care services as well as increase in the knowledge of general population regarding solutions like surgeries, refractive devices to manage the problems associated with visual impairment and blindness. association of blindness and visual impairment with effect to the different age groups and gender was not statistically significant in our study with p-value of 0.798 and 0.969 respectively while several studies12-16 showed significant association of age and gender with the prevalence of blindness and visual impairment. our study showed that refractive errors were the most common cause of blindness. the results are comparable to other recent studies17-19 showed the refractive errors were the primary cause of blindness. cataract was the second most common cause of blindness in our study. several studies conducted in africa and asia20,21 have showed that the blindness and visual impairment were caused by cataract. cataract is a curable condition and the burden of blindness caused by cataract can be reduced by public health awareness and cataract surgical services. in summary, the frequency of visual impairment and blindness was 142 (14.2%) and 49 (4.9%) respectively. refractive errors, cataract and diabetic retinopathy were the major causes of blindness. cataract and refractive errors were the main causes of visual impairment. conclusion the current study provides the useful information regarding the burden of visual impairment and blindness in our society and this burden can be reduced with early treatment and avoided by different preventive measures such as awareness, visual screening, early correction of refractive error, cataract surgeries for those individuals requiring it and effective visual rehabilitation for all visually impaired people. author’s affiliation dr. farnaz siddiqui assistant professor department of ophthalmology dow international medical college (dimc) dow university hospital (duh) dow university of health sciences (duhs) karachi dr. saba alkhairy assistant professor department of ophthalmology dow international medical college (dimc) dow university hospital (duh) dow university of health sciences (duhs) karachi the frequency and causes of visual impairment and blindness among middle and older population pakistan journal of ophthalmology vol. 33, no. 1, jan – mar, 2017 45 dr. mazhar-ul-hassan professor department of ophthalmology dow international medical college (dimc) dow university hospital (duh) dow university of health sciences (duhs) karachi role of authors dr. farnaz siddiqui paper writing, data collection. dr. saba alkhairy data collection. dr. mazhar-ul-hassan statistical analysis. references 1. pascolini d, mariotti sp, pokharel gp, et al. 2002 global update of available data on visual impairment: a compilation of population-based prevalence studies. ophthalmic epidemiol 2004; 11: 67-115. 2. dandona l and dandona r. revision of visual impairment definitions in the international statistical classification of diseases. bmc medicine 2006; 4: 7. 3. congdon n, o’colmain b, klaver cc, et al. eye diseases prevalence research group: causes and prevalence of visual impairment among adults in the united states. arch ophthalmol. 2004; 122: 477-85. 4. laitinen a, koskinen s, harkanen t, et al. a nation wide population-based survey on visual acuity, near vision and self reported visual function in the adult population in finland. ophthalmology, 2005; 112: 222737. 5. taylor hr, keefe je, vu htv, et al. vision loss in australia. med j aust. 2005; 182: 565-8. 6. holden ba. blindness and poverty: a tragic combination. clin exp optom 2007; 90: 401-3. 7. binnawi kh, mohamed ah, alkhair alshafae b, et al. prevalence and causes of blindness and visual impairment in population aged 50 years and over in north kordofan state, sudan. albasar int j ophthalmol. 2015; 3: 6-10. 8. geneva, switzerland: world health organization, 20092013. world health organization. action plan for the prevention of avoidable blindness and visual impairment. 9. salamao sr, marcia rkh, mitsuhiro, et al. visual impairment and blindness: an overview of prevalence and causes in brazil. an acad bras cienc. 2009; 81: 53949. 10. pascolini d, mariotti sp. global estimates of visual impairment: 2010. br j ophthalmol. 2012; 96: 614-8. 11. progress in prevention of blindness in sudan (20032010).unpublished report by sudan national program for prevention of blindness; 2011. 12. hashemi h, khabazkhoob m, emamian mh, et al. visual impairment in the 40to 64-year-old population of shahroud, iran. eye (lond). 2012; 26: 1071-7. 13. kyari f, gudlavalleti mv, sivsubramaniam s, et al. prevalence of blindness and visual impairment in nigeria: the national blindness and visual impairment study. invest ophthalmol vis sci. 2009; 50: 2033-9. 14. zhao j, ellwein lb, cui h, et al. prevalence of vision impairment in older adults in rural china; the china nine-province survey. ophthalmology, 2010; 117: 40916. 15. zheng y, lavanya r, wu r, et al. prevalence and causes of visual impairment and blindness in an urban indian population; the singapore indian eye study. ophthalmology. 2011; 118: 1798-1804. 16. budenz dl, bandi jr, barton k, et al. blindness and visual impairment in an urban west african population: the tema eye survey. ophthalmology, 2012; 119: 174453. 17. rajavi z, katibeh m, ziaei h, et al. rapid assessment of avoidable blindness in iran. ophthalmology, 2011; 118: 1813-8. 18. al-shaaln ff, bakman ma, ibrahim am, et al. prevalence and causes of visual impairment among saudi adults attending primary health care centres in northern saudi arabia. ann saudi med. 2011; 31: 47380. 19. you qs, xu l, yang h, et al. five-year incidence of visual impairment and blindness in adult chinese the beijing eye study. ophthalmology, 2011; 118: 1069-75. 20. wang gq, bai zx, shi j, et al. prevalence and risk factors for eye diseases, blindness and low vision in lhasa, tibet. int j ophthalmol. 2013; 6: 237-41. 21. li j, zhong h, cai n, et al. the prevalence and causes of visual impairment an elderly chinese bai ethnic rural population: the yunnan minority eye study. invest ophthalmol vis sci. 2012; 53: 4498-504. microsoft word shahid wahab.doc 209 original article removal of silicone oil from the anterior chamber: new technique shahid wahab, nasir mahmood pak j ophthalmol 2007, vol. 23 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: shahid wahab 45-b, s.m.c.h.s karachi received for publication february 2006 …..……………………….. purpose: to describe a new technique of removal of silicone oil from the anterior chamber and to report the safety and effectiveness of the procedure. material and methods: the prospective feasibility study of a new technique was concluded on twenty patients who presented with silicone oil in the anterior chamber postoperatively between six weeks to six months after complicated retinal detachment surgery. an air pump commonly used in vitreo-retinal procedures was connected with tubing to anterior chamber, which was entered by a twenty seven gauge needle. air was pumped gradually (maximum pressure required to build-up was 40 mmhg) into the chamber with the foot pedal to push silicone posteriorly as well as across the anterior chamber to the opposite side. simultaneously oil was egressed out through a self sealing corneal incision held open by depressing its posterior lip. results: 20 patients under went removal of silicone oil from the anterior chamber by this technique. the procedure was uneventful and complete removal of oil was accomplished in all patients. conclusion: the technique is simple, safe, effective and cheap for managing silicone oil in the anterior chamber. iliconc oil has been used in the management of complex retinal detachments for over a quarter of a century. silicone oil is very efficacious in producing retinal reattachment and improves vision in eyes with severe proliferative vitreoretinopathy (pvr)1,2. it has been associated with complications l i k e anterior chamber herniation3. silicone oil in the anterior chamber may obstruct the view when emulsified3, can cause glaucoma4,5 and keratopathy6. most frequent causes of siliconc oil herniation into the anterior chamber are blockage of the inferior peripheral iridectomy in aphakic eyes, recurrent retinal detachment and hypotony3. silicone oil in the anterior chamber is quite challenging for vitreo-retinal surgeons. air being lighter than silicone and could be compressed hence we used sterile air to evacuate silicone oil from anterior chamber. air was pumped into the anterior chamber through a standard infusion set tubing by an air pump commonly used in vitreo-retinal procedures. material and methods this procedure was done in 20 eyes of 20 patients (12 men, 8 women) who presented with silicone oil in the anterior chamber postoperatively after complicated retinal detachment surgery between six weeks to six months. in our patient population there is high rate of pvr may be because of highly pigmented eyes. we prefer not to remove silicone oil especially from one eyed patients for years if it is causing no complications. seventy percent of our patients were pseudophakic, twenty percent were phakic and ten percent were aphakic. s 210 equipment used in this procedure was an air pump with filter, standard infusion set tubing, 27 gauge needle and 3.2 mm phaco knife. all cases were done under topical anesthesia except six uncooperative patients who were given retrobulbar anesthesia. conjunctiva was washed with povidoneiodine 5% solution. miosis was achieved with intracameral carbachol 0.01% to truncate silicone oil in the anterior chamber from posterior chamber. an air pump was connected to the anterior chamber by tubing and the chamber was entered by a 27 gauge needle. air was pumped gradually (maximum pressure required to buildup was 40 mmhg) into the chamber with the foot pedal to push silicone posteriorly as well as across the anterior chamber to the opposite side. a self sealing corneal incision was made by phaco knife opposite to the needle entry. simultaneously silicone oil was egressed out by depressing the posterior lip of the corneal incision (figure 1). pre-placed single stitch of ten zero nylon applied in eight cases to seal the wound in patients who were squeezing and in which the posterior pressure was high. intraocular pressure was checked in all cases with tonopen. to avoid the risk of glaucoma every patient was put on antiglaucoma medication t i l l all air absorbed from the anterior chamber. fig. 1: schematic diagram of silicone oil removal from anterior chamber results twenty eyes of twenty patients underwent silicone oil removal from the anterior chamber by this technique. seventy percent were pseudophakic, twenty percent were phakic and ten percent were aphakic. in all patients silicone oil was removed successfully from anterior chamber. one patient under went the same procedure again after one week. discussion silicone oil is an accepted form of intraocular tamponade for complicated retinal detachment. silicone oil is usually removed from the eye to avoid complications when the retina is attached, while chorioretinal adhesions are formed and no significant traction on the retina is present. the timing of silicone oil removal remains controversial in different reports in the literature7,8. the silicone is left in generally for 6 months to 1 year, but in some cases it is left in permanently9. in our patient population there is high rate of pvr may be because of highly pigmented eyes. we prefer not to remove silicone oil especially from only eyed patients for years if it is causing no complications. one of the complications of silicone oil is herniation into the anterior chamber leading to vision threatening keratopathy and glaucoma3,6. removal of silicone oil from anterior chamber is a challenging job for vitreo-retinal surgeons. for managing silicone oil in the anterior chamber complete removal has been suggested from both anterior chamber and posterior segment followed by re-injection3. this is a major procedure and it is costly and risky. it has been mentioned in the literature that injecting sodium hyaluronate to evacuate silicone oil from the anterior chamber prevents further herniation of oil from the posterior segment, but it needs to be replaced with physiological infusion fluid3. in our opinion this procedure with infusion fluid does not prevent silicone getting again in to the anterior chamber. kirkby and gregor10 have advocated the removal of silicone oil using sodium hyaluronate replacing it with infusion fluid. zivojnovic11 also is of the opinion to inject sodium hyaluronate into the anterior chamber which prevent getting silicone into the anterior chamber. he does not explain when and how to replace sodium hyaluronate with physiological infusion fluid. in our experience if sodium hyaluronate is left it induces severe inflammatory reaction and membrane formation within pupillary area. complication like raised intraocular pressure can be managed but intense fibrin reaction leading to membrane formation is difficult to manage. zivojnovic11 very rightly expressed that it is a nerve-racking game to deal with silicone oil in the anterior chamber. we describe a new technique in which an air pump is used to create a pressurized air bubble in the anterior chamber that pushes the silicone oil out of the anterior chamber through a self sealing 211 incision at the limbus. we found this technique simple and effective and it also saves time and money. author’s affiliation prof. shahid wahab department of ophthalmology dow university of health sciences karachi dr. nasir mahmood department of ophthalmology dow university of health sciences karachi reference 1. the silicone study group. vitrectomy with silicone oil or sulfur hexafluoride gas in eyes with severe proliferative vitreoretinopathy: results of a randomized c l i ni c a l trial. silicone study report 1. arch ophthalmol. 1992; 110: 770-9. 2. the silicone study group. vitrectomy with silicone oil or perfluoropropane gas in eyes with severe proliferative vitreoretinopathy: results of a randomized clinical trial. silicone study report 2. arch ophthalmol. 1992; 110: 780-92. 3. gallemorc rp, mccuen ii bw. silicone oil in vitreoretinal surgery. wilkinson cp. retina. third edition. volume three. st. louis, c.v. mosby company. 2001. 2208-11. 4. valone jr j, mccarthy m. emulsified anterior chamber silicone oil and glaucoma. ophthalmology 1994; 101: 1908-12. 5. nguyen qh, lloyd ma, heuer dk, et al. incidence and management of glaucoma after intravitreal silicone oil injection for complicated retinal detachments. ophthalmology 1992; 99: 1520-6. 6. gurelik g, safak n, koksal m, et al. acute corneal decompensation after silicone oil removal. int ophthalmol. 1999; 23: 131-5. 7. hutton wl, azen sp, blumenkrans ms, et al. the effects of silicone oil removal. silicone study report 6. arch ophthalmol. 1994; 112: 778-85. 8. bassat ib, desatnik h, alhalel a, et al. reduced rate of retinal detachment following silicone oil removal. retina 2000; 20: 597603. 9. coleman j. advances and new controversies in vitreoretinal surgery part-2. highlights of ophthalmology. 1994; 22: 4. 10. kirkby gr, gregor zj. the removal of silicone oil from the anterior chamber in phakic eyes. arch ophthalmol. 1987; 105: 1592. 11. zivojnovic r. silicone oil in vitreoretinal surgery. peroperative complications. martinus nijhoff / dr w. junk publishers, 1987. 126. pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 242 original article avascular retinal pigment epithelial detachment treated with intravitreal ranibizumab: 3-year follow-up imran akram, amjad akram pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mr. imran akram consultant ophthalmic & vitreoretinal surgeon st helens & knowsley teaching hospitals nhs trust email: imranakram2020@gmail.com …..……………………….. purpose: to evaluate the long-term effect of intravitreal ranibizumab on visual acuity and the morphology of retinal pigment epithelial detachments, not associated with choroidal neovascularization. place and duration of study: ophthalmology department at st helens & knowsley teaching hospital, united kingdom, between 2011 and 2013. study design: retrospective case series. patients and methods: this was a retrospective case series looking at case notes and retinal imaging of 12 patients with avascular pigment epithelial detachment. at pre-treatment baseline all patients had demographic characteristics recorded such as date of birth, sex, race and a general health questionnaire. these patients were treated with three injections of ranibizumab at monthly interval. corrected visual acuity and ped height were compared at 3, 6, 12, 24 and 36 months post injection. results: at 6 months post-injection ped height decreased by up to 50% as compared to baseline height and this was largely maintained over 36 months post-injection. two eyes showed subsequent increase in ped height to baseline level although further treatment was not performed. visual acuity did not improve in any case although was maintained at baseline in 8 cases for 36 months and reduced in 4 cases due to central macular atrophic changes observed over 36 months. no case of rpe rip was seen in this series. conclusion: avascular ped treated with intravitreal ranibizumab shows some reduction of the height of the ped, which in turn reduced the risk of a spontaneous rpe rip. key words: avascular pigment epithelial detachment, ranibizumab, choroidal neovascularisation. retinal pigment epithelial detachment (ped) is a common manifestation in several retinal conditions including age-related macular degeneration1. based on retinal imaging as well as clinical examination, peds can be classified as drusenoid, serous or vascular2,3,4. vascularised peds, as the name suggest, are associated with choroidal neovascularization (cnv). drusenoid and serous peds may or may not have an associated cnv. anti-vegf therapy has a well proven role in the treatment of vascularized ped5,6. less well established is the beneficial effect of anti-vegf therapy in those peds where a cnv is not clearly present. large serous peds were excluded from phase 3 clinical trials such as tap, anchor and marina7,8,9 trials. as such these trials cannot be relied upon to provide management strategies for these lesions. development of a rip in a ped can result in permanent damage to central vision10,11. such a rip is mailto:imranakram2020@gmail.com imran akram, et al 243 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol often spontaneous although intravitreal therapy can also precipitate an rpe rip12,13. it is therefore desirable to reduce the height of a ped in order to minimize the risk of a rip. furthermore, a longstanding ped presumably interferes with the nutrition to the rpe and photoreceptors and thus early flattening of the ped or reducing its height was an important treatment rationale in this study. no universally agreed guidelines exist on the treatment of peds not associated with a cnv. one study14 looked specifically at the role of the anti-vegf agent, ranibizumab (lucentis) in non-vascularised peds but the follow-up period in that study was 12 months. the purpose of this study was to look at the long term effects of 3 ranibizumab injections given in eyes with non-vascularised peds. the effects were monitored for up to 36 months and to date this is the longest follow-up published for this sub-set of treated patients. methods in this study, we looked at eyes with fovea involving avascular ped of at least 100 microns height, which were treated with 3 injections of intravitreal ranibizumab between 2011 and 2013. all patients had a baseline visual acuity of at least 50 etdrs letters. absence of associated choroidal neovascularization (cnv) was established by structural oct and fluorescein angiography (heidelberg spectralis). patients with co-existing macular pathology such as diabetic macular edema, cscr, retinal angiomatous proliferation (rap) and epiretinal membrane were not treated with anti-vegf. at pre-treatment baseline, all patients had demographic characteristics recorded such as date of birth, sex, race and a general health questionnaire. best corrected visual acuity was recorded using etdrs letter score. volume oct scanning of the macula was performed. fluorescein angiography was performed in all patients to rule out presence of cnv. oct angiography was not available at the time. the patients were then evaluated by a retina specialist to consider suitability for ranibizumab treatment. ped height was measured using the inbuilt calipers in the oct software (see fig). maximum vertical distance between bruchs membrane and the rpe was used as a measure of baseline ped height. the ped was classified as drusenoid or serous based on the reflectivity of the sub-rpe space on oct examination. informed consent was obtained for the full course of treatment. all patients received three ranibizumab injections at four weekly intervals according to departmental protocol. no supplementary injections were performed in these patients as we did not consider the royal college of ophthalmologists wet amd guidelines to be applicable to these cases. the aim of treatment was to reduce height of the ped in order to prevent the possibility of a future rip as well as to stabilize and improve visual acuity. the primary outcome measures were effect on reduction in ped height and effect on visual acuity over the course of 3 years following the initial loading dose of 3 ranibizumab injections. following 3 initial injections all patients were monitored for up to 36 months. at each visit visual acuity was measured using etdrs letters. ped height was measured on structural oct scan. results twelve eyes of 12 patients met the inclusion criteria for this study. there were 7 females and 5 males. median age was 77 (age range 58-90). at baseline, 9 peds were considered serous based on hyporeflectivity on oct scanning. 3 peds were considered drusenoid. mean baseline visual acuity was 59.66 etdrs letters (range 50-69). mean ped height was 281 microns (range 90-410). table 1. baseline characteristics. median age in years (range) 77 (58-90) gender (male: female) 5:7 ped morphology (serous: drusenoid) 9:3 visual acuity mean in etdrs letters (range) 59.66 (50-69) ped height mean in microns (range) 281 (90-410) table 2: measurements of ped mean height in microns (sd) and mean best corrected visual acuity bcva in etdrs letters (sd). baseline month 3 month 6 month 12 month 24 month 36 bcva 59.66 (14.66) 58.55 (15.12) 54.78 (14.99) 54.34 (14.81) 53.85 (14.96) 53.12 (15.32) ped height 281 (148.92) 216.22 (135.66) 142.34 (119.32) 111.02 (120.73) 98.34 (129.45) 96.66 (131.22) avascular retinal pigment epithelial detachment treated with intravitreal ranibizumab: three year pak j ophthalmol vol. 35, no. no. 4, oct – dec, 2019 244 fig. 1: oct scan of same eye (a) before any treatment, showing “dry” ped. (b) 6 months after 3rd injection showing almost complete resolution of ped. (c) 36 months after injections showing complete ped flattening and rpe atrophy. ped height reduced by 64.78 microns at month 3 following the third ranibizumab injection. from there onwards, the reduction in height was gradual and a further mean reduction of 96.56 microns was noted between month 3 and month 36 post-injection. least reduction in height was noted in the drusenoid peds although these eyes showed the most stable va. five eyes with serous ped showed complete resolution of the ped with no recurrence during the follow-up period. two eyes with serous ped showed a recurrent increase in ped height to baseline levels between months 12 and 24. bcva showed a gradual mean decrease of 6.54 etdrs letters over the 36 months of follow-up. no eye showed development of cnv throughout the study period. discussion the pathogenesis of pigment epithelial detachment (ped) is not completely understood. anatomical apposition of the rpe to the underlying bruch’s membrane is crucial for the nutritional support of the outer retina. the forces maintaining this adhesion are not fully clear. a decrease in overall conductivity across bruch’s membrane resulting in reduced fluid exchange between the choroid and rpe is considered to be a widely accepted underlying mechanism of ped formation15, although it may be likely that drusenoid and serous peds could have different pathogenesis16. inflammatory mediators17 as well as vegf18 have been implicated in the increased permeability across bruch’s membrane. for ease of description, we would like to introduce the terms “dry ped” to denote avascular peds, as distinguished from “wet ped” which are clearly associated with choroidal neovascularization as shown by structural oct and fluorescein/indocyanine green angiography. dry peds include drusenoid peds and serous peds which show no features of cnv. there is no universally accepted treatment strategy for dry peds. this study represents the longest published follow-up (3 years) of eyes with avascular ped treated with ranibizumab in a real world setting. in 12 eyes of 12 patients, 3 intravitreal injections of ranibizumab were performed to treat dry age-related ped. maximum reduction in ped height was seen in the first 6 months followed by a more gradual mean reduction. this effect was sustained in 10 eyes over 3 years whereas 2 eyes showed recurrence of the ped. in 5 eyes complete flattening of the ped was observed. beneficial effect on visual acuity was less encouraging as compared to treating fibrovascular peds with ranibizumab19,20. however, 8 eyes maintained their baseline visual acuity. interestingly these included the 2 eyes which developed recurrent ped. four eyes showed a gradual decline in visual acuity over 36 months. all of these were eyes in which the ped had completely flattened and outer retinal degenerative changes gradually developed. our study findings compare favorably with a similar study from vienna14 although ritter et al’s follow-up period was 12 months compared to our 36 month follow-up. they also recruited 12 patients but half of these were treated with up to 6 ranibizumab injections over 6 months. they also concluded that ranibizumab treatment can reduce ped height and volume but the effect was not maintained over the 12 months period of their study. other studies have found limited benefit of anti-vegf in bringing about complete resolution of the ped element of wet amd21 whereas one large series22 has correlated the anatomic response of treatment to baseline ped height, associated vascularization and also the type of antivegf used. the findings of this retrospective case series imran akram, et al 245 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol suggest structural benefit and visual stability in some patients with age-related “dry” peds treated with intravitreal ranibizumab. this further suggests that vegf may indeed have a role in the pathogenesis of age-related pigment epithelial detachments even when no structural or angiographic features of choroidal neovascularization are present. compliance with ethical standards we have no financial disclosure and no conflict of interest in this case. informed consent was obtained from the patient in order to use his images in this publication. references 1. zayit-soudry s, moroz i, loewenstein a. retinal pigment epithelial detachment. surv ophthalmol. 2007; 52: 227-243. 2. hartnett me, weiter jj, garsd a, jalkh ae. classification of retinal pigment epithelial detachments associated with drusen. grafes arch clin exp ophth. 1992; 230: 11-19. 3. poliner ls, olk rj, burgess d, gordon me. natural history of retinal pigment epithelial detachments in agerelated macular degeneration. ophthalmology, 1986; 93: 543-551. 4. gass jd. serous retinal pigment epithelial detachment with a notch: a sign of occult choroidal neovascularization. retina. 1984; 4: 205-220. 5. arias l. treatment of retinal pigment epithelial detachment with antiangiogenic therapy. clinical ophthalmol. 2010; 4: 369-374. 6. chevreaud o, oubraham h, cohen sy. ranibizumab for vascularized pigment epithelial detachment: 1-year anatomic and functional results. graefes arch clin exp ophthalmol. 2017; 255 (4): 743–51. 7. photodynamic therapy of subfoveal choroidal neovascularisation in age-related macular degeneration with verteporfin: one-year results of 2 randomized clinical trials–tap report. treatment of age-related macular degeneration with photodynamic therapy (tap) study group. arch ophthalmol. 1999; 117: 1329– 1345. 8. rosenfeld pj, brown dm, heier js, boyer ds, kaiser pk, chung cy et al. ranibizumab for neovascular age related macular degeneration. n engl j med. 2006; 355: 1419–1431. 9. brown dm, kaiser pk, michels m, soubrane g, heier js, kim ry, sy jp, schneider s, anchor study group. ranibizumab versus verteporfin for neovascular age-related macular degeneration. n engl j med. 2006; 355: 1432–1444. 10. decker wl, sanborn ge, ridley m. retinal pigment epithelial tears. ophthalmology. 1983; 207: 27-35. 11. bakri sj, kitzmann as. retinal pigment epithelial tear after intravitreal ranibizumab. am j ophthalmol. 2007; 143: 505–507. 12. chang lk, sarraf d. tears of the retinal pigment epithelium: an old problem in a new era. retina. 2007; 27: 523-534. 13. ronan sm, yoganathan p, chien fy, corcostegui ia, blumenkranz ms, deramo va, elner sg, et al. retinal pigment epithelium tears after intravitreal injection of bevacizumab (avastin) for neovascular age-related macular degeneration. retina. 2007; 27: 535-540. 14. ritter m, bolz m, sacu s, deak gg, kiss c, pruente c, schmidt-erfurth um. effect of intravitreal ranibizumab in avascular pigment epithelial detachment. eye, 2010; 24: 962-968. 15. moore dj, hussain aa, marshall j. age-related variation in the hydraulic conductivity of bruch's membrane. invest ophthalmol vis sci. 1995; 36: 1290– 1297. 16. sheraidah g, stein metz r, maguire j, pauleikhoff d, marshall j, bird ac. correlation between lipids extracted from bruch’s membrane and age. ophthalmology. 1993; 100: 47-51. 17. hollyfield jg, bonilha vl, rayborn me, yang x, shadrach kg, lu l, ufret rl, salomon rg, perez vl. oxidative damage-induced inflammation initiates agerelated macular degeneration. nat med. 2008; 14: 194– 198. 18. oh h, takagi h, takagi c, suzuma k, otani a, ishida k, matsumura m, ogura y, honda y. the potential angiogenic role of macrophages in the formation of choroidal neovascular membranes. invest ophthalmol vis sci. 1999; 40: 1891–1898. 19. arora s, mckibbin m. one-year outcome after intravitreal ranibizumab for large, serous pigment epithelial detachment secondary to age-related macular degeneration. eye, 2011; 25: 1034-1038. 20. panos gd, gatzioufas z, petropoulos ik, dardabounis d, thumann g, hafezi f. effect of ranibizumab on serous and vascular pigment epithelial detachments associated with exudative age-related macular degeneration. drug des devel ther. 2013; 7: 565–9. 21. cho hj, kim km, kim hs, lee dw, kim cg, kim jw. response of pigment epithelial detachment to antivascular endothelial growth factor treatment in agerelated macular degeneration.am j ophthalmol. 2016 jun; 166: 112-119. 22. dirani a, ambresin a, marchionno l, decugis d, mantel i. factors influencing the treatment response of pigment epithelium detachment in age-related macular degeneration. am j ophthalmol. 2015 oct; 160 (4): 732-8 avascular retinal pigment epithelial detachment treated with intravitreal ranibizumab: three year pak j ophthalmol vol. 35, no. no. 4, oct – dec, 2019 246 author’s affiliation mr imran akram frcs frcophth do consultant ophthalmic & vitreoretinal surgeon st helens & knowsley teaching hospitals nhs trust marshalls cross road, st helens wa9 3da, united kingdom brigadier amjad akram fcps, frcs(glas), frcs(ed) consultant ophthalmic surgeon combined military hospital, kharian cantt, district gujrat author’s contribution mr imran akram data collection, manuscript writing. brigadier amjad akram manuscript writing, literature review, critical analysis. 87 pakistan journal of ophthalmology, 2020, vol. 36 (1): 87-91 author communication the importance of determining a proper imaging modality in medial orbital wall and blowout fracture yunia irawati 1 , carennia paramita 2 , dian farikha 3 1 plastic and reconstructive surgery division, dr. cipto mangunkusumo hospital, jakarta, indonesia. 2,3 department of ophthalmology, dr. cipto mangunkusumo hospital, jakarta, indonesia abstract a 27-year-old man was first seen 4 weeks after his right eye being accidentally hit by branches of tree. he complained of diplopia which was significant on the right gaze. there were partial thickness superior and inferior eyelid rupture and full thickness superior eyelid margin laceration (which got repaired), hematoma, and swelling of the right eye. orbital x-ray demonstrated no abnormality. however, orbital ct scan was eventually obtained and it showed medial wall and orbital floor fracture of the right eye, hence, we planned to do the reconstruction of orbital fracture. we concluded that patient with severe soft tissue swelling, unclear ocular movement restriction and diplopia with normal orbital x-ray should undergo orbital ct scan, as it is the best radiologic imaging in establishing an orbital wall fracture. this author communicationn will discuss the importance on determining a proper imaging modality in blowout fracture. key words: blowout fracture, x-ray orbit, orbital ct scan, diplopia. how to cite this article: irawati y, paramita c, farikha d. the importance of determining a proper imaging modality in medial orbital wall and blowout fracture. pak j ophthalmol. 2020;36 (1): 87-91 doi: https://doi.org/10.36351/pjo.v36i1.983. introduction orbital trauma can damage facial bones and adjacent soft tissue 1 . the most common site for blowout fracture is the postero-medial aspect of the orbital floor medial to the infraorbital neurovascular bundle where the maxillary bone is very thin 2 . blowout fracture occurs when a major blow occurs across the anterior orbital entrance, the fracture results from hydraulic collapse of the orbital floor. fracture results from transmission of energy from a transient deformation of the inferior orbital rim. correspondence to: yunia irawati head of plastic and reconstructive surgery division, department of ophthalmology, faculty of medicine universitas, indonesia, dr. ciptomangunkusumo hospital, jec eye hospitals, jakarta, indonesia from chi study about surgically treated orbital fractures, 74.9% of the patients were male. the incidence reached its peak in the 20 to 29 years age 3 . medial wall fractures were the most common (38.6%), followed by inferior wall (35.7%), medial and inferior walls (21%) and other walls (4.6%). case presentation a 27-year-old man came with complaint of double vision which was significant on right gaze after a 4month history of accidentally hit by a branch of tree. ophthalmic examination revealed that his visual acuity of the right eye was 6/7.5 and his right eyelid rupture had been repaired, whereas visual acuity of the left eye was 6/6.there were no abnormalities found on anterior and posterior segment in either eye. orbital x-ray showed no fracture nor intraocular foreign body (fig. 1.) https://doi.org/10.36351/pjo.v36i1.983 the importance of determining a proper imaging modality in medial orbital wall and blowout fracture pakistan journal of ophthalmology, 2020, vol. 36 (1): 87-91 88 fig. 1: preoperative condition a. partial thickness superior and inferior eyelid rupture and full thickness superior eyelid margin laceration b. orbital x-ray. the diplopia chart showed double vision on right gaze and lower right gaze. there were restriction of right eye movement on upper gaze, upper right gaze and right gaze and down gaze. the goldmann diplopia perimetry and hess screen test were performed. hertel exophthalmometry test with base 108 showed 15 mm in right eye and 18 mm in left eye. orbital ct scan showed right medial orbital wall fracture, edema of the right medial rectus muscle and edema of orbital fat (fig. 2). he was diagnosed with medial wall and orbital floor fracture of the right eye. reconstruction of the orbital wall fracture was then scheduled. unfortunately, the surgery was postponed until 3 months after trauma due to financial problem. fig. 2: preoperative examination a. goldmann diplopia perimetry b. hess screen c. orbital ct scan. the surgery was performed through medial incision and subciliary trans-cutaneous approach. after incision at medial canthus, the wound was further dissected until the medial orbital wall was seen. the adjacent tissue was freed, silicon block was placed over the medial defect. then, subciliary incision was made and the wound was further dissected until the inferior orbital rim was seen. the adjacent tissue was freed, periorbital fat and inferior oblique muscle of the right eye were visualized within the orbital floor fracture. silicon block was placed over the floor defect. forced duction test was performed and there was no restricted vertical movement. the periosteum was stitched and the skin was closed. antibiotics and nsaid were given postoperatively. at first follow-up after surgery, the eyelid was edematous with stitches in lateral and medial canthus. movement of the right eye was hard to evaluate due to edema. the other part was normal. the patient was told to train the movement of extraocular muscle and allowed to go home. three weeks following surgery, diplopia was reduced. from diplopia chart, there was no diplopia at 11 weeks after surgery. there were restricted movement on upgaze and upper right gaze of the right eye. goldmann diplopia perimetry was performed. visual acuity of both eyes were 6/6 (fig. 3 & 4.) fig. 3: postoperative examination with goldmann diplopia perimetry a. three weeks after surgery. b. eleven weeks after surgery. fig. 4: eleven weeks post-operative. no restriction on ocular movement. discussion the diagnosis of blowout fracture is made by patient history of being struck by an object, physical examination and radiology. common signs and symptoms in blowout fracture are periorbital ecchymosis and swelling, restriction of extraocular movements, diplopia and enophthalmos 3,4 . patient with orbital fractures can present with traumatic iritis, corneal abrasion, hyphema, acute glaucoma, lens trauma, vitreous hemorrhage, commotio retinae, retinal tears or detachment and traumatic optic neuropathy. x-ray, as an ancillary examination in orbital trauma, has some disadvantages; such as irawati y, et al 89 pakistan journal of ophthalmology, 2020, vol. 36 (1): 87-91 difficulty to show clearly all bone complex structures of the facial skeleton and inability to assess detailed soft tissue elements of the face. orbital computed tomography scan (ct scan) is the chosen radiologic imaging in establishing orbital wall fractures. pure orbital blowout fracture is used to describe fracture of the orbital floor, the medial orbital wall, or both with an intact bony orbital margin 2 . impure orbital blowout fracture is used when fractures occur in conjunction with fracture of the orbital rim 2,5 . treatment of systemic and cranial injury precede the repair of orbital fractures. in view of the sight threatening nature of acute orbital cellulitis, a short course of systemic antibiotics should be considered. oral anti-inflammatory medications can be given to accelerate resolution of edema and orbital inflammation. when surgical intervention is indicated, it involves release of the entrapped tissue and repair of the bony defect. in an early severe facial trauma, clinical decision making to diagnose an orbital wall fracture is difficult if there is laceration and soft tissue swelling. the diagnosis of blowout fractures is suggested by anamnesis of trauma mechanism, clinical presentation and imaging. patient with history of blunt periorbital trauma forceful enough to cause ecchymosis may be suggestive of blowout fracture 1 . some symptoms suggestive of blowout fracture include vertical diplopia with restriction of up or down gaze, pain on extremes of eye movement, hypoaesthesia in the infraorbital nerve territory, periocular emphysema, enophthalmos, and hypoglobus. in cases with medial rectus muscle or asscociated soft tissue entrapment, patients may complain of diplopia in horizontal gaze, pain on eye movement, or epistaxis due to avulsion of anterior ethmoidal artery if there is concomitant nasal fracture respectively 6 . diplopia and ocular movement disturbances in orbital trauma may be caused by entrapment of connective tissue septa or an extraocular muscle within the fracture, hematoma and or edema in the orbital fat adjacent to the fracture, hematoma or contusion of an extraocular muscle and palsy of an extraocular muscle due to neuronal damage 2,7 . traumatic enophthalmos may occurr due to atrophy and prolapse of orbital fat, displacement of the orbital walls with significant increase in orbital volume and cicatricial contraction of orbital tissues. enophthalmos may be masked by orbital hematoma, swelling or air, which may even cause proptosis in the first few days following trauma. enophthalmos is always significant in the presence of combined fractures of the orbital floor and medial orbital floor 2 . in the absence of surgical intervention, enophthalmos may increase until 6 months as posttraumatic orbital degeneration and fibrosis. in this patient, the orbital floor and medial wall fractures were not diagnosed at the first time when he came to the emergency room. orbital ct scan was not suggested earlier because of the absence of discontinuity on orbital rim palpation and normal orbital x-ray. although the orbital x-ray showed no fractures, the ct scan should have been performed earlier, because the patient had severe blunt facial injury and possibility of orbital wall fracture could not be excluded by an orbital x-ray alone 8 . the basic imaging method to detect facial bone fractures is x-ray. antero-posterior (ap) and lateral projection show the floor and posterolateral orbital wall. caldwell’s view gives the superior and inferior rims, medial walls, ethmoid and frontal sinuses a better image. waters’ view also isolates the orbital roof and floor from surrounding structures 8 . x-ray is the key in establishing fractures and presence of foreign bodies, especially metal. overlapping of spatial bone structures of the facial skeleton and inability to assess a detailed image of soft tissue elements make it difficult to detect orbital fractures. early blunt orbital fracture is sometimes challenging to be established, due to soft tissue swelling. orbital ct scan should be done in patient with severe soft tissue swelling, unclear ocular movement restriction and diplopia with normal orbital x-ray. late diagnosis of orbital wall fracture may cause soft tissue entrapment and periocular fibrosis resulting in difficulty in releasing the entrapped tissue when surgery is performed and yield a non-optimal postoperative condition. ct scan is capable of determining the size and morphology of the fracture, which aids in both clinical assessment and surgical planning. ct scan can determine whether the fracture involves the optic canal, acute proptosis secondary to orbital hemorrhage or orbital emphysema. it can also detect entrapment of rectus muscles, recognized by displacement of the muscle into the fracture site, with or without bone displacement. in this patient, surgery was indicated because there the importance of determining a proper imaging modality in medial orbital wall and blowout fracture pakistan journal of ophthalmology, 2020, vol. 36 (1): 87-91 90 were diplopia, restricted eye movements, enophthalmos (> 2 mm) and orbital ct scan showed orbital floor and medial wall fractures. surgical intervention is indicated in a large fracture involving at least half of the orbital floor, particularly when associated with large medial wall fractures. orbital fractures of this size have a high incidence of subsequent significant enophthalmos 1 . the proper timing of surgical treatment in pure orbital fractures should be customized for each patient. surgical timing of orbital fractures was strongly related to combination of anatomical location of fracture, eventual exposition of fracture, cerebro spinal fluid (csf) leakage or penetrating wounds, patient’s age, eventual functional impairments or muscle entrapment and serious conditions of compression or ischemia 9 . orbital soft tissue entrapment may generate the oculocardiac reflex (bradycardia, heart block, nausea, vomiting and syncope) 10 . absolute and immediate indication of surgery are potentiation of the oculocardiac reflex and retrobulbar hematoma with compression of the globe or the optical nerve in combination with impaired vision 10 . surgery is generally recommended within two weeks of the injury. if the surgery is delayed, fibrosis between orbital tissues, sinus mucosa and bone fragments will make surgery more difficult. although most surgeons prefer early surgery for better postoperative result, dal canto and linberg showed delayed orbital floor and or medial wall fracture repair (15-29 days after trauma) as effective as early (1-14 days after trauma) repair in regard to postoperative motility, diplopia and time to resolution. surgical approach to the orbital fracture varies. an orbital floor blowout fracture is usually approached via lower eyelid incision. a medial wall fracture can be repaired via medial canthal incision. alternatively, a transcaruncular approach can be used. if the patient already has a significant eyelid laceration in association with the fracture, this can be utilized for access to the fracture 2 . the lower eyelid incision can be made through the skin or through the conjunctival (fornix inferior) 1,2 . this provides an excellent access to the whole of the orbital floor and to the medial orbital wall. for the management of small “trapdoor” orbital floor fractures, the transconjunctival approach without lateral canthotomy and inferior cantholysis is adequate 2 . in this patient, we did transcutaneous incision for medial and orbital floor fracture. there is a wide array of implants such as silicone, titanium, porous polyethylene, hydroxyapatite, methylmethacrylate, autologous bone or cartilage, which were used to bridge the fracture gap in orbital reconstruction 2 . autogenous bone can be harvested from iliac crest or outer table of the skull. this entails a lengthier operation, a longer stay and a higher risk of morbidities and complications for donor 2 . we chose silicone among other implants because it was easily available, affordable and inert. to ensure proper placement of the implant, it is suggested to do the ct scan postoperatively. postoperative complications (eg. persistent diplopia, intraorbital hemorrhage, orbital cellulitis, loss of vision, dacryocystitis, ptosis, lower lid retraction, lower lid entropion, lower lid lymphedema, implant extrusion, infraorbital sensory loss, undercorrection of enophthalmos, proptosis, hyperglobus, and cyst formation) may occur after orbital fractures reconstruction 2,3 . in this patient, enophthalmos still persisted after the surgery. this sub-optimal result might be due to fibrosis and bone fragments between orbital tissues that occurred in delayed management. in summary, early blunt orbital trauma is difficult to be established as an orbital wall fracture. hence, patient with severe soft tissue swelling, unclear enophthalmos and ocular movement restriction, diplopia with normal orbital x-ray should undergo an orbital ct scan. in a late diagnosed orbital wall fracture, the entrapped soft tissue may become fibrotic and make it difficult for the surgeon to release the entrapped tissue. consequently, a sub-optimal postoperative condition may occur. therefore, it is important to choose the proper imaging modality in medial orbital wall and blowout fracture. conflict of interest authors declared no conflict of interest authors’ designation and contribution yunia irawati; head of plastic and reconstructive surgery division: data collection, manuscript writing and final review. carennia paramita; research assistant: data collection, manuscript writing and final review. dian farikha; resident department of ophthalmology: data collection, manuscript writing and final review. irawati y, et al 91 pakistan journal of ophthalmology, 2020, vol. 36 (1): 87-91 references 1. foster j, carter k, durairaj v, kavanagh mc, korn bs, nelson cc, et al. section 7. orbit, eyelids, and lacrimal system. in: american academy of ophthalmology. singapore: leo, 2015: 129-134. 2. leatherbarrow b. oculoplastic surgery. in: 2nd ed. london: informa healthcare; 2011: 547-562. 3. chi mj, ku m, shin kh, sehyun b. an analysis of 733 surgically treated blow out fractures. ophthalmologica. 2010; 224: 167-175. 4. kamath sj, kamath m, kamath m, pai sg, chhablani j, chowdary s. short report a study of orbital fractures in a tertiary health care center. online j heal allied scs. 2007; 6 (1): 1-4. 5. kanski j, bowling b. orbital trauma. in: clinical ophthalmology: a systematic approach. 6th ed. philadelphia: elsevier ltd. 2007: 848-851. 6. fan m, burkat cn, wladis e. orbital medial wall fractures. available at http://eyewiki.aao.org/orbital_medial_wall_fractures# symptoms. accessed september 6, 2012. 7. myga-porosiło j, skrzelewski s, sraga w, borowiak h, jackowska z, kluczewska e. ct imaging of facial trauma. role of different types of reconstruction. part i bones. polish j radiol. 2011; 76 (1): 41-51. 8. thaller s, mcdonald w. facial trauma. in: new york: marcell dekker, 2004: 241-250. 9. matteini c, renzi g, becelli r, belli e, iannetti g. surgical timing in orbital fracture treatment: experience with 108 consecutive cases. j craniofac surg. 2004; 15 (1): 145-150. 10. ceylan o, mutlu f, altinsoy h, uysal y, tuncer k. management of diplopia in patients with blowout fractures. indian j ophthalmol. 2011; 59 (6): 461. .…  …. 223 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol original article effectiveness of micropulse mp3 cyclodiode laser in controlling intraocular pressure without acetazolamide imran ghayoor, sahira wasim, munira shakir, shakir zafar doi 10.36351/pjo.v35i4.935 pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. sahira wasim department of ophthalmology, liaquat national hospital karachi email: sahirawasim@gmail.com purpose: to determine the effectiveness of micropulse mp3 cyclodiode laser in controlling intraocular pressure without acetazolamide. study design: descriptive case series. place and duration of study: department ophthalmology, liaquat national hospital, karachi for 6 months duration from 15-03-19 to 15-09-19. material and methods: all patients of either gender with age 20 to 50 years with primary open angle glaucoma, neovascular, refractory, uveitic, trauma induced glaucoma and post vitrectomy glaucoma were included. patients with primary angle closure and normal tension glaucoma were excluded from the study. descriptive statistics were calculated. frequencies and percentages were computed for qualitative variables. quantitative variables were presented as mean ± standard deviation. the mean baseline iop was compared with mean iop of 3 months using student t-test. effect modifiers were controlled through stratification. fisher exact test was used to see the association of effectiveness with stratified groups. p-value ≤ 0.05 was considered as significant. results: out of 98 patients included in the study, 63.3% were males and 36.7% were females. mean age of the patients was 48.46±13.39 years. the effectiveness of micropulse mp3 cyclodiode laser was observed in 85.7% cases. significant mean difference was found between pre-op iop with iop after 3 months for right eye and left eye. insignificant association of effectiveness was effectiveness of micropulse mp3 cyclodiode laser in controlling intraocular pressure pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 224 …..……………………….. found with gender, age, type and procedure. conclusion: micro pulse mp3 provides promising results with high level of effectiveness and with great potential advantages to be considered as a safe alternative procedure. key words: micropulse mp3 cyclodiode laser, intraocular pressure, acetazolamide. laucoma is leading towards the second most common cause of worldwide irreversible blindness1 and approximately sixty million people are suffering from glaucoma globally1,2. glaucoma therapies are designed to either increase the outflow or decrease the production of aqueous humor in order to reduce intraocular pressure (iop) and preserve visual function3. studies have shown that reducing intraocular pressure helps to preserve visual function in most cases3. surgical intervention is needed when medication fails to control intraocular pressure (iop), which is required to preserve optic nerve function4. current glaucoma therapies include topical medications, laser therapies, microinvasive glaucoma surgery, and incisional glaucoma surgery. most therapies are designed to reduce the production of aqueous humor, increase uveoscleral outflow or both5. trabeculectomy with or without anti-metabolites, and glaucoma drainage devices are considered to be the initial iop lowering surgical procedures followed by6 cycloablation, in which destruction of ciliary body epithelium and stroma is done, thus reducing aqueous production7. cyclo g6 system with mp3 probe, deliver microsecond thermal energy that is confined to target tissue, preventing destruction of surrounding tissue by on and off cycles mode, allowing energy to build up in the targeted pigmented tissues, reaching to coagulative threshold7. in ten et al study the mean preoperative iop was 39.3 ± 12.6 mm hg that decreased to 31.1 ± 13.4 mm hg, 28.0 ± 12.0 mm hg, 27.4 ± 12.7 mmhg, 27.1 ± 13.6 mm hg, 25.8 ± 14.5 mm hg, 26.6 ± 14.7 mm hg and 26.2 ± 14.3 mm hg at 1st day, 1st week, 1, 3, 6, 12 and 18 months respectively. after a mean of 1.3 treatment sessions, success achieved was 72.7%8. numerous studies have demonstrated the efficacy and high safety profile of micro pulse trans-scleral cyclophotocoagulation mp-tscpc in refractory glaucomas9-14. reduction of mean iop was seen in 60.3% at 1 week and 33.4% at 1 month. the procedure was safe in all cases and effectiveness was found in 71% of the patients15. there are few international studies in literature describing the clinical outcomes of micropulsed mp3 cyclodiode laser, in which the work is mostly done in patients with advanced glaucoma with no local studies. the aim of this study is to consider mp3 cyclodiode laser for other glaucoma patients, to control intraocular pressure with the reduction of number of treatments especially excluding the oral acetazolamide to minimize collateral damage, unwanted side effects and to overcome the unavailability of this drug in pakistan. material and methods this descriptive case series was conducted from 15.03.19 to 15.09.19 at liaquat national hospital, karachi in the department of ophthalmology after the approval of ethical committee. who sample size calculator was used to calculate sample size. all patients of either gender with age 20 to 50 years having primary open angle glaucoma, neovascular, refractory, uveitic, trauma induced glaucoma, and post vitrectomy induced glaucoma were included in the study. patients with primary angle closure and normal tension glaucoma were excluded from the study. clinical history was recorded. informed written consent was taken before enrolment. data was collected using a proforma, which included age, gender, duration of glaucoma, number of antiglaucoma medications, visual acuity using snellen chart and intraocular pressure with the goldmann applanation tonometer. type of glaucoma was labeled after slit lamp examination. the micro pulse trans-scleral cyclophotocoagulation (mptscpc) diode laser procedure was performed after injecting retro bulbar anesthesia of 3-5ml of lidocaine. cyclo g6 laser system (iridex laser system) which uses a laser diode g imran ghayoor, et al 225 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol of 810 nm infrared wavelength with mp3 probe was used. treatment was done using total duration of 1.6 millisecond (ms) including 0.5 millisecond on time, 1.1 ms off time, 31.33% duty cycle and power of 2000 mw. globe manipulation by cotton swabs and placement of speculum was censured by adequate exposure to the targeted area. the laser probe was positioned perpendicular to the surface of the globe with fiberoptic tip 3 mm away from the limbus. laser application was done to the upper and lower hemisphere in “painting” direction, avoiding the 3 and 9 o’clock positions to avoid risk of damage to the neurovascular bundles. the laser was delivered for 80 seconds for superior and inferior hemisphere for a total of 160 seconds of treatment. patients received post-operative dose of dexamethasone ointment and were patched for 1 hour. all patients were started on topical moxifloxicin, fluoromethalone and neomycin one hourly and after 1 week tapered to 4 times a day. the following baseline parameters were collected for each visit at 1 week, 1 month and 3 months. intraocular pressure, number of anti-glaucoma medications used including oral acetazolamide and any complications were recorded. topical antiglaucoma medications were tapered or adjusted at the doctor’s discretion. effectiveness of the procedure of the treated eyes was defined as reduction of iop by 30% from baseline iop after 1 month follow up or withdrawal of oral acetazolamide. spss version 22 was used for data compilation and analysis. frequencies and percentages were computed for categorical variables. quantitative variables were presented as mean ± standard deviation. the mean baseline iop was compared with mean iop at 3 months using student t test. effect modifiers were controlled through stratification. poststratification chi square and fisher exact test was used to see the association of effectiveness with stratified groups. repeated measures of anova were applied to compare means. p value ≤0.05 was considered level of significance. results ninety-eight cases were included in study. out of whom 62 (63.3%) were males and 36 (36.7%) were females. the descriptive statistics including mean age of the patients, type of glaucoma, side of treatment, quadrants treated are given in table 1. effectiveness of treatment was seen in 85.7% cases. we found insignificant association of effectiveness with gender (p = 0.199), age groups (p = 0.096), type (p = 0.656) and procedure (p = 0.231) as shown in table-2. mean pre-op iop, after 1 week, 1 month and 3 months for unilateral and bilateral cases is shown in table-3. acetazolamide was not given to 35(35.7%) cases while stopped for 53 (54.1%) cases and 10(10.2%) cases continued with acetazolamide. mean post-operative iop at each time point was significantly lower than pre op iop for unilateral (right and left eye) and bilateral (right and left eye) cases as shown in figure 1 (a), figure 1 (b), figure 2 (a) and figure 2 (b). significant mean difference was found for pre-op iop with iop after 3 months for unilateral right eye (p = 0.000), unilateral left eye (p = 0.00), bilateral right eye (p = 0.000) and bilateral left eye ( p =0.000) as presented in table-4. our complications which were generally tolerated well were conjunctival hemorrhage because of the tip of the probe, which resolved later. the most significant but rare side effect seen was severe surface epithelial erosion all over cornea and it took 3-6 weeks to come back to normal with autologus serum. in one patient, permanent central scar was formed because of infection. four to five patients did not respond to treatment even after repeating the procedure after 3 months. we could not explain this phenomenon. effectiveness of micropulse mp3 cyclodiode laser in controlling intraocular pressure pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 226 table 1: descriptive statistics of study population. n(%) age(years)˚ 48.46 ± 13.39 gender male 62 (63.3) female 36 (36.7) number of drops 0 to 0 1 (1) 1 to 1 16 (16.3) 2 to 0 9 (9.2) 2 to 1 11 (11.2) 2 to 2 22 (22.4) 3 to 0 6 (6.1) 3 to 1 8 (8.2) 3 to 2 17 (17.3) 3 to 3 7 (7.1) 4 to 2 1 (1) azm stop 53 (54.1) continue 10 (10.2) not given 35 (35.7) type chronic 18 (18.4) neovascular 4 (4.1) refractory 28 (28.6) trauma 14 (14.3) uveitic 6 (6.1) vitrectomy 28 (28.6) eye right 36 (36.7) left 36 (36.7) both 26 (26.5) procedure 180 34 (34.7) 360 64 (65.3) effectiveness yes 84 (85.7) no 14 (14.3) mean ± sd table 2: association of effectiveness with population characteristics. effectiveness pvalue yes no gender male 51 (60.7) 11 (78.6) 0.199 female 33 (39.3) 3 (21.4) age group ≤50 years 34 (40.5) 9 (64.3) 0.096 >50 years 50 (59.5) 5 (35.7) type↨ chronic 16 (19) 2 (14.3) 0.656 neovascular 4 (4.8) 0 (0) refractory 25 (29.8) 3 (21.4) trauma 11 (13.1) 3 (21.4) uveitic 4 (4.8) 2 (14.3) vitrectomy 24 (28.6) 4 (28.6) procedure↨ 180 degree 27 (32.1) 7 (50) 0.231 360 degree 57 (67.9) 7 (50) chi square test was applied. ↨fisher exact test was applied. p≤0.05, considered as significant. table 3: iop according to right and left eye. unilateral (n = 74) bilateral (n = 49) right eye (n = 40) left eye (n = 34) right eye (n = 25) left eye (n = 24) pre op iop 31.22 ± 13.28 34.05 ± 13.39 26.68 ± 11.99 25.75 ± 7.99 1st week iop 16.13 ± 5.87 22.23 ± 12.65 14.72 ± 5.79 14.83 ± 4.47 1st month iop 14.30 ± 5.21 18.85 ± 12.61 13.52 ± 4.20 13.41 ± 3.07 3rd month iop 12.73 ± 4.73 16.79 ± 12.54 11.60 ± 3.68 11.12 ± 2.00 table 4: mean difference of iop at pre-op and after 3 months. unilateral bilateral mean sd p-value mean sd p-value left eye pre op iop 34.05 13.39 < 0.001 25.75 7.99 < 0.001 iop after 3 months 16.79 12.54 11.12 2.00 right eye pre op iop 31.23 13.28 < 0.001 26.68 11.99 < 0.001 iop after 3 months 12.73 4.73 11.60 3.68 paired t-test was applied. p≤0.05, considered as significant. imran ghayoor, et al 227 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol fig. 1: discussion cyclo photocoagulation (cpc) with micropulse 3 device represents a new tissue-sparing technology used for simple as well as for complex glaucoma15. standard coagulation involves ciliary body epithelium and stroma destruction by targeting it, resulting in decreased aqueous secretion and eventually iop control. as compared to conventional cpc which delivers continuous, high intensity energy, mp3 delivers repetitive short pulse laser energy series followed by rest period8,15,16-18. complications related to cyclodestruction procedure includes vision loss, pupillary distortion, corneal edema, cystoid macula, hypotony, and edema19,20. micro pulse mp3 cyclophotocoagulation showed effectiveness for 85.7% of the cases in our study which is nearly same as reported by kareen zaroor (81.7%)21. yelenskiy a reported 71% effectivness.19 success rate varies from 40% to 80% in different studies22-24. the advent of micro-pulsed trans-scleral diode laser has revolutionized diode laser as well as other laser types, even co2 laser. concept of micro-pulsing allows maximum effectiveness by generating significant amounts of energies to reach target tissues and allowing time for heat to diffuse instead of building up, to reduce the risk of unwanted side effects and to make this laser safe and predictable figure-1(a) and 1(b):mean post-operative iop at each time point is significantly lower than pre op iop for right and left eye in unilateral cases (p<0.001). anova indicates analysis of variance. fig.-2(a) and 2(b): mean post-operative iop at each time point is significantly lower than pre op iop for right and left eye in bilateral cases (p < 0.001). anova indicates analysis of variance. effectiveness of micropulse mp3 cyclodiode laser in controlling intraocular pressure pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 228 enough to use in seeing eyes1. the procedure is wellknown for its ease, non-invasiveness and well toleration. bleeding and postoperative infection risks are eliminated by trans-scleral application. at every level of the glaucoma spectrum, mp3 is shown as safe and effective procedure for affected eyes1. excellent safety profile is documented with this treatment. one of the recent studies also reported very good results of the procedure with no complications (i.e. phthisis bulbi, hypotony and macular edema).6 in our study, we found significant mean difference for pre-op iop with iop after 3 months for right eye (p = 0.000) and left eye (p = 0.00). emanuel et al. showed higher reduction of iop24, this has been attributed both to the possibility of increased uveoscleral outflow, as well as decreased aqueous production22. emanuel et al also reported reduction in the need of topical eye drops21. other studies also reported lesser need of number of eye drops10. however, it is noteworthy that in 54% of the patients in our study we were able to withdraw acetazolamide tablets, a treatment that was not used in other studies1,16,24. this could explain the reason why the number of hypotensive drops did not decrease as drastically as reported in other studies24. the limitation of our study is the short-term follow up but we are continuing our study for long term follow-up. previously, cyclodestructive procedures such as cyclocryotherapy and cpc were reserved for poorly controlled glaucoma, limited visual prognosis and mainly retained for end stage glaucoma, because of associated complication with cyclodestructive procedures that include vision loss, corneal edema, pupillary distortion, cystoid macula edema, and hypotony19. we did not notice any significant complications following mp-tscpc in our study. tan et al found mp-tscpc comparable to conventional tscpc with potentially lower rate of complication23. conclusion this new method of micropulse delivery may be of help in patients who cannot take medications or want to delay incisional surgery. micro pulse mp3 can thus be a viable option in patients with prior failed filtering surgery, given the fact that repetition of incisional glaucoma procedures can be technically demanding and fraught with complications, not to mention the lower success rates of glaucoma reoperations. micro pulse mp3 provides promising results with high level of effectiveness and with great potential advantages to be considered as a safe alternative procedure. conflict of interest none references 1. toyos mm, toyos r. clinical outcomes of micropulse transcleral cyclophotocoagulation in moderate to severe glaucoma. j clin exp ophthalmol. 2016; 7 (620): 2. 2. quigley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006; 3: 262–7. 3. weinreb rn, khaw pt. primary open-angle glaucoma. the lancet. 2004; 363 (9422):1 711-20. 4. lai js, tham cc, lam ds. surgical management of chronic closed angle glaucoma. asian pac j ophthalmol. 2003; 15: 5–10. 5. nguyen qh. primary surgical management refractory glaucoma: tubes as initial surgery. curr opin ophthalmol. 2009; 20: 122–5. 6. noecker rj, kelly t, patterson e, herrygers la. diode laser contact trans-sclera cyclophotocoagulation: getting the most from the g – probe. ophthalmic surg lasers imaging, 2004; 35: 124–30. 7. abdelrahman am. refractory glaucomas. types and management. j ophthalmol related sci. 2017; 1 (1): 1-14. 8. aquino mc, barton k, tan am, snq c, li x, loon sc, et al. micropulse versus continuous 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continuous wave transscleral cyclophotocoagulation. am glaucoma soc annual meeting, 2016. imran ghayoor, et al 229 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol 14. maslin j, noecker r. micropulse trans-scleral cyclophotocoagulation for the treatment of glaucoma. assoc res vision ophthalmol. 2016. 15. gavris mm, olteanu i, kantor e, mateescu r, belicioiu r. iridex micropulse p3: innovative cyclophotocoagulation. romanian j ophthalmol. 2017; 61 (2): 107. 16. tan am, chockalingam m, aquino mc, lim zl, see jl, chew pt. micropulse trans-scleral diode laser cyclophotocoagulation in the treatment of refractory glaucoma. clin exp ophthalmol. 2010; 38 (3): 266-72. 17. sivaprasad s, sandhu r, tandon a, sayed ahmed k, mchugh da. subthreshold micropulse diode laser photocoagulation for clinically significant diabetic macular oedema: a three‐ year follow up. clin exp ophthalmol. 2007; 35 (7): 640-4. 18. parodi mb, di stefano g, ravalico g. grid laser treatment for exudative retinal detachment secondary to ischemic branch retinal vein occlusion. retina. 2008; 28 (1): 97-102. 19. yelenskiy a, gillette tb, arosemena a, stern ag, garris wj, young ct, et al. patient outcomes following micropulse transscleral cyclophotocoagulation: intermediate-term results. j glaucoma. 2018; 27 (10): 920-5. 20. vernon sa, koppens jm, menon gj, negi ak. diode laser cycloablation in adult glaucoma: long‐term results of a standard protocol and review of current literature. clin exp ophthalmol. 2006; 34 (5): 411-20. 21. zaarour k, abdelmassih y, arej n, cherfan g, tomey kf, khoueir z. outcomes of micropulse transscleral cyclophotocoagulation in uncontrolled glaucoma patients. j glaucoma. 2019; 28 (3): 270-5. 22. kuchar s, moster mr, reamer cb, waisbourd m. treatment outcomes of micropulse transscleral cyclophotocoagulation in advanced glaucoma. lasers med sci. 2016; 31 (2): 393-6. 23. aquino mc, barton k, tan am, sng c, li x, loon sc, et al. micropulse versus continuous wave transscleral diode cyclophotocoagulation in refractory glaucoma: a randomized exploratory study. clin exp ophthalmol. 2015; 43 (1): 40-6. 24. emanuel me, grover ds, fellman rl, godfrey dg, smith o, butler mr, et al. micropulse cyclophotocoagulation: initial results in refractory glaucoma. j glaucoma. 2017; 26 (8): 726-9. author’s affiliation dr. imran ghayoor professor and consultant department of ophthalmology, liaquat national hospital, karachi dr. sahira wasim resident department of ophthalmology liaquat national hospital, karachi dr. munira shakir associate professor department of ophthalmology, liaquat national hospital, karachi dr. shakir zafar associated professor department of ophthalmology, umdc author’s contribution dr. imran ghayoor supervisor, surgeon & advising consultant, manuscript writing and final review dr. sahira wasim researcher, data analysis and final review dr. munira shakir surgeon, data analysis and final review dr. shakir zafar statistics, data analysis and final review microsoft word partab rai.doc 136 original article usefulness of b-scan ultrasonography in ocular trauma partab rai, syed imtiaz ali shah, alyscia m. cheema, javed hassan niazi, shahid jamal sidiqui pak j ophthalmol 2007, vol. 23 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: partab rai department of ophthalmology larkana medical center railway station road larkana received for publication august’ 2006 …..……………………….. purpose: to detect and differentiate the nature of various traumatic intraocular pathologies by b-scan ultrasonography. material and methods: this study was conducted in the department of ophthalmology, chandka medical college larkana, from oct. 2003 to sept. 2005 and included patients with history of first time ocular trauma in association of secondary opaque ocular media were included in this study. the exclusion criteria included known anterior / posterior segment pathology and previous ocular surgery or trauma. (group a) results: the total patients referred to us for ocular b-scan in two years were 340. out of these the traumatic cases were 72 (21.2%). in these, 51 (70.8%) patients had suffered from penetrating ocular trauma (group a) and 21 (29.2%) from blunt ocular trauma (group b). the major causative agents in penetrating cases were pellet 6 cases (11.8%), metallic foreign body 5 cases (9.8%), road traffic accident 5 cases (9.8%), thorn 4 cases (7.8%), scissor and grinding machine 8 cases (15.7%), followed by knife, wire, iron rod 3 cases each (17.6%), and needle, tip of pen, bird bite, fire cracker, electric wire, mirror, screw driver 2 cases each (27.5%), the major causative agents in blunt trauma were assault by fist / stick 5 cases (23.8%), cricket ball 4 cases (19%), followed by gulli danda (tip cat), stone 3 cases each (28.6%), and buckle of belt, toy, corner of door 2 cases each (29.6%). the traumatic ocular findings seen on b-scan were cataract alone 11 cases (15.3%), iofb 10 cases (13.8%) retinal detachment alone 6 cases (8.3%), vitreous haemorrhage alone 5 cases (6.9%), hyphema alone 5 cases (6.9%), and combined lenticulo-vitroretinal abnormalities 35 cases (48.6%). conclusion: ocular b-scan is safe non-invasive technique which is used easily to detect and differentiate various traumatic intra ocular pathologies and therefore help in the planning of further line of management. he clinical use of ophthalmic ultrasound has increased dramatically over the past twenty years and has presently reached the point where it is universally regarded as an essential means of soft tissue examination of the eye and orbit1. principles of ultrasound: ultrasound is an acoustic wave in which compressions and rarefactions occur due to changes in density within fluid and solid substances2. an ultrasonic wave differs from a sonic wave in that the former exhibits frequencies above 20 kilohertz (1 khz equals one thousand cycles per second) and is thus not audible to humans. sound waves, like light waves can be directed, focused, and reflected according to established principles. in ophthalmic ultrasound, high frequencies (about 10 t 137 megahertz, or 10 million cycles per second) and small wavelengths make detailed resolution of ocular structures possible. sound travels in biological tissue at a rate of approximately 1,500 meters per second, and for most purposes the speed in a tissue may be considered independent of frequency. the time required for sound to travel to the rear of the eye and return is only about 33 microseconds (1 microsecond equals 1 millionth of a second)3. methods of display after the electrical energy is converted into sound energy and then reconverted into electrical energy by the crystal, the echoes can be displayed in graphic form. the three types of display are a-mode, b-mode, and m-mode. each of this presents structural information in a unique display format. ultrasonic system: transducer scanning and electronic processing are incorporated into a basic ultrasonic system to produce cross-sectional images of the eye and orbit. in a-mode the transducer is fixed in position, resulting in one-dimensional display, in bmode the transducer undergoes a sweeping or scanning motion in any selected plane, and the resulting display is two dimensional. the word scan is loosely used in terms of a-scan and b-scan. it is inappropriate to describe a-mode as a-scan because no scanning motion of transducer takes place). the resultant two-dimensional image is composed of numerous spots, and the brightness of each spot is proportional to the sound energy reflected by the corresponding tissues boundary. this type of b-mode is also known as intensity modulated ultrasonography, and the term “gray scale” is often used to describe the relative brightness of the displayed tissue echoes. a system that incorporates a gray scale with many steps of gradations of gray, ranging from black to white, is quite desirable since the relative brightness of a displayed echo helps the examiner in identifying the corresponding tissue4. examination procedure after the patient is comfortably situated in either a lying or sitting position with eyelids closed, a coupling agent, such as methylcellulose, is applied on the scanning head or the closed lids. the procedure can also be done with probe directly over cornea. sound waves of very high frequency, such as ophthalmic ultrasound, are not transmitted through air, and thus the probe must be coupled with closed lids. the technique causes no discomfort, so patients generally cooperate. the examination is dynamic, and the examiner must move the scanning head over the closed lid in all directions to ensure that representative cross sections of the globe are obtained. various recording systems are available so that each photo can be labeled as to which of the infinite cross sections it represents5. in a typical contact b-mode exam, the anterior portion of the eye is not visualized well. however, the posterior lens capsule may be noted behind the position of the cornea and closed lid, which is at the extreme left of the screen. normal vitreous reflects sound poorly, and such poorly reflecting structures are termed sonolucent. they appear black as opposed to structures that reflect sound well, which appear white or shades of gray. similarly, the optic nerve is sonolucent and appears black. the black horizontal vshaped optic nerve is an important landmark in bmode ultrasound. in the normal eye, the retina appears as a smooth, concave surface with a sharp acoustic boundary on the right of the screen, which disappears late as the sensitivity is reduced. this acoustically opaque concave surface results from echoes arising from the vitreo-retinal interface and is inseparable from the choroid and sclera. if a sheet like membrane is observed in the vitreous, the sensitivity should be reduced to estimate its relative acoustic density. if the echo persists at low sensitivity, the membrane is more likely to be retina, whereas if it disappears early, a vitreal membrane is the more likely diagnosis6. material and methods prospectively we studied ocular b-scan of 83 traumatized eyes of 72 patients aged between 15 months and 58 years, from october 2003 to september 2005, at the department of ophthalmology, chandka medical college and hospital larkana. in each case, patients name, age, sex, occupation, address, detailed history of trauma i.e. nature, duration, cause, place, site and ocular clinical examination was noted on a specific performa. patients with first time history of ocular trauma showing secondary ocular changes i-e. hyphema, cataract, and vitreo-retinal pathology were included in this study. the exclusion criteria included known anterior or posterior segment pathology, history of previous ocular surgery or trauma. all 72 patients were divided into two main groups on the basis of nature of trauma. group a comprised 51 (70.8%) patients who came with history of penetrating ocular 138 trauma (table 1), and the group b comprised 21 (29.16%) patients who presented with history of blunt ocular trauma (table 2). results in group a out of 51 patients with history of penetrating ocular trauma 38 (74.5%) were males and 13 (25.5%) were females. eight (15.7%) patients were presented with history of bilateral ocular trauma and 43 (84.3%) patients with unilateral ocular trauma in which right eye was involved in 22 (51.2%) cases, and left eye was involved in 21 cases (48.8%) (table 1). in group b out of, 21 patients with history of blunt ocular trauma, 16 (76.2%) were males and 5 (23.8%) were females. three (14.3%) patients presented with history of bilateral ocular trauma and 18 (85.7%) patients with unilateral ocular trauma in which right eye was involved in 13 (72.2%) cases and left eye was involved in 5 (27.7%) cases (table 2). the causes of penetrating ocular trauma are shown in table 3, and the causes of blunt ocular trauma are shown in table 4. the traumatic ocular findings on b–scan ultrasonography are shown (table 5). table 1: age, sex, & laterality distribution of group a patients with penetrating ocular trauma age in years no. of patients n=51 (70.8%) male n=38 (74.5%) female n=13 (25.5%) laterality bilateral n = 8(15.7%) unilateral n = 43(84.3%) 1 – 10 7 5 2 bil=1, rt=4, lt=2 11 – 20 11 8 3 bil=2, rt=5, lt=4 21 – 30 15 12 3 bil=3, rt=5, lt=7 31 – 40 8 6 2 bil=2, rt=3, lt=3 41 – 50 7 5 2 rt=4, lt=3 51 – 60 3 2 1 rt=1, lt=2 n = number, rt = right, lt = left, bil = bilateral table 2: age, sex, & laterality distribution of group b patients with blunt ocular trauma. age in years no: of patients n=21 (29.2%) male n=16 (76.2%) female n=5 (23.8%) laterality bilateral n = 3(14.3%) unilateral n = 18(85.7%) 1 – 10 2 1 1 rt=1, lt=1 11 – 20 4 3 1 bil=1, rt=1, lt=2 21 – 30 7 5 2 bil=1, rt=4, lt=2 31 – 40 5 4 1 bil=1, rt=4 41 – 50 2 2 0 rt=2 51 – 60 1 1 0 rt=1 discussion traumatic patients with opaque light conducting media were the main cause of referral. in hyphema, bscan shows echoes in the anterior chamber (fig. 1). the normal lens produces extremely low internal reflectivity, whereas dense cataract often produces highly reflective echoes indicates. lens subluxation or dislocation presence of increased echoes of lens contour at abnormal site (fig. 2). mostly traumatic cataracts are associated with vitreoretinal abnormalities. we have noticed 11.1% prevalence of vitreoretinal abnormalities associated with traumatic cataract, which is less as reported 20-30% by kaskalogu m8. in fresh mild vitreous hemorrhage, dots and short lines are displayed on b-scan. but when the haemorrhage spreads diffusely, it creates scattered 139 low amplitude echoes (fig. 3). organization of blood creates interfaces that may have a pseudomembranous appearance. on b-scan, detached vitreous is usually smooth and may be thick posteriorly when blood is layered along its surfaces (fig. 4). retinal detachment typically appears as a bright, continuous smooth and some what folded membrane within the vitreous, which is reflective and freely moving on real time imaging. the movements become less pronounced in long standing detachments. if total and extensive, the detached retina gives a typical triangular funnel shape appearance with insertion into the optic disc and ora serrata (fig.5). table 3: penetrating causative agents penetrating object no. of patients n = 51 (%) pellet 6(11.8) metallic foreign body 5(9.8) road traffic accident 5(9.8) thorns, scissor, grinding machine 12(23.5) knife, wire, iron rod 9(17.6) needle, tip of pen, bird bite, fire cracker, electric wire, mirror, screw driver (2 each) 14(27.5) table 4:. blunt causative agents blunt objects no. of patients n = 21 (%) assault by fist / wooden stick 5(23.8) cricket ball 4(19) gulli danda (tip cat), stone (3 each) 6(28.6) buckle of belt, plastic toy, corner of door (2 each) 6(28.6) the tractional retinal detachment appears as a tented or tabletop configuration with the vitreous band connected to anterior surface (fig. 6). the choroidal detachment typically appears as smooth, thick, dome-shaped membrane in the periphery with little after-movement on kinetic evaluation (fig. 7). blunt trauma can lead to posterior scleral rupture that may be difficult to detect clinically and table 5: ocular traumatic findings on b–scan ultrasonography findings no. of patients n = 72 (%) hyphema alone 3(4.2) hyphema + cataract 5(6.9) hyphema + cataract + vitreous haemorrhage + retinal detachment 1(1.4) dense cataract alone 11(15.3) cataract + vitreous haemorrhage 4(5.65) cataract + anterior and posterior lens capsule rupture 4(5.6) cataract + vitreous haemorrhage + retinal detachment 3(4.2) subluxation of lens + vitreous haemorrhage 2(2.8) dislocation of natural ocular lens 4(4.2) subluxation of lens 1(1.4) posterior dislocation of implanted intraocular lens 1(1.4) vitreous haemorrhage alone 5(6.9) vitreous haemorrhage + posterior vitreous detachment 3(4.2) vitreous haemorrhage + retinal detachment 3(4.2) subhyaloid haemorrhage 2(2.8) intraocular foreign body in the iris 1(1.4) intraocular foreign body in the lens 2(2.8) intraocular foreign body in the vitreous 4(5.6) intraocular foreign body in the retina 3(4.2) retinal detachment alone 6(8.3) peripheral retinal tear 2(2.8) peripheral retinal dialysis 1(1.4) posterior scleral rupture 1(1.4) 140 table 6: occupational ocular trauma type of occupational trauma occupation no. of patients n = 23 (%) industrial lathe machine worker 3(13) tool grinders 1(4.3) welders 2(8.7) carpenter 2(8.7) marble grinder 1(4.3) gold smith 1(4.3) agriculture iron & steel worker 1(4.3) farmer 3(13) harvester 2(8.7) electrical electrician 2(8.7) cooker hot cooking oil 1(4.3) laborer brick / stone 4(17.4) with ultrasonography, although the affected area may show irregular contour and decreased reflectivity (fig. 8). however, such a rupture should be suspected when few of the following or all indirect signs like: incarceration of vitreous and vitreous hemorrhage with pvd; demonstra-tion of folds and traction bands that extend in the direction of rupture; thickening or detachment of retina or choroids; haemorrhage in episcleral space closest to the site may co-exist. b-scan offers advantages in determining the foreign body’s position and distance from ocular structures. the major value of b-scan in detecting foreign bodies is its independence from radio-opacity. softer materials, which are only intermediately reflective (wood and vegetative materials) are more difficult to detect. metal or glass foreign bodies deflect or absorb sound so that they produce an anechoic area posterior to the body. if the foreign body is not visible clearly due to echoes from nearby tissues then gain should be reduced so that echoes from less reflective tissues are obliterated and the foreign body stands out clearly (fig. 9a and b). plain radiograph (fig. 9 c) and c.t. scan are superior for detecting foreign bodies, specially if they are multiple, although ultrasound contributes to their exact location with respect to other ocular structures710. in our study, the non occupational traumatic cases were 49 (68.1%) on the other hand occupational traumatic cases were 23 (31.9%) (table 6 & 7). because of outdoor activities, the ocular trauma is more common in males than females. the prevalence of ocular trauma in young males was 83% (45 cases) which is comparable with those reported by mirza shafique et al 91% (90 cases)11. because of having a rural and non industrial catchment area, the occupational ocular traumatic cases in our study were 31.9% (table 6), which are less as compared with other national studies carried out by uzma fasih et al – 72%12 and butt nh et al – 54%13. table 7: non occupational ocular trauma object no. of patients n = 49 (%) pellet 6(12.2) road traffic accidents 5(10.2) assault by fist/stick 5(10.2) cricket ball 4 (8.2) thorn 4(8.2) gulli danda (tip cat) 3(6.1) stone 3(6.1) knife 3(6.1) mirror 2(4.1) fire cracker 2(4.1) bird bite 2(4.1) tip of pen / pencil 2(4.1) needle 2(4.1) buckle of belt 2(4.1) toy 2(4.1) corner of door 2(4.1) in international studies of bakers s, et al14 and fong lp et al15, the occupational ocular traumatic cases were 14.3% – 15% of all the ocular injuries, which are significantly less than our national studies12,13 141 fig. 1: left eye b-scan of master waheed ali, 8 years old showing anterior chamber hyphema (h) after blunt trauma by gulli danda. fig. 2: right eye b-scan of mr. hadee bux 58 years old showing posteriorly dislocated natural lens (l) with surrounding vitreous haemorrhage (h) after blunt trauma by corner of door. fig. 3: left eye b-scan of mr. altaf hussain 32 year old showing cataract (c) and vitreous haemorrhage (h) after blunt trauma by buckle of belt. fig. 4: left eye b-scan of miss sajida 17 year old showing cataract (c), vitreous haemorrhage (h) and posterior vitreous detachment (p) after blunt trauma by fist. fig. 5: left eye b-scan of mr. ghulam rasool 52 years old showing cataract (c), vitreous haemorrhage (h) and total retinal detachment (r) after blunt trauma by cricket ball. fig. 6: right eye b-scan of baby fareeda 6 years old showing cataract (c), vitreoretinal tractional bands (b) and tractional retinal detachment (r) after blunt trauma by toy. 142 fig. 7: right eye b-scan of mr. abdul ghani 55 years old showing posterior chamber intra ocular lens (l) and choroidal detachment (c) after blunt trauma by stone. fig. 8: right eye b-scan of baby mornee 4 years old showing lens rupture (l), vitreous haemorrhage (h), retinal detachment (r), posterior scleral rupture (s) after penetrating trauma by drip set needle. fig. 9a: left eye b-scan of allah warayo 58 years old showing vitreous haemorrhage (h) and intra ocular foreign body (f) on the retina after penetrating trauma by fire arm. fig. 9b: b-scan of same patient showing prominence of intra ocular foreign body (f) and obliteration of echoes from near by tissues on decreasing the gain of b-scan fig. 9 c: plain x-ray orbit p.a view of same patient showing multiple pellets(p) on the left side and few on the right side showing 54% 72%, due to the modernization of most industries and the proper adaptation of protective measures by the workers in various occupations. conclusion ocular trauma is important cause of morbidity and visual loss in children to middle aged males, which can be prevented by adopting safety measures especially in children and occupational individuals. early to diagnose posterior segment pathology by bscan will lead the surgeon to plan surgical procedure in advance or refer to another tertiary care center. 143 author’s affiliation dr. partab rai department of ophthalmology chandka medical college and hospital larkana prof. syed imtiaz ali shah department of ophthalmology chandka medical college and hospital larkana dr. alyscia m. cheema department of ophthalmology chandka medical college and hospital larkana dr. javed hassan niazi department of ophthalmology chandka medical college and hospital larkana dr. shahid jamal sidiqui department of ophthalmology chandka medical college and hospital larkana. reference 1. colemon dj, lizzi fl, jack rl. ultrasonography of the eye and orbit. philiadelphia, lea and febiger, 1977, p.vii. coleman et al. ultrasonography, 1977:3. 2. giglio, e. diagnostic ultrasound application of a-scan to the eye. in sherman, j.: advanced diagnostic procedures. duncan, okla., optometric extension foundation, 1976; . 23. coleman et al, ultrasonography, 1977; 79. 3. bronson, n.r, fisher, y.l. et al. ophthalmic contact b-scan ultrasonography for the clinicion. westport, conn., international publications. inc, 1976; 27. 4. kinghton rw, blankenship gw. electrophysiological evaluation of eyes with opaque media. in sokol, s. (ed.): electrophysiology and psychophyslics: their use in ophthalmic diagnosis. int 1 ophthalmol. clin, 20 (1). boston, mass, little, brown and co. (inc). 5. giglio e, sherman j. ophthalmic ultrasound as a diagnostic tool. j am optom assoc, 1979; 50: 73-8. 6. kaskalogu m. us findings in eyes with traumatic cataracts. am j ophthalmol. 1985; 9: 496. 7. pavlin cj, harasiewics k, sherar md, et al: clinical use of ultrasound biomicroscopy. ophthalmology 1991; 98: 287-95. 8. jp chugh, susheel, m verma. role of ultrasonography in ocular trauma. ind. j. radiol imag. 2001; 11: 75-9. 9. baig msa, zafar m, anwar m. major ocular traumaan analysis of 98 admitted cases. pak j ophthalmol. 2004; 20: 148–52. 10. fasih u, sheikh a, fehmi ms. occupational ocular trauma (causes, management and prevention). pak j ophthalmol. 2004; 20: 65–73. 11. butt nh. visual outcome of penetrating injuries of anterior segment of eye. pak j ophthalmol. 1998; 14: 172–6. 12. bakerrs s, wilson mr, flower cwg, et al. demographic factors in a population based survey of hospitalized work related ocular injuries. am j ophthalmol. 1996; 213–9. 13. fong lp, taouk y. role of eye protection in work related eye injuries. anst – nzj ophthalmol. 1995; 23: 101–6.. 203 vol. 35, no. 3, jul – sep, 2019 pakistan journal of ophthalmology original article pediatric aphakic glaucoma zia muhammad, john grigg, ikramullah, ihsan ali pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zia muhammad prof & head department of ophthalmology, bacha khan medical college, mardan, pakistan. email: eyesurgzia@gmail.com …..……………………….. purpose: to find the frequency and pathogenesis of post-operative aphakic glaucoma in children operated for congenital cataract at mardan medical complex, mardan, pakistan. study design: retrospective cohort study. place and duration of study: mardan medical complex, mardan between january 2001 and december 2014. material and methods: all cases were operated for congenital cataracts between the ages of 2 months to 30 months were included in the study. babies having congenital cataracts with increased intraocular pressure (iop), those showing signs of congenital glaucoma and those having congenital cataracts with specific syndromes were not included in the study. results: we reviewed the records of 110 patients who had bilateral lens aspiration for congenital cataracts. we found 7 patients (12 eyes) who developed increased intra-ocular pressure (iop) after bilateral lens matter aspiration for congenital cataracts. four patients (three males one female), developed early onset pupil block glaucoma, (2 bilateral and 2 unilateral) while in 3 female patients the onset of glaucoma was delayed for several months to years and was of the open angle type in both the eyes. poor compliance with follow up, poor pupillary dilatation, prolonged surgical time, severe inflammation and residual lens matter are some of the risk factors for early onset pupillary block aphakic glaucoma in pediatric age group. conclusions: pediatric aphakic glaucoma is a significant complication of congenital cataract surgery which requires continuous followup of the patients. key words: pediatric aphakic glaucoma, congenital cataract, aphakic open angle glaucoma, pupil block, primary posterior capsulotomy, phakic glaucoma is one of the most serious, sight threatening and well recognized complications following uncomplicated pediatric cataract surgery1,2. the incidence has been reported in the literature to be between 15% and 45%3,4. the incidence of aphakic glaucoma seems to increase when these patients are followed up for longer periods. 2,4 in patients who were watched for more than 5 years, the incidence of glaucoma in aphakic patients has reached to levels as high as 41%4. pupillary block glaucoma is becoming less common because of the technical innovations and improvements in ophthalmic equipments, cutting instruments and procedures. however, aphakic glaucoma still is a challenge and a sight threatening complication of pediatric cataract surgery2,4,5. some of these children may develop aphakic glaucoma with open angles. the exact pathogenesis of this form of open angle glaucoma in these patients is unknown5. the diagnosis of aphakic glaucoma in children with open angles is quite a challenging task and at times difficult to detect. poor post-operative follow-up and absence of typical symptoms increases the risk of delayed diagnosis. also patients need to be examined under general anesthesia to reach the diagnosis. aphakic children require regular monitoring for iop a pediatric aphakic glaucoma pakistan journal of ophthalmology vol. 35, no. 3, jul – sep, 2019 204 and optic disc changes. aphakic glaucoma occurring after removal of congenital cataract is an established complication. mills et al2 have observed a bimodal presentation of aphakic glaucoma in children. it may be in the form of pupillary block glaucoma due sticking of the pupillary margin to the anterior vitreous face; or due to angle closure from peripheral anterior synechiae2,3. or it may be an open angle type glaucoma of late onset. surgery before 9 months of age and micro-cornea are two important risk factors for development of glaucoma following pediatric cataract surgery. it has been recognized that visual outcome is excellent if surgery is performed in neonates during the first few weeks of life6,7. but early surgery between 1–2 weeks of age also make the babies vulnerable to develop aphakic glaucoma8. johnson et al9, have not observed any relationship between age at cataract surgery (prior to 12 weeks of age) and development of glaucoma. others10 have reported a greater risk of glaucoma during the initial nine months of age. ` we undertook this study to find out the frequency of aphakic glaucoma in the patients operated for congenital cataracts at our institution. this will help us identify the causes of pediatric aphakic glaucoma. also we may be able to modify our techniques to avoid this vision threatening complication. material and methods we analyzed the documents of all pediatric patients who were operated for congenital cataracts between the ages of two months to 30 months from january 2001 to december 2014. babies having congenital cataracts with increased intraocular pressure (iop), those showing signs of congenital glaucoma and those having congenital cataracts with specific syndromes were not included in the study. patients were labeled as having aphakic glaucoma if repeated intraocular pressure (iop) measurements were greater than 25 mm hg after follow up of these patients. schiotz and perkins applanation tonometers were used to determine iop. in all our patients, we performed closed chamber anterior capsulotomy followed by lens matter aspiration through a limbal incision. no posterior capsulotomy and no vitrectomy was performed. all patients were left aphakic, and none of the patients received intraocular lens (iol) implant. one hundred and ten lens aspirations were performed by the same surgeon (zm). both eyes were operated in the same sitting taking strict aseptic precautions. after completion of the surgical procedure, all patients received sub-conjunctival injections of gentamycin and dexamethasone. topical medications (hourly dexamethasone (maxidex, alcon) and 4 hourly tropicamide 1% (mydriacyl 1%, alcon) eye drops were started 2 hours after the operation. from the next day 2 hourly dexamethasone and 4 hourly tropicamide 1% were continued over a 6 week period. moxifloxicin eye ointment at night was used for couple of weeks. we re-examined the patients on the 3rd day post-operative day to assess the wound, pupil, performed retinoscopy and advised glasses. results we reviewed the records of 110 patients who had bilateral lens aspiration for congenital cataracts. we found 7 patients (12 eyes) developed increased intraocular pressure (iop) after bilateral lens matter aspiration for congenital cataracts. four patients (three males one female), developed early onset pupil block glaucoma, (2 bilateral and 2 unilateral) while in 3 female patients the onset of glaucoma was delayed for several months to years and was of the open angle type in both the eyes. descriptive analysis of the study is given in tables 1-5. table 1: demography. total no. of patients: 110 no. of male patients: 69 (62.73%) no. of female patients: 41 (37.27 %) table 2: age & sex distribution. age males females total 2 – 6 months 30 16 46 (41.81%) 7 – 12 months 21 15 36 (32.72 %) 13 – 30 months 18 10 28 (25.45 %) table 3: no. of patients who developed aphakic glaucoma 07 (6.36%). age males females total 1 – 6 months 02 01 03 7 – 12 months 01 02 03 13 – 30 months nil 01 01 zia muhammad, et al 205 vol. 35, no. 3, jul – sep, 2019 pakistan journal of ophthalmology table 4: type of glaucomas. age pupil block glau. open angle glau. total 2 – 6 months 03 m 02/f 01 7 – 12 months 01 01 m 0/f02 13-30 months 02 m 0/f 02 table 5: details of patients who developed aphakic glaucoma. no. name /age/sex lma date a g dx. on surgery for ag type of ag gap 1. patient a 4 months/m march 2012 may 2012 10/5/2012 right eye pupil block 67 days 2. patient b 5 months/m may 2014 june 2014 10/6/2014 left eye pupil block 19 days 3. patient c 5 months/f march 2008 april 2008 22/4/2008 bilateral pupil block 28 days 4. patient d 8 months/m february 2013 march 2013 12/3/2013 bilateral pupil block 33 days 5. patient e 12 months/f february 2004 may 2004 6/5/2004 bilateral oa glaucoma 78 days 6. patient g 18 months/f august 20013 february 2014 25/2/2014 bilateral oa glaucoma 6 months 7. patient h 30 months/f june 2005 june 2011 16/6/2011 bilateral oa glaucoma 6 years discussion congenital cataracts may be classified as congenital idiopathic cataracts, congenital cataracts associated with other ocular or systemic anomalies (aniridea, congenital rubella syndrome etc) and developmental cataracts10. the angle findings are normal in congenital idiopathic cataracts and signs of glaucoma and increased iop are usually not present.11 glaucoma in these children results from the surgical removal of cataracts with or without iol implantation. the diagnostic criteria as defined by the glaucoma research network consist of two or more of the following: iop more than 21 mm hg, progressive increase in the cup to disc (c/d) ratio, asymmetrical cupping of the discs, corneal haab’s striae, enlarged corneal diameter (> 11 mm in the newborn, > than 12 mm in children below one year and > than 13 mm at any age and progressive myopia/myopic shift. glaucoma may be suspected when there is increase in the size of the globe with raised iop without other features mentioned above. we reviewed all infants 3 weeks post surgery and enquired from the mother about the progress and development of any new symptoms. the common symptoms in suspected cases were photophobia and irritability of the infants. infants with these symptoms were called for examination under general anesthesia for iop measurement, assessment of anterior chamber angle and depth, horizontal corneal diameters, refraction and fundus examination. aphakic glaucoma was suspected when the baby was having repeated intraocular pressures (iops) greater than 25 mm hg, progressive increase in the c/d ratio and increase in the horizontal corneal diameter after congenital cataract surgery. schiotz or perkins applanation tonometry was used to determine intra-ocular pressures. patients with these findings were started with medical treatment or glaucoma surgery if the pressure was not controlled with topical medications. glaucomatous eyes with pupil block and shallow anterior chambers were treated with removal of the inflammatory pupillary membrane if present, breaking the posterior synechie, peripheral iridectomy and anterior vitrectomy and re-formation of the anterior chamber. in glaucomatous eyes with open angles, trabeculecomy was performed if there was poor response to topical anti-glaucoma medications. surgery for congenital pediatric cataract increases the risk for developing aphakic glaucoma. preoperative angle findings do not suggest a role in pathogenesis of this form of glaucoma12. the precise cause for the open angle glaucoma following pediatric cataract surgery is not known but may be triggered by trabecular meshwork dysfunction from surgically induced inflammation, corticosteroids `induced increased iop, damage to the developing angle structures by the residual lens fibers or vitreous pediatric aphakic glaucoma pakistan journal of ophthalmology vol. 35, no. 3, jul – sep, 2019 206 interfering with the aqueous drainage or angle maldevelopment13. two risk factors most commonly associated with glaucoma after pediatric cataract surgery include age at the time of surgery and micro-cornea. there is a higher risk in infants operated during the first year of life. a number of studies14,15 report an increased risk of glaucoma at different ages in the first 12 months of life. some observers16 have reported that cataract surgery in the first 9 months of age carries a higher risk of aphakic glaucoma. in this series, we operated on 110 infants (220 eyes) having bilateral congenital cataracts with ages ranging from 2 months to 30 months. both eyes were operated in the same sitting. based on eye count, 12 eyes (5.45%) of our patients developed aphakic glaucoma. based on the patients count 7 of our patients (6.36%) developed aphakic glaucoma. postoperative glaucoma following pediatric cataract surgery has been reported to vary between 6% and 26% of eyes (15% to 45% of patients) among children operated before, as well as after one year of age17,18. rabiah19 has reported an incidence of 37% if the cataract was removed during the first 9 months of age. the risk dropped to 14% when surgery was delayed to between 9 months and 2 years of age. the risk of developing glaucoma further drops to only 9% if surgery is performed between 2 and 3 years of age. after bilateral lensectomy within the first month of life, vishwanath et al8 found an incidence of 50% in at least one eye which decreased to 14.9% if surgery was delayed beyond one year. the incidence of glaucoma in our patients is relatively lower compared to the above studies. we need to counsel the parents, and relatives about the importance of regular examination and follow-up. it will be worthwhile to involve both parents during the course of the treatment of their child, from identification to surgery and follow-ups. the pediatric unit should have trained staff with childfriendly attitude for greater acceptance of the available pediatric ophthalmology services. aphakic glaucoma itself poses a significant diagnostic challenge, as classical manifestations are not always present and children are uncooperative for proper examination. it can be extremely challenging to measure the iop with the child awake and sedation is usually required. in our series we did not see any patient before 2 months of age because of late presentation. fortyseven infants (42.72%) were operated between 2 months and 6 months of age. sixty three patients (57.26%) were operated between 7 months and 30 months. we did not perform posterior capsulotomy and anterior vitrectomy in any of our patients. this could be the reason for the lower incidence of glaucoma in our patients. michaelides and co workers17 have reported a marked increase in risk of aphakic glaucoma after bilateral lensectomies at an early age. they have also observed that respecting the posterior capsule may be associated with a lower rate of aphakic glaucoma. the pattern of aphakic glaucoma in our series was bimodal as reported by mills et al2. in our series 4, (3.63%) of our patients developed early-onset glaucoma. two patients developed bilateral whereas two patients developed unilateral pupil block/angle closure glaucoma. the time interval between cataract extraction and development of pupillary block was from 19 days to 67 days’ post operative. in our study, pupil block with secondary angle closure caused the early-onset post-operative aphakic glaucoma. this was due to severe inflammation leading to synechia formation, absence of peripheral iridectomy, and poor pupillary dilatation causing pupil block and raised iop. early-onset glaucoma typically occurs during the first few weeks after surgery and has an abrupt onset. mills and co-workers2 have reported the occurrence of pupillary block glaucoma within the first few months after lensectomy while the open-angle glaucoma type has a delayed onset (average 7.4 years). chen et al 16 however, have not witnessed the bimodal pattern in their patients operated for congenital cataracts. they found the filtration angles open in 94% of their patients. in our series, eyes developing glaucoma in the first few weeks after surgery had closed angles. the open-angle glaucoma occurring in both eyes in three of our patients was delayed for a period from 3 months to 6 years. patients with delayed onset glaucoma (6 eyes) in our series were without any symptoms and were diagnosed on routine examination. in a study conducted by simon et al 4 open angle glaucoma occurred 5.5 years after surgery in children. in other studies1, the onset of glaucoma was delayed up to 12.2 years following cataract surgery in the pediatric age group. in our follow up of 3 years to 14 years, we found a delay of 3 months to 6 years before the patients developed open angle glaucoma. the zia muhammad, et al 207 vol. 35, no. 3, jul – sep, 2019 pakistan journal of ophthalmology incidence of open angle glaucoma increases with longer post operative follow up of these patients. children operated for congenital cataracts have a perpetual risk of developing open angle glaucoma throughout their lives18,19,20. whether an intact posterior capsule and putting an intraocular lens (iol) has a protective role for development of aphakic glaucoma is not clear. although primary posterior capsulectomy and anterior vitrectomy may aid in early visual recovery, and may help reduce the risk pupil block but it also increases the chances of open-angle glaucoma down the line. michel michaelides et al17 found the development of aphakic glaucoma in 100% of their patients who had posterior capsulotomy during lensectomy for pediatric cataracts. rabiah21 also has reported an increased risk of aphakic glaucoma after primary posterior capsulotomy/anterior vitrectomy. papadopoulos et al22 noted a reduced incidence of aphakic glaucoma when the posterior capsulotomy was not performed at the time of primary lens aspiration in children. in a series of 377 eyes who had lensectomy with posterior chamber iols, asrani et al1 found only one patient developing glaucoma. the follow up however, was only 3.9 years. the limitation of our study was that it was performed at a single center. further studies are needed with more patients to determine more generalizable results. the challenges we are facing include; lack of awareness about pediatric cataracts, delay in presentation for surgery, poor access to quality surgical care, and poor follow-ups. in addition, lack of financial resources, inadequate health facilities, and an insufficient number of pediatric ophthalmologists are other major obstacles. conclusion pediatric aphakic glaucoma may be angle-closure type secondary to pupillary block2 which occurs within the first few weeks after surgery. etiology of this type of glaucoma include surgery at an early age, severe inflammatory reaction, poor pupil dilatation, not performing an iridectomy and shallow anterior chamber due to poor wound suturing. post operative open angle glaucoma is unpredictable and can occur months and even years after surgery.1 this form of glaucoma is probably not directly related to the procedure itself and often difficult to manage. references 1. asrani sg, wilensky jt. glaucoma after congenital cataract surgery. ophthalmology, 1995; 102: 863-867. 2. mills md, robb rm. glaucoma following childhood cataract surgery. j pediatric ophthalmology & strabismus, 1994; 31: 355-360. 3. russell-eggitt i, zamiri p. review of aphakic glaucoma after surgery for congenital cataract. j cataract refract surg. 1997; 22: 664–668. 4. simon jw, mehta n, simmons st, catalano ra, lininger ll. glaucoma after paediatric lensectomy ⁄ vitrectomy. ophthalmology, 1991; 98: 670–674. 5. walton ds. pediatric aphakic glaucoma: a study of 65 patients. trans am ophthalmol soc. 1995; 93: 403–420. 6. gelbart ss, hoyt cs, jastrebski g, marg e. long-term visual results in bilateral congenital cataracts. am j ophthalmol. 1982; 93: 615–21. 7. gregg fm, parks mm. stereopsis after congenital monocular cataract extraction. am j ophthalmol. 8. vishwanath m, cheong-leen r, taylor d, russeleggit i, rahi j. is early surgery for congenital cataract a risk factor for glaucoma? br j opthalmol. 2004; 88: 905– 910. 9. johnson cp, keech rv. prevalence of glaucoma after surgery for phpv and infantile cataracts. j pediatr ophthalmo strabismus. 1996; 33 (1): 14-7. 10. beck a, chen t, freedman s. definition, classification, differential diagnosis. in weinreb r, grajwski a, papadopoulos a, grigg j, freedman s, editors. childhood glaucoma: world glaucoma association, consensus series -9. amersterdam, the netherland: kugler publications; ch. 1, p 3. 11. cecilia fenerty, nicola freeman, john grigg. glaucoma following cataract surgery. in weinreb. r, grajewski a, papadopoulos a, grigg j, freedman s. editors. childhood glaucoma: world glaucoma association, consensus series 9, amersterdam, the netherland: kugler publications; 2013. ch. 10: p. 233248. 12. lambert sr, lynn m, drews-botsch c, loupe d, plager da, medow nb, et al. a comparison of grating visual acuity, strabismus and reoperation outcomes among children with aphakia and pseudophakia after unilateral cataract surgery during the first 6 months of life. j aapos. 2001; 5 (2): 70-5. 13. haargaard b, ritz c, oudin a, wohlfahrt j, thygesen j, oslen t. et al. risk of glaucoma after pediatric cataract surgery. invest ophthalmol vis sci. 2008; 49 (5): 1791-6. 14. phelps cd, arafat ni. open-angle glaucoma following surgery for congenital cataracts. arch ophthalmol. 1977; 95: 1985–7. 15. pressman sh, crouch er jr. pediatric aphakic glaucoma. ann ophthalmol. 1983; 15: 568–73. 16. chen tc, walton ds, bhatia ls. aphakic glaucoma after congenital cataract surgery. arch ophthalmol. 2004; 122: 1819–1825. pediatric aphakic glaucoma pakistan journal of ophthalmology vol. 35, no. 3, jul – sep, 2019 208 17. michaelides m, bunce c, adams gg. glaucoma following congenital cataract surgery – the role of early surgery and posterior capsulotomy. bmc ophthalmology, 2007; 7: 13. 18. freedman sf, lynn mj, beck ad, bothun ed, örge fh, lambert sr; infant aphakia treatment study group. glaucoma-related adverse events in the first 5 years after unilateral cataract removal in the infant aphakia treatment study. jama ophthalmol. 2015 aug;133(8):907-14. 19. zhang s, wang j, li y, liu y, he l, xia x. the role of primary intraocular lens implantation in the risk of secondary glaucoma following congenital cataract surgery: a systematic review and meta-analysis. plos one. 2019 apr 1;14(4):e0214684. 20. chen d, gong xh, xie h, zhu xn, li j, zhao ye. the long-term anterior segment configuration after pediatric cataract surgery and the association with secondary glaucoma. sci rep. 2017 feb 21;7:43015. 21. rabiah p. frequency and predictors of glaucoma after pediatric cataract surgery. am j ophthalmol. 2004; 137: 30–37. 22. papadopoulos m, khaw pt. meeting the challenge of glaucoma after paediatric cataract surgery. editorial, eye, 2003; 17: 1–2. author’s affiliation zia muhammad mbbs, mcps, fcps, fics, fellowship in pediatric ophthalmology, university of sydney, australia. prof & head department of ophthalmology, bacha khan medical college, mardan, pakistan. john grigg mbbs (qld) md (syd) franzco fracs professor and head, discipline of ophthalmology, save sight institute, sydney eye hospital campus sydney medical school, the university of sydney, ikramullah mbbs, m.phil (community medicine) prof. and head, department of community medicine, nowshera medical college, nowshera. ihsan ali mbbs. trainee medical officer, department of ophthalmology, mardan medical complex, mardan. author’s contribution zia muhammad data collection, manuscript writing, critical analysis. john grigg manuscript review, critical analysis. ikramullah data analysis, manuscript writing. ihsan ali data analysis, manuscript writing. blindness due to glaucoma ahmad i, khan bs 31 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology original article effect of intravitreal bevacizumab in macular edema caused by branch retinal vein occlusion imran ahmad, mubashir rehman, mir ali shah, irfan aslam khattak pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mubashir rehman mbbs, fcps, assistant professor, department of ophthalmology, nowshera medical college/qazi hussain ahmad medical complex, nowshera. email: drmubashirrehman78@gmail.com …..……………………….. purpose: to evaluate the effect of intra-vitreal bevacizumab in macular edema caused by branch retinal vein occlusion. study design: interrupted time series study. place and duration of study: department of ophthalmology hayatabad medical complex, peshawar and department of ophthalmology lady reading hospital peshawar from 1 st july 2016 to 31 st december 2016. material and methods: there were 60 patients included in the study. all patients with macular edema due to brvo visible clinically and evident on sdoct and visual acuity of less than 6/9 were included in the study. patients who used other intra-vitreal drug for macular edema, those with surgery in the same eye and those with macular laser for macular edema were excluded from the study. all patients were given intra-vitreal 0.05 ml bevacizumab injection every month for 6 months. after 6 months oct was repeated. at each monthly visit va was measured and fundoscopy was done. follow up of all patients was at six months. results: our study included 60 patients with mean age of 54.42 ± 9.19 years. the mean baseline central macular thickness was 427.06 µ with sd ± 63.54 µ. after 6 months significant improvement in visual acuity was documented. also marked reduction in central macular thickness was noted after six months with mean of 327.44 µ with sd ± 55.55 µ. conclusion: intra-vitreal bevacizumab is an effective treatment for macular edema caused by brvo in terms of both anatomic and visual improvement. key words: branch retinal vein occlusion, bevacizumab, macular edema. ranch retinal vein occlusion is not an uncommon condition that occurs in patients with underlying systemic illness like arteriosclerosis and hypertension. it is the second most common cause of macular edema after diabetes1. brvo is caused by focal occlusion of a retinal vein usually at an arteriovenous crossing, where, mostly, the artery is passing superficial to the vein2. narrowing of vascular lumen results in alteration in laminar blood flow and endothelial damage. the prevalence of brvo is 4.42 per 1,000 and accounts for about 80% of retinal venous occlusions3. the main cause of visual impairment in brvo is macular edema4. the exact pathogenesis of macular edema in patients with brvo is not clearly understood, but multiple factors are supposed to be responsible for this, including increased hydrostatic venous pressure, abnormalities in endothelium tight junction, increased concentration of inflammatory cytokines, and vascular permeability factors5. different studies have shown that in eyes with brvo there is a significantly elevated level of vascular endothelial growth factor (vegf) which is considered to be the major contributor to macular edema. the severity of b effect of intravitreal bevacizumab in macular edema caused by branch retinal vein occlusion pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 32 macular edema in brvo is directly related with an increase in vegf levels6. on the basis of these findings, inhibition of vegf is considered to be a more scientific approach in treating patients with macular edema due to brvo. bevacizumab (avastin, genentech; roche, basil, switzerland) is a full-length, humanized, recombinant antibody that binds to all isoforms of vegf-a and has been used extensively off-label to treat macular edema associated with brvo. different studies have shown that intra-vitreal bevacizumab reduces macular thickness and improves visual acuity in brvo7,8. literature search has demonstrated the efficacy of ranibizumab on macular edema due to brvo but very limited data is available for bevacizumab. purpose of our study was to find out the efficacy of bevacizumab in the treatment of macular edema caused by brvo. material and methods a total of sixty patients were included in our study. all the patients were screened following the inclusion criteria which included macular edema due to brvo visible clinically through indirect ophthalmoscopy through slit lamp and 78 d lens, macular edema of more than 250 µ measured on spectral domain optical coherence tomography and visual acuity of less than 6/9 on snellen visual acuity chart. patients who had previous history of other intra-vitreal drug injection for macular edema, those with history of surgery in the same eye, history of scatter or macular laser for edema and patients with other macular diseases like age related macular degeneration were excluded from the study. all the patients underwent detailed ocular examination including visual acuity, anterior segment examination, dilated fundus examination and measurement of intra ocular pressure. sd-oct was performed at baseline to measure the amount of macular edema and fundus fluorescein angiography was performed to check the macular perfusion. all the patients were given intravitreal 0.05 ml (1.25 mg) bevacizumab injection using 30 gauge needle in the operation theater under sterile conditions using topical anesthesia. povidone-iodine 5% solution was used to clean the periocular region. injections were given monthly for the first 6 months. after 6 months oct was repeated to check for macular thickness, if macular thickness was more than 250 µ, the injections were continued. at each monthly visit va was measured and fundoscopy was done. all patients were followed for at least six months. effectiveness was determined in terms of improvement in visual acuity of at least two lines on snellen visual acuity chart from baseline visual acuity and decrease in macular thickness on sd-oct of 200 microns from baseline macular thickness after 6 months. data analysis was done using spss version 20.0. quantitative variables include age, central macular thickness and visual acuity; and qualitative variables include gender. mean ± standard deviation was calculated for quantitative variables; percentage and proportion was calculated for qualitative variables. results a total of sixty patients were included in our study with age ranges from 42 years to 78 years with mean age of 54.42 ± 9.19 years. table 1 shows age distribution of patients. table 1: age distribution. age frequency percentage 41 – 50 years 12 20.00% 51 – 60 years 22 36.67% 61 – 70 years 18 30.00% 71 – 80 years 8 13.33% total 60 100% mean age was 54.42 years with sd ± 9.19 gender distribution among patients was analyzed as 38 (63.33%) patients were male while 22 (36.67%) patients were female. all the patients received intravitreal injections of 0.05ml (1.25 mg) of bevacizumab monthly injections. table 2 and table 3 shows baseline visual acuity and central macular thickness respectively. table 2: base line va (n = 60 eyes). base line va frequency percentage < 6/36 4 6.66 6/36 – 6/18 31 51.67% 6/24 – 6/12 13 21.67% 6/18 – 6/9 12 20.00% total 60 100% imran ahmad, et al 33 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology table 3: base line oct (n = 60 eyes). base line oct frequency total > 500 µ 6 10.00% 400 – 500 µ 32 53.34% 300 – 400 µ 18 30.00% 200 – 300 µ 4 6.66% total 60 100% mean baseline oct was 427.06 µ with sd ± 63.54µ after 6 months significant improvement in visual acuity was documented (table 4). similarly central macular thickness also reduced (table 5). table 4: va at 6 months (n = 60 eyes). va at 6 months frequency total < 6/36 2 3.34% 6/36 – 6/18 10 16.66% 6/18 – 6/12 16 26.66% 6/12 – 6/9 32 53.34% total 60 100% table 5: oct at 6 months (n = 60 eyes). oct at 6 months frequency total >500 µ 2 3.33% 400 – 500 µ 12 20.00% 300 – 400 µ 38 63.33% 200 – 300 µ 8 13.34% total 60 100% mean oct 6 months was 327.44µ with sd ± 55.55µ efficacy of intra-vitreal bevacizumab in causing improvement in va was analyzed as bevacizumab was effective in 49 (81.67%) patients and efficacy of intra-vitreal bevacizumab in causing reduction in macular thickness was analyzed as bevacizumab was effective in 42 (70.00%) patients (table 6 and table 7). table 6: efficacy regarding va (n = 60 eyes). efficacy frequency percentage yes 49 81.67% no 11 18.33% total 60 100% the mean number of intra-vitreal injections required per 6 months were 3.87 ± 0.54 whereas the retreatment rate of intravitreal bevacizumab after first 3 injections was 24.6%. table 7: efficacy regarding oct (n = 60 eyes). efficacy frequency percentage yes 42 70.00% no 18 30.00% total 60 100% discussion different studies have reported that repeated intravitreal anti-vascular endothelial growth factor treatments are associated with significant improvements at six months, and no significant safety concerns relating to the drug were identified in this time. our study also showed that the first intra-vitreal injection of bevacizumab was associated with significant improvement visually and anatomically. the mean improvement was 0.24 after first injection with a further improvement of 0.30 after 6 months. in the branch retinal vein occlusion (brvo) study, six monthly intraocular injections of 0.3 mg or 0.5 mg of ranibizumab provided rapid anatomic and visual improvements in patients with brvo9,10. ranibizumab or bevacizumab for macular edema secondary to brvo may have similar efficacy for improving the va. branch retinal vein occlusion is associated with decreased perfusion of retinal cells resulting in hypoxia. this hypoxia causes increased release of vegf, which increases vascular permeability resulting in vascular leakage. intra-vitreal bevacizumab is a vascular endothelial growth factor inhibitor which causes a rapid improvement in macular edema but repeated injections are usually required to maintain this effect11,12. the transient nature of the effect of bevacizumab may be explained by the short intravitreal half-life of 1.25 mg (approximately 3 days), resulting in a rapid reduction in the intra-ocular concentration of the drug11. several studies have suggested that in ischemic brvo the amount of nonperfused areas are associated with the severity of macular edema. noma et al. reported in their study that there is a positive correlation between the amount of macular edema measured on oct and nonperfused area size13,14. significant improvements in macular edema secondary to brvo have been reported after intra-vitreal bevacizumab injections15. bevacizumab may not require monthly injections to effect of intravitreal bevacizumab in macular edema caused by branch retinal vein occlusion pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 34 gain an optimal therapeutic response. an early report of intra-vitreal anti-vegf agents in animal models suggested that bevacizumab has a longer intra-vitreal half-life than ranibizumab. in rabbits, the vitreous half-life of ranibizumab is 2.88 days while it is 4.32 days for bevacizumab16,17. although there is no clinical evidence that patients receiving bevacizumab for retinal disease require less frequent injections than patients receiving ranibizumab, epstein and coworkers23 achieved the same visual improvement in response to intra-vitreal bevacizumab injections administered every 6 weeks for central retinal vein occlusion as that obtained after ranibizumab administered every 4 weeks in the treatment of macular edema after central retinal vein occlusion18-20. conclusion intra-vitreal bevacizumab is an effective treatment for macular edema caused by brvo in terms of both anatomic and visual improvement. author’s affiliations dr. imran ahmad mbbs, fico, fcps, assistant professor, department of ophthalmology, gajju khan medical college/bacha khan medical complex, swabi. dr. mubashir rehman mbbs, fcps. assistant professor, department of ophthalmology, nowshera medical college/qazi hussain ahmad medical complex, nowshera. prof. mir ali shah mbbs, fcps. associate professor, department of ophthalmology, postgraduate medical institute, lady reading hospital peshawar. dr. irfan aslam khattak mbbs, fcps. vitreo-retina trainee, department of ophthalmology, hayat abad medical complex, peshawar. author’s contribution dr. imran ahmad patient’s selection, data collection, results and discussion dr. mubashir rehman patient’s selection, data collection, results and discussion prof. mir ali shah patient’s selection, data collection, results and discussion dr. irfan aslam khattak literature search refrences 1. klein r, moss se, meuer sm, klein be. the 15-year cumulative incidence of retinal vein occlusion: the beaverdam eye study. arch ophthalmol. 2008; 126: 513-8. 2. wu l, arevalo jf, roca ja, maia m, berrocal mh, rodriguez fj, evans t, costa ra, cardillo j. comparison of two doses of intravitreal bevacizumab (avastin) for treatment of macular edema secondary to branch retinal vein occlusion: results from the panamerican collaborative retina study group at 6 months of follow-up. retina. 2008; 28: 212–9. 3. rehak j, rehak m. branch retinal vein occlusion: pathogenesis, visual prognosis, and treatment modalities. curr eye res. 2008; 33: 111-31. 4. rogers s, mcintosh rl, cheung n, et al. the prevalence of retinal vein occlusion: pooled data from population studies from the united states, europe, asia, and australia. ophthalmology, 2010; 117: 313-9. 5. campochiaro pa, hafiz g, shah sm, et al. ranibizumab for macular edema due to retinal vein occlusions: implication of vegf as a critical stimulator. mol ther. 2008; 16: 791-9. 6. noma h, funatsu h, yamasaki m, et al. aqueous humour levels of cytokines are correlated to vitreous levels and severity of macular oedema in branch retinal vein occlusion. eye (lond), 2008; 22: 42-8. 7. yilmaz t, cordero-coma m. use of bevacizumab for macular edema secondary to branch retinal vein occlusion: a systematic review. graefes arch clin exp ophthalmol. 2012; 250: 787-93. 8. ehlers jp, decroos fc, fekrat s. intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion. retina. 2011; 31: 1856-62. 9. brown dm, campochiaro pa, bhisitkul rb, et al. sustained benefits from ranibizumab for macular edema following branch retinal vein occlusion: 12-month outcomes of a phase iii study. ophthalmology, 2011; 118: 1594–602. 10. chen ch, chen yh, wu pc, chen yj, lee jj,liu yc &kuo hk. treatment of branch retinal vein occlusion induced macularedema in treatment-naive cases with a single intravitreal triamcinolone or bevacizumab injection. chang gung med j. 2010; 33: 424-35. 11. beer pm, wong sj, hammad am, falk ns,o’malley mr & khan s. vitreous levels of unbound https://www.ncbi.nlm.nih.gov/pubmed/?term=wu%20l%5bauthor%5d&cauthor=true&cauthor_uid=18301025 https://www.ncbi.nlm.nih.gov/pubmed/?term=arevalo%20jf%5bauthor%5d&cauthor=true&cauthor_uid=18301025 https://www.ncbi.nlm.nih.gov/pubmed/?term=roca%20ja%5bauthor%5d&cauthor=true&cauthor_uid=18301025 https://www.ncbi.nlm.nih.gov/pubmed/?term=maia%20m%5bauthor%5d&cauthor=true&cauthor_uid=18301025 https://www.ncbi.nlm.nih.gov/pubmed/?term=berrocal%20mh%5bauthor%5d&cauthor=true&cauthor_uid=18301025 https://www.ncbi.nlm.nih.gov/pubmed/?term=rodriguez%20fj%5bauthor%5d&cauthor=true&cauthor_uid=18301025 https://www.ncbi.nlm.nih.gov/pubmed/?term=evans%20t%5bauthor%5d&cauthor=true&cauthor_uid=18301025 https://www.ncbi.nlm.nih.gov/pubmed/?term=costa%20ra%5bauthor%5d&cauthor=true&cauthor_uid=18301025 https://www.ncbi.nlm.nih.gov/pubmed/?term=cardillo%20j%5bauthor%5d&cauthor=true&cauthor_uid=18301025 https://www.ncbi.nlm.nih.gov/pubmed/20804672 imran ahmad, et al 35 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology bevacizumab and unbound vascular endothelial growth factor in two patients. retina. 2006; 26: 871-6. 12. noma h, funatsu h, mimura t & shimada k. influence of ischaemia on visual function in patients with branch retinal vein occlusion and macular edema. clin ophthalmol. 2011; 5: 679–685. 13. donati s, barosl p, bianchi m, et al. combined intravitreal bevacizumab and grid laser photocoagulation for macular edema secondary to branch retinal vein occlusion. eur j ophthalmol. 2012; 22: 607–14. 14. bakri sj, snyder mr, reid jm, et al. pharmacokinetics of intravitreal ranibizumab (lucentis). ophthalmology, 2007; 114: 2179–82. 15. brown dm, campochiaro pa, signh rp, et al. the cruise investigators ranibizumab for macular edema following central retinal vein occlusion: six-month primary end point results of a phase iii study. ophthalmology, 2010; 117: 1124–33. 16. hayreh ss, zimmerman mb. branch retinal vein occlusion: natural history of visual outcome. jama ophthalmol. 2014; 132: 13-22. 17. rogers sl, mcintosh rl, lim l, mitchell p, cheung n, kowalski jw, nguyen hp, wang jj, wong ty. natural history of branch retinal vein occlusion: an evidencebased systematic review. ophthalmology, 2010; 117: 1094-1101. 18. liu h, li s, zhang z, shen j. predicting the visual acuity for retinal vein occlusion after ranibizumab therapy with an original ranking for macular microstructure. exp ther med. 2018; 15: 890-896. 19. mitry d, bunce c, charteris d. anti-vascular endothelial growth factor for macular oedema secondary to branch retinal vein occlusion. cochrane database syst rev. 2013; 31: 951-957. 20. ivanovska adjievska b, boskurt s, orovcanec n, dimovska-jordanova v. the outcome of low-frequency intravitreal bevacizumab therapy for macular edema in retinal vein occlusions. clin ophthalmol. 2017; 11: 11831190. https://www.ncbi.nlm.nih.gov/pubmed/17031285 https://www.ncbi.nlm.nih.gov/pubmed/24158729 https://www.ncbi.nlm.nih.gov/pubmed/24158729 https://www.ncbi.nlm.nih.gov/pubmed/24158729 https://www.ncbi.nlm.nih.gov/pubmed/?term=rogers%20sl%5bauthor%5d&cauthor=true&cauthor_uid=20430447 https://www.ncbi.nlm.nih.gov/pubmed/?term=mcintosh%20rl%5bauthor%5d&cauthor=true&cauthor_uid=20430447 https://www.ncbi.nlm.nih.gov/pubmed/?term=lim%20l%5bauthor%5d&cauthor=true&cauthor_uid=20430447 https://www.ncbi.nlm.nih.gov/pubmed/?term=mitchell%20p%5bauthor%5d&cauthor=true&cauthor_uid=20430447 https://www.ncbi.nlm.nih.gov/pubmed/?term=cheung%20n%5bauthor%5d&cauthor=true&cauthor_uid=20430447 https://www.ncbi.nlm.nih.gov/pubmed/?term=kowalski%20jw%5bauthor%5d&cauthor=true&cauthor_uid=20430447 https://www.ncbi.nlm.nih.gov/pubmed/?term=nguyen%20hp%5bauthor%5d&cauthor=true&cauthor_uid=20430447 https://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20jj%5bauthor%5d&cauthor=true&cauthor_uid=20430447 https://www.ncbi.nlm.nih.gov/pubmed/?term=wong%20ty%5bauthor%5d&cauthor=true&cauthor_uid=20430447 https://www.ncbi.nlm.nih.gov/pubmed/20430447 https://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20h%5bauthor%5d&cauthor=true&cauthor_uid=29399095 https://www.ncbi.nlm.nih.gov/pubmed/?term=li%20s%5bauthor%5d&cauthor=true&cauthor_uid=29399095 https://www.ncbi.nlm.nih.gov/pubmed/?term=zhang%20z%5bauthor%5d&cauthor=true&cauthor_uid=29399095 https://www.ncbi.nlm.nih.gov/pubmed/?term=shen%20j%5bauthor%5d&cauthor=true&cauthor_uid=29399095 https://www.ncbi.nlm.nih.gov/pubmed/29399095 https://www.ncbi.nlm.nih.gov/pubmed/?term=mitry%20d%5bauthor%5d&cauthor=true&cauthor_uid=23440840 https://www.ncbi.nlm.nih.gov/pubmed/?term=bunce%20c%5bauthor%5d&cauthor=true&cauthor_uid=23440840 https://www.ncbi.nlm.nih.gov/pubmed/?term=charteris%20d%5bauthor%5d&cauthor=true&cauthor_uid=23440840 https://www.ncbi.nlm.nih.gov/pubmed/23440840 https://www.ncbi.nlm.nih.gov/pubmed/23440840 https://www.ncbi.nlm.nih.gov/pubmed/23440840 https://www.ncbi.nlm.nih.gov/pubmed/?term=ivanovska%20adjievska%20b%5bauthor%5d&cauthor=true&cauthor_uid=28790803 https://www.ncbi.nlm.nih.gov/pubmed/?term=boskurt%20s%5bauthor%5d&cauthor=true&cauthor_uid=28790803 https://www.ncbi.nlm.nih.gov/pubmed/?term=orovcanec%20n%5bauthor%5d&cauthor=true&cauthor_uid=28790803 https://www.ncbi.nlm.nih.gov/pubmed/?term=dimovska-jordanova%20v%5bauthor%5d&cauthor=true&cauthor_uid=28790803 https://www.ncbi.nlm.nih.gov/pubmed/28790803 microsoft word abstracts vol. 23,4, 07.doc 234 abstracts edited by dr. tahir mahmood intravitreal triamcinolone acetonide for diffuse diabetic macular edema: phase 2 trial comparing 4 mg vs 2 mg audren f, lecleire-collet a, erginay a, haouchine b, sman rb, bergmann j, gaudric a, massin p am j ophthalmol 2006; 142: 794-9. macular edema remains a major cause of visual impairment in diabetic patients. intravitreal triamcinolone acetonide (ta) has been proposed as an alternative treatment for eyes with diabetic macular edema (dme) refractory to laser photocoagulation, and there is growing evidence that it effectively reduces macular thickness and improves visual acuity (va) in dme. in previous studies of the effects of triamcinolone on dme, various doses of ta were used. the most frequent is 4 mg, chosen empirically, because it constitutes 0.1 ml of the commercially available 40-mg ta formula. so far, the effects of different doses of intravitreal ta on macular edema have only been compared in one study, the authors of which found a correlation between dose and maximal increase in va, but no difference in the increase of intraocular pressure (iop) between doses. the main objective of this study was to compare the efficacy of the two doses by using central macular thickness (cmt), measured by optical coherence tomography (oct), as the main criterion. the secondary objectives were to compare the side effects of the doses and the duration of their respective effects. this study included thirty-two patients with diabetic macular edema unresponsive to laser photocoagulation. patients were randomly assigned to receive 4 or 2 mg intravitreal ta in one eye (16 patients in each group). the main outcome was central macular thickness (cmt) measured by optical coherence tomography (oct) at four, 12, and 24 weeks. secondary outcomes were gain in early treatment diabetic retinopathy study (etdrs) scores, intraocular pressure (iop), cataract progression, and duration of effect. before injection, mean (± sd) cmt was 564.5 ± 119 µm and 522.9 ± 148.5 µm in the 4and 2-mg groups, respectively. at four, 12, and 24 weeks after injection, it was 275.0 ± 79.8, 271.4 ± 128.7, and 448.7 ± 146.4 µm respectively, in the 4-mg group, and 267.3 ± 82.4, 289.8 ± 111.4, and 394-7 ± 178.9 µm, respectively, in the 2-mg group. at no time was the difference in cmt between both groups statistically significant (p> 0.3). the between-group differences in the gain in the etdrs score and in top were not statistically significant either. diabetic macular edema recurred after a median period of 20 weeks vs 16 weeks in the 4and 2mg groups, respectively (p = 0.11). authors concluded that in the short term, intravitreal injection of 4 or 2 mg ta does not have different effects on cmt, visual acuity, or iop. the treatment of congenital dacryocystocele becker bb am j ophthalmol 2006; 142:835-8. congenital dacryocystocele usually presents as a blue, cystic enlarged lacrimal sac at birth. the lacrimal drainage system is obstructed both proximally at the level of the common canaliculus, and distally at the level of the valve of hasner. the proximal obstruction is functional. fluid is thus trapped within the lacrimal drainage system. dacryocystitis and preseptal cellulitis may develop within days or weeks. the treatment of dacryocystocele is controversial. some physicians have advocated conservative treatment with antibiotics and massage, whereas others have recommended early surgical intervention if there is not a rapid response to conservative therapy or recommended prompt surgical therapy. this study evaluates the findings and results of treatment of patients with dacryocystocele and makes recommenddations derived from this experience. twenty-seven consecutive patients with 29 congenital dacryocystoceles who presented from 1987 through 2006 are included in this study. dacryocystitis and preseptal cellulitis requiring intravenous antibiotic therapy were present in 11 lacrimal systems (37.9%), and dacryocystitis without cellulitis was present in an additional 10 lacrimal systems (34.5%). one or more probing were performed in 26 patients 235 (89.7%). resolution with conservative therapy occurred in three lacrimal systems. the initial probing was successful in seven of seven lacrimal systems (100%) that did not have infection, but was successful in only 10 of 19 lacrimal systems (53%) that had dacryocystitis with or without cellulitis. the mean age of probing in the surgical patients who did not develop infection was 5.9 days, whereas the mean age at first probing in surgical patients who developed infection was 17.3 days. authors concluded with remarks that patients with congenital dacryocystocele should have probing on an urgent basis and as early in life as possible, unless the lacrimal sac decompresses into the nose at the time of the initial examination. this approach will reduce the incidence of dacryocystitis and cellulitis, and improve the success rate of surgery. a control-matched comparison of laser epithelial keratomileusis and laser in situ keratomileusis for low to moderate tobaigy fm, ghanem rc, sayegh rr, hallak ja, azar dt am j ophthalmol 2006; 142:901-8. photorefractive keratectomy (prk) was the most commonly performed surgical procedure until the introduction of laser in situ keratomileusis (lasik) in the mid nineties. while prk is safe and effective, the risk of corneal haze, especially in high myopia, is significant. postoperative pain and slow visual rehabilitation are other limiting factors in prk. lasik has minimal postoperative pain, a faster visual recovery, less regression, and no haze even in high myopia. however, it is not a complication free procedure: flap-related complications (free cap, incomplete flap, irregular flap, button-holes, and lost flaps), interface related complications (epithelial ingrowths, deep lamellar keratitis, and interface debris), flap-related conical biomechanical instability, and iatrogenic keratectasia have been reported. laser epithelial keratomileusis (lasek) may combine the advantages of prk and lasik while avoiding the disadvantages of both. it avoids all of the flap-related complications and reduces the risk of keratectasia associated with lasik. in addition, it has relatively faster recovery periods with slightly less pain and haze than prk. lasek may be considered in patients with low to moderate myopia and myopic astigmatism, thin corneas with no signs of keratoconus, extreme keratometric values (such as steep or flat corneas), deep set eyes and small palpebral fissure, recurrent erosion syndrome, dry eye, glaucoma suspect, a wide scotopic pupil, scleral buckle, and for patients who are more predisposed to trauma, such as military personnel and athletes. the purpose of this study was to compare the visual and refractive outcomes of laser epithelial keratomileusis (lasek) and laser in situ keratomileusis (lasik) for the treatment of low to moderate myopia. the charts of 2257 eyes that underwent lasek or lasik treatment were reviewed. patients who were 21 years of age or older having between -0.75 and -6.00 diopters (d) of myopia with up to -2.25 d of astigmatism were included. one hundred twenty-two lasek-treated eyes were matched with 122 lasiktreated eyes having preoperative spheres, cylinders, and spherical equivalent (se) within ±0.50 d. both groups had similar preoperative best spectaclecorrected visual acuity (bscva), laser platform, and follow-up durations. outcome measures were visual and refractive results. preoperatively, the mean se was -3.50 ± 1.40 d for lasek and -3.50 ± 1.42 d for lasik (p = .59). postoperatively, the mean logarithm of minimum angle of resolution (logmar) uncorrected visual acuity (ucva) was 0.01 ± 0.08 (20/21) for lasek and 0.06 ± 0.12 (20/23) for lasik; the mean se was -0.15 ± 0.40 d for lasek and -0.37 ± 0.45 d for lasik; and the mean logmar of bscva was -0.03 ± 0.06 (20/19) for lasek and -0.02 ± 0.05 (20/19) for lasik. no eye lost 2 or more lines of bscva in both groups. slight differences in the visual and refractive results between lasek and lasik were observed, despite the use of the same nomogram. both procedures were safe, effective, and predictable. nomogram adjustment may be necessary for lasik surgeons adopting surface ablation. retrobulbar haemodynamics in non-arteritic anterior ischaemic optic neuropathy kaup m, plange n, arend ko, remky a br j ophthalmol 2006; 90: 1350-3. the aetiology of non-arteritic anterior ischaemic optic neuropathy (naion) is believed to be multifactorial, resulting in acute hypoperfusion of the short posterior 236 ciliary arteries (pcas). the pathogenic mechanisms encompass various risk factors together with an acute incident of hypoperfusion for example, nocturnal arterial hypotension. several studies investigated circulatory abnormalities in patients with naion. patients with naion showed decreased velocities of blood cells in the capillaries of the optic nerve head measured by laser doppler velocimetry. the retrobulbar haemodynamics of patients with naion have been studied previously by means of colour doppler imaging (cdi). cdi is an ultrasound technique with a simultaneous b-mode image using colour to represent intravascular movement on the basis of doppler frequency shifts. blood-flow velocities of the ophthalmic artery, the central retinal artery (cra) and the short posterior ciliary arteries (pcas) can be measured using cdi. a previously published study evaluated the peak-systolic velocities (psvs) and gosling’s pulsatility indices of retrobulbar vessels in naion before and after optic nerve sheath decompression. preoperatively, eyes with naion showed considerably lower psvs in the cra and the pcas than the remarkable increase in blood flow velocities in the ophthalmic artery and cra, and a marked decrease in vascular resistance in the pcas. the purpose of this study was to compare retrobulbar haemodynamics in patients with acute non-arteritic anterior ischaemic optic neuropathy (naion) and age-matched controls by colour doppler imaging (cdi). 25 patients with acute naion and 35 agematched controls participated in this study. by means of cdi, the blood flow velocities of the ophthalmic artery, central retinal artery (cra), and nasal and temporal short posterior ciliary arteries (pcas) were measured. peak-systolic velocity (psv) and enddiastolic velocity (edv) and pourcelot’s resistive index were determined. in the ophthalmic artery, no marked differences between patients with naion and controls were detected. psv and edv of the cra (p<0.001, p = 0.002) and psv of the nasal pca (p<0.05) were significantly decreased in patients with naion compared with healthy controls. no marked differences between patients and controls were detectable for temporal pcas. authors concluded that blood flow velocities of the nasal pca and the cra are considerably reduced in patients with acute naion compared with controls. patients with naion in part showed markedly different retrobulbar haemodynamics. influence of tobacco use on cataract development raju p, george v, ramesh s ve, arvind h, baskaran m, vijaya l br j ophthalmol 2006; 90: 1374-7. cataract is the lending cause of blindness and moderate visual impairment worldwide. it has been estimated that developing countries such as india have a large cataract burden, accounting for 44% of blindness. numerous risk factors have been identified for early cataract development: environmental factors such as sunlight or ultraviolet exposure, systemic diseases such as diabetes mellitus, indices of nutrition such as low body mass index, and lifestyle factors such as smoking. although effective treatment options are available to restore vision, identifying risk factors helps establish preventive measures as primary intervention. tobacco use is a major public health problem worldwide and is the leading preventable cause of disease, disability and premature death. it has been reported to be responsible for a considerable amount of morbidity and mortality among middleaged adults. it is estimated that one third of all women and two thirds of men in india use tobacco in some form, such as smoking tobacco in the form of cigarettes, bidis and cheroots, and smokeless tobacco in the form of snuff or chewing tobacco. in south asia, the use of smokeless tobacco is common. the various forms are chewed, sucked, or applied to teeth or gums. the use of unprocessed tobacco, the cheapest form, varies in different parts of india. in tamil nadu, smokeless tobacco is sold as packets of strands and is used alone or along with betel leaf, areca nut and lime. tobacco is also inhaled nasally in powdered form as dry snuff. smoking is reported to be a risk factor for eye diseases such as cataract, age-related macular degeneration and glaucoma. no epidemiological studies have been carried out so far on the effect of smokeless tobacco on the eye. this paper reports the relationship between both use of both forms of tobacco (smoking and smokeless) and cataract in a populationbased sample from rural south india. 3924 subjects from the chennai glaucoma study conducted in rural south india underwent a comprehensive eye examination, including lens opacities classification system ii grading. information 237 on tobacco use, type of tobacco (smoking and smokeless), duration and quantity of use was collected. 1705 (male:female (m:f) 1106:599) people used tobacco and were significantly older (mean (standard deviation (sd)) age 55.80 (10.64) years) than non-users (52.23 (10.51); p<0.001). 731 (m:f 730:1) people smoked, 900 (m:f 302:598) used smokeless tobacco, and 74 (m:f, 74:0) used tobacco in both forms. the unadjusted and adjusted (age and sex) odds ratio (or) for a positive history of tobacco use and cataract was 1.72 (95% confidence interval (cl) 1.51 to 1.96) and 1.39 (95% cl 1.1 5 to 1.68), respectively. the unadjusted or for smokers and smokeless tobacco users was 1.04 (95% cl 0.88 to 1.23) and 2.74 (95% cl 2.31 to 3.26), respectively. the adjusted or was 1.19 (95% cl 0.89 to 1.59) and 1.54 (95% cl 1.22 to 1.95), respectively. no significant association was noted between smoking and any particular type of cataract. smokeless tobacco use was found to be significantly associated with nuclear cataract even after adjusting for age and sex (or 1.67, p = 0.067, 95% cl 1.16 to 2.39). authors concluded with remarks that tobacco use was significantly associated with cataract. smoking was not found to be significantly associated with cataract formation; however, smokeless tobacco use was more strongly associated with cataract. structural and functional assessment of the macular region in patients with glaucoma kanadani fn, hood dc, grippo tm, wangsupadilok b, harizman n, greenstein vc, liebmann jm, ritch r br j ophlhalmol 2006; 90: 1393-7. despite recent technological advances, the diagnosis of glaucoma is still appearance of the optic disc. some have suggested that in seeking early diagnosis of glaucomatous damage, it might be advantageous to assess the tissue loss in the perifoveal or macular region. support for this comes from primate models of glaucoma, where considerable loss of retinal ganglion cells (rgc) occurs in the perifoveal region. the macular region is rich in rgc bodies and undergoes thinning in glaucoma. whereas rgcs cannot yet be counted directly in vivo in humans, retinal thickness can be measured with many different techniques. loss of retinal thickness can be used as a surrogate measure for the loss of rgc bodies and nerve fibre loss, as these layers contribute up to 40% of the entire retinal thickness in normal eyes. macular retinal thickness, as measured by optical coherence tomography (oct), can detect glaucomatous damage and corresponds with peripapillary nerve fibre layer (nfl) thickness, a measure of rgc axons as well as glial cells. thus, the question arises as to how this structural measure (macular thickness) of glaucomatous damage compares with functional measures of macular function. this study compare oct measures with two functional measures: the visual fields obtained with standard automated perimetry and the topographical information provided by the multifocal visual evoked potential (mfvep). with the mfvep technique, many (typically 60) responses, each associated with a local region of the visual field (or retina), are recorded simultaneously. compared with other electrophysiological tests of visual function, the mfvep has the advantage of producing a topographical measure of glaucomatous damage. thus, mfvep results can be compared with visual fields obtained with standard automated perimetry, as well as with structural measures. the purpose of this study was to investigate the correlation of a structural measure of the macular area (optical coherence tomography (oct)) with two functional measures (10-2 humphrey visual field (hvf) and multifocal visual evoked potential (mfvep)) of macular function. 55 eyes with open-angle glaucoma were enrolled. the 10-2 hvf was defined as abnormal if clusters of ≥3 points with p<5%, one of which had p<l%, were present. the mfvep was abnormal if probability plots had ≥2 adjacent points with p< 1 %, or ≥3 adjacent points with p<5% and at least one of these points with p< 1 %. two criteria were used for the macular oct: (i) ≥2 sectors with p<5% or 1 sector with p<l% and (ii) 1 sector with p<5%. 54 of the 55 eyes showed an abnormal 10-2 hvf and 50 had central mfvep defects. the two oct criteria resulted in sensitivities of 85% and 91%. when both functional tests showed a defect (in 49 eyes), the oct was abnormal in 45. for the oct the outer and inner inferior regions were the most likely to be abnormal, and both functional techniques were most abnormal in the superior hemifield. authors concluded with the remarks that good agreement exists between macular thickness and functional defects in patients with glaucoma. study of 238 the macular region may provide a quantitative measure for disease staging and monitoring. peripapillary fundus perimetry in eyes with glaucoma convenfo e, midena e, dorigo mt, maritan v, cavarzeran f, fregona ia br j ophthalmol 2006; 90: 1398-1 403 glaucoma is an optic neuropathy characterized by a specific and progressive injury to the optic nerve head (onh) and retinal nerve fibre layer (rnfl), resulting in progressive loss of vision. early detection and prevention of rnfl glaucomatous damage is mandatory, because injury to the rnfl is largely irreversible. the diagnosis of glaucoma is based on the appearance of the onh and standard achromatic automated perimetry, but damage to the rnfl has been shown to precede visual field loss. it has been shown that 30-50% of retinal ganglion cells may be lost before an abnormality appears on standard automated perimetry. therefore, morphological and functional evaluation of rnfl is essential in detecting and monitoring glaucoma. onh and rnfl morphometry is carried out using different approaches, mainly optical coherence tomography. many different functional tests (short-wavelength automated perimetry, frequency-doubling technology perimetry) have also been proposed with controversial results. fundus perimetry, or microperimetry, is a functional test that quantifies differential light threshold (dlt) at selected areas, chosen by the examiner, under realtime fundus control. fundus perimetry data are independent of eye movements, and exactly related to the stimulated areas. the aim of this study was to evaluate whether peripapillary fundus perimetry is modified in eyes with glaucoma and ocular hypertension (oht), and to compare the functional data and morphological information obtained by peripapillary optical coherence tomography (oct). 35 glaucomatous, 29 oht and 24 control eyes were included. peripapillary dlt at 1° from the optic nerve head was quantified with fundus perimetry; peripapillary rnfl thickness was measured over the same area by optical coherence tomography. mean (sd) peripapillary dlt was 19.2 (1.7), 17.6 (4.2) and 10.1 (6.9) db in control, oht and glaucomatous eyes, respectively (p<0.001). mean (sd) rnfl thickness was 98.4 (35.3), 83.9 (35.1) and 55.8 (28.2) µm, respectively (p<0.001). mean peripapillary dlt showed higher sensitivity and specificity in differentiating the three groups compared with rnfl thickness. authors concluded that progressive, significant reduction of peripapillary dlt was documented in oht and glaucomatous eyes compared with controls (p<0.001). dlt reduction parallels rnfl reduction. detection of glaucoma using operator-dependent versus operator-independent classification in the heidelberg retinal tomograph-ill harizman n, zelefsky jr, ilitchev e, tello c, ritch r, liebmann jm br j ophthalmol 2006; 90: 1390-2. primary open-angle glaucoma is a leading cause of blindness worldwide. glaucomatous changes to the optic nerve head and retinal nerve fiber layer (rxfl) loss often precede achromatic visual field defects, which may become manifest only after a large percentage of retinal ganglion cells have been damaged. as such, early disease detection may be important in disease management strategies. confocal scanning laser ophthalmoscopy has become an important tool for detecting structural damage of the optic nerve head and rnfl, and may assist in early glaucoma detection. there seem to be important racial differences between people of african and european ancestry regarding optic disc configuration and neuroretinal rim area. given these variations, questions exist as to whether the current heidelberg retinal tomograph (hrt)-ii database of people of european ancestry can be applied to other racial groups. heidelberg retinal tomography (heidelberg engineering, gmbh, dossenheim, germany) uses confocal scanning laser technology to calculate topographic measurements of the optic nerve and parapapillary rnfl. one method of the hrt-ii software analysis, moorfields regression analysis (mra), uses an algorithm to compare measured optic nerve parameters with those from a normative database. although there is good reproducibility of hrt measurements, a major limitation of this device is the need for an operator to draw a contour line at the border of the optic disc. this can result in variability in measurements between different observers. the hrtii uses a normative database consisting of 349 normal 239 eyes of white people, whereas hrt-iii uses an enlarged race-specific database, consisting of eyes of 733 white and 215 black people. the purpose of this study was to compare the abilities of a new glaucoma probability scoring (gps) system and moorfields regression analysis (mra) to differentiate between glaucomatous and normal eyes using heidelberg retinal tomograph (hrt)-iii software and race-specific databases. in this prospective study, one eye (refractive error < 5 d) each of consecutive normal patients and those with glaucoma was enrolled. all patients underwent a full eye examination, standard achromatic perimetry (swedish interactive threshold algorithm-standard automated perimetry (sita-sap), program 24-2) and confocal scanning laser ophthalmoscopy (hrt-ii) within 1 month. normal patients had two normal visual fields in both eyes (pattern standard deviation (psd) >5% and glaucoma hemifield test within 97% normal limits) and a normal clinical examination. glaucoma was defined on the basis of sita-sap visual field loss (psd<5% or glaucoma hemifield test outside normal limits) on two consecutive visual fields. hrt-ii examinations were exported to the hrt-iii software (v.3.0), which uses an enlarged racespecific database, consisting of 733 eyes of white people and 215 eyes of black people. race-adjusted mra for the most abnormal sector (operatordependent contour line placement) was compared with the global race-adjusted gps (operator independent). mra sectors outside the 99.9% confidence interval limits (outside normal limits) and gps 3≥0.64 were considered abnormal. 136 normal patients (72 black and 64 white patients) and 84 patients with glaucoma (52 black and 32 white patients) were enrolled (mean age 50.4 (sd 14.4) years). the average visual field mean deviation was -0.4 (sd 1.1) db for the normal group and -7.3 (sd 6.7) db for the glaucoma group (p<0.001). mean gps values were 0.21 (sd 0.23) and 0.73 (sd 0.27) for normal and glaucomatous eyes, respectively (p<0.001). sensitivity and specificity values were 77.1% and 90.3% for gps, and 71.4% and 91.9% for mra, respectively. in this cohort, gps software sensitivity and specificity values are similar to those of mra, which requires placement of an operator-dependent contour line. the development of software to detect glaucoma without a contour line is critical to improving the potential use of hrt as a tool for glaucoma detection and screening. pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 95 original article efficacy of emla cream in pain reduction during botulinum toxin injections for facial dystonias muhammad moin, abdullah irfan pak j ophthalmol 2019, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. abdullah irfan pg trainee ophthalmology, lahore general hospital, lahore. email: abd_irfan@yahoo.com …..……………………….. purpose: to determine the efficacy of emla cream (eutectic mixture of local anesthetics) in pain reduction while injecting botulinum toxin in patients with hemifacial spasm and blepharospasm. study design: quasi experimental study. place & duration of study: yaqin vision eye center from january 2015 to december, 2018. material & methods: patients undergoing routine treatment of blepharospasm and hemifacial spasm since 2010 were offered pre-injection emla cream application to reduce the pain during injections. a total of 74 botulinum a toxin injections were given for blepharospam and hemifacial spasm, half of which were administered without the use of any topical analgesia while other half were given to same patient on next visit using emla cream 15 minutes prior to injection. pain was assessed as mild, moderate and severe in all the patients by the consultant administering the medication. results: among 37 cases of facial dystonias, 17 (45.9%) were males and 20 (54.1%) were females. it was observed that when emla was not used, severe pain was observed during 8 injections (21.6%), moderate pain in 17 (45.9%), and mild pain in 12 (32.4%) sessions. however when emla was used mild pain was observed during 33 (89.2%) injections, moderate pain in 3 injections and severe pain in 1 (2.7%) case. there was a statistically significant difference in pain control during the sessions involving use of emla. conclusion: use of topical emla cream dramatically reduces the pain and makes the administration of botulinum toxin a injection easier in patients with hemifacial spasm and blepharospasm. keywords: topical anesthetia, blepharospasm, hemifacial spasm, botulinum toxin. acial dystonias is a disease which causes significant disability to the patient as it progresses over time. the time tested and most reliable therapy for hemifacial and blepharospasm is repeated botulinum toxin (botox, allergan) injection given subcutaneously. it is also very effective in the reduction of deep creases and wrinkles formed by weakening of the facial muscles with age1. the treatment requires injection of botulinum toxin just beneath the skin so that it can diffuse to the targeted facial muscles. although the injection is given with a 30 gauge needle the patients can feel varying degree of pain and anxiety while receiving this treatment in the very sensitive periocular region2. an effective alternate method to avoid this pain and discomfort is by using eutectic mixture of local anaesthetics. f abdullah irfan, et al 96 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology emla cream is available as an emulsion which is a eutectic mixture containing 2.5% prilocaine and 2.5% lidocaine established to numb the skin surface. both the drugs which anesthetise the skin have been mixed in such a way that the cream does not melt at room temperature and the ingredients are present as liquid oil instead of crystals. indications of emla cream include topical pain relief for needle pricks, especially in children, and minor surgery involving superficial skin. the depth of anaesthesia is proportional to the duration of application of the cream on the skin. skin is anesthetised 1-2 mm after 60 minutes of application while after 3-4 hours the depth of anaesthesia increases to 6 mm3,4. for minor surgical procedures involving needle insertion the recommended concentration of emla cream is the most effective and safe agent which can anesthetise the skin5 (including blood testing, intravenous cannulation, lumbar puncture and botulinum a toxin injections). it is also very useful for minor procedures used in dermatology such as removal of warts, biopsy of skin and laser treatment6. adequate anaesthesia of skin is attained after the cream has been applied for 1 hour. it reaches its peak in 2-3 hours and remains present for 1-2 hours after the cream has been removed. the rationale of our study was to find an effective drug to relieve pain in patients receiving botulinum toxin injections for the treatment of facial dystonias. review of literature shows studies on this topic but no local literature was found. the purpose of the study was to determine the usefulness of emla cream (eutectic mixture of local anesthetics) in pain reduction while injecting botulinum toxin in patients with hemifacial spasm and blepharospasm. material & methods the study was conducted at yaqin vision center, lahore from jan 2015 to dec 2018 as a quasi experimental study. ethical approval of the study was taken from the ethical review committee of lahore general hospital, lahore. patients included in the study were > 25 years of age of both genders who presented with hemifacial spasm and essential blepharospasm. only those patients were selected who had already undergone botulinum toxin a injection (botox, allergan) without use of emla cream previously, as it was not readily available before. patients who were excluded from the study had blepharospasm due to secondary reasons such as drugs, ophthalmic and neurological conditions. intracranial pathology was ruled out in all patients before start of treatment using computed tomography or magnetic resonance imaging. patients undergoing routine treatment of blepharospasm and hemifacial spasm since 2010 were offered pre-injection emla cream application to reduce the pain during injections. the sample size (n) was calculated by 95% confidence level, with anticipated population proportion (p) 74% and keeping absolute precision (d) 10%. a total of 74 botulinum a toxin injections were given for routine treatment of blepharospam and hemifacial spasm, half of which were administered without the use of any topical analgesia while other half were offered emla cream treatment prior to injection. the cream was applied for 15 minutes before the procedure. each botox injection was carefully administrated in the area where emla cream was applied. we used botulinum toxin-a 100 units (botox, allergan) diluted in 2 ml normal saline. the injections were given using a 1 ml insulin syringe, with a 30g needle (microlance 30g × ¾ 0.4 × 19 mm). pain was assessed as mild, moderate and severe without and later with emla cream application by the consultant administering the medication. pain grading was modified from the visual analog scale which is a reliable tool used worldwide7. data entry and analysis was done using spss statistics for windows package, version 25.0 (ibm, usa). categorical variables such as pain scoring was analysed using the chi square test. the study reported on the effects of emla with regard to the mean difference in pain between the group that received emla for botox injection and the control group with no intervention previously. results among 37 cases of facial dystonias, 17 (45.9%) were males and 20 (54.1%) were females with a male to female ratio of 1:1.8 (table 1). table 1: comparison of gender distribution between groups. gender use of emla total not used used male 17 17 34 45.9% 45.9% 45.9% efficacy of emla cream in pain reduction during botulinum toxin injections for facial dystonias pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 97 female 20 20 40 54.1% 54.1% 54.1% total 37 37 74 100.0% 100.0% 100.0% categorizing the patients into three age groups revealed that majority of the patients 81.1% (60 patients) were above 45 years of age (table 2). table 2: comparison of age groups distribution between groups. age groups use of emla total not used used 19-30 years 4 4 8 10.8% 10.8% 10.8% 31-45 years 3 3 6 8.1% 8.1% 8.1% >45 years 30 30 60 81.1% 81.1% 81.1% total 37 37 74 100.0% 100.0% 100.0% blepharospasm was present in 46 patients (62.2 %) and 28 patients (37.8%) were diagnosed with hemifacial spasm (table-3). table 3: comparison of diagnosis between groups. diagnosis use of emla total not used used blepharospasm 23 23 46 62.2% 62.2% 62.2% hemifacial spasm 14 14 28 37.8% 37.8% 37.8% total 37 37 74 100.0% 100.0% 100.0% patients were categorized in three groups according to pain: mild pain, moderate pain and severe pain. it was seen that in patients in which emla was not used, 21.6% (8 patients) had severe pain, 45.9% (17) had moderate pain, and 32.4% (12) had mild pain. however emla cream was used 89.2% (33) patients had mild pain, 8.1% (3 patients) had moderate pain and only 2.7% (only 1 patient) had severe pain. (table 4). this demonstrates a significant reduction in pain during the procedure with use of topical emla cream (figure 1). table 4: comparison of pain scale between groups. pain scale use of emla total p-value not used used mild pain 12 33 45 0.000004 32.4% 89.2% 60.8% moderate pain 17 3 20 45.9% 8.1% 27.0% severe pain 8 1 9 21.6% 2.7% 12.2% total 37 37 74 100.0% 100.0% 100.0% *a small p-value (typically ≤ 0.05) indicates strongest evidence of results being significant. fig. 1: comparison of pain with and without the use of emla cream. the effectiveness of the botox injections among these patients was also noted on follow up by categorizing them into 3 groups: no effect, fair effect and good effect. it was seen that there was no significant difference in results and effectiveness of botulinum toxin a injections on facial dystonias among patients with emla, and without use of topical emla cream (table 5). table 5: comparison of effect of botox on spasm. effect of botox on spasm use of emla total p-value not used used no effect 5 5 10 0.356 13.5% 13.5% 13.5% fair effect of botox 2 0 2 5.4% 0.0% 2.7% good effect of botox 30 32 62 81.1% 86.5% 83.8% total 37 37 74 100.0% 100.0% 100.0% abdullah irfan, et al 98 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology discussion topical anaesthetics are commonly used for routine minor procedures like subcutaneous injections, intravenous cannulisation, catheterization and removal of superficial skin lesions. emla has been shown to be tolerated well by the patients. in our study no patients experienced any side effect. small sample size and experienced injector could be the reason for this. emla cream has not been found to show any toxicity except in infants. local side effects which have been reported by other physicians include contact dermatitis, erythema, oedema and increased pigmentation of the skin8. one case report has shown that respiratory depression and seizures can occur. the worst complication reported was methaemoglobinaemia which can be potentially fatal but only infants develop this condition9,10. soylev mf et al11 demonstrated that percutaneous anaesthesia produced by using emla cream is quite adequate and it is a safe technique to enhance the patient comfort when repeated botulinum toxin injections are required for facial dyskinesia. applying a dot of emla cream is easy, convenient, and inexpensive way of anesthetizing the site of injection. many other methods of lowering pain in botox injections are suggested. using a small gauge needle as demonstrated by flynn tc et al12, is an obviously a preferred intervention, combined with a minimal number of pricks, also helps ensure proper management of discomfort. using an isotonic mixing solution (preservative-containing saline solution) for reconstitution of the drug and reducing the temperature of the skin with the use of various cooling techniques (eg, ice, aerosol sprays) have also been reported to reduce injection discomfort in a study done by alam m et al13. same results were obtained by linder js et al14, by using various skin cooling techniques. however, kuwahara rt et al15 reported that cold sponging with ice, is inconvenient and the pain control it affords is only partially effective. essential blepharospasm is an involuntary spasm of eyelid muscles affecting patients in fifth and sixth decade of life and predominantly affect females than male with 3:116. hemifacial spasm is a neuromuscular movement disorder characterized by brief or persistent involuntary contractions of the muscles innervated by the facial nerve17. botox injections are effective treatment for both these facial dystonias i.e. for blepharospasm as shown by hellman a et al18 in a recent study, and also for hemifacial spasm as demonstrated by singh s et al19 with a success rate of 95%. botulinum a toxin inhibits cholinergic transmission at neuromuscular synapses and relaxes muscles. clinical effects are usually observed after 2–5 days and last for 16–24 weeks as reported by basaret al20. the pain during this procedure can be measured by a standardized system or scale, like visual analogue scale (vas), that we modified for reliable measurement of pain and its relief21. in our study, we applied botulinum toxin a (botox) injections in 74 eyes, among 34 (45.9%) males and 40 (54.1%) females. among these patients 46 (62.2%) presented with blepharospasm and 28 (37.8%) had hemifacial spasm. we grouped the patients according to pain suffered, into three categories: mild pain, moderate pain and severe pain. it was seen that in 89.2% (33) patients in which emla was used had only mild pain, 8.1% (3 patients) had moderate pain and 2.7% (only 1 patient) had severe pain. however, among the patients in which emla was not used, 21.6% (8 patients) had severe pain, 45.9% (17 patients) had moderate pain, and 32.4% (12 patients) had mild pain. all these results clearly indicated that topical emla cream can be used as an effective tool in management of pain among patients having botox injections for their facial dystonia treatments. similar results were seen in a comprehensive study done on anaesthetic effectiveness of emla cream during botulinum a injections in eyelids by soylev mf et al11. another recent study by elibol oet al22 reported that emla applications significantly decrease the pain associated with periocular botulinum toxin injections. it also demonstrated that patients had a slight preference for emla cream over skin cooling for pain relief. in a study done by barry l. eppley, md23 on twenty patients, receiving 200 botox injections in the glabellar area, it was seen that patients experienced a 60% reduction in pain in emla pre-treated sites compared with that in matched control sites. similar dose of botulinum toxin can usually be repeated to get stable results of the injection24. the use of emla, however, did not have any significant effect on efficacy of botulinum injection in relieving the spasm itself, apart from reduction in pain. the limitation of our study was the limited number of patients in our study. moreover it was also performed at a single centre. a multi-centre study is needed to find the efficacy in large sample of population. https://www.ncbi.nlm.nih.gov/pubmed/?term=elibol%20o%5bauthor%5d&cauthor=true&cauthor_uid=17413628 efficacy of emla cream in pain reduction during botulinum toxin injections for facial dystonias pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 99 conclusion use of emla cream can dramatically reduce pain, make administration of botulinum toxin a injection easier in patients with blepharospasm and hemifacial spasm. this can improve the therapeutic relationship of the patients with health professionals. disclosure the authors have no financial benefit or conflicts of interest in this work. author’s affiliation prof. muhammad moin mbbs, mrcophth, frcs, frcophth department of ophthalmology, postgraduate medical institute, lahore general hospital, yaqin vision eye center, lahore. abdullah irfan pg trainee ophthalmology, lahore general hospital, lahore. author’s contribution prof. muhammad moin data collection, study design, critical analysis. abdullah irfan manuscript writing, statistical analysis. references 1. beer kr, wilson f. skin cooling provides minimal relief of patient discomfort during periocular botulinum toxin type a injection. dermatol surg. 2011; 37 (6): 870-2. 2. yazuver r, demirtas y. painful injections with botox. plast reconstructive surg. 2003; 111: 509-510. 3. friedman pm, mafong ea, friedman es, geronemus rg. topical anesthetics update: emla and beyond. dermatol surg. 2001; 27: 1019-1026. 4. wahlgreen cf, quiding h. depth of cutaneous analgesia after application of a eutectic mixture of the local anestheticslidocaine and prilocaine (emla cream). j am acad dermatol. 2000; 42: 584-588. 5. russell sc, doyle e. a risk-benefit assessment of topical percutaneous local anaesthetics in children. drug saf. 1997; 16 (4): 279-87. 6. mccafferty df, woolfson ad, handley j, et al. effect of percutaneous local anaesthetics on pain reduction during pulse dye treatment of portwine stains. br j anaesthesia, 1997; 78: 286-9. 7. dauphin ap, guillemin f, virion jm, briançon s. bias and precision in visual analogue scales: a randomized controlled trial. american journal of epidemiology, 1999; 150 (10): 1117-1127. 8. godwin y, brotherston m. hyperpigmentation following the use of emla cream. br j plast surg. 2001; 54 (1): 82-83. 9. rincon e, baker rl, iglesias aj, et al. cns toxicity after topical application of emla cream on a toddler with molluscumcontagiosum. pediatr emerg care, 2000; 16 (4): 252-254. 10. essink-tebbes cm, wuis ew, liem kd, et al. safety of lidocaine-prilocaine cream application four times a day in premature neonates: a pilot study. eur j pediatr. 1999; 158 (5): 421-423. 11. soylev mf, kocak n, kuvaki b, ozkan sb, kir e. anesthesia with emla cream for botulinum a toxin injection into eyelids. ophthalmologica. 2002; 216: 355358. 12. flynn tc, carruthers a, carruthers j. surgical pearl: the use of the ultra-fine ii short needle 0.3-cc insulin syringe for botulinum toxin injections. j am acad dermatol. 2002; 46: 931-932. 13. alam m, dover js, arndt ka. pain associated with injection of botulinum a exotoxin reconstituted using isotonic sodium chloride with and without preservative: a double-blind randomized controlled trial. arch dermatol. 2002; 138: 510-514. 14. linder js, edmonson bc, laquis sj, drewry rd jr, fleming jc. skin cooling before periocular botulinum toxin a injection. ophthal plast reconstr surg. 2002; 18: 441-442. 15. kuwahara rt, skinner rb. emla versus ice as a topical anesthetic. dermatol surg. 2001; 27: 495. 16. jankovic j, orman j. blepharospasm: demographic and clinical survey of 250 patients. annals of ophthalmology, 16 (4): 371-6. may 1984. 17. rosenstengel c, matthes m, baldauf j, fleck s, schroeder h. hemifacial spasm: conservative and surgical treatment options. dtsch arztebl int. 2012; 109 (41): 667–673. 18. hellman a, torres-russotto d. botulinum toxin in the management of blepharospasm: current evidence and recent developments. ther adv neurol disord. 2015; 8 (2): 82-91. 19. singh s. botulinum toxin in hemifacial spasm: revisited. indian j plast surg. 2013; 46 (1): 159-160. 20. basar e, arici c. use of botulinum neurotoxin in ophthalmology. turk j ophthalmol. 2016; 46 (6): 282290. 21. sherman sa, eisen s, burwinkle tm, varni jw. the peds ql present functioning visual analogue scales: preliminary reliability and validity. health qual life outcomes, 2006; 4: 75. 22. elibol o, ozkan b, hekimhan pk, cağlar y. efficacy of skin cooling and emla cream application for pain relief https://paperity.org/search/?q=authors%3a%22francis+guillemin%22 https://paperity.org/search/?q=authors%3a%22jean-marc+virion%22 https://paperity.org/search/?q=authors%3a%22serge+brian%c3%a7on%22 https://www.ncbi.nlm.nih.gov/pubmed/?term=elibol%20o%5bauthor%5d&cauthor=true&cauthor_uid=17413628 https://www.ncbi.nlm.nih.gov/pubmed/?term=ozkan%20b%5bauthor%5d&cauthor=true&cauthor_uid=17413628 https://www.ncbi.nlm.nih.gov/pubmed/?term=hekimhan%20pk%5bauthor%5d&cauthor=true&cauthor_uid=17413628 https://www.ncbi.nlm.nih.gov/pubmed/?term=ca%c4%9flar%20y%5bauthor%5d&cauthor=true&cauthor_uid=17413628 abdullah irfan, et al 100 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology of periocular botulinum toxin injection. ophthalmic plast reconstr surg. 2007 mar-apr; 23 (2): 130-3. 23. barry l. eppley, md. easing botox administration with emla cream. aesthetic surg j. 2004; 24: 79-81. 24. moin m, khalid s. fixed dose botulinum toxin therapy for blepharospasm. pak j ophthal. 2016; 32 (2): 91-94. https://www.ncbi.nlm.nih.gov/pubmed/17413628 https://www.ncbi.nlm.nih.gov/pubmed/17413628 microsoft word a rasheed qamar 79 original article eye screening in school children: a rapid way abdul rasheed qamar pak j ophthalmol 2006, vol. 22 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: abdul rasheed qamar associate professor deptt. of ophthalmology, university college of medicine 1 km raiwind road, lahore received for publication november’ 2004 …..……………………….. purpose: a screening program was carried out in different school in punjab to detect the children with refractive errors and refer them to nearest hospitals for treatment. materials and methods: the screening program was carried out through the sight first program of lion’s club international. 38575 school children in different school were screened in 3 years from 2002 to 2004. a maximum participation of the teachers and volunteer paramedical staff made it possible to screen this huge number of schoolchildren. results. out of total 38575 schoolchildren 2069 (5.4%) were found to have refractive errors. conclusion: the protocol described in this paper can be used to screen a large number of children in less time and with minimal involvement of the ophthalmologist(s). arly detection of refractive errors in children is very important. it prevents the development of amblyopia and increases the potential for more effective learning1. the early treatment of amblyopia leads to better visual outcome2. in a trial on 177 children, conducted in department of ophthalmology, school of neurobiology, neurology and psychiatry, university of newcastle upon type, it was observed that delay in treatment until the age of 5 years did not seem to influence effectiveness3. age over 6 years is less likely to achieve successful outcome4. this shows the importance of school health service. in france a 23 years experience of involving the mother and child welfare services with school health services has shown better results5. unluckily both these services are rudimentary in pakistan. in this paper a protocol has been described which was used by author in screening school children through sight first program of lion’s club international. materials and methods the sight first program is run on noncommercial basis exclusively by the vonlunteers. the eye screening program was done in 3 steps. step 1. teaching the teachers. on the day of screening the first step was to brief the teachers about the signs which they can themselves detect in the children with refractive errors. i have found that when these signs are discussed with the teachers, most of them had already noted them in some of students in their class not knowing their significance. after the discussion, the teachers were asked to go to their classes and note carefully these signs in all of their students. this did not waste any time of the students because these signs could be noted during their routine teaching. the signs were: e 80 1. placing the book very close to the eyes when reading. 2. squinting: the teachers very readily learned the hirschburg test 3. closing or covering one eye. 4. excessive blinking. 5. frequent “day dreaming”. 6. “learning disabled or “ trouble makers” when they otherwise had good iq. 7. children already using glasses. i have noted that the students which had been isolated by the teachers on the basis of these signs were almost always “positive “, in the sense that they did have a problem. the “negative” cases (not detected by the teachers) were covered by giving the students an option to go to step 2 if they felt any problem. step 2: eyesight testing in step 2 the children were taken to the eyesight testing area. these children were from two sources: 1. the children isolated by the teachers in step 1. 2. the children who themselves felt that they had defective vision. the eyesight testing area consisted of a square marked on the floor of a hall or in the playground. each side of the square was 12 meters so that when “vision box” was placed in the center, it was about 6 meters from each side (fig 1). the children stand on the middle part of each side and by occluding each eye one by one read the chart. those who could read whole of the chart with each eye had normal eyesight and were sent back to the classes. the trained paramedical staff was present in the eyesight testing area to guide the children. they also sent the children, according to their age, to the side of the vision box with e chart, pictures or letters. fig 1: eyesight testing area consists of a square 12 m x 12 m. the vision box which is in the center is 6 m from each side. the children stand on the middle part of each side (shown as the darker part). the children stand, according to their age, to the side of the vision box with e chart, pictures or letters. in this method the turn over was very fast because every 5 minutes about 20 to 40 children could check their eyesight depending on the efficiency of the paramedical staff. it must be noted that most of the children were checking their eyesight themselves. only very young children needed help. most of the children were normal. they either wanted to confirm their eyesight of just came for fun sake. they were not discouraged. the paramedical staff recorded the eyesight of only those children who had defective vision and referred them for step 3. step 3. final disposal in the step 3 the children referred from step 2 were examined by an ophthalmologist. their eyesight was rechecked and a pinhole test was done to confirm the refractive errors. they were advised treatment if time and facilities permitted otherwise they were referred to the nearest hospitals with their concurrence. table 1: number of children detected in different steps of screening programs n (%) children detected in step 1 1647 (4.3) confirmed in step 2 1288 (78.2) final confirmation in step 3 1130 (68.6) 81 children detected directly in step 2 954 (2.5) cinfirmed in step 3 939 (98.4) total children in step 3 2069 (5.4) results the screening program was conducted in 18 schools in punjab. 38575 school children from kg to class 10 were screened during 3 years from 2002 to 2004. a total number of 2069 (5.4%) children were detected to have refractive errors. in step 1, 1647 children were detected and referred for step 2. out of these 1647 children 1288 were found to have decreased vision. when these children were referred to step 3 for confirmation 1130 children were confirmed to have refractive errors. out of the children directly reporting in step 2, 954 were found to have decreased vision. from this group 939 children were confirmed to have refractive errors. the children diagnosed in different steps of screening programs are shown in (table 1). discussion the importance of the eye screening in children cannot be overestimated considering the value of prevention of permanent amblyopia. the magnitude of the problem can be assessed by a study conducted in muscat, sultanate of oman. in this study 416,157 school children were evaluated for their visual status and it was found that 28,765 (6.9 %) students had defective vision6. our result showed 5.4% of schoolchildren having refractive errors. it may be that some cases were missed in these rapid screening programs. it is recommended that, to be more effective, such screening programs should be repeated at regular intervals by different organizations. in birmingham, uk a study has shown the efficacy of optometric profession7 for this purpose. in pakistan the qualified optometrists are not available for screening programs. so we mostly depend upon the ophthalmologists for these programs. the screening programs are very time consuming, exhausting and difficult to run especially on noncommercial volunteer basis. considering these difficulties and limitations i have always been trying to make the eye screening program more effective with minimum wastage of time and convenient both of the school children and the screening team. the protocol presented is in fact the product of the process of evolution of a number of procedures tried and rejected. it involves the teachers and paramedical staff for eye screening, although every one is working under the direct supervision of the ophthalmologist(s). 82 conclusion the protocol is useful economical and easy to perform for those interested in eye screening programs for the children. the real benefit of the eye screening programs is when they are repeated at regular. a mandatory eye examination or health evaluation at the time of admission in school will gradually reduce the need for such big exercises. author’s affiliation dr. abdul rasheed qamar associate professor of ophthalmology, university college of medicine 1 km raiwind road, lahore reference 1. krumholtz i. results from a pediatric vision screening and its ability to predict academic performance. optometry. 2000; 71: 426-30. 2. williams c, northstone k, harrad ra, et al. amblyopia treatment outcomes after screening before or at age 3 years: follow up from randomised trial. br j ophthalmol. 2002; 324: 1549. 3. clarke mp, wright cm, hrisos s, et al. randomised controlled trial of treatment of unilateral visual impairment detected at preschool vision screening. bmj. 2003; 327:1251. 4. hussein ma, coats dk, muthialu a, et al. risk factors for treatment failure of anisometropic amblyopia. jaapos. 2004; 8: 429-34. 5. speeg-schatz c, lobstein y, burget m, et al. a review of preschool vision screening for strabismus and amblyopia in france: 23 years experience in the alsace region. binocul vis strabismus q ; 19: 151-8. 6. khandekar rb, abdu-helmi s. magnitude and determinants of refractive error in omani school children. saudi med j 2004; 25:1388-93. 7. logan ns, gilmartin b. school vision screening, ages 5-16 years: the evidence-base for content, provision and efficacy. ophthalmic physiol opt. 2004; 24: 481-92. microsoft word abstract 22,2,06 114 abstracts edited by dr. tahir mahmood early changes in corneal sensation, ocular surface integrity, and tear-film function after laser-assisted subepithelial keratectomy winter jh, vidic b, schwantzer g, schmut o. j cataract refract surg 2004; 30:2316-21 the past decade has seen changing trends in refractive surgery, with the evolution of several different procedures. reshaping the anterior corneal surface by excimer laser photorefractive keratectomy (prk) and laser in situ keratomileusis (lasik) have shown considerable promise for the surgical correction of myopia. in prk, refractive surgical ablation is performed on the corneal surface after epithelial debridement. the disadvantage is that the epithelium is lost during this procedure, with potential problems of delayed improvement caused by epithelial defects, postoperative pain, and formation of stromal haze due to the healing process. during lasik, a hinged lamellar corneal flap is raised with a microkeratome followed by ablation in the stromal bed and repositioning of the flap. the rapid recovery, good visual acuity, and absence of pain in most lasik patients have led to an increase number of procedures performed yearly. however, epithelial ingrowth, corneal-flap-related complications, and corneal ectasia are shortcomings of lasik. the purpose of this study was to investigate the changes in corneal sensation, ocular surface integrity, and tear-film function after laser-assisted subepithelial keratectomy (lasek). laser-assisted subepithelial keratectomy was performed in 21 consecutive patients (37 myopic eyes). the patients were observed for subjective complaints of dry eye, corneal sensation, tear-film breakup time (but), schirmer test without local anesthesia, and fluorescein and lissamin-green staining preoperatively and 1 week and 1, 3, and 6 months postoperatively. the subjective score for dry-eye symptoms was not statistically significantly higher after the procedure. corneal sensation was reduced up to 1 month after lasek (p<.05). there were obvious decreases in but at 1 week and 1 month (p<.01) and no significant changes in schirmer test results. in fluorescein staining of the cornea, dots were more concentrated at 1 week (p<.05). in lissamin-green staining, no significant changes were found at any follow-up examination. the authors concluded that laser-assisted subepithelial keratectomy induced a short-term reduction in corneal sensation and affected the ocular surface and tear film slightly. epithelial flap repositioning in lasek may have a positive influence on tear-film and ocular-surface factors. effect of anterior capsule polishing on fibrotic capsule opacification: three-year results sacu s, menapace r, wirtitsch m, buehl w, rainer g, findl o. j cataract refract surg 2004; 30:2322-7. the most frequent complication of modern cataract surgery is, mainly late, opacification of the lens capsule. it arises from 2 distinct causes: fibrosis of the capsule and proliferation of lens epithelial cells (lecs) on the capsule. contact with the intraocular lens (iol) optic causes the lecs of the anterior capsule undergo myofibroblastic transdifferentiation, resulting in fibrotic anterior capsule opacification (aco). fibrotic posterior capsule opacification (pco) is caused by anterior lecs that have migrated onto the posterior capsule, where they cause whitening and shrink eye. anterior capsule opacification and fibrotic pco seal the lens capsule around the iol optic (shrink wrapping). however, aco may reduce the free optic zone by contracting (capsulorhexis phimosis) or retracting the capsulorhexis opening (buttonholing). the fibrotic pco can compromise visualization of the peripheral retina and, when excessive, increases glare disability and decreases image brightness and visual acuity. in recent years, it has become obvious that in the bag implantation of an iol with a sharp edged optic 115 helps reduce pco, especially, when circumferentially overlapped by a continuous curvilinear capsululorhexis (ccc). removing the lecs from the lens capsule to reduce capsule opacification formation has also been under investigation. the present study examined the long-term effect of anterior capsule polishing on the fibrotic component of capsule opacification (both aco and fibrotic pco) in eyes with round-edged silicone iols using a standardized slitlamp photographic technique. two iols manufactured by different companies with a similar open-loop design were used to study the impact of the differences in the silicone optic material of the 2 lenses. this randomized double-blind study comprised 104 eyes of 52 patients with bilateral age-related cataract. all patients received round-edged intraocular lenses (lols); 26 received an si-40 iol (advanced medical optics inc.) in both eyes, and 26 received a silens6 iol (domilens) in both eyes. both lols consist of different silicone material and have different haptic angulation. the si-40 iol has 13.0 mm open-loop poly methyl methacrylate (pmma) haptics angulated by 10 degrees. the silens6 iol has 12.5 mm open-loop pmma haptics with no angulation. in 1 eye, the anterior capsule was extensively polished. the anterior capsule was left unpolished in the contralateral eye, which acted as a control. digital slitlamp photographs of the aco and fibrotic pco were taken with a standardized technique for 3 years postoperatively. the intensity of aco was measured objectively (score 0% to 100%) using adobe photoshop software. fibrotic pco was graded subjectively (score 0 to 4). the mean aco was 17% in the polished eyes and 26% in the control eyes (p = .0001). the mean fibrotic pco score was 0.5 and 1.0, respectively (p = .0007). the mean aco was 15% in the polished si-40 eyes and 26% in the control si-40 eyes (p = .01). it was 19% in the polished silens6 eyes and 26% in the control silens6 eyes (p = .003). the mean fibrotic pco score was 0.4 in the polished si-40 eyes and 1.1 in the control si-40 eyes (p = .0006). it was 0.6 in the polished silens6 eyes and 0.9 in the control silens6 eyes (p = .08). the authors concluded that three years after surgery, eyes in which the anterior capsule was extensively polished had less aco and fibrotic pco with both round-edged silicone lols. in eyes with silens6 lols, however, the reduction in fibrotic pco was not significant. predicting cataract surgery results using a macular function test vryghem jc, cleynenbreugel hv, calster jv, leroux k. j cataract refract surg 2004; 30:2349-53. potential vision tests can help determine whether patients with impaired vision caused by cataract may benefit from improved vision after surgery. it is important to determine whether the visual impairment is from the cataract alone or whether other ocular pathology exists that might affect the prognosis. poor visual recovery after phacoemulsification is frequently linked to retinal or corneal pathology. fundoscopy is difficult in cases of severe cataract and may lead to undiagnosed retinal disease, making prediction of visual recovery unreliable. various methods have been developed for predicting retinal acuity (ie, visual acuity determined by macular and optic nerve function) and for determining whether vision will improve after cataract surgery. several are based on retinal qualitative indices. these include electroretinography, visual evoked potentials, color vision tests, blue-field entoptic tests, and b-scan ultrasonography. other potential vision tests are based on quantitative criteria and include pinhole techniques, laser or white-light interferometry, and potential acuity meter (pam) assessment. the guyton-minkowski pam (mentor) and the rodenstock laser interferometer are currently the most popular instruments for predicting postoperative visual acuity; they are reported to be useful and accurate. the newer potential acuity pinhole (pap) test seems to be more accurate in predicting postoperative distance visual acuity than the pam. in this report, authors described the vryghem macular function (vmf) test (precision vision), a simple and inexpensive method of measuring potential visual acuity in patients with cataract. the test uses a a parinaud near reading chart, a +8.0 diopter (d) trial lens, and a heine ophthalmoscope. in a prospective study, we used the vmf test to measure the accuracy in predicting the visual outcome after cataract surgery. the purpose of this study was to assess the predictive value of a macular function test in the preoperative evaluation of cataract patients. 116 this prospective study comprised 396 uneventful consecutive cataract procedures performed by 1 surgeon from september 2000 to february 2001. the best corrected visual acuity (bcva) and the density and location of the lens opacities were recorded preoperatively. macular function was assessed preoperatively using a parinaud test at 12 cm with a hyperaddition of +8.0 diopters and extra illumination. the postoperative bcva was compared with the results of the macular function test. of the 359 eyes (90.7%) that could read the parinaud 1 line on the pre-operative hyperaddition test, 338 (94.2%) attained a final bcva of 20/25 or better and 356 (99.2%), of 20/30 or better. twenty-five eyes that could not read parinaud 1 and presented with a dense nuclear or posterior subcapsular cataract also achieved a bcva of 20/25 or better. three eyes could read parinaud 1 preoperatively but did not attain a bcva of 20/30 or better postoperatively; 2 of the eyes had macular edema and 1, an opaque posterior capsule. the authors concluded with the remarks that the results of this study suggest that this simple macular function test has a positive predictive value of 94.2% in predicting a visual outcome of 20/25 or better after cataract surgery. the sensitivity was 94.2% and the specificity, 32.4%. the negative predictive value was 32.4% and the positive predictive value for a bcva of 20/30 or better, 99.2%. incidence of and risk factors for residual posterior capsule opacification after cataract surgery mootha vv, tesser r, quails c, j cataract refract surg 2004; 30:2354-8. posterior capsule opacification (pco) is a common complication after cataract surgery with intraocular lens (iol) placement. the reported incidence of pco is as high as 50% with use of poly (methyl methacrylate) lols. posterior migration of residual lens epithelial cells (lecs) from the anterior capsule is thought to be important in the pathophysiology of acquired pco. barriers to posterior migration of lecs include in-the bag iol placement, maximum optic-capsule contact with angulated iol haptics, and use of a square, trim cated-edged iol. soemmering’s ring formation cause by proliferation of sequestered cortical cells is another important factor in the development of peripheral pco. performing meticulous cortical cleanup, using biocompatible lols (acrylic and newer silicone materials) to reduce cell proliferation, and creating a small continuous curvilinear capsulorhexis with the capsule edge on the iol surface are thought to reduce soemmering’ ring formation. eliminating posterior capsule folds and minimizing anterior capsule lec aspiration may also reduce pco. posterior capsule plaque, or residual capsule opacity, at the time of cataract surgery has been noted by cataract surgeons since the advent of extracapsular cataract extraction techniques. although surgical instruments to polish residual capsule opacities have been designed, there are few published studies of residual capsule opacity. it is not known to what extent residual capsule opacity noted at the end of surgery will contribute to visually significant pco over time. the purpose of this study was to evaluate the incidence of and determine the risk factors for residual posterior capsule opacification (pco). this study evaluated 194 uneventful cataract surgeries. immature cataracts were graded for nuclear sclerosis (ns), posterior subcapsular cataract (psc), and anterior cortical spokes on a 1 to 4 scale. preoperative snellen best corrected visual acuity was converted to the logmar scale. the posterior capsule was examined after polishing and was classified as clear or as having residual opacity. those with residual capsule opacity were evaluated 6 weeks postoperatively for the presence of visually significant pco. the incidence of residual capsule opacity was 23% (44 eyes). seven (54%) of 13 eyes with white mature cataract had residual capsule opacity. in contrast, 37 (20%) of 181 eyes with immature cataract had residual capsule opacity (p = .01). in eyes with immature cataract, the mean preoperative logmar acuity was +1.14 ± 0.60 (sd) in the residual capsule opacity group and +0.73 ± 0.46 in the clear group (p<.001). in eyes with immature cataract, the adjusted odds ratio for each increasing grade of ns was 2.3 and of psc, 1.8 (p = .002 and p<.001, respectively). eleven percent (5 eyes) of residual capsule opacities resulted in visually significant pco 6 weeks postoperatively. all 5 opacities were centrally located at surgery. the authors concluded with the remarks that the results indicate that aggressive polishing of peripheral or adherent residual capsule opacities is not advisable as only 5 eyes with central residual capsule opacities developed visually significant pco. microsoft word jamshed nasir.doc 84 original article non massaging management of congenital and infantile naso lacrimal duct obstruction jamshed nasir, mueen mohyuddin, shahid a bhatti pak j ophthalmol 2007, vol. 23 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: jamshed nasir fatima memorial hospital college of medicine & dentistry shadman, lahore received for publication august’ 2006 …..……………………….. purpose: to evaluate non massaging management of congentical and infantile nasolacrimal duct obstruction. material and methods: forty infants were divided in two groups. group a followed the conventional procedure of massage of lacrimal sac, whereas group b had usual advisable management for the congential nasolacrimal obstruction except the massage of naso lacrimal sac. both groups were followed for eight months. results: after eight month followup nasolacrimal obstruction was resolved in 90% of patient in group a and in 95% in group b. 10% of patient in group a and 5% of patient in group b required probing of the nasolacrimal duct. conclusion: non massaging management of nasolacrimal obstruction is as effective as massaging of lacrimal sac but it also ovoids certain complications. ongenital and neonatal epiphora is a common presenting feature generally referred by pediatrician in the out door clinic. the condition usually resolve in less than eighteen months of age but causes lot of discomfort and worry to the young parents who are inexperienced and apprehensive about their new born babies. a better understanding of the problem by the parent and relatives can avoid unnecessary stress but also can give good results with minimum tissue handling of a newborn baby who are very fragile at that age. epiphora in this age group could be due to multiple reasons like dacryostenosis, punctal and canalicular atresia and sac diverticula. congenital naso lacrimal duct (cnld) obstruction being the commonest of all is usually due to non canalization of the lower end of nasolacrimal duct where auto canalization as a rule should normally occur during eighth month of gestation which in some cases is delayed till or after birth. post birth auto canalization occurs in majority of cases leaving a few cases to be handled with surgical probing. auto canalization takes place any time from birth to one year of age varies from patient to patient and is independent of any maneuver like massage as is shown from this study. the auto canalization if for some reason does not take place in one year time usually requires surgical intervention and responds well to simple and single probing. the condition has an incidence of 6% with disappearance of symptom with or without surgical management in approximately 95% of cases as is proved with various studies. massage is thought to be a useful maneuver and tool in the management of cnld obstruction and is associated with certain discomfort for the patient and parents. repeated massage is associated with local tissue reaction, skin ulceration along with infection & cellulitis of the skin and lacrimal sac. in rare cases the infection can travel into the orbit producing devastating complications. to avoid these discomforting state and the risk of infection and to make the procedure a simplified one, this study was carried out at fatima memorial hospital lahore c 85 between 2004 and 2006 when a non massaging management of the cnld obstruction was compared with the usual massaging cnld obstruction management (the conventional method). material and method the study comprises of prospective and randomized forty infants with epiphora divided equally into two groups. the study period for an infant was eight month after that the infant was either discharged upon cessation of symptoms or managed with probing. the selection criteria included healthy infants referred for epiphora by the pediatrician. the ophthalmic examination was carried out for any associated pathology, which in case of positivity was excluded out of the study. the patency of lacrimal system was assessed indirectly with the dye disappearance test out of the conjunctival sac. cases with pure cnld obstruction were picked up and placed in two groups. group a included infants who followed the usual procedure of massage and observation with or without use of antibiotic if needed and the other group b was observed for any sign of inflammation which in case treated promptly but were not advised any massage of the lacrimal sac or tissue handling of the lacrimal system. these infants were examined for the first time in the out door from birth to two months of age depending upon their first presentation at the clinic, subsequently followed up after one month of initial examination and then every second month till a period of eight months is completed when they were discharged from the clinic. the patient visits were divided into five visits from age 0-8 months of age. results a total of forty infants were included in the study with each group containing twenty infants and were followed up till the end of the study. patient fall out was zero as all the patients completed the study. the male to female ratio for group a was 2:3 (40% to 60%) while that of group b was 9:11 (45% to 55%). as is shown in the study the success rate of group b was better than group a. two cases (10%) in group a at the end of eight months continued to have epiphora whereas eighteen cases settled with the massage management (90%) as compared to one case (5%) in group b which continued to have epiphora and required further management whereas nineteen cases (95%) settled by itself without any lacrimal massage. two cases (10%) in group a and one case (5%) in group b who did not improve with the conservative management and required surgical probing under general anesthesia. they improved after single non irrigational probing under general anesthesia. the pattern of disappearance of epiphora also shows variability in the two groups with majority of the cases in this study having settled before the age of four months. 12 patients (66%) in group a and 11 patients (55%) in group b settled before the age of four months how ever they completed their visits with regular follow up till the end of the study. the remaining 6 patients (33%) in group a and 8 patients (42%) in group b settled before the end of the study period which was eight months. success rate in group a was 90% with over all failure rates of 10% while that of group b was 95% with over all failure rates of 5% only. eighteen infants in group a and nineteen infants in group b at the end the study period of eight months settled without any surgical intervention. dry non irrigational probing required in two cases in group a and one case in group b at the termination of the study period which were successful as a primary procedure and did not require any further management. table 1: consultation and visit plan for the study first consultation 0-2 months of age visit 2 2-3 months of age visit 3 2-4 months of age visit 4 4-6 months of age visit 5 6-8 months of age discussion congenital nasolacrimal duct obstruction (cnld) is a common clinical condition often referred to ophthalmologist from pediatrician. the condition generally settles down in time. conventionally it has been taught that massage of the lacrimal sac for cnld obstruction is an important key for a successful outcome. there is little doubt with this statement but is the massage of lacrimal sac really necessary for a successful out come. massage of lacrimal sac for cnld obstruction is not free from complications like skin ulceration, skin roughening, and infection of the overlying skin, conjunctiva and dacryocystitis. in rare cases orbital cellulitis has been reported. improper and exertional massage is associated with number of 86 complications and discomfort for the infant. in this study a comparison is done between two group one following the usual teaching of lacrimal sac massage and use of antibiotic eye drops in case of infection and the second group followed the same procedure but was not allowed to do the massage of the lacrimal sac. the thick discharge collected in the eye corner were advised to be cleaned on regular basis and use of antibiotic eye drops were reserved for eyes showing sign of infection. the end results of the study showed that non massaging management proved to be more successful (95%) than the massaging management of cnld obstruction (90%). minimum tissue handling can avoid certain complications to which these new born babies are quite susceptible to in that age group. parent reassurance and better understanding of the problem, with proper hygiene and minimum tissue handling can give better results. table 2: group a (with lacrimal massage) description cases n (%) total number of cases 20 (100) male 08 (40) female 12 (60) patient fall out 00 (0) success after eight months 18 (90) symptoms persisted after eight months 02 (10) success after four months 12 (60) cases requiring lacrimal probing 02 (10) table 3: group b (with lacrimal massage) description cases n (%) total number of cases 20 (100) male 09 (45) female 11 (55) patient fall out 00 (0) success after eight months 19 (95) symptoms persisted after eight months 01 (05) success after four months 11 (55) cases requiring lacrimal probing 01 (05) conclusion congenital and infantile epiphora due to nasolacrimal duct obstruction generally follows auto canalization course from one month to eighteen months of age with maximum number of infants settling with this problem before the age of four months as is shown in the two groups in our study. massage is not mandatory and fairly good results are obtained without lacrimal massage as is confirmed in our study. the need of the time is to make the parents understand about the auto canalization process in infants and better success rate can be achieved with minimum tissue handling. author’s affiliation jamshed nasir associate professor department of ophthalmology fatima memorial hospital college of medicine & dentistry, lahore mueen mohyuddin associate professor department of paediatrics fatima memorial hospital college of medicine & dentistry, lahore shahid bhatti senior registrar department of ophthalmology fatima memorial hospital college of medicine & dentistry, lahore references 1. baker jd. treatment of congenital nasolacrimal system obstruction, j pediatr ophthalmol strabismus. 1985; 22: 34-6. 2. wagner rs. management of congenital nasolacrimal duct obstruction. pediatr ann. 2001; 30: 481-8. 3. kushner bj. congenital naso lacrimal duct obstruction. arch ophthalmol. 1982; 100: 597-600. 4. busse h. connatal dacryostenoses. clinical picture and treatment. ophthalmology. 2004; 101: 945-54. 5. ingels k, kestelyn p, meire f, et al. the endoscopic approach for congenital nasolacrimal duct obstruction. clin otolaryngol. 1997; 22: 96-9. 6. lim cs, martin f, beckenham t. nasolacrimal duct obstruction in children: outcome of intubation. j aapos. 2004; 8: 466-72. 7. mcnab aa. congenital absence of the nasolacrimal duct. j pediatr ophthalmol strabismus. 1998; 35: 294-5. 87 8. paul to, shepherd r. congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention. j pediatr ophthalmol strabismus. 1994; 31: 362-7. 9. sevel d. development and congenital abnormalities of the nasolacrimal apparatus. j pediatr ophthalmol strabismus. 1981; 18: 13-9. 10. welham ra, hughes sm. lacrimal surgery in children. am j ophthalmol. 1985; 99: 27-34. 11. wagner rs. natural history of nasolacrimal duct obstruction pediatrics in review march 1989. 12. ghuman t, gonzales c, malcolm l et al. mazow, treatment of congenital nasolacrimal duct obstruction, am orthopt j. 1999; 49: 161-6. 13. kim ys, moon sc, yoo kw. congenital nasolacrimal duct obstruction: irrigation or probing? korean j ophthalmol. 2000; 14: 90-6. pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 168 original article intracameral versus sub-conjunctival dexamethasone injection for postoperative inflammation in congenital cataract surgery afia matloob rana, ali raza, waseem akhter pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: afia matloob rana assistant professor ophthalmology department hbs general hospital, islamabad email: afiamatloob@yahoo.com …..……………………….. purpose: to compare the effect of intracameral with sub-conjunctival injection of dexamethasone in preventing immediate postoperative inflammation after congenital cataract extraction. study design: randomized control trial. place and duration of study: holy family hospital, rawalpindi from june 2014 to may 2015. material and methods: all pediatric patients less than 15 years of age and of both genders, undergoing cataract surgery in holy family hospital, were included in the study using a random table. using standardized sample size calculator and statistical assumption with 95% ci and 5% alpha error, the study sample was 95 cases in each group. group a patients got intracameral injection of dexamethasone while group b patients got subconjunctival injection of dexamethasone. the outcome measure was intraocular inflammation after cataract surgery. examination was done within first three postoperative days for signs of anterior chamber inflammation. standard slit lamp or hand held slit lamp was used for this purpose. results: one hundred and ninety patients were included in the study. the patients were equally divided into 2 groups. male cases were in majority in group b (58.9%) whereas in group a females (55.8%) were in majority. mean age was 6.43 ± 4.69 years in group-a compared to 5.85 ± 4.10 years in group-b. frequency of posterior synechiae (inflammation) was 4.21% (n = 4) in group-a (intracameral) compared to 15.79% (n = 15) in group-b (subconjunctival) which was significantly different (p-value = 0.007). conclusion: intracameral injection is better than sub-conjunctival injection of dexamethasone in the management of post-operative inflammation in children with congenital cataract. keywords: congenital cataract, dexamethasone, injections, inflammation. ataract is one of the leading causes of blindness worldwide. it accounts for nearly half (47.8%) of the total 17.7 million cases of blindness1. pakistani population is also getting equally affected from cataract, with high prevalence2. the partial or complete blindness is mainly affecting the elder population and reducing their quality of life by making them dependent on others and posing economic burden on communities and the country2,3. nevertheless, cataract affects all age groups c mailto:afiamatloob@yahoo.com afia matloob rana, et al 169 vol. 35, no. 2, apr – jun, 2019 pak j ophthalmol but comparatively it is less common in children. vision 2020 the „right to sight‟ is the main initiative program to control the visual deterioration and ultimate lasting blindness among children of developing countries.3 lifelong impact of cataract in childhood is very large considering the potential lifespan of a child4. congenital cataract is cloudiness of the crystalline lens of the eye, which is present at birth and is mostly bilateral, clinically present with decreased vision or white reflex. it is diagnosed on slit-lamp biomicroscopy of the anterior segment of the eye. it can present in any form like nuclear, lamellar, sutural, coronary, polar and membranous cataract. the most common presentation is the nuclear cataract5. the treatment for visually significant cataract is surgical, a highly cost effective intervention, with excellent prognosis for sight restoration. early management of congenital cataract prevents the child from developing amblyopia and ensures good visual outcome6. congenital cataract surgery can result in complications like posterior capsule opacification, glaucoma and retinal detachment7. most common post operative complication in congenital cataract is inflammation8. inflammation can lead to complications like peripheral anterior synechiae, posterior synechiae, exudative membrane and pupil block glaucoma, thus hampering good visual rehabilitation. the rationale of the study was to find a treatment option which would reduce the post-operative inflammation and prevent complications. intensive conventional topical steroid treatment is still main trusted mode of managing inflammation, along with other available options, like subconjunctival injection during surgery, collagen shield, intracameral injection and sustained release intraocular drug delivery system9,10. there are various therapeutic options for inflammation with different levels of efficacy and safety. we planned a study with the purpose of comparing the role of intracameral injection with subconjunctival injection of dexamethasone in preventing immediate postoperative inflammation after congenital cataract extraction. material and methods a randomized controlled trial was conducted at the department of ophthalmology, holy family hospital, rawalpindi for a period of one year from june 2014 to may 2015. using standardized sample size calculator and statistical assumption with 95% ci and 5% alpha error, the study sample was 95 cases in each group. it was hypothesized that intracameral injection of 0.5 ml (2 mg) dexamethasone reduces immediate postoperative inflammation after surgery for congenital cataracts. a total of 190 children with cataract were enrolled (who calculator), using a random table, 95 cases each in intra-cameral injection and sub-conjunctival injection groups. children less than 15 years and of both genders were enrolled. visually significant congenital cataract was determined by snellen‟s visual acuity of < 6/6 for verbal child and cataract size more than 3 mm in the area of visual axis, obscuring fundal glow for nonverbal child. cases with no associated anterior or posterior segment pathology were selected. patients with secondary cataract, prior ocular surgery and per operative complication e.g. posterior capsular rent, nucleus drop were excluded from the study. all the children were operated for aspiration of the lens, primary posterior surgical capsulotomy and anterior vitrectomy. children below age of two years were operated without intraocular lens implantation while above two years with intraocular lens implantation. in group a, patients were given intracameral dexamethasone injection 0.5 ml (2 mg) and 0.5 ml (20 mg) gentamycin injection in sub-conjunctival area. in group b, 0.5 ml (2 mg) dexamethasone and 0.5 ml (20 mg) gentamycin injection were given in the sub-conjunctival space at the end of surgery. examination was done within first three postoperative days, for signs of immediate anterior chamber inflammation, by standard slit lamp or hand held slit lamp. in case of non-cooperative children, examination was done with hand held slit lamp under sedation or general anesthesia for posterior synechiae. postoperatively all patients were given topical dexamethasone suspension (1 drop after every 1 hour), tobramycin eye drops (one drop after every 2 hours), 1% cyclopentolate eye drops (one drop after every 8 hours) for one week. the study outcome was measured in terms of efficacy of intracameral injection and subconjunctival injection of dexamethasone in the treatment of inflammation after surgery of congenital cataract. the data was entered and analyzed in spss version 20.0. continuous variable like age was presented as mean and sd. the categorical variables intracameral versus subconjunctival dexamethasone for congenital cataract surgery pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 170 like gender, inflammation (posterior synechiae) was analyzed as frequency and percentages and compared between the two groups using chi-square test, a pvalue of < 0.05 was taken as significant. results one hundred and ninety cases (95 in each group) fulfilling the inclusion/exclusion criteria were enrolled to intracameral injection or sub-conjunctival injection of dexamethasone to see their effect on postoperative inflammation in congenital cataracts. age distribution of the cases showed that majority of the cases were within 1-10 years of age. in group a there were 73.68% (n = 70) patients and in group-b there were 78.95% (n = 75). the results of age distribution are shown in table 1. the gender distribution showed that there was nearly equal distribution among males and females. the results of gender distribution are shown in figure 1. comparison of the intracameral injection with sub-conjunctival injection of dexamethasone in terms of frequency of posterior synechiae (inflammation) was recorded which showed that 4.21% (n = 4) in group-a and 15.79% (n = 15) in group-b had posterior synechiae while remaining 95.79% (n = 91) in group-a and 84.21% (n = 80) in group-b had no findings of the morbidity. this difference in the incidence of inflammation post operatively was found statistically significant between the two groups (pvalue, 0.007) (table 2). table 1: age distribution (n = 190). age (in years) intracameral injection group (a) (n = 95) subconjunctival injection group (b) (n = 95) no. of patients % no. of patients % 1 – 10 70 73.68 75 78.95 11 – 15 25 26.32 20 21.05 mean ± sd 6.43 ± 4.69 5.86 ± 4.10 table 2: comparison of posterior synechiae between the two study groups (n = 190). inflammation (posterior synechiae) intracameral injection group (a) (n = 95) subconjunctival injection group (b) (n = 95) p-value no. of patients % no. of patients % yes 4 4.21 15 15.79 0.007 no 91 95.79 80 84.21 fig. 1: gender distribution in both study groups (n = 190). discussion congenital cataract is an important reason of visual impairment among children, throughout the world and 5%-20% of blindness in children is because of congenital cataract11,12. all over the world 1.4 million children are blind and blindness in 190,000 children is because of cataract13. congenital cataract presents either since birth or shortly after birth14,15. in asia 1 million children are blind because of congenital cataracts16. the estimated prevalence of cataract among children is 3 in 10,000 live biths17. surgical option is the main management strategy in these conditions, which is successful, however, some side effects also worries the patients. ocular inflammation is one such complaint. the perioperative use of anti-inflammatory therapy has well afia matloob rana, et al 171 vol. 35, no. 2, apr – jun, 2019 pak j ophthalmol established role in standard cataract surgery. the aim is to treat postoperative intraocular inflammation and enhance patient's comfort. different anti-inflammatory agents are used according to the patient's need and surgeon‟s preferences18. in the present study posterior synechiae were recorded in 4.21% cases in group-a and 15.79% in group-b, and the difference was statistically significant (p-value, 0.007). our findings regarding significantly greater success of intracameral dexamethasone are in accordance with many previous studies. a study by iqbal and colleagues reported that dexamethasone when injected intracamerally increased its efficacy by about 5% as compared to subconjunctival route19. ahmad et al who evaluated the role of subconjunctival and intracameral dexamethasone found that the later had better results and concluded that intracameral injection of dexamethasone was superior to sub-conjuctival injection of dexamethasone in preventing immediate postoperative anterior uveitis20. another recent study evaluated the effect of intracameral dexamethasone on corneal endothelium, and concluded that the use of intracameral dexamethasone at the end of cataract surgery is safe for corneal endothelium21. the study by zhang et al demonstrated that the average inflammation score was significantly lower in dexamethasone group compared with the indomethacin and ciprofloxacin groups. moreover, they also witnessed decreased intra-ocular pressure with dexamethasone compared to other study interventions22. our findings are in agreement with the above body of evidence, which is justifying the hypothesis that “intracameral injection of 0.5 ml (2 mg) dexamethasone reduces immediate postoperative inflammation after surgery for congenital cataracts”, intracameral injection may be used for better management of postoperative inflammation following congenital cataract extraction. limitation of the study was that it was a single center study, which was focused on early postoperative results. further study needs to be done to evaluate long term results of this intervention at multiple centers. conclusion intracameral injection of dexamethasone is significantly better than subconjunctival injection in terms of frequency of early postoperative inflammation in congenital cataracts. this leads to better visual rehabilitation. references 1. rao gn, khanna r, payal a. the global burden of cataract. curr opin ophthalmol. 2011; 22: 4-9. 2. jadoon z, shah sp, bourne r, dineen b, khan ma, gilbert ce. cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in pakistan: the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007; 91: 1269-73. 3. sheeladevi s, lawrenson jg, fielder ar, suttle cm. global prevalence of childhood cataract: a systematic review. eye (lond). 2016; 30: 1160–69. 4. courtright p, hutchinson ak, lewallen s. visual impairment in children in middleand lower-income countries. arch dis child. 2011; 96: 1129-34. 5. hoffman rs, braga-mele r, donaldson k, emerick g, henderson b, kahook m et al. cataract surgery and nonsteroidal anti-inflammatory drugs. j cat refract surg. 2016; 42: 1368-1379. 6. chan wh, biswas s, ashworth jl, lloyd ic. educational paper: congenital and infantile cataract: etiology and management. eur j pediatr. 2012; 171: 62530. 7. kuhli hc, lüchtenberg m, kohnen t, hattenbach lo. risk factors for complications after congenital cataract surgery without intraocular lens implantation in the first 18 months of life. am j ophthalmol. 2008; 146: 1-7. 8. huang y, dai y, wu x, lan j, xie l. toxic anterior segment syndrome after pediatric cataract surgery. j am acad ped ophthalmol strabismus, 2010; 14: 444-6. 9. chang dt, herceg mc, bilonick ra, camejo l, schuman js, noecker rj. intracameral dexamethasone reduces inflammation on the first postoperative day after cataract surgery in eyes with and without glaucoma. clin ophthalmol. 2009; 3: 345-55. 10. dieleman m, wubbels rj, kooten-noordzij m, dewaard pw. single perioperative subconjunctival steroid depot versus postoperative steroid eye drops to prevent intraocular inflammation and macular edema after cataract surgery. j cataract refract surg. 2011; 37: 1589-97. 11. halilbasic m, zvornicanin j, jusufovic v, et al. pediatric cataract in tuzla canton, bosnia and herzegovina. med glas (zenica). 2014; 11: 127-31. 12. santhiya st, kumar gs, sudhakar p, gupta n, klopp n, illig t, etc. molecular analysis of cataract families in india: new mutations in the crybb2 and gja3 genes and rare polymorphisms. mol vis. 2010; 16: 1837-47. 13. randrianotahina hc, nkumbe he. pediatric cataract surgery in madagascar. niger j clin pract. 2014; 17: 147. 14. nkumbe he, randrianotahina hc. meeting the need for childhood cataract surgical services in madagascar. http://www.ncbi.nlm.nih.gov/pubmed?term=randrianotahina%20hc%5bauthor%5d&cauthor=true&cauthor_uid=24326800 http://www.ncbi.nlm.nih.gov/pubmed?term=nkumbe%20he%5bauthor%5d&cauthor=true&cauthor_uid=24326800 http://www.ncbi.nlm.nih.gov/pubmed/24326800 intracameral versus subconjunctival dexamethasone for congenital cataract surgery pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 172 afr j paediatr surg. 2011; 8: 182-4. 15. bronsard a, geneau r, shirima s, courtright p, mwende j. why are children brought late for cataract surgery? qualitative findings from tanzania. ophthalmic epidemiol. 2008; 15: 383-8. 16. world health organisation. prevention of childhood blindness. geneva: who; 1992. 17. sana n, muhammad a, humaira f. congenital cataract: morphology and management pak j ophthalmol. 2013; 29: 151-55. 18. aptel f, colin c, kaderli s, deloche c, bron am, stewart mw, chiquet c. osiris group. management of postoperative inflammation after cataract and complex ocular surgeries: a systematic review and delphi survey. br j ophthalmol. 2017; 101: 1-10. 19. iqbal cj, ali z, ahmad ka, akram ma. comparison of intracameral dexamethasone and subconjunctival dexamethasone in reducing postoperative inflammation after cataract surgery. ophthalmol pak. 2011; 1: 8-11. 20. ahmad cn, khan aa, siddique z, ahmed s. role of intracameral dexamethasone in preventing immediate postoperative anterior uveitis in paediatric cataract extraction. pak j med health sci. 2010; 4: 338-42. 21. jamil az, ahmed a, mirza ka. effect of intracameral use of dexamethasone on corneal endothelial cells. j coll phys surg pak. 2014; 24: 245-8. 22. zhang g, liu s, yang l, li y. the role of dexamethasone in clinical pharmaceutical treatment for patients with cataract surgery. experiment therap med. 2018; 15: 2177-2181. author’s affiliation dr. afia matloob rana mbbs, fcps assistant professor; ophthalmology hbs general hospital, islamabad. pakistan dr. ali raza mbbs; mcps; fcps professor; ophthalmology holy family hospital. rawalpindi pakistan dr. waseem akhter mbbs; mcps; fcps associate professor; ophthalmology rawal institute of health sciences, islamabad author’s contribution dr. afia matloob rana data collection, preoperative and postoperative patient evaluation, assistance during surgeries of patients, included in the study dr. ali raza surgeon performed the surgeries upon the study cases, helped in preoperative and post-operative evaluation to the primary author dr. waseem akhter final compilation of data, preparation of spss data sheets, data analysis, paper writing https://www.ncbi.nlm.nih.gov/pubmed/?term=aptel%20f%5bauthor%5d&cauthor=true&cauthor_uid=28774934 https://www.ncbi.nlm.nih.gov/pubmed/?term=colin%20c%5bauthor%5d&cauthor=true&cauthor_uid=28774934 https://www.ncbi.nlm.nih.gov/pubmed/?term=kaderli%20s%5bauthor%5d&cauthor=true&cauthor_uid=28774934 https://www.ncbi.nlm.nih.gov/pubmed/?term=deloche%20c%5bauthor%5d&cauthor=true&cauthor_uid=28774934 https://www.ncbi.nlm.nih.gov/pubmed/?term=bron%20am%5bauthor%5d&cauthor=true&cauthor_uid=28774934 https://www.ncbi.nlm.nih.gov/pubmed/?term=stewart%20mw%5bauthor%5d&cauthor=true&cauthor_uid=28774934 https://www.ncbi.nlm.nih.gov/pubmed/?term=chiquet%20c%5bauthor%5d&cauthor=true&cauthor_uid=28774934 https://www.ncbi.nlm.nih.gov/pubmed/?term=osiris%20group%5bcorporate%20author%5d https://www.ncbi.nlm.nih.gov/pubmed/28774934 pakistan journal of ophthalmology, 2020, vol. 36 (1): 24-28 24 original article intracameral bevacizumab versus subconjunctival bevacizumab in the treatment of neovascular glaucoma sharjeel sultan 1 , nisar a. siyal 2 , nazish waris 3 , a. rasheed khokar 4 1,2,4 department of ophthalmology, dow university of health sciences, civil hospital, 3 baqai institute of diabetology and endocrinology, baqai medical university, karachi-pakistan abstract purpose: to compare the effect of intracameral bevacizumab with sub-conjunctival bevacizumab in the treatment of neovascular glaucoma. study design: quasi experimental study. place and duration of study: this study was conducted at civil hospital karachi, pakistan from september 2017 to october 2018. material and methods: patients with intractable neo-vascular glaucoma visiting the outpatient department of civil hospital, karachi were included in the study and followed up for 8 months. patients with sulcus or scleral fixation iols and those who were treated with vitreoretinal surgeries were excluded. patients were divided into two groups. group a included patients treated with intracameral bevacizumab and in group b, patients treated with sub-conjunctival bevacizumab were included. best-corrected visual acuity (bcva), intraocular pressure (iop) and neovascularization of the iris (nvi) were compared between the two groups. results: thirty-eight eyes were included in the study; 24 (56.7%) right eyes and 14 (43.3%) left eyes. most of the patients were males with mean age of 54.53 ± 7.2 years. mean total injections per eye were 3.45 ± 1.73 in group a and 3.12 ± 2.10 in group b. pre-injection bcva (log mar) was 0.48 ± 0.32 in group a and 0.34 ± 0.32 in group b. at 8 months, bcva was 1.7 ± 0.2 in group a and 0.48 ± 0.34 in group b which was statistically significant. pre-injection iop (mm hg) was 48.9 ± 1.8 in group a and 47.34 ± 1.8 in group b. post-injection iop was 28.7 ± 0.8 in group a (p = 0.001) and 34.2 ± 3.4 in group b (p = 0.11) at eight months. conclusion: this study demonstrates that intracameral bevacizumab significantly improves bcva and controls iop in neovascular glaucoma. however, sub-conjunctival bevacizumab significantly improves bcva but decrease in iop is not statistically significant. keywords: neovascular glaucoma, intracameral bevacizumab, intraocular pressure. how to cite this article: sultan s, siyal na, waris n, khokar ar. comparative analysis of intracameral bevacizumab vs subconjunctival bevacizumab in the treatment of neovascular glaucoma, pak j ophthalmol. 2020; 36 (1): 24-28. doi: https://doi.org/10.36351/pjo.v36i1.993 introduction neovascular glaucoma (nvg) most commonly results from conditions, which lead to retinal ischemia 1 . correspondence to: sharjeel sultan assistant professor ophthalmology, dow university of health sciences, karachi, pakistan email: sharj35@yahoo.com various diseases are involved in its occurrence including proliferative diabetic retinopathy (pdr), retinal vein occlusion, ocular ischemic syndrome, and chronic uveitis resulting in elevated intraocular pressure (iop) and severe vision loss 2 . retinal ischemia is a common factor in most of these diseases; only 3% of nvg cases are not associated with retinal ischemia 3 . https://doi.org/10.36351/pjo.v36i1.993 sultan s, et al 25 pakistan journal of ophthalmology, 2020, vol. 36 (1): 24-28 nvg can be treated by different ways. the most important strategy is to tackle the underlying disease process by retinal photocoagulation, thus reducing retinal ischemia and inhibiting the release of angiogenic factors. there are other methods as well; such as cyclo-destructive procedures or drainage devices for controlling iop 4 . anti-vascular endothelial growth factors (anti-vegf) have some role to modify the disease course of nvg. these anti-vegf agents have been widely used not only in nvg but also for wound healing response in traditional glaucoma surgery 5 . literature shows the direct effect of these injections in inflammatory glaucoma 6 . anti-vascular endothelial growth factor injections are increasingly used in the treatment of rubeosis and neovascular glaucoma. several studies have reported regression of iris neovascularization with intravitreal and intracameral bevacizumab 7,8 . the sub-conjunctival bevacizumab approach for nvg is less commonly reported and has more often been described in treating corneal neovascularization 9 . although, pan retinal photocoagulation (prp) effects are long lasting, but requires several weeks to show results which may lead to optic nerve damage due to elevated iop, resulting in loss of vision 10 . in many studies, rapid and obvious therapeutic effects of intravitreal bevacizumab have been reported, but little is known about the long-term efficacy of intracameral injection 11 . most patients eventually required laser or surgical procedures for iop control, but few studies on the predictive factors have been reported for surgical treatment in spite of intraocular injection, especially intracameral injection 2,7 . the purpose of this study was to assess the role of intracameral bevacizumab and compare the results with sub-conjunctival bevacizumab for the treatment of nvg. material and methods this study was conducted at civil hospital karachipakistan from september 2017 to october 2018. patients who visited outpatient department for control of nvg were recruited for this study. following patients with nvg were included in the study; patients in whom prp was deemed ineffective or impossible, patients who had undergone trabeculectomy, ahmed valve implantation, trans-scleral cyclophotocoagulation with poor control of iop and patients with intraocular anti-vegf injection. patients with sulcus or scleral fixation of iols, and those who were treated with pars plana vitrectomy by using intraocular tamponades with silicon oil/vitreoretinal surgeries were excluded from this study. all patients were divided into two groups; group a included patients treated with intracameral bevacizumab and group b included patients treated with sub-conjunctival bevacizumab. nvg was defined as an iop of greater than 22 mm hg, and presence of rubeotic vessels in the anterior chamber angle or corneal edema with obvious rubeosis iridis. baseline characteristics including age, gender, laterality, causes of nvg, topical glaucoma medication and history of previous treatment were noted for each patient. details of therapeutic interventions including intra-vitreal injection, interval between previous anti-glaucoma surgery and initial injection, complete prp detail and laser spot area were also obtained. pre-operative bcva by log mar (logarithm of the minimum angle of resolution) scale and iop (mm hg) were noted. serial changes for nvi during eight months’ follow-up were also noted and compared between the two groups. diminished vision, which varied from hand movements to 6/18 was the main complaint of all the cases. in case of recurrence of nvi and iop > 21 mm hg, despite medical and laser treatment during followup, intracameral bevacizumab was repeated. for the prevention of further nerve damage, target iop was estimated and set for each patient based on their initial iop and degree of existing damage. using 5% povidone-iodine solution (an aseptic preparation) and topical anesthetic eye drops (proparacaine hydrochloride 0.5%; alcaine, alcon, fort worth, tx, usa), intracameral bevacizumab (1.25 mg/ml, 0.05 ml) was injected in the temporal quadrant, by a 30gauge needle after paracentesis. weiss and gold classification was used for nvi grading and categorized into four stages of neovascularization. classification was based on the area of new vessels in the iris, anterior chamber angle and the location of pas. fine surface neovascularization of the pupillary zone of the iris involving ≤ 2 quadrants was called grade 1, surface neovascularization of the pupillary zone of the iris involving ≥ 2 quadrants was called grade 2. in addition to the pupillary zone, neovascularization of the ciliary zone of the iris and/or ectropion uveae involving 1 to 3 quadrants called grade 3 and neovascularization of the intracameral bevacizumab vs subconjunctival bevacizumab in the treatment of neovascular glaucoma pakistan journal of ophthalmology, 2020, vol. 36 (1): 24-28 26 ciliary zone of the iris and/or ectropion uveae involving ≥ 3 quadrants was called grade 4. data was analyzed using statistical package for social sciences (spss) version 20. data was presented as mean ± sd and percentage. p-value was defined significant at > 0.05. results table 1 presents the patients’ baseline characteristics. there were 38 eyes included in this study, 24 (56.7%) right eyes and 14 (43.3%) left eyes. table 2 shows the details of therapeutic interventions; intracameral bevacizumab versus subconjunctival bevacizumab group. in table 3, bcva and iop changes are shown after intracameral bevacizumab versus subconjunctival bevacizumab injection. pre-injection bcva (log mar) was 0.48 ± 0.32 in group a. it improved to 0.15 ± 0.09 at 1 st week, 0.14 ± 0.12 at first month, 1.4 ± 0.5 at third months, 1.1 ± 0.6 at six months, and 1.7 ± 0.2 at eight months. on the other hand, pre-injection bcva was 0.34 ± 0.32 in group b and post-injection improved to 0.41 ± 0.09, 0.14 ± 0.12, 0.31 ± 0.9, 0.98 ± 0.1 and 0.48 ± 0.34, at 1 st week, 1 st month, 3 rd month, 6 th month and 8 th month, respectively. similarly, pre-injection iop (mm hg) was 48.9 ± 1.8 in group a and post-injection 47.1 ± 2.5 at first week, 38.3 ± 1.5 at first month, 35.1 ± 0.5 at third months, 29.5 ± 1.6 at six months, and 28.7 ± 0.8 at eight months. pre-injection iop was 47.34 ± 1.8 in group b and post-injection was 47.4 ± 2.5, 42.34 ± 1.5, 39.5 ± 2.5, 34.4 ± 1.7 and 34.2 ± 3.4, respectively at 1 st week, 1 st month, 3 rd month, 6 th month and 8 th month. serial changes for nvi during eight-months follow-up are shown in table 4. table 1: patients baseline characteristics. characteristics results no. of eyes 38 gender males 16 (42.6%) females 14 (57.3%) laterality right eye 24 (56.7%) left eye 14 (43.3%) mean age of patients (years) 54.53 ± 7.2 causes of neovascular glaucoma proliferative diabetic retinopathy 26 (68.4%) central retinal vein occlusion 5 (13.2%) post vitrectomized silicon filled eyes 7 (18.4%) topical glaucoma medication 3.85 ± 0.34 previous treatment pan-retinal photocoagulation 29 (76.3%) pars plana vitrectomy 4 (10.5%) cataract surgery 12 (31.6%) data presented as mean ± sd or n (%) table 2: details of therapeutic interventions in intracameral bevacizumab vs. sub-conjunctival bevacizumab group. parameters group a group b p-value no. of eyes 28 10 total injections per eye 3.45 ± 1.73 3.12 ± 2.10 p = 0.43 interval between previous surgery and first injection (in days) 32.54 ± 20.15 29.14 ± 28.39 p = 0.001 complete prp 8 (28.6%) 3 (30.0%) p = 0.21 laser photocoagulation 1-2 quadrant 19 (67.9%) 7 (70.0%) 0.001 3-4 quadrant 9 (32.1%) 3 (30.0%) 0.035 pre-injection surgical treatments for nvg trabeulectomy 15 (53.6%) 6 (60.0%) 0.006 ahmed valve implantation 2 (7.1%) 0 (0.0%) 0.04 trans scleral cyclophotocoagulation 11 (39.3%) 4 (40.0%) 0.001 data presented as mean ± sd or n (%), p-value < 0.05 considered as significant table 3: changes in bcva and iop after intracameral bevacizumab and sub-conjunctival bevacizumab injection. characteristics preoperative first week first month third months six months eight months pvalue group a bcva(log mar) 0.48 ± 0.32 0.15 ± 0.09 0.14 ± 0.12 1.4 ± 0.5 1.1 ± 0.6 1.7 ± 0.2 0.001 iop (mm hg) 48.9 ± 1.8 47.1 ± 2.5 38.3 ± 1.5 35.1 ± 0.5 29.5 ± 1.6 28.7 ± 0.8 0.001 group b bcva (log mar) 0.34 ± 0.32 0.41 ± 0.09 0.14 ± 0.12 0.31 ± 0.9 0.98 ± 0.1 0.48 ± 0.34 0.001 iop (mm hg) 47.34 ± 1.8 47.4 ± 2.5 42.34 ± 1.5 39.5 ± 2.5 34.4 ± 1.7 34.2 ± 3.4 0.11 data presented as mean ± sd, p-value < 0.05 considered as significant sultan s, et al 27 pakistan journal of ophthalmology, 2020, vol. 36 (1): 24-28 table 4: serial changes for nvi during eight-month follow-up after intracameral bevacizumab vs. sub-conjunctival bevacizumab injection. nvi grade baseline nvi first week first month third months six months eight months group a 0 6 (21.4%) 11 (39.3%) 9 (32.1%) 8 (28.6%) 5 (17.9%) 6 (21.4%) 1 3 (10.7%) 4 (14.3%) 3 (10.7%) 5 (17.9%) 6 (21.4%) 5 (17.9%) 2 5 (17.9%) 4 (14.3%) 7 (25.0%) 4 (14.3%) 3 (10.7%) 10 (35.7%) 3 8 (28.6%) 6 (21.4%) 5 (17.9%) 6 (21.4%) 8 (28.6%) 3 (10.7%) 4 6 (21.4%) 3 (10.7%) 4 (14.3%) 5 (17.9%) 6 (21.4%) 4 (14.3%) p-value 0.035 0.001 0.001 0.024 0.003 0.02 group b 0 0 (0.0%) 1 (10.0%) 1 (10.0%) 0 (0.0%) 2 (20.0%) 2 (20.0%) 1 0 (0.0%) 3 (30.0%) 2 (20.0%) 3 (30.0%) 1 (10.0%) 3 (30.0%) 2 2 (20.0%) 3 (30.0%) 3 (30.0%) 2 (20.0%) 3 (30.0%) 1 (10.0%) 3 3 (30.0%) 1 (10.0%) 1 (10.0%) 2 (20.0%) 2 (20.0%) 1 (10.0%) 4 5 (50.0%) 2 (20.0%) 3 (30.0%) 3 (30.0%) 2 (20.0%) 3 (30.0%) p-value 0.001 0.025 0.05 0.034 0.01 0.41 data presented as n (%) p-value < 0.05 considered as significant discussion although majority of nvg patients are effectively treated with prp alone, still many necessitate additional maneuvers to control iop 12 . our results are consistent to wolf a et al study, which showed fast and effective response to intracameral bevacizumab injection in cases of nvg 13 . bhagat pr et al reported that the effect of injection was initially acceptable but deteriorated after 8 weeks 14 . contrary to that, we observed that intracameral route was effective in controlling iop even at 8 th month. some researchers have shown that sub-conjunctival bevacizumab injection could be potentially useful as an initial treatment before laser or surgical treatment for nvg. however, recent studies have also shown that intracameral injections of bevacizumab may be a better adjunct for the treatment of nvg. it results in regression of angle and iris neovascularization and the stabilization of iop 14 . in our study, intracameral bevacizumab was injected at the limbus close to nvi. kim tw et al proposed that after subconjunctival bevacizumab injections, macromolecules diffuse through the sclera directly into the iris 15 . ghanem aa et al injected multiple injections of bevacizumab in eyes with massive nvi that showed reappearance of nvi at 8 th month 16 . however, in his study, transient iop-lowering effects were seen in patients and the patients eventually required iop-lowering surgery. other studies showed that iop and nvi rapidly decreased after intracameral bevacizumab but to control new vessels a single intracameral injection was not enough 2,17 . in our study, the patients received 3.45 ± 1.73 (group a) and 3.12 ± 2.10 (group b) injections, and 9 (32.1%) and 4 (40.0%) eyes received more than two injections in group a and b, respectively, similar to ha jy et al study 2 . laser prp is also an important therapy along with injection of bevacizumab in nvg. as laser prp is a confounding factor in clinical assessment of iop, bcva, and nvi, it was not given as a primary mode of therapy in our study, up to eight months of followup 18 . intracameral bevacizumab was followed-up for eight months in our study and it was considered a safe procedure for corneal endothelium. other studies evaluated the safety of intracameral becacizumab for nvg and found no side effects on corneal endothelim 19,20 . limitation of our study was the small sample size. furthermore, absence of control group (non-treated) or other forms of injections for comparison such as intravitreal or combined intracameral and intravitreal to determine the effect of intracameral injection was also the limitation of our study. conclusion this study demonstrates that intracameral bevacizumab significantly improves bcva and controls iop in neovascular glaucoma. however, subconjunctival bevacizumab significantly improves bcva but decrease in iop is not statistically significant. ethical approval the study was approved by the institutional review board/ethical review board. intracameral bevacizumab vs subconjunctival bevacizumab in the treatment of neovascular glaucoma pakistan journal of ophthalmology, 2020, vol. 36 (1): 24-28 28 conflict of interest authors declared no conflict of interest. authors’ designation and contribution sharjeel sultan; assistant professor: concept and design, data analyses, manuscript writing, final review of manuscript. nisar a. siyal; associate professor: concept and design, interpretation of data and final review of manuscript. nazish waris; phd scholar: interpretation of data, final review of manuscript. a rasheed khokar; professor: concept and design, final review of manuscript. references 1. shazly ta, latina ma. neovascular glaucoma: etiology, diagnosis and prognosis. in seminars in ophthalmology. taylor & francis, 2009; 24 (2): pp. 113-121. 2. ha jy, lee th, sung ms, park sw. efficacy and safety of intracameral bevacizumab for treatment of neovascular glaucoma. korean j ophthalmol. 2017; 31 (6): 538-47. 3. sivak-callcott ja, o’day dm, gass jd, tsai jc. evidence-based recommendations for the diagnosis and treatment of neovascular glaucoma. ophthalmology, 2001; 108 (10): 1767-76. 4. khattab a, azmy e. combined intracameral and intravitreal bevacizumab injection in neovascular glaucoma. j egypt ophthalmol soc. 2013; 106 (3): 117. 5. li z, van bergen t, van de veire s, van de vel i, moreau h, dewerchin m, et al. inhibition of vascular endothelial growth factor reduces scar formation after glaucoma filtration surgery. invest ophthalmol. vis. sci. 2009; 50 (11): 5217-25. 6. slabaugh m, salim s. use of anti-vegf agents in glaucoma surgery. j ophthalmol. 2017; 2017. 7. wakabayashi t, oshima y, sakaguchi h, ikuno y, miki a, gomi f, et al. intravitreal bevacizumab to treat iris neovascularization and neovascular glaucoma secondary to ischemic retinal diseases in 41 consecutive cases. ophthalmology, 2008; 115 (9): 1571-80. 8. chalam kv, gupta sk, grover s, brar vs, agarwal s. intracameral avastin dramatically resolves iris neovascularization and reverses neovascular glaucoma. eur j ophthalmol. 2008; 18 (2): 255-62. 9. yip vc, yip lw, laude a. subconjunctival bevacizumab for iris neovascularization. the lancet diabetes & endocrinology, 2014; 2 (6): 449-50. 10. ehlers jp, spirn mj, lam a, sivalingam a, samuel ma, tasman w. combination intravitreal bevacizumab/panretinal photocoagulation versus panretinal photocoagulation alone in the treatment of neovascular glaucoma. retina, 2008; 28 (5): 696-702. 11. wakabayashi t, oshima y, sakaguchi h, ikuno y, miki a, gomi f et al. intravitreal bevacizumab to treat iris neovascularization and neovascular glaucoma secondary to ischemic retinal diseases in 41 consecutive cases. ophthalmology, 2008; 115: 1571–1580. 12. wasik a, song hf, grimes a, engelke c, thomas a. bevacizumab in conjunction with panretinal photocoagulation for neovascular glaucoma. optometry-joaoa. 2009; 80 (5): 243-8. 13. wolf a, von jagow b, ulbig m, haritoglou c. intracameral injection of bevacizumab for the treatment of neovascular glaucoma. ophthalmologica. 2011; 226 (2): 51-6. 14. bhagat pr, agrawal ku, tandel d. study of the effect of injection bevacizumab through various routes in neovascular glaucoma. j curr glaucoma prac. 2016; 10 (2): 39. 15. kim tw, lindsey jd, aihara m, anthony tl, weinreb rn. intraocular distribution of 70-kda dextran after subconjunctival injection in mice. invest ophthalmol vis sci. 2002; 43 (6): 1809-16. 16. ghanem aa, el-kannishy am, el-wehidy as, elagamy af. intravitreal bevacizumab (avastin) as an adjuvant treatment in cases of neovascular glaucoma. middle east afr j ophthalmol. 2009; 16 (2): 75–79. 17. soohoo jr, seibold lk, kahook my. recent advances in the management of neovascular glaucoma. in seminars in ophthalmology. taylor and francis, 2013; 28 (3): 165-172. 18. shin jp, lee jw, sohn bj, kim hk, kim sy. in vivo corneal endothelial safety of intracameral bevacizumab and effect in neovascular glaucoma combined with ahmed valve implantation. j glaucoma, 2009; 18 (8): 589-94. 19. ha ya, sung ms, park sw. efficacy and safety of intracameral bevacizumab for treatment of neovascular glaucoma. korean j ophthalmol. 2017; 31: 6. doi:10.3341/kjo.2017.0017 20. duch s, buchacra o, milla e, andreu d, tellez j. intracameral bevacizumab (avastin) for neovascular glaucoma: a pilot study in 6 patients. j glaucoma, 2009; 18 (2): 140–3. .…  …. https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.3341%2fkjo.2017.0017?_sg%5b0%5d=xbykszrkd1dofsikmuk5ozv4q_-ykc88gyahqgeekk2hpvzb1nckygmavm2lvby6sm5ishzzrtb6ltibexvbp9itna.n7jd-wv9r_xyi1b0diyinh-atl8lzusgtr-tg-ntqlxfdvct0x9qfpsrxvzfwj2t1rqlnd99d--qe-nlsrw6vw microsoft word p s mahar 151 review article ocular blood flow and its determination and relevance in glaucoma p.s. mahar pak j ophthalmol 2006, vol. 22 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: p.s mahar isra university & aga khan university karachi received for publication october2005 …..……………………….. although intraocular pressure (iop) is closely linked to the pathogenesis of primary open angle glaucoma (poag) and reduction of iop slows down the glaucoma damage, 12% of subjunctives with controlled iop continue to have progressive visual field loss and about 30% of glaucoma patients never experience high iop. clinical existence of normotensive or low tension glaucoma confounds the traditional theory that elevated iop is the only causative factor. also various anti glaucoma drugs to lower iop do not always prevent disease progress. glaucoma may not be fully addressed by lowering iop alone but also increasing the ocular perfusion dynamics by enhancing blood supply to the ocular tissues. multiple techniques should be used to measure all relevant vascular beds in glaucoma such as carotids, choroidal circulation, retinal circulation and optic nerve head. we discuss usefulness of some techniques such as color doppler imaging, scanning laser ophthalmoscope (slo) angiography, heidelberg retinal flowmetry, pulsatile ocular blood flow and laser speckle tissue circulation analyzer to determine the ocular hemodynamics. aised intraocular pressure (iop) is a major risk factor in the pathogenesis of glaucoma. all major clinical trials such as ocular hypertension treatment study (ohth)1, early manifest glaucoma trial (emgt)2 and advance glaucoma intervention study (agis)3 showed that reduction of iop slows down glaucoma damage. however these trials have also indicated that despite controlled iop a number of glaucoma patients continued to have deterioration of their visual function. there is about 20% 30% of glaucoma patients who have never experienced iop of more than 20mmhg but still show glaucomatous damage. clinical existence of normotensive (ntg) or low tension glaucoma (ltg) also confounds the traditional theory that raised iop is the only causative factor in the pathogenesis of glaucoma. this determines that although raised iop is the main risk factor for visual deterioration in glaucoma patients, there are also other risk factors contributing in the pathogenesis of glaucoma. over the years there has been great debate among the ophthalmic community about the mechanical or vascular effect, raised iop can exert on the retinal axonal nerve fibers. raised iop can have mechanical effect and can also reduce the ocular blood flow (obf). however is this alteration of blood flow a consequence of the glaucomatous disease or a primary vascular factor causing glaucomatous optic neuropathy (gon). r 152 the reduced ocular blood flow (obf) in glaucoma can be a primary vascular dysfunction or secondary to elevated iop resulting in ischemia of retinal axonal fibers leading to apoptosis defined as non-metabolic programmed cell death. what ever argument is, it is important to measure ocular blood flow (obf) in glaucoma patients to determine its relationship with the gradual visual loss. blood flow in glaucoma however does not depend upon one type of circulation but rather involves multiple circulations including retina, choroid and optic nerve head. so far there is not a single device or a technique, which can measure all three circulations. therefore one has to employ multiple techniques to study these circulations. retinal circulation it is supplied by central retinal artery, which is a first branch of ophthalmic artery. it is low level of flow and high level of 02 extraction system. it is characterized by blood retinal barrier, inner part of which is maintained by tight endothelial junctions. the system is auto-regulated by myogenic and metabolic mediators, such as partial pressure of oxygen (pco2) , partial pressure of carbon dioxide (pco2), angiotensin ii and adenosine diphosphate. optic nerve head (onh) the anterior part of the optic nerve is divided into superficial nerve fiber layer, the pre-laminar region, the laminar region and the retro-laminar region. the superficial nerve fiber layer is supplied from arterioles arising from central retinal artery. the temporal nerve fiber layer may have an additional supply from cilioretinal artery when ever present. the pre-laminar region is supplied by branches of the short posterior ciliary artery and via vessels originating from circle of zinn and haller. the laminar region is supplied either directly by short posterior ciliary artery or via arterial circle of zinn and haller. the retro-laminar part of the optic disc receives numerous perforating arterioles from pia mater and occasionally small branches from central retinal artery. the optic nerve head is the only part of central nervous system, which has no proper blood – brain barrier. there is evidence that there is some diffusion from surrounding choroid into optic nerve head. this makes optic nerve head circulation sensitive to chemical molecules like endothelin-1 and angiotensin ii4. choroidal circulation the choroid is supplied by posterior ciliary arteries and accounts for 85% of total blood flow in the eye. it is characterized by very high flow and low oxygen extraction5. the choricapillaris have fenestration therefore leaking smaller molecules like fluorescein into subretinal space. the choroidal circulation is poorly autoregulated and therefore is dependent on perfusion pressure6 but has rich autonomic innervation. perfusion pressure ocular blood flow depends upon the perfusion pressure, which is the difference between the pressure in the arteries entering the eye and pressure in the veins leaving the eye. the pressure in the arteries entering the eye is equivalent to the mean arterial pressure measured in the brachial artery. mean arterial pressure is defined as the diastolic pressure plus one third of the pulse pressure (difference between systolic and diastolic pressure). the pressure in the veins leaving the eye is equivalent to the intraocular pressure. blood flow is reduced if mean arterial pressure is reduced or iop is increased. measurement of ocular blood flow (obf) there is no single technique available which can accurately assess all the relevant vascular beds in glaucoma. however there are several non-invasive techniques available, which can provide reliable and accurate information. some of these techniques are available in our country while some are not. however it is important to know the usefulness and limitation of all these techniques. color doppler imaging (cdi) this is an ultrasound technique, which combines bscan imaging of the tissue with color representation of blood flow based on doppler shift. it measures blood velocity in retrobulbar vessels such as ophthalmic artery, central retinal artery and posterior ciliary artery. these arteries are important specifically in glaucoma as they supply blood to the choroid and optic nerve head. cdi is a non invasive technique facilitating quantification of retobulbar blood velocities. it does require pupil to be dilated and is not affected by media opacity7-9. 153 scanning laser ophthalmoscope angiography (slo) slo is a technique producing high resolution images of fundus. it uses different filters to perform fluorescein and indo-cyanine green (icg) angiography recorded on videotape at a rate of 30 images per second. slo angiography with fluorescein is analyzed using digital video analysis equipment. the amount of time for fluorescein dye to move from proximal to a distal location on a retinal vessel is measured by quantifying the brightness in two locations. the distance between these two locations is also measured to obtain mean dye flow velocity. one can also measures arterio-venous passage time (avp) through the retina by measuring the time between first appearance of dye in a retinal artery and its corresponding vein. slo with icg dye can image the choroidal circulation, which is not possible with fluorescein dye as it flows out of choroidal wall fenestration blocking the background view. icg absorbs mid-infrared light and binds completely to plasma proteins and also because of larger molecule size stays inside choriocapillaries. reduced blood flow in retina, choroid and optic nerve head has been demonstrated in glaucoma patients using angiography10. delayed filling and prolonged passage time has been also shown in retinal and choriodal circulation11. while the reduction of retinal circulation occurs in poag, reduction of choroidal blood flow has been noticed in ntg12. on icg, local filling defects, slow filling and increased leakage has been seen on optic nerve head13. heidelberg retinal flowmetery (hrf) this is a scanning version of laser doppler technology which analyses the doppler shift in laser light and measures volumetric flow in capillary beds of choroid and optic nerve head14. it is non invasive technique requiring clear media and good fixation. it is highly sensitive to illumination changes and eye movements. some workers have shown that ocular blood flow in the onh and retina of glaucoma patients is reduced15. pulsatile ocular blood flow (pobf) the blood flow to the eye varies with the cardiac cycle. the choroidal volume and iop are highest during systole and lowest during diastole. this pulsatile component of ocular blood flow is measured by recording the amplitude of iop pulse wave causing changes in the ocular volume. the shortcoming of this technique is that it is influenced by scleral rigidity. reduced pobf has been observed in patient with poag and ntg16. laser speckle tissue circulation analyzer this technique is developed in japan and is based on the principle that a random speckle pattern in created when laser light is shown on retinal blood vessels. it measures blood flow indirectly by taking advantages of an optical effect. this technique is mostly used to see the effect of unoprostone and timoptol on the ocular blood flow17 ocular blood flow in glaucoma various researchers have found reduced ocular perfusion in glaucoma patients with blood flow decreasing with increasing damage. there is reduction in blood flow involving optic nerve head, choroid and retina. blood flow disturbances are more pronounced in normal tension glaucoma than poag18. it has also been shown that blood flow reduction is more marked in progressive than in non progressive eye19. some reservations about these finding are that different workers have used different techniques measuring different aspects of ocular circulation. and this also involves different type of glaucoma at different stages of progression. topical medications influencing the ocular blood flow topical beta blockers all topical beta blockers possess ca++ channel blocking property. betaxolol, a selective b 1 receptor blocker however exerts this property to its maximum. it has special ca ++ channel blocking property for the voltage dependent ca++ channels. by blocking the ca++ channels, betaxolol diminishes the ca++ influx across the cell wall of smooth muscle cells and pericytes causing vasodilatation of the contracted vessels. in several studies using color doppler imaging, increasing blood velocity and decreased resistance 154 index were found in retrobulbar and ocular vessels after the topical instillation of betaxolol drops20-22. some observer have not found similar improvement of ocular perfusion with the use of topical betaxolol23,24. carbonic anhydrase inhibitors (cai) it has long been know that systemic administration of acetazolamide causes increase in the cerebral blood flow. a similar effect on the ocular circulation was found after short term topical and systemic application of acetazolamide and brinzolamide in invivo animal models25,26. in the human studies, using topical cais using scanning laser ophthalmoscope with fluorescein and icg, the retinal arterio-venous transit time was found to be decreased and the macular capillary transport velocity increased23,27,28. the mechanism of the accelerated retinal perfusion seen in humans after topical use of cais remains unclear but is though to be related to the release of co2 causing vasodilatory effect. unoprostone it is a synthetic docosanoid showing low affinity for prostaglandin (pg) receptors but strong property of ca++ channel blocking. this effect leads to decrease in intracellular ca++ causing dose dependant vascular relaxation. by using laser speckle tissue circulation analyzer makimoto29 found increase microcirculatory blood flow in human ocular fundus probably due to reduction in vascular resistance. it has been shown that decrease in choroidal blood flow induced by intravenous endothelin -1 was neutralized by topical instillation of unoprostone as measured with laser doppler flowmetery and laser interflowmetery30. however in one study31, laser doppler flowmetery failed to record any alteration in choroidal and onh blood flow. conclusion the raised iop is no longer an integral part of glaucoma as a number of glaucoma patients have their iop within the normal range (under21mmhg). several well designed clinical trials have demonstrated the importance of iop reduction in halting the progression of the glaucomatous damage. however these studies also confirm the involvement of other risk factors such a vascular dysregulation. effective management of glaucoma therefore requires management of mechanical (iop) and vascular (obf) forces simultaneously. author’s affiliation dr. p.s mahar professor of ophthalmology isra university consultant eye surgeon, aga khan university karachi reference 1. kass ma, heuer dk, higginbotham ej, et al. the ocular hypertension treatment study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. arch ophthalmol. 2002; 120: 701-3. 2. heijl a, leske mc, bengtsson b, et al. reduction of intraocular pressure and glaucoma progression: results from the early manifest glaucoma trial. arch ophthalmol. 2002; 120: 1268–79. 3. the agis investigators. the advanced glaucoma intervention study (agis) the relationship between control of intraocular pressure and visual field deterioration. am j ophthalmol. 2004; 130: 429-40. 4. flammer j, haefliger io, orgil s, et al. vascular dysregulation a principal risk factor for glaucomatous damage. j glaucoma. 1999; 8: 212-9. 5. flammer j, orgul s, costa vp, et al. the impact of ocular blood flow in glaucoma. prog retin eye res. 2002;21:359-93. 6. delaey c, van de vourde j. regulating mechanism in the retinal and choriodal circulation. ophthalmic res. 2000; 32: 249-56. 7. williamson th, harris a. major review: color doppler ultrasound imaging of the eye & orbit. surv ophthalmol. 1996; 40: 255-67. 8. harris a, kageman l, cioffi ga. major review: assessment of human ocular hemodynamics. surv ophthalmol. 1998; 42: 50933. 9. quaranta l, harris a, donato f, et al. color doppler imaging of ophthalmic artery blood flow velocity: a study of repeatability and agreement. ophthalmology 1997; 104: 653-8. 10. hitching ra, spaeth gl. fluorescein angiography in chronic simple and low tension glaucoma. br j ophthalmol. 1977; 61: 126-32. 11. duijim hf, van den berg tj, greve el. choroidal hemodynamics in glaucoma. br j ophthalmol. 1997; 81: 735-42. 12. geijseen hg, green el. vascular concepts in glaucoma. curr opin ophthalmol. 1995; 6: 71-7. 13. o’ brart dp, de souza lima m, bartsch du, et al. indocyanine green angiography of the peripapillary region in glaucomatous eyes by confocal scanning laser ophthalmoscopy. am j ophthalmology. 1997; 123: 657-66. 155 14. kagemann l, harris a, chung hs, et al. heidelberg retinal flowmetry: factors affecting blood flow measurement. br j ophthalmol. 1998, 82, 131-6. 15. michelson g, langhans mj, groh mj. perfusion of the juxtapapillary retina and the neuroretinal rim area in primary open angle glaucoma. j glaucoma 1996; 5: 91-8. 16. fontana l, poinoosawmy d, bunce cv, et al. pulsatile ocular blood flow investigation in asymmetric normal tension glaucoma and normal subjects. br j ophthalmol. 1998; 82: 7316. 17. tamaki y, araie m, kawamoto e, et al. noncontact, twodimensional measurement of retinal microcirculation using laser speckle phenomenon. invest ophthalmol vis sci. 1994; 35: 3825-34. 18. michelson g, welzenbach j, pal i, et al. automatic full field analysis of perfusion images gained by scanning laser doppler flowmetry. br j ophthalmol. 1998; 82: 1294-1300. 19. yamazaki y, drance sm. the relationship between progression of visual field defects and retrobulbar circulation in patients with glaucoma. am j ophthalmol. 1997; 124: 287-95. 20. gupta a, chen hc, rassam smb, et al. effect of betaxolal on the retinal circulation in eyes with ocular hypertension, a pilot study. eye 1994; 8: 668-71. 21. harris a, spaeth gl, sergott rc, et al. retrobulbar arterial hemodynamic effects of betaxolol and timolol in normaltension glaucoma. am j ophthalmol. 1995; 120: 168-75. 22. turacli me, ozden rg, curess ma. the effect of betaxolal on ocular blood flow and visual field in patients with normotension glaucoma. eur j ophthalmol. 1998; 8: 62-6. 23. harris a, arend o, chung hs, et al. a comparative study of betaxolal and dorzolamide effect on ocular circ glaucoma patients. ophthalmology 2000; 107: 430-4. 24. carenini ab, sibour g, carenini bb. difference in the long term effect of timolol and bextaxol on the pubatile ocular blood flow. surv of ophthalmol. 1994; 38: 118-24. 25. lacour m. optic nerve oxygen tension, effects of intraocular pressure and dorzolamide. br j ophthalmol. 2000; 84: 1045-49. 26. barnes ge, li b, dean t, et al. increased optic nerve head blood flow after 1 week twice daily topical brinzolamide treatment in dutch-belted rabbits. surv of ophthalmol. 2000; 44: 131-40. 27. harris a, arend o, kagemann l, et al. dorzolamide, visual function and ocular hemodynamics in normal-tension glaucoma. j ocul pharmacol ther. 1999; 15: 189-97. 28. schmidt kg, von ruckmann a, pillunat le, et al. topical carbonic anhydrase inhibition increases ocular pulse amplitude in high tension primary open angle glaucoma. br j ophthalmol. 1998; 82: 758-62. 29. makimoto y, sugiyama t, kojima s, et al. long-term effect of topically applied isopropyl unoprostone on microcirculation in the human ocular fundus. jp j ophthalmol. 2002; 46: 31-5. 30. polska e, doelemeyer a, luksch a, et al. partial antagonism of endothelin 1-induced vasoconstriction in the human choroid by topical unoprostone isopropyl. arch ophthalmol. 2002; 120: 348-58. 31. beano f, orgul s, stumpfig d, et al. an evaluation of the effect of unoprostone isopropyl 0.15% on ocular hemodynamics in normal-tension glaucoma patients. graefes arch clin exp ophthalmol. 2001; 239: 81-6. 261 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol original article frequency of ocular diseases in the prisoners of district jail lahore muhammad iqbal javed, arif hussian, asad aslam khan pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad iqbal javed senior optometrist gulab devi teaching hospital, lahore email: iqbaljaved_opt@yahoo.com …..……………………….. objective: to find the frequency of different ocular diseases in the prisoners of district jail, lahore. place and duration of study: health care unit within the vicinity of jail during 1st week of june 2014. material and methods: total number of jail inmates was 3050. two hundred and seventy individuals reported ocular problems who were examined by the visiting team. complete eye examination was performed and data was collected. the patients with refractive errors were given spectacles and diseases manageable with eye drops were treated accordingly. patients having glaucoma, cataract, retinal disorders of diabetes or hypertension were referred to mayo hospital for more detailed examination and free treatment. this activity was a joint venture of social welfare department home department punjab, administration of district jail lahore and college of ophthalmology and allied vision sciences, king edward medical university/mayo hospital lahore. the jail inmates were the beneficiaries of this project and all medicines and spectacles were provided free of cost, funded by sight savers, pakistan. results: there were 56.29% individuals who had normal vision (better than 6/12). 79% of inmates were more than 40 year of age. conjunctivitis was seen in 3%, glaucoma in 1% and cataract in 2% of the individuals. there was 4.07% myopia (n = 11), 3.33% hypermetropia (n = 9), 2.22% astigmatism (n = 6) and cases of presbyopia were 34.07% (n = 92). conclusion: screening jail inmates to prevent and control ocular diseases is essential to blindness in this community. key words: refractive errors, eye health, screening, vision. ife behind the bars is very hard because there are no privileges for the inmates of prison in a country like pakistan. district jail, established during british era in 1930, situated on ferozepur road, lahore, is managed by the government of punjab. there is a dispensary for primary health care, a medical store and a ward containing 30 beds. the social welfare officer (swo) of social welfare department punjab is responsible for the welfare activities of prisoners. in a country where systems are not much developed, role of swo is vital especially for the socially marginalized people like prisoners. prison department with the support of swo, therefore, provides a valuable opportunity to offer screening to inmate prisoners who have considerable unmet needs. various social groups including prisoners remain outside healthcare system due to the social marginalization. in pakistan, corporate sector or government health department is not so strong that all tasks could be managed by the government alone. this is the mutual responsibility of the state, social sector, ngos and the community at large to strive and resolve health related tribulations through carefully designed health care programs. on behalf of jail administration, the designated social welfare officer (swo) appointed in the jail l frequency of ocular diseases in the prisoners of district jail lahore pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 262 requested college of ophthalmology and allied vision sciences (coavs), king edward medical university/mayo hospital lahore, to look into the matter of ophthalmic diseases and refractive errors in inmates. swo was responsible for our complete protocols, responsibilities within the prison and he also helped in planning and executing this activity. the purpose of the disease was to find the frequency of different ocular diseases in the prisoners of district jail, lahore. material and methods the social welfare officer of the district jail lahore (djl) made a proposal for this activity and a letter was signed by him on behalf of the superintendent, district jail lahore. principle/director general, coavs, king edward medical university/mayo hospital lahore designated a full ophthalmic team on a formal letter for the activity. the jail administration was also informed about the time and date of this activity. we followed the jail protocol with all necessary security provided from the jail administration. whole of the activity was performed in the presence of medical staff and security staff of the jail hospital. to examine the individuals, they were called one by one in the examination room, which was declared ophthalmic consultation room on that day of activity. the prisoners were divided into groups containing 5 individuals each. for security purpose, each group was examined separately and then sent back to their barracks. the other group was then called in for examination. the total number of jail inmates was 3050, among those 270 individuals were selected by convenient sampling technique. all the prisoners with any ocular problem were included in the study. the individuals were examined by ophthalmologist and optometrist to evaluate the underlying cause of ocular problem and to decide about further management. the team had to manage referrals for any surgical or medical interventions and any further investigations for a complex case. this project also had the facility to provide spectacles to all the individuals receiving prescription for glasses. the team made arrangements for the early diagnosis of cataract, glaucoma, diabetic retinopathy, hypertensive retinopathy, bacterial and viral diseases along with the refractive errors. the superficial corneal and conjunctival diseases were treated with antibiotic eye drops and ointments. patients having glaucoma, cataract, retinal disorders of diabetes or hypertension were referred to mayo hospital for more detailed examination and free treatment of the patients. glasses were delivered to the inmates through swo within 2 weeks. results fifty-eight prisoners out of 270 (21.48%) were between 30-40 years, 31.85% (n = 86) were of 41.50 years of age. 31.11% (n = 84) were placed in 51.60 years of age group and 15.55% (n = 42) were more than 60 years. normal vision was seen in 56.29% (n = 152). visual acuity (va) of < 6/12 — 6/60 were found in 8.88% (n = 24). 0.74% (n = 2) of them were blind. 34.07% had problem for near vision. there was 4.07% myopia (n = 11), 3.33% hypermetropia (n = 9), 2.22% astigmatism (n = 6) and cases of presbyopia were 34.07% (n = 92). for details, see tables 1 to 4. table 1: age wise breakdown of the prisoners. s/n age group total percentage 1. 30 – 40 58 21.48% 2. 41 – 50 86 31.85 % 3. 51 – 60 84 31.11 % 4. > 60 42 15.55 % total 270 100% table 2: vision status of the sample population. s/n unaided visual acuity right eye left eye percentage 1. normal 6/6 – 6/12 152 152 56.29 2. < 6/12 – 6/60 24 24 8.88 3. < 6/60 – 3/60 2 2 0.74 4. < n-6 (near vision scale) 92 92 34.07 total 270 270 100 muhammad iqbal javed, et al 263 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol table 3: types of refractive errors. condition total percentage normal 152 56.29% myopia 11 4.07 % hypermetropia 9 3.33 % astigmatism 6 2.22% sub total 26 presbyopia 92 34.07 % total 270 100 table 4: types of ocular disorders in the sample. s/n disorder total percentage 1. refractive errors 12 38.51 % 1a. presbyopia 92 2. conjunctivitis 9 3.33 % 3. glaucoma 2 0.74% 4. cataract 6 2.22 % 5. eye injury 1 0.37 % 6. normal (with no ocular pathology) 152 56.29 % total 270 100 discussion life in prison is deprived of many basic needs. according to a study done in usa, data of 7500 inmates revealed that they faced severe stress and were victimized (sexual, physical, either, or both) during the life span in prison1. along with other basic needs, health care facilities are also important for the prisoners. the quality of healthcare delivery within correctional settings such as prisons, jails and other detention facilities is vital and an issue of human rights concern too2. as the prison population continues to grow, there is more than ever a need to have regular and comprehensive eye examinations for these persons3. brian r has suggested frequent eye examinations in the prisoners4. in prison administration bureau of jiangsu province, nanjing, china, efforts were done for the health training of male and female prisoners along with the health care facilities5. in the last national survey of blindness conducted in 2004 in pakistan, visual cut off point was same (6/12) as in this particular study. in australia, 16% of adults of 40 years and above had myopia and 6% had hyperopia6. in another study of persons with age 40 years and above in japan, the prevalence of myopia and hyperopia was 42% and 8% respectively7. in a population-based study at singapore with people aged 40 years and above, prevalence of myopia was 31% and the prevalence of hyperopia was 27%8. another research in a primary eye care setup, myopia was 15%9. rapid assessment of refractive error (rare) protocol has shown prevalence of refractive error of 6.4% and prevalence of presbyopia 33%10. both of these are similar to our values. in a prison study in nigeria, mean age was 32 years in which 492 prisoners were examined. seventy percent had various eye disorders. refractive error was the most common eye disorder. the most common ocular conditions were refractive error (35%), allergic conjunctivitis (15%), presbyopia (11%) and glaucoma (9%)11. in our study, 38% of total had some type of refractive error including presbyopia, 2% of them had cataract, 3% had conjunctivitis and 0.7% had glaucoma. in a severely poor and socially marginalized population (cocco formers) in ghana, refractive error was identified in 29%, cataract in 20%, glaucoma in 12% and conjunctivitis as high as 13%12. in another survey, prevalence of presbyopia was 63%13. in kenya 15% had at least one ocular morbidity and presbyopia was the leading cause with 25% of participants over 35 years14. it was similar to our results. a population-based study was conducted with 3000 people aged ≥ 40 years in weaving communities who were all illiterate. the prevalence of presbyopia was 62% and the prevalence of functional presbyopia was 35%15. in northern iran, prevalence of presbyopia was 58%16. similarly, presbyopia was 31% among 1560 marine fishermen of india17. in a previous study conducted in pakistan, prevalence of myopia, hypermetropia and astigmatism was 36.5%, 27.1%, and 37%, respectively18. cataract is the largest cause of blindness worldwide19,20. the number of people blind from cataract in the world is increasing by approximately 1 million per year and the number of ‘operable’ cataract eyes with a visual acuity of less than 6/60 is increasing by 4–5 million per year. there were 6 cases of cataract in our study who were referred for management. keeping in view the status of ocular diseases in district jail, lahore, visit of ophthalmologist or optometrist should be planned twice a year and proper referral chain for refractive errors, cataract, glaucoma, epidemic eye diseases, diabetic retinopathy, and hypertensive retinopathy is suggested for prevention of the eye problems in jail inmates. although round the clock dispensary with medical staff and other facilities are available in every jail but there should be proper and comprehensive eye care frequency of ocular diseases in the prisoners of district jail lahore pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 264 training for the medical staff for screening of eye diseases and vision problems. conclusion this activity is a very good example to work for the betterment of jail inmates to control ocular diseases and to prevent this under-privileged class from blindness. references 1. wolff n, shi j, siegel ja. patterns of victimization among male and female inmates: evidence of an enduring legacy. violence vict. 2009; 24 (4): 469-84. 2. friestad. socio-economic status and health in a marginalized group: the role of subjective social status among prison inmates. eur j public health, 2009; 20 (6): 653-658. 3. griffin mm, ryan jg, briscoe vs, shadle km. effects of incarceration on hiv-infected individuals. j natl med assoc. 1996; 88 (10): 639-44. 4. brian r. ariel, donald f.c. the incidence and significance of low visual acuity in a prison population, 2004; 1: 33-34. 5. health in prisons, a who guide to the essentials in prison health. 2007. publications. who regional office for europe, scherfigsvej 8, dk-2100 copenhagen ø, denmark. 6. kempen jh, mitchell p, lee ke, tielsch jm, broman at. the prevalence of refractive errors among adults in the united states, western europe, and australia. arch ophthalmol. 2004; 122 (4): 495-505. 7. sawada a, tomidokoro a, araie m. refractive errors in an elderly japanese population: the tajimi study. ophthalmology, 2008; 115 (2): 363-370. 8. saw sm, chan yh, wong wl, shankar a, sandar m. prevalence and risk factors for refractive errors in the singapore malay eye survey ophthalmology, 2008; 115 (10): 1713-9. 9. rodriguez nm, romero af. the prevalence of refractive conditions in puerto rican adults attending an eye clinic system. j optom. 2014; 7 (3): 161-7. 10. chan vf, mebrahtu g, ramson p, wepo m, naidoo ks. prevalence of refractive error and spectacle coverage in zoba ma'ekel eritrea: a rapid assessment of refractive error. ophthalmic epidemiol. 2013; 20 (3): 131-7. 11. ajite ko, adegbehingbe bo, omotoye oj, ajayi ia, taiwo o. prevalence of eye disease among inmates of ilesa prison, southwest nigeria. njcm. 2001; 4: 1. 12. boadi-kusi sb, hansraj r, kumi-kyereme a, agromedicine j. ocular health assessment of cocoa farmers in a rural community ghana, 2014; 19 (2): 17180. 13. uche jn, ezegwui ir, uche e. prevalence of presbyopia in a rural african community. rural remote health, 2014; 14 (3): 2731. 14. kimani k, lindfield r, senyonjo l, mwaniki a, schmidt e. prevalence and causes of ocular morbidity in mbeere district, kenya. results of a population-based survey. plos one, 2013; 8 (8): e70009. 15. marmamula s, narsaiah s, shekhar k, khanna rc. presbyopia, spectacles use and spectacle correction coverage for near vision among cloth weaving communities in prakasam district in south india. ophthalmic physiol opt. 2013; 33 (5): 597-603. 16. hashemi h, khabazkhoob m, jafarzadehpur e. population-based study of presbyopia in shahroud, iran. clin experiment ophthalmol. 2012; 40 (9): 863-8. 17. marmamula s, madala sr, rao gn. prevalence of uncorrected refractive errors, presbyopia and spectacle coverage in marine fishing communities in south india: rapid assessment of visual impairment (ravi) project. ophthalmic physiol opt. 2012; 32 (2): 149-55. 18. shah sp, jadoon mz, dineen b, bourne rr, johnson gj, gilbert ce, khan md. refractive errors in the adult pakistani population: the national blindness and visual impairment survey. ophthalmic epidemiol. 2008; 15 (3): 183-90. 19. bloo gj, hesselink gj, oron a, emond ej, damen j. meta-analysis of operative mortality and complications in patients from minority ethnic groups. br j surg. 2014; 101 (11): 1341-9. 20. minassian dc, mehra v. 3.8 million blinded by cataract each year: projections from the first epidemiological study of incidence of cataract blindness in india. br j ophthalmol. 1990; 74 (6): 341-343. author’s affiliation muhammad iqbal javed senior optometrist al-aleem medical college/ gulab devi teaching hospital, lahore arif hussian community ophthalmologist coas, mayo hospital, lahore asad aslam khan professor of ophthalmolgy kemu, lahore author’s contribution muhammad iqbal javed study design, data collection, manuscript writing, final review. arif hussian study design, final review. asad aslam khan study design, final review. http://www.ncbi.nlm.nih.gov/pubmed?term=wolff%20n%5bauthor%5d&cauthor=true&cauthor_uid=23681327 http://www.ncbi.nlm.nih.gov/pubmed?term=shi%20j%5bauthor%5d&cauthor=true&cauthor_uid=23681327 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http://www.ncbi.nlm.nih.gov/pubmed?term=broman%20at%5bauthor%5d&cauthor=true&cauthor_uid=15078666 http://www.ncbi.nlm.nih.gov/pubmed?term=broman%20at%5bauthor%5d&cauthor=true&cauthor_uid=15078666 http://www.ncbi.nlm.nih.gov/pubmed/15078666 http://www.ncbi.nlm.nih.gov/pubmed/15078666 http://www.ncbi.nlm.nih.gov/pubmed/15078666 http://www.ncbi.nlm.nih.gov/pubmed?term=sawada%20a%5bauthor%5d&cauthor=true&cauthor_uid=18243904 http://www.ncbi.nlm.nih.gov/pubmed?term=tomidokoro%20a%5bauthor%5d&cauthor=true&cauthor_uid=18243904 http://www.ncbi.nlm.nih.gov/pubmed?term=araie%20m%5bauthor%5d&cauthor=true&cauthor_uid=18243904 http://www.ncbi.nlm.nih.gov/pubmed?term=saw%20sm%5bauthor%5d&cauthor=true&cauthor_uid=18486221 http://www.ncbi.nlm.nih.gov/pubmed?term=chan%20yh%5bauthor%5d&cauthor=true&cauthor_uid=18486221 http://www.ncbi.nlm.nih.gov/pubmed?term=wong%20wl%5bauthor%5d&cauthor=true&cauthor_uid=18486221 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http://www.ncbi.nlm.nih.gov/pubmed?term=shekhar%20k%5bauthor%5d&cauthor=true&cauthor_uid=23758169 http://www.ncbi.nlm.nih.gov/pubmed?term=khanna%20rc%5bauthor%5d&cauthor=true&cauthor_uid=23758169 http://www.ncbi.nlm.nih.gov/pubmed/23758169 http://www.ncbi.nlm.nih.gov/pubmed?term=hashemi%20h%5bauthor%5d&cauthor=true&cauthor_uid=22429288 http://www.ncbi.nlm.nih.gov/pubmed?term=khabazkhoob%20m%5bauthor%5d&cauthor=true&cauthor_uid=22429288 http://www.ncbi.nlm.nih.gov/pubmed?term=jafarzadehpur%20e%5bauthor%5d&cauthor=true&cauthor_uid=22429288 http://www.ncbi.nlm.nih.gov/pubmed/22429288 http://www.ncbi.nlm.nih.gov/pubmed?term=marmamula%20s%5bauthor%5d&cauthor=true&cauthor_uid=22276902 http://www.ncbi.nlm.nih.gov/pubmed?term=madala%20sr%5bauthor%5d&cauthor=true&cauthor_uid=22276902 http://www.ncbi.nlm.nih.gov/pubmed?term=rao%20gn%5bauthor%5d&cauthor=true&cauthor_uid=22276902 http://www.ncbi.nlm.nih.gov/pubmed/22276902 http://www.ncbi.nlm.nih.gov/pubmed?term=shah%20sp%5bauthor%5d&cauthor=true&cauthor_uid=18569814 http://www.ncbi.nlm.nih.gov/pubmed?term=jadoon%20mz%5bauthor%5d&cauthor=true&cauthor_uid=18569814 http://www.ncbi.nlm.nih.gov/pubmed?term=dineen%20b%5bauthor%5d&cauthor=true&cauthor_uid=18569814 http://www.ncbi.nlm.nih.gov/pubmed?term=bourne%20rr%5bauthor%5d&cauthor=true&cauthor_uid=18569814 http://www.ncbi.nlm.nih.gov/pubmed?term=johnson%20gj%5bauthor%5d&cauthor=true&cauthor_uid=18569814 http://www.ncbi.nlm.nih.gov/pubmed?term=johnson%20gj%5bauthor%5d&cauthor=true&cauthor_uid=18569814 http://www.ncbi.nlm.nih.gov/pubmed?term=johnson%20gj%5bauthor%5d&cauthor=true&cauthor_uid=18569814 http://www.ncbi.nlm.nih.gov/pubmed?term=gilbert%20ce%5bauthor%5d&cauthor=true&cauthor_uid=18569814 http://www.ncbi.nlm.nih.gov/pubmed?term=khan%20md%5bauthor%5d&cauthor=true&cauthor_uid=18569814 http://www.ncbi.nlm.nih.gov/pubmed/18569814 http://www.ncbi.nlm.nih.gov/pubmed?term=bloo%20gj%5bauthor%5d&cauthor=true&cauthor_uid=25093587 http://www.ncbi.nlm.nih.gov/pubmed?term=hesselink%20gj%5bauthor%5d&cauthor=true&cauthor_uid=25093587 http://www.ncbi.nlm.nih.gov/pubmed?term=oron%20a%5bauthor%5d&cauthor=true&cauthor_uid=25093587 http://www.ncbi.nlm.nih.gov/pubmed?term=emond%20ej%5bauthor%5d&cauthor=true&cauthor_uid=25093587 http://www.ncbi.nlm.nih.gov/pubmed?term=damen%20j%5bauthor%5d&cauthor=true&cauthor_uid=25093587 http://www.ncbi.nlm.nih.gov/pubmed/25093587 http://www.ncbi.nlm.nih.gov/pubmed/25093587 http://www.ncbi.nlm.nih.gov/pubmed pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 131 original article evaluation of chitosan; a thermosensitive hydrogel drug delivery agent for loading dexamethosone hussain ahmad khaqan, muhammad yar, usman imtiaz, atteq-ur-rehman, hasnain muhammad buksh pak j ophthalmol 2019, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hussain ahmad khaqan lahore general hospital, ircbm (interdisciplinary research centre and biomedical materials) comsats institute of information technology, lahore, pakistan email: drkhaqan@hotmail.com purpose: to evaluate the characteristics of thermosensitive hydrogel (chitosan) drug delivery agent loaded with dexamethasone/chitosan which can be used in the treatment of macular edema and non infectious uveitis applied in sub tenon space. study design: quasi experimental study. place and duration of study: lahore general hospital, ircbm comsats institute of information technology, lahore, pakistan from july 2017 to july 2018. material and methods: acetic acid (0.5 m, 2.5 ml) and chitosan (0.2g) were dissolved and stirred for 1 hour and 30 minutes at room temperature. powdered dexamethasone (3.5 mg) was added and stirred for further 30 min at room temperature. this solution was placed at 4°c for 30 min to cool it down. after this, nahco3 solution (0.48 m, 2 ml) was added drop wise. once required ph was achieved, solution was placed inside oven at 37°c. formation of gel started after 3-5 minutes and it took 2 hours for complete conversion of liquid into hydrogel. results: the gelling time of the synthesized gel was 2 hours and was tested by test tube invert method. to prove the non-irritancy of thermosensitive hydrogel, hens egg test on chorioallantoic membrane assay (het-cam) was performed. results showed that synthesized hydrogel was non-irritant. outcomes hussain ahmad khaqan, et al 132 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology …..……………………….. of in vitro degradation tests displayed that synthesized hydrogels were biodegradable. the drug release tests revealed that synthesized hydrogels displayed sustained release of drug. conclusion: the analysis showed that physical changes and drug loading did not alter the chemical structure of chitosan therefore it is an effective potential vehicle for slow release of dexamethasone if placed in the sub tenon space. keywords: chitosan, dexamethasone, macular edema, non-infectious uveitis. o treat posterior segment eye diseases, four routes are available i.e., topical, periocular, intraocular and systemic. topical and systemic routes are not preferred route of drug administration because of having some significant disadvantages i.e., low ocular bioavailability of drug, frequent administration of high amount of drugs1. periocular route is the most preferable route for instillation of drug to the posterior segment of eye2 ensuring higher retinal and vitreal drug bioavailability (0.01-0.1%) which is higher than topical medication (≤ 0.001%)3. sub-tenon route is most preferable periocular route. the disadvantages of this route include cataract, hyphema, corneal decompensation and rise in intra ocular pressure. disadvantages of intravitreal steroid injections are worse than periocular sub-tenon pathway. therefore, sub-tenon route is preferred pathway for administration of steroid4. intravitreal injections have earned fame among researchers and clinicians. unlike topical and systemic routes, it offers high concentration of drug to vitreous, retina and choroid5. though it ensures bioavailability of drug, instillation of drug through this pathway is invasive and potentially risky which causes endophthalmitis, retinal detachment and vitreous hemorrhages6. scientists have made many efforts to enhance bioavailability of drug by designing different drug delivery systems i.e. ointments, suspensions, gels, collagen shields, implants and hydrogels7. in general there are three types of implants available in market for treatment of posterior segment eye diseases: nonbiodegradable, biodegradable and stimuli responsive implants. in non-biodegradable implants, fda has approved vitrasert® and retisert®. former implant carries ganciclovir drug for treatment of cytomegalo virus retinitis. it releases drug for 8 months. while the later implant carries fluocinolone acetonide to treat chronic non-infectious posterior uveitis. iluvien® implant is waiting for fda approval but accepted in some eu countries. for degradable implants, fda has approved only ozurdex®. none of these implants are available in pakistan for treatment of patients suffering from posterior segment eye diseases. however, each system has its own advantages and disadvantages.8 among all such devices, in-situ forming hydrogel has gained enormous attention by scientists. these hydrogels are liquid at room temperature and solid under physiological conditions9. these in-situ hydrogels can be achieved by several ways such as ph change, ionic cross linkage and temperature modulation. among all these, thermosensitive hydrogels got immense attention for ocular treatments because of its easy handling and low viscosity at room temperature10,11. chitosan, (poly-β(1,4)-d-glucosamine), has been extensively used as implant in the form of gels, fibers and membranes in the field of tissue engineering and biomedical sciences and drug controlled release systems. since chitosan is highly biocompatible, therefore, it has been extensively used for the synthesis of thermosensitive hydrogels which help to treat ocular diseases. various drugs have been loaded on to chitosan based thermosensitive hydrogels for treatment of ocular diseases for example, latanoprost was loaded on chitosan and gelatin based thermosensitive hydrogel for controlling ocular hypertension12. chitosan in combination with disodium α-d-glucose 1-phosphate (dgp) has been used for ocular drug delivery system13. a novel copolymer, poly (n-isopropylacrylamide)–chitosan (pnipaam–cs), was investigated for its thermosensitive in situ gel-forming properties and t evaluation of chitosan; a thermosensitive hydrogel drug delivery agent for loading dexamethosone pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 133 potential utilization for ocular drug delivery14. another novel thermosensitive hydrogel was made by using chitosan and glycidyltrimethylammonium chloride (gtmac) and named as n-[(2-hydroxy-3trimethylammonium) propyl] chitosan chloride (htcc)15. chitosan has been used as a carrier of dexamethasone drug to treat ocular diseases i.e., mucoadhesive chitosan-coated cationic microemulsion of dexamethasone for ocular delivery16,18. keeping in mind all such information, in present work, we are for the first time, aiming to use biodegradable chitosan thermosensitive gel loaded with dexamethasone and finding the potential use of sub-tenon space for insertion of these synthesized gels. this will provide sustained release of drug and will overcome the side effects of previous treatments to treat posterior segment eye diseases especially macular edema and uveitis. the cost of pre-existing treatments of these diseases are expensive and sometimes unaffordable when considering needs of individual patient. material and methods chitosan (dd = 80.91% and mol. wt. = 25992.88) was synthesized in our laboratories. acetic acid (ch3cooh) was purchased from riedel-dehaen (origin). from bio world (origin) pbs (phosphate buffer saline) was bought. nahco3 was bought from daejung chemicals and metals co., ltd (korea). dexamethasone was bought from zhejiang xianju junye pharmaceutical co., ltd (china). nacl was obtained from omicron sciences ltd (uk). from sigma-aldrich (germany) sodium hydroxide (naoh) was bought. in acetic acid (0.5 m, 2.5 ml) chitosan (0.2g) was dissolved and stirred for 1 hour and 30 min at room temperature. powdered dexamethasone (3.5 mg) was added and stirred for further 30 min at room temperature. this solution was placed at 4°c for 30 minutes to cool it down. after this, nahco3 solution (0.48 m, 2 ml) was added drop wise. in the meanwhile, ph change was monitored and finally maintained at 7. constant stirring was done to remove effervescence. once required ph was achieved, solution was placed inside oven at 37°c. formation of gel started after 3-5 minutes and it happened from the surface first. it took 2 hour for complete conversion of liquid into hydrogel. test tube invert method was used to analyze solto-gel transition. in this method, 0.5 ml polymer solution of given concentration was taken in 3 different vials. the vials containing polymer solution were placed at 4°c for 30 min – 1 hour. after this, each vial was immersed in separate water bath having different temperatures i.e. 10°, 25° and 37°, for 10 min. after 10 mins, each vial was taken out and inverted to 180°. if no visible flow was observed within 30s of inversion, sample was considered as ―gel‖. the ph of sample before and after gelation was calculated by calibrated ph meter (eutech instrument pc 150). neutral ph is the indication of completion of reaction between acid and base which is required for conversion of sol-to-gel. also, acidic or basic gel implant can cause irritation to the eye and can permanently damage the tissue. therefore, it is important to measure the ph of the gel. structural characterization of prepared thermosensitive hydrogels was carried out by fourier transfer infrared (ftir) spectroscopy, coupled with smart atr accessory. thermo-nicolet 6700p ftir spectrometer (usa) was used and the average number of scans were 256 at the resolution of 8 cm-1. spectra that were recorded ranged in wavelength of 4000650cm1. scanning electron microscope (tescan, vega lmu) at 10 kv under low vacuum mode at 10 pa was employed for the assessment of pore size and compact structure of synthesized hydrogel. at different magnifications images were obtained. image processing software (image j) was used to calculate the diameter of pore by selecting 30 pores randomly. for every sample composition (n=3) degradation tests were performed gravimetrically. two weights were taken to achieve this purpose. before immersing them into solutions, initial dry weight ( ) of hydrogels was taken. then the samples were kept in phosphate buffered saline (pbs), lysozyme solution (1mg/ml) in pbs at 37oc for different time points (day 1-day 28). the samples were taken out at each time point, dried at 37oc for 24 h and subsequently weighed ( ). the dried weight (without water content) remaining ratios were determined as following: drug release test was carried out in pbs. for this purpose, powdered dexamethasone was added in hussain ahmad khaqan, et al 134 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology stirring solution of chitosan and sodium bicarbonate wherein drug content was 0.7 mg/ml. after adding drug, resultant mixture was placed in oven at 37°c to form gel. hydrogel was cut into triplicates of equal weight (10 mg) and dipped into 5 ml pbs solution. at different time intervals (after 3 h, after 16 h, after 24 h and after 48 h) pbs solution in vials was replaced with the fresh one. collected pbs solutions were analyzed under uv/visible spectrophotometer (perkin elmer). amount of drug release was determined by following straight line equation: het-cam (hen’s egg test – chorioallantoic membrane) assay, most robust and successful assay, was used to evaluate irritation properties of chemicals and consumer products that might come in contact with human eyes. the assay covers a broad spectrum of chemicals with whole range of degrees of irritation and physical appearances of different substances. to evaluate the ocular tolerance of the developed thermosensitive hydrogel, het-cam test was performed with small modifications. briefly, freshly fertilized hen’s eggs were bought from big bird group (lahore, pakistan). they were put in an incubator at 37.8 ± 0.5°c and 55% humidity for nine days. at day 10, the egg shell was opened, and white egg membrane was removed carefully without injuring any underlying blood vessels. subsequently, the surface of the cam was exposed to 0.1g of the test substance, 0.1 m sodium hydroxide (naoh) solution (positive control), and a 0.9% nacl w/v saline solution (negative control). the chorioallantoic membrane and its clearly delineated vascular system was further assessed subjectively in terms of hyperemia, hemorrhage or coagulation. changes were examined using a light microscope (mitotic, china) before exposure and at different time points post-application for 5 min. scoring of each test substance was designated by using a classification system previously described by luepke and kemper (1986): non irritation: up to 0.9; slight irritant: 1-4.9; moderate irritant: 5-8.9; severe irritant: 9 and above. moreover, images were obtained before application and for 30 s, 2 min, and 5 min after exposure. results in the preparation of thermosensitive hydrogel of chitosan and loading with dexamethasone, it was shown that neutralization occurred which resulted in the formation of physical junctions (hydrogen bonding) between polymeric chains of chitosan. in chemical structure analysis by fourier transform infrared spectroscopy it was shown that fig. 1: step by step illustration of synthesis of thermosensitive hydrogel. fig. 2: ftir results of pure chitosan (a) and thermosensitive hydrogel (b). only temperature changed the physical appearance of polymer which was not significant. evaluation of chitosan; a thermosensitive hydrogel drug delivery agent for loading dexamethosone pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 135 fig. 3: sequence of pictures illustrating physical changes occurred at 37°c. (a) clear solution mixture before gelation. (b) gelation started at 37°c. (c) gelation completed at 37°c. yellow arrows are indicating effervescence of co2. fig. 4: scanning electron micrographs of synthesized hydrogel (magnification bars are given with each image). characterization of sol-to-gel transition temperature by test-tube invert method showed that no co2 was released at 4°c hence no gelation occurred. at 25°c, no gelation was observed within 10 minutes. but after immersing vial for 2 h, gelation started at very slow rate. best results were obtained at 37°c. before gelation the ph was 4.9 and after gelation it was 7.14. in-vitro drug release results showed that hydrogel can stay in sub-tenon region of eye over a month and release drug. based on these results, we are proposing that our synthesized biomaterial will be the first thermosensitive chitosan based hydrogel which will support sustained release of dexamethasone in subtenon region of the eye. to assess degradation potential of synthesized biomaterial, in vitro degradation test were performed. fig. 5: in vitro accumulative release of dexamethasone from chitosan hydrogel. fig. 6: in vitro degradation in pbs and lysozyme. we managed to mimic the physiological environment by selecting two media for degradation; pbs and lysozyme. from the results, it was concluded that hussain ahmad khaqan, et al 136 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology synthesized materials were degradable. pbs and lysozyme, both caused degradation to synthesized hydrogels. statistical analysis revealed significant difference (p = 0.0005) between the degradation values of day 7 and 28. in ocular irritancy test by het-cam which is a semi qualitative test to asses the irritation potential of a testing material. from figure 8, it was concluded that synthesized thermosensitive hydrogel was not irritant. discussion in the preparation of thermosensitive hydrogel of chitosan and loading with dexamethasone, the gelling mechanism of solution mixture of chitosan at 37°c involves neutralization of chitosan solution in the presence of nahco3 (figure 1). when chitosan is dissolved in 0.5m acetic acid solution, protonation of amino groups of chitosan takes place. at this point the ph of solution is 4.9. as 0.48m of nahco3 solution is added into the 0.5m of chitosan solution, co2 evolves. by experimentation, it is concluded that this neutralization reaction occurs only at or above 37°c19. in chemical structure analysis by fourier transform infrared spectroscopy, ftir spectra are obtained for pure powdered chitosan and synthesized thermosensitive hydrogel. broad peak between 32003500 cm-1 appears due to nh/oh stretching vibrations. the absorptions present in the range of 2919-2910 cm-1 are assigned to ch stretching vibrations and peaks for ch bending vibration were present around 1400 cm-1,. the absorptions around 1650 and 1585 cm-1 are attributed to amide i (-c = o stretch) and amide ii (-c-n stretch and -c-n-h bending vibrations), respectively20. it is found that co-c deformation band appears around 1097cm1 characterization of sol-to-gel transition temperature by test tube invert method is used to analyze the temperature required for sol-to-gel transition. for this purpose, 5 ml of fresh chitosan/nahco3 mixture having dispersed dexamethasone is added into vial. this vial is immersed in water bath for 10 minutes at three different temperatures: 4°c, 25°c and 37°c. gelation time is observed by tilting vial at an angle of 90° for 1 min till no flow. from results it is observed that no co2 is released at 4°c hence no gelation occurs. at 25°c, no gelation is observed within 10 minutes. but after immersing pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 1 fig. 7: sequence of photographs of het/cam test illustrating the effect of a) saline 0.9% w/v, b) 0.1m naoh, c) chitosan/naco3/dex. fig. 8: cumulative het-cam score: 0.9% saline solution (nacl 0.9% w/v) (-ve control); o.1m naoh (+ve control); synthesized thermo-gel. vial for 2 h, gelation starts at very slow rate. best results are obtained at 37°c. as solution mixture in vial gains 37°c temperature, gelation starts instantly but completes after 2 h. the reason is quick liberation of co2 which results into neutralization of solution mixture and conversion of liquid solution into solid hydrogel21. in addition to other factors, drug release from hydrogels depends upon pore structure and pore size of hydrogel. the porous nature of biomaterial assists in high loading capacity and controllable release of drug. to analyze porous nature of synthesized dried hydrogels, scanning electron microscopic (sem) technique is employed. sem images show that pores and void spaces are present and are very well connected with each other. the mean pore size of hydrogels is: 31.7913 µm ± 2.855µm. from literature, it is confirmed that 30 µm pore size in chitosan based thermosensitive hydrogel provides sustained release of drug for ocular diseases treatment. half-life of dexamethasone is shorter than other corticosteroids22. therefore, sustained and continuous release of dexamethasone is important. from this evaluation of chitosan; a thermosensitive hydrogel drug delivery agent for loading dexamethosone pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 137 current research the cumulative release of dexamethasone is shown in figure 6. it is concluded that hydrogel exhibits sustained release of drug. it provided only 5% release of dexamethasone over time span of two days. this sustained release of drug may be attributed to the inner dense network of hydrogel which traps the drug through hydrogen bonding causing slow release of drug23. results show that hydrogel can stay in sub-tenon region of eye over a month and release drug. degradation studies are performed for 28 days. lysozyme is taken because it is confirmed from literature that it is present in specific quantity in various ocular inflammations. to investigate the biodegradation of polymeric scaffolds, lysozyme, a renowned enzyme is used for cleavage of carbohydrates. in vitro studies of chitosan, lysozyme have been used extensively as it breaks 1, 4-β linkage of carbohydrates, disassociate them24. lysozyme is taken as 0.0068 mg/ml that corresponds to the concentration of lysozyme in human eye. potential of irritation can be detected by observing changes to the delicate vasculature of chorio allantoic membrane which is similar to the vascularized mucosal tissue of human eye. scoring of irritancy potential is classified according to luepke and kemper (1986)25. to compare the results, 0.1m naoh is used as positive control and 0.9% (w/v) nacl solution is used as negative control. naoh caused flower like bursting, hemorrhaging and swelling on cam. the score of irritancy potential is recorded as 9. saline solution and thermosensitive hydrogel does not cause any bleeding, swelling or hemorraging. scoring of irritancy potential is recorded as 0.23 for negative control (saline solution) and 0.3 for tested thermogel. hence, we conclude that synthesized hydrogel will not cause any harm to eyes. conclusion in current study, a biodegradable, non-irritant and an inexpensive injectable thermosensitive gel was prepared to use in the sub-tenon’s space for sustained release of dexamethasone. this study was supported by performing various tests: ft-ir confirmed that chemical structure of thermogel was not altered by dexamethasone, in vitro degradation studies exhibited 24.52% degradation in pbs solution and 43.45% in lysozyme solution, in vitro drug release studies confirmed sustained release of dexamethasone from thermogel and het-cam assay helped in assessing irritancy potential of prepared hydrogel confirming their non-irritant behaviour.. the synthesized hydrogel is a promising economical vehicle for sustained release of dexamethasone to the posterior segment of eye and efficient alternative of existent costly procedures. acknowledgement we acknowledge higher education commision and ministry of science and technology pakistan for financial support. author’s affiliation dr. hussain ahmad khaqan md, frcs, (glas), fcps, (ophth), fcps (vr), cico (london), cmt (uol),fellowship medical retina, fellowship in surgical retina associate professor ameer-ud-din medical college, pgmi lahore general hospital eye unit ii muhammad yar phd, ircbm (interdisciplinary research centre and biomedical materials) comsats institute of information technology, lahore, pakistan usman imtiaz mbbs, fcps (ophth), mrcsed, vr fellow senior registrar, lahore general hospital, atteq-ur-rehman mbbs, 2nd year pgr ameer-ud-din medical college, pgmi lahore general hospital eye unit ii hasnain muhammad buksh mbbs, fcps, (ophth) vr fellow senior registrar ameer-ud-din medical college, pgmi lahore general hospital eye unit ii author’s contribution hussain ahmad khaqan manuscript writing, critical review muhammad yar study design, drug preparation and laboratory tests, statistical analysis usman imtiaz data collection and statistical analysis hussain ahmad khaqan, et al 138 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology atteq-ur-rehman data collection hasnain muhammad buksh data collection and statistical analysis references 1. hughes pm, olejnik o, chang-lin je, wilson cg. topical and systemic drug delivery to the posterior segments, adv drug del. 2005; 57: 2010-2032. 2. duvvuri s, majumdar s, mitra ak. drug delivery to the retina: challenges and opportunities, expert opin biol ther. 2003; 3: 45-56. 3. kim h, robinson mr, lizak mj, tansey g, lutz rj, yuan p, et al. controlled drug release from an ocular implant: an evaluation using dynamic threedimensional magnetic resonance imaging, invest ophthalmol vis sci. 2004; 45: 2722-2731. 4. urtti a, pipkin jd, rork g, sendo t, finne u, repta a. controlled drug delivery devices for experimental ocular studies with timolol 2. ocular and systemic absorption in rabbits, int j pharm. 1990; 61: 241-249. 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nanoparticles and thermosensitive hydrogel for challenging ophthalmic drug delivery. colloids and surfaces b: biointerfaces, 2014 feb. 1; 114: 111-20. 25. luepke np, kemper fh. the het-cam test: an alternative to the draize eye test. food and chemical toxicology, 1986 jun. 1; 24 (6-7): 495-6. frequency, causes and management of pseudophakic glaucoma in out patient department of a tertiary care hospital 13 pakistan journal of ophthalmology, 2020, vol. 36 (1): 13-16 original article frequency of pseudophakic glaucoma in a tertiary care hospital of pakistan uzma fasih 1 , erum shahid 2 , arshad shaikh 3 1-3 department of ophthalmology, abbasi shaheed hospital, pakistan abstract purpose: to evaluate the frequency, causes and management of pseudophakic glaucoma among the pseudophakic patients presenting in a tertiary care hospital of pakistan. study design: this was a descriptive cross sectional study. place and duration of study: department of ophthalmology, abbasi shaheed hospital, pakistan, from august 2017 to june 2018. material and methods: adult patients between 50 to 70 years of age with pseudophakic glaucoma were included in the study by non-probability convenience sampling after institutional review board approval. patients with primary open angle, primary angle closure, traumatic glaucoma, diabetes mellitus and hypertension were excluded. pseudophakic glaucoma was labeled in case of cataract surgery with intraocular lens implantation and intraocular pressure > 21 mmhg or more in one eye along with glaucomatous optic disc or retinal nerve fiber layer defect on oct (optical coherence tomography). frequencies were computed for categorical variables. data was analyzed on spss version 20. results: twenty-eight eyes with pseudophakic glaucoma were studied. there were 15 (53.57%) males. mean age was 63 ± 10.4 sd years. mean iop was 30.78 ± 7.5 mm hg. patients with extracapsular cataract extraction were 18 (64.2%) and 10 (35.8%) had phacoemulsification. most frequent cause was posterior capsular rupture (n = 16, 57.1%) followed by pupillary block, (n = 4, 14.2%) and ugh (n = 3, 10.7%). medical treatment was successful in 20 (71.4%) and surgical treatment was done in 8 patients. conclusion: most common causes of pseudophakic glaucoma are posterior capsular rupture, vitreous loss, uveitis and pupillary block. pseudophakic glaucoma is more common with anterior chamber intraocular lenses and extracapsular cataract extraction. key words: anterior chamber intraocular lens, extracapsular cataract extraction, glaucoma, posterior chamber intraocular lens, pseudophakic glaucoma. how to cite this article: fasih u, shahid e, shaikh a. frequency of pseudophakic glaucoma in a tertiary care hospital of pakistan, pak j ophthalmol. 2020;36 (1): 13-18. doi: https://doi.org/10.36351/pjo.v36i1.903 introduction glaucoma is the second leading cause of blindness worldwide 1 . it affects 60 million people globally and is responsible for 12% of global blindness. 2 the term correspondence to: uzma fasih associate professor eye department abbasi shaheed hospital, karachi medical & dental college. email: yousufuzma@hotmail.com ‘pseudophakic glaucoma’ refers to the development of glaucoma following cataract surgery with implantation of intraocular lens. it may present immediately after cataract surgery within few hours or present few weeks to months later. pseudophakia is not directly responsible for development of glaucoma but multiple mechanisms play role in commencing glaucoma, like anterior chamber distortion, hemorrhage, inflammation, pigment dispersion, vitreous in anterior chamber, https://doi.org/10.36351/pjo.v36i1.903 frequency of pseudophakic glaucoma in a tertiary care hospital of pakistan pakistan journal of ophthalmology, 2020, vol. 36 (1): 13-18 14 pupillary block, malignant glaucoma and nd: yag (neodymium-doped yttrium aluminum garnet) laser capsulotomy 3,4 . incidence of pseudophakic glaucoma differs widely across the globe. various studies have reported the incidence of pseudophakic glaucoma from 5-41% in complicated surgeries 5 . prevalence of chronic pseudophakic glaucoma has been reported between 2.1-4% after a standard extracapsular cataract surgery and 11.3% in secondary anterior chamber implants 5 . cataract surgery is associated with postoperative inflammation. outpouring of inflammatory cells in anterior chamber after surgical trauma leads to obstruction of trabecular meshwork. this is followed by increase in intra ocular pressure (iop) causing glaucoma. rupture of posterior capsule and retained lens matter may be another cause for pseudophakic glaucoma. viscoelastic substances like sodium hyaluronate and methylcellulose used, during cataract surgery to protect the corneal endothelium and maintain the depth of anterior chamber, might lead to transient obstruction of trabecular meshwork and rise of postoperative intraocular pressure 6 . sulcus implanted posterior chamber intraocular lenses, malpositioned, and improperly sized anterior chamber intraocular lenses result in uveitis-glaucomahyphema syndrome (ugh) 7 . pseudophakic pupillary block glaucoma is also seen in anterior chamber iol (intra ocular lenses) due to vitreous humor in anterior chamber or formation of peripheral anterior synechiae. yag laser capsulotomy for posterior capsular opacification is associated with transient rise in intraocular pressure and may become a chronic problem 6 . the pseudophakic glaucoma can be diagnosed by taking a proper history regarding the cataract surgery and thorough examination including slit lamp examination, applanation tonometry, gonioscopy, fundoscopy, perimetry and oct (optical coherence tomography) 6 . management of pseudophakic glaucoma depends on the mechanism by which it is caused 6 . pseudophakic glaucoma is sometimes misdiagnosed and mismanaged. a thorough postoperative examination in this context would help in timely diagnosis and management of the disease. a thorough literature search has been done on various search engines including pubmed, medscape, science of web, elsevier, scopus and pakmedinet but no relevent local study has been found on pseudophakic glaucoma. causes of pseudophakic glaucoma have been addressed independently in different studies but few presented them collectively 3,4 . in addition, few studies have been done on pseudophakic glaucoma among children but causes among adults are not dealt with 8 . we conducted this study to evaluate the frequency, causes and management of pseudophakic glaucoma among the pseudophakic patients presenting in an eye opd of a tertiary care hospital of pakistan. material and methods this was a descriptive cross sectional study carried out in an eye opd of abbasi shaheed hospital, from august 2017 to june 2018. sample size was calculated using open epi sample size calculator version 3 for demographic studies. keeping confidence interval at 95%, margin of error 5% and the hypothesized frequency p for the pseudophakic glaucoma 17, the sample size calculated was 213. the study adheres to the tenets of declaration of helsinki. patients were selected through nonprobability consecutive sampling technique. we included pseudophakic patients between 50-70 years of age with anterior chamber and posterior chamber intraocular lens implantation with minimum 6 weeks to maximum 5 years post operative period. patients with history of primary open angle glaucoma, primary angle closure glaucoma, traumatic glaucoma, inflammatory glaucoma, congenital glaucoma, pseudoexfoliation, chronic uveitis, corneal opacities, aphakia, hypertension, diabetes and patients using topical or oral steroids were excluded. a detailed history of the patients was taken. an ocular examination was carried out. visual acuity was assessed on snellen’s chart. slit lamp examination was done to rule out corneal edema, presence of cells or flare in anterior chamber, vitreous in anterior chamber, anterior chamber or posterior chamber iol. applanation tonometry was done to measure intra ocular pressure (iop). angle was assessed with the help of gonioscopy. a detailed fundoscopic assessment of the disc and rnfl was done. perimetry and oct (optical coherence tomography) were further done to establish the diagnosis of glaucoma. pseudophakic glaucoma was labeled when the patient had history of cataract surgery with intraocular lens implantation (anterior chamber iol/posterior chamber iol) and intraocular pressure greater than 21 mm hg fasih u, et al 15 pakistan journal of ophthalmology, 2020, vol. 36 (1): 13-18 or more in one eye along with glaucomatous optic disc (vertical cup to disc ratio 0.7 ± 0.2) and retinal nerve fiber layer defect on oct or typical glaucomatous field defects on perimetery. patients were managed according to the mechanism of glaucoma either medically or surgically or by laser treatment (argon laser trabeculoplasty or yag laser iridotomy). as the post operative duration for inclusion criteria was from 6 weeks to 5 years post operatively, the topical steroids had been stopped by that time and if they had to be prescribed for postoperative inflammation the patients were monitored for iop and responders were excluded. data was collected and analyzed on spss version 20. frequencies were computed for categorical variables like gender, causes and management of pseudophakic glaucoma. means with standard deviation sd were calculated for age, intraocular pressure and duration of cataract surgery. results total number of pseudophakic patients in this study was 213. among them 28 (13.1%) patients were diagnosed with pseudophakic glaucoma. there were 15 (53.5%) male patients. mean age was 63 ± 10.4 years. mean iop was 30.78 ± 7.5 mm hg. eighteen patients (64.2%) underwent extracapsular cataract extraction and 10 (35.8%) underwent phacoemulsification. there were 7 (25.0%) patients with anterior chamber intraocular lens and 21 (75.0%) patients with posterior chamber intraocular lens. mean duration of presentation after cataract surgery was 2.7 ± 2.6 years. other demographic features of glaucoma patients at one year follow up are given in table 1. most frequent cause of pseudophakic glaucoma was posterior capsular rupture at the time of surgery (n = 16, 57.1%). this was followed by pupillary block (n = 4, 14.2%) and ugh (n = 3, 10.7%). less common causes were yag laser capsulotomy (n=2, 7.1%) and retained lens matter (n=1, 7.1%). frequencies of other causes of pseudophakic glaucoma are given in table 2. medical treatment was successful in 20 (71.4%) cases followed by surgical treatment (trabeculectomy in 4, 14.2%), and peripheral iridotomies in 4 (14.2%) patients for control of intraocular pressure as shown in table 3. table 1: demographic characteristic of the patients. variables frequency (%) pseudophakic glaucoma 28 (13.1%) mean age 63 ± 10.4 years sd male 15 (53.5%) female 13 (46.5%) mean iop 30.78 ± 7.5 mm hg sd mode of surgery ecce 18 (64.2%) phacoemulsification 10 (35.8%) type of intra ocular lens ac iol 7 (25.0%) pc iol 21 (75.0%) mean duration of surgery 2.7 ± 2.6 years sd iop: intra ocular pressure ac iol: anterior chamber intra ocular lens pc iol: posterior chamber intra ocular lens ecce: extra capsular cataract surgery table 2: causes of pseudophakic glaucoma. causes of pseudophakic glaucoma frequency n (%) posterior capsular rupture + uveitis pupillary block ugh syndrome yag laser capsulotomy retained lens matter pigment dispersion malignant glaucoma 16 (57.1%) 4 (14.2%) 3 (10.7%) 2 (7.1%) 1 (3.5%) 1 (3.5%) 1 (3.5%) table 3: management of pseudophakic glaucoma. treatment modality frequency n (%) medical treatment 20 (71.4%) trabeculectomy 4 (14.2%) peripheral iridectomy 4 (14.2%) discussion the term pseudophakic glaucoma refers to the glaucoma, which is seen after the cataract surgery with implantation of intraocular lens. there may be any one or multiple mechanisms working together for this entity 9 . we studied 213 pseudophakic patients and pseudophakic glaucoma was diagnosed in 28 (13.1%) patients. a study conducted in the same center in 2007 for evaluation and management of secondary glaucoma, reported 31 (29.2%) patients with pseudophakic glaucoma, 21 with posterior chamber intraocular lens and 10 with anterior chamber intraocular lens 10 . they had reported a higher frequency as their sample size specifically consisted of frequency of pseudophakic glaucoma in a tertiary care hospital of pakistan pakistan journal of ophthalmology, 2020, vol. 36 (1): 13-18 16 secondary glaucoma patients. chennai glaucoma study reported a prevalence of aphakic/pseudophakic glaucoma in 9.77% patients in rural india and 9.36% in their study in urban parts of india 11 . another study from andhra pardesh reported a prevalance of 14.6% which is quite similar to our study 12 . in south africa a prevalence of 0.02–0.04% is reported 13 . another study from thailand reported no case of pseudophakic glaucoma following cataract surgery 14 . these figures display a drastic difference in frequency of pseudophakic glaucoma between india, pakistan and other developed countries. this disparity could be due to the fact that different cataract eradication programs including camp surgeries have been running in our part of the world but unfortunately quality and standard is still questionable. phacoemulsification is the procedure of choice for cataract removal in developed countries, which is associated with fewer complications. mean age of patients in our study was 63 ± 10.4 sd years. arvind et al have reported a mean age of 64.85 ± 8.74 years, which is quite similar to our study. they have also suggested that increasing age could also be a risk factor for pseudophakic glaucoma 9 . mean intraocular pressure reported in our study was 30.78 ± 7.5 mm hg. arshinoff et al reported a mean iop of 22.2 mm hg in their study 15 . in our study, pseudophakic glaucoma was more frequent among patients with ecce than phacoemulsification. prevalence of pseudophakic glaucoma was reported in 2.1–4% patients in a study by park et al, after standard extracapsular cataract extraction 16 . cinoti has also reported an increased incidence (7.5%) of glaucoma after ecce 17 . in developing countries, patients are still presenting with mature and hypermature cataracts, which are dealt with extra capsular cataract surgery or small incision cataract surgery. high frequency of glaucoma in our setup could be due to the fact that our hospital is a tertiary care hospital. patients from other primary and secondary centers are being referred, particularly the complicated cases. surgeries are also sometimes performed by trainees. this again has high surgical complication rate. posterior chamber intraocular lens implant in our study was seen in 21 (75.0%) patients while anterior chamber intraocular lens implant was reported in 10 (25.0%) patients. a study by stark has also reported an incidence of 5.5% rise in intraocular pressure in anterior chamber intraocular lens implantation as compared to that of posterior chamber intraocular lens implantation (1.6%) 18 . ang et al has reported a rise of 30 mm hg in iop in 20% of the patients following posterior capsular rupture during phacoemulsification even after 24 hours of the surgery. more than 50% of his patients required anterior vitrectomy 19 . both openangle and closed-angle glaucoma may present in the early as well as late postoperative period. open-angle glaucoma may result from blockage of trabecular meshwork by vitreous, retained nuclear/cortical fragments, inflammatory cells, and pigment dispersion due to excessive intraocular manipulation 20 . postoperative uveitis along with posterior capsule rupture is one of the common causes of glaucoma among pseudophakic patients. diverse causes of uveitis that lead to glaucoma after cataract surgery are vitreous in anterior chamber following posterior capsular rupture, pigment dispersion, retained lens matter, retained viscoelastic and hyphema 3,4 . patients who presented with glaucoma in association with posterior capsular rupture were managed medically by topical beta blockers, topical and systemic carbonic anhydrase inhibitors and topical steroids and nonsteroidal anti-inflammatory drops. topical beta blockers and carbonic anhydrase inhibitors should be the preferred choice and miotics and prostaglandin inhibitors should be avoided 21 . pupillary block glaucoma was encountered in 4 (14.2%) patients. all of them were treated medically with beta blockers, carbonic anhydrase inhibitors and oral carbonic anhydrase inhibitors. later on iridectomy along with pupilloplasty was done when the corneal edema was clear. ugh syndrome caused glaucoma in 3 (10.7%) patients in this study. all of these patients had anterior chamber lens implantation (ac iol). ugh syndrome also known as ellingson syndrome is generally caused by a subluxated or malposition anterior or posterior chamber intraocular lens. it causes mechanical trauma to the adjacent structures as iris or cilliary body. as a result, there may be persistent inflammation, micro hyphema, pigment dispersion and rise in intraocular pressure 22 . in this group, all patients had to go for trabeculectomy while one patient required removal of ac iol. a study from china had reported 9.1% ugh syndrome, in which intraocular lenses had to be removed 22 . nd: yag laser capsulotomy for posterior capsular fasih u, et al 17 pakistan journal of ophthalmology, 2020, vol. 36 (1): 13-18 opacification is often accompanied with transient rise of intraocular pressure due to blockage of trabecular meshwork by inflammatory cells. it may become a chronic problem 6 . presentation of glaucoma following yag laser capsulotomy was in 2 (7.1%) patients. both were medically managed. one (3.5%) patient presented with glaucoma associated with retained lens matter. glaucoma associated with retained lens matter is an open angle glaucoma caused by the obstruction of outflow by macrophages and inflammatory mediators. in addition, there may be precipitation of lens proteins in trabecular meshwork 6 . this patient was treated medically by topical beta blockers, topical and oral carbonic anhydrase inhibitors and topical steroids. glaucoma due to pigment dispersion was seen in 1 (3.5%) patients. mierlo et al had reported a case series of 3 patients with pigment dispersion. improperly sulcus implanted posterior chamber intraocular lenses cause iatrogenic insult 23 . these patients had to undergo trabeculectomy after failure of medical treatment. viscoelastic substance causes 55–60% reduction in aqueous drainage when injected in anterior chamber. arshinoff et al had reported that dispersive viscoelastics are more helpful in protecting the ocular structures like corneal endothelium but are difficult to remove from the anterior chamber as compared to the cohesive ones 16 . they also reported that retained viscoelastic might be one of the main factors for postoperative rise of iop more than 21 mm hg 16 . fortunately, no case of retained viscoelastic substance was encountered in our study. malignant glaucoma presented in 1 (3.5%) patient in our study who was a hypermetrope. this is a rare entity, which is frequently encountered after trabeculectomy in narrow angle glaucoma but rarely can be seen after cataract surgery with intraocular lens implantation 24 . our patient responded well to medical treatment, which included cycloplegic, steroid and pressure lowering agents. we found carbonic anhydrase inhibitors alone or in combination with beta blockers to be more effective for long term control of iop in pseudophakic glaucoma. ermis et al also found carbonic anhydrase inhibitors more effective for long term reduction of iop 25 . strength of our study is that it has thoroughly investigated into the causes of pseudophakic glaucoma. it represents local data and will be helpful in managing patients in our region. this data can be used to generate hypothesis. further case control or cohort studies can be carried out in future to see association with variables. however, pseudophakic glaucoma should be thoroughly investigated and managed accordingly. postoperative care of such patients will significantly improve the quality of vision and life. limitation of our study is short follow up period of one year. conclusion anterior chamber intraocular lens is more frequently associated with pseudophakic glaucoma than sulcus implanted posterior chamber lens. chances of pseudophakic glaucoma are more in patients who undergo ecce as compared to phacoemulsification. majority of pseudophakic glaucoma responded well to medical treatment while others to surgical treatment. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest authors’ designation and contribution uzma fasih; associate professor: study design, manuscript writing, literature review. erum shahid; assistant professor: literature review and final review. arshad shaikh; professor: literature review and final review. references 1. kumarasamy na, lam fs, wang al, theoharides tc. glaucoma: current and developing concepts for inflammation, pathogenesis and treatment. eur j inflam. 2006 sep; 4 (3): 129-37. 2. dineen b, bourne rr, jadoon z, shah sp, khan ma, foster a, gilbert ce, khan md. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007 aug. 1; 91 (8): 1005-10. 3. tomey kf, traverso ce. the glaucomas in aphakia and pseudophakia. surv ophthalmol. 1991 sep. 1; 36 (2): 79-112. frequency of pseudophakic glaucoma in a tertiary care hospital of pakistan pakistan journal of ophthalmology, 2020, vol. 36 (1): 13-18 18 4. lee lc, pasquale lr. surgical management of glaucoma in pseudophakic patients. semin ophthalmol. 2002; 17(3-4):131-7 5. yi k, chen tc. aphakic glaucoma after congenital cataract surgery. intern ophthalmol clin. 2008; 48 (2): 87-94. 6. shields mb, rand r.. allingham, karim f.. damji. shields' textbook of glaucoma. chapter 26 lippincott williams & wilkins; 2005. 7. zhang l, hood ct, vrabec jp, cullen al, parrish ea, moroi se. mechanisms for in-the-bag uveitisglaucoma-hyphema syndrome. j cat ref surg. 2014; 40 (3): 490-2. 8. kirwan c, lanigan b, o’keefe m. glaucoma in aphakic and pseudophakic eyes following surgery for congenital cataract in the first year of life. acta ophthalmologica. 2010; 88 (1): 53-9. 9. arvind h, george r, raju p, ramesh sv, baskaran m, paul pg, mccarty c, vijaya l. glaucoma in aphakia and pseudophakia in the chennai glaucoma study. br j ophthalmol. 2005; 89 (6): 699-703. 10. fasih u, fehmi ms, shaikh n, shaikh a. secondary glaucoma—causes and management. pak j ophthalmol. 2008; 24 (2): 86-92. 11. george r, arvind h, baskaran m, ramesh sv, raju p, vijaya l. the chennai glaucoma study: prevalence and risk factors for glaucoma in cataract operated eyes in urban chennai. indian j ophthalmol. 2010; 58 (3): 243. 12. dandona l, dandona r, srinivas m, mandal p, john rk, mccarty ca, rao gn. open-angle glaucoma in an urban population in southern india: the andhra pradesh eye disease study. ophthalmology. 2000; 107 (9): 1702-9. 13. rotchford ap, johnson gj. glaucoma in zulus: a population-based cross-sectional survey in a rural district in south africa. archives ophthalmol. 2002; 120 (4): 471-8. 14. bourne rr, sukudom p, foster pj, tantisevi v, jitapunkul s, lee ps, johnson gj, rojanapongpun p. prevalence of glaucoma in thailand: a population based survey in rom klao district, bangkok. br j ophthalmol. 2003; 87 (9): 1069-74. 15. arshinoff sa, albiani da, taylor-laporte j. intraocular pressure after bilateral cataract surgery using healon, healon5, and healon gv. j cat ref surg. 2002; 28 (4): 617-25. 16. kurimoto y, park m, sakaue h, kondo t. changes in the anterior chamber configuration after smallincision cataract surgery with posterior chamber intraocular lens implantation. am j ophthalmol. 1997; 124 (6): 775-80. 17. cinotti aa, jacobson jh. complications following cataract extractions*: an analysis of 1,001 cataract operations. am j ophthalmol. 1953; 36 (7): 929-36. 18. stark wj, worthen dm, holladay jt, bath pe, jacobs me, murray gc, et al. the fda report on intraocular lenses. ophthalmology, 1983; 90 (4): 311-7. 19. ang gs, whyte if. effect and outcomes of posterior capsule rupture in a district general hospital setting. j cat ref surg. 2006; 32 (4): 623-7. 20. chakrabarti a, nazm n. posterior capsular rent: prevention and management. indian j ophthalmol. 2017; 65 (12): 1359. 21. zemba m, camburu g. uveitis–glaucoma–hyphaema syndrome. general review. romanian j ophthalmol. 2017; 61 (1): 11. 22. chan tc, lok jk, jhanji v, wong vw. intraocular lens explantation in chinese patients: different patterns and different responses. int ophthalmol. 2015; 35 (5): 679-84. 23. mierlo vc, pinto la, stalmans i. surgical management of iatrogenic pigment dispersion glaucoma. j curr glaucoma pract. 2015; 9 (1): 28. 24. reed je, thomas jv, lytle ra, simmons rj. malignant glaucoma induced by an intraocular lens. ophthalmic surgery, lasers and imaging retina. 1990; 21 (3): 177-80. 25. ermis ss, ozturk f, inan uu. comparing the effects of travoprost and brinzolamide on intraocular pressure after phacoemulsification. eye. 2005; 19 (3): 303. .…  …. 235 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol original article intra-vitreal bevacizumab (ivb): safety of multiple doses preparation from a single vial in tertiary care centre asfandyar asghar, amna rizwan, naila obaid, ume sughara, badar-ud-din ather naeem, tehmina nazir pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. asfandyar asghar professor, ophthalmology department fauji foundation hospital, rawalpindi email: docasfandyar@gmail.com …..……………………….. purpose: to determine the safety of multiple doses preparation of bevacizumab from a single vial in minor operation theatre. study design: retrospective exposure assessment. place and duration of study: department of ophthalmology, fauji foundation hospital (ffh), rawalpindi, from june 2016 to march 2018. material and methods: 1690 eyes belonging to 1001 patients were included using computer logs of patients receiving intravitreal bevacizumab (ivb). we allocated three consecutive days every month in order to administer ivb at ffh. approximately 50 patients were given ivb over three-days period. 1-2 ml (depending upon the number of patients) of bevacizumab was withdrawn in a 3cc syringe. later 1 cc insulin syringe with 29 g needle was taken and, 0.05 ml (1.25 mg) bevacizumab was injected from behind using the 3cc syringe, resulting in preparation of 10-20 injections of ivb. the bevacizumab vial was then stored at 4 degrees celsius. results: total 1690 eyes belonging to 1001 patients were analyzed. the occurrence of endophthalmitis was 2/1690 (0.12%) corresponding to a 95% ci of 0.03%-0.43%, which does not represent an increase in cases as compared to endophthalmitis resulting from using a compounding pharmacy. conclusion: preparation of ivb from single vial technique using proper sterilization protocols is safe and economical in a minor eye operation theater. key words: bevacizumab, intravitreal injection, endophthalmitis. ntravitreal anti-vascular endothelial growth factor (antivegf) agents have revolutionized therapeutic advances in ophthalmology1. anti vegf agents are increasingly being used to treat retinal diseases including age related macular degeneration (armd), diabetic macular edema (dme), macular edema secondary to retinal vein occlusion(rvo) etc2. of these anti-vegf agents, the three most commonly used are aflibercept (eylea®), ranibizumab (lucentis®) and bevacizumab (avastin®)3. these anti-vegf agents are administered intravitreally and often needs repeat dosages for continued therapeutic effects4.there is, thus, a cost associated with these expensive drug treatments5. in addition, intravitreal administration may lead to endophthalmitis as a serious complication6. studies have shown that the frequency of endophthalmitis ascribed to intravitreal administration in trials of antivegf usage is between 0.019% and 0.09%7. in our clinical practice, we usually use bevacizumab, an off-label drug initially prescribed for colon cancer treatment, whose ophthalmological efficacy has been well-demonstrated8,9. the low cost of i intra-vitreal bevacizumab: safety of multiple doses preparation from a single vial in tertiary care centre pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 236 bevacizumab compared with other anti-vegf agents is a deciding factor in its favor, particularly in the developing world. it is to be noted that the risk of contamination may be exacerbated by the method of preparation as the drug is prepared in batches. this is because bevacizumab is commercially available in concentrations of 100 mg/4ml vials. these high concentrations are meant to be used for colon cancer patients as a single dose. however, the ophthalmic use of bevacizumab requires much less concentrations10.in a bid to reduce the health care costs, the same vial is used for approximately more than 30 injections11. currently, there is no consensus on whether compounding the vial into a large number of aliquots is better than repeated usage from the same vial. for instance, several studies deny the existence of cluster endophthalmitis following withdrawal of anti vegf agents from a single vial for a batch of patients6,10,12,13, and, therefore, see no statistically significant difference in using the drug from compounded aliquots. khan et al, however, do claim the opposite and report cluster endophthalmitis even in the scenario of multiple withdrawals in one sitting from the same vial14. the rationale of this retrospective study is to confirm the assertion, in our clinical setting, that preparing bevacizumab in minor operation theatre (i.e. in the absence of a compounding frequency) leads to no statistically significant increase in cases of endophthalmitis. certainly, it is desirable to reduce both the cost and risk of infection by figuring out an optimum protocol for drug preparation in the clinic. we work with the hypothesis that the method of multiple dosage preparation and administration is clinically safer in terms of leading to reduced frequency of endophthalmitis. purpose of this study was to determine the safety of multiple doses preparation of bevacizumab from single vial in a minor operation theatre. material and methods a retrospective exposure assessment series was conducted at ophthalmology department, fauji foundation hospital (ffh), from june 2016 to march 2018. ethical committee of hospital approved this study. total 1690 eyes belonging to 1001patients were analyzed. age of the patients ranged from 25-85 years and both genders were included. patients diagnosed with proliferative diabetic retinopathy, diabetic maculopathy, non-ischemic central retinal vein occlusion (crvo) and wet type of age related macular degeneration were included. exclusion criteria were intravitreal injections of non–anti-vegf medications (eg steroids and antibiotics), or concomitant surgical procedures (e.g. phacoemulsification and vitrectomy). patients were informed about the off-label conditions of intravitreal bevacizumab. at each postinjection visit, patients were monitored for ocular and systemic side-effects. best corrected visual acuity, intra-ocular pressure (iop), slit-lamp biomicroscopy and indirect ophthalmoscopy was also performed. three consecutive days every month were reserved in ffh in order to administer intravitreal bevacizumab (ivb) to our patients. around 50 patients were typically seen over a three-day period. extreme care was taken for proper sterilization, including scrubbing by using manorapid and properly wearing head cap, mask, gown and gloves. 1-2 ml (depending upon the number of patients) of bevacizumab was withdrawn with the help of 3 cc disposable syringe, taking care to keep the aluminium and rubber seals intact. 1 cc insulin syringe with 29 g needle was taken and, after removal of piston of insulin syringe, 0.05 ml (1.25 mg) bevacizumab was injected from behind. this resulted in preparation of 10-20 injections of bevacizumab. the bevacizumab vial was then stored at 4 degrees celsius after replacing the plastic seal atop it. on second and third day of ivb injection administration, the rubber seal of the bevacizumab vial was doused with 10% povidone iodine for 3-4 minutes. in all patients before intravitreal injection the blood glucose level was monitored and 10% povidone iodine was used to cleanse the eyelids and orbital adenexa. proparacaine (alcain) was then instilled 23 times with an interval of 4-5 minutes, followed by 5% povidone – iodine instillation in conjunctival sac region for 2-3 minutes before ivb. sterilized towel and speculum were used in all cases. depending on the status of the lens, ivb was given 3.5 mm or 4.00 mm away from the limbus. after ivb injection, 5% povidone iodine was again instilled in conjunctival sac. ofloxacin eye drops 4 times a day were recommended for a 5-day period. complications like endophthalmitis and others were identified from the computerized system logs of our hospital. all the cases of post intravitreal endophthalmitis, irrespective of the cause, received intravitreal antibiotics followed by pars plana vitrectomy if there was no response of antibiotics. we asfandyar asghar, et al 237 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol evaluated endophthalmitis cases that occurred after ivb. data was collected on age, sex, pre-injection best corrected visual acuity (bcva), indication for ivb, date of injection, date of onset of symptoms of endophthalmitis, nature of symptoms, and date of presentation. data was also collected regarding the findings of examination at presentation, treatment, response to treatment, and any additional procedures and findings at final follow-up and bcva at last followup were noted. data was further acquired on the results of microbial laboratory investigations such as gram stain, culture and sensitivity to antimicrobials. the occurrence of endophthalmitis was computed and was reported as a percentage. the corresponding 95% confidence intervals (cis) were calculated by using the freely available utility at http://vassarstats.net/prop1.html.6 results we studied the effects of intravitreal bevacizumab on 1690 eyes belonging to 1001 patients. out of these, 95% were female while the remaining 5% were males. this gender disparity is due to the fact that ffh typically caters to the families of ex-service men. the mean age of our study subjects was 60.73 years with a standard deviation of 9.1 years. the patients presented with varying diagnoses. as shown in table 1, maximum number of patients had diabetic maculopathy. intravitreal injections were distributed in four quadrants such that the bulk of injections (1484/1690) were given at the inferotemporal site. the remaining 143, 47 and 16 injections were given at the superotemporal, superonasal and inferonasal quadrants, respectively, as shown in figure 1 below. the occurrence of endophthalmitis was 2/1690 (0.12%) corresponding to a 95% ci of 0.03%-0.43%. both cases presented within 48 hours of intravitreal bevacizumab, with pain, redness associated with loss of vision. a summary of the clinical findings in the two cases thus presented is given in table 2. in table 3 we present the complications resulting from ivb. as can be seen, 1564/1690 eyes did not exhibit any side effects. the most common problem was subconjunctival hemorrhage which was present in 4.7% of the eyes. table 1: diagnosis of patients included in the study (n = 1001). diagnosis no. of patients (n) n (%) diabetic maculopathy 649 64.83% crvo 102 10.18% pdr 83 8.29% brvo 67 6.69% vitreous hemorrhage 50 4.99% armd 47 4.69% nvg 3 0.29% total patients 1001 100 age related macular degeneration (armd), branch retinal vein occlusion (brvo), central retinal vein occlusion (crvo), neovascular glaucoma (nvg), proliferative diabetic retinopathy (pdr). fig. 1: site of intravitreal injection. http://vassarstats.net/prop1.html.%206 intra-vitreal bevacizumab: safety of multiple doses preparation from a single vial in tertiary care centre pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 238 table 2: description of endophthalmitis cases. case # age/ gender preinjection bcva bcva at diagnosis of endophthalmitis interval b/w injection and endophthalmitis symptoms bacteria isolated c/s treatment given final bcva 1 55/f 6/24 pl 2 days pain, redness, ↓ va staph aureus ivab ppv 6/24 2 49/f 6/9 cf 1 day pain, redness, ↓ va no growth ivab 6/12 bcva (best corrected visual acuity), c/s (culture/sensitivity), cf (counting fingers), pl (perception of light), va (visual acuity), ivab (intravitreal antibiotics) table 3: post intravitreal injection complications in patients. complication # of eyes (n) percentage (%) nil 1564 92.5% subconjunctival hemorrhage 79 4.7% raised iop 37 2.2% corneal abrasion 8 0.5% endophthalmitis 2 0.1% total eyes 1690 100 table 4: comparison of studies with respect to preparation techniques and complications. study (country) method of preparing aliquots number of injection number and rate of endophthalmitis number and rate of culture – positive endophthalmitis percentage of culture-positive cases jan15 et al (pakistan) multiple injection from same vial 6107 03 (0.069%) ----- ----- falavarjani16 et al (iran) multiple injection from same vial 5901 06 (0.10%) 1 (0.01) 16.6 artunay17 et al (turkey) multiple injection from same vial 3022 03 (0.09) 2 (0.06) 66 inoue18 et al (japan) multiple injection from same vial 1209 05 (0.41) 2 (0.16) 40 this study multiple injection from same vial 1690 02(0.12) 1 50 discussion in recent times, the advent and increasing use of antivegf agents for intraocular use has resulted in a paradigm shift in the management of various medical retinal pathologies including neovascular amd, diabetic retinopathy, dme, and rvo. numerous trials conducted worldwide (catt trial, ivan trial, gefal, manta)3,13,19,20 on thousands of patients have shown equivalent results of bevacizumab and ranibizumab regarding efficacy and safety. in bevacizumab, added advantage is reduced cost of treatment. in developing countries because of limited resources it plays key role in reducing the financial burden of multiple injections19. compounding of bevacizumab has been a major safety concern ever since the first intravitreal use. several outbreaks of compounding-related endophthalmitis have been reported in the united states and canada in patients receiving bevacizumab. in almost all cases, the endophthalmitis outbreak occurred because of breakdown in sterile technique owing to inability to follow united states pharmacopeia chapter 797 guidelines20. the risk of endophthalmitis due to compounded bevacizumab was a concern of the past, with recent reports suggesting that the overall incidence of endophthalmitis may be lower with bevacizumab compared with either ranibizumab or aflibercept21. the method of preparation of bevacizumab is different in every centre where compounding pharmacies are not present. some ophthalmologists asfandyar asghar, et al 239 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol withdraw the required dose from the vial of bevacizumab directly to insulin syringe and then change the needle and inject it intravitreally. other ophthalmologists withdraw a maximum of ten doses from the vial during a session for 10 patients and discard the remaining drug. yet others use the maximum number of doses that are required on that day and discard the remaining drug. another technique in vogue is for ophthalmologists to withdraw bevacizumab from the same vial using separate needle and syringe for several patients for a period of 03 weeks of the first use of vial. all these methods of preparation have not reported any cluster of endophthalmitis and incidence of endophthalmitis in these studies was 0 – 0.41%6. however, khan et al reported cluster of endophthalmitis after ivb injection prepared from same vial multiple times14. the method of preparing multiple intravitreal bevacizumab, 1.25 mg/0.05 ml in minor operating theatre (ot) in our study, differs from other studies. we prepared bevacizumab for intravitreal use daily for three consecutive days and kept the vial in the refrigerator at 4 degrees celsius. the incidence of endophthalmitis after intravitreal bevacizumab (ivb) in our study was 0.12% which is comparable to national and international studies (0.027% 0.19%)22,23,24 when multiple intravitreal injections were prepared from same vial. both cases presented within 48 hours of intravitreal bevacizumab, with pain, redness associated with loss of vision. visual acuity dropped to pl–cf in both patients. b-scan was performed to confirm our diagnoses followed by vitreous tap and intravitreal vancomycin 2 mg/0.1 ml and ceftazidime 2 mg/0.1 ml. one patient started improving after intravitreal antibiotics and in the other patient, pars plana vitrectomy was done with intravitreal vancomycin and ceftazidime. vitreous tap report showed staphylococous aureus in one patient and no growth in the other. visual acuity improved in both cases; 6/24 in pars plana vitrectomy (ppv) patient and 6/12 in patient where intravitreal antibiotics were given. probably patient who had undergone ppv had severe diabetic maculopathy and in other there was focal diabetic maculopathy. most common complications experienced in this study was subconjunctival hemorrhage in 4.7% of eyes. it was reported in the range of 17.1% to 72% in other studies19,25. subconjunctival hemorrhage develops due to rupture in small capillaries and vessels during the procedure and gets resolved within 9–15 days26. national and international studies showed that 0.06% to 0.5% eyes developed corneal abrasions10,25 which is consistent with our rate of 0.5%. in our study 2.1% eyes developed raised intraocular pressure after intravitreal bevacizumab injection, which correlates with a reported incidence of 1-5% as mentioned by yannuzzi na8. it is hypothesized that bevacizumab, being a higher molecular weight protein (148k-da) may obstruct the trabecular meshwork. it has been reported that sustained increase in iop was associated with the number of injections. in particular, it has been reported that those who had received more than 29 injections had 16.1% more chance of increased iop than those with less than 12 injections15. no eyes developed retinal detachment, retinal ischemia or cataract in our study. to conclude, we present in table 4 a comparison of several similar studies. the findings of these studies are fairly consistent. conclusion multiple injections preparation from a single vial is one of the options available to prepare the intravitreal bevacizumab where compounded pharmacy is not available with nearly equal outcomes in comparison of sight threatening endophthalmitis. financial disclosure none. references 1. nikkhah h, karimi s, ahmadieh h, azarmina m, abrishami m, ahoor h, et al. intravitreal injection of anti-vascular endothelial growth factor agents for ocular vascular diseases: clinical practice guideline. j ophthalmic vis res. 2018; 13 (2): 158–169. 2. sivertsen ms, jørstad øk, grevys a, foss s, moe mc, andersen jt. pharmaceutical compounding of aflibercept in prefilled syringes does not affect structural integrity, stability or vegf and fc binding properties. sci rep. 2018; 8 (1): 2101. 3. li e, greenberg pb, voruganti i, krzystolik mg. cost and selection of ophthalmic anti-vascular endothelial growth factor agents. r i med j. 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wani vb, al-kandari j, sabti k, aljassar f, qali h, kumar n,. et al. incidence of endophthalmitis after intravitreal bevacizumab using aliquots prepared onsite in 2 operating rooms in kuwait. middle east afr j ophthalmol. 2016; 23 (1): 64–70. 7. lau pe, jenkins ks, layton cj. current evidence for the prevention of endophthalmitis in anti-vegf intravitreal injections. j ophthalmol. 2018; 2018: 8567912. 8. yannuzzi na, klufas ma, quach l, beatty lm, kaminsky sm, crystal rg, et al. evaluation of compounded bevacizumab prepared for intravitreal injection. jama ophthalmol. 2015; 133 (1): 32-39. 9. holfinger s, miller ag, rao lj, rowland dy, hornik jh, miller dg. effect of regulatory requirement for patient-specific prescriptions for off-label medications on the use of intravitreal bevacizumab. jama ophthalmol. 2016; 134 (1): 45–48. 10. ng ds, kwok kha, chan wc. intravitreal bevacizumab: safety of multiple doses from a single vial for consecutive patients. hong kong med j 2012; 18: 488-495. 11. phasukkijwatana n, tanterdtham j, lertpongparkpoom d. stability of bevacizumab divided in multiple doses for intravitreal injection. j med assoc thai. 2015; 98 (8): 798-803. 12. falavarjani kg, modarres m, hashemi m, parvaresh mm, naseripour m, zare-moghaddam a, et al. incidence of acute endophthalmitis after intravitreal bevacizumab injection in a single clinical center. retina. 2013; 33: 971-4. 13. lee sh, woo sj, park kh, kim jh, song jh, park ku, et al. serratiamarcescens endophthalmitis associated with intravitreal injections of bevacizumab. eye (lond). 2010; 24: 226-32. 14. khan p, khan l, mondal p. cluster endophthalmitis following multiple intravitreal bevacizumab injections from a single use vial. indian j ophthalmol. 2016; 64 (9): 694-96. 15. jan s, nazim m, karim s, hussain z. intravitreal bevacizumab: indications and complications. j ayub med coll abbottabad, 2016; 28 (2): 364–8. 16. falavarjani kg, aghamirsalim m, modarres m, hadavandkhani a, hashemi m, parvaresh mm, et al. endophthalmitis after resident-performed intravitreal bevacizumab injection. can j ophthalmol. 2015; 50: 33-6. 17. artunay o, yuzbasioglu e, rasier r, sengul a, bahcecioglu h. incidence and management of acute endophthalmitis after intravitreal bevacizumab (avastin) injection. eye (lond). 2009; 23: 2187-93. 18. inoue m, kobayakawa s, sotozono c, komori h, tanaka k, suda y, et al. evaluation of the incidence of endophthalmitis after intravitreal injection of anti‑ vascular endothelial growth factor. ophthalmologica. 2011; 226: 145-50. 19. jain p, sheth j, anantharaman g, gopalakrishnan m. real-world evidence of safety profile of intravitreal bevacizumab (avastin) in an indian scenario. indian j ophthalmol. 2017; 65 (7): 596-602. 20. stewart mw, narayanan r, gupta v, rosenfeld pj, martin df, chakravarthy u, et al. counterfeit avastin in india: punish the criminals, not the patients. am j ophthalmol. 2016; 170: 228–31. 21. vanderbeek bl, bonaffini sg, ma l. association of compounded bevacizumab with post-injection endophthalmitis. jama ophthalmol. 2015; 133 (10): 1159–64. 22. zafar s, hamid a, mahmood sub, burq ma, maqsood n. incidence of endophthalmitis after intravitreal injections at a tertiary care hospital.can j ophthalmol. 2018; 53 (2): 94-7. 23. haider ma, imtiaz u, javed f, haider z. incidence of acute endophthalmitis after office based intravitreal bevacizumab injection. j pak med assoc. 2017; 67 (12): 1917-19. 24. pradhan e, duwal s, bajimaya s, thapa r, sharma s, manandhar a, et al. acute endophthalmitis after intravitreal bevacizumab injections at the tertiary centre in nepal. nepal j ophthalmol. 2018; 10 (19): 10710. 25. rojas js, sanchez rj, saucedo ca, celis bs, perez cr, espinosa is, et al. intravitreal anti-vascular endothelial growth factor complications. int j ophthalmol clin res. 2015; 2: 2. author’s affiliation dr asfandyar asghar professor, ophthalmology department fauji foundation hospital, rawalpindi dr amna rizwan trainee, ophthalmology department fauji foundation hospital, rawalpindi dr naila obaid assistant professor, ophthalmology department fauji foundation hospital, rawalpindi dr ume sughara al-shifa school of public health pakistan institute of ophthalmology, rawalpindi dr. badar-ud-din ather naeem professor, head of ophthalmology department fauji foundation hospital, rawalpindi dr. tehmina nazir assistant professor, ophthalmology department fauji foundation hospital, rawalpindi https://jamanetwork.com/searchresults?author=nicolas+a.+yannuzzi&q=nicolas+a.+yannuzzi https://jamanetwork.com/searchresults?author=michael+a.+klufas&q=michael+a.+klufas https://jamanetwork.com/searchresults?author=lucy+quach&q=lucy+quach https://www.sciencedirect.com/science/article/abs/pii/s0008418217303678#! https://www.sciencedirect.com/science/article/abs/pii/s0008418217303678#! https://www.sciencedirect.com/science/article/abs/pii/s0008418217303678#! https://www.sciencedirect.com/science/journal/00084182 https://www.sciencedirect.com/science/journal/00084182 https://www.sciencedirect.com/science/journal/00084182 asfandyar asghar, et al 241 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol author’s contribution dr. asfandyar asghar study design, data collection, data analysis, manuscript writing and final review. dr amna rizwan study design, data collection, data analysis, manuscript writing and final review. dr naila obaid study design, data collection, data analysis and final review. dr ume sughara study design, data collection, data analysis and final review. dr. badar-ud-din ather naeem study design, data collection, data analysis and final review. dr. tehmina nazir study design, data collection, data analysis and final review. microsoft word khayyam durrani 120 original article a comparison of automated and manifest refraction: the effect of age khayyam durrani, amanullah khan, sohail ahmed, jehangir durrani pak j ophthalmol 2006, vol. 22 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: khayyam durrani department of ophthalmology and community health sciences aga khan university karachi, pakistan received for publication may’ 2005 …..……………………….. purpose: autorefraction without subjective refinement is being increasingly employed by opticians in pakistan for prescribing glasses. the purpose of this study is to compare the refractive correction obtained by autorefraction alone and manifest refraction at a tertiary care hospital in pakistan and to determine the relationship of this difference with age. material and methods: two hundred and sixty nine patients visiting the ophthalmology clinic of a large tertiary-care hospital in karachi, pakistan were studied. autorefraction alone using a canon r-10 autorefractor and manifest refraction were performed at the same visit. a clinically significant difference between autorefraction and manifest refraction was defined as a difference of >0.50 d in sphere, cylinder, spherical equivalent or weighted axis, or >10° in axis. results: in 266 right eyes, the median difference between autorefraction and manifest refraction in spherical corrections was +0.01 d (p=0.85), -0.33 d in cylindrical corrections (p<0.01), 10° in axes (p<0.01), and –0.16 d in spherical equivalent (p=0.02). children 10 years of age or younger were 2.23 times more likely to have a clinically significant difference in spherical corrections (or: 2.23, 95% ci: 1.12-4.47).comparable results were observed for the left eye. conclusions: there is a significant difference between the corrections obtained by autorefraction alone and manifest refraction, particularly in children. autorefraction alone without subjective refinement cannot be substituted for manifest refraction, especially in children 10 years of age or younger. t is widely accepted that autorefraction is not sufficiently accurate to substitute for subjective refraction for the purposes of prescribing spectacles1,2. autorefraction without subjective refinement is being used by opticians in pakistan as the sole method of prescribing glasses. we attempted to highlight this problem by comparing the corrective refractive error obtained by autorefraction with manifest refraction and to determine the relationship of this difference with age. material and methods a cross-sectional study based on hospital records at the aga khan university hospital was performed. patients having both autorefraction and manifest refraction performed on the same visit were included, while individuals with an ocular pathology causing opacity in the media were excluded from analysis. a convenience sample of 269 persons was performed and age, sex, sphere, cylinder and axis corrections obtained by automated and manifest refraction recorded. spherical equivalents were calculated and i 121 two tailed paired t-tests applied to compare corrections obtained by both methods in each individual. a clinically significant difference between autorefraction and manifest refraction was defined as a difference of >0.50 d in sphere, cylinder, or spherical equivalent or >10° in axis. chi-square tests were performed after establishing cut-offs for age and clinically significant difference in refractive error. results in the 266 right eyes for which complete data were available, the median difference between autorefraction and manifest refraction in spherical corrections was +0.01 d (p=0.85), -0.33 d in cylindrical corrections (p<0.01), 10° in axes (p<0.01), and -0.16 d in spherical equivalent (p=0.02) (table 1a). for cylinder corrections, the median difference between the two methods varied from -0.20 d to -0.53 d, a finding that was statistically different across all age groups (table 2a). children 10 years of age or younger were 2.23 times more likely to have a clinically significant difference in spherical corrections [odds ratio (or): 2.23, 95% confidence interval (ci): 1.124.47] (table 3a). comparable results were observed for the 269 left eyes analyzed (tables 1b-3b). discussion automated infrared refractors, or autorefractors, are microcomputers that employ the optometer principle and infrared waves to objectively determine the refractive error of subjects in a clinical setting. the first modern autorefractors were developed in 1937. however, it was not until the early 1970s that necessary advances in electronics were made to allow for routine use of the instrument in clinical practice. during the 1980s, coherent medical’s instrument, dioptron (1974) was largely replaced by the more compact and reliable canon autoref f-1 and nidek ar-2000. so much so, in fact, that at the present moment, their genre is almost invariably used from solo office practices to the outpatient departments of large tertiary care hospitals in pakistan and throughout the world. the main reason behind this trend is thought to be the speed and relative consistency with which these devices detect and quantify refractive errors, and their ability to provide a reliable starting point from which to measure subjective refraction1,2. table 1a: mean difference between auto refraction and subjective. refraction, right eye mean difference standard deviation p-value sphere 0.01 1.06 0.85 cylinder -0.33 0.89 <0.01 axis 9 34 <0.01 spherical equivalent -0.16 1.04 0.02 table 1b: mean difference between auto refraction and subjective. refraction, left eye mean difference standard deviation p-value sphere 0.10 0.81 0.04 cylinder -0.37 0.99 <0.01 axis 7 38 <0.01 spherical equivalent -0.09 0.74 0.06 table 2a: mean difference between auto refraction and subjective. refraction by age, right eye age (y) no sph cye axis s e 1-10 48 0.32 -0.53 5 0.06 11-20 47 -0.18 -0.38 9 -0.37 21-30 55 -0.12 -0.30 10 -.27 31-40 53 0.11 -0.29 15 -0.04 >40 59 -0.03 -0.20 7 -0.13 p=0.05, p=0.01 -0.049, p<0.01; n=262 table 2b: mean difference between auto refraction and subjective. refraction by age, left eye age (y) no sph cye axis s e 1-10 51 0.52 -0.53 13 0.26 11-20 48 -0.11 -0.28 3 -0.25 21-30 56 -0.01 -0.44 5 -0.23 31-40 52 0.01 -0.28 14 -0.13 >40 58 -0.09 -0.34 2 -0.07 122 p=0.05, p=0.01 -0.049, p<0.01; n=265 numerous independent studies have evaluated the performance of automated refractors in clinical settings3-7. this research has generally highlighted the fact that there is a significant difference between the refractive errors determined by the objective autorefractors and the manifest refraction assessed by conventional subjective means. this difference is such that the autorefractor alone without subjective testing refinements cannot be substituted for conventional complete refraction with subjective refinement8-12. the discrepancy has also been shown to vary significantly with age13,14. all the evidence notwithstanding, the practice observed in pakistan is quite different. although no studies have been conducted to date, it is generally believed that the use of autorefractors has mushroomed to such an extent that many opticians use these devices as the sole means of prescribing lenses to patients with decreased visual acuity. this could lead to inappropriate and inaccurate prescriptions, leading in turn to suboptimal visual acuity, asthenopia, and even loss of vision if a more sinister reason lies behind the blurred vision and remains undetected. this is especially important in children as inadequately corrected refractive errors may result in irreversible long-term sequelae in later life15,16. we found that significant differences occurred in the refractions obtained by automated and manifest refraction in cylinders, axes, and spherical equivalent. a statistically significant difference in the cylindrical corrections attained by both methods was present in all age groups analyzed, but differences in sphere were significant only in children and adolescents. this additional discrepancy in younger individuals is consistent with previously published data, and may be secondary to the difficulties in fixation and repeated blinking during autorefraction that are more frequent in this age group10,14 of particular concern is the finding that children ten years of age or younger were at a higher risk of having a clinically significant difference in the spheres obtained by both methods, being 2.23 to 3.47 times more likely to have such a difference when compared with patients above the age of 10. a substantial number of these patients had a difference greater that the minimum cutoffs of 0.5 d or 10° in axes used for the purposes of this study. inadequately corrected refractive error is a major risk factor for the development of amblyopia15. the deleterious effects of amblyopia can be serious and wide ranging, including strabismus, loss of binocularity, restricted future employment opportunities, and increased risk for psychosocial problems16,17. it is also a widely held clinical belief that the risk of developing amblyopia and strabismus can be effectively reduced if abnormal refractive errors can be identified and adequately corrected at a young age18,19. table 3a: odd ratios of a clinically significant difference between auto refraction and subjective refractiona in patients <10 years of ageb, right eye age patients n (%) or 95%ci sphere <10 >10 29 (60) 87 (41) 2.23 1.12-4.47 cylinder <10 >10 29 (60) 106 (50) 1.56 0.78-3.11 axis <10 >10 18 (38) 100 (47) 0.68 0.43-1.37 spherical <10 23 (48) 1.22 0.62-2.41 equivalent >10 92 (43) aclinical significance for diopteric powers: -.5< x <.5 and 10o x <170o for axes btotal no of patients <10 years: 48 (18.3%); >10 years: 214 (81.7%); n=262 or: odds ratio, 95% ci: 95% confidence interval table 3b: odd ratios of a clinically significant difference between auto refraction and subjective refractiona in patients <10 years of ageb, left eye age patients n (%) or 95%ci sphere <10 >10 33 (65) 74 (35) 3.47 1.74-6.96 cylinder <10 >10 36 (71) 111 (52) 2.23 1.09-4.58 axis <10 >10 29 (57) 93 (44) 1.72 1.27-4.90 123 spherical <10 29 (57) 2.49 0.88-3.35 equivalent >10 74 (35) aclinical significance for diopteric powers: -.5< x <.5 and 10o x <170o for axes btotal no of patients <10 years: 51 (19.2%); >10 years: 214 (80.8%); n=265 or: odds ratio, 95% ci: 95% confidence interval conclusion in conclusion, there is both a statistically and clinically significant difference between autorefraction and manifest refraction when used in the pakistani population. the magnitude of this difference is greater in children 10 years of age or younger. autorefraction alone cannot be used to determine an individual’s refractive error, especially in children. author’s affiliation khayyam durrani departments of ophthalmology and community health sciences, the aga khan university, karachi, pakistan amanullah khan departments of ophthalmology and community health sciences, the aga khan university, karachi, pakistan sohail ahmed departments of ophthalmology and community health sciences, the aga khan university, karachi, pakistan jehangir durrani department of ophthalmology, shaikh zayed federal postgraduate medical institute, lahore, pakistan references 1. goss da, grosvenor t: reliability of refractiona literature review. j am optom assoc 1996; 67: 619-30. 2. bullimore ma, fusaro re, adams cw: the repeatability of automated and clinician refraction. optom vis sci. 1998; 75: 617-22. 3. dyson c: a clinical study of the autorefractor, an automatic refracting device. can j ophthalmol 1997; 12: 29-33. 4. yeiw pt, taylor sp: clinical evaluation of the humphrey autorefractor. ophthalmic physiol opt. 1989; 9: 171-5. 5. wood ic, papas e, burghardt d, hardwick g: a clinical evaluation of the nidek autorefractor. ophthalmic physiol opt. 1984; 4: 169-78. 6. salvesen s, kohler m: automated refraction: a comparative study of automated refraction with the nidek ar-1000 autorefractor and retinoscopy. acta ophthalmol copenh. 1991; 69: 342-6. 7. pappas cj, anderson dr, briese fw: is the autorefractor reading closest to manifest refraction? a comparison of the patient’s previous spectacles and the 6600 autorefractor reading. arch ophthalmol. 1978; 96: 997-8. 8. pappas cj, anderson dr, briese fw: clinical evaluation of the 6600 autorefractor. arch ophthalmol. 1978; 96: 993-6. 9. kinge b, midelfart a, jacobsen g: clinical evaluation of the allergan humphrey 500 autorefractor and the nidek ar-1000 autorefractor. br j ophthalmol. 1996; 80: 35-9. 10. pesudovs k, weisinger hs: a comparison of autorefractor performance. optom vis sci. 2004; 81: 554-8. 11. mallen eah, wolffsohn js, gilmartin b, et al: clinical evaluation of the shin-nippon srw-5000 autorefractor in adults. ophthal physiol opt. 2001; 21: 101-7. 12. jorge j, queiros a, almeida jb, et al: retinoscopy/ autorefraction: which is the best starting point for a noncycloplegic refraction? optom vis sci. 2005; 82: 64-8. 13. joubert l, harris wf: excess of autorefraction over subjective refraction: dependence on age. optom vis sci. 1997; 74: 439-44. 14. chat sws, edwards mh: clinical evaluation of the shinnippon srw-5000 autorefractor in children. ophthal physiol opt. 2001; 21: 87-100. 15. atkinson j, braddick o, robier b, et al: two infant vision screening programmes: prediction and prevention of strabismus and amblyopia from photoand videorefractive screening. 1996; 10: 189-98. 16. satterfield d, keltner jl, morrison tl: psychosocial aspects of strabismus study. arch ophthalmol. 1993; 111: 1100-5. 17. simon jw, kaw p: commonly missed diagnoses in childhood eye examination. am fam physician. 2001; 64: 623-8. 18. olitsky se, nelson lb: common ophthalmologic concerns in infants and children. pediatr clin north am. 1998; 45: 9931012. 19. kvarnstrom g, jakobsson p, lennerstrand g: visual screening of swedish children: an ophthalmological evaluation. acta ophthalmol scand. 2001, 79: 240-4. 1 pakistan journal of ophthalmology, 2020, vol. 36 (1): 1-2 editorial open journal system in the era of paperless papers tayyaba gul malik 1 1 department of ophthalmology, rashid latif medical college, lahore with the start of 2020, we have entered a new decade with the never-ending challenges of the developing world. one of the challenges is the barrier against access to the latest scientific knowledge. to cope with this barrier, it is indispensable that the current scientific literature should be made freely available to the resource-constrained countries like pakistan. pakistan journal of ophthalmology has taken a step forward and joined the club of open access journals through ―open journal system‖ (ojs). to understand the importance of ojs let us turn the wheel of time backwards. imagine the world where the only source of documentation of knowledge was wood painting. centuries passed by and in 100 bc, chinese invented paper and in 105 ad the first ever papermaking industry was started. in mid fifteenth century, gutenberg invented a printing press, which made possible the more consistent form of printed copies than the professional copyist did 1,2 . it was a revolution in the scientific world where the scientists were called natural philosophers. in 1665, another milestone was reached with the creation of first scientific journal ―the journal des sçavans” and the ―philosophical transactions” which were published in france and in england respectively and simultaneously 3 . sixth of march 2020 will be the 355 th anniversary of the creation of scientific journals. before that, the scientists had personal correspondence through letters, which was made more systematic and structured with the publishing of these journals. it led to the process of peer review for development and progression of scientific knowledge. how to cite this article: malik tg. open journal system in the era of paperless papers. pak j ophthalmol. 2020; 36 (1): 1-2. doi: https://doi.org/10.36351/pjo.v36i1.908 correspondence to: tayyaba gul malik rashid latif medical college, lahore email: tayyabam@yahoo.com this not only resulted in wider and more structured propagation of knowledge but also recording and archiving was made more systematic 4 . another breakthrough occurred in 1983 with the advent of ‗network of networks‘ now called internet. development of worldwide web in 1990 brought another spin, which paralleled the gutenberg‘s discovery of printing press, if not exceeded it. this was followed by adoption of the concept of paperless office (although the term was already coined even before the development of internet) 5 . the idea was to end reliance on paper and to adopt a digital approach. this concept helped in saving time, space and money, improving efficiency and streamlining the workflow. from submission of research article in hard copies to the use of online platform, there is a huge hidden effort, which has done more than just saving the trees. after the digitalization of the research papers, now is the era of open access journals. by definition, open access (oa) is a mechanism by which research outputs are distributed online, free of cost and free of other access barriers. a stricter definition would be the removal or reduction of barriers to copying or reuse by an open license 6 . time has shown that open access has increased the citations of articles 7 . another advantage of open access journal is the capability to record views, downloads and citations of articles. although increased citations are not a criterion to indicate the importance and influence of the particular research paper in the concerned field but it does indicate the impact a particular article has in a discipline. later surveys provided further evidence that open access journals had increased readership as compared to the similar work without open access 8,9 . keeping in view the convenience, capability, efficiency and increased readability by the use of open access to the journals, public knowledge project (pkp) launched open journal systems (ojs) in 2002. it is a free online journal publishing and managing software. it was an undergraduate computer science https://doi.org/10.36351/pjo.v36i1.908 https://en.wikipedia.org/wiki/research tayyaba gul malik pakistan journal of ophthalmology, 2020, vol. 36 (1): 1-2 2 project at the university of british columbia (ubc) in vancouver, canada, under the direction of john willinsky, with subsequent participation by simon fraser university library, the canadian centre for studies in publishing, and stanford university. the idea was to explore the feasibility of journals to publish their content online and to see the consequences. ojs is currently in version 3.1.2.4 (pakistan journal of ophthalmology is using version 3.1.1.4). in version 2.3, there are 17 languages with complete translations 10 . it was the convenience and the practicality of this system that within one and a half decade there were more than 8,000 journals worldwide, which were using ojs 11 . by 2018, 9412 journals were using ojs. among these, 200 journals were in canada, 674 in usa, 1656 in brazil and 173 in russia. in 2008, only 11 journals were making use of ojs in india and pakistan. exactly after 10 years, in 2018, this number has increased to 139 in india and still 13 in pakistan 12 . once this system was disseminated throughout the whole world, pkp decided to make criteria for journals to be included in the count of ojs. it was determined that an ojs journal must have at least 10 articles published in a single year to be officially included in the count of ojs journals. every change brings problems associated with it, which needs to be tackled. scientific content is the most valuable treasure of this time and it needs to be protected for the coming generations. with a complete transition to the electronic-only open access journals, there arose the need for an emergency preservation strategy for the journal contents. the idea was to prevent the disaster of knowledge famine in case of system failure or human error. stanford university developed the open source lockss project (lots of copies keeps stuff safe). lockss comprise of servers, which are distributed and maintained throughout the world in different libraries to collect and secure the journal content at various places. lockss and clockss (controlled lots of copies keeps stuff safe) are important features of ojs. by acquiring this archiving facility, the data can be saved for hundreds of years. with shifting to ojs, it is now possible to manage the workflow starting from submission of article, multiple rounds of peer review, revision after review, copy editing, publishing, making articles‘ availability online and indexing. the whole process is managed by different individuals playing different roles online; journal manager, editor, reviewer, author, and reader. journal subscription is also controlled by a subscription management component. with all these benefits, the time has come to break the ―inertia‖ of resisting change and to move forward to bridge the gap of knowledge, which exists between the developed and developing countries. conflict of interest none. references 1. desolla price dj. little science, big science. new york: columbia university press; 1963. 2. haustein s. multidimensional journal evaluation. analyzing scientific periodicals beyond the impact factor. berlin/boston: de gruyter saur; 2012. 3. tenopir c, king dw. the growth of journals publishing. in cope b, phillips a, editors. the future of the academic journal. oxford: chandos publishing. 2009: 105–123. 4. zuckerman h, merton rk. patterns of evaluation in science—institutionalization, structure and functions of referee systems. minerva. 1971; 9 (1): 66–100. 5. the paperless office trademark registration, united states patent and trademark office. the office of the future. business week, 1975; 1975:48-70. 6. peter s. open access overview, focusing on open access to peer-reviewed research articles and their preprints. mit press; 2012. available from: http://legacy.earlham.edu/~peters/fos/overview.htm 7. alma s. ―policy guidelines for the development and promotion of open access‖. unesco. 2012. 8. harnad s, brody t, vallieres f, carr l, hitchcock s, gingras y, oppenheim c, hajjem c, hilf e. the access/impact problem and the green and gold roads to open access: an update. serials review 2008; 34 (1): 36-40. http://eprints.ecs.soton.ac.uk/15852 9. hitchcock s. the effect of open access and downloads (‗hits‘) on citation impact: a bibliography of studies. unpublished paper. open citation project, 2009. available from: http://opcit.eprints.org/oacitationbiblio.html 10. ojs languages. public knowledge project. retrieved 21 august 2013. available from: https://pkp.sfu.ca/contributors/translation/ 11. ojs stats. public knowledge project. retrieved 20 october2015. available from: .https://pkp.sfu.ca/ojs/ojs-usage/ojs-stats/ 12. ojs map. public knowledge project. retrieved 20 october2015. available from: https://pkp.sfu.ca/ojs/ojs-usage/ojs-map http://tmsearch.uspto.gov/bin/showfield?f=doc&state=4801:gp9aaa.2.7 https://en.wikipedia.org/wiki/united_states_patent_and_trademark_office https://en.wikipedia.org/wiki/united_states_patent_and_trademark_office https://en.wikipedia.org/wiki/united_states_patent_and_trademark_office http://legacy.earlham.edu/~peters/fos/overview.htm http://eprints.ecs.soton.ac.uk/15852 http://opcit.eprints.org/oacitationbiblio.html http://pkp.sfu.ca/ojs-languages https://pkp.sfu.ca/contributors/translation/ https://pkp.sfu.ca/ojs/ojs-usage/ojs-stats/ https://pkp.sfu.ca/ojs/ojs-usage/ojs-stats/ ../e-mail/ojs%20map.%20journals%20using%20open%20journal%20systems. ../e-mail/ojs%20map.%20journals%20using%20open%20journal%20systems. https://pkp.sfu.ca/ojs/ojs-usage/ojs-map/ microsoft word editorial.doc 112 editorial diabetic macular edema diabetic retinopathy is the commonest cause of blindness in the working-age population all over the world. poor glycemic control in diabetes is usually associated; with hypertension and increased blood lipid levels hence it is very important to control these risk factors during the management of diabetic retinopathy. the most frequent cause of significant and progressive visual loss is diabetic macular edema which may start from the very early stage of retinopathy resulting in central vision loss. with the availability of noninvasive diagnostic instrumentations we can now better diagnose, study, analyse, follow and manage diabetic macular edema keeping the various factors into consideration like: • location relevant to fovea • duration (recent or chronic) • signs of ischaemia • any vitreoretinal traction • state of pigment epithelium • status of diabetic and b.p control • presence of vascular leakage based on above factors we can now offer more appropriate management of diabetic retinopathy and macular edema with the availability of recent therapeutic modalities like: 1. pkc enzyme inhibition with ruboxistaurin. 2. intravitreal steroids 3. intravitreal injections of vegf inhibitors like pegaptanib sodium (macugen), ranibizumab (lucentis), bevacizumab (avastin) alone or with traditional laser applications. laser treatment is still the mainstay in management of diabetic retinopathy and macular edema. while stabilizing the visual field and acuity in the long term actual improvement in visual acuity is an exception rather than the rule. many a times there is some immediate vision loss and some patients keep on complaining of loss of peripheral field and night vision that is why we are looking for better alternatives like pharmacological modalities. pkc enzyme inhibition with ruboxistaurin seemed very exciting during the extensive trials as the drug can be given orally in tablet form, is well tolerated and effective in the early stages of diabetic retinopathy when the changes are still reversible and its use over an extended period reduced the loss of vision. however there was one significant drawback that it did not influence the progression of nonproliferative diabetic retinopathy to the proliferative form and also it did not appear to reduce the need for panretinal photocoagulation in diabetic retinopathy. hence ruboxistaurin despite having significant potential as a treatment of diabetic retinopathy is not yet approved by fda for want of further information and evidence regarding its efficacy which might take some further time in exploring, modifying and developing this molecule to an approvable level. an increase in the vasoendothelial growth factors (vegf) is reported to be responsible for diabetic retinopathy changes and diabetic macular edema resulting in loss of vision and blindness. there is enough evidence now that the use of vegf inhibitors like pagaptanib (macugen), ranibizumab (lucentis), bevacizumab (avastin) as intravitreal injections are dramatically effective in regression or disappearance of neovascularisation and macular edema resulting in improvement of visual acuity. the intraocular injections of these vegf inhibitors are well tolerated and are not associated with any local or systemic adverse effects. the only concern is the rare incidence of endophthalmitis and retinal detachment. as the effect of these injections lasts 46 weeks it comes down to repeating these injections for the rest of life which makes the complication of endophthalmitis etc of greater concern in the long run. hence there are efforts to develop agents with prolonged effect or use them as slow release vitreous inserts or use them in combination with other modalities like steroids and or laser for prolonged and synergistic effectivity. avastin is already being used as an adjunt in vitrectomy, if the surgery is performed within seven days of intravitreal injection bleeding during cutting and removal of fibrovascular tissues is greatly reduced making the surgery quicker, easier and safer due to reduction or complete resolution of neovascularisation in majority of the cases. 113 macugen and lucentis are already approved by fda but avastin being very economical is extensively used all over the world despite not been approved as yet. there are encouraging results of improved visual acuity after intravitreal injections of steroids (triamcinolone acetonide, kenacort, kenalog etc) in diabetic macular edema particularly diffuse chronic variety, the effect again being short term, reported with complications of cataract and glaucoma in addition to chances of endopthalmitis etc. an alternative being a deep subtenon injection of steroids with lesser effectivity and reduced complications. diabetic macular edema due to traction of taut posterior hyaloid tends to get reduced with visual improvement following vitrectomy with intraoperative use of kenacort. as already mentioned 1. the most common cause of progressive visual deterioration in diabetes is macular edema. 2. laser treatment in macular edema can slow down or stabilize visual loss and any improvement in visual acuity is an exception rather than the rule. 3. improvement of visual acuity is reported in significant number of patients following intravitreous injections of vegf inhibitors which is an exciting breakthrough but the beneficial effect is short lived requiring repeat injections at 4-6 weeks intervals for the rest of life exposing the patients to increased risks of complications. we are anxiously waiting for an alternative with prolonged effect. 4. intravitreal steroids are also beneficial with slightly longer duration specifically for chronic diffuse macular edema with attendant risks of complications, deep subtenon injections are a lesser effective and safer alternative. 5. pkc enzyme inhibitors like ruboxistaurin would be an ideal therapeutic tool when refined, .approved and available. 6. as the different treatments attack the disease at different stages of development, all the therapeutic modalities if used together intelligently are likely to have an additive and synergistic effect with better outcomes like combining intravitreal injection of avastin with deep subtenon steroids and laser treatment alongwith vitrectomy within intraoperative intravitreal steroids if indicated. 7. we should always keep on stressing the importance of proper diabetic and blood pressure control ,no smoking ,healthy diet and regular exercise. m lateef chaudhry editor in chief pakistan journal of ophthalmology microsoft word mmoin[1]pjocorrectedpics original article efficacy of amniotic membrane after short term storage muhammad moin, ihtesham-ud-din, muhammad khalil, nadia lateef, i. a. naveed, mumtaz hussain pak j ophthalmol 2007, vol. 23 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. muhammad moin department of ophthalmology king edward medical university, lahore, pakistan. email: mmoin7@hotmail.com received for publication june’ 2006 …..……………………….. purpose: to evaluate the short term viability of amniotic membrane clinically and histopathologically. material and methods: this study was conducted over a period of one year from 1st january to 31st december, 2005 at the institute of ophthalmology, king edward medical college, mayo hospital, lahore. amniotic membrane was stored at 4 degrees centigrade in normal saline for 5 days after retrieval and analyzed by a histopathologist before and every day after storage to check for its viability. amniotic membranes stored in this way were used in 20 patients for various corneal surface disorders and assessed for their clinical efficacy. results: histopathology showed that the basement membrane remained intact for 7 days and the epithelium for 5 days. there were 4 cases of descematocle, 5 cases of corneal ulcers, 2 cases of hypopyon corneal ulcers, one case of perforated corneal melt, 2 cases of bullous keratopathy, one case of chemical burn, 4 cases of pterygia excision and one case of necrosed dermis fat graft. thirteen cases, including descematocele, corneal ulcers, bullous keratopathy and chemical burn showed improvement of corneal pathology in various ways. five cases, including pterygia and necrosed dermis fat graft, showed epithelial growth beneath or above the membrane respectively. one case showed failure of the membrane when applied over a perforated corneal melt and another case with hypopyon fungal keratitis failed to show any improvement after amniotic membrane transplantion. conclusion: short term storage of amniotic membrane shows stable clinical and histopathological behavior for the management of corneal surface disorders. mniotic membrane is the inner most layer of fetal membranes1,2. it consists of a single layer of epithelial cells that are attached to a thick basement membrane, and an avascular stromal matrix. its use has been described in persistent epithelial defects, corneal ulcers3, bleb leaks4, pterygium excision5 and conjunctival reconstruction after tumor removal6 or fornix formation7. in ophthalmology, it has been used as a graft with its epithelium up when it is expected to become covered by host conjunctival or corneal epithelium; as a protective patch with its epithelium down, which facilitates trapping of inflammatory cells in the stroma, reducing inflammation; and in a combination of both, one used as a graft and the other as a patch1. the success of this membrane in all these procedures is due to its anti-inflammatory effect, its antiscarring effect and neurotrophic factors, and its antiangiogenic effect. amniotic membrane transplant (amt) is normally stored in eye banks at −70°c and it is a defrosted immediately before use2. in pakistan, where eye banks are still being developed, there is nonavailability of frozen amt. therefore we developed this method for short term storage of the membrane. materials and methods it was a retrospective interventional case series conducted over a period of one year from 1st january to 31st december, 2005 at the institute of ophthalmology, king edward medical college, mayo hospital, lahore. amniotic membrane was stored at 4 degrees centigrade in normal saline for 5 days after retrieval and analyzed by a histopathologist before and every day after storage to check for its viability. amniotic membranes stored in this way were used in 20 patients for various corneal surface disorders and assessed for their clinical efficacy. amniotic membrane was harvested from the placenta of elective caesarean section delivery after taking consent from the patient. the mother was screened for hepatitis b, c and hiv. under sterile conditions the placenta was washed with normal saline and then a large piece of amniotic membrane was removed. this large piece was then washed with 5% povidone iodine solution and later cut into 8 squares measuring approximately 2.5 cm2. each piece was put in a separate sterile container filled with normal saline and labelled day 0 to day 7. they were then stored in a refrigerator at 4 degree centigrade. over the next week a specimen of amniotic membrane was sent for histopathology daily from one of the containers according to the labelled day. all the 8 histopathology slides, which had been processed earlier, were reviewed by 2 consultant pathologists at the end of the week. amniotic membranes were harvested again in the same fashion over the subsequent months as a large piece measuring approximately 10 cm2 and stored in normal saline at 4 degree centigrade for 5 days. the date of retrieval of the membrane was labelled on the container. the necessary amount of the membrane was retrieved when required under aseptic conditions and used for reconstruction of various ocular surface disorders after washing it again in 5% povidone iodine solution. the age of the amniotic membrane on the day of transplantation was noted and recorded in the chart of the patient. patients were photographed pre-operatively once and post-operatively daily for the first week and then weekly for the first month. all patients not willing to receive amniotic membrane were excluded from the study. results histopathology was done serially every day for 8 days on the stored amniotic membranes (am) using hematoxlyin and eosin (h & e) stains. examination showed that the epithelium and basement membranes of the first 4 specimens remained intact (fig. 1-3). but the epithelium showed various stages of disintegration in specimens stored for 5 days and more (fig. 4). these changes included, reduction in the size of the cells, loss of the cells, pyknosis of the nuclei and loss of the cytoplasm. the basement membrane remained intact in all the specimens till 7 days (fig. 5). the amniotic membrane was transplanted in 20 patients for various corneal surface disorders (table 1). the viability of the membrane and its integration with the cornea or conjunctiva was evaluated. there were 4 cases of descematocle, 5 cases of corneal ulcers, 2 cases of hypopyon corneal ulcers, one case of perforated corneal melt, 2 cases of bullous keratopathy, one case of chemical burn, 4 cases of pterygia excision and one case of necrosed dermis fat graft. fifty percent of the amniotic membranes were 0-1 days old while the rest were 2-5 days old (table 2). thirteen cases, including descematocele, corneal ulcers, bullous keratopathy and chemical burn showed improvement of corneal pathology in various ways. five cases, including pterygia and necrosed dermis fat graft, showed epithelial growth beneath or above the membrane respectively. one case showed failure of the membrane when applied over a perforated corneal melt and another case with hypopyon fungal keratitis failed to show any improvement after amniotic membrane transplantation (table 1). the amt remained viable on the ocular surface for 2-3 weeks after grafting. no patient developed any corneal infection due to amt on follow up. there were four cases having corneal scarring with central descematocele formation. three patients had resolved bacterial keratitis and one patient had resolved viral keratiitis. amniotic membrane was used as a single layer epithelial side up graft in such cases after removal of corneal epithelium surrounding the descematocele. post-operative follow up showed the formation of a thin white membrane over the descematocele. there were 7 cases having corneal ulcers, out of which 2 had hypopyon. two cases had fungal keratitis, 4 cases had bacterial keratitis and one had shield corneal ulcer associated with atopic conjunctivitis. all patients had poor response with topical antibiotics or antifungal. five patients had localized patches of amniotic membrane applied over the area of corneal ulcer (fig. 6) while two patients had large graft covering the whole of the cornea. all patients were told to continue their topical drops after the amniotic membrane transplantation. the patients with localised bacterial keratitis and shield ulcers responded well (fig. 7) with rapid improvement of the keratitis. patients with fungal keratitis showed subjective improvement in pain with good response in one case while the other showed no improvement in keratitis in one case. this case also had hypopyon measuring 3 mm. there was one case having corneal melt with iris prolapse measuring 4 mm in size. double layered amt was done but the defect failed to close and needed tectonic graft. two cases of bullous keratopathy responded very well to amt. one patient had inferior bullous keratopathy secondary to insect bite (fig. 8) while the other had bullous keratopathy involving the whole cornea secondary to endothelial decompensation after cataract surgery. both patients had resolution of symptoms with stabilization of the corneal epithelium (fig. 9,10). four patients underwent amniotic membrane transplant after primary pterygium excision. the amniotic membrane was buried beneath the conjunctiva surrounding the bare sclera left after excision of the pterygium. we found no recurrence after 3 months of follow up. we used amt with favourable outcome in one patient with grade iii alkali burn as a double layered graft to prevent immediate corneal melt. a case having dermal necrosis following a dermis fat graft was salvaged using amt. the amniotic membrane gave time to the surrounding conjunctiva to grow beneath the amt and save the dermis. discussion amniotic membrane transplant (amt) is normally stored at −70°c after being placed in a sterile vial containing 10% dimethylsulphoxide (dmso) medium. the membrane is defrosted immediately before use by warming the container to room temperature for 10 minutes, and rinsed three times in saline2. due to the non-availability of frozen amt we developed this method for short term storage of the membrane. it was harvested every week and used as required during the first five days. thus it was very cost effective and convenient to use. while developing this technique our main concern was the viability of the membrane during storage. this was confirmed by histology and clinical examination. we found that the epithelium remained viable for 5 days and the basement membrane for 7 days when it was stored at 4 degree c in normal saline. clinically it was observed that the membrane remained at the transplanted site for 2-3 weeks. it has been recommended that the donor mother should be screened for hepatitis b, c and hiv at the time of harvesting of the membrane. the membrane should then be stored for at least 6 months after which it should be used only if the donor is still hiv test negative. we could not adhere to this method in our study because the membrane could only be stored for 5 days using our technique. we can only justify this act by comparing it to corneal donations in which the donor is screened only once at the time of retrieval. table 1: clinical condition no. of cases clinical response success descematocele 4 formation of thin membrane over it y corneal ulcer 5 promoted healing y hypopyon corneal ulcer 2 promoted healing in 1 case 50 % corneal melt with iris prolapse 1 did not stay in place n bullous keratopathy 2 adhesion with epithelium y chemical burn (grade iii) 1 prevented corneal melt y pterygium 4 epithelial growth above y dermis fat graft 1 epithelial growth beneath y table 2: age of am no. used 0 day old am 2 membranes 1 day old am 8 membranes 2 day old am 1 membrane 3 day old am 4 membranes 4 day old am 1 membrane 5 day old am 4 membranes fig 1. h/e stain of day 1 amt. fig 2. h/e stain of day 2 amt. fig 3. h/e stain day 4 amt. fig 4. h/e stain of day 5 amt. fig 5. h/e stain of day 7amt. fig 6. post op day 1, amt for corneal ulcer. . fig 7. post op 3weeks, amt for corneal ulcer. fig 8. pre op bullous keratopathy (bk) inferiorly. fig 9. post op day 1, amt for bk. fig 10. post op 3 mths, amt for bk. several mechanisms have been proposed to be involved in the selective anti-inflammatory effect8,9. one is the reduction of tissue inflammation by modulation of the production of activin10. another mechanism is the presence of lactoferrin and interleukin-1 receptor antagonist on amniotic membrane11. lactoferrin is an antibacterial protein that exerts an anti-inflammatory effect by serving as an antioxidant and an iron chelator and sequestor11. by contrast, interleukin-1 receptor antagonist is a potent inhibitor of interleukin-1 and thus will suppress the inflammation mediated by interleukin-112. kim et al13. reported that the patching of amniotic membrane on epithelial defects of the cornea resulted in rapid epithelialization and decreased infiltration of inflammatory cells by suppressing proteinase and matrix metalloproteinase activation. this evidence may explain some of the clinical effects observed in the use of amnioticmembrane for ocular surface reconstruction. we found the anti-inflammatory properties of amt to be very helpful in treating bacterial and fungal keratitis. all 7 patients except one had marked improvement of keratitis after amniotic membrane transplantation as a patch graft. a key aspect of the protective function of amniotic membrane in utero is its ability to promote scarless healing8,9. one theory is supported by suppression of transforming growth factor-b signaling in the fetus, therefore inhibiting scar formation14. amniotic membrane also supports nerve growth and synthesizes various neurotransmitters, neuropeptides, and neurotrophic factors15,16. the fact that the amniotic membrane contains and produces these neurotrophic factors strongly suggests that it may help the development of the nervous system in the fetus and ensure scarless wound healing. the fact that the amniotic membrane does not have blood vessels prompts one to hypothesize that the amniotic membrane should hold an antiangiogenic effect17. further investigations have shown expression of vascular endothelial growth factor and basic fibroblast growth factor in the amniotic membrane, indicating that it possesses the angiogenic factors like many other vascularized tissues18-20. apart from these angiogenic factors, a recent study has shown that human amniotic membrane proteins inhibit vascular endothelial cell proliferation while promoting cornea epithelial cell growth8,9. the latter activity may explain why amniotic membrane transplantation promotes epithelialization and wound healing in the cornea21. amniotic membrane is used for corneal reconstructtion, conjunctival reconstruction, and other miscellaneous applications. in corneal reconstruction, amniotic membrane is used for limbal stem cell deficiency, corneal ulcers and perforations, and bullous keratopathy. several publica-tions have demonstrated the effects of amniotic membrane in limbal stem cell deficiency8,22-27. sangwan et al28. reported excellent results with the use of amniotic membrane for partial limbal stem cell deficiency, confirming previous reports by tseng et al.23 and gomes et al26. as for total limbal stem cell deficiency, studies have shown successful outcomes varying between 60% and 70% of the cases22-26. it can also be used as a substrate for expanding limbal epithelial stem cells for subsequent transplantation in the treatment of limbal stem cell deficiency8,29-32. one or multiple layers of amniotic membrane have been used for the treatment of corneal ulcers8,33,34. rodrı´guez-ares et al35. reported the use of amniotic membrane transplantation in the treatment of corneal perforations of different sizes. the authors found that multilayer amniotic membrane transplantation was successful in 73% of the cases (11/15 cases) and was effective for treating corneal perforations with diameters less than 1.5 mm. three of the four unsuccessful treatments were of perforations 3 mm or more in diameter. hick et al.36 proposed the use of amniotic membrane in the management of different types of corneal ulcers by fibrin glue and amniotic membrane and observed an overall success rate of 80% (27/33 eyes). grafts with fibrin sealant showed a success rate of 92.9% (13/14 eyes) compared with 73.7% (14/19 eyes) for amniotic grafts alone. we had one case with failure of the amt for a large corneal perforation 4 mm in size. while 4 cases with descematoceles responded quite well to amt. amniotic membrane has been used successfully for the treatment of symptomatic bullous keratopathy8,37. espana et al.38 evaluated the long-term outcome of epithelial debridement and amniotic membrane transplantation in 18 eyes with symptommatic bullous keratopathy and poor visual potential. complete corneal epithelial healing occurred in all except one eye. pain relief was obtained in 88% of patients. the results are similar to those in other series reported in the literature37. gomes and dua have used a 9mm trephine to punch out disks of amniotic membrane and an 8.5mm trephine to mark the area of epithelium to be debrided. with a crescent blade, they make a 360subepithelial/superficial stromal pocket out of the 8.5mm mark. the amniotic membrane disk is placed on the bed of the de-epithelialized 8.5mm area, and its edge is rolled outward to the subepithelial/superficial stromal pocket and sutured with continuous 10.0 nylon. a bandage contact lens is placed after the procedure39. we used the amniotic membrane as a patch graft after denuding the epithelium in cases of bullous keratopathy and found favorable results. amniotic membrane is used for primary and recurrent pterygium, tumors, symblepharon, and other applications. recent comparative studies have presented controversial results on the use of amniotic membrane for primary and recurrent pterygium8,5,40. tananuvat and martin performed a prospective randomized study in thailand comparing the use of amniotic membrane (39 eyes) with conjunctival autograft (42 eyes) as an adjunctive therapy after surgical excision of primary pterygium. the authors found a much higher rate of recurrence in the amniotic membrane group (40.9%) than in the conjunctival transplantation group (4.76%). this is not the experience reported by most of the other authors5,40,39,41. interestingly, the recurrences occurred within 3 months in eyes that underwent conjunctival transplantation and as long as 1 year postoperatively in eyes with amniotic membrane transplantation. we did not find any recurrence till 3 months in our cases. to further improve the surgical results for pterygium and decrease its recurrence rate, many authors are trying different combinations of amniotic membrane and other adjunctive treatments. shimazaki et al.41 performed a retrospective study of recurrent pterygia that underwent amniotic membrane transplantation combined with either limbal autograft (15 eyes) or conjunctival autograft transplantation (12 eyes). the authors observed a lower recurrence rate with the latter procedure (8.3% compared with 20%), but there was no statistically significant difference. ma et al.42 compared the excision of recurrent pterygia followed by amniotic membrane alone (48 eyes) with amniotic membrane combined with intraoperative 0.025% mitomycin c for 3 minutes (47 eyes). the authors found 12.5% and 12.5% of conjunctival and corneal recurrences for amniotic membrane, respectively, and 8.5% and 12.8% of conjunctival and corneal recurrences for the combination of amniotic membrane with mitomycin c (mmcd), respectively. no significant difference was found in the conjunctival and corneal recurrence rate between the two groups. amniotic membrane transplantation has been used successfully in the treatment of ocular surface neoplasia8,6,. espana et al.6 described a series of 16 eyes that underwent excision of large (>20 mm square) ocular surface neoplasia, including conjunctival intraepithelial neoplasia, primary acquired melanosis, and malignant melanoma, that was followed by adjunctive cryotherapy and amniotic membrane transplantation. complete ocular surface healing occurred in all cases. tumor recurrence occurred in 1 of 10 cases of conjunctival intraepithelial neoplasia (10%), and no recurrences were observed in the patients with melanotic lesions. more recently, gunduz et al.43 reported the use of nonpreserved human amniotic membrane for conjunctival reconstructtion after excision of 10 ocular surface neoplasias. over a mean follow-up time of 10 months, all but one eye remained free of tumor recurrence. treatment complications included partial limbal stem cell deficiency in two eyes and symblepharon formation in one eye. solomon et al.44 described a success rate of 70.6% (12/17 eyes) with the use of amniotic membrane transplantation for fornix reconstruction in a variety of ocular surface disorders. in cases in which the surrounding host tissue was associated with inflammatory activity, subconjunctival injections of long-acting triamcinolone acetonide were given along the edges of the excised conjunctiva. the authors also observed that the underlying cause of a lack of success was either recurrent pterygia or an autoimmune disorder. jain and rastogi45 reported a recurrence rate in 40% (8/20) of eyes that underwent amniotic membrane transplantation for symblepharon, but in two of these the cicatrization was focal and did not induce functional impairment. preoperative dry eye and previous conjunctival surgery were important risk factors identified. besides eyes with severe dry eye, recurrent pterygia seems to present an extremely high potential for the recurrence of symblepharon. more recently, tseng et al.7 reported excellent results with the intraoperative use of mitomycin c and amniotic membrane transplantation for fornix reconstruction in 16 patients with severe cicatricial ocular surface diseases. after a mean follow-up time of 14 months, the authors observed deeper fornix and noninflamed ocular surface in all eyes. partial motility restriction recurred in 10% of the cases (2 recurrent pterygia and 1 chemical burn). amniotic membrane transplantation alone is not sufficient to obtain a successful reconstruction of the conjunctival fornices in cases with active inflammation, recurrent pterygia, and autoimmune diseases. the use of intraoperative longacting steroids and mitomycin c may improve these results. amniotic membrane can be used as an antiinflammatory patch in the acute phase of chemical and thermal burns and in stevens-johnson syndrome8,46. it is reabsorbed after a few days, depending on the degree of the inflammatory process. with its properties, it seems to facilitate corneal surface recovery by reducing corneal and limbal inflammation and restoring the conjunctival surface, which in turn limits symblepharon formation46. the amniotic membrane patch, however, may not be enough to treat more severe chemical burns (grades iii and iv) with an important ischemic component47. we found that amniotic membrane prevented early melting of the cornea and gave more time for the growth of blood vessels from the fornices. anderson et al.48 successfully used amniotic membrane graft for the treatment of 16 eyes with band keratopathy after removing the calcium deposits; however, this method does not prevent new calcium deposits from forming. by contrast, the stromal side of amniotic membrane seems to attract new deposits of calcium. amniotic membrane transplantation also can be used successfully to cover large conjunctival defects after resection of the conjunctiva in conjunctivochalasis. meller et al.49 reported good results in 47 eyes with improvement of the symptoms and avoidance of conjunctival cicatricial complications such as symblepharon and motility restriction. in severe vernal conjunctivitis, amniotic membrane transplantation can be used successfully as a patch or a graft, in the treatment of shield ulcer, or as a tarsal conjunctival substitute after resection of giant papillae50. we found amt to be very successful in treating one case of shield ulcer in our series. amniotic membrane also may be used in glaucoma as an adjunct to reduce scarring or to treat conjunctival complications after glaucomatous filtrating surgery, such as leaking blebs, or to cover valve implants and scleral or pericardium patches. we recently reported a case in which amniotic membrane was used successfully to save a dermis fat graft. the patient had developed necrosis of the dermis one week after surgery thereby exposing the fat which was protected by the amniotic membrane. the surrounding conjunctiva grew beneath the amniotic membrane to resurface the fat51. conclusion short term storage of amniotic membrane shows stable clinical and histopathological behaviour for the management of corneal surface disorders. author’s affiliation dr. muhammad moin assistant professor department of ophthalmology king edward medical university, lahore dr. ihtesham ud din associate professor department of pathology king edward medical university, lahore dr. muhammad khalil registrar department of ophthalmology king edward medical university, lahore dr. nadia lateef department of ophthalmology king edward medical university, lahore prof. i.a. naveed department of pathology king edward medical university, lahore prof. mumtaz hussain department of ophthalmology king edward medical university, lahore references 1. gomes ja, romano a, santos ms, dua hs. amniotic membrane use in ophthalmology. curr opin ophthalmol. 2005; 16: 233-40. 2. azuara-blanco a, pillai ct, dua hs. amniotic membrane transplantation for ocular surface reconstruction. br j ophthalmol. 1999; 83: 399-402. 3. hanada k, shimazaki j, shimmura s, tsubota k. multilayered amniotic membrane transplantation for severe ulceration of the cornea and sclera. am j ophthalmol. 2001; 131: 324-31. 4. budenz dl, barton k, tseng sc. 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wound healing. plast reconstr surg 2000; 105: 140-7. 16. sakuragawa n, elwan ma, uchida s, et al. non-neuronal neurotransmitters and neurotrophic factors in amniotic epithelial cells: expression and function in humans and monkey. jpn j pharmacol. 2001; 85: 20-3. 17. burgos h. angiogenic factor from human term placenta: purification and partial characterization. eur j clin invest. 1986; 16: 486-93. 18. bogic lv, brace ra, cheung cy. cellular localization of vascular endothelial growth factor in ovine placenta and fetal membranes. placenta. 2000; 21: 203—9. 19. mignatti p, tsuboi r, robbins e, rifkin db. in vitro angiogenesis on the human amniotic membrane: requirement for basic fibroblast growth factorinduced proteinases. j cell biol. 1989; 108: 671-82. 20. hao y,ma dh, hwang dg, et al. identification of antiangiogenic and anti-inflammatory proteins in human amniotic membrane. cornea. 2000; 19: 348-52. 21. li h, niederkorn jy, neelam s, et al. immunosuppressive factors secreted by human amniotic epithelial cells. invest ophthalmol vis sci. 2005; 46: 900-7. 22. shimazaki j, yang hy, tsubota k. amniotic membrane transplantation for ocular surface reconstruction in patients with chemical and thermal burns. ophthalmology. 1997; 104: 2068-76. 23. tseng scg, prabhasawat p, barton k, et al. amniotic membrane transplantation with or without limbal autografts for corneal surface reconstruction in patients with limbal stem cell deficiency. arch ophthalmol. 1998; 116: 431-41. 24. tsubota k, satake y, kaido m, et al. treatment of severe ocular surface disorders with corneal epithelial stem cell transplantation. n engl j med. 1999; 22: 1697-1703. 25. solomon a, ellies p, anderson df, et al. long-term outcome of keratolimbal allograft with or without penetrating keratoplasty for total limbal stem cell deficiency. ophthalmology. 2002; 109: 1159-66. 26. gomes jap, santos ms, cunha mc, et al. amniotic membrane transplantation for partial and total limbal stem cell deficiency secondary to chemical burn. ophthalmology. 2003; 110: 466-73. 27. gomes jap, santos ms, donato wbc, et al. amniotic membrane and livingrelated conjunctival limbal allograft for ocular surface reconstruction in stevens-johnson syndrome. arch ophthalmol. 2003; 121: 1369-74. 28. sangwan vs, matalia hp, vemuganti gk, rao gn. amniotic membrane transplantation for reconstruction of corneal epithelial surface in cases of partial limbal stem cell deficiency. indian j ophthalmol. 2004; 52: 281-5. 29. schwab ir, reyes m, isseroff rr. successful transplantation of bioengineered tissue replacements in patients with ocular surface disease. cornea. 2000; 19: 421-6. 30. tsai rj, li lm, chen jk. reconstruction of damaged corneas by transplantation of autologous limbal epithelial cells. n engl j med. 2000; 3431: 86-93. 31. koizumi n, inatomi t, suzuki t, et al. cultivated corneal epithelial stem cell transplantation in ocular surface disorders. ophthalmology. 2001; 108: 1569-74. 32. shimazaki j, aiba m, goto e, et al. transplantation of human limbal epithelium cultivated on amniotic membrane for the treatment of severe ocular surface disorders. ophthalmology 2002; 109: 1285-90. 33. lee sh, tseng scg. amniotic membrane transplantation for persistent epithelial defects with ulceration. am j ophthalmol. 1997; 123: 303-12. 34. kruse fe, rohrschneider k, vo lcker he. multilayer amniotic membrane transplantation for reconstruction of deep corneal ulcers. ophthalmology. 1999; 106: 1504-10. 35. rodrı´guez-ares mt, tourin˜o r, lo´ pez-valladares mj, gude f. multilayer amniotic membrane transplantation in the treatment of corneal perforations. cornea. 2004; 23: 577-83. 36. hick s, demers pe, brunette i, et al. amniotic membrane transplantation and fibrin glue in the management of corneal ulcers and perforations: a review of 33 cases. cornea. 2005; 24: 369-77. 37. pires rtf, tseng scg, prabhasawat p, et al. amniotic membrane transplantation for symptomatic bullous keratopathy. arch ophthalmol. 1999; 117: 1291-97. 38. espana em, grueterich m, sandoval h, et al. amniotic membrane transplantation for bullous keratopathy in eyes with poor visual potential. j cataract refract surg. 2003; 29: 279-84. 39. tananuvat n, martin t. the results of amniotic membrane transplantation for primary pterygiumcompared with conjunctival autograft. cornea. 2004; 23: 458-63. 40. solomon a, pires rtf, tseng scg. amniotic membrane transplantation after extensive removal of primary and recurrent pterygia. ophthalmology. 2001; 108: 449-60. 41. shimazaki j, kosaka k, shimmura s, tsubota k. amniotic membrane transplantation with conjunctival autograft for recurrent pterygium. ophthalmology. 2003; 110: 119-24. 42. ma dh, see l, hwang y, wang s. comparison of amniotic membrane graft alone or combined with intraoperative mitomycin c to prevent recurrence after excision of recurrent pterygia. cornea. 2005; 24: 141-50. 43. gunduz k, ucakhan oo, kanpolat a, gunalp i. nonpreserved human amniotic membrane transplantation for conjunctival reconstruction after excision of extensive ocular surface neoplasia. eye. 2006; 20: 351-7. 44. solomon a, espana em, tseng scg. amniotic membrane transplantation for reconstruction of the conjunctival fornices.ophthalmology. 2003; 110: 93-100. 45. jain s, rastogi a. evaluation of the outcome of amniotic membrane transplantation for ocular surface reconstruction in symblepharon. eye. 2004; 18: 1251-7. 46. meller d, pires rtf, mack rjs. amniotic membrane transplantation for acute chemical or thermal burns. ophthalmology. 2000; 107: 980-90. 47. joseph a, dua hs, king aj. failure of amniotic membrane transplantation in treatment of acute chemical burns. br j ophthalmol. 2001; 85: 1065-69. 48. anderson df, prabhasawat p, alfonso e, tseng sc. amniotic membrane transplantation after the primary surgical management of band keratopathy. cornea. 2001; 20: 354-61. 49. meller d, maskin sl, pires rtf, tseng scg. amniotic membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. cornea 2000; 19: 796-803. 50. sridhar ms, sangwan vs, bansal ak, rao gn. amniotic membrane transplantation in the management of shield ulcers of vernal keratoconjunctivitis. ophthalmology. 2001; 108: 121822. 51. moin m, qayyum i, hussain m. amniotic membrane to the rescue of partially necrosed dermis fat graft. clin experiment ophthalmol. 2006; 34: 717-8. microsoft word khalid mahmood.doc 204 original article transscleral diode laser cyclophotocoagulation for the treatment of refractory glaucoma khalid mahmood, rafay amin baig, mirza jameel ud din baig, asim waseem, muhammad tariq khan, z. a. qazi pak j ophthalmol 2007, vol. 23 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. khalid mahmood consultant ophthalmologist lrbt eye hospital, 436,sector a1 township lahore. received for publication february’ 2007 …..……………………….. purpose: to study the efficacy and safety of diode laser cycloablation to achieve adequate iop reduction and a comfortable eye. material and methods: the study was conducted at the glaucoma unit of lrbt eye hospital lahore. 102 eyes of 88 patients treated between august 2004 and january 2006 with a minimum follow up of 6 months were included in the study. results: the mean pre treatment iop of 102 eyes (of 88 patients) was 41.79±9.50 mmhg. mean iop at 1, 3 and 6 months after treatment was 16.65±9.71 mmhg, 16.5±9.52 mmhg and 16.18±8.21 mmhg respectively. complications encountered included uveitis, hyphema, hypotony and neurotrophic ulcer. conclusion: transscleral diode laser cycloablation is highly effective in lowering intraocular pressure. high success and low complication rate combined with portability, durability and easy to learn technique makes diode laser cycloablation the treatment of choice for refractory and complex glaucoma. efractory glaucoma is the term used for glaucoma resistant to conventional management.1 this includes maximally tolerated medical therapy, one or more than one glaucoma surgeries with or without antimetabolites and in cases of rubeotic glaucoma, panretinal photocoagulation or cryoablation. multiple factors contribute to the failure of intraocular pressure control during glaucoma management. glaucoma more likely to become refractory includes neovascular, inflammatory, post retinal surgery, post traumatic and rare conditions like aniridia and congenital anterior chamber anomalies. long term topical medical therapy for primary open angle glaucoma or primary angle closure glaucoma is a known factor compromising the outcome in glaucoma surgery. cyclodestructive procedures are used when glaucoma becomes resistant to conventional medical and surgical procedures. these procedures destroy the non pigmented and pigmented epithelium of the ciliary body leading to decrease in aqueous production and thus drop in intraocular pressure. modalities tried for cyclodestruction are cryotherapy and laser photocoagulation of the ciliary body using energy of different wavelengths2-7. of these cyclocryoablation and nd: yag laser cyclophotocoagulation are more commonly used. contact diode laser cryoablation is emerging as the preferred treatment because these two methods are associated r 205 with greater risk of hypotony and phthisis due to excessive ciliary body destruction8-10. diode laser causes destruction of pigmented and non-pigmented ciliary epithelium and capillaries in the ciliary processes with pigment clumping, coagulative necrosis, and extensive destruction of ciliary muscle with moderate reduction in vascularity11. main objective was to study the efficacy and safety of diode laser cycloablation and to achieve adequate iop reduction and a comfortable eye. materials and methods the study was conducted at the glaucoma unit of lrbt eye hospital lahore. 102 eyes of 88 patients treated between august 2004 and january 2006 with a minimum follow up of 6 months were included in the study. glaucoma was labeled refractory if the iop was above 21 mmhg despite all efforts using medical, surgical and laser treatment options. pre laser assessment included best corrected visual acuity, slit lamp biomicroscopy of the anterior and posterior segment, applanation tonometery using goldman tonometer in adults and air puff non contact tonometery under sedation in children. gonioscopy was also done in all patients except infants. personal profile including age and gender was also recorded. transscleral diode laser cyclophotocoagulation ("cyclodiode") was performed using the iridis quantal medical diode laser with a wavelength of 810 nm. local anesthesia in the form of peribulbar injection using 3-4 cc of 2% xylocaine was used in patients 18 years or above. in younger patients treatment was performed under general anesthesia. laser energy was delivered using the g-probe placed 1.5mm from the limbus. the direction of the probe was parallel to the visual axis. 25-30 laser burns were applied for 270 degrees strictly avoiding 3 and 9 o’clock positions to save the ciliary nerves and vessels. energy settings were 1.8 – 2.1 w applied for 1 second duration resulting in a power delivery of 1.8 – 2.1 j per application (45 – 63 joules per session). pop sound of the laser burn was the end point. oral nsaids, topical dexamethasone 0.1% eye drops along with antiglaucoma medication except miotics were continued for the 1st week. anti glaucoma medication was tapered in accordance with the drop in intraocular pressure. at 1 week post laser treatment oral acetazolamide was discontinued if the lop was <22 mmhg, with reintroduction of topical iop lowering medications at the discretion of the clinician. topical steroids, usually dexamethasone 0.1 % eye drops, were prescribed four times a day for 2-4 weeks after treatment. post treatment follow up was done on day 1, week 1, 4, 6 and then at 4, 5 and 6 months. topical iop lowering medications were reintroduced if lop control was inadequate. retreatment was done if the iop was above 22 mmhg at 4th post laser week. number of applications and power was increased to 32 and 2.4 w respectively. duration was kept the same as before that is 1 second. treatment was repeated for a maximum of 3 times. the treatment was considered successful if the iop at 6 months was between 5 and 21 mmhg with or without topical medication. results 114 eyes of 94 patients were treated. 88(94%) patients (102 eyes) completed at least 6 months follow up and were included in the study. those who did not complete at least 6 months follow up were excluded from the study. mean follow up was 11 months ranging from 6 months to 22 months. mean age of the patients was 41 years. (range 1-62 years). visual acuity was pl to 6/36. the diagnostic groups of patients receiving treatment are shown in table 1. primary angle closure glaucoma was found to be the most common cause of refractory glaucoma in our patients followed by neovascular glaucoma, post retinal detachment surgery and primary open angle glaucoma. the mean pre treatment iop of 102 eyes (of 88 patients) was 41.79±9.50 mmhg. the effect of treatment at 1, 3 and 6 months is shown in fig 1. mean iop at 1, 3 and 6 months was 16.65±9.71 mmhg, 16.5±9.52 mmhg and 16.18±8.21 mmhg respectively. figure 2 shows a comparison of pre and post treatment iop in 102 eyes. eyes were divided into 5 groups based on pre and post treatment intraocular pressure. maximum number of sessions in our patients were 3 (table 2). there were 6 eyes of 3 patients that received treatment thrice. 38(37%) eyes had two and 58(57%) eyes had only one treatment session. complications are tabulated in table 3. uveitis and hyphema were the more commonly observed complications which resolved in 2-4 weeks with more 206 frequent instillation of topical steroids. hypotony defined as iop less than 5 mmhg was seen in 2 eyes (2 patients). neurotrophic ulcer which was believed to occur due to inadvertent application of laser to ciliary nerves was seen in 1 eye only. no case of phthisis or lens damage was seen. discussion diode laser cycloablation has developed an acceptable track record for the treatment of refractory glaucoma1214. it has also been tried as a primary surgical treatment in different types of glaucoma15-17.. complications profile is acceptable and most authors have reported insignificant and transient complica-tions like pain and inflammation18-20. some surgeons are trying it as an alternative to drainage implant surgery in complex glaucomas21. table 1: diagnostic groups of eyes undergoing dlca primary angle closure glaucoma 26 neovascular glaucoma 21 post retinal surgery 16 primary open angle glaucoma 14 trauma 10 inflammatory 6 buphthalmos 3 aniridia 3 sturge weber syndrome 1 peter’s anomaly 1 steroid induced 1 table 2: no. of laser sessions no of sessions no of eyes n (%) 1 58 (57) 2 38 (37) 3 6 (6) table 3: complications anterior segment inflammation 8 hyphema 8 moderate to severe pain 6 hypotony 2 vitritis 2 neurotrophic ulcer 1 16.18 16.516.65 20.86 41.79 0 5 10 15 20 25 30 35 40 45 pre o p pos top 1 w eek pos top 1 n ont h pos top 3 m ont hs pos top 6 m ont hs fig. 1: decrease in intraocular pressure after treatment 64 18 29 62 1112 8 0 0 10 20 30 40 50 60 70 <15 16-24 23-35 36-45 >45 pre treatment post treatment fig. 2: comparison of intraocular pressure pre and post treatment n o of e ye s iop mmhg io p ( m m h g) 207 11, 11% 54, 53% 37, 36% oral + topical topical no medications fig. 3: topical and oral medications required after surgery (no of eyes) no standard protocol has yet been agreed upon for the energy settings. different settings have been used ranging from 1.5 watts to 2.5 watts for 1-2 seconds22-24. we used a power of 1.8-2.1 w titrating with the pop sounds. spencer and vernon used a fixed setting and did not alter it to hear the pop sound24. we had a mean drop of 50.08% in iop. this is comparable to other studies mentioned above where a decrease of 20%-65% in mean iop has been reported. regarding the number of treatment sessions again there is no agreement on how many times the procedure should be repeated. spencer and vernon repeated the procedure up to five times24. we had a maximum of 3 sessions in our series. retreatment was done in 44% of which only 6% received 3 treatment sessions. brancato et al20 and bock et al25 had a retreatment rate of 65% and 70% respectively. noureddin et al22 recommend that a high power setting results in better iop control and lesser need for retreatments. our success rate is 80.3% (iop < 21 mmhg) at 6 months. results in literature vary from 48%92%14,17,21,24. reviewing the literature one finds that better success rate is seen with higher power settings and increased number of treatments. egbert et al17 had a success rate of 48%. their power settings were low and treatment repeated only in 20% cases. they recommend that higher power settings and repeated treatment would improve success but they were conservative because they were undertaking the procedure as a primary treatment. highest rate we could find in literature is that of gupta and agarwal21 which is 92%. a striking difference in their method was that they treated 360 degrees instead of 270 degrees. murphy et al1 have also measured the sensitivity to cyclophotocoagulation and found chronic angle closure glaucoma and glaucoma secondary to retinal surgery to be the most sensitive to this treatment. though we specifically did not measure the sensitivity but our findings seem to confirm this. most serious adverse effects of this therapy are hypotony and phthisis. rates reported are highly variable. in our series there was no case of phthisis and hypotony occurred only in 2 of 102 eyes. (<2%). conclusion our results confirm the findings of other investigators that transscleral diode laser cycloablation is highly effective in lowering intraocular pressure. high success and low complication rate combined with portability, durability and easy to learn technique makes diode laser cycloablation the treatment of choice for refractory and complex glaucoma. author’s affiliation dr. khalid mahmood consultant ophthalmologist lrbt, eye hospital lahore. dr. rafay amin baig resident medical officer lrbt, eye hospital lahore. dr. mirza jameel ud din baig resident medical officer lrbt, eye hospital lahore. dr. asim waseem ophthalmologist lrbt, eye hospital lahore dr. muhammad tariq khan consultant ophthalmologist lrbt, eye hospital lahore. dr. z a qazi chief consultant ophthalmologist lrbt, eye hospital lahore. 208 reference 1. murphy cc, burnett cam, spry pgd, et al. a two centre study of the dose-response relation for transscleral diode laser cyclophotocoagulation in refractory glaucoma. br j ophthalmol. 2003; 87: 1252-7. 2. bietti g. surgical interventions on the ciliary body. new trends for the relief of glaucoma. jama 1950;142: 889-97. 3. weekers r, lavergne g, watillon m, et al. effects of photocoagulation of ciliary body upon ocular tension. am j ophthalmol. 1961; 52: 156-63. 4. beckman h, kinoshita a, rota an, et al. transscleral ruby laser irradiation of the ciliary body in the treatment of intractable glaucoma. trans am acad ophthalmol otolaryngol 1972; 74: 423-36. 5. beckman h, sugar hs. neodymium laser cyclophotocoagulation. arch ophthalmol. 1973; 90: 27-8. 6. lee pf. argon laser photocoagulation of ciliary processes in cases of aphakic glaucoma. arch ophthalmol. 1979; 97: 2135-8. 7. finger pt, smith pd, paglione rw, et al. transscleral microwave cyclodestruction. invest ophthalmol vis sci. 1990; 31: 2151-5. 8. benson mt, nelson me. cyclocryotherapy: a review of cases over a 10 year period. br j ophthalmol. 1990; 74: 103-5. 9. schuman js, bellows ar, shinglelon bj, et al. contact transscleral nd: yag laser cyclophotocoagulation. midterm results. ophthalmology 1992; 99: 1089-94. 10. ulbig mw, mchugh da, mcnaught ai, et al. clinical comparison of semiconductor diode versus nd:yag noncontact cyclophotocoagulation. br j ophthalmol. 1995; 79: 56974. 11. mckelvie pa, walland mj. pathology of cyclodiode laser: a series of nine enucleated eyes. br j ophthalmol. 2002; 86: 381-6. 12. ataullah s, biswas s, artes ph long term results of diode laser cycloablation in complex glaucoma using the zeiss visulas ii system. br j ophthalmol. 2002; 86: 39-42. 13. martin krg, broadway dc. cyclodiode laser therapy for painful, blind glaucomatous eyes. br j ophthalmol. 2001; 85: 474-6. 14. schlote t. derse m. zierhut m. transscleral diode laser cyclophotocoagulation for the treatment of refractory glaucoma secondary to inflammatory eye diseases. br j ophthalmol. 2000; 84: 999-1003. 15. heinz c, koch jm, heiligenhaus a. transscleral diode laser cyclophotocoagulation as primary surgical treatment for secondary glaucoma in juvenile idiopathic arthritis: high failure rate after short term follow up. br j ophthalmol. 2006; 90: 737-40. 16. lai js, tham cc, chan jc. diode laser transscleral cyclophotocoagulation as primary surgical treatment for medically uncontrolled chronic angle closure glaucoma: longterm clinical outcomes. j glaucoma. 2005; 14: 114-9. 17. egbert pr, fiadoyor s, budenz dl, et al. diode laser transscleral cyclophotocoagulation as a primary surgical treatment for primary open angle glaucoma. arch ophthalmol. 2001; 119: 345-50. 18. bloom pa, tsai jc, sharma k, et al. cyclodiode transscleral diode laser photocoagulation in the treatment of advanced refractory glaucoma. ophthalmology 1997; 104: 1508-19. 19. kosoko o, gaasterland de, pollack ip, et al. the diode laser ciliary ablation study group. long term outcome of initial ciliary ablation with contact diode laser transscleral cyclophotocoagulation for severe glaucoma. ophthalmology 1996; 103: 1294-1302. 20. brancato r, carassa rg, bettin p, et al. contact transscleral cyclophotocoagulation with diode laser in refractory glaucoma. eur j ophthalmol. 1995; 5: 32-9. 21. gupta v, agarwal hc. contact trans-scleral laser cyclophotocoagulation treatment for refractory glaucomas in the indian population. indian j ophthalmol. 2000; 48: 295-300. 22. noureddin bn, zein w, haddad c, et al. diode laser transscleral cyclophotocoagulation for refractory glaucoma: a 1 year follow-up of patients treated using an aggressive protocol. eye. 2006; 20: 329-35. 23. chang sh, chen yc, li cy, wu sc. contact diode laser transscleral cyclophotocoagulation for refractory glaucoma: comparison of two treatment protocols. can j ophthalmol. 2004; 39: 511-6. 24. spencer af, vernon sa. “cyclodiode”: results of a standard protocol. br j ophthalmol. 1999; 83: 311-6. 25. bock cj, freedman sf, buckley eg, et al. transscleral diode laser cyclophotocoagulation for refractory pediatric glaucomas. j pediatr ophthalmol strabismus. 1997; 34: 235-9. 404 not found microsoft word arshadiqbacorrectedsent.doc 58 original article admitted ocular emergencies: a four year review arshad iqbal, snaullah jan, muhammad naeem khan, salim khan, shad muhammad pak j ophthalmol 2007, vol. 23 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: arshad iqbal registrar khyber institute of ophthalmic medical sciences lady reading hospital peshawar received for publication may’ 2006 …..……………………….. purpose: to acquaint the ophthalmologists and related health professionals about the magnitude of admitted ocular emergencies (oe) for better prevention and management. material and methods: this study was conducted over a period of 4 years from 1st january 2000 to 31st december 2003 at the department of ophthalmology, khyber institute of ophthalmic medical sciences, lady reading hospital, peshawar, pakistan. a comprehensive review of the computer record available for admitted ocular emergencies was carried out. results: total admissions during the study period were 13807. total admitted ocular emergencies (oe) were 2789 i.e 20.2% of the total admission. male to female ratio was 2:1. non-traumatic oe were 53.0% while traumatic oe were 47.0%. in non-traumatic group males were 59.9% while females were 40.1%. in traumatic group males were 74.2% and females were 25.8%. in non-traumatic group almost 2/3 of the patients were of 40 years and above age group while in traumatic group more than half of the patients were less than 20 years of age. corneal ulcers (39.8%) and acute glaucomas (23.3%) were the leading causes of the non-traumatic group while open globe injuries (ogi) (71.9%) were leading the list of traumatic oe. total surgical procedures performed for ocular emergencies were 1988 i.e 16.0% of the total major ophthalmic surgeries. average stay in the hospital for non-traumatic oe was 6.6 days, whereas, for the traumatic oe was 5.5 days. conclusions: oe formed significant proportion of total ophthalmic admissions. traumatic oe were almost equal to non-traumatic oe. male were affected more commonly specially in traumatic group. average hospital stay for oe was longer than routine admissions. most of oe needed surgical intervention for proper management. he health professionals and especially the ophthalmologists are frequently encountered by ocular emergencies, both traumatic and non-traumatic. most of the times they are difficult to manage and are associated with high risk of complications. they usually require prolonged admissions for proper management. it has been reported that 5-16% of all admissions in eye hospitals are trauma related1. ocular trauma victims are predominantly male, young2 and have a potential risk of blindness. the nonexistence or inadequacy of safety measures at home, workplace in sports, lack of adequate eye care facilities, delay in presentation and the use of traditional medicine are some of the important factors responsible for such poor outcome of ocular trauma in developing countries. it has been t 59 reported that 5% of blindness in the developing countries is trauma related3. blindness has profound human and socioeconomic consequences in all societies. the costs of lost productivity, rehabilitation and education of the blind are a significant economic burden. furthermore, in such settings blindness is often associated with lower life expectancy. the global magnitude of blindness is estimated at 50 million and is expected to increase to 75 million by the year 20204. almost 80% of global blindness is avoidable and 90% blind people live in developing countries5. vision 2020, a global initiative by the world health organization, non-government organizations and others, aim to eliminate avoidable blindness by the year 2020 through coordinated strategies aimed at the primary causes of blindness. information about oe especially the non-traumatic is very limited. we conducted this study with the objective to acquaint the ophthalmologists and health authorities about the magnitude of admitted oe for better prevention and management. material and methods it was a retrospective, descriptive study carried out at department of ophthalmology, khyber institute of ophthalmic medical sciences (kioms), lady reading hospital, peshawar, pakistan from 1st january 2000 to 31st december 2003. a comprehensive review of the clinical data available in the “golden eye” for admitted oe was carried out. golden eye is an access based software in which relevant data of every indoor and outdoor patient who attends the department of ophthalmology, lady reading hospital is entered and can be reviewed and analyzed whenever needed. all the patients who were admitted as oe over the study period were included in the study. ocular emergencies were grouped into traumatic and nontraumatic and frequency of various conditions was noted. age and sex distribution was studied among both the groups. surgical procedures performed for oe were noted. hospital stay of both the groups was evaluated. results total admissions during the study period were 13807 whereas total admitted oe were 2789 i.e 20.2% of the total admissions. males were 1858(66.6%) while females were 931 (33.4%). non-traumatic oe were 1478 (53%). males were 885 (59.9%) while females were 593 (40.1%). traumatic oe were 1311 (47%). males were 973 (74.2%) and females were 338 (25.8%). age and sex distribution of non-traumatic and traumatic groups is shown in (table 1, 2) respectively. (table 3-5) shows the frequencies of non-traumatic and traumatic oe respectively. table 1: age and sex distribution of non-traumatic group (n=1478) age distribution male n (%) female n (%) 0-19 year 184 (12.5) 103 (7) 20-39 year 169 (11.4) 65 (4.4) 40-59 year 209 (14.1) 155 (10.5) 60 and above 323 (21.95) 270 (18.3) total 885 (59.9) 593 (40.1) table 2: age and sex distribution of traumatic group (n = 1311) age distribution male n (%) female n (%) 0-19 year 545 (41.6) 220 (16.8) 20-39 year 259 (19.8) 47 (3.6) 40-59 year 91 (7) 33 (2.5) 60 and above 78 (6) 38 (2.9) total 973 (74.2) 338 (25.8) among non-traumatic oe, corneal ulcers 588 (39.8%) and acute glaucomas 344 (23.3%) were the leading causes. frequency of various causes of corneal ulcers is shown in (fig 1). total surgical procedures performed for oe were 1988 which is 16% of the total admitted major ophthalmic surgeries performed during the study period. surgical intervention was required in 71.2% of admitted oe. different surgical procedures performed for oe are shown in (table 5). conjunctival flaps were done for different corneal ulcers. out of 373 cases of bacterial corneal ulcers, 122 (32.7%) needed conjunctival flap. 39 (31.2%) of fungal 60 ulcers had conjunctival flap while 5 (7.9%) of viral ulcers needed conjunctival flap and 6 (37.5%) cases of other corneal ulcers needed conjunctival flap. different oe that needed evisceration/enucleation are shown in (fig 2). average hospital stay for oe was 6.05 days. nontraumatic oe had an average stay of 6.6 days whereas traumatic oe had 5.5 days, while for routine cases it was 2.3 days. average hospital stay for various nontraumatic and traumatic oe is given in table 6 and 7 respectively. 373 125 63 11 16 0 50 100 150 200 250 300 350 400 bacterial fungal viral nutritional others fig. 1: causes of corneal ulcers (n=588) 27 40 72 4 11 0 10 20 30 40 50 60 70 80 com. ulcers endophth ogi hyphema others fig. 2: evisceration/enucleation for ocular emergencies (n=154) discussion an enormous share of the workload of health professionals especially ophthalmologists and institutions is constituted by ocular emergencies. in our study 1/5th of the patients were admitted as ocular emergencies. almost similar ratio has been reported earlier6. traumatic and non-traumatic oe had almost equal share. in our study almost 2/3rd of the patients of nontraumatic oe were of 40 years or older. this could he explained that certain diseases of older age groups present as oe, such as lens induced glaucoma (lig) and angle closure glaucoma (acg). male predominance (59.87%) was seen in non-traumatic group. table 3: non-traumatic ocular emergencies (n = 1478) disease no. of patients n (%) corneal ulcers 588( 39.8) acute glaucomas 344 (23.3) vitreoretinal 164 (11.1) endophthalmitis 158 (10.7) orbit/adnexa 106 (7.2) neurophthalmology 55 (3.7) uveitis 43 (2.9) miscellaneous 20 (1.4) table 4: traumatic ocular emergencies (n = 1311) disease no. of patients n (%) open globe injuries 942 (71.9) iofb 56 (4.3) traumatic hyphema 238 (18.2) chemical/thermal injuries 46 (3.5) miscellaneous 29 (2.2) corneal ulcers were the most frequent cause of non-traumatic oe. valid estimates of the annual incidence of infective ulceration are difficult to obtain in most countries. however, available data indicate that, while in the usa there are 11 corneal ulcers per 100,000 population annually7, in india the number is 10 times higher with 113 per 100,000 population per year8. by conservative estimates corneal ulcers blind at least 1.5 million eyes every year in the world, and the true number may be several times greater9. recent evidence suggests, however, that primary corneal n o. of p at ie nt s n o. of p at ie nt s cor. ulcers 61 ulceration is a much more common event than was previously recognized and that it is a major cause of corneal scarring and visual loss in developing countries10. it has been reported that corneal opacity is the second leading cause of blindness in thailand11. in our study bacterial corneal ulcers (63.5%) were the most frequent type followed by fungal (21.2%). the less number of viral ulcers (10.7%) was probably because most of them are treated as out patients. naseem et al in their study have reported that among corneal ulcers, 16.5% were fungal12. conjunctival flaps were needed to manage corneal ulcers in 29.3% cases while 4.6% of the eyes with corneal ulcers were eviscerated. table 5: surgical procedures for ocualr emergencies (n = 1988) surgery no. of patients n (%) repair ± iofb removal 857 (43.1) conjunctival flap 172 (8.7) cataract extraction ± iol 168 (8.5) evisceration/ enucleation 154 (7.8) trabeculectomy 145 (7.3) conventional r/d surgery 98 (5) a .c wash 66 (3.3) surgical pi 35 (1.8) others 293 (14.7) rd= retinal detachment pi= peripheral iridectomy table 6: hospital stay in days (non-traumatic group) disease no of days corneal ulcers 10.0 acute glaucomas 5.5 vitreoretina 5.0 endophthalmitis 10.0 orbit/adnexa 6.5 neurophthalmology 5.0 uveitis 6.0 miscellaneous 5.0 in our study, we found that 23.3% cases in the non-traumatic group were admitted with acute glaucomas (lig and acg) and was the second frequent cause following corneal ulcers among the non-traumatic group. wajid and khan in their study have reported that 5% of their cases with irreversible blindness were due to primary angle closure glaucoma13. only 2.9% cases of non-traumatic group comprised of uveitis which is 0.3% of the total admissions during the study period. it has been reported previously that 0.8% of the admissions were of uveitis14. table 7: hospital stay in days (traumatic group) disease no. of days open globe injuries 5.0 iofb 5.5 traumatic hyphema 5.0 chemical/thermal injuries 8.0 miscellaneous 4.0 almost half of the total admitted ocular emergencies were trauma related. mostly preventable by the use of suitable eye protection, trauma is a common cause of ocular morbidity. damage may be immediately apparent or may develop after the injury as a secondary complication. ocular trauma has greater potential to cause permanent visual or cosmetic defect for the rest of the life in the affected individuals and is a major cause of monocular blindness and visual impairment through out the world, although little is known about its epidemiology or associated visual outcome in developing 62 countries15. khattak et al have also reported trauma as a common cause of unilateral blindness16. a national population based survey of blindness in nepal found a blindness prevalence rate of 0.8%, and trauma was responsible for 7.9% of monocular blindness17. in our study 9.5% of the ophthalmic admissions were due to ocular trauma compared to 12.9% reported by khan et al18. in traumatic group 58.2% of the patients were less than 20 years of age, in which the number of male patients were more than double of the female patients. this predominance of young male patients in traumatic group has been reported by many authors in national and international studies. al-rajhi, et al observed that 77% of ocular trauma occurred in males20. in another study it was found that male to female ratio is usually greater than 4:1 for acquired trauma related blindness in children21. impaired vision from birth or in early childhood can have a profound impact on infant’s or child development, restricting participation in social, physical educational and later employment opportunities22. children are particularly vulnerable because of lack of awareness and inability to protect themselves. among the traumatic cases, ogi with or without iofb were 76.1% in our study which is in contrast to that reported by earlier studies23, where described blunt objects related trauma is the most common source of eye injury. after ogi the second common cause of traumatic oe was traumatic hyphema due to blunt trauma i-e 18.2%. according to fasih et al, 22.2% of the patients presented with hyphema in their study24. islam et al have reported stone as the commonest source of blunt trauma25. however, jan et al in their study have reported cricket ball as the most common cause of blunt trauma and reported hyphema as a cause of legal blindness in 19.4% of the affected eyes in their study26. chemical and thermal injuries, though relatively less frequent are still very devastating to eye. in our study 3.5% patients presented with chemical or thermal injuries, compared to 5.6% as reported by fasih et al24. the management of ocular surface disorders particularly ocular burns has been a challenging condition for years for the ophthalmologists. even under favourable circumstances, visual performance is disturbed by ocular surface scarring, vascularization, persistent epithelial defects and associated dry eye in most cases of ocular burns27. 10.7% of the patients were admitted for the management of endophthalmitis, which include both the post-operative endophthalmitis and traumatic endophthalmitis. it has been reported that endophthalmitis associated with trauma has a poorer prognosis than that associated with cataract extraction28. high compressive and concussive forces, as well as heavy body injuries with multiple organ involvement can make an eye vulnerable to infection29. post traumatic endophthalmitis is a catastrophic complication of penetrating ocular trauma. it has been shown that the microbiology of traumatic endophthalmitis is distinct from other subgroups of exogenous endophthalmitis30, 31. the risk factors for the development of endophthalmitis in the setting of trauma are the presence of an iofb, delay in primary repair, disruption of the crystalline lens and a rural setting35. brinton et al reported increased incidence of endopthalmitis in eyes with iofb (10.7%) compared to in eyes without iofb (5.2%)33. complications of postoperative endophthalmitis may also be devastating. it has been reported that despite appropriate therapy post-operative endophthalmitis results in severe visual loss in at least 30% patients and retinal detachment in 8-10% of patients 34. evisceration and enucleation were performed for 7.8% of oe. ogi (46.8%) was the commonest indication followed by endophthalmitis (26%). the relative frequencies of the indications for the procedures are almost similar to as that reported by babar et al 35. average stay in the hospital for oe was almost double of the routine admissions. nontraumatic oe had a longer stay than the traumatic oe as corneal ulcers and endophthalmitis needed prolonged hospitalization. conclusions oe contributes heavily to the workload of health care centers and professionals as almost 1/5th of the total admissions were admitted as oe and young men were more at risk for severe oe. the work load, expenses, morbidity and permanent visual, cosmetic or physiological impact of oe should not be under estimated. primary prevention is the key to the solution of the problem as secondary and tertiary prevention could not achieve what the primary prevention can. 63 acknowledgements the authors are grateful to mr. fawad hafeez, our computer operator, whose hard work made it possible to complete the article. author’s affiliation dr. arshad iqbal registrar khyber institute of ophthalmic medical sciences lady reading hospital peshawar dr. snaullah jan senior registrar khyber institute of ophthalmic medical sciences lady reading hospital peshawar dr. muhammad naeem khan consultant ophthalmologist khyber institute of ophthalmic medical sciences lady reading hospital peshawar dr. salim khan resident ophthalmologist khyber institute of ophthalmic medical sciences lady reading hospital peshawar prof. shad muhammad khyber institute of ophthalmic medical sciences lady reading hospital peshawar reference 1. negral ad. magnitude of eye injuries. j comm eye health. 1997; 10: 49-53. 2. tielsch jm, parver lm. determination of hospital charges and length of stay for ocular trauma. ophthalmology. 1990; 97: 2317. 3. thylefors b. epidemiological pattern of ocular trauma. aust nzj opthalmol. 1991; 7: 15-8. 4. frick kd, foster a. the magnitude and cost of global blindness: an increasing problem that can be alleviated. am j ophthalmol. 2003; 135: 271-6. 5. fouad d, mousa a, court right p. sociodemographic characteristics associated with blindness in a nile delta governorate of egypt. br j ophthalmol. 2004; 88: 614-8. 6. jan s, khan s, mohammad s. profile of ocular emergencies requiring admission. pak j ophthalmol. 2002; 18: 72-6. 7. eric jc, nevitt mp, hodge do. incidence of ulcerative keratitis in a defined population from 1950-1988. arch ophthalmol. 1993; 111: 1665-71. 8. gonzales ca, srinivasan m, whitcher jp. incidence of corneal ulceration in madurai district, south india. ophthal epidemiol 1996; 3: 159-66. 9. whitcher jp, srinivasan m. corneal ulceration in the developing world: a silent epidemic. br j ophthalmol. 1997; 81: 622-3. 10. upadhaya mp, karmacharya pc, koirala s, et al. the bhaktapur eye study: ocualr trauma and antibiotic prophylaxis for the prevention of corneal ulceration in nepal. br j ophthalmol. 2001; 85: 388-92. 11. jenchitr w. prevention of blindness and control of visual impairement programme in thailand. thai j public health opthalmol. 2003; 17: 58-70. 12. naseem a, nawaz a, jan s, et al. fungal keratitis: a two years retrospective study. pak j opthalmol. 2001; 17:129-33. 13. wajid sa, khan md. causes of irreversible blindness. j coll physicians surg pak. 2001; 11: 51-4. 14. iqbal a, jan s, saeed n, khan md. two years audit of admitted uveitis patients. pak j ophthalmol. 2003; 19: 108-12. 15. jackson h. bilateral blindness due to trauma in cambodia. eye 1996; 10: 517-20. 16. khattak mnk, khan md, mohammad s, mulk ra. untreatable monocular blindness in pakistani eye patients. pak j ophthalmol. 1992; 8: 3-5. 17. khatry sk, lewis ae, schein od, et al. the epidemiology of ocular trauma in rural nepal. br j ophthalmol. 2004; 88: 456-60. 18. khan md, mohammad s, islam z, khattak mn. an 11 years review of ocular trauma in the north west frontier province of pakistan. pak j ophthalmol. 1991; 7: 15-18. 19. butt nh. management of ocular trauma in children. pak j ophthalmol. 2001; 17: 115-18. 20. al-rajhi aa, awad a, badeeb o, bwchari a. causes of blindness in students attending schools for the blind in saudi arabia. saudi j ophthalmol. 2003; 17: 276-80. 21. negral a.d, thylefors b. the globel impact of eye injuries. opthalmic epidemiol 1998; 5: 143-69. 22. keeffe j. childhood vision impairement. br j opthalmol 2004; 88: 728-29. 23. mac evan c, naines p, desai p. eye injuries in children: the current picture. br j ophthalmol. 1999; 83: 933-6. 24. fasih u, shaikh a, fehmi ms. occupational ocular trauma (causes, management and prevention). pak j ophthalmol. 2004; 20: 65-73. 25. islam z, khan d, mohammad s. incidence and prognosis of concussive hyphema in north west frontier province of pakistan. pak j ophthalmol. 1990; 6: 39-42. 26. jan s, khan s, mohammad s. hyphaema due to blunt trauma. j coll physcians surg pak 2003; 13: 398-401. 27. ozdemir o, tekeli o, ornek k, et al. limbal autograft and allograft transplantation in patients with corneal burns. eye 2004; 18: 241-8. 28. kreslof ms, castellarin aa, zarbin ma. endophthalmitis. surv ophthalmol. 1998; 43: 193-224. 29. sabaci g, bayer a, mutlu m, et al. endophtahlmitis after deadly-weapon-related open-globe injuries: risk factors, value of prophylactic antibiotics and visual outcomes. am j ophthalmol. 2002; 133: 62-9. 30. han dp, wisniewski sr, wilson la. spectrum and susceptibilities of microbiologic isolates in the endophthalmitis vitrectomy study. am j opthalmol. 1996; 122: 1-17. 31. al-jishi z, el-asrar ama. post traumatic endophthalmitis caused by xanthomonas maltophilia. saudi j ophthalmol 2003; 17: 291-4. 64 32. knox fa, best rm, kinsella f, et al. management of endophthalmitis with retained intraocular foreign body. eye 2004; 18: 179-82. 33. brinton gs, tapping tm, hyndin kra, et al. post traumatic endophthalmitis. arch opthalmol. 1984; 102: 547-50. 34. olson rj. reducing the risk of postoperative endophthalmitis. surv opthalmol. 2004; 49: 55-61. 35. babar tf, masud mz, iqbal a, et al. should ophthalmologist ever opt for mutilating operations like evisceration, enucleation and exenteration. pak j opthalmol. 2003; 19: 113-8. microsoft word mazhar u zaman soomro case report 161 case report squamous cell carcinoma mazhar-u-zaman soomro, rao rashad qamar pak j ophthalmol 2006, vol. 22 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: mazhar u zaman soomro shifa eye clinic 9-a, model town, khan pur district r.y. khan received for publication april’ 2006 …..……………………….. 38 years old young man presented with mass on the temporal side of cornea in the interpelpebral fissure area with symptom of only irritation in the right eye. on excision biopsy, mass turned out to be squamous cell carcinoma of the conjunctiva. quamous cell carcinoma is a malignant tumor characterized by invasion of basement membrane by malignant cells or distant metastasis. when it does not involve basement membrane it is called squamous cell carcinoma in situ. squamous cell carcinoma is believed to arise from limbal stem cell and present a mass in the interpelpebral fissure at temporal or nasal limbus. it occur commonly in elderly people. but may occur in younger people. case report a male patient 38 years consulted the clinic with irritation in his right eye. on examination his vision was 6/6 in both eyes.. on slit lamp examination there was a mass about 3x4 mm on temporal side of interpelpebral fissure in the vicinity of limbus. it has gelatinous appearance with corrugated surface feeded by blood vessels. anterior chamber was quite. fundus examination revealed no abnormality. regional lymph nodes were impalpable. patient was explained about before surgical intervention s 162 after surgical intervention the possibilities of the lesion and consent was obtained for excision. mass along with surrounding conjunctiva was excised under topical anesthesia and sent for histopathology and report revealed squamous cell carcinoma. discussion epithelial tumor of conjunctiva is similar to cervical intraepithelial tumor (cin). squamous cell carcinoma manifest unilateral localized patch of redness, a mass with gelatinous appearance or diffuse conjunctivitis. due to its variable appearance, it may pose a diagnostic challenge as a masquerade syndrome. it is more common in caucasian people having male (75%) dominance, elderly tendency as more common after 60 years. purported causes of sqaumous cell carcinoma of conjunctiva are excessive ultraviolet light, human papiloma virus type 16, long standing inflammation, chronic wear of contact lenses and cigarette smoking. morbidity is related primarily involvement of conjunctiva and cornea. distant metastasis is possible. death may occur due to intracranial spread. squamous cell carcinoma should be differentiated from other local causes like pterygium, pingecula cancer like conditions like squamous cell carcinoma, basal cell carcinoma, rhabdomyosarcoma, dermoid. once there is suspicion about squamous cell carcinoma, lesion should be excised and sent for histopathology. recurrence rate is 50% after incomplete excision and 10% for completely excised lesion. prognosis is reasonably good for completely excised lesion. patient should be informed about the entity and recurrence even after years. so patient should have routine follow-up. author’s affiliation dr. mazhar u zaman soomro shifa eye clinic 9-a, model town teh. khan pur district rahim yar khan dr. rao rashad qamar assistant professor of ophthalmology bahawal victoria hospital bahawalpur reference 1. akpek ek, polcharonw, chan r. ocular surface neoplasia masquerading as chronic blaphroconjuctivitis. cornea 1999; 18: 282-8. 2. erie jc, campbell rj, liesigang tj. conjuctival and corneal intraepithelial and invasive neoplasia. ophthalmology. 1986; 93: 176. 3. fraunfelder ft, wingfield dl. management of intraepithelial conjuntival tumours and invasive squamous cell carcinoma. am j ophthalmol. 1983; 95: 359. 4. shields ja, shields cl, gunduz k. the 1998 pan american lecture. intraocular invasion of squamous cell carcinoma in five patients. opthalimic plast reconstr surg. 1999; 15: 153-60. 5. shields ja, shields cl, depotter p. surgical management of conjunctival tumours. the 1994 lynn b. mcmahan. arch ophthalmol. 1999; 115: 808-15. microsoft word zahra khalif bile orginal article spectrum of ophthalmic diseases in children at a referral hospital zahra khalif bile, shakeel ahmad, asad aslam khan pak j ophthalmol 2007, vol. 23 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zahra khalif bile medical officer eye unit 3 mayo hospital lahore received for publication february’ 2006 …..……………………….. purpose: to give an overview of diseases seen at a tertiary care hospital pediatric ophthalmology outpatient clinic in punjab. material and methods: a descriptive retrospective study was done of patients visiting the paediatric ophthalmology clinic from may 2004 to april 2005 by accessing the opd registers kept by the hospital. patients were categorized into ten different groups, using an anatomical classification. the age categories were divided into three groups, children below the age of one, ages1-5 years and the older children were placed in the six to fifteen years category. results: a total number of 3289 children were included with a male 63.6% and females 36.4% and the mean age was 5.1 years. diseases of lens effected 33% of the patients examined. squint was the second most common disorder seen affecting 17% of these children. errors of refraction affected 15% and oculoplastic 9%. trauma was an important cause of morbidity in 10% of these children and corneoscleral tear was the main culprit. the rest of the conditions were glaucoma 6%, conjunctival diseases 4%, vitreoretinal 3%, orbital 3% and miscellaneous 3%. conclusion: in this study, boys were found to be more often affected with eye diseases and the presentation to a tertiary care hospital was most often late. most paediatric eye diseases need special care and early intervention; therefore it is crucial that good provincial and district paediatric ophthalmology centers are set up. more than 1500 children per year may need surgery in a busy tertiary care hospital, therefore expansion of facilities and training more health professions is important. here are about 1.5 million blind children in the world and more than one million children in asia alone1,2. approximately half of all blindness in children especially in poor countries is avoidable3. cataract is the leading cause of preventable blindness4,5. globally 190,000 children are blind from cataract alone4. these facts and figures are alarming and as healthcare providers, parents and teachers, we need to come together to identify the childhood eye diseases early enough in-order to give the child a more happy and productive life. paediatric ophthalmology is an upcoming field in pakistan as in many other developing countries. keeping in mind the alarming situation of eye diseases in children, this specialty is all the more vital to our setup. in-order to streamline local pediatric t ophthalmology services, reliable data is required by medical community and policy makers. therefore we need more and more audits to be conducted at different levels of health facilities starting from basic health units to tertiary care hospitals. keeping the above requirements in mind, we undertook this study. the objective is to highlight the spectrum of childhood diseases that are seen at a tertiary care level in-order to provide input for prevention and control of diseases to all stakeholders. material and method this retrospective analysis was conducted in the pediatric eye clinic of unit iii of mayo hospital, lahore on patients attended the hospital from may 2004 to april 2005. hospital receives patients from all over lahore and the neighboring cities in the middle punjab area. all the children seen in the pediatric ophthalmology opd clinic up to fifteen years of age were included in this study and patients lacking a definitive diagnosis and missing patient profiles were excluded. the opd registers of the audit period were accessed and closely studied. all the relevant information was then entered into the computer. the ophthalmic technicians and the senior registrar himself maintain these registers. the eye diseases diagnosed at the clinic during this one-year period were categorized into ten different groups, using an anatomical classification and described in order of frequency. the age categories were divided into three groups1, children below the age of one2, aged 1-5 years3 and the older children were placed in the 6-15 years age category. statistical analysis was done using spss. the data was analyzed according to age, gender, diagnosis, and management. simple descriptive analysis was carried out. results this study comprised of a total number of 3289 children, out of which, 2093 (63.6%) were male and 1196(36.4%) were female. the average age of all the children examined was 5.1 years. forty five patients were excluded because of lack of definitive diagnosis and missing profiles. diseases of lens were the highest in number, affecting 1100 children. the male to female ratio was 1.8. in this group 15% of the affected children were less than one year of age, while the majority, 52% were in the six to fifteen years age group, (table1). cataract alone was further scrutinized and it was found that the majority of cases (71%) were acquired and males were affected mostly in the 5-15 years age group. traumatic cataract made up 15% of the cataract cases with predominance again in males in the older group of patients (5-15 years). congenital cataract closely followed with 14%, affecting 5-15 year old children with a fractional increase in males (table 2). squint was the second most common disorder seen among these children. a total number of 545 cases were seen. the male to female ratio was 1.9:1. the greater part of these children 51% were above the age of five years, where as 40% were between the ages of one to five. only 9% were under the age of one year (table 1). errors of refraction were the third common disorder, affecting 494 children, of which the majority, (63%) were above the age of five, 30% in the one to five age group and only 7% were under the age of one. in the gender distribution major bulk of the cases were males (table 1). the cases in this category comprised of hypermetropia (82%), myopia (11%), and astigmatism (5 %). the majority of the children, (54%) were males between the ages of five and fifteen and were affected by hypermetropia. oculoplastic disorders affected 281 cases of which 58% were males and 42% were females. the one to five age group comprised of 45%, 34% above the age of five and only 21% under the age of one (table 1). within this category, nasolacrimal duct blockage was the major disease seen among these children who presented with epiphora (fig. 1). ptosis made up 11% of the oculoplastic cases, 73% acquired and 27% congenital and in both categories, ptosis affected boys more frequently in the five to fifteen years age group (fig.1). corneoscleral diseases made up a total of 236 cases of which 66.5% were male and 33.5% female. out of the total number, 56% were above the age of five , 34% in the one to five years and only 10% under one year of age (table 1). majority of the corneoscleral disorders were caused by trauma in the form of corneoscleral tears. glaucoma cases numbered 183. the types of glaucoma presented to the clinic were acquired 52%, congenital 40%, and secondary 8%. those in the above five years age group were 43%, in the one to five age category 37% and under the age of one were only 20% (table1). conjunctival diseases numbered 140 cases. the majority of the cases comprised of conjunctivitis. there were cases of subconjunctival haemorrhage and conjunctival cyst numbering four and eight cases respectively. the remaining 128 cases were of conjunctivitis of which 68% were male and 32% female. in the age categories, the majority of the cases (56%) belonged to the five to fifteen age group (table 2). vitreoretinal diseases numbered 120, with 61% males and 39% female. the majority of the cases belonged in the 6-15 age group category. there were 62 cases of retinal detachment, eight of which were traumatic. there were 31 cases of retinoblastoma of which one was a recurrent case. only 12 cases of vitreous hemorrhage were seen. table 1: frequency, gender and age distribution of children presenting to paediatric ophthalmology clinic (n=3289) diseases (n) <1 year 1 to 5 years 6 to 15 years m/f (%) m/f (%) m/f (%) lens (1100) 1.6 (15) 1.7 (33) 1.9 (52) squint (545) 1.2 (9) 1.6 (40) 2.2 (51) errors of refraction (494) 2 (7) 1.6 (30) 1.9 (63) oculoplastic (281) 1.9 (21) 1.1 (45) 1.6 (34) corneoscleral (236) 2.1 (10) 1.3 (34) 2.6 (56) glaucoma (183) 1.9 (20) 1.2 (37) 1.6 (43) conjunctival (140) 1.2 (8) 2.3 (36) 2.2 (56) vitreoretinal (120) 0.4 (11) 1.8 (28) 1.9 (61) orbital (103) 5 (6) 3 (27) 1.7 (67) miscellaneous (87) 1.3 (10) 1.9 (30) 1.4 (60) table 2: frequency, gender and age distribution of cataract and glaucoma (n= 572 and 183) respectively. cataract < 1 year 1 to 5 years 6-15 years total cases acquired 18% 29% 53% 407 traumatic 1% 23% 76% 83 congenital 31% 29% 40% 82 glaucoma acquired 16% 40% 44% 95 congenital 26% 36% 38% 74 secondary 29% 14% 57% 14 orbital diseases numbered 103 cases. in this category, 40% (41 cases) were affected with phthisis bulbi. there were 30 cases (29%) of soft eye with the etiology not known. endophthalmitis comprised of 14 cases (14%). other pathologies of the orbit such as orbital mass and proptosis made up a small fraction of the disorders. miscellaneous group of cases comprised of all the diseases (87 cases) for which the anatomical classification was not applicable. 43(49%) of the cases were of nystagmus, mostly in males in the 6-15 age group. the rest of the cases were very few in number. discussion the evidence seen in these results is self-explanatory. a great deal needs to be done in the field of pediatric ophthalmology, but in order to proceed; the current situation in this field needs to be identified. primarily, the commonly seen eye diseases in children should be determined. mayo hospital, lahore is an ideal set up for this kind of research. this hospital covers the most congested area of the city and therefore receives a large number of outdoor patients who come from all corners of the city as well as other parts of the country. boys were more affected in all the diseases encountered. this is probably due to the fact that boys are greatly valued by culture and are more often brought to the hospital. this unfortunate fact can be tackled with the help of counseling. in a population based cross-sectional survey done in karachi from july to august 2003, the pattern and prevalence of eye diseases among children age 5-15 years was assessed. the total number of children examined was 5110. it was found that errors of refraction (2%) made up the majority followed by conjunctivitis (1.2%) and squint (0.6%)7. this shows that the reality on the ground is quite different from that in a tertiary care hospital. the reason could be that in this society, low vision is not taken all so seriously unless it is so severe that it interferes with everyday life activities. many children don’t even go to school, and children have a great capacity for adaptation that low vision can be tolerated fairly easily at first. worldwide, the main cause of visual impairment and blindness among children are genetic conditions1, even though it is difficult to generalize to this extent as there is no uniform survey and the results differ in different parts of the world. but in this setup, along with genetic diseases, there is the added burden of preventable eye diseases as well. taking this into consideration, the genetic aspect becomes less significant. diseases of the lens was the main category of the diseases encountered in the clinic with cataract being the essential component, keeping in mind that the patients are filtered out before they reach the eye clinic. cataract surgery is one of the most cost effective public health interventions4, yet many children all over the world are blind simply from cataract. in this setup, there are many reasons, as many of the children seen at the clinic belonged to lower socioeconomic status and many come from faraway areas. countless parents believe that congenital blindness, regardless of the cause is untreatable and therefore never seek help. fear of the parents plays a crucial role for not bringing children to the hospital. fear mainly revolves around surgery in such a young child and fear of the child dying during the operation4. children were brought rather late to the clinic at the age of three or four. it was difficult to diagnose whether the cataract was congenital or acquired. in some children it was obvious as they already had developed nystagmus. there was no means of determining the causative factors but, according to a study carried out in western india, 4.6% cases of congenital cataract is due to rubella2. this is a common cause of cataract blindness in this region and accounts for more than 25% of all new cases of congenital cataract in western india2. the ingestion of corticosteroids, antibiotics, antidiabetic drugs, others (busulfan, triparanol, chlorpromazine, dinitrophenol, etc.) has been implicated as a cataractogenic factor by a number of studies. use of abortifacients is also cited as a cause of congenital cataract2,6. squint affected boys more than girls and presentation was more in the older age group. most parents are able to recognize a squint, but due to financial restraints are not able to make the trip to a faraway tertiary care hospital. with proper spread of information and counseling, these children do not have to live with the stigma that often accompanies squint. errors of refraction are the cause of blindness in one quarter of blindness and half of low vision5. hypermetropia was most often seen in this study. this is consistent with the majority of the studies done, as hypermetropia is more common during childhood10. at the clinic, it was common to see children up to the age of four who have hypermetropia of three or four diopters. where a child presented with hypermetropia of more than four, glasses were prescribed. oculoplastic diseases category was dominated by nasolacrimal duct blockage, which presented as epiphora. in children, the duct may not be completely developed at birth. parents were initially counseled and given instructions for massage of the lacrimal sac area. persistent cases required probing and syringing. this congenital tear duct blockage clears spontaneously by 6 months of age11. if it does not clear on its own, the outcome is still likely to be good with treatment. according to present literature, the majority (61%) of lacrimal drainage obstruction in children is developmental; others are caused by infections (24%), trauma (12%), and dysfunction (3%). the condition is bilateral in almost one third of the cases11. follow up is an integral part of patient eye care especially in children suffering from glaucoma. most parents are unaware of the signs and symptoms of glaucoma. in children, unlike adults, glaucoma has clear-cut signs and symptoms such as excessive tearing, photophobia and enlarged eyes, or one eye larger than the other. if parents are educated about these signs and symptoms, they will then be in a better position to save their children from potential blindness. people with positive family history have four times increased risk of developing glaucoma5, 13, raising awareness among the community is therefore essential. trauma was a major category in this audit and corneoscleral tear was the most significant type of trauma seen at the clinic (fig. 2). families are usually large and children are not always given proper care, so they are more at risk of sustaining trauma. in this study, there was a large male predominance in trauma. in most cases, boys comprised of double the number of girls affected (fig. 3). also boys are more often allowed to do outside activities that put them at risk of injuring themselves. a study conducted at a hospital in central africa, showed that males are more often affected by ocular trauma than females with a ratio of 1:314. community-based education should stress on raising awareness among families especially in the lower socioeconomic status group. involvement of parents plays a positive role in the well being of a child. good visual outcome does not only depend on competency and good surgical skills, because in children, frequent regular post-op follow up is highly essential3,8. parents need to know that the inflammatory process is more severe in children as compared to adults2,8. many of them believe that there is no need for follow up after the surgery. they need to understand the implications of not coming back for follow up. this is not easy for the parents, as it is a social as well as a financial burden on the families involved. the frustrations and depression which follows low vision and blindness need to be acknowledged1. this does not affect only the children involved, but also the rest of the family, as the child slowly loses the capability to take care of himself. he will then grow up to be an economical burden on the family. conclusion it is evident in this study that most children presented late with the disease and mostly, boys in above-five age group were affected. good strategies for case finding need to be devised specially for cataract in children. there is also need to train people in the community about signs of cataract8. in this way early presentation and surgery will lead to a better visual outcome. most pediatric eye diseases need special care and early intervention; therefore it is crucial that good provincial and district pediatric ophthalmology centers are set up. trauma is potentially preventable and therefore every effort should be made, not only to establish, but also to maintain community education centers, which are effective in delivering the message. fig. 1: frequency of different oculoplastic diseases in children presenting to paediatric ophthalmology clinic (n=281) lid tear 6% traumatic cataract 26% traumatic rd 3% corneal fb 1% corneoscleral tear 64% fig. 2. types and frequency of trauma (n = 325) 141 65 13 8 60 23 6 4 0 3 1 1 0 20 40 60 80 100 120 140 160 f r e q u e n c y corneoscleral tear lid tear traumatic cataract traumatic rd corneal fb perforated eye male female fig. 3: age and gender distribution of different types of trauma cases (n = 325) author’s affiliation dr zahra khalif bile medical officer eye unit 3 mayo hospital, lahore dr shakeel ahmad assistant professor paediatric ophthalmology eye unit 3 mayo hospital, lahore dr asad aslam khan head of eye unit 3 king edward medical university & mayo hospital, lahore reference 1. oduntan ao. prevalence and causes of low vision and blindness worldwide. s afr optom 2005; 64: 44-54. 2. kaid johar sr, savalia nk, vasavada ar. epidemiology based etiological study of pediatric cataracts in western india. indian j medical sciences trust. 2004; 58: 115-1213. 3. clare g, haroon a. blindness in children editorial, bmj. 2003; 327: 760-1. 4. muhit ma. childhood cataract: home to hospital. community eye health. 2004; 17: 19-22. 5. hugh rt, jill ek. world blindness: a 21st century perspective, br j ophthalmol. 2001; 85: 261-6. 6. angra sk. aetiology and management of congenital cataract. ind j pediatrics. 1987; 54: 673-77. 7. sheikh sp, aziz tm. pattern of eye diseases in children of 5-15 years at bazzertaline area in karachi, jcps pakistan. 2005; 15: 145-8. 8. shamanna br. childhood cataract: magnitude, management, economics and impact (editorial). community eye health journal. 2004; 17: 17-8. 9. who fact sheet n 282, magnitude and causes of visual impairment. 2004; 10. 10. gilbert c, awan h. blindness in children (editorial), bmj 2003; 327: 760-61. 11. gilbert c, foster a. childhood blindness in the context of vision 2020 the right to sight, bull world health organ. 2001; 79. 12. who fact sheet n 282, magnitude and causes of visual impairment. 2004; 13. 13. tielsch jm, sommer a, witt k. blindness and visual impairment in an american urban population, arch ophthalmol. 1990; 108: 286-90. 14. yaya g, bobossi sg, gaudeuille a. ocular injuries in children aged 0-15 years: epidemiological and clinical aspects at the bangui national teaching hospital. j fr ophthalmol. 2005; 28: 708-12. 216 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology original article effect of contact lens wear on cornea rabia ammer pak j ophthalmol 2016, vol. 32 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: rabia ammer department of allied health sciences/ school of optometry/ the university of faisalabad email: rabbia.ammer@gmail.com …..……………………….. purpose: to determine contact lens induced corneal changes among contact lens users. study design: cross-sectional study. place and duration of study: this study recruited the sample from madinah teaching hospital faisalabad, e plomer optics and punjab optics lahore. the study was conducted in 4 months from 05 april to 5 august 2016. materials and methods: data of 100 contact lens users were collected. corneal changes were observed by using slit lamp and fluorescein strips. spss version 23 was used for data analysis. descriptive and inferential statistics were reported for variables. results: 58 (58%) of contact lens users found with corneal changes. significant association of corneal changes were found with years of contact lens use (x 2 = 31.636; p = .000) and minus power of contact lens (x 2 =14.325; p = .000). no significant association (p > 0.05) of corneal changes were found with type of contact lens, daily wearing time of contact lenses and plus power of contact lenses. neovascularization was found in 38% of contact lens users followed by corneal staining in 33%, corneal infiltrates in 17% and corneal abrasions in 12%. conclusion: it was concluded that long term, unmonitored use of contact lenses induced many corneal changes among contact lens users. key words: contact lens, corneal changes, neovascularization, infiltrates, staining, abrasion. he cornea is the principal refracting surface of the eye and accounts for two-thirds of the total eye’s power. it is an avascular transparent tissue and has richest sensory nerve supplies in the body. oxygen is a very important metabolite for cornea and 15-20.9% oxygen is necessary for its regular function. the cornea derives its oxygen supply mainly from the atmosphere via the tear film1. due to corneal hypoxia aerobic glycolysis reduces, consequently glucose metabolizes into lactic acid and start to accumulate in the cornea. corneal osmotic pressure raises due to increased concentration of lactic acid in corneal stroma and results in osmotically driven swelling in the stroma (stromal oedema) which leads to functional and structural changes in the cornea1. contact lens wear causes reduction in the supply of oxygen to the cornea which leads to significant effects on the corneal structural integrity and function. functional alterations in the cornea due contact lens wear includes reduction in epithelial mitosis, decrease in the density of the terminal nerve endings, reduction in corneal sensitivity and stromal environment becomes more acidic due to decrease in corneal ph2. significant structural changes in corneal tissue due to contact lens wear includes corneal neovascularization3, corneal infiltrates4, corneal staining,5 reduced corneal thickness, presence of vacuoles and microcysts, endothelial polymegathism and endothelial polymorphism6. the purpose of the study was to determine the contact lens induced corneal changes among contact lens users. t effect of contact lens wear on cornea pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 217 material and methods it was a cross-sectional study and convenient sampling technique was used to collect the sample. the study was conducted in 4 months from 05 april to 5 august 2016. data were collected from 3 different settings; madinah teaching hospital faisalabad, e plomer optics and punjab optics, lahore. for ethical concerns, approval of study obtained from the ethical review board of the university of faisalabad in accordance with the principles of declaration of helsinki. subjects aged 15 to 55 years, those who used contact lenses for more than 1 year and without any complaint / symptom related to contact lens use were included in the study. an informed consent form delivered to gain consent from participants for their voluntary participation by briefly describing the study topic, its purpose, duration and assuring for confidentiality of respondents personal information. subject’s demographic details, history related to the contact lens type, daily wearing time, power and years of contact lens use were recorded in specially designed self-structured performa. due to unavailability of many different instruments required to determine all corneal changes, this study focused on only 4 corneal changes, i.e. corneal neovascularization, corneal infiltrates, corneal abrasions and corneal staining. firstly a gross slit lamp examination was performed in a consistent, orderly fashion from eyelid to cornea by using diffuse illumination slit lamp technique. to observe corneal neovascularization and corneal infiltrates slit lamp direct observation (optic section) technique was used. to observe corneal abrasions slit lamp direct observation (parallelepiped) technique was used. to determine corneal staining, the subject was asked to look upward and sodium fluorescein was applied to the sclera at lower fornix by using fluorescein strip moistened by normal saline and then observed with a slit lamp under cobalt blue light. spss version 23 was used for data analysis. descriptive and inferential statistics were generated and reported for variables. results a sample of 100 contact lens users was recruited in which female contact lens users were 67 (67%) and male contact lens users were 33 (33%). age of contact lens users was ranged from 16 to 55 years with mean age of 30.10 ± 7.86 years. the study subjects were found wearing different types of contact lenses. there were 54% subjects using soft contact lenses, 17% were using soft cosmetic contact lens, 14% were rgp contact lenses users, 12% were soft toric contact lens users and 3% were silicone hydrogel contact lens users. the daily wearing time of contact lens determined in this study ranged from 4 to 16 hours/day and mean value was 9.82 ± 2.19 hours/day. the years of contact lens use found in this study was from 1.5 to 30 years with a mean value of 8.35 ± 5.81 years. in this study very high proportion of contact lens users was myopic (96 %) and used contact lenses of minus power. minus power of contact lens ranged from -0.50 to -17.00 d with a mean value of -4.46 d ± 3.69 d. proportion of hyperopic contact lens users was only 4 % and plus power of contact lenses ranged from +2.00 to +5.00 d with a mean value of +4.00 d ±1.35 d. in this study various corneal changes were found among contact lens users. results showed that 58 % (58 out of 100) of contact lens users presented with corneal changes while 42% (42 out of 100) of contact lens users had no corneal change. more than one corneal changes were present among some subject. neovascularization was found in 38% of contact lens users followed by corneal staining in 33%, corneal infiltrates in 17% and corneal abrasions in 12%. no significant (p > 0.05) association was found between corneal changes and types of contact lenses. it was observed that overall ratios between subjects with corneal changes and subjects without corneal changes did not differ largely for different types of contact lens (table 1). table 1: association between corneal changes and types of contact lenses. type of contact lens no. of subjects with corneal change total yes no soft 29 25 54 hard 9 5 14 soft toric 7 5 12 silicone hydrogel 1 2 3 soft cosmetic 12 5 17 total 58 42 100 pearson chi-square 2.492 p-value .646 rabia ammer 218 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology no significant (p > 0.05) association was found between corneal changes and daily wearing time of contact lenses. it was observed that overall ratios between subjects with corneal changes and subjects without corneal changes did not differ largely for different categories of daily wearing time of contact lens (table 2). table 2: association between corneal changes and daily wearing time of contact lenses. daily wearing time (hours/day) no. of subjects with corneal change total yes no 4 – 8 17 18 35 9 – 12 38 22 60 13 – 16 3 2 5 total 58 42 100 pearson chi-square 1.986 p-value .370 a significant (x2 = 31.636; p = .000) association was found between corneal changes and years of contact lens use. number of subjects with corneal changes increased with increase in number of years of contact lens use. it was determined that all of subjects those used contact lenses for 26 – 30 years and half of subjects those used contact lenses for 21 – 25 years presented with corneal changes (table 3). table 3: association between corneal changes and years of contact lens use. years of cl use no. of subjects with corneal change total yes no 1 – 5 10 29 39 6 – 10 31 6 37 11 – 15 8 4 12 16 – 20 6 1 7 21 – 25 1 2 3 26 – 30 2 0 2 total 58 42 100 pearson chi-square 31.636 p-value .000 a significant (x2 = 14.325; p = .000) association was found between corneal changes and minus power of contact lens. number of subjects with corneal changes increased with increase in minus power of contact lens. it was determined that all subjects those used contact lens power ranged from -15.25 to -18.00 d and -12.25 to -15.00 d had corneal changes and half of the subject those used contact lens power ranged from -9.25 to -12.00 d had corneal changes (table 4). table 4: association between corneal changes and minus power of contact lenses minus contact lens power (d) no. of subjects with corneal change total yes no -0.50 to -3.00 19 27 46 -3.25 to -6.00 19 7 26 -6.25 to -9.00 11 4 15 -9.25 to -12.00 1 1 2 -12.25 to -15.00 4 0 4 -15.25 to -18.00 3 0 3 total 57 39 96 pearson chi-square 14.325 p-value .014 no significant (p > 0.05) association was found between corneal changes and plus power of contact lens. in both categories of plus contact lens power similar ratio was found between subject with corneal changes and subjects without corneal changes (table 5). table 5: association between corneal changes and plus power of contact lenses. plus contact lens power (d) corneal changes total yes no +0.50 to +3.00 0 1 1 +3.25 to +6.00 1 2 3 total 1 3 4 pearson chi-square .444 p-value .505 effect of contact lens wear on cornea pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 219 table 6: association of corneal changes with different contact lens parameters. contact lens parameters pearson chi square p value type of contact lens 2.492 .646 daily wearing time 1.986 .370 years of contact lens use 31.636 .000 minus power of contact lens 14.325 .014 plus power of contact lens .444 .505 discussion various corneal changes among contact lens users were observed in this study. the reason might be that the long term contact lens wear induces hypoxia and dryness in the eye which lead to corneal changes. these results are in line with those reported by liesegang7, efron et al.8 and beljan et al.9 studies. this study observed corneal neovascularization, corneal infiltrates, corneal staining and corneal abrasions among contact lens users. these results are in agreement with those reported by nichols and sinnott,5 liesegang7, efron et al. 8, beljan et al.9, æuruvija-opaèiæ10, kymionis and kontadakis11, lee et al.12 and wong et al.13, du toit et al. 14, nichols et al.15, riley et al. 16, santodomingo-rubido et al. 17, ishak et al.18, kastelan et al.19 and pili et al.20 and muntz et al.21 studies. this study found no significant association between corneal changes and types of contact lenses. the reason might be that most of the subjects included in the study used soft contact lens and fewer subjects used other types of contact lenses. these results were similar to the efron et al. 8, nichols et al.15 and ishak et al.18 studies. but contrary to those found in nichols and sinnott5, æuruvija-opaèiæ10 and riley et al.16 studies. this study found no significant association between corneal changes and daily wearing time of contact lenses. these results were in line with those reported by nichols et al.15 study. nevertheless, the results were found to be contrary to those reported by nichols and sinnott5 and beljan et al.9 studies. this contrast might be due to regional and racial differences and use of different types of contact lens material and quality of contact lens could also change the results. this study determined a significant association between corneal changes and years of contact lens use. the reason might be that long term use of contact lens caused prolonged hypoxia that lead to corneal changes. the results of this study were in favor with the results of beljan et al.9 study. this study found a significant association between corneal changes and minus power of contact lens. this might be due to reason that high power contact lens were thicker and reduced the oxygen permeability through the contact lens and hence caused more damaging effects in cornea. nichols et al.5 and lee et al.12 studies were in favor with these results. no significant association was found between corneal changes and plus power of contact lens. these results might be because of very less number of hyperopic contact lens users included in the study. no other study was found to sufficiently discuss these findings. conclusion it was concluded that long term use of contact lenses induced many corneal changes (neovascularization, staining, infiltrates, abrasions) among contact lens users. as the number of years of contact lens use and minus power of contact lens increased, more corneal changes were found. author’s affiliation rabia ammer bsc (optom), m.phil (optom) department of allied health sciences/ school of optometry/ the university of faisalabad role of authors rabia ammer concept, design of study, sample collection, data collection, data analysis, manuscript drafting, revision data analysis, critical review, drafting and revision of manuscript references 1. williams l. anatomy and physiology of the anterior segment. the iacle contact lens course: module 1 anterior segment of the eye. 1st edition. australia. the international association of contact lens educators, 2000: p. 3-80. rabia ammer 220 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology 2. terry r. corneal oxygen requirements and the effects of hypoxia. the iacle contact lens course: module 6 the cornea in contact lens wear. 1st edition. australia. the international association of contact lens educators, 2000: p. 3-36. 3. sapkota k, lira m, martin r, battarai s. ocular complications of soft contact lens wearers in a tertiary eye care centre of nepal. cont lens anterior eye, 2013; 36 (3): 113-7. 4. jansen me, situ p, begley cg, boree d, chalmers rl, osborn lorenz k, wilson t. characterizing contact lens related corneal infiltrates: a pilot study. cornea 2016 aug 24. [epub ahead of print] 5. nichols jj, sinnott tl. tear film, contact lens, and patient factors associated with corneal staining. invest ophthalmol vis sci. 2011; 52: 1127-37. 6. doughty mj. an observational cross-sectional study on the corneal endothelium of medium-term rigid gas permeable contact lens wearers. cont lens anterior eye 2016 dec 13. pii:s1367-0484(16)030190-4. 7. liesegang tj. physiologic changes of the cornea with contact lens wear. clao j. 2002; 28: 12-27. 8. efron n, jones l, bron a, knop e, arita r, barabino s et al. the tfos international workshop on contact lens discomfort: report of the contact lens interactions with the ocular surface and adnexa subcommittee. invest ophthalmol vis sci. 2013; 54: tfos 98-122. 9. beljan j, beljan k, beljan z. complications caused by contact lens wearing. coll antropol. 2013; 37: 179–87. 10. æuruvija-opaèiæ k. soft contact lenses and long term corneal hypoxia: what is changing with silicone hydrogel lens. acta clin croat. 2007; 46: 17-20. 11. kymionis gd, kontadakis ga. severe corneal vascularization after intacs implantation and rigid contact lens use for the treatment of keratoconus. semin ophthalmol. 2012; 27: 19-21. 12. lee d, kim m, wee w. biometric risk factors for corneal neovascularization associated with hydrogel soft contact lens wear in korean myopic patients. korean j ophthalmol. 2014; 28: 292. 13. wong la, weissman ab, mondino jb. bilateral corneal neovascularization and opacification associated with unmonitored contact lens wear. am j ophthalmol. 2003; 136: 957-8. 14. du toit r, situ p, simpson t, fonn d. the effects of six months of contact lens wear on the tear film, ocular surfaces, and symptoms of presbyopes. optom vis sci. 2001; 78: 455-62. 15. nichols kk, mitchell lg, simon mk, chivers ad, edrington bt. corneal staining in hydrogel lens wearers. optom vis sci. 2002; 79: 20-30. 16. riley c, young g, chalmers r. prevalence of ocular surface symptoms, signs, and uncomfortable hours of wear in contact lens wearers: the effect of refitting with daily-wear silicone hydrogel lenses (senofilcon a). eye contact lens. 2006; 32: 281-6. 17. santodomingo-rubido j, wolffsohn js, gilmartin b. changes in ocular physiology, tear film characteristics, and symptomatology with 18 months silicone hydrogel contact lens wear. optom vis sci. 2006; 83: 73-81. 18. ishak b, thye jjy, ali bm, mohidin n. blinking characteristics and corneal staining in different soft lens materials. world acadscieng technol. 2012; 72: 1661-5. 19. kastelan s, lukenda a, salopek-rabatic j, pavan j, gotovac m. dry eye symptoms and signs in long-term contact lens wearers. coll antropol. 2013; 37: 199–203. 20. pili k, kaštelan s, karabatic m, kasun b, culig b. dry eye in contact lens wearers as a growing public health problem. psychiatr danub. 2014; 26: 528-32. 21. muntz a, subbaraman nl, sorbara l, jones l. tear exchange and contact lenses: a review. j optom. 2015; 8: 2-11. pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 258 original article relationship of hba1c with visual and anatomical outcomes of bevacizumab in diabetic macular edema royala zaka, burhan abdul majid khan, mirza zaki-ud-din ahmed sabri, rabia qureshi pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: royala zaka prevention of blindness (pob), karachi – pakistan email: drroyala@hotmail.com …..……………………….. purpose: to find relationship of baseline hemoglobin a1c (hba1c) with visual outcomes, central macular thickness and number of intravitreal bevacizumab at 12 months in patients with diabetic macular edema (dme). study design: quasi experimental study. place and duration of study: prevention of blindness (pob) hospital, karachi, pakistan between october 2018 and september 2019. material and methods: two hundred and eighty patients with diabetic macular edema (dme) presenting to the eye opd of pob, who did not receive any treatment for dme were recruited. patients who had concurrent retinal disease and were treated with intravitreal injections and/or laser were excluded. all patients were evaluated with history, ophthalmological examination and sd-oct for central subfield macular thickness. patients received 3 intravitreal injections of bevacizumab one month apart. oct was done after 3 months and retreatment for diabetic macular edema was based on the persistence of macular thickness more than 300 microns. all the data was analyzed using spss version 20. results: there were 280 patients, 53.2% were males and 46.8% were females. patients were divided into 3 groups; patients with hba1c < 7.0, 7.1 – 8.0 and > 8.0. central macular thickness decreased significantly from baseline in all 3 groups. maximum vision improvement was seen in group 1 with hba1c < 7.0 and group 2 with 7.1 – 8.0. significant inverse correlation was seen between hba1c and vision at 12 months (r = 0.40, p < 0.01) and positive correlation with central macular thickness (r = 0.53 p < 0.01). conclusion: initial baseline hba1c is strongly related with visual and anatomic outcome at 12 months. key words: diabetic macular edema; bevacizumab; hemoglobin a1c. pproximately 21 million people are affected by diabetic macular edema worldwide1. by 2025, the incidence of diabetes in pakistan will get doubled2. the high burden of diabetic complications is associated with uncontrolled diabetes3. therefore, control of diabetes is the main pillar for prevention and delaying of diabetic complications. in diabetes mellitus, the main reason of visual loss is macular edema4. evidence shows that diabetic macular edema and moderate visual loss can be reduced by tight glycemic control5. the royal college of ophthalmologists’ clinical guidelines for diabetic retinopathy” recommends laser alone6. until recently, macular photocoagulation was the treatment of choice for diabetic macular edema. even with this treatment, macular edema persists in the presence of a royala zaka, et al 259 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol uncontrolled diabetes7. the entire treatment picture has changed with the introduction of anti-vascular endothelial growth factors especially for dme8. not only we have seen the relationship of hba1c with visual and anatomical outcome like previous studies, but also seen the relationship of baseline hba1c with frequency or number of anti-vegf injections in diabetic macular edema. the frequency of anti-vegf injections is an important aspect to know as in the developing country like pakistan, the cost is one of the main issues. the rationale of our study was that patients with baseline lower hba1c may have better visual and anatomical outcome and may require fewer number of anti-vegf injections in one duration as compared with patients having high baseline hba1c. the purpose of our study was to find relationship of baseline hemoglobin a1c (hba1c) with visual outcomes, central macular thickness and number of intravitreal bevacizumab at 12 months in patients with diabetic macular edema (dme). material and methods this study was done between october 2018 to september 2019 at prevention of blindness, a charity based hospital where approximately 100 patients receive anti-vegf injections weekly for different ocular conditions. ethical approval was taken before the start of study. two hundred and eighty patients diagnosed with diabetic macular edema with initial hba1c of less than or more than 7.0, who received at least three anti-vegf injections were recruited for the study. they were followed up for 12 months. the exclusion criteria of our study was those individuals who had concomitant retinal disease or who had macular edema due to reasons other than diabetes or had previous treatment with pan-retinal photocoagulation or macular photocoagulation or macular ischemia or did not have baseline hba1c or those who were lost to follow-up. all patients were evaluated starting from the history and comprehensive ophthalmological examination that included best corrected visual acuity using snellen chart, biomicroscopy to diagnose clinically significant macular edema and oct optical coherence tomography (sd-oct) with a central subfield macular thickness (csmt) measurement to quantify, document and follow-up the macular thickness. the patients whose visual acuity was affected by disruptive anatomy of macula due to the intracystic spaces involving the macula or had more than 300 micron macular thickness on oct were given intravitreal injections of bevacizumab. patients received 3 intravitreal injections at one-month interval. oct was done after 3 months and retreatment for diabetic macular edema was based on the persistence of macular thickness more than 300 microns. patients were followed monthly and hba1c was recorded 3 to 4 monthly interval until 12 months. consent was taken from all the patients after brief explanation about the study, treatment and follow-up. all the data was entered in spss version 20, paired ttest, test of proportion and pearson correlation coefficient were used for statistical analysis. results out of 280 patients, 149 (53.2%) were males and 131 (46.8%) were females. twenty (7.1%) patients had hba1c of < 7.0, 187 (66.8%) had 7.1-8.0 and 73 (26.1%) patients had > 8.0 hba1c (table1). central macular thickness was significantly decreased on 12 months from baseline (p < 0.01). number of injections given were more according to hba1c (< 7.0, 7.1 – 8.0 and > 8.0) but statistically not significant (p > 0.05). increase in visual acuity was more in patients with hba1c of < 7.0 as compared to the patients with higher hba1c (table 2). initial baseline hba1c was strongly related with visual and anatomic outcome at 12 months. table 1: demographic characteristics (n = 280). frequency percent gender male 149 53.2 female 131 46.8 age in years under 50 27 9.6 50-59 158 56.4 60 & above 95 33.9 range 44–73 mean ± s.d 58.1 ± 6.11 hba1c group 1 (hba1c ≤ 7.0) 20 7.1 group 2 (hba1c 7.1-8.0) 187 66.8 group 3 (hba1c > 8.0) 73 26.1 relationship of hba1c with visual and anatomical outcomes of bevacizumab in diabetic macular edema pak j ophthalmol vol. 35, no. no. 4, oct – dec, 2019 260 table 2: comparison of hba1c with cmt, number of injection and visual status. hba1c <=7.0 (n=20) n, mean ± s.d hba1c 7.1-8.0 (n=187) n, mean ± s.d hba1c > 8.0 (n=73) n, mean ± s.d hba1c base line (day 0) 19, 6.93 ± 0.09 163, 7.49 ± 0.25 67, 9.37 ± 1.24 at 12 months 19, 7.17 ± 0.31 163, 7.38 ± 0.44 67, 8.64 ± 1.43 p-value 0.005 0.003 0.001 duration of dm (years) 20, 10.0 ± 2.51 180, 13.7 ± 4.71* 73, 16.4 ± 4.46* º cmt right base line (day 0) 19, 365 ± 72.1 161, 353 ± 81.7 67, 424 ± 138.4 at 12 months 19, 287 ± 315 161, 302 ± 60.1 67, 378 ± 135.3 p-value 0.001 0.001 0.001 cmt left base line (day 0) 19, 292 ± 44.4 159, 324 ± 70.7 67, 389 ± 118.7 at 12 months 19, 272 ± 33.6 159, 294 ± 47.8 67, 357 ± 103.2 p-value 0.043 0.001 0.001 number of injections used in 12 months right 6, 6.67 ± 2.16 87, 7.39 ± 1.49 52, 7.94 ± 1.29 left 2, 10.00 ± 0.00 62, 8.19 ± 1.04 44, 8.20 ± 1.30 vision increased on 12 months right 16 (94%) out of 17 1 line 6 (35%) 2 line 9 (53%) 3 line 1 (6%) 73 (64%) out of 113 * 1 line 23 (20%) 2 line 34 (30%) 3 line 15 (13%) 4 line 1 (1%) 24 (41%) out of 59 * º 1 line 13 (22%) 2 line 7 (12%) 3 line 3 (5%) 4 line 1 (2%) left 5 (83%) out of 6 3 line 5 (83%) 60 (68%) out of 88* 1 line 31 (35%) 2 line 20 (23%) 3 line 9 (10%) 18 (36%) out of 50 * 1 line 12 (24%) 2 line 2 (4%) 3 line 4 (8%) significant from hba1c <= 7.0 *p < 0.05 significant from hba1c 7.1 – 8.0 ºp < 0.05 discussion our study showed that baseline hba1c has positive correlation with baseline cmt (r = 0.53, p < 0.01) that means if the initial hba1c is uncontrolled, patients can have high central macular thickness (cmt). we found that in patients with < 7.0, 7.1 to 8.0 and > 8.1 hba1c, cmt decreased in all patients after anti-vegf injections. our results also correspond to the previous studies in which the patients having low hba1c showed greater visual improvement with the use of anti-vegf injections9. matsuda and colleagues showed that with hba1c of 7.0 or less there was significant decrease in cmt with the use of bevacizumab and similar results were seen with the use of another anti-vegf ranibizumab10,11. diabetic retinopathy research group vienna also showed that cmt was decreased at its maximum by using either bevacizumab or ranibizumab if the hba1c was less than 7.012. diabetic macular edema is the biggest cause of visual loss in diabetic retinopathy and can happen at any stage of diabetic retinopathy13. tight glycemic control < 7.0 can delay or prevent the complications in both type 1 and type 2 diabetes14,15. however vivid and vista dme studies showed that there was no relationship of baseline hba1c with visual and anatomical outcome. the difference in results might be because the anti-vegf used was aflibercept and less or more than 8.0 hba1c was used in the study16. according to matsuda et al dme with regulated blood glucose can impact the response to bevacizumab. the patients with a starting hba1c of 7.0 or less showed more improvement in bcva during the 12 months of therapy than those with starting hba1c > 7.09. pemp and colleagues also described that the visual improvement could be gained at its highest level by using bevacizumab or ranibizumab if the baseline hba1c was < 7.0 at the start of therapy12. pakistan is a developing country where cost matters for everything and same is for the ani-vegf injections. bevacizumab being a cost effective injection could be the reason for the increased number of injections used in our study. we did not compare among different anti-vegf injections like ranibizumab or aflibercept that might have given results at a lower number of injections as compared royala zaka, et al 261 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol with bevacizumab which is commonly used in our set up. an article showed that bevacizumab in relation with cost effectiveness is superior to other anti-vegf injections17. another study showed that the cost of ranibizumab is 20 to 40 folds higher than the cost of bevacizumab and the treatment of dme is 10 to 15 million euros higher in netherland18. the bevacizumab is the cost effective choice as compared to ranibizumab and aflibercept19. the other reason of increase number of injections in the group having < 7.0 hba1c might be the increase in its hba1c until 12 months. the drcr.net compared the efficacy of 3antivegf at 2 years. vision improved in all 3 drug groups however, the frequency of injections became half in 2nd year20. our follow up was only 1 year so future studies can check this frequency of injections for more than a year. one study showed that despite different levels of glycemic control during the treatment the baseline hba1c affects the visual and anatomical outcome however, the required number of anti-vegf injections decrease during the course of treatment if the hba1c remains controlled4. limitation of our study was the small number of patients and it was a retrospective study. there were also lesser number of patients in group 1. future studies can be planned to investigate this group further. only bevacizumab was used in this study. other anti-vegf like ranibizumab and aflibercept can be compared with bevacizumab in future studies. conclusion baseline hba1c has a strong relation with visual and anatomic outcome in diabetic macular edema. references 1. bansal as, khurana rn, wieland mr, wang p-w, van everen sa, tuomi l. influence of glycosylated hemoglobin on the efficacy of ranibizumab for diabetic macular edema: a post hoc analysis of the ride/rise trials. ophthalmology, 2015; 122 (8): 1573-9. 2. mumtaz sn, fahimmf, arslan m, shaikh sa, kazi u, memon ms. prevalence of diabetic retinopathy in pakistan; a systematic review. pak j med sci. 2018; 34 (2): 493–500. 3. fasil a, biadgo b, abebe m. glycemic control and diabetes complications among diabetes mellitus patients attending at university of gondar hospital, northwest ethiopia. diabetes, metabolic syndrome and obesity: targets and therapy.diabetes metab syndr obes. 2019; 12: 75–83. 4. nezhad gs, razeghinejad r, janghorbani m, mohamadian a, jalalpour mh, bazdar s. prevalence, incidence and ecological determinants of diabetic retinopathy in iran: systematic review and metaanalysis. j ophthalmic vis res. 2019; 14 (3): 321-335. 5. chew ey, davis md, danis rp, lovato jf, perdue lh, greven c, et al. the effects of medical management on the progression of diabetic retinopathy in persons with type 2 diabetes: the action to control cardiovascular risk in diabetes (accord) eye study. ophthalmology 2014; 121 (12): 2443-51. 6. jafri as, aziz-ur-rehman ahm, memon s. outcomes of intravitreal bevacizumab and macular photocoagulation for treatment of diabetic macular edema in a tertiary care eye hospital, karachi. pak j med sci. 2017; 33 (5): 1215. 7. do dv, shah sm, sung ju, haller ja, nguyen qd. persistent diabetic macular edema is associated with elevated hemoglobin a1c. american journal of ophthalmology, 2005; 139 (4): 620-3. 8. ajlan rs, silva ps, sun jk. vascular endothelial growth factor and diabetic retinal disease. semin ophthalmol. 2016; 31 (1-2): 40-8. 9. singh rp, habbu k, ehlers jp, lansang mc, hill l, stoilov i. the impact of systemic factors on clinical response to ranibizumab for diabetic macular edema. ophthalmology, 2016; 123 (7): 1581-7. 10. matsuda s, tam t, singh rp, kaiser pk, petkovsek d, carneiro g, et al. the impact of metabolic parameters on clinical response to vegf inhibitors for diabetic macular edema. jdiabetes complications, 2014; 28 (2): 166-70. 11. ozturk bt, kerimoglu h, adam m, gunduz k, okudan s. glucose regulation influences treatment outcome in ranibizumab treatment for diabetic macular edema. j diabetes complications, 2011; 25 (5): 98-302. 12. pemp b, deak g, prager s. diabetic retinopathy research group vienna distribution of intraretinal exudates in diabetic macular edema during antivascular endothelial growth factor therapy observed by spectral domain optical coherence tomography and fundus photography. retina, 2014; 34 (12): 2407-15. 13. midena e, gillies m, katz ta, metzig c, lu c, ogura y. impact of baseline central retinal thickness on outcomes in the vivid-dme and vista-dme studies. j ophthalmol. 2018; 29: 3640135. 14. nathan dm, mcgee p, steffes mw, lachin jm, group der. relationship of glycated albumin to blood glucose and hba1c values and to retinopathy, nephropathy, and cardiovascular outcomes in the dcct/edic study. diabetes, 2014; 63 (1): 282-90. 15. clarke pm, gray am, briggs a, farmer aj, fenn p, stevens rj, et al. a model to estimate the lifetime health outcomes of patients with type 2 diabetes: the united kingdom prospective diabetes study (ukpds) outcomes model (ukpds no. 68). diabetologia. 2004; 47 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6306061/ relationship of hba1c with visual and anatomical outcomes of bevacizumab in diabetic macular edema pak j ophthalmol vol. 35, no. no. 4, oct – dec, 2019 262 (10): 1747-59. 16. singh rp, wykoff cc, brown dm, larsen m, terasaki h, silva fq, et al. outcomes of diabetic macular edema patients by baseline hemoglobin a1c: analyses from vista and vivid. ophthalmology retina, 2017; 1 (5): 382-8. 17. heier js, bressler nm, avery rl, bakri sj, boyer ds, brown dm, et al. comparison of aflibercept, bevacizumab, and ranibizumab for treatment of diabetic macular edema: extrapolation of data to clinical practice. jama ophthalmol. 2016; 134 (1): 95-9. 18. schauwvlieghe ame, dijkman g, hooymans jm, verbraak fd, hoyng cb, dijkgraaf mgw, et al. comparing the effectiveness and costs of bevacizumab to ranibizumab in patients with diabetic macular edema: a randomized clinical trial (the brdme study). bmc ophthalmol. 2015; 15 (1): 71. 19. ross el, hutton dw, stein jd, bressler nm, jampol lm, glassman ar. cost-effectiveness of aflibercept, bevacizumab, and ranibizumab for diabetic macular edema treatment: analysis from the diabetic retinopathy clinical research network comparative effectiveness trial. jama ophthalmol. 2016; 134 (8): 888-96. 20. wells ja, glassman ar, ayala ar, jampol lm, bressler nm, bressler sb, et al. aflibercept, bevacizumab, or ranibizumab for diabetic macular edema: two-year results from a comparative effectiveness randomized clinical trial. ophthalmology, 2016; 123 (6): 1351-9. author’s affiliation royala zaka prevention of blindness (pob), karachi, pakistan burhan abdul majid khan prevention of blindness (pob), karachi, pakistan mirza zakiuddin ahmed sabri prevention of blindness (pob), karachi, pakistan rabia qureshi prevention of blindness (pob), karachi, pakistan author’s contribution royala zaka study design, data collection, manuscript writing, final review. burhan abdul majid khan critical revision, final review. mirza zakiuddin ahmed sabri critical revision, final review. rabia qureshi. data collection, final review. 1 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology editorial back to basics – part 1: are we over treating ocular hypertension and primary open angle glaucoma patients? rashid zia, s. a. raja, s. aqil pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . opulation explosion, availability of life saving drugs and perusal of healthier life styles is leading to rising life expectancy worldwide. this indirectly translates to increasing prevalence of open angle glaucoma1 worldwide and pakistan is no exception to these myriad factors of population increase and related healthcare issues. studies have in general shown increased glaucoma severity corelating with direct and indirect costs associated with the progression of disease2. hence there is a wide spread tendency to treat suspicious optic nerve heads, mild to moderate high intraocular pressures or even documented but non progressive glaucoma damage without comprehensive structural, visual function, local and systemic risk assessment. this has in turn led to plethora of adverse clinical, socioeconomic and financial concerns triggering chain of adversities at individual and as well as national level. the term, “target iop” is widely used in clinical practice. unfortunately, it tends to steer the management of glaucoma patients solely dependant on reducing iop to “acceptable” levels. the acceptable target range(s) for iop are often the recommendations of large land mark clinical trials (rct‟s). this however frequently leads clinicians to ignore the wood for the trees. there is an inclination towards treating the pressure rather than the patient. there is an inclination towards treating the iop to reduce it to a magic lower value rather than fully assess the patient/ individualised needs, incorporating a holistic approach based on quality of life and patient choice(s). clinicians in their busy clinics often forget that patients are not concerned about their iop values, digits (decibel loss) on visual fields or colours (red disease) on oct scans. rather patient is only concerned about two things: (a) am i going to lose vision? or/and (b) am i going to develop disability? to answer these questions, clinicians are required to assess the progression of the disease and the likelihood of disability in expected life span 3,4,5. assessing progression and then the rate of progression is pivotal in taking decisions regarding glaucoma management, for example, it is hard to justify addition of second line of topical ocular antihypertensive drug to a regimen when patient with intraocular pressures of 26 mm hg on a single ocular antihypertensive drug has not shown any evidence of structural or functional loss on trend analysis. similarly, a patient with documented progression on visual fields or oct may still not require further lowering of iop if the rate of progression is unlikely to cause or worsen existing disability in the life span of terminally ill patient. major risk factors for glaucoma blindness are the severity of disease at presentation and life expectancy4,6. a 60 years old patient with bilateral moderate glaucomatous (structural and visual functional) damage at diagnosis has a greater risk of blindness than an 85 years old with a similar amount of damage. similarly a young patient with mild bilateral damage is at much larger risk of disability in his life tile than an 80 years old patient with moderate unilateral disease. thus assessing rate of progression is an integral part of glaucoma management and the measured rate is what should determine the target intraocular pressure and treatment intensity. many p back to basics – part 1: are we over treating ocular hypertension and primary open angle glaucoma pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 2 studies have found that progression is usually linear 77 (although variable or non-linear progression modelling has been documented as well). hence the goal of initiating or intensifying the treatment is to reduce the rate of progression to prevent disability or cause further disability. preservation of visual function and related quality of life should be planned at a sustainable cost. the cost of treatment should be calculated in terms of inconvenience and side effects as well as financial implications for the individual and society and this requires careful evaluation marrying the „art and science of glaucoma‟. european glaucoma society (egs) guidelines state, “quality of life is closely related to visual function. over all, patients with early to moderate glaucoma damage have good visual function and modest reduction in quality of life (qol), while qol is considerably reduced with advanced visual functional loss”8. common perception that no symptoms are experienced in the early stage of the disease typically9,10 has been challenged in the recent studies, including one large scale epidemiological study. it has been suggested that patients with even mild unilateral visual field damage may experience reduced vision related qol (vrqol) even if they are unaware that they suffer from glaucoma11. for example, inferior hemifield damage shows a stronger correlation than superior damage with respect to general vision, risk of falling, eye hand coordination and mobility. while superior field is more likely to interfere with reading and near activities12,13. this decreased quality of life may also result in less engagement in the real world behaviour; significantly reduced physical activity9, restriction to home and suffering with apprehension14 and depression. thus when taking in consideration the rate of progression, life expectancy, local and systemic risk factors, patient preferences and effects on vision related quality of life, it is clear that there is no single “target iop” level that is appropriate for every patient. the target iop needs to be estimated separately for each eye of every patient on every visit. the hippocratic oath includes the promise “primum non nocere” i.e. as to the matter of diseases, first do no harm. glaucoma management is complex and requires a holistic approach without bringing harm to patients by carefully identifying “target iop” author’s affiliation rashid zia lead ophthalmologist new hayesbank ophthalmology services; ashford kent; uk lead ophthalmologist beltinge ophthalmic services; kent uk glaucoma fellow east kent hospitalsuniversitynhs foundation trust uk mohammad s. a. raja consultant ophthalmologist with a specialist interest in retinal diseases and ophthalmic imaging clinical lead ophthalmology james paget university hospital nhs trust norfolk uk clinical lead eadesp (east anglian diabetic eye screening programme) s. aqil post graduate trainee financial interest: none. conflict of interest: none. references 1. than yc li x, wong ty, et al. global prevalence of glaucoma and projections of glaucoma burden through 2040: a systemic review and meta analysis. ophthalmology, 2014; 121: 2081-2090. 2. schmier jk, halpren mt, jones ml. the economic implications of glaucoma: a literature review. pharmacoeconomics, 2007; 25 (4): 287-308. 3. martus p, strous a, budde wm, et al. predictive factors for progressive optic nerve damage in various types of chronic open angle glaucoma. am j ophthalmology, 2005; 139 (6): 999-1009. 4. peters d bengtsson b, heijl a. factors associated with life time risks of open angle glaucoma blindness. acta ophthalmologica. 2013. 5. foresman e, kivea t, vest e. life time visual disability on open angle glaucoma and ocular hypertension. journal of glaucoma, 2007; 16 (3): 313-9. 6. martus p, stroux a, budde wm, et al. predictive factors for progressive optic nerve damage in various types of chronic open angle glaucoma. am j ophthal. 2005; 139 (6): 999-1009. 7. pererira ml, kim cs, zimmerman mb, et al. rate and pattern of visual field decline in primary open angle glaucoma. ophthalmology, 2002; 109 (12): 2232-40. 8. terminology and guidelines for glaucoma; european glaucoma society; 4th edition; chapter 3 treatment principles and options, pg 133. 9. ramulu py, maul e, hochberg c, et al. real world assessment of physical activity in glaucoma using an accelerometer. ophthalmology, 2012; 119: 1155-1166. https://en.wikipedia.org/wiki/hippocratic_oath rashid zia, et al 3 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology 10. kong xm, zhu wq, hong jx, sun xh. is glaucoma comprehension associated with psychological disturbance and vision related quality of life for patients with glaucoma? a cross-sectional study. bmj open, 2014. 11. peters d, heijl a, brenner l, bengston b. visual impairment and vision-related quality of life in the early manifest glaucoma trial after 20 years of follow up. acta ophthalmol. 2015; 93: 745-752. 12. maruta h, hirasawa h, ayoma y, et al. identifying areas of the visual field important for quality of life in patients with glaucoma. ploss one 8,e58695 10.1371/journal.pone.0058695(2013) 13. sun y linc c, waisbourd m, et al. the impact of visual field clusters on performance-based measures and vision-related quality of life in patients with glaucoma. am j ophthalmol. 2016; 163: 45-52. 14. kotecha a; o’leary n, melmonth d, grant s, crabb dp. the functional consequences of glaucoma for eyehand coordination. invest ophthalmol vis sci 20. 09; 50 (1): 2003-213. microsoft word akram shahwani 82 original article ocular injuries: its etiology and consequences in balochistan muhammad akram shahwani, khalid hameed, barkat jamali pak j ophthalmol 2006, vol. 22 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: mohammad akram shahwani department of ophthalmology bolan medical college helpers eye hospital quetta received for publication may’ 2005 …..……………………….. purpose: to find out the etiologies and consequence of ocular injuries presented in helper eye hospital quetta, blochistan. we analysed 200 cases of ocular injuries in helpers eye hospital, quetta regarding its etiology in three different age groups of 0-15, 16-30 and above 30 years of ages. material and methods: retrospective analysis of 200 cases of ocular injuries was done who presented in the eye department of the helper eye hospital quetta blochistan. data was recorded on the proforma for further analysis. recording were made specifically for age, sex and type of injury patients were divided into three groups according to age 0-15, 15-30 and above 30 years to find out the comment injury in each age group. results: the majority 48.5 % (n=97) was due to sports and play, maximum being in children (n=87). occupational and firearm injuries were the second commonest cause (12.5 %) n=25 and 12 % (n=24) respectively. whereas fight and assault was found responsible in 10 % (n=20) and road traffic accident 6.5 % (n=13) in our study. conclusion: keeping in view the above etiological factors it is being emphasized that efforts should be made towards the prevention, and proper management of ocular injuries in pakistan. key words: ocular trauma, blochistan. cular trauma is a major cause of unilateral blindness, particularly in young patients, affecting people on the most productive time of their working career1. blunt injuries are more common than penetrating injuries and they represent a spectrum from mild corneal abrasions to forceful blunt trauma causing marked tissue disruption1. like many other developing countries ocular trauma is more common in pakistan in general and in the province of balochistan in particular. since the injuries occurred from innumerable causes in every instance of life, it is difficult to compare with previous authors2. hence etiologically they have been broadly classified as: • occupational, • play ground injuries, • fighting and assault, o 83 • domestic injuries, • firearm injuries, • road traffic accidents; and • miscellaneous. the purpose of this study is to present the common causes of ocular injuries, its incidence and types in our region. material and methods two hundred cases of ocular injuries were divided into three groups according to ages of 0-15, 16-30 and over 30 years. out of 200 cases, 107 (53.5 %) were below 15 years, 61 (30.5 %) were within 16-30 years, whereas 32 (16 %) were above 30 years (table 1). male to female ratio was 4:1, the number of patients being 162 (81 %) and 38 (19 %) respectively (table 2). moreover, all cases of ocular injuries were classified in seven categories regarding involvement of ocular structures (table 3). the preoperative evaluation of all the patients included documentation of cause, site, shape and extent of injury, structures involved investigations for intraocular fb. detection and its location by x-rays in primary, up, down, right and left gazes from anteroposterior and lateral views and ultrasonography and time of trauma. results the most common cause of anterior segment ocular trauma was accident during play in children (97 patients, (48.5%). this correlates well with a study from northwest frontier province of pakistan in which the highest cases (42.21%) fell into the category of accidents at play3. a study from india by panda et al in which commonest cause of trauma to the eye was also attributed to sports and play. out of 97 patients, 87 were under 15 years of age, in which 66 were male and 21 female. only 9 cases were affected during play and sport in adults. at all ages the prominent sex was male. this is mainly because of children being engaged in aggressive activities like throwing stone (24 cases male, 15 female), hitting with stick (20 cases) pieces of glass, metal, sharp instrument (knife), airgun (5 cases), mudball (4 cases), disposable syringe (3 cases), finger/fist (6 cases), cricket ball (2 cases) (table 4 and pie chart). according to the 10 years survey of eye injuries in northern ireland by canvan and archer5, 9, the most common injuries occur during play and sports (33.8%) in children under 16 years of age. the second major group fell into the category of occupational (12.5%). the commonest cause was flying particles while using a hammer and chisel and majority patient had intraocular foreign body. out of 25 cases, 17 were male 6 female above 16 years of age. only 2 cases were below 16 years of age. children sustained injuries invariably during play and adults at work (panda, bhatia and dayal 1985)4. the third major group was firearm injuries due to explosion (12%). these injuries were most often found in those affected by the afghan war. out of 24 patients, 22 patients were injured by bomb blast, mine blast etc. very few patients were injured by shotgun and bullet. explosions usually affected both eyes and often caused serious damage. corneoscleral perforation was the most-prevalent injury and intraocular or intraorbital foreign body was present in majority of patient. rate of infection was higher. most of the patients were in the 16-30 or above 30 years of age groups. most of the trauma occurred in men (table 4). the delay between injury and admission varied from 2-7 days. primary repair was possible in 15 patients while 8 eyes were excised because of irreparable damage. traumatic cataracts were dealt with surgically. the fourth major group was domestic injuries (10.5%). common causes of domestic injuries were knives, scissors, stone, needles, children fingers and toys etc. 8.5% resulted from accidents in the home. home is an area in which serious eye injuries can occur commonly in the young. injuries during fighting and assault accounted for 10%. the common causes were stone, stick, fist etc. in usa 14.3% of eye injuries were inflicted during fight and assault. in our study all patients affected during fighting were male. road traffic accidents accounted for 6.5% of all cases. road traffic accidents usually affected both eyes. major cause was the windscreen and front seat passenger were more affected then the back seat passenger. in our study most of the eye injuries in road traffic accidents occurred in males that is just opposite to the survey done by canvan and archer in northern ireland5 where mostly females were affected in road traffic accidents (table 4). 84 discussion it has been observed that ocular injuries are a characteristic of particular environment6,7. in our study in helpers eye hospital, various types of environmental factors were observed to work simultaneously. manual occupational industries are constant source of perforating ocular injuries with or without foreign bodies. table 1: age no of patients n (%) 5-15 107 (53.5) 16-30 61 (30.5) above 30 32 (16) total 200 (100) table 2: sex n (%) sex distribution n (%) male 162 (81%) children 81 (40.5) adults 81 (40.5) female 38 (19%) children 26 (13) adults 12 (6) total 200 (100) table 3: types of ocular injuries (200 cases) classification structures involved no. of cases n (%) category i category ii category iii category iv category v category vi category vii scleral perforation with intact cornea corneal perforation with or without iris prolapse and hypheama combined corneo-scleral perforation with or without ureal prolapse and hyphema. cornea or corneoscleral perforation with lens perforation corneal, scleral or corneoscleral perforation with lens and vitreous prolapse and presence of intraocular f.b. double perforating injuries with or without the presence of f.b. totally lost eyeball (irreparable eyeball) 20 (10) 65 (32.5 55 (27.5) 20 (10) 25 (12.5) 7 (3.5) 8 (4) table 4: causes of injury with regard to age and sex distribution causes 0-15 yrs 16-30 yrs above 30 total n (%) m f m f m f play and sports stone stick air gun toy pistol mud ball cricket ball disposable syringe finger/fist glass piece occupational domestic fire arm injury 66 24 20 04 02 04 01 02 02 07 02 04 04 21 15 00 00 00 00 01 01 04 00 00 02 01 07 01 02 01 00 01 00 00 02 00 17 02 11 01 00 01 00 00 00 00 00 00 00 06 03 01 02 00 00 00 00 01 00 00 01 00 00 09 07 00 00 00 00 00 00 00 00 00 00 00 01 00 97 (48.5) 40 23 05 02 06 02 03 09 07 25 (12.5) 21 (10.5) 24 (12) 85 bullet gunshot bomb blast fight and assault road traffic accidents miscellaneous 00 01 03 02 03 00 00 01 00 01 00 00 01 10 10 03 00 00 00 01 00 00 00 00 00 07 08 06 00 00 00 00 00 00 00 00 02 22 20 (10) 10 (5) 3 (1.5) total 81 26 50 11 31 01 200 (100) the male to female ratio for the ocular trauma patients is 4:1 as compared to general ophthalmic male to female ratio, which is (1.2: 1) during our study. this difference of ratio confirms the findings in other large surveys that men are more often affected8, 9. the afghan war is another factor of eye injuries especially the male having serious ocular penetrating injuries because they are the direct victims as compared to females. in our region, girls after puberty are often confined to their homes because of traditional environment therefore they are least prone to ocular trauma as compared to boys, who are always engaged in aggressive activities getting more ocular injuries. in this study it was observed that most eye injuries occurred during sports and play below the ages of 15 years especially in boys (n = 66) as compared to girls (n = 21). disposable syringes were found more responsible for ocular injuries and loss of eyeball but fortunately during our study only 3 cases were observed (two boys and one girl). bomb blast and firearm injuries are another cause of ocular trauma. most of these were victims of the afghan war. road traffic accidents also remained responsible for ocular injuries, which was 6.5 % in our study in contrast to reports of nwfp of pakistan, (2.2 %)10. conclusion ocular trauma has always been and always will be challenge to ophthalmologists. in this violent and sophisticated age of motor car, increased industrializetion, heightened interest in sport activities and assault, both the number and severity of ocular injuries are increasing. in developing nations the problem of eye trauma is much more severe because of inadequate awareness, poverty and long distances to obtain appropriate treatment. dr. robert stegmann and david miller state that approach to the anterior segment ocular trauma is very important in restoration of vision8. repair of trauma is the most challenging operation in ophthalmology. skilled teams of doctors and nurses should do it. surgical intervention may be safely delayed until next morning when the best surgical team can be assembled and secondary repair should be done after disappearance of initial inflammations. there is no doubt, however, that modern advances have significantly improved the prognosis for perforating injuries involving the anterior segment. ocular trauma in the province of balochistan is a major eye health problem therefore despite improvement for its management attention should also be given for its prevention in the following manner. 1. trauma register should be maintained in the department of ophthalmology nationwide for obtaining ocular-injury-statistics. 2. the nature of certain types of trauma should be recorded and reported. 3. the public should be given awareness through public health education about the dangers and hazards of certain games (gulli danda, sharp needles, knives, scissors, syringes etc.). 4. regular public education seminars should be held in all parts of the country regarding ocular injuries. 5. ocular trauma centers should be developed and provided with sophisticated ocular equipments for proper repair of ocular injuries all over the country. author’s affiliation dr. muhammad akram shahwani assistant professor ophthalmology bolan medical college helpers eye hospital, quetta dr. khalid hameed assistant professor ophthalmology bolan medical college 86 helpers eye hospital, quetta dr. barkat jamali helpers eye hospital, quetta reference 1. heimann sk. management of ocular trauma. highlights of ophthalmology 1996; 24: 3-9. 2. chandra p, parmer ip, kumar j. some aspects of ocular injuries. j indian med assoc. 1974; 62: 15-7. khan md, kundi n, muhammad s, et al. eye injuries in nwfp of pakistan. pak j ophthalmol. 1988; 4: 5-9. 3. panda a, bhatia im, dayal y: ocular injuries-a socio-economic importance (incidence). afro asia j ophthalmol. 1985; 111: 1701. 4. canvas yh, archer db. anterior segment consequences of blunt ocular injury. br j ophthalmol. 1982; 66: 549-55. 5. `lambach p. adult eye injuries at wolverhampton. trans ophthalmol. uk 1968; 88: 661-73. 6. niiranen m. perforating eye injuries. a comparative epidemiological, prognostic and socioeconomic study of penetrating trauma in 1930-1939 and 1950-1959. acta ophthalmol. 1978; 135: 1-87 7. miller d, stegmann r. treatment of anterior segment ocular trauma, montreal, medicopia 1986; 7-21 8. canvas yh, o‘flaherty mj, archer db, et al. a 10 year survey of eye injuries in northern ireland. br j ophthalmol. 1980; 64: 618-25. 9. khan md, muhammad s. an 11½ years review of ocular trauma in nwfp of pakistan. pak. j ophthalmol. 1991; 7: 15-8. 209 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol review article use of mitomycin c in ocular surgery; a narrative review p. s. mahar pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p.s. mahar frcs, frcophth consultant eye surgeon aga khan university hospital professor & dean isra postgraduate institute of ophthalmology karachi email: salim.mahar@aku.edu …..……………………….. mitomycin c is an alkylating agent with an anti-proliferative activity. because of its potent anti-fibroblastic effect, it is used in multiple ocular surgical procedures where inhibition of proliferation of fibroblasts and vascular ingrowths is required. it is dispensed in blue violet crystalline powder and it dissolves in water. mmc is stable for 2 weeks when refrigerated at 2 – 8 degrees centigrade after the powder is reconstituted for topical use. because of its anti-fibroblastic activity, mmc is used in various ocular surgical procedures. the optimal dose of mmc is not known but is usually used in concentration of 0.1 mg/ml (0.01%) to 0.5 mg/ml (0.05%) in different clinical setups. key words: mitomycin c, fibroblasts, ocular surgery. itomycin is an alkylating agent with an anti-proliferative effect. it inhibits dna synthesis of cells exhibiting highest rate of mitosis. mitomycin is isolated from soil bacterium streptomyces caesopitosus. it has got 3 types mitomycin a, mitomycin b and mitomycin c which are produced by streptomyces caesopitosus under different conditions. therefore, this medication is called as mitomycin c (mmc) to differentiate it from others.1mitomycin c inhibits proliferation of fibroblasts, suppresses vascular ingrowths and is much more potent than 5 – fluorouracil (5 fu)2. it is dispensed in blue violet crystalline powder and it dissolves in water. mmc is stable for 2 weeks when refrigerated at 2 – 8 degrees centigrade after the powder is reconstituted for topical use. because of its anti-fibroblastic activity, mmc is used in various ocular surgical procedures. the optimal dose of mmc is not known but is usually used in concentration of 0.1 mg/ml (0.01%) to 0.5 mg/ml (0.05%) in different clinical setups. pterygium surgery pterygium is a fibro-vascular growth which extends across the limbus onto the cornea. it is a common corneal disorder witnessed in countries with hot climate.3 once grown over cornea, apart from the cosmetic blemish, it induces irregular astigmatism. if it’s growth involves the visual axis, it can also severely curtail the vision. surgical removal of the pterygium is the preferred treatment but the rate ofrecurrent pterygium is very high at 30% – 50% after simple excision is performed4,5. kunitomo and mori6 were the first workers suggesting the adjunct use of mmc in patients undergoing surgical excision. in 1988, hayasaka et al7 published their work on the instillation of lower dose of mmc after surgery in the treatment of primary pterygium. they found recurrence rate of 7% in group of patients treated with 0.2 mg/ml mmc drops used for 1 week duration. the recurrence rate was 11% with the use of 0.4 mg mmc drops and 32% recurrence was noted in their cohort of patients undergoing simple surgical excision. singh m mailto:salim.mahar@aku.edu use of mitomycin c in ocular surgery; a narrative review pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 210 and co-workers8 reported similar favourable results of non-recurrence in their patients using 1 mg/ml mmc drops postoperatively. mahar and nwokora9 in their published work concluded no recurrence of pterygium when mmc 0.4 mg/ml drops were used postoperatively for 2 weeks duration. lack of optimal dosage and variable duration of instillation of mmc has led to some serious complications. rubenfeld10 described group of patients developing secondary glaucoma, corneal edema, corectopia, corneal perforation, iritis and scleral calcification when mmc was used in higher concentration and for long duration of upto 4 weeks. this treatment modality was followed by many clinicians to use mmc intra-operatively in a single dose after surgical excision. this has not only successfully reduced recurrence of pterygium but showed minimal complications. cardillo and colleagues11 in a prospective study treated 227 patients with primary pterygia. after surgical excision these patients were divided in 5 groups: group 1 received single intra-operative application of 0.2 mg/ml mmc for 3 minutes; group 2 received a single intra-operative application of 0.4 mg/ml mmc for 3 minutes; group 3 received mmc eye drops 0.2 mg/ml 3 times a day for 7 days; group 4 received 0.4 mg/ml mmc drops 3 times a day for 2 weeks and group 5 acted as control. at mean follow up of 28 months all groups receiving mmc in single application or drops showed around 5% recurrence rate in comparison to control group with recurrence rate of 29.27%. this study indicated that there was no difference in recurrence between intra-operative application of mmc or drops and also no statistically difference was found in groups receiving 0.2 mg/ml or 0.4 mg/ml mmc for 3 minutes. since thenmultiple studies have followed with intra-operative use of mmc in concentration of 0.2 mg/ml or 0.4 mg/ml with application time of 3 – 5 minutes12,13,14. several workers have also used 0.1 ml of mmc in concentration of 0.2 mg/ml injected under pterygium head and then removing pterygium with simple excision after 4 weeks. the success rate of this approach has been comparable to the topical application of mmc in reducing the recurrence rate of pterygium15,16. trabeculectomy the aim of drainage surgery for glaucoma like trabeculectomy is to create an outflow channel for aqueous humor leading into subconjunctival space. the common cause of failure of this drainage area is to get occluded due to fibrosis at conjunctival – scleral interface and intrasclerally. the various risk factors for the fibrosis resulting in drainage failure are long term antiglaucoma medication, patients under 50 years of age and various uveitic, rubeotic and pseudophakic glaucomas. the scarring process occurs due to proliferation of fibroblasts at the site of surgical fistula17, resulting in uncontrolled intraocular pressure (iop). because of its anti fibroblastic activity, mmc has been used topically over sclerectomy area to maintain the drainage facility with controlled iop. the first use of mmc in trabeculectomy is attributed to chen18 who claimed higher success in his cohort of 59 eyes undergoing trabeculectomy in refractory glaucomas. this has been followed by numerous reports in the literature on the use of mmc in trabeculectomy in all types of glaucoma achieving higher success rate in maintaining the iop19–23. traditionally mmc soaked sponges are placed at the time of surgery under conjunctiva before or after scleral flap dissection. the average concentration of mmc is 0.1 mg/ml – 0.5 mg/ml with duration of application between 1 – 5 minutes. afterwards mmc is washed out with copious irrigation of balanced salt solution (bss). some clinicians have used the sponges placed under the scleral flap and claimed higher success of iop control.24one alternative approach for using mmc is to inject it subconjunctivally over the site of bleb at the start of the surgery25. maquet and colleagues26 described protocol for mmc use in glaucoma surgery. they divided 143 eyes of 124 patients in multiple groups receiving mmc in different concentrations. first group received mmc 0.1 mg/ml, second group had 0.2 mg/ml while third group of patients received 0.4 mg/ml. no significant difference were found in final mean iop values or in postoperative complications at the end of 12 month follow-up. pakravan and co-workers27 in multicentre clinical trial randomized 80 patients in 2 groups: group 1 received subtenon injection of 0.1 ml of 0.1 mg/ml mmc while group 2 received 0.2 mg/ml mmc soaked sponges. at the end of 1 year follow-up both groups showed success of 82.5% in controlling the iop. they reported that, blebs tended to be more diffused, less vascularized and shallower in patients receiving mmc by subtenon injection. the use of mmc is not without certain complications when used in higher concentration and for longer duration. therefore, it is important to weigh p. s. mahar 211 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol the risks and benefits of mmc use in glaucoma surgery. the use of mmc can cause corneal epithelium toxicity resulting in superficial punctuate erosions and corneal abrasions. conjunctival wound leaks are also frequently described in patients treated with mmc. the thin-walled blebs produced with mmc use are also at greater risk for developing blebitis and endophthalmitis. hypotony and resulting maculopathy is also witnessed in patients receiving mmc during trabeculectomy28. refractive surgery photorefractive keratectomy (prk) is the original surface ablation technique involving removing the epithelium of the cornea mechanically with subsequent ablation of the bowman’s layer and anterior stroma using the excimer laser. although this technique is followed by pain and discomfort during the first 24 hours and slow visual recovery but it is the corneal haze formation which complicates the visual outcome. corneal haze can develop frequently after treatment of high myopia (≥ 6.00 diopters) due to ablation depth. the pathogenesis of haze formation is due to keratocytes apoptosis caused by laser and is followed by proliferation and migration of surrounding keratocytes to repopulate the stroma. some of these keratocytes differentiate into myofibroblasts which not only are basis for corneal haze but also cause scattering of light29. talamo was the first one using mmc in an animal model suggesting that it’s use can prevent corneal haze formation30. mitomycin c is applied over the deepitheliazed stroma after laser ablation. it causes lower keratocytes and myofibroblasts density with reduced deposit of collagen and extracellular matrix resulting in decreased corneal haze31. the optimal dose and duration of mmc is not known in prk. but it is used in a concentration of 2 mg/ml (0.2%)–0.2 mg/ml (0.02%) with duration of application from 12 seconds to 2 minutes. majmudar first used mmc as a prophylactic agent in patients undergoing prk.32 leccisotti reported significant less haze in eyes treated with mmc 0.2 mg/ml for 45 seconds. patients refractive error ranged from – 6.50 to – 10 diopters33. similarly wallu and campos reported better outcome for prk with mmc than lasik with no haze observed in eyes treated with mmc34. sigonos and colleagues advise 30 seconds application of mmc 0.2 mg/ml (0.02 %) for primary prk and in complicated cases involving penetrating keratoplasty (pkp), radial keratotmy (rk), and re-docases 1 minute or more application of mmc is suggested35. medina and co-workers found no change in endoethelium cell count, epithelial thickness, keratocyte density and number of corneal nerve fibers with mmc use after 5 years postoperatively36. strabismus surgery postoperative scarring and formation of adhesions following strabismus surgery can compromise the final outcome. the intraoperative adjunctive use of mmc has been found with encouraging results in rabbit model with reduction in formation of adhesions and scarring37. chen and colleagues38 found that use of mmc in dose of 0.2 mg/ml applied for 5 minutes duration was associated with better range of passive duction at all postoperative follow-ups in patients undergoing strabismus surgery. the use of mmc is also associated with delayed adjustments after strabismus surgery39. lacrimal surgery dacryocystorhinostomy (dcr) is the preferred procedure in treating blockage of nasolacrimal duct with excessive lacrimation. the common cause of failure in dcr is closure of the common canaliculus and obstruction of the site of osteotomy40,41. this occurs due to proliferation of fibrous tissue, and formation of granulation tissue. the mmc soaked sponges (0.2 mg/ml) when placed at the site of osteotomy and anastomosed flaps can slow proliferation of fibrous tissue and development of scar. liao and co-workers treated 44 eyes undergoingdcr surgery with application of mmc 0.2 mg/ml applied to osteotomy site for 30 minutes. the non-patency rate in mmc group was 4.5% compared with 11.4% with conventional group.42rathore and colleagues placed a nasal pack soaked in 1 ml of 0.5 mg/ml (0.05%) mmc for 48 hours after endonasal dcr. postoperatively, the nasal cavity with mmc pack had healthy nasal mucosa during the entire follow-up as compared to the control group with saline nasal pack which showed synechiae formation in 65.2% cases43. xue and co-workers conducted a meta-analysis of randomized controlled clinical trials related to adjunctive use of mmc in primary and revision external and endonasal dcr. they concluded use of mitomycin c in ocular surgery; a narrative review pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 212 that surgical success rate in primary and revision external dcr can be enhanced when mmc is applied at the site of osteotomy effectively but there was no significant advantage in primary endonasal dcr44. nair et al in their review suggest that studies should be done on innovative drug delivery methods like intraoperative injection of mmc in depot form or using silicone stents coated with mmc45. conclusion the use of mitomycin c is established in various ocular surgical procedures. the optimal dose and duration of application of mmc is still not known. one has therefore to weigh the risks and benefits of its use in different clinical conditions. financial interest none. conflict of interest none. references 1. wakaki s, marcimo h, tomioka k. isolation of new fractions of antitumor mitomycins. antibiot chemother. 1958; 8: 228-40. 2. sutphin je. basic and clinical science course: external disease and cornea. san francisco: american academy of ophthalmology, 2008; 8: 429-32. 3. hill jc, maske r. pathogeneses of pterygium. eye, 1989; 3: 218-26. 4. de keizer rjw. pterygium excision with or without postoperative irradiation, a double-blind study. doc ophthalmol. 1982; 52: 309-15. 5. zauberman h. pterygium and its recurrence. am j ophthalmol. 1976; 63: 1780-6. 6. kunitomo n, mori s. studies on pterygium. report iv. a treatment of the pterygium by mitomycin c installation. acta soc ophthalmol jpn. 1963; 67: 1809-14. 7. hayasaka s, noda s, yamamoto y, setogawa t. postoperative instillation of low-dose mitomycin c in the treatment of primary pterygium. am j ophthalmol. 1988; 106: 715-8. 8. singh g, wilson mr, foster s. mitomycin eye drops as treatment for pterygium. ophthalmology, 1988; 95: 81321. 9. mahar ps, nwokora ge. role of mitomycin c in pterygium surgery. br j ophthalmol. 1993; 77: 433-35. 10. rubinfeld rs, pfister rr, stein rm, et al. serious complications of topical mitomycin-c after pterygium surgery. ophthalmology, 1992; 99: 1647-54. 11. cardillo ja, alves mr, ambrosio le, poterio mb, jose nk. single intraoperative application versus postoperative mitomycin c eye drops in pterygium surgery. ophthalmology, 1995; 102: 1949-52. 12. frucht-pery j, siganos cs, ilsar m. intraoperative application of topical mitomycin c for pterygium surgery. ophthalmology, 1996; 103: 674-77. 13. mastropasqua l, carpineto p, ciancaglini m, gallenga pe. long term results of intraoperative mitomycin c in the treatment of recurrent pterygium. br j ophthalmol. 1996; 80: 288-91. 14. nuzzi r, tridico f. how to minimize pterygium recurrence rates: clinical perspectives. clin ophthalmol. 2018 nov. 19; 12: 2347-2362. 15. donnenfeld ed, perry hd, fromer s, doshi s, solomon r, biser s. subconjunctival mitomycin c as adjunctive therapy before pterygium excision. ophthalmology, 2003; 110: 1012-26. 16. khakshoor h, razavi me, daneshvar r, shakeri mt, ghate mf, ghooshkhanehi h. preoperative subpterygeal injection vs intraoperative mitomycin c for pterygium removal; comparision of results and complications. am j opthalmol. 2010; 150: 193-98. 17. jampel hd, mc guigen ljb, dunkelbergu gr et al. cellular proliferation after experimental glaucoma filtration surgery. arch ophthalmol. 1988; 106: 89-94. 18. chen c, huang h, bair j, lee c. trabeculectomy with simultaneous topical application of mitomycin c in refractory glaucomas. j ocular pharmacol. 1990; 6: 17582. 19. palmer ss. mitomycin as adjunct chemotherapy with trabeculectomy. ophthalmology, 1991; 98: 317-21. 20. singh k, mehta k, shaikh nm et al. trabeculectomy with intraoperative mitomycin c vs. 5 fluorouracil: prospective randomized clinical trail. ophthalmology, 2000; 107: 2305-9. 21. bindish r, condon gp, schlosser jd, d’ antonio j, lauer kb, lehrer r. efficacy and safety of mitomycin c in primary trabeculectomy. ophthalmology, 2002; 109: 1336-42. 22. panarelli jf, banitt mr, gedde sj, shi w, schiffman jc, feuer wj. a retrospective comparison of primary baerveldt implantation versus trabeculectomy with mitomycin c. ophthalmology, 2016 apr; 123 (4): 789-95. 23. beckers hj, kinders kc, webers ca. five year results of trabeculectomy with mitomycin c. graefes arch clin exp ophthalmol. 2003; 24 (12): 106-10. 24. prata ja jr, minkler ds, baerveldt g et al. site of mitomycin c application during trabeculectomy. j glaucoma. 1994; 3: 298-301. 25. apostolov vi, siarrov np. subconjunctival injection of low-dose mitomycin c for treatment of failing human trabeculectomies. int ophthalmol. 1999; 201: 101-5. 26. maquet ja, dios e, aragon j, bailez c, ussa f, laguna n. protocol for mitomycin c use in glaucoma surgery. acta ophthalmol scand. 2005; 83: 196-200. 27. pakravan m, esfandiari h, yazdani s et al. mitomycin c augmented trabeculectomy: sub-tenon injection versus soaked sponges: a randomized clinical trial. br j p. s. mahar 213 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol ophthalmol. 2017; 0: 1-6. 28. fontana h, nourimahdavi k, lumba j, ralli m, caprioli j. trabeculectomy with mitomycin c: outcomes and risk factors for failure in phakic openangle glaucoma. ophthalmology, 2006; 113: 930-36. 29. teus ma, benito-llopis l, alio jl. mitomycin c in corneal refractive surgery. surv ophthalmol. 2009; 54: 487-502. 30. talamo jh, gollamudi s, green wr et al. modulation of corneal wound healing after excimer laser keratomileusis using topical mitomycin c and steroids. arch ophthalmol 1991; 109 (8): 1141-46. 31. tomas-juan j, larranaga am, hanneken l. corneal regeneration after photorefractive keratectomy: a review. j opto. 2015; 8: 149-69. 32. majmudar pa, forstot sl, nirankari vs, dennis rf, brenart r, epstein rj. topical mitomycin-c for subepithelial fibrosis after refractive corneal surgery. ophthalmology, 2000; 107: 89-94. 33. leccisotti a. mitomycin c in photorefractive keratectomy: effect on epithelization and predictability. cornea, 2008; 27 (3): 288-91. 34. wallau ad, campos m. one-year outcomes of a bilateral randomized prospective clinical trial comparing prk with mitomycin c and lasik. br j ophthalmology, 2009; 93 (12): 1634-38. 35. siganos ds, katsanevaki vj, pallikaris ig. correlation of subepithelial haze and refractive regression 1 month after photorefractive keratectomy for myopia. j refract surg. 1999; 15 (3): 338-42. 36. midena e, gambato c, miotto s, cortese m, salvi r, ghirlando a. long-term effects on corneal keatocytes of mitomycin c during photorefractive keratectomy: a romdomized contralateral eye confocal microscopy study. j refract surg. 2007; 23 (9 suppl.): s1011-4. 37. esme a, yildirim c, tatlipinar s, duzcan e, yaylali v, ozden s. effects of intraoperative sponge mitomycin c and 5-fluorouracil on scar formation following strabismus surgery in rabbits. strabismus, 2004; 12 (3): 141-8. 38. chen pl, chen wy, lu dw. evaluation of mitomycin c in reducing postoperative adhesions in strabismus surgery. j ocul pharmacol ther. 2005; 21 (5): 406-10. 39. oh s, chang bl, lee j. effects of mitomycin c on delayed adjustment in experimental strabismus surgery. korean j. ophthalmol. 1995; 9: 51-58. 40. allen k, berlin aj. dacryocystorhinostomy failure: association with nasolacrimal silicone intubation. ophthalmic surg. 1989; 20: 486-9. 41. rosen n, sharir m, moverman dc, rosner m. dacryocystorhinostomy with silicone tubes: evaluation of 253 cases. ophthalmic surg. 1989; 20: 115-9. 42. liao sl, kao scs, tseng jhs, chen ms, hou pk. results of intraoperative mitomycin c application in dacryocystorhinostomy. br j ophthalmol. 2000; 84: 9036. 43. rathore pk, kumarisodhi p, pandey rm. topical mitomycin c as a postoperative adjunct to endonasal dacryocystorhinostomy in patients with anatomical endonasal variants. orbit. 2009; 28: 297-302. 44. xue k, mellington fe, norris jh. meta-analysis of the adjunctive use of mitomycin c in primary and revision, external and endonasal dacryocystorhinostomy. orbit. 2014; 33 (4): 239-44. 45. nair ag, ali mj. mitomycin-c in dacryocystorhinostomy: from experimentation to implementation and the road ahead: a review. indian j ophthalmol. 2015 apr; 63 (4): 335-9. doi: 10.4103/03014738.158082. pmid: 26044474; pmcid: pmc4463559. author’s affiliation prof p.s. mahar consultant eye surgeon, aga khan university hospital professor & dean, isra postgraduate institute of ophthalmology, karachi author’s contribution prof. p.s mahar study design, manuscript writing. data collection. pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 36 original article visual outcome of vision threatening diabetic retinopathy after various treatment modalities sidra shakil, m. saleh memon, p. s. mahar, abdul fattah memon, muhammad faisal fahin, seema n. mumtaz, sikandar ali sheikh pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: p.s. mahar frcs, do, frcophth professor & dean isra postgraduate institute of ophthalmology, karachi. email: salim.mahar@aku.edu …..……………………….. purpose: to determine the visual outcome of laser treatment and intra-vitreal avastin (bevacizumab) injection as mono-therapy or combined, in patients with vision threatening diabetic retinopathy (vtdr). study design: quasi experimental study with non-probability convenient sampling. place & duration of study: isra postgraduate institute of ophthalmology, alibrahim eye hospital, karachi from january 2016 to december 2017. material & methods: patients with diabetic retinopathy (dr) were graded according to international clinical diabetic retinopathy & macular edema disease severity scale. patients with vtdr were offered laser therapy, intra-vitreal avastin injection or both. results: vtdr was witnessed in 586 patients out of 1988 patients with dr. out of which 108 had proliferative diabetic retinopathy (pdr), 382 had clinically significant macular edema (csme) and 96 had advanced diabetic eye disease (aded). laser was done in 78 eyes, intravitreal avastin was given in 340 eyes and combined laser and avastin were given in 35 eyes. when visual outcome was correlated with treatment modalities, improvement was found in 248 eyes, deterioration in 34 eyes and stabilization in 58 eyes of avastin group, whereas improvement was seen in 45 eyes, deterioration in 15 eyes and stabilization in 18 eyes of laser group. in combined treatment group, improvement was witnessed in 23 eyes, deterioration in 4 eyes and stabilization in 8 eyes. conclusions: visual outcome of avastin alone or combined with laser was found to be better than laser treatment alone in stabilizing the visual acuity in patients with vision threatening diabetic retinopathy. keywords: bevacizumab, laser, intra vitreal injection, avastin. iabetic retinopathy (dr) is an important complication of diabetes and is a global cause of blindness. it is classified into non proliferative diabetic retinopathy (npdr), proliferative retinopathy (pdr) and diabetic macular edema (dme). involvement or threatening of the center of the macula is termed clinically significant macular edema (csme) by the early treatment diabetic retinopathy study (etdrs)1. in clinical situation, csme has become synonymous with dme. worldwide, there are approximately 93 million people with dr, out of which 17 million have pdr and 21 million have dme2. in pakistan, based on national survey of blindness carried out in 20073, it was estimated that there were at least 90,000 to 100,000 adults with vision threatening diabetic retinopathy (vtdr) requiring immediate eye care4. several national studies since then have shown that d sidra shakil, et al 37 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology prevalence of diabetes is 7.5% to 11% and that of dr and vtdr is 27.43% and 8.73% respectively in pakistan5,6. clinical based evidence shows that control over modifiable factors like hyperglycaemia7, hypertension8, and hyperlipidemia9,10 effectively prevent the development and progression of dr and dme. however this control is not possible in the developing countries making them more venerable to complications of diabetes. early detection and timely treatment of diabetes and dr is necessary to prevent visual impairment. focal/grid laser photocoagulation for csme and pan retinal photocoagulation (prp) for pdr has remained the gold standard for last 30 years after monumental work of early treatment diabetic retinopathy study (etdrs). recently anti-vegf drugs have become the first line of treatment for csme11 and laser therapy remains an adjuvant therapy to save the frequent visits, whereas prp is still the first line of treatment for pdr12. anti-vegf before or along with prp are of added benefit in high risk cases of pdr13. this study was designed to show the visual outcome of various treatment modalities like laser application and intravitreal avastin (bevacizumab) injection as monotherapy or combined in patients with vtdr in our setup where follow up is poor14. material & methods this was a quasi experimental study with nonprobability convenient sampling carried out at diabetes eye clinic of al ibrahim eye hospital (aieh), isra postgraduate institute of ophthalmology, karachi from january 2016 to december 2017. all the patients with diabetes mellitus type 2 attending diabetic eye clinic of aieh were included in this study. those with cataract, glaucoma and advanced diabetic eye disease (aded) were excluded. every patient had best corrected visual acuity (bcva) recorded along with bio-microscopic examination of anterior segments and intraocular pressure using goldman tonometer. they were all screened with non mydriatic fundus camera (nmfc) taking one view of the posterior pole. the patients without dr were examined by a general ophthalmologist and diabetologist. patients with any dr or un-readable fundus photograph had dilated pupil examination with 90 d fundus lens. dr was graded according to international clinical diabetic retinopathy & macular edema disease severity scale.15 patients with non vision threatening diabetic retinopathy (nvtdr) were given a follow up date as per directions of royal college of ophthalmologist. 16 patients with vtdr (pdr and dme) were all considered for intervention. intervention advised was either monotherapy laser or intra-vitreal avastin injection at monthly interval, or both. patients with csme or vitreous hemorrhage (pdr) were given intra-vitreal avastin at monthly interval till the macular edema and hemorrhage were absorbed. it was then followed by modified grid laser for csme and prp for pdr. in dme patients with macular edema away from the fovea, patients were preferably treated with laser before anti vegf. follow up routine was according to the recommendations of royal collage of ophthalmologist.16 accordingly the patients receiving only laser application were advised three to four monthly follow-ups, whereas patients having intra-vitreal avastin injections alone or with laser were advised monthly follow-up, at least in the first year. on each follow-up visit, bcva on log mar, blood sugar level, lipids and bp were checked. hba1c was done in individuals with labile glycaemia. optical coherence tomography (oct) and fundus fluorescein angiography (ffa) were carried out on all patients requiring treatment. in the present study, the criteria for labeling improved, stable or worse visual outcome were single line improvement, no change or decrease on log mar chart. statistical analysis was done through statistical package for social sciences (spss) version 23.0. for continuous variable mean ± standard deviation were presented. qualitative variables were shown in frequency and percentages. to see the significance between treatment and visual acuity (improved, stable or worse) chi-square test was applied. the significance of pre & post visual outcome (log mar) was compared through paired sample t-test. the cut off value of p ≤ 0.05 considered to be statistically significant. results from january 2016 to december 2017, a total number of 11,027 patients with diabetes were registered in diabetic clinic. on screening these patient, 1988 were found to have dr (18.02%) and 586 had vtdr (5.3%). amongst the patients with vtdr, 108 (18.3%) had pdr, 382 (65.2%) had csme and 96 (16.3%) had aded. (table 1) patients with pdr and csme (490) were advised intervention which was accepted by 380 patients with 453 eyes. laser was done in 78 (17.2%) eyes, avastin injection was given in 340 (75.1%) eyes and combined treatments of intra-vitreal avastin and visual outcome of vision threatening diabetic retinopathy after various treatment modalities pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 38 argon laser were given in 35 (7.7%) eyes. over all bcva improved in 316 (69.8%) eyes, remained stable in 84 (18.5%) eyes and worsened in 53 (11.7%) eyes. (table ii). pre and post treatment bcva was noted in laser, avastin injection and combined treatment group. it was observed that laser group showed improvement in bcva from log mar 0.35 ± 0.23 to 0.24 ± 0.21. in avastin injection group improvement was from log mar 0.40 ± 0.24 to 0.23 ± 0.20. while in combined treatment, visual improvement was recorded from log mar 0.40 ± 0.24 to 0.20 ± 0.14. figure 1). when bcva was correlated with treatment modalities separately, laser group showed visual improvement in 45 (57.7%) eyes, stable in 18 (23.1%) eyes and worsened in 15 (19.2%) eyes. the avastin injection group showed visual improvement in 248 (72.9%) eyes, stable in 58 (17.1%) eyes and decrease in 34 (10%) eyes. while the group given combined treatment showed visual improvement in 23 (65.7%) eyes, stable in 8 (22.9%) eyes and worsened in 4 (11.4%) eyes with p-value < 0.0001 (table 3). table 1: patients attended aieh during the study period january 2016 to december 2017. description number percentage total eye patients in opd of aieh 225603 patient with diabetes 11027 4.80% dr detected 1988 18% vtdr in all diabetics 586 5.30% 5.3% in people with diabetes pdr, alone 108 5.4% of dr 0.979% in people with diabetes, (1.65% when pdr with csme s included) csme 382 (79 csme were associated with pdr) 19.2% of dr 3.464% in people with diabetes aded 96 16.30% 0.87% in people with diabetes intervention advised 96 + 110 = 206 out of 586 100% treatment accepted 380 persons (64.8) with 453 eyes 64.80% table 2: overall outcome of the treatment. bcva log mar (n = 453 eyes) n (%) improved 316 (69.8) stable 84 (18.5%) worse 53 (11.7%) total 453 *best corrected visual acuity (bcva) table 3: association beteween diagnosis, treatment and visual outcome. treatment bcva condition total improved stable worse laser csme 4 4 2 10 40.0% 40.0% 20.0% 100.0% csme with npdr 14 1 5 20 70.0% 5.0% 25.0% 100.0% csme with pdr 5 0 0 5 100.0% 0.0% 0.0% 100.0% pdr 22 13 8 43 51.2% 30.2% 18.6% 100.0% total 45 18 15 78 sidra shakil, et al 39 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology 57.7% 23.1% 19.2% 100.0% injection csme 40 13 8 61 65.6% 21.3% 13.1% 100.0% csme with npdr 133 26 12 171 77.8% 15.2% 7.0% 100.0% csme with pdr 34 15 10 59 57.6% 25.4% 16.9% 100.0% pdr 41 4 4 49 83.7% 8.2% 8.2% 100.0% total 248 58 34 340 72.9% 17.1% 10.0% 100.0% both laser and injection csme with npdr 7 0 2 9 77.8% 0.0% 22.2% 100.0% csme with pdr 12 3 0 15 80.0% 20.0% 0.0% 100.0% pdr 4 5 2 11 36.4% 45.5% 18.2% 100.0% total 23 8 4 35 65.7% 22.9% 11.4% 100.0% total csme 44 17 10 71 62.0% 23.9% 14.1% 100.0% csme with npdr 154 27 19 200 77.0% 13.5% 9.5% 100.0% csme with pdr 51 18 10 79 64.6% 22.8% 12.7% 100.0% pdr 67 22 14 103 65.0% 21.4% 13.6% 100.0% total 316 84 53 453 69.8% 18.5% 11.7% 100.0% table 4: comparison of visual acuity with different treatments. treatments pre visual acuity post visual acuity p-value laser 0.35 ± 0.23 0.24 ± 0.21 < 0.001 injection 0.40 ± 0.24 0.23 ± 0.20 < 0.001 both 0.40 ± 0.24 0.20 ± 0.14 < 0.001 *data presented in mean ± sd, visual acuity was noticed on log mar chart. *paired sample t-test was applied discussion this study showed that bcva in the laser group improved by one line or 5 letters (from 0.35±0.23 to 0.24 ± 0.21). avastin group showed improvement in bcva by two lines or 10 letters on log mar (from 0.40 ± 0.24 to 0.23 ± 0.20). visual acuity in combined group improved from 0.40 ± 0.24 to 0.20 ± 0.14 (2 lines or ten letters) same as monotherapy with anti-vegf group. the present study is in accordance with many studies in favor of anti-vegf. brucker et al17 and elman et al18 reported that results of anti vegf vs. prp in diabetic retinopathy have better visual acuity, less visual field loss and fewer surgical interventions in injection groups. adam et al19 and sivaparsad s et al20 has shown the superiority of anti vegf as the more effective treatment for preserving visual function associated with dr. present study differs from the international studies in loss of patients to follow up. adam & sivaparsad et al (the clarity trial)19,20 quoted 9% loss to follow up at 1 year. in the present study 69% were lost to follow up and only 31% individuals returned for follow-ups. out of those who attended, 43.7% attended once, 42.65% attended twice, 4.5% attended thrice, 6.8% attended four times while 2.1% came five times. this raises the question of cautious use of anti vegf alone as primary treatment. anti-vegf treatment needs multiple injections at monthly interval. at least three monthly injections and visual outcome of vision threatening diabetic retinopathy after various treatment modalities pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 40 then monthly follow up for assessing need of repeat injection or laser is indicated21. low follow up compliance mainly due to unawareness, affordability and accessibility in developing countries22,-24, makes monitoring of anti-vegf difficult. in pakistan, health service uptake is not more than 25%14. the ultimate result of anti-vegf may be better than laser alone; but it is only possible when patient can afford multiple injections and visits. in the light of this study the anti-vegf combined with laser will be better management of csme as well as pdr. with these considerations laser can be considered as first line of treatment in pdr without macular edema; but if the patient has csme alone or with pdr anti vegf can be the first line of treatment followed by laser. visual outcomes of vtdr after treatment with intra-vitreal avastin (bevacizumab) is superior to prp alone. keeping in view the loss to follow ups, we can suggest prp in pdr and 1-2 injections of anti-vegf followed by laser application in csme. however larger prospective studies are required to further evaluate the long term effects of these recommendation in halting the disease progression and extended improved visual outcomes. however regardless of whatever treatment is offered to the patient, it is mandatory to educate and adequately address the importance of regular follow-ups and medical compliance at patient’s end. it is important that the physician should keep in mind the costaffectivity and affordability of the patient without compromising the outcome of the treatment. conclusions visual outcome of avastin alone or combined with laser was found to be better than laser treatment alone in stabilizing the visual acuity in patients with vision threatening diabetic retinopathy. conflict of interest the authors declared that there is no conflict between authors. financial disclosure none. author’s affiliation sidra shakil senior registrar isra postgraduate institute of ophthalmology m. saleh memon director research/executive director isra postgraduate institute of ophthalmology prof. p s mahar frcs, frcophth professor & dean isra postgraduate institute of ophthalmology abdul fattah memon professor isra postgraduate institute of ophthalmology muhammad faisal fahin statistician isra postgraduate institute of ophthalmology seema n mumtaz consultant epidemiologist isra postgraduate institute of ophthalmology sikandar ali sheikh project manager isra postgraduate institute of ophthalmology author’s contribution sidra shakil conceive the study, manuscript writing. m. saleh memon manuscript writing, critical review. prof. p s mahar review the final manuscript and intellectual contribution. abdul fattah memon clinical evaluation and management of patients. muhammad faisal fahin statistical analysis and interpretation. seema n mumtaz review and final drafting of manuscript. sikandar ali sheikh data collection, study design and review. references 1. early treatment diabetic retinopathy study research group. photocoagulation for diabetic macular edema. early treatment diabetic retinopathy study report number 1. archives of ophthalmology, 1985; 103 (12): 1796– 1806. 2. yau jwy, rogers sl, kawasaki r, lamoureux el, kowalski jw, bek t et al. global prevalence and major risk factors of diabetic retinopathy. diabetes care, 2012; 35: 556–564. sidra shakil, et al 41 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology 3. jadoon mz, dineen b, bourne ra, shah sp, khan ma, johnson gj et al. prevalence of blindness and visual impairment in pakistan: the pakistan national blindness and visual impairment survey. investigative ophthalmol& vis sci. 2006; 47 (11): 4749-55. 4. groves n. diabetic retinopathy on the rise in pakistan, investigative ophthalmol& vis sci. 2006; 47 (11): 474955. 5. hakeem r, fawwad a. diabetes in pakistan: determinants and prevention. journal of diabetology, october, 2010; 1 (3): 1-13. 6. mumtaz sn, fahim mf, arslan m, shaikh sa, kazi u, memon ms. prevalence of diabetic retinopathy in pakistan: a systematic review. pak j med sci. 2018; 34 (2): 493-500. 7. uk prospective diabetes study group: intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes: ukpds 33. lancet. 1998; 352: 837–853. 8. uk prospective diabetes study group: efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: ukpds 39. br med j. 1998; 317: 713–720. 9. klein bek, moss se, klein r, surawicz ts. the wisconsin epidemiologic study of diabetic retinopathy, xiii: relationship of serum cholesterol to retinopathy hard exudate. ophthalmology, 1991; 98: 1261– 1265. 10. gordon b, chang s, kavanagh m, berrocal m, yannuzzil, robertson c et al. the effects of lipid lowering on diabetic retinopathy. am j ophthalmol. 1991; 112: 385–391. 11. bhagat n, grigorian ra, tutela a, zarbin ma. diabetic macular edema: pathogenesis and treatment. surv ophthalmol. 2009; 54 (1): 1-32. doi: 10.1016/j.survophthal.2008.10.001. 12. the diabetic retinopathy study research group. indications for photocoagulation treatment of diabetic retinopathy: diabetic retinopathy study report no. 14. int ophthalmol clin. 1987; 27: 239–253. 13. osaadon p, fagan xj, lifshitz t, levy j. a review of anti-vegf agents for proliferative diabetic retinopathy. eye (lond). 2014; 28 (5): 510–520. 14. alvi r, memon ms, shera s, mumtaz sn, shaikh sa, fahim mf. visual outcome of laser treatment in diabetic macular edema: study from an urban diabetes care center. pak j med sci. 2016; 32 (5): 1229-1233. doi: http://dx.doi.org/10.12669/pjms.325.10597 15. wilkinson cp, ferris fl, klien re, at al. proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales. ophthalmology, 2003; 110 (9): 1677-82. 16. ghanchi f. a summary and the diabetic retinopathy guidelines working group. the royal college of ophthalmologists' clinical guidelines for diabetic retinopathy, 2013; 27 (2): 285–287. 17. brucker aj, qin h, antoszyk an, et al. diabetic retinopathy clinical research network. observational study of the development of diabetic macular edema following panretinal (scatter) photocoagulation given in 1 or 4 sittings. arch ophthalmol. 2009; 127 (2): 132-140. 18. elman mj, aiello lp, beck rw, et al. diabetic retinopathy clinical research network. randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. ophthalmology, 2010; 117 (6): 1064-1077. 19. adam r. glassman, ms1. results of a randomized clinical trial of aflibercept vs. panretinal photocoagulation for proliferative diabetic retinopathy is it time to retire your laser? jama ophthalmol. 2017; 135 (7): 685-686. 20. sivaprasad s, prevost at,vasconcelos jc, riddell a, murphy c, kelly j et al. clinical efficacy of intravitreal aflibercept versus panretinal photocoagulation for best corrected visual acuity in patients with proliferative diabetic retinopathy at 52 weeks (clarity): a multicentre, single-blinded, randomised, controlled, phase 2b, non-inferiority trial. the lancet. 2017; 389 (10085): 2193–2203. 21. michaelides m, kaines a, hamilton rd. a prospective randomized trial of intravitreal bevacizumab or laser therapy in the management of diabetic macular edema (bolt study) 12-month data: report 2. ophthalmology, 2010; 117 (6): 1078–1086. 22. hakeem r, awan z, memon s, gillani m, shaikh sa, sheikh ma, et al. diabetic retinopathy awareness and practices in a low-income suburban population in karachi, pakistan. j diabetol. 2017; 8: 49-55. 23. memon ms, mumtaz sn, sheikh sa, fahim mf. community perception and service utilization of diabetic retinopathy management project in gaddap town. pak j ophthalmol. 2016; 32 (2): 70-77. 24. memon ms, shaikh sa, shaikh ar, fahim mf, mumtaz sn, ahamad n. an assessment of knowledge, attitude & practices (kap) towards diabetes & diabetic retinopathy in suburban town of karachi. pak j med sc. 2015; 3191): 183-188. http://dx.doi.org/10.12669/pjms.325.10597 https://www.ncbi.nlm.nih.gov/pubmed/?term=ghanchi%20f%5bauthor%5d&cauthor=true&cauthor_uid=23306724 microsoft word ziaul haq ansari.doc 144 original article relative distribution of refractive errors: an audit of retinoscopic findings muhammad zia-ul-haque ansari, abrar ali, adnan afaq, tabassum ahmed, khawaja sharif-ul-hassan pak j ophthalmol 2007, vol. 23 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: m. zia-ul-haque ansari department of ophthalmology baqai medical university karachi received for publication september’ 2006 …..……………………….. purpose: to observe the relative distribution of refractive errors in the mixed ethnic population of karachi and review the current concepts into the pathophysiology of refractive errors. material and methods: we retrospectively analyzed the retinoscopic findings of 1924 eyes of 962 patients presenting with refractive problems from january 1984 to december 1991 to determine their refractive status. refraction was performed objectively on all patients by one of us (ksh) using streak retinoscope. sphero-cylindrical method of refraction was used to minutely neutralize the reflex. subsequently, retinoscopic findings were subjectively verified. half-diopter cross cylinder was used to verify and refine the power and axis of any cylindrical lens. any error, stigmatic (spherical) or astigmatic (cylindrical), of ¼-diopter or more was considered an error and included in the analysis. result: astigmatism was the most common refractive error found in this retinoscopic analysis (914 of 1898 eyes; 48.16%) followed by myopia (894 of 1898 eyes; 47.10%) and hypermetropia (90 of 1898 eyes; 4.74%). myopic error (stigmatic and astigmatic myopia combined) comprised the largest group among the analyzed population (1554 of 1898 eyes; 81.88%) followed by hypermetropic error (stigmatic and astigmatic hypermetropia combined) (265 of 1898 eyes; 13.96%) and mixed error (mixed astigmatism) (39 of 1898 eyes; 2.05%). conclusion: myopia and myopic astigmatism were the major refractive errors found in the mixed ethnic population of karachi city in the age group from 1 to 40 years. efractive errors are a significant cause of visual impairment worldwide1. the most common cause of mild to moderate visual impairment observed in comparable surveys is uncorrected refractive error2. refractive errors are also a significant cause of morbidity besides having social and economic implications3. a refractive error, or ametropia, is an optical state wherein parallel rays of light passing through the optical media fail to converge on to the neurosensory retina when the eye is at rest4. in terms of optics, the second principal focus of an unaccommodated eye does not coincide with the retina5. ametropia results from an imbalance between the refractive power and the axial length of the eyeball6. the purpose of this article is to present clinic based audit of the refractive status of the ametropic mixed ethnic population of karachi and to review the current concepts into the pathophysiology of refractive errors. r 145 materials and methods we retrospectively analyzed the retinoscopic findings of 1924 eyes of 962 patients presenting with refractive problems to determine their refractive status. all patients were examined at a private clinic located in a medical complex in the central part of the city where patients of multiple ethnic origins used to report from different districts of karachi. records of patients seen from january 1984 to december 1991 were included in the analysis. refraction was performed objectively on all patients by one of us (ksh) using streak retinoscope. sphero-cylindrical method of refraction was used to minutely neutralize the reflex (one meridian was neutralized by spherical lens and the perpendicular meridian was neutralized by an appropriate cylindrical lens when required). subsequently, retinoscopic findings were subjectively verified. half-diopter cross cylinder was used to verify and refine the power and axis of any cylindrical lens. cycloplegic refraction, after instillation of atropine eye ointment for three days, was performed on all children less than 5 years of age. older children were refracted 40 to 60 minutes following topical instillation of 1% cyclopentolate eye drops twice at 5 to 10 minute interval. a complete adnexal and biomicroscopic anterior segment examination on slit-lamp was performed on all patients. fundus examination was also performed using direct ophthalmoscope. all efforts were made to exclude pathological causes of refractive errors from the audit. records of patients with any adnexal, anterior segment and posterior segment pathology were not included in the analysis; records of patients with pathological myopia were, therefore, also excluded. records of patients less than one year and more than forty years were also excluded. any error, stigmatic (spherical) or astigmatic (cylindrical), of ¼-diopter or more was considered an error and included in the analysis. results retinoscopic findings of 1924 eyes of 962 patients presenting with refractive problems were analyzed. the gender distribution of the 962 patients whose records were analyzed revealed a slight preponderance of males over the females as shown in (table 1). unfortunately, we were not been able to retrieve conclusive information about ethnicity of all the patients and it would not been possible for us to give a valid account of the ethnicity of the patients. however, we would not be far away from truth in postulating an almost equal proportion of patients belonged to the different ethnic groups residing in this cosmopolitan city of karachi, namely, punjabi, pathan, baloch, old sindhi and new sindhi, with probably a slight preponderance of new sindhis which constitute the majority of the city’s populace. table 2 summarizes the relative age distribution of the patients. age group >10 to 20 years comprised the largest group and consisted of 393 of 962 patients (40.85%). age group >20-30 years comprised the second largest group and consisted of 320 of 962 patients (33.26%). age group >30-40 years comprised the third largest group and consisted of 151 of 962 patients (15.70%). age group 1 to 10 years was the least populous group and consisted of only 98 of 962 patients (10.19%). bilateral ametropia was found in 1898 eyes of 949 patients (98.65%) while unilateral ametropia was found in 26 eyes of 26 patients (1.35%). right eye was emmetropic in 13 patients while left was emmetropic in the other 13 patients (table 3). table 1: gender distribution. male n (%) female n (%) total n(%) 549 (57.07) 413 (42.93) 962 (100) table 2: relative age distribution of the patients. age group (yrs) re n(%) le n(%) total n(%) 1 to 10 98 (10.19) 98 (10.19) 196 (10.19) >10 to 20 393 (40.85) 393 (40.85) 786 (40.85) >20-30 320 (33.26) 320 (33.26) 640 (33.26) >30-40 151 (15.70) 151 (15.70) 302 (15.70) total 962 (100) 962 (100) 1924 (100) table 4 summarizes the relative distribution of three major refractive errors in 1898 eyes with ametropia. astigmatism was the most common refractive error found in this retinoscopic analysis; of the 1898 eyes with ametropia, 914 eyes (48.16%) were astigmatic. myopia was also common and found in 146 894 of 1898 eyes (47.10%), while hypermetropia was the least common and found in only 90 of 1898 eyes (4.74%). table 3: bilateral vs unilateral ametropia. refractive status no. of patients n(%) no. of eyes n(%) bilateral ametropia 949 (98.65%) 1898 (98.65%) unilateral ametropia 13 (01.35%) 26 (01.35%) total 962 (100%) 1924 (100%) table 4: relative distribution of astigmatism, myopia, & hypermetropia. refractive status re n(%) le n(%) total n(%) astigmatism 462 (48.68) 452 (47.63) 914 (48.16) myopia 438 (46.16) 456 (48.05) 894 (47.10) hypermetropia 49 (05.16) 41 (04.32) 90 (04.74) total 949 (100) 949 (100) 1898 (100) table 5: relative distribution of myopic (combined stigmatic and astigmatic myopia), hypermetropic (combined stigmatic and astigmatic hypermetropia) and mixed error (mixed astigmatism). refractive status re (%) le (%) total (%) myopic error 795 (82.64) 799 (83.06) 1594 (84.00) hypermetropic error 131 (13.80) 134 (14.12) 265 (13.96) mixed error (mixed astigmatism) 23 (02.42) 16 (01.69) 39 (02.05) total 949 (100) 949 (100) 1898 (100) table 5 summarizes the relative distribution of myopic (stigmatic and astigmatic myopia combined), hypermetropic (stigmatic and astigmatic hypermetropia combined), and mixed error (mixed astigmatism). myopic error (stigmatic and astigmatic myopia combined) comprised the largest group among the analyzed population. of the 1898 ametropic eyes, myopic error (stigmatic and astigmatic myopia combined) was present in 1554 eyes (84%). hypermetropic error (stigmatic and astigmatic hypermetropia combined) was relatively less prevalent refractive error in the analyzed population and found in 265 of 1898 eyes with ametropia (13.96%). prevalence of mixed error (mixed astigmatism) was relatively rare in the analyzed population. of the 1898 ametropic eyes, mixed astigmatism found in only 39 eyes (2.05%). table 6 summarizes the relative distribution of different types of myopic error (stigmatic myopia, compound myopic astigmatism, and simple myopic astigmatism). among the patients with myopic error (stigmatic and astigmatic myopia combined), stigmatic myopia was the most common and found in 894 of 1594 eyes (56.09%). compound myopic astigmatism found in 583 of 1594 eyes (36.57%), while simple myopic astigmatism, which was the least common, found in 117 of 1594 eyes (7.34%) with stigmatic and astigmatic myopia combined. table 6: relative distribution of different types of myopic error (stigmatic myopia, compound myopic astigmatism, and simple myopic astigmatism). refractive status re n(%) le n(%) total n(%) stigmatic myopia 438 (55.10) 456 (57.07) 894 (56.09) compound myopic astigmatism 300 (37.74) 283 (35.42) 583 (36.57) simple myopic astigmatism 57 (07.16) 60 (07.51) 117 (07.34) total 795 (100) 799 (100) 1594 (100) table 7 summarizes the relative distribution of different types of hypermetropic error (stigmatic hypermetropia, compound hypermetropic astigmatism, and simple hypermetropic astigmatism). among the patients with hypermetropic error (stigmatic and astigmatic hypermetropia combined), compound 147 hypermetropic astigmatism was the most common and found in 160 of 265 eyes (60.38%). stigmatic hypermetropia found in 90 of 265 eyes (33.96%), while simple hypermetropic astigmatism, which was the least common, found in only 15 of 265, eyes (5.66%) with stigmatic and astigmatic hypermetropia combined. table 7: relative distribution of different types of hypermetropic error (stigmatic hypermetropia, compound hypermetropic astigmatism, and simple hypermetropic astigmatism). refractive status re n(%) le n(%) total n(%) compound hypermetropic astigmatism 77 (58.78) 83 (61.94) 160 (60.38) stigmatic hypermetropia 49 (37.40) 41 (30.60) 90 (33.96) simple hypermetropic astigmatism 5 (03.82) 10 (07.46) 15 (05.66) total 131 (100) 134 (100) 265 (100) discussion the world health organization (who) has grouped uncorrected refractive error with cataract, macular degeneration, infectious disease, and vitamin a deficiency among the leading causes of blindness and vision impairment in the world. ‘vision 2020’, a global initiative for the elimination of avoidable blindness by the who, also included refractive errors among the five conditions of immediate priority7. according to the national survey conducted by the ministry of health in collaboration with who during 1987-90 to determine the prevalence of different causes of blindness in the country, refractive errors were the third leading cause of preventable blindness in pakistan after cataract and corneal opacities8. in spite of extensive search of the local, regional and international literature we were unable to find a comparable audit of retinoscopic findings on ametropic patients. it is, therefore, not possible for us to compare our results and to find out any similarities or differences. most studies presented prevalence of refractive errors in a given population or a selected group of individuals. we would like to review the prevalence of refractive errors as presented by some of the recently conducted studies before giving a brief review of the current concepts into the most speculative and controversial topic of pathophysiology of refractive errors. the prevalence of astigmatism is high in infants. mohindra et al reported astigmatism of >1 d in about 50% of full-term infants9. the prevalence decline with age; howland et al reported about 15% prevalence of astigmatism of >1 d in adult population10. the prevalence of myopia and hypermetropia varies by country and by ethnic group. in baltimore, us study prevalence of myopia of -0.5 d or worse in a sample of 2659 whites aged 40 or above was 28.1% while it was 19.4% in 2200 blacks of same age group; the prevalence of hypermetropia of greater than +0.5 d was a little higher in both the groups11. in victoria, australia myopia of -0.5 d or worse was present in 16.9% among 4506 individuals aged 40 or above, while the prevalence of hypermetropia of greater than +0.5 d was greater than that of myopia in the same population12. in andhra perdesh, india the prevalence of myopia of -0.5 d or worse was 36.6% among 3588 individuals aged 40 or above; the prevalence of hypermetropia of greater than +0.5 d was almost identical13. in taiwan myopia of -0.25d or worse was present in 53.9% of 11,178 children 7 to 18 years of age14. prevalence of myopia is highest in singapore; 20% of children were myopic at 7 years at the start of their primary education, with prevalence exceeding 70% upon completing college education15. the prevalence of pathological myopia is estimated at 1 to 3% in population based studies16. genetic studies of families with a strong history of pathological myopia have uncovered two polymorphisms and two separate loci for high myopia, indicating an autosomal dominant predisposition for the development of pathological myopia17. at birth, most infants are 2 to 3 d hypermetropic. from approximately 6 years of age there is a gradual decrease in the amount of hypermetropia which continues through puberty18. this process, wherein the refractive state of children's eyes shifts in magnitude and reduces in variance to reach near emmetropia, is called emmetropisation. 148 genetic factors and environmental influences interact to determine the refractive status of an individual’s eyes. the prevalence of myopia in children with two parents with myopia is 30% to 40%, decreasing to 20% to 25% in children with one parent with myopia and to less than 10% in children with no parents with myopia; monozygotic twins tend to resemble each other in refractive error more than do dizygotic twins19-21. clinical and laboratory evidence strongly suggests that environment is as important as or more important than genetics. a study of the correlation between refractive error in parents and siblings showed stronger correlation than would be expected by chance22. a longitudinal prospective study conducted by zadnik et al showed that children with myopic parents, although not yet myopic themselves, tended to have longer eyes than children with non-myopic parents, resulting in a predisposition to becoming myopic later in life23. an analysis of the health interview survey revealed that individuals who read for long periods of time are more likely to have myopia24. a large-scale study of u.s. patients showed that the incidence of myopia increases with education. among 18 to 24 years with less than five years of schooling, only 3.1% were myopic as compared to 30% in the same age group with more than 12 years of education25. a study of eskimo volunteers from barrow, alaska showed that the prevalence of myopia was 8.4 percent among parents and 58 percent among children. this study also showed that no eskimos over the age of 51 were myopic. researchers observed that prior to 1947 this community only offered the first six grades of education. after 1947, children were required to attend through eighth and ninth grades. myopia in the group without compulsory education was 1.5% and in those with compulsory education were 40.3 %26. researchers in asia point to their rigorous schooling system and the long hours children spend studying as being responsible for the high rates of myopia in asia27-29. support for an important role for near work also comes from animal studies that have demonstrated the plasticity of refractive error in response to environmental stimuli. neonatal chicks, tree shrews, or monkeys experience increased ocular growth and become myopic or less hypermetropic after wearing minus lenses, presumably to compensate for the hyperopic defocus produced by these lenses30-33. hypermetropic defocus from a deficient accommodative response in juvenile myopes is theorized to be the connection between near work in human myopia and the minus lens results from animal studies34. this retinal blur initiates a biochemical process in the retina to stimulate biochemical and structural changes in the sclera and choroid that lead to axial elongation and myopia35. most probably, in children with a familial or ethnic predisposition to myopia the emmetropisation process continues, leading to mild myopia early in life. when they are exposed to myopiogenic factors, such as extensive near work, myopisation proceeds unchecked, causing further axial elongation and moderate myopia in late adolescence. additional myopiogenic factors such as extensive near work in secondary or postgraduate school or in an occupation can lead to higher degrees of myopia. we thought the process of emmetropization stops nearer to the customary working distance of an individual. in individuals who are not exposed to the environmental myopiogenic factors, especially extensive near work, the process of emmetropization stops at their customary far working distance and they stay nearer to emmetropia. on the other hand, individuals who are engaged in extensive near work and occupation requiring extensive near work achieve emmetropisation for their customary close working distance and become myopic for distance. therefore, it seems prudent to advice the parents to avoid prolonged near tasks for their children and encourage regular daily outdoor activity. this would probably help to minimize the role of accommodation and keep the process of myopization within limits. we would like to classify refractive errors as ‘primary’’, ‘secondary’ and ‘consecutive’ or ‘iatrogenic’. when refractive error is the only deficit in an otherwise normal eye it should be labeled as ‘primary’. on the other hand, refractive errors caused by ‘pathological alteration’ in the normal anatomical or structural parameters of any of the components of the eye or its adnexa should be categorized as ‘secondary’. table 8 summarizes some the causes of ‘secondary’ refractive errors. finally, refractive errors induced by surgical alterations of the normal anatomical, structural or refractive elements of the eye should be categorized as ‘consecutive’ or ‘iatrogenic’. table 9 summarizes some of the causes of ‘consecutive’ refractive errors. 149 table 8: some the causes of ‘secondary’ refractive errors. pathology secondary’ refractive error lid tumours/chalazion astigmatism pterygium astigmatism keratoconus myopic astigmatism kertoglobus / megalocornea myopia nanophthalmos hypermetropia microophthalmos hypermetropia buphthalmos myopia terrian’s marginal degeneration against the rule or oblique astigmatism pellucid marginal degeneration against the rule astigmatism corneal scarring irregular astigmatism cornea plana hypermetropia anterior lens displacement myopic error (stigmatic or astigmatic) posterior lens displacement hypermetropic error (stigmatic or astigmatic) sperophakia /lenticonus myopia nuclear sclerosis myopia choroidal tumour/ hypermetropia central serous chorioretinopathy (cscr) hypermetropia posterior staphyloma formation high (‘degenerative’) myopia silicone oil in an aphakic eye acts as a strong converging lens, causing high myopia. on the other hand, silicone oil in a phakic eye acts as a strong diverging lens by converting the convex posterior lens surface into a concave lens-silicone oil interface, inducing hypermetropia of 5 to 7 diopters. this division has clinical as well as psychological implications. ‘primary’ refractive errors reflect a physiological variation of the normal and their distribution in a population exhibit a symmetrical, bell-shaped, ‘guassian’ pattern like other characteristics such as height, weight, blood pressure, intraocular pressure and serum levels of haematological and biochemical substances. therefore, when the eye is otherwise normal, the error induced by this physiological variation should be considered normal and labeled as ‘primary’. it is quite reassuring for the patients or their parents when they come to know that the error of refraction they or their children have is the result of normal physiological variation rather than due to any defect or ‘weakness’ in the eyes. table 9: some of the causes of ‘consecutive’ refractive errors. cause consecutive refractive error cataract surgery stigmatic or astigmatic error air bubble in the anterior chamber hypermetropia vitreoretinal surgery (silicone oil) myopia or hypermetropia* encircling buckle myopia keratoplasty astigmatism refractive surgery: all types residual or induced stigmatic or astigmatic error iol power miscalculation residual or induced stigmatic or astigmatic error iol decenteration or tilt induced astigmatic error author’s affiliation dr. muhammad zia-ul-haque ansari assistant professor of ophthalmology baqai medical university, karachi dr. abrar ali professor of ophthalmology hamdard medical university, karachi dr. adnan afaq assistant professor of ophthalmology baqai medical university, karachi 150 dr. tabassum ahmad assistant professor of ophthalmology hamdard medical university, karachi professor khwaja sharif-ul-hasan professor & chairman department of ophthalmology baqai medical university, karachi reference 1. thylefors b, negrel ad, pararjasegaram r, et al. global data on blindness. bull world health organ. 1995; 73:115-21. 2. vannewkirk mr. the hong kong vision study: a pilot assessment of visual impairment in adults. trans am ophthalmol soc. 1997; 95: 715-49. 3. javitt jc, chiang yp. the socioeconomic aspects of laser refractive surgery. arch ophthalmol 1994; 112: 526-30. 4. duke-elder s. duke-elder’s practice of refraction, 9th edition, churchill livingstone inc, 1978; 29. 5. elkington ar, frank hj, greaney mj. clinical optics, 3rd edition, blackwell science ltd, 1999;.113. 6. mittelman d. geometric optics and clinical refraction. in principles and practice of ophthalmology, w b saunders company. 1980; 1: 197. 7. pararajasegaram r. vision 2020 the right to sight: from strategies to action. am j ophthalmol. 1999; 182: 359-60. 8. national committee for the prevention of blindness; ministry of health, special evaluation and social welfare, islamabad: five year plan, 1994-98; pakistan national programme for the prevention of blindness. p. 24 9. mohindra i, held r, gwajda j, brill s. astigmatism in infants. science. 1978; 202: 329-30. 10. howland hc, atkinson j, braddick o, et al. astigmatism measured by photorefraction. science. 1978; 202: 331-3. 11. tielsh jm, sommer a, witt k, et al. blindness and visual impairment in an american urban population: the baltimore eye survey. arch ophthalmol. 1990; 108: 286-90. 12. attebo k, ivers rq, mitchell p. refractive errors in an older population: the blue mountain eye study. ophthalmology. 1999; 106: 1066-72. 13. dandona l, dandona r, naduviath tj, et al. burden of moderate visual impairment in an urban population in southern india. ophthalmology. 1999; 106: 497-504. 14. lin ll, shih yf, tsai cb, et al. epidemiological study of ocular refraction among school children in taiwan in 1995. optom vis sci. 1999; 76: 275-81. 15. seet b, wong yy, tan dt, et al. myopia in singapore: taking a public health approach. br j ophthalmol. 2001; 85: 521-6. 16. vongphanit j, mitchell p, wang jj. prevalence and progression of myopic retinopathy in an older population. ophthalmology 2002; 109: 704-11. 17. young tl, ronan sm, drahozal la, et al. evidence that a locus for familial high myopia maps to chromosome 18p. am j hum genet genet 1998; 63: 109-19. 18. young tl, ronan sm, drahozal la, et al. evidence that a locus for familial high myopia maps to chromosome 18p. am j hum genet. 1998; 63: 109-19. 19. young tl, ronan sm, alvear ab, et al. a second locus for familial high myopia maps to chromosome 12q. am j hum genet. 1998; 63: 1419-24. 20. mittelman d. geometric optics and clinical refraction. in principles and practice of ophthalmology, w b saunders company. 1980, 1: 198. 21. ashton gc. segregation analysis of ocular refraction and myopia hum hered. 1985; 35, 232-9. 22. gwiazda j, thorn f, bauer j, et al. emmetropization and the progression of manifest refraction in children followed from infancy to puberty clin vis sci. 1993; 8: 337-44. 23. mutti, do, zadnik, k. the utility of three predictors of childhood myopia: a bayesian analysis vision res. 1995; 35: 1345-52. 24. teikari j, o'donnell j, kaprio j, et al. genetic and environmental effects on oculometric traits. optom vis sci. 1980; 66: 594-9. 25. zadnik k, satariano wa, mutti do, et al. the effect of parental history of myopia on children's eye size. jama. 1994; 271: 1323. 26. angle j, wissman da. age, reading, and myopia. am j optom physiol optics. 1978; 55: 302-8. 27. sperduto rd, seigel d, roberts j, et al. prevalence of myopia in the united states. arch ophthalmol. 1993; 101: 405-7. 28. young fa, leary ga, baldwin wr, et al. the transmission of refractive errors within eskimo families. am j optom physiol opt. 1969; 46: 676-85. 29. tay mth, au eong kg, ng cy, et al. myopia and educational attainment in 421, 116 young singaporean males ann acad med. 1992; 21:785-91. 30. au eong kg, tay th, lim mk. education and myopia in 110,236 young singaporean males singapore med j. 1993; 34: 489-92. 31. zhao j, pan x, sui r, et al. refractive error study in children: results from shunyi district, china am j ophthalmol. 2000; 129: 427-35. 32. irving el, sivak jg, callender mg. refractive plasticity of the developing chick eye ophthalmic physiol opt. 1992; 12: 448-56. 33. wildsoet, c, wallman, j. choroidal and scleral mechanisms of compensation for spectacle lenses in chicks vision res. 1995; 35: 1175-94. 34. siegwart jt, jr norton tt. regulation of the mechanical properties of tree shrew sclera by the visual environment vision res. 1999; 39: 387-407. 35. smith, el, iii, hung, lf. the role of optical defocus in regulating refractive development in infant monkeys vision res. 1999; 39: 1415-35. 36. gwiazda j, thorn f, bauer j, et al. myopic children show insufficient accommodative response to blur invest ophthalmol vis sci. 1993; 34: 690-94. microsoft word irfan shafiq 2.doc 87 original article comparison between central corneal thickness measurements obtained with orbscan ii topographer and ultrasonic pachymeter irfan shafiq, sharif hashmani pak j ophthalmol 2007, vol. 23 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irfan shafiq assistant professor department of ophthalmology, dow university of health sciences & civil hospital, karachi. received for publication june 2006 …..……………………….. purpose: to compare the central corneal thickness measurements obtained with orbscan ii scanning slit topographer and ultrasonic pachymeter in eyes undergoing corneal refractive surgery. material and methods: this non-interventional, observational comparative study was conducted in hashmanis eye hospital karachi. a total of 108 eyes evaluated for central corneal thickness measurement with orbscan ii scanning slit topographer and ultrasonic pachymeter that had undergone corneal refractive surgeries (lasik, lasek, prk). the average age of the patients was 29.85 years. result: the mean central corneal thickness (cct) was 537.44µm standard deviation (sd) ±27.31µm standard error mean (sem) ±2.63µm with orbscan ii scanning slit topographer and mean cct 542.04 µm sd ±26.35µm and sem ±2.54µm with ultrasonic pachymeter (p = 0.007). conclusion: the mean central corneal thickness (cct) from both devices was found not statistically significantly different from each other. achymetry is defined as measurement of corneal thickness and instrument used to measure corneal thickness is referred to as a pachymeter1. normal central corneal thickness is 490560 µm and corneal thickness is greatest at limbus2. measurement of thickness of cornea is very important for keratorefractive surgeries to avoid surgical complications3. corneal thickness is also an important factor to evaluate corneal barrier and endothelial pump function and in the diagnosis of corneal diseases4-6. ultrasonic pachymetry is currently the most commonly used technique to evaluate corneal thickness. recently, other sophisticated noncontact pachymetry instruments have been developed. the orbscan ii scanning slit topography (bausch and lomb, rochester, ny, usa) has multiple functions in the assessment of the cornea, including its thickness profile, anterior and posterior topography, elevation, and anterior chamber depth. the usefulness of this system has been reported previously7. pachymetry values obtained with orbscan ii topographer may differentiate early keratoconus and advanced keratoconus from keratoconus suspects and normal controls8. in ultrasound pachymetry an ultrasound probe applanates the cornea and measures corneal thickness when it is perpendicular to the posterior surface9. it requires a direct contact of the probe on to the cornea, which may increase the risk of infection and corneal epithelial damage. in addition, its accuracy is dependent on the perpendicularity of the probe application to the cornea and on precise probe p 88 placement on the corneal center10. orbscan pachymetry measures corneal thickness like manual ultrasound pachymetry but it is more repeatable, simpler to perform, non-invasive and returns a map of corneal thickness rather than a point measurement. it combines a slit scanning system and a placido disk (with 40 rings) to measure the anterior elevation and curvature of the cornea and the posterior elevation and curvature of cornea, it offers a full corneal pachymetry map with white to white measurements. orbscan pachymetry is able to acquire over 9000 data points in 1.5 seconds and measure anterior chamber depth, angle kappa, pupil diameter, simulated keratometry readings and the thinnest corneal pachymetry reading11. in this study, we compared central corneal thickness measurements in prekeratorefractive surgery eyes such as laser in-situ keratomileusis (lasik), laser sub-epithelial keratomileusis (lasek) and photorefractive keratectomy (prk) obtained with orbscan ii scanning slit topographer (bausch and lomb, rochester, ny, usa) and ultrasonic pachymetry (pocket ii pachymeter echo graph, quantel medical inc. usa). the purpose of this study was, to compare the central corneal thickness measurements obtained with orbscan ii scanning slit topographer and ultrasonic pachymeter in eyes undergoing corneal refractive surgery. material and methods the proposed study was a non-interventional study spanning over a period of 12 months from january 2005 to december 2005, conducted at hashmanis eye hospital, karachi. the object of this study was, to compare the central corneal thickness values from orbscan ii topographer and ultrasonic pachymeter. in this study central corneal thickness was evaluated in 108 eyes (54 right eyes, 54 left eyes) of 54 subjects (21 males and 33 females) who had undergone corneal refractive surgeries (lasik, lasek, prk). data was analyzed by spss software and we applied paired t-test for p value. the average age of patients was 29.85 years. there was no upper age limit in this study. patients below the age of 18 years were not included in this study. patients with clinically significant ocular pathologic conditions (e.g. keratoconus), dry eyes, underlying autoimmune vasculopathies (e.g. lupus, rheumatoid arthritis, polyarteritis nodosa etc.), systemic diseases known to effect corneal healing, functionally monocular vision, taking medication affecting wound healing such as steroids, unable to discontinue rigid contact lenses for a minimum of 4 weeks or soft contact lenses for 1 week before procedure were excluded from the study. informed consent was obtained form all patients. all eyes were examined with scanning slit topographer and ultrasonic pachymeter. for orbscan measurements, the patient’s chin was placed on the chin rest and the forehead was pressed against the forehead strap. the patient was asked to look at a blinking red fixation light. the examiner adjusted the optical head using a joystick to align and focus the eye so that the cornea was centered on the video monitor. the video image was then captured and measured anterior and posterior corneal elevation (relative to a best fit sphere), surface curvature and corneal thickness. pachymetry is determined by this instrument from the difference in elevation between the anterior and posterior surface of the cornea. this instrument averages pachymetry in nine circles of 2mm diameter that are located in the center of the cornea and at eight locations in the mid peripheral cornea (superior, superotemporal, temporal, inferotemporal, inferior, inferonasal, nasal, superonasal) each located 3mm form the visual axis. the orbscan corneal topography system also determines the thinnest point on cornea and marks its distance from visual axis and its quadrant location (superotemporal, inferotemporal, superonasal and inferonasal). for ultrasonic pachymetry, measurements were taken on the table before surgery. the cornea was anaesthetised with topical proparacaine hydrochloride 0.5% (alcain) and asked the patient to look at distant object. the sterilized probe was applied as perpendicular as possible on the central cornea and three consecutive measurements were made with pocket ii. the pocket ii uses the principle of sonar (pulsed ultrasound) to measure corneal thickness. the ultrasonic transducer makes contact with and transmits ultrasonic pulses through the surface of the cornea. echoes are returned from the anterior and posterior surfaces of the cornea. the system measures the time between returning echoes and using the known values of the velocity of sound in the corneas and calculates the thickness. 89 results out of 54 patients included in this study, 21 patients were males and 33 patients were females. the average age was 29.85 (sd ± 8.9) years, the mean age of male patients was 27.66 and the mean age of female patients was 31.24. a total number of 108 eyes were investigated using the orbscan ii corneal topography system and ultrasonic pachymeter the mean central corneal thickness (cct) was 537.44µm (sd ± 27.31µm) standard error mean (sem ± 2.63µm) with orbscan ii scanning slit topographer and mean cct 542.04 µm (sd ± 26.35µm) and sem ± 2.54µm with ultrasonic pachymeter. p value was 0.007. in this study 21 patients (42 eyes) were males, the mean cct was 539.69 µm with orbscan topographer and mean cct was 545.52 µm with ultrasonic pachymeter. 33 patients (66 eyes) were females the mean cct was 536.0 µm with orbscan topographer and the mean cct was 539.82 µm with ultrasonic pachymeter. the standard deviation (sd) and standard error mean (sem) between male and female patients obtained with orbscan ii topographer and ultrasonic pachymeter are summarized in table. we divided all the investigated patients into three groups. in the first group we examined 19 patients (38 eyes) the mean cct was 541.9µm with orbscan topographer and mean cct 549.2µm with ultrasonic pachymeter. in the second group we examined 20 patients (40 eyes) the mean cct was 530.35µm with orbscan topographer and mean cct 538.35µm with ultrasonic pachymeter. in the third group examined patients were 15 (30 eyes) and the mean cct was 541.2µm with orbscan topographer and mean cct 536.9µm with ultrasonic pachymeter. the standard deviation (sd) and standard error mean (sem) among different age groups patients are summarized in table. discussion corneal thickness can be evaluated by number of methods including ultrasonic pachymetry12-14, optical slit lamp pachymetry14, specular microscopy15, confocal microscopy16,17 and partial coherence interferometry18. each of these methods has different clinical advantages and disadvantages. discrepancies in optical pachymetry results can be obtained by different observers or with different instruments. ultrasonic measurement requires corneal contact and it is difficult to locate accurately the same points of measurements in serial examinations. this may result in large variation in corneal thickness measurement. the orbscan corneal topography system is a new device to evaluate corneal thickness by measuring the anterior and posterior corneal surfaces simultaneously. it provides both anterior and posterior corneal elevation maps as well as corneal thickness data. this system produces more information about corneal thickness than ultrasonic pachymeter because it evaluates corneal thickness across the entire corneal surface and yields corneal thickness in nine different locations of cornea. in our study, the mean central corneal thickness measured by obrscan ii scanning slit topographer was slightly lesser (no statistically significant difference observed) than the mean cct obtained by ultrasonic pachymetry, which agrees with the results as reported by touzeau o and associates19. table 1: the standard deviation (sd) and standard error mean (sem) between male & female and among different age group patients obtained with orbscan ii topographer and ultrasonic pachymeter. gender & age groups examined orbscan ii topographer ultrasonic pachymeter no. of patient no. of eyes mean (µm) sd (µm) sem (µm) mean (µm) sd (µm) sem (µm) male 21 42 539.69 22.56 3.48 545.52 25.79 3.98 female 33 66 536.00 30.02 3.70 539.82 26.67 3.28 18-25 years 19 38 541.90 33.3 5.41 549.20 27.20 4.42 26-35 years 20 40 530.35 26.63 3.74 538.35 24.54 3.88 36 & above 15 30 541.20 21.77 3.98 536.90 26.05 4.76 90 p= 0.007 fig. 1: orbscan ii scanning slit topographer (bausch and lomb, rochester, ny, usa) fig. 2: anterior best fit sphere (bfs) of left cornea from orbscan ii fig. 3: posterior best fit sphere (bfs) of left cornea from orbscan ii fig. 4: corneal thickness (pachymetry) of left eye from orbscan ii fig. 5: ultrasonic pachymeter (pocket ii 91 pachymeter echo graph, quante l medical inc. usa) 92 the pachymetry data in the present study is not consistent with previous report by yaylali and associates who reported that measurements of the corneal thickness with the orbscan system were 2328µm greater (statistically significantly different) than values obtained with ultrasonic pachymeter20. further studies are required to provide the exact relationship between orbscan ii scanning slit pachymetry and ultrasonic pachymeter conclusion the mean central corneal thickness (cct) from both devices was found to be not significantly different from each other but orbscan pachymetry is repeatable, simpler to perform, non-invasive and provides corneal thickness in nine different locations. author’s affiliation irfan shafiq assistant professor department of ophthalmology, dow university of health sciences & civil hospital karachi sharif hashmani consultant ophthalmologist hashmani hospital karachi reference 1. schwab ir, epstein rj, harris dj et al. clinical examination techniques. external disease and cornea. basic and clinical science course. sec 8. san francisco american academy of ophthalmology. 1996-97: 82. 2. kanski jj. cornea. clinical ophthalmology a systematic approach. 5th ed. london: butterworth-heineman. 2003: 100. 3. liu z, huang aj, pflugfelder sc. evaluation of corneal thickness and topography in normal eyes using the orbscan corneal topography system. br j ophthalmol 1999; 83: 774-8. 4. o'neal mr, polse ka. in vivo assessment of mechanism controlling corneal hydration. invest ophthalmol vis sci. 1985; 26: 849-56. 5. waring go 3d, bourne wm, edelhauser hf, et al. the corneal endothelium. normal and pathologic structure and function. ophthalmology 1982; 89: 531-90. 6. cheng h, bates ak, wood l, et al. positive correlation of corneal thickness and endothelial cell loss. serial measurements after cataract surgery. arch ophthalmol 1988; 106: 920-2. 7. lattimore mr, kaupp s, schallhorn s, et al. orbscan pachymetry: implications of a repeated measures and diurnal variation analysis. ophthalmology 1999; 106: 977–81. 8. azar dt, koch dd. preoperative considerations. lasik fundamentals, surgical techniques, and complications. new york: marcel dakker, inc. 2003: 153-62. 9. elkington ar, frank hj, greaney mj. instruments. clinical optics. 3rd ed. london: blackwell science ltd. 1999: 208-9. 10. kawana k, tokunaga t, miyata k, et al. comparison of corneal thickness mearsurments using orbscan ii, non-contact specular microscopy, and ultrasonic pachymetry in eyes after laser in situ keratomileusis. br j ophthalmol 2004; 88: 466-8. 11. buratto l, brint sf. lasik principles and techniques. usa: slack incorporated 1998: 151-66. 12. remon l, cristobal ja, castillo j, et al. central and peripheral corneal thickness in full-term newborns by ultrasonic pachymetry. invest ophthalmol vis sci 1992; 33: 3080-3. 13. argus wa. ocular hypertension and central corneal thickness. ophthalmology 1995; 102: 1810-12. 14. salz jj, azen sp, berstein j, et al. evaluation and comparison of sources of variability in the measurement of corneal thickness with ultrasonic and optical pachymeters. ophthalmic surg. 1983; 14: 750-54. 15. klyce sd, maurice dm. automatic recording of corneal thickness in vitro. invest ophthalmol. 1976; 15: 550-3. 16. lemp ma, dilly pn, boyde a. tandem-scanning (confocal) microscopy of the full-thickness cornea. cornea 1985; 4: 205-9. 17. petroll wm, roy p, chuong cj, et al. measurement of surgically induced corneal deformations using three dimensional confocal microscopy. cornea 1996; 15: 154-64. 18. hitzenberger ck, baumgartner a, drexler w, et al. interferometric measurement of corneal thickness with micrometer precision. am j ophthalmol. 1994; 118: 468-76. 19. touzeau o, allouch c, borderie v, et al. precision and reliability of orbscan and ultrasonic pachymetry. j fr ophthalmol. 2001; 24: 912-21. 20. yaylali v, kaufman sc, thompson hw. corneal thickness measurements with the orbscan topography system and ultrasonic pachymetry. j cataract refract surg. 1997; 23: 134550. trabeculectomy as such or with antimetabolites like mitomycin c is still the choicest procedure in open angle glaucomas. prof. m lateef chaudhry refractive results after cataract surgery using optical biometry 53 pakistan journal of ophthalmology, 2020, vol. 36 (1): 53-56 original article refractive results after cataract surgery using optical biometry mehvash hussain 1 , muhammad muneer quraishy 2 , muhammad akram 3 1,2 department of ophthalmology, dow medical college, 3 ruth k m pfau civil hospital, karachi abstract purpose: to assess the refractive outcome of optical biometry (nidek al-scan) after elective phacoemulsification in a study of 30 eyes. study design: descriptive case series. place and duration of study: elective cataract surgeries done at a private clinic from july 2015 to june 2016 were selected and their records were analyzed. material and methods: the measurements of iol calculation was done using optical biometry with partial coherence interferometry (nidek al-scan) that provides information about axial length, central keratometry, white to white diameter and anterior chamber anatomical depth. srk-t formula was used to calculate iol power. all patients underwent a complete ophthalmological examination. phacoemulsification with clear corneal incision of 2.75 mm was done and iol was implanted in the bag (alcon acrysof sn60wf iol and ma60ac iol). postoperative refraction was taken with autorefractor (huvitz hrk-7000) after 4 weeks and it was compared with preoperative objective refraction. comparison of k readings taken by al-scan and autorefractor were done. results: we studied 30 eyes of 23 patients who underwent elective cataract surgery with foldable iol. postoperative spherical equivalent was plano in 53% of cases with mean of -0.05 after 4 weeks postoperatively. the mean keratometric power using autorefractor was 44.4 d while with al-scan it was 44.7 d. there were no intraoperative complications or postoperative subjective complaints (such as halo or glare) in our patients. conclusion: intraocular lens power calculations done by optical biometry are easy to use, reliable and result in excellent refractive outcomes. ultrasound biometry may still be required in case of mature and dense posterior subcapsular cataract. key words: biometry, optical biometry, phacoemulsification, cataract. how to cite this article: hussain m, quraishy mm, akram m. refractive results after cataract surgery using optical biometry, pak j ophthalmol. 2020; 36 (1): 53-56. doi: https://doi.org/10.36351/pjo.v36i1.994 introduction most clinicians now use optical biometry for intraocular lens (iol) power calculations in their practice. optical biometry is a highly accurate noninvasive automated method for measuring the anatomical characteristics of the eye. correspondence to: mehvash hussain assistant professor of ophthalmology dow medical college email: mehvashh@hotmail.com accurate measurements are critical for determining the correct power of an iol before it is implanted during cataract surgery 1 . the process of measuring the various anatomical characteristics of the eye that are needed for iol power calculation is called ocular biometry. optical biometry with the al scan uses partial coherence interferometry to calculate iol power. it is highly accurate, easy to perform, noninvasive method and is comfortable for the patient. third-generation formulae, such as the srk/t and hoffer q use the axial length (al) and keratometry https://doi.org/10.36351/pjo.v36i1.994 refractive results after cataract surgery using optical biometry pakistan journal of ophthalmology, 2020, vol. 36 (1): 53-56 54 (k) values to predict iol power 2,3 . precise measurements of keratometric data and axial length are very important. the optical biometric method is more precise and reproducible compared to ultrasound measurement 4,5 . the advantages of optical compared with usb method are that it is easy to use, has reduced risks of trauma and infection, and is comfortable for the patient as well 6,7 . however, optical biometry is not accurate in eyes with mature or dense posterior sub-capsular cataracts and in certain macular diseases 8 . the purpose of the study was to find the refractive outcomes of optical biometry (nidek al-scan) after elective phacoemulsification. material and methods patients who underwent cataract surgery with foldable iol (alcon acrysof sn60wf iol and ma60ac iol) from 1 st july 2015 to 30 th june 2016 were selected. patients with history of any previous ocular surgery, a pterygium, corneal scarring, pre-existing astigmatism > 3.0 diopters (d), als < 22.0   mm or > 27.0  mm, previous contact lens use (within 4 weeks), severe dry eye, inflammatory disease of the eye, and/or systemic connective tissue disease were excluded. their preoperative and post-operative records were collected and analyzed. thirty cataractous eyes of 23 adult patients who underwent cataract surgery, with no history of any previous ocular surgery or laser, were selected. detailed ophthalmological examinations were performed in the following order: measurement of refractive error and k-readings by using autorefractor (huvitz hrk 7000), assessment of best-corrected visual acuity (bcva) using snellen’s acuity chart, slit lamp examination, optical biometric measurements with al-scan, intraocular pressure (iop) measurement using goldmann applanation tonometer and fundus examination using 90d lens was done. one surgeon performed all of the cataract surgeries using a 2.75  mm clear corneal incision on the steep axis with implantation of the iol in the bag. phacoemulsification was performed on the steep corneal axis, because surgically induced astigmatism was to be minimized. foldable iol was implanted in the bag. the a-constants used for iol power calculations with al-scan for the sn60wf and ma60ac were 118.9 and 118.6 respectively. to restrict the comparison of eyes, iol power calculations were performed only using the srk/t formula, which is universally accepted and suitable for als between 22.0 and 27.0  mm. the postoperative final objective refraction and kreadings were measured using autorefractor (huvitz hrk-7000) 4 weeks after cataract surgery. subjective refraction was evaluated at the same time. comparisons were performed in terms of objective refraction. k measurements of the al-scan were compared to autorefractor data. results we studied 30 eyes of 23 patients (16 right and 14 left eyes) who underwent phacoemulsification. mean age was 62.4 years with the youngest patient being 36 years old while the maximum age was 85 years. males were 56.6% while females were 43.3%. data analysis showed that the mean post-operative spherical equivalent was plano in 53% of cases. with mean spherical equivalent -0.05. the keratometric power was compared between autorefractor and al-scan. the mean power by autorefractor was 44.4 d while with al-scan it was 44.7 d. there were no intraoperative complications or postoperative subjective complaints (such as halo or glare) in our patients. graph 1: gender and eye distribution discussion accurate iol power calculation is very important for attainment of patient satisfaction after cataract surgery 9,10,11 . residual refractive error after the surgery is a major cause of dissatisfaction and may require iol explantation 9 . the main causes of inaccuracy in biometry are k errors and incorrect al determination 10 . hussain m, et al 55 pakistan journal of ophthalmology, 2020, vol. 36 (1): 53-56 currently, al measurement using optical biometry is regarded to be the most accurate 11 . however, in cases with dense cataracts, usb is more successful 12 . the al-scan is a noncontact optical biometer using an 830   nm superluminescent diode as a light source. the device is very fast, measuring 6 different parameters within a few seconds: al, corneal curvature radius, anterior chamber depth (acd), central corneal thickness (cct), pupil size, and whiteto-white distance (wtw). the device employs the partial coherence laser interferometry to measure al within the range 14 to 40  mm. the system incorporates 3-dimensional autotracking and autoshot features for ease of use in practice. the scheimpflug principle is used for measurement of acd and cct. corneal power is determined by keratometry at 2.4 and 3.3 mm diameter circles. the 2.4-mm circle data are used to calculate iol power. in usb, power is calculated by measuring the time delay of the sound wave echo received from the corneal surface and the internal limiting membrane. in contrast in optical biometry laser light is reflected from the retinal pigment epithelium 13,14 . several studies have compared the refractive outcomes yielded by earlier optical devices with those afforded by usb, mainly in the context of iol calculations. these studies found that optical devices gave more reliable results than usb method 15,16 . there is a very high reproducibility between the axial length measurements by iol master and usb in normal eyes (r  =   0.985; p  =   0.001) 17 . the al measurements by lenstar which is one of the earlier biometers also gives more reliable results than those of usb 18 . several studies have shown that the repeatability and reproducibility of al-scan was excellent in terms of all parameters, except the wtw and pd. excluding wtw, similarity was found between the al-scan and iol master results 19 . another study also found that the repeatability and reproducibility of both devices were high for all ocular biometry measurements tested (icc = 0.87–1.00). except for the wtw and corneal diameter (icc = 0.44), the extent of agreement between the 2 instruments was high (icc = 0.98– 0.99) 20 . the mean absolute error (mae) in terms of iol power prediction was 0.42   ±   0.08 d with the al-scan 21 . a study undertaken previously showed that the repeatability and reproducibility of al-scan is excellent in terms of all parameters, except the wtw and pd and compares favorably with the iol master 22 . another study also found that the repeatability and reproducibility of both devices were high for all ocular biometry measurements tested except for the wtw corneal diameter 23 . both these studies also showed that the iol power calculation was similar with the al-scan and iol master. the limitation of our study was that the small sample size but other studies done on al-scan measurements have shown similar results making it an excellent choice for iol calculations. conclusion intraocular lens power calculations done by al-scan are easy to use, reliable and result in excellent refractive outcomes. since minimum expertise is required to use al-scan, technicians can easily perform it. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest authors’ designation and contribution mehvash hussain; assistant professor: study design, manuscript writing, final review. muhammad muneer quraishy; professor: data collection, analysis, final review. muhammad akram; senior medical officer: study design, manuscript writing, final review. references 1. wang j-k, hu c-y, chang s-w. intraocular lens power calculation using the iol master and various formulas in eyes with long axial length. j cataract refract surg 2008; 34 (2): 262–7. 2. hoffer kj. the hoffer q formula: a comparison of theoretic and regression formulas. j cataract refract surg. 1993; 19 (6): 700–12. 3. sanders dr, retzlaff ja, kraff mc, gimbel hv, raanan mg. comparison of the srk/t formula and other theoretical and regression formulas. j cataract refract surg. 1990; 16 (3): 341–6. 4. findl o, drexler w, menapace r, heinzl h, hitzenberger ck, fercher af. improved prediction https://www.ncbi.nlm.nih.gov/pubmed/?term=sanders%20dr%5bauthor%5d&cauthor=true&cauthor_uid=2355322 https://www.ncbi.nlm.nih.gov/pubmed/?term=retzlaff%20ja%5bauthor%5d&cauthor=true&cauthor_uid=2355322 https://www.ncbi.nlm.nih.gov/pubmed/?term=kraff%20mc%5bauthor%5d&cauthor=true&cauthor_uid=2355322 https://www.ncbi.nlm.nih.gov/pubmed/?term=gimbel%20hv%5bauthor%5d&cauthor=true&cauthor_uid=2355322 https://www.ncbi.nlm.nih.gov/pubmed/?term=raanan%20mg%5bauthor%5d&cauthor=true&cauthor_uid=2355322 refractive results after cataract surgery using optical biometry pakistan journal of ophthalmology, 2020, vol. 36 (1): 53-56 56 of intraocular lens power using partial coherence interferometry. j cataract refract surg. 2001; 27 (6): 861–7. 5. goel s, chua c, butcher m, jones ca, bagga p, kotta s. laser vs. ultrasound biometry-a study of intra and interobserver variability. eye, 2004; 18 (5): 514–8. 6. rose lt, moshegov cn. comparison of the zeiss iolmaster and applanation a-scan ultrasound: biometry for intraocular lens calculation. clin exp ophthalmol. 2003; 31 (2): 121–4. 7. németh j, fekete o, pesztenlehrer n. optical and ultrasound measurement of axial length and anterior chamber depth for intraocular lens power calculation. j cataract refract surg. 2003; 29 (1): 85–8. 8. tehrani m, krummenauer f, blom e, dick hb. evaluation of the practicality of optical biometry and applanation ultrasound in 253 eyes. j cataract ref surg. 2003; 29 (4): 741–6. 9. mamalis n. complications of foldable intraocular lenses requiring explantation or secondary intervention: 1998 survey. j cataract refract surg. 2000; 26 (5): 766–772. 10. jin gj, crandall as, jones jj. intraocular lens exchange due to incorrect lens power. ophthalmology, 2007; 114 (3): 417–424. 11. chen y-a, hirnschall n, findl o. evaluation of 2 new optical biometry devices and comparison with the current gold standard biometer. j cataract refract surg. 2011; 37 (3): 513–517. 12. prinz a, neumayer t, buehl w, kiss b, sacu s, drexler w, findl o. influence of severity of nuclear cataract on optical biometry. j cataract refract surg. 2006; 32 (7): 1161–65. 13. raj ps, ilango b, watson a. measurement of axial length in the calculation of intraocular lens power. eye, 1998; 12 (pt 2): 227–9. 14. aktas s, aktas h, tetikoglu m, sagdk hm, özcura f. refractive results using a new optical biometry device: comparison with ultrasound biometry data. medicine, 2015; 94 (48): e2169. 15. buckhurst pj, wolffsohn js, shah s, naroo sa, davies ln, berrow ej. a new optical low coherence reflectometry device for ocular biometry in cataract patients. br j ophthalmol. 2009; 93 (7): 949–953. 16. jasvinder s, khang tf, sarinder kks, loo vp, subrayan v. agreement analysis of lenstar with other techniques of biometry. eye, 2011; 25 (6): 717– 24. 17. németh j, fekete o, pesztenlehrer n. optical and ultrasound measurement of axial length and anterior chamber depth for intraocular lens power calculation. j cataract refract surg. 2003; 29 (1): 85–8. 18. goel s, chua c, butcher m, jones ca, bagga p, kotta s. laser vs. ultrasound biometry-a study of intra and interobserver variability. eye, 2004; 18 (5): 514–8. 19. huang j, savini g, li j, lu w, wu f, wang j, et al. evaluation of a new optical biometry device for measurements of ocular components and its comparison with iol master. br j ophthalmol. 2014; 98 (9): 1277– 81. 20. srivannaboon s, chirapapaisan c, chonpimai p, koodkaew s. comparison of ocular biometry and intraocular lens power using a new biometer and a standard biometer. j cataract refract surg. 2014; 40 (5): 709–715. 21. kaswin g, rousseau a, mgarrech m, barreau e, labetoulle m. biometry and intraocular lens power calculation results with a new optical biometry device: comparison with the gold standard. j cataract refract surg. 2014; 40 (4): 593–600. 22. mandal p, berrow ej, naroo sa. validity and repeatability of the aladdin ocular biometer. br j ophthalmol. 2014; 98 (2): 256–258. 23. salouti r, nowroozzadeh mh, zamani m, ghoreyshi m, khodaman ma, comparison of horizontal corneal diameter measurements using the orbscan iiz and pentacam hr systems. cornea, 2013; 32 (11): 1460–1464. .…  …. http://www.ncbi.nlm.nih.gov/pubmed/?term=jones%20ca%5bauthor%5d&cauthor=true&cauthor_uid=15131684 http://www.ncbi.nlm.nih.gov/pubmed/?term=bagga%20p%5bauthor%5d&cauthor=true&cauthor_uid=15131684 http://www.ncbi.nlm.nih.gov/pubmed/?term=kotta%20s%5bauthor%5d&cauthor=true&cauthor_uid=15131684 http://www.ncbi.nlm.nih.gov/pubmed/?term=dick%20hb%5bauthor%5d&cauthor=true&cauthor_uid=12686242 http://www.ncbi.nlm.nih.gov/pubmed/?term=prinz%20a%5bauthor%5d&cauthor=true&cauthor_uid=16857503 http://www.ncbi.nlm.nih.gov/pubmed/?term=neumayer%20t%5bauthor%5d&cauthor=true&cauthor_uid=16857503 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http://www.ncbi.nlm.nih.gov/pubmed/?term=kotta%20s%5bauthor%5d&cauthor=true&cauthor_uid=15131684 microsoft word editorial 1 editorial off the label not uncommon in the field of medicine including ophthalmology since a long while there has been a practice to use an approved drug for an indication not approved by the regulating authorities i.e. off the label use. this trend is becoming more wide spread in ophthalmic practice all over the world like the use of intravitreal: • antibiotics (for prevention and cure of endophthalmitis) • steroids (triamcilone acctonide for situations like venous occlusions, uveitis, diabetic macular edema etc) • anti hiv drugs as injections or slow release inserts • various gases and temponading materials and chemo therapeutic adjuncts like 5fu with heparin during vitreo-retinal surgery. • lately the rampant use of avastin (an anti v.e.g.f. branded as magic drug for varculopathic conditions like s.m.d, diabetic retinopathy, rubiosis iridis and similar other conditions. we have also been using many off the label other drugs routinely for example mitomycin and 5fu in glaucoma filtering surgery, during pterygium operations and refractive surgery procedures like p.r.k. etc. when approved therapy fails or is not affordable, the use of off the label drugs as salvage therapy makes it a standard of care, gradually adopted as primary therapy and after a while is even thought off as legal and necessary part of medical practice. all said and done still it does not absolve us of liabilities and we should be reasonably certain in good faith about its efficacy and benefits with no serious risks to our patients. let us reemphasize that the sole purpose of the use of the off the label drugs is to benefit our patients suggested by its reported wide spread use by reasonable number of pioneers and colleagues, having been also recommended during conferences, presentations, writings and clinical trials. we should pay special attention to proven indications, recommended concentrations and dosage, route of administration with due precautions, all the time remaining vigilant about any adverse effects. m lateef chaudhry editor in chief pakistan journal of ophthalmology 215 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol editorial choosing the correct visual field test for routine glaucoma diagnosis and management rashid zia pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . laucoma, is a group of conditions characterized by optic disc cupping and visual field defects. evaluation, staging and monitoring of glaucoma requires a series of functional tests which is a time consuming process. so far, standard automated perimetry (sap) is recognized as a reference standard for all the functional testing1. glaucoma may present with a structural or a functional change. therefore, the correct test strategy for diagnosis is vital to prevent overlooking the onset of glaucoma2. assessment of functional loss in glaucoma is traditionally done by static automated perimeter, most commonly humphrey visual field analyzer. routinely 24-2 or 30-2 sita patterns are widely employed strategies. there is a positive predictive value of each location in 24-2 test pattern for the detection of glaucomatous visual field loss. according to wang et al 95% of visual field defects could be identified with only 30 of the 52 test locations. they determined that only 43 test locations were required to detect all visual field defects in the database3. the national institute of health and care excellence (nice) guidelines were updated in november 2017 to better achieve appropriate diagnosis and management of primary open angle glaucoma (poag) patients4. the nice guidelines, recommend central visual field assessment using standard automated perimetry (full threshold or supra-threshold) as a major criteria in both the diagnosis and the monitoring of primary open angle glaucoma4. however, recent evidence provides various challenges to the above mentioned algorithms. thirty percentage of the ganglion cells of the entire retina, corresponding to over 60% of the visual cortex are expressed in the central 10-degrees of the visual field5. changes or the visual field defects in the central 10 degrees are not fully assessed in the 24-2 test because the total number of points tested within the central 9 degrees is only 4 plus the foveal sensitivity. in contrast, the 10-2 visual field test has 68 test points each separated by only 2 degrees in the central 10 degrees of visual field. thus, it is more reliable to detect the presence and progression of the paracentral visual field defects. recommendations by the world glaucoma association consensus series are: (a) “threshold algorithms are preferred over supra threshold for glaucoma diagnosis. suprathreshold algorithms can be helpful in cases of unreliable results from threshold algorithms6. and (b) “using the 10-2 strategy in addition to the conventional 24-2 humphrey grid can improve the detection of central functional loss”7. it is important to detect and monitor central and paracentral visual field loss because early, even initial macular field loss occurs in some patients7. studies have shown that 16% of the normal 24-2 hemifield tests were actually abnormal when tested with 10-2 algorithm8. having said that the 10-2 algorithm is not able to detect the more peripheral field defects. however, it was also shown that by adding 4 points from the 10-2 test pattern to the 24-2 test pattern resulted in better detection of macular defects9. chen et al showed that if two points were added to the superior macular region of the humphrey 24-2 pattern, it increased the number of abnormal locations g choosing the correct visual field test for routine glaucoma diagnosis and management pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 216 in individuals with glaucoma10. thus, clinicians should be aware of the limitations of the 24-2 in the presence of suspicious discs and „normal‟ visual fields11. carl ziess has developed a 24-2 test augmented with additional points from 10-2 as suggested by ehrilch et al12 called sita faster 24-2c. this software upgrade is available for only new humphery machines i.e. hfa3. the sita faster 24-2c test pattern showed an enhanced sensitivity to detect visual field loss in the central 10 degrees over the sita fast 24-2 pattern. the increased total and pattern deviation flagging of the 10 additional sita faster 24-2c points corresponded to the flagging of the same points tested on the sita fast 10-2 test. the sita faster 24-2c test may offer earlier detection of central visual field loss without the need to run a supplementary 10-2 test for some patients. similar facility is also available in g programme by octopus perimeter (haag striet, gmbh). references 1. diagnosis of primary open angle glaucoma; the 10th consensus report of the world glaucoma association; vison function: consensus statements 1 pp 21; 2016 ©kugler publications. 2. diagnosis of primary open angle glaucoma; the 10th consensus report of the world glaucoma association; vison function: consensus statements 9 pp 22; 2016 ©kugler publications. 3. wang y, henson db. diagnostic performance visual field test using subsets of 24-2 test pattern for early glaucomatous field loss. invst ophthalmol vis sci. 2013; 54 (1): 756-761. 4. national institute for health and care excellence. diagnosis and management of chronic open angle glaucoma and ocular hypertension. national institute for health and care excellence, 2017: 5. schira mm, wade ar, tyler cw. two dimential mapping of the central and parafoveal visual field to human cortex. j neurophysiol. 2007; 97 (6); 4282-4295. 6. traynis i, de moraes cg raza as, liebmann jm, ritch r, hood dc. prevalence and nature of early glaucomatous defects in the central 10 degrees of visual field jama ophthalmol. 2014; 132 (3): 291-297. 7. rao hl, begum vu, khada d, mandal ak, senthil s, garudadri sh. comparing glaucoma progression on 24-2 and 10-2 visual field examination plos one, 2015; 10 (5); e0127233. 8. chen s, mckendrick am, turpin a. choosing two points to add to the 24-2 pattern to better describe macular visual field damage due to glaucoma. the british journal of ophthalmology, 2015; 99 (9): 1236-9. 9. heijl a, lundqvist l. the frequency distribution of earliest glaucomatous visual field defects documented by automatic perimetry. acta ophthalmol (copenh). 1984; 62 (4): 658-64. 10. traynis i, de moraes cg, raza as, liebmann jm, ritch r, hood dc. prevalence and nature of early glaucomatous defects in the central 10 degrees of the visual field. jama ophthalmol. 2014; 132 (3): 291-7. 11. hood dc, moraes cg. four questions for every clinician diagnosing and monitoring glaucoma. j glaucoma, 2018 jun 18. 12. ehrlich ac, raza as, ritch r, hood dc. modifying the conventional visual field test pattern to improve the detection of early glaucomatous defects in the central 10 degrees. translational vision science & technology, 2014; 3 (6): 6. author’s affiliation mr. rashid zia lead ophthalmologist new hayesbank ophthalmology services; ashford kent, uk email: rashidzia@nhs.net https://www.ncbi.nlm.nih.gov/pubmed/?term=hood%20dc%5bauthor%5d&cauthor=true&cauthor_uid=29917000 https://www.ncbi.nlm.nih.gov/pubmed/29917000 https://www.ncbi.nlm.nih.gov/pubmed/29917000 https://www.ncbi.nlm.nih.gov/pubmed/29917000 pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 139 original article analysis of rnfl thickness among different refractive states using oct safa omer wd haj hamed, nuha mohamed fath elrahman, manzoor ahmad qureshi, abd elaziz mohamed elmadina, muhammad ijaz ahmad pak j ophthalmol 2019, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. muhammad ijaz ahmad fcps (corresponding author) assistant professor ophthalmology, qassim medical university, saudi arabia e-mail: dejazbhatti@gmail.com …..……………………….. purpose: to measure the retinal nerve fiber layer (rnfl) thickness in myopic and hyperopic eyes and to compare it with emmetropic control eyes by optical coherence tomography. study design: cross sectional comparative study. place and duration of study: done in makka eye complex alkalakla, sudan, from may to november 2017. material and methods: in this study 150 participants (300 eyes) of myopia, hypermetropia and emmetropia were recruited and arranged in three groups having 50 cases each. myopia and hypermetropia greater than 2.00 d, and emmetropia (+0.50 to -0.50 d) were recruited. the participants were 15-30 years old and they were free from ocular disease and had not undergone any surgery. objective refraction by auto refractor and corrected visual acuity by snellen projector chart was checked. rnfl thickness was measured by oct. results: the nerve fiber layer thickness mean in myopic (92.32 ) group was significantly different from hyperopic (102.12 ) and emmetropic (98.80 ) groups. after applying anova test the difference between the myopes against hypermetropes, and myopes against emmetropes were found statistically significant (p < 0.05) as compared to hypermetropes against emmetropes (p = 0.152). the mean values of rnfl thickness were thinner in nasal, temporal, superior and inferior in myopes than hypermetropes and were statistically significant (p < 0.05). but the mean value of rnfl thickness of temporal and superior part was thicker in emmetropes than hypermetropes. conclusion: the rnfl thickness was found thinner in myopic participants as compared to hyperopic and emmetropics. keywords: retinal nerve fiber layer, optical coherence tomography, refractive error. ptical coherence tomography (oct) is noncontact and non-invasive device which provides real time cross-sectional images of the retina and an underlying sub retinal tissues, which are helpful to diagnose and manage different retinal diseases and glaucoma1. the oct performs on the principle of interferometry, where the device works as an optical biopsy by using reflected light to determine the interface between different ocular tissues and produces a cross-sectional image for tissue of interest. because rnfl is a highly reflective layer due to the distinctive perpendicular arrangement of nerve fibers in relation to the direction of the oct light beam1,2. the retinal nerve fiber layer is the most susceptible tissue which gets damaged in glaucoma patients leading to visual field loss3,4. for the diagnosis of early glaucoma, one requires accurate and reliable o mailto:dejazbhatti@gmail.com safa omer wd haj hamed, et al 140 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology measurement of rnfl thickness, as well as adequate knowledge of the normal values of the rnfl thickness and optic disc arrangement in normal subjects. the thickness of the rnfl is affected by age, gender, axial length, optic disc size, and refractive error of the eye512 and is also affected by ethnicity and race13. the rnfl thickness may be affected by different refractive errors and it may be relevant for the inspection of perceptual processes by studying the effect that is used in the diagnosis of glaucoma and other optic nerve disorders including the follow-up. this discrepancy is important when rnfl loss is observed during the disease process. therefore, this study was carried out to scrutinize rnfl thickness, in different refractive states among sudanese. material and methods in this cross sectional comparative study, 150 participants (300 eyes) having myopia, hypermetropia and emmetropia were recruited from makka eye complex alkalakla and arranged 50 in three groups of 50 each. the participants were free from ocular disease and had not undergone any surgery. myopia and hypermetropia greater than 2.00 d and emmetropia (+0.50 to -0.50 d) was considered for study with age range from15-30 years. the objective refraction was determined in both eyes using auto-refractometer (version ar 510a. nidek), whereas visual acuity was obtained by projector snellen vision chart (version cp-77o nidek). all the three groups underwent retinal nerve fiber layer thickness measurement using spectral domain oct in the four quadrants (cirrus hd oct, model 5000, zeiss, germany). data analysis was done by using statistical package for social sciences (spss). anova test was used to find statistical significance and the p-value of < 0.05 was chosen to be statistically significant. results in this study 300 eyes of 150 individuals were arranged in three groups of different refractive states. the age ranged from 15-30 years in both gender. the mean refractive error (se) of myopic, hypermetropic and emmetropic group was – 4.8300 (std. d ± 2.95737), +5.1550 (std. d ± 3.15900), .1400 (std. d ± .35771) respectively and the mean age of the participants was 21.87 years as shown in (table 1 & 2). the mean value of rnfl thickness was found thinner in myopic (92.32 ) participants as compared to hypermetropic (102.12 ) and emmetropics (98.80 ). all the details are given in (table: 3, fig. 1). as per anova test as shown in (table 4), the mean value differences between the myopes against hyperopes, and myopes against emmetropes were statistically significant (p < 0.05) as compared to hypermetropes against emmetropes (p= 0.152). the quadrantic assessment for different retinal sectors was evaluated further in anova test and found that the mean value of rnfl thickness was thinner in nasal, temporal, superior and inferior in myopes compared to hypermetropes and was statistically significant (p < 0.05). but the mean value of rnfl thickness of temporal and superior part was more in emmetropes compared to hypermetropes as shown in (table 5). table 1: refractive error in different groups. refractive state mean std. deviation minimum maximum myope -4.83002.95737 -16.50-2.25 hypermetrope +5.1550 3.15900 1.75 17.00 emmetrope -.1400.35771 -.50.50 table 2: mean ages of different groups. refractive state mean std. deviation minimum maximum myope 22.14 5.334 15 30 hypermetrope 20.98 4.736 15 30 emmetrope 22.42 4.554 15 29 total 21.85 4.893 15 30 analysis of rnfl thickness among different refractive states using oct pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 141 table 3: distribution of retinal nerve fiber layer thickness average ( ) according to refractive state. refractive state mean std. n myope 92.32 10.127 50 hypermetrope 102.12 15.285 50 emmetrope 98.80 7.936 50 total 97.75 12.163 150 table 4: comparison of retinal nerve fiber layer thickness average mean ( ) according to refractive state. refractive state pvalue myope vs. hypermetrope 0.000 myope vs. emmetrope 0.006 hypermetrope vs. emmetrope 0.152 fig. 1: retinal nerve fiber layer thickness average ( ) based on refractive state. table 5: rnfl thickness means (µ) of different quadrants in three groups. refractive state average nasal temporal superior inferior myope 92.32 ± 10.13 68± 15.93 66 ± 10.80 114.16 ± 16.02 121.56 ± 20.27 hypermetrope 102.12 ± 15.29 82.22 ± 18.60 67.94 ± 10.10 122.4 ± 32.69 135.82 ± 21.25 emmetrope 98.80 ± 7.94 71.46 ± 10.98 70.14 ± 13.21 126.62 ± 13.93 123.46 ± 20.24 all errors 97.75 ± 12.16 73.89 ± 16.54 68.31 ± 11.46 121.06 ± 22.95 126.95 ± 21.42 discussion measurement of retinal nerve fiber layer thickness is essential for early diagnosis of glaucoma, because the thinning of the retinal nerve fiber layer would be the earliest clinically detectable sign in glaucoma before visual field loss14. with the new revolution and advancement technique of oct, the rnfl thickness can be measured reliably. studies conducted previously have concluded that rnfl thickness analysis using oct is quite reproducible15 as well as reliable16. therefore, it is important to know the knowledge of normal distribution of nerve fiber layer thickness to avoid confusion with physiological and pathological variations17. in our study 300 eyes of 150 individuals were arranged in three groups of different refractive stateswith age ranges of 15-30 years in both genders. the refractive error of myopic group (se) mean was – 4.8300 (std. d ± 2.95737). hypermetropic (se) mean was 5.1550 (std. d ± 3.15900) and the mean of emmetrops was .1400 (std. d ± .35771) as shown in (table 1). whereas the author v. sowmya, et al, had analyzed the same number of individuals but divided into five groups, which were almost equally in range of refractive error and between 20-40 years of age12. in our cases, the mean age of the participants was 21.87 (table 2) and similar average age of subjects 21.70 was selected in other study18. in our study, the distribution of retinal nerve fiber layer thickness according to refractive error type shows that the mean value differences between the myopes against hypermetropes, and myopes against emmetropes are statistically significant (p < 0.05) as compared to hypermetrope against emmetropes (p= 0.152) (table 3 & 4, fig. 2). a study done by v sowmya et al, also detected significant changes in rnfl thickness (p < 0.001) in different refractive errors. it showed that there was a progressive thinning of rnfl as the power increased in myopic people and there was significant increase in the rnfl thickness as the power increased as in hypermetropic people12. our findings were also consistent with sung-won choi et al, who conducted peripapillary rnfl thickness study in 3 groups of safa omer wd haj hamed, et al 142 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology myopic patients (less than -2, -2 to -4 and more than 4d)19. in our study, the quadrantic assessment for different retinal sectors was analyzed and found that the mean value of rnfl thickness was thinner in nasal, temporal, superior and inferior in myopes then hypermetropes, which was statistically significant (p < 0.05). whereas the similar findings in other study by oner v et al. found that the rnfl thickness values were thinner in the myopic eyes than in the hyperopic eyes, except for lower and upper nasal sectors. on the other hand, the average rnfl thickness and the rnfl thicknesses of the upper temporal and inferonasal sectors were significantly different between the hypermetropic and emmetropic20, but in our study, the mean value of rnfl thickness of temporal and superior part was generally thicker in emmetropes than hypermetropes as shown in (table 5). conclusion the rnfl thickness was found thinner in myopic participants as compared to hyperopic and emmetropics. mean rnfl thickness values in this population may be providing a point of reference for comparison with findings in disease situation like glaucoma. in this respect, ophthalmologist and optometrist should be vigilant when measuring the rnfl thickness in myopic or hyperopic eyes to diagnose glaucoma. conflict of interest none. author’s affiliation safa omer wd haj hamed msc optometrist in makkah eye complex-sudan. nuha mohamed fath elrahman ph.d assistant professor, faculty of optometry and visual science alneelain university, sudan. dr. manzoor ahmad qureshi fcps assistant professor ophthalmology, qassim medical university, saudi arabia. abd elaziz mohamed elmadina ph.d faculty of optometry and visual science, alneelain university, sudan. dr. muhammad ijaz ahmad fcps (corresponding author) assistant professor ophthalmology, qassim medical university, saudi arabia. author’s contribution safa omer wd haj hamed conceivement of idea and data collection. nuha mohamed fath elrahman introduction and literature review of optometry. dr. manzoor ahmad qureshi discussion and literature review in ophthalmology. abd elaziz mohamed elmadina methodology data analysis. dr. muhammad ijaz ahmad discussion and proof reading. references 1. leite mt, rao hl, zangwill lm, weinreb rn, medeiros fa. comparison of the diagnostic accuracies of the spectralis, cirrus, and rtvue optical coherence tomography devices in glaucoma. ophthalmology, 2011; 118 (7): 1334–1339. 2. alasil t, wang k, keane pa, lee h, baniasadi n, de boer jf, chen tc. analysis of normal retinal nerve fiber layer thickness by age, sex, and race using spectral domain optical coherence tomography. j glaucoma. 2013; 22 (7): 532–541. 3. quigley ha, dunkelberger gr, green wr. chronic human glaucoma causing selectively greater loss of large optic nevre fibers. ophthalmology, 1988; 95: 357–63. 4. airaksinen pj, alanko hi. effect of retinal nerve fibre loss on the optic nerve head configuration in early glaucoma. graefes arch clin exp ophthalmol. 1983; 220: 193–96. 5. baquero-aranda im, morilla sanchez mj, garcia campos jm. use of optical coherence tomography to study variations of normal parameters with age. archivos de la sociedad espanola de oftamologia. 2005; 80 (4): 225-31. 6. kanai k, abe t, murayama k, yoneya s. retinal thickness and changes with age. nippon ganka gakkai zasshi. 2002; 106 (3): 162-65. 7. alamouti b, funk j. retinal thickness decreases with age:an oct study. br j ophthalmol. 2003; 87: 899-901. 8. schuman js, hee mr, puliafito ca, wong c, pedutkloizman t, lin cp, hertzmark e, izatt ja, swanson ea, fujimoto jg. quantification of nerve fobre layer thickness in normal and glaucomatous eye using optical https://www.ncbi.nlm.nih.gov/pubmed/?term=oner%20v%5bauthor%5d&cauthor=true&cauthor_uid=23143906 analysis of rnfl thickness among different refractive states using oct pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 143 coherence tomography. arch ophthalmol. 1995; 113: 58696. 9. yanoff m, fine bs. ocular pathology: a text and atlas, hagerstown, md, 1989; harper and row. 10. asrani s, zou s, d’anna s, vitale s, zeiner r. noninvasive mapping of the normal retinal thickness at the posterior pole. ophthalmology, 1999; 106: 269-73. 11. garcia-valenzuela e, mori m, edward dp, shahidi m. thickness of the peripapillary retina in healthy subjects with different degrees of ametropia. ophthalmology, 2000; 107: 1321-27. 12. sowmya v, venkataramanan vr, prasad v. effect of refractive status and axial length on peripapillary retinal nerve fiber layer thickness: an analysis using 3d oct journal of clinical and diagnostic research, 2015 sep, vol-9 (9): nc01-nc04. 13. poinoosawmy d, fontana l, wu jx, fitzke fw, hitchings ra. variation of nerve fibre layer thickness measurements with age and ethnicity by scanning laser polarimetry. br j ophthalmol. 1997; 81: 350-54. 14. nukada m, hangai m, mori s, takayama k, nakano n, marooka s, ikeda ho, akagi t, nonaka a, yoshimura n. imaging of localized retinal nerve fiber layer defects in preperimetric glaucoma using spectral domain optical coherence tomography. j glaucoma. 2014; 23 (3): 150–159. 15. jones al, sheen nj, north rv, morgan je. the humphrey optical coherence tomography scanner: quantitative analysis and reproducibility study of the normal human retinal nerve fiber layer. br j ophthalmol. 2001; 85: 673–77. 16. carpineto p, ciancaglini m, zuppardi e, falconio g, doronzo e, mastropasqua l. reliability of nerve fiber layer thickness measurements using optical coherence tomography in normal and glaucomatous eyes. ophthalmology, 2003; 110: 190–95. 17. pinilla i, garcia-martin e, idoipe m, sancho e, fuertes i. comparison of retinal nerve fiber layer thickness measurements in healthy subjects using fourierand time domain optical coherence tomography. j ophthalmol. 2012, article id 107053, 6 pages http://dx.doi.org/10.1155/2012/107053. 18. singh n, rohatgi j, gupta vp, kumar v. measurement of peripapillary retinal nerve fiber layer thickness and macular thickness in anisometropia using spectral domain optical coherence tomography: a prospective study. clin ophthalmol. 2017; 11: 429–434. 19. choi sw, lee sk. thickness changes in the fovea and peripapillary retinal nerve fiber layer depend on the degree of myopia. korean journal of ophthalmology, 2006; 20 (4): 215–19. 20. oner v, aykut v, tas m, alakus mf, iscan y. effect of refractive status on peripapillary retinal nerve fibre layer thickness: a study by rtvue spectral domain optical coherence tomography. br j ophthalmol. 2013 jan; 97 (1): 75-9. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5328294/ https://www.ncbi.nlm.nih.gov/pubmed/?term=oner%20v%5bauthor%5d&cauthor=true&cauthor_uid=23143906 https://www.ncbi.nlm.nih.gov/pubmed/?term=aykut%20v%5bauthor%5d&cauthor=true&cauthor_uid=23143906 https://www.ncbi.nlm.nih.gov/pubmed/?term=tas%20m%5bauthor%5d&cauthor=true&cauthor_uid=23143906 https://www.ncbi.nlm.nih.gov/pubmed/?term=alakus%20mf%5bauthor%5d&cauthor=true&cauthor_uid=23143906 https://www.ncbi.nlm.nih.gov/pubmed/?term=iscan%20y%5bauthor%5d&cauthor=true&cauthor_uid=23143906 https://www.ncbi.nlm.nih.gov/pubmed/23143906 microsoft word jamsheed nasir after correction 129 original article light guided endoscopic dacryocystorhinostomy jamshed nasir, iftikhar aslam pak j ophthalmol 2006, vol. 22 no.3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: jamshed nasir department of ophthalmology fatima memorial hospital lahore received for publication july’ 2005 …..……………………….. purpose: to evaluate the outcome of light guided endoscopic dacryocystorhinostomy (dcr). material and methods: seven patients above the age of 35 years were recruited for the said study at the combined military hospital lahore. careful selection of patient and assessment of their lacrimal apparatus status was established with radiological test. all those with nasolacrimal duct obstruction irrespective of the level of obstruction were included in the study after proper consent. a joint venture by ent and eye surgeon involving introduction of fiber optic bright light commonly used for vitrectomy through the lower canaliculus into the lacrimal sac directed towards the medial wall of the sac which shines through in the dark room environment from the lateral wall of the nasal cavity and is marked by the surgeon. the mucous membrane and than the bone is removed through a bone cutter and the sac is reached. the sac wall is incised and later intubated for a period of three months. results: initial results were encouraging in the form of reduction and disappearance of epiphora. once the tube was removed, five out of seven patients showed remarkable and two showed moderate improvement in their symptoms of epiphora. a success rate of 100% was achieved as far the patient symptom was concerned. individual patients were followed for a period of one year, after which a final assessment of their drainage system was made and was found to have satisfactory drainage system and patency. conclusion: this study demonstrated that good results can be achieved in cases of persistent epiphora due to nasolacrimal duct obstruction with less traumatic surgical procedure under local anaesthesia with equal or better results. a long term follow up is still awaited and we expect to have good outcome once a long term follow up is established. key words: dacryocystorhinostomy, endoscopic dacryocystorhinostomy. nasolacrimal duct obstruction, epiphora. acryocystorhinostomy or dcr, a very well known surgical procedure for chronic dacryocyctitis with nld obstruction has dual approach, the external conventional approach done by the ophthalmic surgeon and the relatively new approach, the internal/transnasal endoscope assisted approach, a joint venture by the ent and eye surgeon. the transnasal dcr can be traced as back as 1893 when caldwell and west first did this procedure with some success but later on this procedure was d 130 surrendered in favour of external dcr. the endoscopic transnasal dcr is gaining popularity due to its added advantages of direct visualization over the operated area nasally, less traumatic a procedure in general and the procedure can be done under local infiltration anesthesia easily with good even better results than the external procedure. the endoscopic dcr is primarily mcdonogh and meiring’s original work some fifteen years ago. since than every effort is being made to further improve upon it. the further recent advances in dcr surgery with the use of lasers(yag, carbon dioxide, argon and ktp lasers etc) has further simplifies the technique but laser availability with the specified laser power and setting is still unavailable to most of us. the use of silicone tubing, stents and other devices also plays important role in the overall success of the procedure. an overall success rate of external dcr ranges between 80-95% and that of endoscopic dcr between 82-96% has been claimed by various surgeons through their studies1,3,15. material and methods a prospective study of seven patients for epiphora due to nld obstruction was included in the study between august’ 2001 to august’ 2003. these seven patients were followed individually for period not less than 12 months post operatively. patency of the lacrimal system was assessed by repeated syringing, ent examination and dcg if needed. the silicone tubing left in the system for maintaining passages along with the sleeve was removed three month post male to female ratio 1. male (white shade) 04 2. female (grey) 03 total number of cases 07 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 1 2 131 intra operative complications 1. total cases 07 2. intra operative complications 04 3. intra operative bleeding 02 4. increased blood pressure 02 post operative complications 1. total cases 07 2. post operative eechymosis 03 operatively once the clearance by the ent surgeon was given about the patency of the ostium. after proper packing of the nasal cavity with guaze soaked in 4% lignocaine with adrenaline 1 in 100,000 for ten minutes, clear and decongested area was achieved. 30* light supported rigid endoscope introduced through the nose to mark the area anterior to the middle meatus. the guide line for the mark area is guided through 20g fiber optic light used for vitrectomy procedure is directed through the lower canaliculus and directed towards the medial walls of the lacrimal fossa. this light, the intensity of which is controlled by the main booster, when shines through the nasal cavity is marked. a u shaped incision is made in the mucous membrane with open end of this u directed posteriorly with a sickle knife. once the mucous membrane is dissected out, using a bone punch, reverse if needed, the lacrimal bone of same size was removed .the edge of the bone are smoothened by repeated cutting or bone drill if needed (in one case). the tenting of lacrimal sac by fiber optic light can clearly be seen which then is excised in similar u fashion using a knife. the dcr tube with its guide wire passed through each of the punctum and the canaliculus is secured at the nostril when extruded. the two tube then are embraced with a sleeve which is wired superiorly towards the ostium and is secured there for the stay period of three months till removal. after the procedure the nasal packing done for 24 hours which then was removed. results the study was conducted for a period of two years starting in august 2001 ending august 2003. the cases were carefully selected for the study and a proper follow up was explained to the patients who followed the instruction with a regular follow up during the study period. a total of seven patients were enrolled for the study with a follow up of one year for individual patient with zero shortfalls at the end of the study. this high success rate is attributed to the available means of communication with the physicians and the patients. the average age of the patient was 50.5 years ranging from thirty five to seventy two years. the male to female ratio was 4:3 with male dominance in this study. the patients had an ent examination pre operatively revealing dns in four cases of mild to moderate nature without nasal obstruction. there was no sign of nasal allergy. the ocular examination pre operatively also did not revealed any major abnormality. all the patients under went light guided endoscopic dcr after proper explanation of the procedure to which they accepted on a written form. the intra operative complication included bleeding in two cases (28.57%) and rise in the blood pressure during the procedure in two cases (28.57%) controlled during the surgery. three patients had ecchymosis (42.88%). this eventually settled in three weeks time. all patients (seven) improved with the procedure with success rate of 100% in the disappearance of their symptom of epiphora and improvement of their clinical condition till the completion of their follow up period of one year. during the follow up period, a joint examination was done by the ophthalmologist and the ent surgeon as a routine. the results were appreciably 0 1 2 3 4 5 6 7 8 1 2 3 4 0 1 2 3 4 5 6 7 8 1 2 132 better3,12 than the more traumatic and general anesthesia dependant conventional dacryocystorhinostomy. successful criteria • disappearance of symptoms • improvement in clinical signs • open ostium of the operated area as seen by the ent surgeon (table 1) discussion dacryocystorhinostomy is considered the treatment of choice surgical option for epiphora due to naso lacrimal duct obstruction of various causes discussed earlier. the procedure has a high success rate (over 90% as is proved with various studies) but has some limitation due to following reasons. the procedure preferably is done under general anesthesia therefore per and post operative risks2 of general anesthesia are well known to every one although over period of time the anesthesia has become quite safer now. the traumatic procedure of osteotomy used has an impact over the patient for which patient remains uncomfortable for quite some time after the surgery. as compared to conventional dcr3 this procedure is as a routine done under local anesthesia and minimum tissue handling and disruption with even better out come as is shown by the results. the procedure can closely be compared with laser endo dcr started recently in some centre. the laser endo dcr is laser dependant which is generally not available in most of the tertiary care eye centre what to talk of primary and secondary centre. this procedure “light guided endoscopic dcr’ therefore is an alternative to more traumatic general anesthesia dependant conventional dcr and pretty expensive laser assisted endo dcr and can be done even at smaller centre due to availability of instrument. the technical expertise is not different from the other procedure however an ent surgeon is asked to help for better per operative and post operative results. table 1: study period, follow up period and age are in years description results study period 02 total patient 07 follow up period 01* follow up shortfall 00 average age 50.5 male to female ratio 4:3 previous dcr 00 deviated nasal septum 4 intra operative bleeding 2 post operative eechymosis 3 success rate 100% conclusion the result of endoscopic light guided dcr as compared to conventional external dcr in our study are very encouraging. the initial response is excellent and it appears to be better than the quoted data in the literature of 82% to 92%1,15 success of internal dcr as is mentioned in numerous studies in the literature. all patients (100%) were satisfied with the surgical procedure itself and there was no symptoms of epiphora till the end of first year. a better coordination between ent and eye surgeon is the key to successful outcome and the procedure should be followed more than the external dcr. author’s affiliation dr. jamshed nasir department of ophthalmology fatima memorial hospital lahore dr. iftikhar aslam department of ent cmh abbatabad references 1. zaman m, babar tf, saeed n. a review of 120 cases of dacryocystorhinostomies (dupuy dutemps and bourguet technique). j ayub med coll abbottabad. 2003;15:10-2. 2. fayet b, racy e, assouline m. complications of standardized endonasal dacryocystorhinostomy with unciformectomy. ophthalmology. 2004; 111: 837-45. 3. tsirbas a, davis g, wormald pj. mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. ophthalmol plast reconstr surg. 2004; 20: 50-6. 4. berlucchi m, staurenghi g, rossi brunori p, et al. transnasal endoscopic dacryocystorhinostomy for the treatment of 133 lacrimal pathway stenoses in pediatric patients. int j pediatr otorhinolaryngol. 2003; 67: 1069-74. 5. cokkeser y, evereklioglu c, tercan m, et al. hammer-chisel technique in endoscopic dacryocystorhinostomy. ann otol rhinol laryngol. 2003; 112: 444-9. 6. kashkouli mb, parvaresh m, modarreszadeh m, et al. factors affecting the success of external dacryocystorhinostomy. orbit. 2003; 22: 247-55. 7. dietrich c, mewes t, kuhnemund m, et al. long-term followup of patients with microscopic endonasal dacryocystorhinostomy. am j rhinol. 2003; 17: 57-61. 8. dolman pj. comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. ophthalmology. 2003; 110: 78-84. 9. tsirbas a, wormald pj. endonasal dacryocystorhinostomy with mucosal flaps. am j ophthalmol. 2003; 135: 76-83. 10. tsirbas a, wormald pj. mechanical endonasal dacryocystorhinostomy with mucosal flaps. br j ophthalmol. 2003; 87: 43-7. 11. minasian m, olver jm. the value of nasal endoscopy after dacryocystorhinostomy. orbit. 1999; 18: 167-76. 12. woog jj, kennedy rh, custer pl, et al. endonasal dacryocystorhinostomy: a report by the american academy of ophthalmology. ophthalmology. 2001; 108: 2369-77. 13. vanderveen dk, jones dt, tan h, et al. endoscopic dacryocystorhinostomy in children. jaapos. 2001; 5: 143-7. 14. struck hg. value of external dacryocystorhinostomy klin monatsbl augenheilkd. 1999; 215: 1-3. 15. zilelioglu g, tekeli o, ugurba sh, et al. results of endoscopic endonasal non-laser dacryocystorhinostomy. doc ophthalmol. 2002; 105: 57-62. 16. fayet b, bernard ja, ritleng p, et al. internal transient palpebral inclusion following dacryocystorhinostomy. j fr ophtalmol. 1994; 17: 195-9. pak j ophthalmol. 2020, vol. 36 (2): 114-118 114 original article practice patterns in the management of strabismus in pakistan nasir ahmed 1 , muhammad shaheer 2 , sarmad zahoor 3 , salman hamza 4 , samran asim 5 1’3’4’5 king edward medical university, 2 lahore general hospital, lahore abstract purpose: to study the current practice patterns of pediatric ophthalmologists in the management of strabismus in punjab. study design: questionnaire based practice pattern survey. place and duration of study: teaching hospitals of punjab from july 2018 to july 2019. methods: this study was conducted at ophthalmology departments of various teaching hospitals of punjab. a questionnaire was designed to find out the current practice pattern for management of strabismus. ophthalmologists who were members of ophthalmological society of pakistan (osp), having their expertise in strabismus surgery for more than 5years and practicing pediatric ophthalmology were selected. discussion was also held regarding questionnaire and practices being performed after filling the proforma. this data was compiled, analyzed and was converted to a summary in points. results: we contacted 90 ophthalmologists out of whom 76 responded to our questionnaire. complete orthoptic assessment was performed by only 46% (35) of the ophthalmologists. prism cover test was used as a diagnostic tool by 70 (92%) ophthalmologists. rest of the ophthalmologists used synoptophore with it. percentage of ophthalmologists performing cycloplegic refraction was very low. only 5 (6.57%) surgeons used adjustable sutures. only 46% of surgeons used to explain the complications of anesthesia. more than 90% of surgeons explained the surgical procedures being done, its complications, post-operative care and need to use glasses or need for orthoptic exercises. all the surgeons kept follow up of the patients on 1 st post-operative day. conclusion: the current practices in strabismus need to be standardized and a consensus should be developed at a national level. key words: strabismus, prisms, refraction, orthoptics how to cite this article: ahmed n, shaheer m, zahoor s, hamza s, asim s. survey of practice patterns in the management of strabismus in pakistan. pak j ophthalmol. 2020, 36 (2): 114-118. doi: 10.36351/pjo.v36i2.889 introduction strabismus is a fairly common problem having multi directional impacts affecting different populations with a prevalence varying from 0.5 to 5 %. 1,2,3,4 strabismus correspondence: nasir ahmed chaudhary institute of ophthalmology, mayo hospital, lahore email: drnasirch1@gmail.com received: september 13, 2019 accepted: february 9, 2020 is associated with amblyopia, strange cosmetic look, decreased social esteem and emotional discouragement disturbing quality of life of the patient. 5 stereotypical myths often considering a strabismic person to be of low intelligent quotient and sign of bad destiny has also contributed in affecting the life of these patients. 6 symptoms include disturbed vision, double vision, headache, eye strain, abnormal posturing of head and easy fatigability after reading. 7 newborns often have misalignment that resolves spontaneously. however most of the time it remains even in the adult life. 8 the main purpose of treatment is restoration of binocular mailto:drnasirch1@gmail.com nasir ahmed, et al 115 pak j ophthalmol. 2020, vol. 36 (2): 114-118 vision, normal alignment of eyes, stereoacuity and correction of abnormal head posture. 9 treatment modalities to achieve the targets are; use of patches, glasses, optometric vision therapy including orthoptic exercises, injecting botulinum toxin and surgery including recession and resection procedures. 10,11,12 strabismus is both a social and pathological problem. it needs to be addressed and practiced in an organized and established manner. the main goal of our effort is to find out the current practice of management of strabismus and highlight the short comings being practiced. this will help in better management of strabismus. it is the need of hour to establish a consensual protocol for strabismus to be followed in the light of experiences of renowned ophthalmologist of the country. methods in order to design this study an extensive literature was reviewed regarding standard guidelines being followed in the best centers of the world. after having reviewed the current practices prevailing in different centers, a questionnaire was designed. this focused on common shortcomings and on standards being followed differently by different ophthalmologists. ophthalmologists who were members of ophthalmological society of pakistan (osp), having their expertise in strabismus surgery for more than 5 years and practicing pediatric ophthalmology were selected. those having less than 5 years’ experience was excluded from the study. this was sent through email and online to 90 renowned selected ophthalmologists. this data was compiled, analyzed and was converted to a summary in points. each point of that summary was discussed with 10 renowned ophthalmologists having their expertise in strabismus at one to one meetings held at conference of ophthalmological society of pakistan (osp). results we contacted 90 ophthalmologists, out of whom 76 responded to our questionnaire. more than 90% (69) surgeons had an experience of more than ten years in squint surgery. almost all the surgeons were also performing cataract surgery regularly. oculoplastics was performed by 19 (25%) of them. complete orthoptic assessment (sensory and motor) was performed by only 46% (35) of the ophthalmologists. prism cover test was used as a diagnostic tool by 70 (92%) ophthalmologists. rest of the ophthalmologists used synoptophore with it. a single assessment was never considered reliable and more than one assessment was performed before surgery. fundoscopy was performed by almost all the ophthalmologists. percentage of ophthalmologists performing cycloplegic refraction was very low. non surgical techniques used and their relative distribution is shown in figure 1. only 5 (6.57%) surgeons used fig. 1: non-surgical methods. adjustable sutures. rest of 71 used non adjustable sutures in strabismus surgery (figure 2). almost all the surgeons used to counsel about need for redo surgery. fig. 2: types of sutures used by the surgeons. management of strabismus in pakistan pak j ophthalmol. 2020, vol. 36 (2): 114-118 116 85% of surgeons were of the view that redo surgery was needed in almost 10 – 15% cases. consecutive squint surgery was performed in less than 20% according to view of expert ophthalmologist. there were 96% ophthalmologists who performed surgery under general anesthesia but only 46% of them explained the complications of anesthesia (figure 3). more than 90% of surgeons explained the surgical procedures being done, its complications, postoperative care and need to use glasses or need for orthoptic exercises. however only 30 (39.47%) of them also explained per-operative complications. all the surgeons kept follow up of the patients on 1 st postoperative day. fig. 3: patient counselling. discussion strabismus is actually a condition in which two eyes are not in accord with each other, setting a stage for developing amblyopia, double vision, abnormal head posture. there are various treatment modalities for its management, which include; use of patches, prism glasses, orthoptic exercises and botulinum toxin injection. yilmaz et al 13 studied the effect of prism cover test on the post-operative outcomes in patients of strabismus. they found that the surgical outcomes with and without prism cover test lead to a successful motor alignment in 80% of cases. however, they were of the opinion that prism cover test may lead to a better functional result. 13 hatt sr and colleagues studied the importance of deviation measurement in patients of intermittent exotropia and they urged upon the repeatability of prism cover test measurement in order to get an accurate measurement and detect any significant change in deviation. 14 in our study, most common symptom of strabismus, which was encountered by more than 90% of the ophthalmologists was misalignment of eyes and was confirmed with prism cover test. our panel recommended this test for diagnostic purposes to be performed in every patient of suspected strabismus. tejedor j et al assessed the applicability of prism cover test in quantifying the horizontal deviation and found it to be useful in measuring the deviation. 15 de jongh 16 e et al compared the difference of prism cover test measurement between four examiners and found that a difference of more than 10 prism diopter is due to inter-observer variability. however, they emphasized upon the importance of orthoptic assessment for accurate measurement of deviation. complete orthoptic assessment was performed by only 46% of the experts. our panel discussed it and finalized the recommendation of complete orthoptic assessment in all the patients. half of the ophthalmologists had the assessment done by both the surgeon and the orthoptist. cycloplegic refraction was a neglected step, not being taken by the surgeons participating in the study. only 18% of our study participants had incorporated it into their practice. leffler ct 17 and associates studied the success rates of strabismus surgery comparing adjustable versus conventional suture techniques. they concluded that adjustable suture technique was associated with less re-operation rate than conventional suture technique in cases of horizontal strabismus while the converse was true for vertical strabismus surgery. kamal am et al compared the adjustable versus non-adjustable sutures in paediatric horizontal strabismus surgery. while finding no significant difference in maneuvering the two techniques, they concluded that adjustable suture technique was associated with better success rates. 18 goerg tvkg 19 published a case series about the use of botulinum toxin in patients diagnosed with cyclic strabismus. they recommended the use of botulinum toxin in those patients of alternate strabismus who have undergone at least one-month trial of prismatic correction for phoric angle. saunte jp 20 et al administered botulinum toxin in patients of intermittent exotropia and after one-month post injection, they found a significant reduction in the deviation and an improvement in the reading symptoms. other methods to correct strabismus were orthoptic exercises, refraction, botulinum injection and glasses. most of the surgeons used combination of these treatments. our panel suggested an amalgam of these measures to be taken before progressing to nasir ahmed, et al 117 pak j ophthalmol. 2020, vol. 36 (2): 114-118 surgery. a huge percentage of the surgeons (more than 90%) explained redo surgery and its post-operative complications including under correction and over correction in detail to the patient. the percentage of redo surgery was found almost 10-15%, which is still a higher percentage. better pre-operative assessment, pre-operative use of non-surgical measures and education of patients can reduce the incidence of redo strabismus surgery. in our study, less than 50% surgeons explain complications of anesthesia. we lay a great stress to educate the patients about complications of general anesthesia. the limitation of our study was it only included those ophthalmologists who were members of ophthalmological society of pakistan. in future a study involving more ophthalmologists and further aspects related to strabismus need to be studied in order to improve standard of care provided by health professionals. conclusion the current practices in strabismus need to be standardized and a consensus should be developed at a national level. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest references 1. mckean-cowdin r, cotter sa, tarczy-hornoch k, wen g, kim j, borchert m et al. prevalence of amblyopia or strabismus in asian and non hispanic white preschool children: multiethnic pediatric eye disease study. ophthalmology, 2013; 120 (10): 21172124. 2. graham pa. epidemiology of strabismus. br j ophthalmol. 1974; 58: 224–231. 3. stidwell d. epidemiology of strabismus. ophthal physiol opt. 1997; 17: 536–539. 4. fu j, li sm, liu lr, li jl, li sy, zhu bd, et al. prevalence of amblyopia and strabismus in a population of 7th-grade junior high school students in central china: the anyang childhood eye study (aces). ophthal epidemiol. 2014; 21: 1972. 5. hatt sr, leske da, kirgis pa, bradley ea, holmes jm. the effects of strabismus on quality of life in adults. am j ophthalmol. 2007; 144: 643-647. 6. olitsky se, sudesh s, graziano a, hamblen j, brooks se, shaha sh. the negative psychosocial impact of strabismus in adults. j aapos. 1999; 3: 209211. 7. olson jh, louwagie cr, diehl nn, mohney bg. congenital esotropia and the risk of mental illness by early adulthood. ophthalmology, 2012; 119 (1): p. 145149. 8. beauchamp gr, felius j, stager dr, beauchamp cl. the utility of strabismus in adults. trans am ophthalmol soc. 2005; 103: 164-172. 9. schalij-delfos ne, de graaf mel, trevers wf, engel j, cats bp. long term follow up of premature infants: detection of strabismus, amblyopia, and refractive errors. br j ophthalmol 2000; 84: 963–967. 10. serna a, rogers dl, mc gregor ml, golden rp, bremer dl, rogers gl. treatment of symptomatic convergence insufficiency with a home based computer orthoptic exercise program. j am assoc pead ophthalmol & strab. 2011; 15 (2): 140-143. 11. biglan, a.w., burnstine ra, rogers gl, saunders ra. management of strabismus with botulinum a toxin. ophthalmology, 1989. 96 (7): 935943. 12. simonz hj, els v, ruijter jm, bakker d, spekrijse h. preliminary report: prescription of prism glasses by measurement and correction method of h-j haase or by conventional orthoptic examination: a multicenter, randomized, double blind, cross over study. j strab. 2001; 9 (1): 17-27. 13. yilmaz ak, kose s, yilmaz sg, uretman o. the impact of prism adaptation test on surgical outcomes in patients with primary exotropia. clin and exp optometry, 2015; 98 (3): 224-227. 14. hatt sr, leske da, liebermann l, mohney bg, holmes jm. variability of angle of deviation measurements in children with intermittent exotropia. j am assoc pead ophthalmol strab. 2012; 16 (2): 120124. 15. tejedor j, gutierrez-carmona fj. prism under cover tests in alternate fixation horizontal strabismus. curr eye res. 2018; 43 (2): 186-192. 16. de jongh e, leach c, tjon-fo-sang mj, bjerre a. inter-examiner variability and agreement of the alternate prism cover test (apct) measurements of strabismus performed by four examiners. strabismus. 2014; 22 (4): 158-166. 17. leffler ct, vaziri k, cavuoto km, mckeown km, schwartz sg, kishor ks, et al. strabismus surgery reoperation rates with adjustable and conventional sutures. am j ophthalmol. 2015; 160 (2): 385-390. management of strabismus in pakistan pak j ophthalmol. 2020, vol. 36 (2): 114-118 118 18. kamal am, abozeid d, hassan m. a comparative study of adjustable and non-adjustable sutures in primary horizontal muscle surgery in children. eye, 2016; 30: 1447-1451. 19. georg tvkg. botulinum toxin for the treatment of cyclic strabismus in children: three case reports. klin monatsbl augenheilkd. 2018; 235 (4): 465-468. 20. saunte jp, christensen t. improvement in reading symptoms following botulinum toxin an injection for convergence insufficiency type intermittent exotropia. act ophthalmol. 2015; 93 (5): e391-e392. authors’ designation and contribution nasir ahmed; associate professor: research idea conception, data collection and analysis, article writing. muhammad shaheer; assistant professor: literature search and data analysis, editing article draft. sarmad zahoor; data collection and analysis. salman hamza; assistant professor: data collection and analysis. samran asim; post graduate resident: literature search, final review. .…  …. 3 pakistan journal of ophthalmology, 2020, vol. 36 (1): 3-7 original article corneal endothelial cell loss after phacoemulsification in patients of type 2 diabetes syed abdullah mazhar 1 , sehar zahid 2 , junaid hanif 3 , muhammad asharib arshad 4 rana naveed iqbal 5 department of ophthalmology, 1 rashid latif medical college, 2,5 services institute of medical sciences 3 lrbt hospital, 4 fmh college of medicine and dentistry, lahore abstract purpose: to assess the mean corneal endothelial cell loss after phacoemulsification in patients of type 2 diabetes. study design: cross-sectional study. place and duration of study: layton rahmatullah benevolent trust free eye and cancer hospital for a period of six months, from may 2015 to november 2015. material and methods: three hundred and fifty-five patients were selected by non-probability convenience sampling. patients with cataract, diagnosed at least after 6 months of diagnosis of type 2 diabetes were included in this study. patients with any systemic disease or ocular disease other than senile cataract were excluded from the study. endothelial cell count was measured with specular microscopy one day before surgery. one experienced surgeon with post-graduate experience of at least five years performed all the procedures. follow up by specular microscopy was done at 6 weeks after phacoemulsification. statistical analysis was done using spss version 23. results: mean age of the patients was 59.32 ± 7.60 years. there were 41.97% males and 58.03% females. mean endothelial cell count before phacoemulsification was 2177.21 ± 591.078 and 6 weeks after surgery was 1984 ± 597.51. age, gender, laterality, duration of diabetes and type of cataract was not significantly related with endothelial cell loss, p-value > 0.05. mean endothelial cells loss was higher in patients with hba1c > 7 as compared to those with hba1c < 7 (p-value = 0.01). conclusion: patients with poor control of diabetes have higher endothelial cell loss after phacoemulsification than patients with good control. key words: diabetes mellitus, cataract, corneal endothelial cell, phacoemulsification. how to cite this article: mazhar sa, zahid s, hanif j, arshad ma, iqbal rn. effect of type 2 diabetes on corneal endothelial cell loss after phacoemulsification, pak j ophthalmol. 2020; 36 (1): 3-7. doi: https://doi.org/10.36351/pjo.v36i1.908 introduction in pakistan, cataract contributes around 66.7% of the cases of blindness 1 . one of the major causes of correspondence to: syed abdullah mazhar assistant professor, rashid latif medical college, lahore email: abdullah_mazhar@hotmail.com cataract is diabetes mellitus. corneal abnormalities are present in more than 70% of the diabetic patients and others include clinically detectable changes such as increased epithelial fragility, recurrent erosions, reduced corneal sensitivity, endothelial cell loss and predisposition to corneal edema 2,3 . cataract surgery is the most commonly performed https://doi.org/10.36351/pjo.v36i1.908 corneal endothelial cell loss after phacoemulsification in patients of type 2 diabetes pakistan journal of ophthalmology, 2020, vol. 36 (1): 3-7 4 surgery, which is always associated with damage to corneal endothelium 4 . during phacoemulsification, endothelial cell loss depends upon many factors. few of these are the size and site of incision, technique of phacoemulsification, hardness of the cataract, anterior chamber depth, the axial length of the eye, viscoelastic material used and skills of the surgeon 5,6,7 . the patients presenting in lrbt eye hospital come from both urban and rural areas of pakistan and these patients have poor diabetic control on presentation. the purpose of the study was to observe endothelial cell loss in diabetic cataract patients after phacoemulsification in our population. material and methods this study was conducted for a period of six months in layton rahmatullah trust hospital after approval from the hospital ethical committee. total of 355 patients were selected through non-probability convenience sampling. patients of either gender with age range of 50-80 years and presenting with cataract, diagnosed at least after 6 months of diagnosis of type 2 diabetes were included in this study. patients with hypertension, asthma, uveitis (anterior chamber cells on slit lamp), previous history of any neurological disease, and history of trauma to eye were excluded from this study. demographic information like name, age, gender, etc. was noted after taking the informed consent. hba1c was recorded. preoperative endothelial cell count was measured one day before surgery. specular microscopy was used to measure endothelial cell count. to avoid bias one experienced surgeon with post-graduate experience of at least five years performed all the procedures. follow up by specular microscopy was done at 6 weeks after phacoemulsification. all the data was collected on a proforma and analyzed in spss version 23.0. quantitative variables like age, pre/post endothelial cell count, endothelial cell loss, duration of diabetes mellitus, hba1c and duration of cataract was in the form of mean and standard deviation. qualitative variables i.e. gender were presented as numbers and percentages. effect modifiers, like gender, age, duration of diabetes, cataract and hba1c were controlled with the help of stratification. poststratification t-test was used. a p-value of ≤ 0.05 was considered significant. results there were 149 (41.97%) male and 206 (58.03%) female patients. mean age was 59.32 ± 7.60 years, the minimum age was 50 and the maximum age was 80 years. two hundred and seventy four (77.18%) patients were 50-64 years old and 81 (22.82%) patients were 65-80 years of age. for details refer to tables 1 and 2. table 1: descriptive statistics of the patients. mean std. deviation range minimum maximum age 59.32 7.6 30 50 80 duration of type 2 dm 6.51 4.72 42 2 44 hba1c % 6.47 0.94 3.8 4.9 8.7 duration of cataract 2.29 0.92 4 1 5 endothelial count (p <0.001) pre-operative 2177.21 591.078 2242 1021 3263 after 6 weeks 1984.03 597.51 2320 728 3048 cell loss 193.18 60.07 422 110 532 table 2: relation of endothelial cell loss with different factors. n mean p-value age groups (years) 50-64 274 195.78 ± 63.20 0.135 65-80 81 184.42 ± 47.30 gender male 149 187.57 ± 63.88 0.134 female 206 197.25 ± 56.98 side of cataract eye right 104 199.53 ± 61.65 0.201 left 251 190.56 ± 59.33 duration of type 2 dm (years) ≤ 5 years 202 196.15 ± 61.94 0.286 > 5 years 153 57.48 ± 189.27 duration of cataract (years) ≤ 2 years 233 192.811 ± 63.55 0.871 > 2 years 122 193.91 ± 53.03 hba1c% ≤ 7 248 187.79 ± 50.99 0.01 > 7 107 205.67 ± 75.95 the endothelial loss was significant 6 weeks after surgery, p-value < 0.001. when data were stratified over the duration of type 2 diabetes and duration of cataract, we found no significant difference in endothelial cell loss, p-value > 0.05. mean endothelial cells loss was significantly high in patients with hba1c > 7% as compared to those whose hba1c was < 7% i.e. 205.67 ± 75.95 (9.45%) and 187.79 ± 50.99 (8.63%) respectively, p-value = 0.01. discussion previous studies in other parts of the world have mazhar sa, et al 5 pakistan journal of ophthalmology, 2020, vol. 36 (1): 3-7 shown results comparable to our study. in a similar study, that included 153 diabetic patients undergoing manual small incision cataract surgery (sics) were assessed for the endothelial cell loss and change in central corneal thickness (cct). the results showed that patients undergoing manual small incision cataract surgery in diabetic patients had a less functional reserve. a steady drop in the endothelial density was noticed, with the mean endothelial loss at 6 weeks and 3 months being 9.26 ± 9.55 and 19.24 ± 11.57, respectively, in patients with diabetes. in patients with diabetes, it was seen that the cct increased initially till the second postoperative week, followed by a reduction of cct in the subsequent follow-up (sixth week) and a further reduction in the last follow-up (3 months). in diabetic patients, the change in cct between the second and sixth weeks was significantly high 6,7 . in a study by hugod et al. the corneal thickness and cell count were measured before surgery, and three months after surgery 8 . a significant decrease in hexagonal cells percentage was observed. the mean decrease in endothelial cell density at three months in the diabetic group was 154 cells per square millimeter (6.2%). results revealed that diabetic patients have more corneal damage and endothelial cells loss. in recent years, the surgical equipment has been improved, new viscoelastic agents, and techniques have been introduced 9 . reshma et al 10 conducted a study at 152 eyes and the mean endothelial cells loss after phacoemulsification was 10-15% at the end of 6 months. in a study by kaur et al 11 that included 100 patients, mean endothelial cell loss was 19.53% at the end of 42 days. these results are comparable to our study i.e. 8.87% in 335 patients. similar results were noted by gogate 12 at the end of 6 weeks, thakur 13 at the end of one month and akram 14 at the end of three months. in our study, mean endothelial loss in patients with age, 50-64 years was 184.42 ± 47.30 (8.47%) and in patients of 65-80 years was 195.78 ± 63.20 (8.99%). reshma et al 10 stated in their study that mean endothelial cell loss was greater in patients having age > 75 years. hwang et al 15 also stated that the degree of mean endothelial cell loss after phacoemulsification increased with the advancing age. mean endothelial cell loss in male and female patients in our study was 9.28% and 8.83% respectively and no significant difference was found. these results are in accordance with george et al 16 and maggon et al 17 i.e. there was no significant difference in mean endothelial cell loss in either gender. diabetes affects both the corneal thickness and the morphology of the endothelial cells. hyperglycaemia in these patients causes metabolic stress, which can lead to lower endothelial cell density and greater pleomorphism and polymegethism. these endothelial changes, because of the disease, may lead to a highrisk cornea, particularly in hard cataract 18,19 . in another study, decrease in the endothelial cell density at 3 months in the diabetic group was 154 cells per square millimeter (6.2%) and it was compared with the control group that had 42 cells per square millimeter (1.4%) 8 . the difference between the diabetic group and the control group in cell loss was statistically significant (p=0.04). another study described that the mean pre-operative endothelial count was higher in the control group when compared to the diabetic group (p < 0.001) and the postoperative mean endothelial cell loss was higher in the diabetic group (14.19%) (p < 0.001) as compared to the control group (8.05%) 20 . work done in 2003 by spaide rf showed that there was a steady decline in the endothelial density, with the mean endothelial loss in patients with diabetes at 6 weeks and at 3 months being 9.26 ± 9.55 and 19.24 ± 11.57, respectively 6 . the change in cct between the second and sixth weeks was significantly high in the diabetic group (p = 0.045). in a study by siribunkum et al, it was noted that corneas of the diabetic patients had more polymegethism and pleomorphism. this suggested that corneal changes should be evaluated and confirmed before intraocular surgery in chronic diabetic patients 18 . mean endothelial cells loss was significantly high in patients with hba1c > 7% as compared to those whose hba1c was < 7% i.e. 205.67 ± 75.95 (9.45%) and 187.79 ± 50.99 (8.63%). hugod m et al 8 and akram et al 14 also reported similar kind of statistics i.e. the patients with diabetes with greater hba1c or blood sugar had higher cell loss than the patients with lower hba1c or nondiabetics. the literature shows that the corneal endothelium is more vulnerable in diabetic patients with delayed repair after surgery and greater endothelial cell loss. patients in our part of the world have poor control of diabetes, due to which our diabetic patients may have more loss of corneal endothelial cells after phacoemulsification. on the basis of the results of present study, more precautionary measures or corneal endothelial cell loss after phacoemulsification in patients of type 2 diabetes pakistan journal of ophthalmology, 2020, vol. 36 (1): 3-7 6 techniques can be used to minimize endothelial cell loss in diabetic patients after phacoemulsification. the limitations in our study are that we did not include the non-diabetic patients as a control group and we did not compare our results with the grades of cataract. conclusion patients with poor control of diabetes have higher endothelial cell loss after phacoemulsification than patients with good control. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest authors’ designation and contribution syed abdullah mazhar; assistant professor: research planning, manuscript writing. sehar zahid; postgraduate resident: literature search, manuscript writing junaid hanif; consultant ophthalmologist: manuscript drafting, data collection. muhammad asharib arshad; final year mbbs student: data collection, final manuscript review. rana naveed iqbal; assistant professor: data analysis, final manuscript review. references 1. barar j, asadi m, mortazavi-tabatabaei sa, omidi y. ocular drug delivery; impact of in vitro cell culture models. j ophthalmic vis res. 2009; 4 (4): 238-52. 2. müller lj, marfurt cf, kruse f, tervo tm. corneal nerves: structure, contents and function. exp eye res. 2003;76 (5): 521-42. 3. rüfer f, schröder a, erb c. white-to-white corneal diameter: normal values in healthy humans obtained with the orbscan ii topography system. cornea. 2005; 24 (3): 259-61. 4. ventura acs, wälti r, böhnke m.corneal thickness and endothelial density before and after cataract surgery br j ophthalmol. 2001; 85: 18-20. 5. saini js, mittal s. in vivo quantification of corneal endothelium function. acta ophthalmol scand 1996; 74: 468–72. 6. harper cl, boulton me, bennett d. diurnal variations in human 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https://www.ncbi.nlm.nih.gov/pubmed/?term=yaba%c5%9f%20kizilo%c4%9flu%20%c3%96%5bauthor%5d&cauthor=true&cauthor_uid=26281334 https://www.ncbi.nlm.nih.gov/pubmed/?term=akova%20y%5bauthor%5d&cauthor=true&cauthor_uid=26281334 https://www.ncbi.nlm.nih.gov/pubmed/26281334 mazhar sa, et al 7 pakistan journal of ophthalmology, 2020, vol. 36 (1): 3-7 17. maggon r, bhattacharjee r, shankar s, kar rc, sharma v, roy s. comparative analysis of endothelial cell loss following phacoemulsification in pupils of different sizes. indian j ophthalmol. 2017; 65 (12): 1431. 18. siribunkum j, kosrirukvongs p, singalavanija a. corneal abnormalities in diabetes. j med assoc thai. 2001; 84 (8): 1075-83. 19. lee js, oum bs, choi hy, lee je, cho bm. differences in corneal thickness and corneal endothelium related to duration in diabetes. eye, 2006; 20 (3): 315-8. 20. dhasmana r, singh ip, nagpal rc. corneal changes in diabetic patients after manual small incision cataract surgery. j clin diagn res. 2014; 8 (4): vc03-vc6. .…  …. microsoft word tanveer ch artical.doc 114 original article postoperative wound leak and anterior chamber reaction in patients undergoing phacoemulsification cataract surgery with sutured and sutureless corneal incisions tanveer anjum chaudhry, m. h. shahzad, sameer khan, khabir ahmad pak j ophthalmol 2007, vol. 23 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tanveer a chaudhry section of ophthalmology department of surgery agha khan university karachi received for publication august’ 2006 …..……………………….. purpose: to compare the rates of significant post operative wound leak and anterior chamber (ac) reaction in patients undergoing phacoemulsification cataract surgery with sutured and sutureless corneal incisions. material and methods: all eyes scheduled to have phacoemulsification surgery by two surgeons at two centers were selected. the first group of eyes underwent phacoemulsification surgery with 3.25 mm superior and superior-temporal clear corneal incisions. the incision was sutured using a single 10/0 nylon suture. the second group of eyes underwent an identical surgery, but the incision was not sutured. patients were followed up at 24 hours, and 1 week and evaluated by slit lamp for wound leak (using seidel's test) and ac cells and flare. results: forty eight eyes underwent surgery with sutured corneal incisions and 50 eyes underwent sutureless surgery. the mean age of patients in groups i and ii were 61.2 years and 63.3 years, respectively. following surgery, none of the patients in two groups showed wound leak at 1 day and 1 week. at the first post-op day, only 14.6% of eyes in group 1 showed ac reaction, compared to 32.0 % in group ii (p = 0.04). at one week postop, 16.7% and 20.0% of eyes in groups i and ii showed ac reaction, respectively. however, the difference was not statistically significant (p = 0.67). conclusions: the rates of postoperative wound leak and anterior chamber reaction in patients undergoing phacoemulsification cataract surgery with sutured and sutureless corneal incisions are not different. thus sutured surgery offers no added advantages. he world health organization (who) estimates that 161 million people worldwide have visual impairment, including 37 million blind and 124 million with visual impairment. cataract is the leading cause of worldwide blindness. globally, it accounts for almost 16 million cases of blindness and 50 million cases of low vision1. in south asian countries like india and nepal around 70% of cases of blindness are due to cataract. in pakistan, 66% of the blindness is due to cataract2. an estimated 2.5 million people are blind due to cataract in one eye and 1.5 million in both eyes3. the treatment for cataract is surgical removal, usually followed by replacement of the cataractous lens with an intraocular lens (iol) implant. there are t 115 several techniques for cataract extraction4. out of these, phacoemulsification is now the gold standard. as compared to conventional extracapsular cataract extraction (ecce), phacoemulsification offers the advantages of faster, more predictable wound healing, reduced discomfort to patients, and fewer wound complications and less chances of post-operative astigmatism. these advantages are mainly due to the smaller incision (usually 3.5 mm or less) that is used in phacoemulsification. the sutureless clear corneal incision was first described 1992 and is currently the preferred incision for phacoemulsification cataract surgery. the wound generally does not require any stitch as it is watertight. sutureless surgery has generally been shown to be associated with less astigmatism compared with conventional ecce. larger incisions made to insert non foldable lols are likely to require at least one stitch. in addition, some surgeons simply prefer the safety of having the incision sutured, even if the incision is already watertight. wound instability is associated with wound leak, endopthalmitis, and other feared complications of cataract surgery5. we report the findings of a study which compared the rates of significant post operative wound leak and anterior chamber (ac) reaction in patients undergoing phacoemulsification cataract surgery with sutured and sutureless corneal incisions. materials and methods all eyes that were scheduled to have phacoemulsification surgery by tag at the agha khan university hospital and by mhs at shahzad eye hospital were included in the study. eyes with very dark brown cataracts were excluded because of a likelihood of converting to ecce or prolonged phacoemulsification time. eyes with phacoemulsification time greater than 1.5 minutes were also excluded. post-operatively, eyes with corneal edema were excluded as this interfered with the evaluation of anterior chamber reaction. the first group of eyes underwent uncomplicated phacoemulsification surgery with 3.25 mm superior and superior-temporal clear corneal incisions. the incision was sutured using a single 10/0 nylon suture. the second group of eyes underwent an identical surgery, but the incision was not sutured. patients were followed up at 24 hours, and 1 week and evaluated by slit lamp for the presence of wound leak (using seidel’s test), and ac cells and flare. a seidel's test includes application of a fluorescein strip with local anesthetic into the conjunctival sac and then examination of the wound using a cobalt blue filter. if fluid appears to flow from the wound, there's a leak. anterior chamber (ac) reaction was assessed using slit lamp to determine the number of cells and the amount of flare in the anterior chamber. ac reaction was called significant if the number of cells in one field, with any amount of flare, were > 10. surgeons who operated, assessed the patients postoperatively and recorded the findings. the data were entered and analyzed using spss software (version 11.5; spps inc., chicago, usa). means (± sd) were calculated for continuous variables and frequencies and proportions for categorical variables. chi-square test was used to compare the rates of wound leak and ac reaction in the two groups. results 48 eyes of 42 patients, 28 men and 14 women, underwent surgery with sutured corneal incisions and 50 eyes of 44 patients, 25 men and 19 women, underwent sutureless surgery. the mean ages of patients in groups 1 and ii were 61.2 years and 63.3 years, respectively. following surgery, none of the patients in two groups showed wound leak at 24 hours and 1 week. in addition, at 24 hours only 14.6% of eyes in group 1 showed ac reaction, compared to 32.0 % in group ii (p = 0.04). at one week post-op, 16.7% and 20.0% of eyes in groups i and ii showed ac reaction, respectively. however, the difference was not statistically significant (p = 0.67). discussion to the best of our knowledge, this is the first study in pakistan to compare the rates of postoperative wound leak and anterior chamber reaction in patients undergoing phacoemulsification cataract surgery with sutured and sutureless corneal incisions. we found that that there were no statistically significant differences in the rates of postoperative wound leak and anterior chamber reaction in the two groups at 24 hours and one week. these findings may have important implications. for example, unsutured surgery is less time-consuming than sutured surgery. in addition it is cost effective because no suture is required. some surgeons may still prefer to suture the incision after phacoemulsification for their own satisfaction although our study showed no added advantage of this practice. 116 comparison with other studies an extensive review of national and international literature revealed there were no studies that directly compared the rates of postoperative wound leak and anterior chamber reaction in the two groups we studied. however, there were several studies that compared postoperative astigmatism between sutured and unsutured phaco surgery. we plan to address these in our future studies. our study had the following limitations: first, the sample size was small, especially for the assessment of wound leak which is a relatively rare outcome. second, participants were not assigned to the two interventions randomly. randomization eliminates selection biases. we conclude that the rates of postoperative wound leak and anterior chamber reaction in sutured and suture less phacoemulsification are not different. thus sutured surgery offers no added advantages. author’s affiliation tanveer anjum chaudhry assistant professor section of ophthalmology department of surgery agha khan university karachi m. h. shahzad shahzad eye hospital b-2 block 16, gulshan-e-iqbal karachi-75300 sameer khan agha khan university medical college karachi khabir ahmad section of ophthalmology department of surgery agha khan university karachi reference 1. resnikoff s, pascolini d, etya'ale d, et al. global data on visual impairment in the year 2002. bull world health organ 2004; 82: 844-51. 2. memon ms: prevalence and causes of blindness in pakistan. j pak med assoc 1992; 42: 196-8. 3. ahmad k, khan md, qureshi mb, et al. prevalence and causes of blindness and low vision in a rural setting in pakistan. ophthalmic epidemiol. 2005; 12: 19-23. 4. snellingen t, evans jr, ravilla t, et al. surgical interventions for age-related cataract. cochrane database syst rev 2002: cd001323. 5. buratto l, werner l, zanini m, et al. phacoemulsification: principles and techniques, slack incorporated, thorafore nj, usa; 2003.. comparison of salbutamol delivered by a metered dose inhaler with spacer versus a nebulizer in children presenting with wheeze in pediatric emergency department 229 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol original article efficacy of 0.03% dermatological tacrolimus ointment for refractory vernal keratoconjunctivitis hafiza sadia imtiaz, irfan qayyum malik, usama iqbal, farhan ali, muhammad sharjeel doi 10.36351/pjo.v35i4.872 pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. hafiza sadia imtiaz department of ophthalmology, dhq-uth, gujranwala email: sadiaimtiaz69@gmail.com …..……………………….. purpose: to determine the efficacy of 0.03% dermatological tacrolimus ointment in patients with refractory vernal keratoconjunctivitis. study design: quasi-experimental study. place and duration of study: eye department, dhq-teaching hospital, gujranwala, pakistan from april 2018 to march 2019. material and methods: after approval from hospital ethical committee and obtaining written informed consent from each patient/guardian, patients of either gender between 4-16 years of age with vkc not responding to conventional treatment for more than 8 weeks or having steroid-induced complications were included in this study. dermatological tacrolimus ointment 0.03% was placed in inferior fornix in bd dose frequency along with topical lubricants. patients were followed up on a regular schedule. individual symptoms score was assessed from the questionnaire and signs score from observer’s clinical assessment. data were analyzed using spss v23.0. pvalue <0.05 was considered as statistically significant. results: forty eyes of 20 patients were included in this study. out of 40, four (20%) were female and 16 were male (80%). mean baseline score for clinical symptoms was 6.65 ± 1.81 that reduced to 1.65 ± 0.81 after 12 weeks’ treatment course of tacrolimus with a significant p-value of 0.006 (p < 0.05). mean baseline score for clinical signs was 5.9 ± 1.59 that improved to 1.80 ± 0.83 after 12 weeks’ treatment course with a statistically significant p-value of 0.003 (p < 0.05). conclusion: in conclusion, topical tacrolimus dermatological ointment 0.03% is highly effective in refractory vkc and can be safely used as an alternative in vkc patients who are steroid-responders. key words: tacrolimus, vernal keratoconjunctivitis, mast cell stabilizers, antihistamines. ernal keratoconjunctivitis (vkc) is a chronic, recurrent, bilateral conjunctival inflammation that has seasonal exacerbations in summer and late spring and involve both type i as well as type iv hypersensitivity reactions1. it mainly affects children between 3 and 16 years of age with remission by late teens in 95% of cases. young boys in dry and hot climates are generally affected2. patients with vkc suffer from significant morbidity. symptoms include severe itching, foreign body sensation, mucoid discharge, photophobia, and blurred vision. common clinical signs of vkc are conjunctival hyperemia, papillary hypertrophy, mucous discharge, hornertrantas dots, and corneal involvement3. v mailto:sadiaimtiaz69@gmail.com efficacy of 0.03% dermatological tacrolimus ointment for refractory vernal keratoconjunctivitis pak j ophthalmol vol. 35, no. no. 4, oct – dec, 2019 230 treatment options available for vernal keratoconjunctivitis include topical antihistamines, mast cell stabilizers, nsaids, steroids, and immunomodulators4. prolonged treatment course with multiple remissions is the major threat faced among vkc patients. secondly, as topical steroids are the mainstay of management for moderate to severe vkc but their injudicious and prolonged use can lead to secondary glaucoma, cataract, and secondary infections5. risk of these complications is particularly high among children who are the most commonly affected age group in vkc. to prevent the occurrence of steroid-induced complications in vkc patients, certain immunomodulators are in use.6 two being cyclosporine and tacrolimus, of which tacrolimus is strong, nonsteroidal, macrolide immunomodulator isolated from streptomyces tsukubaensis that has 100 times more potency than cyclosporine7. though uncertainty exists about its mechanism of action but it is known to interact with 12-kda fk506-binding protein in t-cells and thus inhibits calcineurin activity that ultimately leads to reduced de-phosphorylation of the nuclear factor of activated t-cells and hence th1 (il-2, interferonγ), as well as th2 cytokines (il-4, il5) production is reduced8. tacrolimus is also known to inhibit histamine release from mast cells thus alleviating the symptom of itching9. in ophthalmic practice, topical tacrolimus in doses of 0.001–0.1% are in use for many refractory inflammatory ocular surface diseases including vernal keratoconjunctivitis (vkc)10. its proper dosage, frequency, duration and adverse events in the eye still lie in an undiscovered domain. the rationale of this study was to confirm efficacy and safety of low dose topical tacrolimus ointment 0.03% for refractory vernal keratoconjunctivitis nonresponding to conventional treatment and also to find out an alternative treatment for vkc eyes suffering from steroid-induced complications. material and methods after approval from the hospital ethical committee, a written informed consent with demographic variables was collected from patients/guardians. patients of either gender between 4-16 years of age with vkc not responding to conventional treatment (antihistamines/mast cell stabilizers/nsaids/steroids) for more than 8 weeks or having steroid-induced complications were included in this study. exclusion criteria was immunocompromised patients, pregnant females, recent ocular surgery in previous 3 months and infectious ocular disease in particular, herpes infection. this study included 40 eyes of 20 patients and was conducted at eye department of dhqteaching hospital gujranwala during 12 months (april 2018 – march 2019). all patients underwent routine ophthalmic examination including visual acuity, bcva, slit lamp biomicroscopy with fluorescein staining as well as photography, fundus evaluation, and applanation tonometry. diagnosis of vkc was made on a clinical basis with 4 symptoms of itching, redness, photophobia, mucoid discharge and 4 clinical signs of conjunctival hyperemia, papillary hypertrophy, horner-trantas dots, and corneal involvement. before starting treatment with tacrolimus and at each visit thereafter, all patients/guardians were given a questionnaire to grade all four symptoms into scale 0 (none), scale 1 or mild, scale 2 or moderate, and scale 3 or severe11. similarly, clinical signs were also categorized by one observer into scale 0 (none), scale 1 (mild), scale 2 (moderate), or scale 3 (severe) in following way11. table 1: signs score grading. signs score description conjunctival hyperemia 3 2 1 0 diffuse dilated vessels over entire bulbar conjunctiva dilatation of many vessels dilatation of few vessels none papillae 3 2 1 0 papillae size > 0.3 mm papillae size 0.2-0.3mm papillae size <0.2mm none trantas 3 2 1 0 > 6 dots 4-6 dots 1-3 dots none spk 3 2 1 0 total corneal surface more than half corneal surface less than half corneal surface none dermatological tacrolimus ointment 0.03% was advised to be placed in inferior fornix in bd dose while all other conventional topical medications (antihistamine, mast cell stabilizers, nsaids) were discontinued except for steroids that were tapered off. topical lubricants were also prescribed in bd frequency to reduce irritation, which is seldom observed with tacrolimus ointment. hafiza sadia imtiaz, et al 231 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol patients were followed up at 3 days after starting the medication and then at 2 weeks, 4 weeks, 8 weeks and final follow up at 3 months. in each visit, the above mentioned questionnaire and ophthalmic examination were repeated to attain final clinical score along with photographs and the patients were also specifically asked about the discomfort associated with the use of tacrolimus ointment. improvement of each symptom or sign was defined as at least 1-score reduction in severity compared with values before the treatment. paired ttest was used to statistically analyze the changes in mean clinical score before and after treatment. data was analyzed using spss v23.0. results were expressed as mean ± sd and percentages. p-values of 0.05 or less were considered as statistically significant. results average age of the participants of the study was 9.05 ± 3.58 (range 4-16) years. eleven (55%) patients were between 4-8 years of age, 5 (25%) between 9-12 years of age and 4 (20%) between 13-16 years of age. mean duration of conventional treatment before starting tacrolimus ointment was 10 months with sd of ± 5.96. while using conventional treatment, 4 patients (20%) were only on topical steroids, 9 patients (45%) were using anti-histamines, mast cell stabilizers and nsaids and 7 (35%) were on combination of all. most common symptom found in this study was itching that was present in 90% of total study population and it also first responded to treatment within 2 weeks. least common symptom observed was photophobia that was present in 40% of cases. most common sign observed in this study was papillary hypertrophy that was present in 80% of total study population and it slowly responded to treatment within 8 weeks’ duration. least common sign observed was corneal involvement that was present in 30% of cases. symptoms sore was calculated from questionnaire. each symptom (total 4) was graded on a scale of 0-3 thus rendering individual symptoms score out of 12. mean symptoms score at baseline was 6.65 ± 1.81 that reduced to 6.25 ± 1.68 after three days post-treatment with insignificant pvalue of 0.354. at 4 weeks follow up, p-value turned out statistically significant (p = 0.009) with symptoms score of 3.30 ± table 2: individual symptoms and signs in percentages. symptoms / signs percentage (%) total no. (n) itching 90% 36 eyes of 18 pts. redness 70% 28 eyes of 14 pts. mucoid discharge 50% 20 eyes of 10 pts. photophobia 40% 16 eyes of 8 pts. papillary hypertrophy 80% 32 eyes of 16 pts. conjunctival hyperemia 70% 28 eyes of 14 pts. trantas dots 40% 16 eyes of 8 pts. corneal involvement (spk) 30% 12 eyes of 6 pts. table 3: symptoms score at different intervals. symptoms score at different intervals mean std. deviation p-value symptoms score at baseline 6.65 1.81 symptoms score after 3 days 6.25 1.68 0.354 symptoms score after 2 weeks 4.45 1.23 symptoms score after 4 weeks 3.30 1.17 0.009 symptoms score after 8 weeks 2.45 1.19 symptoms score after 12 weeks 1.65 0.81 0.006 table 4: signs score at different intervals. signs score at different intervals mean std. deviation p-value signs score at baseline 5.90 1.59 signs score after 3 days 5.45 1.36 0.233 signs score after 2 weeks 4.10 1.07 signs score after 4 weeks 3.30 1.08 0.035 signs score after 8 weeks 2.60 1.05 signs score after 12 weeks 1.80 0.83 0.003 1.17 that markedly reduced to 1.65 ± 0.81 with significant p-value of 0.006. signs score was calculated from observer’s clinical response at each visit in which each clinical sign (total 4) was graded by observer on a scale of 0-3, again rendering the total score of 12. mean signs score at baseline was 5.90 ± 1.59 that reduced to 5.45 ± 1.38 three days post-treatment with insignificant p-value of 0.233. at 4 weeks follow up, p-value turned out statistically significant (p = 0.035) with signs score of 3.30 ± 1.08 that markedly reduced to 1.80 ± 0.83 with significant p-value of 0.003. at baseline, mean score for symptoms was 6.65 while that for efficacy of 0.03% dermatological tacrolimus ointment for refractory vernal keratoconjunctivitis pak j ophthalmol vol. 35, no. no. 4, oct – dec, 2019 232 fig. 1: line chart showing gradual decline in symptoms and signs score. 2a): grade iii papillary hypertrophy at baseline. 2b): grade i papillary hypertrophy at 4 weeks. 2c): grade 0 papillary hypertrophy at 8 weeks duration. fig. 2(a-c): resolution of papillary hypertrophy with tacrolimus. 3a): grade iii trantas dots at baseline. 3b): grade i trantas dots at 8 weeks duration fig. 3(a-b): resolution of limbal trantas dots with tacrolimus. hafiza sadia imtiaz, et al 233 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol signs was 5.90. at 4 weeks interval both mean scores were found to be 3.30. while after 4 weeks, symptoms score reduced more markedly than signs score and at final follow up, mean score for symptoms was 1.65 and that for signs was 1.80. discussion this study confirmed the efficacy and safety of topical tacrolimus 0.03% in vkc, which were refractory to conventional treatment. all patients showed marked improvement in signs and symptoms without developing any significant adverse effects. mild irritation was noted in 4 patients initially with the use of tacrolimus ointment but that subsided after one week. chatterjee et al. also reported mild transient stinging sensation in their study population but that also lasted only for few days12. most common symptom in our study was itching that was noted in 90% (36 eyes of 18 patients) of patients and it was also first to resolve within 2 weeks duration. in a similar study by al-amri et al 17 out of 20 patients complained of itching and all cases improved within 1 week13. most common clinical sign noted was papillary hypertrophy that was present in 80% of patients (32 eyes of 16 subjects) and it resolved in relatively longer period of about 8 weeks. conjunctival hyperemia responded to treatment first and resolved within 4 weeks in 12 out of 20 patients. barot et al. also reported conjunctival hyperemia to get resolved within 1 month in 60% of patients.14 corneal involvement was least observed among participant patients probably due to early visit to ophthalmologist. in our study, mean baseline score for clinical symptoms was 6.65 ± 1.81 that reduced to 1.65 ± 0.81 after 12 weeks treatment course of topical tacrolimus with significant p-value of 0.006 (p < 0.05). mean baseline score for clinical signs was 5.9 ± 1.59 that improved to 1.80 ± 0.83 after 12 weeks treatment course with statistically significant p-value of 0.003 (p < 0.05). results of this study are also supported by few other recently conducted studies15,16,17. fukushima et al. carried out similar study on large population including 1436 patients with refractory allergic conjunctivitis and concluded that 0.1% tacrolimus eye drops are highly effective in treating this refractory condition with corneal involvement thus alleviating need for topical steroids use.15 muller et al. suggested topical tacrolimus 0.03% as sole therapy in vkc by dividing study population in two groups; one with only topical tacrolimus ointment and other with topical tacrolimus ointment + olopatadine eye drops and found out same efficacy with no significant difference between the two groups16. kheirkhah et al. used low dose 0.005% topical tacrolimus drops in refractory vkc cases and results showed it effective and safe alternative for steroid resistant cases17. tacrolimus is widely used in many refractory ophthalmic conditions other than vernal keratoconjunctivitis. al-amri reported the successful use of 0.1% dermatological tacrolimus ointment in 22 patients with atopic kertoconjunctivitis18. many studies have concluded the therapeutic efficacy of tacrolimus ointment in chronic ocular graft versus host disease (gvhd)19,20,21. choi et al. reported the effective role of 0.03% tacrolimus eye drops in refractory dry eye disease associated with chronic ocular gvhd21. the limitation of our study is the off-label use of drug, as its ophthalmic preparation is not available in pakistan. but many other authors also safely recommended the use of this skin preparation for ophthalmic usage18,22. second limitation of this study is relatively small sample size and that is due to patient’s/guardian’s reluctance towards use of offlabel drug. third being short duration of follow up (3 months) as it cannot be determined the risk of recurrence after drug has been stopped. in the end, the author suggests that its ophthalmic preparation should be available in our country like elsewhere so similar studies can be carried out on large scale for a long period of time for better determination of its efficacy and safety. conclusion in conclusion, topical tacrolimus dermatological ointment 0.03% is effective in relieving signs and symptoms of refractory vkc cases that are not responding to conventional treatment and also that topical tacrolimus can be safely used as an alternative in vkc patients who are steroid-responders, to lower the risk of steroid-induced complications. conflict of interest the author has no financial or personnel conflict of interest in this study. source of funding no source of funding in this study. efficacy of 0.03% dermatological tacrolimus ointment for refractory vernal keratoconjunctivitis pak j ophthalmol vol. 35, no. no. 4, oct – dec, 2019 234 references 1. addis h, jeng b. vernal keratoconjunctivitis. clin ophthalmol. 2018; 12: 119-23. 2. nebbioso m, zicari a, celani c, lollobrigida v, grenga r, duse m. pathogenesis of vernal keratoconjunctivitis and associated factors. semin ophthalmol. 2014; 30 (5-6): 340-4. 3. dahal p, bhattarai s. clinical presentation of vernal keratoconjunctivitis in bharatpur medical college. j coll med sci-nepal. 2015; 11 (2): 17-9. 4. nagrale d. study of clinical features and management of vernal keratoconjunctivitis. j med sci clini res. 2017; 05 (01): 15754-9. 5. phulke s, kaushik s, kaur s, pandav s. steroidinduced glaucoma: an avoidable irreversible blindness. j curr glaucoma pract. 2017; 11 (2): 67-72. 6. sacchetti m, bruscolini a, abicca i, nebbioso m, la cava m, bonini s et al. current and emerging treatment options for vernal keratoconjunctivitis. expert opin orphan drugs, 2017; 5 (4): 343-53. 7. singla e, singh 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872-80. 18. al-amri a. long-term follow-up of tacrolimus ointment for treatment of atopic keratoconjunctivitis. am j ophthalmol. 2014; 157 (2): 280-6. 19. jung j, lee y, yoon s, kim t, kim e, seo k. long-term result of maintenance treatment with tacrolimus ointment in chronic ocular graft-versus-host disease. am j ophthalmol. 2015; 159 (3): 519-27. 20. ryu e, kim j, laddha p, chung e, chung t. therapeutic effect of 0.03% tacrolimus ointment for ocular graft versus host disease and vernal keratoconjunctivitis. korean j ophthalmol. 2012; 26 (4):241-7. 21. choi s, chung s. therapeutic effects of 0.03% tacrolimus eye drops for chronic ocular graft-versushost disease. j korean ophthalmol soc. 2015; 56 (10): 1505-10. 22. liu f, liu h, chu h, chen w, hu f, wang i. dermatologic tacrolimus ointment on the eyelids for steroid-refractory vernal keratoconjunctivitis. graefes arch clin exp ophthalmol. 2019; 257 (5): 967-74. author’s affiliation dr. hafiza sadia imtiaz postgraduate trainee department of ophthalmology dhq-uth, gujranwala dr. irfan qayyum malik associate professor department of ophthalmology dhq-uth, gujranwala dr. usama iqbal postgraduate trainee department of ophthalmology dhq-uth, gujranwala dr. farhan ali assistant professor department of ophthalmology dhq-uth, gujranwala hafiza sadia imtiaz, et al 235 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol dr. muhammad sharjeel senior registrar gomal medical college dera ismail khan author’s contribution dr. hafiza sadia imtiaz manuscript writing, data collection and analysis dr. irfan qayyum malik supervisor, manuscript review dr. usama iqbal data collection, manuscript writing dr. farhan ali data analysis, manuscript writing dr. muhammad sharjeel manuscript writing http://www.gmcdikhan.edu.pk/ http://www.gmcdikhan.edu.pk/ 173 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol original article comparison of post-operative inflammatory pattern between intracameral ceftazidime and cefuroxime used for the prevention of post-operative endophthalmitis muhammad moin, arooj amjad, sameer nagi pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: arooj amjad, assistant professor, postgraduate medical institute, ameer ud din medical college, lahore phone: +92-33344380677 email: arooj.amjad@gmail.com …..……………………….. purpose: to compare the post operative inflammatory pattern after phacoemulsification in patients receiving intra-cameral injection of ceftazidime and cefuroxime per-operatively for the prevention of post-operative endophthalmitis. study design: quasi experimental study. place and duration of study: ophthalmology department unit-1, lahore general hospital, lahore from november 2016 to march 2018. material and methods: patients undergoing phacoemulsification with intraocular lens implantation were divided into 2 groups by convenient sampling. group a received cefuroxime and group b received ceftazidime both as 1 mg/0.1ml intra-cameral injections at the end of the routine surgery. the patients were examined pre and post operatively on slit lamp and the number of cells in the anterior chamber (a/c) were counted on first day, first week and 6 weeks after surgery. results: out of 260 patients there were 130 in each group. on the first postoperative day in group a there were grade 1 cells in a/c in 22 patients, grade 2 in 93 patients, grade 3 in 14 patients and grade 4 in 1 patient. in group b there were grade 1 cells in a/c in 11 patients, grade 2 in 96 patients, grade 3 in 20 patients and grade 4 in 3 patients. after one week, in group a, cell counts were grade 0 in 27 patients while in group b, cell counts were grade 0 in 23 patients. after 6 weeks no patient in any group showed any activity in the anterior chamber. conclusion: there is little difference in post operative inflammatory pattern of intracameral ceftazidime antibiotic prophylaxis as compared to intracameral cefuroxime. key words: endophthalmitis, cataract surgery, cefuroxime, ceftazidime. ataract is one of the most common causes of reversible blindness in the world and cataract surgery is one of the most commonly performed routine procedures by the ophthalmologists. although there is a high success rate but still cataract surgery can lead to serious complications such as endophthalmitis, which is an inflammatory reaction that occurs as a result of intraocular colonization by microorganisms such as bacteria, fungi and rarely parasites. it can either be exogenous in type which can occur post-operatively or after trauma because of microbial contamination that spreads from the ocular surface or open wound or through contaminated instruments, intraocular c comparison of post-operative inflammatory pattern between intracameral ceftazidime and cefuroxime pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 174 implants such as lenses (iols) or intraocular foreign bodies or it can be endogenous (septicemia) in origin. endophthalmitis has a poor visual outcome as shown by the european society of cataract and refractive surgeons (escrs) study where 17% of the patients had a final visual acuity 20/200 or worse and 48.3% had a final visual acuity 20/40 or worse1. furthermore, if it is not treated it can progress and the inflammation can spread to other intraocular structures leading to great reduction in quality of life2. it can cause complete loss of visual acuity and/or loss of the involved eye. according to the escrs study the patients undergoing cataract surgery using a clear corneal incision were more likely to develop postoperative endophthalmitis by 5.88 times as compared to those in which scleral incision was used although there were other risk factors such as old age and wound dehiscence3. there have been many methods described to prevent post-operative endophthalmitis. one of the most commonly used methods to prevent the infection was prophylactic instillation of 5% povidone–iodine or topical antibiotic drops into the conjunctival sac per-operatively4. one study described that per-operative injection of antibiotics in the anterior chamber (intra-cameral) might be able to eliminate the bacteria that got access to the anterior chamber. in this regard, the antibiotics could either be given as continuous infusion during the surgery along with the irrigating bss (basic salt solution) as a variable dose5 or at the end of surgery as a fixed dose bolus injection. a uk based study compared the efficacy of subconjunctival antibiotic injection and intracameral antibiotic injection6 for the prevention of post-operative endophthalmitis concluding that the intracameral injections were more effective than subconjunctival injections. many studies compared different antibiotics to be given as an intracameral injection at the end of surgery for the same purpose. in a retrospective study and some prospective trials, cephalosporins and vancomycin were studied extensively and evidence was provided on clinical efficacy of intracameral cephalosporins7. in this regard, the drug that proved to be very effective in reduction of the risk for acute onset of post-operative endophthalmitis was intracameral cefuroxime8. these studies however, did not compare the efficacy and safety of cephalosporins other than cefuroxime. this limitation was addressed by another study which compared cefuroxime, cefazolin and ceftazidime and their safety profiles for intracameral use9. apparently, 1 mg intracameral injection of cefuroxime effectively inhibited all the sensitive bacterial strains and therefore, it was associated with a low incidence of postoperative endophthalmitis. cefuroxime was chosen on the basis of a swedish study which comprised of a series of endophthalmitis cases from the year 1996 to the year 2000. moreover, a thirdgeneration cephalosporin, ceftazidime was also used in sweden following an epidemic that was caused by a gram-negative bacterial strain. another study showed the availability of intracameral antibiotics according to spectrum of activity, pharmacology, preparation, dosage as well as their safety and efficacy10. the rationale of our study was to consider more alternatives to cefuroxime for the treatment of postoperative endophthalmitis. although cefuroxime is used on regular basis, it has been less available in areas where it is not produced locally with pharmaceutical companies discontinuing its production abroad. ceftazidime being its potential substitute could therefore be used. the purpose of this study was to compare the post operative inflammatory pattern after phacoemulsification in patients receiving intra-cameral injection of ceftazidime and cefuroxime per-operatively for the prevention of post-operative endophthalmitis. material & methods patients undergoing cataract surgery in the ophthalmology department of lahore general hospital, lahore were selected by convenient sampling to receive prophylactic intracameral injections of antibiotics towards the end of routine cataract surgery. the patients included in this study were adult patients who presented in ophthalmology department of lahore general hospital from november 2016 to march 2018. the patients with history of previous trauma, uveitis, corneal disease, glaucoma and complicated cataract were excluded from the study. patients with only eye and/or those with history of endophthalmitis in the other eye were also not included. these patients were divided into two groups. in group a, the patients received cefuroxime whereas those in group b received ceftazidime both as 1 mg/0.1ml intracameral injections at the end of the surgery after wound hydration and before chamber formation. approval was taken from the hospital ethical review committee. the patients were examined pre and post operatively on slit lamp prior to pupillary dilatation on the slit lamp (haag streit, bq 900). post operative inflammation was graded according to the number of anterior chamber cells in a 1 mm by 1 mm slit beam muhammad moin, et al 175 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol field using 16 times magnification as anterior chamber cells are a dispensable indicator of inflammatory activity. this was done according to sun (standardization of uveitis nomenclature) working group grading of the anterior chamber cells11 as shown in table 1. follow up examinations were done on day 1, week 1 and week 6 after surgery. the data was recorded on an electronic medical database and later on analyzed by using spss 20.0. comparison of the table 1: grading of anterior chamber cells (1 mm by 1 mm slit beam) according to sun11. grade cells in field 0 < 1 1+ 6 – 15 2+ 16 – 25 3+ 26 – 50 4+ > 50 two groups was done using chi square test and p value equal to or less than 0.05 was taken as significant. results out of total 260 patients, 130 were allocated to each group. the first post-operative day results showed mostly mild to moderate inflammation (grade 1 and 2) in both groups. after 1st post operative week there was mostly none to mild inflammation (grade 0 and 1) in both groups. on last follow up at 6 weeks there was no inflammation (grade 0) in both groups (table 2). while performing pearson chi square tests for independence on day 1 and week 1 the values were high on chi square test statistics (5.773 and 3.540) indicating that there is very little if no relationship between the antibiotics used (table 3). furthermore, none of the patients developed endophthalmitis. table 2: results on first day, first week and 6 weeks after surgery. antibiotic cells in anterior chamber 1st day post-op total p value grade 0 grade 1 grade 2 grade 3 grade 4 (group a) cefuroxime (group b) ceftazidime total 0 0 0 22 (17%) 11 (8 %) 33 93 (71%) 96 (74%) 189 14 (11%) 20 (16%) 34 1 (1%) 3 (2%) 4 130 130 260 .123 cells in anterior chamber 1st week post-op total p value grade 0 grade 1 grade 2 grade 3 grade 4 (group a) cefuroxime (group b) ceftazidime total 27 (21%) 23 (18%) 50 100 (76.5%) 102 (78.5%) 202 2 (1.5%) 3 (2%) 5 0 (0%) 2 (1.5%) 2 1 (1%) 0 (0%) 1 130 130 260 .472 cells in anterior chamber 6 week post-op total p value grade 0 grade 1 grade 2 grade 3 grade 4 (group a) cefuroxime (group b) ceftazidime total 130 (100%) 130 (100%) 260 0 0 0 0 0 0 0 0 0 0 0 0 130 130 260 .472 table 3: statistical analysis using chi square test for day 1 and week 1. statistical analysis analysis for day 1 analysis for week 1 value df asymp. sig. (2-sided) value df asymp. sig. (2-sided) pearson chi-square likelihood ratio linear by linear association no. of valid cases 5.773 5.896 5.313 260 3 3 1 .123 .117 .021 3.540 4.700 .000 260 4 4 1 .472 .319 1.00 comparison of post-operative inflammatory pattern between intracameral ceftazidime and cefuroxime pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 176 discussion post-operative endophthalmitis (poe) after cataract surgery is a dangerous and vision-threatening yet uncommon complication that is reported to occur at approximate rates ranging from 0.03% to 0.2%. the most critical steps for minimizing the incidence of visual loss due to endophthalmitis are prompt diagnosis and early treatment. however, most recently all the efforts have been focused on the administration of antibiotics prophylactically so as to prevent the development of endophthalmitis12. for prevention of this serious complication many methods have been tried and tested from instillation of 5% povidone iodine in the eye pre-operatively to subconjunctival and intra-cameral antibiotic injections at the end of surgery. among these methods, intracameral injection of cephalosporins has been under limelight for the past two decades. according to a survey conducted in pakistan in 2005 only 1.87 percent of the consultants used intracameral antibiotic injections prophylactically for the prevention of post-operative endophthalmitis13. in our study, we have compared the efficacy of two commonly used intracameral cephalosporins; cefuroxime and ceftazidime. due to non-availability of intracameral preparations of cephalosporins on a commercial level, we had to reconstitute the injection from the readily available powder form provided for either intravenous or intramuscular injections. for this purpose the manufacturers of these drugs recommended the use of distilled water. we used normal saline to reconstitute the solutions for intracameral use so as to avoid hypo-tonicity, as in the majority of clinical studies. gupta et al used balanced salt solution as control14. lockington et al however, gave a comparison of two protocols for dilution of cefuroxime injection13. they concluded that errors were bound to arise with usage of small (1cc) syringes. in our study, we used preparations that were reconstituted from 1 gram ceftazidime vials and 750 milligrams cefuroxime vials. we used 10 cc syringes for this purpose, ensuring complete dissolution of the powdered drug and accuracy of dose. errors in drug dilution and dose calculation may lead to increased risk of toxic anterior chamber syndrome. the reconstituted cephalosporin solutions were discarded after 4 hours of preparation so as to avoid any possible loss of efficacy. after all these measures, we injected intracameral cefuroxime in group a patients and ceftazidime in group b patients. we then measured cells in their anterior chambers on day 1, week 1 and week 6 post-operatively. there was no statistically significant difference in the efficacy of both drugs. however, just like barry et al this study only counted number of anterior chamber cells, not taking other diagnostic criteria for both acute and chronic endophthalmitis and other potential measurable features into account15. also, in our study the absolute endothelial cell loss was not measured as montan et al did in their study which was done on the safety of intracameral cefuroxime10. some large case series and randomized clinical trials showed the safety and efficacy of prophylactic use of intracameral cephalosporin injections for prevention of post-operative endophthalmitis following cataract surgery. according to the results from european society of cataract and refractive surgeons (escrs) multicenter randomized control trial which was done on 16,211 patients, the risk of development of endophthalmitis could be fairly reduced by 4.9-fold with use of a prophylactic intracameral injection of cefuroxime16. another analysis comparing the efficacy and safety of different antibiotic groups has shown that intracameral injections of moxifloxacin and cefuroxime reduce the rate of occurrence of endophthalmitis as compared to the controls with minimal or no toxicity events at the standard routine doses17. according to a ten year comparative study also, intracameral cefuroxime has proven to be very effective in reduction of risk for acute-onset endophthalmitis after cataract surgery18. another study concluded that 1 mg intracameral injection of cefuroxime apparently inhibited all the sensitive bacterial strains effectively and was also associated with a low incidence of postoperative endophthalmitis19. seal et al concluded that the risk of contracting endophthalmitis after cataract removal by phacoemulsification was fivefold decreased by per-op intracameral injection of cefuroxime20. the p values were given as 0.001 for presumed endophthalmitis and 0.005 for proven endophthalmitis. a german study also gave results that supported the significantly effective role of intracameral injection of cefuroxime in reduction of the rate of postoperative infectious endophthalmitis after cataract surgery21. the economic evaluation also compared many different prophylaxis regimens and drew the inference that intracameral cefuroxime has proved to be the best when it comes to cost-effectiveness22. however, we needed an effective substitute of cefuroxime because of its non-availability in areas where it is not produced locally with international pharmaceutical companies discontinuing distribution muhammad moin, et al 177 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol locally. therefore, in our study we compared the effect of intracameral cefuroxime injection with intracameral ceftazidime injection and found that both produced similar post operative inflammatory patterns and endophthalmitis was not seen in any patient. a randomized control trial on the safety of intracameral cephalosporins concluded that ceftazidime, cefuroxime and cefazolin all could be safely used as 1 mg in 0.1 ml prophylactic intracameral injection during cataract surgery towards the end. in this series, 55 out of 59 strains of microbial pathogens that were isolated were found sensitive to cefuroxime9. according to a recent study, the evidence to support intracameral cefuroxime use for reduction in the rate of acute post-operative endophthalmitis after cataract surgery is not strong enough. there is however, a marginal benefit that might be considered to justify its use23. more recently there have been debates about the use of intracameral antibiotic prophylaxis in every patient undergoing cataract surgery on routine basis24. the limitation of our study was that it was done at one center only and the sample size was small. to get more generalizable results in the population larger multicenter study needs to be done. if substantiated by a further research involving many centers our study may provide further rationale for the use of ceftazidime as compared to cefuroxime. conclusion in summary, we demonstrate that there is no significant statistical difference between the post operative inflammatory patterns of both the treatments. they both prevent endophthamitis and there is little if any difference in ceftazidime antibiotic prophylaxis compared to the current cefuroxime regimen used in the patients. this, in turn, can further aid and help in the evaluation of the safety and effectiveness of the two antibiotics above and beyond just prevention of a post-operative complication. financial disclosure no author has a financial or proprietary interest in any material or method mentioned. conflict of interest none. references 1. barry p, gardner s, seal d, gettinby g, lees f, peterson m et al. clinical observations associated with proven and unproven cases in the escrs study of prophylaxis of postoperative endophthalmitis after cataract surgery. j cataract refract surgery, 2009; 35 (9): 1523-1531.e1. doi: 10.1016/j.jcrs.2009.03.049. pubmed pmid: 19683148. 2. clark a, ng j, morlet n, tropiano e, mahendran p, spilsbury k et al. quality of life after postoperative endophthalmitis. clin exp ophthalmol, 2008; 36 (6): 526-531. j cataract refract surg. 2009 sep;35(9):1523-31, 1531.e1. doi: 10.1016/j.jcrs.2009.03.049. pubmed pmid: 19683148. 3. wejde g, samolov b, seregard s, koranyi g, montan p. risk factors for endophthalmitis following cataract surgery: a retrospective case–control study. j hosp infec, 2005; 61 (3): 251-256. 4. ciulla ta, starr mb, masket s. bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update. ophthalmology, 2002; 109 (1): 13–24. 5. sobaci g, tuncer k, taş a, özyurt m, bayer a, kutlu u. the effect of intraoperative antibiotics in irrigating solutions on aqueous humor contamination and endophthalmitis after phacoemulsification surgery. eur j ophthalmol. 2003; 13 (9–10): 773–778. 6. yu-wai-man p, morgan sj, hildreth aj, steel dh, allen d. efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery. j cat refract surg, 2008; 34 (3): 447-451. doi: 10.1016/j.jcrs.2007.10.041. 7. romero p, méndez i, salvat m, fernández j, almena m. intracameral cefazolin as prophylaxis against endophthalmitis in cataract surgery. j cataract refract surg. 2006; 32 (3): 438–441. 8. garcía-sáenz mc, arias-puente a, rodrígeuzcaravaca g, bañuelos jb. effectiveness of intracameral cefuroxime in preventing endophthalmitis after cataract surgery: ten-year comparative study. j cataract refract surg. 2010; 36 (2): 203–207. 9. lam pt, young al, cheng ll, tam pm, lee vy. randomized controlled trial on the safety of intracameral cephalosporins in cataract surgery. clin ophthalmol. 2010; 4: 1499–1504. 10. braga-mele r, chang df, henderson ba, mamalis n, talley-rostov a, vasavada a. intracameral antibiotics: safety, efficacy, and preparation. j cataract refract surg. 2014 dec; 40 (12): 2134-42. 11. trusko b1, thorne j, jabs d, belfort r, dick a, gangaputra s, nussenblatt r, okada a, rosenbaum j. the standardization of uveitis nomenclature (sun) project. development of a clinical evidence base utilizing informatics tools and techniques. methods inf med. 2013; 52 (3): 259-265. 12. george nk, stewart mw. the routine use of intracameral antibiotics to prevent endophthalmitis comparison of post-operative inflammatory pattern between intracameral ceftazidime and cefuroxime pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 178 after cataract surgery: how good is the evidence ophthalmol ther. 2018 dec; 7 (2): 233-245. 13. ashraf km, siddique m. endophthalmitis prophylaxis for cataract surgery: the first pakistan survey. j cataract refract surg. 2006; 32 (2): 368. 14. gupta ms, mckee hdr, saldaña m, stewart og. macular thickness after cataract surgery with intracameral cefuroxime. j cataract refract surg. 2005; 31 (6): 1163–1166. 15. barry p, behrens-baumann w, pleyer u, seal d. escrs guidelines on prevention, investigation and management of post-operative endophthalmitis. european society for cataract & refractive surgeons, 2007: 2. 16. endophthalmitis study group, european society of cataract and refractive surgeons. prophylaxis of postoperative endophthalmitis following cataract surgery: results of the escrs multicenter study and identification of risk factors. j cataract refract surg. 2007; 33 (6): 978–988. 17. bowen rc, zhou ax, bondalapati s, lawyer tw, snow kb, evans pr et al. comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin and vancomycin at the end of cataract surgery: a meta-analysis.br j ophthalmol. 2018 sep; 102 (9): 1268-1276. 18. garcía-sáenz mc, arias-puente a, rodríguezcaravaca g, bañuelos jb. effectiveness of intracameral cefuroxime in preventing endophthalmitis after cataract surgery: ten-year comparative study. j cataract refract surg, 2010; 36 (2): 203-7. 19. montan pg, wejde g, koranyi g, rylander m. prophylactic intracameral cefuroxime: efficacy in preventing endophthalmitis after cataract surgery. journal of cataract refract surg, 2002; 28 (6): 977-81. 20. seal dv, barry p, gettinby g, lees f, peterson m, revie cw et al. escrs study of prophylaxis of postoperative endophthalmitis after cataract surgery: case for a european multi-centre study. j cataract refract surg. 2006; 32: 396-406. 21. röck t, bramkamp m, bartz-schmidt ku, mutlu u, yörük e, röck d et al. using intracameral cefuroxime reduces postoperative endophthalmitis rate: 5 year experience at the university eye hospital tübingen. klin monbl augenheilkd. 2014 oct; 231 (10): 1023-1028. 22. linertová r, abreu-gonzález r, garcía-pérez l, alonso-plasencia m, cordovés-dorta lm, abreureyes ja et al. intracameral cefuroxime and moxifloxacin used as endophthalmitis prophylaxis after cataract surgery: systematic review of effectiveness and cost-effectiveness. clin ophthalmol. 2014 aug 14; 8: 1515-22. doi:10.2147/opth.s59776. 23. sharma s, sahu sk, dhillon v, das s, rath s. reevaluating intracameral cefuroxime as a prophylaxis against endophthalmitis after cataract surgery in india. j cataract refract surg. 2015 feb; 41 (2): 393-9. 24. grzybowski a. has the time come for all to routinely use intracameral antibiotic prophylaxis at the time of cataract surgery? am j ophthalmol. 2016 sep; 169: 293294. author’s affiliation prof. muhammad moin professor of ophthalmology postgraduate medical institute ameer-ud-din medical college lahore general hospital, lahore dr. arooj amjad assistant professor ophthalmology postgraduate medical institute ameer ud din medical college lahore general hospital, lahore sameer nagi elective student lahore general hospital, lahore final year medical student st. georges hospital, london, uk author’s contribution prof. muhammad moin study design, data collection, critical review. dr. arooj amjad manuscript writing and data analysis. sameer nagi statistical analysis and manuscript writing. pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 101 original article incidence of primary open angle glaucoma in patients presenting with retinal vein occlusion ch. javed iqbal, muhammad salman hamza, ch. nasir ahmed, qunber abbas, muhammad awais asghar pak j ophthalmol 2019, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: prof. ch. javed iqbal mbbs, mcps, fcps, fellowship in vitreoretina professor of ophthalmology 11-a nursery lane lawrence road lahore email: drj4eye@yahoo.com …..……………………….. purpose: to determine the incidence of primary open angle glaucoma in patients presenting with retinal vein occlusion in tertiary care hospital. study design and place of study: cross-sectional study. place and duration of study: eye unit ii, institute of ophthalmology, king edward medical university, mayo hospital, lahore. from january 2016 to december 2017. material and methods: a sample size of 100 cases was calculated with 95% confidence level, 5% margin of error. non-probability consecutive sampling was done. adult patients of either gender presenting with retinal vein occlusion (rvo) diagnosed within a month were included in the study. the demographic information and visual acuity were recorded and a detailed slit lamp examination, gonioscopy and fundoscopy was carried out. applanation tonometry for intra ocular pressure (iop) measurement was performed. central corneal thickness was measured and the correction factor was applied. if there was raised intraocular pressure (> 20 mm hg), then patient was labeled as glaucoma. data was collected and analyzed by spss. data was stratified. post stratification, chi-square was applied. results: the mean age was 46.28 ± 15.02 years. on gender basis male were found more involved as ratio was 1.6: 1. the mean intraocular pressure was 15.87 ± 4.52 mm hg. primary open angle glaucoma was found in 14 (14%) of patients. conclusion: our study concluded that the incidence of glaucoma is significant in patients presenting with retinal vein occlusion (rvo) in local population. keywords: primary open angle glaucoma, retinal vein occlusion, intraocular pressure. mong the retinal vascular diseases retinal vein occlusion (rvo) is the second common reason of vision loss after diabetic retinopathy1. central and branch retinal vein occlusion are its two distinct types based upon site of occlusion. its prevalence varies from 0.7% to 1.6% in different studies2. the pathogenies of acute rvo is still not well understood3. the natural history of rvo is variable, many patients have good prognosis with one study showing half of patients achieved 20/40 vision after 6 months without treatment4. other causes of vision loss due to rvo include cystoid macular edema, neovascularization leading to vitreous hemorrhage, retinal detachment or glaucoma5. glaucoma is a specific form of optic neuropathy causing irreversible blindness and second most common cause to blindness worldwide6. relationship a ch. javed iqbal, et al 102 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology between rvo and glaucoma has been well established since the start of the 20th century1. in one study the percentage of central retinal vein occlusion was 25% while for brvo was 8.6% in diagnosed case of chronic simple glaucoma7. hayreh reported prevalence of rvo among glaucoma was higher than normal population i.e. approximately 10%5,8. the eye disease case-control study, in a large series of patients with rvo, found that in all types of rvo, history of glaucoma was found9. so, aim of this study was to find the incidence of glaucoma in patients presenting with rvo in a tertiary care hospital. in rvo the comorbidity of glaucoma enhances the severity of rvo. timely diagnosis and management can prevent patients from permanent vision loss. literature has reported that in few cases of rvo glaucoma occurs, but some studies reported little higher incidence/prevalence. moreover, no local evidence was available regarding this issue which can discover the extent of glaucoma in rvo cases in local population, knowing the exact incidence can help in setting the guidelines for prevention of glaucoma in rvo cases. material and methods this observational study was conducted in eye unit ii, institute of ophthalmology, king edward medical university, mayo hospital, lahore for two years from jan 2016 to december 2017. a sample size of 100 cases was calculated with 95% confidence level, 5% margin of error and taking expected % glaucoma 9.9% in patients presenting with retinal vein occlusion. nonprobability consecutive sampling was done. patients’ age ranging from 18 to 70 years of either gender presenting with rvo diagnosed (history of loss of vision and fundoscopy show dilation and tortuosity of vein with retinal hemorrhages) within a month were included in the study. patients with history of ocular trauma or surgery for glaucoma, previous corneal opacity and base line visual acuity of no perception of light (npl) were excluded from the study. patients were registered from outpatient department (opd), an informed consent was taken. the demographic information like name, age, sex and address was recorded. visual acuity of all the patients was recorded by snellen’s visual acuity chart. a detailed slit lamp examination with fundoscopy carried out by 90d and 66d fundus lenses and gonioscopy was carried out with goldman three mirror gonioscopy lens to confirm the diagnosis of retinal vein occlusion and primary open angle glaucoma. examination of fellow eye was also carried out. all the patients then underwent applanation tonometry for the intra ocular pressure measurement. central corneal thickness was measured and the correction factor was applied. if there was abnormally raised intraocular pressure (> 20 mm hg), then patient was labeled as glaucoma as per operational definition of study. all the information was collected on a predesigned proforma. no ethical issue and risk was involved. data was analyzed by spss version 17. the quantitative variable like age was presented as mean and standard deviation the qualitative variable like gender and glaucoma were presented as frequency and percentage. data was stratified for the age, gender and duration of rvo, history of diabetes mellitus and hypertension. post stratification, chi-square was applied taking p –value < 0.05 as significant. results the mean age was 46.28 +15.02 years among the patients. there were 62% male patients while 38% female patients (figure 1). 62% 38% male female fig. 1: gender distribution. the male/female ratio was 1.6 to 1. hypertension was present in 46 (46%) patients and diabetes mellitus was present in 28 (28%) patients (figure 2). the mean iop of the patients was 15.87 ± 4.52 mm hg and glaucoma was observed in 14 (14%) patients (figure 3). incidence of primary open angle glaucoma in patients presenting with retinal vein occlusion pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 103 fig. 2: 86 14 poag non-glaucomatous fig. 3: incidence of glaucoma. fig. 4: glaucoma gender distribution. the study results showed that among 47 patients of age less than 45 years, glaucoma was found in 4 cases but in 53 patients of age ≥ to 45 years, glaucoma was found in 10 cases. statistically there is insignificant difference found between the glaucoma with age i.e. p-value = 0.160. similarly, among 62 males glaucoma was found in 9 cases while out of 38 females glaucoma was found in 5 cases. statistically there is insignificant difference found between glaucoma with gender i.e. p-value = 0.849 (figure 4). among 51 patients who had duration of rvo less than or equal to 2 months glaucoma was found in 5 cases and in 49 patients who had duration of rvo > 2 months, glaucoma was found in 9 cases but the difference was insignificant i.e. p-value = 0.217. among 46 hypertensive patients glaucoma was found in 7 cases. the difference was insignificant i.e. p-value = 0.746. in 28 diabetic patients, glaucoma was found in 10 cases but in 72 non diabetic cases, glaucoma was found in 4 cases. statistically there was significant difference found between the glaucoma with diabetes mellitus i.e. p-value= 0.000 (table 2). discussion glaucoma encompasses group of ophthalmic diseases that ultimately result in progressive optic neuropathy and loss of visual function. retinal vein occlusion is an important cause of loss of vision. glaucoma and retinal vein occlusion have an important causal relationship with one another. most of the information about this relationship comes from case control studies, clinical trials and clinical case series. the second leading cause of bilateral blindness is glaucoma i.e. about 8.4 million people have bilateral blindness because of glaucoma (4.5 million people having open angle glaucoma (oag) and 4 million people having angle closure glaucoma (acg). in united states, in 2004 about 2.2 million people were suffering from primary open angle glaucoma (poag) and the burden is estimated to rise to 3.36 million by 202010. hayreh ss et al reported that the overall prevalence of glaucoma was 9.9% in patients with rvo5. fu chan et al supported the evidence and reported the frequency of glaucoma 9.3% among patients with rvo11. while in our study the incidence of glaucoma was 14% in the patients diagnosed as rvo, which appears higher as compared to the other studies. while another study conducted by b jonas et al found the frequency of glaucoma in 1.59% cases, among them it was more common in crvo (18.9%) as compared to brvo (2.7%)12. https://www.ncbi.nlm.nih.gov/pubmed/?term=hayreh%20ss%5bauthor%5d&cauthor=true&cauthor_uid=14711725 ch. javed iqbal, et al 104 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology a study by hirota a et al showed highest incidence of primary angle closure exhibiting retinal vein occlusion by reporting 8.1% prevalence13. one study by da silva et al showed that prevalence of ocular hypertension and glaucoma was 3.74% (4 patients) and 2.8% (3 patients) respectively. when considering age wise, patients > 40 years, the prevalence of ocular hypertension and glaucoma was 5.4% (4 patients) and 4.76% (3 patients) respectively14. the geneva study (2010) showed that hypertension was found in 64% of patients and diabetes in 12% of 1267 patients with occlusion of retinal vein (central/branch retinal vein occlusion), while in our study 46 patients were hypertensive out of which 7 were diagnosed as a case rvo15. study conducted by sperduto et al found an association of crvo with increased systemic hypertension, diabetes, and glaucoma. these associations were higher association with ischemic crvo. this study compared 258 patients diagnosed with crvo over four years span in five centers with 1142 age matched controls. these controls were recruited a year after diagnosis of crvo from same eye clinics9,16. however, in one study, for example, klein and associates at the 5 year follow-up were unable to find an association between ocular hypertension (oht), iop, brvo and glaucoma17,18. studies conducted by frucht j et al, amelie p et al and appiah ap et al reported a higher frequency of raised iop in cases of occlusion of central retinal vein as compared with branch retinal vein4,19,20. as a result of above discussed findings in future there a need to find individual incidence’s of different rvo subtypes. these results are comparable with the results of our study. our study does have some limitations like small sample size and was conducted in only one tertiary care center. it is proven that with our study and other that there is strong association between glaucoma and retinal vein occlusion. it is recommended that multicenter future studies are required to find out the exact incidence of the patients with crvo for the presence of glaucoma. conclusion our study concluded that the incidence of glaucoma was significant in patients presenting with retinal vein occlusion (rvo). the frequency seems to be high. so it is recommended that every patient with rvo should be screened for glaucoma. author’s affiliation prof. ch. javed iqbal mbbs, mcps, fcps, fellowship in vitreoretina professor of ophthalmology eye unit ii, mayo hospital, lahore dr. muhammad salman hamza mbbs, fcps, assistant professor eye unit ii, mayo hospital, lahore dr. ch. nasir ahmed mbbs, fcps, fellowship in vitreoretina assistant professor eye unit iii, mayo hospital, lahore dr. qunber abbas mbbs, fcps, assistant professor eye unit ii, mayo hospital, lahore dr. muhammad awais asghar mbbs, post graduate resident eye unit ii, mayo hospital, lahore author’s contribution prof. ch. javed iqbal selection of topic, data collection and data analysis. dr. muhammad salman hamza data collection, manuscript writing and data analysis. dr. ch. nasir ahmed data collection and data analysis. dr. qunber abbas data collection and data analysis. dr. muhammad awais asghar data compilation and statistical analysis. references 1. verhoeff f. the effect of chronic glaucoma on the central retinal vessels. arch ophthalmol. 1913; 42: p. 145-152. 2. chew ey, trope ge, mitchell bj. diurnal intraocular pressure in young adults with central retinal vein occlusion. ophthalmology, 1987 december; 94 (12): p. 1545-9. 3. dryden rm. central retinal vein occlusions and chronic simple glaucoma. arch ophthalmol. 1965 may; 73 (5): 659-663. 4. frucht j, shapiro a, merin s. intraocular pressure in retinal vein occlusion. br j ophthalmol. 1984 january; 68 (1): 26-28. 5. hayreh ss, zimmerman mb, beri m, podhajsky p. intraocular pressure abnormalities associated with central and hemicentral retinal vein occlusion. ophthalmology, 2004 january; 111 (1): 133-41. incidence of primary open angle glaucoma in patients presenting with retinal vein occlusion pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 105 6. luntz mh, schenker hi. retinal vascular accidents in glaucoma and ocular hypertension. surv ophthalmol. 1980 nov-dec; 25 (3): 163-7. 7. soni kg, woodhouse df. retinal vascular occlusion as a presenting feature of glaucoma simplex. br j ophthalmol. 1971 march; 55 (3): 192–195. 8. vannas s, tarkkanen a. retinal vein occlusion and glaucoma: tonographic study of the incidence of glaucoma and of its prognostic significance. br j ophthalmol. 1960 october; 44 (10): 583-589. 9. risk factors for central retinal vein occlusion. the eye disease case-control study group. arch ophthalmol. 1996 may; 114 (5): 545-54. 10. quigley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006 march; 90 (3):262-267 11. chen hf, chen mc, lai cc, yeung l, wang nk, chen hs, ku wc, wu sc, chang sh, chuang lh. neovascular glaucoma after central retinal vein occlusion in pre-existing glaucoma. bmc ophthalmol. 2014 october; 14 (1): 119-125. 12. jonas jb, nangia v, khare a, sinha a, lambat s. prevalence and associations of retinal vein occlusions: the central india eye and medical study. retina. 2013 january; 33 (1): 152-159. 13. hirota a, mishima hk, kiuchi y. incidence of retinal vein occlusion at the glaucoma clinic of hiroshima university. ophthalmologica. 1997; 211 (5): 288-291. 14. da silva fl, de lourdes veronese rodrigues m, akaishi pm, cruz aa. graves' orbitopathy: frequency of ocular hypertension and glaucoma. eye (lond). 2009 april; 23 (4): 957-959. 15 haller ja, bandello f, belfort r jr, blumenkranz ms, gillies m, heier j, et al. dexamethasone intravitreal implant in patients with macular edema related to branch or central retinal vein occlusion twelve-month study results. ophthalmology 2011;118:2453-60. 16. sperduto rd, hiller r, chew e, seigel d, blair n, burton tc, farber md, gragoudas es, haller j, seddon jm, yannuzzi la. risk factors for hemiretinal vein occlusion: comparison with risk factors for central and branch retinal vein occlusion: the eye disease casecontrol study. ophthalmology, 1998 may; 105 (5): 765771. 17. klein r, klein be, moss se, meuer sm. the epidemiology of retinal vein occlusion: the beaver dam eye study. trans am ophthalmol soc. 2000; 98 (1): 133143. 18. klein r, moss se, meuer sm, klein be. the 15-year cumulative incidence of retinal vein occlusion: the beaver dam eye study. arch ophthalmol. 2008 april; 126 (4): 513-518. 19. appiah ap, trempe cl. risk factors associated with branch vs. central retinal vein occlusion. ann ophthalmol. 1989 april; 21 (4): 153-157. 20. amelie p, nicolas f, christin i, josep c, bernd j, christine s. efficacy and safety of intravitreal therapy in macular edema due to branch and central retinal vein occlusion: a systematic review. plos one, 2013 october; 8 (10): p. e78358.. microsoft word ibrar ali.doc 64 original article phacoemulsification: complications in first 300 cases abrar ali, tabassum ahmed, tahir ahmed pak j ophthalmol 2007, vol. 23 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. abrar ali 1-d-1/2, nazimabad, karachi. received for publication august’ 2006 …..……………………….. purpose: to find out complications of phacoemulsification in our first 300 cases. material and methods: retrospective analysis of our first 300 cases of phacoemulsification was done. operations were performed in different hospitals of city. after thorough examination and investigations, patients were operated. most were operated under retrobulbar anaesthesia. first examination was on first post operative day and then followed up after one week, three weeks and eight weeks. their operative and postoperative complications were analysed. results: posterior capsular rupture was the most common intraoperative complication in our initial cases. corneal edema on first postoperative day was significant problem and because of this vision on first post operative day was low in most of our initial cases. after three weeks the vision was 6/12 or better in 83% of cases. conclusion: complications rate in initial learning curve was higher, which was dissatisfying for both surgeon and patients. better outcome was achieved with more experience and adopting better techniques. n the era of modern cataract surgery phacoemulsification is most demanding procedure by cataract patients and similarly patients’ expectations are also high about the out come. to stay in practice it is becoming essential to learn the art and science of phacoemulsification as once stated by durrani j “we must not succumb to inertia and stay static or else the world will pass us by”1. in this study we retrospectively evaluated our first 300 cases of phacoemulsification to find out various complications. methods and patients we started after proper wet lab. operations were done in different hospitals of the city on company and private patients. phacoemulsifications done in free eye camps are not included in this study. complete thorough eye examination was done. routine laboratory investigations were done. in all patients i/v cannula was passed before operation. after all aseptic precautions operation was started. in majority of patients retrobulbar anaesthesia was given. facial block was given in 15.7% of cases (table 1). superior rectus suture was given in 34% of cases. pupils were dilated with tropicamide 1% and phenylephrine 10% eye drops. three step tunnel incision was given at about 11 o’ clock position with 3.2 mm keratome. anterior chamber was filled with methylcellulose 2%. capsulorhexis was done in all cases by bent 27g needle. capsulorhexis was not central and circular in few cases. side port was made with 15 degree knife and in few cases with no.11 knife. peritomy was done at incision site. hydrodisection was done in 99% of cases and in few cases especially with posterior subcapsular cataract hydrodelineation was also done. i 65 bimanual phacoemulsification technique was used in all cases. machine parameters were set at two memories. at first setting phaco power was 70%, vacuum at 30mm of hg and flow rate at 25mm, after sculpting and nucleus division, vacuum was changed to 70mmhg keeping same phaco power and flow rate. the remaining lens matter was removed and aspirated by simco i/a cannula. the anterior chamber and bag were refilled with methylecellulose 2%. the incision was enlarged by 5.2 or 5.5 mm keratome. in few cases the enlargement was done by no 11 knife. in about 85% cases phaco pmma intraocular lens (iol) were implanted in the bag. in few patients we were not sure about position of superior haptic whether it was in or out of bag. where there was large posterior capsular break, larger optic iol was implanted in the sulcus. in few patient miosis was achieved by intracameral injection of miotics. one or two 10/0 nylon sutures were given at phaco port in 75% of cases. subconjunctival antibiotic gentamycin 40 mg and steroid dexamethasone 2 mg injections were given. these injections were not given in topically anaesthetized patients. no pad and dressing was done in topically anaesthetized patients after operation. patients were followed in opd on next day, after one week and then after four weeks and two months. average follow up was of 2 years. results patients were operated in different hospitals of city. on first post operative day the vision was less than 6/60 in majority of patients (table 2) and was 6/12 and better in majority of patients (table 3) after three weeks. the complications were analysed as occurred during operation (table 4) and those faced after the operation (table 5). the commonest intraoperative complication was posterior capsular rupture. corneal edema was present in 61.7% of cases, which was the main cause for reduced vision on first post operative day. discussion surgeons’ main concern is minimal operative and post operative complications. the complications correlate themselves with the surgeon experience2. we faced problems in the initial phase of conversion to the phacoemulsification till we became experienced in that procedure. in this study we have analysed our complications in phacoemulsification cases. anaesthesia retrobulbar anaesthesia was the commonest technique for this procedure we adopted. in few cases the experience of topical technique was very bad. in only 16% of cases facial block was given and there was no problem without facial block. post operative vision the main concern of the patient is their vision in first few days after operation. other wish of patients is to have 6/6 vision without glasses. in our initial cases this patients’ concern was very upsetting as vision was not good in first few days postoperatively. (table 2). the main reason was corneal edema and striate keratopathy in early post operative period. as the cornea cleared the vision improved in majority of the cases (table 2) which is comparable to the other studies3,4. table 1: type of anaesthesia type no of cases n (%) peribulbar 75 (25) retrobulbar 179 (45) topical 46 (30) total 300 (100) facial block 47 (15.67) table 2: vision on 1st postoperative day snellen’s vision no of cases n (%) 6/12-6/6 53 (17.67) 6/60-6/18 83 (27.67) cf-6/60 159 (53) <cf 5 (1.67) total 300 (100) cf= counting finger table 3: post-operative vision after three weeks vision no of cases n (%) 6/12-6/6 251 (83.67) 6/60-6/18 37 (12.33) 66 cf-6/60 7 (2.33) <cf 3 no perception of light (nlp) 2 (0.67) total 300 (100) nlp= no perception of light table 4: complications during operation no of cases n (%) corneal abrasion 48 (16) long tunnel incision 7 (2.3) iris prolapse 11 (3.7) iris damage 28 (9.3) descemet's membrane detachment 3 (1) subconjunctival haemorrhage 35 (11.7) hyphaema 6 (2) corneal hydration 7 (2.3) conjunctival chemosis 12 (4) posterior capsular rupture 49 (16.3) nucleus drop 2 (0.7) nucleus fragments 4 (1.3) machine problem 3 (1) conversion to manual ecce 5 (1.6) table 5: complications after operation no of cases n (%) transient corneal edema and striate keratopathy 185 (61.67) uveitis 8 (2.67) endophthalmitis 2 (0.67) decentration of iol 6 (2) bullous keratopathy 1 (0.33) iris atrophy 39 (13) corneal abrasion and damage for incision, 3.2 mm keratomes were used and eye was fixated by corneal forceps at 180 degree from incision site. in few cases corneal damage was with keratome. that was healed in 24 hours and post operatively there was no problem. long tunnel incision was developed in 2.3% of cases. descemet’s membrane detachment was developed in 4% of cases of popiela g et al5. in our cases detachment of descemet’s membrane was noted in 1% of cases. the cause was direct mechanical damage by the chopper and in one case by phaco tip. corneal hydration was one of the complications, which occurred in those cases where the incision tunnel was longer. the major problem with this complication was decreased visibility through hazy cornea. subconjunctival haemorrhage subconjunctival haemorrhage developed especially at site of fixation of globe by forceps. in few cases the haemorrhage was large to make the eye ball red and angry looking. it took few days to weeks to clear. usually if the vision was good the patients were not very much worried about the redness but in those cases where redness was with corneal edema and decreased vision, these patients were difficult to handle. iris damage, chewing and prolapse iris prolapsed during surgery was the problem in those posterior incisions in which three or two step tunnel was not achieved and the keratome went directly in to the anterior chamber at phaco tip incision or side port incisions. in 9.3% of our cases there was damage to the iris either by phaco tip or by the chopper. this developed in those cases where pupil was not fully dilated and when there was iris prolapse through incision site. other phaco surgeons also reported this problem with the rate ranging from 2% to 7.5%6,3,7. they also had iris damage because of poor pupillary dilatation. popiela g et al had iris damage in 4% of their cases5. posterior capsular rupture posterior capsular rupture was the commonest operative complication in our study. when we recalled the incidence of posterior capsular rupture in our cases where we did ecce, it was very low. in our 67 initial cases of phacoemulsification, this rate was high upto 13%. it occurred in different stages of phacoemulsification procedure. this was mainly because of the lack of knowledge of the phacodynamics and machine parameters. in the initial learning curve of the phacoemulsification, other colleagues also faced posterior capsular rupture as major complication3,7-10. in most of their cases they had this problem while chasing the nuclear fragments and hitting the rhexis rim. posterior capsular rupture occurred in 7% to 9 % of cases in different studies3,6,8. in 400 phacoemulsification operations capsular tear occurred in 6.3 % of cases of seward et al11. rate was 9.9% in cruz et al cases12. in juneijo study posterior capsule rupture rate was 4.5 %7. in one study posterior capsular rupture rate was 4% in surpervised and 15% in unsupervised surgeries13. in those patients where we had posterior capsular rupture majority had vitreous and loss prolapse. hashmani had vitreous loss in all posterior capsular rupture cases3. in juneijo study out of the 4.5% of posterior capsular rupture cases vitreous loss was in only 1% of cases7. out of 6.3% posterior capsular rupture, vitreous loss occurred in 1.5% of cases of seward et al10. incidence of vitreous loss was 14.7% in study of allinson et al14. when there is posterior capsular rupture, early recognization and proper management would decrease the risk of vitreous loss. nucleus, its fragments and cortex drop in vitreous nearly all phaco surgeons faced the problem of nucleus drop in their learning phase. rate of nucleus drop into vitreous ranged from 0.25% to 0.79% mentioned by national and international surgeons in their initial cases of phacoemulsification 2,3,7,10. in one study analysis was done for incidence of complications and visual outcomes in the initial 70 phacoemulsification procedures performed by first two residents learning phacoemulsification, both were experienced in standard manual ecce. no nuclei were lost into the vitreous4. nucleus drop was the problem, which developed in 0.67% of our cases. this is the complication in which patients faced problems. we referred these cases to vitreoretinal surgeons for proper management. in 1.33% of cases of posterior capsular rupture, nucleus was removed successfully but cortical and small fragments of nucleus, dropped in the vitreous were managed conservatively. corneal edema and striate keratopathy corneal edema is the second most common complication of phacoemulsification which cleared within one to two weeks3,7. it was between 4% to 7% in different series during learning phase of phacoemulsification procedure2,3,4,15. it was also fairly high 20% in one study by popiela g et al5. the incidence of this complication was high in our cases on first post operative day, which took about 2-3 weeks to clear. this period, till the clearance of corneal edema and improvement of vision, was very much annoying for the patients. the main reason for this high rate was that we did phacoemulsification in pupillary area or slightly above in anterior chamber because of fear of damaging the posterior capsule, which might have caused increased endothelial cell damage and loss. in one study the risk factors for endothelial cell loss after phacoemulsification cataract surgery performed by a junior resident were assessed. the mean overall endothelial cell loss was 11.6%. they found different factors significantly associated with endothelial cell loss on univariate analysis. multivariate analysis identified a grade 3 nucleus (severely dense) and long absolute phaco time as independent predictors for endothelial cell loss, with longer absolute phaco time being the stronger predictor16. phacoemulsification in the capsular bag by directing probe away from the corneal endothelium and keeping the lens fragments at deeper plane are the measures which would be helpful in minimizing the chances of corneal edema and striate after phacoemulsification as suggested by zetterstrin c17. iol decentration and dislocation the most significant complication of posterior capsule disruption during phacoemulsification is the inability to implant an intraocular lens18. in our posterior capsular rupture cases we implanted iols in the sulcus. we got iol decentration in 2% of cases and iol dislocation in 0.7% of cases. uveitis mild to moderate uveitis occured in 2.67% of our cases. they were managed conservatively. this was in the form of fibrin exudation in 1.18% to 2% of cases in different series2,5. only 0.7% of our cases developed severe endophthalmitis and vision was npl. endophthalmitis developed only in cases where cortex or nucleus fragment droped in the vitreous. 68 endophthalmitis developed in 0.59% of cases of gavris m et al2. conversion to ecce in 1.67% of our initial 300 cases we converted to ecce and by radial incision in rhexis. nucleus was delivered. it was difficult to extend the incision to deliver the broken nucleus pieces especially in cases of topically anaesthetized patients. conclusion phacoemulsification is good technique for cataract extraction though in our initial cases few complications were higher than others surgeons. corneal problems can be decreased by doing chopping and phacoemulsification in the bag and keeping the phacotip away from the cornea. in order to avoid iris damage pupillary dilatation is important. we think that in order to minimize complications during and after phacoemulsification we should start phacoemulsification after wet labs and perform initial surgeries under supervision. beginner should attend workshops for phacoemulsification surgery. author’s affiliation abrar ali department of ophthalmology hamdard college of medicine and dentistry hamdard university, karachi tabassum ahmed department of ophthalmology hamdard college of medicine and dentistry hamdard university karachi tahir ahmed department of ophthalmology hamdard college of medicine and dentistry hamdard university karachi reference 1. durrani j. phacoemulsification: to convert or not to convert? pak j ophthalmol. 1995; 11: 47-8. 2. gavris m, caciula d, popa d, et al: phacoemulsification personal experience on my first 507 cases. oftalmologia. 2004; 48: 48-52. 3. hashmani s, haider i, khan ma. phacoemulsification results and complications during the learning curve. pak j ophthalmol. 1997; 13: 32-6. 4. thomas r, naveen s, jacob a, et al. a visual outcome and complications of residents learning phacoemulsification. indian j ophthalmol. 1997; 45: 215-9. 5. popiela g, markuszewska j, chelstowska j, et al. analysis of phacoemulsification complications during mastering of the method. klin oczna. 2004; 106: 23-7. 6. khan aa, azher an, chohan am. review of 100 cases of phacoemulsification. pak j ophthalmol. 1997; 13: 37-40. 7. junejo sa, khan sa. phacoemulsification by stops and chop technique: review of 200 cases. pak j ophthalmol. 1999; 15: 138-41. 8. haider sa. phacoemulsification versus conventional extracapsular surgery: a study of early astigmatism and complication rates. pak j ophthalmol. 1999; 15: 20-3. 9. smeets b, tabandeh h, teimory m, et al. learning phaco in a teaching environment. bull soc belge ophtalmol. 1993;249:23-8. 10. hussain m, durrani j, nisar a. phacoemulsification: a review of 210 cases. pak j ophthalmol. 1996; 12: 38-43. 11. seward hc, dalton r, davis a. phacoemusification during the learning curve: risk/benefit analysis. eye 1993; 7: 164-8. 12. curz oa, wallace gw, gay ca, et al. visual results and complications of phacoemulsification with intraocular lens implantation performed by ophthalmology residents. ophthalmology 1992; 99: 448-52. 13. hennig a, schroeder b, kumar j. learning phacoemulsification. results of different teaching methods. indian j ophthalmol. 2004; 52: 233-4. 14. allinson rw, metrikin dc, fante rg. incidence of vitreous loss among third year residents performing phacoemulsification. ophthalmology. 1992; 99: 726-30. 15. breusegem r. the nuclear cracking technique for the beginning phaco surgeon. bull soc belge ophtalmol. 1993; 249: 29-32. 16. o’brien pd, fitzpatrick p, kilmartin dj, et al. risk factors for endothelial cell loss after phacoemulsification surgery by a junior resident. j cataract refract surg. 2004; 30: 839-43. 17. zetterstrin c, laurell cg. comparison of endothelial cell loss and phacoemulsification energery during endocapsulr phacoemulsification surgery. j cataract refract surgery. 1999; 21: 55-8. 18. johnstone n, ward da. the incidence of posterior capsule disruption during phacoemulsification and associated postoperative complication rates in dogs: 244 eyes (1995-2002). vet ophthalmol. 2005; 8: 47-50. glaucoma and cataract management 1. combined surgery is safe in experienced hands. 2. cataract extraction first followed by filtration surgery. if filtration is done first followed by cataract extraction 69 the post operative reaction after cataract extraction has a tendency to compromise the already functional filtration bleb. prof. m lateef chaudhry microsoft word sardar bahadur khan.doc 212 original article keratoconus and its association with other ocular diseases sardar bahadur khan, mohammad saleem, mohammad kamran khalid, iftikhar ahmad mohammad daud khan pak j ophthalmol 2007, vol. 23 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sardar bahadur khan sardar flour mills, daraban road d.i.khan (nwfp) received for publication february’ 2007 …..……………………….. purpose: to determine the association of keratoconus with other ocular diseases. material and methods: a study on keratoconus (kc) was conducted in the department of ophthalmology, gomal medical college, dhq teaching hospital, dera ismail khan (nwfp) from july 2003 to june 2006. fifty cases of keratoconus were studied. each patient underwent a complete ocular examination including visual acuity, refraction, slitlamp biomicroscopy, keratoscopy, keratometry, applanation tonometery, direct and indirect ophthalmoscopy. results: the majority of patients 41 (82%) presented between 13 and 28 years of age. male to female ratio was 7:1.forty one (82%) patients had bilateral keratoconus and nine (18%) had unilateral keratoconus. the most common ocular association was vernal catarrh (64%). penetrating keratoplasty was suggested for 49 eyes (53.85%), and spectacles correction alone or spectacles with contact lens correction in 42 eyes (46.15%) in order to improve the visual acuity of the patients to acceptable level. conclusion: the commonest ocular association was vernal catarrh (64%). keratoconus is a problem of young people and 53.85% of eyes needed corneal graft. because of non availability of donor tissue material, educating the people in our society through all the possible media to donate their eyes is required. eratoconus (kc) is a progressive, non inflammatory1, bilateral (but usually asymmetrical) disease of the cornea, characterized by paraxial stromal thinning that leads to corneal surface distortion. painless visual loss2 occurs primarily from irregular astigmatism, myopia and secondarily from corneal scarring. all layers of the cornea are believed to be affected by kc, although the most notable features are the thinning of the corneal stroma, breaks in bowman layer, and the deposition of iron in the basal epithelial cells, forming the fleischer ring. breaks in and folds close to the descemet’s membrane result in acute hydrops and vogt’s striae respectively. although kc may be associated with a number of ocular and systemic disorders, its exact pathogenesis is not clear3. commonly recognized ocular associations include vernal keratoconjunctivitis, retinitis pigmentosa and leber’s congenital amaurosis. particular risk factors include atopic history, especially ocular allergies, rigid contact lens wear and vigorous eye rubbing4. early in its course, optical correction is achieved through spectacles. as the irregular astigmatism k 213 progresses, rigid contact lens can be quite successful in restoring vision. when patient’s visual acuity can not be significantly improved with contact lenses or contact lenses are not tolerated well, then surgery in the form of penetrating keratoplasty is indicated. material and methods we included 50 cases of kc at the department of ophthalmology, gomal medical college, d.h.q teaching hospital dera ismail khan from july 2003 to june 2006. the details of history and clinical examination of the patients were recorded on a specially designed performa. each patient underwent a complete ocular examination. ocular examination included the following: visual acuity both uncorrected and best corrected visual acuity with glasses was checked with standard snellen’s chart. refraction retinoscopy, autorefraction and trial and error methods were performed to achieve best corrected visual acuity with glasses. biomicroscopy slitlamp biomicroscopy was performed to examine the anterior segment in detail with special attention to detect. corneal thinning. vogt’s striae. fleischer’s ring (with cobalt blue filter). stromal scarring. rupture in descemet’s membrane. acute corneal hydrops. vernal conjunctivitis. keratoscopy it was performed to study the general shape of the cornea. keratometry keratometry with von helmohltz keratometer was performed to measure the radius of curvature of the central cornea and diopteric refracting power of the cornea. corneal sensation corneal sensation at the apex of the cone was checked with cotton wick. munson’s sign munson’s sign was checked by asking the patient to look down, to see the angulation of the lower lid. rizzuti illumination test penlight was thrown from the temporal side anterior to the iris plane. in kc, the ectatic cornea focuses the light sharply inside the nasal limbus. intraocular pressure before checking the intraocular pressure both eyes were anaesthetized by putting drops of proparacaine hydrochloride (alcaine) twice, one minute apart. sterile fluorescein paper strips were used to colour the lachrymal fluid. intraocular pressure was measured with hand-held perkin’s applanation tonometer. the graduation value of the prism in the axis of minus cylinder was set at the mark of the prism holder (equivalent of red 43o mark of goldmann applanation tonometer). direct ophthalmoscopy before ophthalmoscopy pupils were dilated by putting drops of 10% phenylephrine (isonefrine) and 1% tropicamide (mydriacyl) in the conjunctival sac. direct ophthalmoscopy was performed to see the dark area with in the illuminated field. indirect ophthalmoscopy fundus examination was difficult with direct ophthalmoscope due to higher astigmatism, for detailed fundus examination indirect ophthalmoscopy was performed. results the majority of patients, i.e. 41 (82%), presented between 13 and 28 years of age. their age ranged from 9 to 50 years. mean age was 22.3 years (figure 1). there were 44 males (88%) and 6 females (12%). male to female ratio was 7:1. forty one patients (82%) had bilateral kc and nine patients (18%) had unilateral kc. so the total number of eyes involved were 91. out of 41 bilateral cases 36(87.8%) were males and 5(12.2%) were females, while out of 09 unilateral cases 8(88.89%) were male and 1(11.11%) was female (table 1). uncorrected visual acuity was hand movement (h.m) to 6/60 in 60 eyes (65.93%), 6/60 – 6/24 in 21 eyes (23.07%), 6/18 in 5 eyes (5.50%), 6/12 in 2 eyes (2.20%) and 6/9 in 3 eyes (3.30%) (figure 2). best corrected visual acuity with glasses was h.m. to 6/60 in 33 eyes (36.26%), 6/60-6/24 in 24 eyes (26.37%), 6/18 in 9 eyes (9.89%), 6/12 in 8 eyes (8.79%), 6/9 in 9 eyes (9.89%) and 6/6 in 8 eyes (8.79%) (figure 2). 214 the duration of kc at the time of presentation ranged from 3 months to 30 years. mean duration was 7.9 years (table 2). 35 patients (70%) gave positive history of excessive eye rubbing, while 12 patients (24%) gave no such history, and 3 patients (6%) gave history of occasional eye rubbing. munson’s sign was present in 72 eyes (79.12%) and was not detectable in the remainder of eyes. rizzuti’s sign was present in 82 eyes (90.10%), while in the rest of eyes it was absent. fleischer’s ring was seen in 27 eyes (29.67%), out of which in 7 eyes it was complete and in 20 eyes the ring was incomplete. vogt’s striae were present in 51 eyes (56.04%), and were absent in 34 eyes (37.36%), while in 6 eyes (6.59%) vogt’s striae were not detectable due to acute corneal hydrops. corneal sensation at the apex of cone was normal in 67 eyes (73.63%), while it was decreased in 24 eyes (26.37%). stromal scarring was present in 60 eyes (65.93%) and was absent in 31 eyes (34.07%). table 1: laterality, sex distribution and total number of eyes involved in kc patients no: of patients no. of eyes males females bilateral kc 41 82 36 5 unilater al kc 9 9 8 1 total 50 91 44 6 table 2: duration of disease at the time of presentation duration in years no of patients n (%) 0-5 28 (56) 6-10 8 (16) 11-20 12 (24) 21-30 2 (4) total 50 (100) intraocular pressure ranged from 2 to 15 mm hg in 89 eyes. mean intraocular pressure was 7.6 mm hg. in 2 eyes intraocular pressure was not recordable. five patients (10%) presented with acute corneal hydrops. at the time of presentation their ages ranged from 7-25 years, mean age was 12.2 years. one patient at the age of 12 years developed bilateral acute corneal hydrops, first left, followed by right eye after 40 days. she had bilateral aphakia, operated for steroid induced cataract three years back. one other patient at the age of 7 years developed right acute corneal hydrops, which resolved after some weeks, but he developed left acute corneal hydrops after 7 months following resolution of the right hydrops. we found oval cones in 54 eyes (59.34%) and round cones in 37 eyes (40.66%). in 23 patients (46%) there was family history of vernal catarrh and kc. in three families, two brothers in each were suffering from vernal catarrh and kc. in the rest of 27 patients (54%) there was no family history of either kc or any other associated disorder (table 3). most of the patients in our series belonged to poor and lower middle class i.e. 40 patients (80%). eight patients (16%) belonged to upper middle class and 2 patients (4%) belonged to upper class. ocular associations (table 4) table 3: family history of kc patients disease no of patients n (%) nil 27 (54) vernal catarrh 20 (40) vernal catarrh + kc 3 (6) total 50 (100) table 4: ocular association of patients with kc disease no of patients n (%) vernal conjunctivitis 32 (64) steroid induced cataract 6 (12) pre senile mature cataract 2 (4) blepharoptosis 3 (6) strabismus 3 (6) arcus juvenilis 2 (2) steroid induced glaucoma 1 (1) epicanthus 1 (1) 215 total 50 (100) vernal catarrh thirty two patients (64%) were suffering from vernal catarrh in our series. cataract eight patients (16%) had cataract, of which 6 patients had bilateral steroid induced posterior subcapsular lenticular opacities and 2 patients had bilateral presenile mature cataract. blepharoptosis three patients (6%) had bilateral mild ptosis due to vernal catarrh and or topical steroids. strabismus three patients (6%) had strabismus, 2 had convergent and i had divergent strabismus. arcus juvenilis two patients (4%) had arcus juvenilis. glaucoma bilateral steroid induced glaucoma was present in 1 patient (2%), for which he had bilateral trabeculectomy. epicanthus we noted bilateral epicanthus in 1 patient (2%). discussion kc has generated considerable interest in a large number of ophthalmologists since it was recognized as a pathological entity in the middle of the eighteenth century. about a century later kc was differentiated from other corneal ectatic disorders by nottingham5, who defined its essential clinical features. since then a considerable amount of work has been published on the subject, most addressing either the clinical or the etiological aspects of the disorder. in our series 82% of patients presented between 13 and 28 years of age. kc is thus a problem of young people and should be suspected in any adolescent with progressive myopic astigmatism6. a female predominance has been observed in most studies, however the ratio varies1. in our study males were affected more than females with a ratio of 7:1. this high male: female ratio is probably because of high number of vernal catarrh patients, which is predominantly a disease of male children. our male dominant society, religious veil and dependence of females on males might also play some role so they are unable to seek medical advice in time for most of minor and some of the major problems. we detected 18% of patients with unilateral kc, which closely resembles the figure 14.3% reported by amsler7. in our study 70% of patient with kc gave positive history of excessive eye rubbing. several reports have implicated eye rubbing as an important etiological factor in the development of kc4,5,8-11. the reported prevalence ranges from 66% to 73%10-12. eye rubbing may be the etiological link between conical cornea and associated systemic and ocular diseases. itching, ocular irritation and eye rubbing are common features of vernal catarrh and atopic disease. we found 32 patients (64%) associated with vernal catarrh. perhaps the chronic ocular massage is responsible for the increased occurrence of kc in these patients. gritz and mcdonnell13 also suggest such an association, but a direct cause and effect relationship has not been proven. waardenburg et al14 cites seven cases of kc involving blood relatives and thus suspects a recessive genetic factor. the early development of kc and the consanguinity of the parents support the hypothesis that this is likely to be an autosomal recessive disorder15. our results support this hypothesis. mild forms of kc are treated with spectacles or contact lenses. contact lens wear becomes necessary when cone progression increases the degree of irregular astigmatism. although contact lenses have been speculated to cause kc16, they are also essential for the optical treatment of this disorder, and their use can not be avoided. in south africa 0.92% of all the blind were due to kc17. blindness due to kc is treatable. surgery for kc in indicated when the patient is unable to obtain clear, comfortable vision with contact lenses. kc patients have one of the highest success rates of any group of patients undergoing penetrating keratoplasty18. we advised penetrating keratoplasty in 49 eyes (53.85%). penetrating keratoplasty in this part of the world is a difficult option because of non availability of donor tissue material. the answer naturally is to tap a national source. the major obstacle for tissue donation is the religious faith that by enucleating the eye, you are desecrating the human body which is a sacred gift from god. this thinking is based on total misconception. the eyes of the deceased individual are enucleated after due permission from the deceased when he was alive, or 216 from the next of kin after his death and with the noble idea of transplanting it to a needy fellow human being. this point needs to be properly explained to all the relevant religious quarters by ophthalmologists and other members of eye bank society, a society dedicated to the promotion of corneal grafts in pakistan. the newspapers and the electronic media may be involved to play their due role in this campaign. conclusions after studying 50 cases of kc we arrived at the following conclusions: 1. the commonest ocular association is vernal catarrh (64%). 2. kc is a problem of young people, majority of patients present between 13 and 28 years of age. 3. males are affected more commonly than females 4. 53.85% of eyes needed corneal graft. indeed the commonest indication for keratoplasty nowadays is kc at some centers. 5. educating the people in our society through all the possible media to donate their eyes may be of great help in improving the grim future of kc patients. author’s affiliation dr. sardar bahadur khan assistant professor of ophthalmology gomal medical college d.i.khan. dr. mohammad saleem assistant professor of ophthalmology gomal medical college d.i.khan. dr. mohammad kamran khalid senior registrar, dhq teaching hospital, d.i.khan. dr. iftikhar ahmad senior lecturer, community medicine, gomal medical college d.i.khan professor mohammad daud khan rector, khyber institute of ophthalmic medical sciences, hayatabad medical complex peshawar. references 1. krachmer jh, feder rs, belin mw. keratoconus and related non inflammatory corneal thinning disorders. surv. ophthalmol. 1984; 28: 293-322. 2. bron aj, tripathi rc, harding jj, et al. stromal loss inkeratoconus. trans ophthalmol. soc. u k. 1978; 98: 393-6. 3. rahi a, davies p, ruben m, et al. keratoconus and coexisting atopic disease. br j ophthalmol. 1977; 61: 761-4. 4. helen o, greg g. a profile of keratoconus in new zealand. cornea. 2003; 22: 122-5. 5. duke elder s, leigh ag. system of ophthalmology. vol 8, disease of the outer eye. part 2. henry kimpton, london. 1965; 964-76. 6. maguire lj, meyer rf. ectatic corneal degenerations. in: the cornea. kaufman h.e, barron b.a, mc donald m.b, waltman s.r. (eds). churchill livingstone, new york, edinburgh, london, melbourne. 1988; 485-510. 7. pouliquen y. doyne lecture. keratoconus. eye 1987; 1: 114. 8. hanna c, o’brien je. cell production and migration in the epithelial layers of the cornea. arch ophthalmol. 1960; 65: 536. 9. freedman j, gombos gm. bilateral macular coloboma, keratoconus and retinitis pigmentosa. ann ophthalmol. 1971; 3: 664-5. 10. karseras ag, ruben m. aetiology of keratoconus. br j ophthalmol. 1976; 60: 522-5. 11. gasset ar, hinson wa, frias jl. keratoconus and atopic diseases. ann. ophthalmol. 1978; 10: 991-4. 12. copeman pw. eczema and keratoconus. br med j. 1965; 2: 977-9. 13. gritz dc, mc donnell pj. keratoconus and ocular massage. am j ophthalmol. 1988; 106: 757-8. 14. waardenburg pj, franceschetti a, klein d. genetics and ophthalmology. springfield charles c thomas. 1961; 452-6. 15. nucci p, brancato r. keratoconus and congenital hip dysplasia. am j ophthalmol. 1991; 111: 775. 16. macsai ms, varley ga, krachmer jh. development of keratoconus after contact lens wear. arch ophthalmol. 1990; 108: 534-8. 17. bucher pjm, ijsselmuiden cb. prevalence and causes of blindness in the northern transvaal. br j ophthalmol. 1988; 72: 721-6. 18. sharif kw, casey ta. penetrating keratoplasty for keratoconus: complications and long term success. br j ophthalmol. 1991; 75: 142-6. editor’s note: 217 as the endothelium of most of the keratoconus patients is healthy, we should utilize it for better, lasting results and laser complications etc etc by recommending lamellar keratoplasty rather than penetrating keratoplasty requiring training our young corneal surgeons for this techniques. 247 vol. 35, no. 4, oct – dec, 2019 pakistan journal of ophthalmology original article treatment of ocular surface squamous neoplasia with interferon alpha-2b zahid kamal, farooq ahmad, shahid tarar, farah huma, amir yaqoob pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: prof. zahid kamal ophthalmology unit -1, mayo hospital/ king edward medical university, lahore email. zahidkamal@hotmail.com. …..……………………….. purpose: to study the efficacy and safety of interferon (ifn) alpha 2b for ocular surface squamous neoplasia (ossn). study design: quasi experimental study. place and duration of study: mayo hospital lahore, lahore general hospital, armed forces institute of ophthalmology, rawalpindi, pakistan october 2010 to august 2016. material and methods: patients with suspected conjunctival growth underwent incisional biopsy. ninety-one eyes of 88 patients were included in the study. the patients with suspected conjunctival growths underwent incisional or excisional biopsy +/cryotherapy. after confirming the diagnosis of ocular surface squamous neoplasia (ossn), on histopathology, cases were inducted in the study. intralesional/peri-lesional interferon (ifn) alpha-2b was given to the patients weekly along with interferon alpha-2b topical drops four times daily, for three months. these patients were followed-up in respective hospitals and examined for resolution or recurrence of lesion for atleast three (03) months. results: out of 88 patients, 29 were females and 59 were males. the age of the patients was between 52 to 76 years. eighty eyes tolerated and responded well to the treatment. there was recurrence in 08 eyes, which had advanced squamous cell neoplasia. three patients were lost to follow up. mean resolution time of tumor was 3 months and mean follow up time was 12 months with range of 3 months to 5 years. the side effects recorded in our study were filamentary keratitis, conjunctivitis and pyogenic granuloma. conclusion: for the management of ocular surface squamous neoplasia ifn alpha 2 b is safe and effective choice with low recurrence rates. key words: conjunctival squamous cell carcinoma, conjunctival intraepithelial neoplasia (cin), ocular surface squamous neoplasia (ossn), interferon alpha2b. cular surface squamous neoplasia encompasses a broad spectrum of neoplastic abnormalities which include squamous dysplasia, squamous cell carcinoma in situ, and invasive squamous cell carcinoma. squamous cell carcinoma of the conjunctiva includes neoplastic abnormalities that may cause severe morbidity to the patients. it is the third most common conjunctival malignancy worldwide and is commonest in darkskinned, caucasians and in tropics1.itsincidence is 37.3 per million eyes with ocular tumors2. thorough clinical assessment and early diagnosis is the key for preventing the visual loss and morbidity in patients. persons in the older age group, those who have uvlight exposure and are smokers have increased risk of developing ocular surface squamous neoplasia. recurrence rate after surgical excision within 2 years is 15-52% and associated with tissue disruption enhancing the ability of tumor cells to enter in the eye. previously, mitomycin-c and 5-fluorouracil have been o treatment of ocular surface squamous neoplasia with interferon alpha-2b pakistan journal of ophthalmology vol. 35, no. 4, oct – dec, 2019 248 used with very good results but the complications associated with these drugs have alarmed the physicians5. the complications include uveitis, epithelial erosions, ulceration, and glaucoma. recent advances suggest use of interferon-2b for treating these neoplasms6,7,8. interferons are glycoproteins that bind to cell receptors, and trigger effector proteins that inhibit viruses, activate immunocompetent cells and regulate oncogenes. interferon α-2b is a recombinant form that has been used for hepatitis b/c, malignant melanoma, follicular lymphoma, condylomaaccuminatum, kaposi’s sacrcoma, multiple myeloma, and hairy cell leukemia. the standard dose of topical interferon α-2b is 1m iu/ml. median age for the complete tumor resolution was three months. few adverse effects of interferon α-2b are reported as photophobia, follicular conjunctivitis, conjunctival hyperemia with foreign body sensation and pyogenic granuloma. however, stillit is better tolerated than the other forms of topical therapies. rationale of the study was to analyze non-surgical treatment of ossn. topical interferon alpha-2b therapy can be used to treat ossn (immuno-therapy) as well as to reduce the size of ossn (immunoreduction) prior to excision. it may avoid the morbidity of excision that includes loss of limbal stem cells or scarring of ocular surface. the purpose of the study was to find the efficacy and safety of topical and intra-lesional interferon (ifn) α-2b for ocular surface squamous neoplasia (ossn) in pakistani population. material & methods this was a quasi experimental study, which was conducted in mayo hospital/kemu lahore, armed forces institute of ophthalmology, rawalpindi and lahore general hospital, pakistan from october 2010 to august 2016. total sample size of 90 patients was estimated by using 95% confidence level, 10% absolute precision with expected percentage of ocular surface squamous neoplasia as 91.6%. n = (z1-α/2)2 x p x q / d2 z1-α2 = confidence level 95% = 1.96 p = prevalance 91.6% q = 1-p d = absolute precision 10% non-probability purposive sampling was done. the patients with suspected conjunctival growths underwent incisional or excisional biopsy +/ cryotherapy. after histological confirmation of ocular surface squamous neoplasia (ossn) the case was included in the study. patients with all other forms of growths and patients with previous history of ossn were excluded from the study. all the preand postoperative data was recorded on a proforma. intralesional/peri-lesional ifn α-2b was injected weekly with a dose of 3 million iu along with interferon α2btopical drops qid (1 miu) until the resolution of tumor. the drug was aspirated using a sterile syringe and transferred into an emptied bottle of the artificial tears. the bottle was kept refrigerated until used. only those cases that completed at least 3 months follow-up after the resolution or recurrence of lesion were included. descriptive statistical results like frequency and percentage was calculated by using spss version 21. results ninety-one eyes of 88 patients were included in study. out of these, 29 were females and 59 were males. the age of the patients was52-76 years (mean 64years). eighty eyes tolerated and responded well tothe treatment and got cured. there was recurrence in 08 eyes (9.2%), all of which had advanced squamous cell neoplasia. three patients were lost to follow up. mean resolution time of tumor was 3 months and mean follow up time was 12 months with range of 3 months to 5 years. the resolution time is shown in fig-1. the side fig. 1: resolution rate. zahid kamal siddiqui, et al 249 vol. 35, no. 4, oct – dec, 2019 pakistan journal of ophthalmology effects recorded in our study were filamentary keratitis (1 patient), conjunctivitis (2 cases) and pyogenic granuloma (2 cases). most of these resolved with lubricants. however, the pyogenic granulomas needed excision under local anesthesia. discussion ocular surface squamous neoplasia is the most common malignancy in elderly patients, resulting in severe ocular damage and visual impairment. we note that mean age of our study population was a bit younger than those of caucasian population. any lesion that is epithelial in origin mostly grows at the limbus, because normal epithelial cellular activity is maximum at limbus9due to the presence of limbal stem cells. the squamous cell carcinoma incidence varies from 0.02 to 3.5 per 100,00010. in conjunctival intraepithelial neoplasia (cin/bowen’s disease), basement membrane is not breached and lesion is involving epithelial membrane only. if the tumor cells invade the basement membrane and involve the sub-epithelial tissues, it is called squamous cell neoplasia. histological spectrum of squamous cell carcinoma includes; micro-invasive, invasive, poorly differentiated and spindle cell. conjunctival and corneal surface can be involved with tumor, showing dysplastic changes in epithelium from mild to moderate grade, and also of infiltrative variety. previously, tumor was treated with excision leaving 2-3 mm tumor free margins, and cryotherapy was applied for the prevention of recurrence11. still, patients showed recurrence rate of 6–30% with negative margins and up to 55% with positive margins12. a study from victoria (australia) reported death of 8% cases due to metastasis, despite orbital exenteration for invasive ossn13. in 18 patients reported from pakistan, 42% needed exenteration even after aggressive treatment of this tumor14.therapy with antimetabolite agents like mitomycin c, 5fluorouracilhas been effective in treating the small lesion and can be given as adjunctive therapy following excision5 but have higher rate of recurrence. on the other hand, recurrence rates after topical or injected interferon alpha-2b are between 1% and 28%15,16 with follow-ups ranging from 2 to 28 months, which is much lower. our study also showed a similar recurrence rate (8.7%). interferon α-2b has proven beneficial in small sized localized lesions, large diffuse lesions and partially excised ocular surface neoplasia, as well as in recurrent disease (immunotherapy)15. analysis of 36 studies were published by siedlecki et al16and they concluded that excision of ossn with positive margins followed by topical interferonα-2b is the best strategy to reduce recurrence or persistent disease. in diseases that include extensive involvement of ocular tissues, interferon asα-2b can be used to reduce the size of the tumor (immuno-reduction) so that after excision there is less bare surface and lesser complications17. mitomycin-c, can result in corneal epitheliopathy, corneal ulceration, dry-eye, uveitis and glaucoma. it has to be used as a tedious“on andoff” regimen, to prevent the complications associated with its continuous use12,17. with the use of topical interferon α-2b we came across very few side effects as compared to other agents18. the side effects we came across in our study were filamentary keratitis, conjunctivitis and pyogenic granuloma formation, which were managed effectively. most of the time these resolved with lubricants, though pyogenic granuloma needed excision. the major benefit of interferon topical therapy is, that it obviates the need of wide surgical excision.a study19 comparing the quality of life in excision versus interferonα-2bresulted in similar outcomes. this topical medication is not available commercially in pakistan hence, the drops had to be dispensed in a sterile eye drops bottle. patients should be counseled about refrigeration and compliance of the therapy. the limitation in our study was a smaller population. conclusion intra-lesional and perilesional interferon α-2b along with topical drops is a better option for the treatment of ocular surface squamous neoplasia (ossn) in our population. future studies are needed to determine the long-term effects. acknowledgement we want to acknowledge hafiza ummara rasheed coavs lahore for assistance in statistical analysis. reference 1. kaines a, davis g, selva d, leibovitch i, dodd t, malhotra r. conjunctival squamous cell carcinoma treatment of ocular surface squamous neoplasia with interferon alpha-2b pakistan journal of ophthalmology vol. 35, no. 4, oct – dec, 2019 250 with perineural invasion resulting in death. ophthalmic surg lasers imaging, 2005; 36 (3): 249-51. 2. basti s & macsai ms. ocular surface squamous neoplasia: a review. cornea. 2003; 22 (7): 687-704. 3. ng j, coroneo mt, wakefield d, di girolamo n.ultraviolet radiation and the role of matrix metalloproteinases in the pathogenesis of ocular surface squamous neoplasia.investophthalmol vis sci. 2008 dec; 49 (12): 5295-306. 4. sen s, sharma a, panda a. immuno-histochemical localization of human papilloma virus in conjunctival neoplasias: a retrospective study. indian j ophthalmol. 2007; 55 (5): 361–3. 5. c chen, d louis, t dodd, j muecke. mitomycin c as an adjunct in the treatment of localised ocular surface squamous neoplasia.br j ophthalmol. 2004; 88 (1): 17– 18. 6. di pascuale, mario a, espana, edgar m, tseng, scheffer c.a case of conjunctiva-cornea intraepithelial neoplasia successfully treated with topical mitomycin c and interferon alfa-2b in cycles; cornea. 2004: 23 (1): 89-92. 7. karp cl, galor a, chhabra s, barnes sd, alfonso ec. subconjunctival/perilesional recombinant interferon α2b for ocular surface squamous neoplasia: a 10-year review. ophthalmology, 2010; 117 (12): 2241-6. 8. kobayashi a, yoshita t, uchiyama k,shirao y, kitagawa k, fujisawa a, tseng sc. successful management of conjunctival intraepithelial neoplasia by interferon alpha-2b. jpn j ophthalmol. 2002; 46 (2): 215– 7. 9. lee ga, hirst lw. ocular surface squamous neoplasia. surv ophthalmol. 1995; 39 (6): 429-450. 10. yang j, foster cs. squamous cell carcinoma of the conjunctiva. int ophthalmol clin. 1997; 37 (4): 73-84. 11. fraunfelder ft, wingfield d. management of intraepithelial conjunctival tumors and squamous cell carcinomas. am j ophthalmol. 1983; 95 (3): 359-63. 12. daniell m, maini r, tole d. use of mitomycin c in the treatment of corneal conjunctival intraepithelial neoplasia. clin experiment ophthalmol. 2002; 30 (2): 948. 13. mckelvie pa, daniell m, mcnab a, loughnan m, santamaria jd. squamous cell carcinoma of the conjunctiva: a series of 26 cases. br j ophthalmol. 2002; 86 (2): 168–173. 14. siddiqui zk, mahmood k, lateef q, haider wa. management of ocular surface squamous cell carcinoma at lahore general hospital, pakistan. pak pg med jr. 2009; 20 (1): 30-31. 15. boehm md, huang aj. treatment of recurrent corneal and conjunctival intraepithelial neoplasia with topical interferon alfa-2b. ophthalmology, 2004; 111 (9): 175561. 16. siedlecki an, tapp s, tosteson an, larson rj, karp cl, lietman t, zegan me. surgery versus interferon alpha-2b treatment strategies for ocular surface squamous neoplasia: a literature-based decision analysis. cornea, 2016; 35 (5): 613-618. 17. kim hj, shields cl, shah su, kaliki s, lally se. giant ocular surface squamous neoplasia managed with interferon alpha-2b as immunotherapy or immunoreduction. ophthalmology, 2012; 119 (5): 938– 44. 18. galor a, karp cl, chhabra s, barnes s, alfonso ec. topical interferon alpha 2b eye-drops for treatment of ocular surface squamous neoplasia: a dose comparison study. br j ophthalmol. 2010; 94 (5): 551–4. 19. mercado cl, pole c, wong j, batlle jf, roque f,shaikh n, et al. surgical versus medical treatment for ocular surface squamous neoplasia: a quality of life comparison. the ocular surface, 2019; 17 (1): 60-63. 20. mcclellan aj, mcclellan al, pezon cf, karp cl, feuer w, galor a. the epidemiology of ocular surface squamous neoplasia in a veterans affairs population. cornea, 2013; 32 (10): 1354. author’s affiliation prof. zahid kamal siddiqui eye unit -1, mayo hospital king edward medical college, lahore. dr. farooq ahmad eye unit -3, mayo hospital king edward medical college, lahore. dr. shahid tarar armed forces institute of ophthalmology (afio) rawalpindi. dr. farah huma eye unit -1, mayo hospital king edward medical college, lahore. prof. amer yaqoob armed forces institute of ophthalmology (afio) rawalpindi. author’s contribution prof. zahid kamal siddiqui study design, surgical procedures, data collection, manuscript writing. dr. farooq ahmad data collection, manuscript writing. dr. shahid tarar data collection, manuscript writing and final manuscript review. https://www.sciencedirect.com/science/article/pii/s1542012418300685#! https://www.sciencedirect.com/science/article/pii/s1542012418300685 https://www.sciencedirect.com/science/article/pii/s1542012418300685 https://www.sciencedirect.com/science/article/pii/s1542012418300685 https://www.sciencedirect.com/science/article/pii/s1542012418300685 https://oladoc.com/pakistan/rawalpindi/h/afio-rwp/431 https://oladoc.com/pakistan/rawalpindi/h/afio-rwp/431 https://oladoc.com/pakistan/rawalpindi/h/afio-rwp/431 https://oladoc.com/pakistan/rawalpindi/h/afio-rwp/431 zahid kamal siddiqui, et al 251 vol. 35, no. 4, oct – dec, 2019 pakistan journal of ophthalmology dr. farah huma data collection, biostatistics, final manuscript review. prof. amer yaqoob conceiving the idea, study design, surgical procedures, performed procedures, final manuscript review. microsoft word abstract 22,3, 2006 abstracts edited by dr. tahir mahmood quality-of-life improvements in cataract patients with bilateral blue light-filtering intraocular lenses. espindle d, crawford b, maxwell a, rajagopalan k, barnes r, harris b, hileman k. j cataract refract surg 2005; 31: 1952-9. progressive vision impairment due to cataract growth can result in significant reduction in patients quality of life (qol). specifically, patients may have difficulty driving, reading, and performing other daily activities that depend on vision. cataract extraction with implantation of intraocular lens (lols) has become a widely used treatment for cataract patients and can result in improvements in patient’s self-reported visual function and qol. because cataract surgery can change patients’ qol. sell-assessment of visual function and healthrelated qualm of life (hrqol) are important outcome measures. the purpose of this study was to compare change in patient-reported vision-related and health-related functioning and quality of life (hrqol) following bilateral implantation with a new blue light-filtering intraocular lens (iol) with the results of a similar iol that does not filter blue light. patients were enrolled from 6 clinical sites in the united states that performed a high volume of cataract surgeries. the hrqol assessments occurred via telephone while patients were at home. patients requiring bilateral cataract extraction were randomly assigned to 1 of the 2 iol groups for the first eye. the second eye was later implanted with the same type of iol. patients and hrqol data collectors were treatment-masked, but investigators could not be. health-related functioning and quality of life was measured with the 39-item national eye institute visual functioning questionnaire (nei vfq-39) and 12-item short form health survey (sf-12). assessments were at baseline before implantation in the first eye and 30 to 60 days and 120 to 180 days after implantation of the lens in the second eye. both iol types improved most aspects of patients' hrqol including color vision and driving. the largest gains occurred on the vfq composite, general vision, near activities, distance activities, driving, mental health, peripheral vision, and role difficulties scales. significant gains also occurred on color vision and other vision-specific scales as well as the sf-12 physical component summary score. there were no significant differences in hrqol gains between the lols. the authors concluded with the remarks that the blue light-filtering iol improved color vision, driving, and other aspects of hrqol in a manner similar to that of a lens that does not filter blue light. effect of postoperative refractive error on visual acuity and patient satisfaction after implantation of the array multifocal intraocular lens lee es, lee sy, jcong sy, moon ys, chin hs, cho sj, hyub oh jh j cataract refract surg 2005; 31:1960-65 in the management of cataract surgery, using a state of the art surgical technique, accurate biometry, and third generation power calculation formulas have made it possible to improve uncorrected distance visual acuity (ucdva). this eventually leads to a high quality of life. currently available monofocal intraocular lenses (iols) have a single focal distance and therefore require the patient to wear glasses to focus at near distances. various approaches have been proposed to give patients good vision through a range of distances after cataract surgery. accommodating iols are currently in use but have limitations in that anterior posterior movements are not sufficient to provide the degree of accommodation required. capsule filling with flexible polymeric gels is another approach, but preliminary animal experiments have revealed limitations such as capsule fibrosis. bifocal and multifocal lols have had the most success in restoring a range of functional vision after cataract surgery. the array multifocal iol (sa40n), advanced medical optics) uses a series of 5 concentric rings on the apical surface, alternating between distantdominant zones and near dominant zones with a + 3.50 diopter (d) add. unlike bifocal iols, the array multifocal iol provides functional near, intermediate, and distance vision and has a zonal progressive design to provide a smooth transition between zones and to diminish glare and night halo. the purpose of this study was to determine the ideal target refraction to optimize visual acuity (va) and patient satisfaction after implantation of array sa40n multifocal intraocular lens. the study prospectively enrolled 188 eyes of 163 patients and assigned them to 1 of 3 groups according to their postoperative refractive status: group 1 (43 myopic eyes, 0.50 diopter [d] to -1.50 d), group 2 (114 emmetropic eyes, -0.50 d to +0.50 d) and group 3 (31 hyperopic eyes, + 0.50 d to +1.50 d). uncorrected distance visual acuity (ucdva), uncorrected near visual acuity (ucnva), ucdva under glare conditions, contrast sensitivity, and patient satisfaction were then compared between the 3 groups. three months postoperatively, ucdva, ucnva, ucdva under glare conditions, and contrast sensitivity were good in all eyes and more than 72% of patients never wore glasses for near vision. in group 2, ucdva was significantly better (0.74 ± 0.20; p<.05) compared with groups 1 and 3 (0.40 ± 0.24 and 0.38 ± 0.30, respectively); ucnva was also significantly better in group 2 (0.68 ± 0.08; p<.05) than in groups 1 and 3 (0.45 ± 0.21 and 0.41 ± 0.17, respectively). however, there were no significant differences in patient satisfaction, contrast sensitivity, and ucdva under glare conditions between the 3 groups (p>.05). the authors concluded with the remarks that the aiming for emmetropia rather than myopia when calculating the power for the multifocal intraocular lens may improve visual acuity. however, patients must be considered on an individual basis to meet their expectations and requirements. effect of preoperative counseling on patient fear from the visual experience during phacoemulsification under topical anesthesias voon lw, eong kga, saw sm, verma d, laude a. j cataract refract surg 2005; 37:7966-9. cataract surgery is the most common eye surgery performed worldwide. cataract surgery rates are estimated to he about 3500 to 3000 per million of the general population in developed countries. with advances in technology, a large proportion of cataract surgeries are currently carried out using phacoemulsification performed under topical anesthesia. the subjective visual experience of patients during cataract surgery has been reported in several studies. in general, these papers report similar visual experiences during cataract surgery: no perception of light, light perception, perception of 1 or more colors, flashes of light, movements, instruments, and surgeon’s hands or fingers. of clinical significance is that some patients have found these visual sensations frightening. the purpose of this study was to determine whether preoperative counseling about potential intraoperative visual experience during phacoemulsification under topical anesthesia reduces fear in patients having cataract surgery. in this prospective multicenter randomized clinical trial, patients with cataracts having elective phacoemulsification under topical anesthesia were recruited and randomized into 2 groups. both groups received routine preoperative counseling regarding risks and benefits of cataract surgery. one group received additional counseling on the potential intraoperative visual experience during phacoemulsification; the other group did not. the patients were then interviewed within 24 hours following phacoemulsification regarding their intraoperative experience. two hundred nineteen patients were recruited over an 11-month period. there were 104 men and 115 women. the mean age was 68 years (range 20 to 89 years). there were 188 singaporeans, comprising 168 chinese, 13 malays, and 7 indians, and 31 british patients, all of whom were white. the mean fear score was 0.3 in the group that received additional counseling and 0.9 in the group that did not receive additional counseling (p = .036). the effect of counseling on fear was significant (p = .002) even after controlling for sex, age, and whether first or second cataract surgery. the authors concluded with the remarks that the preoperative counseling about the potential intraoperative visual experience during phacoemulsification under topical anesthesia helped to reduce the fear from the visual sensations in patients having cataract surgery. predicting patients' night vision complaints with wavefront technology tuan ka, chernyak d, feldman st. am j ophthalmol 2006; 141: 1-6. if the human eye were a perfect optical system, the appearance of a point source of light would be limited only by diffraction effects, and the source would appear as a single point to the observer. in addition to spherocylindrical components, the optical system of the human eye generates other complex optical aberrations, which contribute to the distortion of retinal images and determine the quality of the image formed on the retina. the optical imperfections of the eye cause rays of light traveling from a point source through the eye’s optics to intercept the retina at different locations, thereby blurring the appearance of the point. the distorted appearance of the point on the retina is called a point-spread function (psf). the recent development of wavefront aberrometers for use in ophthalmology has given clinicians an objective measurement method for optical aberrations other than sphere and cylinder. the wavefront maps generated by such devices represent deviations from the ideal diffraction limited optical systems and enable the physician to precisely diagnose visual impairment. in addition to guiding customized refractive surgery, wavefront sensors can be used to evaluate the source of visual complaints. the appearance of the psf can be computed directly from the wavefront measurement and corroborated by the patient with a simple drawing. the purpose of this study was to evaluate the accuracy of the diagnostic capabilities of optical metrics generated from wavefront measurements in relationship to post-laser-assisted in situ keratomileusis (lasik) visual complaints as expressed and drawn by patients. patient wavefront data from an investigational device exemption study for wavefront-guided ablations were used to derive normative modulation transfer function (mtf), encircled energy (ee), and strehl ratio. these optical metrics and their pointspread functions (psf) were compared with data from five postoperative patients with night vision complaints. patients were asked to draw their symptoms, which were elicited by testing with a fenthoff muscle light, while using their best-corrected distance vision. the mtf, ee, and strehl ratio of most patients were markedly different from those of the averages of 208 normal myopic eyes before and after lasik surgery. the spatial extent of the psf correlated positively with the severity of the visual complaints. wavefront-derived psfs were markedly similar to the patients' drawings. the authors concluded with the remarks that the results of this study demonstrated the diagnostic capability of the wavefront system in predicting visual symptoms and complaints of patients with high-order aberrations. objective visual metrics from patients with night vision complaints were different from those of normal myopic eyes that had undergone lasik procedures. comparison of three methods of measuring corneal thickness and anterior chamber depth buehl w, stojanac d, sacu s, drexler w, findl o. am j ophthalmol 2006; 141: 7-12. parallel to the developments of surgical technique in cataract and refractive surgery, the accurate measurement of corneal topography, anterior chamber depth, thickness of the crystalline or artificial lens, and eye length has gained in importance. until recently, ultrasound biometry has been a common method for measuring corneal thickness (ct) and anterior chamber depth (acd). however, this method is operator dependent. the most common method is applanation ultrasound, requiring corneal contact, which may lead to false results due to indentation of the cornea. the measuring results also depend on the exact axial placement of the probe relative to the center of the cornea. like all contact methods, it may be uncomfortable for the patient or even lead to damage of the corneal epithelium. thus, noncontact methods are preferred for biometry of the eye. an accurate noncontact ocular biometry technique, based on the dual laser beam partial coherence interferometry (pci) principle, has been developed in the past decade. the pci technology has been used for precise axial length measurements and resulted in the commercially available iol master (carl zeiss meditec, jena, germany). however, the iol master uses a photographic (not pci) technique for measuring acd. therefore, the ac-master (zeiss meditec) has been developed for pci measurements of central corneal thickness (cct) and acd as well as lens thickness. the precision of this technique is in the micron region, and it is highly reproducible. in addition, several other optical (non-pci) methods for imaging and measuring the corneal surface and the anterior chamber of the eye have been developed recently and are already commercially available. one of these is the pentacam (oculus, wetzlar, germany), which uses a rotating scheimpflug camera to image the anterior segment of the eye. it is also a noncontact method, and it is specifically designed to calculate a three dimensional model of the anterior segment, including data for corneal topography (also of the posterior corneal surface), ct pachymetry), acd measurements, and measurements of lens opacity and lens thickness. an already established instrument for analysis of cornea and anterior chamber, which does not make use of the scheimpflug principle, is the orbscan (1) scanning slit topography system (orbtek inc, salt lake city, utah, usa). it uses a horizontally moving slit beam to produce multiple slit images of the anterior segment and provides data for (anterior and posterior) corneal topography and acd. the purpose of this study was to compare three different methods of measuring corneal thickness (ct) and anterior chamber depth (acd). central ct (cct), ct at four peripheral points, and central acd were measured in 88 eyes of 44 healthy subjects with the pentacam (rotating scheimpflug camera; oculus, wetzlar, germany), orbscan i (scanning-slit topography system; orbtek inc, salt lake city, utah, usa), and ac-master (partial coherence interferometry; zeiss meditec, jena, germany), and the results were compared. the upper (lower) limits of agreement for cct measurements were 7.9 (-22.2) µm between ac-master and pentacam, 17.6 (-32.5) µm between ac-master and orbscan, and 25.2 (-25.9) µm between pentacam and orbscan. correlation was high between all three methods (r = 0.94 to 0.97). the upper and lower limits of agreement for acd were 0.174 (-0.251) mm between ac-master and pentacam, 0.406 (-0.004) mm between ac-master and orbscan, and 0.384 (0.095) mm between pentacam and orbscan. correlation was high between the three methods (r = 0.96 between orbscan and pentacam; others 0.92). correlation was lower for the ct measurements at the four peripheral points. the authors concluded with the remarks that the cct and acd values obtained by pentacam, orbscan, and ac-master measurements correlated well and showed few outliers. the two new systems (pentacam, ac-master) provide a reliable, easy-to-use, noncontact method of measuring cct and acd. larger differences occurred only when measuring peripheral ct values, especially between ac-master and the other two methods. categorizing the stage of glaucoma from prediagnosis to end-stage disease mills rp, budenz dl, lee pp, noecker rj, walt j, siegartel lr, evans sj, doyle jj. am j ophthalmol 2006; 141:24-30. in the united states glaucoma is the second leading cause of blindness in the general population and the leading cause of blindness in black patient. although only half of the individuals who have the disease are aware of their condition, glaucoma affects approximately 2.5 million people, including three percent of the age 55 years and older. annual us healthcare costs glaucoma total an estimated $2.5 billion, including $ 1.9 billion in direct costs and $0.6 billion in indirect costs. additionally, costs for the treatment of a newly diagnosed case of open-angle glaucoma have been estimated at $1055 per year. for the approximately 120,000 patients who have become blind as a result of glaucoma, costs benefits, healthcare, and reduced tax revenues total $1.5 billion per year. primary open-angle glaucoma (poag), accounting more than 90% of us cases of glaucoma, is a chronic progressive disease characterized by optic disk cupping and visual field loss. although this form of glaucoma commonly associated with elevated intraocular press we (iop), more than two-thirds of patients with iop exceeding 21 mm hg do not have glaucoma. as 15% of patient with glaucoma have a normal iop of 21 mm hg or less on a consistent basis, there are factors other than iop that likely contribute to disease development. a glaucoma staging system (gss) provides a way measuring the progress of glaucoma in patients who have the disease. with clearly defined stages of disease progression, it becomes possible to observe disease progression, and thus gauge the effectiveness of treatment at each stage. the definition of each disease stage needs to be adequately precise to allow patients at different stages of disease and from different glaucoma treatment centers to be meaningfully compared. further, such a system must allow for precise categorization without ambiguity, and must be easily usable and provide consistent (reliable) results. the purpose of this article is to provide a reliable, comprehensive staging system to assess glaucoma stage in the absence of an universally accepted glaucoma staging system (gss) on the basis of visual field results. after a review of published gsss was conducted, the bascom palmer (hodapp-anderson-parrish) gss was selected as an appropriate platform for a retrospective gss on the basis of visual fields. the system was modified by a panel of glaucoma specialists, and additional modifications were made after pilot testing to cover the full range of disease progression, from preglaucoma diagnosis to complete blindness; the ordered stages reflect the typical progression of glaucoma. the gss is comprised of six ordered stages and is on the basis of the humphrey visual field. the completed gss was validated by reviewing patient charts from 12 us glaucoma centers. the authors concluded with the remarks that the gss allows accurate staging of 100% of glaucoma on the basis of visual fields and other data, enabling evaluation of disease progression and resource utilization at various glaucoma stages. additionally, treatment costs may be assigned to determine costeffectiveness of treatment. research utilizing the gss has found that cost of care increases with increasing disease severity. the gss may be used as the basis for creating treatment guidelines, which have the potential to delay glaucoma progression and lower treatment costs. 239 pak j ophthalmol. 2021, vol. 37 (2): 239-242 brief communication polypoidal choroidal vasculopathy sana nadeem department of ophthalmology, foundation university medical college & fauji foundation hospital, rawalpindi abstract a 76-year-old, hypertensive lady, presented with a three year history of gradual decrease in vision in her right eye. examination revealed a large, bullous, serous pigment epithelial detachment (ped) of right fovea, a choroidal neovascular membrane, clusters of hard exudates, drusen and surrounding, multifocal, small peds. the left eye showed a series of small peds mostly on the inferior macula, pigmentary disturbance of the retinal pigment epithelium and scant hard exudates. a diagnosis of polypoidal choroidal vasculopathy was made. we decided to treat her with intravitreal bevacizumab injections in her right eye. at 18 months of follow up, her peds had resolved and visual acuity had improved from 6/60 od to 6/36. key words: polypoidal choroidal vasculopathy, age related macular degeneration, pigment epithelial detachment, choroidal neovascular membrane. how to cite this article: nadeem s. polypoidal choroidal vasculopathy. pak j ophthalmol. 2021, 37 (2): 239242. doi: http://doi.org/10.36351/pjo.v37i2.972 introduction the term polypoidal choroidal vasculopathy (pcv) was first coined by yannuzzi in 1982, as an idiopathic choroidal vascular disease. in 1984, kleiner termed it ‘posterior uveal bleeding syndrome’. 1 it is characterized by a bilateral multiple recurrent serosanguinous pigment epithelial detachments (peds) and orange-red aneurysmal dilatations called polyps. it is believed by many to be a subtype of neovascular age related macular degeneration with an abnormal branching network of vessels. others believe that choroidal thickening (pachychoroid) in pcv suggests a different etiology from age related macular degeneration (amd) and believe it to be part of the pachychoroid spectrum. 2 classification of pcv depends on polyp location, and can be subfoveal, juxtafoveal, extrafoveal, peripapillary, or peripheral. it correspondence: sana nadeem department of ophthalmology, foundation university medical college & fauji foundation hospital, rawalpindi email: sana.nadeem018@gmail.com received: december 8, 2019 accepted: june 20, 2020 can also be classified into quiescent, exudative, or haemorrhagic, depending upon presentation. 3 dilated and multi-layered choroidal venules are involved in pcv; occlusion leads to ischemia and choroidal stasis, predisposing to serous peds and sub-retinal pigment epithelium (rpe) neovascularization, subsequently leading to sub-rpe or sub-retinal haemorrhages. the grape-like polyps are seen as a result of dilated venules and capillaries within the sub-rpe neovascular membrane. definitive diagnosis can be made with indocyanine green angiography (icga), which delineates the polyps, but fluorescein angiography (fa) and optical coherence tomography (oct) are also useful in its diagnosis. ideal therapy for pcv is still unclear. combination of intravitreal anti-vegf and pdt is superior to either agent alone. 4,5 case presentation a 76-year-old, hypertensive lady presented to us in the out-patient department of fauji foundation hospital, rawalpindi. it is a tertiary care teaching hospital, affiliated with foundation university medical college. the patient complained of gradual, progressive visual loss of her right eye for the previous 3 years. she had undergone uneventful bilateral cataract surgeries 4 http://doi.org/10.3352/jeehp.2013.10.3 mailto:sana.nadeem018@gmail.com polypoidal choroidal vasculopathy pak j ophthalmol. 2021, vol. 37 (2): 239-242 240 years back. on examination, best corrected visual acuity (bcva) was 6/60 in her right eye and 6/9 in her left with the snellen chart. fundus examination of the right eye revealed a large, bullous, serous ped involving the fovea, 3-4 dd (disc diameter) in size with an associated choroidal neovascular membrane (cnvm) in the papillomacular bundle. cnvm was 1 dd in size, with surrounding multiple, serous peds, and scattered clumps of hard exudates and drusen. orange aneurysmal dilatations could be seen on closer inspection. the left fundus showed multiple drusen, cnvm and multiple small peds in the inferior macular region. (figure 1a and 1b). a diagnosis of polypoidal choroidal vasculopathy (pcv) was made. she was taking losartan (k) 50 mg od for hypertension. fig. 1: fundus photographs showing bilateral, multifocal, serous peds (blue arrows), cnvm, hard exudates and drusen. orange aneurysmal dilatations (green arrows) can be seen on the right side only. a: ffa in mid-venous phase showing occult cnv adjacent to the disc and filling of the large ped b: filling of multifocal peds and mottled hyperfluorescence c. late frames showing cnvm, ped and diffuse macular leakage d. late frames showing the small peds. cup-to-disc ratio (cdr) was 0.3 od and 0.5 os. intraocular pressures were 25 mm hg od and 22 mm hg os. glaucoma was confirmed with oct of the optic nerve and retinal nerve fiber layer. she was started on timolol eye drops 0.5% bd and ketorolac tromethamine eye drops 0.4% tds. ffa showed occult cnvm od (figure 1). oct of the macular region showed a large, bullous ped od, cystic degeneration of the overlying retina, with multifocal peds and cnvm. on the left side, multifocal, small peds were evident [figure 2]. indocyanine green angiography (icga) was not available in our city, so the aneurysms could not be highlighted. we decided to treat her right eye with intravitreal bevacizumab injections 1.25 mg in 0.05 ml. the left eye was kept on observation due to good vision. six intravitreal injections of bevacizumab were administered on the right side. fig. 2: oct showing the macular thickness maps and evident peds. fig. 3a: fundus photographs at 1.5 year of follow up showing scarring from the cnvm od with resolved peds ou. fig. 3b: red-free photographs showing the improvement. at 19 months of follow up, her visual acuity in right eye had improved to 6/36, peds had resolved sana nadeem 241 pak j ophthalmol. 2021, vol. 37 (2): 239-242 and macular thickness profile was improved. the left eye also showed improvement but visual acuity remained stable at 6/9 [figure 4a & 4b]. oct macula revealed reduced size of the peds on both sides, with mild cystic retinal spaces os [figure 4]. fig. 4: oct macula showing resolution of the peds bilaterally. discussion age related macular degeneration is the third leading cause of blindness in east asia. 6 pcv has a higher prevalence amongst asians (22.3% to 61.6%) as compared to caucasians. shared risk factors for amd and pcv are smoking, raised c-reactive protein, plasma homocysteine and genetic factors. 6,7 pcv is widely believed to be a type of exudative amd or choroidal neovascularization, although others argue it to be a distinct choroidal vasculature abnormality. features distinguishing pcv from typical amd are: its distinct polypoidal lesions, often extramacular location, natural course and treatment response. 8 diagnosis of pcv can be made clinically and confirmed by investigations. ffa usually shows occult cnv, although rarely polyps can be visualised. icg is the investigation of choice for delineating the diagnostic polyps. oct shows characteristic domeshaped rpe elevations, which are highly reflective with moderately reflective polypoidal activity within the peds. the double-layer sign is composed of the rpe and the inner boundary of the bruch membrane/ choriocapillaris complex. fundus autofluorescence (faf) and octa help us in the diagnosis and management of pcv. 2,9 natural history of pcv is variable and reveals a favourable course in 50% cases, with spontaneous regression of polyps. visual morbidity can occur with polyp rupture, subsequent sub-retinal and vitreous haemorrhage, rpe and photoreceptor degeneration. 10 the left eye in our patient showed spontaneous resolution of polyps and peds without treatment. therapeutic approaches include thermal laser, pdt with verteporfin, anti-vegf agents and combined pdt/anti-vegf therapy. combination therapy is often considered to be the one yielding superior results. 1-6,10 in our case, favourable outcome in the right eye was achieved with anti-vegf injections of bevacizumab only. conflict of interest authors declared no conflict of interest. references 1. mori f, eguchi s. polypoidal choroidal vasculopathy. from the viewpoint of an asian ophthalmologist. [editorial]. br j ophthalmol 2007; 91: 1104-1105. 2. kumar a, kumawat d, sundar md, gagrani m, gupta b, roop p, et al. polypoidal choroidal vasculopathy: a comprehensive clinical update. ther adv ophthalmol. 2019; 11: 2515841419831152. 3. cheung cm, lai yy, ruamviboonsuk p, chen sj, chen y, freund kb, et al. polypoidal choroidal vasculopathy: definition, pathogenesis, diagnosis, and management. ophthalmology, 2018; 125 (5): 708-724. 4. tso mo, suarez mj, eberhart cg. pathologic study of early manifestations of polypoidal choroidal vasculopathy and pathogenesis of choroidal neovascularization. am j ophthalmol case rep. 2017; 4 (11): 176-180. 5. kim jb, nirwan rs, kuriyan ae. polypoidal choroidal vasculopathy. curr ophthalmol rep. 2017; 5 (2): 176-186. 6. weng hy, huang tl, chang py, wang jk. oneyear outcome of combination therapy with intravitreal aflibercept and photodynamic therapy for polypoidal choroidal vasculopathy. bmc pharmacol toxicol. 2019; 20:29. 7. wong cw, wong ty, cheung cm. polypoidal choroidal vasculopathy in asians. j clin med. 2015; 4 (5): 782–821. 8. honda s, matsumiya w, negi a. polypoidal choroidal vasculopathy: clinical features and genetic predisposition. ophthalmologica. 2014; 231 (2): 59-74. polypoidal choroidal vasculopathy pak j ophthalmol. 2021, vol. 37 (2): 239-242 242 9. tan cs, ngo wk, lim lw, tan nw, lim th. everest study report 4: fluorescein angiography features predictive of polypoidal choroidal vasculopathy. clin exp ophthalmol. 2019; 47 (5): 614620. 10. wong rl, lai ty. polypoidal choroidal vasculopathy: an update on therapeutic approaches. j ophthalmic vis res. 2013; 8 (4): 359-371. author’s designation and contribution sana nadeem; assistant professor: principle author, drafting of manuscript, diagnosis, assessment, evaluation & follow up of patient. .…  …. pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 4 original article comparative analysis between pretest/post-test model and post-test-only model in achieving the learning outcomes tayyaba gul malik, rabail alam pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyaba gul malik professor of ophthalmology rashid latif medical college email: tayyabam@yahoo.com …..……………………….. purpose: to compare the effectiveness of pre-test/post-test model with posttest-only model in achieving the learning outcomes of a lecture of 45 minutes. study design: quasi experimental study. study place and study period: rashid latif medical college, in 2018. sample collection: non-probability convenience sampling. material and methods: 131 students of fourth year mbbs in a private medical college of pakistan were selected for the study. students of the same year and same college were included in the study. two teaching models were compared on the same set of students at different time-periods. pre-test followed by posttest model was compared with post-test-only model. in the pre-test/post-test design, the students were given a test before the lecture was delivered. the same test was given after a lecture of 45 minutes. the same group of students were taught another topic in another lecture of 45 minutes. there was no pretest this time. 50 percent score was selected as the passing criteria. results: there were 131 students, 66 males and 65 females (ratio of 1.01:1). in the pre-test/post-test model, 82% (n = 107) students passed the test while 5% (n = 6) failed. 14% (n = 18) students scored borderline marks. in the post-testonly model, 57% (n = 74) students passed the test while 6% (n = 8) failed. 37% (n = 49) students scored borderline marks. conclusion: pre-test/post-test model was significantly more effective in students in achieving the learning outcomes in a lecture as compared to posttest only model (p < 0.01). key words: pre-test post-test teaching model, post-test-only design, evaluation. valuation in teaching is an integral part of successful and effective teaching1. it is defined as "the process of obtaining information about a course or a program of teaching for subsequent judgment and decision-making"2. the importance of evaluation in medical education cannot be overlooked, as evaluation drives curriculum. a sound curriculum in medical education breeds good clinicians, which improves the healthcare of the patients. hence, good medical teaching is directly concerned with development of good clinicians3,4,5. pre-test/post-test and post-test-only designs are important assessment tools that help in direct and effective evaluation of a course or lecture to improve student learning. the idea of pre-test/post-test evaluation model is to measure baseline knowledge of participants at the beginning of a course/lecture and compare it with the knowledge gained after the course. comparing participants’ post-test scores to their pre-test scores enables to see whether the activity was successful in e mailto:tayyabam@yahoo.com tayyaba gul malik, et al 5 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology fig. 1: (above) showing the pre-test/post-test design. (below) post-test only design is shown. increasing participants’ knowledge of the taught content. in the post-test only model, the design is the same as pre-test/post-test but the pre-test is omitted. the idea is shown in its simplified form in figure 1. “outcomes of teaching” is a broad term, which encompasses not only the acquisition of knowledge but also practical skills and attitudes6,7. in lectures, skills and attitudes cannot be assessed. pres-test/posttest and post-test only models are just one aspect. it must be combined with other assessments, for example, peer evaluation and program review to present an authentic and holistic data to reflect the educational gains3. in this study, we have tried to find out which of the two evaluation designs; pre-test/post-test model and post-test-only model is more effective in achieving the learning outcomes after 45 minutes lecture in a class of fourth year mbbs, in a private medical institution of punjab. to the best of our knowledge, this is the first comparative study between pre-test/ post-test and post-test-only designs. material and methods 131 students of fourth year mbbs in a private medical college of pakistan were selected for the study. the study was approved by the institutional review board. the inclusion criteria was students of fourth year mbbs, age between 21 and 23 years (average 22 years), irrespective of gender. students of the same year and same college were included in the study. students from other mbbs classes and other colleges were not included. pre-test/post-test model and post-test-only model were compared on the same set of students at different time-periods. the lectures in both models were delivered on two different topics of ophthalmology. pre-test followed by post-test model was compared with post-test-only model. in the pre-test/post-test design, the students were given a test before the lecture was delivered. the same test was given after a lecture of 45 minutes. the questions given in the test were problem-based and not just the recall of knowledge. the pre-test, post-test and the lecture were done on the same day. the same group of students were taught another topic in another lecture of 45 minutes. there was no pre-test this time. however, post-test was given on the same day immediately after the lecture was over. in both evaluation models, the lecturer was not changed. the tests were prepared and scoring was also done by the same teacher. 50 percent score was selected as the passing criteria. scores between 45 and 49 percent were regarded as borderline and less than 45 percent score was considered fail. the data was collected, compiled and then analyzed using chi square test. results there were 131 students, 66 males and 65 females (ratio of 1.01:1). in the pre-test/post-test model, 82% (n = 107) students passed the test while 5% (n = 6) failed. 14% (n = 18) students scored borderline marks. in the post-test-only model, 57% (n = 74) students passed the test while 6% (n = 8) failed. 37% (n = 49) students scored borderline marks. pre-test/post-test model was significantly more effective in achieving the learning outcomes in a lecture as compared to post-test only model (p < 0.01). according to frequencies and percentages, the pre/post-test model is providing more help to students to pass the test and post-test-only design gives higher frequency of students at borderline (figure 2). students pre-test lecture post-test students lecture post-test comparative analysis between pre-test/post-test model and post-test-only model in achieving the learning pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 6 fig. 2: comparison of pre-test/post-test model with post-test-only model. discussion research in medical education is increasing day by day and advancements in the research methods is gaining momentum. research methodology in medical education uses techniques which are adopted in psychology, epidemiology and related fields8. different types of research designs, which are used in these fields include “one shot case study”, one group pre-test-post-test, two group pre-test/post-test, posttest-only, two group randomized post-test-only design and solomon four-group design. in “one shot case study” there is only one group, which is exposed to intervention and there is no control group9. in “one group pre-test-post-test design”, there is no control group and the pre-test is compared with the posttest10,11. “two group pre-test/post-test design” compares the intervention group with the control12. although pre-test/post-test design is more widely used in medical education, some researchers have found “two group randomized post-test-only design” to be more useful provided there are 40 participants in each group13. the solomon four-group design is another model in which there are four groups; two with a pre-test (experimental and control groups) and other two without pre-test (experimental and control groups)14. pre-test-post-test and post-test-only designs are widely used in behavioral research but less frequently employed in medical education research. in annual system of education, the results of the students in final examination is the only way to evaluate the teaching methodology in the previous year. pre-test/post-test and post-test-only designs provide measurement of change for assessing the impact of teaching during academic year. there are many situations where a pre-test is either impossible or difficult due to time constraints. in such conditions, post-test-only method can be employed. many studies are available which have shown that pretest/posttest model helps to monitor student progression and learning throughout a course or program15. this technique is not only used at many educational setups to test the success of a teaching session but is also found to be a tool of research in medical education. the results of this particular study showed that pre-test/post-test model is comparatively more effective in achieving the learning outcomes in a lecture setting. by michael delucchi, a pretest/ posttest technique, once put into practice, can be used to improve the process of teaching skills16. for example, the topics and areas in which students show poor performance in post-test can be revised and later given increased emphasis. the drawback is that extra time has to be devoted to these topics. both the instructor and students can benefit from a pretest/ posttest course design. in this particular research, the tests were taken with hidden students’ identity. however, if the identity of the students is discernable, we are able to know very weak and strong students in the class. students showing poor performance can be identified for extra coaching. with pre-test, difficult topics are determined and further planning of the lectures is done keeping in view all the difficult points. this is not possible with post-test-only model. this is the reason, why pre-test/post-test design was more effective in achieving the desired learning outcome. in our research, the pre-test and post-test were performed on the same day. if pre-test is given before the start of a course, the lecturer/teacher is able to know which topics to stress upon and which topics to touch lightly based on the response of the learners. there are some recommendations by t. wood & g. cole, regarding use of pretest/posttest technique17. firstly, the instructors should not include pretest/post-test scoring as a part of final assessments. secondly, questions should be formed based on the primary learning objectives. he further suggested that if the teacher is not able to write a test item on the learning objective, then he/she should rewrite the learning objectives. the question items for pre-and post-tests can be multiple choice, true/false and short answer. they should be created in a clear manner. faulty questions cannot accurately measure changes in knowledge. a very important proposal is that the questions should not include material, which demands tayyaba gul malik, et al 7 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology the memorization of minor unimportant details. the students should not be tested on whether they remember a particular term or percentage etc. rather they should be tested on important concepts and related facts. to determine the short-term and long-term effects, the post-test should be administered directly at the completion of the course and also at a later date to measure long-term impact of learning. later assessment was not part of this study. there are few disadvantages of this technique. in very short teaching programs, these tests do not meet the time requirements. secondly, pre-test is only useful when a student has some relevant baseline knowledge on the course topic. another objection to good performance in post-test of pre-test/post-test design is that the students taking the test for a second time mostly do better than those taking the test for the first time making the results biased7. some students may drop out of the course before the post-test has been conducted, resulting in post-test results that may be higher than they should be because those who remained in the course were more successful. in our study, the number of students was same in pretest/post-test design as well as post-test-only design. so, dropout flaw was effectively taken care of. boston university has given certain guidelines for developing a pre/post-test18. they recommend to create 10 to 15 questions that could test students’ knowledge of a learning outcome at the end of a course. if a course has more than one topic, all the faculty members, teaching the topics should meet to create these questions. difficulty level of the questions should be according to the level of the students. for example, post-graduate students will have questions with different level of difficulty from the undergraduate students. questions in pre-test and post-test should be exactly the same. according to martyn shuttle worth, pre-test/ posttest model was a derivative of post-test-only model19. one of the drawbacks of post-test-only design is that we do not have pre-existing knowledge of the student, it cannot be said that the score in the post-test is the outcome of intervention (lecture in this particular case). outcome of teaching is not only the increase in knowledge but also improvement of practical skills and development of professional attitudes. unfortunately, both these models are not effective in evaluation of skills and attitudes. most of the studies available in literature evaluate a single or two components of a course or program and are not comprehensive20. in addition to traditional “pre-test before the class” and “post-test after the class” design, there is “post-then-pre test design” called “retrospective pretest/post-test”. in this design, the learner is asked to first report present behaviors in a post-test and then, their perception of the same behavior before taking the course (a pre-test equivalent). because the student is asked their perception of improved performance in the same reference of the post-test, some educators feel this is a more accurate measurement21. the positive points of our study is that, it made comparisons between the same people, or groups of people, at different points in time. limitations of this study are that the tests in both models were different. another drawback was that only short-term effect was studied. no long-term impact on knowledge was seen in this study. conclusion pre-test/post-test design is more effective in achieving teaching goals in a lecture setting than post-test-only design. author’s affiliation dr. tayyaba gul malik professor of ophthalmology rashid latif medical college rabail alam assistant professor institute of molecular biology and biotechnology the university of lahore author’s contribution dr. tayyaba gul malik research planning, data acquisition and analysis, literature research, manuscript writing and final review. rabail alam statistical analysis, final review of manuscript. conflict of interest: none references 1. snell l, tallett s, haist s et al. a review of the comparative analysis between pre-test/post-test model and post-test-only model in achieving the learning pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 8 evaluation of clinical teaching: new perspectives and challenges. med educ. 2000; 34 (10): 862-70. 2. goldie fj. amee guide no. 29: evaluating educational programmes. med teach. 2006; 28: 210-24. 3. prideaux d, alexander h, bower a et al. clinical teaching: maintaining an educational role for doctors in the new health care environment. med educ. 2000; 34 (10): 820-6. 4. cook, d. a. twelve tips for evaluating educational programs. medical teacher, 2010; 32 (4): 295-301. 5. gilman sc, cullen rj, leist jc, craft ca. domainsbased outcomes assessment of continuing medical education: the va model. acad med. 2002; 77: 810–7. 6. blumberg p. multidimensional outcome considerations in assessing the efficacy of medical educational programs. teach learn med. 2003; 15 (3): 210–214. 7. frank jr, danoff d. the can meds initiative: implementing an outcomes-based framework of physician competencies. med teach. 2007; 29 (7): 642– 647. 8. carney pa, nierenberg dw, pipas cf, brooks wb, stukel ta, keller am. educational epidemiology: applying population-based design and analytic approaches to study medical education. jama. 2004; 292 (9): 1044-1050. 9. kerlinger, f. n. foundations of behavioral research (2nd ed.). new york, ny: holt, rinehart, and winston, 1973. 10. campbell, d. t., & stanley, j. c. experimental and quasi-experimental designs for research on teaching. in handbook of research on teaching. n. l. gage (ed.), chicago, il: 1963 (pp. 171-246). 11. knapp tr. why is the one group pre-test post-test design still used? clin nurs res. 2016; 25 (5): 467-72. 12. pat d, john t. analysis of pre‐test‐post‐test control group designs in educational research. educational psychology educ psychol-uk, 1995; 15: 181-198. 13. fraenkel, jr., wallen n. e. how to design and evaluate research in education. new york, ny: mcgraw-hill. 2003. 14. sawilowsky, d. kelley l, blair c, markman bs. metaanalysis and the solomon four-group design, the journal of experimental education, 1994; 62 (4): 361-376. 15. felix a. pre/post-testing to evaluate the effectiveness of online language programs. jltr. 2016; 4 (1): 176. 16. delucchi m. measuring student learning in social statistics: a pretest-posttest study of knowledge gain. teaching sociology, 2014; 42 (3): 231–239. 17. wood t, cole g. developing multiple choice questions for the royal college of physicians and surgeons of canada certification examinations. educational research and development, june, 2004: p. 4. 18. chabot, mira costa, chaffey, and cabrillo colleges. boston university, slo websites 12/17/2013; revised 4/23/2014. 19. martyn shuttleworth. pretest-posttest designs. retrieved nov 08, 2018 from explorable.com: https://explorable.com/pretest-posttest-designs 20. gibson ka, boyle p, black da, cunningham m, grimm mc, mcneil hp. enhancing evaluation in an undergraduate medical education program. acad med. 2008 aug; 83 (8): 787–793. 21. bhanji f, gottesman r, de grave w, steinert y, winer lr. the retrospective pre-post: a practical method to evaluate learning from an educational program. acad emerg med. 2012; 19 (2): 189-94. https://explorable.com/users/martyn https://explorable.com/pretest-posttest-designs 281 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol original article correlation of ankle-brachial index with diabetic retinopathy in patients of type 2 diabetes abdullah mazhar, tayyaba gul malik, aalia ali, hina nadeem doi 10.36351/pjo.v35i4.877 pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: professor tayyaba gul malik department of ophthalmology, rashid latif medical college, lahore. email: tayyabam@yahoo.com …..……………………….. purpose: to find a relationship of diabetic retinopathy with ankle-brachial (abi) in patients of type 2 diabetes. study design: cross-sectional observational study. place and duration of study: arif memorial teaching hospital and rashid latif medical college from january 2019 to june 2019. material and methods: 120 patients were selected by purposive convenient sampling from outpatient department of arif memorial teaching hospital. after clinical history, complete ocular examination was performed. random blood glucose levels were measured using glucometer. ankle-brachial index was calculated by dividing the systolic pressure at ankle by the systolic blood pressure at arm. statistical analysis was done using spss 25. independent sample t test and chi square tests were used to find out the significance of the results. results: in this study of 120 diabetic patients, 80 (66.7%) were female and 40 (33.3%) were males. mean ankle branchial index (abi) of males was 0.96 ± 0.11 and for females was 0.97 ± 0.14. among 120 participants of this study, 73 (60.83%) patients had no signs of diabetic retinopathy, 35 (29.16%) patients had npdr and 12 (10%) patients had pdr. abi was not associated with gender and duration of diabetes. however, there was negative and weak linear relationship between bsr and abi (r = -0.221). this correlation was higher in diabetics of less than 5 year duration (r = -0.286) than in patients of more than 5 years duration of diabetes (r = -0.129). conclusion: our study indicates that abi is not significantly related with diabetic retinopathy. however, there is a weak linear relationship of abi with high blood sugar levels. key words: ankle brachial index, toe-brachial index, diabetic retinopathy. n late 1960s, ankle-brachial index (abi) was developed as a simple test to find out existence of peripheral artery disease especially the lower extremity artery disease (lead). the american diabetes association has recommended screening for lead in all diabetic patients1. lead increases the risk of complications of diabetes including diabetic retinopathy, cardiovascular episodes and even death in severe cases2,3. in normal persons, lower limb systolic pressure at ankle is 10 to 15 mm hg greater than pressure at arm. this is responsible for abi of about 1.1 to 1.3. a range between 0.9 to 1.0 is suspicious, less than 0.9 is dangerous and indicative of peripheral artery disease. however, more than 1.4 is also abnormal and it shows calcification and stiffening of arteries (poorly compressible arteries). as micro-angiopathy and macro-angiopathy, which are responsible for peripheral artery disease, are i mailto:tayyabam@yahoo.com correlation of ankle-brachial index with diabetic retinopathy in patients of type 2 diabetes pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 282 reflected in retina as diabetic retinopathy, we have tried to find out a relation between abi and diabetic retinopathy in this research. the purpose of this study was to find a relationship of diabetic retinopathy with anklebrachial (abi) in patients of type 2 diabetes. material and methods it was a cross-sectional observational study carried out from january 2019 to june 2019. institutional ethical review board approved the study. sample size was calculated by who software 2.0. 120 patients were selected by purposive convenient sampling from outpatient department of arif memorial teaching hospital. all patients with type 2 diabetes between 25 and 80 years of age of both genders were included in the study. exclusion criteria were patients with systemic diseases other than diabetes, type 1 diabetic patients, smokers, patients who had undergone laser therapy or intravitreal anti-vegf injections for diabetic retinopathy and patients with vitreo-retinal diseases other than diabetic retinopathy. table 1: association of abi with bsr and duration of diabetes. abi bsr and duration of diabetes p-value < 5 years > 5 years normal 203.28 ± 84.42 193.87 ± 66.42 0.645 below 259.94 ± 131.21 235.09 ± 95.37 0.390 p-value 0.066 0.054 after clinical history, examination was performed. random blood glucose levels were measured using glucometer. we checked visual acuity for distance and near. pupillary reactions were checked. slit lamp examination was performed to inspect any anterior segment abnormality. goldman tonometry was done to check intra ocular pressures. fundus examination was performed using 90 d lens at slit lamp and with indirect ophthalmoscope. retinal findings were categorized into, nad (no abnormality detected), npdr (non-proliferative diabetic retinopathy) and pdr (proliferative diabetic retinopathy). table 2: association of abi with gender, duration of diabetes and diabetic retinopathy. variable ankle branchial index p-value normal (1-1.4) below 1 gender female 39 (49.4%) 40 (50.6%) 0.333 male 16 (40.0%) 24 (60.0%) duration of diabetes < 5 years 25 (43.9%) 32 (56.1%) 0.621 > 5 years 30 (48.4%) 32 (51.6%) ophthalmoscopy nad 37 (51.4%) 35 (48.6%) 0.082 npdr 16 (45.7%) 19 (54.3%) pdr 2 (16.7%) 10 (83.3%) graph 1: relation of abi with gender, bsr and duration of diabetes. we determined ankle-brachial index by checking the systolic blood pressure in supine position with the help of mercury sphygmomanometer. blood pressure was recorded in both arms in supine position after 5 minutes of resting. mean of the two pressures was taken as brachial systolic pressure. the cuff was inflated 20 mm hg higher than the arm systolic blood pressures while ankle pressures were measured at dorsalis pedis artery. anklebrachial index was calculated by dividing the systolic pressure at ankle by the systolic blood pressure at arm. all data was collected using a selfdesigned proforma and compiled in excel file. statistical analysis was done using spss 25. independent sample t test and chi square tests were used to find out the significance of the results. results in this study of 120 diabetic patients, 80 (66.7%) were female and 40 (33.3%) were males. mean age of the females was 50.94 ± 12.74 years and mean age of males was 51.98 ± 10.73 years. mean bsr of males abdullah mazhar, et al 283 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol was 216.28 ± 98.94 and in females was 227.19 ± 102.61. mean ankle branchial index (abi) of males was 0.96 ± 0.11 and for females was 0.97 ± 0.14 (table 2). among 120 participants of this study, 58 patients had diabetes for less than 5 years and 62 were suffering from this disease for more than 5 years. seventy three (60.83%) patients had no signs of diabetic retinopathy, 35 (29.16%) patients had npdr and 12 (10%) patients had pdr (table 2). abi was not associated with gender and duration of diabetes. see table 1. patients who had abi in normal range had mean bsr 198.15 ± 74.56. patients who had low abi had bsr of 247.52 ± 114.47. this difference was statistically significant (p-value 0.007). there was negative and weak linear relationship between bsr and abi (r = -0.221). this correlation was higher in diabetics of less than 5 year duration (r = -0.286) than in patients of more than 5 years duration of diabetes (r = -0.129). discussion lower extremity artery disease, also known as peripheral artery disease (pad) is a common complication of diabetes and it increases with increase in the duration of diabetes. studies have shown that diabetic retinopathy is an independent risk factor for pad4. abi has a sensitivity of 90% and specificity of 95% for angiographically proved pad5. diabetic patients are prone to pad and hence abnormal and borderline abi is a very useful, non-invasive test to detect pad6. abi values of 1 to 1.3 are considered normal, less than 1 are abnormal but the 2011 american college of cardiology foundation (accf) and american heart association (aha) guidelines for the management of pad have recommended abi values of 0.90–0.99 as ‘borderline’7. in our study, we took 0.9 as abnormal rather than borderline. studies have shown that women were more likely to have borderline abi (11.6%) than men (8.0%)8. similarly, in the national health and nutrition examination survey nhanes (1999–2002) and the multi-ethnic study of atherosclerosis (mesa), the prevalence of borderline abi nearly doubled in women (11.7% and 10.6%) than men (6.0% and 4.3%)9. this was not the case in our study and abi was not significantly higher in women as compared to men (p = .333). low abi is also associated with increased risk of mortality10. studies have shown that ankle–brachial index is very effective and cost effective tool for diagnosis of pad11. however, abi values have shown variable results in diabetic patients as compared to normal population12. different studies have shown varying results of association of diabetic retinopathy with abi. one of the reasons for studying abi in our diabetic population was that this relation is not yet studied in our population and to the best of our knowledge; this is the first research being reported from pakistan. our data revealed that, there was no statistically significant relation of diabetic retinopathy with abnormal or low abi. contrary to this, papanas et al had shown low abi in type 2 diabetic patients with diabetic retinopathy13. similarly, emerson et al. described a direct relation of severity of diabetic retinopathy and microalbuminuria with abnormal abi scores. this indicated that patients with abnormally low abi have not only the kidneys at stake but also their vision14. other studies have shown similar results indicating abi as a marker of not only pad but also diabetic retinopathy15,16,17,18. according to joint asia diabetes evaluation program, 12,777 patients with type 2 diabetes had borderline abi, which was associated with increased prevalence of microvascular complications. abi was found to be an independent risk factor for diabetic retinopathy in a chinese study19. (odds ratios: 1.19 (95% confidence interval: 1.04–1.37)). they also proposed a higher cut off value < 1.0 to early prevent onset of diabetic complications including diabetic retinopathy (dr). they also described association of low abi with duration of diabetes, which is consistent to our study. similar results were reported from germany20. zander et al supported an increased prevalence of diabetic retinopathy and neuropathy in patients with abnormal abi values. overall, in their study, patients with diabetic retinopathy had higher proportion of low abi than those without dr. (53 out of 138 vs. 59 out of 337). another study from china with multivariate forward logistic regression analysis showed positive relation of pdr with abnormal abi as compared to non-dr. however, npdr was not significantly related with abnormal abi when compared with normal population21. there are conflicting data as far as abi and dr are concerned. there were other reports, which were similar to our results showing no relationship of abi to presence or absence of retinopathy in diabetic individuals. yun et al related their negative findings correlation of ankle-brachial index with diabetic retinopathy in patients of type 2 diabetes pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 284 regarding abi and dr with other conditions for example sample size, age and characteristics of study population16. similarly, a study from israel showed that type 2 diabetes was associated with higher bmi, larger waist circumference but abi was normal in all patients with or without dr22. this variability of results was explained by some researchers in terms of arterial stiffness. when abi is measured in patients with arterial stiffness, which is also associated with diabetes, abi values appear higher due to lesser vascular compressibility. hence, abi values in diabetic patients show lower prevalence in some studies. for the same reason some epidemiological researchers have shown that abi < 0.9 as well as > 1.4 is indicative of pad23,24. strength of this research is that this study was conducted to find a relation of abi with diabetic retinopathy in pakistani population. our limitation was that, as normal abi in our study could have been due to arterial calcification, we can further expand our research using toe-brachial index, which according to some recent data, is found to be of superior diagnostic value as compared to the abi25. conclusion our study indicates that abi is not significantly related with diabetic retinopathy. however, there is a weak relationship of decreased abi with high blood glucose levels. declarations authors declare no conflict of interest in this study. there was no funding source. the institutional review board approved the research. references 1. american diabetes association. standards of medical care in diabetes – 2013. diabetes care, 2013; 36: 11–66. 2. criqui mh, aboyans v. epidemiology of peripheral artery disease. circ res. 2015; 116 (9i): 1509–26. 3. selvin e, erlinger tp. prevalence of and risk factors for peripheral arterial disease in the united states: results from the national health and nutrition examination survey, 1999–2000. circulation. 2004; 110 (6i): 738–43. 4. nativel m, potier l, alexandre l, baillet-blanco l, ducasse e, velho g, et al. lower extremity arterial disease in patients with diabetes: a contemporary narrative review cardiovasc diabetol. 2018; 17: 138. 5. criqui mh. systemic atherosclerosis risk and the mandate for intervention in atherosclerotic peripheral arterial disease. am j cardiol. 2001; 88: 43j–47j. 6. natsuaki c, inoguchi t, maeda y, yamada t, sasaki s, sonoda n, et al. association of borderline anklebrachial index with mortality and the incidence of peripheral artery disease in diabetic patients. atherosclerosis, 2014; 234: 360–365. 7. american college of cardiology foundation, american heart association task force, society for cardiovascular angiography and interventions, et al. 2011 accf/aha focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline). vasc med. 2011; 16: 452–476. 8. mcdermott mm, liu k, criqui mh, ruth k, goff d, saad mf, et al. ankle-brachial index and subclinical cardiac and carotid disease: the multiethnic study of atherosclerosis. am j epidemiol. 2005; 162: 33–41. 9. menke a, muntner p, wildman rp, dreisbach aw, raggi p. relation of borderline peripheral arterial disease to cardiovascular disease risk. am j cardiol. 2006; 98: 1226–1230. 10. khan t, farooqi f, niazi k. critical review of the ankle brachial index. curr cardiol rev. 2008; 4: 101-106. 11. weiss ns, mcclelland r, criqui mh, wassel cl, kronmal r. incidence and predictors of clinical peripheral artery disease in asymptomatic persons with a low ankle–brachial index. j med screen, 2018; 25 (4): 218-222. 12. guirguis-blake jm, evans cv, redmond n, lin js. screening for peripheral artery disease using the ankle– brachial index: updated evidence report and systematic review for the us preventive services task force. jama. 2018; 320 (2i): 184–96. 13. papanas n, symeonidis g, mavridis g, georgiadis gs, papas tt, lazarides mk, et al. ankle-brachial index: a surrogate marker of microvascular complications in type 2 diabetes mellitus? int angiol. 2007; 26 (3): 253-257 17622207. 14. molina ejb, yutangco ra, cruz-anacleto mas, castillo jdd, aguinod-cheng pj. relationship of diabetic retinopathy with ankle brachial index and microalbuminuria in type 2 diabetics philipp j ophthalmol. 2014; 39: 12-15. 15. kawasaki r, cheung n, islam a, klein r, klein bek, cotch mf et al. is diabetic retinopathy related to subclinical cardiovascular disease? ophthalmology, 2011; 118: 860-865. 16. yun yw, shin mh, lee yh, rhee ja, choi js. arterial stiffness is associated with diabetic retinopathy in korean type 2 diabetic patients. j prev med public health, 2011; 44: 260-266. 17. tryniszewski w, gadzicki m, maziarz z, kusmierczyk j, gos r, rysz j, et al. progression of diabetic retinopathy correlated with muscle perfusion disturbances of the lower limbs, with clinically important diagnostic recommendations. arch med sci. 2010; 6: 904-911. 18. rani p, raman r, gupta a, pal ss, kulothungan v, sharma t. albuminuria and diabetic retinopathy in abdullah mazhar, et al 285 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol type 2 diabetes mellitus. sankara nethralaya diabetic retinopathy epidemiology and molecular genetic study (sn-dreams, report 12). diabetol metab syndr. 2011; 3: 9. 19. yan bp, zhang y, kong ap, luk ao, ozaki r, yeung r, et al. borderline ankle–brachial index is associated with increased prevalence of microand macrovascular complications in type 2 diabetes: a cross-sectional analysis of 12,772 patients from the joint asia diabetes evaluation program. diabetes vasc dis re. 2015; 12 (5): 334–341. 20. zander e, heinke p, reindel j, kohnert kd, kairies u, braun j, et al. peripheral arterial disease in diabetes mellitus type 1 and type 2: are there different risk factors? vasa. 2002; 31: 249e54. 21. chen sc, hsiao pj, huang jc, lin kd, hsu wh, lee yl, et al. abnormally low or high ankle-brachial index is associated with proliferative diabetic retinopathy in type 2 diabetic mellitus patients. plos one. 2015; 10 (7): e0134718. 22. blum a, socea d. clinical characteristics of diabetic patients with diabetic retinopathy. j. nutr. ther. 2013; 2 (1): 46-52. 23. aboyans v, ho e, denenberg jo, ho la, natarajan l, criqui mh. the association between elevated ankle systolic pressures and peripheral occlusive arterial disease in diabetic and nondiabetic subjects. j vasc surg. 2008; 48 (5): 1197-1203 18692981. 24. papanas n, symeonidis g, mavridis g, georgiadis gs, papas tt, lazarides mk, et al. ankle-brachial index: a surrogate marker of microvascular complications in type 2 diabetes mellitus? int angiol. 2007; 26 (3): 253-257 17622207. 25. tehan pe, barwick al, sebastian m, helaine v. diagnostic accuracy of resting systolic toe pressure for diagnosis of peripheral arterial disease in people with and without diabetes: a cross-sectional retrospective case-control study. j foot ankle res. 2017; 10: 58. author’s affiliation dr. abdullah mazhar assistant professor department of ophthalmology, rashid latif medical college, lahore prof. tayyaba gul malik professor department of ophthalmology, rashid latif medical college, lahore dr. aalia ali medical officer department of ophthalmology, arif memorial teaching hospital, lahore dr. hina nadeem medical officer department of ophthalmology, arif memorial teaching hospital, lahore author’s contribution dr. abdullah mazhar data acquisition and analysis, literature research and final review. prof. tayyaba gul malik research planning, data acquisition and analysis, literature research, manuscript writing and final review. dr. aalia ali data acquisition and analysis, literature research and final review. dr. hina nadeem data acquisition, data analysis, final manuscript review. microsoft word akhtarjamalkhan[1]checked 1 original article prevalence and importance of hepatitis b & c screening in cases undergoing elective eye surgery akhtar jamal khan, taranum ruba siddiqui pak j ophthalmol 2007, vol. 23 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: akhtar jamal khan akhtar eye hospital flat-1(4/c). block 5 p.o. box 11177 karachi-75300 received for publication july’ 2006 …..……………………….. purpose: to determine the sero-prevalence of hepatitis b & c viral infection in the patients undergoing elective eye surgery. material and method: a total of 1418 subjects undergoing major and minor eye surgery were screened for hepatitis b, & 1158 patient were screened for hepatitis c. screening was done by one step test device that is a rapid chromatography immunoassay for the qualitative detection of antibodies to hepatitis c virus whereas for hepatitis b the qualitative detection of surface antigen of hepatitis b virus was performed. result: out of 1418 subjects, 1.8% subjects were found to be hepatitis b positive, out of these 61.5% were males and 38.4% were females. out of 1158 subjects, 1.2% subjects were found to be hepatitis c positive, out of these 50% were males and 50% were females. conclusion: screening of blood borne viral infections has great importance in minimizing the transmission of the virus to health patients doctors and paramedical staff through sharp knives, needles and other surgical instruments. the alarming percentage of positive viral infection gives us an idea of the risks involved & how to adopt such practices which ensures the safety from onset of these infections. epatitis b and c is a major disease affecting mankind and a serious global public health problem. according to who studies, out of the 2 billion people who have been infected with the hepatitis b virus (hbv), more than 350 million have chronic (life long) infection. these chronically infected persons are at high risk of death from cirrhosis of the liver and liver cancer1. in case of hcv infection who estimates that about 170 million people, 3% of the world’s population are infected with hcv and are at risk of developing liver cirrhosis and or liver cancer. the prevalence of hcv infection in some countries of africa, the eastern mediterranean, south-east asia and the western pacific is high compared to countries in north america and europe2. pakistan is also facing a huge burden of these infections. a large number of symptomatic carriers are present in our country. the carrier rate of hepatitis hbsag is quoted to be around 10%3,4 and seroprevalence of anti hcv antibodies varies from 4% to 7% in different segment of pakistani population5,6. in a community-based study in hafizabad, hepatitis b surface antigen (hbs ag) was positive in 4.3% of residents and anti-hepatitis c virus antibody was positive in 6.5% of residents7. in northern pakistan h 2 3.3% of healthy blood donors were hbsag positive, 4.0% were anti-hepatitis c virus positive and 0.007% were anti-human immunodeficiency virus positive8. majority of the population in pakistan have several misconceptions regarding hcv and hbv infection. one main misconception is that hepatitis c is a vaccine preventable disease. the eastern mediterranean health journal quotes that mostly people are not aware that hcv remain asymptomatic for several years9. there is lack of understanding that hepatitis b infection is major public health problem in pakistan, and the transmission risk rate is continuously increasing due to lack of awareness and poverty. hepatitis b & c is highly endemic in pakistan & its incidence is increaseing since the last decade3,10. in this situation the most effective preventive measure against these two bloodborne pathogens is building awareness and adopting preventive measures to minimize transmission. this study was carried out to determine the incidence of hepatitis b and c in our patients undergoing elective eye surgery. patients and methods this analytical study was carried out at the microbiological and biotech research and diagnostic laboratory of akhtar eye hospital, karachi, in collaboration with the surgical unit of akhtar eye hospital, karachi. to reduce the risk of transmission of blood-borne pathogens, surgeons decided to question patients regarding hbv, hcv and hiv infection. for prevention and safety, it has become mandatory for all patients undergoing minor or major surgery to undergo blood screening for hbv and hcv virus at akhtar eye hospital. although it was thought to be an additional expense, patients soon realized that its benefits outweigh the cost. our test proved to be reliable. ‘hbsag’ and ‘anti-hcv ab’ were screened by rapid chromatography immunoassay. both of these tests are not as sensitive as elisa, but they provide rapid and efficient qualitative analysis which is useful to determine the presence of infections. the test device is a lateral flow immunoassay used for the qualitative detection of hbsag in serum or plasma. the membrane is pre-coated with anti-hbsag antibodies on the test line region of the device. during testing, the serum or plasma specimen reacts with the particle coated with anti-hbsag antibody. the mixture migrates upwards on the membrane chromatographically by capillary action to react with anti-hbsag antibodies on the membrane and generates a color line in the test region indicating positive results, while its absence indicates negative result. in case of hcv a one step test device is used. a membrane is coated with recombinant hcv antigen on the test line region of the device. during testing, serum or plasma specimen reacts with the protein a coated particles. the mixture migrates upward on the membrane chromatographically by capillary action to react with recombinant hcv antigen on the membrane. this reaction generates a colored line, indicating a positive result, while its absence indicates a negative result. in both devices, a colored line will always appear at the control line region indicating that proper volume of specimen has been added and membrane wicking has occurred. results during study period, out of 1418 patients (in which 740 were male and 678 were female patients,.26 (1.8%) patients were found to be hbv positive. in these 26 patients 16 (61.5%) were males & 10 (38.4%) were females (table 1). in case of hcv screening 1158 patient was screened (in which 611 were male and 547 were female patients). after screening 14 (1.2%) patients were found to be hcv positive out of these 14 patients 7 (50%) were male and 7 (50%) were females (table 1). discussion the alarming situation of both hbv and hcv infection require that preoperative screening is necessary to avoid the transmission of blood-borne pathogens. this early detection can help in better management of patients and reduction in patient to health care workers (hcw) transmission, of hcv and hbv infection in surgical units. patients should be encouraged to participate in routine and voluntary testing for blood-borne pathogens. in case of corneal transplantation, the eye bank association of america has recommended screening of all potential corneal donors for hiv and as well as hbv (memorandum dated nov.7, 1986)11. wilson se et al quoted that ‘some problems in eye for example corneal ulceration is directly associated due to viremia like mooren-type hepatitis c’12. in these cases transmission of virus during surgery are likely to be more possible than other cases. 3 implementation of criteria to manage the risk of transmission should be applied on cases that show symptoms of jaundice, but majority of patients with chronic hcv and hbv are undiagnosed and asymptomatic. an american based studies shows that 75% of acute hcv infected cases have no symptoms or only mild, non specific complaints13. this further strengthens the argument that screening of blood for hbv and hcv is indispensable. table 1: month hbv hcv male female positive n (%) male female positive n (%) no positive n (%) no positive n (%) no positive n (%) no positive n (%) january 49 1 (2.04) 43 0 (0.00) 1 (1.08) 33 0 (0.00) 30 0 (0.00) 0 (0.00) february 52 1 (1.92) 52 1 (1.92) 2 (1.92) 30 0 (0.00) 30 1 (0.33) 1 (1.66) march 85 2 (2.35) 75 1 (1.33) 3 (1.87) 58 1 (1.72) 48 0 (0.00) 1 (0.94) april 76 3 (3.94) 56 0 (0.00) 3 (2.27) 52 1 (1.92) 36 0 (0.00) 1 (1.13) may 57 1 (1.75) 62 2 (3.22) 3 (2.52) 38 0 (0.00) 43 0 (0.00) 1 (0.00) june 48 2 (4.16) 44 0 (0.00) 2 (2.17) 41 0 (0.00) 33 0 (0.00) 0 (0.00) july 46 0 (0.00) 56 0 (0.00) 0 (0.00) 40 1 (2.50) 41 0 (0.00) 1 (1.20) august 57 2 (3.50) 44 0 (0.00) 2 (1.98) 51 0 (0.00) 40 1 (0.00) 0 (0.00) september 56 0 (0.00) 51 1 (1.96) 1 (0.93) 55 0 (0.00) 51 1 (1.96) 1 (0.90) october 34 1 (2.94) 20 0 (0.00) 1 (1.85) 33 0 (0.00) 20 0 (0.00) 0 (0.00) november 57 0 (0.00) 55 0 (0.00) 0 (0.00) 57 2 (3.50) 55 3 (4.46) 5 (4.46) december 72 0 (0.00) 78 3 (3.84) 3 (2.00) 72 2 (2.77) 78 1 (2.00) 3 (2.00) january,06 51 3 (5.88) 42 2 (4.76) 5 (5.37) 51 0(0.00) 42 0 (0.00) 0 (0.00) total 740 16 (2.16) 678 10 (1.47) 26 (1.83) 611 7(1.14) 547 7 (1.27) 14 (1.20) the most possible reason for the asymptomatic situation and sometime undiagnosed hcv infection is mutability of genome of hcv which is related to high propensity (80%) of inducing chronic infection2. serum antibodies to hcv become detectable 4 to 10 weeks after exposure. percutaneous injuries may occur at a rate approximating 1 to 3 per 100 operative procedure performed, the frequency varying by the type of surgery, length, and emergent nature13. in 2000 the international journal of std aids estimated that contaminated injection caused 21 million (40%) hbv infection, two million (32%) hcv infection and 260’000(5%) hiv infection through out the world14. transmission of hbv and hcv is a welldocumented occupational hazard for health care workers (hcws). in health care settings, transmission of these viruses have been reported from patient to hcw, from hcw to patient, and from patient to patient. although these viruses are blood-borne and share a common route of transmission, the epidemiology of transmission differs based on the virus involved and circumstances of the exposure. hbv is more efficiently transmitted than hcv or hiv, because of the high volume of hepatitis b viruses in the blood of infected people compared to the lower viral load in people infected with hiv or hepatitis c15. the international journal of std aids estimate that hcv while less infectious than hbv, is six times more likely than hiv to be transmitted after a percutaneous 4 exposure14.the transmission risk of hiv after exposure is 0.3%, hcv in 3% and hbv is transmitted in 30% of exposure16. our retrospective review of hbv and hcv in elective eye surgery is very alarming. fig. 1 shows that monthly prevalence average rate of hbv is 0.14% and hcv is 0.09%. the results shows that rate of hbv infection in patients is high as compare to hcv. this is comparable with the other study carried out in karachi18,17,24 and in lahore25. but our study is contradictory with the studies carried out in nwfp and punjab, where studies shows high prevalence of hcv as compared to hbv20,27,22,26,19,21. the results shows that sero prevalence of hbv & hcv is high in males as compared to female patients. fig. 2. this is similar in comparison to the other studies carried out in karachi17,18 and other parts of the country19-21 but this is contradictory to the results from the study carried out in nwfp region of pakistan22,23. 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% p er ce nt ag e of p os iti ve c as es jan feb mar apr may jun jul aug sep oct nov dec jan, 06 months of surgery hbv +ve% hcv -ve% fig 1: prevalence (%) of hepatitis b and c according to months. 0 10 20 30 40 50 60 hbv hcv male female fig. 2: prevalence (%) of hbv and hbv in male and female undergoing elective eye surgery during the year january 2005 to january 2006. our results are in concordance with the study carried out in different parts of the world such as india, where prevalence of hbv infection is 4.7% and hcv prevalence is 1.9%28. similarly in iran hbv infection is 1.1% and hcv infection is 0.6%29. in istanbul, turkey hbv infection rate is 6.6% and hcv infection is 2.4%30. in adult german population hbv infection is 0.6%31 and hcv infection is 0.6%32. in athens hbv infection rate is high as compare to hcv infection33. in brazilian army hbv infection rate is 2.6% and hcv infection rate is 1.5%34. in kuwait hbv infection is 1.1% and hcv infection is 0.8%35. international journal of infectious diseases quotes that prevalence of hepatitis b among afghan refugees living in balochistan, pakistan is highly endemic36. the prevalence of hbv infection in male and female patients according to age is shown in (fig. 3), in both genders a high prevalence rate was observed in the 41-60 years age group. similarly prevalence of hcv infection in male and female patients according to age is shown in (fig. 4), shows high prevalence rate of hcv infection in the 4160 years age group. while 1-20 years age group shows no infection in both genders. 0 1 2 3 4 5 6 7 8 01--20 21-40 41-60 61-90 male female fig. 3: prevalence of hbv in male and female undergoing elective eye surgery during the year 2005 and january 2006, according to age. years 5 0 1 2 3 4 5 01--20 21-40 41-60 61-90 male female fig -4: prevalence of hcv in male and female undergoing elective eye surgery during the year 2005 and january 2006, according to age. in developing countries like pakistan the treatment for chronic hepatitis c and b infection is very costly for the common man. awareness of the facts risks & dangers involved in spread & onset of these infections should cultivate concern and promote behavior required to prevent the spread of these infections. conclusion strict preventive measures and an intensive precautionary environment, promoting mandatory screening of preoperative patient for hbv and hcv viruses is essential to prevent the spread. it is important to educate the patients and to encourage them for screening or other medical treatments to ensure minimal risk of transmission, spread and onset of these diseases. author’s affiliation akhtar jamal khan akhtar eye hospital flat-1(4/c). block 5, po. box 11177 karachi-75300 taranum ruba 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international j of std aids. 2004; 15: 7-16. 15. cdcrecommendation for preventing transmission of human immunodeficiency virus and hepatitis b virus to patient during exposure prone in vasive procedures. mmwr. 1991; 12: 1-9. 16. american academy of orthopaedic surgeon & american association of orthopaedic surgeons (advisory statement) document no 1028 last modified on 2002. 17. mujeeb sa, mehmood k. prevalence of hbv, hcv and hiv infections among family blood donors. annals of saudi med. 1996; 16:. 18. kakepoto gn, bhally hs, khaliq g et al. epidemiology of blood-borne viruses: a study of healthy blood donors in southern pakistan. theast asian j trop med public health. 1996; 27: 703-6. 19. khokhar n, gill ml, malik gj. general seroprevalence of hepatitis c and hepatitis b virus infection in population. j coll phys surg pak. 2004; 14: 534-6. 20. khan ts, rizvi f, rashid a. hepatitis c seroprevalence among chronic liver disease patient in hazara, pakistan. j ayub med coll. (jamc). 2003; 15: 53-5. 21. khan ts, rizvi f, rashid a. hepatitis b seroprevalence among chronic liver disease patient in hazara, pakistan. bmc gastroenterology. 2005; 5: 26. 22. ahmad j. taj as, rahim a et al. frequency of hepatitis b and hepatitis c in healthy blood donors of nwfp: a single center experience original article. j postgrad med inst. 2004; 18: 34352. years 6 23. chaudhary ia, khan sa, samiuallah. should we do hepatitis b & c, screening on each patient before surgery: analysis of 142 cases. pak j med sci. 2005. 24. mujeeb a, jamal q, khanani r, et al. prevalence of hepatitis b surface antigen and hcv antibodies in hepatocellular carcinoma cases in karachi. pak j tropical doctor. 1997; 27: 45-6. 25. rehman k, khan aa, haider z, et al. prevalence of seromarkers of hbv and hcv in health care personnel and apparently healthy blood donors. j pak med assoc. 1997; 47: 100-1. 26. shah sma, khan mt, ullah z, et al. prevalence of hepatitis b hepatitis c virus infection in multitransfused thalassaemia major patient in north west frontier province. pak j med sci. 2005; 21: 281-4. 27. ally sh, hanif r, ahmed a. hbs ag and hcv: increasing test request and decreasing frequency of positive tests at clinical laboratory of ayub teaching hospital. 28. arora dr, sehgal r, et al. prevalence of parenterally transmitted hepatitis viruses in clinically diagnosed cases of hepatitis. indian j med microbiology. 2005; 23: 44-7. 29. ghavanini aa, sabri mr. hepatitis b surface antigen and anti-hepatitis c antibodies among blood donors in the islamic republic of iran. eastern mediterranean health journal. 2000; 6: 1114-6. 30. erden s, buyukozturk s., calangu s, et al. study of serological markers of hepatitis b and c viruses in istanbul, turkey. med principles and practice. 2003; 12: 184-8. 31. palitzsch kd, hottentrager b, schlottmann k, et al. prevalence of antibodies against hepatitis c virus in german population. european j gastro & hepatology. 1999; 11: 1215-20. 32. jilg w, hottentrager b, et al. prevalence of markers of hepatitis b in adult german population. j med virology. 63: 96-102. 33. roussos a, goritsas c, et al. prevalence of hepatitis b and c markers among refugees in athens. world j gastro. 2003; 9: 993-5. 34. toledo ac jr, greco db, felga m, et al. seroprevalence of hepatitis b and c in brazilian army conscripts in 2002: a crosssectional study. brazilian j infec disease. 2005; 9: 374-83. 35. ameen r, sanad n, al-shemmari s, et al. prevalence of viral markers among first-time arab blood donors in kuwait. transfusion. 2005; 45: 1973-80. 36. quddus a, stephen p. prevalence of hepatitis b among afghan refugees living in blochistan, pak international j infec diseases. 2005; 4: 07. microsoft word nadeem qureshi.doc 151 original article traumatic retinal detachment due to tennis ball injury nadeem qureshi, muhammad abbas, mizan ur rehman miah, nadeem ishaq, muhammad mumtaz ch., wajid ali khan pak j ophthalmol 2007, vol. 23 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: nadeem qureshi department of vitreo retina al-shifa trust eye hospital rawalpindi received for publication september’ 2006 …..……………………….. purpose: to evaluate the visual outcome of surgical intervention in retinal detachment (rd) due to tennis ball injury. material and methods: total 29 cases with retinal detachment having history of tennis ball trauma to the eye were included in this study. all patients were male of age ranging between 6 to 26 years. of them 8 (27.58%) were children and 21 (72.42%) were of working age group. types of retinal detachment encountered were inferior retinal detachment 17 (58.6%), sub total to total retinal detachment 11(34.5%), tractional retinal detachment 1 (3.45%) and total retinal detachment with severe pvr 1 (3.45%). conventional rd surgery was done in 28 cases and 7 cases required vitrectomy, endolaser, and silicone oil injection. result: out of twenty nine patients included in this study 27.58% were children below the age of 15 years and 72.42% were between the age of 16 to 30 years. all patients were male with only one female patient that was not included in the study. it showed substantial improvement of vision in 24 cases and vision remained unchanged in 5 cases after they underwent vitreoretinal surgical procedures. the mean follow up period was one year. conclusion: although useful vision could be achieved in most of the tennis ball injury induced retinal detachment cases by surgical intervention but more emphasis should be given on the preventive aspect like use of protective eye wear. hegmatogenous retinal detachment affects one in 10,000 of the population each year1. a variety of systemic and ocular disorders are responsible for causing retinal detachment. important predisposing entities include high myopia, aphakia. pseudophakia, ocular trauma etc. pathological myopia makes up 30-40% of all retinal detachments2. severe blunt ocular trauma accounts 70-80% of retinal detachments that occurs in young males3. common examples of blunt ocular trauma include cricket ball/tennis ball trauma, boxing ocular trauma, fist and stones etc. there are several studies regarding the ocular complications of boxing, squash ball trauma and paintball trauma4,5. vision threatening complications of posterior segment trauma include commottio retinae, macular hole, retinal pigment epithelial edema, choroidal rupture, vitreous hemorrhage and most important of these is the formation of retinal break/breaks leading to retinal detachment6. in indo-pak subcontinent cricket is a popular game. youngsters play cricket with rubber tennis ball instead of actual hard cricket ball. trauma by tennis ball affects the eye particularly the posterior segment causing retinal tear/s, which lead to retinal detachment. there is no available data regarding r 152 retinal detachment due to tennis ball trauma and the visual consequences after treatment. it is to be mentioned here that the youngster are most common victims of such type of trauma. our aim of this study is to provide the idea about the number and location of tears, the extent of retinal detachment and the visual consequences resulting after surgical intervention in these cases of tennis ball trauma attended in our hospital from july 2002 to december 2004. material and methods the study included all the patients presenting to the retina clinic of al shifa trust eye hospital with tennis ball trauma to the eye between july 2002 to dec 2004. the total number of patients was thirty (30). age of the patients was between 7 years to 26 years except one who was 52 years old. all of them were male except the 52 year aged female who was watching the game and was accidentally hit by the tennis ball. for the convenience of this study female patient was excluded from the study. all of them attended our hospital with the complaints of decreased vision following trauma with tennis ball. each eye was taken as a single case. data regarding the case history of these patients were collected on a standardized form. data included the age, sex, profession, address, presenting vision, and duration of decreased vision. visual acuity was recorded by snellen’s chart. examination of the anterior segment was performed by slit lamp and intraocular pressure was recorded by applanation tonometer. posterior segment was examined on slit lamp with +78d lens, fundus contact lens and with indirect ophthalmoscope with indentation. a detailed retinal drawing was charted on standard retinal charts with conventional color codes. data sheet also contained the type of first surgical intervention and subsequent surgical intervention if needed and materials used for external tamponade. follow up date and final corrected visual acuity was also recorded at the end of one-year follow up. in 28 cases we performed conventional retinal detachment surgery. sub retinal fluid was drained externally in all cases. trans-scleral cryo was applied at the margins of the breaks to create an inflammatory reaction. an appropriate scleral buckle was placed to close the retinal breaks and to support the vitreous base. in majority of the cases a 4mm grooved silicone strip with a 2mm silicone band was used. in few cases we used a segmental 7mm silicone tyre with a 2.5mm silicone band. in one case we did not perform surgery due to very advanced pvr and sever retinal contraction. during the first three months of follow up, 7 out of 28 cases had recurrent retinal detachment after the first surgery. all these seven cases underwent pars plan vitrectomy, endolaser application and silicone oil injection as a secondary procedure. two of these cases also required a buckle adjustment as well in order to ensure complete closure of the break. results all patients were male of age ranging between 6 to 27 years distribution of which is mentioned in table 1. table i: age distribution of patients. age no. of patients n(%) children 6-10 3 8 (27.58) 11-15 5 working age group 16-20 10 21 (72.42) 21-25 7 26-30 4 in this study we found that 17 cases out of 29 had infero-temporal breaks with inferior retinal detachment. ten cases had more than one retinal break with subtotal to total retinal detachment. one patient was found to have infero-nasal retinal tear and one case had a total retinal detachment with severe pvr and sub retinal fibrosis. macula was detached in 16 cases and three cases had a full thickness macular hole. outcome and complication: in twenty one cases anatomical success with retinal reattachment was achieved after the primary surgical intervention. however after the second surgical intervention with three port pars plana vitrectomy and silicone oil injection the anatomical success was achieved in 26 cases. visual acuity attained at the end of follow up period were 6/18 or better in 8 cases, 6/60 to 6/18 in 7 cases, 3/60 to 6/60 in 9 cases, and in 5 cases visual acuity was less than 3/60. 153 there was no significant intra-operative complication. overall postoperative complications included mild vitreous hemorrhage, raised intraocular pressure, and corneal haziness. all of these were managed by conservative treatment. at the end of one year follow up of 29 cases, we noticed severe proliferative vitreoretinal reaction in 4 cases including one, upon which we did not perform any surgical procedure. pvr and epiretinal membranes usually develop within six to twelve weeks after trauma6,8. three cases had pre-existing full thickness macular holes, which were diagnosed at the time of first presentation. three cases developed epiretinal formation, one patient developed a nebular corneal opacity due to corneal edema and in one case there was development of secondary cataract. reasons of diminished final visual acuity severe pvr 4 cases 13.8% macular hole 3 cases 10.3% epiretinal membrane 3 cases 10.3% cataract 1 case 3.4% corneal opacity 1 case 3.4% discussion retinal detachment is a known complication in patients with blunt trauma and is a common problem encountered by the vitreo-retinal surgeons. it comprises 10-15% of all rhegmatogenous retinal detachments1. retinal tears and detachment related to blunt trauma are thought to result from anatomical and mechanical changes in the vitreous leading to acute pvd and retinal traction. but blunt trauma due to tennis ball can cause sever damage to the posterior segment including vitreous hemorrhage, choroidal rupture and rhegmatogenous retinal detachment with or without macular hole. trauma causes macular hole in 10% cases7. children under 15 years of age are the main victims of injuries related to sports and recreation, which comprises 1/3rd of the total sports injured personnal8,9. the cost in terms of medical care and personal disability is staggering. most of the sports related injuries are preventable. in our study we had 29 retinal detachment patients with marked decrease in vision following blunt ocular trauma received while playing cricket by rubber tennis ball during the period of july 2002 to december 2004. majority of these cases had inferior retinal tears. table 2: uniocular (affected eye) preoperative and final (post operative) corrected visual acuity sr. no pre operative va final va 1 6/60 6/9 2 1/60 3/60 < 3 1/60 6/60 4 c.f 4/60 5 c.f 2/60 6 6/60 6/24 7 1/60 6/60 8 6/60 6/9 9 6/36 6/6 10 hm 3/60 11 hm 2/60 > 12 2/60 6/60 13 cf 2/60> 14 6/60 6/36+ 15 3/60 6/12 16 pl 4/60 17 1/60 5/60 18 4/60 6/12 19 3/60 6/60 20 6/9 6/6 21 6/12 6/9 22 6/36 6/24 23 6/60 6/24 24 2/60 3/60 < 25 3/60 3/60 26 6/60 6/9 27 cf 6/60 28 hm 3/60 29 6/36 6/24 154 table 3: prevalence of blindness and svi in the injured eye at the time of presentation and at final visit. category before treatment n (%) after treatment n (%) blind 14 (48.27) 5 (17.24) svi 4 (13.79) 7 (24.13) vi 9 (31.03) 9 (31.03) normal 2 (6.89) 8 (27.58) who grading of visual acuity < 3/60 – blind, >6/18 – normal, 6/60 – 6/18 – visual impaired (vi), 6/60 – 3/60 severe visual impaired (svi). it was due to this fact that there were minimal pvr changes on the inner retinal surface in most cases. however sub retinal fibrous bands and demarcation lines were not uncommon. 28 patients underwent conventional rd surgery that included scleral buckling with silicone bands and tyres, cryo application at the margin of the tear/s along with drainage of sub retinal fluid. among 28 operative cases 21 achieved anatomical retinal reattachment with comprising 75% success rate. and after performing vitrectomy and silicone oil injection in the redetached cases the anatomical success rate increased to 93%. the anatomical success rate after second time surgery is comparable to ryan sj et al3. a major determinant of post operative visual acuity is the status of the macula. macular detachment of any duration, even one day results in reduced post operatively visual acuity3. all patients attended alshifa, tertiary eye care hospital being referred by ophthalmologist having the duration of four days to four years after trauma. in summary our study demonstrates that a useful visual outcome is possible in most eyes with traumatic rhegmatogenous retinal detachment due to tennis ball injury. the presence of macula-off retina detachment, however, significantly affects the visual outcome in an adverse manner. conclusion useful vision can be attained in most of the tennis ball related injury induced retinal detachments by surgical intervention. but a large number of such cases can be prevented by taking appropriate preventive measures. our approach to prevention and management of ocular trauma must change if we hope to reduce the prevalence of blindness and severe visually impaired personal. in this regard canadian ice hockey is the prototype for a successful injury prevention programme. prevention programme in tennis ball injury will attain the same success. ophthalmologist has the potential to prevent eye injury each year in various ways by educating the patients about the risk of eye injuries in various sports and explaining the benefit of the use of protective eyewear. author’s affiliation dr. nadeem qureshi department of vitreo retina al-shifa trust eye hospital, rawalpindi dr. muhammad abbas department of vitreo retina al-shifa trust eye hospital, rawalpindi dr. mizan ur rehman miah department of vitreo retina al-shifa trust eye hospital, rawalpindi dr. nadeem ishaq department of vitreo retina al-shifa trust eye hospital, rawalpindi dr. muhammad mumtaz ch. department of vitreo retina al-shifa trust eye hospital, rawalpindi dr. wajid ali khan department of vitreo retina al-shifa trust eye hospital, rawalpindi reference 1. myron y, duker js. ophthalmology, 1999; 2: 39.1-39.7. 2. albert daniel m, jakobiee fraderick a. principles and practice of ophthalmology. 2000; 2: 1086. 3. ryan stephen j. retina 2001; 3: 2550. 4. ferenc k, pieramici dj. ocular trauma, principles and practice. 2002; 206-31. 5. kanski jj. clinical ophthalmology. 2003; 5: 380-2. 6. brinton gs, aaberg ta, reeser fh, toppin tm. surgical result in ocular trauma involving the post segments. am. j, ophthalmol. 1982; 93: 271-8. 7. spencer willim h. ophthalmic pathology. 1996; 2: 1053-81. 8. editorial-racket-sports ocular injuries-arch ophthalmol. 1986; 104: 1453-4. 9. vinger pf. sports related eye injury – a preventable problem, surv ophthalmol. 1980; 20: 47-51. microsoft word shahid jamal siddiqui.doc 92 original article study of 189 cases of diabetic retinopathy at cmc larkana shahid jamal siddiqui, sayed imtiaz ali shah, abdul qadir shaikh, mohammed yousuf depar, safder ali abbassi pak j ophthalmol 2007, vol. 23 no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: shahid jamal siddiqui assistant professor department of ophthalmology chandka medical college larkana received for publication july’ 2006 …..……………………….. purpose: to study the frequency, presentation and visual outcome after the management of diabetic retinopathy. material and methods: the study was carried out at the department of ophthalmology, chandka medical college larkana from september 2003 to march 2006. 361 eyes of 189 patients were included in this study. all patients were known diabetic. after taking careful history, complete ocular examination was carried out. the investigations included blood sugar, ocular b scan and ffa was performed where necessary. treatment modalities include conservative in non proliferate diabetic retinopathy(npdr) and laser photocoagulation in clinically significant macular edema(csme) and proliferative diabetic retinopathy(pdr). patients with vitreous hemorrhage and tractional retinal detachment require vitreoretinal surgery. results: mean age at the presentation was 52 years with a range of 22-75 years. 62.5% of the patients were male and 37.5% female. 91% of the patients presented with bilateral diabetic retinopathy and 9% unilateral among the 189 patients. 205 eyes (57%) presented as non proliferative diabetic retinopathy(npdr) and 156 eyes (43%) as proliferative diabetic retinopathy(pdr), clinically significant macular edema (csme) was seen in 90 eyes with npdr and 29 eyes with pdr i.e. 119 eyes (33%). vitreous hemorrhage was seen in 28 eyes (8%) and tractional retinal detachment in 14 eyes (4%). neovascular glaucoma in 4 eyes (1%). laser photocoagulation was done in 180 eyes. visual acuity improved in 54 eyes (30%) remained same in 89 eyes (49.5%) and deteriorated in 37 eyes (20.5%). conclusion: in this hospital based descriptive study diabetic retinopathy was more frequently seen in male individuals. non proliferative diabetic retinopathy was more frequent, as compared to proliferative diabetic retinopathy. laser photocoagulation improved the vision in patients who had no vitreous hemorrhage and tractional retinal detachment. he diabetes mellitus is one of the major cause of blindness in the world. it is the leading cause in usa and uk1. according to who estimates in 1995 4.3 million people in pakistan had diabetes mellitus. it will swell up to 11.6 million by the year 20252. according to pakistan national survey overall prevalence of diabetes mellitus is 11.47% and of t 93 impaired glucose tolerance is 9.39%3. the advanced age, positive family history and obesity were associated risk factors. diabetes mellitus causes 10% of new cases of blindness in uk each year4. diabetic retinopathy is the most severe cause of blindness influenced by the risk factors and predicted by duration of diabetes mellitus. the incidence is 27% in 5 10 years, 71% in longer than 10 years and 90-95% after 30 years5. the diabetic retinopathy is classified as non proliferative diabetic retinopathy (npdr), proliferative diabetic retinopathy (pdr), and clinically significant macular edema (csme)6,7. non proliferative diabetic retinopathy is further described as: mild moderate severe very severe proliferative diabetic retinopathy (pdr) is described as: early high risk advanced macular edema can be present at any level of diabetic retinopathy. macular edema is more common cause of visual loss in diabetic patients. laser photocoagulation is generally recommended for eyes with clinically significant macular edema (csme) and high risk proliferative diabetic retinopathy (pdr). material and methods the hospital based descriptive study was carried out at the department of ophthalmology chandka medical college, larkana from september 2003 to march 2006.the patients were selected from retina clinic which is routinely being held twice a week at the department of ophthalmology chandka medical college larkana. 361 eyes of 189 patients were included in the study. all patients were known diabetic. the specific proforma was established and the following protocol was followed in all cases. 1. history a. ocular and systemic status of the complaints or symptoms. b. type and duration of diabetes mellitus. c. other associated risk factors such as: renal problem, obesity, hypertension, pregnancy status, serum lipid levels, onset of puberty, family history, social history including, smoking and alcohol use. d. review of medical management: treatment. medication and dosage usage. method and frequency of blood sugar monitoring. average blood sugar. recent laboratory values including hb a1c complete ocular examination a. visual acuity: distance and near. b. pupillary reflexes. c. refraction. d. slit lamp biomicroscopy. e. applanation tonometry. f. gonioscopy. g. fundus examination. direct ophthalmoscopy indirect ophthalmoscopy with 90 d, three mirror. investigations laboratory: blood sugar (fasting + random) lipid profile. ultrasonography: ocular b scan. fundus photography. fundus fluorescien angiography. treatment modalities a. conservative treatment in non proliferative diabetic retinopathy npdr: patients were advised about strict blood sugar control, diet control, reduction of weight, exercise, follow up and complete ocular examination after six months. b. laser photocoagulation was done in: a. clinically significant macular edema (macular grid) b. severe/very severe non proliferative diabetic retinopathy. c. proliferative diabetic retinopathy pdr. (panretinal photocoagulation prp). patients with vitreous haemorrhage and tractional retinal detachment required vitreoretinal surgery. 94 results number of patients and age distribution: the hospital based descriptive study of 361 eyes of 189 patients was carried out. individuals from 22–75 years of age , average age 52 years presented with diabetic retinopathy (table 1). mode of presentation and sex distribution: among 189 patients 118 were male (62.5%) and 71 female (37.5%). the presentation of retinopathy was bilateral in 172 patients (91%) including 108 male (63%), 64 female (37%) and unilateral in 17 patients (9%), 10 male (59%) 7 female 41% (table 2). clinical presentation among 361 eyes non proliferative diabetic retinopathy (npdr fig. 1) was seen in 205 eyes (57%), proliferative diabetic retinopathy (pdr fig. 2) in 156 eyes (43%), clinically significant macular edema (csme fig. 3) in 119 eyes (33%) including 90 eyes with npdr and 29 eyes with pdr (table 3). advanced diabetic eye disease was seen in eyes with proliferative diabetic retinopathy, vitreous hemorrhage in 28 eyes (8%), tractional retinal detachment in 14 eyes (4%) and neovasculer glaucoma in 4 eyes (1%) (table 4). treatment laser photocoagulation was done in 180 eyes. visual acuity remained same in 89 eyes (49.5%) , improved in 54 eyes (30%) and decreased in 37 eyes (20.5%) as an outcome after laser photocoagulation (table 5). discussion in this hospital based descriptive study about 361 eyes of 189 patients were included to study the frequency presentation and visual outcome after the management of diabetic retinopathy. diabetic retinopathy is one of the major complication of diabetes mellitus that affects the retinal blood vessels and leads to blindness. about 4-8 million diabetics exist in pakistan and very little work has been done on this complication of diabetes mellitus8. the age group involved in this study was 22-75 years, this shows that diabetic retinopathy is commonest cause of legal blindness in this age group. same is reported by italian diabetologist grassi.9 in our study the prevalence of diabetic retinopathy was significantly higher among males (62.5%) as compared to females (37.5%). the male preponderance has also been reported by kayani and his colleagues in their study carried out at lahore.8 the report mentioned higher ratio among males (42.8%) as compared to females (27.9%). the diabetic retinopathy is usually a bilateral disease. at our centre 172 (91%) individuals out of 189 presented with bilateral disease and 17 (9%) with unilateral disease. although it is a bilateral disease but it could be due to asymmetrical presentation in the early stages of the disease. non proliferative diabetic retinopathy (npdr) was present in (57%) of eyes, proliferative diabetic retinopathy (pdr) in (43%). this shows that npdr is more common as compared to pdr. this has also been reported by kayani and his colleagues in their study8. table 1: number of patients and age distribution: number of patients 189 number of eyes 361 age group 22 – 75 years average age 52 years table 2: mode of presentation and sex distribution: no of patients n (%) sex 189 male 118 (62.5) female 71 (37.5) bilateral 172 (91) male 108 (63) female 64 (37) unilateral 17 (9) male 10 (59) female 7 (41) table 3: clinical presentation status no of eyes n (%) total eyes 361 non proliferative diabetic retinopathy (npdr) 205 (57) proliferative diabetic 156 (43) 95 retinopathy (pdr) clinically significant macular edema (csme) 119 (33) csme & npdr 90 (25) csme & pdr 29 (8) fig. 1: fundus photograph showing non proliferative diabetic retinopathy fig. 2: fundus photograph showing nvd (pdr) table 4: advanced diabetic eye disease with proliferative diabetic retinopathy. no of eyes n (%) vitreous hemorrhage 28 (8%) tractional retinal 14 (4%) detachment neovascular glaucoma 4 (1%) clinically significant macular edema (csme) was common cause of visual loss in 119 eyes (33%). csme was seen in 90 eyes with npdr and 29 eyes with pdr. leske and his colleagues have reported the incidence fig. 3: fundus photograph showing csme fig. 4: fundus photograph showingprp 96 fig. 5: angiogram showing macular grid in csme table 5: visual outcome after laser photocoagulation laser photocoagulation was done in 180 eyes. level of visual acuity no of eyes n (%) same 89 (49.5%) improved 54 (30%) deteriorated 37 (20.5%) of csme 8.7% in their study at stony brooks university new york10. laser photocoagulation was performed in 180 eyes. the laser treatment was performed in the eyes with very severe bilateral npdr showing extensive areas of capillary non perfusion on fundus fluorescein angiography (ffa), proliferative diabetic retinopathy (pdr) and clinical significant macular edema(csme). according to the visual outcome visual acuity remained same in most of the eyes i.e (49.5%) and was improved in (30%) and deteriorated in (20.5%). while treatment options of severe non proliferative and proliferative forms of diabetic retinopathy are limited to laser photocoagulation, photocoagulation has proven efficacy in slowing down the progression of diabetic retinopathy.9 timely laser treatment obviates visual loss in diabetic retinopathy11. although laser treatment keeps vision damaged by diabetic retinopathy from becoming worse, it only rarely improves vision12. when laser is deemed necessary, the patient should be informed of the risks and benefits of the procedures. they should understand that the goal of laser treatment is to reduce the rate of visual loss, and appropriate treatment may be 90% effective in preventing severe visual loss (defined as va <5/200)13. conclusion in this hospital based descriptive study we conclude that: 1. diabetic retinopathy was more frequently seen in male individuals. 2. non proliferative diabetic retinopathy was more frequent, as compared to proliferative diabetic retinopathy. 3. laser photocoagulation improved the vision in those patients: a. who were treated early. b. who had no vitreous hemorrhage and tractional retinal detachment. 97 author’s affiliation dr. shahid jamal siddiqui assistant professor ophthalmology chandka medical college larkana. prof: sayed imtiaz ali shah professor of ophthalmology chandka medical college larkana. dr. abdul qadir shaikh department of ophthalmology chandka medical college hospital larkana. dr. mohammed yousuf depar department of ophthalmology chandka medical college hospital larkana. dr. safdar ali abbasi department of ophthalmology chandka medical college hospital larkana. reference 1. sorsby a. the incidence and causes of blindness in england and wales 1963—1968. no.28 her majesty’s stationary office, 1972:33. 2. ahmed mm: diabetes mellitus. editorial: pak j ophthalmol. 2002; 18: 90. 3. shera as, rafiq g, ahmed ki, et al. prevalence of glucose intolerance and associated factors in baluchistan province. diabetic research and clinical practice. 1999; 44: 49-58. 4. kahn ha, hiller r. blindness caused by diabetic retinopathy. am j ophthalmol. 1974; 78: 58. 5. klien r, klien bek, moss se et al. the wisconsin epidemiologic study of diabetic retinopathy. iii. prevalence and risk of diabetic retinopathy when age is 30 or more years. arch ophthalmol. 1984; 102: 527-32. 6. jann ed, noorily sw, pico wp, et al. retinovascular diseases: diabetic retinopathy: in textbook of ophthalmology by kenneth w.wright.1st edition. williams & wilkins. 1997: 845. 7. early treatment diabetic retinopathy study research group: etdrs report no:9. ophthalmology. 1991; 98: 766-85. 8. kayani h, rehan n, ullah n: frequency of retinopathy among diabetics admitted in a teaching hospital of lahore. in j ayub med coll abottabad. 2003; 15: 53-6. 9. grassi g. diabetic retinopathy. in minerva med. 2003; 94: 41935. 10. leske mc, wu sy, hennis a, et al. barbados eye study group.in nine year study of diabetic retinopathy in the barbados eye studies. arch ophthalmol. 2006; 124: 250-5. 11. nwosu sn. diabetic retinopathy: management update. niger postgrad. med j. 2003; 10: 115-20. 12. sinclair sh, delvecchio c. the internest’s role in managing diabetic retinopathy: screening for early detection. cleve clin j med. 2004; 71: 151-9. 13. fennis fl. how effective are treatments for diabetic retinopathy? jama. 1993; 269: 1290-1. microsoft word mianmshafique[1]correctedmoinsent 1 original article incidence of amblyopia in strabismic population mian m. shafique, naeemullah, nadeem h. butt, muhammad khalil, tayyaba gul pak j ophthalmol 2007, vol. 23 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: mian m. shafique 209a block, gulshan ravi, lahore, pakistan received for publication august’ 2006 …..……………………….. purpose: to find the incidence and density of amblyopia with reference to the type of squint among the strabismic patients visiting eye department. material and methods: this prospective study was started in january 2000 and a total of 177 patients have been dealt with. both male and female patients of all age groups and all types of squints were included. all the patients underwent standard procedure of assessment including history, examination and investigations to find the type of deviation, amount of the deviation, the presence of amblyopia and the depth of amblyopia. it was then followed by analysis to see the effect of different factors on the depth of amblyopia results: out of 177 patients 94 had uniocular squint (group-i) and 83 alternating squint (group-ii). majority of patients in group-i had some degree of amblyopia (82%). amblyopia was much less in group-ii (18%). all the 106 patients having amblyopia showed at least two lines difference of snellen’s acuity between both eyes. amblyopia is relatively denser in uniocular than alternating strabismus. it is more common and dense in esotropia than exotropia. conclusion: strabismic amblyopia is a condition of arrested development of vision due to misalignment of visual axis in the first 5-6 years of life. this can be avoided if it is treated at the right time. earlier detection and treatment of squint in the amblyogenic years can save the patient from this life long disability. trabismic amblyopia is a serious blinding condition, which affects the patients in very early part of their life, due to misalignment of one of the eyes while the other eye remains straight. when a child is born his retina is almost fully developed structurally, but his vision is very poor (6/60) as it has not fully developed functionally. to develop its full function it requires a clear sharp image formed on its center (macula) within 5-6 yrs of age (vision developing age or amblyogenic age). if squint develops within this period, the eye will not be straight or directed towards the object of regard and the image of this object will not be formed on the macula rather it will be formed in the periphery. so there will be no further development of macular vision. visual acuity will remain arrested either at 6/60 or it will develop partially to few more lines but it will never become normal (6/6). there are many causes of amblyopia but strabismus is one major treatable cause not only in other parts of the world but also in our country. in pakistan no reliable statistical data is available up till now. we have therefore started a study in lahore, to find out the percentage of amblyopia in strabismic patients of our population. among the other causes of amblyopia including, anisometropia, high ametropia, and visual s 2 deprivation due to diseases like cataract, are also common. by ruling out all other causes and treating strabismus in early years of life we can prevent the child from such a grave problem, the affects of which are life long. material and methods this study on incidence of strabismic amblyopia was conducted in department of ophthalmology fatima jinnah medical college and sir ganga ram hospital, lahore from january 2000 to december 2002. patients of squint attending the eye out patient department were screened for amblyopia. the percentage of amblyopia in strabismic patients and the density of amblyopia in relation to the type of deviation was evaluated. 177 patients of all age groups, both sexes and all types of squint were included. all the patients who visited the eye department and were found to have squint underwent thorough orthoptic assessment which included history, examination and a series of diagnostic tests. visual acuity was recorded in all cases applying different test types for different age groups. gross and slit lamp examination was done to rule out any cause of visual deprivation in anterior segment. cover tests was an essential to label the type of squint. ocular movements in six cardinal positions of gaze and convergence helped to detect any restrictive or paralytic element. prism and alternate cover test and synoptophore were main tools to detect the amount of deviation. for binocular functions and suppression, worth four dot test, bagolini striated glasses, frisbee test or synoptophore were applied. retinoscopy (cycloplegic or non-cycloplegic) was also done in every patient to find out the refractive status of each eye. ophthalmoscopy, direct or indirect, was always performed to rule out any organic cause of reduced vision in the posterior segment. all the findings detected by above mentioned series of tests were recorded in a performa which was later on was used for further study. results total number of patients in the study were 177. age of the patients ranged from 3 years to 40 years females were found to be more than males (56% vs. 44%) fig 1. two major groups of the patients were uniocular squint in 94 cases (group-i) while 83 cases had alternating variety of squint (group-ii). corrected visual acuity was 6/6 in both eyes in 71 cases while amblyopia was recorded in 106 cases (59.9%) (table 1). 82% of total amblyopes belonged to groupi (uniocular squint) while only 18% were from group-ii (alternating squint). as far as the density of amblyopia is concerned, mild amblyopia (two lines snellen’s chart difference) was seen in 30 patients (28.3%), moderate amblyopia (3 lines snellen’s chart difference) in 51 patients( 48.1%) and dense amblyopia( 4 or more lines snellen’s chart difference) in 25 patients(23.6%) (fig. 2 and table 2). female 56% male 44% fig. 1: sex distribution 0 10 20 30 40 50 60 mild sever fig. 2: density of amblyopia the effect of the type of deviation on the density of amblyopia is quite evident (table 3). the risk of development of amblyopia is more in patients of unilateral squint (87 out of 94, 92.5%) while the risk is four times less in alternating squint (19 out of 83, 22.9%). in esotropia the amblyopia is more common (60 out of 91, 66%) and more dense (mild in 13 cases while moderate to sever in 47 cases) while in exotropia, the amblyopia is relatively less common (46 out of 87, 53.5%) and less dense (mild to moderate in 39 cases while severe in only 7 cases). 3 discussion amblyopia and strabismus are the most common ocular conditions occurring during childhood. amblyopia is the leading cause of visual loss in childhood. strabismus is a significant cause of ocular morbidity leading to amblyopia and psychosocial distress1. the overall prevalence of amblyopia varies between 1.6 to 3.6% in different regions of the world2. almost all age groups have been studied and the recorded prevalence in children is 3.0%3, in untreated adults 3.0%4 and untreated olds 2.9%5. although it has been recorded low in certain countries but there is no significant difference seen in different racial groups6. strabismus has been proved to be the most common cause of amblyopia7-8. other causes are anisometropia, combined strabismus with anisometropia and sensory deprivation9-10. in our study out of 177 strabismic patients 106 had some degree of amblyopia regardless of the type of deviation. so the overall incidence of amblyopia in strabismic population was 59.9 % (table-1). table-1: incidence of amblyopia group type of squint no of patients no. of amblyopia patients overall incidence i unilateral 94 87 49.1 ii alternating 83 19 10.8 total 177 106 59.9 table-2: density of amblyopia type of strabismus no of amblyopic patients density of amblyopia mild mild mild uniocular 87 16 47 24 alternating 19 14 4 1 total 106 30 51 25 it is important to note that the incidence of amblyopia in unilateral squint was found to be higher (49.1%) fig. 3, than alternating squint (10.8%) fig. 4. it is quite clear that those strabismic patients who develop alternation are at 4 times less risk of developing amblyopia than the uniocular squinters. the direction of the deviation definitely has some relation to the development of amblyopia. according to our study the prevalence of amblyopia in esotropia was higher (66%) than its prevalence in exotropia (53.5%). similar but slightly higher figures are seen in other international research work11. density of amblyopia in our study has been graded on basis of difference of corrected visual acuity between the two eyes in the absence of any organic reason for reduced vision. three recognized categories are mild, moderate and severe or dense. it is mild if there is difference of two lines, moderate if difference of three lines and fig. 3. left exotropia with sever amblyopia 4 fig. 4: alternating exotropia with normal visual acuity severe or dense if difference of four or more lines between the visual acuity of two eyes. 28.3% of the amblyopes had mild amblyopia, majority of these belonged to alternating squint and more so to exotropia (fig 5). 48.1% of the amblyopia is moderate and is seen almost equally in uniocular esotropia and exotropia (fig 6). remaining 23.6% amblyopia is severe or dense and most of it seen in uniocular esotropia. (table 3). presence of strabismic amblyopia in all age groups in our study indicates the lack of treatment in early table 3: effect of type of strabismus on density of amblyopia type of squint no of patients no of amblyopic patients density of amblyopia mild moderate severe esotropia uniocular (rt or lt) 53 48 6 25 17 alternating 38 12 7 4 1 exotropia uniocular (rt or lt) 41 39 10 22 7 alternating 45 7 7 total 177 106 30 51 25 total fig. 5: left intermittent exotropia with mild amblyopia 5 fig. 6: accommodative esotropia with right moderate amblyopia years of life. atropine penalisation has been shown to be as effective as occlusion therapy in the treatment of amblyopia12-13. these techniques can only be applied and become useful if the diagnosis of amblyopia is made early in amblyogenic or vision developing age. early detection of amblyopia and its treatment can reduce the overall prevalence as proved by many studies in different parts of the world14-15. early screening of visual acuity and strabismus is a real need of our country. conclusion amblyopia due to strabismus is a problem faced in all age groups in our society. to save the future generations from this life time visual disability, an enthusiastic approach to the problem is required, and this must be based on the identification and treatment of strabismus and amblyopia during the sensitive period. a comprehensive screening programme must be devised and applied. the best time for screening may be at school entry into the play group. authors affiliations dr. mian m. shafique assistant professor department of ophthalmology lahore medical & dental college, lahore professor naeemullah department of ophthalmology fatima jinnah medical college, lahore dr. nadeem h. butt associate professor department of ophthalmology allama iqbal medical college, lahore dr muhammad khalil assistant professor department of ophthalmology lahore medical & dental college, lahore 6 dr tayyaba gul senior registrar department of ophthalmology lahore medical & dental college, lahore references 1. sala na. amblyopia and strabismus. pa med. 1996; 99: 63-6. 2. simons k. amblyopia characterization, treatment, and prophylaxis. sury ophthalmol. 2005; 50:123-66. 3. thompson jr, woodruff g, hiscox fa, et al. the incidence and prevalence of amblyopia detected in childhood. public health. 1991; 105: 455-62. 4. webber al, wood j. amblyopia: prevalence, natural history, functional effects and treatment. clinical and experimental optometry. 2005; 88: 365-75. 5. vinding t, gregersen e, jensen a, et al. prevalence of amblyopia in old people without previous screening and treatment. an evaluation of the present prophylactic procedures among children in denmark acta ophthalmol. 1991; 69: 796-8. 6. rosman m, wong ty, koh cl, et al. prevalence and causes of amblyopia in a population-based study of young adult men in singapore. am j ophthalmol. 2005; 140: 551-2. 7. pediatric eye disease investigator group. the clinical profile of moderate amblyopia in children younger than 7 years arch ophthalmol. 2002; 120: 281-7. 8. lithander j. prevalence of amblyopia with anisometropia or strabismus among schoolchildren in the sultanate of oman. acta ophthalmol. 1998; 76: 658-62. 9. attebo k, mitchell p, cumming r, et al. prevalence and causes of amblyopia in an adult population. ophthalmology. 1998; 105: 154-9. 10. shah m, khan mt, khan md, et al. clinical profile of amblyopia in pakistani children age 3 to 14 years. j coll physicians surg pak. 2005; 15: 353-7. 11. ebana mvogo c, ellong a, owona d, et al. amblyopia and strabismus in our environment. bull soc belge ophthalmol. 2005; 39-44 12. aisling foley-nolan, aoife mccann, michael o'keefe, atropine penalisation versus occlusion as the primary treatment for amblyopia. br j ophthalmol. 1997; 81: 54-7. 13. pediatric eye disease investigator group. a randomized trial of atropine vs. patching for treatment of moderate amblyopia in children arch ophthalmol. 2002; 120: 268-78. 14. williams c, northstone k, harrad ra, et al. amblyopia treatment outcomes after screening before or at age 3 years: follow up from randomized trial, bmj. 2002; 324: 1549. 15. ingram rm. amblyopia: the need for a new approach? br j ophthalmol. 1979; 63: 236-7. 287 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol original article frequency of hepatitis c in patients undergoing ophthalmic surgeries; a multicenter study m. ali a. sadiq, faiqa jabeen naeem, mehrin usman ali arifa, haroon tayyab, saima jamshed, irfan qayyum malik, hafiz muhammad qamar, ayesha hanif pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: m. ali a. sadiq associate professor, king edward medical university, lahore email: sadiq.maa@gmail.com …..……………………….. purpose: to find the frequency of hepatitis c in tertiary care hospitals in gujranwala and lahore. study design: cross sectional observational study. place and duration of study: ophthalmology departments of district head quarters teaching hospital gujranwala and at sardar trust eye hospital, garhi shahu, lahore for a duration of 12 months from march 2017 to march 2018. material and methods: a chart review of all patients admitted in the above mentioned hospitals was conducted. patients with insufficient clinical information documented in hospital record were excluded from the study. status of each of the patient whether hepatitis c positive or not, was determined by the method of rapid chromatography immunoassay for qualitative detection. the results of all patients were recorded according to their age, sex and their demography. results: the study was conducted on 4968 patients admitted for ophthalmic surgeries above the age of 13 years. there were 1003 patients at dhq hospital gujranwala and 3965 at sardar trust eye hospital. out of 1003, 548 patients (54.6%) were male and 455 (45.3%) were female. 189 patients turned out to have hepatitis c having a prevalence of 18.8%. however, at sardar trust eye hospital, out of 3965 patients admitted, 2914 (73%) were male, and remaining (27%) were female. 418 patients were found to be hepatitis c positive, which constituted about 10.5% of all patients in lahore. conclusion: frequency of hepatitis c was 18% in gujranwala with female dominance and 10.5% in lahore with male predominance. key words: eye surgery, hepatitis c, frequency. epatitis c is a single stranded enveloped rna virus1,2 belonging to family flaviviridae3,4 transmitted primarily via blood, body surface secretions and by piercing through percutaneous veins and mucosal surfaces5,6. hepatitis c virus has an incubation period of 14 to 180 days with an average of 45 days3,4. it can occur in both acute and chronic form leading to cirrhosis7,8, hepatic encephalopathy, coma and death. worldwide, an estimated 130-150 million people (2-3%) are living with hepatitis c infection with highest prevalence in middle income countries including pakistan. more than 350,000 deaths have been reported to occur with hepatitis c9. in pakistan, 6% of its population is actively infected with 1 in every 20 person suffering from it10. the prevalence in punjab is 5.46% with maximum population of 25.77% affected in balochistan11. the purpose of this study is to determine the frequency of hepatitis c presenting in tertiary care hospital in lahore and gujranwala. it is also a reflection of the h frequency of hepatitis c in patients undergoing ophthalmic surgeries; a multicenter study pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 288 table 1: demographics of patients in gujranwala. age group total patients screened patients diagnosed with hepatitis c virus male female total less than 21 40 2 0 2 (5%) between 21 and 40 150 8 16 24 (16%) between 41 and 60 476 44 57 101 (21%) between 61 and 80 308 33 19 52 (17%) more then 80 29 6 4 20 (34%) total 1003 93 (17%) 96 (21%) 189 (18%) table 2: demographics of patients in sardar trust eye hospital, lahore, age group total patients screened patients diagnosed with hepatitis c virus male female total less than 21 268 4 1 5 (1.8%) between 21 and 40 644 28 27 55 (9%) between 41 and 60 1787 136 104 240 (13%) between 61 and 80 1221 80 32 112 (9%) more then 80 45 4 3 7 (15%) total 3965 250 (6.3%) 168 (4.2%) 418 (10.5%) risk faced by health care workers due to cross infection. material and methods a cross sectional observational study was conducted at district head quarter teaching hospital gujranwala and sardar trust eye hospital from 1st march 2017 to 31st march 2018 after approval by institutional review boards of the two hospitals. patients were excluded if there was insufficient clinical information documented in hospital record. the age and sex of patients, demographical distribution and method of screening used were recorded from medical record. cases were identified as hepatitis c positive through screening kits. the primary outcome was the occurrence of hepatitis c among patients being admitted for surgical procedures. secondary outcome was the distribution of the disease among masses respective to their age, gender and demography. the data collected in both the hospitals was stored electronically and analyzed by spss version 20. percentages were calculated for gender, age and demographical distribution. results majority of the patients presenting for ocular surgery were from the age group of 50 to 70 years, with 101 patients (21%) between 51 to 60 years of age and 52 (17%) patients in their 60’s in gujranwala while 1161 patients (29.25%) between 51 to 60 years of age and 979 (24.6%) patients in their 60s in lahore. out of the 1003 patients admitted in dhq hospital gujranwala, 548 (54.6%) patients were male and 455 (45.3%) were female. however out of 3965 patients admitted in sardar trust eye hospital, 2895 (73%) were male and 1030 (26%) were females. in dhq hospital gujranwala, 189 (18.8%) out of 1003 patients turned out to be positive for hepatitis c. the frequency of hepatitis c in sardar trust eye hospital, lahore was 10.5% (418 patients out of 3965). out of the hepatitis c positive patients in sardar trust eye hospital lahore 194 (46%) cases were reported from lahore followed by gujranwala 60 cases (14. 28%). discussion aslam et al showed the prevalence of hepatitis c in lahore to be 6.7%12. tanveer et al found the prevalence to be 1.48%13. however, it varied from 2.1 to 13.5 % in the study conducted by bostan et al14. our current estimate of frequency (10.6%) was higher when compared to nationwide data surveillance study conducted through elisa blood screen15 which showed the prevalence to be 6.8% in lahore. furthermore, the frequency was more among males in lahore which was different from that found in previous studies conducted in jinnah and sheikh zayed hospital lahore16. however, the prevalence of hepatitis c in pakistan is much more when compared to bangladesh (1.3%), india (0.8%) and other south asian countries17. in a study conducted in new delhi in 2007, prevalence of 0.66% was noted in blood donors18. chowdery et al. from west bengal depicted m. m. ali a. sadiq, et al 289 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol a seroprevalence of 0.87%. it showed a rise from 0.31% in children aged below 10 years to 1.85% in adults aged 60 years with no difference in prevalence between males and females19. in punjab, 5% anti hcv positive persons were found in 201220. one exception was that of uzbekistan (central asian country) which had got slightly higher prevalence (11.3%). the percentages were on the lower side for central, southern, northern and tropical areas of america which demonstrates percentages varying from 1.2% to 1.6%, depicting rapidly inclining trend of hepatitis c (10.6%) in pakistan. the total global prevalence was estimated to be less than 2%, with major chunk comprising of population older than 15 years, congruent to our estimate. according to our result, there was 1.6 times surge in incidence as compared to standard nationwide rate (6%)17. the actual burden of disease may be much higher than current and previous estimates. a limitation to our study was its retrospective nature because in some cases only limited data were available to be reviewed. another limitation was the screening technique which was less sensitive as compared to elisa technique. more studies are needed to fill the gap in our knowledge regarding the burden of hcv disease in pakistan. conclusion frequency of hepatitis c in admitted patients is mostly concentrated between 50-60 years indicating the enhanced expression of disease in middle to older age groups with decreased immunity. references 1. lanini s, easterbrook pj, zumla a, ippolito g. hepatitis c: global epidemiology and strategies for control. clin microbiol infect. 2016; 22 (10): 833-8. 2. kim cw, chang km. hepatitis c virus: virology and life cycle. clin mol. hepatol. 2013; 19 (1): 17. 3. umer m, iqbal m. hepatitis c virus prevalence and genotype distribution in pakistan: comprehensive review of recent data. world j gastroenterol. 2016; 22 (4): 1684. 4. neyts j, leyssen p, de ec. infections with flaviviridae. verhandelingen-koninklijke academie voor geneeskunde van belgie. 1999; 61 (6): 661-97. 5. alter mj. epidemiology of hepatitis c virus infection. world j gastroenterol. 2007; 13 (17): 2436. 6. chevaliez s, pawlotsky jm. hcv genome and life cycle. hepatitis c viruses. genet mol bio. 2006: 5-47. 7. ali sa, donahue rm, qureshi h, vermund sh. hepatitis b and hepatitis c in pakistan: prevalence and risk factors. inter j infect dis. 2009; 13 (1): 9-19. 8. renau pl, berenguer m. introduction to hepatitis c virus infection: overview and history of hepatitis c virus therapies. hemodial int. 2018; 22: s8-21. 9. lavanchy d. evolving epidemiology of hepatitis c virus. clin microbiol infect. 2011; 17: 107–115. 10. al kanaani z, mahmud s, kouyoumjian sp, aburaddad lj. the epidemiology of hepatitis c virus in pakistan: systematic review and meta-analyses. roy soc open sci. 2018; 5 (4): 180257. 11. arshad a, ashfaq ua. epidemiology of hepatitis c infection in pakistan: current estimate and major risk factors. crit rev eukar gene. 2017; 27 (1). 12. aslam m, aslam j. sero-prevalence of the antibody to hepatitis c in select groups in the punjab region of pakistan. j clin gastroenterol. 2001; 33 (5): 407-11. 13. tanveer a, batool k, qureshi aw. prevalence of hepatitis b and c in university of the punjab, quaid-eazam campus, lahore. arpn j agri and bio sci. 2008; 3: 30-2. 14. ali m, idrees m, ali l, hussain a, rehman iu, saleem s, et al. hepatitis b virus in pakistan: a systematic review of prevalence, risk factors, awareness status and genotypes. virol j. 2011; 8: 102. 15. qureshi h, bile km, jooma r, alam se, afrid hu. prevalence of hepatitis b and c viral infections in pakistan: findings of a national survey appealing for effective prevention and control measures. east mediterr health j. 2010; 16 suppl.: s15-23. 16. mukhtar o, zaheer f, malik mf, khan js, ijaz t. socio-demographic study of hepatitis c patients visiting tertiary care hospital. j ayub med coll. 2015; 27 (3): 6502. 17. gower e, estes c, blach s, razavi-shearer k, razavi h. global epidemiology and genotype distribution of the hepatitis c virus infection. j hepatol. 2014 nov. 1; 61( 1): s45-57. 18. pahuja s, sharma m, baitha b, jain m. prevalence and trends of markers of hepatitis c virus, hepatitis b virus and human immunodeficiency virus in delhi blood donors: a hospital based study. jpn j infec dis. 2007; 60 (6): 389. 19. chowdhury a, santra a, chaudhuri s, dhali gk, chaudhuri s, maity sg et al. hepatitis c virus infection in the general population: a community‐based study in west bengal, india. hepatol. 2003; 37 (4): 802-9. 20. sood a, sarin sk, midha v, hissar s, sood n, bansal p et al. prevalence of hepatitis c virus in a selected geographical area of northern india: a population based survey. indian j gastroenterol. 2012; 31 (5): 232-6. frequency of hepatitis c in patients undergoing ophthalmic surgeries; a multicenter study pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 290 author’s affiliation m. ali a. sadiq associate professor, king edward medical university, lahore. faiqa jabeen naeem house officer king edward medical university, lahore mehrin usman ali arifa house officer mayo hospital, lahore haroon tayyab assistant professor, king edward medical university, lahore saima jamshed women medical officer gujranwala medical college gujranwala irfan qayyum maliks associate professor gujranwala medical college gujranwala hafiz muhammad qamar post graduate resident gujranwala medical college gujranwala ayesha hanif senior registrar gujranwala medical college gujranwala author’s contribution m. ali a. sadiq project design, manuscript writing, critical analysis. faiqa jabeen naeem data analysis, manuscript writing. mehrin usman ali arifa data analysis, final review. haroon tayyab data analysis, final review. saima jamshed data analysis, manuscript writing. irfan qayyum malik project design, final review. hafiz muhammad qamar data analysis, manuscript writing. ayesha hanif data analysis, final review. microsoft word khalid iqbal talpur orginal article amniotic membrane transplantation in ocular surface disorders khalid iqbal talpur, faiz muhammad halepota, muhammad pak j ophthalmol 2005, vol. 22 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: khalid iqbal talpur associate professor liaquat university eye hospital jamshoro/hyderabad received for publication september2005 …..……………………….. we report our experience of amniotic membrane transplantation. altogether eight cases were performed for different ocular surface disorders. two cases of extensive symblepheron due to ocular cicatrical pemphigoid and acute epidermal toxic necrolysis. one each case of persistent epithelial defect due to stevensjohnson syndrome, mooren's ulcer, shield ulcer in vernal keratoconjunctivitis, central corneal perforation following treated infective keratitis, conjunctival squamous cell carcinoma excision and bowen's disease excision. all the cases were successful except one case of extensive symblepheron following epidermal toxic necrolysis, leading to detachment of amniotic membrane and perforation of cornea. n 1910 davis first reported use of fetal membranes for skin transplantation1. in ophthalmology the first use of amniotic membrane transplantation (amt) was by de roth in 1940 for conjunctival epithelial defects after symblepharon2. then after a long gap in 1995 amt was reported by kim and tseng in severely damaged corneas in a rabbit model3. since then amt has been used in persistent corneal epithelial defects, neurotrophic corneal ulcers, leaking filtering blebs after glaucoma surgery, conjunctival surface reconstruction with or without limbal stem cell grafting and in patients with ocular cicatrical pemphigoid or stevens johnson syndrome. the ocular surface is covered by corneal, limbal and conjunctival epithelial cells. limbal stem cells give rise to corneal epithelium and in fornices lie the conjunctival stem cells, giving rise to conjunctival epithelium. together with this ocular surface epithelium, stable tear film maintain the health of ocular surface and so allow good visual acuity. in certain ocular and systemic disorders there is damage to limbal stem cells or to corneal epithelium. this results in chronic epithelial defects in cornea which are resistant to conventional treatment. conventionally these defects have been treated with topical lubrication, punctal occlusion, therapeutic contact lenses and temporary or permanent tarsorrhaphy. human amniotic membrane transplantation may be used as an alternative or adjunctive therapy in this situation. human amniotic membrane is derived from fetal membranes and consists of single epithelial layer, thick basement membrane and vascular stroma. epithelial surface is shiny and non sticky, stromal surface is rough and sticky. the exact mechanisms by which amniotic membrane delivers its beneficial effects on ocular surface are still being investigated. however it has been found that it modulates levels of cytokines and growth factors, which have unique properties that results in reduction of pain, including pain suppression of fibrosis and protection of wound. its basement membrane acts as scaffold on which the i corneal epithelium can regrow. it has also very low antigenecity, so minimum chances of rejection. to date, most clinical experience with amt have been with tissue preserved using method described by tseng and colleagues. however there have been some reports of use of fresh amniotic membrane. material and methods we used amniotic membrane for 8 different cases of ocular surface disorders. in all cases stored membrane was used. preparation of membrane human amniotic membrane was obtained from an elective c-section without ruptured membranes in a seronegative (hiv, human hepatitis type b and c and syphilis) woman. under sterile conditions placental membrane was washed and cleaned from blood clots and any fetal remnants. this cleaned membrane was washed with sterile saline containing penicillin (50 micro gm /ml), streptomycin (50micro gm/ml), gentamycin (l00micro gm/ml) and amphoterecin b (2.5micro gm/ml). the amnion is separated from rest of chorion by blunt dissection through potential spaces between these tissues and chorion is discarded. the amniotic membrane is the stretched and flattened over sterile nitrocellulose filter paper with epithelial surface (shiny and non sticky) up and stromal matrix (rough and sticky) down in contact with paper and was stored in standard refrigeration at -20 degree centigrade and utilized with in a month. case no. l a 65 year old male with ocular mucous membrane pemphigoid in both eyes left more than right had amt in left (worst) eye (fig. 1,2). all the fibrous tissue was excised, symblepharon released and conjunctiva recessed up to fornices. amniotic membrane with epithelium up was placed on cornea and sclera up to both fornices. it was sutured with double armed 4-0 silk passing through the conjunctiva and the amniotic membrane at the intended depth of fornix and exiting at the eye lid skin and tied over silicone sponge (bolsters). the membrane was anchored to episclera with 10-0 nylon for amniotic membrane to cover cornea evenly without stretching and folding. bandage contact lens was applied with conformer. upper lid entropion with trichiasis was also corrected with anterior lamellar repositioning with anterior raw surface covered with amniotic membrane. case no. 2 a 25 year old male having extensive symblepharon and ankyloblepharon as a result of acute toxic necrolysis, was treated with amt in right eye (fig. 3,4). membranes were excised, lids separated, all fibrous tissue over cornea and conjunctiva was excised meticulously. amniotic membrane was applied on all corneal and scleral surfaces with fornix forming sutures and episcleral sutures as was done in case no. 1.bandage contact lens and conformer were applied. case no. 3 a 22 year old lady having non healing corneal epithelial defect as a result of stevens johnson syndrome was treated with amt in her left eye. loose corneal epithelium was scraped leaving healthy edges. amniotic membrane was transplanted with epithelial side up and sutured with 10-0 nylon on healthy cornea surrounding the defect. bandage contact lens was applied. case no. 4 a 30 year old male having mooren’s ulcer in left eye between 12 to 20, clock was treated with topical corticosteroids for one year with out any significant success. it was treated with conjunctival recession around the ulcer, limbal stem cell autograft from contralateral eye and amniotic membrane sutured all around the ulcerated area. bandage contact lens was applied. case no. 5 a 20 year old male with vernal keratoconjunctivitis (vkc) developed shield ulcer in left cornea. the cornea was thin and threatening to perforate. patient’s eye got worse after application of conjunctival hood flap. a multilayer amt was performed with conjunctival recession. amniotic membrane was sutured all around with both circumferential and interrupted sutures. bandage contact lens was applied over it and treated with vkc treatment medically. case no. 6 a 55 year old male had central corneal perforation following infective keratitis. a multilayer amt was performed and bandage contact lens applied. case no. 7 a 70 year old lady had biopsy proven squamous cell carcinoma of temporal bulbar conjunctiva in right eye. the neoplasm was removed leaving healthy edges with cryopexy applications around excised area in circumferential fashion. the gap was filled with amt. case no. 8 an 80 year old lady having a large bowen’s disease in left eye covering conjunctiva, limbus and cornea was treated with excision of lesion along with perilimbal conjunctiva with circumferential cryopexy application. the gap was filled with amt. fig. 1: fig. 2: fig. 3: fig. 4: fig. 5: results in case no.l corneal and conjunctival epithelium reformed. both fornices formed (fig 2).though excellent cosmetic results were achieved, patient developed dry eyes which needed life long treatment with lubrication. in case no.2, postoperatively for one week patient was improving nicely and his vision improved to counting fingure from perception of light (fig. 4). then the membrane detached from upper half and following day cornea started melting (fig. 5) .to protect the globe tarsorrhaphy was performed. in case no.3 amniotic membrane was successfully taken up. epithelial defect healed, leaving healthy corneal surface. mooren’s ulcer, which was case no.4, healed successfully without any recurrence with one year follow up but unfortunately ulcer occurred in other eye proving its strong autoimmune basis. he was advised 360 degree peritomy with amt but he was lost to follow up. in case no.5 the ulcer healed, leaving quiet avascular corneal scar with good integrity. perforation in case no.6 sealed nicely leaving small central scar with good integrity. in both cases no.7 and 8 the membrane epithelialized successfully leaving no defect in the excised area. discussion lately amniotic membrane has generated enormous interest among ophthalmologists, and the indication of its use are ever increasing. the ophthalmic uses of human amniotic membrane for transplantation are many and its rediscovery has greatly improved our ability to treat debilitating ocular surface diseases. while results from many studies are encouraging, others show less enthusiastic results. meller de et al showed its successful use in mild to moderate acute chemical and thermal burns4. honavar et al reported that amt restores adequate bulbar surface and fornix depth and also prevents recurrence of symblepheron in severe cases of stevens johnson syndrome5. parbhasawat et all assessed the use of amt in prevention of recurrence of pterygium and reported a relatively low recurrence rate for primary pterigia6. tsubota et al reported its successful ocular surface reconstruction in advanced ocular cicatrical pemphigoid and in stevens johnson syndrome7. multilayer amt has also been used for reconstruction of corneal epithelium and stroma in deep corneal ulcers8. tseng and lee have also reported that alternative method for persistent epithelial defects and sterile ulceration that are refractory to conventional treatment, can be treated with amt before considering treatment with conjunctival flap and tarsorrhaphy9. in our study amt was successful in treating persistent epithelial defects in stevens johnson syndrome. amt in ocular cicatrical pemphigoid resulted successfully in formation of fornix and epithelialization of corneal and conjunctival surface. multilayer amt for shield ulcer in vernal keratoconjunctivitis was successful in prevention of perforation and eventually healing and maintaining corneal integrity. mooren’s ulcer was also successfully treated with amt but it was combined with conjunctival recession and limbal cell auto graft. central corneal perforation was also managed successfully with filler technique. after excision of squamous cell carcinoma and bowen's disease conjunctival gap was filled with amt and it was successfully taken up. one of the disappointing case was cicatrizing ocular surface following acute epidermal toxic necrolysis. the membranes excised, symblepharon released and amt performed. patient’s vision improved to counting finger from perception of light. however after one week amniotic membrane was detached followed by melting of cornea. then the eye was closed with tarsorrhaphy. it is likely that the limbal stem cell deficiency contributed to the lack of success. our overall experience showed that amniotic membrane transplantation is effective in ocular surface disorders when medical therapy fails. future studies directly comparing amt to other methods of treatment of persistent epithelial defects would help to better define the role of amt in ocular surface disease and perhaps further explain mechanisms by which this therapy seems to work. author’s affiliation dr. khalid iqbal talpur associate professor department of ophthalmology liaquat university of medical and health sciences jamshoro/hyderabad prof. faiz muhammad halepota director and consultant ophthalmologist hayat medical centre satellite town mirpurkhas, sindh dr. muhammad postgraduate student for fcps-ii department of ophthalmology liaquat university of medical and health sciences jamshoro/hyderabad reference 1. davis jw. skin transplantation with a review of 550 cases at john hopkins hospitals. john hopkins med j. 1910; 15: 307-96. 2. de roth a. plastic repair of conjunctival defects with fetal membranes. arch ophthalmol. 1994; 23: 522-5. 3. kim jc, tseng sco. transplantation of preserved amniotic membrane for surface reconstruction in severely damaged rabbit cornea. cornea 1995; 14 : 473-84. 4. meller d, pires rtf, mack rjs et al. amniotic membrane transplantation for acute chemical and thermal burns. ophthalmology 2000; 107: 980-90. 5. honavar sg, bansal ak, sangwan vs et al. amniotic membrane transplantation for ocular surface reconstruction in stevensjohnson syndrome . ophthalmology 2000; 107: 975-9. 6. parbhasawat p, barton k, burket g et al. comparison of conjunctival autografts, amniotic membrane grafts and primary closure of pterygium excision. ophthalmology 1997; 104: 974-85. 7. tsubota k, satake y, ohyama m et al. surgical reconstruction of ocular surface in advanced ocular cicatrical pemphigoid and stevens-johnson syndrme. am j ophthalmol. 1996; 122: 38-52. 8. kruse fe, rohrschneider k, volcker he. multilayer amniotic membrane transplantation for reconstruction of deep corneal ulcers. ophthalmology.1999; 106: 1504-11. 9. lee s, tseng scg. amniotic membrane transplantation for persistent epithelial defects with ulceration. am j ophthalmol. 1997; 123: 303-12. microsoft word younas khan 87 original article visual outcome after nd-yag capsulotomy in posterior capsule opacification mohammad younas khan, sanaullah jan, mohammad naeem khan, shafqatullah khan, niamatullah kundi pak j ophthalmol 2006, vol. 22 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations .…………………………….. correspondence to: mohammad younas khan h # 22 sector: d1, phase: i, hayatabad, peshawar received for publication may’ 2005 .…………………………….. purpose: to find out the immediate visual outcome after performing nd-yag laser capsulotomy for posterior capsular opacification (pco) in adults. materials and methods: after thorough prelaser assessment, nd-yag laser capsulotomy was carried out with zeis visulas yag ii through zeiss slit lamp under topical anaesthesia for 58 eyes with pco in 58 patients. postlaser visual acuity (va) compared to preoperative va was noted. associated comorbidities were also noted. results: of the 58 patients, 39 (67.2%) were male and 19 (32.8%) were female. nine (15.5%) were aphakic and 49 (84.5%) were pseudophakic. the average age was 52 years (range 18 years to 83 years). the average time interval between cataract surgery and nd-yag laser capsulotomy was 23 months (2 months to 12 years). capsular fibrosis (62%) was the predominant type of pco. elschnig’s pearls were present in 20.7% and capsular wrinkling found in 15.5%. all these capsulotomies were performed for optical purposes and the results were rewarding. the pre laser va of more than 70% of eyes was 6/36 or below while 44.8% had va of hand movements or finger count. visual acuity of 6/18 or better was achieved in 60.2% of eyes while 12.0% recovered to 6/9 and 3.4% achieved 6/6. none of these eyes showed further deterioration in va. conclusion: neodymium-yag capsulotomy for pco is rewarding procedure in adults and visual outcome is good. comorbidities may reduce the better visual outcome. ince the recognition of cataract, its removal was recommended and practiced in the ancient era. as the evolution of cataract surgery continued from couching, preliminary techniques of extracapsular cataract extraction to intracapsular cataract extraction, high incidence of complications after intracapsular cataract extraction such as vitreous loss, cystoid macular oedema and retinal detachment, triggered the search for perfection. in the last two decades resurgence of refined techniques of extracapsular extraction, not only reduced the rate of complications but also, intact posterior capsule encouraged implantation of posterior chamber intraocular lens (iol) for attaining better visual results. since the development of extracapsular cataract extraction and phacoemulsification and adaptation of the procedure as being the standard one globally, its after effects are studied meticulously. after cataract (pco) is a natural consequence of extracapsular cataract extraction and phacoemulsification. overall incidence of 25% has been reported for pco after extracapsular cataract extraction within s 88 5 years of surgery1. as a result of this opacification, there is gradual deterioration of visual function which ultimately become symptomatic in the form of decreased va, decreased contrast sensitivity, glare or even monocular diplopia2,3. the pco develops in months to years postoperatively. in younger age groups it develops earlier but in elderly, its incidence declines4. since the use of neodymium-yag laser for posterior capsulotomy, this procedure has been gradually replacing the surgical capsulotomy5 as it is less invasive, safe and can be performed as an outpatient procedure. size of capsulotomy should be according to the purpose of the procedure. optical purposes need 2-3mm while therapeutic need large size capsulotomy. it should be noted that capsular opening created with neodymium-yag laser tends to increase in size with smoothing of edges from capsular tag retraction and may become circular6,7. our study was designed to find out different types of pco, time interval between surgery and development of visually significant pco and immediate visual outcome in terms of va after neodymium-yag laser capsulotomy in pseudophakia or aphakia material and methods all patients who were previously operated for cataract by routine ecce or phaco emulisification with or without intraocular lens and presented to department of ophthalmology, khyber teaching hospital, peshawar from october 1998 till 1999, with after cataracts (pco) were randomly included in this study. all patients who required capsulotomy for therapeutic purposes were excluded. patients with thick posterior capsule where we thought that yag laser capsulotomy would not be possible but would need surgical intervention were also excluded from our study. the extent of pco needing laser capsulotomy was determined clinically and by its functional impairment and symptoms of patients. after thorough history, all patients were evaluated clinically. after recording va (snellen’s), evaluation by torch, slit lamp, fundoscopy and applantaion tonometry (goldman’s) was carried out. the type and extent of pco was carefully noted after pupil dilation. visulas yag ii (zeiss) neodymium-yag laser for laser was used capsulotomy. the red 4 point diode laser beam was used for accurate aiming and focusing of the invisible therapeutic beam. the parameters of laser system were adjusted accordingly to the needed of patients depending upon the type and extent of pco. as capsulatomy was done for optical purpose its size was restricted to 2 – 3 mm in diameter. after laser capsulotomy, the patients were rest given for 1 hour. postlaser evaluation was carried out. topical fluorometholone (fml eye drops) was advised four times daily. if intraocular pressure (iop) was found raised then topical beta-blocker was advised. after control of iop and inflammation, final corrected postlaser va was recorded on next morning. results we used the neodymium-yag laser to perform posterior capsulotomies on 58 eyes of 58 patients that had undergone extracapsular cataract extraction. thirty nine (67.2%) of our cases were male and 19 (32.8) were female. the average age of these patients was 52 years, ranging from 18 years to 83 years. of the 58 eyes, 49 (84.5%) had implanted posterior chamber iol, while 9(15.5%) eyes were aphakic. the time period between cataract extraction and opacification of the posterior capsule and performing neodymiumyag laser capsulotomy ranged from 2 months to 12 years. the posterior capsulotomy was performed on average of 23 months after cataract extraction. the time period between cataract surgery and laser capsulotomy is shown in (table 1). types of posterior capsule opacification in our study is shown in (table 2). the average pulse energy used for neodymiumyag laser posterior capsulotomy was 1.9 mj (milli joules) ranging from 0.9 to 6.5 mj. the energy was delivered as single pulse per burst and number of pulses required to produce appropriate size of capsulotomy were at average 16, ranging from 4 to 71 pulses. capsulotomy was completed in all of these cases in single session and the total energy used at average was 87 mj, ranging from 10.4 mj to 566 mj. the results of prelaser va and immediate postlaser va are compared in table 3. it shows that majority of patients (70.6%) had va of 6/36 or less before capsulotomy. among these 70.6% patients, 44.8% had va of less than 6/60 ranging from hand movement to counting of fingers. the va after neodymium-yag laser capsulotomy showed dramatic improvement as shown in (table 3). visual acuity was improved by one or more snellen’s lines in 51 (88%) out of 58 eyes. thirty-five (60.3%) patients recorded va of 6/18 or better. it was also observed that no one had further deterioration of va after neodymium-yag laser capsulotomy. 89 there was no improvement in the va after laser treatment in seven eyes. comorbidities found in these 7 (12%) eyes causing limited or no visual improvement after neodymium-yag laser capsulotomy in our patients are shown in (table 4). immediate postlaser complications are enumerated in (table 5). discussion since the introduction of refined techniques of extracapsular cataract extraction and popularity of the phacoemulsification, opacification of the posterior capsule has become the commonest cause of postoperative reduction in vision following cataract removal8. the neodymium-yag laser has become popular non-invasive technique of creating a posterior capsulotomy in both aphakic and pseudophakic eyes. its safety and efficacy can be argued but it has established its place as a standard treatment for pco replacing surgical capsulotomy5,9-12. table 1:. time period between cataract extraction and nd: yag laser capsulotomy (n = 58) time period no of eyes n (%) less than 6 months 4 (6.9) 6 months to 1 year 10 (17.2) 1 year to 2 years 18 (31.0) 2 years and above 26 (44.8) table 2. types of posterior capsule opacification (n = 58) pco no of patients n (%) capsular fibrosis 36(62.0) elschnig’s pearls 12 (20.7) capsular wrinking 9 (15.5) pigmentary deposits on capsule 1 (1.7) pco = posterior capsule opacification table 3: va before and after nd: yag laser capsulotomy (n = 58) va prelaser n (%) postlaser n (%) less than 6/60 26 (44.8) 4 (6.9) 6/60 5 (8.6) 4 (6.9) 6/36 10 (17.2 7 (12.0) 6/24 6 (10.3) 8 (13.8) 6/18 7 (12.0) 16 (27.6) 6/12 3 (5.1) 10 (17.2) 6/9 1 (1.7) 7 (12.0) 6/6 0 2 (3.4) table 4:. comorbidities noted after nd: yag laser capsulotomy comorbidities no of patient’s n (%) diabetic retinopathy 3 (5.17) age related maculopathy 2 (3.44) traumatic maculaopathy 2 (3.44) table 5: immedaiate complications after nd: yag laser capsulotomy (n = 58) complications no of eyes n (%) raised intra ocular pressure 48 (82.7) damage to intra ocular lens 13 (22.4) hyphema 1 (1.7) rupture of anterior vitreous face 8 (13.8) herniation of vitreous into anterior chamber 4 (6.9) anterior uveitis 1(1.7) opacities/debris in anterior chamber 10 (17.2) macular oedema 1 (1.7) in our study out of 58 patients, 39 were male (67.2%) and 19 were female (32.8%). which probably reflects that female population less commonly undergo surgery for cataract or present to hospital for 90 their reduced vision after surgery. as female population in our area are socio-economically dependant on male population and also they have nearly all activities within the premises of the house, therefore reduced va either due to immature cataract or pco after cataract surgery, is not much significant. tayyab and collegues have found sex ratio as 60% vs 40% in one group of patients and 50% vs 50% in second group of their study30. hasan, et al also have reported almost the same sex ratio4. opacification of posterior capsule is the commonest complication of extracapsular cataract extraction occurring more frequently in younger age group ranging from 1.5%13 and 4%14 in adults to 92% in children15. the time period between cataract extraction and performing neodymium-yag laser capsulotomy at average was 23 months in our study while it was reported as 2.49 years by hasan et al4, and 24 months in another national study15. the relative incidence of different types of pco showed that the capsular fibrosis was the predominant type of pco as compared to hasan, et al who reported elschnig’s pearls in pseudophakic and secondary fibrosis in aphakic eyes4. the main mechanism of postoperative pco is proliferation and migration of lens epithelial cells onto the posterior capsule. equatorial epithelial cells undergo fibrous metaplasia, causing fibrosis of posterior capsule. while elschnig pearls formation, is due to anterior subcapsular epithelium migration on to the posterior capsule and appear like bladder cells16,17. there was dramatic improvement in va on snellen chart, after neodymium-yag laser capsulotomy, i.e. 60.2% of patients recorded va of 6/18 or better in our study. it was also noted that there was no further deterioration of va in any case. and in 51 (88%) out of 58 patients, the va improved to one or more snellen lines. in the study conducted by hasan, et al, improvement of va after neodymium-yag laser capsulotomy on snellen chart was, 1-3 lines in 42 out of 86 patients, 4-6 lines in 31 out of 86 patients and there was no improvement of va in 13 cases due to comorbidities4. a similar study reported before showed improvement of va of one or more snellen’s lines in 56 out of 63 eyes15. in an other study conducted by wilkins et al, there was va improvement in 7 out of 17 patients under non glare conditions, and under glare conditions 10 patients showed increase in the va18. a study conducted by latif and aasi, using neodymium-yag laser for membranectomy recorded improvement in the va, from 16.66% of patients prelaser to 72.22% of patients (postlaser) in the range 6/36 or better on snellen chart19. over all 87.5% showed improvement in the va of an average of three lines on snellen chart after laser treatment in their study19. in study by panezai mn and colleagues, pre laser va was between hand movements and 6/36 in 80% of cases and postlaser va attained was between 6/18 and 6/6 in 91% of cases29. all of these studies reported there was definite improvement in va in high percentage of patients after neodymium-yag laser treatment and no one has reported deterioration of va after laser treatment. neodymium-yag laser use has been accepted as standard technique for treating pco5 resulting in rapid visual improvement20-22 and so was found in study. complications which we encountered in our study such as raised iop, damage to iol, disruption of anterior vitreous face, cystoid macular edema etc are all recognized complications of neodymium-yag capsulatomy and had been reported previously23-28. conclusion the posterior capsule opacification is a common complication after cataract surgery worldwide and it can be managed safely as an outdoor procedure by neodymium-yag laser posterior capsulotomy. its indications are similar to indications for cataract surgery. in our patients the indications were optical but it can be performed for therapeutic purpose. other possible causes responsible for dimness of vision should be excluded before predicting visual outcome. patients of axial myopia, retinal degeneration and preexisting glaucoma should be properly evaluated and capsulotomy if necessary, performed with care. capsulotomy with neodymium-yag laser should not be performed in uncooperative and patients who cannot maintain a steady position on slit lamp. patient education is of vital importance in this procedure. his confidence and co-operation is of great value in performing the procedure. author’s affiliation dr mohammad younas khan consultant ophthalmologist, khyber institute of ophthalmic medical sciences, hayatabad medical complex peshawar. dr. sanaullah jan senior registrar khyber institute of ophthalmic medical sciences 91 hayatabad medical complex peshawar dr. mohammad naeem khan consultant ophthalmologist khyber institute of ophthalmic medical sciences hayatabad medical complex peshawar dr. shafqatullah khan trainee medical officer khyber teaching hospital peshawar prof niamatullah kundi incharge department of ophthalmology khyber teaching hospital peshawar references 1. schauumberg da, dana mr, christen wg, et al. a systemic overview of the incidence of posterior capsule opacification. ophthalmology. 1998; 105: 1213-21. 2. claesson m, klaren l, beckman c, et al. glare and contrast sensitivity before and after nd:yag laser capsulotomy. acta ophthalmol. 1994; 72: 27-32. 3. sunderraj p, villada jr, joyee pw, et al. glare testing in pseudophakes with posterior capsule opacification. eye 1992; 6: 411-3. 4. hasan ks, adhi mi, aziz m, et al. nd:yag laser posterior capsulotomy. pak j ophthalmol. 1996; 12: 3-7. 5. murril ca, stanfield dl, van brockiln md. capsulotomy. optom clin 1995; 4: 69-83. 6. capone ajr, rehkopf pg, warnicki jw, et al. temporal changes in posterior capsulotomy dimensions following neodymuun:yag laser discission. j cataract refract surg 1990; 16: 451-6. 7. clayman hm, jaffe ns. spontaneous enlargement of neodyminm: yag posterior capsulotomy in aphakic and pseudophakic patients. j cataract refract surg. 1988; 14: 667-9. 8. aslam tm, devlin h, dhillon b. use of nd: yag laser capsulotomy. survey ophthalmol. 2003; 48: 594-612. 9. knolle ge jr. knife versus neodymium: yag laser posterior capsulotomy: a one year follow up. j am intraocular implant soc. 1985; 11: 448–55. 10. riggins j, pedrotti ls, keates rh. evaluation of the neodymium: yag laser for treatment of ocular opacities. ophthalmic surg. 1983; 14: 657-82. 11. stark wj, warthen d, holladay jt, et al. neodymium: yag laser. an fda report. ophthalmology 1985; 92: 209–12. 12. terry ac, stark wj, maumenee af, et al. neodymium-yag laser for posterior capsulotomy. am j ophthalmol. 1983; 96: 716-20. 13. halepota fm, dahri gr, anjum n. complications of iol implantation: a review of 400 cases. pak j ophthalmol. 1995; 11: 109–12. 14. nisar a, durrani j. causes of failure of visual rehabilitation in pseudphakic patients: a review of 100 cases. pak j ophthalmol. 1998; 14: 52–7. 15. kundi nk, younas m. nd-yag laser posterior capsulotomy. j med sciences. 1998; 8: 90-4. 16. bertelmann e, kojetinsky c. posterior capsule opacification and anterior capsule opacification. curr opin ophthalmol. 2001; 12: 35–40. 17. spalton dj. pco after catract surgery. eye 1999; 13: 489–92. 18. wilkins m, mcpherson r, fergusson v. visual recovery under glare conditions following laser capsulotomy. eye 1996; 10: 117–20. 19. latif e, aasi na. treatment of postoperative pupillary membranes with nd-yag laser. pak j ophthalmol. 1996; 12: 8– 12. 20. magno bv, datiles mb, lasa ms. evaluation of visual function following neodymium: yag laser posterior capsulotomy. ophthalmology 1997; 104: 1287–93. 21. weiblinger rp. review of the clinical literature on the use of the nd yag laser for posterior capsulotomy. j cataract refract surg. 1986; 12: 162–70. 22. wilhelmus kr, emery jm. posterior capsule opacification following phacoemulsification. ophthalmic surg.1980;11:264–7. 23. ge j, wand m, chiang r. long-term effect of nd: yag laser posterior capsulatomy on intraocular pressure. arch ophthalmol. 2000; 118: 1334–7. 24. bath pe, fankhauser f. long-term results of nd:yag laser posterior capsulotomy with swiss laser. j cataract refract surg. 1986; 12: 150–3. 25. krauss jm, puliafito ca, miglior s. vitreous changes after neodymium – yag laser photodisruption. arch ophthalmol 1986; 104: 592–7. 26. trinavarat a, atchaneeyasakul l, udompunturak s. neodymium: yag laser damage threshold of foldable intraocular lenses. j cataract refract surg. 2001; 27: 775–80. 27. smith rt, moscoso wf, trokel s, et al. the barrier function in neodymiumyag laser capsulotomy. arch ophthalmol. 1995; 113: 645– 52. 28. newland tj, mc dermott ml, eliott d. experimental neodymium: yag laser damage to acrylic, polymethylmethacrylate and silicone intraocular lens materials. j cataract refract surg. 1999; 25: 72–6. 29. panezai mn, shawani ma, hameed k. posterior capsular opacification (pco) and ndd: yag laser capsulotomy in helpers eye hospital quetta. pak j ophthalmol 2004; 20: 115-8. 30. tayyab aa, sahi tn, ajmal m, et al. frequency of posterior capsular opacificatoin following pmma vs silicone posterior chamber iol implantation with phacoeouclsigfication. pak j ophthalmology. 2004; 20: 96—9. pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 42 original article central macular thickness: a comparative study of diabetics vs healthy beenish khan, muhammad muneer quraishy, asma shams pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: beenish khan assistant professor department of ophthalmology united medical and dental college, creek general hospital, korangi, karachi email: beenish_aquarian@hotmail.com …..……………………….. purpose: to compare the central macular thickness amongst diabetics with that of healthy population by using optical coherence tomography. study design: case control study. place and duration of study: department of ophthalmology unit i, civil hospital karachi from 5 th march 2012 to 4 th september 2012. material and methods: we randomly selected patients with diabetes (cases) and healthy patients (control) with clinically normal macula and no diabetic retinopathy. detailed relevant history was acquired. best corrected visual acuity (bcva) was measured with standard snellen’s chart. detailed dilated fundus examination was done using +90d and +78d lens. central macular thickness within an area of 1000 µm was measured using optical coherence tomography. results: there were 68 patients in each group. the mean age of patients in the diabetic group was 47.94 ± 14 (20-80) years and in the healthy group it was found to be 39.53 ± 14.93 (20-80) years. out of these 26 were male and 42 were female in the diabetic group whereas 27 were male and 41 were female in the healthy group. mean central macular thickness of diabetic eyes were 214.48 ± 31.41 µm and that of healthy eyes were 236.79 ± 19.38 µm with mean difference of 22.31 ± 4 µm (p value = 0.000).. a statistically significant difference in the central macular thickness of diabetics and healthy patients was observed. conclusion: the central macular thickness is significantly decreased in eyes of patients with diabetes. keywords: central macular thickness, optical coherence tomography, oct, diabetic retinopathy, diabetic maculopathy. iabetes mellitus is a multifactorial disease which can lead to multiple organ dysfunction. diabetic retinopathy including diabetic maculopathy is one of the complications of diabetes mellitus which leads to the sight threatening consequences. diabetic maculopathy is the most prevalent sight threatening condition in diabetes1. conventional methods of evaluating macular thickness like slit lamp biomicroscopy and stereo fundus photography are relatively insensitive to small changes in retinal thickness. thus for measuring retinal thickness quantitatively several new techniques have been explored2. retinal imaging techniques can provide detailed cross sectional information which can be complementary to conventional fundus photography and fluorescein angiography3. optical coherence tomopgraphy (oct) is a new medical diagnostic imaging technology which can perform cross sectional or tomographic imaging of biological tissues in micrometer resolution4. its application has been demonstrated in normal human eyes with certain macular abnormalities and glaucoma3,5,6. despite normal findings in slit lamp biomicroscopy early changes in the retinal thickness d beenish khan, et al 43 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology can be detected by optical coherence tomography7 and it has been observed that a greater than 10% change in baseline macular thickness by optical coherence tomography is considered significant8. macular thickness measurements may be used to assess disease, monitor its progress and evaluate treatment9. macular thickness has been shown to be increased in diabetics with clinically normal macula10. the macular thickness measurement may differ with the population. thus it is desirable that measurements derived from the normative population be as close as possible to the population for which the instrument is to be used11. it has been observed that strict diabetes control slowed down the appearance of diabetic retinopathy and can play an important part in protection of macula12-13. the rationale of our study is to ascertain whether there is any difference in the macular thickness of normal with diabetics with clinically normal maculae in pakistani population, so that early diagnosis can be made. this will ensure that strong check on the diabetes control is maintained and proper treatment can be applied at proper time before the appearance of sight threatening complications. material and methods we randomly selected patients with diabetes (cases) and healthy patients (control) with clinically normal macula and no diabetic retinopathy attending the ophthalmology out patients department of unit i, civil hospital karachi from 5th march 2012 to 4th september 2012. healthy patients included in the study had a best corrected visual acuity of 6/6, no associated ocular co morbidity, no history of previous ocular surgery or laser therapy, no history of systemic disorder that can effect eye and no history or evidence of pathology features of retina. diabetic patients included in the study had established diabetes and were using insulin or oral hypoglycemic agents either controlled or uncontrolled as detected by hba1c. the duration of diabetes was more than 5 years. there were no signs of diabetic maculopathy clinically. the null hypothesis made was made that there is no difference in macular thickness between diabetics with clinically normal macula and healthy individuals. it was a case control study with a sample size of 136 eyes in each group. sampling technique used was non probability purposive sampling. all subjects who fulfilled the criteria of healthy and diabetic subjects, subjects of either gender, subjects ranging from 20 yrs – 80 yrs age and duration of diabetes greater than 5 yrs were included in the study. patients having proliferative diabetic retinopathy or advance diabetic eye disease, ocular comorbidities other than diabetic retinopathy like armd, retinal dystrophy, glaucoma etc., history of previous ocular surgery or laser therapy and subjects in whom scans with signal strength ≤ 60 could not obtained on oct were excluded from the study. subjects selected from the outpatient department of civil hospital karachi underwent slit lamp examination including +90d and +78d lens examination after dilatation with 1% tropicamide. we included 136 healthy eyes that fulfilled the selection criteria. there were 136 diabetic eyes with established diabetes, using insulin or oral hypoglycaemic agents since ≥ 5yrs that were selected. an informed consent was taken after explaining the whole procedure. refraction and fundus flourescein angiography of all patients was done to control effect modifying. all included subjects underwent scanning with a spectral domain optical coherence tomography (sd oct) device (3d oct 1000 topcon japan) by one designated experienced person. follow up of the table 1: base line characteristics. controls (healthy) cases (diabetics) p value no. of eyes 136 136 age (years) 47.94 ± 14.07 39.52 ± 14.93 0.47* gender no. (%) males 27 (39.7%) 26 (38.2%) 0.86** females 41 (60.3%) 42 (61.8%) mean cmt (µm) 236.79 ± 19.38 214.48 ± 31.41 0.00* *independent sample t test **chi square test patient was not required. for quantitative evaluation, the thickness of the central circular area of 1000 micrometers in diameter was used as defined by the early treatment diabetic retinopathy study (etdrs).14 statistical packages for social science (spss16) was used to analyze data. mean was calculated for quantitative variables (central macular thickness central macular thickness: a comparative study of diabetics vs healthy pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 44 and age). frequency and percentage was used for qualitative variables like gender. independent sample t test was used to see the difference between the two groups i.e. diabetic and healthy. p ≤ 0.05 was considered significant. we stratified the data in multiple groups according to age, gender, diabetic control, and duration of diabetes. then we calculated through chi square for both groups to see the effect of each variable accordingly. age stratification was done decade wise and 7 groups were made. group 1; 20-29 years, group 2; 30-39 years, group 3; 40-49 years, group 4; 50-59 years, group 5; 60-69 years, group 6; 70-79 years and group 7; 80 years. patients were stratified in 2 groups according to glycemic control. group 1; controlled diabetes, group 2; uncontrolled diabetes. patients were stratified according to duration of diabetes in 5 groups. group 1; 5-10 years, group 2; 11-15 years, group 3; 16-20 years, group 4; 21-25 years. results there were 68 subjects in each group. table 1 details the characteristics of both the groups. statistically significant difference was found with respect to age in healthy group (p = 0.038) (table 3) but not in diabetic group (p = 0.669) (table 2). the two groups had statistically insignificant variations with respect to gender (p = 0.86) (table 1 & 4), duration of diabetes (p = 0.311) (table 6) and type of diabetes (p = 0.72) (table 5). all patients had controlled diabetes. the mean central macular thickness in the control group was 236.79 ± 19.38 µm which was table 2: effect of age on cmt in diabetic patients. age of the patients in groups no. of cases mean cmt p value 20 – 29 yrs 11 206.27±28.69 0.669* 30 – 39 yrs 3 217.67±50.52 40 – 49 yrs 14 219.14±28.09 50 – 59 yrs 28 210.93±34.94 60 – 69 yrs 8 218.62±29.07 70 – 79 yrs 4 235.00±11.43 total 68 *one way anova table 3: effect of age on cmt in healthy subjects. age of the patients in groups no. of cases mean cmt p value 20 – 29 yrs 19 240.62 ± 20.27 0.038* 30 – 39 yrs 18 224.83 ± 18.78 40 – 49 yrs 15 240.40 ± 16.55 50 – 59 yrs 8 251.50 ± 10.85 60 – 69 yrs 5 234.80 ± 23.91 70 – 79 yrs 1 n/a 80 yrs 2 232.50 ± 3.53 total 68 *one way anova table 4: effect of gender on cmt. gender p value* male female cmt control 245.59 ± 15.25 231.00 ± 19.77 0.086 cmt case 214.19 ± 34.69 214.67 ± 29.64 0.027 *independent samples t test. table 5: effect of type of diabetes on cmt. type of diabetes total no of cases mean cmt p value* iddm 13 211.69 ± 27.92 0.72 niddm 55 215.15 ± 32.38 *independent sample t test table 6: effect of duration of diabetes on cmt. duration of diabetes no. of cases mean cmt p value* 5-10 yrs 37 221.13 ± 33.16 0.189 11-15 yrs 19 206.84 ± 25.26 16-20 yrs 8 213.50 ± 27.29 21-25 yrs 4 214.48 ± 40.46 total num of cases 68 *one way anova test beenish khan, et al 45 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology significantly thicker than the value of 214.48 ± 31.41 µm obtained for the case group (p = 0.00). the mean central macular thickness in the cases group was thinner by 22.31 ± 4.47 µm as compared to the control group (p = 0.00). thus the decreased cmt in diabetic group showed a significantly thinner mean cmt even in the absence of clinical maculopathy. discussion optical coherence tomography is considered as a useful tool for the measurement of retinal thickness. it raises the probability of correct diagnosis, helps in following the disease progression as well as monitoring the efficacy of treatment given for diabetic retinopathy15. that is the reason we have chosen diabetic patients with normal maculae so that we find earliest changes that are not evident in other ways. we included 68 diabetic cases with no maculopathy and compared them with that of normal. the mean age of diabetic patients was 39.52 ± 14.93 years and that of healthy group was 47.94 ± 14.07 years. our study showed that the mean central macular thickness of the diabetic patients came out to be 214.48 ± 31.41 which is thinner than the mean central macular thickness of the healthy cases 236.79 ± 19.38 µm (p 0.000). in 2013, a same study was done in turkey also revealing decreased macular thickness in diabetics (227.19 ± 29.94 µm in healthy as compare to 232.12 ± 24.41 µm in diabetics)16. murugesan s17, and jiang jing et al18 also found decreased central macular thickness in clinically normal diabetic maculae in comparison to that of healthy individuals. statistically significant pericentral retinal thinning has also been demonstrated by biallosterski and co-workers19, when they compared the retinal thicknesses of diabetics and healthy individuals, supporting the hypothesis of nerve tissue cell loss in the initial stages of diabetic retinopathy. in addition to this study by nilsson et al20 also upholds our study result by demonstrating decreased retinal thickness in diabetic patients with early or no diabetic retinopathy. pre-clinical retinal nerve fiber layer thickness is also found to be less in the superior quadrant and other areas of retina in diabetic patients in comparison to the healthy retina21. all of these studies suggest damage to the neural tissue in diabetes which involves mostly the ganglion cell layer and inner plexiform layer22. certain factors were observed in healthy eyes also that can directly or indirectly impact the measured central macular thickness on oct. these include ethnicity and gender of the subject23-24. in our study we didn’t find any significant difference in central macular thickness with respect to gender. eriksson and alm25 reported negative relationship between retinal thickness and age for all etdrs areas, total macular volume and rnfl thickness in healthy individuals (retinal thickness decreased by 0.26-0.46 mm, macula volume 0.01 mm3 and rnfl 0.09 mm per year). in our study significant difference was found in cmt with respect to age in healthy groups but no definite pattern was found. there was no significant difference in the macular thickness of diabetic group according to the age. overall, we found the following findings: significant decreased central macular thickness of diabetics vs. healthy in normal maculae, no specific pattern of macular thickness was found according to the age, no specific pattern of macular thickness was found according to duration of diabetes. one limitation to our article was decreased sample size which was total of 136 eyes in both groups conclusion since p-value is significant (0.000) therefore null hypothesis is rejected and we come to the conclusion that the macular thickness of diabetic patients is less than that of healthy individual even when there is no clinical evidence of any changes. this study suggests that there are certain changes that occur during the course of diabetes which lead to the retinal damage and resultant decreased thickening. author’s affiliation dr. beenish khan assistant professor department of ophthalmology united medical and dental college creek general hospital korangi, karachi dr. muhammad muneer quraishy professor of ophthalmology dow university of health sciences civil hospital karachi dr. asma shams senior registrar ophthalmology shaheed mohtarrma benazir bhutto medical college liari central macular thickness: a comparative study of diabetics vs healthy pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 46 author’s contribution dr. beenish khan manuscript writing, data collection, analysis and interpretation. dr. muhammad muneerquraishy study concept and design. dr. asma shams manuscript review. references 1. klein r, klein be, moss se, davis md, de mets dl. the wisconsin epidemiologic study of diabetic retinopathy iv. diabetic macular edema. ophthalmol. 1984; 91: 1464-74. 2. nussenblat rb, kaufman sc, palestine ag, davis md, ferris fl. macular thickening and visual acuity. ophthalmology 1987; 94: 1134-9. 3. hee mr, puliafito ca, duker js, reichel e, coker jf, wilkins jr et al. topography of diabetic macular edema with optical coherence tomography. ophthalmol. 1998; 105: 360-70. 4. chauhan ds, marshall j. the interpretation of optical coherence tomography images of the retina. invest ophthalmol vis sci. 1999; 40: 2332-42. 5. koozekanani d, roberts c, katz se, herderick ed. intersession repeatability of macular thickness measurements with the humphrey 2000 oct. invest ophthalmol vis sci. 2000; 41: 1486–91. 6. munuera jm, garcia-layana a, maldonado mj, aliseda d, morenomontanes j. optical coherence tomography in successful surgery of vitreo-macular traction syndrome. arch ophthalmol. 1998; 116: 1388-9. 7. tocino hs, vidal aa, maldonado mj, montanes jm, layana ag. retinal thickness study with optical coherence tomography in patients with diabetes. invest ophthalmol visual sci. 2002; 43: 1588-94. 8. browning dj, fraser cm, propst bw. the variation in optical coherence tomography–measured macular thickness in diabetic eyes without clinical macular edema. am j ophthalmol. may 2008; 145 (5): 889-93. 9. workman hl, hosking sl. repeatability and reproducibility of macular thickness measurements using oct 3 system in normal subjects and diabetics patients. invest ophthalmol visual sci. 2004; 45: 2378b13. 10. emerah sh, labib hm, farag my, kamel hf. macular thickness measurements in diabetic patients without diabetic retinopathy using optical coherence tomography. j am sci. 2011; 7 (11): 223-7. 11. tewari hk, wagh vb, sony p, venkatesh p, singh r. macular thickness evaluation using the optical coherence tomography in normal indian eyes. ind j ophthalmol. 2004; 52 (3): 199-204. 12. peng yj, tsai mj. impact of metabolic control on macular thickness in diabetic macular oedema. diab vasc dis res. 2018; 15 (2): 165-8. 13. teberik k, eski mt, kaya m. associations of glycated hemoglobin (hba1c) level with central corneal and macular thickness in diabetic patients without macular edema, 2018; 4 (4): 294-9. 14. early treatment diabetic retinopathy study research group. photocoagulation for diabetic macular edema. etdrs report number 1. arch ophthalmol. 1985; 103: 1796-806. 15. hannouche rz, avila mp. retinal thickness measurement and evaluation of natural history of the diabetic macular edema through optical coherence tomography. arq bras oftalmol. 2009; 72 (4): 433-8. 16. demir m, dirim b, acar z, yilmaz m and sendul y. central macular thickness in patients with type 2 diabetes mellitus without clinical retinopathy. j ophthalmol, 2013. 17. murugesan s, jha k n, krishnagopal s and ezhumalai g. central macular thickness in diabetics without retinopathy. tnao j ophthalmic sci & research, 2018; 56 (3): 150-4. 18. jiang j, liu y, chen y, ma b, qian y, zhang z et al. analysis of changes in retinal thickness in type 2 diabetes without diabetic retinopathy. j diabetes research, 2018. 19. biallosterski c, van velthoven me, michels rp et al. decreased optical coherence tomography-measured pericentral retinal thickness in patients with diabetes mellitus type 1 with minimal diabetic retinopathy. br j ophthalmol. 2007; 91 (9): 1135-8. 20. nilsson m, wendt g, wanger p, martin l. early detection of macular changes in patients with diabetes using rarebit fovea test and optical coherence tomography. br j ophthalmol. 2007; 91 (12): 1596-8. 21. peng hp, lin hs, lin s. nerve fibre layer thinning in patients with preclinical retinopathy. can j ophthalmol. 2009; 44 (4): 417-22. 22. cabrera bd, somfai gm. early detection of retinal thickness changes in diabetes using optical coherence tomography. med sci monit. 2010; 16 (3): 15-21. 23. kelty pj, payne jf, trivedi rh, kelty j, bowie em, burger bm. macular thickness assessment in healthy eyes based on ethnicity using stratus optical coherence tomography. invest ophthalmol visual sci. 2008; 49: 2668-72. 24. ooto s, hangai m, sakamoto a, tomidokoro a, araie m, otani t, et al. three-dimensional profile of macular retinal thickness in normal japanese eyes. invest ophthalmol visual sci. 2010; 51: 465-73. 25. eriksson u, alm a. macular thickness decreases with age in normal eyes: a study on the macular thickness map protocol in the stratus oct. br j ophthalmol. 2009; 93: 1448-52. 144 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology case report silicone oil droplets in vitreous after intravitreal bevacizumab injection haroon tayyab, asad aslam khan, muhammad ali a sadiq, sana jahangir, suhail sarwar pak j ophthalmol 2018, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. haroon tayyab assistant prof. of vitreoretina coavs – kemu (mayo hospital lahore) email: haroontayyab79@gmail.com …..……………………….. intravitreal injection of bevacizumab for various retinal vascular disorders has become the mainstay of treatment. the injection of bevacizumab is usually dispensed through local pharmacies after formulating from a larger vial under sterile conditions. we report an interesting finding of silicone oil bubble in vitreal cavity after intravitreal bevacizumab injection. this is attributed to the fact that the syringes used for dispensing bevacizumab are coated with silicone oil that acts as a lubricant. these silicone oil droplets can lead to floaters and other possible complications. we report two cases of such occurrence and propose strategies to avoid this complication. keywords: bevacizumab, diabetic macular edema, silicone oil, ranibizumab. n last one decade, intravitreal drug delivery in the form of anti-vascular endothelial growth factor (anti-vegf) has become the mainstay of treatment for many retinal vascular disorders including diabetic retinopathy, diabetic maculopathy and macular edema resulting from retinal vein occlusions1,2. also, the current recommended treatment for wet age related macular degeneration (armd) is intravitreal antivegf injections3. given the highly prevalent nature of conditions like diabetic maculopathy and wet armd, it is no surprise to us that intravitreal injections of bevacizumab, ranibizumab and aflibercept have become the most commonly performed vitreoretinal intervention and second most commonly performed ophthalmic surgical procedure. there have been many studies where local and systemic side effects of intravitreal injections have been mentioned.4 an interesting finding after injection of bevacizumab and ranibizumab is finding of silicone oil bubble in vitreous cavity. this can be symptomatic in the form of a floater or an incidental finding during detailed retinal examination. first of such reports was by fruend and richard f spaide in 20065. this peculiar finding has been infrequently but persistently reported in western literature up till mid 20166. this finding has been attributed to the fact that intravitreal i silicone oil droplets in vitreous after intravitreal bevacizumab injection pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 145 injection syringes are pretreated with silicone oil that acts as a lubricating agent for smooth entry in the tissue7. here we report our first few cases of intravitreal silicone oil bubble in patients who had received bevacizumab for diabetic macular edema. to date, local literature has provided no such report about this interesting finding. the rationale of reporting these cases is to discuss possible ocular implications and propose remedy to this problem. these case reports are from the outdoor patient department (opd) of ophthalmology unit 3, mayo hospital, lahore from the period between october 2017 to february 2018. an informed consent was sought from both patients and hospital ethics committee approval was obtained before proceeding with reporting of these cases. while presenting these case series, the authors do not have any conflict of interest to disclose. case 1 our first case (october 2017) was a 54 year old male diabetic patient who had been on intravitreal bevacizumab injection for his diabetic macular edema in left eye. he had history of 7 such injections in his right eye and presented to our outdoor patient department for routine follow-up. his last injection was one week ago. he had no complaints of floaters at the time of presentation. his best corrected visual acuity in left eye was 20/80 and intraocular pressure was 15 mmhg. he had a history of uneventful phacoemulsification with iol implantion one year ago. a fundus photograph was taken using topcon fundus camera (trc-50dx topcon medical systems, inc. oakland, nj. usa). the next follow-up of this patient was in december 2017 by which time the silicone oil bubble was no more visible on slit lamp examination. this patient has remained complication free and symptom free to date as far as the silicone oil bubble was concerned (fig. 1). b-scan was performed and classic ringing bell sign due to silicone oil droplet was noted (fig. 2). the size of silicone oil droplet was noted to be 0.3 mm. fig. 1: silicone oil bubble in vitreous cavity after intravitreal bevacizumab injection – left eye. case 2 the second case (february 2018) was a 60 year old female who presented to opd and was scheduled to have her left eye examination prior to intravitreal bevacizumab injection for diabetic macular edema. this was her third injection in left eye. her best corrected visual acuity was 20/200 and intraocular pressure was 17 mm hg. she was phakic with no haroon tayyab, et al 146 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology history of ocular surgery apart from intravitreal bevacizumab. we noted intravitreal silicone oil bubble suspended in superior half of post vitreous cavity but could not capture this finding on fundus camera due to very small and indistinct appearance of this bubble on photography. her last injection was one month ago. she also remained symptom free. fig. 2: ringing bell sign on b – scan. size of silicone oil bubble is 0.3mm. fig. 3: three distinct silicone oil bubbles in vitreous cavity (marked in black circle). case 3: our third case was a 60 year old lady who presented to us with traumatic crystalline dislocation after blunt trauma in her right eye. on detailed fundus examination, she was found to have old central retinal vein occlusion with subhyaloid hemorrhage for which she had received 2 bevacizumab injections 8 months ago. she was also noted to have 2 silicone oil bubbles on her vitreous cavity. her fundus photograph shows silicone oil bubbles suspended in vitreous cavity (fig. 3). she also did not have any history of ocular surgery apart from mentioned intervention for her crvo. discussion the most frequent anti-vegf used in pakistan is bevacizumab. it is usually dispensed by pharmacies in pre-formulated insulin syringes from a larger vial under sterile conditions. the largest dispenser of bevacizumab in the province of punjab, pakistan is shaukat khanum memorial cancer hospital and research centre (skmch). we have not noted any clinical report about the presence of silicone oil bubbles after intravitreal bevacizumab injections in local literature. this problem was recently reported by american society of retina specialists (asrs) in 2016, where they attributed this finding to silicone oil lining the syringe and needle that acts as a lubricating agent to facilitate movement6. in our clinical practice, lots of patients report of floaters after intravitreal bevacizumab injection but it was never attributed to silicone oil droplets. only recently that we started noting presence of silicone oil bubbles in vitreous cavity after this intervention and thus reported the three cases. none of our patients had any symptoms related to silicone oil bubble because on both occasions the bubble was above and away from the nodal point; and on one occasion the bcva was decreased to an extent that floater may not have been noted by the patient. in one of the largest case series reported in american journal of ophthalmology, it was quoted that the rate of this finding was 0.026% per injection or 0.15% per patient (a total of 7 patients reported).6 with time the complaints of patient decreased because the oil bubble rose superiorly to pars plicata region of fundus and became un-noticeable to patient and ophthalmologist alike. polydimethylsiloxane (pdms) is the most frequently used silicone oil to lubricate the syringes and is density is less than vitreous (pdms: 965 kg/m3; vitreous 1000 kg/m3). it should be remembered that bevacizumab is dispensed for intravitreal use in insulin syringes that are manufactured with the intent of subcuticular use especially in diabetic patients. we use syringes manufactured by becton dickinson (bd) and company (30 g; 12.7mm length; u100 1 ml insulin silicone oil droplets in vitreous after intravitreal bevacizumab injection pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 147 syringe bd ultra-fine™ needle, becton dickinson and company, franklin lakes, nj). bd states that needles and syringes are lubricated with silicone oil during the manufacturing process to facilitate smooth drug delivery and less leaching of drug with syringe and needle walls. the lubricant most likely used is 365 dow corning surfactant that contains 2-3% of silicone oil7. the dow corning company has claimed that there are no adverse effects related to its surfactant and that this surfactant has also been used in other products that have human contact including food industry8. kocabora reported similar finding while using injections of pegabtanib9. pegabtanib was packaged in a sterile, 1-ml, usp type 1, graduated, prefilled glass syringe fitted with a sterile 27-gauge needle manufactured by bd (similar manufacturing process).7 ranibizumab is drawn up with a 19-gauge filter needle (5-um filter) and injected intravitreal using a 30-gauge 0.5-in needle (precision glide, becton dickinson and company, franklin lakes, nj). since these syringes are very commonly used in diabetic patients, there is compelling evidence of presence of silicone oil in these syringes in diabetic literature. a subcuticular granulomatous reaction induced by silicone oil was found in one case series.10 miller et al documents the extrusion of silicone oil from these syringes after repeated flushing with distilled water. in another report, silicone oil became incorporated in insulin after repeated pumping of plunger in the syringe shaft9. the efficacy of insulin has also been reported to be decreased after getting mixed with silicone oil. this area still remains to be unexplored whether the efficacy of anti-vegfs is reduced after coming in contact with silicone oil. perhaps further insight into this problem will give us a better idea about the interaction of anti-vegfs and silicone oil. we need to review the methodology by which pharmacies dispense bevacizumab despite no adverse effects have been reported due to the problem of inadvertent silicone oil injection in eye. since it has been reported that repeated pumping of plunger can lead to release of silicone oil from hub and syringe lining, it is suggested that the drug should be withdrawn from the vial in the syringe with minimal manipulation of plunger. we also recommend to perform bevacizumab stability test after being packaged in the syringe to ensure its efficacy and to avoid any potential degradation. syringes have been in use which incorporate silicone oil free surfactant as lubricant but they are slightly more expensive6. the use of such syringes can also be suggested to avoid this potential problem. in my impression, the incidence of this finding is more than what we have observed in our recent experience. possible reasons may include ignorance towards this potential problem, busy outdoor patient department schedules, tiny size and innocuous nature of the droplet and the likelihood of this droplet to rise up and become un-noticeable to the examining ophthalmologist. conclusion in context of this interesting observation, we recommend following changes in the process of dispensing and injecting bevacizumab: • education of pharmacists to prepare intravitreal bevacizumab with minimal manipulation of plunger. • use of silicon oil polymer free syringes (can be discussed with skmch). • revision of consent forms for patients where this problem is well explained to the patients. author’s affiliation dr. haroon tayyab assistant prof. of vitreoretina coavs – kemu (mayo hospital lahore) prof. dr. asad aslam khan professor & head department of ophthalmology kemu (mayo hospital lahore) dr. muhammad ali a sadiq assistant prof. of ophthalmology kemu (mayo hospital lahore) dr. sana jahangir assistant prof. of ophthalmology sharif medical & dental college – lahore dr. suhail sarwar associate prof. of diagnostic opthalmology coavs– kemu (mayo hospital lahore) haroon tayyab, et al 148 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology role of authors dr. haroon tayyab principle investigator, article write-up. prof. dr. asad aslam khan literature search dr. muhammad ali a sadiq literature search, discussion. dr. sana jahangir photography, data maintenance. dr. suhail sarwar b-scan, photography. references 1. miller k, fortun ja. diabetic macular edema: current understanding, pharmacologic treatment options, and developing therapies. asia pac j ophthalmol (phila). 2018 jan-feb; 7 (1): 28-35. 2. brogan k, precup m, rodger a, young d, gilmour df. pre-treatment clinical features in central retinal vein occlusion that predict visual outcome following intravitreal ranibizumab. bmc ophthalmol. 2018 feb. 9; 18 (1): 37. 3. miere a, oubraham h, amoroso f, butori p, astroz p, semoun o, et al. optical coherence tomography angiography to distinguish changes of choroidal neovascularization after anti-vegf therapy: monthly loading dose versus pro re nata regimen. j ophthalmol. 2018 feb. 4; 2018: 3751702. 4. gupta a, sun jk, silva ps. complications of intravitreous injections in patients with diabetes. semin ophthalmol. 2018; 33 (1): 42-50. 5. freund kb, laud k, eandi cm, spaide rf. silicone oil droplets following intravitreal injection. retina. 2006 jul-aug; 26 (6): 701-703. 6. jea h. yu, esmeralda gallemore, jisoo k. kim, rocky patel, jorge calderon, ron p. gallemore. silicone oil droplets following intravitreal bevacizumab injections. american journal of ophthalmology case reports, 2018; 10: 142-144. 7. bakri sj, ekdawi ns. intravitreal silicone oil droplets after intravitreal drug injections. retina. 2008 jul-aug; 28 (7): 996-1001. 8. corporation dc. corning 365, 35% dimethicone nf emulsion. midland, michigan: medical products division; 2002. 9. kocabora ms, ozbilen kt, serefoglu k. intravitreal silicone oil droplets following pegaptanib injection. acta ophthalmol. 2010 mar; 88 (2): e44-45. 10. travis wd, balogh k, abraham jl. silicone granulomas: report of three cases and review of the literature. hum pathol. 1985 jan; 16 (1): 19-27. https://www.ncbi.nlm.nih.gov/pubmed/?term=miller%20k%5bauthor%5d&cauthor=true&cauthor_uid=29473719 https://www.ncbi.nlm.nih.gov/pubmed/?term=fortun%20ja%5bauthor%5d&cauthor=true&cauthor_uid=29473719 https://www.ncbi.nlm.nih.gov/pubmed/?term=brogan%20k%5bauthor%5d&cauthor=true&cauthor_uid=29426292 https://www.ncbi.nlm.nih.gov/pubmed/?term=precup%20m%5bauthor%5d&cauthor=true&cauthor_uid=29426292 https://www.ncbi.nlm.nih.gov/pubmed/?term=rodger%20a%5bauthor%5d&cauthor=true&cauthor_uid=29426292 https://www.ncbi.nlm.nih.gov/pubmed/?term=young%20d%5bauthor%5d&cauthor=true&cauthor_uid=29426292 https://www.ncbi.nlm.nih.gov/pubmed/?term=gilmour%20df%5bauthor%5d&cauthor=true&cauthor_uid=29426292 https://www.ncbi.nlm.nih.gov/pubmed/?term=gilmour%20df%5bauthor%5d&cauthor=true&cauthor_uid=29426292 https://www.ncbi.nlm.nih.gov/pubmed/?term=miere%20a%5bauthor%5d&cauthor=true&cauthor_uid=29507810 https://www.ncbi.nlm.nih.gov/pubmed/?term=oubraham%20h%5bauthor%5d&cauthor=true&cauthor_uid=29507810 https://www.ncbi.nlm.nih.gov/pubmed/?term=amoroso%20f%5bauthor%5d&cauthor=true&cauthor_uid=29507810 https://www.ncbi.nlm.nih.gov/pubmed/?term=butori%20p%5bauthor%5d&cauthor=true&cauthor_uid=29507810 https://www.ncbi.nlm.nih.gov/pubmed/?term=astroz%20p%5bauthor%5d&cauthor=true&cauthor_uid=29507810 https://www.ncbi.nlm.nih.gov/pubmed/?term=semoun%20o%5bauthor%5d&cauthor=true&cauthor_uid=29507810 https://www.ncbi.nlm.nih.gov/pubmed/?term=gupta%20a%5bauthor%5d&cauthor=true&cauthor_uid=29420143 https://www.ncbi.nlm.nih.gov/pubmed/?term=sun%20jk%5bauthor%5d&cauthor=true&cauthor_uid=29420143 https://www.ncbi.nlm.nih.gov/pubmed/?term=silva%20ps%5bauthor%5d&cauthor=true&cauthor_uid=29420143 https://www.ncbi.nlm.nih.gov/pubmed/?term=freund%20kb%5bauthor%5d&cauthor=true&cauthor_uid=16829818 https://www.ncbi.nlm.nih.gov/pubmed/?term=laud%20k%5bauthor%5d&cauthor=true&cauthor_uid=16829818 https://www.ncbi.nlm.nih.gov/pubmed/?term=eandi%20cm%5bauthor%5d&cauthor=true&cauthor_uid=16829818 https://www.ncbi.nlm.nih.gov/pubmed/?term=spaide%20rf%5bauthor%5d&cauthor=true&cauthor_uid=16829818 https://www.ncbi.nlm.nih.gov/pubmed/?term=bakri%20sj%5bauthor%5d&cauthor=true&cauthor_uid=18698303 https://www.ncbi.nlm.nih.gov/pubmed/?term=ekdawi%20ns%5bauthor%5d&cauthor=true&cauthor_uid=18698303 https://www.ncbi.nlm.nih.gov/pubmed/?term=kocabora%20ms%5bauthor%5d&cauthor=true&cauthor_uid=18976315 https://www.ncbi.nlm.nih.gov/pubmed/?term=ozbilen%20kt%5bauthor%5d&cauthor=true&cauthor_uid=18976315 https://www.ncbi.nlm.nih.gov/pubmed/?term=serefoglu%20k%5bauthor%5d&cauthor=true&cauthor_uid=18976315 https://www.ncbi.nlm.nih.gov/pubmed/?term=travis%20wd%5bauthor%5d&cauthor=true&cauthor_uid=3882545 https://www.ncbi.nlm.nih.gov/pubmed/?term=balogh%20k%5bauthor%5d&cauthor=true&cauthor_uid=3882545 https://www.ncbi.nlm.nih.gov/pubmed/?term=abraham%20jl%5bauthor%5d&cauthor=true&cauthor_uid=3882545 57 pakistan journal of ophthalmology, 2020, vol. 36 (1): 57-61 original article visual and anatomical outcomes of pars plana vitrectomy in refractory diabetic macular edema hussain ahmad khaqan 1 , usman imtiaz 2 , hasnain muhammad buksh 3 hafiz ateeq-ur-rehman 4 , raheela naz 5 , usman shabbir 6 1-6 ameer-ud-din medical college, pgmi, lahore general hospital, lahore – pakistan abstract purpose: to find the visual and anatomical outcomes of pars plana vitrectomy in cases of refractory diabetic macular edema. study design: quasi experimental study. place and duration of study: department of ophthalmology, lahore general hospital from january 2013 to april 2019. material and methods: seventy-six patients between the age of 18 and 60 years of both genders having refractory diabetic macular edema with macular thickness of 400 micrometers or more on oct were enrolled. informed consent was taken. detailed preoperative workup including visual assessment, examination on slit lamp using 90d or 78d lens for assessment of macular edema and oct was done. patients underwent pars plana vitrectomy, erm, and ilm peeling. visual assessment and macular thickness was recorded 4 weeks after surgery. results: this study included 76 patients with the mean age of 48.15 ± 8.16 years. patients were further categorized according to age into 2 groups. the gender distribution of patients showed that most of the participants were female in this study. mean duration of diabetes mellitus was 9.95 ± 6.29 years. most of the patients did not have previous history of laser and only three patients (3.9%) did not receive intravitreal antivegf. mean preoperative visual acuity was 0.44 ± 0.13 while postoperative visual acuity was 0.876 ± 0.18 (p = 0.000). similarly, significant decrease in macular thickness was observed after the procedure (p = 0.000). conclusion: pars plana vitrectomy, erm and ilm peeling can be an effective treatment option for refractory diabetic macular edema. key words: diabetes mellitus, retinopathy, macular thickness, visual acuity, vitrectomy. how to cite this article: khaqan ha, imtiaz u, buksh hm, rehman ha, naz r, shabbir u. visual and anatomical outcomes of pars plana vitrectomy in refractory diabetic macular edema, pak j ophthalmol. 2020; 36 (1): 57-61. doi: https://doi.org/10.36351/pjo.v36i1.995. introduction in working age group, diabetic macular edema is one of the leading causes of visual impairment occurring in correspondence to: hussain ahmad khaqan associate professor, ameer-ud-din medical college pgmi, lahore general hospital, lahore – pakistan email: drkhaqan@hotmail.com almost 12% of patients diagnosed with diabetic retinopathy (drp) and due to which every year more than 10,000 cases of blindness are reported. dme is the result of one of the major complications of drp 1,2 . the rate of prevalence of dme is directly affected by the type and duration of diabetes. following the diagnosis of type 1 diabetes in patients, dme can https://doi.org/10.36351/pjo.v36i1.995 mailto:drkhaqan@hotmail.com visual and anatomical outcomes of pars plana vitrectomy in refractory diabetic macular edema pakistan journal of ophthalmology, 2020, vol. 36 (1): 57-61 58 develop in the first five years. within 30 years, the frequency of dme reaches up to 40% 3 . at the time of diagnosis, dme is present in about five percent of patients with type ii diabetes. systemic risk factors include duration of diabetes, gender, cardiovascular disease, proteinuria, abnormal levels of hba1c, and use of diuretics. dme can occur at any stage of drp 2-4 . ocular treatments include administration of anti vegf (vascular endothelial growth factor) 5 , triamcinolone acetonide 6 and vitreoretinal surgery 7 . according to clinical trials, macular edema is reduced by doing pars plana vitrectomy (ppv) in selected cases of diabetic macular edema. proinflammatory substances and traction forces are eradicated by ppv and also increase inner retinal layers oxygenation along with reduction in thickness of macula and gain in visual acuity 8 . in dme cases, the presence of vitreous hemorrhage, hard exudates, and vmt (vitreomacular traction) may be considered as indications for ppv 7 . in a study, mean visual acuity was 0.84 ± 0.32 pre-operatively and 0.72 ± 0.26 postoperatively while macular thickness was 559 ± 89 µm preoperatively and 354 ± 76 µm postoperatively following pars plana vitrectomy 9 . already published literature showed variable results. the purpose of the study is to evaluate the effect of the pars plana vitrectomy in the diabetic patients presenting with macular edema in our population. material and methods the study was conducted at the department of ophthalmology, lahore general hospital, lahore after institutional ethical committee approval. a total of 76 patients were included in this study between january 2013 to april 2019. patients were selected by nonprobability convenience sampling. inclusion criteria comprised of patients having refractory diabetic macular edema with macular thickness of 400 micrometers or more on oct in diabetics, diagnosed at least 1 year back with previous history of laser or intravitreal anti-vegf injections. patients having diabetic macular edema associated with tractional retinal detachment, hba1c > 8, patients with serum creatinine level of > 1.5 mmol were excluded. informed consent was taken from all patients. personal profile of the patients including name, age, sex, patient registration number and address was noted. detailed preoperative work-up including bcva (best-corrected visual acuity), examination on slit lamp using 90d and 78d lens for assessment of macular edema and tractional retinal detachment was done. oct was done to confirm and quantify macular edema before undergoing pars plana vitrectomy. post-operative visual acuity and macular thickness was recorded 4 weeks after surgery. all data was recorded on a pre-designed proforma and was analyzed using spss version 21. age, preoperative bcva and post-operative bcva of patients, pre-operative, post-operative macular thickness was presented by calculating mean and standard deviation. categorical variables like gender, previous laser and previous intra-vitreal anti vegf was presented using frequency and percentages. data was stratified for age, gender, previous laser, previous intra-vitreal anti vegf and duration of dm to control effect modifier. post-stratification t-test was used taking p-value < 0.05 as significant. results mean age of the patients was 48.15 ± 8.16 years. most of the participants were female in this study. mean duration of diabetes mellitus was 9.95 ± 6.29 years and is given in table 1. most of the patients did not have previous history of laser; however, only three patients (3.9%) had not received intravitreal antivegf. table 1: distribution according to duration of diabetes mellitus (n = 237). duration of dm no. of patients % < 5 years 32 42.1% ≥5.1 years 44 57.9% total 76 100 mean ± sd 9.95 ± 6.29 years mean preoperative visual acuity was 0.44 ± 0.13 while postoperative visual acuity was 0.876 ± 0.18. similarly, significant decrease in macular thickness was observed after the procedure. comparison of preoperative and post-operative outcomes as shown in table 2. stratification of outcome variables (postoperative visual acuity and post-operative macular thickness) was done for age, gender, duration of diabetes mellitus, history of previous intravitreal anti-vegf and previous history of laser. all details are summarized in tables 3 and table 4. khaqan ha, et al 59 pakistan journal of ophthalmology, 2020, vol. 36 (1): 57-61 table 2: comparison of pre-operative and post-operative findings (n = 76). preoperative visual acuity postoperative visual acuity p-value 0.44 ± 0.13 0.876 ± 0.181 0.000 preoperative macular thickness postoperative macular thickness p-value 554.66 ± 37.01 371.63 ± 32.12 0.000 table 3: stratification of postoperative visual acuity with respect to age, gender, duration of diabetes mellitus, history of previous intravitreal antivegf and previous history of laser. variables post-operative visual acuity pvalue age groups 18-40 years 0.892 ± 0.173 0.534 41-60 years 0.871 ± 0.183 gender male 0.875 ± 0.177 0.991 female 0.876 ± 0.184 duration of diabetes mellitus < 5 years 0.877 ± 0.177 0.924 ≥ 5.1 years 0.875 ± 0.184 history of previous intravitreal antivegf yes 0.876 ± 0.177 0.812 no 0.860 ± 0.282 previous history of laser yes 0.873 ± 0.184 0.920 no 0.876 ± 0.181 table 4: stratification of postoperative macular thickness with respect to age, gender, duration of diabetes mellitus, history of previous intravitreal antivegf and previous history of laser. variables post-operative macular thickness pvalue age groups 18-40 years 373.44 ± 31.72 0.665 41-60 years 371.168 ± 32.31 gender male 372.61 ± 30.98 0.274 female 371.01 ± 32.94 duration of diabetes mellitus < 5 years 372.05 ± 31.38 0.445 ≥ 5.1 years 371.38 ± 32.68 history of previous intravitreal antivegf yes 372.13 ± 31.82 0.262 no 358.85 ± 39.61 previous history of laser yes 381.85 ± 26.97 0.050 no 370.80 ± 32.43 discussion in developed countries, edema secondary to diabetes is primary reason behind visual deficit. with satisfactory results, a lot of therapeutic approaches including grid macular photocoagulation and anti-vegf (vascular endothelial growth factor) have been experimented for treating refractory dme. pars plana vitrectomy is controversial and has shown moderate outcomes 10 . this technique depends on the idea that vitreous adhesions could unfavorably have an effect on dme; thus, removing vitreomacular traction would be helpful. increasing the supply of oxygen to the retina and henceforth improving retinal ischemia. the viscosity of vitreous is 300–2,000 times greater than aqueous viscosity, the diffusion constant of molecules in the vitreous ought to multiply by an analogous magnitude after vitrectomy 11 . pars plana vitrectomy (ppv) was introduced back in 1971, and it has been employed largely to treat ocular diseases involving the posterior segment and it has been increasingly evolving with smaller and quicker vitrectomy systems. over the last 10 years, micro-incision suture-less vitrectomy (misv) instruments i.e. 20-gauge (20g) have provided varied benefits and dramatically simplified vitrectomy procedures, together with diminished postoperative pain, shorter operative time, self-sealing scleral wound and inflammation, reduced astigmatism and quicker visual recovery 12 . out of the many causes of diabetic macular edema (dme), one is vascular leakage. this is due to compromised blood retinal barrier and number of proinflammatory factors like cytokines, lipoprotein deposition around the fovea and the osmotic gradient. this makes retinal pigment epithelial cells deficient in clearing fluid from the retina and consequently aggravates macular edema. this resists fluid evacuation by the retinal pigment epithelium and consequently increases macular edema. after vitrectomy, the visual improvement in eyes with resolved dme is completely in correlation with the postoperative photoreceptor status of the fovea. since permanent photoreceptor dysfunction is caused by chronic dme, long standing dme causes irreversible photoreceptor disfunction and disrupts external limiting membrane 13,14 . in patients with diabetes, vision loss is mainly caused by dme and may be refractory to traditional treatment. vitrectomy is suggested in patients with vmt. in refractory dme cases, the part of vitrectomy without taking into consideration the tractional component is more disputable. though studies have indicated that peeling of ilm could facilitate getting better results, others studies have depicted similar results by vitrectomy 15 . in a study, mean macular thickness decreased from visual and anatomical outcomes of pars plana vitrectomy in refractory diabetic macular edema pakistan journal of ophthalmology, 2020, vol. 36 (1): 57-61 60 baseline 558.27 ± 86.68μm to final 355.97 ± 77.45μm. same consequences for vitrectomy were reported in patients with refractory diabetic macular edema and no vitreomacular interface abnormality. intravitreal triamcinolone and macular laser photocoagulation together with vitrectomy in diabetic macular edema patients with no erm was performed by kim et al 16 and reported a major decline in macular thickness from 433.7 ± 78.2 μm before surgery to 310.6 ± 80.6 μm six months after procedure. they conjointly noted improvement in thickness three months after surgery. two teams were formulated, one with cases of diabetic macular edema refractory to standard treatment (macular laser photocoagulation) and the other with diabetic macular edema unresponsive to intravitreal antivascular endothelial growth factor (vegf) treatment, and deduced that former showed considerably greater decline in macular thickness than latter. the effectiveness of combined vitrectomy, intravitreal triamcinolone on macular thickness and best corrected visual acuity (bcva) of forty eyes with refractory diabetic macular edema with a long-run follow-up of three years was evaluated in another study by kim et al 17 . throughout the three years postoperatively (decline from 498.1 ± 174.8 μm to 219.4 ± 66.6μm) a major trend towards continued decrease in macular thickness was reported. once vitrectomy has been performed, similar outcomes concerning changes in macular thickness have been found by similar studies. all this information support that in cases of intractable diabetic macular edema, reduction in macular thickness is effectively caused by vitrectomy. the impact of vitrectomy on best corrected visual acuity by many reports is heterogenous. we compared our results with other studies showing vitrectomy in refractory diabetic macular edema without vitreomacular interface abnormality. in the last followup, insignificant visual acuity improvement was shown by our findings which corresponds to the already reported results in which improvement from 1.00 ± 0.81 log mar to 0.83 ± 0.18 log mar was seen. kim et al 17 reported a major improvement in best corrected visual acuity (from 0.46 ± 0.17 log mar to 0.37 ± 0.25 log mar at six months). a mild reduction in best corrected visual acuity was found after 2.5 or 3 months by them and they attributed it to cataract formation. baseline mean best corrected visual acuity in other studies was significantly higher as compared to ours 18,19 . at least partially, these variations could justify completely different results. however, other studies report significant improvement of bcva 20 with baseline mean best corrected visual acuities worse than the study mentioned by kim et al and by a study 17 with a number of patients similar to our study. moreover, rosenblatt et al have found worse baseline visual acuity as the only clinical variable that is associated with improvement in postoperative visual acuity 18 . the limitation of the study was the small sample size. moreover, it was also conducted at one center. more studies are required to obtain more generalizable results. conclusion pars plana vitrectomy, erm and ilm peeling can be effective treatment options for refractory diabetic macular edema and for improvement of visual acuity. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest authors’ designation and contribution hussain ahmad khaqan; associate professor: study design, manuscript writing, literature review and final review. usman imtiaz; vitreo-retina fellow: study design, manuscript writing, literature review and final review. hasnain muhammad buksh; vitreo-retina fellow: study design, manuscript writing, literature review and final review. hafiz ateeq-ur-rehman; postgraduate resident: study design, manuscript writing, literature review and final review. raheela naz; postgraduate resident: study design, manuscript writing, literature review and final review. usman shabbir; postgraduate resident: study design, manuscript writing, literature review and final review. references 1. mehboob q, hussain z, arif m. diagnosis of diabetic macular edema (dme) based on fundus fluorescein khaqan ha, et al 61 pakistan journal of ophthalmology, 2020, vol. 36 (1): 57-61 angiography (ffa) findings. j uni med dent coll. 2015; 6 (1): 28-32. 2. urias ea, urias ga, monickaraj f, mcguire p, das a. novel therapeutic targets in diabetic macular edema: beyond vegf. vision research. 2017; 139: 221-7. 3. zhang x, zeng h, bao s, wang n, gillies mc. diabetic macular edema: new concepts in pathophysiology and treatment. cell & bioscience, 2014; 4: 27. 4. ung c, borkar ds, young lh. current and emerging treatment for diabetic macular edema. int ophthalmol clin. 2017; 57 (4): 165-77. 5. heier js, bressler nm, avery rl, bakri sj, boyer ds, brown dm, et al. comparison of aflibercept, bevacizumab, and ranibizumab for treatment of diabetic macular edema: extrapolation of data to clinical practice. jama ophthalmology, 2016; 134 (1): 95-9. 6. liu q, hu y, yu h, yuan l, hu j, atik a, et al. comparison of intravitreal triamcinolone acetonide versus intravitreal bevacizumab as the primary treatment of clinically significant macular edema. retina (philadelphia, pa). 2015; 35 (2): 272-9. 7. navarrete-sanchis j, zarco-bosquets j, tomastorrent jm, diago t, ortega-evangelio l. longterm effectiveness of vitrectomy in diabetic cystoid macular edema. graefe's archive for clinical and experimental ophthalmology. albrecht von graefesarchiv fur klinische und experimentelle ophthalmologie. 2015; 253 (5): 713-9. 8. moisseiev e, loewenstein a. diabetic macular edema: emerging strategies and treatment algorithms. dev ophthalmol. 2017; 60: 165-74. 9. ghassemi f, bazvand f, roohipoor r, yaseri m, hassanpoor n, zarei m. outcomes of vitrectomy, membranectomy and internal limiting membrane peeling in patients with refractory diabetic macular edema and non-tractional epiretinal membrane. j curr ophthalmol. 2016; 28 (4): 199-205. 10. elkareem am, rashed ma. outcomes of pars plana vitrectomy for the treatment of persistent diffuse diabetic macular edema. al-azhar assiut medical journal, 2018 oct 1; 16 (4): 414. 11. chatziralli i, dimitriou e, theodossiadis g, chatzirallis a, kazantzis d, theodossiadis p. treatment of macular edema after pars plana vitrectomy for idiopathic epiretinal membrane using intravitreal dexamethasone implant: long-term outcomes. ophthalmologica. 2019; 242 (1): 16-21. 12. flikier s, wu a, wu l. revisiting pars plana vitrectomy in the primary treatment of diabetic macular edema in the era of pharmacological treatment. taiwan j ophthalmol. 2019; 9 (4): 224-32. 13. dimopoulos s, deuter cm, blumenstock g, zierhut m, dimopoulou a, voykov b, et al. interferon alpha for refractory pseudophakic cystoid macular edema (irvine-gass syndrome). oculimmuno linflam. 2019; 3: 1-7. 14. el-baha sm, abdel hadi am, abouhussein ma. submacular injection of ranibizumab as a new surgical treatment for refractory diabetic macular edema. j ophthalmol. 2019; 2019. 15. koronis s, stavrakas p, balidis m, kozeis n, tranos pg. update in treatment of uveitic macular edema. drug desdevelther. 2019; 13: 667. 16. kim yt, kang sw, kim sj, kim sm, chung se. combination of vitrectomy, ivta, and laser photocoagulation for diabetic macular edema unresponsive to prior treatments; 3-year results. graefe's archive for clinical and experimental ophthalmology = albrecht von graefes archiv fur klinische und experimentelle ophthalmologie. 2012; 250 (5): 679-84. 17. kim jh, kang sw, ha hs, kim jr. vitrectomycombined with intravitreal triamcinolone acetonide injection and macular laser photocoagulation for nontractional diabetic macular edema. korean j ophthalmol. 2013; 27 (3): 186-93. 18. rosenblatt bj, shah gk, sharma s, bakal j. pars plana vitrectomy with internal limiting membranectomy for refractory diabetic macular edema without a taut posterior hyaloid. graefe's archive for clinical and experimental ophthalmology. albrecht von graefes archiv fur klinische und experimentelle ophthalmologie. 2005; 243 (1): 20-5. 19. recchia fm, ruby aj, carvalho recchia ca. pars plana vitrectomy with removal of the internal limiting membrane in the treatment of persistent diabetic macular edema. am j ophthalmol. 2005; 139 (3): 44754. 20. dehghan mh, salehipour m, naghib j, babaeian m, karimi s, yaseri m. pars plana vitrectomy with internal limiting membrane peeling for refractory diffuse diabetic macular edema. j ophthalmic vis res. 2010; 5 (3): 162-7. .…  …. microsoft word naila ali.doc 117 original article the relative frequency and risk factors of primary open angle glaucoma and angle closure glaucoma naila ali, syed ali wajid, nasir saeed, muhammad daud khan pak j ophthalmol 2007, vol. 23 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: naila ali department of ophthalmology khyber institute of ophthalmic medical sciences hayatabad medical complex, peshawar received for publication august’ 2006 …..……………………….. purpose: to determine the frequency and compare the potential risk factors for primary open angle glaucoma and primary angle closure glaucoma in admitted patients. materials and methods:a detailed history was taken. patient’s height and mentovertex (mvht) height was measured in centimeters. complete ocular examination was carried out, including recording visual acuity, anterior segment examination, posterior segment examination, intraocular pressure measurement, peripheral and central anterior chamber depth, corneal diameter and axial length measurement. gonioscopy was performed. visual field was recorded by automated visual field analyzer. results: one hundred patients were examined, 60 were males and 40 were females. 58 patients had primary open angle glaucoma (poag), 42 had primary angle closure glaucoma (pacg). ten patients had systemic associations of hypertension and/ or diabetes mellitus. mean intraocular pressure was 25.54 mm hg with no significant difference in gender distribution and with type of glaucoma. no significant difference was found in the height of patient with either type of glaucoma. in poag the average mentovertex height was 23.52 cm and in pacg it was 20.98cm. mean axial length of globe in poag was 23.2mm and in pacg it was 21.3mm. mean corneal diameter in poag was 11.29mm and in pacg 11.13 mm. anterior chamber depth was calculated to be less than 1/4th of corneal thickness in 29%, 1/4-1/2 in 19% and more than1/2 in 52% cases of pacg. it was found significantly shallower in pacg cases than in poag. conclusions: we concluded from this study that primary open angle glaucoma is more common and males are more prone to glaucomatous optic neuropathy. no correlation exists between patient’s height and the type of glaucoma but strong positive correlation is there between the short mentovertex height and angle closure glaucoma. shorter axial length, smaller corneal diameter and shallower anterior chamber were found to be significant risk factors for angle closure glaucoma. 118 ho program of prevention of blindness, has given estimates of glaucoma blindness for year 2000 as 8 million i.e. 16% of the total blindness1. so far, there have been twenty published population based surveys about prevalence of glaucoma. globally, there are 13.5 million cases of poag out of which 3 million are blind while out of total 6 million pacg cases 2 millions are blind2. early diagnosis and management is the key to address the disease and has many avenues to work upon. glaucoma is a multifactor optic neuropathy for which the most blamed risk factor is raised intraocular pressure. however, optic nerve damage of more or less same extent has been seen with much lower pressures or there are normal eyes with much higher pressures. this gives us the clue that there has to be some other risk factor/s that predisposes the optic nerve to glaucomatous damage. these factors are systemic as well as local, physiological as well as anatomical. keeping in view of these multiple factors that are still unclear, a cross-sectional comparative study was conducted to find out the relative anatomical risk factors for primary open angle and angle closure glaucoma in 100 consecutive patients admitted to the department of ophthalmology, khyber institute of ophthalmic medical sciences, hayatabad medical complex, peshawar. material and methods to find out the relative frequency and risk factors of primary open angle and angle closure glaucoma, a detailed performa was prepared to record the personal details and chief complaints of the patients. hundred consecutive patients of primary glaucoma admitted to the khyber institute of ophthalmic medical sciences hayatabad medical complex were included in the study. the inclusion criteria were any primary glaucoma case aging more than forty years with iop more than or equal to 21 mm, cup disc ratio (cd) of more than or equal to 0.5 and any degree of visual field defect. the exclusion criteria were all cases below age 40, normal tension glaucoma ocular hypertension and secondary glaucoma’s were excluded. after informed consent, detailed history was taken including the history of present illness, past history, systemic history with special emphasis given to diabetes mellitus and hypertension, family history and relevant drug history with special reference to anti glaucoma medication and steroids. patient’s height and mento-vertex height was measured in centimeters. for mento-vertex calculation, patient was seated on slit lamp and distance from his/her chin to vertex was measured with a measuring tape. a thorough ocular examination was performed with special emphasis placed upon the objectives of the study, including uncorrected and best-corrected visual acuity using log mar charts. anterior segment was examined with slit-lamp (topcon slit lamp sl-3c japan). peripheral anterior chamber depth was measured by van herrick method4 and graded as 1=less than one fourth of corneal thickness, 2= one fourth to half of corneal thickness and 3= more than half of corneal thickness, corneal diameter was measured with vernier caliper, axial length was measured by a-scan (storz compuscan lt, ult1000 usa), and posterior segment examination was conducted with direct (hiene beta 2000 japan) and indirect ophthalmoscopes and biomicroscopy with 78 d lens was performed if required. intraocular pressure was measured with the goldmann tonometer (haagstreit) detailed gonioscopy was performed on every patient to acertain the angle width and its configuration with gonioscope (single mirror goniodiagnostic lens, ocular instruments inc usa) and angle was graded according to scheie’s classification5. visual field was recorded on automated visual field analyzer (kowa automatic visual field plotterao-125, japan). data was entered using spss 8 software. the files were them merged and validated for any data entry errors. frequency of all the variables was checked and any missing values or outliers were confirmed from the questionnaires. frequency was calculated as percentages and proportions. comparisons were made through analysis of variance (anova) and p-values were calculated using students t test. results description of sample subjects the sample included 40% females and 60% males. the mean age and standard deviation of the sample was 65 years (sd 1.94). mean height of the sample subjects was 176cm (sd 1.42) mean mentovertex height (mvht) of the sample subjects was 22.46cm (sd 1.94) mean axial length was 22.45mm (sd 1.43) mean corneal diameter was 11.23mm (sd 1.43) w 119 58 % of the sample subject had poag and 42% had pacg (fig. 1). no statistically significant difference was found between the male to female ratio in the two types of glaucoma (fig. 2). patients with poag had significantly longer mvht (23.52cm) than those with poag (20.98cm) (pvalue 0.00) (fig. 3). there was no effect of age or gender on this relationship. (p-values 0.45 and 0.35). 58 42 poag pacg fig. 1: type of glaucoma. 0 5 10 15 20 25 30 35 40 poag pacg males females fig. 2: gender distribution in poag and pacg. 22.46 23.52 20.98 19 20 21 22 23 24 mean poag pacg fig. 3: mentovertex height. 22.45 23.28 21.3 20 20.5 21 21.5 22 22.5 23 23.5 mean poag pacg fig. 4: axial length of eyeball. 11.23 11.29 11.13 11.05 11.1 11.15 11.2 11.25 11.3 mean poag pacg fig. 5: corneal diameter. 0 0 58 22 8 12 0 10 20 30 40 50 60 poag pacg <1/4 corneal thickness 1/4-1/2 corneal thickness >1/2 corneal thickness fig. 6: distribution of anterior depth. mean axial length was found significantly longer i.e.23.20mm (p-value 0.00) in poag cases than pacg (21.30mm) as shown in (fig. 4). corneal diameter was found significantly smaller i.e.11.13mm (p-value 0.00) in pacg than poag (11.29mm) as can be seen in (fig. 5). anterior chamber depth was found significantly shallower (p-value 0.00) in pacg cases than in poag. anterior chamber depth was calculated to be less than 1/4th of corneal thickness in 29% (12), 1/4-1/2 in 19% (8) and more than 1/2 in 52% (22) cases of pacg. 120 none of the poag patients (58) had acd less than 1/2 corneal thickness (fig. 6). discussion hundred consecutive admitted patients of primary adult glaucoma were included in the study at the khyber institute of ophthalmic medical sciences, hayatabad medical complex, peshawar with the aim to document the relative frequency of primary open angle and angle closure glaucoma and their correlation with anatomical risk factors like individual’s height, mentovertex height (mvht), axial length of eyeball, corneal diameters and anterior chamber depth. all patients were above 40 years of age, 27% were in 4150years age group, 62% in 51-60years age group and 11% were above 60 years. this compares well with the results of the study from hyderabad, where out of total glaucoma admissions, only 10.81% were under 40 years of age while the rest were above 40 years, out of these 44% were 41-50 years old, 32% were 51-60 years, 8% were 61-70 years and 4% were more than 70 years of age6. fifty eight percent cases in our study suffered from poag and 42% cases from pacg. another hospital based study done in the same setting by wajid sa, and khan md three years ago has also given preponderance of primary open angle glaucoma3. sixty patients (60%) were males and forty females (40%). this is supported by barbados and rotterdam study where males are reported to be 1.5 and 3 times, respectively, more at risk for glaucoma. the baltimore7, beaverdam, rosscommon and blue mountain8 studies do not give any gender specificity. however, another hospital based study reports females glaucomatous patients as 58% and males as 42% of the total primary glaucoma admissions3. we recorded height in every patient with the view of considering that shorter height may be a predisposing risk factor for primary angle closure glaucoma and may be correlated with shorter eyeball, steeper cornea and shallow anterior chamber. average height in our study was 176cm. females were on average shorter than males. however no statistically significant difference was noted with the type of glaucoma. thorough literature search has not shown any such relationship between the height and the type of glaucoma. we measured mentovertex height in every case with the view of its possible association as anatomical risk factors for the two types of glaucoma. the hypothesis was that poag have longer mentovertex height (mvht) than pacg. mean mvht was 22.46cm with no significant gender difference. in poag the mentovertex height was significantly longer (23.52cm) than in pacg cases (20.98). no reference supporting this relationship could be extracted from literature. mentovertex height was also found to have a linear correlation with the anterior chamber depth and axial length of the eyeball. anatomical characteristics of eyes with primary glaucoma’s are reported at several places in literature, all favoring shorter axial lengths, steeper corneas and shallow anterior chambers in angle closure glaucoma patients. mean corneal diameter was calculated as 11.23mm in all primary glaucoma cases. on average it was 11.29mm in poag and 11.13mm in pacg. the difference was statistically significant, matching with study by tomlinson et al., who gave normal values of 11.05mm and for acg patients it was 10.72mm9. anterior chamber depth has always been related with the angle grading. measurement of the peripheral anterior chamber depth is a very reliable and noninvasive method of finding out the status of the angle. central anterior chamber depth is about 2.5-3mm in normal individuals but in patients with acg it is shallower. anterior chamber depth is negatively correlated with lens thickness and positively correlated with axial length i.e. the thicker the lens shallower will be the anterior chamber and the longer the eyeball deeper will be the anterior chamber. we studied the peripheral anterior chamber depth by von herrick method and found that anterior chamber depth was less than one fourth of corneal thickness in 29%(12), one fourth to half of the corneal thickness in 19%(8) and more than half in 52%(22) cases of pacg. in all poag cases (58) the peripheral anterior chamber depth was more than half of the corneal thickness. eyes with pacg are studied for axial lengths and collectively shorter axial lengths are more common in pacg. we found an average axial length of 22.45mm. eyes with pacg had a mean axial length 21.30mm while those with poag had 23.28mm, showing statistically significant difference. two studies report similar values of 23.10mm and 23.58mm for normal 121 and 22.01mm and 22.06mm for patients with angle closure glaucoma10 respectively. conclusions from this hospital-based study, we conclude that primary open angle glaucoma is more common patients and males are more prone to glaucomatous optic neuropathy than primary angle closure glaucoma. no correlation exists between patient’s height and the type of glaucoma, but strong positive correlation is there between the short mentovertex height and primary angle closure glaucoma. patients with primary angle closure glaucoma have shorter axial length, smaller corneal diameter and shallower anterior chamber as compared to primary open angle glaucoma patients. acknowledgements i am highly indebted to professor mohammad daud khan for his continuous guidance at every step. i am very grateful to dr. aliya qadir khan and mr. ibrahim for providing me help in references collection. my regards are due for mr. ali and mr. ikram for their help in providing the images required for the completion of this manuscript. i am very thankful to my friend dr. nazli for all her support at every stage of my writing efforts. i owe profound thanks to dr. zahid jadoon for his help in statistical analysis of the study. author’s affiliation dr naila ali department of ophthalmology khyber institute of ophthalmic medical sciences hayatabad medical complex peshawar dr syed ali wajid senior registrar department of ophthalmology khyber institute of ophthalmic medical sciences hayatabad medical complex peshawar dr nasir saeed associate professor department of ophthalmology khyber teaching hospital peshawar professor mohammad daud khan department of ophthalmology khyber institute of ophthalmic medical sciences hayatabad medical complex peshawar reference 1. foster a. blindness prevention, statistics and principles of control. manual for planning in eye care module. london school of hygiene and tropical medicine. 2001. 2. johnson gj, minassian dc, weale r. the epidemiology of eye diseases. the glaucomas. chapman and hall. 1998 3. wajid sa, khan md. prevalence and causes of blindness. j coll physicians surg pakistan. 2001; 11:51-4. 4. basic and clinical science course. american academy of ophthamology. section 10. san francisco. 2001-2: 28. 5. jackobiec r, allingham r. bellow r and ritcher c; glaucoma in: albert r jackobiec. principles and practice of ophthalmology, vol 3, wb saunders, philadelphia. 1994; 6. jatoi sm, rathi d, channa ia. presentation of primary open angler glaucoma at liaqat medical college eye hospital, hyderabad. specialist 1997; 13:147-50. 7. tielsch jm, katz j, singh k, et al. population based evaluation of glaucoma screening: the baltimore eye survey. am j epidemiol. 1991; 134: 1102-10. 8. mitchell p, smith w, attebo k, et al. prevalence of primary open angle glaucoma in australia: the blue mountain eye study. ophthalmology 1996; 103: 1661-9. 9. tomlinson a, leighton da. ocular dimensions in heredity of angle closure glaucoma. br j ophthalmol. 1973; 57: 475-8. 10. lowe r. primary angle closure glaucoma: a review of ocular biometry. aus j ophthalmol. 1997; 5: 9-13. 33 pakistan journal of ophthalmology, 2020, vol. 36 (1): 33-37 original article mean visual acuity measured by autorefraction and subjective refraction shakeel ahmad 1 , rashida riaz 2 , muhammad haseeb 3 , hafiza ammara rasheed 4 , samia iqbal 5 1 services institute of medical sciences, 2,4 coas, mayo hospital, lahore. 3 hbs medical and dental college, islamabad. 5 the university of lahore abstract purpose: to calculate the mean difference of visual acuity as measured by auto refraction and subjective refraction. study design: descriptive cross-sectional study. place and duration of study: department of ophthalmology, services hospital lahore from november 2013 to april 2014. material and methods: using non-probability consecutive sampling 300 eyes of 300 patients fulfilling inclusion criteria were recruited through opd registration slip. demographic data including age and gender was recorded. complete ophthalmic examination was performed. this included measurement of refractive error by autorefraction as well as subjective refraction. detailed anterior segment examination with slit lamp and dilated fundus examination with indirect ophthalmoscopy was performed. the collected data was analyzed by using software spss version 17. results: the mean age of patients was 34.71 ± 7.45 years. there were 156 (52%) males and 144 (48%) females. there were 263 (87.69%) patients who had visual acuity of 6/6 and 37 (12.33%) had 6/9. mean spherical auto-refraction and subjective refraction was 0.0290 ± 2.58 and -0.2842 ± 2.37 d with mean difference of -0.3133 ± 1.27 d. the mean cylindrical auto and subjective refraction in this study was -.9742 ± 0.78 d and -0.7500 ± 0.81 d and mean difference was 0.2242 ± 0.74 d. the mean cylindrical axis of auto and subjective refraction was 114.88 ± 49.75 and 115.60 ± 49.70 with mean difference as 0.72 ± 3.02 d (p-value < 0.05). conclusion: difference of spherical, cylindrical and cylindrical axis in auto and subjective refraction was significantly different. key words: refraction, subjective refraction, auto-refractometer, retinoscopy. how to cite this article: riaz r. comparison of mean visual acuity as measured by auto-refraction and subjective refraction, pak j ophthalmol. 2020; 36 (1): 33-37. doi: https://doi.org/10.36351/pjo.v36i1.909. introduction refraction is a significant component of visual acuity. clinically, refraction is used to write spectacle prescription. subjective refraction is the gold standard for assessing refractive errors 1 . trial frame refraction correspondence to: rashida riaz research officer, coas, mayo hospital, lahore email:rashidariaz@hotmail.com is ideal as it allows for a more likely view position. moreover, the phoropter presents lens changes in 0.25diopter (d) increment, while trial frame refraction allows the examiner to determine the difference of magnitude between the lens choices accessible so that the variations are distinct by the patient. autorefractor is frequently used along with subjective refraction in ophthalmological practice for spectacle prescription. the category of autorefractors depend on clinical practice for their ease of use, excellent outcome and https://doi.org/10.36351/pjo.v36i1.909 mean difference of visual acuity with auto-refraction and subjective refraction pakistan journal of ophthalmology, 2020, vol. 36 (1): 33-37 34 increase response between practitioners and patients 2 . two studies linked subjective refraction to the autorefraction in clinical trials for the therapy of diabetic retinopathy 3,4 . these two trials assessed spherical equivalent difference between the two refractive techniques. autorefraction cannot be replaced by subjective refinement, particularly in children 10 years of age or younger 5,6 . in series of lenses, autorefractors worked to determine which lens is the clearest for the patient by determining which lens provides the maximum contrast to the retina 7 . although, this eliminates patient subjectivity, it is less than perfect. less than 70 percent of patients get a prescription for spectacles from the autorefractor. it can be used as a static retinoscopy, but the consistency and validity of the procedure is smaller as compared to subjective refraction 7 . there are small amount of instruments which appear to control the accommodation effectively in children. non-cycloplegic autorefractions are mostly incorrect for measuring hyperopia 8,9 . however, they are perfect, compared to subjective refraction in cycloplegic conditions 10 . autorefraction instruments have inner objectives. they are insufficiently used in young patients. however, autorefractors are helpful as a starting point for subjective refraction. similar to retinoscopy, autorefractors give a starting point, but patients will never be satisfied with auto-refraction alone 11,12 . further issue with autorefractors is that they only measure to the inner membrane of the retina, rather than to bruch's membrane, where the photoreceptors are placed. this gives inaccurate readings. fine-tuning must be performed in front of the patient to obtain the best outcomes. auto-refraction without subjective refinement is progressively being used by opticians in pakistan to prescribe lenses. this research evaluates the mean difference of the visual acuity as measured by autorefraction and subjective refraction between the vision tests of adults who presented in outpatient department. material and methods using non-probability consecutive sampling 300 eyes fulfilling inclusion criteria were included through opd registration slip. informed consent was taken. socio demographic information like age and gender was recorded. complete ophthalmic examination was performed. this included measurement of refractive error by auto-refraction as well as subjective refraction. detailed anterior segment examination with slit lamp and dilated fundus examination with indirect ophthalmoscopy was performed. difference was calculated as per operational definition. all data was entered on pre-designed proforma. the collected data was analyzed by using software spss version 17. results the mean age of patients was 34.71 ± 7.45 years with minimum and maximum age as 16 and 45 years. for details of subjective and auto-refraction refer to tables 1, 2 and 3. the mean cylindrical auto and subjective refraction in this study was -0.9742 ± 0.78 d and -0.7500 ± 0.81 d respectively and mean difference was 0.2242 ± 0.74 d. there was significant difference between mean cylindrical auto and subjective refraction, p-value < 0.001. table 1: comparison of auto and subjective refraction (spherical). refraction (spherical) auto subjective difference mean .0292 -.2842 -.3133 s.d 2.58 2.37 1.27 minimum -7.75 -7.50 -9.00 maximum 5.50 4.50 .75 paired sample t-test = 4.26 p-value < 0.001 table 2: comparison of auto and subjective refraction (cylindrical). refraction (cylindrical) auto subjective difference mean -.9742 -.7500 .2242 s.d .78 .81 .74 minimum -3.50 -3.00 -1.50 maximum .25 2.25 4.50 paired sample t-test = -5.23 p-value < 0.001 table 3: comparison of auto and subjective refraction (cylindrical axis). refraction (cylindrical axis) auto subjective difference mean 114.88 115.60 .72 s.d 49.75 49.70 3.02 minimum 25 20 -5 maximum 180 180 5 paired sample t-test = -4.11 p-value < 0.001 riaz r, et al. 35 pakistan journal of ophthalmology, 2020, vol. 36 (1): 33-37 table 4: comparison of auto and subjective refraction when stratified for age groups. age mean s.d p-value 16-30 years auto-refraction (spherical) 0.79 1.82 0.001 subjective refraction (spherical) 0.37 1.65 31-45 years auto-refraction (spherical) -0.30 2.80 0.004 subjective refraction (spherical) -0.57 2.57 16-30 years auto-refraction (cylindrical) -0.83 0.66 0.042 auto-refraction (cylindrical) -1.04 0.83 31-45 years subjective refraction (cylindrical) -0.79 0.82 < 0.001 subjective refraction (cylindrical) -0.65 0.81 16-30 years auto-refraction (cylindrical axis) 108.13 45.63 0.593 subjective refraction (cylindrical axis) 108.30 45.65 31-45 years auto-refraction (cylindrical axis) 117.82 51.27 0.001 subjective refraction (cylindrical axis) 118.78 51.15 on stratifying data for age, gender and visual acuity we found significant difference in all refraction (spherical, cylindrical and cylindrical axis). p-value was < 0.05 in cylindrical axis auto and subjective refraction in 16-30 years of age. for details see tables 4, 5 and 6. table 5: comparison of auto and subjective refraction when stratified for gender. gender mean s.d p-value male auto-refraction (spherical) 0.70 2.25 0.001 subjective refraction (spherical) 0.32 2.08 female auto-refraction (spherical) -0.70 2.74 0.006 subjective refraction (spherical) -0.93 2.50 male auto-refraction (cylindrical) -0.92 0.62 < 0.001 subjective refraction (cylindrical) -0.70 0.64 female auto-refraction (cylindrical) -1.03 0.94 < 0.001 subjective refraction (cylindrical) -0.81 0.97 male auto-refraction (cylindrical axis) 121.60 48.99 0.002 subjective refraction (cylindrical axis) 122.31 48.85 female auto-refraction (cylindrical axis) 107.60 49.71 0.007 subjective refraction (cylindrical axis) 108.33 49.77 table 6: comparison of auto and subjective refraction when stratified for visual acuity. visual acuity mean s.d p-value 6/6 auto-refraction (spherical) 0.34 2.24 < 0.0001 subjective refraction (spherical) 0.10 2.05 6/9 auto-refraction (spherical) -2.16 3.68 0.075 subjective refraction (spherical) -3.03 2.66 6/6 auto-refraction (cylindrical) -0.98 0.80 < 0.001 subjective refraction (cylindrical) -0.75 0.84 6/9 auto-refraction (cylindrical) -0.90 0.69 < 0.001 subjective refraction (cylindrical) -0.77 0.63 6/6 auto-refraction (cylindrical axis) 114.37 50.17 0.005 subjective refraction (cylindrical axis) 114.90 50.20 6/9 auto-refraction (cylindrical axis) 118.51 47.17 < 0.001 subjective refraction (cylindrical axis) 120.54 46.36 mean difference of visual acuity with auto-refraction and subjective refraction pakistan journal of ophthalmology, 2020, vol. 36 (1): 33-37 36 discussion refractive correction is given in order to correct refractive errors 13 . clinically, refraction is used to begin the spectacle prescription so that the best possible acuity can be achieved 14,15 . ever since, several patients with low vision report that their glasses do not help and some may find it appropriate to neglect refraction. refraction is the most significant component for patients who use a phoropter to maximize efficacy; however, the refraction of trial frame is favorable for low vision patients because it allows additional position that is extraordinary when required 16 . furthermore, the phoropter presents lens change in 0.25 diopter (d) increments, although the assessment of refraction allows the examiner to establish the magnitude of difference among the lens choices. trial frame refraction of low vision patients is time consuming. different methods are used to find best corrected visual acuity with refraction. predominately subjective refraction is used with assessment of lenses or a phoropter, or objective refraction with streak retinoscopy and auto-refraction 17 . the two refractive techniques involve distinct levels of examiner instruction, practice, and time to conduct each method. subjective refraction needs a fundamental knowledge of optics. typically, it takes months of practical skills for the clinician to complete subjective refraction appropriately and reproducibly. to master subjective refraction, the technique must be practiced on a large number of patients. in comparison, auto-refraction does not need knowledge about basic ophthalmic optics or practical knowledge in refraction 18 . it only requires fundamental knowledge of how the autorefractor works. it can be acquired from the manual that comes with the autorefractor and it does not require extensive practice on the patients 19 . over the last few centuries, auto-refraction has become a significant component of routine eye care and clinical practice. it has been shown to be a good tool for screening refractive error in pediatric patients. an objective refraction in a patient with decreased vision due to refractive error, generally takes about few minutes per eye, while subjective refraction in the same patient with a phoropter or trial frames usually takes time about 10 to 15 minutes. in practice, refraction in a patient with decreased vision and incapability to focus centrally caused by macular disease, requires more time with both auto-refraction and subjective refraction. the difference in time to conduct both refractive methods, whether in patients with good or poor vision, becomes essential part when large numbers of patients are screened. a study was done to compare the refractive correction attained by auto-refraction and subjective refraction at a tertiary care hospital in pakistan and to establish the association of this difference with age 20 . two hundred and sixty-nine patients visiting the eye clinic of a large tertiary care hospital in karachi, pakistan were studied. auto-refraction using a canon r-10 at the same visit, autorefractor and subjective refraction were performed. a clinically major difference among autorefraction and subjective refraction was defined as a difference of > 0.50 d in sphere, cylinder, spherical equivalent or weighted axis > 10 in axis. the report showed that in 266 right eyes, the medium variation among auto-refraction and subjective refraction in spherical corrections was +0.01d (p = 0.85), -0.33d in cylindrical corrections (p < 0.01), 10° in axis (p < 0.01), and –0.16 d in spherical equivalent (p = 0.02). children 10 years of age or older were 2.23 times more probable to have a clinically significant difference in spherical corrections (or: 2.23, 95% ci: 1.12-4.47). for left eye, comparable results were observed. hence, it is concluded that there is a significant difference among the corrections obtained by auto-refraction without help of subjective refraction, typically in children. auto-refraction without subjective refinement cannot replace subjective refraction. in this research, the mean of all parameters was considerably distinct, p-value < 0.05. attebo et al. reported in their research that after adjustment for age, women were slightly more hyperopic (mean +0.75 diopters) than men (mean +0.59 d). the gender adjusted mean spherical error increased with age +0.03 d in persons aged < 60 years to +1.2 d in persons aged ≥80 years (p < 0.0001). the gender adjusted mean cylinder power also increased with age, from −0.6 d in persons aged < 60 years to −1.2 d in persons aged ≥ 80 years 21 . these data are similar to our result. conclusion the difference of spherical, cylindrical and cylindrical axis in auto and subjective refraction was statistically significant. due to the large difference, patients must undergo subjective refraction for best corrected visual acuity. riaz r, et al. 37 pakistan journal of ophthalmology, 2020, vol. 36 (1): 33-37 ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest authors’ designation and contribution shakeel ahmad; vitreo-retina fellow: study design, data collection, analysis, manuscript writing, final review. rashida riaz; research officer: study design, data collection, analysis, manuscript writing, final review. muhammad haseeb; 3 rd year, mbbs student: data collection, final review. hafiza ammara rasheed; statistician: data analysis, final review. samia iqbal; doctor of optometrist: data collection, final review. references 1. demirel s, bilakş, yuvaci̇, cumurcu t, çolak c. objective measurement of refractive errors: comparison of plusoptix s08 with a standard autorefractometer. j clin exp invest. 2013; 4 (1): 4046. 2. vilaseca m, arjona m, pujol j, peris e, martínez v. non-cycloplegic spherical equivalent refraction in adults: comparison of the double-pass system, retinoscopy, subjective refraction and a table-mounted autorefractor. intern j ophthalmol. 2013; 6 (5): 618. 3. sun jk, aiello lp, cavallerano jd, stockman m, miller km, qin h, et al. visual acuity testing using auto-refraction or pinhole occluder compared with a manual protocol refraction in individuals with diabetes. ophthalmology, 2011; 118 (3): 537-42. 4. sun jk, qin h, aiello lp, melia m, beck rw, andreoli cm, et al. evaluation of visual acuity measurements after auto-refraction vs manual refraction in eyes with and without diabetic macular edema. arch ophthalmol. 2012; 130 (4): 470-9. 5. decarlo dk, mcgwin g, searcey k, gao l, snow m, waterbor j, et al. trial frame refraction versus auto-refraction among new patients in a low-vision clinic refraction versus auto-refraction in low vision patients. invest ophthalmol vis sci. 2013; 54 (1): 1924. 6. durrani k, khan a, ahmed s, durrani j. a comparison of automated and manifest refraction: the effect of age. pak j ophthalmol. 2006; 22 (3): 120-123. 7. cleary g., spalton d., patel p., lin p.-f., marshall j. diagnostic accuracy and variability of autorefraction by the tracey visual function analyzer and the shinnippon nvision-k 5001 in relation to subjective refraction. ophthalmic physiol opt. 2009; 29: 173–181. 8. sanfilippo p.g., chu b., bigault o. what is the appropriate age cut-off for cycloplegia in refraction? acta ophthalmol. 2014; 92: 458–462. 9. jorge j., queiros a., gonzález-méijome j., fernandes p., almeida j., parafita m. the influence of cycloplegia in objective refraction. ophthalmic physiol opt. 2005; 25: 340–345. 10. queirós a., gonzález-méijome j., jorge j. influence of fogging lenses and cycloplegia on open-field automatic refraction. ophthalmic physiol opt. 2008; 28: 387–392 11. benjamin w. borish's clinical refraction. 2nd ed. butterworth-heinemann; st louis, mo: 2006. 12. rabbetts r.b. clinical visual optics. 4th ed. butterworth-heinemann; 2007. 13. pesudovs k., parker k.e., cheng h., applegate r.a. the precision of wave front refraction compared to subjective refraction and autorefraction. optom vis sci. 2007; 84: 387–392. 14. mackenzie g.e. reproducibility of sphero-cylindrical prescriptions. ophthalmic physiol opt. 2008; 28: 143– 150. 15. optometric clinical practice guideline. care of the patient with myopia. american optometric association; 2006. 16. goss da, grosvenor t. reliability of refraction—a literature review. j am optom assoc 1996; 67: 619– 30. 17. zadnik k, mutti do, adams aj. the repeatability of measurement of the ocular components. invest ophthalmol vis sci. 1992; 33: 2325–33. 18. bullimore ma, fusaro re, adams cw. the repeatability of automated and clinician refraction. optom vis sci. 1998; 75: 617–22. 19. allen pm, radhakrishnan h, o’leary dj. repeatability and validity of the power refractor and the nidek ar600-a in an adult population with healthy eyes. optom vis sci. 2003; 80: 245–51. 20. durrani k, khan a, ahmed s, durrani j. the effect of age. a comparison of automated and manifest refraction. pak j ophthalmol. 2006; 22 (3): 120-123. 21. attebo k, ivers rq, mitchell p. refractive errors in an older population: the blue mountains eye study. ophthalmology, 1999; 106 (6): 1066-72. .…  …. https://www.ncbi.nlm.nih.gov/pubmed/10366072 179 vol. 35, no. 2, apr – jun, 2019 pak j ophthalmol original article comparison of intralesional kenacort injection versus surgical intervention for primary chalazion narain das, asma shams, beenish khan, muhammad nasir bhatti pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: narain das (nd) assistant professor smbbmc lyari, karachi e-mail: narainpagarani@yahoo.com …..……………………….. purpose: to compare the efficacy and safety of intralesional steroid injection versus surgical intervention (incision and curettage) in primary chalazion. study design: prospective, comparative and interventional hospital based study. place and duration of study: shaheed mohtarma benazir bhutto medical college lyari and sindh government lyari general hospital, karachi from 15 th october, 2016 to 15 th april, 2017. material and methods: all patients diagnosed with chalazion on clinical basis from the outpatient department of ophthalmology were included in the study. all patients were randomly divided into two groups with 25 patients in each group. group 1 received intralesional 0.2 ml triamcinolone acetonide while group 2 received surgical intervention (incision and curettage). results: there were 50 eyes of 50 patients between the age group of 15 to 40 years and of either gender. mean age was 25 ± 12.2 with male to female ratio of 2:1. there were 19 (76%) patients who achieved complete resolution of chalazion after intra-lesional triamcinolone acetonide in group i and there were 21 (84%) patients out of 25 who achieved complete resolution of chalazion after incision and curettage in group ii. no ocular complication such as bleeding, elevation of intra ocular pressure, eye lid de-pigmentation or any loss of vision in either group was observed. conclusion: intralesional triamcinolone acetonide injection is nearly as effective as surgical treatment (incision and curettage) in primary chalazion. keywords: triamcinolone, chalazion, eyelid diseases. halazion is a chronic inflammatory lipogranulomatous lesion of the eyelid1. it is the most common benign eyelid lesion accounting for 13.4% of cases2. the site of pathology is the meibomian gland, which lines the tarsus of the eyelid3. the most common presentation is a painless lump or swelling on the upper or lower eyelid. the condition may be unilateral or bilateral, external or internal and may consist of single or multiple lesions2. it can occur in individuals of all age groups but most commonly presents in adults with 80% lesions occurring in individuals in the age group of 11 to 30 years4. although it can occur in any location of the eyelid, most chalazia are found on the upper eyelid. this is because of the concentrated anatomical distribution of meibomian glands in the upper eyelid5. an inflamed chalazion can be visualized through the tarsal conjunctiva upon eversion of the eyelid. the lesion may take up the appearance of a whitish granuloma with potential to rupture5. the most common symptoms include swelling, redness and irritation. swollen eyelids with a hard nodule may c mailto:narainpagarani@yahoo.com comparison of intralesional kenacort injection vs surgical intervention for primary chalazion pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 180 also occur3. larger lesions have a tendency to induce mechanical ptosis and cause blurred vision due to astigmatism by pressing the cornea6. rarely, conjunctivitis and cellulitis may also occur5. on histology, a chalazion is composed of various inflammatory cells such as histiocytes, mononuclear lymphocytes, plasma cells, polymorphonuclear cells and eosionphils7,8. chalazia can also occur with other eye conditions and can have inflammatory and viral causes. inflammatory causes include seborrheic dermatitis, acne rosacea and chronic blepharitis. viral conjunctivitis most commonly constitutes viral causes2. biopsy and microbiological analysis are needed to rule out neoplasms especially in the elderly and in recurrent chalazion9. neoplasms which may mimic chalazia include sebaceous gland carcinoma, basal cell carcinoma, squamous cell carcinoma or merkel cell carcinoma2. a chalazion can be treated by medical treatment as well as surgical interventions. the conservative treatment involves warm compresses for 10 minutes four times daily, eyelid massage, lid scrubs and mild topical steroids. warm compresses help to open the glands, to break and express the nodules. antibiotics are only indicated in conditions where the chalazion is associated with severe blepharitis or blepharitis associated with rosacea. tetracycline is used commonly. alternative antibiotics are azithromycin and erythromycin. interventions include intralesional steroid injection (ilsi) triamcinolone acetonide and incision and curettage2. injection of 0.05 to 0.3 ml of the steroid is given in the palpebral side using the insulin syringe3. conservative management by warm compresses and antibiotics is effective in up to 80% of cases while ilsi is found to be effective in 93% of cases7,10,11. according to the literature, steroid injection is an effective management for young patients while incision and drainage is recommended for patients with multiple chalazia. combined treatment is recommended for patients with large, recurrent and multiple chalazia12. for the past several years, a lot of research has been conducted to compare the effectiveness of ilsi triamcinolone acetonide and surgical intervention13. the literature reveals a mixed opinion and no definite conclusion has been drawn yet. secondly, very few studies have been conducted in pakistan to compare the effectiveness of steroid injection and surgical management. the primary goal of our study was to compare the treatment outcomes and success of 0.2 ml triamcinolone injection and surgical intervention. material and methods the study was conducted at shaheed mohtarma benazir bhutto medical college lyari and sindh government lyari general hospital, karachi for duration of six months from 15th october, 2016 to 15th april, 2017. fifty eyes of 50 patients between the age group of 15 to 40 years diagnosed with primary chalazion on clinical basis of either gender were included in the study from the outpatient department of ophthalmology. patients were selected after taking ethical approval and informed consent. patients having acute infections and recurrent chalazion were excluded from the study. all patients were randomly divided into two groups with 25 patients in each group. group 1 received intralesional 0.2 ml (40 mg/ ml) triamcinolone acetonide while group 2 received surgical intervention (incision and curettage). patients were briefed about the procedure, its benefits and complications. informed and written consent was taken from all the patients and also advised for co-operation during the procedure. slit lamp examination was done before the procedure. before starting the procedure in both the groups, topical anesthesia (proparacaine 0.5%) eye drops were instilled two to three times in the affected eyes. after taking all aseptic measures, in group i eyelid was everted and 0.2 ml (8 mg of 40 mg/ml) of triamcinolone acetonide (injection kenacort) was injected trans-conjunctively in the center of the lesion by using 26.5 gauge needles. in some patients when it was not possible to evert the lid due to large swelling the same was injected transcutaneously. patching was done after putting betamethasone neomycin (betnesoln) eye ointment for one to two hours. in group 2 lignocaine 2% with adrenaline one to two ml was injected subcutaneously in the eyelid over the site of the chalazion. chalazion clamp was applied over the chalazion site and eyelid was everted, then a small vertical incision was given with surgical blade no. 11. after that curettage was done with chalazion currette. pressure was applied for five minutes to stop bleeding after removing the clamp. patching was done for six hours after putting betnesol-n eye ointment. post operatively, tablet augmentin 625 mg (500 mg amoxicillin and 125 mg clavulanic acid, glaxo smith kline, uk) was given 3 times a day, tablet narain das, et al 181 vol. 35, no. 2, apr – jun, 2019 pak j ophthalmol denzen ds (serratiopertidase 10 mg, helix pharma) was given 3 times a day, tablet ibuprofen 400 mg (brufen 400 mg, mylan products limited) 3 times a day, moxigan eye drops 4 times a day (moxifloxacin hydrochloride, barret hodgson) and betnesol-n eye ointment (betamethasone and neomycin, pharmaceutical ab) were advised for one week. the treatment outcomes were observed and data was collected. data analysis was done by using spss version 20. descriptive statistics was done and data was presented in the form of tables. results out of 50 patients, majority consisted of males 32 (64%) and the rest were females 18 (36%). the average age at the time of presentation was 25 ± 12.2 years. half of the patients underwent surgical treatment (50%) while the other half were treated with 0.2 ml triamcinolone injection (table 1). the treatment outcomes of both groups were compared. patients treated with surgical intervention had a better treatment outcome with 84% achieving complete recovery compared to 76% of patients achieving complete resolution when treated with 0.2 ml triamcinolone (table 2). table 1: general features and distribution of patients. variables (n = 50) mean ± sd/ n (%) age 25 ± 12.2 gender male 32 (64%) female 18 (36%) treatment group 1 25 (50%) group 2 25 (50%) table 2: outcomes of 0.2 ml triamcinolone and surgical intervention. variable (n=50) complete resolution p-value yes no group 1 19 (76%) 6 (24%) 0.480 group 2 21 (84%) 4 (16%) a total of 10 patients (20%) failed to achieve resolution. out of these, six were treated with ilsi and four were treated with surgical intervention. therefore, ilsi had a slightly greater risk of failure in our study (table 2). discussion leinfelder first proposed the treatment of chalazion by ilsi in 196414. since then, many studies have been conducted and have demonstrated surgery and ilsi to be equally effective4,15. ilsi has proved to be an effective and safe treatment for chalazia due to the fact that it is rarely associated with serious complications. however, skin depigmentation remains a common side effect in pigmented patients.16. ho et al stated that 2 out of 56 patient developed skin depigmentation in their study. however, in the goawella study none of the patients out of 56 developed this complication5. other rare side effects reported in literature include yellow deposits at the site of injection12, microembolism, rise in intraocular pressure17, and formation of pyogenic granuloma7. the findings of the above studies are contradictory to our study in which no side effects of the treatment modalities were observed. although extremely effective, ilsi is painful compared to injection of triamcinolone into the subcutaneous tissue14. the later causes less pain and does not require local anaesthetic. therefore, it can be considered as an alternative first line treatment14. surgical treatment of chalazion is a minor surgical procedure used to treat complicated and recurrent lesions3. post-surgical cold compresses, maintenance of eyelid hygiene and avoidance of contact lenses are essential measures to prevent infection18. several studies have been conducted to compare the effectiveness of both these treatments. according to a study from 2014, two ilsis were sufficient to produce complete resolution of multiple and recurrent chalazia19. similarly, according to ben simon et al most cases resolved with an average of one to two ilsis. resolution was defined as a decrease in size of 80% or more with no recurrence20. cf chung et al demonstrated a statistically significant success rate of patients treated with conservative management (58.3%) compared to those treated with ilsi (93.8%)14. tl jackson et al concluded that surgical treatment and ilsi both are equally effective in eradicating three quarters of chalazia compared to one third treated by conservative management21. comparison of intralesional kenacort injection vs surgical intervention for primary chalazion pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 182 in the light of the above literature, it can be concluded that both ilsi and surgical treatment are equally effective. the findings of the above studies are consistent with our results in which we also observed the near equal effectivity of the injection and surgical management. however, biuk d et al states a significant difference in pain sensation experienced between the two groups. surgical treatment resulted in higher pain scores with a median score of 65. in contrast, patients who received ilsi did not experience any pain (pain score=0) thus producing higher rates of patient satisfaction. furthermore, patients treated by ilsi needed less opd visits, did not require antibiotics or analgesics or compressive occlusion of the eye5. therefore, ilsi is the treatment of choice in children and when the chalazion is in close proximity to the lacrimal drainage system to avoid surgical damage. surgical treatment is preferred in cases of infected chalazion, patients not responding to ilsi and patients with suspected adenocarcinomatous lesions in which histopathology is needed for confirmation of diagnosis5. it was also seen that the response to treatment correlated with the size of the lesion as demonstrated by a local study conducted by tahir mz et al15. the authors found that the success rate of the treatment was greater in patients presenting with lesions ranging between 2-6 mm (100%) compared to patients who had lesions sized between 6-9 mm (97%)15. similarly, another study from 2017 highlighted that patients with lesions less than 5mm responded well to treatment3. furthermore, lee j et al showed that there was no significant difference between the treatment outcomes for adult and pediatric patients undergoing treatment with ilsi.17. conclusion intralesional triamcinolone acetonide injection is nearly as effective as incision and curettage in primary chalazion. it means it is a good alternative first line treatment in cases where diagnosis is straight forward. references 1. arbabi em, kelly rj, carrim zi. chalazion. bmj. 10; 341: c4044. 2. el sayed ma, kahtani s. chalazion management: evidence and questions. ophthalmic pearls. 2015; 9: 3739. 3. janicijevic-petrovic ma, jancic s, janicijevic k, popovic a. treatment of multiple chalazions with intralesional kenalog-40 injections in juvenile patient: a case report. maced j med sci. 2013 dec. 15; 6 (4): 42124. 4. gonagi s, bhaskar a, gonsalves s. role of intralesional triamcinolone injection in management of chalazia. iosr jdms. 2017; 16 (10): 25-26. 5. biuk d, matic s, barac j, vukoric mj, biuk e, matic m. chalazion treatment. coll. antropol. 2013; 37: 247– 250d. 6. cosar cb, rapuanob cj, cohen ej, laibson pr. tarsorrhaphy: clinical experience from a cornea practice. cornea, 2001; 20 (8): 787-91. 7. parveen s, babar zd, ishaq m, islam q. comparison of subcutaneous extralesional and intralesional triamcinolone injection for the treatment of chalazion. pak armed forces med j. 2015; 65 (4): 502-5. 8. yanoff m, fine bs. ocular pathology. 5th ed. 2002; 173174. 9. costea, cf. petraru, d, dumitrescu g, sava a. sebaceouscarcinoma of the eyelid: anatomoclinical data. rom j morphol embryol. 2013; 54 (3): 665-668. 10. goawalla a, lee v. a prospective randomized treatmentstudy comparing three treatment options for chalazia: triamcinoloneacetonide injections, incision and curettage and treatment with hot compresses. clin exp ophthalmol. 2007 nov; 35 (8): 706-12. 11. ben simon gj, rosen n, rosner m, spierer a. intralesional triamcinolone acetonide injection versus incision and curettage for primary chalazia: a prospective, randomized study. am j ophthalmol. 2011; 151: 714-718. 12. mustafa ta, oriafage ih. three methods of treatment of chalazia in children. saudi med j. 2001; 22 (11): 96872. 13. aycinena ar, achiron a, paul m, burgansky-eliash z. incision and curettage versus steroid injection for the treatment of chalazia: a meta-analysis. ophthalmic plast surg. 2016; 32 (3): 220-224. 14. chung cf, lai jsm, li psh. subcutaneous extralesional triamcinolone acetonide injection versus conservative management in the treatment of chalazion. hong kong med j. 2006; 12: 278-81. 15. tahir mz, rehman m, ahmad i, aqbal a, hussain i. effectiveness of intralesional triamcinolone acetonide in the treatment of chalazion. pak j ophthalmol. 2015; 31: 9-14. 16. ahmad s, baig ma, khan ma, khan iu, janjua ta. intralesional corticosteroid injection vs surgical treatment of chalazia in pigmented patients. j coll physicians surg pak. 2006; 16 (1): 42-44. 17. lee j, yau g, wong m, yuen c. comparison of intralesional triamcinolone acetonide injection for primary chalazion in children and adults. the scientific journal 2014: 1-4. 18. maurer k. chalazion treatment [internet]. 2015; 1-3. https://www.ncbi.nlm.nih.gov/pubmed/21155069 https://www.ncbi.nlm.nih.gov/pubmed/17997772 https://www.ncbi.nlm.nih.gov/pubmed/17997772 narain das, et al 183 vol. 35, no. 2, apr – jun, 2019 pak j ophthalmol www.med.umich.edu/1libr/ophthalmology/ comprehensive/chalaziontreatment.pdf 19. wong my, yau gs, lee jw, yuen cy. intralesional triamcinolone acetonide injection for the treatment of primary chalazions. int ophthalmol. 2014; 34 (5): 10491053. 20. ben simon gj, huang l, nakra t, schwarcz rm, mccann jd, goldberg ra. intralesional triamcinolone acetonide injection for primary and recurrent chalazia: is it really effective? ophthalmology, 2005; 112 (5): 9137. 21. jackson tl, beun l. a prospective study of cost, patient satisfaction and outcome of treatment of chalazion by medical and nursing staff. br j ophthalmol. 2000; 84: 782-785. author’s affiliation dr. narain das (nd) mbbs, fcps (ophthal) assistant professor smbbmc lyari, karachi dr. asma shams (as) mbbs, fcps (ophthal) senior registrar smbbmc lyari, karachi dr. beenish khan (bk) mbbs, fcps, frcs (ophthal) assistant professor united medical & dental college, karachi dr. muhammad nasir bhatti (mnb) mbbs, fcps (ophthal) professor, smbbmc lyari, karachi author’s contribution dr. narain das data collection, performed all surgeries. dr. asma shams data collection and statistical analysis. dr. beenish khan manuscript writing and language correction. dr. muhammad nasir bhatti critical review. http://www.med.umich.edu/1libr/ophthalmology/%20comprehensive/chalaziontreatment.pdf http://www.med.umich.edu/1libr/ophthalmology/%20comprehensive/chalaziontreatment.pdf http://www.med.umich.edu/1libr/ophthalmology/%20comprehensive/chalaziontreatment.pdf microsoft word editorial 21-2 58 editorial watery eyes the word “watering” from the eyes is one of the commonest word which an ophthalmologist hear every day, probably everywhere in the world. it is among the most common lacrimal symptoms. there is a long list of causes, which may be responsible for this, and patients of all ages are affected. one of two reasons; either they produce too many tears or the tears that are produced are not properly drained from the conjunctival sac. in order to find out the cause, where a through knowledge of the anatomy and pathophysiology is required, there a thorough history of the condition is essential to make the distinction between the two possible mechanisms. a clinician's approach to lacrimal disorders should be logical and organized. just as neurologic disorders must be carefully localized, so too should lacrimal problems be correctly localized and diagnosed before treatment is implemented. a thorough evaluation of the lacrimal drainage system should begin with the eyes, eyelids, and puncta and terminate with the distal nasolacrimal duct and intranasal passages. haphazard trial-and-error therapies are to be avoided. by careful history taking and a thorough examination, causes of hyper secretions are easy to isolate and with appropriate management symptom usually are relieved in short period of time, whereas overflow problems or outflow obstructions need appropriate investigations to find out the site of obstruction. two age groups need special attention regarding watering from the eyes. one of them is a neonate and other is an old age patient. new born who are presented with watering from one or both eyes need special attention. for this age group few facts should be kept in mind. canalization of epithelial cords, which will form lacrimal cannaliculi, starts at the 4 months of gestation, beginning as scattered patches throughout the system and creating a lumen through the system. this lumen finally breaks through in the nasolacrimal duct to form a continuous opening just before birth. the lower end of the lacrimal duct is the last to canalize, and in more than one half of infants the last portion of this nasolacrimal stem may not completely finalize its patency at birth. during embryonic development, migrations of epithelial cords can cause various anomalies within the lacrimal system. neonates have tear secretion at birth, and 96% to 98% have a totally patent and functional lacrimal drainage system. the 2% to 4% who do not have a lacrimal drainage system intact have a thin residual membrane at the distal end of the nasolacrimal duct. this membrane spontaneously dissolves in 80% to 90% of patients within the first few months of life. clinical manifestations of congenital nasolacrimal duct obstruction are amniotocele, dacryocystitis and tearing and mattering. tearing and mattering is the most common and usually manifest at two weeks of age simply having tearing and mucoprulent discharge. simply topical antibiotic and proper sac compression and massage relieve the problem. congenital nasolacrimal duct obstruction has a high rate of spontaneous resolution during the first year, and there is, not surprisingly, some difference of opinion about how early to resort to probing to resolve the situation. mucopurulent discharge from infection in the collecting system is nearly always present to some degree. it can be lessened with lid hygiene and the application of antibiotic ointments. pressure over the lacrimal sac usually results in retrograde flow of the sac contents onto the eye, where it can be wiped away. occasionally the pressure is transmitted hydrostatically down the nasolacrimal duct to open the obstruction with a sudden popping sensation. failing this, persistent purulent discharge and lid irritation are reasons to proceed with probing. an episode of frank dacryocystitis with swelling and redness in the area of the lacrimal sac is an indication for probing. the dacryocystitis is first treated with systemic antibiotics, but subsequent probing to relieve the obstruction is necessary to prevent recurrence. a special indication for early probing is distention of the lacrimal sac at birth, associated with nasolacrimal duct obstruction and a physiologic canalicular blockage of retrograde flow, the so-called congenital dacryocystocele. probing should be undertaken in the newborn period rather than later, because secondary infection is likely to develop in the closed system. the 59 lacrimal puncta and canaliculi are small at this early age, but the inferior canaliculus can usually be dilated and probed to decompress the lacrimal sac, and passing the probe on into the nose can break the distal duct obstruction. usually it is recommended that where relief is achieved by conservative measures, probing should be delayed till the age 6 to 9 months and in any case probing should be done by experienced ophthalmologist familiar with neonatal anatomy. in older age group, before deciding for probing and syringing it is very important to give special emphasis to the local adnexal factors such as lid laxity, eversion of puncta, phemosis of the punctums and not to forget the nasal examination. correction of the adnexal factors relieves most of the symptoms and later probing and syringing further facilitates the flow of tears through the passages. patency of both upper and lower canalicular system is essential for the proper flow of tears. a traditional teaching that the lower canalicular drainage system was far more important than the upper system. this old wives' tale is completely incorrect. various studies have demonstrated equal tear flow between the upper and lower canalicular systems using radioactive dacryoscintigraphy flow studies. approximately 50% of patients experience mild intermittent symptoms of epiphora associated with experimental monocanalicular obstruction. the symptoms were identical whether patients' upper canalicular system or lower canalicular system was occluded. dr. tahir mahmood associate editor microsoft word abdul hameed khokhar 1.doc 69 original article effectiveness of peribulbar (extracone) anesthesia in comparison with combined retrobulbar and facial nerve block for anterior ocular surgery abdul hameed khokhar, raiz baloch, ifthkhar ahmed pak j ophthalmol 2007, vol. 23 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: abdul hameed khokhar hameed manzil h/no: 3-15/9 natha singh street quetta. received for publication december’ 2005 …..……………………….. purpose: to compare the effectiveness of combined retro bulbar and facial nerve block, alone with that of peribulbar block, for anterior ocular surgery. material and method: one hundred and fifty patients were randomly divided into two groups. group 1 received retro bulbar block combined with facial never block. group 2 received peribulbar block. anesthetic agent used was a mixture of equal volumes of 2% xylocaine and 0.5% bupivacaine. twenty minutes after the block the effectiveness was assessed on the basis of eyelid movements, ocular movement and intraocular pressure. results: sixty nine patients (92%) in group i and 67 (92%) patients in-group ii had complete blockade of lid movements. one (1.33%) patient in group i and two (2.66%) patients in-group ii had almost normal eyelid movements and required a supplementary block. three (4%) patients in group i and two (2.66%) in group ii had almost normal eyeball movements. one patient (1.3%) in group i developed a hard eye due to retrobulbar hemorrhage. sixty-two (82.66%) patients in group i and forty-two (56%) in group ii had intraocular pressure (iop) less than15 mm hg. conclusion: no significant difference was found in overall effectiveness of anesthesia between the two groups. ost of the anterior segment ocular surgery in our country is being performed under local anesthesia. the traditional method has been a retro bulbar block combined with facial nerve block. facial nerve block is usually quite painful. retrobulbar block has potential risks of retro bulbar hemorrhage, optic nerve trauma, retinal vascular occlusion, perforation of the globe, convulsions and brain stem anesthesia1-10. peribulbar anesthesia is another choice for anterior segment ocular surgery that has gained popularity among ophthalmologists, as it avoids the painful facial nerve block and has relatively fewer complications. in this study we compared the effectiveness of combined retrobulbar and facial nerve block with the peribulbar block alone for anterior segment ocular surgery. m 70 material and methods one hundred and fifty (asa 1 & ii) patients aged between 40-70 years included for cataract and glaucoma surgery under local anesthesia were randomly divided into two groups. group 1 received the traditional retrobulbar with facial nerve block. group ii received peribulbar block alone. patients undergoing all forms of anesthesia require adequate counseling and explanation of the procedures and half an hour before surgery usually receive oral dazefoam and phenargan for sedative effect. method of anesthesia for facial nerve block, 5ml of the anesthesia mixture was injected at the neck of the mandible after negative aspiration for blood as an o’brien method and as for the retrobulbar block, 3 ml of the same anesthetic agent was injected inside the muscle cone entering through the lower lid at the junction of the lateral and the middle third of the inferior orbital margin taking infraorbital notch as guide point. for the peribulbar block, two injections each, containing 4 ml of the same anesthetic mixture as in group 1 were injected in to the orbit outside the muscle cone in superomedial and inferotemporal compartments through the upper and the lower lids, respectively (3ml from each injection was given approximately at the depth of 15-20 mm, while the remaining 1ml was injected after retracting the needle in the muscular plane of the orbicular is oculi). alcain (alcon, usa) drops were instilled in the conjunctival sac after completion of the block and repeated immediately before surgery. following the injection, digital ocular massage was carried out for at least 3-5 minutes after the block, assessment was made by the surgeon (unaware of the type of the block, according to the following scoring criteria. eyelid movements normal movements slight movements no movements score 0 1 2 ocular movements full movements slight movements no movements score 0 1 2 intaocualr pressure 30 mm hg or more 15-30 mm hg score 0 1 <15 mm hg 2 the overall assessment of the quality of the block was made at the completion of the surgery. results the physical characteristic of the patients and the type of surgery are shown in table 1. there was no significant difference in the physical characteristics between the two groups. table 2 compares scores of the patients according to the assessment criteria in the two groups. sixty nine patients (92%) in group i and 67 (92%) patients ingroup ii had complete blockade of lid movements. one (1.33%) patient in group i and two (2.66%) patients in-group ii had almost normal eyelid movements and required a supplementary block. table 1: physical characteristics and type of surgery characteristics group-1 group-2 mean age in years (range) 64 (45-68) 64 (46-70) sex male 43 29 female 32 46 asa status 1 15 10 ii 60 65 type of surgery cataract 68 69 glaucoma 07 06 table 2. score according to assessment criteria criteria score group i group ii eyelid movement 0 1 2 1 5 6 2 69 67 ocular movement 0 3 2 71 1 11 10 2 61 63 intraocular pressure 0 1 0 1 12 33 2 62 42 three (4%) patients in group i and two (2.66%) in group ii had almost normal eyeball movements. one patient (1.3%) in group i developed a hard eye due to retrobulbar hemorrhage. sixty-two (82.66%) patients in group i and forty-two (56%) in group ii had intraocular pressure (iop) less than15 mm hg. twelve (16%) patients in group i and thirty-three patients (44%) in group ii had iop between 15-30 mm hg. table 3 shows the overall assessment of the quality of block made by the surgeon at the completion of the surgical procedure. sixty seven (89.33%) patients in group i and sixty one patients (81.33%) in group ii had excellent operating conditions. three (4%) patients in each group had inadequate anesthesia and required a supplementary block. table 3. overall assessment of the quality of block quality of block group i n (%) group ii n (%) excellent 67 (89.33%) 61 (81.33%) adequate 5 (6.66%) 11 (14.66%) inadequate 3 (4%) 3 (4%) (n.b: one patients in group i developed retro bulbar hemorrhage and surgery was postponed) discusson in this study, we compared the effectiveness of the traditional combined facial and retro bulbar block with the relativity recent method of peribulbar block, for anterior segment ocular surgery. we conclude that both methods are almost equally effective, as far as the eyelid and eyeball movements are concerned. although the patient’s in group ii, on an average had higher iop levels as compared to group i but this did not produce any difficulty during operation. the higher level of iop in peribulbar blocks is most probably due to the larger volume of the anesthetic agent injected in the orbit. one patient in group i developed a hard eye following retro bulbar injection due to retro bulbar hematoma as there was leaking of blood from blood vessels, and the surgery was postponed. retro bulbar hemorrhage is well known complication of retro bulbar injection but peribulbar block has comparatively less incidence of such a complication. complications of both procedures can be reduced by using a short (25-30 mm) needle. facial nerve block is the most painful part of the local anesthesia for eye surgery. from this study we conclude that the peribulbar anesthesia is an excellent alternative to the traditional retro bulbar and facial nerve anesthesia as it avoids the painful facial nerve block and at the same time has less incidence of vision and the life threatening complications. the use of peribulbar block is not limited to the anterior segment ocular surgery, in slightly larger volumes it is being used for vitreoretinal and other surgical procedures6-12. efficacy of peribulbar can be enhanced by the addition of hyaluronidase for the better tissue penetration13-15. author’s affiliation dr. abdul hameed khokhar assistant professor of ophthalmology bolan medical college, quetta. dr. raiz baloch assistant professor of ophthalmology bolan medical college, quetta. dr. ifthkar ahmed senior registrar bolan medical college, quetta. reference 1. morgan md. schatz 11, vine ak complications associated with retrobulbar injections ophthamology. 1988; 95: 660-5. 2. castillo a, lopez-sbad ac, macias jm, et al. respirtory arrest after 0.75% bupivacaine retrobulbar block. ophthalmic surgery. 1994; 25: 628-9. 3. grey at, hynson jm. pulmonary edema after nadbath and retrobulbar blocks. anesth analg. 1994; 78: 1177-9. 4. gizzard ws, krik nm, pavan pr, et al. perforating ocular injuries caused by anesthesia personnel. ophthalmology. 1991; 98: 1177-9. 72 5. sullivan kl, brown gc, forman ar, et al. retrobulbar anesthesia and retinal vascular obstruction. ophthalmology 1983; 90: 373-7. 6. demadiuk om, dhaliwal rs, papworth dp, et al. a comparison of peribulbar and retro bulbar anesthesia for vitreoretinal surgical procedure. arch ophthalmol. 1995; 113: 908-13. 7. kimble ja, morris re, witherspoon cd, et al. globe perforation from peribulbar injection [letter]. arch ophthalmology. 1987; 105: 749. 8. nicoli jm, achrya pa, ahlen k, et al. central nervous system complication after 6000 retrobulbar blocks anesth analog. 1987; 66: 1298-1302. 9. hamilton rc. brain stem anesthesia following retro bulbar blockade anesthesiology. 1985; 63: 688-90. 10. edge kr, nicoll jm. retrobulbar hemorrhage after 12,500 retrobulbar blocks. anesth analog 1993; 76: 1019-22. 11. nicholson ad, singh p, badrinath ss, et al. peribulbar anesthesia for primary vitreoretinal surgery. ophthalmic surg. 1992; 23: 657-61. 12. arora r, verma l, kumar a, et al. peribulbar anesthesia in retinal re-attachment surgery. ophthalmic surg. 1992; 23: 499501. 13. sanchez-capuchino a, meadows d, morgan l. local anesthesia for eye surgery without a facial nerve block. anesthesia. 1993; 48: 428-5. 14. saunders dc, sturgess da, pemberton cj. peribulbar and retro bulbar anesthesia with prilocanie: a comparison of two methods of local ocular anesthesia. ophthalmic surg: 1993; 24: 842-5. 15. crawford m, kerr wj. the effect of hyaluronidase on peribulbar block. anesthesia. 1994; 49: 907-8. as there are various mechanisms of angle closure, only laser iridotomy or surgical iridectomy may not work in all cases of angle closure glaucomas. further medication or surgery may be required especially in chronic angle closure glaucoma. while laser iridotomy or surgical peripheral iridectomy is effective in most situations of angle closure only iridoplasty works better for plateau iris cases. prof. m lateef chaudhry pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 276 original article correlation of ankle-brachial index with diabetic retinopathy in patients of type 2 diabetes abdullah mazhar, tayyaba gul malik, aalia ali, hina nadeem pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: professor tayyaba gul malik department of ophthalmology, rashid latif medical college, lahore. email: tayyabam@yahoo.com …..……………………….. purpose: to find a relationship of diabetic retinopathy with ankle-brachial (abi) in patients of type 2 diabetes. study design: it was a cross-sectional observational study. place and duration of study: arif memorial teaching hospital and rashid latif medical college from january 2019 to june 2019. material and methods: 120 patients were selected by purposive convenient sampling from outpatient department of arif memorial teaching hospital. after clinical history, complete ocular examination was performed. random blood glucose levels were measured using glucometer. ankle-brachial index was calculated by dividing the systolic pressure at ankle by the systolic blood pressure at arm. statistical analysis was done using spss 25. independent sample t test and chi square tests were used to find out the significance of the results. results: in this study of 120 diabetic patients, 80 (66.7%) were female and 40 (33.3%) were males. mean ankle branchial index (abi) of males was 0.96 ± 0.11 and for females was 0.97 ± 0.14. among 120 participants of this study, 73 (60.83%) patients had no signs of diabetic retinopathy, 35 (29.16%) patients had npdr and 12 (10%) patients had pdr. abi was not associated with gender and duration of diabetes. however, there was negative and weak linear relationship between bsr and abi (r = -0.221). this correlation was higher in diabetics of less than 5 year duration (r = -0.286) than in patients of more than 5 years duration of diabetes (r = -0.129). conclusion: our study indicates that abi is not significantly related with diabetic retinopathy. however, there is a weak linear relationship of abi with high blood sugar levels. key words: ankle brachial index, toe-brachial index, diabetic retinopathy. n late 1960s, ankle-brachial index (abi) was developed as a simple test to find out existence of peripheral artery disease especially the lower extremity artery disease (lead). the american diabetes association has recommended screening for lead in all diabetic patients1. lead increases the risk of complications of diabetes including diabetic retinopathy, cardiovascular episodes and even death in severe cases2,3. in normal persons, lower limb systolic pressure at ankle is 10 to 15 mm hg greater than pressure at arm. this is responsible for abi of about 1.1 to 1.3. a range between 0.9 to 1.0 is suspicious, less than 0.9 is dangerous and indicative of peripheral artery disease. however, more than 1.4 is also abnormal and it shows calcification and stiffening of arteries (poorly compressible arteries). as micro-angiopathy and macro-angiopathy, i mailto:tayyabam@yahoo.com abdullah mazhar, et al 277 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol which are responsible for peripheral artery disease, are reflected in retina as diabetic retinopathy, we have tried to find out a relation between abi and diabetic retinopathy in this research. the purpose of this study was to find a relationship of diabetic retinopathy with anklebrachial (abi) in patients of type 2 diabetes. material and methods it was a cross-sectional observational study carried out from january 2019 to june 2019. institutional ethical review board approved the study. sample size was calculated by who software 2.0. 120 patients were selected by purposive convenient sampling from outpatient department of arif memorial teaching hospital. all patients with type 2 diabetes between 25 and 80 years of age of both genders were included in the study. exclusion criteria were patients with systemic diseases other than diabetes, type 1 diabetic patients, smokers, patients who had undergone laser therapy or intravitreal anti-vegf injections for diabetic retinopathy and patients with vitreo-retinal diseases other than diabetic retinopathy. table 1: association of abi with bsr and duration of diabetes. abi bsr and duration of diabetes p-value < 5 years > 5 years normal 203.28 ± 84.42 193.87 ± 66.42 0.645 below 259.94 ± 131.21 235.09 ± 95.37 0.390 p-value 0.066 0.054 after clinical history, examination was performed. random blood glucose levels were measured using glucometer. we checked visual acuity for distance and near. pupillary reactions were checked. slit lamp examination was performed to inspect any anterior segment abnormality. goldman tonometry was done to check intra ocular pressures. fundus examination was performed using 90 d lens at slit lamp and with indirect ophthalmoscope. retinal findings were categorized into, nad (no abnormality detected), npdr (non-proliferative diabetic retinopathy) and pdr (proliferative diabetic retinopathy). table 2: association of abi with gender, duration of diabetes and diabetic retinopathy. variable ankle branchial index p-value normal (1-1.4) below 1 gender female 39 (49.4%) 40 (50.6%) 0.333 male 16 (40.0%) 24 (60.0%) duration of diabetes < 5 years 25 (43.9%) 32 (56.1%) 0.621 > 5 years 30 (48.4%) 32 (51.6%) ophthalmoscopy nad 37 (51.4%) 35 (48.6%) 0.082 npdr 16 (45.7%) 19 (54.3%) pdr 2 (16.7%) 10 (83.3%) graph 1: relation of abi with gender, bsr and duration of diabetes. we determined ankle-brachial index by checking the systolic blood pressure in supine position with the help of mercury sphygmomanometer. blood pressure was recorded in both arms in supine position after 5 minutes of resting. mean of the two pressures was taken as brachial systolic pressure. the cuff was inflated 20 mm hg higher than the arm systolic blood pressures while ankle pressures were measured at dorsalis pedis artery. anklebrachial index was calculated by dividing the systolic pressure at ankle by the systolic blood pressure at arm. all data was collected using a selfdesigned proforma and compiled in excel file. statistical analysis was done using spss 25. independent sample t test and chi square tests were used to find out the significance of the results. results in this study of 120 diabetic patients, 80 (66.7%) were female and 40 (33.3%) were males. mean age of the females was 50.94 ± 12.74 years and mean age of males was 51.98 ± 10.73 years. mean bsr of males correlation of ankle-brachial index with diabetic retinopathy in patients of type 2 diabetes pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 278 was 216.28 ± 98.94 and in females was 227.19 ± 102.61. meanankle branchial index (abi) of males was 0.96 ± 0.11 and for females was 0.97 ± 0.14 (table 2). among 120 participants of this study, 58 patients had diabetes for less than 5 years and 62 were suffering from this disease for more than 5 years. seventy three (60.83%) patients had no signs of diabetic retinopathy, 35 (29.16%) patients had npdr and 12 (10%) patients had pdr (table 2). abi was not associated with gender and duration of diabetes. see table 1. patients who had abi in normal range had mean bsr 198.15 ± 74.56. patients who had low abi had bsr of 247.52 ± 114.47. this difference was statistically significant (p-value 0.007). there was negative and weak linear relationship between bsr and abi (r = -0.221). this correlation was higher in diabetics of less than 5 year duration (r = -0.286) than in patients of more than 5 years duration of diabetes (r = -0.129). discussion lower extremity artery disease, also known as peripheral artery disease (pad) is a common complication of diabetes and it increases with increase in the duration of diabetes. studies have shown that diabetic retinopathy is an independent risk factor for pad4. abi has a sensitivity of 90% and specificity of 95% for angiographically proved pad5. diabetic patients are prone to pad and hence abnormal and borderline abi is a very useful, non-invasive test to detect pad6. abi values of 1 to 1.3 are considered normal, less than 1 are abnormal but the 2011 american college of cardiology foundation (accf) and american heart association (aha) guidelines for the management of pad have recommended abi values of 0.90–0.99 as ‘borderline’7. in our study, we took 0.9 as abnormal rather than borderline. studies have shown that women were more likely to have borderline abi (11.6%) than men (8.0%)8. similarly, in the national health and nutrition examination survey nhanes (1999–2002) and the multi-ethnic study of atherosclerosis (mesa), the prevalence of borderline abi nearly doubled in women (11.7% and 10.6%) than men (6.0% and 4.3%)9. this was not the case in our study and abi was not significantly higher in women as compared to men (p = .333). low abi is also associated with increased risk of mortality10. studies have shown that ankle–brachial index is very effective and cost effective tool for diagnosis of pad11. however, abi values have shown variable results in diabetic patients as compared to normal population12. different studies have shown varying results of association of diabetic retinopathy with abi. one of the reasons for studying abi in our diabetic population was that this relation is not yet studied in our population and to the best of our knowledge; this is the first research being reported from pakistan. our data revealed that, there was no statistically significant relation of diabetic retinopathy with abnormal or low abi. contrary to this, papanas et al had shown low abi in type 2 diabetic patients with diabetic retinopathy13. similarly, emerson et al. described a direct relation of severity of diabetic retinopathy and microalbuminuria with abnormal abi scores. this indicated that patients with abnormally low abi have not only the kidneys at stake but also their vision14. other studies have shown similar results indicating abi as a marker of not only pad but also diabetic retinopathy15,16,17,18. according to joint asia diabetes evaluation program, 12,777 patients with type 2 diabetes had borderline abi, which was associated with increased prevalence of microvascular complications. abi was found to be an independent risk factor for diabetic retinopathy in a chinese study19. (odds ratios: 1.19 (95% confidence interval: 1.04–1.37)). they also proposed a higher cut off value < 1.0 to early prevent onset of diabetic complications including diabetic retinopathy (dr). they also described association of low abi with duration of diabetes, which is consistent to our study. similar results were reported from germany20. zander et al supported an increased prevalence of diabetic retinopathy and neuropathy in patients with abnormal abi values. overall, in their study, patients with diabetic retinopathy had higher proportion of low abi than those without dr. (53 out of 138 vs. 59 out of 337). another study from china with multivariate forward logistic regression analysis showed positive relation of pdr with abnormal abi as compared to non-dr. however, npdr was not significantly related with abnormal abi when compared with normal population21. there are conflicting data as far as abi and dr are concerned. there were other reports, which were similar to our results showing no relationship of abi to presence or absence of retinopathy in diabetic individuals. yun et al related their negative findings abdullah mazhar, et al 279 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol regarding abi and dr with other conditions for example sample size, age and characteristics of study population16. similarly, a study from israel showed that type 2 diabetes was associated with higher bmi, larger waist circumference but abi was normal in all patients with or without dr22. this variability of results was explained by some researchers in terms of arterial stiffness. when abi is measured in patients with arterial stiffness, which is also associated with diabetes, abi values appear higher due to lesser vascular compressibility. hence, abi values in diabetic patients show lower prevalence in some studies. for the same reason some epidemiological researchers have shown that abi < 0.9 as well as > 1.4 is indicative of pad23,24. strength of this research is that this study was conducted to find a relation of abi with diabetic retinopathy in pakistani population. our limitation was that, as normal abi in our study could have been due to arterial calcification, we can further expand our research using toe-brachial index, which according to some recent data, is found to be of superior diagnostic value as compared to the abi25. conclusion our study indicates that abi is not significantly related with diabetic retinopathy. however, there is a weak relationship of decreased abi with high blood glucose levels. declarations authors declare no conflict of interest in this study. there was no funding source. the institutional review board approved the research. references 1. american diabetes association. standards of medical care in diabetes – 2013. diabetes care, 2013; 36: 11–66. 2. criqui mh, aboyans v. epidemiology of peripheral artery disease. circ res. 2015; 116 (9i): 1509–26. 3. selvin e, erlinger tp. prevalence of and risk factors for peripheral arterial disease in the united states: results from the national health and nutrition examination survey, 1999–2000. circulation. 2004; 110 (6i): 738–43. 4. nativel m, potier l, alexandre l, baillet-blanco l, ducasse e, velho g, et al. lower extremity arterial disease in patients with diabetes: a contemporary narrative review cardiovasc diabetol. 2018; 17: 138. 5. criqui mh. systemic atherosclerosis risk and the mandate for intervention in atherosclerotic peripheral arterial disease. am j cardiol. 2001; 88: 43j–47j. 6. natsuaki c, inoguchi t, maeda y, yamada t, sasaki s, sonoda n, et al. association of borderline anklebrachial index with mortality and the incidence of peripheral artery disease in diabetic patients. atherosclerosis, 2014; 234: 360–365. 7. american college of cardiology foundation, american heart association task force, society for cardiovascular angiography and interventions, et al. 2011 accf/aha focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline). vasc med. 2011; 16: 452–476. 8. mcdermott mm, liu k, criqui mh, ruth k, goff d, saad mf, et al. ankle-brachial index and subclinical cardiac and carotid disease: the multiethnic study of atherosclerosis. am j epidemiol. 2005; 162: 33–41. 9. menke a, muntner p, wildman rp, dreisbach aw, raggi p. relation of borderline peripheral arterial disease to cardiovascular disease risk. am j cardiol. 2006; 98: 1226–1230. 10. khan t, farooqi f, niazi k. critical review of the ankle brachial index. curr cardiol rev. 2008; 4: 101-106. 11. weiss ns, mcclelland r, criqui mh, wassel cl, kronmal r. incidence and predictors of clinical peripheral artery disease in asymptomatic persons with a low ankle–brachial index. j med screen, 2018; 25 (4): 218-222. 12. guirguis-blake jm, evans cv, redmond n, lin js. screening for peripheral artery disease using the ankle– brachial index: updated evidence report and systematic review for the us preventive services task force. jama. 2018; 320 (2i): 184–96. 13. papanas n, symeonidis g, mavridis g, georgiadis gs, papas tt, lazarides mk, et al. ankle-brachial index: a surrogate marker of microvascular complications in type 2 diabetes mellitus? int angiol. 2007; 26 (3): 253-257 17622207. 14. molina ejb, yutangco ra, cruz-anacleto mas, castillo jdd, aguinod-cheng pj. relationship of diabetic retinopathy with ankle brachial index and microalbuminuria in type 2 diabetics philipp j ophthalmol. 2014; 39: 12-15. 15. kawasaki r, cheung n, islam a, klein r, klein bek, cotch mf et al. is diabetic retinopathy related to subclinical cardiovascular disease? ophthalmology, 2011; 118: 860-865. 16. yun yw, shin mh, lee yh, rhee ja, choi js. arterial stiffness is associated with diabetic retinopathy in korean type 2 diabetic patients. j prev med public health, 2011; 44: 260-266. 17. tryniszewski w, gadzicki m, maziarz z, kusmierczyk j, gos r, rysz j, et al. progression of diabetic retinopathy correlated with muscle perfusion disturbances of the lower limbs, with clinically important diagnostic recommendations. arch med sci. 2010; 6: 904-911. 18. rani p, raman r, gupta a, pal ss, kulothungan v, sharma t. albuminuria and diabetic retinopathy in correlation of ankle-brachial index with diabetic retinopathy in patients of type 2 diabetes pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 280 type 2 diabetes mellitus. sankara nethralaya diabetic retinopathy epidemiology and molecular genetic study (sn-dreams, report 12). diabetol metab syndr. 2011; 3: 9. 19. yan bp, zhang y, kong ap, luk ao, ozaki r, yeung r, et al. borderline ankle–brachial index is associated with increased prevalence of microand macrovascular complications in type 2 diabetes: a cross-sectional analysis of 12,772 patients from the joint asia diabetes evaluation program. diabetes vasc dis re. 2015; 12 (5): 334–341. 20. zander e, heinke p, reindel j, kohnert kd, kairies u, braun j, et al. peripheral arterial disease in diabetes mellitus type 1 and type 2: are there different risk factors? vasa. 2002; 31: 249e54. 21. chen sc, hsiao pj, huang jc, lin kd, hsu wh, lee yl, et al. abnormally low or high ankle-brachial index is associated with proliferative diabetic retinopathy in type 2 diabetic mellitus patients. plos one. 2015; 10 (7): e0134718. 22. blum a, socea d. clinical characteristics of diabetic patients with diabetic retinopathy. j. nutr. ther. 2013; 2 (1): 46-52. 23. aboyans v, ho e, denenberg jo, ho la, natarajan l, criqui mh. the association between elevated ankle systolic pressures and peripheral occlusive arterial disease in diabetic and nondiabetic subjects. j vasc surg. 2008; 48 (5): 1197-1203 18692981. 24. papanas n, symeonidis g, mavridis g, georgiadis gs, papas tt, lazarides mk, et al. ankle-brachial index: a surrogate marker of microvascular complications in type 2 diabetes mellitus? int angiol. 2007; 26 (3): 253-257 17622207. 25. tehan pe, barwick al, sebastian m, helaine v. diagnostic accuracy of resting systolic toe pressure for diagnosis of peripheral arterial disease in people with and without diabetes: a cross-sectional retrospective case-control study. j foot ankle res. 2017; 10: 58. author’s affiliation abdullah mazhar department of ophthalmology, rashid latif medical college, lahore tayyaba gul malik department of ophthalmology, rashid latif medical college, lahore aalia ali department of ophthalmology, arif memorial teaching hospital, lahore hina nadeem department of ophthalmology, arif memorial teaching hospital, lahore author’s contribution abdullah mazhar data acquisition and analysis, literature research and final review. tayyaba gul malik research planning, data acquisition and analysis, literature research, manuscript writing and final review. aalia ali data acquisition and analysis, literature research and final review. hina nadeem data acquisition, data analysis, final manuscript review. pak j ophthalmol. 2020, vol. 36 (2): 172-175 172 brief communication axenfeld-rieger syndrome in a pakistani family rebecca 1 , murtaza sameen junejo 2 , syed jamil 3 , sameen afzal junejo 4 1,3 isra university hospital, 3,4 liaquat university of medical and health sciences, jamshoro abstract a case of 46-year-old male is presented who came with complaints of painless, progressive deterioration of vision in both eyes and he was using latanoprost and cosopt eye drops in both eyes. his visual acuity was 6/60 in right eye and perception of light in left eye. the intraocular pressures were 28   mm  hg (od) and 18  mm  hg (os). there was iridocorneal adhesion and posterior embryotoxon in his right eye and leucoma in left eye. cup-disc ratio was 0.7. he had hypodontia, midface hypoplasia, hypertelorism, and telecanthus. family history was also positive. his sister also had iris stromal hypoplasia along with posterior embryotoxon. a diagnosis of axenfeld rieger syndrome was made. the patient underwent glaucoma drainage devise (agv) surgery in his right eye. post operative pressures were 10 mm hg. he was later referred to maxillofacial surgeon, cardiologist and counseled for avoiding cross marriages to prevent this inherited disease. key words: anterior segment dysgenesis, axenfeld-rieger syndrome, corectopia. how to cite this article: rebecca, junejo ms, jamil s, junejo sa. axenfeld-rieger syndrome in a pakistani family. pak j ophthalmol. 2020, 36 (2):172-175. doi: 10.36351/pjo.v36i2.974 introduction world-wide prevalence of axenfeld-reiger syndrome (ars) is 1:200,000. it is a rare disorder characterized by systemic and ocular anterior segment dysgenesis. various overlapping phenotypes, including axenfeld anomalies, rieger anomalies and rieger syndrome are associated with ars. 1 the posterior embryotoxon, changes in iris stroma and anterior chamber angle anomalies are ocular manifestations of ars. in ars patients, characteristic systemic features like dental anomalies including, hypodontia, microdontia and oligodontia, umbilical anomalies and maxillary hypoplasia have been reported. 1 correspondence: murtaza sameen junejo liaquat university of medical and health sciences. email: drmurtazasameen@gmail.com received: january 20, 2020 accepted: march 2, 2020 due to developmental anomalies of angle, there is glaucoma. in patients with ars, gene mutations in fork head box protein c1 (foxc1, chromosomes increase of outflow resistance and ocular hypertension in nearly 50% of the cases, resulting in secondary6p25) and pituitary homeobox 2 (pitx2, chromosomes 4q25) encoding transcription have been noted. 2 another chromosome 13q14 has been reported in ars but its function is still unknown. 3 up till now, there have been only few cases reported in asian population. 4,5 in pakistan ars is very rare. our purpose to report this case is to familiarize the ophthalmologists and health care professionals to counsel the patients regarding this disease and its inheritance pattern in families and to avoid it by discouraging cross marriages. case presentation a well oriented male 46-years-old (weight: 83 kg) presented to laser sight on november 7, 2019, with mailto:drmurtazasameen@gmail.com murtaza sameen junejo, et al 173 pak j ophthalmol. 2020, vol. 36 (2): 172-175 complaints of painless, progressive deterioration of vision in his right eye for 1 month and decreased vision in left eye for 10 years. he was using latanoprost eye drops (1 drop once a day) and cosopt eye drops (1 drop twice a day) in both eyes for 1 year. an informed consent was obtained from the patient. on ocular examination his best-corrected visual acuity (bcva) was 6/60 (od) and perception of light (os), while the intraocular pressure (iop) was 28 mm hg (od) and 18 mm hg (os) measured with goldmann applanation tonometer. the slit-lamp examination of right anterior segment showed paracentral corneal opacity of 1.5 cm and bullae at 6 and 7’o clock (fig. 1). the diameters of cornea were 10 mm ou (fig. 1). the iris changes included stromal hypoplasia with corectopia (fig. 1). gonioscopy showed an iridocorneal adhesion of the anterior angle on his right eye at all 4 quadrants along with posterior embryotoxon. the retinal photography of the right eye showed cup-disc ratio of 0.7 with notching of vessel and neuroretinal rim thinning along with peripapillary atrophy. the ultrasound b scan of left eye was unremarkable while the anterior segment examination of left eye showed leucoma from limbus to limbus. on general physical examination and systemic examination, hypodontia of the maxillary anterior teeth was observed in both the primary and permanent dentition, for which he was referred to a dentist. craniofacial anomalies, including mid face hypoplasia, hypertelorism, and telecanthus were observed. ars was diagnosed on the basis of clinical features discussed above. the patient underwent glaucoma drainage devise (agv) surgery in his right eye. one week later iop was 10 mm hg in his right eye. family history was also positive due to consanguineous marriage. he had six brothers and five sisters, out of whom two brothers and one sister had positive history of decreased vision due to glaucoma. his sister also had maxillary, anterior teeth and iris stromal hypoplasia along with posterior embryotoxon. they were referred to maxillofacial surgeon, cardiologist and counseled for cross marriages to prevent this inherited disease. discussion in 1920, theodor axenfeld first described ars characterized by posterior embryotoxon and prominent iris strands extending from the peripheral iris to this line. a case with hypoplasia, fig. 1: top: hypertelorism with left leucocoria. middle: dental abnormalities. ahmed: glaucoma valve fig. 2: b-scan of left eye. asian family with axenfeld-rieger syndrome pak j ophthalmol. 2020, vol. 36 (2): 172-175 174 iris like stromal hypoplasia and corectopia was described in 1934. 6 ars includes a group of disorders and is divided into three subgroups; axenfeld anamoly is characterized by a prominent, anteriorly displaced schwalbe line called posterior embryotoxon and prominent iris strands extending from the peripheral iris to this line. rieger anomaly includes the condition with central iris changes like stromal hypoplasia and irregular-shaped pupils along with features mentioned in axenfeld anomaly. rieger syndrome includes rieger anomaly associated with systemic features. 7 the diagnosis of axenfeld-rieger syndrome was made as he presented with ocular anomalies of rieger anomaly together with systemic anomalies. thus, since 1985 the term ars has been used clinically and ozeki et al 8 reported that rieger anomaly accounted for 10%, axenfeld anomaly accounted for 71%, while rieger syndrome covered 19% cases of ars. however, we have seen that most of the ars cases are sharing an overlap of features within this spectrum so that the delineation of each of these is not clear. apart from such considerations, other unusual ocular anomalies have also been reported. two cases were reported by espana et al 9 and parikh et al 10 with different presentation of detached schwalbe line suspended in anterior chambers. schwalbe line originates from neural crest cells, due to which impaired development is related to the pathogenesis of ars. 9 hypoplasia of extraocular muscles derived from mesodermal complex also appeared in ars. retinal detachment have also been reported in few cases of ars. glaucoma drainage devices are very useful adjunct for the treatment of refractory glaucoma. however, these devices come with an array of potential serious complications. 10 the most common delayed complication is exposure of the tube overlying eroded conjunctiva. 10 in our study, we also used glaucoma drainage device in the right eye which improved the vision of patient and reduced intraocular pressure. about 50% of ars patients develop glaucoma. with a 20-year follow-up, mandal and pehere showed the safety and effectiveness of trabeculotomy and trabeculectomy for ars children with early-onset of glaucoma. in the present case report, the patient was referred to maxillofacial surgeon. in summary, ars is a rare disorder, the ocular manifestations may be vision threatening, therefore a regular and long term follow up by an ophthalmologist is necessary. a convincing conclusion is still awaited about prognosis of this disease in pakistani population. limitation of this case report is that we had not yet obtained the ocular and physical examinations from his father and sister, and gene analysis could not be performed. conflict of interest there is no conflict of interest between authors and on funding. references 1. titheradge h, togneri f, mcmullan d, brueton l, lim d, williams d. axenfeld-rieger syndrome: further clinical and array delineation of four unrelated patients with a 4q25 microdeletion. am j med genet. 2014; 164a: 1695–1701. 2. ito ya, walter ma. genomics and anterior segment dysgenesis: a review. clin exp ophthalmol. 2014; 42 (1): 13–24. 3. tumer z, bach-holm d. axenfeld-rieger syndrome and spectrum of pitx2 and foxc1 mutations. eur j hum genet. 2009; 17 (12): 1527–1539. 4. seifi m, footz t, taylor sa, elhady gm, abdalla em, walter ma. novel pitx2 gene mutations in patients with axenfeld-rieger syndrome. acta ophthalmol. 2016; 94 (7): e571–e579. 5. yin hf, fang xy, jin cf, yin jf, li jy, zhao sj, et al. identification of a novel frame shift mutation in pitx2 gene in a chinese family with axenfeld-rieger syndrome. j zhejiang univ sci. b. 2014; 15 (1): 43–50. 6. idrees f, vaideanu d, fraser sg, sowden jc, khaw pt. a review of anterior segment dysgeneses. surv ophthalmol. 2006; 51: 213–231. 7. rao a, padhy d, sarangi s, das g. unclassified axenfeld-rieger syndrome: a case series and review of literature. semin ophthalmol. 2016; 1–8. 8. ozeki h, shirai s, ikeda k, ogura y. anomalies associated with axenfeld-rieger syndrome. graefes arch clin exp ophthalmol. 1999; 237: 730–734. 9. espana em, mora r, liebmann j, ritch r. bilateral prominent schwalbe ring in the anterior chamber in a patient with axenfeld-rieger syndrome and megalocornea. cornea, 2007; 26: 379–381. 10. parikh rs, parikh sr, debashish b, harsha bl, thomas r. unusual presentation in axenfeld-rieger syndrome. indian j ophthalmol/. 2011; 59: 312–314. murtaza sameen junejo, et al 175 pak j ophthalmol. 2020, vol. 36 (2): 172-175 author designation and contribution rebecca; postgraduate resident: data collection, literature review, final review. murtaza sameen junejo; senior registrar: data collection, manuscript writing, literature review. syed jamil; assistant professor: literature review and final review. sameen afzal junejo; professor: literature review and final review. .…  …. microsoft word tahir.doc 97 original article visual outcome of prk and lasik: five year followup tahir mahmood pak j ophthalmol 2007, vol. 23 no. 02 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tahir mahmood associate professor department of ophthalmology shaikh zayed hospital lahore received for publication june’ 2006 …..……………………….. purpose: to evaluate the visual outcome of prk and lasik in age and refractive error matched eyes. material and methods: this retrospective study was conducted on the fifth year follow up of the refractive surgery patients who have under gone photorefractive keratectomy (prk) and laser in situ keratomileusis (lasik) procedures for moderate degree of myopia. one surgeon operated all patients by using visx 20/20b excimer laser system. age and refractive error matched patients were divided in two groups. preoperative and five years postoperative uncorrected, best corrected visual acuity and manifest refractions were recorded to compare the out comes of both the procedures. results: forty eyes of 27 patients were found matched regarding age and refractive error. in prk group among 19 patients, 12 (63.2) were male and 7 (36.8) were females whereas in lasik group, males were equal to female patients, four each. uncorrected postoperative visual acuity was comparable in both groups. patients in both groups were happy regarding their visual outcome. conclusion: prk is as effective as lasik for the correction of moderate degree of myopia regarding visual out come and corneal health and is cost effective. ajority of the spectacle or contact lens wearers desire to see clearly without glasses or contact lenses. with the availability of excimer laser for the correction of myopic refractive errors1 this dream seems to come true. kerato refractive procedures are well established and have become more acceptable in the recent years among the people suffering from refractive errors. photorefractive keratectomy (prk) and laser in situ keratomileusis (lasik) are among the commonly performed procedures. prk is a simpler and easy to learn technique whereas lasik is more complicated and has a steep learning curve. it involves creation of corneal flap, application of laser and repositioning of flap exactly back to its place. use of micro keratome makes this procedure more expensive. cost of the procedure is the main concern of most of the patients in third world countries. the purpose of this study was to evaluate the visual outcome of both prk and lasik in age and refractive error matched eyes. material and method retrospective analysis of the patient’s records was done who attended the clinic for follow up. these patients had refractive surgery procedure (prk or lasik) from june 1997 to june 1998 and have completed five years of follow up. patients were divided in two groups (prk patients group a and lasik patients group b) and only age and m 98 refractive error matched patients were included in the study. selected age range was 20 to 25 years and mean refractive error between -6d and -9d were included in the study. one surgeon (author) operated all patients by using the same excimer laser machine (visx 20/20 b). there were no operative and postoperative complications recorded in the notes regarding the procedure. data collected was preoperative manifest refraction and best corrected visual acuity and postoperative uncorrected visual acuity, manifest refraction and best corrected visual acuity. results in group a, 104 eyes of 52 patients whereas in group b, 32 eyes of 16 patients completed five year followup. in group a 30 eyes and in group b 10 eyes ( of 27 patients) met the inclusion criteria of age and preoperative refraction. both eyes of 11 patients in group a and of 4 in group b met the inclusion criteria.(table 1) table 1: total patients 27, eyes 40 group a group b prk n(%) lasik n(%) patients 19 (70.3) 8 (29.6) eyes 30 (75) 10 (24) age(mean) 23.6 years 23.4 years sex male 12 (63.2) 4 (50) female 7 (36.8) 4 (50) table 2: visual acuity preoperatively postoperatively mucva mbcva mucva mbcva prk 0.1 0.85 0.82 0.9 lasik 0.1 0.9 0.84 0.9 mucva=mean uncorrected visual acuity mbcva= mean best corrected visual acuity preoperatively in group a, mean manifest spherical equivalent was -7.16d (sd) ± 0.64 d (range -6 to -9d), mean uncorrected snellen’s visual acuity was 0.1 and mean best corrected visual acuity was 0.85 (range 0.8 to 1.0). whereas in group b, mean manifest spherical equivalent was -8.06 d (sd) ± 0.61 d (range 6.to -9d), mean uncorrected visual acuity was 0.1 and mean best corrected snellen’s visual acuity was 0.9 (range 0.6 to 1.0).(table 2,3). postoperatively in group a, mean uncorrected snellen’s visual acuity was 0.82 (range 0.8 to 1.0), mean manifest spherical equivalent was -0.64 (sd) ± 0.54d (range +0.63 to -1.63d) and mean best corrected snellen’s visual acuity was 0.9 (range 0.8 to 1.0). whereas in group b, mean uncorrected snellen’s visual acuity was 0.84 (range 0.8 to 1.0), mean manifest spherical equivalent was -0.45 (sd) ± 0.7d (range +0.63 to -1.88d) and mean best corrected snellen’s visual acuity was 0.9 (range 0.8 to 1.0).(table 2,3) table 3: refractive status preoperatively postoperatively mse (sd) mse (sd) prk -7.16 (±0.64) -0.64 (±0.54) lasik -8.06 (±0.61) -0.45 (±0.7) msc= mean spherical equivalent sd= standard deviation all corneas were clear. no patient had any loss in best corrected visual acuity. patients had no complaint regarding vision except 2 in group a and one in group b reported gritty sensations in eyes occasionally. all patients were happy regarding visual outcome. discussion the visual out come of both prk and lasik is comparable in the given range of refractive error. all patients in both groups achieved satisfactory level of uncorrected vision. health of the cornea after five years appears satisfactory in both groups. the patients reported no disturbances of night vision. stability of refraction in both groups is found not statistically different after five years post excimer laser treatment. saragoussi d and saragoussi jj2 reported 99 similar kinds of results, though they reported occasional night vision symptoms but 97.8% of the patients were satisfied with their vision. efficacy out comes were generally similar in the prk and lasik groups and both achieved good objective and subjective results after treatment which was also reported by neeracher b3. by careful selection of patients desirable results can be achieved by photorefractive keratectomy in moderate degree of myopia with preservation of corneal health4. conclusion for moderate degree of myopia prk is as effective as lasik in low economic setups where patients cannot afford the cost of expensive procedures but care must be taken to treat higher degrees of myopia by photorefractive keratectomy. author’s affiliation dr. tahir mahmood associate professor department of ophthalmology shaikh zayed hospital, lahore reference 1. seiler t, khale g, kriegerowski m: excimer laser myopic keratomileusis in sighted and blind human eyes.refract corneal surg 1990; 6: 165. 2. saragoussi d, saragoussi jj: lasik, prk and quality of vision:a study of prognostic factors and satisfaction survey. j fr ophthalmol. 2004; 27::755-64. 3. neeracher b, senn p, schipper i: glare sensitivity and optical side effects 1 year after photorefractive keratectomy and laser in situ keratomileusis. j cataract refract surg 2004; 30: 1696701. 4. erie j, mclaren jw, hodge do, et al: long term corneal keratocyte deficit after photorefractive keratectomy and lase in situ keratomileusis. trans am ophthalmol soc. 2005; 103: 5666. as chronic simple glaucoma is nonsymptomatic disease there is a tendency to go slack on recommended medical regimen, hence the adherence and persistensce with medications should be stressed. whatever vision is lost in glaucoma is permanent and irreversible "drugs do not work for people who don't take them" prof. m lateef chaudhry microsoft word ayyazhussainawancasereport2_1_ case report visual loss following laproscopy with contrast ayyaz hussain awan pak j ophthalmol 2007, vol. 23 no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: ayyaz hussain awan classified eye specialist pns shifa, defence, karachi. received for publication april’ 2005 …..……………………….. ase reports of serious operative complications resulting in permanent visual loss have appeared in the ophthalmology, anesthesialogy, and surgical literatures since the 1940’s. perioperative ischemic optic neuropathy (poion), unilateral or bilateral, is a common cause of visual loss in non-ophthalmologic surgery. it is associated with anemia, hypotension, long duration of surgery, excessive hydration (causing intra-operative and immediate postoperative anemia), or a combination of these factors. bilateral visual loss in the presence of normal pupillary light reflexes places the causative lesion posterior to the initial synapse between the retinal ganglion cells and cells of the lgn (lateral geniculate nuclei of the thalamus). case report i present two cases of complete visual loss after laparoscopy with contrast (methylene blue) complicated by accidental dye intravasation into the circulation. the procedure was done as one of the investigations for primary infertility. case 1. thirty three years old female presented with severe deterioration of vision both eyes one week after the procedure. her vital signs were, pulse 80/min, blood pressure 110/70 mm of hg, body temperature. 98.40f. on ocular examination visual acuity was hand movements (hm) both eyes. no affrent pupillary defect (apd) seen. fundus revealed macular edema on both sides. on investigation, hemoglobin % 11.4 mg/dl, total leucocyte count 10.7x109/l, serum urea 4.9 mmol/l, serum creatinine 1502 µmol/l, sodium 126 mmol/l, potassium 4.2 mmol/l, serum bilirubin 0.4 µmol/l, serum alt 49 u/l, serum alkaline phosphtase 316 u/l, serum total protein 67 g/l. ultrasonography abdomen revealed 40ml fluid (dye) in pelvis. after repeated haemodialysis renal function parameters stabilized and she was discharged. poor prognosis regarding visual status was explained to the patient and her family. c case 2: a 22 years old female developed anaphylactic shock followed by fluid overload and alveolar membrane diffusion defect after the procedure. on general physical examination, skin cold and clammy. vital signs: pulse 124/min, blood pressure 90/50 mm of hg, respiratory rate 40/min. on ocular examination: visual acuity hm on both sides. no apd. fundus revealed macular edema on both sides. nasal margins of the optic disc were blurred. on systemic examination: chest auscultation revealed bilateral crackles more on right side. blood oxygen saturation 68%. she was diagnosed as suffering from acute respiratory distress syndrome (ards) and managed with intra venous steroids, peripheral vasoconstrictors and oxygen inhalation. after 10 days she developed maculopapular rash on trunk and ecchymotic patches over left forearm. she was diagnosed with serum sickness and treated accordingly. her visual status remained same except increased pallor of the optic disc and development of apd. discussion postoperative visual loss is a rare but disastrous complication that has an estimated incidence of 0.011% after non-ocular surgery1. poion, most likely related to compromised blood flow to the optic nerve, is subdivided into an anterior type, with swelling of the optic disc, and a posterior or retro bulbar type, in which the optic disc initially appears normal. in both types, the optic disc becomes pale over time if there is irreversible damage to the nerve. although no treatment has been proven to improve vision in poion, several groups recommend treatment with systemic corticosteroids, transfusion to a hematocrit above 30% and mean arterial pressure kept reasonably close to the patient's baseline2. retro bulbar poion is the most likely diagnosis in case 2 with the appearance of apd even though 10 days after the procedure. knox and associates3 reported a variety of uremic optic neuropathy characterized by bilateral visual loss with disc swelling in patients with severe renal disease manifested by uremia, anemia and hypertension with improvement following haemodialysis. bilateral ischemic optic neuropathy (ion) was reported in a young woman with optic disc drusen and chronic hypotension while she was undergoing renal dialysis.4 these risk factors, that is, pre-existing hypertension, anemia and uremia, taken collectively, interfere with vital auto regulation of arterial perfusion at the disc or retro-bulbar nerve in ways not yet completely understood. frequently enough, both eyes are involved, and bilateral retro-bulbar infarcts with mild disc edema have been documented histologically.5 risk factors apparently include systemic hypertension, diabetes, coronary artery disease6, pre-existing anemia and occasionally renal failure with uremia. patients with acute non-surgical hypotensive episodes, including unduly rapid correction of malignant hypertension and during renal dialysis, had anterior ion with partial recovery on immediate reversal of hypotension, however pre-existing anemia was present (hematocrit range of 23% to 28%)7,8. one may conclude that intra operative hypotension, usually coupled with low hematocrit, is the single most common cause of genuine posterior ion. cases of blood loss with visual loss have been reversed apparently by blood replacement9. case 1 presented with bilateral visual loss with reactive pupils placing the causative lesion posterior to the site of the initial synapse between the retinal ganglion cells and cells of the lgn, the optic radiations, or the cerebral cortex of the occipital lobes. this is because pupillary reactivity requires intact function of the pupillomotor fibers, which diverge from the optic tracts anterior to the lateral geniculate nuclei. bilateral occipital cortex lesions are more common than lesions of both thalami10. cortical visual loss, decreased vision from involvement of the occipital cortex, is most commonly due to vascular lesions (infarction), but may also result from trauma, compressive lesions, and toxic agents. the visual loss may occur in association with other neurological deficits or in isolation. it should be noted that even with a complete homonymous hemianopia, visual acuity is preserved. this means that patients with reduced visual acuity from a cortical lesion must have bilateral cortical involvement. bilateral occipital infarcts occur after involvement of both posterior cerebral circulations. although simultaneous occipital cortical lesions may occur, a more common scenario is a sequential lesion. the initial lesion causes a homonymous hemianopia, which may go undetected. the second lesion, to the contra lateral occipital lobe, results in loss of visual acuity, which may be the first sign of trouble recognized by the patient11. the predominant ct finding is edema of the sub cortical white matter involving the parieto-occipital lobes. this predilection for the parieto-occipital lobes may be explained by the sparse sympathetic innervation of the vertebrobasilar system, resulting in increased perfusion during periods of hypertension and breakthrough of auto regulation affecting these areas12. could the visual loss have been due to leber hereditary optic neuropathy13 but it presented coincidentally with the procedure performed, is a question, which remains to be answered. conclusion patients with bilateral visual loss and normal pupillary light reflexes should undergo neuro imaging focusing on the visual pathways posterior to the lgn14. bilateral sudden visual loss is a great trauma for the patient and referral to the psychiatrist is a must to reduce the suicidal tendencies developing in such cases and also for the guidance they need to tackle with the daily life problems they would be facing in future. author’s affiliation surg. cdr. ayyaz hussain awan classified eye specialist pns hafeez, (naval hospital) sector e-8, islamabad references 1. kamming d, clarke s. postoperative visual loss following prone spinal surgery. br j anaesth. 2005; 95: 257-60. 2. chang sh, miller nr. the incidence of vision loss due to perioperative ischemic optic neuropathy associated with spine surgery. the johns hopkins hospital experience. spine. 2005; 11: 1299-1302. 3. knox dl, hanneken am, hollows fc. uremic optic neuropathy. arch ophthalmol. 1988; 106: 50. 4. michaelson c, behrens m, odel j. bilateral anterior ischemic optic neuropathy associated with optic disc drusen and systemic hypotension. br j ophthalmol. 1989; 73: 767. 5. johnson mw, kincaid mc, trobe jd. bilateral retrobulbar optic nerve infarctions after blood loss and hypotension: a clinicopathologic case study. ophthalmology 1987; 94: 1577. 6. slavin ml. ischemic optic neuropathy after cardiac arrest. am j ophthalmol. 1987; 104: 435. 7. connolly se, gordon kb, horton jc. salvage of vision after hypotension-induced ischemic optic neuropathy. am j ophthalmol. 1994; 117: 235. 8. shapira om, kimmel wa, lindsey ps. anterior ischemic optic neuropathy after open heart operations. ann thorac surg 1996; 61: 660. 9. jaben sl, glaser js and daily m. ischemic optic neuropathy following general surgical procedures. j clin neuro ophthalmol. 1983; 3: 239. 10. medscape general medicine. 2005; 7: 58. 11. foroozan r, coats dk. bilateral visual loss with normal pupillary light reaction. medscape ophthalmol. 2003; 4. 12. knower mt, pethke sd, valentine vg. reversible cortical blindness after lung transplantation. southern medical journal posted 07/01/2003. 13. kanski jj. neuro-ophthalmology. in: kanski jj, editors. clinical ophthalmology. 5th ed. philadelphia: butterworthheinemann 2003; 607. 14. cardone sc, coats dk. an occult cause of bilateral visual loss in a child. medscape ophthalmology 2005; 6. 106 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology original article treatment of localized retinal redetachment in silicon oil filled eyes muhammad tariq khan, sidrah riaz, qasim lateef chaudhry pak j ophthalmol 2019, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad tariq khan (mbbs, fcps) associate professor ophthalmology akhter saeed medical and dental college bahria town, lahore farooq hospital/medicare eye center e-mail: stariq69@hotmail.com …..……………………….. purpose: to assess the success rate of retinal reattachment surgery in localized re-detachment in silicon oil filled eyes which had previously undergone primary retinal detachment (rd) repair with pars plana vitrectomy (ppv) with silicon oil. study design: retrospective cross sectional case series. place and duration: farooq hospital and medicare eye centre, lahore from october 2016 to november 2017. material and methods: all those patients were included in our study who underwent primary retinal attachment surgery with pars plana vitrectomy (ppv) and silicon oil for complicated retinal detachment as an internal tamponade and later presented with localized inferior retinal detachment within 6 months of previous rd repair. patients with total detachment, extensive pvr, retinal shortening, gas tamponade, total re rd, and external scleral buckle were excluded. two ports were made under local anesthesia instead of three conventional ports, simple non irrigation vitrectomy technique was used to achieve retinal reattachment under silicon oil without exchange of so. results: ten eyes of ten patients were included, eight (8) males and two (2) females. the age range was from 18 to 79 years. most common cause of re detachment (rd) in all cases was proliferative retinopathy (pvr) followed by retinal break. the new retinal break was identifiable in three (3) cases. all cases attained anatomical success in term of complete retinal attachment after second operation in one year follow up period. conclusion: simple non irrigation vitrectomy surgical technique under local anesthesia is effective, economical and time saving as compared to complicated three port vitrectomy with oil exchange. keywords: silicon oil, rhegmatogenous retinal detachment, proliferative retinopathy, retinal break, perflourocarbon. etinal detachment (rd) is separation of neurosensory retina (nsr) from retinal pigment epithelium (rpe). incidence of rhegmatogenous retinal detachment (rrd) repair surgery is 6.3 to 17.9 per 100,000 population annually. first surgical repair attempt fails to attain anatomical success in 10 to 20% cases and needs a second surgery and 5% cases are unsuccessful even after second surgical repair1. in eyes with proliferative retinopathy (pvr) success rate of anatomical repair are less 2. major risk factors for developing rhegmatogenous retinal detachment (rrd) are myopia, lattice degeneration, intraocular surgery aphakia or pseudophakia and nd: yag capsulotomy. silicon oil (so) is a good long term intraocular tamponade used in repair of rrd and retinal detachment (rd) associated with pvr2-5. it is a good choice in complicated retinal detachments11-15 but when used as tamponade, it is also associated with certain complications like corneal band keratopathy, high intraocular pressure (iop), lens opacification, hypotony and possible retinal toxicity6. although the current techniques of retinal repair are much improved, still pvr is the most common cause of redetachment. pvr can occur even in eyes filled with so as endotamponade, mostly in inferior quadrant7. the major causes of failure of first attachment repair are missed breaks, anterior or posterior pvr, poor patient r mailto:stariq69@hotmail.com treatment of localized retinal redetachment in silicon oil filled eyes pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 107 head positioning, inadequate endolaser application and retinal shortening. the proliferative retinopathy (pvr) is a clinical syndrome associated with retinal traction and detachment in which cells with proliferative potential contract and there is multiplication on the retinal surface and in vitreous8-11. some degree of pvr is found in up to 10% of rd124. it takes 4 to 12 weeks usually to develop pvr. there are multiple techniques of retinal re-detachment repair with so in situ i.e. surgical intervention with or without silicon oil removal, elimination of membranes with or without retinectomy, use of pfcl with internal tamponade of gas or silicon oil. the purpose of our study was to assess the success rate of retinal reattachment surgery for localized re-detachment under oil in eyes which had previously undergone primary retinal detachment (rd) repair with pars plana vitrectomy (ppv) with silicon oil with simple two ports non irrigation technique without so exchange. material and methods there were 10 eyes of 10 patients included in the study who presented with re-detachment in eyes filled with silicon oil. all patients had history of rd repair with ppv and so (primary vitrectomy) within the last 6 months. anatomical success rate was defined as complete reattachment of retina and functional success rate was defined as recovery of ambulatory vision that was counting fingers (cf) or above. all patients presented within 6 weeks of first rd repair. the primary rd repair was performed somewhere else in nine (9) patients by different eye surgeons and one was operated by same surgeon who performed all secondary surgeries. all second surgeries in ten (10) patients were performed by single surgeon in medicare eye centre, from november 2016 to october 2017. inferior retinal re-detachment with grade c 1 pvr was observed in all cases under silicon oil. all patients were delayed till 6 to 8 weeks after primary rd repair surgery to allow membranes to mature so that membrane could be removed easily as grabbing of immature membranes during surgery can be difficult. scleral buckling was not used in any of these cases. seventy percent cases showed pvr in one quadrant of retina (in seven patients) while open new breaks were identified in 30% cases (in three patients). none of these cases showed opening of primary break. all patients underwent thorough history, clinical examination on slit lamp with wide field indirect fundus lens and indirect ophthalmoscope. on history poor post operative positioning was common among all patients. visual acuity (va), pupil reaction, iop (intra ocular pressure) was noted and fundus diagram was drawn to show any identifiable break and extent of retinal detachment. the grading of pvr was done according to retina society classification 198315. patients were examined postoperatively at day one than at 1st, 3rd and 6th weeks and then two monthly. under local anesthesia two sclerectomies were created at 2 and 11 o’clock positions with 23 gauge. one port was used for endoillumination and the other for second instrument (laser probe, flute needle and cannula). the vitreous cutter was not used in our procedure and silicon oil was not removed. membranes were peeled off from surface of retina with retinal forceps and scissors. as all patients had inferior rd, inferonasal retinotomy was created with help of cautery and subretinal fluid (srf) was aspirated under silicon oil through flute needle. laser photocoagulation was applied to the entire previously detached retina sparing the macula. laser application extended from ora serrata to inferior vascular arcade. to counteract hypotony more silicon oil was injected if required during surgery. sclerectomy ports were closed. results there were 8 male patients and 2 female patients (fig. 1). the age range was 18 to 79 years with a mean of 49 ± 30 years. proliferative retinopathy (pvr) was the fig. 1: muhammad tariq khan, et al 108 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology leading cause of re-detachment due to inadequate positioning, incomplete oil fill and inadequate laser. retinal breaks were seen in 30% cases. in 70% cases break was not found (fig. 2). fig. 2: nine patients were pseudophakic and 1 was aphakic. as silicon oil was not removed therefore the total time duration of the procedure was reduced considerably. all the patients were followed up for one year and all patients were stable with ambulatory vision (counting fingers or above) with anatomically successful attachment. none of these patients suffered from glaucoma, corneal opacification, band keratopathy or oil emulsification after one year of follow up. all patients had silicon oil in situ as tamponade and silicon oil was not removed till 6 months of follow-up. table 1: showing cause of re-rd. sr. causes no. of patients % age male female 1. poor head position 4 1 50 2. new break formation 3 0 30 3. under fill oil 1 1 20 total 8 2 100 discussion after primary repair of complicated retinal detachment with silicon oil16-18, recurrent detachment may still occur due to open retinal break with or without pvr19-22. the rate of recurrence of rd in so filled eyes varies from 21.4% to 77%25. recurrence of rd under so provides management challenge. unfortunately, guidelines for the diagnosis and management of these complicated cases are not defined clearly. multiple factors contribute towards failure of primary retinal detachment (rd) repair. there are multiple options available for surgery under so including membrane surgery with so in situ, followed by removal of membranes and internal tamponade with so or gas, and supplementing with sb without repeat vitrectomy. the major causes of re-detachment after first repair are missed breaks during primary repair (small peripheral breaks located at vitreous base are difficult to identify during ppv so 360 laser photocoagulation is recommended). perisilicon oil proliferation due to poor patient head positioning is seen in early post operative period of incomplete oil fill. even with complete fill a small concave meniscus of vitreous fluid remains inferiorly when patient is upright and oil bubble rises slightly superiorly. this vitreous fluid contains inflammatory and metaplastic cells and proteins leading to proliferation on retinal surface in 50 to 60% eyes called perisilicon proliferation23. incidence of macular pucker in eyes with pvr is 5 to 15 % and peeling is not difficult under silicon oil. second surgery was delayed till 2 months to allow membranes to mature. membranes under the so may vary in thickness and adherence to the underlying detached retina. sometimes they are so thin, pigmented, and strongly adherent to the retina that it is difficult to get at an edge and lift. more often, these membranes in so-filled eyes can be held and removed with intraocular forceps with great ease. as the retina remains attached under oil, membrane removal is easier. surgery under oil has an advantage in reducing the operation time. there are different techniques to treat re-detachment including complete redo vitrectomy after removal of silicon oil, use of segmental or encircling scleral buckle with external drainage of srf; silicon oil may or may not be injected. gas may be used to reinforce internal tamponade. we used a simple technique without any scleral buckle and found it effective for achieving anatomical success during 12 months follow up period. no statistical data is available on such study in pakistan but results of our study are comparable with studies in other countries(24,25). the study conducted in india by nagpal et al. showed success rate of 85.2%25 and in our study success rate was 100% in selected patients. it is recommended to use 5000 cs silicon oil as its complications are less than 1000 cs silicon oil. the limitation of our study was that the sample treatment of localized retinal redetachment in silicon oil filled eyes pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 109 size was small and more extensive studies are required to elaborate the results further. conclusion the results of this small case series showed that irrigation free vitrectomy with added laser photocoagulation without scleral buckling is effective in term of achieving retinal attachment. this is significant time saving technique as silicon oil is not removed for treatment of inferior re-detachment in eyes filled with silicon oil with without extensive proliferation. financial disclosure the authors have no financial interest. author’s affiliation dr. muhammad tariq khan mbbs, fcps associate professor ophthalmology akhter saeed medical and dental college bahria town lahore dr. sidrah riaz mbbs, doms, fcps, frcs associate professor ophthalmology, akhter saeed medical and dental college, bahria town, lahore dr. qasim lateef chaudary mbbs, fcps, frcs associate professor of ophthalmology jinnah hospital, lahore author’s contribution dr. muhahammad tariq khan concept, study design, primary surgeon, critical analysis. dr. sidrah riaz data collection, manuscript writing, assistant in surgery. dr. qasim lateef chaudary critical analysis. references 1. cibis pa, becker b, okun e, canaan s. the use of liquid silicone in retinal detachment surgery. arch ophthalmol. 1962; 68: 590-9. 2. scott jd. the treatment of massive vitreous retraction by the separation of pre-retinal membranes using liquid silicone. mod probl ophthalmol. 1975; 15: 285-90. 3. watzke rc. silicone retinopoiesis for retinal detachment: a long-term clinical evaluation. arch ophthalmol. 1967; 77: 185-96. 4. cockerham w, schepens cl, freeman hm. silicone injection in retinal detachment. mod probl ophthalmol. 1969; 8: 525-40. 5. leaver pk, grey rhb, garner a. silicone oil injection in the treatment of massive preretinal retraction: ii. late complications in 93 eyes. br j ophthalmol. 1979; 63: 3617. 6. gonvers m, hornug jp, de couten c. the effect of liquid silicon on the rabbit retina. arch ophalmol. 104; 1057-62 7. singh ak, glaser bm, lemor m, et al. gravitydependent distribution of retinal pigment epithelial cells dispersed into the vitreous cavity. retina. 1986; 6: 77-80. 8. scott jd. treatment of massive vitreous retraction. trans ophthlmo soc uk. 1975; 95: 429-32. 9. machemer r. pathogenesis and classification of massive periretinal proliferation. br j ophthalmol. 1978; 62: 73747. 10. the classification of retinal detachment proliferative vitreoretinopathy. ophthalmology, 1983; 90: 121-5. 11. machemer r, aaberg tm, freeman hm, et al. an updated classification of retinal detachment with proliferative vitreoretinopathy. am j ophthalmol. 1991; 112: 159-65. 12. charteris dg, sethi cs, lewis gp, et al. proliferative vitreoretinopathy developments in adjunctive treatment and retinal pathology. eye (lond). 2002; 16: 369-74. 13. tseng w, cortez rt, ramirez g, et al. prevalence and risk factors for proliferative vitreoretinopathy in eyes with rhegmatogenous retinal detachment but no previous vitreoretinal surgery. am j ophthalmol. 2004; 137: 1105-15. 14. heimann h, bartz-schmidt ku, bomfeld n, et al. scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. ophthalmology, 2007; 114: 2142-54. 15. the retina society terminology committee. the classification of retinal detachment with pvr. ophthalmology, 1983; 90: 121-125. 16. cox ms, trese mt, murphy pl. silicone oil for advanced proliferative vitreoretinopathy. ophthalmology, 1986; 93 (5): 646—650. 17. mccuen 2nd bw, landers 3rd mb, machemer r. the use of silicone oil following failed vitrectomy for retinal detachment with advanced proliferative vitreoretinopathy. ophthalmology, 1985; 92 (8): 1029— 1034. 18. grey rh, leaver pk. results of silicone oil injection in massive preretinal retraction. trans ophthalmol soc uk. 1977; 7 (2): 238— 241. muhammad tariq khan, et al 110 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology 19. mccuen 2nd bw, de juan jr e, landers 3rd mb, machemer r. silicone oil in vitreoretinal surgery. part 2: results and complications. retina. 1985; 5 (4): 198-205. 20. federman jl, schubert hd. complications associated with the use of silicone oil in 150 eyes after retinavitreous surgery. ophthalmology, 1988; 95 (7): 870-876. 21. sell ch, mccuen 2nd bw, landers 3rd mb, machemer r. long-term results of successful vitrectomy with silicone oil for advanced proliferative vitreoretinopathy. am j ophthalmol. 1987; 103 (1): 2428. 22. yang cm. surgical treatment for diabetic retinopathy: 5year experience. j formos med assoc. 1998; 97 (7): 477484. 23. lewis h, burke jm, abrams gw, et al. perisilicone proliferation after vitrectomy for proliferative vitreoretinopathy. ophthalmology, 1988; 95: 583-91. 24. yang cm, hsieh yt, yang ch, liu kr. irrigation-free vitreoretinal surgery for recurrent retinal detachment in silicone oil-filled eyes. eye (lond) 2006; 20: 1379–82. 25. nagpal. m, chaudhary p., wachasundar p., eltayib a., and raihan a. indian journal of ophthalmology. 2018 dec; 66 (12): 1763–1771. https://www.ncbi.nlm.nih.gov/pubmed/?term=nagpal%20m%5bauthor%5d&cauthor=true&cauthor_uid=30451176 https://www.ncbi.nlm.nih.gov/pubmed/?term=chaudhary%20p%5bauthor%5d&cauthor=true&cauthor_uid=30451176 https://www.ncbi.nlm.nih.gov/pubmed/?term=wachasundar%20s%5bauthor%5d&cauthor=true&cauthor_uid=30451176 https://www.ncbi.nlm.nih.gov/pubmed/?term=eltayib%20a%5bauthor%5d&cauthor=true&cauthor_uid=30451176 https://www.ncbi.nlm.nih.gov/pubmed/?term=raihan%20a%5bauthor%5d&cauthor=true&cauthor_uid=30451176 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6256876/ 263 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol original article the efficacy and safety of 0.3% acetylcysteine eye drops in filamentary keratitis sameera irfan pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: sameera irfan consultant envision” squint & oculoplastics centre email: sam.irfan48@gmail.com …..……………………….. purpose: to determine the safety and efficacy of 0. 3% acetylcysteine eye drops for the resolution of symptoms and signs of filamentary keratitis. study design: quasi experimental study place & duration of study: this study was conducted at a tertiary care centre (envision, squint & oculoplastics centre, lahore) from april 2016 to october 2018. material and methods: fifty two consecutive cases (104 eyes) with mild to severe filamentary keratitis, from 9-72 years (mean 49 ± 8.6) were included. cases with active ocular surface infection, uveitis, recent ocular surgery (<1 month) and pregnant/lactating patients were excluded. all cases were prescribed lubricants, anti-inflammatory therapy (tacrolimus skin cream 0.03%) and tetracycline eye ointment for meibomian gland disease (mgd). alternate cases were divided into two equal groups of 26 cases; group a received acetylcysteine eye drops 0.3%, four times daily, group b cases received placebo eye drops (distilled water in a bottle). clinical symptoms on ocular surface disease index (osdi), corneal filaments, corneal fluorescein staining, tear film but and schirmer’s test were recorded at the beginning of the study and every two weeks, for the next 12 weeks. results: primary outcome measure was reduction of symptoms (osdi score) and absence of filament formation after treatment. the patients were followed-up for a mean duration 12 ± 2 weeks. a marked subjective and objective improvement (100%) was noted in all cases that received acetylcysteine 0.3% eye drops as compared to the placebo group. conclusion: acetylcysteine 0.3% eye drops efficiently dissolve filaments and offer quick resolution of symptoms even in severe cases of filamentary keratitis. key words: filamentary keratitis, dry eyes, acetylcysteine eye drops, mucolytic agents. ilamentary keratitis is a chronic, recurrent and functionally debilitating condition in which mucous strands or filaments are present over the ocular surface. with each blink, the eyelids pull upon the filaments and the traction/pull exerted on the underlying corneal epithelium results in a lot of ocular discomfort, pain and a constant foreign body sensation in the eye1. it occurs in association with a number of ocular surface diseases like sjögren syndrome (ss), non-sjogren’s dry eyes syndrome (non-ss), stevens johnsons syndrome, vitamin a deficiency, lacrimal gland tumour/dacryo-adenitis, superior limbic keratoconjunctivitis, chronic vernal keratoconjunctivitis, post-herpetic keratitis, recurrent corneal erosions, neurotrophic keratitis, thyroid eye disease (ted), facial palsy, bullous keratopathy, and f the efficacy & safety of 0.3% acetylcysteine eye drops in filamentary keratitis pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 264 prolonged patching following ocular surgery. normally, there is a certain fixed ratio of aqueous: mucin in the tear-film2. the mucin molecules float freely in the aqueous component of the tear-film and act as scavenger molecules, and secondly, it forms a smooth, uniform coating over the glycocalyx of the corneal apical cells thus making the normally hydrophobic cornea hydrophilic, and allow the aqueous component of the tear-film to spread uniformly over the cornea. the basic mechanism for filament formation is an increased ratio of mucin to aqueous. excess mucin accumulates in the lower conjunctival fornix and is joint together by disulphide bonds, thereby forming mucous strands. the free mucin molecules are no longer available to coat the glycocalyx over the apical corneal epithelial cells so the corneal surface becomes hydrophobic. the reduction of aqueous component increases the osmolarity of the tear-film; the increased concentration of solutes in the tear-film produce chemical inflammation of the ocular surface. this affect is exaggerated in the hot, dry climate, as a part of the ageing process (androgen deficiency) and in diabetes. the hyper-osmolar tears lead to sloughing of the desiccated corneal surface epithelial cells thus producing epithelial defects that act as high-energy pits or a nidus to which mucous strands adhere firmly. the corneal epithelium grows around the mucous to form a filament. in addition, the inflammatory cytokines and enzymes released from eosinophils and lymphocytes in vkc, sjogrens syndrome, viral keratitis etc, further increase the osmolarity of the tear film, thereby creating a chronic inflammation3 and ocular surface damage. the filaments are gelatinous structures, refractile in appearance, consisting of a focal “head” firmly adherent to the compromised areas of corneal epithelium and a freely floating “tail” of varying length4. the head is made up of a central core of desquamated corneal epithelial cells, surrounded by degenerating conjunctival epithelial cells and a thick layer of mucin. they vary in size from 0.5 mm sessile adhesions to 10 mm long strings. with each blink, vertical friction causes a lot of ocular discomfort and pain5, while further shearing of the corneal epithelium results in increased inflammation of the underlying exposed stroma. mechanical removal of filaments increases the inflammation and promotes further filament formation. to manage filamentary keratitis6, the treatment needs to be targeted towards treating the underlying cause, the associated ocular surface inflammation and preventing further epithelial degradation, to remove/treat the filaments. in order to address all these issues, the therapeutic drug armamentarium must include topical lubricants (to reduce the mechanical stress and ocular discomfort by diluting inflammatory cytokines, and also stabilise the tear film) and topical anti-inflammatory drugs (tacrolimus, cyclosporin a, corticosteroids and nonsteroidal agents). in order to dissolve the filaments, oral (acetylcysteine, carboxymethyl cysteine, bromhexine) as well as topical mucolytic agents like 510% acetylcysteine eye drops have been used in various studies. they dissolve the filaments efficiently but the main problem with these eye drops is the severe ocular irritation, burning and stinging upon their instillation that persists for 10-30 min. this results in a reduced patient compliance to therapy. unless the filaments are dissolved efficiently, the vicious cycle of further filament formation cannot be broken. in pakistan, commercially preparation of acetylcysteine eye drops are not available. with the help of a dispensing pharmacist, we prepared a diluted preparation of 0.3% acetylcysteine eye drops for our patients. this study was conducted to analyzse whether such a diluted preparation can efficiently dissolve the filaments and whether it is better tolerated than the 5-10% preparation by the patients. material & methods a prospective interventional study was conducted at a tertiary care centre, for a period of two and a half years, from april 2016–october 2018. an approval from the centre’s ethical committee was obtained and there was no conflict of interest to conduct this study. during this period, 52 consecutive cases (104 eyes) which presented with mild to severe filamentary keratitis were included in the study. they were between the age of 9-72 years (median 49 ± 8.6), with 31 females and 21 males. a detailed history was taken regarding the duration and severity of symptoms, systemic illness (arthritis, thyroid dysfunction, psoriasis, vitiligo and other auto-immune disorders), recent ocular surgery and a detailed list of all topical and systemic medications being used by the patient. the time spent on digital screens per day, occupation and smoking was also noted. the baseline characteristics of the 52 cases are shown in table 1. cases with an active ocular surface infection, uveitis and recent ocular surgery (< one month) and pregnant/lactating patients were excluded from the study. sameera irfan 265 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol a detailed ophthalmic examination was performed in order to assess the underlying cause of the patient’s problems and to grade the severity of disease before initiating the specific therapy. facial appearance regarding brow droop, increased frequency of blinking, blepharospasm, dermatochalasis, position and contour of the eyelids was noted. presence or absence of meibomian table 1: baseline characteristics of 52 cases. age range: 9 – 7 years mean : 41.20 median: 55 sex males: 21 (40.38%) females 31 (59.61%) severity of dry eyes moderate: 16 cases (30.76%) severe 36 cases (69.23%) severity of filaments mild: 4 cases (7.7%) moderate: 12 cases (23%) severe 36 cases (69.23%) underlying cause post-cataract surgery: 4 cases vkc : 6 cases facial palsy: 4 cases thyroid eye disease; 4 cases non-ss dry eyes: 23 cases ss dry eyes: 5 cases stevens johnsons: 8 cases gland dysfunction was assessed by looking for lid margin thickening, telangiectasia, hyperemia, keratinization or frothing at the angles; noting the quality of meibum, the ease with which it could be expressed, position of the meibomian duct orifices, their clogging or notching (indicating absence), trichiasis/distichiasis. the lower tear meniscus height and its clarity was noted; the presence of corneal filaments, their number/site, as well as that of corneal epithelial punctate staining with fluorescein, corneal epithelial defect, scarring, pannus formation was also noted. the primary parameters assessed for the purpose of the study were osdi, fluorescein staining score (fss) of the ocular surface, tfbut, and schirmer’s 1 test. the patients were asked to fill in the ocular surface disease index questionnaire7, osdi, which is a 12-question survey that was developed by the outcomes research group at allergan inc; to record the fss8, the ocular surface was divided into three zones: the nasal bulbar conjunctiva, temporal bulbar conjunctiva, and the cornea. each zone was evaluated on a scale of 0-3, with 0 = no staining, 1 = a few separated spots, 2 = many separated spots, 3 = an area of confluent staining; the maximum score possible was 9. the severity of filamentary keratitis was graded by counting the number of filaments on the cornea as grade 1 (mild) = 1-4 filaments, grade 2 (moderate) = 5-9 filaments, grade 3 (severe) = filaments scattered over the whole surface of cornea. the schirmer’s test readings were recorded after instillation of one drop of topical anaesthetic (0.5% proparacaine hydrochloride). in a silent room, away from the fan, a filter paper strip (35 × 5 mm, bent at 5 mm) was placed at the lateral one-third of the lower lid margin. care was taken to prevent the paper from touching the cornea, by asking the patient to look up while placing the strip. the patient was instructed to keep the eyes closed, and not to talk during the test. after 5 minutes, the strip was removed and the level of strip wetting (in mm) was measured. the tear secretion was considered abnormal if the reading was equal to or less than 15 mm. all cases were prescribed the regular dry eyes treatment protocol9 comprising of lubricant eye drops 1 – 2 hourly during the day (depending upon the disease severity), lubricant eye ointment (lacrilube, allergan pharma) at night, anti-inflammatory therapy as tacrolimus skin cream 0.03% (crolimus, valor pharma) applied in the evening into the lower conjunctival fornix by a cotton-tip. for the associated meibomian gland dysfunction, tetracycline eye ointment (xinoxy, remington pharma) was prescribed, to be massaged into the lid margins at night and application of a hot, wet towel to lid margins for 10 minutes in the morning followed by gentle scrubbing of closed eyelids with baby shampoo. all patients were instructed to quit/reduce smoking and drink at least 8 glasses of water daily. in addition, the compounding pharmacist was instructed to divide the alternate cases into two equal groups; the odd number of cases, from 1-51 were included in group a, and even number of cases from 2-52 were included in the group b, so that each group consisted of 26 alternate cases. the group a cases received acetylcysteine eye drops 0.3%, freshly prepared by the compounding pharmacist, to be instilled four times daily, whilst the group b cases received placebo eye drops (distilled water in a bottle). patients were instructed to keep the bottle refrigerated the efficacy & safety of 0.3% acetylcysteine eye drops in filamentary keratitis pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 266 in between instillation, discard them after a month and get a fresh bottle from the pharmacist. only the compounding pharmacist had the list of cases who received either the acetylcysteine or the placebo eye drops. the list was disclosed to the examining ophthalmologist at the end of the study for analyzing the results. the manual removal of filaments or application of a bandage contact lens was not performed in any case. the severity of clinical symptoms (osdi), the number of corneal filaments, corneal fluorescein staining, tear film but, schirmer’s test readings were recorded at baseline and then at each follow-up visit which was conducted every 2 weeks for 12 weeks. for statistical analysis, the spss software version 20 was used. the data was expressed as mean and standard deviation (frequency distributions ± sd) for the osdi score while it was expressed as median and range for the fss, tfbut, filament grade and schirmer’s test. a “paired" t-test was used to assess the scores from the same set of patients (for both group a and group b cases) at baseline and then at the 12 week follow-up. the final 12 week score obtained by group a and b cases was analyzed separately to see which indices improved significantly between the two groups, and p < 0.05 was taken to indicate statistical significant. the efficacy analysis population included all cases that completed the study. the safety analysis population included all cases that were enrolled in the study. the statistical analyses included data for the worst affected eye. results the baseline demographics of the 52 consecutive cases (104 eyes) included in the study are demonstrated in table1; there were 21 males (48.38%) and 31 females (59.61%), with an age range of 9 72 years (mean 41.20, and median 55 years). severe dry eyes were noted in 36 cases (69.23%)out of the total 52 and were due to non-sjogren’s syndrome (ss) (23 cases) or ss (5 cases), and the filaments were present in the inter-palpebral region of the cornea along with punctate corneal staining in the same region. the 8 cases due to chronic stevens johnson’s syndrome also had severe dry eyes, with the corneal filaments and staining diffusely scattered all over the cornea. the remaining 16 cases (30.76%) had dry eyes of a moderate severity. they included 6 cases with acute-on chronic vkc, the filaments were present next to the area of limbitis, while the 4 cases with exposure keratopathy due to chronic facial palsy and 2 cases of thyroid eye disease had filaments at the lower limbus. the 4 post-cataract surgery cases had a mild dry eye with a few filaments at the incision site while one had mucous plaques around the corneal sutures. the presenting complaints of all 52 cases are shown in table 2; the most common presenting complaints were ocular discomfort, photophobia and a foreign body sensation in the eyes in all 52 cases (100%). corneal filaments were present in all 52 cases (100%); the site of filaments was determined by the underlying cause while the number was related to the severity and chronicity of the disease. table 2: frequency of symptoms in 52 cases. symptoms baseline photophobia foreign body sensation eye pain eye discomfort itching blurred vision blepharospasm watering discharge 52 cases (100%) 52 cases (100%) 52 cases (100%) 52 cases (100%) 47 cases (90.38%) 31 cases (59.6%) 28 cases (53.84%) 47 cases (90.38%) 12 cases (23%) the primary parameters assessed for the purpose of the study are demonstrated in table 3, and their response to therapy in both groups from baseline till 12 weeks of regular two weekly follow-up. in all group a cases, the osdi score gradually improved from a mean score of 41.5 ± 5.26 to 4 ± 1.5 over the 12 weeks of continued therapy with acetylcysteine. even the diluted preparation of 0.3% efficiently removed corneal filaments in all cases within 2-4 weeks of therapy. a recurrence of filaments was noted only in 3 cases who had stopped using acetylcysteine abruptly. therefore, the remaining patients were instructed to continue with acetylcysteine therapy for at least one more month after the total clearance of filaments. all 26 cases in group a completed the 12 weeks follow-up and showed excellent compliance to therapy. only 2 patients (7.7%) complained of mild discomfort on instillation of acetylcysteine drops, but no pain or stinging. the fluorescein staining score (fss), as shown in table 3, improved in group a cases from a median of 2 (range 1 – 4) at baseline, to 0 at 12 weeks follow up which was highly statistically significant (p < 0.00001). the tfbut increased from 4 (range 1-7) sec to 9 (range 7-13) sec at 12 weeks, indicating a marked improvement (p < 0.0001). the schemer’s 1 readings sameera irfan 267 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol gradually improved in all cases from 2.5 (range 0-4) mm at baseline to 8 (range 5-12) sec (p < 0.001), though very slowly in cases with stevens johnson’s syndrome. in group b cases, the osdi score improved very slowly and gradually from the baseline score of 40.67 to 28.5 ± 3.4 over the 8-10 weeks, despite the continued use of lubricants and tacrolimus therapy. this was much less improvement as compared to the group a cases (improved to 4 ± 1.5). it was due to the persistence of corneal filaments and the resultant ocular discomfort, because of which 3 cases did not complete the 12 weeks follow up and dropped out of the study. a statistically significant difference (p = 0.05) between acetylcysteine therapy and the placebo group was found for the osdi score as well as all the objective parameters assessed i.e. the fss, tfbut and schirmer’s score, which showed only a slight improvement in the placebo group, as demonstrated in table 3. table 3: results: comparison between group a & b. parameter group baseline 2 wks 4 wks 6 wks 8 wks 10 wks 12 wks p value osdi a 41.5±  5.26 32 ±   6.97 24.5 ±   5.50 18 ±   3.26 11 ±   4.50 7 ±   4.60 4 ± 1.5 0.00001 b 40.67 37 ±   3.42 33 ±   5.55 31.5 ±   5.15 30.20 ±   4.42 28.5 ±   4.52 25 ± 3.4 0.01 filament grade a 3 (1-3) 2 (1-3) 0.5 (0-1) 0 0 0 0 0.00001 b 3 (1-3) 3 (1-3) 2 (1-3) 2 (1-2) 2 (1-2) 2 (1-2) 2 (1-2) > 0.5 fss score a 2 (1-4) 2 (1-3) 1 (1-2) 1 (0-1) 0 (0-1) 0 0 <0.00001 b 2 (1-4) 2 (1-3) 2 (1-3) 2 (1-2) 1 (0.5-2) 1 (0-1.5) 0 (0-1) <0.5 tfbut sec a 4 (1-7) 4 (3-7) 5 (4-8) 7 (4-9) 8 (5-11) 8.5 (5-13) 9 (7-13) < 0.0001 b 4 (1-6) 4 (1-7) 4 (2-8) 5 (3-7) 5 (3-8) 5.5 (4-9) 6 (5-9) < 0.01 schirmer test mm a 2.5 (0-4) 3 (1-4) 4 (2-5) 5 (4-7) 6 (4-8) 7 (5-9) 8 (5-12) < 0.001 b 2 (0-4) 2 (0-4) 3 (1-5) 3 (1-6) 4 (2-6) 4 (3-6) 5 (3-7) < 0.01 fss (fluorescein staining score), tfbut (tear-film break up time), schirmer’s test readings: shown as median and range (minimum to maximum). discussion filamentary keratitis is a sight-threatening and a functionally debilitating complication of a number of ocular and systemic conditions, as already mentioned. the site of filament formation depends upon the underlying cause. in our study, the cases with aqueous deficient dry eyes (ss and non-ss = 5 + 23 = 28 cases) and exposure keratopathy due to facial palsy (4 cases) and proptosis due to thyroid eye disease (4 cases), the filaments were noted in the inter-palpebral area. this was due to an excessive evaporation of aqueous from the most exposed area of the ocular surface. the additional factors noted in these patients were smoking, working in an indoor environment, air pollution, prolonged staring at digital screens (computers, mobile phones10, television) or prolonged reading which reduces the blinking rate and replenishing the tear film. the 4 post-cataract surgery cases in our study complained of watery eyes, intermittent blurring of vision and grittiness that gradually worsened over 2-6 months after the surgery, which was performed in both eyes one after the other. corneal filaments were noted at the site of corneal incision in 3 cases and around the corneal sutures in one case. this was due to a pre-existing mild to moderate tear film instability that generally exists in the elderly population due to androgen deficiency and was missed pre-operatively. the added surgical trauma11,12 destroyed the nerve plexus at the incision site and reduced the corneal sensitivity and the tfbut. moreover, the mechanical injury from surgical instrumentation, chemical toxicity of medicines (particularly the preservatives) used preoperatively, intra-operatively and during the postoperative period, and the co-existent meibomian gland dysfunction in this age group, further aggravated the the efficacy & safety of 0.3% acetylcysteine eye drops in filamentary keratitis pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 268 ocular surface inflammation mainly at the site of corneal incision/suture (due to suture irritation) and filaments formed in the late postoperative period at that site. it takes a long time for the composition and production of the tear film to recover post-operatively. however, all our cases responded well to the dry eyes therapy and the 0.3% acetylcysteine eye drops; their vision cleared up as well as the ocular discomfort. in vkc (6 cases) and autoimmune disorders (sjogren’s syndrome 5 cases), the filaments were noted at the limbal area. this is because the corneal limbal tissue is vulnerable to inflammatory mediators, antibodies, and complement released by the activated eosinophils and lymphocytes present in the perilimbal vascular arcade13. the perilimbal swelling results in tear-film instability and filaments are formed in that area. additionally, the autoimmune disease process often affects the secretion of lacrimal gland, conjunctival goblet cells, and meibomian glands resulting in a severe form of dry eyes. ultimately, the filaments are distributed over the whole cornea. according to various studies, allergic conjunctivitishas been found to be accompanied by dry eyes with an incidence of 62.5% to 83.3% while itching of eyes have frequently been noted as a symptom of dry eyes. systemic medications14 like diuretics, antihistaminics and anti-depressants reduce the production of aqueous and can alter the balance between aqueous: mucin in the tear film, thereby precipitating filamentary keratitis. one patient in our study with vkc was on oral anti-histaminic and two were on diuretics. when these were stopped, their osdi improved rapidly. in this study, 38 cases were already on topical lubricants for months and they still developed the corneal filaments. therefore, the addition of antiinflammatory medicines topically was mandatory. tacrolimus15,16 has been used in various studies as a potent anti-inflammatory agent when applied topically as 0.03% eye drops. similar to cyclosporin eye drops 17, it is a potent calcineurin inhibitor, known to reduce the ocular surface inflammation by inhibiting the t cell-mediated immune responses. they both promote corneal healing and improve secretion and quality of all the three components of the tear-film. they are safe drugs with minimal side effects (stinging and burning upon instillation) after prolonged usage, in comparison to the topical steroids that can be safely used for dry eyes for only 1-2 weeks. since the tacrolimus eye drops are not available commercially, the 0.03% skin cream (crolimus by valor pharma) was prescribed to all cases, to be applied into the lower conjunctival fornix twice daily. patients with associated meibomitis18 were advised warm wet towel application to closed eyelids twice daily; the heat melts the thick meibum and opens up the clogged duct orifices. they were also instructed to scrub the lid margin with baby shampoo, after the hot fomentation, so as to remove the melted toxic meibum and massage tetracycline eye ointment into the lid margins at night to control the associated inflammation of the meibomian glands and the eyelids. for the severe cases of mgd, oral tetracyclines (doxycycline 100 mg/day for 6 weeks) were also prescribed. in patients with severe ocular pain or discomfort, topical diclofenac sodium 0.1% eye drops three times a day was added to the therapeutic armamentarium; this not only reduces the ocular discomfort but has an additive anti-inflammatory affect. filaments on the ocular surface can be dissolved by using topical or oral mucolytic agent like nacetylcysteine19 which is a derivative of the natural amino acid l-cysteine. it is frequently used in acute and chronic broncho-pulmonary disease. it exerts its affects by opening up the disulfide bonds in mucoproteins, thereby lowering the viscosity of mucous, inhibiting collagenase enzymes that are secreted by inflammatory cells and cause corneal thinning by melting collagen, by chelating calcium or zinc, it inhibits mmp-9 secretion, thereby inhibiting the inflammatory cytokine responses and reducing ocular surface inflammation. hence, acetylcysteine has multiple beneficial effects in filamentary keratitis. it is available in europe and usa commercially. a recent preparation, chitosan-n-acetylcysteine20 has been used in various studies with remarkable results in dry eyes associated with filamentary keratitis. unfortunately, no commercially prepared eye drops are available locally in the market, and it has to be prepared on request by a compounding pharmacist. it is readily available as tablets and in sachets containing powder (mucolyte 200 mg) that is water soluble. it is a relatively strong acid and cannot be applied directly to the ocular surface, but only after being suitably neutralised. the prepared solution should have a neutral ph between 6.6-7.5. the solvent used for preparing the solution and neutralisation should not increase the osmolarity from an initial value of 241 mosm/kg (of the powdered form) to more than 300 mosm/kg. the 5% or 10% n-acetylcysteine solution that has been used sameera irfan 269 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol in various studies had a much higher osmolarity of > 1000 mosm/kg. we previously used 0.5% preparation but that also caused a lot of stinging in the eyes upon instillation. it is due to the high osmolarity of these preparations which irritates the inflamed, irritable ocular surface. the 5% eye drops cause a lot of ocular surface irritation (manifested as stinging, burning on instillation of eye drops and an increase in punctate epithelial erosions) and potential corneal damage as the tear fluid is already hypertonic in patients with the dry eyes syndrome. in this study, we used a diluted preparation of 0.3% acetylcysteine eye drops, freshly prepared by our compounding pharmacist. the ph was kept at 7 and osmolarity of the prepared solution at 300 mosmol/litre. the patients were instructed to keep the freshly prepared eye drops refrigerated at 2-8ºc. to avoid decomposition of the solution. it not only dissolved the corneal filaments efficiently within 2-4 weeks in all group a cases but helped in restoring the quality of mucin, so that further formation of filaments was not noted in cases that continued using it for at least 6-8 weeks even after the filaments had cleared up. recurrence was noted in only 3 cases who abruptly stopped acetylcysteine. it also helped in improving the overall osdi score, the tear-film but and corneal staining in all group a cases. this was because the diluted preparation was well tolerated with no ocular discomfort or stinging, thus ensuring a good patient compliance. the marked improvement in patient’s symptoms and clinical signs was particularly noticeable early within 2-4 weeks in cases with vkc, post-cataract surgery and exposure keratopathy due to facial palsy and thyroid eye disease. this was in comparison to the 26 group b cases in which despite the usual treatment protocol for dry eyes, the absence of a mucolytic agent delayed the clearance and further production of filaments. the filamentary keratitis persisted for 8-10 weeks despite using lubricants, tacrolimus and tetracycline eye ointment so the ocular discomfort failed to show a remarkable improvement. the other parameters assessed also failed to show as much improvement as in group a cases. there was no possible bias in the study as the lead ophthalmologist conducting the study was totally unaware as to which cases were using 0.3% acetylcysteine eye drops or placebo. manual debridement of filaments can be performed under topical anaesthesia, using a finetipped forceps at the slit lamp. but it was not done in any case in our study as pulling upon the corneal filaments causes traction on the corneal epithelial cells, resulting in more damage to the underlying epithelium with shearing of their basal lamina; this increases the ocular surface inflammation (by the release of cytokines from the damaged epithelial cells) and further promotes the adherence of mucus as well as recurrent filament formation. conclusion filamentary keratitis is a chronic, recurrent, and debilitating condition. with the correct and a systematic approach to diagnosis and management, the acute condition can be effectively controlled and the incidence and severity of recurrences minimised. certain important points highlighted by this study need to be kept in mind while managing such patients: 1) acetylcysteine eye drops constitute an integral part of the therapy of filamentary keratitis due to any cause. 0.3% acetylcysteine eye drops efficiently clear up the filaments and are well tolerated by the patients, thus ensuring a better compliance to therapy. manual removal of corneal filaments should be avoided. 2) the therapy has to be continued for at least 6 weeks even after the filaments have cleared up, to avoid recurrence. 3) filamentary keratitis can be induced or exacerbated by systemic medications and ocular surgery, particularly in the elderly age group. therefore, a pre-operative assessment for dry eyes should be considered in the surgical planning of such patients by tear film break up time and schirmer’s test. references 1. mannis mj, holland ej, gensheimer wg, davidson rs. chapter 85: filamentary keratitis. in: cornea: fundamentals, diagnosis and management. vol 1. 4th ed. elsevier, 2017: 1025-1029. 2. bron aj, de paiva cs, chauhan sk, bonini s, gabison ee, jain s, knop e, markoulli m, ogawa y, perez v, uchino y, yokoi n, zoukhri d, sullivan da. tfos dews ii pathophysiology report. ocul surf. 2017 jul; 15 (3): 438-510. 3. nelson jd, craig jp, akpek et, azar dt, belmonte c, bron aj, et al. tfos dews ii. introduction. ocul surf. 2017; 15: 269-5. 4. tanioka h, yokoi n, komuro a, shimamoto t, kawasaki s, matsuda a, kinoshitaet s, et al. investigation of the corneal filament in filamentary keratitis. invest ophthalmol vis sci. 2009; 50: 3696-3702. https://www.ncbi.nlm.nih.gov/pubmed/?term=azar%20dt%5bauthor%5d&cauthor=true&cauthor_uid=28736334 https://www.ncbi.nlm.nih.gov/pubmed/?term=belmonte%20c%5bauthor%5d&cauthor=true&cauthor_uid=28736334 https://www.ncbi.nlm.nih.gov/pubmed/?term=bron%20aj%5bauthor%5d&cauthor=true&cauthor_uid=28736334 the efficacy & safety of 0.3% acetylcysteine eye drops in filamentary keratitis pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 270 5. galor a, batawi h, felix er, margolis tp, sarantopoulos kd, martin er, levitt rc. incomplete response to artificial tears is associated with features of neuropathic ocular pain.br j ophthalmol. 2016 jun; 100 (6): 745-9. 6. mridula pentapati, suchi shah. filamentary keratitis. a case series. international journal of scientific and research publications, volume 5, issue 3, march 2015. 1 issn 2250-3153. 7. grubbs jr, tolleson-rinehart s, huynh k, davis rm. a review of quality of life measures in dry eye questionnaires. cornea, 2014; 33 (2): 215-218. 8. j. bron, p. argüeso, m. irkec, and f. v. bright, “clinical staining of the ocular surface: mechanisms and interpretations,”progress in retinal and eye research, 2015; vol. 44: pp. 36–61. 9. sambursky r. presence or absence of ocular surface inflammation directs clinical and therapeutic management of dry eye. clin ophthalmol, 2016; 10: 2337-43. 10. moon jh, kim kw, moon nj. smartphone use is a risk factor for pediatric dry eye disease according to region and age: a case control study. bmc ophthalmol. 2016 oct 28; 16 (1): 188. 11. denoyer a, landman e, trinh l. dry eye disease after refractive surgery: comparative outcomes of small incision lenticule extraction versus lasik. ophthalmology, 2015; 122: 669–676. 12. cho yk, kim ms. dry eye after cataract surgery and associated intraoperative risk factors. korean j ophthalmol. 2009 jun; 23 (2): 65-73. 13. chen l, pi l, fang j, chen x, ke n, liu q. high incidence of dry eye in young children with allergic conjunctivitis in southwest china. acta ophthalmol. 2016 dec; 94 (8): e727-e730. 14. lyndon jones, laura e. downie, donald korb, jose m. benitez-del-castillo, reza dana, sophie x. deng, pham n. dong et al. tfos dews ii management and therapy report, the ocular surface, 2017; 15: 575-628. 15. moscovici bk, holzchuh r, sakassegawa-naves fe, et al. treatment of sjogren’s syndrome dry eye using 0.03% tacrolimus eye drop: prospective double-blind randomized study. cont lens anterior eye, 2015 may 5. 16. samir s. shoughy topical tacrolimus in anterior segment inflammatory disorders. eye and vision, 2017; volume 4, article number 7. 17. irfan s and qurban t. ophthalmic uses of cyclosporine eye drops. f1000research 2016, 5: 1941 (poster). (doi: 10.7490/f1000research.1112798.1) 18. irfan s. meibomian gland dysfunction.review paper. pjo, jan-march 2019; volume 35, issue no 1. 19. ramaesh t, ramaesh k, riley sc, west jd, dhillon b. effects of n-acetylcysteine on matrix metalloproteinase-9 secretion and cell migration of human corneal epithelial cells. eye (lond). 2012; 26 (8): 1138-44. 20. lorenz k, garhofer g, hoeller s, peterson w, vielnascher rm, ivezi z. long-term management of dry eye by once-daily use of chitosan-n acetylcysteine (lacrimera®) eye drops. j clin ophthalmol.2018; 2 (1). doi: 10.35841/clinicalophthalmology.2.1.47-54e. author’s affiliation dr. sameera irfan frcs consultant author’s contribution dr. sameera irfan literature review, manuscript writing. https://www.ncbi.nlm.nih.gov/pubmed/27788672 https://www.ncbi.nlm.nih.gov/pubmed/27788672 https://www.ncbi.nlm.nih.gov/pubmed/27788672 https://www.ncbi.nlm.nih.gov/pubmed/27226346 https://www.ncbi.nlm.nih.gov/pubmed/27226346 https://www.ncbi.nlm.nih.gov/pubmed/27226346 http://dx.doi.org/10.7490/f1000research.1112798.1 https://doi.org/10.35841/clinical-ophthalmology.2.1.47-54 comparison of image opacity between swept source oct and spectral domain oct in the setting of media opacification pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 125 editorial femtosecond laser versus manual technique in ophthalmic surgery pak j ophthalmol 2016, vol. 32, no. 3 femtosecond laser (fs) in ophthalmic surgery has been in use for almost twenty years. first approved by the u.s. food and drug administration in 2001 for creating corneal flaps in laser – assisted in situ keratomileusis (lasik), the applications for fs has been expanded to other ophthalmic procedures including astigmatic keratotomy, intrastromal corneal ring segments, corneal pockets for presbyopiaaddressing inlays, small incision lenticule extraction, keratoplasty, and most recently, fs laser-assisted cataract surgery (flacs)1. it is the increasing use of the latter that has raised the question: are fs lasers truly advantageous over traditional manual techniques? the implications are profound as an estimated 19 million cataract surgeries were performed in 2011 and is expected to reach 30 million worldwide by 20202. in theory, ultrashort laser pulse lasers that operate in the infrared range (wavelength: 1,053 nm) to create precise cleavage planes with minimal collateral damage sounds ideal. but the questions that have to be addressed, as with any new technologies, are: do they result in superior refractive outcomes? are they safer in that complication rates are reduced? this editorial puts into perspective lessons learned from over 15 years of femtosecond laser use in keratorefractive surgery and also summarizes to date, the evidence from literature, flacs versus manual phacoemulsification to see whether it is truly advantageous. the superior accuracy of fs over microkeratomes in lasik flap creation is well-established3,4. however, whether greater accuracy translates into clinical benefit is questionable. a meta-analysis of seven prospective randomized controlled trials of 577 eyes concluded that fs lasik did not have an advantage in efficacy, accuracy, and safety over mechanical microkeratomes, although it might induce fewer aberrations5. it is difficult to compare complication rates because associated complications are rare and different. fs lasik flap complications are from an inflammatory etiology of the laser such as diffuse lamellar keratitis and transient light-sensitivity syndrome, whereas complications with the microkeratome are associated with mechanical complications such as epithelial defects and flap dislocations6. there appears to be no difference in long-term visual function and keratocyte density five years postoperatively; a recent randomized clinical paired – eye study found that keratocyte density in the lasik flap decreased by 20% the first year after lasik and remained low through 5 years, and higherorder aberrations increased and uncorrected visual acuity improved immediately after surgery. interestingly, there were no differences in any of the variables between the microkeratome versus femtosecond treatments7. for the other aforementioned keratorefractive procedures such as astigmatic keratotomy (ak), channel creation for intrastromal corneal ring segments (icrs), pockets for inlays, and small incision lenticule extraction (smile), or various partial to full – thickness keratoplasties, there have been less longterm experience and hence, little published data on head-to-head comparisons of fs versus mechanical techniques. there are many case reports and small series on the effectiveness of reducing corneal astigmatism with limbal relaxing incisions, however the challenge is that there are various nomograms for manual, femtosecond, and more recently, intrastromal fs (fisk) incisions to address corneal steepening and thus, standardization for comparative studies is difficult. since being approved for cataract surgery by the us fda in 2010, to date, more than 1.2 million eyes in the us and 2 million eyes globally have undergone flacs. (marketscope, llc. st. louis, mo)there are currently 5 femtosecond platforms for flacs: lensx (alcon, aliso viejo, ca, usa), lens ar (lensar, inc., winter park, fl, usa), catalys (abbott medical jimmy k. lee m.d. 126 vol. 32, no. 3, jul – sep, 2016 pakistan journal of ophthalmology optics inc., santa ana, ca, usa), victus (bausch and lomb inc., dornach, germany), and femto ldv z (ziemer ophthalmic systems, port, switzerland). proponents have touted the accuracy and precision of the fs laser over manual steps including construction of clear corneal incisions, capsulotomy, and lens fragmentation. the accuracy and reproducibility of the fs have been reported previously, but comparative meta-analysis of flacs versus manual cataract surgery (mcs) with regards to refractive outcomes and reduced complication rates are now available. a meta – analysis of 2802 screened articles comprising of 14,567 eyes from 15 randomized controlled trials and 22 observational cohort studies concluded that there were no statistically significant differences between flacs and mcs with regard to visual and refractive outcomes and complications.8 theoretically, precise capsulotomies would ensure capsule overlap of the intraocular lens, reducing the risk of myopic shift or astigmatism from anterior shift or tilt of the iol. however, the meta-analysis revealed that there were no difference in udva, cdva, and mean absolute error (mae). the investigators do state that this lack of difference may be attributable to numerous sources of error in refractive predictability, including choice of iol formula, and methods of prediction error assessment. safety analysis revealed no difference between flacs and mcs for capsular, pupillary, and corneal complications. however, with flacs, there was a greater incidence of posterior capsular tearswhich is associated with increase risk for cystoid macular edema, endophthalmitis, and retinal detachment. furthermore, flacs was associated with a significantly greater concentration of prostaglandin relative to mcs. in favor of flacs was a statistically significant difference in effective phacoemulsification time, absolute mean deviation from intended capsule diameter, horizontal iol centration, and post-operative central corneal thickness. the investigators of this meta-analysis note that “it is important to consider the clinical significance of the measured differences when interpreting these findings” and that “there will be continued head-to-head comparisons between these 2 techniques…[it is important to] await this evidence and recommend that a subsequent re-evaluation be performed after a significant number of well – designed randomized trials are introduced into the literature.” this need is reiterated by a recent cochrane database systematic review of flacs versus mcs, whereby risk of bias was also taken into consideration9. from the screening of search results by two independent investigators, 16 randomized controlled trials (rcts) conducted internationally enrolled a total of 1638 eyes of 1245 participants. however, in 11 of the 16 studies, the authors reported financial interests with the laser platform evaluated in their studies. even then, the cochrane authors conclude that their review “could not determine the equivalence or superiority of laser-assisted cataract surgery compared to standard manual phacoemulsification for their chosen outcomes (intraoperative complications, udva, cdva, refractive outcomes, quality of vision, postoperative complications, cost – effectiveness) due to the low to very low certainty of the evidence available from these studies.” if fs laser adoption in the keratorefractive market is an indicator, fs penetration into flacs will continue to grow. despite a clear lack of benefit and a tenfold greater investment required for fs lasers over mechanical microkeratomes, fs lasers for lasik experienced a 15% growth from 2000 to 2015. (marketscope, llc. st. louis, mo) the growth chart for fs in flacs appears even more aggressive. flacs penetration rate increased from 0.6% in 2011 to 9.0% in 2016 in the us and from 0.1% to 2.5% globally during the same time period. (marketscope, llc. st louis, mo) but to say that new technology is better because it is being rapidly adopted is not based on evidence. good data from adequately powered, well – designed, independent rcts will benefit all parties. if no clear advantage is evident, it validates those who are waiting until fs technology improves, or advances until it confers a true benefit. conversely, if flacs proves to be superior over mcs, it will stimulate more competition into the market, improving the technology while decreasing the costs, both which will benefit patients. references 1. ratkay – traub i, juhasz t, horvath c, suarez c, kiss k, ferincz i, kurtz r. ultra-short pulse (femtosecond) laser surgery: initial use in lasik flap creation. ophthalmol clin north am. 2001; 14 (2): 347-55, 2. uy hs1, edwards k, curtis n. femtosecond phacoemulsification: the business and the medicine. curr opin ophthalmol. 2012; 23 (1): 33-9. 3. ahn h1, kim jk, kim ck, han gh, seo ky, kim ek, kim ti. comparison of laser in situ keratomileusis flaps created by 3 femtosecond lasers and a microkeratome. j cataract refract surg. 2011; 37 (2): 349-57. femtosecond laser versus manual technique in ophthalmic surgery pakistan journal of ophthalmology vol. 32, no. 3, jul – sep, 2016 127 4. zhou y1, tian l, wang n, dougherty pj. anterior segment optical coherence tomography measurement of lasik flaps: femtosecond laser vs microkeratome. j refract surg. 2011; 27 (6): 408-16. 5. zhang zh1, jin hy, suo y, patel sv, montés-micó r, manche ee, xu x. femtosecond laser versus mechanical microkeratome laser in situ keratomileusis for myopia: metaanalysis of randomized controlled trials. j cataract refract surg. 2011; 37 (12): 2151-9. 6. santhiago mr1, kara-junior n, waring go 4th. microkeratome versus femtosecond flaps: accuracy and complications. curr opin ophthalmol. 2014; 25 (4): 2704. 7. mclaren jw, bourne wm, maguire lj, patel sv. changes in keratocyte density and visual function five years after laser in situ keratomileusis: femtosecond laser versus mechanical microkeratome. am j ophthalmol. 2015; 160 (1): 163-70. 8. popovic m, campos – möller x, schlenker mb, ahmed ii. efficacy and safety of femtosecond laserassisted cataract surgery compared with manual cataract surgery: a meta – analysis of 14 567 eyes. ophthalmology, 2016 aug 15. (16) 30607-8. 9. day ac, gore dm, bunce c, evans jr. laser – assisted cataract surgery versus standard ultrasound phacoemulsification cataract surgery. cochrane database syst rev. 2016 jul. 8;7: jimmy k. lee director of cornea and refractive surgery department of ophthalmology and visual sciences montefiore medical center albert einstein college of medicine new york, usa http://www.ncbi.nlm.nih.gov/pubmed/27538796 http://www.ncbi.nlm.nih.gov/pubmed/27538796 http://www.ncbi.nlm.nih.gov/pubmed/27538796 http://www.ncbi.nlm.nih.gov/pubmed/27387849 http://www.ncbi.nlm.nih.gov/pubmed/27387849 http://www.ncbi.nlm.nih.gov/pubmed/27387849 microsoft word syed amjad rizvi 137 original article “continuous stimulus at the physiological blind spot to improve fixation during perimetry: an experimental pilot study” syed amjad rizvi pak j ophthalmol 2006, vol. 22 no.3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: syed amjad rizvi a-11, block-9, federal b area karachi received for publication september 2005 …..……………………….. purpose: to evaluate if patients can fixate better during perimetry if a continuous stimulus on the physiological blind spot (cspbs), present throughout the test, becomes visible to them in real time as soon as fixation is lost, the patient being properly educated accordingly prior to the test. material and methods: subjects between the ages of 20 to 60 years, having no major ocular or systemic disease, underwent a simulation of automated perimetry using a software developed by the author, with a 21-inch personal computer monitor used as a campimeter. there was an option in the software whether or not a conspicuous cspbs was presented throughout the test. fixation losses were recorded by heijl-krakau method. patients who consistently had fixation loss of more then 30% without a cspbs were subsequently tested with the cspbs present during the test. results: 9 subjects out of 50 initially tested (18%), persistently had more then 30% fixation losses with out cspbs during the test. seven out of these 9 (14% of the total) showed improvement in fixation when tested with a cspbs. the remaining 2 (4% of the total) had poor fixation in the presence of cspbs also. conclusion: cspbs present throughout an automated perimetry test can potentially improve fixation and should be evaluated on larger scale. roper fixation at a target is important for a reliable perimetric test1,2, and much advancement has been made to ensure it by devising several strategies to monitor fixation, e.g., visualizing eye movements directly by a telescope or through a video camera, the heijl-krakau method, and gaze tracking3. in the majority of automated perimeters currently used clinically, the patient is warned through a human or computer generated voice message after a certain amount of fixation loss is detected. however it is a common observation that some people are still unable to fixate properly. if, however, a patient can be made aware of fixation loss in real-time, he or she can re-fixate immediately as a feedback response, thus minimizing the total duration of inaccurate fixation during the test. a study is presented to evaluate the usefulness of presenting a conspicuous stimulus on the testing screen, continuously throughout an automated perimetry test, at the area representing the physiological blind spot. this stimulus falls on the optic nerve, and hence remains invisible to the patient, as long as the p 138 proper fixation is maintained. it becomes visible as soon as the fixation is lost, as the stimulus falls on the light sensitive retina, thereby warning the patient of a fixation loss in real time. material and methods description of the software and hardware. the author developed a simple program in basic language that presents supra threshold stimuli randomly over the personal computer monitor. a flat screen 21-inch monitor (optiquest q110, ca, usa) was used as a campimeter in this study, with the subject seated such that the eye being examined was about 40 centimeters away from the center of the screen, with the chin and head supported by a chin rest taken from a slitlamp. in this position the central 25 degrees of the patient’s visual field can be assessed. the software first presented a central fixation target, and then the physiological blind spot could be delineated using a bright red spot that could be moved horizontally and vertically, and also altered in size. subsequently, supra threshold stimuli were presented randomly across the screen, which were not corrected for the age or the retinal area, as the main purpose of the study was determination of the fixation pattern and not the retinal sensitivity. any key pressed in response to the stimulus was recorded as a stimulus seen. the test could proceed in either of the two ways: (i) test a. the perimetric test proceeded without a cspbs, as in currently used perimeters. (ii) test b. there was a conspicuous cspbs present throughout the perimetric test. the cspbs was in the form of a bright red circular spot. the fixation losses were recorded according to heijl-krakau blind spot monitoring. immediately before the presentation of the stimulus at the blind spot for this purpose the red cspbs disappeared, and reappeared soon after. 10 such blind spot monitoring stimuli were presented during the test; and if a key was pressed in the presence of such a stimulus a fixation loss was recorded. test procedure each subject was tested for one eye. after giving the usual instructions for conventional automated perimetry, the subjects were given two one-minute training tests with test a, and then the complete test a was carried out. if the subject showed fixation losses of more then three, he or she was asked to repeat the test at another date, again preceded by the training tests. the subjects, who still had fixation losses of more then three, were then tested with test b. this time the patients were instructed that a red light would become visible to them as soon as the fixation was lost, and hence they should re-fixate as soon as they glimpse the red spot. they were asked to move their eyes intentionally before proceeding with the test to clarify the phenomenon of red light appearance, which disappeared with re-fixation. two one-minute training tests with test b were repeated before the start of the test. selection of patients subjects between 20 to 60 years of age, who attended the outpatient clinic, whether as patients or attendant of the patients, were offered to take part in the study. 50 consecutive subjects who agreed, and had no ocular or systemic disease likely to influence the performance, were included in the study, provided that they were able to complete all the required tests. informed consent was obtained. results of the 50 subjects, 31 were males and 19 females. 9 subjects (18% of the total 50) showed fixation losses of more then 3 on repeated testing with test a. (the results of performance of these 9 subjects are given in the (table 1). 7 subjects out of these 9 (14% of the total), showed improvement (i.e. 3 or less fixation losses) with test b. the other 2 subjects (4% of total) had more than 3 fixation losses in test b also. discussion the blind spot has been used during perimetry to record fixation losses i.e. in the heijl-krakau monitoring, and to determine the correct distance between the subject's eye and the screen4, but to the author’s knowledge no study has been carried out to determine it’s value in enhancing fixation by means of a conspicuous stimulus, that falls on the area representing the physiological blind spot, throughout the test. in this study such a stimulus was used in the form of a bright red spot, which remained invisible to the subject as long as the fixation was maintained. as the eye deviated significantly from the fixation target the image of the red spot fell on the light sensitive retina and suddenly became visible to the subject. this 139 possibility of awareness of a fixation loss in real time, and hence the opportunity for the subject to immediately re-fixate will reduce the actual duration of incorrect fixation. in this study an obvious improvement in fixation was obtained in a substantial number of patients by using the cspbs, thereby providing proof of principle and justifying a controlled study of this simple method to achieve better fixation during perimetry. since the currently available automated perimeters do not offer the option of a cspbs during table 1: performance of patients who had fixation losses of more then 3 in test a pts age sex fixation losses decrease in fixation loss with cspbs test a test b 1 42 m 7 2 5 2 55 f 5 0 5 3 60 f 8 9 1 4 45 f 4 0 4 5 50 f 6 0 6 6 55 m 4 2 2 7 53 f 10 10 0 8 60 f 7 3 4 9 45 m 4 0 4 the test, the author wrote a simple program in q basic language that presents supra threshold stimuli randomly over the personal computer monitor. this software is quite easy to use on any personal computer. the stimuli are supra threshold without being precisely corrected for age, retinal area etc., since the only purpose of this study was to observe the fixation behavior. although the majority of the participants were able to perform satisfactorily with out the cspbs, this study shows that there are patients in whom the presence of a cspbs can improve fixation. it also indicates that there is a small population in which fixation remains poor regardless of the cspbs. this study, however, was relatively small in terms of number of participants, and hence the influence of factors, such as age, sex, level of education etc. cannot be determined with confidence. similarly, since only normal subjects were included, it does not represent the behavior of patients with visual field defects. larger studies in different populations are therefore required. although it was not tested in this study, increasing the size of the cspbs could theoretically reduce small deviations. such deviations have been shown to occur in a high proportion of subjects undergoing the automated perimetry without affecting the reliability of the usual tests5. however this can be useful in the high-resolution perimetry6 where minor deviations are more likely to affect reliability. author’s affiliation syed amjad rizvi a-11, block-9, federal “b” area karachi references 1. katz j, sommer a. screening for glaucomatous visual field loss. the effect of patient reliability. ophthalmology 1990; 97: 1032-7. 2. johnson ca, nelson-quigg jm. a prospective three-year study of response properties of normal subjects and patients during automated perimetry. ophthalmology. 1993; 100: 26974. 3. kunimatsu s, suzuki y, shirato s, et al. usefulness of gaze tracking during perimetry in glaucomatous eyes. jpn j ophthalmol. 2000; 44: 190-1. 4. damato b, groenewald c. multifixation campimetry on line: a perimeter for the detection of visual field loss using the internet. br j ophthalmol. 2003; 87: 1296-8. 5. henson db, evans j, chauhan bc, et al. influence of fixation accuracy on threshold variability in patients with open angle glaucoma. invest ophthalmol vis sci 1996; 37: 444-50. 6. westcott mc, garway-heath df, et al. use of high spatial resolution perimetry to identify scotomata not apparent with conventional perimetry in the nasal field of glaucomatous subjects. br j ophthalmol. 2002; 86: 761-6. microsoft word bakht samar khan.doc 217 original article management of traumatic hyphema with raised intraocular pressure bakht samar khan, ibrar hussain, abid nawaz pak j ophthalmol 2007, vol. 23 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: bakht samar khan eye “b” unit, khyber teaching hospital peshawar received for publication march’ 2007 …..……………………….. purpose: to find out the incidence of high iop (≥ 25 mm hg), its management and visual outcome in traumatic hyphema patients. material and methods: a retrospective study was carried out of all patients with traumatic hyphema admitted to khyber teaching hospital peshawar between january 2003 and december 2004. results: out of 118 patients with traumatic hyphema requiring hospitalization high iop was found in 50 cases. amongst these more than 60% had an iop≥45mm hg. the mean age at time of presentation was 7 years. glaucoma was controlled in 26% cases by medical means while 74% needed surgical intervention. visual out come was 6/12 or better in 22% cases. conclusion: surprisingly traumatic hyphema with raised iop has high incidence and poor visual outcome than expected. yphema is not an uncommon intraocular pathology. the incidence has been reported as 17-24 100,000 population1. the peak incidence is below 20 year of age. blunt trauma ruptures vessels of iris stroma and ciliary body by antero posterior compression and equatorial globe expansion, which causes stress. a lacerating injury directly damages the blood vessels and causes hypotony. both these cause hyphema. hyphema can also occur after intraocular surgery. hyphema absorption occurs through the anterior surface of iris.2 uncomplicated hyphema clears in about a week. the serious complications of hyphema include raised iop corneal staining and poor va. one third of all hyphema patients have increased iop. the iop is elevated for several reasons. these are, 1. occlusion of trabecular meshwork by clot, inflammatory cell or rbc debris. 2. pupillary block due to blood clot. 3. peripheral anterior synechiae. 4. other late causes include damaged trabecular meshwork with angle recession, fibrosis of trabecular meshwork, siderosis of trabecular endothelium3 and ghost cell glaucoma4. the raised iop in hyphema is treated medically, if these measures fails, surgical intervention is required. despite of all these measures the final visual acuity in traumatic hyphema is not satisfactory. this is either due to uncontrolled glaucoma or corneal blood staining. the purpose of this study is to find out the incidence of glaucoma with hyphema, its acceptable management and the visual outcome. material and methods a retrospective study of all patients with traumatic hyphema admitted to khyber teaching hospital peshawar was carried out between january 2003 and december 2004. history charts of these patients were reviewed and the examination data was analyzed. this included va recording both with and without correction, corneal pathology likes edema and blood staining, the size and colour of hyphema and daily h 218 hyphema drawing, cells and flare in the anterior chamber, synechiae, pupillary reaction, lens pathology, daily morning and evening iop measurement with applanation tonometer and fundus examination. traumatic hyphema patients with retinal detachment, ectopia lentis, traumatic maculopathy and those patients requiring only outdoor treatment were excluded from the study. results the study comprised a total of 118 cases of hyphema admitted in kth, peshawar. the males being 63% and female 37% (table 1). among these, 50 cases (42.37 %) were associated with raised iop. the highest incidence of hyphema with and without raised iop was in patients up to 10 years of age (table 2). in 9 cases (18%) the iop range was 25 to 30 mm hg, in 8 cases (16%) it was 31 to 45 mm hg, while in 33 cases (66%) it was more than 45 mm hg (table 3). table 1: hyphema and glaucoma intraocular pressure no. of eyes n (%) high iop (≥ 22 mmhg) 50 (42.37) within normal limit 68 (57.63) total 118 (100) table 2: age distribution age hyphema no. of eyes with increased iop up to 5 years 30 14 (21.34%) 05 – 10 years 45 21(46.66%) 11 – 20 years 18 6 (33.33%) 21 – 40 years 15 6 (40%) 41 + 29 3 (10.30%) table 3: raised intraocular pressure no. of eyes iop range (%) 9 25 – 30 (18) 8 31 – 45 (16) 33 > 45 (66) visual acuity at the time of admission was doubtful perception of light in 11 eyes, (22%), perception of light with good projection in 18 eyes (36%) and cf in 31 eyes (62%) (table 4) in 13 eyes (26%) raised iop was successfully managed by medical means while in 37 eyes (74%) surgical intervention was required. this consisted of paracentasis and evacuation in 7 eyes (14%), paracentasis and peripheral iridectomy in 6 eyes (12%), trabeculectomy in 12 eyes (24%), trabeculectomy with mitomycine in 7 eyes (14%) and extra capsular cataract extraction with intraocular lens implant in 5 eyes (10%). (table 5). on discharge va was 6/12 or better in 11 eyes (22%), up to 6/18 in 6 eyes (12%), up to 6/60 in 15 eyes (30%), while up to 3/60 in 6 eyes (12%) and doubtful perception in 12 eyes (24%). (table 6). table 4: visual acuity at presentation va no. of eyes n (%) pl± 11 (22) pl with good projection 18 (36) cf 21 (42) table 5: management no procedure no. of eyes n (%) a medication (controlled) 13 (26) b surgical (controlled) 37 (74) (i) paracentasis & evacuation 07 (14) (ii) paracentasis with pi 06 (12) (iii) trabeculectomy 12 (24) (iv) trabeculectomy with mmc 07 (14) (v) ecce with iol 05 (10) table 6: visual acuity at discharge 219 va no. of eyes n (%) pl± 12 (24) up to 3/60 06 (12) up to 6/60 15 (30) up to 6/18 06 (12) 6/12 or better 11 (22) discussion hyphema with raised iop is an ocular emergency. the majority of patients are children or young individuals. negral reported 5-16% of all admissions to be related to eye injuries5. derespinis et al found that the most common admitting diagnosis in children sustaining ocular trauma was hyphema 32%6. evaluating the age and sex distribution, traumatic hyphema has been reported to be more frequent in children, predominantly affecting the males8-9). in this study a raised iop (≥ 25 mm hg) was found in 42.37% of cases with hyphema. this compares with the previously reported incidence by various authors10. coler bryon 14 – 60 % henry 14 – 51 % kitazawa 07 – 67 % shea 02 – 25 % in study conducted at abbasi hospital karachi, by fasih et al reported that hyphema was present in 22.22% of patients sustaining ocular injuries while glaucoma due to hyphema was found in 50%11. in another study conducted at postgraduate medical institute, lady reading hospital peshawar, raised iop was found in 41.66% of cases with hyphema12. onethird of these cases required surgical intervention. the medical management of hyphema with raised iop includes the use of steroids and antiglaucoma agents. steroids can be used topically and systemically. they control the inflammation, stabilize the blood ocular barrier and reduce the congestion of blood vessels to decrease the risk of rebleeding. negra et al studied 462 cases in 10 years and concluded that steroids decreased rebleeding and inflammation13. to control iop topical/systemic antiglaucoma agents are given. they include: • carbonic anhydrase inhibitors (topical/ systemic) • topical β blocker • hyperosmotic agents in cases unresponsive to the above medications • in addition cycloplegic and antiemetics are given in selected cases and analgesic may be required for symptomatic relief of pain with this regime 1/4th of our cases were controlled whereas the remaining 3/4th required surgical intervention. this was undertaken in cases with raised iop despite maximal medical therapy non-resolving total hyphema. there are various criteria for surgical intervention reported in the literature. important one are; a) read and goldberg criteria supported by deutch et al14. 1. iop> x 60 mm hg for 2 days 2. iop> x 25 mm hg + total hyphema for 5 days 3. microscopic corneal blood staining 4. hyphema absorption < 50% by 8 days 5. sickle cell disease or trait + iop 24 mm hg for 1st 24 hours or iop spike of 30 mm hg. b) walton et al criteria10 1. microscopic corneal staining 2. risk of optic atrophy (unacceptable iop) 3. risk of corneal blood staining e.g. iop ≥ 25 mm hg + 50 % hyphema 4. risk of synechiae formation e.g. hyphema ≥ 8 days even after following the above criteria the final va is not what one would expect. the visual prognosis is, of course, much favorable in simple hyphema with normal iop. gilbert and jensen reported a visual acuity worse than 6/12 in 86% of patients with hyphema and associated complications and in 14% of cases with simple hyphema, whereas this incidence was reported, respectively as 92% and 8% by gregersen, 67% and 33% by read and goldberg 10. this compares with our study (78% and 22%). the cases responding well to medical treatment have obviously, a better prognosis. in unresponsive cases early surgical intervention is advisable: such an intervention however may be associated at times, with its own complications. these are, mainly cataract formation, infectious and intense inflammation. conclusion 220 glaucoma is one of the leading complications of traumatic hyphema. in medically uncontrolled glaucoma early surgical intervention is recommended. author’s affiliation dr. bakht samar khan senior registrar, eye “b” unit, khyber teaching hospital peshawar dr. ibrar hussain assistant professor eye “b” unit khyber teaching hospital peshawar dr. abid nawaz associate professor department of ophthalmology kabir medical college gandhara university peshawar reference 1. agapitos pj, noel lp, clarke wn. traumatic hyphema in children. ophthalmology 1987; 94: 1238-41. 2. duke elder s, macfaul pa. system of ophthalmology, part-i, vol. 14: mechanical injuries. london, henry kimpton, 1965, 982-4. 3. gottsch jd. hyphema; diagnosis and management. retina 10 (suppl). 1990; 565-71. 4. campbell dg. ghost cell glaucoma following trauma. ophthalmology 1981; 88: 1151-8. 5. negral ad. magnitude of eye injuries. j comm eye health. 1997; 10: 49-53. 6. derespinis pa. a survey of severe eye injuries in children. am j dis child. 1989; 143: 711-6. 7. jan s, khan s, mohammad s. profile of ocular emergencies requiring admission. pak j ophthalmol. 2002; 3: 72-6. 8. khan bs, khan md. areview of 100 cases of ectopia lenties; presentation management and visual prognosis. pak j ophthalmol. 2002; 1: 3-9. 9. khan md, mohd islam z, khattak mn. an 11 ½ year review of ocular trauma in nwfp. pak j ophthalmol. 1991; 7:15-8. 10. walton w, von hagen s, grigorian r et al. management of traumatic hyphema. survey ophthalmol. 2002; 47: 297-334. 11. fasih u, shaukh a, fehmi ms. occupational ocular trauma. causes management and prevention. pak j ophthalmol. 2004; 20: 65-76. 12. jan s, khan s, mohammad s. hyphema due to blunt trauma. j coll physicians surg pak. 2003; 13: 398-401. 13. ng cs, strong np, sparrow jm, et al. factors related to the incidence of 2ndry hemorrhage in 462 patients with traumatic hyphema. eye 1992; 6: 305-7. 14. deutsch ta, weinreb rn, goldberg mf. indication for surgical management of hyphema in patients with sickle cell trait. arch ophthalmol. 1984; 102: 566-9. microsoft word asfndyarasgharcorrected1 original article role of vitrectomy in the management of eales’ disease asfandyar asghar, javed hassan niazi pak j ophthalmol 2007, vol. 23 no.1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: asfandyar asghar senior registrar isra postgraduate institute of ophthalmology, al-ibrahim eye hospital, malir, karachi received for publication december’ 2005 …..……………………….. purpose: to study the visual outcome and complications after pars plana vitrectomy in eales’disease. patients and methods: patients were admitted from the outpatients department at jinnah postgraduate medical centre, karachi, from november 2001 up to may 2002. patients were diagnosed as eales’ disease after all causes of ocular and systemic vasculitis had been ruled out on the basis of history, clinical examination and laboratory investigations. patients with non-resolving vitreous hemorrhage, recurrent vitreous hemorrhage, fresh vitreous hemorrhage in only eye patients, combined tractinal and rhegmatogenous retinal detachment were included in the study. patients with past history of trauma to the eye, ocular surgery, corneal opacity, rubeosis iridis, glaucoma were excluded from the study. result: 10 eyes of patients were included. mean age of presentation was 27.75 years. male to female ratio were 4:1. most common presentations were non– resolving vitreous hemorrhage in 7 eyes (70%), combined tractional and rhegmatogenous retinal detachment in 2 eyes (20%) and tractional retinal detachment in 1 eye (10%). pre-operative visual acuity in all patients was perception of light to counting finger. 90% of eyes regained good visual acuity after pars plana vitrectomy i.e. 0.2 (6/30) or better, after follow up period of 6 months. per-operative complications included active bleeding in 3/10 cases and sub-retinal seepage of perflurocarbon liquid in 1/5 cases. post-operative complications included cataract in 2/7 cases, secondary glaucoma in 2/7 cases, rhegmatogenous retinal detachment in 2/10, emulsifications of silicone oil in 3/7 cases and pre-retinal membrane formation in 1/7 cases. conclusion: in eales’ disease, uncomplicated pars plana vitrectomy has shown improvement of visual acuity in majority of patients. n 1880 henry eales’ noted abnormal retinal vein in a healthy young man with recurrent vitreous hemorrhage1. henry eales believed that epistaxis was associated with the retinal hemorrhages and that constipation and elevated venous pressure were underlying cause of this condition. in the century date as followed, he has been honored with the eponym for the disease. however, it remains a diagnosis by exclusion, and retinal diseases with other causes of inflammation or neovascularization must be excluded2. eales disease is an idiopathic obliterative vasculopathy that primarily affects the peripheral i retina3. eales’ disease is distributed world wide though it is more common in south east asian sub continent4. henry eales’ treated his patients with mixture of laxative, digitalis and belladonna. other medications included vitamin c, thyroid extract, osteogenic hormones and endogenic hormones. systemic steroid therapy in massive doses has also been used. none of these treatments has demonstrated a clear cut benefit2. since eales’ disease is basically a retinopathy of peripheral fundus and severe visual loss usually results from complications of neovascularization such as persistent vitreous hemorrhage, retinal detachment and anterior segment neovascularization with secondary glaucoma. vitrectomy techniques often can be employed for removing persistent vitreous hemorrhage and scar tissue. in this study we evaluated visual out come and complications of pare plana vitrectomy. patients and methods a descriptive study was conducted at the department of the ophthalmology jinnah postgraduate medical center karachi from november 2001 to may 2002. patients were diagnosed as eales’ disease after all causes of ocular and systemic vasculitis had been ruled out on the basis of history, clinical examination and laboratory investigations. patients were divided into two groups. first groups included those patients who were treated with systemic steroids and the vitreous hemorrhage cleared. these patients were subsequently subjected to photocoagulation and or fundus fluorescein angiography (ffa) followed by photo coagulation. they were followed for any recurrence of vitreous hemorrhage. all those patients who had vitreous hemorrhage in one eye and the fellow eye showed sign of perivasculitis and ischemic areas on ffa were lasered in the follow eye. light panretinal photocoagulation was done using 1200– 1500 burns. second group included those patients with non resolving vitreous hemorrhage, recurrent vitreous hemorrhage, fresh vitreous hemorrhage in only eye patients, tractional retinal detachment and combined retinal detachment were included in the study. patients with past history of ocular trauma, ocular surgery, corneal opacity, rubeosis iridis and glaucoma were excluded from the study. all 10 eyes underwent 3 port pars plana vitrectomy to remove non resolving vitreous hemorrhage, but some eyes needed secondary surgical intervention to flatten the retina. the written consents were taken from all patients before pars plana vitrectomy. questionnaire and check files were created in spss for data entry. results 10 eyes of 10 patients were included in the study. mean age of presentation was 27.75 years. there were 8 males (80%) and 2 females (20%) patients. the most common presentations was non resolving vitreous hemorrhage 7 eyes (70%), combined tractional and rhegmatogenous retinal detachment in 2 eyes (20%) and tractional retinal detachment in 1 eye (10%). five eyes (50%) needed pars plana vitrectomy as primary procedure to remove the non resolving vitreous hemorrhage while the other 5 eyes (50%) needed secondary surgical intervention to flatten the retina. surgical complications during and after the surgery were noted and are shown in (table 1,2). after removing the vitreous hemorrhage, tractional retinal bands were seen in 2 eyes (20%), active bleeding occured in 3 eyes (30%) and an operculated tear was localized in 1 eye (10%). internal tamponade, long and short term was used and shown in (table 3). in eyes where perfluorocarbon liquid was used to flatten the retina perfluoro-silicone oil exchange was performed in 5 eyes (50%), fluid silicone oil exchanged were perform in 2 eyes (20%). scleral buckling as well as internal tamponade techniques were used in eyes with combined tractional and rhegmatogenous retinal detachment or with tractional retinal detachment. pre operative visual acuity is shown in (table 4). statistically results were significant as compare to pre operative visual acuity of the patient with post operative visual acuity, as shown in (table 5). discussion annual incidence of eales’ disease in india is about 1 in 200–2504, but no statistics are available in our country. gieser and murphy5 reported average age of onset as 20 to 30 years and usually occurs bilaterally. in our study mean age of presentation is 27.75 years. howard10 reported higher incidence of ealse’ disease in males (80% – 90%) as compared to females8. in our study males to females ratio were 4:1. vitreous hemorrhage was the most frequent indication for vitrectomy in eales’ disease patients in our study (70%). the same indication was mentioned by shanmugam8 (87.5%) combined tractional and rhegmatogenous retinal detachment was the indication of vitrectomy in 20% patients in our study while 4.7% was indicated by shanmugam8 in his study. tractional retinal detachment was the indication of vitrectomy in 10% of cases in our study as compared to 3.1% indicated by shanumugam8 in his study. the high percentage of tractional retinal detachment and combined tractional and rhegmatogenous retinal detachment might be due to late presentation of our patients. in our study, most of the eyes regained good visual acuity after vitrectomy i.e. 0.2 (6/30) or better after follow up period of 6 months (90%). shanmugam8 had mentioned visual improvement in 71.8% of the eyes after vitrectomy with the follow up period of 60 months. the better results in our study may be due to availability of endocautery, endolaser photocoagulation, and smaller number of patients. hence we can expect better visual results in eyes with vitreous hemorrhage in eales’ disease, where patients have reported earlier and there has timely intervenetions which have undergo uncomplicated vitrectomy. table 1: complications (per-operative) complications no of eyes n (%) active bleeding 3/10(30) sub retinal perflurocarbon liquid 1/5 (20) table 2: complications (postoperative) complications no of eyes n (%) cataract 2/7 (28.6) secondary glaucoma 2/7 (28.6) rhegmatogenous detachment 2/10 (20) emulsification of silicone oil 3/7 (42.9) pre retinal membrane formation 1/7 (14.3) table 3: internal tamponade tamponade no of eyes n (%) silicone oil 7/10 (70) perflurocarbon liquid 5/10 (50) no tamponade 3/10 (30) in the majority of the patients we had performed endolaser photocoagulation per-operatively. three (30%) out of 10 eyes developed active bleeding which was managed initially by raising the height of bottle followed by applying endocautery to the bleeding site. gadkari9 had mentioned 14 eyes (56%) out of 25 eyes in which active bleeding occurred. one (20%) out of 5 eyes, in which perfluorocarbon liquid (pfcl) was used, the pfcl incidentally went in sub retinal space. in this case we removed the subretinal perfluorocarbon liquid with the help of extrusion needle by doing retinotomy followed by endo laser photocoagulation. de queiroz et al11 noticed subretinal seepage of perfluorocarbon liquid in 0.9% of cases. table 4: pre-operative visual acuity visual acuity no of eyes n (%) pl 1 (10) hm 5 (50) cf 4 (40) pl= perception of light; hm= hand movement; cf= counting fingers table 5: peroperative/postoperative visual status cross tabulation visual acuity preoperative postoperative .00 .2 .6 1.0 cf 4 4 hm 5 1 4 pl 1 1 total 10 1 4 1 4 cf= counting fingers; pl = perception of light; hm= hand movement; 00= no improvement; 0.2 = 6/30; 0.6= 6/9; 1.00= 6/6 rhegmatogenous retinal detachment occurred in 2 eyes (20%) out of 10 eyes. in one eye retina was successfully re – attached with help of perfluorocarbon liquid and perfluorocarbon liquid / silicone oil exchange. in addition to the above mentioned measures external tamponade was also used. in the other eye, retina failed to reattach due to proliferative vitreo retinopathy (pvr). gadkari9 had mentioned in his study 1 eye (4%) out of 25 eyes and shanmugam8 mentioned 9 eyes (14.06) in his study in which rhegmatogenous retinal detachment occurred. during 6 months follow up, 2 eyes (20%) out of 10 eyes developed secondary raised intraocular pressure due to silicone oil use. in both eyes, intraocular pressure was controlled with anti glaucoma treatment and subsequently silicone oil was removed. intraocular pressure was controlled after removing silicone oil in one eye, but second eye had to undergo trabeculectomy to control intraocular pressure in 6 months follow up period. casswell12 reported 19 eyes with uncontrollable glaucoma. cataract occurred in 2 eyes (28.57%) out of 7 eyes in which silicone oil was used. both eyes had a clear lens preoperatively. one eye developed cataract, while silicone oil was in the eye and the other developed cataract 1 month after removal of silicone oil. phaco emulsification was performed to remove both cataracts, followed by intraocular lens implantation. caswell12reported 32 eyes, in which 11 had clear lens at the time of silicone oil removal, but 6 eyes later developed cataract. twenty eyes already had lens opacities at the time of silicone oil removal. emulsification of silicone oil occurred in 3 eyes (42.85%) out of 7 eyes. this was managed by removal of silicone oil. federman13has mentioned that within a period of 1 year the intraocular silicone oil showed some degree of emulsification in 150 eyes out of 170 patients. epiretinal fibrous proliferation occurred in 1 eye (14.28%) out of 7 eyes. federman13 mentioned in his study 15% cases with epiretinal fibrous proliferation. conclusion in eales’ disease, uncomplicated pars plana vitrectomy has shown to improve visual acuity in majority of patient with non resolving vitreous hemorrhage, recurrent vitreous hemorrhage and complicated retinal detachment. better visual results can be achieved with vitrectomy by a well trained vitreo retinal team as well as better equipped vitreo retinal setup. prognosis of patient suffering from non resolving vitreous hemorrhage or recurrent vitreous hemorrhage and complicated retinal detachment, who undergo uncomplicated vitrectomy is good provided these patient present at an early stage of the disease. author’s affiliation dr. asfandyar asghar senior registrar isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi dr. javed hassan niazi isra postgraduate institute of ophthalmology al-ibrahim eye hospital, malir karachi references 1. eales’ h. cases of retinal hemorrhage associated with epistaxis and constipation. birmingham medical review. 1880; 9: 262-3. 2. gieser sc, murphy rp. eales’ disease. in: stephen j ryan. retina. 3rd ed, st. louis, c-v mosby company. 2001; 1505–8. 3. charles h. retinal vasculitis. in: herpes & row. duanes clinical ophthalmology. philaddphia, wb saunders, 1989; 2-4. 4. jalali s, was tp. eales’. in modern ophthalmology. 2nd ed, new delhi, jaypee, 2000, 704-8. 5. gieser sc, murphy rp. eales’ disease. in: allbert jackobiee principle and practice of ophthalmology. philadelphia,wb saunders, 1994; 791. 6. ricci a, sorians h. cryo coagulation for massive hemorrhage into vitreous. bull ophthalmol soc j fr. 1971; 84: 131. 7. das tp, namperumalsamy p. combined photocoagulation & cryotherapy in treatment of eales’ disease retinopathy. proc 45 all ind ophthalmol soc. 1987; 108. 8. shanmugam mp, badrinath ss, gopal l. long term visual result of vitrectomy for eales’ disease complications. int ophthalmol. 1998; 22: 61-4. 9. gadkari ss, kamdar pa, jehangir rp. pars plana vitrectomy in vitreous hemorrhage. ind j ophthalmol. 1992; 40: 35-7. 10. howard c. retinal vasculitis. in herpes & row. duane clinical ophthalmology. philadelphia, wb saunders. 1989; 4. 11. de queiroz jp, blanks jc, ozler sa. subretinal perfluorocarbon liquids: an experimental study. retina 1992; 12: 33–9. 12. casswell ag, gregor zj. silicone oil. br j ophthalmol. 1987; 71: 893-7. 13. federman jl, schubert hd. complications associated with the use of silicone oil in 150 eyes after retinal – vitreous surgery, ophthalmology. 1988; 95: 870-6. 226 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology original article color vision deficiency in pakistan railways employees yasir iqbal, aqsa malik, sohail zia, aneeq ullah baig mirza pak j ophthalmol 2016, vol. 32 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: yasir iqbal eye department / iimc, riphah international university, pakistan railways hospital, rawalpindi email: yasir.iqbal@riphah.edu.pk …..……………………….. purpose: to determine the frequency of color vision deficiency (cvd) in pakistan railways employees study design: cross sectional descriptive study. place and duration of study: outdoor patient department of ophthalmology, pakistan railways hospital, rawalpindi over a period of one year from 1 feb 2015 to 30 jan 2016. material and methods: prospective data was collected by using convenient non probability sampling technique of pakistan railways employees presenting for the annual vision checkup. slit lamp was used to evaluate the anterior and posterior segments whereas visual acuity was measured on the snellen’s chart after refraction. color vision was assessed binocularly using the ishihara isochromatic color plates (38 plates) with the best correction in a trial frame. the type of color vision deficiency was labeled from the ishihara chart key. the patients with best corrected visual acuity 6/9 after refraction and no history of medication or surgery were included in the study. the patients who had visual acuity <6/9, medication history of anti tuberculosis, central nervous system acting drugs or ocular surgical history were excluded from the study. results: a total of 1000 candidates full filling the inclusion criteria were included in the study. patient’s age ranged from 20 years to 52 years with mean age of 32.21 ± 8 years. cvd was found in 5.1% of patients and all of them were males. conclusion: the screened population was unaware of their cvd and had never undergone any color vision screening test indicating that the knowledge and the information on cvd is lacking in pakistan. key words: color vision, ishihara chart, screening, visual acuity. he human eye is unique in having trichromatic vision and a visual sense to differentiate between dissimilar wavelengths of light1. this is possible because of the presence of three unique types of retinal photoreceptors called the cones (red, green and blue) having specific pigments1. the cones detect an appropriate mixture of red, green and blue lights which enables the eye to match any color which is visible to it. when this normal trichromatic vision is absent in a person he or she is labeled as having abnormal color vision, color vision deficiency2, or commonly the flawed name, color blind. in cvd a person is unable to differentiate among certain colors due to the absence, malfunction, or alteration of one (dichromatism), two (monochromatism) or all (achromatism) of the photo pigments3. in dichromats color vision is only because of two pigments. the dichromats in which there is absence of green cones are called deuteranopia, while those with of red cones deficiency are called protanopia and those with absence of blue cones are called tritanopia. mild forms of defective color vision are called anomalous trichromacy and the terms protanomaly, deuteranomaly and tritanomaly are given in red, green and blue pigments defects, t mailto:zia.sohail@yahoo.com color vision deficiency in pakistan railways employees pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 227 respectively. color vision deficiency can be acquired due to optic nerve disease or medication but is usually congenital4. clinically the congenital cvd is characterized as partial (red-green and blue-yellow) and total color vision deficiency5. throughout the world cvd is taken as an occupational hazard with severe troubles happening in everyday life. mostly patients with cvd are never aware of their deficiency which results in various handicaps1. the problems they face include career selection (33%), disability in job (25%), traffic signal recognition (13%) and judgment in daily routines (75%)6. even in medical profession, color is a clinical sign for identifying anemia and cyanosis, which is vital in recognizing and diagnosing diseases7. in the literature cvd has been reported from many countries and populations. the prevalence of color vision deficiency in europe is reported to be 6.0% in males and 0.25% in females.5 another study done in australia showed prevalence of cvd 7.4% in males and 0.7% in females7 whereas in asian population it is reported as 4.9% in males compared to 0.64% in females6. in pakistan very little data is available regarding cvd and population based studies are lacking. the aim of our study was to provide information to fill the gap. material and methods it was a cross sectional descriptive study, with non probability convenient sampling, done at outdoor department of ophthalmology, pakistan railways hospital. the principles outlined in the declaration of helsinki (2008) were followed for the conduction of study and a formal approval from the ethical review committee was obtained for the conduction the study. with informed consent, data was collected of all pakistan railways employees presenting for the annual vision checkup during a period of year from feb 2015 to jan 2016. a sample of 1000 was estimated using the standard formula: n =z2p (1 – p) d2 where: n = sample size z = z statistic for a level of confidence (95% level of confidence used, therefore z value is 1.96) p = expected prevalence of proportion (0.0554), d = precision (0.02) detailed history using a structured questionnaire including age, gender, occupation, any medication or surgery was recorded by the authors and later examination was done. visual acuity was measured on the snellen’s chart (after refraction if required). the patients with best corrected visual acuity 6/9 after refraction and no history of medication or surgery were included in the study. the patients who had visual acuity < 6/9, medication history of anti tuberculosis, central nervous system acting drugs or ocular surgical history were excluded from the study. anterior and posterior segment examination was done by using slit lamp biomicroscopy and a condensing lens. color vision was assessed binocular with the best correction in a trial frame using the ishihara isochromatic color plates (38 plates). the color vision plates were held about 75 cm from the patient parallel to the face of the patient and perpendicular to the line of sight of the patient. the ishihara chart is a group of polychromatic plates in which figures are printed by colored spots with a background of likewise shaped colored spots. the figures are prepared in such a manner that to a patient of cvd they will give the impression of being the same as the background. each plate was shown to the patient for 3 to 5 seconds and they were asked to read the numbers in the color chart. the numbers read by a normal color vision patient were different from the patients with color vision deficiency. the documentation of the result was done as type of color vision deficiency with the help of the chart key. data was entered and analyzed using the spss version 22. the age was analyzed by descriptive method with range and mean ± sd where as the qualitative variables were analyzed as frequencies and percentages. results during the study period a total of 1178 patients presented to the hospital for annual checkup among which 1000 candidates full filling the inclusion criteria were included in the study. majority of the patients were males 95.8%. patient’s age ranged from 20 years to 52 years with mean age of 32.21 ± 8 years. cvd was found in 5.1% of the patients, all males (table 1). among the cvd patients 3.4% had red green color defect, 0.4 % had green color defect and 1.3% were total color blind. the screened out patients were unaware of their cvd and did not report any difficulty in their job. yasir iqbal, et al 228 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology table 1: color vision deficiency among the different employees. occupation red green color defect n (%) green color defect n (%) total color blind n (%) total (n=1000) n (%) constable 18 (1.8) 3 (0.3) 5 (0.5) 26 (2.6) sub inspector 1 (0.1) 3 (0.3) 4 (0.4) cabin man 4 (0.4) 4 (0.4) assistant driver 2 (0.2) 2 (0.2) guard 5 (0.5) 5 (0.5) head clerk 3 (0.3) 3 (0.3) point man/ signal clearer 3 (0.3) 3 (0.3) gate man 2 (0.2) 2 (0.2) assistant 2 (0.2) 2 (0.2) 34 (3.4) 4 (0.4) 13 (1.3) 51 (5.1) discussion color vision deficiency or color blindness is not blindness at all. it is the reduced ability of the eyes to see colors. cvd is a not a fatal disorder; therefore most of the patients with cvd remain ignorant of the deficiency since their vision remains normal otherwise 10. a patient with cvd may misidentify, confuse, and fail to notice or notice color less quickly than normal. this is because of underdevelopment or absence of one or more retinal cones which are responsible for detecting colors in light and transmitting them to the optic nerve and later to the brain. cvd is classified by type (protan, deutan or tritan) as well as the extent which can be mild, moderate or strong. protans have a red-green color vision deficiency caused by an anomaly in the red-sensitive retinal cone cells. protans typically confuse between orange versus green, red versus black, blue versus purple and light red (or “salmon”) versus gray. deutans have a red-green color vision deficiency caused by an anomaly in the green-sensitive retinal cone cells. deutans typically confuse shades of yellow versus green, green versus gray and magenta (or "pink") versus gray. tritans have a blue-yellow color vision deficiency caused by an anomaly of the blue-sensitive retinal cone cells. tritans typically confuse shades of yellow versus gray and blue versus gray. it is usually a hereditary genetic disease which is present since birth but the person remains unaware of it until screened for it. the genes producing photo pigments are passed on via the x chromosome and hence there is a higher possibility of cvd in males, if any genes are damaged. some researchers claim that the ability to discriminate color changes throughout a person’s life. kim s11 found an improvement in color discrimination while checking color vision from childhood to adolescence. but others believe this improvement might be because of the person’s ability in understanding the tests over the passing years. according to tiffin and ikoro nc12 discrimination remains stable until approximately 40 years and then begins to decline due to pupil miosis, which decreases retinal illumination, yellowing of the human lens, and an increase in retinal diseases occurring in later life. nagel anomaloscope is the standard test to measure adult red/green color vision13. in the test the subject simultaneously adjusts red and green mixture against the yellow field to achieve a precise color and brightness matching. it is very accurate in determining color anomaly but is a meticulous and difficult process14. in addition; the equipment is rather burdensome and expensive. more manageable and cheaper alternatives are farnsworth 100 hue test and its reduced version, the d15 panel. however, these test demand a good cognition while arranging color chips in a predefined spectral order and is easier said than done. in screening for cvd, the purpose is only to detect if it is present or not. protan and deutan defects are the highest in congenital cvd. for this the ishihara color vision deficiency in pakistan railways employees pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 229 test is reliable, having a mean sensitivity of 96% and the mean specificity of 98.5%6, therefore serve the purpose of screening. large random population surveys have reported cvd in 0.4% women10. in our study none of the females had cvd. this is contrary to the previous studies in which the reported cvd in women in denmark is 0.54%, in greenland is 0.4%, ethiopia 0.2%, iraq 3.2%, iran 0.43%, jordan 0.33%, spain 0.75% and saudi arabia 0.75%15. on the other hand we detected cvd in 5.1% males in our study whereas reported cvd worldwide in males are: india 8.73%7, belgium 8%, united states 8%, turkey 7.33% and china 6.5%16. universally cvd is detected more in males as compared to females17. the abnormality is inherited as x linked recessive disease18 therefore males are affected and females act as carriers. the female carriers of the abnormal gene have 50% chance of abnormal color vision for sons whereas the cvd males pass on their x-chromosomes to daughters only, which leads to all daughters as carriers and sons with normal color vision. a person with cvd is considered to be handicapped in comparative color tasks. in everyday life cvd imposes significant hazards like recognizing traffic signals and signs while driving a car, judging the freshness of fruits, choosing and preparing food, gardening, and even selecting clothing. therefore in many occupations cvd is considered a handicap e.g. telecommunication, electrical mechanics, seamen, train drivers, air traffic controllers, painters etc. cvd can lead to difficulty in detecting color codes on electrical components, end points in chemical tests, problems in industries like paint, textile and plastics; leading to inappropriate and unsafe function19. in railways organization, people concerned for the control of train movements must be able to distinguish red, yellow and green signals at one kilometer distances20. we in our study found 2 assistant drivers and 3 signal clearers suffering from cvd. when inquired, they reported no difficulty in performing their tasks. one probable reason for this could be that they have trained themselves over the years as how to differentiate between different colors by the help of other clues like numbers, shape, size and pattern. this finding is a concern and emphasizes mandatory cvd screening in all professions as most of people are unacquainted of their cvd and do not report any difficulty in their job. even in medical profession people are unaware of their cvd because screening policy does not exist in most countries21. although cvd does not cause any significant disability but till now no treatment or surgical procedure has been proven to recover the chromatic vision 10. in the past techniques like warming one’s eye, stimulating by electricity, injecting iodine or cobra venom extracts22 and multivitamins were advocated but it was concluded that no method can correct cvd. special contact lenses and glasses23 have been designed that may help people with cvd to tell the difference between similar colors but clinical trials are awaited. further ongoing research for cvd involves gene technology using an injection of an adenovirus to get the genes into the cone cells of the retina of squirrel monkeys24. researchers have shown promising results but human trials are awaited. we know the limitations of our study. the study is based on data of a particular hospital and it is not population based; hence does not give a true measure of the incidence and prevalence of cvd in the population of pakistan but it might prove helpful for further population based studies. conclusion in our study found we cvd was present in 5.1% of the candidates. the screened population was unaware of their cvd and had never undergone any screening test indicating that the knowledge and the information on cvd is lacking in pakistan. author’s affiliation dr yasir iqbal assistant professor ophthalmology department iimc, riphah international university pakistan railways hospital, rawalpindi dr aqsa malik demonstrator /pgt biochemistry department iimc, riphah international university rawalpindi dr. sohail zia assistant professor ophthalmology department iimc, riphah international university pakistan railways hospital, rawalpindi dr aneeq ullah baig mirza professor of ophthalmology ophthalmology department yasir iqbal, et al 230 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology iimc, riphah international university pakistan railways hospital, rawalpindi role of authors dr. yasir iqbal research design, data analysis, interpretation and manuscript review dr. aqsa malik data compiling, statistical analysis and manuscript drafting dr. sohail zia research design, data analysis, interpretation and manuscript review dr. aneeq ullah baig mirza research design, data 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797800. 8. citirik m, acaroglu g, batman c, zilelioglu o. congenital color blindness in young turkish men. ophthalmic epidemiology, 2005 jan. 1; 12 (2): 133-7. 9. thiadens aa, hoyng cb, polling jr, bernaerts-biskop r, van den born li, klaver cc. accuracy of four commonly used color vision tests in the identification of cone disorders. ophthalmic epidemiol. 2013 apr; 20 (2): 114-21. 10. shah a, hussain r, fareed m, afzal m. prevalence of red-green color vision defects among muslim males and females of manipur, india. iran j public health, 2013; 42 (1): 16-24. 11. kim s, chen s, tannock r. visual function and color vision in adults with attention-deficit/hyperactivity disorder. journal of optometry, 2014 mar. 31; 7 (1): 2236. 12. ikoro nc. the ageing eye” functional changes from cradle to gray: a review .jnoa 2010; 16: 6-9. 13. birch j. worldwide prevalence of red-green color deficiency. josa a. 2012 mar. 1; 29 (3): 313-20. 14. seshadri j, christensen j, lakshminarayanan v, bassi cj. evaluation of the new web-based "colour assessment and diagnosis" test. optom vis sci. 2005 oct; 82 (10): 882-5. 15. oriowo om, alotaibi az. color vision screening among saudi arabian children. s afr optom. 2008; 67 (2): 56-61. 16. cruz em, cerdana hgs, cabrera amb, garcia cb, morabe ets, nañagas mlr. prevalence of color-vision deficiency among male high-school students. philipp j ophthalmol. 2010; 35: 20–24. 17. jafarzadehpur e, hashemi h, emamian mh, khabazkhoob m, mehravaran s, shariati m, fotouhi a. color vision deficiency in a middle-aged population: the shahroud eye study. international ophthalmology, 2014 oct. 1; 34 (5): 1067-74. 18. ebrahim nk, shaker ia, kadhir a. prevalence of color vision deficiency (cvd) and abo blood groups in kannur district of kerala, india. international journal of bioassays, 2016 jan. 1; 5 (01): 4760-3. 19. chan xb, goh sm, tan nc. subjects with colour vision deficiency in the community: what do primary care physicians need to know? asia pacific family 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2007, vol. 23 no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: abid naseem department of ophthalmology saidu medical college saidu sharif, swat received for publication september’ 2006 …..……………………….. purpose: to study the complications encountered during and after cataract surgery in eyes with pseudoexfoliation and their visual outcome. materials and methods: this non-interventional descriptive study was conducted in the ophthalmology department of lady reading hospital, khyber institute of ophthalmic medical sciences, peshawar from june 2002 to december 2002. all patients admitted for cataract surgery during june to september 2002 were examined on slit lamp without and with pupillary dilatation to diagnose pseudoexfoliation. patients of cataract with pseudoexfoliation above fifty years of age belonging to either sex were included in the study. all patients underwent cataract surgery with intraocular lens implantation. the patients were reviewed up to 60th postoperative day; operative and post-operative complications and the bestcorrected visual acuity on 60th post-operative day were measured. results: thirty-two eyes of thirty patients with pseudoexfoliation underwent cataract surgery, of which twenty (67%) were male whereas ten (33%) were female. complications encountered during surgery were zonular dialysis five (15.6%) cases, posterior capsular rupture five (15.6%), vitreous loss three (9.4%), residual lens matter in five (15.6%) and hyphema in one (3.1%) case. post-operative complications were severe anterior chamber reaction in 18 (56.2%) cases, corneal oedema 14 (43.8%), raised intraocular pressure five (15.6%), hyphema three (9.4%), pigment dispersion 13 (40.6%), posterior capsular opacification six (18.8%) cases, while iris prolapse, endophthalmitis, intraocular lens decentration and endothelial decompensation in one (3.1%) case each. final bestcorrected visual acuity was between 6/6-6/12 in 18 (56.3%) cases, 6/186/36 in ten (31.3%) cases; 6/60 to counting finger in three (9.4%) and one (3.1%) case had visual acuity of hand movement. conclusions: cataract surgery in eyes with pseudoexfoliation has higher incidence of operative complications like posterior capsular rupture, zonular dialysis, vitreous loss and intraocular bleeding. post-operatively, these patients are at greater risk for developing an immediate elevation of intraocular pressure and inflammation. posterior capsular opacification and intraocular lens decentration are more common in patients with pseudoexfoliation in post-operative period. 156 seudoexfoliation is an age related disease characterized by production and progressive deposition of protein like abnormal fibrillar extracellular material in the anterior segment of the eye and conjunctiva. the disease may be unilateral or bilateral and usually affects persons over 50 years of age. pseudoexfoliation is a familial condition and seems to be genetically inherited1. the composition and origin of the deposited material is not entirely clear. exfoliation material may be a form of amyloid or basement membrane material. fibrillogranular white material is deposited in and on the lens epithelium, iris stroma and blood vessels, corneal endothelium, anterior hyaloid face, zonular fibers, trabecular meshwork and subconjunctival tissue. the deposit is most prominent on the anterior lens capsule and at the pupillary margin2 (fig. 1). similar material has also been detected in skin and connective tissue portions of various visceral organs3,4. so pseudoexfoliation is now suspected to be a systemic disorder. fig. 1: left eye: anterior segment photograph; pseudoexfoliation of iris at papillary margin. there is atrophy of iris in eyes with pseudoexfoliation especially at the pupillary margin, which is evident by transillumination. pseudoexfoliation has been recognized as the most common identifiable cause of glaucoma. pseudoexfoliation is frequently associated with open angle glaucoma5 and poor pupillary dilatation6. there is increased melanin pigment liberation and deposition throughout the anterior chamber structures. phacodonesis and iridodonesis are not uncommon and they are most likely related to zonular degeneration and disintegration. spontaneous lens subluxation occurs in as many as 16% of patients with pseudoexfoliation7. making the diagnosis often requires a careful slit lamp examination after pupillary dilatation, and it frequently goes undiagnosed, leading to unexpected problems in management and during surgery. cataract surgery on eyes with pseudo exfoliation has higher incidence of complications like posterior capsular rupture, zonular dialysis, intraocular bleeding8 and vitreous loss during surgery9. the exfoliation material may be elaborated even after the crystalline lens is removed. the contraction of the anterior capsule opening and intraocular lens tilt is greater in the pseudoexfoliation eyes than in the healthy eyes 10. the higher frequency of secondary cataract could be considered as another potential complication of cataract surgery in eyes with pseudoexfoliation11. patients with pseudoexfoliation are reported with delayed spontaneous dislocation of intraocular lens within the capsular bag after uncomplicated cataract surgery12. pseudoexfoliation is being reported with increasing frequency in pakistan13. the study was undertaken at the ophthalmology department, khyber institute of ophthalmic medical sciences, lady reading hospital, peshawar. the study was concerned mainly with complications encountered during and after cataract surgery in patients with pseudoexfoliation and their visual outcome. materials and methods this non-interventional descriptive study was conducted on thirty consecutive patients of cataract with pseudoexfoliation above fifty years of age belonging to either sex, admitted to the ophthalmology department of lady reading hospital, khyber institute of ophthalmic medical sciences, peshawar. all patients admitted for cataract surgery during june 2002 to september 2002 were examined on slit lamp before and after pupillary dilatation to diagnose pseudoexfoliation. pseudoexfoliation was defined as the presence of white grayish pseudoexfoliation material on the anterior lens capsule and/ or near the pupil. inclusion criteria 1. patients diagnosed to have cataract with pseudoexfoliation on the basis of slit lamp examination before and after pupillary dilatation. p 157 2. patients of cataract with pseudoexfoliation above fifty years of age belonging to either sex. exclusion criteria 1. patients below fifty years of age. 2. patients with traumatic cataract. 3. patients with history of exposure to intense infrared light i.e., glass blowing. 4. patients with eye diseases other than pseudoexfoliation or early mild cataract. 5. patients with uncontrolled diabetes mellitus or other severe systemic and cardiovascular diseases and a history of transient ischemic attacks or stroke were excluded. informed consent was obtained from all participants before entry into study. a separate data collecting proforma was filled for every patient. patients underwent cataract surgery with pmma intraocular lens (iol) implantation. patients were discharged on the 1st post-operative day. the patients were reviewed up to 60th post-operative day. the operative and post-operative complications were recorded and best-corrected visual acuity after 60 days was measured. after completion of the data collection on proforma, it was stored in spss (statistical package for social sciences) 8.0 for windows statistical package. statistical analysis of continuous data were made. frequency of pseudoexfoliation in patients admitted for cataract surgery was made. mean, median, mode, range and standard deviation (sd) of age & pre and post-operative intraocular pressure (iop) distribution were determined. sex distribution and laterality of pseudoexfoliation with cataract, frequencies of different complications encountered during cataract surgery, frequencies of different post-operative complications and their correlation with final visual outcome were determined. final best-corrected visual acuity on 60th post-operative day was also determined. results thirty (5.8%) patients had cataract with pseudoexfoliation. among thirty patients of cataract with pseudoexfoliation twenty (67%) were male whereas ten (33%) were female. the mean age was 68.8 years (sd ± 7.37); the youngest patient was 55 years old while the oldest patient was 80 years of age (range 25 years). median and mode age was 70 years. further analysis of age and sex distribution is given in fig. 2. twenty three (76.7%) patients had bilateral cataract with pseudoexfoliation, while seven (23.3%) patients had unilateral cataract with pseudoexfoliation; out of which four were right and three were left sided. thirty two eyes of thirty patients with pseudoexfoliation underwent cataract surgery of which 20 (62.5%) were right while 12 (37.5%) were left sided. pre-operative visual acuity is given in fig. 3. pre-operative iop ranged from 6-40 mm hg with mean of 16.3 mm hg (sd ± 7.31). median iop was 14, while mode was 10 mm hg. 0 1 2 3 4 5 6 7 8 n o. o f p at ie nt s 50-59 60-69 70-79 80 & above age in years male female fig. 2: age and sex distribution. 0 2 4 6 8 10 12 14 16 6/6 6/12 6/18 6/36 6/60 cf hm pl+ive visual acuity n o. o f c as es cf = counting fingers, hm = hand movement pl = perception of light fig. 3: pre-operative visual acuity. three (9.4%) eyes underwent combined extraction, 28 (87.5%) eyes underwent extracapsular extraction while one (3.1%) eye underwent intracapsular cataract 158 extraction. all 32 eyes had a pmma iol implant, 30 (93.8%) eyes had posterior chamber iol while two (6.3%) eyes received anterior chamber iol. peripheral iridectomy was done in eight (25%) eyes; sphinterotomy was done in five (15.6%) eyes and injection carbachol was used in two (6.25%) cases. complications encountered during surgery are given in table i. table i: surgical complications complications no. of cases n (%) zonular dialysis 5 (15.6) posterior capsular rupture 5 (15.6) residual lens matter 5 (15.6) vitreous loss 3 (9.4) hyphaema 1 (3.1) re-surgery was required in two (6.3%) cases. one case underwent lens matter wash on 1st post-operative day for residual lens matter. one case needed reposition of prolapsed uveal tissue from wound on 5th post-operative day. post-operative complications are listed in table 2. mean iop on 60th post-operative day was 12.6 mm hg (sd ± 2.56). median and mode iop was 12 mm of hg. best-corrected visual acuity was checked on 60th post-operative day and is given in fig.4. causes of decreased visual acuity are given in table 3. discussion although pseudoexfoliation occurs in every race, its prevalence varies considerably. it has been reported with increasing frequency in pakistan, the latest study shows incidence of 1.99% out of 1604 patients14. patients with age related cataracts are elderly and often have coexisting pseudoexfoliation. our data indicates that the frequency of pseudoexfoliation in patients with age related cataract is 5.8%. this study also indicates that the incidence of the disease is higher among males (67%) than females (33%). this is consistent with the finding of studies done by mohammad 7 and naeem 15. comparing the frequency of monocular versus binocular involvement our study indicates bilateral involvement to be more common, with ratio of 3:1. many series have reported similar results16,17. cataract surgery on eyes with pseudoexfoliation has higher incidence of operative complications like posterior capsular rupture, zonular dialysis, intraocular bleeding8 and vitreous loss9. pupillary diameter and zonular fragility have been suggested as the most important risk factors for capsular rupture and vitreous loss18. zonular fragility increases the risk of lens dislocation, zonular dialysis or vitreous loss up to ten times 19. vitreous loss has been reported to be five times more common than in patients without pseudoexfoliation (9% vs. 1.8%) 18. this is related to an increased incidence of zonular dialysis, lens dislocation and capsular rupture20. in our study posterior capsular rupture (15.6%) was found in patients with poor pupillary dilatation and zonular fragility. this is consistent with previous report that capsular rupture is more common in patients with pseudoexfoliation and has been reported to occur in 27% of pseudoexfoliation eyes as compared to 2% of control eyes21. our data indicates 9.4% of vitreous loss, which is related to zonular dialysis and capsular rupture. table 2: post-operative complications complications no of cases n (%) severe anterior chamber reaction 18 (56.3) corneal edema 14 (43.8) pigment dispersion 13 (40.6) posterior capsular opacification 6 (18.8) raised intraocular pressure 5 (15.6) residual lens matter 5 (15.6) hyphema 3 (9.4) posterior synechiae 2 (6.3) iris prolapse 1 (3.1) endophthalmitis 1 (3.1) intraocular lens decentration 1 (3.1) endothelial decompensation 1 (3.1) 159 table 3: causes of decreased visual acuity causes no of cases n (%) glaucomatous cupping 7 (21.9) posterior capsular opacification 6 (18.8) corneal opacity 5 (15.6) corneal degeneration 3 (9.4) raised intraocular pressure 1 (3.1) intraocular lens decentration 1 (3.1) endophthalmitis 1 (3.1) endothelial decompensation 1 (3.1) 0 2 4 6 8 10 12 14 16 18 6/6 6 /12 6/1 8 6/ 36 6/6 0 c f hm p l+ ive cf = counting fingers, hm = hand movement, pl = perception of light fig. 4: final best corrected visual acuity. post-operatively, these patients are at greater risk of developing an immediate elevation of iop22. in our study 15.6% had raised iop in immediate postoperative period. post-operative inflammation is more common in eyes with pseudoexfoliation19. our data indicates similar results, 56.3% cases had severe anterior chamber reaction in immediate post-operative period. 40.6% of our cases had pigment deposition on iol in post-operative period. combined cataract and glaucoma surgery decreases the incidence of an acute post-operative rise in iop23 and may improve longterm control of iop. this is consistent with the finding of our study in which three cases underwent combined extraction with normal post-operative iop. posterior capsular opacification is increased in eyes with pseudoexfoliation (11%) compared to those without it (9%)11. in our study 18.8% of cases had posterior capsular opacification. intraocular lens decentration is more common even when the lens is entirely in the capsular bag, primarily due to decentration of the entire bag24. in our study 3.1% of cases had iol decentration. subluxation of the iol can occur if the zonules break or the capsular bag dislocates. limitation of our study was that our follow-up period was 60 days, so late post-operative complications are not evaluated. also a control group was not available for comparison. our study was small-scale descriptive study; a larger scale study is required to test the findings in larger population. conclusions pseudoexfoliation is not uncommon in patients with age related cataract. it is more common in males over 50 years of age and is usually bilateral. cataract surgery in eyes with pseudoexfoliation has higher incidence of operative complications like posterior capsular rupture, zonular dialysis, vitreous loss and intraocular bleeding. post-operatively, these patients are at greater risk of developing an immediate elevation of iop and inflammation. posterior capsular opacification and intraocular lens decentration are more common in patients with pseudoexfoliation in post-operative period. acknowledgement this paper was also presented in part at the 24th lahore ophthalmo on 19th december 2003. author’s affiliation dr. abid naseem senior registrar department of ophthalmology saidu teaching hospital, saidu medical college saidu sharif, swat dr. salim khan medical officer khyber institute of ophthalmic medical sciences hayatabad medical complex, peshawar dr. mohammad naeem khan consultant ophthalmologist khyber institute of ophthalmic medical sciences hayatabad medical complex, peshawar n o. o f c as es 160 prof. shad mohammad head of ophthalmology department khyber institute of ophthalmic medical sciences lady reading hospital, peshawar reference 1. allingham rr, loftsdottir m, gottfredsdottir ms, et al. pseudoexfoliation syndrome in icelandic families. br j ophthalmol. 2001; 85: 702-7. 2. prince am, ritch r. clinical signs of the pseudoexfoliation syndrome. ophthalmology 1986; 93: 803-7. 3. schlotzer-schrehardt um, koca mr, naumann go, et al. pseudoexfoliation syndrome. ocular manifestation of a systemic disorder? arch ophthalmol 1992; 110: 1752-6. 4. streeten bw, li zy, wallace rn. pseudoexfoliative fibrillopathy in visceral organs of a patient with pseudoexfoliation syndrome. arch ophthalmol. 1992; 110: 1757-62. 5. brooks amv, gillies we. the presentation and prognosis of glaucoma in pseudoexfoliation of the lens capsule. ophthalmology 1988; 95: 271-6. 6. carpel ef. pupillary dilation in eyes with pseudoexfoliation syndrome. am j ophthalmol. 1988; 105: 692-4. 7. mohammad s, kazmi n. subluxation of the lens and ocular hypertension in exfoliation syndrome. pak j ophthalmol. 1986; 2: 77-8. 8. awan kj, humayun m. extracapsular cataract surgery risks in patients with exfoliation syndrome. pak j ophthalmol 1986; 2: 79-80. 9. kirkpatrick jnp, harrad ra. complicated extracapsular cataract surgery in pseudoexfoliation syndrome: a case report. br j ophthalmol. 1992; 76: 692-3. 10. hayashi h, hayashi k, nakao f, et al. anterior capsule contraction and intraocular lens dislocation in eyes with pseudoexfoliation syndrome. br j ophthalmol. 1998; 82: 142932. 11. kuchle m, amberg a, martus p, et al. pseudoexfoliation syndrome and secondary cataract. br j ophthalmol. 1997; 81: 862-6. 12. jehan fs, mamalis n, crandall as. spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients. ophthalmology 2001; 108: 1727-31. 13. khanzada am. exfoliation syndrome in pakistan. pak j ophthalmol. 1986; 2: 7. 14. shafiq i, hassan ks. prevalence of pseudoexfoliation syndrome in a given population. pak j ophthalmol. 2004; 20: 49-52. 15. naeem s. incidence, age of presentation and lenticular changes in exfoliation syndrome. rawalpindi; military hospital rawalpindi. dissertation. 1997: 149. 16. kozobolis vp, papatzanaki m, vlachonikolis ig. epidemiology of pseudoexfoliation in the island of crete (greece). acta ophthalmol scand. 1997; 75: 726-9. 17. hirvela h, luukinen h, laatikainen l. prevalence and risk factors of lens opacities in the elderly in finland. a population based study. ophthalmology 2000; 102: 108-17. 18. naumann goh. exfoliation syndrome as a risk factor for vitreous loss in extracapsular cataract surgery. acta ophthalmol. 1988; 184: 129-31. 19. zetterstrom c, olivestedt g, lundvall a. exfoliation syndrome and extracapsular cataract extraction with implantation of posterior chamber lens. acta ophthalmol (copenh). 1992; 70: 85-90. 20. guzek jp, holm m, cotter jb. risk factors for intraoperative complications in 1000 extracapsular cataract cases. ophthalmology 1987; 94: 461-6. 21. goder gj. our experiences in planned extracapsular cataract extraction in the exfoliation syndrome. acta ophthalmol. 1988; 184: 126-8. 22. savage ja, thomas jv, belcher cd 3d, simmons rj. extracapsular cataract extraction and posterior chamber intraocular lens implantation in glaucomatous eyes. ophthalmology 1985; 92: 1506-16. 23. krupin t, feid me, bishop ki. postoperative intraocular pressure rise in open-angle glaucoma patients after cataract or combined cataract-filtration surgery. ophthalmology 1989; 96: 579-84. 24. auffarth gu, tsao k, wesendahl ta. centration and fixation of posterior chamber intraocular lenses in eyes with pseudoexfoliation syndrome. an analysis of explanted autopsy eyes. acta ophthalmol scand 1996; 74: 463-7. microsoft word qasim mansoor 92 original article long-term follow-up of corneal and sclerocorneal grafting in severe eye perforations qasim mansoor, roa rashad qamar, s. biswas, h.p. adhikary pak j ophthalmol 2006, vol. 22 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. corrrespondence to: qasim mansoor 12-bluestone drive heaton mersey stockport, cheshire uk received for publication august’ 2005 …..……………………….. purpose: the objective of the present study was to assess the prognosis of grossly perforated eyeballs due to pathological condition by attempting a repair with corneal or corneo-scleral graft with anterior segment reconstruction. material and method: a retrospective analysis of 26 eyes of 23 patients who underwent free-hand corneal or sclero-corneal graft for perforated eyeballs over a period of 15 years was performed. the minimum follow up period was 3 years, except one patient who died after 4 months from an unrelated cause. the causes of perforations included corneal melt associated with rheumatoid arthritis, chronic non-specific corneal ulcer, rupture of acute hydrops of keratoconus (down’s syndrome), herpes zoster keratitis, trauma in a buphthalmic eye, sloughing of the cornea due to strep. pneumoniae infection and chronic ulcer due to chemical injury. results: all the patients were able to keep their eyes with a variable amount of vision, except one eye that became phthisical after three months. the patients who did not develop better vision were for various reasons, e.g., pre-existing poor vision, retinal problems and cataract still to be dealt with. conclusion: the long-term psychological benefits of retaining the eye, preserving a modicum of ocular motility, avoiding enophthalmos which might occur post-enucleation, and in the case of children, facilitation of orbital development make free-hand corneal graft worth considering even in grossly perforated eyeballs due to pathological condition. there is also an uncertain but distinct possibility of restoring a partial degree of vision that might be extremely useful to the patient. he management of grossly perforated eyeballs due to a pathological condition is a very difficult task. the choices of management are evisceration and enucleation or an attempt at corneal repair with or without anterior segment reconstruction, using a corneal or corneo-scleral graft. the major principles of penetrating keratoplasty in pathologically ruptured globe or perforated cornea are excision of devitalised and infected tissue, anterior chamber reconstruction including anterior vitrectomy if needed, cataract extraction if indicated, medical control of raised intraocular pressure or prophylaxis by filtering surgery and careful follow-up to control postoperative complications1. various adjunctive procedures like tarsorrhaphy, conjunctival flap, cyanoacrylate glue and amniotic membrane grafting have also been tried. t 93 although there is a high risk of not being able to save the eye in gross perforations, it might be worth availing of the small chance of preserving globe integrity, if not visual acuity, by attempting a repair and reconstruction instead of a primary evisceration or enucleation. corneal or corneo-scleral grafting in a perforated eyeball due to pathological condition is a daunting task to perform. the preparation of recipient bed, with the usual technique of trephination is neither safe nor possible, due to the collapse of globe. moreover, it is difficult to ascertain the exact extent of the pathological process in order to make a viable bed with minimum tissue loss; hence the graft is not always circular. so in these circumstances the only choice on many occasions is to consider a free hand corneal graft or corneo-scleral graft. there have been reports of free hand lamellar graft for marginal corneal degeneration2,3 penetrating graft in epithelial down growth4, or in otherwise healthy perforated cornea5. to our knowledge there are few reports on free hand graft in such grossly perforated eyeballs due to pathological conditions. material and methods this is a retrospective analysis of 26 eyes of 23 patients who underwent penetrating keratoplasty or sclerocorneal graft along with anterior segment reconstruction for perforated eyeballs over a period of 15 years from january 1984 to december 1999. of the 23 patients, 9 were male and 14 female. their age range was 13 years to 87 years, the mean age being 63 years. the pathological conditions leading to these perforations are shown in (fig. 1). all these patients had very soft eyeball and all the patients were conservatively managed by medical treatment prior to their referral for corneal graft, except the one with trauma in a buphthalmic eye that also had posterior synechae and seclusio-pupil. he had been receiving argon laser treatment for corneal and iris vessel, prior to planned corneal graft with triple procedure. he received a blunt injury leading to a rupture of the globe. corneal grafting was performed in 15 eyes. in another 11 eyes, along with corneal grafting various other associated procedures were performed as shown in (fig. 2). a single surgeon operated all the patients, as an urgent case. extensive corneal disease and perforation of the cornea needed free hand corneal grafting. for descriptive purposes, these patients were divided into two groups. in group i there were 15 eyes, whose associated pathological conditions are shown in (table 1). in this group it was possible to make a free hand circular bed on the recipient cornea. so it was not necessary for free hand cutting of the donor corneal disc, with the usual circular trephination being performed for watertight closure of the wound. the donor corneal disc was trephined through endothelial surface. in group ii there were eleven eyes whose donor cornea needed to be cut by free hand. the associated pathological conditions in this group are shown in (table 2). in these cases due to uncertainty and the extent of pathological condition, it was necessary for free hand cutting of both the recipient and donor’s disc for water tight closure of the wound. trephines were used to mark the area to be excised and the cornea dissected free hand, in view of the softness of the globe, to avoid the risk of collapse and excess tissue loss. an oversized donor button was trephined or fashioned to allow for adequate wound closure. viscoelastic substance (sodium hyalunorate) was used to reform the anterior chamber and delaminate the iris from the lens; part of it was left to reduce the risk of synechiae formation. the graft was sutured, using continuous 10/0 nylon. along with corneal grafting various other procedures were also carried out in some cases at the same sitting. the average follow up period of all the patients was 3 years (range 4 months to 4 years). the short follow-up period of 4 months was due to death of a patient from an unrelated cause. results all the patients were able to keep their eyes with variable amount of vision, as shown in fig. 3. the patients who did not develop better vision were for various reasons, such as pre-existing poor vision, retinal problems and cataract still to be dealt with. the patients with corneal melt associated with rheumatoid arthritis were all above eighty years, except one. summary of the complicated cases with highly unfavorable outcome is given below: case i: a sixty-seven years old female patient with poorly controlled rheumatoid arthritis presented with simultaneous bilateral melting of the cornea except in the areas of calcification, in her aphakic eyes. she had a free hand corneo-scleral graft, anterior vitrectomy and iris supported secondary implants. two years 94 later the same pathology started in both eyes together and a similar surgical procedure, involving anterior vitrectomy, was carried out. however, within three months one eye became phthisical while the other eye regained an unaided vision of 6/60. (fig. 4-5) case ii: a patient who had severe atrophy of the upper eyelid in the affected eye, following herpes zoster ophthalmicus, and presented with perforation of the cornea due to exposure keratitis. she had to have multiple procedures like corneal graft, cataract extraction and intra ocular lens implants, pupilloplasty and reconstruction of upper eyelid. she regained an unaided vision of 6/36. this patient died after four months from an unrelated cause. two of the 3 patients with down’s syndrome, who had hydrops of cornea, were severely mentally challenged. one patient also suffered from severe psoriasis of the eyelids, which was successfully managed by the dermatologists. table i: group i: free hand cutting of recipient bed only. (associated pathological conditions leading to perforation) n (%) corneal melt associated with rheumatoid arthritis 5 (33.3) herpes zoster ophthalmicus 2 (13.3) trauma on buphthalmic eye 1 (6.7) non-specific corneal ulcer 5 (33.3) keratoconus 1 (6.7) infective corneal ulcer 1 (6.7) total 15 (100) table 2: group ii: free hand cutting of both donor and recipient beds (associated pathological conditions leading to perforation) n (%) corneal melt associated with rheumatoid arthritis 5 (45.5) acute hydrops of ruptured keratoconus 3 (27.3) sloughing of cornea due to strep. pneumoniae 2 (18.2) chemical injury 1 (9.1) total 11 (100) discussion the major causes of destruction of corneal tissue are infections, dry eye syndrome, chronic exposure keratitis, trophic ulcerations, melting syndromes and trauma. the primary goal of therapeutic penetrating keratoplasty is to excise devitalised and infected tissue and to restore structural integrity1. corneal grafts undertaken in disorganized eyes are at risk of failure. kirkness et al6 in an analysis of the relative success and complications of penetrating keratoplasty in perforated eyes found no significant difference between sterile perforated eyes and infected perforated eyes, suggesting that perforation itself is a major risk factor. they recommend that when perforation is imminent, it is better to proceed to a penetrating keratoplasty as the angle may be better protected from peripheral anterior synechiae formation. the risk is increased by the presence of anterior synchiae that may exert traction at the site of attachment, and may perhaps expose the donor endothelium to blood vessels and increase the risk of rejection7. it has been shown that after anterior segment reconstruction and restoration of anatomical integrity, there is reduction of postoperative corneal oedema and also improvement of visual acuity8. corneal perforations due to herpetic keratitis and rheumatoid arthritis have been treated with temporising measures such as tissue adhesives provided the perforation is small, to be followed by therapeutic keratoplasty as soon as donor tissue is available9,13-15. in both these conditions, melting and perforations are associated with increased corneal collagenase activity. intensive topical steroid are widely used post-operatively to reduce anterior chamber inflammation, with an umbrella of antiviral coverage in herpetic infections9. the systemic immune mediated inflammation in the late stages of rheumatoid arthritis can cause a melting of host-graft junction, which might necessitate even systemic immunosuppression. it has also been suggested that an unstable corneal epithelium might trigger collagenase activity; hence tear supplements are helpful to stabilise the epithelium in these patients10,16,17. patients with down’s syndrome have a poorer outcome following keratoplasty, as there is less ability of patients with down’s syndrome to report graft reactions and infections, their tendency to selftraumatise and their increased susceptibility to 95 infections. post-operative results depend on severity of the disease itself, tendency of eye rubbing and selftraumatization11,12. however, careful post-operative follow-up with care provided by an attendant can improve outcomes as was also borne out by our study. in all of the cases presented here, it was possible to retain the eye following surgery. in addition to the psychological benefits gained in retaining the eye, associated pathological conditions 10 5 4 2 1 3 1 corneal melt associated with rheumatoid arthritis chronic non-specific corneal ulcer rupture of acute hydrops of keratoconus chronic ulcer herpes zoster ophthalmicus trauma on buphthalmic eye sloughing of cornea due to strep.pneumoniae infection chronic ulcer due to chemical injury fig. 1: associated pathological conditions of the perforated eyeballs. corneal graft with other procedures 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 corneal, anterior vitrectomy with secondary iris supported lens corneal graft, cataract with pc iol corneal graft, pupiloplasty cataract iol corneal graft, iol in situ vitrectomy corneal graft, pupiloplasty, cataract extraction,iol, reconstruction of the upper lid fig. 2: corneal graft performed with other associated surgical procedures. results 0 2 4 6 8 10 12 14 16 18 20 no perception of light hand movements cf to 6/18 6/9 or better series1 fig. 3: fig. 4: corneal melt and perforation associated with rheumatoid arthritis preoperative appearance of the right eye (the left eye having the same condition had a similar appearance). 96 fig. 5: postoperative appearance of the same eye after the first reconstructive keratoplasty with an unaided vision of 6/60 six months after the operation. ocular motility is preserved, thus avoiding enophthalmos, which may occur post-enucleation. in the case of children, retention of the globe may have an advantageous effect on future orbital development. conclusion surgical repair of a perforated eyeball with a free-hand corneal or corneo-scleral graft is a difficult proposition even in the best of circumstances. however, the possibility of retention of the eyeball, if not useful vision, makes repair and reconstruction a worthwhile first line of approach in preference to removal of the remnants of the globe. free-hand corneal or corneo-scleral graft with anterior segment reconstruction, even in cases with poor visual prognosis, is perhaps the desired procedure in perforated eyeballs due to pathological conditions, despite the sometimes small chance of retaining the eyeball. in addition to retaining the eye, there is also the prospect of restoring partial vision in a miniscule proportion of patients, which might still make a significant difference for them. there is always the option of removal of the eye at a later date if required. however, by attempting reconstruction and restoration of the normal anatomy as a first step, there is a possibility of a favourable outcome even in an apparently futile scenario. author’s affiliation dr. qasim mansoor 12-bluestone drive heaton mersey stockport, cheshire uk roa rashad qamar assistant professor bahawal victoria hospital bahawalpur s. biswas 12-bluestone drive heaton mersey stockport, cheshire uk h.p adhikary 12-bluestone drive heaton mersey stockport, cheshire uk references 1. taylor dm, stern a l. reconstructive keratoplasty in the management of conditions leading to corneal destruction. ophthalmology. 1980; 87: 892-902. 2. pettit th. corneo-scleral free hand lamellar keratoplasty in terrien’s marginal degeneration of the cornea long-term results. refract corneal surg. 1991; 7: 28-32. 3. brown ac, rao gn, aquavella jv. peripheral corneal graft in terrien’s marginal degeneration. ophthalmic surg. 1983: 14: 931-4. 4. friedman ah. radical anterior segment surgery for epithelial invasion of anterior chamber: report on three cases. trans. am aca ophthalmol otolaryngol. 1997; 83: 216-223. 5. kramer sg. simplified technique for freehand corneal grafting in traumatic cases. arch. ophthalmol. 1971; 86: 182-5. 6. collin m, kirkness, linda a, et al: the role of penetrating keratoplasty in the management of microbial keratitis. eye 1991; 425-431. 7. keneyon kr, strack t, hersch ps. penetrating keratoplasty and anterior segment reconstruction for severe ocular trauma. ophthalmology. 1992; 396-402. 8. waring iii, keneyon kr, gemmil md. results of anterior segment reconstruction for aphakic and pseudophakic corneal oedema. ophthalmology. 1988: 836-41. 9. james t, patten, cavanagh d. penetrating keratoplasty in acute herpetic corneal perforations. annals of ophthalmology. 1976. 10. bernauer w, ficker la. the management of corneal perforation associated with rheumatoid arthritis. ophthalmology. 1995; 102. 11. joanathan m, frantz, micheal s, et al. penetrating keratoplasty for keratoconus in down’s syndrome. am j ophthalmol. 1990, 109:143-7. 12. akova ya, dabil h, kavalcioglu o, et al. clinical features and keratoplasty results in keratoconus complicated by acute hydrops. ocul immunol inflamm 2000; 8: 101-9. 97 13. reed jw, joyner sj, knauer wj 3rd. penetrating keratoplasty for herpes zoster keratopathy. am j ophthalmol. 1989 15; 107: 257-61. 14. claerhout i, beele h, abeele kvd, et al. therapeutic penetrating keratoplasty, clinical outcome and evolution of endothelial cell density. cornea. 2002; 21: 637-42. 15. killlingsworth dw, stern ga, driebe wt, et al. results of therapeutic penetrating keratoplasty. ophthalmology. 1993; 100: 534-41. 16. palay da, stulting rd, waring go. penetrating keratoplasty in patients with rheumatoid arthritis. ophthalmology. 1992; 99: 622-7. 17. vanathi m, sharma n, jeevan s, et al. vajpayee. tectonic grafts for corneal thinning and perforations. cornea. 2002; 21: 792-7. efficacey and safety of argon laser trabeculoplasty in lowering intraocular pressure as adjunctive treatment to primary open 9 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology original article efficacy and safety of argon laser trabeculoplasty in lowering intraocular pressure as adjunctive treatment to primary open angle glaucoma uzma fasih, erum shahid, arshad sheikh pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: uzma fasih fcps, associate professor eye department, karachi medical and dental college abbasi shaheed hospital email: yousufuzma@hotmail.com …..……………………….. purpose: to assess efficacy and safety of argon laser trabeculoplasty (alt) to lower intra ocular pressure (iop) as adjunctive treatment in primary open angle glaucoma (poag) patients. study design: descriptive cross sectional. place and duration of study: ophthalmology department, abbassi shaheed hospital from may 2016 to august, 2017. materials and methods: primary open glaucoma patients were selected from eye opd. patients with inflammatory, angle closure, traumatic glaucoma were excluded. pre laser and post laser iop was measured at 1 st week then at 1, 3 and 6 months. data was collected and analyzed on spss version 20. there were 114 patients. sample size was calculated by rao soft sample size calculator. results: there were 69 (61%) male patients. mean age of patients was 60.53 ± 10.71 years. mean pre laser intraocular pressure was 23.98 ± 10.01 mm hg. mean post laser iop at one month was 15.6 ± 3.25 and at 6 months was 14.8 ± 3.28 mm hg. overall mean reduction of iop was 9.18 mm hg from baseline, with p value less than < 0.005. pre laser 3 medications were used by 20 (18%) and 2 medications by 49 (43%). at 6 months follow-up 4 (3.5%) patients were on 3 medications and 31 (37%) were on 2 medications. it has a p value < 0.005. drug free patients at 6 months follow-up were 37 (33%). mild iritis was seen in 7 (6.14%) patients. conclusion: argon laser trabeculoplasty is effective and safe method to control iop in poag when used as an adjunct to medical therapy. it also decreases number of drugs used by patients. key words: argon laser trabeculoplasty, intraocular pressure, primary open angle glaucoma. laucoma is the leading cause of irreversible blindness world over. it is estimated that 64 million people suffer from this diease around the world1. it is characterized by optic nerve damage, cupping of the optic disc and typical visual field defects. rise in intra ocular pressure is a major risk factor. reduction of intraocular pressure (iop) may be helpful in reducing the optic nerve damage2. it is the third leading cause of irreversible blindness over the age of 40 years in pakistan3. primary open angle glaucoma (poag) commonly presents in our clinics where the cause of raised g efficacy and safety of argon laser trabeculoplasty in lowering iop in poag pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 10 intraocular pressure is functional impairment of trabecular meshwork (tm). medical treatment is the first line of treatment. surgical treatment is generally offered when patient does not respond to medical treatment. wise and witter are credited for describing first successful protocol, which is widely known as laser trabeculoplasty (ltp) in 19794. the utilized energy source for modern ltp is continuous-wave argon laser, operated in the bluegreen wavelength spectrum (454-529 nm)5. the exact mechanism of the procedure is not known, but it is believed that the laser energy applied to the trabecular meshwork initiates structural and/or physiologic changes that facilitate aqueous outflow6. wise and witter stated that thermal energy produced by pigment absorption of laser light causes fibrosis of collagen in trabecular lamellae. subsequent shortening of treated meshwork might enlarge existing spaces between two treatment sites and expands schlemm’s canal by pulling meshwork centrally which facilitates the aqueous drainage from the trabecular meshwork4,7. microscopic and immune histochemical analysis of the trabecular meshwork after alt has shown local photocoagulation of treated trabecular tissue, while cells adjacent to treated areas have shown increased phagocytic activity. moreover studies have reported changes in the extracellular matrix after ltp related to an induction of matrix metalloproteinases. these enzymes normally break down extracellular matrix to maintain normal turnover of trabecular meshwork. thus there is cellular activation of trabecular mesh work with increased trabecular cell replication and increased number of cells involved in maintaining the outflow from trabecular meshwork8. laser trabeculoplasty (ltp) is a well known therapeutic method for the management of glaucoma since the last 30 years, which became popular during the past 10 years. ltp is an effective therapeutic option, as it can supplement topical medical treatment. one laser session can reduce the intraocular pressure (iop) for many years, thus reducing the adverse effects of poor compliance associated with medical treatment. more over ltp is in general a well tolerated and usually a low-risk procedure, as compared with glaucoma surgery5. majority of patients coming to government hospitals belong to poor socioeconomic class with poor compliance. this procedure will be safe and cost effective in lowering intraocular pressure. it will also decrease number of topical anti glaucoma medication which are a financial burden for them. little work has been published on this topic in local journals. we conducted this study to asses efficacy and safety of argon laser trabeculoplasty to lower intra ocular pressure as adjunctive treatment in patients with primary open angle glaucoma. materials and methods the study was carried out at ophthalmology department abbasi shaheed hospital and karachi medical & dental college from may 2016 to august 2017. it was a descriptive cross sectional study. it was started after approval from ethical review committee of the hospital. informed consent was taken. patients were registered through non probability consecutive sampling technique. sample size was calculated using rao soft sample size calculator taking confidence interval 90%, margin of error 5%, population size 10,000 and prevalence p for reduction in intraocular pressure 12.1 mm hg from the reference study.9 calculated sample size was 114. patients 45 years of age or above, diagnosed with primary open angle glaucoma with failed medical treatment were included in the study. patients with angle closure glaucoma, inflammatory glaucoma, traumatic glaucoma, aphakic and pseudophakic glaucoma and those having history of previous trabeculectomy and cataract surgery were excluded from the study. written informed consent was taken from them. detail history was taken. ocular examination was conducted including visual acuity, slit lamp examination, intraocular pressure, gonioscopy and fundoscopy. diagnosis of primary open glaucoma was established after ocular examination, optical coherence tomography and visual fields. these patients underwent laser trabeculoplasty under topical anaesthesia. pressure lowering agents brimonidine and pilocarpine were instilled 1 hour before surgery. a goldmann 3-mirror goniolens was placed on the eye with 1% methylcellulose. the helium-neon aiming beam was focused at the junction of pigmented and non pigmented trabecular meshwork with a spot size of 50 microns and duration of 0.1 seconds, keeping the starting energy level at 200 watts and increased according to the level of tm pigmentation. blanching of the tm or bubble formation was taken as the end result. approximately uzma fasih, et al 11 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology 50 adjacent laser spots were applied over inferior 180° of the tm, 25 spots in each quadrant. post laser iop was measured at one hour, one day, one week, and one, three, and six months. these responses were recorded on predesigned performa. during the post laser follow-up period, patients were treated with mild steroid (flouromethalone) 4 times a day which was withdrawn after i week, topical nonsteroidal anti-inflammatory drug (nepafenac) 3 times a day which was continued for 1 month and topical antiglaucoma medications as required. progression of glaucoma was monitored by visual fields and oct (optical coherence tomography) throughout the study. data was collected and analyzed on spss version 20. means were computed for numerical variables like age, pre-laser intraocular pressure and post laser intraocular pressure with standard deviations. frequencies of gender, eye, systemic diseases, visual acuity, prelaser and post laser medications were calculated. a paired t test was used for assessing changes in iop at different follow up visits. reduction in number of topical medications pre laser and post laser treatment was assessed with help of pair t test. p value of less than 0.05 was taken as statistically significant. results a total of 114 patients were included in our study. out of these male patients were (69) 61%. mean age of the patients was 60.53 ± 10.71 sd years ranging from 45 to 82 years. right eye was treated in 54 (47%) patients and left eye was treated in 60 (53%) patients. all other demographic features of patients are given in table 1. mean pre laser iop was 23.98 ± 10.01 sd mm hg. mean iop at day one post laser was 15.7 ± 3.68 sd mm hg. mean iop at one month post laser follow up was 15.6 ± 3.25 sd mm hg. mean iop at 3 and 6 months post laser follow up visit was 14.8 ± 2.61 sd mm hg and 14.8 ± 3.28 sd mm hg respectively. there was an overall mean reduction of 9.18 mm hg from baseline which was statistically significant (table 2). pre laser patients on 3 medications were 20 (18%) and those on 2 medications were 49 (43%) while at 3 months follow 4 (3.5%) patients were on 3 medications and 39 (34%) were on 2 medications. at 6 months follow-up 4 (3.5%) patients were on 3 medications and 31 (37%) patients were on 2 medications (table 3). this reduction in medications was statistically significant with p value < 0.005. drug free patients at 6 months follow up were 37 (33%) (table 1). no significant post laser complications were seen except mild iritis in 7 (6.14%) patients and transient rise in iop in 2 (1.75%) patients which were managed with topical steroids and pressure lowering agents. pair t test was conducted to evaluate the effect of argon laser trabeculoplasty on intra ocular pressure. there was a significant difference in mean pre laser iop (23.98 ± 10.01 mm hg sd) and 1 month post laser iop (15.5 ± 3.2 mm hg sd) with 95% ci ranging from 6.66 to 10.1 with p value of less than 0.005. three table 1: demographic characteristics. variables frequencies percentages mean age in years minimum maximum 60.53 ± 10.71sd 45 82 gender male 69 61% right eye left eye 54 60 47% 53% duration of glaucoma (mean) years 6 ± 3.6 years visual acuity 6/6 -6/9 6/126/18 6/246/60 less than 6/60 21 18 41 34 18.4% 16% 36% 30% systemic disease htn dm 15 7 13% 6% both eyes 78 68.4% drug free at 6 months post laser 37 33% efficacy and safety of argon laser trabeculoplasty in lowering iop in poag pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 12 table 2: post alt reduction in iop. no. iop mean iop ± sd mmhg comparison p value 1. pre laser 23.98 ± 10.01 2. 1 day 15.7 ± 3.68 1 & 2 <. 000 3. 1 month 15.6 ± 3.25 1 & 3 <. 000 4. 3 months 14.8 ± 2.61 1 & 4 <. 000 5. 6 months 14.8 ± 3.28 1 & 5 <. 000 table 3: post alt reduction in medications. frequency % pre laser medication 1 medication 2 medications 3 medications 4 medications 25 49 20 20 22% 43% 18% 18% post laser 3 month 1 medication 2 medications 3 medications 4 medications 45 39 4 0 40% 34% 3.5% post laser 6 month 1 medications 2 medications 3 medications 4 medications 38 35 4 0 33% 31% 3.5% table 4: pair-t test. no. no of medications p value 1. prelaser medications & at 3 month <. 000 2. prelaser medication & at 6 month <. 000 month post laser mean iop was 14.8 ± 2.61sd mm hg with 95% ci ranging from 7.4 to 10.8 and p value of less than .005. six month post laser mean iop was 14.8 ± 3.2 mm hg sd with 95% ci ranging from 7.4 to 10.9 and p value of less than .005. so the difference between pre laser mean iop and post laser mean iop at 1, 3 and 6 months was highly significant. pair t test was conducted to see the reduction in prelaser and post laser medication. mean difference in prelaser medication was 2.307 with 95% confidence interval from 2.12 to 2.49. while 6 months post laser medication mean difference was 1.053 with 95% confidence interval ranging from 0.89 to 1.22. with p value less than 0.005 which was highly significant. discussion in the developing world treatment options for glaucoma are becoming more complicated as all treatment modalities and health care facilities are not available in all environments. in addition cost of medicines and hurdles in their distribution make medical treatment of glaucoma very difficult and sometimes impossible in most of the developing countries. prostaglandin analogs are said to be the first line of treatment currently10. topical b blockers, alpha adrenergic agonists and carbonic anhydrase inhibitors may be used as additional therapies when required but there may be a significant inter patient variability in their response.11,12. alt has been known to be an effective method for reduction of iop in poag patients. use of this modality as an adjunctive to the medical treatment cannot be overlooked. alt does not cure glaucoma but provides a long term reduction in iop when used as an adjunctive treatment to medical treatment of glaucoma. in addition alt cannot be relied upon as primary treatment option in patients who have poor compliance as there may be long periods of uncontrolled iop. so alt could be a better adjunctive treatment for glaucoma rather than primary treatment10. we conducted this study to document the efficacy of this procedure as an adjunctive therapy to medical treatment in patients of poag. we found in our study that there was a mean reduction of 9.18 mm hg in post laser iop as compared to base line and 6 month follow up period there was a significant reduction in number of topical medications. a randomized clinical trial known as glaucoma laser trial glt was carried out in america to assess safety and efficacy of ltp for controlling iop in poag patients .they reported a mean reduction of 9 mm hg in iop among the laser treated eyes as compared to 7 mm hg reduction in iop among those who were treated with medical treatment. the study also reported that alt could be regarded as an equally effective therapy as medical treatment for poag patients. our study also reported similar reduction in iop12. shawartz and coworkers also reported a drop of 9.7 mm hg in mean iop at 2 months follow-up, 7.3 uzma fasih, et al 13 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology mm hg at 2 years and 4.9 mm hg at 5 years follow up after argon laser trabeculoplasty in cases of poag13. speath and et al concluded in their study that ltp deferred the need of surgical treatment in about one third of the patients of poag14. sharma and gupta reported 76% success rate of alt in poag in their study.9 one of the local study by mehar and et al reported 12.1 mmhg reduction in mean iop at 6 months follow up in their case series of 35 eyes15. detry-morel et al also reported a mean reduction of 4.9 mmhg in iop and significant reduction in number of drugs required at final visit along with minimal anterior chamber inflammation16. grinich et al reported 7.8 mmmhg reduction in iop at 3 years follow-up17. achadi et al reported 40.3% success rate of alt at 5 years follow up18. agarwal and et al reported reduction of 7.2 mm hg in mean iop at 6 month follow up after ltp which is quite similar to 9.18 mm hg post laser reduction of iop in our study. post laser complications in their study like transient rise of iop was found to be 51.3% patients, iritis in 5% patients, formation of peripheral anterior synechia in 2.5% patients and rarely hyphaema19. the frequency of complications was fewer in our study like mild iritis was seen in 7 (6.14%) patients, transient rise in iop in 2 (1.75%) patients and no hyphaema. the reason for few complications could be that patients were kept on topical nonsteroidal antinfammatory drugs in addition to steroids and topical brimonidine. in our study pre laser patients on 3 medications were 20 (18%), those on 2 medications were 49 (43%) and on one medication were 25 (22%). at 6 months follow up 4 (3.5%) patients were on 3 medications and 35 (31%) patients were on 2 medications and 38(33%) on one medication. this reduction in medications was statistically significant p value < 0.005. drug free patients at 6 months follow up were 37 (33%) while 4 (3.7%) patients had to be supplemented with trabeculectomy due to uncontrolled iop at 6 months follow up. in study by agarwal 10.2% patients underwent trabeculectomy at 6 momths follow up. agarwal and et al reported 10% drug free patients, 15% on one medication and 20% on 2 medications at 5 year follow up. the differences from our study could be due to their prolonged follow up period19. adequate safety and efficacy profiles of laser trabeculoplasty have been reported .due to the reliable safety and efficacy of laser trabeculoplasty this procedure can be used at any time during the treatment of poag as primary or adjunctive therapy and also decreases the need of any medical treatment before going for any surgical intervention20. it can also be tried before cataract surgery of glaucoma patients to achieve a better management of iop and to reduce the number of medications in patients who are on more than one drug. in addition it can be used in patients who are at risk of rise in iop after receiving intravitreal injections21. majority of the studies reported 25-30% post laser decrease in iop22. another study reported that if ltp is used earlier in treatment of poag the risk of adverse effect is diminished as the number of medications are decreased to reduce the iop.23 stein et al reported that ltp is economical and cost effective as compared to medical treatment24. limitation of our study is short term follow up period. long term follow up is required to determine efficacy of alt as an adjunctive therapy for prolonged control of iop in poag. conclusion we concluded from our study that alt is a safe and effective method to control iop in poag when used adjunct to medical therapy. it helps in decreasing the number of topical medications used for management of poag and is thus cost effective. conflict of interest: none. author’s affiliation dr. uzma fasih fcps, associate professor eye department, karachi medical and dental college abbasi shaheed hospital. dr. erum shahid mcps, fcps, assistant professor eye department, karachi medical and dental college abbasi shaheed hospital dr. arshad sheikh mcps, fcps, professor and head of department eye department, karachi medical and dental college abbasi shaheed hospital efficacy and safety of argon laser trabeculoplasty in lowering iop in poag pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 14 role of authors dr. uzma fasih concept design, data collection, manuscript writing, data analysis, critical review. dr. erum shahid concept, design, critical review. dr. arshad sheikh concept design, data collection, critical review. refrences 1. tham yc, li x, wong ty, quigley ha, aung t, cheng cy. global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. ophthalmology, 2014; 121 (11): 2081–2090. 2. sommer a. introcular pressure and glaucoma am j ophthalmol. 1989; 107: 186-8. 3. dineen b, bourne rr, jadoon z, et al. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. br j ophthalmol. 2007;91(8):1005-10. 4. wise jb, witter sl. argon laser therapy for open-angle glaucoma. a pilot study. arch ophthalmol. 1979; 97 (2): 319-322. 5. the glaucoma laser trial research group.the glaucoma laser trial (glt). 2. results of argon laser trabeculoplasty versus topical medicines. ophthalmology. 1990; 97 (11): 1403-1413. 6. stein jd, challa p. mechanisms of action and efficacy of argon laser trabeculoplasty and selective laser trabeculoplasty. curr opin ophthalmol. 2007; 18 (2): 140-145. 7. bradly jm, anderssohn am, clovis cm, et al. mediation of laser trabeculoplasty induced matrix metlloprotienase expression by il-beta and tnf alpha. invest ophthalmol vi sci. 2000; 41: 422. 8. singh k, shrivastava a. medical management of glaucoma: principles and practice indian j ophthalmol. 2011 jan; (1): s88–s92. 9. sharma a, gupta a. primary argon laser trabeculoplasty vs pilocarpine in primary open angle glaucoma 2 years follow up study br j ophthalmol. 1997; 45: 109-13. 10. feldman rm, tanna ap, gross rl, chuang az, baker l, reynolds a, prager tc. additivity study group. comparison of the ocular hypotensive efficacy of adjunctive brimonidine 0.15% or brinzolamide 1% in combination with travoprost 0.004% ophthalmology, 2007; 114: 1248–54. 11. bagga h, liu jh, weinreb rn. intraocular pressure measurements throughout the 24 h. curr opin ophthalmol. 2009; 20: 79–83. [pubmed] 12. the glaucoma laser trial (glt) 2, results of argon laser trabeculoplasty vs topical medication. the glaucoma research group. ophthalmology, 1990 ; 97: 1403-13. 13. shcawarz al, love dg, schawartz ma. long term follow up of argon laser trabeculoplasty for un controlled open angle glaucoma arch ophthalmol. 1985; 103: 1482-4. 14. speath gl, baez ka. argon laser trabeculoplasty controls one third of cases of progressive uncontrolled open angle glaucoma for 5 years arch ophthalmol. 1999; 110: 491-4. 15. mehar p.s, jalai kk. argon laser trabeculoplasty as primary therapy in primary open angle glaucoma jcpsp. 2008; 18 (2): 102-104. 16. detry-morel m, muschart f, pourjavan s. micropulse diode laser (810nm) versus argon laser trabeculoplasty in the treatment of open-angle glaucoma: comparative short-term safety and efficacy profile. bull soc belge ophthalmol. 2008; 308: 21-28. 17. grinich np, buskirk mv, samples jr. three year efficacy of argon laser trabeculoplasty. ophthalmology, 1987; 94: 858–62. 18. adachi m, shirato s, kaburagi t, et al. ten year results of argon laser trabeculoplasty. nippon ganka gakkai zasshi. 1994; 98: 374–8. 19. agarwal hc, sihota r, das c, dada t. role of argon laser trabeculoplasty in primary open angle glaucoma in indian patients br j ophthalmol. 2002; 86: 733-6. 20. mansouri k, shaarawy t. comparing pattern scanning laser trabeculoplasty to selective laser trabeculoplasty: a randomized controlled trial acta ophthalmol. 2017; 95: 361-365. 21. bozkurt e, kara n. yazici at, et al. prophylactic selective laser trabeculoplasty in the prevention of intraocular pressure elevated after intravitreal triamcinolone acetonide injection. am j. ophthlamol. 2011; 152: 976-981. 22. latina ma, sibayan sa, shin dh, et al. q switched 532 nm nd: yag laser trabeculoplasty (selective laser trabeculoplasty): a multicenter, pilot clinical study. ophthalmology, 1998; 105: 2082-2088, discussion, 20892090. 23. francis ba, ianchulev t, schofield jk, minckler ds. selective laser trabeculoplasty as a replacement for medical therapy in open-angle glaucoma. am j ophthalmol. 2005; 140 (3): 524-525. 24. stein jd, kim dd, peck ww, et al. cost-effectiveness of medications compared with laser trabeculoplasty in patients with newly diagnosed open-angle glaucoma. arch ophthalmol. 2012; 130 (4): 497-505. pakistan journal of ophthalmology, 2020, vol. 36 (1): 72-78 72 original article comparison of axial ocular measurements with contact and non-contact biometry muhammad arslan ashraf 1 , muhammad suhail sarwar 2 , muhammad awais afzal 3 imran khalid 4 , sehrish shahid 5 1,2,5 department of ophthalmology, kemu. 3 lahore general hospital, 4 services hospital, lahore abstract purpose: to compare between non-contact and contact biometry for measurements of central corneal thickness (cct), anterior chamber depth (acd), lens thickness (lt) and axial length (al). study design: descriptive cross sectional study. place and duration of study: mayo hospital, lahore from june 2018 to december 2018. material and methods: eighty-four subjects, (168 non-pathological eyes) visiting the eye outpatient’s department were recruited by non-probability convenience sampling. patients with high refractive errors and suffering from any ocular pathology were excluded from the study. cct, acd, lt and al were measured with non-contact biometer (haag streit) followed by contact biometer (ultrasound) after taking consent from the patient. data was entered and analyzed by using spss-21 and medcalc software. normality of quantitative data was checked with shapiro wilk test. independent sample t test was used for parametric variable and mann whitney-u test was used for non-parametric data. for the agreement between two techniques cohen’s kappa test used and bland-altman plot was drawn for graphical presentation. p-value equal or less than 0.05 was taken as significant. results: mean age of 84 subject (female: 45.24% and male: 54.76%) was 53.05 ± 13.56 years. the al was significantly longer for the non-contact measurement with the difference of 0.53 ± 0.32 mm (p < 0.001). contact pachymetry was significantly higher with the difference of 8.67 ± 20.83 µm (p = 0.046). acd was significantly deeper for non-contact measurements with the difference of 0.51 ± 0.32 mm (p < 0.001). contact ultrasound ascan measured lt significantly thicker with the difference of 0.59 ± 0.56 mm (p < 0.001). conclusion: there is significant difference of axial ocular measurements (cct, acd, lt and al) between contact (ultrasound a-scan) and non-contact (haag streit) biometry (p < 0.05). keywords: biometry, cataract, axial length, anterior chamber depth, central corneal thickness. how to cite this article: ashraf ma, sarwar ms, afzal ma, khalid i, shahid s. comparison of axial ocular measurements with contact and non-contact biometry, pak j ophthalmol. 2020; 36 (1): 72-78. doi: https://doi.org/10.36351/pjo.v36i1.922. introduction it has been proven that ocular optics is working on the basis of refractive parameter of eyeball structure, which changes with age. continuous flattening of anterior chamber (ac) and ocular crystalline lens correspondence to: muhammad arslan ashraf bs vision sciences, email: rajkumararslan@yahoo.com thickening is the best example of such structural changes with increasing age. 1 in current century, advances in cataract surgery techniques have made ocular biometry more and more important. instead of advancement in cataract surgery techniques, the accuracy is still dependent on precise biometry technique. the patients going for cataract surgery have high expectations of visual results and expect a spectacle-free life. this patient’s expectancy of good https://doi.org/10.36351/pjo.v36i1.922 mailto:rajkumararslan@yahoo.com ashraf ma, et al 73 pakistan journal of ophthalmology, 2020, vol. 36 (1): 72-78 visual quality after cataract surgery depends upon accurate measurement of keratometry (k-reading), anterior chamber depth (acd), lens thickness (lt) and axial length (al) 2-5 . biometry can be classified as (a) contact and (b) non-contact 6,7 . it is found that the 1mm measurement error in al, corneal radius and acd can induce 2.7d, 5.7d and 1.5d of refractive error, respectively. noncontact biometry devices use the principle of partial coherence interferometry (pci). however, the ultrasound technique requires physical direct or indirect (immersion technique) contact of transducer with the cornea. both ultrasound (us) a-scan biometry and non-contact pci based devices are used for calculating iol power 6,8 . al in ultrasound method is measured from corneal vertex to the internal limiting membrane (ilm) 9 . the ultrasound biometry can be performed by applanation of the probe to the corneal surface or by indirectly contact of probe to corneal surface in immersion technique (by using saline filled shell). due to saline filled shell, in immersion a-scan technique the chance of corneal indentation is negligible as a result the al length measured in immersion technique is longer as compared to direct contact a-scan method. the pci non-contact device simultaneously measures al, acd, lt and keratometry reading. all these factors play important role for iol calculation. the pci uses laser diode in the near infrared spectrum of 780nm for measuring al and other parameters 10,11 . non-contact biometer calculates the al as distance between corneal epithelium to retinal pigment epithelium (rpe). another advantage of non-contact biometer over ultrasound contact method is to provide different iol power formulas for single iol model, however, it is unable to measure biometric parameters in dense cataract 12 . therefore, in all cases ultrasound biometry cannot be replaced by non-contact biometry 9,13 . a recent study on comparison between contact and noncontact biometry reported that both techniques were comparable with no clinical significant difference in measuring al 13 . we compared biometric parameters to find difference between ultrasound biometry and noncontact haag streit biometer. material and methods this study was done at mayo hospital, lahore. it was a cross-sectional study done on 168 non-pathological eyes of 84 subjects. participants of the study were selected by non-probability convenience sampling. patients with high refractive errors (±4 diopters) were excluded. axial ocular measurements cct, acd, lt and al were measured with non-contact biometer (haag streit) followed by contact biometer (ultrasound) after instilling alcaine eye drops as local anesthesia. data was entered and analyzed by using spss-21 and medcalc software. normality of quantitative data was checked with shapiro wilk test. variables having p value ≥ 0.05 was considered as normally distributed. independent sample t test was used for parametric variable and mann whitney-u test was used for nonparametric data. for the agreement between two techniques, cohen’s kappa test was used and blandaltman plot was drawn for graphical presentation. bland–altman plots are graphs of the differences between the readings measured with the two methods plotted on the y-axis against the mean for the pairs of measurements plotted on the x-axis. p-value equal to or less than 0.05 was taken as significant. before examination, written consent was taken from all participants after giving detailed description of methodology of the study. the study was reviewed and approved by ethical committee of king edward medical university, lahore. results we examined 168 eyes of 84-subjects. out of 84 subjects 38 (45.24%) were female and 46 (54.76%) were male. mean age of the female participants was 49.92 ± 12.81 years and mean age of male participants was 55.63 ± 13.75 years. mean age of 84 participants recorded was 53.05 ± 13.56 years (table 1). table 1: age distribution. descriptive statistics of age female male total n (%) 38 (45.24%) 46 (54.76%) 84 minimum 25.0 21.0 21.0 maximum 70.0 80.0 80.0 mean 49.921 55.630 53.048 std. deviation 12.8071 13.7507 13.5575 comparison between cct measured with noncontact and ultrasound technique showed that there was statistically significant difference (p < 0.046). the cct was lesser in non-contact biometer (table 2). comparison of axial ocular measurements with contact and non-contact biometry pakistan journal of ophthalmology, 2020, vol. 36 (1): 72-78 74 comparison of acd also showed that there was statistically significant difference (p < 0.001). the acd was deeper in non-contact biometer. the difference between both techniques was 0.51 ± 0.32mm. lt was thinner in non-contact biometer as compared to contact biometer (ultrasound). the difference between both techniques was 0.59 ± 0.56mm (table 2). the comparison of al also showed a statistically significant difference between noncontact and ultrasound technique (p < 0.05). al was larger in non-contact biometer as compared to contact biometer (ultrasound). the kappa value showed that there is poor agreement between both techniques as it is less than 0.20 (table 2). the kappa value showed that there was poor agreement in measuring axial ocular measurements with both techniques, as it is less than 0.20 (fig. 1). table 2: statistical comparison of cct, al, acd and lt measured with non-contact (haag streit) and contact (ultrasound) technique. technique minimum maximum mean std. error std. deviation mean diff. mean diff. std. deviation p-value central corneal thickness non-contact 461 610 521.625 2.4645 31.943 -8.67 20.83 0.046 ultrasound 450 648 530.292 2.9168 37.8061 axial length non-contact 21.15 25.48 23.3139 0.06773 0.87784 0.53 0.32 < 0.001 ultrasound 20.44 25.26 22.7855 0.07121 0.92295 anterior chamber depth non-contact 2.24 4.14 3.1786 0.03291 0.42656 0.51 0.32 < 0.001 ultrasound 2.17 3.77 2.6718 0.02511 0.32544 lens thickness non-contact 2.59 5.6 4.2643 0.03719 0.48204 -0.59 0.56 < 0.001 ultrasound 1.85 5.95 4.8537 0.04924 0.63824 fig. 1a: bland-altman plot for cct comparing us with non-contact biometry. -49.5 to 32.2 µm was the 95% limit of agreement (r 2: 0.08633). 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 -2.5 -2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 mean of lt non-contact and ultrasound l t n o n -c o n ta ct u ltr a so u n d mean -0.59 -1.96 sd -1.70 +1.96 sd 0.52 fig. 1b: bland-altman plot for al comparing us with non-contact biometry. -0.11 to 1.16 mm was the 95% limit of agreement (r 2: 0.01992). 450 500 550 600 650 -80 -60 -40 -20 0 20 40 60 80 mean of cct non-contact and ultrasound c c t n on -c on ta ct u ltr as ou nd mean -8.7 -1.96 sd -49.5 +1.96 sd 32.2 fig. 1c: bland-altman plot for lt comparing us with non-contact biometry. -1.70 to 0.52 mm was the 95% limit of agreement (r2: 0.09983). 2.0 2.5 3.0 3.5 4.0 4.5 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 mean of acd non-contact and ultrasound a c d n on -c on ta ct a c d u ltr as ou nd mean 0.51 -1.96 sd -0.12 +1.96 sd 1.14 fig. 1d: bland-altman plot for acd comparing us with non-contact biometry. -0.12 to 1.14 mm was the 95% limit of agreement (r2: 0.1183). ashraf ma, et al 75 pakistan journal of ophthalmology, 2020, vol. 36 (1): 72-78 fig. 2a: lt contact vs. non-contact. fig. 2b: cct contact vs. non-contact. fig. 2c: acd contact vs. non-contact. fig. 2d: al contact vs. non-contact. there was also strong correlation found between axial parameters as cct increases with deepening of acd. likewise, acd and cct had negative correlation but strong positive relationship with acd. discussion partial coherence interferometry (pci) is a noncontact biometry technique, which provides dexterity in measuring k-reading, cct, acd, lt and al in a single sitting. this is the main advantage of noncontact pci biometer when compared with conventional ultrasound biometer. one more disadvantage of ultrasound biometry is that it is time consuming and requires topical anesthesia for corneal applanation. further, the precision achieved with partial coherence laser interferometry was shown to be 10 times better than that of ultrasound in earlier studies 14 . this study found significant difference between non-contact and ultrasound technique with the bias of 8.67 ± 20.83 µm (p = 0.046). the mean cct was 521.63 ± 31.943 µm and 530.29 ± 37.806 µm measured with non-contact and ultrasound technique, respectively. in contrast to previous studies, in which cct with noncontact biometer was always less than the corresponding us biometer of up to 36 µm, the mean difference in our study was 8.67 µm (95% confidence interval [95% ci] -49.5 to 32.2). suzanna airiani et al, also found that cct with noncontact appeared to measure slightly smaller than us. 15 comparison of axial ocular measurements with contact and non-contact biometry pakistan journal of ophthalmology, 2020, vol. 36 (1): 72-78 76 christoph tappeiner et al, found that the mean cct with noncontact and ultrasound technique was 549 ± 36.4 µm and 545 ± 38.2 µm respectively with the difference of -3.60 µm (p = 0.005). slight indentation by the examiner may alter the measurement of cct with ultrasound biometry 16 . sallet g et al. also found that the non-contact biometer measured less cct as compared to contact ultrasound technique 17 . much and haigis compared cct measurements in 104 eyes with 4 pachymeters (3: pci biometers; 1: ultrasound biometer). ultrasound pachymeter was used as the gold standard. the researcher found that the difference between pci and ultrasound biometer was statistically significant. the difference was < 10 µm, the agreement was good and the results can be regarded as clinically interchangeable 18 . in the comparison of anterior chamber depth, the mean acd found was 3.18 ± 0.43mm and 2.67 ± 0.33mm measured with non-contact and ultrasound technique, respectively. the difference between both techniques was 0.51 ± 0.32mm (p < 0.001). another study showed that the results of acd measurements with several noncontact instruments can differ greatly 19 . kim hj et al, found that the ultrasound method measured shorter acd measurement as compared to noncontact biometer 20 . christoph tappeiner et al, also reported shorter acd with ultrasound biometer with the mean significant difference of -0.055mm (p < 0.0001) 16 . however, j santodomingo-rubido et al, reported the nonsignificant difference in anterior chamber depth (−0.01 ± 0.08mm, p = 0.24) 21 . p j buckhurst et al, found that the ultrasound biometry measured shorter acd as compared to pci lenstar (0.32 ± 0.62mm) 22 . the mean lens thickness measurement was 4.26 mm and 4.85 mm with non-contact and ultrasound technique, respectively. the standard deviation of lens thickness was 0.48mm and 0.63mm with pci and ultrasound, respectively. there was a significant difference of 0.59 ± 0.56mm found between both techniques (p < 0.001). huseyin gursoy et al, found similar results in his research (0.24 ± 0.28mm). kurtz et al. showed that the ultrasound is sensitive to lt changes only if they exceed the measurements that are equivalent to 1.00d, whereas depending on the measured intraocular distance, precision values from 0.3 to 10 µm have been reported when using pci technology. buckhurst et al 22 , found similar lt measurements with the non-contact pci and the us, whereas another report showed a 0.24mm lower mean lt value with the non-contact pci biometer 23 . it was seen that the indention in ultrasound technique did not alter the lens thickness as echoes of lens capsule is not affected by corneal indentation. many possible clarifications for obtaining higher lt with ultrasound can be made; for example, accommodation could be possibly induced more with ultrasound biometer as both instruments do not have non-accommodative target for fixation. the second possible explanation is the measurement of the off-axis portion of the crystalline lens. another possible explanation is facing difficulty to always obtain perpendicularity of ultrasound probe, oblique probe may cause thicker lens measurement with ultrasound 23 . this study also found strong negative correlation between acd and lt. hasan hashemi et al, also found the similar results 24 . comparison between axial length measured with non-contact and ultrasound technique showed that there was statistically significant difference (p < 0.05) between the two. the axial length was recorded larger in non-contact biometer as compared to contact biometer (ultrasound) mean axial length was 23.31 ± 0.88mm and 22.79 ± 0.92mm measured with noncontact and ultrasound technique, respectively. the difference between both techniques was 0.53 ± 0.32mm. in earlier studies, the precision achieved with pci was shown to be 10 times better than that of us. the data from our study showed that there was a tendency for hyperopic shift in eyes that undergo pci biometry. this hyperopic shift may be due to measurement of longer axial length (0.53mm) as compared to ultrasound. ms rajan et al, found that the mean axial length was 23.47 ± 11mm in the pcli and 23.43 ± 1.2mm in the ultrasound 14 . globally, in ophthalmology clinics, the understandable advantage has been seen in utilizing pci devices in consultation sessions. after installation of non-contact technique, the patients do not need to wait for longer time, there is no need of topical anesthesia with no contamination risk. these improvements will be well received by patients, as hospital visits are often time consuming, and can be costly and inconvenient if unanticipated side effects occur. however, some researchers concluded that optical biometry provided no clinical advantage over conventional applanation ultrasound biometry 16 . both techniques have their own limitation and advantages over other. age matched comparison of axial ocular parameters can also improve the results. repeatability ashraf ma, et al 77 pakistan journal of ophthalmology, 2020, vol. 36 (1): 72-78 of both instruments can also give a rough estimation of more accurate device. conclusion there is a statistically significant difference of axial ocular measurements (cct, acd, lt and al) between the results obtained with contact (ultrasound a-scan) and non-contact (haag streit) biometry. the non-contact biometer is more preferable as there is no chance of indentation. however, contact biometer is useful in mature cataract. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution muhammad arslan ashraf; optometrist: study design, data collection, data analysis, manuscript writing and final review. muhammad suhail sarwar; professor of ophthalmology: study design and final review. muhammad awais afzal; postgraduate resident: data collection and final review. imran khalid; orthoptist: data collection and final review. sehrish shahid; optometrist: data collection and final review. references 1. zocher mt, rozema jj, oertel n, dawczynski j, wiedemann p, rauscher fg, et al. biometry and visual function of a healthy cohort in leipzig, germany. bmc ophthalmol. 2016; 16: 79. 2. aydin r, erdur ks, cabuk sk, karahan e, kaynak s. comparison of optical low coherence reflectometry versus ultrasonic biometry in high hypermetropia. eye contact lens, 2018; 44 (12): 1463-1468. 3. cao x, hou x, bao y. the ocular biometry of adult cataract patients on lifeline express hospital eyetrain in rural china. j ophthalmol. 2015; 2015: 171564. doi:10.1155/2015/171564. 4. cinar y, cingu ak, sahin m, sahin a, yuksel h, turkcu fm, et al. comparison of optical versus ultrasonic biometry in keratoconic eyes. j ophthalmol. 2013; 2013: 481238. https://doi.org/10.1155/2013/481238. 5. erb-eigner k, hirnschall n, hackl c, schmidt c, asbach p, findl o. predicting lens diameter: ocular biometry with high-resolution mri. invest ophthalmol vis sci. 2015; 56 (11): 6847-54. 6. eleftheriadis h. iol master biometry: refractive results of 100 consecutive cases. br j ophthalmol. 2003; 87 (8): 960-3. 7. ribeiro fm, ferreira fd, gil ln, jorge j, meijome jm. errors associated with iol master biometry as a function of internal ocular dimensions. j optom. 2014; 7 (2): 75-8. 8. karabela y, eliacik m, kaya f. performance of the srk/t formula using a-scan ultrasound biometry after phacoemulsification in eyes with short and long axial lengths. bmc ophthalmol. 2016; 16: 96. doi:10.1186/s12886-016-0271-8. 9. pongsachareonnont p, tangjanyatam s. accuracy of axial length measurements obtained by optical biometry and acoustic biometry in rhegmatogenous retinal detachment: a prospective study. clin ophthalmol. 2018; 12: 973-80. 10. wissa ar, wahba ss, roshdy mm. agreement and relationship between ultrasonic and partial coherence interferometry measurements of axial length and anterior chamber depth. clin ophthalmol. 2012; 6: 193-8. 11. németh j, fekete o, pesztenlehrer n. optical and ultrasound measurement of axial length and anterior chamber depth for intraocular lens power calculation. j cat refract surg. 2003; 29 (1): 85-8. 12. hirnschall n, varsits r, doeller b, findl o. enhanced penetration for axial length measurement of eyes with dense cataracts using swept source optical coherence tomography: a consecutive observational study. ophthalmol ther. 2018; 7 (1): 119-24. 13. dong j, zhang y, zhang h, jia z, zhang s, wang x. comparison of axial length, anterior chamber depth and intraocular lens power between iol master and ultrasound in normal, long and short eyes. plos one. 2018; 13 (3): e0194273. 14. rajan m, keilhorn i, bell j. partial coherence laser interferometry vs. conventional ultrasound biometry in intraocular lens power calculations. eye (lond). 2002; 16 (5): 552. 15. airiani s, trokel sl, lee sm, braunstein re. evaluating central corneal thickness measurements with noncontact optical low-coherence reflectometry and contact ultrasound pachymetry. am j ophthalmol. 2006; 142 (1): 164-5. 16. tappeiner c, rohrer k, frueh be, waelti r, goldblum d. clinical comparison of biometry using the non-contact optical low coherence reflectometer https://doi.org/10.1155/2013/481238 comparison of axial ocular measurements with contact and non-contact biometry pakistan journal of ophthalmology, 2020, vol. 36 (1): 72-78 78 (lenstar ls 900) and contact ultrasound biometer (tomey al-3000) in cataract eyes. br j ophthalmol. 2010; 94 (5): 666-7. 17. sallet g. comparison of optical and ultrasound central corneal pachymetry. bull soc belge ophtalmol. 2001; 281: 35-38. 18. much mm, haigis w. ultrasound and partial coherence interferometry with measurement of central corneal thickness. j refract surg. 2006; 22 (7): 66570. 19. rohrer k, frueh be, wälti r, clemetson ia, tappeiner c, goldblum d. comparison and evaluation of ocular biometry using a new noncontact optical low-coherence reflectometer. ophthalmology, 2009; 116 (11): 2087-92. 20. kim hj, kim hj, joo ck. comparison of iol master, a-scan and orb scan ii for measurement of axial length and anterior chamber depth. j korean ophthalmol soc. 2003; 44 (7): 1519-27. 21. rubido sj, mallen e, gilmartin b, wolffsohn j. a new non-contact optical device for ocular biometry. br j ophthalmol. 2002; 86 (4): 458-62. 22. buckhurst pj, wolffsohn js, shah s, naroo sa, davies ln, berrow ej. a new optical low coherence reflectometry device for ocular biometry in cataract patients. br j ophthalmol. 2009; 93 (7): 949-53. doi:10.1136/bjo.2008.156554. 23. gursoy h, sahin a, basmak h, ozer a, yildirim n, colak e. lenstar versus ultrasound for ocular biometry in a pediatric population. opt vis sci. 2011; 88 (8): 912-9. 24. hashemi h, khabazkhoob m, miraftab m, emamian mh, shariati m, abdolahinia t, et al. the distribution of axial length, anterior chamber depth, lens thickness, and vitreous chamber depth in an adult population of shahroud, iran. bmc ophthalmol. 2012; 12: 50. .…  …. 149 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol editorial inverted ilm flap technique zofia michalewska, jerzy nawrocki pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . as recently as 30 years ago, macular holes were thought to be untreatable. kelly and wendel showed that this was not the case in 1991 when they published their pilot study on vitreous surgery for idiopathic macular holes1. in 1997, eckardt et al. introduced internal limiting membrane (ilm) peeling2, following which, pars plana vitrectomy, internal limiting membrane peeling, fluid/gas exchange and face-down positioning were soon adopted as the standard treatment method for successful hole closure and bcva improvement. surgeons improved their own results by using smaller gauge instruments and, especially, by more qualified patient selection: earlier treatment, non-myopic eyes, better initial visual acuity, and smaller macular holes. despite these huge advances, 100% success rates of the classical approach, briefly described above, that were often quoted in the past were perhaps overly optimistic. modern oct-based studies reveal that 1939% of cases actually result in “flat open” anatomical outcomes (also referred to in the literature as type two closure), where the margins of the macular hole remain flat with bare retinal pigment epithelium. although the hole will normally not increase in size, visual acuity does not improve in these cases thus the surgical intervention cannot be said to have been fully successful3. oct images reveal u-type, v-type and irregular closure are the three successful macular hole anatomical closure types that also provide better functional improvement. after careful investigation of oct images from “flat open” results, jerzy nawrocki came to the conclusion that ilm tissue has an actual role to play in ensuring that the macular hole is successfully closed. as a base membrane, its properties enable cell proliferation and reactive gliosis. inverting the ilm and laying it over the macular hole on the surface of the retina may create a scaffold, over which müller cells can spread and photoreceptor cells may follow the gliosis, either re-approximating or re-growing over time. the first surgeries with the “inverted ilm flap technique” were carried out between 2006 and 2009 and the highly encouraging results were presented at the american society of retinal specialists (asrs), european vitreo-retinal society (evrs) and german ophthalmological society (dog) meetings. our first papers on the inverted flap technique were published in 2009 and 20104,5. the technique itself was modified in 2015 when we introduced the “temporal inverted ilm flap technique” in order to reduce overall trauma to the nerve fibres thereby reducing the amount of dissociated optic nerve fibre layer (donfl), described by tadayoni et al6 and to help prevent the flap moving away from the macular hole during fluid/air exchange7. it is a straightforward procedure although the manoeuvres involving manipulating the flap can take some time to perfect. core vitrectomy is performed and posterior hyaloid detached and removed. trypan blue is applied for 40 seconds to 1 minute to aid visualisation of the ilm, which is peeled on the temporal side of the macular hole but it is not completely removed. a sufficiently large piece of ilm is left attached at the margins of the hole and turned over and inverted so that the surface previously facing the vitreous body is now facing the retinal pigment epithelium. it is gently massaged over the macular hole (keeping it on top of the retina) and is held in place with fluid/air injection (with the flow moving from the attached end of the ilm flap towards the free end). patients are asked to maintain a position where the air bubble stays in the centre of their visual field for 3 days. the flap appears to perform its intended role as a scaffold, as confirmed immunohistochemically by shiode et al8. gliosis, migration and proliferation of inverted ilm flap technique pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 150 müller cells, microstructural regeneration, decreased ellipsoid zone defects and the macular hole closing and filling with tissue have all been reported along with bcva improvements of 1-4 lines as early as one day after surgery9. since its introduction, the flap technique has been investigated by many surgeons across the world and various authors have introduced their own adaptations and modifications. these have included filling the hole with attached ilm (which has led to the original techniques proposed by our group being called a “cover” technique and the others “fill” or “stuffing” techniques). others have used free flaps of unattached ilm, created multiple flaps, transplanted ilm to cover or fill the hole, used a lens capsular flap, or an amniotic membrane flap. different dyes have been used and alternative methods to hold the flap in place such as viscoelastic and gluconated blood have been reported in the literature10-14. as with any invasive surgical technique and any intervention involving dyes, there are potential risks involved when using the various flap techniques. comparative studies of the inverted ilm flap technique (“cover” techniques), “fill” techniques and classical ilm peeling seem to show that the inverted flap technique is a highly effective surgical method to close large macular holes and restore retinal tissue and improve bcva5,15. initially developed to deal with large macular holes the inverted flap technique tends to be used more often to treat large, old and myopic macular holes and for reoperations after conventional surgery has failed. however, it has also been adopted to treat routine small cases and has successfully resolved macular hole with retinitis pigmentosa, in an eye with coat’s disease, (both unpublished) and a case of secondary rupture of a retinal arterial macroaneurysm16, as well as to successfully treat persistent macular hole after retinal detachment surgery, macular holes with amd, traumatic macular holes, diabetic macular holes, macular holes secondary to uveitis and optic pit maculopathy. sd and ss oct show foveal microstructure recovery following surgery with the inverted flap technique. hayashi and kuriyama found reappearance of the ellipsoid zone and elm during 6months-follow up (more frequently in large and myopic cases compared to macular hole retinal detachment)17. despite finding expansion of submacular pigment epithelium atrophy during follow-up, imai and azumi reported visual acuity improvement 0.08 to 0.3 (landolt c)18. chen et al. found improvement in multifocal electroretinography after the inverted flap technique for large macular hole and although it was not significantly correlated with bcva it may be a useful supplement when evaluating functional recovery19. a new macular hole closure type: “flap closure” has recently been described by bonińska, nawrocki and michalewska. in these cases, large macular holes with lower preoperative visual acuity which probably would not have been closable without the use of the inverted flap technique, sd or ss-oct revealed a thin flap of tissue that had closed the hole one week after surgery. foveal architecture continuously restored up to one year follow-up and mean visual acuity improved. however, final visual acuity was lower when compared to eyes with initial utype, v-type or irregular closure20. whether or not the inverted flap technique should be considered as the first approach for the treatment of all macular holes is still open to discussion. the published outcomes of surgery as well as the comparative studies published to date have meanwhile led to the inverted flap technique and its adaptations being adopted by a significant number of ophthalmic surgeons throughout the world. references 1. kelly ne, wendel rt. vitreous surgery for idiopathic macular holes. results of a pilot study. arch ophthalmol. 1991; 109: 654-9. 2. eckardt c, eckardt u, groos s, reale e. entfernung der membrana limitans interna bei makulalöchern klinische und morphologische befunde. ophthalmologe [article in german], 1997; 4: 545-51. 3. michalewska z, michalewski j, cisiecki s, adelman r, nawrocki j. correlation between foveal structure and visual outcome following macular hole surgery: a spectral optical coherence tomography study. graefes arch clin exp ophthalmol 2008; 246: 823-30. 4. michalewska z, michalewski j, nawrocki j. macular hole closure after vitrectomy: the inverted flap technique. retina today, 2009: 73. 5. michalewska z, michalewski j, adelman ra, nawrocki j. inverted internal limiting membrane flap technique for large macular holes ophthalmology, 2010; 117: 2018-25. 6. tadayoni r, paques m, massin p, mouki-benani s, mikol j, gaudric a. dissociated optic nerve fiber layer appearance of the fundus after idiopathic epiretinal membrane removal. ophthalmology, 2001; 108: 2279-83. https://www.ncbi.nlm.nih.gov/pubmed/?term=adelman%20r%5bauthor%5d&cauthor=true&cauthor_uid=18386040 https://www.ncbi.nlm.nih.gov/pubmed/?term=adelman%20r%5bauthor%5d&cauthor=true&cauthor_uid=18386040 https://www.ncbi.nlm.nih.gov/pubmed/?term=adelman%20r%5bauthor%5d&cauthor=true&cauthor_uid=18386040 https://www.ncbi.nlm.nih.gov/pubmed/?term=nawrocki%20j%5bauthor%5d&cauthor=true&cauthor_uid=18386040 zofia michalewska, et al 151 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol 7. michalewska z, michalewski j, dulczewska-cichecka k, adelman ra, nawrocki j. temporal inverted internal limiting membrane flap technique versus classic inverted internal limiting membrane flap technique: a comparative study. retina, 2015; 35 (9): 1844-50. 8. shiode y, morizane y, matoba r, hirano m, doi s, toshima s, takahashi k, araki r, kanzaki y, hosogi m, yonezawa t, yoshida a, shiraga f. the role of inverted internal limiting membrane flap in macular hole closure. invest ophthalmol vis sci. 2017; 58: 484755. 9. michalewska z, michalewski j, dulczewska-cichecka k, nawrocki j. inverted internal limiting membrane flap technique for surgical repair of myopic macular holes. retina, 2014; 34 (4): 664-9. 10. nawrocki j, michalewska z. ss-oct for macular hole treated with the inverted internal limiting membrane flap technique. in nawrocki j, michalewska z (ed.): an atlas of ss-oct. springer, 2017: p.97-113. 11. imai h, azumi a. the expansion of rpe atrophy after inverted ilm flap technique for a chronic large macular hole. case rep ophthalmol. 2014; 5; 5 (1): 83-6. 12. andrew na, chan wo, tan m, ebneyter a, gilhotra js. modification of the inverted internal limiting membrane flap technique for the treatment of chronic and large macular holes. retina, 2016; 36 (4): 834-7. 13. pires j, nadal j, gomes nl. internal limiting membrane translocation for refractory macular holes. br j ophthalmol. 2017; 101(3):377-382. doi:10.1136/bjophthalmol-2015-308299. epub 2016 may 4. 14. dai y, dong f, zhang x, yang z. internal limiting membrane transplantation for unclosed and large macular holes. graefes arch clin exp ophthalmol. 2016; 254 (11): 2095-2099. epub 2016 aug 12. 15. rizzo s, tartaro r, barca f, caporossi t, bacherini d, giansanti f. internal limiting membrane peeling versus inverted flap technique for treatment of full-thickness macular holes: a comparative study in a large series of patients. retina, 2017; 38 suppl. 1: s73-s78. 16. iwakawa y, imai h, kaji h, mori y, ono c, otsuka k, miki a, oishi m: autologous transplantation of the internal limiting membrane for refractory macular hole following ruptured retinal arterial macroaneurysm: a case report. case rep ophthalmol. 2018; 1; 9 (1): 113-119. ecollection. 17. hayashi h, kuriyama s. foveal microstructure in macular holes surgically closed by inverted internal limiting membrane flap technique. retina, 2014; 34 (12): 2444-50. 18. imai h, azumi a. the expansion of rpe atrophy after inverted ilm flap technique for a chronic large macular hole. case rep ophthalmol. 2014; 5 (1): 83-6. 19. chen z, zhao c, ye jj, wang xq, sui rf. inverted internal limiting membrane flap technique for repair of large macular holes: a short-term follow-up of anatomical and functional outcomes. chin med j (engl). 2016; 129 (5): 511-7. 20. bonińska k, nawrocki j, michalewska z. mechanism of “flap closure” after the inverted internal limiting membrane flap technique. retina, 2017; 38 (11): 21842189. author’s affiliation zofia michalewska, md, phd ophthalmic clinic “jasne blonia”. ul. rojna 90. lodz, 91-162, poland. tel: +48 (0)42 636 8282 ; fax: +48 (0)42 611 0505 e-mail: zosia_n@yahoo.com jerzy nawrocki md, phd. ophthalmic clinic “jasne blonia” rojna 90, lodz, poland. https://www.ncbi.nlm.nih.gov/pubmed/?term=shiode%20y%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=morizane%20y%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=matoba%20r%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=hirano%20m%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=doi%20s%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=toshima%20s%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=takahashi%20k%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=araki%20r%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=kanzaki%20y%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=hosogi%20m%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=hosogi%20m%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=hosogi%20m%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=yonezawa%20t%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=yoshida%20a%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=shiraga%20f%5bauthor%5d&cauthor=true&cauthor_uid=28973331 https://www.ncbi.nlm.nih.gov/pubmed/?term=rizzo%20s%5bauthor%5d&cauthor=true&cauthor_uid=29232338 https://www.ncbi.nlm.nih.gov/pubmed/?term=tartaro%20r%5bauthor%5d&cauthor=true&cauthor_uid=29232338 https://www.ncbi.nlm.nih.gov/pubmed/?term=barca%20f%5bauthor%5d&cauthor=true&cauthor_uid=29232338 https://www.ncbi.nlm.nih.gov/pubmed/?term=caporossi%20t%5bauthor%5d&cauthor=true&cauthor_uid=29232338 https://www.ncbi.nlm.nih.gov/pubmed/?term=bacherini%20d%5bauthor%5d&cauthor=true&cauthor_uid=29232338 https://www.ncbi.nlm.nih.gov/pubmed/?term=giansanti%20f%5bauthor%5d&cauthor=true&cauthor_uid=29232338 47 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology original article epidemiology of ocular trauma in a tertiary hospital setting usama iqbal, irfan qayyum malik, hamza iqbal pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to usama iqbal mbbs, pgrdepartment of ophthalmology dhq teaching hospital gujranwala email: usamaiqqbal@gmail.com …..……………………….. purpose: to determine the epidemiology of ocular trauma in a tertiary hospital setting. study design: cross-sectional study. place and duration of study: ophthalmology department, dhq teaching hospital gujranwala from december 2016december 2017. material and methods: all patients included in the study had the following data recorded at presentation and follow up; date, age, gender, location and nature of injury, residence place, cause of injury, duration of hospitalization, anatomical site, adjuvant treatment, initial and final best-corrected (snellen) visual acuity. data was classified into five groups on the basis of place of eye injury. results: the total numbers of patients was 95. mean age of patients was 31.9 ± 18.1 years. out of these patients, 80 (84.2%) were males and 15 (15.8%) were females. there were 23 (24.2%) patients in 1-18 years age group, 40 (42.1%) patients in 18-35 years age group and 32 (33.7%) in >35 years age group. the tissues involved during trauma included 22 (33.8%) lid tears, 30 (46.2%) corneal tears, 2 (3.1%) scleral tears and 8 (12.3%) corneo-scleral tears. the most common location of ocular trauma was workplace (31.5%), household injuries (27.4%), sports injuries (7.3%), animal related injuries (8.4% and miscellaneous (25.2%). best corrected visual acuity (bcva) improved in 28 (29.5%) cases, deteriorated in 8 (8.4% cases and remained same in 59 (62.1%) cases. conclusion: young patients (18-35 years) are at more risk of ocular trauma especially at work, and this translates into a higher economic burden for the country at large. keywords: ocular trauma, road injuries, domestic injuries. cular trauma is an injury or damage to the eye. the injury may have been due to chemical agents, radiation (ultraviolet or ionizing) and mechanical trauma (penetrating or blunt)1. infiltrating objects can cause slashes of the cornea and sclera, can affect or involve iris, lens, choroid, retina & optic nerve. at times prolapse of vitreous and uvea is also observed2. patients presenting with damage to the posterior segment have a poor prognosis compared to patients with anterior segment damage3. coup, countercoup and ocular compression are the three underlying mechanisms by which blunt trauma can harm the eye. local harm at the site of effect is coup, while countercoup alludes to damage at the contrary side of the eye. ocular compression may cause scleral burst in eyes at zones where sclera is thin (at sites of muscle insertions)4. as per statistics, in young population a chief cause of visual loss is ocular trauma. study results of ocular trauma vary based on study design, geographical and societal factors. every year, approximately 2.5 million eye injuries occur in the united states, of which, more o epidemiology of ocular trauma in a tertiary hospital setting pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 48 than 40 thousand results in permanent visual impairment. rates have ranged from 857/100,000, when eye injuries require hospital admission5-7. a population based investigation in usa showed a prevalence rate of 19.8% and a normal yearly rate of 3.1×1000 population8. different reports in australia have assessed the yearly rate of all damages at 11.8/100,000 in rural setting and 15.2/100,000 in urban setting9. there are 200,000 open globe injuries a year estimated by the who programme for the prevention of blindness10-11. in general, it seems that ocular trauma follows a bimodal age distribution, affects more males than females and occurs more frequently in the lower socioeconomic groups. a higher male prevalence might be relevant to work-related disclosure, interest in unsafe games and pastimes, liquor utilization, and hazard taking behaviour12,14. as most ocular injuries are preventable, epidemiological studies are useful in informing prevention of blindness programs. from a general well being and injury anticipation point of view, current data on eye injury rates can help to devise plans for general public to reduce their occurrence and to give guidelines on safety measures. this can save a major group of public from getting blind because of this preventable cause13,15-18. in this paper, we present the clinical profile of patients with ocular trauma presenting to the ophthalmology department at dhq teaching hospital, gujranwala, over a period of one year. material & methods study area included the city of gujranwala, located to the north of lahore in pakistan. gujranwala district is spread over an area of 3,622 km square. gujranwala is an industrial city with a large portion of population working in factories and related to industry for their household. the current population is just over 5,014,196. a cross-sectional study was conducted at ophthalmology department, dhq teaching hospital gujranwala from december 2016 december 2017. all patients who were admitted in ophthalmology from december 2016 to december 2017 with ocular trauma were included in the study. ophthalmic unit of dhq hospital is the major adult eye trauma centre which serves as a major referral centre for a large geographic area. data collection was done from patient files through a pre devised performa. there was no discrimination of age and gender among the patients. patients with history of previous ocular trauma were excluded from the study. all patients included in the study had the following data recorded at presentation and follow up; date, age, gender, location and nature of injury, residence place, cause of injury, duration of hospitalization, anatomical site, adjuvant treatment, initial and final best-corrected (snellen) visual acuity. data was classified in five groups on the basis of place of eye injury: injuries which happened at home (door strike, fall from bed & others), injuries which happened while at work (occupational), injuries which happened during recreational activities (sports injuries), injuries related to the animals & others / miscellaneous (road accident related injuries, assault related injuries, and various outdoor activities related injuries). injuries were classified according to the birmingham eye trauma terminology system. data collection included; demographic details (age, gender), tissues involved during trauma, clinical features at the time of presentation. (frequency of iris prolapse, traumatic cataract, retinal detachment, iofb, visual axis involvement), frequency distribution of form of object, comparison of bcva, as per snellen’s chart, before and after treatment, relation with gender and age group. results total numbers of patients was 95. mean age group of patients was 31.9 ± 18.1 years. out of 95 patients, 80 (84.2%) were males and 15 (15.8%) were females (table 1). there were 23 (24.2%) patients in 1 18 years age group, while 40 (42.1%) patients in 18 35 years age group and 32 (33.7%) in > 35 years age group respectively (table 2). table 1: frequency distribution of gender. gender frequency percent male 80 84.2 female 15 15.8 total 95 100.0 there were 65 patients with full thickness lacerations. out of these 22 (33.8%) were lid tears, usama iqbal, et al 49 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology table 2: frequency distribution of age groups. age groups frequency percent 1-18 years 23 24.2 18-35 years 40 42.1 >35 years 32 33.7 total 95 100.0 while 30 (46.2%) were corneal, 2 (3.1%) were scleral and 8 (12.3%) were corneo-scleral respectively. remaining 30 patients were admitted with other complaints following trauma including hyphema (10), preseptal/orbital cellulitis (5), corneal abscess after h/o foreign body (9), macular hole (2), retinal detachment (5) and others (4), (table 3). table 3: type of tear & tissue injured type of tear frequency percent lid 22 33.8 corneal 30 46.2 scleral 2 3.1 corneo-scleral 8 12.3 fb 2 3.1 perforation 1 1.5 total 65 100.0 intraocular foreign bodies (iofb) were found in 10 (12.7%) and iris prolapse in 19 (24.1%). visual axis was involved in 27 (35.5%), incidence of traumatic cataract was 22.5%. retinal detachment occurred in 5 (6.3%) patients (figure 2). in type of object, 34.7% of trauma was related to sharp objects, 64.2% to blunt objects and 1.1% to liquid (table 4). the most common location of ocular trauma was work place (31.5%), this was followed by household injuries (27.4%). sports injuries accounted for (7.3%) of the total ocular trauma cases, animal related injuries (8.4%) and others (25.2 %) (outdoor activities, rta) (table 5). table 4: frequency distribution of form of object. object form frequency percent sharp 33 34.7 blunt 61 64.2 liquid 1 1.1 total 95 100.0 table 5: frequency distribution of place of injuries. place of injuries frequency percent occupational 30 31.5 house-hold 26 27.4 sports injuries 7 7.3 animal related 8 8.4 others 24 25.2 total 95 100.0 best corrected visual acuity (bcva) improved in 28 (29.5%) cases, bcva deteriorated in 8 (8.4%), preoperative and post-operative bcva was same in 59 (62.1%) (table 6). table 6: frequency distribution of post-operative bcva. post-operative bcva frequency percent same 59 62.1 improved 28 29.5 decreased 8 8.4 total 95 100.0 epidemiology of ocular trauma in a tertiary hospital setting pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 50 fig. 1: tissues involved/injured during trauma fig. 2: frequency distributions of visual axis (involved/not involved), iofb (yes/no), iris prolapse (yes/no), traumatic cataract (yes/ no), retinal detachment (yes/ no). improvement in post-operative bcva in male (24%) was better than females (7%) (table 7). improvement in postoperative bcva in age group 18 35 years was (15%) better than age groups < 18 years (8%) and < 35 years (5%) (table 8). according to injury distribution (as per birmingham eye trauma terminology), 34 (46.6%) were closed globe injuries, while 39 (53.4%) were open globe injury. among closed globe injury, contusion were 23 (67.6%) and 11 (32.4%) were lamellar lacerations. among open globe injury, lacerations were 28 (71.8%) and 11 (28.2%) were ruptures. according to laceration distribution, 23 (82.1%) were penetrating, while 5 (17.9%) and 0 (0.0%) were iofb and perforating respectively (figure 3). usama iqbal, et al 51 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology table 7: comparison of post-operative bcva with gender. gender post-operative bcva total p-value same improved decreased male 49 24 7 80 0.917* 83.1% 85.7% 87.5% 84.2% female 10 4 1 15 16.9% 14.3% 12.5% 15.8% total 59 28 8 95 100.0% 100.0% 100.0% 100.0% *applying chi-square test table 8: comparison of post-operative bcva with age. age groups post-operative bcva total p-value same improved decreased 1-18 years 15 8 0 23 0.137* 25.4% 28.6% 0.0% 24.2% 18-35 years 21 15 4 40 35.6% 53.6% 50.0% 42.1% > 35 years 23 5 4 32 39.0% 17.9% 50.0% 33.7% total 59 28 8 95 100.0% 100.0% 100.0% 100.0% *applying chi-square test epidemiology of ocular trauma in a tertiary hospital setting pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 52 fig. 3: flow chart. (birmingham eye trauma terminology) discussion this study found that most injuries occurred in males 80%. mean age of patients was 32 years. blunt objects accounted for most of the injuries with the cornea being the most affected tissue followed by eyelids. open globe injuries occurred in 53.4% of patients. most common place of ocular trauma was occupational injuries followed by house hold injuries including fall, door injuries and accidental injuries. our study found that improvement in best corrected visual acuity (bcva) occurred in 29.5% cases, bcva became worse in 8 (8.4% ), pre-operative and post operative bcva was same in 59 (62.1%). it was also noted that improvement in post operative bcva was more in those falling in age group 18-35 years (53%) as compared to age groups 1-18 years (28.6%) and age group > 35 years (17.9%). about (80%) of the ocular injuries occurred in men, in age groups 18–35 years of age. this is the most productive age group. similar results are observed in other studies around the globe. kikira, et al., found that, retina, optic nerve injuries and posterior vitreous are accounted for 12.7% of all blunt trauma eye injuries19. in another study by soliman m in egypt reported that, out of 153 eyes, after blunt trauma, 2.5% had vitreous haemorrhage with retinal detachment20. the site of visual injury in the usa is taking a move from work environment to domestic established wounds. this is because of laws implementing the utilization of defensive wear at the work environment and an expansion in the quantity of elderly individuals21. attack is the reason for eye damage in 19% of injuries in the useir, 1% of which are self inflicted22. kikira, et al. in kenya watched low speed rockets to represent the primary etiological factors.19 high speed rockets like explosive and slings represented less cases in contrast with oluwole omolase in nigeria who discovered metallic things to cause the vast majority of the injuries with 21.2%23. this study is limited by its relatively small size for internal sub-group comparison and the retrospective design. data extracted included information which injury closed globe injury 34(46.6%) open globe injury 39 (53.4%) contusion 23 (67.6%) lamellar laceration 11 (32.4%) laceration 28 (71.8%) rupture 11 (28.2%) iofb 5 (17.9%) perforating 0 (0.0%) penetrating 23 (82.1%) usama iqbal, et al 53 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology was available from patient’s record files. a few things like the nature of job, primary health care facility contact or referral information use of any eye protection device were not mentioned in few cases. although dhq teaching hospital is a main tertiary eye hospital in gujranwala division the statistics are not representative of the whole country. conclusion this study has a number of implications nationally and internationally. on a local level, there needs to be collaboration between the different health-care facilities to collect population-based data and informing the need for establishing an ocular trauma registry where by standardization of documentation is possible. the young (18-35 years) are more at risk of ocular trauma, and this translates into a higher economic burden to the country at large. work related injuries, especially among the working class are preventable, and there needs to be a public health initiative to promote the importance of protective eyewear. health related education and mindfulness about the quality of life following blindness is required. delayed presentation need to be addressed. in underdeveloped area of the country this campaign is needed on a large scale. the staff of basic health care units and rural health care centers should be trained to provide initial care and timely referral to the tertiary health care facilities. author’s affiliation dr. usama iqbal mbbs, pgrdepartment of ophthalmology dhq teaching hospital gujranwala dr. irfan qayuum malik mbbs, doms, fcps fellowship in vitreoretina associate professor dhq teaching hospital gujranwala hamza iqbal 4th year mbbs student king edward medical university, lahore author’s contribution dr. usama iqbal data entry, writing of synopsis and approval from institutional review board, result analysis, final article writing and submission to the journal. dr. irfan qayyum malik supervision, synopsis writing, critical review. hamza iqbal data collection from hospital record and transfer of data to performa. references 1. malik iq, ali z, rehman a, moin m and hussain m, epidemiology of penetrating ocular trauma. pak j ophthal 2012; 28 (1): 14-16. 2. babar tf, khan mt, marwat mz, shah sa, murad y, khan md. patterns of ocular trauma. j coll physicians surg pak. 2007; 1: 148-53. 3. wong ty, tielsch jm. a population-based study on the incidence of severe ocular trauma in singapore. am j ophthalmol. 1999; 128: 345–51. 4. tielsch jm, parver l, shankar b. time trends in the incidence of hospitalized ocular trauma. arch ophthalmol. 1989; 107: 519–23. 5. guly cm, guly hr, bouamra o. ocular injuries in patients with major trauma. emerg med j. 2006; 23: 9157. 6. babar tf, khan mn, jan su. frequency and causes of bilateral ocular trauma. coll physicians surg pak. 2007; 17: 679-827. 7. glynn rj, seddon jm, berlin bm. the incidence of eye injuries in new england adults. arch ophthalmol. 1988; 106: 785–9. 8. mcgwin g, jr, owsley c. incidence of emergency department-treated eye injury in the united states. arch ophthalmol. 2005; 123: 662–6. 9. kuhn f, morris r, witherspoon cd, mester v. the birmingham eye trauma terminology system (bett) j fr ophtalmol. 2004; 27: 206–10. 10. dandona l, dandona r, srinivas m, john rk, mccarty ca, rao gn. ocular trauma in an urban population in southern india: the andhra pradesh eye disease study. clin exp ophthalmol. 2000; 28: 350–6. 11. pandita a, merriman m. ocular trauma epidemiology: 10-year retrospective study. n z med j. 2012; 125: 61–9. 12. voon lw, see j, wong ty. the epidemiology of ocular trauma in singapore: perspective from the emergency service of a large tertiary hospital. eye (lond), 2001; 15 (1): 75–81. 13. kapadia mk, singh rp, sheridan r, hatton mp. gender differences in etiology and outcome of open globe injuries. j trauma. 2005; 59: 175–8. 14. romaniuk vm. ocular trauma and other catastrophes. emerg med clin north am. 2013; 31 (2): 399-411. 15. serrano f, stack lb, thurman rj, et al. traumatic eye injuries: management principles for the prehospital setting. jems. 2013; 38 (12): 56-62. 16. colby k. management of open globe injuries. int ophthalmol clin. 1999; 39 (1): 59-69. 17. negrel ad, thylefors b. the global impact of eye https://www.ncbi.nlm.nih.gov/pubmed/?term=babar%20tf%5bauthor%5d&cauthor=true&cauthor_uid=17374300 https://www.ncbi.nlm.nih.gov/pubmed/?term=khan%20mt%5bauthor%5d&cauthor=true&cauthor_uid=17374300 https://www.ncbi.nlm.nih.gov/pubmed/?term=marwat%20mz%5bauthor%5d&cauthor=true&cauthor_uid=17374300 https://www.ncbi.nlm.nih.gov/pubmed/?term=shah%20sa%5bauthor%5d&cauthor=true&cauthor_uid=17374300 https://www.ncbi.nlm.nih.gov/pubmed/?term=murad%20y%5bauthor%5d&cauthor=true&cauthor_uid=17374300 https://www.ncbi.nlm.nih.gov/pubmed/?term=khan%20md%5bauthor%5d&cauthor=true&cauthor_uid=17374300 epidemiology of ocular trauma in a tertiary hospital setting pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 54 injuries. ophthalmic epidemiol. 1998; 5 (3): 143-169. 18. scott r. the injured eye. philos trans r soc lond b biol sci. 2011; 366 (1562): 251-260. 19. kikira s., sajabi sm. ocular complications on blunt non perforating trauma. knh: university of nairobi; m med dissertation (unpublished) 1992. 20. soliman mm, macky ta. pattern of ocular trauma in egypt. graefes arch clin exp ophthalmol albrecht von graefes arch für klin exp ophthalmol. 2008; 246 (2): 205–12. 21. ruiz-moreno j.m, ashok garg. clinical diagnosis and management of ocular trauma. 1st ed. jaypee brothers medical publishers (p) ltd; 2009: 86. 22. kuhn ferenc. ocular traumatology 1st ed. springer 2008: 59. 23. omolase co, omolade eo, ogunleye ot, omolase bo, ihemedu co, adeosun oa. pattern of ocular injuries in owo, nigeria. j ophthalmic vis res. 2011; 6 (2): 114–8. pakistan journal of ophthalmology, 2020, vol. 36 (1): 48-52 48 original article mean change in refractive status after levator muscle resection in patients of simple congenital ptosis rana muhammad mohsin javaid 1 , ch. nasir ahmad 2 , rehab habib 3 asad aslam khan 4 , kashif siddique 5 1-5 department of ophthalmology, kemu, lahore abstract purpose: to determine the mean change in refractive status after levator muscle resection in patients of simple congenital ptosis. study design: quasi experimental study. place and duration of study: this study was carried out at institute of ophthalmology, king edward medical university, mayo hospital lahore, from 2014 to 2015. material and methods: fifty patients were selected under the age of 12 years with no sex predilection presenting with simple congenital ptosis of pupil sparing type. patients with neurogenic, aponeurotic ptosis, mechanical ptosis, blepharophimosis syndrome, patients with previous failed ptosis surgery and patients with corneal anomalies were excluded. after history and examination, cycloplegic retinoscopy was done, which was repeated after surgical intervention. all interventions were done by a single ophthalmic surgeon. the patients were examined and discharged on the second post operative day. all data including preoperative and postoperative recordings of spherical and cylindrical values were collected on a self-designed proforma. follow up period was extended to 3 months. at 3 rd month cycloplegic retinoscopy was done and change in character of refractive status was analyzed. mean change in refractive status was calculated by difference of preoperative and postoperative sphere and cylinder values. results: mean age of patients was 4.26 ± 3.78 years. mean change in spherical value after treatment was 0.447 ± 0.339. this difference was statistically significant with p-value = 0.000. while mean change in cylindrical value after treatment was 0.640 ± 0.580. this difference in cylinder value after treatment was also statistically significant with p-value = 0.000. conclusion: levator muscle resection has a significant effect on refractive status of the patients with congenital ptosis. key words: refractive error, levator muscle resection, congenital, ptosis. how to cite this article: javaid rmm, ahmad cn, habib r, khan aa, siddique k. mean change in refractive status after levator muscle resection in patients of simple congenital ptosis. pak j ophthalmol.2020; 36 (1):4852. doi: https://doi.org/10.36351/pjo.v36i1.996 introduction congenital ptosis is a common condition in pediatric correspondence to: rana muhammad mohsin javaid vitreo-retina fellow, mayo hospital, kemu, lahore email: lmdc99@hotmail.com population visiting oculoplasty clinics. it is more common than acquired blepharoptosis. surgical repair is challenging and recurrence, necessitating more than one operation, is common. children often require close follow-up post operatively because changes in refractive error have been reported following ptosis https://doi.org/10.36351/pjo.v36i1.996 mailto:lmdc99@hotmail.com javaid rm, et al 49 pakistan journal of ophthalmology, 2020, vol. 36 (1): 48-52 surgery. simple myogenic congenital ptosis is the commonest type in pediatric population 1,2 . pediatric ptosis is much more challenging and sensitive than adult ptosis as refractive errors with consequent possible amblyopia may be associated with it 3 . anisometropia is the disparity in refractive status of both eyes. anisometropic amblyopia may develop and progress rapidly during early childhood. pediatric ptosis can lead to reduction of visual potential albeit amblyopia by two means; by directly obstructing the visual axis in case of pupil obscuring ptosis; or by mechanically altering the shape of cornea which leads to astigmatism 4 . in one study of patients with unilateral ptosis, the difference in refractive state of both eyes was more than 1 diopter cylinder that was enough to cause amblyopia and permanent visual damage 5 . berry brincat and willshaw reported that 18.7% pediatric patients of simple congenital ptosis had visually significant refractive errors 5 . drooping of the lid can be addressed surgically by levator muscle resection or sling suspension of the upper lid 6,7 . sling surgery can be executed by using natural material or artificial suspenders. klimek dl studied refractive status before and after levator resection and mean spherical change of 1.23 ± 0.875 diopters and mean cylindrical change of 0.83 ± 0.75 diopters was present after 20 months follow-up 8 . we reviewed the patient at 03 months by presuming that change in refractive status will be the same as after 20 months‟ follow-up. pupil obscuring ptosis is always an indication for early surgical intervention but we studied the patients of pupil sparing ptosis in which lid pressure is thought to be the cause of astigmatism and surgical intervention might play an important role in preventing amblyopia. by doing this study especially in our part of the world the results of this study can generate data for further research. material and methods this was a quasi experimental study conducted at eye unit-iii, institute of ophthalmology, king edward medical university, mayo hospital lahore. the patients were admitted from eye opd of mayo hospital lahore by non-probability convenience sampling. study was completed in 6 months i.e. from november 2014 to may 2015. total 50 patients were included in the study. sample size of 50 cases was calculated with 95% confidence level, d = 0.25 and taking expected mean ± s.d of mean change in refractive error i.e. 1.23d ± 0.875 (sphere) in patients with simple congenital ptosis undergoing ptosis surgery (unilateral levator resection) 9 . patients under the age of 12 years with no sex predilection presenting with simple congenital ptosis of pupil sparing type (assessed by birth history, absence of upper lid crease with no systemic association e.g. chronic progressive external ophthalmoplegia etc. by a senior pediatric ophthalmologist) were included. patients of other causes of ptosis like neurogenic, aponeurotic and mechanical ptosis (assessed by senior paediatric ophthalmologist and senior neurologist), patients having ptosis associated with syndromes e.g. blepharophimosis syndrome, patients with previous failed ptosis surgery and patients with corneal anomalies like microcornea, megalocornea, anterior segment dysgenesis and previous anterior segment surgeries were excluded. cycloplegic retinoscopy was done before and after surgical intervention for simple congenital ptosis to determine refractive status. after briefing the merits and demerits of the treatment to parents of the patients, a written informed consent was taken. all the interventions were done by a single senior pediatric ophthalmic surgeon. optical correction after cycloplegic retinoscopy with 1% cyclopen with glasses was done on scheduled visit. levator muscle resection under general anaesthesia was carried out. the patients were examined and discharged on the second post-operative day. all data including pre-operative and post-operative recordings of spherical and cylindrical values were collected on a self-designed proforma. follow up period was extended to 3 months. at 3 rd month cycloplegic retinoscopy was done and change in character of refractive status (spherical and cylindrical value) was compiled and analyzed. mean change in refractive status was calculated by difference of pre-operative and post-operative sphere and cylinder values. data was entered and analyzed using computer program spss version-16. descriptive statistics were applied to determine the mean and standard deviation (sd) for quantitative variables like age and pre and post-operative refractive status in terms of sphere and cylinder values. qualitative variables like gender were presented in the form of frequency and percentages. paired „t‟ test was applied to compare the pre and postoperative change in refractive status (sphere and mean change in refractive status after levator muscle resection in patients of simple congenital ptosis pakistan journal of ophthalmology, 2020, vol. 36 (1): 48-52 50 cylinder values). p-value ≤ 0.05 was considered significant. results mean age of patients was 4.26 ± 3.78 years. gender distribution of patients showed that there were 35 male and 15 female patients. mean sphere before treatment was 1.119 ± 0.236 and after treatment was 1.566 ± 0.238. mean change in sphere after treatment was 0.447 ± 0.339. this difference in sphere was statistically significant (p-value = 0.000). mean cylindrical value before treatment was -0.360 ± 0.127 and after treatment was 0.280± 0.120. before treatment, minimum and maximum cylindrical values were -2.00 and 1.25 while after treatment, minimum and maximum cylindrical value was -1.75 and 2.25 respectively. mean change in cylinder after treatment was 0.640 ± 0.580. this difference in cylinder after treatment was statistically significant (p-value = 0.000). table 1: pre & post operative sphere and cylinder value. pre operative post operative mean change pvalue sphere value 1.11 ± 1.67 1.56 ± 1.68 -0.44 ± 0.33 0.000 cylinder value -0.36 ± 0.89 0.28 ± 0.85 -0.64 ± 0.580 0.000 discussion blepharoptosis is a common eyelid problem. degree of levator function determines the choice of operation. levator resection is employed for cases with good levator function while frontalis sling is reserved for patients with poor levator function. many surgeons prefer levator resection in eyes with levator function greater than 4 mm and most of them believe that levator resection yields a better lid contour and position as compared to frontalis sling 9 . children with congenital ptosis have a higher incidence of clinically significant astigmatism in the ipsilateral eye and are known to have an increased incidence of strabismus and amblyopia 10-12 . these children often require post-operative refractive correction and amblyopia therapy. close follow-up is needed postoperatively as well because changes in refractive error have been reported following ptosis surgery. ptosis repair can be both challenging and frustrating, especially given ever-increasing demands for an optimal cosmetic surgical result 13,14 . the diagnosis and management of pediatric ptosis presents challenges because of difficulties in performing preoperative examinations 13 . the timing for surgical treatment varies depending on age, severity and laterality. the ideal procedures in ptosis surgery are those that disturb normal anatomy the least and also allow for good results 15,16 . cates and tyers performed levator resection in 100 patients less than 7 years of age with congenital ptosis and having a levator function of at least 4 mm. they reported a 75% success rate, which was defined as a post-operative lid margin position within 1 mm of normal. in that study, the most common complication was under-correction (19%) and overcorrection was less common (7%). they found that the pre-operative amount of levator function was the strongest predictor of a favorable outcome following levator resection surgery 17 . stark and walther reviewed 54 patients who had congenital ptosis surgery to determine the incidence of refractive errors, strabismus, and amblyopia. of these patients, 70% had significant refractive error, 43% had astigmatism of more than 1.0 d, 55% had anisometropia of more than 1.25 d sphere or 0.75 d cylinder, 27.5% had strabismus, and 50% had amblyopia 18 . in cases of unilateral ptosis, the drooping eye has more amblyogenic refractive error than the normal eye 19,20 . cadera et al reviewed 88 eyes that had undergone unilateral or bilateral ptosis surgery using either fascia lata sling or levator resection. thirty-six normal eyes were used as controls. twenty-nine eyes underwent levator resection, whereas 59 eyelids received a frontalis sling. twelve months post-operatively, 58 of 88 eyes underwent cycloplegic refraction. of the operated eyes, 35 (40%) had a pre-operative cylinder greater than 1.00 d. there was a significant difference in the mean cylindrical error: the operated eyes showed a mean increase in cylinder of 0.30 d, whereas the control group demonstrated a mean decrease of 0.15 d at 12 months postoperatively 11 . cadera et al 11 compared those eyes that had undergone unilateral surgery and had a change in cylinder of at least 0.75 d with their own matched control (contralateral eye). there were 12 eyes that met these criteria, but only 8 of these had unilateral javaid rm, et al 51 pakistan journal of ophthalmology, 2020, vol. 36 (1): 48-52 levator resections. the authors reported a “noteworthy” difference between the control and operated eyes, with the operated eye having a greater change in each case, but no statistics were provided. they also noted that patients older than 4 years at the time of surgery showed an increase in mean cylinder (0.50 d), whereas those younger than 4 years had a decrease in mean cylinder (0.20 d). because of this, they proposed early surgery in patients with large amounts of cylinder in the eye with ptosis in order to lessen the amount of post-operative astigmatism and eliminate the need for glasses and amblyopia therapy 11 . in a study done by klimek dl refractive status was studied before and after levator resection and mean spherical change of 1.23 ± 0.875 diopters and mean cylindrical change of 0.83 ± 0.75 diopters was present after 20 months follow-up 8 . when mean refractive errors (sphere and cylinder) were compared inter-ocularly, no statistically significant difference was found between eyes with associated ptosis and control eyes pre-operatively or post-operatively. no association was found between age at the time of surgery or the amount of pre-operative ptosis and the amount of post-operative cylindrical change. our results are consistent with the results reported by klimek dl for change in cylindrical value post operatively. however, klimek dl reported insignificant change for spherical value postoperatively which is not consistent with the results of this study as our results showed change in both sphere and cylinder values. no study was done in our population, which addressed the effectiveness of levator muscle resection and change in refractive error post-operatively. a gap exists in this domain for treating congenital ptosis with levator muscle resection. however, these results have shown the effectiveness of this procedure as well as addressed the significant change in refractive error. with the help of these results, it is clear that use of levator muscle resection in patients improves the cosmetic appearance and prevents amblyopia by clearing the visual axis in severe ptosis. treatment of ptosis related astigmatism in mild to moderate ptosis with glasses is essential. conclusion results of this study showed that levator muscle resection has a significant effect on refractive status of the patients with congenital ptosis. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest. authors’ designation and contribution rana muhammad mohsin javaid; vitreo-retina fellow: literature search, manuscript write-up. chaudhary nasir ahmad; associate professor: study concept, final review. rehab habib; demonstrator psychology: data collection, final review. asad aslam khan; professor: study design, final review. kashif siddique; biostatistician: data analysis, final review. references 1. kanski jj. b. ptosis, in: clinical ophthalmology. 7th ed. china: butterworth heinemann, 2011: p. 39-47. 2. griepentrog gj, diehl nn, mohney bg. incidence and demographics of childhood ptosis. ophthalmology, 2011; 118 (6): 1180-3. 3. srinagesh v, simon jw, meyer dr, zobal-ratner j. the association of refractive error, strabismus, and amblyopia with congenital ptosis. j am assoc ped ophthalmoland strab. 2011; 15 (6): 541-4. 4. zinkernagel ms, ebneter a, ammann-rauch d. effect of upper eyelid surgery on corneal topography. arch ophthalmol. 2007; 125 (12): 1610-2. 5. berry-brincat a, willshaw h. paediatric blepharoptosis: a 10-year review. eye. 2008; 23 (7): 1554-9. 6. allard fd, durairaj vd. current techniques in surgical correction of congenital ptosis. middle east afr. j ophthalmol. 2010; 17 (2): 129. 7. abrishami a, bagheri a, salour h, aletaha m, yazdani s. outcomes of levator resection at tertiary eye care center in iran: a 10-year experience. korean j ophthalmol. 2012; 26 (1): 1-5. 8. klimek dl, summers cg, letson rd, davitt bv. change in refractive error after unilateral levator resection for congenital ptosis. jaapos. 2001; 5 (5): 297-300. 9. keyhani k, ashenhurst m. modified technique and ptosis clamp for surgical correction of congenital pediatric ptosis by anterior levator resection. arch facial plast surg. 2007; 23 (3): 156-61. mean change in refractive status after levator muscle resection in patients of simple congenital ptosis pakistan journal of ophthalmology, 2020, vol. 36 (1): 48-52 52 10. hoick de, dutton jj, wehrly sr. changes in astigmatism after ptosis surgery measured by corneal topography. ophthal plast recons surg. 1998; 14 (3): 151-8. 11. cadera w, orton r, hakim o. changes in astigmatism after surgery for congenital ptosis. j pediat ophth strab. 1991; 29 (2): 85-8. 12. lee ds, kim jm, woo ki, chang hr. changes in astigmatism after surgery for congenital ptosis. j korean ophthalmol soci. 2006; 47 (9): 1459-64. 13. ungerechts r, grenzebach u, harder b, emmerich k. causes, diagnostics and therapy for paediatric ptosis. klinische monatsblatter fur augenheilkunde. 2012; 229 (1): 21-7. 14. ng j hm. ptosis repair. facial plast surg. 2013; 29 (1): 22-5. 15. mesa gj, mascaró zf, muñoz qs, prat bj, arruga gj. upper eyelid surgery for treatment of congenital blepharoptosis. cirugia pediatrica: organo oficial de la sociedad espanola de cirugia pediatrica. 2007; 20 (2): 91-5. 16. meyer dr, linberg jv, wobig jl, mccormick sa. anatomy of the orbital septum and associated eyelid connective tissues: implications for ptosis surgery. ophth plast recons surg. 1991;7 (2): 104-13. 17. cates ca, tyers ag. outcomes of anterior levator resection in congenital blepharoptosis. eye, 2001; 15 (6): 770-3. 18. stärk n, walther c. refractive errors, amblyopia and strabismus in congenital ptosis. klinische monatsblatter fur augenheilkunde. 1984; 184 (1): 37-9. 19. paik js, kim sa, park sh, yang sw. refractive error characteristics in patients with congenital blepharoptosis before and after ptosis repair surgery. bmc ophthalmol. 2016; 16: 177. doi:10.1186/s12886016-0351-9. 20. maseedupally v, gifford p, swarbrick h. variation in normal corneal shape and the influence of eyelid morphometry. optom vis sci. 2015; 92 (3): 286–300. .…  …. pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 201 original article should vitreo-retinal diseases be treated by retina specialists only? hussain ahmad khaqan, abdul hye, hassan raza ch. pak j ophthalmol 2016, vol. 32 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: hussain ahmad khaqan assistant professor, eye unit ll lahore general hospital, lahore email: drkhaqan@hotmail.com …..……………………….. purpose: to evaluate the views of ophthalmologists about referral and treatment of retinal disorders by vitreo-retinal (vr) surgeons study design: cross sectional study. place and duration of study: national ophthalmic conferences in lahore, karachi and nathiya gali (2014-2016) and ophthalmological society of pakistan, lahore branch monthly clinical meetings (2014-2016). material and methods: a questionnaire based survey, involving 610 ophthalmologists was conducted through random sampling. the questionnaire was structured to evaluate the views about prescribing and treating with anti vascular endothelial growth factors (anti-vegfs) and retinal lasers among random population of ophthalmologists. survey was conducted during three national congresses and ophthalmological society monthly meetings and in different ophthalmology departments of the city. results: among 610 ophthalmologists from different parts of pakistan enrolled for the survey, 200 were female and 410 male. responses from all participants showed that 479 (78.5%) ophthalmologist were in favor that patients with vitreoretinal disease should be referred to vr surgeons for treatment. moreover, 472 (77.3%) ophthalmologists among 610 were in favor of intravitreal anti-vegf advise by vitreo-retinal surgeons. and 469(76.8%) ophthalmologist agreed that intravitreal anti-vegf should be injected by vitreo-retinal surgeon. only 279(45.73%) ophthalmologists among 610 thought that focal or prp laser can be performed safely by general ophthalmologists. conclusion: ophthalmologists believe that retinal disorders should be referred to and treated by vitreo-retinal surgeons. key words: survey, anti vascular endothelial growth factor, intravitreal injections, laser itreo-retinal disorders have an important role in decreasing vision worldwide1 as well as in pakistan2. importance of early and correct diagnosis of vitreo-retinal disorders cannot be underestimated, for its effective management and prevention of blindness. early detection of vitreoretinal disorders is often difficult due to unavailability of vitreo-retinal surgeons or non referral by general ophthalmologists. diabetes3, hyprtension4, ischemic heart diseases5, pregnancy6, radiations7, premature births8 have an important impact on retina leading to markedly decreased vision. nowadays anti-vegf9 and argon laser10 have an important role in treating retinopathies described by all above predisposing conditions. these modalities of treatment are highly effective when prescribed to a well diagnosed and deserving patient at the right time. assessment of pathology is the first step in the planning of disease management. non availability of vitreo-retinal surgeons and lack of referral by general v mailto:drkhaqan@hotmail.com hussain ahmad khaqan, et al 202 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology ophthalmologists are among the major reasons for late, wrong diagnosis and improper management of vitreo-retinal disorders. intra vitreal anti-vegf injections are prescribed by vitreo-retinal specialists rather than general ophthalmologists. due to increasing prevalence of age related retinal disorders in west general ophthalmologists are thinking to manage it in collaboration with vireo-retinal specialists. such a survey has been published in which different views were discussed regarding advise of intra vitreal anti vegf. finally it was concluded that a vitreo-retinal specialist should advise and inject intra-vitreal anti vegf. in addition a vitreo-retinal specialist can handle any complication related to intra vitreal anti-vegf more competently. general ophthalmologist can advise and treat after proper training under vitreoretinal specialist11. another report has been published in usa, in which for diagnostic tests and management of retinal disorders including intra-vitreal anti-vegf, prp, grid and focal laser patients were referred to vitreo-retinal specialist12. to the best of our knowledge literature estimating the awareness among ophthalmologists about the role of vitreo-retinal surgeons is not available from pakistan. the present study is designed to evaluate the awareness among ophthalmologists of pakistan about the role and need of retinal surgeons in dealing with vitreo-retinal disorders. material and methods a questionnaire based survey, involving 610 ophthalmologists was conducted through random sampling. the questionnaire was structured to evaluate the level of awareness among a random population of ophthalmologists about the role of vitreo-retinal surgeons in prescribing and treating with anti vascular endothelial growth factors (vegfs) and retinal lasers. survey was conducted during three national congresses and ophthalmological society monthly meetings and in different ophthalmology departments of the city. the questionnaire was designed in english and was pilot tested on 25 ophthalmologists to assess any query regarding understanding of questions. the questionnaire had two sections. first section had seven questions about the awareness of the role of retinal surgeons in managing vitreo-retinal disorders. section two pertained to the participant’s personal data including name and hospital name. name of participant was kept optional. each question had three options and the respondent had to tick the response of their choice. this final version of questionnaire was given to actual participants of the survey. six hundred and ten ophthalmologists of variable age were enrolled by random sampling. the enrollment was done by distributing questionnaires randomly before the start of scientific sessions and collected back after the end of sessions. the approximate population (ophthalmologists) attending these ophthalmic conferences and meetings was 3000 at 95% confidence level and confidence interval of 1.5; the required sample size was 200. the survey was done by ophthalmologists. statistical package spss version 15.0 was used for data analysis. results among 610 ophthalmologists enrolled for the survey, responses from all participants were evaluated. out of 610 participants 479 (78.5%) were in favor of referring the patient with vitreo-retinal diseases to retina specialists while 131 participants were against it. there were 138 (22.6%) participants in favor of advising intra-vitreal injections by general ophthalmologists out of the total participants. there were 141 (23.11%) participants in favor of injecting intra-vitreal injections by general ophthalmologists out of the total participants. there were 279 (45.73%) participants in favor of doing focal laser and prp by general ophthalmologist. there were 469 (76.88%) participants in favor of injecting intra-vitreal injections by retinal surgeons. there were 331 (54.26%) participants in favor of doing focal laser and prp by retinal surgeons. there were 472 (77.37%) participants in favor of advising intra-vitreal injections by vitreo-retinal surgeons. participant’s responses regarding questionnaire are shown in bar chart with respect to each question separately (figure 1). fig. 1: participant’s responses regarding questionnaire. should vitreo-retinal diseases be treated by retina specialists only? pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 203 questionnaire q.1 patient of vitreo retinal disease should be referred to vitreo retinal specialist by general ophthalmologist? yes no q.2 intra vitreal injections should be advised by general ophthalmologists? yes no q.3 intra vitreal injections should be injected by general ophthalmologists? yes no q.4 focal lasers and prp should be performed by general ophthalmologists? yes no q.5 intra vitreal injections should be injected by vitreo retinal specialist? yes no q.6 focal laser and prp should be perfomed by vitreo retinal specialist? yes no q.7 intra vitreal injections should be advised by vitreo retinal specialist? yes no discussion this was a double blinded survey with minimum bias. this study assesses the awareness and knowledge about the need and role of vitreo-retinal surgeon in assessing and managing vitreo-retinal disorders among ophthalmologists participating in ophthalmic conferences, clinical meetings and in different ophthalmology departments. the intent of the survey was to highlight the importance of specialized vitreoretinal surgeons in securing maximum vision in minor or vision threatening vitreo-retinal disorders. most of the ophthalmologists were well aware of need and importance of vitreo-retinal surgeons. lack of awareness and non referral to vitreo-retinal surgeon often lead to under-diagnosis or late presentation to vitreo-retinal specialist leading to profound deterioration of curable vision. timely vitreo-retinal consultation can improve visual outcome. a metaanalysis suggested that scleral buckling for macular detachment must preferably be performed within 3 days to optimize visual outcome.13 another study was done explaining that chronicity of retinal detachment at presentation is an important and poor prognostic indicator for reattachment surgery14. laser treatment by an experienced vitreo-retinal surgeon in time can save vision in many retinal disorders i.e proliferative diabetic retinopathy15, retinal vascular occlusions16, angiomatous proliferation in age related macular degeneration17. anti-vegf advised by a certified vitreo-retinal surgeon after proper diagnosis can dramatically improve vision in conditions e.g wet age related macular degeneration18, diabetic macular edema19, retinal vein occlusion20,21 etc. overall the awareness among ophthalmologists in pakistan is good regarding the role of vitreo-retinal specialists and their importance in managing vitreoretinal disorders. the findings of our study shed light on the level of awareness about the role and need of vitreo-retinal specialists among ophthalmologists in pakistan. this awareness can lead to early detection, proper management and improvement of visual prognosis in vitreo-retinal disorders. furthermore there is still need to identify interventions e.g conduction of seminars, workshops, talks etc that reinforce ophthalmologist’s attitude above the perceived level of awareness and devise strategies for the betterment of patients. no such data is published earlier to compare. conclusion ophthalmologists believe that retinal disorders should be treated by a vitreo-retinal surgeons. the survey findings stress the need for referral of vitreo-retinal disorders to vitreo-retinal surgeons. author’s affiliation dr. hussain ahmad khaqan assistant professor, eye unit ll lahore general hospital lahore prof. abdul hye professor, eye unit ii, lahore general hospital, lahore dr. hassan raza ch. assistant professor (ophthalmology) amir ud din medical college pgmi/ lahore general hospital lahore role of authors dr. hussain ahmed khaqan performa design, article writing and collecting data prof. abdul hye manuscript review. hussain ahmad khaqan, et al 204 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology dr. hassan raza ch composing of article & collection of performa references 1. thapa s, thapa r, paudyal i et al. prevelance and pattern of vitreo-retinal diseases in nepal. bmc ophthalmology, 2013. 2. khan a, riaz, soomro f et al. frequency and pattern of eye diseases in retina clinic of a tertiary care hospital in krarachi. pak j ophthalmol. 2011; 27; 155-9. 3. negi a, vernon sa. an overview of the eye in diabetes. j r soc med. 2003; 96: 266-72. 4. handerson ad, bruce bb, newman nj et al. hypertension related eye abnormalities and the risk of stroke. rev neurol dis. 2011; 8: 1-9. 5. mcclintic br, mcclintin ji, bisogano jd et al. relationship between retinal microvascular abnormalities and coronary heart disease. am j med. 2010; 123: 374. 6. errera mh, kohly rp, cruz ld. pregnency associated retinal diseases and their management” survey of ophthalmology, moorfield eye hospital uk. j. surv ophthalmol. 2013; 58: 127-42. 7. hong kh, chang sd.”a case of radiation retinopathy of left eye after radiation therapy of brain metastasis”. k j ophthalmol. 2009; 23: 114-7. 8. wang y, r li. effect of preterm birth on normal retinal vascular development. investigative ophthalmology and visual science. 2013; 54. 9. hussain n, ghanekar y, kaur i. future implications and indications of anti-vegf therapy in ophthalmic practice i j ophthalmol. 2007; 445-50. 10. kozak i, lutrull jk. modern retinal laser therapy” s j ophthalmol. 2015; 29: 137-46. 11. claringbolg tv, helzner j, goldberg l. general ophthalmologists and intra vitreal anti vegf. retinal physician 2009; jul/aug. 12. abbott d. ophthalmologists advisory committee for education.”clinician’s corner”. american academy of ophthalmology. 2012. 13. van bussel em1, van der valk r, bijlsma wr, la heij. impact of duration of macula-off retinal detachment on visual outcome: a systematic review and meta-analysis of literature. retina. 2014; 34: 1917-25. 14. james m, doherty mo, beatty s. the prognostic influence of chronicity of rhegmatogenous retinal detachment on anatomic success after reattachment surgery. am j ophthalmol. 2007; 143: 1032-4. 15. khandekar r, lawatii j al, mohammed aj, raisi a al. diabetic retinopathy in oman: a hospital based study .br j ophthalmol. 2003; 87: 1061-4. 16. hayreh ss, klugman mr, podhajsky p, servais ge, perkins e. argon laser panretinal photocoagulation in ischemic central retinal vein occlusion. a 10-year prospective study. graefes arch clin exp ophthalmol. 228: 281-96. 17. bottoni f, massacesi a, cigada m. treatment of retinal angiomatous proliferation in age-related macular degeneration. arch ophthalmol. 2005; 123: 1644-50. 18. csakyk. anti vascular endothelial factor for neovascular armd .ophthalmology. 2003; 110: 879-81. 19. avery rl, pearlman j et al. intravitreal bevacizumab (avastin) in the treatment of proliferative diabetic retinopathy. ophthalmology. 2006; 113: 1695. 20. clark wl, boyer ds, heier js, brown dm, haller ja, vitti r, et al. intravitreal aflibercept for macular edema following branch retinal vein occlusion: 52-week results of the vibrant study. ophthalmology. 2016; 123: 330-6. 21. brown dm. therapies for macular edema associated with central retinal vein occlusion. american academy of ophthalmology. 2012; 155: 429-37. 404 not found pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 184 original article effect of short-term use of oral contraceptive pills on intraocular pressure tayyaba gul malik, hina nadeem, eiman ayesha, rabail alam pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: tayyaba gul malik department of ophthalmology, rashid latif medical college, lahore. email: tayyabam@yahoo.com …..……………………….. purpose: to study the effect of short-term use of oral contraceptive pills on intra-ocular pressures of women of childbearing age. study design: observational case control study. place and duration of study: the study was conducted at arif memorial teaching hospital and allied hospital faisalabad from october 2017 to march 2018. material and methods: there were 100 female subjects, who were divided into two groups of 50 each. group a, included females, who had been taking oral contraceptive pills (ocp) for more than 6 months and less than 36 months. group b, included 50 age-matched controls, who had never used ocp. ophthalmic and systemic history was taken. careful slit lamp examination was performed and intraocular pressures (iop) were measured using goldman applanation tonometer. fundus examination was done to rule out any posterior segment disease. we compared the intra ocular pressures between the two groups by using student t test. results: average age was 29.16 in group a and 27.74 years in group b. average duration of using ocp was 14.9 months. mean iop in right eye was 13.08 ± 1.41 mm of hg and 13.34 ± 1.27 mm of hg in left eye in group a. while, mean iop in right eye was 11.72 ± 1.35 mm of hg and in left eye was 11.92 ± 1.3 mm of hg in controls. significant difference was noted between the iop of ocp group and controls. (p = 0.000). conclusion: ocp significantly increases iop even when used for short time period. key words: oral contraceptive pills, intra-ocular pressure, glaucoma. ral contraceptive pills (ocp) are commonly used throughout the world. these pills contain different compositions of estrogen and progesterone. many side effects of ocp have been reported in literature. ophthalmological adverse events are no exceptions. in one study, the incidence of ocular side effects was reported to be 1 in 230,0001. thromboembolic conditions associated with ocp can lead to retinal artery occlusion and neuroophthalmologic consequences can occur secondary to cerebro-vascular accidents2. ophthalmic migraine and intolerance to contact lenses are also reported in literature3. the risk of complications increases in smokers and in women older than 35 years. primary open angle glaucoma and raised intra ocular pressures are also known side effects of ocp, when used for longer duration. it was reported by wang et al that women taking ocp for more than three years had a two-fold increase in the risk of developing glaucoma4. however, in a recent study, it was found that ocp cause an increase in the central corneal thickness, which could be responsible for the higher intra ocular pressure readings in these patients5. contrary to the increased risk of developing glaucoma with ocp, newmann casey et al have shown the protective effect of female sex hormones by decreasing intra ocular o tayyaba gul malik, et al 185 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol pressure in post-menopausal women taking hormone replacement therapy6,7. rationale of our study is to find out whether ocp are safe to use for a short period of time. we included subjects who had taken ocp for more than six months and less than 3 years. paradoxical effect of female sex hormones in decreasing iop is also discussed. the purpose of our study was to determine the effect of short-term oral contraceptive pills (ocp) on intra ocular pressure of women of childbearing age. material and methods the study was conducted at arif memorial teaching hospital and allied hospital faisalabad from october 2017 to march 2018. it was a comparative observational study. sample was collected using nonprobability convenience sampling. one hundred female subjects were divided into two groups of 50 each. group a, included females of childbearing age, who had been taking oral contraceptive pills for more than 6 and less than 36 months. group b included 50 age-matched controls who had never used ocp. inclusion criteria for the subjects were non diabetic and non-hypertensive healthy females, taking ocp for at least six months and not more than 3 years and for controls were non diabetic and nonhypertensive age-matched females who had never taken ocp. the following subjects were excluded from the study: females having any systemic and ocular disease, females with moderate to high refractive errors (≥ +2 hypermetropia and ≥ -2 myopia), post-menopausal women and girls of prepubertal age, subjects using any ocular or systemic drugs which might affect intra ocular pressures, and subjects with history of any blunt or penetrating ocular trauma. study instruments were proforma, slit lamp biomicroscope, applanation tonometer and ophthalmoscope. verbal informed consent was taken from the participants. history included special emphasis on systemic and ocular diseases, use of topical or systemic drugs and use of ocp. careful slit lamp examination was performed and intraocular pressures were measured using goldman applanation tonometer. fundus examination was done to rule out any posterior segment disease. data was recorded on specially designed proforma. statistical analysis was done using anova with spss version 21. significance was set at (p < 0.05). results the average age of the patients was 29.16 years in group a and 27.74 years in group b. average duration of using ocp was 14.9 months. the mean and standard distribution of iop in the 2 groups is shown in table 1 and their distribution is shown in box and whisker plot is shown in graph 1. there was a significant difference between the iop of both groups p = 0.000. average cup to disc ratio was 0.29 in group a and 0.27 in group b and the difference was not significant (p = 0.109). graph 1: showing a box-whisker plot indicating distribution of iop in both eyes of group a (taking ocp) and group b (without ocp). table 1: mean and standard deviation of iop values. descriptive statistics group mean std. deviation n iop re without taking pills 11.7200 1.35586 50 with taking pills 13.0800 1.41190 50 total 12.4000 1.53741 100 effect of short-term use of oral contraceptive pills on intraocular pressure pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 186 iop le without taking pills 11.9200 1.30681 50 with taking pills 13.3400 1.27151 50 total 12.6300 1.46787 100 discussion intra ocular pressure is the only modifiable risk factor in primary open angle glaucoma (poag). different studies have shown contrasting results regarding the effect of ocp/female sex hormones (estrogen and progesterone) on iop. there are also some studies, that showed the influence of female reproductive health on incidence of glaucoma8. american academy of ophthalmology (aao) 2013 annual meeting reported that women using ocp for more than three years had two folds increased risk of developing glaucoma3. later, similar reports were published showing that women using ocp for more than five years had a 25 percent increased risk of poag9,10,11. our results showed that women using ocp for even less than three years had significantly raised iop when compared with controls. although the intra ocular pressures in our study were in the normal range and there was no significant difference in cup to disc ratio, yet these pressures may have detrimental effects on susceptible optic discs. this contradicts the protective role of estrogens as found in other studies. according to blue mountain study, women who had less exposure to estrogen in their lifetime were more prone to develop glaucoma12. it was shown that there was a 2-fold increased risk of poag in women who had late age of menarche and early menopause before 45 years. hence decreasing the exposure of estrogen to body tissues including optic nerve and retinal ganglion cells, which become more susceptible to damage. similar results were shown by nurses’ health study by pasquale lr9. it was further supported by vajaranant ts, who explained that estrogen deficient states lead to accelerated aging of the optic nerve hence making it more prone to glaucomatous damage13. this effect was explained by another research, which proved that estrogen-deprived optic nerve becomes more susceptible to mechanical stress caused by high iop14. it is a known fact that age related thinning of rnfl occurs by approximately 0.2% or 0.2 μm per year15,16. estrogen deprived optic nerve undergoes early aging changes making the optic nerve more prone to glaucomatous damage. increased iop with ocp and decreased with endogenous estrogen can be explained by the different chemical structure of endogenous hormones from the ocp. further studies are needed to prove this. another possibility of increased iop with ocp can be explained by the fact that ocp results in decrease in the levels of normal estrogen which is considered to have a protective effect in glaucoma. this was further supported by bayard’s work, according to which, the normal circadian rhythm of estrogen is lost with ocp. this results in a false effect of deficient estrogen state17. another explanation of increase in iop with ocp could be the increase in central corneal thickness (cct) with estrogen use18. according to one study, iop was increased around ovulation after the estrogen peaks19. ocp may have the same effect on the cct, which might have given false impression of raised iop. however, aging of optic nerve is also proposed as a cause of increased incidence of glaucoma in postmenopausal women20. the strength and importance of our study is that we have considered short duration of ocp, which was not addressed in earlier research works. this can be considered a pilot study and more elaborative inquest with multivariate analysis including the effect of ocp on cct, iop, rnfl and visual fields needs to be done. limitations of our study were that no particular composition of ocp was studied. different results in different studies might be due to variety of salts and combinations used in ocp. we also did not take into account cct, oct and retinal nerve fiber layer thickness. conclusion ocp significantly increase iop even when used for short time period. women who are prone to develop poag because of positive family history, advancing age, diabetes, myopia and smoking should have baseline tests of glaucoma before commencing ocp. these tests should be followed up on regular basis at least after every six months. references 1. leff sp. side effects of oral contraceptives: occlusion of branch artery of the retina. bull sinai hosp detroit. 1976; 24: 227–9. tayyaba gul malik, et al 187 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol 2. aggarwal rs, mishra vv, aggarwal sv. oral contraceptive pills: a risk factor for retinal vascular occlusion in in-vitro fertilization patients. j hum reprod sci. 2013; 6: 79–81. 3. hayreh ss. prevalent misconceptions about acute retinal vascular occlusive disorders. prog retin eye res. 2005; 24: 493–519. 4. wang ye et al. association between oral contraceptive use and glaucoma in the united states. poster presented at: annual meeting of the american academy of ophthalmology; nov. 17-19, 2013; new orleans. po339. 5. kurtul be, inal b, ozer pa, kabatas eu. impact of oral contraceptive pills on central corneal thickness in young women. indian j pharmacol. 2016; 48 (6): 665–668. 6. newman-casey pa, talwar n, nan b, musch dc, pasquale lr, stein jd. the potential association between postmenopausal hormone use and primary open-angle glaucoma. jama ophthalmol. 2014 mar; 132 (3): 298-303. doi: 10.1001/jamaophthalmol.2013.7618. pmid: 24481323; pmcid: pmc4106136. 7. scott e, zhang qg, wang r, vadlamudi r, brann d. estrogen neuroprotection and the critical period hypothesis. front neuroendocrinol. 2012 jan; 33 (1): 85– 104. 8. wang ye, kakigi c, barbosa d, porco t, chen r, wang s et al. oral contraceptive use and prevalence of self-reported glaucoma or ocular hypertension in the united states. ophthalmology. 2016 apr; 123 (4): 729-36. doi: 10.1016/j.ophtha.2015.11.029. epub 2016 feb 11. pmid: 26948305; pmcid: pmc4857187. 9. pasquale lr, kang jh. female reproductive factors and primary open-angle glaucoma in the nurses' health study. eye, 2011; 25 (5): 633-641). 10. dong sy, si yb, zhang yy, zhao gm. risk factors analysis of primary open angle glaucoma in women. zhonghua yan ke za zhi. 2013; 49: 122–5. 11. bhanwra s, ahluwalia k. the association of oral contraceptive pills with increase in intraocular pressure: time for pharmacovigilance to step in. j pharmacol pharmacother. 2015; 6: 51-2. 12. lee aj, mitchell p, rochtchina e, healey pr. blue mountains eye study. female reproductive factors and open angle glaucoma: the blue mountains eye study. br j ophthalmol. 2003; 87 (11): 1324–8. 13. vajaranant ts, pasquale lr. estrogen deficiency accelerates aging of the optic nerve. menopause, 2012; 19: 942-7. 14. burgoyne cf. a biomechanical paradigm for axonal insult within the optic nerve head in aging and glaucoma. exp eye res. 2011; 93 (2): 120–32. 15. harwerth rs, wheat jl, rangaswamy nv. age-related losses of retinal ganglion cells and axons. invest ophthalmol vis sci. 2008; 49 (10): 4437–43. 16. sung kr, wollstein g, bilonick ra, townsend ka, ishikawa h, kagemann l et al. effects of age on optical coherence tomography measurements of healthy retinal nerve fiber layer, macula, and optic nerve head. ophthalmology, 2009; 116 (6): 1119–24. 17. bayard f, louvet jp, moatti jp, smilovici w, duguet l, boulard c. plasma concentrations of lh and of sex steroids during the normal menstrual cycle and during contraceptive treatment. j gynecol obstet biol reprod. 1975; 4: 915-26. 18. sen e, onaran y, nalcacioglu-yuksekkaya p, elgin u, ozturk f. corneal biomechanical parameters during pregnancy. eur j ophthalmol. 2014; 24: 314-9. 19. giuffrè g, di rosa l, fiorino f, bubella dm, lodato g. variations in central corneal thickness during the menstrual cycle in women. cornea, 2007; 26: 144–6. 20. vajaranant ts, maki pm, pasquale lr, et al. effects of hormone therapy on intra ocular pressure: the women’s health initiative –sight wxam study. am j ophthalmol. 2016; 165: 115-24. author’s affiliation prof. tayyaba gul malik ophthalmology department rashid latif medical college. dr. hina nadeem post graduate resident arif memorial teaching hospital. dr. eiman ayesha house officer faisalabad medical university. rabail alam phd scholar university of lahore author’s contribution prof. tayyaba gul malik research planning, data acquisition and analysis, literature research, manuscript writing and final review. dr. hina nadeem data acquisition, data analysis, final manuscript review dr. eiman ayesha data acquisition, literature research, final manuscript review dr. rabail alam statistical analysis, final manuscript review 210 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology original article frequency of pterygium recurrence with limbal stem cell autograft muhammad sharjeel, farhan ali, irfan qayyum malik pak j ophthalmol 2016, vol. 32 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: irfan qayyum malik associate professor gujranwala medical college e.mail: irfan790@yahoo.com …..……………………….. purpose: to determine the frequency of recurrence of pterygium with limbal stem cells autograft. study design: descriptive, case series study. place and duration of study: department of ophthalmology, mayo hospital lahore for eight months (1 st january 2013 till 31 st august). material and method: there were 120 cases aged between 30-60 years of both genders. included patients had primary pterygium encroaching cornea up to 2 mm from limbus. patients with pseudopterygium, recurrent pterygium and active ocular infection were excluded. all the selected patients underwent limbal stem cell autograft technique for pterygium treatment and recurrence was noted after 6 months post-operatively. results: mean age was 41.18 ± 11.03 years with majority of the patients i.e. 38 (31.67%) were between 41 to 50 years of age. out of these 120 patients, 79 (65.83%) were male and 41 (34.67%) were females with ratio of 1.9:1. pterygium recurrence was found in only 06 (5.0%) patients. therefore the success rate was 95.0%. conclusion: limbal stem cells autograft with pterygium excision significantly reduces the recurrence of pterygium surgery. keywords: pterygium, surgical treatment, autografts, recurrence. terygium is a triangular shaped degenerative fibro vascular encroachment of sub conjunctival tissue on to the cornea, and is made up of a cap, head and body and more frequently located on the temporal side rather than nasally. it is one of the common eye diseases of our region1. corneal epithelium is being constantly replaced by healthy cells originating from limbal stem cells. these cells are supposed to resist growth of conjunctival vascular tissue over the cornea. uv light damages stem cells in exposed limbal area resulting in abnormal cells that cannot resist growth of conjunctival vessels. hence long term exposure to sunlight, especially ultraviolet rays, uv-a and -b (290400 nm) is considered the main cause2. it is also more common in tropical areas where environment is hot, dry, windy and dusty3. elastotic degenerations of subepithelial conjunctiva most frequently occur when we do histopathology4. anti inflammatory drugs and lubricating drops have some important role in reducing the patient discomfort but they don’t treat the actual disease. ablation by yag laser and smoothening the surface of the cornea by applying excimer laser has been tried but the results are not so favourable5. indications of surgery are decreased vision, cosmetic problems, muscle damage, inflammation and problems with contact lens wear6. surgical treatment is the treatment of choice if pterygium is progressive in nature7. simple excision (the technique in which sclera is left bared) is sometimes associated with very higher chances of recurrence (up to 80%) that is usually more aggressive than the primary lesion8. previous and current surgical management includes simple excision p frequency of pterygium recurrence with limbal stem cell autograft pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 211 with or without beta irradiation, intra-operative and postoperative mitomycin c4,9, 5-fu9, amniotic membrane grafting and different maneuvers of conjunctival grafting3,5,10. however autologous conjunctival stem cells grafting proved to be the best method, that gave low recurrence rate and as well as high safety10. in 1985 kenyon, first time described conjunctival autograft. they reported that there are relatively minor complications with conjunctival cell grafting. but when you compare conjunctival grafting with bare scleral technique the surgical time is more prolonged. but these disadvantages are out weighted now. due to lack of sight threatening complications and the relatively low recurrence rate, this procedure gained popularity in many centers. limbalconjunctival stem cells grafting with limbus sutures looks to be an effective and safe operation for decreasing the recurrence rate after pterygium excision11 due to replenishment of normal corneal epithelial cells by the stem cells. in one study (12.9%) recurrence is seen out of 41 patients with limbal conjunctival stem cells autograft for primary pterygia03 so prevention of pterygium recurrence (87.1%) is significant. in previous studies pterygium recurrence with limbal conjunctival auto grafting in primary pterygia is as high as 39%13 (efficacy61%) out of 52 patients to as low as 1.9%12(efficacy 98.1%) out of 30 patients so we need to address this variability in results. so to the best of my knowledge no study previously has taken such a larger sample size of limbal stem cells autograft technique in primary pterygia cases specifically to estimate the true efficacy of this technique and correct the variability of previous results. material and methods it was descriptive, case series study. the study was done at ophthalmology department of mayo hospital lahore. the duration of study was 8 months from january 2013 to august 2013. patients of both gender with ages between 20 – 60 years having primary pterygium encroaching cornea up to 2 mm from the limbus on slit lamp examination and causing discomfort, visual impairment or cosmetic disfigurement were selected. patients who were excluded were those having pseudopterygium, active ocular infection and recurrent pterygium. approval from the hospital ethical committee was taken for all 120 cases who presented in opd of ophthalmology department, mayo hospital, lahore. informed consent was taken from each patient meeting the inclusion criteria, explaining to them the purpose and procedure of the study and ensuring the confidentiality of information. participants were also told that there was no risk of participating in this research. moreover; early detection of this complication carried a potential benefit of good treatment results. after informed consent, personal profile of all patients (name, age, sex, and postal address) and eye having pterygium was noted. procedure was done under topical anaesthesia. conjunctiva was dissected away from pterygium, excision of the pterygium mass was done avoiding damage to the medial rectus muscle. conjunctival limbal stem cell autograft was then taken from superior limbus and stitched on excised area at limbus. all procedures were done by one consultant ophthalmologist. after the procedure, combination of topical steroid antibiotic drops was used and pad was applied for 48 hours. this combination of drops was continued for a month four times a day and then tapered off. follow up with slit lamp examination of patients was done at 6 months post-operatively for recurrence of pterygium (fibrovascular re-growth crossing the corneo-scleral limbus by 1.0 mm or more). all data was collected on pre-designed performa which contained two parts i.e. part one contained patient’s bio-data while part two contained study variables. results age range in this study was from 20 to 60 years with mean age of 41.18 ± 11.03 years. majority of the patients i.e. 38 (31.67%) were between 41 to 50 years of age as shown in table i. table 1: % age of participants according to age distribution (n=120). age (in years) no. of patients n (%) 20 – 30 23 (19.17) 31 – 40 35 (29.17) 41 – 50 38 (31.67) 51 – 60 24 (20.0) total 120 (100.0) mean ± sd = 41.18 ± 11.03 years muhammad sharjeel, et al 212 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology out of these 120 patients, 79 (65.83%) were male and 41 (34.67%) were females with ratio of 1.9:1 respectively (figure 4). all the selected patients then underwent limbal stem cell autograft technique for pterygium treatment and recurrence was noted after 6 months postoperatively. the results show pterygium recurrence in 06 (5.0%) while 114 (95.0%) patients had no recurrence as shown in figure 1. stratification of age groups and gender is shown in table 2 and 3 respectively which show no significant difference in pterygium recurrence with respect to age of patients and gender. table 2: stratification of patients with respect to age (n=120). age (in years) frequency pterygium recurrence p-value yes n (%) yes n (%) 20 – 30 23 00 (0.0) 23 (100.0) 0.582 31 – 40 35 02 (6.06) 33 (93.94) 41 – 50 38 03 (7.89) 35 (92.11) 51 – 60 24 01 (4.17) 23 (95.83) table 3: stratification of gender with respect to pterygium recurrence. gender frequency pterygium recurrence pvalue yes n (%) yes n (%) male 79 04 (5.06) 75 (94.94) female 41 02 (4.88) 39 (95.12) discussion pterygium in the conjunctiva is characterized by elastotic degeneration of collagen (actinic elastosis) and fibrovascular proliferation. it has an advancing portion called the head of the pterygium, which is connected to the main body of the pterygium by the neck. sometimes a line of iron deposition can be seen adjacent to the head of the pterygium called stocker's line. the location of the line can give an indication of the pattern of growth. the exact cause is unknown but seems to be due to limbal stem cells damage that resist the conjunctival growth onto the cornea, but pterygium do occur with increased exposure to wind, ultraviolet light, or sand14. figure 1: post op pictures. it causes chronic irritative symptoms, cosmetic complaints and decreased vision as the pterygium encroaches the visual axis or induces astigmatism. indications of intervention include interference with vision, looking bad, motility problem, recurrent inflammation and hindrance with contact lens wear. although the diagnosis of pterygium has been http://en.wikipedia.org/wiki/collagen http://en.wikipedia.org/wiki/actinic_elastosis http://en.wikipedia.org/wiki/neck http://en.wikipedia.org/wiki/iron http://en.wikipedia.org/wiki/wind http://en.wikipedia.org/wiki/sunlight http://en.wikipedia.org/wiki/sand frequency of pterygium recurrence with limbal stem cell autograft pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 213 extremely easy, it remains an unresolved disease with unsatisfactory outcomes and frequent recurrences.15 different options available are bare sclera excision with or without the use of adjuncts like beta irradiation, thiotepa eye drops, intra-operative or post operative mitomycin-c (mmc) or anti neoplastic agents, amniotic membrane transplantation, conjunctival autograft with or without limbus stem cells have been described16. despite these innovative procedures, recurrence continues to be a complication. reported rates of recurrence range from 2% for excision with cag to 89% for bare sclera excision. in recent two years, 2 surgical techniques have become increasingly accepted as methods likely to prevent pterygium recurrence, namely mitomycin c application and conjunctival autograft transplantation17. conjunctival auto-grafting is a surgical technique that is effective and safe procedure for pterygium removal. when the pterygium is removed, the tissue that covers the sclera known as the conjunctiva is also extracted. autografting replaces the bare sclera with conjunctival tissue that is surgically removed from the temporal healthy conjunctiva. that “self-tissue” is then transplanted to the bare sclera and is fixated using sutures, tissue adhesive, or glue adhesive18. it has been suggested that limbal stem cells in the conjunctiva of the autograft may act as a barrier to conjunctival cells migration onto the corneal surface and helps in preventing the recurrence. the limbal conjunctival graft includes approximately 0.5 mm of the limbus and peripheral cornea. the limbal side of the conjunctival autograft is sutured with interrupted 10/0 nylon sutures, and the conjunctival side is sutured with absorbable sutures. the recurrence rates after limbal conjunctival autograft surgery (ranging from 0 to 15%) are almost identical to the conjunctival autograft surgery19-21, while some authors suggest that limbal conjunctival autografts are more effective than conjunctival autografts in preventing the recurrence of pterygium. this study was conducted to determine the frequency of recurrence of pterygium with limbal stem cells autograft. the mean age of patients in our study was 41.18 ± 11.03 years with majority of the patients i.e. 51.67% were above 40 years of age which was very much comparable to studies of salagar km et al and rao sk et al who had a mean age of 41 and 42 years respectively with majority of patients were above 40 years of age. similarly, mejia lf et al22 in his study had found mean age of 42 years in pterygium patients. on the other hand, ahmed i et al23 and saleem mi et al had found mean age of 55 and 60 years in their studies respectively which is much larger compared to our study. but the mean age reported by al-fayez mf et al24 was very low i.e. 33 years, compared to our study. in our study, 79 (65.83%) were male and 41 (34.67%) were females with male to female ratio of 1.9:1. many previous studies have also shown higher incidence of pterygium in male than female.2,4,5,8. while young al et al25 has shown female predominance in his study. this male predominance in our study is confined to the fact that men mostly work outside and are exposed to dust and environmental hazards more than women. our study showed the pterygium recurrence in 06 (5.0%) while 114 (95.0%) patients have shown no recurrence after limbal stem cell autograft technique for pterygium treatment. this is a little lower to the results observed by rasool au et al7 i.e. 10.0%. there are also many clinic based studies on limbal stem cell autograft technique for pterygium treatment which have shown almost higher recurrence rates to our study i.e. kralj p et al26 reported 11.11%, while rao sk et al have reported lower recurrence rate i.e. 4.7% and 3.8% respectively. patel d et al and shimazaki j et al in their studies reported pterygium recurrence in 7.4% and 7% patients respectively after limbal stem cell autograft technique for pterygium treatment. gris o et al used a similar technique closer to the one used in our study in 7 patients with recurrent pterygium. they reported no recurrence or significant complications. young al et al12 compared mitomycin c and limbal conjunctival autograft surgery in preventing pterygium recurrence, and they showed that the mitomycin c patients were associated with a higher recurrence rate (15.9%) as compared to limbal conjunctival autograft patients (1.9%). in one study (12.9%) recurrence is seen out of 41 patients with limbal conjunctival stem cells autograft for primary pterygia4 so prevention of pterygium recurrence (87.1%) is significant. in one study by chen pp et al13 pterygium recurrence with limbal conjunctival autografting in primary pterygia is as high as 39% that is much higher as compared to our study. this high recurrence rate was also found in the study by simona et al that reported recurrence rate of 35%. salagar km et al reported recurrence in 6.38% eyes after 3-4 months post-operatively. in a prospective, randomized study, al-fayez mf et al found limbal conjunctival autograft transplantation more effective than conjunctival muhammad sharjeel, et al 214 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology autograft alone in prevention of recurrence after pterygium excision and has found no recurrence after the limbal–conjunctival autograft. many other authors have shown variable recurrence rates after limbal–conjunctival autograft transplantation for pterygium. in a long-term study, pulte p et al found recurrences in 2.86% patients who underwent limbal–conjunctival autograft transplantation. in a group of 41 cases of recurrent pterygia, mutlu fm et al reported a 14.6% recurrence rate with a minimum follow-up of 15 months. dekarisi et al in his study recorded no pterygium recurrence in 90.90% patients and only 9.1% showed recurrence after follow up of 5 months. mejia lf et al22 has shown this rate as 1.8%. rasool au et al7 in his study found a positive association of age with recurrence of pterygium. he concluded that youth is associated with increasing risk of recurrence and as the person gets older, the recurrences decrease. this contradicts findings of our study in which we have found no statistically significant difference in pterygium recurrence between different age groups and gender. on the whole, it was concluded that frequency of recurrence of pterygium with limbal stem cells autograft is very low and have no association with age and gender. conclusion the frequency of recurrence of pterygium with limbal stem cells autograft technique is very low i.e. 5.0%. so, we recommend that limbal stem cells autograft technique should be performed as a main surgical option in every patient with pterygium for the prevention of its recurrence after surgery to reduce the morbidity of patients. author’s affiliation dr. muhammad sharjeel mayo hospital lahore dr. farhan ali mayo hospital lahore dr. irfan qayyum malik associate professor gujranwala medical college role of authors dr. muhammad sharjeel main author dr. farhan ali helped in data collection dr. irfan qayyum malik helped in writing manuscript references 1. asokan r, venkatasubbu rs, velmuri l, lingam v, georger. prevalence and associated factors for pterygium and pinguecula in a south indian population. ophthalmic physio op 2012; 32:39-44. 2. khan n, ahmad m, baseer a, kundi na. to compare the recurrence rate of pterygium excision with baresclera, free conjunctival autograft and amniotic membrane grafts. pak j of ophthal 2010; 26: 138-142. 3. mohammad s, khan s, ahmad h, shah z. comparison of frequency of recurrence after surgery for primary pterygium using free conjunctival autograft transplantation and bare sclera technique . ophthalmology update. 2013; 11: 34-9. 4. hussain z, rehman hu, bilal m. comparison of preoperative injection vs intraoperative application of mitomycin c in recurrent pterygium. ophthalmology update. 2013; 11: 21-4. 5. narsani ak, jatoi sm, khanzada ma, dabir sa, gul s. recurrence of pterygium with conjunctival autograft versus mitomycin c. pak j of ophthal 2008; 24: 29-33. 6. sadiq mn, arif as, jaffar s, bhatia j. use of superotemporal free conjunctivo-limbalautograft in the surgical management of pterygium. j ayub med coll abbottabad 2009; 21. 7. rasool au, ahmed cn, khan aa. recurrence of pterygium in patients having conjunctival autograft and bare sclera surgery. annals. 2010; 16: 242-6. 8. kanski jj, bowling b. clinical ophthalmology – a systemic approach 7th ed. philadelphia butterworth heinemann; 2011; 5: 163. 9. rahman l, baig ma, islam q. prevention of pterygium recurrence by using intra-operative 5-fluorouracil, pakistan armed forces medical j. 2008; 1. 10. ozer a, yildirim n, erol n, yurdakul s. long-term results of bare sclera, limbal-conjunctival autograft and amniotic membrane graft techniques in primary pterygium excisions. ophthalmologica. 2009; 223: 26973. 11. han sb, hyon jy, hwang jm, wee wr. efficacy and safety of limbal-conjunctival autografting with limbal fixation sutures after pterygium excision. ophthalmologica. 2012; 227: 210-4. 12. young al, leung gys, wong akk, cheng ll, lam dsc. a randomized trial comparing 0.02% mmc and limbal conjunctival autograft after excision of primary pterygium.british j of ophthal 2004; 88: 995-7. 13. chen pp, ariyasu rg, kaza v, labree ld, mcdonned pj. a randomized trial comparing mitomycin c and conjunctival autograft after excision of primary pterygium. am j ophthal 1995; 120: 151-60. frequency of pterygium recurrence with limbal stem cell autograft pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 215 14. luthra r, nemesure bb, wu sy, xie sh, leske mc. barbados eye studies group. frequency and risk factors for pterygium in the barbados eye study. arch ophthalmol. 2001; 119: 1827-32. 15. king jh. the pterygium. arch ophthal. 44:854:1950. 16. hirst lw. the treatment of pterygium. surv. ophthalmology 2003; 45: 145-80. 17. gifford h. treatment of recurrent pterygium. ophthal. soc. rec. 1909; 18: 1. 18. rao sk, lekha t, mukesh bn, sitalakshmi g, padmanabhan p. conjunctival limbal autografts for primary and recurrent pterygia: technique and results. indian j opthalmol. 1998; 46: 203-9. 19. frau e, labetoulle m, lautier-frau m. corneo– conjunctival autograft transplantation for pterygium surgery. acta ophthalmol scand. 2004; 82: 59–63. 20. du z, jiang d, nie a. limbal epithelial autograft transplantation in treatment of pterygium. chin j ophth. 2002; 38: 351-4. 21. al-fayez mf. limbal versus conjunctival autograft transplantation for advanced and recurrent pterygium. ophthalmology 2002; 109: 1752-55. 22. mejia lf, sanchez jg, escobar h. management of primary pterygia using free conjunctival and limbalconjunctival autografts without antimetabolites. cornea. 2005; 24: 972–5. 23. ahmed i, ahmed m, ahmed w. comparison of limbal conjunctival autograft with conventional bare sclera technique in the prevention of recurrence of pterygium. pak j med health sci. 2012; 6 (3): 629-31. 24. al-fayez mf. limbal versus conjunctival autograft transplantation for advanced and recurrent pterygium. ophthalmol. 2002; 109: 1752–55. 25. young al, leung gy, wong ak. a randomized trial comparing 0.02% mitomycin c and limbal conjunctival autograft after excision of primary pterygium. br j ophthalmol. 2004; 88: 995–7. 26. kralj p, ivekovic r, novak– laus k, mandic z. efficacy of limbal stem cell transplantation in the treatment of recurrent pterygium. acta clin croat. 2008; 47 (suppl. 1): 35–7. microsoft word raorashadqamarcasereport[1]sent case report delayed supra choroidal haemorrhage after secondary anterior chamber intra ocular lens implant in a patient on warfarin therapy rao m rashad qamar, muhammad a ahad, tariq m arian pak j ophthalmol 2007, vol. 23 no.1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: rao muhammad rashad qamar 29-b, medical colony bahawalpur received for publication july’ 2006 …..……………………….. purpose: to report a case of delayed suprachoroidal haemorrhage after secondary anterior chamber intra-ocular lens implant in a patient on anticoagulant therapy. material and method: an 80 years old patient, who had been on warfarin for 3 years underwent secondary anterior chamber implant through clear corneal incision under local anesthesia. the warfarin was stopped four days before the surgery and her international normalized ratio (inr) on the day of surgery was 2.7. two weeks later, she developed suprachoroidal haemorrhage. results: the suprachoroidal haemorrhage was managed conservatively and the condition settled down in one-month time. conclusion: serious sight threatening complications can develop in patients on anticoagulants even with minimal surgery. elayed supra choroidal haemorrhage (dsch) is a rare surgical complication, which has been reported to occur after glaucoma filtration surgery1, penetrating keratoplasty2, cataract extraction3, vitrectomy3 and the needling of trabeculectomy blebs4. we report a case of dsch and vitreous haemorrhage following secondary anterior chamber intra ocular lens (ac iol) implantation in a patient on long-term warfarin therapy. case report an 80-year old woman with a 5-year history of pseudo-exfoliation and ocular hypertension had undergone routine cataract surgery 10 months previously, which was complicated by a tear in the posterior capsule and vitreous loss. no implant was inserted at that time and the patient returned for secondary intraocular lens insertion. she had a history of acromegaly, atrial fibrillation, congestive cardiac failure, and pulmonary embolism and was regularly taking digoxin, frusemide, and warfarin tablets. her warfarin was stopped 4 days before surgery when her inr was noted to be 5.71 and on the day of surgery was recorded as 2.7. the procedure was carried out through a clear superior corneal incision under local anaesthesia in order to reduce the risk of an anticoagulation related complication. moderate bleeding was noted following a peripheral iridectomy performed after the lens had been inserted. when reviewed one day after surgery, the vision in her right eye had dropped to hand movement. there was d diffuse conjunctival congestion and total hyphaema in the right eye. the intraocular pressure (iop) of the right eye was 29 mm hg and there was no fundal view. the right eye had visual acuity of 6/24, a moderate cataract, pseudo exfoliation, and iop of 24mm hg. ultrasonic b scan of the right eye revealed vitreous haemorrhage (fig. 1a) with no evidence of retinal or choroidal detachment. her warfarin was discontinued, and she was started on topical atropine 1% and dexamethasone 1%. over the next 2 weeks, her vision improved to finger counting at 2 meters with gradual resolution of the hyphaema. the iop was still 29 mmhg, so she was started on levebunolol 0.5% eye drops twice a day in right eye. she was again started on oral warfarin, as her inr was noted to be 0.89. four days later, she re-presented to the eye casualty department with pain and a sudden decrease in the vision of the right eye, which was measured to be perception of light only. the anterior segment examination was normal but examination of the fundus revealed a reddish black elevated lesion at the posterior pole along with organised vitreous haemorrhage. b scan ultrasound was consistent with the clinical picture of a supra-choroidal haemorrhage (fig. 1b). the inr at this time was 2.5. in view of the localized nature of the detachment, it was decided to continue with conservative management. the suprachoroidal haemorrhage resolved completely over a period of one month (fig. 1c). the visual acuity 6 weeks following surgery was 6/24 in the right eye, the anterior chamber was quiet, the iop on medication was 12mm hg, the vitreous was almost clear and the inr was 1.91. at this time all, her topical medication was stopped. four months after the event, the bestcorrected visual acuity in right eye was 6/18, and the ac iol was well placed. discussion chronic anticoagulation therapy with warfarin is not uncommon in elderly patients requiring cataract surgery. for such patients, the risk of thromboembolism associated with the discontinuation of anticoagulant therapy must be weighed against the risks of per-operative and post-operative bleeding complications, if anticoagulant therapy is continued through surgery. as far as we are aware, the ophthalmic literature contains no definitive prospective controlled studies that address these issues. nevertheless, retrospective reports indicate that there is no increase in the risk of surgical complications in patients treated with warfarin5. the most feared anticoagulation-related complication in cataract surgery is a suprachoroidal haemorrhage, which can result in expulsion of the intraocular structures. a more common event is the retrobulbar haemorrhage, which usually occurs at the time of retrobulbar or peribulbar anaesthesia and is usually diagnosed before surgery is commenced. recent advances in cataract surgery, such as small incision surgery and topical or subtenon’s anaesthesia should logically reduce the frequency of these events. delayed suprachoroidal haemorrhage is a rare complication, most frequently observed after glaucoma filtration surgery, where it is usually associated with risk factors like aphakia/ac iol, history of vitreous loss, high myopia, postoperative hypotony, anticoagulant therapy1 and systemic vascular disease. our patient developed suprachoroidal haemorrhage two weeks following secondary ac iol implantation. she had the two important risk factors associated with dsch, aphakia/ac iol and preoperative anticoagulant therapy1. to minimise the risk of a retrobulbar haemorrhage ac iol was implanted under topical anaesthesia. significant bleeding occurred following the peripheral iridectomy in this patient whose inr was 2.7. although, there are no set guidelines for the per-operative inr levels during cataract surgery, a ratio of 2.5 is considered a safe limit, although there have been case reports of uneventful surgery at levels up to 5.46,7. when the patient developed dsch two weeks after surgery, the inr was 2.5. the exact cause of dcsh is not clear, but it might be attributed to simultaneous rise in inr and altered haemodynamics in choroid, secondary to levebunolol eye drops. in conclusion, this case, which to our knowledge is the first report of dsch after secondary ac iol implant, highlights the hazards of anticoagulation therapy during cataract surgery. author’s affiliation dr. rao m rashad qamar assistant professor, bahwal victoria hospital/ quaid-e-azam medical college bahawalpur dr. muhammad a ahad moorfields eye hospital london uk dr. tariq m arain assistant professor bahwal victoria hospital/ quaid-e-azam medical college bahawalpur reference 1 tuli ss, wudunn d, ciulla ta, et al. delayed suprachoroidal hemorrhage after glaucoma filtration procedures. ophthalmology. 2001; 108: 1808-11. 2 duncker gi, rochels r. delayed suprachoroidal hemorrhage after penetrating keratoplasty. int ophthalmol. 1995; 19: 173-6. 3 becquet f, caputo g, mashhour b, et al. management of delayed massive suprachoroidal hemorrhage: a clinical retrospective study. eur j ophthalmol. 1996; 6:393-7. 4 howe lj, bloom p. delayed suprachoroidal haemorrhage following trabeculectomy bleb needling. br j ophthalmol. 1999; 83: 753. 5 gainey sp, robertson dm, fay w, ilstrup d. ocular surgery on patients receiving long-term warfarin therapy. am j ophthalmol. 1989; 108: 142-6. 6 mccormack p, simcock pr, tullo am. management of the anticoagulated patient for ophthalmic surgery. eye 1993; 7: 74950. 7 langston rh. what is the risk of complications from cataract surgery in patients taking anticoagulants? cleveland clinic journal of medicine. 2001; 68: 97-8. delayed supra choroidal haemorrhage after secondary anterior chamber intra ocular lens implant in a patient on warfarin therapy rao m rashad qamar assistant professor, bahwal victoria hospital/quaid-e-azam medical college bahawalpur muhammad a ahad moorfields eye hospital, london uk tariq m arain assistant professor, bahwal victoria hospital/quaid-e-azam medical college bahawalpur corresponding author: dr.rao muhammad rashad qamar 29-b, medical colony bahawalpur phone no: 00923009687434 e-mail: drrashadqr@yahoo.com abstract: purpose: to report a case of delayed suprachoroidal haemorrhage after secondary anterior chamber intra-ocular lens implant in a patient on anticoagulant therapy. method: an 80 years old patient, who had been on warfarin for 3 years underwent secondary anterior chamber implant through clear corneal incision under local anaesthesia. the warfarin was stopped four days before the surgery and her international normalized ratio on day of surgery was 2.7. two weeks later, she developed suprachoroidal haemorrhage. results: the suprachoroidal haemorrhage was managed conservatively and the condition settled down in one-month time. conclusion: serious sight threatening complications can develop in patients on anticoagulants even with minimal surgery. delayed supra choroidal haemorrhage (dsch) is a rare surgical complication, which has been reported to occur after glaucoma filtration surgery, (1) penetrating keratoplasty, (2) cataract extraction, (3) vitrectomy (3) and the needling of trabeculectomy blebs. (4) we report a case of dsch and vitreous haemorrhage following secondary anterior chamber intra ocular lens (ac iol) implantation in a patient on long-term warfarin therapy. case report: an 80-year old woman with a 5-year history of pseudo-exfoliation and ocular hypertension had undergone routine cataract surgery 10 months previously, which was complicated by a tear in the posterior capsule and vitreous loss. no implant was inserted at that time and the patient returned for secondary intraocular lens insertion. she had a history of acromegaly, atrial fibrillation, congestive cardiac failure, and pulmonary embolism and was regularly taking digoxin, frusemide, and warfarin tablets. her warfarin was stopped 4 days before surgery when her inr was noted to be 5.71 and on the day of surgery was recorded as 2.7. the procedure was carried out through a clear superior corneal incision under locall anaesthesia in order to reduce the risk of an anti-coagulation related complication. moderate bleeding was noted following a peripheral iridectomy performed after the lens had been inserted. when reviewed one day after surgery, the vision in her right eye had dropped to hand movement. there was diffuse conjunctival congestion and total hyphaema in the right eye. the intraocular pressure (iop) of the right eye was 29 mm hg and there was no fundal view. the right eye had visual acuity of 6/24, a moderate cataract, pseudo exfoliation, and iop of 24-mm hg. ultrasonic b scan of the right eye revealed vitreous haemorrhage (fig. 1a) with no evidence retinal or choroidal detachment. her warfarin was discontinued, and she was started on topical atropine 1% and dexamethasone 1%. over the next 2 weeks, her vision improved to finger counting at 2 meters with gradual resolution of the hyphaema. the iop was still 29 mmhg, so she was started on levebunolol 0.5% eye drops twice a day in right eye. she was again started on oral warfarin, as her inr was noted to be 0.89. four days later, she re-presented to the eye casualty department with pain and a sudden decrease in the vision of the right eye, which was measured to be perception of light only. the anterior segment examination was normal but examination of the fundus revealed a reddish black elevated lesion at the posterior pole along with organised vitreous haemorrhage. b scan ultrasound was consistent with the clinical picture of a supra-choroidal haemorrhage (fig. 1b). the inr at this time was 2.5. in view of the localised nature of the detachment, it was decided to continue with conservative management. the supra-choroidal haemorrhage resolved completely over a period of one month (fig. 1c). the visual acuity 6 weeks following surgery was 6/24 in the right eye, the anterior chamber was quiet, the iop on medication was 12mm hg, the vitreous was almost clear and the inr was 1.91. at this time all, her topical medication was stopped. four months after the event, the best-corrected visual acuity in right eye was 6/18, and the ac iol was well placed. discussion: chronic anticoagulation therapy with warfarin is not uncommon in elderly patients requiring cataract surgery. for such patients, the risk of thromboembolism associated with the discontinuation of anticoagulant therapy must be weighed against the risks of peroperative and postoperative bleeding complications, if anticoagulant therapy is continued through surgery. as far as we are aware, the ophthalmic literature contains no definitive prospective controlled studies that address these issues. nevertheless, retrospective reports indicate that there is no increase in the risk of surgical complications in patients treated with warfarin. (5) the most feared anticoagulation-related complication in cataract surgery is a suprachoroidal haemorrhage, which can result in expulsion of the intraocular structures. a more common event is the retrobulbar haemorrhage, which usually occurs at the time of retrobulbar or peribulbar anaesthesia and is usually diagnosed before surgery is commenced. recent advances in cataract surgery, such as small incision surgery and topical or subtenon’s anaesthesia should logically reduce the frequency of these events. delayed suprachoroidal haemorrhage is a rare complication, most frequently observed after glaucoma filtration surgery, where it is usually associated with risk factors like aphakia/ac iol, history of vitreous loss, high myopia, postoperative hypotony, anticoagulant therapy (1) and systemic vascular disease. our patient developed suprachoroidal haemorrhage two weeks following secondary ac iol implantation. she had the two important risk factors associated with dsch, aphakia/ac iol and pre-operative anticoagulant therapy. (1) to minimise the risk of a retrobulbar haemorrhage ac iol was implanted under topical anaesthesia. significant bleeding occurred following the peripheral iridectomy in this patient whose inr was 2.7. although, there are no set guidelines for the per-operative inr levels during cataract surgery, a ratio of 2.5 is considered a safe limit, although there have been case reports of uneventful surgery at levels up to 5.4. (6) (7) when the patient developed dsch two weeks after surgery, the inr was 2.5. the exact cause of dcsh is not clear, but it might be attributed to simultaneous rise in inr and altered haemodynamics in choroid, secondary to levebunolol eye drops. in conclusion, this case, which to our knowledge is the first report of dsch after secondary ac iol implant, highlights the hazards of anticoagulation therapy during cataract surgery. references: 1 tuli ss, wudunn d, ciulla ta, cantor lb. delayed suprachoroidal hemorrhage after glaucoma filtration procedures. ophthalmology 2001 oct; 108(10):1808-11 2 duncker gi, rochels r. delayed suprachoroidal hemorrhage after penetrating keratoplasty. int ophthalmol 1995-96; 19 (3):173-6 3 becquet f, caputo g, mashhour b, chauvaud d, pouliquen y. management of delayed massive suprachoroidal hemorrhage: a clinical retrospective study. eur j ophthalmol 1996 oct-dec; 6 (4):393-7 4 howe lj, bloom p. delayed suprachoroidal haemorrhage following trabeculectomy bleb needling. br j ophthalmol 1999; 83:753 5 gainey sp, robertson dm, fay w, ilstrup d. ocular surgery on patients receiving long-term warfarin therapy. am j ophthalmol 1989; 108:142-146. 6 mccormack p, simcock pr, tullo am. management of the anticoagulated patient for ophthalmic surgery. eye 1993; 7(pt. 6):749-750. 7 langston rh. what is the risk of complications from cataract surgery in patients taking anticoagulants? cleveland clinic journal of medicine. 2001(feb); 68 (2): 97-8 figure legends 1-a b-scan of right eye showing vitreous haemorrhage 1-b b-scan of same eye two weeks later showing supra-choroidal haemorrhage 1-c b-scan of same eye four weeks later showing resolved supra-choroidal haemorrhage pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 111 original article frequency of cataract and its association with tobacco use in subjects of an eye camp saba alkhairy, farnaz siddiqui, mazhar-ul-hassan, arif nayani pak j ophthalmol 2019, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. saba alkhairy mbbs, fcps, (ophth) assistant professor dimc, duhs email: saba.alkhairy1@gmail.com …..……………………….. purpose: to find the frequency of cataract and to study the relationship between cataract development and tobacco use. study design: cross sectional study. place and duration of study: single day eye camp at dow university hospital karachi in august 2016. material and methods: all patients presenting to the camp were screened through standard eye examination including refraction and fundoscopy. after dilatation of pupil these patients were examined with a slit lamp by a consultant ophthalmologist for confirmation of the presence of cataract and its type. participants were then questioned regarding the type of tobacco use and its duration and frequency with which it was consumed. those patients with a history of tobacco consumption for more than ten years were included in the study. results: a total of 550 patients presented to the eye camp of which 120 (21.81%) subjects were found to have a cataract. the mean age of the subjects was 58.02 ± 8.3 years. there were 67 (55.8%) males and 53 (44.2%) females. among the patients diagnosed with cataract 89 (74.2%) had no history of tobacco usage while 31 (25.8%) gave a positive response regarding tobacco consumption. in nonsmokers the most common cataract was cortical where as in cigarette smokers it was nuclear 8 (57.1%) and in users of smokeless tobacco it was posterior subcapsular 5 (38.5%). there were no pseudophakic patients seen as almost all came from remote areas where there was lack of surgical facility. conclusion: tobacco consumption has a strong association with cataract development. cigarette smoking as well as chewing smokeless tobacco should be curtailed or avoided altogether. keywords: cataract, tobacco, visual acuity. ataract is one of the major causes of blindness worldwide accounting for nearly half of all blindness globally1. according to the world health organization (who), nearly 20 million people throughout the world suffer from reduced vision, of 3/60 or less, due to cataract. these figures are predicted to increase to 40 million by the next year. although there are now various surgical procedures for extraction of cataract and hence to improve vision, many people continue to have poor vision from cataracts due to lack of awareness, poor access to health care and operative facilities and high surgical expense2. epidemiologic studies imply that etiology of cataract is due to various factors and that their occurrence is related to increase in age. one particular factor suggested to be the cause of cataract c http://www.news-medical.net/health/cataract-research.aspx saba alkhairy, et al 112 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology development is injury to the lens by oxygen free radicles3. raw tobacco products and tobacco smoke both contain several materials, including nicotine, free radicals, and carbon monoxide, which can enhance the injury caused by oxidation and have a significant role in the development of cataract4,5. tobacco use has emerged as a serious health challenge in pakistan that now stands among the top four countries of the world with rapid increase in tobacco market6. the various forms used are chewed, sucked, or applied to teeth or gums. smokeless tobacco is sold as packets of strands and is used alone or along with betel leaf, areca nut and lime. as the country is currently suffering from epidemic of tobacco addiction therefore the rationale of the study was to study the effects of tobacco use in general and smoking in particular so as to increase public awareness about its potential health hazards. strict laws should be implemented to actively ban advertisement and promotion of tobacco and tobacco related products. the objective of this study was to study the frequency of cataract and to determine the association between tobacco consumption and cataract development. material and methods a total of 550 adult patients visited an eye camp which was held on a single day in august 2016.all these patients underwent visual acuity assessment using a topcon kr-800pa auto refractor followed by a subjective test with snellen chart at 6 meters with standard illumination by two qualified optometrists. illiterate subjects were assessed using the e chart while literate subjects were tested using the standard letters. individuals including both males and females and those aged more than 40 were analyzed further. they were dilated with tropicamide 1% eye drops instilled every 10 minutes for 30 minutes .after full dilatation the cataract if detected was graded with lens opacities classification system. cataract was categorized as any locs iii grading of ≥ 2 in either eye. cortical, nuclear, and posterior sub capsular cataracts (psc) were defined as locs iii ≥ 2. also detailed examination was done of the cornea, the anterior segment, disc, macula and remaining retina along with gonioscopy and tonometry to rule out other causes of decreased vision. they were then questioned in detail by a single person as most were illiterate and were not able to answer the questionnaire themselves. the subjects were then divided into two groups: those who consumed tobacco in any form and those who had no history of smoking, chewing tobacco or its utilization. those who were smokers or consumed tobacco in any form were further inquired about the kind of tobacco (cigarette or smokeless tobacco) use if any and the duration of usage in terms of quantity and years. all the data gathered was entered into questionnaires and was analyzed statistically using ibm spss version 21. the results were presented as mean ± sd for age, frequency and percentages for gender, tobacco use and type of cataract. statistical association was calculated between cataract type with gender and tobacco use using chi-square test. a p-value of 0.05 or less was considered statistically significant. results amongst the total number of 550 patients presenting to the opd those who fulfilled the criteria were found to be 120 subjects, who were analyzed. table 01 describes the descriptive statistics of all respondents. mean ± standard deviation of age (58.02 ± 8.3 years). frequency and percentages of males were 67 (55.8%) and females were 53 (44.2%). persons who did not use any tobacco were higher i.e. 89 (74.2%). for cataract type psc was found to be 36 (30%) followed by cortical 35 (29.2%) and others respectively. table 1: descriptive statistics of respondents. characteristics n = 120 (%) age years (mean ± sd) 58.02 ± 8.3 gender male 67 (55.8%) female 53 (44.2%) tobacco use nil 89 (74.2%) betel nuts 13 (10.8%) cigarettes 14 (11.7%) others 4 (3.3%) cataract type psc 36 (30%) cortical 35 (29.2%) nuclear cataract 24 (20%) cortical + nuclear 12 (10%) cortical + psc 13 (10.8%) table 2 describes the association of cataract type with gender and tobacco use. amongst the 67 male patients the occurrence of cortical cataract was higher 29.9% where proportions of cortical with nuclear were https://academic.oup.com/aje/article/162/1/73/166454/intensity-of-smoking-and-smoking-cessation-in http://iovs.arvojournals.org/article.aspx?articleid=2128544 http://bjo.bmj.com/content/90/11/1374.short frequency of cataract and its association with tobacco use in subjects of an eye camp pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 113 table 2: relationship of cataract with gender and tobacco use. characteristics cataract type psc (n=36) cortical (n=35) nuclear cataract (n=24) cortical + nuclear (n=12) cortical + psc (n=13) total p-value gender male 19 (28.4%) 20 (29.9%) 13 (19.4%) 5 (7.5%) 10 (14.9%) 67 0.8 female 17 (32.1%) 15 (28.3%) 11 (20.8%) 7 (13.2%) 3 (5.7%) 53 tobacco use nil 25 (28.1%) 28 (31.5%) 12 (13.5%) 12 (13.5%) 12 (13.5%) 89 0.02*~ betel nuts 5 (38.5%) 3 (23.1%) 4 (30.8%) 0 (0.0%) 1 (7.7%) 13 cigarettes 4 (28.6%) 2 (14.3%) 8 (57.1%) 0 (0.0%) 0 (0.0%) 14 others 2 (50.0%) 2 (50.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 4 significant at 5% ~cells proportion > 20% very less i.e. 7.5%. in females out of 53, 17 (32.1%) had psc and only 5.7% had cortical with psc. there was no significant association found for gender (p-value = 0.8). a significant association was found due to the tobacco and occurrence of different cataract types (pvalue = 0.02 < 0.05). fig 1: association between tobacco and cataract type. discussion of all the causes leading to visual impairment all over the world, cataract is at the top of the list7. in a study conducted on elderly patients living in taiwan the three most common causes of visual impairment were found to be cataract (41.7%), seconded by myopic macular degeneration (12.5%) and then age-related macular degeneration (10.4%)8. in another study done in an elderly home in south india the most common causes of visual impairment were due to avoidable causes including cataract (57.1%) and uncorrected refractive errors (26.4%)9. a global data on visual impairment concluded the number of people with visual impairment worldwide in 2002 was more than 161 million and among them cataract remained the most important and leading cause of visual disability10. smoking causes damage to the lens through oxidation by reducing the inherent antioxidative ability of the lens by depleting substances as such as vitamin c, vitamin e, and β-carotene11.12. another reason is that certain substances of tobacco contain heavy metals, such as cadmium, lead, and copper, which are directly harmful to lens and can also lead to formation of cataract13,14. in southeast asia, tobacco is consumed in various ways, including cigarettes or bides (dried tobacco rolled in paper or leaf), chewing khaini (tobacco with slaked lime and aromatic spices), sutra (dried tobacco leaves for chewing), or pan masala (tobacco with betel leaf), sucking gutka (mixture of tobacco and molasses available in small sachets), and inhaling of naswar (nasal inhalation of tobacco powder)15. in our study we analyzed a total of 120 subjects of whom 89 were nonsmokers and 31 were smokers. cigarette smoking was the most common form of tobacco use observed in 14 subjects (11.7%), followed by betel nut chewing with grounded tobacco which was noted to be 13 (10.8%) subjects, while a category of others included 4 (3.3%) subjects. the others represented a category who consumed tobacco in various smokeless forms of tobacco as mentioned above. the most common type of cataract seen in nonsmokers was cortical cataract while in those individuals who were cigarette smokers saba alkhairy, et al 114 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology the most common type was nuclear cataract and in users of smokeless tobacco such as betel nut users it was posterior subcapsular cataract. this is consistent with other studies such as a meta analysis done by juan le et al16 and various other studies conducted in different countries of the world such as singapore, india and australia respectively17-20. in our study there was no significant association found in gender p = 0.8. overall in all of 120 subjects cataract was found more in males as opposed to females but that is because of the increased number of male subjects presenting to the hospital. the most common cataract found in females was posterior subcapsular which was seen in 17 (32.1%) while the most common cataract found in males was cortical that was seen in 20 (29.9%). this conflicts with studies which have concluded that most common cataract found in women is nuclear conducted in united states and australia21.22. the prevalence of cataract seen in our study was estimated to be 21.81%.this is almost similar to another study conducted known as the beaver eye dam study which estimated an incidence of 21%23. however the prevalence was higher in other studies such as zhang js who estimated the prevalence of cataract in china to be 35%24. in another study done in singapore the prevalence reported was 34.7% (95% ci, 31.5, 38.0)25. limitations of the study are that prevalence of age related cataracts alone is difficult to determine as there are multifactorial causes of cataract formation such as increasing age, trauma, use of steroids etc. also to study association of tobacco smoking with cataract a larger sample size is recommended. people were vague in their history regarding the mode of tobacco consumption and were especially hesitant to discuss the duration of its usage because of social stigma. furthermore as most patients selected for final evaluation were more than 40 years old in which age related cataracts are more common it adds more confusion to build any definite association. conclusion the prevalence of cataract seen in our study was estimated to be 21.81%. there was no significant association found for gender and cataract development. a significant association was found between tobacco consumption and occurrence of different cataract types of which the most common type of cataract seen was posterior subcapsular. author’s affiliation dr. saba alkhairy mbbs, fcps, (ophth) assistant professor dimc, duhs dr. farnaz siddiqui mbbs, fcps, (ophth) assistant professor dimc, duhs dr. mazhar ul hassan mbbs, mcps, fcps, (ophth) professor and head of department dimc, duhs dr. arif nayani mbbs, medical officer dimc, duhs author’s contribution dr. saba alkhairy data collection, analysis and manuscript writing. dr. farnaz siddiqui data collection and analysis. dr. mazhar ul hassan study design and critical analysis. dr. arif nayani data collection and literature review. conflict of interest the authors have no conflict of interest to declare. references 1. bourne r, stevens ga, white ra, et al. causes of vision loss worldwide. lancet global health, 2013; 1: e339–e349. 2. lindfield r, vishwanath k, ngounou f, khanna rc. the challenges in improving outcome of cataract surgery in low and middle income countries. indian j ophthalmol. 2012; 60: 464–469. 3. vinson ja. oxidative stress in cataract. pathophysiology, 2006 aug; 13 (3): 151-62. 4. prakash c g, cecily s r. smokeless tobacco and health in india and south asia. respirology, 2003; 8: 419–431. 5. fletcher ae. free radicals, antioxidants and eye disease: evidence from epidemiological studies on cataract and age-related macular degeneration. ophthalmic res. 2010; 44 (3): 191-193. 6. gilani si, leon da. prevalence and sociodemographic determinants of tobacco use among adults in pakistan: findings of a nationwide survey conducted in 2012. popul health metr. 2013; 11: 16. 7. brian g, taylor hr. cataract blindness; challenges for the 21st century. bull world health org. 2001; 79: 249– 256. frequency of cataract and its association with tobacco use in subjects of an eye camp pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 115 8. hsu wm cheng cy liu jh tsai sy chou p. prevalence and causes of visual impairment in an elderly chinese population in taiwan: the shihpai eye study. ophthalmology, 2004; 111: 62–69. 9. dandona l, dandona r, srinivas m, et al. blindness in the indian state of andhra pradesh. invest ophthalmol vis sci. 2001; 42 (5): 908-916. 10. resnikoff s, pascolini d, etya’ale d, et al. global data on visual impairment in the year 2002. bull world health organ. 2004; 82 (11): 844-851. 11. valero mp, fletcher ae, de stawola bl, vioque j, alepuz vc. vitamin c is associated with reduced risk of cataract in a mediterranean population. j nutr. 2002; 132 (6): 1299-306. 12. wei l, liang g, cai c, lv j. association of vitamin c with the risk of age-related cataract: a meta-analysis. acta ophthalmol. 2016; 94: 170-176. 13. langford-smith a, tilakaratna v, lythgoe pr, clark sj, bishop pn, day aj. age and smoking related changes in metal ion levels in human lens: implications for cataract formation. plos one. 2016 jan 21;11(1):e0147576. 14. nirmalan p k, robin a l, katz j, tielsch jm, thulasiraj rd, krishnadas r, ramakrishnan r. risk factors for age related cataract in a rural population of southern india: the aravind comprehensive eye study. br j ophthalmol. 2004; 88: 989–994. 15. jarvis mj, wardle j. social patterning of individual health behaviours: the case of cigarette smoking. edited by marmot m, wilkinson rg. oxford: oxford university press; 2005. 16. ye j, he j, wang c, wu h, shi x, zhang h, xie j, lee sy. smoking and risk of age-related cataract: a metaanalysis. investigative ophthalmology and visual science, 2012; 53: 3885-3895. 17. foster pj, wong ty, machin d, et al. risk factors for nuclear, cortical and posterior subcapsular cataracts in the chinese population of singapore: the tanjong pagar survey. br j ophthalmol. 2003; 87: 1112–20. 18. nirmalan pk, robin al, katz j, et al. risk factors for age related cataract in a rural population of southern india: the aravind comprehensive eye study.br j ophthalmol. 2004; 88: 989–94. 19. krishnaiah s, vilas k, shamanna br, et al. smoking and its association with cataract: results of the andhra pradesh eye disease study from india. invest ophthalmol vis sci. 2005; 46: 58–65. 20. tan js wang jj younan c cumming rg rochtchina e. smoking mitchell p and the long-term incidence of cataract: the blue mountains eye study. ophthalmic epidemiol. 2008; 15: 155–161. 21. congdon no, colmain b, klaver cc et al. eye diseases prevalence research group, causes and prevalence of visual impairment among adults in the united states. arch ophthalmol. 2004; 122 (4): 477-485. 22. delcourt c, cristolj p, tessier f. leger cl. michel f, papoz l. pola study group. risk factors for cortical, nuclear, and posterior subcapsular cataracts: the pola study. am j epidemiol. 2000; 151 (5): 497-504. 23. klein bek, klein r, linton klp, magli yl, neider mw. assessment of cataracts from photographs in the beaver dam eye study. ophthalmology, 1990; 97: 1428– 33. 24. zhang js, xu l, wang yx, you qs, wang jd, jonas jb. five-year incidence of age-related cataract and cataract surgery in the adult population of greater beijing: the beijing eye study. ophthalmology, 2011; 118: 711–718. 25. seah skl, wong ty, foster pj, ng tp, johnson gj. prevalence of lens opacity in chinese residents of singapore: the tanjong pagar survey. ophthalmology, 2002; 109: 2058–2064. pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 231 original article is silicone intubation necessary in dacryocystorhinostomy? zia muhammad, muhammad tariq, mubashir jalis, anjum khalid pak j ophthalmol 2016, vol. 32 no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zia muhammad house no. g139 sadberg road sheikh maltoon town mardan 23200. email: eyesurgzia@gmail.com …..……………………….. purpose: to study the results of standard dcr without silicon intubation in patients suffering from chronic dacryocystitis. study design: quasi experimental study. place and duration of study: mardan medical complex teaching hospital, from december 2010 to december 2011. material and methods: fifty patients (31 females and 19 males) having chronic dacryocystitis were operated using the standard dacryocystorhinostomy (dcr) procedure at mmc teaching hospital mardan. all patients were followed for at least 6 months post operatively. success was defined as symptomatic relief of epiphora and a patent nasolacrimal passage on syringing. results: on first post operative day 47 patients were found to have freely patent passage on syringing done in the ward and rest of 3 patients below 15 years also had patent passage on syringing done in general anesthesia (ga). the success rate after 6 months of follow-up was 98 % without using silicon tubes conclusion: standard external dcr is a simple and cost effective procedure for the management of chronic dacryocystitis and routine intubation is unnecessary and probably unjustified. key words: dacryocystorhinostomy (dcr), epiphora, silicone tube. or nearly a century, the gold standard for epiphora and nasolacrimal duct obstruction has been dacryocystorhinostomy (dcr). although the high success rate of external dcr continues to be confirmed in the literature, there have been promising advances in other modalities of treatments for dcr namely endocanalicular surgery and endonasal dcr1. dacryocystitis results from some kind of obstruction in the nasolacrimal duct. this acquired nasolacrimal duct obstruction may be primary where cause for the inflammation is not defined, whereas secondary nasolacrimal duct obstruction is due to a known cause for the inflammation. the causes may be infectious, inflammatory, neoplastic, traumatic or mechanical2. silicone intubation has been used to improve the success rate of dcr in the recent years. it has been reported to cause cheese wiring of canaliculi and granuloma formation at the ostium2. we undertook this study to find out the success rate of dcr without silicone intubation. material and methods this study was conducted at mardan medical complex teaching hospital (kpk) from december 2010 to december 2011. fifty patients (31 males 19 females) were included in the study. patients with acute dacryocystitis lacrimal abscess and stenosed canaliculi were excluded from the study. all patients were recruited from the outpatient department of mardan medical complex teaching hospital mardan. all patients underwent a thorough ophthalmic examination and systemic evaluation for diabetes mellitus and hypertension. patients having anomalies f zia muhammad, et al 232 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology of the nasolacrimal puncti, blockage of the upper and lower canaliculi or common canaliculus, previous lacrimal surgery, post-traumatic dacryocystitis and bony deformity were excluded from the study. a written informed consent was taken from all patients undergoing the procedure. forty seven patients were operated under local anesthesia and three patients under 15 years were operated under general anesthesia. standard external dcr was performed on all patients, with suturing of the anterior flaps of the lacrimal sac and nasal mucosa and trimming of the posterior flaps of the lacrimal sac. the first dressing was changed after 24 hours and irrigation of the lacrimal passage was done to ascertain the patency of the newly formed ostium and to wash out any blood clots and debris in the passage. children below 15 years were syringed under general anesthesia on the next operation day. patients were then followed after 7 days, one month and 6 months. successful outcome was defined as resolution of epiphora and discharge and patency of the passage on syringing. results fifty randomly selected patients were operated for dcr during the period from december 2010 to december 2011. thirty one (62%) were females and 19 (38%) were males. the age range was between 4 to 70 years. forty seven patients were operated under local anesthesia while 3 patients were operated under general anaesthesia. follow-up period was from 6 months to one year. per-operative complications included severe bleeding in three patients (6%), controlled with pressure packing and the procedure completed successfully. on first post-operative day all patients (above 15 years of age) the nasolacrimal passage was washed in the ward examination room. the passage was found freely patent in all the 47 patients. in three patients (below 15 years) syringing of the nasolacrimal passage was performed under general anesthesia in the next operation day i.e. on third post-operation day. the passages were found patent in these patients as well. subsequently the patients were followed every month. after 6 months of follow-up 49 patients 98%) were found to have patent nasolacrimal passage. only one patient (2%), a 19 year old male patient had a blocked nasolacrimal passage to syringing. table 1: age male female total 4-20 years 5 3 8 21-40 years 5 11 16 40-70 years 9 17 26 discussion dacryocystitis is defined as inflammation of the lacrimal sac usually caused by some kind of obstruction in the nasolacrimal duct1. the condition is commonly seen in infants and people over 40 years of age. there are two types of acquired nasolacrimal duct obstructions, primary or secondary. primary nasolacrimal duct obstruction is caused by inflammation without any known cause whereas, the secondary acquired nasolacrimal duct obstruction is caused by a known cause of inflammation or fibrosis. these causes could be infectious, inflammatory, neoplastic, traumatic or mechanical. galen3 originally described the anatomy, pathology of the lacrimal drainage system and etiology of tearing. his treatment for dacryocystitis was dacryocystectomy. in 1904, toti developed the first modern external dcr. in 1921 dupuy dutemps and bourguet4 described the methods of forming the mucosal flaps. since that time, silicon intubation has been the only major advance in the technique. for nearly a century the gold standard treatment for epiphora and nasolacrimal duct obstruction has been dacryocystorhinostomy (dcr). in spite of the high success rate of external dcr, there have been advances in alternative procedures like endonasal dcr and endocanalicular surgery. external dcr has the advantages of ease of performance and lower economic impact2. the success rate of dacryocystorhinostomy (dcr) has been reported from 69% to 99%5. factors influencing the outcome of the procedure include the surgical approach (endonasal dcr vs. external dcr), the presence of preoperative acute dacryocystitis or postoperative soft tissue infection, a history of trauma to the lacrimal apparatus and the use of silicone tubes6. other factors attributable to dcr failure include membranous occlusion of the rhinostomy site, common canalicular obstruction and an inappropriate size or location of the bony ostium. the most common cause of primary dcr failure, according to many is silicone intubation necessary in dacryocystorhinostomy? pakistan journal of ophthalmology vol. 32, no. 4, oct – dec, 2016 233 authors, is the soft tissue scarring at the rhinostomy site7. external dcr is a technically challenging procedure. it needs considerable experience and atraumatic handling of the soft tissues, careful dissection of the lacrimal sac, proper size and location of the osteotomy for a successful outcome8. we operated on 50 patients (31 females and 19 males) having chronic dacryocystitis. patients with lacrimal abscess in the recent past, stenosed canaliculi, were excluded from the study. chronic dacryocystitis was more common in females 31 (62%) in our study as compared to males 19 (38%). similar female preponderance has been noted by other observers as well1,7,8. we followed the technique of dutemps and bourguet10, suturing only the anterior flaps of the lacrimal sac and the nasal mucosa. the posterior flaps were trimmed only like other surgeons11,12. some surgeons12, suture the posterior flaps as well. we did not use silicone tube in any patient. to enhance the success rate of the procedure and prevent postoperative cellulitis, we routinely use systemic antibiotics in all patients. it has been observed that there is a significant reduction in postoperative cellulitis after dcr with either intraoperative intravenous antibiotics or postoperative oral antibiotics compared with intra-operative saline wash without antibiotics13,14,15. the cellulitis rate was approximately 1% in both antibiotic groups compared with 18 % in the non antibiotic group. raj kumar advani et al16, has reported a success rate of 95 % in their series without intubation. gibbs17 in 1967 described a technique of inserting a silicone rubber tube when performing dcr, however, there is no significant difference between the success rates of routine external dcr irrespective of silicone intubation18. silicone intubation may be beneficial in complicated cases with distal and common canaliculus obstruction and repeat dcr procedures19. we achieved a success rate of 98% in our patients after one year of follow-up. in one patient, a 19 years old male, the passage remained patent for two months and reported with epiphora 5 months after the operation. in experienced hands, external dacryocystorhinostomy is a highly successful procedure without silicone tubes even in children14,15. saiju et al in their prospective randomized study found no statistically significant difference in the success rate between the groups of patients undergoing dcrs with and without silastic intubation. silicone tubes increased the surgical cost by 20% in their study20. based on the meta-analysis that included 5 randomized controlled trials and 4 cohort studies, no benefit was found for silicone tube intubation in primary dcr21. author’s affiliation prof. zia muhammad prof. and head dept. of ophthalmology bacha khan medical college mardan dr. muhammad tariq assistant prof. of ophthalmology bacha khan medical college mardan dr. mubashir jalis associate prof. of ophthalmology islamabad medical and dental college islamabad dr. anjum khalid community ophthalmologist mardan medical complex, mardan. role of authors prof. zia muhammad operating on some of the selected patients. writing and composing the article. dr. muhammad tariq searching the literature and collecting the references. dr. mubashir jalis proof reading and editing the paper. dr. anjum khalid operating on the selected patients and follow-up references 1. babar tf, masud mz, nasir saeed, khan md. an analysis of patients with chronic dacryocystitis. pak j ophthalmol. 2003; 19: 77-82. 2. t. duffy mt. advances in lacrimal surgery. current opinion in ophthal. 2000, 11: 352-6. 3. hughes sm: the history of lacrimal surgery. adv ophthalmic plast reconst surg. 1986, 5: 139-68. 4. werb a: the history and development of lacrimal surgery in england and europe. adv ophthalmic plast reconstr surg. 1986, 5: 233-40. 5. use of mitomycin c in repeat dacryocystorhinostomy. ophthalmic plastic and reconstructive surgery, vol. 15: zia muhammad, et al 234 vol. 32, no. 4, oct – dec, 2016 pakistan journal of ophthalmology 19-22. 6. walland mj, rose ge. factors affecting the success rate of open lacrimal surgery. br j ophthalmol. 1994; 78: 88891. 7. welham ran, wulc ae. management of unsuccessful lacrimal surgery. br j ophthalmol. 1987; 71: 152-7. 8. zaman shah, ibrar hussain, naeem khattak, mustafa iqbal. a review of 144 cases of dacryocystorhinostomy. pak j ophthalmol. 2009; 25: 89-92. 9. boobak sm. results and complications of external dacryocystorhinostomy at tertiary referral centre. ophthalmology update, 2011; 9: 82-5. 10. dupuy-dutemps l, bourguet j. procede plastique de dacryocystorhinostomie et ses resultantants. ann ocul j. 1921; 158: 241-61 11. serin d, alagoz g, karsloglu s, et al. external dacryocystorhinostomy: double flap anastomosis or excision of the posterior mucosal flaps? ophthal plast reconstr surg. 2007; 23: 28-31. 12. elwan s. a randomized study comparing dcr with and without excision of the posterior mucosal flaps. orbit. 2003; 22: 7-13. 13. vardy sj, rose ge: prevention of cellulitis after open lacrimal surgery; a prospective study of three methods. ophthalmology, 2000, 107: 315-7. 14. barnes ea, rayyah ya, rose ge. pediatric dacryocystorhinostomy for nasolacrimal duct obstruction. ophthalmology, 2001; 108: 1562-4. 15. nawas m, sultan m, hanif q, sadiq m. dacryocystorhinostomy; a comparative study of the results with and without intubation in pakistani patients of chronic dacryocystitis. professional med j mar. 2008; 15: 81-6. 16. advani rk, halepota fm, shah sia, qadri wm. comparative results of dacryocystorhinostomy with and without silicon intubation. pak j. ophthalmol. 2004; 20: 29-34. 17. pakdel f. silicone intubation does not improve the success of dacryocystorhinostomy in primary acquired nasolacrimal duct obstruction. j ophthalmic vis res. 2012; 7: 271-3. 18. buttanri ib, serin d. silicone intubation indications in external dacryocystorhinostomy. med hypothesis, medical hypothesis, discovery and innovation in ophthalmology. winter, 2014; 3: 101. 19. monka a, zhungli s. silicone intubation in external dacryocystorhinostomy. international j of science and research, volume 4 issue 12, december 2015. pp 18141816. 20. saiju r, morse lj, weinberg w, shrestha mk, ruit s. prospective randomized comparison of external dacryocystorhinostomy with and without silicone intubation. british j of ophthalmology, 2009; 93: 1220. 21. feng yf, cai jq, zhang jy, han xha. meta-analysis of primary dacryocystorhinostomy with and without silicone intubation. can j ophthalmol. 2011; 46: 521-7. microsoft word tariq farooq 60 review article normal tension glaucoma tariq farooq babar, muhammad tariq khan, mir zaman, mohammad daud khan pak j ophthalmol 2006, vol. 22 no.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations .…………………………….. correspondence to: tariq farooq babar house no: 8/101 new defence colony, p.o. tehkal payan peshawar received for publication december 2004 .…………………………….. normal tension glaucoma (ntg), also called as low-tension glaucoma, continues to be a diagnostic and therapeutic challenge even in the new millennium. ntg can be differentiated from primary open angle glaucoma by having an infero-temporally displaced large cup, notching of the neuro-retinal rim in the infero-temporal quadrant, decreased nerve fiber layer (nfl) thickness, flameshaped disc hemorrhage on temporal side and visual field defects steeper sided & deeper and within five degrees of fixation. risk factors for normal tension glaucoma include, females aged 60 years or above, history of peripheral vascular spasm in cold, migrainous headaches and nocturnal systemic hypotension. ocular examination includes measuring intraocular pressure environment central corneal thickness and paying attention to the optic disc, neuro-retinal rim, nfl thickness & visual fields. neuro-imaging is required only in specific cases. polymorphisms in the opa1 gene is considered to be a marker for this disease. careful screening in positive families may detect disease at an earlier stage. treatment modalities include differentiating non-progressive from progressive form of normal tension glaucoma. progressive form requires intra-ocular pressure reduction by 30% by medical or surgical treatment. betaxolol, latanoprost and dorzolamide are effective as they can increase optic nerve blood flow. trabeculectomy can be offered when there is progressive visual field loss in spite of intra-ocular pressure being in the lower teens. he definition of the normal or low tension glaucoma has been a diagnostic dilemma since its original description by von graefe in 18571. in addition to cupping and visual field loss, duke elder and jay2 included reduced aqueous outflow facility in their definition. chandler and grant3 and hoskins considered that progression of visual field loss or optic disc cupping as an integral part of the definition. spaeth5 and kolker and hetherington6 believed that in normal tension glaucoma optic nerve damage was induced by intraocular pressure, even though the pressure was always within the normal range. recently kamal and hitchings7, putting all puzzles together, have defined normal tension glaucoma with the following criteria. • a mean iop equal to or less than 21 mm hg on diurnal testing, with no pressure spikes greater than 24 mm hg. • glaucomatous cupping of the optic nerve head with corresponding visual field defects. • open angles on gonioscopy. • absence of any possible contributing ocular or systemic disorder(s). • progression of glaucomatous damage. t 61 normal tension glaucoma has also been regarded as a variant of primary open angle glaucoma. it is also called as “pseudoglaucoma”, “posterior glaucoma”, “paraglaucoma” and “low tension glaucoma”8. epidemiology the prevalence of normal tension glaucoma is not exactly known. in individuals above 40 years of age, its prevalence is 0.2%. it represents 16 %to 50% of all cases of primary open angle glaucoma8, 9. it is said to be more common in women than men10. there is increased prevalence in female patients with collagen diseases. of the 153 patients with collagen diseases examined by yamamoto, maeda and sawada et al, 6 patients were found to have normal tension glaucoma and 2 had primary open angle glaucoma. of these 8 patients, two had progressive systemic sclerosis – out of these two, one was suffering from normal tension glaucoma and the other with primary open angle glaucoma and had a history of systemic steroid therapy11. normal tension glaucoma usually affects adults, with an average age of 60 years10,12,13. risk factors it is important to realize that certain factors may affect the incidence and severity of normal tension glaucoma. many authors believe that their presence significantly increases the risk for developing normal tension glaucoma. general risk factors normal tension glaucoma is said to be more common in people over 60 years of age and is more common in women than men. the disease may run within the family14 and may be progressive15. (a) ocular risk factors a. intraocular pressure: in most cases of normal tension glaucoma, the intraocular pressures usually cluster at the upper end of the so-called normal range. many authorities consider intra-ocular pressure to be an important risk factor for the development of normal tension glaucoma as it is for ocular hypertension. cartwright and anderson16 reported significant amount of cupping and visual field loss in the eye with the higher intra-ocular pressure. similarly according to the collaborative normal tension glaucoma study, the level of intraocular pressure does influence the course of normal tension glaucoma. there is a slower rate of coincident visual field loss in cases with 30% or more lowering of intraocular pressure. some patients experience greater benefit from lowering of intraocular pressure than others17. b. optic disc hemorrhage in 1889, bjerrum8 is reported to be the first person to describe optic disc hemorrhage and its relation to glaucoma. since then, many authors have described the prevalence of optic disc hemorrhage in glaucoma. optic disc hemorrhage is described in open angle glaucoma, both with high and normal pressures. it is said to be five times more frequent in normal tension glaucoma18. flame-shaped hemorrhages are more common. the usual site is the temporal site of the disc, with the supero-temporal quadrant being more affected than the infero-temporal quadrant. they are usually transient, resolving within four to six weeks. budde19 reported that disc hemorrhages are larger in normal tension glaucoma. he observed that smaller hemorrhages in primary open angle glaucoma could be the result of higher intraocular pressure. flame-shaped disc hemorrhages are associated with notching of neuro-retinal rim, localized nfl defects and worsening of visual field defects20,21. however these are not specific and can occur in a variety of other conditions including anterior ischemic optic neuropathy, optic disc drusen, posterior vitreous detachment, diabetes mellitus, central and branch retinal vein occlusions, papilloedema, optic neuritis and systemic hypertension22. they have also been reported in normal eyes23. c. peri-papillary defects these are atrophic changes in the retinal pigment epithelium and chorio-capillaries in the peri-papillary area. they occur with a greater frequency in normal tension glaucoma24. confocal scanning laser ophthalmoscopy and doppler flowmetry has revealed reduced blood flow in the peri-papillary region in normal tension glaucoma as compared with age matched controls25 myopia myopia occurs more frequently among patients with open angle glaucoma, ocular hypertension and normal tension glaucoma26. it is said that congenital misalignment of the peri-papillary tissue layers in myopia, may contribute to the increased vulnerability to pressures even in the normal ranges27. 62 systemic risk factors among systemic risk factors, the following are more common in normal tension glaucoma than in primary open angle glaucoma. • peripheral vascular spasm on exposure to cold (raynaud’s phenomenon). • migraine headaches28. • nocturnal systemic hypotension and over-treated systemic hypertension. • reduced blood flow velocity in the ophthalmic artery, when measured with trans-cranial doppler ultrasonography. • paraproteinemia and the presence of serum auto antibodies. • hemodynamic crisis, including myocardial infarction and peri-operative hypotension29. patho-physiology two types of mechanisms are thought to be involved in the pathogenesis of normal tension glaucoma, working either individually or in combination. these are: a) pressure-dependant mechanisms b) pressure-independent mechanisms (a) pressure-dependant mechanisms: some cases of normal tension glaucoma may not be very different from primary open-angle glaucoma. however in ntg, there is a heightened sensitivity to otherwise normal intraocular pressure. intra-ocular pressure tends to be higher in normal tension glaucoma than in the general population30. moreover in normal tension glaucoma, patients with asymmetric intra-ocular pressure, the eye with higher pressure generally has worse optic nerve damage16. this concept is also supported by the collaborative normal tension glaucoma study. the study was designed to see the impact of a combination of medical, laser and surgical treatment to produce 30% reduction in intraocular pressure versus no treatment in patients with progressive normal tension glaucoma. the study confirmed that reduction of presenting pressure by 30% slowed the rate of glaucomatous progression in significant number of patients31-32. burgoyne, in the year 2000, demonstrated that certain anatomic features of optic nerve head may increase its susceptibility to a wide range of otherwise normal intra-ocular pressures33. thus the mechanisms of optic nerve damage in normal tension glaucoma may be similar to those, postulated for primary open angle glaucoma; like mechanical and ischemic theories of glaucomatous optic nerve damage. mechanical theory of glaucomatous optic nerve damage according to this theory, increased intra-ocular pressure distorts the lamina cribrosa, which then causes compression damage to axons and interfere with axoplasmic flow. in normal tension glaucoma, there may be local weaknesses of the structural components of the nerve itself. a connective tissue defect at the lamina or in the glial support tissue increases the nerve susceptibility to damage, even in the presence of normal pressures8. ischemic theory of glaucomatous optic nerve damage: according to this theory, the elevated intra-ocular pressure causes relative ischemia of the optic nerve head that eventually destroys the axons. hypo-perfusion of the optic nerve head may play a primary role in the development of the normal tension glaucoma. one-third of normal tension glaucoma patients had a history of previous acute hypotensive episode; e.g. gasto-intestinal or uterine hemorrhage, cardiac arrest, severe anesthetic hypotension, congestive cardiac failure and postural hypotension 29. (a) pressure-independant mechanisms: corbet demonstrated increased incidence of migraine among patients with normal tension glaucoma, relative to patients with primary open angle glaucoma34. drance noted that digital blood flow to capillaries in the finger decreased with and without exposure to cold in patients with normal tension glaucoma as compared with controls35, while butt observed increased ophthalmic and central retinal artery resistance while working with colour doppler imaging techniques36. various conditions may alter blood flow to the optic nerve head. drance suggested a non-progressive form of normal tension glaucoma associated with shock or an episode of severe blood loss; while a progressive form associated with vaso-spasm, systemic hypotension and abnormal blood coagulobility37. 63 hayreh demonstrated a greater nocturnal decrease and a lower level of diastolic blood pressure in normal tension glaucoma relative to patients with anterior ischemic optic neuropathy and primary open angle glaucoma38. thus we can summarize that in normal tension glaucoma, a vascular failure leading to perfusion deficits of the optic nerve head, the retina, the choroids or the retro-bulbar vessels, by means of vaso-sclerosis, small vessel disease, vaso-spasm or auto-regulatory dysfunction may contribute to the optic nerve fibers loss in glaucomatous optic neuropathy39. clinical presentation and investigations clinical presentation of normal tension glaucoma is similar to that of primary open angle glaucoma. it is an insidious disease, which lacks symptoms until central vision is threatened. ocular examination is the same as with primary open angle glaucoma, with some key distinctions, which are as follows. optic disc cupping normal tension glaucoma tends to have large cupping, with usually infero-temporal displacement of the cup; whereas in primary open angle glaucoma, there is more diffuse cupping. heidelberg retinal tomography parameters are useful to differentiate patients with primary open angle glaucoma, normal tension glaucoma and ocular hypertension40. neuro-retinal rim notching of the rim is more common in the inferotemporal quadrant of the disc41. scanning laser ophthalmoscopy shows detailed analysis of the neuroretinal rim, measuring rim area to highlight localized as compared to generalized loss. digital planimetry gives quantitative assessment even of slight changes of the neuro-retinal rim area, and is a useful tool for follow up of glaucoma patients42. retinal nerve fiber layer defect heidelberg retinal tomography shows decreased nerve fiber layer thickness. there is a mixture of diffuse retinal nerve fiber layer damage in the superotemporal and infero-temporal regions. local damage in infero-temporal region is observed in patients with ocular hypertension and normal tension glaucoma – suggesting that both these glaucomas may follow similar pathological processes43. disc hemorrhage it is five-times more common in normal tension glaucoma than primary open angle glaucoma. patients with normal tension glaucoma with disc hemorrhage tend to show visual field progression in areas within 10 degrees field10. peri-papillary atrophy there is higher incidence of peri-papillary atrophy in patients with normal tension glaucoma than the controls. visual field defects there is more visual field damage within five degrees of fixation and a high probability of defects in the superior hemi-field in normal tension glaucoma. superior arcuate defects occur 2 to 4 times more frequent than inferior defects13. moreover, visual field defects tend to be steeper sided and deeper in normal tension glaucoma44. intra-ocular pressure there is a diurnal variation of intraocular pressure, being observed in normal tension glaucoma. maximum intraocular pressure occurs at 6 a.m., 9 a.m., and at noon and minimum pressure at midnight and at 3 a.m. thus measuring intraocular pressure in early morning is important for determining the precise diurnal variation of the intra-ocular pressure45. central corneal thickness it has been observed that central corneal thickness is higher in ocular hypertension, whereas patients with normal tension glaucoma and primary open angle glaucoma showed lower readings. thus by determining the central corneal thickness with optical coherence tomography (oct) – a new and precise technique to measure the central corneal thickness, there is need for a combined measurement of intraocular pressure and central corneal thickness; in order to obtain exact intra-ocular pressure readings46. polymorphism in opa1-gene a major marker for normal tension glaucoma normal tension glaucoma is usually diagnosed late, when loss of neurons has already caused significant 64 and irreversible visual field loss. opa1-gene (located on chromosome-3), the gene responsible for autosomal dominant optic atrophy, represents an excellent candidate gene for normal tension glaucoma; as the clinical phenotypes are similar and opa1 is expressed in the retina and optic nerve47. polymorphism in the opa1-gene is associated with normal tension glaucoma and is considered a marker for the disease. thus careful screening in positive families may detect earlier signs of the disease, allowing commencement of treatment before significant visual field loss has occurred48. differential diagnosis differential diagnosis constitutes both glaucomatous and non-glaucomatous entities. conditions causing optic neuropathy and visual field defects and mimicking glaucoma comes into this category. (a) glaucomatous entities • undetected primary open angle glaucoma • systemic medications, which mask elevated intraocular pressures, e.g. digoxin, acetazolamide, propranolol, etc. • pigmentary glaucoma • elevated intraocular pressure due to past use of topical or systemic steroids. • secondary glaucomas, causing episodic rise of iop, e.g. uveitic glaucoma non-glaucomatous entities • neurological causes congenital anomalies optic nerve pit optic nerve coloboma morning glory syndrome compressive lesions intra-cranial aneurysms intra-cranial tumors vascular diseases prior episodes of shock or anemia anterior ischemic optic neuropathy49 diagnostic examination history one should inquire about previously raised intraocular pressure, past episodes of visual loss, ocular inflammation or trauma, and use of steroids (both topical and systemic). history for hypotensive episodes in the past, e.g. associated with severe blood loss, shock and myocardial infarction, atherosclerosis, cerebrovascular disease, temporal arteritis etc, should be inquired. nutritional inadequacies, use of digitalis and/or beta-blockers, and history of migrainous headaches should also be recorded. ocular examination this includes routine external ocular examination and pupillary reflexes. careful intraocular pressure measurement with applanation tonometer is needed to be checked hourly throughout 24 hours, to assess diurnal variations. central corneal thickness should be estimated to get an exact iop reading. gonioscopy should be done to rule out secondary angle-closure glaucomas. optic nerve assessment should be done by careful direct ophthalmoscopy and slit-lamp biomicroscopy. if required, should be supplemented by optic disc stereo-photography with hrt or nfl-analyzer. visual field should be recorded with both kinetic and static perimetric techniques. in suspected cases, optic nerve perfusion should be assessed by ophthalmo-dynamometer. medical evaluation for every patient, blood pressure monitoring and carotid pulses auscultation should be mandatory. heart should be screened for cardiac valvular diseases and temporal artery tenderness should be observed. complete blood count should be done to rule out anemia. esr and c-reactive protein should be checked for ruling out giant cell arteritis. biochemical, coagulation and hematologic testing should be offered in appropriate cases. all systemic medications having potential for masking raised intra-ocular pressure, e.g. betablockers, digitalis – should be discontinued. neuro-imaging, like ct or mri should be advisable in suspected normal tension glaucoma patients where pallor of the neuro-retinal rim appears excessive compared with the degree of cupping. 65 patient with normal tension glaucoma should be referred to neurologist or neuro-ophthalmologist, if there is poor glaucomatous correlation between the disc and visual field, and complains of symptoms that cannot be explained by their visual loss49. management management of normal tension glaucoma involves determining progressive nature of the disease. if the disease is non-progressive, monitoring of visual fields and optic disc is done to establish stability. in this case, monitoring is advised every three months during the first year, then every six months during the second year and then annually thereafter. if the disease is progressive, the aim of the therapy is to reduce intra-ocular pressure by 30% by whatever mechanisms available50. medical treatment betoxolol, a selective beta adrenergic blocker, is drug of choice because of its beneficial effects on optic nerve blood flow in addition to its intra-ocular pressure lowering effects51. carteolol hydrochloride is found to be effective by inhibiting deterioration of the local visual field in eyes with normal tension glaucoma52. prostaglandin analogues, e.g. latanoprost works by increasing uveo-scleral outflow. it appears to affect ocular perfusion more favorably than timolol in patients with normal tension glaucoma53. it significantly decreases intraocular pressure throughout the day with no effect on blood pressure and pulse rate. there is 20% reduction of intra-ocular pressure from base-line in patients with normal tension glaucoma54. dorzolamide, a topical carbonic anhydrase inhibitor improves contrast sensitivity in patients with normal tension glaucoma, related to either intraocular pressure reduction or altered ocular perfusion effects55. 0.2% brimonidine eye drops – an alpha-2 adrenoceptor agonist, can induce a significant intraocular pressure decrease in eyes with normal tension glaucoma56. systemic calcium channel blockers, e.g. nifedipine, can be considered in young patients and in those with early disease. they improve blood flow in the optic nerve head by inhibiting constriction of smooth muscles in the vessels, and reduce vascular resistance in distal retro-bulbar arteries in normal tension glaucoma without affecting the more proximal blood vessels57. monitoring of systemic blood pressure for 24 hours period is advisable. if a significant nocturnal drop is detected, it may be necessary to avoid antihypertensive medications, especially if taken prior to bed time9. surgical treatment trabeculectomy in normal tension glaucoma is required, if progressive visual field loss occurs despite intra-ocular pressure being in lower teens. adjunctive anti-proliferatives in normal tension glaucoma may be required. the use of mitomycin-c is associated with a greater risk of visual field defect progression, despite a greater fall in iop. the use of adjunctive peri-operative 5-fu should maintain a suitable target intraocular pressure with preservation of visual functions, without additional complications & associated visual field deterioration as seen with adjunctive mitomycin-c58. recently there has been emphasis on the use of neuro-protective drugs that may act independently of the effect of lowering the intra-ocular pressure50. no data are yet available which can demonstrate that treatment with neuro-protective agents will indeed result in long-term preservation of visual fields59. summarizing, patients with normal tension glaucoma benefit from lowering of intra-ocular pressure. the treatment should be individualized according to the stage of disease and rate of progression. trials are on their way that will help predict risk and the rate of progression and response to treatment; and when fully known, will help in treating patients with normal tension glaucoma17. author’s affiliation dr. tariq farooq babar assistant professor khyber institute of ophthalmic medical sciences hayatabad medical complex peshawar dr. muhammad tariq khan trainee medical officer khyber institute of ophthalmic medical sciences hayatabad medical complex peshawar, pakistan dr. mir zaman senior registrar 66 khyber institute of ophthalmic medical sciences hayatabad medical complex peshawar, pakistan. prof. mohammad daud khan rector khyber institute of ophthalmic medical 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qasim university, saudi arabia abstract purpose: to see the effect of binocular vision problems on childhood academic performance and to record the teacher's perspectives about childhood eye care in khartoum state of sudan. place and duration of study: a descriptive cross-sectional study done among the school going children in the khartoum state of sudan from february to may, 2018. study design: descriptive cross sectional study. methods: three hundred and forty (340) primary school children were recruited for study by convenient sampling technique during the academic year 2018. after relevant history, ocular examination was performed. it included visual acuity measurement, assessment of refractive errors and binocular function tests. academic performance of the children was recorded from academic records of the children. finally, the qualitative data was derived from teachers’ perspectives about childhood eye care. results: mean age of the participants was 11.96 ± 1.63 years. the findings revealed that (78.6%) of children achieved poor academic performances with decompensated exophoria at near. 52.7% children with poor academic performances had weak positive fusion reserve at near p = 0.04. 37.2% of the poor performers had convergence insufficiency. forty-eight percent of females with ocular complaints achieved poor academic performances p = 0.034. with regard to teacher's perspectives about childhood eye care, 98.8%believed that the vision problems had effect on the academic record of the children. seventy percent of the teachers reported that the students did not undergo eye examinations before joining school. conclusion: convergence insufficiency and weak positive fusional reserve at near has a significant effect on academic performances. key words: convergence insufficiency, binocular vision, exophoria. how to cite this article: al-rasheed sh, elmadina aem. the effect of binocular vision problems on childhood academic performance and teachers’ perspectives. pak j ophthalmol. 2020, 36 (2): 162-167. doi: 10.36351/pjo.v36i2.896 introduction childhood vision problems are different in nature and correspondence: saif hassan al-rasheed al-neelain university, khartoum, sudan. e-mail: saif.alrasheed@yahoo.com received: september 17, 2019 accepted: february 2, 2020 severity, ranging from mild refractive errors to binocular anomalies and vision impairment. many vision problems lead to a variety of symptoms that greatly affect skills of learning. 1 the most common vision problems are uncorrected refractive errors that impair vision at distance (myopia) or at near (hypermetropia); these are often treatable with spectacles or contact lenses. other important vision problems include astigmatism, strabismus (latent or mailto:saif.alrasheed@yahoo.com saif hassan al-rasheed, et al 163 pak j ophthalmol. 2020, vol. 36 (2): 162-167 manifest), amblyopia (lazy eye), problems with binocular coordination of eye movements, and problems with the integration of visual sensory perception and the brain. these problems could be avoided with eyeglasses, medication, or vision therapy. 2-5 basch, 2011 reported that more than 20% of school going have some kind of vision problem. 6 in a nationally representative sample of more than 48,000 students under age 18, those from poor families were less likely to have diagnosed eye problems than the children living in higher income families. uncorrected refractive errors drive children into poverty by limiting their opportunities to education, and employment, and can seriously affect their quality of life and academic productivity. 7-10 in a recent study conducted by al-rasheed, et al to assess the visual impairment (vi) and refractive error (re) among sudanese school going children, revealed that the most common cause of vi was uncorrected re (57%) and amblyopia was 5.6%. 11 they reported that prevalence of exophoria at near fixation was 46.9%. in another study by hassan, et al, it was they reported that the prevalence of convergence insufficiency (ci) among secondary school-children in sudan was 7.8%. 12 phillips in 2017 13 revealed that patients with ci had symptoms during activities that required near fixation, such as reading. thus, ci was associated with reading impairment and could lead to poor academic performance. as mentioned above from the previous study, the vision problems (refractive errors, binocular anomalies and amblyopia) are more prevalent among school going children in sudan. the rates of vision problems increase with the increasing age of children. vision related problems among school going children have great effect on childhood academic performances in school or at any work achievements and have a negative influence on the future of the children the current study was conducted to assess the effect of binocular vision problems on childhood academic performance and teacher's perspectives about childhood eye care in khartoum state of sudan. methods this cross-sectional school-based study, which was conducted among school going children in khartoum state of sudan, aimed to assess the effect of binocular vision problems on childhood academic performances and teachers’ perspectives about childhood eye care. the study used a convenience sample of four public primary schools located in the centre of khartoum city (two schools for males and two schools for females). the study was performed in the academic year 2018 from february to may. before data collection the primary schools selected for the study were visited by the researchers to explain the aim of the study to the school administration, and children were given requests for informed consent of their parents to allow them to participate in the study. all the children from grade three to grade eight attending the school on days of examinations, after their parents’ signed informed consent and the children, agreed to participate were included in the study. three hundred forty school-going children fulfilled the criteria of this study. optometric research assistants graduated from the school of optometry and with experience in clinical optometry were recruited to assist in data collection. the data collector underwent training in the study protocol procedures. the principal investigator explained the procedures for gathering the clinical data from the children as well as qualitative information from 80 schoolteachers. visual acuity (va) of the participants at distance was assessed using snellen tumbling e-chart with e's of standard size from a 6-meter distance. amplitude of accommodation and near point of convergence was measured using raf rule. prism cover test was performed at 33 cm for near fixation and for 6-meter distance fixation, the subjects fixed above the line of thresholds of poor eye to assess the degree of heterophoria and heterotropia. the subjects underwent motility tests to assess the function of eye muscles; objective refraction was assessed using retinoscopy (neitz rx, japan). the positive and negative fusional reserve was measured with prism bar at 33 cm and 6 – meter for near and distance respectively. the academic performance of the children was obtained from the files that recorded the final examination of the last year. finally, the qualitative data about the knowledge of childhood eye care was collected from school teachers by a completed semi-structural questionnaire. the data was analyzed using statistical package for social science (spss version 25, armonk, ny: ibm corp usa). descriptive statistics was used to describe data. for all statistical determinations, the significance level was established at p < 0.05. binocular vision problems and childhood academic performance pak j ophthalmol. 2020, vol. 36 (2): 162-167 164 results in addition to 340 children from four schools (two male schools and two female schools), 80 school teachers were also included in this study. the sample consisted of 191 (56.0%) males and 149 (44%) females, with a mean age of 11.96 ± 1.63 years. most of the students 61.2% presented without ocular symptoms χ 2 = 656.18, p < 0.0001, 15.9% complained of blurred vision, followed by 12.0% and 5.9% of children complained of headache and ocular pain respectively. with regard to the relationship between academic performances of children and ocular complaints, majority of the students with excellent academic performance were without ocular complaints. however, only 21.0% and 13.2% of children who complained of blurred vision and headache respectively, achieved excellent academic performance. sixty-four percent children without any ocular complaints had poor academic performance χ 2 = 55.18, p < 0.0001. however, 14.5% and 9.2% of children who complained of blurring vision and headache respectively achieved poor academic performance. the spearman's rho correlation revealed very strong correlation (r = 0876, p = 0.008) between academic performance of children and ocular complaints as showed in table 1. fifty-one percent of females were free from ocular complaints, 43.3% complained of (blurred vision, ocular pain, difficulty in fixation, photophobia, tearing and itching). the relationship between academic performance of female children and ocular complaints was statistically significant χ 2 = 0.127; p = 0.034 as shown in table 2. the study found that 66.7% of the males without ocular complaints had excellent academic performances. the association between academic performance of male children and ocular complaints was not statistically significant χ 2 = 0.034; p = 0.645 as shown in table 2. the relationship between academic performances of children and vision was not statistically significant χ 2 = 0.034; p = 0.645 as shown in table 3. the relationship between academic performance of children and refractive errors was statistically not significant (χ 2 = 23.172; p = 0.335). seventy-eight percent children with poor academic performance had exophoria, followed by 8.4% having esophoria and 0.8%with tropias. the relationship between academic performances of children and ocular deviation at near was statistically significant (χ 2 = 3.578; p = 0.014) as shown in table 4. table 1: the relationship between academic performance of children and ocular complaints. symptoms academic performance of participant total n (%) excellent n (%) v good n (%) good n (%) poor n (%) normal 22 (57.9) 48 (66.6) 54 (54.5) 84 (64.1) 208 (61.2) headache 5 (13.2) 12 (16.6) 12 (12.1) 12 (9.2) 41 (12.0) blur of vision 8 (21.0) 9 (12.5) 18 (18.2) 19 (14.5) 54 (15.9) ocular pain 2 (5.3) 0 (0.0) 9 (9.1) 9 (6.9) 20 (5.9) difficult fixation 0 (0.0) 0 (0.0) 2 (2.0) 1 (0.7) 3 (0.9) photophobia 1 (2.3) 2 (2.7) 0 (0.0) 1 (0.7) 4 (1.2) tearing and itching 0 (0.0) 1 (1.3) 4 (4.0) 5 (3.8) 10 (2.0) total 38 (100) 72 (100) 99 (100) 131 (100 340 (10) χ 2 = 19.9 p = 0.008 table 2: relationship between academic performance of male and female children and ocular complaints. symptoms academic performance of female participants total n (%) excellent n (%) v good n (%) good n (%) poor n (%) normal 12 (52.0) 22 (66.7) 21 (42.0) 22 (51.2) 77 (51.7) ocular complaints 11 (48.0) 11 (33.3) 29 (58.0) 21 (48.8) 72 (48.3) total 23 (100) 33 (100) 50 (100) 43 (100) 149 (100) symptoms academic performance of male participants normal 10 (66.7) 26 (66.7) 33 (67.30) 62 (70.5) 131 (68.6) ocular complaints 5 (33.3) 13 (33.3) 16 (32.7) 26 (29.5) 60 (31.4) total 15 (100) 39 (100) 49 (100) 88 (100) 191 (100) saif hassan al-rasheed, et al 165 pak j ophthalmol. 2020, vol. 36 (2): 162-167 seventy-three percent children with excellent academic performances had normal near point of convergence (npc); however, only 26.3% of children with abnormal npc had excellent academic performance. the relationship between academic performance of children and npc was statistically not significant (χ 2 = 2.05; p = 0.562). chi square test revealed significant difference between academic performance of children and positive fusion at near (χ 2 = 5.684; p = 0.042) as shown in table 5. table 3: relationship between vision of participants and academic performance. vision academic performance of participant total n (%) excellent n (%) v good n (%) good n (%) poor n (%) normal 31 (81.6) 63 (87.5) 82 (82.0) 112 (85.5) 288 (84.7) vi 7 (18.4) 9 (12.5) 18 (18.) 19 (14.5) 52 (15.3) total 38 (100) 72 (100) 99 (100) 131 (100) 340 (100) v i= vision impairment ≤ 6/12 table 4: the effect of ocular deviation on academic performance of school going children. ocular deviation academic performance of participant total n (%) excellent n (%) v good n (%) good n (%) poor n (%) orthophoria 30 (78.9) 51 (70.8) 38 (38.4) 16 (12.2) 135 (39.7) exophoria 5 (13.2.) 17 (23.6) 55 (55.5) 103 (78.6) 180 (52.9) esophoria 3 (7.9) 4 (5.6) 5 (5.1) 11 (8.4) 23 (6.8) tropia 0 (0.0) 0 (0.0) 1 (1.0) 1 (0.8) 2 (0.6) total 38 (100) 72 (100) 99 (100) 131 (100) 340 (100) table 5: relation of positive fusional vergence and academic performance of participant. positive fusional vergence academic performance of participant total n (%) excellent n (%) v good n (%) good n (%) poor n (%) normal (30-45) 26 (68.4) 38 (52.8) 52 (52.5) 61 (47.2) 177 (52.4) abnormal (2-25) 12 (31.6) 34 (34.3) 47 (47.5) 68 (52.7) 161 (47.6) total 38 (100) 72 (100) 99 (100) 129 (100) 338 (100) table 6: teachers knowledge and practice about childhood eye care. question yes n (%) no n (%) total q1: do you the think vision problem has any effect on the academic achievement? 79 (98.8) 1 (1.3) 80 (100%) q2: are teachers attending any course for identifying childhood eye problems? 11 (13.8) 69 (86.3) 80 (100%) q3: do teachers inform the student’s guardian/parents about the childhood eye problems? 77 (96.3) 3 (3.8) 80 (100%) q4: do teachers have knowledge to identify the children with vision problem in classroom? 78 (97.5) 2 (2.5) 80 (100%) q5: whether special attention is given to the student who has vision impairment? 75 (93.8) 5 (6.3) 80 (100%) q6: do you think the size of print in the books is suitable for reading? 53 (66.3) 27 (33.8) 80 (100%) q7: do the students undergo eye examinations when joining the school? 24 (30) 56 (70) 80 (100%) q8: is there any annual comprehensive eye examination for children? 29 (36.3) 51 (63.7) 80 (100%) q9: do you think that increasing the number of home work hours causes eye strain? 57 (71.3) 23 (28.7) 80 (100%) q10: do you think that eye fatigue is increased during the examination period? 71 (88.8) 9 (11.3) 80 (100%) binocular vision problems and childhood academic performance pak j ophthalmol. 2020, vol. 36 (2): 162-167 166 discussion good vision and binocular functions are important for achieving high academic performance. in fact, many authors. 14-16 reported that children with good vision and binocular functions could perform better in learning activity. therefore, good visual functions are cornerstone for the students in all learning stages to achieve good academic performances. our results were in accordance with shin, et al who found a significant relationship between symptomatic children with binocular vision problems and their scores in every academic area (reading, mathematics, social science, and science). 17 a study conducted in singapore to assess the effect of distance visual acuity on the academic achievements of children, concluded that the distance visual acuity did not play a significant role in predicting academic school performance. 18 they concluded that most of the reading and writing activities needed good near vision and near binocular functions. our findings also endorse the results of chen, at el who concluded that children with low academic achievement were more likely to exhibit problems in ocular motor balance. 19 our results that convergence insufficiency (ci) was more common among females than males was in agreement with study by hassan, et al 12 in sudan who reported that ci was common among school going children. scheiman, et al reported that after treatment of ci statistically significant improvements were found for reading activities. 20 near activities like reading, writing and watching need good positive fusional reserve (pfr) and the children with weak pfr find difficulties in concentration for long time. there is a chance that children with poor fusional reserve may become symptomatic when attempting near task; their heterophoria may become uncontrollable and lead to heterotropia. al-rasheed et al 10 indicated that knowledge about childhood eye care was low among the community. they concluded that, there was a need for structured educational program to raise awareness about childhood eye disease and visual impairment in order to address the barriers for accessing childhood eye care in sudan. this can lead to early diagnosis and treatment of eye problems in children. as the most common cause of vision problem in children was uncorrected refractive error it can be easily corrected if discovered early. 7,9,21,22 we found in our study that most of the teachers (98.8%) were aware of the fact that vision problems had effects on the academic achievement of students, whereas only 1.3% of teachers believed that vision problems did not affect the academic performance of the students. almost 86.3% of teachers reported that they did not attend any course for identifying childhood eye problems, whereas 13.8% of school teachers were attending courses for identifying childhood eye problems. ninety-six percent of teachers had informed the students’ guardians/parents about the eye problems of the children whereas 3.8% did not. most of teachers (97.5%) reported that they had knowledge to identify children with vision impairment in classroom while 2.5% did not. there were 93.8% teachers, who provided special management to the students with poor vision. more than half (66.3%) of school teachers thought that the size of print in the books was suitable for reading, however 33.8% of teachers believed that the size of print in the books was not suitable for reading. seventy-one percent teachers had concern about the increasing numbers of homework hours, which could lead to eye strain (table 6) the limitation of our study was the sample size. further studies need to be done to include more schools from different areas. conclusion the study concluded that convergence insufficiency is the most common binocular problem among school going children and is more common in females than males. weak positive fusional reserves has a significant effect on academic performance in both genders. females are more affected by weak positive fusional reserve; the majority of cases have decompensated exophoria. acknowledgement we are grateful to the staff of the schools that helped us in the process of data collection. we extend our sincere thanks to doa ali, emtithal gamal and rowiada jadin for their help in data collection. we would also like to thank all the students and teachers who participated in 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(1): 2547. 16. scheiman m, rouse mw. optometric management of learning-related vision problems. 2 nd ed. st. louis: mosby elsevier. 2006. 17. shin hs, park sc, park cm. relationship between accommodative and vergence dysfunctions and academic achievement for primary school children. ophthic physiol optics. 2009; 29 (6): 615-624. 18. dirani m, zhang x, goh lk, young tl, lee p, saw sm. the role of vision in academic school performance. ophthalmic epidemiol. 2010; 17 (1): 1824. 19. chen ah, bleything w, lim yy. relating vision status to academic achievement among year-2 school children in malaysia. j am optom assoc. 2011; 82 (5): 267-273. 20. scheiman m, chase c, borsting e, lynn mitchell g, kulp mt, cotter sa. citt‐rs study group. effect of treatment of symptomatic convergence insufficiency on reading in children: a pilot study. clin exp optometry, 2018; 25. 21. li z, xu k, wu s, lv j, jin d, song z, et al. population‐based survey of refractive error among school‐aged children in rural northern china: the heilongjiang eye study. clin exp ophthalmol. 2014; 42 (4): 379-384. 22. mayro el, hark la, shiuey e, pond m, siam l, hill-bennett t, et al. prevalence of uncorrected refractive errors among school-age children in the school district of philadelphia. jaapos. 2018; 22 (3): 214-217. authors’ designation and contribution dr. saif hassan al-rasheed; assistant professor optometry: data collection, data analysis, manuscript writing, final review. dr. abd elaziz mohamed elmadina; assistant professor optometry: data collection, data analysis, final review. .…  …. pakistan journal of ophthalmology, 2020, vol. 36 (1): 8-12 8 original article macular hole closure with minimal or no posturing after macular hole surgery muhammad amer awan 1 , javeria muid 2 , aiman hafeez 3 1-3 department of ophthalmology, shifa international hospital, islamabad – pakistan abstract purpose: to find the success rate of idiopathic and traumatic macular hole (mh) with minimal/ no posturing after macular hole (mh) surgery. study design: interventional case series. place and duration of study: ophthalmology clinic, shifa international hospital islamabad from july 2017 to december 2018. material and methods: nineteen eyes of 19 patients with either idiopathic or traumatic mh were included in the study. all the patients with decreased vision due to any other cause or previous failed mh surgery were excluded. their preoperative swept source oct scans were done and mh was categorized according to size of mh. twenty seven gauge 3 port pars plana vitrectomy, inner limiting membrane peel and gas (hexafluoroethane) tamponade was performed in all the patients. no posturing was advised for small mh while minimal prone positioning was advised for medium and large sized mh. results: all the patients had closed mh at post-operative day 1 except one patient who showed decrease in size of hole after surgery. there was significant improvement in vision in all patients from mean preoperative visual acuity of 0.8 logarithm of minimum angle of resolution (range 0.3 to 2.0) to mean post-operative visual acuity of 0.3 logarithm of minimum angle of resolution (range 0.1 to 0.5). on an average 4 lines improvement in visual acuity occurred. conclusion: this study confirms mh closure within 24 hours on the basis of swept source oct. prone positioning does not appear to affect closure of small mh. for medium and large sized mh, minimal posturing is needed. key words: macular hole, pars plana vitrectomy, hexafluoroethane, optical coherence tomography. how to cite this article: awan ma, muid j, hafeez a. macular hole closure with minimal or no posturing after macular hole surgery, pak j ophthalmol. 2020; 36 (1): 8-12. doi: https://doi.org/10.36351/pjo.v36i1.940 introduction macular hole (mh) is a full thickness break in the neurosensory retina that involves the center of macula 1 . mhs have an incidence rate of 7.8/1000,000 and they more commonly affect elderly females 2 . most common etiological factors are idiopathic and trauma. correspondence to: muhammad amer awan consultant ophthalmologist shifa international hospital, islamabad, pakistan email: dramer_awan@yahoo.co.uk various theories have been proposed in the pathogenesis of idiopathic mh but over the past decade, it has been accepted worldwide that vitreomacular traction at the fovea is the leading cause 3 . therefore, treatment is usually surgical that is 3-ports pars plana vitrectomy with internal limiting membrane peel and gas tamponade. it has a success rate of over 90 percent 1 . five years follow up of the patients has shown that 58 percent of the patients achieve visual acuity of 20/40 or better and 77 percent of patients gain 3 or more lines of snellen visual acuity chart 4 . prone positioning is recommended by vitreoretinal surgeons after mh surhttps://doi.org/10.36351/pjo.v36i1.940 mailto:dramer_awan@yahoo.co.uk awan ma, et al 9 pakistan journal of ophthalmology, 2020, vol. 36 (1): 8-12 gery and is considered as an important factor in closure of mh 5 . yorston et al showed comparable results in posturing and non-posturing groups in a randomized controlled trial and suggested that face down posturing is not required for small and medium sized mh 6 . prone positioning can be very inconvenient for the patients because of aging, breathing problems, obesity and arthritis 4,5 . furthermore, detailed examination of the retina in the early postoperative period after mh surgery is very hard because of intraocular gas tamponade 7 . optical coherence tomography (oct) has emerged from an experimental instrument to an important non-invasive imaging tool providing us the three dimensional cross sectional view of the retina and giving us the minute details of ellipsoid zone and myoid zone 8 . intact ellipsoid zone is a prognostic factor for post-operative visual improvement 9 . tomographic images of swept source oct in early post-operative period (within 24 hours) enables us to see the mh status in gas-filled eyes, thus allowing early discontinuation of, or no necessity for, prone positioning upon confirmation of mh surgery to see the layers of retina and to debate on whether prone positioning is mandatory or not 10 . the purpose of our study was to evaluate mh closure on oct within 24 hours of surgery, at 1week and at 8 weeks and to identify the success rate of macular hole surgery with minimal/ no posturing in idiopathic and traumatic mh. material and methods the institutional review board approval for the study was taken and it was conducted in ophthalmology clinic, al-shifa international hospital islamabad. consecutive sampling technique was used that included 19 eyes of 19 patients from july 2017 to december 2018. patients with idiopathic mh and traumatic mh with or without cataract were included in the study. all the patients with decreased vision due to any other cause or previous failed mh surgery were excluded. dri oct triton, swept source oct (ss-oct), topcon was used for this study. after taking informed written consent, patients had their preoperative oct scans done and size of the base of mh was measured. patients were categorized into three groups according to the size of mh. closure of mh on oct was defined as: type 1 closure: closed mh without foveal neurosensory retinal defect. type 2 closure: closed mh with foveal neurosensory retinal defect, which shows decrease in size of base of defect as measured on oct. primary outcome measure was closure of mh as proved by oct. secondary outcome measure was visual improvement as measured by logarithm of minimum angle of resolution scale at 2 months postoperatively. twenty seven gauge 3 ports pars plana vitrectomy, internal limiting membrane peel and gas tamponade with c2f6 (hexafluoroethane) was performed in all the patients. in patients with cataract, combined phacoemulsification and vitrectomy was performed. patients were advised prone positioning if required immediately after the surgery, as shown in table 1. after which all the patients were advised not to lie on their back for 2 weeks. follow up visits were done at 1 day, 1 week, 1 month and 2 months post operatively. oct scans were done at 1 st post-operative day and then were repeated at 1 st and 8 th post-operative weeks to confirm the closure of macular hole. results there were 19 patients with female to male ratio of 12:7. mean age was 60 years that ranged between 1977 years. seventeen patients had idiopathic and 2 had traumatic mh. categories of the patients were as follows: ▪ category a (mh less than 400 μm): 6 patients. ▪ category b (mh 400-700 μm): 4 patients. ▪ category c: mh greater than 700 μm): 9 patients. table 1: prone positioning in patients according to the size of macular hole. serial no macular hole size posture duration 1. mh < 400μm no posture advised nil 2. mh 400μm – 700μm face down 4-6 hours 3. mh > 700μm face down 12 hours sixteen patients were phakic and 3 were pseudophakic. in 5 patients vitrectomy was performed and remaining 14 patients had phacoemulsification plus pars plana vitrectomy was done. there was no per macular hole closure with minimal or no posturing after macular hole surgery pakistan journal of ophthalmology, 2020, vol. 36 (1): 8-12 10 fig. 1a: swept source optical coherence tomography (oct) of the left eye that shows small stage 3 full thickness macular hole (mh). fig. 1b: swept source oct on first post-operative day that depicts closure of mh in the left eye with very good view in spite of gas bubble. fig. 1c: swept source oct of the left eye after 8 weeks that confirms closure of mh. operative complication. at first post-operative day, all the patients who had closed mh on oct, were advised to stop the prone positioning. all the idiopathic mh were closed on first postoperative day and one traumatic mh was not closed, as seen on oct. scan was further repeated at 1 and 8 weeks, as shown in figure 1a, 1b and 1c. all the patients had closed mh (table 2) except one patient who showed type 2 closure of mh with decrease in size of macular hole. later this patient had vitrectomy, ilm patch graft and c3f8 (octafluoropropane) gas tamponade that closed mh with improvement in vision from 2 to 0.5 logarithm of minimum angle of resolution. this patient was advised to do prone positioning 6 hours daily for 1 week. there was significant improvement in vision in all patients from mean preoperative visual acuity of 0.8 logarithm of minimum angle of resolution (range 0.3 to 2.0) to mean post-operative visual acuity of 0.3 logarithm of minimum angle of resolution (range 0.1 to 0.5). the limitation of this study is the small sample size. further research can be planned by comparing the results of prone posturing versus non-prone posturing and large sample size. table 2: postoperative closure of macular hole at post op day 1, week 1 and week 8. s. no macular hole size category type of mh no. of patients macular hole on pod 1 macular hole on pod 8 macular hole after 8 weeks 1. mh < 400 μm a idiopathic 5 closed closed closed 2. mh 400μm – 700μm b idiopathic and traumatic 5 closed closed closed 3. mh > 700μm c idiopathic 8 closed closed closed 4. mh > 700μm c traumatic 1 flat hole flat hole flat hole (type ii closure) 883µm to 312µm closed after further surgery mh: macular hole; pod: postoperative day discussion in this study, the primary mh closure rate is 95 percent, which is comparable to international results. however, the final closure rate is 100 percent and the study also shows significant improvement in visual acuity which is an average of 4 lines on snellen’s chart. it is better than the previously reported international studies. ss-oct also confirmed the closure of mh on the first post-operative day in 18 eyes that led to no further prone positioning. these facts clearly a b c awan ma, et al 11 pakistan journal of ophthalmology, 2020, vol. 36 (1): 8-12 show that prone positioning is probably not an important factor in determining the favorable outcome. it explains that prone positioning is not required for mh less than 400µm and minimal positioning is required for medium and large mh. previous studies have shown mixed results. some of them reported better outcome with prone positioning while others revealed no difference in overall results in prone positioning group versus non-supine positioning group. one possible explanation for this can be that the patients might not be following the prone positioning instructions properly as it is difficult for them to do it because of obesity, asthma or other health issues. in a recent study, mh closure rates were 95.5% and 96.4% in the prone posturing group as compared to non-supine posturing group, respectively. median visual acuity at 6 months post operatively was 69 early treatment diabetic retinopathy study (etdrs) letters in both the groups (p = 0.64) 11 . however, a meta analysis showed that prone posturing after mh surgery does improve the overall mh closure rate. combining cataract surgery with vitrectomy does not affect the closure rate 2 . another survey of american society of retina specialists has revealed that 95 percent of retinal surgeons still advise prone positioning in the treatment of mhs 7,8 . the prognosis of idiopathic mh is predictable by seeing the details of layers of central retina on oct, size of macular hole and its duration. closure of these types of mh as well as visual upgradation can be foreseen preoperatively but for traumatic macular holes the prognosis is variable. some have shown significant improvement and spontaneous closure while others may show incomplete closure with little betterment when surgery is performed after 3 months of trauma 12 . it certainly depends upon the duration and structures of inner retina. lindtjørn et al strongly proposed that non-supine positioning provided excellent closure of idiopathic macular holes. he also suggested that complete gasfoveal contact without minor interruptions was not necessary for macular hole closure 13 . contrary to that another researcher suggested that degree of gas fill had considerable effect on the results of hole closure 14 . recently, ss-oct enables tomographic images of mh in gas-filled eyes immediately postoperatively, thus permitting early discontinuation of face-down positioning upon confirmation of mh closure 15 . however, a meta-analysis of 181 records with 726 cases had shown that face down posturing was more effective in macular hole closure when compared with the non-posturing cases, especially in patients with mh larger than 400 μm 2 . there are multiple factors, which affect closure of macular hole after surgery. one is the gas tamponade for which some authors have suggested additional gas injection in case of non-closure at first attempt 16 . in addition to that emi morimoto showed that 50% of the patients are non-compliant regarding face down posturing 17 . some studies have indicated the non-supine posturing was equally good for macular hole closure 18 . to increase patient compliance issues, nadal j presented the idea of isolating macula with a large long lasting gas, which can help macular closure without posturing 19 . to increase the patient compliance, another researcher suggested a regimen of ilm peel, 20% c2f6 with a one night prone posturing 20 . with advancement in oct technology, ss-oct is a wonderful tool to assess mh closure or macular attachment within few hours after surgery in a gas/oil filled eyes. this study clearly shows the benefit of swept source oct in assessing earlier closure of mh after surgery and justifying no need for extensive prone positioning. however, ss-oct is relatively difficult to perform in gas-filled eyes and experienced personnel is required for this purpose to adjust the focusing. conclusion prone positioning does not affect the rate of closure of mh with size less than 400μm. for medium and large sized mh, posturing can be stopped within 24 hours of surgery after confirming hole closure on swept source oct. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest authors’ designation and contribution muhammad amer awan; consultant ophthalmologist: study design, data analysis, manuscript writing, final review. macular hole closure with minimal or no posturing after macular hole surgery pakistan journal of ophthalmology, 2020, vol. 36 (1): 8-12 12 javeria muid; medical officer: data analysis, manuscript writing, final review. aiman hafeez; optometrist: data collection, final review. references 1. kang sw, ahn k, ham di. types of macular hole closure and their clinical implications. br j ophthalmol. 2003; 87 (8): 1015-9. 2. xia s, zhao xy, wang eq, chen yx. comparison of face-down posturing with nonsupine posturing after macular hole surgery: a meta-analysis. bmc ophthalmol. 2019; 19 (1): 34. 3. hu z, xie p, ding y, zheng x, yuan d, liu q. face‐down or no face‐down posturing following macular hole surgery: a meta‐analysis. acta ophthalmol. 2016; 94 (4): 326-33. 4. patel s, sternberg jr p. face-down positioning following macular hole surgery: pros and cons. j vitreoretin dis. 2017; 1: 331-3. doi: https://doi.org/10.1177/2474126417715368 5. shimada y, seno y, mizuguchi t, tanikawa a, horiguchiet m. patient adherence to the face-down positioning after macular hole surgery. clin ophthalmol. 2017; 11: 1099. 6. yorston d, siddiqui ma, awan ma, walker s, bunce c, bainbridge jw. pilot randomised controlled trial of face-down posturing following phacovitrectomy for macular hole. eye, 2012; 26 (2): 267. 7. jumper jm, gallemore rp, toth ca. features of macular hole closure in the early postoperative period using optical coherence tomography. retina 2000; 20 (3): 232-7. 8. ehlers jp, goshe j, dupps wj, kaiser pk, singh rp, gans r, eisengart j, et al. determination of feasibility and utility of microscope-integrated optical coherence tomography during ophthalmic surgery: the discover study rescan results. jama ophthalmol. 2015; 133 (10): 1124-32. 9. kothari n, tran kd, read sp, berrocal am. optical coherence tomography imaging after surgical closure of pediatric traumatic macular holes optical coherence tomography imaging after surgical closure of pediatric traumatic macular holes. j vitreoretin dis. 2018; 2: 104-6. doi: https://doi.org/10.1177/2474126417749320 10. ehlers jp, uchida a, srivastava sk, hu m. predictive model for macular hole closure speed: insights from intraoperative optical coherence tomography. transl vis sci technol. 2019; 8 (1): 18. 11. alberti m, la cour m. face-down positioning versus non-supine positioning in macular hole surgery. br j ophthalmol. 2015; 99 (2): 236-9. 12. miller jb, yonekawa y, eliott d, kim ik, kim la, loewenstein ji, et al. long-term follow-up and outcomes in traumatic macular holes. am j ophthalmol. 2015; 160: 1255-8.e1. 13. lindtjorn b, krohn j, austeng d, fossen k, varhaug p, basit s, et al. nonsupine positioning after macular hole surgery: a prospective multicenter study. ophthalmol retina. 2019; 3 (5): 388-92. 14. alberti m, la cour m. nonsupine positioning in macular hole surgery. retina 2016; 36 (11): 2072-9. 15. kikushima w, imai a, toriyama y, hirano t, murata t, ishibashi t. dynamics of macular hole closure in gas-filled eyes within 24 h of surgery observed with swept source optical coherence tomography. ophthalmic res. 2015; 53 (1): 48-54. 16. iwase t, sugiyama k. additional gas injection after failed macular hole surgery with internal limiting membrane peeling. clin exp ophthalmol. 2007; 35 (3): 214–9. 17. morimoto e, shimada y, sugimoto m, mizuguchi t, tanikawa a, horiguchi m. adherence to face-down and non-supine positioning after macular hole surgery. bmc ophthalmol. 2018; 18 (1): 322. 18. forsaa va, raeder s, hashemi lt, krohn j. shortterm postoperative non-supine positioning versus strict face-down positioning in macular hole surgery. acta ophthalmol. 2013; 91 (6): 547-51. 19. nadal j, delas b, pinero a. vitrectomy without facedown posturing for idiopathic macular holes. retina. 2012; 32 (5): 918-21. 20. malik a, dooley i, mahmood u. single night postoperative prone posturing in idiopathic macular hole surgery. eur j ophthalmol. 2012; 22 (3): 456-60. .…  …. https://doi.org/10.1177%2f2474126417715368 https://doi.org/10.1177%2f2474126417749320 15 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology original article prophylaxis of macular edema with peroperative intravitreal bevacizumab in patients with diabetic retinopathy undergoing phacoemulsification sidra jabeen, rizwan khan, ali raza pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. sidra jabeen fcps, ophthalmology department, holy family hospital, rawalpindi email: sidrajabeen16@gmail.com …..……………………….. purpose: to determine frequency of post-operative macular edema in patients with diabetic retinopathy receiving peroperative intravitreal bevacizumab, as compared to controls after phacoemulsification cataract surgery. study design: randomized control trial. place and duration of study: ophthalmology department holy family hospital rawalpindi from july, 2016 to january, 2017. materials and methods: 60 patients who reported at the health care facility with diabetic retinopathy were included in the study. out of these 30 were kept as control and 30 as cases. data was collected and entered into spss version 19.0. numerical variables were accounted for as mean and standard deviation whereas qualitative variables were accounted for as frequency and percentages. to compare the occurrence of macular edema at completion of 6 weeks in both study groups, pearson’s chi-square test at 5% level of significance was applied. a pvalue of 0.05 was considered as statistically significant. to control effect modifier by gender, and age, stratified analysis was also executed. results: the participants of the study had mean age of 61.97 ± 5.7 years. out of the 60 patients 33 (55%) were female. analysis of both groups showed that macular edema was found in 4 (13.33%) patients in control group and 17 (56.67%) patients in group b. most significant macular edema was seen in 11 patients in age group of 61-70 years. gender wise stratification showed that 9 (56.5%) female patients reported with macular edema. conclusion: peroperative intravitreal bevacizumab is effective in prophylaxis of macular edema in patients with mild to moderate npdr, as compared to controls, keywords: npdr, intravitreal bevacizumab, diabetic retinopathy, macular edema, phacemulsification surgery. acular edema (me) is defined as abnormal thickening of the macula due to excessive accumulation of fluid in extracellular spaces of central retina.1 it is a leading cause of irreversible vision loss, in the ocular conditions such as diabetic retinopathy, venous occlusion, uveitis, after cataract surgery, ocular inflammations, and branch retinal vein occlusion2. diabetic macular edema (dme) is a noteworthy reason for loss of central vision in diabetic patients. post cataract surgery visual outcomes can be negatively affected by diabetic maculopathy3. m prophylaxis of macular edema with peroperative intravitreal bevacizumab in patients with diabetic pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 16 it has been proposed that among diabetic patients undergoing uncomplicated cataract surgery 22% develop an increment of > 30% in central macular thickness as quantified by optical coherence tomography (oct)3. another study showed an increment of maximum macular thickness of at least 11% was found in 25.7% of the diabetic retinopathy (dr) eyes undergoing cataract surgery, but no such increase occurred in the non-diabetic retinopathy control eyes4. increase in vascular permeability because of diabetes mellitus brings about extravasation of plasma constituents into the retina prompting dme; vascular endothelial growth factor (vegf) is documented to be basic underlying pathogenic factor for development and progression of macular edema auxiliary to diabetes5. vegf is produced by normal retinal pigment epithelial cells under hypoxic stress. eyes with substantial spillage from retinal microvasculature leading to thickening of macula have altogether higher vegf levels when contrasted with eyes with less spillage. subsequently, anti vegf agents are reflected as an adjunctive treatment for dme5. anti vegf therapy can lead to decreased leakage from blood vessels6 bevacizumab is a full-length monoclonal humanized antibody that binds and blocks all isoforms of the vegf-a family. food and drug administration (fda) has approved its use in the management of colorectal carcinoma5. currently its use in ophthalmology is off-label. numerous studies have suggested the prophylactic use of either anti vegf or steroids as an intravitreal injection after phacoemulsification in patients with diabetic exudative maculopathy to improve the final surgical outcomes in terms of visual acuity and to keep the increase in thickness of macula3. the objective of the study was to determine frequency of macular edema in patients of mild to moderate non-proliferative diabetic retinopathy (npdr) receiving peroperative intravitreal bevacizumab, as compared to controls, at completion of 1month after phacoemulsification cataract surgery. to assess the efficacy of bevacizumab given through intravitreal injection at the conclusion of standard surgery for cataract extraction on the development of diabetic retinopathy (dr) and diabetic maculopathy postoperatively. participants were randomized to an institutionalized strategy of cataract surgery along with intraocular monofocal lens implantation alone (control group; 30 eyes) or to get an intravitreal injection of 1.25mgbevacizumab towards the finish of cataract extraction procedure (ivb group; 27 eyes). visual acuity with and without correction, optical coherence tomography (oct), and dilated fundoscopic examination were the viablility measures checked monthly postoperatively for a total 6-months follow-up period. there was no noteworthy contrast in central macular thickness (cmt), bcva, or foundational condition between the control and ivb bunches at gauge. progression of diabetic retinopathy was documented in 15 among 30 eyes (50%) in the control group and 2 among 27 eyes (7.4%) in the intervention group (p = 0.0008). 1.25 mg bevacizumab injection given through intravitreal route on conclusion of cataract surgery was established to be efficient in keeping the progression of dr and diabetic maculopathy in patients with dr undergoing cataract surgery7. this study is used as reference study to calculate sample size. a study published in korean journal of ophthalmology in 2011 showed that 18% of the diabetic patients undergoing cataract develop macular edema, with the highest incidence at the conclusion of 1 month after cataract surgery8, therefore outcome was measured at 1 month post-operatively. rationale of our study was to determine effectiveness of preoperative intravitreal bevacizumab in prophylaxis of macular edema in patients with mild to moderate diabetic retinopathy undergoing phacoemulsification so as to improve the visual outcomes. this study has not been previously done in pakistani population. material and methods a randomized control trial study was carried out to highlight that the peroperative intravitreal bevacizumab is effective in prophylaxis of macular edema in patients with mild to moderate npdr, when compared to controls. study population included patients who reported at hospital with cataract and diabetic retinopathy. sample size for the study was taken by non-probability, consecutive sampling form a total of 60 participants divided into two groups, the allocation was done through simple random sampling technique by formulating a list of randomly allocated 60 numbers in random number list generated through spss, 30 to group a or study group and 30 to control group (b).the study was carried out for a period of 6 months (20th july 2016 to 19th january 2017). sidra jabeen, et al 17 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology for the procedure all participants were randomly allocated in a 1:1 ratio to either have an injection of bevacizumab (1.25 mg in 0.05 ml) through intravitreal route on the conclusion of surgery (study group) or not (control group). a thorough ocular examination and oct was done 1 week prior to the surgery and then 1 month post surgery by the same researcher in all cases. the researcher was not aware of the allocation of the patients to the study groups. the standard ocular examination at each visit comprised of slit lamp examination, uncorrected and best corrected visual acuity, and quantification of the central macular thickness with oct as an average of three consecutive measurements. patients underwent standard cataract surgery (phacoemulsification and monofocal intraocular lens (iol) implantation). one surgeon performed all the surgeries and intravitreal injections. postoperatively all patients were prescribed moxifloxacin-dexamethasone eye drops two hourly for two weeks followed by tapering over 1 month. every patient was followed-up and was reassessed at completion of 1 month after baseline and occurrence of macular edema based on central macular thickness was the outcome variable. results of the collected data were entered into spss version 22.0. numerical variables were described as mean and standard deviation. while qualitative variables that included the macular edema, the diabetic maculopathy, central macular thickness and side of eye were reported in the form of frequency and percentages. results sample was calculated from a total of 60 patients. mean age of the study participants was reported as 61.97 ± 5.70 years. out of the 60 participants 33 (55.0%) were females while female to male ratio was 1.2:1. macular edema was seen in 04 (13.33%) patients in study group and 17 (56.67%) patients in control group. sample selected showed that 02 (12.50%) patients reported with right eye macular and 02 (14.29%) noticed with left eye in group a while in group b for the right eye macular edema was reported in 08 (53.33%) of patients and 09 (60.0%) reported with left eye. the gender wise sample collection of patients is described in the pie chart given below (fig. 1). fig. 1: gender wise distribution of the patients. the central macular thickness in group a was 233.23 ± 30.16 µm and in group b was 253.21 ± 22.34 µm. macular edema was seen in 04 (13.33%) patients in study group and 17 (56.67%) patients in control group (p-value = 0.0001).distribution of patients according to side of eye is shown in figure 2 below. fig. 2: distribution of patients according to side of eye. stratification of macular edema with respect to age groups showed significant difference in macular edema in all age groups among both groups. similarly, statistically significant difference was found in macular edema in female among both groups. stratification of macular edema with respect to side of eye has shown in table 1 below. table 1: stratification of macular edema according to side of eye. side of eye group a (n = 30) group b (n = 30) p-value macular edema macular edema yes no yes no left 02 (14.29%) 12 (85.71%) 09 (60.0%) 06 (40.0%) 0.0001 right 02 (12.50%) 14 (87.50%) 08 (53.33%) 07 (46.67%) 0.015 as the details of macular edema found in both groups are graphically shown in figure 3 below. fig. 3: distribution of patients according to macular edema in both groups. discussion diabetic maculopathy is a foremost cause of loss of visual acuity in diabetic population9. it is well-known fact that outcomes of cataract surgery in terms of visual acuity can be negatively affected by dme.10it was suggested by some authors that any clear evidence is lacking to show that phacoemulsification cataract surgery causes advancement of dme, specifically in low-risk population; i-e, those with mild diabetic retinopathy or with controlled retinal disease. however, it was established by kim et al11 that 22% of the diabetic patients undergoing uncomplicated phacoemulsification show > 30% increase in central retinal thickness as quantified by optical coherence prophylaxis of macular edema with peroperative intravitreal bevacizumab in patients with diabetic pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 18 tomography (oct). numerous studies have proposed the prophylactic use of intravitreal injection of either bevacizumab or steroids in patients with dme that are undergoing phacoemulsification to improve the final anatomical and physiological outcome of intervention in terms of retinal thickness and visual acuity.12-15 i have conducted this study to determine frequency of macular edema in patients of mild to moderate nonproliferative diabetic retinopathy (npdr) receiving peroperative intravitreal bevacizumab, as compared to controls, at completion of 1 month after phacoemulsification cataract surgery. age range in this study was from 50 to 70 years with mean age of 61.97 ± 5.70 years. the participants in group a (study group) had a mean age of 61.60 ± 5.75 years while that of participants in group b was 62.33 ± 5.71 years. majority of the patients 38 (63.33%) were between 61 to 70 years of age. out of 60 patients 33 (55.0%) were females and 27 (45.0%) were males with female to male ratio of 1.2:1. macular edema was seen in 04 (13.33%) patients in study group and17 (56.67%) patients in control group (p-value = 0.0001). the purpose of this study was to assess adequacy of bevacizumab given as an intravitreal injection at the conclusion of cataract surgery on the postoperative outcomes of surgery in terms of diabetic retinal changes. for this purpose all the participants were randomly allocated in a 1:1 ratio to either have an intravitreal injection of bevacizumab (1.25 mg in 0.05 ml) at the completion of surgery (study group) or not (control group). visual acuity with and without correction, optical coherence tomography (oct), and dilated fundoscopic examination were the efficacy parameters checked monthly for a 6 months postintervention follow-up period. noteworthy contrast was not seen in central macular thickness (cmt), bcva, or foundational condition between the control and ivb groups at baseline. progresson of diabetic retinopathy was documented in 15 among 30 eyes (50%) in the control group and 2 among 27 eyes (7.4%) in the intervention group (p = 0.0008). in a study16, 42 patients with diabetic macular edema were randomly allocated to either phacoemulsification only or combined with intravitreal injection of bevacizumab. macular thickness (mt) as quantified by optical coherence tomography was 3˃00μm in all patients. the eyes with pdr or those that had received laser treatment at least 1 year before surgery were excluded. reassessment of cmt at first and third month after surgery, demonstrated a substantial decrease in the intravitreal bevacizumab group in comparison to no bevacizumab group in which it increased significantly. likewise bevacizumab group showed significantly higher improvement in va as compared to the control group; which was correlated to be due to the reduction in mt in the bevacizumab group16. cheema and colleagues17investigated as to whether intravitreal bevacizumab injection with cataract surgery prevents postoperative diabetic macular edema (pme) in patients with stable dr with no notable me. eighty patients each with visually significant lenticular opacity, steady preproliferative dr, and no substantial me were randomized to a sham group (cataract surgery only), or a study group undergoing cataract surgery with bevacizumab injection at the end of procedure. best-corrected visual acuities, central subfield foveal thickness, and macular volume were measured by means of optical coherence tomography at baseline and then 1 week, 1, 3, and 6 months postoperatively. clinically significant postoperative macular edema (pme) was defined as >60μm increase in central subfield thickness as compared to baseline. there was no significant difference in measured parameters at baseline. the sham group showed significantly larger increment in central subfield thickness at 1 week and 1 month postoperatively as compared to baseline, larger increases in total macular volume at all follow ups, greater development of pme at 1 month follow up, and poorer best-corrected visual acuities outcome from baseline to 6 months post intervention. it was concluded from the study that, intravitreal injection of bevacizumab given at the time of surgery in patients with stable dr without significant me, undergoing cataract surgery might be effective in preventing the postoperative worsening of me and it might improve the concluding visual outcome of cataract surgery17. in another study18, participants were randomly allocated to a control group undergoing standard procedure of cataract extraction followed by intraocular lens implantation alone or intervention group to get an intravitreal injection of standard dose of bevacizumab on the conclusion of cataract surgery. patients were monitored postoperatively up to a duration of 6 months specifically for development and progression of any retinal and macular changes attributed to diabetes. in total sixty-eight eyes were enrolled in the study. diabetic retinal changes progressed in 15 (45.45%) among 33 eyes in the cataract surgery only group and 4 (11.42%) among 35 eyes in the cataract surgery plus bevacizumab group sidra jabeen, et al 19 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology (p = 0.002). 17 eyes (51.51%) in the control group showed progression of maculopathy as compared to only 2 eyes (5.71%) in the intervention group (p = 0.0001). but visual acuities did not show any significant contrast between the 2 groups postoperatively (p = 0.772); however, two eyes in the control group progressed to neovascular glaucoma as compared to none in intervention group. no significant difference was seen between the mean postoperative central macular thickness and mean macular thickness between the 2 groups (p = 0.874 and 0.942, respectively)18. an interventional, randomized, open-label and control study19 of two parallel groups of already diagnosed patients with pre-proliferative diabetic retinopathy without macular edema was done. the study included sixty eyes of sixty patients, having non-proliferative diabetic retinopathy without macular edema and lens opacity (grade 1 to 3). one group (n = 30) received intra-vitreal injection of bevacizumab and the control group (n = 30) did not received intra-vitreal injection of bevacizumab during standard phacoemulsification. best-corrected visual acuity (bcva) on the conclusion of two months compared with the baseline visual acuity recorded along with central macular thickness (cmt) measured on optical coherence tomography (oct) was the key outcome measured. the mean age of the patients was also similar in the control (55.2 ± 9.66 years) and bevacizumab groups (56.47 ± 9.13 years) ranging from 40 to 75 years. all of the patients in bevacizumab group had visual acuity of 6/6postoperatively except one eye (3.33%) had 6/12 due to csme that was evident on oct as increase in macular thickness. while in control group 10 (33.33 %) eyes out of 30 had bcva of 6/12 or less (evident on oct as increase in macular thickness)19. another study carried out by lanzagorta et al12 has shown improvement in the vision and decrease in the retinal thickness in the bevacizumab group in contrast to control group. mason et al20 described noticeable improvement of visual acuity in 2 patients with persistent cme which has been effectively treated with bevacizumab. on the whole, it was concluded that peroperative intravitreal bevacizumab is effective in prophylaxis of macular edema in patients with mild to moderate npdr, as compared to controls, at completion of 1 month after phacoemulsification cataract surgery. conclusion the study concludes that the peroperative intravitreal bevacizumab is effective in prophylaxis of macular edema in patients with mild to moderate npdr, as compared to controls, at completion of 1 month after phacoemulsification cataract surgery. so, we recommend that peroperative intravitreal bevacizumab should be used as a prophylaxis of macular edema in patients with mild to moderate npdr after phacoemulsification cataract surgery. author’s affiliation dr. sidra jabeen f cps, ohthalmology department holy family hospital, rawalpindi dr. rizwan khan fcps, senior registrar, ophthalmology department holy family hospital, rawalpindi dr. ali raza mcps, fcps, professor, ophthalmology department holy family hospital role of authors dr. sidra jabeen corresponding author, planning of research including data collection, collection methods, setting, collection of data, drafting. dr. rizwan khan all surgical interventions done, analaysis and interpretation of data. dr. ali raza critical revision of all work, supervisor of research project. references 1. qazi ha. intravitreal administration of 1.25 mg bevacizumab at the time of cataract surgery was safe and effective in preventing the progression of dr and diabetic maculopathy in patients with cataract and dr. j res med sci. 2012; 17: 1180–1187. 2. chae jb, joe sg, yang sj, lee jy, sung kr, kim jy, kim jg, yoon yh. effect of combined cataract surgery and ranibizumab injection in postoperative macular edema in nonproliferative diabetic retinopathy. retina, 2014; 34: 149-56. 3. brito pn, rosas vm, coentrão lm, carneiro âv, rocha-sousa a, brandão e, falcão-reis f, falcão ma. evaluation of visual acuity, macular status, and subfoveal choroidal thickness changes after cataract prophylaxis of macular edema with peroperative intravitreal bevacizumab in patients with diabetic pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 20 surgery in eyes with diabetic retinopathy. retina, 2015; 35: 294-302. 4. ateeq a, tahir ma, cheema a, dahri a, tareen s. intravitreal injection of bevacizumab in diabetic macular edema. pak j med sci. 2014; 30: 1383-7. 5. salehi a, beni an, razmjoo h, beni zn. phacoemulcification with intravitreal bevacizumab injection in patients with cataract and coexisting diabetic retinopathy: prospective randomized study. j ocul pharmacol ther. 2012; 28: 212-8. 6. bonnin s, dupas b, lavia c, erginay a, dhundass m, couturier a, gaudric a, tadayoni r. antivascular endothelial growth factor therapy can improve diabetic retinopathy score without changes in retinal perfusion. retina. 2019 mar; 39(3): 426-434. 7. kwon si, hwang dj, seo jy, park iw. evaluation of changes of macular thickness in diabetic retinopathy after cataract surgery. korean j ophthalmol. 2011; 25 (4): 238-42. 8. moss se, klein r, klein bek. the incidence of vision loss in a diabetic population. ophthalmol. 1998; 95 (10): 1340–1348. 9. nelson l, martidis a. managing cystoid macular edema after cataract surgery. curr opin ophthalmol. 2003; 14 (1): 39–43. 10. shah aa, chen sh. cataract surgery and diabetes. curr opin ophthalmol. 2010; 21 (1): 4–9. 11. kim sj, equi r, bressler nm. analysis of macular edema after cataract surgery in patients with diabetes using optical coherence tomography. ophthalmol. 2007; 114 (5): 881–889. 12. lanzagorta-aresti a, palacios-pozo e, menezo rozalen jl, navea-tejerina a. prevention of vision loss after cataract surgery in diabetic macular edema with intravitreal bevacizumab: a pilot study. retina, 2009; 29 (4): 530–535. 13. takamura y, kubo e, akagi y. analysis of the effect of intravitreal bevacizumab injection on diabetic macular edema after cataract surgery. ophthalmol. 2009; 116 (6): 1151–1157. 14. akinci a, muftuoglu o, altınsoy a, ozkılıc e. phacoemulsification with intravitreal bevacizumab and triamcinolone acetonide injection in diabetic patients with clinically significant macular edema and cataract. retina, 2010; 31 (4): 755–758. 15. elman mj, aiello lp, beck rw, bressler nm, bressler sb, edwards ar, et al. randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. ophthalmology, 2010 jun. 117 (6): 1064-1077.e35. 16. ahmed m, nawaz m, javed ea, sultan m. efficacy of intra-vitreal bevacizumab combined with phacoemulsification in the prophylaxis of macular edema in patients with non-proliferative diabetic retinopathy. apmc. 2016; 10 (2): 58-62. 17. cheema ra, al-mubarak mm, amin ym, cheema ma. role of combined cataract surgery and intravitreal bevacizumab injection in preventing progression of diabetic retinopathy: prospective randomized study. j cataract refract surg. 2009; 35: 18–25. 18. klein r. the diabetes control and complications trial. kertes c, ed. clinical trials in ophthalmology: a summary and practice guide, 1998: 49-70. 19. akduman l, olk rj. the early treatment for diabetic retinopathy study. kertes c, ed. clinical trials in ophthalmology: a summary and practice guide, 1998: 15-36. 20. mason jo, albert ma, vail r. intravitreal bevacizumab (avastin) for refractory pseudophakic cystoid macular edema. retina, 2006; 26: 356–7. pak j ophthalmol. 2020, vol. 36 (2): 96-102 96 original article comparison of high intensity accelerated corneal cross linking protocols in treatment of progressive keratoconus bushra akbar 1 , imran basit 2 , amjad akram 3 , maham zahid 4 1,2 armed forces institute of ophthalmology, rawalpindi. 3 combined military hospital (cmh), kharian 4 national university of medical sciences (nums), rawalpindi – pakistan abstract purpose: to compare the safety and efficacy of accelerated corneal cross linking (axl) protocols, 9 mw/cm 2 for 10 min with 18 mw/cm 2 for 5 min in terms of refractive and topographic keratometric indices in patients with progressive keratoconus. study design: quasi experimental study. place and duration of study: armed forces institute of ophthalmology, rawalpindi pakistan, from nov 2016 to jun 2018. methods: sixty eyes, 30 in each group, of 55 consecutive patients diagnosed with progressive keratoconus were enrolled through convenience sampling and were subjected to axl with irradiance protocols of 18 mwatt/cm 2 for 5 minutes in group 1 and 9 mw/cm 2 for 10 minutes in group 2. all patients underwent a comprehensive ophthalmic examination at baseline and postoperative follow up visits at 3, 6, 12 and 18 months. primary outcome parameter was disease stability defined as increase in maximum keratometry over baseline k max of no more than 1 diopter at 1 year after axl. statistical analysis of data was performed with ibm spss software (version 20.0 spss). p value of < 0.05 was considered as statistically significant. results: disease stability was 96 % in each group. at the final time point of 18 months, group 2 (axl 9 mm watt/cm 2 for 10 min) was superior as compared to group 1 (axl 18 mm watt/cm 2 for 5 min) in terms of flattening of steep and sim k (p = 0.007, 0.023 respectively). conclusion: the two axl protocols are safe and appear to show comparable efficacy in disease stability. they can be used alternatively in the treatment of progressive keratoconus. key words: corneal cross linking, keratoconus, ultraviolet a, accelerated corneal cross linking. how to cite this article: akbar b, basit i, akram a, zahid m. comparison of high intensity accelerated corneal cross linking protocols in treatment of progressive keratoconus. pak j ophthalmol. 2020, 36 (2): 96-102. doi: 10.36351/pjo.v36i2.976 introduction high intensity accelerated corneal collagen cross correspondence: bushra akbar armed forces institute of ophthalmology, rawalpindi– email:dr.bushra.akbar@gmail.com received: january 2, 2020 accepted: march 5, 2020 linking protocols (axl) with optimized beam profiles have been new options in treatment armamentarium of progressive keratoconus. axl protocols are in accordance with bunsen-roscoe law of chemical reciprocity that states “same photochemical effect can be achieved by reducing the irradiation interval, provided that the total energy level is kept constant by a corresponding increase in irradiation intensity.” 1 mailto:dr.bushra.akbar@gmail.com bushra akbar, et al 97 pak j ophthalmol. 2020, vol. 36 (2): 96-102 the classical cxl dresden protocol included debridement of the corneal epithelium in the central 7 to 9 mm area and a pre-soak of 30-minute, with riboflavin-5-phosphate and 20% dextran. it was followed by uva irradiance of 3 mw/cm2 (365nm, total energy 5.4j/cm 2 ) for 30 minutes. 2 axl protocols incorporated a fraction of time of dresden protocol, with a proportionate increase in irradiation intensity in order to achieve total energy levels of 5.4 j/cm 2 equivalent to that proposed by dresden classical protocol i.e.9 mw/cm 2 for 10 minutes, 18m w/cm 2 for 5 minutes and 30m w/cm 2 for 3 minutes. 3 the reduced surgical time of axl confers the benefit of increased patient and surgeon comfort, minimal corneal dehydration and a decreased risk of postoperative infection owing to less exposure of denuded corneal epithelium. 4 the same photochemical effect or photoactivated corneal covalent intra and interlamellar stromal cross linking achieved by axl and conventional protocols promise comparable efficacy in terms of disease stabilization and a relative improvement in topographic keratometric indices and refractive profiles by augmenting the biomechanical strength of cornea. 3-5 previous comparative clinical trials conducted with variable beam profiles, with different riboflavin solutions, in different populations have claimed safety and comparable efficacy of conventional protocol vs. axl algorithms. 5-9 we aimed to directly compare the safety and efficacy of axl protocols, 9 mw/cm 2 for 10 minutes with 18 mw/cm 2 for 5 minutes in terms of refractive and topographic keratometric indices, in patients with progressive keratoconus. methods this study was conducted at armed forces institute of ophthalmology, rawalpindi pakistan, from nov 2016 to jun 2018 after approval from hospital ethical committee and, in accordance with tenets of declaration of helsinki. sixty eyes of 55 consecutive patients diagnosed with progressive keratoconus were enrolled in this study after obtaining an informed written consent. thirty eyes, each were randomized to axl with irradiance protocols of 18 mwatt/cm 2 for 5 minutes in group 1 and 9 mwatt/cm 2 for 10 minutes in group 2. inclusion criteria were; clear cornea, age between 18 to 40 years, documented evidence or reported progression with reduced visual acuity by more than 0.50 snellen lines, an increase in the spherical/cylinder refraction of more than 0.50 d, an increase in the maximum keratometry reading of more than 1 d and a reduction in cct of more than 10 µm over the previous 12 months; documented on a minimum of 2 corneal topographies over a period of 6 months. any active or previous ocular infections, corneal opacities, dry eyes, corneal pachymetry of less than 400 microns at thinnest point, previous cxl treatment or any ocular surgery, active autoimmune disorders, pregnancy and lactation were excluded from the study. all patients underwent a comprehensive ophthalmic examination at baseline and postoperative follow up visits at 3, 6, 12 and 18 months, which included udva (uncorrected distance visual acuity), cdva (corrected distance visual acuity) (snellen visual acuity converted to log mar notation), slit lamp biomicroscopy, dual scheimpflug corneal topography (galilie g4), pachymetry (galilie g4), specular microscopy (topcon sp-3000, usa) for endothelial cell density analysis and dilated fundus examination. rigid gas permeable contact lenses were discontinued for three weeks and soft contact lens for at least two weeks prior to baseline evaluation. axl was performed under topical anaesthesia 0.05% proparacaine hydrochloride (alkaine), in both groups as a day care procedure. standard preoperative preparation with 5% povidine iodine solution was done. central 9 mm of epithelium was scraped off, followed by instillation of one drop of isotonic riboflavin (0.1% riboflavin (vit b2), hpmc 1.1% (peschke m, peschke trade gmbh) every 2 minutes for 20 minutes. cornea with pachymetry of less than 400 microns after epithelium removal and isotonic riboflavin instillation were treated with hypotonic riboflavin drops peschke h (peschke trade gmbh) one drop every 5 seconds till it reached 400 microns. cornea was exposed to uva light of 366-370 microns at a distance of 55 mm from the eye at an irradiance of 18 mw/cm 2 for 5 minutes in group 1 and 9 mwatt/cm 2 for 10 minutes in group 2, delivering a total energy of 5.4 joules/cm 2 (ccl vario 365, peschke trade gmbh, huenenberg switzerland) in both groups, with continued instillation of riboflavin drops every 2 minutes. a bandage contact lens (interojo, korea) was applied and removed on 7 th postoperative day, if epithelium had healed. post operatively cyclopentolate 1% eye drops were advised 8 hourly for 3 days and moxifloxacin (vigamox 0.05%, alcon) for 2 weeks respectively. topical steroids flourometholone (fml 0.1%, corneal cross linking in treatment of progressive keratoconus pak j ophthalmol. 2020, vol. 36 (2): 96-102 98 allergen) were added after one week, if epithelium had healed and continued for 4 weeks along with topical lubricants hypromellose, dextran (tear natural ii, alcon). primary outcome parameter was disease stability defined as increase in maximum keratometry over baseline kmax of no more than 1 diopter at 1 year after axl. refractive outcome udva, cdva, spherical equivalent se, refractive astigmatism, change in simulated k and steep k, corneal pachymetry (central corneal thickness) were additional outcome measures documented at 3, 6, 12 and 18 months post axl test points. statistical analysis of data was performed with ibm spss software (version 20.0 spss). p value of < 0.05 was considered as statistically significant. normality of data was established utilizing kolmogorov smirnov test. within the groups, related two samples comparisons at multiple points were performed with one way repeated measure anova for normally distributing data and wilcoxon matched pairs test for non-normally distributing data. between the group comparisons for normally distributing data was done with independent sample t test and mann whitney u test was applied to non-normal distributions. results the mean age was 24.47 ± 4.90 years in axl group 1 and 24.81 ± 6.39 in axl group 2, with no statistically significant difference. keratometric parameters (simulated k, steep k, kmax), refractive data (udva, cdva, refractive astigmatism, spherical equivalent se) and pachymetry, central corneal thickness (cct) were comparable at baseline between the two axl groups (table 1). the mean postoperative log mar udva improved at test points of 6, 12 and 18 months in both axl groups, however these differences were not statistically significant (p = 0.361 and p = 0.138 respectively) (table 2 and 3). the mean postoperative log mar cdva significantly improved over mean preoperative value in both the groups (p = 0.020 and p = 0.020). however, the difference in post-operative log mar udva and cdva was not statistically significant between the axl groups at any time point (p = 0.979, 0.700, 0.873, 0.125, 0.072, 0.171 respectively) (table 4). the refractive astigmatism and spherical equivalent se showed significant reduction from baseline at all postoperative test points of 3, 6, 12 and 18 months in both groups (p < 0.05). astigmatism reached significance in group 2 only at table 1: preoperative comparison of parameters. parameters accelerated cxl p value gp 1 (n = 30) gp 2 (n = 30) ucva 0.75 ± 0.51 0.65 ± 0.58 0.486 cdva 0.37 ± 0.27 0.26 ± 0.22 0.090 se -6.05 v 3.08 -6.2 ± 2.85 0.781 ast -4.15 ± 1.69 -3.81 ± 5.52 0.540 steep k 50.4 ± 3.72 49.6 ± 3.53 0.404 sim k 48.37 ± 2.96 47.8 ± 2.92 0.379 b k max 53.97 ± 4.29 53.63 ± 4.80 0.774 cct 471.20 ± 36.91 479 ± 37.7 0.442 b ecd 2566.19 ± 428.61 2516.88 ± 343.85 0.781 a independent samples t-test, b mann-whitney u test *p<0.05. ucva = uncorrected distance visual acuity, cdva = corrected distance visual acuity, se = spherical equivalent, ast = refractive astigmatism, steep k = steep keratometry, sim k = simulated keratometry, kmax = maximum or apex keratometry, cct=central corneal thickness 12 and 18 months follow-up (p = 0.000, 0.000) (tables 2, 3). the change in se and astigmatism did not differ between two groups (table 4). disease stability that was the primary outcome measure was 96% in each group in present study. similar trend of significant flattening of kmax, sim k, steep k was observed in each group (p < 0.05) against baseline indices. at 6 and 12 months follow up, no significant differences in keratometric parameters kmax, sim k, and steep k were ascertained comparing both procedures. at the final time point of 18 months, group 2 (axl 9 mwatt/cm 2 for 10 minutes) was superior as compared to group 1 (axl 18mwatt/cm 2 for 5 minutes) in terms of flattening of steep and sim k (p = 0.007, 0.023 respectively) and kmax, that barely missed statistical significance (table 4). cct in group 2 showed reduction of 23.16 ± 21.77 microns in group 1 and 25.06 ± 28.18 in group 2 with no statistically significant difference at any follow-up between the groups (p = 0.855, 0.351,0.771 respectively) (table 4). intra-group analysis showed significant reduction in endothelial cell count at the end of six, twelve and eighteen months in all groups (p < 0.05 in all groups). however, between the groups, the reduction in endothelial cells was not statistically significant at any time point. in group 2, one eye had a mild stromal haze that resolved with corticosteroid treatment by 6 weeks. no incidence of corneal endothelial de-compensation or any other adverse effect was recorded in any treatment bushra akbar, et al 99 pak j ophthalmol. 2020, vol. 36 (2): 96-102 table 2: comparison of pre and post-operative refractive and topographical measurements in axl group 1 (18 mwatt/cm 2 for 5 min). parameters postoperative follow-up time period p value pre-operative (n = 30) 3 months (n = 30) 6 months (n = 30) 12 months (n = 30) 18 months (n = 30) ucva 0.75 ± 0.51 0.71 ± 0.47 0.73 ± 0.46 0.67 ± 0.45 0.65 ± 0.43 0.361 cdva 0.37 ± 0.27 0.34 ± 0.20 0.38 ± 0.25 0.32 ± 0.27 0.31 ± 0.27 0.020* se -6.05 ±3.08 -5.05 ± 2.67 -4.12 ± 2.57 -4.66 ± 3.03 -4.60 ± 2.96 0.000* ast -4.15 ± 1.69 -3.79 ± 1.61 -3.48 ± 1.11 -3.03 ± 1.20 -2.97 ± 1.18 0.000* steep k 50.48 ± 3.72 49.95 ± 3.76 49.71 ± 3.67 49.31 ± 3.62 49.18 ± 3.59 0.000* sim k 48.37 ± 2.96 48.02 ± 3.20 48.09 ± 3.18 47.64 ± 3.18 47.57 ± 3.20 0.001* k max 53.97 ± 4.29 53.45 ± 4.09 53.26 ± 3.74 52.22 ± 3.92 52.27 ± 3.94 0.000* cct 471.20 ± 36.91 452.60 ± 43.57 456.96 ± 44.38 447.40 ± 43.24 446.50 ± 44.25 0.000* one-way anova repeated measures test, *p < 0.05. axl = accelerated cxl, ucva = visual acuity, cdva = corrected distance visual acuity, se = spherical equivalent, ast = refractive astigmatism, steep k = steep keratometry, sim k = simulated keratometry, kmax = maximum or apex keratometry, cct=central corneal thickness table 3: comparison of pre and post-operative refractive and topographical measurements in axl group 2 (9 mwatt/cm 2 for 10 min). parameters postoperative follow-up time period p value preoperative (n = 30) 3 months (n = 30) 6 months (n = 30) 1 year (n = 30) 18 months (n = 30) ucva 0.65 ± 0.58 0.73 ± 0.49 0.62 ± 0.53 0.60 ± 0.51 0.56 ± 0.45 0.138 cdva 0.26 ± 0.22 0.27 ± 0.20 0.32 ± 0.25 0.28 ± 0.27 0.26 ± 0.25 0.022* se -6.27 ± 2.85 -5.68 ± 2.80 -4.52 ± 2.18 -4.96 ± 2.84 -4.27 ± 2.25 0.000* ast -3.81 ± 2.52 -3.98 ± 1.87 -3.68 ± 1.49 -2.62 ± 2.32 -2.50 ± 1.26 0.000* steep k 49.69 ± 3.53 49.17 ± 3.44 48.78 ± 3.49 48.40 ± 3.47 47.56 ± 3.41 0.000* sim k 47.84 ± 2.92 47.36 ± 2.94 47.10 ± 3.09 46.72 ± 2.95 46.07 ± 3.00 0.000* k max 53.63 ± 4.80 52.95 ± 4.37 52.94 ± 4.39 51.70 ± 4.38 50.92 ± 4.33 0.001* cct 479.80 ± 37.75 455.10 ± 44.72 467.26 ± 45.97 461.93 ± 47.99 454.73 ± 47.05 0.000* anova repeated measures test, *p < 0.05. axl = accelerated cxl, ucva = uncorrected distance visual acuity, cdva = corrected distance visual acuity, se = spherical equivalent, ast = refractive astigmatism, steep k = steep keratometry, sim k = simulated keratometry, kmax = maximum or apex keratometry, cct =central corneal thickness table 4: comparison of post-operative changes in refractive data, keratometry and pachymetry between two study groups. parameters follow-up time period g r o u p c o m p a r is o n a t 6 m o n th s (p 1 v a lu e ) g r o u p c o m p a r is o n a t 1 2 m o n th s (p 2 v a lu e ) g r o u p c o m p a r is o n a t 1 8 m o n th s (p 3 v a lu e ) group 1 group 2 6 months (n = 30) 12 months (n = 30) 18 months (n = 30) 6 months (n = 30) 12 months (n = 30) 18 months (n = 30) ucva -0.29 ± 0.27 -0.82 ± 0.29 -0.82 ± 0.29 -0.31 ± 0.40 -0.05 ± 0.28 -0.94 ± 0.29 0.979 0.700 0.873 cdva 0.11 ± 0.15 -0.045 ± 1.56 -0.45 ± 0.15 0.06 ± 0.12 0.22 ± 0.12 0.01 ± 0.11 0.125 0.072 0.171 se 1.93 ± 3.29 1.39 ± 1.04 -5.42 ± 3.46 1.74 ± 2.45 1.30 ± 1.54 -4.93 ± 2.69 0.803 0.793 0.548 ast 0.67 ± 1.02 1.12 ± 0.99 1.12 ± 0.99 0.12 ± 1.98 1.18 ± 3.25 1.31 ± 2.10 0.189 0.922 0.660 steep k -0.77 ± 1.10 -0.77 ± 1.10 -1.16 ± 1.40 -0.91 ± 1.68 -0.91 ± 1.68 -2.13 ± 1.77 0.694 0.694 0.023* sim k -0.28 ± 1.15 -0.73 ± 1.44 -0.73 ± 1.44 -0.73 ± 1.13 1.11 ± 1.30 -1.77 ± 1.42 0.130 0.283 0.007* k max -0.70 ± 2.04 -1.74 ± 2.34 -1.70 ± 2.48 -0.68 ± 1.32 -1.93 ± 1.51 -2.71 ± 1.43 0.967 0.723 0.058 cct -14.23 ± 35.45 -23.80 ± 21.99 -23.16 ± 21.77 -12.53 ± 36.27 -17.86 ± 26.62 -25.06 ± 28.18 0.855 0.351 0.771 ecd -3.66 ± 6.00 -4.16 ± 6.28 -4.16 ± 6.28 -3.52 ± 5.99 -4.01 ± 6.30 -3.44 ± 6.58 0.926 0.929 0.670 independent samples t test. *p < 0.05. axl = accelerated cxl, ucva = visual acuity, cdva = corrected distance visual acuity, se = spherical equivalent, ast = refractive astigmatism, steep k = steep keratometry, sim k = simulated keratometry, kmax = maximu m or apex keratometry, cct =central corneal thickness, ecd = endothelial cell count corneal cross linking in treatment of progressive keratoconus pak j ophthalmol. 2020, vol. 36 (2): 96-102 100 table 5: previous clinical trials of axl. study study design conventional cross linking accelerated cross linking follow-up (months) findings n protocol/ platform n protocol/platform cinar et al. 2014 7 prospective comparative case series 13 3 mw/cm 2 for 30 mins 13 9mw/cm 2 for 10 mins 6 comparable visual and refractive results, decrease in km and kmax in both groups hashemi et al. 2015 8 prospective randomized comparative case series 31 3 mw/cm 2 for 30 mins uv-x 31 18mw/cm 2 for 5 mins uv-x 6 comparable visual acuity, refractive, keratometric and biomechanical outcomes hashemi et al. 2015 9 prospective randomized 31 18 mw/cm 2 for 5 mins uv-x 31 3mw/cm 2 for 30 mins uv-x 18 comparable visual acuity, refractive, keratometric and biomechanical outcomes chow et al. 2015 10 prospective comparative case series 19 3 mw/cm 2 for 30 mins uv-x 19 18mw/cm 2 for 5 mins ccl-vario 12 comparable visual acuity and refractive outcomes. more topographic flattening in the conventional group compared to accelerated group shetty et al. 2015 11 prospective randomized interventional study 36 3 mw/cm 2 for 30 mins avedro kxl 36 9mw/cm 2 for 10 mins 12 conventional group and accelerated groups with irradiance of 9mw/cm2 and 18mw/cm 2 showed better visual, refractive and tomographic 33 18mw/cm 2 for 5 mins cummings et al 2016 12 retrospective interventional study 66 3mw/cm 2 for 30 mins 36 9mw/cm 2 for 10 mins 12 accelerated corneal cxl is effective in stabilizing topographic parameters better after 12 months 9mw/cm 2 yildrim et al 2017 13 prospective comparative study 74 18mw/cm 2 for 5 mins 72 30mw/cm 2 for 3 mins 12 comparable visual acuity, refractive, keratometric ucva = uncorrected distance visual acuity, cdva = corrected distance visual acuity, se = spherical equivalent, ast = refractive astigmatism, steep k = steep keratometry, sim k = simulated keratometry, kmax = maximum or apex keratometry, cct = central corneal thickness group during follow-up. one eye (4%) in each group exhibited continued ectatic progression in terms of increase in kmax of more than 1 dioptre. discussion the promising effects of axl in halting disease progression by augmenting corneal strength and halving the surgical time with increased patient comfort have excited ophthalmologic researchers. modified higher uva irradiation intensity protocols with different time settings utilizing variable riboflavin solutions, soak time and cxl devices have been tested with the aim of achieving a short and equally effective procedure to date. 3-13 in this particular study, both axl showed equivalent improvement in udva, cdva and topographic indices at 3, 6, 12 and 18 months follow-up except for flattening of keratometry (sim k, steep k) that was significantly superior in axl group 2 (p < 0.007, 0.023) at 18 months followup. comparable clinical stabilization of disease (96%) was achieved with optimum safety in each group. failure rate of 4% in terms of continued progression, with no other adverse effects were documented in our study. significant improvements in our study in udva, cdva along with reduction in se and ast at 6 and 12 months over baseline were consistent with refractive outcomes of prospective well designed interventional trials that recruited one arm of cohort to receive cxl irradiance protocol similar to our study. 6,11,12 hashemi et al 8,9 and al-nawaeiseh et al 14 in contrast to our results reported no significant improvements in refractive parameters at 12 months in patient receiving 5 minutes accelerated protocol. cxl alone without excimer laser is not considered a refractive procedure bushra akbar, et al 101 pak j ophthalmol. 2020, vol. 36 (2): 96-102 albeit, the effect on refractive parameters in different studies may be attributed to variable grades of keratoconus and associated difficult non repeatable subjective manifest refractions due to distorted multi focal optics of ectatic steep corneas. 12 in present study, axl groups demonstrated significant trend of flattening of keratometric indices kmax, steep k, sim k within groups, with no superiority between the groups, except for sim k and steep k at 18 months follow-up. although k max only just missed statistical significance at 18 months, a marked flattening of 2.7d was attained with 9 mwatt/cm 2 for 10 minutes regimen as compared to 1.5d in group 1. this trend of decrease in keratometric values was generally in accordance with results of previous studies of accelerated protocols. shetty et al 11 in a prospective interventional study on 138 keratoconic eyes, with randomization at radiance of 3, 9, 18 or 30 mwatt/cm 2 found that cross linking, flattening effect was abridged in higher irradiance and shorter duration treatments, in conformation with our results. however, the disease stability with axl in each group in our study with no further corneal steeping at a long term follow up of 18 months is a significant clinical finding, even if it misses statistical significance between the groups. the decrease in cct is an indirect marker of efficacy of axl, confirming compactness of collagen fibrils, apoptosis of stromal keratocytes and improved biomechanical stability. 8,9,15 hashemi et al 8,9 identified a statistically significant decrease in cct at 18 months following axl with 18 mwatt/cm 2 for 5minutes. we also observed a parallel decrease in cct for both groups, without significance between the protocols at 18 months. significant decrease in thinnest pachymetry was also reported for axl 9 mwatt/cm 2 in comparison against conventional cxl in literature. 12,16,17 we lack the evidence of axl induced structural change in anterior corneal stroma as anterior segment optical coherence tomography was not done in our study to assess the depth of demarcation line. in addition to this, the major limitation of this study was a relatively small sample size. we intend to follow our patients and publish our long term results to further validate efficacy of our procedures. we had 4% eyes in each group that experienced ectatic progression at 12 and 18 months, in terms of increase in kmax, with no incidence of sterile infiltrates, persistent corneal haze and damage or loss of endothelial cells succumbing to corneal endothelial decompensation, akin to previous axl trials. 12,18,19,20 conclusion axl protocols are safe and comparable in disease stability, and change in refractive parameters and topographic indices in progressive keratoconus. these two modified high intensity protocols may be recommended alternatively in treatment of progressive keratoconus, considered fit for epithelium off cxl. acknowledgements mr kashif siddique, king salman armed forces hospital, ksa academic affairs (research unit) for helping in data analysis. miss paree chera, ex optometrist, armed forces institute of ophthalmology for helping in collection of data. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest references 1. bunsen rw, roscoe he. photochemical researches– part v. on the measurement of the chemical action of direct and diffuse sunlight. proc r soc lond. 1862; 12: 306–312. http://rspl.royalsocietypublishing.org/content/12/306. 2. wollensak g, spoerl e, seiler t. riboflavin/ultraviolet-a– induced collagen cross linking for the treatment of keratoconus. am j ophthalmol. 2003; 135 (5): 620–627. https//doi.org/10.1016/s0002-9394(02)02220-1. 3. krueger rr, herekar s, spoerl e. first proposed efficacy study of high versus standard irradiance and fractionated riboflavin/ultraviolet a cross-linking with equivalent energy exposure. eye & contact lens, 2014; 40 (6): 353–357. doi: 10.1097/icl.0000000000000095. 4. schumacher s, oeftiger l, mrochen m. equivalence of biomechanical changes induced by rapid and standard corneal cross linking, using riboflavin and ultraviolet radiation. invest. ophthalmol. vis. sci., 2011; 52 (12): 9048-9052. doi:10.1167/iovs.11-7818. corneal cross linking in treatment of progressive keratoconus pak j ophthalmol. 2020, vol. 36 (2): 96-102 102 5. raiskup-wolf f, hoyer a, spoerl e, pillunat le. collagen cross linking with riboflavin and ultraviolet-a light in keratoconus: long-term results. j cataract refract surg. 2008; 34 (5): 796–801. https://doi.org/10.1016/j.jcrs.2007.12.039. 6. o’brart dps. corneal collagen cross-linking: a review. j optom. 2014; 7 (3): 113–124. doi: 10.1016/j.optom.2013.12.001. 7. cınar y, cingü ak, türkcü fm, cınar t, yüksel h, ozkurt zg, et al. comparison of accelerated and conventional corneal collagen cross-linking for progressive keratoconus. cutan ocul toxicol. 2014; 33 (3): 218-222. doi: 10.3109/15569527.2013.834497. 8. hashemi h, fotouhi a, miraftab m, bahrmandy h, seyedian ma, amanzadeh k, et al. short-term comparison of accelerated and standard methods of corneal collagen crosslinking. j cataract refract surg. 2015; 41 (3): 533-540. doi:10.1016/j.jcrs.2014.07.030 9. hashemi h, miraftab m, seyedian ma, hafezi f, bahrmandy h, heidarian s, et al. long-term results of an accelerated corneal cross-linking protocol (18 mw/cm 2 ) for the treatment of progressive keratoconus. am j ophthalmol. 2015; 160 (6): 1164–1170. doi: 10.1016/j.ajo.2015.08.027. 10. chow vw, chan tc, yu m, wong vw, jhanji v. one-year outcomes of conventional and accelerated collagen cross linking in progressive keratoconus. sci rep. 2015; 5: 14425. doi: 10.1038/srep14425. 11. shetty r, pahuja nk, nuijts rm, ajani a, jayadev c, sharma c, et al. current protocols of corneal collagen cross-linking: visual, refractive, and tomographic outcomes. am j ophthalmol. 2015; 160 (2): 243-249. doi: 10.1016/j.ajo.2015.05.019. 12. cummings ab, mcquaid r, naughton s, brennan e, mrochen m. optimizing corneal cross linking in the treatment of keratoconus: a comparison of outcomes after standardand high-intensity protocols. cornea, 2016; 35 (6): 814–822. doi:10.1097/ico.0000000000000823. 13. yıldırım y, olcucu o, gunaydin zk, aqca a, ozgurhan eb, alagoz c, et al. comparison of accelerated corneal collagen cross-linking types for treating keratoconus. current eye research, 2017; 42 (7): 971-975. doi:10.1080/02713683.2017.1284241. 14. alnawaiseh m, rosentreter a, böhm mr, eveslage m, eter n, zumhagen l. accelerated (18 mw/cm 2 ) corneal collagen cross linking for progressive keratoconus. cornea, 2015; 34 (11): 1427–1431. doi: 10.1097/ico.0000000000000578. 15. woo jh, iyer jv, lim l, hla mh, mehta js, chan cm, et al. conventional versus accelerated collagen cross-linking for keratoconus: a comparison of visual, refractive, topographic and biomechanical outcomes. the open ophthalmology journal, 2017; 11: 262. doi:10.2174/1874364101711010262. 16. akbar b, intisar-ul-haq r, ishaq m, fawad a, arzoo s, siddique k. comparison of transepithelial corneal cross linking with epithelium-off crosslinking (epithelium-off cxl) in adult pakistani population with progressive keratoconus. taiwan j ophthalmol, 2017; 7 (4):185. doi: [10.4103/tjo.tjo_38_17]. 17. haq i, fawad a, saeed m, humayun s, islam q, arzoo s, et al. comparison of rapid and conventional corneal collagen cross linking in patients having keratoconus. pakistan armed forces medical journal, 2015; 1 (1): 105-109. 18. koller t, mrochen m, seiler t. complication and failure rates after corneal cross linking. j cataract refract surg. 2009; 35 (8): 1358–1362. doi:10.1016/j.jcrs.2009.03.035. 19. cerman e, toker e, ozarslan ozcan d. transepithelial versus epithelium off cross linking in adults with progressive keratoconus. j cataract refract surg. 2015; 41 (7): 1416-1425. 20. lesniak sp, hersh ps. transepithelial corneal collagen cross linking for keratoconus: six months results. j cataract refract surg. 2014 dec; 40 (12): 1971-1979. authors’ designation and contribution bushra akbar; registrar: study design, analysis of data, manuscript drafting and critical revision of final draft. imran basit; assistant professor: study design, analysis of data, manuscript drafting and critical revision of final draft. amjad akram; research advisor: critical revision of manuscript, final approval of draft for publication. maham zahid; research associate: data collection, analysis of data, interpretation of data, manuscript drafting and final approval of draft. .…  …. https://doi.org/10.1016/j.jcrs.2007.12.039 https://doi.org/10.1016/j.ajo.2015.05.019 https://doi.org/10.1016/j.jcrs.2009.03.035 55 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology `original article frequency of cataract in diabetic verses non-diabetic patients kiran aslam, muhammad sufyan aneeq ansari, imran khalid, khurram nafees pak j ophthalmol 2019, vol. 35, no. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: kiran aslam bsc.(hons) optometery & orthoptics department of ophthalmology, fatima memorial hospital lahore email: kiranaslam1103@gmail.com …..……………………….. purpose: to determine the frequency of cataract in diabetic verses non-diabetic patients. study design: descriptive cross-sectional study. place and duration of study: eye outpatients department of fatima memorial hospital lahore from december to march 2018. material and methods: patients between 20-50 years of age with and without diabetes were included in the study. the diabetic patients included in the study had diabetes for at least 6-7 years. patients with any other systemic disease and patients <20 years and > 50 years were excluded from the study. all patients underwent a complete eye examination including uncorrected and best corrected visual acuity, refraction, dilated slit lamp and fundus examination. results: a total of 194 patients were examined. average duration of diabetes was 6-7 years with age groups 20-35 years (34.02%) and 35-50 years (65.97%). there were 79 (79.79%) patients with diabetes who had cataract while only 13 (13.68%) nondiabetic patients had cataract. most common type of cataract in diabetic patients was posterior subcapsular cataract (pscc) 43 (54.43%). this was followed by nuclear cataract in 17 (21.51%) and cortical cataract in 14 (17.72%) patients. while in non-diabetic patients nuclear cataract was seen in 6 (46.15%) patients and cortical and pscc were the same percentage 3 (23.07%). cataract frequently developed in the age group of 35-50 years in diabetic patients. conclusion: diabetic patients should be screened for cataract early as pscc can cause significant deterioration of vision between 35-50 years. keywords: cataract, diabetes mellitus (dm), posterior sub capsular cataract (pscc), nuclear cataract (nc) and cortical cataract (cc). ny opacity in the lens or in its capsule, either congenital or acquired, unilateral or bilateral is commonly called cataract1. diabetes is characterized by fasting blood glucose level <70mg/dl2. cataract is the leading cause of blindness worldwide. it is 2-5 times more in diabetic patients3. co-existence of cataract and diabetes mellitus results in overall 45% visual impairment4. in 2017, survey suggest that cataract was the predominant cause contributing to severe vi (70%) and blindness (57%)5. there is evidence that the risk of cataract increases with increasing duration of diabetes and severity of hyperglycemia6.even though aging is another risk factor for development of cataract, while nutritional deficiencies, trace metals, exposure to sunlight, smoking are also responsible for development of cataract7. according to who (world health organization) meaning of blindness is “visual acuity of <3/60 using snellen chart with the best possible correction & visual field less than 10 degree”. in 2002, who enlisted the cataract was one of the top leading cause of blindness. it was presented as 47.9% cataract and 4.8% diabetic a frequency of cataract in diabetic verses non-diabetic patients pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 56 retinopathy. in pakistan, national survey on blindness reported in 2004-5, which concluded that 53% cataract, 11% cataract related like aphakia and pco and <0.5% diabetes related blindness existed. vision 2020 is worldwide activity to take out primary driver of all preventable and treatable visual impairment continuously 20208. predominance of visual impairment was higher because of cataract in punjab territory of pakistan, particularly in rustic zones and uneducated individuals. the predominance of cataract was higher in ladies than men (1.80% versus 1.67%, p < 0.001). there are around 570 000 grown-ups (225 000 men and 345 000 ladies) who are visually impaired from cataract in pakistan, which will be increment to 1 210 000 continuously 2020.9 pervasiveness of cataract causing < 6/60 in eyes was 5.0%, around 3 560 000 eyes in pakistan (year 2003). the number is anticipated to increment to 7 380 000 continuously 2020. around 2 million individuals are visually impaired in pakistan. cataract is in charge of 66.7% visual impairment in pakistan10. in pakistan 6.9 million individual are affected by diabetes. with the international diabetes federation evaluating that this number will develop to 11.5 million by 2025 unless measures are taken to control the susceptive disorders. this is the principle explanation behind profoundly required pharmacological intercession that will keep up the transparency of lens; it is assessed that a deferral in cataract development of around 10 years would diminish the commonness of outwardly incapacitating cataract by around 45%11. dominant part of cataract patient's vision could be reestablished to an attractive level by carefully expelling the lens and substituting it with a lens made of manufactured polymers12.phacoemulsification is protected and successful method with great visual result whenever performed in experienced hands under fastidious sterilization and aseptic measures.13 the rate of cataract is large to the point that medical procedure alone has been discovered insufficient in tackling this issue. diabetic patient must need observing of fundus consistently after at regular intervals12. material and methods this is descriptive cross-sectional study included 194 diabetic and non-diabetic patients randomly presented in the medical opd of fatima memorial hospital in 2017. eligibility criteria were as followed: age between 20-50 years old, diabetic patients with at least 6-7 year duration of diabetes. the duration of diabetes was taken as the period from the diagnosis of dm to the day of examination for cataract surgery as informed by the patient. the patients with age < 20 and > 50 were excluded in this study. the capacity to give data about vision and consent to answer a survey about socioeconomics, diabetic entanglements and other restorative determination and medicines utilized. in the wake of taking patient's consent and noting the survey all subjects underwent a complete eye examination, including uncorrected and best corrected visual acuity, refraction, dilated slit lamp and fundus examination. individual with any other systemic and ocular diseases were excluded. after taking patient's history, subjects were classified into diabetic and nondiabetic, diagnosis made by general physician. visual examination including visual acuity & pinhole testing was done monocularly at six meter distance using snellen chart. an improvement of visual acuity with pinhole was considered refractive error and visual acuity of ≤ 6/12 was regarded as reduced vision. patient’s visual assessment data was recorded on well defined proforma. after taking consent patient was dialated with tropicamide (mydriacyl 1%) and were examined by ophthalmologist to decide the presence and absence of cataract and the type of cataract using a slit lamp. the following variables were assessed; presence of diabetes, presence of cataract and type of cataract. pearson's chi square test was utilized for catagorical factors. the p value was viewed as noteworthy if p-value<0.05. after examination, diabetic patients with cataract were referred to ophthalmologist for monitoring impacts of cataract on vision, make regular follow-ups to monitor the fundus for diabetic retinopathy and for surgical plan in correspondence to cataract severity. results the data was entered and analyzed in spss 20.0 version. all quantitative variables age distribution was discussed in mean ± standard deviation form. all qualitative variables like gender, diabetes, cataract and its type was discussed in frequency or percentage form. in this study, one hundred and ninety-four (n = 194) patients were enrolled including diabetic and non-diabetic patients. in both genders, the prevalence of cataract was found to be decreased initially by kiran aslam, et al 57 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology table 1: distribution of cataract in subjects. presence of cataract absence of cataract total p-value subjects 92 (47.4%) 102 (52.6%) 194 male 29 (38.66%) 46 (16.33%) 75 0.036* female 63 (52.94%) 56 (47.05%) 119 age (20-35) 6 (9.1%) 60 (90.9%) 66 0.000* (35-50) 86 (67.2%) 42 (32.8%) 128 table 2: relative risk of cataract in diabetics verses non-diabetics cataract diabetic nondiabetic. total p-value present 79 (85.9%) 13 (14.1%) 92 absent age (20-35) (36-50) 20 (19.6%) 8 (12.1%) 91 (71.1%) 82 (80.4%) 102 0.001* 58(87.9%) 66 37 (28.9%) 128 total 99 95 group 20-35 years and then increased in ≥ 40 years group. cataract is more typical in female when contrasted with male as appeared in table: 1 by applying chi square test outcomes were critical with p value < 0.05. frequency of cataract in diabetic patients with age groups shown in the table 2. table 3: distribution of cataract type in diabetics verses non-diabetics type of cataract diabetic non-diabetic pscc 43 (54.43%) 3 (23.07%) early lenticular changes 5 (6.32%) 1 (7.69%) nuclear cataract 17 (21.51%) 6 (46.15%) cortical cataract 14 (17.72%) 3 (23.07%) total 79 (100.0%) 13 (100.0%) graph 1: type of cataract in diabetic and nondiabetic patients. presence of diabetes and cataract is shown in the table 2 by applying chi square test result showed that diabetes is significantly associated with cataract with p value 0.001 at 5% margin of error with 95% confidence interval. the outcomes were critical with p value <0.05. table 3 shows; out of 99 diabetic patients, the most common type of cataract was pscc 43 (54.43%). out of 95 non-diabetic patients, the most common type was nuclear cataract 6 (46.15%) as shown in table 3. discussion duration of diabetes and age is a hazard factor for advancement of cataract in diabetic patients. charles et al. examine in 2003 in which normal term of diabetes was 7 years and the time of diagnosis was 46.5 years.14 while in present examination, the span of diabetes was 6-7 years. although in present study age was classified into two groups 20-35 &36-50 years. results showed that subjects in 20-35 years, 6 (9.1%) had cataract. while subjects in 36-50 years, 86 (67.2%) were presented with cataract including diabetic and non-diabetic. cataract was more in age between 36-50 years. thus, result of both studies are almost equal. in 2003 charles et al. reported prevalence of cataract 44.9% in west african type 2 diabetic patients which is almost half as compared to in our population14.in present study diabetic cataract was present in 79 (85.9%) and absent in 20 (19.6%). although in non-diabetic patients cataract was present in 13 (14.1%) and absent in 82 (80.4%) patients. frequency of cataract in diabetic verses non-diabetic patients pakistan journal of ophthalmology vol. 35, no. 1, jan – mar, 2019 58 diabetes is the major risk factor for cataract. when considering the higher prevalence of diabetes mellitus in females, it follows that the incidence of diabetic cataract would be higher in females than male. sung et al.in 2006 reported that two groups of diabetic patients, one was control group and the other was cataract group. the author (s) concluded that females were more common in cataract group than control group.12 similar to present study in which prevalence of diabetes and cataract was more in females than male. out of 194 patients 63 (52.94%) females and 29 (38.66) male were presented with cataract. in term of relationship between diabetes and gender, the increased incidence of diabetic cataract were appeared in females. in 2012 eydis conducted study on prevalence of cataract in a population with and without type 2 diabetes mellitus. according to author 274 patients were diagnosed with diabetes and 256 controlled. three types of cataract was observed 65.5% cortical, 42.5% pscc and 48% nuclear cataract in type 2 diabetes15.similarly to compare most recent studies, patricia et al. conducted study in 2017 on pre-senile cataract in diabetic patients. the hypothesis of patricia was a cortical cataract is more common in diabetic population. patricia looked at the discoveries of best quality level locs iii (lens opacity classification system iii) with scheimpflug target measures in a presenile population. author(s) concluded that out of 43 diabetic patients 88.4% were having sub capsular cataract, 52.3% cortical and 7% nuclear cataract that is twice as compared to present study16.while in 2010 rajiv raman concluded that among the monotype cataracts, cc was the most common subtype in patients with type 2 dm (15.1%). in the mixed cataracts, the combination of nc, cc, and psc was the most common (19.5%)17. results of present study shows for diabetic as well as for non-diabetic patients. it shows significant association between diabetes and pscc. in this study 43 (54.43%) pscc, 14 (17.72%) cortical and 17 (21.51%) nuclear cataract in diabetic patients that was definitely higher than previous study. while in non-diabetic patients 3 (23.07%) were present with pscc, 1 (7.69%) present with early lenticular changes, 6 (46.15%) present with nuclear cataract and cortical cataract was 3 (23.07%).subsequently, early improvement of pharmacological and careful methods for cataract anticipation ought to be one of the fundamental needs for future cataract examine. these intercessions must encouraging to overcome the expanding pervasiveness of cataract in diabetic patients18. currently the only available treatment for disease is surgical removal of opaque lens and followed by replacement with synthetic implants. efforts have been taken to explore the traditional medicine to delay and retard the progression of cataract. several numbers of plants and synthetic compounds has been reported to possess anti-cataract activity.19success rate of cataracts surgery, without serious complications and improved vision is possible with the advanced surgical procedure and with the aid of equipment’s.20 however, most common side effects reported in the post-surgical treatment was inflammatory reaction and cystoid macular oedema21. conclusion cataract was present 79% in defined population. this study shows that there is high frequency of cataract in diabetic patients which can be avoided its consequences delayed if they are timely referred to ophthalmologist to diagnose and manage early for better visual outcomes. acknowledgment i paid my tributes and thank to miss tayyaba rahat for encouragement and support from the initial to the final level of this work. special thank for helping me in statistical analysis. conflict of interest approved by ethical committee & irb of institute. funding sources self-funded hospital data was used. authors affiliation kiran aslam bsc.(hons) optometery & orthoptics fmh college of medicine & dentistry dr. muhammad sufyan aneeq ansari assistant professor of ophthalmology fatima memorial hospital lahore imran khalid orthoptist bsvs, m.phil (sch), crcp services hospital lahore kiran aslam, et al 59 vol. 35, no. 1, jan – mar, 2019 pakistan journal of ophthalmology dr. khurram nafees assistant professor of ophthalmology, fatima memorial hospital lahore author’s contribution kiran aslam substantial contribution in conception, designing, acquisition, analysis or interpretation of data. dr. muhammad sufyan aneeq ansari final approval of manuscript. imran khalid manuscript drafting & revision for intellectual content. dr. khurram nafees contribution in conception & designing of manuscript. references 1. kanski jj. clinical ophthalmology. 8th ed. vol. 1. newsouth wales, australia: butterworths, 1989: 270300. 2. thomson william. diseases of the eye. 4th ed. vol. 1. s.l: hansebooks, 2016: 110-114. 3. lathika v, ajith t. association of grade of cataract with duration of diabetes, age and gender in patients with type ii diabetes mellitus. international journal of advances in medicine, 2016; (1): 304–8. 4. gupta s, selvan v, agrawal s, saxena r. advances in pharmacological strategies for the prevention of cataract development. indian journal of ophthalmology, 2009, 57(3):175. 5. open access research prevalence and causes of visual... [internet].[cited 2018oct14].availablefrom:https://bmjopen.bmj.com/c ontent/bmjopen/8/3/e018894.full.pdf 6. negahban k, chern k. cataracts associated with systemic disorders and syndromes. current opinion in ophthalmology, 2002; 13(6):419–22. 7. patel pm, jivani n, malaviya s, gohil t, bhalodia y. cataract: a major secondary diabetic complication. international current pharmaceutical journal, 2012; mar 1(7): 3-57. 8. jatoi sm. clinical ophthalmology. 5th ed. vol. 1. karachi,, pakistan: paramount books; 2013: 269-272. 9. dineen b, bourne rra, jadoon z, shah sp, khan ma, foster a, et al. causes of blindness and visual impairment in pakistan. the pakistan national blindness and visual impairment survey. british journal of ophthalmology, 2007; 91(8):1005–10. 10. jadoon z, shah s, bourne r, dineen b, khan m, gilbert c et al. cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in pakistan: the pakistan national blindness and visual impairment survey. british journal of ophthalmology, 2007; 91(10):1269-1273. 11. marathe ph, gaohx, close kl. american diabetes association standards of medical care in diabetes2017.journal of diabetes, 2017; 9(4):320–4. 12. kim si, kim sj. prevalence and risk factors for cataracts in persons with type 2 diabetes mellitus. korean journal of ophthalmology, 2006; 20(4):201. 13. visual outcome of cataract surgery after phacoemulsification [internet]. [cited 2018oct15]. available from: http://www.pjo.com.pk/33/4/9. sanaullah mm31dec.pdf 14. rotimi c, daniel h, zhou j, et al. prevalence and determinants of diabetic retinopathy and cataracts in west african type 2 diabetes patients. ethn dis 2003; 13(2 suppl 2): s110-7. 22 15. olafsdottir e, andersson dkg, stefánsson e. the prevalence of cataract in a population with and without type 2 diabetes mellitus. actaophthalmologica.2011; 90(4):334–40. 16. kyselova z, stefek m, bauer v. pharmacological prevention of diabetic cataract. journal of diabetes and its complications, 2004; 18(2):129–40. 17. raman r, pal ss, adams jsk, rani pk, vaitheeswaran k, sharma t. prevalence and risk factors for cataract in diabetes: sankara nethralaya diabetic retinopathy epidemiology and molecular genetics study, report no. 17. invest opthalmol & vis sci. 2010; 51(12):6253. 18. rooban bn, sasikala v, sahasranamam v, abraham a. vitexnegundo modulates selenite-induced opacification and cataractogensis in rat pups. biological trace element research, 2010; 138(1-3):282– 92. 19. dowler jg, hykin pg, hamilton am. phacoemulsification versus extracapsular cataract extraction in patients with diabetes. ophthalmol. 2000; 107(3):457-62. 23. 20. prokofyeva e, wegener a, zrenner e. cataractprevalenceandpreventionineurope:aliteraturere view.actaophthalmologica.2012; 91(5):395–405. 21. gus pi, zelanis s, marinho d, kunzler al, nicola f, folle h, et al. pre-senilecataract in diabetic patients: prevalence and early diagnosis. journal of clinical trials, 2017; 07(02): 44-67. http://www.pjo.com.pk/33/4/9 pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 302 author communication bilateral post-electrocution cataract anum javed, owais arshad, javeria nasir, mohammad hanif chatni pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: dr. owais arshad ophthalmology department, patel hospital, karachi, pakistan email: owaisarshad17@gmail.com …..……………………….. trauma from electricity can be of multiple forms, ranging from mild damage, to life-threatening conditions like cardiac arrest. ophthalmic injuries are not uncommon following electrocution. we report a case of post electrocution cataract in a 24-year old male who presented to us three years after injury. on examination his best corrected visual acuity was 1/60 in the right eye and hand movement in the left eye. slit lamp examination revealed a white, mature cataract in the left eye and a developing anterior capsular cataract in the right eye. b-scan of left eye was normal. fundoscopic examination of right eye was normal. left cataract surgery was done. per-operatively, the capsulorhexis was surgically challenging due to the adherence of the cataract with the anterior capsule. the bcva in the left eye was 6/6 postoperatively. key words: electric injury, cataract, phacoemulsification. lectricity related injuries are more common in developing countries like pakistan as compared to the developed world1. effects of electric current entering the body are a result of inflow of charges on the molecular and sub-molecular level, generating thermal energy causing disturbance of cellular physiology. the consequences may involve any part of the body and the eyes are no exception. cataract induced by electric current may present much later with respect to the time of injury, with rapid progression and diminishing vision2. we report a case of postelectrocution cataract in a young male. case report a 24-year old male presented to the outpatient eye department of patel hospital with complaint of decreased vision in both eyes for the past five months. his symptoms were more in the left eye. on enquiring the detailed past history he revealed that he was electrocuted 3 years ago from high tension wire affecting the left side of his body. on physical examination, there was a wound of electrical injury on the left palm. bcva in the right eye was 1/60, and hand movement in the left eye. slit lamp examination showed a white, mature cataract with adherent central plaque to the anterior capsule in the left eye as shown in figure 1 (left side). in the right eye, there was also a developing anterior sub capsular plaque like cataract similar to the left eye (right side of figure 1). fig. 1 (left): white, mature cataract in the left eye, adherent to the anterior capsule. (right): cataract developing in the right eye. dilated fundus examination of right eye was normal. b-scan ultrasound was done which showed a flat retina. left cataract surgery was planned. during phacoemulsification, the anterior capsule was adherent with the underlying cortex forming a plaque. capsulorhexis was extended towards the zonules and e anum javed, et al 303 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol typical argentinian flag sign was observed but the situation was managed and acrylic soft hydrophobic posterior chamber intra-ocular lens (pc-iol) was implanted in the bag under general anesthesia. postoperatively, unaided vision in the left eye was 6/6 with normal fundoscopic findings on 2-weekly followup. right eye surgery was also planned in the following month. informed consent was obtained from the patient for reporting this case. discussion ocular post electrocution injuries include entities like cystic macular edema/macular cyst, iritis, anisocoria, chemosis and corneo-epithelial keratitis. among these, lens is particularly more vulnerable to electric current. therefore, cataract remains the commonest form of electrical ocular injury. there are several factors, which are responsible for the variable manifestations and features of these pathologies including location and orientation of body tissues in the current path, duration of electric current as well as its amperage, voltage and resistance3. etiology of electric cataract is unknown but thought to be related to the protein coagulation in the lens that occurs after an electric shock. worldwide, post-electrocution cataract occurs in 0.8% of the population4. even there is high prevalence of electrocution cases in our country, but due to lack of awareness and increased mortality, very few cases have been reported. duration in which the visually significant cataract develops ranges from 1-18 months5 as in our case, the patient presented after three years of latent period following injury. patient usually remains asymptomatic for a long duration with subsequent decreasing vision over a short period of time, as cataract approaches the visual axis, like in our case. morphologically the cataract starts as a vacuolar appearance in the mid-periphery of the lens which may be easily missed out in an undilated examination6. cataract in these cases, may have a strong attachment anteriorly and/or posteriorly with the capsule, making it a surgical challenge7. in our case also, due to the adherent nature of the cataract to the capsule, it was forming a plaque like appearance with cortical spokes. surgically, it is possible to extract this cataract via phacoemulsification with pc-iol, provided it is performed by a well-trained surgeon owing to the peculiar nature of this type of cataract. in our case, the capsulorhexis was difficult. the capsule was unidentifiable as a separate entity due to its rubbery and adherent nature as found in other few cases that are reported. pc-iol is usually implanted after extraction of the cataract provided that the capsule is intact. post operatively, the visual outcome is good5, in most of the cases as in our case. conclusion post electrocution cataract may present late. detailed history is important in finding out the cause of presenile cataract. cataract surgery of such patients may be surgically challenging. grant support & financial disclosures none. references 1. zeb a, arsh a, bahadur s, ilyas sm. spinal cord injury due to fall from electricity poles after electrocution. pak j med sci. 2019; 35 (4): 1036–1039. 2. zhang l, zhang k, zhu yn, wang qw, yao k. case report of unilateral electric cataract with transmission electron microscopy image. int j ophthalmol. 2016; 9 (4): 636–637. 3. fish rm, geddes la. conduction of electrical current to and through the human body: a review. eplasty. 2009; 9: e44. 4. kasana ra, baba pu, wani ah. pattern of high voltage electrical injuries in the kashmir valley: a 10-year single centre experience. ann burns fire disasters, 2016; 29 (4): 259–263. 5. baranwal vk, satyabala k, gaur s, dutta ak. a case of electric cataract. med j armed forces india, 2014; 70 (3): 284–285. 6. sofi r, qureshi t, gupta v. electric cataracts: a cause of bilateral blindness in kashmir. eye (lond). 2018; 32 (10): 1676–1677. 7. kumawat d, ramananda k, sahay p, et al. posterior capsular rupture and spontaneous posterior dislocation of lens following electrical injury. case reports, 2017; 2017: bcr-2017-222765. bilateral post-electrocution cataract – short communication pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 304 author’s affiliation dr. anum javed department of ophthalmology, patel hospital, karachi, pakistan. dr. owais arshad department of ophthalmology, patel hospital, karachi, pakistan dr. javeria nasir department of ophthalmology, patel hospital, karachi, pakistan dr. mohammad hanif chatni department of ophthalmology, patel hospital, karachi, pakistan author’s contribution dr. anum javed manuscript design, writing and final review. dr. owais arshad manuscript design and critical review. dr. javeria nasir manuscript design and critical review. dr. mohammad hanif chatni manuscript design and critical review microsoft word 9. nasir ahmad chaudhry mm pakistan journal of ophthalmology, 2020, vol. 36 (3): 231-235 231 original article outcomes of intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion nasir ahmad chaudhry1, sarmad zahoor2, usama iqbal3, muhammad owais sharif4 muhammad sharjeel5, asima rafique6 departments of ophthalmology, 1-2eye unit 2 mayo hospital, lahore. 3dhq teaching hospital, gujranwala. 4,6eye unit 3 mayo hospital, lahore. 5gomal medical college, di khan – kpk abstract purpose: to determine the functional and anatomical outcome of intravitreal bevacizumab in patients with macular edema secondary to branch retinal vein occlusion. study design: quasi experimental study. place and duration of study: institute of ophthalmology, king edward medical university/mayo hospital lahore, from february 2016 to december 2018. material and methods: forty eyes of 40 patients with macular edema on oct (macular thickness > 300 µm) secondary to brvo were included in the study. all the patients suffering from other types of macular edema caused by diabetes, epi-retinal membrane (erm), surgery involving posterior segment, vitreoretinal traction and history of intravitreal vegf or steroids were excluded from the study. intravitreal bevacizumab was given when macular thickness was > 300 µm or visual acuity was < 6/12. follow-up was at 1st, 3rd, 6th and 12th month. results: the mean age of the patients was 52.12 ± 5.63 years. male to female ratio was 1.5:1. infero-temporal venous arcade was the most common site of brvo (55%) followed by supero-temporal (35%) and macular brvo (10%). baseline visual acuity was 6/12 or better in 17.5% of the patients at presentation. this proportion increased to 27.5%, 40%, 52.5% and 67.5% at 1, 3, 6 and 12 months respectively. macular thickness measured at presentation was 540 ± 120 μm. macular thickness gradually reduced on follow-up. at one month mean macular thickness was 430 ± 90 μm. it was less than 300 μm after 6 months. conclusion: intravitreal bevacizumab results in improved functional and anatomical outcomes in cases of macular edema secondary to brvo. key words: bevacizumab, retinal vein occlusion, branch retinal vein occlusion, vascular endothelial growth factor, macular edema. how to cite this article: chaudhry na, zahoor s, iqbal u, sharif mo, sharjeel m, rafique a. outcomes of intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion. pak j ophthalmol. 2020; 36 (3): 231-235. doi: 10.36351/pjo.v36i3.998 introduction among the vascular diseases of retina, branch retinal correspondence to: usama iqbal dhq teaching hospital, gujranwala email: usamaiqqbal@gmail.com received: february 4, 2020 revised: may 4, 2020 accepted: may 4, 2020 vein occlusion (brvo) is the most common disease after diabetic retinopathy1,2. several factors have been associated with pathogenesis of brvo. these include hypertension, diabetes mellitus, age, open angle glaucoma, hyperlipidemia, alcohol and increased alpha2 globulin3-5. the possible mechanism of its progress is occlusion of vein leading to stasis of blood. this is turn leads to wide spread retinal hemorrhages along the distribution of involved branch retinal vein. nasir ahmad chaudhry, et al 232 pakistan journal of ophthalmology, 2020, vol. 36 (3): 231-235 resulting hypoxia leads to production of vascular endothelial growth factor (vegf). vegf causes proliferation of abnormal new vessels, which are leaky and have increased permeability. this ultimately leads to swelling of the macula, termed as macular edema6. macular edema (me) occurs due to accumulation of extracellular fluid within the retina because of break down in blood retinal barrier7. fluid accumulates primarily in the outer plexiform and inner nuclear layers8,9. there have been several therapeutic modalities for the treatment of macular edema secondary to brvo, which include both interventional and pharmacological therapies. the earliest of all interventional procedures was laser photocoagulation10-11. among pharmacological therapies, people have been using topical non-steroidal anti-inflammatory drugs, oral acetazolamide, corticosteroids, sub-tenon steroid and intravitreal injections to treat macular edema12. intravitreal dexamethasone was initially used to reduce inflammatory cytokines in addition to stabilizing vascular membranes13. later, intra-vitreal triamcinolone was used14. latest modality is antivegf treatment that inhibits growth of new vessels offering a better era of treatment of macular edema in brvo15. these anti-vegf includes aflibercept, ranibizumab16, bevacizumab17 and pegaptanib18. bevacizumab is used off label but is the most commonly used due to its low cost19. the purpose of our study was to see the improvement in visual acuity (as per snellen chart) and anatomy of macula (macular thickness on oct) after the use of intravitreal antivascular endothelial growth factor (anti-vegf). material and methods single arm, single centre, open-label, prospective quasi-experimental study was conducted at the institute of ophthalmology, king edward medical university/mayo hospital lahore. patients with macular edema secondary to brvo were diagnosed on fundus examination and confirmed on oct (macular thickness > 300 μm). treatment regimen was on as needed basis. all the patients suffering from other diseases leading to macular edema like diabetic retinopathy, epi-retinal membrane (erm), any history of surgery involving posterior segment, vitreoretinal traction and any history of intravitreal vegf or steroids were excluded from the study. applying inclusion and exclusion criteria, 40 eyes of 40 patients with a diagnosis of macular edema due to brvo were included. participants of the study were informed about the details of study and an institutional permission of ethical board was taken. all the participants were examined by a single observer in order to reduce bias. complete examination of anterior and posterior segment was done. visual acuity was recorded using snellen’s visual acuity chart. oct macula was done to measure macular thickness. intravitreal injection of bevacizumab 1.25mg /0.05ml was given in operation theatre taking aseptic measures. decision of second injection was based on macular thickness on oct (> 300 μm) and visual acuity (< 6/12). patients were followed up at 1 month, 3 months, 6 months and after 12 months. on each follow-up, visual acuity was measured with snellen chart and oct macula was done. collected data was analyzed using spss 20. results mean age of the patients was 52.12 ± 5.63 years. hypertension was found in 60% (24 patients) patients, ischemic heart disease in 10% (4 patients), diabetes in 15% (6 patients), cerebrovascular accidents were found to be in 2.5% of the patients, while hematological disorders were present in 7.5% (3 patients). all these factors were compared with outcome using chi-square test. it was found that none of them was associated with outcome (p-value was more than 0.05). this showed that outcome of macular edema was independent of these factors. at presentation va of 6/9 to 6/12 was found in 7 patients, 6/18 – 6/24 in 12 patients, 6/36 – 6/60 in 14 table1: number of injections per patient. no. of patients no of injections given percentage 2 1 5% 5 2 12.5% 6 3 15% 12 4 30% 15 5 – 7 37.5% 40 100% patients and counting finger or worse in 7 patients. number of patients presenting with supero-temporal outcomes of intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion pakistan journal of ophthalmology, 2020, vol. 36 (3): 231-235 233 brvo were 14. twenty-four patients had inferotemporal brvo while 4 had macular brvo. visual acuity improved to 6/6 in 60% cases, 6/9 – 6/12 in 7.5% cases, 6/18 – 6/24 in 20% cases and 6/36 – 6/60 in 12.8% cases in 12 months. further details of improvement in visual acuity are shown in table 2. efficacy of this treatment was found significant functionally by applying paired sample t-test. p-value was less than 0.005. this proves the functional outcome of intravitreal bevacizumab (table 3). the mean central retinal thickness at presentation was 540 table 2: functional improvement after injection. visual acuity no of patients improved after therapy after 1 month after 3 months after 6 months after 12 months 6/6 0 1 6 24 6/9 to 6/12 11 16 21 3 6/18 to 6/24 16 14 9 8 6/36 to 6/60 13 9 4 5 table 3: statistical significance of visual improvement. variables p-value va at presentation and va at 12 months 0.000 va at presentation & va at 1 month 0.000 va at 3 months & va at 6 months 0.000 va at 6 months & va at 12 months 0.000 table 4: anatomical improvement after injection. duration (follow-up) central macular thickness (μm) basal thickness at presentation 540 ± 120 1 month 430 ± 90 3 month 360 ± 110 6 month 270 ± 60 12 month 210 ± 40 540 230 430 360 270 210 0 100 200 300 400 500 600 presentation 1 month 3 months 6 months 1 year macular thickness graph 1: macular thickness at different times after injection. ± 120 that reduced to 430 ± 90 at 1 month, 360 ± 110 at 3 months, 270 ± 60 at 6 months and 210 ± 40 at 1 year. (table 4, figure 1). discussion our study demonstrates the safety and beneficial outcomes of bevacizumab in terms of improvement in visual acuity (va) and decrease in macular thickness, in patients with macular edema secondary to brvo. in this prospective study baseline visual acuity was 6/12 or better in 17.5% of the patients. after 1 month, 27.5% of the patients had va of 6/12 or better. trend towards further improvement in va was seen on successive follow-ups. the bervolt study showed significant improvement in visual acuity and decrease in central macular thickness with no adverse events with intravitreal bevacizumab in macular edema due to brvo20. in a local, single center study done by azhar et al, baseline macular thickness was 358 ± 36 µm. at one month, 2 months and 3 months macular thickness reduced to 326 ± 34 µm, 295 ± 34 µm and 252 ± 12 µm respectively. the macular thickness was below 300 µm, as early as 2 months after intravitreal bevacizumab. in this study regimen was three consecutive injection of bevacizumab at one monthly interval21. in our study higher baseline macular thickness was noted and macular thickness was below 300 µm after approximately 6 month follow up. this is in accordance with a study done by kondo m., et al22. they showed that macular thickness decreased significantly from 523 to 305 µm during the 12-month follow-up period. maximum number of intravitreal bevacizumab injections given to a single patient were 0724. in our study 95% of the patients required more than one injection of bevacizumab. this study is limited to single center. prospective multi center trials are needed to highlight the safety and effectiveness of this treatment modality. conclusion intravitreal bevacizumab is a safe treatment modality. it can be used for treatment of macular edema secondary to brvo. it results in improvement in visual acuity and also helps in the return of macular thickness over time to normal. ethical approval the study was approved by the institutional review board/ethical review board. nasir ahmad chaudhry, et al 234 pakistan journal of ophthalmology, 2020, vol. 36 (3): 231-235 conflict of interest authors declared no conflict of interest. authors’ designation and contribution nasir ahmad chaudhry; professor: supervisor of this project, study design, final manuscript review. sarmad zahoor; medical officer: data collection and analysis, statistical work. usama iqbal; post graduate resident: manuscript writing and final review muhammad owais sharif; senior registrar: data collection, article review. muhammad sharjeel; assistant professor: data collection and compiling, final review, discussion writing. asima rafique; post graduate resident: data collection, manuscript writing, final review references 1. rogers s, mcintosh rl, cheung n, lim l, wang jj, mitchell p, kowalski jw, nguyen h, wong ty. international eye disease consortium: the prevalence of retinal vein occlusion: pooled data from population studiesfrom the united states, europe, asia, and australia. ophthalmology, 2010; 117: 313–319. 2. klein r, moss se, meuer sm, klein be. the15-year cumulative incidence of retinal vein occlusion: the beaver dam eye study. arch ophthalmol. 2008; 126: 513–518. 3. hayreh ss, zimmerman b, mccarthy mj, podhajsky p. systemic diseases associated with various types of retinal occlusion. am j ophthalmol. 2001; 131: 61–77. 4. cugati s, wang jj, rochtchine e, mitchell p. tenyear incidence ofretinal vein occlusion in an older population: the blue mountain eye study. arch ophthalmol. 2006; 124: 726–732. 5. rath ez, frank rn, shin dh, kim c. risk factors for retinal vein occlusion. a case-control study. ophthalmology, 1992; 99: 509–514. 6. aiello lp, avery rl, arrig pg, keyt ba, jampel hd, shah st, et al. vascular endothelial growthfactor in ocular fluid of patients with diabetic retinopathy and otherretinal disorders. n engl j med. 1994; 331: 1480– 1487. 7. bringmann a, reichenbach a, wiedemann p. pathomechanisms of cystoid macular edema. ophthalmic res. 2004; 36: 241-249. doi: 10.1159/000081203. 8. kent d, vinores sa, campochiaro pa. macular oedema: the role of soluble mediators. br j ophthalmol. 2000; 84: 542-545. 9. the branch vein occlusion study group. argon laserphotocoagulation for macular edema in branch vein occlusion. am j ophthalmol. 1984; 98: 271-282. 10. raszewska-steglinska m, gozdek p, cisiecki s, michalewska z, michalewski j, nawrocki j. parsplana vitrectomy with ilm peeling for macular edema secondaryto retinal vein occlusion. eur j ophthalmol. 2009; 19: 1055-1062. 11. fekrat s, goldberg mf, finkelstein d. laser-induced chorioretinal venous anastomosis for non-ischemic central or branch retinal vein occlusion. arch ophthalmol. 1998; 116: 43-52. 12. hahn p, fekrat s. best practices for treatment of retinal vein occlusion. curr opin ophthalmol. 2012; 23 (3): 175–181. 13. haller ja, bandello f, belfort jr r, blumenkranz ms, gillies m, heier j, et al. ozurdexgeneva study group. randomized, sham-controlled trial ofdexamethasone intravitreal implant in patients with macularedema due to retinal vein occlusion. ophthalmology, 2010; 117: 1134-1146. 14. park sp, ahn jk. changes of aqueous vascular endothelialgrowth factor and interleukin-6 after intravitreal triamcinolonefor branch retinal vein occlusion. clin experiment ophthalmol. 2008; 36: 831835. 15. lee jh, canny md, de erkenez a, krilleke d, ng ys, shima dt, et al. a therapeutic aptamer inhibits angiogenesis by specifically targeting the heparin binding domain of vegf165. proc natl acad sci u sa. 2005; 102: 18902-18907. 16. ferrara n, damico l, shams n, lowman h, kim r. development of ranibizumab, an anti-vascular endothelial growth factor antigen binding fragment, as therapy for neovascular age-related macular degeneration. retina, 2006; 26: 859-870. 17. ferrara n, hillan kj, gerber hp, novotny w. discovery and development of bevacizumab, an antivegf antibody for treating cancer. nat rev drug discov. 2004; 3: 391-400. 18. wroblewski jj, wells ja, adamis ap, buggage rr, cunningham et, goldbaum m, et al. pegaptanib sodium for macular edema secondary to central retinal vein occlusion. arch ophthalmol. 2009; 127: 374-380. 19. abegg m, tappeiner c, wolf-schnurrbusch u, barthelmes d, wolf s, fleischhauer j. treatment of branch retinal vein occlusion induced macular edema with bevacizumab. bmc ophthalmology, 2008 dec; 8 (1): 18. 20. kornhauser t, schwartz r, goldstein m, neudorfer m, loewenstein a, barak a. bevacizumab treatment of macular edema in crvo and brvo: long-term follow-up. (bervolt study: bevacizumab for rvo long-term follow-up). graefe's arch clin exp outcomes of intravitreal bevacizumab for macular edema secondary to branch retinal vein occlusion pakistan journal of ophthalmology, 2020, vol. 36 (3): 231-235 235 ophthalmol. 2016; 254 (5): 835-844. 21. azhar mn, muzaffar w, arain ma, farooq o. intravitreal bevacizumab (ivb) for macular edema secondary to branch retinal vein occlusion (brvo). j coll phys surg pak. 2018 oct. 1; 28 (10): 758-61. 22. kondo m, kondo n, ito y, kachi s, kikuchi m, yasuma tr, ota i, miyake k, terasaki h. intravitreal injection of bevacizumab for macular edema secondary to branch retinal vein occlusion: results after 12 months and multiple regression analysis. retina, 2009; 29 (9): 1242-8. .……. pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 188 original article role of topical cyclosporine in prevention of pterygium recurrence, after primary excision munawar ahmed, atif mansoor, noman ahmed, ghazi khan mari, azfer ahmed mirza pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: munawar ahmed associate professor, institute of ophthalmology liaquat university of medical & health sciences jamshoro e-mail: munawar_404@yahomail.com …..……………………….. purpose: to study the effect of cyclosporine on pterygium recurrence after primary excision study design: non randomized controlled trial. place and duration of study: the study was conducted in the department of ophthalmology, liaquat university of medical and health sciences, jamshoro from 2015 to 2017. material and methods: one hundred and thirty eyes of 65 patients having bilateral pterygium, at least 2 mm encroaching on the cornea, were selected for study. dimensions of pterygium were measured on slit lamp. half of the eyes were selected for post-operative cyclosporine and was named as cycloeye and fellow other eye was named as non-cyclo eye. immediate post-operative treatment was tobramycin dexamethasone eye ointment twice and moxifloxacin eye drops three times daily until corneal epithelium was restored, followed by moxifloxacin and cyclosporine eye drops twice daily until complete healing of ocular surface occurred and then cyclosporine 0.05% alone once daily in the evening up to three months. in the fellow eye tobramycin dexamethasone eye ointment and moxifloxacin eye drops were used for complete healing time followed by tears alone three times for three months. follow up was done for six months. results: only fifty-three patients who completed 6 months of follow-up were included in the results. in cyclo-eyes recurrent pterygium was observed only in 4 (07.55%) and in non-cyclo eyes recurrence was observed in 23 (43.40%) eyes. mean healing time in cyclo-eyes was 21.1354 days and in non-cyclo-eyes, 15.0213 days. conclusion: cyclosporine is effective in reducing the recurrence rate of pterygium. key words: pterygium, cyclosporine, cornea. terygium is a fibrovascular growth of conjunctiva over cornea at 3 and 9 o’ clocks. it occurs most commonly in hot, dry and dusty atmosphere, which makes ocular surface dry, inviting the conjunctival blood vessels to reach the cornea. as cornea is avascular structure, it cannot maintain its integrity without sufficient tears for the outdoor workers in hot and dry atmosphere. the degenerative changes in pterygium formation is accompanied by cellular proliferation and vascularization of corneal surface. secretion of pro-inflammatory substances such as interleukin-1 and tumor necrosis factor-α secondary to long time ultraviolet (uv) radiation, is a main known factor in the formation of pterygium1,2. the vascular endothelial growth factor (vegf), also increases in pterygium epithelium which is stimulated p munawar ahmed, et al 189 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol by tnf-α through uvb radiation3,4. ultraviolet induced inflammation and release of cytokines stimulates proliferation of tenon’s capsule fibroblasts to produce fibrovascular tissue of pterygium5. if pterygium is left untreated it involves visual axis and leads to loss of vision. many procedures are done to treat this problem for example, simple excision, use of conjunctival autograph and amniotic membrane. as a medical treatment, interferon, mmc, and anti vegf are also used but they are expensive and may have complications and they do not have additional benefit of treating the dry eyes. so, we conducted study on cyclosporine-a which is already being used to treat dry eyes and safe even for long term use6. cyclosporine is an immune modulating substance. it is derived from the fungus to lypocladium inflatum and approved by world health organization as a safe medicine. it decreases the production of inflammatory cytokines by t-lymphocytes. it has also been used topically to reduce sub-epithelial infiltrates in epidemic keratoconjunctivitis6. systemic use can increase the risk of lymphoma. cyclosporine-a shows a selective effect against thelper cells and prevents the synthesis and secretion of ils. cs-a also blocks angiogenic effect induced by vegf. therefore, we have evaluated the effects on pterygium recurrences. the aim of this study was to investigate the outcome of topical cs-a in prevention of pterygium recurrence after simple excision. material and methods a comparative study on 130 eyes of 65 patients having bilateral pterygium, encroaching on the cornea at least 2 mm, was done using convenient sampling. the study was conducted in the department of ophthalmology, liaquat university of medical and health sciences, jamshoro from 2015 to 2017. the patients with pseudo-pterygium and other causes of corneal vascularization were excluded from study. after informed consent and explanation of research procedure, patients were seen on slit lamp, the extent of pterygium was assessed. half of the eyes with pterygium were selected for post-operative cyclosporine and were named as cyclo-eyes and half fellow eyes were selected for simple excision done by the same surgeon after an interval of one to two week and were named as non-cyclo eyes. immediate postoperative treatment was tobramycin dexamethasone eye ointment twice and moxifloxacin eye drops three times daily until corneal epithelium was restored, followed by moxifloxacin and cyclosporine 0.05% eye drops twice daily until complete healing of ocular surface. then moxifloxacin was stopped and only cyclosporine 0.05% eye drops once daily in the evening were continued upto three months. in the fellow eye only tobramycin dexamethasone eye ointment and moxifloxacin eye drops were used for complete healing time followed by tears three times daily up to three months. follow up was done after one week, one month, three months and six months. one mm growth of conjunctival blood vessels on the cornea was considered as recurrence. the results of cyclo-eyes were compiled and compared with the fellow eyes and processed on spss to see the significance. the results were evaluated by spss 2014. the variables used were healing time and pterygium recurrence period in days. quantitative data were evaluated by independent samples t-test, paired ttest, and chi-square test. results fifty-three out of 65 patients who completed 6 months follow up were included in the final results. in cycloeyes recurrent pterygium was observed in 04 (07.55%) patients and recurrence in fellow non-cyclo eyes occurred in 23 (43.40%) patients (table 1). table 1: bio data of patients having bilateral pterygium (n=53 each group). total no: of eyes 106 (100.0%) male 31 (58.49%) female 22 (41.51%) average age 51.00 years cyclo-eyes 53 (50.00%) non cyclo-eyes 53 (50.00%) extent of pterygium 2 mm to 4 mm table 2: comparisons of results after 6 months follow up (n=53 each group). groups cyclo-eyes non-cyclo-eyes no: of eyes 53 (50.00%) 53 (50.00%) recurrence 04 (07.55%) 23 (43.40%) mean healing time 21.1354 days 15.0213 days standard deviation 1.3412 1.0413 p-value 0.002 0.004 complications none none role of topical cyclosporine in prevention of pterygium recurrence, after primary excision pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 190 immediate post-operative use of cyclosporine interferes with healing process. it takes longer time for healing of corneo-scleral wound produced by pterygium excision. mean healing time in cyclo-eyes was 21.1354 ± 1.3412 days and in non-cyclo-eyes was 15.0213 ± 1.0413 days. p-value was 0.002 and 0.004 respectively (table 2). fig. 1: pterygium shown pre and postoperatively. fig. 2: post op picture with cyclosporin eye drops after 2 weeks and with no cyclosporine drops after 2 weeks. discussion pterygium is a growth disorder rather than degenerative condition, and mainly proliferative factors are investigated to find out etiology and pathogenesis. as sutures can increase the risk of recurrence therefore bare sclera suture-less technique was used in our patients. a definitive treatment without recurrence and minimal complications, has yet to be found. the main culprits for pterygium are uv radiation, dry and hot atmosphere, which, leads to release of inflammatory vascular growth factors and formation of pterygium. it varies in people living in the same environment. hypersensitivity is also a powerful factor in the pathogenesis of pterygium7. t-lymphocytes are elevated in the pterygium tissue. all available data shows the importance of tlymphocyte-mediated strong cellular immunity in pterygium pathogenesis. cs-a selectively suppresses functions of t-helper lymphocytes and production of both inflammatory cytokines and inflammatory mediators. it also suppresses ige production in a t-celldependent manner and inhibit histamine release from basophil and mast cells8. in vivo and in vitro studies have showed that csa inhibits angiogenesis triggered by vegf. we believed that inhibiting all those paths with cs-a, which are thought to have a role in pterygium pathogenesis, might be effective in preventing recurrence9. cs-a 0.05% is effective in inhibiting the fibroblasts proliferation in tenon’s capsule10. in another similar study, thiotepa and cyclosporine were compared following pterygium excision where cs-a was found to be significantly more effective than thiotepa11. in turan-vural study recurrence rate was 44.4% in simple bare sclera technique but 22.2% with 0.05% post-operative cyclosporine and no side effect except mild burning sensation. they also used fellow eye as control in patients having bilateral pterygium and reported recurrence in 12.9% with cyclosporine and 45.2% in simple bare sclera technique12,13. in literature, recurrence of pterygium after simple excision exceeds 50%. in our study, we have used tears for three months which might have reduced the recurrence rate even in simple excision. topical cs-a plays a role in the inhibition of t lymphocyte proliferation and suppression of the inflammation of the ocular surface. it is reported in literature that topical cs-a is effective in various concentrations in ocular inflammation cases such as vernal keratoconjunctivitis, ulcerative keratitis in rheumatoid arthritis, anterior uveitis, corneal graft rejection, superior limbic keratoconjunctivitis, graft versus host disease, mycotic keratitis, cogan syndrome, behçet’s disease, herpetic stromal keratitis, mooren ulcer, atopic keratoconjunctivitis and scleritis14. topical 0.05% cs-a relieves dryness of eyes in meibomian gland dysfunction without significant systemic or ocular side effects when compared to bevacizumab and mitomycin-c15. treatment of patients with dry eye disease for 12 months with topical 0.05% cs-a does not cause changes in the corneal endothelium.16 according to munawar ahmed, et al 191 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol duke-elder, pterygium occurs frequently on the nasal side of conjunctiva. this can be explained on the basis of light, which is coming to the temporal cornea and focused on the nasal side. pterygia on the temporal side are rare and should be differentiated from squamous cell tumor. double-headed pterygium, is very rare, only 2.5%17. in a retrospective study, it was seen that pterygium recurrence rate was 5.3% with glue, versus 13.5% with sutures in conjunctival autograft18. recurrence of 3.3% was reported with stem cell graft by another researcher19. our recurrence rate was 06% in the cyclosporine group, which was more than the recurrence observed by aydin et al18. (3.4%), but lower than observed by tok et al. (12.9%)17. it may be higher than observed by aydin et al because of the study population of only vascularized and recurrent pterygium, which is more prone for higher recurrence compared to primary pterygium20. conclusion this short-term study has given promising results in reducing pterygium recurrence after primary excision. as pterygium is common in tear deficient eyes. it worsens with advancing age. cyclosporine is effective in reducing the ocular surface dryness and pterygium recurrence. neat and clean pterygium excision and post-operative topical use of cyclosporine is very safe and effective method to prevent recurrence of pterygium. long term use of cyclosporine 0.05% eye drops twice daily is harmless to the ocular surface and intraocular structures. this is cheaper and safer method and should be adopted to reduce the risk of pterygium recurrence. therefore, use of cyclosporine after primary excision is recommended. acknowledgement i am thankful to my professor sameen afzal junejo who always encouraged us for research projects. references 1. di giriloma n, chui j, coreneo mt, wakefield d. pathogenesis of pterygia: role of cytokines, growth factors, and matrix metalloproteinases. prog retin eye res. 2004; 23 (2): 195–289. 2. girolama nd, kumar rk, cornea mt, wakefield d. uvb. mediated indication of interleukin-6 and 8 in pterigia and cultured human pterigium epithelial cells. inves opthalmol vis sci. 2002; 143 (119): 3430–3437. 3. coroneo mt, girolamo n, wakefield d. the pathogenesis of pterygia. curr opin ophthalmol. 1999; 10: 282–288. 4. chan cm, liu yp, tan dt. ocular surface changes in pterygium. cornea. 2002; 21: 38–42. 5. turan-vural e, torun-acar b, kivanc sa, acar s. the effect of topical 0.05% cyclosporine on recurrence following pterygium surgery. clin ophthalmol. 2011; 5: 881–885. 6. okumus s, coskun e, tatar mg, kaydu e, yayuspayi r, comez a et al. cyclosporine a 0.05% eye drops for the treatment of subepithelial infiltrates after epidemic keratoconjunctivitis. bmc ophthalmol. 2012; 18: 12: 42. 7. nakamura m, nishida t. differential effects of epidermal growth factor and interleukin 6 on corneal epithelial cells and vascular endothelial cells. cornea, 1999; 18 (4): 452–458. 8. nussenblatt rb, palestine ag. cyclosporine: immunology, pharmacology and therapeutic uses. surv opthalmol. 1986; 31: 159–169. 9. okudaira h, sakurai y, terada k, terada e, ogita t, miyamoto t. cyclosporin a-induced suppression of ongoing ige antibody formation in the mouse. int arch allergy appl immunol. 1986; 79 (2): 164-8. pubmed pmid: 3484729. 10. hercules la, viveiros mm, schellini sa, cadeias j, padovani cr. exposure of tenon’s capsule fibroblasts of pterygium to cyclosporin 0.05% arg bras oftalmol. 2006; (69): 831–834. 11. wu h, chen g. cyclosporine a and thiotepa in prevention of postoperative recurrence of pterygium. yan ke xue bao. 1999; 15 (2): 91–92. 12. turan-vural e, torun-acar b, kivanc sa, acar s. the effect of topical 0.05% cyclosporine on recurrence following pterygium surgery. clin ophthalmol. 2011; 5: 881–885. 13. hwang s, choi s. a comparative study of topical mitomycin c, cyclosporine, and bevacizumab after primary pterygium surgery. korean j ophthalmol. 2015; 29 (6): 375-81. 14. irfan s, iqbal h. role of topical cyclosporine in scleritis; a case series. pak j ophthalmol. 2013; 29 (2): 68-72. 15. pérez-rico c, germain f, castro-rebollo m, morenosalgueiro a, teus má. effect of topical 0.05% cyclosporine a on corneal endothelium in patients with dry eye disease. int j ophthalmol. 2013 aug 18; 6 (4): 471-4. 16. duman f, köşker m. demographics of patients with double-headed pterygium and surgical outcomes. turk j ophthalmol. 2015 dec; 45 (6): 249-253. 17. tok o y, nurozler ab, ergun g, kocaoglu af, duman s. topical cyclosporine a in the prevention of pterygium recurrence. ophthalmologica. 2008; 222 (6): 391-6. doi: 10.1159/000151740. 18. aydin a, karadayi k, aykan u, can g, colakoglu k, bilge ah. effectiveness of topical ciclosporin a treatment after excision of primary pterygium and limbal conjunctival autograft. j fr ophtalmol. 2008 sep; role of topical cyclosporine in prevention of pterygium recurrence, after primary excision pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 192 31 (7): 699-704. 19. zahid n, qayyum i, hanif a. comparison of recurrence after pterygium excision with amniotic membrane graft versus stem cell graft pak j ophthalmol. 2018; 34 (1): 15-18. 20. dhar sk, kapoor g, parihar jks. role of pre and postoperative topical cyclosporine (0.05%) on recurrent and vascularized pterygium. iosr jdms. 2017; 16 (1): 23-25. author’s affiliation munawar ahmed associate professor ophthalmology liaquat university of medical and health sciences jamshoro dr. noman ahmed assistant professor liaquat university of medical and health sciences jamshoro dr. atif mansoor ahmed associate professor shaikh zayed pgmi & medical complex lahore dr. ghazi khan mari assistant professor liaquat university of medical and health sciences jamshoro dr. azfer ahmed mirza assistant professor liaquat university of medical and health sciences jamshoro author’s contribution dr. munawar ahmed study design, data collection, manuscript writing. dr. noman ahmed data collections, manuscript writing. dr. atif mansoor ahmed shared his experience regarding topical use of cyclosporine. dr. ghazi khan mari surgical management, critical review of manuscript. dr. azfer ahmed mirza data collection, manuscript writing. 109 pak j ophthalmol. 2020, vol. 36 (2): 109-113 original article pain score in adjustable strabismus surgery sana nadeem 1 1 department of ophthalmology, fauji foundation hospital, rawalpindi abstract purpose: to assess the pain experienced by patients at the time of suture adjustment using topical proparacaine hydrochloride 0.5% anesthesia, in adjustable suture strabismus surgery. study design: prospective, interventional study. place and duration of study: eye department of fauji foundation hospital, rawalpindi from may, 2017 to march, 2019. methods: a prospective study was carried out to assess the pain experience of patients undergoing suture adjustment under topical proparacaine hydrochloride 0.5% anesthesia, during routine adjustable squint surgery. all surgeries were performed under general anesthesia with suture adjustment done 1 hour or more after surgery when the effects of general anesthesia had worn off. horizontal and vertical muscle recessions and resections were included along with inferior oblique surgeries, and transposition procedures. the patients were given the ‘wong-baker faces ® pain rating scale’; along with a ‘numeric pain rating scale’ from 0 to 10 (0 signifying ‘no pain’ and 10 signifying ‘worst possible pain’) on a proforma. the response of the patients was noted. results: thirty three patients who underwent adjustable strabismus surgery were included in this study. the mean age was 19.1 ± 11.1 years. the average number of muscles operated upon for each patient were 2.87 ± 1.08. the patients’ response to the ‘wong-baker faces ® pain rating scale’ ranged from 0 to 8, with a mean of 2.03 ± 1.81 sd. on the ‘numeric pain rating scale’ a similar response was obtained with a mean of 2.0 ± 1.82 sd. augmentation of anesthesia was not needed in any patient. conclusion: adjustment of sutures under topical proparacaine hydrochloride 0.5% anesthesia after strabismus surgery is a practical, comfortable and safe procedure. key words: adjustable suture, strabismus, pain score, pain scale, topical anesthesia. how to cite this article: nadeem s. pain score in adjustable strabismus surgery. pak j ophthalmol. 2020, 36 (2): 109-113. doi: 10.36351/pjo.v36i2.912 introduction adjustable suture strabismus surgery was first described in 1907 by bielchowsky thus allowing the correspondence: sana nadeem assistant professor, department of ophthalmology fauji foundation hospital, rawalpindi received: september 24, 2019 accepted: march 15, 2020 surgeon a second chance at realigning the eyes and improving his results. jampolsky in 1975 described a two-stage adjustable strabismus technique, with the surgery performed under general anesthesia and suture adjustment done later under topical anesthesia, 4 – 24 hours after surgery to fine tune the results. 1-3 tripathi 3 et al believe that adjustable strabismus surgery is the procedure of choice for all fit and willing patients. awadein and guyton et al 4 recommend adjustable sutures in all patients including infants and children as well. pain score in adjustable strabismus surgery pak j ophthalmol. 2020, vol. 36 (2): 109-113 110 topical anesthesia with proparacaine hydrochloride 0.5% has been a safe and effective tool during the final suture adjustment and has been advocated by many strabismus surgeons. 4,5,6 seijas et al recommend topical anesthesia only, for strabismus surgery even without the need of a general anesthetic. 7 the rationale of our study was to assess the pain score at the time of suture adjustment after strabismus surgery using two scales, in order to find out if it is a comfortable and effective procedure. methods a total of 33 patients were included in this study by convenient sampling technique. the study was carried out in the department of ophthalmology, fauji foundation hospital, rawalpindi; a tertiary care teaching hospital affiliated with the foundation university medical college. approval from the ethical committee was taken. horizontal, vertical and complex strabismus cases were included along with patients with a previous history of strabismus surgery. myasthenia gravis and uncooperative children less than 7 years of age were excluded. a detailed ocular assessment was done and bestcorrected visual acuity was documented for every case. refractive correction was given to the patients before surgery. the prism cover test (pct) was used to assess the preoperative angle of deviation with the refractive correction in place, for both near and distance in primary gaze position, as well as in 25° of upgaze (chin down) and 35° of downgaze (chin up), right and left gaze, and head tilt in case of paralytic strabismus. 8 in certain cases of sensory strabismus with poor fixation, the krimsky test was used for analysis of the angle or a pen torch used as a target for near and distance. the distance angle in primary position with the refractive correction in place was considered as the angle of deviation in all cases, and the surgical alignment was sought to correct this angle, although at the time of suture adjustment, both near and distance alignment was corrected. exception to this was accommodative refractive esotropia, for which the near deviation with distance spectacles in place was considered for correction of the alignment. the measurements were taken by the operating surgeon and repeated one day prior to the surgery, to obtain maximum cosmesis. extraocular motility was checked with muscle overaction graded from +1 to +4 and underaction graded from -1 to -5. binocular vision and stereopsis were assessed by the titmus fly test and worth four dot test in every case. a thorough eye examination was performed including fundus and intraocular pressures. in case of significant oblique overaction, paralytic or vertical strabismus, fundus torsion was also assessed with the indirect ophthalmoscope. all surgeries were performed by the author under general anesthesia. a drop of phenylephrine 10% (ethifrin ® ) was instilled into the conjunctival sac prior to the surgery in each eye. the fornix approach for strabismus surgery was used in every case. each muscle was hooked, and then secured with a double armed 6 – 0 vicryl (polyglactin 910) absorbable suture, which was passed through the sclera at muscle insertion, or transposed above or below the insertion in case of “a” or “v” patterns, in a ‘hang-back’ fashion. the muscles placed for adjustable purpose were held in position by guyton‟s modification of the sliding noose knot, which was fashioned with a 6 – 0 vicryl suture. 9 the amount of ‘hang-back’ recession was calculated for each patient using standard tables. 10-12 the traction suture for holding the sclera for postoperative adjustment was created with ethibond 5-0 in every case. for the nonadjustable recessions, the muscle was tied and allowed to ‘hang-back’ from its insertion, with the amount of recession calculated as required. for resections, the amount of resection was overcorrected by 2 mm, and allowed to ‘hang-back’ for this distance, to be adjusted if required postoperatively. at least one muscle was kept on an adjustable sliding noose knot per case; with complex strabismus, all muscles were kept on adjustable sutures. all patients were assessed for alignment and final adjustment at least 1 hour or more after surgery, in the recovery room, to allow the effects of general anesthesia to wear off. the eyes were anesthetized topically with alcaine ® (proparacaine hydrochloride 0.5%) eye drops a few times. the patients were fully conscious at the time of suture adjustment and were not placed on a monitor. however, they were observed for discomfort, syncope or oculocardiac reflex. the patients were assessed with the cover-uncover test at distance and near, with a torch light for distance if the vision was blurred, or a distance readable target; and for near an accommodative target was used. if the alignment was satisfactory, with no movement on cover testing, the sutures were tied off in their existing position, held in place by the sliding noose, which was removable after tying the ends of the muscle sutures. sana nadeem 111 pak j ophthalmol. 2020, vol. 36 (2): 109-113 thereafter, the traction knot was cut, and the conjunctiva was sutured with at least one 6-0 vicryl suture. the final tying off point was orthotropia or maximum possible under-correction as required. in cases of exotropia, the goal was orthotropia or mild esotropia. in cases of esotropia, the goal was either orthotropia, if achieved, or slight under-correction. topical steroid and antibiotic drops and ointment were instilled. no bandage was applied in any case. the next day, the patients were asked about their pain experience by giving them a proforma with two scales; the ‘wong-baker faces ® pain rating scale 13 ‟ and a ‘numeric pain rating scale 14 (nprs)‟. the wong-baker scale is a pain grading scale which was developed by donna wong and connie baker, depicting a series of 6 faces starting from a happy face with 0 or ‘no hurt’ to a weeping face at 10 representing ‘worst pain imaginable’ (figure 1). this scale was initially developed for children, but nowadays is used for patients 3 years and above. the numeric pain rating scale is a unidimensional assessment of pain severity in adults and is a segmented numeric version of the visual analog scale (vas). it ranges from 0-10 with 0 representing ‘no pain’, 5 representing „moderate pain’ and 10 representing „worst possible pain’ (figure 2). fig. 1: fig. 2: numeric pain rating scale. the patients were explained each scale and asked to point their level of pain on each scale with a finger. the name, age and gender of the patient, type of strabismus, diagnosis, surgery performed and the number of muscles operated upon, were filled on each performa. the results were noted, tabulated and analyzed using spss statistics version 20. frequencies and percentages were calculated for age, gender, type of strabismus, surgical procedure performed, number of muscles and the pain score. paired t-tests were used to assess the effect of number of muscles operated upon on the pain score. results a total of 33 consecutive patients with strabismus presenting to us were included in this study. the mean age was 19.1 ± 11.1 years (range 7 – 69). majority of the patients were female (81.8%) and the rest were male (18.2%). the deviation type in the majority of the patients was exotropia in 14 (42.5%) cases (table 1). table 1: type of deviation. type of deviation frequency (percent) exotropia 14 (42.4) esotropia 7 (21.2) esotropia & dvd ɸ 2 (6.1) exotropia & hypertropia 4 (12.1) esotropia & hypertropia 1 (3) esotropia & hypotropia 3 (9.1) exotropia & hypotropia 2 (6.1) horizontal 13 (39.4) horizontal and vertical 4 (12.1) complex € 13 (39.4) horizontal & complex € 2 (6.1) horizontal, vertical & complex € 1 (3) ɸ dissociated vertical deviation € sensory, monocular elevation deficit, paralytic strabismus, nystagmus or dvd table 2 outlines a list of surgeries performed for the primary deviation. the average number of muscles operated upon for each patient were 2.87 ± 1.08 (range 2-6). the patients‟ response to the ‘wong-baker faces ® pain rating scale’ ranged from 0 to 8, with a mean of 2.03 ± 1.81 sd, signifying ‘hurts little bit’. on the ‘numeric pain rating scale’ a similar response was obtained with a mean of 2.0 ± 1.82 sd (range 0 – 8), signifying mild discomfort. only one patient complained of significant pain, rating 8 on both scales, but in this case too, no additional anaesthesia was needed and adjustment was performed successfully. she also had all three muscles on adjustable sutures, pain score in adjustable strabismus surgery pak j ophthalmol. 2020, vol. 36 (2): 109-113 112 table 2: surgical procedures performed for primary deviation. a. horizontal muscle surgery. surgery frequency (percent) blrc ¶ 8 (24.2) bmrc § 8 (24.2) mrc ¤ + lrs × 1 (3) mrs ø + lrc ħ 7 (21.2) blrc ¶ + mrs ø 2 (6.1) bmrc § + lrs × 2 (6.1) mrc ¤ 2 (6.1) lrc * 1 (3) lrc ħ +mrs ø + mrc ¤ 1 (3) none 1 (3) ¶ bilateral recessions § bimedial recessions ¥ bimedial resections ¤ unilateral medial rectus recession × unilateral lateral rectus resection ø unilateral medial rectus resection ħ unilateral lateral rectus recession * unilateral lateral rectus recession b. vertical muscle surgery. surgery frequency (percent) none 17 (51.5) unilateral io α myectomy 4 (12.1) bilateral io α myectomies 6 (18.2) irc ϡ +io α myectomy 1 (3) bilateral io α myectomy + sr ω transposition 1 (3) irc ϡ + src ʃ 3 (9.1) irc ϡ 1 (3) α inferior oblique ω superior rectus ʃ superior rectus recession ϡ inferior rectus recession and this could have contributed to her discomfort. however, no correlation between the number of muscles operated upon and the pain scales was observed. 10 patients (30.3%) reported no pain whatsoever, scoring 0 on both scales. no complication of any kind was seen in any case during the suture adjustment procedure. discussion adjustable suture strabismus surgery has been done under many different types of anaesthesia. general anaesthesia is preferred for the initial procedure and final suture adjustment is done under topical anaesthesia. proparacaine hydrochloride 0.5% ophthalmic solution or proxymetacaine is topical anaesthetic of the aminoester drug group, which antagonizes the voltage-gated sodium channels to alter permeability of neuronal membranes. 15 topical anaesthesia has been found to be a safe and effective tool during suture adjustment in strabismus surgery 4 . sharma et al 5 reported that adjustable strabismus surgery under topical anaesthesia was a safe and better option than conventional recession-resection surgery for concomitant exodeviation. however, seijas et al 7 reported oculocardiac reflex in 3 patients for which atropine was given. they also suggested that monitoring by anaesthetist was necessary because of vagal reflex. none of our patients experienced any complication like that. mazow ml 16 also described good results following adjustable suture strabismus surgery but stressed upon the importance of good case selection. similarly 81.8% success was reported by park jm et al in adjustable suture strabismus surgery. 17 nowadays, many surgeons are striving for strabismus surgery under local anaesthesia only including retrobulbar, peribulbar, subconjunctival and subtenon injections or even topical anaesthesia only. for local anaesthetic injections, although the complications of general anaesthesia are avoided, at least 6 hours are required before adjusting sutures, to allow the effects of the local anaesthetics to wear off. 18-21 we prefer general anaesthesia for our strabismus surgeries in all cases, with suture adjustment under topical proparacaine hydrochloride 0.5% drops only, after 1 hour or more has elapsed after surgery, at which time the patient is fully conscious, able to obey commands and no longer under the effects of the general anaesthetics. this provides an accurate assessment of the residual strabismus. in our study, we found suture adjustment under topical proparacaine hydrochloride 0.5% to be safe, comfortable and reliable. all patients reported a good experience, with no or mild pain during suture adjustment, ranging from 0-4 on both scales, with the exception of one lady who reported significant pain at a rating of 8 on both scales. the number of muscles operated upon did not correlate with excessive pain on the pain scales. augmentation with other anaesthetic agents was not needed in any case, and neither was a reoperation required for any patient at a later time. no complications were seen during adjustment, and all patients were cooperative and adjusted on the same day. oculocardiac reflex was not observed in any patient during suture manipulation. topical sana nadeem 113 pak j ophthalmol. 2020, vol. 36 (2): 109-113 anaesthesia also saved time compared to the local anaesthesia procedures. limitations of this study are small sample size, but still we want to share our thoughts on adjustable strabismus pain score at this time. the findings of our study suggest adjustable strabismus surgery as a good technique for better cosmetic and functional results. conclusion final suture adjustment under topical proparacaine hydrochloride 0.5% drops is a safe, effective and comfortable procedure, with minimal pain experienced by patients. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest references 1. nihalani br, hunter dg. adjustable suture strabismus surgery. eye, 2011 oct; 25 (10): 1262-1276. 2. saxena r, dhiman r. commentary: adjustable strabismus surgery. indian j ophthalmol. 2019 feb; 67 (2): 263. 3. tripathi a, haslett r, marsh ib. strabismus surgery: adjustable good for all? eye, 2003; 17: 739-742. 4. awadein a, sharma m, bazemore gm, saeed ha, guyton dl. adjustable suture strabismus surgery in infants and children. j aapos. 2008; 12: 585-590. 5. sharma p, julka a, gadia r, chhabra a, dehran m. evaluation of single-stage adjustable strabismus surgery under conscious sedation. indian j ophthalmol. 2009; 57 (2): 121-125. 6. nadeem s, naeem ba, khan f. adjustable strabismus surgery: an early glance. pak j ophthalmol. 2018; 34 (2): 89-97. 7. seijas o, de liao gp, merino p, roberts cj, gómez de liao r. topical anesthesia in strabismus surgery: a review of 101 cases. j pediatr ophthalmol strabismus, 2009; 46 (4): 218-222. 8. kekunnaya r, mendonca t, sachdeva v. pattern strabismus and torsion needs special surgical attention. eye (london). 2015; 29 (2): 184-190. 9. deschler ek, irsch k, guyton kl, guyton dl. a new, removable, sliding noose for adjustable-suture strabismus surgery. j aapos. 2013; 17 (5): 524-527. 10. coats dc, olitsky se. strabismus surgery and its complications. springer: berlin, 2007. p: 37-39. 11. yanoff m, duker js. ophthalmology. third edition. mosby: st. louis, 2009; p 1331-1338. 12. lueder gt, archer sm, hered rw, karr dj, kodsi sr, kraft sp, et al. pediatric ophthalmology and strabismus. section 6. basic and clinical science course. american academy of ophthalmology. san francisco. 2015-2016; p 131-182. 13. wong-baker faces pain rating scale (internet) wikipedia contributors. wikipedia, the free encyclopedia; 4 december 2018 available from: https://en.wikipedia.org/w/index.php?title=wong baker_faces_pain_rating_scale&oldid=871901004 accessed: 30 april 2019. 14. numeric pain rating scale (internet) physiopedia contributors. physiopedia; 26 april 2019. available from:https://www.physiopedia.com/index.php?title=nu meric_pain_rating_scale&oldid=209667. accessed: 30 april 2019 15. proxymetacaine wikipedia, the free encyclopedia; available from: https://en.wikipedia.org/w/index.php?title= proxymetacaine&oldid=830475900. accessed: 1 may 2019. 16. mazlow ml, fletcher j. selection of patients and results of 25 years of topical anesthesia and adjustable suture surgery. am orthopt j. 2013; 63 (1): 85-91. 17. park jm, lee sj, choi hy. intraoperative adjustable suture strabismus surgery under topical and sunconjunctival anesthesia. ophthalmic surg lasers imaging, 2008; 39 (5): 373-378. 18. hakim om, el-hag yg, haikal ma. strabismus surgery under augmented topical anesthesia. j aapos. 2005; 9 (3): 279-284. 19. santhan ksg, kelkar ja, arora er. our experience with strabismus surgery under topical anesthesia performed at a tertiary care eye center. indian j ophthalmol. 2018; 66 (2): 342-343. 20. vallés-torres j, garcia-martin e, fernándeztirado fj, gil-arribas lm, pablo le, pea-calvo p. contact topical anesthesia versus general anesthesia in strabismus surgery. arch soc esp oftalmol. 2016; 91 (3): 108-113. 21. modabber m, dan af, coussa rg, flanders m. retrobulbar anaesthesia for adjustable strabismus surgery in adults: a prospective observational study. can j ophthalmol. 2018; 53 (6): 621-626. author’s designation and contribution dr. sana nadeem; assistant professor: concept and study design, drafting of manuscript, data collection & analysis, final review .…  …. https://en.wikipedia.org/w/index.php?title=wong-%20baker_faces_pain_rating_scale&oldid=871901004 https://en.wikipedia.org/w/index.php?title=wong-%20baker_faces_pain_rating_scale&oldid=871901004 https://www.physiopedia.com/index.php?title=numeric_pain_rating_scale&oldid=209667 https://www.physiopedia.com/index.php?title=numeric_pain_rating_scale&oldid=209667 https://www.physiopedia.com/index.php?title=numeric_pain_rating_scale&oldid=209667 https://en.wikipedia.org/w/index.php?title=%20proxymetacaine&oldid=830475900 https://en.wikipedia.org/w/index.php?title=%20proxymetacaine&oldid=830475900 ambreen gul phacomulsificationin senile white mature cataracts original article phacoemulsification in senile white mature cataracts ambreen gul pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: ambreen gul ophthalmology department of holy family hospital, lahore email: amber-gul@hotmail.com …..……………………….. purpose: to evaluate the intraoperative difficulty, complications and post-operative outcome in patients with white mature cataracts undergoing phacoemulsification. study design: interventional case series. place and duration of study: ophthalmology department of holy family hospital, from january 2017 to june 2017. material and methods: fifty patients who had senile white mature cataract were enrolled in this study. detailed preoperative and intraoperative notes were taken. a small capsulorhexis was attempted initially after staining the capsule with trypan blue. an initial cut was made with cystotome and it was enlarged with utrata forceps. phacoemulsification was done with stop and chop technique. intraoperative difficulties related to continuous curvilinear capsulorhexis, phacoemulsification and post-operative visual outcomes were analyzed. post-operative examinations were done at day 1, 1 week, 1 month and 3rd month. results: there were 28 males (56%) and 22 females (44%). the mean age was 63.18 ± 7.997. the mean preoperative best corrected visual acuity (bcva) was 0.0276 ± 0.013 with snellen chart, (0.01-0.05) and mean post-operative bcva was 0.638 ± 0.305 (0.1-1.0). mean phaco time was 4.08 ± 1.03 minutes (2.08-6.66). posterior capsular rupture occurred in 3 (6%) and vitreous loss occurred in 1 (2%) patient. 5 (10%) cases were converted to extracapsular cataract extraction (ecce). postoperatively, 10 (20%) patients had transient corneal edema, 3 patients (6%) had persistent corneal edema and corneal burn treated with steroids and hyper osmotic agents. conclusion: white mature cataract is a challenge for cataract surgeon, yet by means of additional dyes and proper techniques and expertise, the rate of complications during phacoemulsification can be reduced. key words: phacoemulsification, cataract, trypan blue, posterior capsular rupture, corneal edema. c ataract is the most frequent treatable blindness worldwide. in developing countries, white mature cataracts are seen very frequently1. in pakistan, the most common cause of blindness and low vision is an un-operated cataract. a review conducted in pakistan yielded prevalence of 1.78% and found out that cataract is a major cause of treatable blindness constituting 66.7% of total blindness. mature and hypermature cataracts constitute a major volume of surgical load2. surgical removal of white mature cataracts presents special challenges to the surgeon. it is associated with high rate of intraoperative and postoperative complications; such as incomplete ccc, radial tears in anterior capsule extending to equator and posterior capsule, rupture of posterior capsule, vitreous loss, nucleus drop, iol dislocation, corneal burns, iop rise, persistent corneal edema and anterior chamber reaction3-5. continuous curvilinear capsulorhexis and emulsification of hard nucleus are two critical steps that make phacoemulsification challenging in these cases. visualization of the anterior capsule depends on red reflex, which is compromised in eyes with white mature cataract. the capsule is extra fragile and seepage of liquefied cortical material causes the capsulorhexis tear to extend to the periphery on account of high intracapsular pressure. the anterior capsule may undergo disintegration with deposition of calcium or growth of focal plaques may hinder the capsulorhexis6. the use of trypan blue facilitates ccc formation, provides a safe surgery, resulting in decrease in intraoperative complications. nuclei of varying hardness may be masked by a totally opaque cortex. after the nucleus is removed by the divide and conquer or the phaco chop technique, a posterior chamber intraocular lens can be implanted. even for an experienced surgeon harder nucleus will require a longer time and higher power of phacoemulsification. a plaque or residual posterior capsule is observed in spite of successful surgery7. this study was conducted in the department of ophthalmology, holy family hospital, rawalpindi. we evaluated the safety and postoperative visual outcome in patients undergoing phacoemulsification in white mature cataract. material and methods after approval from the local ethical committee, this cross sectional study was carried out between january 2017 and june 2017. in this study, 50 eyes of the 50 patients with white mature cataract were evaluated prospectively. all eyes in mature cataract group lacked red fundus reflex. cataracts appearing white on slit lamp examination were defined as white mature, hypermature or brunescent cataracts. patients with diabetes mellitus, glaucoma, pseudo exfoliation, complicated cataract, poor pupil dilation (< 5mm), history of ocular surgery, laser treatment or trauma were excluded. written informed consent was obtained from each patient. preoperative ocular examinations included snellen visual acuity, detailed biomicroscopic examination including anterior chamber examination, goldmann applanation tonometry, axial length and anterior chamber depth measurements with a-scan ultrasonography. keratometry was performed using an autokeratorefractometer. mydriacyl 1% and phenylephrine 2.5% eye drops were used for mydriasis, 1 hour before the surgery. three surgeons performed all surgeries. endocapsular phacoemulsification was performed in all cases by using infinity alcon and opticon phacoemulsification unit by one of the three surgeons in an identical manner. topical or retrobulbar anaesthesia was used. pieces of cotton sponge impregnated with proparacaine hcl 0.5% were placed deep into superior and inferior fornix, for 15 minutes before surgery for topical anaesthesia. retro bulbar injection was performed using a 23-gauge needle, 3 ml of 2 % lidocaine was given intraconallly. nuclear hardness was subjectively evaluated by the surgeon intraoperatively during phacoemulsification and was graded as soft, semi soft, medium, hard, very hard. effective phaco time displayed by the phacoemulsification unit for each surgical procedure was recorded. a three-step clear corneal tunnel incision was made with a 3.2 mm disposable metal blade and a side port incision was made with side port knife. staining of the anterior capsule was done with trypan blue under air. after injection of dispersive viscoelastic sodium chondroitin sulfate-sodium hyaluronate into the anterior chamber of eyes, continuous curvilinear capsulorhexis was performed. before completing the ccc liquefied milky cortex was aspirated in eyes to decrease high intracapsular pressure for the safety of capsulorhexis. radial tears occurred in patients and conversion to extra capsular cataract extraction was preferred in these patients. after ccc hydro dissection was performed carefully in these cases because posterior capsule is thinner and more fragile in hard cataracts. nucleus was removed by using divide and conquer or stop and chop to prevent damage to corneal endothelial cells as more energy is used in hard cataracts. cortex was aspirated with irrigation and aspiration and anterior chamber was filled with cohesive viscoelastic substance and foldable monofocal posterior chamber iol was implanted in the capsular bag through an injector system. the viscoelastic material was aspirated completely, the entrances were closed with stromal hydration and for endophthalmitis prophylaxis sub-conjunctival antibiotic ceftriaxone and steroid dexamethasone injection was given. post-operative examinations were done at 1 day, 1 week, 1st and 3rd months. after surgery patient used topical antibiotics 2 hourly, steroid 4 hourly, daily for 1 week and topical steroid was tapered for subsequent 4 weeks. patients who had transient or persistent corneal edema were managed with intense topical steroid and hyper-osmotic agents that took 6 weeks to resolve. preoperative and postoperative bcva values were used for statistical analyses. preoperative and intraoperative findings as well as postoperative outcomes were analyzed. spss version 21 was used for statistical analysis. data was compared by using paired t test.p< 0.05 was accepted as significant. results out of total 50 patients, there were 28 males (56%) and 22 females (44%).the mean age was 63.18 ± 7.997 years with a range of 48 to 78 years. out of 50 patients, 22 (44%) patients had mature cataract, 15 (30%) patients had hyper-mature cataract, 13 (26%) patients had brunescent cataract. pre-operative best-corrected visual acuity (bcva) was recorded which ranged from light perception (0.01) to 3/60 (0.05) (table 1). forty one patients had uneventful surgery with no intraoperative complications. intraoperative complications included premature entry of the tunnel into the anterior chamber, incomplete capsulorhexis, and posterior capsular tear, conversion to a manual non-phacoemulsification technique, intraoperative miosis, and iris chafing. intraoperatively trypan blue staining was used in all patients. aspiration of liquefied milky cortex was performed in patients before completing ccc. radial tears occurred in 5 (10%), posterior capsular rupture occurred in 3 (6%), vitreous loss occurred in 1 (2%) patient. 5 (10%) cases were converted to extra capsular cataract extraction (ecce) with iol implantation in the sulcus. no nucleus drop occurred. mean phacoemulsification time was 4.08±1.03 (sd) minutes with a range of 2.08-6.66 minutes (figure 1). the mean preoperative intraocular pressure iop was 15.90 ± 1.799 (sd) mmhg range (12-22) and mean post op iop was 11.98 ± 2.035 (sd) mmhg range (10 – 18). the mean post operative iop was significantly lower than that of preoperative value. preoperatively phacomorphic glaucoma was present in none patient and their iop were significantly lower postoperatively without any medication. postoperatively 10 (20%) patients had transient corneal edema lasting one week which resolved with topical steroid therapy, 3 patients (6%) had persistent corneal edema and corneal burn treated with intense topical steroids and hyper osmotic agents, their corneal edema resolved within 6 weeks. corneal burn occurred in two (4%) cases. severe striate keratitis occurred in four (8%) patients. three (6%) patients had three plus cell count in anterior chamber, which resolved with intense topical steroids in 1 month. postoperatively iol dislocation occurred in one (2%) patients. postoperative iop rise occurred in none of the cases. these postoperative complications are summarized in table 2. at 3rdpost-operative month, bcva ranged from ≤6/60 (≤ 0.1) to 6/6 (1.0) (table 3). bcva was significantly higher than mean preoperative bcva. (p < 0.001). table 1: preoperative best corrected visual acuity. grading of visual acuity (snellen decimal fraction) frequency percent valid percent cumulative percent perception of light(0.01) 15 30.0 30.0 30.0 hands movement(0.02) 26 52.0 52.0 82.0 counting finger up to 3 meters(0.03) 6 12.0 12.0 94.0 counting finger better than 3 meters to 6/60(0.04-0.05) 3 6.0 6.0 100.0 total 50 100.0 100.0 table 2: postoperative complications. post-operative complications frequency percent valid percent cumulative percent no complication 29 58.0 58.0 58.0 transient corneal edema 10 20.0 20.0 78.0 persistent corneal edema 1 2.0 2.0 80.0 corneal burn 1 2.0 2.0 82.0 striate keratitis 4 8.0 8.0 90.0 post-operative uveitis 3 6.0 6.0 96.0 corneal burn plus striate keratitis 1 2.0 2.0 98.0 iol dislocation plus persistent corneal edema 1 2.0 2.0 100.0 total 50 100.0 100.0 table 3: post-operative best corrected visual acuity. grading of visual acuity (snellen decimal fraction) frequency percent valid percent cumulative percent less than or equal to 6/60(≤0.1) 2 4.0 4.0 4.0 6/36 to 6/18(0.1-0.3) 10 20.0 20.0 24.0 6/12 to 6/6(0.5-1.0) 38 76.0 76.0 100.0 total 50 100.0 100.0 fig. 1: mean phacoemulsification time discussion mature and hypermature cataracts constitute a significant volume of the cataract surgical load in ophthalmic practice in the developing countries. there were an estimated 1,140,000 (962,000-1,330,000) blind adults in pakistan in 2003. countryside areas had a higher frequency of blindness than did urban areas (3.8% vs. 2.5%). most patients have advanced stages of cataract with intumescent, mature or hypermature cataract. majority of these patients are less privileged8. white mature cataracts are a challenge for cataract surgeon and carry some difficulties. the most critical step of phacoemulsification surgery is continuous curvilinear capsulorhexis. if it is not complete, some intraoperative complications such as posterior capsule rupture, vitreous loss and nucleus drop may occur. because the red reflex is compromised in white cataract, it is difficult to complete ccc safely. trypan blue provides a safe ccc7,9. general recommendations for visualization of anterior capsule in eyes with mature white cataract include dimming the operation room lights, increasing the magnification of microscope, using oblique illumination, capsule dyes. giammaria d et al and wong et al, stained the capsule under an air bubble, it was reported that using the dye under the dispersive viscoelastic material was easier and safe. the air bubble technique was reported to be time consuming7,10. the rate of conversion to ecce in white cataracts as a result of an incomplete ccc has been as low as 3.85% when trypan blue is used compared to 28.3% when no staining was used. in our study, we used trypan blue in all patients, and radial tears occurred in five patients and rate of conversion to ecce was 10%. it has been reported that trypan blue did not cause any inflammation, corneal edema, corneal thickening, decrease in endothelial cell count and iop rise11. portes et al demonstrated that trypan blue caused lens epithelial cell death, which supported the hypothesis that staining with trypan blue 0.1% helps reducing the incidence of posterior capsule opacification after cataract surgery. the frequency of capsular rupture and vitreous loss can be reduced by staining the anterior capsule with the trypan blue to identify the capsular tear at an early stage. we achieved a 5 mm capsulorhexis in most of the cases 12. kara junior et al recommended the mini rhexis technique for white intumescent cataracts in which primarily a small ccc was performed then enlarged. two stages ccc prevented unanticipated radial tears of the initial capsulotomy due to elevated intra capsular pressure13. we aspirated liquefied milky cortical matter via cannula in 15 patients before finishing ccc to avoid sudden radial tears due to highly intracapsular pressure. chen and wu suggested automated irrigation and aspiration by lowering of bss bottle to aspirate the liquefied milky lens contents before phacomulsification14. daglioglu et al suggested an innovative capsulorhexis technique in white cataract surgery in which ccc was completed by using an irrigation and aspiration system by phaco machine, it was found safe in white cataracts15. although hydro dissection was not recommended in white mature cataracts, we observed that gentle hydro dissection broke the cortico-capsular adhesions that could resist free nucleus rotation1. singh et al reported cortico-capsular adhesions resulted in different nucleus rotation in brunescent and black cataracts. nucleus rotation is critical for phacoemulsification16. posterior capsule is not only weak but also flaccid with wrinkles and laxity that makes it prone to be ruptured. the problem is worsened by absence of any epinucleus that protects the posterior capsule. a useful step is to inject a dispersive non–cohesive viscoelastic behind the nucleus during the phacoemulsification, which will provide an artificial epinucleus to keep the posterior capsule back from the operating plane and stabilize the nucleus against tumbling17. in brunescent and black cataracts, the lens fibers were found to be very cohesive thus making division difficult. white cataracts in our study were usually brittle and not very hard; they were safely divided and emulsified. during the division and aspiration of the nucleus, edge of the hard nucleus may cut the posterior capsule, resulting in rupture; also radial tears in anterior capsulotomy may extend to posterior capsule and cause rupture. therefore, the incidence of posterior capsule rupture is higher in mature cataracts18. in our study rate of posterior capsular rupture was 6%. phacoemulsification of hard nucleus requires higher ultrasonic energy, which is partially converted to heat energy causing corneal endothelial damage and corneal burns. fluid dynamics during phacoemulsification may cause endothelial cell damage if it lasts longer18. with aging, endothelial cell count decreases, this is another risk for patients with mature cataracts; therefore, chances of post-operative corneal edema is higher in patients with mature cataract18,19. in our study, we did not encounter complications of capsular fibrosis and geometrical decentration. in another study, capsular fibrosis was reported to occur in 12% of eyes with white mature cataracts all of which had a capsulorhexis diameter of less than 5 mm20. small capsulorhexis leads to capsule contraction. yuan et al recommended that ophthalmic viscosurgical device assisted sutureless cataract surgery, usually without additional instruments, or sutures presented an efficient and uncomplicated technique for managing a brunescent or mature cataract21. venkatesh et al compared manual small incision cataract surgery with phacoemulsification for white cataract and reported that both techniques achieved excellent visual outcomes with low complication rates22. wong et al suggested that micro-incisional cataract surgery with bimanual phacoemulsification appeared to be a hopeful alternative for management of white cataracts23. kim and jang proposed drill and chop technique for hard cataracts, which required complete engagement of central nucleus by phaco tip. first, a hole was drilled into the endonucleus by rotating the kelman phaco tip clockwise, nucleus was deeply impaled horizontally and completely engaged by phaco tip followed by vertical chopping and it resulted safer and more effective vertical chopping in patients with harder cataracts24. li et al described the peripheral radial chop technique in phacoemulsification of harder nuclei and stated that it was effective without grave complications in hands of skilled surgeons25. the limitation of our study was that it was performed in one center. more studies need to be performed with larger number of patients in multiple centers. conclusion white mature cataract is a challenge for phaco surgeons but with appropriate techniques such as two stage capsulorhexis and use of additional capsule staining dyes can achieve excellent visual outcomes and low complication rates. 1. references 2. ermisş ss, oztürk f, inan uu. comparing the efficacy and safety of phacoemulsification in white mature and other types of senile cataracts. br j ophthalmol. 2003 nov; 87(11):1356-9. 3. khan aq, qureshi b, khan d. rapid assessment of cataract blindness in age 40 years and above in district skardu, baltistan, northern areas, pakistan. pak j ophthalmol. 2003; 19: 84-9. 4. ilavska m, kardos l. phacoemulsification of mature and hard nuclear cataracts. bratisl lek listy, 2010; 111 (2): 93-6. 5. susic n, brajkovic j, susic e, kalauz-surac i. phacoemulsification in eyes with white cataract. acta clin croat, 2010; 49 (3): 343-5. 6. hawlina m, stunf s, hvala a. ultrastructure of anterior lens capsule of intumescent white cataract. acta ophthalmol. 2011; 89 (4): e367-70. 7. lobue sa, tailor p, lobue td. a simple, novel approach to capsulorhexis formation in the setting of a mature cataract and miotic pupil. clin ophthalmol. 2019 dec 2;13:2361-2367. 8. giammaria d, gianotti m, scopelliti a, pellegrini g, gianotti b. under-air staining of the anterior capsule using trypan blue with a 30 g needle. clin ophthalmol. 2013; 7: 233-235. 9. jadoon mz, dineen b, bourne rr, shah sp, khan ma, johnson gj, et al. prevalence of blindness and visual impairment in pakistan: the pakistan national blindness and visual impairment survey. invest ophthalmol. 2006; 11: 4749-55. 10. rossiter j, morris a. trypan blue vital staining of the anterior lens capsule in the management of cataract in true exfoliation of the lens capsule. eye, 2005; 19: 809-10. 11. wong vw, lai ty, lee gk, lam pt, lam ds. a prospective study on trypan blue capsule staining under air vs under viscoelastic. eye (lond.), 2006; 20 (7): 820-825. 12. cheour m, ben biahim f, zauad a. trypan blue capsule staining for phacoemulsification in white cataract. j fr ophthalmol. 2007; 30 (9): 914-917. 13. portes al, almeida ac, allodi s, monteiro ml, miguel nc. trypan blue staining for capsulorhexis; ultrastructural effect on lens epithelial cells and capsules. j cataract refract surg. 2010; 36 (4) 582-7. 14. kara-junior n, de santhiago mr, kawakami a, caricondo p, hidaet wt. mini-rhexis for white intumescent cataracts. clinics (sao paulo). 2009; 64 (4): 309-312. 15. chen yj, wu pc. automated irrigation/aspiration before phacoemulsification in eyes with white cataracts. ophthalmic surg lasers imaging, 2005; 36 (2): 118-21. 16. daglioglue mc, coskun m, ilhan o, tuzco ea, ilhan n, ayintap e, et al. a novel capsulorhexis technique in white cataract surgery. semin ophthalmol. 2014; 30 (4): 264-267. 17. singh r, vasavada a, janaswamy g. phacoemulsification of brunescent and black cataracts. j cataract refract surg. 2001; 27: 1762-9. 18. cetinkaya s, gurdag t, akcam n. phacoemulsification in eyes with white mature cataract. sch. j. app. med. sci. 2015; 3 (2c): 701-4. 19. bilgin b, eltutar k, sezgin bi. comparison of phacoemulsification results of mature and nucleocortical cataracts. turk j ophthalmol. 2006; 36: 219-22. 20. sizmaz s, peli a, yaycioglu ra. the use of trypan blue in patients with white cataract. turk j ophthalmol. 2007; 37: 178-181. 21. shahid e, sheikh a, fasih u. complications of hypermature cataract and its visual outcome. pak j ophthalmol. 2011; 27 (2): 58-62. 22. yuan x, song h, hua x. ophthalmic viscosurgical deviceassisted sutureless-incision cataract surgery for a hard nucleus or mature cataract. j cataract refract surg. 2014; 40 (4): 517-20. 23. venkatesh r, tan cs, sengupta s, ravindran rd, krishan kt, chang df. phacoemulsification versus manual small incision cataract surgery for white cataract. j cataract refract surg. 2010; 36 (11): 1849-54. 24. wong vw, lai ty, lee gk. safety and efficacy of micro-incisional cataract surgery with bimanual phacoemulsification for white mature cataract. ophthalmologica. 2007; 221 (1): 24-8. 25. kim dy, jang jh. drill and chop: modified vertical chop technique for hard cataract. ophthalmic surg lasers imaging, 2012; 43 (2): 169-72. 26. li sw, xie lx, song zh. peripheral radial chop technique for phacoemulsification of hard cataracts. chin med j (engl.). 2007; 120 (4): 284-86. author’s affiliation ambreen gul ophthalmology department of holy family hospital, lahore email: amber-gul@hotmail.com author’s contribution ambreen gul study design, data collection, analysis, manuscript writing and final review pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 1 6 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 5 pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 152 original article difference in central corneal thickness between applanation ultrasound and oculus wave light occulyzer ii munira shakir, ronak afza memon, sahira wasim, shakir zafar pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: munira shakir department of ophthalmology, liaquat national hospital karachi email: dr_munirasz@yahoo.com …..……………………….. purpose: to determine the mean difference of central corneal thickness measurements by using ultrasound pachymetry and oculus wave light occulyzer ii. study design: cross-sectional comparative study using non-probability consecutive sampling. place and duration of study: this study was conducted at department of ophthalmology, liaquat national hospital karachi from november 2018 to june 2019. material & methods: after approval from ethical committee, patients were included in our study on the basis of inclusion & exclusion criteria. central corneal thickness measurements were taken by using ultrasound pachymetry & oculus wave light occulyzer ii. all the data was collected by single researcher. the results were plotted, compared & analyzed. paired t-test was used for the comparison of quantitative variables. results: there were 130 patients included in the study out of which 73 (56.2%) were males and 57 (43.8%) were females. mean age of these patients was 33.9 ± 8.9 years. the mean ± sd thinnest oculus wave light occulyzer ii measurement was 538.61 ± 23.46 μm and ranged between 476.0 and 619.0 μm whereas the mean thinnest ultrasound pachymetry measurement was 535.1 ± 21.816 μm and ranged between 482 and 601 μm. there was highly significant correlation of central corneal thickness between both the instruments. (r = 0.96, p < 0.001). conclusion: there is a high correlation of central corneal thickness between the readings obtained from ultrasound and optical pachymetry machines therefore oculus wave light occulyzer ii can be used as an alternative technique to ultrasound pachymetry while assessing cct in clinical settings. key words: central corneal thickness, ultrasound pachymetry, optical pachymetry. ornea is the main refractive surface of human eye and along with sclera it forms the outer fibrous layer of eyeball. it is transparent and avascular, with normal diameters of about 11-12 mm & 9-11 mm horizontal & vertical respectively1. corneal thickness is a precise indicator of corneal hydration & normal functioning of endothelial pump2. cct has also got an important role in determining the flap thickness along with residual stromal thickness before refractive surgeries3. besides, central corneal thickness, which measures about the central 3 mm of cornea, is an independent risk factor for the development and progression of glaucoma4. there are various methods for assessing the c munira shakir, et al 153 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol central corneal thickness. the most common is ultrasound pachymetry, which measures cct by estimating the time difference between echoes of ultrasound waves reflected from anterior and posterior surface of cornea. but this method carries more chances of errors due to misalignment of probe or obliquely placed probe in relation to cornea, lack of light fixation, excessive indentation during procedure & dryness related problems which include variability in sound transmission5. another method is corneal topography that uses newer technique known as scheimpflug imaging, in which a rotating camera is used to photograph corneal cross-sections illuminated by slit beams at different angles (pentacam). it provides information about anterior segment including iris, angle and cillary body. from these details, the corneal maps give an idea about corneal thickness at different points along with the thinnest point6. the rationale of our study is to find pachymetry techniques with reliable results. internationally available research also shows wide variability. as central corneal thickness has impact on measuring the intraocular pressure which in turns helps in early detection and management of glaucoma and will help in reducing the overall burden of blindness caused by glaucoma. the purpose of our study is to measure the central corneal thickness using contact (ultrasound) technique & non-contact (oculus wave light occulyzer ii) technique and compare the results of two methods in our population. material and methods this study was conducted from nov 2018 to june 2019 at the department of ophthalmology, liaquat national hospital karachi after approval from ethical committee. the total sample size of 130 patients was calculated using who software taking 95% confidence level. one eye of each of 130 patients, aged between 20-50 years was assessed. thorough slit lamp examination was performed. patients with corneal problems (e.g. scar, keratoconus, keratoglobus), those who were using contact lenses, those who had previous history of refractive or any ocular surgery, those with history of ocular trauma or using ophthalmic drops were not included in this study. central corneal thickness was firstly measured on oculus wave light occulyzer ii (am wolfmantel 91058 erlangen, german). local anesthetic drops were then instilled and central corneal thickness was measured by ultrasound pachymetry (sonomed model 300 ap+) by placing the probe perpendicular to the cornea. five consecutive readings were taken. all measurements of central corneal thickness were conducted by a single researcher. patient’s data was compiled and analyzed through statistical package for social sciences (spss) version 25. frequency and percentages were computed for qualitative variables such as gender and side of eye. mean ± sd was calculated for age and corneal thickness as quantitative variables. sample size was calculated by taking mean ± sd of the thinnest corneal thickness of 538.7 ± 0.29 μm5 with oculus wave light occulyzer ii using margin of error (d) = 5%. paired ttest was used for the comparison of quantitative variables. p ≤ 0.05 was considered as significant. results there were 130 patients attending ophthalmology department and fulfilling the inclusion criteria. one eye of each patient was measured (65 were right eyes and 65 were left eyes). 73 (56.2%) were males and 57 (43.8%) were females (table 1). mean age of these patients was 33.9 ± 8.9 years. about 78 patients were less than 35 years & 52 were greater than 35 years (table 1). in our study, we found that the mean thinnest pentacam measurement was 538.615 ± 23.4677 μm and ranged between 476.0 and 619.0 μm, whereas the mean thinnest ultrasound pachymetry measurement was 535.1 ± 21.816 μm and ranged between 482 and 601 μm. (table 2). table 1: descriptive statistics. characteristics mean ± sd age 33.93 ± 8.91 age group ≤ 35 years 27.6 ± 4.26 >35 years 43.42 ± 4.52 there was highly significant correlation of central corneal thickness between both the instruments. (r = 0.96, p < 0.001). according to the results of our study, there were no differences of cct readings measured by two devices i.e. oculus wave light occulyzer and ultrasound pachymeter. difference in central corneal thickness between applanation ultrasound and oculus occulyzer ii pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 154 table 2: comparison of central corneal thickness between ultrasound pachymeter and topography. characteristics n(%) ulrrasound pachymeter topography correlation r p-value corneal thickness 130 (100 535.10 ± 21.8 538.61 ± 23.4 0.96 < 0.001** age ≤ 35 years 78 (60 535.29 ± 22.65 537.59 ± 23.48 0.97 < 0.001** > 35 years 52 (40) 534.82 ± 20.71 537.59 ± 23.48 0.95 0.01** gender male 73 (56.2) 532.28 ± 20.26 536.64 ± 21.55 0.96 < 0.001** female 57 (43.8) 538.71 ± 23.34 541.14 ± 25.68 0.95 0.017** eyes left 65 (50) 536.29 ± 22.12 539.29 ± 24.16 0.96 0.001** right 65 (50) 533.92 ± 21.60 537.95 ± 22.91 0.96 < 0.001** paired t-test is applied. *significant at p-value < 0.05 **insignificant at p-value > 0.05 discussion central corneal thickness measurement has a major role in both diagnostic and therapeutic aspects7. accurate assessment of central corneal thickness is necessary for various concerns such as used preoperatively to prevent corneal ectasia prior to refractive surgery8. cct represents the physiologic function of corneal endothelium9,10. it is also useful for diagnosis of some corneal diseases like keratoconus, which is a progressive disease having four stages (1-4), causing thinning and steepening of central cornea11. cct also helps to decide the management options for keratoconus, which include corneal crosslinking (cxl) and corneal transplant. cxl basically stabilizes the disease process and requires at least 400-450 μm of central corneal thickness. cct helps in cases of fuch’s dystrophy12. glaucoma is one of the main causes of blindness these days. intraocular pressure (iop) being an important and modifiable risk factor in diagnosis and management of glaucoma has a correlation with central corneal thickness measurement13. there are various methods for cct measurement, which include both contact and non-contact methods. an ideal method should be accurate, safe, easy, and less time consuming. ultrasound pachymetry is considered as gold standard for cct measurement14,15. this method requires contact with central cornea. up has got the disadvantage of using topical anesthetic agents which can affect the thickness. fixation along with proper position of ultrasound probe has got a major role in cct measurement. errors can also occur due to excessive indentation and dryness. on the other hand, pentacam overcomes all the above problems with up16. pentacam uses the rotating scheimpflug principle, which obtains about 25,000 data points for assessing not only cct but also corneal curvature and anterior chamber details17. our study compared the central corneal thickness by applanation ultrasound and oculus wave light occulyzer ii. most of the previous literature review showed greater cct with oculus wave light occulyzer ii as compared to ultrasound pachymetry (up). the reason behind this could be the displacement of pre-corneal tear film, which is about 7-30 μm. in addition, the compression by ultrasound probe over the epithelium can give thinner cct measurements by up18. study conducted by khater et al also compared the mean thinnest corneal thickness with oculus wave light occulyzer ii 538.7 ± 29.35 μm and with quantel pocket ii up 527.6 ± 28.04 μm. their study showed that both devices are highly correlated & wave light occulyzer ii can be used as a substitute for up19. zlatanović et al reported the mean cct with occulyzer as 552.94 μm ± 22.88 μm and with ultrasound pachymetry as 559.46 ± 26.0 μm. there were no statistically significant differences among both devices20. piotrowiak et al conducted a study which showed higher value of cct with ultrasound pachymetry (555 μm) as compared with pentacam (545 μm)21. tai et al showed closest agreement for len star– up, followed by len star–pentacam and pentacam– up22. limitation of our study was the small sample size and single center for data collection. multicenter studies are required for further analysis. munira shakir, et al 155 vol. 35, no. 3, jul – sep, 2019 pak j ophthalmol conclusion according to the results of our study, there is a high correlation of central corneal thickness found between the readings obtained from both up and oculus wave light occulyzer ii. so we concluded that oculus wave light occulyzer ii can be used as an alternative technique to ultrasound pachymetry, while assessing cct in clinical settings to decrease the risk of procedure associated problems with up like epithelial trauma and infection, to decrease the frequent use of topical anesthetic agents, for early detection and management of glaucoma & in anxious patients as well. disclaimer none. conflict of interest none. source of funding none. refrences 1. sridhar ms. anatomy of cornea and ocular surface. indian j ophthalmol. 2018; 66 (2): 190-4. 2. al-farhan hm. measurements of central corneal thickness using two immersion ultrasound techniques and optical technique. j pak med assoc. 2014; 64 (3): 266-70. 3. sadoughi mm, einollahi b, einollahi n, rezaei j, roshandel d, feizi s. measurement of central corneal thickness using ultrasound pachymetry and orbscan ii in normal eyes. j ophth vision resear. 2015; 10 (1): 4-9. 4. rashid rf, farhood qk. measurement of central corneal thickness by ultrasonic pachymetry and oculus pentacam in patients with well-controlled glaucoma: hospital-based comparative study. clinical ophthalmol. 2016; 10: 359-64. 5. bayhan ha, bayhan sa, can i̇. comparison of central corneal thickness measurements with three new optical devices and a standard ultrasonic pachymetry. intern j ophthalmol. 2014; 7 (2): 302-8. 6. grewal ds, grewal sp. clinical applications of scheimpflug imaging in cataract surgery. saudi j ophthalmol. 2012; 26 (1): 25-32. 7. qamar-ul-islam sm. comparison of central corneal thickness measurement using non-contact and contact pachymetry devices in normal eyes. pak j ophthalmol. 2015; 31 (1): 27-32. 8. rainer g, findl o, petternel v, kiss b, drexler w, skorpik c, et al. central corneal thickness measurements with partial coherence interferometry, ultrasound, and the orbscan system. ophthalmol. 2004; 111 (5): 875-9. 9. kocamis o, kilic r. repeatability, reproducibility and agreement of central corneal thickness measurements by two noncontact pachymetry devices. medical hypoth disc innovat ophthalmol j. 2019; 8 (1): 34-9. 10. tam es, rootman ds. comparison of central corneal thickness measurements by specular microscopy, ultrasound pachymetry, and ultrasound biomicroscopy. j catar refract surg. 2003; 29 (6): 1179-84. 11. amiri ma, hashemi h, ramin s, yekta a, taheri a, nabovati p, et al. corneal thickness measurements with scheimpflug and slit scanning imaging techniques in keratoconus. j curr ophthalmol. 2017; 29 (1): 23-7. 12. lackner b, schmidinger g, pieh s, funovics ma, skorpik c. repeatability and reproducibility of central corneal thickness measurement with pentacam, orbscan, and ultrasound. optomet vision sci. 2005; 82 (10): 892-9. 13. yazdani s, doozandeh a, haghighat m, akbarian s, pakravan m, yaseri m. intrasubject difference in cct among poag versus normal individuals. optomet vision sci. 2015; 92 (8): 879-83. 14. wong ac, wong cc, yuen ns, hui sp. co-relational study of central corneal thickness measurements on hong kong chinese using optical coherence tomography, orbscan and ultrasound pachymetry. eye, 2002; 16 (6): 715-21. 15. binnawi kh, elzubeir h, osman e, abdu m, abdu m. central corneal thickness measurement using ultrasonic pachymetry, optical coherence tomography, and tms-5 topographer. oman j ophthalmol. 2019; 12 (1): 15-9. 16. al-mezaine hs, al-amro sa, kangave d, sadaawy a, wehaib ta, al-obeidan s. comparison between central corneal thickness measurements by oculus pentacam and ultrasonic pachymetry. internl ophthalmol. 2008; 28 (5): 333-8. 17. o'donnell c, maldonado-codina c. agreement and repeatability of central thickness measurement in normal corneas using ultrasound pachymetry and the oculus pentacam. cornea, 2005; 24 (8): 920-4. 18. amano s, honda n, amano y, yamagami s, miyai t, samejima t, et al. comparison of central corneal thickness measurements by rotating scheimpflug camera, ultrasonic pachymetry, and scanning-slit corneal topography. ophthalmol. 2006; 113 (6): 937-41. 19. khater mm. comparative study between oculus wave light occulyzer ii and quantel pocket ii ultrasonic pachymetry in measuring central corneal thickness. tanta med j. 2016; 44 (1): 1-3. 20. zlatanović m, živković m, hristov a, stojković v, novak s, zlatanović n, brzaković m. central corneal thickness measured by the oculyzer, biograph, and ultrasound pachymetry. acta medica med. 2019; 58 (2): 33-7. 21. piotrowiak i, soldanska b, burduk m, kaluzny bj, difference in central corneal thickness between applanation ultrasound and oculus occulyzer ii pak j ophthalmol vol. 35, no. 3, jul – sep, 2019 156 kaluzny j. measuring corneal thickness with soct, the scheimpflug system, and ultrasound pachymetry. isrn ophthalmol. 2012; 2012: 1-5. 22. tai ly, khaw kw, ng cm, subrayan v. central corneal thickness measurements with different imaging devices and ultrasound pachymetry. cornea, 2013; 32 (6): 766-71. author’s affiliation dr. munira shakir fcps, frcs department of ophthalmology, liaquat national hospital, karachi dr. ronak afza memon mbbs, r4 department of ophthalmology, liaquat national hospital, karachi dr. sahira wasim mbbs, r4 department of ophthalmology, liaquat national hospital, karachi dr. shakir zafar fcps, department of ophthalmology, liaquat national hospital, karachi author’s contribution dr. munira shakir study design, manuscript writing, critical analysis. dr. ronak afza memon researcher, data collection and manuscript writing. dr. sahira wasim data analysis, manuscript writing. dr. shakir zafar statistical analysis and critical review. 116 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology original article frequency and characteristics of ocular trauma in a tertiary care hospital in lodhran muhammad luqman ali bahoo, ahmad zeeshan jamil, beenish karamat pak j ophthalmol 2019, vol. 35, no. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: muhammad luqman ali bahoo, mbbs, fcps, fico, facs, fellowship refractive and cornea surgery associate professor and head of ophthalmology, shahida islam medical and dental college, lodhran. email: drluqmanali@yahoo.com ahmadzeeshandr@yahoo.com …..……………………….. purpose: to find the frequency and characteristics of ocular trauma in a tertiary care hospital in lodhran. study design: cross sectional study. sampling technique: convenient non-probability sampling. place and duration of study: this study was conducted at shahida islam teaching hospital affiliated with shahida islam medical college, lodhran from december 2016 to september 2018. material and methods: detailed history and ocular examination were performed with regard to age, gender, classification of ocular trauma, aetiology of trauma, place where trauma occurred, note of ocular damage, nature of object, activity at the time of injury, presenting visual acuity and time lapse before presentation to hospital after trauma were recorded. results: there were 393 patients included in this study. mean age of patients was 28.97 ± 12.59 years. there were 198 (50.4%) closed globe and 195 (49.6%) open globe injuries. in 53 (13.5%) cases injury was caused by metal object. in 132 (33.6%) cases injury was classified as contusion. in 146 (37.2%) cases cornea was involved. there were 95 (24.2%) cases that occurred in home. in 156 (39.7%) cases presenting visual acuity was less than 6/60. there were 272 (69.2%) males and 121 (30.8%) females. there were 342 (87.0%) patients who presented within 1 day after trauma. in 122 (31.0%) cases there was prolapse of ocular contents. conclusion: ocular trauma occurred more commonly in males. it was blunt and occurred in home setting in most of the times. most of the eye injuries aetiological agent was metal and wood. key words: blindness. contusion. corneal injuries. ocular trauma. ye trauma is cause of ocular morbidity that can be prevented1. it is one of the leading causes of blindness2-4. every year about 1.6 million people become blind due to ocular trauma5. eye injury results in a large number of hospital visits6. ocular trauma results in significant physical, psychological and economical loses7. eye injury results in functional disability, cosmetic blemish, economical loss and psychological distress. impact of eye injury is long lasting and disturbing for the patient and the whole family. impact of ocular injury and vision loss is greatest in magnitude compared to the loss of any other sensory organ of the body. eye injuries can occur in a variety of settings like during playing, in home, at work or as a result of assault or accident8. due to their anatomical location and consistency eyes are prone to get hurt event by trivial trauma. ocular trauma can be profession specific as persons engaged in certain e mailto:drluqmanali@yahoo.com mailto:ahmadzeeshandr@yahoo.com frequency and characteristics of ocular trauma in a tertiary care hospital in lodhran pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 117 professions are likely to get hurt by certain objects9. every year around 55 million people get injuries in their eyes. one out of every twenty patients coming for eye examination by an ophthalmologist is a sufferer of eye injury10. trauma to eye can lead to immediate damage or it can lead to establishment of inflammation and infection afterwards. sequel of ocular trauma can cause significant ocular morbidity even after months or years11. self medication by the patients or improper management by the quacks is another contributing factor in morbidity related to ocular trauma. ocular trauma is often preventable and proper management of ocular injuries can significantly lessen the burden of blindness12. data about ocular trauma is limited in developing countries in terms of aetiology, setting, extent of injury, pattern of injury and management strategies. as depending on occupation and socio-demographic factors, nature and characteristics of ocular injury differ from region to region, so we want to know the frequency and characteristics of ocular trauma in lodhran. good knowledge of aetiology of trauma, patterns and characteristics of trauma and at-risk population is needed to device strategies for prevention and management of this disabling condition. proper resource allocation for the prevention and treatment of ocular injuries can be planned according to burden of ocular injuries in the region. material and methods this cross-sectional study was conducted at shahida islam teaching hospital affiliated with shahida islam medical college, lodhran from december 2016 to september 2018. sample size was calculated according to the following formula: s=z2 p(1-p)/m2 s is sample size z is z score its value is 1.96 p is population proportion assumed to be 50% or 0.5 m is margin of error that is taken 5% or 0.05 s = (1.96)2 (0.5)(1-0.5)/0.05 = 384.16 = 384 all ocular trauma patients presenting in the out patients department and emergency department who required hospital admission were included in the study. all patients were told about the purpose of the study and informed consent was taken. demographic profile like age and gender of all patients were recorded. history regarding aetiology of injury, eye structures involved, place where injury occurred and pattern of injury were recorded. ocular injuries were graded according to birmingham eye trauma terminology into two types namely closed globe and open globe injuries. closed globe injuries were further divided into contusion and lamellar laceration. open globe injuries were divided into laceration and rupture. mechanism of rupture was trauma with blunt object while trauma with sharp object resulted in laceration. laceration was further divided into penetrating, perforating and presence of intraocular foreign body13. periorbital and adnexa injuries were recorded. record was taken of the time elapsed between injury and presentation to hospital. presenting visual acuity was recorded with snellen’s chart. detailed ocular examination was performed with the help of slit lamp biomicroscopy. b-scan and x-ray imaging were performed when required. all the information was gathered with the help of specially designed proforma. statistical analysis was performed with spss version 23. mean and standard deviation was calculated for age. frequencies and percentages were calculated for gender, aetiology of injury, type of injury, structures involved, place of injury, presence of hyphema, status of lens, presence of vitreous haemorrhage, status of retina, optic nerve status, presenting visual acuity, time lapse between injury and presentation to hospital and prolapse of intraocular contents. results there were 393 patients included in this study. there were 272 (69.2%) males and 121 (30.8%) females. mean age of patents was 28.97 ± 12.59 years. distribution of cases according to gender and age is shown in table 1. there were 198 (50.4%) closed globe injuries and 195 (49.6%) open globe injuries. the most common cause of injury was trauma with metal object. the distribution of cases according to trauma is given in table 2.there were 132 (33.6%) cases of contusion, 99 (25.2%) cases of rupture, 66 (16.8%) cases of lamellar laceration, 59 (15.0%) cases of penetration, 27 (6.9%) cases of intraocular foreign bodies and 10 (2.5%) cases of globe perforation. cornea was involved in 146 (37.2%) cases, corneoscleral injury was present in 126 (32.1%) cases, sclera in 46 (11.7%) cases and adnexa in 27 (6.9%) cases. there was lid tear in 12 (3.1%) cases, muhammad luqman ali bahoo, et al 118 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology periocular swelling in 16 (4.1%) cases and blow out fracture was noted in 2 (0.5%) cases. in 18 (4.6%) cases posterior segment was the predominant site of injury. hyphema was present in 186 (47.3%) cases, lens damage was present in 128 (32.6%) cases, vitreous table 1: distribution of cases according to gender and age. age of patient in years gender of patient mean (years) number of cases std. deviation male 28.20 272 14.108 female 30.70 121 8.030 total 28.97 393 12.597 table 2: distribution of cases according to aetiology. injury aetiology frequency percent metal 53 13.5 wood/vegetable matter 49 12.5 stone 26 6.6 road traffic accident 35 8.9 wielding arc 10 2.5 acid (chemical) 18 4.6 alkali (chemical) 18 4.6 superglue (chemical) 16 4.1 oil 15 3.8 fist/hand 19 4.8 fall 11 2.8 fire work/fire cracker 18 4.6 fire 9 2.3 pellet gun 27 6.9 plant sap 7 1.8 insect fall/bite 14 3.6 animal attack 11 2.8 glass 21 5.3 plastic scale/pencil/pen 12 3.1 tennis ball 4 1.0 total 393 100.0 table 3: distribution of cases according to place of injury. place of occurrence frequency percent work place 81 20.6 road traffic accident 44 11.2 home 95 24.2 sports 31 7.9 assault 58 14.8 at school 24 6.1 outdoor 60 15.3 total 393 100.0 table 4: distribution of cases according to time to presentation in hospital. time to presentation frequency percent within 1 day 131 86.2 within 1 week 17 11.2 after 1 week 4 2.6 total 152 100.0 fig. 1: hyphema as a result of blunt ocular trauma. fig. 2: ocular penetration with vegetable matter. frequency and characteristics of ocular trauma in a tertiary care hospital in lodhran pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 119 haemorrhage was present in 103 (26.2%) cases, retinal tear was present in 13 (3.3%) cases, retinal detachment was present in 29 (7.4%) cases, commotio retina was present in 22 (5.6%) cases. optic nerve swelling was noted in 32 (8.1%) cases. distribution of cases according to place of injury is given in table 3. presenting visual acuity was 6/12 or better in 139 (35.4%) cases, between 6/12 and 6/60 in 98 (24.9%) cases and less than 6/60 in 156 (39.7%). distribution of cases according to time to presentation in hospital is shown in table 4. prolapse of intraocular contents was noted in 122 (31.0%) cases. fig. 3: lamellar corneal laceration with hyphema. fig. 4: limbal perforation, iris and vitreous prolapsed following ocular trauma with key. discussion ocular trauma is one of the major causes of preventable blindness and visual impairment14. three hundred and ninety-three patients with ocular trauma were included in this study. mean age of patients was 28.97 ± 12.59 years. results of our study are similar with the findings of study done by dhulikhel that showed the most vulnerable age group was 21-30 years15. study of godar and co-authors also recognized the most vulnerable age group for ocular trauma was between 21 to 29 years. ocular trauma in young age group may be due to their increased risktaking behaviour and active life style. morbidity resulted thereof has great impact in terms of economical burden and quality of life. there were 272 (69.2%) males and 121 (30.8%) females included in our study. work performed by sengupta and co-authors also showed the preponderance of male patients affected by ocular trauma16. increase ocular trauma in male patients may be due to their increase outdoor activity and engagement in certain professions17. in our study there were 198 (50.4%) closed globe injuries and 195 (49.6%) open globe injuries. among closed globe injuries, contusion was the most common cause. among open globe injuries, globe rupture was the most common cause. our results are similar to findings of other studies. in our study most common cause of injury was metal object and cornea was involved in majority of cases. our results are in accordance with the result of other studies18. in our study most common place of injury was home. our results are in contrast with the results of other studies19 where most of ocular trauma occurred at work place and during road traffic accidents. our results are in accord with that of the study conducted by shaeri and co-authors20. due to inadequate adoption of safety measures during common house hold activities may be reason for majority of ocular trauma at home. most of the trauma among women and children occur at home. it is irony that home environment that is considered the safest accounted for majority of ocular trauma. adoption of safety measures at home while doing house hold activities is as much needed as during outdoor activities. in our study time to presentation to hospital was within one day in 342 (87.0%) cases, within 7 day in 41 (10.4%) cases and after 1 week in 10 (2.5%) cases. our results are comparable to that of godar and coauthors14. muhammad luqman ali bahoo, et al 120 vol. 35, no. 2, apr – jun, 2019 pakistan journal of ophthalmology in our study presenting visual acuity was less than 6/60 in 156 (39.7%) while in another study conducted by sengupta and co-authors majority of patients presented with visual acuity less than 3/6016. this is in contrast with the result of study conducted by iqbal and co-authors19. in their study majority of patients presented with good visual acuity. this difference in presenting visual acuity may be due to severity of ocular trauma. in our study we included patients who required hospital admission. patients with minor ocular trauma were not included in our study. among the limitations of our study is the small sample size. this study may not be true representative of population as patients from high socioeconomic strata were unlikely to come to public hospital. patients who needed hospital admission were included in our study. this is another limitation. patients with minor injuries who did not need hospital admission or did not come to hospital were not included in the study. nevertheless, our study underscores the frequency and patterns of ocular trauma in particular locality. it will help establish preventive and management strategies to cope with ocular trauma. future research is needed to study the impact of health education on adaption of safety measures in preventing ocular trauma. moreover, it will be important to study the anatomical and physiological outcomes of ocular trauma management strategies. conclusion ocular trauma occurred more commonly in males. ocular trauma was blunt and occurred in home setting in most of the times. the aetiological agent in most of the eye injuries was metal and wood. ocular injuries resulted in substantial visual loss at the time of presentation. author’s affiliation dr. muhammad luqman ali bahoo associate professor and head of ophthalmology, shahida islam medical college, lodhran. dr. ahmad zeeshan jamil associate professor of ophthalmology, sahiwal medical college, sahiwal. dr. beenish karamat resident medical officer, department of radiology, lgh. author’s contribution dr. muhammad luqman ali bahoo concept, study design, interpretation of data dr. ahmad zeeshan jamil drafting of article and critical revision for important intellectual content dr. beenish karamat statistical analysis, literature research and proof reading conflict of interest: none. financial disclosure: none. references 1. bahoo mla, jamil az. types of ocular surface foreign bodies and their correlation with location in the eye. pak j ophthalmol. 2018; 34 (1): 25-9. 2. jan s, khan s, khan mt, et al. ocular emergencies. jcpsp. 2004; 14: 333-6. 3. guerra garcia ra, garcia d, martinez fe et al. the cuban ocular trauma registry. j clin exp ophthalmol. 2013; 4 (2): 276. 4. negral ad, thylefors b. the global impact of eye injuries. ophthalmic epidemiol. 1998; 5: 143-69. 5. tsedeke a, yeshigeta g, fessehaye a. a 2 year review of ocular trauma in jimma university specialized hospital. ethiop j health sci. 2009; 19: 67-74. 6. babar tf, khan mn, jan s, et al. frequency and causes of bilateral ocular trauma. jcpsp. 2007; 17: 679-82. 7. bahoo mla, jamil az, khalid ms. ocular surface foreign bodies and their association with profession. pjmhs. 2018; 12 (2): 495-8. 8. khatry sk, lewis ae, schein od, et al. the epidemiology of ocular trauma in rural nepal. br j ophthalmol. 2004; 88: 456-60. 9. khatry sk, lewis ae, schein od, thapa md, pradhan ek, katz j. the epidemiology of ocular trauma in rural nepal. br j ophthalmol. 2004; 88: 456-60. 10. magarakis m, mundinger gs, kelamis ja, dorafshar ah, bojovic b, rodriguez ed. ocular injury, visual impairment and blindness associated with facial fractures: a systematic literature review. plastic and reconstructive surgery, 2012; 129: 227-33. 11. bowling, b. kanski's clinical ophthalmology a systematic approach, 2015; sydnery: saunders. 12. pandita a, merriman m. ocular trauma epidemiology: 10-year retrospective study. n z med j. 2012; 125: 61-9. 13. kuhn f, morris r, witherspoon d, et al. a standardized lassification of ocular trauma. ophthalmology, 1996; 103: 204-3. 14. godar st, kaini kr, amatya p, joshi k, singh l. magnitude of ocular trauma in a tertiary care hospital of western nepal. njms. 2013; 2 (2): 140-3. frequency and characteristics of ocular trauma in a tertiary care hospital in lodhran pakistan journal of ophthalmology vol. 35, no. 2, apr – jun, 2019 121 15. sthapit pr, marasini s, khoju u, thapa g, nepal bp. ocular traumain patients presenting to dhulikhel hospital. kathmanduuniv med j 2011; 33: 54-7. 16. sengupta p, mazumdar m, gyatsho j. epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural area in west bengal, india over a period of 2 years. iosr-jdms. 2016; 15: 92-7. 17. hussain m, moin m, aasi na. epidemiology of penetrating trauma. annals of kemc (lahore) 2003;9(2):163-166. 18. oum bs, lee js, han ys. clinical features of oculartrauma in emergency department. korean j ophthalmol. 2004; 18: 70-8. 19. iqbal y, khan qa, zia s, malik a. frequency and characteristics of ocular trauma in gilgit, pakistan. jiimc. 2016; 11: 157-62. 20. shaeri m, moravveji a, fazel mr, jeddi fr. status of ocular trauma in hospitalized patients in kashan, 2011: as a sample of industrial city. chin j traumatol. 2016 dec. 1; 19 (6): 326-329. https://www.ncbi.nlm.nih.gov/pubmed/?term=status+of+ocular+trauma+in+hospitalized+patients+in+kashan%2c+2011%3a+as+a+sample+of+industrial+city 19 pakistan journal of ophthalmology, 2020, vol. 36 (1): 19-23 original article comparison of epiretinal membrane peel after dual staining versus en bloc peel using negative staining technique tehmina jahangir 1 , qasim lateef chaudhry 2 , haroon tayyab 3 1-2 department of ophthalmology, allama iqbal medical college, lahore, 3 department of ophthalmology, mayo hospital, kemu lahore abstract purpose: to compare the completeness of ilm peel in cases of idiopathic epiretinal membranes following double staining and double peeling versus en bloc dissection of both using negative staining method. study design: quasi experimental study. place and duration of study: jinnah hospital lahore, from october 2017 to march 2018. material and methods: forty eyes of forty patients with idiopathic epiretinal membranes (erm) were selected by non-probability convenient method and divided into two groups. in group a, the erm was initially stained with trypan blue and then peeled. subsequently the macula was re-stained with brilliant blue g (bbg). in group b, erm and ilm were successfully peeled together as a single membrane utilizing the single block technique, after a desired negative staining effect was obtained by injecting bbg. the thoroughness of the ilm peel was established using another injection of bbg although a few remains were often identified outside the central macular area, no other dyes were used. results: in group a, 8 of the 20 eyes (40%) had full undisturbed ilm present whereas in 10 eyes (50%) the ilm was there but damaged, only 2 eyes (10%) had near total ilm removed. in group b, the dual peeling was successful in 17 of the 20 cases (85%). there has been no recurrence of erm until now. conclusion: instead of peeling twice, the single en bloc negative staining technique with brilliant blue g is a safer and more effective method for removal of erm together with ilm. key words: pars plana vitrectomy, epiretinal membrane, internal limiting membrane. how to cite this article: jahangir t, chaudhry ql, tayyab h. comparison of residual internal limiting membrane following epiretinal membrane peel after dual staining versus en bloc peel using negative staining technique, pak j ophthalmol. 2020; 36 (1): 19-23. doi: https://doi.org/10.36351/pjo.v36i1.897 introduction epiretinal membrane (erm) is a disorder of the vitreomacular interface and is used to describe a condition in which there is cellular proliferation on the inner retinal surface. epiretinal membrane is a very address for correspondence: tehmina jahangir assistant professor ophthalmology department allama iqbal medical college, lahore e-mail: tehminajahangir@gmail.com ` common finding in people over the age of 50 years. the prevalence of idiopathic erm is 2% in people younger than 60 years and approximately 12% in those who are more than 70 years of age 1 . most are discovered incidentally during routine ophthalmoscopic examination. others become symptomatic and require treatment. the standard of treatment for a symptomatic erm is its surgical removal. modern vitreoretinal techniques involve small-gauge vitrectomy and the use of dyes to https://doi.org/10.36351/pjo.v36i1.897 comparison of residual internal limiting membrane following epiretinal membrane peel after dual staining versus en bloc peel using pakistan journal of ophthalmology, 2020, vol. 36 (1): 19-23 20 facilitate the visualization of membrane 1 . several studies have advocated peeling of ilm during erm surgery to minimize the recurrence of erm without negatively affecting visual outcomes 2,3 . it has been suggested that ilm removal per-operatively removes the scaffolding for any fibroblast proliferation and residual microscopic erm, therefore diminishing the risk of recurrence in addition to improving the final visual outcomes 1 . we conducted a prospective interventional study to compare the completeness of ilm peel using two different methods of erm staining. material and methods we studied 40 consecutive patients (40 eyes), 22 males and 28 females who underwent surgery for primary idiopathic epiretinal membrane over a period of 6 months from october 2017 to march 2018. all patients were followed up for ≥ 6 months after they were enrolled in the study. all ophthalmic surgeries were performed by one ophthalmic surgeon (xy) at the department of ophthalmology, jinnah hospital, lahore. patients with secondary erm, presence of glaucoma, retinal degeneration, optic neuropathy and age less than 18 years were excluded from the study. approval for the study was obtained by the hospital ethics committeeand informed consent was taken in writing from all subjects. a standard subtotal 23g 3-ports pars plana vitrectomy (ppv) was performed using the optikon pulsar 2 vitrectomy system. the microscope in use was leica m844 f20 with its built-in ruv 800 viewing system. in group a, a standard 23g ppv was performed. after performing core vitrectomy and inducing posterior vitreous detachment, fluid air exchange was done and erm was stained with trypan blue dye. the fluid was reopened through the infusion cannula and the stained erm was peeled with 23g intraocular endgripping forceps. bbg (0.025%) was applied to the peeled area (under air) for another one minute and the extent of the residual ilm was noted. a second peeling of the ilm was performed using ilm forceps in all cases with residual ilm whether it was intact or damaged. in group b, a standard 23g ppv was performed. after core vitrectomy and induction of pvd, fluid air exchange was done. we proceeded with a singular technique of staining by introducing the bbg dye 0.025%, through either of the superior ports. the injected dye was directed towards the macula but injected in a very gentle manner while keeping a safe distance. the dye was left in place under air for a minute before reopening the fluid. since bbg primarily stains the ilm it did not stain the areas concealed by the erm. therefore, in this group we aimed to stain the erm negatively while staining the ilm directly, so the contrasting margins between the unstained erm and the stained ilm were clearly distinguished thus achieving a negative staining effect (fig. 1). with a 23 g ilm peeling forceps the ilm was pinched and peeled temporally simultaneously double peeling i.e., dragging enbloc the erm and the underlying ilm and in a single step in an annular direction around the fovea (fig. 2). in almost all cases, the peel was extended up to the temporal vascular arcades releasing any centripetal and tangential tractions along the way. we then reinjected the bbg to re-stain the peeled area to confirm any residual ilm requiring removal (fig. 3 and 4). all cases in both groups were closed under sf6 tamponade. all data was recorded on a predesigned proforma. the data was entered and analyzed by spss (version 20) using the chi square test for statistical analysis and results. results in group a, the erm was initially stained with trypan blue, the erm was peeled. subsequently the macula was re-stained with bbg. eight of the 20 eyes (40%) had full undisturbed ilm whereas in 10 eyes (50%) the ilm was there but damaged, only 2 eyes (10%) had near total ilm removed. in group b, the dual peeling was successfully performed in 17 of the 20 cases (85%) by utilizing the en block technique, after successfully obtaining a negative staining effect using bbg. the completeness of ilm peel was established using an additional bbg injection although some residual ilm was often encountered further away from the central macular area. no other dye was injected. there has been no recurrence of erm to date. in either of the two groups there were no significant complications related to peeling except for a few superficial self-resolving retinal hemorrhages and one case of small iatrogenic hole in the temporal macula. jahangir t, et al 21 pakistan journal of ophthalmology, 2020, vol. 36 (1): 19-23 fig. 1: negative staining effect: the blue areas represent the internal limiting membrane as stained with the brilliant blue g dye; areas devoid of the dye are covered with the epiretinal membrane. fig. 2: enbloc peeling: both the internal limiting membrane and the epiretinal membrane are removed in a single step. fig. 3: second time brilliant blue g dye injected near the macula. all data was recorded on a predesigned proforma. the data was entered and analyzed by spss (version 20). fig. 4: no residual internal limiting membrane can be seen after en bloc removal of both membranes in a single step. discussion erm usually requires removal when it leads to structural damage to the retina, an increase in macular thickness or troublesome visual symptoms. ideally the surgery for erm removal should both have a minimal recurrence and little or no retinal trauma and toxicity 4,5 . this can be accomplished by simultaneously peeling the ilm and by using the least toxic dye in as little a concentration as feasible. the rate of erm recurrence is lower when combined with ilm peel 6 . the postoperative bcva or cmt is not influenced significantly by ilm peeling which endorses the use of the surgical technique for patients with erm 7,8 . moreover, ilm peeling has a clear advantage of decreasing erm recurrence 9,10 . although in 30 to 70% of patients, ilm is often removed together with erm, complete and sufficient area of ilm peeling is essential to avoid erm recurrence 11 . the technique of negative staining reported by foster et al 12 aimed to decrease injury to the retina and increase visibility, by utilizing indocyanine green (icg) to preferentially stain the ilm surrounding the margins of the erm, although it lightly stained the erm as well. however, when selecting dyes that preferentially stain the ilm, recent studies suggest that bbg may be the least toxic, especially in comparison to icg 13,14 . brilliant blue g is a selective dye used to stain the ilm on a stand-alone basis, with little to no affinity for the erm, and a suitable safety profile 15 . moreover, current evidence suggests that this dye may also have a protective role against cell apoptosis 16 . the comparison of residual internal limiting membrane following epiretinal membrane peel after dual staining versus en bloc peel using pakistan journal of ophthalmology, 2020, vol. 36 (1): 19-23 22 results of our study are comparable with those of carpentier et al and shimada 2,3 . removal of the two membranes in a single step has several advantages. it reduces the number of times the retina is grasped as well as traction on the retinal surface while simultaneously reducing the membrane removal time and diminishing phototoxicity; all of which are probable causes of iatrogenic damage to the retina 17,18 . although the availability of stains for the ilm has made peeling safer, the procedure is still not free of complications. these include: retinal edema, nerve fiber layer damage, retinal hemorrhages, electrophysiological shifts and visual field changes have all been documented after ilm peeling 19,20,21 . the limitation of our study is the small sample size. research with large sample size and data from different hospitals will be helpful in further proving the results. conclusion instead of using two dyes for staining and peeling of erm twice, using a single en bloc technique is not only less time-consuming but also safer in terms of decreased exposure to dyes, reduction in grasping attempts and overall reduced surgical time as well as decreased phototoxicity. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest authors’ designation and contribution tehmina jahangir; assistant professor: study design, manuscript writing, literature review. qasim latif chaudhary; associate professor: literature review and final critical review. haroon tayyab; assistant professor: literature review and final critical review. references 1. wickham l, konstantinidis l, thomas j. wolfensberge. macular epiretinal membranes. in: ryan sj, wilkinson cp, editors. retina – vol iii, surgical retina. philadelphia, pa: elsevier inc.; 2018. p. 2261-2279. 2. carpentier c, zanolli m, wu l, sepulveda g, berrocal mh, saravia m, et al. pan-american collaborative retina study group. residual internal limiting membrane after epiretinal membrane peeling: results of the pan-american collaborative retina study group. retina. 2013; 33 (10): 2026-2031. 3. shimada h, nakashizuka h, hattori t, mori r, mizutani y, yuzawa m. double staining with brilliant blue g and double peeling for epiretinal membranes. ophthalmology, 2009; 116 (7): 1370-1376. 4. liu h., zuo s., ding c., dai x., zhu x. comparison of the effectiveness of pars plana vitrectomy with and without internal limiting membrane peeling for idiopathic retinal membrane removal: a meta-analysis. j ophthalmol. 2015; 2015: 974568. doi:10.1155/2015/974568. 5. gandorfer a, haritoglou c, scheler r, schumann r, zhao f, kampik a. residual cellular proliferation on the internal limiting membrane in macular pucker surgery. retina. 2012; 32 (3): 477-485. 6. bovey eh, uffer s, achache f. surgery for epimacular membrane: impact of retinal internal limiting membrane removal on functional outcome. retina, 2004; 24 (5): 728–735. 7. geerts l, pertile g, van de sompel w, moreels t, claes c. vitrectomy for epiretinal membranes: visual outcome and prognostic criteria. bull soc belge ophtalmol. 2004; 293: 7–15. 8. jung jj, hoang qv, ridley-lane ml, sebrow db, dhrami-gavazi e, chang s. long-term retrospective analysis of visual acuity and optical coherence topographic changes after single versus double peeling during vitrectomy for macular epiretinal membranes. retina, 2016; 36 (11): 2101–2109. 9. sandali o, el sanharawi m, basli e, bonnet s, lecuen n, barale po, et al. epiretinal membrane recurrence: incidence, characteristics, evolution, and preventive and risk factors. retina, 2013; 33 (10): 2032–2038. 10. oh hn, lee je, kim hw, yun ih. clinical outcomes of double staining and additional ilm peeling during erm surgery. korean j ophthalmol. 2013; 27 (4): 256–260. 11. chang s, gregory-roberts em, park s, laud k, smith sd, hoang qv. double peeling during vitrectomy for macular pucker: the charles l. schepens lecture. jama ophthalmol. 2013; 131 (4): 525–530. 12. foster re, petersen mr, da mata ap, burk se, rosa rh jr, riemann cd. negative indocyanine green staining of epiretinal membranes. retina, 2002; 22 (1): 106-108. 13. enaida h, hisatomi t, hata y, ueno a, goto y, jahangir t, et al 23 pakistan journal of ophthalmology, 2020, vol. 36 (1): 19-23 yamada t, et al. brilliant blue g selectively stains the internal limiting membrane/brilliant blue gassisted membrane peeling. retina, 2006; 26 (6): 631–6. 14. kawahara s, hata y, miura m, kita t, sengoku a, nakao s, et al. intracellular events in retinal glial cells exposed to icg and bbg. invest ophthalmol vis sci. 2007; 48: 4426–32. 15. azuma k, noda y, hirasawa k, ueta t. brilliant blue g assisted internal limiting membrane peeling for macular hole: a systematic review of literature and meta-analysis. retina, 2016; 36 (5): 851–858. 16. remy m, thaler s, schumann rg, may ca, fiedorowicz m, schuettauf f, et al. an in vivo evaluation of brilliant blue g in animals and humans. br j ophthalmol. 2008; 92 (8): 1142–7. 17. azuma k, ueta t, eguchi s, aihara m. effects of internal limiting membrane peeling combined with removal of idiopathic epiretinal membrane: a systemic review of literature and meta-analysis. retina, 2017; 37 (10): 1-7. 18. pournaras cj, emarah a, petropoulos ik. idiopathic macular epiretinal membrane surgery and ilm peeling: anatomical and functional outcomes. semin ophthalmol. 2011; 26 (2): 42–46. 19. liu y, kato c, herai t. evaluation of peeling of inner limiting membrane for idiopathic epiretinal membrane. jpn j clin ophthalmol. 2001; 55: 1239–1243. 20. wu l. epiretinal membrane surgery: to peel or not to peel the ilm? retina today. 2017: 30-32. 21. roh m, eliott d. internal limiting membrane peeling during idiopathic epiretinal membrane removal: literature review. int ophthalmol clin. 2015; 55 (4): 91-101. .…  …. 217 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol original article bibliometric review of pakistan journal of ophthalmology zameer hussain baladi, mumtaz hussain satti pak j ophthalmol 2019, vol. 35, no. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: zameer hussain baladi king saud bin abdul aziz university for health sciences, college of applied medical sciences, riyadh. kingdom of saudi arabia. email: baladiz@ksau-hs.edu.sa & zameer.baladi@gmail.com …..……………………….. purpose: to analyze the publication patterns of pakistan journal of ophthalmology (pjo) for the last 24 years from 1995 to 2018. study design: descriptive bibliometric analysis. place and duration of study: medical libraries, college of applied medical sciences and college of science & health profession, king saud bin abdul aziz university for health sciences, riyadh saudi arabia. june 2018 to april 2019. material and methods: the data for the study was retrieved from websites of pakistan journal of ophthalmology (pjo) and pak medi net for statistical analysis in ms excel 2010 version. the data was analyzed by dividing the studied period into two parts; a) first 12 years (1995 – 2006) and b) the last 12 years (2007 – 2018) for better understanding. this study examined 855 articles published in 24 volumes with 8.9 articles per issue from 1995 to 2018 contributed by 2816 authors. results: a gender-wise comparison among the contributing authors revealed 2378 males (84.4%) and 437 females (15.5%). it was also revealed that 141 (16.4%) articles were written by a female as the first author during the studied period. majority of the articles (n = 734, 85.8%) were written by multiple authors instead of single authors (n = 121, 14.1%). maximum number of articles were published in the year 2014 & 2018 (48 articles in each volume) and minimum number of articles were published in 1995 and 1997 (20 articles in each volume). conclusion: this study finds that pakistan journal of ophthalmology (pjo) is published regularly and over the last 24 years has gained the confidence of researchers, institutes, and readers. key words: authorship, bibliometrics, eye diseases, journal. akistan journal of ophthalmology is the official journal of ophthalmological society of pakistan (osp) recognized by the pakistan medical and dental council (pmdc) under ip/008. the society’s leaders have endeavored to support programs, which would improve the knowledge of ophthalmologists to provide better patient care and management in vitreo-retina, oculoplastics, glaucoma, pediatric ophthalmology, cataract and refractive surgery1. bibliometric study is one of the several methods to calculate the research productivity of a journal using a combination of mathematical and statistical methods2. bibliometric data plays a vibrant role in research efficiency of a journal connected with a special or specific subject, and an institute in terms of new ideas, techniques for analyzing scientific research as correct and relevant to practice3,4. according to scimago journal & country rank (2018), pakistan stands at 44th position in all regions and 10th position in asiatic region with 109,760 citable p mailto:baladiz@ksau-hs.edu.sa mailto:zameer.baladi@gmail.com bibliometric review of pakistan journal of ophthalmology pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 218 documents. there are 74 journals enrolled in web of science (wos) and 117 enrolled on a link scimago journal and country rank, related to various ophthalmic sub-specialties5,6. scientific writings began with the two general medical journals; french journal des savants and the british philosophical transactions of the royal society in the 17th century until the end of 18th century. before the end of 20th-century specialist medical journals were famous, and later the journals which reflected the sub-specialties of any discipline of health sciences got attention of medical communities7. this particular study was conducted to find the characteristics of publications in pakistan journal of ophthalmology during the last 24 years. material and methods the data of articles published in pakistan journal of ophthalmology (pjo) during the year 1995 – 2018 was downloaded, collected and tabulated in ms office (excel 2010) in the library of college of applied medical sciences, king saud bin abdul aziz university for health sciences riyadh, kingdom of saudi arabia. data was collected from june 2018 to april 2019 from the websites of pakistan journal of ophthalmology (pjo) (http://www.pjo.com.pk/), and from pak medinet (http://www.pakmedinet.com/). the data was analyzed by dividing the studied period into two parts; a) first 12 years (1995 – 2006) and b) the last 12 years (2007 – 2018) for better understanding. the objectives of the study were; a) to find the year, volume & issue wise publications, b) to explore the contribution of authors in publications, c) to discover the gender-wise distribution of the authors, d) to identify the pattern of authorship. statistical analysis of the results was done using microsoft excel, version 2010. results there were 2816 authors who contributed 855 articles, which were published with an average of 35 articles per volume and 8.9 per issue during the studied period. maximum number of articles were published in the year 2014 & 2018 (48 articles in each volume) and minimum number of articles were published in 1995 and 1997 (20 articles in each volume) as shown in figure 1. male authors were 2378 (84.4%) and female authors were 437 (15.2%) out of 2816 total authors. the ratio of female authors was significantly increased as the first author in the last 11 years of publication (figure 2). majority 85.8% articles were written by multiple authors in both halves (25.8% and 56.9%). there were 14.1% articles written by solo or single author out of 855 articles. the first half shows that the solo articles were 33.2% higher than the second half (figure 3). there were only ten female authors who submitted article as single-author. distribution of articles year, volume & issue-wise during the years 1995 to 2018 is given in table 1. table 2 (distributed in a & b halves) explains the http://www.pjo.com.pk/ http://www.pakmedinet.com/ zameer hussain baladi, et al 219 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol table 1: distribution of articles year, volume & issue-wise during the years 2018 – 1995. s. no year volume issue 1 issue ii issue iii issue iv total % apia* 1 2018 34 12 10 13 13 48 5.61% 12 2 2017 33 11 11 11 12 45 5.26% 11.25 3 2016 32 11 11 11 10 43 5.03% 10.75 4 2015 31 11 11 10 10 42 4.91% 10.5 5 2014 30 12 12 13 11 48 5.61% 12 6 2013 29 10 11 11 12 44 5.15% 11 7 2012 28 11 12 9 10 42 4.91% 10.5 8 2011 27 9 12 10 11 42 4.91% 10.5 9 2010 26 10 10 11 11 42 4.91% 10.5 10 2009 25 10 11 11 11 43 5.03% 10.75 11 2008 24 11 10 10 9 40 4.68% 10 12 2007 23 10 12 11 12 45 5.26% 11.25 13 2006 22 11 10 9 10 40 4.68% 10 14 2005 21 8 8 11 11 38 4.44% 9.5 15 2004 20 7 7 8 8 30 3.51% 7.5 16 2003 19 6 5 7 6 24 2.81% 6 17 2002 18 5 5 5 8 23 2.69% 5.75 18 2001 17 5 6 5 6 22 2.57% 5.5 19 2000 16 6 7 6 7 26 3.04% 6.5 20 1999 15 7 9 8 10 34 3.98% 8.5 21 1998 14 7 9 7 8 31 3.63% 7.75 22 1997 13 5 6 4 5 20 2.34% 5 23 1996 12 6 6 5 6 23 2.69% 5.75 24 1995 11 4 4 7 5 20 2.34% 5 all issues with % 205 (24%) 215 (25.1%) 213 (14.9%) 222 (25.9%) 855 apia: articles per-issue average table 2(a): breakdown of authorship pattern. authors 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 total single 10 6 7 5 3 8 7 7 8 5 8 10 84 (25.3) two 7 7 6 4 7 5 12 12 6 6 3 3 78 (23.5) three 8 10 7 5 6 4 3 11 9 6 4 3 76 (23) four 7 6 5 5 3 4 3 4 4 3 1 4 49 (14.8) five 5 4 4 3 1 1 0 4 3 25 (7.5) six 2 5 1 2 3 1 4 18 (5.4) seven & above 1 1 (0.3) total 40 38 30 24 23 22 26 34 31 20 23 20 331 table 2(b): breakdown of authorship pattern. authors 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 total single 3 3 3 0 3 4 5 2 2 4 3 5 37 (7) two 12 5 5 7 11 6 4 4 4 7 7 8 80 (15.2) three 12 17 14 14 10 11 8 11 8 11 11 10 137 (26.1) four 8 6 11 8 10 8 9 11 13 8 13 9 114 (21.7) five 7 12 9 10 8 10 8 9 9 6 6 10 104 (19.8) six 5 2 1 2 5 5 6 3 5 6 3 43 (8.2) seven & above 1 1 1 2 2 1 1 9 (1.7) total 48 45 43 42 48 44 42 42 42 43 40 45 524 breakdown of authorship pattern in the publications during the studied period. the first half shows that the production of 25.3% articles were as single or solo author as compared to 7% in the second half. the increased number of publications over the past years shows constant publication approach and bibliometric review of pakistan journal of ophthalmology pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 220 determination of the researchers and the editorial team of pjo. discussion according to an editor of the american journal of ophthalmology, there are many hardships faced by the editors including, irregular behaviors by authors, delayed information by the authors for submission and rejection by other journals8. american journal of ophthalmology received 1042 full-length original manuscripts from 53 countries, between october 2009 to september 2010. majority of articles (273) were from the united states of america followed by japan (141). among these, 257 (24.6%) were accepted for publication8. an interesting study was applied on ophthalmic literature published in american journal of ophthalmology and archives of ophthalmology from january 2012 to december 2012 to determine the statistical methods used to evaluate the participation of an author in research productivity. this study examined 780 peer-reviewed articles and 618 (79.2%) articles were reported to use most of the statistical methods. contingency tables, t-tests, and nonparametric tests were frequently used9. to assess the contribution of arab authors in ophthalmology, a study was designed and conducted in web of science (wos) in 2015. the study found that 216,921 articles were published under the title of ―ophthalmology‖ worldwide. it was also revealed that the participation of arab countries in researching ophthalmology is 0.96% around the globe. the contribution of researchers affiliated with arab countries was constant, with 828 articles. kingdom of saudi arabia had the highest research output followed by egypt 461 articles and tunisia 210 articles. countries with the highest collaboration with researchers in the arab world in ophthalmology research were usa followed by england and spain. the most research productive organization in arab countries was king khalid eye specialist hospital with 396 articles authored or co-authored10. a similar study was initiated on pubmed (free) database to know the participation of indian ophthalmic papers published from 2001 to 2006 in the peer-reviewed journals in the discipline of ophthalmic and vision research. results showed that 2163 articles were published during the studied period11. in the previous decade, a study was conducted to analyze the scientific production published in the field of ophthalmology and visual sciences in argentina, brazil, chile, paraguay and uruguay from 1995-2004. study found that 1216 articles were published in this period. this study provides a novel perspective in this field to maintain quality and quantity in ophthalmology and visual sciences research 12. an analysis was conducted in 2018 on quarterly pakistan journal of pharmaceutical sciences (pjps) from 1998 to 2012. total 2941 authors contributed 722 articles. this study revealed that publications were doubled in pjps after the year 2005. the percentage of female authors was 32.4%13. writing scholarly in a journal is the core component for communicating to a specific audience in the specialty with other subspecialties of the subject. a retrospective appraisal of this journal displayed the robust peer-review system, which helps researchers to communicate research idea appropriately to its readers. a similar study was conducted to explore research trends in the ophthalmic literature published in the top twenty ranked ophthalmology journals from 2009 to 2013 relative to the research productivity of a country14. it showed that 7,338 articles were published by the usa, uk, and europe out of 19338 articles, followed by china, korea and india as major contributors14. additionally, an interesting study unfolds the development in the past decade and found 100 most cited articles under the title ―ophthalmic epidemiology‖ which were published in ophthalmology journal and cited 61 to 333 times15. simultaneously, an observational study conducted to analyze women’s participation in original articles and editorials on three ophthalmology journals, which comprised past ten years as academic publications. the study found the participation of female researchers was 671 original articles with 89 editorials16. moreover, a huge study was conducted in ophthalmologic journals indexed in web of science (wos) from 2008 to 2018 to determine the representation of female authorship according to first name, under the title ―sex disparities in ophthalmic research: a descriptive bibliometric study on scientific authorships‖. the data of 248 ophthalmic journals retrieved 87,640 (25.4%) articles, which were written by 344,433 authors. overall 120,305 (34.9%) female participants were calculated17. however, according to one research, the contribution of female scholars is advanced in dermatological research as compared with other medical disciplines18. in january 2019, a study was conducted to estimate the number of publications on nephrology clinical trials published from 1966 to 2017 and preclinical studies from 1945–2017 in two databases zameer hussain baladi, et al 221 vol. 35, no. no. 4, oct – dec, 2019 pak j ophthalmol namely; a cochrane library and pubmed indexed journals. study reported that 118 clinical trials and 135 preclinical studies were published in leading journals19. moreover, an interesting study figures out that 2,135 peer-reviewed papers were published from 2009 to 2018 on retinal vein occlusion (rvo) a subspecialty of ophthalmology from web of science core collection to identify potential collaborators and partner institutions20. lastly, assessing gaps are important to researchers between the specialty and subspecialty of visual sciences to categorize the objectives for achieving goals in future. our study enlightened the encouraging policies of pjo to publishing, organizational environment and support of information technologies, which are influential factors in encouraging contributors in ophthalmic research. conclusion this study finds that pakistan journal of ophthalmology (pjo) is published regularly and over the last 23 years has gained the confidence of researchers, institutes, and readers. disclaimer none to declare. conflict of interest none to declare. funding disclosure none to declare. references 1. butt, n. ophthalmological society of pakistan. retrieved on september 05, 2018 from: http://www.apaophth.org/ophthalmological-societyof-pakistan/ 2. liu, l., jiao, j.h. and chen, l. bibliometric study of diabetic retinopathy during 2000–2010 by isi. international journal of ophthalmology, 2011; 4 (4): 333. 3. ferraz, vct, amadei jrp, santos cf. the evolution of the journal of applied oral science: a bibliometric analysis. j appl oral sci. 2008; 16 (6): 420-427. 4. porter al, kongthon a, lu jc. research profiling: improving the literature review. scientometrics, 2002; 53 (3): 351-370. 5. liu j, tian j, kong x, lee i, xia f. two decades of information systems: a bibliometric review. scientometrics, 2019; 118: 617–643. doi:10.1007/s11192018-2974-5 6. scimago, (n.d.). sjr — scimago journal & country rank [portal]. retrieved on september 05, 2018, from: http://www.scimagojr.com/countryrank.php?region= asiatic%20region 7. smith, r. the trouble with medical journals. j roy soc med. 2006; 99 (3): 15-119. 8. liesegang tj. the international american journal of ophthalmology. american j ophthalmol. 2011; 152 (1): 1-2. 9. lisboa r, meira-freitas d, tatham aj, marvasti ah, sharpsten l, medeiros fa. use of statistical analyses in the ophthalmic literature. ophthalmology, 2014; 121 (7): 1317-21. 10. sweileh wm, al-jabi sw, shanti yi, sawalha af, sa’ed hz. contribution of arab researchers to ophthalmology: a bibliometric and comparative analysis. springer plus, 2015; 4 (1): 42. 11. kumaragurupari r, sieving pc, lalitha p. a bibliometric study of publications by indian ophthalmologists and vision researchers, 2001-06. indian j. ophthalmol. 2010; 58 (4): 1/6. 12. ragghianti cp, martínez r, martins j, gallo je. comparative study of scientific publications in ophthalmology and visual sciences in argentina, brazil, chile, paraguay and uruguay (1995-2004). arquivos brasileiros de oftalmologia. 2006; 69 (5): 719723. 13. baladi zh., haq iu, hussain m, elahi g. a bibliometric assessment from 1998-2012. pak j pharm sci. 2018; 33 (3): 714-718. 14. schulz cb, kennedy a, rymer bc. trends in ophthalmology journals: a five-year bibliometric analysis (2009-2013). int j ophthalmol. 2016; 9 (11): 1669. 15. liu l, li y, zhang gs, wu jy, majithia s, tham yc et al. top 100 cited articles in ophthalmic epidemiology between 2006 and 2016. int j ophthalmol. 2018; 11 (12): 1994. 16. franco-cardenas v, rosenberg j, ramirez a, lin j, tsui i. decade long profile of women in ophthalmic publications. jama ophthalmol. 2015; 133 (3): 255-60. 17. kramer pw, kohnen t, groneberg da, bendels mh. sex disparities in ophthalmic research: a descriptive bibliometric study on scientific authorships. jama ophthalmol. 2019 aug 15. doi:10.1001/jamaophthalmol.2019.3095. 18. bendels mhk, dietz mc, brüggmann d. gender disparities in high-quality dermatology research: a descriptive bibliometric study on scientific authorships bmj open, 2018; 8: e020089. 19. chatzimanouil mk, wilkens l, anders hj. quantity and reporting quality of kidney research. j am soc nephrol. 2019; 30 (1): 13-22. 20. zhao f, du f, shi d, zhou w, jiang y, ma l. mapping research trends of retinal vein occlusion from 2009 to 2018: a bibliometric analysis. peer j. 2019; 7: e7603. http://www.apaophth.org/ophthalmological-society-of-pakistan/ http://www.apaophth.org/ophthalmological-society-of-pakistan/ http://www.scimagojr.com/countryrank.php?region=asiatic%20region http://www.scimagojr.com/countryrank.php?region=asiatic%20region bibliometric review of pakistan journal of ophthalmology pak j ophthalmol vol. 35, no. 4, oct – dec, 2019 222 author’s affiliation zameer hussain baladi dpa. mlis. m.phil librarian, king saud bin abdul aziz university for health sciences, college of applied medical sciences, riyadh. kingdom of saudi arabia. mumtaz hussain satti mlis librarian, king saud bin abdulaziz university for health sciences, college of science & health profession, riyadh. kingdom of saudi arabia. author’s contribution zameer hussain baladi study design, data collection, manuscript writing, final review. mumtaz hussain satti study design, data collection, manuscript writing final review. 103 pak j ophthalmol. 2020, vol. 36 (2): 103-108 original article descemet stripping automated endothelial keratoplasty (dsaek) zaman shah 1 , ibrar hussain 2 , sadia sethi 3 , bakht samar khan 4 , tajamul khan 5 1-5 department of ophthalmology, khyber teaching hospital, peshawar abstract purpose: the purpose of this study to analyze the visual outcome and complications of dsaek with their management. study design: interventional case series. place and duration of study: department of ophthalmology khyber teaching hospital peshawar, from january 2017 to april 2019. methods: twenty-one patients were selected by convenient sampling method from the outpatient department of khyber teaching hospital peshawar. informed written consent was obtained from all patients. ethical approval of the study was obtained from institutional review board (irb) of khyber medical college, in accordance with the declaration of helsinki. all cases of dsaek were performed by a single surgeon. we received the precut dsaek tissue and then endoglide was used in 5 (23.8%) and busin glide in 16 (76.19%) of cases. the unfolding of the donor tissue was performed by preplaced anterior chamber maintainer using balance salt solution. any complication either intra operative or post-operative, which happened, was recorded and managed either medically, or by appropriate surgical means. results: the average visual acuity before surgery was cf-1m. after dsaek procedure, average best-corrected visual acuity was 6/36. per-operative complications included incomplete stripping of the descemet membrane and loss of donor button during mounting in glide. complications in the early post-operative period were pupillary block glaucoma in 3 eyes and donor tissue dislocation in 2 eyes. late post-operative complications included edema and non-attachment after re-bubbling, late secondary glaucoma, cystoid macular edema (cme) and interface opacification. conclusion: dsaek is a promising alternative to penetrating keratoplasty for corneal endothelial decompensation. key words: dsaek, keratoplasty, lamellar keratoplasty, endothelial keratoplasty. how to cite this article: shah z, hussain i, sethi s, khan bs, khan t. descemet stripping automated endothelial keratoplasty (dsaek). visual outcome, complications and their management, pak j ophthalmol. 2020, 36 (2): 103-108. doi: 10.36351/pjo.v36i2.977 introduction in descemet stripping automated endothelial correspondence: zaman shah, assistant professor khyber teaching hospital, peshawar email: zamanshah73@hotmail.com received: december 26, 2019 accepted: march 8, 2020 keratoplasty (dsaek), the diseased endothelium is replaced with healthy donor endothelium, descemet membrane and part of the thin posterior corneal tissue. it is a good alternative to penetrating keratoplasty (pkp) in cases of endothelial decompensation. in literature, dsaek appears similar to pkp in terms of graft clarity, visual acuity, surgical risk, complications rate and endothelial cell loss but it mailto:zamanshah73@hotmail.com descemet stripping automated endothelial keratoplasty pak j ophthalmol. 2020, vol. 36 (2): 103-108 104 seems to be superior to pkp in terms of early visual recovery, refractive stability, post-operative astigmatism wound and suture related complications and intraoperative risk. 1 some surgeons are using automated micro keratome for the preparation of donor endothelial graft, mounted on artificial anterior chamber. the procedure is known as dsaek. at the same time many surgeons are still using manual dissection for preparation of donor tissue mounted on artificial anterior chamber and the procedure is termed as dsek (descemet stripping endothelial keratoplasty). some of the donor tissue complications are inability to separate newly prepared donor tissue from the anterior layer, excessively thickened donor posterior lenticule, donor tissue perforation and inadvertent slipping of the tissue inside of the eye. 2 the most frequent complication encountered in dsaek is donor lenticule dislocation, which can be resolved with repositioning of the graft and rebubbling. 3 the proposed causes of graft detachment include patient eye rubbing and poor donor tissue dissection technique. there are reports on air induced pupillary block, primary graft failure and interface infection in early post-operative period. 3 in the late post-operative period, the most important reported complications are secondary glaucoma and graft rejection. 4 the purpose of this study is to evaluate the visual outcome and to analyze the per-operative and postoperative complications of dsaek with their possible management. methods this study was performed in the department of ophthalmology khyber teaching hospital peshawar, from jan 2017 to april 2019. all cases of dsaek were performed by a single surgeon. the informed written consent was obtained from all patients. ethical approval of the study was obtained from institutional review board (irb) of khyber medical college, in accordance with the declaration of helsinki. the procedures were performed using the similar technique. we received the precut dsaek tissue and then endoglide was used in 5 (23.8%) and busin glide in 16 (76.19%) cases. the unfolding of the donor tissue was performed by preplaced anterior chamber maintainer using balance salt solution. early post operation complications were defined as the complications that occurred within 2 months after surgery and late complications were those, which happened after 2 months of surgery. any complication either intra operative or post-operative, were managed either medically, or by appropriate surgical means. the data was analysed using spss version 20 and p value of < 0.05 was considered significant. results total 21 patients were included in the study, which comprised of 5 males (23.8%) and 16 females (76.2%). the median age of these patients was 51.5 years (range 40 – 65). all patients had pseudophakic corneal edema/bullous keratopathy. 20 (95.23%) out the total had posterior chamber intraocular lens and only one (4.7%) had anterior chamber intraocular lens. all 21 patients had va less than 5/60 (0.08) with most of the patients having va of cf-1m (0.04). the average va before surgery was cf-1m (0.03). after dsaek procedure the best corrected va in 8 (38.09%) patients was 6/60 (0.1) and in 5 (23.8%) patients, it was 6/24 (0.25). the overall average bcva after dsaek was 6/36 (0.17). on paired sample t-test the p value was 0.001. table 1 shows per-operative complications. in 2 (9.52%) cases, incomplete stripping of the descemet membrane occurred. in these cases, the remaining un-stripped tissue was left as such and donor graft applied. the two most common early post-operative complications were pupillary block glaucoma in 3 (14.28%) eyes and donor graft dislocation in 2 (9.52%) eyes. air induced pupillary block cases were initially treated with table 1: complications of daesk. complications no of cases %age intra-operative complications incomplete stripping of dm 2 9.52 dsaek detachment 2 9.52 loss of button in glide 1 4.76 early post-operative complications donor dislocation 1 4.76 air induced pupillary glaucoma 3 14.28 partial donor non-attachment 2 9.52 blood in interface 1 4.76 decentration 1 4.76 late post-operative complications edema and non attachment after rebubbling in donor dislocation 1 4.76 late secondary glaucoma 1 4.76 cystoid macular edema 1 4.76 interface opacification 2 9.52 zaman shah, et al 105 pak j ophthalmol.2020, vol. 36 (2): 103-108 table 2: comparison of “tan endoglide” vs “busin glide”. no. %age delivery of donor tissue site of incision iris prolapsed incision size tan endoglide 5 23.8% difficult scleral none 4.5mm busin glide 16 76.19% comparatively easy corneal none 4 mm intravenous injection of mannitol and oral acetozolamide 250 mg – four times a day and pupillary dilatation. air bubble was not removed in any of the cases. in our case series, one donor graft dislocation happened in a case with ac iol. this case was managed by pupillary dilatation, repositioning and rebubbling on first post-operative day. the second case was treated by repositioning and re-bubbling. decentration occurred in one (4.76%) case, which was also managed with repositioning and re-bubbling. the most common late post-operative complication was corneal edema and non attachment of dsaek tissue in one (4.76%) case. the other important complication was late secondary glaucoma in one (4.76%) case, cystoid macular edema (cme) occurred in one (4.76%) eye and interface opacification in 2 (9.52%) eyes. cme was treated with sub-tenon injection of triamcinolone acetonide and nepafenec eye drop 3 times a day for 3 months. there was an improvement in vision with resolution of macular edema. in this study the rate of complications was more in cases where venting incision was done. edema and non-attachment after re-bubbling was seen in one (4.76%) case of venting incision. while these complications were not seen in non-venting cases. post-operative scarring at the venting site and epithelial ingrowths were not seen in any case. table 2 shows comparison of busin glide and tan endoglide in the dsaek procedure. we did 5 (23.8%) cases with tan endoglide which was found difficult for delivery and time consuming and 16 (76.19%) cases were performed with busin glide which was comparatively easy and less time consuming. the site for incision was selected as 4.5 mm scleral with tan endoglide and 4.00 mm corneal for busin glide. no iris prolapse occurred with any of the two glides. the overall medium endothelial cell loss (ecl) after 6 months was 16.7%. it was 20.3%, 32.2% after 12 months and 18 months follow-up (figure 1). however, the ecl has not been analyzed independently with different groups of patients and with or without complications. 23.2 0 20.3 16.7 0 5 10 15 20 25 pre-operative 6 months 1 year 18 months percentage fig. 1: endothelial cell loss in % age with time. discussion the dsaek offers an effective and efficient alternative to traditional pkp for the treatment of corneal endothelial dysfunctions. the different complications of dsaek are pupillary block by air, donor dislocation, graft failure, secondary glaucoma and graft rejection. the potential causes of donor dislocation include; presence of interface viscous fluid or air, patient squeezing and eye rubbing. there are complications with preparation, handling and insertion of donor lamellar tissue into the anterior chamber of the recipient. most of the reported complications are with automated dissection of the donor tissue but evidence is lacking about management of these complications. as previously described, pupillary block by air is an important complication of dsaek procedure. the reported incidence of pupillary block varies between 0.5% and 13% in different series. 5 this is due to the displacement of an excessively large air bubble. in our series, the overall frequency was 4.76%. this complication can be prevented by placing a freely mobile air bubble and putting a drop of cycloplegic at the end of surgery. donor dislocation is one of the most important complications and the rate varies from 0% to 82%, with an average dislocation rate of 14.5%. the graft dislocation may represent either fluid in the interface descemet stripping automated endothelial keratoplasty pak j ophthalmol. 2020, vol. 36 (2): 103-108 106 of an otherwise well positioned graft or complete dislocation into the anterior chamber. it is interesting to notice that the incidence of this unique complication is reduced with experience and the same author had reported 8% dislocation rate in 2008. 6 price reported a dislocation rate of 50% on the first 10 eyes undergoing dsaek, which was reduced to 13% in the next 126 cases after changing the procedure to include face up position after surgery and smoothening of the corneal surface. 7 with experience and time, the dislocation rate is reduced. the results of dislocation management are also satisfactory with a success rate of 72.3% that is comparable with other published series. 8 the published studies showed rate of primary graft failure (pgf) from 0% to 29%, with an average pgf rate of 5%. 9 pgf has been linked with poor surgical technique of dsaek and related excessive iatrogenic intraoperative manipulation of donor endothelial cells. 10 in our series, no case of pgf was recorded, probably due to less manipulation of dsaek button. published reports on secondary glaucoma after dsaek are between 0% and 15%, with an average of 3% 1 . in our series, the incident of secondary glaucoma was 4.76% and the commonest cause of this late secondary glaucoma was topical corticosteroid. among reviewed studies the endothelial rejections rates varied from 0% to 45%, with an average rejections rate of 10% with the follow-up ranging from 3 to 24 months. 10 in our series the rejection rate was 0%. epithelial ingrowths, interface opacification and interface hemorrhage are less common complications in our series and these are comparable with reported studies. 11,12 among theses, interface opacity is one of the important reasons for repeat endothelial keratoplasty reported by letko et al, following 1050 consecutive dsaek cases in 5 years. 13 interface fibrosis was also described histopathologically in failed dsaek cases where pkp procedure was performed later on. the incomplete removal of dm as a cause of partial graft detachment in dsaek has been reported. 14 in our series, partial donor detachment happened in two cases and with time they attached completely, which was because of incomplete stripping of dm in two cases. in both cases the graft was initially attached in more than two third areas. postoperative cystoid macular edema developed in one (4.76%) eye, which resolved with topical nonsteroidal anti-inflammatory agent and sub-tenon triamcinolone acetonide injection. this is again comparable with the previous reports. 15 late secondary donor failure due to chronic endothelial cell loss is a question in dsaek procedure. the reported late graft failure varies between 0 and 45 % after 01 year with an average of 6% in first year. 16 in our series the study duration is up to 18 months and the endothelial cell loss was 23.2%. late graft failure was more in pseudophakic eye with ac iols than with pc iol (11.7% versus 2.4%). previous studies have also shown that endothelial cell loss (ecl) in dsaek in pseudophakic eyes with ac iols is higher and the graft failure was 16% with up to 30 months follow up. 15 therefore, dsaek surgery in patients with ac iol remains controversial. as the published report of dsaek beyond 5 years are few in number, so long term graft clarity with dsaek is yet to be determined. retanasi et al showed that only four (7.8%) eyes had a late donor failure among 5% cases in their longest follow up of more than 5 years. 16 the author states that long term results of dsaek were excellent. the grafts were clear despite lower than normal endothelial cell count. the total graft failure in this large series was 31 (7.2%) eyes. the failed dsaek cases, early or late can be managed by redo procedure in majority (54.8%) of cases. the infection following dsaek procedure, either in the form of interface kerititis and endophthalmitis in early post operative period or delayed kerititis after 03 months is always serious. 17-19 in our study, at the end of 18 months follow up, not a single case of infection was seen. as a fairly new procedure the relative experience of surgeons in earlier cases may account for more graft manipulation and ecl during surgery. in addition, the dsaek in certain indications have more complications then clear case of pc iol related pseudophakic bullous keratopathy or fuchs endothelial dystrophy. the different conditions are aphakic ac iol related pseudophakic bullous keratopathy (pbk); post penetrating keratoplasty (pkp) failed graft, congenital hereditary endothelial dystrophies (ched) and irido-corneal endothelial syndrome (ices). in aphakic cases there are reports of posterior dislocation of the donor disc into the vitreous cavity with or without retinal detachment. 20 other difficult cases include vitreous in anterior chamber, previous large peripheral iridectomy, large yag laser capsulotomy even in the presence of pc iol and a zaman shah, et al 107 pak j ophthalmol.2020, vol. 36 (2): 103-108 large filtration bleb. extra care and precautions are required in these difficult cases. conclusion in conclusion, the dsaek is an exciting and promising alternative to the traditional pkp. like other corneal transplantation surgeries, the learning curve is steep and the potential for complication is significant during first few cases. both operative and post-operative complications do occur in dsaek and increase with the long postoperative follow up, but all are within an acceptable limit. the re-dsaek can be easily performed in most of the failed cases with satisfactory results. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest references 1. lee wb, jacobs ds, msch kanfinan sc. descemet’s stripping endothelial keratoplasty: safety and outcomes. a report by american academy of ophthalmology, 2009; 116: 1818-1830. 2. glasser db. tissue complication during endothelial keratoplasty. cornea. 2010; 29: 1428-1429. 3. terry ma, shamie n, chen es. endothelial keratoplasty for fuchis dystrophy with cataract: complication and clinical results with the new tripling procedure. ophthalmology, 2009; 116: 631-639. 4. terry ma, hoar kl, wall j. histology of dislocations in endothelial keratoplasty (dsaek and dalk): a laboratory based surgical solution to dislocation in 100 consecutive dsek cases. cornea, 2006; 25: 926-932. 5. koenig sb, covert dj. early results of small-incision descemet's stripping and automated endothelial keratoplasty. ophthalmology, 2007; 114: 221–226. 6. basak sk. descemet stripping and endothelial keratoplasty in endothelial dysfunctions: three-month results in 75 eyes. indian j ophthalmol. 2008; 56: 291– 296. 7. price mo, gorovoy m, benetz ba. descemet's stripping automated endothelial keratoplasty outcomes compared with penetrating keratoplasty from the ornea donor study. ophthalmology, 2010; 117: 438–444. 8. chaurasia s, vaddavalli pk, ramappa m. clinical profile of graft detachment and outcomes of rebubbling after descemet stripping endothelial keratoplasty. br j ophthalmol. 2011; 95: 1509–1512. 9. shih cy, ritterband dc, rubino s. visually significant and non-significant complications arising from descemet stripping automated endothelial keratoplasty. am j ophthalmol. 2009; 148: 837–843. 10. ashar jn, madhavi latha k, vaddavalli pk. descemet’s stripping endothelial keratoplasty (dsek) for children with congenital hereditary endothelial dystrophy: surgical challenges and 1-year outcomes. graefes arch clin exp ophthalmol. 2012; 250: 1341– 1345. 11. ku bi, hsieh yt, hu fr, wan ij, chen wl, hou yc. endothelial cell loss in penetrating keratoplasty, endothelial keratoplasty, and deep anterior lamellar keratoplasty. taiwan j ophthalmol. 2017; 7 (4): 199– 204. doi:10.4103/tjo.tjo_55_17 12. schmitt aj, feilmeier mr, piccoli fv. interface blood after descemet stripping automated endothelial keratoplasty. cornea, 2011; 30: 815–817. 13. letko e, price da, lindoso em. secondary graft failure and repeat endothelial keratoplasty after descemet's stripping automated endothelial keratoplasty. ophthalmology, 2011; 118: 310–314. 14. lass jh, gal rl, dontchev m. cornea donor study investigator group. donor age and corneal endothelial cell loss 5 years after successful corneal transplantation. specular microscopy ancillary study results. ophthalmology, 2008; 115: 627–632. 15. gupta pk, bordelon a, vroman dt. early outcomes of descemet stripping automated endothelial keratoplasty in pseudophakic eyes with anterior chamber intraocular lenses. am j ophthalmol. 2011; 151: 24–28. 16. ratanasit a, gorovoy ms. long-term results of descemet stripping automated endothelial keratoplasty. cornea, 2011; 30: 1414–1418. 17. sengupta j, khetan a, saha s. bacterial keratitis after manual descemet stripping endothelial keratoplasty–a different pathophysiology? eye contact lens, 2010; 36: 62–65. 18. lee wb, foster jb, kozarsky am. interface fungal keratitis after endothelial keratoplasty: a clinicpathological report. ophthalmic surg lasers imaging, 2011 apr 14: 42. online e44-48. doi: 10.3928/15428877-20110407-01. 19. ortiz-gomariz a, higueras-esteban a, gutiérrezortega ár. late-onset candida keratitis after descemet stripping automated endothelial keratoplasty: clinical and confocal microscopic report. eur j ophthalmol. 2011; 21: 498–502. descemet stripping automated endothelial keratoplasty pak j ophthalmol. 2020, vol. 36 (2): 103-108 108 20. afshari na, gorovoy ms, yoo sh. dislocation of the donor graft to the posterior segment in descemet stripping automated endothelial keratoplasty. am j ophthalmol. 2012; 153: 638–642. author’s designation and contribution dr. zaman shah; assistant professor: research design, data collection, manuscript writing, final review. dr. ibrar hussain; head of department of ophthalmology: research design, final review. dr. sadia sethi; professor: research design, final review. dr. bakht samar khan; associate professor: research design, final review. dr. tajamul khan; associate professor: research design, final review. .…  …. 67 pakistan journal of ophthalmology, 2020, vol. 36 (1): 67-71 original article change in central corneal thickness after phacoemulsification fariha s. wali 1 , sajjad ali surhio 2 , rafeen talpur 3 , muhammad jawed 4 , shehnilla shujaat 5 1-5 department of ophthalmology, sindh institute of ophthalmology and visual sciences, hyderabad – pakistan abstract purpose: to determine changes in central corneal thickness after phacoemulsification at first post-operative day, one week and one month. study design: descriptive observational study. place and duration of study: sindh institute of ophthalmology and visual sciences, hyderabad. from june 2018 to march 2019. material and methods: ninety-two patients with ages between 35 and 72 years presenting with senile and presenile cataract were selected by non-probability convenience sampling. patients with previous ocular surgery, ocular trauma, glaucoma, uveitis, contact lens wear and long-term use of ocular medication were excluded. the patients were subdivided into three groups depending on variability in their corneal thickness. patients with preoperative central corneal thickness (cct) from 480 to 529 µm were placed in group 1 (thin), group 2 included patients with cct ranging between 530 and 569 µm (moderate), patients with cct from 570-640 µm were placed in group 3 (thick). preoperative cct was measured before extraction of cataract with phacoemulsification and then repeated on first post-operative day and then at one week and one month. results: preoperative mean central corneal thickness increased by 10.2% on first post-operative day. it reduced to 3.1% on seventh post-operative day. it further reduced to 0.7% on 30 th post-operative day. central corneal thickness reduced to mean value of 548.8 µm on 30 th post-operative day, which was statistically non-significant as compared with preoperative mean value (544.96 µm). conclusion: there was no statistically significant change in cct one month after phacoemulsification when compared with the pre-operative cct. key words: pachymetry, central corneal thickness, phacoemulsification, cataract. how to cite this article: wali fs, surhio sa, talpur r, jawed m, shujaat s. change in central corneal thickness after phacoemulsification. pak j ophthalmol. 2020; 36 (1): 67-71. doi: https://doi.org/10.36351/pjo.v36i1.999. introduction corneal endothelium consists of a monolayer of polygonal cells. endothelial cells maintain this tissue in a dehydrated state by their pumping activity, thereby assuring its transparency 1 . this is an active correspondence to: muhammad jawed sindh institute of ophthalmology and visual sciences, hyderabad – pakistan email: jawedbiotech@yahoo.com process, which is controlled by na + /k + -atpase 2 . numerical density of 400–500 cells/mm 2 is required to sustain the pumping activity of the endothelium. dysfunction of endothelial cells results in water accumulation in the cornea causing increased thickness of cornea 3 . thickness of the cornea is an important parameter to see the endothelial cell function 4 . positive correlation exists between endothelial cell function and central corneal thickness (cct) 5 . central corneal thickness can be measured by ultrasonic pachymeter 6 . https://doi.org/10.36351/pjo.v36i1.999 mailto:jawedbiotech@yahoo.com change in central corneal thickness after phacoemulsification pakistan journal of ophthalmology, 2020, vol. 36 (1): 67-71 68 ultrasonic pachymeters allow surgeons to measure the thickness of the cornea in patients suffering from glaucoma, hypertension or those who are considered for refractive surgery without causing damage to this sensitive organ. measurements of cct are useful to evaluate corneal hydration and the corneal endothelial cells function 7 . when functioning normally, the endothelial pump balances the leak rate to maintain the corneal stromal water content at 78% and the cct at ~540 µm that is considered as the normal cct 8 . phacoemulsification is one of the most widely used surgical procedures for removal of cataract 9,10 . the corneal endothelium is known to undergo damage during phacoemulsification due to incision, use of ultrasonic energy, irrigation solutions, visco-elastics, etc 11 . precise measurements of corneal thickness may therefore serve as a parameter for assessing overall endothelial function. a healthy cornea is able to compensate rapidly for transient increases in cct after cataract surgery 12,13 . in the following study, we present our results of measurement of cct before and after phacoemulsification to evaluate the recovery of endothelial cell function at one month after surgery. material and methods in this observational study, participants were recruited from outpatient department of sindh institute of ophthalmology and visual sciences, pakistan. consent was taken from participants. all the participants were divided into 3 sub-groups based upon normal variability in their corneal thickness. group 1 included patient who had preoperative corneal thickness from 480 to 529 µm, group 2 covered patients whose preoperative corneal thickness ranged from 530 to 569 µm. group 3 patients had corneal thickness ranging from 570 to 640 µm. this division into sub groups decreased the chances of error when comparing thin corneal behavior with thick corneas 14 . all patients aged between 35 and 72 years, presenting with pre-senile and senile cataract were included and all the patients with diabetes, previous ocular surgery, ocular trauma, glaucoma, uveitis, contact lens wear and long-term use of ocular medication were excluded from the study. after acquiring cct by means of ultrasonic pachymeter (pacline optikon, italy), patients were scheduled for phacoemulsification with intra ocular lens implant. experienced surgeons operated all patients. on first postoperative day, patients were prescribed topical antibiotics and steroids. any patient with striate keratopathy was excluded from the study. all the patients were examined on 7 th day and after one month of surgery and cct were measured. results in this study, 92 participants were included, the male: female ratio was 5:4. age of patients ranged from 35 to 72 years (mean age 53.3 years ± 12.0). fig. 1 shows the mean cct of first sub-group with cct ranged between 450 and 529 µm, which increased to a level of 558.4 µm from baseline of 497.65 µm on first postoperative day, which then reduced to 526.75 µm on seventh post-operative day. on 30 th day, the mean cct reduced to 502 µm. second sub-group had a cct ranging from 530 to fig. 1: correlation of cct in sub-group1 (thin cct; 450 – 529 µm), before and after phacoemulsification. fig. 2: correlation of cct in sub-group 2 (normal cct; 530 – 569 µm), before and after phacoemulsification. wali fs, et al 69 pakistan journal of ophthalmology, 2020, vol. 36 (1): 67-71 569 µm, as shown in fig. 2 the mean cct increased to a level of 604.7 µm from baseline of 543.35 µm on first post-operative day, reduced to 567.17 µm on seventh post-operative day and on 30 th day, the mean cct of second sub-group reduced to 547 µm. in 3 rd subgroup cct ranged from 570–650 µm, there was increase in average cct of 635.16 µm from baseline mean of 593.9 µm on first post-operative day. it reduced to mean of 603.5 µm on 7 th day and then to 597.5 µm at one month (fig. 3). fig. 3: correlation of cct in group-3 (thick cct; 570 – 640 µm), before and after phacoemulsification in all sub groups, there was a mean increase in cct to 599.42 µm (10.2% increase) on 1 st day postoperatively, 565.8 µm (3.1%) on 7 th day, and 548.3 µm (0.7%) on 30 th day. fig. 4: mean cct of all participants at different time intervals. discussion corneal endothelium maintains deturgescence by pumping fluid out of the corneal stroma. after phacoemulsification, endothelial cell function may alter due to inflammation or surgical trauma. this leads to increase in corneal thickness, which can be measured by pachymetry. repeated pachymetry over a period after phacoemulsification can give us indirect information about endothelium cell function. corneal endothelium is exposed to different insults during cataract surgery, which even if mild can cause transient alterations in endothelial cell function. this leads to increase in cct. surgical instruments, viscoelastics, and solutions used for irrigation and aspiration can induce changes in endothelium by direct trauma or by inflammatory process 15,16 . decreased pumping action of endothelium to maintain corneal deturgesence leads to increased corneal thickness 4,17 . this change can easily be quantified by the use of pachymeter to measure corneal thickness 18 . corneal endothelium slowly recovers from the insult and pumps the fluid out of the cornea. over a time-period, the cornea regains its normal thickness. the duration of recovery may vary from patient to patient depending on general health, corneal endothelial cell count, surgical trauma and inflammatory response 19,20 . in our study, cct was measured over a period of one month postoperatively to allow enough time for recovery. results in all the groups showed that preoperatively healthy corneas were able to recover smoothly to approximately the same thickness as it was preoperatively. changes in the endothelial function depicted by pachymetry to measure cct is also discussed by ot aribaba et al 21 . they showed an increase in mean cct fig. 5: comparison of central corneal thickness (cct) in 3 subgroups before and after corneal surgery. cct; central corneal thickness, thin; sub-group with cct 450 – 529 µm, normal; sub-group with cct 530 – 569 µm, thick; sub-group with cct 570 – 640 µm. change in central corneal thickness after phacoemulsification pakistan journal of ophthalmology, 2020, vol. 36 (1): 67-71 70 from 520.6 ± 20.3 μm to 597.9 ± 30.4 μm, 24 hours after cataract surgery followed by relative reduction in the mean cct to 555.2 ± 24.7 μm and 525.1 ± 19.7 μm at 2 weeks and 12 weeks, respectively. another study showed that there was no statistically significant difference in cct after small incision cataract surgery and phacoemulsification 22 . similarly, ganekal s, nagarajappa a. have shown results consistent with our study 23 . in the immediate post-operative period in cataract surgery, central corneal thickness increases but this change is reversible. these changes come to base line after some time. however, the transient increase in central corneal thickness may give falsely high intra ocular pressures. hence, if spikes in intra ocular pressure are noticed in the early post-operative period, it should not be treated until central corneal thickness is also taken into account. limitations to our study are shorter study time, and lack of information about endothelial cell count measured by specular microscopy. on the other hand, in this study we used ultrasound pachymetry, which is shown to have more variable results as compared to optical pachymetry. conclusion corneal thickness increases transiently after phacoemulsification due to surgical trauma and inflammation. corneal endothelium recovers its normal function and corneal thickness reduces to preoperative level over one month. ethical approval the study was approved by the institutional review board/ethical review board. conflict of interest authors declared no conflict of interest authors’ designation and contribution fariha sher wali; assistant professor: study design, data collection, manuscript drafting, and final review. sajjad ali surhio; associate professor: data collection, manuscript drafting, final review. rafeen talpur; assistant professor: data collection, final review. muhammad jawed; research associate: data collection, manuscript drafting, final review. shehnila shujaat; assistant professor: data collection, final review. references 1. ali m, raghunathan v, li jy, murphy c, thomasy s. biomechanical relationships between the corneal endothelium and descemet's membrane. exp eye res.2016; 152: 57-70. doi:10.1016/j.exer.2016.09.004. 2. thériault m., roy o, brunette i, proulx s. physiological pressure enhances the formation of tight junctions in engineered and native corneal endothelium. exp eye res. 2019; 179: 102-105. doi:10.1016/j.exer.2018.11.004 3. whikehart dr. corneal endothelium: overview, in encyclopedia of the eye, d.a. dartt, editor. academic press: oxford, 2010: 424-434. 4. maugeri g, longo a, d’amico, agata g, rasà d, maria, reibaldi m, russo a, et al. trophic effect of pacap on human corneal endothelium. peptides, 2018; 99 (1): 20-26. 5. doughty mj, jonuscheit s. corneal structure, transparency, thickness and optical density (densitometry), especially as relevant to contact lens wear—a review. cont lens anterior eye, 2019; 42 (3): 238-245. 6. hoehn al, thomasy sm, kass ph, horikawa t, samuel ms, shull or, et al. comparison of ultrasonic pachymetry and fourier-domain optical coherence tomography for measurement of corneal thickness in dogs with and without corneal disease. the vet j. 2018; 242: 59-66. 7. garcía je, camarena c, ramírez f, zavala d, lloves, j. correlation of age, corneal curvature and spherical equivalent with central corneal thickness. revista mexicana de oftalmología, 2017; 91 (4): 172176. 8. marelli a, devita i, cozza f, tavazzi s. criticality of the measurement of corneal thickness in specular reflection by digital biomicroscope. cont lens anterior eye, 2018; 41 (6): 531-537. 9. rouhbakhshzaeri m, azar n, ghahari e, putra i, eslani m. new ex vivo model of corneal endothelial phacoemulsification injury and rescue therapy with mesenchymal stromal cell secretome. j cat refract surg. 2019; 45 (3): 361-366. 10. duman r, tokçevik m, çevik s, duman r, i̇rfan p. corneal endothelial cell density in healthy caucasian population. saudi j ophthalmol. 2016; 30 (4): 236-239. 11. foster gjl, quentin ab, brandon ad, devgan u, richard hs. sumitra ks, et al. phacoemulsification https://www.ncbi.nlm.nih.gov/pubmed/30503546 wali fs, et al 71 pakistan journal of ophthalmology, 2020, vol. 36 (1): 67-71 of the rock-hard dense nuclear cataract: options and recommendations. j cat refract surg. 2018; 44 (7): 905-916. 12. kaplowitz k, yazdanie m, abazari a. a review of teaching methods and outcomes of resident phacoemulsification. surv ophthalmol. 2018; 63 (2): 257-267. 13. meeks la, blomquist ph, sullivan br. outcomes of manual extracapsular versus phacoemulsification cataract extraction by beginner resident surgeons. j cat refract surg. 2013; 39 (11): 1698-1701. 14. park sjk, ghee as, simon nw, anthony p. the effect of thin, thick, and normal corneas on goldmann intraocular pressure measurements and correction formulae in individual eyes. ophthalmology, 2012; 119 (3): 443-449. 15. zota ig, melnic em, untesco mi. the role of endothelial cell in the immune inflammation initiation during the atherosclerosis. atherosclerosis supplements, 2008; 9 (1): 224-225. 16. ludewig p, winneberger j, magnus t. the cerebral endothelial cell as a key regulator of inflammatory processes in sterile inflammation. j neuroimmunol. 2019; 326: 38-44. 17. zhang s, wu n, zhong y, weiwei j, christopher m, chun j. optogenetic intervention to the vascular endothelium. vascular pharmacol. 2015; 74: 122-129. 18. cairns r, graham k, o’gallagher m, jackson aj. intraocular pressure (iop) measurements in keratoconic patients: do variations in iop respect variations in corneal thickness and corneal curvature? cont lens anterior eye, 2019; 42 (2): 216-219. 19. parekh m, gary pm, jodhbir s, ahmad s, ponzin d, ferrari s. effects of corneal preservation conditions on human corneal endothelial cell culture. exp eye res. 2019; 179: 93-101. 20. blanch rj, peter ga, shah p, jon br. logan as, robert ah. visual outcomes after blunt ocular trauma. ophthalmology, 2013; 120 (8): 1588-1591. 21. aribaba ot, adenekan oa, onakoya ao, samuel ar, olutola jo, olatunbosun mk, et al. central corneal thickness changes following manual small incision cataract surgery. clin ophthalmol (auckland, n.z.). 2015; 9: 151-155. 22. deshpande s, agarwal a, shah p, gala y. study of central corneal thickness (cct) before and after smallincision cataract surgery (sics) and phacoemulsification surgery. niger j ophthalmol. 2018; 26 (1): 35-9. 23. ganekal s, nagarajappa a. comparison of morphological and functional endothelial cell changes after cataract surgery: phacoemulsification versus manual small-incision cataract surgery. middle east afr j ophthalmol. 2014; 21: 56-60. .…  …. 193 vol. 35, no. 2, apr – jun, 2019 pak j ophthalmol original article to study the safety of multi-dose topical anaesthetic eye drops for one month after opening mehr-un-nisa, irfan qayyum malik, muhammad wasif irshad pak j ophthalmol 2019, vol. 35, no. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . see end of article for authors affiliations …..……………………….. correspondence to: mehr-un-nisa department of ophthalmology dhq teaching hospital, gujranwala email: 06mehru@gmail.com …..……………………….. purpose: to determine the risk of ocular infections due to topical multi-dose anaesthetic eye drops in patients one month after opening the bottle. study design: quasi experimental study. place and duration of study: department of ophthalmology dhq teaching hospital, gujranwala from 22 nd may 2018 to 22 nd june 2018. materials and methods: in this study topical anaesthetic eye drops containing proparacaine hydrochloride 0.5% as main ingredient and benzalkonium choride as preservative (alcaine®) were tested daily to see if any bacterial/fungal growth occurs in the bottle containing eye drops or not. same bottle was used in patients presenting in outdoor and indoor departments. samples taken from the bottle contents were cultured on different media to see growth of fungi or bacteria. patients who already had keratitis, conjunctivitis, corneal opacities, thin corneas and having dry eyes which were prone to get infected were excluded from this study. results: there were 60 patients included in our study and they were divided in two groups. group a included those who presented in the outdoor department and group b comprised of those admitted for various operative procedures. there were 30 patients in each group. all patients were adults (18-60 years). after 1 month of daily culturing on agar plates, no micro-organism growth was seen in both groups. conclusion: topical anaesthetic eye drops can be used safely for 1 month in different patients after opening the bottle without any risk of causing infectious keratitis, conjunctivitis or endophthalmitis. keywords: proparacaine, culture medium, endophthalmitis. opical anaesthetic eye drops are used extensively in ophthalmology. these agents provide sufficient corneal and conjunctival anaesthesia for comfortable performance of different examination techniques like tonometry, biometry, gonioscopy, contact lens fundoscopy and nd-yag laser posterior capsulotomy. apart from examination techniques, these agents are used for certain therapeutic purposes as well; like removal of superficial corneal and conjunctival foreign bodies, removal of stitches and during surgeries of smaller duration like cataract extraction by phacoemulsification1. topical anaesthetics used in ophthalmology are tertiary amines linked by either ester or amide bonds to an aromatic residue. these act by blocking nerve impulse conduction by decreasing sodium permeability across the cell membranes1. these agents are weak bases, are more soluble in protonated form and their hydrolysis is slow in acidic environment so these are bound with hydrochloride1. proparacaine is t mehr-un-nisa, et al pak j ophthalmol vol. 35, no. 2, apr – jun, 2019 194 the preferred topical anaesthetic used for ophthalmological purposes as it causes lesser pain on instillation and longer anesthesia2. topical medications are easy to get contaminated and the rate of contamination is directly related to multiple use and also to duration for which the drops are being used3,4. these drops are used extensively in ophthalmology outdoor departments and also during various operative procedures which are known to have potentially vision threatening infectious complications like endophthalmitis. the rationale of the study was to check if these drops are a potential cause of endophthalmitis or other infections of lesser severity like conjunctivitis and keratitis. the purpose of the study was to determine the risk of ocular infections due to topical anaesthetic eye drops in patients one month after opening the bottle. materials and methods this quasi experimental study was conducted after approval from the ethical and research committee of dhq teaching hospital, gujranwala/gujranwala medical college. the bottle contents of a topical formulation containing proparacaine hydrochloride (0.5%) as the anaesthetic agent and benzalkonium chloride (0.01%) as a preservative used in ophthalmology department of dhq university teaching hospital, gujranwala was tested on daily basis to check if any growth occurs or not. one bottle of alcaine® eye drops was labelled as “study case” for this purpose and drops were instilled daily in eyes of different patients, one from the outdoor patient department and the other in the operation theater. thus, 60 patients were included in our study and they were divided in two groups comprising of 30 patients in each. group a included those who presented in the outdoor department and group b comprised of those presenting for various operative procedures. all patients were adults (18-60 years). gender of the patients was not taken as a measure. patients were selected through random sampling technique. those who already had keratitis, conjunctivitis, corneal opacities, thin corneas and having dry eyes, which were prone to get infection were excluded from this study. great care was taken while instilling eye drops, not to touch tip of the bottle to the ocular surface, adnexa or any other thing to avoid any possible contamination, which could give false positive culture results. after instilling drops, the bottle was capped carefully and tightly before taking any samples for culture growth and stored in a refrigerator afterwards. in the laboratory, sample was applied on blood agar, macconkey agar and sabouraud agar following the conventional techniques. blood agar and macconkey agar plates were incubated at 37° c for 24 hours whereas sabouraud agar plate was incubated at 37°c for 24-48 hours to provide adequate time and environment for bacterial and fungal growth respectively. samples were cultured daily for 30 days consecutively. all the patients were followed up on day 1, day 7 and day 30 to see if any microbial infection had occurred or not. results more than half (58%) of the patients in group a presented with complaint of superficial corneal/ conjunctival foreign body (figure 1). there were 14 of 30 (47%) patients in group b who were candidates of cataract extraction by phacoemulsification (figure 2). there were 37 of 60 (61.6%) patients who complained of transient mild irritation/stinging after instilling the anaesthetic eye drops while 17 of 60 (28.3%) were noted to have increased blinking. others complained of redness and increased lacrimation (table 1). all these complaints were short-lived and subsided within an hour. all patients were followed up on already defined times and sampling of eye drops was done daily for 30 days. no signs of bacterial or fungal infection was noted in any of these patients and no microbial growth was seen on the culture media we used in our study (table 2). 37% 58% 5% others superficial corneal/conjunctival foreign body tonometery fig. 1: cause of presentation in group a (outdoor patients). cause of presentation in group a to study the safety of multi-dose topical anaesthetic eye drops one month after opening 195 vol. 35, no. 2, apr – jun, 2019 pak j ophthalmol 47% 36% 17% others removal of stitches phacoemulsification fig. 2: cause of presentation in group b (operation theater patients). table 1: complaints while instilling the topical anesthetic drops. complaints while instilling the drops no. of patients percentage irritation/stinging 37 61.6% redness 5 8.3% increased lacrimation 11 18.3% increased blinking 17 28.3% table 2: results of growth on different culture media on consecutive 30 days. culture medium growth on day 1 – 30 macconkey agar no blood agar no sabouraud agar no discussion topical anesthetics eye drops are widely used in ophthalmology for various outdoor and indoor procedures of short duration; removal of superficial corneal and conjunctival foreign bodies, tonometry, phacoemulsification etc. these agents provide sufficient anaesthesia to carry out these procedures under comfortable circumstances both for the patient and the doctor1. topical anaesthesia has largely replaced other techniques of local anesthesia like retrobulbar/peribulbar anaesthesia being employed during cataract extraction via phacoemulsification5-7. a study conducted by rong han wu and co-authors has found topical anaesthesia as a safer alternative to peribulbar/retrobulbar anaesthesia for patients undergoing pars plana vitrectomy8. it is a common practice to use a single bottle of topical formulations in different patients with different complaints. asegedech tsegaw and colleagues found out that multi-dose eye drops are easily contaminated due to frequent and long-term usage and may result in inadvertent damage to ocular surfaces by causing unwanted infections9. nentwich mm and co-authors conducted a similar study in kenya on 101 bottles of multi-use and single-use topical ophthalmic solutions with similar conclusions10. the rate of contamination is variable in literature and it ranges from as low as 0.07%11 to as high as 35.8%12 and is directly related to the increased duration of use4. a study conducted by mohammad reza fazeli et al. stated that topical anesthetic eye drops were the most commonly contaminated drops among all other multi-use topical formulations13. contamination of the topical formulations is the source of different ocular infections. the most severe of these is endophthalmitis, which is infective inflammation of the intraocular structures and is potentially sight-threatening14. topical anaesthetic eye drops are easily available as an over-the-counter drug and people are likely to get addicted to these medications because of the temporary relief these agents provide in case of ocular surface irritation. some of the medical professionals (the primary care practitioners) also recommend these as routine medication for this purpose without knowing the adverse effects these can cause on ocular surface integrity15. cases have been reported where the use of topical anaesthetics over long time periods have been linked to severe damage to eyes in the form toxic keratopathy and infections16-18. in a previous study, it was found that eye drops can be used safely in the hospital settings for up to 2 weeks without being a risk factor for ocular infections4. in our study, we extended the time period upto 30 days. the reported source of infection in most of the literature review is contaminated tip 3,9-12 and contamination of the bottle contents12. in our study, we cultured only the bottle contents. garcia-arumi and co-authors have conducted a similar retrospective study on patients undergoing cataract surgery and have found topical anesthesia to be related to postoperative endophthalmitis with an odds ratio [or] of 11.8 and 95% confidence interval [ci]19. hou-chuan lai and co-authors have also conducted a retrospective study comparing different types of anaesthesia for intraocular surgeries and found out that the rate of postoperative cause of presentation in group b mehr-un-nisa, et al pak j ophthalmol vol. 35, no. 2, apr – jun, 2019 196 endophthalmitis after phacoemulsification is significantly higher for topical anaesthesia as compared to general anaesthesia (0.083:0)20. the results of our study are in contrast to all the similar studies conducted in the past as no growth was observed in the bottle contents and no signs of infection was noted in the eyes of patients in whom the drops were instilled. the limitation of the study is small sample size and a similar study is needed to be conducted on a larger scale considering other risk factors like time of presentation to the doctor, duration of surgery and the frequency and technique of instillation of eye drops to carry out different procedures with full convenience. we also recommend to carry out this research on a large scale so as to get more references in this regard. conclusion on the basis of results of our study, we conclude that alcaine® eye drops remain sterile for 1 month and can be used safely in different patients for this duration without any risk of causing bacterial or fungal infections, if care is taken while instilling the drops as previous studies have documented tip contamination as a source of ocular infections. this is also beneficial from economical point of view. conflict of interest the authors have no conflicts of interest to disclose regarding this study. references 1. kumar m, chawla r, goyal m. topical anesthesia. j anaesthesiol clin pharmacol. 2015; 31 (4): 450–456. doi:10.4103/0970-9185.169049. 2. bartfield jm, holmes tj, raccio-robak n. a comparison of proparacaine and tetracaine eye anesthetics. acad emerg med. 1994; 1 (4): 364–367. 3. tamrat l, gelaw y, beyene g, gize a. microbial contamination and antimicrobial resistance in use of ophthalmic solutions at the department of ophthalmology, jimma university specialized hospital, southwest ethiopia. can j infect dis med microbiol. 2019, article id 5372530, 8 pages, 4. livingstone dj, hanlon gw, dyke s. evaluation of an extended period of use for preserved eye drops in hospital practice. br j ophthalmol. 1998; 82 (5): 473–475. doi:10.1136/bjo.82.5.473. 5. guay j, sales k. sub‐tenon's anaesthesia versus topical anaesthesia for cataract surgery. cochrane database of systematic reviews, 2015, issue 8. art. no.: cd006291. doi:10.1002/14651858.cd006291.pub3. 6. jacobi pc, dietlein ts, jacobi fk. a comparative study of topical vs. retrobulbar anesthesia in complicated cataract surgery. arch ophthalmol. 2000; 118 (8): 1037–1043. doi:10.1001/archopht.118.8.1037. 7. malik a. efficacy and performance of various local anesthesia modalities for cataract surgery. j clinic experiment ophthalmol. 2013; s1: 007. doi:10.4172/2155-9570.s1-007 8. wu rh, zhang r, lin z, liang qh, moonasar n. a comparison between topical and retrobulbar anesthesia in 27-gauge vitrectomy for vitreous floaters: a randomized controlled trial. bmc ophthalmol. 2018; 18 (1): 164. 9. tsegaw a, abula t, assefa y. bacterial contamination of multi-dose eye drops at ophthalmology department, university of gondar, northwest ethiopia. middle east afr j ophthalmol. 2017; 24 (2): 81–86. doi:10.4103/meajo.meajo_308_16. 10. nentwich mm, kollmann kh, meshack j, ilako dr, schaller uc. microbial contamination of multi-use ophthalmic solutions in kenya. br j ophthalmol. 2007; 91 (10): 1265–1268. doi:10.1136/bjo.2007.116897. 11. wessels if, bekendam p, calvin ws, zimmerman j. open drops in ophthalmology offices: expiration and contamination. ophthalmic surg lasers 1999; 30: 540– 546. 12. brudieu e, duc dl, masella jj, croize j, valence b, meylan i, et al. bacterial contamination of multi‐dose ocular solutions. a prospective study at the grenoble teaching hospital. pathol biol (paris), 1999; 47: 1065– 1070. 13. fazeli mr, nejad hb, mehrgan h, elahian l, “microbial contamination of preserved ophthalmic drops in outpatient departments: possibility of an extended period of use,” daru j pharm. sci.2004; 12 (4): 151–155. 14. durand ml. bacterial and fungal endophthalmitis. clin microbiol rev. 2017; 30 (3): 597–613. doi:10.1128/cmr.00113-16 15. erdem e, undar ih, esen e, yar k, yagmur m, ersoz r. topical anesthetic eye drops abuse: are we aware of the danger? cutan ocu toxicol. 2013; 32 (3): 189-193. 16. aksoy a, başkan am, aslan l, aslankurt m. topical proparacaine abuse resulting in evisceration. bmj case rep. 2013; 2013: bcr2013009539. published 2013 apr 22. doi:10.1136/bcr-2013-009539 17. tok oy, tok l, atay im, argun tc, demirci n, gunes a. toxic keratopathy associated with abuse of topical anesthetics and amniotic membrane transplantation for treatment. int j ophthalmol. 2015; 8 (5): 938–944. doi:10.3980/j.issn.2222-3959.2015.05.15 18. kintner jc, grossniklaus he, lass jh, jacobs g. infectious crystalline keratopathy associated with topical anesthetic abuse. cornea. 1990; 9 (1): 77–80. 19. garcia-arumi j, fonollosa a, sararols l, fina f, to study the safety of multi-dose topical anaesthetic eye drops one month after opening 197 vol. 35, no. 2, apr – jun, 2019 pak j ophthalmol martínez-castillo v, boixadera a et al. topical anesthesia: possible risk factor for endophthalmitis after cataract extraction. j cataract refract surg. 2007; 33(6): 989-92. 20. lai hc, tseng wc, pao si, wong cs, huang rc, chan wh et al. relationship between anesthesia and postoperative endophthalmitis: a retrospective study. medicine, 2017; 96: e6455. author’s affiliation dr. mehr-un-nisa postgraduate resident mbbs ophthalmology department dhq teaching hospital, gujranwala. dr. irfan qayyum associate professor mbbs, fcps, fvr ophthalmology department dhq teaching hospital, gujranwala dr. muhammad wasif irshad house officer mbbs, ophthalmology department dhq teaching hospital, gujranwala. author’s contribution dr. mehr-un-nisa study design and manuscript writing. dr. irfan qayyum manuscript review and critical analysis. dr. muhammad wasif irshad data collection and manuscript writing. 83 pakistan journal of ophthalmology, 2020, vol. 36 (1): 83-86 author communication a ‘mirage’ of a dislocated lens in uveitis sana nadeem 1 , b. a. naeem 2 1-2 department of ophthalmology, foundation university medical college/fauji foundation hospital, rawalpindi abstract we present a very strange case of a 44-year-old diabetic lady who presented with what appeared to be a cataractous lens dislocated in the anterior chamber of her left eye, following weight bearing, a week prior to presentation. the possibility of this being the lens became doubtful on slit lamp examination, as keratic precipitates and flare was noted bilaterally. her pupil was miosed rendering posterior segment view extremely difficult. subconjunctival mydriacaine and dexamethasone were given along with topical steroids and cycloplegics, which allowed a better view of the pupillary area, revealing a hint of a nuclear sclerotic cataract, very well in its natural anatomical location. this is a rare presentation of exudate in anterior uveitis presenting as a lens-like mass, producing such an illusion, as to completely baffle doctors regarding its diagnosis. the mass-like exudate subsequently diminished with topical therapy, and disappeared in around a week’s time. both eyes are quiet at a five months’ follow-up. key words: anterior uveitis, dislocated lens, exudate, diabetes. how to cite this article: nadeem s, naeem ba. a ‘mirage’ of a dislocated lens in uveitis, pak j ophthalmol. 2020; 36 (1): 83-86. doi: https://doi.org/10.36351/pjo.v36i1.883. introduction uveitis is a broad term encompassing any inflammation of the uveal tract; iris, ciliary body and choroid, and their surrounding structures. it is the fourth leading cause of blindness 1 in the developed world, accounting for 10 – 15% of preventable blindness 2 in the west. its causes are manifold ranging from infections, autoimmune diseases, vasculitis, neoplasia, and drugs; to idiopathic cases, which are the commonest. anterior uveitis is the most common, amounting to 28 – 66% of the cases referred to tertiary hospitals 3 . idiopathic anterior uveitis has been described several times in poorly controlled diabetic patients, but the association between the two is still questionable 4 . clinical features of diabetic anterior uveitis 5 include posterior synechiae, fibrin in anterior correspondence to: sana nadeem assistant professor, department of ophthalmology foundation university medical college/fauji foundation hospital, rawalpindi email: sana.nadeem@fui.edu.pk chamber, keratic precipitates, folds in descemet membrane, or hypopyon. we present an unusual case of anterior uveitis in a poorly controlled diabetic lady, who presented with a mirage of a dislocated lens in her anterior chamber, which was in fact exudate. case presentation a 44-year-old lady presented to the opd of fauji foundation hospital, rawalpindi; which is a teaching hospital affiliated with the foundation university medical college; with sudden pain and loss of vision of the left eye for the past seven days, which occurred when she lifted a heavy object. examination revealed her visual acuity in the left eye to be hand movements only and 6/36 in the right eye, with the snellen chart. the anterior chamber seemed to have a moderately cataractous dislocated lens in it, with mild corneal edema. she was admitted immediately for emergency evacuation of the lens. the intraocular pressures were 17 mm hg od and 10 mm hg os. in the ward however, the possibility was raised that this disciform structure might be something else, https://doi.org/10.36351/pjo.v36i1.883 mailto:sana.nadeem@fui.edu.pk a ‘mirage’ of a dislocated lens in uveitis pakistan journal of ophthalmology, 2020, vol. 36 (1): 83-86 84 fig. 1a: solid lens-like mass in the anterior chamber with well-defined margins touching the cornea. b: the cloudiness of the lenticular mass and margins contributing to the lens-like effect. c: dilating the pupil with mydriacaine sub-conjunctival injection, did indeed reveal a nuclear sclerotic natural lens, very much in its natural place. d: partially resolved exudate after repeated sub-conjunctival steroid injections and topical steroids and cycloplegics on day 2. e: at day 4, the exudate has diminished and settled inferiorly. f: complete resolution of the uveitis at five months follow-up. nadeem s, et al 85 pakistan journal of ophthalmology, 2020, vol. 36 (1): 83-86 as it was observed, that it was thinner anteroposteriorly than the natural lens, and that the anterior chamber details were also hazy, with + 3 cells a few fibrin strands, and few white keratic precipitates inferiorly. the edges of the presumed lens were well defined, except for an indentation inferotemporally, which could be considered a lenticular coloboma, with fibrin filaments attached at the margins (figure 1). the pupil was miosed and it was not possible to assess the posterior chamber or segment at the slit lamp. the other eye had scant posterior synechiae and +1 cells. the patient was a known diabetic on regular treatment and did not give any prior history of uveitis or its symptoms. it was decided to dilate the pupil with subconjunctival mydriacaine (lignocaine, adrenaline, and atropine) 0.5 ml injection along with dexamethasone injection (decadron®) 1 ml, to assess the presence of lens in its position and to confirm the possibility of this lens-like mass to be exudate, rather than ectopia lentis. she was also started on half-hourly topical steroid (prednisolone acetate 1%) and atropine drops 1% thrice a day in the left eye, and four times in the right eye. b-scan ultrasound revealed no abnormality of the posterior segment. half hour later, the pupil only dilated a little due to posterior synechiae, however, the patient’s natural crystalline lens which also had nuclear sclerosis, became visible clearly enough to refute the diagnosis of ectopia lentis. thus, our suspicion was confirmed that this was pseudo ectopia lentis due to intense exudate in the anterior chamber, which had for some reason organized. an enquiry about review of systems for uveitis was negative except for type 2 diabetes mellitus. the patient was counseled, and routine investigations were undertaken for uveitis; complete blood count, esr, chest x-ray, mantoux test, and serum angiotensin converting enzyme (ace). the exudate decreased on the next day. sub-conjunctival dexamethasone 1 ml was repeated, and the mass sank down by day 4 of topical therapy. she had bilateral grade 2 brunescent nuclear sclerosis and mild posterior subcapsular cataract. fundus examination revealed bilateral mild non-proliferative diabetic retinopathy (npdr) with clinically significant macular edema (csme) in the left eye. her diabetes mellitus was uncontrolled at the time and a medical consultation was sought to normalize here blood sugar levels. she was discharged after resolution of her exudate, on topical steroid four times a day and ketorolac eye drops thrice a day and cyclopentolate eye drops 1% thrice a day. the drops were tapered soon as her uveitis settled. her csme was managed by an intravitreal injection of bevacizumab 1.25 mg in 0.05 ml (avastin). her investigations for uveitis were negative. five months later, she had bilaterally quiet anterior chambers. her best corrected visual acuity was 6/60 od and 6/18 os, her posterior subcapsular cataracts and nuclear sclerosis had progressed and cataract surgery was planned in due time. the retinopathy was stable at the moment. discussion uveitis has long been described in patients with diabetes mellitus. little is known about its pathogenesis however in such patients, whether it represents a true inflammation or ischemia 6 is a causative factor. elevated intraocular fibronectin 7 may play a role in such cases. however, poor diabetic control and idiopathic uveitis has been linked 8,9 with severe anterior segment inflammation and poor vision at presentation, along with diabetic retinopathy; all three features were present in our patient. bilateral uveitis 9 is also more common in such patients with a higher complication rate. dense fibrin 9 is also reported to be more common in diabetic eyes, as is the case with our patient whose exudate took a lenticular shape, with fibrin strands visible at the margins of the mass. however, no case of an organized mass in a diabetic patient or uveitis patient has ever been reported in literature. the history of heavy weight bearing added suspicion to delude doctors enough to warrant admission and planning of emergency cataract surgery. whether the patient’s diabetes added to the organization of her anterior chamber reaction, is not known to us, but the question does arise at this time. investigations routinely done for uveitis cases, in our set up were all negative, thus raising the possibility of either diabetes as causation, or it could be an idiopathic condition. the patient was fortunate that she was diagnosed correctly and steroid therapy was ensued promptly. the sub-conjunctival injections on two consecutive days contributed to urgent resolution of the exudate, which could have resulted in pupil block glaucoma or corneal decompensation, if left untreated. she did not respond to topical cycloplegics or steroids initially in the first half hour. subconjunctival mydriacaine was phenomenal in partly dilating her pupil, to lead us to the correct diagnosis. thus, it is important in uveitis to correctly a ‘mirage’ of a dislocated lens in uveitis pakistan journal of ophthalmology, 2020, vol. 36 (1): 83-86 86 diagnose and treat it, to prevent significant visual morbidity that follows it. we were fortunate that at that time, the decrease in vision of our patient was attributed to her pre-existing cataracts, rather than uveitis, although it may have played a role in the causation or progression of cataracts, although the patient did not give a prior history of such episodes. we decided to share our unique case to consider an exudate to be ectopia lentis. extensive literature search has failed to generate a similar case of a lenslike mass in the anterior chamber. conflict of interest authors declared no conflict of interest authors’ designation and contribution sana nadeem; assistant professor: manuscript drafting, literature review and final review. ba naeem; professor: literature review and final review. references 1. akinsoji e, goldhardt r, galor a. a glimpse into uveitis in the aging eye: pathophysiology, clinical presentation and treatment considerations. drugs aging. 2018; 35 (5): 399–408. doi:10.1007/s40266-018-0545-3. 2. dick ad, tundia n, sorg r, zhao c, chao j, joshi a, skup m. risk of ocular complications in patients with noninfectious intermediate uveitis, posterior uveitis, or panuveitis. ophthalmology. 2016; 123 (3): 655-62. 3. yanoff m, duker js. ophthalmology. third edition. mosby: st. louis, 2009: p. 783. 4. kheir wa, sheheitli ha, hamam rn. intraocular inflammation in diabetic populations. curr diab 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